Korean J Hosp Palliat Care.  2020 Sep;23(3):126-138. 10.14475/kjhpc.2020.23.3.126.

Barriers to Counseling on Advance Directives Based on Counselors’ Experiences: Focus Group Interviews

  • 1Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Korea
  • 2Departments of Pediatrics, Seoul National University Hospital, Seoul, Korea
  • 3Departments of Psychiatry, Seoul National University Hospital, Seoul, Korea
  • 4Departments of Internal Medicine, Seoul National University Hospital, Seoul, Korea


In Korea, since the Act on Hospice and Palliative Care and Decisions on LifeSustaining Treatment for Patients at the End of Life was implemented in February 2018, advance directives (ADs) have become legally effective and should be documented after sufficient explanation by a registered counselor. However, little is known regarding the adequacy of current AD counseling. This qualitative study aimed to explore the barriers to AD counseling based on counselors’ experiences.
We conducted focus group interviews using purposive sampling. Seven counselors working at hospitals, community health institutions, and non-profit organizations participated in this study. They were asked about the challenges and problems they encountered during AD counseling.
Three themes emerged from this study; 1) issues regarding consistency in AD counseling, 2) issues regarding AD counselors’ competency and work environment, and 3) issues regarding the adequacy of the service system. The interviewees stated that the lack of a manual for standardized service made AD counseling inconsistent. The limited competency and poor work environment of counselors were pointed out as major barriers. The interviewees also stated that a proper service system considering individual circumstances is absent.
The goals of AD counseling should be clarified and guidance should be implemented for providing standardized services. Further efforts to enhance the competency of AD counselors and to improve their working conditions are needed. Establishing an integrated framework for an adequate service system is also essential to overcome systematic barriers to AD counseling.


Advance directives; Advance care planning; Terminal care; Counselors
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