It's never too early to make your final wishes known - Starting the conversation End-of-life: Start at the beginning
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MARCH – MAY 2021 • MCI (P) 003/10/2020
Starting the
conversation
End-of-life:
Start at the
beginning
It’s never too
early to make
your final
wishes known
PLUS
The value of
Advance Care
Planning
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T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1
CHIEF EXECUTIVE’S NOTE
Members’ Contacts
Alexandra Hospital
378 Alexandra Road, S(159964)
T: 6472 2000 F: 6379 4339
www.ah.com.sg
AH_Enquiries@nuhs.edu.sg
The Palliative Care Centre
for Excellence in Research
and Education (PalC)
PalC c/o Dover Park Hospice
10 Jalan Tan Tock Seng, S(308436)
Contents
“
In the end, it’s not the years in your life that count.
It’s the life in your years.”
T: 6500 7269
Assisi Hospice www.palc.org.sg
832 Thomson Road, S(574627) enquiries@palc.org.sg ABRAHAM LINCOLN
T: 6832 2650 F: 6253 5312
www.assisihospice.org.sg Ren Ci Hospital
assisi@assisihospice.org.sg 71 Irrawaddy Road, S(329562)
T: 6385 0288 F: 6358 0900 ur legacy is vital and for Letting your family know your EASE OF MIND
O
Buddhist Compassion Relief www.renci.org.sg
that reason we should plans will enable them to carry Knowing that you have put your
8
Tzu Chi Foundation (Singapore) renci@renci.org.sg
9 Elias Road, S(519937) live with a well-planned out your wishes and minimise any final affairs and arrangements
T: 6582 9958 F: 6582 9952 Sengkang General Hospital life journey. There are financial burden on loved ones in in order will give you a sense of
www.tzuchi.org.sg/en 110 Sengkang East Way, S(544886)
T: 6930 6000 many who understood and saw the future. It is also among the most contentment and relief as you
Changi General Hospital www.skh.com.sg the importance of making the right unselfish and loving things that one are aware that your options
2 Simei Street 3, S(529889)
T: 6788 8833 F: 6788 0933 Singapore Cancer Society decision to pre-plan for their final generation can do for another. will be honoured as planned.
www.cgh.com.sg 15 Enggor Street, #04-01, wishes as it provides peace of mind. We are great planners only if our Pre-planning would make it
Realty Centre, S(079716) 2 Members’ Contacts Ironically, talking about end-of-life plan includes our final wishes for: more affordable as the plans
Dover Park Hospice T: 1800 727 3333
10 Jalan Tan Tock Seng, S(308436) www.singaporecancersociety.org.sg decisions and final wishes would will be locked within your
T: 6500 7272 F: 6258 9007 hospice@singaporecancersociety.org.sg 3 Chief Executive’s Note probably never be ranked as the UNFORESEEN CIRCUMSTANCES means where it is cost-effective
www.doverpark.org.sg
info@doverpark.org.sg Singapore General Hospital most pleasurable or anticipated You never know what life has in and practical.
Department of Internal Medicine, conversation. store and therefore it is sensible, It’s never too early to make
HCA Hospice Care The Academia, Level 4, 4 Starting the
The peace-of-mind benefits will not necessary and timely to pre-plan your final wishes known as
705 Serangoon Road, Block A #03-01 20 College Road, S(169856) conversation
@Kwong Wai Shiu Hospital, S(328127) T: 6222 3322 be complete if it is not discussed with your end-of-life care and wishes. letting your loved ones know
T: 6251 2561 F: 6291 1076 www.sgh.com.sg the relevant loved ones. Therefore, it’s This will enable your family to about your plans will relieve
www.hca.org.sg sghfeedback@sgh.com.sg
contactus@hcahospicecare.org.sg
6 A life-affirming project essential to actualise that discussion be aware of your preferences or them from unnecessary
SingHealth Community Hospitals even if you think your family may decisions, which will make it easier conflicts and stress about
Khoo Teck Puat Hospital (Bright Vision Hospital,
90 Yishun Central, S(768828) Outram Community Hospital, 8 The value of Advance question or not be prepared to go for them to cope at a time of crisis making decisions during a
T: 6555 8000 F: 6602 3700 Sengkang Community Hospital) Care Planning through what you have decided. or loss. time of grief.
www.ktph.com.sg 10 Hospital Boulevard, S(168582)
T: 6970 3000
KK Women’s and www.singhealth.com.sg/SCH
Children’s Hospital 10 It’s never too early Consider talking about your final wishes
100 Bukit Timah Road, S(229899) St. Andrew’s Community Hospital to plan for the end
T: 6225 5554 F: 6293 7933 8 Simei Street 3, S(529895) with these professionals and anyone else
www.kkh.com.sg T: 6586 1000 you believe will have an impact
www.sach.org.sg
Lien Centre for Palliative Care general@sach.org.sg 12 Advantages of early on your final arrangements: Lawyers
Duke-NUS
Medical School Singapore St Joseph’s Home
Advance Care Planning
8 College Road 36 Jurong West St 24, S(648141)
Level 4, S(169857) T: 6268 0482 F: 6268 4787
T: 6601 2034 / 6601 7424 [Education] www.stjh.org.sg 14 Never a better time
T: 6601 5113 [Research] general@stjh.org.sg than now Funeral Healthcare
www.duke-nus.edu.sg/lcpc
St Luke’s Hospital Directors Professionals
Metta Hospice Care 2 Bukit Batok Street 11, S(659674)
32 Simei Street 1, T: 6563 2281 F: 6561 8205 16 Seize the moment
Metta Building, S(529950) www.slh.org.sg
T: 6580 4695 F: 6787 7542 referral@stluke.org.sg
www.metta.org.sg
hhospice@metta.org.sg Tan Tock Seng Hospital
18 End-of-life You should
conversations: start at
MWS Home Care & Home Hospice
11 Jalan Tan Tock Seng, S(308433)
T: 6256 6011 the beginning speak to:
2 Kallang Avenue, www.ttsh.com.sg
CT Hub #08-14, S(339407)
T: 6435 0270 F: 6435 0274 Tsao Foundation 20 A mother’s love Immediate
www.mws.sg/centre-location/ 298 Tiong Bahru Road Insurance
mws-home-care-home-hospice/ Central Plaza, #15-01/06, S(168730) Family
MWShh@mws.sg T: 6593 9500 F: 6593 9505 Agents
www.tsaofoundation.org 22 Get started on end-of- Members
National Cancer info@tsaofoundation.org life care planning with
Centre Singapore
11 Hospital Drive, S(169610) Woodlands Health Campus SHC resources!
T: 6436 8000 F: 6225 6283 9 Maxwell Road,
www.nccs.com.sg MND Complex Annex A, Caregivers
Ng Teng Fong General Hospital
#03-01A, S(069112)
T: 6681 5999
24 Announcements /
1 Jurong East Street 21, S(609606) www.whc.sg Events calendar Ms Evelyn Leong
T: 6716 2000 F: 6716 5500 Chief Executive
www.ntfgh.com.sg Singapore Hospice Council
enquiries@juronghealth.com.sg
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T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1 T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1
COMPLETE
TAKE THE FIRST
HOMESTEP
CARE
Starting the “
Planning for EOL
conversation early allows you
to prepare for any
Planning for end-of-life early empowers
us to make the best decisions for unfinished business
ourselves and also reassures our loved
ones. HCA Senior Medical Social Worker to be completed,
Yap Ching Sian shares some tips on
beginning the end-of-life conversation.
reconcile with people
whom you might not
At what age should I start planning for
end-of-life? have spoken to for a
Planning for your end-of-life (EOL) requires
you to start thinking about how you would
like to be cared for when you are diagnosed
while and have proper
Planning for end-
with a life-threatening illness or when your
prognosis is guarded.
It also requires considerations to be given
of-life early enables
your loved ones
and medical team
time to say goodbye
to understand and
to who you want to appoint as a decision-
maker, in the event that you lose your
act in accordance to
your wishes. to your loved ones.”
mental capacity. These decisions include
how your assets should be managed, funeral
arrangements to be made and the legacy made under such circumstances would can begin spontaneously. For example, you These conversations can lead to powerful
you want to leave behind. likely be ones that are thought through and your loved ones might have watched moments, where affirmations and words
As these considerations require significant rationally and carefully. a TV programme, in which one of the of love and gratitude get conveyed and
deliberation, it is advisable that you characters fell ill, or you and your loved expressed. These conversations sometimes
only start to plan for EOL when you are Where do I start? ones might have visited someone at the become shared and precious experiences
sufficiently mature. While there is no A good place to start is Advance Care hospital. These are good opportunities to for you and your loved ones, which can be
specific age to start planning for one’s EOL, Planning (ACP). It involves the process of start having EOL conversations with your deeply moving, meaningful and life-giving.
a good gauge is when one enters adulthood. planning for one’s future personal and loved ones in a more natural and less
When planning your EOL, you must have health care. It requires you to identify a threatening way. What are the advantages of planning for
a good understanding of your values and spokesperson to make medical decisions EOL early?
preferences. on your behalf, while being guided by the What are some of the obstacles that I might Planning for EOL early allows you to prepare
medical team, when you are unable to make encounter during the conversation? for any unfinished business to be completed,
I am young and healthy. Why do I have to your own decisions. Your loved ones may not be ready for the reconcile with people whom you might not
plan for EOL so soon? ACP also reflects your views on what gives topic due to many reasons. They may find have spoken to for a while and have proper
Having a plan for your EOL is about being meaning to your life, elements of care that it inauspicious or taboo to be talking about time to say goodbye to your loved ones.
WORDS & PHOTO HCA HOSPICE CARE
prepared should unforeseen circumstances are important to you and how you would such topics. Others may find it difficult to It also gives you the chance for your
arise. We often get emotionally like to be cared for in the event of an illness dive into the conversations as the fear and wishes regarding your care, financial
overwhelmed when we find out about or injury. sadness of losing you are too much to bear. matters and funeral matters to be heard. In
a major illness or when we meet with Care and consideration about your loved doing so, your loved ones will not feel the
an accident. How do I include my loved ones in the ones’ readiness to have these conversations burden of having to make guesses about
Under these difficult situations, it would conversation? should be taken into account. However, your preferences. They can be empowered
be challenging for us to think about EOL You would know your loved ones best. You getting your loved ones involved in your EOL and assured that they are carrying out your
matters rationally. Hence, EOL plans are could start by asking questions to gauge conversations is equally important, as they preferences and can even take comfort
ideally made when you are healthy and in a how far your loved ones can go with the get a chance to hear you out and also to knowing that things are being carried out in
good emotional and mental state. Decisions conversation. Sometimes, the conversation express their views about your EOL plans. accordance to your wishes.
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T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1 T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1
SEIZE THE OPPORTUNITY
A life-affirming project
Despite an ongoing pandemic, St. Andrew’s Community Hospital’s
successful initiative saw the extension of Advance Care Planning
beyond the Palliative Care ward to the Rehabilitation ward.
ave for a rainy day, or surgery, and require some time they reach the end of their lives and
S prepare for our future,
what would you like
to do when you grow
to regain or improve their functional
state. They prove to be a captive
audience between therapy sessions!
to share what is important to them.
Our multidisciplinary team was
really thrilled that this little project
up, what are your retirement plans. ACP influencers, who are staff yielded very encouraging results.
These are some commonly heard such as nurses, pastors and Over 30 patients in just one ward
sayings as we go through life in therapists, were trained to reach managed to complete an ACP
Singapore. We make many of out to patients and their families discussion with a facilitator over a
such preparations but what about to raise awareness of ACP. Using span of six months. Families have
our health? materials such as videos, brochures expressed gratitude towards the
We can also make plans for our and workbooks from the Agency of ACP team, as now they know more
future health. Integrated Care, the team found that about what their loved ones would
Due to restrictions as a result of the there was interest among patients in like for their future and will not feel
COVID-19 pandemic, I found myself attending ACP awareness sessions. guilty at making a wrong decision.
serving in St. Andrew’s Community During one such session, a patient They are thankful that these
Hospital (SACH) for six months longer raised his hand to show interest discussions bring the family closer
than I had anticipated. Harbouring in having the discussion in the together. Our staff awareness has
a passion for Advance Care Planning hospital. Another heard how we also increased through this initiative
(ACP), my initial efforts to learn more engaged another patient on ACP and and they are now more capable of
about this work blossomed into a said he too wanted to do it all along carrying out an ACP discussion.
full-fledged effort to introduce ACP but did not have the time, and “this We aim to eventually roll out this
into the Rehabilitation ward of SACH. is the best time for me to do so while initiative to the rest of the wards
A Quality Improvement Initiative was being an inpatient”. Some patients in SACH.
started in July after discussions with who live alone felt assured that they This year may have bought great
team members during the Circuit have been given the opportunity to disruption to the world. Amidst
Breaker. Patients admitted into the think and discuss their end-of-life this, I was glad for the opportunity
ward are usually elderly and have care plans. This only goes to show to carry out this life-affirming
suffered a health-related setback that many do wish to talk about initiative and leave a legacy for
such as a stroke, a serious infection how they wish to be cared for when others to build on.
COMMUNITY HOSPITAL PHOTO ST. ANDREW’S COMMUNITY HOSPITAL
WORDS DR NG HAN XIAN, MEDICAL OFFICER, ST. ANDREW’S
The team members of the Quality Improvement Initiative are (left to right): Tabitha Low (Senior
Executive, Healthcare Performance Office), Marcia Chung (Principal Medical Social Worker), Dr Ng
Han Xian (Medical Officer), Leong Peiyu (Associate Chaplain, Pastoral Care Services), Dr Melissa
Abamonga (Resident Physician) and Dr Kyi Theint Theint Thu (Principal Resident Physician)
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T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1 T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1
PLAN FOR FINAL DIGNITY
Far left: Senior Staff
Nurse Hasnah bte
Abdullah with Nurse
Clinician Sahnan bin
Rahim work together
on ACP outreach;
Below: SSN Hasnah
guides ACP sessions
with relevant materials
experience an ACP discussion. Attorney (LPA) and to draw up death to be in a hospice. I guided
The value of Advance Mr L was initially very angry; he felt
that he did not get much time with
a will.
However, he was still very much
him and his sister with information
about the signs of active dying,
WORDS SENIOR STAFF NURSE HASNAH BTE ABDULLAH, ADVANCE CARE PLANNING NURSE,
doctors and had many unanswered in denial about his life-limiting what the final hours might be like,
CHANGI GENERAL HOSPITAL PHOTOS CHANGI GENERAL HOSPITAL, UNSPLASH.COM
Care Planning
questions. Although he was a soft- illness. After that initial discussion, and how his sister should take care
spoken and respectful man, he got he subsequently underwent of herself after her brother’s death.
so agitated that we had to calm aggressive chemotherapy and Both Mr L and his sister were very
him down. We assured him that we many medical interventions. The open to hearing this. They were
would help him where we could. next time I saw him was one year thankful for the information as it
Changi General Hospital Senior Staff Nurse Hasnah bte Abdullah shares He soon became very appreciative later. He was admitted and again prepared them for the end through
the importance of making your final wishes known through a case study. of the time we spent talking to referred to me. This time, he was knowing what to expect.
him. He finally felt heard and much weaker, wheelchair-bound, Relevant information provided at
taken seriously. and appeared to have accepted a pace suited to both Mr L and his
As a single 68-year-old man, that further treatment was not family meant that he could make
ontrary to popular ACP discussions include talking Let me share this through Mr L’s main concern was not to going to reverse the course of his decisions that prioritised what was
C perception, Advance
Care Planning (ACP)
is much more about
about preparation for end-of-
life care and death, dealing with
unfinished business, avoiding
a memorable meeting with
Mr L, who was referred to me in
November 2019. Mr L had received
burden his siblings with his care.
I explained that the ACP is an
ongoing discussion that can be
disease. It had progressed to a
very advanced stage and he was
given a prognosis of less than
important to him. It might have
seemed premature to talk about
end-of-life care right at the start
life than death. It is about helping unnecessary prolongation of bad news of metastatic cancer revisited anytime. At the end of the three months. He was seen by the of the disease, but it got him to
people live out the final stage of life dying, strengthening of personal and limited prognosis from a discussion, referrals were made palliative team and referred to carry out certain important actions
as fully as possible and to make the relationships, and relieving urologist. He was devastated, at a to a psychiatrist, medical social Assisi Hospice. early, such as appointing an LPA,
most of each remaining moment. In burdens placed on family. They loss, anxious, angry, and in denial. worker and a private nursing I revisited his ACP with his before he was not able to do so. The
the end, when the time comes, ACP are a key step towards provision I was asked to see him as soon as service provider to meet the needs sister who was the nominated discussions respected his desire
is a means to help people die with of care that is in line with a I could. he had described. As a result of healthcare spokesperson. During not to burden his siblings and
dignity in the place and manner of person’s wishes, at a time when it I went to see him with two other the discussion, he also agreed that discussion, Mr L made the facilitated his eventual death in a
their choice. matters most. senior nurses who wanted to to nominate a Lasting Power of decision for his preferred place of place of his choice.
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T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1 T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1
COMPLETE
A YOUTHFUL
HOME
EXAMPLE
CARE
was in a lot of pain and could not and have one of them join the reflect on what is truly important
communicate his wishes to my session. After all, an ACP is a to them. This is then a chance for
mother and her sister. Both of them piece of document. What matters them to make choices that are
It’s never too early
could not come to an agreement more is the conversation, where congruent with their values. Life
on whether to prolong his life or to we have a nominated healthcare and death are two sides of the
let him go. I am bringing this story spokesperson listen to you and same coin; in planning for their
to plan for the end
up to illustrate that these difficult respect your wishes. death, they also plan how they
decisions may have been easier if want to live.
they had talked about it before it Did you encourage your family
became too late. and/or friend(s) to do their ACP It always seems too early, until it’s
as well? too late. How would you encourage
Hilda sat down and did her Advance Care Plan at the tender age What made you decide to finally do Yes, I shared about my experience young adults like yourself to
your ACP? during my volunteering work start planning for their future
of 23. We find out more about her motivations.
I had wanted to try it myself and and if I sense that my friends are healthcare preferences, while they
use the experience to persuade my interested, I would encourage them are still healthy?
parents to get their ACP done as to get their ACP done. However, I I understand that thinking about
well — it’s still a work in progress. do not rush people into it. I rather your own mortality can be scary,
t always seems too early As I am an only child, I worry about trust that they will do it when they and that is normal. In your youth,
I until it is too late.
Advance Care Planning
(ACP) is for everyone,
not knowing what to do when my
parents pass away. We do not talk
about end-of-life matters as they
are ready.
What do you think is one major
you want to savour your own
vitality, to feel alive and delay
adult responsibilities for as long as
including healthy adults, and does are resistant to it. advantage of having an ACP done? you can. Having an ACP done does
not need to be done only in our senior ACP covers a broad range of not mean that you have everything
years. More often than not, it usually Did you discuss with your family questions beyond healthcare figured out. It also does not mean
takes a major illness to prompt such and/or friend(s) while considering preferences. For example: “What that you must be fearless of your
discussions with our loved ones. to get your ACP done? makes each day meaningful?”, own death. You simply accept that
However, it is always better to plan No. I simply did a search online “What are the important aspects death is inevitable; it will come to
for our future healthcare preferences on where I could get my ACP done about your well-being?”, “Who everyone eventually. Hence, what
when we are still well. In this way, it without charge, then proceeded to or what helps you face serious we can do is really to prepare as
allows our needs and wishes to be make an appointment for myself. challenges in life?”. Thinking about much as we can. Starting your ACP
met should we be unable to speak or On hindsight, it may be more the answers to these questions conversation early will bring you
communicate for ourselves and relieves effective to talk to my parents gives one the opportunity to comfort in the future.
our loved ones of having to make these
difficult decisions.
Hilda (as she wants to be known)
at 23 years old is one of the many
“
It is never too early to
who had their ACP done with an ACP start a conversation
Facilitator at Khoo Teck Puat Hospital. about Advance Care
Planning. Opposite
The hospital hopes more young adults page: Hilda having a
will consider having their ACP done. tele-ACP discussion
with the ACP Facilitator
KHOO TECK PUAT HOSPITAL PHOTOS KHOO TECK PUAT HOSPITAL, PIXABAY
How did you first know about ACP?
Having an ACP done does I found out about it at a volunteer
training on ACP in August 2018.
not mean that you have
WORDS TRICIA TAN, EXECUTIVE, ADVANCE CARE PLANNING,
Was there any past experience, e.g.
from a loved one, that contributed to
everything figured out. It also your decision of doing an ACP?
No. However, months after I got my
does not mean that you must ACP done, I had my first experience of
death in the family. It does not feel real
that someone I knew for my whole life
be fearless of your own death. is now gone. When I was a child, I was
close to my grandfather who taught
me watercolour painting. We grew
You simply accept that death distant as I got older because it became
harder for us to communicate due to
is inevitable; it will come to my limited vocabulary and his hearing
loss. Upon knowing about his death, I
did not know how to react. In the days
everyone eventually.” leading to my grandfather’s death, he
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T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1 T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1
LEAVING CLEAR DIRECTIONS
Opposite page: Assisi
Hospice’s Senior
Medical Social Worker/
Counsellor Ms Ivee
Tee (left) facilitates
Advance Care Planning
discussions with patients
and their caregivers
Mr Tan’s wife’s worries
were addressed and
eased with assurance of
the available resources,
decreasing her sense
of uncertainty over her
caregiving journey.
Why ACP?
Advantages of early Why should we do ACP early?
• Illness can strike any time
• It reduces the pressure of decision-making on our
Advance Care Planning loved ones
What should the conversation cover?
• Sharing of your values and beliefs
Assisi Hospice’s Senior Medical Social Worker/Counsellor • Exploring how your values and beliefs affect your
Ms Ivee Tee shares a patient’s case study. had thought through their decisions, the MSW medical/care decisions when you are seriously ill
proceeded to discuss the details with them. • Choosing one or more spokesperson(s) who can
Mr Tan’s wife did not really want to talk about
represent you when you are unable to express your wishes
ixty-four-year-old Mr Tan (name in his direct care, and they were not on good end-of-life initially as she had been grieving
S has been changed) was diagnosed terms with his wife. due to his illness. The ACP conversation gave
WORDS ASSISI HOSPICE IMAGES ASSISI HOSPICE,
with cancer and referred to Assisi Assisi Hospice’s MSW visited Mr Tan and his the couple a platform to talk about Mr Tan’s Should I and how do I document my ACP?
Hospice for palliative care and wife twice to discuss ACP. During the MSW’s wishes for his care openly and helped his wife to • Though ACP is not a legal document in Singapore,
symptom management in July 2020. Even first visit, she identified and brought to his understand what he wanted. This also gave her documenting it would enable your loved ones and the
though Mr Tan could still care for himself at that attention the family dynamics and possible more time to prepare herself mentally in caring medical team to provide care according to your wishes
point in time, he decided to discuss Advance challenges his wife might face regarding his for Mr Tan. Her worries were addressed and
PIXABAY.COM & PEXELS.COM
when you lose your mental capacity.
Care Planning (ACP) with Assisi Hospice’s Medical end-of-life care. She then introduced ACP to eased with assurance of the available resources,
Social Worker (MSW) as he was concerned that him and his wife, engaging them in a series decreasing her sense of uncertainty over her
• You can use your own ways to document it and share with
his wife, who was his sole caregiver, would of discussions to understand their values caregiving journey. your loved ones.
be confronted with disagreements with his and wishes regarding the various important Mr Tan conveyed his decision to his siblings. • You may also document your plans in the ACP workbook
siblings regarding his decisions on his care plan elements of care, including preferences relating They respected it and gave their full support to available at www.livingmatters.sg
at his end-of-life. Mr Tan’s siblings visited him to resuscitation, care and treatment, place his wife.
regularly even though they were not involved of care and death. After Mr Tan and his wife Mr Tan passed on in September 2020.
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T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1 T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1
COMPLETE
PREPARINGHOME
FOR CRISIS
CARE
Never a better
time than now
COVID-19 is a clarion call for Advance Care Planning,
highlighting how an unexpected and sudden health crisis
increases the urgency of making our care preferences known.
he COVID-19 pandemic we cannot hide from death. Every we have witnessed how this
T has irrevocably changed
our lives — how we
work, how we socialise,
day, we receive news on the rising
caseloads and death tolls worldwide.
COVID-19 is a stark reminder of
uncertainty causes significant
stress to the family members who
struggle to make decisions on their
and even how we eat. The global what we have always known but do loved one’s care. This is why we
spread and impact of the virus have not openly acknowledge — anyone are calling for people, even those
demonstrated that we humans are can suddenly fall seriously ill. who are young and well, to do
not as invulnerable as we think we In a serious illness, healthcare their Advance Care Planning (ACP). Everyone should take the
are, despite the many advancements decisions are complicated, with ACP is a series of conversations time to talk to their families
and loved ones about what
of modern medicine. The COVID-19 no single best answer. With the where a person’s values and they value in terms of
virus has afflicted young and old, rich advice of the healthcare team, the preferences are shared with their health and lives
and poor, and brought many of us, patient can then make a choice their loved ones and healthcare
perhaps for the first time, face to face after weighing the benefits and providers. These values and
with our mortality. risks of various treatments, based preferences are what shape an
In pre-COVID times, acute serious on their own personal values and individual’s healthcare decisions.
TOCK SENG HOSPITAL & DR RAYMOND NG, SENIOR CONSULTANT & HEAD, PALLIATIVE MEDICINE, WOODLANDS HEALTH
illnesses could happen to anyone goals. But when someone becomes They are unique to each and the risks, benefits and trade- 1. What are the things in life that and telemedicine consultations
CAMPUS THIS ARTICLE FIRST APPEARED IN LIFEWISE (JAN-MAR2021), AN NHG PUBLICATION PHOTO SHUTTERSTOCK
WORDS DR EUNICE CHUA, CONSULTANT, DEPARTMENT OF GENERAL MEDICINE & CLINICAL CO-LEAD FOR ACP, TAN
at any time as well — a sudden seriously ill and is unable to individual and allow for person- offs of various treatment options. give me meaning and purpose? right now on how to conduct
bout of acute pancreatitis triggered make decisions for themselves, it centred care. These conversations The Circuit Breaker period 2. How would I like my loved ones and implement ACP. In Singapore,
by previously silent gallstones, an becomes very challenging for their are documented and used to created many challenges and even to remember me? while there are some fledgling
insidious skin infection in the leg healthcare team. Without knowing guide both family members a certain degree of suffering for 3. What would I be most fearful of tele-health efforts to help people
from poorly controlled diabetes a patient’s unique preferences and and healthcare teams when the some, but it also brought great should I become seriously ill? do their ACP, we think there
resulting in septic shock, a road traffic values, healthcare teams default patient cannot make decisions clarity. We began to appreciate 4. If I should become dependent needs to be a louder call to
accident causing severe irreversible to choosing treatments that aim to for themselves during serious what we used to take for granted — and require a full-time caregiver, promote ACP in our population
brain injury. But these incidents of prolong life as much as possible, illness. When you are well and the freedom to simply sit outdoors what are my concerns and and systemically entrench it in
human vulnerability and mortality as well as consult patients’ families have the time and mental space and have a conversation with a preferences? our healthcare system. We need
were largely kept away from public or loved ones to make decisions on to think about what matters most loved one, to hug a friend, or share 5. How do I feel about the use of to change, en masse, our attitude
view, contained by the healthcare treatment options. to you, do your ACP; it allows you a meal with extended family. We life-support machines? towards talking about death and
teams in hospitals; the resulting grief However, in our experience, most to achieve a clear understanding learned that living well is more 6. Who knows me best and would dying, and embrace having these
and loss, no less painful, leaving their family members are uncertain as of what your health journey than just being physically alive. As be able to share my values with important conversations early
indelible marks on individual families this topic has never been discussed may look like, the potential we move forward as a country, we the doctors, to make healthcare with our families and healthcare
rather than whole nations. Now, before. In the face of time pressures, complications that may occur, should not lose sight of this clarity. decisions for me? practitioners.
We should take the time to talk ACP is not to a panacea for the
to our families and our loved ones We plan for everything in life: our pain and suffering one might
about what we value in terms studies, our career, vacations, whom face when one is seriously ill. But
We need to change, en masse, our attitude of our health and lives. By doing
our ACP, we could empower them
we marry, how many kids we
want, and our retirement. However,
it can be very helpful — for you,
your family, and your healthcare
with the right information so that studies have shown that the large team. Most importantly, the ACP is
towards talking about death and dying, if we cannot make decisions for
ourselves, our loved ones will be
majority of us do not plan for
serious illness or share our values
not cast in stone. As an on-going
conversation, it provides a way for
and embrace having these important able to have certainty and peace of
mind to make healthcare decisions
and preferences on our care with
our families.
us to talk about our fiercest loves
and our deepest fears and allows
on our behalf. This public health crisis could our loved ones to make difficult
conversations early with our families To help you get started, here
are some questions that you can
be an impetus for us to turn the
tide for ACP. In some countries,
decisions should they be called
upon. Rather than thinking about
think about and discuss with your such as the US and Australia, there this as taboo, embrace it as a gift of
and healthcare practitioners. loved ones: are COVID-specific advisories love to those you care about.
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T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1 T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1
ENGAGING WITH SENIORS
Carrying on
Seize the the conversation
Once you’ve started the conversation, what can you
moment
talk about? Here are three ideas to consider.
Providing companionship
If your loved one is home-bound and living alone,
there is a high chance that he or she is feeling lonely.
With seniors being more The rapid pace at which the world is moving may also
susceptible to the adverse effects add to the feeling of being isolated or left behind.
Palliative home care, which provides a range of
of COVID-19, it may be time to get services, may be an option. At MWS Home Care &
the conversation going with your Home Hospice, there are teams of doctors, nurses and
medical social workers who make regular home visits
loved one sooner rather than later. and provide round-the-clock support. Many seniors
actually look forward to the visits even when they are
well because of the companionship and camaraderie.
Getting care according to their wishes
While you may be focused on curative treatment
to treat your loved one’s condition, he or she may
have other thoughts about the care they want.
Hence, it may be a good time to bring up Advance
Care Planning (ACP), which promotes care that is
consistent with his or her values and preferences. It
guides you and the healthcare team to make decisions
in your loved one’s best interests should he or she
lose the mental capacity to do so. One tool that often
complements ACP is the Advance Medical Directive,
which informs the doctor treating your loved one to
An MWS Home stop aggressive life-prolonging treatments should this
Care & Home
Hospice patient be what he or she wishes. This helps to avoid disputes
receives holistic care
between family members when the time comes for
critical medical decisions to be made.
Having a better quality of life
hile the COVID-19 situation According to a press release issued by who are in short supply as many have returned We all want our loved ones to be comfortable, not
W has improved in Singapore,
especially with the vaccine
the Ministry of Health, Singapore*, seniors
aged 60 and above form at least 80% of all
home and there are travel restrictions for their
replacements. This results in them not being able
suffering towards the end. Yet, more often than not,
the curative treatment route may cause pain and side
WORDS & PHOTO METHODIST WELFARE SERVICES
now available, it is widely COVID-19 deaths. The number is even higher in to receive the optimal care required. Many are
effects. This makes it important to talk about palliative
acknowledged that the crisis has been Singapore, where seniors made up 95% of all also more emotionally distressed due to myriad
particularly hard on seniors. From being COVID-19 deaths. The statistics also indicated reasons, such as having to adhere to strict safe
care, which gives him or her the option for pain and
more susceptible to dying from the virus that nearly 1 in 6 or 16% developed severe distancing guidelines and juggling the needs of symptom management, as well as a higher quality
to experiencing adverse effects of various symptoms and required intensive care in the other family members. In addition, they may of life by meeting their physical, psychological and
containment measures, seniors have borne hospital compared to just 0.2% of non-seniors. be experiencing a higher level of anxiety when spiritual needs. Giving your loved ones better control
the brunt of the impact. Although the various measures to safeguard visiting hospitals and polyclinics for fear of over their pain and symptoms will also enable them
This makes it more important than ever to the health and well-being of seniors may getting infected by the virus. to spend their remaining time in a more meaningful
start that end-of-life conversation with your have kept the death toll low, these may have manner. Palliative care could also be helpful for those
loved one as soon as possible. One way to resulted in undesirable effects. *Ministry of Health, Support Measures for Seniors who are struggling with the emotional distress and
broach the topic could be to share about the At MWS Home Care & Home Hospice, many During COVID-19, 8 May 2020. Retrieved from anxiety brought on by the COVID-19 situation.
COVID-19 situation and its serious impact patients are facing limited access to care https://www.moh.gov.sg/news-highlights/details/
on seniors. resources, such as foreign domestic workers support-measures-for-seniors-during-covid-19.
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T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1 T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1
LEAVING MEMORIES
End-of-life Caption for the nurse
here Caption for the
nurse here Caption
conversations: start
for the nurse here
Caption for the nurse
here Caption for the
nurse here
at the beginning
Patients and their caregivers can use the recently published
A Family Dignity Intervention Journey: Our Lasting
Legacy to create their own legacy document.
id you know that the But we are not just ‘the patient’. caregivers, with the goal of
D most important and
meaningful stories in
our lives are actually
We are not just ‘the caregiver’.
We are unique individuals with
wonderful stories to tell. We are
deepening emotional connections,
creating lasting legacies and paving
the way for end-of-life discussions.
our own? The ones that were spouses, children, siblings, parents The FDI is conducted by a trained Senior counsellor
created since the day we were born, and friends. We have loved and lost, therapist who delves into an Geraldine Tan-Ho and
Associate Professor Andy
continued as we walk through life, given and received, dreamed and exploration of recollections, life Ho with their publication
and shared with special people we accomplished, failed and learned. accomplishments, words of wisdom A Family Dignity
Intervention Journey:
meet along the way. Most importantly, we have shared and expressions of appreciation Our Lasting Legacy
Sometimes, painful events such these precious experiences and between patients and their
as the diagnosis of a serious illness memories with some special people family caregiver. This interview
can seem to consume our entire in our lives. All of these cannot be is later transformed into a ‘legacy
lives. As patients, we may feel undermined by the presence of a document’ — an edited and
SINGAPORE AND A MEMBER OF SHC’S COMMUNITY ENGAGEMENT & COMMUNICATIONS COMMITTEE
overwhelmed by the daily physical life-threatening illness. personalised copy of the interview “When they have the opportunity we should always remember to start 8. What are your hopes and
PHOTOS NANYANG TECHNOLOGICAL UNIVERSITY SINGAPORE CORPORATE COMMUNICATIONS
discomfort, and the emotional transcript that is designed like to first recall shared memories from at the beginning. Based on the FDI dreams for yourself, and
WORDS GERALDINE TAN-HO, SENIOR COUNSELLOR, NANYANG TECHNOLOGICAL UNIVERSITY
rollercoaster of uncertainty, hope FAMILY DIGNITY INTERVENTION – an autobiography — and given to childhood to adulthood and think interview, patients, family caregivers your loved ones?
and fear that accompany our CREATING LASTING LEGACIES patients and their families. Last about what they have accomplished and healthcare professionals can 9. What are some things you
illnesses. As family caregivers, we Associate Professor Andy Ho and year, the team published A Family and learned in life, they begin to embark on a meaningful storytelling would want your loved one
may feel completely absorbed by his team at the Action Research Dignity Intervention Journey: reflect also on what they would journey with such questions: to know about you, or to
our caregiving responsibilities, for Community Health (ARCH) Our Lasting Legacy, a book with like for themselves and their loved remember about you?
while coping with the tiredness Lab designed the Family Dignity activities based on the FDI for ones in the future. The FDI provides 1. Tell me about your childhood.
that comes with our devoted acts Intervention (FDI) in 2017 to patients and caregivers to create a gentle and empowering way of What are some of the important In bringing back old
of caregiving. On top of all these, facilitate valuable conversations their own legacy document. This inviting patients and caregivers and memorable times in memories, new and cherished
we are asked to participate in end- between patients and family book has been distributed to local into these difficult but crucial your life? ones are made. In expressing
of-life care conversations, such as hospices, hospital palliative care conversations.” 2. How has your relationship appreciation and love, family
Advance Care Planning or units and intermediate long-term with your loved one influenced bonds are rekindled. In
Lasting Power of Attorney, care facilities (ILTC) such as START AT THE BEGINNING your life? talking about our lives, we
something many of us nursing homes. An interactive Mr. Ahmed*, a patient who had 3. What do you think are your most pave the way to reflections
had never even thought web version of the book is received Family Dignity Intervention, meaningful accomplishments about our death. The end-
about before the also underway. once wisely declared, “If someone in life? of-life conversation must be
illness. Suddenly, our A/Prof Andy Ho observes does not ask about your life, how 4. What do you think your loved dignifying, empowering and
present lives seem to that a significant feature can they ask about your death?” one is most proud of you for? meaningful; perhaps a lasting
revolve solely around of the FDI is that while the Indeed, end-of-life care 5. What do you appreciate most legacy and a story in itself.
the illness and its interview questions did not conversations must begin from about your loved one? After all, life is a gift to us, and
repercussions; the ask about end-of-life care a place of love and concern, and 6. What would you like to thank sharing our life stories can be
‘good old days’ feel like planning, many patients and not simply from a place of urgent your loved one for? our gift to the ones we love.
a distant memory, or caregivers brought up these necessity. Whether or not we are in 7. Are there any words of wisdom
even a figment of our topics organically during a hurry to acquire or convey final or advice that you would like to *Name has been changed
imagination. the interview. wishes and plans for the very end, offer to your family? for confidentiality
18 19
T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1 T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1AN HEIRLOOM TO TREASURE
Left: The ties bound by
A lifetime of love and shared food memories
memories are wrapped are unbreakable and a
up in the legacy strong legacy. Below:
works left behind for This recipe book
patients’ families will help Mdm Wee’s
children continue the
tradition of cooking
for the family.
The Medical Social Services (MSS) team on the
other hand provided psycho-emotional support for
her to complete the project.
But the process was not as easy as the team
thought it would be. Madam Wee was lethargic and
needed rest most of the time due to her condition.
“
To help her complete her wish, the Rehabilitation
team focused on getting one recipe done at a time.
They broke down the tasks into smaller steps and
completed them day by day. For example, the team
would start with getting the list of ingredients
followed by recording the methods the next day.
Some examples of legacy Once they have gotten all the information,
they began to decorate the recipe book based on
Madam Wee’s instructions. There was also the
work are conducting a life language barrier that the team had to overcome.
The team had to enlist the help of Teochew-
review, creating a recipe speaking colleagues so they could understand
Madam Wee’s wishes.
With all the help from the team, Madam Wee was
book, written or audio letters, finally able to complete her recipe book. She passed
away three months later in August 2020 in her
A mother’s love
late 80s, but not without leaving something very
or photograph albums to valuable behind.
Madam Wee’s legacy work taught many staff and
To most, it’s merely a cookbook. But for one palliative patient at Sengkang
family members.” patients about a mother’s unconditional love. She
was able to be a part of her children’s life despite
her illness, continuing to celebrate their birthdays
Community Hospital, the collection of recipes was part of her legacy that PRABHA D/O TECHNA MITI, whenever her recipes are recreated in the kitchen
SKCH SENIOR MEDICAL SOCIAL WORKER she left behind.
allowed her to live out the remainder of her life meaningfully.
adam Julie Wee’s life was not always She envisioned the book to be filled with
M smooth sailing. Ever since her
husband passed away many years
traditional dishes that she used to make for their
birthday celebrations. A part of her will stay with
Starting legacy work
Legacy works help patients to reflect and initiate
PHOTOS SINGHEALTH COMMUNITY HOSPITALS, PEXELS.COM
ago, she worked hard to raise her them as memories and remind them how she
three children on her own. It was tough being a used to prepare their favourite dishes on those
a review of their life experiences and document
single parent, but her love for them was far greater special occasions. it as a tangible item so that their stories can be
than anything else. It will also help her children to continue with passed on to the future generations.
WORDS SINGHEALTH COMMUNITY HOSPITALS
the tradition of cooking for the family at home.
HER LAST WISH The Rehabilitation team then initiated Some questions that can be asked are:
Madam Wee was known by her fellow patients and this piece of legacy work — something that • What activities are meaningful to them to create a
the hospital staff to be a reserved person. She only allowed palliative patients to reflect on what’s tangible memory?
opened up and shared about her life experiences important to them, and motivate them to have a • What are some tips or life experiences that they
when spoken to in the Teochew dialect. dignified rest-of-their-lives during their stay in a would like to share with others?
The fluent Teochew speaker knew that time community hospital. • What would they want their family to remember
was not on her side. She could feel her condition “The Rehabilitation team provided her with them for?
worsening each day and so, expressed her wish different art materials to create her cards and • What would they like to leave behind for their
to write a card for each of her children and recipe book. She would request for what she loved ones?
also to create a recipe book that contained their needed and the designs she wanted,” shared
favourite dishes. Tricia Ng, SKCH Senior Occupational Therapist.
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T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1 T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1SHC COMMUNITY RESOURCES HAPPENINGS
Get started on
end-of-life care planning
with SHC resources!
Conversation Cards Time Of My Life:
It’s important to know your values, motivations, beliefs Past Perfect,
and life goals, and identify people in your life that could The Journal of
act as spokespersons in times of critical need. There are Self-Discovery
30 questions classified in three levels of complexity. Here
are some examples you can try with your loved ones! The first step in creating a legacy
1. Easy and the beginning of important
• What is one life lesson I have learnt from conversations with your loved ones is
my grandparents? by sharing your own story, desires and
• What is the most memorable experiences. There are 10 chapters to
event that has happened in explore! Here are some questions from
my life? the “Favourites” chapter, so you can
2. Intermediate better care for your loved ones when
• Who and/or what they are terminally ill.
encourages or inspires 1. What is your favourite: colour,
me most? country, TV show, radio station,
• When am I most animal, celebrity?
comfortable being myself? 2. What are your favourite childhood food or snacks?
3. Advanced 3. Where can you find your favourite dishes now?
• What do I think about 4. What are your hobbies and favourite activities?
death and dying? 5. What is your memorable moment during your
• Who can speak for me if I’m admitted to hospital? favourite public holiday?
Palliative Care Communicator (PCC) online training course
To get physical copies of these Who Should Attend:
resources in English and Mandarin, Social workers, psychologists, counsellors, allied health
which are part of SHC’s Community professionals, education and social service practitioners,
Engagement Kit, sign up for SHC’s volunteers and general public. We invite social service
le play
Participants ro on cards
Palliative Care Communicator agencies to organise the training course for their staff and
with conversati (PCC) online training course today! volunteers, and members of the public to form a group of
minimum three participants.
Course Objectives:
For more details of the programme and to download the response form, please visit
At the end of the two-hour free course, participants will: Course Requirement:
https://singaporehospice.org.sg/events/charity-show-25
• Gain knowledge to start conversations with their service Each participant is required to use the Community
recipients on palliative care and end-of-life care Engagement Kit to have conversations with at least two
• Develop skills in using the Community Engagement Kit individuals and provide feedback of experience in a survey form.
and to help the service recipients reflect on life and
end-of-life matters SHC will send a trained professional to
conduct the training.
Mode of Course Delivery:
The course can be conducted in English or Mandarin. Sign up via the online form at
It will be delivered through lecture, structured group https://singaporehospice.org.sg/
Please complete the response form and email to rsvpshc@singaporehospice.org.sg.
discussions, case studies and interactive role-plays. training-courses/.
22 23
T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1 T H E H O S P I C E L I N K • M A R C H – M AY 2 0 2 1ANNOUNCEMENTS
SHC welcomes
Upcoming Events
Ren Ci Hospital as our MARCH - MAY 2021
SHC “Live Well. Leave Well.”:
25th member All You Need To Know About Palliative Care Talk
Join us for an informative session to understand
palliative care and end-of-life matters. The session
also aims to increase awareness of the attitude
towards death and its impact on the willingness to
converse with family or loved ones. It also aims to
provide the participants with the suite of Community
Resources available for palliative care in Singapore.
Time: 2.00pm - 3.30pm
Venue: Online via Zoom
Contact: contact@singaporehospice.org.sg
Ren Ci Hospital is a charity healthcare institution Registration*: https://tinyurl.com/shctalks21eng
founded in 1994 with the primary mission *Please indicate your interest in the link and we will
of providing affordable medical, nursing and contact you via email.
rehabilitative care services for the community,
based on the principles of loving kindness and
23 MARCH 2021
SDSPCC-SHC Palliative Care MDF* –
compassion, regardless of race, religion and Patient-Centred Outcomes That Matter
background. Over the years, Ren Ci has played Speaker: Professor of Palliative Care Fliss Murtagh,
an active role in the lives of a growing silver Hull York Medical School, UK
population in Singapore through expanding its Time: 12:00pm – 1:00pm
spectrum of services to support the healthcare Venue: Zoom Webinar
needs of the senior community. Partnering the Registration: https://bit.ly/3cOTxoz
*SingHealth Duke-NUS Supportive and Palliative Care
community remains pivotal to the sustainability
Centre - Singapore Hospice Council Palliative Care
of our care delivery, providing those we serve Multidisciplinary Forum
with the hope for quality and meaningful living.
20-28 MARCH 2021
Singapore Cancer Society –
TalkMed Relay For Life 2021
This event offers everyone a chance to celebrate
cancer survivors and caregivers’ triumphs against the
EDITORIAL COMMITTEE disease, remember loved ones lost to cancer and fight
back against the disease. Participants can fundraise
for the cancer community by running / walking /
Editor Christina Wee
cycling / swimming or come up with their own
Associate Editor Anne Loh
fundraising challenge to show cancer patients that
they are not alone in the fight against cancer.
Alexandra Hospital Yvonne Lee Venue: Anywhere (Virtual Event)
Assisi Hospice Angela Yeo Admission: Free
Buddhist Compassion Relief Tzu Chi Editorial Team Registration: https://scsrelayforlife.sg/ (Registration
Tzu Chi Foundation (Singapore) closes on 19 March 2021)
Changi General Hospital Rasidah bte Alias
Dover Park Hospice Jenny Goo 1 APRIL 2021 - 31 MAY 2021
HCA Hospice Care Toh Wei Shi SHC @ Ang Mo Kio Public Library
Khoo Teck Puat Hospital Tricia Tan Explore and learn more about palliative care and
Lien Centre for Palliative Care Tang Swee Noi end-of-life care planning through stories and
Metta Hospice Care Cecilia Soh printed resources!
MWS Home Care & Home Hospice Nicolette Yeo Venue: Level 1, 4300 Ang Mo Kio Avenue 6, S(569842)
Ren Ci Hospital Sharon Tan
In view of the COVID-19 situation, please check our
website www.singaporehospice.org.sg for updates.
The Palliative Care Centre for Tan Li Kuan
Excellence in Research and Education
Sengkang General Hospital Farah Rahman
Singapore Cancer Society Kumudha Panneerchelvam
Singapore General Hospital Mavis Law
Singapore Hospice Council Sheena Koong
SingHealth Community Hospitals Muhammad Azhar bin
Abdul Rahim
St Andrew’s Community Hospital Peh Lay Koon
St Joseph’s Home Shereen Ng 1 Lorong 2 Toa Payoh #07-00, Braddell House, S (319637)
St Luke’s Hospital Chua Hwee Leng T: 6538 2231 • E: secretariat@singaporehospice.org.sg
Tan Tock Seng Hospital Candice Tan www.singaporehospice.org.sg
Tsao Foundation Desiree Lim
Design Christian Subrata Contents are not to be quoted or reproduced without the prior
Printer Yung Shung Printrade Pte Ltd written permission of the Singapore Hospice Council.
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