Advance Care Planning

Take charge of your own care in your elder years with Advance Care Planning, also known as Elder Care Planning. Here’s what you need to know about the care planning process.

Have you ever thought about how you would like to be cared for when you are in your older years, or considered your preferred treatment options in the event that you are in a medical crisis and unable to communicate your thoughts? 

Here’s where Advanced Care Planning comes in.

What is Elder Care Planning or Advance Care Planning?

Advance Care Planning (ACP) is the process of planning for future healthcare options through a series of voluntary, non-legally binding conversations with your family and doctors. In an ACP discussion, patients are guided to understand, reflect upon, and discuss their goals, values and beliefs; then led to indicate their preferences with regard to future healthcare treatments.

ACP also involves nominating a “substitute decision-maker” who can make decisions on the patient’s behalf. The documented discussion provides guidance for the medical team in making decisions when crisis strikes and the patient is no longer able to communicate.

Stages of Advance Care Planning ​ ​
General ACP Discussion Disease-Specific ACP Preferred-Plan-of-Care ACP

Inclusion Criteria

  • Adult, generally healthy or with early chronic disease
  • Has decision-making capacity



  • Appoint substitute decision-maker(s)
  • Decision on goal of care if one is to be rendered severely mentally impaired with low chance of recovery
  • Comfort care
  • Life-sustaining



Inclusion Criteria

  • Adult with decision-making capacity
  • Organ failure with recurrent hospital admissions and declining function



  • Appoint substitute decision-maker(s)
  • Statement of treatment preference in three clinical scenarios:
    1. Serious complications with low chance of survival
    2. Serious complications with low chance of recovery of physical function or ability to communicate and will require total nursing care
    3. Serious complications with high chance of mental incapacity and will require total nursing care
  • Specific disease-related care


Inclusion Criteria

  • Adult with decision-making capacity (DMC)
  • Includes family members / other informants who have demonstrated acts of care for patients lacking DMC


  • Care options on CPR
  • Care goals for medical intervention when one suffers a potentially life-threatening crisis
  • Preference of place of care
  • Preference of place of death
  • Appointment of substitute decision-maker(s)


Elder Care or Advance Care Planning in Singapore

With funding administered by the Agency of Integrated Care, Khoo Teck Puat Hospital began its Advance Care Planning initiative in 2013. The pilot initiative was launched in the hospital’s palliative care department in January 2013, and has since extended to other departments such as geriatrics, transitional care, dementia, renal and diabetes. As part of the initiative, the hospital also hopes to target the cardiology and respiratory medicine departments in future. 
The ACP Clinic in Khoo Teck Puat Hospital is open from Monday to Friday in Clinic C41 and C44. ACP Clinic sessions are facilitated by our trained facilitators. For enquiries, please contact Khoo Teck Puat Hospital’s main line at (+65) 6555 8000 or email

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