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Retrospective cohort analysis of real-life decisions about end-of-life care preferences in a Southeast Asian country
  1. Woan Shin Tan1,2,3,
  2. Ram Bajpai1,
  3. Andy Hau Yan Ho1,4,5,
  4. Chan Kee Low6,
  5. Josip Car1,7
  1. 1 Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
  2. 2 NTU Institute for Health Technologies, Interdisciplinary Graduate School, Nanyang Technological University, Singapore, Singapore
  3. 3 Health Services and Outcomes Research Department, National Healthcare Group, Singapore, Singapore
  4. 4 Psychology Programme, School of Social Sciences, Nanyang Technological University, Singapore, Singapore
  5. 5 Research Department, Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
  6. 6 Economics Programme, School of Social Sciences, Nanyang Technological University, Singapore, Singapore
  7. 7 Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
  1. Correspondence to Miss Woan Shin Tan; woan_shin_tan{at}


Objective To describe the end-of-life care preferences of individuals, and to examine the influence of age and gender on these preferences.

Design, setting and participants A retrospective cohort study was conducted. Participants included all adults (≥21 years old) (n=3380) who had completed a statement of their preferences as part of a national Advance Care Planning (ACP) programme in Singapore. Data were extracted from the national and Tan Tock Seng Hospital ACP database.

Main measures End-of-life care preferences were obtained from the ACP document and differentiated by health status (healthy, chronically ill or diagnosed with advanced illnesses). To analyse the data, descriptive statistics and logistic regression analysis were used.

Results Across healthy and chronically ill patients, the majority did not opt for cardiopulmonary resuscitation (CPR) or other life-sustaining measures. Among individuals with advanced illnesses, 94% preferred not to attempt CPR but 69% still preferred to receive some form of active medical treatment. Approximately 40% chose to be cared for, and to die at home. Age and sex significantly predict preferences in those with advanced illnesses. Older age (>=75 years) showed higher odds for home as preferred place of care (OR 1.52; 95% CI 1.23 to 1.89) and place of death (OR 1.29; 95% CI 1.03 to 1.61) and lower odds for CPR (OR 0.31; 95% CI 0.18 to 0.54) and full treatment (OR 0.32; 95% CI 0.17 to 0.62). Being female was associated with lower odds for home as preferred place of care (OR 0.69; 95% CI 0.57 to 0.84) and place of death (OR 0.70; 95% CI 0.57 to 0.85) and higher odds for full treatment (OR 2.35; 95% CI 1.18 to 4.68).

Conclusion The majority preferred to not proceed with life-sustaining treatments, but there was still a strong preference to receive some form of limited treatment. Better understanding of end-of-life care preferences through ACP can better guide end-of-life care programme planning, and resource allocation decisions.

  • advance care planning
  • patient preferences
  • place of care
  • place of death
  • cross sectional study

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  • Patient consent for publication Not required.

  • Contributors WST and RB conceived and designed the study, obtained, analysed, interpreted the data, drafted and revised the article. CKL, AHYH and JC conceived the study, participated in the interpretation of results and revised the article. All authors were involved in revising the manuscript critically for important intellectual content and have given final approval of the final version of the manuscript.

  • Funding WST was funded by the Singapore National Medical Research Council Research (grant number: NMRC/Fellowship/0017/2015) and the Singapore National Healthcare Group. This study was funded by Agency for Integrated Care Singapore (grant number: RCA 16-099), which receives public funding from the Ministry of Health of the Singaporean Government.

  • Disclaimer The funder has played no role in the study design, analysis or interpretation of data.

  • Competing interests None declared.

  • Ethics approval Ethics approval was obtained from theinstitutional review boards of Nanyang Technological University (Ref: IRB-2016-03-010) and the National Healthcare Group’s Domain Specific ReviewBoard (Ref: 2016/00739).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Access restrictions apply to the data underlying the findings due to national data protection laws and restrictions imposed by the Ethics Committees to ensure data privacy of thestudy participants. As such they cannot be made freely available in the manuscript, the supplemental files, or a public repository. Request for the data may be sent to the national office for Advance Care Planning at

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