16.3 Advance Care Planning (ACP) & Care of the Dying Patient
Key Takeaways
- Advance Care Planning (ACP) in Singapore is a voluntary process of discussing and documenting future healthcare preferences, categorised into General ACP, Disease-Specific ACP, and Preferred Care Plan (PCP).
- ACP works alongside legal instruments such as the Lasting Power of Attorney (LPA) under the Mental Capacity Act and the Advance Medical Directive (AMD) under the AMD Act (Cap. 163A).
- Nursing care during the active dying phase (last days to hours) focuses on comfort, discontinuing non-essential medications/interventions, subcutaneous syringe driver management, skin/mouth care, and supporting family distress.
- Post-mortem care in Singapore mandates respectful body preparation while adhering to cultural/religious rites (Muslim, Buddhist, Christian, Hindu customs) and legal protocols including HOTA/MTERA organ donation checks and death certification procedures.
16.3 Advance Care Planning (ACP) & Care of the Dying Patient
Advance Care Planning (ACP) Framework in Singapore
Advance Care Planning (ACP) in Singapore is an organized, voluntary process of communication that enables individuals to articulate and document their future healthcare preferences, personal values, and goals of care in discussion with healthcare providers and loved ones. Managed under the national framework coordinated by the Agency for Integrated Care (AIC) and uploaded to the National Electronic Health Record (NEHR), ACP ensures that a patient's voice is respected if they subsequently lose decision-making capacity.
The Three Types of ACP in Singapore
- General ACP: Designed for healthy individuals or individuals with early chronic conditions to record general healthcare philosophies and designate a Nominated Healthcare Spokesperson (NHS).
- Disease-Specific ACP: Tailored for patients with progressive, life-limiting medical conditions (e.g., stage IV organ failure, ALS) to address specific disease trajectories, acute deterioration management, and mechanical ventilation preferences.
- Preferred Care Plan (PCP): Formulated for frail elderly patients or those in the terminal phase of illness, explicitly documenting preferences regarding cardiopulmonary resuscitation (CPR), place of care (home vs. acute hospital vs. hospice), and place of death.
Role of the Nominated Healthcare Spokesperson (NHS)
During the ACP process, the patient appoints an NHS (and optional alternate NHS) who understands the patient's values and agrees to advocate for their preferred care decisions if the patient loses mental capacity. The NHS does not have legal power over property, but acts as the surrogate voice in clinical goals-of-care discussions with the medical team.
Legal Instruments: AMD vs. LPA vs. ACP
Nurses practicing in Singapore must clearly distinguish between three distinct legal and planning instruments:
| Feature | Advance Medical Directive (AMD) | Lasting Power of Attorney (LPA) | Advance Care Planning (ACP) |
|---|---|---|---|
| Legal Basis | Advance Medical Directive Act (Cap. 163A) | Mental Capacity Act (Cap. 177A) | National ACP Framework (AIC administrative document) |
| Primary Purpose | Legally binding directive to withhold extraordinary life-sustaining treatment in terminal illness | Legal instrument appointing Donee(s) to make personal welfare and/or property decisions | Documented goals-of-care discussion guiding healthcare decisions during incapacity |
| Trigger Condition | Patient is certified terminally ill by 3 independent doctors AND lacks capacity | Donor loses mental capacity (certified under Mental Capacity Act) | Patient loses decision-making capacity during clinical deterioration |
| Witness Requirements | 2 doctors (1 must be an accredited specialist); patient must be 21+ and mentally competent | Accredited LPA Certificate Issuer (Doctor, Psychiatrist, or Lawyer) | Trained ACP Facilitator (Nurse, MSW, Doctor) |
| Key Limitation | Applies ONLY to terminal illness where death is imminent regardless of treatment | Donee cannot consent to withholding life-sustaining treatment unless explicitly authorized | Not a legally binding contract per se, but strongly guides clinical treatment plans |
Nursing Care in the Active Dying Phase (Last 24-72 Hours)
The active dying phase marks the final hours to days of life characterized by multi-organ shutdown. Nurses play a crucial role in recognizing physical signs of impending death and re-orienting care toward pure comfort:
Clinical Signs of Impending Death
- Cardiovascular: Weak, thready, irregular pulse; profound hypotension; cool, clammy skin; peripheral cyanosis and mottling of knees, hands, and feet (livedo reticularis).
- Respiratory: Altered breathing patterns including Cheyne-Stokes respiration (apnea alternating with hyperpnea), shallow agonal breathing, and terminal respiratory secretions ("death rattle").
- Neurological: Progressive somnolence, unresponsiveness, semi-comatose state, glazed unblinking eyes, hallucinations, or terminal restlessness.
- Renal/GI: Oliguria/anuria (dark concentrated urine), urinary and fecal incontinence, loss of swallow reflex, and complete cessation of oral intake.
Nursing Management Protocol for Active Dying
- Care Plan Re-alignment: Discontinue routine, burdensome clinical interventions that do not contribute to comfort (e.g., routine vital sign monitoring, capillary blood glucose checks, routine blood draws, IV fluid infusions, and oral maintenance medications).
- Subcutaneous Syringe Driver Management: Establish continuous subcutaneous infusion (CSCI) via a syringe driver (e.g., McKinley T34 pump) using a sub-clavicular or upper arm SC site. Syringe drivers allow continuous 24-hour administration of compatible palliative medications (e.g., Morphine for pain/dyspnoea + Midazolam for agitation + Hyoscine Butylbromide for secretions + Haloperidol for nausea).
- Comfort & Hygiene:
- Oral Care: Clean oral mucosa every 1-2 hours using soft foam swabs moistened with water or saline; apply water-based lip balm to dry lips.
- Positioning & Eye Care: Reposition gently for comfort. Apply lubricating eye drops if eyelids are incompletely closed to prevent corneal drying.
- Family Presence: Create a peaceful, quiet environment; encourage unrestricted family visits and soft reassuring speech (hearing is often the last sense to be lost).
Cultural & Religious Considerations at End-of-Life in Singapore
Nurses must demonstrate cultural sensitivity and respect religious protocols:
- Islamic Traditions (Muslim Patients): Position the bed so the patient faces Qibla (towards Mecca) if feasible. Upon death, close eyes and lower jaw gently. The deceased body must be handled with extreme modesty, touched only by same-gender individuals or immediate family, and prepared for ritual washing (mandi jenazah) and rapid burial within 24 hours.
- Buddhist & Taoist Traditions: Family members may chant prayers at the bedside. Avoid sudden loud noises or unnecessary disturbance immediately following death, as some traditions believe the consciousness remains near the body for several hours.
- Hindu Traditions: Family may place holy water (Ganges water) or basil leaf (tulsi) in the patient's mouth prior to or at death. Holy threads should not be cut or removed without family consent.
- Christian Traditions: Facilitate visits by priests/pastors for the Sacrament of the Anointing of the Sick (Last Rites) or final prayers.
Post-Mortem Care Protocol & Legal Requirements
Following the cessation of life, the nurse carries out post-mortem care (last offices) in accordance with Singapore healthcare institution standards:
- Verification & Certification of Death: Death must be formally verified by a registered medical practitioner (attending doctor or house officer assessing absence of carotid pulse, absence of heart sounds and breath sounds for 5 minutes, fixed dilated pupils, and absence of response to verbal/painful stimuli).
- Coroner's Cases vs. Natural Death: If death is sudden, unexpected, unnatural, caused by trauma, surgical complications, or suspicious circumstances, the case must be reported to the Police and Coroner under the Criminal Procedure Code. In Coroner's cases, DO NOT remove any invasive tubes, lines, catheters, or dressings; leave all equipment intact for forensic examination.
- Routine Post-Mortem Care: For natural deaths, gently remove IV lines, catheters, and drains (applying pressure dressings). Clean the body, close eyes, elevate head slightly on a pillow to prevent facial blood pooling/lividity, place a clean gown, attach identification tags (wrist and body bag), and allow family private viewing time.
- Organ Donation Legislation:
- Human Organ Transplant Act (HOTA): Opt-out organ donation framework applying to all Singapore Citizens and Permanent Residents aged 21 and above who are of sound mind. Covers donation of kidneys, heart, liver, and corneas in cases of brain death for transplantation.
- Medical Therapy, Education and Research Act (MTERA): Opt-in framework allowing individuals of any age to donate their whole body or specified organs/tissues for medical research, education, or transplantation.
A 72-year-old patient with competent mental capacity wishes to ensure that no extraordinary, life-sustaining medical treatment is used to artificially prolong life if they become terminally ill. Which document in Singapore provides a legally binding statutory directive for withholding extraordinary life-sustaining treatment in terminal illness?
A registered nurse is caring for a terminal cancer patient who enters the active dying phase. The patient exhibits Cheyne-Stokes breathing, cold mottled lower extremities, and somnolence. The patient's routine orders include Q4H blood pressure checks and Q6H capillary blood glucose monitoring. What is the most appropriate nursing action?
A 50-year-old Singapore Citizen is declared brain dead following a massive intracranial hemorrhage. The patient had never submitted an opt-out objection under the Human Organ Transplant Act (HOTA). Which organs are covered for compulsory transplantation under Singapore's HOTA framework?