His hospital bill: $1.2 million
This is not what someone paid for a home. Rather it is the medical bill businessman Danny Foo accumulated for the 14 months he was in a vegetative state.
The 48-year-old partner of Quayside Group died last Tuesday. He had collapsed and fallen into a coma in July last year, two weeks after he first sought treatment for an infected leg at a private hospital.
"Fortunately, Danny had the foresight to buy insurance early. We have only to pay 10 per cent of the bill, but $120,000 is still a pretty huge amount for the family to pay," Mr Foo's elder brother Steven, 49, told The New Paper.
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Your Life, Your Wishes
Your Life, Your Wishes is an important initiative brought to you by AllSpire Health Partners that focuses primarily on advance care planning and discussing your life wishes at any age.
It all starts with a conversation
- The idea is a simple one. Your Life, Your Wishes is about generating a meaningful dialogue with loved ones about your long-term health care needs and wishes. By starting the conversation today, you’ll be confident about tomorrow, prepared for the future no matter what life brings.
- For loved ones, the conversation will provide a gift like no other: Harmony in knowing they will be honoring Your Life. Your Wishes.
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Honouring last wishes
When you are lying on a bed in the intensive care unit of a hospital, so sick that you are no longer able to interact with anyone, what would you choose?
Do you want to have a tube placed into your windpipe to help you breathe, through a procedure called endotracheal intubation?
If your condition worsens, do you want to be cared for in a hospital or elsewhere, such as in a nursing home, hospice or at home?
It may seem unthinkable that someone in such dire straits can still make choices. However, he can, if his preferences have already been made known to the health-care team and his loved ones, in what is known as advance care planning (ACP).
Drafting an ACP document involves a series of conversations with the patient, substitute decision-makers and an ACP facilitator – usually a doctor, nurse or medical social worker.
Several public health institutions here started offering ACP since 2010. So far, their efforts appear to have helped patients to fulfil their final wishes, statistics show.
Since 2012, of the 28 patients who did an ACP and subsequently died at National University Hospital, 15 died in their chosen places, 22 received their preferred treatment and 12 had both wishes met.
In all, 78 patients, including those from National University Cancer Institute, Singapore (NCIS) and National University Heart Centre Singapore, made ACPs during this period, said Dr Noreen Chan, a senior consultant at the department of haematology-oncology at NCIS.
At Tan Tock Seng Hospital (TTSH), more than 95 per cent of patients who signed an ACP and died at the hospital between October 2011 and June this year received their preferred medical treatment, said Dr Raymond Ng, a consultant at the hospital’s department of palliative medicine. For example, some did not wish to proceed with cardiopulmonary resuscitation (CPR).
Another 23 per cent died in their chosen places, added Dr Ng. The findings came from an audit of 172 patients. In all, 741 patients did an ACP at TTSH and 348 have since died.
Similarly, most of the patients at Khoo Teck Puat Hospital (KTPH) who had done an ACP had their wishes honoured.
The hospital helped 312 patients with their plans, of whom 137 have died. About 80 per cent of them were treated in their preferred places and 64 per cent died in their chosen places.
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‘Die-logue’, education needed on dying well
More than a century ago, death was a social event among family and friends, occurring in the home setting and drawing the community together. With the advent of medical advances promising the hope of cure and the prolonging of life expectancy, people with advanced illnesses would seek the latest treatments at healthcare institutions.
Many people die at very advanced stages of chronic illness in hospitals and not at home. Dying stopped being a part of life. It became taboo, unfamiliar and invisible, expected only in old age. The dying process is medicalised, something that can be postponed. When medicine loses the battle to cure, it is deemed to have failed.
Palliative medicine developed as a counter-culture to the modern imperative of medicine to cure and to prolong life at all costs. It is an approach that improves the quality of life of patients and their families facing life-threatening illness and is now integrated into mainstream biomedicine. However, there is a huge gap to cross before we become a death-friendly and a death-literate society.
Death remains a dirty word, heavily laden with superstition and cultural taboo. As a doctor, I have witnessed the struggle and confusion that patients and their loved ones face when negotiating the dying process. They are rarely prepared, if at all, and there may be complicated grief, regrets and loss of peace.
To help mitigate such issues, Advance Care Planning (ACP) can be introduced. ACP is the process of eliciting people’s values and wishes regarding care in the event that they are seriously ill. As an advocate for ACP, I have met my fair share of resistance and apprehension from both patients – especially the elderly – and healthcare professionals.
However, research has shown that people who have conversations with their physicians and loved ones about end-of-life wishes have higher satisfaction and better quality of life at the terminal phase. Post-bereavement depression in loved ones is lessened, too. Patients are also less likely to receive burdensome interventions and are more likely to receive palliative care. Paradoxically, when introduced earlier in the patient’s illness trajectory, palliative care can even improve survival.
ACP conversations are currently targeted at people with advanced illnesses in hospitals, hospices and palliative home care services. These conversations may include discussions on the extent of treatment and preferred place of care and demise.
However, a significant number of people are mentally incapacitated from making their own decisions at this stage. They face a lot of stress when they are seriously ill and broaching end-of-life conversations for the first time may not be ideal.
ACP conversations are not just for the very ill. They are also suitable for healthy individuals. One part of ACP involves nominating a spokesman if one is struck with a sudden neurological catastrophe that results in mental incapacity. This spokesman must know your preferences for end-of-life care. The starting point of ACP conversations is to explore a person’s values and beliefs, fears and concerns.
Such discussions need not be restricted between people and healthcare professionals. Loved ones can be a part of the process. Useful online tools are available at www.makingyourwishesknown.com and www.livingmatters.sg.
Voluntary welfare and philanthropic organisations have taken on the mantle of advocating for a public discourse on living and dying well. In 2014, the Lien Foundation teamed up with the Ang Chin Moh Foundation and ArtsWok Collaborative to introduce Both Sides Now, an immersive arts experience on end-of-life issues. In the same year, the Good Death Project was launched by Montfort Care with the aim of promoting a “death-friendly community”.
While grassroots efforts are working the ground, we have not reached the tipping point and it remains a hard sell in Singapore to get people talking about living and dying well. A different tack is needed to break the shroud of silence. There needs to be deep community engagement, as well as visible efforts by the Government and professional bodies to promote a healthy discourse on death and dying.
Public awareness campaigns should be staged on mainstream and social media, akin to the Dying To Know Day in Australia which aims to bring death to life through community events and social action. Community centres can be focal points, with regular workshops to encourage “die-logues” or end-of-life conversations.
To truly increase death literacy, we should start with the young. Death education, like sex education, should have a place in the core curriculum. Beyond being better prepared, having open discussions about death and dying has the immense potential to foster a value-laden perspective towards life. In understanding death as a normative life event, one has a better appreciation of the finitude of life and how to make the most of it. Trite but true, a common refrain I hear from patients when faced with their impending demise is: “I wish I had…” We do not have to wait for the end of life to fulfil our bucket list.
Death is the one thing which is certain in life. In realising our own mortality, death becomes a part of life again. Just as how we treat the terminally ill is a reflection of the heart of biomedicine, how we talk about death and dying is a reflection of our maturity as a society and our awareness of being human.
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Let’s talk about living and dying well, today
To some, death is a remote event far removed from life’s daily pursuits or a taboo subject to be avoided, yet, to others, there is peaceful acceptance of death as a final chapter of the natural cycle of life.
As a palliative care physician treating patients with advanced illness, I have witnessed an entire gamut of emotions and reactions to death and dying.
However, my first personal experience with death was not with my patients.
It was when my mother died when I was 18 years old. She had advanced ovarian cancer and battled the disease for five years through multiple operations and cycles of chemotherapy.
Those years were like a blur as we tried to have a normal family life, and I coped by burying myself in my studies. Though she grew cachectic and weak and was literally wasting away nearing the end, death was a taboo subject which never surfaced in our conversations. It just hit one day whenI received a phone call during my basic military training at the army camp. It was only then that I knew she had died and was gone forever. My mother died without the family’s presence and with a certain degree of pain in the final stage.My only goodbye was a tender kiss on her cheek as she lay life lesson her bed.
Perhaps my parents wanted to shield us from the spectre of dying, or perhaps her doctor did not adequately prepare us. Death and dying were issues that we did not talk about. It was not just about death and dying, there were many things I would have liked to say to or ask her, if only I knew.
After my mother’s death, I entered medical school and found my way into palliative care some years after graduation. My experience with my mother was one of the reasons why I chose this speciality. Many have asked if it is a depressing practice. Personally, it has been a rewarding experience of professional and personal growth. I have been privileged to journey with many patients in their final act of life and to be let into their life stories and deepest thoughts.
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Tackling end-of-life issues in community
Does a bedridden patient suffering from pain and being sustained through tube feeding have the right to refuse such sustenance?
Yes, said Associate Professor Chin Jing Jih, a senior geriatric specialist at Tan Tock Seng Hospital (TTSH).
While fluids and nutrition are basic needs, tube feeding is not natural and is considered medical treatment. Patients have the right to refuse it even if it leads to their death, he said.
Hospitals have ethics committees that can help doctors make such decisions. But as Singapore shifts its focus from hospital to community care, this and other problems facing people at the end of their lives need to be addressed in situations outside of a hospital.
Associate Professor Benjamin Ong, the director of medical services at the Ministry of Health (MOH), said similar clinical ethics support is needed for decision-making outside of hospitals.
“Clinical ethics is also relevant and should have an important role in the decisions made in areas such as advanced-care planning, and long-term care and management plans for the aged and the infirm,” he said.
Speaking at the opening of the three-day 13th International Conference on Clinical Ethics Consultation at the Grand Copthorne Waterfront hotel yesterday, Prof Ong added: “We should start to make clinical ethics support more available to clinicians practising in these (community) settings.”
With Singapore’s rapidly ageing population, there is also some urgency for the population to talk about what it wants done in such cases, said Prof Ong.
He announced that the National Ethics Capability Committee, set up in 2014 to design a framework to equip healthcare professionals with “a good understanding of clinical ethics that will inform and guide their professional practice”, had just submitted its report to the ministry, which is reviewing it.
Speaking at the same conference, Prof Chin said some doctors in hospitals do not recognise that sometimes quality of life can be more important that quantity of life.
This is because most doctors have a “professional bias towards rescue and survival”, he said. But aggressive medical treatment may not be in the patient’s best interest.
Today, most patients suffering from end-stage organ failure spend the last six to 12 months of their lives “undergoing multiple rounds of invasive investigations and interventions”, said Prof Chin. This results in an inevitable trade-off “in their already marginal quality of life, as well as limited lifespan”. Some doctors continue prolonging life because they fear legal backlash should they not do so.
Doctors have also asked him: “Even if this were end of life, how do I know if this is the right time to change the therapeutic goal from one based on quantity of life (or survival at all costs) to one that is focused on achieving the best possible quality of life and comfort?”
His answer is, there are no absolute rules.
To help both doctors and patients, hospitals here are putting in a process where such patients’ conditions and needs are reviewed periodically, since their condition can deteriorate subtly. Regular reviews ensure that treatment is aligned with the best care for the patient.
Decisions on the course to pursue should be discussed with the patient or family, before a crisis occurs, so doctors would not automatically treat the patient aggressively to keep him alive, he added.
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It matters, because living matters
Advance Care Planning - Most of us cannot imagine a time when we are unable to speak for ourselves, but it may happen. Your loved ones may have to make difficult healthcare decisions for you. You can ease their burden by voicing your choices now.
Advance Care Planning (ACP) is a series of conversations about your wishes for care and treatment in the event you are unable to speak for yourself . ACP creates opportunities to discuss and document your care preferences with your loved ones. Your loved ones will know what your treatment preferences are in a medical crisis, if you cannot speak for yourself. ACP helps to ease the burden of decision-making for your loved ones.
Advance Care Planning (ACP) is for everyone, regardless of age or state of health. It is a series of voluntary discussions that help you better understand your state of health.
Your preferences will be recorded and used to guide the healthcare team and your loved ones to make healthcare decisions on your behalf, in your best interests, if you are unable to do so yourself.
The participants in ACP discussions are a trained ACP facilitator, your loved ones, your healthcare providers and you. These discussions will be guided by your values and beliefs.
There are just five simple steps to Advance Care Planning:
- Talk to your healthcare provider and/or make an appointment with a certified ACP facilitator.
- Discuss what living well means to you in open conversations with your loved ones and ACP facilitator.
- Choose a substitute decision-maker to be your voice when you are unable to speak for yourself.
- Document your preferences with the help of your ACP facilitator.
- Review your ACP document when your medical condition or life circumstances change.
Advance Medical Directive (AMD) is a legal document stating you do not want to receive extraordinary life-sustaining treatment to prolong your life if you become terminally ill and unconscious, where death is imminent. AMD can only be effected when you are terminally ill. In order to activate your AMD and suspend life-sustaining treatment, a panel of three doctors must certify that you are terminally ill without any chance of recovery. Your loved ones need not be involved in the documentation and may not fully understand the reasons for your decision.
Lasting Power of Attorney (LPA) is a legal document to appoint a substitute decision maker to make decisions on your behalf when you lack the capacity to do so. LPA focuses on the appointment of a donee to make decisions on your behalf for financial and personal welfare matters should you lose
your mental capacity in the future. A LPA does not give your loved ones the authority to make life-sustaining treatment decisions on your behalf.
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Caring for someone near the end
Caring for someone at the end of his or her life is a challenging experience. Expect to have many different feelings. Focus on making the situation a loving and calm one for you and your care recipient.
It is important to involve your care recipient as much as possible when deciding how to manage the end of his or her life. Your care recipient has the right to make decisions on how to live his / her last days.
How long does this stage of care last?
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Making the Best Choices for End-of-Life Care - Advance Care Planning (ACP) Programme
Death and dying can be sensitive topics to discuss, and culturally taboo to some. The discussion of Advance Care Planning (ACP) is an important one though, as it enables one to define the type of care he or she would prefer in the event of sickness and the inability to make health care decisions for themselves in the future.
Dr Raymond Ng, Consultant, Department of Palliative Medicine, had this to say, “There is evidence that ACP helps to reduce the stress and anxiety of surviving family members, as well as decrease the use of burdensome interventions, and enhance the quality of end-of-life care for the patient.”
The TTSH ACP project team was formed in 2012, with a pool of healthcare staff trained in the United States of America in 2009. Dr Ng stated, “While we’ve found that most are receptive to the idea and realise its value and importance, there is very low awareness among the general public. And many think it’s too early to have the ACP discussion, until it is too late.”
There needs to be greater awareness of ACP among the general public. There are efforts to bring ACP upstream to primary care and outpatient clinics. Many of these are driven by hospitals and voluntary welfare organisations, and staged by community arts groups.
GPs and family doctors often have a closer, long-term relationship with patients and their families, and are ideally positioned to advocate ACP.
They can also facilitate ACP conversations themselves, and upload the completed documents to the national ACP IT platform. The ACP project team does conduct activities to raise awareness of ACP, and can also provide training for GPs in the central zone.
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Five steps of Advance Care Planning (ACP)
In advance care planning (ACP), your preferences will be recorded and used to guide the medical team and your loved ones in making health-care decisions on your behalf if you are unable to do so.
There are five steps in this process:
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What is Advance Care Planning
Advance Care Planning (ACP) is the process of planning for your future health and personal care. Having ACP conversations with your loved ones allows you to:
Other ways to plan ahead - As you discuss your wishes and preferences in your Advance Care Plan, questions about completing legal documents such as the Advance Medical Directive (AMD) and the Lasting Power of Attorney (LPA) may come up:
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Advance Care Planning (ACP) Programme
Death and dying can be sensitive topics to discuss, and culturally taboo to some. The discussion of Advance Care Planning (ACP) is an important one though, as it enables one to define the type of care he or she would prefer in the event of sickness and the inability to make health care decisions for themselves in the future.
Dr Raymond Ng, Consultant, Department of Palliative Medicine, had this to say, “There is evidence that ACP helps to reduce the stress and anxiety of surviving family members, as well as decrease the use of burdensome interventions, and enhance the quality of end-of-life care for the patient.”
The TTSH ACP project team was formed in 2012, with a pool of healthcare staff trained in the United States of America in 2009. Dr Ng stated, “While we’ve found that most are receptive to the idea and realise its value and importance, there is very low awareness among the general public. And many think it’s too early to have the ACP discussion, until it is too late.”
There needs to be greater awareness of ACP among the general public. There are efforts to bring ACP upstream to primary care and outpatient clinics. Many of these are driven by hospitals and voluntary welfare organisations, and staged by community arts groups.
GPs and family doctors often have a closer, long-term relationship with patients and their families, and are ideally positioned to advocate ACP.
They can also facilitate ACP conversations themselves, and upload the completed documents to the national ACP IT platform. The ACP project team does conduct activities to raise awareness of ACP, and can also provide training for GPs in the central zone.
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Sign this form to have the final say
When Mr John Tay’s 90-year-old mother could not be woken up from her sleep to take part in a family barbecue event in 2011, the family whisked her off to Tan Tock Seng Hospital (TTSH).
She fell into a coma afterwards and doctors said she had little chance of recovery and would be bedridden. Mr Tay and his family already knew what to do – stop all life-sustaining treatment and focus on making her last days comfortable.
After all, it was what she had wanted. Three years earlier, she had taken part in advance care planning (ACP), a process in which she decided on her end-of-life care and had these wishes written down.
In the two-page document, Madam Yap, who suffered from congestive heart failure, type 2 diabetes, hypertension and renal impairment, had chosen her only son, Mr Tay, a cab driver who is now 63, as her substitute decision-maker. She has five other daughters.
Madam Yap had not wanted to have her life prolonged if she was in a vegetative state, so her doctor did not put her on intubation and ventilator support.
To fulfil her wish to die at home, she was discharged from TTSH and managed to spend her last three days at home with family members by her side, although she was unconscious throughout. Said Mr Tay: “She had a meaningful death as we had strictly followed her wishes. Once, I even told her that she could just sit back and enjoy life as everything had already been planned for.”
That experience prompted Mr Tay to firm up his own ACP, with the help of facilitators at TTSH, in January last year, nominating one of his two daughters to be his substitute decision-maker.
Mr Tay has several medical conditions, including type 2 diabetes and glaucoma. He has also encouraged his sisters to do likewise.
One sister and her husband have taken his advice, while two other sisters and a brother-in-law will be getting their plans done soon.
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ADVANCE MEDICAL DIRECTIVE
An Advance Medical Directive (AMD) is a legal document that you sign in advance to inform the doctor treating you (in the event you become terminally ill and unconscious) that you do not want any extraordinary life-sustaining treatment to be used to prolong your life.
New advances in medical knowledge and technology create new choices for both patients and healthcare providers. Some of these choices raise new ethical and legal issues.
One issue is that modern medical technology can technically prolong life in the final stages of a terminal illness. However, it cannot stop the dying process. In such situations, further medical intervention would be medically ineffective, and a decision has to be made whether to withdraw such futile medical intervention. Some terminally ill persons who are unable to express their wishes at that time, may want to be spared further suffering and be allowed to die naturally, in peace and with dignity.
The law in Singapore allows Singaporeans who wish to make an advance medical directive to do so.
What is an AMD:
If the witnesses are relatives, so long as they have no vested interests in your demise, they would be allowed to act as witness.
A doctor who for any reason objects to the AMD and registers his objection with the Registrar can refuse to witness the signing of an AMD. You can then approach another doctor to witness your AMD.
Return The Form To The Registrar Of AMD - The completed form should be sent in a sealed envelope by mail or by hand to the Registrar of Advance Medical Directives at Ministry of Health, Singapore, College of Medicine Building, 16 College Road, Singapore 169854
Your AMD is only valid when it is registered with the Registrar of Advance Medical Directives. The Registrar will send you an acknowledgement when the directive has been registered.
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Advanced Medical Directive
In the event that you become terminally ill and unconscious, an AMD lets you inform the doctor that you do not want any extraordinary life-sustaining treatment to be used to prolong your life.
What is an Advance Medical Directive (AMD):
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AN IMPORTANT DOCUMENT FOR THE TERMINALLY ILL
You can extend a person's life in many ways as medical technology advances. This means even a terminally ill person can live longer.
But some people prefer to die naturally and in peace, and do not want to keep being treated. Sometimes, they may be so ill that they cannot make their wishes known to their loved ones.
This is why an Advance Medical Directive (AMD) is important.
What Is An AMD:
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How much does it cost to make an AMD?
To make an AMD, you will have to consult a doctor who, as a witness, is required to explain the AMD to you. You may have to pay the doctor for the services rendered. However, the AMD form itself is free.
What if my family objects?
If you have made an AMD regardless of objections from members of your family, the doctors will have to respect your AMD. We encourage you to discuss it with your family members and loved ones. This will help them to understand and respect your wishes should you become terminally ill.
How does the hospital know I have made an AMD?
Hospital staff, including doctors and nurses, do not know who has made an AMD as it is confidential and they are NOT allowed to ask you if you have made an AMD. However, if your attending doctor has reasons to believe that you are terminally ill and unable to make your wishes known to him, he can check with the Registrar of Advance Medical Directives on whether you have made an AMD.
Can an AMD be used as euthanasia or mercy killing?
Euthanasia/mercy killing is the deliberate ending of the life of a person suffering from an incurable and painful disease by unnatural means, such as the administration of lethal chemicals. An AMD acts as advanced instruction for your doctor not to prolong your life with extraordinary life-sustaining treatment, and to let the dying process take its natural course when you become terminally ill and unconscious. The AMD Act does NOT encourage euthanasia. On the contrary, the AMD Act is explicitly and categorically against euthanasia.
When will an AMD be enforced?
The AMD will only come into force once you have been determined to have a terminal illness and a Certificate of Terminal illness has been issued.
Three doctors, including the patient's hospital doctor, must unanimously certify a patient's terminal illness. Two of the doctors must be specialists.
If the first panel of three doctors cannot agree unanimously that the patient is terminally ill, the doctor-in-charge will review his diagnosis. If he is still of the opinion that the patient is terminally ill, the matter will be referred to a second panel of three specialists, to be appointed by the Ministry of Health.
If the second panel of doctors also cannot agree unanimously that the patient is terminally ill, the AMD CANNOT take effect. The patient's life will continue to be sustained and he will receive medical treatment as normal.
What if I change my mind and want to revoke the AMD made?
An AMD can be revoked at any time in the presence of at least one witness. You should do so by completing Form 3, which is the standard form for revocation of an AMD. (Those who have made an AMD will receive Form 3 together with Form 2, which confirms that their AMD has been registered by the Registry of AMDs)
Alternatively, you or your witness could write a simple letter to the Registrar of AMDs.
The letter should contain the following information:
The name and NRIC of both the person revoking the AMD and the witness, along with their addresses and home and office telephone numbers.
Time, date and place where the revocation was made.
If the letter is written by the witness, the method of communication which the person used to communicate his intention to revoke the AMD (e.g. orally, sign language, etc.)
Revocations should be sent to the Registry of AMDs as soon as possible.
What if I'm unable to write?
In this case, the AMD can be revoked orally or in any other way in which you can communicate. It is then the responsibility of the witness to the revocation to submit the notice of revocation using Form 3 or the letter as described above. The witness should also state the reason why the person revoking the AMD could not do so himself.
related: FORM FOR MAKING OF ADVANCE MEDICAL DIRECTIVE
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What is a Lasting Power of Attorney and How to Make One in Singapore
A Lasting Power of Attorney (LPA) is a legal document that allows a person who is 21 years of age or older to plan the management of his affairs in the event of a loss of mental capacity.
In the LPA, the person making the LPA (known as the donor) appoints one or more persons (known as the donee) to act and make decisions on his behalf.
A donee should be someone you trust who is reliable and competent to act on your behalf. The use of an LPA is especially important if one is a sole breadwinner for the family, or is frequently beset with health problems.
As of end-March 2018, over 43,000 people have applied to make LPAs. Do note that there are many types of powers of attorney, and that the LPA is one special type that applies in the loss of mental capacity.
Why Get a Lasting Power of Attorney:
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Lasting Power of Attorney
APPOINTING SOMEONE YOU TRUST TO HELP YOU
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5 things you need to know about the Lasting Power of Attorney
Last year, 8,360 applications for the Lasting Power of Attorney (LPA) were accepted, an increase of almost 160 per cent from 2014. Minister for Social and Family Development Tan Chuan-Jin revealed these figures in Parliament on Thursday.
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Office of Public Guardian: Why Should You Make An LPA?
The Lasting Power of Attorney (LPA) is a legal document which allows a person who is at least 21 years of age ('donor'), to voluntarily appoint one or more persons ('donee(s)') to make decisions and act on his behalf should he lose mental capacity one day. A donee can be appointed to act in the two broad areas of personal welfare and property & affairs matters. Benefits of an LPA:
The Lasting Power of Attorney
Why Should You Make An LPA?
LPA Application Form
How to Make a Lasting Power of Attorney Form 1
Where to find a Certificate Issuer
Using a Lasting Power of Attorney
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Caring for someone near the end
Caring for someone at the end of his or her life is a challenging experience. Expect to have many different feelings. Focus on making the situation a loving and calm one for you and your care recipient.
It is important to involve your care recipient as much as possible when deciding how to manage the end of his or her life. Your care recipient has the right to make decisions on how to live his / her last days.
How long does this stage of care last?
- End-of-life care can last between days and months. Each person’s situation is different, and your healthcare professional will be able to give you more information about this.
- Helping your care recipient stay comfortable and safe during his / her last days
- Supporting your loved one in his / her financial and legal matters
- Coping with your own feelings and the feelings of your family
- Cherishing your last moments with your care recipient
- Home Hospice Service
- Hospice Day Care Centre
- Inpatient Hospice Care
- Has your care recipient expressed his / her wish to remain at home at the end of life?
- Do you have reliable, 24-hour support at home, or do you need additional help?
- Is there space for a hospital bed or special bed and wheelchair in your home?
- How will you transport your loved one for everyday needs and emergencies?
- Can you lift, turn and move your care recipient? If you are not home, can someone else do it?
- The importance of early preparation
- The end-of-life stage is easier to manage when you discuss what to expect.
- Your loved one may have special end-of-life wishes and religious practices. You can help your care recipient at this stage through Advance Care Planning.
- Ask your care recipient to consider drawing up documents such as a Will, Lasting Power of Attorney and Advance Medical Directive. These will help your care recipient to ensure that his/ her wishes are carried out. It will also help your care recipient feel secure in his/ her financial matters because his/ her estate (savings, property, other valuable items) are given to the intended people and causes
- The stress of seeing a loved one suffer can lead to family disagreements. Talk about your problems honestly and ask a doctor or social worker to help you if you need it.
- Keep track of changes in your care recipient’s health and emotions. This could be useful when talking to healthcare professionals and handling legal matters.
- Whether you choose Home Hospice Service, Hospice Day Care or Inpatient Hospice Care, create a peaceful and loving environment for your care recipient.
- Limit family disagreements and spend time chatting and having fun together. Your care recipient may not feel like eating. That is okay. Just keep him/ her comfortable.
- Sometimes, your care recipient may not want to talk. Just sit with him/ her in silence. If your care recipient wants to talk, listen to him/ her. Share good memories with each other and laugh about funny moments.
- Caregiving at the end of life can stress you out, and you will become tired if you do not take a break.
- Remember to care for your health by eating a balanced diet and taking time to exercise and relax. You and your family can try taking turns to care for your loved one.
- You may have many mixed feelings. Your feelings are not wrong. They are a natural part of life. Here are some suggestions to deal with them.
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Making the Best Choices for End-of-Life Care - Advance Care Planning (ACP) Programme
Death and dying can be sensitive topics to discuss, and culturally taboo to some. The discussion of Advance Care Planning (ACP) is an important one though, as it enables one to define the type of care he or she would prefer in the event of sickness and the inability to make health care decisions for themselves in the future.
Dr Raymond Ng, Consultant, Department of Palliative Medicine, had this to say, “There is evidence that ACP helps to reduce the stress and anxiety of surviving family members, as well as decrease the use of burdensome interventions, and enhance the quality of end-of-life care for the patient.”
The TTSH ACP project team was formed in 2012, with a pool of healthcare staff trained in the United States of America in 2009. Dr Ng stated, “While we’ve found that most are receptive to the idea and realise its value and importance, there is very low awareness among the general public. And many think it’s too early to have the ACP discussion, until it is too late.”
There needs to be greater awareness of ACP among the general public. There are efforts to bring ACP upstream to primary care and outpatient clinics. Many of these are driven by hospitals and voluntary welfare organisations, and staged by community arts groups.
GPs and family doctors often have a closer, long-term relationship with patients and their families, and are ideally positioned to advocate ACP.
They can also facilitate ACP conversations themselves, and upload the completed documents to the national ACP IT platform. The ACP project team does conduct activities to raise awareness of ACP, and can also provide training for GPs in the central zone.
read more
Five steps of Advance Care Planning (ACP)
Sign this form to have the final say
In advance care planning (ACP), your preferences will be recorded and used to guide the medical team and your loved ones in making health-care decisions on your behalf if you are unable to do so.
There are five steps in this process:
- Talk to your health-care provider or make an appointment with a certified ACP facilitator.
- Discuss what living well means to you in open conversations with your loved ones and the ACP facilitator.
- Choose up to two substitute decision-makers to be your voice should you be unable to speak for yourself.
- Document your preferences with the help of your ACP facilitator.
- Review your ACP document when your medical condition or life circumstances change.
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What is Advance Care Planning
Advance Care Planning (ACP) is the process of planning for your future health and personal care. Having ACP conversations with your loved ones allows you to:
- Share your personal values and beliefs
- Explore how your values and beliefs affect your healthcare preferences in difficult medical situations
- Think about who among your loved ones can be your voice if you become very ill one day
- Be willing to represent my voice during a medical crisis.
- Know my preferences, values and goals.
- Be willing to follow my known care wishes as much as possible in making decisions about my healthcare.
- Be able to make decisions on my behalf under stressful situations.
Other ways to plan ahead - As you discuss your wishes and preferences in your Advance Care Plan, questions about completing legal documents such as the Advance Medical Directive (AMD) and the Lasting Power of Attorney (LPA) may come up:
- Advance Medical Directive (AMD) is a legal document stating you do not want to receive extraordinary life-sustaining treatment to prolong your life if you become terminally ill and unconscious, where death is imminent.
- Lasting Power of Attorney (LPA) is a legal document that you sign to appoint a donee to make financial or personal welfare decisions on your behalf when you no longer have mental capacity to do so (e.g dealings with banks, CPF matters, where to live etc). However, the donee may not make any decision with respect to the carrying out or continuation of life-sustaining treatment.
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Advance Care Planning (ACP) Programme
Death and dying can be sensitive topics to discuss, and culturally taboo to some. The discussion of Advance Care Planning (ACP) is an important one though, as it enables one to define the type of care he or she would prefer in the event of sickness and the inability to make health care decisions for themselves in the future.
Dr Raymond Ng, Consultant, Department of Palliative Medicine, had this to say, “There is evidence that ACP helps to reduce the stress and anxiety of surviving family members, as well as decrease the use of burdensome interventions, and enhance the quality of end-of-life care for the patient.”
The TTSH ACP project team was formed in 2012, with a pool of healthcare staff trained in the United States of America in 2009. Dr Ng stated, “While we’ve found that most are receptive to the idea and realise its value and importance, there is very low awareness among the general public. And many think it’s too early to have the ACP discussion, until it is too late.”
There needs to be greater awareness of ACP among the general public. There are efforts to bring ACP upstream to primary care and outpatient clinics. Many of these are driven by hospitals and voluntary welfare organisations, and staged by community arts groups.
GPs and family doctors often have a closer, long-term relationship with patients and their families, and are ideally positioned to advocate ACP.
They can also facilitate ACP conversations themselves, and upload the completed documents to the national ACP IT platform. The ACP project team does conduct activities to raise awareness of ACP, and can also provide training for GPs in the central zone.
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Sign this form to have the final say
When Mr John Tay’s 90-year-old mother could not be woken up from her sleep to take part in a family barbecue event in 2011, the family whisked her off to Tan Tock Seng Hospital (TTSH).
She fell into a coma afterwards and doctors said she had little chance of recovery and would be bedridden. Mr Tay and his family already knew what to do – stop all life-sustaining treatment and focus on making her last days comfortable.
After all, it was what she had wanted. Three years earlier, she had taken part in advance care planning (ACP), a process in which she decided on her end-of-life care and had these wishes written down.
In the two-page document, Madam Yap, who suffered from congestive heart failure, type 2 diabetes, hypertension and renal impairment, had chosen her only son, Mr Tay, a cab driver who is now 63, as her substitute decision-maker. She has five other daughters.
Madam Yap had not wanted to have her life prolonged if she was in a vegetative state, so her doctor did not put her on intubation and ventilator support.
To fulfil her wish to die at home, she was discharged from TTSH and managed to spend her last three days at home with family members by her side, although she was unconscious throughout. Said Mr Tay: “She had a meaningful death as we had strictly followed her wishes. Once, I even told her that she could just sit back and enjoy life as everything had already been planned for.”
That experience prompted Mr Tay to firm up his own ACP, with the help of facilitators at TTSH, in January last year, nominating one of his two daughters to be his substitute decision-maker.
Mr Tay has several medical conditions, including type 2 diabetes and glaucoma. He has also encouraged his sisters to do likewise.
One sister and her husband have taken his advice, while two other sisters and a brother-in-law will be getting their plans done soon.
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ADVANCE MEDICAL DIRECTIVE
An Advance Medical Directive (AMD) is a legal document that you sign in advance to inform the doctor treating you (in the event you become terminally ill and unconscious) that you do not want any extraordinary life-sustaining treatment to be used to prolong your life.
New advances in medical knowledge and technology create new choices for both patients and healthcare providers. Some of these choices raise new ethical and legal issues.
One issue is that modern medical technology can technically prolong life in the final stages of a terminal illness. However, it cannot stop the dying process. In such situations, further medical intervention would be medically ineffective, and a decision has to be made whether to withdraw such futile medical intervention. Some terminally ill persons who are unable to express their wishes at that time, may want to be spared further suffering and be allowed to die naturally, in peace and with dignity.
The law in Singapore allows Singaporeans who wish to make an advance medical directive to do so.
What is an AMD:
- An Advance Medical Directive (AMD) is a legal document that you sign in advance to inform the doctor treating you (in the event you become terminally ill and unconscious) that you do not want any extraordinary life-sustaining treatment to be used to prolong your life.
- Making an AMD is a voluntary decision. It is entirely up to you whether you wish to make one. In fact, it is a criminal offence for any person to force you to make one against your will.
- Obtain An AMD Form - The forms are available from medical clinics, polyclinics and hospitals. You may also ask your doctor for the form if you have decided to make an AMD. Alternatively, you can also download the AMD form online (print both sheets on a single sheet of paper front and back).
- Consult A Doctor With A Witness
- You are not being forced into making the AMD.
- You are not mentally disordered.
- You understand the nature and implications of making an AMD.
If the witnesses are relatives, so long as they have no vested interests in your demise, they would be allowed to act as witness.
A doctor who for any reason objects to the AMD and registers his objection with the Registrar can refuse to witness the signing of an AMD. You can then approach another doctor to witness your AMD.
Return The Form To The Registrar Of AMD - The completed form should be sent in a sealed envelope by mail or by hand to the Registrar of Advance Medical Directives at Ministry of Health, Singapore, College of Medicine Building, 16 College Road, Singapore 169854
Your AMD is only valid when it is registered with the Registrar of Advance Medical Directives. The Registrar will send you an acknowledgement when the directive has been registered.
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Advanced Medical Directive
In the event that you become terminally ill and unconscious, an AMD lets you inform the doctor that you do not want any extraordinary life-sustaining treatment to be used to prolong your life.
What is an Advance Medical Directive (AMD):
- An Advance Medical Directive (AMD) is a legal document. You sign it in advance to inform the doctor who is treating you (in the event that you become terminally ill and unconscious) that you do not want any extraordinary life-sustaining treatment to be used to prolong your life.
- Extraordinary life-sustaining treatment is any medical treatment which serves only to prolong the process of dying for terminally ill patients but does not cure the illness.
- An example is the respirator that is connected to a patient to assist him/her to breathe. It serves only to artificially prolong the life of a terminally ill patient. The patient will breathe using the machine, but will not get better or heal. The dying process will just take longer.
- Making an AMD is a voluntary decision. It is entirely up to you whether you wish to make one. In fact, it is a criminal offence for any person to force you to make one against your will.
- As medical technology advances, there are many ways of extending a person’s life. This can make a person live for longer even when he/ she is terminally ill.
- A person may not be able to express his/ her wishes to continue or stop treatment. Some people would prefer to die naturally in peace, and not extend treatment. If you have an AMD, in the situation that you are not able to communicate your wishes to your doctor in the future, your doctor will be guided by it.
- You must be above the age of 21 and of sound mind
- Three doctors (including your hospital doctor) must all certify that you are terminally ill. Two of the doctors must be specialists.
- You need to complete and sign the AMD form in the presence of two witnesses – your doctor and someone who is above 21. Both witnesses cannot stand to gain anything from your passing.*If there is disagreement between the doctors, the doctor-in-charge can review it. If there is still no agreement, the Ministry of Health will appoint three additional specialists to review your case. If all the three appointed specialists still cannot certify that you are terminally ill, the AMD cannot take effect.
- To find out more about making an AMD, click here
- You can cancel (revoke) your AMD at any time.
- However, you will need one witness. You can do this by completing a form, or writing a letter to the Registrar of AMDs.
- If you are unable to write, you can communicate your wishes to cancel your AMD by speaking or using sign language. Your witness will have to submit the notice and explain why you cannot submit it yourself.
- For more information on revoking the AMD, check here.
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AN IMPORTANT DOCUMENT FOR THE TERMINALLY ILL
You can extend a person's life in many ways as medical technology advances. This means even a terminally ill person can live longer.
But some people prefer to die naturally and in peace, and do not want to keep being treated. Sometimes, they may be so ill that they cannot make their wishes known to their loved ones.
This is why an Advance Medical Directive (AMD) is important.
What Is An AMD:
- It is a legal document that tells your doctor that you do not want extraordinary life-sustaining treatment. This means treatment that only prolongs the process of dying for terminally ill people, but does not cure the illness.
- For example, a patient may use a respirator because he cannot breathe on his own. This machine will only help prolong the patient's life, but the patient will not get better or heal.
- In such cases, people may voluntary make an AMD to tell their doctors they do not want this treatment. It is up to you whether you wish to make a document like this or not.
- You must be above the age of 21 and of sound mind
- You need to complete and sign the AMD form in the presence of two witnesses – your doctor and someone who is above 21. Both witnesses cannot stand to gain anything from your death.
- *Note: If the doctors cannot agree that you are terminally ill, the doctor-in-charge can review it. If there is still no agreement, the Ministry of Health will appoint three more specialists to review your case. If all three appointed specialists still cannot certify that you are terminally ill, the AMD cannot take effect.
- You can cancel your AMD at any time. However, you will need one witness. You can do this by completing a form, or writing a letter to the Registrar of AMDs.
- If you are unable to write, you can communicate your wishes to cancel your AMD by speaking or using sign language. Your witness will have to submit the notice and explain why you cannot submit it yourself. Here is more information on revoking the AMD.
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How much does it cost to make an AMD?
To make an AMD, you will have to consult a doctor who, as a witness, is required to explain the AMD to you. You may have to pay the doctor for the services rendered. However, the AMD form itself is free.
What if my family objects?
If you have made an AMD regardless of objections from members of your family, the doctors will have to respect your AMD. We encourage you to discuss it with your family members and loved ones. This will help them to understand and respect your wishes should you become terminally ill.
How does the hospital know I have made an AMD?
Hospital staff, including doctors and nurses, do not know who has made an AMD as it is confidential and they are NOT allowed to ask you if you have made an AMD. However, if your attending doctor has reasons to believe that you are terminally ill and unable to make your wishes known to him, he can check with the Registrar of Advance Medical Directives on whether you have made an AMD.
Can an AMD be used as euthanasia or mercy killing?
Euthanasia/mercy killing is the deliberate ending of the life of a person suffering from an incurable and painful disease by unnatural means, such as the administration of lethal chemicals. An AMD acts as advanced instruction for your doctor not to prolong your life with extraordinary life-sustaining treatment, and to let the dying process take its natural course when you become terminally ill and unconscious. The AMD Act does NOT encourage euthanasia. On the contrary, the AMD Act is explicitly and categorically against euthanasia.
When will an AMD be enforced?
The AMD will only come into force once you have been determined to have a terminal illness and a Certificate of Terminal illness has been issued.
Three doctors, including the patient's hospital doctor, must unanimously certify a patient's terminal illness. Two of the doctors must be specialists.
If the first panel of three doctors cannot agree unanimously that the patient is terminally ill, the doctor-in-charge will review his diagnosis. If he is still of the opinion that the patient is terminally ill, the matter will be referred to a second panel of three specialists, to be appointed by the Ministry of Health.
If the second panel of doctors also cannot agree unanimously that the patient is terminally ill, the AMD CANNOT take effect. The patient's life will continue to be sustained and he will receive medical treatment as normal.
What if I change my mind and want to revoke the AMD made?
An AMD can be revoked at any time in the presence of at least one witness. You should do so by completing Form 3, which is the standard form for revocation of an AMD. (Those who have made an AMD will receive Form 3 together with Form 2, which confirms that their AMD has been registered by the Registry of AMDs)
Alternatively, you or your witness could write a simple letter to the Registrar of AMDs.
The letter should contain the following information:
The name and NRIC of both the person revoking the AMD and the witness, along with their addresses and home and office telephone numbers.
Time, date and place where the revocation was made.
If the letter is written by the witness, the method of communication which the person used to communicate his intention to revoke the AMD (e.g. orally, sign language, etc.)
Revocations should be sent to the Registry of AMDs as soon as possible.
What if I'm unable to write?
In this case, the AMD can be revoked orally or in any other way in which you can communicate. It is then the responsibility of the witness to the revocation to submit the notice of revocation using Form 3 or the letter as described above. The witness should also state the reason why the person revoking the AMD could not do so himself.
related: FORM FOR MAKING OF ADVANCE MEDICAL DIRECTIVE
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What is a Lasting Power of Attorney and How to Make One in Singapore
A Lasting Power of Attorney (LPA) is a legal document that allows a person who is 21 years of age or older to plan the management of his affairs in the event of a loss of mental capacity.
In the LPA, the person making the LPA (known as the donor) appoints one or more persons (known as the donee) to act and make decisions on his behalf.
A donee should be someone you trust who is reliable and competent to act on your behalf. The use of an LPA is especially important if one is a sole breadwinner for the family, or is frequently beset with health problems.
As of end-March 2018, over 43,000 people have applied to make LPAs. Do note that there are many types of powers of attorney, and that the LPA is one special type that applies in the loss of mental capacity.
Why Get a Lasting Power of Attorney:
- Without an LPA, a court order would have to be obtained in order to administer the affairs of a person who lacks mental capacity. This court order is one where the court appoints a person to be the court-appointed deputy to manage the affairs of the person who lacks mental capacity.
- An LPA avoids the hassle of getting a court order, which can be both time-consuming and expensive. Additionally, where a deputy is appointed, you do not get a say in who is appointed to act for you, unlike an LPA.
- A will operates only after the will-maker’s death. The LPA operates after the donor loses his mental capacity.
- The LPA also does not deal with the distribution of a person’s assets after his death. This is settled according to the terms of his will, or the laws of intestacy if the deceased had not made a will.
- The donee must be a person who is at least 21 years old when the LPA is signed. He also cannot be an undischarged bankrupt.
- The donee is given the authority to make decisions about the donor’s personal welfare and/or property and financial matters. This includes where a donor is to live and how he is to be cared for.
- The LPA can also allow the donee to access your bank accounts on your behalf.
- The donee, in the exercise of his powers conferred by the LPA, must act in the best interests of the donor. Best interests is defined in section 6 of the Mental Capacity Act. The Office of the Public Guardian (OPG), which is the government body responsible for administering the Mental Capacity Act, can investigate cases where the donee does not act in donor’s best interests.
- Additionally, the LPA document itself may include restrictions or conditions limiting the power of the donee. Where the donor recovers his mental capacity, the donee no longer has the power to make decisions for the donor.
- Restraining the donor
- Medical treatment or healthcare of the donor
- Nominations under the Insurance Act
- Execution of wills for the donor
- CPF funds
- Dealing with the donor’s property;
- Making gifts out of the donor’s property
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Lasting Power of Attorney
APPOINTING SOMEONE YOU TRUST TO HELP YOU
- If you lose the ability to make decisions in future, you will want someone you trust to help you. A Lasting Power of Attorney (LPA) lets you to appoint someone you trust to make decisions and act on your behalf if this happens.
- You may lose capacity, or the mental ability to make decisions, because of a stroke, a mental illness, or even an accident.
- Making an LPA early therefore gives you and your loved ones peace of mind.
- This is a legal document that lets you appoint one or more persons to make decisions for you if you are unable to make decisions for yourself. You can choose more than just one person to be your “donee”. The person you choose can make decisions on your personal welfare, your property and affairs, or both.
- Your donee should be someone trustworthy, reliable and competent to make decisions for you only when you lack the mental capacity to do so for yourself Your donee must be at least 21 years old, and must not be a bankrupt if you are appointing him/her for property and affairs matters. More information about being a done can be found in “The Mental Capacity Act: A Donee’s Guide”.
- Be at least 21 years of age
- Possess mental capacity to make your own LPA
- Not be bankrupt if you are appointing a property and affairs donee
- Register your LPA with the Office of Public Guardian for it to be legally valid
- The person you choose must also agree to be your donee.
- There are two different prescribed LPA forms. LPA Form 1 is the standard version. You use it to give your donee general powers with basic restrictions. LPA Form 2 is for those who have unique requirements and want to give specific powers to donee(s). This form needs to be drafted by a lawyer.
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5 things you need to know about the Lasting Power of Attorney
Last year, 8,360 applications for the Lasting Power of Attorney (LPA) were accepted, an increase of almost 160 per cent from 2014. Minister for Social and Family Development Tan Chuan-Jin revealed these figures in Parliament on Thursday.
- WHAT IS THE LPA? - The LPA is a legal document that allows a person to appoint an individual to make key decisions for him, should he lose his mental capacity and become unable to do so.
- WHO CAN MAKE AN LPA? - You must be at least 21 years old, have the mental capacity to make the LPA, and not be an undischarged bankrupt.
- WHAT ARE THE BENEFITS OF MAKING AN LPA? - The LPA allows you to protect your interests by indicating your personal, considered choice of a proxy decision maker - someone you trust to be reliable, competent and capable - to make decisions and act on your behalf should you become vulnerable when you lose the mental capacity to make your own decisions one day. By having an LPA in place, it also alleviates the stress and difficulties faced by your loved ones if you should lose mental capacity.
- HOW DO I MAKE AN LPA? HOW MUCH DOES IT COST? - You first need to decide who you want to appoint as your donee, or the one who would make decisions and act on your behalf, and what decision-making powers you want to give him. You may choose to give him general powers for all your personal welfare and/or property & affairs - then you would use LPA Form 1 - or only specific powers as indicated in your LPA - then you would use LPA Form 2. Most applicants use Form 1, and the $50 application fee for that form has been waived till Aug 31 for all Singaporeans. The fee for Form 2 is $200, and is for those who have larger, more complicated assets. There are also online guides available to help you prepare your LPA application here: https://www.publicguardian.gov.sg/opg/Pages/The-LPA-How-Can-I-Make-a-Last
- WHERE CAN I GO TO FOR MORE INFORMATION? - call 1800-226-6222, or e-mail enquiry@publicguardian.gov.sg, or goto https://www.publicguardian.gov.sg/opg/
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Office of Public Guardian: Why Should You Make An LPA?
The Lasting Power of Attorney (LPA) is a legal document which allows a person who is at least 21 years of age ('donor'), to voluntarily appoint one or more persons ('donee(s)') to make decisions and act on his behalf should he lose mental capacity one day. A donee can be appointed to act in the two broad areas of personal welfare and property & affairs matters. Benefits of an LPA:
- Early preparations to protect your interests should one become vulnerable one day.
- Enables you to make a personal, considered choice of a trusted proxy decision maker, who is reliable and competent to act in his or her best interests.
- Alleviates the stress and difficulties faced by loved ones who need to apply for a Deputyship order, if you lose mental capacity without an LPA in place.
- To encourage more Singaporeans to pre-plan to protect their interests, the OPG extended the LPA application fee waiver until 31 August 2020 for Singaporeans making an LPA Form 1.
- Click here to see the LPA application fee table.
- Applicants are required to pay a fee to engage an LPA Certificate Issuer to witness and certify their application.
- Click here to view the list of most visited LPA Certificate Issuers and the fees they charge. This list includes Non-Government Organisations who also offer LPA Certificate Issuing services.
- For more information on how to make an LPA, please click here.
The Lasting Power of Attorney
Why Should You Make An LPA?
LPA Application Form
How to Make a Lasting Power of Attorney Form 1
Where to find a Certificate Issuer
Using a Lasting Power of Attorney
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