SINGAPORE – Over the past three decades, more than 84,500 individuals have signed an advance medical directive (AMD).

This is a legal document allowing individuals to refuse extraordinary life-sustaining treatment if terminally ill and unconscious.

Nominated MP Kuah Boon Theng, a medical law and ethics lawyer, asked in Parliament on April 7 if the Ministry of Health (MOH) can remove the requirement for a doctor to be present at the signing of AMDs.

Currently, when one signs an AMD, two witnesses are required to be present and also sign the directive. One of the witnesses has to be a doctor, and the other has to be at least 21 years old, among other criteria.

Minister of State for Health Rahayu Mahzam said in response that the decision to sign an AMD has to be taken seriously as it states that the individual does not want to use any treatments to prolong their life if they become terminally ill, unconscious or require life-sustaining treatment.

“Hence, safeguards are in place to protect the interests of individuals. For example, a witnessing doctor ensures that the individual understands the medical implications of making an AMD, is not being coerced, and is of sound mind,” added Ms Rahayu.

In response, Ms Kuah said lawyers can also make the same assessment of the individual and provide the same advice on implications of the AMD.

She added that an advantage of doing away with the requirement is that individuals can benefit from a “one-stop shop” – being able to sign both an AMD and the lasting power of attorney (LPA) at the same time with a lawyer present.

Ms Kuah noted that the take-up rate for AMDs has been “quite slow” compared with that of LPAs, which appoint one or more trusted persons to make decisions on an individual’s personal matters including welfare, property and finances, if that individual loses mental capacity.

As at Feb 20, about 404,000 Singapore citizens have made an LPA since the scheme started in 2010.

In comparison, more than 84,500 individuals have signed an AMD as at February, after the AMD Act was passed in Parliament in May 1996.

Ms Rahayu emphasised the need to have a doctor as there may be explanations required from a medical perspective, and the need to ensure that the individual is of sound mind.

Difficulties in ascertaining patients’ AMD status

Ms Kuah also asked if MOH can reassess the need to continue prohibiting doctors from asking patients if they have an AMD.

Doctors are not allowed to ask patients or their families if they have an AMD. Instead, they have to verify this information with the Registrar of Advance Medical Directives.

She cited feedback from doctors on difficulties ascertaining their patients’ AMD status as they have to wait till they can contact the registrar.

This is especially so when the certification of terminal illness occurs after office hours and at inconvenient timings such as in the middle of the night, said Ms Kuah.

According to information on the MOH website, the doctor has to fill up a search request form on AMD status and fax or mail it to the registrar, whose address is indicated as MOH’s address at 16 College Road. The registrar will then inform the doctor in writing whether the patient has an AMD in force.

In her response, Ms Rahayu emphasised that strict confidentiality of AMDs is maintained to ensure that treatment decisions are not inappropriately influenced before a patient is certified terminally ill.

In addition, MOH has established operational processes to ensure that AMD search requests made by doctors receive prompt attention, including after regular office hours.

“In terms of the process, it is something that we have been monitoring, and it is something that is done very promptly. So, it is not something that causes any inordinate delay,” added Ms Rahayu.