Korean Experience of Withholding and Withdrawing of Life-Sustaining Therapy in Intensive Care Units

Introduction

Patients should be treated with dignity and respect at the end of their lives, and unnecessary and painful life-sustaining therapy (LST) should be avoided. A painful end-of life (EOL) experience of a loved one remains in the memories of the relatives. Family members of critically ill patients often ask physicians about withholding or withdrawing (WH/WD) of LST. Open communication of physicians and patients or their surrogates could allow physicians to develop plans for better EOL care. In the present report, we describe the current status of WH/WD of LST in intensive care units (ICUs) in Korea.

Withholding (WH) and Withdrawing (WD) of Life-Sustaining Therapy (LST) in Korea: Past and Present

The Korean medical society did not have much attention to advance care planning for EOL care until recently. EOL care should be individualised based on socially agreed-upon guidelines that meet a patient's and family's wishes about LST. Physicians should identify, document, and respect patients' needs, priorities, and preferences for EOL care. However, there is no generally accepted consensus regarding EOL care decision-making in Korean society at large, or even the Korean medical community.

EOL care has been dependent on a physician's individual perceptions and preferences. In 2007, a questionnaire survey (Kim, Kang, Koh, and Koh 2009) of 100 members of the Korean Society of Critical Care Medicine evaluated the attitudes and practices of critical care physicians in Korean ICUs regarding EOL care decisions. There were 88 responses from individuals in 53 different institutions. The results indicated significant differences between perceptions and actual practices regarding WH/WD of LST. Attitudes and practices varied according to the respondents' clinical experience years of service as a critical care professional, and medical specialty. Physicians with relatively short careers as critical care specialists tended not to agree to the WH/WD of LST. However, even among young physicians, there was a discrepancy between their attitudes and actual practices depending on the consent of patients and families, or the competence of patients, and the request for a surrogate. That reflected the current level of perception of Korean critical care physicians on the WH/WD of LST. These results suggest a need to provide consensus guidelines and continued medical education on LST for Korean physicians and healthcare workers in ICUs.

Among all EOL decision-making processes, a do-not-resuscitate (DNR) order in the event of cardiac arrest is the most common discussion between a patient's family and physicians. A previous study (Lee, Jang, Hong, Lim, and Koh 2008) of ICU patients with DNR orders in one medical centre reported that families are accepting of DNR orders proposed by attending physicians. However, most DNR orders are not initiated by clinicians till a patient's death is imminent.

The above study (Kim et al. 2009) reported that 75% of respondents considered that more than three discussions were needed to communicate with patients or families about the WH/WD of LST. However, only 60.8% of all respondents actually had three or more discussions on this topic. Regarding informed consent, 89.7% of ICU physicians endorsed the need for Advance Directives (AD). However, this policy is not yet institutionalised in most Korean ICUs. A total of 93.8% of respondents recognised the need for ethics committees and a multidisciplinary team approach to resolve the decisions regarding EOL decisions, and 96.6% agreed on the need for standardised guidelines.

There are recent movements to establish a "death with dignity act" in the Korean National Congress, following a legal case (2009Da17417 Decided, May 2009) by the family of a patient in a persistent vegetative state which requested withdrawal of mechanical ventilator support. A set of consensus guidelines (published in 13 October 2009) prepared by a task force team for withdrawal of LST has been endorsed by the Korean Medical Association, the Korean Academy of Medical Science, and the Korean Hospital Association.

However, in our own survey on the 2009 consensus guidelines regarding the WH/WD of LST, 26 respondents of 81 Korean critical care...