Living arrangements shape the determinants of life-sustaining treatment preferences among Korean older adults

When people face the end of life, they often think about what kind of medical care they would want if they became too sick to speak for themselves. This is the heart of advance care planning, a process where individuals decide in advance whether to accept treatments that keep the heart beating or the lungs breathing when the body is failing. In South Korea, a law passed in 2018 gave these personal choices legal weight, allowing doctors to follow a patient's wishes rather than automatically using every possible machine to prolong life. However, making these decisions is not just a medical calculation; it is deeply tied to a person's daily life and who is around them. For older adults, the people they live with—whether a spouse, children, or no one at all—shape how they view support, independence, and the future. Understanding how these living situations influence choices about life-sustaining treatment helps families and doctors have more meaningful conversations about what truly matters to the patient.

Researchers set out to understand exactly how living arrangements change these preferences among older adults in South Korea. They analyzed data from a massive national survey of nearly 6,700 people aged 65 and older. To ensure the results reflected clear thinking, they excluded anyone with diagnosed dementia, depression, or significant cognitive issues. The team sorted the participants into three distinct groups based on their household: those living only with a spouse, those living with their children or grandchildren, and those living completely alone. The goal was to see if the reasons behind accepting or refusing life-prolonging treatment were the same for everyone, or if they shifted depending on who was sharing the home.

The study revealed a striking consistency at the top level: regardless of who they lived with, more than 92 percent of the older adults surveyed said they would decline life-sustaining treatment if they were at the end of life. This overwhelming preference for letting nature take its course was the same across all three groups. However, the factors that pushed a small minority toward acceptance were entirely different depending on the household structure. For the group living with a spouse, the decision to accept treatment was linked to being younger, living in a city, having trouble with daily tasks like bathing or dressing, not using a smartphone, and not having heart disease. In this context, the presence of a spouse seemed to make the prospect of managing daily care feasible, so those with physical limitations were more open to keeping life going.

The picture changed completely for those living with their children. In this group, medical conditions like heart disease or stroke did not drive the decision. Instead, personal habits played a major role. People in this group who currently smoked were much more likely to accept life-sustaining treatment, while those who drank alcohol frequently were less likely to accept it. This suggests that for those living with offspring, lifestyle choices and perhaps the values they share with their families might influence these deep decisions more than their specific medical diagnoses.

For the group living alone, the drivers were again unique. Those living by themselves who had suffered a stroke were more likely to accept life-sustaining treatment, perhaps because a stroke represents a sudden, dramatic loss of independence that feels particularly threatening without a partner or child nearby to help. Conversely, those living alone who had heart disease, chronic pain, or a religious affiliation were less likely to accept treatment. It appears that for the solitary elderly, the fear of sudden disability outweighs the burden of chronic pain or long-term illness when considering whether to fight for more life.

The researchers found that while the vast majority of older Koreans prefer to avoid aggressive medical intervention at the end of life, the reasons behind that preference are not one-size-fits-all. The study suggests that the social context of a person's home is just as important as their medical chart. A person living with a spouse weighs their options differently than someone living with children or someone living alone. These findings indicate that when doctors and families discuss end-of-life care, they should look beyond the diagnosis and consider the living situation. Understanding whether a patient has a partner to help with daily tasks, children involved in decision-making, or no one at home could help tailor these crucial conversations to the specific realities of the person facing the end of life.