Every year, some people choose death over dialysis when their kidneys fail.
Without dialysis to clear toxins in their body, they are unlikely to survive long.
But there are others who are forced to forgo dialysis because they cannot afford it, or because their families said no.
At the Khoo Teck Puat Hospital (KTPH), 24 patients suitable for dialysis declined the procedure in 2011.
Instead, they were placed under palliative care to ease their suffering as they died.
Out of this group, 10 turned down dialysis because they did not have anyone to take them for the treatment or help them with home dialysis.
Two among them wanted the treatment, but their families refused.
Another four turned down the procedure because they did not want to be a burden to their families as they were "old already".
Six rejected dialysis because it was too expensive.
The rest of the KTPH patients declined for various personal reasons, including fear of pain.
In Singapore, dialysis centres are run either by for-profit private companies, where it costs $2,500 to more than $4,000 a month, or by voluntary welfare organisations which charge highly subsidised rates.
But patients have to be means-tested to qualify for the subsidy.
Medical insurance coverage ranges from a third to full reimbursement.
Professor A. Vathsala, head of nephrology at the National University Hospital (NUH), said patients who do not undergo dialysis have a median survival of six months.
These findings appeared in the December edition of the Annals, a publication of the Academy of Medicine.
The median age of the 24 patients was 71, with the youngest at 45 years old.
A check by The Straits Times found that most hospitals, including KTPH where the study was done, do not keep track of the number of patients who decline dialysis, although all the hospitals say they do have such cases.
At Singapore General Hospital (SGH), which treats about 400 end-stage kidney patients a year, about 30 patients a year choose not to do dialysis, though some change their minds later when they start feeling unwell, said Associate Professor Lina Choong, a senior renal consultant.
Prof Vathsala said that about two NUH patients a year would reject dialysis "for their own reasons rather than due to issues such as family support or lack of funding for transport to dialysis centres".
She said that the low numbers are the result of painstaking counselling when patients initially refuse.
"All patients who refuse treatment are referred to a medical social worker to ensure that they have no financial reasons to reject the treatment.
"For patients who lack family support, we apply for residential homes for the patients. Further, the decision for a patient not to be dialysed is reviewed at every opportunity as an inpatient or outpatient, so as to give the patient every opportunity to change his mind about refusing treatment."
Dr Laurence Tan, a geriatric doctor at KTPH, and his team who did the study concluded: "More must be done to improve social structures which help support patients and their families who desire treatment, particularly if it is a means of prolonging life meaningfully at this stage."
Mr Gan Ah Soy, 68, had turned down dialysis when his kidney failed because "it's very troublesome, you have to waste so much time and money".
But he listened to friends who told him that dialysis would let him live 20 to 30 years more. Now, he helps persuade other patients at SGH who decline the treatment.
Recently, he talked to a 77-year-old patient who has five children and 10 grandchildren.
But the man was adamant about not wanting to spend the money on dialysis or trouble his family.
He told Mr Gan: "I'm 77, I'm old, I've lived enough."
Additional reporting by Lee Jian Xuan
