​By Adj Asst Prof David Sim
Director, Heart Failure Programme
Consultant, Cardiology
National Heart Centre Singapore

"The Asian doctor is not comfortable talking about end of life issues with patients." 

Singapore’s medical system is excellent in treating patients – we have the evidence-based drugs and devices that are recommended in major American and European treatment guidelines – but the Asian doctor is not comfortable talking about end of life issues with patients.

In our Heart Failure Programme*, I see a huge care gap between giving a patient their prognosis and preparing them for their healthcare journey ahead.   There is a pronounced need for advance care planning for heart failure patients because of significant morbidity and mortality rates, along with potential sudden cardiac issues and the rapid deterioration that follow.

This patient care gap is representative of our community today.   We must overcome this and create bespoke treatment plans according to patients’ needs and wishes.
The key is to empower the patients with knowledge so they can make an informed decision, exercising their rights to decide on their healthcare journey based on their education, cultural and family backgrounds.

Advance care planning allows a patient to decide the course of action for his treatment should he collapse, be very sick, or reach a semi-comatose state – instead of allowing the responsibility to fall on immediate relatives or caregivers who are already emotionally challenged at that stage to make such a demanding decision.

I, together with the Medical Social Services department of NHCS, initiated advance care planning for heart failure patients in NHCS as a pilot study after my study trip to Lacrosse, Wisconsin, in 2012. It was the first of such programmes in SingHealth.

A best case scenario for Singapore would be what I had witnessed in Lacrosse, where literally everyone has done advance care planning.   Whenever an ambulance was dispatched, the paramedics would go straight to the fridge when they enter the house, where the patient would have stuck the advance care plan.

We need to educate healthcare professionals and patients, and shift the idea of advance care planning as a terminal-stage need to a norm for every healthy person. As healthcare professionals, we need to overcome such cultural barriers, and acknowledge that it is perfectly fine to opt for quality of life and a graceful exit into the night.