Knowledge, attitudes, and applied practices regarding "Do Not Attempt Resuscitation" among healthcare workers in...

Do Not Attempt Resuscitation (DNAR) decisions are ethically and clinically complex, shaped by prognostic uncertainty, communication barriers, and sociocultural factors. In Saudi Arabia, Fatwa No. 12086 and Ministry of Health national policy permit withholding cardiopulmonary resuscitation (CPR) without family consent when three qualified physicians deem resuscitation futile. Despite this established framework, inconsistent DNAR implementation persists across Saudi clinical settings.

To assess the knowledge, attitudes, and applied practices regarding DNAR among multidisciplinary healthcare workers (HCWs) in the Aljouf region of northern Saudi Arabia and to identify barriers to its consistent implementation.

In this multicenter cross-sectional survey, 461 licensed HCWs, including physicians, nurses, and allied health professionals, from 10 hospitals and 7 primary healthcare centers across the Aljouf region completed a structured, bilingual, self-administered online questionnaire between September 20 and November 15, 2025. Data were analyzed using descriptive statistics, the Kruskal-Wallis test with Bonferroni-corrected post-hoc comparisons, and multivariable logistic regression to identify independent predictors of high knowledge scores. Exposures and outcomes were defined a priori.

Overall, 96% of participants achieved satisfactory knowledge scores (≥60%), with a median score of 9 out of 10 (IQR: 8-9). However, two clinically critical gaps were identified: only 52.9% correctly recognized that family consent is not legally required for DNAR in Saudi Arabia, and only 51.2% identified the correct management of cardiac arrest following confirmed brain death. Physicians scored significantly higher than nurses, technicians, and pharmacists (Kruskal-Wallis, p = 0.0003). In multivariable logistic regression, prior direct involvement in a DNAR decision was the strongest independent predictor of high knowledge (OR 2.39; 95% CI 1.11-5.16; p = 0.03), while nurses were approximately 50% less likely than physicians to achieve a high knowledge score (OR 0.50; 95% CI 0.29-0.83; p = 0.008). Although 78.3% considered DNAR ethically necessary and 82.2% agreed it protects patients from unnecessary suffering, 78.5% found family discussions challenging and 83.1% acknowledged strong cultural influences on DNAR decisions. Only 55.1% knew where to locate their institutional DNAR protocol.

This study suggests that, although most HCWs appear to possess adequate theoretical knowledge of DNAR policy, two clinically critical gaps were identified: widespread misconception that family consent is legally required and poor understanding of cardiac arrest management following confirmed brain death. Acknowledging the limitations of convenience sampling and potential self-selection bias, these findings point toward the value of targeted multidisciplinary education, structured communication training, and improved institutional protocol accessibility as potentially important strategies to bridge the gap between policy and practice.