Advance Medical Directive

17 Nov 2008

Question No:  846, 848, 860  

Question

Name of the Person: Dr Fatimah Lateef, Dr Lam Pin Min, Mdm Halimah Yacob

Question No. 846

To ask the Minister for Health how many Singaporeans have signed the Advanced Medical Directive since 1996 and, of these, (a) what proportion have (i) chronic, debilitating illnesses; (ii) terminal stage malignancy; and (iii) other conditions such as advanced age and dementia; and (b) how many have revoked their decision after signing.

Question No. 848

To ask the Minister for Health (a) how many Singaporeans have signed the Advanced Medical Directive (AMD) since the Act was passed in 1996; (b) how many patients have exercised the AMD since; and (c) what strategies will his Ministry employ to enhance the awareness of AMD amongst Singaporeans.

Question No. 860

To ask the Minister for Health (a) whether his Ministry will review the current procedures in order to make it easier for Singaporeans to sign the Advanced Medical Directive (AMD); (b) how does our current AMD sign-up rate compare with other countries with a similar provision; and (c) what are the reasons for the low sign-up rate.

Reply

Reply From MOH

1. More than 10,100 Singaporeans have signed Advance Medical Directives (AMDs).  Over the years, 19 AMDs have been revoked and 6 have been put into effect. 

2. As signatories are not required to disclose their medical conditions when making an AMD, I do not have the breakdown as requested by Dr Fatimah Lateef.

3.   Our AMD rate of 0.4% is low.  But this is the experience in many other countries too.  For example, in Australia the sign-up rate is even lower, at 0.2%.  The US is unique in having a much higher sign-up rate compared to the rest of the world.  Their rate is around 20% in adult population. 

4. One major reason for the higher sign-up rate in the US is the openness in which the patients and the doctors there are able to actively engage in discussions on advance directives and end of life issues. In fact, they have a Patient Self-Determination Act which requires Government-funded hospitals, hospices and nursing homes to ask all adult patients, at the time of admission, if they have made an advance directive, and if not, to inform them about their right to do so.  Such information is required to be documented in the patient’s medical records.

5. In sharp contrast, our society remains rather squeamish about discussions on AMDs. Our AMD Act specifically prohibits doctors and nurses involved in the care of a patient from asking whether or not the patient has made or intends to make an AMD. There are severe penalties including a fine and jail term for those who do so.

6. Our AMD Act further requires the AMD Register to be kept strictly confidential.  A doctor may request for a search of the AMD Register only when his patient is terminally ill, unconscious and would require extraordinary life-sustaining treatment.  These restrictions are quite unique in the world.

7. Reading the Hansard records of the debate in the House on AMD, I gather that these restrictions were put in as there were concerns by some Singaporeans that a doctor may be less forth-coming in his treatment if he knows that his patient has already signed an AMD.  I am confident that our doctors are ethical and will do what is necessary for their patients, regardless of their AMD status. Unfortunately, such fear, though groundless, remains amongst some Singaporeans. 

8. The restrictions have inadvertently become counterproductive to the intent of the AMD by making discussions on AMD taboo.  This is a major reason for the lack of awareness and apathy among the public and even healthcare professions on the AMD. 

9. It is my view that we should change this attitude and help Singaporeans cope with end-of-life issues in a much more scientific and mature manner.  Death is a certainty and must not be a taboo subject.  For the terminally ill, we do need to engage them and their family members early to understand their concerns and preferences. 

10. I am inclined to amend the AMD Act in two ways. First, make it simpler to sign up for an AMD.  The requirement that the form must be witnessed by a doctor has deterred many as they find it a hassle and costly.  Many have asked me to drop this requirement.

11. Second, drop the restrictions that have made AMD a taboo subject between doctors and patients.  We must promote greater openness the way the Americans have done.  

12. However, I do not know if Singaporeans are ready for these amendments.  I will do more sounding and welcome Members’ advice on this. 

13. Meanwhile, we will ensure that written materials on AMDs will be made easily accessible to the public, at the clinics, in the hospitals and nursing homes.  The recent public debate on euthanasia, hospice and palliative care has been useful to get more Singaporeans to think about and discuss end-of-life issues.  My Ministry will also encourage hospitals and nursing homes to engage their patients and their families in general discussions on advance care planning including AMD.