ebn critical

7/25/2019 EBN Critical

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ISU ETIS & EBN IN CRITICAL CARE

Ninuk Dian K

FAKULTAS KEPERAWATAN

UNIVERSITAS AIRLANGGA



Isu etis di Keperawatan Kritis

1

2



ASPEK LEGAL, END OF LIFE, LOSS

AND GRIEVING



KELALAIAN

• kegagalan melakukan askep disebut kelalaian

menyebabkan kerugian pada pasien

masalah hukum

• Kelalaian dibuktikan: membandingkan kerja

perawat dengan standar



Contoh kelalaian

• Pasien tidak di monitor ketat: amputasi



Kasus

• Ny. K datang ke IGD RS A dengan keluhan nyeri

dada hebat menjalar ke dagu, leher dan

lengan kiri.

• Dokter tidak berada di tempat dan susah

dihubungi.

• Apa yang harus dilakukan oleh perawat?



Penyelesaian

• Bila perawat diperlukan melakukan tindakan

medik yang tidak di bawah pengawasan

langsung dan segera harus berdasar

protokol.

• Delegasi dokter yang tidak jelas/dipertayakan

bila dilaksanakan dan psien menderita

kerugian: konsekuensi sekunder harusditanggung perawat/dokter



ISU b.d. Tindakan bantuan hidup

• DNR: sah/eutanasia?

• Surat wasiat/surat kuasa• Pengambilan keputusan wali

• Penolakan tindakan pendukung hidup

• Kematian otak• Donor organ



Kasus

• Tn. X dirawat di ICU dengan multiple traumadengan kondisi tidak sadar, menggunakanventilator dengan mode control FiO2 60%. GCS 1X 2, klien mendapatkan dopamine 10 gama,dobutamin 8 gama. Setelah 1 bulan dirawat kliendinyatakam MOF. Hasil diskusi dengan keluargadidapatkan bahwa keluarga sudah tidak mampulagi membiayai biaya perawatan pasien dalam 3

hari kedepan. Keluarga meminta perawat untukmencabut saja ventilatornya .




Keywords:

• MBO

• Keluarga tidak mampu lagi membiayai pasien

• Keluarga meminta penghentian bantuan hidup



Learning issues:

• Hak-hak pasien dan kaitannya dengan hukum

• Pasien mati batang otak

• End-of-life decision making• Aspek social budaya

• Aspek agama/nilai yang dianut pasien dan

keluarga



ETIK

• Melibatkan prinsip-prinsip dan aturan yang

membimbing dan menjadi dasar tindakan.

• Etik individu: serangkaian nilai-nilai moralyang menjadi dasar perilaku seseorang

• Etik profesi: perilaku dan standar yang telah

disetujui untuk diterapkan oleh anggota dari

kelompok profesi tertentu



Prinsip etik

• Asas menghormati otonomi klien

• Klien mempunyai kebebasan untuk

mengetahui dan memutuskan apa yang akandilakukan terhadapnya, untuk ini perlu

diberikan informasi yang cukup



Prinsip etik

• Asas kejujuran

Tenaga kesehatan hendaknya mengatakan yangsebenarnya tentang apa yang terjadi, apa yang

akan dilakukan serta risiko yang dapat terjadi.• Asas tidak merugikan

Tenaga kesehatan tidak melakukan tindakan yangtidak diperlukan dan mengutamakan tindakan

yang tidak merugikan klien serta mengupayakanrisiko yang paling minimal atas tindakan yangdilakukan.



Prinsip etik

• Asas Manfaat

• Semua tindakan yang dilakukan terhadap klien harusbermanfaat bagi klien untuk mengurangi penderitaanatau memperpanjang hidupnya

• Asas kerahasiaan

• Kerahasiaan klien harus dihormati meskipun klien telahmeninggal.

• Asas keadilan

• Tenaga kesehatan harus adil, tidak membedakankedudukan sosial ekonomi, pendidikan, jender, agama,dan lain sebagainya. (Hariadi, 2004)



Kode etik, perawat:

• Menghargai kebutuhan, nilai, budaya, dan kerentananindividu dalam memberikan asuhan keperawatan

• Menerima hak individu untuk membuat pilihan b.d.

Perawatan diri mereka• Memberikan askep berkualitas pada semua orang

• Menjaga kerahasiaan pasien, menggunakan jugdementprofesional saat menentukan kapan harus membagiinformasi yang dimiliki tentang pasien demikepentingan terapi dan kesejahteraan pasien

• Janji Ners



Informed consent

• Semua tindakan yang melibatkan kontak

dengan tubuh pasien secara sengaja merup

tindakan invasi terhadap integritas tubuh

memerlukan persetujuan pasien



Persetujuan sah bila:

• Pembuat keputusan memahami untung rugi

keputusan yang dibuat serta pilihan-pilihan

yang ada

• Dibuat tanpa paksaan

• Dibuat oleh orang yang secara hukum

kompeten



Orang yang boleh memberikan

consent:• Mampu memahami dan meretensi informasi

• Mampu menelaah informasi dan menimbang

untung rugi/baik-buruk• Mampu membuat keputusan berdasar info

yang diberikan



PERSETUJUAN UTK BERPARTISIPASI

DLM RISET KESEHATAN

• Norma etik dalam riset biomedik: autonomy,beneficience, non maleficience & Justice(Declaration of Helsinki , 1975).

• Pasien berhak atas informed consent sebelummereka berpartisipasi dalam riset.

• Partisipasi seseorang dalam riset harusdiberikan secara suka rela dan berdasarkanpengetahuan tentang risiko dan keuntunganberpartisipasi.



End of life decision making



• Di rawat di ICU: seringkali merupakanpercobaan, jika gagal, klg harus

mempertimbangkan dari pemulihan ke

paliatif

• Perubahan dari pengobatan ke pemberian

rasa nyaman, aspek plg sulit dlm praktik

kedokteran dan keperawatan di ICU



• Advance technology in health care

• Possible to sustain, prolong, restore the life

with the use of complex tech and associatetherapies such as mech ventilation, ecmo, iab

counterpulsation devices, hd, organ transplat



• Combination of advance tech and therapy

are part of everyday management in crit

care settings

• Tech is capable of maintaining some of vital

funct, but less able to provide cure

• Managing critically ill patients in many

cases represents a provision of supportiverather than curative tx



End of Life and Palliative care

• Melibatkan masalah etik yang kompleks

• Penanganan pasien lebih banyak ditujukan

untuk kebutuhan spiritual dan psikologis kliendan juga keluarga



End of life and palliative

• A common ethical dilemma is r.t to

maintaining life at all costs and relieving

suffering associated with prolonging life

ineffectively



• Assessment of their post critical illness quality

of life is complex, emotive and forms the basis

of significant debate



End of life decision making

• Usually very difficult and traumatic

• As a result, there is sometimes a lack of

consistency and objectivity in the initiation,continuation and withdrawal of life supporting

tx in a critical care setting



Kasus

• Tn. X dirawat di ICU dengan multiple traumadengan kondisi tidak sadar, menggunakanventilator dengan mode control FiO2 60%. GCS 1X 2, klien mendapatkan dopamine 10 gama,dobutamin 8 gama. Setelah 1 bulan dirawat kliendinyatakam MOF. Hasil diskusi dengan keluargadidapatkan bahwa keluarga sudah tidak mampulagi membiayai biaya perawatan pasien dalam 3

hari kedepan. Keluarga meminta perawat untukmencabut saja ventilatornya .




THE MULTI LAYERED APPROACH

Patient Preferences

Medical Goals

Foundational Principles, Type of Ethical Problem

Contextual

features:

legal,

social, family,

economic

societal

Quality of lifeissues



Definitions of End-of-Life

Categories:

• cardiopulmonary resuscitation (CPR)

• brain death

• withholding life-sustaining treatment

• withdrawing life-sustaining treatment

• and active shortening of the dying

process.



Withholding treatment

a decision that was made not

to start or increase a life-sustaining intervention.

Patients not undergoingCPR were classified as withholding

therapy.



Withdrawing treatment

a decision that was made to actively

stop a life-sustaining intervention

presently being given.



Withdraw of tx

Guidelines

Pharmacologic Paralysis and End-of-

Life Care. Neuromuscular blockingagents, such as pancuronium, vecuronium,

and atracurium, can be involved in

end-of-life care



Withholding and withdrawing

• Withholding and withdrawing from life

support is considered ethically acceptable and

clinically desirable if it reduces unnecessary

patient suffering in patients whose prognosis

is considered hopeless

• Based on understanding that pat will most

probably die from underlying disease



Life support, includes:

• Ventilatory support

• Inotropic support

• HD• etc



• In most cases where there is doubt about

the efficacy and appropriateness of a lifesustaining treatment, it may be consideredpreferable to commence tx, with an optionto review and cease tx in particular after

broad consultation with team and family• Because ethical positions are

fundamentally based in an individual own’sbeliefs and ethical perspective, it may be

difficult to gain consensus view on acomplex clinical situation



Active shortening of the dying process

a circumstance in which someone performed an

act with the specific intent of shortening the

dying process; these acts did not include

withholding or withdrawing treatment

although withholding or withdrawing could

occur prior to SDP. Examples included an

intentional overdose of narcotics, anesthetics,or potassium chloride.



Cardiopulmonary resuscitation

a death despite use of ventilation

and cardiac massage, that is,

failed or unsuccesful CPR



DNR

• Decision against any further proactive tx such

as CPR



Brain death

a documented cessation

of cerebral function and meeting

the criteria for brain death.



Brain death, criteria

• Irreversible coma

• Loss of brainstem reflexes

• Loss of respiratory function

• Cessation of intracranial blood flow

• Respon to pain stimuli• Pupillary respons to light

• Corneal reflex

• Gag reflex

• Cough reflex

• Oculovestibular reflex

• Apnoe test

• Oculcephalic reflex (doll’s eyes)



• In some countries, patient with dx of brain

death is suggested to commence organ

donation



Nancy was in a persistent vegetative state after a serious

automobile accident. She was dependent, lived in a

long-term care facility, and received tube feedings formany years. On the basis of their belief that Nancy

would not want to continue to live under these

circumstances, her parents requested that the feeding

tube be removed and that Nancy be allowed to die. TheMissouri Supreme Court stated that no one could

exercise Nancy’s right to refuse treatment without “clear

and convincing evidence” of her wishes. After a long and

arduous struggle with the healthcare system and thecourts, Nancy’s family and attorney were able to present

the sufficient evidence. The feeding was stopped and

Nancy was allowed to die



What do you think

about Nancy’s case??



Killing vs. Allowing to Die ??



Strategies for improving end-of-life

communication in the intensive care

unit (ICU)1. Communication skills training for clinicians

2. ICU family conference early in ICU course

• Evidence-based recommendations for conducting

family conference:

• Find a private location

• Increase proportion of time spent listening to family



• Value statements made by family members.

• Acknowledge emotions.

• Listen to family members.

• Understand who the patient is as a person.

• Elicit questions from family members.

• Identify commonly missed opportunities

• Listen and respond to family members.

• Acknowledge and address family emotions.



•Explore and focus on patient values and treatmentpreferences.

• Affirm nonabandonment of patient and family.

• Assure family that the patient will not suffer

• Provide explicit support for decisions made by the family

• Additional expert opinion recommendations for conducting family conference:

• Advance planning for the discussion among the clinicalteam

• Identify family and clinician participants who should beinvolved.



• Focus on the goals and values of the patient.

• Use an open, flexible process.

• Anticipate possible issues and outcomes of thediscussion.

• Give families support and time.3. Interdisciplinary team rounds

4. Availability of palliative care and/or ethicsconsultation

5. Development of a supportive ICU culture forethical practice and communication



Research highlight

• A research by Truog et al (2008) concludes thatFamily-centered care, which emphasizes theimportance of the social structure within whichpatients are embedded, has emerged as acomprehensive ideal for managing end-of-life care in

the ICU.• ICU clinicians should be competent in all aspects of

this care (practical and ethical aspects of withdrawingdifferent modalities of life-sustaining treatment andthe use of sedatives, analgesics, and

nonpharmacologic approaches to easing the sufferingof the dying process.



Caring for dying patients in ICU

• Privacy

• Dignity

• A noise free environment with minimaldisturbance

• Relief of pain

• Provision of comfort

• Support for both pt and relatives

• Coordination of bedside visits



Caring ...

• Discussion re arrangements, wishes,

belongings, and cultural consideration after

the patient’s death

• Guiding and supporting fam during this time



Symptom management

• Pain

• Dyspnoea and respiratory distress

• Delirium• Specific medication: opioid



Consideration at the time of death

• Determination of brain death

• Organ donation

• Bereavement and support



EVIDENCE-BASED PRACTICENinuk Dian K

1



Evidence-based Nursing

‘The process by which nurses make clinical

decisions using the best available research

evidence, their clinical expertise and patient

preferences, in the context of available

resources’

Dicenso et al., 1998



Komponen EBN



Tahapan EBN

1 Reflecting on your practice and questioning

2 Framing an answerable question

3 Searching for the evidence4 Appraising the evidence

5 Implementing and evaluating



Melakukan refleksi dan

membuat pertanyaan



1. Reflecting on your practice and

questioning

• Reflect on your clinical practice

• Identify areas of uncertainty

•A better way of doing things

• Ask why do we do it this way



Refleksi

• Pasien Kritis berbau tidak sedap

• Kejadian infeksi cukup tinggi

•dll

• dll



Merumuskan masalah yang bisa

dijawab



Memfokuskan pertanyaan

Memecah pertanyaan menjadi komponen-

komponen (PICOT/PECOT):

•Participants (& setting)

• Intervention/Exposure

• Control

•Outcome

• Time



Contoh:

Apakah oral hygiene dengan sikat gigi dan

gosok lidah lebih efektif dibandingkan

dengan kasa dalam mengurangi biakan

kuman di mulut pasien ICU dewasa dengan

ventilator?



Participant dan Tempat• Populasi khusus: misal: pasien ICU lansia

• Kelompok umur? Jenis kelamin?

• Diagnosis? Orang-orang dengan penyakittertentu misalnya GBS

• Lokasi geografi• Suku bangsa

• Penting: populasi harus spesifik tetapi

rasional



Tempat

Tempat yang ingin diteliti?

• ICU

•HDU

• Emergency ICU

• Specific ICU: CCU, PICU, NICU



Intervensi (exposure)

Intervensi apa yang diberikan pada partisipan?

• Obat?

•Paket pendidikan kesehatan?

• Bentuk pelayanan yang berbeda?

• Paparan suara dan cahaya

•Sesuatu yang menyenangkan misalnya pijat



Kontrol

• Plasebo?

• Perawatan standar?

•Intervensi yang lain?

• Tidak ada penyakit

• Hilangnya faktor risiko (misal: suara dan

cahaya berlebihan)



Outcome yang diharapkan?

• Reduction in symptoms?

• Improved quality of life?

•Reduced number of deaths?

• Reduced costs?

• Improved service delivery?



Waktu

• Is the outcome measured immediate?

• Are outcomes measured at different time

points?

• Is it a longitudinal study where outcomes are

measured over 20 years?



3. Mencari evidence

Sumber-sumber informasi:

• Papers published in peer review journals &systematic reviews

•Colleagues, newsletters, CPGs, hospital webpages, drug manuals, personal communication,

textbooks, protocol manuals,distilled/consolidated research, databases, dst..dst..

Searching the literature to find answers to yourquestions



Level of evidences

1. Systematic reviews

2. Randomised controlled trials

3. Cohort studies

4. Case-control studies

5. Surveys

6. Case reports

7. Respected authorities/expert committees8. Opinion



Dasar dari tingkatan evidence

Systematic review mendokumentasikan

homogenitas hasil sejumlah penelitian RCT

berkualitas tinggi sehingga merupakan bukti

yang paling tidak bias dan memberikanestimasi efek dari intervensi



Sumber sistematik review

The Cochrane Library

• ‘Publication type’ in Medline = Meta-analysis

• ‘Publication type’ in CINAHL = Systematic review

NHS CRD Database of Abstracts of Reviews of Effectiveness (DARE)

‘Distilled’ information sources

• Evidence Based Nursing (EBN)

• Evidence Based Medicine (EBM)• ACP Journal Club

• Best Evidence



Sumber referensi ilmiah:

• Primer: jurnal, majalah, skripsi, tesis, disertasi,

laporan penelitian

• Sekunder: abstrak, bibliografi

• Tersier: textbook, ensiklopedia



Sumber-sumber artikel

• CINAHL

• Scopus: abstract only

• The Cochrane Library• Medline / Pubmed

• Web of Science

• Google Scholar• Journal collections (ScienceDirect, Synergy



Sumber Ilmiah Perpustakaan Unair

• Hardcopy: Buku, jurnal, karya ilmiah sivitas

akademika

• Softcopy: ebooks, e-journal yang dilanggan

perpus ataupun Dikti, ADLN

• Fasilitas lain di ruang baca



Strategi pencarian

Butuh strategi karena:

• Informasi yang tersedia sangat banyak dan

luas

• Untuk memperoleh informasi yang relevan

• Menghemat waktu

• Mempermudah pencarian

• Mendapat info lain yang berkaitan



Operator bantuan pencarian di

jurnal elektronik

• Boolean operators/boolean logic (AND, OR,

NOT) e.g virus ebola

• Frase (“...”) mencari symber informasi

mengandung frase yang tepat sama

• Truncation (pemotongan kata atau

penggunaan akar kata ...*



SCOPUS

• Berisi abstrak research online, bukan fulltext



Springerlink

• Database yang dapat dimanfaatkan adalah

semua jurnal yang tersedia



Science direct

• Current: veterinary (science and medicine)

lainnya abstract saja

• Backfiles (< 1995): business-manag, accounting,

economics, econometrics, finances, psychology,nursing and health professions, vet, forensic med,

pathology and medical tech, orthopedics sports

med and rehab tahun depan unair akan

berlangganan fulltext. Saat ini bisa

memanfaatkan fasilitas kartu sakti: ITS



Sage Premier

• HSS (Humanities and Social Sciences: 351

journals

• STM (Science-technical-medical): 144 Journals



Proquest

• Art module, Business, agriculture, biology. Sociology journals

• Ebsco: academic source premier, business, medline

with fulltext

• Gale:

• Gale virtual lib (ensiklopedia + penelitian berbagaidisiplin)

• Gale science standard package (fisika, math, nano tech)

• Gale arts, humanities & edu (humaniora & pendidikan)



Sumber lain

• Google scholar

• Familiar Google interface for articles, books andacademic websites

• Go to Find Database.

• Search results ranked by Google algorithm• Links to cited articles and full text

• Very easy to use

• Free journals; cara mencari: “ list ... journal” will

include unpublish journals• Google book: ketik judul, cari adakah yang gratis di

gigapedia atau web ebook yang lain



Melakukan critical appraisal



4. Critical appraisal

• Assessing the quality of the research identified

• Involves the use of criteria against which to

measure or evaluate steps of the research

process

• Guides/tools to assist in critical appraisal:

JAMA guides, BMJ series – ‘How to read a

paper’



Prinsip Critical appraisal

• Setiap rumusan masalah berimplikasi pada

design penelitian yang sesuai.

• Gunakan dan baca hanya penelitian yang

menggunakan design yang tepat untuk

menjawab pertanyaan.



Prinsip Critical appraisal

• Adalah menelaah kualitas penelitian.

• Menggunakan kriteria tertentu untuk menilai suatupaper

• Tools: JAMA

Pertanyaan yabg harus diajukan setiap membaca hasilpenelitian adl:

• Apakah hasil penelitian valid?

•Apa hasil penelitiannya?

• Akankah hasil penelitian membantu saya dalammerawat pasien?

A k h t j di b tk d



Apakah tujuan disebutkan dengan

jelas?

Dalam pendahuluan, lihat:

• Why was the study conducted?

• Are the research question, aims &/or objectivesclearly stated?

• Is the significance of the study clearly identified?

• Studies which have unclear aims are unlikely toproduce meaningful results

• Are the method and study design appropriate?

• Are the philosophical underpinnings of theresearch described?



Validkah hasil penelitian?

• Apakah besar sampel dijelaskan? Sample sizecalculation (power) – to ensure the sample size islarge enough to detect an effect if there is one

• Are the methods clearly described?

• Statistical analysis?

• Methods section

• Is enough detail provided?

• Beware of large numbers of tests – thegreater the number of tests the greater thelikelihood of spuriously significant results




Apakah ada kejadian yang tidak diinginkan

selama penelitian?

• The researchers should acknowledge and

explain any deviations from the original

research design

• Large amounts of missing data may bias the

study findings• Often found in the limitations section



Validkah hasil penelitian

Apakah besar sampel tetap?

Missing data should be identified

• Numbers of participants reported in subgroups

within tables should add up to N

• Inconsistencies i.e. participants lost to follow-

up should be explained

• Were all patients who entered the study

accounted for?




Adakah efek penting yang tidak dilaporkan?

• Are there are any relevant findings that have

not been acknowledged or discussed?

• Are there any confounders/bias not

acknowledged



Apakah hasil dari penelitian?

• Apakah data dasar dideskripsikan dengan

adekuat?

• Jumalh partisopan harus dilaporkan,

bagaimana rekrutmen responden, data

demografi, dilaporkan sebagai nomor, persen,

mode, median, mean, SD

• Descriptive statistics

Were the basic data adequately



q y

described?

• Were the groups similar at the start of the

study?

• Simple statistical analyses should be presented

in table or figure format

• More complex statistics should follow

Apakah kelompok sama pada awal perlakuan?



Apa makna dari Hasil Penelitian?

• Examine the findings of each reported outcome to decide if you believe it is of clinical significance

• A statistically significant finding will not necessarily beclinically significant

Apa beda hasil penelitian dengan penelitian sebelumnya?

• Apakah hasil penelitian konsisten dengan penelitian lain?

• Apakah peneliti menginterpretasikan hasil penelitiandengan mempertimbangkan penelitian sebelumnya?

• Apakah peneliti menghubungkan hasil penelitian denganteori yang ada?



Riset Kualitatif

• Study things in their natural setting,

attempting to make sense of, or interpret,

phenomena in terms of the meanings people

bring to them

Black ,1994

Contoh metode penelitian kualitatif:



Contoh metode penelitian kualitatif:

• Documents: Study of documentary accounts of events

• Passive observation: Systematic watching of behaviourand talk in a natural setting

• Participant observation: Observation in which theresearcher also occupies a role

• In-depth interviews: Face-to-face conversation toexplore issues or topics in detail. (Does not use pre-setquestions but a defined set of topics)

• Focus groups: roup interview that explicitly includesand uses group interaction to generate data



Pertanyaan:

• Struktur: apakah jelas bahwa sampel dipilih mewakili fenomenayang akan diteliti?

• Data collection: Are data sources and methods of collectionspecified? Is there evidence that participant consent is an integralpart of the data collecting process?

• Data analysis: Can the analysis strategy be identified? How does theresearcher show they are reporting the participant’s reality? Isthere evidence the researcher’s interpretation captured theparticipant’s meaning? What evidence is provided to demonstraterigour?

• Describing the findings does the researcher demonstrate themethod for analysing the data? Does the researcher indicate howthe findings relate to theory? Does the researcher link findings toexisting theory/literature or is a new theory generated?

Will the results help me in caring



Will the results help me in caring

for my patients?

What implications does the study have for your practice

• Should the findings arising from this study be used toinform/change your practice?

• Consider the size of the effect and its clinicallysignificance

• Consider the overall quality of the study to decidewhether the findings are likely to be true

• Is the sample similar to your own patients/clients?

• Does the setting resemble your own setting?



Implementasi

Making decisions about whether it is appropriate toimplement the research in your practice:

• Research evidence

• Patient’s preferences

• Clinician’s expertise• Healthcare resources

Developing implementation strategies

Contoh:

• Vitamin C reduces the risk & severity of scurvy. Treatment

was effective plus: Cost effective (cheap), Acceptable, lowrisk, available. TAPI membutuhkan waktu > 300 tahununtuk mengimplementasikan