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A patient moves through a university hospital in Seoul. /Yonhap

South Korea is set to begin a public consultation on whether to allow life-sustaining treatment to be withheld or withdrawn during the terminal stage of an illness, rather than only when death is imminent. The discussions will examine how patients can decide what medical treatment they wish to receive at the end of their lives and how necessary medical care and support can continue after those decisions are made. Participants will also consider whether people other than family members should be allowed to make decisions on behalf of patients who cannot express their wishes.

The Ministry of Health and Welfare and the Medical Innovation Committee announced Friday that they would hold the "Second Medical Innovation Citizens' Panel Deliberative Forum on Strengthening End-of-Life Medical Care and Support" at Seoul National University's Siheung Campus on Nov. 7 and 8. Approximately 300 citizen panelists will participate in the two-day event, listening to expert presentations, taking part in question-and-answer sessions and holding small-group discussions before gathering their views. 

A key issue will be whether to expand the point at which life-sustaining treatment can be withheld or withdrawn, which is currently limited to patients in the process of dying. Life-sustaining treatment refers to medical interventions, including cardiopulmonary resuscitation, hemodialysis, the administration of anticancer drugs and mechanical ventilation, that merely prolong the dying process without providing therapeutic benefits. The current system sets out procedures for withholding or withdrawing such treatment from patients whose death is imminent.

Withholding or withdrawing life-sustaining treatment requires both a medical determination that the patient is in the process of dying and confirmation of the patient's wishes. The determination must be made jointly by the attending physician and a specialist in the relevant medical field. The patient's wishes are verified through documents such as an advance directive on life-sustaining treatment or a life-sustaining treatment plan. 

An advance directive on life-sustaining treatment is a document in which a person aged 19 or older personally records their wishes regarding decisions to forgo life-sustaining treatment and hospice care. A life-sustaining treatment plan, meanwhile, is prepared by the attending physician in accordance with the wishes of a terminally ill patient or a patient in the process of dying. Although terminally ill patients can prepare such plans in advance, life-sustaining treatment cannot actually be withheld or withdrawn until they are medically determined to be in the process of dying.

The distinction between the terminal stage of an illness and the dying process is important. A terminally ill patient is someone diagnosed with a condition that is expected to result in death within several months because there is no prospect of fundamental recovery despite active treatment and their symptoms continue to worsen. A patient in the process of dying, by contrast, is someone whose death is imminent because there is no possibility of recovery, treatment is no longer effective and symptoms are rapidly deteriorating. This generally refers to the final few days of life. 

On the first day, Nov. 7, participants will discuss whether to maintain the current requirement that life-sustaining treatment can be withheld or withdrawn only during the dying process or to extend that option to the earlier terminal stage of an illness.

On the second day, Nov. 8, discussions will focus on who should be authorized to make decisions when patients are unable to express their wishes. Under the current system, family members play a central role in confirming patients' intentions or making decisions on their behalf.

If a patient has neither an advance directive nor a life-sustaining treatment plan and cannot communicate their wishes, at least two family members must provide consistent statements about the wishes the patient had previously expressed. If the patient's wishes cannot be established at all, a decision must be made through the unanimous agreement of the patient's family. 

The forum will examine how the scope of decision-making authority should be defined if people other than family members are permitted to make decisions on a patient's behalf. Participants will also discuss who should make decisions when a patient's wishes cannot be confirmed and no one is available to act on their behalf, as well as what procedures and safeguards would be necessary.

In addition, participants will consider where patients should be able to spend the final stage of their lives and what medical and caregiving support would be needed to make that possible. The aim is to examine both patients' choices regarding life-sustaining treatment and the protection and support they need afterward.

The public consultation is intended to gather opinions for potential improvements to the system. No changes have yet been made to the point at which life-sustaining treatment may be withheld or withdrawn or to the scope of surrogate decision-making authority.

"Respecting patients' wishes at the end of life and ensuring that they receive sufficient medical care and support are both important issues that must be considered together," said Lee Hyung-hoon, South Korea's second vice minister of health and welfare.

"Through this public consultation, we will listen to a wide range of public opinions and examine policy measures to ensure that patients receive the protection and support they need while respecting their dignity and right to self-determination," he added.

                                                                                                                 Lee Se-mi