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How to make an Advance Medical Directive

Updated: Apr 10, 2021



This article belongs to a three-part series on the documents that you can make to record your healthcare decisions and preferences to be used in the event that there is a difficult medical decision to be made and you are not able to speak for yourself. Do check out the other articles:


Content



What is an AMD?


An AMD is a a legal document that, when signed, indicates that your decision not to receive any extraordinary life-sustaining treatment to prolong your life in the event you become terminally ill and unable to make decisions and where death is imminent.


It is made when you are mentally capable of making decisions and used during instances when you lose the ability to express your healthcare preferences.


An AMD does not prevent the healthcare team from providing you with necessary treatment (that is not extraordinarily life-sustaining) and from alleviating your pain and suffering.


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When will an AMD be used?


The situation in which an AMD can be used is very specific:

  • You will need to be suffering from a terminal illness (which is defined by the AMD Act 1996 as an incurable condition caused by injury or disease from which there is no reasonable prospect of a temporary or permanent recovery).

  • You will need to become unconscious or incapable of exercising rational judgement (and therefore be unable to communicate your wishes).

  • Extraordinary life-sustaining treatment is required to continue to keep you alive.

  • However, death is still imminent despite any use of extraordinary life-sustaining treatment.

Being diagnosed with a terminal illness does not mean that an AMD is immediately applicable. For example, if death is not imminent (i.e. you still have a prognosis of 5 years left) and you have a serious but reversible illness (e.g. widespread infection), an AMD cannot be applied. Additionally, it may still be prudent to preserve your life as you still have a decent amount of years left.


Some people may be concerned that their quality of life may be compromised if life-sustaining treatment is employed while treating the serious but reversible illness.


Do note that the definition of quality of life differs for everyone. To one person, living his life with a feeding tube is worth it if this means he will be able to witness his child being born. To another person, if eating and enjoying food is no longer possible, he would rather be allowed to pass on.


If you would like to express your healthcare preferences with regards to individual medical interventions, an Advance Care Plan may be more helpful.


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What constitutes extraordinary life-sustaining treatment?


The definition of "extraordinary life-sustaining treatment" is any medical procedure or measure which, when administered to a terminally ill patient, will only prolong the process of dying when death is imminent.


This could include (but is not limited to):

  • Intubation and ventilation (when the patient is not able to support breathing on his own)

  • Cardiopulmonary respiration (when the patient's heart is no longer able to pump blood efficiently on its own)

  • Dialysis (when the patient is not longer able to remove toxins via the production of urine)

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Why is an AMD helpful?


Modern medical technology can technically prolong life in the final stages of terminal illness. However, it cannot stop the dying process. Some terminally ill people may wish to be spared from further suffering and be allowed to die naturally.


Making an AMD allows you to exert control over your healthcare decisions and offers reassurance that your decision continues to be valid even if you have lost your mental capacity.


The process of preparing an AMD can also help you reflect on your current condition and the kind of treatment you are willing to undergo and treatment side effects that you are willing to accept in exchange for more time. Involving your loved ones in this decision-making process can also help them understand your wishes better.


The AMD Act does not authorise an act that causes or accelerates death. The Act does not condone, authorise or approve abetment of suicide, mercy killing or euthanasia.


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Who can make an AMD?


To make an AMD, you will need to be 21 years old and above and have mental capacity.


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How do I make an AMD?


Fill in your particulars in this form (print both sheets on a single sheet paper - front and back) and have the form signed by two witnesses. The criteria for the witnesses are as such:

  • One witness has to be a registered medical practitioner.

  • The other witness has to be 21 years old and above and have mental capacity.

  • Both witnesses must

  • Not be beneficiaries of your will or policy of insurance

  • Not have interest under any instrument under which the you is the donor, settlor or grantor e.g. not part of the organ transplant coordinating team or research institution that you have pledged to donate your organ/body to after you pass on

  • Not be entitled to an interest of your estate upon your death if you pass on without a will

  • Not be entitled to an interest of your CPF savings or other provident funds upon your death

  • Not have registered an objection under section 10(1) of the AMD Act 1996.


As one of the witnesses has to be a registered medical practitioner, this form is usually done in the doctor's clinic. The other witness signing the AMD should also be present in the consult at the same time. The doctor will ask some questions to ensure that:

  • You are of sound mind.

  • You are at least 21 years old.

  • You are making the AMD voluntarily without inducement or compulsion.

  • You have been informed of the nature and consequences of making the directive.

Mail the completed hardcopy or hand-deliver it to the Registrar of Advance Medical Directives (address given within the form itself). Do keep a copy of the form for your own record-keeping purposes. You will receive an acknowledgement from the Registrar of AMDs once the directive has been registered.


Advance Medical Directive form from MOH


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How much does it cost to make an AMD?


The cost of making an AMD is free. However, you will need to pay the cost of the doctor's consult.


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How will the healthcare staff know if I have made an AMD?


Healthcare staff will not know when you have made an AMD as the process of making an AMD is confidential. Under normal circumstances, healthcare staff are not allowed to ask you if you have made an AMD. However, if you fulfil the criteria needed for an AMD to take effect, the doctor-in-charge can contact the Registrar of AMDs to make a formal inquiry on whether you have an AMD.


When the doctor receives confirmation from the Registrar that the patient has an AMD which is in force, the doctor will then need to obtain the opinions of two other doctors to agree and confirm in official writing that the patient is indeed suffering from a terminal illness and not pregnant*. Two of these doctors must be a specialist.


Even though healthcare staff are not generally allowed to ask you if you have made an AMD, you are allowed to inform your healthcare team if you have made an AMD. You can also inform your loved ones who can notify the medical team in the event that you are unable to.


*Not pregnant with a foetus which will probably develop to the point of live birth with continued application of extraordinary life-sustaining treatment.


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What happens if I don't make an AMD?


As long as you are mentally capable of making decisions, the healthcare team will obtain your medical decisions directly from you.


However, if there comes a point of time when you are terminally ill and death is imminent and you not capable of communicating your wishes, the healthcare team will make a medically-guided decision based on all the information they have about your condition and what they know about your values and wishes from previous consultations and discussion with your family.


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How do I revoke an AMD?


An AMD can be revoked at any time by completing this form in the presence of at least one witness and sending the form to the Registrar of AMDs.


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Conclusion


Making an AMD allows you to exert control over your healthcare decisions and offers reassurance that your decision continues to be valid even if you have lost your mental capacity.


As it is a legal document, the process to formalise the decision (or to revoke the decision) can be rather cumbersome.


Furthermore, healthcare professionals are usually not allowed to directly ask you if you have an AMD. The time taken to contact the registrar of AMDs to verify the presence of a valid AMD can hinder medical treatment.


If you would like to consider recording your medical decisions in a format that is more flexible and can be made known to all healthcare teams looking after you, you can consider an ACP which is a non-legally binding document.


Do check out the related articles at these links:


References

Advance Medical Directive, MOH

Handbook for medical and healthcare professionals, MOH

Advance Medical Directive Act (Chapter 4A), Singapore Statutes Online

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