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Lasting Power of Attorney
Lasting Power of Attorney
A Lasting Power of Attorney ( LPA ) refers to a legal document, signed by a person who is at least 21 years old, to voluntarily appoint 1 or more persons to act and make decisions on his behalf as his proxy decision maker if he should lose mental capacity one day. The person initiating the LPA is called the 'donor', since he 'donates' his legal right for decision making to the other person(s). The proxy decision maker is called a 'donee'. There are 2 main areas of decision-making which are covered by the LPA - personal welfare, as well as property & affairs matters.
Why should I make an LPA?
An LPA is an important pre-planning tool which allows you to protect your interests by indicating your preferred choice of a proxy decision maker(s). With the LPA, you can choose someone trustworthy, dependable and competent to make decisions on your behalf should you be unable to do so when you lose mental capacity.
By planning ahead, it alleviates the stress and difficulties faced by your loved ones if you should lose mental capacity.
A separate, but equally important, pre-planning tool to consider is the Advanced Medical Directive. You can find out more about the AMD here.
How do I make an LPA?
Before making the LPA, you may wish to have a look at the website of the Office of the Public Guardian. The website provides write-ups and even instructional videos on making the LPA.
There are several steps to making the LPA. These are summarised as follows:
1) Decide which LPA form applies to you. Most people will use LPA Form 1, which is the standard form. Form 2 is for those who prefer to customise the powers to be granted to the donee. This will require the services of a lawyer. Complete your part of the the LPA form.
2) See a certificate issuer to complete parts D & E of your LPA form. In our context, this will be the accredited medical doctor. The certificate issuer needs to ascertain that
- You understand the purpose of the LPA and the scope of authority conferred under it.
- There is no fraud or undue pressure on you to create the LPA
- There is nothing else that would prevent the LPA from being created
3) Decide if there are persons you wish to notify. If there are, they will each need to be sent a NOTICE.
4) Book an appointment with the Office of the Public Guardian for submission of documents. For the appointment, you will need to bring:
- Completed LPA Form ( either Form 1 or Form 2 )
- Completed Application Form for LPA.
- Completed Mode of Receipt Form ( this tells the Office whether you wish to receive the registered LPA in person or where it should be mailed to if not ).
- NRIC of donor [original and clear photocopy of front & back of NRIC]
- NRIC of donee(s) [clear photocopy of front & back of NRIC]
- NRIC of replacement donee(s) (if any) [clear photocopy of front & back of NRIC]
5) Pay the application fee. This fee is $50 for Form 1 if you are Singaporean or PR. If you are neither Singaporean nor PR, or if you are using Form 2 instead, the cost is $200. Please note that this fee is paid to the the Office of Public Guardian. Our clinic does not collect the application fee on behalf of OPG. Charges collected by our clinic are only for our role as certificate issuer.
AMD - Advanced Medical Directive
ADVANCED MEDICAL DIRECTIVE
The AMD, or Advanced Medical Directive, is a legal document which a person signs in advance, to inform his or her doctor that:
- in the event of a terminal ( incurable ) illness,
- when the person becomes unconscious and death is deemed to be imminent
- the person does not want any extraordinary life-sustaining treatment to be used merely to prolong life. Extraordinary life-sustaining treatment refers to medical treatments which serves only to prolong the process of dying but does not actually cure the illness. A common example used is the respirator, which is connected to the patient to help him or her to breath, but does not reverse the underlying cause of the patient's coma.
The implication here is that even if all available equipment is used, life will merely be artificially prolonged and death will eventually occur anyway because the patient's condition or illness is terminal ( as certified by 3 different doctors, including at least 2 specialists ). The AMD is only activated when all the 3 conditions are met.
Here are some frequently asked questions ( FAQ ):
1) Should I make an AMD?
Making the AMD should be a purely voluntary decision. Nobody should force you to do it ( it is actually a criminal offence to force another person to make the AMD against his will!)
If you have any doubts or queries, you may wish to take a look at the Ministry of Heath ( Singapore ) website. We also welcome you to drop in and speak with our doctor regarding the AMD and decide if this is something which may help in your end-of-life planning.
Not everyone agrees with signing the AMD. Opponents of the scheme argue that patients often change their minds about the level of care they want after being hospitalised and making a pre-decision with the AMD assumes that you can predict your own choices many years ahead, which may not be true. They argue that having your loved ones make the decision only when it is needed, based on their understanding of your thoughts and needs and fears and priorities at that point in time, would more likely reflect what you would have chosen for yourself.
I would like to suggest an alternative way of looking at the AMD. Making the AMD ( or alternatively, consciously deciding NOT to make it ), is primarily to help your family and loved ones avoid the sticky situation of having to decide on your behalf. In other words, you make the decision for yourself now so that should the time come, your loved ones will not have to make it for you. Why? Because it is never easy to make these decisions on behalf on someone else. Think about it - if you don't even trust your present self to make the decision for your future self, why would you trust the future versions of your children or next of kin to make the same decision for you?
The difficulty is compounded if there are many individuals involved in a joint decision making, such as several next-of-kin, or your spouse and your child, or several children together. Can all your loved ones agree on the same plan? Or will one blame and begrudge another for the difficult decision? Will your children be plagued with self doubt years down the road?
2) Should family and/or close friends be informed that you have made the AMD?
For reasons of their own, the persons who sign their own AMD may or may not wish their family to be informed. It is not compulsory to inform your family members that you have signed the AMD.
Here at Prudence Family Clinic, we believe that it can be useful to involve your family or loved ones in the decision, as well as to inform them of your decision when it is made. This will help reduce the probability of misunderstandings occurring between different family members or between medical staff and your family should the time come for the AMD to take effect. Even if, after an open discussion with your loved ones, you decide NOT to go ahead with the AMD, the discussion itself will likely have helped your family make the decision on your behalf in the future, should the need arise.
The final decision, however, lies with you, and we are committed to assist you whether you choose to involve your loved ones or not.
3) What if I change my mind after I have made the AMD. How do I revoke ( cancel ) it?
Here is the link to the MOH ( Singapore ) site for revoking the AMD. Essentially, you can revoke the AMD at any time, in the presence of at least 1 witness. The AMD can be revoked by:
- completing Form 3 ( which would have been sent to you after your AMD is registered with the Registry of AMDs )
- writing a simple Revocation Letter addressed to the Registrar of AMD ( Our clinic can assist in this, if you are unable to find a copy of your Form 3 )
- orally ( or in any other reasonable manner of communication ) to the witness(es)
In the 3rd scenario, the witness should then complete Form 3 or write a Revocation Letter to the Registrar of AMD. In addition, the witness should explain why the person revoking the AMD is unable to do so himself/herself. These should be sent to the Registry as soon as possible.
The completed Form 3 or Revocation Letter can be sent to:
The Registry of Advance Medical Directives
Ministry of Health, Singapore
College of Medicine Building,
16 College Road,
Singapore 169854
Tel: 63259136 Fax: 63259212
If a Revocation Letter is sent in place of Form 3, it should contain the following information:
- The name and NRIC of both the person revoking the AMD and the witness, along with their addresses and home and office telephone numbers.
- Time, date and place where the revocation was made.
- If the letter is written by the witness, the method of communication which the person used to communicate his intention to revoke the AMD (e.g. orally, sign language, etc)
4) Where do I get the form for making the AMD?
You may download the form from the Ministry of Health ( Singapore ) website - here.
Adult Vaccinations
Apart from travel vaccines, there are also a number of other vaccines which are recommended for use in adults. Note that specific contraindications to vaccination may apply. Always check with your primary care physician before receiving the vaccines mentioned. In general, here's the suggested vaccination schedule for adults.
| Category | Vaccine | Remarks |
|---|---|---|
| Anytime | Cervical cancer Chicken pox | 3 doses required ( at 0, 1-2 months and 6 months ) 2 doses required, 2 months apart |
| 50 years old and above | Zoster | if not previously vaccinated against chicken pox |
| 65 years old and above | Zoster Pneumococcal ( 23-valent ) Influenza | if not previously vaccinated against chicken pox 1 dose is usually sufficient annually |
| Females, before trying for child | Chicken pox ( if not immune ) MMR Hepatitis B | 2 doses required, 2 months apart if not immune if not immune |
| Females, after delivery | Pertussis ( whooping cough ) | 1 dose required - to help reduce risk to newborn |
Caretakers of, or staying with
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Influenza | annually |
Anytime, if you are at high risk for pneumococcal disease such as:
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Pneumococcal ( 23-valent ) Influenza | booster after 5 years if previous dose taken before 65 years old |
Travel Medicine
Nothing ruins the fun of travelling more than falling ill or getting injured and having to look for a doctor in an unfamiliar country. At Prudence Family Clinic, we are happy to provide advice and help you prepare medical essentials, tailored to your needs. So come speak with us before your next holiday. Appointments are just a phone call ( 6251 5512 ) or SMS (9662 5512 ) away. Our travel medicine services include:
- common travel vaccines
1.Influenza
2.Hepatitis A
3.Hepatitis B
4.Typhoid
5.Tetanus
- specialised travel vaccines ( do let us know in advance so we can advise on availability of vaccines )
1.Meningococcal disease ( vaccinate at least 10 days before travelling )
2.Japanese encephalitis ( Live vaccine, single dose )
3.Rabies ( 3 doses, on Days 0, 7, 21-28 )
- malaria prevention
- traveller's diarrhoea ( treatment and preventive medications are available )
- mountain sickness / altitude sickness
- travel medicines, customised to your needs and concerns.
- jetlag
Health Screening Packages
Essential $98
Full blood count
ESR ( inflammation marker )
* Highly sensitive CRP
Diabetes screen ( fasting required from midnight )
Cholesterol panel ( fasting required from midnight )
Kidney screen
Urinary protein screening
Liver panel
Uric acid
* Calcium & Phosphate levels
Urine microscopy ( No culture )
Essential Plus $138
Full blood count
* Blood group & typing
ESR ( inflammation marker )
Diabetes screen ( fasting required )
Cholesterol panel ( fasting required )
Kidney screen
Urinary protein screening
* Bicarbonate ( acid-base balance )
* Thyroid panel ( free T4 / TSH )
Liver panel
* Hepatitis A & B screen
Uric Acid
Urine microscopy
* Urine culture ( if microscopy is suspicious for infection )
Standard $228
Full blood count
Blood group & typing
ESR ( inflammation marker )
* Highly-sensitive CRP
Diabetes screen ( fasting required )
Cholesterol panel ( fasting required )
Kidney screen
Urinary protein screening
Bicarbonate ( acid-base balance )
Thyroid panel
Liver panel
* Hepatitis A, B and C markers
Uric acid
* Calcium & Phosphate levels
* Rheumatoid factor
* Syphilis ( VDRL )
* HIV
* Cancer markers ( AFP, CEA, PSA/Ca125, Ca 19.9 )
Urine microscopy
Urine culture ( if microscopy is suspicious for infection )
* Stool occult blood
Comprehensive Male $328
Full blood count
Blood group & typing
* Reticulocytes
ESR ( inflammation marker )
Highly-sensitive CRP
* Iron studies
Diabetes screen ( fasting required )
Cholesterol panel ( fasting required )
Kidney screen
Urinary protein screening
Liver panel
* Thyroid panel ( incl T3 )
* Total testosterone
Uric Acid
Calcium & Phosphate levels
Rheumatoid factor
Syphilis ( VDRL )
HIV serology
Hepatitis A, B and C markers
Cancer markers ( AFP, CEA, PSA, Ca19.9 )
* Helicobacter pylori serology
Urine microscopy
Urine culture ( if microscopy is suspicious for infection )
Stool occult blood
Comprehensive Female $ 338
Full blood count
Blood group & typing
* Reticulocytes
ESR ( inflammation marker )
Highly-sensitive CRP
* Iron studies
Diabetes screen ( fasting required )
Cholesterol panel ( fasting required )
Kidney screen incl Urine ACR
Liver panel
* Thyroid panel ( incl T3 )
Uric Acid
Calcium & Phosphate levels
Rheumatoid factor
Syphilis ( VDRL )
HIV serology
Hepatitis A, B and C markers
Cancer markers ( AFP, CEA, Ca125, Ca19.9 )
* Helicobacter pylori serology
Urine microscopy
Urine Culture ( if microscopy is suspicious for infection )
Stool occult blood
* Pap Smear using Thin Prep ( avoid doing test during the menstrual period )
All package prices include 1 review of test results.
Add-on tests ( prices quoted are only for patients taking above packages )
| No. | Test | Package Price ($) |
|---|---|---|
| 1 | ECG | 25 |
| 2 | CXR | 25 |
| 3 | Pap Smear ( conventional ) Pap Smear ( liquid based / Thin Prep ) | 2045 |
| 4 | Tumour-related Markers
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65 45 30 30 30 30 30 30 30 |
| 5 | Infections
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20 20 20 20 20 |
| 6 | Hormones
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20 20 30 30 |
| 7 | Uric acid ( UA ) | 10 |
| 8 | HbA1c ( HBA ) | 20 |
| 9 | CK | 10 |
| 10 | HsCRP ( CRP ) | 25 |
| 11 | Iron studies ( Fe/TIBC ) | 30 |
| 12 | Blood Group/Typing | 10 |
| 13 | Calcium/Phosphate | 20 |
| 14 | Fertility screen ( male ) - FS02 + SA
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183 |
| 15 | Fertility screen ( female ) - FS01 + QTP2
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183 |
| Our Health screening packages can be tailored to your needs and concerns. If you are interested in a test which is not included in your package of choice, do let us know so we can add it in or advise you accordingly. | ||
STD Treatment
Many STDs / STIs are curable. Even those which are not, such as HIV and genital herpes, have treatments which control or suppress the infection.
At Prudence Family Clinic, STD consultations and treatments are conducted privately and in confidence. Our philosophy is timely screening and cost-effective treatments when warranted. Contact tracing, screening, treatments and counselling can also be provided in a sensitive and thoughtful manner.
A wide range of treatments are available for the following infections:
- Gonorrhoea
- Chlamydia
- Non-specific urethritis ( NSU ), which may include Mycoplasma hominis and Ureaplasma urealyticum
- Syphilis
- Trichomonas
- Candidiasis
- Bacterial vaginosis
- Herpes simplex type 1 ( cold sores )
- Genital Herpes
- Genital warts ( 'cauliflower' )
- Molluscum contagiosum
- Pubic lice ( 'crabs' )
It is important to mention your drug allergies and any history of previous ( successful or unsuccessful ) treatments to our doctor. Patients who are HIV positive may require prolonged or more intensive treatments for their other STDs. Do highlight your HIV status to our doctor. Rest assured that all information conveyed to us will be held in strictest confidence.
Of course, it may not be possible to know immediately which infection you may have caught. The links below may give you an idea of what we are dealing with:
- STD symptoms
- HIV symptoms
STD Tests / Screening
As explained earlier, almost all STDs have a risk of causing infection without displaying any symptoms, even for many months.
Yet a patient with asymptomatic infection can still be passing it on to his sexual partners.
If you or your partner has recently or previously been at risk, it may be helpful to consider some of the following tests:
( Please note that consultation charges are separate from the test prices. We do not charge GST ).
| PACKAGE | Tests included | Price ( S$ ) | Remarks | |
|---|---|---|---|---|
| Basic STI |
|
108 | Blood tests;no fasting necessary | |
| Standard STI |
|
168 | Blood tests;no fasting necessary | |
| Urethritis ( Men ) |
|
280 | Urine tests;please hold urine for 4 hours | |
| Urethritis & Vaginitis ( Women ) |
|
360 | Urine and swab tests - please avoid testing when having menses. | |
| Full screen Men |
|
|
390 | Blood + Urine required;Please hold urine for 4h;No fasting necessary |
| Full screen Women |
|
|
430 | Blood + Urine + Swabs required;Please hold urine for 4h;No fasting necessary; Pls avoid testing when having menses. |
Individual tests are also available. The more popular ones include:
- Gonorrhoea & chlamydia PCR ( urine test - please hold urine for 4 hours )
- Herpes simplex serology ( blood tests )
- Herpes simplex PCR ( swab )
- Syphilis serology and titres
- Rapid HIV antibody tests using either fingerprick blood, or saliva
- Rapid HIV P24 antigen/antibody test using fingerprick blood
- HIV ELISA test ( blood test )
- HIV DNA PCR ( blood test - to be done on weekdays, before 11am. No fasting required. )
- HIV RNA PCR ( blood test - to be done on weekdays, before 11am. No fasting required. )
More details on HIV testing can be found here.
Rapid screening tests which give results in 20min are now available for: syphilis and HIV
HPV DNA testing ( eg. Digene ) is also available. However, do note that the high-risk strains which are screened for in these tests are the cancer-causing subtypes, not specifically those which cause genital warts.
STD Prevention
STDs, including HIV, can be prevented. The Ministry of Health (Singapore) recommends the ABCD approach. This refers to
- Abstinence,
- Be faithful,
- consistent use of Condom and
- early Detection.
Because STDs may be asymptomatic, early detection often depends on doing early screening tests. For patients who consistently engage in high risk sexual behaviour, it may be advisable to go for regular screening tests for HIV and other STDs.
We would like to propose some additional strategies. These include:-
Vaccination
Vaccines are available against Hepatitis A, Hepatitis B and Human Papillomavirus ( HPV ). HPV is the virus which may cause cervical cancer ( women ), anal cancer and genital warts. Use of Medisave may be allowed for Hepatitis B and HPV vaccines ( please check with our staff for eligibility )
Post-exposure prophylaxis
Post-exposure prophylaxis ( PEP ) refers to treatment with oral medications or injections after potentially being exposed to the virus. In the context of STDs, PEP is available for HIV in the form of ( oral ) pills and for Hepatitis B in the form of injections. For Hepatitis B post-exposure prophylaxis, depending on circumstances of the exposure, Hepatitis B vaccine, with or without Hepatitis B Immunoglobulin, may be necessary. You can read more about it from the US CDC website.
Post-exposure prophylaxis is actually also available for some non-STD infections, likeVaricella ( chicken pox ) and rabies. With the exception of rabies and Hepatitis B Immunoglobulin, the above-mentioned PEP are all available in our clinic.
Suppression
Treatment of viral infections with anti-virals or antibiotics may not be able to 'cure' the infection totally. This happens when a certain amount of the virus remains in the body, often 'hidden' in the nerve or liver cells or elsewhere, despite a full course of anti-viral medication. Famously, viruses like HIV, Hepatitis B, Hepatitis C and herpes viruses ( eg. HSV ) cannot be cured. Nonetheless, anti-virals may still be given for suppression of the infection.
Suppression of infection aims to reduce the viral load as much as possible, even if a true cure cannot be achieved. Intuitively, that may sound like a waste of time and money but the advantages of viral suppression include:
- Reducing, delaying or even preventing the onset of complications resulting from the infection. In the case of HIV, this means buying crucial time for your immune system. In the case of Hepatitis B or C, this means potentially saving your liver or delaying or preventing liver cancer.
- Reducing the severity and duration of symptoms.
- Minimizing the risk of spread to your close contacts and sexual partners. In most infections, the viral load ( concentration of virus in the blood ) corresponds directly with the risk of passing the infection on. Lowering the viral load thus helps to reduce the chance of passing it on.
STD Symptoms
Common symptoms which are caused by STDs may include:
For men
-discharge from the penis / urethra / anus
- pain when passing urine
- blisters or sores on the penis / pubic region / anus
- rash on the penis / pubic region
- itch or pain in the urethra
- aching, pain or swelling in the testicles
- blood in the semen / ejaculate
- growths or lumps around the penis / anus
- swellings at the groin
For women
- discharge from the vagina / urethra / anus.
- pain when passing urine
- blisters or sores on the vagina / pubic region / anus
- rash on the vagina / pubic region
- itch or pain in the urethra or vagina
- pain during sex
- bleeding during sex
- growths or lumps around the genitalia / anus
- swellings at the groin
Occasionally, symptoms which are non-specific, such as fever, tiredness, bodyaches, rash over the body, including the palms and soles or neck swellings, may be present. These symptoms may happen 1 or several weeks after the sexual encounter.
However, we believe the most important message on this issue is that most STDs can be totally asymptomatic or symptom-less for a long period of time. STDs can be passed on to sexual partners even when they are not causing any symptoms. The consequences of sexually transmissible infections can include cancer, problems with fertility, prostate irritation and inflammation ( in men ), pelvic inflammatory disease ( in women ) and damage to other organs such as the liver, kidney, heart, spinal cord and brain.
This is why preventive strategies and going through screening tests ( with timely treatment of any infection detected ) are crucial in protecting your loved ones from infection.
