Family Satisfaction with the End-of-life discussions and resuscitation orders for patients with severe COVID-19: A multicenter study in Saudi Arabia

Family Satisfaction with the End-of-life discussions and resuscitation orders for patients with severe COVID-19: A multicenter study in Saudi Arabia | 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 Family Satisfaction with the End-of-life discussions and resuscitation orders for patients with severe COVID-19: A multicenter study in Saudi Arabia Abdullah Mobeireek, Hamdan Al-Jahdali, Ahmed Aljohaney, Nuha Al-Rajhi, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6212653/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Jul, 2025 Read the published version in BMC Medical Ethics → Version 1 posted 9 You are reading this latest preprint version Abstract Background Despite the significant mortality, data on end-of-life (EoL) discussions during COVID-19 pandemic are scarce. Health care providers had to cope with significant challenges, particularly overcoming barriers to effective communication with patients and their families, and lack of information on therapy and prognosis. This study was undertaken to assess the satisfaction of close family members (CFMs) with EoL discussions for patients hospitalized with severe COVID-19 infection. Methods The study was conducted in five major hospitals in Saudi Arabia. Medical charts of consecutive patients who died from COVID-19 complications were retrospectively reviewed.Demographic and clinical data were collected, and communication with close family members (CFMs) about clinical decisions were evaluated. A follow-up telephone interview was conducted using a validated Arabic questionnaire to evaluate satisfaction of CFMs with the EoL discussions prior death. Results EoL discussions were documented in less than half (67, 49.28%) and were often delayed (the median time 19.75 days [range 1–119] after admission. However, in the interviews of the CFMs, 109 of 136 (80.15%) acknowledged that physicians had shared with them information regarding the medical condition of the patient. Most of these discussions were conducted with the CFMs rather than the patients. DNAR orders were implemented in half of the patients, and most CFMs (70%) felt they were appropriate. Satisfaction levels for physicians, were as follows: 61.68% for the adequacy of information provided, 60.00% for time spent, and 61.49% for empathy from physicians. A strong correlation existed between the time spent and both the adequacy of information (rs = 0.89, p < 0.001) and empathy (rs = 0.82, p < 0.001). As for nursing performance, satisfaction was 47.83% for information, 48.06% for time, and 55.81% for empathy. Physicians’ scores were significantly higher than nurses on information sharing (P = 0.022) and time spent (P = 0.05), but there was not significant difference with regards to empathy. Conclusion Despite the challenges associated with the pandemic, there is room for improvement in EoL discussions. Defining roles and fostering coordination between health professionals may enhance satisfaction of patients and their families. physician-patient communication COVID-19 pandemic healthcare professionals physicians nurses autonomy Figures Figure 1 Background Shared decision-making among patients, their close family members (CFM), and healthcare providers is emphasized in the current clinical practice, as it is central to improving patients’ experience and satisfaction. 1 – 5 Multiple studies have indicated that end-of-life discussions (EoL) provide numerous benefits to patients as well as the healthcare system. 1 – 11 However, many factors may impede effective communication with the healthcare provider. Conventional challenges include physicians’ training, lack of experience, limited public awareness, and variability in patients’ values and goals. 12 Even in oncology, where the disease trajectory can often be predicted, discussions regarding the EoL remain challenging. 10 , 11 In other disciplines or emerging events, such as a pandemic, although these discussions are of equal importance, the situation remains unclear. For example, the recent coronavirus disease 2019 (COVID-19) pandemic presented additional barriers arising from the sheer number of severely ill patients, overwhelmed healthcare resources, a disease with an uncertain natural history, transmission risk to healthcare professionals, and infection control policies. 13 – 20 Notably, telephone calls and virtual platforms were used to replace direct in-person communication with patients and their CFMs. 17 , 18 , 20– 22 Interestingly, several studies, mainly in North America and Western Europe, reported that EoL discussions and limitations of life-sustaining therapies were enhanced during the COVID-19 pandemic, with greater involvement of patients and their CFMs in decision-making. 8 , 20 , 21 Furthermore, racial and cultural discrepancies in attitudes toward the intensity of treatment and EoL care for COVID-19 were observed in some studies. 8 , 16 – 17 , 23 – 24 Awareness of these discrepancies is important to improve the experience and satisfaction of patients and their families. However, in other parts of the globe, studies are limited. A recent survey in the Czech Republic highlighted the ethical dilemmas that physician had to deal with information giving and decision-sharing with patients and their families during the crisis time of COVID-19. 19 Also, studies on EoL discussions in the Middle East remain scarce 3 , 25 – 27 , and none were conducted during the COVID-19 pandemic to our knowledge. Although the pandemic status has abated, the risk of yet another pandemic in the next few decades has been increased by urbanization and global climate change. 28 Lessons learnt from the recent COVID-19 pandemic will help equip the healthcare community to engage effectively with patients and their families. Hence, this study was performed to explore the satisfaction levels of the CFMs of patients who died of severe COVID-19 at five major institutions in Saudi Arabia. Methods Settings The study was conducted at five main tertiary care centers in Saudi Arabia King Faisal Specialist Hospital & Research Center (KFSHRC), King Abdulaziz Medical City, King Khalid University Hospital, King Fahad Medical City, all located in Riyadh, and King Abdulaziz University Hospital located in Jeddah. Table 1: Characteristics, comorbidities, and interventions for the patients (n = 136) Characteristic No. % Age (mean + range) Mean 66 ±16.2 Range 22–90 Sex (male) 84 61.76 Nationality (Saudis) 91 66.91 Area of residence : Central Western Others 103 25 8 75.74 18.38 5.88 Comorbidities Hypertension Diabetes Coronary artery disease Chronic renal disease Malignancy Chronic respiratory disease Cerebrovascular disease Chronic liver disease 86 73 33 28 23 19 13 8 63.24 53.68 24.26 20.59 16.91 13.24 9.59 5.88 Interventions High Flow nasal oxygen and (or) non-invasive ventilation Mechanical ventilation Inotropes Renal dialysis ECMO # 88 100 75 43 4 64.70 73.53 55.15 31.61 2.94 Length of stay (days) Median 16 IQR 8–27 Cause of death Respiratory failure Multi-organ failure Cardiac cause Miscellaneous 108 51 24 11 79.41 37.50 17.65 8.09 The interval between DNAR* decision and death: (n = 71) 1–3 days 3 days > 2 weeks 25 18 17 11 35.21 25.35 23.94 15.49 Place of death ICU on mechanical Ventilation ICU with no mechanical ventilation The ward Emergency department 96 10 26 3 70.58 7.35 19.11 2.20 The interval between DNAR decision and death: (n = 71) 1–3 days 3 days > 2 weeks 25 18 17 11 35.21 25.35 24.6 14.5 # ECMO: extracorporeal membrane circulation *DNAR: Do Not Attempt Resuscitation. Study design and procedure This study adopted a mixed research design consisting of a retrospective chart review and a prospective survey. We collected data from the electronic medical records of all patients who died directly due to COVID-19-related complications from 25 April 2020 to 20 June 2022 Data collected included demographics, clinical characteristics, management, the extent of patient–doctor communication, documentation of the communications, and the Do Not Attempt Resuscitation (DNAR) decision. This was followed by a telephone survey with the CFMs 2–6 months following the patient’s death. The questionnaire was administered by experienced and trained interviewers. Attempts to contact CFMs were performed up to three times including at least one attempt made after business hours. The questionnaire was designed to assess EoL discussions and the satisfaction of CFMs with the physicians’ and nurses’ communication process, particularly adequacy of information and the time given for these discussions, and empathy. The questionnaire survey was conducted in Arabic and was validated on a sample of patients before being used across the participating centers. The English and Arabic versions of the questionnaire are attached as supplementary information (Appendix 1). Participants This study included all consecutive adult patients aged over 14 years who died as a result of COVID-19 or related complications. Patients were excluded if they were younger than 14 years, if their deaths were attributed to causes other than COVID-19, if they lacked a confirmed COVID-19 diagnosis, or if their CFMs) did not consent to participate in the survey. Outcome variables The primary outcome measured was the satisfaction level regarding EoL discussions as perceived by the CFMs. Secondary outcomes encompassed several aspects: the occurrence of EoL discussions and DNAR orders with patients prior to the escalation of care; EoL discussions and DNAR orders with the CFMs before the escalation of care; EoL discussions and DNAR orders with relatives or CFMs regarding the ceiling of care; and the documentation of these discussions in the medical records. Data collection and analysis Data were collected using RedCap. 29 , 30 Descriptive statistics were used to describe demographics, patient characteristics, comorbidities, and place of care. The communication skills and expression of empathy of physicians and nurses were assessed using a 5-point Likert scale, with 1 indicating not satisfied and 5 indicating very satisfied . To effectively present the results, the scale was dichotomized into two categories: satisfied and not satisfied. The reliability of the CFMs’ survey was analyzed using Cronbach’s alpha. Spearmen’s correlation was used to analyze Likert scale data. Likert scale data are presented as numbers, percentages and medians. Statistical analyses were performed using IBM SPSS Statistics for Windows version 29.0 (IBM Corp., Armonk, NY, USA). Results Demographics Data were collected from 138 consecutive patients who died due to COVID-19 infection at the 5 centers. Only two of the CFMs did not agree to participate, and their cases were thus excluded. Out of the total 136, 128 (94.12%) patients were of Arab ethnicity, including 91 (66.91%) Saudi nationals and 35 (25.76 non-Saudi Arabs; 10 (7,35%) were non-Arabs. Out of the total 136 cases, 84 (61.76%) were men and 52 (38.24%) were women; 57 (41.91%) were aged > 70 years (33 men and 25 women); and 103 (75.74%) were living in the central region ( Table 1 ) . In the prospective satisfaction survey from the CFMs, most respondents were men (80%), Saudis (68%), and lived in the central region (74%). Furthermore, all of them were Muslim. Relevant comorbidities included hypertension in 86 (63.24%); diabetes in 73 (53.68%); coronary artery disease in 33 (24.26%); chronic renal disease in 28 (20.59%); malignancy in 23 (16.91%); chronic respiratory disease in 18 (13.24%); cerebrovascular disease in 13 (9.59%), and chronic liver disease in 8 (5.88%). Of the 136 patients, 117 (86.03%) were admitted to the ICU. Eighty-eight (64.70%) patients were managed with a high-flow nasal cannula and/or noninvasive ventilation (HFNC/NIV); 100 (73.53%) were subjected to mechanical ventilation; and 75 (55.15%) used vasopressors; moreover, 4 (2.94%) patients required extracorporeal membrane oxygenation (ECMO) support. The median length of hospital stay was 16 days (interquartile range [IQR]: 7.25–27 days) and ranged from 1 to 65 days (mean ± standard deviation = 19.7 ± 15.3 days). The causes of death included respiratory failure due to COVID-19 pneumonia in 108 (79.41%), multi-organ failure in 51 (37.50%), cardiac causes in 24(17.65%), and sepsis in 11 (8.09%). EoL discussions between physicians, patients, and their CFMs EoL discussions with CFMs were documented in less than half (67, 49.28%) of the medical charts. The median interval between the admission and discussions was 19.75 days (range 1–119 days) in 45 cases where information was documented. Out of the 67, EoL discussions with CFMs on values and goals of treatment were documented in 37 (55%) patients. A conservative palliative versus aggressive management was discussed with in 42 (30.88%) cases [directly with 11 (26.19%) patients and with their CFMs in 31/42 cases (73.81%)]. The prospective survey revealed that 109/136 (80.15%) of the CFMs acknowledged that physicians had discussed with them regarding the medical condition of the patient. Of those, 87 (79.82%) stated that physicians specifically discussed diagnoses and prognoses with them, and 72 (66.06%) had a discussion regarding the management strategy (aggressive versus palliative). Furthermore, 59 (43.38%) received the explanation in person, whereas 76 (55.88%) stated that information and updates on the patients’ conditions were delivered by physicians by telephone. Most of these discussions were conducted with the CFMs rather than the patients, often because the patients were too ill. Details are presented in Table 2 . Table 2 Information obtained by phone survey from the CFMs on discussions regarding end-of-life care Question Yes No. (%) No No. (%) & Reason: CFMs* doesn’t know -Did physicians inform the patient on diagnosis and prognosis? 32 (23.53) 104 (76.47) -The patient was too ill: 71 (68.2) -Physicians didn’t tell: 23 (22.11) -Miscellaneous: 10 (9.61) -Did physicians inform the CFMs on diagnosis and prognosis? 87 (63.97) 49 (36.03) -Physicians didn’t tell: 32 (65.31) -The CFMs did not ask: 1 (2.04) -Miscellaneous: 16 (32.65) -Did physicians discuss aggressive versus palliative options with the patient? 10 (7.35) 110 (80.88) -The patient was too ill: 69 (50.37) -Physician didn’t tell: 34 (30.90) -The patient didn’t ask: 2 (1.82) -Miscellaneous: 5 (3.67) 16 (11.76) -Did physicians discuss aggressive versus palliative options with the CFMs? 72 (52.94) 58 (42.65) -Physician didn’t tell: 37 (63.79) -The CFMs didn’t ask: 4 (2.94) -Miscellaneous: 17 (12.5) 6 (4.41) *CFMs: Close family members. DNAR discussions DNAR orders were implemented in 68 (50.00%) of the total 136. Of the 68, 41/68 (60.29%) were discussed with the CFMs; only in one instance it was conducted with the patient, and the remainder were purely based on medical decisions. Other interventions that were still permitted in those patients included: noninvasive ventilation in 24/68 (35.29%), use of inotropes and vasopressors in 20/68 (29.41%), and in 11/68 (16.18%) it was decided that there will be no escalation of therapy. Of 60 of the CFMs who expressed their feelings about the DNAR order, 42 (70.00%) patients felt the DNAR decision was appropriate; 32/42 (76.19%) of these cases were based on trust in the attending physician’s decision; and 10/42 (23.80%) were based on keeping with the patient and family’s wishes. On the other hand, 18 (30.00%) of the CFMs felt the DNAR decision was inappropriate. The intervals from DNAR designation and death are presented in Table 1 . DNAR decisions were often made shortly before death, with over a third occurring in < 24 hours. Regarding the place of death, most mortality cases occurred in the ICU while on assisted ventilation (96/136; 70.59%), followed by the ward (26/136; 9.12%). Satisfaction of the CFMs The communication and empathy of physicians and nurses were assessed using a Likert scale of 1 to 5, with 1 indicating not satisfied and 5 indicating very satisfied . The Cronbach’s alpha was 0.91. Regarding the total instances of communication with the physicians, 84 (61.68%) of the CFMs were satisfied with the information provided, 81 (60.00%) agreed that they were satisfied with the time taken to explain the condition, 83 (61.49%) were satisfied about the physicians’ empathy (Table 3 & Fig. 1 ). Table 3 Satisfaction of the CFMs regarding EoL discussions with physicians and nurses Response Healthcare professional Very satisfied (%) Somewhat satisfied (%) Neutral (%) Somewhat dissatisfied Totally dissatisfied A. Discussions with physicians - Adequacy of information 55 (40.04) 29 (21.64) 7 (5.22) 11(8.21) 32 (23.88) - Adequacy of Time 56 (41.48) 25 (18.52) 11 (8.15) 12 (8.89) 31 (23.96) - Empathy 62 (45.93) 21(15.56) 14 (10.37) 9 (6.67) 29 (21.48) B. Discussions with nurses : - Adequacy of information 41 (31.78) 22 (17.05) 31 (24.03) 9 (6.98) 26 (20.16) - Adequacy of Time 42 (32.56) 20 (15.50) 33 (25.58) 8 (6.20) 26 (20.16) - Empathy 52 (40.31) 20 (15.50) 28 (21.71) 8 (6.20) 21 (16.28) *CFMs: Close family members, EoL: end-of-life care. A strong correlation was observed between the time taken by the physicians with the adequacy of the information provided ( r s = 0.89; n = 134; p < 0.001), as well as between the time taken and the expression of empathy by physicians ( r s = 0.82; n = 135; p < 0.001). Regarding communication with the nursing team, 132 of 136 the CFMs reported having communicated with the nurses. Of those, 63 (47.83%) of the CFMs were satisfied with the information provided, 62 (48.06%) were satisfied about time taken to explain the condition, and 72 (55.81%) were satisfied about the empathy of the nursing team. There was a very strong correlation between the time spent with the CFMs and information provided by the nursing team r s = 0.86, n = 129, p < 0.001. Moreover, there was a strong correlation between the time spent with the CFMs and the empathy of the nursing team r s = 0.83, n = 129, p < 0.001 . A significant difference was observed between physicians and nurses’ performance in terms of the adequacy of information provided (63% vs 49%, p = 0.022; difference = 14%) and the time given (60% vs 48%, p = 0.05; difference = 12%). However, physicians and nurses expressed comparable levels of empathy (61% vs 56%, p = 0.41; difference = 5%), as per the responses of CFMs. Discussion EoL discussions can be a formidable task requiring a significant amount of experience and adequate time to address the patient and their CFMs’ emotional and psychological needs. 2 , 12 , 13 , 18 However, such a task is vital, as satisfaction of patients and their families is more related to their ICU experience than the final outcome. 5 , 20 Our primary outcome was satisfaction of CFMs in communicating with healthcare providers. We found that a significant proportion of CFMs were dissatisfied with the given information (32% and 27%, respectively) and the time spent during those discussions (33% and 26%, respectively). However, the CFMs were satisfied by and large when communication occurred. Furthermore, EoL discussions were documented in less than half of the cases, and the initiation of such discussions was often delayed. These findings highlight the need more research to explore ways to improve the communication process during such a critical instance in patient care. The differences in the satisfaction of the CFMs in discussions with physicians versus the nurses are interesting. The specific roles of each of these professions in the communication process is still not well defined and awaits further research. 31 However, our results indicate that physicians consider themselves primarily responsible for conveying the information regarding diagnosis and prognosis, taking more time than nurses in doing so, and thus, delivering greater satisfaction to CFMs in this aspect. However, unsurprisingly no significant difference was found in the satisfaction of CFMs with the level of empathy expressed by both sets of healthcare professionals. Teleconsults were implemented to circumvent the COVID-19 restrictions on in-person communication. 18 , 20 , 22 , 32 , 33 Phone calls were found useful for updates, and video conferences were used for more detailed discussions and critical decision-making. 32 Our survey showed that more of the CFMs held EoL discussions (69%) by telephone than by in-person (51.6%), which is similar to another study conducted during the COVID-19 pandemic in the USA. 17 However, despite this advantage in the setting of a pandemic, it was shown that goals of management are more likely to be discussed during in-person encounters 22 and that it was more preferred by patients and their clinicians. 34 Majority of patients admitted to the ICU were subjected to various invasive interventions and died in the ICU, and most of these patients were on ventilators (69.6%). A significant proportion of these patients were of advanced age and had multiple comorbidities, indicating poor outcomes. A possible explanation for this is that at the onset of the pandemic, physicians and patients did not have adequate knowledge about the prognosis. 17 , 35 Ideally, a personalized goal-oriented care plan that is concordant with the patients’ values needs to be established as early as possible. 3 , 14 , 36 However, in our study, only 9.4% of the CFMs reported that the patient expressed preferences on the type of desired care, and none had these legally documented prior to their illness. While living wills or advanced directives and legal surrogates are well-established in Western societies, they are unheard of in the Arab communities. 25 , 26 In our study, EoL discussions were held more frequently with the CFMs than the patients. However, a study in the UK during the COVID-19 pandemic that found 90% of discussions were conducted with patients than with families. 21 This difference possibly highlight cultural differences, specifically the Western principle of individual autonomy, which demands self-determination that promotes individual independence, versus the Middle Eastern/East Asian principle of autonomy, which requires family determination upholding the value of harmonious dependence. 3 , 26 , 37 – 39 These discussions, which usually include DNAR decisions, are stressful and can generate negative emotions, such as feelings of guilt and anxiety. 2 , 3 , 12 , 25 Therefore, many patients and/or their CFMs may delegate the decision to the physician. In our study, over 60% of the CFMs accepted and were satisfied with the DNAR decisions, fully trusted the physicians, or otherwise considered the decisions to be in keeping with the patients’ values. Nevertheless, nearly a quarter felt the decisions were inappropriate and, consequently, were dissatisfied. This study has some limitations. First, it was conducted posthumously rather than contemporaneously. Second, we restricted the scope to patients who passed away from COVID-19. Including survivors in the analysis might have given different results, particularly concerning the satisfaction of the CFMs. However, considering the pandemic restrictions, the feasibility of running such a study contemporaneously would have been challenging. Nevertheless, the strength of our study is that it was supplemented with a prospective survey of the CFMs and thus offers a real-world and timely perspective. Furthermore, we are aware of only one multicenter study that addressed the resuscitation orders in patients with COVID-19. 17 Finally, there is a gap in research on EoL care in the Middle East with its specific cultural milieu and traditional beliefs; results of this study may be generalizable to neighboring countries or communities in diaspora with similar cultural norms and values. Conclusions This study demonstrated that EoL discussions with patients and their families need to be addressed, especially in the context of a pandemic. Healthcare providers and the public need to be educated on EoL discussions, especially for critically ill patients. Specifically, knowing patients’ values and goals and sharing the decision-making with them and their loved ones is essential to meet their satisfaction and improve their ICU experience. This might mitigate some of the challenges when dealing with a disease with an unknown outcome and trajectory, as witnessed at the beginning of COVID-19. We hope that our study will provide baseline data that could aid future studies, education, and policies. Abbreviations CFM: close family member, COVID-19: coronavirus disease 2019, DNAR: Do not attempt resuscitation, EoL: End of life, ICU: Intensive care unit. Declarations Ethical approval and informed consent& This study was approved by the Institutional Review Boards (IRB) of King Faisal Specialist Hospital Research Centre (Project No. 2201251), King Abdullah International Medical Research Centre, King Fahad Medical City and King Khalid University Hospital all located in Riyadh, Saudi Arabia, and King Abdulaziz University Hospital in Jeddah, Saudi Arabia. Informed consent was obtained from all participants in the phone survey, and participation was voluntary (please refer to Supplementary information, the Arabic section). Consent for the chart review, being retrospective and anonymous, was waived by the IRB. National and international ethical standards and policies for conducting research on human subjects, such as the Declaration of Helsinki, were upheld throughout the study. Data availability statement Data may be provided upon reasonable request from Ms. Areej AlFattani MPH, CCRP, Biostatistics, Epidemiology and Scientific computing, King Faisal Hospital & Research Centre, Riyadh, Saudi Arabia, Tel: +966114647272, Ext: 32143, [email protected] . Competing interests None to any of the authors. Funding No funding for this project. Authors’ contributions: A Mobeireek: conception of the project & coordination, writing the initial manuscript, interviews of the subjects, analysis of the results. H Al-Jahdali, L Ahmed: Design of the work, data acquisition and interpretation, and revision of the manuscript. A Aljohaney, N Al-Rajhi, S Al-Fadhli, H Lababidi: Data acquisition and revision of the manuscript. 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Kennedy NR, Steinberg A, Arnold RM, et al. Perspectives on telephone and video communication in the intensive care unit during COVID-19. Ann Am Thorac Soc. 2021;18(5):838–847. Paladino J, Mitchell S, Mohta N, et al. Communication tools to support advance care planning and hospital care during the COVID-19 pandemic: a design process. The Jt Comm J Qual Patient Saf. 2020;47(2):127–136. Crook RL, Iftikhar H, Moore S et al. A comparison of in-person versus telephone consultations for outpatient hospital care. Future Healthc J. 2022;9(2):154–160. Doi: 10.7861/fhj.2022-0006. PMID: PMC9345241. Cardona M, Anstey M, Lewis ET, Shanmugam S, Hillman K, Psirides A. Appropriateness of intensive care treatments near the end of life during the COVID-19 pandemic. Breathe (Sheff). 2020;16(2):200062. doi: 10.1183/20734735.0062-2020. PMID: 33304408; PMCID: PMC7714540. Sudore RL, Lum HD, You JJ, et al. Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi panel. J Pain Symptom Manag. 2017;53(5):821–832.e1. Fan R. Self‐determination vs. family‐determination: two incommensurable principles of autonomy. Bioethics. 1997;11(3-4):309–322. Lim MYH. Patient autonomy in an East-Asian cultural milieu: a critique of the individualism-collectivism model. J Med Ethics. 2024; 50(9):640–642. doi: 10.1136/medethics-2022-108123. PMID: 35672134. Mobeireek AF, Al-Kassimi F, Al-Zahrani K, et al. Information disclosure and decision-making: the Middle East versus the Far East and the West. J Med Ethics. 2008;34(4):225–229. Additional Declarations No competing interests reported. Supplementary Files EOLCOVIDQuestionnaireF8Mar25.pdf Appendix 1 Cite Share Download PDF Status: Published Journal Publication published 26 Jul, 2025 Read the published version in BMC Medical Ethics → Version 1 posted Editorial decision: Revision requested 09 May, 2025 Reviews received at journal 30 Apr, 2025 Reviews received at journal 25 Apr, 2025 Reviewers agreed at journal 25 Apr, 2025 Reviewers agreed at journal 24 Apr, 2025 Reviewers invited by journal 24 Apr, 2025 Editor assigned by journal 01 Apr, 2025 Submission checks completed at journal 01 Apr, 2025 First submitted to journal 01 Apr, 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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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-6212653","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":448656037,"identity":"afeca5b8-ce1a-4b6a-ade6-fa42c7de0c65","order_by":0,"name":"Abdullah Mobeireek","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYFACHgaGBCAlwd7AwEyiFp4DpGgBAQmJBCK16Lb3HnzwcI+NnOTMN4afCypsGPjbuxPwajE7cy7ZIOFZmrG0dI6x9IwzaQwSZ85uwK/lRo6ZRMKBw4nzpHMMpHnbDjMYSOQS1GL+I+HA//p5kmeMfxOrxYwh4cCBBGkJHjMibQH6BeiwZMOZPWll1jxn0ngI++V478GPPw7YyUscP7z5Nk+FjRx/ey9+LUiAwwBE8hCrHATYH5CiehSMglEwCkYQAADPJEcGe2ZMPwAAAABJRU5ErkJggg==","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Centre","correspondingAuthor":true,"prefix":"","firstName":"Abdullah","middleName":"","lastName":"Mobeireek","suffix":""},{"id":448656038,"identity":"0dfa2b64-fc98-42de-998f-05d0f36d927a","order_by":1,"name":"Hamdan Al-Jahdali","email":"","orcid":"","institution":"King Abdulaziz Medical City Riyadh","correspondingAuthor":false,"prefix":"","firstName":"Hamdan","middleName":"","lastName":"Al-Jahdali","suffix":""},{"id":448656039,"identity":"82291e48-3ed1-4b9c-adb7-4ff271184759","order_by":2,"name":"Ahmed Aljohaney","email":"","orcid":"","institution":"King Abdulaziz University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Aljohaney","suffix":""},{"id":448656040,"identity":"b067c66e-8598-4796-adda-4c3f9675816d","order_by":3,"name":"Nuha Al-Rajhi","email":"","orcid":"","institution":"King Khalid University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nuha","middleName":"","lastName":"Al-Rajhi","suffix":""},{"id":448656041,"identity":"2de01e7f-84a3-43d4-9938-8540af1c6558","order_by":4,"name":"Salem Al-Fadhli","email":"","orcid":"","institution":"King Fahad Medical City","correspondingAuthor":false,"prefix":"","firstName":"Salem","middleName":"","lastName":"Al-Fadhli","suffix":""},{"id":448656042,"identity":"5587aeec-590e-40d0-b7c4-50314c3bc303","order_by":5,"name":"Hani Lababidi","email":"","orcid":"","institution":"King Fahad Medical City","correspondingAuthor":false,"prefix":"","firstName":"Hani","middleName":"","lastName":"Lababidi","suffix":""},{"id":448656043,"identity":"b7cfe2ad-9054-4bff-8878-f632d1948949","order_by":6,"name":"Abeer Al-Firm","email":"","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Centre","correspondingAuthor":false,"prefix":"","firstName":"Abeer","middleName":"","lastName":"Al-Firm","suffix":""},{"id":448656044,"identity":"71fe5a34-243c-453d-865d-edb5ffed4407","order_by":7,"name":"Areej AlFattani","email":"","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Centre","correspondingAuthor":false,"prefix":"","firstName":"Areej","middleName":"","lastName":"AlFattani","suffix":""},{"id":448656045,"identity":"dcdb48f1-1a2a-4556-aa1a-4304b6f77d54","order_by":8,"name":"Liju Ahmed","email":"","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Centre","correspondingAuthor":false,"prefix":"","firstName":"Liju","middleName":"","lastName":"Ahmed","suffix":""}],"badges":[],"createdAt":"2025-03-12 13:53:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6212653/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6212653/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12910-025-01248-8","type":"published","date":"2025-07-26T15:57:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82146481,"identity":"9c26a12d-c517-42fe-a3a9-9a171825ff04","added_by":"auto","created_at":"2025-05-07 06:55:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":242463,"visible":true,"origin":"","legend":"\u003cp\u003eSatisfaction of close family members toward the communication of physicians and nurses\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6212653/v1/0612ceac217e98215eeec686.png"},{"id":87756797,"identity":"7a46d9b2-3545-4ae8-8a2d-4b11629dc28c","added_by":"auto","created_at":"2025-07-28 16:09:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1210488,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6212653/v1/21fbee88-bd05-4946-a5ba-450dfa59d7cd.pdf"},{"id":82146485,"identity":"fa8f727a-2acd-4af4-b91d-d9e34dbbaec5","added_by":"auto","created_at":"2025-05-07 06:55:32","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":210526,"visible":true,"origin":"","legend":"\u003cp\u003eAppendix 1\u003c/p\u003e","description":"","filename":"EOLCOVIDQuestionnaireF8Mar25.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6212653/v1/d14433caa74a3a86fbf40b27.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Family Satisfaction with the End-of-life discussions and resuscitation orders for patients with severe COVID-19: A multicenter study in Saudi Arabia","fulltext":[{"header":"Background","content":"\u003cp\u003eShared decision-making among patients, their close family members (CFM), and healthcare providers is emphasized in the current clinical practice, as it is central to improving patients\u0026rsquo; experience and satisfaction.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Multiple studies have indicated that end-of-life discussions (EoL) provide numerous benefits to patients as well as the healthcare system.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e However, many factors may impede effective communication with the healthcare provider. Conventional challenges include physicians\u0026rsquo; training, lack of experience, limited public awareness, and variability in patients\u0026rsquo; values and goals.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Even in oncology, where the disease trajectory can often be predicted, discussions regarding the EoL remain challenging.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e In other disciplines or emerging events, such as a pandemic, although these discussions are of equal importance, the situation remains unclear. For example, the recent coronavirus disease 2019 (COVID-19) pandemic presented additional barriers arising from the sheer number of severely ill patients, overwhelmed healthcare resources, a disease with an uncertain natural history, transmission risk to healthcare professionals, and infection control policies.\u003csup\u003e\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18 CR19\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Notably, telephone calls and virtual platforms were used to replace direct in-person communication with patients and their CFMs.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, 20\u0026ndash; \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Interestingly, several studies, mainly in North America and Western Europe, reported that EoL discussions and limitations of life-sustaining therapies were enhanced during the COVID-19 pandemic, with greater involvement of patients and their CFMs in decision-making.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Furthermore, racial and cultural discrepancies in attitudes toward the intensity of treatment and EoL care for COVID-19 were observed in some studies.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Awareness of these discrepancies is important to improve the experience and satisfaction of patients and their families. However, in other parts of the globe, studies are limited. A recent survey in the Czech Republic highlighted the ethical dilemmas that physician had to deal with information giving and decision-sharing with patients and their families during the crisis time of COVID-19.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Also, studies on EoL discussions in the Middle East remain scarce \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e, and none were conducted during the COVID-19 pandemic to our knowledge.\u003c/p\u003e \u003cp\u003eAlthough the pandemic status has abated, the risk of yet another pandemic in the next few decades has been increased by urbanization and global climate change.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Lessons learnt from the recent COVID-19 pandemic will help equip the healthcare community to engage effectively with patients and their families. Hence, this study was performed to explore the satisfaction levels of the CFMs of patients who died of severe COVID-19 at five major institutions in Saudi Arabia.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSettings\u003c/h2\u003e \u003cp\u003eThe study was conducted at five main tertiary care centers in Saudi Arabia King Faisal Specialist Hospital \u0026amp; Research Center (KFSHRC), King Abdulaziz Medical City, King Khalid University Hospital, King Fahad Medical City, all located in Riyadh, and King Abdulaziz University Hospital located in Jeddah.\u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cstrong\u003eTable 1: Characteristics, comorbidities, and interventions for the patients (n = 136)\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003eAge (mean + range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMean 66 \u0026plusmn;16.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eRange 22\u0026ndash;90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003eSex (male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e61.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003eNationality (Saudis)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e66.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eArea of residence\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003eCentral\u003c/p\u003e\n \u003cp\u003eWestern\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e75.74\u003c/p\u003e\n \u003cp\u003e18.38\u003c/p\u003e\n \u003cp\u003e5.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidities\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003cp\u003eCoronary artery disease\u003c/p\u003e\n \u003cp\u003eChronic renal disease\u003c/p\u003e\n \u003cp\u003eMalignancy\u003c/p\u003e\n \u003cp\u003eChronic respiratory disease\u003c/p\u003e\n \u003cp\u003eCerebrovascular disease\u003c/p\u003e\n \u003cp\u003eChronic liver disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e63.24\u003c/p\u003e\n \u003cp\u003e53.68\u003c/p\u003e\n \u003cp\u003e24.26\u003c/p\u003e\n \u003cp\u003e20.59\u003c/p\u003e\n \u003cp\u003e16.91\u003c/p\u003e\n \u003cp\u003e13.24\u003c/p\u003e\n \u003cp\u003e9.59\u003c/p\u003e\n \u003cp\u003e5.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterventions\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eHigh Flow nasal oxygen and (or) non-invasive ventilation\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMechanical ventilation\u003c/p\u003e\n \u003cp\u003eInotropes\u003c/p\u003e\n \u003cp\u003eRenal dialysis\u003c/p\u003e\n \u003cp\u003eECMO\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e64.70\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e73.53\u003c/p\u003e\n \u003cp\u003e55.15\u003c/p\u003e\n \u003cp\u003e31.61\u003c/p\u003e\n \u003cp\u003e2.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength of stay (days)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMedian 16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eIQR 8\u0026ndash;27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCause of death\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eRespiratory failure\u003c/li\u003e\n \u003cli\u003eMulti-organ failure\u003c/li\u003e\n \u003cli\u003eCardiac cause\u003c/li\u003e\n \u003cli\u003eMiscellaneous\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 108\u003c/p\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e79.41\u003c/p\u003e\n \u003cp\u003e37.50\u003c/p\u003e\n \u003cp\u003e17.65\u003c/p\u003e\n \u003cp\u003e8.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe interval between DNAR* decision and death: (n = 71)\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026lt;24 h\u003c/li\u003e\n \u003cli\u003e\u0026gt;1\u0026ndash;3 days\u003c/li\u003e\n \u003cli\u003e3 days\u003c/li\u003e\n \u003cli\u003e\u0026gt; 2 weeks\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35.21\u003c/p\u003e\n \u003cp\u003e25.35\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23.94\u003c/p\u003e\n \u003cp\u003e15.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of death\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eICU on mechanical Ventilation\u003c/p\u003e\n \u003cp\u003eICU with no mechanical ventilation\u003c/p\u003e\n \u003cp\u003eThe ward\u003c/p\u003e\n \u003cp\u003eEmergency department\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003cp\u003e3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e70.58\u003c/p\u003e\n \u003cp\u003e7.35\u003c/p\u003e\n \u003cp\u003e19.11\u003c/p\u003e\n \u003cp\u003e2.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe interval between DNAR decision and death: (n = 71)\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026lt;24 h\u003c/li\u003e\n \u003cli\u003e\u0026gt;1\u0026ndash;3 days\u003c/li\u003e\n \u003cli\u003e3 days\u003c/li\u003e\n \u003cli\u003e\u0026gt; 2 weeks\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35.21\u003c/p\u003e\n \u003cp\u003e25.35\u003c/p\u003e\n \u003cp\u003e24.6\u003c/p\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003csup\u003e#\u003c/sup\u003eECMO: extracorporeal membrane circulation\u003c/p\u003e\n\u003cp\u003e*DNAR: Do Not Attempt Resuscitation.\u003c/p\u003e\n\n\u003ch3\u003eStudy design and procedure\u003c/h3\u003e\n\u003cp\u003e This study adopted a mixed research design consisting of a retrospective chart review and a prospective survey. We collected data from the electronic medical records of all patients who died directly due to COVID-19-related complications from 25 April 2020 to 20 June 2022 Data collected included demographics, clinical characteristics, management, the extent of patient\u0026ndash;doctor communication, documentation of the communications, and the Do Not Attempt Resuscitation (DNAR) decision.\u003c/p\u003e \u003cp\u003eThis was followed by a telephone survey with the CFMs 2\u0026ndash;6 months following the patient\u0026rsquo;s death. The questionnaire was administered by experienced and trained interviewers. Attempts to contact CFMs were performed up to three times including at least one attempt made after business hours. The questionnaire was designed to assess EoL discussions and the satisfaction of CFMs with the physicians\u0026rsquo; and nurses\u0026rsquo; communication process, particularly adequacy of information and the time given for these discussions, and empathy. The questionnaire survey was conducted in Arabic and was validated on a sample of patients before being used across the participating centers. The English and Arabic versions of the questionnaire are attached as supplementary information (Appendix 1).\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThis study included all consecutive adult patients aged over 14 years who died as a result of COVID-19 or related complications. Patients were excluded if they were younger than 14 years, if their deaths were attributed to causes other than COVID-19, if they lacked a confirmed COVID-19 diagnosis, or if their CFMs) did not consent to participate in the survey.\u003c/p\u003e\n\u003ch3\u003eOutcome variables\u003c/h3\u003e\n\u003cp\u003eThe primary outcome measured was the satisfaction level regarding EoL discussions as perceived by the CFMs. Secondary outcomes encompassed several aspects: the occurrence of EoL discussions and DNAR orders with patients prior to the escalation of care; EoL discussions and DNAR orders with the CFMs before the escalation of care; EoL discussions and DNAR orders with relatives or CFMs regarding the ceiling of care; and the documentation of these discussions in the medical records.\u003c/p\u003e\n\u003ch3\u003eData collection and analysis\u003c/h3\u003e\n\u003cp\u003eData were collected using RedCap.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Descriptive statistics were used to describe demographics, patient characteristics, comorbidities, and place of care. The communication skills and expression of empathy of physicians and nurses were assessed using a 5-point Likert scale, with 1 indicating \u003cem\u003enot satisfied\u003c/em\u003e and 5 indicating \u003cem\u003every satisfied\u003c/em\u003e. To effectively present the results, the scale was dichotomized into two categories: satisfied and not satisfied. The reliability of the CFMs\u0026rsquo; survey was analyzed using Cronbach\u0026rsquo;s alpha. Spearmen\u0026rsquo;s correlation was used to analyze Likert scale data. Likert scale data are presented as numbers, percentages and medians. Statistical analyses were performed using IBM SPSS Statistics for Windows version 29.0 (IBM Corp., Armonk, NY, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eDemographics\u003c/h2\u003e\n \u003cp\u003eData were collected from 138 consecutive patients who died due to COVID-19 infection at the 5 centers. Only two of the CFMs did not agree to participate, and their cases were thus excluded. Out of the total 136, 128 (94.12%) patients were of Arab ethnicity, including 91 (66.91%) Saudi nationals and 35 (25.76 non-Saudi Arabs; 10 (7,35%) were non-Arabs. Out of the total 136 cases, 84 (61.76%) were men and 52 (38.24%) were women; 57 (41.91%) were aged\u0026thinsp;\u0026gt;\u0026thinsp;70 years (33 men and 25 women); and 103 (75.74%) were living in the central region \u003cstrong\u003e(\u003c/strong\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. In the prospective satisfaction survey from the CFMs, most respondents were men (80%), Saudis (68%), and lived in the central region (74%). Furthermore, all of them were Muslim.\u003c/p\u003e\n \u003cdiv\u003eRelevant comorbidities included hypertension in 86 (63.24%); diabetes in 73 (53.68%); coronary artery disease in 33 (24.26%); chronic renal disease in 28 (20.59%); malignancy in 23 (16.91%); chronic respiratory disease in 18 (13.24%); cerebrovascular disease in 13 (9.59%), and chronic liver disease in 8 (5.88%). Of the 136 patients, 117 (86.03%) were admitted to the ICU. Eighty-eight (64.70%) patients were managed with a high-flow nasal cannula and/or noninvasive ventilation (HFNC/NIV); 100 (73.53%) were subjected to mechanical ventilation; and 75 (55.15%) used vasopressors; moreover, 4 (2.94%) patients required extracorporeal membrane oxygenation (ECMO) support.\u003c/div\u003e\n \u003cp\u003eThe median length of hospital stay was 16 days (interquartile range [IQR]: 7.25\u0026ndash;27 days) and ranged from 1 to 65 days (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation\u0026thinsp;=\u0026thinsp;19.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3 days). The causes of death included respiratory failure due to COVID-19 pneumonia in 108 (79.41%), multi-organ failure in 51 (37.50%), cardiac causes in 24(17.65%), and sepsis in 11 (8.09%).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eEoL discussions between physicians, patients, and their CFMs\u003c/h3\u003e\n\u003cp\u003eEoL discussions with CFMs were documented in less than half (67, 49.28%) of the medical charts. The median interval between the admission and discussions was 19.75 days (range 1\u0026ndash;119 days) in 45 cases where information was documented. Out of the 67, EoL discussions with CFMs on values and goals of treatment were documented in 37 (55%) patients. A conservative palliative versus aggressive management was discussed with in 42 (30.88%) cases [directly with 11 (26.19%) patients and with their CFMs in 31/42 cases (73.81%)].\u003c/p\u003e\n\u003cp\u003eThe prospective survey revealed that 109/136 (80.15%) of the CFMs acknowledged that physicians had discussed with them regarding the medical condition of the patient. Of those, 87 (79.82%) stated that physicians specifically discussed diagnoses and prognoses with them, and 72 (66.06%) had a discussion regarding the management strategy (aggressive versus palliative). Furthermore, 59 (43.38%) received the explanation in person, whereas 76 (55.88%) stated that information and updates on the patients\u0026rsquo; conditions were delivered by physicians by telephone. Most of these discussions were conducted with the CFMs rather than the patients, often because the patients were too ill. Details are presented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eInformation obtained by phone survey from the CFMs on discussions regarding end-of-life care\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eQuestion\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo. (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eNo. (%) \u0026amp; Reason:\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCFMs* doesn\u0026rsquo;t know\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-Did physicians inform the patient on diagnosis and prognosis?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32 (23.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e104 (76.47)\u003c/p\u003e\n \u003cp\u003e-The patient was too ill: 71 (68.2)\u003c/p\u003e\n \u003cp\u003e-Physicians didn\u0026rsquo;t tell: 23 (22.11)\u003c/p\u003e\n \u003cp\u003e-Miscellaneous: 10 (9.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-Did physicians inform the CFMs on diagnosis and prognosis?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e87 (63.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49 (36.03)\u003c/p\u003e\n \u003cp\u003e-Physicians didn\u0026rsquo;t tell: 32 (65.31)\u003c/p\u003e\n \u003cp\u003e-The CFMs did not ask: 1 (2.04)\u003c/p\u003e\n \u003cp\u003e-Miscellaneous: 16 (32.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-Did physicians discuss aggressive versus palliative options with the patient?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10 (7.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e110 (80.88)\u003c/p\u003e\n \u003cp\u003e-The patient was too ill: 69 (50.37)\u003c/p\u003e\n \u003cp\u003e-Physician didn\u0026rsquo;t tell: 34 (30.90)\u003c/p\u003e\n \u003cp\u003e-The patient didn\u0026rsquo;t ask: 2 (1.82)\u003c/p\u003e\n \u003cp\u003e-Miscellaneous: 5 (3.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16 (11.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-Did physicians discuss aggressive versus palliative options with the CFMs?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e72 (52.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58 (42.65)\u003c/p\u003e\n \u003cp\u003e-Physician didn\u0026rsquo;t tell: 37 (63.79)\u003c/p\u003e\n \u003cp\u003e-The CFMs didn\u0026rsquo;t ask: 4 (2.94)\u003c/p\u003e\n \u003cp\u003e-Miscellaneous: 17 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6 (4.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e*CFMs: Close family members.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eDNAR discussions\u003c/h2\u003e\n \u003cp\u003eDNAR orders were implemented in 68 (50.00%) of the total 136. Of the 68, 41/68 (60.29%) were discussed with the CFMs; only in one instance it was conducted with the patient, and the remainder were purely based on medical decisions. Other interventions that were still permitted in those patients included: noninvasive ventilation in 24/68 (35.29%), use of inotropes and vasopressors in 20/68 (29.41%), and in 11/68 (16.18%) it was decided that there will be no escalation of therapy.\u003c/p\u003e\n \u003cp\u003eOf 60 of the CFMs who expressed their feelings about the DNAR order, 42 (70.00%) patients felt the DNAR decision was appropriate; 32/42 (76.19%) of these cases were based on trust in the attending physician\u0026rsquo;s decision; and 10/42 (23.80%) were based on keeping with the patient and family\u0026rsquo;s wishes. On the other hand, 18 (30.00%) of the CFMs felt the DNAR decision was inappropriate.\u003c/p\u003e\n \u003cp\u003eThe intervals from DNAR designation and death are presented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. DNAR decisions were often made shortly before death, with over a third occurring in \u0026lt;\u0026thinsp;24 hours. Regarding the place of death, most mortality cases occurred in the ICU while on assisted ventilation (96/136; 70.59%), followed by the ward (26/136; 9.12%).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eSatisfaction of the CFMs\u003c/h2\u003e\n \u003cp\u003eThe communication and empathy of physicians and nurses were assessed using a Likert scale of 1 to 5, with 1 indicating \u003cem\u003enot satisfied\u003c/em\u003e and 5 indicating \u003cem\u003every satisfied\u003c/em\u003e. The Cronbach\u0026rsquo;s alpha was 0.91. Regarding the total instances of communication with the physicians, 84 (61.68%) of the CFMs were satisfied with the information provided, 81 (60.00%) agreed that they were satisfied with the time taken to explain the condition, 83 (61.49%) were satisfied about the physicians\u0026rsquo; empathy (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026amp; Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSatisfaction of the CFMs regarding EoL discussions with physicians and nurses\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eResponse\u003c/p\u003e\n \u003cp\u003eHealthcare professional\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVery satisfied (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSomewhat satisfied (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNeutral\u003c/p\u003e\n \u003cp\u003e(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSomewhat dissatisfied\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotally dissatisfied\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eA. Discussions with physicians\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Adequacy of information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e55 (40.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29 (21.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7 (5.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11(8.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32 (23.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Adequacy of Time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e56 (41.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25 (18.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11 (8.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12 (8.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31 (23.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Empathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e62 (45.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21(15.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14 (10.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29 (21.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eB. Discussions with nurses\u003c/strong\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Adequacy of information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41 (31.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22 (17.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31 (24.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9 (6.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26 (20.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Adequacy of Time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42 (32.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20 (15.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33 (25.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8 (6.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26 (20.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Empathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e52 (40.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20 (15.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28 (21.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8 (6.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21 (16.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e*CFMs: Close family members, EoL: end-of-life care.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eA strong correlation was observed between the time taken by the physicians with the adequacy of the information provided (\u003cem\u003er\u003c/em\u003e\u003csub\u003e\u003cem\u003es\u003c/em\u003e\u003c/sub\u003e = 0.89; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;134; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), as well as between the time taken and the expression of empathy by physicians (\u003cem\u003er\u003c/em\u003e\u003csub\u003e\u003cem\u003es\u003c/em\u003e\u003c/sub\u003e = 0.82; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;135; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n \u003cp\u003eRegarding communication with the nursing team, 132 of 136 the CFMs reported having communicated with the nurses. Of those, 63 (47.83%) of the CFMs were satisfied with the information provided, 62 (48.06%) were satisfied about time taken to explain the condition, and 72 (55.81%) were satisfied about the empathy of the nursing team. There was a very strong correlation between the time spent with the CFMs and information provided by the nursing team \u003cem\u003er\u003c/em\u003e\u003csub\u003e\u003cem\u003es\u003c/em\u003e\u003c/sub\u003e \u003cem\u003e= 0.86, n\u0026thinsp;=\u0026thinsp;129, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/em\u003e Moreover, there was a strong correlation between the time spent with the CFMs and the empathy of the nursing team \u003cem\u003er\u003c/em\u003e\u003csub\u003e\u003cem\u003es\u003c/em\u003e\u003c/sub\u003e \u003cem\u003e= 0.83, n\u0026thinsp;=\u0026thinsp;129, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e.\u003c/p\u003e\n \u003cp\u003eA significant difference was observed between physicians and nurses\u0026rsquo; performance in terms of the adequacy of information provided (63% vs 49%, p\u0026thinsp;=\u0026thinsp;0.022; difference\u0026thinsp;=\u0026thinsp;14%) and the time given (60% vs 48%, p\u0026thinsp;=\u0026thinsp;0.05; difference\u0026thinsp;=\u0026thinsp;12%). However, physicians and nurses expressed comparable levels of empathy (61% vs 56%, p\u0026thinsp;=\u0026thinsp;0.41; difference\u0026thinsp;=\u0026thinsp;5%), as per the responses of CFMs.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eEoL discussions can be a formidable task requiring a significant amount of experience and adequate time to address the patient and their CFMs\u0026rsquo; emotional and psychological needs.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e However, such a task is vital, as satisfaction of patients and their families is more related to their ICU experience than the final outcome.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Our primary outcome was satisfaction of CFMs in communicating with healthcare providers. We found that a significant proportion of CFMs were dissatisfied with the given information (32% and 27%, respectively) and the time spent during those discussions (33% and 26%, respectively). However, the CFMs were satisfied by and large when communication occurred. Furthermore, EoL discussions were documented in less than half of the cases, and the initiation of such discussions was often delayed. These findings highlight the need more research to explore ways to improve the communication process during such a critical instance in patient care.\u003c/p\u003e \u003cp\u003eThe differences in the satisfaction of the CFMs in discussions with physicians versus the nurses are interesting. The specific roles of each of these professions in the communication process is still not well defined and awaits further research.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e However, our results indicate that physicians consider themselves primarily responsible for conveying the information regarding diagnosis and prognosis, taking more time than nurses in doing so, and thus, delivering greater satisfaction to CFMs in this aspect. However, unsurprisingly no significant difference was found in the satisfaction of CFMs with the level of empathy expressed by both sets of healthcare professionals.\u003c/p\u003e \u003cp\u003eTeleconsults were implemented to circumvent the COVID-19 restrictions on in-person communication.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Phone calls were found useful for updates, and video conferences were used for more detailed discussions and critical decision-making.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Our survey showed that more of the CFMs held EoL discussions (69%) by telephone than by in-person (51.6%), which is similar to another study conducted during the COVID-19 pandemic in the USA.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e However, despite this advantage in the setting of a pandemic, it was shown that goals of management are more likely to be discussed during in-person encounters\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e and that it was more preferred by patients and their clinicians.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMajority of patients admitted to the ICU were subjected to various invasive interventions and died in the ICU, and most of these patients were on ventilators (69.6%). A significant proportion of these patients were of advanced age and had multiple comorbidities, indicating poor outcomes. A possible explanation for this is that at the onset of the pandemic, physicians and patients did not have adequate knowledge about the prognosis.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e Ideally, a personalized goal-oriented care plan that is concordant with the patients\u0026rsquo; values needs to be established as early as possible.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e However, in our study, only 9.4% of the CFMs reported that the patient expressed preferences on the type of desired care, and none had these legally documented prior to their illness. While living wills or advanced directives and legal surrogates are well-established in Western societies, they are unheard of in the Arab communities.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn our study, EoL discussions were held more frequently with the CFMs than the patients. However, a study in the UK during the COVID-19 pandemic that found 90% of discussions were conducted with patients than with families.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e This difference possibly highlight cultural differences, specifically the Western principle of individual autonomy, which demands self-determination that promotes individual independence, versus the Middle Eastern/East Asian principle of autonomy, which requires family determination upholding the value of harmonious dependence.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e These discussions, which usually include DNAR decisions, are stressful and can generate negative emotions, such as feelings of guilt and anxiety.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Therefore, many patients and/or their CFMs may delegate the decision to the physician. In our study, over 60% of the CFMs accepted and were satisfied with the DNAR decisions, fully trusted the physicians, or otherwise considered the decisions to be in keeping with the patients\u0026rsquo; values. Nevertheless, nearly a quarter felt the decisions were inappropriate and, consequently, were dissatisfied.\u003c/p\u003e \u003cp\u003eThis study has some limitations. First, it was conducted posthumously rather than contemporaneously. Second, we restricted the scope to patients who passed away from COVID-19. Including survivors in the analysis might have given different results, particularly concerning the satisfaction of the CFMs. However, considering the pandemic restrictions, the feasibility of running such a study contemporaneously would have been challenging. Nevertheless, the strength of our study is that it was supplemented with a prospective survey of the CFMs and thus offers a real-world and timely perspective. Furthermore, we are aware of only one multicenter study that addressed the resuscitation orders in patients with COVID-19.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Finally, there is a gap in research on EoL care in the Middle East with its specific cultural milieu and traditional beliefs; results of this study may be generalizable to neighboring countries or communities in diaspora with similar cultural norms and values.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrated that EoL discussions with patients and their families need to be addressed, especially in the context of a pandemic. Healthcare providers and the public need to be educated on EoL discussions, especially for critically ill patients. Specifically, knowing patients\u0026rsquo; values and goals and sharing the decision-making with them and their loved ones is essential to meet their satisfaction and improve their ICU experience. This might mitigate some of the challenges when dealing with a disease with an unknown outcome and trajectory, as witnessed at the beginning of COVID-19. We hope that our study will provide baseline data that could aid future studies, education, and policies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCFM: close family member,\u003c/p\u003e\n\u003cp\u003eCOVID-19: coronavirus disease 2019,\u003c/p\u003e\n\u003cp\u003eDNAR: Do not attempt resuscitation,\u003c/p\u003e\n\u003cp\u003eEoL: End of life,\u003c/p\u003e\n\u003cp\u003eICU: Intensive care unit.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and informed consent\u0026amp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Boards (IRB) of King Faisal Specialist Hospital Research Centre (Project No. 2201251), King Abdullah International Medical Research Centre, King Fahad Medical City and King Khalid University Hospital all located in Riyadh, Saudi Arabia, and King Abdulaziz University Hospital in Jeddah, Saudi Arabia. Informed consent was obtained from all participants in the phone survey, and participation was voluntary (please refer to Supplementary information, the Arabic section). Consent for the chart review, being retrospective and anonymous, was waived by the IRB. National and international ethical standards and policies for conducting research on human subjects, such as the Declaration of Helsinki, were upheld throughout the study.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData may be provided upon reasonable request from Ms. Areej AlFattani MPH, CCRP, Biostatistics, Epidemiology and Scientific computing, King Faisal Hospital \u0026amp; Research Centre, Riyadh, Saudi Arabia, Tel: +966114647272, Ext: 32143, [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone to any of the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding for this project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA Mobeireek:\u0026nbsp;\u003c/strong\u003econception of the project \u0026amp; coordination, writing the initial manuscript, interviews of the subjects, analysis of the results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eH Al-Jahdali, L Ahmed:\u003c/strong\u003e Design of the work, data acquisition and interpretation, and revision of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA Aljohaney, N Al-Rajhi, S Al-Fadhli, H Lababidi:\u003c/strong\u003e Data acquisition and revision of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA Al-Firm\u003c/strong\u003e: Data acquisition and analysis,\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA AlFattani\u003c/strong\u003e: Data computing and statistical analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors are grateful for assistance of Dr. Mohammad AlShahrani in reviewing the original proposal, Dr. Abdullah Alrbiaan for facilitating access to ICU data, and Raneem Alzahrani and Manal AlHagbani for their work on data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eInstitute of Medicine. 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Einstein (S\u0026atilde;o Paulo). 2019;18:eRW4852.\u003c/li\u003e\n\u003cli\u003eRobinson L, Lawrie I, Hard J, et al. Preparing for end-of-life: learning from do not attempt cardiopulmonary resuscitation decision-making during COVID-19. Postgrad Med J. 2023;99(1172):516\u0026ndash;519.\u003c/li\u003e\n\u003cli\u003eCurtis JR, Kross EK, Stapleton RD. The importance of addressing advance care planning and decisions about do-not-resuscitate orders during novel coronavirus 2019 (COVID-19). JAMA. 2020;323(18):1771\u0026ndash;1772.\u003c/li\u003e\n\u003cli\u003eNolan JP, Monsieurs KG, Bossaert L, et al. European resuscitation council COVID-19 guidelines executive summary. Resuscitation. 2020;153:45\u0026ndash;55.\u003c/li\u003e\n\u003cli\u003eKiker WA, Cheng S, Pollack LR, et al. Admission code status and end-of-life care for hospitalized patients with COVID-19. J Pain Symptom Manag. 2022;64(4):359\u0026ndash;369.\u003c/li\u003e\n\u003cli\u003eMoin EE, Okin D, Jesudasen SJ, et al. Code status orders in patients admitted to the intensive care unit with COVID-19: a retrospective cohort study. Resuscitation Plus. 2022;10:100219.\u003c/li\u003e\n\u003cli\u003eReja M, Naik J, Parikh P. COVID-19: implications for advanced care planning and end-of-life care. West J Emerg Med. 2020;21(5):1046\u0026ndash;1047.\u003c/li\u003e\n\u003cli\u003eTietzova I, Buzgova R, Kopecky O. Decision-making and ethical dilemmas experienced by hospital physicians during the COVID-19 pandemic in the Czech Republic. BMC Med Ethics. 2024 Dec 4;25(1):144. doi: 10.1186/s12910-024-01133-w. PMID: 39633385; PMCID: PMC11619269.\u003c/li\u003e\n\u003cli\u003eYounan S, Cardona M, Sahay A, et al. Advanced care planning in the early phase of COVID-19: a rapid review of the practice and policy lessons learned. Front Health Serv. 2023;3:1242413.\u003c/li\u003e\n\u003cli\u003eColeman JJ, Botkai A, Marson EJ, et al. Bringing into focus treatment limitation and DNACPR decisions: how COVID-19 has changed practice. Resuscitation. 2020;155:172\u0026ndash;179.\u003c/li\u003e\n\u003cli\u003ePiscitello GM, Fukushima CM, Saulitis AK, Tian KT, et al. Family meetings in the Intensive Care Unit during the coronavirus disease 2019 pandemic. Am J Hosp Palliat Care. 2021;38(3):305-312. doi: 10.1177/1049909120973431. Epub 2020 Nov 19. PMID: 33207937; PMCID: PMC7859662.\u003c/li\u003e\n\u003cli\u003eBarnato AE, Johnson GR, Birkmeyer JD, et al. Advance care planning and treatment intensity before death among black, hispanic, and white patients hospitalized with COVID-19. J Gen Intern Med. 2022;37(8):1996\u0026ndash;2002.\u003c/li\u003e\n\u003cli\u003eOlds PK, Musinguzi N, Geisler BP, et al. Evaluating disparities in code status designation among patients admitted with COVID-19 at a quaternary care center early in the pandemic. Medicine. 2023;102(30):e34447.\u003c/li\u003e\n\u003cli\u003eAlfayyad IN, Al-Tannir MA, Alessa WA, et al. Physicians and nurses\u0026rsquo; knowledge and attitudes towards advance directives for cancer patients in Saudi Arabia. PLoS One 2019;14(4):e0213938.\u003c/li\u003e\n\u003cli\u003eBaharoon S, Alzahrani M, Alsafi E, et al. Advance directive preferences of patients with chronic and terminal illness towards end of life decisions: a sample from Saudi Arabia. East Mediterr Health J. 2019;25(11):791\u0026ndash;797.\u003c/li\u003e\n\u003cli\u003eMobeireek AF, Al-Kassimi FA, Al-Majid SA, et al. Communication with the seriously ill: physicians\u0026apos; attitudes in Saudi Arabia. J Med Ethics. 1996;22(5):282\u0026ndash;285.\u003c/li\u003e\n\u003cli\u003eWilliams BA, Jones CH, Welch V, et al. Outlook of pandemic preparedness in a post-COVID-19 world. NPJ Vaccines 2023;8(1):178.\u003c/li\u003e\n\u003cli\u003eHarris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377\u0026ndash;381. doi: 10.1016/j.jbi.2008.08.010. Epub 2008 Sep 30. PMID: 18929686; PMCID: PMC2700030.\u003c/li\u003e\n\u003cli\u003eHarris PA, Taylor R, Minor BL, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019;95:103208. doi: 10.1016/j.jbi.2019.103208. Epub 2019 May 9. PMID: 31078660; PMCID: PMC7254481.\u003c/li\u003e\n\u003cli\u003eWoldring JM, Gans ROB, Paans W, Luttik ML. Physicians and nurses view on their roles in communication and collaboration with families: a qualitative study. Scand J Caring Sci. 2023;37(4):1109\u0026ndash;1122. doi: 10.1111/scs.13185. Epub 2023 May 29. PMID: 37248644.\u003c/li\u003e\n\u003cli\u003eKennedy NR, Steinberg A, Arnold RM, et al. Perspectives on telephone and video communication in the intensive care unit during COVID-19. Ann Am Thorac Soc. 2021;18(5):838\u0026ndash;847.\u003c/li\u003e\n\u003cli\u003ePaladino J, Mitchell S, Mohta N, et al. Communication tools to support advance care planning and hospital care during the COVID-19 pandemic: a design process. The Jt Comm J Qual Patient Saf. 2020;47(2):127\u0026ndash;136.\u003c/li\u003e\n\u003cli\u003eCrook RL, Iftikhar H, Moore S et al. A comparison of in-person versus telephone consultations for outpatient hospital care. Future Healthc J. 2022;9(2):154\u0026ndash;160. Doi: 10.7861/fhj.2022-0006. PMID: PMC9345241.\u003c/li\u003e\n\u003cli\u003eCardona M, Anstey M, Lewis ET, Shanmugam S, Hillman K, Psirides A. Appropriateness of intensive care treatments near the end of life during the COVID-19 pandemic. Breathe (Sheff). 2020;16(2):200062. doi: 10.1183/20734735.0062-2020. PMID: 33304408; PMCID: PMC7714540.\u003c/li\u003e\n\u003cli\u003eSudore RL, Lum HD, You JJ, et al. Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi panel. J Pain Symptom Manag. 2017;53(5):821\u0026ndash;832.e1.\u003c/li\u003e\n\u003cli\u003eFan R. Self‐determination vs. family‐determination: two incommensurable principles of autonomy. Bioethics. 1997;11(3-4):309\u0026ndash;322.\u003c/li\u003e\n\u003cli\u003eLim MYH. Patient autonomy in an East-Asian cultural milieu: a critique of the individualism-collectivism model. J Med Ethics. 2024; 50(9):640\u0026ndash;642. doi: 10.1136/medethics-2022-108123. PMID: 35672134.\u003c/li\u003e\n\u003cli\u003eMobeireek AF, Al-Kassimi F, Al-Zahrani K, et al. Information disclosure and decision-making: the Middle East versus the Far East and the West. J Med Ethics. 2008;34(4):225\u0026ndash;229.\u003c/li\u003e\n\u003c/ol\u003e"}],"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-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"physician-patient communication, COVID-19, pandemic, healthcare professionals, physicians, nurses, autonomy","lastPublishedDoi":"10.21203/rs.3.rs-6212653/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6212653/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite the significant mortality, data on end-of-life (EoL) discussions during COVID-19 pandemic are scarce. Health care providers had to cope with significant challenges, particularly overcoming barriers to effective communication with patients and their families, and lack of information on therapy and prognosis. This study was undertaken to assess the satisfaction of close family members (CFMs) with EoL discussions for patients hospitalized with severe COVID-19 infection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in five major hospitals in Saudi Arabia. Medical charts of consecutive patients who died from COVID-19 complications were retrospectively reviewed.Demographic and clinical data were collected, and communication with close family members (CFMs) about clinical decisions were evaluated. A follow-up telephone interview was conducted using a validated Arabic questionnaire to evaluate satisfaction of CFMs with the EoL discussions prior death.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEoL discussions were documented in less than half (67, 49.28%) and were often delayed (the median time 19.75 days [range 1–119] after admission. However, in the interviews of the CFMs, 109 of 136 (80.15%) acknowledged that physicians had shared with them information regarding the medical condition of the patient. Most of these discussions were conducted with the CFMs rather than the patients. DNAR orders were implemented in half of the patients, and most CFMs (70%) felt they were appropriate. Satisfaction levels for physicians, were as follows: 61.68% for the adequacy of information provided, 60.00% for time spent, and 61.49% for empathy from physicians. A strong correlation existed between the time spent and both the adequacy of information (rs = 0.89, p \u0026lt; 0.001) and empathy (rs = 0.82, p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eAs for nursing performance, satisfaction was 47.83% for information, 48.06% for time, and 55.81% for empathy. Physicians’ scores were significantly higher than nurses on information sharing (P = 0.022) and time spent (P = 0.05), but there was not significant difference with regards to empathy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite the challenges associated with the pandemic, there is room for improvement in EoL discussions. Defining roles and fostering coordination between health professionals may enhance satisfaction of patients and their families.\u003c/p\u003e","manuscriptTitle":"Family Satisfaction with the End-of-life discussions and resuscitation orders for patients with severe COVID-19: A multicenter study in Saudi Arabia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 06:55:27","doi":"10.21203/rs.3.rs-6212653/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-09T09:55:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-30T12:35:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-25T16:46:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53029261019361022190492996004410302528","date":"2025-04-25T07:36:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"298761026837455459138173694038834751240","date":"2025-04-24T19:03:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-24T15:14:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-01T10:55:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-01T10:35:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Ethics","date":"2025-04-01T10:34:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9892be0a-ac45-468f-bd12-0f3527d7d5df","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-28T16:05:05+00:00","versionOfRecord":{"articleIdentity":"rs-6212653","link":"https://doi.org/10.1186/s12910-025-01248-8","journal":{"identity":"bmc-medical-ethics","isVorOnly":false,"title":"BMC Medical Ethics"},"publishedOn":"2025-07-26 15:57:16","publishedOnDateReadable":"July 26th, 2025"},"versionCreatedAt":"2025-05-07 06:55:27","video":"","vorDoi":"10.1186/s12910-025-01248-8","vorDoiUrl":"https://doi.org/10.1186/s12910-025-01248-8","workflowStages":[]},"version":"v1","identity":"rs-6212653","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6212653","identity":"rs-6212653","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}