Background Since 2010, within Tan Tock Seng Hospital (TTSH), pilot projects in advance care planning (ACP) were initiated with patients with chronic disease, organ failure and advanced illnesses such as terminal cancer. Aim To evaluate the attitudes and perceptions of trained ACP facilitators in TTSH. Method An anonymous cross-sectional survey in the form of a questionnaire was administered to all certified ACP facilitators in the hospital. Results A total of 59 trained facilitators, comprising nurses (36%), doctors (29%), medical social workers (25%) and case managers (8%) responded to the survey. Majority (95%) of respondents favour ACP and 86% consider ACP as one of their roles. More than 90% respondents felt that ACP promotes patientcentred care, improves communication, and reduces burden of decision making on families. Most of the time (53%), initiation of ACP was by doctors.90% respondents felt that ACP is challenging to conduct. Major barriers to conducting ACP are lack of time (66%), perception of low receptivity to ACP in patients' families (53%), patients' lack of understanding of ACP (50%) as well as language barriers (48%). Discussion While the attitudes of trained facilitators towards ACP are largely positive, there are significant barriers to ACP facilitation, namely a lack of time. Conclusion Whilst it helps to spread advocacy for and practice of ACP in training facilitators from multiple healthcare disciplines, there is also a need for careful consideration of resource allocation such as dedicated ACP facilitators, for successful implementation of ACP.

Background This study evaluated the impact of the adapted version of the Respecting Choices® The Living Matters Advance Care Planning (ACP) facilitator training programme on trainees’ attitudes on facilitation 6 months post-training. Setting and participants Two hundred and twenty-one healthcare professionals consisting of doctors, nurses, medical social workers from different training venues in Singapore participated in the first phase of the study (pre- and post) of which 107 participated in the second phase 6 months later (follow-up). Methods Participants self-rated their attitudes, beliefs and behavioural intentions through surveys at three time points in an evaluation design that utilised repeated measures one-way ANOVA (pre-, post-, follow-up). Between-group differences were also examined using independent t-test. Results At follow-up, mean scores increased significantly in understanding, confidence, and competence. Changes in effect sizes were large. Although trainees continued to think that ACP is emotionally draining for facilitators, more than before, facilitation experience was considered pleasant for themselves with the positive change significant and moderate in effect size. Those who had experience completing/initiating ACP significantly held more positive views than those who did not. Conclusions The ACP facilitator training programme had lasting effects on enhancing the understanding, competence, and confidence of trainees. Importantly, findings showed that experience in actual facilitation within 6 months after training was important and giving trainees opportunities to facilitate is recommended.

is advised and a single-port laparoscopic liver resection using intrahepatic Glissonian approach is proposed. The patient was informed about the advantages and risks of the technique, and she gave consent for its use. A transumbilical incision is performed, and a single-incision platform is introduced. The operation begins with ultrasound examination of the liver. Intrahepatic Glissonian access of the portal pedicle from segments 2 and 3 is performed, and the pedicle is divided with a stapler. The liver is transected, and the left hepatic vein is divided with a stapler. A surgical specimen is retrieved through the single umbilical incision. No drains are left in place. Results: Operative time was 90 minutes and there was minimal bleeding. Recovery was uneventful and patient was discharged on the first postoperative day. Final pathology showed hepatocellular adenoma with no signs of malignancy. Conclusion: Single-port laparoscopic left lateral sectionectomy is feasible and can be safely performed in specialized centers. Intrahepatic approach is a useful tool to control the Glissonian pedicle.

Background Advance care planning (ACP) is a process and people can change their minds about treatment preferences when goals of care change. The ACP project team in Tan Tock Seng Hospital continually audits ACP outcomes including any change in ACP plans. Aim To examine rate of change in ACP plans and factors that may have contributed to changes in ACP plans. Methods ACP outcomes for readmissions and death were analysed from retrospective audit of paper and electronic medical records. Results Between October 2011 to December 2012, a total of 154 Preferred Plan of Care (PPC), a POLST-type ACP were completed with patients and/ or their next-of-kin (NOK). Out of these 154 PPCs, 5 ACP plans were revised. Time lapse between creation of first and second ACP plan ranged from 3 to 91 days. One patient had decision making capacity at first and second ACP documentation, while 4 other patients had no decision making capacity at both ACP documentation. four revisions were initiated by doctors whilst one was initiated by the substitute decision maker. Two ACP plans were changed after further clarifications with NOK whilst three revisions took place when there were changes in the patients' medical condition or after trial of medical intervention. Three of the patients have since passed away. Discussion The number of changed ACP plans is a small fraction of the total completed. Doctors were active in continual exploration of ACP plans. Conclusion In our cohort, ACP plans remain relatively stable. ACP is a dynamic process that need a culture of review and re-exploration of care preferences in order to be responsive to changes in medical condition and care preferences.

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