Everyone hopes for a good death, or rather, a good life to the very end (1). Dying with dignity, also called “well-dying” in South Korea, has been the subject of hot national debates for nearly two decades which was galvanized by the case frequently referred as the Boramae incident of 1997; two physicians had been convicted of assisted murder and sentenced for suspended prison terms in May 1998 on the charge that they discharged a brain-damaged patient with no possibility of recovery at the request of his wife against the medical policy at the time (2,3). Medical decision makers, having no proper legal protection, have continued meaningless life-sustaining treatments for the no-hope patients in terminal phase, and paid less effort in developing the hospice and palliative care system which was introduced in Korea since 1965, resulting in South Korea to be ranked 32 out of 40 countries in the 2010 Quality of Death Index (QDI): Ranking End-of- Life Care Across the World (4).

However, mounting medical and social demands in hospice palliative care (HPC) finally allowed the National Health Insurance Service to cover for the care cost for terminal cancer patients in July 2015, fifty years after the introduction of the HPC in South Korea; and the result has been immediately reflected in the 2015 QDI survey by the Economist Intelligence Unit, bringing up the national ranking to 18th out of 80 countries (1).

In addition, the National Assembly passed a legislation termed ‘The Law on the Hospice and Palliative Care and the Determination of Life-Sustaining Treatment for Terminally Ill Patients ｢호스피스완화의료 및 임종과정에 있는 환자의 연명의료 결정에 관한 법률｣’ in Jan 2016 that allowed incurable terminally ill patients to opt out life-sustaining treatment. The legislation paved the way for rapid development of HPC services that had been applied to restrictive cases in Korea (2). This law comes into effect in 2017, and its success critically depends on how the government and all interested parties in medical, academic and social sectors prepare and collaborate together to make the law effective in coming years.

This article reviews the half century history of HPC in Korea, and discuss the issues how we can actively prepare and cope with the problem of death and, thereby, improve the quality of death in this rapidly changing society.

Hospice in Korea began in 1965 at the Calvary Hospice in Gangneung City by Sisters of the Little Company of Mary came from Australia in 1964, and has been developed mostly by the efforts of some nurses, priests, and sisters of catholic church, ministers of protestant church, and some devoted physicians in early stage (5-7).

Hospice care expanded in the 1980s through the revolutionary care provided for the terminally ill by the Catholic University of Korea at Seoul St. Mary’s Hospital. The first physician to introduce hospice care in South Korea was Kyung-Shik Lee, a hemato-oncology specialist who was an assistant professor in internal medicine at the Catholic University of Korea School of Medicine in 1981. Most of the academic focus in the early 1980s was on prolonging the life span of patients, and thus hospice care was not a widely discussed topic. However, Dr. Lee believed that the process of dying was as important as the process of living and surviving in many of his cancer patients. A department dedicated to hospice care centered on the nursing staff was established at Seoul St. Mary’s Hospital, and began operation in March 1987, and the first hospice unit (10 beds total) was established at St. Mary’s Hospital in October 1988 (5,6).

A program for home hospice care was also initiated in the oncology department of Severance Hospital in 1988, while another project on home hospice care began that same year in the nursing department of Ewha Women’s University. Saint Columban Hospice opened its doors in 1989 by providing house calls that eventually evolved into home hospice care. Thereafter, hospice programs largely provided by religious social services or volunteer activities blossomed around the nation (5,6). Table 1 shows major events of the history of HPC in South Korea.

Table 1 . Brief History of Hospice Palliative Care in South Korea..

Year	Events
1965	Hospice began at the Calvary Hospice in Gangneung City by Sisters of the Little Company of Mary
1981	Voluntary hospice care were provided by medical and nursing student of Catholic University of Korea at Seoul St. Mary’s Hospital
1988	The first hospice inpatient unit in Seoul St. Mary’s Hospital
1991	Korean Hospice Association was established
1995	The Catholic University of Korea College of Nursing was selected as WHO’s Collaborating Center for Hospice Palliative Care
1998	Korean Society for Hospice and Palliative care was established
2000	‘National Cancer Center Act’ enacted and clinical Care services started
2003	Korean Hospice Palliative Nurses Association was established
2003	‘Cancer Control Act’ enacted
2003∼2004	Hospice palliative care demonstration project by Ministry of Health and Welfare
2005	The 6th Asia Pacific Hospice Conference was held in Seoul Hospice palliative care supporting project started by Ministry of Health and Welfare
2008	Palliative Care Units for terminally ill cancer patients were authorized
2011	‘Cancer Control Act’ was revised. It was first legal basis for hospice palliative care for cancer patients
Feb 2015	Enforcement rules of Cancer Control Act was revised for legal basis of home hospice and palliative care team
Jul 2015	National Health Insurance Service cover the hospice palliative care cost for terminal cancer patients
Jan 2016	‘The Law on the Hospice and Palliative Care and the Determination of Life-Sustaining Treatment for Terminally Ill Patients’ enacted and effective in August 2017

The increase of hospice facilities led to the establishment of the Korean Hospice Association in 1991 and the Korean Catholic Hospice Association in 1992. These two associations have greatly influenced the expansion of hospice care in Korea, despite the religious undertones that were inextricably linked to their missions.

In 1995, So Woo Lee, a professor of the Seoul National University College of Nursing, with colleagues conducted a study, The National Hospice Care Service Development in Korea funded by the Ministry for Health and Welfare, reporting on the status of terminal patients and their family caregivers (8). The researchers who participated in The National Hospice Care Service Development in Korea realized the need for establishing an academic society. Some of the researchers and Dr. Kyung-Shik Lee who were operating the hospice inpatient unit at the time joined forces to form an eight-member steering committee. After 3 months of preparation, the Korean Society for Hospice and Palliative Care (KSHPC) was established in 1998 (www.hospicecare.co.kr). The purpose for the establishment of the KSHPC was to advance academics related to HPC in Korea; to increase the quality of life for terminal cancer patients, factoring in the public health policies and medical regulations that would help them to lead a comfortable life; to interact with the international HPC academic societies and associations; and to exchange information (5,6). Moreover, KSHPC has been published the Korean Journal of Hospice and Palliative Care, first edition, volume 1, in December 1998, the year when the academic society was established, at least once a year until 2001, twice a year from 2002 to 2006, and quarterly since 2007, contributing to the academic development of the HPC interdisciplinary team (5,6).

After the foundation of KSHPC, each discipline of HPC professionals established their own organizations. The nurses established their own organization, The Korean Hospice Palliative Nurses Association (KHPNA), dedicated to promoting excellence in pain management and end-of-life care in 2003. The doctors belonged to KSHPC organized ‘Hospice Clinical Research Association’ to activate researches in HPC field in 2002. At the end of 2009, this research network changed its official name as ‘Korean Palliative Medicine Research Network (KPMRN)’ and opened the door to all doctors who have interests in the field. The social workers belonged to KSHPC also organized ‘Korean Social Work Hospice Palliative Care Research Network’ in 2013 to activate researches and build unique and valuable roles of social workers in HPC; the organization may contribute to defining and advocating their services in the field. And, in 2009, Korean Buddhist Hospice Association for affiliated buddhist hospice organizations and individuals also was established (Table 2).

Table 2 . Palliative Care Organizations in South Korea..

Name	Established Year	Remark	Home page
Korean Society for Hospice and Palliative care (KSHPC)	1998	The nation’s largest professional organization which provides	http://www.hospicecare.or.kr
		leadership in hospice palliative care in Korea
		The members are physicians, nurses, social workers and other medical professionals dedicated to excellence in and advancement of palliative care
Korean Hospice Palliative Nurses Association (KHPNA)	2003	Professional nursing organization dedicated to promoting excellence in pain management and end-of-life care	http://www.hospicenurse.or.kr
Korean Palliative Medicine Research Network (KPMRN)	2009	The doctors’ network under KSHPC dedicated to promote researches and educate in hospice palliative care field	http://www.kpmrn.org
Korean Social Work Hospice Palliative Care Research Network	2013	The social workers’ network under KSHPC dedicated to activate researches and education in hospice palliative care field	http://www.hospicecare.or.kr
Korean Hospice Association	1991	Non-profit Organization (NPO) dedicate to improve end-of-life care in Korea	http://www.hospicekorea.com
		The members are hospice organization or individual who agree with gospel of Christianity
Korean Catholic Hospice Association	1992	NPO dedicate to improve end-of-life care in Korea	http://www.kcha21.net
		The members are hospice organization or individuals who affiliate with Catholic
Korean Buddist Hospice Association	2009	NPO dedicate to improve end-of-life care in Korea
		The members are hospice organization or individuals who affiliate with buddism

Governmental approach has been progressing slowly compared with the academic advancement in HPC in Korea.

The KSHPC hosted the hearing session on the hospice systemization in 1999 along with the Korean Catholic Hospice Association and Korea Hospice Association at the National Assembly Member Center. In 2002, it published Guidance for Cancer Patient Pain Management jointly with the Korean Cancer Study Group. In 2003, it organized a symposium on the Korean HPC Systemization jointly with the National Cancer Center which was founded in March 2000 as a government-funded institution devoted to research, patient care, education, and training in cancer (http://www.ncc.re.kr), and submitted a draft hospice law to the Ministry for Health, Welfare, and Family Affairs. The National Cancer Center sponsored several studies that provided evidence to support Korean standardization of HPC services. Followed by incessant efforts of the academic society and the National Cancer Center, in 2003, the central government began supporting institutions that offer HPC service to terminally ill cancer patients which were number one cause of death to provide necessary support under the Cancer Control Act, and then the governmental approval of establishing Palliative Care Units (PCUs) in hospital was enacted in 2004 in order to provide the end-of-life care for the patients with terminal cancer and the medical costs for the inpatient in PCUs have begun to be supported by Cancer Control Act besides National Health Insurance Service since 2005 (5). In 2006, there were 23 institutions offering hospice palliative care for 2,060 terminal cancer patients, and by 2014 the support was increased to provide for 10,559 terminal cancer patients in 54 institutions (Table 3) (11).

Table 3 . 2005∼2015 Government Supporting Project for PCUs.*.

Year	05	06	07	08	09	10	11	12	13	14	15
Budget (million Won)	240	800	1,050	1,300	1,300	1,730	2,160	2,310	2,720	2,720	2,700
Number of Palliative facility	15	21	23	30	34	40	43	44	53	54	56
Number of bed	261	362	415	524	546	628	722	720	848	868	939
PCUs user (n)	-	-	-	5,046	6,396	7,654	8,494	8,742	9,573	10,559	-
Cancer death (n)	-	-	-	68,912	69,780	72,046	71,579	73,759	75,334	76,611	-
Coefficient of utilization (%)	-	-	-	7.3	9.1	10.6	11.9	11.9	12.7	13.8	-

PCUs: Palliative Care Units..

^*Source: National Cancer Center. Government supporting project for selected hospice palliative facility. Goyang: National Cancer Center;2015.

In June 2011, through the amendment to the Cancer Control Act, the government established more progressive HPC systems to improve the quality of life for terminally ill cancer patients and their families. The Ministry of Health and Welfare (www.mohw.go.kr) had managed a demonstration project to develop national health insurance service policy for HPC from 2009 to 2015. Five years of the demonstration project in HPC finally led the National Health Insurance Service to cover the care cost for terminally ill cancer patients in PCUs from July 2015, fifty years after the introduction of the HPC in South Korea. A demonstration project for home hospice care and palliative care team (PCT) in hospital also has been started from March 2016 (National Cancer Information Center, www.cancer.go.kr), and it is expected that these services will also be covered by National Health Insurance Service soon.

Government engagement has been crucial in recent hospice palliative care service development in Korea. The way of dying with dignity, also called “well-dying” in South Korea, has been the subject of a hot national debate for nearly two decades which was galvanized by the case frequently referred as the Boramae incident of 1997 (2,3). Medical decision makers, having no proper legal protection, has continued futile life-sustaining treatments for the patients in terminal phase, and paid less effort in developing the hospice and palliative care system. In addition to Cancer Control Act, the National Assembly passed a legislation ‘The Law on the Hospice and Palliative Care and the Determination of Life- Sustaining Treatment for Terminally Ill Patients’ on(in) Jan 2016 that allows the incurable terminally ill patients to opt out life-sustaining treatment; it is expected that this legislation will greatly promote a rapid development of HPC services that are still quite insufficient in Korea (2). The law consists of 6 chapters and 43 articles, including a management system for decision-making, field performance, hospice and palliative care. Under this law, South Korea will consist a national committee for hospice care and futile life-sustaining treatment, and a national management institute for life-sustaining treatment, and designate annually the second Saturday of October annually as ‘Hospice Day’. This law also contains the writing method of Advance Directives and Physician Orders for Life- Sustaining Treatment (POLST) (9). This law comes into effect in August 2017, and its success critically depends on how the government and all interested parties in medical, academic and social sectors prepare and collaborate together to make the related Enforcement Ordinance and Regulations.

In Korea, the institutions that provide HPC can be divided into three groups: PCUs and free-standing HPC facilities, home hospice care, and PCT in the hospital.

There were 17 hospice programs available in 1980, which steadily grew to 73 in 1990, and 113 in 2007 (10). The 113 HPC institutions in 2007 include 21 home hospice institutions, 19 palliative care units, 19 mixed types, 12 free- standing hospice institutions, and 42 other types of institutions. In June 2011, through the amendment of the Cancer Control Act, standard guidelines for authorization of PCUs for terminal cancer patients and their families have been announced, and as of Jan. 2015, 56 palliative care units had been authorized nationally (National Cancer Information Center, http://www.cancer.go.kr). The revised Cancer Control Act 2011 has increased the PCUs while pushing other charity facilities steadily decline. The government’s second-term 10-year plan to conquer cancer aims to secure 2,500 beds by 2015 to provide HPC for 40,000 terminally ill cancer patients (about 50% of the target population). To secure the beds in medical facilities, the Government had supported PCUs services for terminally ill cancer patients and families from 2005 to 2015 (Table 3) (11).

However, the government policies in HPC in the last decade (2005∼2015) has been rather slow and ineffective; their aggressive initial plan of providing 2,500 beds which are 50 beds per a million population based on the statistics of England is now reduced to provide 1,400 beds by 2020 in comparison of the case of Taiwan which projects 20% occupancy rate by HPC patients (12).

National Health Insurance Service reimburses the costs used for the services of pain management, bereavement services, counselling, and related treatments for terminally ill cancer patients and families in PCUs.

Since the reimbursement for the HPC service by National Health Insurance Service has begun, the PCUs authorized by the Ministry of Health and Welfare have been rapidly increasing from 60 institutes (1,009 beds) in Sep 2015 to 66 in Jan 2016 (13). The positive impact of the Cancer Control Act and the subsequent reimbursement policy by National Health Insurance Service may be seen in the recent surveys on QDI ranking by Economist Intelligence Unit; it was 18th out of 80 countries in 2015 while 32nd out of 40 in 2010 (1,4).

However, home hospice care and PCT in hospital has not yet been authorized by National Health Insurance Service yet. Most home hospice relies heavily on support from charity organizations, government or local government funding, and volunteers. As of 2011, 29 home HPC facilities had been reported in South Korea: 11 (37.9%) hospital-based facilities, 4 (13.8%) hospital-independent-center-based care facilities, and 10 (34.5%) home-based care only. Issues such as lack of trained physicians and social worker participation, lack of financial support, and lack of interdisciplinary team members’ awareness of home HPC had been reported (14).

The Ministry of Health and Welfare enacted the revised enforcement rules of Cancer Control Act that allows hospital based home hospice care from Dec 29 2015. While the government provided the care for the inpatient in PCUs, surveys reveal that most terminal cancer patients want the care in their homes. For example, the survey of 465 cancer patients by the Ministry of Health and Welfare showed that 75.9 % expressed their desire to stay in their home and 89.1% receive the care at home (15). From March of 2016, Ministry of Health and Welfare announced that 17 HPC facilities will be involved in the demonstration project to develop home hospice National Health Insurance Service for terminally ill cancer patients and their families (16).

Although HPC services are available to dying patients in Korea, the service utilization rate and the length of stay in palliative care units are still relatively low and short compared to the statistics of other country systems (7). And, other issues to be solved is most PCUs located in Seoul, Incheon and Gyeonggido, so regional variance in bed occupancy rate was significantly high (17).

Statistics shows that national policies are vital for extending access to hospice palliative care; the UK or Taiwan, or the countries ranked high in the QDI have comprehensive policy frameworks that integrate palliative care into their healthcare systems through a national health insurance scheme (1).

HPC team members can include physicians, nurses, social workers, clergies, volunteers, pharmacists, nutritionists, physical therapists, art therapists, music therapists, and speech therapists. Of these interdisciplinary members, physicians, nurses, social workers, and volunteers are required to establish a palliative care unit by Cancer Control Act and the other members are included according to the care setting. The Cancer Control Act also requires that physicians, nurses, and social workers in HPC settings complete over 60 hours of mandatory education in hospice palliative care beginning from 2012 (Health Insurance Review and Assessment Service, http://www.hira.or.kr; Ministry of Health and Welfare, http://www.mw.go.kr).

The National Cancer Center with the support of the government appointed physicians, nurses, and social workers developed a 60-hour-long basic level standard curricula for all interdisciplinary team in HPC in 2008, and they have been actively used to train professionals interested in HPC since 2009 (12). The National Cancer Center developed advanced level curricula for each interdisciplinary professional; curriculum for the nurses was developed in 2009, the pilot course was operated in 2010, and for physicians and social workers were developed in 2011.

In South Korea, the nurses are coordinators for the HPC team while the physicians are responsible for leading the team. Thus, active participation of physicians is essential for accelerating the development, and improving the patient’s ‘Quality of Life’ to a higher level (7). Dr. Hong suggested to develop education systems for physicians and medical students in 2008 (7), but hospice palliative medicine has not been recognized as an official subspecialty yet.

Meanwhile, we have specialist nursing qualification up to advanced practice level (APN) in hospice palliative care. The APN in hospice palliative care program started in March 2004, and the nurses must complete at least 33 credits in master degree program and pass the nationally administered board examination to qualify as APN. The role of the APN in Korea is very similar to that of APN in the United States except prescription privileges (5).

The End-of-Life Nursing Education Consortium (ELNEC) project is a national education initiative to improve palliative care. The project provides undergraduate and graduate nursing faculty, CE providers, staff development educators, specialty nurses in pediatrics, oncology, critical care and geriatrics, and other nurses with training in palliative care so they can teach this essential information to nursing students and practicing nurses. The project began in February 2000 in USA (18). The Core course of ELNEC train-the-trainer programs developed by City of Hope (COH) National Medical Center and the American Association of College of Nursing (AACN) were introduced in August 2009, Geriatrics course in July 2010, Pediatric Palliative Care course in July 2012 in Seoul organized by ELNEC Project-Korea (six member team led by Hyun Sook Kim, R.N., Ph.D.) collaborating with KHPNA, KSHPC, and Korean Academy of Child Health Nursing. 145 trainers in Core course, 203 trainers in Geriatric course, and 191 trainers in Pediatric Palliative Care were certified as ELNEC trainers. The successful implementation of these programs greatly helped increasing the nurse’s knowledge, and the dissemination led to educating and training other nurses and health professionals to improve the quality of end-of-life care not only for terminal cancer patients but also for all suffering from life-threatening illness (5,19,20).

Training all doctors and nurses about HPC with well- organized contents is essential for meeting the growing demand. In 2015 highly ranked QDI countries such as UK and Germany recognized that palliative care expertise is a required component of both general and specialized medical qualifications, while several other top-scoring countries manage it in the national accreditation systems. Countries without sufficient training resources experience a severe shortage of specialists, while general medical staff may also lack the training in applying opioid analgesics appropriately (1).

In South Korea, the qualification standard for social workers in HPC remains inadequate. There seems to be insufficient professional social worker training resources, in terms of both the number of educators and training programs (21). The curriculum for clinical social workers and social work student is urgently needed to fill the void.

With enormous growth in economy, Korea which once received foreign aids now gives help to other countries. On September 18, 1995, The Catholic University of Korea College of Nursing was selected as WHO’s Collaborating Center for Hospice Palliative Care, and the following year, the Research Institute for HPC was established within College of the school. The research institute began medical training for over 300 hours of structured HPC program, focusing on nursing in 1996 (http://hospice.catholic.ac.kr). And, the establishment of academic organizations (KSHPC) in 1998, has served as a turning point in increasing interaction between Korean experts on HPC with oversea’s institutions (5).

In 2001, the Asia Pacific Hospice Palliative Care Network (APHN) was established to empower and support individuals and organizations committed to alleviating suffering from life threatening illness in Asia Pacific region (www.aphn.org) as an academic forum for HPC professionals in Asia Pacific region; Hong Kong, Japan, Taiwan, Singapore, Indonesia, India, Thailand, Malaysia, Vietnam, Myanmar, Nepal, Pakistan, Sri Lanka, Australia, New Zealand, and Korea subscribed as the member nations. After the establishment of the APHN, the network was in charge of the Asia Pacific Hospice Conference (APHC). Dr. Young Seon Hong represented Korea from the establishment of the academic society, and he also served as the president for two years (2007∼2009). APHC is held every 2 years in the Asia Pacific region has been contributing to develop a HPC model that is appropriate for our culture along with the people of Asia Pacific region. The sixth APHC was held from 16th to 19th March 2005 in Seoul, Korea, with the theme of Changing Society and Human Life with Hospice and Palliative Care from 16th to 19th March 2005; hosted by the KSHPC collaboration with APHN. The conference provided an opportunity for Korean members to interact with nearby foreign professionals while exchanging stimulating academic researches, comparing various aspects of hospice and palliative care in each nation, and augmenting public awareness in the cancer patient’s quality of life problem. The conference also influenced the Korean government to consider supporting inpatient in PCUs with terminal cancer (5). During sixth APHC, international colleagues of the HPC, which became the Worldwide Hospice Palliative Care Alliance (WHPCA) later, gathered in Seoul and announced the ‘The Korea Declaration’ which calls for the expansion of the government’s support on the policy level (5).

In 2011, KSHPC considered ways to make an international contribution; the members could help terminal patients both in Korea and neighboring countries, overcome sufferings, maintain their dignity as human beings until the end of their lives, and have a comfortable moment of death (22). The board members of KSHPC decided Korea can lead researches about HPC to contribute to the international hospice society. KSHPC donated 10 million Korean won for research development in Asia Pacific area to APHN, and also established the international collaborating research team to promote cross cultural studies among Korea, Japan, and Taiwan in December 2013 in Seoul, Korea. South Korea, Japan, and Taiwan share a similar life expectancy at birth and have fast growing older population (23). But, there seem to be significant intercounty differences in beliefs and practices when death is approaching even in East Asian countries (23-25). Future studies on direct observations of patients and families are needed. The Network promotes education and skills development, enhances awareness and communication, and fosters research and collaboration (26).

The WHPCA is an international non-governmental organization focusing exclusively on HPC development worldwide. Since APHN is a WHPCA organization member, KSHPC also involved in global network (27,28).

Since the inception of hospice was introduced to Korea 50 years ago, the country has observed a steady development in HPC services.

The Economist Intelligence Unit reported the leading countries with a high quality of death have the following elements in place:

A strong and effectively implemented national palliative care policy framework;

High levels of public spending on healthcare services;

Extensive palliative care training resources for general and specialize medical workers;

Generous subsidies to reduce the financial burden of palliative care on patients;

Wide availability of opioid analgesics;

Strong public awareness of palliative care (1).

To improve the quality of death in South Korea, there are many challenging issues to overcome.

Comprehensive national HPC policies are vital for extending access to palliative care. The Korean government allowed the National Health Insurance Service to cover for the hospice care cost for terminal cancer patients in July 2015. And, ‘The Law on the Hospice and Palliative enacted on 2016 and will be effective on August 2017. With these new HPC policies, we are expecting the HPC services are only focused on the hospitalized terminally ill cancer patients will be expanded to home hospice care who want to stay his/her own home at end-of-life, and also expanded to all life threatening illness in near future (29). South Korea is undergoing several efforts to expand the services in palliative care unit along with the development of quality indicators for PCUs. Nevertheless inpatients HPC services are available to terminal cancer patients, yet the utilization rate of HPC services or the length of stay in the PCUs is still relatively short compared to other country systems (30).

While establishing PCUs and increasing the number of beds are critical, it is also important to secure the units that can serve for diverse needs of patients considering the provincial distribution of the institutes.

People prefer to spend their end-of-life at home. The demonstration project to develop the per-diem rate of home hospice care started from March 2016, should be presented the resolution as a first measure. And, the extensive integration of palliative care into its National Health Insurance Service are needed among inpatient PCUs, home hospice care and PCT in the hospital, and other health related resources like public community health center. HPC need be designed to be available 24 hours a day, 7 days a week.

Second, before ‘The Law on the Hospice and Palliative Care and the Determination of Life-Sustaining Treatment for Terminally Ill Patients’ comes into effect in August 2018, and the government and all interested parties in medical, academic and social sectors prepare and collaborate together to make effective Enforcement Ordinance and Regulations of the law with the process of emerging consensus.

Third, HPC service, which is currently targeting only terminal cancer patients and their families, need to be provided for anyone with a serious, life-threatening illness by National Health Insurance Service. In other words, HPC program should be developed for special groups such as pediatrics, geriatrics, people in emergency room, or intensive care unit. The proportion of older people in the population is rapidly growing in South Korea, the need for comprehensive palliative care is rising especially in elders (1,28).

Fourth, standardization of training and operation of advanced training program for all types of professionals who participate in the hospice palliative interdisciplinary team are required. The professional caregivers training program are operated by KSHPC since 2015 need evaluated and standardized. And, standardized education systems for physicians and medical students need be developed and hospice palliative medicine need be recognized as an official subspecialty. Or accreditation system need be developed for palliative medicine. Standardized education systems for social workers and social work students also need be developed. Furthermore, educating and training nurses and other health professionals to improve quality of end-of-life care that is not confined to terminal cancer but rather address all life-threatening illness (5). HPC need be provided with a care plan tailored to a patient’s individual need by trained interdisciplinary team.

Fifth, HPC services are still unfamiliar to the public so it requires raising awareness for the public. We also need to increase the level of social and medical acceptance for the use of narcotics for pain control of terminal patients.

Finally we need to perform clinical trial as well as the basic research associated with HPC, and these data can be the basement of future advance hospice development in Korea (7).

Over the past 50 years there has been a steady development of palliative care services in South Korea. This article provided a review of the development and impact of hospice palliative care, current issues, and remaining challenges in making effective policies and infrastructure in South Korea to improve the quality of life of terminal patients and their family caregivers. Comprehensives hospice palliative care system tailored to cultural values and traditions that are always available and easily accessible will need to be developed. A concerted effort and collaboration amongst the medical, academic, and social sectors would make this possible.