Perceptions, knowledge, and attitudes toward do-not-resuscitate (DNR) and do-not-intubate (DNI) orders among caregivers of cancer patients in Lebanon: A cross-sectional study.

Abstract

284 Background: DNR/DNI orders are central to end-of-life (EOL) planning but remain underutilized in the Middle East due to cultural, religious, and systemic barriers. Data from Lebanon and the Arab world are scarce. We assessed DNR/DNI perceptions, knowledge, and attitudes among cancer-patient caregivers at a Lebanese tertiary oncology center. Methods: We surveyed 434 caregivers of cancer patients at the American University of Beirut Medical Center using a 5-point Likert-scale questionnaire assessing attitudes toward DNR/DNI, preferred timing of discussions, perceived barriers, and self-reported understanding. Primary outcomes were (1) adequate understanding of DNR/DNI and (2) positive attitude toward their use. Multivariable logistic regression identified predictors of each, adjusting for age, sex, education, religion, and prior exposure to code-status discussions. Results: Caregivers were predominantly female (62.4%), Lebanese (86.4%), and postgraduate-educated (66.4%). Knowledge was limited: 39.9% had never heard of DNR/DNI, 28.3% remained unclear, and only 31.8% had a good/clear understanding. Only 26.3% had been approached about code status. Positive attitudes toward DNR/DNI were modest, with <44% agreeing on any positive statement (see Table). Cultural and emotional barriers were prominent: 48.7% reported that cultural factors complicate DNR/DNI decisions, 60.8% feared patient abandonment, and 48.0% believed DNR/DNI may alter care level. Caregivers preferred "Allow Natural Death" (45.6%) over "DNR/DNI" (23.3%) and favored a shared patient-and-family decision-making (57.6%). For timing, 58.3% preferred discussion during disease progression vs 41.0% at diagnosis. Prior code-status discussion was the strongest predictor of good understanding (OR 3.48, 95% CI 1.98–6.13, p<0.001). Lower cultural barrier scores were independently predicted more positive attitudes (OR 1.27, 95% CI 1.06–1.52, p=0.009). Conclusions: Caregiver knowledge of DNR/DNI in Lebanon is limited, and EOL discussions are rarely initiated. Limitations include self-reported knowledge assessment and a single-center design. Prior code-status discussion improves understanding, underscoring the need for structured, culturally sensitive EOL communication programs in Middle Eastern oncology settings. Attitudes of caregivers towards DNR/DNI. Attitude Statement Agree/Strongly Agree DNR/DNI necessary for terminal-stage patients 37.8% DNR/DNI protects from unnecessary suffering 41.7% DNR/DNI is morally acceptable 39.2% DNR/DNI is religiously acceptable 22.9% DNR/DNI maintains human dignity 35.7% DNR/DNI helps determine resuscitation plan 43.4% Fear of abandoning patient with DNR/DNI 60.8% Fear that DNR/DNI changes level of care 48.0% Culture makes DNR/DNI choice hard 48.7%