Advance care planning: How should we talk about it?

SINGAPORE — Like most adults, Michelle Tan did not see the idea of planning for future healthcare options in her later years as a pressing matter.

It was only after suffering a near-death experience, where she had difficulty breathing from throat inflammation due to an allergic reaction, that the 42-year-old started making decisions about her preferred medical and personal care arrangements.

The incident occurred while Tan was on a conference call at home five years ago. She had to make her way from her flat in Hougang to a clinic, where she was given an adrenaline injection, and was subsequently taken to hospital.

Since the incident, Tan has crafted her own Advance Care Plan (ACP), which states her preference for a quiet, peaceful environment should she fall critically ill, as well as Buddhist rituals to be performed in line with her faith.

Tan had previously believed that she still had another 20 to 30 years to make decisions about her future healthcare treatments.

"I kept procrastinating and postponing it because I thought it wasn't going to happen so soon," she said. "I didn't anticipate my allergic reaction. If I had died there and then, I would have left my mum with the inconvenience of having to settle all my matters."

After her health incident, Tan completed her ACP in two sessions. The first required her to meet with a counsellor to understand more about ACP, before receiving documents to fill. The second session, held a couple of months later, was for the submission of forms.

What is advance care planning (ACP)?

Do you prefer being cared for at home or in a nursing home? How would you like your body to be handled upon passing? These are conversations worth having to ensure one's wishes are met, in the event that you are in a medical crisis and unable to communicate your thoughts.

ACP helps Singaporeans record important preferences about their future care in the National Electronic Healthcare Records (NEHR), and ensures their care preferences and treatment decisions are respected by the care team and loved ones during moments of mental incapacitation.

Under the plan, an individual may nominate a trusted person to be their Nominated Healthcare Spokesperson (NHS) to understand your preferences under the ACP and express them on your behalf.

It is complementary to a Lasting Power of Attorney (LPA), which is a legally-binding document that empowers a trusted person to manage your financial affairs (including assets), in the event of personal loss of mental capacity.

As of 31 May this year, more than 36,600 individuals have completed their ACP, said the Ministry of Health (MOH).

How is ACP beneficial?

Changi General Hospital (CGH) medical social worker Heng Zengrong shared that ACP can provide "a sense of relief" for both patients and their loved ones during medical crisis, by reducing the burden of decision making.

He quotes two incidents on which ACP discussions have positively impacted adoptees through increased awareness.

In a discussion, a senior fulfilled his wish of dying at home instead of spending his final days in the hospital. The patient had previously thought his children would not be able to take leave from work to provide care for him at home.

Through ACP conversations, another patient was able to share his willingness to be cared for in a nursing home, in the event care at home was no longer possible. This came as a surprise to the patient's children, who had always thought the patient would only consider home care.

Why end-of-life planning is not talked about enough

Heng said that ACP is "not a topic that is commonly discussed" among families in Singapore, as many do not know how to start conversations with their parents.

This was echoed by Tan, who had initial reservations broaching the topic with her mother due to personal concerns and fear.

"These are issues you don't think about everyday right? It's pretty morbid," she said.

Eventually, she decided to share her ACP with her mother after the incident. Her mother is now appreciative that all has been taken cared of, and is able to "follow it without any worries".

Heng said that it is common for family members to face difficulty making critical care or treatment decisions for their loved ones.

"While most people may feel loved ones would understand them well enough to make the best treatment or care decisions for them, it may not always be true," he said, adding that the preferences of patients may not always be aligned with loved ones.

Other reasons seniors may choose to delay early planning, even with awareness of its benefits, might be their belief that loved ones are busy, and simply lack the time to have early planning conversations.

Approaching ACP and end-of-life discussions tactfully

Heng suggests normalising ACP and end-of-life planning conversations with a softer approach.

This can be done by going through the different care options available, and not focusing on planning for the final phase, as seniors might be prone to "a sense of hopelessness" when end-of-life conversations come up.

"This will help ease them into thinking about end-of-life issues, and allow them to gradually plan further when they feel comfortable enough to do so," he said.

Heng adds that a soft approach can also help senior parents understand plans like these are not just for the sick and elderly, and that they are for everyone, even for those who are healthy.

How more people can be aware of end-of-life planning

Tan hopes that the process of setting up an ACP and LPA can be simplified. She suggested bringing the process entirely online through the use of Singpass.

She added that the stigma of future-care planning can be changed, by "seeding ideas in the young", through educational curriculums in secondary schools and tertiary institutes.

Information on ACP can be found in the ACP booklet developed by the Agency for Integrated Care (AIC). CGH patients can also visit CGH’s ACP website to download ACP brochures and booklets to read.

Free LPA certification and ACP facilitation sessions will be available for Singapore citizens aged 50 years old and above, on 26 and 27 August at Queenstown Community Centre, from 10am to 6pm. The public may sign up for the sessions through My Legacy @ LifeSG's website.

The Office of the Public Guardian has extended the LPA Form 1 application fee waiver for Singapore Citizens till 31 March 2026.

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