Table 3 Review themes, sub-themes and explanatory narratives
1. Meaning-Making of DNAR construct | Awareness and Understanding | 66.8% heard about the term DNAR [83] 27% had not heard about DNR [35] 50% knew what an order of “do-not-resuscitate” is [84] 73.7% lacks absolute understanding [83] Only 37.5% had DNR knowledge [74] Perceived as passive euthanasia—65.3% knew what “passive euthanasia is [84] Positive attitude to passive euthanasia was reported [75, 78] “End-of-life and DNR were frequently conflated” [69] DNR orders as permitting death to occur [36] All life-sustaining therapy should be withdrawn [37] ICU training associated with greater awareness [37] Most got information about DNR order from clinical experience [88] |
Perceived Implications | DNR to apply only to withholding CPR [69] Were aware that DNAR did not imply withdrawal of life-sustaining treatment [37] 97.1% knew that DNR does not mean "do-not-treat" [88] Would use vasopressors, haemodialysis and non-invasive mechanical ventilation in a DNR patient [86] DNR order doesn’t involve limitation in therapeutic measures [90] ICU and EOL care training associated with “DNACPR does not entail withdrawal of life support” [37] Does not mean do not take care [61] DNR does not mean “no-care” [88, 90] Must continue active treatment of pain [69] Most common treatment offered to patients with DNR were palliative treatments, personal hygiene and prevention cares for pressure ulcer [75] DNR orders get that same quality of care [75, 79] Agreed about providing emotional support for patients with DNR status [90] Providing ‘comfort measures’ for a DNR patient’ [86] | |
Timing | Delaying DNR discussions until serious clinical deterioration [66] Code status to be discussed when patients get sick [89] Delaying DNR discussions until serious clinical deterioration [66] The cognitive status of the patient as a barrier to discussion with patients [69] “Who is patient’s guardian? How can we determine him?” [76] Patients’ preference about DNAR must be taken in advance before they lose competence [70] 81.5% agreed that DNR status should be determined before emergency situation arise [88] Review of cardiopulmonary resuscitation should happen prior to patients entering the end-of-life phase [87] EOL care training (aOR = 2.48) was independently associated with knowing when to consider DNACPR decisions [37] | |
Benefit versus burdens | CPR of patients unlikely to survive is futile care [64] Effort and care with unattainable goals [9] CPR should not be done if seemed futile [34, 57, 63, 71] Want DNR order for loved ones If CPR is futile [34, 57] Futile to prolong the life of frail, elderly patients [55, 75, 79] CPR should not be initiated if it is vain [80] It was useless work [53] Most effective factor is chance of patients survival [53] 64.8% disagreed or strongly disagreed that resuscitation should always be done in a terminally ill patient [58] 62.5% felt that CPR should be done selectively in patients [73] 60% strongly disagreed/disagreed that doctor should try to resuscitate every patient in ICU [63] “sometimes we are given end-stage patients and we know that nothing can be done to save them” [60] “…Well, for some patients, the DNR order is given, because no one believes in their recovery” (n 11, emergency medicine specialist) [61] 19.3% thought that terminally ill cancer patients should receive cardiopulmonary resuscitation [84] Majority (58.6%) of respondents disagreed to the negative statement that every critically ill patient should have DNR order [88] | |
Mitigates Suffering | Reduction of patient suffering as the reason [83] DNR protects the patient from unnecessary suffering [34, 55, 57, 63, 71, 75, 79, 80] “DNR is good at the terminal stage to prevent suffering of the patient as well as the friends and family” [69] Death as a cause of Comfort [61] “They say don’t hurt him, let him die easily and in peace.” (P.10) [92] CPR hurts both physically and mentally [64] “It decreases our tiredness, saves equipment and facilities” [67] 62.9% disagreed with discomfort to be one of the factors influencing DNR status [90] | |
Allows fair allocation of resources | Limited resources as the justification [83] It saves money and resources [69] “…., he accepted the DNR order because he really did not have any money” [64] Saves equipment and facilities [67] Millions of national capital lost on useless CPR [9] Lack of appropriate allocation of resources [9] Monetary factor of keeping a terminally ill patient alive is difficult to justify [55, 75, 79] Concerned about economic constraints [66] 70% disagreed with socioeconomic status to be one of the factors influencing DNR status [90] 83% never apply DNR orders when a patient’s family cannot afford treatment costs [63] (90.0%) agreed that “the basis for DNR order is medical judgment along with patient’s wish.” [88] | |
2. Facilitators and Barriers | Individual factors | DNAR helps clarify treatment plan [34, 55, 57, 75, 79, 80] Health care staff have a positive attitude toward the order [78] DNR plays an important role in healthcare [69] “…think there should be a do-not-resuscitate order…” [67] Terminally ill patients have the right to choose DNR [55, 62, 77] Cardiopulmonary resuscitation status should be reviewed and is relevant at end of life [87] 63.2% agreed about ‘DNR’ choice being the patient or his family right [62] 59.4% accept the concept of DNR [35] 62.7% nurses compared to 90.5% physicians in surgical speciality believed that terminally ill patients have the right to a do not resuscitate order [50] Disagreed to implementation of DNAR in Sri Lanka [83] Healthcare team must always provide hope to patients even when death is imminent [75, 79] Prolonging life should always be the goal of the healthcare team [55, 79] 39.0% rejected the concept of DNR [35] Consultants have more sophisticated understanding [69] Medical officers compared to interns had less problems and conflicts [57] Significant relationship between work experience and attitudes towards DNR [78] Less work experience associated with better attitude towards DNR [85] Higher educational qualification had more positive attitudes towards DNR [34, 71] DNR decision had significant relationship with educational level [74] Postgraduate training associated with less reluctance [37] Educational level not associated with attitude [90] Male gender associated with less reluctance [37] Females had a more negative attitude toward DNR [78] Gender has no impact on nurses’ attitude [37, 74, 80, 81, 85, 90] DNR decision has significant relationship with DNR knowledge [74] Experience of implementing DNR orders has no impact on attitude [80, 90] No significant association between DNR knowledge and attitude [88, 90] History of COVID-19 and death of relative due to COVID-19 increased DNR attitude score [78] Death attitude profile scores associated with DNR attitude [85] Lack of education around end of life and resuscitation [69] |
Family views | Family preferences tended towards a wish for maximum life [69] ‘In Sri Lanka, the family don’t want patients to know [about DNR].’ – Consultant surgeon. [69] Family denial, education level and conflict between family members on DNR were most frequent family-related barriers in code status discussion [89] Giving up on by agreeing to DNR [72] Iranian people are emotional and struggle to keep patients alive [9] Families are reluctant to ask for DNR because of strong attachment [64] Respect the wishes of the family who refuse to involve the patient [66] "If a competent patient's family prefers not to tell the patient about the DNAR order, the request must be respected" [70] Code status discussion is dependent more on patients' sociocultural background rather than physicians' academic background [89] Family-related barriers played the most important role in discussing code status [89] Application or non-application of a DNR order only depends on the patient's family [64] Families are not well informed; therefore, they try to save their patient until the last moment [9] Code of “money as a facilitating or hindering factor” [64] | |
Religious beliefs | Religious beliefs greatly influence view of DNR [55, 75, 79] Religion affects opinion regarding DNR order [55] “useless CPRs are not only non-rewarding, but a sin” [9] DNR order is not in contrast to the will of God [64] DNR not in contrast with religious beliefs [34, 57, 63, 71, 80] DNR is a sin [83] Religiosity strongly associated with decision to forego CPR [81] Oppose DNR order as believe prolonged disease is a way for forgiveness of the sins [64] Disagree with DNR orders as the power of God is above all [64] Against our religious believes [37] 30% not sure about religion’s view towards DNR [63] No religious permission for avoiding resuscitation [59] Seeing miracles feel doubtful about DNR [9] DNR is Sin [83] The most challenging reason for participating in DNR process for nurses was cultural religious beliefs (53.9%) [75] Religiosity strongly associated with decision to forego CPR [81] | |
Society and Sociocultural norms | Society feels that a doctor should always do the maximum [69] Culture makes it hard for me to encounter DNR orders [71] According to Rwandan culture only God can decide about life and death [36] My culture has ideas that are incompatible with the issuance and execution of DNR order [34] Culture influences their decision on the DNR [55] Culture makes it difficult to deal with DNR orders [75, 79, 80] Symbol of hope and not death [89] DNR not culturally accepted in Iran [60] DNR orders are culturally prohibited in Uganda [72] Indonesian respondents placed less emphasis on quality of life compared to Mexicans [81] High importance was accorded to pre- and post-admission quality of life [66] DNR order does not conflict with my cultural beliefs [57] | |
Organizational challenges | No formal protocol or even informally accepted system for resuscitation decisions [69] Weak organizational support, the lack of clear protocol [53] No certain protocol [9] Hospital doesn’t have a written DNR policy [90] Absence of a written directive for do not resuscitate (DNR) [65] Lack of DNR order is a barrier [67] 71.5% reported not having a written or implied DNR policy [35] Current Iranian health care was a routine and stereotyped care [64] Time constraints as a barrier [89] Lack of proper place/room for such discussion [89] Reported lack of national guidance for making DNR decisions [72] Lack of training in communication skills as barrier to code status discussion [89] 57.1% perceived Time constraints as a barrier [89] “…and the doctors are busy” – Consultant surgeon [69] 71.4% of the critical care nurses disagreed about hospital policy to be among the factors influencing DNR status [90] “I feel pressure from the hospital utilization review to push for DNR orders” [75, 79] | |
Ethical and Moral Conundrums | DNR order is morally correct [57, 80] DNR is morally acceptable and right [34, 71] Violent CPR on end-stage patients an example of violating moral principle of nonmaleficence [60] Issuance and execution is morally and ethically acceptable [63] Every human being has the right to decide freely [9] Most important moral principle is non-maleficence [64] DNAR is unethical and should not be practiced [83] “do not know whether it is morally right or not” [61] Moral conflict with DNR [36] | |
Legal status | Lack of legal support as the most important principle of non-compliance with DNR [9] “Why should we get ourselves in trouble?” [9] “we should not intervene because we do not have legal support” [64] DNR code status were not legally binding in Pakistan [91] “we don’t have legal or religious right to disconnect the machine” [65] Lack of clear legal guidelines [68] There is no legal permission for executing DNAR [59] No legal do-not-resuscitate order policy in Iran [67] Informal and illegal identity of DNR order [61] DNR code status were not legally binding in Pakistan [91] None of the Christians were in favour of legalizing the DNR order in Palestine [55] Wished to have a better understanding of the legal ramifications of DNR/advance directives/patient’s rights [55, 75, 79] Want the DNR order to be legalized in Palestine [55] | |
3. Tensions and complexities of Contemporary practice | Emotions evoked | Fear of being prosecuted/ legal consequences [9, 55, 59, 61, 64, 65, 67, 68, 75, 76, 79, 89, 90, 92] Resuscitation of patients who may not survive lead to staff burnout [9] “the useless and vain things that we do, sometimes it won’t be effective but harmful, and then we will have a guilty conscience” [64] Uncomfortable with the decision to limit resuscitation [66] Felt depressed, frustrated, powerless, Confused, Anxiety, Anger, Guilt regarding DNR status [90] It is depressing to find patient in DNR order [88] DNR experience was challenging [75] Psychological stress associated with DNR decisions [57] Fear that the DNR decision could be ‘wrong’ [69] Feared family reaction [89] Fear of public distrust in healthcare system [64] Doctors fear to write DNR [36] “we're the scapegoat, so actually we’d better not interfere” [64] 48.6% always ensure that the patient looks presentable [90] “… It can influence the nursing care” [36] “..the useless and vain things that we do, sometimes it won’t be effective but harmful, and then we will have a guilty conscience..” [64] |
Arbitrary and variable practice | Every physician acts arbitrarily [9] Non-implementation was more likely in low- to middle-income economies [82] “Resuscitation status very rarely discussed with patients” [87] Place of work have a method for making decisions [72] It is considered in a case-by-case basis [69] 28.5%, reported having a DNR policy, implying DNR was practiced [35] Some are scared, some happy to give DNR order, some do not give [61] Only 13% reported they almost always/often order DNR [63] Experience of withholding CPR [57] Impossibility of following a DNR order in Iran [60] “All the companions told us not to resuscitate their patient, but we didn’t have a legal thing called the do-not-resuscitate order. So, we had to ineffectively resuscitate the patient for 45 min.” [67] Participants believed that the current Iranian health care was a routine and stereotyped care [64] "Resuscitation status very rarely discussed with patients" [87] 56.2% had experience of taking to patient or their relative about making decision of DNR [57] | |
Informal and verbal orders | “There is no such an order in the patient's file and it is not documented” [61] Physicians verbally order DNR [74] 51% and 17% almost always/often apply written and verbal DNR orders respectively [63] DNR orders not written in patient's record and ordered verbally as the challenge [75] Communicate DNR decisions verbally [72] DNR order is given only orally and isn't written in the medical record [90] Wrong resuscitation measures applied because not written in the patient records [36]: “Sometime we apply resuscitation measures wrongly because it is not written in the patient records.” (Leon, Nankundwa and Brysiewicz 2017, p.21) DNR order in oral form is illegal [88] Majority of the doctors did not administer CPR when there was a documented DNR order [57] 51% apply written DNR orders while only 17% apply verbal DNR orders [63] | |
Threatened Autonomy | Combination of patient, clinician and family should make a DNR decision [69] Patient or the patient’s family should be in control of all medical decisions [55, 75, 79] Consent of patients is essential for DNAR order [34, 57] “Cannot decide about asset of another person” [9] Mixed reviews if patients should be informed of DNR decision [69] Patients’ autonomy is violated and this leads to medical paternalism [60] Little informing of patients is performed [69] Personal belief that the patient does not want to be engaged [66] Want to discuss code status with family instead of the patient [89] ‘Doctors have power; respect for doctors is good, but it is too much as patients fear asking questions’ [69] | |
Hierarchical and non-consensual decision-making | Nurses cannot recommend DNAR order [70] In majority of cases (96.1%) DNR was commanded by the doctor [75] “nurses are not included in the discussion, it’s very painful” [36] DNR order placed without consulting nurses [75] Only 42.9% agreed that The nurse can recommend DNR order [88] Both nurses and physicians agreed that it is the physician’s responsibility to give DNAR order [70] Physicians are the ones who should make all the decisions [55] 66.8% attributed the decision to physicians [75] It difficult to talk about death [55, 75, 79] It difficult to talk about DNR [55] Physician is the responsible person for the designation of DNR status (100%) [90] | |
Symbolic and Tokenism | CPR for tokenistic aims for satisfying the patient's family [61] “…in the internal emergency department, CPR is nor performed, because the majority of patients need the DNR order. The patient with cancer does not need CPR and 99% of CPR cases are tokenistic to satisfy the patient's companions with regard to the provision of care” (n 17, pediatric ICU staff nurse, Assarroudi et al. 2017, p.5) [61] Perform it for our job safety [53] Even if a patient has written consent for do not resuscitate (DNR), we do not have written permission to ignore it and we have to perform it for our job safety. (Participant No. 6, Torabi et al. 2020, p.412) [53] Acts were also taken such as causing intentional rib fractures [92] “Sometimes acts were also taken to prevent legal problems, such as causing intentional rib fractures and injecting medications to increase its blood level concentration in the case of complaint” (Zali et al. 2023, p. 251) [92] “comforts the family to know that CPR will happen” [69] “CPR so that the patient’s companions did not think we did nothing for the patient” [64] CPRs are done only for show [9] “If the companion sees the patient, the resuscitation will start again, only chest compressions, because the companion is sensitive to chest compressions. Then we quickly draw the curtains and take the companion out and no more resuscitation is done.” (P.12, Zali et al. 2023, p.251) [92] “Perform resuscitation in a fake way” [68] “We had to ineffectively resuscitate the patient” [67] “Some patients don’t respond to resuscitation due to their terminal conditions; however, they (i.e., authorities) have required us to perform resuscitation in a fake way due to the ethical and legal issues related to resuscitation” (P. 13, Dehi et al. 2021, p.125) [68] |