To the best of our knowledge, the present study was the first to explore the approach of Lebanese physicians towards EOL decisions. in general, Lebanese physicians seemed to be well-versed in EOL situations, such as Do-Not-Resuscitate (DNR) decisions. Uncertainty when handling DNR decisions was infrequent in both studied establishments. Regardless, a clear preference towards patient-initiated and delayed EOL discussions could be observed in the French establishment (European training). Literature shows that hesitancy in EOL care might not be restricted to particular countries or cultures. Despite the increasing legalization of EOL practices such as euthanasia and physician assisted suicide, physician and public support of these interventions remains tentative . In fact, such interventions remain widely debated and remain rarely practiced even in countries and American states where they have been legalized .
Consistently with our study, reluctance to initiate EOL discussions seems rampant among European physicians . In fact, physicians were reported to be often ready to respond to patient requests and initiatives but hesitate to take the initiate upon themselves . A study from France has shown that the reluctance of physicians towards EOL practices, such as physician assisted death and treatment withdrawal, could be mediated by their lack of training and perceived inadequate professional competence in this regard . It thus becomes difficult for physicians to discern the optimal ethical and legal choice, which promotes feelings of uncertainty and ambivalence towards EOL care practices .
Providing training is thus critical to facilitate the navigation of the moral, ethical and practical dilemmas posed by EOL care. Evidence from the Middle East revealed that training background accounted for the variability of physician’s interpretation of concepts related to EOL care, such as DNR orders , while inadequate training prevented effective EOL discussions . Education targeting terminal care discussions could not only boost the confidence of medical professionals implicated in the care of terminally ill patients but also emphasize the importance of early EOL discussions . Updating available course offerings could also help to promote patient-centric considerations of preferences in terms of EOL care and dying. Training should address the need for early individualized approaches to EOL discussion, and their integration into existing care structures , which would ultimately promote favorable attitudes towards EOL practices among physicians .
Regardless of the establishment they practiced in, Lebanese physicians reported being uncomfortable with the decision to stop or limit resuscitation. EOL care is an immature concept in Lebanon with little to no guidance provided to physicians in this regard. This could explain the attitude of Lebanese physicians seeing as insecurities among medical care staff often lead to delayed discussions with either patients or their relatives . Shared decisions in the context of EOL also reflect societal, educational, cultural, and religious values in both patients and physicians. In our study, religiosity was comparable in both study samples. Religiosity was previously shown to carry a significant negative influence on the attitude of physicians towards EOL and physician-assisted dying practices . This was emphasized in the Middle East, where religion was an important consideration in physicians’ DNR decisions despite their exposure to Western curriculums . When provided, EOL care guidance in this region must account for religious beliefs considering that its population remains deeply entrenched in religion. EOL practices such as euthanasia and assisted suicide are actually forbidden in Islam. Regardless, Islamic guidance in the form of Fatwa has accorded medical professionals with the ability to undertake DNR decisions in hopeless medical cases irrespective of family and patient preferences . This could account for studies reporting that Muslim religiosity does not affect views of the religious feasibility of DNR decisions  and palliative medicine among physicians , which highlights the need to account for the capacity of other factors, such as country of origin and country of practice, to overshadow religious beliefs .
Paternalistic intervention overrides individual autonomy in our study despite physicians from both samples having been exposed to western curriculums and spent a considerable portion of their specialization abroad. Similarly, almost half of physicians surveyed in the middle east preferred having the ultimate authority in DNR decisions . Even in Western countries, it remains debated whether palliative care and EOL practices alleviate suffering or cause it. Physicians thus continue to exhibit paternalistic and death-denying predilections, preferring life-prolonging and curative approaches to patient care . Regardless, Anglo-Saxon medical professionals lean towards patient autonomy, while French physicians considering EOL decisions remain constrained by rationalistic, paternalistic, and religious traditions in addition to fears of legal prosecution .
As opposed to patient autonomy-oriented states, considerations of patient autonomy are disregarded in most countries in favor of delivering culturally sensitive medical care . Consistently, physicians exposed to the French curriculum were significantly more likely to exclude patients from EOL decisions due to familial preferences and cultural (e.g. religion, ethnicity) considerations. This translates into physicians believing they are better placed to make the DNR decision than the patient, or even families and medical staff as was reported in Hungary . Cultural and religious backgrounds most likely contribute to this paternalistic approach to EOL, seeing as similar issues are observed in religious societies such as India . In Saudi Arabia, cultural factors and lack of understanding from the patient and family side were reported as notable barriers to the initiation of DNR orders and effective EOL discussions, respectively .
Regardless, it should be noted that paternalistic EOL practices were reported in physicians both study groups. Personal physician characteristics have been previously shown to affect attitudes towards EOL decisions . In our study, physicians were predominately male and middle aged. This could have further potentiated paternalistic behavior seeing as older Arab physicians were actually reported to be more likely to perceive DNR orders as taboo and were less likely to undertake them . Another of the frequent barriers to patient participation in DNR decision in our study was the personal belief that the experience will be traumatic to the patient. Avoidance of the negative psychological sequelae of EOL discussion among patients seem to be a frequent deterrent among medical care staff . Physicians were reported to recognize the psycho-existential suffering that terminal illnesses carry and integrate them into their EOL decisions, albeit in variable manners .
Regardless, physicians from the French university were more likely to exclude patients from the decision in order to spare them from a traumatic and anxiety-inducing situation (42.9 vs. 32.7%, p=0.003), further highlighting the paternalistic predilection of this group.
Graduates from the French university were more significantly concerned by patient and clinical factors, such as prognosis, age, and gravity of disease in EOL situations, reflecting their preference of the nonmaleficence ethical approach. They also seemed more concerned about patient age, socioeconomic status and economic constraints when formulating their EOL decisions when compared to their counterparts in the American curriculum. Poor prognosis actually remains a prevalent facilitator of DNR orders and treatment discontinuation decisions among physicians in different contexts [33, 34]. Consistently, European physicians seemed to consider EOL practices such as euthanasia and forgoing artificial nutrition and hydration more favorably should patients be known to be near death . This reflects the preference of Saudi Arabian outpatients, who preferred to discuss DNR directives when suffering from illness . A study from Saudi Arabia showed that while medical expenses were not prevailing concerns in EOL decisions among physicians, the dignity and prognosis of elderly patients played an important role in issuing DNR orders . In another study, Saudi Arabian physicians reported the implication of debilitating patient diagnosis, particularly neurological diseases, in determining the likelihood of DNR orders being issued . When facing EOL situations, it seems that preparing for death while managing pain and disease symptoms are prioritized by both physicians and patients, with the latter exhibiting additional concerns of not being a burden on the family and coming to peace with God .