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Don't Leave Your Family Feeling Devastated From Your AMD Decision. Communication Is Crucial.

Updated: May 12, 2023

Doctors play an important role in ageing well. In this interview, we spoke to Dr. Chung Wing Hong, Resident Physician and Director at Chung & Ee Medical Clinic, to understand more about the services that general practitioners provide in the Last Mile of Life space as well as family struggles when it comes to making tough decisions on signing documents like Lasting Power of Attorney and Advance Medical Directive.

 

Name: Chung Wing Hong

Company: Chung & Ee Medical Clinic

Specialization: General Practitioner (Elder-related services)

Base Country: Singapore

Service Style: Compassionate, personable, relatable

Anything Interesting: Likes cars and watches

Clinic Location: 10 Telok Blangah Crescent #01-151 Singapore 090010 (Central Singapore CDC)




Q: Can you tell me about yourself? Why did you choose to be a doctor and what made you start your own clinic?

Chung: I was born in Hong Kong, but moved to Singapore when I was 4 years old and grew up here. I practiced medicine for about a decade before starting my private practice in 2020.


I started my own clinic because there is more accountability and flexibility compared to working in an institution.



Q: What services do you provide in the Last Mile of Life space?

Chung: Because of the higher elderly population in the vicinity of my clinic, most of the services that we provide are related to seniors and aging. These include chronic and acute conditions management as well as services such as Lasting Power of Attorney (LPA), Advance Medical Directive (AMD), mental capacity assessment, disability assessment and death certification.



Q: What is acute and chronic condition management and how are they related to elders?

Chung: Acute illnesses are generally illnesses that happen suddenly and last for a short period of time, whereas chronic illnesses develop slowly but last for a much longer period.


Common chronic conditions that can be seen in elderlies include diabetes, high blood pressure, high cholesterol, degenerative joint disease, heart, kidney and prostate problems.


For patients whose conditions are stable enough to be discharged from the hospital, we can take over, manage, and monitor their chronic illnesses as outpatients in the clinic. As soon as complications arise, they will be referred to the hospital for further evaluation and management.



Differences Between Clinics And Hospitals For Chronic Condition Management

Benefits of having a doctor from a clinic manage your medical conditions as opposed to seeing a doctor at the hospital are much shorter waiting time and more convenience.


If you require a long list of chronic medications, your medical expenses from private clinics may be higher than that of public healthcare institutions. However, there are multiple government schemes and subsidies in place, such as the Community Health Assist Scheme (CHAS) and MediSave, that can help reduce the costs patients need to pay for private clinics.


[CHAS is a healthcare scheme provided by the Singapore government to help Singapore Citizens or Permanent Residents receive subsidies for medical or dental care from participating general practitioners (GP) and dental clinics.


MediSave is a national medical savings scheme that helps Singapore Citizens or Permanent Residents set aside a part of their income to pay for medical expenses, such as certain outpatient expenses and hospitalization, and healthcare needs during old age.]



Q: You mentioned that you can certify Lasting Power of Attorney (LPA). Since not all doctors are authorized to certify LPAs, how does a doctor become an LPA certificate issuer?

[Lasting Power of Attorney (LPA) is a legal document that allows you to appoint someone to make decisions for you when you lose mental capacity.]



Chung: Medical professionals like doctors have to go through an online course conducted by the Singapore Medical Association. Upon completion of the course, the doctor will be certified as an LPA certificate issuer.



Q: What are some of the common issues that your patients face when it comes to getting their LPA certified?

Chung: For LPA, the most common issue people face is that often the donee (person appointed) and the donor (person appointing) do not agree on the decisions that are indicated in the document.


I would suggest that both the donor and donee(s) be present during the consultation so decisions can be discussed together. Hopefully, the parties are able to reach a consensus to proceed with the LPA application. In the event that an agreement could not be reached, I would suggest the donor and donee(s) to come back another time after they have reached an agreement.



Q: What about Advance Medical Directive (AMD)? Are there any issues that people face when they want to get their AMD signed?

[Advance Medical Directive (AMD) is a legal document that allows you to inform medical professionals in advance that you do not want to prolong your life with any extraordinary life-sustaining treatment when you become terminally ill and unconscious.]



Chung: The most common issue for AMD is disagreement between the family and patient on whether the patient should do his/her AMD.


Patients who are keen to make an AMD need to understand that the aim of an AMD is to avoid prolonged dying process and suffering, and not for the purpose of saving on medical expenses. You deciding in advance will also save the family members from having to make difficult decisions when they are under tremendous emotional pressure.


AMD is completely voluntary. Not having done your AMD does not affect your right to receive medical treatment of any sort.



Q: We have heard of lawyers suggesting that certain elders should have their mental capacity assessed by a doctor before drafting their wills. How does a doctor assess someone’s mental capacity?

Chung: First, you must complete an Assessment of Mental Capacity form by the Singapore Medical Association to state why you need the assessment.


Family members or caregivers are encouraged to be in the same room as the patient who is being assessed. However, they are not to interfere with the assessment of the patient.



Testing For Cognitive Impairment

A basic cognitive test will be performed to ensure that you are oriented to time, place and person. For example, “Do you know whether it’s morning, afternoon, or night? Do you know where you are? Are you able to recognize your caregiver or your attending doctor?”


An Abbreviated Mental Test (AMT) will also be performed. This is a 10-question test to screen for cognitive impairment. A score below 7 out of 10 means there is cognitive impairment.


If there is no cognitive impairment, the Assessment of Mental Capacity form will be completed.


However, If there is an indication of cognitive impairment via the basic cognitive test or AMT, then we cannot proceed with the certification. The patient will then be referred to a psychiatrist for further evaluation and assessment.



Q: Considering that you have many elderly patients, what happens if someone passed away at home?

Chung: Should there be a death that occurred at home or outside of a hospital, the next-of-kin or the caregiver would need to find a registered medical practitioner to issue a Certificate of Cause of Death (CCOD).


[Certificate of Cause of Death (CCOD) is a legal document issued by a registered medical doctor that certifies a person’s death if the cause of death is known and is due to natural causes.]


Doctors can certify deaths if they can identify the cause of death. That usually means that the deceased family or caregiver needs to have proper documentation from their principal doctor.


For example, a family could have proper documentation from an oncologist saying that the deceased was diagnosed with a particular type of cancer and is in the late stage. The memos drafted by the oncologist is one of the ways that can help determine whether the patient has died of natural causes.


If the cause of death can’t be clearly identified, then that will be an issue. In this case, we would suggest calling an ambulance and sending the deceased to the hospital. The body will be sent to the mortuary and an autopsy will be done to determine the cause of death.



Digitization of Death Certificates

Once you obtain a CCOD, you can register the death. The government has started digitizing death certificates, where the death registration process is simpler, and certificates will be issued electronically instead of a physical one.


Normally, after we issue a CCOD, the deceased’s next-of-kin will have to register the death either in a hospital or with a police station before a death certificate is issued.


With the digitization, after the death is certified by a medical doctor online, the death will automatically be registered, and the next-of-kin will be able to receive a digital death certificate.


[The Singapore Government has started digital death certificates on May 29, 2022]



Q: What are your interests or hobbies?

Chung: I like to spend time with my family, and if I’m not with my family, I’d be at the clinic. I also like cars and watches.



This interview has been edited for length.





 

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FAQs


Can all doctors issue Lasting Power of Attorneys (LPA) certificates?

No, only accredited doctors who have passed a course conducted by the Singapore Medical Association can issue LPA certificates.


Do I have to do an Advance Medical Directive (AMD)?

No, AMD is completely voluntary. Whether you have an AMD in place or not does not affect your right to receive medical treatment when needed.


How is mental capacity assessed by doctors?

An Assessment of Mental Capacity form will first be filled to state why you need the assessment. Then your doctor will perform a basic cognitive test and an Abbreviated Mental Test (AMT) to find out if you have any cognitive impairment. After which, your doctor will either complete your Assessment of Mental Capacity form or refer to a psychiatrist for further assessment.


 

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Disclaimer: Nothing in this article or site should be construed as providing legal advice or advice of any sort. The information provided are general in nature and may become inaccurate over time. Please consult a professional for advice.


For any issues or queries, please contact j@immortalize.io

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