Observations were done since 2008 in hospital, community concluded that end of life patients, and families did not understand how to respond to advance treatment. Besides, there were no similar standard of procedure applied into patients. There were some doctors told the families about patients' conditions and some did not. Moreover, some families understood that patients' condition could not be cured, but in dying process, the physicians suggested to be treated in an intensive care unit. In this situation, the families did not have any choice instead of to follow the physician suggestion. Indonesian's health care system that embrace doctor's domination over decision-making on patient treatment exists, although nurse has their own skills, function and knowledge that need to be incorporated in the treatment plan. On the other hand, nurses do not have initiatives to challenge this system in health care structure. This study refers to a Philosophical Carol Gilligan Theory, and Bakker & Zubair Qualitative Method of Philosophical Research. The results were divided into 2 groups: firstly were the nurses who were mostly women had their limitation to raise up their profession, and secondly, the basic nurses education was insufficient to encounter the doctors.
In Indonesia, it is a fact that patients do not know the appropriate intervention applied to them1. Although the families understand that the patients are in dying phase, but they do not have ability to face with the physicians who continue to the advance treatment. An appropriate treatment can be performed when nurses play their advocacy role, means nurses have to know and have ability to do. However, nurses although they know what should to do but they do not have capability. The result is the patients continue to the advance treatment, which they do not need anymore.
As a profession, nurses are under the shadow of the doctors. So far, nursing profession is difficult to practice their roles. This is due to the rejection from other health professions when nurses discussing their thoughts. Other professions will not listen, or listen but rejected and then be blamed. Nurses will be slipped away, and if it is necessary, they will be interfered. While nurses listen and follow the voice of other health professions, they will be appreciated and will be utilized in the hospital organization. Nurses realized that there are no one will help them, event from their colleagues1. In these occasions, nurses think better not to talk because it will destroy them.
Beside the limitation from nursing profession itself and other health professions, patients and families not clear enough the nursing roles. Some of them look at nursing profession as an assistant of the physicians. The patients perceive nursing tasks as a routine and instrumental job. The patients and families do not know the intellectualized though founded behind the nursing tasks.
Respond to this situation, there is no one method except nurses has to raise up their profession. Nurses have to talk to other professions2. Speak up to discuss and explain about their roles. Nurses should raise up to help the terminal illness patients and families from the unexpected interventions. Raise up is aimed to formulate planning and intervention3 for the patients and families in delivering appropriate of nursing interventions. These thoughts are applied as a caring ethics in philosophical nursing area, those are respect to others, compassion, advocacy and intimacy. Nursing caring ethics when provided will be prevented unexpected interventions.
MethodThis study was used a philosophical research method, developed by Bakker & Zubair4. Anton Bakker was born in Amsterdam in 1931. He moved to Indonesia in 1951. He graduated from Leuven in Belgium and Nijmegen in Holland. His interested area was Thomistic philosophy. Achmad Charris Zubair was born in Yogyakarta. His interested area is Ethical and Philosophical Method, and teach at Universitas Gadjah Mada.
This method used to reflect the chronic illness patients who were in end of life (EOL) conditions. The phenomena were obtained based on inductive process, where the rights of EOL patients were not met. The problems obtained due to the conflicts of medical advance technology that applied to the patients contribute to not meet patients' rights. Moreover, in the other side, nurses who were responsible as advocate profession not play their important role. Philosophical reflection method was done in Carol Gilligan Perspective. Carol Gilligan is a theorist who named her theory “In a different voice”. In a different voice is a theory that describe the inability woman in a man area.
Bakker & Zubair Method and Carol Gilligan Theory constructed the internal coherence in among internal research objects. The research objects were the relationships among the sickness patients who suffer from EOL situations. The ethical professions who conducted nursing and the medical interventions that should be accepted by the patients were analyzed. The existence of patients and families, the existence of nursing professions and the power of other professions were the items which would be constructed and described. The useless of advance technology which were applied to EOL patients were constructed. At the end, it obtained the holistic philosophical concepts of EOL patients (how many participants did you recruit? how to recruit them? Where the study took place? Why? How to collect data? What instruments did you use? How about ethical clearance? Those are important to make your paper more valuable).
ResultsThe result of this study divided in two groups. Group 1 was about nursing profession in perspective Carol Gilligan Theory; and group 2 was about descriptions of EOL as a supporting data for group 1.
Nursing ethics work as a guideline of nursing interventions and nursing services5. Chronic illness patients come to hospital in a crisis situation. Come to the hospital means to exposure of health professions, those are doctors and nurses mostly. At this situation, the patients expose to crisis-oriented treatment6, which need the advance of medical technology. The advanced of medical technology might create some ethical problems7.
Ethical problems can be reduced when nursing profession play their important roles. However, these roles do not exist in the health institutions due to the nurses' inability to perform the roles. This inability was analyzed by Carol Gilligan theory in a different voice2. The Gilligan theory is a feminist theory that can be applied to the nursing profession who are mostly women. Gilligan synthesized her theory in 6 components, those are woman's place in man's life cycle, images of relationship, concepts of self and morality, crisis and transition, women's rights and women's judgment and visions of maturity. In these 6 components this study was done.
Women are positioned to be cared for other persons. Nurses who are mostly occupied by women are expected to care with people in their environments. The closely professions in nurses environments is medical profession. In the last more than ten years, medical professions turn on women people. Although the medical profession is occupied by women, however the patriarchy culture is remained. In the other side, nurses as women found themselves the difficulties in formulate in their thought and opinion resulting as unable profession to perform. In fact, the nurses are able to perform their ability, but because of social and moral understanding lead the nurses not to perform theirs. Related to EOL patients, the inability of nurses were discussed.
In this situation, nursing interventions, which reflect the profession, cannot be observed. Nursing interventions are done as an instrumental activities, not as part of nursing activities as a profession. For example, when the nurse records the patient fluid balance, the meaning of fluid balance cannot be understood. Similar to terminal illness nursing care, commonly nurses do not have their opinion.
The nurses do not want to say their opinion because they thing no need to say. Others profession especially medical doctors would not be listened. The environment will not standing for nursing profession who majority is women, so it is better to keep silence. When some of nurses who want to express their opinions, some of other nurses do not respect to them. It will lead to the nurses not convenience situation. As a result, it will have a negative impact for the nurses.
Nursing profession close to women activities, so it should be considered women growth and development. Gilligan observed there was a different growth and development between boys and girls or between men and women. In fact, the instruments that developed tend to evaluate boys growth and development. As an impact, when the instrument used for girls or women it do not reflect the real result.
Nurses who are mostly women tend to face the gender problems. People tend to see the nurses in man's life, so nurses who are mostly women do not reflect her sexual identity. In fact, the result does not describe the real profession. As a conclusion, there is something wrong with nurses' profession. When women growth and development was looked as should be, which perceived as a natural process, it would give a nothing wrong with women gender. When it is believed women create by God, will God create women who are done their wrong activities due to not relevant instruments?
A relationship is related to moral a responsibility8. Therefore, a relationship needed a responsibility. To be responsible person need ability. So, nurses must have an ability to be responsible nurses. Men tend to see as a logical people. Women used to see what it should be. Because in women perspective, even something is logic it is not always good or wise. Once people consider in men perspective, will lead women or nurses in an understandable profession.
This situation will affect in a nursing profession itself, the solution is the nurses should propose their voice2. The nurses' voice has to be soft, not hurting other profession. The nurse's voice must be accepted by nurses themselves. When the member of nursing profession does not agree to the voice, it will lead an ambiguity of the nurses and find difficulties in solving the problem. To make it similar understand among nurses, they must see that their profession is different from others. Once the nurses get the agreement, they can play their role as a caring profession.
Caring is aimed to meet the needs of nursing profession itself. With caring, the nursing profession will not be isolated; it will be disclosure to other professions. Once the profession is disclosure, the nurses will be involved in the patients' discussion. At this time, the nurses leave their selfish stage2. When nurses leave this phase, is the time for nurses to go to the development profession. The nurses can go through the Goodness and Truth phase, which is the highest of moral women development2. When nurses reach the truth stage, it means the nursing profession can play her role as a caring profession, so the nurses have to deliver their voice.
In each moving out of phase from selfish, Goodness and Truth has a crisis impact. The crisis either can be predicted or not2. In the crisis phase, it can destroy the nurses' personality. In transition phase, the feel of responsibility is the power to move out. Once nurses realize, they can manage the crisis. When they do not, they will not draw down in the crisis. If the crisis cannot be managed, will end in a loose feeling. When the nursing profession can manage the crisis, they will find the profession different from before. At this stage, the nurses can help the patients and families and they found themselves in a truth stage8.
The nurses, as mostly women, should have their rights and judgment. Have the rights because every man or woman has his or her rights. Therefore, the rights are not due to considerations of weakness, because the rights are human or natural. Once the nurses have their rights, it is followed by responsibility in social relationship8. Rights are reflected in every aspect of life. The rights indeed reflect the ability of intellectual, communication and benefit to environment.
Formulate and propose the rights is not easy, it will take the process8. This because is not easy to change the community opinion into nursing profession. Therefore, the nursing profession should be realized which method will be used, evolution or revolution. Each of this method has its own consequences.
The nurses should be aware that they have power and ability. The power and ability should be used for arranging the objectives of nursing goals, where need the opinion. The opinion should be true and logic and it will be obtained through education (Figure 1).
The pathway of end of life, and physicians-nurses responsibities1.
Women and education emerged since last century in Indonesia. Education in nursing profession has come to strata 3. The weakness founded, there is a vocational education, which give a vague impact in the field area. The cheaper salary to hire them is the reason to hire. There is no information when this vocational education will be ended. As result, the quality of nursing services is questionable due to vocational nurses do not take the chance discussing with other health profession.
Intimacy and relationships are two of the ethic components in nursing professions9. These components allow nurses to disclosure in order to perform their rights to do the nursing care. The problem found, the difficulties of the environment to listen to nurses' voice8. Nurses should be able to talk to formulate their thought and try to explain their visions8. Visions of maturity can be provided to the leader in the hospital. Nurses' voice should be nice to be listened. Dialogues should be done regularly till get the agreements among health professions. These all will help nursing profession in developing their professions, and also to help patients and families to face the EOL difficulties.
In Indonesia, Code of Nursing Ethics was available since the last three decades10. It was stated how to conduct the nurses when providing nursing care. However, the nursing profession tends to use medical ethics instead of their own code. Medical profession refers his code of ethics into Hippocrates, beneficence, non-maleficence and justice. Centuries later, Beauchamp and Childress8 completed autonomy as a basic bioethics for medical profession in order to conduct them to perform invasive procedures. These procedures are known as curing interventions.
Nurses is a caring profession, they do not do an invasive procedure as part of their interventions. However, nurses prefer to do invasive activities such as insertion urethra catheter or nasogastric tube catheter instead of practice caring such as respect to others, compassion, advocacy and intimacy to the patients and families10. As a result, the basic nursing needs are not met. To conclude, the nursing profession either has to deliver their voice, they also have to make up their understanding of their code of ethics.
Refer to caring and curing interventions, there some differences between nurses and medical profession in looking after the patients and families. These differences should be recognized by these 2 professions. Medical profession main task is to cure; nursing profession is to care. Curating only happen if the disease can be treated. Once the disease cannot be reached by the physician—such as stage 4 of cancer disease—means the physicians terminate his or her interventions. The very minimal medical interventions still remain such as providing the pain killer medications. Failure to meet the appropriate medical care, such as continue to advance treatment will lead to inappropriate interventions and will affect to patients and families, such as spending more money or the patients expose to resuscitation.
The nursing profession main task in terminal illness is to prepare the patient to die in dignity, which need the competencies of nurses. The nurses are responsible for the quality of patients EOL. So, the quality of EOL process is based on nurses' competency. The worse of the patients' health, the biggest nurses' responsibilities have (Figure 2).
Education in nursing profession1.
Nursing and medical profession has its own task. To describe the differences between nurses and medical responsibilities are illustrated in Table 1. This description will help each member profession to understand their main interventions. Failure to understand the task will affect to interventions of each profession.
The differences between medical and nursing profession interventions1
| No. | Source of interventions | Medical profession | Nursing profession |
|---|---|---|---|
| 1 | Technical Intervention | Limited | Unlimited |
| 2 | Possessive of patients | Patients are treated in certain time | Patients care based on the disease |
| 3 | Type of interventions | Reduced | Holistic |
| 4 | The instruments of interventions | Medical health instruments | Individual and nursing health instruments |
| 5 | Type of work | Individual | In a group |
| 6 | The place for end of life | Hospital: ward, intensive care ward | Home, hospice |
Nurses have an important role to help the patients die in dignity and prevent the ineffectual cost. The nurses competencies; knowledge, affective and psychomotor skills are needed to look after the patients. These competencies are practiced in unlimited time, where the patients can observe. Therefore, the patients can recognize whose nurses competent or who do not. The nursing interventions that are done in every time can lead as a routine procedure. It should be prohibited, because it will not treat the patients subjectively.
The place of nurses work is in ward, look after the simple to complex cases, at outpatients clinics, wards and intensive care units. When the illness becomes deteriorate, the appropriate place for providing care is at home or hospice. These two places are needed to help the patients' basic needs such as fluid, oxygenation or elimination. It is different when the patients are hospitalized. The patients will have the opportunity to have advance treatment, such as resuscitation. It should be prevented curing treatment due to terminal illness.
Refer not to provide curing, lead the nurses to be able to take a responsibility for dying process. Nurses should refer to the ethics guidelines, respect to others, compassion, intimacy and advocacy10. These guidelines help the patients and families encounter difficulties separation. Unfortunately, the guidelines are not applied, as they should be. Lack of appropriate education is the most reason taken place.
