Dying with Dignity: 10 Advance Medical Directive Facts You Never Knew

doctor using a medical machine beside a patient.

An Advance Medical Directive (AMD) is a legal document that you sign in advance to inform your doctor you do not want your life to be artificially prolonged with life-sustaining treatment, in the event you are terminally ill and unconscious.

An AMD is made in the spirit of conferring patients with dignity and autonomy by allowing them to choose a natural death and spare them further suffering.

In light of the freedom to make such end-of-life choices, here are 10 facts about AMDs to help you understand your decision, and the consequences, of making an AMD:

1) You Cannot be Forced into or Prevented from Making an AMD

This applies to both people you know personally, as well as institutions.

No friends or family should pressurise you into making an AMD. This includes anyone you know intentionally giving you untrue information to encourage your making of an AMD.

Alternatively, it would also count if you feel that someone is overly relentless in persuading you to make one, to a point that it could be deemed as undue influence.

If found guilty, they could be fined up to $10,000 or be imprisoned up to 3 years, or both. In addition, if they were a beneficiary to your will or any policy of insurance, they forfeit their interests automatically. This is regardless of whether they have been convicted for the offence.

In the case that someone is convicted of this offence, the AMD will be voided and will have no effect. If someone is merely charged for it and not convicted (yet or otherwise), the directive will not be acted on unless it is ascertained that it has been made validly and voluntarily.

In addition, anyone requiring or prohibiting the making of the AMD as a condition for being insured for or receiving medical or health care services can also be found guilty of an offence. If so, they can be fined up to $5,000 or imprisoned for up to 12 months, or both.

Any such conditions in insurance policies will also be void and have no legal effect. Other clauses in the insurance policy will be unaffected.

For example, if your family member’s insurance policy contains a clause that says you will not receive insurance pay-outs unless you make an AMD, that clause will be void.

2) Your Witnesses Must Not have a Vested Interest in Your Death

You are required to have at least 1 witness when executing your AMD. However, your witness cannot in any way benefit from your death.

In other words, to the best of their knowledge, your witness must not be:

  • A beneficiary of your will or insurance policy;
  • Entitled to receive your CPF monies upon your death;
  • Entitled to a share of your estate upon your death; or
  • A beneficiary in any instrument under which you are a donor, settlor or grantor (for example, if you have set up a trust for certain beneficiaries)

In addition, your witness cannot be a medical practitioner who has previously objected to acting on an AMD.

3) An AMD Takes Effect Only When You are Unable to Make Decisions for Yourself

This means that if you are terminally ill but conscious and capable of exercising rational judgement, your doctor cannot refer to the AMD for any actions to be taken. Instead, you should communicate your wishes directly to your doctor.

You can still reject medical or surgical treatment if you would like to.

At this point, you might want to inform your medical practitioner if you have made an AMD to prepare for the possible situation that you, at a later time, lose consciousness and the ability to exercise rational judgement. This is especially since it is an offence for doctors to ask if you have made an AMD (see point 5).

4) An AMD is Not Easily Invoked

When the doctor who is in charge of your medical treatment and care believes you are:

  1. Suffering from a terminal illness;
  2. Require extraordinary life-sustaining treatment; and
  3. Unconscious or incapable of exercising rational judgement,

he/she has to certify these in writing and make a request with the Registrar of Advance Medical Directives to check if you have made an AMD.

If you have made an AMD, the doctor will then have to obtain the agreement of 2 other medical practitioners on their diagnosis that you are terminally ill, before acting according to the wishes in your AMD. Out of these 3 doctors, at least 2 have to be specialists.

If there isn’t an unanimous agreement that you are terminally ill at this stage, your case would be referred to another committee of 3 specialists.

If this committee of 3 specialists are unable to unanimously agree that you are terminally ill, you will be presumed to not be terminally ill. As a result, your AMD will not be put into execution.

5) It is an Offence for a Doctor to Ask If You Have Made an AMD

It is illegal for your doctor, or any other person who provides you with medical care (or who will be likely to do so), to ask you if you have made, or intend to make an AMD.

If they do so, they can be found guilty of an offence and fined up to $5,000 or imprisoned for up to 12 months, or both.

However, doctors can still discuss the topic with their patients, provided that such discussions are:

  • Held in the context of a relationship between a doctor and his/her patient
  • Held with the intention of educating the patient on AMDs
  • Consistent with good medical practice

Hence, should you not have communicated to the doctor that you have made an AMD, and no one else (e.g. your family members) knows that you’ve made one, then the doctor is unlikely to find out that you have made an AMD.

This is unless, and until the point where, you have met the 3 conditions for a doctor to be required to check if you have made an AMD (see point 3).

6) Your AMD Might Not be Complied with If You are Pregnant

If there are reasons to believe that you are pregnant with a foetus which could probably survive to the point of being birthed if you were kept alive, your doctor is not allowed to withhold extraordinary life-sustaining treatment to you.

This is even if you have made an AMD stating that you don’t want to be given such treatment.

7) An AMD Does Not Affect Palliative Care

Palliative care refers to the provision of reasonable medical procedures for relief of pain, suffering and discomfort, as well as food and water.

Even if you have signed an AMD, these services should still be provided to you if necessary or desired.

8) An AMD is Not Irrevocable

You can revoke an AMD, should you change your mind after signing it. All you need is to communicate your intention to revoke your AMD to at least 1 witness through writing, speaking, or in any way you can.

Both you (if you are still capable of doing so) and the witness will then be responsible for writing and communicating your new wishes to the Registrar.

The notice to the Registrar must include:

  • Full particulars of the names, addresses and telephone numbers of the patient and witness; and
  • The time, date and place where you informed the witness you wanted to revoke your AMD.

The Registrar will then issue you an acknowledgement and mark the directive as being revoked in the register.

9) Your AMD Cannot be Overridden through Having a Lasting Power of Attorney

A Lasting Power of Authority (LPA) is a legal document that allows you to appoint a person (i.e a donee) to make decisions on your behalf should you lose the mental capacity to do so.

However, if you made both an LPA and an AMD, your LPA does not override your AMD. Your donee under the LPA will not be able to make a decision on your behalf to give you extraordinary life-sustaining treatment to prolong your life.

This is because the making of an AMD is a voluntary decision and such a decision cannot be made on behalf of another person.

Similarly, your family members will have no authority to override your wishes in the AMD.

10) An AMD is Not Synonymous With Euthanasia

It is explicitly stated in the AMD Act that it does not condone, authorise or approve abetment of suicide, mercy killing or euthanasia.

According to the Ministry of Health, mercy killing or euthanasia refers to 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.

The AMD does not do this as it is about letting the dying process take its natural course, rather than taking acts that cause or accelerate death.

We hope that this article has helped you in your understanding and decision of making an AMD.

As part of ensuring your affairs are further properly managed in the unfortunate event of death, sickness and/or lack of mental capacity, you may wish to consult our lawyers on making a will or a Lasting Power of Attorney.

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