End of Life

White Paper

Refer to White Paper

Needs Assessment

Refer to Needs Assessment

Resource Directory

Government Policy and Organisations

Government Organisations

Name	Description
Agency for Care Effectiveness (ACE)	National health technology assessment agency in Singapore, established by MOH in 2015 Publishes guides that outline recommendations on the appropriate use of health technologies
Butter	Ice cream

Agency for Care Effectiveness (ACE) is the national health technology assessment agency in Singapore, established by the Ministry of Health in 2015 to drive better decision-making about clinically effective and cost-effective patient care. From May 2017, ACE will be publishing guides, which outline recommendations on the appropriate use of the health technologies evaluated, provide a brief summary of the rationale for the subsidy decision, as well as the key clinical and economic evidence which informed the recommendations. ACE will also be publishing 'Appropriate Care Guides', which are concise sets of recommended care practices and pathways aimed at improving selected areas of therapy.

Agency for Integrated Care (AIC) Under the Ministry of Health, AIC coordinates and facilitates efforts among care providers for care integration. To encourage individuals to discuss and share their care preferences with loved ones in advance through an ongoing process of communication, AIC developed Living Matters, which is a national Advance Care Planning Programme in Singapore started since 2011. Living Matters ACP has been adapted from the Respecting Choices Programme at the Gunderson Health System in Wisconsin, US.

Ministry of Health (MOH) Statistics on Admissions and Outpatient Attendances, as well as home and in-hospice palliative care, is provided

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End-of-Life Planning

There are two legal documents:

Advanced Medical Directive (AMD) was started in 1997. It refers to the oral and/or written instructions that convey treatment preferences in the event of a loss of decision-making capacity. This includes living wills, which are written, legal documents that spell out the preferred types of medical treatments and life-sustaining measures under specific circumstances. In Singapore, the AMD Act allows patients to indicate their wish not to have any extraordinary life-sustaining treatment to be administered should they become unconscious or incapable of decision-making and are suffering from terminally illness.

Lasting Power of Attorney (LPA) legally designates a healthcare proxy who would make decisions on the healthcare of the individual in the event the individual is unable to do so. The Singapore Mental Capacity Act (MCA), enacted in 2008 and implemented on 1 March 2010, allows a person, called the “donor”, to make an LPA to appoint a proxy, called the “donee”, to make medical decisions (consent to carry out or continue treatment) on the donor’s behalf, should he eventually become mentally incompetent. However, a donee may not make any decision concerning life-sustaining treatment or treatment which is reasonably believed to be necessary to prevent a serious deterioration of the patient’s condition.

There is one non-legal option:

ACP is not limited to end-of-life scenarios, but extends to long-term care situations as well. ACP is intended to put the best interests of the individual into practice in the event of a serious illness. It could involve all healthy adult individuals living in the community, who may or may not be patients, but would be especially useful for the individual who becomes mentally incapacitated and is unable to make decisions or communicate his wishes.

ACP is a process of assisting the individual to :

• understand their medical condition and potential future complications;
• understand the options for future medical care as it relates to their current health condition;
• reflect upon their goals, values and personal beliefs;
• consider the benefits and burdens of current and future treatments;
• discuss choices with family/important others and health providers, and document these choices.

The intended outcome of ACP discussions is a statement of wishes, which can be in either written or oral form. This statement is not legally binding, but would be of importance when a judgment is to be made in the person’s best interests. This statement of wishes does not mark the end of ACP. There should be an ongoing update and clarification of concerns, values and preferences over time, whether or not a statement of wishes is made.

Some patients may also subsequently decide in advance their preferred treatment and care option for a predefined future medical situation, such as the refusal of certain treatment or procedures. ACP may thus lead to, but should not be reduced to, the writing of an advance directive, or the making of a lasting power of attorney to appoint a donee to make medical decisions on their behalf should they become mentally incompetent.

Syariah Court Singapore (for Muslims) The Syariah Court facilitates the distribution of the deceased’s estate through the Inheritance Certificate according to Muslim law

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Palliative Care

National Cancer Centre Singapore, Department of Palliative Medicine NCCS is the first institution to establish a stand-alone Division of Palliative Medicine in Southeast Asia. It provides care to patients with cancer by optimising pain and symptom management and psychosocial support. It also provides similar care to patients with advanced stages of neurological diseases and advanced kidney, heart, lung and liver failure where symptoms are troublesome.

National University Hospital (NUH) As more elderly have died in the Emergency Department (ED) in recent years, NUH started a dedicated palliative care service in its emergency department to relieve patients' suffering. The ED has carved out a quiet room where family members can spend their last moments with the patient, instead of being surrounded by beeping machines and busy hospital staff. Doctors and nurses in the ED will also be trained to prepare family members for the death of their loved ones.

Palliative Care @ TTSH Services provided include

• Inpatient Palliative Care Services
• Dedicated Palliative Care Ward - specialised 13-single bedded Palliative Care ward
• Outpatient Palliative Care Services
• Care Continuity - by collaborating with Hospice partners to ensure seamless care transition for patients who want to transit to home or to inpatient hospices to receive palliative care. Partner Hospices include Dover Park Hospice, Assisi Hospice and HCA Hospice Care.

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Non-Governmental Organisations (NGOs)

Hospice Care

Singapore Hospice Council The Singapore Hospice Council is the umbrella body representing all organisations actively providing hospice and palliative care in Singapore.It aims to coordinate and promote hospice and palliative care in Singapore; to support the training of doctors, nurses, allied-health workers, caregivers and volunteers; to improve on the quality of palliative care, and to raise public awareness. It acts as the voice of hospice and palliative care within Singapore and internationally.

Assisi Hospice Founded by the Franciscan Missionaries of the Divine Motherhood (FMDM) Sisters in 1969, Assisi Hospice provides palliative care to patients with life-limiting illnesses, caring for them and their families regardless of faith, age, race and financial position.

Dover Park Hospice Founded in 1992, Dover Park Hospice has served as a tranquil sanctuary for over 10,000 patients and families over the years, meeting their unique physical, emotional, psycho-social and spiritual needs through holistic palliative care.

HCA Hospice Care HCA Hospice Care is Singapore's largest home hospice care provider and is a registered charity since 1989. The organisation provides comfort and support to patients with life-limiting illnesses regardless of age, religion, ethnicity, nationality and financial status. The organisation conducts palliative care training for its patients' caregivers, as well as other services such as day hospice care, paediatric palliative care, bereavement support and outreach programmes.

Hua Mei Centre for Successful Ageing (HMCSA) Under Tsao Foundation, HMCSA is an integrated collective of various community aged care service models that have been pioneered by the organisation since 1993. They offer services ranging from care management, to traditional chinese medicine and dementia care systems.

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Nursing Homes

Active Ageing Hub

• MOH plans to build 10 Active Ageing Hubs in new public housing estates
• Part of a $3 billion plan, first announced by MOH to help Singaporeans lead active lives as they age
• Rehabilitative care and social programmes for the residents in the area, complementing services offered by the hospital in Serangoon Road
• First completed Hub located in McNair Road, meeting the needs of elderly residents in Kallang and Whampoa
• For a nominal annual fee of $5, residents have access to gym and activities like line-dancing and IT classes
• 40 daycare places for elderly residents, and provides medical care at home for 100 house-bound residents in the area
• Another centre to be opened in St George's Lane in 2019, just five minute from the centre in McNair Road. Together, they will serve 1500 elderly residents

Allium Healthcare's new nursing home along Venus Drive

• Proposed 4-storey, 129-bed facility with a built-up area of 5600 square metres
• Designed to be a premium product, to meet the demand from the middle- to upper-income group
• Of the 129 beds, 51 are single-occupancy care suits of 225 sq ft each, while 16 are companion suites of 327 sq ft each with en-suite bathroom, and executive suites start from 409 sq ft.
• 6 care suits and 2 companion suites will be set aside for residents with dementia, and 15 companion suites for subsidised residents
• 10 to 12 residents will share a living and dining area and a kitchen, as well as an area for rehabilitation and exercise facilities, in a "household"

Jade Circle Nursing Home

• Co-funded by Lien Foundation and Khoo Chwee Neo Foundation, in partnership with Peacehaven nursing home
• Following the "Silver Hope" Model
• In 2015, Jade Circle was proposed as a 60-bed nursing home with single and twin-bedded rooms for subsidised patients, not just private patients
• However, this was aborted because MOH considered that the conversion of all nursing homes to single and double-bedded rooms would hurt the affordability of care, if this model were to be scaled up
• Lien Foundation commissioned 3 studies:
  • "The Economics of Singapore Nursing Home Care" by consulting firm Oliver Wyman concluded that if the next 5000 nursing home beds (MOH to increase number of nursing home beds from 12000 to 17000 in 2020) follow the Silver hope model it would cost an additional $19 million annually – or an additional $8 to 13 per resident per day. However, cost savings would be generated through lower hospitalisation rates as these proposed living arrangements would ensure that elderly have the opportunities to be more mobile
  • "Safe but Soulless" by Radha Basu provided an overview of nursing homes today and suggested possible ways to overcome challenges. Chapters include:
    • 1: The State of Demand and Supply
    • 2: A Growing Need for Help with Daily Living
    • 3: The Challenges around Quality of Care
    • 4: Manpower Issues: Overworked, Underpaid
    • 5: Adding Purpose to Life in a Home
    • 6: Remodelling the Old 'Dorms of Dread'
    • 7: Aged Care Financing Requires a Revamp
    • 8: Are we doing Quality Control right?
    • 9: Private Players Plead for More
    • 10: Across the Causeway: Homes away from Home
    • 11: Rethinking the Choices for Tomorrow
    • 12: Recommendations: Considerations for Better Care
  • "Supporting Singaporeans’ Aspirations for Aged Care" by The Nielsen Company showed that Singaporeans are most concerned about being able to care for oneself and ageing in place, 60% of respondents thought that residents in nursing homes should stay in single or twin-bedded rooms
• 90% of current nursing home beds are in 6- or 8-bedder dorms. The other 5% to 10% are single or twins, but more for infection control purposes. Japan had already phased out 6-bedder wards 40 years ago, and single beds has been the norm for almost a decade.
• Revived in 2019 after the revision of plans:
  • Extension to the north of the current Peacehaven Nursing Home in Changi
  • First in Singapore to adopt an ‘anti-diaper, restraint-free’ policy, made possible with specially imported beds that can be lowered to prevent falls, and which have sensors that can detect movement.
  • Reduction from original 60 beds to 22 beds (8 single rooms and 7 twin-sharing rooms)
  • Non-nurses to be trained as senior care associates, to give the caregiving manpower at the nursing home a boost. 22 residents in Jade Circle will be divided into two “households”, each cared for by a senior care associate, who will be assisted by a nursing aide.
  • Expanded scope to include bigger day activity centre so that elderly can age in community. Two-storey activity centre to include hydrotherapy pool, cafe, hair salon and gym
  • Unlike original concept, includes "full spectrum" of senior services from active ageing and preventive care to rehabilitation and residential care
  • Depending on the level of care needed, the estimated fees range between 1500 and 2500 for day centre care, and 2000 to 3500 for residential care before means testing
  • Overall development cost of Jade Circle has been reduced from the original $15 million to $14 million
• Jade Circle as important pilot to set people thinking about long term care and the philosophy of dignity and humanity – providing a de-medicalised and more home-like model of care that prioritises resident autonomy beyond safety and risk management

Kampung Admiralty

• An 11-storey Housing Board complex as Singapore's first 'retirement kampung'
• 100 studio flats for the elderly
• Includes medical and senior-care centres, a food court, shops and community gardens
• Hopes to empower seniors to function independently in the community for as long as they can
• Similar to Assisted Living Options, but with no caregiver on standby for residents with dementia

Lions Home

• Runs two facilities in Bishan and Bedok
• Initiative to let residents wear their own clothes since 2001 so as to make care "less institutional"
• Rehabilitation programmes include a motion sensing video game system for residents to exercise their range of movement, coordination and other physical functions

NTUC Health

• Has three nursing home in Geylang East, Chai Chee and Jurong West
• Focus on getting seniors back home as early as possible, so that they can continue their rehabilitation in the community

Orange Valley Nursing Home

• Largest operator of nursing home facilities in Singapore with more than 1000 beds
• First privately owned nursing home to provide outpatient rehabilitation services
• Cost of staying at the home ranges from $3500 for private patients who opt for the open ward to $9000 for a private one-bedded room a month. Open wards are also available for subsidized patients.

Peacehaven Nursing home

• Introduced incentivising model of care: Residents have to “earn” money through exercise sessions and daily chores before they can “spend” it activities they enjoy e.g. massage, instant noodles, biscuits, sweets
• Giving residents their autonomy and keep their way of life, replicated from outside
• Giving them choices and a sense of control in how much they exercise and spend their money empowers them with a sense of purpose

Ren Ci Nursing Home in Ang Mo Kio

• Dementia-friendly 'cluster-living' options for nursing home residents
• 470-bed nursing home is the "biggest departure yet from the medicalised dormitory-style accommodation"
• 16 residents in each four-bedded rooms 'household'

St. Andrew Nursing Home (SANH)

• Jurong home: Inter-generation playground and childcare within its premises for inter-generational bonding
• Henderson home: "open concept" to encourage,and allow residents to interact with the community, especially those living in Henderson, Telok Blangah and Bukit Merah

St Bernadette Lifestyle Village

• Private facility in Bukit Timah that provides 24-hour medical concierge and meals
• 8 residents get help to live independently, including going on shopping trips to shopping malls
• Fees are at $3650 per month

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Other NGOs

Lien Centre for Palliative Care The Lien Centre for Palliative Care is a collaboration between Lien Foundation and Duke-NUS Medical School. It aims to build up a strong pool of palliative care professionals to enhance service delivery. With research programmes looking into clinical, social and cultural aspects of palliative care in Singapore and Asia, it also focuses on palliative care education and development of healthcare professionals.

Project: One More Thing A youth movement started by the non-profit group Youth Without Borders to fulfill the wishes of elderly folk from hospices, day care centres and poorer neighbourhoods. Using social media, the group posts these wishes online in order to connect the youth and elderly in the community.

Senior Activity Centres Located in the void decks of HDB rental blocks, the elderly living nearby are encouraged to spend their time at the centres, where they can meet their neighbours to chat, do some exercises and enjoy fun activities.

Singapore Cancer Society The mission statement of Singapore Cancer Society is to be community-based voluntary welfare organisation dedicated to maximising life by minimising the impact of cancer through research and advocacy, public education, screening, financial assistance, patient services and support, and rehabilitation.

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