NUR3500 Chap.3 Advance Care Planning in Singapore
Advance Care Planning in Singapore
What planning actually is
Advance care planning is a structured conversation in which a person explores what matters to them, what they would and would not want if they became seriously unwell, and who should speak for them if they could not speak for themselves.
It is led by a trained facilitator, it usually takes about an hour, and it is held with family present so that the people who may later be asked to decide have heard the reasoning first hand. It has been offered here since 2011, and it is for everyone rather than only for older people.
Three stages, increasing in specificity
Planning is staged across adult life rather than done once.
General planning suits people who are well or early in an illness and focuses on values and on appointing a nominated healthcare spokesperson. Disease specific planning is for people with a progressive illness who are already having complications, and it settles what should happen if a predictable complication produces a poor outcome.
A preferred plan of care is for people whose prognosis is under about a year, or who need long term institutional care, and records a concrete plan rather than a general preference.
Four instruments, four moments
The most examinable content here is the difference between a conversation and a legal instrument. The plan itself records values, goals and a spokesperson; it guides the team but is not legally binding.
A lasting power of attorney appoints someone to decide and takes effect while the person is alive but has lost mental capacity. An advance medical directive declines extraordinary life sustaining treatment and applies only in terminal illness where death is imminent, under the 1996 Act. A will directs the estate and takes effect only after death.
Two errors follow from blurring these.
The first treats the plan as though it bound the family or overrode clinical judgement. The second treats the directive as a general refusal of treatment, when in fact it says nothing about whether a person would want antibiotics for a chest infection.
What the evidence supports
A systematic review of randomised trials found a consistent pattern.
Planning reliably improves the outcomes closest to the conversation: quality of communication, agreement between patient and caregiver about preferences, a stated preference for comfort focused care, reduced decisional conflict and better documentation. Results are mixed on the outcomes furthest from it, including care that matches documented preferences, quality of life and healthcare cost.
The proximal outcomes are the mechanism, and whether they translate depends on whether the plan is visible to the team on duty.
Why it does not happen
A national survey of 911 health care professionals trained to facilitate these conversations found that more than half had not facilitated one in the previous year.
The barriers ranked highest were clinician factors: no protected time, and the conversation being slow. Patient and family factors came next, chiefly refusal to engage and difficulty accepting a poor prognosis. Nurses and allied staff were more likely than doctors to report fear of upsetting the patient and low confidence in facilitating.
What this chapter covers
- 01
What the conversation involves
- 02
General, disease specific and preferred plan stages
- 03
Planning compared with the legal instruments
- 04
What the trial evidence supports
- 05
Barriers reported by clinicians
A plan that will not survive the night
- 2State the legal status of the plan and what it can and cannot settle.
- 3Identify the step of the planning process that was incomplete.
- 3Give your immediate clinical and communication actions.
Key terms
- Advance care planning
- A facilitated conversation recording a person's values, treatment goals and nominated spokesperson, which guides the team without binding it.
- Nominated spokesperson
- The person named to speak for a patient who can no longer decide, identified during the planning conversation and known to the family.
- Preferred plan of care
- The most specific stage of planning, used where prognosis is under about a year or long term institutional care is needed.
- Lasting power of attorney
- A legal appointment of a decision maker that takes effect while the person is alive but has lost mental capacity.
- Advance medical directive
- A legal declaration declining extraordinary life sustaining treatment in terminal illness where death is imminent.
- Proximal outcome
- An outcome close to the intervention itself, such as the quality of a conversation, as distinct from distal outcomes such as place of death.
Advance Care Planning in Singapore FAQ
Is an advance care plan legally binding on the team?
No. It is a record of values, goals and a nominated spokesperson, and it guides decisions rather than dictating them. The legally operative instruments are the lasting power of attorney, which appoints a decision maker once capacity is lost, and the advance medical directive, which is narrow and applies only in terminal illness.
Who should have this conversation, and when?
Anyone, at any adult age. The staged model begins with general planning for people who are well or early in illness, moves to disease specific planning once complications are recurring, and becomes a concrete preferred plan of care when prognosis is short or long term institutional care is needed.
If the evidence on distal outcomes is mixed, is planning worth doing?
Yes, because the reliable benefits are the mechanism rather than a consolation prize. Better communication, agreement between a patient and their caregiver and reduced decisional conflict are what make a plan usable at three in the morning; whether they change the place of death depends on the system around them.
Exam move
Build a four column table of the instruments, with what each one does, when it operates and who it binds. Then rehearse one sentence for each that you could say to a family. Finally, list the barriers under two headings, clinician and family, and mark which you can change.
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