The Decision not to Resuscitate Order for Children and Related Ethical Issues from Students’ Perspective

Background : Nurses and PharmD have communicated the for elaborate and properly documented DNR orders for terminally ill children and informed child with terminally ill diseases and relatives to offer excellent care attention, such as more family support, assisting the child with terminally ill disease in passing on peacefully, and preventing unnecessary CPR This research aimed to survey attitudes of nursing and PharmD (PharmD) undergraduate students about the “do not resuscitate” order for children with terminally ill diseases. Method: Across-sectional correlational design was used. More than 400 nursing and PharmD students were recruited in this study. All nursing and doctors of pharmacy undergraduate students were E-mailed information regarding the study, including the web survey link. Results: Approximately 60% of the nursing and PharmD students would disclose the need for the do not resuscitate order for children with terminally ill diseases. The results showed that there was a signicant difference in perception toward DNR order between nursing and PharmD. PharmD students had more positive attitude toward DNR than nursing students. Conclusion: The results of this study showed that all demographic variables not associated with the perception toward DNR orders (p value > 0.05). This study shows that Jordanian nursing and PharmD students are willing to learn more about different aspects of DNR orders for terminally ill children and analyzing their responses to many items showed their misconception about DNR orders for terminally ill children.


Background
There are frequent do not resuscitate (DNR) decisions in the circumstances involving end of life; that is choosing not to trigger the heart in the event of a heart attack. DNR decisions are made when a child with terminally ill disease refuses resuscitation, poor diagnosis, or if it is evident that the child with terminally ill disease will not survive cardiopulmonary resuscitation (CPR) with better life quality [1,2]. WHO de nes the quality of life as the subjective perception of how and where an individual resides, associated objectives, anticipations, quality, and concerns [2]. Orders of DNR entails avoiding basic CPR, compressing the chest combined with or without concurrent ventilation, and exceptional CPR that involves de brillation and medication [3].
According to western regulations, if there is no DNR order for a child with terminally ill disease, CPR must commence within 60 seconds, and de brillation within three minutes [3]. Provisions of western laws dictate that child with terminally ill disease DNR's decision lies with the responsible doctor [4]. After discussing with other quali ed experts (other providers of healthcare like physicians, nurses and doctors of pharmacy), the decision should be made after consulting the child with terminally ill disease. However, the physician usually makes the nal decision [4,5].
The child with terminally ill disease Act gives a child with terminally ill disease more privilege to be involved in his/her care and the right of information [5]. If the children with terminally ill disease and their families cannot receive the information, a relative should receive the news [5]. The DNR decisions should be recorded in the medical records of the child with terminally ill disease, including information regarding why the resolution was arrived at and who participated in the decision making.
Additionally, there should be documentation of the details on whether or not the children with terminally ill disease and their families were consulted before the decision, modes of conveying the decision to the child with terminally ill disease and relatives, and the attitude they expressed regarding the decision [4]. The rst description of DNR was at the beginning of the 1970s. In 1974, the Medical Association in America suggested that the decision should be recorded in the medical records of the child with terminally ill disease, while medical staff members who care for the child with terminally ill disease be informed [6]. Based on studies, DNR orders for terminally ill children can be ambiguous [7,8], and that there can be inconsistent and varying DNR documentation [7,9,10]. Besides, results indicate that there are often late DNR decisions while caring for child with terminally ill diseases [11][12][13].
Lack of proper documentation predisposes child with terminally ill diseases to unnecessary CPR [15,16]. Reviews of nurses, doctors of pharmacy, and other healthcare providers have revealed that representatives of these occupations may approach DNR decisions differently. Although the decision lies with the other providers of healthcare with extensive medical understanding, nurses and PharmD who spend a lot of time with the sick, offering bedside nursing and medical attention within several hours of their duty shift and, therefore, frequently start discussing DNR [7,17,18]. Besides, nurses and PharmD have communicated the for elaborate and properly documented DNR orders for terminally ill children and informed child with terminally ill diseases and relatives to offer excellent care attention, such as more family support, assisting the child with terminally ill disease in passing on peacefully, and preventing unnecessary CPR [7,15].
According to Pfeil et al., healthcare providers could play an active role by conveying the DNR decisions to each child with terminally ill disease, or a passive duty where they wait for the child with terminally ill disease to start discussing DNR. Generally, DNR's process can be complicated, involving future nurses, doctors of pharmacy, and other healthcare providers with varying backgrounds and approaches. Future healthcare staff may have different DNR perspectives from outsiders in the eld of health. The attitudes of an individual towards DNR decisions may have changed due to medical training, particularly clinical education.
Exploring the attitudes of future nurses and PharmD regarding whether or not to opt for a DNR will be worthwhile since it may indicate the impact of their education. Besides, it is helpful to explore the varying attitudes between nursing and PharmD students, since it may reveal the impact of clinical contact on their opinions. Noting any difference in attitudes between undergraduate students in the healthcare eld during DNR decisions would be helpful. Therefore, this study aims aimed to survey attitudes of nursing and PharmD undergraduate students about do not resuscitate order for children with terminally ill diseases and whether differences in attitudes existed between nursing and PharmD students.

Method
The descriptive correlational study, utilizing an online survey as a beginning point, was conducted. A total of 800 nursing and PharmD undergraduate students were contacted, and yer sent to them to participate in the study. Information regarding the background and objectives of this study were sent to the prospective respondents. This information had a web survey link. Since the web survey was undisclosed, all potential respondents were reminded at least twice. First, the researcher gave brief details regarding the study and which project the study constitutes. Online surveys were disseminated to undergraduate students who preferred this manner of completing the survey. Data collection began in April 2020 and closed in June 2020.
Two hundred sixty-two nursing students and 160 doctors of pharmacy students were participated and lled the web survey. The total number who participated in the study was 402 undergraduate students. Data collection began in April 2020 and closed in June 2020.

Data Collection
The web survey included two sections: rst, undergraduate students were requested to complete background information (see Table 1). The second part was based on a tool about DNR developed by Dunn (2000). This tool consisted of 25 statements (items), which were scored based on a ve-point Likert scale. Likert scale from 1 (not signi cant/probable) to 5(very substantial/likely) was used. This tool was subdivided into three categories: overall perception, expertise, and personal opinions about the issue of DNR. It was acquired from comparable research of nurses 'perception toward DNR order in Saudi Arabia; a Cronbach alpha of 0.82 con rmed the accuracy and suitability of this questionnaire for use in the current study context (Alfallahi, 2018).

Data Analysis
Social Sciences [SPSS], version 24 (S1 File), was used to conduct data analysis. Numbers, percentages, measures of central tendency, and ranges were used to represent descriptive data. Multiple regressions test was conducted to determine the predictors of attitude toward DNR in nursing and PharmD students.

Ethical Consideration
An ethical approval was given from Jordan University of Science and Technology IRB (2020243). The research was carried out while adhering to the national and international empirical research guidelines and regulations. All nursing and doctors of pharmacy undergraduate students were E-mailed information regarding the study, including the web survey link. Respondents agreed that the ndings be published in a scienti c journal when they responded to the survey. The survey did not ask questions deemed sensitive or inappropriate. Signi cance and probability results-Elements of the process of DNR decision, table 2 show the undergraduate students' responses regarding DNR.

Demographic Characteristics
Total of 402 nursing and PharmD students participated in the study include 242 nursing students and 160 doctors of pharmacy students. Students from both gender participated in this study male 90 (22.4%) and female 312 (77.6% ). Demographic characteristics of the study participants are shown in Table 1.

Perceptions toward DNR amongNursing and PharmD Students
Attitude toward DNR among nursing and doctor of nursing students was satisfactory (M= 69.9, SD=10.3). Many students respond to the following question correctly "DNR orders for terminally ill children help keep patients from suffering unnecessarily (M=3.99, SD=5.7) and " The patient or the patient's family must give written permission in orders for the physician to initiate DNR orders for terminally ill children. (

Discussion
This study is the rst to investigate the attitude of Jordanian nursing and PharmD students toward DNR orders for terminally ill children. The ndings indicate that, despite favorable perspectives on a few elements, Jordanian nursing and PharmD students retain a pessimistic attitude for "DNR orders for terminally ill children" in various important elements on the "attitude on the DNR" survey. In a systematic literature review study, only a few studies have investigated the perspectives of students regarding 'DNR orders for terminally ill children or adult. In a study, Al-Mobeireek revealed, recommendation of DNR for healthy adult patients were made by just 16% of Saudi physicians. [23] Another study by Iyilikci found that 66% of anesthesiologists in turkey had ordered written/oral 'DNR orders for terminally ill children.' [24] Further research performed by Varon in Singapore observed some misconception regarding 'DNR orders for terminally ill children' in healthcare service providers. [25] These ndings show that the DNR implementation differs based on the Muslim healthcare service providers from one country to another.
Moreover, the response of children show that many students answered I would like to know more about patient's rights and their religious beliefs greatly in uence their attitude toward DNR (2.63, SD= 1.12). Our literature, show no prior studies investigating the perception toward DNR orders for terminally ill children in Jordanian nursing and PharmD students. It's noteworthy, in few studies, medical students and nurses [26,27] attitude on euthanasia were analyzed. In Moghadas [26] and Rastegari-Najafabadi [27] found that almost 50 % nurses in Iran accepted the practice of euthanasia during surgery. In another observation study found 50% medical scholars in Iran described encouraging opinion in the use of euthanasia. [28] previous literature can be compared to our study since most undergraduate students from the same religion. Followed by every Islamic sects, any kind of euthanasia are not allowed. [29] But "DNR orders for terminally ill children" are not going against the fundamental regulations Islamic. [30] Islam assumes life as sacred [30] while comprehends death to be unavoidable aspect of life. [20] Muslims acknowledges death is authorized by God.
[31] Thus,, treatments are not implied when they just prolong the sufferings of terminal sickness. [30] Removing life-enduring remedies in that situation may appear to allow death to make its natural approach.
[31] Hence, the pessimistic impression of Jordanian nursing and PharmD students over "DNR orders for terminally ill children" is not explained in contrast of religious principle. It's noteworthy that undergraduate students' are showing favorable opinion to additionally understand distinct characteristics of DNR orders for terminally ill children. On the other hand, many undergraduate students revealed that their strict religious convictions greatly impact their attitude toward DNR. One main explanation of the pessimistic approach on "DNR orders for terminally ill children" might arise from absence of deep understanding over DNR orders for terminally ill children. The same way earlier studies indicated that nursing and PharmD students have limited information about many ethical dilemmas. [32]. Though many differences in point of view is observed between Muslims, the perspectives on death remained the same. [30] Multiple regression tests conducted in the current study to understand the impact of nurses' demographic characteristics on their perceptions of DNR orders for terminally ill children showed that these characteristics were not linked substantially to the nursing and PharmD students' attitudes toward the DNR issue. However, this nding is in contrast to a prior study, which revealed that religious convictions signi cantly affect more than 70% of the undergraduate students concerning their opinion of DNR orders for terminally ill children [34]. Nevertheless, the nding of the current study does correspond with the outcomes of several studies in this area [34-36}. The current study revealed that religion had no role in the perception of DNR because nurses from different religions participated. Further clari cation of the religion plays role as a signi cant part in life. In many ways, spiritual and religious problem is generally awakened or worsened for dying patients [34]. Many researchers and investigators have examined the in uence of religion and culture to ensure an appropriate end to life (Puchalski & Romer, 2000; Astrow, Puchalski, & Sulmasy, 2001). Furthermore, consideration of the impact of cultural and faith on the attitude and posture of nursing and PharmD students should be an essential part of any strategy that is developed to aid patients when it's a life and death situation (Blackhall, Frank, Murphy, Michel, & Palmer, 1999). Based on our results, gender did not signi cantly in uence the DNR decision. However, there is a need for more research to substantiate this claim.

DNR related Ethics
Ethical reasoning and justi cation of the do-not-resuscitate (DNR) order in critically ill patients with prolonged suffering should be based on the clinical reality, patient preferences, quality-of-life considerations, and the likelihood of surviving cardiopulmonary resuscitation (CPR). Physicians use their knowledge and skills to make reasonable actions to optimize patients' health outcomes in accordance with professional judgment. Physicians are also obligated to provide care for patients and make all necessary efforts to provide life support and symptom management at the end of life. However, when the potential bene ts of resuscitation are low and a high risk of death is consistently predicted by physicians, hard decisions to stop life-prolonging treatments could be emotionally stimulating for patients and their families, which create intriguing and challenging ethical dilemmas in DNR practices. When curative care and technological interventions are not feasible or unlikely to bene t the patient, the goal of DNR at the end of life is to provide comfort to the patients. Although physicians are cognizant about factors that in uence the goal of medical care, yet medical decision-making regarding resuscitation must be made promptly based on the potential bene ts and risks of resuscitation. Further, studies showed that survival rates for patients had CPR was unpredictable due to several in uencing factors such as age, comorbidities, presence of early de brillation, and cardiac activity. Accordingly, the American Heart Association Guidelines recommend resuscitation for all patients unless they signed DNR orders and expressed clear signs of death. Despite resuscitation is associated with a low success rate of survival and subnormal levels of function, many physicians opt to resuscitate to avoid litigation or criticism, which might result into overwhelming nancial issues, excessive resource utilization, and suboptimal quality of life [37].
Studies revealed that the lack of public knowledge regarding CPR led to inaccurate beliefs and over-expectation regarding the outcomes and the success rate of CPR, which might have in uence patients' inclinations to DNR orders. As CPR may only prolong the dying process accompanied by adverse health sequences that might extend the length of hospital stay, DNR can be ethically acceptable, especially when death is welcome by the patient as a natural process of life. Since physicians are portioned to communicate with patients and families about end-of-life care and some hard decisions to make with a great focus on patients' preferences and autonomy, they may be aware of the emotional pressure they may exert on patients and family members when assisting with communication about DNR orders, although it could be justi ed, potentially helpful, and aligned with autonomy preferences of patients [38]. Without prior singed DNR orders, the role of physicians can be more complex. One of the big ethical challenges of end-of-life care is withholding and withdrawing care that is unlikely to provide physiological bene ts for patients. Thus, standards for excellent care should be established to respect the autonomy of patients at the end of life, which in turn can help physicians make effective decision-making without being hesitant from providing care for desperately ill patients [38,39]. Education of patients regarding DNR orders that might be considered near the end of life and how likely resuscitation attempts can bene t those patients and whether these orders comply with patients' values, beliefs, and the goals of receiving treatment, are essential to improving their decision-making and enhance physicians' aptitudes to deal with patients' needs.

Implications for practice
The outcomes of this research have suggestions for real life exercises. Results showed that Jordanian nursing and PharmD students have a negative attitude toward many key aspects of DNR orders for terminally ill children.
This means that Jordanian nursing and PharmD students are one of the obstacles to legalized DNR orders for terminally ill children. Besides, this study shows that Jordanian nursing and PharmD students are willing to learn more about different aspects of DNR orders for terminally ill children and analyzing their responses to many items showed their misconception about DNR orders for terminally ill children. So, it is important to provide education programs during studying program about DNR or other ethical issues face nursing and PharmD students. Also, Addition of such courses in educational curriculums of Baccalaureate nursing students will be bene cial. According to the study outcome, the attitude of Jordanian nursing and PharmD students about DNR orders for terminally ill children may change by such education.

Conclusion
. A non-Western nation adds to knowledge as it extends our understanding of this particular subject in another context. The ndings of the current study suggest that further consideration should be given to the effect of religious and cultural issues on nursing and PharmD students' perceptions toward the DNR. This study shows that Jordanian nursing and PharmD students are willing to learn more about different aspects of DNR orders for terminally ill children and analyzing their responses to many items showed their misconception about DNR orders for terminally ill children. Consent to publish: We gave the right to BMC Palliative Care to publish Availability of data and materials: data will be sent upon request Competing interests: no con ict of interest for any author in this paper Funding Section: This project was carried out as part of "The Research Ethics Education Program in Jordan" and has been supported by NIH grant number (1R25TW010026-01). The funder support data collection and fees for publication.

Declarations
All authors have read and approved the manuscript", and ensure that this is the case.