What is an Advance Medical Directive (“AMD”)?
An Advance Medical Directive is a legal document that you sign in advance to inform the doctor treating you that you do not want any extraordinary life-sustaining treatment to be used to prolong your life if you become terminally ill and unconscious.
What does it mean to be “terminally ill”?
Simply put, terminal illness is when you have an incurable condition caused by injury or disease from which there’s no reasonable prospect of recovery. Death is imminent and any application of extraordinary life-sustaining treatment only serves to postpone the moment of death.
What does “extraordinary life-sustaining treatment” include?
It includes any medical procedure or measure which, when administered to a terminally ill patient, will only prolong the process of dying when death is imminent, but excludes palliative care.
Why make an AMD?
If you are in a permanent vegetative state (unconscious), terminally ill and will die shortly without life support, do you still want to be on life support?
If you answer is no, making an AMD can help you legally communicate that.
Some terminally ill patients may be unable to express their wishes to be spared from suffering and be allowed to die naturally. Having an AMD helps your family and doctor act on your wishes. If you have an AMD, regardless of objections from your family, the doctors will have to respect your AMD. Having the discussion about AMD will help your family understand and respect your wishes should you become terminally ill.
*Note: An AMD acts as instruction for your doctor not to prolong your life with extraordinary life-sustaining treatment, and let the dying process take its natural course, and not through an act that causes or accelerates death.
It cannot be used as approval for euthanasia, abetment of suicide or mercy killing. Euthanasia/mercy killing is the deliberate ending of the life of a person suffering from an incurable and painful disease by unnatural means, such as the administration of lethal chemicals.
How to make an AMD?
Anyone who is above 21 years old and not mentally disordered can choose to make an AMD.
The form can be downloaded here and have to be signed by two witnesses present at the same time. One of the witness must be a doctor and the other must be at least 21 years old. The witnesses cannot have vested interest in your death. Relatives can be witness as long as they don’t have a vested interest in your demise.
The witnesses' duties include ensuring that you:
Are of sound mind
Are over 21 years old
Are making the AMD voluntarily and without inducement or compulsion
Have been informed of the nature and consequences of making an AMD.
Send the completed form to the Ministry of Health’s Registrar of Advance Medical Directives (“Registrar”). The Registrar will send you an acknowledgment after the AMD has been registered. Your AMD is only valid after it has been registered.
How much does it cost to make an AMD?
The AMD form is free. The cost comes from paying the doctor for the services (being a witness as well as explaining the AMD to you) rendered.
What happens after you make an AMD?
AMD is a confidential document. Hospital staff, including doctors and nurses, do not know who has made an AMD and they are not allowed to ask you if you have made an AMD.
The Process
If your doctor has reasons to believe that you are terminally ill and unable to make your wishes known, the doctor can check with the Registrar on whether you have made an AMD.
If the Registrar informs that you have an AMD, three doctors, including the patient's doctor, must unanimously certify a patient's terminal illness. Two of the doctors must be specialists.
If the first panel of three doctors cannot agree unanimously that the patient is terminally ill, the matter will be referred to a second panel of three specialists that are appointed by the Ministry of Health.
If the second panel of doctors also cannot agree unanimously that the patient is terminally ill, the AMD cannot take effect. The patient's life will continue to be sustained and receive medical treatment as normal.
Note: This is a simplified explanation of the procedure. See here for full details.
How to revoke your AMD?
An AMD can be revoked anytime in the presence of at least one witness. A revocation form needs to be submitted to the Registrar or you/your witness can write a letter to the Registrar.
Please check here for full details.
Can you make an AMD while overseas?
As long as the first witness is a doctor currently registered with the Singapore Medical Council, and the AMD is filed with the Registrar in Singapore, the AMD is considered valid.
Note: This article has been summarized from the following sources:
Advanced Medical Directive Act - https://sso.agc.gov.sg/Act/AMDA1996#pr9-
Ministry of Health website: https://www.moh.gov.sg/policies-and-legislation/advance-medical-directive
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