Perceptions of ICU Nurses Regarding Do Not Resuscitate (DNR) Orders in Tertiary Care Hospitals of Peshawar

Abstract

Background: Do-Not-Resuscitate (DNR) orders are ethically sensitive decisions in critical care settings, particularly in contexts where religious beliefs, family-centered decision-making, limited legal clarity, and institutional policy gaps influence end-of-life care. ICU nurses are directly involved in caring for critically ill patients under DNR orders and may experience emotional, moral, and professional challenges during implementation. Objective: This study aimed to explore ICU nurses’ perceptions regarding DNR orders in tertiary care hospitals of Peshawar, Pakistan, with specific attention to ethical, emotional, communication-related, organizational, and legal challenges. Methods: A qualitative phenomenological study design was used. Thirteen registered ICU nurses working in adult intensive care units of tertiary care hospitals in Peshawar were recruited through purposive sampling. Data were collected through face-to-face semi-structured interviews lasting 30–45 minutes. Interviews were audio-recorded with consent, transcribed verbatim, anonymized, and analyzed using Braun and Clarke’s six-step thematic analysis framework. Trustworthiness was addressed through credibility, dependability, confirmability, and transferability procedures. Results: The analysis generated 50 initial codes, which were organized into 12 categories, 6 subthemes, and 3 final themes: ethical, religious, and emotional burden; communication, family, and decision-making barriers; and organizational and legal challenges. Nurses reported emotional exhaustion, moral distress, religious uncertainty, family misunderstanding, physician dominance, exclusion from decision-making, lack of formal DNR protocols, documentation gaps, and fear of legal consequences. Conclusion: ICU nurses perceived DNR implementation as emotionally demanding, ethically complex, and institutionally under-supported. Clear hospital policies, structured documentation, family counseling, interdisciplinary decision-making, legal guidance, and ethics training are needed to support nurses and improve end-of-life care.