Older Persons' Rights
for Self-Determination
in End-of-Life Decisions Abroad
Sooyoun Han, PhD, MSW, Founder
Care Rights (Republic of Korea)
Table of Contents
 Problem Statements…………………….…………………………...
3
 Increase of Ageing Migration in South Korea…………………........
5
 Lack of Awareness and Cultural Incompetency Regarding EOL
Decisions in South Korea……………………………..……………..
6
 Identified Problems for Foreign Travelers and Foreign Nationality
Residents…………………………………………………………….
9
 Care Rights Program Goals, Activities & Outcome………………..
12
2
Problem Statements
 The phenomenon of rapid global ageing has led to challenges related to
human well-being.
 The older population is itself ageing. Globally, the share of older persons
aged 80 years or over (the“oldest old”) within the older population was
14 percent in 2013 and is projected to reach 19 percent in 2050.
If this projection is realized, there will be 392 million persons aged 80 years
or over by 2050 –more than three times the present number
(U.N. Department of Economic and Social Affairs, 2013)
 The number of international migrants worldwide reached 232 million,
up from 154 million in 1990. The global population of international
migrants is growing at a rate of about 1.6 percent per year (U.N. DESA, 2013).
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Figure. 1. International Migration, 2013
4
Figure 2. Age distribution of international Migrants, 2013
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Figure 3. Eight-Point Agenda for Making Migration Work
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Problem Statements
 Numerous potential obstacles for foreigners in need of EOL
care abroad are seen, including:
 Absence of EOL decision processing for foreigners
 Differences in cultural and healthcare legislation regarding
patients’ autonomy between two countries
 Language barriers
 Such problems could lead to:
 Disparities in the decision-making process regarding EOL care
 Violation of human rights
 Elder abuse in crisis situations, including “stranded migrants”
 Unnecessary medical expenditures
7
Increase of Ageing Migration
in South Korea
 Return migrants: “persons returning to their country of citizenship after
having been international migrants in another country and who are
intending to stay in their home country for at least a year”
(U.N. Division for collecting data on international migration, 1998).
 In 2011, 2,128 people reverse migrated to South Korea from the U.S.
: the largest population of reverse migrators to South Korea overall.
(Korean Ministry of Foreign Affairs, 2012).
 95,234 American Nationals aged 60 years or older entered South Korea
in 2011: 14,708 of them remained in the country three months or longer
with registered foreigner status from the U.S. (Han, 2012).
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Lack of Awareness and Cultural
Incompetency Regarding EOL Decisions
1. Family Norms and Patients’ Autonomy
on EOL Decisions in South Korea.
 Cultural ideas and expectations for family caregiving play a crucial role
in the EOL decision process : Many Asian countries find such discussions
taboo and against filial piety.
 Often, elders do not understand the concept of patient autonomy and EOL
decisions are relegated to family caregivers
(Haung, Hu, Chiu, & Chen, 2008; Kwon 2010).
 As a result, Korean healthcare staffs are not trained in EOL communication
skills for EOL decision making processing (Han & Lee, 2013).
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Lack of Awareness and Cultural
Incompetency Regarding EOL Decisions
2. Lack of Hospice Services and Social Services
for EOL Decisions in South Korea.
 Lack of legal and social services raise the risk of misconduct and/or
neglectance in EOL processes, leaving insufficient EOL decisions that
could lead to elder abuse in the forms of neglect, inequality, and
discrimination.
 Foreign travelers or residents are vulnerable to have possibly unwanted
aggressive treatments, as opposed to pre-requested EOL decisions that are
culturally-designed, pain-free and provided by comfortable hospice care.
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Lack of Awareness and Cultural
Incompetency Regarding EOL Decisions
3. Healthcare Legislature and Patients’ Autonomy
Regarding EOL Decisions in South Korea.
 Legislation such as the U.S.’s Patient Self-Determination Act (Pub. L. No. 101508, PSDA), which calls for Advance Directives for Health Care,
but not yet enacted in South Korea.
 As of now, the South Korean Emergency Medical Service Act (EMSA)
requires that hospitals and healthcare providers provide mandatory emergency
medical services to all patients, contingent upon certain disparities.
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Identified Problems for Foreign Travelers
and Foreign Nationality Residents
1. Conflicts Between Legal and Health Insurance Systems
 The Korean government founded the Emergency Service Fund (ESF) to
reimburse unpaid expenses to medical service providers (Song, Kim & Lee,
2008). One fourth of this fund was paid for by foreign emergency patients.
 Most travel insurance plans have a max. coverage cap and do not always
cover all options for life-sustaining treatments.
 Public insurance like Medicare does not cover medical costs abroad; others
cover only partial medical costs.
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Identified Problems for Foreign Travelers
and Foreign Nationality Residents
1. Conflicts Between Legal and Health Insurance Systems (continued)
 Issues such as unwanted life-sustaining treatments for those with
completed Advance Directives for Health Care may arise due to
responsibility of expenses and national and international legal issues.
 Reasons for such problems include:
 Lack of clear and culturally-sensitive information
 Deficits in health care legislation
 Lack of legislation for self-determination of EOL decision in some countries
 Cultural differences and language barriers
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Identified Problems for Foreign Travelers
and Foreign Nationality Residents
2. Violation of Human Rights
 Foreign travelers and/or residents are
at a higher risk for misconduct and/or
neglectance in EOL care left with insufficient EOL decisions that could form
another type of elder abuse abroad.
 Foreign travelers and/or residents are easily deprived of rights to being
informed about self-determination at EOL care in abroad.
 In South Korea’s current state, the rights of foreign travelers and/or residents
who do not wish to receive aggressive life-sustaining treatments cannot be
protected if unable to make EOL decisions at the time of service.
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Program Goals
Care Rights is working…
1. To prevent neglect, abuse, and the violation of human rights of
older persons in their EOL care in South Korea.
2. To ensure human rights are met by allowing older adults who are
foreign travellers or foreign national residents to make EOL
decisions in advance with the benefits of cultural sensitivity and
competent language services.
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Program Goals
Care Rights is working…
3.To reduce misconduct in life-sustaining treatments caused
by a lack of health legislation, communication, and educational
materials about EOL care and the rights of foreign travellers and
foreign nationality residents.
4.To provide a psychoeducational intervention program to reduce
the tremendous emotional and psychological burdens of longdistance family caregivers, as well as healthcare providers and
staffs.
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Program Target Population
Care Rights’ Target Populations…
1.Foreign travellers and foreign nationality residents in South Korea
2.Long-distance family caregivers of foreign travellers and foreign
nationality residents in South Korea
3.Health care providers and staffs who provide emergency medical
services to patients who are foreign travelers and/or foreign
nationality residents
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Program Activities
Care Rights’ Activities…
1. Provide a psycho-educational intervention program for older persons
who are foreign travelers and/or foreign nationality residents and
their caregivers about end-of-life care and rights in South Korea
2. Implement National Advance Directives for Health Care Form and
provide them to foreign travelers and foreign nationality residents on
a regular basis.
3. Educate healthcare workers and social workers about EOL decision
processing, and publicly advocate the rights of elderly patients in their
autonomy in EOL decisions.
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Program Activities
Care Rights’ Activities…
4.Develop brochures and materials about the rights to EOL decisions,
National Advance Directives for Health Care Form, and cultural
supports to ensure that foreign travelers and foreign nationality
residents are aware of their rights and do make decisions regarding
their EOL care
5. Work collaboratively with the Korean Ministry of Foreign Affairs
and National Immigration Service to provide such materials and
services to foreign travelers and foreign nationality residents visiting
South Korea.
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Care Rights Program Outcome
Care Rights’ Outcome…
1. Protect older foreign travelers and foreign nationality older
residents’ rights to EOL decisions abroad, ensured by the Madrid
International Plan of Action on Ageing, 2002.
2. Improve older person’s dignity and autonomy in the process of
dying.
3.Lighten stress and burden of long-distance family caregivers,
including those who are located abroad.
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Program Outcome
Care Rights’ Outcome…
4.Reduce unnecessary medical expenses incurred by misconduct and
neglect that go against the rights of foreign older travelers and
foreign nationality older residents’ in their EOL decisions.
5.Develop International Older Persons’ Human Rights Instruments
for EOL decisions and well-dying processing, focused on one of the
main areas of concern for the lack of special measures, mechanisms
and services (The Second Assembly on Ageing, A/66/173, 2011).
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References
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2.
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3.
U.N DESA. (2013). World Population Ageing 2013. New York: U.N.
4.
United Nations (1998). Statistics Division for collecting data on international migration.
5.
Korean Ministry of Foreign Affairs (2012) Diplomatic White Paper.
www.mofa.go.kr/ENG/policy/whitepaper/index.jsp?menu=m_20_160
6.
Han, S. B. (2012, 05 03) Rush of reverse migration due to expensive medical cost in abroad. Seoul
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Substantive Session
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