Article contributed by Dr Michael Chong – Founder of Livewell Medical Clinic, a family practice GP clinic that he has managed for the past four years. He was previously with Raffles Medical for ten years, and was the Physician Leader for the A&E and also working as a palliative care physician at HCA Hospice for three years. Livewell Medical Clinic and Ninkatec are now collaborating to provide home care, palliative care, and elderly care for patients who need care at home.
The article discusses the importance of Advance Care Planning for the elderly as well as for younger adults and their family members in Singapore. Dr Michael Chong shares his perspectives as to why elderlies and younger adults alike in Singapore need Advance Care Planning and guides Singaporeans to break the taboo and take the steps to embrace the power to control their quality of life.
1. What is Advance Care Planning & Elder Care Planning?
Advance Care Planning (ACP), sometimes referred to as Elder Care Planning, is the process of planning for one’s health in the future. The practice helps individuals, families, and caregivers more readily traverse the ever-changing route of caring for a family member. The term ‘Elder Care Planning’ suggests the process applies to elderly adults and seniors who are more prone to chronic and terminal illnesses, health issues, and diseases. However, it is also useful for young adults at any stage of life and health conditions who would like to make decisions about future care goals and care options for themselves in the event such decisions are needed. Advance Care Planning, or ACP in short, therefore, is often used as a more universal term than Elder Care Planning.
Advance Care Planning and Elder Care Planning often involves 2 parts:
- actively planning for the different care scenarios in advance, also known as a living will
- appointing a ‘proxy’ or a ‘spokesperson’ to make future care decisions on one’s behalf for scenarios that are not planned for.
This implies that Advance Care Planning elicits discussions about end-of-life matters with loved ones when a person is in good health and sound state of mind, including personal values, beliefs, wishes and even fears. Holding such conversation in the middle of a health crisis might not guarantee the best decisions, as we shall discuss further in this article. On the other hand, talking about various advance care options when one is healthy might provoke uneasiness and discomfort. Advance Care Planning therefore should be a voluntary personal process and decision, yet best done with professional help.
It is important to note that ACP is not a legal process or document. The planning could be done by writing or having a conversation with your family or doctors. It can be changed at any time, either by writing or stating it verbally.
2. Why is Advance Care Planning needed?
For elderlies, the health care needs are typically fluid, and as such, one must always be prepared to deal with whatever happens next, making it necessary for seniors to have an advanced care plan in place. It becomes relevant for the families and friends of seniors and elderlies because it gives a better insight into how they can support their loved ones for a quality life, as they manage their medical requirements well in advance of unforeseen and challenging times.
For younger adults, though relatively less imperative, it is always useful to plan ahead. Dr Michael Chong advises that “it is best to do it as soon as possible because it will probably be too late by the time something happens. There is no specific age group that is recommended for ACP. Prevention is always the better option compared to cure.”
3. Benefits of Advance Care Planning for the Elderly & Family
For elderlies, Advance Care Planning benefits elderlies by giving them a voice. It aids in facilitating practical conversations between the seniors, healthcare providers, family members, caregivers and even financial advisors, legal persons about decisions they want to have made when they are no longer able to make decisions for themselves.
For everyone, discussing and getting your future care wishes recorded in advance gives you the peace of mind that you will be cared for according to the standards you hold. It also makes the task of caring for you at that point in life more manageable for your medical provider and caregivers with a recording of your preference available to them for reference. For example, in the case of a medical emergency, healthcare professionals and the family can discuss the arrangements using the ACP, and make decisions in line with loved one’s wishes although one is unable to make independent decisions at that moment, for example, whether CPR should be used, whether ventilator or tube feeding should be used and for how long.
In the end, families may not even need Advance Care Planning. However, in the instances where it is required, having it on hand gives family members or caregivers great confidence that they can facilitate the expressed and suitable wishes in doing the right thing on behalf of their loved one.
4. The Requirements for Advance Care Planning & the Best Time to Get Started
While there is no set time, in order to discuss for ACP, a person is required to be of sound mind, be able to understand what is going on, and be able to communicate his or her wishes. As one can’t be certain of when a health care crisis may strike, it is recommended to start thinking about future medical care goals and care options and communicating or documenting one’s wish for advance planning as early as possible.
In elderly care, patients often initiate the necessary discussions on Advance Care Planning (ACP) after reflecting on how they would like to be cared for as they become older, or during or after surviving a medical crisis. Elderlies would often engage their primary healthcare provider and caregiver to get a better understanding of their options and outline their wishes relating to future healthcare treatments to their family members.
There are plenty of questions to cover such as the patient’s preferred place of care, their willingness to undergo surgery or extraordinary life-sustaining treatment or surgery, etc. Some of the questions are matters of personal value more than medical questions, which may take time to reflect and decide on. For example, some elderlies would prefer to receive long-term care at home rather than in a hospital as they age. Or some individuals absolutely do not want to undergo surgery, CPR, or get placed in ICU because they would rather die a natural death. Other decisions may be better made collectively by the family rather than individually, such as whether the elderly patient should go for costly extraordinary treatment and what is the chance of improving quality of life for the patient compared with the financial burden for the family.
This makes it highly challenging to do Advance Care Planning in the middle of a healthcare crisis when emotions run high and time runs short. As a general guidance, Dr Chong advises “If your elderly loved one hasn’t started advance care planning, the best time is now. Take the opportunity to reflect on those advance care planning questions yourself as well. It is never too early to start thinking about it, because when you realise you need it, it might be too late.”
5. How to Get Started with Advance Care Planning?
Starting the conversation about advance care options and final days with elderly loved ones can be uncomfortable for many. Fortunately, there are many online resources that can help you get started. According to Dr. Chong, “It can be as easy as sitting down with a family member at appropriate moments, such as after a health checkup where the elderly’s health concerns are brought up by doctors, and bringing up questions about future healthcare treatment preferences. The purpose is to start the thinking and reflecting process. There are quite a few aspects and questions to cover, but you can always ask an ACP facilitator to help, or refer to online resources such as from AIC, or Khoo Tech Puat Hospital where ACP was first initiated in Singapore in 2013, or from Tan Tock Seng Hospital where ACP is actively practised. Many other clinics, hospitals and healthcare facilities across the island also offer ACP facilitation service.”
You can also enquire from the medical provider for your elderly loved one for help concerning Advance Care Planning. A three-way conversation between the elderly, family members and a family physician- typically an ACP facilitator – provides an excellent opportunity for the senior to plan their future for personal healthcare in the compassionate understanding of their family members and medical professionals that they trust. The family and the caregivers also get a better understanding of their loved one’s wishes and preferences first hand, since they are the ones who are likely to make the difficult decisions when the elderly can no longer do so for themselves. The conversations may also include financial and legal wishes, etc.
For others who would like to start ACP early for yourself, you can use the same resources above to start reflecting the ACP questions on your own and express your wish to a trusted proxy of your choice, such as a spouse, a sibling or a family member. Though ACP is a voluntary and personal matter, Dr. Chong recommends involving an ACP facilitator, as you could benefit from the medical knowledge and experience of a professional. This will ensure that there is no ambiguity and the questions are without misinterpretation. Also, it ensures that all the relevant stakeholders obtain a copy (if written) or are present. While ACP is not legally binding, having an ACP facilitator makes it more ‘official’.
Of note, this is rarely a one-off exercise where all questions can be answered and finalised in one sitting. Nor should it be treated as answering a questionnaire. Rather, Advance Care Planning is a framework to guide you through your ‘living will’. It is best to take time, even revisit your own choices as circumstances or health care options change.
6. Advance Care Planning Related Processes
The process for planning advance care is neither set in stone nor legally binding. However, there are several related components that are helpful to be made into legal documents such as those related to financial management, property management in case a person becomes metally incapacitated or unable to make decisions, or the use of extraordinary life-sustaining treatment in case a person becomes terminally ill and loses consciousness. The most common related legal processes include a Lasting Power of Attorney (LPA) and an Advance Medical Directive (AMD).
A Lasting Power of Attorney (LPA) is a legal document in which an individual nominates a person, known as the donee, to be in charge of arrangements and decisions about medical care if they become mentally incapacitated or unable to make decisions. An Advance Medical Directive (AMD) refers to a legal document that a person signs in advance stating that in case of terminal illness, he or she does not want excessive treatment to prolong life.
LPA and AMD can be done together with ACP. For example, once you have thought through your care options, you can first discuss your wishes with those who will be caring for you along with your healthcare team. During this conversation, you can disclose your wishes and preferences for care. Next, you can determine where you would want to be cared for, such as at home or in a hospice. After you have made that choice, document your wishes, preferences, feelings and beliefs, you can select a Lasting Power of Attorney for Health and Welfare and sign an Advance Medical Directive for yourself.
Remember, the steps in this process can get reordered according to what you, your caregiver or your healthcare provider thinks is best for you. Similar to ACP, LPA and AMD are both voluntary processes. However, different from ACP, LPA and AMD are legally binding. If you want to change your mind for some reason, LPA and AMD can be revoked at any time by using the revocation forms.
7. Limitations to Advance Care Planning
Even documented and recorded advance care plans can have the limitation of non-application by some family members and healthcare workers who opt not to abide by the documented wishes of the patients. This non-application is most times a result of conflicting factors. This means that there are unforeseen and uncontrollable situations that hinder the application of the client’s wishes.
8. Breaking the Taboo and Live More Fully with Advance Care Planning
Advance Care Planning elicits thoughts about death – an uncomfortable topic for many people because of the finality of it and general avoidance of the topic. Yet the focus of ACP isn’t about dying. It is essentially about living well and with dignity, and taking control of your life story and outcome until the last moments. It also provides peace of mind for the person planning advance care and their loved ones, knowing that all the decisions at critical moments are thought through and made according to one’s wishes, life goals, values and beliefs. The process can even bring families together, as they go through ACP together and get to understand each other’s deepest thoughts, hopes and feelings.
Although it is not currently a common practice in Singapore, Dr Chong is optimistic that “It will become a common practice. Hospitals are actively practicing ACP, and government agencies are also strongly promoting it. Many healthcare professionals are now trained in ACP and will play an important role in initiating the conversations. Many of our elderlies in their 80s and 90s may still find it a taboo and uncomfortable to discuss this. But those in their 50s and 60s, who are more aware and open-minded, would voluntarily want to address this, for their beloved elderlies and themselves.”
9. A Doctor’s Advice for Advance Care Planning for the Elderly & Families in Singapore?
“In my practice, I see that some patients are aware of their health condition and the importance of ACP but still refuse to speak about it. It may be a taboo, or they don’t want to face reality for a number of reasons. We can’t force them and would have to respect their decision regardless. But with more awareness, baby step approach in initiating ACP conversation, familial love and care while going through the process, and trusted guidance from healthcare professionals, I believe more people will complete ACP and benefit from it in the near future.” Dr Chong said optimistically.
Singaporean seniors, elderlies, younger adults and families are encouraged to avail themselves of the wide range of ACP touchpoints established at selected community centers, polyclinics, hospitals around the island to kick start their advanced care planning. It facilitates improving our quality of life and giving families, friends and caregivers the chance to prepare for the challenging times we and our loved ones will face while coping with bereavement and possibly deter any family conflict. You can speak to your trusted doctor on how to initiate an ACP.