Knowledge and Attitude of the General Population About Do Not Resuscitate (DNR) in the Western Region, Saudi Arabia

Background: A do-not-resuscitate (DNR) order is a medical order issued by a doctor. It directs medical professionals to refrain from performing cardiopulmonary resuscitation (CPR) if a patient's breathing or heartbeat ceases. Patients can refuse CPR in an emergency if they have a DNR order. The DNR order includes precise directives about CPR. Instructions for extra therapies like nourishment, other drugs, or painkillers are not included. Aim: The aim of the study is to learn more about the western region's general population's knowledge and attitudes toward DNR orders and identify any challenges that may arise when dealing with DNR patients. Methodology: A cross-sectional study was conducted in 2023 in the western region of Saudi Arabia. An online, self-administered questionnaire was distributed randomly from April 8, 2023 to June 6, 2023. The estimated sample size was 384, and 604 were the collected responses. Results: A total of 383 (63.4%) participants were females, and 221 (36.6%) were males. Regarding the knowledge and attitude of the general population about DNR orders in the western region of Saudi Arabia, 276 (45.7%) study participants had satisfactory knowledge and awareness, while 328 (54.3%) had inadequate knowledge. A total of 343 (56.8%) participants thought that DNR is important; 255 (42.2%) felt that the DNR has reduced the pain of their relatives, and 181 (30%) believed that it has reduced the stress felt by the patient’s families. Of participants aged 20-30 years, 58.4% had satisfactory knowledge about DNR orders compared with those aged 50 and above; 76.1% of healthcare workers had satisfactory knowledge versus 26.5% of unemployed participants (P=.001). Conclusion: We recommend increasing awareness and knowledge about DNR by conducting educational events about the concept and how to deal with patients who choose to acquire a DNR order.


Introduction
When a patient experiences cardiac arrest, cardiopulmonary resuscitation (CPR), an emergency technique, is performed to save the patient's life [1]. Even when CPR resumes a patient's heartbeat or breathing, only a small percentage of patients fully recover. They might still require additional medical care, be critically ill, and never fully recover from their previous state of health. In addition, long-term damage to their brain or heart is possible. Do-not-resuscitate (DNR) forms are created for this reason. They indicate that patients will not receive any intervention that could prolong their lives or cause them to suffer [2]. A doctor issues a DNR order. If a patient's heartbeat or breathing stops, it instructs medical professionals not to perform CPR [3]. When it is anticipated that the patient will likely have a poor outcome, may not survive with CPR, or may survive with low function and quality of life after, medical professionals may occasionally recommend a DNR order [4]. A DNR is a predetermined order for patients to refuse CPR in an emergency. A DNR order includes precise directives about CPR. Instructions for other therapies like nourishment, drugs, or painkillers are not included. The patient, the proxy, or the patient's family are consulted before the doctor issues the DNR order [3]. The DNR decisions, based on various factors, including patient and relative preferences, ethical and legal issues, and the patient's state, have been the subject of numerous studies [5]. A study conducted in 2012 to assess the patient's comprehension of DNR orders reported that of 429 patients, 84% had heard of the term DNR, and 56% thought the initial DNR discussions should occur when they were still in good health [6]. Moreover, according to an interventional study conducted in Switzerland, patients' understanding of DNR was drastically enhanced after being provided information on new DNR orders' implementation and the DNR code of ethics [7]. Another study in Riyadh, Saudi Arabia, on 307 patients demonstrated that three-fourths of the participants were aware of the DNR order, 50% of whom correctly defined it. Additionally, 90% preferred discussing DNR when ill [8]. Further, a study evaluating the DNR order by interviewing 97 patients noted that 66% preferred sharing the decision with their family or doctor, and 58% had already discussed resuscitation with their physician [9]. The general population should be informed about DNR terminology. In this situation, the study aims to learn more about the general population's knowledge and attitudes toward DNR orders in the western region and identify any challenges that may arise when engaging with patients with a DNR order.

Study design
A cross-sectional study was conducted in 2023 in Jeddah, Saudi Arabia. An online, self-administered questionnaire was distributed randomly from April 8 to June 6, 2023, to assess the general population's knowledge and attitude about a DNR order in the western region of Saudi Arabia.

Inclusion and exclusion criteria
The study included male and female subjects aged 18 and older who live in the western region of Saudi Arabia and excluded children under 18 years of age and those who are intellectually disabled.

Sample size and sampling procedure
The estimated population of the western region of Saudi Arabia is 11.27 million [10]. We used the public service of Creative Research Systems survey software to determine the precise population target of the sample size. This study's estimated sample size was 384 participants with a 95% confidence interval and a 5% margin of error; a p-value of less than 0.05 would be considered significant.

Questionnaire
An online, self-administered questionnaire was distributed randomly among people living in the western region of Saudi Arabia [4]. The questionnaire is divided into three sections: The first section contains consent and demographic information, and the second evaluates DNR knowledge. The third section assesses attitudes toward DNR orders.

Data collection and analysis
Data entry and statistical analysis were performed using IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. Descriptive statistics were applied in the form of tables and graphs, as appropriate. The chi-square test was used to highlight factors associated with study participants' knowledge of DNR. Statistical significance was set at p<0.05.

Data analysis
The data were collected, reviewed, and fed into IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. All statistical methods used were two-tailed tests, with an alpha level of 0.05 considered significant if the p-value is less than or equal to 0.05. The overall level of knowledge regarding DNR orders was determined by summing up discrete scores for different correct and appropriate knowledge items. The overall knowledge score was categorized as unsatisfactory if the participants' score was less than 60% of the correct items and satisfactory if the overall score was 60% or more. Descriptive analysis was performed by prescribing frequency distributions and percentages for study variables, including participants' personal data, education, and employment. Also, knowledge regarding DNR orders was tabulated, while overall knowledge of their source of information was graphed. Cross tabulation to record factors associated with study participants' knowledge of DNR orders was conducted with a Pearson chisquare test for significance and an exact probability test if there were small frequency distributions.

Results
A total of 604 participants eligible for this study completed the study questionnaire. Participants ranged from 18 to above 50 years old, with a mean age of 27.9 ± 12.7 years old. A total of 383 (63.4%) participants were female, and 588 (97.4%) were Saudi. As for employment, 276 (45.7%) were students, 214 (35.4%) were non-healthcare staff, and 46 (7.6%) were healthcare staff. There were 458 (75.8%) university graduates, while 118 (19.5%) had a secondary level of education, and 28 (4.6%) had a lower education level ( Table 1).

in the Eastern Region, Saudi Arabia
Overall knowledge and awareness of the general population is shown in Figure 1. Of the respondents, 276 (45.7%) displayed satisfactory knowledge and awareness about DNR orders, while 328 (54.3%) had unsatisfactory knowledge.

FIGURE 2: Source of information regarding Do Not Resuscitate (DNR) among study participants
A total of 56.8% of participants thought that DNR orders were important: 42.2% felt that DNR orders reduced pain, and 30% believed they would reduce the stress faced by the patient's family ( Table 3).

Discussion
In this study, we attempted to evaluate awareness, knowledge, and attitudes about DNR orders and identify challenges that may arise when treating patients with a DNR order in place.
To our knowledge, no previous study in this region has reviewed a similar subject.
There were 604 participants in the study. The results indicate that most participants had never heard of DNR (65.7%) and could not identify the correct definition (39.7%). In a previous Saudi study report from Jeddah, it was discovered that there was poor knowledge and understanding of resuscitation [11]. This agreed with the study's findings.
The sources of information reported by the study participants indicated that 27.6% received their information from social media applications, considered the least reliable sources of information. A study in Jeddah reported that 34.3% of participants had heard the term DNR on social media [12], supporting our results. Most participants strongly agreed that patients should be included in decision-making, whereas 31% chose parents as decision-makers. According to a study in Hong Kong, most participants believed that the patient's preferences should come first when making a DNR choice, followed by the family's wishes and then the patient's social status [13]. When asked to define DNR correctly, approximately 22.5% of the participants selected "Medical order written by a doctor. It instructs healthcare providers not to do CPR." Research from Riyadh, Saudi Arabia, supports our findings, revealing that 44.0% of participants had a similar opinion about a DNR order [14]. In this study, regarding conditions where a DNR order was obtained, we discovered that more than half of our participants selected the option indicating that a patient's condition was not suited for resuscitation. Compared to the research in the Aseer region, they observed that 42.58% of their participants chose the same reason. Also, we discovered that 42.5% of our participants chose the following conditions to consider a DNR order: if a patient's disease is incurable, not treatable, or death occurs; in the Aseer region study, 6.69% of their participants opted for the same reason [4].
In our research, we discovered that 56.8% of the participants believed a DNR order was important; this was corroborated by a study in the Aseer region of Saudi Arabia, which concluded that more than half of the participants believed a DNR order was important. However, we observed that less than half of our participants believed that DNR reduces pain; in contrast, more than half of the participants in the Aseer region study agreed with it. Lastly, fewer than half of our participants believed that implementing a DNR order would ease the strain on the patient's family; in contrast, the Aseer region study had more than half of their participants believe that [4]. The study illustrated that 53% of the participants didn't consider a DNR order as an option for their relatives, and only 20.7% were willing to agree. Only 10.7% (63 of the 604 participants) had a DNR order in place for a relative; 74.6% had procured a DNR order for a relative in the past five years, and most participants (60.3%) felt sad about that decision. Some participants (15.9%) felt relieved for their relatives by ending their suffering. The study also highlighted that most of our participants belonged to the age group of 20-30 years; it revealed that 58.4% of the participants, which is the majority, had good awareness levels of DNR. It also showed that the health workers are more familiar with, understand more, and are better educated about DNR orders by 76.1% compared to the unemployed. Mainly satisfactory knowledge came from TV (68.6%), in contrast to the information from the radio, where only 38.5% of them were satisfied. Additionally, most of the participants with a DNR order for a relative were able to define and understand DNR better by 54% than those who didn't. And in general, despite the difference between the sample size in our study and the study in Vancouver, the results on average and percentage differ vastly; the percentage of satisfying knowledge also has a huge variation [6].

Limitations
Limited validation was conducted on our survey instrument. It is possible that a large percentage of respondents misidentified the term DNR due to the way the question was worded rather than a lack of knowledge. It was a small study; thus, the findings could not be generalized to populations in suburban, rural, and other areas. Religion and education weren't investigated in this study, which may be significant factors in patients' attitudes regarding this topic.

Conclusions
Of the people living in the western region of Saudi Arabia, 45.7% have good knowledge and awareness about DNR orders, while 45.3% have poor knowledge and awareness. We recommend increasing awareness and knowledge about DNR orders by conducting educational events about the approach to DNR and how to engage with patients who opt for a DNR order.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Umm Al-Qura University issued approval HAPO-02-K-012-2023-04-1566. The present study adhered to strict ethical standards and obtained approval from the Research and Ethics Committee ofUmm Al-Qura University , Makka, Saudi Arabia (approval number: HAPO-02-K-012-2023-04-1566). . Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.