Attitudes Toward Do Not Resuscitate Orders Among Health Science Students

Abstract

This study aimed to examine health-related university students' awareness of and attitudes toward do-not-resuscitate (DNR) orders and to identify differences according to academic year and department, as well as factors influencing DNR attitudes. A descriptive cross-sectional survey design was employed. Data were collected from 183 health-related university students in the Gyeongnam region using a structured questionnaire consisting of items on general characteristics, awareness of DNR, attitudes toward DNR, and the perceived need for DNR education. The collected data were analyzed using SPSS version 24.0, including descriptive statistics, independent t-tests, one-way analysis of variance, and multiple linear regression analysis. The results indicated that the participants generally exhibited neutral to moderately positive attitudes toward DNR orders. Significant differences in DNR attitudes were observed according to academic year and department (p < .05), with students majoring in emergency medical services demonstrating more positive attitudes than those in other departments. In addition, higher awareness of DNR was significantly associated with more positive attitudes (p < .05). The perceived need for DNR education was also identified as a significant factor influencing DNR attitudes. Multiple linear regression analysis revealed that academic year and perceived need for DNR education were significant predictors of attitudes toward DNR. In conclusion, this study highlights the importance of DNR and end-of-life care education for health-related university students. It suggests that educational programs should be systematically developed and tailored according to students' academic characteristics and disciplinary backgrounds. Future studies should include larger and more diverse samples and adopt qualitative approaches to gain a deeper understanding of the formation and changes in attitudes toward DNR. These findings provide fundamental data for improving bioethics education in healthcare.

1. Introduction

Advances in medical technology have significantly prolonged the life of critically ill patients. Although medical technologies such as ventilators, cardiopulmonary resuscitation (CPR), and hemodialysis play a vital role in prolonging patient life, these treatments do not always guarantee optimal outcomes. Their effectiveness can sometimes be limited, raising ethical questions about whether continuing treatment is the best option for patients. Although prolonging life is a key goal, quality of life and dignity are also considered crucial values and balancing them has become a crucial challenge in modern medicine [1,2].

A Do Not Resuscitate (DNR) order refers to a medical decision not to perform CPR or other life-sustaining treatments when the patient’s condition is critical. This decision is intended to reduce patient suffering and maintain their dignity at the end of life. DNR decisions have evolved to respect patients’ right to self-determination and avoid unnecessary medical interventions [3,4]. The Act on Decisions on Life-Sustaining Treatment first established a legal basis for discontinuing life-sustaining treatment and DNR in Korea. Discussing and applying these principles are becoming increasingly important in medicine [5].

DNR decisions must be made based on trust and information sharing among patients, guardians, and medical professionals, who play a crucial role in this process. Because medical professionals’ perceptions and attitudes toward DNR influence the decisions of patients and guardians, understanding prospective healthcare professionals’ views on DNR is essential for anticipating their future ethical decision-making in clinical practice [6,7].

Healthcare students, as prospective healthcare practitioners preparing for clinical work, develop values and attitudes that will exert a lasting influence on their professional conduct and decision-making. The curricula, clinical practice, and ethics education provided by universities play crucial roles in shaping professional attitudes about and understanding of bioethics. Examining attitudes toward DNR can provide essential baseline data for preparing individuals to address ethical situations that arise in clinical practice [8]. However, prior research has focused predominantly on practicing healthcare professionals, resulting in a relative scarcity of studies involving healthcare students [9,10]. Moreover, limited attention to differences in DNR attitudes across academic years and majors has constrained the development of targeted educational strategies [11]. Research that considers the characteristics of each healthcare major could serve as valuable reference material for future curricula and clinical practice.

With the convergence of industry, medicine, and education in modern society, healthcare education must evolve to encompass both practice-oriented and ethical training. Ethical decision-making issues, such as DNR orders, have significant implications beyond medical considerations, encompassing social, educational, and industrial dimensions. This study thus examined healthcare students’ perceptions and attitudes toward DNR to provide the foundational data necessary for systematically designing future ethical education [13,14].

This study investigated the attitudes of health science college students toward DNR, analyzed the differences related to their general characteristics and educational experiences, suggests directions for health ethics education, and provides basic data contributing to improving clinical education curricula [15].

2. Research Methods

2.1 Research Design and Subjects

This study employed a descriptive survey design to examine health science college students’ attitudes toward DNR orders using a structured questionnaire. The participants comprised 183 students enrolled at a university in the Gyeongnam region who understood the study’s purpose and provided informed consent to participate.

2.2 Data Collection and Analysis Methods

This study examined the students’ attitudes toward DNR order. Data were analyzed using the statistical program SPSS 24.0.

1) Percentages were used to analyze the participants’ general characteristics.

2) Attitudes toward DNR orders were analyzed using means and standard deviations.

3) The association between general characteristics and DNR attitudes was analyzed using t-tests and ANOVA, with Duncan’s test used as a post hoc test.

4) Factors influencing DNR attitudes were analyzed using multiple linear regression analysis.

2.3 Research Tools

The questionnaire was developed by∼, referencing previous research examining DNR orders. It comprised 18 items: 8 questions on attitudes related to CPR decisions and 10 questions on the general characteristics of the subjects. Attitudes toward CPR were measured on a 5-point Likert scale, with higher scores indicating more positive attitudes. Reliability analysis revealed that Cronbach’s alpha for DNR attitudes was .757, exceeding the cutoff value of 0.6, thus demonstrating the measurement data’s internal consistency.

3. Research Results

3.1 General Characteristics of the Subjects

Table 1 shows the general characteristics of the study participants. A total of 183 respondents were included in this study. Of the participants, 55 (30.1%) were male and 128 (69.9%) were female. With respect to age, 117 students (63.9%) were 20 years old, 49 (26.8%) were 21 years old, seven (3.8%) were 22 years old, three (1.6%) were 23 years old, five (2.7%) were 24 years old, and two (1.1%) were 25 years old. By department, 83 students (45.4%) were enrolled in Emergency Medical Services, 37 (20.2%) in Biomedical Sciences, 35 (19.1%) in Clinical Pathology, and 28 (15.3%) in Companion Animal Science. There were 123 students (67.2%) in the first year, 59 (32.2%) in the second year, and 1 (0.5%) in the fourth year. Thirty-one students (16.9%) were religiously active; 152 (83.1%) were nonreligious. 37 students (20.2%) were medical professionals in their families, while 146 (79.8%) were non-religiously active. A total of 118 students (64.5%) had experienced the death of people around them, whereas 65 students (35.5%) did not. A total of 105 students (57.4%) were aware of DNR, while 78 (42.6%) were not. A total of 171 participants (93.4%) said that DNR education was necessary, whereas 12 (6.6%) said it was not.

Table 1. General characteristics.

3.2 Overall Level of DNR Orders

The reported standard deviation (e.g., SD=3.076) exceeds the possible range of a 5-point Likert scale, suggesting a data entry or calculation error that requires correction.

To determine the overall level of DNR orders, we conducted a descriptive statistical analysis; Table 2 presents the results. Overall, the average was 3.45, which was between no (three points) and average (four points), and the following opinions were expressed in advance: In cases of poor health, opinions on DNR should be expressed in advance (M=4.04); I hope that decisions will be respected when they go against the family’s opinion (M=3.88); DNR will hurt the family’s feelings (M=3.75); DNR can differentiate between the rich and the poor (M=2.04); I want to inform my family before making the DNR decision (M=3.66); DNR is necessary (M=3.48); CPR education will increase DNR (M=2.54); It is necessary to establish CPR guidelines tailored to each situation (M=4.20).

Table 2. Attitudes Toward Decisions on Do-Not-Resuscitate (DNR).

¹⁾ Likert 5-point scale: 1=t’s not like that at all., 3=normal, 5=That’s very much the case.

Additionally, the standard deviation of the total score appears inappropriate and should be recalculated.

3.3 Differences in Attitudes toward DNR Orders by General Characteristics

Differences in attitudes toward DNR orders according to general characteristics are presented in Table 3. Statistically significant differences (p < .01) were observed among the following departments: Emergency Medical Services (M=3.57), Biomedical Health Sciences (M=3.40), Clinical Pathology (M=3.48), and Companion Animal Sciences (M=3.13). A post-hoc Duncan test revealed that Emergency Medical Services, Biomedical Health Sciences, and Clinical Pathology had higher scores than Companion Animal Sciences.

Table 3. Differences in Attitudes Toward Do-Not-Resuscitate (DNR) According to General Characteristics.

p<.05, **p<.01

3.4 Factors Influencing DNR Attitudes

The factors influencing attitudes toward DNR orders are listed in Table 4. The reported F-value (1.795) is inconsistent with the stated significance level (p<.01), indicating a critical statistical error in the regression model. and the adjusted R2 value was .094. Factors influencing DNR attitudes included grade level and the statement, “DNR education is necessary.” The regression model shows low explanatory power (Adjusted R²=.042), and its statistical validity is questionable given the inconsistency between the F-value and p-value. Categorical variables such as gender, department, and religion were included in the regression analysis without appropriate dummy coding, which may have resulted in biased regression estimates.

Table 4. Factors affecting attitude.

4. Discussion

This study examined the perceptions and attitudes of healthcare students toward DNR orders, focusing on how these attitudes vary by academic year and department. The findings revealed that most students held either positive or neutral attitudes toward DNR. This suggests that they had an awareness of basic ethical principles. Significant differences in attitudes were observed across academic years.

This statement is inconsistent with the results presented in Table 3, where academic year was not statistically significant (p=.162). and departments, with emergency medicine students showing more positive views than their peers in other disciplines. This may be attributed to the department’s hands-on, practice-oriented education, which likely enhanced ethical decision-making capabilities. In contrast, students in other departments displayed comparatively lower levels of support for DNR orders, possibly because of their limited exposure to ethical discussions within their curricula.

The results here underscore the need for specialized ethics education for healthcare students. In particular, students who demonstrated a higher level of awareness of DNR orders tended to have more favorable attitudes, highlighting the influence of targeted educational efforts on improving ethical decision-making. Therefore, DNR and life-sustaining treatment education should be core components of healthcare training and progressively incorporated throughout students’ academic training.

In addition to theoretical instruction, integrating case-based learning and simulation exercises that reflect real-life clinical scenarios could be highly beneficial in fostering practical decision-making skills and preparing students to confront ethical dilemmas. This approach will help students build experience in resolving real-world ethical challenges central to the medical profession.

This study calls for a structured, department-specific approach to DNR education that incorporates theoretical and practical elements tailored to the needs of each discipline. Future research should expand this study’s scope to include a larger and more diverse sample of healthcare students and explore the factors influencing their attitudes toward DNR orders.

Qualitative studies that focus on how students form their attitudes and how these attitudes evolve over time will provide deeper insights. This study serves as a valuable foundation for refining ethics education and enhancing the ability of future health professionals to navigate complex ethical situations in clinical practice.

5. Conclusion

This study focused on how health majors perceive DNR orders, the attitudes they develop based on this perception, and how these attitudes differ across grades and departments. The results showed that the participants’ attitudes toward DNR orders were generally neutral or positive, suggesting that students with health majors possessed a certain level of ethical decision-making capacity. In particular, significant differences in attitudes toward DNR orders were observed across grades and departments, clearly demonstrating that educational factors and major characteristics significantly influenced students’ attitudes. For example, emergency medical technician (EMT) students had more positive attitudes toward DNR than students in other departments, suggesting that their department’s practice-oriented education positively impacted their ethical decision-making abilities. Furthermore, the fact that students with higher levels of DNR awareness had more positive attitudes highlights the importance of enhancing DNR awareness through educational programs.

These findings suggest the necessity for systematic and step-by-step DNR education for healthcare majors. It is crucial to provide progressive education on DNR orders and life-sustaining treatment, starting from the lower grades, and to develop curricula tailored to each major’s characteristics. For example, in practice-oriented majors, such as emergency medicine and nursing, simulations and discussion classes based on real-world cases should be used to cultivate practical decision-making skills while resolving various ethical dilemmas. Moreover, combining theoretical education with practical training provides students with experiences closer to real-world medical settings and significantly enhances their ethical thinking and decision-making skills.

This study provides some avenues for future research. As this study was conducted at a single institution, future research should expand the sample to diverse regions and institutions and employ a longitudinal design to track the formation of DNR attitudes temporally. Furthermore, qualitative research that conducts in-depth analyses of how students form their attitudes toward DNR orders would enable the development of more specific and nuanced educational approaches. Such research would deepen understanding of healthcare students’ ethical awareness and attitudes and provide valuable foundational evidence for the future design of healthcare ethics education programs. Ultimately, this study’s findings serve as a valuable guide for healthcare students to enhance their ethical decision-making skills in the medical field.