A Qualitative Study on End-of-Life Psycho-Familial Tasks for Older Chinese Terminally-Ill Singaporeans

1
A Qualitative Study on End-of-Life Psycho-Familial Tasks
for Older Chinese Terminally-Ill Singaporeans
Wong Su Ting
Supervisor: Prof. Andy Hau Yan Ho
Nanyang Technological University
A Final Year Project submitted to the School of Social Sciences, Nanyang Technological
University, in partial fulfillment for the degree of Bachelor of Arts (Hons) in Psychology.
Academic Year 2018/19

PSYCHO-FAMILIAL TASKS AT THE END OF LIFE 2
Author Note
The author would like to thank Asst. Prof. Andy H.Y. Ho, Ms. Choo Ping Ying, Ms.
Geraldine Tan-Ho, Ms. Casuarine Low Xinyi, Ms. Oindrila Dutta, Mr. Paul V. Patinadan, Ms.
Hilary Ma, Janice, and Jun Hao for their feedback, advice and support.
Correspondence concerning this article should be addressed to Wong Su Ting.
Contact: wong0994@e.ntu.edu.sg

Abstract
Background and Aim: The completion of psycho-familial tasks is essential for older Chinese
terminally ill Singaporeans to prepare for a good death that is in line with their values, beliefs,
and end-of-life goals. However, Singaporean society lacks understanding in what these tasks are,
what patients’ aims are for embarking on them, and the methods patients use to achieve those
aims. Policies such as Advance Care Planning, which involve facilitating discussions on patients’
end-of-life goals, can be substantially improved if policy-planners better understand the tasks
that Singaporeans find relevant to a good death. This would increase their eagerness to
participate in the currently under-utilised ACP. Society would then be able to equip
Singaporeans in achieving the good death they desire.
Method: Four patient-caregiver dyads participated in the Family Dignity Intervention study.
They were interviewed on two occasions each, with their interview data utilised for this study,
and analysed using thematic analysis.
Results and Discussion: Findings were categorised into two overarching categories. The first,
Expressions of Sentiment, contained the themes Expressions Beseeching Forgiveness;
Expressions of Love; and lastly, Expressions of Gratitude. The second overarching category was
Arrangements and Instructions for the Family, which contained the themes Ensuring Continued
Familial-Care; Ensuring Family Understanding in Treatment Goals; and lastly, Advice for
Family. Implications of the findings on the current Advance Care Planning framework are
discussed, with relevant suggestions made while taking into account the increasingly pressing
demands of the ageing population and the cultural needs and norms of the older Singaporean-
Chinese population.

Keywords: Psycho-familial tasks, Advance Care Planning, end-of-life, Chinese,
Singapore, terminally ill

A Qualitative Study on Psycho-Familial Tasks at the End of Life
for Older Chinese Terminally Ill Singaporeans
What does a good death mean? How do we prepare for a good death? These are perennial
questions that Singaporeans are concerned about, as exhibited in the Death Attitudes Survey by
Lien Foundation (2014). Given Singapore’s age structure, the task of providing an answer to
these questions above will only become increasingly urgent.
By 2025, Singapore would be considered a ‘super-aged’ country, where one in five
Singaporeans would be aged 65 and older (Prime Minister’s Office, 2016). The death rate in a
society also tends to increase as the population ages; in 2010, there were 4.4 deaths per 1000
residents in Singapore; this figure rose to five in 2017 (Singapore Department of Statistics,
2019). With this comes the pressing need to prepare Singaporeans for a good death that is
aligned with their values, beliefs, and end-of-life goals.
Singaporeans are aware of the need to prepare themselves for a good death. In the Lien
Foundation Death Attitudes Survey (2014), it was found that amongst desires to die
inexpensively at home and without imposing financial burden on their family, Singaporeans also
expressed their need for a platform that openly discusses issues on death and dying. They also
desired better guidance from medical professionals to help them in matters of palliative care.
These signs pointed clearly to Singaporeans’ desire to exercise volition in creating their good
death. End-of-life care policies such as the Advance Care Planning (ACP) scheme implemented
by the Singapore government aim to help Singaporeans fulfill this desire. Unfortunately, the
ACP is one area in which end-of-life care has a fair amount to improve. Current trends discussed
below indicate that the ACP may be falling short in answering the needs of the population.

Advance Care Planning (ACP)
The ACP scheme in Singapore was adapted from the American model of ACP, named
Respecting Choices, which formulates the ACP to focus on the individuals’ needs, values, and
practices (Living Matters, 2019). ACP was implemented in Singapore in response to the
increasing needs regarding death and dying, and to ultimately prepare the population for their
end-of-life matters. ACP is a series of discussions of healthcare decisions that an individual
makes for his or her future care at the end of life (MacKenzie, Smith-Howell, Bomba, &
Meghani, 2018). These discussions are essential; they make an individual’s choices known to his
family and healthcare providers, pre-empting adverse situations at the end of life, especially in
the event that the patient loses the ability to make personal medical decisions (Ng, 2009).
Adverse situations can occur when patients do not communicate their beliefs, values, and
goals at the end of life to their loved ones, or when they do not document such information
appropriately. When patients’ loved ones have little of such information, yet are given the
authority to make decisions for patients, there is a higher risk that those decisions could run
against the patient’s wishes. This phenomenon was manifested in a retrospective study of 683
patients who had died in Singapore hospitals. While Do Not Resuscitate (DNR) orders were
discussed with the patient’s family 82.9% of the time, discussions on both DNR or CPR orders
involved only 4.6% of patients who were alert and able to communicate at the time of admission.
In the same study, it was found that extraordinary life-sustaining interventions, including tube
feeding and intubation, were frequently administered in the last 24 hours of life (Phua et al.,
2011). The lack of discussion of the patient’s preferences in his or her care decisions evidently
contributes to unnecessary and burdensome complications in end-of-life care. Had the patient
had the opportunity to share his or her preference on whether to administer or withdraw life

support and advanced cardiac life support at the end-of life, such complications could have been
circumvented.
ACP discussions provide the very platform to overcome these unnecessary complications
by allowing patients to communicate essential information to their family. In a meta-analysis of
80 systematic reviews on ACP, Jimenez et al. (2018) found that ACP was generally associated
with patients undergoing treatment consistent with their goals of care. They were more likely to
document their goals and preferences of treatment, die in their desired places of care, obtain
healthcare savings, in addition to being less likely to undergo intrusive life-sustaining treatments.
Severe underutilisation of ACP. Unfortunately, ACP has been severely underutilised in
Singapore. The nationwide development of the ACP programme had started since 2011 (Living
Matters, 2019). Over the next few years, main stakeholders and implementors embarked on their
versions of the ACP programme. Hospitals like Tan Tock Seng Hospital established their
programme in 2012 (Tan Tock Seng Hospital, 2019) and Khoo Teck Puat Hospital followed suit
in 2013 (Khoo Teck Puat Hospital, 2019). Regrettably, after millions of dollars and substantial
efforts were invested, only approximately 10,000 Advance Care Plans were completed six years
after the establishment of the programme (Ho et al., 2017). This is in stark contrast with the
figure of 117,596 deaths from 2012 to 2017 (Singapore Department of Statistics, 2019).
Evidently, the ACP scheme is facing difficulties in its outreach to the population. The
need to locate where exactly this issue of delivery lies is urgent, given how those who are ill,
dying, and in most palpable need of ACP discussions may not have the motivation to participate
in it, or may not even be in the know of the policy and its benefits.
Mismatch between existing individualistic model and population’s familial needs. One
of the possible reasons for the underutilisation of the ACP is its focal point — the individual. The

individual is the central focus of ACP in the American Respecting Choices model; however,
various studies (Berkman & Ko, 2010; Bito et al. 2007; Jimenez et al., 2018; Kwak & Salmon,
2007; Ng, Chan, Ng, Chiam, Lim, 2015) have shown that Asian cultures, including Singaporean
culture, need an ACP framework that incorporates a family-centric decision-making model rather
than an individual-centric one, while balancing its focus on both the individual and the family.
These studies will be expounded on later in this paper.
The Lien Foundation Survey on Death Attitudes (2014) demonstrated that Singaporeans’
top fears about dying were (a) medical costs (88%), (b) burdening their family (87%), and (c)
their family’s well-being after death (80%). It is evident that these three fears are entangled, as
can be inferred from 87% of participants expressing that their top end-of-life priority was to
ensure they would not financially burden their family. Among the main Chinese, Malay and
Indian ethnic groups in Singapore, these top three fears were most pronounced in the Chinese
group, and even more accentuated in older Chinese individuals aged 50 and above. These fears
are not transitory; the same three fears found in 2014 also emerged among the top five fears
found in the Lien Foundation’s 2009 street survey on death attitudes (Lien Foundation, 2009). It
is clear that in the final stages of life, a common theme among Singaporeans’ biggest concerns is
the family.
In 2017, Ng et al. studied the awareness and attitudes towards ACP in Singapore through
the responses of 406 participants, mean age 46.8 years, and of which 67.4% were Chinese. 97%
of participants had either never heard of ACP, or knew of it but never had a discussion.
Consequently, they were given a brief introduction to ACP. Upon learning about it, 60.1% of
those participants agreed to start an ACP discussion. It was found that this group was more likely

to have the practice of discussing personal decisions with family, and it was also more probable
that they had financial support from their family.
These studies and surveys give insight into how the family unit is intrinsic to
Singaporeans’ deliberations and plans for their end-of-life processes. Furthermore, in Eastern
culture, individuals’ identities and needs are defined in relation to their families and communities
(Chan, 2004). Thus, an ACP framework which discusses Singaporean patients’ end-of-life
matters in relation to their families could be more effective than the existing individualistic
framework. Currently, the ACP emphasises strongly on the individuals’ own needs, values,
beliefs and goals, such that they appear to be separate from the individuals’ community. The
Singaporean patient who is more likely to connect their end-of-life needs to their families’ needs
would thus find that the current ACP framework lacks in relevance to their cultural beliefs and
practices.
In a country where 74.3% of its population are Chinese (Singapore Department of
Statistics, 2017), enhancing the involvement of the family in ACP could improve the ACP’s
relevance and appeal to the population. The Chinese that for an individual to exercise autonomy,
the family has to agree — this makes the family’s opinion necessary in decision-making (Tse,
Chong & Fok, 2003). These concepts are heavily expounded in the writings of revered Chinese
scholars, including Confucius and Mencius, whose teachings form some of the cornerstones of
prevalent Singaporean Chinese culture (Khan, 2001; Tan, 2012). Studies have likewise shown
that Asian cultures involve the family’s needs and opinions in making end-of-life decisions more
than Western cultures do, as will be explicated below. Improving the family unit’s pertinence to
ACP processes of discussing, documenting and implementing patients’ wishes at the end of life
could thus answer Singaporean’s needs and increase their motivation to participate in ACP.

Specific reasons to increase the family’s involvement in ACP. The following are some
distinct reasons that could explain Singaporeans’ hopes to have their families involved in their
end-of-life needs.
The family-centric decision framework in Asia. The failure to incorporate a family-centric
decision framework in ACP could be one of the reasons why the current programme lacks appeal
in Singapore. This is for two main reasons, the first being that the family-centric decision
framework involves the family as a collaborative decision-maker, an aspect that lacks emphasis
in the individualistic ACP framework. The second reason is that decisions made at patients’ end
of life are often in the interest of the family, but the individualistic ACP framework assumes that
patients’ end-of-life decisions are made mainly for personal interests.
Firstly, several studies show how the family-centric decision framework involves the
family unit as a collaborative decision-maker in Asian patients’ final stages of life. Kwak &
Salmon (2007) found that individuals in Western societies were inclined to make end-of-life
decisions independently. In contrast, older Asians strongly believed in decision-making as a
family, and thus preferred having their families make those decisions for them (Berkman & Ko,
2010; Bito et al. 2007; Kwak & Salmon, 2007). Similarly, Jimenez et al. (2018) found that
Western societies were found to plan medical care decisions around patients’ self-determination
and autonomy, while Asian communities integrated the family and community into their medical
decisions. Bowman and Singer (2001) had similar findings in their study of older Chinese adults,
which showed that older Chinese adults believed that their family, especially their adult children,
hold the responsibility in making medical care and end-of-life decisions for them.
This responsibility stems from traditional Chinese culture, which prescribes the principles
of filial piety rooted in Confucianism (Yao, 2000). Bowman and Singer (2001) also explained

that the Chinese believe that one’s choices do not belong to themselves, but to the entire family.
Blackhall and colleagues (1995) also had similar findings among Korean American older adults,
who too believed it was the responsibility of their family to make end-of-life decisions for them,
a belief stemming from principles of filial piety and family-centric decision-making. A parallel
can be drawn between these preferences of older Korean Americans and those of older
Singaporean Chinese due to the similar Confucian values, descended from China, that are upheld
by both groups (Canda, 2013). Additionally, the low acculturation scores of the Korean
Americans in Blackhall et al.’s (1995) study evidence their retainment of Confucian family-
oriented values.
Kwak and Haley (2005) found that the family unit’s involvement in end-of-life care
decision-making mostly served the purpose of relieving the patient’s burden of making those
decisions. For other cultures, family units were involved for different reasons. Thus, they posited
that it is not possible to use one type of end-of-life decision-making framework for different
cultures, and that it is even more unlikely for the Western individual-centric model to work in the
family-centric Asian society.
Secondly, decisions made at Asian patients’ end of life are often in the interest of the
family, and are made possible through the family-centric decision framework. Hancock et al.
(2007) found that non-Anglo Saxon cultures, including Hong Kong-Chinese and Japanese
cultures, placed the wellbeing of the family unit before the wellbeing of the individual. Chan
(2004) further explains that especially for the Chinese, the needs and interests of the self are
inseparable from those of the family, a cultural distinction which the individual-centric model of
decision-making does not take into consideration. In the individual-centric model, the role of the
family is secondary to the role of the patient, thus making the family only a unit of assistance

that realises the patients’ plans. These plans largely ignore the needs of the family’s interests,
beliefs and values, and pays disproportionate concern to those of the patient’s.
In the same vein, Japanese Americans take this family-centric focus in end-of-life
planning; those who had completed advance directives in Bito et al. (2007)’s study were mainly
driven by the motive to ease their families’ emotional burdens that come with having to cease
life-sustaining treatment for the patient. These patients were less driven by the motive to achieve
self-determination and autonomy as is advocated in the individual-centric model. This is despite
the fact that the Japanese American participants had, to differing extents, acculturated to the
United States. Thus, it shows that some Asian familial values are ingrained and resistant to
change, and thus must not be overlooked when planning end-of-life care for Asians. Bito et al.’s
study (2007) also highlights the blurring between the interests of the self, and the interests of the
family in Asian culture, re-emphasising how self-concepts in Asian cultures are defined in
relation to one’s community. These Confucian family-oriented values, prevalent in Singapore
(Khan, 2001; Tan, 2012), are also significant to the Japanese identity, once again due to the
definitive influence of Confucianism which spread from China, through Korea, and finally to
Japan in the Han dynasty (Tucker, 2018).
Chan (2004) posits that in Oriental culture, advance directives should not be merely an
indication of one’s self-determination and autonomy; they should also serve as a way for patients
to show care and devotion in providing for their loved ones’ wellbeing. Similarly, the ACP
framework should be sensitive to Singaporeans’ end-of-life decision-making preferences,
including who they wish to be decision-makers, and whose needs those decisions should answer.
In the Asian society of Singapore, it is highly likely that the family unit is inextricable in these
two aspects.

Benefits of ACP on both patient and family. Another main reason to increase familial
involvement in the ACP is due to the heavy impact that end-of-life matters and ACP can make
on patients’ families, even though the fundamental purpose of the ACP is to aid patients in
preparing for a good death. As explicated above, those who subscribe to Asian values and
beliefs, including Chinese Singaporeans, perceive fulfilling their family’s needs as one of their
essential end-of-life goals. The ACP has the potential to be an instrumental tool that helps
patients achieve this goal, and in successfully do so, the ACP will contribute to patients’ abilities
to achieve a good death.
One of the needs of family caregivers that can thus be addressed is their hopes of a
lightened burden of caregiving. At the end of life, patients’ families are not just involved in end-
of-life decision-making; they are also occupied with caregiving tasks and subsequently the
management of patients’ afterlife matters, including funeral plans and estate distributions. As
such, family members often undergo intense periods of stress due to the overwhelming practical
and emotional demands the entire process of a loved one’s death and dying can bring about
(Bascom & Tolle, 1995).
Zimmerman (2012) explains that open discussion of end-of-life plans is necessary to
ensure that the management of care for dying patients is efficient and smooth. Given how
patients in Singapore are likely to be cared for at the end of life by their family, the ACP
discussions would be greatly beneficial to family members consumed by caregiving. In fact,
caregivers often express the desire for patients to complete medical directives, in which medical
care preferences are documented and preferred surrogate decision makers are legally appointed,
in order to facilitate end-of-life decision-making processes (Kwak & Salmon, 2007). Ng et al.
(2013) found that caregivers in Singapore expressed the same desires, explaining that they

themselves would have ACP discussions to lighten the burden of decision-making on their
family.
An effective ACP would allow patients’ preferences to be clearly documented and
discussed, allowing family caregivers to act in concordance with these preferences, and thus
have greater ease in making decisions (Ng, 2016; Phua et al., 2011; Zimmerman, 2012). The
clarity this process gives to patients’ wishes is critical, given that up to a third of surrogate
decision-makers make decisions for patients using their own values and goals, and lack
understanding of patients’ preferences (Vig, Taylor, Starks, Hopley & Fryer-Edwards, 2006).
In the case where the patient is unresponsive, family members will take comfort in
having the resources to prepare the patient for a death in concordance with his or her beliefs,
values, and goals. This sense of comfort in knowing they had enabled their loved one to have a
good death can be vital to easing their bereavement experience. Zimmerman (2012) explains that
open discussion of death and dying matters can aid patients in coming to accept their impending
death; this acceptance can lighten the psychological and spiritual burdens of family members,
while enabling patients to die peacefully.
Unfortunately, there are obstacles to having an open discussion on death and dying in
Singapore. It has been shown that Asian cultures have an aversion to discussing death and dying
openly due to beliefs of the topic’s taboo nature (Kwak & Salmon, 2007), a common theme in
Singaporean Chinese culture (Ho et al., 2017; Ng et al., 2015). Specifically, Chinese older adults
in Canada of Confucianist, Buddhist, and Taoist heritage — a common demographic in
Singapore — perceive blatant references to death as taboo due as they believe doing so will
induce bad luck (Bowman and Singer, 2001).

However, Chan (2004) believes that it is precisely ACP discussions that can coax the
family into opening up about issues on death and dying. With improved communication about
these topics, the concept of it being taboo can gradually be eroded, paving the way for better
end-of-life choices to be made for the patient through meaningful, open, and productive
discussion.
In conclusion, the aforementioned reasons to increase the family’s involvement in ACP
denote the inextricable role the family unit plays in patients’ end-of-life matters. Taking such
culturally-specific aspects of Asian beliefs and values into account is an essential measure that
will allow society to tailor an effective end-of-life care approach for Asians (Kwak and Haley,
2005).
In 2015, The Economist Intelligence Unit (EIU) conducted an international study on the
quality and availability of end-of-life care in 80 countries. Given Singapore’s high income per
capita, EIU assessed that the country actually did worse than expected. Singapore’s Gross
National Income per capita is the highest; surpassing Norway at the second-highest by a large
gap of more than 10,000 USD. Yet, Singapore does not even make it to the top ten of the Quality
of Death Index. We are thus reminded that although Singapore may have won acclaim for her
healthcare systems (Wong, 2018), there are undoubted shortcomings in her provision of end-of-
life care, an area in which the rapidly ageing landscape is deeply and urgently concerned about.
Aim of Study
The cumulative evidence points to the probability that the low ACP uptake is partly due
to the undermining of the extent to which patients’ end-of-life plans are focused on the family
unit. This study thus attempts to understand how much the end-of-life needs of older Chinese
terminally ill Singaporeans dovetail with family-centric decision-making and planning processes

by analysing the psycho-familial tasks that patients undertake in preparation for their impending
death. Family-centric decision-making and planning processes are family-centric in that (a) the
family unit is a collaborative decision-maker, and (b) the family’s needs are addressed as part of
patients’ end-of-life goals. Psycho-familial tasks is defined in this paper as the tasks patients
voluntarily undertake with the intention to meet their interrelated psychological and familial
needs, including family cohesion and reconciliation. In these tasks, the patient and their family
are always the main stakeholders: Either (a) the completion of the tasks requires efforts from
these stakeholders, or (b) the stakeholders are meant to benefit from the completion of the tasks.
Often, the completion of patients’ psycho-familial tasks involves both aspects.
By understanding patients’ end-of-life goals, Advance Care Planning can be improved by
tailoring the ACP discussions to these psycho-familial tasks that Singaporeans find essential to
achieve in their hopes of a good death. With ACP discussions that are relevant to what
Singaporeans find important, and which address Singaporeans’ needs, the population will
naturally be more eager to participate in ACP.
Methodology
Study Design
This study adopted the epistemological stance of interpretivism, due to its focus on the
socially-constructed concept of end-of-life psycho-familial tasks. These tasks were explicated
through participants’ idiosyncratic expressions of their thoughts, feelings, and actions. Patients’
end-of-life journeys, including their pursued psycho-familial tasks, are largely shaped by
contextual factors. These factors include, but are not limited to, patients’ personalities, values,
beliefs, goals, life experiences, familial situations and cultural backgrounds, which altogether
rendered the content in each interview unique to each patient.

It was of utmost importance to acknowledge, draw out and understand the unique
experiences of patients in their final stages of life, along with the meanings that they made of this
experience. Therefore, an inductive qualitative research design was utilized. In this way, the
study could focus on encouraging patients and their caregivers to engage in open and in-depth
sharing, thus evoking patients’ rich narratives of their end-of-life experiences, specifically on the
topic of culturally-specific psycho-familial tasks and patients’ beliefs, values, and end-of-life
goals that were associated with those tasks.
Sampling and Recruitment
Participants in this study are patient-caregiver dyads who participated in a larger study on
Family Dignity Intervention (FDI) (Ho et al., 2017), which will be explicated in the next section.
Patients were purposefully sampled and recruited from five collaborators: Dover Park Hospice
(DPH), HCA Hospice Care (HCA), Singapore Cancer Society, Tan Tock Seng Hospital, and
Methodist Welfare Society. Participants were included on the criteria that they were (a) diagnosed
with a terminal illness, (b) had a life expectancy of 12 months or less, (c) were receiving hospice
care, either through home-care, daycare or residency in a hospice facility, and (d) were at least 50
years of age. Patient-caregiver dyads were excluded if they were (a) unable to give their informed
consent, (b) had major cognitive disabilities, or (c) unable to comprehend or communicate in
English, Mandarin, Cantonese, Hokkien, or Malay. Patients who were deemed too ill based on a
clinical assessment with the Karnofsky Performance Status Scale were also excluded. A copy of
the Research Participation Referral Form is appended (See Appendix A).
Eligible patients were first identified by the collaborators, who then obtained patients’
verbal consent before finally referring them to the FDI researchers. Researchers contacted these

patients and the family member identified as their primary caregiver, organising the first
meeting.
In this study, the four participants were terminally ill patients from HCA or DPH. They
were all Singapore citizens, of Chinese ethnicity, and were in the older age group of 58 to 80
years. A summary of the patients’ demographics is provided in Table 1, alongside their
caregivers’ brief details.
Table 1
Participant Demographics
*Pseudonyms have been used.
+
Ivan, 59, had had a throat surgery and was unable to speak. Thus, he provided written
responses to the interview, while verbal interviews were conducted with his primary caregiver,
who was also his wife.
Data Collection
Interviews for the larger FDI study were semi-structured and administered by a therapist
trained in Dignity Therapy (Ho et al., 2017). The interview schedules (see Appendices B and C)
were based on the dignity model and dignity therapy protocol (Chochinov et al., 2005). The 60 to
90-minute interviews were audiotaped and thereafter transcribed verbatim by the student
researcher. Transcripts were carefully reviewed by a trained therapist. Any discrepancies were
Participant
No.
Name* Age Gender Marital
Status
No. of
Children
Race Caregiver Age
1 Min 58 F Single 0 Chinese Niece 29
2 Ong 80 M Married 3 Chinese Wife 79
3 Ivan+
59 M Married 2 Chinese Wife 48
4 Peng 70 F Married 2 Chinese Daughter 40

clarified with the participant-dyad if required. Finally, transcripts that were in Mandarin were
translated to English by the same student researcher and reviewed by the therapist.
Family Dignity Intervention (FDI). This study’s methodology was based on the FDI
framework. The FDI was developed by Ho et al. (2017) and based on Chochinov et al.’s (2005)
Dignity Therapy model. It similarly seeks to understand the factors that promote a sense of
dignity for patients at the end of life. In Asia, familial relationships and processes have been
found to be integral components of this sense of dignity (Ho et al., 2017). This is in addition to
the physical, psychological, social, and existential components that the Western model of
Dignity Therapy has identified (Chochinov et al., 2005). Thus, to incorporate all the
indispensable components, the FDI takes the distinct approach of bringing focus to both the
individual and their families in understanding patients’ conceptions of dignity. In the series of
open dialogues in the FDI interview protocol, patients and their caregivers are engaged in rich
and expansive sharing of what matters most to them at the end of life, including their deepest
concerns, fears and beliefs on death and dying.
Data Analysis
Thematic analysis was utilised in this study (Braun and Clarke, 2006) to study the psycho-
familial tasks which the terminally ill patients embarked on due to their knowledge of their limited
time. This study is mainly an effort to describe patients’ psycho-familial tasks in a manner that
elucidates the values, beliefs, goals that motivated patients to pursue those tasks, in addition to the
methods patients utilized to pursue those tasks. The explication of these facets of patients’ psycho-
familial tasks would make it possible to analyse how much, and in what ways, a family-centric
model in ACP would address the needs of patients. Additionally, there was no intention for the

generation of theory or analysis of speech. Thus, thematic analysis served a sufficient level of
analysis for the data.
Procedures.
Generation of codes. In a data-led approach, coding was carried out every two to three
lines to identify codes that would describe the data accurately. These codes were revised a few
times in attempts to create more fitting and meaningful descriptions of the data.
Search for themes. Any meaningful similarities among codes that were relevant to end-of-
life psycho-familial tasks were carefully picked out. Codes which conveyed similar psycho-
familial tasks were grouped together.
Review of themes. In an iterative and analytical process, themes were checked to ensure
that they conveyed unique psycho-familial tasks, and that coded quotes were most appropriate
under their assigned themes.
Theme-labelling. Themes were defined and labelled with names attempted to describe the
data meaningfully and accurately, thus making clear what the different psycho-familial tasks
pursued were. Sub-themes were also created to achieve more precise and concise definitions of the
data within each theme. This is because some psycho-familial tasks were observed to share
common characteristics with other tasks, thus making it meaningful to group them into a broader
set of tasks. With initial theme groupings eliciting a clearer overall picture of the data, some
discrepancies and ambiguities became more striking, resulting in a need to repeatedly review and
revise themes, and reallocate some codes.
Reflexivity. In the generation of themes in relation to psycho-familial tasks, it was essential
that the student researcher did not allow her own opinions on end-of-life care and decision-making
to influence the data, or let any intention to propagate a personal stance affect the analysis. Data

was translated with efforts to make quoted narratives comprehensible for readers, while also
retaining the voice of the participants. Reviews of the student researcher’s work by the trained
researchers served as a fundamental cross-check. In subsequent meetings with the participant
dyads, any misinterpreted information was also corrected by the dyads, ensuring that their
narratives were respected.
Ethics Approval and Informed Consent
Participants’ consent was obtained both in verbal and written form. Copies of the informed
consent forms are supplied in Appendices D and E (Ho et al., 2017).
All participants were briefed on the study’s purpose and any benefits or risks involved,
including remuneration. The processes of ensuring anonymity and confidentiality of information
and the voluntary right to withdraw at any part of the study was explained to participants. This
study, as an extension of the FDI study, was approved by the Nanyang Technological University
Institutional Review Board (Ho et al., 2017). A copy of the IRB Approval Form is affixed in
Appendix F.
All participants were also debriefed after each interview so that participants could raise any
concerns they had for the researchers to address or clarify (Ho et al., 2017). A copy of the debrief
forms is found in Appendices G and H. Researchers expressed their gratitude to the participants
for their time and effort after every interview.
Confidentiality. Participants’ names were replaced by pseudonyms, and all other
identifying information in the data such as names of family members and doctors were replaced
with appropriate descriptions.
Comfort of participants. All participants in this study were interviewed in their own
homes at their preferred times. The interviewers ensured the participants’ comfort in the interviews,

especially when discussing sensitive topics. Interviewers were alert to any need to refer
participants to professional psychological help.
Findings
Based on the analysis, six main themes emerged from the data. These themes depicted the
psycho-familial tasks which the older Chinese Singaporean patients undertook in preparation for
their impending death. These tasks are therefore different from everyday psycho-familial tasks
because they were specifically pursued at the end of life. To meet the intertwined psychological
and familial needs, or psycho-familial needs, that patients and their families share, patients
communicated important messages to express different sentiments, made arrangements for their
family, and lastly relayed various types of instructions and advice to their family members. A
summary of the findings is found in Table 2.
Table 2
Emergent Themes
Psycho-Familial Tasks at The End of Life
I: Expressions of Sentiment
1. Expressions beseeching forgiveness
(n=2)
2. Expressions of love (n=4)
o Expressions of love through
affectionate sharing (n=3)
o Expressions of hopes for family
(n=4)
3. Expressions of gratitude (n=4)
II: Arrangements and Instructions for the
Family
1. Ensuring continued familial-care (n=4)
2. Advice for family (n=4)
3. Ensuring family’s understanding in
treatment goals (n=2)

Category I: Expressions of Sentiment
Expressions of Sentiment is the overarching category that encompasses the emotional
messages that patients communicate to their family members. These messages are distinct
from other sentimental messages due to what had caused them; patients were motivated to
express them due to their cognition of the limited time they had left. These messages
explicate the deep emotions rooted in patients’ relationships with their family. They also
show what patients genuinely hope to achieve by expressing those emotions.
There are three themes within this category, which are expressions beseeching
forgiveness; expressions of love which subsumes the sub-themes expressions of love through
affectionate sharing and expressions of hopes for family; and lastly, expressions of gratitude.
Theme 1.1: Expressions beseeching forgiveness (n=2). Upon terminally ill patients’
acknowledgement of their prognoses, they often feel compelled to ask for forgiveness for
mistakes they had made. These messages are crucial to heal broken relationships and to
nurture them thereon (Byock, 2014). The theme expressions beseeching forgiveness thus
details what patients said to their families in asking for forgiveness. Ultimately, the goal of
expressing such regret and apology in hopes of receiving their families’ forgiveness and
ultimately achieve reconciliation.
Min, aged 58, apologised for losing her temper often at her family in the past,
particularly to her eldest sister who had, and still was, looking after her in her illness:
“My eldest sister has helped me so much…Even though I used to lose my temper
frequently, she still cared a lot about me in my illness…So, I would really like to
apologise to her.”

Ivan, aged 59, sincerely apologised for past hurts he had caused his wife and children,
hoping to be forgiven. His wife explained:
“Just last month he really ask me for…my forgiveness. Because he said his time is not
long. So yes, I tried to put it down.”
“He did Whatsapp to them [patient’s children]. He said he’s very sorry for what he’s
done to them…his main purpose is to apologise to them.”
In Confucian Singaporean-Chinese culture, it is advocated that in times of conflict
between parent and child, the latter bears the onus of apologising (Khan, 2001; Tan, 2012).
Ivan was described by his wife as a stern traditional Chinese father to his children; his
decision to apologise to his children could hence suggest the absolutely necessity of familial
reconciliation in terminally ill patients.
In sum, when patients near the end of life, they find it necessary to find a means for
their family to recognise that they have admitted to their own mistakes and are regretful, so as
to obtain forgiveness.
Theme 1.2: Expressions of love (n=4). Expressions of love is a theme which
explicates the strong feelings of love that patients communicate to their family. These
expressions can be as direct as statements of “I love you”, or they can be less direct, such as
when patients express love through sharing their hopes for their families’ future wellbeing.
Expressions of love often make a great impact in end-of-life conversations; they help build a
stronger sense of connection and closeness between the patient and their family, before the
terminally ill patient eventually dies (Keeley, 2007).

Expressions of love through affectionate sharing (n=3). Even though love is a
convoluted concept, Floyd (2008) proposed that messages of love can be encapsulated in two
forms, the first being verbal affection, and the second being non-verbal affection.
In light of their limited time, patients were motivated to express love through words
of affection. Some patients accompanied those words with nonverbal expressions that showed
feelings of their fondness and connectedness to their loved ones. For instance, Min and her
niece were both moved to tears as they expressed their love to each other:
Niece: “The last thing I want to say is, I love you.” [tears up]
Min: “I love you too, you know that?” [tears up]
Peng expressed her love slightly less directly by telling the interviewer that she loved
her daughter, albeit in her daughter’s presence:
“I love and dote on her a lot.” [pats daughter’s back]
Ivan wrote that he loved his wife, particularly because he valued how much she cared
for the family and brought happiness to him. He also cherished how she understood him
thoroughly:
“I very happy to have my wife that I [married]. It give me a real family of my life
with the children that I have…I love my wife the most, that she look after my 2
children & [do] the housework to keep clean, so when I come back home, I feel like I
really have a happy family.”

In a separate piece of writing, Ivan added:
“I love my wife for knowing everything (about) me.”
The expressions of love described above are relatively direct, but expressions of love
can often be indirect. Such affectionate messages may be expressed through spending time
together, doing chores for each other, or gifting things (Keeley et al., 2014). It was common
for this study’s patients to express love to their family members indirectly. Peng’s daughter
explained that when Peng was ill and at home every day, she would take extra notice of what
her daughter wanted to eat, making sure to prepare the food:
“She has been extra caring these few months…there have been many instances where
I could tell how much she doted on us. She would show it through her actions.
Sometimes, we’d just casually remark about wanting something, like food, and she
would buy it or make it for us when we least expected it. She makes a special effort
for us, and this is how she expresses her love and gratitude.”
Patients also expressed their love through sharing how much they desired to spend
quality time with their family. Both Peng and Min expressed affection for their family by
showing that of the few desires they had left, one of the most important was to spend quality
time together. Peng hoped to have her family as company for everyday activities:
“(With my remaining time,) I just wish to be able to spend time with my children
every day, be it gathering over meals or going out with our family.”

Min expressed her hopes to spend quality time with her family for special occasions.
She told her niece of her hopes to be present at her wedding, and attempted to assure her
niece that she would try her best to be there:
Niece: “I hope you’ll be by my side when I get married.”
Min: “…Well, you know I hope so too. I know you want me to try my best, to eat
more and get stronger. I’ll see you get married and give birth to your children, okay?”
[laughs]
Expressions of hopes for family (n=4). In expressions of hopes for family, terminally
ill patients expressed love for their family in the specific form of well wishes for their future.
Many of these well wishes involved hoping for their family members’ happiness and good
health. In expressing his hopes for his family, Ivan communicated a simple message:
“My only hope is in future, they will have a good life [and] harmony in life.”
Min had well wishes for her niece, who was soon to get married. She said:
“I only hope she will be okay. (I hope she will) have a job, good health…(and) her
own family in future, and that everything will be well.”
Peng shared the deep hopes she had for the success and wellbeing of her two
daughters. She stated:
“I hope they will have accomplished careers and lead healthy and peaceful lives. I’ll
bear any difficulty if it means making sure they are safe and well.”

“As for my youngest daughter, I too hope that she may prosper in life.”
Ong hoped that his elderly wife would live in comfort and good health after he dies.
He shared:
“I hope she stays healthy and (is) able to move around on her own. I hope the helper
can do her chores, like mopping the floor, so she doesn’t have to work hard.”
Ong also had hopes for his entire family to be happy. He stated:
“I hope my family stays together safe and sound.”
“I want the most for them to be blissful, and without worries.”
In summary, patients made it a point to express their love, and they did so in various
ways that could be verbal or non-verbal. Although some patients expressed love to their
family members directly during the interview, it was common for patients to also express
love indirectly through their well wishes for their family, and through their desire to spend
quality time with their family.
Theme 1.3: Expressions of gratitude (n=4). Expressions of gratitude is a theme that
encompasses patients’ sharing of their gratitude to their family. Gratitude refers to “a sense
that one ought to make a positive response to an act of kindness” (McConnell, 2013).
Although patients’ expressions of gratitude may seem closely related to their expressions of

love, gratitude can exist without feelings of love as McConnell explained in various
scenarios. Thus, it necessitated allocating gratitude a theme of its own.
Patients in this study showed gratitude by acknowledging and detailing how they
appreciated the manifold acts of love and kindness their family members showed them.
Often, they directly said “thank you” to those family members present. Min and Peng recalled
the various things their family caregivers did for them in their sickness. Min described the
tremendous amount of effort and time her niece put in to care for her, highlighting how her
niece’s efforts were instrumental and indispensable in lightening Min’s burdens:
“[To caregiver] Thank you, for taking care of me. [To interviewer] In my sickness,
my niece has really looked after me, helping me take care of my mother and my puppy. It’s a
lot of work. When I was hospitalised, she had to visit me, then rush home to walk the dog. On
weekends, she would get her friend to take my mother to visit me at the hospital. Honestly, if
she weren’t around, I really don’t know how I would cope.”
Min also expressed gratitude for her sisters’ care for her, in both effort and financial
support:
“I want to tell my sisters that it has been a joy being their sister for all these decades. I
am so grateful for how much they have taken care of me…they invested both effort
and money, and I really have to thank them.”
“I really have to thank my sisters for looking after me. I have been so lucky to have
them, I really have.”

Like Min, Peng also mentioned the specific acts of love and kindness her eldest
daughter, who is also her caregiver, showed her. She additionally expressed appreciation for
how much her daughter understands her, so much so that Peng feels exceptionally cared for:
“I am definitely grateful to my daughter for taking such good care of me…She would
always accompany me to the doctor…we would spend practically the entire day there.
At mealtimes, she would ask if I was hungry. She would buy food for me; she knows
what I like to eat and what I don’t.”
Peng also mentioned how her youngest daughter would go the extra mile for her,
despite having her own demanding responsibilities as a mother of two children in
kindergarten:
“I’m very grateful to my youngest daughter too. Even though she has a family to look
after, if my eldest daughter is busy and asks for her help to take me to the doctor, she
would do it. If she was unable to, she would get her husband to take me. She has a
family with two children who are still very little, so it’s understandable (that she must
be busy), right?”
Ong and Ivan expressed gratitude to their family for past events, going back to times
before their illness. Ong thanked his wife for having been his long-time companion, and his
children for being filial to him:
“(I would like to thank my wife for) being by my side all these years.”

“I want to thank my children for coming to visit us often…(and for) giving us a
monthly allowance…when they come by, they would also bring food for us.”
Ivan specifically acknowledged his wife’s efforts in bringing their children up, and his
children’s obedience and respect for him. He shared the following:
“I really want to thanks my wife for bring up the two children…I want to thanks my
two children [for] listen to what I say.
“I want to thank my wife [for] take care of the family so well.”
When love and affection had been shown from a family member to a patient, it was
common for the patient to desire to acknowledge and reciprocate appreciation for their loved
ones’ care.
In conclusion, patients undertook the psycho-familial task of conveying sentimental
messages which served different purposes, whether it was to ask for forgiveness, or express
their love and gratitude at the end of life.
Category II: Arrangements and Instructions for the Family
This category contains the specific instructions or completed tasks that patients wish
to inform their family members about, so as to ensure that appropriate arrangements are in
place when they reach the end of life and are unable to communicate. There are three
subsumed themes in this category. The first theme is ensuring continued familial-care. The
second theme is advice for family, while the last theme is ensuring family’s understanding in
treatment goals.

Theme 2.1: Ensuring continued familial-care (n=4). Patients were keen to make
arrangements to make sure their family members were looked after upon patients’ death.
These arrangements were made either through delegating caregiving tasks to other family
members, or by patients’ own undertaking of familial-care tasks.
Firstly, patients believed it necessary to hand over their existing care for a loved one
to another trusted person, or to simply be certain that their loved one will always be cared for
in their absence. Ivan had founded and operated two businesses with his wife for a few
decades prior to falling ill. As such, the couple’s lives were intertwined with each other’s,
both at work and at home. He believed that in his absence, there was a need for his children
to take his place in his care for his wife:
“I also want my two children to take care of my wife when I not around.”
Ong was specifically concerned that his elderly wife would face difficulties in living
alone after his death. He explained how he instructed his children to ensure his wife received
help in her daily living:
“What I worry now for her, is how she may be unable to manage when I’m gone. I
told my children to hire a helper, so that when I’m gone, she will take care of my
wife.”
Min had looked after her mother for decades in her mother’s sickness and old age.
She repeatedly expressed profound hopes for her family to continue looking after her mother
after she dies:

“I just hope they [patient’s family] take good care of my mother, if I go before she
does…In the past, they never looked after her; I shouldered all the responsibilities.”
“When I’m not around, I hope they can look after my mother well…even though my
mother is very stubborn…she still has to be taken care of.” [cries]
These instructions are messages of patients’ acknowledgement that their death will
change the status quo, and their belief that the baton of caring for their loved ones must be
passed on. Being certain that someone will take over this task that once was theirs eases their
worries. This suggests how plans borne out of familial love can benefit patients themselves
too.
Secondly, patients sought to undertake care tasks for their family in culturally-specific
ways. In the case of Peng, she had made arrangements for her own funeral urn after her first
diagnosis of cancer. In the considerations of purchasing her columbarium niche, she made
comprehensive arrangements to ensure the convenience and comfort of her family in events
when they would visit the niche. She ensured the columbarium was convenient to travel to
especially in the crowded season of the traditional Qing Ming Festival, unique to the Chinese
culture, when Singaporean Chinese families would pay respects to their deceased loved ones.
Her thoughtfulness and considerable effort to make it convenient for her family to pay
respects to her was a way of ensuring that her care for her family continues after she dies:
“(I bought the niche so that) when the time comes, there will be no trouble (for my
family). I picked the (nearby) location so that they will only travel a short distance. It
would be troublesome to go to (another columbarium)…”

Another way that terminally ill patients hoped to care for their loved ones after their
death is through giving them personal possessions that they hope will be valuable or useful
for the new owners. As Keeley et al. (2014) had described, giving gifts to loved ones is a
common non-verbal expression of love. Peng set about this task of showing love in advance
by regularly seeking her daughter’s opinion on who she should give her possessions to. She
hoped to settle these arrangements as soon as she could:
Daughter: “For the past few months, she has been asking me, “Who should I give this
to? What about that?”
Peng: “It’s alright to get these matters settled now. It’s better this way.”
Terminally ill patients in Singapore often make arrangements in advance as they
know they do not have much time left. These arrangements for familial care go beyond
delegating care for their partners and parents to other family members; patients also take
effort to ease the burdens of their family or add value to their family’s lives after they die.
Theme 2.2: Advice for family (n=4). In the interviews, patients often gave out
advice for family, as illustrated in this theme. Patients’ advice for their family were often in
the form of instructions for future situations their family might find themselves in. These
words of advice also indicated patients’ hopes for their family to live well. However, they
were significantly more specific. For example, patients would express their advice in the
context of family members’ current occupations, or other situations they knew their family
members would likely face in future. Ivan addressed his advice to his wife, saying:
“I would love to give advices to my wife that she must be humble and caring toward
other people.”

Min hoped for her niece, who is also her caregiver, to learn to regulate her temper,
manage her finances wisely, and be filial to her parents. She shared:
“When you have a family…you can’t throw tempers as you wish. You need to
compromise…(Also) I hope that you don’t spend your money carelessly on
clothes…You have to save once you start a family…(And) be filial to your parents.”
Min continued to share her advice for another niece whom she used to look after,
saying:
“I hope she doesn’t busy herself too much at the church…and manages her time
well…(I hope she) learns to tidy up her own room, so that her future home will be
organised too.”
“(She should also) learn how to cook a bit…so that she can cook for her family.”
Lastly, Min had some words of advice for her nephew. She said:
“I hope he finds a girlfriend who truly loves him, and marries her. (I hope he) doesn’t
choose his partner carelessly. He’s still young, and I told him that he should keep his
relationships with girls platonic for now.”
Peng shared her expectations and advice for her youngest daughter, saying:

“I hope that she takes good care of her two daughters. It’s important she gives them a
good education. The older child will soon be enrolling in Primary One.”
Peng also shared some words of caution for her family against dabbling in vices. She
stated:
“I hope they may do their best in life, and not mix around with bad company. It’s best
they don’t gamble, or engage in such vices…these vices can bring out the worst in
people.”
Peng then had specific instructions for her family in times of difficulty. She said:
“I think I would tell them [clicks tongue] not to be hasty, and to take things slowly.
When facing unfortunate circumstances, one should not focus on their frustration, and
should instead strive to solve the issue gradually…reflect on what can and cannot be
done, and never break the law.”
Ong had described spending significantly more time with his youngest grandson
compared to his other grandchildren. He had simple advice for this grandchild who was still
schooling:
“I just hope he studies hard.”
Patients also commonly expressed significant fears that in the event of their death, their
families may fail to keep in contact with each other, and thus gave clear advice to their family

that they must keep in contact. Ong made it a point to repeatedly relay these words of advice
to his children:
“I’ve told them many times, ‘You siblings have to gather often, stay in close touch,
and take care of one another. That way, I will feel at ease.’”
Peng shared how it was a significant concern to her that her family remained in
contact after she dies. She shared that the family must not disperse as she viewed family
connectedness as essential:
“When I’m gone, I hope they will all remain in harmony. They shouldn’t forsake
contact with each other just because I'm gone…it is one of my fears to imagine my
family becoming detached.”
Patients in this study had a clear idea of how important it was for their families to stay
connected and harmonious after they die. They also gave advice to their family in hopes that
these words will contribute to their families’ future wellbeing.
Theme 2.3: Ensuring family’s understanding in treatment goals (n=2). This
theme depicts how patients share their preferences on treatment goals with their family. It is
evident that patients found it essential to inform their family members on decisions they had
made regarding their treatment, because their family members often took part in making and
implementing these decisions. This result is in line with the aforementioned studies’ findings
on the importance of the family unit in Asian individuals’ process of end-of-life decision-
making (Chan, 2004; Kwak & Haley, 2005; Hancock et al., 2007). For example, Ong shared
that he made it clear to his children of his wish to die without any form of resistive effort:

“I’ve already told my son clearly…if an issue occurs, such as my
illness worsening, don’t worry. Let me die naturally.”
Peng was aware of her impending death, but made sure to inform her daughter that
she wished to take any last resort and let the doctor treat her the best he can, even if treatment
was unlikely to succeed:
“I always tell my daughter, ‘Let the doctor treat me, and do whatever he deems
appropriate. Let him try anything, even if it’s unlikely that I get better.’”
To terminally ill patients, ensuring that their family was on the same page as them in
their medical care preferences was an important concern.
In conclusion, patients undertook the psycho-familial task of making arrangements
and giving instructions to their family. This task, as illustrated in Category II, was taken on to
ensure their family’s wellbeing in future, be it through specific plans made by patients, or the
words of advice that patients gave their families. Words of instruction also enabled patients to
pursue treatment goals that were in line with their preferences.
Discussion and Implications
In the healthcare landscape of Singapore, Advance Care Planning has been a relatively new
policy that has had little returns despite the hefty amounts invested into its development and
implementation. It is worrying that in less than a decade, Singapore will become a super-aged
population, resulting in the population’s end-of-life needs becoming even more pressing and
demanding on resources than they already are. It is thus an exigent need to review and rethink the
ACP model to discover where its limitations are, and how it has fallen short in answering to the

needs of the current ageing generation and future generations. By understanding patients’ priorities,
intentions, and methods in planning their end-of-life journey, we can better understand what their
needs and desires are. With this knowledge, we are then equipped to check if the current ACP truly
fulfills those needs and wants, and enables the patient, through methods they accept or are
accustomed to, in planning and making decisions at the end-of-life. Only through this process of
matching the needs of the people to the results ACP can achieve, will ACP truly aid Singaporeans in
achieving a good death.
This study has thus contributed to the knowledge gap by elucidating some of the psycho-
familial tasks that older Chinese terminally ill Singaporeans pursue, and the intended goals they wish
to achieve through them. The findings appear to show that in end-of life planning and decision-
making, patients may prioritise the needs of their family over their own personal needs. For example,
the task of purchasing a final resting place is often perceived as driven by personal psychological
needs and preferences (Casal, Aragonés & Moser, 2010); however, it was shown in this study that
patients may instead pay more attention to ensuring their family can visit their remains with ease.
However, it would be incorrect to completely separate personal and familial needs entirely as these
needs are often integrated with each other. This has been evidenced in the current findings and in
studies on Asian cultures (Chan, 2004).
Of the psycho-familial tasks shown in the findings, it is evident that one of the priorities of
patients is to communicate important messages of sentiment to their family. Successfully expressing
such messages of sentiment is a fundamental stepping stone to achieving reconciliation and
establishing love between patients and family members (Keeley, 2007). These messages must thus be
expressed to allow the patient to achieve good psychological and emotional health at the end of life.
In end-of-life planning, care decisions go beyond purely medical ones. The ACP is in part
meant to facilitate discussions among the patient, their family, and healthcare providers in achieving
good end-of-life care for the patient — consequently, since the psychological health of patients is one

of the mainstays in achieving good end-of-life care, the emotional needs of patients must also be
attended to. The ACP should thus incorporate a platform for patients to express messages of
sentiment.
In an Asian culture, many might be uncomfortable to start such sentimental conversations on
their own (Chan et al., 2012; Ho et al., 2017). Hence, it is a must to fulfill some basic requirements
needed for successful emotional disclosure between families and patients. ACP facilitators must be
equipped in both verbal and non-verbal interpersonal skills so as to build trust and genuine
connection in their facilitator-client relationships. These interpersonal skills should be tailored to the
Asian context. For example, a culturally-sensitive ACP facilitator would refrain from being too open
and direct in his or her discussion with the patient and the family. He or she would also pay attention
to the hierarchy in the family, so as to show respect to the senior family members and thus build the
foundational rapport that brings about meaningful emotional disclosure (Yeo, 1993). Only then can
ACP facilitation make a real impact in being the invested stakeholder that empowers patients and
their families to meaningfully engage in these significant conversations.
Another one of patients’ priorities is in regard to ensuring that their families live well after
they die. Most of the urgent instructions that patients in this study gave to their families were
intended to benefit their families themselves. Given the existing literature on how the family unit is
one of the central components in an Asian patient’s life, this finding does not come as a surprise.
Conversely, the ACP has retained the primarily individualistic approach of the American Respecting
Choices ACP framework, which is unfortunately a lesser fit for the collectivistic and family-oriented
Singaporean Chinese culture. Thus, it is essential to change the approach of implementing ACP for
the older population; the Singaporean version should focus on the family-oriented patient’s
perspective. This includes incorporating culturally-specific traditions and practices of the Chinese
Singaporean community, which often involve familial processes and relationships, into the

delineated topics that are discussed in the ACP. For example, it was shown that the delegation of care
of one family member to another member was a notable concern for patients nearing the end of life.
Patients also made sure that their end-of-life care goals were clearly explained, and agreed to,
by their families. ACP facilitators must thus always have comprehensive background knowledge on
this collectivistic culture of Asians, and understand how it places strong emphasis on familial values.
This knowledge will guide the ACP discussion in the direction that patients and families desire and
require to complete a meaningful ACP. A meaningful ACP profoundly support patients’ and their
families’ journeys in achieving the patient’s good death, which is the topmost concern of the ACP.
Limitations and Recommendations for Future Research
Generalisability
Small number of participants. In analysing the data of only four patients, strict
limits are placed on the thoughts, feelings and behaviours related to end-of-life psycho-
familial tasks that can be analysed. Thus, to gain a more accurate understanding of the end-
of-life psycho-familial tasks of the Singapore population, studies with much larger numbers
of participants must be pursued.
Applicability to younger age groups. The findings are mostly applicable to the older
Singaporean Chinese population, and may have limited generalisability to other generations.
This is due to the close proximity of the older generation to the first immigrants from China,
leading to their life values being strongly influenced by Confucianist teachings descended
from China that focused on familial values (Li, 2014; Tan, 1989), and the Singapore
government’s widespread attempts to inculcate collectivistic Confucian teachings in the
seventies, when it was thought that Singapore was becoming too individualistic (Nichol &
Sim, 2007). However, today, Singapore’s young population are drastically different; they
have ready access to omnipresent Western culture predominantly through mass media and
predominantly the Internet. 93% of Singaporeans are online an average of seven hours and

nine minutes every day (Singapore Business Review, 2018), with children in Singapore at the
age of 12 already using six and a half hours of the Internet every day (Yang, 2017). As
precipitated by the high volume of exposure to Western culture in the young and tech-savvy
population, there may be a mindset shift away from traditional Confucian values to
individualistic Western values. Thus, the family-oriented ACP framework may have to
undergo changes to serve the needs of the now-young population when they near the end of
life in future.
Applicability to other cultures in Singapore. In this case, the perspective of the
Chinese Singaporean terminally ill patient is taken. However, given that psycho-familial
tasks are influenced by cultural norms and values, it certainly warrants studies into persons of
other cultural backgrounds, and their end-of-life psycho-familial tasks. In the multi-cultural
landscape of Singapore, the Chinese, Malay and Indian ethnicities make up the bulk of the
population; ACP discussions and resources must be customised to be relevant to the psycho-
familial tasks related to each ethnic groups’ cultural values, norms and practices. Only then
can ACP adequately equip each ethnic group with the tools they need to prepare for their
good death.
Conclusion
The mismatch between the currently individual-centric ACP policy and the
contrasting demand for a family-centric model is a costly issue in terms of government
expenditure and the wellbeing of an ageing nation. Only by studying and aligning the needs
and cultural beliefs of ACP’s target audience, will Singapore be able to witness the returns of
their investment into ACP development. Society is morally responsible for addressing its
citizens’ needs; especially when it is a need that is present in all cultures, has lasted
throughout history, and reaches the depths of the human psyche. To empower Singaporeans
in achieving a good death would be an astounding achievement of deep purpose.

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