Previous main body of research on end-life-care in South Korea has focused on developing services quality in hospital settings or service payment system in National Health Insurance Program. The delivery system of hospice and palliative care services has evolved in diverse ways but there is little research on reviewing the past history of development and whole picture of them so far. So, the aim of this study is to review the old hospice and palliative care system and also to introduce the current one supported by the National Health Insurance Program in South Korea. The palliative care or hospice services in South Korea have been available in diverse settings and provided by different organizations (i.e. catholic hospitals or charity organizations). Finally, it was set up in 2004 that the hospice team or official Palliative Care Units (PCUs) was established in hospitals, in order to meet the end-of-life care for the patients with terminal cancer under the Cancer Control Act. The current hospice and palliative care services such as pain management, bereavement services, and counselling can be reimbursed by National Health Insurance program since 2008. Nevertheless hospice and palliative care services are available to dying patients, yet the utilization rate of hospice and palliative care services or the length of stay in the palliative care unit (PCU) is still relatively short compared to other country systems. South Korea is undergoing several efforts to expand the services in PCU along with the development of quality indicators for PCU. Hospice and palliative care services are still new in the health care system and unfamiliar to the public so it requires raising awareness for medical professionals and the public as well as further research.
Hospice or palliative care is a relatively new concept in South Korea under its national health care system. Even though hospice care has been available through religious organizations such as the Gabari Catholic Organization since 1963, the services were not considered “professional” or “medical” by the public. In 1980, a Catholic general hospital set up a hospice unit as part of an oncology unit [
Since 2008, hospice and palliative care has been offered to patients with terminal cancer in certified hospitals with the support of the National Health Insurance Program [
This study will introduce the background of the development of hospice and palliative care services in South Korea, explain current services and their utilization, and identify new efforts for better hospice and palliative care in South Korea. Furthermore, this study will address the future direction of hospice and palliative care services to meet the needs of South Koreans.
“Hospice and palliative care” in South Korea can be explained as end-of-life care for dying patients. It is available mainly in hospital setting. Independent hospice clinics and free-stranding hospice organizations do not exist in South Korea. According to the definition of palliative care services supported by the Cancer Control Act Article 2, a “Terminal Cancer Patient” is defined as a patient who does not have the potential to recover and is expected to die within a few months due to aggressive declines brought on by his or her symptoms. “Hospice and Palliative Care Service” is defined as a comprehensive care service that aims increase the quality of life among terminal cancer patients, assist their families in assessing physical, psychosocial, and spiritual domains, and evaluate treatment options for pain management and symptom relief [
To accomplish these aims, Palliative Care Units (PCUs) in hospitals provide following major categories of services such as pain and symptom relief management, bereavement management, support services, spiritual care services and therapeutic programs. With pain and symptom relief management, medical professionals (physicians and nurses) assess the pain and symptoms of patients (i.e. loss of appetite, cachexia, pain, breathing irregularities, skin appearance, and mental symptoms) during the initial visits and then manage them according to a care plan agreed upon during a team conference. Next is bereavement management is a service offered to patients and their families prior to a patient’s death. The services provide assistance to patients and their families undergoing physiological changes prior to death. After death, providers of this service keep the family informed of the details remaining in the process. Support services for families that to help with bereavement processes are available for one year following after a patient’s death that may have in regarding to death. Additionally, spiritual care services of unresolved personal issues are designed to offer support for patients in finding answers to spiritual questions such as a the meaning of life, closure and religious worship services. Therapeutic programs (i.e. horticulture, art, music, aroma therapy and massage) are also available to increase the quality of life and emotional stability of patients. Patients and their families can also agree to receive pain control and physical symptom management, social and economic care, emotional care, safety enhancement care, nurse visits, and terminal care at home through home hospice if facing patient with terminal cancer. A 24-hour-hotline counselling and visitation services is available for emergencies during night and weekends.
The Ministry of Health and Welfare in South Korea has been involved in developing hospice and palliative care services heavily. They have been responsible for monitoring the licensing of professionals, regulating requirements, and building up a database for clinical and policy purpose. The Ministry of Health and Welfare along with the National Cancer Center have played major roles. The National Cancer Center is a national organization tasked with performing basic and clinical cancer research on cancer, providing medical care services for cancer patients, offering education and training, and assisting the government in formulating regulations. Both the Ministry of Health and Welfare and the National Cancer Center have played major roles in the research and implementation of end-of-life care in South Korea.
A pilot project to assess the costs involved in hospice and palliative care services was launched in 2008. After the initial pilot project (2008-2011), a second pilot project was begun in 2012 and remains ongoing. Twelve institutes were engaged with these pilot projects to assist in establishing a payment system for hospice and palliative care.
A number of studies were conducted on quality issues related to hospice and palliative care services even before South Korean government officially incorporated these services into the National Health Insurance Program. These studies addressed in part the education of medical providers, the outcomes of hospice and palliative care, and approaches to pain management [
Due to a lack of comparable data, South Korea established a national database for patients who receive hospice and palliative care in hospitals throughout the nation.
The National Cancer Center estimates and provides basic statistics among terminal cancer patients who received hospice and palliative care services. This data is then utilized for health care policy decisions to support patients with terminal cancer. This Terminal Cancer Patient DB Registry includes all information about palliative care, home visits, hospitalization and discharge, and bereavement information. Furthermore, this database also includes the results of patient and family surveys in regarding to their satisfaction with the services provided.
The National Cancer Center functions plays a major role in educating professionals who works in PCUs and distributing information on how to manage PCUs through workshops and training for hospice and palliative care services. People who receive special training from the National Cancer Center become experts who then visit PCUs in hospitals and provide mentoring for medical professionals working there. They train other in the protocol for dealing with difficulties in the PCU and for promoting the quality of care in the PCU. Experts can also provide these services to hospitals that want to set up a PCU that plan to offer a PCU in the near future. The usual spectrum of training involves: management and evaluation, patient and family education and counseling, relief therapy, spiritual care, bereavement care, and home hospice. In addition, the South Korean government established requirements and regulations for hospice and palliative care in hospitals in areas such as facilities, personnel, and equipment.
To expand the services of palliative care for terminal cancer patients, the Ministry of Health and Welfare enacted the Notification of Palliative Care Institution Designation Standards in September 2008, and by 2014, 54 palliative care institutions were established. Since 2005, the Ministry of Health and Welfare has subsidized public palliative care institutions to be subsidized for their operating expenses [
This is the most common format for providing hospice and palliative care services for terminal cancer patients. Services such as pain management and bereavement care are provided in independent PCUs in general hospitals to help patients and their families [
In 1990, Medical Act 56 was passed to allow registered nurses to visit homes in order to provide home care for patients [
There were pilot projects conducted to provide home hospice for terminal cancer patients through community health centers between 2000 and 2002 [
The current reimbursement for hospice and palliative care services is per diem, which uses a flat rate per day, mainly differentiated by a provider’s size (i.e. tertiary hospital, hospital, or clinic) for institutes involved with the pilot project. A few supplementary services are paid according to a fee schedule that takes into consideration the resources (i.e. nurse level) and time needed to provide a service (
In 2012, 8472 cancer patients received services from 44 palliative care institutions. Among those who died from cancer only, 11.9% received palliative care from these institutions. In 2011, 87.7% of cancer deaths occurred at health institutions, 9.3% occurred in patients’ homes and 1.3% during transfer, respectively [
Provider Information | Hospice and Palliative Care Services | ||
---|---|---|---|
Organizations | Total Number | ||
Involved with Pilot Project to Develop Palliative Care Services | Not involved with Pilot Project to Develop Palliative Care Services | ||
Number of Organizations | 12 | 42 | 54 |
Number of Beds | 206 | 662 | 868 |
Payment System | Per Diem | Fee for Service | |
Out of Pocket Money Payment | 5% | 5% | |
Provided System | Separate Units in Hospital | Separate Units (or Beds) in Hospital | |
Government Funding | Yes | Yes | 2,720,000,000 (Korean Won) |
Source: National Cancer Center (2014), Support for activation of palliative care service. Seoul, Korea: National Cancer Center.
cancer patients obtained services from palliative care institutions. According to the type of cancer, lung cancer patients received the most assistance was the highest (1329, 19.7%), followed by gastric cancer (883, 13.1%), colorectal cancer (684, 10.1%), pancreatic cancer (619, 9.2%), and liver cancer (584, 8.7%) [
In general, dying patients who received hospice and palliative care services did not utilize expensive care and treatment plans prior to death, therefore resulting in overall lower costs for health care services [
South Korea has done well to develop end-of-life care under the National Health Insurance program within the past 15 years, but new efforts are required. South Korean citizens are generally aware of the need for end-of-life care [
Currently, only low-income patients with terminal cancer are able to access home hospice [
The body of research on end of life care illustrates that the hospice use increased over time after a similar program from the US was instituted in South Korea [
In addition to extending of end-of-life care, the National Health Insurance program, also take steps to guarantee the quality of care provided. Previous studies and current monitoring systems have focused on structural level aspects such as equipment and personnel qualifications and training [
Despite many challenges to implementing services, South Korea, over the past decade, has developed and improved its end-of-life care for terminal cancer patients through its National Health Insurance program. Ongoing care and appropriate policy changes should be considered based on more in-depth research. More empirical research is needed on quality assurance for hospice and palliative care and the development of a comprehensive service delivery system for end-of-life care in hospital settings and in communities in the future. Thus, these research findings can help to establish feasible and reliable health policy implications.
Author thanks for assistance that Hee-ae Kim provided for this manuscript.