"I decide myself"- A qualitative exploration of end of life decision making processes of patients and caregivers through Advance Care Planning

Background The Singapore national Advance Care Planning (ACP) programme was launched in 2011 with the purpose of ensuring that healthcare professionals are fully aware of patients’ treatment preferences. There is little research assessing the performance of such programmes in ethnically diverse Asian countries; hence, the purpose of this study was to qualitatively examine patients and caregivers’ experiences with the ACP programme. Method We conducted interviews with 28 participants, thirteen of whom identified as proxy decision makers (PDMs) and the remainder as patients. Interviews focused on respondents’ experiences of chronic illness and of participating in the ACP programme. Textual data was analysed through a framework analysis approach. Results Participants’ narratives focused on four major themes with 12 subthemes: a) Engagement with Death, factors influencing respondents’ acceptance of ACP; b) Formation of Preferences, the set of concerns influencing respondents’ choice of care; c) Choice of PDM, considerations shaping respondents’ choice of nominated health spokesperson; and d) Legacy Solidification, how ACP is used to ensure the welfare of the family after the patient passes. These findings led to our development of the directive decision-making process framework, which delineates personal and sociocultural factors influencing participants’ decision-making processes. Respondents’ continual participation in the intervention were driven by their personal belief system that acted as a lens through which they interpreted religious doctrine and socio-cultural norms according to their particular needs. Conclusion The directive decision-making process framework indicated that ACP could be appropriate for the Asian context because participants displayed an awareness of the need for ACP and were able to develop a concrete treatment plan. Patients in this study made decisions based on their perceived long-term legacy for their family, who they hoped to provide with a solid financial and psychological foundation after their death

Perceived Roles and Barriers in Delivering Community-Based Care: A Qualitative Study of Health and Social Care Professionals

Introduction: As healthcare systems increasingly embrace population health management, the integration of health and social care to improve the health and well-being of individuals is crucial. Thus, we conducted a qualitative study in Singapore to understand health and social care professionals’ (HCPs and SCPs) perception of the roles they played in delivering community-based care. Methods: A descriptive phenomenological research design was adopted. HCPs and SCPs (n = 53) providing services in community settings were recruited purposefully and interviewed through eleven focus group discussions. Each session was recorded and transcribed. Thematic analysis was applied. Results: Our results revealed eight themes in three main categories describing the roles played by HCPs and SCPs, including: (1) delivering needs-based care in community settings; (2) activating and empowering clients in health care, and (3) fostering community-based sustainable support networks. Six barriers encountered while performing these roles were also identified. Discussion and Conclusion: Our results highlight that the roles of HCPs and SCPs go beyond the provision of direct medical and social care. They were involved in activating and empowering clients to take care of their health, and importantly, fostering community-based sustainable support networks to better empower individuals in coping with health challenges. The identified barriers shed light on areas for potential improvements for integrated community care

RETHINKING POLICIES ON PUBLIC HOUSING IN SINGAPORE

Bachelor'sBACHELOR OF SOCIAL SCIENCES (HONOURS

Eliciting and honouring end-of-life care preferences : a multiple methods study on place of death

“Home” is not just a physical compound. It is our natural habitat where meaningful and intimate time with our loved ones can be shared. This narrative has underpinned the motivation for individuals wanting to live out their last days at home. With swift medical advancement and growing perceptions that hospitals provide higher quality end-of-life care, deaths have however shifted from the home to hospitals. This dissertation aimed to explore the complex contextual factors involved in eliciting end-of-life care preferences and to identify facilitators and barriers of home deaths in Singapore with a specific focus on the impact of Advance Care Planning (ACP). A multiple methods approach using qualitative and quantitative research methodologies were used: (i) retrospective cohort study to identify factors associated with home deaths, and to profile end-of-life care preferences and determine concordance of care with these preferences; (ii) semi-structured focus group discussions with 63 healthcare professionals to understand the implementation of ACP and the elicitation of end-of-life care preferences; (iii) quasi-experimental study to ascertain the impact of ACP on the place of death. The dissertation results challenged the popular viewpoint that home is the most preferred place of death. Among individuals diagnosed with advanced illnesses, only 40% had a documentation of “home” as the preferred place of death in their ACP documents. Instead of being an independent decision, preferences for place of death were formed through negotiation between and co-constructed by the patient, family, and healthcare professionals. Families also often believed that better care can be provided for, in the hospital. Besides non-modifiable person- and family-level factors, our results suggested that receiving home palliative care and having an ACP documentation, were associated with a higher chance of dying at home. For non-cancer patients - who had limited access to home palliative care – ACP was associated with increased home deaths, and a significant reduction in unnecessary life-sustaining treatments and health resource use in their last month of life. With the expansion of the national ACP programme already underway, our results underscored the importance for policy makers to focus on changing societal mindsets regarding conversations about death and dying and shifting healthcare practices towards one that supports pro-active patient participation and shared decision-making. Further, given that most deaths still occurred in hospitals, hospitals must continue to be viable sites where high-quality end-of-life care is available.Doctor of Philosoph

Acceptance of communication technology, emotional support and subjective well-being for Chinese older adults living alone during COVID-19: A moderated mediation model

Geriatric Education and Research Institutio

Moderated mediation model between acceptance and competency of CT (X) on SWB (Y) through emotional support (M), moderated by living arrangement (W).

Moderated mediation model between acceptance and competency of CT (X) on SWB (Y) through emotional support (M), moderated by living arrangement (W).</p

Demographic and variable descriptive statistics.

Stringent social distancing measures implemented to control the spread of COVID-19 affected older adults living alone by limiting their social interaction beyond their households. During these restrictions, interactions beyond the household could be facilitated by communication technology (CT) such as voice calls, instant messages. Our study provides evidence on how CT acceptance could influence the emotional support and in turn, subjective well-being (SWB) of older adults living alone. We did a cross-sectional survey with 293 community-dwelling Chinese older adults. Participants were surveyed from September to November 2020 and had completed measures on CT acceptance (competency), emotional support, and SWB. PROCESS Model 1 was used to estimate the conditional effects of CT acceptance (competency) on emotional support for those living alone versus with others. Following which, PROCESS Model 7 was used to estimate the conditional indirect effects of CT acceptance (competency) on SWB through emotional support. Our results suggested that living arrangement moderated the indirect effect of CT acceptance (competency) on SWB. For older adults living alone, CT acceptance (competency) was significantly associated with perceived emotional support and, in turn, their SWB. For older adults living with others, CT acceptance was not associated with emotional support and SWB. Our findings call for more research and support to increase older adults’ acceptance of CT as an option for communication to increase emotional support for older adults living alone, even during non-pandemic times.</div

Correlation between variables (N = 293).

Stringent social distancing measures implemented to control the spread of COVID-19 affected older adults living alone by limiting their social interaction beyond their households. During these restrictions, interactions beyond the household could be facilitated by communication technology (CT) such as voice calls, instant messages. Our study provides evidence on how CT acceptance could influence the emotional support and in turn, subjective well-being (SWB) of older adults living alone. We did a cross-sectional survey with 293 community-dwelling Chinese older adults. Participants were surveyed from September to November 2020 and had completed measures on CT acceptance (competency), emotional support, and SWB. PROCESS Model 1 was used to estimate the conditional effects of CT acceptance (competency) on emotional support for those living alone versus with others. Following which, PROCESS Model 7 was used to estimate the conditional indirect effects of CT acceptance (competency) on SWB through emotional support. Our results suggested that living arrangement moderated the indirect effect of CT acceptance (competency) on SWB. For older adults living alone, CT acceptance (competency) was significantly associated with perceived emotional support and, in turn, their SWB. For older adults living with others, CT acceptance was not associated with emotional support and SWB. Our findings call for more research and support to increase older adults’ acceptance of CT as an option for communication to increase emotional support for older adults living alone, even during non-pandemic times.</div

Factor analysis for GAS.

Stringent social distancing measures implemented to control the spread of COVID-19 affected older adults living alone by limiting their social interaction beyond their households. During these restrictions, interactions beyond the household could be facilitated by communication technology (CT) such as voice calls, instant messages. Our study provides evidence on how CT acceptance could influence the emotional support and in turn, subjective well-being (SWB) of older adults living alone. We did a cross-sectional survey with 293 community-dwelling Chinese older adults. Participants were surveyed from September to November 2020 and had completed measures on CT acceptance (competency), emotional support, and SWB. PROCESS Model 1 was used to estimate the conditional effects of CT acceptance (competency) on emotional support for those living alone versus with others. Following which, PROCESS Model 7 was used to estimate the conditional indirect effects of CT acceptance (competency) on SWB through emotional support. Our results suggested that living arrangement moderated the indirect effect of CT acceptance (competency) on SWB. For older adults living alone, CT acceptance (competency) was significantly associated with perceived emotional support and, in turn, their SWB. For older adults living with others, CT acceptance was not associated with emotional support and SWB. Our findings call for more research and support to increase older adults’ acceptance of CT as an option for communication to increase emotional support for older adults living alone, even during non-pandemic times.</div