말기의료에 관한 미국 법제의 연구 - 말기의료결정 제도를 중심으로

석희태 대한의료법학회 2013 의료법학 Vol.14 No.1

The first legislation for terminal health-care decision was California’s Natural Death Act (NDA) of 1976 that permitted any adult person to execute a directive directing the withholding or withdrawal of life–sustaining procedures. Advance directive legislation has subsequently progressed on a state-by-state basis. By 1992, all 50 states, as well as the District of Columbia, had passed legislation to legalize some form of advance directive. This state legislation, however, has resulted in an often fragmented, incomplete, and sometimes inconsistent set of rules. Statutes enacted within a state often conflict and conflicts between statutes of different states are common. In an increasingly mobile society where an advance health-care directive given in one state must frequently be implemented in another, there is a need for greater uniformity. In 1993, the Uniform Law Commissioners approved the Uniform Health-Care Decisions Act (UHCDA) in order to bring order to the existing chaos. Unfortunately, the Commissioners waited too long to act. By the time the UHCDA was approved, nearly all states had passed legislation governing advance directives. Consequently, the UHCDA has achieved only a limited success, picking up but one or two enactments a year. The UHCDA is currently in effect in around 10 states: Alabama, Alaska, California, Delaware, Hawaii, Kansas, Maine, Mississippi, New Mexico, Tennessee, Wyoming. In these states the previous laws related to the subjects have been all repealed. The overall objective of the UHCDA is to encourage the making and enforcement of advance health care directives including living will or individual instruction, power of health-care attorney and to provide a means for making health care decisions for those who have failed to plan. The U. S. House of Representatives in 1991 enacted the Patient Self- Determination Act (PSDA). The Act stipulates that all hospitals receiving Medicaid or Medicare reimbursement must ascertain whether patients have or wish to have advance directives. The Patient Self- Determination Act does not create or legalize advance directives; rather it validates their existence in each of the states. Now in America, terminal health-care decision or advance directive for health care is common and universal system. The problem, however, is how to let more people use these good tools to make their lives more beautiful and honorable.

Health Economic Approach to End-of-Life Care in the US : Based on Medicare

Ryan Suk 대한의료법학회 2014 의료법학 Vol.15 No.1

한 자료에 의하면 2011년 미국의 의료비 지출 총액은 국내총생산의 약 18 퍼센트에 달하였으며, 그 비율은 다른 대다수 선진국의 두 배에 해당하는 것이었다. 그중 메디케어 비용은 전체 의료비의 21 퍼센트인 5540억 달러 였는 데, 환자의 최후 6 개월에 들어간 의료비는 그 5540억 달러의 28 퍼센트 (전체 의료비의 5.9 퍼센트)인 1700억 달 러에 달하였다. 이러한 말기의료의 고비용성은 어떤 사유에 기인하며, 그 해소 방안은 무엇인가. 지난 수십 년 간의 의료경제학적 연구는 말기의료가 일반적으로 공급민감성을 지니며 비용대비 효율성이 매우 낮다는 결론에 도달하였다. 의료서 비스 공급의 양은 질병의 정도나 환자의 선호도와는 무관하고, 그보다는 의료서비스 공급자원에 민감하게 반응한 다는 것이다. 이는 말기의료에서는 의료자원이 과용된다는 것을 의미한다. 한편 더 많은 의료처치에 더 나은 효용이라는 일반적인 추론과는 반대로, 많은 의료처치의 결과는 오히려 매우 부정적인 것이었다. 실제 환자들의 선호와 관심사는 격렬한 말기의료가 기도하는 것과는 아주 달랐던 것이다. 이 논문은 먼저 말기의료에서의 공급민감성의 원인을 분석한다. 그 원인으로는 격렬한 치료와 그 효용성에 대한 일반적인 오해, 의사들의 환자에 대한 직업적인 사명의식, 환자 자신의 말기의료 의향결정의 부재, 의사들의 법적 책임에 대한 우려, 의료기관의 경영차원에서의 관리전략 등을 들 수 있다. 다음으로, 논문에서는 말기의료의 공급민감성에서 연유하는 과잉진료에 대한 현실적 해결책을 제시한다. 그 해결 책은 두 가지 측면으로 나누어서 들 수 있는데, 하나는 사전의료의향서 제도의 활성화 방안이고, 다른 하나는 의 료기관 경영관리전략적 관점에서의 방안이다. 우선 사전의료의향서의 활용도를 제고하기 위해서 다음과 같은 구체적 노력이 필요하다. 즉 의사들의 말기의료에 대한 태도를 바꾸도록 하는 새로운 의료윤리 교육 실시, 의사와 환자 간 말기의료에 대한 소통 기회의 강화, 환자 와 말기의료에 대한 대화를 적극적으로 실천하는 의사에 대한 보상제도 도입, 일반 공공에 대한 관련 교육 확대, 온라인 등록시스템과 같은 용이하고도 공식적인 사전의료의향서 등록체제의 구축 확대 등이 필요하다. 경영관리적 측면에서는 대체 전략이 필요하다. 예컨대 불필요한 비용을 절감하고 의료공급자로서의 가치를 재정 립하는 등의 새로운 재무전략과 경영교육계획 등이 고려되어야 할 것이다. 효과적으로 말기의료의 경제적 문제점을 해소하고 환자에게 더 나은 의료경험을 제공하기 위해서는 의료·환자·국 가 등 모든 부문에서 관행과 오해에서 비롯된 신조가 시급히 수정되어야 하고, 그 기초 위에서 제도와 문화가 개 선되어야 하는 것이다. According to one Medicare report, in the US, total federal spending on health care expends almost 18 percent of the nation's GDP, about double what most industrialized nations spend on health care. And in 2011, Medicare spending reached close to $554 billion, which amounted to 21 percent of the total spent on U.S. health care in that year. Of that $554 billion, Medicare spent 28 percent, or about $170 billion, on patients' last six months of life. So what are the reasons of this high cost in EOL care and its possible solutions?Much spendings of Medicare on End-of-Life care for the terminally ill/chronically ill in the US has led health economics experts to assess the characteristics of the care. Decades of study shows that EOL care is usually supply-sensitive and poor in cost-effectiveness. The volume of care is sensitively depending on the supply of resources, rather than the severity of illness or preferences of patients. This means at the End-of-Life care, the medical resources are being overused. On the other hand, opposed to the common assumption, The more care the better utility, the study shows that the outcome is very poor. Actually the patient preference and concerns are quite the opposite from what intense EOL care would bring about. This study analyzes the reasons for the supply-sensitiveness of EOL care. It can be resulted from the common misconception about the intense care and the outcome, physicians' mission for patients, lack of End-of-Life Care Decision which helps the patients choose their own preferred treatment intensity. It also could be resulted from physicians' fear of legal liabilities, and the management strategy since the hospitals are also seeking for financial benefits. This study suggests the possible solutions for over-treatment at the End-of-Life resulting from supply-sensitiveness. Solutions can be sought in two aspects, legal implementation and management strategy. In order to implement advance directive properly, active ethics education for physicians to change their attitude toward EOL care and more conversations about end-of-life care between physicians and patients is crucial, and incentive system for the physicians who actively have the conversations with patients will also help. Also, the general education towards the public is also important in the long run, and easy and official advance directive registry system - such as online registry - has to be built and utilized more widely. Alternative strategies in management are also needed. For example, the new strategic cost management and management education, such as cutting unnecessary costs and resetting values as medical providers have to be considered. In order to effectively resolve the problem in EOL care for the terminally ill/chronically ill and provide better experience to the patients, first of all, the misconception and the wrong conventional wisdom among doctors, patients, and the government have to be overcome. And then there should be improvements in systems and cultures of the EOL care.

Health Economic Approach to End-of-Life Care in the US: Based on Medicare

석리언 대한의료법학회 2014 의료법학 Vol.15 No.1

According to one Medicare report, in the US, total federal spending on health care expends almost 18 percent of the nation's GDP, about double what most industrialized nations spend on health care. And in 2011, Medicare spending reached close to $554 billion, which amounted to 21 percent of the total spent on U.S. health care in that year. Of that $554 billion, Medicare spent 28 percent, or about $170 billion, on patients' last six months of life. So what are the reasons of this high cost in EOL care and its possible solutions?Much spendings of Medicare on End-of-Life care for the terminally ill/chronically ill in the US has led health economics experts to assess the characteristics of the care. Decades of study shows that EOL care is usually supply-sensitive and poor in cost-effectiveness. The volume of care is sensitively depending on the supply of resources, rather than the severity of illness or preferences of patients. This means at the End-of-Life care, the medical resources are being overused. On the other hand, opposed to the common assumption, "The more care the better utility", the study shows that the outcome is very poor. Actually the patient preference and concerns are quite the opposite from what intense EOL care would bring about. This study analyzes the reasons for the supply-sensitiveness of EOL care. It can be resulted from the common misconception about the intense care and the outcome, physicians' mission for patients, lack of End-of-Life Care Decision which helps the patients choose their own preferred treatment intensity. It also could be resulted from physicians' fear of legal liabilities, and the management strategy since the hospitals are also seeking for financial benefits. This study suggests the possible solutions for over-treatment at the End-of-Life resulting from supply-sensitiveness. Solutions can be sought in two aspects, legal implementation and management strategy. In order to implement advance directive properly, active ethics education for physicians to change their attitude toward EOL care and more conversations about end-of-life care between physicians and patients is crucial, and incentive system for the physicians who actively have the conversations with patients will also help. Also, the general education towards the public is also important in the long run, and easy and official advance directive registry system - such as online registry - has to be built and utilized more widely. Alternative strategies in management are also needed. For example, the new strategic cost management and management education, such as cutting unnecessary costs and resetting values as medical providers have to be considered. In order to effectively resolve the problem in EOL care for the terminally ill/chronically ill and provide better experience to the patients, first of all, the misconception and the wrong conventional wisdom among doctors, patients, and the government have to be overcome. And then there should be improvements in systems and cultures of the EOL care.

사전지시에 의한 연명치료의 중단에 관한 연구

강명구(Kwang, Myeng-Ku) 원광대학교 법학연구소 2012 圓光法學 Vol.28 No.4

2009년에 우리 나라 대법원은 영구적으로 의식이 없는 말기적 질환 상태에 있는 환자에게 연명장치의 제거를 허용하는 판결을 하였다. 대법원이 인정한 연명치료 중단의 요건은 다음과 같다. 첫째, 환자가 말기적 질환 상태에 있어서 이의 회복가능성이 없을 것, 둘째, 환자가 사전지시를 하였을 것, 만약 환자가 사전지시를 하지 않았다면 이를 인정할만한 다른 사정으로 환자의 의사를 추정할 수 있을 것, 셋째, 환자의 지시는 충분한 의료정보를 가지고 행하여 졌을 것, 넷째, 사전지시는 의료공급자에게 행하여지고, 이를 충분히 입증할 것 다섯째, 환자가 말기상태인지 여부는 법원 혹은 관련 위원회의 판단을 따를 것을 요건으로 하였다. 요컨대 대법원 판결은 환자가 자기결정권 차원에서 스스로 연명치료 중단결정을 할 수 있다는 것을 인정한 다음, 사전의료지시에 의한 연명치료중단의 요건을 제시한 것이다. 그러나 대법원이 제시한 연명치료중단의 사전지시의 요건중 환자가 충분한 의료정보를 취득한 후 이를 지시하여야 한다는 요건은 환자가 연명치료중단을 위한 사전지시를 하는 것을 불가능하게 요건이며, 이는 연명치료의 중단과 상관없는 일반적인 의료행위의 지시에 경우에 적용되어야 하는 것으로 적절하지 않다는 점을 지적하였다. 또, 2011년 개정민법상 성년후견제도 및 임의후견계약제도에서 개정민법은 2013년부터 후견인이 신상보호를 할 수 있도록 하고 있는데, 이러한 신상보호의 개념속에 사전의료지시에 의한 연명치료의 중단이 포함될 수 있을 것인지도 살펴보았다. 사견으로는 개정민법상 성년후견 및 임의후견제도에서 연명치료중단을 위한 사전지시가 가능하다고 보고 있지만, 연명치료중단을 위한 지시를 실행함에 있어서 관련자의 민형사상 직무상 면책규정이 없는 상황이므로 이의 활성화를 위해서 는 입법이 필요로 하고, 이를 위해서는 외국의 법 특히 미국 각주의 지속적 대리인의 선임 및 생전유언제도에서 규정하고 있는 제요소를 참조할 것을 제언하였다. In 2009, the Korea Supreme Court held that discontinuance of life-extending treatment can be allowed, upon reaching the stage of irrecoverable death, on the ground of the patient’s right to self decision to die based on dignity, value and the right to pursuit of happiness as a human being. The Court noted following requisites of the withholding or withdrawal of life-prolonging treatment by advanced directive for health care. First, the patient should be in the terminal condition, that will result in imminent death or has an irreversible injury or illness that results in a persistent vegetative state or permanent unconsciousness. Second, there should be patient’s advanced directive for withholding or withdrawal of life-prolonging treatment on his or her terminal condition. Third, provided medical information directly from medical provider or physician, the competent patient should execute the advance directive soberly as to the specific medical treatment based on the medical information and his own values. Fourth, The advance directive should be executed to the patient’s medical provider or patient’s attending physician and it’s existence should be clearly proved by written instructions or medical records. And last, unless the patient files a lawsuit directly in court, it is desirable that a committee composed of expert doctors, etc. decides whether the patient has reached the irrecoverable death stage. This paper notes that the third requisite of the Court for withholding or withdrawal of life-prolonging treatment may be the obstacle to be executed a valid advance directive by patient. Since, generally, prior to the patient’s terminal and irreversible condition, sufficient medical information of the patient’s irreversible injury or illness, is not provided to patient/declarant executing advance directive. This paper argues that the requisite may be fitted to the advance directive for medical treatment irrelevant to patient’s terminal condition. This paper also examines, the amended Korean Civil Code Article 947-2(effective on July.1.2013) that provides the adult guardian’s power of decision regarding personal affairs of the incompetent adult, the amended Code of Article 959-14 that provides the durable power of attorney by contract between principal and agent. The power of attorney created by principal will take effective when the principal loses capacity to decide his or her personal affairs. According to the Art. 947-2 or 959-14, this paper admits the possibility, a principal giving advance directive for health care to withhold or withdraw life-prolonging treatment. But, there is no provision immunizing criminal, civil, or professional liability of physicians or the agents who participated in advance directive regarding life-sustaining treatment. So, this paper insists to establish an Act that permits individuals to execute advance directive for health care.

사전지시에 의한 연명치료의 중단에 관한 연구

강명구 원광대학교 법학연구소 2012 法學硏究 Vol.28 No.4

In 2009, the Korea Supreme Court held that discontinuance of life-extending treatment can be allowed, upon reaching the stage of irrecoverable death, on the ground of the patient’s right to self decision to die based on dignity, value and the right to pursuit of happiness as a human being. The Court noted following requisites of the withholding or withdrawal of life-prolonging treatment by advanced directive for health care. First, the patient should be in the terminal condition, that will result in imminent death or has an irreversible injury or illness that results in a persistent vegetative state or permanent unconsciousness. Second, there should be patient’s advanced directive for withholding or withdrawal of life-prolonging treatment on his or her terminal condition. Third, provided medical information directly from medical provider or physician, the competent patient should execute the advance directive soberly as to the specific medical treatment based on the medical information and his own values. Fourth, The advance directive should be executed to the patient’s medical provider or patient’s attending physician and it’s existence should be clearly proved by written instructions or medical records. And last, unless the patient files a lawsuit directly in court, it is desirable that a committee composed of expert doctors, etc. decides whether the patient has reached the irrecoverable death stage. This paper notes that the third requisite of the Court for withholding or withdrawal of life-prolonging treatment may be the obstacle to be executed a valid advance directive by patient. Since, generally, prior to the patient’s terminal and irreversible condition, sufficient medical information of the patient’s irreversible injury or illness, is not provided to patient/declarant executing advance directive. This paper argues that the requisite may be fitted to the advance directive for medical treatment irrelevant to patient’s terminal condition. This paper also examines, the amended Korean Civil Code Article 947-2(effective on July.1.2013) that provides the adult guardian’s power of decision regarding personal affairs of the incompetent adult, the amended Code of Article 959-14 that provides the durable power of attorney by contract between principal and agent. The power of attorney created by principal will take effective when the principal loses capacity to decide his or her personal affairs. According to the Art. 947-2 or 959-14, this paper admits the possibility, a principal giving advance directive for health care to withhold or withdraw life-prolonging treatment. But, there is no provision immunizing criminal, civil, or professional liability of physicians or the agents who participated in advance directive regarding life-sustaining treatment. So, this paper insists to establish an Act that permits individuals to execute advance directive for health care.

국가별 사전의료의향서 서식 분석 및 사전의료의향서 표준 서식 제안

이은영(Eunyoung Lee),박인경(Inkyoung Park),이일학(Ilhak Lee) 이화여자대학교 생명의료법연구소 2011 생명윤리정책연구 Vol.5 No.1

May of 2009, Korean Supreme Court ruled that foregoing life sustaining treatment of patients in the ‘irreversible’ stage of death should be permitted. June of 2010, the Ministry of Health and Welfare reported the decision of “the Council for Institutionalizing Foregoing Life Sustaining Treatment”, which presented “advance directives” as primary source for identifying patient’s will about life sustaining treatment. But there is no legislation or official form about decisions of terminal condition available in Korea. In this article, advance directives forms of 4 nations(Chinese Taipei, Singapore, United Kingdom and United States) were analysed and model advance directive form was proposed for future use. The model form is to stand as a reference for medical decision making for adults who becomes incompetent for terminal medical conditions. This form separates required items from optional items and requires designation of primary and secondary medical decision making proxy. The place of keeping document can be given, and patient and witness information are provided.

노인환자와 가족의 연명치료 의사결정 참여에 관한 소고

한수연(Han, Soo-Youn),이홍직(Lee, Hong-Jik) 경기연구원 2013 GRI 연구논총 Vol.15 No.2

This study aims to discuss the elderly patients and their family caregivers’ decision making for life sustaining treatment in such end-of-life care. Due to the recent increase in human longevity and the implementation of the 2007 Long-Term Care Insurance Policy, Korea can expect a drastic rise in patient enrollment in hospitals and long-term care facilities in the coming 20~30 years. Thus, debates to clarify the subject of these elderly patients’ rights to their end-of-life decisions will soon follow within the policy-making sphere. To contend that the decision making privileges should be uniquely reserved for these patients, and their family members in the case of these patients’ incapacity, this study analyzes the problems inherent to Advance Directive for Health Care(ADHC)-related medical insurance policy and explores these patients’ attitudes toward ADHC and the factors that influenced them by citing previous literature. Based on them, this study explains the current circumstances, as well as possible opportunities of improvement for family participation. It delivers suggestions to provide services and policies for Korean elderly patients and their family caregivers, and finally ensures their rights in end of life care decision as well as life sustaining treatments.

중화민국(타이완)「안녕완화의료조례(安寧緩和醫療條例)」의 연혁과 내용

석희태 대한의료법학회 2008 의료법학 Vol.9 No.2

In Republic of Chaina (Taiwan), Natural Death Act named “Anning Huanhe Yiliao Tiaoli” which means palliative and hospice care act was enacted in year of 2000. And enforced in the same year. Many scholars say that Taiwan's Act took Many U.S.A.'s acts such as ‘Federal Patient Self-Determination Act 1990’, ‘California Natural Death Act 1976’ and ‘Washington Natural Death Act 1979’ for a model. Taiwan's Act adopts a few outstanding systems - ‘advance declarations’ including ‘living will’ and ‘durable power of attorney for health care’, ‘family-determination system’ for a patient who is in a persistent unconscious state. This paper disusses this Act. The content is as follow : 1. A background of legislation. 6. Keeping documents. 2. The purpose of legislation. 7. Punitive provision. 3. The concept of terms. 8. The relationship with euthanasia. 4. Patient's self-determination. 9. Controversial issues. 5. Subrogated determination by family.

무연고환자의 연명의료 결정 : 사전연명의료의향서 등록기관 및 결정 대행권자의 범위에 대한 고찰

이지은 梨花女子大學校 法學硏究所 2022 法學論集 Vol.26 No.3

현행 연명의료결정법에 의하면 연명의료결정에 관한 환자의 의사는 연명의료의향서와 연명의료계획서를 통해 확인될 수 있다. 그런데 사전연명의료의향서를 작성하지 않은 환자가 임종기에 이르렀으나 환자에게 가족이 없을 때는 연명의료중단에 관한 결정을 내릴 수 없다. 연명의료결정법의 사각지대에 놓인 소위 무연고환자의 문제는 연명의료결정에 관한 입법적 불비라는 비판 하에 여러 가지 대안이 제시되고 있으나 수차례의 연명의료결정법의 개정에도 불구하고 해결책은 마련되지 않았다. 사전에 의사표시를 하지 않은 무연고환자의 경우 타인이 그를 대신하여 연명의료결정을 내리는 것이 환자의 자기결정권을 침해한다는 우려가 있지만, 노령인구가 증가하고 전통적 가족이 빠른 속도로 해체되는 현 상황에서 무연고환자의 연명의료결정에 관한 문제를 입법적 공백 하에 두는 것은 바람직하지 않다. 이 논문에서는 무연고환자의 개념 및 연명의료결정시의 문제점을 살펴보고 그에 대한 제도적 보완방법을 강구하고자 하였다. 그리고 최근 개정된 연명의료결정법 제11조의 내용을 비판적으로 검토하면서, 환자가 사전에 연명의료의향서를 작성하여 등록하는 절차에의 접근성을 강화하기 위해 사회복지시설 및 치매안심센터를 활용하는 방안을 제안하였다. 그리고 사회적으로 고립되지 않은 환자임에도 가족의 사망으로 인해 법률적으로는 무연고환자와 같이 연명의료결정법의 사각지대에 놓이는 상황을 막기 위해 환자의 연명의료결정을 대행할 수 있는 사람의 범위를 확대하는 방안에 대해서도 고찰하였다. According to the current Life-sustaining Treatment Decision Act, patients who have not resistered advanced directive have reached their deathbed, but when the patient does not have a family, a decision on the suspension of life-sustaining treatment cannot be made. Some alternatives have been proposed against this legislative deficiency in life-sustaining treatment decisions, but were not reflected in the process of enacting and revising the Life-sustaining Treatment Decision Act. In the case of a patient without family or friends who did not express his/her intention in advance, there is a view that it violates the patient's right to self-determination to make a life-sustaining treatment decision on his/her behalf. In the current situation where the elderly population increases and traditional families are rapidly dismantling, it is not desirable to put the issue of life-sustaining treatment decisions for elderly patients under a legislative vacuum. In this paper, we tried to examine the meaning of patients without family or friends and the problems in determining life-sustaining treatment of patients without family or friends and devise an institutional supplementary method. First, while critically reviewing the contents of Article 11 of the recently revised Life-sustaining Treatment Decision Act, we looked at ways to use social welfare facilities and dementia relief centers to strengthen access to the procedure for patients to prepare and register their intentions in advance. In addition, measures to expand the scope of surrogates who can make decision on behalf of unbefriended patients.

Socio-Demographic Factors Affecting the Elderly's Preference for Life-Sustaining Treatment: Based on the 2017 National Survey of Older Koreans

Sang-Jun Shin,Hyeong-Cheol Lee,강희택 대한임상노인의학회 2022 대한임상노인의학회지 Vol.23 No.1

Background: The Act on Decisions on Life-Sustaining Treatment (LST) for patients in hospice and palliative care or at the end of life was legislated in 2016 in Korea. This study aimed to identify factors that affect disagreement with LST in Koreans aged 65 years or older. Methods: This study was a cross-sectional design based on data from the 2017 National Survey of Older Persons. This study included 9,699 old individuals (3,856 males and 5,843 females). Multiple logistic regression analyses were conducted to investigate which factors were associated with LST disagreement. LST disagreement was defined as “strongly disagree” with LST according to a self-reported questionnaire. Results: In, total, 42.9% of males and 42.5% of females strongly disagreed with LST. Odds ratios (ORs) (confidence intervals [CIs]) of females with mild cognitive impairment or dementia for LST disagreement were 0.729 (0.632-0.841) and 0.707 (0.586-0.853), respectively, compared with those with normal cognition. Compared with a long education period (≥12 years), the OR (95% CIs) of an intermediate education period (6-11 years) was 0.837 (0.713-0.981) in females. Female private insurance holders were more likely to disagree with LST (1.151 [1.006-1.316]), while female regular exercisers were less likely to do so (0.817 [0.731-0.913]). However, males living with others besides spouse were less likely to disagree with LST compared with males living alone (0.757 [0.603-0.949]). Conclusion: Cognitive status, education, private insurance subscription, and regular exercise were significantly associated with LST disagreement in females, while only household structure was associated with it in males.