More Singaporeans signing up for 'living wills'

15,000 have opted for Advance Medical Directives, waiving life support to keep them alive
By Poon Chian Hui, The Straits Times, 13 Feb 2012

A GROWING number of Singaporeans are making the difficult decision not to be put on life support when the end comes.

By last December, about 15,000 had signed up for 'living wills', which aim to minimise suffering by instructing doctors not to use artificial means, such as respirators, to keep them alive. This is a steady increase from the 10,100 Advance Medical Directives (AMDs) made by 2008.

The rise may be due to an increased awareness of living wills, said Dr Lam Pin Min, chairman of the Government Parliamentary Committee for Health.

Mr J. Lee made a living will eight years ago after deciding he would like to die with the minimum of suffering. He went to his doctor to sign up, after reading about AMDs in the newspapers.

'If I die tomorrow of a stroke, I don't mind,' said the retired dentist, 88. 'What I'm concerned is that if I'm on life support, I may be suffering for five or six months before I go.'

Anyone above the age of 21 and of sound mind can make a living will for free. These AMDs are acted upon when a person is terminally ill and is either unconscious or unable to make a rational decision.

Application forms are available at polyclinics and most private clinics. The person making the will does not need to hire a lawyer, but the form must be signed by two witnesses, one of whom must be a doctor. The other witness must not stand to gain from the applicant's death.

Once the will has been made, family members cannot stop the doctor from carrying out its wishes, even if they have objections. But applicants are free to change their mind at any time.

Of the current living wills signed, seven have been acted on. Last year, five people revoked their decisions, according to Ministry of Health figures.

Back in 2006, it was revealed in Parliament that few had taken up living wills. Only 3,840 had signed up at that time, even though they had been in place for a decade. It prompted then Health Minister Khaw Boon Wan to say that the ministry would focus on living wills for the next five years. Public awareness about such issues has since improved.

The living wills, advance care planning and palliative care all play a role in care for the dying. To raise awareness, the ministry has been holding discussions, talks and seminars for health-care professionals, as well as publicising the matter through the media. Educational materials on living wills were also distributed to doctors and health-care institutions, it added.

While these efforts seem to have paid off, some barriers remain. Associate Professor Cynthia Goh, head of palliative medicine at the National Cancer Centre Singapore, said the narrow scope of the wills means that they may end up useless, even for those who had signed up. The directive is carried out only in very specific circumstances, she noted. Patients must be terminally ill and unable to communicate, unconscious or mentally unsound.

This is when doctors will turn to the living will, if one is made. Three of them must first certify the patient as terminally ill.

'It's very prescribed,' said Prof Goh. 'Most people do not get into such circumstances. For example, many would still be able to communicate until the end.'

Most general practitioners and health-care staff also do not routinely bring up the issue with patients, she added. This is partly because it is illegal for them to ask patients if they have signed a living will or intend to do so. Doctors who do so could be fined up to $5,000, sent to jail for a year, or both.

Dr Chai Chin Yoong, chief executive of the Parkway Shenton chain, said its doctors will help only when patients inquire.

Some of its limitations were discussed in Parliament in 2008, and a public consultation was held two years later but no policy changes have yet been made.

Public awareness also needs to be shored up. For one thing, many may mistakenly associate living wills with euthanasia, said Dr Chia Shi-Lu, a member of the Government Parliamentary Committee for Health.

Euthanasia means deliberately ending a life, while living wills are used only when there is no hope of a cure.

Dr Lam added: 'I believe Singaporeans are generally still quite traditional and conservative in our thoughts, and speaking about death and end-of- life issues remains a taboo subject.'

But the living wills are useful, practically as well as ethically. End-of-life issues can be a significant emotional and financial burden on the family, pointed out Dr Chia.

Mr Lee was diagnosed with stomach cancer last year. He is undergoing radiotherapy and receiving palliative care from Assisi Hospice. But if his condition worsens to the point where life support is required, he may have to move into a hospice.

Fees for the stay, as well as daily medication and life support treatment, are likely to run high. 'I rather save the money for my daughter,' he said.