GRAPHICAL ABSTRACT

INTRODUCTION

In Korea, individuals who die alone and are discovered only after a considerable delay—commonly referred to as “lonely deaths”—have generated significant social concern [1]. Although there is growing unease that such deaths may be undignified, their exact causes remain unclear. Limited qualitative research suggests that lonely deaths often result from the failure of social safety nets [2–4]. High-profile cases, such as the Songpa 3-female case involving a mother and 2 daughters, have heightened public awareness and concern about lonely deaths in Korean society [5].

In response, legislation has been enacted to address this issue. While there is no universal academic or social consensus on the definition of a lonely death, the Lonely Death Prevention and Management Act—enacted in April 2021—legally defines it as “a person living in a state of social isolation, disconnected from family, relatives, and others, who dies from suicide, illness, or other causes” [6].

According to this legal definition, social isolation is a key factor, even though the causes of death vary widely. A survey conducted by the Ministry of Health and Welfare in 2024 found that the number of lonely deaths increased from 3378 in 2021 to 3661 in 2023 [7]. The survey also revealed that many of these individuals suffered from conditions such as circulatory and musculoskeletal diseases and belonged to vulnerable groups, including basic livelihood security recipients. Case studies based on media reports have similarly identified poverty, single-person households, chronic diseases, and mental health issues as major risk factors for lonely deaths. Therefore, it is presumed that individuals who die alone face significant health and socioeconomic challenges [4,8].

Previous studies have extensively examined the impact of loneliness on health [9–13]. However, in Korea, the term “lonely death” refers specifically to deaths that occur when an individual is alone and discovered after some time, making it difficult to attribute these outcomes solely to loneliness. Instead, lonely deaths raise questions about the dignity of dying alone and whether they reflect shortcomings in social safety nets [14–16].

Korea operates a national health insurance system in which the average individual makes over 15 outpatient visits and is hospitalized for more than 2.5 days each year. Consequently, healthcare utilization patterns among specific subgroups may differ from those of the general population. While these patterns do not directly cause lonely deaths, understanding them can provide insights for developing policies aimed at prevention [17]. This study also examines how the distribution of lonely deaths varies by age and insurance type. Although the number of cases is limited, characteristic patterns may differ by age group. Based on prior research, we hypothesize that lonely deaths are more prevalent among individuals in their 50s and 60s and among those receiving Medical Aid (MA) [7,8,18]. Unlike earlier studies that relied on data from specific institutions or qualitative approaches [19–23], our analysis utilizes claims data from all lonely death cases, offering more objective indicators. The objective of this study is to identify the characteristics of individuals who die alone in Korea—particularly with respect to diseases and healthcare utilization—using National Health Insurance Service (NHIS) data.

METHODS

Data Source, Study Population and Design

Our study identified lonely death cases using Korea Crime Scene Investigation (KCSI) data from the Scientific Crime Analysis System operated by the Korea National Police Agency. The KCSI dataset comprises information on on-site investigations, evidence collection and extraction, evidence appraisal, and other scientific investigation data relevant to crime analysis. Individuals were identified as lonely death cases through keyword searches related to “lonely death” and were subsequently reviewed by social welfare experts.

The study timeframe was limited to the single year of 2021. Dependent variables included baseline characteristics, underlying diseases, and healthcare utilization patterns related to lonely deaths. Because the KCSI data did not contain all variables of interest, we supplemented our analysis with data from the NHIS database, which provided healthcare utilization information spanning 5 years. To merge the datasets, we provided the NHIS with the birth date, sex, and name of each lonely death case. The NHIS then matched these individuals based on birth date, sex, name, death status, and year of death, ensuring no duplicates. In total, data for 3122 individuals were obtained.

The NHIS database includes information on demographics, insurance type, diagnoses, treatments, prescriptions, and death status and date. Demographic details such as sex (male and female), age groups (<20, 20–29, 30–39, 40–49, 50–59, 60–69, 70–79, and ≥80), insurance type (NHIS, MA), and geographical regions (Seoul areas, metropolitan areas, and others) were extracted from the claims data. Geographical regions were defined as follows: Seoul areas include Seoul, Incheon, and Gyeonggi-do; metropolitan areas include Busan, Daegu, Gwangju, Daejeon, Ulsan, and Sejong. Approximately 97% of the Korean population are NHIS subscribers, while the remaining 3%—those who have difficulty paying premiums—are covered by MA, with the government subsidizing their medical expenses. Due to the absence of a direct income variable in the NHIS database, insurance type is often used as a proxy for income level [24–26].

Disease prevalence over the past 5 years among individuals who experienced lonely deaths was analyzed based on major underlying conditions (Supplementary Material 1). Diseases were classified according to the eighth edition of the Korean Standard Classification of Diseases and Causes of Death, derived from the 10th edition of the International Classification of Diseases. Healthcare utilization was assessed by categorizing outpatient visits, hospital admissions, and emergency room visits—metrics commonly used to characterize specialized population groups [27–29].

Statistical Analysis

A descriptive analysis was conducted to examine demographic characteristics, underlying diseases, and healthcare utilization patterns among lonely death cases. The t-test was used for continuous data, the chi-square test for categorical data, and analysis of variance for variables with multiple groups. Healthcare utilization was expressed in terms of days and reported as mean (standard deviation, SD). Statistical significance was defined as p-value <0.05. All analyses were performed using SAS Enterprise Guide 7.4 (SAS Institute Inc., Cary, NC, USA).

Ethics Statement

This study was reviewed and approved by the Institutional Review Board of Seoul National University Bundang Hospital (IRB No. X-2406-904-901). The requirement for informed consent was waived because the study used anonymized data.

RESULTS

Baseline Characteristics of Lonely Deaths

Of the 3122 individuals identified, 2621 (84.0%) were male and 501 (16.0%) were female. The most common age groups among lonely death cases were 50–59 years (930 individuals, 29.8%) and 60–69 years (900 individuals, 28.8%). This distribution markedly differs from that of the general population, which has an approximately equal sex ratio. The proportions of individuals in the 50–59 (16.6%) and 60–69 (13.7%) age groups were considerably higher among lonely death cases. Regarding insurance type, although MA beneficiaries comprise only 2.9% of the total population, 961 individuals who experienced lonely deaths (30.8%) were on MA. Among NHIS subscribers, workplace subscribers (employed individuals) and regional subscribers (unemployed individuals, with household members dependent on the householder’s insurance) were both represented. The largest subgroup consisted of NHIS regional subscribers, totaling 1359 individuals (43.5%). Additionally, 940 individuals (30.1%) on MA were householders. The highest number of lonely death cases was observed in Seoul areas, with 1468 individuals (47.0%), and 421 individuals (13.5%) had disabilities. Although the overall distribution is similar to that of the general population, lonely deaths were more common in metropolitan cities (Figure 1 and Table 1).

When stratified by age group, the highest number of male lonely death cases occurred in the 50–59 age group (846 individuals, 32.3%), followed by the 60–69 age group (796 individuals, 30.4%). Among females, the most common age group was 60–69 years (104 individuals, 20.8%), followed by 70–79 years (98 individuals, 19.6%). Analysis by insurance type revealed that among NHIS subscribers, the highest number of cases was in the 50–59 age group (615 individuals, 28.5%), whereas among MA recipients, the peak occurred in the 60–69 age group (347 individuals, 36.1%). Further subdivision by insurance subtype consistently showed that the 50–59 and 60–69 age groups had the highest numbers of lonely death cases. Among individuals with disabilities, the highest occurrence was in the 50–59 age group (802 individuals, 29.7%), followed by the 60–69 age group (758 individuals, 28.1%). Similarly, among those without disabilities, lonely deaths most frequently occurred in the 60–69 (142 individuals, 33.7%) and 50–59 (128 individuals, 30.4%) age groups (Figure 1 and Table 2).

Distribution of Underlying Diseases in Cases of Lonely Death

Dyslipidemia was the most prevalent underlying disease, affecting 1669 individuals (53.5%), followed by hypertension in 1548 individuals (49.6%) and diabetes in 1275 individuals (40.8%). In contrast, common underlying diseases in the general population include hypertension (13.2%), cancer (8.4%), diabetes (6.9%), and dyslipidemia (6.4%). Some conditions that are rare nationally were common among lonely death cases. Schizophrenia was present in 150 individuals (4.8%), and mood disorders were diagnosed in 1020 individuals (32.7%). Various alcohol-related conditions were also identified. Mental and behavioral disorders due to alcohol use were found in 611 individuals (19.6%), and alcoholic liver disease was present in 689 individuals (22.1%). Although hepatitis (587 individuals, 18.8%) and cirrhosis (258 individuals, 8.3%) are not directly alcohol-related, they were also observed (Table 3). A comparison between NHIS subscribers and MA recipients revealed a higher prevalence of most diseases among MA patients. For example, stroke was observed in 61 NHIS individuals (2.8%) compared with 64 MA individuals (6.7%), more than doubling the prevalence. Schizophrenia affected 59 individuals (2.7%) in the NHIS group compared with 91 individuals (9.5%) in the MA group—approximately 3.5 times higher. Among mood disorders, depression was noted in 508 NHIS individuals (23.5%) versus 412 MA individuals (42.9%), indicating it was about 1.8 times more common in the MA group. Bipolar disorder affected 167 NHIS individuals (7.7%) compared with 183 MA individuals (19.0%), roughly 2.5 times more prevalent among MA recipients. Similarly, mental and behavioral disorders due to alcohol use were diagnosed in 303 NHIS individuals (14.0%) versus 308 MA individuals (32.0%) (Table 4).

Time Trend of Healthcare Utilization for Lonely Deaths

Over the 5 years preceding death, the average number of outpatient visits increased significantly from 15.4 (SD, 25.8) 5 years prior to death to 17.4 (SD, 27.3) 1 year prior to death (p=0.013). The average number of hospitalization days peaked at 13.6 (SD, 51.3) 3 years before death (p=0.019) and generally declined during the final year. Emergency room visits increased from an average of 1.0 day (SD, 6.9) 5 years prior to death to 1.8 days (SD, 8.1) 1 year before death (p=0.002). When analyzed by age group, significant increases in outpatient visits were observed in the 20–29 age (p=0.036) and 50–59 age groups (p=0.011) (Figure 1, Supplementary Material 2).

Analysis of healthcare utilization in 3-month intervals during the final year revealed that outpatient visits decreased as death approached (p=0.033). Hospitalization days dropped from 2.9 days (SD, 12.6) in the 9–12 months preceding death to 1.7 days (SD, 7.4) in the final 3 months. This decline was also significant in the 50–59 age (p=0.003) and 60–69 age groups (p=0.047). In contrast, emergency room visits increased among individuals in the 70–79 age group, rising from 0.1 days (SD, 1.2) in the 9–12 months before death to 0.5 days (SD, 2.9) in the last 3 months (p=0.030) (Figure 1, Supplementary Material 3).

DISCUSSION

Analysis of 3122 lonely death cases revealed that these deaths were most prevalent among males and individuals aged 50–59 and 60–69. Although MA recipients constitute only 2.9% of the general population, they represented 30.8% of lonely death cases. Lonely deaths most frequently occurred in urban areas and were associated with underlying conditions such as chronic diseases (hypertension, diabetes, and dyslipidemia), mental health disorders, and alcohol-related illnesses. Male in their 50s to 60s were most affected, while lonely death among female was more common in the 60–79 age range. Notably, the rate of lonely deaths among MA recipients increased after the age of 40. Outpatient visits increased as death approached but declined within the final 3 months, hospitalizations decreased, and emergency room visits showed a slight rise.

Individuals who experience lonely death represent a socioeconomically, physically, and mentally vulnerable population, distinct from the general population. These findings are consistent with previous studies, which have shown that individuals at risk are often older, have experienced divorce or bereavement, and are more likely to live in small or single-person households. Moreover, many of these individuals have ceased working or lost their jobs, contributing to their low socioeconomic status [4,21,22,30]. Such circumstances may lead to emotional distress, increased alcohol consumption, and other health issues that reduce access to healthcare services—including outpatient visits, hospital admissions, and emergency room care—which can ultimately contribute to death. Similar risk factors—namely, being African American, male, living alone (divorced, separated, or never married), middle-aged, unemployed, and having a low socioeconomic status— have been observed in studies from the United States examining individuals whose bodies were unclaimed by kin, suggesting that these risk factors not only increase mortality but also promote social isolation [1,31].

There is no consensus on the definition of lonely death, and few national statistics exist on the subject globally. In Japan, lonely death—referred to as “kodokushi” or “koritsushi”—is defined as occurring in individuals who live alone and experience social isolation, with death occurring in their homes [32,33]. A survey reported that 1451 individuals aged 65 or older died alone in their homes in Tokyo in 2003; by 2018, this number had increased to 3882 [33]. Although the age and sex distribution of individuals who die alone in Japan is similar to that in Korea, dementia has a stronger association with lonely death in Japan. In our study, dementia was diagnosed in 5.2% of lonely death cases, compared to a reported prevalence of 7.4% among Koreans aged 60 and above [34]. Although a direct comparison is challenging due to differences in age and sex matching with the general population, the current data do not suggest an unusually high prevalence of dementia among lonely death cases in Korea. This discrepancy may be due to the reliance on claims data, which could underestimate dementia prevalence among vulnerable populations who do not seek care for the condition. Moreover, in Korea, individuals with advanced dementia are more likely to live with family or be admitted to care facilities [35,36].

Korea’s drinking culture further complicates the issue of lonely death. Reports indicate that 49.8% of individuals in Korea experience alcohol-related problems, abuse, or dependence, and 92.4% of these individuals are male [37]. This distribution mirrors that observed in lonely death cases. Although there is no conclusive evidence that alcohol consumption directly causes lonely death, studies have shown that individuals living alone—regardless of sex or socioeconomic status—face an increased risk of alcohol-related mortality [38]. According to the World Health Organization’s 2018 Alcohol Dependence Index, Korea ranks ninth among 190 countries [39]. With the rising trend of individuals living alone, the potential risk factors for lonely death are likely to increase.

Defining what constitutes a “good” or “bad” death is controversial. The view that lonely death is a form of “social murder” contrasts with perspectives that consider it a personal choice stemming from a “desire to die alone”. As Lederman [1] stated, “individuals in society are obligated to assure a certain degree of well-being, flourishing, or care among and for fellow individuals”. This suggests that, regardless of whether a lonely death is seen as good or bad, society must provide a minimal level of care and support for this vulnerable group. The high prevalence of lonely deaths among vulnerable populations underscores the need to strengthen social safety nets.

This study has several limitations. First, because the analysis was restricted to lonely death cases, it was difficult to directly compare these individuals with the general population. Second, the exclusive use of NHIS claims data made it challenging to assess whether social services or informal care were provided. Additionally, several important variables—such as multimorbidity, family composition, place of death, time until discovery, and suicide—were not captured. Incorporating autopsy information in future research could further clarify the causes of lonely death.

Nevertheless, understanding the characteristics of lonely death cases is critical for developing strategies to address this issue. Moreover, assessing healthcare utilization patterns related to lonely deaths—an area not previously examined—may help identify individuals at high risk and enable timely, targeted interventions [17].

In conclusion, this study found that most lonely death cases involved male in their 50s, with a significantly higher proportion of MA beneficiaries, and many had mental health or alcohol-related disorders. Healthcare utilization patterns changed as death approached, notably with a reduction in hospitalizations during the final 3 months. To reduce the incidence of lonely deaths, it is imperative to strengthen social safety nets and implement targeted policy interventions for economically vulnerable male in their 50s, particularly those with mental health or alcohol-related issues.

Supplemental Materials

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

This research was supported by the Ministry of Health and Welfare.

Acknowledgements

This study summarizes key findings from the “Prevention of Lonely Death Survey in 2022” report.

Author Contributions

Conceptualization: Yun J, Kang MJ, Jun YH, Lee H. Data curation: Lee J, Lee H. Formal analysis: Lee J, Bai H. Funding acquisition: Lee H. Methodology: Lee H. Visualization: Bai H. Writing – original draft: Bai H, Lee H. Writing – review & editing: Bai H, Lee JR, Kang MJ, Jun YH, Koo HY, Yun J, Sohn JH, Lee JY, Lee H.

Figure 1

Characteristics of individuals who experienced lonely deaths. (A) Demographical distribution of individuals who experienced lonely deaths by age group. (B) Distribution of individuals who experienced lonely deaths by insurance types. (C) Number of days of healthcare utilization for lonely death in the past 5 years. (D) Number of days of healthcare utilization for lonely death in the past 1 year. NHIS, National Health Insurance Service; MA, Medical Aid.

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References

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