{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T18:15:05Z","timestamp":1782843305496,"version":"3.54.5"},"reference-count":52,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,3,3]],"date-time":"2026-03-03T00:00:00Z","timestamp":1772496000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>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\u2014\u201cResilience from Scale\u201d and \u201cResilience from Structure\u201d\u2014to explain cross-national variations in EoL care policy effectiveness among China, South Korea, the United States, and the United Kingdom.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>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 \u201cScale\u201d and \u201cStructure\u201d indicators to assess how resource capacity and institutional configurations align with divergent policy outcomes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The comparative evidence suggests that higher structural resilience\u2014operationalized through national legislation, insurance integration, and state capacity\/legitimacy\u2014tends to be more consistently aligned with higher AD implementation than cultural explanations or resource availability alone. South Korea\u2019s 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>These findings challenge culturally deterministic interpretations in EoL policy research and propose a \u201cStructural Adaptation Model\u201d as a heuristic for jurisdictions seeking to develop effective advance care planning systems.<\/jats:p>\n                  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