Advance Medical Directive
What is an Advance Medical Directive?
An Advance Medical Directive ('AMD') is a document you sign to instruct the doctor treating you (where you are terminally ill and unconscious or incapable of making a rational decision) that you do not want any artificial means of prolonging your life, such as the use of life-sustaining equipment (eg breathing machine), where there is clearly no hope of finding a cure on either a temporary or permanent basis.
What is Meant by 'Terminal Illness’?
The Advance Medical Directive Act (the 'Act') defines 'terminal illness' as 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 use of extraordinary life-sustaining treatment and where such use would only serve to postpone the moment of death of the patient.
What is Meant by 'Extraordinary Life-sustaining Treatment’?
The Act defines 'extraordinary life-sustaining treatment' as any medical procedure or measure which will only prolong the process of dying for terminally ill patients when death is imminent but excludes palliative care. Palliative care is the provision of reasonable medical procedures for relieving pain, suffering or discomfort and the reasonable provision of food and water.
How Do I Make an AMD?
If you are 21 years and above and of sound mind, you may obtain a prescribed AMD form at any polyclinic or private clinic. After completing the form, you must have it signed in the presence of two witnesses, one of whom must be a doctor, preferably your family doctor or the doctor treating you at that time.
Who Can be a Witness and What Must the Witness Do?
As explained above, one of the witnesses must be a doctor. The other witness must be at least 21 years old and must not stand to gain upon your death (eg a beneficiary under your will or your policy of insurance or CPF monies). Both witnesses must be physically present to witness you signing the AMD as well as to sign the AMD as witnesses. The doctor who signs as your witness is responsible for ensuring that you are at least 21 years of age, of sound mind, and having made the AMD voluntarily and without inducement or compulsion, are informed of the nature and understand the consequence of making the AMD.
How Much Does it Cost to Make an AMD?
You do not need to see a lawyer to make an AMD. However, since one of your witnesses has to be a doctor, you may be required to pay the doctor for services rendered. The AMD itself is free.
What Happens After You Make an AMD?
After an AMD is made, it must be registered with the Registrar of Advance Medical Directives (Registrar of AMD) at:
The Registry of Advance Medical Directives
Ministry of Health
College of Medicine Building
16 College Road
Tel: 6325 9136
Fax: 6325 9212
Although you are not compelled to disclose your AMD to anyone, it would be preferable if you could discuss it with your family and loved ones before making an AMD. The Register of AMD is kept confidential and will only be disclosed to persons authorised by you in writing and/or your doctor when he has reason to believe that you are terminally ill and are unable to make your wishes known to him.
Can I be Assured That I Will be Given the Necessary Treatment Before the AMD is Carried Out?
It is the practice and professional responsibility of every doctor, regardless of whether an AMD is made or not, to ensure that all necessary treatment be given as long as the patient is not certified terminally ill and there is a possibility of recovery. Even if the patient is terminally ill, the doctor has the responsibility to provide treatment to minimise pain and suffering.
When Does the Doctor Certify That the Patient is Terminally Ill?
Three doctors, including the patient's hospital doctor, must unanimously certify that the patient is terminally ill. Two of the doctors must be specialists. If the first panel of three doctors cannot reach a unanimous decision that the patient is terminally ill, the doctor-in-charge will review his diagnosis and may refer the matter to a second panel of three specialists, to be appointed by the Ministry of Health whose services will not be charged to the patient. If the second panel of specialists cannot agree unanimously that the patient is terminally ill, the AMD will not take effect.
Can I Revoke the AMD if I Change My Mind?
Yes, you can. An AMD can be revoked at any time in the presence of at least one witness either orally, in writing, or by any other means of communication that the patient can manage. There is a prescribed form which can be completed to revoke an AMD made earlier. It is the duty of the person witnessing the revocation to inform the Registrar of AMDs of the revocation. Alternatively, you can send a simple letter to the Registrar of AMDs containing information such as the name, address, NRIC number, home and office telephone numbers of the person revoking the AMD and the witness, the time, date and place of the revocation and the method of communication (eg orally, in sign language). All revocations should be sent to the Registrar of AMDs as soon as possible.
Can Family Members Object to and Prevent My AMD from Being Carried Out?
No, your family members cannot overrule or prevent your AMD from being carried out. Even if your family has strong opposition to your AMD for religious or other reasons, the doctor will respect your wishes as expressed in the AMD.
Is the AMD the Same as Euthanasia?
No, euthanasia (or mercy killing) is the deliberate ending of life of a person suffering an illness by unnatural means; AMD on the other hand, are your written instructions to your doctor not to prolong your life with extraordinary life-sustaining treatment where death in imminent and there is no hope for recovery. The law assures that the AMD Act is explicitly and categorically against euthanasia and nothing in the Act shall condone, authorise or approve abetment or suicide, mercy killing or euthanasia.
What Happens if I am Terminally Ill and Unconscious, and Have not Made an AMD?
If you do not have an AMD and you are incapable of expressing your wishes, the doctor will consult your family on the type and extent of life-prolonging treatment you will receive.