# From cultural constraints to structural resilience: a comparative analysis of end-of-life care policies in China, South Korea, the U.S., and the U.K

## TL;DR

This study compares end-of-life care policies in four countries and finds that structural factors, not just culture, influence the success of advance directives.

## Contribution

The paper introduces a new dual-dimensional framework to analyze end-of-life care policy effectiveness across nations.

## Key findings

- Structural resilience, such as legislation and insurance integration, is more strongly linked to advance directive adoption than cultural factors.
- South Korea's policy changes after 2018 show how institutional design can improve advance care planning despite cultural constraints.
- The study proposes a Structural Adaptation Model to guide the development of effective end-of-life care systems.

## Abstract

As global populations age at unprecedented rates, nations worldwide confront the challenge of developing effective end-of-life (EoL) care systems. While advance directives (ADs) represent a cornerstone of patient-centered dying, their adoption varies dramatically across jurisdictions. This study introduces a novel dual-dimensional analytical framework—“Resilience from Scale” and “Resilience from Structure”—to explain cross-national variations in EoL care policy effectiveness among China, South Korea, the United States, and the United Kingdom.

Using a comparative, secondary-data-based design, we apply a Most Similar Systems Design to the East Asian cases and comparative institutional analysis to the Western cases. We employ semi-quantitative, ordinal coding of “Scale” and “Structure” indicators to assess how resource capacity and institutional configurations align with divergent policy outcomes.

The comparative evidence suggests that higher structural resilience—operationalized through national legislation, insurance integration, and state capacity/legitimacy—tends to be more consistently aligned with higher AD implementation than cultural explanations or resource availability alone. South Korea’s post-2018 shift following the Life-Sustaining Treatment Decision Act provides a salient within-case contrast, supporting the comparative plausibility that institutional design can coincide with substantial changes in advance care planning uptake even where cultural constraints are often assumed to be strong.

These findings challenge culturally deterministic interpretations in EoL policy research and propose a “Structural Adaptation Model” as a heuristic for jurisdictions seeking to develop effective advance care planning systems.