This post is about death, disability, disease and decision-making.
There comes a time when someone is ill or dying, and decisions have to be made about treatment and whether or not to prolong life, or suffering, as the case may be. Who makes the decisions? When? How? Singaporean not only love acronyms, they like things neat and orderly. And so several laws and programs have been put in place to help people do things properly.
Unfortunately, the introduction of these new programs have been muddled up with rules, details and legal jargon. Let me try to demystify it a bit…
Last will and testament
This is obvious. This is a legal document determining how to distribute one’s worldly possessions upon death.
Example – Aunty Helen died, and in her last will and testament, left her house to her son, her jewellery to her daughter, her bank account to her chauffeur and favorite charity, and only $100 to her constant companion, whom we all knew was after her money.
Advanced Medical Directive (AMD)
This is legal document you sign to request your doctor to let you die, in the event your are unconscious and death is imminent. Once the document is registered, your wish will be recorded in a secure and secret place. Only when you are seriously ill, about to die and unconscious, will you doctor be able to request to check whether you have made an AMD. An AMD can be revoked anytime, verbally.
Example – Mr. Shia Vo had a bad car accident and was brought to hospital unconscious from a smashed skull. They managed to hook him up to a ventilator and revive him, but his organs are failing one by one and he’s not going to recover. The doctors checked and found he had an AMD, but his mother is adamant he revoked the AMD last week when she discussed life and death matters with him. The doctors have no choice but to leave him on the ventilator until his heart stops in about a week.
Lasting Power of Attorney (LPA)
This is a legal appointment for someone to take charge of your affairs should you lose your mind. Also used in the case of adults with mental incapacity. A person holding the LPA (called the donee), cannot make serious* healthcare treatment decisions.
Example – When Aunty Dora realised 3 of her siblings had developed dementia, she quickly gave her son Sam the LPA because she was worried about herself. It was lucky she did that early, because a couple of years later, she became demented rather rapidly, and Sam was able to go to the bank and stop the swindlers from cheating her of all her money. He further arranged for Aunty Dora to receive round the clock nursing care at home, and paid for it from her bank account.
Advance Care Planning (ACP)
To express one’s wishes and values to loved ones, so that when the time comes, your loved ones are able to make your healthcare decisions, consistent with what’s important to you.
Example – Mr Gar had kidney failure and needed renal dialysis three times weekly. It was hard for him, but he coped with it. A nurse there got the family involved in ACP, and Mr Gar told everyone how much he hated being dependent, and how he would rather be dead than bedridden and unable to talk, unable to eat. A few months later, Mr Gar developed sepsis and was admitted to the Intensive Care Unit (ICU). He was very weak, and doctors gave him powerful antibiotics. However during the second week of ICU he developed a severe stroke from a large bleed in the brain. Mr Gar’s family knew from the ACP what Mr Gar would want, and requested his doctors switch from aggressive treatment to comfort care.
Story Combining All
Mrs K was found to have a brain tumor 3 years ago. Before her brain surgery, the neurosurgical nurse conducted an ACP session and spoke to her about appointing a surrogate decision maker in case of complications. Mrs K, chose her daughter, Sara, who was close to her. Mrs K expressed she was willing to live with moderate disability, as she was looking forward to her son Dan’s graduation from law school, Sara’s upcoming wedding, and grandchildren.
Before going into surgery, Mrs K called her lawyer and revised her last will and testament, and made an LPA appointing Dan the donee (Sara was hopeless with money matters). The surgery went well and Mrs K was as good as new. That is, until several months ago, when the tumor recurred and Mrs K developed behavioral abnormalities. She became apathetic and could no longer handle her household affairs. Her children were deeply saddened, but because they had already discussed it, cared for her as she had wished.
When Mrs K deteriorated, Sara arranged for home nursing, called the doctors in when required, and decided against hospitalisation as that was against her mother’s stated wishes. Dan paid the bills and managed his mother’s finances.
An AMD was not applicable and no one sought to check if Mrs K had one, because Mrs K declined gradually and death was not “imminent”.
Conclusion
See, that wasn’t so difficult, was it?
* The donee in an LPA can only make basic healthcare decisions and cannot make any decisions which involve refusing life sustaining treatment or treatment required to prevent
a serious deterioration in the condition of the person lacking capacity – see Guidelines. (edited 20 Jan 2015)
Dementia, Caregiving and Life in General 