Chronic Disease Management

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Malhotra et al. (2012) conducted a qualitative focus-group based study involving Singaporeans (≥50 years) to understand the key components of good-end-of-life care as perceived by middle-aged and older Singaporeans (≥50 years). Eight components of good end-of-life care were identified:

The strength of the physician-patient relationship helps you as your patient's General Practitioner to better gauge the patient's readiness and broach the topic accordingly (Wichmann et al., 2018). Additionally, General Practitioners can make use of the longitudinal relationship to dissect the ACP discussion into multiple sessions (Sharp et al., 2018), resulting in more discussions being held (Aoki et al., 2017).

To help mitigate the time pressure in your clinic, here are a few questions that you may ask your patients to help kick start the idea of planning ahead (Mahon 2011):

1. If you cannot, or choose not to participate in healthcare decisions, with whom should we speak with?
2. If you cannot, or choose not to participate in decision making, what should we consider when making decisions about your care?
3. If you cannot, or choose not to participate in finance decisions, have you appointed someone who can do that for you?

When your patient is ready to make his or her Advance Care Plan, you can help refer them to an ACP node in the community. You may find the nearest ACP community node to your practice here.

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