Physician's Role and Obligation in the Withdrawal of Life-sustaining Management

Patients should be treated with dignity and respect toward the end of their lives, being freed from unnecessary and painful life-sustaining therapy in hospitals. In Korea, the quality of end-of-life (EOL) care has been variable, a major factor being the physicians' perception to the care. A firm consensus of EOL care decision-making has not yet explicitly stated in Korean law and ethics until recently. However, movements to make a law of so-called "the death with dignity act" are presently making its way to the National Assembly, initiated by a law case that allowed the hospital to withdraw mechanical ventilator support per request by the patients' family of a permanently vegetative patient. Socially agreed guidelines for EOL care can facilitate clinical decision process and communication between health service provider and the patient or his/her family. At the same time, EOL care should be individualized also in the same line of guideline to meet patient' and patient' family wish regarding the withdrawal of life-sustaining therapy. The painful EOL care experience of the loved one remains in the memory of the relatives who live on. Physicians should identify, document, respect, and act on behalf of the hospitalized patients' needs, priorities, and preference for EOL care. It has been advocated that competent patients can express their right of self-determination on ECL care through advance directives in Western countries. Advance directives are considered as a tool to facilitate EOL decision making. However, there are barriers to adopt the advance directives as a legitimate tool for an EOL decision making in Korea. For one thing, the reality of death and dying is rarely discussed in our society. In addition, the discussion about EOL care with chronically and critically ill patients has been considered as a taboo in the hospitals. In spite of these difficulties, physicians could do better EOL care by the open communication with patients or with their surrogates. Through the communication, physician should set a goal how to manage the EOL patient. The set goal should be shared among the caregivers to achieve the maximum benefit of the patient. The lack of open discussion with patient prior to EOL care results in inappropriate protraction of a patient's dying process. In summary, physicians, who know the clinical significance of delivering treatments to EOL patients, should play a central role in assisting patients' and their families' to make the best decision on EOL care. Moreover, the concerted actions to improve EOL care in our society among general public, professionals, stakeholders for EOL care, and governmental organizations are required to address ongoing social requests, although a policy or a guideline is made in this time.