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

Kata kunci: End-of-life-care, nursing ethic in critical care, issue end of-life in critical care, ethical dilemmas in ICU Student of Emergency Nursing Postgraduate Program, Padjajaran University, Bandung, Indonesia Magister of Nursing Study Program, Faculty of Nursing, Padjajaran University, Bandung, Indonesia Corresponding email: albertusbudi12@gmail.com Albertus Budi Arianto. Yanny Trisyani, Etika Emiliyawati


INTRODUCTION
The end-of-life (EOL) care is the progressive 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 including 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, respect, 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 lifethreatening situation in correlation with the situation 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 interaction periods with the patient.The role of patient to implement the critical care is very important the nurse have competency and experi-
Kata kunci: End Of Life Care, Nursing Ethic in critical care, issue End-of-life in critical Care, Dilema Ethic in ICU experiences in treatment of end-of-life patient (Ferrell, Virani, Paice, Malloy, & Dahlin, 2010).
The result of research shows that the nurse, especially 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, palliative, and cultural factors has becomes the resultant 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, Goberna-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).
Based on the background, carried out an identification and analysis of description of ethical issue occurred in intensive area, especially in EOL care, with the special purpose to identification of any potential ethical issue and observe the ethical principles involved in EOL care.

METHOD
The method used in article review uses manual 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 keywords established according to the MeSH database by NCBI involves "End of Life Care" and "Nursing Ethic in Critical Care" and "issue Endof-Life in Critical Care" and "Ethical Dilemmas in ICU".The searching process specified on inclusion criteria as follows:

Article of research of open access and full text
After searching and categorizing, it is carried out summarizing the relevant articles.The consideration of relevance based on clarity of resource and correlation with the topic.The summarizing result described in table in fluent the analysis.The analysis of results using descriptive thematic analysis

DISCUSSION
It is found that there are 4 themes of obtained result of finding articles in correlation with the ethical dilemmas in EOL care, as follows: 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 action 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.
Moreover, any other research was found that the most experienced personal ethical dilemmas of nurse is related to the near the end-of-life decision 11%, justice 7%, professional relation 6%; then 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).

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 service in the hospital is 181.558cases, 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 ethical 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.
According to the study arranged by Oerlemans et al., (2015) causing problem of ethical conflict in ICU related to the EOL involves complex 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 impact, healthcare staff considered that they sustaining 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 transportation and organ transplantation.

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, & Gagnon, 2011).Moreover, the situation will increase the suffering for patient and cost of treatment (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).

Response of Nurse in Face of Ethical Dilemmas in EOL Case at
The ICU There is not the answer of the question was found in any research on how to control the ethical 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, intervention, decision on situation of patient as soon as possible in avoid the ethical problem that developing into the complex ethical dilemmas (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 implementation of ethical practice that they must sacrifice their competence to provide the competent treatment.Second, the nurse tend to gives the conventional reason in face of daily ethical dilemmas 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 showing that environmental factor tend to guide them 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 suffering.Second, sustaining autonomy of patient (21.4%); that in this situation the nurse must give priority for request of patient than the family or healthcare staff.The substandard of health treatment is the third priority (14.3%), the authentic 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, according to Crump, Schaffer, & Schulte, (2010) explains that the existence of clear procedures in End of life care will reduce the sense of confusion that occurs in nurses.Other factors such as lack of communication between nurses and doctors 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 attempt 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 quality 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 follows: 1. Quality of life for treatment of distress, pain and suffering, in this case, the nurse must inquiring loss and benefit in aggressive medication 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 prognoses to give information for family on expectation of unrealistic treatment.
The study arranged by Crump, Schaffer, & Schulte (2010), identifying any experienced impediment, 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 correlation 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 information on what supposed to do first to the patient.
4. The preliminary information has given in prior can reduce an obscure about the treatment 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 morality distress situation for doctor and the family of patient.nurses frequently confront ethical issues in clinical practice, especially in the ICU.However experience, common sense, and simply being 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 impediments restricting an action that conflicting to the faith of morality.Moreover, it will result in failure in protect the right of patient, that can bring into the empathy and lead to the morality distress 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.
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).

Fig. 1
Fig.1 Scheme of PRISMA flow diagram of trial selection process for the critical review