Futile Life-sustaining Treatment Research Articles

Factors Associated with Advance Directives Documentation: A Nationwide Cross-Sectional Survey of Older Adults in Korea.

Advance directives (ADs) can support autonomy in making healthcare decisions and minimize unnecessary discomfort during the treatment process at the end of life (EOL). This study aimed to investigate the factors that influence AD documentation among community-dwelling older adults. We used data from the National Survey of Older Koreans which was conducted nationwide in 2020. Data from participants aged 65 years or older were extracted using stratified multistage cluster sampling and the survey was conducted through one-on-one interviews. A total of 9920 older adults were included in this study: 421 respondents (4.7%) claimed that they had prepared for AD. Multivariable logistic regression analysis showed that being 75 years or older, having higher educational attainment, higher income, having any chronic disease(s), being screened for dementia in the past, being against futile life-sustaining treatment, taking a lecture on death and being registered for organ donation were positively associated with AD. Furthermore, when health was rated as average, it was associated with reduced odds of AD documentation compared when health was rated as good. These results suggest that more targeted efforts are required to promote EOL discussions among older adults.

Problems Related to the Act on Decisions on Life-Sustaining Treatment and Directions for Improvement.

The Act on Decisions on Life-Sustaining Treatment has been in effect since 2018 for end-of-life patients. However, only 20~25% of deaths of terminally ill patients comply with the law, while the remaining 75~80% do not. There is significant confusion in how the law distinguishes between those in the terminal stage and those in the dying process. These 2 stages can be hard to distinguish, and they should be understood as a single unified "terminal stage." The number of medical institutions eligible for life-sustaining treatment decisions should be legally expanded to properly reflect patients' wishes. To prevent unnecessary suffering resulting from futile life-sustaining treatment, life-sustaining treatment decisions for terminal patients without the needed familial relationships should be permitted and made by hospital ethics committees. Adult patients should be permitted to assign a legal representative appointed in advance to represent them. Medical records can be substituted for a patient's judgment letter (No. 9) and an implementation letter (No. 13) for the decision to suspend life-sustaining treatment. Forms 1, 10, 11, and 12 should be combined into a single form. The purpose of the Life-sustaining Medical Decisions Act is to respect patients' right to self-determination and protect their best interests. Issues related to the act that have emerged in the 3 years since its implementation must be analyzed, and a plan should be devised to improve upon its shortcomings.

Change in perception of the quality of death in the intensive care unit by healthcare workers associated with the implementation of the \u201cwell-dying law\u201d

PurposeThe importance of dying with dignity in the intensive care unit (ICU) has been emphasized. The South Korean government implemented the “well-dying law” in 2018, which enables patients to refuse futile life-sustaining treatment (LST) after being determined as terminally ill. We aimed to study whether the well-dying law is associated with a significant change in the quality of death in the ICU.MethodsThe Quality of Dying and Death (QODD) questionnaires were prospectively collected from the doctors and nurses of deceased patients of four South Korean medical ICUs after the law was passed (January 2019 to May 2020). Results were compared with those of our previous study, which used the same metric before the law was passed (June 2016 to May 2017). We compared baseline characteristics of the deceased patients, enrolled staff, QODD scores, and staff opinions about withdrawing LST from before to after the law was passed.ResultsAfter the well-dying law was passed, deceased patients (N = 252) were slightly older (68.6 vs. 66.6, p = 0.03) and fewer patients were admitted to the ICU for post-resuscitation care (10.3% vs. 20%, p = 0.003). The mean total QODD score significantly increased after the law was passed (36.9 vs. 31.3, p = 0.001). The law had a positive independent association with the increased QODD score in a multiple regression analysis.ConclusionOur study is the first to show that implementing the well-dying law is associated with quality of death in the ICU, although the quality of death in South Korea remains relatively low and should be further improved.

Knowledge of palliative care and preference of end of life care: a cross-sectional survey of residents in the Chinese socio-cultural background of Macao

BackgroundSince the establishment of a hospice in the year 2000 and the development of a palliative care ward in 2019, there is no study examining public’s knowledge of palliative care, nor preference of end of life care in Macao.AimTargeting Chinese residents of Macao, the current study has 3 goals: i) to understand the level of knowledge of palliative care, ii) to explore the preference of end of life treatments, and iii) to identify the associated factors of the preference of end of life treatments.MethodsA cross-sectional questionnaire survey was conducted using a structured questionnaire. The study employed non-probability quota sampling through which Macao residents aged 18 and above were recruited between July and September 2020.ResultsA total of 737 responses were valid. The average correct rate of palliative care knowledge ranged from 40.4% to 85.5%. Pertaining to end of life treatments, 62.0% of the respondents chose comfort care. However, almost half of the respondents agreed that life-sustaining treatments should not be stopped under any circumstances. Respondents who scored higher in palliative care knowledge and those with secondary and tertiary education were associated factors of choosing comfort care rather than life-sustaining treatments. In addition, respondents who agreed that futile life-sustaining treatments should be stopped were also associated with preference for comfort care.ConclusionThe understanding of palliative care amongst Macao residents is inadequate. Despite the public’s inclination towards comfort care, it is generally believed that life-sustaining treatments should not be stopped at the end of life. The study results suggest that not only the knowledge of palliative care should be enhanced amongst the general public in Macao, but information about life-sustaining treatments should also be offered to patients and families by healthcare professionals, in aiding end of life treatment decision making.

Consent for withholding life-sustaining treatment in cancer patients: a retrospective comparative analysis before and after the enforcement of the Life Extension Medical Decision law

BackgroundThe Life Extension Medical Decision law enacted on February 4, 2018 in South Korea was the first to consider the suspension of futile life-sustaining treatment, and its enactment caused a big controversy in Korean society. However, no study has evaluated whether the actual implementation of life-sustaining treatment has decreased after the enforcement of this law. This study aimed to compare the provision of patient consent before and after the enforcement of this law among cancer patients who visited a tertiary university hospital's emergency room to understand the effects of this law on the clinical care of cancer patients.MethodsThis retrospective single cohort study included advanced cancer patients aged over 19 years who visited the emergency room of a tertiary university hospital. The two study periods were as follows: from February 2017 to January 2018 (before) and from May 2018 to April 2019 (after). The primary outcome was the length of hospital stay. The consent rates to perform cardiopulmonary resuscitation (CPR), intubation, continuous renal replacement therapy (CRRT), and intensive care unit (ICU) admission were the secondary outcomes.ResultsThe length of hospital stay decreased after the law was enforced from 4 to 2 days (p = 0.001). The rates of direct transfers to secondary hospitals and nursing hospitals increased from 8.2 to 21.2% (p = 0.001) and from 1.0 to 9.7%, respectively (p < 0.001). The consent rate for admission to the ICU decreased from 6.7 to 2.3% (p = 0.032). For CPR and CRRT, the consent rates decreased from 1.0 to 0.0% and from 13.9 to 8.8%, respectively, but the differences were not significant (p = 0.226 and p = 0.109, respectively).ConclusionAfter the enforcement of the Life Extension Medical Decision law, the length of stay in the tertiary university hospital decreased in patients who established their life-sustaining treatment plans in the emergency room. Moreover, the rate of consent for ICU admission decreased.

Comparison of attitudes towards five end-of-life care interventions (active pain control, withdrawal of futile life-sustaining treatment, passive euthanasia, active euthanasia and physician-assisted suicide): a multicentred cross-sectional survey of Korean patients with cancer, their family caregivers, physicians and the general Korean population

ObjectivesThis study determined attitudes of four groups—Korean patients with cancer, their family caregivers, physicians and the general Korean population—towards five critical end-of-life (EOL) interventions—active pain control, withdrawal of futile life-sustaining...

Physician–patient end-of-life care discussions: Correlates and associations with end-of-life care preferences of cancer patients—a cross-sectional survey study

Background: Honoring patients’ treatment preferences is a key component of high-quality end-of-life care. Connecting clinical practices to patients’ preferences requires effective communication. However, few cancer patients reported discussing end-of-life-care preferences with their physicians. Aim: To identify correlates of physician–patient end-of-life-care discussions and to investigate associations of physician–patient end-of-life-care discussions with patient end-of-life-care preferences. Design: A cross-sectional survey from April 2011 through November 2012. Setting/participants: A convenience sample of 2467 cancer patients (89.3% participation rate) whose disease was diagnosed as terminal and unresponsive to current curative cancer treatment was recruited from 23 teaching hospitals throughout Taiwan. Results: Only 7.8% of respondents reported discussing end-of-life-care preferences with their physicians. Physicians were more likely to discuss end-of-life-care preferences with cancer patients who accurately understood their prognosis but less likely to do so if patients were married or received care in a hospital with an inpatient hospice unit. Furthermore, physician–patient end-of-life-care discussions were significantly, positively associated with the likelihood of preferring comfort-oriented care and hospice care, but negatively associated with preferences for receiving cardiopulmonary resuscitation when life is in danger and aggressive life-sustaining treatments at end of life, including intensive care unit admission, cardiac massage, intubation, and mechanical ventilation support. Conclusion: Physician–patient end-of-life-care discussions are correlated with accurate prognostic awareness, marital status, and institutional characteristics and negatively associated with terminally ill cancer patients’ preferences for aggressive end-of-life care. Interventions should be developed to facilitate timely end-of-life-care discussions between at-risk patients and their physicians, thus honoring patients’ end-of-life-care preferences and possibly avoiding futile life-sustaining treatments.

The Understanding of Terminal Cancer and Its Relationship with Attitudes toward End-of-Life Care Issues

Although terminal cancer is a widely used term, its meaning varies, which may lead to different attitudes toward end-of-life issues. The study was conducted to investigate differences in the understanding of terminal cancer and determine the relationship between this understanding and attitudes toward end-of-life issues. A questionnaire survey was performed between 2008 and 2009. A total of 1242 cancer patients, 1289 family caregivers, 303 oncologists from 17 hospitals, and 1006 participants from the general population responded. A "6-month life expectancy" was the most common understanding of terminal cancer (45.6%), followed by "treatment refractoriness" (21.1%), "metastatic/recurrent disease" (19.4%), "survival of a few days/weeks" (11.4%), and "locally advanced disease" (2.5%). The combined proportion of "treatment refractoriness" and "6-month life expectancy" differed significantly between oncologists and the other groups combined (76.0% v. 65.9%, P = 0.0003). Multivariate analyses showed that patients and caregivers who understood terminal cancer as "survival of a few days/weeks" showed more negative attitudes toward disclosure of terminal status compared with participants who chose "treatment refractoriness" (adjusted odds ratio [aOR] 0.42, 95% confidence interval [CI] 0.22-0.79 for patients; aOR 0.34, 95% CI 0.18-0.63 for caregivers). Caregivers who understood terminal cancer as "locally advanced" or "metastatic/recurrent disease" showed a significantly lower percentage of agreement with withdrawal of futile life-sustaining treatment compared with those who chose "treatment refractoriness" (aOR 0.19, 95% CI 0.07-0.54 for locally advanced; aOR 0.39, 95% CI 0.21-0.72 for metastatic/recurrent). The understanding of terminal cancer varied among the 4 participant groups. It was associated with different preferences regarding end-of-life issues. Standardization of these terms is needed to better understand end-of-life care.

Cultural sensitivity in paediatrics

In a recent Journal of Medical Ethics article, ‘Should Religious Beliefs Be Allowed to Stonewall a Secular Approach to Withdrawing and Withholding Treatment in Children?’, Joe Brierley, Jim Linthicum and...

Life-Sustaining Medical Treatment for Terminal Patients in Korea

Life-sustaining medical treatment like mechanical ventilation has contributed much for acute illnesses. However, it might be harmful for the terminal patients with chronic illnesses like metastatic cancer, because it just prolongs dying process without reversing the underlying medical condition. In Korea, 86.6% of terminal cancer patients admitted the hospital near the end-of-life period in 2010, in contrast to 19.3% in 1991. About 180,000 patients are dying with terminal diseases due to chronic illnesses like metastatic cancer and more than 30,000 patients had futile life-sustaining treatments at the end-of-life period (1, 2). Despite the fact that most cancer patients are resistant to chemotherapy at the end of life, 30.9% of Korean cancer patients in the last month of life received chemotherapy (3). The proportion who visited an emergency room more than once during the last months of life was 33.6% (4). In contrast, only 12% of cancer patients utilized hospice-palliative care service at the end-of-life period. Active euthanasia or physician-assisted suicide is not an issue in Korea, but futility near the end-of-life is a big problem.

1434P - The Understanding of Terminal Cancer and its Relationship with Attitudes Toward End-of-Life Care Issues

ABSTRACT Objective To investigate differences in the understanding of terminal cancer and determine the relationship between this understanding and attitudes toward end-of-life issues. Design A questionnaire survey was performed between 2008 and 2009. Participants: A total of 1242 cancer patients, 1289 family caregivers, 303 physicians from 17 university hospitals, and 1006 participants from the general population responded (response rates: 90.1%, 95.1%, 81.0%, and 75.9%, respectively). Main outcome measures Individual understanding of terminal cancer and its relationship with preference for disclosure of terminal prognosis and critical end-of-life interventions. Results A “six-month life expectancy” was the most common understanding of terminal cancer (45.6%), followed by “treatment refractoriness” (21.1%), “metastatic/recurred disease” (19.4%), “survival of a few days/weeks” (11.4%), and “locally advanced disease” (2.5%). The combined proportion of “treatment refractoriness” and “six-month life expectancy” differed significantly between physicians and the other groups combined (76.0% vs 65.9%, P = 0.0003). Multivariate analyses showed that patients and caregivers who understood terminal cancer as “survival of a few days/weeks” showed more negative attitudes toward disclosure of terminal status compared with participants who chose “treatment refractoriness” (adjusted odds ratio [aOR] 2.39, 95% CI 1.26 to 4.54 for patients; aOR 2.94, 95% CI 1.58 to 5.47 for caregivers). Caregivers who understood terminal cancer as “metastatic/recurred” or “six-month survival” tended to disagree with withdrawing futile life-sustaining treatments (aOR 2.57, 95% CI 1.39 to 4.75 for “metastatic/recurred,” aOR 1.86, 95% CI 1.06 to 3.28 for “six-month survival”) and active pain control (aOR 2.29, 95% CI 1.13 to 4.64 for “metastatic/recurred”, aOR 1.86, 95% CI 0.97 to 3.54 for “six-month survival”), compared with caregivers who selected “treatment refractoriness.” Conclusion The understanding of terminal cancer varies among the four participant groups. It was associated with different preferences regarding end-of-life issues. Standardizing this terminology is needed to better understand end-of-life care. Disclosure All authors have declared no conflicts of interest.

Awareness and Attitude Change after End-of-Life Care Education for Medical Students

Purposes: Most medical schools in Korea do not provide adequate education in end-of-life care. This study was designed to illustrate the need to improve end-of-life care edu cation and to assess the effect of the education on fourth-year medical students’ awareness and attitude towards hospice and palliative care for terminally ill patients. Methods: One hundred sixty six fourth-year medical students were surveyed with questionnaires on end-of-life care before and after they received the education. Results: Before receiving the education, students most frequently answered “ at the end of life” (33.6%) was appropriate time to write an advance medical directive. After the education, the most frequent answer was “ in healthy status” (58.7%). More students agreed to withholding or withdrawing futile life-sustaining treatment increased after the education (48.1% vs. 92.5% (P＜0.001) for cardiopulmonary resuscitation, 38.3% vs. 92.5% (P＜0.001) for intubation and mechanical ventilation, 39.1% vs. 85.8% (P＜ 0.001) for inotropics, 60.9% vs. 94.8% (P＜ 0.001) for dialysis and 27.8% vs. 56.0% (P＜0.001) for total parenteral nutrition). Significantly more students opposed euthanasia after the education (46.6% vs. 82.1%, P＜0.001). All students agreed to the need for education in end-of-life care. Conclusion: After reflecting on the meaning of death through the end-of-life care education, most s tudents recognized the need for the education. The education brought remarkable changes in students’ awareness and attitude towards patients at the end of life. We suggest end-of-life care education should be included in the regular curriculum of all medical schools in Korea. (Korean J Hosp Palliat Care 2012;15:30-35)

Attitudes of cancer patients, family caregivers, oncologists and members of the general public toward critical interventions at the end of life of terminally ill patients

Whereas most studies have focused on euthanasia and physician-assisted suicide, few have dealt comprehensively with other critical interventions administered at the end of life. We surveyed cancer patients, family caregivers, oncologists and members of the general public to determine their attitudes toward such interventions. We administered a questionnaire to four groups about their attitudes toward five end-of-life interventions--withdrawal of futile life-sustaining treatment, active pain control, withholding of life-sustaining measures, active euthanasia and physician-assisted suicide. We performed multivariable analyses to compare attitudes and to identify sociodemographic characteristics associated with the attitudes. A total of 3840 individuals--1242 cancer patients, 1289 family caregivers and 303 oncologists from 17 hospitals, as well as 1006 members of the general Korean population--participated in the survey. A large majority in each of the groups supported withdrawal of futile life-sustaining treatment (87.1%-94.0%) and use of active pain control (89.0%-98.4%). A smaller majority (60.8%-76.0%) supported withholding of life-sustaining treatment. About 50% of those in the patient and general population groups supported active euthanasia or physician-assisted suicide, as compared with less than 40% of the family caregivers and less than 10% of the oncologists. Higher income was significantly associated with approval of the withdrawal of futile life-sustaining treatment and the practice of active pain control. Older age, male sex and having no religion were significantly associated with approval of withholding of life-sustaining measures. Older age, male sex, having no religion and lower education level were significantly associated with approval of active euthanasia and physician-assisted suicide. Although the various participant groups shared the same attitude toward futile and ameliorative end-of-life care (the withdrawal of futile life-sustaining treatment and the use of active pain control), oncologists had a more negative attitude than those in the other groups toward the active ending of life (euthanasia and physician-assisted suicide).

Prognosis-based futility guidelines: does anyone win? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.

Advocates for health care reform and others claim that significant savings could be achieved if "futile" care were eliminated. Our objective was to provide an initial estimate of the effects of a public policy that would preclude futile life-sustaining treatments, defined as those employed despite < or = 1% chance of surviving for 2 months. Simulation using data from an observational cohort study. Five academic medical centers. Seriously ill hospitalized adults enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT). We examined the impact of prognosis-based futility guidelines on survival and hospital length of stay on a cohort of seriously ill adults. We calculated the number of days of hospitalization that would not be used if, on the third study day, life-sustaining treatment had been stopped or not initiated for subjects with estimated 2-month survival probability of < or = 1%. Of the 4301 patients, 115 (2.7%) had an estimated chance of 2-month survival of < or = 1%. All but one of these 115 subjects died within 6 months. Almost 86% died within 5 days of prognosis. At the time of death, 92 subjects (80.0%) had had no attempt at resuscitation; 35 (30.4%) had had a life-sustaining mechanical ventilator withdrawn. A Do-Not-Resuscitate order was written either before (n = 61) or within 5 days (n = 18) of reaching this prognosis for 68.6% of the patients. These 115 subjects had total hospital charges of $8.8 million. By forgoing or withdrawing life-sustaining treatment in accord with a strict 1% futility guideline, 199 of 1,688 hospital days (10.8%) would be forgone, with estimated savings of $1.2 million in hospital charges. Nearly 75% of the savings in hospital days would have resulted from stopping treatment for 12 patients, six of whom were under 51 years old, and one of whom lived 10 months. Patients at a high risk of dying can be identified prospectively. Implementation of a strict, prognosis-based futility guideline on the third day of a serious illness would result in modest savings.