Increasing the Uptake of Advanced Directives in SingHealth Polyclinics

Study Overview
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Brief Summary
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An Advanced Medical Directive (AMD) is a legal document in Singapore that allows one to inform their medical practitioner that they do not want any life-sustaining treatment should they become unconscious and terminally ill where death is imminent. Despite the AMD act being passed in Singapore Parliament in 1996, uptake remains low among the population. Several intervention studies have shown that education and communication can be effective in promoting end-of-life discussion and planning. In this study, we aim to compare the effectiveness of counselling sessions together with pamphlets, versus pamphlets alone, versus current care, in increasing the completion rates of the AMD in the Singapore Polyclinic setting.

Detailed Description
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An Advanced Medical Directive (AMD) is a legal document in Singapore that allows one to inform their medical practitioner that they do not want any life-sustaining treatment should they become unconscious and terminally ill where death is imminent. It may be completed by any person, of sound mind, aged 21 years and above.The AMD Act was passed in the Singapore Parliament in May 1996. A cross-sectional, community-based study surveyed 1200 selected households in Singapore. Only 37.9% of the sample population had heard of the AMD prior to the study, though when approached, 60.6% were willing to sign an AMD. As of 2017, less than 25,000 people (0.45%) in Singapore have opted to sign an AMD. Past studies have shown that end of life discussions reduce stress, anxiety, and depression in surviving relatives. A local study in 2010 revealed a 33% patient-surrogate discrepancy in end-of-life decision making. There are a lack of intervention studies regarding AMD in Singapore. In this study, we aim to compare the effectiveness of counselling sessions together with pamphlets, versus pamphlets alone, versus current care, in increasing the completion rates of the AMD in the Singapore Polyclinic setting.

Official Title
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Assessing the Effectiveness of Different Interventions in Increasing the Completion Rates of the Advanced Medical Directive in the Polyclinic Setting in Singapore - A Randomized Controlled Trial

Conditions
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Advanced Medical Directive, a Legal Document Signed in Advance to State Healthcare Preferences

Intervention / Treatment
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* Behavioral: standardised face-to-face counselling session
* Behavioral: advanced medical directive pamphlet


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age > 40 Patient who seeks medical consultation at Singhealth Polyclinics (Bedok, Marine Parade, Outram, Tampines) Exclusion Criteria: History of dementia History of depression Known diagnosis of terminal illness Signed Advanced Medical Directive/Advanced Care Plan previously

Ages Eligible for Study
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Minimum Age: 41 Years
Maximum Age: 100 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: 3-arm, randomised control trial Active Intervention group (n=65) Counselling provided Pamphlet given Passive Intervention group (n=65) Pamphlet given Control group (n=65) Neither counselling nor pamphlet given
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Active Intervention<br>subjects will be given a pamphlet about the advanced medical directive, and a standardized face-to-face counselling session will be conducted with their healthcare provider | Behavioral: standardised face-to-face counselling session<br>* the healthcare provider will conduct a standardised face-to-face counselling session guided with subjects guided by a check-list of topics to cover regarding the Advanced Medical Directive.<br>Behavioral: advanced medical directive pamphlet<br>* A standardised pamphlet containing information about the Advanced Medical Directive produced by the Ministry of Health, Singapore.<br>|
| Active Comparator: Passive Intervention<br>subjects will be given a pamphlet about the advanced medical directive | Behavioral: advanced medical directive pamphlet<br>* A standardised pamphlet containing information about the Advanced Medical Directive produced by the Ministry of Health, Singapore.<br>|
| No Intervention: Control<br> | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of patients who completed the Advanced Medical Directive |  | 4 months | 
| Number of patient who expressed interest to complete the Advanced Medical Directive |  | 4 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Barriers to completion of the Advanced Medical Directive |  | 4 months |