Objectives: Healthcare delivery in Singapore is currently fragmented with over-emphasis on expensive episodic hospital care. Most family physicians can be better equipped to deliver chronic disease management (CDM). The distribution of CDM between family physicians in the public and private sectors is disproportionate. We believe that the Patient-Centered Medical Home (PCMH) model of care which emphasizes integrated care will a) lead to improved patient outcomes, reduced cost and greater efficiency; b) increase the engagement of private family physicians for CDM. Methodology: In this paper, we describe the implementation and initial experience of the Frontier Family Medicine Clinic (a public-private partnership to pilot the PCMH model) and its potential to address the care gaps in our healthcare system. The PCMH model involves population management of 1000 patients, including 100 high-risk patients for complex case management. Results: Implementation required intensive engagement of multiple stakeholders, including educating both family physicians and hospital leadership on the value of this approach. With

With increasing emphasis on patient autonomy, patients are encouraged to be more involved in end-of-life issues, including the use of extraordinary efforts to prolong their lives. Being able to make anticipatory decisions is seen to promote autonomy, empower patients and optimise patient care. To facilitate shared decision-making, patients need to have a clear and accurate understanding of cardiopulmonary resuscitation (CPR). This study aims to understand the knowledge and perspectives of the local community regarding resuscitation options and end-of-life decision-making and to explore ways to improve the quality of end-of-life discussions. An interviewer-administered survey was conducted with a prospectively recruited group of surgical patients admitted postoperatively to the day surgery ward of a single tertiary institution in Singapore from April to May 2015. The survey, modelled after two validated questionnaires, measured patients' knowledge, attitudes and preferences regarding CPR in a series of 18 questions. Fifty-one out of 67 (76.1%) patients completed the survey. Results indicated that 80.4% (n=41) of participants correctly understood the purpose of CPR, but 64.7% (n=33) did not know of any possible complications of CPR. Less than half (n=21, 41.2%) of participants had thought about life support measures they wanted for themselves. Most of the participants agreed that they should personally be involved in making end-of-life decisions (n=44, 86.3%). Many patients had a poor knowledge of CPR and other resuscitation measures and the majority overestimated the success rate of CPR. However, a majority were receptive to improving their knowledge and keen to discuss end-of-life issues with physicians.

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Dear Editor,Organ transplantation is the treatment of choice for end-stage organ failure. However, there still exists a great imbalance between organ demand and organ availability worldwide, limiting the application of organ transplantation. 1 The Human Organ Transplant Act (HOTA) was enacted in Singapore in 1987, with amendments made in 2004 and 2008 to expand the organ donor pool. Currently, HOTA includes donation of kidneys, liver, heart and corneas after certification of brain death. It remains an opt-out scheme in which all Singapore citizens and permanent residents aged 21 years old and above, who are not mentally disordered, are presumed to consent for organ donation. 2,3 For a patient who is eligible, the process briefly starts with the certification of brain death by 2 independent specialists, activation of the transplant coordinator, followed by assessment of suitability of organs, and if suitable, proceeding to organ retrieval. This is coordinated by a trained brain death coordinator.Despite legislative amendments, the rate of organ donation in Singapore has remained low at 6.6 to 8.9 organ donors per million population (pmp) (unpublished data from the National Organ Transplant Unit, Ministry of Health, Singapore), in contrast to other developed countries such as the United States, Spain and the United Kingdom. [4][5][6] Healthcare workers caring for potential brain-dead donors face highly stressful circumstances. A perceived "ethical dilemma" between the physician's primary responsibility of acting in the patient's best interests and supporting the social objectives of HOTA may make some intensive care unit (ICU) physicians reluctant to actively identify and refer potential donors. 4 Other barriers include unfamiliarity, variability in the conduct of brain death certification, and lack of knowledge about donor identification. 4,7 Good working knowledge and positive attitudes of healthcare workers towards organ donation may result in increased donor actualisation rates, as well as improved holistic care of the donor's family-2 goals that are not mutually exclusive. A survey of medical students in Singapore found that the majority had favourable attitudes towards organ donation, but knowledge on HOTA was inadequate. 8 To date, there is scant literature on the attitudes of ICU healthcare providers in Singapore.