Web-based Advance Care Planning Intervention for Patients With Kidney Failure on Dialysis: Pilot Testing of 'My Voice'

Inclusion Criteria: For patients * Singapore citizens or permanent residents; aged 21 years (age of majority) or older * CKD stage 5; receiving dialysis * Identified as eligible for SIC by NKF HCPs based on one or more of the following: 1. clinical deterioration with a terminal condition or 2. intolerability to dialysis or 3. having two or more unplanned hospitalizations for renal complications in the past 6 months (from medical records); or 4. known to palliative care or under conservative care as indicated in the discharge summary or 5. poor functional status indicated by the Fragility Assessment for Elders (FIFE) score \>4 * Normal cognitive function as indicated by Mini Mental Scale Examination (MMSE) score of 24 or more (based on medical record) * Able to speak and read English, Mandarin or Malay * Agreeable to be audio-recorded Inclusion Criteria: For caregivers * Aged 21 years old and above * Family caregivers of the patients recruited i.e. Caregiver primarily involved in providing care, ensuring provision of care, and/or in making decisions regarding patient's care, with no expectation of financial compensation * Able to speak and read English, Mandarin or Malay * Have a phone and/or an electronic device with internet access. * Agreeable to be audio-recorded Exclusion Criteria: For Patients * Patients with cognitive impairment or serious mental illness will be excluded * Patients who had prior serious illness conversations (SIC) will be excluded * Are not easily contactable via mobile phone or landline Exclusion Criteria: For Caregivers * Those who are foreign domestic workers/maids * Are not easily contactable via mobile phone or landline