People often delay advance care planning (ACP) for many reasons.
For those in the pink of health, planning for future care arrangements can seem excessive and unnecessary since mental incapacity feels unlikely and/or on the far horizon. Even individuals with chronic conditions or terminal illnesses may choose to avoid the topic since making such important decisions can seem daunting, and conversations around death and disease are often regarded as a taboo subject.
However, ACP is important to ensure that we receive the form of care we want in scenarios where we are unable to make decisions and speak up for ourselves — and it’s not as difficult as it seems! There are many tools, tips, and resources available to get you started. Let’s break it down together step-by-step.
What is Advance Care Planning (ACP)?
Advance Care Planning (ACP) refers to the process of planning for your current and future care arrangements. This process involves communicating your values, beliefs, and healthcare preferences to a trusted individual or healthcare team. It also involves the nomination of a trusted individual, called a nominated healthcare spokesperson (NHS), who can make healthcare decisions on your behalf in the event of diminished decision-making capability.
ACP will guide decision makers in delivering quality care that is in your best interest and aligned with your values, should you no longer be able to speak or make decisions for yourself one day.
Types of Advance Care Planning
There are 3 stages of ACP across an individual’s lifespan:
| General ACP | Disease-Specific ACP | Preferred-Plan-of-Care ACP | |
|---|---|---|---|
| What does it involve? | - Appoint a NHS - Decision on the goals of care if you are rendered severely mentally impaired with low chance of recovery | - Appoint a NHS - Decision on the goals of treatment if complications result in “bad outcomes”, particularly in these 3 scenarios: a. Low chance of survival b. Low chance of recovery of physical function or ability to communicate and will require total nursing care c. High chance of mental incapacity and will require total nursing care - Specific disease-related care | - Appoint a NHS - Care options on CPR - Care goals on medical intervention in the event of a potentially life-threatening crisis - Preference on place of care and place of death |
| Who is it for? | Healthy adults Adults with early chronic disease | Adults who are diagnosed with a progressive, life-limiting illness and experience frequent complications | Adults with an estimated life expectancy of 12 months of less |
Besides existing health conditions, you should also take into account your family history of hereditary conditions when carrying out ACP.
Steps to carry out ACP
It can be difficult to start conversations around advance care planning, especially when many consider diseases and death a taboo subject. If you are not sure where to start, here are some tips and steps to guide you in your ACP process:
1. Reflect on things that are important to you
Think about your values and any wishes that are important to you. Remember that each individual is different and not everybody wants and values the same things in the same way as you do. There are no right or wrong answers, so it’s important to focus on the things that are uniquely important to you.
Starting with this reflection as your first step in advance care planning can help you gain greater clarity and be more confident in the choices you are about to make.
If you are not sure what you need to consider when you are self-reflecting, the Agency for Integrated Care (AIC) has kindly prepared an ACP workbook to guide you in exploring and communicating your care preferences.
2. Decide on your Nominated Healthcare Spokesperson (NHS)
An important aspect of ACP is appointing a trusted individual who will be your voice if you are unable to speak for yourself. This person will be your NHS, and can be a family member or friend. Most importantly, he/she should be someone whom you trust and feel comfortable sharing your wishes with.
In an ideal scenario, your NHS should be an individual who meets the following criteria:
- At least 21 years old
- Understands you well, will talk with you, and listens to and respects your wishes
- Willing to speak to the medical team and relevant parties about your values and treatment goals on your behalf
- Able to make decisions and act in your best interest under stressful situations
You can appoint up to 2 persons to be your NHS, and they can discuss and work with one another to act in your best interest when required.
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3. Speak with your chosen Nominated Healthcare Spokesperson (NHS)
Here comes the tricky part: starting the conversation. Conversations surrounding death are often regarded as taboo. Here are 3 tactful ways to broach the topic on ACP and have this crucial conversations with important people in your life:
Bring up an event that affected you
I was thinking about Auntie Jess recently and it made me reflect about what healthcare I would want if I got really sick. I realised that if something similar happened to me, I’d want you to know my healthcare preferences and what to do for me. Can we talk about this?
Discuss plans for the future
I’m living with <health condition> right now, and this puts me at an increased risk of <potential complications>. I figured that if something happens to me, I’d want you to know what to do. Can we have a conversation about this?
Be direct
Even though I’m healthy right now, I want to be prepared if there ever is an unexpected situation where my mind is no longer active and I can’t make decisions for myself. Can I share with you my healthcare preferences and have you speak and make decisions on my behalf if the situation arises?
4. Document your ACP
The next step is to document your ACP so that it can guide your healthcare team whenever necessary. ACP documentation can be done at most hospitals, selected polyclinics, and community care providers. If you are a patient at a polyclinic or hospital, you can ask for a referral to do your ACP. Healthy individuals can make an appointment at ACP nodes. ACP through video conferencing is possible as well. Here is a list of places where you can make an appointment for an ACP session.
Do note that while documenting your ACP is important, it is not a legally binding document. It simply facilitates discussion and helps your loved ones and healthcare team understand your values and preferences so they can act in your best interest. If you are looking for legally binding documents, consider drawing up an Advance Medical Directive (AMD) to state your healthcare preferences and/or a Lasting Power of Attorney (LPA) to legally grant a loved one the rights to make decisions on your behalf when you can no longer do so.
5. Review your ACP regularly
Your life goals and decisions may change through the years, so it’s important to update your ACP to reflect those changes. As long as your decision making capabilities are not impaired, you can make changes to your ACP.
Review your ACP every few years, especially after any of the following events:
- Every new decade of life
- After a significant medical diagnosis
- After a significant change in daily function (ability to perform activities of daily living)
If you have made changes to your ACP, do remember to let your NHS know as well so they are aware of your latest care preferences.
Other ways to plan ahead
Besides ACP, there are many other ways you can plan ahead and prepare for situations where you no longer have the mental capacity to make decisions for yourself.
Lasting Power of Attorney (LPA)
A Lasting Power of Attorney (LPA) is a legal document which allows you to appoint one or more person(s) to make decisions and act on your behalf should you lose mental capacity one day. This may include decisions on personal welfare, property, and financial affairs. If a LPA is not set up, your loved ones will need a court order to administer decisions on your behalf, which can be costly and time-consuming.
While LPA grants another person the legal rights to make decisions for you, it doesn’t tell them what to do. Therefore, ACP is still important in helping you communicate to your loved one your preferences and how to act in your best interest.
Advance Medical Directive (AMD)
An Advance Medical Directive (AMD) is a legal document that specifically informs your healthcare team that you do not wish to use life-sustaining treatment to artificially prolong your life should you become incapable of communicating your decisions and death is imminent. You can set up an AMD as long as you are at least 21 years of age with decision-making capability.
Do take note that a LPA does not override an AMD.
Will planning
A will indicates the distribution of wealth after you have passed on. This includes any money and possessions (called estate) you may have. Upon death, your loved ones can apply to the Courts for a Grant of Probate to distribute the estate according to the will. If no will is set up, assets will be distributed according to the Intestate Succession Act (or Inheritance Certificate for Muslims).
CPF nomination
A CPF nomination allows you to distribute the money in your CPF according to your wishes after death. Nomination is free and can be done as soon as you turn 16. Similar to ACP, it is recommended that you review your CPF nomination regularly, especially after any key milestones in your life such as marriage, childbirth, divorce, and death of any nominee(s).
Upon death, CPF savings will be distributed to the nominees in cash or cheque. If no CPF nomination is made, your CPF savings will be transferred to the Public Trustee’s Office, and your loved ones can apply to have the CPF monies distributed according to the intestacy laws, for a fee.
Insurance
Having adequate coverage in the form of health insurance can help to greatly offset the financial burden of healthcare costs on yourself and your loved ones. Discuss with your financial advisor to decide on the best health insurance plan to ensure you are adequately covered financially.
Plan your own care arrangements in advance
If you are diagnosed with a chronic condition or terminal illness but are still able to make decisions for yourself in the present, you can arrange long-term or end-of-life care for yourself in advance. However, it is still essential to conduct ACP and discuss your decision with your loved ones, so that they are aware and prepared when it happens and can make sure that things are carried out as you have planned.
Key Takeaways
Making major life decisions is no doubt a daunting task, but we hope that our step-by-step guide and the various tools and resources available have encouraged you to take your first steps towards advance care planning. After all, not only does it ensure that you get the care you prefer, your loved ones can also feel more assured and do not have to second-guess if the decisions they make are in your best interest.
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