KJCKorea
Journal Central

Although South Korea’s Life-Sustaining Treatment Act institutionalized self-determination in end-of-life care, a substantial gap remains between stated preferences and care delivered near death. This study examines the pathway through which patient preferences are formed, documented, and translated into care. Using National Health Insurance claims for 2013–2023 (N ≈ 2.59 million decedents aged ≥ 65), we compare the pre-implementation (2013–2017) and post-implementation (2019–2023) periods, quantifying burdens through an LST Distress Index and associated expenditures. Claims are complemented by surveys of 500 older cancer patients, 1,000 bereaved family members, and a randomized experiment among 2,000 adults. Findings show that despite the Act, end-of-life LST exposure remains common, decisions are often delayed, and burdens concentrate in the final stage of life. This gap reflects frictions across linked stages: limited early conversations, unspecified or inaccessible documentation, uneven ethics committee access, uncertainty in determining the dying phase, and weak palliative care continuity. We propose policy interventions to strengthen the linkage between early preference formation and clinical execution, including integrating advance directives with physician-patient advance care planning, broadening participation, addressing institutional blind spots, and enhancing care continuity.

This commentary examines the ethical implications of the mandatory provision of artificial nutrition and hydration (ANH) under Korea’s Act on Decisions on Life-Sustaining Treatment. Building upon a target article derived from a policy research report, we focus on the proposal to incorporate ANH into advance directives and argue that the current legal framework creates serious clinical ethical problems. Although ANH is widely recognized as a medical intervention requiring individualized proportional judgment, the Act effectively mandates its provision even during the end-of-life process. We argue that this rigid approach violates the principles of nonmaleficence, justice, and respect for autonomy by prolonging suffering, producing unequal end-of-life options across institutional settings and according to the type of intervention sustaining patients’ lives, and undermining trust between patients and clinicians. Accordingly, ANH should not be treated as a universal obligation but as a medical intervention subject to proportionality, patient preferences, and clinical judgment. Finally, we argue that active public deliberation is necessary for the ethical and legal incorporation of ANH into advance directives.

South Korea's life-sustaining treatment decision-making system, despite institutional expansion following legislative reform, continues to face friction in translating patient preferences into clinical reality. Three assumptions underlying the current system warrant reexamination. First, insights from the advance care planning outcomes debate, affective forecasting, and the disability paradox reveal that patient preferences are not stable, predefined objects, but rather an evolving process of formation, reformation, and translation. Second, within Korea's relational decision-making culture, family consensus operates not merely as an external constraint on autonomy but as a medium through which autonomy is shaped; critiques of family-unanimity provisions should therefore focus on the quality of dialogue rather than on the minimization of family involvement. Third, in cases of progressive cognitive decline such as dementia, the temporal authority of precedent autonomy reaches its limit, calling for approaches that accommodate patients’ fluctuating capacity. Advance directives should therefore be redesigned from static, one-time documents into iterative, relational dialogues anchored in clinical ethics committees and integrated community care.