Implementation of Anesthesia Ethics to Improve Medical
Professionalism
Aulia Wiratama Putra
Faculty of Medicine, Universitas Trisakti, Indonesia
ABSTRACT
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.
Keywords:
anesthesia, ethics,
medicine, professionalism.
Correspondent: Aulia Wiratama Putra
Email: [email protected]�� �
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.
Table 1. Factors Causing Operations
|
Diagnosis |
Supporting factors |
Obstacle factor |
Recommendation |
|
Caesar |
Ease of process, speed and painless mules |
Postoperative pain |
Medical medicine |
|
Head tumour |
Minor surgery |
Healthy lifestyles |
Traditional therapy and medicine |
|
Breast cancer |
Minor surgery |
Healthy lifestyles |
Traditional therapy and honey |
|
Cervical cancer |
Minor surgery |
Healthy lifestyle and reproductive care |
Traditional therapy and honey |
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.
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