The Bank of Korea published an issue note reviewing Korea's life-sustaining treatment decision system and arguing that patients' stated preferences are not being fully reflected in clinical practice. While the Decisions on Life-Sustaining Treatment Act has become more established since taking effect in 2018 and registered advance directives have exceeded 3 million, the note finds a wide gap between preferences and outcomes. Among adults aged 65 and older, 84.1% said they would refuse life-sustaining treatment when recovery is not possible, but only 16.7% of deceased people in that age group actually had treatment withheld or withdrawn. The number of older decedents receiving life-sustaining treatment rose at an average annual rate of 6.4% between 2013 and 2023, reaching 67% of decedents in 2023. The note attributes the gap to barriers across the full decision chain. Advance discussion is limited by low awareness, reluctance to discuss death and a binary advance directive that does not capture treatment-specific choices, while registration remains restricted to a small group of designated institutions and generally requires in-person visits. Access is also constrained at the hospital stage because ethics committees are concentrated in large metropolitan hospitals, with only 13 shared ethics committees supporting about 200 institutions nationwide. In implementation, withdrawal is allowed only once a patient is determined to be in the end-of-life process, a threshold the note says is medically difficult and subjective, contributing to delayed decisions. Among withdrawals made within one month before death, about 40% occurred only in the final week, after patients had received an average of 6.8 interventions in that month. The paper also points to weak post-withdrawal care capacity, with 103 inpatient hospice institutions nationwide in 2025 and a large gap between hospice willingness and actual use. It says out-of-pocket end-of-life medical spending per patient receiving life-sustaining treatment nearly doubled from KRW 5.47 million in 2013 to KRW 10.88 million in 2023, equivalent to about 40% of median household income for households headed by people aged 65 and older. The issue note proposes four reform directions. These are broader public education and participation channels, including community clinics and digital access for advance directives, a more personalized directive that allows treatment-specific choices and could later incorporate issues such as artificial nutrition and hydration, organ donation and a healthcare proxy, stronger institutional support to reduce ethics committee blind spots and discussion of whether withdrawal should remain limited to the end-of-life process, and expanded hospice and palliative care with better continuity of care after withdrawal. It suggests a phased approach where elements requiring wider social deliberation are introduced gradually.
Bank of Korea2026-03-05
Bank of Korea issue note finds major gap between end of life treatment preferences and practice, proposes personalized directives
The Bank of Korea published an issue note saying Korea's life-sustaining treatment system still leaves a large gap between patient preferences and clinical practice. It highlights an 84.1% refusal intention among older adults versus a 16.7% actual withholding or withdrawal rate, alongside rising treatment use, late decision-making and higher end-of-life costs. The paper proposes more detailed advance directives, wider access through clinics and digital channels, better ethics committee coverage, possible healthcare proxies and stronger hospice and palliative care capacity.