Model Perawatan Paliatif Terpadu di Intensive Care Unit Melalui Intervensi RESPEK (PPT-ICU RESPEK)

SRI SETIYARINI, S.KP., M.KES, Prof. dr. Sunartini, Sp.A(K)., Ph.D; Dr. Indria L. Gamayanti, M.Si., Psi; Dr. dr. Sri Rahardjo, Sp.An., KNA-KAO

2016 | Disertasi | S3 Ilmu Kedokteran

Latar Belakang: Angka kematian pasien ICU di Propinsi Yogyakarta pada tahun 2011 sekitar 25% +- 30%. Penyelenggaraan perawatan paliatif di ICU di Indonesia telah diatur dalam KEPMENKES RI No. 812 tahun 2007, namun masih sedikit ICU di Indonesia yang menyelenggarkan perawatan paliatif secara terstruktur dan belum ada pelatihan perawatan paliatif yang khusus bagi klinisi ICU. Dibutuhkan satu model perawatan dan modul pelatihan agar klinisi ICU dapat mengintegrasikan perawatan paliatif di ICU dengan lebih baik. Tujuan: Mengembangkan model dan modul pelatihan perawatan paliatif yang khusus untuk ICU di Indonesia dan menguji pengaruh pelatihan dan penerapan model terhadap variabel pengetahuan klinisi ICU, kualitas perawatan paliatif dan akhir hayat, kolaborasi interprofessional dan peran serta keluarga dalam pengambilan keputusan terapi akhir hayat di ICU. Metode: merupakan penelitian mix method dengan pendekatan utamanya kualitatif untuk mengembangkan model beserta modul pelatihan perawatan paliatif di ICU. Data kualitatif diperoleh dari wawancara mendalam, merekam pertemuan keluarga, data field note dan data rekam medis pasien yang dianalisa secara konten. Didapat 52 sampel pasien ICU dan keluarganya, 9 klinisi untuk wawancara mendalam, 48 rekaman dan 27 klinisi sebagai peserta pelatihan. Hasil: Tersusun model dan modul pelatihan perawatan paliatif terpadu dengan perawatan kritis di ICU dengan intervensinya RESPEK (PPT+-ICU RESPEK). Model PPT+-ICU RESPEK merupakan pelayanan yang menerapkan prinsip+- prinsip paliatif yaitu holistic, komprehensif, interdisiplin yang berjalan terpadu dengan perawatan kuratif di ICU bagi pasien dan keluarganya sejak pasien dirawat sampai akhir hayat. Intervensi RESPEK adalah dukungan rasa nyaman (R), dukungan etik (E), dukungan spiritual dan screening akhir hayat (S), dukungan psikososial (P), edukasi (E) dan komunikasi dan kolaborasi interprofessional (K). Pelatihan interprofessional meningkatkan nilai rata+-rata (++-SD) kualitas pengetahuan klinisi ICU sebelum dibanding setelah pelatihan sebesar 34,07 (8,90) vs 70,37 (12,36), p=0,001, IK +-42,99 (+-) 29,59, d=3,37 dan nilai kolaborasi interprofessional 70,14 (2,67) vs 75,50 (5,16), p=0,001, CI 95% +- 8.353 (+-) 2.375), d =1,304. Penerapan model ini dapat meningkatkan kualitas perawatan paliatif dan akhir hayat sebesar 57,84 (15,48) vs 72,07 (10,37), p=0,003, d=1,080; namun pada aspek peran serta keluarga dalam pengambilan keputusan terapi akhir hayat adalah tidak meningkat, 100% vs 98,2% (p=0,100). Kesimpulan: Tersusun Model PPT+-ICU RESPEK yang dapat meningkatkan kualitas pengetahuan klinisi ICU, kualitas perawatan paliatif dan akhir hayat dan kolaborasi interprofessional. Tidak terdapat perbedaan pada peran keluarga dalam pengambilan kelutusan terapi akhir hayat.

Background: The mortality rate of ICU patients in the province of Yogyakarta in 2011 is about 25% +- 30%. Implementation of palliative care in the ICU in Indonesia has been arranged in KEPMENKES No. 812 in 2007, unfortunately there is still a little number of ICU in Indonesia that structurally implement the palliative care. Therefore, it necessary to have a model of care and training modules that ICU clinicians can integrate palliative care in the ICU better. Purpose: To develop a model and training modules palliative care that is specific to the ICU in Indonesia and evaluate the effect of training and application of models to variable knowledge of ICU clinicians, quality palliative care and end of life, collaborative inter+-professional and the role of the family in the making of therapeutic decisions for end of life treatment in the ICU. Methods: The study used a mix method with primarily qualitative approach to develop a training module along with the model of palliative care in the ICU. The qualitative data obtained from in+-depth interviews, recording a family gathering, data field notes and the result of content analysis of patients medical records. There were 9 ICU clinicians for deep interview, 54 samples of ICU patients and their families, and 27 clinicians for the training session. Results: Palliative care module and model were developed that integrated with critical care in the ICU. The intervention used for this study was RESPEK (PPT+- ICU RESPEK). This model was an integrated, holistic, comprehensive, and interdisciplinary model for ICU patient and the family when patient admits to the ICU until end of patients life. RESPEK means comfort (rasa nyaman/R), ethical support (E), spiritual support and screening (S), psychosocial support (P), communication and collaboration (K). Interprofessional training improved the quality of knowledge of trainees before and after application (mean ++- SD) was 34,07 (8,90) vs 70,37 (12,36), p=0,001, IK +-42,99 (+-) 29,59, d=3,370; and interprofessional collaboration was 70,14 (2,67) vs 75,50 (5,16), p=0,001, CI 95% (+-) 8.353 (+-) 2.375) d =1,304. The implementation of PPT+-ICU model improved the quality of palliative care and end of life care was 57,84 (15,48) vs 72,07 (10,37), p=0,003, d=1,080; but did not improve the family role in the decision+- making of end of life treatment (26 vs 25, p = 0.100). Conclusion: The RESPEK PPT+-ICU model could improve the quality of ICU clinicians, quality palliative care, and end of life care and interprofessional collaboration. There were no differences in the role of the family in the decision+- making end of life treatment.

Kata Kunci : Integrating palliative care, training, ICU, the quality of palliative care, end of life care