PROSES PENGAMBILAN KEPUTUSAN PENUNDAAN ATAU PENGHENTIAN TERAPI BANTUAN HIDUP PADA ANAK SAKIT RITIS STADIUM TERMINAL: STUDI KASUS DI RSUP DR SARDJITO YOGYAKARTA

NURNANINGSIH, Prof. dr. Moh. Juffrie, SpA(K), PhD.; Dr. Sri Setiyarini S.Kp., M.Kes..; Prof. Syafaatun Al Mirzanah, PhD, D.Min.

2021 | Disertasi | DOKTOR ILMU KEDOKTERAN DAN KESEHATAN

Latar belakang: Pada situasi akut, anak sakit kritis diberikan penanganan agresif untuk mempertahankan hidup. Apabila dalam evaluasi pemberian terapi bantuan hidup tidak lagi memberi manfaat maka dianggap bahwa pengobatan menjadi sia- sia (futile). Tujuan penelitian ini adalah mengetahui tentang pengambilan keputusan penundaan atau penghentian terapi bantuan hidup pada anak sakit kritis stadium terminal di RSUP DR Sardjito Yogyakarta. Metode: Pendekatan penelitian ini adalah kualitatif studi kasus dengan rancangan studi kasus tunggal untuk memahami secara mendalam tentang proses pengambilan keputusan penundaan atau penghentian terapi bantuan hidup pada anak sakit kritis stadium terminal. Subyek penelitian adalah orang tua pasien, dokter, direktur rumah sakit, ketua Subkomite Etika dan Disiplin Profesi Komite Medik serta ketua Komite Etik dan Hukum Rumah Sakit serta Kebijakan, Pedoman, Standar Operasional Prosedur tentang penundaan atau penghentian pemberian terapi bantuan hidup pada anak sakit kritis stadium terminal. Dilakukan wawancara mendalam tidak terstruktur terhadap semua partisipan. Hasil: Proses pengambilan keputusan adalah tipe share decision making. Semua partisipan orang tua pada awalnya meminta pemberian pengobatan sampai maksimal. Setelah dilakukan edukasi berulang, sebagian memutuskan tetap melanjutkan pemberian terapi bantuan hidup, sebagian menyerahkan keputusan kepada dokter, sebagian menyetujui penundaan pemberian bantuan hidup yang berupa tidak dilakukan resusitasi jantung paru (DNAR) ketika henti jantung atau tidak reintubasi. Sebagian menyetujui penghentian pemberian bantuan hidup berupa penghentian obat secara bertahap, namun semua partisipan tidak setuju ventilator dihentikan. Didapatkan 8 tema faktor yang memengaruhi orang tua dalam pengambilan keputusan. Sebagian besar dokter menyetujui penundaan atau penghentian pemberian terapi bantuan hidup, namun tidak dengan pelepasan ventilator. Terdapat 6 tema pandangan dokter, sementara terdapat 4 tema pandangan direktur dan 4 tema pandangan Komite Etik & Hukum serta Subkomite Etika dan Disiplin Profesi. Aspek legal berupa panduan nasional, kebijakan rumah sakit serta panduan praktik klinis (PPK) dan standar operasional prosedur (SOP), belum ada kebijakan tentang tindakan kedokteran yang sudah sia-sia (futile). Kesimpulan: Di RSUP Dr Sardjito Yogyakarta proses pengambilan keputusan penundaan atau penghentian terapi bantuan hidup pada anak sakit kritis stadium terminal adalah tipe share decision making yang dipengaruhi oleh pandangan orang tua, pandangan dokter, pandangan pemangku kebijakan dan aspek legal.

Background: In acute situations, critically ill children are given aggressive treatment to maintain life. If the evaluation of the provision of life support therapy shows that it is no longer beneficial, the treatment is considered futile. The purpose of this study was to find out about the decision process to forgo life sustaining treatment in terminal critically ill children at RSUP Dr. Sardjito Yogyakarta. Methods: The research was qualitative case study with a single case study design to understand deeply about the process of decision-making forgo life sustaining treatment in terminal critically ill children. The research subjects were parents, physicians, the director of the hospital, the chairman of the Ethics and Professional Discipline Subcommittee of the Medical Committee and the chairman of the Hospital Ethics and Legal Committee and Policies, Guidelines, Standard Operating Procedures regarding forgo life sustaining treatment in terminal critically ill children. Unstructured in-depth interviews were conducted on all participants. Results: Decision making process was share decision making type. All parents participants initially asked for maximum treatment. After repeated education, some participants still decided to continue giving life support therapy until the patient died, some left the decision to the doctor, 3 participants agreed to gradually discontinue the drug, 1 participant did not agree to reintubation. All participants did not agree that the ventilator was discontinued. Some participants agreed not to carry out cardiopulmonary resuscitation (DNAR). There were 8 themes of factors that influence parents in making decisions. Most doctors agreed to postpone or discontinue life support therapy, did not agree to remove the ventilator and all participants had never read the guidelines about forgo life sustaining treatment in terminal critically ill patients. There were 6 themes of doctors views, while there were 4 themes of the directors view and 4 themes from the views of the Ethics & Law Committee and the Professional Ethics and Discipline Subcommittee. There were national guidelines, hospital policies and clinical practice guidelines (PPK) and standard operating procedures (SOP), there was no policy on futile therapy. Conclusion: At RSUP Dr Sardjito Yogyakarta, the decision-making procedure about forgo life sustaining treatment in terminal critically ill children is a type of share decision making that is influenced by the views of parents, doctors, policy makers and legal aspects.

Kata Kunci : pengambilan keputusan, penundaan atau penghentian bantuan hidup, anak sakit kritis stadium terminal, faktor yang memengaruhi, aspek legal, decision making, forgo life sustaining treatment, terminal critically ill children, factors influence, legal aspect