Table 2 Characteristics of included studies
Author Year | Country | Study aims | Participants | Setting | Study design, Data collection and Analysis | Data | Hawker’s Score |
|---|---|---|---|---|---|---|---|
Abu-Saad Huijer and Dimassi 2007 [50] | Lebanon | To determine KAP towards PC of: Physicians and nurses working in different specialties | 956 nurses and 240 physicians | 15 geographically spread hospitals | Quantitative, Questionnaire-based Cross-sectional survey. Chi-square and t-test | N (%), Mean ± SD, P value | 29 |
Abu-Saad Huijer et al. 2009 [51] | Lebanon | To determine KAP towards PC of: nurses working in different specialties, Multicentric | 956 nurses | 15 geographically spread hospitals | Pearson’s chi-square test, ANOVA in SPSS | N (%), P value | 27 |
Abu-Saad Huijer et al. 2009 [52] | Lebanon | Physicians and nurses from different specialties | 645 nurses and 223 physicians specialized in the medical, surgical, pediatrics, acute critical care, oncology, and obstetrics/gynecology | 15 geographically spread hospitals | ANOVA, chi-square, and Fisher exact test, regression analysis in SPSS | N (%), P value | 25 |
Adhikari and Rijal 2019 [57] | Nepal | To find attitude of doctors working in a tertiary hospital towards DNR decisions | 53 medical officers and 53 interns | Single Hospital | Quantitative, Questionnaire-based Cross-sectional study. Chi-square in SPSS | N (%), Mean score, P value | 20 |
Agrawal et al. 2019 [58] | India | To assess awareness and knowledge toward EOLC in critically ill patients | 216 doctors working in ICU, of any specialty, of either gender, having at least 3 months of completely dedicated adult ICU postings in the past 3 years | Single tertiary care center | Quantitative, Questionnaire-based Cross-sectional Survey. Chi-square test, ANOVA, Kruskal–Wallis and Dunn’s test | N (%), adjusted Odds ratio, 95% CI, P value | 26 |
Aghabarary and Nayeri 2017 [59] | Iran | To explore Iranian nurses’ and physicians’ perceptions of the reasons behind providing FMTs | 21 nurses and 9 physicians | Four teaching hospitals affiliated to Tehran University of Medical Sciences | Qualitative, in-depth semi-structured interviews. Graneheim and Lundman Conventional content analysis | Theme, category, sub-categories and participant quotes | 33 |
Aghakhani et al. 2022 [60] | Iran | To explore and identify components of moral sensitivity with respect to CPR | 20 critical care nurses with rich CPR experience, atleast bachelor’s nursing degree, and 2 years of work experience | Critical care units from different universities | Qualitative, In-depth semi-structured interviews and field notes Grounded theory | Themes and sub-themes with participant quotes | 36 |
Assarroudi et al. 2017 [61] | Iran | To understand experiences about DNR order | 24 CPR team members (17 nurses, 5 physicians, and 2 bachelor degree anesthesiologists) | Teaching hospitals in an urban area | Qualitative, semi-structured interviews. Conventional content analysis | Categories, sub-categories with participant quotes | 30 |
Awny et al. 2022 [62] | Egypt | To assess physicians knowledge, attitude and practice towards patients needing PC | 220 physicians expected to introduce medical care to terminally ill patients | Single university Hospital | Quantitative, Questionnaire-based survey. SPSS used for analysis | N (%) | 22 |
Azab et al. 2022 [63] | Egypt | To investigate attitudes towards EOLC and reported practices in adult ICUs | 100 physicians | Adult ICUs in Ain Shams University Hospitals, Cairo | Quantitative, Questionnaire-based survey. SPSS used for analysis | N (%) | 29 |
Bahramnezhad et al. 2016 [64] | Iran | To describes perspective on the formulation of the DNR guideline | 8 Nurses | Intensive care and oncology units at Tehran University of Medical Sciences | Qualitative semi-structured in-depth interviews. Content analysis | Categories and codes with participant quotes | 26 |
Borhani et al. 2014 [65] | Iran | To identify perspectives of intensive care nurses about EOLC in an Iranian and Islamic context | 12 nurses | Three ICUs at an Iranian teaching hospital affiliated to Kerman University in South-East of Iran | Qualitative, semi-structured interviews. Inductive coding approach | Themes, sub-themes with illustrative quotes | 28 |
Chang et al. 2021 [37] | Sri Lanka | To assess attitudes about DNACPR | 450 doctors | Multiple government tertiary care hospitals | Quantitative, Questionnaire-based Cross-sectional Survey Logistic regression analysis in SPSS | Percentage, adjusted odds ratio | 33 |
Cheraghi et al. 2016 [9] | Iran | To determine perspectives regarding DNR for dying patients | 8 Iranian physicians | Not explicitly mentioned | Qualitative, semi-structured in-depth interviews Hsieh and Shannon directed content analysis | Categories and codes with participant quotes | 28 |
Dabar et al. 2021 [66] | Lebanon | To explore approaches towards PC, EOLC and patient management | 167 medical doctors | Two tertiary care academic hospitals with distinct medical culture | Quantitative, Questionnaire-based survey. Chi-square, Mann–Whitney U, independent samples t-test in SPSS | N (%), P value | 27 |
Dehghan-Nayeri et al. 2021 [67] | Iran | To identify factors affecting CPR within the pre-hospital EMS | 16 pre-hospital emergency personnel with different professional backgrounds, at least 1 year work experience and caring for 4 CPR cases during the last 2 months | - | Qualitative semi-structured interviews. Elo and Kyngäs content analysis | Category and sub-categories with participant quotes | 34 |
Dehi et al. 2021 [68] | Iran | To explore barriers to EOL care delivery to home‐dwelling terminally‐ill older patients | 10 healthcare providers (nurses and physicians) who had experience of EOL care delivery to home‐dwelling terminally‐ill older patients | Homes, home care institutes, and Imam Reza, Madani, and Ghazi Tabatabaei hospitals, Tabriz, | Qualitative in‐depth semi‐structured interviews. Graneheim and Lundman Conventional content analysis | Categories, sub-categories, codes and participant quotes | 33 |
Dodd et al. 2018 [69] | Sri Lanka | Not mentioned | 15 doctors | Two hospitals | Qualitative, semi-structured interviews. Data driven (Boyazatis) thematic analysis | Themes with illustrative quotes | 28 |
Fallahi et al. 2016 [34] | Iran | To evaluate attitudes of toward the issuance of DNR order | 152 general practitioners, residents, and specialists | Hospitals of Kermanshah University of Medical Sciences | Quantitative, Questionnaire-based Descriptive analytical. Independent t-test, ANOVA in SPSS | N (%), Mean ± SD, P value | 28 |
Fallahi et al. 2018 [70] | Iran | To compare nurses and physicians’ attitudes about DNAR order | 152 nurses and 152 physicians | Three educational hospitals affiliated with Kermanshah University of Medical Sciences | Quantitative, Questionnaire-based Descriptive analytical study. Kolmogrov-Smirnov and independent t-test in SPSS | Mean score, P value | 29 |
Fayyazi Bordbar et al. 2019 [71] | Iran | To assess attitude toward the DNR order | 47 healthcare providers (nurses and doctors) with at least 6 month work experience | One oncology hospital | Quantitative, Questionnaire-based Cross-sectional Survey | N (%), Mean ± SD, P value | 26 |
Gibbs et al. 2016 [72] | India, Lebanon, Pakistan, Sri Lanka, Uganda | To examine international variation in clinicians’ perception of DNACPR decisions and implementation and explores which factors influencing variation | 8 Physicians (out of 78 total) | Who had previously published material relating to DNACPR decisions (or similar end-of-life issues) within their country | Mixed methods, Questionnaire based survey. Analysis not described | N (%), Themes with participant quotes | 23 |
Goel et al. 2014 [73] | India, Chile, UK, Netherlands (Data extracted only for India) | To ascertain opinions and attitudes of on EOLC issues | 24 nurses (out of 109 from all over the countries) | Single tertiary care hospital in India | Quantitative, Questionnaire-based Cross-sectional survey. Chi-square, Mann–Whitney and Student-t tests | N (%) | 22 |
Goodarzi et al. 2022 [74] | Iran | To evaluate DNR and ToR knowledge, attitude, and decision making among | 128 resuscitation team nurses with bachelor’s degree or higher in nursing and membership in CPR team for at least one year | Two hospitals in Kermanshah and Hamedan, Iran | Quantitative, Questionnaire-based Cross-sectional study. Chi-square, Fisher’s exact, and Mann–Whitney U tests, Spearman’s correlation and regression analysis in SPSS | Percentage, Mean ± SD, 95% CI, P value | 29 |
Hassanin et al. 2016 [35] | Egypt | To assess knowledge, attitudes, or conceptual beliefs of DNR | 318 Medical professionals | Two large teaching hospital and faculty of pharmacy and dentistry | Quantitative, Questionnaire-based Cross-sectional. STATA software used for analysis | N (%), 95% CI, Odds ratio, P value | 27 |
Hemmatpour et al. 2021 [75] | Iran | To investigate attitude and experience of DNR | 630 Nurses with bachelor's degree in nursing with at least two years of clinical experience | Hospitals affiliated with one University in western province of Iran | Quantitative, Questionnaire-based Cross-sectional study. SPSS | N (%), Mean ± SD | 25 |
Jafari et al. 2019 [76] | Iran | To explore EMS staff’s experiences of the factors behind their moral distress | 14 prehospital EMS staff with associate degree or higher in medical emergency, anesthesia, operating room, or nursing, a work experience of 3 years or more | Several cities in Iran | Qualitative, in‐depth unstructured and semi‐structured interviews, Graneheim and Lundman Conventional content analysis | Categories, sub-categories with participant quotes | 31 |
Kassa et al. 2014 [77] | Ethiopia | To assess the knowledge, skills, attitudes and associated factors with PC in nurses | 341 nurses | Governmental and non-governmental hospitals in Addis Ababa, Ethiopia | Quantitative, Questionnaire-based Cross-sectional study. Chi-square and logistic regression in SPSS | N (%), P value | 31 |
Mirhosseini et al. 2022 [78] | Iran | To investigate attitudes toward the DNR in COVID-19 patients | 332 health care providers with at least 1 year of work experience | Single COVID-19 referral hospital in Shahroud, Iran | Quantitative, Questionnaire-based Cross-sectional Survey. Multivariate linear regression analysis | Mean ± SD, P value | 27 |
Mogadasian et al. 2014 [79] | Iran | To investigate attitudes regarding DNR orders and determine the role of religious sects in such attitudes | 306 nurses | Five hospitals affiliated to TUOMS in East Azerbaijan Province and 420 nurses in KUMS’ affiliated hospitals in Kurdistan province | Quantitative, Questionnaire-based Descriptive‐comparative. Independent sample t‐test in SPSS | N (%), Mean ± SD, P value | 24 |
Naghshbandi et al. 2019 [80] | Iran | To investigate attitude of nurses in intensive care units towards DNR order | 255 nurses | ICUs of hospitals of Tabriz University of Medical Sciences | Quantitative, Questionnaire-based survey. Independent t-test, chi-square in SPSS | N (%), Mean ± SD, P value | 25 |
Brysiewicz and Nankundwa 2017 [36] | Rwanda | To explore lived experience of nurses caring for a patient with a DNR order | 6 nurses registered with the Rwanda Nursing Council, at least 6 months’ experience in the ICU | ICU of a single 200-bed tertiary hospital in Kigali, Rwanda | Qualitative, in-depth semi structured interviews, Giorgi’s phenomenological approach | Categories with participant quotes | 31 |
Ozer et al. 2019 [81] | Indonesia | To compare physicians’ attitudes towards and identify physician characteristics associated with withholding CPR for IHCA in patients they do not know in three countries | 295 physicians practicing internal medicine, anaesthesiology, cardiology, emergency medicine and critical care; likely to be code team members and key decision-makers during unexpected IHCA | Multi-country (Indonesia, Israel, Mexico, Data extracted only for Indonesia) | Quantitative, Questionnaire-based Cross-sectional. Chi-square, Kruskal–Wallis, Mann–Whitney U- tests, Logistic regression analysis | N (%), odds ratio, 95% CI, P value | 30 |
Phua et al. 2015 [82] | Bangladesh, India, Indonesia, Iran, Pakistan, Philippine, Vietnam | To describe attitudes and practice of physicians managing critically ill patients in Asian countries at the EOL with emphasis on the WLST, and to evaluate factors associated with these attitudes | 524 ICU physicians from LLMIC | ICUs of 16 Asian countries and regions (524 from LLMIC) | Quantitative, Questionnaire = based survey. SPSS used for analysis | Percentage, adjusted Odds ratio, 95% CI, P value | 29 |
Pinto et al. 2013 [83] | Sri Lanka | To assess knowledge and attitude about EOL decisions | 232 medical practitioners at least MBBS and one year work experience | Three teaching hospitals of Kandy district | Quantitative, Questionnaire-based Cross-sectional study SPSS used for analysis | N (%) | 29 |
Pinto et al. 2020 [84] | Mozambique | To evaluate general knowledge, attitudes, and practices of Mozambican physicians on palliative care | 207 physicians | Four Major hospitals in Mozambique | Quantitative, Questionnaire-based Cross-sectional survey. Chi-square, Kolmogorov–Smirnov, Student-t and Mann–Whitney tests in SPSS | N (%), Median (95% CI) | 27 |
Safari Malak-Kolaei et al. 2022 [85] | Iran | To investigate relationship between Death attitude and DNR attitude | 156 ICU nurses with minimum bachelor’s degree and six months of work experience | ICU of educational- therapeutic centers affiliated to Golestan University of Medical Sciences (Golestan, Iran) | Quantitative, Questionnaire-based Cross-sectional survey. two-sample T test, ANOVA and regression analysis in SPSS | N (%), Mean ± SD, P value, 95% CI | 23 |
Saifan et al. 2016 [55] | Palestine | 1.Are the Palestinian physicians and nurses for or against legalizing the DNR order in Palestine? 2.Does their religion, culture or both affect their decision regarding the DNR order? | 48 ICU physicians and 75 nurses with a diploma degree or higher | 4 hospitals in Palestine | Quantitative, Questionnaire-based Cross-sectional study. Bi-variant spearman rho test in SPSS | N (%), p value | 22 |
Abdallah et al. 2016 [56] | Palestine | 1.To investigate attitudes of ICU physicians and nurses on the DNR order in Palestine for the terminally ill patients, and 2.whether culture and religion have any affect regarding their decision on DNR order | 48 Physicians and 75 nurses, who have experience in the ICU, with a diploma, bachelors’ degree or higher | Three different governmental hospitals and one charitable hospital | Percentages | 20 | |
Salahuddin et al. 2008 [86] | Pakistan | What Pakistani physicians know about EOL and practice in the ICU once EOL is determined? | 37 nurses and 100 physicians involved in caring for critically ill patients placed on life support in the ICU | Three hospitals of Karachi, Pakistan | Quantitative, Questionnaire-based Cross-sectional study. Chi-square, Fisher exact test and ANOVA tests in SPSS | N (%), p value | 25 |
Salins et al. 2017 [87] | India | To assess feasibility and acceptability of the agreed integrated care plan in the Indian setting | 21 senior Palliative care physicians | 16 Palliative Care institutes | Quantitative, Questionnaire-based Cross-sectional Survey. Analysis not described | N, summary of participant comments | 23 |
Shrestha and Shrestha 2021 [88] | Nepal | To identify knowledge of and attitude towards DNR order | 70 nurses with certificate or bachelor level nursing qualification | ICUs, step down unit, neuro ICU, emergency unit and medical units of a tertiary level central hospital | Quantitative, Questionnaire-based Descriptive correlation study. Spearman rho test in SPSS | N (%) | 29 |
Syed et al. 2017 [89] | Pakistan | To determine barriers and perceptions to code status discussion | 77 physicians from who had discussed at least five code statuses | Department of medicine of a university hospital in Karachi | Quantitative, Questionnaire-based Cross-sectional study. SPSS | N (%),Mean ± SD, P value | 28 |
Taha et al. 2010 [90] | Egypt | To describe critical care nurses' knowledge and attitudes regarding the DNR status | 140 nurses | Critical care units of Alexandria Main University Hospital | Quantitative, Descriptive study. ANOVA, Kruskal Wallis test, Linear correlation in SPSS | N (%) | 23 |
Torabi et al. 2019 [53] | Iran | To describe experiences and identify strategies used in Ethical decision making | 15 pre-hospital EMS with at least 3 years of professional experience | Urban and road bases in some major cities in Iran | Qualitative, In-depth semi-structured interviews, Lundman and Graneheim conventional content analysis | Categories and sub-categories with participant quotes | 34 |
Torabi et al. 2020 [54] | Iran | To identify barriers of ethical decision-making | 15 pre-hospital EMS | 32 | |||
Zafar 2015 [91] | Pakistan | To explore perspectives of EM residents and physicians regarding the common ethical challenges faced during patient care | 13 ED Physicians working full-time in the ED and senior (3rd and 4th year) residents | EM residency programme of a private teaching hospital in Karachi, Pakistan | Qualitative, semi-structured in-depth interviews. Grounded theory | Themes and sub-themes with illustrative quotes | 28 |
Zali et al. 2023 [92] | Iran | To explore experiences of ethical and legal issues in post-resuscitation care | 17 nurses with at least a bachelor’s degree and 2 years of clinical experience with rich experiences of providing care during and after resuscitation | Three educational hospitals affiliated with one University | Qualitative, semi-structured interviews, Graneheim and Lundman Conventional content analysis | Categories, sub-categories and participant quotes | 32 |