Advance Medical DirectiveAct 1996

Advance Medical Directive Act 1996 2020 REVISED EDITION This revised edition incorporates all amendments up to and including 1 December 2021 and comes into operation on 31 December 2021 An Act to provide for, and give legal effect to, advance directives to medical practitioners against artificial prolongation of the dying process and for matters connected therewith. [1 July 1997] Short title 1.—(1) This Act is the Advance Medical Directive Act 1996. (2) This Act does not apply to any act done or any directive or instrument made or executed before 1 July 1997. Interpretation 2. In this Act, unless the context otherwise requires — “directive” means an advance medical directive made under section 3; [Deleted by Act 11 of 2023 wef 01/05/2023] “Director‑General” means the Director‑General of Health; [Act 11 of 2023 wef 01/05/2023] “extraordinary life‑sustaining treatment” means 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 excludes palliative care; “medical practitioner” means a person who is registered, or deemed to be registered, as a medical practitioner under the Medical Registration Act 1997; “palliative care” includes — (a) the provision of reasonable medical procedures for the relief of pain, suffering or discomfort; and (b) the reasonable provision of food and water; “patient” means any person (whether or not he or she is undergoing any medical treatment, care or therapy) who is not mentally disordered, who has attained 21 years of age and who has made or desires to make a directive in accordance with this Act; “recovery”, in relation to a terminal illness, includes a remission of symptoms or effects of the illness; “register” means the register of advance medical directives established under section 6; “Registrar” means the Registrar of Advance Medical Directives appointed under section 6 and includes a Deputy Registrar and an Assistant Registrar; “specialist” means a medical practitioner who possesses such postgraduate medical qualifications as the Director‑General may recognise for the purposes of this Act; [Act 11 of 2023 wef 01/05/2023] “terminal illness” means an incurable condition caused by injury or disease from which there is no reasonable prospect of a temporary or permanent recovery where — (a) death would, within reasonable medical judgment, be imminent regardless of the application of extraordinary life‑sustaining treatment; and (b) the application of extraordinary life‑sustaining treatment would only serve to postpone the moment of the patient’s death. [21/2008] Power to make advance medical directive 3.—(1) A person who is not mentally disordered, who has attained 21 years of age and who desires not to be subjected to extraordinary life‑sustaining treatment in the event of his or her suffering from a terminal illness, may at any time make an advance medical directive in the prescribed form. [21/2008] (2) Subject to subsection (3), the directive must be witnessed by 2 witnesses present at the same time — (a) one of whom must be the patient’s family medical practitioner or any other practitioner of the patient’s choice; and (b) the other must be a person who has attained the age of 21 years. (3) A witness must be a person who to the best of his or her 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 that patient’s death; and (e) has not registered an objection under section 10(1). Duty of witness 4. Before witnessing the execution of the directive on the prescribed form, a witness who is a medical practitioner must take reasonable steps in the circumstances to ensure that the patient — (a) is not mentally disordered; (b) has attained 21 years of age; (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. [21/2008] Registration of directives 5.—(1) Any person who has made a directive in accordance with section 3 must register his or her directive with the Registrar. (2) Upon receipt of the directive registered under subsection (1), the Registrar must issue to the person who made the directive an acknowledgment in the prescribed form. (3) A person must not act on a directive if it has not been registered in accordance with this section. Registry of directives and objections 6.—(1) The Director‑General must cause a register of advance medical directives to be established and maintained for the purposes of this Act and which comprises — (a) all directives registered under section 5; (b) all revocations of directives registered under section 7; and (c) all objections of medical practitioners registered under section 10(1). [Act 11 of 2023 wef 01/05/2023] (2) The Minister must appoint a Registrar, a Deputy Registrar and an Assistant Registrar of Advance Medical Directives and such other officers and employees as the Minister may consider necessary for the purposes of this Act. (3) The register must be kept confidential and must not be disclosed to any person except to the following: (a) the person who made the directive or any other person that he or she may in writing authorise; (b) the Registrar and other persons appointed to maintain and administer the register; (c) the medical practitioner responsible for the treatment of the person who made the directive only if a certificate in respect of that person has been forwarded to the Registrar in accordance with section 9(1). (4) Any person who wilfully destroys, mutilates or makes any unauthorised alteration or manipulation in the register shall be guilty of an offence and shall be liable on conviction to a fine not exceeding $10,000 or to imprisonment for a term not exceeding 3 years or to both. Revocation of directive 7.—(1) Any patient who has made a directive may, in the presence of at least one witness, revoke the directive — (a) in writing; (b) orally; or (c) in any other way in which the patient can communicate. (2) As far as may be practicable, the revocation must be registered with the Registrar. (3) Where a revocation is made in accordance with subsection (1), the patient (if practicable) and each witness must notify the Registrar in writing of the revocation with full particulars of the name, address and telephone number of the patient and of the witness and the time, date and place where the revocation was made. (4) It is the duty of any other person who has witnessed a revocation, whether made in writing, orally or in any other way in which the patient can communicate, to inform the Registrar of that fact. (5) Upon receipt of the notice of revocation (if there is more than one notice, the first notice), the Registrar must issue to that person an acknowledgment in the prescribed form and must mark the directive as a revoked directive in the register. Panel of specialists 8.—(1) The Minister must appoint a panel of at least 20 specialists who have each at least 10 years’ experience in medical practice. (2) The Minister must, in appointing the members of the panel, have regard to the need to appoint specialists who possess the requisite skills, knowledge and qualifications in diagnosing terminal illness. (3) Every member of the panel is, except where his or her appointment is revoked by the Minister under subsection (4) or he or she resigns during the period of his or her appointment, appointed for a period of 3 years or for any shorter period that the Minister may, in any case, determine and is eligible for re‑appointment. (4) The Minister may at any time revoke the appointment of a member of the panel on the ground of the member’s unfitness to continue in office or incapacity to perform the duties of the member. Certification of terminal illness 9.—(1) Where a medical practitioner, who is responsible for the treatment of any person, has reason to believe that the person — (a) is suffering from a terminal illness; (b) requires extraordinary life‑sustaining treatment; and (c) is unconscious or incapable of exercising rational judgment, the medical practitioner must — (d) determine and certify in the prescribed form that the person is suffering from a terminal illness and the reasons for the determination; and (e) forward the certificate to the Registrar with a request that a search of the register be conducted in order to ascertain whether the person has made a directive which is in force. (2) Upon receipt of a request made under subsection (1), the Registrar must cause a search of the register to be conducted in order to ascertain whether the person has made a directive which is in force and must thereafter inform the medical practitioner accordingly. (3) Where the Registrar informs the medical practitioner responsible for the treatment of the person who has been certified to be terminally ill that the patient has made a directive which is in force, that medical practitioner must obtain, in the prescribed form, the opinion of 2 other medical practitioners as to whether they agree with the determination that the patient is terminally ill. (4) Where the medical practitioner responsible for the treatment of the patient — (a) is not a specialist, the 2 other medical practitioners mentioned in subsection (3) must both be specialists; or (b) is a specialist, at least one of the 2 other medical practitioners mentioned in subsection (3) must be a specialist. (5) Where the opinions of the 2 medical practitioners mentioned in subsection (3) are not unanimously in agreement that the patient is terminally ill, the issue must be referred for determination to a committee of 3 specialists (called in this section the committee) appointed by the Director‑General from among the panel of specialists referred to in section 8. [Act 11 of 2023 wef 01/05/2023] (6) A patient is, on a reference to the committee, determined to be terminally ill only on the unanimous decision of the committee. (7) If the committee is unable to reach a unanimous decision, the patient is presumed not to be terminally ill. (8) The committee’s determination must be recorded in the prescribed form and sent to the medical practitioner responsible for the treatment of the patient. (9) A medical practitioner must not certify or participate in the determination or certification that the patient is terminally ill if the medical practitioner — (a) is a beneficiary under the patient’s will or any policy of insurance; (b) has an interest under any instrument under which the patient is the donor, settlor or grantor; (c) would be entitled to an interest in the moneys of the patient held in the Central Provident Fund or other provident fund on that patient’s death; or (d) has registered an objection under section 10(1). Duty of medical practitioner 10.—(1) A medical practitioner or any person who acts under the instructions of a medical practitioner, who for any reason objects to acting on a directive, must register his or her objection in the prescribed form to this effect and register it with the Registrar and such objection may be revoked by notifying the Registrar in the prescribed form. (2) Where a person who has made a directive in accordance with section 3 has been determined in accordance with section 9 to be suffering from a terminal illness, it is the duty of the medical practitioner responsible for his or her treatment (unless he or she has registered his or her objection under subsection (1)) to act in accordance with the directive unless there is reasonable ground to believe — (a) that a notice of revocation under section 7 has been received by the registry or such revocation has been sent to the registry; (b) that the person has, whether in writing, orally or in any other way, communicated to any medical practitioner his or her intention to revoke the directive; or (c) that the person was not, at the time of making the directive, capable of understanding the nature and consequences of the directive. (3) Before a medical practitioner acts in accordance with a directive, he or she must — (a) ascertain from the Registrar that the directive has been registered under section 5 and is in force; (b) ensure that the patient has been certified to be terminally ill in accordance with section 9; and (c) as far as may be practicable determine and certify in writing whether the patient is pregnant with a foetus which will probably develop to the point of live birth. (4) A medical practitioner must not act in accordance with a directive if the medical practitioner — (a) is a beneficiary under the patient’s will or any policy of insurance; (b) has an interest under any instrument under which the patient is the donor, settlor or grantor; or (c) would be entitled to an interest in the moneys of the patient held in the Central Provident Fund or other provident fund on that patient’s death. (5) Where a medical practitioner has registered his or her objection under subsection (1) or is disqualified under subsection (4), he or she must, in the circumstances referred to in subsection (2), take all reasonable steps as soon as practicable for the care of the patient to be transferred to another medical practitioner who has not registered such an objection. (6) Extraordinary life‑sustaining treatment must not be withheld or withdrawn pursuant to this section from a patient known to the medical practitioner to be pregnant so long as it is probable that the foetus will develop to the point of live birth with continued application of extraordinary life‑sustaining treatment. Advance directive not to affect palliative care 11. This Act does not apply to palliative care and does not affect any right, power or duty which a medical practitioner or any other person has in relation to palliative care. Patient’s rights to make informed decisions on treatment not affected 12.—(1) Section 3 or 10 does not derogate from any duty of a medical practitioner to inform a patient who is conscious and capable of exercising a rational judgment of all the various forms of treatment that may be available in his or her particular case so that the patient may make an informed judgment as to whether a particular form of treatment should, or should not, be undertaken. (2) This Act does not affect the right of a patient to make decisions in relation to the use of extraordinary life‑sustaining treatment, so long as he or she is able to do so. Act not to affect other rights 13.—(1) This Act does not affect the right of any person to refuse medical or surgical treatment. (2) This Act (other than section 20) does not affect the legal consequences (if any) of — (a) taking, or refraining from taking, therapeutic or palliative measures (not being extraordinary life‑sustaining treatment) in the case of a patient who is suffering from a terminal illness, whether or not he or she has made a directive; or (b) taking, or refraining from taking, extraordinary life‑sustaining treatment in the case of a patient who has not made a directive or has revoked a directive made by him or her. Penalty for obtaining directive by fraud, forging directive or concealing revocation 14.—(1) Any person who — (a) by any deception, fraud, misstatement, unconscionable conduct or undue influence, procures or obtains, directly or indirectly, the execution by another person of a directive; (b) falsifies or forges the directive of another person; or (c) wilfully conceals or withholds personal knowledge of a revocation of a directive, shall be guilty of an offence and shall be liable on conviction to a fine not exceeding $10,000 or to imprisonment for a term not exceeding 3 years or to both. (2) Any person who — (a) is a beneficiary under the will or any policy of insurance of another person; (b) has an interest under any instrument under which another person is the donor, settlor or grantor; (c) would be entitled to an interest in the estate of another person on the death intestate of that person; or (d) would be entitled to an interest in the moneys of another person held in the Central Provident Fund or other provident fund on that person’s death, and who is guilty of an offence under subsection (1) (whether or not he or she has been convicted of that offence) shall forfeit any interest under the will, policy, instrument, intestacy or memorandum executed under the Central Provident Fund Act 1953, as the case may be. (3) Where a person is charged for an offence under subsection (1), no person may act on a directive unless it is ascertained that the directive has been validly and voluntarily made in accordance with the provisions of this Act. (4) Where a person is convicted of an offence under subsection (1), the directive is deemed to be revoked and has no effect. Offence to enquire whether directive made 15.—(1) Except in the circumstances specified in subsection (2), a person who has or who will be likely to have the medical care of any patient (whether or not he or she has made or intends to make a directive) must not ask or otherwise enquire of the patient as to whether or not the patient has made or intends to make a directive. (2) Nothing in subsection (1) affects the duty or right of a medical practitioner responsible for the care of a patient to discuss and explore with his or her patient the concept of directives and the objects and provisions of this Act and any regulations made under this Act where such discussions are — (a) consistent with good medical practice; (b) held in the context of the relationship between a medical practitioner and his or her patient; and (c) in furtherance of the purposes of public education. (3) Except where a patient has been determined in accordance with section 9 to be suffering from a terminal illness, all information relating to the patient’s making of a directive, or of the patient’s intention to make a directive communicated by the patient to the medical practitioner or other medical worker having the care of the patient must be kept confidential by the medical practitioner or other medical worker. (4) Any person who contravenes subsection (1) or (3) shall be guilty of an offence and shall be liable on conviction to a fine not exceeding $5,000 or to imprisonment for a term not exceeding 12 months or to both. Offence to require directive as condition for insurance or medical care 16.—(1) Any person who requires or prohibits the making of a directive as a condition for being insured for, or receiving medical or health care services shall be guilty of an offence and shall be liable on conviction to a fine not exceeding $5,000 or to imprisonment for a term not exceeding 12 months or to both. (2) Any condition of a policy of insurance mentioned in subsection (1) is void to the extent that it requires or prohibits the making of a directive. Act permits only natural death and not euthanasia or abetment of suicide 17.—(1) Nothing in this Act authorises an act that causes or accelerates death as distinct from an act that permits the dying process to take its natural course. (2) To avoid doubt, it is declared that nothing in this Act condones, authorises or approves abetment of suicide, mercy killing or euthanasia. Act not to affect insurance policies 18.—(1) The making of a directive does not affect the sale, procurement or issuance of a policy of insurance or any of its terms. (2) Except in the circumstances provided in section 14(2), a policy of insurance is not avoided, invalidated or otherwise affected by the withholding or withdrawal of extraordinary life‑sustaining treatment from an insured person in accordance with this Act. Protection of medical practitioners and other persons acting in good faith and without negligence 19.—(1) A medical practitioner shall not be subject to civil or criminal liability or discipline for professional misconduct for a decision made by him or her in good faith and without negligence as to whether — (a) a patient is, or is not, suffering from a terminal illness; (b) a patient has revoked, or intended to revoke, a directive; (c) a patient was, or was not, at the time of making a directive, capable of understanding the nature and consequences of the directive; or (d) a directive was valid. (2) A person acting under a medical practitioner’s instructions shall not be subject to civil or criminal liability or discipline for professional misconduct for giving effect to a directive in the absence of knowledge of revocation or intended revocation of the directive. Certain aspects of causation of death 20.—(1) For the purposes of the laws of Singapore, the non‑application of extraordinary life‑sustaining treatment to, or the withdrawal of extraordinary life‑sustaining treatment from, a person suffering from a terminal illness does not constitute a cause of death where the non‑application or withdrawal was as a result of and in compliance with a directive validly made in accordance with this Act by the person. (2) This section does not relieve a medical practitioner from the consequences of a negligent decision as to whether or not a patient is suffering from a terminal illness. Composition of offences 21.—(1) The Director‑General or any person authorised by him or her may compound any offence under this Act or any regulations made under this Act which is prescribed to be a compoundable offence by accepting from the person reasonably suspected of having committed the offence a sum not exceeding $1,000. [Act 11 of 2023 wef 01/05/2023] (2) On payment of the sum of money, no further proceedings are to be taken against that person in respect of the offence. (3) The Minister may make regulations to prescribe the offences which may be compounded. Regulations 22. The Minister may make regulations to prescribe anything which is required to be prescribed by this Act and generally to give effect to the provisions of this Act.