A patient in the hospital with saline intravenous, in Asian elderly man hand. Blurred his face from Shutterstock.com

Singaporeans’ ideal situation of a “good death” is to die at home surrounded by loved ones. But according to a report released by the Institute of Policy Studies (IPS) on Friday (12 July), this desire to have a dignified passing is far from the reality on the ground and argues that a lot needs to be done to change the way end-of-life care is handled.
The report, titled “Leaving Well: End-of-Life Care Policies in Singapore”, cited a 2014 survey by the Lien Foundation which revealed that 77% of Singaporeans wanted to die at home. Unfortunately, as of 2017, nearly 70% of them passed away in hospitals, nursing homes or charitable institutions. In fact, lesser than one in four Singaporeans (24%) actually died at home.
As such, the report stated that it wants the government to relook at this matter to bridge the reality gap.
“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,” said the authors.
As such, the study called for a realistic outlook on death which focused less on finding cure for terminally-ill patients as treatment may be pointless, and more on giving them a better quality of life as their final days get closer.
The study also offered a few suggestions on how to improve end-of-life care for Singaporeans like bringing up conversations on death. It also recommended to have a payment system based on the overall needs of the patient, rather than the current method that focuses on the number of consultations.
The researchers, Christopher Gee and Yvonne Arivalagan, conducted the study through consultations with experts from different areas – ranging from healthcare and social work to policy-planning. The discussions were held among the experts over three working group set up by IPS, between 2017 and 2019. In addition to that, the authors also supported their findings with prior studies on end-of-life care.

The main problems

  1. Expensive healthcare

The study raised a few issues in the healthcare system in Singapore. One of the main problems highlighted is that end-of-life care is deemed unaffordable by Singaporeans, resulting to them not thinking about it until it’s too late.
This is particularly true for elderly poor and “sandwiched” class of middle-income caregivers. Expensive medical cost in terms of out-of-pocket payment, deductibles and co-insurance is stopping people from receiving treatment, especially for treating terminal illness in an expensive tertiary care setting.

  1. Problem in speaking about someone’s final days

Another issue is that there were barriers for people to talk about their final days with their families. Some of the examples include superstition about discussing death as well as not wanting to reduce the patient’s will to live. The study also noted that the cost of medical bill is also a common reason for conflict within families, forcing them to not have conversation with patients about end-of-life care.

  1. Interference by family in making healthcare decisions

The study also revealed that it was hard for patients to make their own healthcare decisions as they’re often interrupted by their family. Some families don’t even reveal the diagnosis to the patients. Due to this cultural attitude, patients don’t get the chance to make decision about their own healthcare.

Key suggestions

  1. Advocating conversation about death sooner

One of the recommendations in the study include initiating conversations about end-of-life care sooner. The authors pointed out that by talking about key moments in one’s life like marriage or childbirth, it can raise the issue of end-of-life care in order for people to be more proactive in making plans. For example, organisations like Registry of Marriages or insurance companies could offer platforms for discussion about a person’s last days.

  1. Testing new approach of healthcare payment

The researchers suggested to opt for a different payment model for doctors. Right now, Singapore has a “fee-for-service” model where patients pay doctors for each consultation or service. But the study suggested to embark on the “capitation payment” model. This means that doctors will be paid a fixed sum per patient for a predetermined period of time.
Mr Gee explained at a media briefing that a general practitioner could be assigned to give primary care services to 1000 people within a certain neighbourhood. As for the payment model, it could be done through insurance schemes, the state, or a combination of both.
The authors said that this model will push doctors to proactively care for patients and understand their conditions better, resulting to a better and lower healthcare costs.

  1. Limitation in Mental Capacity Act

Under the Mental Capacity Act, Singaporeans who are appointed with a Lasting Power of Attorney (LTA), also known as donees, are not given the rights to make decisions regarding life-sustaining treatment or any other treatment that will worsen the health of a mentally incapacitated individual. In short, the LPA is a legal document that allows another appointed person to make decisions on behalf of the patient if he has lost his mental capacity.
As more elderly patients permit healthcare decisions to their family members, the authors recommended that facilitators of advanced care planning should raise these restrictions when talking about end-of-life matters with patients, and seek clarifications from them on their preferred life-sustaining treatment.

  1. Boosting the palliative care sector

The authors also called for the palliative care sector to be strengthened as it is under-resourced compared to hospitals and tertiary institutions. They added that home and community-based providers should be enhanced through training, remuneration, working conditions and new models of delivering care.
Besides that, doctors and medical professionals should also be equipped in palliative care to promote community-centred care.
Upon reading this news, netizens commented on TODAY’s Facebook page stating that they support the study’s points as end-of-life care is crucial. Andrew John pointed out that he has been “advocating this concept of preparing for ones death instead of pumping money into medicare or medisave funds that limit the usefulness as oppose to funeral”. He also suggested that the government should introduce a funeral insurance, just like in Australia.

Some suggested that the government legalise euthanasia like other countries in the world, as well as build a suicide forest just like the one in Japan.

A bunch of other online users said that Singaporeans are required to pay so many different insurances like Medisave, Medishield and Eldershield, but they still have to fork out more money when seeking treatment. As such, they feel that it’s unfair that the government can’t offer free treatment given that they pay for insurances. If that is not all, they also noted that the insurances only cover basic care and not advanced medical treatment or other serious illnesses. Therefore, they want the government to look into this matter, especially on the high medical cost in the country.

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