The purpose of the end-of-life (EOL) discussion is to allow dying patients to die peacefully without undergoing aggressive interventions before death. In Korea, do-not-resuscitate (DNR) is an order to withhold cardiopulmonary resuscitation (CPR) or advanced cardiac life support in respect of the wishes of a patient in case they were to stop breathing or their heart were to stop. A DNR directive must be explained to the patients or the surrogate decision maker during EOL care. Indeed, the DNR directive involves ethical, legal, medical, and economical considerations, and many studies have shown that DNR consent has wide cultural differences [1,2].

In Korea, cultural values and social norms preclude active discussions regarding death. Thus, physicians, family members and patients experience considerable difficulties when communicating with one another about the subject [3]. Equally importantly, the Korean legal system has yet to acknowledge the legal authority of DNR documentation; therefore, EOL care planning is only conducted when death is imminent [4,5]. However, late DNR consent is associated with increased hospital cost [6] and patients receiving unnecessary medical intervention to sustain life [7].

Many experts have recommended that EOL care discussions be initiated while the patient can still actively participate in the discussion [8,9]. However, to the best of our knowledge, there is a lack of data regarding the association between each EOL intervention and the time interval between DNR consent and death, especially in regions such as Korea, where proxy decision-making and imminent DNR consent near death are a common social practice. Therefore, we investigated decision making and current medical practices relating to EOL care of terminal cancer patients in Korea. We also evaluated the association between EOL care and the time interval between provision of DNR consent and death.

We designed a retrospective cohort study composed of patients who had been admitted into expire rooms (designated as rooms for peaceful death), which require DNR consent to occupy, and who died between July 2006 and June 2009 in Seoul National University Hospital (SNUH), a tertiary referral hospital. In SNUH, most patients are referred from primary care physicians or secondary hospitals and receive active chemotherapy and cancer surgery. There is no inpatient hospice unit, and patients who do not want to transfer to a regional hospice center or secondary hospital for hospice care die at SNUH. Patients were required to meet these criteria: admission and death in an expire room, provided DNR consent, being over 18 years of age, diagnosed with cancer and having medical records showing consent and the time interval between DNR consent and death. This study was approved by the Institutional Review Board of SNUH (H-1602-047-739).

Among the 322 patients who expired in an expire room during the study period, 321 died due to terminal cancer. Information about the time interval between DNR consent and death was available for 295 patients of these 321 patients. Medical records and DNR consent were reviewed. Clinical data including age, sex, route of admission, type of cancer, whether verbal or written DNR consent was provided, person( s) who consented DNR (in person or by proxy), and the time interval between DNR consent and death were obtained. DNR consent was defined as the patient having a preprinted DNR form or recorded verbal communication on a medical note. EOL care consisted of invasive medical intervention (e.g., CPR, intubation, and hemodialysis) within 7 days of death and less aggressive medical intervention (e.g., transfusion, antibiotic use, inotropic use, and laboratory test) within 7 days of death.

The subjects were divided into three groups (G1, G2, and G3) according to the time interval between DNR consent and death (G1, 0 < time interval ≤ 1 day; G2, 1 day < time interval ≤ 3 days; and G3, 3 days < time interval). For each individual, implementation of each less aggressive intervention was given a score of 1 (implementation) and 0 (no implementation). All scores were summed to yield the “less aggressive intervention score,” which ranged from 0 to 4.

Early EOL care discussions and planning could help patients meet death with peace and dignity. Previous data also indicate that such discussions lead to reduced medical costs and better allocation of medical resources by decreasing unnecessary and expensive invasive procedures [6,7]. Our results were consistent with these previous reports, and showed that those with earlier DNR consent received fewer aggressive interventions (CPR, intubation, and hemodialysis) and fewer less aggressive interventions, especially inotrope use and laboratory tests. Between 12% and 87% of patient groups provide DNR consent in Korea [4,5,10]. The median time from DNR consent to death in this study was 1.76 days, which is shorter than what has been reported in previous studies. This study was conducted at a tertiary hospital in which patients tend to receive more active anti-cancer therapy. At this facility, 12% of all cancer patients provide DNR consent, and the hospital does not have an inpatient hospice [10]. In general, patients at this facility have little time to discuss the DNR directive before death, and the surrogate(s) have little time to make important EOL care decisions [11].

In this study, fewer transfusions and laboratory tests were performed as the day of death approached. However, use of antibiotics and inotropes did not change, despite initiation of the DNR protocol. According to previous reports in Korea, 68% of the general population and 71% of medical professionals agree that there are ethical and legal differences between withdrawal of treatment and withholding life-sustaining treatment [12], with withholding being acceptable, but withdrawing unacceptable [13]. Our data demonstrate that these ideals were practiced in this setting. For example, if a patient had an infection or hypotension and had already begun to receive antibiotics or inotropes, the physician and/or family might think that withdrawal of those drugs was unethical. However, they may not consider it to be unethical to withhold laboratory tests or transfusions. In turn, these ethical ideals would decrease the frequency of one-time tests and interventions while maintaining regimens that last several days or weeks. Indeed, in our study, the use of antibiotics was not related to the time interval between DNR consent and death, and over 80% of patients were receiving antibiotics. However, those who consented to DNR at least several days before death exhibited less inotrope use and had fewer laboratory tests ordered than those who consented approximately one day before death (i.e., median of 1.76 days between DNR consent and death).

As mentioned in previous studies [4,5,14], DNR discussions and proxy decision-making of DNR consent is emotional, stressful and overwhelming for terminal patients and their families. In Asian cultures, making a decision to withhold or withdraw life-sustaining treatment from a close family member may feel unfilial or unaffectionate. Indeed, family caregivers tend to have a significantly more aggressive attitude toward EOL care for their ill family members than the patients' own stated preferences [15]. Life-sustaining medical interventions can prolong, albeit to a limited extent, the lives of cancer patients near death. While this can be very meaningful and valuable time for families, patients may feel a prolongation of suffering and hope for discontinuation of futile interventions.

The issues regarding EOL decisions for patients who are terminally ill reflect the different cultural backgrounds between Western and Eastern countries. In the United States and many European countries, there is a concept of autonomy and the best interest of the patients in decision making [16,17]. However, Korea, China, and Japan have a family-oriented Confucian culture, and many patients prefer to also consider the best of interest of all family members [18]. Although patients’ autonomy in decision making is important, patients also wish to discuss EOL care with their families. Therefore, family members need to play a large role in the EOL discussion. Earlier discussions of EOL care can help mediate different perspectives among patients and family members regarding life prolongation. Accordingly, physicians should broach the subject of death with cancer patients and family members in advance and help them discuss their EOL care with family members.

It should be noted that there are several limitations to our study. First, because our study was a single-institution study, these results may not reflect typical national practices in Korea. Indeed, there are no large databases and DNR order styles vary drastically among hospitals; therefore, future work should investigate different practices regarding DNR consent from throughout the country. Second, the median time from DNR consent to death in this study was very short compared to other investigations, which again suggests that these data do not accurately represent Korean practices nationwide. However, data from this hospital can still be used to investigate the time interval between DNR consent and death and EOL care in cancer patients, as well as the decision-making course of EOL care near death. Finally, we did not include quality-of-life data. Nevertheless, this study is the first to assess the association between each EOL care intervention and the time interval between DNR consent and death.

In summary, the DNR decision by proxy was typically performed within the last days of the patients’ life in a tertiary referral hospital in Korea. Earlier DNR permission (i.e., at least several days before death) allowed patients to receive fewer aggressive interventions, including CPR, as well as less aggressive interventions in the days before death. Therefore, to spare patients from unnecessary, potentially uncomfortable procedures and reduce medical costs, physicians should disclose terminal prognoses to cancer patients in advance and include patients in EOL care discussions.