“To pull or not to pull the plug?”

This question might hover in the head of many when our love ones are on the life-sustaining machine. While we cannot bear to let our love ones go, the financial aspects of keeping him or her with us is taking a toll on the family.

“So should we pull or not to pull the plug?”

An Advance Medical Directive (AMD) is a legal document you sign in advance to inform your doctor that you do not want the doctor to use any extraordinary life-sustaining treatment to prolong your life, in the event that you are terminally ill and become unconscious or incapable of exercising rational judgment. The Advance Medical Directive Act (the AMDA) is a law in Singapore passed in 1996 authorising the use of AMDs in Singapore.

What is Extraordinary Life-Sustaining Treatment?

“Extraordinary life-sustaining treatment” means 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.

What is a Terminal Illness?

Terminal illness means an incurable condition caused by injury or disease from which there is no reasonable prospect of a temporary or permanent recovery where —

  • death would, within reasonable medical judgment, be imminent regardless of the application of extraordinary life-sustaining treatment; and
  • the application of extraordinary life-sustaining treatment would only serve to postpone the moment of death of the patient.

When Will the AMD Not Have Any Effect?

A medical practitioner has a duty to inform a patient who is conscious and capable of exercising a rational judgment of all the various forms of treatment that may be available in his particular case so that the patient may make an informed judgment as to whether a particular form of treatment should, or should not, be undertaken.

Who Can Make an AMD?

A person who is not mentally disordered, who has attained the age of 21 years and who desires not to be subjected to extraordinary life-sustaining treatment in the event of his suffering from a terminal illness, may at any time make an advance medical directive in the prescribed form.

How Can You Make an AMD?

To make an AMD, you will have to complete an AMD form (which is available from any clinics, polyclinics, or hospitals, or online from the Ministry of Health website), sign it in the presence of two witnesses, and return it to the Registrar of AMDs at the Ministry of Health. More detailed instructions may be found on the AMD form itself.

Witnesses for the AMD

An AMD must be witnessed by 2 witnesses present at the same time one of whom shall be the patient’s family medical practitioner or any other practitioner of his choice; and the other shall be a person who has attained the age of 21 years.

A witness shall be a person who to the best of his knowledge

  • is not a beneficiary under the patient’s will or any policy of insurance;
  • has no interest under any instrument under which the patient is the donor, settlor or grantor;
  • would not be entitled to an interest in the estate of the patient on the patient’s death intestate;
  • would not be entitled to an interest in the moneys of the patient held in the Central Provident Fund or other provident fund on the death of that patient; and
  • has not registered an objection to the AMD (a doctor who for any reason objects to the AMD and registers his objection can refuse to witness the signing of an AMD)

Even if the witness is a relative of the signer, he would be allowed to act as witness so long as he has no vested interests in the signer’s death.

Cost of making an AMD

To make an AMD, you will have to consult a doctor who, as a witness, is required to explain the AMD to you. You may have to pay the doctor for the services rendered. However, the AMD form itself is free.

Making the AMD while overseas

As long as the first witness is a doctor currently registered with the Singapore Medical Council (SMC), and the AMD is filed with the AMD Registry in Singapore, the AMD is considered valid.

Other matters to note

  • Validity
    • It is NOT compulsory. The AMD is valid only when it is made voluntarily. No one can force another person to make an AMD.No one can make an AMD on behalf of another person, whether child or adult (even if the person is mentally incapable of making an AMD on his own)
  • Coercion
    • It is the doctor’s responsibility to fully explain and discuss the matter with the person and to ensure that he/she fully understands what he/she is signing.Forcing or misleading another person into signing an AMD is an offence punishable under the law.If convicted, such a person can be fined and imprisoned and disqualified as a beneficiary.
  • Family objections
    • If you have made an AMD regardless of objections from members of your family, the doctors will have to respect your AMD.Hence, while making an AMD is a very personal decision, we encourage you to discuss it with your family members and loved ones. This will help them to understand and respect your wishes should you become terminally ill.
  • Admission to hospital
    • Hospital staff, including doctors and nurses do not know who has made an AMD as it is confidential and they are NOT allowed to ask you if you have made an AMD.However, if your attending doctor has reasons to believe that you are terminally ill and unable to make your wishes known to him, he can check with the Registrar of Advance Medical Directives on whether you have made an AMD.
  • Terminal illness
    • It is actually best to make an AMD when there is no pressure to do so – when you are well and healthy. If your family opposes it, you may wish to obtain their understanding before making the AMD. If you do not wish to inform your family, you can still proceed to make an AMD, which will remain confidential, until you wish to disclose it to someone.
  • AMD is NOT euthanasia 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.An AMD acts as advanced instruction for your doctor not to prolong your life with extraordinary life-sustaining treatment, and to let the dying process take its natural course when you become terminally ill and unconscious.The AMD Act does NOT encourage euthanasia. On the contrary, the AMD Act is explicitly and categorically against euthanasia.

Can an AMD be Revoked?

An AMD can be revoked at any time in the presence of at least one witness, by completing the AMD revocation form. Alternatively, the person or his witness could write a letter to the Registrar of AMDs.

The letter should contain the following information:

  • The name and NRIC of both the person revoking the AMD and the witness, along with their addresses and home and office telephone numbers.
  • Time, date and place where the revocation was made.
  • If the letter is written by the witness, the method of communication which the person used to communicate his intention to revoke the AMD (e.g. orally, sign language, etc)

Revocations should be sent to the Registry of AMDs as soon as possible.

Where a person is unable to write, the AMD may 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.

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