Comparison of factors influencing the decision to withdraw life-sustaining treatment in intensive care unit patients after implementation of the Life-Sustaining Treatment Act in Korea

Abstract

Background: The decision to discontinue intensive care unit (ICU) treatment during the end-oflife stage has recently become a significant concern in Korea, with an observed increase in life-sustaining treatment (LST) withdrawal. There is a growing demand for evidence-based support for patients, families, and clinicians in making LST decisions. This study aimed to identify factors influencing LST decisions in ICU inpatients and to analyze their impact on healthcare utilization.

Methods: We retrospectively reviewed medical records of ICU patients with neurological disorders, infectious disorders, or cancer who were treated at a single university hospital between January 1, 2019 and July 7, 2021. Factors influencing the decision to withdraw LST were compared between those who withdrew LST and those who did not.

Results: Among 54,699 hospital admissions, LST was withdrawn in 550 cases (1%). Cancer was the most common diagnosis, followed by pneumonia and cerebral infarction. Among ICU inpatients, LST was withdrawn from 215 (withdrawal group). The withdrawal group was older (78 vs. 75 years, P=0.002), had longer total hospital stays (16 vs. 11 days, P<0.001), and higher ICU readmission rates than the control group. There were no significant differences in the healthcare costs of ICU stay between the two groups. Most LST decisions (86%) were made by family.

Conclusions: The decisions to withdraw LST of ICU inpatients were influenced by age, readmission, and disease category. ICU costs were similar between the withdrawal and control groups. Further research is needed to tailor LST decisions in the ICU.

Keywords: cancer; death; healthcare cost; intensive care unit; palliative care; terminal care.

Figure 1.

Distribution of diseases between patients for whom life-sustaining treatment was withdrawn and the control group. Patients in the life-sustaining treatment (LST) group and control group were assigned to one of three common critical disease categories of neurological disorders, infectious disorders, and cancers. The proportion of cancer patients was significantly higher in the withdrawal group than the control group. Conversely, the numbers of patients with neurological disorders and infectious disorders were higher in the control group than the withdrawal group. ICU: intensive care unit.

Figure 2.

Types of intensive care performed in the life-sustaining treatment (LST) withdrawal group (A) and control group (B) during their intensive care unit stay. The legal definition of LST includes not only cardiopulmonary resuscitation (CPR), but also mechanical ventilation, hemodialysis, vasopressors, and blood transfusion, which are commonly performed in intensive care units. The most common intensive care received during the intensive care unit stay among those who withdrew LST was, in order of frequency, mechanical ventilation, vasopressor usage, and blood transfusions. ECLS: extracorporeal life support.

Figure 3.

Identity of decision-makers to withdraw life-sustaining treatment among intensive care unit inpatients. Overall, withdrawal of life-sustaining treatment was predominantly by family determination, but it varied by the nature of the disease: self-determination was higher for cancer patients compared to other diseases and lower for neurological disorders with altered consciousness and sepsis with the possibility of rapid deterioration.