Dr Ng Lee Beng, a seasoned doctor and Advance Care Planning trainer in Singapore General Hospital, shares how ACP addresses challenges about future healthcare and personal care conversations with patients and their families.

“‘Isn’t ACP a form of euthanasia?’, a colleague asked me early in my journey as an advocate for patients to do Advance Care Planning (ACP) while they are still able. “Such misconception was one of many reasons why doctors hesitated to initiate ACP conversations,” says Dr Ng Lee Beng.

“Others declined starting such conversations because they are time consuming, and doctors already have many other tasks to complete during ward rounds, house visits or clinic consultation time. It is true that such conversations cannot be rushed, and pacing with the patient and family is important to avoid creating unintended negative experiences,” she acknowledges.

Dr Lee Beng admits that ACP conversations can be challenging. “This is  especially so when patients or families have a limited understanding of the medical condition and treatment options, or when they are not ready for the discussion.”

How the ACP framework helps

Singapore General Hospital started the ACP programme in 2013. As of March 2025, 1071 ACP facilitators have been trained among staff and 3066 patients have completed their Advance Care Planning. Dr Lee Beng is a certified ACP trainer dedicated to empowering her fellow doctors to integrate ACP into their clinical practice.

“Through regular reiteration of the training in ethical principles in end-of-life care, I believe more doctors are now clearer that ACP is about respecting patient choices, based on their values, beliefs and preferences while providing appropriate care,” says Dr Lee Beng. “ACP training has helped me to understand what the complete ACP discussion comprises, be more sure-footed of the ethics of end-of-life care and the authority of the medical team, and realise that ACP is not so difficult after all!”

She stressed that ACP discussions should be ongoing, with clinicians patiently revisiting the conversation to help families gain a clear understanding of the disease progression and the realistic outcomes of medical interventions.  “Discussion in disease understanding must include explaining the course of the disease, its treatment modalities including the option of non-treatment, and its variable outcomes.”

“An easily identifiable and retrievable clinical document called ACP discussion record has been created in our electronic medical record system to allow for the recording of evolving conversations. With this tool, ACP discussions can take place over several visits," shares Dr Lee Beng.

Mastering the art of difficult conversations

“I personally believe that such conversations are best handled by the doctor in attendance, as he has the voice of authority trusted by the patient. Optimally he has all the knowledge at hand to answer  the many questions about  the treatment options. However, just as training is needed  for surgical and procedural skills, doctors also need to acquire knowledge and be trained in the ACP conversation framework and skills for such discussions. It gets easier with practice,” says Dr Lee Beng.

Apart from frequent practice, Dr Lee Beng shares the following tips to help doctors in starting the ACP conversation: 

“I think all doctors share some common challenges - time constraint, language barriers, families who are too upset and not ready, and so on.”

“Always pace with the patient and assess his readiness for such dialogue. Be sensitive and empathetic to pick up verbal and non-verbal cues of whether the patient or family is ready for such discussions. Learn some phrases that the different ethnic or dialect groups use to refer to death or dying. Some seniors will say ‘time to return my IC’, ‘birth, aging, sickness, death - this is the cycle of life that everyone undergoes’, ‘time to cross the bridge’ to indicate their readiness for such conversations.”  

“When a patient or family is in grief over his diagnosis or the condition of their loved one respectively, validate the emotion with appropriate silences or empathetic responses first before starting the conversation. Don’t try to do too much in one conversation – such as giving the diagnosis, prognosis and starting ACP discussion altogether.”

Dr Lee Beng emphasised the need for an empathetic approach, especially when families are grieving, assuring them that their loved ones are being cared for compassionately and appropriately, and are not being abandoned. “Families must always be assured that their loved ones are receiving the most appropriate care and are not being denied care. They must not feel that the medical team has given up and abandoned their loved one.”  

Make ACP conversations a normal part of clinical care

“I believe sincerely that the ACP conversation should be a normal part of clinical care, to ensure that we help patients live well to the very end.

We should be as skilled in holding timely conversations to guide patients make appropriate decisions about their care options as we are in  delivering aggressive curative treatments, such as those for eradicating a cancer"  says Dr Lee Beng.

“A doctor should feel as responsible for facilitating a good death as in removing a tumour. And letting a patient go in a timely way, without suffering, should not be seen as a failure on the part of the doctor, or of medicine. Doctors must accept that we cannot cure death or old age.”

“I hope my fellow doctors will be encouraged and inspired by the relating of my experiences that ACP discussions can help them give the best appropriate care to their patients and enable peaceful closure to patients and their relatives. Such closure can provide doctors with as much a sense of meaningfulness of their work as that gained from performing successful surgery and strengthens us to go on doing good work for the next patient and the next.”

A Call to Action: Get Trained, Get Started

ACP is a valuable conversation in the provision of holistic, patient-centred care. You may start by attending ACP training to be equipped with skills to initiate an ACP conversation with your patients. 

For healthcare professionals looking to enhance their ACP skills:

• Begin with the online ACP advocacy course to acquire basic  ACP conversation skills

• Pursue certification as an ACP facilitator which authorises you to upload your patients’ wishes onto the National Electronic Health Records

• Advance skills through Serious Illness Conversation workshops

• Learn through observation of experienced colleagues

• Maintain regular practice to build confidence

If you are keen to sign up for ACP facilitator training, please refer to the ACP Infopedia page here (Advance Care Planning)* to learn more about upcoming workshops and how to sign up. The online ACP advocacy training is also available on blackboard here (Blackboard)*.  Alternatively, you may contact the ACP office at livingmatters@sgh.com.sg or 6576 2152 for any queries relating to ACP.  

*infopedia access required

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