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With the number of nursing home residents on the rise, it is crucial to ensure that the frail elderly are cared for comfortably, according to their wishes. Changi General Hospital’s EAGLEcare programme, in partnership with nursing homes and general practitioners, has helped to meet these needs – by facilitating discussions on their end-of-life care preferences, and thus reducing unnecessary hospital admissions.
Older people living in nursing homes (NHs) have a high
level of comorbidity and frailty, as well as complex
health needs. Admissions to hospital are associated
with a number of drawbacks including dissatisfaction
with care, rapid functional decline, low survival rates
and suboptimal end-of-life (EOL) care, and should be
avoided if not clinically indicated.
Yet, hospitalisation for NH residents at the end of life
is still prevalent in Singapore. In 2019, NH residents
accounted for 1,751 cases presented at Changi General
Hospital’s (CGH) Accident & Emergency Department,
of which 80% were admitted to inpatient wards.4
Given the rising NH population (77 NHs and 16,300
NH beds as of 2020)5, it is important for NH residents
at the end of life to receive adequate and appropriate
The Enhancing Advance Care Planning, Geriatric Care and End-of-Life Care in the Eastern Region (EAGLEcare) programme was set up in 2015 by CGH to equip and support NHs in advance care planning
(ACP), geriatric and EOL care. It aims to ensure NH
residents at the end of life are cared for comfortably
in their NH according to their preferences, thereby
reducing unnecessary hospital utilisation.
To date, EAGLEcare has partnered with three NHs in
the East, namely Peacehaven Nursing Home, Moral
Home for the Aged Sick and NTUC Health (Chai Chee)
Nursing Home. EAGLEcare has also been actively reaching out to other NHs in the region to explore
collaborations.Figure 1 Framework for the EAGLEcare programme
EAGLEcare’s goals include:
Upskilling of NH staff to provide ACP services
Developing professional capabilities of NH staff in
geriatric and EOL care
Developing a model to deliver EOL care for suitable
Training NH staff to better meet EOL needs
As of March 2022, EAGLEcare has trained 91 NH staff
in ACP / preferred plan of care (PPC) facilitation, and
conducted more than 696 ACP/PPC conversations
for residents among partnering NHs. There has also
been an increasing proportion of ACP/PPCs completed
by NH staff independently as their confidence and
proficiency have increased.
EAGLEcare has also conducted geriatric and EOL
training courses on topics such as safe feeding
and swallowing, poor oral intake and dysphagia
management, as well as EOL care (comprising topics
in advanced diseases, symptom management,
communication and terminal care) to 335 NH staff. These courses were a mixture of face-to-face and blended learning modules, and were converted to
Zoom workshops in 2020/2021 during the COVID-19
Partnering NH staff are empowered and supported
by the EAGLEcare team to implement a system to
proactively identify and enrol residents eligible for
Residents from partnering NHs are enrolled in the
EAGLEcare programme if they meet the following
Are screened eligible based on the EAGLEcare
Screening Assessment Tool,
Have PPC preferences for comfort measures or
limited intervention, and
Consent to be enrolled in the programme
EAGLEcare Screening Assessment Tool
The EAGLEcare Screening Assessment Tool was
adapted from the Gold Standards Framework (GSF)6
and the Supportive and Palliative Care Indicators Tool
(SPICT)7. Click here to view more information on the tool.
ACP is a process of planning for one’s current and
future healthcare8, especially when one becomes
too unwell to communicate or make treatment
It is a voluntary and non-legally binding discussion
about life-sustaining treatments, how one would like to be cared for and where one would like to spend
their last days when seriously ill. Patients can then
receive healthcare that is tailored to their values and
Decision making through ACP discussions
In the EAGLEcare programme, two types of ACPs are
discussed9 – general ACP and PPC.
Primarily for adults with DMC
Family members / other informants who have demonstrated acts of care for patients lacking DMC
Documenting what is
important to live well and
make life meaningful
Discussing the goals of care
if one becomes severely
mentally impaired with a low
chance of recovery
Care options on cardiopulmonary resuscitation (to go
ahead or let nature take its course)
Goals of care for medical intervention when one
suffers a potentially life-threatening crisis, or with
regard to questions such as tube feeding
Preference for place of care (e.g., hospital, hospice or
Preference for place of death (e.g., hospital, hospice,
nursing home or own home)
Appointment of Nominated Healthcare
Spokesperson(s) if necessary
After ACP discussions:
EAGLEcare enrolment and care
After these ACP conversations are carried out,
if residents (and/or their NOK) have expressed
a PPC preference for comfort care or a trial of
limited interventions (i.e., not for cardiopulmonary
resuscitation or intensive care), and consent to being
cared for in the NH by the EAGLEcare team, they are
enrolled in the EAGLEcare programme.
Here, they are looked after by their regular NH general
practitioners (GPs) and a core EAGLEcare team during
the day, as well as an on-call palliative team from St.
Andrew’s Community Hospital (the Violet Programme)
As of March 2022, the NHs, supported by the
EAGLEcare team, have screened 1,095 residents. Of
this group, 508 residents were identified as eligible
for EOL care and 426 unique residents were enrolled
(after consent was obtained from either the resident or
EAGLEcare, in collaboration with three partner NHs
and their GPs, has helped reduce the number of
hospital admissions among partner NHs from 722 in
2018 to 410 in 2020.
EAGLEcare has also honoured at least 98% of
enrolled decedents’ wishes in terms of treatment
preferences, and at least 93% in terms of preferred
place of death in 2020 and 2021.
"EAGLEcare provides a responsive and
wholesome approach to end-of-life care
for nursing home patients. The quality
of care for such patients has certainly
improved significantly with such close
collaboration. It also strongly reassures
the nursing home medical staff that they
are well supported by the tertiary hospital
in all medical situations."
- Comment from a partnering
NH GP of EAGLEcare
EAGLEcare has developed a close working
relationship with the GPs from their partnering NHs,
where both parties work closely in consultation with
each other to jointly care for residents enrolled in the
Based on our perspective from working with GPs looking
after the frail elderly in NHs, we hope that it will help all
GPs identify residents who may be approaching the end
of their lives, and to explore their wishes surrounding that
time, so as to complete their life journeys in dignity and
among familiar caregivers according to their preferences.
Mdm T was an 83-year-old Chinese lady from one of the NHs in the East. She had a background of hypertension, hyperlipidaemia and stroke, causing her to be bedbound, requiring a nasogastric tube for sustenance and unable to communicate.
Meeting the EAGLEcare team
Understanding the patient’s conditions
When the EAGLEcare team first met her, she had already had approximately 15 hospital admissions over the past year and a half, averaging about one per month, mostly due to recurrent catheter-associated urinary tract infections (CAUTI), likely secondary to a large staghorn calculus she had.
Conducting the PPC discussion
After the EAGLEcare team determined that she was a possible candidate for EOL care based on the aforementioned criteria, the team approached her family to conduct a PPC discussion.
Enrolling in EAGLEcare
The family was amazed to hear that there was such an option as keeping Mdm T in the nursing home, rather than sending her to the hospital each time for intravenous antibiotics.
They felt that she was suffering while going in and out of the hospital. As she had already lived a fulfilled life, they were keen to keep her comfortable among familiar caregivers in the nursing home at the end of her life.
Leaving with dignity
Mdm T eventually passed away a few months later in the nursing home, cared for by her NH GP who had known her for years, with the support of the EAGLEcare team. Her family was grateful that they could keep her suffering to a minimum as she reached the end of her life journey.
GPs who would like more information about the EAGLEcare programme, please contact Ms Yee Kai Ying, Executive, ILTC Integration at email@example.com.
Honinx E, van Dop N, Smets T, et al. Dying in long-term care facilities in Europe: the PACE epidemiological study of deceased residents in six countries. BMC Public Health 2019;19:1199
Ouslander JG, Lamb G, Perloe M, et al. Potentially avoidable hospitalizations of nursing home residents: frequency, causes, and costs: [see editorial comments by Drs. Jean F. Wyman and William R. Hazzard, pp 760-761]. J Am Geriatr Soc 2010;58:627–35
Honinx E, Piers RD, Onwuteaka-Philipsen BD, et al. Hospitalisation in the last month of life and in-hospital death of nursing home residents: a crosssectional analysis of six European countries. BMJ Open 2021;11:e047086. doi:10.1136/ bmjopen-2020-047086
CGH internal data (extracted from SAP)
8 nursing homes set up in past 5 years, but institutionalising elderly should be very last resort: Koh Poh Koon. The Straits Times. https://www.straitstimes.com/singapore/politics/eight-nursing-homes-set-up-in-past-5-years-but-institutionalising-elderly-should
Thomas K et al. The GSF Prognostic Indicator Guidance. 4th Edition Oct 2011. The Gold Standards Framework Centre in End of Life Care CIC.
Supportive & Palliative Care Indicators Tool. SPICT. https://www.spict.org.uk
All about ACP. Agency for Integrated Care. https://www.aic.sg/care-services/all-about-acp
Advance Care Planning. Health Hub. https://www.healthhub.sg/a-z/medical-and-care-facilities/56/advance-care-planning
Dr Wong Ka-Loon is a Senior Resident Physician at Changi General Hospital. She has an interest in the end-of-life care of frail nursing home residents and has recently completed a postgraduate course in palliative medicine.
Dr Christopher Lien is the Director of Community Geriatrics at Changi General Hospital and the Clinical Lead of the EAGLEcare programme. He has an interest in the development of transitional, intermediate and long-term care services for the elderly.
GPs can call the SingHealth Duke-NUS Supportive & Palliative Care Centre for appointments at the following hotlines:
Singapore General Hospital: 6326 6060Changi General Hospital: 6788 3003Sengkang General Hospital 6930 6000KK Women’s and Children’s Hospital: 6692 2984National Cancer Centre Singapore 6436 8288National Heart Centre Singapore 6704 2222National Neuroscience Institute 6330 6363