Intensive care unit physician's attitudes on do not resuscitate order in palestine
Background: There is some ambiguity concerning the do-not-resuscitate (DNR) orders in the Arabic world. DNR is an order written by a doctor, approved by the patient or patient surrogate, which instructs health care providers to not do CPR when cardiac or respiratory arrest occurs. Therefore, this research study investigated the attitudes of Intensive Care Unit physicians and nurses on DNR order in Palestine.
Keywords: Cardiopulmonary resuscitation, Culture, Do-not-resuscitate, Religious beliefs
Over the decades, there have been many methods to improve health care in the world; the biggest improvements were the rise in the average age of human life and the reduced mortality rate. One of these methods was the implementation of cardiopulmonary resuscitation (CPR), which is “a series of lifesaving actions that improve the chance of survival following cardiac arrest.” The first CPR method was the mouth-to-mouth method, in the year 1740. The methods of CPR have evolved and in 1891, the first certified chest compression was performed by Dr. Friedrich Maass, and it was first successfully achieved in 1903 by Dr. George Crile (American Heart Association [AHA], 2013), in the 1920s, development of practical defibrillators began  and in 1979, Advanced Cardiac Life Support (ACLS) developed (AHA, 2013), and nowadays, ACLS has evolved to the use of chest compressions, ventilation, defibrillation, and medications in ACLS management.
There is a high percentage of survival after the administration of CPR for the witnessed and not-witnessed arrest cases, despite these results, another study showed that the survival rate for terminally ill patients despite the performance of CPR on 65.7% patients, only 42.2% survived, but they shortly died after the resuscitation. Terminally ill patients are “persons with an incurable or irreversible illness at the end stage that will result in death within a short time.” Because of low survival rate in terminally patients after the administration of CPR, a new term was found, which is do-not-resuscitate (DNR), which was first legalized after the mid-1970s. DNR is an order written by a doctor, approved by the patient or patient surrogate, which instructs health care providers to not do CPR when cardiac or respiratory arrest occurs, and sustaining from medications was nothing to do with the DNR order.,, There is some ambiguity concerning the DNR orders, this is why this study will focus on the appliance of the DNR order for only the terminally ill patients. In Palestine, the DNR order was implemented without the presence of a legal consent form as well as the implementation of the paternalistic model by the physicians; meaning the physicians ordered a DNR for the patient without the consent of the patient, patient surrogate or the patients family.
The DNR order is practiced in many countries around the world such as the USA, Brazil, UK, Spain, and France, but there is no consensual practice in the Middle East. And despite these discussions, there was not one single documented study conducted in Palestine which was found, and because the DNR order is not practiced in the Middle East, the aim of this study was to investigate the attitudes of Intensive Care Unit (ICU) physicians and nurses on the DNR order in Palestine for the terminally ill patients, the presence of a legal consent form will make the DNR order more known to the public, the health professionals and the public will be more educated about DNR, fore that this will help in the decision making process in case one gets serious illness. “Attitudes are the individual overall evaluation (favorable or unfavorable feelings) of the object or behavior, that is, the beliefs that performing the behavior will lead to certain consequences, and the evaluation of these consequences.,
Arabs are majorly affected by religion which plays a vital role in the decision-making process when it comes to interfere with the termination of life., Furthermore, they have a false perception regarding the DNR order, and making this legal will change attitude toward it, by educating the medical professionals and the public, explaining that it is not the termination of life, it is not against religion. The primary significance of this study is to investigate the attitudes of ICU physicians' and nurses' on the DNR order in Palestine, and to see whether culture and religion have any affect regarding their decision on the DNR order.
Second, since the Middle Eastern countries have similar cultures and beliefs, this study will help researchers in their studies regarding this subject.
End-of-life care has been widely discussed over the years. The decision-making process is very difficult, so three types of decision-making models were found, the “paternalistic model, consumerist and shared decision-making (SDM) model.” The Paternalistic model was used mostly in the past, but nowadays, the main ideal decision-making model is the SDM model, in which the decision-making is entirely up to the patient. The end-of-life decision-making process to limit or withdraw therapy in the ICU is affected by many factors such as, “chances of curability, overall patient performance status, quality-of-life, local practice variations of the attending intensivists, and the socioeconomic support. Other factors may affect the decision-making process according to the patient such as beliefs, the curability of illness, age, ethnicity, family support, the number of children, education level, and knowledge about the result of CPR.” The end-of-life decision-making process is similar between some cultures and ethnicities, such as American Asians, Hispanics, and Arab Muslims which tend to give up their autonomy and give the family full paternalistic jurisdiction of their end-of-life issues. Despite the bad prognosis of their case, Muslims choose CPR because they have hope that God will save them from their illness.
The DNR decision should be based on the agreement that it is what's best for the patient. This decision has many ethical dilemmas such as the inability to regard whether resuscitation is appropriate or not, the involvement of patient and patient family in the decision-making, and the obstacle of communication among the doctors, nurses, and family. Although, a recent study showed that nurses did not agree with the DNR decision for only 7% of the patients, whereas the doctors did. As for the physicians, a study has found that they have different perspectives on the DNR order, for example, pulmonary critical care medicine physicians strongly recommend DNR orders in comparison to cardiologists. Another study found that men were more confident in discussing the DNR order than women. These results may be related to different levels of knowledge on the subject, religion, ethnicity, and gender; therefore, it beneficial to investigate the physicians' and nurses' attitudes toward the DNR order.
This study will follow a nonexperimental, quantitative, descriptive, and co-relational method. A questionnaire that was retrieved from the IJCP, The attitude of Iranian nurses about Do Not Resuscitate Orders  and got the approval from Azad Rahamni to use in this research study in order to investigate the attitudes of ICU physicians and nurses on the DNR order in Palestine.
The participants who are considered qualified for this study were physicians and nurses, who have experience in the ICU, with a diploma, bachelors' degree or higher. Participants will be recruited from three different governmental hospitals, as well as one charitable hospital. The number of participants was 25 nurses and 25 physicians from each hospital, with a total of 200. A 24 item-based questionnaire based on a 5-point-Likert scale from strongly agree (score 1) to strongly disagree (score 5) will be given to them after signing a consent form, and collecting these questionnaires will be by the researcher.
Ethical approval was obtained from the Institutional Review Board Committee at Birzeit University BZU, as well as the approval to hand out questionnaires in the four hospitals from the ministry of health. Each participant received a consent form, explaining how their participation is voluntary; they can withdraw at any time, as well as explaining the study, its aim, and how their anonymity will be guaranteed.
The general demographic characteristics of the subjects (n = 123) are given in [Table 1]. The majority occupation was nursing (61.0%), and (66.7%) of the subjects that were handed out questionnaires were males. Most of them were in their 20s (52.0%), the most frequent duration of entire working experience was 1–5 years (40.7%), and the majority had less than 1-year experience in the ICU (38.2%). Furthermore, 95.9% of the health care providers were Muslims, (67.5%) were married, and 62.6% had a bachelor's degree.
[Table 2] in both physicians and nurses shows that religion and culture affect their decision regarding the DNR order. 73.1% said that religion affects their opinion regarding the DNR order, and 69.9% said that culture influences their decision on the DNR order. Despite these large percentages, still 64.3% want the DNR order to be legalized in Palestine.
Our study is the first study being conducted in Palestine regarding the DNR order. This study investigated the attitudes of physicians and nurses with ICU experience toward the DNR order, and their religious and cultural beliefs affecting their decision.
From our literature review, there are a few studies that explain the opinion of Muslims and Christians regarding the DNR order, a study showed that there are no consensual practices concerning the DNR in the Middle Eastern countries, due to their religious beliefs, nor were there any studies done in the Middle East discussing the attitudes of physicians and nurses toward the DNR order.
There was a positive attitude toward the legalization of the DNR order in Palestine, and culture and religion did not have any affect toward their attitudes regarding the legalization in Palestine. According to the study, were the questionnaire obtained, there was a negative attitude toward the DNR order in Iran, influenced by their Islamic religion both Sunni and Shiite. A study done in Saudi Arabia, which discusses when the seeking of remedy is hateful in Islam, and how the abstaining of remedy is allowed in certain cases. The study found that Muslims believe that the DNR order is forbidden in Islam and showed that the DNR order is allowed in Islam, but within the proper guidelines (Albar, 2007). As for the Christianity religion, to forego CPR is acceptable only in cases of incurable illness, irreversible multi-system disease, or other situations that involve death within a short period of time (Cranston, 2001). A large percentage of physicians' and nurses' are with the Legalization, so they are not an issue but instead the society will be the main issue if DNR is legalized. Hence, education regarding the terminally ill patients should start now; in order to smooth out the way as much as possible, if we are ever going to legalize the DNR order.
About 95.9% of physicians and nurses had the religion of Islam, and the remaining were Christians and Atheists. Therefore, it was difficult to investigate the attitudes of non-Muslims due to the unreliable sample size because it will not be able to represent the attitudes of the majority of Palestinian Christian physicians and nurses.
There are several areas for future researches regarding DNR order in Palestine. First, to expand this study with a larger amount of participants both Muslims and Christians in order to get more accurate results and hopefully legalize the DNR order in Palestine. Finally, future studies are needed to understand family perception about DNR order for terminally ill patients.
The limitations that this study faced were that there were no previous documented studies done on the DNR order in Palestine, as well as the lack of the Middle Eastern studies on the DNR order. This was first considered a limitation, but then it was also considered a motivation; it motivated the researcher to work harder and investigate about the DNR order in Palestine. Another major limitation was the limited staff in the ICU, so physician and nurse with at least 1 year of ICU experience were included in the study. Moreover, the small number of participants will limit the generality of the study.
[Table 1], [Table 2]