General characteristics of groups
Subjects were categorized into four groups according to the LST decision-making method. Each group’s descriptive statistics show a significant relationship between the variables; particularly, age, disease, and hospice use of patients showed differences in each group (Table S1).
Characteristics of patients determined by POLST (G1)
G1 included patients who have written a POLST, an end-of-life judgment, and an implementation. They included 62.71% men and 37.29% women. Their average age was 66.86 years, with the majority in their 70s. The proportion of foreigners was 1.55%. There were 20 minors (0.07%) with average age of 14.3 years, and except for one person aged 18 years, a plan was prepared through agent confirmation. G1 mainly suffered neoplastic diseases (86.36%) and had terminal conditions (63.98%) when writing the POLST.
Medical institutions were mainly concentrated in the metropolitan areas of Seoul (37.22%) and Gyeong-gi (18.70%), and 55.69% were tertiary hospitals and 39.98% general hospitals. Specialists who judged patient’s end-of-life mainly specialized in internal medicine (71.46%), followed by family medicine (10.17%).
Considering patient’s LST-related characteristics, about 0.8% of ADs were written before POLST, and 12.21% used hospice-palliative care services. The content of forgoing LST mainly included cardiopulmonary resuscitation (97.80%), followed by ventilator (96.85%), hemodialysis (90.62%), and chemotherapy (74.54%). More than half of the patients (58.2%) wrote the end-of-life judgment, POLST, and implementation on the same day. Moreover, 29.1% of patients wrote the POLST first and then later completed the end-of-life judgment and implementation on the same day.
Characteristics of patients determined by AD (G2)
G2 included patients who prepared AD, reaffirmed the contents through the confirmation form, and completed the end-of-life judgment and implementation. They included 60.56% men and 39.55% women. Their average age was 74.13 years, and they were mainly in their 70s (37.23%) and 80s or older (34.50%). G1 subjects mostly had neoplasms (65.50%) and respiratory disease (12.31%).
Medical institutions were mainly concentrated in the metropolitan area of Seoul (36.40%) and Gyeong-gi (26.52%), with 51.37% tertiary hospitals and 42.63% general hospitals. Specialists who judged patient’s end-of-life were mainly specialized in internal medicine (66.64%), followed by family medicine (8.66%).
A total of 14.59% used hospice-palliative care services. The content of forgoing LST mainly included cardiopulmonary resuscitation (96.12%), followed by ventilator (90.88%), hemodialysis (87.77%), and chemotherapy (76.06%). In G2, 79.7% of patients reconfirmed the AD content, end-of-life judgment, and implementation the same day. It took an average of 157.25 (standard deviation [SD]: 151) days after writing the AD to reconfirm it.
Characteristics of patients determined by witness by the family (G3)
G3 included patients whose wishes were confirmed through family statements and who had prepared an end-of-life judgment and implementation. They included 56.71% men and 43.29% women. Their average age was 75.24 years, with mainly those over 80 years (42.58%) and 70 years (30.13%). The diseases included neoplasms (46.58%), respiratory diseases (20.04%), and circulatory diseases (12.68%).
Medical institutions were located mostly in Seoul (33.74%), Gyeong-gi (15.59%), and Dae-gu (10.03%), with 63.71% tertiary hospitals and 32.46% general hospitals. Most specialists who judged patients’ end-of-life specialized in internal medicine (78.25%).
Among the patients, 0.22% had previously written AD and 2.37% used hospice-palliative care services. The content of forgoing LST included mainly cardiopulmonary resuscitation (97.52%), followed by ventilator (83.35%), hemodialysis (80.81%), and chemotherapy (56.92%). In G3, 83.4% of patients confirmed through the family with an end-of-life judgment and implementation on the same day. The average number of family member participating was 2.1 (SD 0.48), and the statements were mostly made by the son, daughter, and spouse, in order.
Characteristics of patients determined by consent of family (G4)
G4 included patients who completed the consent of family, end-of-life judgment, and implementation forms. They included 60.14% men and 39.86% women. Their average age was 70.46 years, and they were mainly over 80 years (31.35%) and 70 years (29.76%). The diseases included neoplasms (41.13%), respiratory diseases (19.47%), and circulatory diseases (16.87%).
Medical institutions were located mostly in Seoul (36.31%) and Gyeong-gi (16.81%), with 66.35% tertiary hospitals and 32.16% general hospitals. Most specialists who judged patients’ end-of-life specialized in internal medicine (71.37%).
Moreover, 0.12% of patients had previously written AD, and 1.02% had used hospice-palliative care. The content of forgoing LST mainly included cardiopulmonary resuscitation (97.40%), followed by hemodialysis (74.94%), ventilator (72.91%), and chemotherapy (49.48%). In G4, 78.9% of patients had consent of the family with an end-of-life judgment and implementation on the same day. The average number of family members participating in decision-making was 3.42 (SD 1.58), with consent given by the son, daughter, and spouse, in order.
Characteristics of self-decision-making
This study also conducted a regression analysis to determine the characteristics of patients’ self-determination of withdrawal and withholding of LST. Significant differences existed between self-determined and family-determined according to age, type of medical institution, region, whether AD was prepared, and refusal of some medical treatment (see Table S2).
Self-determination rate of patients in their 40s was 5.685 times higher than that of patients in their 80s. The self-determination rate for patients with circulatory disorders was 0.246 times lower than that of patients with neoplasms; this rate for patients with gastrointestinal disorders was 0.552 times lower than that of patients with neoplasms.
The rate of self-determination of general hospital inpatients was 0.021 times lower than that of those in tertiary hospitals. Regarding subjects of specialists, the self-determination rate of patients with end-of-life judgments by family medicine specialists was 3.460 times higher than that of patients with judgments by internal medicine specialists.
Moreover, the self-determination rate in Gwang-ju was 0.082 times lower than that in Seoul, and that in Gyeongbuk was 0.084 times lower than that in Seoul. Compared with Seoul, the rate was 1.934 times higher in Ulsan, 2.471 times higher in Gyeong-gi, 1.597 times higher in Chung-buk, and 1.987 times higher in Je-ju.
The self-determination rate of patients who had previously prepared AD was 117.475 times higher than that of those who did not.
This rate for patients who decided to withdraw or withhold a ventilator was 5.300 times higher than that of patients who did not, and the rate for patients who decided to withdraw or withhold hemodialysis was 2.120 times higher than that of patients who did not.