A new study suggests that since the implementation of Korea's Life-Sustaining Treatment Decision Act in 2018, in-hospital cardiopulmonary resuscitation (CPR) has been increasingly focused on patients with a higher likelihood of recovery.
Seoul National University Bundang Hospital announced Monday that a research team led by Professors Oh Tak-kyu and Song In-ae of the Department of Anesthesiology and Pain Medicine reached these findings after analyzing 380,488 adult patients nationwide who received in-hospital CPR between 2013 and 2023, using big data from the National Health Insurance Service.
The Life-Sustaining Treatment Decision Act is a system that allows patients in the dying process to decide on their own to discontinue life-sustaining treatment aimed solely at prolonging life. It has been in effect since February 2018 to guarantee patients' right to self-determination and dignity, and to establish legal and institutional standards for end-of-life care. Life-sustaining treatments include CPR, as well as mechanical ventilation, ECMO (extracorporeal membrane oxygenation) therapy, and continuous renal replacement therapy involving dialysis for more than 24 hours. Before the law took effect, there was a strong tendency in Korea's medical field to perform CPR and other life-sustaining treatments even when the likelihood of recovery was low. This was because medical staff faced the risk of legal punishment for discontinuing life-sustaining treatment, even when its medical effectiveness was minimal. Such an environment undermined patient dignity, increased burdens on families, and contributed to overloading the medical system.
To determine whether the enforcement of the law brought changes to end-of-life care, the research team compared and analyzed patterns of in-hospital CPR nationwide during the periods of 2013-2017 and 2019-2023, before and after the law's implementation. The year 2018, the first year of implementation, was excluded from the study sample to account for confusion during the system's settling-in period.
The results showed that the relative mortality risk of patients who received in-hospital CPR after the law's implementation was 0.90, representing a decrease of about 10% compared to before the law took effect. The research team interpreted this as likely reflecting a more selective application of CPR, concentrated on patients with relatively higher chances of recovery, rather than an increase in the total number of lives saved.
The study also confirmed an effect of partially alleviating the overload at critical care sites. Before the law was enforced, in-hospital cardiac arrest and CPR cases were rapidly increasing at a rate of 6.5 per 100,000 population annually, but after implementation, the rate of increase slowed significantly to 1.1 per 100,000. The research team explained that this suggests the Life-Sustaining Treatment Decision Act has helped reduce medically futile CPR on patients with extremely low recovery prospects, moving the medical field toward a more appropriate allocation of limited critical care resources. The study is considered meaningful in that it analyzed nationwide data over a long period.
"The results show that the Life-Sustaining Treatment Decision Act has improved the efficiency of critical care and contributed to the allocation of medical resources," Professor Oh said. "Going forward, the system should evolve beyond the quantitative expansion of life-sustaining treatment decisions toward enhancing the quality of shared decision-making involving patients, families, and medical staff."
The research findings were published in Critical Care Medicine, the official journal of the Society of Critical Care Medicine in the United States.
