A rebel fighter with the Army of Islam rebel group fires a weapon during clashes with government forces in the Eastern Ghouta region near Damascus, Syria, on Feb. 1. (Army of Islam/AP)

Syrian government warplanes attacked the final ­rebel-held city near Damascus on Friday, killing dozens of people, as civilians who had spent days agonizing over whether to stay or go feared that their decision had been made for them.

Douma is the final Damascus-area city to remain in opposition hands after Syrian and allied Russian forces mixed punishing force and negotiations with individual rebel groups to force a withdrawal from what remained of their shattered suburban stronghold of Eastern Ghouta.

Friday’s airstrikes shattered a temporary cease-fire that had provided cover for the Russian authorities to negotiate with holdout rebels from Jaish al-
Islam, a hard-line group. 

The attack killed at least 32 people and wounded dozens more, according to the Britain-based Syrian Observatory for Human Rights, a monitoring group.

Residents said the strikes had targeted civilian areas and left body parts strewn through the streets.

“Medical and emergency points are crowded with the wounded. Intensive care is crowded,” said a medical worker, speaking on the condition of ­anonymity, fearing retribution from both government and rebel forces.

Victory in Eastern Ghouta would effectively spell an end to the war between Syrian President Bashar al-Assad’s forces and the opposition that rose up against them in 2011. Although a number of rebel strongholds remain, none are as strategically important as the enclave of Eastern Ghouta, where Douma is located.

More than 130,000 people have fled the once-besieged enclave in recent weeks, according to the United Nations, most of them to government-run reception centers in Damascus. But tens of thousands more have opted to stay under rebel control in the northern province of Idlib, an area that could become the next target of government bombardment. 

A steady trickle of buses had been carrying residents from Douma for almost a week, apparently under the terms of an agreement struck between Jaish al-
Islam and Russia. Many more people had stayed, fearing what might follow departure from home towns they had not abandoned through seven years of conflict.

On Friday, the buses stopped.

Speaking before the airstrikes, the medical worker said he had decided to stay because his work was not finished. “People still need me,” he said. “People are looking for guarantees for when the Syrian government enters Douma to not be harmed. This is what people are looking for. They are not asking for a lot. People are sick of militia groups. People are bored of the war.” 

Residents said Jaish al-Islam has kept a tight hold over the evacuation, requiring those who wanted to leave to register at local offices. Fighters and civilians with familial ties to the group are being rejected, residents said.

One activist interviewed said the choice to stay had not been his own, after Jaish al-Islam declined to clear two of his relatives to leave and held up his application as a result. 

More than 1,000 people have been killed in Eastern Ghouta since the offensive began Feb. 18, most of them in the bombing and shelling by Syrian and Russian forces and in alleged chlorine strikes by the Syrian government. 

The rebels have also shelled residential districts of Damascus, killing dozens and forcing some schools to close. 

Suzan Haidamous in Beirut and Zakaria Zakaria in Istanbul contributed to this report.