Advance Care Planning – Part Two: Detailing the Process

Part Two: Detailing the Process

In taking a holistic approach to ACP, we have outlined 4 stages to the ACP process.
Stage 1 : Initiating the Conversation
Stage 2 : Involving your Loved Ones
Stage 3 : Incorporating Professionals
Stage 4 : Influencing your Loved Ones

Stage 1 : Initiating the Conversation

ACP starts with initiating a conversation with the most important person. Yes, and that person is none other than You. To help you embark on this journey, we have put together some 1 broad questions you can reflect on in your quiet moments or even during a staycation!

• What gives me my life purpose? What makes each day fulfilling?
• What are the relationships that matter most to me? How do I build and preserve these relationships?
• What do I enjoy doing most in my life? What would I spend my time doing if I am financially independent?
• What are my spiritual or religious beliefs?
• How do I want to celebrate my life when I depart? How do I want my loved ones to remember me? How do I want my epitaph to be written?

Some of these questions are tough indeed. Questions that we instinctively avoid at the mere suggestion of it. But as the saying goes, it is always too early until it is too late. When we reflect on questions on Leaving Well, we are really assuring ourselves that we are Living Well.

For introverts, they may find this an easier exercise to undertake. Extroverts may need to make a more conscious effort to quieten themselves or perhaps even do it together with a family member or good friend. Whether you are an introvert or an extrovert, a good practice would be to pen these thoughts down and record them in a paper or digital journal as part of the ACP process. Writing helps us to articulate and clarify our thoughts, ensuring that there is accuracy and focus in our plans.

The first step is often the hardest. But once you have initiated this intimate conversation with yourself, the journey and view ahead becomes much clearer. Through this self-reflection, you may even discover things about yourself you never knew. It can even be the catalyst for a career change or aligning your life more closely to your core values. Take time to deliberate at this stage. Do not rush through this process as this will form
the foundation of what is to follow later.

Stage 2 : Involving your Loved Ones

Once we have found answers to the above questions, we are ready to involve our loved ones in the ACP process.

At this stage, we are talking specifically about doing ACP when we are in good health and capable of making sound decisions.

It will be good to choose one or two loved ones who can and will be your voice, in the event that you are unable to do so personally. It should be someone you trust and feel comfortable with. We call this person a Nominated Healthcare Spokesperson (NHS). When choosing a NHS, you may consider the following points:

a) Is the person mature and reliable?
b) Does he/she know you well? Eg. A family member or a close friend.
c) Is he/she willing to take up this responsibility?
d) Is he/she someone you can trust to act in your best interests?
e) Is he/she someone who can handle stressful situations well?

Do note that a NHS must be at least 21 years old, and can either be a family member or a trusted friend. You may choose to appoint more than one NHS.

Next, download the 3 “ACP Booklet” from the Agency for Integrated Care (AIC) website. Go through the booklet and record down your answers. Share them with your NHS. You can then make an appointment with an ACP Node to document your wishes. This is the non-legal part of ACP and does not require a lawyer. Your preferences will be updated in the National ACP IT system linked to the National Electronic Health Record. You will also get to keep a copy of your ACP form.

For a full list of the ACP Nodes providing this service, visit this link:
https://www.aic.sg/care-services/acp-directory (Home/Care Services/ACP Directory)

When you have completed Stages 1 and 2, give yourself a pat on the shoulder. You have just done something of utmost importance for yourself and also your loved ones.

Stage 3 : Incorporating Professionals

In the second stage, we will have to involve professionals such as lawyers and doctors for their expertise. To understand where the professionals come in, we need to first understand the 3 different types of ACP documents. The first is the Advance Care Planning (ACP), the second is the Lasting Power of Attorney (LPA) and the third is the Advance Medical Directive (AMD).

In contrast to the ACP, the LPA is a legal document that appoints donee(s) to act on your behalf should you lose the capacity to make your own decisions. This may include property and/or financial affairs on top of personal welfare. One must be at least 21 years old before he/she is able to draw up an LPA. It is also advisable for the NHS and donee to be the same person to avoid possible conflicts.

In comparison to the ACP, the AMD is a document that complements ACP by specifically indicating to the doctor, that in the event of impending death, one does not wish to artificially prolong one’s life through the use of any life-sustaining treatment. If you do make an AMD, you should bring it up during your ACP discussions and have it documented.

For a clearer picture of the similarities and differences between the 3 documents, we have consulted the 4 table below:

	ACP	LPA	AMD
What it is	A planning instrument that involves the appointment of NHS. Can be done informally.	A planning instrument in the format of a legal document for the appointment of donee(s).	A legal document that informs the doctor you do not wish to artificially prolong your life using any life- sustaining treatment.
When it is activated	When one has lost the mental capacity to make decisions	When one has lost the mental capacity to make decisions	When one is terminally ill, requires life- sustaining treatment, unconscious or unable to make sound judgments
Nature of process	Non-legal	Legal	Legal
Nature of concern	Health and personal care	Personal care/Property and Financial affairs	Healthcare (specifically on use of life-sustaining treatment)

Do remember that you are free to review and make changes to your care preferences at any point in time. You only need to inform your NHS verbally, though it is best to document it by updating your ACP booklet. For legal documents, you will need to inform your donee(s) and the relevant professionals.

The key is not to procrastinate. Act now, start by downloading the ACP workbook!

Stage 4 : Influencing Your Loved Ones

Once you have completed your ACP planning, which may or may not include making an LPA and AMD, you are now the best person, the best ambassador to share the importance of ACP with your loved ones. Among them, it is probably hardest to broach the subject with our aged parents, but they are also the ones who need it even more urgently.

As ACP is a sensitive subject, we certainly do not want our parents to misunderstand our good intentions. The best approach is probably to show them our own ACP workbook and share with them why we chose to do it even when we are young and healthy. Share with them how much more peaceful you feel after undertaking such an exercise. Simply invite them to think about it and let them know you are always ready to listen and help should they wish to learn more about the process. By approaching them
in a gentle manner, they may be more open and willing to learn about it.

ACP is never a pleasant topic. Which is why it is even more necessary for us to influence and share with our loved ones its’ importance and benefits. It may be somber to bring up the topic initially, but it may save us from much greater grief, agony and possible conflicts in future. As long as we are willing to make the effort, all of us can play a vital part in breaking the Asian taboo subject and improve overall palliative care in Singapore. Let’s start by changing our mindset – Leaving well assures us that we are living well!

Written by Audrey Lee

Sources:
Https://www.aic.sg/resources, Advance Care Planning, My Care Wishes Workbook
Advance Care Planning in Singapore: Why and How to Get Started, Singaporelegaladvice.com (1 Apr 2019)
3 Advance Care Planning, Brochures and Publications, ACP Booklet, aic.sg 

APEX Private Wealth Management (A group of advisers representing PIAS)
Alan Tang
Senior Financial Services Director
Mobile: 9679 9129
E-mail: alan.tang@proinvest.com.sg