Healthcare service load as a structural barrier to end-of-life autonomy in Taiwan

Background/purpose As Taiwan nears super-aged status, realizing end-of-life autonomy may be limited by structural capacity. We assessed whether county-level healthcare service load was associated with patient-signed do-not-resuscitate (DNR) Letters of Intent under the Hospice Palliative Care Act. Methods We conducted a nationwide ecological study across Taiwan's 22 counties/cities (2014–2024). The outcome was the annual rate of patient-signed DNR Letters of Intent per 1000 population. The primary predictor was healthcare service load (total outpatient and emergency visits per physician); physician density served as an alternative predictor for sensitivity analysis. Covariates included elderly population proportion, disability registration rate, and median income. Kendall's tau and multiple linear regression were used. Results DNR signatories increased during 2014–2018, declined in 2020–2023, and rebounded in 2024. Higher service load was independently associated with a lower DNR signing rate (β = −0.000087, p = 0.0007; Adjusted R 2 = 0.570). Sensitivity analysis confirmed the finding: physician density was positively associated with signing rates (β = 0.094, p = 0.0004; Adjusted R 2 = 0.598). Conclusion Counties with higher healthcare service load had lower rates of patient-signed DNR Letters of Intent. Expanding protected time and accessible ACP pathways in high-load areas may help support end-of-life autonomy in a super-aged society.