Healthcare utilization and end-of-life care based on life-sustaining treatment decisions in patients with cancer

Since the implementation of the 2018 Act on Hospice and Palliative Care and Decisions on Life-Sustaining Treatment (LST), South Korea has legalized the advance directive (AD) and LST Plan-an immediately actionable medical order-and permitted family members to make related decisions. However, the respective roles and clinical influences of these decision types remain unclear. Therefore, this study aims to compare healthcare utilization and end-of-life (EOL) care based on LST decisions.

A retrospective chart review was conducted of 801 patients with cancer who died at Chonnam National University Hwasun Hospital (CNUHH) between May 2022 and December 2023. LST decisions were categorized into AD, LST Plan, and family decision groups. Data were extracted from electronic medical records, and interrater reliability was confirmed (κ = .81). Group differences were analyzed using the χ², Fisher's exact, and Kruskal-Wallis tests with Bonferroni correction. Multivariable logistic regression analyses were further performed to identify factors independently associated with ICU and hospice utilization.

The family decision group was older, more often unconscious at admission, had more comorbidities, and experienced shorter intervals between LST decision and death. This group also showed the highest ICU utilization, average daily medical costs, and aggressive EOL care. In contrast, the LST Plan group had higher hospice use, structured EOL education, greater analgesic use, and more central venous catheterization. The AD group exhibited intermediate patterns for most indicators.

Healthcare utilization and EOL care significantly differed by LST decision type among patients with cancer. The LST Plan group reflected more comfort-oriented care, whereas the family decision group received more aggressive EOL care, with the AD group showing intermediate patterns. These findings suggest that earlier discussions supporting patient self-determination may help align care with patient preferences.