The Straits Times (10 July 2014) - More patients are asked to take part in
advance care planning, which empowers
others to make medical decisions for them
should they be unable to do so themselves
Mr John Tay, 63, discusses his end-of-life care with his younger daughter, Ms Maggie Tay, 29.
PHOTOS: AGENCY FOR INTEGRATED CARE, THE NEW PAPER FILE
When Mr John Tay’s
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
decision-maker. She has
five other daughters.
Five steps of advance
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
There are five steps in this
- 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
- Choose up to two substitute
decision-makers to be your voice
should you be unable to speak
- Document your preferences
with the help of your
- Review your ACP document
when your medical condition or
life circumstances change.
Source: Agency for Integrated
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
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
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.
FACILITATORS ON THE RISE
More people, such as Mr Tay and his
family, are being guided through ACP
by health-care professionals who, in
recent years, are increasingly being
trained to act as facilitators.
Dr Irwin Chung, director of the care
integration division of the Agency for
Integrated Care (AIC), said more than
1,000 health-care professionals,
comprising mostly doctors, nurses and
medical social workers, have
undergone training in this area.
They are taught to broach the topic
with patients and their families,
assess patients’ decision-making
abilities and help them
outline their treatment
standardised forms from
AIC, which oversees the
long-term care sector.
include whether they
would like to proceed
resuscitation if they
should go into cardiac
arrest, the extent of medical
intervention to prolong their lives and,
in the event of deterioration, their
preferred places to receive medical
treatment and die.
MORE AVENUES NOW OPEN
Two weeks ago, Health Minister
Gan Kim Yong announced several key
changes to the palliative-care sector at
the sixth Palliative Care Conference at
Among them was that two regional
health-care groups, led by TTSH and
Khoo Teck Puat Hospital (KTPH), will
train staff at 14 nursing homes in ACP,
geriatric care and end-of-life care. This
is a step up from the days when ACP
was offered as pilot projects at public
TTSH was the first to run such a
project in 2010. A year earlier, it had
invited members of a United States
ACP organisation called Respecting
Choices to train its staff as
The practice of ACP is now in full
swing in many medical institutions
Six public hospitals and one private
hospital now routinely offer ACP to
selected groups of patients, such as
those suffering from heart or kidney
failure. Raffles Cancer Centre at
Raffles Hospital offers ACP to patients
suffering from advanced stages of
cancer. Both national heart centres
also now offer ACP to inpatients.
Last September, Singapore General
Hospital rolled out ACP to more than
33 departments, such as psychiatry,
geriatric medicine, haematology,
infectious diseases and family
medicine. The hospital started offering
ACP in October 2012 only to patients
being cared for by the departments of
renal medicine and respiratory and
critical care. With the change, about
70 patients have had their wishes
At KTPH, an ACP clinic which was
set up last October in the geriatric
clinic has helped 50 patients decide
on end-of-life care.
In all, 312 patients have completed
ACP since the hospital expanded it
from patients in the palliative-care
service to frail and elderly patients
who are frequently admitted to
hospital. It also extended it to those
with multiple medical conditions and
those suffering from dementia, kidney
disease or diabetes, said Dr Siew
Chee Weng, locum principal resident
physician at KTPH’s department of
The list continues to grow.
From Monday, Changi General
Hospital will begin a pilot programme
for patients suffering from advanced
chronic obstructive pulmonary disease.
TALKING ABOUT DEATH
The planning process can be
time-consuming, said KTPH’s nurse
clinician Sim Lai Kiow.
These conversations on end-of-life
care usually take hours and,
sometimes, require several sessions
before decisions are penned down.
Even then, these wishes can be
altered at any time, such as when a
patient’s medical condition or life
Checks showed that at least five
hospices here conduct ACP routinely
with all their patients. This is not a
surprise, as day- and home-care
patients handled by hospices have a
prognosis of a year or less, while
inpatients are not expected to live
beyond three months.
Such conversations have always
been “part and parcel of hospice
work”, said Dr Tan Yew Seng, medical
director of Assisi Hospice, although
there was less focus on documenting
preferred care plans previously when
there were no standardised forms.
However, he stressed that filling up
forms is less important than what
transpires during these conversations
with the patient, their loved ones and
the health-care team.
Sometimes, patients think they
should die in hospital so that they do
not burden their families. It is only
through speaking about this that they
learn that their families do not feel
this way at all.
ACP facilitators whom MYB spoke to
said there are still patients who resist
ACP because they are superstitious or
see it as a sign that they are giving up
on themselves or their loved ones.
“People should know that they are
planning for a situation which may or
may not happen,” said Dr Tan. “If it
doesn’t, then we simply do not have to
make use of these plans.”
TEXT: JOAN CHEW; SOURCES: AGENCY FOR INTEGRATED CARE, WWW.MOH.GOV.SG, WWW.PUBLICGUARDIAN.GOV.SG; ST GRAPHICS: TAY CHERN HUI
Key changes to the palliative-care sector
The palliative-care sector has been
given a booster shot, with the Ministry
of Health (MOH) investing in four areas
– improving the quality of care,
expanding services, ensuring
affordability and raising awareness.
Health Minister Gan Kim Yong
announced this at the sixth Palliative
Care Conference at Singapore
Polytechnic on June 28.
Today, between 5,000 and
6,000 people receive three types of
palliative care – inpatient service,
day-care activities and home-care
assistance – in the community, said
an MOH spokesman.
MOH projected that by 2020, more
than 10,000 will require palliative
Here are the key changes
announced by Mr Gan:
National Guidelines For
This new document spells out what is
required for individualised patient care;
how caregivers and families should be
supported, including the bereavement
period; what is required for good staff
and volunteer management; and what
is needed for safe care.
MOH will partner the Singapore
Hospice Council, the umbrella body for
palliative care in Singapore, to
promote and implement these
guidelines in different care settings.
Care providers will get help to meet
these guidelines, such as through
voluntary self-assessment tools,
staff-training programmes and
Manpower and training
The Ministry of Health projects that by
2020, more than 10,000 people will need
From this month, a new graduate
diploma in palliative medicine will
allow more doctors to be trained in
The one-year part-time course is
launched by the Chapter of Palliative
Medicine Physicians, in partnership
with the division of Graduate Medical
Studies at the National University of
The capacity of home palliative
care will be increased by at least
1,000 more places by 2020, up from
about 5,000 now.
Services will also be extended to
patients with end-stage organ failure
and not only to cancer patients.
Beds for palliative care will be
increased to at least 360 by 2020,
from just 147 now.
There are also plans to set aside
more beds in community hospitals for
patients on palliative care.
End-of-life care at nursing homes
Staff at 14 nursing homes will be
trained in advance care planning,
geriatric care and end-of-life care.
The homes have a total of
2,800 beds. The training will be
conducted by the National Healthcare
Group and Alexandra Health System.
Medisave withdrawal limits
From Jan 1 next year, the daily
withdrawal limit for those staying in
hospices will go up from $160 to
$200, and the lifetime limit for home
palliative care will rise from $1,500 to
However, this cap will be lifted for
those with terminal illness, such as
cancer or end-stage organ failure.
These patients can use as much as
they want from their Medisave
Home palliative care funding
From this month, home palliative care
providers will be funded based on the
number of patients they look after,
instead of the number of visits they
make, reflecting a shift of focus on
This move enables providers to plan
and deliver patient-centric services.
They also get greater flexibility to test
new models of care.
The Agency for Integrated Care will
work with voluntary welfare
organisations to raise awareness of
advance care planning, with an aim of
reaching out to 1,500 seniors in the
It also aims to train at least
150 people at voluntary organisations
in the next three years as advocates
for advance care planning.
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
Do you want to have a tube
placed into your windpipe to help you breathe,
through a procedure called endotracheal
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?
Doctors say one reason why some patients’ last wishes
were not met could be because caregivers find it
difficult to care for the patient at home. ST FILE PHOTO
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.
WHY WISHES WERE NOT MET
However, all three hospitals did not analyse why
some patients’ wishes, as outlined in their ACPs,
were not met.
Doctors say reasons may include a lack of
caregivers at home, while some caregivers may
find it challenging to care for the patient at home.
The rapid deterioration of a patient’s condition can
also prevent him from being sent home in time to
die – if that was what he wanted.
Dr Siew Chee Weng, a locum principal resident
physician at KTPH’s department of geriatric
medicine, noted that reasons as to why wishes are
not met are “usually medical rather than social”.
AT KTPH, one patient received CPR when she
did not want it. Her family, although aware of the
ACP, had called for an ambulance when she
vomited blood and the paramedics applied CPR as
they were not aware of the details.
PLUGGING THE GAPS
This is a problem which Singapore Hospice Council
chairman R. Akhileswaran wants to solve, by
getting paramedics to check ACP documents
before they proceed with CPR.
This is because anxious family members may
still call for an ambulance, even after they have
been told not to do so in order to honour the
patient’s wishes, added Dr Akhileswaran, who is
also the chief executive of HCA Hospice Care, the
largest home palliative care provider here.
Members of the Singapore Hospice Council are
now in talks with the Singapore Civil Defence Force
to plug this gap.
Serious illnesses can also strike the young,
which is why his colleague, Dr Chong Poh Heng, is
offering ACP to children and young adults with
life-limiting or life-threatening conditions, under the
Star Pals (Paediatric Advanced Life Support)
home-care service by HCA Hospice Care.
Since the programme started in April 2012, it
has served 110 patients, of whom 50 have
completed ACP. However, fewer than 10 were
done with input from a child.
Besides the fact that some young patients are
cognitively impaired, others chose to let their
parents decide their treatment. Other parents
chose not to “burden the child with such
decisions”, said Dr Chong, programme director of
Sixteen-year-old Nina Adriana, who suffers from
advanced chronic lung disease, took part in the
ACP process with her housewife mother and
cab-driver father last September.
In the event that she collapses suddenly due to
respiratory or cardiac arrest, she has opted to
have endotracheal intubation and ventilation for no
longer than five days. In addition, she has declined
external cardiac compressions and advanced life
Dr Chong wants to help more patients like her
through the Paediatric and Young Adults ACP
Taskforce, which he co-chairs.
The taskforce – set up last year with eight
health-care professionals, including paediatricians,
social workers, counsellors, and nurses and
doctors trained in palliative care – is looking to
introduce workbooks for children and parents to
prompt discussions about ACP.
They are also looking to roll out the ACP forms
used by his Star Pals team to other institutions
that treat children with life-threatening conditions,
as well as train other health-care professionals on
how to offer ACP to their young charges.
Despite their young age, such conversations
can help parents and doctors to understand the
child’s mentality towards medical treatments and
uncover his fears about dying.
Dr Chong has had some children express their
anxiety that their parents will forget about them
when they die, or worry that their toys may be
given to people they do not approve of.
“If the odds of dying are so high, it may be more
important for a child to go to school to stay
connected with his friends than to receive
aggressive treatment in the hospital,” he said.
Currently, Nina needs to be connected to
oxygen devices around the clock to help her
breathe, but she still attends school regularly.
She has told her parents and Dr Chong that the
only thing she fears is that she cannot breathe.
“It is not all about what we want for her,” said
her mother, Madam Suriani Saini, 39.
“It’s also about what she wants for herself.”
Source: The Straits Times © Singapore Press Holdings Limited Reproduced with permission.