ENHANCING END OF LIFE WITH CHOICES AND DIGNITY

NOTICE PAPER NO. 1884
NOTICE OF ADJOURNMENT MOTION
FOR THE SITTING OF PARLIAMENT ON 9 MAY 2023

Name and Constituency of Member of Parliament

Ms Ng Ling Ling

MP for Ang Mo Kio GRC

Mr Yip Hon Weng

MP for Yio Chu Kang SMC

Enhancing End of Life with Choices and Dignity

ANSWER

        Mdm Deputy Speaker, Sir, I thank Ms Ng Ling Ling and Mr Yip Hon Weng for passionately advocating to enhance end-of-life care. End-of-life may be a sensitive topic to talk about but it is an important one, that will affect all of us. The reality is that in Singapore, despite clear preferences for receiving end-of-life care and dying at home, only about one in four died at home over the past few years. So, we do need to discuss issues surrounding palliative and hospice care.
2     The hospice movement took root in Singapore in the 1980s. Today, more than 20 institutions provide palliative care across various settings. Our community providers supported some 8,800 individuals with life-limiting conditions in 2022. This is 30% more than in 2017, just five years ago. We have come a long way since the 80s, but much more can be done.

3      Today, I will highlight three key areas of work to enhance end-of-life care – first, improving access to palliative care, second, better supporting caregivers, and third, normalising conversations on death and dying.

(a) Improving access to palliative care
4     With an ageing population, more will need palliative care. We will invest in expanding our services and review our financing frameworks to improve access to palliative care.

Building Capacity and Capability5     We have expanded capacity over the years. We will train more doctors, nurses and allied health professionals in specialised palliative care, particularly in home care. We are also setting aside palliative beds in upcoming community hospital developments to cater to the growing demand.

6     Beyond specialised services, we also want to entrench palliative care as a basic skillset for all healthcare professionals across disciplines and settings. This will require us to change the mindsets and instincts of our clinicians, and equip them with the necessary skills and tools. We are working with the Agency for Integrated Care and providers to do this, beginning with nursing homes and home care. We agree that in the longer term, family doctors can play a role, building on the relationships forged with their enrolled residents.

7      We are also working with hospitals and palliative care providers to implement workflows that Ms Ng spoke about, to enable more patients to undergo what we call a ‘compassionate discharge’ back to home. This involves for instance, providing appropriate training and resources, and implementing handover checklists to ensure continuity of care.

Review of Financing Framework8     Mr Yip asked about subsidies for professional palliative caregiving and extending MediShield Life to home hospice care. To keep palliative care affordable, the Government provides subsidies of up to 80% for palliative care, as well as home-based respite care services for caregivers of end-of-life patients. Patients can already tap on MediSave for inpatient, day hospice and home palliative care, and make claims under MediShield Life for inpatient palliative care. Government-funded home medical and nursing providers whose patients are at the end-of-life stage will soon be able to make MediSave claims for these patients, similar to home palliative care providers. In addition, palliative care providers have done well in raising significant charity dollars to complement Government funding and reduce out-of-pocket costs. We are reviewing the overall financing framework for palliative care, to ensure that affordability concerns do not deter anyone who needs palliative care from receiving it.

9     Mr Yip also asked about shifting to a capitation funding model for palliative care. The scope of care included under capitation funding for the Regional Health Systems does not include community palliative care.

10     Instead of capitation funding, the pilot between Dover Park Hospice and Tan Tock Seng Hospital will trial bundled funding for palliative care services across all three community settings, for example on a per patient per month basis. Through a simpler funding formula, providers will be empowered to decide on the most appropriate care setting for the patient. The pilot will also trial interventions to enable earlier referral of patients with non-cancer conditions to community palliative care, and care protocols to better support them in community. We have been working closely with Dover Park Hospice and Tan Tock Seng Hospital to refine the pilot design and develop a robust evaluation and monitoring process to track effectiveness. We aim to launch the pilot in the second half of this year. If the outcomes are promising, we will consider how we can progressively mainstream it, with appropriate safeguards to ensure continued quality of care. 

(b) Supporting caregivers
11    Caregivers are the most critical factor in enabling one to be cared for at home. But they often come under tremendous stress while coping with grief and loss. We have been continuously enhancing measures to support caregivers through this challenging journey.

Respite Care

12     We introduced the home-based respite care pilot as part of the Caregiver Support Action Plan in 2019, to allow caregivers of end-of-life patients to rest or tend to other matters while their loved ones are cared for by palliative-trained care staff. Since January 2023, hospitals can also refer patients to the service, so that patients and their caregivers can be supported more quickly upon discharge. This takes a significant load off caregivers, who often have to arrange for home modifications and adjust to new routines, while dealing with the grief of soon having to say goodbye to a loved one.

13     Home-based respite care complements care provided by day hospices, which allow end-of-life patients with stable conditions to benefit from social activities and rehabilitation while allowing caregivers to take a break. The four day hospice centres today have adequate places to meet demand. We will monitor utilisation and expand capacity if required. Equipping Caregivers14     Indeed, end-of-life patients and their caregivers have unique needs. The Singapore Hospice Council (or SHC) has developed and shared caregiver resources with hospitals and palliative care providers, so that caregivers have the information on hand to better cope at home. The SHC will also be setting up a helpdesk later this year, so that caregivers who need advice can call in to receive timely support.

15     Apart from supporting caregivers with caregiving skills and knowledge, palliative care providers also support their emotional needs, linking them up with grief counsellors, or support groups, if needed. This is part of the care coordination role which palliative care providers play.  Financial Support

16     Over the years, we have enhanced financial support schemes, like the Home Caregiving Grant and Seniors’ Mobility and Enabling Fund, to better support costs of informal caregiving. Other long-term care schemes like CareShield Life also provide cash payouts to eligible Singaporeans. They may also withdraw up to $200 in cash every month from their own or their spouse’s MediSave accounts under the MediSave Care scheme. Through these schemes, Singaporeans with severe disability can currently benefit from payouts of up to $1,300 a month. Terminally ill patients may also withdraw all their CPF savings in a lump sum under the CPF Reduced Life Expectancy scheme, subject to retaining a balance of $5,000 in their MediSave account. 

(c) Normalising conversations on death and dying

17     On top of the schemes and services, we ourselves play an important role in ensuring that we have a good death. We need to take charge of our own end-of-life journey – to be open to discussing with our loved ones what matters to us, what quality of life means, and how we would want to live our last days. We will do more to normalise conversations about death and dying. Awareness and Action18     The Ministry of Health (MOH) and Public Service Division (PSD) set up the My Legacy portal in 2020, to serve as a one-stop resource to provide information on planning ahead, and tools such as the Lasting Power of Attorney (or LPA), Advance Care Planning (or ACP) and the Advance Medical Directive (or AMD). We are looking at further digitalising these processes to make it more convenient for the public to make these tools.

19     MOH, the Ministry of Social and Family Development (MSF) and PSD are also planning a three-year campaign to increase awareness and adoption of pre-planning instruments, with a focus on LPA and ACP. This will be launched later this year and will involve a range of both in-person and digital activities. To complement the campaign’s activities, a series of workshops will be held at Active Ageing Centres, as Ms Ng has suggested.

Community of Advocates20     We are also working with the SHC to engage the community through the grassroots, corporates, faith-based organisations and schools, to build a pool of advocates. Serving as a trusted source of information, these advocates can plant seeds of these important conversations amongst the wider community and spread awareness of palliative care.

Death as a social process21     Many decades ago, people routinely spent their last days at home. They would deteriorate gradually, and loved ones would gather as their activity levels drop.

22     Medical advancement has given us the belief that all conditions can be treated, and life extended. This has led to death becoming medicalised. Many end up dying in hospital, having life-sustaining treatment up to their very last breath, even though this might not have been how they wished to leave.

 23     We now know that health is to a large extent, determined by social factors. Death is, in fact, also very much a social process. What matters to most is being with their loved ones, in a familiar environment, having their final wishes fulfilled and regrets resolved.

24      Bringing end-of-life conversations into our collective consciousness is similarly a social process. It builds on relationships and often evokes strong emotions. If we are successful in building up our preventive care system, centred around family doctors, and aged care system, centred around Active Ageing Centres and community partners, we will be able to normalise end-of-life conversations amongst residents, their loved ones and care teams. This is not a change that will happen overnight, but I am confident that it is one that will gather pace in the coming years.

Conclusion25     In conclusion, end-of-life care is a key priority for the Ministry. We have gathered key partners to refresh our national strategy for palliative care and will share more in the coming months.

26    But to ensure that Singaporeans live well, and leave well, all of us have to play our roles as family members, caregivers and friends, and have conversations about what a good death looks like.