A cross-sectional study among healthcare and non-healthcare students in slovenia and croatia about do-not resuscitate decision-making

Our aim was to conduct a study among first-and final-year students from five different faculties at the University of Ljubljana, Slovenia, and the University of Zagreb, Croatia, using the questionnaire developed by Janiver et al. to find possible differences between variables, such as religious beliefs, gender and year of study, in do-not resuscitate decision-making related to patient’s best interest and autonomy (4, 11).

The hypothesis of the research was that there are differences among Croatian and Slovene students in do-not resuscitate decision-making in regard to the type of study, the year of the study, gender and religious beliefs.

We conducted a cross-sectional survey among Slovenian and Croatian students of the first and final study years at the University of Ljubljana, Slovenia, and the University of Zagreb, Croatia. Students of five different faculties from both universities were included: Faculty of Medicine, Faculty of Nursing, Faculty of Catholic Theology, Faculty of Law, and Faculty of Philosophy. In the academic year 2016/2017, a total of 1,128 students were enrolled in the selected study programs at the University of Ljubljana and 2,142 students at the University of Zagreb. Questionnaires were distributed to all students present at the specific lecture, which was the most visited lecture in each year of study, in agreement with professors from the faculties. We used the questionnaire that was previously used and validated by Janvier et al. (4, 11), which was anonymous and took on average 15–25 minutes to be completely filled in. The questionnaire was accompanied by text that explained the background and purpose of the study.

With the deans of the mentioned faculties, it was agreed that research could be carried out at their faculty during the classes of students of the first and last years of study. If students did not want to participate in the questionnaire, they returned it empty. Questionnaires were given out in a paper form (Appendix 1 and 2) by Jure Puc and Petra Obadić and were collected after the lecture in a paper box to ensure the anonymity of the survey. The survey was carried out during January 1, 2017 and May 5, 2017.

The questionnaire depicts 8 hypothetical clinical cases involving different age groups of currently incompetent, critically-ill patients, all with potential neurologic sequelae (premature baby in the 24th week of gestation, new-born baby, 2-month old infant, 7-year-old boy, 13-year-old girl, 35-year-old adult, 50-year-old adult and 80-year-old elder patient). In all vignettes, the hypothetical patients arrived at the emergency department of a university health centre when a family member could not be immediately consulted. The patients’ expected outcomes were described; gender or other social information such as marital status was not provided. The patients were presented in order from youngest to oldest. After each patient description, the same set of questions was asked: “Would you intubate, resuscitate, and consult intensive care for admission?” (for all cases); “If the parents asked you not to resuscitate, would you respect their decision?” (autonomy of the patient; for paediatric patient cases); “If the family asked you not to resuscitate, would you respect their decision?” (autonomy of the patient; adult patient cases); “Do you think that intubating, resuscitating, and consulting intensive care for admission is in the patient’s best interest?” (all cases); “If it was your child and you had a few moments to consider, would you wish the physician to intubate, resuscitate, and consult intensive care for admission?” (for paediatric patient cases); “If it was your sibling’s child, and you had time to think (not an emergency situation), and she or he asks for your opinion, would you recommend that the physician intubate, resuscitate, and consult intensive care for admission?” (for paediatric patient cases); “If it was your partner, and you had to decide for him or her, would you wish the physician to intubate, resuscitate, and consult intensive care for admission?” (for adult patient cases); “If it was your brother or sister, and you had to decide for him or her, would you wish the physician to intubate, resuscitate, and consult intensive care for admission?” (for adult patient cases); “If this was you and you were able to decide, would you want the physician to intubate, resuscitate, and consult intensive care for admission?”

To each of the questions, the respondents could provide answers on the 4-point scale with the following answers “always”, “usually”, “rarely”, and “never”. Finally, participants ranked the patients in order of resuscitation priority if they presented simultaneously.

The questionnaire was translated from English to Slovenian and Croatian and again back from Croatian and Slovenian to English in order to find any inconsistencies in the understanding of the questions. We followed the recommendations for cross-cultural translation and adaptation (12, 13, 14).

Given that the questions in the questionnaire referred to hypothetical clinical cases, albeit based on real situations, and our survey included students from areas other than medicine and nursing, we tested comprehension of the questions by giving the questionnaire to 20 randomly chosen students from the abovementioned faculties prior to conducting our study.

Categorical variables were described with frequencies and percentages. The measurement reliability of the six parts of the questionnaire, as measured by Cronbach’s alpha, ranged from 0.84 to 0.94 in Slovenia and from 0.88 to 0.96 in Croatia. For the purpose of the analysis, four-point scale questions with possible answers “always”, “usually”, “rarely”, and “never” were combined into two categories; “always” and “usually” were combined into one and “rarely” and “never” into the other category. The number of respondents varied by each question and the percentages were calculated with regard to the number of responses on a given question. As the amount of missing data per question was very low (<3%), it is not expected that the results would change substantially if all the respondents answered all the questions. Chi-square test was used to determine the association between two categorical variables. Multiple logistic regression analysis was used to investigate the association between several factors (country, university courses, year of study, gender and religion) and willingness to resuscitate each hypothetical clinical case. Due to multiple testing, P-values<0.01 were considered as statistically significant. All statistical analyses were performed using IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, New York: IBM Corp. The licence belongs to the University of Maribor, Faculty of Criminal Justice and Security.

In Slovenia, there was a statistically significant difference between students of medical and nursing faculties when compared to other non-healthcare faculties (theology, law, philosophy) in the decision of resuscitating an extremely premature infant (P=0.006) and an 80-year-old patient (P=0.004). A higher share, 225 (97%) of students at medical and nursing faculties, decided to resuscitate a premature infant at 24-weeks of gestation, in comparison to students from non-healthcare faculties 254 (91%). In the case of the 80-years-old patient, fewer students from the Slovenian medical and nursing faculties 194 (84.3%) would decide to resuscitate the patient compared to students from non-healthcare faculties 255 (92.4%). In Croatia, there was a statistically significant difference in decision-making for cases of a 2-month-old infant (P=0.003), a 7-year-old boy (P=0.008) and a 35-year-old adult (P=0.009). In all these cases, students from medical and nursing schools were more likely to resuscitate. Differences between the students in the first and final years of study were statistically significant only in the Slovenian sample (P=0.004) in the case of an 80-year-old patient. Compared to 289 (91.7%) of the first-year students, only 154 (83.2%) of the final-year students would opt for resuscitation in this case (Table 2).

Multiple logistic regression model showed that religious students have higher odds (more than 2-folds) of resuscitating a mature new-born and a 2-month-old infant. Religious students had higher odds (from 1.35 to 1.80) of resuscitating patients in other age groups; however, the effect was statistically not significant.

In Slovenia, there was a statistically significant difference between the students of medical and nursing studies and the students of non-healthcare studies with respect to respecting the wishes of relatives to withhold resuscitation of an 80-year-old patient (P=0.007). In Croatia, a statistically significant difference with respect to withholding resuscitation was found between students of healthcare and non-healthcare studies in all presented cases. A lower share of final-year students of all studies, when compared to first-year students, would take parents’ wishes into consideration in cases of 2-month-old infants (first year of the study 232 [49.5%], last year 134 [39.1%] [P=0.003]) and 7–year-old boy (first year 233 [49.7%], last year 138 [40.2%] [P=0.008]) (Figure 1).

Figure 1

Multiple logistic regression analysis showed that the odds of respecting parents’ or relatives’ wishes to withhold resuscitation in male students were statistically significantly lower when compared to female students in all eight clinical cases (the odds ratio varies between 0.49 and 0.54). The same was true for religious students. The odds ratio varied between 0.68 and 0.83 and was statistically significant in premature, mature new-borns and close to significant in all other cases. Croatian students, when compared to their Slovenian peers, had higher odds of respecting parents’ or relatives’ wishes to withhold resuscitation in six clinical cases from 2-months-old onward, but are close to significant also in premature and new-born children (the odds ratio varies between 1.42 and 2.4) and the same was true for Croatian students in medical and nursing faculties, when compared to students of non-healthcare faculties who show higher odds in relation to respecting parents’ wishes in cases of a new-born child (OR=1.24–1.96; 95% CI: 1.22–3.16).

In the case of an 80-year-old patient, statistically significant lower shares of Slovenian and Croatian students of medical and nursing faculties, compared to students of non-healthcare faculties, believed that resuscitation is in the best interest of the patient. However, in the case of a 2-month-old infant, a significantly higher number of Croatian final year students of healthcare and non-healthcare studies believed that resuscitation is in the best interest of the patient, when compared to Slovenian students (P=0.004) (Figure 2).

Figure 2

Multiple logistic regressions including gender, country, study year, study type, parents education and religion as independent variables, showed that students of healthcare faculties both in Croatia and Slovenia had statistically significantly lower odds when compared to students from non-healthcare faculties of believing that resuscitation is in the best interest of the 80-year-old patient (the odds ratio varies between 0.33 and 0.75; 95% CI: 1.16–2.95; p<0.001). This was true even in cases when the patient is a close (OR=0.41%; 95% CI: 0.25–0.66) or wider family member (OR=0.42; 95% CI: 0.26–0.69). Male and religious students had statistically significantly higher odds to demand to be resuscitated if in the position of adult patients (35-, 50-, and 80-years old) represented in the vignettes.

Both Slovenian and Croatian students would prioritize the resuscitation of children over adult patients (Table 3). The order of resuscitation among children varies among Slovenian and Croatian students.