Prevalence and predictors of Do-Not-Resuscitate orders among advanced cancer patients receiving palliative care at a tertiary cancer center in Jordan: a 10-year retrospective analysis

Prevalence and predictors of Do-Not-Resuscitate orders among advanced cancer patients receiving palliative care at a tertiary cancer center in Jordan: a 10-year retrospective analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence and predictors of Do-Not-Resuscitate orders among advanced cancer patients receiving palliative care at a tertiary cancer center in Jordan: a 10-year retrospective analysis Omar Shamieh, Waleed Alrjoub, Rahaf Tarawneh, Ghadeer Alarjeh, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7461335/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 May, 2026 Read the published version in BMC Palliative Care → Version 1 posted 15 You are reading this latest preprint version Abstract Background: In low- and middle-income countries (LMIC), Do-Not-Resuscitate (DNR) discussions are often delayed or omitted, adversely affecting the quality of end-of-life care. Despite the growing recognition of palliative care, limited evidence exists on the timing and determinants of DNR decisions in these settings. Objective. To assess the prevalence, temporal trends and predictors of DNR orders among advanced cancer patients receiving palliative care at a tertiary center in Jordan. Methods: We conducted a retrospective review of all deceased advanced cancer patients who received palliative care at the King Hussein Cancer Center between 2013 and 2022. Demographic, clinical, and code status data at referral and at death were extracted from medical records. Descriptive statistics, chi-square tests, and t-tests were used to identify patterns and associations . Results : Among 5,264 patients were analyzed, 48.9% female, 79.9% married, and 94.6% Jordanian. The most common cancer types were gastrointestinal (26.5%), breast (16.6%), and genitourinary (14.9%). At referral, 26.4% had a DNR order, increasing to 81% at death. Cancer type was significantly associated with DNR status at death (p < .001), with breast and gastrointestinal cancers more likely to have DNR orders. The proportion of DNR orders at death demonstrated an overall upward trend across the study period. Conclusions: There was a substantial shift from CPR to DNR orders between referral and death primarily influenced by clinical rather than demographic factors. These findings of underscores the importance of early advance care planning and targeted training in culturally sensitive end-of-life communication to promote patient-centered decision making. Do-Not-Resuscitate resuscitation orders End-of-life decisions code status advanced directives palliative care Figures Figure 1 Figure 2 Figure 3 Background Cancer, a life-limiting illness, remains a global health challenge, responsible for millions of deaths each year. In 2018, cancer accounted for 9.6 million deaths worldwide, rising to approximately 10 million in 2020 [1,2]. The burden is particularly severe in low and middle-income countries (LMICs) where healthcare systems often struggle to meet the increasing demand for palliative and end-of-life care [3]. Patients with advanced cancer frequently experience unnecessary suffering due to inadequate symptom management and a lack of well-established advance care planning [4]. This burden is expected to intensify as aging populations and rising cancer prevalence further strain healthcare resources [3]. One key aspect of end-of-life care is the utilization of Do-Not-Resuscitate (DNR) orders, which allow patients to forgo cardiopulmonary resuscitation (CPR) in cases of cardiac arrest. Since the development of PC in the 1980s [5], do-not-resuscitate (DNR) orders, which refer to a patient’s expressed wish to forgo cardiopulmonary resuscitation (CPR) in the event of cardiac arrest, have played a critical role in ensuring a dignified end-of-life experience for patients [5,6], however, despite their importance, DNR decision-making remains highly complex and influenced by cultural, religious, ethical, legal, and institutional factors. In low- and middle-income countries like Jordan, Do-Not-Resuscitate (DNR) discussions are often delayed if at all done, impacting the quality of end-of-life care. Despite the increasing recognition of palliative care, little is known about the timing and factors influencing DNR decisions in this context [7,8]. Cultural and religious beliefs play a particularly significant role in shaping DNR practices. In many Middle Eastern and Asian countries, family involvement in decision-making is emphasized, often differing from Western models that prioritize direct patient autonomy [9]. While some regions have made strides toward open end-of-life discussions, ingrained cultural norms continue to challenge the acceptance and implementation of DNR orders. Palliative care (PC) services also influence DNR decisions as patients receiving PC are more likely to have early discussions about end-of-life preferences [10,11]. However, the relationship between PC and DNR decisions varies by orders varies across different healthcare systems, cultural and regional contexts [9,10,12,13]. Institutional policies and physician practices further shape DNR utilization. As variation in medical training, communication styles, and attitudes toward CPR influence decision-making [14]. In Jordan, DNR policies exist within a unique framework influenced by religious, ethical, and legal considerations. Both Islamic and Christian religious authorities permit withholding CPR in cases of medical futility. National guidelines require approval from three physicians before issuing a DNR order [15,16]. While some hospitals have established DNR policies, implementation remains inconsistent, and the extent to which palliative care influences DNR decisions in Jordan has not been fully explored [7,8]. Despite global research on DNR trends, there is a gap in understanding how DNR orders are utilized within Jordan’s healthcare system, particularly in the context of palliative care and oncology settings where such decisions are highly sensitive and culturally nuanced. The primary objective of this study is to assess the prevalence and trends of DNR orders from palliative care referral to death in patients with advanced cancer at a major tertiary center in Jordan. Secondary objectives are to identify patient-related linked to change in code status and to describe institutional patterns of DNR use. By addressing these objectives, this study aims to provide a valuable insight to a deeper understanding of how cultural, institutional, and clinical factors impact DNR decision-making in a Middle Eastern context. Methods Study Design and sitting This retrospective cohort study analyzed the medical records of deceased patients with advanced cancer who had received palliative care at the King Hussein Cancer Center (KHCC) in Amman, Jordan, between January 1, 2013, and December 31, 2022. A 10-year timeframe was chosen to enable long-term trend analysis of code status changes and reflect on the development of palliative care services. KHCC is the leading comprehensive cancer center in the Middle East, providing care to a majority of cancer patients in Jordan and the region [17]. The Palliative Care Service, established in 2004, is multidisciplinary and provides inpatient, outpatient, and home-based care .[18,19]. The primary objective was to assess the prevalence and temporal progression of Do-Not-Resuscitate (DNR) orders from the time of palliative referral until death, identifying patterns and trends over time. Additionally, the study aimed to examine factors associated with DNR designation. Eligibility criteria We included all adults deceased patients, died from January 1 st , 2013, to December 31 st , 2022, aged 18 years or older with histologically confirmed advanced or metastatic cancer who had at least one documented encounter with the palliative care service. We excluded patients if there was missing or incomplete documentation regarding code status or date of death, if they were lost to follow-up prior to death, or if they died outside KHCC without accessible medical documentation. Ethical Considerations The study was reviewed and approved by the IRB of KHCC (EC/Ref No: 18khcc150) . All data were de-identified and analyzed in aggregate to protect patient confidentiality in accordance with the Declaration of Helsinki and local ethical standards. Data Collection Medical records of the enrolled subjects were reviewed. The data extracted demographic data, including the patient’s age, gender, marital status, and nationality, as well as clinical data including primary cancer diagnosis, date of the first referral to palliative care, place of referral, code status at the time of referral, code status at the time of death, date of death, and place of death. Statistical Methods Descriptive statistics were employed to summarize and characterize the data, including the calculation of frequencies (n), percentages (%), and means ± SD. To examine the associations and differences between patient characteristics and DNR/CPR designations, univariate analyses were conducted using the chi-square test (categorical variables) and independent t-test (continuous variables). A multivariate logistic regression analysis in R was performed with "code transition" (CPR to DNR) as the dependent variable, using sex, nationality, marital status, date of birth, duration of palliative care follow-up , and diagnosis as predictors. A one-tailed t-test assuming unequal variances was used to assess temporal changes in DNR designation rates from 2013 to 2022, and differences in proportions of DNR orders at referral versus death were compared using a two-tailed paired t-test. Statistical significance was set at p < 0.05. All analyses were conducted using R version (4.5.1) Results Participants Characteristics We reviewed 5,800 records; 536 (9%) were excluded due to missing data, leaving 5,264 patients for analysis. The cohort was nearly evenly split by gender 2, 691 (48.9%) were females, 4,207 (79.9%) were married, and 4,981 (94.6%) were Jordanians. The most prevalent cancers were gastrointestinal cancers 1397 (26.5%), breast cancer 872 (16.6%), and genitourinary cancer 783 (14.9%). 3935 (75 %) of patients had their first encounter in an inpatient setting at the time of palliative referral. At the time of palliative referral, 1390 (26.4%) of patients preferred DNR status; however, the prevalence of DNR status had increased to 4263 (81%) at the time of death (Table 1). [Insert Table 1 here] Frequency of CPR vs. DNR designation according to variables Table 2 presents a comparative statistical analysis of Do-Not-Resuscitate (DNR) and Cardiopulmonary Resuscitation (CPR) designations at the time of death based on various demographic and clinical characteristics. [Insert Table 2 here] The analysis of Table 2 demonstrated that no demographic variable was significantly associated with code status at death; however, comparative patterns were observed. The mean age at referral was nearly identical between groups (DNR: 59.89 ± 14.4 years vs. CPR: 59.90 ± 14.4; p = .079). Gender distribution was similarly balanced, with a slightly higher—but non-significant—DNR rate among females (82.2%) compared to males (79.8%; p = .078). Marital status showed minor variation, with divorced patients exhibiting the highest DNR rate (86.6%), followed by being single (82.0%), widowed (81.4%), and married patients (80.8%), though differences were not statistically significant ( p = .072). Nationality-based comparisons revealed that Iraqi patients had the highest DNR rate (87.1%), while the "Other" group had the lowest (75.0%), yet these variations remained non-significant ( p = .091). The setting of initial palliative care—whether inpatient or outpatient—had no influence on code status at death, with both groups showing identical DNR rates (81.0%; p = .314). In contrast, cancer type was significantly associated with code status ( p < .001). DNR rates were highest among patients with breast (82.8%), gastrointestinal (82.3%), gynecologic (81.6%), and lung cancers (81.4%). Conversely, genitourinary (76.8%) and "Other" cancers (76.6%) had the highest proportions of CPR at death (23.2% and 23.4%, respectively), indicating variability in end-of-life transitions by disease type. A marked shift in code status over time was observed ( p < .001). Of those initially designated as CPR, 75.9% converted to DNR before death. In contrast, 95.2% of patients referred as DNR maintained that status, highlighting the dynamic nature of resuscitation decisions during palliative care. Logistic Regression Analysis of Code Status Transitions In a logistic regression analysis of patients who transitioned from CPR at referral to DNR before death, gastrointestinal cancer (coefficient = 0.488, p < .0001), other cancers (endocrine, neuroendocrine, unknown origin) (coefficient = 0.638, p = .0053), gynecological cancer (coefficient = 0.387, p = .0146), and genitourinary cancer (coefficient = 0.288, p = .0407) were significantly associated with code status change. CNS, lung, hematological, and soft tissue cancers showed no significant association (p > 0.1). Additionally, longer palliative care duration (coefficient = 1.0015, p .05). These findings suggest that clinical factors, rather than demographic characteristics, predominantly influence end-of-life code status transitions. Comparison of code status at time of referral and time of death across the years of referrals (2013-2022) Fig. 1 illustrates the dynamic trends in the DNR Vs CPR designations at the time of patient referral. The fluctuation in the percentage of patients with a DNR status at the time of referral is evident over the specified years. In 2013, 36.3% of patients were designated as DNR at referral, with a subsequent increase to a peak of 39.2% in 2016. However, this percentage experienced a decline, reaching 20.5% in 2022. Conversely, the percentage of patients classified as CPR at the time of referral exhibits an inverse trend to that of DNR. [Insert Fig. 1 here] The trend of DNR status at the time of death has remained relatively high but has shown some fluctuation. In 2013, 88.30% of patients who died under palliative care had a DNR designation. This proportion saw a slight decline and more variability over the years, reaching around 79.97% by 2022. The percentage of CPR designations at death correspondingly increased, particularly notable from 2017 onwards, where it reached a peak of 23.93% in 2021 before slightly decreasing again (Fig. 2). [Insert Fig. 2 here] Comparison of DNR designation at time of referral and time of death across the years of referrals (2013-2022) Fig. 3 shows the dynamics of DNR designations at the time referral and at death. [Insert Fig. 3 here] The two-tailed t-test revealed a considerable and statistically significant difference between DNR designations at the time of referral and death (p < .0001). On average, the number of DNR designation at death (Mean=426.2) is significantly higher than the referral (Mean=139). Additionally, the percentage of "DNR at Referral" varied across the years, ranging from 39.2% in 2016 to 18.4% in 2020; showing no clear upward or downward trend over time. In contrast, the percentage of DNR at death exhibited fluctuation but demonstrated an overall upward trend. Discussion To our knowledge, this is the first study in Jordan—and one of the few in the broader Middle East—to provide a decade-long, institution-wide analysis of Do-Not-Resuscitate (DNR) and Cardiopulmonary Resuscitation (CPR) designations among terminally ill cancer patients. By examining demographic, clinical, cultural, religious, and policy-related determinants over a ten-year period at the King Hussein Cancer Center (KHCC), the study offers a rare longitudinal perspective on end-of-life decision-making in a context where palliative care integration is still evolving and legal frameworks for DNR remain undefined. The findings not only reveal shifting trends in code status preferences—most notably the substantial transition from CPR at referral to DNR at the time of death—but also illuminate how clinical deterioration, communication quality, cultural norms, religious guidance, and institutional policy changes converge to shape these decisions. In doing so, this work fills a critical evidence gap, providing a data-driven foundation for practice improvement, policy reform, and culturally sensitive approaches to advance care planning in Jordan and similar low- and middle-income country (LMIC) settings. Our cohort demonstrated an almost equal gender distribution with a slight male predominance, and majority of patients were married, consistent with both global and Jordanian societal norms [20,21]. Gastrointestinal, breast, and genitourinary cancers were the most prevalent malignancies, reflecting global incidence patterns[20]. Notably, 75% of patients first accessed palliative care in an inpatient setting indicating late stage referrals and underscoring the need for earlier integration of palliative care in to oncology care.[22,23] A significant proportion of patients transitioned from a CPR designation at referral (73.6%) to DNR status at the time of death (81%). This shift underscores the dynamic nature of end-of-life preferences, often shaped by declining clinical status, clearer prognostic information and the quality of communication with health care providers. Prior research has similarly found that patients initially opting for CPR may later transition to DNR upon recognizing the limited benefit or futility of resuscitation in advanced illness.[24] In addition nuanced discussions and improved understanding of prognosis play a crucial role in facilitating these changes.[25,26] The importance of effective communication in influencing DNR decisions is well established. A systematic review and meta-analysis by Becker et al[26] demonstrated that communication interventions were associated with a greater tendency for patients to choose DNR, as well as improved understanding of resuscitation procedures. Clear, consistent and compassionate discussions between healthcare providers, patients, and families are essential to ensuring that treatment decisions remain aligned with patients’ values and preferences.[12,27] In predominantly Muslim Jordan, religious beliefs play a pivotal role in shaping end-of-life decision including DNR orders. Islamic teachings permit DNR directives in situations of medical futility, and authoritative fatwas issued by Islamic scholars explicitly support the withholding of life sustaining interventions support under such circumstances.[15,28] These religious guidelines likely contribute to the observed shifts toward DNR preferences among patients and families.. Cultural norms also influence the acceptance and implementation of DNR decisions. In Jordan and other Arab countries, conversations about death are often regarded taboo, which can lead to hesitancy in discussing and executing DNR orders.[29,30] A national survey found that while 92.7% of physicians were familiar with DNR, more than half had never engaged in such discussions with patients or families, highlighting a significant gap between knowledge and clinical practice.[29] This underscores the need for structured training and culturally sensitive educational programs to enhance physician competency in addressing end-of-life discussions effectively.[29,31] The lack of a formal legal framework for DNR orders in Jordan contributes to inconsistencies in clinical practice, potentially undermining patient trust and complicating decision-making for families and healthcare providers.[7,8,29] In contrast, countries with well-defined DNR policies report greater clarity, consistency and professional confidence in managing end-of-life care.[32,33] Establishing a clear regulatory frameworks in Jordan could enhance the ethical foundation of DNR practices and promote uniformity across healthcare settings.[7,8] Over the study period, the proportion of patients with DNR designation at the time of death remained high but demonstrated fluctuations. In 2013, 88.3% of patients who died under palliative care had a DNR order; this proportion declined to 80% by 2022. During this time, CPR designations at death increased, peaking at 23.9% in 2021 before declining slightly (Figure 2). Several factors contributed to theses shifts. The decline from 2019 to 2021 was largely driven by the COVID-19 pandemic, which placed unprecedented strain on healthcare systems, altered patient management pathways, and restricted family presence in clinical settings.[8,30,34–36] Strict visitation policies hindered in-person goals of care discussions, often leading to default CPR designations.[34,37] Pandemic related uncertainty and heightened fears also increased preferences for aggressive treatments,[30] while ethical dilemmas, ICU bed pressures and resource constraints further influenced code status decisions.[30,38] A particularly significant driver was a legal controversy surrounding DNR orders at KHCC and nationally. At one point, the KHCC legal department deemed DNR orders illegal, promoting a temporary suspension of institutional DNR policy. This suspension created significant hesitancy among primary oncology teams in initiating DNR discussions with patients and families, leading to delayed or absent decision making and consequently, more CPR designations. Resolving this required sustained institutional and national engagement, including consultations with legal and ethical experts, high-level meetings involving parliamentary and senate legal and healthcare advisers, and advocacy from patient and family representatives. Ultimately, consensus was reached that no legal amendment was necessary as Jordanian law contained no explicit prohibition of DNR for terminally ill patients. The resolution reaffirmed the use of DNR practices based on clinical judgment – requiring agreement from at least three expert health care providers – supported by fatwa guidance, endorsing the withholding of futile medical interventions in terminal illness. This outcome helped restore confidence in DNR decision-making and likely contributed to the stabilization of trends observed in recent years.[8] Our analysis found no statistically significant difference in age, gender, marital status, nationality, or initial palliative care setting between patients who died with a DNR designation and those who remained CPR at death (p > .05). These findings are consistent with prior research indicating that age and gender alone are not strong predictors of resuscitation preferences.[39] However, other studies have reported a greater likelihood of DNR selection among older patients highlighting the multifactorial and context dependent nature of such decisions [40]. Marital status showed a marginal association (p = .072), with a slightly higher proportion of married patients opting for DNR at death (79.7%). This is consistent with literature suggesting that spousal support and shared decision-making play a critical role in facilitating advance care planning.[41] Our cohort predominantly included patients from Jordan, Palestine, Syria, Libya, and Iraq – populations that share similar cultural and religious values – which may explain the absence of significant nationality-based differences in code status preferences.[9,42] Cancer type significantly associated with DNR code status at death (p < .001*). Patients with breast and gastrointestinal cancers were more likely to have a DNR designation, compared to genitourinary cancers. The aggressive disease trajectory and high symptom burden associated with gastrointestinal cancers may drive a preference for comfort-focused care.[41,43] in contrast, certain genitourinary cancers - particularly prostate cancer, often follow more indolent course, which may contribute to a greater inclination towards CPR.[44,45] From 2013 and 2022, the proportion of patients referred to palliative care with DNR status decreased from 36% to 18%, while referrals with CPR increased. Advances in cancer therapies, evolving prognostic expectations and shifting societal attitudes towards aggressive treatment may have contributed to this trend.[46,47] Despite the initial preference for CPR at referral, the majority of patients transitioned to DNR before death (79-88%), with the exception of a decline to 72% in 2021. This pattern highlights the essential role of palliative care in facilitating informed decision making and guiding transition toward comfort-oriented care near the end-of-life.[32,48] Implications for practice and policy This study demonstrates a clear trend toward increased DNR designation among terminally ill cancer patients referred to palliative care at Jordan’s largest cancer center, with a significant shift from CPR at referral to DNR at the time of death.[8] While clinical factors such as cancer type and longer palliative care duration were associated with this change, demographic variables were not.[49] These findings highlight the importance of early, culturally sensitive, and comprehensive communication regarding end-of-life preferences,[49] and suggest that embedding advance care planning within oncology and palliative care pathways can enhance care quality and alignment with patient values.[24–26] From a practice perspective, integrating structured advance care planning into standard oncology and palliative workflows, coupled with targeted physician training in communication skills, may increase the timeliness and quality of DNR discussions.[14,49] Policy-level interventions are also critical, including the development of a formal national legal framework for DNR orders, clear institutional guidelines, and advocacy for their inclusion in palliative care policy.[8,30] In contexts similar to Jordan, religious and cultural considerations should be explicitly addressed to ensure ethical, acceptable, and patient-centered decision-making.[9,42] Although the single-institution design and local policy environment limit the generalizability of these results, the patterns observed provide valuable insight into end-of-life decision-making in a Middle Eastern, predominantly Muslim context.[8] They offer a foundation for legal reform, targeted physician training, and policy advocacy to facilitate timely DNR discussions.[49] Future multi-center and cross-cultural studies, particularly those incorporating patient, family, and healthcare provider perspectives, are essential to validate these findings and adapt best practices for diverse healthcare systems. Strengths and Limitations A key strength of this study is its large sample size spanning a decade, allowing for the examination of longitudinal trends in DNR and CPR designation within a comprehensive cancer center that serves as a national referral hub. The integration of detailed demographic, clinical, and institutional context enhances the interpretation of observed patterns, and the findings provide rare data from a Middle Eastern setting where research on end-of-life decision-making is limited. The study also uniquely documents the influence of legal, cultural, and institutional factors on DNR trends over time, offering insights that are relevant to similar resource-constrained and culturally conservative contexts. However, the single-institution, retrospective design limits generalizability to other healthcare settings, particularly those with different legal frameworks, cultural norms, or palliative care integration models. Reliance on medical record documentation may have led to incomplete capture of informal or undocumented code status discussions. Additionally, the absence of qualitative data from patients, families, and providers restricts the ability to fully understand the nuanced factors influencing decision-making. Future research should adopt mixed-methods and multi-center approaches to validate these findings and enhance their applicability across diverse healthcare environments. Conclusion Our study demonstrates a clear trend toward increased DNR designation among terminally ill cancer patients referred to palliative care at the largest cancer center in Jordan, with a notable shift from CPR at referral to DNR at the time of death. While clinical factors such as cancer type and longer palliative care duration were associated with this change, demographic factors were not. These findings underscore the importance of early, culturally sensitive and comprehensive communication regarding end-of-life care preferences and suggest the embedding advance care planning within oncology and palliative care pathways can improve the quality and alignment with patient values. Although the single institution design and local policy environment limit the generalizability of these results, the pattern observed provide valuable insight into end-of-life decision-making in a Middle Eastern, predominantly Muslim context. They offer a foundation for legal reform, targeted physician training, and policy advocacy to facilitate timely DNR discussions. Future multi-center and cross-cultural studies, particularly those incorporating patient, family, and healthcare provider perspectives, are essential to validate these findings and adapt best practices for diverse healthcare systems. Abbreviations CPR: Cardiopulmonary Resuscitation DNR: Do-Not-Resuscitate KHCC: King Hussein Cancer Center LMIC: Low- and Middle-Income Country PC: Palliative Care Declarations Ethics approval and consent to participate This study was approved by the Institutional Review Board (IRB) of King Hussein Cancer Center (Approval No: 18khcc150). The IRB waived the requirement for informed consent due to the retrospective nature of the study. All methods were performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki). Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions OS conceptualized and designed the study, supervised the project, analyzed data, and drafted the main manuscript. WA collected data, contributed to analysis, prepared figures/tables, and assisted with drafting. RT performed statistical analysis, prepared figures/tables, and supported manuscript drafting. GA and RS verified data, with RS also managing data entry and review. LA coordinated data collection and reviewed drafts. EA contributed to the literature review, data management, and revisions. AS, FA, MA (Mahmoud), MA (Mohammad), and AM drafted and revised sections for clinical accuracy. HA-R critically reviewed the manuscript, ensured clinical alignment, and approved the final version. Acknowledgements Not applicable. References Ferlay J, Colombet M, Soerjomataram I, Mathers C, Parkin DM, Piñeros M, et al. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods. Int J Cancer. 2019;144:1941–53. WHO. Cancer [Internet]. 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Predictive factors for do-not-resuscitate designation among terminally ill cancer patients receiving care from a palliative care consultation service. J Pain Symptom Manage [Internet]. 2014 [cited 2022 Nov 8];47:271–82. Available from: http://dx.doi.org/10.1016/j.jpainsymman.2013.03.020 Mottet N, van den Bergh RCN, Briers E, Van den Broeck T, Cumberbatch MG, De Santis M, et al. EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer—2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol [Internet]. 2021 [cited 2025 Mar 1];79:243–62. Available from: https://www.sciencedirect.com/science/article/pii/S0302283820307697 Bennett MI, Ziegler L, Allsop M, Daniel S, Hurlow A. What determines duration of palliative care before death for patients with advanced disease? A retrospective cohort study of community and hospital palliative care provision in a large UK city. BMJ Open [Internet]. 2016 [cited 2022 Aug 22];6:1–6. Available from: https://bmjopen.bmj.com/content/6/12/e012576 Bekelman JE, Halpern SD, Blankart CR, Bynum JP, Cohen J, Fowler R, et al. Comparison of site of death, health care utilization, and hospital expenditures for patients dying With cancer in 7 developed countries. JAMA - J Am Med Assoc. 2016;315:272–83. Sundar S, Do J, O’Cathail M. Misconceptions about “do-not-resuscitate (DNR)” orders in the era of social media. Resuscitation [Internet]. 2015 [cited 2025 Mar 19];86:e3. Available from: http://dx.doi.org/10.1016/j.resuscitation.2014.10.014 Hickman SE, Keevern E, Hammes BJ. Use of the physician orders for life‐sustaining treatment program in the clinical setting: a systematic review of the literature. J Am Geriatr Soc. 2015;63:341–50. Al-Shahri MZ, Sroor M, Ghareeb WAS, Alhassanin S, Ateya HA. Discussion of the do-not-resuscitate (DNR) orders with the family caregivers of cancer patients: An example from a major cancer center in Saudi Arabia. Palliat Support Care [Internet]. 2023/12/21. 2024;22:511–6. Available from: https://www.cambridge.org/core/product/B54FDF26D66371EDD43B4A6FAFFA793C Tables Table 1 Patient Characteristics (n = 5264) Category N (%) Gender Male 2573 (51.1) Female 2691 (48.9) Marital Status Married 4205 (79.9) Widowed 458 (8.7) Single 378 (7.2) Unknown 126 (2.4) Divorced 97 (1.8) Nationality Jordan 4982 (94.6) Palestine 93 (1.8) Libya 54(1.0) Syria 80 (1.5) Iraq 31(0.6) Other[1] 24 (0.5) Cancer type Gastrointestinal 1397 (26.5) Lung 517 (9.8) Breast 872 (16.6) Skin, soft tissue& Sarcoma 268 (5.1) Genitourinary 783 (14.9) Gynecologic 364 (6.9) Head & neck 220 (4.2) Hematology 320 (6.1) CNS 335 (6.4) Other 188 (3.6) First encounter sitting In-Patient 3935 (75) Out-Patient 1329 (25) Code Status at time of PC [2] referral DNR[3] 1390 (26.4) CPR[4] 3874 (73.6) Code Status at time of death DNR 4263 (81.0) CPR 1001 (19.0) 1 Other = cancers include endocrine, neuroendocrine, and unknown origin. 2PC = Palliative Care 3DNR = Do Not Resuscitate. 4 CPR = Cardiopulmonary Resuscitation. Table 2 Frequency of CPR vs. DNR Designation by Variables (N = 5,264) Variable DNR at Death n (%) CPR at Death n (%) p -value[1] Age at PC[2] referral (M, SD[3]) 59.89 (14.4) 59.90 (14.4) .079 Gender .078 Female 2,210 (82.2) 481 (17.8) Male 2,053 (79.8) 520 (20.2) Marital status .072 Married 3,399 (80.8) 806 (19.2) Single 310 (82.0) 68 (18.0) Widowed 373 (81.4) 85 (18.6) Divorced 84 (86.6) 13 (13.4) Unknown 97 (77.0) 29 (23.0) Nationality .091 Jordan 4,035 (81.0) 947 (19.0) Palestine 77 (82.8) 16 (17.2) Syria 64 (80.0) 16 (20.0) Libya 42 (77.8) 12 (22.2) Iraq 27 (87.1) 4 (12.9) Other 18 (75.0) 6 (25.0) First encounter setting .314 Inpatient 3,186 (81.0) 749 (19.0) Outpatient 1,077 (81.0) 252 (19.0) Type of cancer < .001 Breast 722 (82.8) 150 (17.2) Gynecologic 297 (81.6) 67 (18.4) Head and neck 173 (78.6) 47 (21.4) Hematologic 260 (81.3) 60 (18.7) Gastrointestinal 1,149 (82.3) 248 (17.7) Lung 421 (81.4) 96 (18.6) Skin, sarcoma, soft tissue 216 (80.6) 52 (19.4) Genitourinary 615 (76.8) 186 (23.2) CNS 266 (79.4) 69 (20.6) Other[4] 144 (76.6) 44 (23.4) Code status at PC referral < .001 DNR 5 1,324 (95.2) 66 (4.8) CPR 6 2,939 (75.9) 935 (24.1) 1 P-values are based on Pearson’s chi-square test and independent t-test. Values in bold are statistically significant (p < .05). 2PC = Palliative Care 3SD = Standard Deviation 4Other = Cancers include endocrine, neuroendocrine, and unknown origin. 5DNR = Do Not Resuscitate. 6CPR = Cardiopulmonary Resuscitation Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 01 May, 2026 Read the published version in BMC Palliative Care → Version 1 posted Editorial decision: Revision requested 17 Nov, 2025 Reviews received at journal 13 Nov, 2025 Reviewers agreed at journal 30 Oct, 2025 Reviewers agreed at journal 24 Oct, 2025 Reviews received at journal 21 Oct, 2025 Reviewers agreed at journal 21 Oct, 2025 Reviewers agreed at journal 18 Oct, 2025 Reviews received at journal 18 Sep, 2025 Reviewers agreed at journal 10 Sep, 2025 Reviewers agreed at journal 09 Sep, 2025 Reviewers invited by journal 09 Sep, 2025 Editor invited by journal 29 Aug, 2025 Editor assigned by journal 27 Aug, 2025 Submission checks completed at journal 27 Aug, 2025 First submitted to journal 26 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7461335","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":514791966,"identity":"85949658-c0a9-4982-96e9-7866013667b8","order_by":0,"name":"Omar 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1","display":"","copyAsset":false,"role":"figure","size":23988,"visible":true,"origin":"","legend":"\u003cp\u003eDNR designation Vs CPR at time of referral across the years (2013-2022)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7461335/v1/93fc465d041371192f822e6a.png"},{"id":91508375,"identity":"849606ea-722c-4082-bbf2-e975ebd366d4","added_by":"auto","created_at":"2025-09-17 08:38:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":24551,"visible":true,"origin":"","legend":"\u003cp\u003eDNR designation Vs CPR at time of death across the years (2013-2022)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7461335/v1/b742831f6e3f13db6e0e1b8a.png"},{"id":91508376,"identity":"42dffb93-cf75-4ec5-8284-9303bfe3c5ee","added_by":"auto","created_at":"2025-09-17 08:38:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":18222,"visible":true,"origin":"","legend":"\u003cp\u003eDNR designation at time of referral and at death across the years (2013-2022)\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7461335/v1/96227a7d7d275105a2d36d08.png"},{"id":108438761,"identity":"2047a40d-dd54-4693-9ca9-79639faf537d","added_by":"auto","created_at":"2026-05-04 16:10:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":418838,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7461335/v1/515bcb67-006d-48fe-b8c7-a8d8626064c9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence and predictors of Do-Not-Resuscitate orders among advanced cancer patients receiving palliative care at a tertiary cancer center in Jordan: a 10-year retrospective analysis","fulltext":[{"header":"Background","content":"\u003cp\u003eCancer, a life-limiting illness, remains a global health challenge, responsible for millions of deaths each year. In 2018, cancer accounted for 9.6 million deaths worldwide, rising to approximately 10 million in 2020 [1,2]. The burden is particularly severe in low and middle-income countries (LMICs) where healthcare systems often struggle to meet the increasing demand for palliative and end-of-life care [3]. Patients with advanced cancer frequently experience unnecessary suffering due to inadequate symptom management and a lack of well-established advance care planning [4].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis burden is expected to intensify as aging populations and rising cancer prevalence further strain healthcare resources [3]. One key aspect of end-of-life care is the utilization of Do-Not-Resuscitate (DNR) orders, which allow patients to forgo cardiopulmonary resuscitation (CPR) in cases of cardiac arrest.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eSince the development of PC in the 1980s [5], do-not-resuscitate (DNR) orders, which refer to a patient\u0026rsquo;s expressed wish to forgo cardiopulmonary resuscitation (CPR) in the event of cardiac arrest, have played a critical role in ensuring a dignified end-of-life experience for patients [5,6], however, despite their importance, DNR decision-making remains highly complex and influenced by cultural, religious, ethical, legal, and institutional factors.\u003c/p\u003e\n\u003cp\u003eIn low- and middle-income countries like Jordan, Do-Not-Resuscitate (DNR) discussions are often delayed if at all done, impacting the quality of end-of-life care. Despite the increasing recognition of palliative care, little is known about the timing and factors influencing DNR decisions in this context [7,8]. Cultural and religious beliefs play a particularly significant role in shaping DNR practices. In many Middle Eastern and Asian countries, family involvement in decision-making is emphasized, often differing from Western models that prioritize direct patient autonomy [9]. While some regions have made strides toward open end-of-life discussions, ingrained cultural norms continue to challenge the acceptance and implementation of DNR orders. Palliative care (PC) services also influence DNR decisions as patients receiving PC are more likely to have early discussions about end-of-life preferences [10,11]. However, the relationship between PC and DNR decisions varies by orders varies across different healthcare systems, cultural and regional contexts [9,10,12,13].\u003c/p\u003e\n\u003cp\u003eInstitutional policies and physician practices further shape DNR utilization. As variation in medical training, communication styles, and attitudes toward CPR influence decision-making [14]. In Jordan, DNR policies exist within a unique framework influenced by religious, ethical, and legal considerations. Both Islamic and Christian religious authorities permit withholding CPR in cases of medical futility. National guidelines require approval from three physicians before issuing a DNR order [15,16]. While some hospitals have established DNR policies, implementation remains inconsistent, and the extent to which palliative care influences DNR decisions in Jordan has not been fully explored [7,8].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite global research on DNR trends, there is a gap in understanding how DNR orders are utilized within Jordan\u0026rsquo;s healthcare system, particularly in the context of palliative care and oncology settings where such decisions are highly sensitive and culturally nuanced. The primary objective of this study is to assess the prevalence and trends of DNR orders from palliative care referral to death in patients with advanced cancer at a major tertiary center in Jordan.\u003c/p\u003e\n\u003cp\u003eSecondary objectives are to identify patient-related linked to change in code status and to describe institutional patterns of DNR use. By addressing these objectives, this study aims to provide a valuable insight to a deeper understanding of how cultural, institutional, and clinical factors impact DNR decision-making in a Middle Eastern context.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003e\u003cem\u003eStudy Design and sitting\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eThis retrospective cohort study analyzed the medical records of deceased patients with advanced cancer who had received palliative care at the King Hussein Cancer Center (KHCC) in Amman, Jordan, between January 1, 2013, and December 31, 2022. A 10-year timeframe was chosen to enable long-term trend analysis of code status changes and reflect on the development of palliative care services. KHCC is the leading comprehensive cancer center in the Middle East, providing care to a majority of cancer patients in Jordan and the region [17]. The Palliative Care Service, established in 2004, is multidisciplinary and provides inpatient, outpatient, and home-based care .[18,19].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe primary objective was to assess the prevalence and temporal progression of Do-Not-Resuscitate (DNR) orders from the time of palliative referral until death, identifying patterns and trends over time.\u0026nbsp;Additionally, the study aimed to examine factors associated with DNR designation.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eEligibility criteria\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eWe included all adults deceased patients, died from January 1\u003csup\u003est\u003c/sup\u003e, 2013, to December 31\u003csup\u003est\u003c/sup\u003e, 2022, aged 18 years or older with histologically confirmed advanced or metastatic cancer who had at least one documented encounter with the palliative care service. We excluded patients if there was missing or incomplete documentation regarding code status or date of death, if they were lost to follow-up prior to death, or if they died outside KHCC without accessible medical documentation.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eEthical Considerations\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eThe study was reviewed and approved by the IRB of KHCC \u003cem\u003e(EC/Ref No: 18khcc150)\u003c/em\u003e. All data were de-identified and analyzed in aggregate to protect patient confidentiality in accordance with the Declaration of Helsinki and local ethical standards.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eData Collection\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eMedical records of the enrolled subjects were reviewed. The data extracted demographic data, including the patient\u0026rsquo;s age, gender, marital status, and nationality, as well as clinical data including \u0026nbsp;primary cancer diagnosis, date of the first referral to palliative care, place of referral, code status at the time of referral, code status at the time of death, date of death, and place of death.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eStatistical Methods\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eDescriptive statistics were employed to summarize and characterize the data, including the calculation of frequencies (n), percentages (%), and means \u0026plusmn; SD. To examine the associations and differences between patient characteristics and DNR/CPR designations, univariate analyses were conducted using the chi-square test (categorical variables) and independent t-test (continuous variables). A multivariate logistic regression analysis in R was performed with \u0026quot;code transition\u0026quot; (CPR to DNR) as the dependent variable, using sex, nationality, marital status, date of birth, duration of palliative care follow-up , and diagnosis as predictors. \u0026nbsp;A one-tailed t-test assuming unequal variances was used to assess temporal changes in DNR designation rates from 2013 to 2022, and differences in proportions of DNR orders at referral versus death were compared using a two-tailed paired t-test. Statistical significance was set at p \u0026lt; 0.05. All analyses were conducted using R version (4.5.1)\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eParticipants Characteristics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe reviewed 5,800 records; 536 (9%) were excluded due to missing data, leaving 5,264 patients for analysis. The cohort was nearly evenly split by gender 2, 691 (48.9%) were females, 4,207 (79.9%) were married, and 4,981 (94.6%) were Jordanians. The most prevalent cancers were gastrointestinal cancers 1397 (26.5%), breast cancer 872 (16.6%), and genitourinary cancer 783 (14.9%). 3935 (75 %) of patients had their first encounter in an inpatient setting at the time of palliative referral. At the time of palliative referral, 1390 (26.4%) of patients preferred DNR status; however, the prevalence of DNR status had increased to 4263 (81%) at the time of death (Table 1).\u003c/p\u003e\n\u003cp\u003e[Insert Table 1 here]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFrequency of CPR vs. DNR designation according to variables\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 presents a comparative statistical analysis of Do-Not-Resuscitate (DNR) and Cardiopulmonary Resuscitation (CPR) designations at the time of death based on various demographic and clinical characteristics.\u003c/p\u003e\n\u003cp\u003e[Insert Table 2 here]\u003c/p\u003e\n\u003cp\u003eThe analysis of Table 2 demonstrated that no demographic variable was significantly associated with code status at death; however, comparative patterns were observed. The mean age at referral was nearly identical between groups (DNR: 59.89 \u0026plusmn; 14.4 years vs. CPR: 59.90 \u0026plusmn; 14.4; \u003cem\u003ep\u003c/em\u003e = .079). Gender distribution was similarly balanced, with a slightly higher\u0026mdash;but non-significant\u0026mdash;DNR rate among females (82.2%) compared to males (79.8%; \u003cem\u003ep\u003c/em\u003e = .078).\u003c/p\u003e\n\u003cp\u003eMarital status showed minor variation, with divorced patients exhibiting the highest DNR rate (86.6%), followed by being single (82.0%), widowed (81.4%), and married patients (80.8%), though differences were not statistically significant (\u003cem\u003ep\u003c/em\u003e = .072). Nationality-based comparisons revealed that Iraqi patients had the highest DNR rate (87.1%), while the \u0026quot;Other\u0026quot; group had the lowest (75.0%), yet these variations remained non-significant (\u003cem\u003ep\u003c/em\u003e = .091).\u003c/p\u003e\n\u003cp\u003eThe setting of initial palliative care\u0026mdash;whether inpatient or outpatient\u0026mdash;had no influence on code status at death, with both groups showing identical DNR rates (81.0%; \u003cem\u003ep\u003c/em\u003e = .314).\u003c/p\u003e\n\u003cp\u003eIn contrast, cancer type was significantly associated with code status (\u003cem\u003ep\u003c/em\u003e \u0026lt; .001). DNR rates were highest among patients with breast (82.8%), gastrointestinal (82.3%), gynecologic (81.6%), and lung cancers (81.4%). Conversely, genitourinary (76.8%) and \u0026quot;Other\u0026quot; cancers (76.6%) had the highest proportions of CPR at death (23.2% and 23.4%, respectively), indicating variability in end-of-life transitions by disease type.\u003c/p\u003e\n\u003cp\u003eA marked shift in code status over time was observed (\u003cem\u003ep\u003c/em\u003e \u0026lt; .001). Of those initially designated as CPR, 75.9% converted to DNR before death. In contrast, 95.2% of patients referred as DNR maintained that status, highlighting the dynamic nature of resuscitation decisions during palliative care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLogistic Regression Analysis of Code Status Transitions\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn a logistic regression analysis of patients who transitioned from CPR at referral to DNR before death, gastrointestinal cancer (coefficient = 0.488, p \u0026lt; .0001), other cancers (endocrine, neuroendocrine, unknown origin) (coefficient = 0.638, p = .0053), gynecological cancer (coefficient = 0.387, p = .0146), and genitourinary cancer (coefficient = 0.288, p = .0407) were significantly associated with code status change. CNS, lung, hematological, and soft tissue cancers showed no significant association (p \u0026gt; 0.1). Additionally, longer palliative care duration (coefficient = 1.0015, p \u0026lt; .0001) and older age (coefficient = 1.0054, p = .0491) increased the likelihood of transitioning to DNR. In contrast, sex, nationality, and marital status had no significant effect (p \u0026gt; .05). These findings suggest that clinical factors, rather than demographic characteristics, predominantly influence end-of-life code status transitions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eComparison of code status at time of referral and time of death across the years of\u003cbr\u003e\u0026nbsp;referrals (2013-2022)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFig. 1 illustrates the dynamic trends in the DNR Vs CPR designations at the time of patient referral. The fluctuation in the percentage of patients with a DNR status at the time of referral is evident over the specified years. In 2013, 36.3% of patients were designated as DNR at referral, with a subsequent increase to a peak of 39.2% in 2016. However, this percentage experienced a decline, reaching 20.5% in 2022. Conversely, the percentage of patients classified as CPR at the time of referral exhibits an inverse trend to that of DNR.\u003c/p\u003e\n\u003cp\u003e[Insert Fig. 1 here]\u003c/p\u003e\n\u003cp\u003eThe trend of DNR status at the time of death has remained relatively high but has shown some fluctuation. \u0026nbsp; In 2013, 88.30% of patients who died under palliative care had a DNR designation. This proportion saw a slight decline and more variability over the years, reaching around 79.97% by 2022. The percentage of CPR designations at death correspondingly increased, particularly notable from 2017 onwards, where it reached a peak of 23.93% in 2021 before slightly decreasing again (Fig. 2).\u003c/p\u003e\n\u003cp\u003e[Insert Fig. 2 here]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eComparison of DNR designation at time of referral and time of death across the years of referrals (2013-2022)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFig. 3 shows the dynamics of DNR designations at the time referral and at death.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[Insert Fig. 3 here]\u003c/p\u003e\n\u003cp\u003eThe two-tailed t-test revealed a considerable and statistically significant difference between DNR designations at the time of referral and death (p \u0026lt; .0001). On average, the number of DNR designation at death (Mean=426.2) is significantly higher than the referral (Mean=139). Additionally, the percentage of \u0026quot;DNR at Referral\u0026quot; varied across the years, ranging from 39.2% in 2016 to 18.4% in 2020; showing no clear upward or downward trend over time. In contrast, the percentage of DNR at death exhibited fluctuation but demonstrated an overall upward trend.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this is the first study in Jordan\u0026mdash;and one of the few in the broader Middle East\u0026mdash;to provide a decade-long, institution-wide analysis of Do-Not-Resuscitate (DNR) and Cardiopulmonary Resuscitation (CPR) designations among terminally ill cancer patients. By examining demographic, clinical, cultural, religious, and policy-related determinants over a ten-year period at the King Hussein Cancer Center (KHCC), the study offers a rare longitudinal perspective on end-of-life decision-making in a context where palliative care integration is still evolving and legal frameworks for DNR remain undefined. The findings not only reveal shifting trends in code status preferences\u0026mdash;most notably the substantial transition from CPR at referral to DNR at the time of death\u0026mdash;but also illuminate how clinical deterioration, communication quality, cultural norms, religious guidance, and institutional policy changes converge to shape these decisions. In doing so, this work fills a critical evidence gap, providing a data-driven foundation for practice improvement, policy reform, and culturally sensitive approaches to advance care planning in Jordan and similar low- and middle-income country (LMIC) settings.\u003c/p\u003e\n\u003cp\u003eOur cohort demonstrated an almost equal gender distribution with a slight male predominance, and majority of patients were married, consistent with both global and Jordanian societal norms [20,21]. Gastrointestinal, breast, and genitourinary cancers were the most prevalent malignancies, reflecting \u003cdel cite=\"mailto:Omar%20Shamieh\" datetime=\"2025-08-10T10:13\"\u003e\u0026nbsp;\u003c/del\u003eglobal incidence patterns[20]. Notably, 75% of patients first accessed palliative care in an inpatient setting indicating late stage referrals and underscoring the need for earlier integration of palliative care in to oncology care.[22,23]\u003c/p\u003e\n\u003cp\u003eA significant proportion of patients transitioned from a CPR designation at referral (73.6%) to DNR status at the time of death (81%). This shift underscores the dynamic nature of end-of-life preferences, often shaped by declining clinical status, clearer prognostic information and the quality of communication with health care providers. Prior research has similarly found that patients initially opting for CPR may later transition to DNR upon recognizing the limited benefit or futility of resuscitation in advanced illness.[24] In addition nuanced discussions and improved understanding of prognosis play a crucial role in facilitating these changes.[25,26]\u003c/p\u003e\n\u003cp\u003eThe importance of effective communication in influencing DNR decisions is well established. A systematic review and meta-analysis by Becker et al[26] demonstrated that communication interventions were associated with a greater tendency for patients to choose DNR, as well as improved understanding of resuscitation procedures. Clear, consistent and compassionate discussions between healthcare providers, patients, and families are essential to ensuring that treatment decisions remain aligned with patients\u0026rsquo; values and preferences.[12,27]\u003c/p\u003e\n\u003cp\u003eIn predominantly Muslim Jordan, religious beliefs play a pivotal role in shaping end-of-life decision including DNR orders. Islamic teachings permit DNR directives in situations of medical futility, and authoritative fatwas issued by Islamic scholars explicitly support the withholding of life sustaining interventions support under such circumstances.[15,28] These religious guidelines likely contribute to the observed shifts toward DNR preferences among patients and families..\u003c/p\u003e\n\u003cp\u003eCultural norms also influence the acceptance and implementation of DNR decisions. In Jordan and other Arab countries, conversations about death are often regarded taboo, which can lead to hesitancy in discussing and executing DNR orders.[29,30] A national survey found that while 92.7% of physicians were familiar with DNR, more than half had never engaged in such discussions with patients or families, highlighting a significant gap between knowledge and clinical practice.[29] This underscores the need for structured training and culturally sensitive educational programs to enhance physician competency in addressing end-of-life discussions effectively.[29,31]\u003c/p\u003e\n\u003cp\u003eThe lack of a formal legal framework for DNR orders in Jordan contributes to inconsistencies in clinical practice, potentially undermining patient trust and complicating decision-making for families and healthcare providers.[7,8,29] In contrast, countries with well-defined DNR policies report greater clarity, consistency and professional confidence in managing end-of-life care.[32,33] Establishing a clear regulatory \u0026nbsp;frameworks in Jordan could enhance the ethical foundation of DNR practices and promote uniformity across healthcare settings.[7,8]\u003c/p\u003e\n\u003cp\u003eOver the study period, the proportion of patients with DNR designation at the time of death remained high but demonstrated fluctuations. In 2013, 88.3% of patients who died under palliative care had a DNR order; this proportion declined to 80% by 2022. During this time, CPR designations at death increased, peaking at 23.9% in 2021 before declining slightly (Figure 2).\u003c/p\u003e\n\u003cp\u003eSeveral factors contributed to theses shifts. The decline from 2019 to 2021 was largely driven by the COVID-19 pandemic, which placed unprecedented strain on healthcare systems, altered patient management pathways, and restricted family presence in clinical settings.[8,30,34\u0026ndash;36] Strict visitation policies hindered in-person goals of care discussions, often leading to default CPR designations.[34,37] Pandemic related uncertainty and heightened fears also increased preferences for aggressive treatments,[30] while ethical dilemmas, ICU bed pressures and resource constraints further influenced code status decisions.[30,38]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA particularly significant driver was a legal controversy surrounding DNR orders at KHCC and nationally. At one point, the KHCC legal department deemed DNR orders illegal, promoting a temporary suspension of institutional DNR policy. This suspension created significant hesitancy among primary oncology teams in initiating DNR discussions with patients and families, leading to delayed or absent decision making and consequently, more CPR designations. Resolving this required sustained institutional and national engagement, including consultations with legal and ethical experts, high-level meetings involving parliamentary and senate legal and healthcare advisers, and advocacy from patient and family representatives. Ultimately, consensus was reached that no legal amendment was necessary as Jordanian law contained no explicit prohibition of DNR for terminally ill patients. The resolution reaffirmed the use of DNR practices based on clinical judgment \u0026ndash; requiring agreement from at least three expert health care providers \u0026ndash; supported by fatwa guidance, endorsing the withholding of futile medical interventions in terminal illness. This outcome helped restore confidence in DNR decision-making and likely contributed to the stabilization of trends observed in recent years.[8]\u003c/p\u003e\n\u003cp\u003eOur analysis found no statistically significant difference in age, gender, marital status, nationality, or initial palliative care setting between patients who died with a DNR designation and those who remained CPR at death (p \u0026gt; .05). These findings are consistent with prior research indicating that age and gender alone are not strong predictors of \u0026nbsp;resuscitation preferences.[39] However, other studies have reported a greater likelihood of DNR selection among older patients highlighting the multifactorial and context dependent nature of such decisions [40].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMarital status showed a marginal association (p = .072), with a slightly higher proportion of married patients opting for DNR at death (79.7%). This is consistent with literature suggesting that spousal support and shared decision-making play a critical role in facilitating advance care planning.[41]\u003c/p\u003e\n\u003cp\u003eOur cohort predominantly included \u0026nbsp; patients from Jordan, Palestine, Syria, Libya, and Iraq \u0026ndash; populations that share similar cultural and religious values \u0026ndash; which may explain the absence of significant nationality-based differences in code status preferences.[9,42]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCancer type significantly associated with DNR code status at death (p \u0026lt; .001*). Patients with breast and gastrointestinal cancers were more likely to have a DNR designation, compared to genitourinary cancers. The aggressive disease trajectory and high symptom burden associated with gastrointestinal cancers may drive a preference for comfort-focused care.[41,43] in contrast, certain genitourinary cancers - particularly prostate cancer, often follow more indolent course, which may contribute to a greater inclination towards CPR.[44,45]\u003c/p\u003e\n\u003cp\u003eFrom 2013 and 2022, the proportion of patients referred to palliative care with DNR status decreased from 36% to 18%, while referrals with CPR increased. Advances in cancer therapies, evolving prognostic expectations \u0026nbsp;and shifting societal attitudes towards aggressive treatment may have contributed to this trend.[46,47] Despite the initial preference for CPR at referral, the majority of patients \u0026nbsp;transitioned to DNR before death (79-88%), with the exception of a decline to 72% in 2021. This pattern highlights the essential role of palliative care in facilitating informed decision making and guiding transition toward comfort-oriented care near the end-of-life.[32,48]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eImplications for practice and policy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study demonstrates a clear trend toward increased DNR designation among terminally ill cancer patients referred to palliative care at Jordan\u0026rsquo;s largest cancer center, with a significant shift from CPR at referral to DNR at the time of death.[8] While clinical factors such as cancer type and longer palliative care duration were associated with this change, demographic variables were not.[49] These findings highlight the importance of early, culturally sensitive, and comprehensive communication regarding end-of-life preferences,[49] and suggest that embedding advance care planning within oncology and palliative care pathways can enhance care quality and alignment with patient values.[24\u0026ndash;26]\u003c/p\u003e\n\u003cp\u003eFrom a practice perspective, integrating structured advance care planning into standard oncology and palliative workflows, coupled with targeted physician training in communication skills, may increase the timeliness and quality of DNR discussions.[14,49] Policy-level interventions are also critical, including the development of a formal national legal framework for DNR orders, clear institutional guidelines, and advocacy for their inclusion in palliative care policy.[8,30] In contexts similar to Jordan, religious and cultural considerations should be explicitly addressed to ensure ethical, acceptable, and patient-centered decision-making.[9,42]\u003c/p\u003e\n\u003cp\u003eAlthough the single-institution design and local policy environment limit the generalizability of these results, the patterns observed provide valuable insight into end-of-life decision-making in a Middle Eastern, predominantly Muslim context.[8] They offer a foundation for legal reform, targeted physician training, and policy advocacy to facilitate timely DNR discussions.[49] Future multi-center and cross-cultural studies, particularly those incorporating patient, family, and healthcare provider perspectives, are essential to validate these findings and adapt best practices for diverse healthcare systems.\u003c/p\u003e\n\u003cp\u003eStrengths and Limitations\u003c/p\u003e\n\u003cp\u003eA key strength of this study is its large sample size spanning a decade, allowing for the examination of longitudinal trends in DNR and CPR designation within a comprehensive cancer center that serves as a national referral hub. The integration of detailed demographic, clinical, and institutional context enhances the interpretation of observed patterns, and the findings provide rare data from a Middle Eastern setting where research on end-of-life decision-making is limited. The study also uniquely documents the influence of legal, cultural, and institutional factors on DNR trends over time, offering insights that are relevant to similar resource-constrained and culturally conservative contexts.\u003c/p\u003e\n\u003cp\u003eHowever, the single-institution, retrospective design limits generalizability to other healthcare settings, particularly those with different legal frameworks, cultural norms, or palliative care integration models. Reliance on medical record documentation may have led to incomplete capture of informal or undocumented code status discussions. Additionally, the absence of qualitative data from patients, families, and providers restricts the ability to fully understand the nuanced factors influencing decision-making. Future research should adopt mixed-methods and multi-center approaches to validate these findings and enhance their applicability across diverse healthcare environments.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study demonstrates a clear trend toward increased DNR designation among terminally ill cancer patients referred to palliative care at the largest cancer center in Jordan, with a notable shift from CPR at referral to DNR at the time of death. While clinical factors such as cancer type and longer palliative care duration were associated with this change, demographic factors were not. These findings underscore the importance of early, culturally sensitive and comprehensive communication regarding end-of-life care preferences and suggest the embedding advance care planning within oncology and palliative care pathways can improve the quality and alignment with patient values. Although\u003cins cite=\"mailto:Waleed%20Alrjoob\" datetime=\"2025-05-04T10:28\"\u003e\u0026nbsp;\u003c/ins\u003ethe single institution design and local policy environment limit the generalizability of these results, the pattern observed provide valuable insight into end-of-life decision-making in a Middle Eastern, predominantly Muslim context. They offer a foundation for legal reform, targeted physician training, and policy advocacy to facilitate timely DNR discussions. Future multi-center and cross-cultural studies, particularly those incorporating patient, family, and healthcare provider perspectives, are essential to validate these findings and adapt best practices for diverse healthcare systems.\u003c/p\u003e\n"},{"header":"Abbreviations","content":"\u003cp\u003eCPR: Cardiopulmonary Resuscitation\u003c/p\u003e\n\u003cp\u003eDNR: Do-Not-Resuscitate\u003c/p\u003e\n\u003cp\u003eKHCC: King Hussein Cancer Center\u003c/p\u003e\n\u003cp\u003eLMIC: Low- and Middle-Income Country\u003c/p\u003e\n\u003cp\u003ePC: Palliative Care\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board (IRB) of King Hussein Cancer Center (Approval No: 18khcc150). The IRB waived the requirement for informed consent due to the retrospective nature of the study. All methods were performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Consent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Competing interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Funding\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Authors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eOS conceptualized and designed the study, supervised the project, analyzed data, and drafted the main manuscript. WA collected data, contributed to analysis, prepared figures/tables, and assisted with drafting. RT performed statistical analysis, prepared figures/tables, and supported manuscript drafting. GA and RS verified data, with RS also managing data entry and review. LA coordinated data collection and reviewed drafts. EA contributed to the literature review, data management, and revisions. AS, FA, MA (Mahmoud), MA (Mohammad), and AM drafted and revised sections for clinical accuracy. HA-R critically reviewed the manuscript, ensured clinical alignment, and approved the final version.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFerlay J, Colombet M, Soerjomataram I, Mathers C, Parkin DM, Pi\u0026ntilde;eros M, et al. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods. 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Lancet. 2020;395:497\u0026ndash;506. \u003c/li\u003e\n\u003cli\u003eRanney ML, Griffeth V, Jha AK. Critical supply shortages\u0026mdash;the need for ventilators and personal protective equipment during the Covid-19 pandemic. N Engl J Med. 2020;382:e41. \u003c/li\u003e\n\u003cli\u003eDragoi L, Munshi L, Herridge M. Visitation policies in the ICU and the importance of family presence at the bedside. Intensive Care Med [Internet]. 2022 [cited 2025 Mar 19];48:1790\u0026ndash;2. Available from: https://doi.org/10.1007/s00134-022-06848-1\u003c/li\u003e\n\u003cli\u003eTruog RD, Mitchell C, Daley GQ. The toughest triage\u0026mdash;allocating ventilators in a pandemic. N Engl J Med. 2020;382:1973\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eLin HM, Liu CK, Huang YC, Ho CW, Chen M. Investigating key factors related to the decision of a do-not-resuscitate consent. Int J Environ Res Public Health. 2022;19. \u003c/li\u003e\n\u003cli\u003eCook I, Kirkup AL, Langham LJ, Malik MA, Marlow G, Sammy I. End of Life Care and Do Not Resuscitate Orders: How Much Does Age Influence Decision Making? A Systematic Review and Meta-Analysis. Gerontol Geriatr Med. 2017;3:233372141771342. \u003c/li\u003e\n\u003cli\u003eHuang BY, Chen HP, Wang Y, Deng YT, Yi TW, Jiang Y. The do-not-resuscitate order for terminal cancer patients in mainland China. Med (United States). 2018;97:1\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eBasubrin O. Assessing Medical Students\u0026rsquo; Understanding of Do-Not-Resuscitate (DNR) Orders. Cureus. 2024;16. \u003c/li\u003e\n\u003cli\u003eKao CY, Wang HM, Tang SC, Huang KG, Jaing TH, Liu CY, et al. Predictive factors for do-not-resuscitate designation among terminally ill cancer patients receiving care from a palliative care consultation service. J Pain Symptom Manage [Internet]. 2014 [cited 2022 Nov 8];47:271\u0026ndash;82. Available from: http://dx.doi.org/10.1016/j.jpainsymman.2013.03.020\u003c/li\u003e\n\u003cli\u003eMottet N, van den Bergh RCN, Briers E, Van den Broeck T, Cumberbatch MG, De Santis M, et al. EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer\u0026mdash;2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol [Internet]. 2021 [cited 2025 Mar 1];79:243\u0026ndash;62. Available from: https://www.sciencedirect.com/science/article/pii/S0302283820307697\u003c/li\u003e\n\u003cli\u003eBennett MI, Ziegler L, Allsop M, Daniel S, Hurlow A. What determines duration of palliative care before death for patients with advanced disease? A retrospective cohort study of community and hospital palliative care provision in a large UK city. BMJ Open [Internet]. 2016 [cited 2022 Aug 22];6:1\u0026ndash;6. Available from: https://bmjopen.bmj.com/content/6/12/e012576\u003c/li\u003e\n\u003cli\u003eBekelman JE, Halpern SD, Blankart CR, Bynum JP, Cohen J, Fowler R, et al. 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Available from: https://www.cambridge.org/core/product/B54FDF26D66371EDD43B4A6FAFFA793C\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e Patient Characteristics (n = 5264)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" title=\"Table 1Patient Characteristics (n= 5264)\" summary=\"Abbreviations: DNR stand for Do not resuscitate; CPR stand for Cardiopulmonary Resuscitation; GIT stand for Gastrointestinal tract; PC indicates palliative care. \" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e2573 (51.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e2691 (48.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e4205 (79.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e458 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e378 (7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e126 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e97 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNationality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eJordan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e4982 (94.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePalestine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e93 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eLibya\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e54(1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eSyria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e80 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eIraq\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e31(0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eOther[1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e24 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCancer type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eGastrointestinal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e1397 (26.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eLung\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e517 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eBreast\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e872 (16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eSkin, soft tissue\u0026amp; Sarcoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e268 (5.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eGenitourinary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e783 (14.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eGynecologic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e364 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHead \u0026amp; neck\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e220 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHematology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e320 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eCNS \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e335 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e188 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFirst encounter sitting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eIn-Patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e3935 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eOut-Patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e1329 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCode Status at time of PC\u003cstrong\u003e[2]\u003c/strong\u003e referral\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eDNR[3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e1390 (26.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eCPR[4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e3874 (73.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCode Status at time of death\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eDNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e4263 (81.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eCPR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e1001 (19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eOther = cancers include endocrine, neuroendocrine, and unknown origin.\u003c/p\u003e\n\u003cp\u003e2PC = Palliative Care\u003c/p\u003e\n\u003cp\u003e3DNR = Do Not Resuscitate.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003eCPR = Cardiopulmonary Resuscitation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e Frequency of CPR vs. DNR Designation by Variables (N = 5,264)\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cu\u003eDNR at Death\u003c/u\u003e\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cu\u003eCPR at Death\u003c/u\u003e\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value[1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eAge at PC[2] referral (M, SD[3])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e59.89 (14.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e59.90 (14.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e.079\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e.078\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e2,210 (82.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e481 (17.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e2,053 (79.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e520 (20.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e.072\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e3,399 (80.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e806 (19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e310 (82.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e68 (18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e373 (81.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e85 (18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e84 (86.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e13 (13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e97 (77.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e29 (23.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNationality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e.091\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eJordan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e4,035 (81.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e947 (19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003ePalestine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e77 (82.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e16 (17.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eSyria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e64 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e16 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eLibya\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e42 (77.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e12 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eIraq\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e27 (87.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e4 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e18 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e6 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFirst encounter setting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e.314\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eInpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e3,186 (81.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e749 (19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eOutpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1,077 (81.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e252 (19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of cancer\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd rowspan=\"11\" valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; .001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eBreast\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e722 (82.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e150 (17.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eGynecologic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e297 (81.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e67 (18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eHead and neck\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e173 (78.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e47 (21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eHematologic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e260 (81.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e60 (18.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eGastrointestinal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1,149 (82.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e248 (17.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eLung\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e421 (81.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e96 (18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eSkin, sarcoma, soft tissue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e216 (80.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e52 (19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eGenitourinary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e615 (76.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e186 (23.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eCNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e266 (79.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e69 (20.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eOther[4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e144 (76.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e44 (23.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCode status at PC referral\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; .001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eDNR\u003csup\u003e5\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1,324 (95.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e66 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eCPR\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e2,939 (75.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e935 (24.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eP-values are based on Pearson\u0026rsquo;s chi-square test and independent t-test. Values in bold are statistically significant (p \u0026lt; .05).\u003c/p\u003e\n\u003cp\u003e2PC = Palliative Care\u003c/p\u003e\n\u003cp\u003e3SD = Standard Deviation\u003c/p\u003e\n\u003cp\u003e4Other = Cancers include endocrine, neuroendocrine, and unknown origin.\u003c/p\u003e\n\u003cp\u003e5DNR = Do Not Resuscitate.\u003c/p\u003e\n\u003cp\u003e6CPR = Cardiopulmonary Resuscitation\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Do-Not-Resuscitate, resuscitation orders, End-of-life decisions, code status, advanced directives, palliative care ","lastPublishedDoi":"10.21203/rs.3.rs-7461335/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7461335/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e In low- and middle-income countries (LMIC), Do-Not-Resuscitate (DNR) discussions are often delayed or omitted, adversely affecting the quality of end-of-life care. Despite the growing recognition of palliative care, limited evidence exists on the timing and determinants of DNR decisions in these settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective. \u003c/strong\u003eTo assess the prevalence, temporal trends and predictors of DNR orders among advanced cancer patients receiving palliative care at a tertiary center in Jordan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe conducted a retrospective review of all deceased advanced cancer patients who received palliative care at the King Hussein Cancer Center between 2013 and 2022. Demographic, clinical, and code status data at referral and at death were extracted from medical records. Descriptive statistics, chi-square tests, and t-tests were used to identify patterns\u003cstrong\u003e \u003c/strong\u003eand associations\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Among 5,264 patients were analyzed, 48.9% female, 79.9% married, and 94.6% Jordanian. The most common cancer types were gastrointestinal (26.5%), breast (16.6%), and genitourinary (14.9%). At referral, 26.4% had a DNR order, increasing to 81% at death. Cancer type was significantly associated with DNR status at death (p \u0026lt; .001), with breast and gastrointestinal cancers more likely to have DNR orders. The proportion of DNR orders at death demonstrated an overall upward trend across the study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThere was a substantial shift from CPR to DNR orders between referral and death primarily influenced by clinical rather than demographic factors. These findings of underscores the importance of early advance care planning and targeted training in culturally sensitive end-of-life communication to promote patient-centered decision making.\u003c/p\u003e","manuscriptTitle":"Prevalence and predictors of Do-Not-Resuscitate orders among advanced cancer patients receiving palliative care at a tertiary cancer center in Jordan: a 10-year retrospective analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-17 08:38:00","doi":"10.21203/rs.3.rs-7461335/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-17T06:03:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-13T12:25:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190916871357455721766462452703797646370","date":"2025-10-30T07:03:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"153037791817240368346354485172680935570","date":"2025-10-24T08:37:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-21T21:18:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"169678104422963979592215781491143033906","date":"2025-10-21T20:41:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"161832532144285629604233434249446034384","date":"2025-10-18T13:30:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-18T15:39:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"232724561165738721486614829613194073388","date":"2025-09-10T21:49:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"39187174775328505938180604188564618744","date":"2025-09-09T23:46:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-09T09:29:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-29T07:27:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-28T02:59:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-28T02:59:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2025-08-26T09:22:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"73ce201d-892a-40bd-9a44-dbdeda016c09","owner":[],"postedDate":"September 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T16:10:08+00:00","versionOfRecord":{"articleIdentity":"rs-7461335","link":"https://doi.org/10.1186/s12904-026-01995-4","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2026-05-01 15:57:16","publishedOnDateReadable":"May 1st, 2026"},"versionCreatedAt":"2025-09-17 08:38:00","video":"","vorDoi":"10.1186/s12904-026-01995-4","vorDoiUrl":"https://doi.org/10.1186/s12904-026-01995-4","workflowStages":[]},"version":"v1","identity":"rs-7461335","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7461335","identity":"rs-7461335","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}