Cancer Research and Treatment

Original Article

Palliative medicine

Factors Affecting Life-Sustaining Treatment Decisions and Changes in Clinical Practice after Enforcement of the Life-Sustaining Treatment (LST) Decision Act: A Tertiary Hospital Experience in Korea: Yoon Jung Jang, Yun Jung Yang, Hoi Jung Koo, Hye Won Yoon, Seongbeom Uhm, Sun Young Kim, Jeong Eun Kim, Jin Won Huh, Tae Won Kim, Seyoung Seo; Cancer Res Treat. 2025;57(1):280-288. Published online July 1, 2024; DOI: https://doi.org/10.4143/crt.2024.360

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Purpose
In Korea, the Act on Hospice and Palliative Care and Decisions on Life-Sustaining Treatment (LST) was implemented on February 4, 2018. We aimed to investigate relevant factors and clinical changes associated with LST decisions after law enforcement.
Materials and Methods
This single-center retrospective study included patients who completed LST documents using legal forms at Asan Medical Center from February 5, 2018, to June 30, 2020.
Results
5,896 patients completed LST documents, of which 2,704 (45.8%) signed the documents in person, while family members of 3,192 (54%) wrote the documents on behalf of the patients. Comparing first year and following year of implementation of the act, the self-documentation rate increased (43.9% to 47.2%, p=0.014). Moreover, the number of LST decisions made during or after intensive care unit admission decreased (37.8% vs. 35.2%, p=0.045), and the completion rate of LST documents during chemotherapy increased (6.6% vs. 8.9%, p=0.001). In multivariate analysis, age < 65 (odds ratio [OR], 1.724; 95% confidence interval [CI], 1.538 to 1.933; p < 0.001), unmarried status (OR, 1.309; 95% CI, 1.097 to 1.561; p=0.003), palliative care consultation (OR, 1.538; 95% CI, 1.340 to 1.765; p < 0.001), malignancy (OR, 1.864; 95% CI, 1.628 to 2.133; p < 0.001), and changes in timing on the first year versus following year (OR, 1.124; 95% CI, 1.003 to 1.260; p=0.045) were related to a higher self-documentation rate.
Conclusion
Age < 65 years, unmarried status, malignancy, and referral to a palliative care team were associated with patients making LST decisions themselves. Furthermore, the subject and timing of LST decisions have changed with the LST act.

Citations

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Impact of Intensivist Authority on End-of-Life Practices in a Korean PICU
Yeonhee Lee, Kyeong Hun Lee, Boyeon Gu, Dagam Kim, In Kyung Lee
Clinical Pediatrics.2026; 65(4): 516. CrossRef
Awareness, attitudes, and educational needs regarding the life-sustaining treatment decision-making act in Korea among healthcare providers and medical students: a comparative analysis
Jooseon Lee, So-yun Kim, Duk-ki Kim, Green Hong, Song I Lee
BMC Medical Ethics.2026;[Epub] CrossRef
Impact of the Life-Sustaining Treatment Decision Act on the Incidence and Outcomes of In-Hospital Cardiopulmonary Resuscitation
Tak Kyu Oh, In-Ae Song
Critical Care Medicine.2026; 54(7): 1691. CrossRef
When advance directives clash with family consent: designing an operational framework for end-of-life decision-making in China and Korea
Songwu Luo, Dongje Cho, Jaehyun Cho
BMC Medical Ethics.2026;[Epub] CrossRef
Association between the timing of palliative care consultation and end-of-life outcomes in patients with cancer
Jung Sun Kim, Wan Taek Lee, Bhumsuk Keam, Jin-Ah Sim, Shin Hye Yoo
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Special Articles

Preparation and Practice of the Necessary Documents in Hospital for the “Act on Decision of Life-Sustaining Treatment for Patients at the End-of-Life”: Sun Kyung Baek, Hwa Jung Kim, Jung Hye Kwon, Ha Yeon Lee, Young-Woong Won, Yu Jung Kim, Sujin Baik, Hyewon Ryu; Cancer Res Treat. 2021;53(4):926-934. Published online June 2, 2021; DOI: https://doi.org/10.4143/crt.2021.326

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Purpose
Six forms relating to decisions on life-sustaining treatment (LST) for patients at the end-of-life (EOL) in hospital are required by the “Act on Decision of LST for Patients at the EOL.” We investigated the preparation and creation status of these documents from the database of the National Agency for Management of LST.
Materials and Methods
We analyzed the contents and details of each document necessary for decisions on LST, and the creation status of forms. We defined patients completing form 1 as “self-determined” of LST, and those whose family members had completed form 11/12 as “family decision” of LST. According to the determination subject, we compared the four items of LST on form 13 (the paper of implementation of LST) and the documentation time interval between forms.
Results
The six forms require information about the patient, doctor, specialized doctor, family members, institution, decision for LST, and intention to use hospice services. Of 44,381 who had completed at least one document, 36,693 patients had form 13. Among them, 11,531, 10,976, and 12,551 people completed forms 1, 11, and 12, respectively. The documentation time interval from forms 1, 11, or 12 to form 13 was 8.6±13.6 days, 1.0±9.5 days, and 1.5±9.7 days, respectively.
Conclusion
The self-determination rate of LST was 31% and the mean time interval from self-determination to implementation of LST was 8.6 days. The creation of these forms still takes place when the patients are close to death.

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Soyou Park, Soo-Young Yu
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Gustavo Batista Ferro, Carlos Arthur da Silva Morais, Erick Antonio Rodrigues Mendes, Francinei Gomes Pinto, Marcelo Gaia Epifane, Ana Cristina Vidigal Soeiro
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Do-not-resuscitate order in ICU cancer patients
Gustavo Batista Ferro, Carlos Arthur da Silva Morais, Erick Antonio Rodrigues Mendes, Francinei Gomes Pinto, Marcelo Gaia Epifane, Ana Cristina Vidigal Soeiro
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Ordem de não reanimação em pacientes oncológicos na UTI
Gustavo Batista Ferro, Carlos Arthur da Silva Morais, Erick Antonio Rodrigues Mendes, Francinei Gomes Pinto, Marcelo Gaia Epifane, Ana Cristina Vidigal Soeiro
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Yu Jung Kim, Sun-Hyun Kim
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Dae Ho Lee
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4 Web of Science
7 Crossref

Life-Sustaining Treatment States in Korean Cancer Patients after Enforcement of Act on Decisions on Life-Sustaining Treatment for Patients at the End of Life: Young-Woong Won, Hwa Jung Kim, Jung Hye Kwon, Ha Yeon Lee, Sun Kyung Baek, Yu Jung Kim, Do Yeun Kim, Hyewon Ryu; Cancer Res Treat. 2021;53(4):908-916. Published online June 2, 2021; DOI: https://doi.org/10.4143/crt.2021.325

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Purpose
In Korea, the “Act on Hospice and Palliative Care and Decisions on Life-sustaining Treatment for Patients at the End of Life” was enacted on February 4, 2018. This study was conducted to analyze the current state of life-sustaining treatment decisions based on National Health Insurance Service (NHIS) data after the law came into force.
Materials and Methods
The data of 173,028 cancer deaths were extracted from NHIS qualification data between November 2015 and January 2019.
Results
The number of cancer deaths complied with the law process was 14,438 of 54,635 cases (26.4%). The rate of patient self-determination was 49.0%. The patients complying with the law process have used a hospice center more frequently (28% vs. 14%). However, the rate of intensive care unit (ICU) admission was similar between the patients who complied with and without the law process (ICU admission, 23% vs. 21%). There was no difference in the proportion of patients who had undergone mechanical ventilation and hemodialysis in the comparative analysis before and after the enforcement of the law and the analysis according to the compliance with the law. The patients who complied with the law process received cardiopulmonary resuscitation at a lower rate.
Conclusion
The law has positive effects on the rate of life-sustaining treatment decision by patient’s determination. However, there was no sufficient effect on the withholding or withdrawing of life-sustaining treatment, which could protect the patient from unnecessary or harmful interventions.

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Jooseon Lee, So-yun Kim, Duk-ki Kim, Green Hong, Song I Lee
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Impact of the Life-Sustaining Treatment Decisions Act on End-of-Life Care in the Emergency Department
Young Woo Um, Hee Eun Kim, Ji Eun Hwang, Seung Hyun Kang, Jae Hyuk Lee, You Hwan Jo
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Association between the timing of palliative care consultation and end-of-life outcomes in patients with cancer
Jung Sun Kim, Wan Taek Lee, Bhumsuk Keam, Jin-Ah Sim, Shin Hye Yoo
Supportive Care in Cancer.2026;[Epub] CrossRef
Factors Affecting Life-Sustaining Treatment Decisions and Changes in Clinical Practice after Enforcement of the Life-Sustaining Treatment (LST) Decision Act: A Tertiary Hospital Experience in Korea
Yoon Jung Jang, Yun Jung Yang, Hoi Jung Koo, Hye Won Yoon, Seongbeom Uhm, Sun Young Kim, Jeong Eun Kim, Jin Won Huh, Tae Won Kim, Seyoung Seo
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Original Articles

Palliative medicine

Difficulties Doctors Experience during Life-Sustaining Treatment Discussion after Enactment of the Life-Sustaining Treatment Decisions Act: A Cross-Sectional Study: Shin Hye Yoo, Wonho Choi, Yejin Kim, Min Sun Kim, Hye Yoon Park, Bhumsuk Keam, Dae Seog Heo; Cancer Res Treat. 2021;53(2):584-592. Published online November 19, 2020; DOI: https://doi.org/10.4143/crt.2020.735

Abstract PDF PubReader ePub

Purpose
This study aimed to investigate difficulties doctors experience during life-sustaining treatment (LST) discussion with seriously ill patients and their families after enactment of the LST Decisions Act in February 2018.
Materials and Methods
A cross-sectional survey was conducted in a tertiary hospital in the Republic of Korea in August 2019. Six hundred eighty-six doctors who care for seriously ill patients were given a structured questionnaire, and difficulties during the discussion were examined.
Results
One hundred thirty-two doctors completed the questionnaire. Eighty-five percent answered they treat cancer patients. Most (86.4%) experienced considerable difficulties during LST discussions (mean score, 7.4±1.6/10). The two most common difficulties were communication with patients and family and determining when to discuss LST. Two-thirds of doctors found direct discussions with the patient difficult and said they would initiate LST discussions only with family. LST discussions were actually initiated later than considered appropriate. When medically assessing whether the patient is imminently dying, 56% of doctors experienced disagreements with other doctors, which could affect their decisions.
Conclusion
This study found that most doctors experienced serious difficulties regarding communication with patients and family and medical assessment of dying process during LST discussions. To alleviate these difficulties, further institutional support is needed to improve the LST discussion between doctors, patients, and family.

Citations

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Awareness, attitudes, and educational needs regarding the life-sustaining treatment decision-making act in Korea among healthcare providers and medical students: a comparative analysis
Jooseon Lee, So-yun Kim, Duk-ki Kim, Green Hong, Song I Lee
BMC Medical Ethics.2026;[Epub] CrossRef
Rédaction d’un modèle de directives anticipées approprié pour les femmes atteintes d’un cancer du sein : méthode Delphi
Bernard Frèche, Axelle Martinet, Yaritza Carneiro, Marc Besnier, Élodie Poupin
Santé Publique.2026; vol. 38(2): 203. CrossRef
Nurses' engagement in advance care planning practices: A descriptive cross‐sectional study
Sangmin Lee, Naixue Cui, Hyejin Kim
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Patterns of engagement in advance care planning among older people living with cancer: a cross-sectional survey
Supakorn Sripaew, Jennifer Philip, Anna Collins, Pawita Limsomwong, Jennifer Weil, Rungarun Kittichest, Polathep Vichitkunakorn, Sawitri Assanangkornchai
BMC Palliative Care.2025;[Epub] CrossRef
Navigating shared decision-making after the Life-Sustaining Treatment Decision Act: a qualitative study of in-depth interviews with terminal cancer patients, families, and healthcare professionals
Soo-Young Yu, Yu-eun Lee, Sung Joon Shin, Go-un Woo, Dalyong Kim, Jung Hye Kwon, Do Yeun Kim, Eunyoung Eunice Suh
Supportive Care in Cancer.2024;[Epub] CrossRef
Advance Care Planning in Palliative Care in Asia: Barriers and Implications
Yoo Jeong Lee, Sun-Hyun Kim, Shin Hye Yoo, A-Sol Kim, Cheng-Pei Lin, Diah Martina, Masanori Mori, Sang-Yeon Suh
Journal of Hospice and Palliative Care.2024; 27(4): 107. CrossRef
Use of high‐flow nasal cannula oxygen therapy for patients with terminal cancer at the end of life
Jung Sun Kim, Jeongmi Shin, Nam Hee Kim, Sun Young Lee, Shin Hye Yoo, Bhumsuk Keam, Dae Seog Heo
Cancer Medicine.2023; 12(13): 14612. CrossRef
Ethical Issues Referred to Clinical Ethics Support at a University Hospital in Korea: Three-Year Experience After Enforcement of Life-Sustaining Treatment Decisions Act
Shin Hye Yoo, Yejin Kim, Wonho Choi, Jeongmi Shin, Min Sun Kim, Hye Yoon Park, Bhumsuk Keam, Jae-Joon Yim
Journal of Korean Medical Science.2023;[Epub] CrossRef
Advance Care Planning in South Korea
Yu Jung Kim, Sun-Hyun Kim
Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen.2023; 180: 68. CrossRef
Physicians’ attitudes and experiences about withholding/withdrawing life-sustaining treatments in pediatrics: a systematic review of quantitative evidence
Yajing Zhong, Alice Cavolo, Veerle Labarque, Chris Gastmans
BMC Palliative Care.2023;[Epub] CrossRef
Public awareness of advance care planning and hospice palliative care: a nationwide cross-sectional study in Korea
Boram Kim, Junyong Lee, Youn Seon Choi
BMC Palliative Care.2023;[Epub] CrossRef
Analysis of Cancer Patient Decision-Making and Health Service Utilization after Enforcement of the Life-Sustaining Treatment Decision-Making Act in Korea
Dalyong Kim, Shin Hye Yoo, Seyoung Seo, Hyun Jung Lee, Min Sun Kim, Sung Joon Shin, Chi-Yeon Lim, Do Yeun Kim, Dae Seog Heo, Chae-Man Lim
Cancer Research and Treatment.2022; 54(1): 20. CrossRef
Physician decision-making process about withholding/withdrawing life-sustaining treatments in paediatric patients: a systematic review of qualitative evidence
Yajing Zhong, Alice Cavolo, Veerle Labarque, Chris Gastmans
BMC Palliative Care.2022;[Epub] CrossRef
Association of perceived life satisfaction with attitudes toward life-sustaining treatment among the elderly in South Korea: a cross-sectional study
Il Yun, Hyunkyu Kim, Eun-Cheol Park, Suk-Yong Jang
BMC Palliative Care.2022;[Epub] CrossRef
Awareness of Doctors’ Shared Decision-Making in Life-Sustaining Care Decisions
Dalyong Kim, Hyun Jung Lee, Soo-Young Yu, Jung Hye Kwon, Hee Kyung Ahn, Jee Hyun Kim, Seyoung Seo, Chi Hoon Maeng, Seungtaek Lim, Do Yeun Kim, Sung Joon Shin
The Korean Journal of Hospice and Palliative Care.2021; 24(4): 204. CrossRef

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Feasibility Study of Physician Orders for Life-Sustaining Treatment for Patients with Terminal Cancer: Ho Jung An, Hyun Jeong Jeon, Sang Hoon Chun, Hyun Ae Jung, Hee Kyung Ahn, Kyung Hee Lee, Min-ho Kim, Ju Hee Kim, Jaekyung Cheon, JinShil Kim, Su-Jin Koh; Cancer Res Treat. 2019;51(4):1632-1638. Published online April 18, 2019; DOI: https://doi.org/10.4143/crt.2019.009

Abstract PDF PubReader ePub

Purpose
Physician Orders for Life-Sustaining Treatment (POLST) form is a legal document for terminally ill patients to make medical decisions with physicians near the end-of-life. A multicenter prospective study was conducted to evaluate the feasibility of POLST administration in actual oncological practice.
Materials and Methods
Patients with terminal cancer, age ≥ 20 years, and capable of communicating were eligible. The primary endpoint was the completion rate of POLST. Data about physicians’ or patients’ barriers were also collected.
Results
From June to December 2017, 336 patients from seven hospitals were eligible. Median patient age was 66 years (range, 20 to 94 years); 52.7% were male; and 60.4% had poor performance status. Primary cancer sites were hepato-pancreato-biliary (26.2%), lung (23.2%), and gastrointestinal (19.9%). Expected survival duration was 10.6±7.3 weeks, with 41.2% receiving hospice care, 37.9% showing progression after cancer treatment, and the remaining patients were under active treatment (15.8%) or initially diagnosed with terminal cancer (5.1%). POLST forms were introduced to 60.1% of patients, and 31.3% signed the form. Physicians’ barriers were reluctance of family (49.7%), lack of rapport (44.8%), patients’ denial of prognosis (34.3%), lack of time (22.7%), guilty feelings (21.5%), and uncertainty about either prognosis (21.0%) or the right time to discuss POLST (16.6%). The patients’ barriers were the lack of knowledge/understanding of POLST (65.1%), emotional discomfort (63.5%), difficulty in decision-making (66.7%), or denial of prognosis (14.3%).
Conclusion
One-third of patients completed POLST forms, and various barriers were identified. To overcome such barriers, social engagement, education, and systematic support might be necessary.

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Hyeon-Su Im, Insook Lee, Shinmi Kim, Jong Soo Lee, Ju-Hee Kim, Jae Young Moon, Byung Kyu Park, Kyung Hee Lee, Myung Ah Lee, Sanghoon Han, Yoonki Hong, Hyeyeoung Kim, Jaekyung Cheon, Su-Jin Koh
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Dae Seog Heo, Shin Hye Yoo, Bhumsuk Keam, Sang Ho Yoo, Younsuck Koh
The Korean Journal of Hospice and Palliative Care.2022; 25(1): 1. CrossRef
Discussing POLST-facilitated hospice care enrollment in patients with terminal cancer
Ho Jung An, Hyun Jeong Jeon, Sang Hoon Chun, Hyun Ae Jung, Hee Kyung Ahn, Kyung Hee Lee, Min-ho Kim, Ju Hee Kim, Jaekyung Cheon, Su-Jin Koh
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The Medical Orders for Scope of Treatment (MOST) form completion: a retrospective study
Anastasia A. Mallidou, Coby Tschanz, Elisabeth Antifeau, Kyoung Young Lee, Jenipher Kayuni Mtambo, Holly Heckl
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Difficulties Doctors Experience during Life-Sustaining Treatment Discussion after Enactment of the Life-Sustaining Treatment Decisions Act: A Cross-Sectional Study
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Life-Sustaining Treatment States in Korean Cancer Patients after Enforcement of Act on Decisions on Life-Sustaining Treatment for Patients at the End of Life
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Cancer Research and Treatment.2021; 53(4): 908. CrossRef
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11,344 View
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