SPEECH BY MR MASAGOS ZULKIFLI, SECOND MINISTER FOR HEALTH AT THE 8TH ADVANCE CARE PLANNING INTERNATIONAL CONFERENCE ON THURSDAY, 25 MAY 2023

Mr Tan Kwang Cheak, CEO, Agency for Integrated Care
Dr Raymond Ng, ACP - I Conference Scientific Committee Chairman,
Prof Tanja Krones, President for ACP - I society
Distinguished speakers and guests
Ladies and gentlemen

                 Good morning. I am happy to be with you at the 8^th Advance Care Planning International Conference. It is wonderful to see so many practitioners from across the world coming together to network and share best practices in fostering person-centered care through ACP. Welcome to our international speakers and visitors.

ACP’s roots, and Singapore’s ACP journey

2.             Person-centred care focuses on what matters to the patient, especially also to their family members. It means involving patients in their own care decisions, before they can no longer express their preferences. Each of us has different values and priorities, and patients with the same conditions may choose very different care and treatment options. Families are more assured, and patients can be at ease knowing that the decisions are made in consultation with trusted loved ones, based on their preferences.

3.             The emergence of healthcare advance directives to enable person-centred care began in the United States in the mid-1970s. Advance directives have since evolved, with different frameworks and legislative permutations across many different countries. Despite our varied cultures and practices, it is heartening to see that our passion for improving person-centred care is universal. ACP has gained increasing attention around the world for its potential to align care with an individuals’ values and preferences, especially at end-of-life.

4.             In Singapore, our ACP journey began in 1996 with the Advance Medical Directive Act. Subsequently, the Mental Capacity Act was enacted in 2008. In 2011, the first National ACP programme in Asia, “Living Matters”, was launched by the Agency for Integrated Care and supported by the Ministry of Health. Since then, more than 35,000 Singaporeans have gone on to complete their ACP.

5.             Take the example of Mr Cheng and Mdm Tio, a married couple. Mr Cheng was first introduced to ACP during a visit by his community care nurse. With the help of the ACP facilitator, Mr Cheng shared his goals, values and personal beliefs and his health priorities. He realised that he would like to opt out of life-sustaining measures should he become seriously ill one day. Initially, his wife Mdm Tio could not accept Mr Cheng’s decision. However, with the help of the ACP facilitator, they managed to have an honest discussion. Mdm Tio eventually accepted Mr Cheng’s decision after gaining a better understanding of his needs. Mdm Tio was later nominated as Mr Cheng’s Nominated Healthcare Spokesperson. The value of an ACP was clear to Mdm Tio and she subsequently completed her own ACP as well.

6.             Starting to think about completing an ACP should not only be for those more senior in age. It should be something that all of us should do, so that we can have greater autonomy over our own end-of-life decisions. The Ministry is taking a serious look at end-of-life and ACP plays an important role in this. We are looking at how we can ramp up ACP awareness and adoption over the coming years.

Challenges and Opportunities

7.             There are three challenges that we need to overcome to enable widespread adoption of ACP.

8.             First, Singapore is still a fairly traditional society, and many, especially the older generation, are uncomfortable talking about death and dying. So we need to bring about a mindset change across society, to normalise conversations around end-of-life. We need to see this stage as part of the journey of life and naturally, to prepare oneself and one’s family for it.

9.             Second, while we have trained a sizeable pool of facilitators – some 6,000 in total – there is still room to have more on board. We need to involve the community in a much larger way, including doctors whom patients often trust the most.

10.          Third, the current ACP facilitation process is resource intensive, and challenging to scale. We need to evolve the framework to effectively support a larger group without sacrificing quality. We need to better leverage technology to better reach out to the growing population of digitally savvy citizens.

Future directions for ACP

11.           ACP exists within a larger health and community care system, in which significant changes are taking place. We are launching a key initiative – Healthier SG which aims to focus our healthcare system more strongly on preventive care. Under HealthierSG, we seek to foster lasting relationships between residents and family doctors through a national enrolment plan, and strengthen partnerships within the community to better support residents in developing healthier lifestyles. The ACP community should ride on these national changes to increase awareness and adoption of ACP.

12.          To address the challenges I mentioned earlier, the ACP community needs to embark on key shifts.

13.          First, bringing about a mindset change across society. Mindset change takes time. We have started work on this and have appointed community agencies to conduct outreach on the ground and offer ACP outside of the healthcare setting. We will make a further push later this year, where we launch a nationwide Pre-Planning Campaign. It will involve bringing ACP to the community through roadshows and on-the-ground workshops at our Active Ageing Centres which are located in each neighbourhood and are key nodes supporting our Healthier SG efforts. A digital campaign will also be launched on My Legacy, a one-stop portal for the public on all end-of-life issues. There, citizens can learn more about ACP and how to get started. They can also learn about other important tools they should make, such as the Lasting Power of Attorney and wills. With these initiatives, we hope that more will have conversations and start planning for end-of-life. It is never too early to start. The conversations are important not just for ourselves, but also our families, so that they can make preparations early on, such as taking out insurance to ensure that they are adequately provided for.

14.          Second, rallying healthcare professionals to have conversations on ACP as part of routine care. Healthcare professionals are accustomed to advising patients on how to “live well”, and on ways to address their health issues. We need to start familiarising and equipping these professionals with the skills to speak to their patients on how to “leave well” too.  For those with serious illnesses, specialists in hospitals can start conversations early, so that care and treatment plans are aligned with patients’ values and priorities, right from the start. In the community, we hope that with Singaporeans enrolling with their trusted GPs, our family doctors in the longer term can also be an advocate for ACP.

15.          Third, digitalising the process to make it more convenient for individuals to complete the ACP. Today, the ACP process is reliant on a third-party facilitator. This is necessary and important in some cases. For example, patients in advanced stages of their diseases need to speak to a trained professional, to better understand care options and talk through the implications. However, for those who are healthy and making what we call the ‘general ACP’, they may not need such in-depth discussions. To cater to the growing population of citizens who are digitally savvy and still relatively well when making their ACP, we must leverage technology and digital platforms to empower citizens to self-facilitate this conversation without the need for a facilitator.

Closing

16.          The needs and preferences of individuals are varied. With the advancement of medical care, we now have more choices, and often, higher expectations. Empowering individuals to make their own decisions about how they want to lead their daily lives is critical, to ensure that they live, and leave well, with dignity.

17.          I hope that this conference will be a platform for honest exchange of ideas, sharing of best practices, and a launch pad for partnerships. There is a lot for us to learn from one another as we explore ACP implementation in different cultural contexts together. I wish everyone a thought-provoking and fruitful conference.

18.          Thank you.