[Sportschosun, Jang Jong-ho] A study has found that the intensity of treatment and medical costs differ significantly depending on whether a patient or the family makes the decision to withhold or withdraw life-sustaining treatment. When patients made the decision themselves, both indicators fell. When families made the decision, both increased.
A research team led by Professors O Tak-gyu and Song In-ae of the Department of Anesthesiology and Pain Medicine at Seoul National University Bundang Hospital said the findings came from an analysis of 1,189,042 adult patients nationwide who were admitted to intensive care units from 2020 to 2023, using big data from the National Health Insurance Service (NHIS).
Life-sustaining treatment refers to medical procedures performed on terminal patients solely to prolong life, without therapeutic benefit. It includes cardiopulmonary resuscitation and dialysis. In the past, there were no legal or institutional standards for stopping such treatment even if a patient did not want it. But with the enforcement of the Life-Sustaining Treatment Decisions Act in 2018, a system was introduced that allows patients to withhold or withdraw life-sustaining treatment on their own.
Patients can directly express their wishes regarding withholding or withdrawing life-sustaining treatment through an advance directive for life-sustaining treatment, which any adult aged 19 or older can complete, or a life-sustaining treatment plan, which can be completed only by patients with terminal or end-of-life conditions that are unlikely to improve. This protects their right to self-determination and dignity.
However, because a life-sustaining treatment plan can only be completed after a patient has been diagnosed with a terminal or end-of-life condition, many patients have already lost decision-making capacity by then. As a result, family members often complete the document on their behalf by inferring the patient's wishes. According to the National Agency for Management of Life-Sustaining Treatment, as of May this year, about 55.7% of withholding or withdrawal decisions were made by family members.
In real-world clinical settings, both patient-led and family-led decisions coexist. The research team sought to determine how the decision-maker affects patterns of medical use. Using patients without any life-sustaining treatment-related documents as the reference group, the team compared those who completed a life-sustaining treatment plan themselves with those whose family members completed it instead.
The group without life-sustaining treatment-related documents consisted of patients who had not completed either an advance directive for life-sustaining treatment or a life-sustaining treatment plan. This included cases in which patients were suddenly admitted to the intensive care unit and were unable to leave a legal document.
As a result, the patient-completed group was about 0.7 times as likely as the no-document group to receive high-intensity invasive life-sustaining treatment such as mechanical ventilation and extracorporeal life support (OR 0.7). When the analysis was limited to patients who died within 90 days of ICU admission, the likelihood was even lower, at about 0.43 times (OR 0.43). By contrast, the family-completed group was about 2.35 times more likely than the no-document group to receive invasive life-sustaining treatment (OR 2.35).
The two groups showed opposite patterns not only in treatment intensity but also in medical costs. The daily medical cost in the patient-completed group was about 14% lower than that of the no-document group (CR 0.86), while the family-completed group was about 4% higher (CR 1.04). The research team explained that this may be related to the reality that family surrogate decisions are often made in situations where it is difficult to confirm the patient's wishes directly, leaving families to decide under psychological burden and uncertainty.
Unlike previous studies that focused on whether life-sustaining treatment was withheld or withdrawn, this study is significant in that it used large-scale nationwide data to show that the decision-maker itself can be a key factor shaping patterns of life-sustaining treatment use.
Professor O Tak-gyu of Seoul National University Bundang Hospital said, "It is desirable for decisions on withholding or withdrawing life-sustaining treatment to be made after sufficient discussion, at a time when patients can express their values and preferences as much as possible." He added, "We need to further expand a culture that ensures patients' right to self-determination by creating an environment in which patients can discuss the matter with family members and medical staff and leave behind their wishes."
Meanwhile, the findings were published in the internationally renowned journal in respiratory and critical care medicine, the American Journal of Respiratory and Critical Care Medicine (AJRCCM), which has an impact factor of 21.7.
Jang Jong-ho, Sportschosun
This article has been translated by GripLabs Mingo AI.
