Singapore was one of the first movers in Asia to legally facilitate the recognition and use of advance directives in end-of-life decision-making. The Advance Medical Directive Act (AMDA) came into force in 1997 to emplace a legislative framework to enable individuals to exercise greater control over the medical care for their terminal illness. Notwithstanding extensive consultative and parliamentary deliberative processes, the Advance Medical Directive facility never really took hold in clinical care for the terminally ill in Singapore. Although uptake rates since 1997 have risen appreciably, rates of implementation are too low to have any measurable impact. This chapter therefore evaluates the merits and weaknesses of the Singapore AMDA framework. It then traces the evolution of anticipatory end-of-life decision-making policy from its original transactional mindset to the current, process-oriented and ‘communications’ model. The question then evaluated is whether advance directives (in statutory or other forms) have any continuing role in the current push towards more widespread advance care planning under the national ‘Living Matters’ programme spearheaded by the Singapore Agency for Integrated Care.

This chapter describes general principles in ethical decision-making, as well as the patient’s critical role in making decisions that are both medically and morally sound. When the patient no longer has capacity to participate in decision-making, various approaches to advance directives can be implemented. A morally appropriate and legally empowered surrogate decision-maker can be appointed; other advance directives could include DNR orders, a living will, or a durable power of attorney for health care. These may inform the discussion of the goals of care for an individual patient, leading to ethically acceptable actions for the patient, family, and medical team. These principles are then applied and discussed in specific cases: disclosing a diagnosis of dementia, substituted judgment and medical futility, and the provision of nutrition and hydration.

Increasingly, medical and legal professionals across the world have been calling for the establishment of special adjudicatory dispute resolution mechanisms to resolve intractable end-of-life medical treatment disputes. Although it is controversial, many commentators regard the conflict resolution provisions in the 1999 Texas Advance Directives Act (TADA) as a leading model and template. This chapter examines the process of passing this law and provides policy-makers in other jurisdictions with tips and strategies for enacting legislation like TADA. It also considers more recent developments, and in particular, efforts to slowly dismantle it. In short, this chapter is an examination of the conditions for the rise and fall of TADA. This inquiry is valuable, because it highlights lessons for other jurisdictions considering law reform on end-of-life medical treatment.