LEAVING WELL: END-OF-LIFE POLICIES IN SINGAPORE

Seventy-seven per cent of Singaporeans wish to die at home, according to a survey by the Lien Foundation in 2014. However, the reality is far from the ideal, with just 24 per cent of deaths occurring at home and close to 70 per cent taking place in hospitals, nursing homes and charitable institutions as of 2017. With over 200,000 Singapore residents currently aged 75 and above and hundreds of thousands of family members having to soon contend with the complex issue that is the end of life, this gap between preferences and reality must be addressed. In addition, as health literacy and awareness regarding care options increase with future generations, Singaporeans’ expectations on what constitutes a “good” death will rise and evolve. It is important that Singapore’s overall care infrastructure adapts to these changing expectations, so that more people feel supported in their care needs and preferences.

In this report, we consider what is needed to help Singaporeans die well and in accordance to their preferences. We look at ways in which end-of-life care can be better integrated with long-term and primary care services so that patients’ needs and preferences are more consistently met throughout their interactions with the healthcare system. We also question the under-resourcing of the palliative care sector in comparison to hospitals and tertiary institutions, and emphasise the need to further support and build the capacities of this sector.

At the same time, we also consider what is needed to help Singaporeans live well, particularly in old age and in the absence of close kin, social and financial resources. Thus, while this report addresses planning for and care at the end of a person’s life, it also addresses issues that emerge much earlier in a person’s life which can have a downstream impact on the quality of death. Some key issues we consider include the tension between patient autonomy laws and the dynamics of joint decision-making in families in healthcare settings. We also consider ways to strengthen community support for individuals, families, and older persons in particular, as the components of end-of-life and even long-term care are social as much as they are medical in nature. We also identify some features of the healthcare system that may prevent individuals from taking a more proactive approach in their own care plans and consider ways to address this.

This report also identifies what the government, healthcare providers, communities, families and individuals can do to improve the quality of death in Singapore.


Government agencies such as the Agency for Integrated Care and the Office of the Public Guardian could work more closely on a number of fronts. They could merge the documentation processes required for services like Advance Care Planning (ACP) and appointing a Lasting Power of Attorney to simply matters for individuals and families. The Agency for Integrated Care and the Office of the Public Guardian could also train professional deputies under the new Professional Deputies and Donees Scheme to conduct ACP facilitations, particularly for those without close kin. Silver Generation Ambassadors could also be equipped with the skills to introduce the Professional Deputies and Donees scheme to older adults living alone.

Members of the community and community-centred initiatives such as the Community Network for Seniors (CNS) could include support for those facing a terminal illness or for families experiencing bereavement. Arts practitioners could be further supported to conduct community events encouraging members of the public to reflect and talk about death. Human resource departments could raise awareness about end-of-life planning in workplaces through talks or workshops and even provide bereavement support for staff members.

Given the importance of culture and spirituality at the end of life, religious organisations should work closely with palliative care providers to raise awareness about ACP and end-of-life planning, and also provide spiritual care at the end of life. Similarly, religious and cultural community leaders could organise discussions with members of their respective communities to draw important cultural concerns about the end-of-life experience and design culturally relevant care programmes.

Schools and universities serve as an important platform to raise awareness among the young about the importance of early ACP, and prepare future generations for the often complex decision-making processes that arise at the end of life.

Players in the healthcare system could trial outcome-driven funding models in long-term care settings so as to better align financial incentives with improved care quality for older persons. The capabilities of the palliative care sector, particularly home and community-based providers must also be enhanced through improving training, remuneration, and working conditions as well as exploring new models of delivering care. A greater pool of healthcare providers, mainly general practitioners, allied health professionals and emergency medical specialists must be trained in palliative care so that more Singaporeans can have access to palliative care should they desire it.

Some initiatives call upon multiple sectors to work together to encourage more Singaporeans to consider early end-of-life planning. Key milestones in a person’s life, such as attaining adulthood at age 21, marriage, childbirth, retirement, purchasing life insurance and making funeral preparations for a late loved one serve as opportunities to initiate conversations on end-of-life planning. Institutions such as the Registry of Marriages, the CPF Board, and even industry players like life insurance providers could provide platforms for individuals and family members to begin thinking about their future care plans in non-clinical settings.

Perhaps most importantly, individuals and families must recognise the importance of planning early for unplanned future events, such as the diagnosis of terminal illness. This report identifies some institutional and cultural barriers that may make it difficult for individuals and families in making choices and decisions on such emotionally charged matters. It recommends solutions to better prepare and support families in their advance care and end-of-life planning. Critically, laws such as Section 13(8) of the Mental Capacity Act forbid family members from making decisions concerning the life-sustaining treatment of an incapacitated individual. Given the close dynamics of healthcare decision-making among families in Singapore, it is vital that more families are made aware of this restriction so that important conversations are not put off until it is too late.
Read the report here.


Media Coverage

A Market Journal. 2019. The need for the government to bridge the reality gap between preference for end-of-life & reality. 17 July.

Berita Harian. 2019. IPS: Warga perlu bincang isu akhir hayat pada usia lebih muda. 13 July. 

Tamil Murasu. 2019. Necessary to plan for the end-of-life. 13 July.

The Independent. 2019. CPF’s Retirement Sum Scheme payout age now at 90 years. 5 November.

The Online Citizen. 2019. Report calls for government to relook at end-of-life care schemes and giving better quality of life, netizens back the call. 15 July.

The Straits Times. 2019. IPS report urges better end-of-life planning. 13 July.

The Straits Times. 2019.  IPS' key recommendations about end-of-life decisions. 12 July.

The Straits Times. 2019. Kick-starting talk on death and dying early. 13 July.

The Straits Times. 2019. Forum: Set up trust fund for funeral pre-planning. 4 November.

TODAY. 2019. Most Singaporeans want a 'good death', but majority don't get their wish: Study. 12 July.