Advanced planning eases end-stage suffering

The Straits Times (2 January 2014) - Mr Tan (not his real name) has been breathless since morning.

We’ve already started him on oxygen. Could the Project Care team take a look at him?” This is a typical call that Project Care would receive from a nursing home. Started in 2009, the project is an ongoing collaboration between Tan Tock Seng Hospital (TTSH) and six nursing homes in central Singapore. Its aim is to coordinate medical care for nursing home residents – including those with advanced or terminal illnesses – who may sometimes require care from specialists in the hospital.

For instance, under the project, adjustments of medication can be made for elderly residents. Should residents need to undergo investigations quickly at TTSH, this can also be arranged.

Staff from the nursing homes are taught how to take care of their residents who have more complex conditions or terminal illnesses.

The project also assists patients and their families in planning for future medical or palliative care in the nursing homes. A team from TTSH and the nursing homes hold conversations about advance care planning with the patients and their family members.

Part of the conversation would be devoted to explaining the patient’s medical condition. After receiving repeated counselling and explanations about the choices available, the patient and his family would eventually decide on their preferred type and place of treatment. Care is then delivered in collaboration with the doctor at the nursing home. Nurses there assess and monitor the patient’s condition.


Mr Tan, for instance, was admitted to the nursing home after suffering a stroke three years ago. He is able to speak and eat normally, but requires a wheelchair to move around. He also suffers from chronic obstructive lung disease, in which the lungs and airways become progressively and irreversibly damaged, resulting in worsening breathlessness.

When he made his advance care plan, he and his son had asked for treatment of his illness in the nursing home, where possible.

On one occasion, when our doctor and nurse from TTSH assessed him, they found that he had a chest infection, which worsened his chronic obstructive lung disease. This resulted in a cough, fever and breathlessness. In addition, the chest infection affected his ability to swallow, making him cough even more when he ate solid food.

We started Mr Tan on intravenous antibiotics, nebulisation, oxygen therapy and oral medication at the nursing home, instead of hospitalising him. At the nursing home, the physiotherapist attended to him to encourage the clearing of phlegm, while the nurses monitored his condition closely. Also, his diet was changed to one with meals of softer consistency.

After 10 days, he recovered. He was able to sit up in the wheelchair, have meals in the common dining hall and participate in his usual activities.


When a patient is terminally ill, it is often difficult for his family members to comprehend or accept his condition. They would usually be told about the patient’s deteriorating medical condition each time he is admitted to a hospital or place of care. But they seldom seem to fully understand, or perhaps they may be in denial, that the repeated admissions are a sign of approaching death.

On numerous occasions, patients would be sent back to the hospital during their last hours when it was obvious that further hospitalisation would not change anything. Families, sometimes, make inappropriate decisions because they are unable to think straight during times of stress. They may also not have been counselled sufficiently well enough to make informed and realistic decisions during the last few precious hours of their loved ones’ lives.


Some patients choose to spend their last days in a nursing home. Take Mrs Lim, for instance. A resident with a brain tumour, she was able to have her pain and breathlessness managed through the collaborative efforts of both the TTSH and nursing home teams.

She died in her nursing home room, with her husband beside her.

Her husband remarked how much more peaceful the nursing home was than a busy hospital ward. Currently, about 400 nursing home residents have completed advance care plan discussions. Many of them have been treated in the homes, instead of being sent back to the hospital.

This has helped them recover from their illnesses in an environment they are familiar with, while being cared for by nurses who understand them well. Many residents and their families have expressed gratitude for the services offered.

The families also said they gained a better understanding of their loved ones’ medical conditions, and were comforted that their loved ones were receiving special care, especially during the end-of-life stage.

Dr Sabrina Wong Kay Wye is a family physician with special interest in geriatrics and end-of-life care at the department of continuing and community care at Tan Tock Seng Hospital. The hospital has a 25-year history in geriatric medicine and is part of the National Healthcare Group, the regional health system for central Singapore. 

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Source: The Straits Times © Singapore Press Holdings Limited. Reproduced with permission.