Experience of advance directives in a hospice center.

To protect patient autonomy when confronting death, the importance of advance directives (ADs) has recently became an issue and gradually accepted in Korea. However, in real practice, ADs were not completed by patients but their families in most cases. To analyze the current situation of performing ADs, we reviewed medical charts of 214 terminal cancer patients admitted to the hospice center from October 2012 to September 2013. Seventy-six (35.5%) patients completed ADs. All ADs were completed by patients themselves. The most common reason for not completing ADs was poor physical and/or mental condition. As a proxy, the majority of patients preferred their spouses (55.3%). Few patients wanted life sustaining treatment (1.3%), however palliative sedation was accepted in 89.5%. The median timing of ADs after admission was three (0-90) days, and duration of survival since ADs was 22 (1-340) days. In conclusion, approximately one third of terminal cancer patients completed ADs by themselves. Considering that patient's poor condition is the main reason for not completing ADs, earlier discussion regarding ADs is necessary to enhance patients' participation. Graphical Abstract Keywords: Advance Directives, Hospice Care, Neoplasms INTRODUCTION Advance directives (ADs) document patients' wishes with respect to end-of-life care and who will make health care decisions for patients when they become incompetent (1). ADs allow patients to protect their autonomy and prevent their caregivers from having difficulty in making decision when patients are near death. In Korea, so-called grand-mom Kim's Case has aroused public attention in protection of patients' autonomy, and has led to the efforts to reach an agreement regarding discontinuation of meaningless life-sustaining treatments (2). Sun et al. (3) reported that most terminal cancer patients in hospice centers had positive attitudes about the need of ADs. Although several hospitals have recently introduced ADs, ADs were not completed by patients but by their families in most cases (4). Because few patients have been given the right to decide end-of life care; to do or not to do (5, 6, 7), there has been a need of nationwide discussions on ADs. In St. Vincent's Hospital, we have introduced an AD form for terminal cancer patients in the hospice center since October 2012 to enhance patient's participation on end-of life care decision. As one year has passed since the introduction of ADs, we aimed to analyze the current situation of ADs in real practice.