研究背景: 韓國已進入超高齡社會，這使得長期照顧（簡稱長照，LTC）系統的財務策略變得日益迫切。因為醫療和照顧費用大多集中在生命的最後階段，我必須仔細研究這段時間的服務使用情況，以預防未來的財務危機。然而，現在大部分的研究只關注最後一年的情況。為了解決這個問題，本研究以韓國的長照服務使用者為對象，探討了生命最後三年長照服務的影響因素，包含服務使用、類型（機構照顧）、時間長度及費用，旨在提高韓國長照系統的永續性。
研究目的: 本研究的目的是調查韓國長照服務使用者在生命最後三年的服務使用情況，並分析影響服務使用、類型（機構照顧）、時間長度及費用的因素。
研究方法: 本研究使用回顧性世代研究方法，資料來自韓國國民健康保險老年資料庫（NHIS-Senior）。研究對象為2008年至2019年間去世、年齡在65歲以上，並且在去世前已擁有長照資格三年以上的老年人。最後共有17,404人參加研究。本研究使用SPSS 25.0軟體進行描述性統計和多元迴歸分析。
研究結果: 關於生命末期的長照使用，資料分析有幾個重要發現。在生命末期，有高達85.1%的人同時使用醫療和長照服務，其中有66.6%的人患有失智症。長期的總費用分析發現，花費非常集中。總費用（醫療+長照）在去世前六個月開始大幅增加，並在去世前一個月達到最高點。相反地，在去世前兩個月之前，同時使用醫療和長照的群體，其平均每月總費用明顯低於只使用醫療服務的群體，這證明了長照服務有正面的費用替代效果。在影響長照使用的因素方面，共病數量是最主要的原因。患有五種以上共病的人，進入長照系統的機率增加了四倍以上 (OR = 4.366, p < .001)。而入住長照機構的最關鍵原因，則是患有失智症以及完全沒有家人的照顧支持 (OR = 1.721, p < .001, OR = 0.113, p < .001)。矛盾的是，患有失智症和需要護理治療的使用者，他們持續使用長照服務的時間反而明顯變短了 (B = -1.492, p < .001, B = -0.052, p < .001)。在長照費用增加方面，共病數量越多，花長照費就越大。與只有0到2種共病的人相比，有3到4種共病 (B = 0.105, p < .001) 和5種以上共病 (B = 0.160, p < .001) 的人，費用都有明顯增加。最後，研究原本假設越接近死亡，健康和身體功能會成為唯一的影響因素，但這個假設被推翻了。實際上，在去世前的三年裡，人口特徵、社會環境，以及健康和身體功能等因素，一直對長照費用的變化產生複雜且互相影響的作用。
研究結論: 本研究透過分析生命最後36個月的資料，評估了國家長照系統的財務永續性，並提出了一個有效的生命末期照顧模式。研究結果得出三個主要結論。
第一，研究證實生命末期的費用非常集中。醫療與長照的總費用在去世前六個月開始急劇增加。這支持了決定晚年花費的主要原因不是年齡而是距離死亡還有多少時間的理論。這也說明我非常需要建立一個整合的生命末期照顧管理系統。
第二，研究發現了目前韓國長照系統的結構弱點以及費用反轉現象。因為現在的系統過度集中在基本的日常生活照顧，導致在去世前五個月，醫療費用開始超過長照費用。因此，長照原本應該有的正面費用替代效果就無法發揮。
第三，研究清楚說明了影響長照使用的因素之間有著動態的互相作用。隨著時間過去，影響因素並沒有單純地從社會環境變成健康變數。相反地，性別、高齡、嚴重程度以及是否有家屬照顧等因素，都在互相影響。具體來說，雖然多種共病是使用長照服務的主要原因，但入住長照機構和長照費用增加的最主要原因，其實是失智症帶來的行為問題，以及缺乏主要家屬照顧者。

This research investigates the utilization trajectories and determinants of long-term care services among South Korean older adults during the last 3 years of life to address impending fiscal challenges within a rapidly aging society. Utilizing the National Health Insurance Service Senior cohort, longitudinal data from 17,404 deceased beneficiaries were analyzed. The empirical results demonstrated that 85 percent of the cohort utilized healthcare and long-term care services concurrently. Aggregate total expenditures (HC+LTC) surged exponentially six months before death, confirming that the remaining time until death primarily drives terminal financial consumption. Regarding long-term care determinants, long-term care utilization was predominantly catalyzed by the accumulation of multiple comorbidities. However, the ultimate transition into institutional admission and soaring financial disbursements were decisively triggered by dementia diagnoses and the absolute absence of an informal primary family caregiver. Paradoxically, the continuous duration of long-term care was significantly abbreviated for beneficiaries requiring nursing treatment. Furthermore, demographic, socio-environmental, and health variables interacted dynamically throughout the entire observation window rather than transitioning linearly. Conclusively, the current framework struggles to manage advanced terminal needs, which systematically dismantles intended fiscal efficiencies. To ensure sustainability, South Korea must urgently expand a comprehensive community integrated long-term care network that encompasses specialized multidisciplinary home medical care, palliative interventions, and robust social support for family caregivers.

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