In emergency situations, physicians sometimes have to make difficult decisions on whether or not to initiate emergency life-sustaining therapy. Usually the principle of the best interest of the patient is taken into account (1). In certain emergency situations, physicians can get guidance from family members and relatives (2, 3).
Janiver et al. performed a study among Canadian physicians and students in law, medicine, anthropology and bioethics on do-not resuscitate decision-making based on hypothetical clinical patients’ case vignettes that they have constructed. The study’s findings suggest that the resuscitation priority of patients is not closely related to the foreseeable survival of the patients and that the age of the patient has a strong influence on the decision-making (4). Similar findings were found in two consecutive studies carried out using the same methodology in Ireland among physicians and students of medicine and in Norway among paediatricians (5, 6). Sham et al. carried out a study in Hong Kong among medical and non-medical students (7). Tyer et al. carried out a qualitative study among physicians and medical students in the United Kingdom regarding factors that influence decisions about cardiopulmonary resuscitation. The factors that were found to be important were the patient’s diagnosis, prognosis, age, quality of life, the opinions of physicians and other medical staff, and the wishes of patients and relevant others (8).
1.1 Aims of the Study
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.
2.2 Data Collection
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.
2.4 Statistical Analysis
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.
The response rates were 45.4% for the University of Ljubljana (512 students) and 37.9% for the University of Zagreb (812 students) (Table 1).
Characteristics of students by country.
|Slovenia f (%)||Croatia f (%)||P|
|Female||375 (75)||510 (62.8)|
|Male||125 (25)||302 (37.2)|
|Philosophy||29 (5.7)||66 (8.1)|
|Medical||201 (39.3)||389 (47.9)|
|Law||220 (43.0)||173 (21.3)|
|Theology||30 (5.9)||102 (12.6)|
|Nursing (Health Sciences)||32 (6.3)||82 (10.1)|
|Year of study||0.055|
|First||318 (63.1)||469 (57.8)|
|Final||186 (36.9)||343 (42.2)|
|Education of father||<0.001|
|Basic or less||20 (4)||24(2.9)|
|High school||174 (34.6)||335 (41.3)|
|Higher||68 (13.5)||91 (11.2)|
|Bachelor||115 (22.9)||271 (33.4)|
|Master’s, PhD||126 (25)||91 (11.2)|
|Education of mother||<0.001|
|Basic or less||18 (3.6)||44 (5.4)|
|High school||134 (26.6)||335 (41.3)|
|Higher||68 (13.5)||77 (9.5)|
|Bachelor||152 (30.2)||277 (34.1)|
|Master’s, PHD||132 (26.2)||79 (9.7)|
|Atheist||228 (44.5)||124 (15.3)|
|Religious||284 (55.5)||688 (84.7)|
3.1 The Age of a Patient and Decision not to Resuscitate
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).
Decision of the students to resuscitate split by type of faculty (non-healthcare vs healthcare) and year of study in Slovenia and Croatia.
|Non-healthcarea f (f%)||Healthcareb f (f%)||P||First yearc f (f%)||Last yeard f (f%)||P|
|Premature of 24-weeks gestation old|
|SLO||254 (91.0)||225 (97.0)||0.006||293 (92.4)||178 (95.7)||0.147|
|CRO||316 (92.7)||449 (95.3)||0.109||435 (92.8)||330 (96.2)||0.037|
|SLO||252 (91.3)||223 (96.5)||0.016||293 (92.7)||175 (95.1)||0.293|
|CRO||312 (91.5)||438 (93.0)||0.428||428 (91.3)||322 (93.9)||0.165|
|SLO||265 (95.0)||226 (97.4)||0.158||303 (95.6)||180 (96.8)||0.509|
|CRO||321 (94.1)||462 (98.1)||0.003||449 (95.7)||334 (97.4)||0.213|
|SLO||259 (93.2)||218 (95.6)||0.238||299 (94.3)||171 (94)||0.867|
|CRO||323 (94.7)||462 (98.1)||0.008||450 (95.9)||335 (97.7)||0.177|
|13-year-old girl SLO||255 (91.7)||214 (93.9)||0.359||297 (93.7)||165 (90.7)||0.213|
|CRO||312 (91.5)||448 (95.1)||0.038||432 (92.1)||328 (95.6)||0.043|
|SLO||248 (89.5)||207 (91.2)||0.532||287 (90.8)||162 (89)||0.513|
|CRO||294 (86.2)||433 (91.9)||0.009||413 (88.1)||314 (91.5)||0.109|
|SLO||263 (94.6)||214 (94.3)||0.871||300 (94.6)||171 (94.0)||0.750|
|CRO||316 (92.7)||452 (96.0)||0.041||436 (93.0)||332 (96.8)||0.017|
|SLO||255 (92.4)||194 (84.3)||0.004||289 (91.7)||154 (83.2)||0.004|
|CRO||313 (91.8)||422 (89.6)||0.293||421 (89.8)||314 (91.5)||0.393|
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.
3.2 The Respect of Parents’ or Relatives’ Wishes to Withhold Resuscitation – Autonomy of the Patient
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).
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).
3.3 Best Interest of the Patient and Decisions to Resuscitate
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).
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.
3.4 Priority Order of Resuscitation
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.
The number and share of surveyed students and their resuscitation priority ratings (“position”) for the eight presented cases.
|SLO (n=489)||Position||CRO (n=812)||Position|
|Premature 24-weeks of gestation infant||96 (19.6)||3||232 (28.6)||2|
|Mature new-born||36 (7.4)||4||22 (2.7)||6|
|2-month-old infant||97 (19.8)||2||139 (17.1)||3|
|7-year-old boy||206 (42.1)||1||336 (41.4)||1|
|13-year-old girl||27 (5.5)||5||29 (3.6)||4|
|35-year-old adult||8 (1.6)||7||8 (1.0)||8|
|50-year-old adult||17 (3.5)||6||24 (3.0)||5|
|80-year-old adult.||2 (0.4)||8||22 (2.7)||7|
Our study showed that there are differences among Croatian and Slovene students in do-not resuscitate decision-making with regards to type of study, gender and religious beliefs.
The results of our research show statistically significant differences in do-not resuscitate decisions in different cases between medical and non-medical students in Slovenia and Croatia. The study of Sham et al. found out that medical education and clinical exposure might influence the students’ views on do-not resuscitate decisions. Medical students, especially those who were already in clinical praxis, tended to take into account a patient’s proposal to not resuscitate more often, if this was their wish. Their study also showed that family wishes were considered less important to all participants. In contrast, findings in our study showed that healthcare students (51.7%) compared to non-healthcare students (39.9%) were more likely to respect relatives’ wishes for resuscitation in all case scenarios (7). This tendency is especially pronounced in Croatian healthcare students, in comparison to non-healthcare students. However, Croatian final-year students would be less likely to accept relatives’ wishes to withhold resuscitation in the cases of a 2-month-old baby and a 7-year-old boy. Richter et al. performed a study on how end-of-life decisions are influenced by cultural and socio-political circumstances and explored the compliance of doctors with patients in Germany, Sweden and Russia. Russian physicians, unlike German and Swedish physicians, were less likely to respect a patient’s family’s wishes (15).
Religious students were more likely to resuscitate all patients from presented cases. Despite already finding differences in groups of new-borns comparing non-healthcare and healthcare faculties in terms of resuscitating (91.3–96.5% would resuscitate him), participants in our study did not devalue new-borns unlike the participants from Janiver et al., where only 79% would decide to resuscitate (4, 11, 16). They treated all patients, whether adult or child/young/infant patients equally. Religious and male students were also more likely to not respect parents’ or relatives’ wishes to withhold resuscitation and wanted to be resuscitated if ever found in the situation of adult patients depicted in the vignettes. Sham et al. did not find differences in decision-making amongst various religions and genders, but stated that further researches should be made on this topic (7). Donohue et al. studied the impact of neonatologists’ religiosity and spirituality on healthcare delivery and found that physicians who reported that their religious beliefs influence their medical practice had similar responses in response as those not influenced by religion (17).
However, unlike the study of Sham et al. where final-year students had lower tendency compared to first-year students to resuscitate patients, Croatian and Slovenian medical and nursing students’ attitudes toward resuscitation did not change between the first and final year of the study. Our findings prompt us to ask the question: has a formal medical curriculum at all helped healthcare students in Slovenia and Croatia in making decisions about resuscitation? Janiver et al. also found in their research that medical knowledge did not contribute to resuscitation decision-making, while Sham et al. suggest that clinical exposure during medical training is a key factor in DNR decision-making (4, 7, 11).
The resuscitation priority ratings differed in our sample, where participants gave the most value to a 7-year-old boy and premature infant and the least to 35- and 80-year-old patients, compared to the studies of Janiver et al, in which participants put in their first two places a 2-month-old baby and a 7-year-old boy, and their last two places a premature baby and an 80-year-old patient. Unlike the participants from Janiver at al., where the 24-week of gestation premature infant was among those patients that are more likely not to be resuscitated (4, 16), students of medical and nursing studies in Slovenia and Croatia were more likely to resuscitate a 24-weeks of gestation premature infant. In Croatia, medical students would also resuscitate more often than non-medical students in all patients from the presented cases except the 80-year-old patient. However, medical and nursing students in Croatia and Slovenia believe that resuscitation is not in the best interest of the 80-year-old patient (368 [78.1%] of Croatian healthcare students in comparison to 300 [88%] students of non-healthcare studies; 142 [61.7%] Slovenian healthcare students in comparison to 215 [78.5%] students of non-healthcare studies). Among Slovenian students, this was the case even if the patient was a family member. As in the Janiver et al. Study, the age of the patient was a strong factor that influenced the do-not resuscitate decision-making of our respondents and the life of a child had higher value then the life of an adult. This tendency to resuscitate younger patients more often than an 80-year-old patient can also be seen in other studies which used the Janiver et al. questionnaire (2, 3). The review of Cook et al. and other studies also shows that age is an important determinant for the initiation of do-not resuscitate orders in critically-ill patients (18, 19, 20). According to our findings, students’ decisions on the same clinical cases went along with their gender, religious beliefs, and type of study. We think that the practice of DNR should be always, when possible, discussed with the patient firstly and then with their relatives that know them and their wishes the best, to avoid biases made solely out of doctor’s own thinking about what is the best for the patient. In addition to this, currently in Slovenia legislation about DNR is still in quite an unfledged state. Our study could serve as a helpful tool to improve it and, thus, make decisions in this medical field easier for doctors.
There are certain limitations with respect to the interpretation of the results. First, we did not include students from other faculties in other Slovenian and Croatian cities. By consequence, the results cannot be generalized to the population of all students. Second, we used hypothetical clinical scenarios which illustrate examples of clinical practice and, therefore, students’ answers may not reflect the reactions that would happen in real-life circumstances, especially considering the socio-economic status of vignette-related patient cases and their outcome comparing various socio-economic situations. Third, the response rate of our study was less than 50%. Finally, an important caveat is that a young person, a student of a non-healthcare faculty, rarely faces an end-of-life or death decision and, consequently, those answers may not give the real picture.
Our study clearly shows that gender, religious beliefs, and type of study are important factors that are associated with the decisions pertaining to the respect for autonomy, patient’s best interest, and initiation or withholding of resuscitation.
The authors wish to thank all the deans and their faculty personnel but mostly the students for collaborating in this research.
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Sousa VD, Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross cultural health care research: a clear and user-friendly guidelines. J Eval Clin Pract. 2011;17:268-74. doi: 10.1111/j.1365-2753.2010.01434.x.)| false 10.1111/j.1365-2753.2010.01434.x
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