Implementation of Anesthesia Ethics to Improve Medical Professionalism

This research aims to increase the professionalism of medical personnel in the field of medicine, especially poly surgery. Research methodology with descriptive qualitative literature review design. Data collection techniques by collecting information from electronic reading sources. This type of research is an analysis of medical journals with primary subjects from several hospitals in Indonesia for analysis based on inclusion criteria such as patients experiencing postoperative anxiety and insecurity, this results in weak physical health due to psychological influences. Data analysis using source triangulation. The research results describe that the medical and health sciences field has ethics and a professional attitude that needs to be realized to increase a sense of comfort and trust in the medical world. From the results of several findings, it was stated that the action decisions taken by medical science were still in agreement or had yet to be mutually agreed upon. They emphasise the element of compulsion because of the conditions requiring it. Patients do not have a voluntary attitude in agreeing to medical action. Such influence becomes a consideration that rules and agreements, the volunteers of doctors and patients must be realized with awareness and voluntarism. If two things are realized, it can increase the value of medical professionalism, especially in anaesthesia.


INTRODUCTION
Developments in health science and technology affect knowledge and improve the quality of human resources (Prasetyowati & Panjawa, 2022). Improved services in several hospitals have become a significant force for the advancement of medical science in Indonesia. Some of the medical personnel become one of the obstacles to becoming more professional because there is an element of trade monopoly practice. Such views become obstacles and problems one after another and are difficult to prevent. One of the essential facilities and infrastructure that can make the world of medical science education develop and compete in the national and international spheres through improving the quality of medical experts and implementing the medical code of ethics properly.
One form of surgical procedure that is often performed by the majority of government and private hospitals is to perform a Caesarean section. Childbirth is ending a pregnancy that every woman looks forward to with great hope and joy. However, the pain that accompanies it can be a torment in itself. With advances in medical technology, this labour pain can be eliminated so pregnant women can give birth calmly, namely by using epidural anaesthesia. Doctors can make a diagnosis first before deciding to deliver through surgery. The diagnosis is not necessarily made only by the desire of one of the parties. In order to apply medical ethics, there must be a willingness from both the patient and the doctor responsible for patient safety elective and emergency surgery. The most common indications are failure to progress the opening of the birth canal, fetal distress, cephalopelvic disproportion, abnormal fetal position, prematurity, and a history of previous cesarean section (Flora et al., 2014). The choice of the anaesthetic technique used is regional or general anaesthesia which has advantages and disadvantages.
As professional medical personnel, it is necessary to explain the various risks that occur. The doctor must explain some of the possibilities that will happen to the patient. Side effects of hypotension and bradycardia are the most common physiological changes that occur due to spinal anaesthesia (Flora et al., 2014). Anesthesia is one of the actions that many patients worry about. Not only experienced in women who will give birth but also felt by other patients. According to (Hartono et al., 2018) 25% of patients will experience symptoms in their first pregnancy. This is due to an increase in blood volume and pulse. Some literature states that spinal anaesthesia is contraindicated in patients undergoing surgery with mitral stenosis because of the risk of hypotension and tachycardia.
The condition of pregnant women has limitations in their daily activities. Changes in physical and psychological conditions result in active and adverse reactions to information on the health of babies and mothers. Routine checks can be carried out monthly to reduce the risk of failure in living a healthy life. Pathological abnormalities of mitral stenosis in pregnancy are associated with acute pulmonary oedema and aortic valve disease (Hartono et al., 2018). Symptoms that arise depend on the severity of the mitral stenosis, including fatigue and dyspnoea at first, then can cause paroxysmal nocturnal dyspnea, orthopnea and shortness of breath. One of the preventions of physical and mental health in pregnant women is by doing pregnancy exercises that medical experts have trained. This activity is carried out to minimize surgery during childbirth. The problem of health services in Indonesia, in line with the development of medical science and technology, as a result, the three basic requirements above still need to be fulfilled. With the development of science and technology, health services have changed. On the one hand, these changes bring benefits such as increasing the quality of health services which can be seen in the decreasing morbidity, disability and death rates.
Clinical settings often use the clinical ethics approach introduced by Jonsen and Siegler with systematic medical considerations according to medical indications, patient preferences, quality of life and contextual features (Ismail & Kulsum, 2020). In mild head trauma, the symptoms that often arise are behavioural changes and neuropsychological changes. General practitioners can work with psychiatrists to treat patients diagnosed with failure to control emotions and other causes. The function of the risk level in the field of anaesthesia based on the American Society of Anesthesiologists (ASA) is 3, and the probability of death on the operating table (Death on the table / DOT). Based on the background above, this study aims to increase the professionalism of medical personnel in the field of medicine, especially poly surgery.

METHODS
This type of research uses a descriptive qualitative library research design (Ross et al., 2020). Library research is research conducted based on information from scientific publications, prior research or other written sources that support the discussion in this writing. This literature study uses online literature search media, namely using electronic databases such as PubMed, PMC, Science Direct, Semantic Scholar, Google Books, and several online search sites. In qualitative research, it does not use samples but uses primary data and secondary data obtained from information sources to support research. There are inclusion criteria such as the presence of patients who are unprepared for surgery resulting in postoperative insecurity, needle phobia, blood phobia, sharp tool phobia, some of these criteria affect physical health conditions. As a professional doctor, you must be able to provide positive suggestions for the patient's irrational mindset. Data analysis technique uses source triangulation.

RESULTS AND DISCUSSION
Operations have been the talk of the past until now. At present, the operation is often felt by pregnant women who will give birth (Rietveld et al., 2020). We need to observe that this action occurs because of the patient's will or compulsion, but there is a medical necessity. Suppose there is no agreement between the two, or it occurs because of compulsion. In that case, there is no voluntary element which can increase the patient's unconsciousness and have other risks, such as increased stressors for the patient and financial unpreparedness. As a medical expert, you must be able to respond professionally to problems that occur in patients. Medical personnel have several alternative offerings to increase patient readiness and mutual consent. No party is harmed and helps each other between patients and doctors.
Excessive workload and working hours have a significant impact on doctor performance and patient safety (Baharuddin et al., 2017). Based on the publication by the Royal College of General Practitioner (RCGP), fatigue is one of the main factors of health workers that can harm patients. Fatigue (fatigue) affects concentration and the ability to complete tasks so that it is often the root cause of mistakes made by doctors. One form of surgery performed is anaesthesia. Anesthesia is removing pain centrally accompanied by loss of consciousness using amnesiac drugs, sedation, analgesia, muscle relaxants or a combination of several of these drugs, which are recoverable (Millizia et al., 2021). General anaesthesia has several side effects that make patients uncomfortable after surgery, including sore throat, nausea, vomiting, delirium, muscle pain, itching, and hypothermia (Tang et al., 2023). Nausea and vomiting is a side effect that often occurs in patients. Postoperative nausea and vomiting (PONV) or postoperative nausea and vomiting is the feeling of nausea and vomiting experienced by patients after anaesthesia and surgery in the first 24 hours after surgery (Qian et al., 2022). PONV may occur in 20-40% of surgical patients, and the percentage at risk increases in high-risk patients up to 80%.
The field of the physical health needs to collaborate with mental health sciences. There is Hypnobirthing which is part of the self-hypnosis method (self-hypnosis) and relaxation techniques to make it easier for prospective mothers to give birth by reducing perceptions of fear, anxiety, tension, and pain during childbirth (Catsaros & Wendland, 2023). Most patients with mitral stenosis are free of complaints. Usually, the main complaint is shortness of breath which can also be fatigue (Hartono et al., 2018). One of the functions of Hypnobirthing is to reduce pain during childbirth and increase positive suggestions and belief in God in the birth process. This method effectively reduces the risk of surgery in pregnant women during childbirth.
The World Health Organization (WHO) explains that relevant and practical clinical learning must be planned, organized, monitored, and evaluated in a structured and continuous manner (Purnamasari, 2019). Minister of Research, Technology and Higher Education No. 44 of 2015 describe that the learning process through curricular activities must be systematically and structured through various courses with a measurable, planned or programmed learning load. The continuity of learning health sciences can improve the quality of human resources and medical services properly. Based on the analysis of table 1, it is known that the type of caesarean section or caesarean section is one of the labour processes or the process of removing the baby from the womb of the expectant mother without going through the birth canal or vagina. However, through surgery performed on the mother's abdomen (laparotomy) and uterus (hysterotomy) Cesarean operation is popular because the Roman ruler, Julius Caesar, was born by surgery or surgery, where in Roman times, every woman who died during childbirth had to have her stomach operated immediately to save the baby. At that time, medical reasons were considered more than patient requests.
In the process of giving birth, there are caesarean sections for medical reasons and those that are planned. Generally, the gestational age of giving birth to a caesarean section of 36 weeks is more advisable if the mother does not have certain diseases. In this planned caesarean section, you do not have to wait for contractions like in a normal birth. The process of 36 weeks of caesarean delivery generally lasts about an hour. PPH or postpartum haemorrhage occurs (bleeding which amounts to more than 500 ml) because cutting the uterine wall while pregnant will cause severe bleeding. However, this bleeding rarely reaches an excessive amount, and if this happens, it can be overcome by transfusion. Consult the doctor on duty in the emergency room with a specialist, or consult a resident doctor with the consultant (Prawiroharjo et al., 2019). This enthusiasm for consulting more skilled doctors is following what is stated in the Code of Medical Ethics (CME) article 14, which reads, "A doctor must be sincere and use all his knowledge and skills for the benefit of the patient, who when he is unable to do something examination or treatment, with the consent of the patient/family, he must refer the patient to a doctor who has expertise (Millizia et al., 2021). The risk factors associated with surgery consist of the duration of the operation and the type of operation. PONV is usually mild and rarely causes serious consequences. However, if it occurs continuously, it can cause complications in patients, including severe sore throat, oesophagal rupture, ruptured abdominal sutures, intraocular bleeding, and airway obstruction. Several actions can minimize the risk of PONV, namely using regional anaesthesia compared to general anaesthesia, using propofol in general anaesthesia, avoiding the use of volatile/inhaled anaesthetics, reducing the use of opioids, and adequate hydration.
The cause of pain in this type of tumour, cancer, can cause the patient's psychological condition to be disturbed. Some patients experience physical complaints that have an impact on psychological complaints. Decreased appetite, lack of enthusiasm for life, and unhealthy lifestyles are one of the factors that cause tumours and cancer or heredity. Stressors in the form of anaesthetic actions and surgical incisions can result in injury and tissue damage, causing activation of the sympathetic nervous system (Purnama et al., 2013). Sympathetic nervous system activation stimulates the adrenal medulla to release epinephrine. Epinephrine works with cortisol to increase blood sugar levels by activating the glycogenolysis pathway. The secreted epinephrine will cause an increase in the rate of metabolism throughout the body up to 100% above average so that the speed of glycogenolysis in the liver and muscles also increases.
The surgical procedure is carried out by a surgeon with a doctor's assistant to make the operation easier. General anaesthesia (Purnama et al., 2013) As many as 29 people (67.4%) had increased blood sugar levels during post-surgery, with an average of 141.1 mg/dl, while 14 patients (32.6%) had blood sugar levels. There are several things that the patient must know when carrying out medical procedures. One of the medical actions is evident that the patient will experience pain and other complaints. The patient's loss is the responsibility of the patient, who is ready to take action. As professional experts, education services need to be provided to increase positive beliefs and minimize patient stress levels.
There are several ways and medical offers to deal with patients who undergo minor or major surgery. In addition to voluntary factors, other risks and impacts need to be explained honestly. Communication that is built between doctors and patients must be communicative. Anesthesiology nursing is one of the lessons that must be passed by anesthesiology nursing students to achieve learning outcomes and competencies as nurse anesthesiologists (Purnamasari, 2019). Anesthesiology nursing is a new study program in Indonesia. Health sciences can introduce the latest updates on how professional doctors deal with patient problems with the best service.
From the results of the analytical study, several alternative options were found before deciding on surgery, such as providing ongoing treatment, therapy and other prescriptions. Several solutions exist to improve physical health sustainably and appropriately. This reason is the leading choice that patients have the freedom to decide on problems while the central role of doctors is to provide recommendations and explanations in terms of medical elements from the results of diagnoses and prognoses that are carried out in real terms based on screening data and other findings. A study found the average decrease in blood pressure from 124/72 mmHg to 67/38 mmHg in mothers positioned supine after spinal anaesthesia was performed at cesarean section. In contrast, the average blood pressure was 100/60 mmHg for those positioned sideways. Hemodynamic changes occur due to sympathetic vasomotor blockade, exacerbated by compression of the aorta and the inferior vena cava by the enlarged uterus when the patient is in the supine position (Flora et al., 2014). A significant decrease in maternal blood pressure will endanger the mother and fetus if the decrease in blood pressure and cardiac output is not immediately recognized and treated.
One of the introductions to specialist surgical medicine is the anaesthetic process. The main principle of anaesthesia in patients with mitral stenosis is to avoid tachycardia, maintain sinus rhythm and aggressively address new occurrences of atrial fibrillation both pharmacologically and with cardioversion, especially in patients with poor hemodynamics, avoiding a decrease in SVR that will cause compensation (Hartono et al., 2018). Several types of actions before surgery are carried out by doctors giving unconscious drugs to patients to make it easier for the activation process. Intrathecal local anaesthetics work by inhibiting voltage-gated sodium channels in the spinal cord, which will affect motor and sensory impulses from afferent and efferent fibres (Hartono et al., 2018). This sensory and motor block degree depends on the technique, agent and dose administered.
Beneficial both as analgesia in expected delivery and in cases of emergency cesarean section (Hartono et al., 2018). Low-dose levels of bupivacaine have been used in cesarean sections (e.g. bupivacaine 5 mg with fentanyl 25 mcg of). The main principle is to reduce hypotension. The incidence of hypotension was approximately 31% in patients receiving 5 mg of bupivacaine in combination with 25 mcg of fentanyl, compared to patients receiving only 10 mg of bupivacaine without opioids, where the incidence of hypotension was 94%. Hyperbaric spinal anaesthetic solutions have also been prepared by combining local anaesthetic solutions with dextrose (glucose). The density of local anaesthetic is directly proportional to the concentration of dextrose.
The type of human health is divided into two parts. Namely physical health that is visible and can be treated physically by medical personnel and psychological or mental health that is not visible and can be treated by a psychiatric specialist or Sp. KJ, psychologist, and psychiatrist. Forms of physical violence, such as violence involving direct contact and intended to cause feelings of intimidation, injury, or other physical suffering or damage to the body (Studi et al., 2022). General practitioners and specialists can perform the physical and visible treatment. Whereas patients who experience mental health disorders resulting in emotional injury, mental burden and perceptions of the causes of mental disorders cause weak psychic conditions and no motivation to live. Some causes of psychological health disorders are the inability to face reality and having a high sense of worry (Zumiarti & Kom, 2022). In patients who have a fear of undergoing surgery, it can have a psychological impact. Personally, this can be overcome by carrying out further treatment with a psychiatrist to get psychological peace.
Other causes besides personal factors are social factors (Tu et al., 2022). A toxic relationship is a social environment that is not good, a lack of self-confidence, a bad past, comparing personal relationships with other people's relationships, a lack of support or attention to each other, and poor communication (Studi et al., 2022). Moreover from these causes, toxic relationships also have consequences, namely, leaving a feeling of trauma, disturbing one's personality, and can disrupt one's body (Puteri et al., 2022). During contact, it is used to study the interaction of causal factors, pathogenesis, physical and psychological, family, community, social and environmental factors that affect the course of the patient's illness.
Psychological stress, such as anxiety, fear or sadness, is a stressor usually experienced by patients before surgery (Purnama et al., 2013). However, in elective surgery patients, the stressors that arise are insignificant because the surgery schedule has been planned, and the patient has prepared himself beforehand so that the existing stressors do not cause an increase in blood sugar. Therefore, the examination showed that the patient's blood sugar levels were normal. The ethical dilemma faced by anesthesiologists is high-risk anaesthetic action. However, the possibility of saving lives is not successful, so whether to continue with surgery or only give supportive measures (Ismail & Kulsum, 2020). To overcome this problem, ethical dilemma solutions are used based on the clinical ethics theory proposed by Jonsen and Siegler with systematic consideration of medical indications, patient preferences, quality of life and contextual features. Contextual features are obtained by using the principles of justice and fairness. Although clinical ethics is more focused on medical indications, patient demands, and quality of life, medical decisions are not only decided by doctors and patients. However, they must also consider other aspects such as socio-culture, beliefs, religion, and finances.

CONCLUSION
The purpose of this study is to improve the quality of medical personnel in hospitals and health clinics in Indonesia by providing educational services before carrying out follow-up examinations from general practitioners to specialist doctors. Some of the hospitals have followed the rules for improving the quality of health services by providing choices to patients in deciding treatment measures. In the case of anesthesia, it is known that there is still disappointment from the patient over the decision that the doctor recommended to take surgery without any confidence from the patient. Such provisions violate the code of ethics as patients who feel aggrieved are mentally not ready and physically do not voluntarily follow up with surgery. The potential that will occur has side effects on drug administration and the continuity of the surgical process. As the hope of the patient to carry out health care with the aim of being healthy again, not the other way around feeling hurt. The efforts of doctors in Indonesia in this case provide confidence that medical performance is required in a professional manner by involving the principles of health in every provision of public services and anesthetic procedures.