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 care.


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.

Framework for the EAGLEcare programme - SingHealth Duke-NUS Supportive & Palliative Care Centre
Figure 1 Framework for the EAGLEcare programme

EAGLEcare objectives

EAGLEcare’s goals include:

  1. Upskilling of NH staff to provide ACP services

  2. Developing professional capabilities of NH staff in geriatric and EOL care

  3. Developing a model to deliver EOL care for suitable NH residents

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 pandemic.


Partnering NH staff are empowered and supported by the EAGLEcare team to implement a system to proactively identify and enrol residents eligible for EOL care.

Eligibility criteria

Residents from partnering NHs are enrolled in the EAGLEcare programme if they meet the following criteria:

  1. Are screened eligible based on the EAGLEcare Screening Assessment Tool,

  2. Have PPC preferences for comfort measures or limited intervention, and

  3. 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 decisions.

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 preferences.

Decision making through ACP discussions

In the EAGLEcare programme, two types of ACPs are discussed9general ACP and PPC.

Type of ACP​General ACP​PPC
Target audience
  • ​Primarily for adults with DMC
  • ​Primarily for adults with DMC

  • Family members / other informants who have demonstrated acts of care for patients lacking DMC

Decisions to be made
  • ​Appointing Nominated Healthcare Spokesperson(s)

  • 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 nursing home)

  • 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) after hours.


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 their NOK).

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 EAGLEcare programme.

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 yee.kai.ying@singhealth.com.sg.


  1. 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

  2. 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

  3. 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

  4. CGH internal data (extracted from SAP)

  5. 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

  6. Thomas K et al. The GSF Prognostic Indicator Guidance. 4th Edition Oct 2011. The Gold Standards Framework Centre in End of Life Care CIC.

  7. Supportive & Palliative Care Indicators Tool. SPICT. https://www.spict.org.uk

  8. All about ACP. Agency for Integrated Care. https://www.aic.sg/care-services/all-about-acp

  9. 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 6060
Changi General Hospital: 6788 3003
Sengkang General Hospital 6930 6000
KK Women’s and Children’s Hospital: 6692 2984
National Cancer Centre Singapore 6436 8288
National Heart Centre Singapore 6704 2222
National Neuroscience Institute 6330 6363