15 May 2006

Mr Wang Answers Some Questions About Life and Death

ST May 15, 2006
Doc won't witness medical directive

MY WIFE and I, aged 73 and 80 respectively, read in The Sunday Times that one can make a legal directive stating that if one is terminally ill and in a coma with no hope of recovery, no life sustaining treatment should be given ('When death strikes'; ST, April 16).

So my wife, who is a stroke victim, and I went to the nearest doctor, each with a prepared advance medical directive, with our daughter who was to be a witness, with a request for the doctor to be the second witness. It was stated in the article that two witnesses are required, one of whom must be a registered medical practitioner.

Imagine my surprise when the doctor declined to be a witness, saying it is not clear she is empowered to do that. She also said that as we had no medical records at her clinic, she could not witness our signatures. In my wife's case, she suggested she go to Tan Tock Seng Hospital where she was admitted for her stroke and ask a hospital doctor to be her witness as her records are there. She suggested I go to Ang Mo Kio Polyclinic as I was treated there for asthma.

From my observations, I believe ours was the first such request this doctor has had, as the advance medical directive is new, and I suspect she decided to play safe and not get involved.

There must be many elderly poor who want to make an advance medical directive, but are either unaware that such a scheme is available or don't know how to do it.

Can the authorities kindly enlighten us what one has to do to get an advance medical directive validated?

Trevor Reginald

It was probably just a case of the doctor not being very sure what to do. There probably aren't that many Singaporeans who have made their Advance Medical Directive. Well, the answers are all in the Advance Medical Directive Act.
3. —(1) A person of sound mind 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.

(2) ...... the directive 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.

What are the duties of the doctor, when acting as witness?
4. Before witnessing the execution of the directive on the prescribed form, a witness who is a medical practitioner shall take reasonable steps in the circumstances to ensure that the patient —

(a) is of sound mind;

(b) has attained the age of 21 years;

(c) has made the directive voluntarily and without inducement or compulsion; and

(d) has been informed of the nature and consequences of making the directive.
The doctor doesn't have to worry too much because he is only required to "take reasonable steps in the circumstances" to satisfy the requirements stated in (a) to (d) above.

In fact, the Act also says that as long as the doctor acted in good faith and without negligence, he can't be subject to any action (whether civil or criminal or in the nature of professional disciplinary proceedings), if it turns out later that the patient wasn't capable of understanding the nature and consequences of signing the directive.

Next point - Trevor Reginald mentioned in his letter that he had asked his daughter to act as his witness. This is probably not so advisable (if he intends to bequeath any of his assets to her). That's because the Act says:
A witness shall be a person who to the best of his knowledge —

(a) is not a beneficiary under the patient’s will or any policy of insurance;

(b) has no interest under any instrument under which the patient is the donor, settlor or grantor;

(c) would not be entitled to an interest in the estate of the patient on the patient’s death intestate;

(d) 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 .....

What would happen to Trevor's daughter if she did act as witness? Well, if for some reason, she is later accused, charged and convicted of having acted criminally in deceiving or inducing Trevor into signing the directive, then apart from the criminal punishment, she may also forfeit her rights under the will, policy, estate, CPF funds etc.

Would Trevor's directive be invalid, if her daughter witnessed it, and:

(a) she knew she was a beneficiary under Trevor's will;

(b) she was a good, kind person without any ulterior motives or bad intentions?

That's a question mark. Although the Act says that a person who knows he is a beneficiary must not be a witness, the Act doesn't say anything about whether the directive would be valid or invalid, if such a person were to act as witness. If I were a judge and this issue arose in a court of law, I would be inclined to the view that the directive should be treated as valid.

However, to avoid any such legal complications, it is best for Trevor's daughter not to act as witness. Especially since a much simpler, fuss-free solution is available. Leave your loved ones out of the picture. Simply get your doctor, and his nurse, to be your witnesses.

Finally I should explain the term "extraordinary life-sustaining treatment". It is is defined to mean "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 it excludes palliative care. That is, you will still get medical treatment to ease your pain and suffering.

Thus the medical directive is basically to cater for the kind of scenario where:

(1) you're terminally ill; and

(2) you're no longer able to make any decisions for yourself (eg you're in a coma).

They will withhold the "extraordinary life-sustaining treatment" so you'll die naturally, instead of cling on to "life", thanks to assorted tubes and machines plugged into your body.


Dr Oz bloke said...

Hi Mr Wang,

In your blog entry you raised question marks whether the patient's daughter could have been the 2nd witness in signing the AMD.

It is stated in MOH publications :

"Both witnesses must not stand to gain upon your death. Hence, family members, relatives and anybody (including doctors) who is a beneficiary of your will cannot be witnesses. "

I hope this clears up some of the doubts.

MOH has actually sent the new AMD booklet to all doctors dated 3 April 2006. It is written in a question and answer form and very easy to understand. I am unable to find an online version of it. But I am sure that if doctors have read this booklet, there would not be problems as that highlighted by Mr Reginald.

While the booklet is not available online, most of the information is found in this article here:

Anonymous said...

My initial reaction upon reading about the doctor who declined to be a witness was that she may have a personal or religious objection to the rationale behind the advance medical directive. After all, doctors have this Hypocritic oath, in particular the part that says "To please no one will I prescribe a deadly drug nor give advice which may cause his death". So she did the right thing to refer Trevor to the physicians or medical units that have attended to his or his wife's health issues.

tscd said...

I'm not sure I'd want to be part of an advance directive. Patients should really get things like that drawn up by lawyers.

Gilbert Koh aka Mr Wang said...

There isn't anything for lawyers to draw up. The advance medical directive comes in a standard format, like an application form from MOH.

Hi Dr Oz Bloke:
Pardon the lawyer-ish thinking in me. The MOH publication may say that such and such a person cannot act as witness .... The legal issue is - what if, notwithstanding the MOH publication, the person DID act as a witness anyway (eg by mistake or ignorance)? The question then is - if the patient does fall very ill etc, would the advance medical directive still be valid?

Keng Lee:
Well, you might be right .....