Advance Medical Directive: Make Your Decisions on Death

Zhi Qi Lim and Chee Seng Tang

7 years ago

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If you are above the age of 21 and are of sound mind, you might consider making an Advance Medical Directive (“AMD”). This is a document that will inform professionals and other parties involved in your healthcare that you do not want extraordinary life-sustaining treatment to prolong your life in the event you become terminally ill, and where death is imminent.
In order to make an AMD, you will need two witnesses – a doctor, and another person who is also above the age of 21. Either witness may be a family member or relative. It is important to note that the witnesses must not have any vested interests in your death.”
You do not need to seek legal advice in order to make an AMD, but you may wish to review it alongside your estate planning considerations.

What is an Advance Medical Directive (AMD)?

The Advance Medical Directive Act was passed in 1996 to allow Singaporeans to make an AMD. The AMD is a legal document that enables a person to tell his healthcare professionals and other parties involved in his health care that he does not want extraordinary life-sustaining treatment to prolong his life in the event he becomes terminally ill and unconscious, and where death is imminent. It is often referred to as a “living will”.

Usually, “extraordinary life-sustaining treatment” refers to any medical treatment which artificially prolongs the life of a terminally-ill patient without curing the illness – e.g. connecting a respirator to a patient in order to help the patient breathe.
Under the Advance Medical Directive Act, “terminal illness” refers to an incurable condition caused by injury or disease from which there is no reasonable prospect of a temporary or permanent recovery, where death would be imminent regardless of the application of extraordinary life-sustaining treatment, and where such treatment merely postpones the person’s death.

It should also be noted that extraordinary life-sustaining treatment excludes palliative care – the former is an artificial way of keeping the person alive and postponing the eventuality of death whereas the latter is about making your last days as comfortable as possible, through the provision of reasonable medical procedures for the relief of pain, suffering, and discomfort, as well as reasonable provision of food and water.

Why is the AMD necessary?

One of the central tenets of medical law is the upholding of a person’s autonomy. The AMD allows a person to retain such autonomy in giving him the option of deciding for himself if he wants to undergo such extraordinary life-sustaining treatment when he is terminally ill and at the last stage of his life.

While these treatments may delay the onset of death, the person may end up with a severely diminished quality of life. Some people would rather be spared from additional suffering that may come with such futile medical interventions; they would rather let nature take its course than try to postpone the inevitable and have a poor quality of life.

Who can make an AMD, and what else is required?

Any person who is aged 21 years old or older, in full control of their mental faculties, and who does not want to be subject to extraordinary life-sustaining treatment in the event that he suffers from a terminal illness.

The person would need to complete a prescribed form (which can be found online, or in any clinic, polyclinic or hospital) and sign it before 2 witnesses present at the same time. The form would then have to be submitted to the Registrar of AMDs at the Ministry of Health.

One witness must be the person’s family doctor or any other medical practitioner of his choice. He or she must take reasonable steps to confirm that the person:

is of sound mind;
is above the age of 21;
is making the Advance Medical Directive voluntarily and have not been forced or induced into making it; and
has been fully informed of the nature and consequences of making an AMD.

The other witness must be 21 years old or older, and may be a relative.

However, both witnesses must not have any vested interests in the person’s death. That means that neither of them should:

Be a beneficiary in the person’s will or insurance policy;
Have any interest under any instrument where he is the donor, settlor or grantor;
Be entitled to an interest in his estate if he were to die intestate; and
Be entitled to an interest in the monies held in his CPF account or other provident funds.

The Advance Medical Directive Act also allows for doctors to object to acting on the AMD. In such a situation, the person would be transferred to the care of another doctor who has not registered an objection.

When will the AMD be applied?

If the person is still conscious and capable of exercising rational judgment, his doctor is obligated to inform him of the different types of treatment available, so that he can make an informed judgment about whether a particular treatment should be undertaken.

The AMD will be applied only after a panel of 3 doctors – 2 of whom must be specialists – have unanimously certified that the patient is terminally ill. It must be established that the person:

is suffering from a terminal illness;
requires extraordinary life-sustaining treatment;
is unconscious or incapable of exercising rational judgment.

If the panel of doctors does not come to a unanimous decision, the matter will be referred to a committee of 3 specialists, who must come to a unanimous decision as to whether the AMD is to be applied. Otherwise, the person will not be presumed terminally ill and the AMD will not be applied.

Do I need a lawyer or any other form of legal advice before I can make an AMD?

In general, you do not need to seek a lawyer or any other form of legal advice before making an AMD. However, while you are still of sound mind and health, it may be helpful for you to review this alongside your estate and succession planning considerations. You may also wish to consider making a Lasting Power of Attorney (“LPA”).

How do I revoke my AMD?

There are two ways in which an AMD is revoked:

You can revoke your AMD by completing a prescribed form in the presence of at least one witness and send it to the Registrar of Advance Medical Directives thereafter.
You or your witness may revoke your AMD by way of a letter addressed to the Registrar of Advance Medical Directives. The letter should state:
- Your name and your witness’ name, NRIC number, and contact details; and
- When and where the revocation was made.

If your witness wrote the letter on your behalf, he or she would also have to state how such revocation was communicated.

After the Registrar receives notice of revocation of the AMD, an acknowledgment will be issued and the directive will be marked ‘revoked’.

What is the difference between an AMD and an LPA?

The AMD is concerned with end-of-life decisions. As stated above, the AMD is a legal document to state that you do not wish to receive extraordinary life-sustaining treatment to prolong your life if the above conditions are met.

On the other hand, the LPA is a legal document to appoint one or more donees to make decisions on your behalf if you do not have the mental capacity to do so while you are still alive. The donee can be appointed to make decisions relating to your personal welfare and/or property and affairs.

The execution of either document does not revoke the other.

Are there other ways of expressing my wishes relating to my healthcare and welfare in advance?

The government launched the Advance Care Planning programme in 2011. This enables you to plan end-of-life care arrangements in relation to the medical treatment and where you wish to die. Unlike the AMD and the LPA, such arrangements are not legally binding and serve as a guide to the parties involved in your healthcare.

Have a question about the Advance Medical Directive?

If you need legal advice on the advance medical directive, you may get a Quick Consult with one of the practicing lawyers for a transparent, flat fee of S$49 and expect a call back within 1-2 days to get your questions answered.

This article is written by Lim Zhi Qi from Withers KhattarWong and edited by Tang Chee Seng from Asia Law Network.

This article does not constitute legal advice or a legal opinion on any matter discussed and, accordingly, it should not be relied upon. It should not be regarded as a comprehensive statement of the law and practice in this area. If you require any advice or information, please speak to a practicing lawyer in your jurisdiction. No individual who is a member, partner, shareholder or consultant of, in or to any constituent part of Interstellar Group Pte. Ltd. accepts or assumes responsibility, or has any liability, to any person in respect of this article.

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