ADVANCE MEDICAL DIRECTIVE

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ADVANCE MEDICAL DIRECTIVE:

(Sign-up rate): 3.

Mdm Halimah Yacob asked the Minister for Health (a) whether his Ministry will review the current procedures in order to make it easier for Singaporeans to sign the Advance 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.

4.

Dr Fatimah Lateef asked the Minister for Health how many Singaporeans have

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signed the Advance 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.

5.

Dr Lam Pin Min asked the Minister for Health (a) how many Singaporeans have signed the Advance 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.

The Minister for Health (Mr Khaw Boon Wan): Sir, may I take Question Nos. 3, 4 and 5 together, please.

Mr Speaker: Yes.

Mr Khaw Boon Wan: More than 10,100 Singaporeans have signed Advance Medical Directives (AMDs). Three-quarter of them did so in the past four years. Over the years, 19 AMDs have been revoked and six have been put into effect.

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.

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%.

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

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advance directives and end-of-life issues. In fact, the Americans 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 then required to be documented in the patient's medical records.

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. It will be a criminal offence if they do and there are severe penalties including a fine and jail term.

Our AMD Act further requires the AMD Register to be kept strictly confidential. So 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. We are quite unique in the world in imposing such restrictions.

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 forthcoming 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 among some Singaporeans.

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

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public and even healthcare professionals on the AMD.

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 their preferences.

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.

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

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

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.

Mdm Halimah Yacob (Jurong): I thank the Minister for his explanation. I would like to ask the Minister why are there only six of the AMDs being put into effect out of 10,000 and why did the 16 revoke the

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AMDs that they made. And finally, could the Minister also look into how to step up publicity and outreach efforts so that there is a better understanding of the AMD? In particular, perhaps instead of the MOH fronting it, maybe MOH can facilitate those who have signed up the AMD to share the experiences as to why they are doing so, so that it appears to come from the people sector rather than the Government pushing it.

Mr Khaw Boon Wan: Sir, I suppose the small number of six AMDs being put into effect in a way reflects that the pool of AMD's signatories is small, to begin with. As I said, we now have 10,000 – I am one of the 10,000 – but the vast majority of them only signed up in the last two to four years and for a long time there were just a couple of hundreds per year. Now we are signing up about 2,000 to 3,000 per year, and it is growing. And we will certainly do our best to promote this more.

But I think the underlying difficulty is this general squeamishness among the people, whether justified or not, and I think that change will take time. I certainly agree that the people sector is a major partner of ours in this exercise, and that is why I welcome the Lien Centre for Palliative Care pushing more "DIE-logues" about death. That is why for several weeks when Zaobao kept up the debate on euthanasia, and despite some misunderstanding among the forum letters, I let the debate continue. Let this topic be discussed more. In a way, the discussions surprised me because I had thought that Asians would find death taboo and would not want to talk about it. I was pleasantly surprised by the great interest the public have on this topic and I consider it positive. It is our job to continue this discussion and help direct it in a positive manner.

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As to the reasons why the 16 revoked their AMDs, we could not ask why do they revoke just as we do ask why they sign up. Hence, I do not have the breakdown. But whatever it is, the number is small.

Dr Lam Pin Min (Ang Mo Kio): Sir, whilst I appreciate the Ministry's effort to raise awareness and to simplify the processes, I like to ask the Minister: how are we going to measure this "awareness" amongst Singaporeans, because not every person who discusses about end-of-life issues will ultimately sign up for the AMD. What implications are there should the sign-up rate be high or low? Let us say, for example, if the AMD sign-up rate is high, does it reflect the fact that maybe health care cost is too high and they think that it is not affordable to maintain or sustain life any longer?

Mr Khaw Boon Wan: Sir, I think AMD should never be a number game whereby we set KPIs and then we chase the numbers. I think that would be totally wrong. In any case, even if you look at the States, where I mentioned the figure of 20% among adults having signed up AMD, there is a wide variation across the States. Some states have single digit percentage of AMD rate and this is after more than 20 years of a much more open attitude towards discussing death and end-of-life matters.

To me, the key issue is not so much about AMDs or how many people sign up, but about advance planning, particularly among the terminally ill. When a patient picks up a terminal illness, for example cancer, then at a suitable point, as health care providers, we really would need to engage the patients and their families so as to mentally prepare them about the possibility of end-of-life issues. There are many personal preferences and decisions that we need to know ahead of time and the earlier it is discussed in an open manner, I think it should help the

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terminally ill as well as their family members cope better. So that is the attitude I am bringing to the table on this subject.

Dr Fatimah Lateef (Marine Parade): Sir, I thank the Minister for the response. I would like to find out if the Ministry of Health is considering doing some sessions to update doctors on the AMD because as we had feedback from some members of the public that the doctors were not aware or not comfortable with talking about the AMD and advising them accordingly.

Secondly, I would like to ask the Minister whether there is a possibility to consider a kind of bridging of information into the health screening programme that we do quite extensively now because I think it is a comprehensive package we have for health screening. Perhaps broaching the idea during these sessions could be good as well.

Mr Khaw Boon Wan: Sir, I agree with Dr Fatimah that we need more sessions both with the public as well as with the doctors. I have mentioned this point in one sitting before that some of our focus group discussions revealed that even among doctors there were some, I hope not the majority, who themselves are uncomfortable about discussing AMD and end-of-life issues with their patients. So you can see we are in a bit of an uphill task here. But there is no shortcut to overcoming this problem, and we just need more "DIElogues" with Singaporeans.

On the second part about health screening and incorporating AMD questions into it, we are bound by the current law. As I said just now, we are not supposed to ask the question, "Have you signed up AMD?" or "Do you intend to sign up AMD?" If we ask such a question, we will be sent to jail. So it is these restrictions which we have imposed

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into the Act, maybe for a good reason 11 years ago but, honestly, I feel that it is outdated and, in any case, no other countries do that. So I am keen to remove these restrictions but let me do more sounding with the public first.

Mr Speaker: Ms Lee, last question.

Ms Ellen Lee (Sembawang): I would just like to ask the Minister whether in the process of consultation and seeking more clarifications and dialogues, he would consider asking the public to come out with a better name for this device because "Advance Medical Directive" is quite a mouthful for the ordinary layman. Even in Chinese, yu xian yi liao zhi shi was also a mouthful for a lot of people. In a recent dialogue that I was involved in, most people got quite confused and did not really understand what it means.

The other point is that compared to euthanasia, it is quite a high-sounding name. But in Chinese, it is called an le si , so that will strike people because it is easier to remember as it refers to death and it comes much easier. So would the Minister mind doing a public consultation for a name for this particular directive?

Mr Khaw Boon Wan: Sir, the short answer is yes. I agree with Ms Ellen Lee that it is really a mouthful, and rather inconvenient when I have to discuss it with the public in Mandarin. That is why I suppose the translators wander into this " an le shi " as an euphemism. But even " an le shi " causes problem because I have had feedback from some of the readers that it is misleading. It has misled many to think that AMD is euthanasia.

Some of the Zaobao' s forum letters on this topic suggests to me that many of them have confused euthanasia with assisted suicide and AMD. These are three very different things. As there are a couple of other PQs on this subject, we can discuss this very interesting subject further.