SINGAPORE — When Singaporeans think about a “good death”, an overwhelming majority imagine dying at home surrounded by loved ones.
But a new report released on Friday (July 12) notes that this ideal scenario is rarely the reality — and argues that much needs to be done to change the way end-of-life care is administered.
The report, titled “Leaving Well: End-of-Life Care Policies in Singapore”, published by the Institute of Policy Studies (IPS), calls for an urgent look at this 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,” the authors stated.
The report cited a 2014 survey by the Lien Foundation which found that 77 per cent of Singaporeans wanted to die at home. However, as of 2017, close to 70 per cent of them did so in hospitals, nursing homes or charitable institutions. Fewer than one in four Singaporeans — 24 per cent — actually ended their days at home.
The study called for a more realistic outlook on death focused less on seeking a cure for terminally-ill patients for whom additional treatment could be futile, and more on providing them with a better quality of life as they approach their final days.
It also recommended several ways to improve end-of-life care for Singaporeans such as initiating conversations on death. It also proposed a payment system based on the overall needs of individual patients, rather than the number of consultations, as is currently the case.
HOW THE STUDY WAS DONE
The researchers, Mr Christopher Gee and Ms Yvonne Arivalagan, embarked on the study following a series of workshops involving about 100 experts held by IPS on Singapore’s future in 2016. During the workshops, end-of-life care was raised as an issue that Singapore would have to grapple with as the local population aged.
The study was conducted through consultations with experts across various sectors ranging from healthcare and social work to policy-planning. The experts held discussions among themselves over three occasions between 2017 and 2019 in a working group set up by IPS. The authors of the report also supplemented their findings with existing studies on end-of-life care.
FROM HIGH COST OF HEALTHCARE TO FAMILY INTERFERENCE: KEY ISSUES RAISED
#1 Perceived high-cost of healthcare:
The study highlighted several issues on the health landscape in Singapore. One key issue is that end-of-life care continued to be seen as unaffordable by Singaporeans, causing people to think about it too late.
This was especially so for the elderly poor and “sandwiched” class of middle-income caregivers. High medical costs in the form of out-of-pocket payments, co-insurance and deductibles put people off receiving treatment, especially when it comes to treating terminal illnesses in an expensive tertiary care setting. Elderly people, in particular, faced the greatest financial burden, with healthcare costs for an 85 year old 10 times higher than those for a 35 year old.
#2 Barriers to talking about one’s final days:
The study also noted that there were barriers preventing individuals from discussing their final days with their families, such as superstition about discussing death, or not wanting to reduce the patient’s will to live. The study also said that with medical cost being a common source of conflict within families, family members also avoided having conversations with patients about their end-of-life care.
#3 Family interference in decisions on healthcare:
The study found that it was difficult for patients here to make their own healthcare decisions given the culture of joint decision-making in families. It said that in Singapore, families play a “central and often dominant role” in the healthcare decisions of the elderly. Elderly patients were also inclined to defer to their family members on decision about healthcare. This was a result of social expectations placed on Singaporeans to care for their elderly parents. It noted that in some cases, families even chose not to reveal the diagnosis to the patient. The study said that such cultural attitudes reduced the patient’s autonomy to make decisions about his or her own healthcare.
#1 Initiating conversations about death earlier:
One recommendation in the study suggested initiating conversations about end-of-life care at earlier points in life. The authors suggested identifying key moments in a person’s life, such as marriage or childbirth, to raise the issue of end-of-life care so that people would be more proactive in making plans. For instance, institutions such as the Registry of Marriages or insurance companies could provide platforms for discussion about a person’s final days.
#2 Testing new models of healthcare payment
The authors also proposed introducing a different payment model for doctors. Currently, the prevalent method of healthcare payment adopted in Singapore is the “fee-for-service” model which involves paying doctors for each consultation or service.
The study suggested trialling the “capitation payment” model. This would involve paying doctors a fixed sum per patient for a predetermined period of time. Explaining how this could work in Singapore, Mr Gee said at a media briefing on Friday that for instance, a general practitioner could be tasked to provide primary care services to 1,000 people within a particular neighbourhood. The patients would each pay a fixed sum for a set period of time. The payment model could be supported in various ways, such as by insurance schemes, the state, or a combination of both.
Such a model, said the authors, would encourage doctors to proactively care for patients and understand their conditions better, leading to better care and lower healthcare costs.
#3 Emphasise restrictions of Mental Capacity Act
Under the Mental Capacity Act, people appointed with a Lasting Power of Attorney (LPA), known as donees, are not allowed to make decisions concerning life-sustaining treatment or any other treatment to prevent serious deterioration in the health of a mentally incapacitated individual.
The LPA is a legal document that allows an individual to appoint one or more persons to act and make decisions on the individual’s behalf in the event that he has lost his mental capacity.
With more older patients deferring healthcare decisions to their family members, the authors of the study suggested that facilitators of advanced care planning should raise these restrictions when discussing end-of-life matters with individuals, and seek clarification from them on their preferences on life-sustaining treatment.
#4 Strengthening the palliative care sector
The report called for the capacities of the palliative care sector to be strengthened, saying it is under-resourced compared to hospitals and tertiary institutions.
The authors said the capabilities of home and community-based providers had to be enhanced through improved training, remuneration and working conditions, as well as through new models of delivering care.
More healthcare providers, especially general practitioners, allied health professionals and emergency medical specialists also need to be equipped in palliative care to promote community-centred care. This would give patients with long-term chronic conditions and less predictable prognoses access to palliative care.