![]() ![]() However, in 2010, New York passed the Family Health Care Decisions Act (FHCDA) which nullified the previous DNR law and subsumed DNR decision-making into a broader standard for the withdrawing and withholding life-sustaining treatments. ![]() From 1988 to 2010, New York’s DNR law allowed a surrogate or two physicians to enter a DNR on a patient if resuscitation is deemed medically futile. New York is another state whose laws evolved towards being more restrictive, constraining physicians’ ability to act in patients’ best interests. Nurses felt more empowered to participate in end-of-life decision-making, thus reducing moral distress and clinicians felt they were better able to maintain a unified message with patients and families. ![]() In a qualitative study of French ICU clinicians following the passage of Leonetti’s Law, this interprofessional process was found to facilitate a more ethical climate around end-of-life decision-making, where discussions around treatment decisions shifted from hushed discussions to more openness and transparency. Leonetti’s law created an explicit collegial interprofessional process for establishing consensus around limitations of non-beneficial life-sustaining treatment. An example of this type of policy is France’s Leonetti law (2005), which focused on improving interprofessional communication about withdrawing or withholding of life-sustaining treatment during terminal illness. These policies often increase the permissibility of limitations of life-sustaining treatment and provide clarity and transparency around the process through which these decisions are made. The well-dying law is similar to other policies that have improved end-of-life care and acceptance of palliative care. As East Asian countries are increasingly exposed to Western attitudes and beliefs, notions of individual autonomy and self-determination become increasingly accepted. South Korea’s well-dying law appears to reflect the influence of shifting cultural norms on policy. Discussing death is seen as inappropriate and filial piety often interpreted as doing one’s best to ensure parents live as long as possible, even if treatments might not be beneficial. South Korea is a traditionally Confucian country, whose social norms are governed by strong familial relationships, filial piety, and a focus on collective harmony rather than individualism and autonomy. In this issue of Intensive Care Medicine, Lee and colleagues describe changes in clinicians’ perceptions of the quality of death in the intensive care unit following the implementation of South Korea’s Hospice, Palliative Care, and Life-sustaining Treatment Decision-Making Act (the “well-dying law”) in 2018, which legalized the ability for terminally ill patients to refuse cardiopulmonary resuscitation (CPR) and life-sustaining treatments. If employed strategically and thoughtfully, institutional, regional, and national policy change can be a useful intervention to improve end-of-life care and foster institutional cultures that promote high-quality palliative care. It is thus essential to understand how the intended and unintended consequences of policy changes might positively or negatively impact clinician attitudes and behaviors, as well as patient and family outcomes. Policies influence clinical practice patterns through direct influences of policy, but also indirectly through culture (Fig. Institutional culture, or the collective values, beliefs, and behavioral norms of an institution, influence clinical practice patterns, behaviors, and attitudes. How do policies influence culture and vice versa? Does culture have more influence on policy, or does it more often flow the other direction? These are important empirical questions which have wide-ranging implications for both policy makers and those who want to improve clinical care. The interplay between health policies and culture at the institutional, regional, and national level are important yet understudied questions in medicine. ![]()
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