Clandestine Strings: The Influence of Sociocultural Factors on the Execution of Do-Not Resuscitate (DNR) Orders in Hospitals

Abstract

This argumentative research paper scrutinizes the impact of sociocultural factors on the execution of DNR orders in hospitals. Particularly, this paper argues that, while often dismissed, the prevailing sociocultural aspects that envelop DNR orders significantly direct its execution through multiple mechanisms. These mechanisms include introducing certain cultural values and practices that shape patient decision-making through societal expectations, as well as exerting significant pressures on patient-physician discussions through cultural norms surrounding taboo topics and family involvement. However, some critics argue that the underlying influence of sociocultural factors is trivial and that ethical and legal obligations directly influence implementation by prompting physicians to abide by stern policy regulations. While this claim has some merit, this paper argues that these policies are not enacted perfectly; instead, there is a gap in implementation, emanating from the interference of sociocultural factors that infuse unprecedented complications. The paper concludes that effective DNR execution necessitates establishing more personalized approaches to both DNR documentation and discussions. In addition, physicians require further training to surpass the lingering barriers to communication, and future research ought to gain a nuanced comprehension of all the factors that influence DNR implementation, ensuring effective integration and protection of patients’ rights.

Introduction

During the late twentieth century, advances in resuscitation technology led to the introduction of “Do-Not-Resuscitate” (DNR) orders. These medical orders allow terminally ill patients to communicate their desire to decline resuscitation in the event of cardiopulmonary arrest. The DNR policy was a revolutionary innovation in the field of medicine; however, numerous controversies and ethical concerns accompanied its implementation. Essentially, this policy bears utmost significance as it revolves around life-or-death decisions and grants patients control over their quality of life, exercising their right to autonomy and freedom of choice. Although patient autonomy has become a priority over beneficence, debate continues over the factors that may influence the execution of DNR orders. The importance of this discussion emanates from the relentless ethical dilemmas in practice, jeopardizing patient autonomy. Consequently, a plethora of studies have been conducted in order to disclose those aspects that compromise DNR decisions such as hospital policies, patient-physician communication, and medical judgments. However, there is no clear consensus on which of these factors, if any, significantly impact DNR decisions, yet there are a few contributors that are often neglected or labeled as limitations. Among the contributors frequently neglected or treated merely as research limitations are sociocultural factors, defined as the social and cultural beliefs that shape individuals’ behavior. Their intervention in DNR execution is typically mediated through societal expectations, familial dynamics, and education. While DNR contracts are applied universally, they consist of rigid criteria and direct questions; they lack a sense of fluidity that enables them to adapt to diverse circumstances and accommodate the various preferences surrounding end-of-life treatment. Although most researchers disregard the impact of sociocultural factors on DNR decisions, these cultural views should be treated as central areas of investigation rather than as minor considerations. Sociocultural factors should be considered contributors to DNR implementation since the complexities of patients’ culture such as traditions, customs, and practices create complications during execution and implicitly yet inherently influence decision-making.

Coerced Patient Decisions

Cultural elements of society exhibit an evident impact on patient decision-making where values, traditions, or customs coerce patients to make certain choices when discussing DNR orders. Despite their deteriorating conditions, patients seem to adhere to their cultural values and utilize them as a foundation to plan their end-of-life treatment. Patients’ sociocultural backgrounds influence how they deal with issues of death, truth-telling, rejection of treatment, and independence where varying ethnic groups tackle DNR orders using different approaches (Ohr et al., 2017). Similarly, statistical evidence proves that distinct samples of diverse cultural backgrounds report different insights on the main principles surrounding DNR orders. For example, Ohr et al. (2017) report that around 50% of the respondents believe death should be avoided at all costs with higher percentages in Eastern Europe (64%) and in Asia/Pacific (53%). Conversely, 70% of the surveyed Anglo-Celtic population were strongly against performing any life-saving measures in late stages of disease progression, emphasizing a striking contrast between regions (Ohr et al., 2017). Furthermore, Yi-An et al. (2025) remark that Chinese societies that follow the teachings of the philosopher, teacher, and political theorist Confucius give precedence to family involvement over patient autonomy. In such cultures, families may choose to abstain from discussing end-of-life decisions with patients; 141 respondents reported that families were reluctant to have Advanced Care Planning discussions, and 73 responses indicated that patients were unaware of their condition (Yi-An et al., 2025). By excluding patients from decisions regarding their own health, these practices violate patient autonomy, a key principle of DNR policies. In essence, every individual is born into a society that follows certain values, norms, and traditions. Families play the role of primary agents of socialization where they encourage their children to internalize these customs, and apply them to their decisions. Moreover, patients endure immense pressure during DNR decisions; these policies are considered uncharted territory for most patients, and they yield precarious consequences. Therefore, when faced with uncertainty, patients turn to culture for support through established values and practices that guide their choices. This guidance includes belief systems that define patients’ understanding of death, autonomy, illness, suffering, and treatment; these convictions manifest during decision-making processes and discussions. Also, these beliefs are reinforced by societal expectations that exert an immense yet veiled pressure on patients to abide by these teachings and enact them even in potentially life-terminating decisions.

However, DNR orders create intricate situations that transcend the limited teachings of culture, thus prioritizing cultural values clouds patients’ judgment and strips them of their freedom to choose for themselves, ultimately leading to a lack of autonomy. Indeed, DNR orders are essentially patient centered decisions structured to ensure their preferences for end-of-life care are voiced. Nevertheless, culture shifts the focus onto certain values and norms that may contradict with patients’ said preferences, initiating conflicts between patients and their families. Although patients refuse to abandon their cultural beliefs and physicians are ethically and legally obligated to yield to their demands, the resolution lies in the cooperation of these two parties. Patient-physician discussions permit patients to firmly declare their preferences in light of physicians’ objective medical judgments.

The Covert Constraints to DNR Discussions

Sociocultural aspects obscure patient-physician discussions through applied rules of discourse, societal norms, taboos, and family involvement. DNR discussions are a fundamental step in processing DNR orders. They involve two parties, patients and physicians: patients utilize these discussions to enunciate their choices and preferences for end-of-life care while physicians explain the policy and all subsequent processes. Nevertheless, there is an evident gap in communication where sociocultural factors such as death-related taboos, unrealistic expectations or demands, and family preferences have complicated discussions. For instance, Trabert et al. (2025) report antithetical communication practices when comparing Western European regions that have more frequent and confident discussions with Southern or Eastern European regions with less acceptance, more discomfort, and fewer discussions. Patients also reported the presence of discomfort and taboo-related barriers: 21% of respondents reported discomfort or a lack of confidence while up to 34.4% in Southern Europe reported embarrassment (Trabert et al., 2025). In addition, Gouda et al. (2018) performed a study on ER and ICU physicians in Saudi Arabia where they disclose that physicians experience notable discomfort. Their engagement in DNR discussions was inadequate where 54.4% of physicians never discussed DNR with patients or families and 44.6% felt uncomfortable during discussions (Gouda et al., 2018). Furthermore, Gouda et al. (2018) noted that most DNR discussions had a mean duration of around 14.3 minutes, alluding that discussions were unduly concise. Physicians attributed this reluctance and deficiency in communication to the pervasive regional practices, including Saudi Arabian cultural tendencies and the more general Islamic teachings (Gouda et al., 2018). Ultimately, current DNR contracts provide rudimentary information on the patients’ preferences for end-of-life treatment. The circulating standardized forms include the decision statement, scope of care administration (oxygen, antibiotics, blood transfusions…), signatures, and room for review in case conditions change. Accordingly, DNR contracts are merely documentations; the true ethical significance lies in the patient-physician discussions occurring before-hand. Evidently, DNR orders are mobilized in dire situations, and they demand informed decisions that surpass basic common knowledge. Hence, physicians are delegated to articulate the needed information during discussion, thereby making them inherently intricate and difficult conversations. Physicians have to carefully and professionally curate their approaches to ensure patients fully understand their commitments to DNR orders. However, when sociocultural factors come into play, new issues of taboo, education gaps, and discomfort create turmoil, hindering communication. To illustrate, some patients may have limited health literacy, so their knowledge of policies and procedures that physicians follow for treatment administration may be narrow. In such instances, further clarification is imperative for rational decision-making, yet some physicians dismiss that fact. Effective DNR orders call for honest discussions where physicians clearly explain to patients and their families the situation at hand, and patients are able to convey their desired course of treatment. This transparency is blurred by the interference of cultural values that shun discussions about death or beliefs that protect life beyond reason. Hence, discussions become tinged with discomfort, confusion, and unreasonable conflicts. Such an observation verifies the influence of sociocultural factors on DNR discussions and therefore execution. Formulated to reduce future complications, these discussions are vital for successful DNR implementation, insinuating the necessity to consider patients’ culture before execution.

The Counterstrike: Clinical and Legal Settings as Pivotal Determinants

The mainstream perspective surrounding the contributors to DNR execution declares that sociocultural factors are mere trivialities that complicate DNR orders but do not impact their execution; instead, other factors exhibit direct correlations. Modern-day research revolves around understanding the direct effects of the interplay between clinical and legal factors on the execution of DNR orders. Studies seek to identify policy-based deficiencies, understand their repercussions, and amend guidelines in hopes of mitigating ethical dilemmas. In other words, efforts are oriented towards revealing the mechanism through which complications emerge in practice. For instance, Sumrall et al. (2016) and Chen et al. (2022) argue that the ensuing complications and ethical dilemmas are attributed to communication gaps or procedural deviations during implementation. Particularly, Sumrall et al. (2016) claim that DNR orders necessitate compliance with institutional policies and legal frameworks: the Patient Self-Determination Act (PSDA) mandates patient rights and advance directives at a federal level, and The Joint Commission requires hospitals to implement DNR policies. Hence, recorded violations of these regulations directly compromised DNR decisions.

In addition, Chen et al. (2022) also report that legal obligations are notable determinants of DNR execution where physicians would be penalized for non compliance, obliging them to carry out the patients’ decisions. Both Sumrall et al. (2016) and Chen et al. (2022) emphasize the importance of patient-physician discussions in upholding the DNR principles. Although 92% of patients believed in mandatory preoperative discussion, only 57% of anesthesiologists addressed resuscitation before operations; the study also reported that the frequency of ethical dilemmas during operations almost doubled (Sumrall et al., 2016). Such findings verify that breaching DNR policies results in immediate conflicts during execution. All things considered, DNR orders necessitate compliance with administrative requirements before enacting any medical procedure. These demands are governed by obligations to respect patient autonomy, comply with universal ethical principles, and ensure hospital requirements are met. Indeed, the field of medicine is constructed upon objective reasoning, proper and thorough training, standardized protocols, and rigorous rules of conduct, and these principles encompass DNR orders. Therefore, critics argue that considering cultural and behavioral inclinations as foundations of DNR orders is a premature assumption. The implementation of DNR orders is far from arbitrary; it obligates professional intervention and appeals to ethical specialists in case of conflict.

An Overlooked Chasm

Despite the significance of clinical and legal settings as contributors to the execution of DNR orders, researchers and physicians alike observe vastly antithetical outcomes when applying preestablished policies in different hospitals worldwide. In theory, DNR policies provide clear instructions and standardized protocols for physicians to adhere to, guaranteeing orderly implementation with minimal ethical complications. In practice, however, DNR execution is far from optimal, with patients reporting dissatisfaction and frustration (Dzeng et al., 2015). This gap is attributed to one essential detail that most researchers overlook: DNR policies are formulated in a sterile environment. Policymakers structure regulations based on hypothetical conditions, disregarding the effect of cultural elements. Consequently, these policies become incapable of accommodating patients’ requests, increasing the likelihood of encountering shortcomings and inducing ethical dilemmas. Indeed, the impact of sociocultural factors on the execution of DNR orders is most prominent through the examination of hospital culture and the education of both physicians and patients. Dzeng et al. (2015) argue that, aside from patients’ individual culture, hospital culture influences DNR execution; the institutional policies a hospital instills emanate from a covert curriculum where certain cultural values, norms, and attitudes guide physician behavior. Upon inspecting multiple hospitals, Dzeng et al. (2015) contrasted two main prevalent ideologies: physicians should prioritize patient autonomy over beneficence or vice versa. They then scrutinized the distinct outcomes when applying the same DNR policy. Particularly, trainees in autonomy-oriented hospitals were compelled to offer patients the choice of resuscitation despite its futility. Conversely, in beneficence-focused hospitals, trainees would abstain from mentioning CPR if its efficiency was not promised, limiting the unnecessary harm the patient could be subjected to (Dzeng et al., 2015). Moreover, the gap in implementation is further exacerbated by insufficient education. Gouda et al. (2018) conducted extensive analyses of DNR conditions in Saudi Arabian hospitals, and they underscored that the lack of patient and physician education, along with the interference of sociocultural factors, comprise the main obstacles during DNR execution. Even though meticulous DNR policies exist and are applied in those hospitals, two thirds of practicing physicians had not read the detailed policy, and their knowledge of local guidelines was below optimal (Gouda et al., 2018).

In addition, Gouda et al. (2018) disclose that 58.7% of physicians regard that the lack of patients’ understanding of their condition, its severity, recommended treatment, and the DNR policy itself embodies a central impediment to DNR implementation. They also emphasize the effect of Saudi Arabian cultural tendencies on DNR policies; family-centered decisions entailed the exclusion of more than half of the surveyed patients from discussions, contradicting the central principle of patient autonomy (Gouda et al., 2018). Ultimately, the numerous documentations of authentic patient experience during DNR execution elucidate how sociocultural factors, namely cultural norms, education, and hospital norms, manifest when DNR policies are employed. Such factors poison the medium of implementation, complicating DNR executions and forging unprecedented ethical dilemmas.

Conclusion

In summary, there are a plethora of interrelated factors that impact DNR orders, yet the main focal point of modern-day research is centered around direct contributors such as legal obligations, ethical principles, and clinical contexts. However, though often overlooked, sociocultural practices play a profound role in shaping how DNR orders are discussed and executed. Specifically, studies have testified how cultural tendencies, belief systems, and societal expectations guide patients’ decisions and DNR discussions. Even though some critics may argue that standardized policies and legal obligations are the sole determinants, the contribution of sociocultural factors is substantiated by the disparate outcomes observed when the same universal policy is exercised in regions with different cultures. DNR guidelines are constructed based on rigorous ideals where most complications are neglected. Consequently, these policies do not depict real clinical conditions and they thereby create gaps during execution.

Essentially, DNR is a relatively novel concept to the field of medicine centered around reducing suffering for patients condemned with fatal diseases. The discourse surrounding DNR orders stems from a responsibility to protect patients’ rights even at the end of life. Principle rights include autonomy and freedom of choice where they ensure patients gain control over their quality of life despite their agony. Therefore, it is imperative to scrutinize all possible factors that may menace DNR processes and dilute their impact. Recognizing cultural factors reconfigures policies to become more resilient against the adversities of implementation, minimizing the contrast between theoretical regulations and clinical practices. For successful DNR execution, some fundamental modifications are compulsory. DNR contracts should be restructured to accommodate patients’ cultural preferences, and physicians require further training to overcome the discomfort of discussing death in order to ensure effective conversations with patients. Most importantly, the circulating belief that deems sociocultural factors insignificant should be abolished. Instead, future research should adopt more comprehensive models to broaden the current understanding of the influence of sociocultural factors on DNR execution, bringing the forces pulling the clandestine strings to finally be revealed.

Download the full document

References

Chen, R., Li, Y., Hsueh, K., Wang, F., Chen, H., & Huang, T. (2022). Factors influencing terminal cancer patients’ autonomous DNR decision: a longitudinal statutory document and clinical database study. BMC Palliative Care, 21(1). https://doi.org/10.1186/s12904- 022-01037-9

Dzeng, E., Colaianni, A., Roland, M., Chander, G., Smith, T. J., Kelly, M. P., Barclay, S., & Levine, D. (2015). Influence of institutional culture and policies on do-not-resuscitate decision making at the end of life. JAMA Internal Medicine, 175(5), 812–819. https://doi org.ezproxy.aub.edu.lb/10.1001/jamainternmed.2015.0295

Gouda, A., Alrasheed, N., Ali, A., Allaf, A., Almudaiheem, N., Ali, Y., Alghabban, A., & Alsalolami, S. (2018). Knowledge and attitude of ER and intensive care unit physicians toward Do-Not-Resuscitate in a Tertiary Care Center in Saudi Arabia: A survey study. Indian Journal of Critical Care Medicine, 22(4)

https://doi.org/10.4103/ijccm.IJCCM_523_1

Ohr, S., Jeong, S., & Saul, P. (2017). Cultural and religious beliefs and values, and their impact on preferences for end-of-life care among four ethnic groups of community-dwelling older persons. Journal of Clinical Nursing (John Wiley & Sons, Inc.), 26(11–12), 1681– 1689. https://doi-org.ezproxy.aub.edu.lb/10.1111/jocn.13572

Sumrall, W. D., Mahanna, E., Sabharwal, V., & Marshall, T. (2016). Do Not Resuscitate, Anesthesia, and Perioperative Care: A Not So Clear Order. The Ochsner Journal, 16(2), 176-179. https://www.proquest.com/scholarly-journals/do-not-resuscitate-anesthesia perioperative-care/docview/2158217225/se-2\

Trabert, J., Trevisan, C., Goluke, N., Chapelet, G., Sanchez-Garcia, E., & Lochlainn, M. N. (2025). Resuscitation discussion practices: A survey of European geriatricians. European Geriatric Medicine, 16, 1527–1536. https://doi.org/10.1007/s41999-025-01218-8

Yi-An, S., Wang, C., Ding, J., Zhou, Y., & Lu, Q. (2025). Cultural and ethical barriers to implementing end-of-life advance care planning among oncology nursing professionals: a content analysis of open-ended questions. BMC Medical Ethics, 26, 1-10. https://doi.org/10.1186/s12910-025-01261-x

Follow our socials

Community

© 2026. All rights reserved.