Advance Medical Directive

The “Advance Medical Directive Act” is (Chapter 4A, 1997 Revised Edition) is the law to “provide for, and give legal effect to, advance directives to medical practitioners against artificial prolongation of the dying process and for matters connected therewith.”

An Advance Medical Directive (“AMD”) is a legal document signed by a person in advance, which informs the doctor that he objects to the use of extraordinary life-sustaining treatment to prolong his life where he becomes terminally ill and unconscious or incapable of exercising rational judgment.

“Extraordinary lifesaving treatment” is any medical procedure or measure which only prolongs the process of dying when death is imminent, when administered to a terminally-ill patient. Palliative care is excluded.

“Terminal illness” is defined as an incurable condition caused by injury or disease from which there is no reasonable prospect of a temporary or permanent recovery.

Creating an Advance Medical Directive

An AMD can be created at any time by any person, who is -

  1. 21 years or older;
  2. Of sound mental mind.

To be valid, the AMD must be in the prescribed form, which can be obtained from clinics, polyclinics, hospitals or the Ministry of Health website) -

  1. In writing;
  2. Witnessed by two (2) witnesses, one of which must be a doctor registered with the Singapore Medical Council and the other must be at least 21 years old;
  3. Returned to the Registrar of AMD, Ministry of Health upon completion.

Further, both witnesses cannot have any vested interests in the death of the creator of the AMD. The witnesses must not -

A relative to the creator of the AMD can be a witness, as long as he does not have any vested interests as listed above.

How AMD works

The AMD is confidential and will not be disclosed to anyone, except if the creator of the AMD has authorised specific persons in writing.

An AMD is activated in the event the creator of the AMD is -

  1. Suffering from a terminal illness;
  2. Unconscious or incapable of exercising rational judgment;
  3. To the point where he/she is unable to communicate his/her wishes to the doctor.

The doctor will then check the AMD Registry to see if an AMD has been registered. If so, extraordinary life-sustaining treatment will not be applied or given to the creator of the AMD.

An AMD is confidential, and therefore the doctor cannot ask their patient whether or not an AMD has been created.

To determine whether a patient is “terminally ill” -

  1. Three doctors, including the doctor who is responsible for the treatment of the patient, must unanimously certify that the patient is terminally ill;
  2. At least 2 out of the 3 doctors must be specialists;
  3. If these doctors cannot unanimously agree, then the matter is referred for determination to a committee of 3 specialists appointed by the Director of Medical Services from among the panel of specialists appointed by the Minister;
  4. If the second panel of 3 doctors cannot unanimously agree, the patient shall be presumed not to be terminally ill and the AMD will not take effect.

Revoking an AMD

An AMD can be revoked at any time in the presence of at least one witness, by -

  1. Completing the AMD revocation form; or
  2. Writing a letter to the Registrar of AMD to revoke it.

If the creator of the AMD is unable to write, the AMD can be revoked orally or in any other way in which he can communicate. It is then the responsibility of the witness to the revocation to submit the notice of revocation using the revocation form or the letter. The witness should also state the reason why the person revoking the AMD could not do so himself.