1st Jul 2023
Mr Robert Chew, Chairman, Singapore Hospice Council
Dr Grace Yang, Chairman, Organising Committee of the 8th Singapore Palliative Care Conference
Distinguished Guests
Ladies and Gentlemen
1. It is my pleasure to join you today at the 8th Singapore Palliative Care Conference.
Conversations About Death
2. Information about our health is always confidential and personal. As our life journey ends, how we wish to leave this world is even more personal. So much so that many of us keep it to ourselves and do not talk about it, not even to the people closest to us.
3. In my lifetime, I have lost three people very close to me in my lifetime – both my parents, and my maternal grandmother who looked after me when I was a kid. All of them passed on in hospitals. Looking back, I wish my family had done things differently and that the way they passed away could have been different or better.
4. Today, let me share just one story – the passing of my grandmother.
5. She was born in Swatow, China, but escaped from her hometown and came to Singapore during the Second World War. She was kind, gentle, but led a hard life which made her very feisty and resilient.
6. She had such a high threshold for pain, that she carried on her usual chores even though she had started to feel a sharp pain in her chest. Eventually we persuaded her and she decided to see a doctor, who diagnosed her with end stage lung cancer. She was 80 then.
7. After the diagnosis, she was going in and out of hospital. Each time I visited her at the hospital she would tell me she wanted to go home. She said that staying at the hospital for one night felt like a month.
8. During one of her several admissions, her condition deteriorated. By then I was living abroad and could only speak to her on the phone moments before her passing. Fortunately, she was surrounded by loved ones gathered around her hospital bed when she left.
9. I had no doubt she would have wanted to go home, even if it was to pass on. She was a devout Buddhist. She had her affairs settled and even her photo for the wake taken. She surely had prepared herself for the inevitable.
10. But none of us knew about palliative care then. No one had spoken to her about how she would like to leave and understood her last wishes. In fact, for my parents, uncles, and aunties, it was taboo, inauspicious, or in Malay ‘pantang’, to talk about death.
11. The reason could be that this was a generation of survivors. Life was hard. My parents and grandmothers lived through the Second World War, racial riots – uncertainties that were matters of life and death. To be alive was a blessing, and they did not like talking about death.
12. The new generation does not have those memories. Our life is not about survival. It is about progress, fulfilling our aspirations and enjoying life. It is also a generation that experienced significant advancements in medical science, knowing that very intrusive interventions and painful surgeries can prolong life, even without quality. Many of us would not want that.
13. While I think talking about death is still sensitive today, it is no longer as taboo a subject as before. Seniors today are much more prepared to express how they wish to leave the world. Surveys done by the Lien Foundation show that three in four seniors prefer to pass on at home. Doctors have told me that in their conversations with patients it was more like nine in 10. Getting their loved ones to accept their wishes is understandably harder because of the emotions and difficult decisions involved.
14. It is time we recognise that palliative care can make a huge difference. It provides comfort not just to patients but also their caregivers, going beyond physical to also emotional and spiritual care, while honouring the wishes of the patients.
15. That is why we have decided we have to increase our support for palliative care as a national policy. I have earlier announced that we intend to reduce the percentage of deaths in hospitals, from about 60% today to 50% in 2027.
16. Given that times and circumstances have changed, policies and practices with regard to palliative care too should change. Today, I will talk about some of the changes we will be implementing in the healthcare ecosystem.
Smoothening care transitions
17. The first change is to bring about smoother care transitions, from acute hospital care to palliative care, and between palliative care settings, whether it is inpatient, day, or home hospice.
18. When a patient who is expected to pass on in a week, transits from hospital acute care to palliative care at home, we call that a compassionate discharge.
19. However, before reaching that stage, we need to be able to identify patients with palliative care needs early. For cancer patients this is a more established process we have been doing for many years, but less so for other diseases, which at an advanced stage can also be terminal.
20. Some hospitals have begun testing out various screening tools in key disciplines such as cardiology, renal medicine, and oncology. We need to do this carefully and sensitively, and we intend to implement these screening and care protocols over the next few years, across all our public hospitals.
21. Compassionate discharges from hospital to home are critical moments, but they encounter barriers today. Many families are concerned about coping with care at home, and we need to address this. We will therefore do more to smoothen the process, with timely access to affordable equipment, curated resources and training for caregivers, and offering respite care services.
22. For example, we are putting in place standardised checklists and resources so that caregivers know what to expect and are equipped with the necessary medications in various situations, and especially when their loved ones are in their final hours. It is quite common that in the final hours, caregivers send them back to A&E, and that is where they pass on. So if we can give them the right support, they will know what to expect and what to do, and we can fulfil the wishes of the patients.
23. We are also expanding the home-based respite care scheme. Hospitals are now making direct referrals for those who are compassionately discharged home, and turnaround time has come down quite significantly.
24. Another major barrier is the capacity constraint of our palliative care providers. This leads me to the second important change we are implementing.
Stronger Financing Support
25. We will strengthen financing support for palliative care, so that capacity can be expanded.
26. Perhaps because it has been a taboo subject, palliative care had not been given its due attention and support. The funding is means-tested, which is not wrong. Maximum subsidy for a lower income patient is 80% (same as hospital acute care), but for a higher income patient it is 0% today.
27. Notwithstanding, home palliative care has been provided at zero or minimal cost to patients and families. Credit goes to the care providers and their donors, who have been raising a significant amount of charity dollars to complement government funding, making home palliative care free-of-charge for patients. That is a significant move because for someone with a dying loved one, palliative care providers can say because of donations and the government’s means-tested support, bringing the patient home is free. That has been a powerful message over the years.
28. However, as the population ages and demand for palliative care rises, and care providers have reached the limit of what they can raise every year as charity dollars, they hit a capacity limit.
29. So even when there is a willing referral or compassionate discharge from a hospital to home palliative care, providers may no longer have the resources to support the family and caregivers.
30. For example, patients’ conditions may fluctuate when they are at home. When patients’ symptoms are beyond what caregivers can manage, they may need professional palliative care support for a short while or those critical moments. That support can only be given if capacity and resources allow.
31. To unlock the capacity constraints, we will significantly increase our financial support for palliative care. We will make the following changes.
32. One, we will ensure a minimum 50% means-tested subsidy for palliative care, (no more 0%) and up to the current maximum of 80%. This is aligned to our subsidy framework for inpatient care at acute hospitals. With this change, almost all palliative care patients will see an increase in subsidies, by up to 55 percentage points.
33. Two, drug subsidies will also be made available to all patients receiving palliative care from MOH-funded providers. Today, not all palliative care patients, such as those from higher income households, benefit from drug subsidies.
34. From the fourth quarter of 2024, all palliative care patients of MOH-funded providers can receive drug subsidies regardless of household income level. Singapore Citizens will receive drug subsidies of at least 50%, and Permanent Residents will receive at least 25%.
35. Three, we will increase MediShield Life claim limits for inpatient palliative care. MediShield Life claim limits will be raised from $250 and $350 per day for general and specialised inpatient palliative care respectively, to $460 and $500 per day. These new limits will be sufficient to fully cover nine in 10 subsidised patients.
36. Four, the lifetime MediSave limit will also be lifted for all home palliative care and day hospice patients using their own MediSave, regardless of their conditions.
37. All these financing changes will be implemented in phases from the first half of 2024 and palliative care providers will receive about $15 million more support a year. Plus the support of their donors, they will be able to expand their care capacity significantly.
38. The current estimated capacity of home palliative care is about 2,000 patients at any point in time. With this, our three major palliative care providers – HCA, Assisi, and Dover Park Hospice – have told me that they are committed to increasing home palliative care capacity by about 40%, or 800 places, by end 2025, and more over the next few years. $15 million is not a huge amount of money in the context of healthcare spending. But with this additional support, we can unlock the capacity, fulfil the wishes of patients and expand this sector in a very meaningful way. MOH will work closely with the providers to realise this.
39. This leads to the next issue, which is how do we recruit sufficient manpower, which leads to the third change.
Expanding Manpower
40. We need to recruit and train palliative care manpower.
41. Palliative care is a fairly niche area, and perhaps not the first career option for healthcare workers. But many who serve in the palliative care sector have become deeply committed. We must therefore promote early awareness and increase career attractiveness of this sector.
42. Beyond developing palliative care talent in the hospice sector, we need to do so in the wider healthcare system. Our nursing homes, home care, and family doctors can and will play a larger role in caring for their patients approaching their end of life. We need to train them, and provide them with more support.
43. We will pilot new care models, for instance, having home medical and nursing providers care for their patients with complex chronic conditions and frailty, towards the end of life, with the support of specialised palliative care providers. We will work together with palliative care providers to recruit both local and foreign manpower. As I mentioned before, for healthcare workers who have integrated into our society, we must be prepared to accord them Permanent Resident status.
Starting Conversations Early
44. Finally, we will start conversations with patients and their loved ones early, so that more of them can plan ahead.
45. This is not yet the norm today. But all our aspirations to better fulfil our loved ones’ wishes can only be realised if we know what their wishes are. Having these conversations early, with the help of healthcare professionals, can take the stress off family members and avoid conflicts.
46. By starting early, we can think through and talk about our wishes when we are well and clear-minded. Of course, our preferences may change, and so we ought to review them from time to time. But starting early allows us to understand and acknowledge the key considerations of the family and loved ones, get more comfortable talking about the issue, and better prepare ourselves for the time when we, or our loved ones, have to make difficult choices.
47. We will actively reach out to the public to explain the advantages of planning ahead, through a series of public awareness and community engagement efforts.
48. This will be a public education effort, which MOH, the Ministry of Social and Family Development and Public Service Division will launch soon. The Singapore Hospice Council will build a pool of community advocates to champion palliative care and create a strong social support system. All these efforts will bring these conversations into communities and homes.
49. The Government can only convey the message that this is something worth doing, and families will have to decide whether to discuss end-of-life issues amongst loved ones.
Cynthia Goh Palliative Care Institute
50. We are releasing these initiatives and policy changes through the refreshed National Strategy for Palliative Care, which we are launching today.
51. The workgroup which worked on the refreshed document comprises practitioners, academics, and partners in the sector. They worked closely with the Ministry and the Agency for Integrated Care to complete the review in a year. I thank them for their contributions.
52. We can take a major step forward for palliative care today, because of the foundations built by our predecessors, such as the late Professor Cynthia Goh.
53. She was a pioneer and visionary who first introduced palliative care to Singapore, and dedicated her life to developing palliative care in Singapore and the Asia Pacific region. Her dedication changed the lives of many patients and families, and she mentored many who have gone on to become experts in the field, some of whom are sitting here today.
54. To continue the legacy of the late Prof Goh’s work, her husband Prof Goh Hak Su, family, friends, and colleagues have donated the initial $6 million to set up the Cynthia Goh Palliative Care Institute, under the SingHealth Duke-NUS Academic Medical Centre.
55. The Institute will develop palliative training, research, and education programmes, and study the treatment efficacy and cost effectiveness of palliative care. The Institute will also promote international faculty development and establish Singapore as a centre of excellence for palliative care. Today, I am pleased to announce the launch of the Cynthia Goh Palliative Care Institute and look forward to its contributions.
56. Let me leave you with one final thought, about my grandmother. She led a hard, but full life. Her final decades were often spent with family members and relatives, celebrating birthdays, going on vacations, watching grandchildren like me grow up.
57. Even on her death bed, she was surrounded by loved ones. It would have been better if she was at her own home, but perhaps home is where family members are. These are the ‘what if’ questions that loved ones like me will continue to ponder, perhaps with a tinge of regret.
58. It is so important to have a good death, for the patient and also for his or her loved ones. I hope that our collective efforts will allow every Singaporean to live well and leave well, according to their wishes.
59. I wish everyone a fruitful conference.