Changes in End-of-Life Discussion for Patients with Advanced Cancer after the Life- Sustaining Treatment Decisions-Making Act in Korea

Abstract

Background: Cancer is a leading cause of death in Korea. To protect the autonomy and dignity of terminally ill patients, the Life-Sustaining Treatment Decision-Making Act (LST-Act) came into full effect in Korea in February 2018. However, it is unclear whether the LST-Act influences end-of-life (EOL) discussion and decision-making processes for terminally ill cancer patients. Methods: This was a retrospective study conducted with a medical record review of cancer patients who died at Ulsan University Hospital between July 2015 and May 2020. Patients were divided into two groups: those who died in the period before the implementation of the LST-Act (from July 2015 to October 2017, Group 1) and after the implementation of the LST-Act (from February 2018 to May 2020, Group 2). We measured the self-determination rate and the timing of documentation of Do-Not-Resuscitate (DNR) or Physician Orders for Life-Sustaining Treatment (POLST) in both groups. Results: A total of 1,834 patients were included in the analysis (Group 1, n=943; Group 2, n=891). Documentation of DNR or POLST was completed by patients themselves in 1.5% and 63.5% of patients in Groups 1 and 2, respectively (p<0.001). The mean number of days between documentation of POLST or DNR and death was higher in Group 2 than in Group 1 (21.2 days vs. 14.4 days, p=0.001). The rate of late discussion, defined as documentation of DNR or POLST within seven days prior to death, decreased significantly in Group 2 (46.6% vs. 41.4%, p=0.027). In the multivariable analysis, hospice palliative care referral (OR [odds ratio] 0.25, p<0.001) and patients’ years of education (OR 0.68, p=0.027) were positively related to self-determination. However, physicians with clinical experience of less than three years had a higher rate of surrogate decision-making (OR 5.1, p=0.029) and late discussion (OR 2.53, p=0.019). Conclusions: After the implementation of the LST-Act, the rate of self-determination increased and EOL discussion occurred earlier than in the era before the implementation of the LST-Act.