Impact of the Life-Sustaining Treatment Decision Act on the Incidence and Outcomes of In-Hospital Cardiopulmonary Resuscitation

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OBJECTIVES: To determine whether the implementation of the Life-Sustaining Treatment Decision Act (LSTDA) in South Korea affected the age-standardized incidence rate (ASIR) of in-hospital cardiac arrest (IHCA) and in-hospital mortality. DESIGN: Retrospective, population-based cohort study. SETTING: Nationwide administrative health database in South Korea. PATIENTS: A total of 380,488 adult patients (≥ 18 yr) who underwent in-hospital cardiopulmonary resuscitation between January 2013 and December 2023. Cases from the implementation year (2018) were excluded to minimize transitional bias. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcomes were the annual ASIR of IHCA and in-hospital mortality. The study population was divided into pre-LSTDA (2013-2017; n = 147,385) and post-LSTDA (2019-2023; n = 233,103) periods. Multivariable logistic regression revealed that the post-LSTDA period was associated with significantly lower in-hospital mortality compared with the pre-LSTDA period (adjusted odds ratio, 0.90; 95% CI, 0.88-0.92; p < 0.001). Regarding incidence, segmented linear regression analysis showed that before the LSTDA, the ASIR increased significantly by 6.5 cases per 100,000 population per year (95% CI, 1.6-11.4; p < 0.001). After implementation, the upward trend decelerated (slope change, -5.4; 95% CI, -12.8 to 1.5; p = 0.177), indicating a shift toward a decline in the growth of IHCA events. CONCLUSIONS: The enactment of the LSTDA was associated with a significant improvement in survival outcomes and a deceleration in the rising incidence of IHCA. These findings suggest that the legal framework for end-of-life decision-making effectively facilitates the withholding of medically nonbeneficial resuscitation, thereby optimizing the allocation of critical care resources toward patients with better reversible potential.

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