The current study by Kim et al. [1] identified factors affecting the decision to withdraw LST of Korean patients admitted to the ICU. It evaluated how the decision to withdraw LST affects the actual use of medical services by comparing medical costs through retrospective analysis in a tertiary hospital. The authors observed that LST withdrawal decisions are affected by subject age, readmission rate, and disease categories. Notably, families made 86% of LST withdrawal decisions, but the decision rates varied according to disease. The total hospital cost was higher in the LST withdrawal group than in the control group, and there was no significant difference between the groups in the ICU cost. The authors concluded that LST withdrawal should be tailored to the individual characteristics of critically ill patients.

This study was based on the Korean LTS Decision Act, so the results are limited to Korea. However, it can be used as a reference in Asian countries with Confucian culture. There are several points to note when interpreting the results. Most of the ICU patients are those with acutely deteriorated physical conditions, and most had no LST plans at admission, regardless of the type of disease. Unlike incurable diseases such as terminal cancer, acute diseases such as neurological diseases and infections are not easy for patients and their families to consider LST plans before the disease occurs. As EOL patients with chronic diseases are likely to have sufficient consultation with a doctor treating them in the long term, it is likely that families of patients with acute diseases would discuss the LST withdrawal plan with unfamiliar ICU doctors without providing sufficient time for decision. Therefore, the decision making process of LTS withdrawal must be different in the ICU versus non-ICU setting.

The admission route (through the emergency room vs. the general ward) to the ICU should also be considered. If patients are admitted to the ICU during treatment in a general ward, the length of hospitalization is longer than that of those admitted to the ICU through the emergency room, the medical costs are higher, and patients and their families have time to determine the patient's condition in the general ward. Despite the long hospitalization period and high ICU readmission rate, there was no significant difference in ICU medical costs or the lengths of ICU stay between the LST withdrawal group and the control group in this study. Thus, decision-making on LST withdrawal could be more affected by the psychological aspect of the patient's expectation of recovery than the economic aspect.

The mortality rates of the LST withdrawal group and the control group were not statistically different (66% vs. 58%) in this study. One-third of LST withdrawal patients did not die, indicating the possibility of over-diagnosing EOL patients. Decisions of EOL often are affected by the subjective characteristics of ICU doctors and families [2,3]. This finding supports the need for a more precise and tailored LST decision-making process. In addition, the items of LST withdrawn are important to explain the mortality results, although such data were not analyzed in this study.

Consequently, Kim et al. [1] showed factors affecting LST withdrawal decisions in ICU patients and the importance of LST decision plans tailored to the individual characteristics of critically ill patients. Studies considering the cultural background peculiar to Asian countries, where discussion of family deaths is considered a taboo subject [4], are scarce, and the subject of the decision to suspend LST, the method of LST withdrawal, and the location of death differ between South Korea and Western countries [4-6]. Thus, further research to develop the optimal LST decision process based on Korean culture is needed, and the current results will enhance the research interests in EOL care in the ICU in South Korea.