Making difficult decisions in advance

For individuals who wish to be actively involved in their end-of-life decisions, an Advanced Medical Directive may be useful.

With advancements in medical technology, terminally ill patients have the choice to prolong their life through various medically assisted means. For some, this may come with a compromised quality of life, thereby raising the question of an individual’s desire to extend the duration of life.

According to a nationwide study in 2019 by Singapore Management University, 62 per cent of Singaporeans wish to live a full and complete life, without regrets. However, less than four in 10 Singaporeans knew what an Advanced Medical Directive (AMD) is, and less than one per cent signed one.

Planning ahead

An AMD is a voluntary legal document that enables individuals to inform doctors of their preference for their end-of-life care, in the event they are incapacitated or unable to make these decisions on their own.

An AMD may be made by anyone aged 21 years and above of mentally sound mind as a preemptive measure to authorise doctors to let dying take its natural course. It is distinctively different from euthanasia, the deliberate ending of life by unnatural means, which is illegal in Singapore.

Through the AMD, the individual expresses his wish to decline extraordinary life-sustaining treatment. It can be any medical procedure or measure, which, when administered to a terminally ill patient, will only prolong the process of dying when death is imminent. Examples of extraordinary life-sustaining treatment are cardiopulmonary resuscitation, the use of machines that support breathing, dialysis, blood transfusion, or medications to support blood pressure.

The AMD was legalised in Singapore in 1996 in view of advancements in medical care that enable organ support to extend life — even for terminally ill patients with irreversible conditions. Such terminal illnesses include end-stage heart, lung, liver and kidney diseases, metastatic cancers, and advanced dementia or neurodegenerative diseases.

Mortality and choices

On average, mortality rates for patients with multi-organ failure admitted to the Intensive Care Unit ranges from 20 to 35 per cent, said Dr Lee Yi Lin (below), Consultant, Department of Intensive Care Medicine, Sengkang General Hospital. Extraordinary life-sustaining treatment may prolong a patient’s life, but it significantly diminishes his or her quality of life.

“Patients may end up requiring long-term dialysis, a tracheostomy (insertion of a breathing tube through the front of the neck), tube feeding, or long-term use of a urinary catheter. They may be unable to speak, lose their functional independence, and become dependent on caregivers for activities of daily living, such as eating and bathing, due to deconditioning from the critical illness,” Dr Lee said.

“The treating physician strives to manage every patient according to the latter’s expressed wishes and in line with the goals of care, the aim of which is to uphold patient autonomy and dignity,” she explained.

However, if an AMD is not made and the patient loses his decision-making capacity, doctors may initiate these difficult conversations with family members instead. This places the burden and, oftentimes, the guilt of decision making on loved ones in times of grief.

Protecting patients

Dr Lee emphasised that, regardless whether an AMD exists, it is the practice of every doctor to first ensure that all necessary treatment is provided to patients as long as there is a chance of recovery.

Indeed, the process of executing an AMD is very stringent and is uncommonly invoked in Singapore. To enforce it, three doctors, comprising the patient’s treating physician and two medical specialists, must unanimously certify that the patient’s condition is considered terminal. If there are any disagreements, a second panel of three doctors will be appointed by the Ministry of Health. If this second panel of doctors is also unable to reach a unanimous decision, the AMD cannot take effect and the medical team will continue to care for the patient with his or her best interests in mind.

To further protect patients, their AMD status is kept strictly confidential, and healthcare providers are not allowed to enquire, unless the treating physician recognises that the patient is terminally ill and has lost his or her decision-making capacity. Patients may also revoke their AMD at any time, should they change their mind.

An informed decision

Before creating an AMD, patients should consider the circumstances where they would prefer to die naturally, and — on the contrary — circumstances where they would prefer to have their life extended, even at the cost of losing functional independence.

Dr Lee also encourages individuals to involve their family in end-of-life discussions so that the goals of care are aligned. “Occasionally, when families are unaware of the patient’s wishes, there will be conflict and unhappiness, and family members may find it extremely difficult to accept the patient’s wishes,” she said.

Read more: AMD (Advance Medical Directive), ACP (Advance Care Planning) and LPA (Lasting Power of Attorney) – we explain them all for you here

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