The State of the Do-Not-Resuscitate Order in a Pediatric Intensive Care Unit in the Middle East: A Retrospective Study

Abstract

Objectives The Do-Not-Resuscitate (DNR) order is part of most hospitals’ policies on the process of making and communicating decisions about a patient's resuscitation status. Yet it has not become a part of our society's ritual of dying in the Middle East especially among children. Given the diversity of pediatric patients, the DNR order continues to represent a challenge to all parties involved in the care of children including the medical team and the family. Methods This was a retrospective review of the medical charts of patients who had died in the pediatric intensive care unit (PICU) of a tertiary academic institution in Beirut, Lebanon within the period of January 2012 and December 2017. Results Eighty-two charts were extracted, 79 were included in the analysis. Three were excluded as one patient had died in the Emergency Department (ED) and 2 charts were incomplete. Most patients were male, Lebanese, and from Muslim families. These patients clinically presented with primary cardiac and oncological diseases or were admitted from the ED with respiratory distress or from the operating room for post-operative management. The primary cause of death was multiorgan failure and cardiac arrest. Only 34% of families had agreed to a DNR order prior to death and 10% suggested “soft” resuscitation. Most discussions were held in the presence of the parents, the PICU team and the patient's primary physician. Conclusions The DNR order presents one of the most difficult challenges for all care providers involved, especially within a culturally conservative setting such as Lebanon. As the numbers suggest, it is difficult for parents to reach the decision to completely withhold resuscitative measures for pediatric patients, instead opting for “soft” resuscitations like administering epinephrine without chest compressions.

What helps or hinders effective end-of-life care in adult intensive care units in Middle Eastern countries? A systematic review

“…Even in Saudi Arabia, where there has been significant progress in introducing palliative and end-of-life care in the health care system, specialist services are not widely available, public knowledge is limited, and there is a persistent focus on curative treatments [ 28 ]. There is little consensus on practice regarding dying patients in Middle Eastern countries, as religious and cultural values raise additional challenges to the implementation of EOL care, especially where this may entail a ‘Do not resuscitate’ (DNR) decision [ 29 , 30 ]. An assessment of knowledge, beliefs, obstacles, and resources available in the provision of palliative care services in fifteen Middle Eastern countries Silbermann et al [ 31 ] found that major barriers include lack of palliative care beds and services, training for healthcare providers, community awareness, access to hospice services, and insufficient time and personnel.…”