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Ethical Dilemmas of End of Life Care in Intensive Care Unit : A Literature Review

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DOI: 10.17509/jpki.v4i2.13637

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 JU RNAL PENDIDIKAN KEPERAWATAN INDONESIA
e-ISSN 2477-3743 p-ISSN 2541-0024

Ethical Dilemmas of End-of-Life Care

in Intensive Care Unit: A Literature Review
Albertus Budi Arianto1*. Yanny Trisyani2, Etika Emiliyawati3
1
Student of Emergency Nursing Postgraduate Program, Padjajaran University, Bandung, Indonesia
2,3
Magister of Nursing Study Program, Faculty of Nursing, Padjajaran University, Bandung, Indonesia
*
Corresponding email: albertusbudi12@gmail.com

ARTICLE INFO ABSTRACT

The end-of-life (EOL) care is the progressive terminal illness, leading
HOW TO CITED: to death; that in the situation the nurse have significant role in decision
Arianto, A.B., Trisyani, Y.,
making. In decision making, temporarily, the nurse will experiences the
and Emiliyawati, E. (2018). ethical dilemmas, including in intensive care unit (ICU) with any
Ethical Dilemmas of End-of- factors resulting in problem in medical decision making. The literature
Life Care in Intensive Care review intends to analyze the description of ethical dilemmas occurred
Unit: A Literature Review.
Jurnal Pendidikan Keperawa- in intensive care unit, especially to the EOL care. A method used is
tan Indonesia 4(2), hlm. 105- critical review full text of 2007-2018 periods in English langguage. The
112 multiple databases used is PubMed, Proquest and Google Scholar with
keyword “End of Life Care” and “Nursing Ethic in critical care” and
“issue End-of-life critical care”, and “Dilemmas Ethic in ICU.” The
DOI: articles selected gradually by using of Appraisal tool of PRISMA and
10.17509/jpki.v4i2.13637 obtained 21 articles. The literature study obtaining 4 themes related to
description of the ethical dilemmas in ICU including (1) the ethical
ARTICLE HISTORY: principle involved in EOL care at ICU, (2) resource of ethical conflict
Accepted in ICU, (3) impact of ethical conflict in ICU, and (4) response of nurse
October 23, 2018 in dealing with ethical dilemmas. The discussion of literature review
Revised related to the perception of nurse on EOL care; that nurse have
December 20, 2018 important role in medical decision making involving ethical principle in
the implementation. it is required further research on exploration of
Published
December 31, 2018 nurse experience on implementation of ethical principle in case of EOL
care.
Kata kunci: End-of-life-care, nursing ethic in critical care, issue end
of-life in critical care, ethical dilemmas in ICU

ABSTRAK
Perawatan end of life (EOL) merupakan suatu perawatan pada
penyakit terminal yang bersifat progresif, yang akan berujung dengan
kematian, pada kondisi ini perawat mempunyai peran dalam
pengambilan keputusan perawatan. Terkadang dalam pengambilan
keputusan ini perawat akan mengalami kondisi dilema etik, tak
terkecuali di ruangan intensive care unit dimana diruangan tersebut
banyak faktor yang mengakibatkan kesulitan dalam pengambilan
keputusan medis. Literature reviews ini bertujuan untuk menganalisis
gambaran dilema etik yang terjadi di area intensive khususnya pada
kasus end of life care. Metode yang digunakan adalah critical review
full text dengan rentang tahun 2007-2018 dalam Bahasa Inggris.

105
 Arianto, A.B., Trisyani, Y., and Emiliyawati, E. | Ethical Dilemmas of End-of-Life Care in Intensive Care Unit : A Literature Review.

Multiple database yang digunakan adalah PubMed, Proquest dan Google Scholar merupakan data-
base yang digunakan, dengan kata kunci “End Of Life Care” and “Nursing Ethic in critical care”
and “issue End-of-life in critical care”, and“Dilema Ethic in ICU”. Artikel diseleksi bertahap
menggunakan Appraisal tool PRISMA dan didapatkan 21 artikel. Studi literatur diperoleh 4 tema
terkait gambaran dilema etik di ruang ICU diantaranya (1) Prinsip etik yang terlibat dalam end of
life care di ICU, (2) Sumber konflik etik di ICU, (3) Dampak konflik etik di ICU, dan (4) Respon
perawat dalam menghadapi dilema etik. Pembahasan telaah literatur ini terkait persepsi perawat
mengenai perawatan end of life, dimana perawat mempunyai peran penting dalam pengambilan
keputusan medis yang melibatkan prinsip etik dalam pelaksanaannya. Diperlukan penelitian lebih
lanjut mengenai eksplorasi pengalaman perawat terhadap implementasi prinsip etik pada kasus
perawatan menjelang ajal.

Kata kunci: End Of Life Care, Nursing Ethic in critical care, issue End-of-life in critical Care,
Dilema Ethic in ICU

INTRODUCTION experiences in treatment of end-of-life patient

The end-of-life (EOL) care is the progres-
sive terminal illness, incurable and potential
leads to the death; this care requiring support of
nurse and family to identify the final phase of
life, including pain management and symptom,
psychosocial problem and spiritual support
(Advanced Illness & End-Of-Life Care, 2017)
The EOL care given to the dying-patient or
in critical phase by implement the theory includ-
ing appropriate preparation concept in encounter
the death, it is called Peaceful End of Life
(Alligood, 2014). An intervention given to the
theoretical concept intends to provide the patient
for pain free, comfortable, and appreciated, re-
spect, peaceful, as well as serenity, intimacy
with the person who is cared for.
The EOL care for critical patient, especially
in ICU increasingly accompanied by progress
and technological development which it will
increase the treatment quality in prolong of life.
The ICU is an area that the nurse have many
complicated experiences on issue and life-
threatening situation in correlation with the situ-
ation of patient in life and death (Jamshidian,
Shahriari, & Aderyani, 2018).
The EOL in ICU involves the staff of any
disciplines including nurse; that have many in-
teraction periods with the patient. The role of
patient to implement the critical care is very im-
portant the nurse have competency and experi-
(Ferrell, Virani, Paice, Malloy, & Dahlin, 2010).
The result of research shows that the nurse, es-
pecially in critical area have the challenge in
ethical principles, for example, in situation of
patient on DNR, medication of patient before
dying, abortion or euthanasia, and use of restrain
whether in physic or chemical (Pavlish, Brown-
Saltzman, Hersh, Shirk, & Rounkle, 2011).
Moreover, nurse in the situation contribute to the
decision making of ethic and advocate to the
virtue of patient, and the socioeconomic, pallia-
tive, and cultural factors has becomes the result-
ant factor of ethical problem. Moreover, based
on the research an ethical dilemmas situation
arise because behavior and attitude of nurse or
doctor before implements the comprehensive
ethical principle in their service given (Falcó-
Pegueroles, Lluch-Canut, Roldan-Merino, Go-
berna-Tricas, & Guàrdia-Olmos, 2015).
The implementation of ethical principle closely
correlated to the situation of ethical dilemmas,
that it is almost exist in clinical practice area,
occurred when the healthcare staff faced with
critical thinking situation in decision making of
experienced case (Sorta-Bilajac, Baždarić,
Brkljačić Žagrović, et al., 2011). The undergone
effect of nurse is ethical dilemmas that will bring
any impediments in implement their action that
contravene to the moral beliefs (Ferrell et al.,
2010).

106 JPKI 2018 volume 4 no. 2

 Arianto, A.B., Trisyani, Y., and Emiliyawati, E. | Ethical Dilemmas of End-of-Life Care in Intensive Care Unit : A Literature Review.
Based on the background, carried out an
identification and analysis of description of ethi-
cal issue occurred in intensive area, especially in
EOL care, with the special purpose to identifica-
tion of any potential ethical issue and observe
the ethical principles involved in EOL care.
METHOD
The method used in article review uses man-
ual of PRISMA (Preferred Reporting Items for
Systematic Reviews and Meta Analyses).
The literature study arranged by reviewing
the result of research whether in qualitative or
quantitatively, the related articles collected by
database of electronic media such as Pubmed,
ProQuest, and Google Schoolar; that the key-
words established according to the MeSH data-
base by NCBI involves “End of Life Care” and
“Nursing Ethic in Critical Care” and “issue End-
of-Life in Critical Care” and “Ethical Dilemmas
in ICU”. The searching process specified on in-
clusion criteria as follows:
1. Article of research of 2007-2018
2. Article of research in English Language
3. Research subject of nurse.
4. Research in ICU or Emergency Department
(ED).
Ide The finding result identified by searching in
nti database
fic (n=18.234)
ati
on
Sc The finding result after reduction on period
ree (2008-2018), Language, duplication of find-
nin ing article, and abstract only
g (n=925)
El- Full-text, carried out feasibility study
igi (intensive reading, summarizing)
bil (n=53)
ity
In- Article enter for reviewed
clu (n=21)
sio
n
Fig.1 Scheme of PRISMA flow diagram of trial selection process for the critical review
JPKI 2018 volume 4 no. 2
5. Article of research of open access and full
text
After searching and categorizing, it is carried out
summarizing the relevant articles. The considera-
tion of relevance based on clarity of resource and
correlation with the topic. The summarizing re-
sult described in table in fluent the analysis. The
analysis of results using descriptive thematic
analysis
RESULT
Total result in searching article with esta-
blished keywords are 18.234 articles. After
screening by publication period (2007-2018),
population in human and full text, obtained 925
articles, by detail as follows: 56 articles of
ProQuest, 380 of PubMed, and the remains 489
articles of Google Scholar. They are chosen based
on criteria of inclusion and exclusion according
to the probable relevance (connection or con-
formity to the review) and obtained total 53 arti-
cles accor-ding to the inclusion criteria and the
feasibility study attains 21 articles.
Inaccessible article and
unachievable target and inclu-
sion criteria
(n=872)
Full-text exclusion, (unparalleled with nursing
ethical principle)
(n=32)
107
 Arianto, A.B., Trisyani, Y., and Emiliyawati, E. | Ethical Dilemmas of End-of-Life Care in Intensive Care Unit : A Literature Review.
DISCUSSION
It is found that there are 4 themes of ob-
tained result of finding articles in correlation
with the ethical dilemmas in EOL care, as fol-
lows:
1. An Implementation of Ethical Principle in
EOL Care in ICU
The situation experienced by nurse in EOL
care is ethical dilemma; that he or she will find
any impediments to restrain the contradiction act
to the conviction of morality (Santiago &
Abdool, 2011). The nurse will find out the ac-
tion that can give to the patient but incapable as
the any considered reasons (B Vanderspank-
Wright, Fothergill-Bourbonnais, Brajtman, &
Gagnon, 2011). The situation will bring into the
failure in protection of right of the patient, and
lead to the empathy and can triggering distress
situation of moral and feeling. The viewpoint of
ethical legal of EOL situation is correlation with
decision making of medical for patient.
The arranged research by Erdil & Korkmaz
(2009) also, shows that the ethical problem arise
in critical unit like physical maltreatment (10%),
psychological maltreatment (34%), ignoring pa-
tient privacy (37%), discrimination (5%), and
relationship (3%). Moreover, another research
shows that the most experienced ethical dilem-
mas by nurse personally is related to the near the
end-of-life decision 11%, justice 7%, profession-
al relation 6%; and the most arising ethical issue
on related situation is limiting life sustaining
therapy (nurse 15%, doctor 24%) and euthanasia
by doctor 28% (Sorta-Bilajac, Baždarić,
Žagrović, et al., 2011). The study of Erdil &
Korkmaz (2009) describes that the infringed eth-
ical principles is autonomy (30%), respect for an
individual’s privacy and intimacy (22%), Non
Maleficence (16%), Beneficence (17%), Justice
(15%).
Moreover, any other research was found that
the most experienced personal ethical dilemmas
of nurse is related to the near the end-of-life de-
cision 11%, justice 7%, professional relation
6%; then ethical issue on related situation is lim-
iting life sustaining therapy (nurse 15%, doctor
24%) and euthanasia by doctor 28% (Sorta-
Bilajac, Baždarić, Žagrović, et al., 2011).
108
2. Main Resource of Conflict in ICU Area
By Moon & Kim (2015) it is described that
the ethical conflict incident occurred in ICU is
higher than common treatment area. The result
of research by Tapper, Vercler, Cruze, &
Sexson, (2010) was found that the existing ser-
vice in the hospital is 181.558 cases, that 0.16%
performs consultation with the ethical committee
staff of hospital; while in other study is 4.968
patients handled in ICU Columbia University
Medical Center of 168 (3.3%) carry out the ethi-
cal consultation in service (Romano, Wahlander,
Lang, Li, & Prager, 2009). The other study by
Park et al. (2015) reports that conflict incident
occurred of 2.1% and 0.5% for two periods of
research.
The medical diagnosis influencing an ethical
conflict involves data of malignance (18%), neu-
rology (18%), cardiovascular (17%), multi or-
gans problem (11%), respiration (9%) obtained
for 10 years by Swetz et al. 2007 (Moon & Kim,
2015).
According to the study arranged by Oer-
lemans et al., (2015) causing problem of ethical
conflict in ICU related to the EOL involves com-
plex treatment for patient, differentiation in
opinion on discontinue the medication among
professional healthcare staffs, stable condition of
patient after withdrawing treatment, and stable
condition of patient in long-term treatment at the
ICU. The other issue resulting in ethical conflict
resource in the EOL cares involves intervention
of withdrawing and withholding treatment, futile
treatment, pain management resulting dual im-
pact, healthcare staff considered that they sus-
taining patient in fast death process (Holt, 2017).
Meanwhile, according to Park, et.al (2015) the
existing ethical issues involves correlation of
attitude whether in communication or attitude
presented by healthcare staff, life sustaining
treatment, informed concept, patient transporta-
tion and organ transplantation.
3. The Effect of Ethical Conflict in ICU Area
The negative effect of EOL care will results
in moral distress as the consequence of treatment
effect to the patient (Brandi Vanderspank-
Wright, Fothergill-Bourbonnais, Brajtman, &
JPKI 2018 volume 4 no. 2
 Arianto, A.B., Trisyani, Y., and Emiliyawati, E. | Ethical Dilemmas of End-of-Life Care in Intensive Care Unit : A Literature Review.
Gagnon, 2011). Moreover, the situation will in-
crease the suffering for patient and cost of treat-
ment (Wiegand & Funk, 2012). The situation of
long-term ethical dilemmas in nurse also will be
the resulting factor of mental exhaustion and
disturbing professional practice that lead to the
worst treatment (McAndrew, Leske, & Garcia,
2011).
Another result of research shows that more
than 70% professional healthcare staff who work
in ICU suffering ethical conflict (Azoulay et al.,
2009), while the other show of 45% nurses with
given survey reports that they have plan to leave
their job in correlation the high moral distress in
ICU (Hamric & Blackhall, 2007).
4. Response of Nurse in Face of Ethical Di-
lemmas in EOL Case at The ICU
There is not the answer of the question was
found in any research on how to control the ethi-
cal issues or dilemmas arising in patient of ICU
as there are many factors and personnel involved
in this case including doctor, multidiscipline
team in healthcare, other staff, patient and their
wish, replacement person in decision making
and relative, but in the implementation we must
determine of particular purpose for therapy, in-
tervention, decision on situation of patient as
soon as possible in avoid the ethical problem
that developing into the complex ethical dilem-
mas (Fridh, Forsberg, & Bergbom, 2009).
When the ethical dilemmas encountered, it is
unavoidable that the nurse must response or take
an action on existing situation, as the study by
De Casterlé, Izumi, Godfrey, & Denhaerynck,
(2008) explores the response of nurse in face of
ethical dilemmas in Belgium, Switzerland, USA,
and Japan was found that nurse consider their
work environment as the impediment in imple-
mentation of ethical practice that they must sac-
rifice their competence to provide the competent
treatment. Second, the nurse tend to gives the
conventional reason in face of daily ethical di-
lemmas guided by conventional rule and norm
of work than creativity and crisis reflection.
Third, the nurse will suffering hard to implement
the ethical decision in challenging context show-
ing that environmental factor tend to guide them
JPKI 2018 volume 4 no. 2
in the ethical practice.
(Pavlish et al., 2011) arguing that the priority
in response an ethical dilemmas, first, is quality
of life (31.4%) that considered as the obligation
for treatment of distress symptom, pain and suf-
fering. Second, sustaining autonomy of patient
(21.4%); that in this situation the nurse must
give priority for request of patient than the fami-
ly or healthcare staff. The substandard of health
treatment is the third priority (14.3%), the au-
thentic diagnosis and information prognostic
(7%), an unrealistic expectation for treatment by
the family (4.3%), concealing information of
patient (2.9%), and decision on treatment for
patient without the relative/family members
(2.9%).
The influencing factor in decision making of
ethical dilemmas in physical situation is usable
protocol to the instinct of nurse (Zeitzer, 2009).
The influencing factor in decision making of
ethical dilemmas in physical situation is usable
protocol to the instinct of nurse (Zeitzer, 2009).
The situation experienced by nurse can result in
confusing situation on what supposed to be done
as there is no certain procedure in ICU as long as
sustain of life for patient is discontinued, accord-
ing to Crump, Schaffer, & Schulte, (2010) ex-
plains that the existence of clear procedures in
End of life care will reduce the sense of confu-
sion that occurs in nurses. Other factors such as
lack of communication between nurses and doc-
tors about making decisions to terminate life
support will result in confusion of nurses in the
provision of end of life care (Fernandes &
Moreira, 2012). The other situation to end the
sustained of life carried out by nurse, they at-
tempt to shows their existence near the patient
and family but confuse when have to focus on
family in sorrow or patient (Efstathiou &
Walker, 2014).
Moreover, the nurse must be participated in
decision making and review committee must
play the important role in controversial case. It
also can do in supervision than decision or quali-
ty assurance (Zeitzer, 2009). (Pavlish, Brown-
Saltzman, Hersh, Shirk, & Rounkle, 2011) was
found that there are any priorities of nurse to
looking for solution of ethical dilemmas, as
109
 Arianto, A.B., Trisyani, Y., and Emiliyawati, E. | Ethical Dilemmas of End-of-Life Care in Intensive Care Unit : A Literature Review.
follows:
1. Quality of life for treatment of distress, pain
and suffering, in this case, the nurse must
inquiring loss and benefit in aggressive med-
ication especially at the end-of-life phase.
2. Respect the autonomy of patient, the patient
desirability must be the priority than family
or healthcare team.
3. Service standard of healthcare team do not
laid on treatment standard that there is a
conflict in choice of treatment.
4. Other ethical problem including provides an
truthful information on diagnose and prog-
noses to give information for family on ex-
pectation of unrealistic treatment.
The study arranged by Crump, Schaffer, &
Schulte (2010), identifying any experienced im-
pediment, support and knowledge required for
giving qualified EOL care. The result shows
that:
1. Family and patient must be given accurate
information, straight, and consistent to make
end-of-life decision.
2. The problem experienced by doctor in corre-
lation how to influence the nurse in provides
the qualified EOL care.
3. The nurse in ICU must be provided many
information, skill and cultural competence
for qualified treatment and preliminary in-
formation on what supposed to do first to the
patient.
REFERENCES
Advanced Illness & End-Of-Life Care. (2017).
Advanced illness & end-of-life care.
Health Affairs, 36(7), 1168–1169. https://
doi.org/10.1377/hlthaff.2017.0544
Alligood, M. R. (2014). Nursing Theorists and
Their Work (8th edn)Alligood, M. R.
(2014). Nursing Theorists and Their Work
(8th edn). Nursing Theorists and Their
Work (8th edn). http://doi.org/10.5172/
conu.2007.24.1.106a. Nursing Theorists
and Their Work (8th Edn), 746. https://
doi.org/10.5172/conu.2007.24.1.106a
Azoulay, É., Timsit, J. F., Sprung, C. L., Soa-
res, M., Rusinová, K., Lafabrie, A.,
Schlemmer, B. (2009). Prevalence and
110
4. The preliminary information has given in
prior can reduce an obscure about the treat-
ment purpose.
CONCLUSION
In the EOL situation the nurse is a part of
decision making; that it is correlated to the end
of life. The decision making will result in moral-
ity distress situation for doctor and the family of
patient. nurses frequently confront ethical issues
in clinical practice, especially in the ICU. How-
ever experience, common sense, and simply be-
ing a good person, do not guarantee that nurses
can identify or resolve ethical dilemmas.
The morality distress situation called ethical
dilemmas will bring consequence to any impedi-
ments restricting an action that conflicting to the
faith of morality. Moreover, it will result in fail-
ure in protect the right of patient, that can bring
into the empathy and lead to the morality dis-
tress and suffering in emotion especially to the
nurse. Good clinical decision-making is only
possible when the medical decision-making and
ethical decision-making are correctly balanced.
Knowledge about common ethical dilemmas and
training in ethical decision-making is essential.
At the same time, the ICU leaders and hospital
directors should prepare protocols to find and
resolve the common ethical problems in their
hospital.
and factors of intensive care unit conflicts:
The conflicus study. American Journal of
Respiratory and Critical Care Medicine.
https://doi.org/10.1164/rccm.200810-
1614OC
Crump, S. K., Schaffer, M. a, & Schulte, E.
(2010). Critical care nurses’ perceptions of
obstacles, supports, and knowledge needed in
providing quality end-of-life care. Dimen-
sions of Critical Care Nursing : DCCN 29
(6), 297–306. https://doi.org/10.1097/
DCC.0b013e3181f0c43c.
De Casterlé, B. D., Izumi, S., Godfrey, N. S., &
Denhaerynck, K. (2008). Nurses’ responses
to ethical dilemmas in nursing practice: Meta
JPKI 2018 volume 4 no. 2
Arianto, A.B., Trisyani, Y., and Emiliyawati, E. | Ethical Dilemmas of End-of-Life Care in Intensive Care Unit : A Literature Review.
analysis. Journal of Advanced Nursing, 63
(6), 540–549. https://doi.org/10.1111/j.1365-
2648.2008.04702.x
Efstathiou, N., & Walker, W. (2014). Intensive
care nurses’ experiences of providing end-of
-life care after treatment withdrawal: A qual-
itative study. Journal of Clinical Nursing, 23
(21–22), 3188–3196. https://
doi.org/10.1111/jocn.12565
Erdil, F., & Korkmaz, F. (2009). Ethical prob-
lems observed By student nurses. Nursing
Ethics. https://
doi.org/10.1177/0969733009106651
Falcó-Pegueroles, A., Lluch-Canut, T., Roldan-
Merino, J., Goberna-Tricas, J., & Guàrdia-
Olmos, J. (2015). Ethical conflict in critical
care nursing: Correlation between exposure
and types. Nursing Ethics, 22(5), 594–607.
https://doi.org/10.1177/0969733014549883
Fernandes, M. I., & Moreira, I. M. (2012). Ethi-
cal issues experienced by intensive care unit
nurses in everyday practice. Nursing Ethics,
20(1), 72–82. https://
doi.org/10.1177/0969733012452683
Ferrell, B. R., Virani, R., Paice, J. A., Malloy,
P., & Dahlin, C. (2010). Statewide efforts to
improve palliative care in critical care set-
tings. Critical Care Nurse, 30(6), 40–45.
https://doi.org/10.4037/ccn2010248
Fridh, I., Forsberg, A., & Bergbom, I. (2009).
Doing one’s utmost: Nurses’ descriptions of
caring for dying patients in an intensive care
environment. Intensive and Critical Care
Nursing, 25(5), 233–241. https://
doi.org/10.1016/j.iccn.2009.06.007
Hamric, A. B., & Blackhall, L. J. (2007). Nurse-
physician perspectives on the care of dying
patients in intensive care units: Collabora-
tion, moral distress, and ethical climate.
Critical Care Medicine, 35(2), 422–429.
https://
doi.org/10.1097/01.CCM.0000254722.5060
8.2D
Holt, J. (2017). Ethical Issues at the end of Life.
Key Concepts and Issues in Nursing Ethics,
101(10), 129–143. https://
doi.org/10.1007/978-3-319-49250-6_10
Jamshidian, F., Shahriari, M., & Aderyani, M.
JPKI 2018 volume 4 no. 2
R. (2018). Effects of an ethical empower-
ment program on critical care nurses’ ethical
decision-making. Nursing Ethics. https://
doi.org/10.1177/0969733018759830
McAndrew, N. S., Leske, J. S., & Garcia, A.
(2011). Influence of moral distress on the
professional practice environment during
prognostic conflict in critical care. Journal of
Trauma Nursing : The Official Journal of
the Society of Trauma Nurses. https://
doi.org/10.1097/JTN.0b013e31823a4a12
Moon, J. Y., & Kim, J.-O. (2015). Ethics in the
Intensive Care Unit. Tuberculosis and Res-
piratory Diseases, 78(3), 175. https://
doi.org/10.4046/trd.2015.78.3.175
Oerlemans, A. J. M., Van Sluisveld, N., Van
Leeuwen, E. S. J., Wollersheim, H., Dek-
kers, W. J. M., & Zegers, M. (2015). Ethical
problems in intensive care unit admission
and discharge decisions: A qualitative study
among physicians and nurses in the Nether-
lands. BMC Medical Ethics. https://
doi.org/10.1186/s12910-015-0001-4
Park, Dong Won., & Moon, Jae Young., & Ku,
Eun Yong., & Kim, Sun Jong., & Koo,
Young-Mo., & Kim, Ock-Joo., & Lee, Soom
Haeng., & Jo, Min-Woo., & Lim, Chae-
Man., & Armstrong II , John David., & Koh,
Y. (2015). Ethical issues recognized by criti-
cal care nurses in the intensive care union of
a Tertiary hospital during two separate peri-
ods. Journal of Korean Medical Science, 30,
495–501. https://doi.org/10.3346/
jkms.2015.30.4.495
Pavlish, C., Brown-Saltzman, K., Hersh, M.,
Shirk, M., & Rounkle, A. M. (2011a). Nurs-
ing priorities, actions, and regrets for ethical
situations in clinical practice. Journal of
Nursing Scholarship. https://
doi.org/10.1111/j.1547-5069.2011.01422.x
Romano, M. E., Wahlander, S. B., Lang, B. H.,
Li, G., & Prager, K. M. (2009). Mandatory
ethics consultation policy. Mayo Clinic Pro-
ceedings. https://doi.org/10.4065/84.7.581
Santiago, C., & Abdool, S. (2011). Conversa-
tions about challenging end-of-life cases:
ethics debriefing in the medical surgical in-
tensive care unit. Dynamics (Pembroke,
111
 Arianto, A.B., Trisyani, Y., and Emiliyawati, E. | Ethical Dilemmas of End-of-Life Care in Intensive Care Unit : A Literature Review.
Ont.).
Sorta-Bilajac, I., Baždarić, K., Brkljačić
Žagrović, M., Jančić, E., Brozović, B.,
Čengić, T., … Agich, G. J. (2011). How
Nurses and physicians face ethical dilemmas
— the Croatian experience. Nursing Ethics,
18(3), 341–355. https://
doi.org/10.1177/0969733011398095
Tapper, E. B., Vercler, C. J., Cruze, D., &
Sexson, W. (2010). Ethics consultation at a
large urban public teaching hospital. Mayo
Clinic Proceedings. https://doi.org/10.4065/
mcp.2009.0324
Vanderspank-Wright, B., Fothergill-
Bourbonnais, F., Brajtman, S., & Gagnon, P.
(2011). Caring for patients and families at
end of life: The experiences of nurses during
withdrawal of life-sustaining treatment. Dy-
namics, 22(4), 31–5. Retrieved from http://
www.ncbi.nlm.nih.gov/pubmed/22282952
112 JPKI 2018 volume 4 no. 2
Wiegand, D. L., & Funk, M. (2012). Consequenc-
es of clinical situations that cause critical care
nurses to experience moral distress. Nursing
Ethics. https://
doi.org/10.1177/0969733011429342
Zeitzer, M. B. (2009). Ethical issues and decision
making related to resuscitation of severely
injured patients: Perceptions of emergency
department nurses. ProQuest Dissertations and
Theses. Retrieved from http://
search.proquest.com/docview/304979280?
accountid=14553%5Cnhttp://
openurl.library.uiuc.edu/sfxlcl3?
url_ver=Z39.88-2004&rft_val_fmt=info:ofi/
fmt:kev:mtx:dissertation&genre=dissertations
+&+the-
ses&sid=ProQ:ProQuest+Dissertations+&+Th
eses+Full+Text&atitl
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1. Penjelasan artikel

Ditemukan bahwa terdapat 4 tema hasil temuan artikel yang berkorelasi dengan dilema etik dalam
perawatan EOL, sebagai berikut:

a. Penerapan Prinsip Etika Perawatan EOL di ICU

Situasi yang dialami perawat dalam perawatan EOL adalah dilema etika; bahwa dia akan
menemukan hambatan untuk menahan tindakan kontradiksi terhadap keyakinan moralitas (Santiago
& Abdool, 2011). Perawat akan mengetahui tindakan yang dapat diberikan kepada pasien tetapi
tidak mampu karena alasan yang dipertimbangkan (B Vanderspank-Wright, Fothergill-
Bourbonnais, Brajtman, & Gagnon, 2011). Situasi tersebut akan membawa pada kegagalan dalam
melindungi hak pasien, dan menimbulkan empati serta dapat memicu situasi distres moral dan
perasaan. Sudut pandang hukum etik situasi EOL berkorelasi dengan pengambilan keputusan medis
untuk pasien.

b. Sumber Utama Konflik di Area ICU

Insiden konflik etik yang terjadi di ICU lebih tinggi dibandingkan area perawatan umum. Hasil
penelitian Tapper, Vercler, Cruze, & Sexson, (2010) menemukan bahwa pelayanan yang ada di
rumah sakit sebanyak 181.558 kasus, dimana 0,16% melakukan konsultasi dengan staf komite etik
rumah sakit; sedangkan pada penelitian lain sebanyak 4.968 pasien yang ditangani di ICU Columbia
University Medical Center sebanyak 168 (3,3%) melakukan konsultasi etik dalam pelayanan
(Romano, Wahlander, Lang, Li, & Prager, 2009). Studi lain oleh Park et al. (2015) melaporkan
bahwa insiden konflik terjadi sebesar 2,1% dan 0,5% selama dua periode penelitian.

c. Pengaruh Konflik Etis di Area ICU

Efek negatif dari perawatan EOL akan mengakibatkan moral distress sebagai akibat dari efek
pengobatan terhadap pasien (Brandi Vanderspank-Wright, Fothergill-Bourbonnais, Brajtman, &
Gagnon, 2011). Selain itu, situasi tersebut akan meningkatkan penderitaan pasien dan biaya
pengobatan (Wiegand & Funk, 2012). Situasi dilema etik jangka panjang pada perawat juga akan
menjadi faktor penyebab kelelahan mental dan praktik profesional yang mengganggu yang
mengarah pada perawatan terburuk (McAndrew, Leske, & Garcia, 2011).

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d. Respon Perawat Menghadapi Dilema Etika Kasus EOL di ICU

Ketika dilema etik ditemui, tidak dapat dihindari bahwa perawat harus menanggapi atau mengambil
tindakan atas situasi yang ada, sebagaimana studi oleh De Casterlé, Izumi, Godfrey, & Denhaerynck,
(2008) mengeksplorasi respon perawat dalam menghadapi dilema etik di Di Belgia, Swiss, Amerika
Serikat, dan Jepang ditemukan bahwa perawat menganggap lingkungan kerjanya sebagai hambatan
dalam penerapan praktik etik sehingga mereka harus mengorbankan kompetensinya untuk memberikan
perawatan yang kompeten. Kedua, perawat cenderung memberikan alasan konvensional dalam
menghadapi dilema etik sehari-hari yang dipandu oleh aturan dan norma kerja konvensional daripada
kreativitas dan refleksi krisis. Ketiga, perawat akan sangat menderita untuk mengimplementasikan
keputusan etis dalam konteks yang menantang yang menunjukkan bahwa faktor lingkungan cenderung
membimbing mereka dalam praktik etis.

2. Metodologi artikel

Metode yang digunakan dalam review artikel menggunakan manual PRISMA (Preferred Reporting
Items for Systematic Review and Meta Analyses).

Studi literatur disusun dengan meninjau hasil penelitian baik secara kualitatif maupun kuantitatif,
artikel-artikel terkait yang dikumpulkan oleh database media elektronik seperti Pubmed, ProQuest, dan
Google Schoolar; bahwa kata kunci yang ditetapkan menurut database MeSH oleh NCBI melibatkan
"Perawatan Akhir Kehidupan" dan "Etika Keperawatan dalam Perawatan Kritis" dan "masalah Akhir
Kehidupan dalam Perawatan Kritis" dan "Dilema Etika di ICU".

3. Metode PICO

Population :

Setelah dilakukan screening menurut periode publikasi (2007-2018), populasi dalam bentuk manusia
dan teks lengkap, diperoleh 925 artikel, dengan rincian sebagai berikut: ProQuest 56 artikel, PubMed
380 artikel, dan sisa 489 artikel Google Scholar.
Arianto, A.B., Trisyani, Y., and Emiliyawati, E. | Ethical Dilemmas of End-of-Life Care in Intensive Care Unit : A Literature Review.

Intervention :

perawat harus berpartisipasi dalam pengambilan keputusan dan komite peninjau harus memainkan
peran penting dalam kasus kontroversial. Itu juga bisa dilakukan dalam pengawasan daripada
keputusan atau jaminan kualitas (Zeitzer, 2009). (Pavlish, Brown-Saltzman, Hersh, Shirk, & Rounkle,
2011) ditemukan bahwa ada prioritas perawat untuk mencari solusi dilema etika, seperti berikut:
1. Kualitas hidup untuk pengobatan distres, nyeri dan penderitaan, dalam hal ini perawat harus
menanyakan kerugian dan keuntungan dalam pengobatan agresif terutama pada fase akhir kehidupan.

2. Menghormati otonomi pasien, keinginan pasien harus menjadi prioritas daripada keluarga atau tim
kesehatan.

3. Standar pelayanan tim kesehatan tidak diletakkan pada standar pengobatan sehingga terjadi konflik
dalam pemilihan pengobatan.

4. Masalah etik lainnya termasuk memberikan informasi yang benar tentang diagnosis dan prognosis
untuk memberikan informasi kepada keluarga tentang harapan pengobatan yang tidak realistis.

Studi yang diatur oleh Crump, Schaffer, & Schulte (2010), mengidentifikasi hambatan yang dialami,
dukungan dan pengetahuan yang diperlukan untuk memberikan perawatan EOL yang berkualitas.
Hasilnya menunjukkan bahwa:

1. Keluarga dan pasien harus diberikan informasi yang akurat, lurus, dan konsisten untuk membuat
keputusan akhir hayat.

2. Masalah yang dialami dokter terkait bagaimana pengaruh perawat dalam memberikan perawatan
EOL yang berkualitas.

3. Perawat di ICU harus diberikan banyak informasi, keterampilan dan kompetensi budaya untuk
perawatan yang berkualitas dan informasi awal tentang apa yang harus dilakukan pertama kali kepada
pasien.

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Comparison

Penelitian yang disusun oleh Erdil & Selain itu, penelitian lain menemukan
Korkmaz (2009) juga menunjukkan bahwa bahwa dilema etika pribadi perawat
masalah etika muncul di unit kritis seperti yang paling banyak dialami terkait
penganiayaan fisik (10%), penganiayaan dengan keputusan mendekati akhir
psikologis (34%), pengabaian privasi pasien hayat 11%, keadilan 7%, hubungan
(37%), diskriminasi (5%), dan hubungan profesional 6%; kemudian masalah etis
(3%). Selain itu, penelitian lain pada situasi terkait adalah pembatasan
menunjukkan bahwa dilema etik yang terapi penunjang hidup (perawat 15%,
paling banyak dialami oleh perawat secara dokter 24%) dan eutanasia oleh dokter
pribadi terkait dengan keputusan mendekati 28% (Sorta- Bilajac, Baždarić,
akhir hayat 11%, keadilan 7%, hubungan Žagrović, et al., 2011).
profesional 6%; dan masalah etika yang
paling banyak muncul pada situasi terkait
adalah pembatasan terapi penunjang hidup
(perawat 15%, dokter 24%) dan eutanasia
oleh dokter 28% (Sorta-Bilajac, Baždarić,
Žagrović, et al., 2011). Studi Erdil &
Korkmaz (2009) menjelaskan bahwa prinsip
etika yang dilanggar adalah otonomi (30%),
menghormati privasi dan keintiman individu
(22%), Non Maleficence (16%),
Beneficence (17%), Justice (15). %).

Outcome

Tidak ada jawaban dari pertanyaan yang ditemukan dalam penelitian manapun tentang bagaimana
mengendalikan masalah etika atau dilema yang timbul pada pasien ICU karena ada banyak faktor dan
personel yang terlibat dalam kasus ini termasuk dokter, tim multidisiplin dalam perawatan kesehatan,
staf lain, pasien. dan keinginan mereka, pengganti orang dalam pengambilan keputusan dan relatif,
tetapi dalam pelaksanaannya kita harus menentukan tujuan tertentu untuk terapi, intervensi, keputusan
 Arianto, A.B., Trisyani, Y., and Emiliyawati, E. | Ethical Dilemmas of End-of-Life Care in Intensive Care Unit : A Literature Review.

situasi pasien sesegera mungkin dalam menghindari masalah etika yang berkembang menjadi dilema
etika yang kompleks (Fridh , Forsberg, & Bergbom, 2009).

4. Penjelasan jurnal menurut teori

Perawatan akhir hidup (EOL) adalah penyakit terminal progresif, tidak dapat disembuhkan dan
berpotensi menyebabkan kematian; perawatan ini membutuhkan dukungan perawat dan keluarga untuk
mengidentifikasi fase akhir kehidupan, termasuk manajemen dan gejala nyeri, masalah psikososial dan
dukungan spiritual (Advanced Illness & End-Of-Life Care, 2017).

Perawatan EOL untuk pasien kritis khususnya di ICU semakin diiringi dengan kemajuan dan
perkembangan teknologi yang akan meningkatkan kualitas perawatan dalam jangka panjang. ICU
adalah area di mana perawat memiliki banyak pengalaman rumit tentang masalah dan situasi yang
mengancam jiwa yang berkorelasi dengan situasi pasien dalam hidup dan mati (Jamshidian, Shahriari,
& Aderyani, 2018).

Pengalaman dalam pengobatan pasien akhir hidup (Ferrell, Virani, Paice, Malloy, & Dahlin, 2010).
Hasil penelitian menunjukkan bahwa perawat, khususnya di area kritis memiliki tantangan dalam
prinsip etik, misalnya dalam situasi pasien di DNR, pengobatan pasien sebelum meninggal, aborsi atau
eutanasia, dan penggunaan pengekangan baik secara fisik maupun kimiawi. Pavlish, Brown-Saltzman,
Hersh, Shirk, & Rounkle, 2011). Selain itu, perawat dalam situasi tersebut berkontribusi pada
pengambilan keputusan etika dan mengadvokasi kebajikan pasien, dan faktor sosial ekonomi, paliatif,
dan budaya telah menjadi faktor resultan dari masalah etika.

Penerapan prinsip etik erat kaitannya dengan situasi dilema etik, yang hampir terjadi di area praktik
klinis, terjadi ketika staf kesehatan dihadapkan pada situasi berpikir kritis dalam pengambilan
keputusan kasus yang dialami (Sorta-Bilajac, Baždarić, Brkljačić Žagrović, et al., 2011). Efek yang
dialami perawat adalah dilema etika yang akan membawa hambatan dalam melaksanakan tindakan
mereka yang bertentangan dengan keyakinan moral (Ferrell et al., 2010).

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5. Kesimpulan

Dalam situasi EOL, perawat merupakan bagian dari pengambilan keputusan; bahwa itu berkorelasi
dengan akhir kehidupan. Pengambilan keputusan akan mengakibatkan situasi tekanan moral bagi
dokter dan keluarga pasien. perawat sering menghadapi masalah etika dalam praktik klinis, terutama di
ICU. Namun pengalaman, akal sehat, dan hanya menjadi orang baik, tidak menjamin bahwa perawat
dapat mengidentifikasi atau mengatasi dilema etika.

Situasi tekanan moralitas yang disebut dilema etis akan membawa konsekuensi pada setiap hambatan
yang membatasi suatu tindakan yang bertentangan dengan keyakinan moralitas. Selain itu akan
mengakibatkan kegagalan dalam melindungi hak pasien, yang dapat menimbulkan rasa empati dan
menimbulkan tekanan moralitas dan penderitaan secara emosional khususnya bagi perawat.
Pengambilan keputusan klinis yang baik hanya mungkin dilakukan ketika pengambilan keputusan
medis dan pengambilan keputusan etis seimbang dengan benar. Pengetahuan tentang dilema etika
umum dan pelatihan dalam pengambilan keputusan etis sangat penting. Pada saat yang sama, pimpinan
ICU dan direktur rumah sakit harus menyiapkan protokol untuk menemukan dan menyelesaikan
masalah etika umum di rumah sakit mereka.