Palliative Care in Singapore

According to the WHO definition of Palliative Care:  “Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (WHO Definition of Palliative Care[1]).

In Singapore, palliative care started as a grassroots movement in the mid-1980s to meet the needs of patients dying of cancer at home. The first home care team worked out of a university lecturer’s apartment in Gillman Heights. No doctors were trained in palliative care and there were limitations on the kind of care and setting where care could be provided.

Things changed a few years later. Singapore saw its first doctor trained in palliative care in the late 1980s. The first palliative care home provider – the Hospice Care Group – was formed in 1987. In 1988 Assisi Home and Hospice was established. This was followed by Agape Home and Hospice and the Hospice Care Association in 1989, Dover Park Hospice in 1995, Metta Hospice Care in 2001 and the palliative arm of Bright Vision Hospital in 2002. In 2007, the Lien Centre for Palliative Care was established to promote research and education in palliative care in Singapore and the region.  Since 1996, the restructured hospitals have also been building up expertise to support palliative care for their patients.

Palliative care has now advanced to the point that it can help manage and stabilise patients’ symptoms, and reduce their suffering. Due to greater and more structured training opportunities for healthcare professionals (palliative care is a subspecialty of medicine now), and a steady expansion of palliative care services, even treatments such as blood transfusions and intravenous infusion can be provided to patients in hospice care.

Palliative care is primarily provided by hospices (at an inpatient, home, or day-care setting).  There are four palliative care providers that offer inpatient hospice care, six providers that offer home hospice care and two that offer day hospice care.

Many restructured hospitals, as well as some community hospitals and nursing homes have also developed palliative care services, including  to meet the needs of certain specialty groups, such as children (for example, in KK Women’s and Children’s Hospital).  These services have largely evolved to meet the needs of patients admitted; the provision of palliative care services is not the main function of these institutions.

Palliative care is financed primarily by government subsidies and charity dollars.  Most home hospice services are free-of-charge for patients. Day hospice services, hospital-based services, and inpatient hospice services are offered at nominal fees, which can also be partly or fully waived depending on the patient’s financial ability.

Palliative care education is provided by a variety of organisations and institutions. For doctors, palliative care is part of the undergraduate medical curriculum. Subspecialty training is also available for some residency programmes. Palliative care is also incorporated in the formal generalist nursing curriculum for nurses and there are options for them to obtain an advance diploma in palliative care at the polytechnics. A number of different training programmes/certificates on palliative medicine/care are also run by different organisations for all health professionals (doctors, nurses, pharmacists, social workers and other health allied workers).

Public awareness and understanding of palliative care is still quite low. Many people still associate palliative care with giving up hope and treatment. The Singapore Hospice Council recently launched a new community outreach program to increase public awareness of inpatient, home and day hospice services available for end-of-life patients here.

Healthcare providers’ willingness to discuss end-of-life care and dying is also low. Research suggests that, even in hospitals, there seems to be some unwillingness of both patients and healthcare staff to talk about the potential of death.  Since 2009, health professionals have started utilising Advanced Care Planning (ACP) as a tool to start having open discussions with dying patients and their families.  ACP is currently being piloted at a few restructured hospitals, nursing homes and other end-of-life programmes.

These changes as well as some others implemented suggest that although willingness to discuss death still remains low, there has been improvement over the last few years.

In late 2011, MOH commissioned the Lien Centre for Palliative Care at Duke-NUS Graduate Medical School to formulate a National Strategy for Palliative Care in consultation with key stakeholders in the healthcare system.  The report reaffirms the important role of palliative care in the health sector as well as the importance of delivering such care in a coordinated and affordable manner. The report lists ten strategic goals and associated recommendations that address the importance of supply-side interventions such as training and ensuring adequate capacity as well as demand-side interventions such as the need for greater awareness and research. It also calls for greater leadership and governance to guide the development of palliative care services in Singapore.[2]

MOH recently accepted the report on the national strategy for palliative care. Presently, the Government has committed to expand the workforce and hospice care services to make end-of-life care more accessible to patients by committing to:

  • Incorporate a greater degree of palliative care training into courses offered in universities, polytechnics and Institutes of Technical Education.
  • Expand public education drives and awareness of the services to the terminally ill.
  • Promote specialised research and improve understanding of palliative care, by learning and adapting models used abroad.
  • Set up an implementation taskforce to put the strategies set forth by the Report on the National Strategy for Palliative Care into action in a country-wide coordinated manner.
  • Ensure that palliative care remains a key part of each regional health system.

Singapore’s ageing population and the effect it will have on epidemiological trends (increased burden of non-communicable disease, frailty and dementia, etc) and the subsequent needs required of the health system (increased demand for preventive services, long-term and end-of-life care), coupled with trends of increasing affluence, demand for more choices and declines in informal care-giving structures, suggest that the case for a greater role for palliative care, to meet the needs of patients who will face terminal illnesses, is strong.

Thus, a National Strategy for Palliative Care is welcome. To fully develop, palliative care needs more measures to promote the awareness of palliative care options, ensure that there are an adequate number of skilled healthcare professionals in the sector, introduce standards of care
across providers and settings, improve the coordination of care and ensure that there is adequate capacity to meet the demands for its care.

A greater role of palliative care will help increase the options, visibility, medical and social support for people facing end-of-life and enable decision-making based on preferences. It also allows for a more efficient use of resources for the health system.

Sources

HLC 2012. Briefing: Palliative Care in Singapore, July 26, 2012 version. Healthcare Leadership College, MOHH Holdings, Inc., Singapore.

Lien Centre for Palliative Care, Duke-NUH Graduate Medical School “Report on the National Strategy for Palliative Care,” Submitted to the Ministry of Health, Singapore, 4 Oct 2011.

World Health Organization (WHO). WHO Definition of Palliative Care .Accessed April 27 2012

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