Later-Life Planning: Living Your Later Life with Dignity

An article first published on Providend website here: https://providend.com/later-life-planning-living-your-later-life-with-dignity/

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Later-Life Planning, commonly known as End-of-Life Planning, is the process of making important decisions and arrangements for your future medical care, financial matters, and personal preferences as you approach the later stages of your life or if you become unable to make decisions due to terminal illness or mental incapacity. It involves thoughtful consideration, communication, and documentation of your wishes to ensure that they are respected and honoured during the final stages of life.

In 2020, the Ministry of Health (MOH) and Public Service Division (PSD) set up the My Legacy portal[1] to serve as a one-stop resource to provide information on Later-Life Planning and Legacy & Estate Planning. It also provides a vault to securely store your legal, healthcare and estate documents, and share them only with the people you trust.

Agency for Integrated Care (AIC)[2] has a nicely done infographic[3] that shows you the tools for Later-Life Planning and Estate Planning, and when you should apply and activate these tools at different stages of your caregiving journey:

In this article, we focus on the often-neglected Later-Life Planning in Singapore context.

Why is Later-Life Planning Important?

In the later stage of our life, we may encounter a medical crisis which impairs our own capacity to make decisions. In such cases, we need our loved ones to participate in decisions related to taking care of our health, managing our personal welfare, property and affairs, and deciding whether to carry out extraordinary life-sustaining treatment when we become terminally ill and unconscious.

Planning ahead can help you document your wishes on receiving the care you want and make things easier for your loved ones in deciding how to care and manage for you. It involves thinking and talking about:

• How would you want to be cared for at the later stage of your life?
• Who can make decisions for you when you lose mental capacity?
• How would you want your assets to be managed when you are mentally incapacitated?

• Do you want extraordinary life-sustaining treatment to prolong your life?

Later-Life Planning Components

The components for Later-Life Planning in Singapore are Advance Care Planning (ACP) [4], Lasting Power of Attorney (LPA)[5], and Advance Medical Directive (AMD)[6].

Advance Care Planning (ACP)

ACP is a planning process, not a legal document. It lets you communicate what you want for your own health care and guide your loved ones in making important care decisions for you when you encounter a medical crisis which impairs your capacity to make decisions.

Some examples of care preferences would be:

• Comfort-focused treatment, which aims to provide you with a reasonable quality of life, or full treatment, which pulls out all the stops to keep you alive.
• Location of care in nursing home, hospital, hospice facility, or at home.
• Do-Not-Resuscitate (DNR) Order, where you indicate that you do not want resuscitation attempts in the event of cardiac arrest.

Steps to Draft Your ACP

1. Reflect on what you want: Think about the quality of life you want, and the medical treatment you are comfortable with. To explore and share your care preferences, you may use the ACP Workbook here: https://www.aic.sg/resources/Documents/Brochures/ACP Publications/Workbook/ACP Workbook-EN.pdf
2. Choose your Nominated Healthcare Spokesperson (NHS): Your Nominated Healthcare Spokesperson is someone you can trust to convey your care preferences, should you no longer be able to do so. This someone is usually a family member or close friend.
3. Record your choices: Find a certified ACP facilitator to discuss and submit your ACP to the National Electronic Healthcare Record (NEHR)[7]. You may find an ACP facilitator here: https://mylegacy.life.gov.sg/find-a-service/find-advance-care-plan-facilitator/.
4. Review your ACP: ACP is a reflection of you. As your life changes, you may make new decisions. When you do, update your ACP and loved ones.

For more details in making your ACP, you may refer to My Legacy website here: https://mylegacy.life.gov.sg/end-of-life-planning/make-an-advance-care-plan/

Some Consequences if You Don’t Have ACP

• Healthcare providers may be uncertain about the types of treatment you would want or refuse in critical medical situations and can lead to delays in treatment.
• Medical professionals may default to providing aggressive treatments to prolong life, even if those interventions are not aligned with your preferences.
• Family members may have differing opinions about the appropriate medical care for you and can lead to disagreements, conflicts, and added stress for your loved ones.

Lasting Power of Attorney (LPA)

LPA is a legal document governed by the Mental Capacity Act (MCA)[8] passed in 2008. It allows you (the ‘Donor’) to appoint one or more trusted people (the ‘Donee’) to help you make decisions on your behalf when you lose mental capacity.

A mental incapacity could happen due to advanced dementia, a mental health illness, a coma, and unconsciousness caused by illness or medical treatment. Once your loss of mental capacity is certified by a registered medical practitioner, your Donee(s) can use the LPA to manage your personal welfare and/or property & affairs.

Steps to Draft Your LPA

1. Choose your Donees: You can appoint 1 or more Donees to manage your personal welfare and/or property & affairs. You can also appoint replacement Donees as a standby to take over all or some of the authority that the original Donee has been given when he/she is no longer able to carry out the responsibilities.
2. Complete your LPA Form 1 or Form 2:With LPA Form 1, you may appoint 1 or 2 Donees, appoint 1 replacement Donee, and grant Donee(s) general powers with basic restrictions. You can draft your LPA Form 1 through the Office of Public Guardian Online (OPGO) portal: https://opg-eservice.msf.gov.sg/OPGO/Login.aspx However, if you want to appoint more than 2 Donees, more than 1 replacement Donees, or grant Donee(s) customized powers, you have to engage a lawyer to draft your LPA Form 2.
3. Certify your LPA: Once all your Donees have accepted their appointments, you will need to certify your LPA by visiting a Certificate Issuer (CI), who can be an Accredited Medical Practitioner, a Practising Lawyer, and/or a Registered Psychiatrist. You may find a CI here: https://opg-eservice.msf.gov.sg/LPA/CIMapService.aspx
4. Register your LPA: Your LPA will only be valid after it has been registered with Office of Public Guardian (OPG)[9].

For more details in making your LPA, you may refer to My Legacy website here: https://mylegacy.life.gov.sg/end-of-life-planing/make-a-lasting-power-of-attorney/

What Happens if You Don’t Have LPA?

If you lose your mental capacity without an LPA, your loved ones must apply to the Family Courts to be appointed as your deputy before they are authorized to make decisions and act on your behalf. The deputyship application process can be time-consuming, costly, and potentially stressful for your loved ones.

While the court process is underway, there may be delays in making important decisions about your medical treatment, personal welfare, and financial matters. These delays can be problematic, especially for urgent decisions.

The deputyship application must state the care and financial plan for you, the deputy powers to apply for and which powers various organisations need to let you perform transactions as your deputy. It is a legally demanding process, likely involve lawyers, and the outcome is subject to the Courts’ approval.

For more details in Deputyship Application, you may refer to the SG Courts website here: https://www.judiciary.gov.sg/family/deputyship

Advance Medical Directive (AMD)

AMD is a legal document governed by the Advance Medical Directive Act (AMDA)[10] passed in 1996. It allows you to state whether you want any extraordinary life-sustaining treatment to prolong your life when you are suffering from an incurable terminal illness and incapable of expressing rational judgement on the treatment.

Some reasons you might opt out of extraordinary life-sustaining treatment:

• Quality of life deteriorate due to severe pain, unnecessary suffering or loss of autonomy
• Avoid financial burden on your families from expensive medical treatment
• Emotional and psychological impact on your loved ones watching you undergo aggressive treatment with little chance of recovery

Steps to Draft Your AMD

1. Obtain an AMD form: You can obtain the forms from medical clinics, polyclinics, hospitals, or download the AMD Form 1 online from: https://www.moh.gov.sg/docs/librariesprovider5/forms/form1amd(270905).pdf
2. Consult a doctor with a witness: The AMD must be made through a doctor, who has the responsibility to ensure that you are not being forced into making the AMD, not mentally disordered, and understand the nature and implications of making the AMD.
3. Return the form to the Registrar of AMD: The completed form must be submitted in a sealed envelope by mail or by hand to the Registrar of AMD at MOH, located at College of Medicine Building, 16 College Road, Singapore 169854.

For more details in making your AMD, you may refer to the MOH website here: https://www.moh.gov.sg/policies-and-legislation/advance-medical-directive

What Happens if You Don’t Have AMD?

If you lose your mental capacity and suffer from an incurable terminal illness without an AMD, your doctor will discuss with your family members and decide on whether to prolong your life by giving or applying extraordinary life-sustaining treatment. This would place emotional burden on them in making difficult decisions on your behalf, especially if they are unsure about your wishes.

There could be disagreements among family members about the best course of medical treatment for you, rendering the decision-making process more difficult to reach a consensus. The absence of clear decisions could lead to delays in receiving necessary medical treatment.

Practical Considerations

Start Early While Still Able

Later-Life Planning is a critical aspect of life that often goes unaddressed until it’s too late. Many would think that accidents or medical mishaps won’t happen to them when they are young. Mental incapacity is usually the furthest concern in their mind. However, we know that such crisis can strike anytime in our life.

Starting Later-Life Planning early is a proactive and prudent step that offers numerous benefits to us and our loved ones. Initiating the planning process well in advance can lead to better outcomes and greater peace of mind for everyone involved. We can ensure our wishes are respected, reduce emotional stress for our loved ones, facilitate honest conversations with family members, avoid hasty decisions in times of crisis, secure legal documents (LPA and AMD) in place, give you time to evaluate various care options, and provide clarity to your loved ones.

Make Use of National Registry Services

Do make use of the following National Registry and Depository Services to register and store your Later-Life Planning documents:

• ACP: National Electronic Health Record (NEHR), ACP facilitator will submit for you
• LPA: Office of Public Guardian (OPG)
• AMD: Registry of Advance Medical Directives, need to submit at MOH office
• My Legacy Vault: https://mylegacy.life.gov.sg/vault/

The My Legacy Vault is particularly useful to consolidate all your documents in one secure storage, and you can share them with your trusted loved ones.

Engage Professional Help

As you can tell from the steps in making ACP, LPA and AMD, the process involves a fair amount of cultural, medical, legal, and practical considerations in preparing these documents. Therefore, it is beneficial to engage professionals to help you in preparing these tools.

Here are some reasons for getting professional help:

• Complex Legal Framework: There are specific legal requirements and regulations governing matters such as LPA and AMD. Legal professionals can help you in navigating these legal complexities and ensuring that your documents are valid and compliant.
• Cultural and Religious Considerations: Singapore is a diverse society with a range of cultural and religious practices. You will need professionals who understand these nuances in creating a later-life plan that respects your cultural and religious beliefs, ensuring that your wishes are upheld while adhering to cultural norms.
• Minimizing Family Conflict: In a culture that value family harmony, professional guidance can help prevent potential conflicts among family members. Professionals can provide an objective perspective and guide discussions to ensure that everyone is on the same page regarding your preferences.
• Safeguarding Assets and Finances: Engaging financial planning professionals ensure that your financial assets are properly managed and distributed according to your wishes.

• Navigating Healthcare Decisions: Medical professionals can help you understand the implications of healthcare and medical choices and guide you and your caregivers in making well-informed medical decisions.

Conclusion

Later-Life Planning is a crucial aspect of Life Planning that ensures our desires and preferences are respected during times of vulnerability. In Singapore context, we can tap into various organizations that provide resources in making later-life plan with ACP, LPA, and AMD. By embracing Later-Life Planning, we can find peace of mind, relieve our loved ones of burdensome decisions, and live our later life stage with dignity.

– Footnotes –

[1] My Legacy: https://mylegacy.life.gov.sg/

[2] AIC: https://www.aic.sg/

[3] Infographic: https://www.aic.sg/caregiving/PublishingImages/Content%20Images/What-You-Should-Apply.jpg

[4] ACP: https://www.aic.sg/care-services/all-about-acp

[5] LPA: https://www.msf.gov.sg/what-we-do/opg/lasting-power-of-attorney/what-is-a-lasting-power-of-attorney

[6] AMD: https://www.moh.gov.sg/policies-and-legislation/advance-medical-directive

[7] NEHR: https://support.healthhub.sg/hc/en-us/articles/15823581714073-What-is-National-Electronic-Health-Record-NEHR-

[8] MCA: https://sso.agc.gov.sg/Act/MCA2008

[9] OPG: https://opg-eservice.msf.gov.sg/

[10] AMDA: https://sso.agc.gov.sg/Act/AMDA1996