Life-sustaining Treatment Decisions Research Articles

Evaluating feedback reports to support documentation of veterans’ care preferences in home based primary care

BackgroundTo evaluate the effectiveness of delivering feedback reports to increase completion of LST notes among VA Home Based Primary Care (HBPC) teams. The Life Sustaining Treatment Decisions Initiative (LSTDI) was implemented throughout the Veterans Health Administration (VHA) in the United States in 2017 to ensure that seriously ill Veterans have care goals and LST decisions elicited and documented.MethodsWe distributed monthly feedback reports summarizing LST template completion rates to 13 HBPC intervention sites between October 2018 and February 2020 as the sole implementation strategy. We used principal component analyses to match intervention to 26 comparison sites and used interrupted time series/segmented regression analyses to evaluate the differences in LST template completion rates between intervention and comparison sites. Data were extracted from national databases for VA HBPC in addition to interviews and surveys in a mixed methods process evaluation.ResultsLST template completion rose from 6.3 to 41.9% across both intervention and comparison HBPC teams between March 1, 2018, and February 26, 2020. There were no statistically significant differences for intervention sites that received feedback reports.ConclusionsFeedback reports did not increase documentation of LST preferences for Veterans at intervention compared with comparison sites. Observed increases in completion rates across intervention and comparison sites can likely be attributed to implementation strategies used nationally as part of the national roll-out of the LSTDI. Our results suggest that feedback reports alone were not an effective implementation strategy to augment national implementation strategies in HBPC teams.

785 Variability in Withdrawal of Life Sustaining Treatment Decision for Patients With Severe Traumatic Brain Injury: An Analysis of 510 North American Trauma Centers

INTRODUCTION: Withdrawal of life sustaining treatment (WLST) in severe traumatic brain injury (TBI) is complex with a paucity of standardized guidelines to inform practice patterns. We hypothesized presence of variability in WLST decision-making across centers, which could have important implications for equitable trauma care provision. METHODS: This retrospective study utilized data from adult severe TBI patients treated at trauma centers participating in the Trauma Quality Improvement Program between 2017-2020. Multivariable hierarchical logistic regression was used to adjust for patient, injury and hospital attributes influencing WLST. Residual between-center variability was characterized using the median odds ratio. Disparate WLST practices were further assessed by ranking centers' tendencies for WLST and assessing mortality between quartiles. RESULTS: We identified a total of 85511 subjects with severe TBI treated across 510 trauma centers, of which 20,300 (24%) had WLST. Patient-level factors associated with increased likelihood of WLST were advanced age, white race, treatment in a non-profit trauma center or self-pay/ Medicare insurance status (compared to private insurance). Black race was associated with reduced tendency for WLST. Higher severity intracranial and extracranial injuries also increased likelihood for WLST.After adjustment for patient and hospital attributes, the median odds ratio was 1.44 (1.40-1.48 95%CI), suggesting substantial residual variation in WLST between centers. When centers were grouped into quartiles by their propensity for WLST, there was a 1.37 (1.30-1.42 95%CI) increased adjusted odds of mortality between fourth versus first quartile centers. CONCLUSIONS: We highlighted the presence of disparate WLST practice patterns between trauma centers after adjustment for case-mix and hospital attributes. These findings highlight a strong need for examination of center-level factors contributing to heterogenous WLST practices to ultimately improve equity of care provision for severe TBI patients.

Factors affecting nurses' attitude toward withdrawal of life-sustaining treatment for children

PurposeThe purpose of study was to investigate factors affecting nurses' attitudes toward withdrawal of life-sustaining treatment in children. Design and methodsThis descriptive survey study included 167 nurses working at children's hospitals or children's wards. Data were collected through a structured self-administered survey in November 2022. Data were analyzed using descriptive analysis, t-test, ANOVA, the Dunnett's T3 test, Pearson's correlation coefficient, and multiple linear regression. ResultsAttitude toward withdrawal of life-sustaining treatment in children showed a significant positive correlation with knowledge of life-sustaining treatment decision-making (r = 0.38, p < .001) and meaning as a subcategory of moral sensitivity (r = 0.21, p 0.008). The factors affecting attitude toward withdrawal of life-sustaining treatment in children were knowledge of life-sustaining treatment decision-making (β =0.31, p < .001) and meaning (β = 0.18, p = .015). This model showed a 21.0% explanation of attitude toward withdrawal of life-sustaining treatment in children. ConclusionsDeveloping an effective educational program designed to improve nurses' knowledge and attitude toward life-sustaining treatment decision-making is necessary. Practice implicationsIt may have a positive influence on attitudes toward withdrawal of life-sustaining treatment in children by improving child nurses' knowledge about life-sustaining treatment decision-making and moral sensitivity.

연명의료결정법 대상 환자의 연명의료결정과 사망 전 의료이용에의 영향요인

This study embarks on a detailed cohort analysis to identify the factors influencing life-sustaining treatment (LST) decisions and healthcare usage before death. Utilizing multinomial logistic regression, it examines a diverse sample of 1,072 patients, categorized into three groups: self-determination, family determination, and DNR. The majority of the cohort, 49.4%, falls under the self-determination group, with a significant proportion of patients (92.8%) suffering from cancer. We find that the most common medical intervention in the week preceding death was blood transfusions, accounting for 49.2% of cases. The study reveals that the self-determination group experienced lower daily healthcare costs, higher hospice utilization rates, and longer intervals between physician orders for life-sustaining treatment(POLST) or DNR completion and death, compared to the other groups. Moreover, patients with stupor on admission were significantly more likely to be in the family determination group (36.225 times) or the DNR group (19.422 times) than in the self-determination group. Furthermore, the likelihood of ICU use was higher in the family determination (3.627 times) and DNR groups (4.137 times), with the application of mechanical ventilation being 2.372 times more common in the family determination group and 4.209 times in the DNR group. Lastly, cardiopulmonary resuscitation was 9.122 times more prevalent in the DNR group compared to the self-determination group. The study concludes that self-determination in LST can significantly reduce unnecessary healthcare utilization before death and promote hospice care utilization, underscoring the necessity of supporting patients in planning their end-of-life care, including decisions about LST.

Admitting Hospital Influences on Withdrawal of Life-Sustaining Treatment Decision for Patients With Severe Traumatic Brain Injury.

Withdrawal of life-sustaining treatment (WLST) in severe traumatic brain injury (TBI) is complex, with a paucity of standardized guidelines. We aimed to assess the variability in WLST practices between trauma centers in North America. This retrospective study used data from trauma centers through the American College of Surgeons Trauma Quality Improvement Program between 2017 and 2020. We included adult patients (>16 years) with severe TBI and a documented decision for WLST. We constructed a series of hierarchical logistic regression models to adjust for patient, injury, and hospital attributes influencing WLST; residual between-center variability was characterized using the median odds ratio. The impact of disparate WLST practices was further assessed by ranking centers by their conditional random intercept and assessing mortality, length of stay, and WLST between quartiles. We identified a total of 85 511 subjects with severe TBI treated across 510 trauma centers, of whom 20 300 (24%) had WLST. Patient-level factors associated with increased likelihood of WLST were advanced age, White race, self-pay, or Medicare insurance status (compared with private insurance). Black race was associated with reduced tendency for WLST. Treatment in nonprofit centers and higher-severity intracranial and extracranial injuries, midline shift, and pupil asymmetry also increased the likelihood for WLST. After adjustment for patient and hospital attributes, the median odds ratio was 1.45 (1.41-1.49 95% CI), suggesting residual variation in WLST between centers. When centers were grouped into quartiles by their propensity for WLST, there was increased adjusted mortality and shorter length of stay in fourth compared with first quartile centers. We highlighted the presence of contextual phenomena associated with disparate WLST practice patterns between trauma centers after adjustment for case-mix and hospital attributes. These findings highlight a need for standardized WLST guidelines to improve equity of care provision for patients with severe TBI.

Surrogate Decision-Making After Stroke in a Community Setting: The OASIS Project.

Patients with severe stroke often rely on surrogate decision-makers for life-sustaining treatment decisions. We investigated ethnic differences between Mexican Americans (MAs) and non-Hispanic White (NHW) individuals in surrogate reports of physician quality of communication and shared decision-making from the OASIS study (Outcomes Among Surrogate Decision Makers in Stroke) project. Patients had ischemic stroke or intracerebral hemorrhage in Nueces County, TX. Surrogates self-identified as being involved in decisions about do-not-resuscitate orders, brain surgery, ventilator, feeding tube, or hospice/comfort care. Surrogate reports of physician quality of communication (scale score, range from 0 to 10) and shared decision-making (CollaboRATE scale score, binary score 1 versus 0) were compared by ethnicity with linear or logistic regression using generalized estimating equations, adjusted for prespecified demographics, clinical factors, and confounders. Between April 2016 and September 2020, 320 surrogates for 257 patients with stroke enrolled (MA, 158; NHW, 85; and other, 14). Overall quality of communication score was better among surrogates of MA patients than NHW individuals after adjustment for demographics, stroke severity, and patient survival though the ethnic difference was attenuated (β, 0.47 [95% CI, -0.17 to 1.12]; P=0.15) after adjustment for trust in the medical profession and frequency of personal prayer. High CollaboRATE scale scores were more common among surrogates of MA patients than NHW individuals (unadjusted odds ratio, 1.75 [95% CI, 1.04-2.95]). This association persisted after adjustment for demographic and clinical factors though there was an interaction between patient age and ethnicity (P=0.04), suggesting that this difference was primarily in older patients. Surrogate decision-makers of MA patients generally reported better outcomes on validated measures of quality of communication and shared decision-making than NHW individuals. Further study of outcomes among diverse populations of stroke surrogate decision-makers may help to identify sources of strength and resiliency that may be broadly applicable.

For the Universal Right to Access Quality End-of-Life Care in Korea: Broadening Our Perspective After the 2018 Life-Sustaining Treatment Decisions Act.

For the Universal Right to Access Quality End-of-Life Care in Korea: Broadening Our Perspective After the 2018 Life-Sustaining Treatment Decisions Act.

「연명의료결정법」의 미성년 환자에 대한 연명의료중단등결정에 관한 검토

In this article, the decision to discontinue life-sustaining treatment for minors under the Life-Sustaining Treatment Decision Act was reviewed. A minor patient's wish to discontinue life-sustaining treatment is expressed only through a life-sustaining treatment plan. If there is no life-sustaining treatment plan, the legal representative with parental authority decides to discontinue life-sustaining treatment for the patient.&#x0D; Therefore, it was examined whether the right to self-determination of minor patients is restricted or reduced under the Life-Sustaining Treatment Decision Act compared to adult patients who can confirm their wishes through advance directives for life-sustaining treatment or family statements.&#x0D; As a result, it was confirmed that they were not treated differently in the Life Sustaining Treatment Decision Act. This is because the only subjects of the Life Sustaining Treatment Decision Act are patients who are in the process of dying. Medically meaningless interruption of medical care for a patient in the process of dying has nothing to do with the right to self-determination.&#x0D; Rather, procedures for discontinuing life-sustaining treatment for minor patients without a legal representative who has parental authority should be discussed in the Life-Sustaining Treatment Act. In order to proceed quickly, it is better to have the decision made by a medical ethics committee rather than expanding the range of families that can make the decision.

DECISION MAKING ABOUT LIFE-SUSTAINING TREATMENT FOR UNREPRESENTED ADULTS IN KOREAN HOSPITALS

Abstract BACKGROUND In South Korea, unrepresented adults are individuals who lack decision-making capacity, written treatment preferences, and available immediate family. Since the enactment of the Life-Sustaining Treatment Decision Act in 2018, ethical and legal dilemmas surrounding decision-making about life-sustaining treatments for unrepresented patients have emerged among healthcare providers in hospitals. Thus, the objectives of this qualitative descriptive study were to explore decision-making practices about life-sustaining treatments for unrepresented patients. METHODS We interviewed 37 healthcare providers including physicians, nurses, and social workers from 22 hospitals in South Korea, and analyzed the interview data using a directed content analytic technique. RESULTS: Healthcare providers reported a lack of decision-making guidelines regarding life-sustaining treatments for unrepresented patients in their institutions or being uncertain about the presence of such guidelines. Physicians primarily make decisions about life-sustaining treatments for these patients. Ethics committees’ involvement in such decision-making is minimal in most hospitals. Basic life-sustaining treatments are usually initiated if necessary. However, life-sustaining treatments unrepresented patients are currently receiving cannot be discontinued even though those treatments seem pointless. Thus, additional life-sustaining treatments (e.g., extracorporeal membrane oxygenation) tend to be withheld. Important considerations in the decision-making process include the person’s reversibility, risk of adverse events, and medical costs. CONCLUSION: Decision-making about life-sustaining treatments for unrepresented patients is currently in legally blind spots in South Korea. Reforms in regulations and policies surrounding such decision-making practices for unrepresented patients and the development of institutional guidelines are urgently necessary to improve decision-making practices about life-sustaining treatments for these individuals.

PERCEPTIONS OF HEALTH PROFESSIONALS, PATIENTS, AND FAMILIES ON DECISION TO DISCONTINUE LIFE-SUSTAINING TREATMENT

Abstract Withholding and withdrawing treatment is debated among health professionals who care for individuals at the end of life. This study aimed to compare the perception of life-sustaining treatment decisions by health professionals, patients, and families by providing data to guide medical professionals to support patients in making self-directed decisions about when to limit or continue their life-sustaining treatment. A descriptive survey was conducted with health professionals (220 from general tertiary hospitals) and 110 patients and their families. The majority of participants (85-95%) agreed with the suspension of meaningless life-sustaining treatment. In a clinical situation, the decision was made mainly by the family (84%), followed by the patient (10%) or the primary doctor (6%). However, the patients and their families reported that patients should make decisions (74%). The appropriate timing to discuss the suspension of the life-sustaining treatment was when the patients were still conscious but expecting severe deterioration” consistently reported by participants (45-58%). The most important factor during their decision-making would be “possibility of the patient’s recovery” by health professionals (43-55%), but “pain of the patients (58%)” was reported by the patients and their families. In conclusion, there is still a significant discrepancy in the perception of life-sustaining treatment decisions among health professionals, patients, and their families. The ambiguity of the timing for the decision to terminate life-sustaining treatment and the discrepancy between patients and their families’ opinions remain obstacles to implementing the Act to respect the patient’s right to self-determination and achieve the goal of a dignified end-of-life.

Intensive Care Unit Nurses' Attitudes Toward Truth-Telling, Life-Sustaining Treatment, and Decision-Making Intention for End-of-Life Patients: A Cross-sectional Survey.

Truth-telling and life-sustaining treatment decisions are important elements of the quality of patients' care at the end of life. As the primary caregivers of patients at the end of life in intensive care units (ICUs), ICU nurses play an important role in patient decision making and hospice care. This study aimed to investigate and analyze ICU nurses' attitudes toward truth-telling, attitudes toward end-of-life life-sustaining treatment, and end-of-life decision-making behavioral intentions. One hundred twenty-two ICU nurses participated in this cross-sectional survey. Data were collected using a validated questionnaire. The results showed that ICU nurses' attitudes toward telling patients the truth and end-of-life life-sustaining treatment were both positive, but further improvement is needed. Nurses have a higher willingness to make palliative care decisions for patients at the end of life and to help patients achieve a good death. The truth-telling attitude, the life-sustaining treatment attitude, and whether they knew that cardiopulmonary resuscitation could be legally forgone at the end of life were factors influencing ICU nurses' behavioral intention toward decision making for patients at the end of life (all P s < .05). We conclude that nurses' participation in truth-telling and end-of-life decision making should be promoted, and timely hospice care should be provided to patients to help them achieve a good death.

Characteristics of Life-Sustaining Treatment Decisions: National Data Analysis in South Korea.

This study analyzed the national data on life-sustaining treatment decisions from 2018 to 2020 to find out the characteristics of South Korea's end-of-life procedure according to the decision-making approach and process. We collected the data of 84,422 patients registered with the National Agency for Management of Life-sustaining Treatment. We divided the patients into four groups (G1, G2, G3, and G4) according to the decision-making approach. A descriptive analysis of each group was conducted using indicators such as the patient's age, status, diagnosis, and content of forgoing life-sustaining treatment. Additionally, logistic regression analysis was performed by dividing the patients into self-determining (G1, G2) and non-self-determining patients (G3, G4). Cancer was the most common diagnosis for each group. The period from life-sustaining treatment decision to implementation was 10.76, 1.01, 0.86, and 1.19days for G1, G2, G3, and G4, respectively. In the logistic regression analysis, the self-determination ratio was higher for 40-49years old and lower for cardiovascular disease and gastrointestinal disease. Age was has a major impact on life-sustaining treatment decisions (LSTD), and with increase in age, the family, and not the patient, made the LSTD. The LSTD method also differed depending on the disease. The self-determination rates of patients with circulatory or digestive diseases were somewhat lower than that of those with neoplastic diseases. The period from decision-making to implementation is short for end-of-life care.

Effects of life-sustaining treatment plans on healthcare expenditure and healthcare utilization

PurposeTo develop an ethical and cultural infrastructure for Life-Sustaining Treatment (LST) plan, it is crucial to carefully analyze its impact and ensure that healthcare utilization is maintained at an appropriate level, avoiding excessive medical interventions. This study aims to investigate the effects of LST decisions on both healthcare expenditure and utilization.MethodsThis cohort study utilized claims data from the National Health Insurance Service, encompassing all medical claims in South Korea. We included individuals who had planned to withdraw or withhold their LST between January and December 2018, identified by claim code IA71, IA72, IA73. We followed a total of 28,295 participants with documented LST plan who were deceased by June 2020. Participants were categorized into LST withdrawal / withholding and LST continuation groups. The dependent variables were healthcare expenditure and utilization. We construct a generalized linear model to analyze the association between these variables.ResultsOut of the 28,295 participants, 24,436 (86.4%) chose to withdraw or withhold LST, while the rest opted for its continuation. Compared to the LST continuation group, those who chose to withdraw or withhold LST had 0.91 times lower odds for total cost. Additionally, they experienced 0.91 times fewer hospitalization days and 0.92 times fewer outpatient visits than those in the LST continuation group.ConclusionHealthcare expenditure and utilization deceased among those choosing to withdraw or withhold LST compared to those continuing it. These findings underscore the significance of patients actively participating in decision regarding their treatment to ensure appropriate levels of medical intervention for LST. Furthermore, they emphasize the critical role of proper education and the establishment of a cultural framework for LST plans.

Awareness of good death, perception of life-sustaining treatment decision, and changes in nursing activities after decision to discontinue life-sustaining treatment among nurses in intensive care units at tertiary general hospitals

Purpose : This study aims to explore nursing activities after the decision to discontinue life-sustaining treatment, awareness of a good death, and perception of life-sustaining treatment decisions among nurses in intensive care units (ICUs) at tertiary general hospitals.Methods : Participants were 173 nurses working in two tertiary general hospitals. The data were collected using structured questionnaires and analyzed using an independent t-test, paired t-test, one-way ANOVA, Scheffé’s test, and Pearson’s correlation coefficient.Results : Participants were 173 nurses working in two tertiary hospitals. The nursing activity increase was the greatest in the spiritual domain, and the physical domain was where the activities decreased the most. There were significant associations between Awareness of good death (Clinical) and Perception of life-sustaining treatment decision(r=.26, &lt;i&gt;p&lt;/i&gt;＜.001), Awareness of good death (Closure) and Perception of life-sustaining treatment decision(r=.36, &lt;i&gt;p&lt;/i&gt;＜.001), and Awareness of good death (Personal control) and Perception of life-sustaining treatment decision(r=.49, &lt;i&gt;p&lt;/i&gt;＜.001).Conclusion : Based on the results, systematic education programs and job training are required to improve the awareness regarding good death and perception of life-sustaining treatment decision for nurses in ICUs where discontinuing lifesustaining treatment decisions are made.

Randomized controlled trial of tailored audit with feedback in VHA long-term care settings

BackgroundThe Long-Term Care QUERI program supported implementation of the Life-Sustaining Treatment Decisions Initiative in US Veterans Health Administration long-term care settings. The program worked with eleven Community Living Centers (CLCs) and twelve Home-Based Primary Care (HBPC) programs to increase rates of completed templates, using audit with feedback. We distributed monthly feedback reports to site champions showing the number of Veterans with appropriate documentation. Although feedback reports are a common implementation tool, little is known about the most effective ways to design, distribute, and support them. We sought to test tailoring reports with tips using site-specific data, as well as national comparator data.MethodsWe conducted a cluster randomized controlled trial of monthly feedback reports utilizing site-tailored tips and national comparator data compared to our original feedback reports that included only graphical and numerical data. CLC and HBPC team members were invited to participate in brief surveys each quarter to determine if they had received and used the feedback reports. The outcome for CLC residents was the percent with a completed LST template any time prior to the 14th day of their stay. The outcome for HBPC residents was the percent of Veterans with a completed LST template by their second HBPC visit.ResultsThe response rate to the survey ranged between 6.8 and 19.3% of staff members across the CLC and HBPC sites with 12.8–25.5% of survey respondents reporting that they had seen the feedback reports. The linear regression models showed no significant association between receiving the enhanced feedback reports and having a higher documentation completion rate.ConclusionsReceiving feedback reports tailored to sites by including tips based on baseline context assessments and qualitative findings, and reports showing national comparator data, did not have an impact on the number of Veterans with a completed LST template. Having a higher proportion of CLC or HBPC team members view the reports was not associated with an increase in LST template completion. These findings suggest that tailored audit with feedback may not have been effective at the program level, although the proportion of respondents who reported seeing the reports was small.

Goals of care and end-of-life communication needs of persons with chronic respiratory disease.

To highlight recent advances in effective communication among persons with chronic respiratory diseases. The authors focus on communication science related to goals of care (GOC) discussions, medical devices, and life-sustaining invasive treatments. The authors discuss important considerations when working with individuals with low literacy and rurality. Communication handoffs between respiratory clinicians and/or palliative care to hospice clinicians are summarized to ensure effective person-centered and caregiver-centered care. Studies suggest the following communication approaches: (1) clarify differences between palliative and end of life; (2) conduct conversations early and gradual throughout the illness trajectory; (3) distinguish types of GOC discussions as they relate to treatment preferences; (4) for patients from rural communities, include family members and spiritual leaders; (5) assess literacy and employ supportive strategies; (6) apply time-limited-trial framework for life-sustaining treatment (LST) decisions; and (7) standardize processes for communication handoffs to hospice clinicians to improve communication fidelity. Effective communication tools for clinicians to engage in GOC discussions for persons with chronic respiratory diseases are grounded in a patient-centered framework. A trained clinician should lead these conversations and include interdisciplinary team members throughout the disease trajectory including at the end of life. These approaches may enable patients to express their values and care preferences as they evolve over time.

Comparison of the end-of-life decisions of patients with hospital-acquired pneumonia after the enforcement of the life-sustaining treatment decision act in Korea

BackgroundAlthough the Life-Sustaining Treatment (LST) Decision Act was enforced in 2018 in Korea, data on whether it is well established in actual clinical settings are limited. Hospital-acquired pneumonia (HAP) is a common nosocomial infection with high mortality. However, there are limited data on the end-of-life (EOL) decision of patients with HAP. Therefore, we aimed to examine clinical characteristics and outcomes according to the EOL decision for patients with HAP.MethodsThis multicenter study enrolled patients with HAP at 16 referral hospitals retrospectively from January to December 2019. EOL decisions included do-not-resuscitate (DNR), withholding of LST, and withdrawal of LST. Descriptive and Kaplan–Meier curve analyses for survival were performed.ResultsOf 1,131 patients with HAP, 283 deceased patients with EOL decisions (105 cases of DNR, 108 cases of withholding of LST, and 70 cases of withdrawal of LST) were analyzed. The median age was 74 (IQR 63–81) years. The prevalence of solid malignant tumors was high (32.4% vs. 46.3% vs. 54.3%, P = 0.011), and the ICU admission rate was lower (42.9% vs. 35.2% vs. 24.3%, P = 0.042) in the withdrawal group. The prevalence of multidrug-resistant pathogens, impaired consciousness, and cough was significantly lower in the withdrawal group. Kaplan–Meier curve analysis revealed that 30-day and 60-day survival rates were higher in the withdrawal group than in the DNR and withholding groups (log-rank P = 0.021 and 0.018). The survival of the withdrawal group was markedly decreased after 40 days; thus, the withdrawal decision was made around this time. Among patients aged below 80 years, the rates of EOL decisions were not different (P = 0.430); however, mong patients aged over 80 years, the rate of withdrawal was significantly lower than that of DNR and withholding (P = 0.001).ConclusionsAfter the LST Decision Act was enforced in Korea, a DNR order was still common in EOL decisions. Baseline characteristics and outcomes were similar between the DNR and withholding groups; however, differences were observed in the withdrawal group. Withdrawal decisions seemed to be made at the late stage of dying. Therefore, advance care planning for patients with HAP is needed.

Recent Trends in the Withdrawal of Life-Sustaining Treatment in Patients with Acute Cerebrovascular Disease : 2017-2021.

The Act on Life-Sustaining Treatment (LST) decisions for end-of-life patients has been effective since February 2018. An increasing number of patients and their families want to withhold or withdraw from LST when medical futility is expected. This study aimed to investigate the status of the Act on LST decisions for patients with acute cerebrovascular disease at a single hospital. Between January 2017 and December 2021, 227 patients with acute cerebrovascular diseases, including hemorrhagic stroke (n=184) and ischemic stroke (n=43), died at the hospital. The study period was divided into the periods before and after the Act. The duration of hospitalization decreased after the Act was implemented compared to before (15.9±16.1 vs. 11.2±18.6 days, p=0.127). The rate of obtaining consent for the LST plan tended to increase after the Act (139/183 [76.0%] vs. 27/44 [61.4%], p=0.077). Notably, none of the patients made an LST decision independently. Ventilator withdrawal was more frequently performed after the Act than before (52/183 [28.4%] vs. 0/44 [0%], p<0.001). Conversely, the rate of organ donation decreased after the Act was implemented (5/183 [2.7%] vs. 6/44 [13.6%], p=0.008). Refusal to undergo surgery was more common after the Act was implemented than before (87/149 [58.4%] vs. 15/41 [36.6%], p=0.021) among the 190 patients who required surgery. After the Act on LST decisions was implemented, the rate of LST withdrawal increased in patients with acute cerebrovascular disease. However, the decision to withdraw LST was made by the patient's family rather than the patient themselves. After the execution of the Act, we also observed an increased rate of refusal to undergo surgery and a decreased rate of organ donation. The Act on LST decisions may reduce unnecessary treatments that prolong end-of-life processes without a curative effect. However, the widespread application of this law may also reduce beneficial treatments and contribute to a decline in organ donation.

Advance Care Planning in South Korea

South Korea is an Asian country with a very low birth rate and a large elderly population. Nearly half of deaths are in the elderly over the age of 80, and cancer is the leading cause of all deaths. As the aging population increases, interest in end-of-life (EOL) care and quality of death is growing, but South Korea is one of the Asian countries that traditionally feels burdened by discussing death openly. In particular, even when a person is suffering from an incurable disease and is about to die, it is customary for the family members to make decisions without directly informing the patient of the disease status or discussing life-sustaining treatment (LST). However, due to a series of social events, the importance of individual autonomy, good death, discontinuation of LSTs, and advance care planning (ACP) gradually spread, and eventually the Life-Sustaining Treatment Decisions Act was implemented in 2018. With the enactment of this law, patients’ autonomy was enhanced in a short period of time, and a legal basis was established to discontinue LST at the EOL. However, there are still many areas to be improved, and it is fundamentally necessary to spread the concept of ‘ACP’ within society.

The NASEM Report: Are the Solutions Part of the Problem?

The NASEM Report: Are the Solutions Part of the Problem?