What is an Advance Medical Directive (AMD) and how is it important?

With advances in medical technology, there are now ways to prolong the life and improve the quality of life of terminally ill patients, even if the patient’s condition cannot be improved or cured. This means that there are increasingly complex decisions that patients may need to make regarding how they would like to be treated – or not treated.

Enacted in Singapore in 1996, the Advance Medical Directive Act provides an avenue for Singaporeans to state their preference for their end-of-life care in the event they are incapacitated or otherwise unable to make these decision on their own.

Even though the law recognising Advance Medical Directives (AMDs) has been in effect for the past 22 years in Singapore, AMDs are still not widely understood, perhaps due to the stigma surrounding the topic of illness and end-of-life care.

Rather than be introduced to AMDs only during a dire situation, here’s what you need to know about AMDs and how it can help give you and your loved ones peace of mind if the worse occurs.

Also known as “living will”, an AMD is a legal document that you sign when you’re still mentally competent expressing your wishes to the medical team treating you regarding the use of extraordinary life-sustaining treatments to prolong your life in the event you are terminally ill and mentally incompetent or unconscious.

The scope of an AMD is very specific, so let’s go into each of the elements in the definition above.

Terminal illness is defined as an incurable condition from which there is no reasonable prospect of a recovery, and for which death is imminent even if extraordinary life-sustaining measures were applied.

Extraordinary life-sustaining treatment refers to any medical procedure which serves to only prolong the process of dying in terminally ill patients and does not cure or heal the illness. It specifically excludes palliative care.

Making an AMD is completely optional, and it is a criminal offence for someone to coerce you into making an AMD.

AMDs are also confidential. In fact, not even hospital doctors and nurses would know if you made an AMD. In fact, they are not even allowed to ask you if you have made an AMD.  Only when you’re terminally ill and unable to make your wishes known can your attending doctor check with the Registrar of Advance Medical Directives if you have made an AMD, and if so, carry out your AMD.

An AMD is NOT the same as euthanasia (mercy killing), which is the deliberate ending of the life of a person suffering from an incurable and painful disease. An AMD simply instructs your doctor not to proceed with extraordinary life-sustaining treatment and allow you to die naturally when you become terminally ill and unconscious, while minimising suffering through palliative care and medication.

If you have an opinion regarding your end-of-life care and wish to state it while you’re of sound mind, an AMD is a legally recognised way to ensure your wishes will be honoured, even if you’re incapacitated.

When faced with a terminal illness, some people would rather die naturally and in peace, rather than continue to have their lives prolonged artificially with no real possibility of recovery and at immense pain and financial costs.

Patients with conditions like cancer can experience tremendous discomfort and pain. An AMD prevents their suffering from being prolonged, and allows them to have a natural death with dignity.

Anyone who is aged 21 years and above and of a sound mind can make an AMD.

Step 1: Download and complete the AMD form or obtain it at hospitals, polyclinics or private clinics.

Step 2: Sign your completed AMD form in the presence of two witnesses – one doctor and an adult above 21. Both witnesses must not stand to gain anything from your death.

Step 3: Submit the signed AMD form to the Registrar of Advance Medical Directives (Ministry of Health, Singapore, College of Medicine Building, 16 College Road, Singapore 169854) in a sealed envelope by mail or by hand.

Step 4: You will receive an acknowledgement from the Registrar of AMD once your AMD has been registered. Your AMD is now valid and legally binding.

You can revoke your AMD any time. You can do this by completing the revocation form in the presence of a witness. This form will be sent to you along with the acknowledgement from the Registrar of AMD. Alternatively, you can write a letter to the Registrar of AMDs.

If you are unable to write, you can communicate your wishes to cancel your AMD verbally or using sign language. Your witness will submit the notice on your behalf and explain why you cannot submit it yourself.

The AMD will only come into force once you have been determined to have a terminal illness and a certificate of terminal illness has been issued. For this to happen, three doctors, including the patient's attending doctor, must unanimously certify a patient's terminal illness. Two of the doctors must be specialists.

If the doctors are not unanimous, then the doctor-in-charge will review his diagnosis. If he is still of the opinion that the patient is terminally ill, then the matter will be referred to another panel of three specialists appointed by the Ministry of Health. If this second panel of doctors cannot agree unanimously that the patient is terminally ill, the AMD will not take effect. All medical treatment will be administered in an attempt to heal the patient.

While family objection to an AMD does not invalidate it, it is recommended that you explain the rationale for your decision with your loved ones, so that they would support and respect your wishes at the end of your days.

Being diagnosed with a terminal illness is the last thing anyone can wish for. In the unfortunate event that happens, you may not want to put your family in a difficult position to make a decision on your life sustaining treatments and you definitely do not want financial constraints to be a burden on their minds. An AMD goes some way towards solving this for you.

While you’re still active and well, having sufficient health and life insurance coverage gives you peace of mind that your family will be taken care of if you are no longer around and frees you to focus on achieving the most important things in your life.

AIA Guaranteed Protect Plus (II) helps you meet your changing protection needs, in the event of death, total permanent disability or critical illness, and savings needs, allowing you to provide for your loved ones. You also have the added flexibility to increase your coverage level when you enter a new stage in life such as when you get married or become a parent. This can be exercised once and without additional underwriting.