Critical care nurses ' knowledge and attitudes regarding the " Do Not Resuscitate ( DNR ) status "

Background: Patients in the critical care unit (CCU) are, by definition, the sickest patients in acute care hospitals and face higher risk of death than any other hospital population and usually require advanced life support such as mechanical ventilation, inotropes, or dialysis. Since every day critical care nurses encounter death and dying in the critical care units, Nurses are vital to end-of-life care as they are the ones present at the bedside, they have an opportunity to observe behaviours and actions that are barriers to a peaceful and dignified death while they provide end-of-life care. Do-notresuscitate orders (DNR) are used in many countries to limit the use of cardiopulmonary resuscitation (CPR) in certain situations. There is still a continuing debate about the ethics, legalities and the appropriate medical indications for use of DNR. The status of DNR can raise many issues for nurses, including ethical dilemmas, conflict, and power struggles among members of the health care team. Objective: This study was carried out to describe critical care nurses' knowledge and attitudes regarding the Do not resuscitate (DNR) status in Critical Care Units. A descriptive design was used was conducted in the critical care units of Alexandria Main University Hospital, namely the: Casualty Care Unit (Unit I), General intensive Care Unit (Unit III), Chest intensive Care Unit, Coronary care unit, Neurosurgery intensive Care Unit, Triage and the Burn intensive care unit. Methods: A convenient sample consisting of one hundred and forty (140) critical care nurses working in the previously mentioned intensive care units were included. They were interviewed by using knowledge and attitudes regarding do not resuscitate (DNR) status structured interview schedule. Results: The majority of critical care nurses have knowledge about DNR status regarding the following: the meaning of DNR as withholding CPR, provided care as administering oxygen, the medical management as defibrillation / cardioversion and documentation. Regarding critical care nurses’ attitudes towards DNR status, most of them were of the opinion of continuing monitoring patients' vital signs, providing care as suctioning artificial airway. Conclusions: Clear policy and documentation for DNR status are suggested to reduce confusion and promoting nurses’ involvement in decision making process of DNR and improving nursing practice. INTRODUCTION Critical care units (CCUs) are designed primarily to save the lives of the people who are critically ill and /or dependent on life sustaining support, or who are at risk of 529 Bull High Inst Public Health Vol.40 No.3 [2010] life-threatening problems and therefore in needs of continuous intensive monitoring.(1,2) According to the American Association of critical care nurses, critically ill patients are defined as those patients who are at high risk for actual or potential life-threatening health problems. The more critically ill the patient is, the more likely he or she is to be highly vulnerable, unstable and complex, thereby requiring intense and vigilant nursing care.(3) Patients in the critical care unit (CCU) are, by definition, the sickest patients in acute care hospitals and face higher risk of death than any other hospital population and usually require advanced life support such as mechanical ventilation, inotropes, or dialysis.(4) Since every day critical care nurses encounter death and dying in the critical care units, nurses are vital to endof-life care as they are the ones present at the bedside. They have an opportunity to observe behaviours and actions that are barriers to a peaceful and dignified death while they provide end-of-life care.(5) Endof-life care is the care provided to people in their final stages of life.(6) It is emerging as a comprehensive area of expertise in the CCU and demands the same high level of knowledge and competence as all other areas of CCU practices.(7) The goal of end-of-life care is to maintain the comfort, choices, and quality of life of a person who is recognized to be dying (in the terminal phase), to support their individuality, and to care for the psychosocial and spiritual needs of themselves and their families. End of life care also aims to reduce inappropriate and burdensome healthcare interventions (8,9). As nursing has progressed as a profession, the level of nurses' input into decision making has slowly increased. Although the medical profession continues to be legally responsible for medical diagnosis and ordering most therapeutic measures, nurses have attempted to differentiate their own roles by rejecting


INTRODUCTION
Critical care units (CCUs) are designed primarily to save the lives of the people who are critically ill and /or dependent on life sustaining support, or who are at risk of Bull High Inst Public Health Vol.40 No.3 [2010]   life-threatening problems and therefore in needs of continuous intensive monitoring. (1,2)cording to the American Association of critical care nurses, critically ill patients are defined as those patients who are at high risk for actual or potential life-threatening health problems.The more critically ill the patient is, the more likely he or she is to be highly vulnerable, unstable and complex, thereby requiring intense and vigilant nursing care. (3)tients in the critical care unit (CCU) are, by definition, the sickest patients in acute care hospitals and face higher risk of death than any other hospital population and usually require advanced life support such as mechanical ventilation, inotropes, or dialysis. (4)Since every day critical care nurses encounter death and dying in the critical care units, nurses are vital to endof-life care as they are the ones present at the bedside.They have an opportunity to observe behaviours and actions that are barriers to a peaceful and dignified death while they provide end-of-life care. (5)Endof-life care is the care provided to people in their final stages of life. (6)It is emerging as a comprehensive area of expertise in the CCU and demands the same high level of knowledge and competence as all other areas of CCU practices. (7)e goal of end-of-life care is to maintain the comfort, choices, and quality of life of a person who is recognized to be dying (in the terminal phase), to support their individuality, and to care for the psychosocial and spiritual needs of themselves and their families.End of life care also aims to reduce inappropriate and burdensome healthcare interventions (8,9) .As nursing has progressed as a profession, the level of nurses' input into decision making has slowly increased.
Although the medical profession continues to be legally responsible for medical nurses gain autonomy and move to a more professional status, nursing roles are expanded and their responsibilities have increased. (5,10)Such role expansion occurred as a result of advances in treatment, devices and technology in CCUs.nd-of-life decision making is the process that healthcare providers, patients, and patients' families go through when considering what treatments will or will not be used to treat a life-threatening illness.
Several forms of this decision making are possible.Among these are advance directives (i.e, living wills and/or durable power of attorney for healthcare) which provide an opportunity for patients to express their preferences in writing before a critical illness occurs. (13)vance directives (ADs) are widely regarded as the best available mechanism to ensure that patients' wishes about medical treatment at the end of life are respected.Patients who had such a directive were significantly more likely to have a do-not-resuscitate (DNR) order. (14- 15) nother common form of end-of life decision making centers on resuscitative efforts.These decisions may result in DNR orders.A third form of end-of-life decision making is withholding or withdrawing lifesustaining therapies, such as antibiotic therapy, use of vasopressors, dialysis, administration of fluids and nutritional feedings, and mechanical ventilation.
6) Cardiopulmonary resuscitation consists of measures undertaken by nurses, medical staff or other skilled practitioners in the event of either a respiratory or a Bull High Inst Public Health Vol.40 No.3 [2010]   cardiac arrest.Nurses have two roles: to provide basic life support as a holding measure to ensure adequate circulation and perfusion of vital organs and to participate in or initiate advanced cardiac life support (ACLS).ACLS requires the ability to manage the patient's airway, initiate intravenous access, read and interpret electrocardiograms, and deliver emergency pharmacology that aims to treat or reverse the cause of the arrest. (17)rdiopulmonary resuscitation was originally designed to save patients who suffered an unexpected cardiac or respiratory arrest, and do-not-resuscitate orders were designed to ease the dying of the terminally ill. (18)With advances in health care technology, nurses have become increasingly involved in the care of patients with a do not resuscitate (DNR) order.A trend in the increase in and wider application of DNR Status has become evident. (19)Strictly defined, DNR is the decision to forgo cardiopulmonary resuscitation (CPR) and was formally introduced as an option for end-of-life care in the early 1970s. (20)atients with Do-Not resuscitate (DNR) orders are very likely to die in the hospital.
A DNR order is an excellent marker for identifying inpatients at the very end of life, and studying such patients provides an excellent opportunity to learn about the quality of end-of-life care in the hospital. (23)-not-resuscitate orders (DNR) are used in many countries to limit the use of cardiopulmonary resuscitation (CPR) in certain situations.There is still a continuing debate about the ethics, legalities and the appropriate medical indications for use of DNR. (24)The status of DNR can raise many issues for nurses, including ethical Tools: Two tools were used in this study.

METHODS
A permission to conduct the study was obtained from Alexandria Main University hospital administrative authorities after explanation of the aim of the study.

Statistical analysis
The raw data were coded and transformed into coding sheets.The results were checked.Then, the data were entered into SPSS system files (SPSS package version 11) using personal computer.Output drafts were checked against the revised coded data for typing and spelling mistakes.Finally, analysis and interpretation of data were conducted.
The following statistical measures were used: • Descriptive statistics including frequency, distribution, were used to describe different characteristics.------------------- involves disagreement regarding the aggressiveness of care for patients once DNR status has been designated. (21)e do-not-resuscitate order can invoke strong emotion among patients and health care providers, yet this order and its implications are often poorly understood.However, these findings are in opposition with those of others who found that only one forth of nurses were able to correctly identify DNR as ''withholding CPR only" (21) Critical care nurses in the current study emphasized that DNR doesn't mean withholding treatment.This is supported by.sabatino (2007) (23) who reported that DNR order doesn't mean "do not treat." Rather, it means that CPR only will not be performed.Other treatments such as administering antibiotic therapy and transfusions, performing dialysis, or the use of a ventilator that may prolong life can still be provided.Treatment that keeps the person free of pain and comfortable (called palliative care) should always be given.
Critical care nurses stated that DNR doesn't mean no care is provided.This is supported by others (24,25) who found that do not resuscitate order didn't not mean no care.who stated that the term DNR is status.This may be attributed to the fact that nurses would keep their patients comfortable and would not do anything to prolong their suffering.This finding is emphasized by Chen (2009). (27)who found that provided care to patient with DNR status should include: suctioning the airway, administering oxygen, positioning for comfort, splinting or immobilization, bleeding control, providing pain medication and providing emotional support.
In this respect, Dar al-lfta al-Misriyyah "fatwa council" has issued about taking terminally ill patients off life support machines under no 11 dated. (28)"It is permissible to take terminally ill patients off life support machines which sustain life without improving a patients' prognosis.
Such patients are declared 'clinically dead ' and are taken off life support only upon the recommendation of a physician.However, it is impermissible to take patients off machines that are for other purpose such as suction machines used to aspirate fluids to facilitate breathing " .

End-of-life decision making frequently occurs in the critical care unit (CCU).
There is a lack of information on how a do- cardioversion.This is may be attributed to the fact that cardiopulmonary resuscitation has been considered an unsuitable modality for patients with no hope of recovery.This result is supported by another study which revealed that DNR means that basic and advanced cardiopulmonary resuscitation will not be initiated in the event of cardiopulmonary arrest. (9)itical care and oncology nurses know that without a written DNR order, nursing staff are obliged to resuscitate the patient.
Critical care nurses reported that many factors are not included in the documentation of DNR order such as the causes, decision maker, participants, and consents of DNR which may be related to the risk of litigation.This is in opposition to findings which revealed that the majority of nurses considered that DNR order was documented in the medical notes, of nurses additionally it identified varying practices regarding the documentation of the rationale for the DNR decision; involvement of the patient and the next-of-kin in DNR decision-making. (30) this respect, palmer (2007) (34) added that documentation of DNR is essential in the progress notes and should include the following and be written or co-signed by the attending physician: the decision-making process which has been and will be followed, role of professional staff involvement, role of patient, family and other decision-makers, data on which decision is to be based.On the other hand, the majority of nurses in the current study reported that DNR order is only given orally and isn't written in the medical record.This is supported by another study finding which stated that verbal DNR permission was more popular in the clinical setting in Korean. (32)licies of DNR orders should be written, designed and implemented at the level of the institution.In the current study all nurses stated that the hospital doesn't Taha et al.,

552
have a written DNR policy and attributed this to the hospital system.These findings are in opposition with another study which revealed that more than half of nurses knew that they had a local DNR policy and that policies facilitate standardization of decisions and reduce controversy relating to DNR status which may improve nursing practice. (24)e end-of-life decision including DNR is made between the physician and a family member with verbal communication or written form when death is near or when an arrest occurs.The current study revealed that the physician is the responsible person for the designation of DNR status since the physician has the legal responsibility for making the decisions of diagnoses.This is in agreement with other findings which revealed that the physicians remain responsible for the ultimate DNR decision. (33)reover, the current study showed that nurses, patient and family aren't responsible for the designation of DNR status since patients are often critically ill, and have altered level of consciousness or intubated thus cannot express their concerns or desires.In addition to the fact that our culture doesn't support DNR decision.This is supported by Palmer (2007) (34) who found that although nurses regularly initiate resuscitation attempts; they are often not included in decisionmaking relating to resuscitation status and lack of involvement of patients and their families.However, this is in opposition to Gendt et al (2007) (22) who revealed that nurses were always consulted in DNR decision-making on a critical care unit because nurses' provide care for hospitalized patients on a daily basis and spend more time with them than physicians do.Moreover, they are mostly well informed about patients' total situation and preferences regarding the end of life.
Also (30)  is contradictory to others who reported that many nurses agreed with the discontinuation of these treatments. (35)reover, critical care nurses reported their agreement about the continuous monitoring of patients with DNR status for electrocardiograph ECG, as well as the administering of antibiotics, total parental nutrition and ventilatory support.This is in line with others who found that the majority of nurses disagreed with discontinuation of the following: fluid therapy; electrocardiographic monitoring; antibiotics; total parenteral nutrition; ventilatory support. (35)This may be attributed to the fact that critical care findings are also emphasized by state of (36) which revealed that provided care to patients with DNR status should include; suctioning the airway, administering oxygen, positioning for comfort, splinting or immobilization, bleeding control, providing pain medication and providing emotional support.
Critical care nurses rating of issues involving a lack of staff and resources is based on the recognition of patients' needs at the end-of-life for high levels of nursing care.Nearly half of critical care nurses reported their agreement that patients with DNR status require higher levels of nursing care.This is because patients with DNR orders would tend to receive more psychological and physical comfort support.
However, these findings stand in line with others who assessed the nursing workload associated with caring for 60 patients with do-not-resuscitate orders and found that this group of critically ill patients required higher levels of nursing care. Bull High Inst Public Health Vol.40 No.3 [2010]   Critical care nurses have observed patients' medical diagnoses influence a DNR status.This has been validated by many findings. (24)reporting that cancer, septic shock, renal insufficiency, multiple have the same level of education.This is in agreement with another study. (44)nally, do not resuscitate issue continues to be a complex problem faced by the health care team.There is no easy resolution to this dilemma.When nurses act as a patient advocate frequently they come into conflict with many institutional regulations and policies.This conflict does not release the nurse of the burden to act in a morally correct manner.The focus must remain on the patient and fulfilling their wishes.Thus, critical care nurses must continue to act as the patients' advocate and make his or her values heard.

Limitation of the study
The small sample size may decrease the generalizability of the study findings.given including instructions about how to deal with these issues.
• Providing in-service training programs for health care professionals; nurses, physicians regarding DNR status.
• Fostering nurses to attend workshops about DNR status important to clarify their further role in nursing care and decision-making process.
• Educating and encouraging physicians to communicate directly, in a more open manner, with each other and with nurses, patients, and patients' families are essential to care for patients with DNR status.

On administrative level
• Establish Clear policy for DNR status with responsible authority, which reflect the need for famly-oriented culture.
• DNR decisions should be recorded in the patients' medical notes.
diagnosis and ordering most therapeutic measures, nurses have attempted to differentiate their own roles by rejecting Taha et al., 530 medical diagnostic terminology and developing their own nursing diagnosis.As

Arabic, and tested
by seven experts (four from the Faculty of Nursing and three from the Faculty of Medicine of University of Alexandria) for content related validity and the necessary modifications were done accordingly (e.g.modifications related to Arabic translation).The tools were tested for its reliability using the test re-test reliability method after 20 days intervals for the same nurse on a sample of 20 subjects.This method provided the opportunity to compare the same measures obtained at different times on the same individual.The correlation coefficient was: -(r) = 0.83for subscale, Nurses' knowledge regarding the "Do not resuscitate (DNR) status".-(r) = 0.85 for subscale, Nurses' attitudes regarding the "Do not resuscitate (DNR) status" Informed consent was obtained from critical nurses to participate in the study after explanation of the study aim.The anonymity and confidentiality of nurses' responses and the right to refuse to participate in the study were emphasized to nurses.A pilot study was conducted on 7 nurses not included in the study to test the clarity and evaluate the feasibility and applicability of the tools, as well as to identify obstacles and problems that might be encountered during data collection and the necessary modifications were done accordingly.Each nurse was interviewed individually once by the researcher using the tools.Nurses were interviewed in the morning, afternoon, and at the beginning of the night shift during their break time.Each interview lasted from 20 to 30 minutes.Data collection took Bull High Inst Public Health Vol.40 No.3 [2010] approximately 3 months starting from the beginning of January to the end of March 2010.

DISCUSSION
Critical care units (CCU) are designed to provide essential therapies for critically ill patients in order to save patients' lives.Ideally, patients who are expected to die and who are unlikely to benefit from intensive therapies are not admitted to these units.Nurses commonly encounter ethical dilemmas surrounding issues of cardiopulmonary resuscitation (CPR) and do not attempt resuscitation (DNAR) decisions.Lack of consensus exists related to nurses' role in DNR decision making and their role in dealing with conflicts that arise once the decision for DNR has been made.A common conflict sometimes expanded or misapplied to include options that pertain to limiting the scope of resuscitative efforts or treatment modalities such as withholding feedings to the overuse of other treatment modalities such as morphine sulfate to decrease respiratory drive, according to the ordering and interpretation of DNR orders.The findings of the present study regarding the meaning of DNR status may be interpreted correctly by nurses who stated that the DNR orders indicate that no resuscitation Taha et al., 550 should be attempted in the event of cardiopulmonary arrest and applies only to the unresponsive, clinically pulseless patient.Critical care nurses believed that, providing care in the form of bleeding, administering oxygen, suctioning, caring of artificial airway (ETT), providing emotional support, positioning the patient and administering pain medications are considered important for patients with DNR nurses' believes that decisions about continuing medical therapies should be based on patients' rights as the right to live since nurses usually take the responsibility of serving as the patients advocate.Critical care nurses emphasized the importance of providing care to patients with DNR status in the form of suctioning artificial airway , administering oxygen, controlling bleeding, and changing position for comfort, performing chest physiotherapy, and immobilization.These Taha et al., 554 The sample is not large enough to allow correlation of study results based on variations in demographic data.Moreover, data were collected only from the University Hospital i.e. one sector of health care institutions and from one geographical area in Arabic Republic of Egypt (ARE) which may hinder the generalizability of the study findings.CONCLUSION AND RECOMMENDATIONS Based on the findings of the present study, it can be concluded that, the majority of critical care nurses have knowledge about DNR status regarding the following: the meaning of DNR as withholding CPR, provided care as administering oxygen, the medical management as defibrillation / cardioversion and documentation.Moreover, the responsible person for DNR decision making is the physician and not the nurse, patient or the family.Regarding critical care nurses attitudes towards DNR status, most of them were of the opinion of continuing monitoring patients' vital signs, providing care as suctioning artificial airway.As for the factors influencing a DNR status, the highest percent of nurses reported patients' functional status, next of kin or surrogate requests for DNR, length of hospital stay and the patients' medical diagnosis such as multiple organ-system failure.Also, the majority of critical care nurses felt frustrated when dealing with DNR patients.RECOMMENDATIONS Based on the findings of the current study, the following recommendations are suggested: On educational level • Educating undergraduate nursing students about the meaning of DNR and advance directives in lectures

"Critical care nurses' knowledge of DNR status"
written (medical condition of patient, DNR in medical record, causes of DNR) and DNR policy, decision making process done by ( physician, nurse, patient, family ).Items were rated on a two-point scale (Yes, No).

Distribution of nurses according to their knowledge of DNR status. Table 2-A: Frequency distribution of critical care nurses' in relation to their knowledge of the meaning of DNR status. Meaning of DNR Status
females and 11.4% were males.Regarding the type of CCU, the table reveals that 30% of critical care nurses were working in the general ICU, 17.2% in the burn ICU, 16.4 % in casualty ICU 10 % were working in coronary ICU, and 10.7% in neurosurgery and , the triage ICUS, respectively.Only 5% of the nurses were working in the chest ICU.Regarding nurses' experience in the CCU, it was found that nearly three quarters of the nurses had less than 10 years experience and only 6.4% of them had more than 19 years of for patients with a DNR status, while only 8.6% nurses had no previous experience.In relation to critical care nurses level of education.It can be seen that 62.1 % held a Baccalaureate degree, 15.7 % were graduates of the Concerning the courses attended by nurses, 61.4% of nurses attended all courses (nursing ethics, critical care nursing and, emergency nursing).Table (1): Characteristics of critical care nurses.Table 2-A shows the frequency distribution of critical care nurses' in relation to their knowledge of the meaning of DNR status.The majority of the nurses knew that DNR doesn't mean (withholding treatment (87.1%) or withdrawal of support (85.0%)).Eighty three point six percent of them knew that DNR doesn't mean "no care".Seventy Taha et al., Table 2-B shows the frequency distribution of critical care nurses' in relation to their knowledge of the provision of care.The majority of nurses knew that the provision of care is important for patients with DNR status such as controlling bleeding which was reported by 94.3%, oxygenation (93.6%) and suctioning artificial airway (90.7%).It can also be noted that more than 3 quarters of the