As Singapore advances its vision of ageing well, preparing for end-of-life care must reflect the realities of smaller families, shrinking kin networks and more diverse living arrangements, says the writer. PHOTO: ADOBE STOCK
As more Singaporeans age with smaller families, end-of-life planning must evolve
The systems and norms continue to assume a central role for family members, even when the reality is often very different.
When Emily (not her real name), a healthy woman in her mid-50s, chose end-of-life planning, she was not motivated by fear. It was foresight. She had watched a family member endure prolonged medical uncertainty without clear instructions. Without children of her own and never having married, she wanted to ensure that her values and wishes would be known.
Planning early, she felt, was a way of taking responsibility – both for herself and for those who might one day have to speak on her behalf.
Emily’s story is not unusual. As families shrink and childlessness rises, more Singaporeans will reach later life without spouses or children who can advocate for them during medical crises.
Advance Care Planning (ACP) allows healthy individuals to record their healthcare preferences. For instance, they may wish to receive life-sustaining treatment such as resuscitation. The individual can designate someone to speak for them if they lose mental capacity, typically through facilitated discussions with trained professionals and formal documentation, with some options also available through the recently launched online myACP platform.
However, while Singapore has been at the forefront in Asia in promoting ACP, the system and norms still largely assume that family members will play a central role. As family structures evolve, planning systems must adapt as well.
Ageing without close kin
Much of Singapore’s demographic conversation understandably centres on the country’s persistently low fertility rate and how policies might encourage marriage and childbearing.
Yet demographic change is also reshaping the other end of the life course. About 15 per cent of Singaporeans aged 60 and older are childless, and among women born in the early 1970s, roughly one in four remains childless – placing Singapore among countries with the highest levels of permanent childlessness.
Many have never married and may be ageing without close kin. As families become smaller, more Singaporeans will move into older age with fewer relatives to rely on for support or decision-making.
In a nationwide study of Singaporeans aged 50 and above, my colleagues and I found that childless Singaporeans are often more proactive in end-of-life planning than those with children. Childless individuals in our sample were more likely than parents to have initiated either formal documentation or informal discussions about their end-of-life preferences.
Childless women stood out in particular. They were the most likely to engage in planning – through conversations, formal documentation, or both. Many described motivations rooted in lived experience: having witnessed family crises, having cared for ageing parents, or wanting to avoid burdening siblings and relatives. Like Emily, they often saw such planning as part of a broader ethic of responsibility and self-reliance.
Planning patterns among childless men were more mixed. While some were proactive, others felt little urgency or cited financial strain. These differences partly reflect broader life course pathways to childlessness in Singapore, where women’s childlessness is more often linked to partnership patterns such as delayed and forgone marriage, while men’s childlessness is more closely associated with economic disadvantage.
No one to speak for them
Importantly, the study also highlights barriers that extend beyond individual motivation. A recurring challenge for childless individuals was the difficulty of identifying a trusted proxy decision-maker.
Some hesitated to appoint siblings who were close in age. Others were reluctant to rely fully on friends, reflecting the enduring cultural preference for kin-based decision-making.
Misunderstandings about ACP further complicated matters. Some childless individuals conflated ACP with costly legal procedures, or assumed it was relevant only for the wealthy or the seriously ill. Others associated it primarily with decisions about withdrawing life support, rather than understanding it as an ongoing conversation about values, preferences and care goals.
Such perceptions can discourage engagement or lead to partial planning, where documentation is completed without discussion, or vice versa.
These findings suggest that as family structures evolve, ACP frameworks must evolve as well. The goal is not simply to increase uptake, but to ensure that planning processes are inclusive and responsive to diverse family realities.
How frameworks can be improved
Start conversations about what you want your end-of-life care to look like while you’re healthy, not just when you’re in crisis. Weaving these discussions into regular doctor visits and community programmes could change how people see them.
People sometimes confuse ACP with complicated legal documents and worry it will cost a fortune. Clear public messaging should explain what it actually is – a straightforward, supported conversation. That alone could ease a lot of unnecessary anxiety.
Many people find choosing someone outside the family to make decisions on their behalf difficult, especially those without close family. Better guidance and stronger protections are needed to ensure these preferences are recognised and acted upon.
As more adults find themselves without traditional family support, helping them find trusted decision-makers will matter more than ever.
Men and people balancing caregiving responsibilities with other demands often don’t think about long-term planning in the same way others do. Reaching them through workplaces and community groups – tailored to their circumstances – could bring them into these conversations.
ACP is not about dwelling on death. It is about ensuring that one’s voice is heard at moments when one cannot speak for oneself.
As Singapore advances its vision of ageing well, preparing for end-of-life care must reflect the realities of smaller families, shrinking kin networks and more diverse living arrangements.
Making ACP work for everyone matters. It’s about respecting people and giving them real clarity about what comes next.
Bussarawan Teerawichitchainan is an associate professor of sociology at the Faculty of Arts and Social Sciences, National University of Singapore, and a 2025-2026 Fellow at the Center for Advanced Study in the Behavioral Sciences, Stanford University.
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