Awareness, attitudes, and educational needs regarding the life-sustaining treatment decision-making act in Korea among healthcare providers and medical students: a comparative analysis

Abstract

Background

The Life-Sustaining Treatment (LST) Decision-Making Act is a South Korean law that aims to empower patients by providing them with more autonomy in end-of-life care decisions. However, there are significant differences between the law’s intentions and its implementation in clinical practice. It is essential to understand the perceptions of current and future healthcare professionals regarding LST in order to improve education, policy and patient-centred decision-making. This study aimed to compare the knowledge, attitudes and perceptions of LST among practicing healthcare professionals and medical students with clinical exposure to LST decision-making.

Methods

A cross-sectional survey was conducted from August to December 2023 at a tertiary hospital in South Korea. The participants included healthcare providers (physicians, trainees, and nurses) and medical students with clinical experience. The survey assessed self-reported knowledge, attitudes, and perceptions of the LST Decision-Making Act. Group differences were analyzed using chi-square tests and logistic regression analyses.

Results

A total of 297 participants responded, including 204 healthcare providers and 93 medical students. Healthcare providers reported significantly higher self-perceived knowledge (88.7% vs. 52.7%) and confidence in participating in LST decisions (69.6% vs. 37.6%) than medical students (both p < 0.001). Both groups supported the ethical purpose of the Act and the need for advance directives, but their educational priorities differed. Providers emphasized procedural knowledge, whereas students prioritized ethical education. Perceptions regarding the timing, decision-makers, and withdrawal of treatment varied. Multivariate analysis revealed that professional roles were independently associated with perceived knowledge and competence. Many healthcare providers have reported systemic barriers, including complex documentation and limited patient or caregiver understanding. Notably, over 25% of providers indicated a continued reliance on Do-Not-Resuscitate forms because of procedural challenges.

Conclusions

This study revealed substantial differences in perceptions of LST between healthcare providers and medical students. The findings underscore the need for improved educational programs and standardized protocols to effectively implement LST legislation and highlight significant implementation gaps.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-025-01363-6.

Background

Life-sustaining treatment (LST) refers to medical interventions that artificially prolong a patient’s life when natural processes would otherwise result in death. As medical technology advances worldwide, questions about the quality of end-of-life care have emerged alongside traditional concerns about quality of life [1]. This evolving landscape underscores the importance of examining how to balance patient autonomy with the clinical and ethical expertise of healthcare professionals, especially in decision-making processes involving LST [2].

The enactment of the LST Decision Act in South Korea in 2018 was a major milestone in promoting patient autonomy at the end of life [3]. However, implementing this legal provision in clinical settings has been difficult. According to a previous study, only 20–25% of terminally ill patients complete the legal documentation for LST decisions, and most cases are managed without formal consent procedures [4]. Physicians often struggle to determine the appropriate timing for end-of-life discussions and frequently delay conversations until patients lose their decision-making capacity [5]. In addition, limitations such as the absence of a designated proxy system and the lack of accessible ethics committees, especially in smaller hospitals, hinder the consistent application of the law [4, 6]. These challenges place considerable ethical and administrative burdens on clinicians responsible for providing end-of-life care.

Healthcare professionals, including physicians and nurses, play pivotal roles in end-of-life decision-making. Their knowledge, attitudes, and perceptions directly influence the quality and delivery of care. As future healthcare providers, medical students are in a formative stage of professional development, and their perspectives on LST will shape future clinical practices. Despite the importance of these groups, few studies have systematically compared their understanding of and views on LST, particularly among those with direct or indirect clinical experience with end-of-life scenarios. Therefore, this study aimed to compare the knowledge, attitudes, and perceptions of LST between practicing healthcare professionals and medical students with clinical experience in LST decision making. These findings may inform the development of targeted educational strategies and policies that support patient-centered end-of-life care at different stages of professional training.

Methods

Study design

This cross-sectional study evaluated the perceptions, attitudes, and current state of LST decision-making among healthcare providers and medical students. The study was conducted from August 1 to December 31, 2023, at Chungnam National University Hospital, a tertiary academic hospital in South Korea. The target population included physicians (interns, residents, and specialists), nurses working in general wards and intensive care units (ICUs), and medical students who had completed clinical rotations with exposure to LST decision-making scenarios.

The study employed a convenience sampling method to investigate current LST decision-making practices and compare the awareness and attitudes of healthcare providers and medical students. The questionnaire was administered in paper format following informed consent procedures. Of the 400 questionnaires prepared, 298 were distributed, and 297 were returned with signed consent forms, yielding a response rate of 99.7% (297 out of 298).

Ethical considerations

This study was approved by the Institutional Review Board of Chungnam National University Hospital (IRB No. 2023-06-094-008) and conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants before survey completion. All data were anonymized and handled confidentially, with analyses performed only in aggregate form.

Questionnaire

The questionnaire was developed based on three previously validated instruments: (1) the “Survey on the Current Status and Needs for Improvement of Hospital Ethics Committees” from the 2019 Policy Development Project for Improving End-of-Life Culture, jointly conducted by the Ministry of Health and Welfare and the National Institute for Bioethics Policy in South Korea [7]; (2) the “2020 National Survey on Public Participation in the Life-Sustaining Treatment Decision-Making System” [8]; and (3) the “2022 Survey on the Life-Sustaining Treatment Decision-Making System in Long-Term Care Hospitals,” conducted by the Korean Association of Long-Term Care Hospitals [9].

The final questionnaire comprised 5 items on respondent characteristics, 7 items assessing knowledge and perceptions of the LST decision-making system, and 21 items exploring the status and practical implementation of the system. The questionnaire included both single-answer and multiple-answer multiple-choice items (see Additional file 1).

Items related to the understanding of LST and agreement with the LST decision-making system were rated on a four-point Likert scale, ranging from “Strongly agree (well understood)” to “Strongly disagree (not understood at all).” For analysis, responses of “Strongly agree” and “Somewhat agree” were categorized as demonstrating understanding/agreement, while “Somewhat disagree” and “Strongly disagree” were categorized as indicating a lack of understanding/agreement. These responses were grouped into two categories and visualized in graphs for comparison.

Data and outcome

Data were collected using a structured, self-administered questionnaire designed to evaluate the characteristics of the participants, understanding of the LST decision-making system, and perceptions of its clinical implementation. The questionnaire included closed-ended and multiple-choice items, and all responses were organized and edited for analysis.

Demographic data included sex, age, professional position (physician, trainee, nurse, or medical student), clinical experience, and affiliated department. To evaluate the participants’ knowledge of and perceptions of the LST system, the survey included items that assessed self-rated knowledge of the system and perceived ability to participate in LST decision-making without difficulty. Additional questions addressed the participants’ views on the ethical purpose of LST and their opinions on the medical interventions that are appropriate to withhold or withdraw. To explore the practical application of the LST system, the questionnaire asked about prior experience with LST withdrawal procedures, perceived challenges encountered during the decision-making process, perceived need for further education on LST, and impressions of changing awareness of LST-related issues among patients and healthcare professionals.

Statistical analyses

Categorical variables are presented as frequencies (n) and percentages, and continuous variables are summarized as means with standard deviations. Logistic regression analysis was used to examine the factors associated with participants’ understanding of LST. Sex, age, and position (e.g., attending physician, resident or intern, nurse, or medical student) were included as covariates in the model. Although clinical experience was initially considered a candidate variable, it was ultimately excluded from the multivariable model because of its strong positive correlation with age (Pearson’s r = 0.731, p < 0.001), which would have resulted in multicollinearity.

Univariate logistic regression analysis was first performed to identify variables significantly associated with the understanding of LST. Variables with a p-value < 0.05 in the univariate analysis were included in the multivariate model. The results are presented as odds ratios (ORs) with 95% confidence intervals. A p-value < 0.05 was considered statistically significant for all analyses.

To compare group differences in responses to LST-related questions between healthcare providers and medical students, the chi-square test and Fisher’s exact test were used as appropriate. All statistical analyses were performed using SPSS software, version 25.0 (IBM Corp., Armonk, NY, USA).

Results

Characteristics of healthcare providers and medical students

From August to December 2023, 297 people completed the survey, including 204 healthcare providers (68.7%) and 93 medical students (31.3%). Most healthcare providers were female (65.2%), while many medical students were male (65.6%), showing a significant sex difference between groups (p < 0.001). Healthcare providers (mean age: 31.55 ± 6.79 years) were significantly older than medical students (mean age: 24.44 ± 2.28 years).

The healthcare providers included attending physicians (10.8%), residents/interns (42.2%), and nurses (47.1%). The providers’ clinical experience varied, with 43.1% having 2–5 years of experience. Most were affiliated with internal medicine (55.9%), followed by rehabilitation medicine and general surgery (Table 1).

Table 1.

Characteristics of healthcare providers and medical students

	Healthcare provider (n = 204)	Medical student (n = 93)	P value
Sex			< 0.001*
Male	71 (34.8)	61 (65.6)
Female	133 (65.2)	32 (34.4)
Age	31.55 ± 6.793	24.44 ± 2.282	< 0.001*
Position			< 0.001*
Attending Physician	22 (10.8)	0 (0)
Resident and Intern	86 (42.2)	0 (0)
Nurse	96 (47.1)	0 (0)
Medical students	0	93 (100)
Clinical experience			< 0.001*
None	0	93 (100)
<2 years	46 (22.5)	0 (0)
2–<5 years	88 (43.1)	0 (0)
5–<10 years	38 (18.6)	0 (0)
≥10 years	32 (15.7)	0 (0)
Clinical department		-	-
Internal Medicine (1)	114 (55.9)
General Surgery (2)	13 (6.4)
Neurology (3)	7 (3.4)
Pediatrics (4)	1 (0.5)
Rehabilitation Medicine (7)	19 (9.3)
Otolaryngology (8)	6 (2.9)
Orthopedic Surgery (9)	10 (4.9)
Ophthalmology (10)	11 (5.4)
Emergency Medicine (11)	11 (5.4)
Neurosurgery (12)	4 (2.0)
Cardiothoracic Surgery (13)	1 (0.5)
Exception (6)	3 (1.5)

* p < 0.05

A comparison of healthcare providers and medical students in terms of knowledge, decision-making ability, and attitudes toward life-sustaining treatment

A significantly higher proportion of healthcare providers (88.7%) than medical students (52.7%) reported being familiar with the LST decision-making system (p < 0.001) (Fig. 1). Similarly, a greater proportion of healthcare providers (69.6%) than medical students (37.6%) perceived themselves as capable of participating in LST decision-making without difficulty (p < 0.001).

Fig. 1.

Comparison of self-reported knowledge and perceived ability to participate in the life-sustaining treatment decision-making process. Bar graph showing the proportion of participants who reported being aware of the Life-Sustaining Treatment (LST) Decision-Making Act (left) and those who perceived themselves as capable of engaging in the LST decision-making process without difficulty (right). Healthcare providers showed significantly higher levels of both knowledge and perceived ability than medical students (p < 0.001 for both comparisons, chi-square test)

Most participants agreed that the LST system enables terminally ill patients to die with dignity (99.0% of healthcare providers vs. 97.8% of medical students), but no significant difference was observed between the two groups (p = 0.099) (Fig. 2). Similarly, agreement on the importance of advance directives was high in both groups (98.5% vs. 97.8%; p = 0.650).

Fig. 2.

Comparison of agreement with the LST decision-making act and the necessity of advance directives. The proportion of respondents who agreed with the purpose of the Life-Sustaining Treatment (LST) Decision-Making Act (left) and the necessity of advance directives for LST (right), stratified by group. No significant differences were observed between the groups for either item (p = 0.099 and p = 0.650, respectively; Fisher’s exact test)

Factors associated with knowledge and ability to make life-sustaining treatment decisions

In the univariate analysis, sex, age, and position were significantly associated with self-reported knowledge of the LST decision-making system (Table 2). Females and older participants were more likely to report familiarity with the LST system. Position was strongly associated with familiarity (all p < 0.01). However, in the multivariate analysis, only the position remained significant (p < 0.001). Compared with attending physicians, medical students were significantly less likely to report LST knowledge (OR = 0.093, p = 0.038). No significant differences were found for residents/interns or nurses.

Table 2.

Factors associated with self-reported knowledge of life-sustaining treatment

	Univariate analysis			Multivariate analysis
	OR	95% CI	P value	OR	95% CI	P value
Sex
Male	Ref	Ref	ref	ref	ref	ref
Female	2.111	1.207–3.694	0.009*	1.175	0.581–2.378	0.653
Age	1.185	1.098–1.278	< 0.001*	1.047	0.965–1.137	0.271
Position			< 0.001*			< 0.001*
Attending Physician	Ref	Ref	ref	ref	ref	ref
Resident and Intern	0.316	0.039–2.591	0.283	0.428	0.049–3.719	0.442
Nurse	0.460	0.055–3.836	0.473	0.549	0.061–4.938	0.593
Medical students	0.053	0.007–0.411	0.005*	0.093	0.010–0.878	0.038*

CI Confidence interval, OR Odds ratio

* p < 0.05

Univariate analysis identified sex, age, and position as significant factors associated with perceived ability to participate in LST decision-making. However, in the multivariate model, only age (p = 0.005) and position (p = 0.031) remained significant. Older participants were more likely to perceive themselves as capable (OR = 1.104). Although individual comparisons did not reach statistical significance, medical students showed a markedly lower perceived ability than attending physicians (OR = 0.186, p = 0.051), and residents/interns showed a similar trend (Table 3).

Table 3.

Factors associated with perceived ability to make life-sustaining treatment decisions independently

	Univariate analysis			Multivariate analysis
	OR	95% CI	P value	OR	95% CI	P value
Sex
Male	ref	ref	ref	ref	ref	ref
Female	2.113	1.315–3.396	0.002*	1.228	0.666–2.266	0.510
Age	1.155	1.093–1.220	< 0.001*	1.104	1.030–1.184	0.005*
Position			< 0.001*			0.031*
Attending Physician	ref	ref	ref	ref	ref	ref
Resident and Intern	0.133	0.029–0.607	0.009	0.236	0.049–1.132	0.071
Registered Nurse	0.336	0.073–1.553	0.163	0.528	0.105–2.662	0.439
Medical students	0.060	0.013–0.274	< 0.001*	0.186	0.034–1.008	0.051

CI Confidence interval, OR Odds ratio 

* p < 0.05

Perceptions of educational needs regarding the life-sustaining treatment decision

As shown in Fig. 3A, the majority of participants reported a perceived need for education on the LST Decision Act, but no significant difference was observed between the healthcare providers and medical students (94.1% vs. 97.8%, p = 0.239).

Fig. 3.

Perceived need and preferred educational topics regarding the life-sustaining treatment decision-making act. a Perceived necessity of education on the Life-Sustaining Treatment (LST) Decision-Making Act. b Comparison of first-priority responses regarding preferred educational topics related to the LST Act. Respondents selected a single topic that they considered to be the most important. A significant difference in response distribution was observed between the two groups (p = 0.001, chi-square test).Abbreviations: LST, life-sustaining treatment; QOL, quality of life

Figure 3B shows the top-ranked educational priorities of the participants among six proposed topics. A significant difference was observed in the overall distribution of responses between the two groups (p = 0.001). In both groups, “communication with patients and families regarding decisions to withhold or withdraw LST” was the most frequently selected item. However, the second most common choice differed: healthcare providers most frequently selected “instructions for completing LST-related forms” (22.9%, p < 0.001), whereas medical students prioritized “medical ethics education for healthcare providers” (28.6%, p = 0.001). Although no significant differences were observed in the other topics, medical students more often chose content related to the LST decision-making process and quality-of-life education. In contrast, healthcare providers more frequently prioritized hospice care and communication with patients and families.

Differences in societal views, withdrawal decisions, and challenges related to life-sustaining treatment decisions

As shown in Table 4, medical students were more likely than healthcare providers to agree that the LST Decision-Making Act promoted respect for patient autonomy (p = 0.001). Healthcare providers were less likely to perceive a significant increase in patient or caregiver engagement with LST decisions (p = 0.023). Although no significant differences were observed in the opinions regarding strategies to promote LST uptake (p = 0.298), providers more frequently emphasized institutional promotion.

Table 4.

Comparison of perceptions regarding societal attitudes toward the life-sustaining treatment decision-making act

	Healthcare provider (n = 204)	Medical student (n = 93)	P value X2 test
Do you feel that the implementation of the LST Decision-Making Act has led to a shift toward greater respect for patient autonomy?
1. Strongly agree	12 (5.9)	7 (7.5)	0.001*
2. Somewhat agree	135 (66.2)	79 (87.9)
3. Somewhat disagree	54 (26.5)	6 (6.5)
4. Strongly disagree	3 (1.5)	1 (1.1)
Since the implementation of the LST Decision-Making Act, how do you perceive the change in patients’ and caregivers’ interest in LST decisions?
1. Interest in LST decisions has increased compared to before.	105 (51.5)	63 (67.7)	0.023*
2. Patients and caregivers occasionally inquire about LST decisions, but actual cases have not increased.	64 (31.4)	18 (19.4)
3. There has been no noticeable change compared to before.	35 (17.2)	11 (11.8)
In your opinion, what is the key factor for promoting the LST decision-making system in society?
1. Fostering a culture that encourages open conversations about death and the withdrawal of LST	103 (50.5)	47 (50.5)	0.298
2. Active promotion and strong engagement from the government and healthcare institutions in implementing the LST decision-making system	45 (22.1)	14 (15.1)
3. Healthcare providers’ willingness to communicate with patients who wish to forgo LST	28 (13.7)	13 (14.0)
4. Support for infrastructure—such as personnel, facilities, and equipment—for the stable operation of the LST decision-making system	25 (12.3)	19 (20.4)

LST Life-sustaining treatment

* p < 0.05

Table 5 summarizes the differences in perceptions of LST decision-making timing and scope. Healthcare providers most frequently selected “before the patient loses consciousness” as the optimal time to complete an LST plan (48.5%) (p = 0.043) and withdraw LST (60.8%). In contrast, medical students showed a more dispersed response pattern: although “while still conscious” remained the most frequent choice for withdrawal (39.8%), a considerably higher proportion of students than providers also selected “after the patient is no longer conscious” (35.5% vs. 17.6%, p < 0.001). Regarding the primary decision maker, providers most frequently selected family members (68.6%), whereas students more often selected the patient (39.8%) (p < 0.001). Medical students were also significantly less likely to support the withdrawal of cardiopulmonary resuscitation, mechanical ventilation, dialysis, chemotherapy, transfusions, and vasopressors (all p ≤ 0.001). No group difference was observed for extracorporeal life support or basic supportive care.

Table 5.

Comparison of perceptions regarding the withdrawal of life-sustaining treatment

	Healthcare provider (n = 204)	Medical student (n = 93)	P value X2 test
When do you think is the most appropriate time to complete a LST plan?
1. When the individual is healthy and has no underlying conditions	30 (14.7)	18 (19.4)	0.043*
2. Immediately after being diagnosed with a terminal illness	47 (23.0)	24 (25.8)
3. After the decision to initiate hospice care	23 (11.3)	18 (19.4)
4. When a serious deterioration is expected but the patient is still conscious	99 (48.5)	32 (34.4)
5. After a serious deterioration has occurred and the patient is no longer conscious	5 (2.5)	0 (0)
6. Other	0 (0)	1 (1.1)
When do you think is the most appropriate time to make a decision to withdraw LST?
1. Immediately after being diagnosed with a terminal illness	17 (8.3)	13 (14)	< 0.001*
2. After the decision to initiate hospice care	27 (13.2)	10 (10.8)
3. When serious deterioration is expected but the patient is still conscious	124 (60.8)	37 (39.8)
4. After serious deterioration has occurred and the patient is no longer conscious	36 (17.6)	33 (35.5)
Who do you think primarily makes decisions regarding the withdrawal of LST at your institution?
1. The patient	28 (13.7)	37 (39.8)	< 0.001*
2. The caregiver(s)	140 (68.6)	46 (49.5)
3. The medical staff	36 (17.6)	10 (10.8)
If a decision must be made to withdraw futile LST, please select all medical interventions you believe should be discontinued.
1. Cardiopulmonary resuscitation (CPR)	190 (93.1)	66 (71.0)	< 0.001*
2. Mechanical ventilation	174 (85.3)	52 (55.9)	< 0.001*
3. Hemodialysis	137 (67.2)	38 (40.9)	< 0.001*
4. Administration of chemotherapy	132 (64.7)	42 (45.2)	0.001*
5. Extracorporeal life support (e.g., ECMO)	166 (81.4)	71 (76.3)	0.241
6. Blood transfusion	82 (40.2)	20 (21.5)	0.001*
7. Use of vasopressors	133 (65.2)	25 (26.9)	< 0.001*
8. Other	20 (9.8)	9 (9.7)	0.952

ECMO Extracorporeal membrane oxygenation, LST Life-sustaining treatment

* p < 0.05

Regarding perceived barriers in LST decision-making, no significant differences were observed between healthcare providers and medical students in relation to challenges faced by patients (p = 0.609) or families (p = 0.514); however, healthcare providers more frequently cited a lack of understanding of the system (Table 6). In contrast, students more frequently cited ethical conflicts regarding patient autonomy and uncertainty about withdrawal timing. The overall distribution of perceived barriers differed significantly between the groups (p = 0.004).

Table 6.

Comparison of perceptions regarding challenges of life-sustaining treatment

	Healthcare provider (n = 204)	Medical student (n = 93)	P value X2 test
What are the challenges faced by patients with decision-making capacity in participating in the LST decision-making process?
1. Lack of patient understanding of the system	65 (31.9)	23 (24.7)	0.609
2. Concern about damaging trust with the patient (e.g., giving the impression of giving up)	56 (27.5)	30 (32.3)
3. Difficulty in communicating with the patient (e.g., sudden loss of consciousness or emergency situations)	80 (39.2)	38 (40.9)
4. Other	3 (1.5)	2 (2.2)
What are the challenges faced by family members of patients without decision-making capacity in participating in the LST decision-making process?
1. Lack of family understanding of the system	42 (20.6)	15 (16.1)	0.514
2. Concern about damaging trust with the family (e.g., giving the impression of giving up)	71 (34.8)	31 (33.3)
3. Difficulty in completing required documentation and reaching consensus among family members	80 (39.2)	41 (44.1)
4. Lack of perceived need to participate in the process (e.g., due to prolonged illness with repeated improvement and deterioration)	11 (5.4)	5 (5.4)
5. Other	0 (0)	1 (1.1)
What do you think is the main reason for not implementing the process of withdrawing LST?
1. Lack of understanding of the LST Decision-Making Act	59 (28.9)	23 (24.7)	0.004*
2. Uncertainty regarding the appropriate timing for withdrawing LST	50 (24.5)	24 (25.8)
3. complex procedures	9 (4.4)	7 (7.5)
4. Value conflict: withdrawal based on family consent may contradict the principle of dignified death based on patient self-determination	30 (14.7)	26 (28.0)
5. Presence of a DNR form or substitution with a DNR form	55 (27.0)	10 (10.8)
6. Other	1 (0.5)	2 (2.2)
7. No response	0 (0)	1 (1.1)

DNR Do-not-resuscitate, LST Life-sustaining treatment

* p < 0.05

Discussion

This study revealed significant differences in knowledge, perceptions, and attitudes toward the LST Decision-Making Act among healthcare providers and medical students. Healthcare providers were more familiar with and confident in LST decision-making than medical students. Both groups, however, recognized the ethical importance of the Act and the need for related education. Notable disparities were observed in their educational priorities, perceptions of decision timing, and views on stakeholder involvement. These findings suggest the need for targeted, role-specific educational approaches to bridge the knowledge gap at different stages of professional development.

Our findings revealed that, compared with medical students, healthcare providers reported significantly greater self-perceived knowledge of LST and higher confidence in participating in decision-making. This difference likely reflects their greater clinical experience and highlights persistent gaps in medical education related to LST and end-of-life care. A nationwide study in Korea found that only 21.2% of medical students felt prepared for end-of-life care, citing limited opportunities to observe key clinical decisions [10]. Despite these knowledge gaps, both healthcare providers and medical students in our study strongly agreed with the ethical purpose of the LST Act and the importance of advance directives, reflecting a growing awareness as Korea transitions toward a super-aged society.

Despite this interest, formal education on end-of-life care remains insufficient. In Jordan, 97.5% of medical students reported having received no formal palliative care training [11], and fewer than 18% of students and residents in the United States centers received structured end-of-life education [12]. Faculty surveys reflect this concern as well: 59% are dissatisfied with the current curriculum, and 81% disagree that students are adequately prepared for clinical end-of-life care [13]. In South Korea, most medical schools rely on lecture-based instruction and only 44% offer clinical experiences related to end-of-life care [13]. Greater exposure has been shown to improve attitudes and preparedness [10], and innovative approaches such as video-based expert-led debriefings have demonstrated effectiveness in teaching the ethical and legal aspects of end-of-life care [14]. These findings underscore the need for structured, experience-based education to better prepare future physicians for LST-related decisions.

This study identified several systemic barriers to the implementation of the LST Decision-Making Act in South Korea. A significantly higher proportion of healthcare providers than medical students disagreed with the statement that the Act led to greater respect for patient autonomy. This finding suggests that, despite the Act’s legislative intent, healthcare providers directly involved in clinical care perceive a difference between policy and practice. Consistent with this finding, when asked who primarily makes LST withdrawal decisions, healthcare providers more often select family members or physicians rather than the patients themselves. This perception aligns with national data from South Korea: Park et al. reported that only 33.5% of patients completed their LST documentation themselves [3], and Kim et al. [15] found that only 28.1% of deceased patients made the decision personally. In ICU settings, family members were reported to be the primary decision-makers in 86% of LST withdrawal cases [16].

Further reinforcing these findings, in our study, healthcare providers more frequently responded that, following the implementation of the Act, patients and caregivers showed limited engagement or interest in LST decisions. Although public discourse suggests growing awareness, these results indicate that such shifts are not yet fully reflected in the clinical setting. A substantial proportion of healthcare providers cited a “lack of understanding of the LST Decision-Making Act” as the main reason for not proceeding with LST withdrawal, suggesting the presence of informational barriers. Consistent with this report, only 20–30% of patients and family caregivers in Korea are aware of advance directives [17], and public awareness of advance care planning and hospice care remains low at 39% and 36%, respectively [18]. Despite legal mechanisms intended to support patient autonomy, a knowledge gap remains among patients and families, highlighting the need for broader public education and improved communication strategies in clinical practice.

Our findings suggest that, compared with medical students, healthcare providers tend to initiate LST discussions at more advanced stages of illness. Healthcare providers were less likely to select earlier points for completing LST documentation, such as “when the individual is healthy,” “immediately after diagnosis of a terminal illness,” or “after initiating hospice care.” This tendency is consistent with previous reports. Kim et al. [19] and Yoo et al. [5] reported that LST decisions are often delayed until the patient’s condition significantly deteriorates and discussions frequently occur between physicians and surrogate decision-makers. Similarly, our previous study [20] found no significant difference in ICU or hospital stay duration between patients for whom LST was withheld or withdrawn and those who were not. This report suggests that such decisions are often made when the prognosis is extremely poor. Yen et al. [21] also noted that do-not-resuscitate (DNR) orders are often made late in the disease course, and other studies have found that the interval between DNR designation and death is typically less than five days [22, 23]. Approximately 25% of patients receive DNR orders on the day of their death [22].

In addition, our data suggests that the complexity of the current LST documentation process contributes to its underutilization. Our findings showed that 27.0% of healthcare providers cited the use of formal DNR consent forms rather than legally recognized LST documentation as a major reason for not implementing LST withdrawal procedures. Although these forms lack legal status under the Act, they are often preferred because of their procedural simplicity. Yoo et al. [5] reported that physicians frequently struggle to locate and complete the correct documents during LST discussions, and Choi et al. [24] highlighted that many clinicians perceive the LST process as administratively burdensome. Song et al. [23] found that, during end-of-life care, 78.4% of patients signed DNR consent forms but only 5.6% completed LST documentation. Only 10.2% completed both documents, underscoring the gap between legal frameworks and clinical realities.

Although the number of completed LST forms and related procedural implementations has increased since the enactment of the Act [3, 25, 26], this growth has not meaningfully influenced the clinical outcomes. Studies have reported no significant differences in ICU admissions or the use of invasive treatments between patients who opted to decline LST and those who did not [20, 27, 28]. Moreover, most LST withdrawal decisions continue to occur very late in the disease course [4, 29]. These patterns reflect ongoing gaps in understanding and applying the LST system among patients, families, and the healthcare system. Moving forward, efforts should prioritize earlier LST discussions, simplified procedures, and enhanced education for both the public and healthcare professionals to support timely and patient-centered decision-making.

This study had several limitations. First, the single-center design at a tertiary hospital may limit the generalizability of the findings to other healthcare settings with different patient populations and institutional policies. Future multicenter studies are needed to determine whether similar patterns are observed across diverse clinical environments. Second, the sample composition, which included a higher proportion of nurses and internal medicine staff, may have introduced selection bias and may not fully represent the perspectives of all healthcare professionals within the institution. Additionally, because convenience sampling was used, the representativeness of the sample is inherently limited. Third, although the participation rate was high, participants may have felt implicit pressure to respond, raising the possibility of response bias. Forth, significant differences in demographic characteristics (e.g., age and sex) and clinical experience between healthcare providers and medical students may have confounded comparisons of their attitudes and knowledge. Finally, reliance on self-reported questionnaire data introduces potential response and social desirability biases, which may have influenced participants’ responses regarding sensitive end-of-life care topics. Given these limitations, future studies involving profession-specific analyses, observational assessments of actual clinical behaviors, and larger multicenter samples are warranted to better understand systemic and procedural barriers to life-sustaining treatment decision-making.

Despite these limitations, this study contributes significantly to our understanding of LST practices in Korea. It is one of the first studies to directly compare the knowledge of and attitudes toward LST among practicing healthcare providers and medical students. Our findings revealed significant educational gaps that warrant attention. The results underscore the urgent need to enhance LST education in medical curricula and develop ongoing professional development programs for healthcare providers. Furthermore, the discrepancies between knowledge and practice identified in this study suggest that implementing the LST Decision-Making Act requires educational improvements and systemic changes to clinical practice guidelines and institutional support structures. These insights provide a foundation for developing targeted educational interventions and informing policy refinements to improve the quality of end-of-life care in Korean healthcare settings.

Conclusions

This study identified significant differences in LST perceptions between healthcare providers and medical students concerning the LST Decision-Making Act, suggesting a gap between the legislation’s ethical objectives and its clinical implementation. Students tended to emphasize patient autonomy principles, while providers appeared to adopt more pragmatic approaches based on clinical experience. These findings suggest the need for enhanced end-of-life education in medical curricula and potentially improved procedural frameworks. Healthcare institutions may benefit from developing clearer protocols and support mechanisms to bridge the theory-practice gap. Future research could include patient and family perspectives and assess the impact of educational interventions on clinical practice.

Abbreviations

DNR

Do-not-resuscitate

ICU

Intensive care unit

IRB

Institutional Review Board

LST

Life-sustaining treatment

OR

Odds ratio

Authors’ contributions

JL and SYK contributed to the conception of the study, performed data analysis, and were the major contributors to writing the manuscript. GH and DKK critically reviewed and revised the manuscript. SIL provided the original study idea, supervised the analysis, and contributed to the final revision and approval of the manuscript. All the authors have read and approved the final manuscript.

Funding

This work (research) was supported by the Chungnam National University Hospital Research Fund (2023-CF-004). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data availability

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of Chungnam National University Hospital (IRB No. 2023-06-094-008) and was conducted in accordance with the ethical principles of the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from all participants prior to participation.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.