Association between religious and socio-economic background of parents of children with solid tumors and DNR orders

The do not resuscitate order (DNR) from the perspective of oncology nurses: A study in Saudi Arabia

PURPOSE

Issues related to life and death are largely influenced by the culture and religious beliefs of a society. This research aimed to survey a sample of oncology nurses in Saudi Arabia about their attitude towards the do not resuscitate order (DNR).

METHOD

A cross-sectional design was employed. A survey was sent to 190 nurses in the Comprehensive Cancer Center (CCC) in King Fahad Medical City (KFMC). A total of 157 nurses with a diploma or higher degree agreed to participate in the study.

RESULTS

Many nurses showed a neutral attitude regarding DNR to cancer patients and/or their families 2.4 ± 0.4. Moreover, the results of the multiple logistic regression tests revealed that all the listed factors are not associated with the attitude towards DNR orders (P > .05).

CONCLUSION

It is generally believed that nurses the faith and background of nurses from Muslim countries has a profound influence on their attitude towards DNR. However, this was not the picture that was revealed by the results of this study. In this study, all the nurses made it clear that they wanted to know about the autonomy of patients in respect of DNR orders.

IMPLICATION TO CLINICAL PRACTICE

It is necessary to develop programmes that address the DNR order and respect patient autonomy and rights. Moreover, hospital policies that address the issues of DNR order are required for all end-of-life care.

DNR and COVID-19: The Ethical Dilemma and Suggested Solutions

Ethics are considered a basic aptitude in healthcare, and the capacity to handle ethical dilemmas in tough times calls for an adequate, responsible, and blame-free environment. While do-not-resuscitate (DNR) decisions are made in advance in certain medical situations, in particular in the setting of poor prognosis like in advanced oncology, the discussion of DNR in relation to acute medical conditions, the COVID-19 pandemic in this example, might impose ethical dilemmas to the patient and family, healthcare providers (HCPs) including physicians and nurses, and to the institution. The literature on DNR decisions in the more recent pandemics and outbreaks is scarce. DNR was only discussed amid the H1N1 influenza pandemic in 2009, with clear global recommendations. The unprecedented condition of the COVID-19 pandemic leaves healthcare systems worldwide confronting tough decisions. DNR has been implemented in some countries where the healthcare system is limited in capacity to admit, and thus intubating and resuscitating patients when needed is jeopardized. Some countries were forced to adopt a unilateral DNR policy for certain patient groups. Younger age was used as a discriminator in some, while general medical condition with anticipated good outcome was used in others. The ethical challenge of how to balance patient autonomy vs. beneficence, equality vs. equity, is a pressing concern. In the current difficult situation, when cases top 100 million globally and the death toll surges past 2.7 million, difficult decisions are to be made. Societal rather than individual benefits might prevail. Pre-hospital triaging of cases, engagement of other sectors including mental health specialists and religious scholars to support patients, families, and HCPs in the frontline might help in addressing the psychological stress these groups might encounter in addressing DNR in the current situation.

Parent-reported family impact in children and young adults with acquired brain injury in the outpatient rehabilitation setting

Purpose: To increase knowledge/awareness on family impact (FI) after acquired brain injury (ABI) in rehabilitation settings, it is essential to investigate the associations between patient-functioning and impact on families. This has been explored in hospital-based cohorts, but not in rehabilitation settings.Methods: A cross-sectional, multi-center study among parents of children/young adults (aged 5-24 years) with ABI referred to rehabilitation was performed. Patient/injury/family-characteristics were noted, and parents completed the PedsQL™Family-Impact-Module and PedsQL™generic-core-4.0 to assess FI and health-related quality of life (HRQoL). Univariate- and multivariable-regression analyses were performed to investigate associations between HRQoL/patient/injury/family-related factors and FI.Results: 246 families participated; patients' median age was 14 year (IQR 11-16), 65 had non-traumatic-brain-injury (nTBI) (26%), 127 were female. FI was found to be considerable (median FIM-score 71.9, IQR:60-85). Especially referral to rehabilitation >6 months after onset, diminished patients' mental/emotional health and HRQoL (child/family factors), and premorbid problems were associated with higher FI.Conclusions: In this rehabilitation cohort, pediatric ABI caused considerably higher FI than in hospital-based studies with referral to rehabilitation >6 months, diminished child/family factors and presence of premorbid problems increasing FI. Assessing and monitoring FI and its associated factors enables professionals to individualize treatment, psychoeducation, support and follow-up.

Nursing and PharmD Undergraduate Students' Attitude Toward the "Do Not Resuscitate" Order for Children with Terminally Ill Diseases

BACKGROUND

Nurses and Doctor of Pharmacy (pharmD) must communicate and properly documented the do not resuscitate orders for terminally ill children and their relatives. They also have to offer excellent care including more family support, assisting the child with terminally ill disease in passing on peacefully, and preventing unnecessary cardiopulmonary resuscitation. This research was aimed to survey attitudes of nursing and pharmD undergraduate students about the "do not resuscitate" order for children with terminally ill diseases.

METHODS

A cross-sectional correlational design was used to study the correlation between attitude toward DNR and demographic variables. More than 400 nursing and pharmD students from Jordan University of Science and Technology were recruited in this study. All the participating students were e-mailed information regarding the study, including the web survey link.

RESULTS

The results showed that there was a significant difference in perception toward do not resuscitate order between nursing and pharmD students (p ≤ 0.05). The pharmD students had more positive attitude toward do not resuscitate than the nursing students. Approximately, 60% of the nursing and pharmD students would disclose the need for the do not resuscitate order for children with terminally ill diseases Demographic variables were not associated with the perception toward do not resuscitate orders (p ≥ 0.05).

CONCLUSION

This study showed that Jordanian nursing and pharmD students are willing to learn more about different aspects of do not resuscitate orders for terminally ill children. Analyzing their responses to many items showed their misconception about do not resuscitate orders for terminally ill children.

Nurses' Opinions on Do-Not-Resuscitate Orders

The aim of this study was to determine nurses' opinions on Do Not Resuscitate (DNR) orders. This is a descriptive study. A total of 1250 nurses participated in this study. The mean age of participants was 34.5 ± 7.7 years; 92.6% were women; 56.4% had bachelor's degrees, and 28.8% were intensive care, oncology, or palliative care nurses. Most participants (94.3%) agreed that healthcare professionals involved in DNR decision-making processes should have ethical competence, while they were mostly undecided (43%) about the statement whether or not DNR should be legal. More than half the participants (60.2%) disagreed with the idea that DNR implementation causes an ethical dilemma. Participants' opinions on DNR decisions significantly differed according to the number of years of employment and unit of duty. The results showed that most of the nurses had positive attitudes towards DNR orders despite it being illegal. Future studies are needed to better understand family members' and decision makers' perceptions of DNR orders for patients.

The Concept of Do Not Resuscitate for the Families of the Patients at King Abdul-Aziz University Hospital

AIM

Do not resuscitate (DNR) is an order in medical practice for the patients who are suffering from a grave medical condition, and their life is in danger to end. DNR decision-making varies from one hospital to another. This study is aimed to assess the knowledge of the patients' relatives about DNR concept and their opinion about the DNR decision-making.

MATERIALS AND METHODS

This was a nonintervention cross-sectional study conducted, during 2016, among 420 patients' relatives in the Emergency Department at King Abdul-Aziz University Hospital in KSA. Data were collected by interviewing the participants. Data were further analyzed using SPSS software. The Chi-square test was used to determine the associations.

RESULTS

Variation in responses related to the DNR concept was observed. Around 44% of participants thought that DNR involved maximum intervention in the hospital, including intensive care. Further, the majority (55.2%) of the participants were assured about the quality of the services the patient would receive. Furthermore, 51% of the participants believed that ultimately, it should always be the doctor who decides on a DNR decision. Meanwhile, 36.4% of the relatives opined that the family members should be involved in the discussion regarding the DNR order.

CONCLUSION

We observed a gap in the understanding of the concept and decision-making of DNR-order among the participants. Health-care providers should provide a greater explanation about DNR orders to the families of the patients to avoid any misunderstandings, and also support them psychologically to avoid any stress they might encounter in such situations.

Clinicians' Attitudes Towards Do-Not-Resuscitate Directives in a Teaching Hospital in Saudi Arabia

The Do-Not-Resuscitate (DNR) directive has provided a major leap in end-of-life care. To demonstrate the factors influencing physicians' DNR decisions in King Fahd University Hospital in the Eastern Province of Saudi Arabia, 42 physicians from the medical and surgical departments of the same center were requested to participate in a cross-sectional survey. Thirty-six questionnaires were completed and returned from a total of 42 distributed among physicians, making a response rate of 85.7%. Certain diagnostic categories increase the likelihood of issuing a DNR order for a patient. Neurological (58.3%) and cardiovascular (41.7%) diseases were the highest response among other diseases in influencing physicians' decisions. In addition, other factors like lack of comorbidities (55.5%), age (52.7%), and previous intensive care unit (ICU) admissions and resuscitation (44.4%) showed an effect on the directive decisions of DNR among investigated physicians. However, weak palliative care in the hospital (11.1%), religious beliefs (5.5%), and gender (2.7%) were the least associated factors affecting physicians' DNR decisions. This study addresses the influencing factors of DNR orders issuance among King Fahd Hospital of the University physicians. Physicians noted that cultural standards and religious beliefs do play a role in their decision-making but had less of an effect as compared to other clinical data such as comorbidities, age, and previous ICU admissions.

The influence of religious beliefs and practices on health care decision-making among HIV positive adolescents

It is unknown if religiousness/spirituality influences end-of-life treatment preferences among adolescents. Investigators assessed whether religiousness/spirituality moderates the relationship between an advance care planning intervention and end-of-life treatment preferences among 85 primarily African-American adolescents living with HIV/AIDS in outpatient-hospital-based HIV-specialty clinics in the United States. Adolescents aged 14-21 years living with HIV/AIDS and their families were randomized to three-weekly-60-minute sessions either: advance care planning (survey, goals of care conversation, advance directive); or control (developmental history, safety tips, nutrition/exercise). At 3-months post-intervention the intervention effect (decreasing the likelihood of choosing to continue treatments in all situations) was significantly moderated by religiousness/spirituality. Highly religious/spiritual adolescents were four times more likely to choose to continue treatments in all situations. Thus, intensive treatments at end-of-life may represent health equity, rather than health disparity. The belief believed that HIV is a punishment from God at baseline (15%, 14/94) was not associated with end-of-life treatment preferences. Twelve percent (11/94) reported they had stopped taking HIV medications for more than 3 days because of the belief in a miracle. Religiousness moderates adolescent's medical decision-making. Adolescents who believe in miracles should receive chaplaincy referrals to help maintain medication adherence.

Spiritual assessment and spiritual care offerings as a standard of care in pediatric oncology: A recommendation informed by a systematic review of the literature

Children with cancer and their families experience shifts in spiritual wellness from diagnosis through treatment and survivorship or bereavement. An interdisciplinary team conducted a systematic review of quantitative and qualitative research on spiritual assessments, interventions, and outcomes in childhood cancer following PRISMA guidelines using a PROSPERO registered protocol. Thirty-nine well-designed studies were included in the final analysis. The findings from this systematic review indicate the need for early spiritual assessment with offering of continued support for the spiritual functioning of children with cancer and their families as a standard of care.

Investigating the Attitude of Healthcare Providers, Patients, and Their Families toward "Do Not Resuscitate" Orders in an Iranian Oncology Hospital

Aim

The decision-making process for do-not-resuscitate (DNR) order has always been challenging. Cultural and religious issues have limited the issuance and execution of DNR orders in Iran. The purpose of this study was to assess the attitude of the nurses, physicians, patients, and their families toward the DNR order.

Subjects and Methods

In this cross-sectional study, 343 participants (201 patients, 95 family members, and 47 healthcare providers) from Omid Oncology Hospital, Mashhad, Iran, were surveyed during 2017-2018. All the participants were asked to fill in a checklist of demographic information and a validated questionnaire about their attitude toward DNR orders after giving consent. The data were analyzed using SPSS software and values of P < 0.05 were considered statistically significant.

Results

Overall, 201 patients and 95 of their family members, as well as 47 healthcare providers (doctors and nurses), were surveyed. The mean age of participants was 48.75 ± 15.62 years. The attitude of the participants regarding the DNR order was significantly different in 10 of the 11 items (P ≤ 0.005). Among the three groups of participants, healthcare providers showed the most positive attitude regarding the DNR order. The attitude of participants regarding the DNR orders was significantly associated with age, occupation status, residential place, educational status, and income level (P < 0.05).

Conclusions

Various factors, such as economic status, level of education, place of residence, and gender, can be effective on decision-making regarding the DNR orders. Unified and sustained education regarding moral and cultural issues can be helpful in the reconciliation of the attitudes between caregivers and patients.

The Influence of Parents' Religiosity or Spirituality on Decision Making for Their Critically Ill Child: An Integrative Review

Background: Religion and/or spirituality are important values for many parents of critically ill children; however, how religion and/or spirituality may influence which treatments parents accept or decline for their child, or how they respond to significant events during their child's illness treatment, remains unclear. Objective: To summarize the literature related to the influence of parents' religiosity or spirituality on decision making for their critically ill child. Design: Integrative review, using the Whittemore and Knafl approach. Setting/Subjects: Data were collected from studies identified through PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL plus), Embase, Scopus, and PsychInfo. Databases were searched to identify literature published between 1996 and 2016. Results: Twenty-four articles of variable methodological quality met inclusion criteria. Analysis generated three themes: parents' religiosity or spirituality as (1) guidance during decision making, (2) comfort and support during the decision-making process, and (3) a source of meaning, purpose, and connectedness in the experience of decision making. Conclusion: This review suggests that parents' religiosity and/or spirituality is an important and primarily positive influence on their decision making for a critically ill child.

Factors Influencing Do-Not-Resuscitate Status in Children During Last Month of Life: Single Institution Experience

BACKGROUND

It is currently expected that about 20% of children with cancer will ultimately die. Writing advanced life directives sufficiently long before the actual death of a child ensues allows both parents and medical staff to develop optimal treatment plans in the best interests of the child.

AIM OF THE STUDY

The aim of the study was to evaluate factors that may influence the process of decision-making regarding Do-Not-Resuscitate (DNR) status.

METHODS

Retrospective single institution study.

RESULTS

Totally, 79 patients died between September 01, 2011 and August 31, 2017. Median age of the children was 10.5 years (range, 1 to 24 y). Forty-five were males. There were 37 Muslims, 27 Jews, 9 Druze, and 6 Christians. Twenty-one patients had sarcomas, 20 had CNS tumors, 10 had neuroblastoma, 17 had leukemias/lymphomas, 11 had carcinomas, and other rare tumors as well as nonmalignant diseases. No statistically significant association between all evaluated factors and DNR order status was found.

CONCLUSIONS

It is possible that, other than demographic, clinical-associated, or therapy-associated factors play an important role in the process of decision-making regarding DNR. We feel that sincere communication between parents, their child (when appropriate) and medical and psychosocial staff may have a more crucial role when such decisions have to be made.

The Perspectives of the General Population and Relatives of Cancer Patients with Respect to the Do-Not-Resuscitate Order

Background A do-not-resuscitate (DNR) order is a medical decision that instructs healthcare providers to withhold cardiopulmonary resuscitations (CPR) to patients in case of cardiopulmonary arrest in respect to their wishes. In Saudi Arabia, the decision is usually made by physicians based on the Fatwa number 12086 regardless of the patients' or their families' desires. Assessing the knowledge, perception, and attitude of Saudi family members towards this medical decision may help guide medical practitioners to make decisions that are legally and ethically acceptable for the patients and their family. Therefore, this study aimed to assess their knowledge, perception, and attitude about DNR decisions and to determine demographic variables that affect their attitude towards DNR decisions. Method This cross-sectional study was conducted from December 2017 to January 2018 utilizing survey distribution through emails and different social media outlets including Facebook, Twitter, Pinterest, and LinkedIn. A self-administered questionnaire was employed to elicit responses regarding knowledge, perception, and attitude towards DNR decisions. Statistical Package for the Social Sciences Windows version 17 (SPSS v.17) (IBM Corporation, USA) was used for data management and analysis. Result Of the 1882 participants who filled the questionnaire, only 1693 participants were eligible as the study sample population and were included in the final data analysis. Most of the participants were from the Makkah region (72.2%) and were mainly from the general population (61.66%). Participants were mainly females (66%) and within the median age of 30 years (IQR: 21). As expected, participants who had heard about the DNR practice were from the medical field (58.6%) and they were mainly distant relatives. Almost 76% of the participants had two to four incorrect answers about the DNR practice, and it indicated that participants have inadequate knowledge about a DNR order. Most of the participants (43.2%) refused to be on a DNR order if they were diagnosed with a terminal illness. However, most participants (69.9%) wanted to have an involvement in the decision-making of being on a DNR order. In terms of willingness to understand and learn about the DNR decision, 1475 (87.1%) of the participants wanted to learn more about the DNR practice. Being a relative of a terminally ill cancer patient did not have a significant effect on the knowledge and perceptions of participants about being on a DNR order. However, having a background in medicine was found to be significantly associated with their acceptance to be on a DNR order. The knowledge score regarding DNR was found to be significantly associated with higher acceptance towards DNR orders. Conclusion The majority of participants had a lack of knowledge about the DNR practice. Their religion's concept of hope and virtue is considered as the major reason for their DNR order refusal. However, proper education about the DNR practice and involvement in the DNR order decision-making will increase the participants' knowledge and will improve their acceptance of the DNR practice.

Retrospective Review of Limitations of Care for Inpatients at a Free-Standing, Tertiary Care Children's Hospital

Limited studies exist regarding the timing, location, or physicians involved in do-not-resuscitate (DNR) order placement in pediatrics. Prior pediatric studies have noted great variations in practice during end-of-life (EOL) care. This study aims to analyze the timing, location, physician specialties, and demographic factors influencing EOL care in pediatrics. We examined the time preceding and following the implementation of a pediatric palliative care team (PCT) via a 5-year, retrospective chart review of all deceased patients previously admitted to inpatient services. Thirty-five percent (167/471) of the patients in our study died with a DNR order in place. Sixty-two percent of patients died in an ICU following DNR order placement. A difference was noted in DNR order timing between patients on general inpatient units and those discharged to home compared with those in the ICUs (p = 0.02). The overall DNR order rate increased following the initiation of the PCT from 30.8% to 39.2% (p = 0.05), but no change was noted in the rate of death in the ICUs. Our study demonstrates a variation in the timing of death following DNR order placement when comparing ICUs and general pediatric floors. Following the initiation of the PCT, we saw increased DNR frequency but no change in the interval between a DNR order and death.

Ethical considerations about changing parental attitude towards end-of-life care in twins with lethal disease

Advances in critical care and technology capabilities may lead to new ethical encounters in paediatrics, especially in the paediatric intensive care unit (PICU). As each patient has unique psychosocial and clinical condition interactions, paediatricians and healthcare providers must develop and adopt a suitable approach for ethical decision-making in the PICU. The healthcare provider needs to balance the four ethical domains of autonomy, beneficence, non-maleficence and justice, and apply these principles to clinical decision-making. One chief factor for ethical decision-making is to have a patient-centered and family-oriented management that is respectful of cultural background. Healthcare providers also need to observe professional ethical conduct and the applicable national laws. Applying these ethical guidelines in paediatric care ensures a more holistic approach to care, whether in the paediatric wards or the highly technical environment of the PICU. We describe two situations in which the parents of twins with a confirmed lethal disease changed their attitude towards end-of-life from full support to "do not resuscitate" and palliative care, after experiencing the palliative care of the first twin, rather than the futile effect of cardiopulmonary resuscitation in the other twin.

Palestinian community perceptions of do-not-resuscitation order for terminally Ill patients: A qualitative study

AIM AND OBJECTIVES

To illustrate the Palestinian community's views, opinions and stances about the concept of do-not-resuscitate for terminally ill patients.

BACKGROUND

Do-not-resuscitate orders are practised in many countries worldwide, but there is no consensus on their practice in the Middle East. Do-not-resuscitate orders may be applied for terminally ill paediatric patients. Some studies have been conducted describing people's experiences with these do-not-resuscitate orders. However, few studies have considered community perspectives on do-not-resuscitate orders for terminally ill patients in Palestine.

DESIGN

A descriptive-qualitative design was adopted.

METHODS

A purposive sample of 24 participants was interviewed, with consideration of demographical characteristics such as age, gender, education and place of residency. The participants were recruited over a period of 6 months. Individual semistructured interviews were utilised. These interviews were transcribed and analysed using thematic analysis.

FINDINGS

Significantly, the majority of the participants did not know the meaning of do-not-resuscitate and thought that removal of life-sustaining devices and do-not-resuscitate were the same concept. Most of the interviewees adopted stances against do-not-resuscitate orders. Several factors were suggested to influence the decision of accepting or rejecting the do-not-resuscitate order. The majority of the participants mentioned religion as a major factor in forming their viewpoints. The participants expressed different views regarding issuing a law regarding do-not-resuscitate orders.

CONCLUSION

Our findings provide a unique understanding that there is a general misunderstanding among our participants regarding the do-not-resuscitate order. Further research with policymakers and stakeholders is still required.

Trends in End-of-Life Care in Pediatric Hematology, Oncology, and Stem Cell Transplant Patients

BACKGROUND

Decisions about end-of-life care may be influenced by cultural and disease-specific features. We evaluated associations of demographic variables (race, ethnicity, language, religion, and diagnosis) with end-of-life characteristics (Phase I enrollment, do-not-resuscitate (DNR) orders, hospice utilization, location of death), and trends in palliative care services delivered to pediatric hematology, oncology, and stem cell transplant (SCT) patients.

PROCEDURE

In this single-center retrospective cohort study, inclusion criteria were as follows: patients aged 0-35 who died between January 1, 2002 and March 1, 2014, and had been cared for in the pediatric hematology, oncology, and SCT divisions. The era of 2002-2014 was divided into quartiles to assess trends over time.

RESULTS

Of the 445 included patients, 64% of patients had relapsed disease, 45% were enrolled in hospice, and 16% had received palliative care consultation. Patients with brain or solid tumors enrolled in hospice (P < 0.0001) and died at home more frequently than patients with leukemia/lymphoma (P < 0.0001). Patients who received Phase I therapy or identified as Christian/Catholic religion enrolled in hospice more frequently (P < 0.0001 and P = 0.03, respectively). When patient deaths were analyzed over quartiles, the frequency of DNR orders (P = 0.02) and palliative care consultation (P = 0.04) increased over time. Hospice enrollment, location of death, and Phase I trial enrollment did not change significantly.

CONCLUSIONS

Despite increases in palliative care consultation and DNR orders over time, utilization remains suboptimal. No increase in hospice enrollment or shift in death location was observed. These data will help target future initiatives to achieve earlier discussions of goals of care and improved palliative care for all patients.

The Associations Between the Religious Background, Social Supports, and Do-Not-Resuscitate Orders in Taiwan: An Observational Study

Prior studies have demonstrated important implications related to religiosity and a do-not-resuscitate (DNR) decision. However, the association between patients' religious background and DNR decisions is vague. In particular, the association between the religious background of Buddhism/Daoism and DNR decisions has never been examined. The objective of this study was to examine the association between patients' religious background and their DNR decisions, with a particular focus on Buddhism/Daoism.The medical records of the patients who were admitted to the 3 surgical intensive care units (SICU) in a university-affiliated medical center located at Northern Taiwan from June 1, 2011 to December 31, 2013 were retrospectively collected. We compared the clinical/demographic variables of DNR patients with those of non-DNR patients using the Student t test or χ test depending on the scale of the variables. We used multivariate logistic regression analysis to examine the association between the religious backgrounds and DNR decisions.A sample of 1909 patients was collected: 122 patients had a DNR order; and 1787 patients did not have a DNR order. Old age (P = 0.02), unemployment (P = 0.02), admission diagnosis of "nonoperative, cardiac failure/insufficiency" (P = 0.03), and severe acute illness at SICU admission (P < 0.01) were significantly associated with signing of DNR orders. Patients' religious background of Buddhism/Daoism (P = 0.04), married marital status (P = 0.02), and admission diagnosis of "postoperative, major surgery" (P = 0.02) were less likely to have a DNR order written during their SICU stay. Furthermore, patients with poor social support, as indicated by marital and working status, were more likely to consent to a DNR order during SICU stay.This study showed that the religious background of Buddhism/Daoism was significantly associated with a lower likelihood of consenting to a DNR, and poor social support was significantly associated with a higher likelihood of having a DNR order written during SICU stay.