This study is the first to investigate the attitude of Jordanian nursing and pharmD students toward DNR orders for terminally ill children. The findings 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 few studies have investigated the perspectives of students regarding ‘DNR orders for terminally ill children or adult. In one study, Al- Mobeireek revealed recommendation of DNR for healthy adult patients were made by only 16% of Saudi physicians . Another study by Iyilikci found that 66% of anesthesiologists in turkey had ordered written/oral 'DNR orders for terminally ill children . Further research performed by Varon in Singapore observed some misconception regarding 'DNR orders for terminally ill children' among healthcare care providers . These findings show that the implementation of DNR 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” where their religious beliefs greatly influence their attitude toward DNR (2.63, SD= 1.12). Literature search showed no prior studies investigating the perception toward DNR orders for terminally ill children in Jordanian nursing and pharmD students. It is noteworthy that in few studies, medical students and nurses’ attitudes toward euthanasia were analyzed [26,27]. Moghadas et al  and Rastegari-Najafabadi et al  found that almost 50% nurses in Iran accepted the practice of euthanasia during surgery. In another observation study, it was found that 50% of medical scholars in Iran described encouraging opinion toward the use of euthanasia . Previous literature can be compared to the current study since most undergraduate students were from the same religion. Followed by every Islamic sects, any kind of euthanasia are not allowed . But "DNR orders for terminally ill children" are not going against the fundamental Islamic regulations . Islam assumes life as sacred  while comprehends death to be unavoidable aspect of life . Muslims acknowledges death is authorized by God . Thus, treatments are not implied when they just prolong the sufferings of terminal sickness . Removing life-enduring remedies in that situation may appear to allow death to make its natural approach . Hence, the pessimistic impression of Jordanian nursing and pharmD students over "DNR orders for terminally ill children" is not explained with their religious principles and affiliations. It is 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 . Though many differences in point of view is observed between Muslims, the perspectives on death remains the same .
The multiple regression analysis was conducted in the current study to understand the impact of demographic characteristics nursing and pharmD students on their perceptions toward DNR orders for terminally ill children. It was shown that these characteristics were not linked substantially to the nursing and pharmD students ' attitudes toward the DNR issue. However, this finding contrasts with a prior study, which revealed that religious convictions significantly affect more than 70% of the undergraduate students concerning their opinion of DNR orders for terminally ill children . Nevertheless, the finding of the current study corresponds with the outcomes of several other studies in this area [34-36]. In many ways, spiritual and religious problem is generally awakened or worsened for dying patients . Many researchers have examined the influence of religion, ethics, and culture to ensure an appropriate end to life [35, 36]. Furthermore, consideration of the impact of culture and faith on the attitude and posture of future healthcare providers should be an essential part of any strategy to be developed to aid patients when it's a life and death situation . According to previous studies, ethical reasoning, and justification of 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). Healthcare providers use their knowledge and skills to make reasonable actions to optimize patients’ health outcomes in accordance with professional judgment. The DNR can be ethically acceptable, especially when death is welcome by the patient as a natural process of life. Since healthcare providers are portioned to communicate with patients and families about end-of-life care and the 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 . 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 benefits 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]. Based on current results, gender did not significantly influence the DNR decision. However, there is a need for more research to substantiate this claim.
Implications for practice
The outcomes of this research have suggestions for real life exercises and could be generalized to all students in developing countries with similar situations. Results showed that Jordanian nursing and pharmD students had a negative attitude toward many key aspects of DNR orders for terminally ill children. This means that Jordanian nursing and pharmD students could be opposing any legalization of DNR orders for terminally ill children. Besides, this study shows that Jordanian nursing and pharmD students were willing to learn more about different aspects of DNR orders for terminally ill children. By analyzing their responses to multiple items, misconception about DNR orders for terminally ill children was apparent. Therefore, it is important to provide education programs about DNR for those students during their study and to integrate DNR within courses in the undergraduate curricula of in nursing and PharmD. 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.