Comparison of the end-of-life decisions of patients with hospital-acquired pneumonia after the enforcement of the life-sustaining treatment decision act in Korea

Ae-Rin Baek; Sang-Bum Hong; Soohyun Bae; Hye Kyeong Park; Changhwan Kim; Hyun-Kyung Lee; Woo Hyun Cho; Jin Hyoung Kim; Youjin Chang; Heung Bum Lee; Hyun-Il Gil; Beomsu Shin; Kwang Ha Yoo; Jae Young Moon; Jee Youn Oh; Kyung Hoon Min; Kyeongman Jeon; Moon Seong Baek; Korean HAP/VAP Study Group

doi:10.1186/s12910-023-00931-y

Comparison of the end-of-life decisions of patients with hospital-acquired pneumonia after the enforcement of the life-sustaining treatment decision act in Korea

BMC Med Ethics. 2023 Jul 18;24(1):52. doi: 10.1186/s12910-023-00931-y.

Authors

Ae-Rin Baek¹, Sang-Bum Hong², Soohyun Bae³, Hye Kyeong Park⁴, Changhwan Kim⁵, Hyun-Kyung Lee⁶, Woo Hyun Cho⁷, Jin Hyoung Kim⁸, Youjin Chang⁹, Heung Bum Lee¹⁰, Hyun-Il Gil¹¹, Beomsu Shin¹², Kwang Ha Yoo¹³, Jae Young Moon¹⁴, Jee Youn Oh¹⁵, Kyung Hoon Min¹⁵, Kyeongman Jeon¹⁶, Moon Seong Baek¹⁷; Korean HAP/VAP Study Group

Affiliations

¹ Division of Allergy and Pulmonary Medicine, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea.
² Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
³ Department of Integrated Internal Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea.
⁴ Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Ilsan, Korea.
⁵ Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea.
⁶ Department of Internal Medicine, Division of Pulmonology, Allergy and Critical Care Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea.
⁷ Division of Allergy, Pulmonary and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Busan, Korea.
⁸ Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
⁹ Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea.
¹⁰ Department of Internal Medicine, Research Center for Pulmonary Disorders, Jeonbuk National University Medical School, Jeonju, Korea.
¹¹ Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea.
¹² Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea.
¹³ Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea.
¹⁴ Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Chungnam National University College of Medicine, Sejong Hospital, Sejong, Korea.
¹⁵ Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea.
¹⁶ Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
¹⁷ Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-Ro, Dongjak-Gu, Seoul, 06973, Republic of Korea. wido21@cau.ac.kr.

Abstract

Background: Although the Life-Sustaining Treatment (LST) Decision Act was enforced in 2018 in Korea, data on whether it is well established in actual clinical settings are limited. Hospital-acquired pneumonia (HAP) is a common nosocomial infection with high mortality. However, there are limited data on the end-of-life (EOL) decision of patients with HAP. Therefore, we aimed to examine clinical characteristics and outcomes according to the EOL decision for patients with HAP.

Methods: This multicenter study enrolled patients with HAP at 16 referral hospitals retrospectively from January to December 2019. EOL decisions included do-not-resuscitate (DNR), withholding of LST, and withdrawal of LST. Descriptive and Kaplan-Meier curve analyses for survival were performed.

Results: Of 1,131 patients with HAP, 283 deceased patients with EOL decisions (105 cases of DNR, 108 cases of withholding of LST, and 70 cases of withdrawal of LST) were analyzed. The median age was 74 (IQR 63-81) years. The prevalence of solid malignant tumors was high (32.4% vs. 46.3% vs. 54.3%, P = 0.011), and the ICU admission rate was lower (42.9% vs. 35.2% vs. 24.3%, P = 0.042) in the withdrawal group. The prevalence of multidrug-resistant pathogens, impaired consciousness, and cough was significantly lower in the withdrawal group. Kaplan-Meier curve analysis revealed that 30-day and 60-day survival rates were higher in the withdrawal group than in the DNR and withholding groups (log-rank P = 0.021 and 0.018). The survival of the withdrawal group was markedly decreased after 40 days; thus, the withdrawal decision was made around this time. Among patients aged below 80 years, the rates of EOL decisions were not different (P = 0.430); however, mong patients aged over 80 years, the rate of withdrawal was significantly lower than that of DNR and withholding (P = 0.001).

Conclusions: After the LST Decision Act was enforced in Korea, a DNR order was still common in EOL decisions. Baseline characteristics and outcomes were similar between the DNR and withholding groups; however, differences were observed in the withdrawal group. Withdrawal decisions seemed to be made at the late stage of dying. Therefore, advance care planning for patients with HAP is needed.

Keywords: Healthcare-associated pneumonia; Resuscitation orders; Terminal care; Withholding treatment.

Publication types

Multicenter Study
Research Support, Non-U.S. Gov't

MeSH terms

Aged
Aged, 80 and over
Death
Decision Making
Hospitals
Humans
Neoplasms*
Pneumonia* / therapy
Republic of Korea / epidemiology
Resuscitation Orders
Retrospective Studies
Withholding Treatment