Advance Care Planning
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Last updated on 13​ Aug 2025

Advance Care Planning Care Protocol will be implemented from January 2026 – HSG GPs may refer to updates from AIC for details on the implementation of these protocols


​​​Advance Care Planning (ACP) is an important part of holistic health planning as it empowers patients to outline their care preferences in the event that the patient is unable to express or make decisions in the future.​​

ACP is an iterative process of ongoing conversations that supports individuals at any stage of health or illness to understand, communicate and document their values, goals and priorities regarding their future care in the event that they lose their mental capacity. The Nominated Healthcare Spokespersons (NHS) will then speak up for the patients' values and care preferences. There are two main types of ACPs: General ACP and Preferred Plan of Care (PPC).  

The General ACP is suitable for well patients or those with early to moderate chronic diseases. There are two ways that individuals can complete their General ACP:

i. ACP self-documentation digitally via My Legacy portal ("myACP") for individuals who can self-help. ACP self-documentation can be considered for patients who:

a. do not have serious illnesses,

b. have SingPass and able to use governmental e-services,

c. have NHS with a SingPass account

d. demonstrate an understanding of their health and disease trajectory

ii. Complete with an ACP facilitator.

PPC are often for patients with serious illnesses* that may result in organ failure or frailty. PPC involves discussions with an ACP facilitator to clarify patients' understanding of their conditions, implications of their condition should the conditions deteriorate and patient's views of other life extending interventions such as dialysis and cardio-pulmonary resuscitation (CPR).​

*Serious illness(es) includes, but not limited to: Cancer, Chronic Neurological Diseases, Chronic Obstructive Pulmonary Disease (COPD) and End-stage Lung Disease, Dementia, End-Stage-Renal Failure (ESRF), Heart Failure, Severe Liver Disease.​

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GPs should proactively check if their enrolled patients have completed their ACP. If they have not done so, GPs should encourage them to complete their ACP during the annual health plan check-in. GPs can use the ACP collaterals (please see Additional Resources section below) to advocate about ACP. AIC is developing an online training resource to support GPs in becoming a stronger advocate for ACP to their patients – this will be available by Oct 2025.  

GPs who are trained as ACP facilita​tors may complete ACP with their patients. GPs may also signpost or refer patients to (Figure 1: Referral Pathway):

(i) myACP on the My Legacy portal, for well patients in general, with no serious illness(es)*

Patients can complete their ACP online through myACP. This is free of charge. ACP self-documentation can be considered for most patients. They or their relevant NHS should be familiar with navigating governmental e-services.

(ii) ACP community providers, for patients with no serious illness(es)* but need face-to-face assistance

GPs may refer to Find an ACP Service Provider for ACP community providers' referral contacts. GPs should direct their patients to either book their appointments directly from the site or to call the ACP community provider directly using the listed phone number to make the ACP appointment.

(iii) their respective public hospital, for patients who have serious illness(es)*

GPs may refer to Find an ACP Service Provider for public hospitals' referral contacts. GPs should direct their patients to call the public hospital via the listed phone number to make the ACP appointment. From April 2026, GPs may make referrals for their patients to public hospitals using their Healthier SG-compatible CMSes.

*Serious illness(es) include, but are not limited to: Cancer, Chronic Neurological Diseases, Chronic Obstructive Pulmonary Disease (COPD) and End-Stage Lung Disease, Dementia, End-Stage Renal Failure (ESRF), Heart Failure, Severe Liver Disease.

GPs should also encourage all enrollees to review their ACP at appropriate timepoints (e.g. when there are changes in their health statuses, activities of daily living and life goals).


Figure 1: Referral Pathway

Figure 1 Referral Pathway.png

Notes

(1)  Patients can check on MyLegacy; GPs may also refer to National Electronic Health Records (NEHR)

(2) Serious illness(es) include, but are not limited to: Cancer, Chronic Neurological Diseases, Chronic Obstructive Pulmonary Disease (COPD) and End-Stage Lung Disease, Dementia, End-Stage Renal Failure (ESRF), Heart Failure, Severe Liver Disease

(3) Factors to consider include: (a) presence of serious illnesses, (b) possession of SingPass and ability to use governmental e-services, (c) has an NHS with a SingPass account, (d) patient's understanding of their health and disease trajectory​

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NHS are trusted individuals, aged 21 years and above, who can speak up for the patients' values and care preferences when the individual can no longer do so and support care decision-making. Patients can appoint up to two NHS. It is recommended for the NHS to be aware and in agreement with the care preferences expressed within the ACP. The NHS may be a spouse, family member or friend who can follow the known care wishes in the ACP, even in stressful situations. If more than 2 NHS are appointed, they should be clear and in agreement with the care preferences documented in the ACP.​

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To become a certified General ACP facilitator, individuals (regardless of professional training) must attend a 1-day General ACP Facilitat​or Training and pass a competency assessment.​ The training will equip participants with the necessary knowledge and skillsets to facilitate General ACP sessions with pati​ents effectively with appropriate communication, ethics and accurate documentation of care preferences.

Access to the ACP IT System will be granted for certified ACP facilitators from authorised healthcare providers and community care organisations (CCOs) to publish ACP (See Figure 2 for Process to Publish an ACP). Published ACPs that are lodged on the ACP IT system will flow automatically to National Electronic Health Record (NEHR) and the patient's My Legacy vault. Patients can access their ACP documentation via My Legacy vault and would usually have a copy of the document for their records.


Figure 2: Process from Training to Publishing ACP

Figure 2 Process from Training to Publishing ACP.png

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The published ACP can be retrieved by healthcare providers with access to NEHR for the purposes of care under the “Patient Dashboard" tab of NEHR. Patients are also able to access the digital copy of their ACP on My Legacy. This information supports the care team in understanding the patient's care preferences and increases the likelihood of care concordance.​


In addition to ACP, GPs can consider advocating for the completion of other important legacy planning tools such as LPA (Lasting Power of Attorney). The main differences between ACP, AMD (Advance Medical Directive) and LPA can be found in Table 1. Patients should consider appointing their NHS and LPA donee(s) as the same person(s).​


Table 1: Differences between ACP, AMD and LPA

 

ACP

AMD

 ​LPA

Purpose​​​

ACP is an iterative process of ongoing conversations to understand, communicate and document the patient's values, goals and priorities regarding their future care when he/she loses their mental capacity.

An Advance Medical Directive (AMD) is a legal document that allows the patient to sign in advance to refuse extraordinary life-sustaining treatment to prolong his/her life if he/she becomes terminally ill and unconscious.

A Lasting Power of Attorney (LPA) is a legal document which allows a person who is at least 21 years of age (“donor") to appoint one or more persons (“donee(s)") to make decisions if he/she should lose mental capacity.

 

It does not state the healthcare preferences such as extent of treatment, pain control options etc.​

Involvement of loved ones

May appoint up to 2 Nominated Healthcare Spokesperson(s).

None

May appoint up to 2 Donee(s) and 1 replacement Donee.
​


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· Location of nearest ACP service provider can be found on My Legacy: Find an Advance Care Plan (ACP) facilitator - My Legacy (life.gov.sg)

· Charges for ACP services: Some ACP service providers may charge a nominal fee for doing an ACP. Patients can enquire with each of the individual providers for more details.​​

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1. Frequently asked questions about ACP: FAQs on ACP - Agency for Integrated Care (aic.sg)

2. Electronic copies of ACP brochures, FAQs and workbooks: ACP Resources - Agency for Integrated Care (aic.sg)

3. Request and delivery of physical ACP collaterals can be made to AIC via FormSG (email confirmation within 5 working days): https://for.sg/acpcollaterals​

For additional questions on ACP, kindly email your enquiries to: acp@aic.sg​​