Singapore Takes Six Steps Forward in ‘The Quality of Death Index’ Rankings

Abstract

In the latest 2015 Quality of Death Index, Singapore managed to move SIX steps forward from 18^th to the 12^th position. This advancement has been hard-won, with victories to improve the level of palliative care such as creating awareness of palliative service, improving coordinated care and growing an adequate capacity to meet the demand of care in our fast -growing ageing population. But it hasn’t always been easy. Despite being a first world country, Asian societies like Singapore have inherited taboos regarding public dialogue about death and dying. Such dialogue is traditionally avoided. However, through years of continual effort in improving the standard of palliative care delivery, redesigning education module, creating public awareness and improving funding system, Singapore's palliative care providers have improved the lives of those with life-limiting illnesses. Nevertheless, the government will continue to improve and work toward achieving single digits in the next ranking of the Quality of Death Index.

Development of Palliative Care in Singapore

In the latest 2015 Quality of Death Index, Singapore has moved six steps forward from 18^th to the 12^th position.[1] This advancement has been hard-won, with victories to improve the level of palliative care such as creating awareness of palliative service, improving coordinated care, and growing an adequate capacity to meet the demand of care in our fast-growing aging population. But, it has not always been easy.

Despite being a first world country, Asian societies such as Singapore have inherited taboos regarding public dialog about death and dying. Such dialog is traditionally avoided. Only an aggressive public educational program would reverse this cultural trait. In 1985, the first hospice was started by a group of Catholic nuns at the St Joseph’ Home, setting aside 16 beds to take care of dying patients.[2] It was during a cover story in the Straits Times entitled “In Singapore, A Place To Die Peacefully,”[3] reported during a visit by Dr. Tetsuo Kashiwagi to Singapore, that helped push the hospice movement forward. The visit by Dr. Kashiwagi, a celebrated Japanese advocate for palliative care, created an uproar of positive responses from the public. It would be a year before the article on Dr. Kashiwagi nurtured the interest of a group of professionals in this area to join forces with Singapore Cancer Society in 1987 to form the first home hospice care volunteers under the Hospice Care Group. Palliative care was further pushed to a higher level by the Group's emphasis on the training of nurses, doctors, and lay volunteers.

The period, 1988–1990, witnessed an increase in demand for palliative care from patients and families. With a donation of $120,000 over a period of 3 years, the volunteers were able to employ a nurse to be trained overseas as a coordinator.[4] Following this, nurse volunteers were sent to Australia for a 3-month residential course in palliative care. In November 1988, the Assisi Home at Mount Alvernia Hospital started taking patients who were terminally ill.[2] This was followed by the founding of Agape Hospice Group in 1989.[2] In December 1989, the Hospice Care Group formed the Hospice Care Association (HCA), an independent organization to provide patients with home and daycare hospice services. To date, HCA Hospice Care is the Singapore's largest home hospice care provider.[2] In the early 1990s, supporters of hospice care included President Wee Kim Wee, Dr. Ee Peng Liang (also known as Singapore's “Father of Charity”), and the former cabinet minister, Dr. Seet Ai Mee. They joined pioneers such as Dr. Cynthia Goh as advocates for hospice care and worked tirelessly, campaigning for funds and better end-of-life care for Singaporeans.

In 1991, the Assisi Home and Hospice was remodeled to house 31 terminally ill patients.[2] Then, in August 1993, it opened its first Hospice Day Care Centre, and in 1995, started a hospice home care service. During this period, Dover Park Hospice was registered as a charity, but plans to build its facilities in Dover Road close to Singapore Polytechnic had to be abandoned due to objections from the students and staff. Eventually, Dover Park Hospice was built at the current location at Jalan Tan Tock Seng. Dover Park Hospice opened its doors to patients in September 1995, as Singapore's first purpose-built hospice, providing inpatient hospice services.[5] Sharing the same plot of land, HCA Hospice Care had its headquarters for the delivery of hospice home care to patients, and also opened its Day Care Centre.

One important milestone in the advancement of palliative care took place on May 5, 1995, when the Singapore Hospice Council (SHC) was formed.[2] Today, it serves as the umbrella body representing all organizations providing hospice and palliative care in Singapore. From the beginning, the SHC worked to improve the lives of patients with life-limiting illnesses by coordinating its members to promote palliative care to the public, supporting the training of doctors, nurses, caregivers, and volunteers, and assisting in establishing better palliative care practices and standards.

Hospital-based palliative care service was introduced in 1996 in the Geriatric Department of Tan Tock Seng Hospital. In 1999, when the National Cancer Centre Singapore opened its doors, it established a Department of Palliative Medicine. Since then, palliative care services have been established in all government acute care hospitals, namely, Changi General Hospital, Khoo Teck Puat Hospital, KK Women's and Children's Hospital, National University Hospital, and Ng Teng Fong General Hospital. The first community hospital to provide palliative care was Bright Vision Hospital in 2003. Now, palliative care services are provided at Ang Mo Kio Community Hospital, St Andrew's Community Hospital, Yishun Community Hospital, and soon at St. Luke's Community Hospital and the planned Outram Community Hospital.

Establishing and Improving Quality End-of-Life Care in Singapore

Education

Although palliative care was first introduced into the National University of Singapore Medical Curriculum in 2002, palliative medicine was only recognized as a medical subspecialty in 2006, after the UK, Australia, and the USA.[6] Palliative care became a compulsory module in the curriculum of all undergraduate medical and nursing courses. As demand for palliative care doctors and nurses increased, courses at postbasic/postregistration and postgraduate levels were created to train more such professionals to work both in the hospitals and the community. A short, postgraduate course in palliative medicine for the medical professionals had been running since the 1990s. Later on, the Graduate Diploma in Palliative Medicine, and for nurses, an introductory course, the Specialist Diploma, and Diploma in Palliative Care Nursing were developed. Singapore also adopted the End-of-Life (EOL) Nursing Education Consortium program to provide basic palliative nursing in the tertiary institutions. Content was modified to suit the local context and practice. To date, Singapore has grown nine palliative advanced practice nurses graduated from both overseas and from the local Master of Nursing programs to serve the hospital, inpatient hospice, and home hospice services. In the recent years, the Lien Centre for Palliative Care (LCPC) developed blended learning courses in palliative care for medical social workers and for pharmacists. Mobile-friendly online resource such as the SG Pall eBook provides quick and easy reference and tips on basic palliative care for busy health-care professionals on the go.[7] SHC also has free monthly interprofessional lunchtime sessions covering a wide spectrum of issues in palliative care.

Improving standards of palliative care delivery

In 2010, Singapore was ranked 18^th out of 40 countries in the first Quality of Death Index by the Economist Intelligence Unit commissioned by the Lien Foundation.[8] The ranking also revealed that Singapore did not have a national strategy in palliative care to provide direction for its development. Hence, the Ministry of Health (MOH) commissioned LCPC and key stakeholders in the health-care system to formulate a national strategy for palliative care to shape the delivery models, based on the best clinical evidence.[6] Following the acceptance of the National Strategy for Palliative Care in 2014, the MOH appointed a committee to look at developing sector-wide standards for all the different types of palliative care services. These included establishing guidelines, quality indicators, and tools to facilitate better quality palliative care for patients with life-limiting diseases and to look at self-care for health-care providers as well. After the guidelines on palliative care were adopted by the MOH, the SHC was asked to implement it. A self-assessment workbook was developed to assist providers to undertake voluntary assessment of their services, as part of a quality improvement through benchmarking initiative.[9]

In July 2017, member countries of the Asia Pacific Hospice Palliative Care Network met in Singapore for the 12^th Asia Pacific Hospice Conference to share experiences, discuss relevant shared concerns, and offer support to countries and groups which were interested in developing hospice and palliative care in the region.

Public awareness

In order to improve the image of palliative care in the community, a nationwide advanced care planning program called “Living Matters” was implemented in 2011.[10] This included an online step-by-step guide to help explore one's beliefs, values, and care presence, which can then be shared with their loved ones or their health-care providers.

Philanthropic houses also contributed by investing in innovative projects and strategic partnerships to create public awareness on EOL issues and to de-stigmatize death and dying. For instance, the use of social media in the “The last outfit” campaign, aimed at encouraging one to talk about death and dying.[11] Also, “Getai,” stage shows based on those usually held during the Lunar 7^th month Hungry Ghost Festival, used humor to encourage people to talk about life and death.[12] Another event was the display of “bit of happiness” photography to showcase life in a hospice institution.[13]

Funding

Over the years, the government had introduced different streams of funding for hospice care in the community, while hospital inpatient palliative care is subsidized like any other hospitalization. Back in 1990 when the HCA Hospice Care started its hospice home care service, the MOH had provided a grant for rental of its premises, and since 1996, hospice home care was funded on a per capita basis of 50% of its cost.[14] Later, this changed to per visit funding according to means testing. Inpatient hospice care had been funded by MOH since 1994, and currently subsidized according to means testing.[14] Medisave has been available for inpatient hospice care since 1994, and much more recently for hospice home care. Insurance companies are beginning to cover inpatient hospice care. The government has been raising Medisave withdrawal limits for palliative care, with increased usage of the patient's own Medisave for terminal illness, and allowing the use of Medisave of each first-degree relative up to a limit, currently $2500/year.[15]

Current Palliative and End-of-Life Care Delivery in Singapore

Home care

There are six MOH-subsidized home hospice care services currently available in Singapore.[16] They provide a 24-h medical and nursing support and holistic management directed at both the patients and their family members, where the focus is to improve the quality of life of these patients who wish to spend the remaining days in the comfort of their home. The services include management of patient symptoms, administering holistic support, prescribing and furnishing medications, pastoral care, and music and art therapy. This requires a unique type of training for palliative workers, catering to the multiracial society in Singapore. Domiciliary services for the elderly, run by mobile clinics, are also offered as a home care service to their clients until the terminal phase.

Inpatient care

Singapore has established four inpatient hospices, catering to all eligible patients with life-limiting diseases and a prognosis of not more than 3 months to live.[16] In the recent years, subspecialist services such as dementia and pediatric care are also available. Services such as playful pets, art, music therapy, and gentle physiotherapist treatments are available for both adult and pediatric patients. For carers who wish to take some time off and recover, institutions also offer respite care services on a short-term basis.

The subacute care service in a step-down institution in Singapore caters to patients with advanced complicated medical conditions and who require institutional care to manage complex and medical nursing care.[16]

Day care

Two established day-care services are available to provide a safe and supportive environment for any eligible patient who requires medical, nursing, and rehabilitation care in the day time while their loved ones are not available. Heavily subsidized by charity, these services provide two-way transportation, meals, recreational activities, medical and nursing review, rehabilitation, art and music therapy, and planned outings.[16]

Today

Through years of continual effort, made by both the government and the palliative care teams, Singapore's palliative care providers have improved the lives of those with life-limiting illnesses.

Over the next 3 years, the Singapore government will be working closely with the SHC to improve on the existing services such as training skilled providers to meet the national guidelines, encouraging an increased awareness on advanced care planning, and designing palliative care programs for noncancer patients (The Straits Times, July 27, 2017).[17] One of the national hospital clusters is also working with the inpatient hospices and university to better understand the management of patients with end-stage organ failure.[18] The SHC has coordinated ongoing training programs among active nursing and medical personnel, to incorporate the latest innovations in care, improved standards, and continued research. From that 1986 ground-breaking article, written on Dr. Tetsuo Kashiwagi, the father of hospice care in Japan, that broke the silence of the death and dying conversation in Singapore, until today, the remarkable advancements in palliative care continue. In summary, when the next “Quality of Death Index” rankings appear, one can expect to find Singapore edging closer (hopefully) to single digit.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.