Advance Care Planning in Singapore: Why and How to Get Started

It is never too early or late to plan for the future.

When it comes to planning for future personal and medical care, Advance Care Planning (ACP) may be your best bet. Read on to find out more on what is ACP about and why you should consider having ACP conversations with your loved ones.

What is ACP?

ACP is the process in which you communicate and/or document your values and wishes regarding your future medical care. This entails a series of conversations with your loved ones.

During these conversations, you will share your personal values and beliefs, and how these impact your healthcare preferences in different medical circumstances.

If you prefer, you may also approach your healthcare providers, such as doctors, and make known your preferences to them. There are also healthcare professionals who are trained to facilitate ACP discussions to guide you on your decisions (see below).

Part of ACP involves you appointing your Nominated Healthcare Spokesperson (NHS) (see below).

The conversations you have with your loved ones and/or doctors will ultimately help your NHS to base any healthcare decisions, made on your behalf, on your medical preferences and personal beliefs. This may occur when, for instance, you are mentally incapacitated, and are no longer able to make decisions/express your views independently.

ACP can be done by everyone, regardless of health condition or age. It simply requires you to start an open conversation with your loved ones.

While it may be advisable for you to pen down your wishes (so that your loved ones could refer to them in the future), it is not a strict requirement. It is also not legally binding and does not require a lawyer.

Why is ACP Important?

As an individual, ACP is important because it gives you an opportunity to think ahead and prepare for the unexpected situation whereby you no longer have the ability to make your own decisions.

It allows you to consider and make known your options based on your medical preferences and beliefs. For example, if you’d prefer to opt for life-sustaining care or comfort care (see below).

Beyond that, communicating your preferences in advance will go a long way in reducing the stress and burden faced by your loved ones during difficult situations, since they will be clearer about your preferences and do not have to rely solely on their own opinions when making decisions for you.

This in turn, enables them to make the best decisions for you, on your behalf, while respecting your wishes.

Role of a Nominated Healthcare Spokesperson (NHS)

Your NHS will play the role of representing your views and preferences in the face of a medical crisis, when you no longer have the mental capacity to make decisions. In light of this, it is crucial for you to appoint somebody who:

• Is willing to be your voice.
• Understands you well, including your preferences, values and goals.
• Is willing to respect your care wishes in making decisions.
• Has the ability to make decisions under stressful circumstances.

Your appointed NHS must also be at least 21 years old, and can either be a family member or a friend. You may choose to appoint more than one NHS.

What is the Difference Between an ACP, a Lasting Power of Attorney and an Advance Medical Directive?

Let us examine the differences between an ACP, Lasting Power of Attorney (LPA) and Advance Medical Directive (AMD), which are other commonly-known estate planning tools:

ACP and LPA

Unlike the ACP, which is non-binding, an LPA is a legal document that appoints donee(s) to act on your behalf should you lose capacity to make your own decisions, in areas spanning personal welfare (including healthcare decisions) and property/financial affairs.

An LPA can only be made if you are at least 21 years of age. On the other hand, there is no age limit to starting an ACP and involves the appointment of an NHS to make solely healthcare decisions for you.

Should you have already made an LPA, it is ideal and advisable for your donee and your NHS to be the same person, to avoid possible disagreements, when making healthcare decisions on your behalf.

ACP and AMD

Unlike the ACP, which is a process of communicating your medical wishes, beliefs and preferences, an AMD is a legal document that specifically informs the doctor that you do not want to use any life-sustaining treatment to artificially prolong your life, should death be imminent.

Both ACP and AMD are not mutually exclusive – you can do both.

If you do make an AMD, you should raise this during your ACP discussions and have your AMD documented, since it goes towards the overall planning of your future healthcare preference.

The table below summarises the key similarities and differences between the ACP, LPA and AMD:

	ACP	LPA	AMD
What it is	Planning instrument which involves the appointment of NHS. Can be done informally.	Planning instrument in the form of a legal document for the appointment of donee(s).	A legal document that informs the doctor that you do not want to use any life-sustaining treatment to artificially prolong your life.
When it is triggered/ activated	You have lost your mental capacity to make decisions.	You have lost your mental capacity to make decisions.	You are terminally ill, require life-sustaining treatment, and are unconscious or unable to exercise rational judgement.
Nature of process	Non-legal	Legal	Legal
What the decision-making concerns	Health and personal care.	Personal welfare, property/financial affairs.	Healthcare (specifically on the use of life-sustaining treatment).

Types of ACP

There are 3 types of ACP. Your NHS will be involved in the ACP, regardless of which type you choose.

1) General ACP

The General ACP is for relatively well and healthy individuals, or individuals with early chronic disease.

The conversations should allow you to decide on:

• The goal of care (the extent of prolonging life with the use of life-sustaining measures) in the event you face a low chance of recovery as a result of severe mental impairment;
• Comfort care (care plan that ensures maximum comfort for dying patients and loved ones); and
• Life-sustaining care.

2) Disease-Specific ACP

The Disease-Specific ACP is for a patient with progressive, life-limiting illness(es) with frequent complications.

The conversations should allow you to decide on specific disease-related care, as well as your treatment preference for the following scenarios:

• Serious complications with low chance of survival;
• Serious complications with low chance of recovery of physical function or ability to communicate, and where you will require total nursing care; and
• Serious complications with high chance of mental incapacity, and where you will require total nursing care.

3) Preferred-Plan-of-Care ACP

The Preferred-Plan-of-Care ACP is for a patient with more advanced illness(es). Given their conditions, such a patient may pass away within a year.

The conversations should allow you to decide on:

• Care options on CPR;
• Care goals for medical intervention if you suffer a potentially life-threatening crisis;
• Preference of place of care; and
• Preference of place of death.

Activation of ACP

As mentioned above, ACP will come into play when you are no longer able to speak for yourself, or, in other words, you have lost the mental capacity to make decisions regarding receiving or ending treatment.

This is when your NHS will step in, and be guided by your preferences in making decisions on your behalf.

Steps Involved in ACP

There are two ways in which ACP can be done – either with or without the involvement of an ACP facilitator.

An ACP facilitator is a trained healthcare professional. Should you have complex health conditions, you might prefer consulting an ACP facilitator.

He/she will take you through your ACP planning process while keeping in mind your condition(s).

Where an ACP facilitator is not involved

1) Start the ACP conversation

The first step you have to take is to start an ACP conversation with your loved ones.

You may wish to refer to the ACP Workbook as a guide for you to reflect on your values and beliefs. You may also document your preferences and wishes in this notebook, with regard to your future healthcare needs.

2) Share your preferences

After completing the ACP Workbook, you should email or, print and share the document with your loved ones and/or doctors. This will allow them to know your wishes, and will come in handy should they ever have to make decisions on your behalf.

Completing an ACP in the presence of a facilitator

1) Make an appointment for an ACP session

A formal completion of an ACP can be done at various ACP Centres. This is recommended if you have more complex medical conditions and/or require more guidance.

Over at the ACP Centres, you will be referred to an ACP facilitator. He/she will take you through the ACP form, which is their version of the ACP Workbook.

The list of ACP Centres can be found here, and include most public hospitals like Khoo Teck Puat Hospital, National University Hospital and Singapore General Hospital, as well as smaller providers like Montfort Care and Life Point – Society of Sheng Hong Welfare Services.

The fees for doing an ACP is expected to lie between $0-$50, depending on the centre you visit.

2) Have your preferences recorded

Your preferences will be updated in the National ACP IT system linked to the National Electronic Health Record.

Additionally, you will also keep a copy of your ACP form.

Changing Your ACP

You are free to review and make changes to your care preferences at any point in time. This may be necessary in light of changes to your medical or living condition(s). All that is required is for you to inform your loved ones about your change in mind.

That said, while verbal sharing is sufficient, it is best to document any changes.

Thus, if you had previously documented your preferences using the ACP Workbook, update it and send a fresh copy to your loved ones and/or doctors.

If you have completed your ACP at one of the ACP Centres, it is recommended that you indicate your new preferences on a fresh ACP form to invalidate the previous form.

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Doing your ACP may not be as daunting as it seems. By confronting questions pertaining to what it means for you to be living well, it allows you to reflect and understand yourself better, and connects you with your loved ones on a deeper level.

Apart from ACP, there are other estate planning tools you can consider using to plan ahead and settle your affairs before you pass on. These include the above-mentioned LPA and AMD.

If you need any assistance and advice on ACP, as well as other estate planning tools, feel free to get in touch with one of our estate planning lawyers.