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"ABSTRAKPelayanan intensif ditujukan untuk memberikan terapi intensif dan perawatan intensif. Biaya pelayanan yang sangat tinggi membutuhkan rasionalisasi pelayanan ini agar dapat memenuhi hak setiap orang yang membutuhkan. Penelitian ini ditujukan untuk mendapatkan pedoman rasionalisasi pelayanan intensif untuk mempertajam peraturan perundang-undangan yang telah ada. Desain penelitian adalah penelitian kombinasi concurrent transformative strategy. Data kuantitatif diperoleh melalui studi longitudinal retrospektif dari rekam medis pasien yang mendapatkan layanan intensif selama tahun 2015 dan dihitung nilai diagnostik dari metode skoring APACHE II dan LODS serta dengan menghitung risiko relatif dan analisis kesintasannya. Data kuantitatif juga diperoleh melalui kuesioner Moral Distress Scale-Revised dan Hospital Ethical Climate Survey. Data kualitatif diperoleh melalui FGD dan wawancara mendalam terhadap tenaga medis dan perwakilan pasien. Skor APACHE II dan LODS hari pertama tidak bermakna sebagai metode diagnosis untuk memasukkan pasien ke dalam ICU. Skor LODS hari ketiga memiliki area di bawah kurva ROC yang lebih baik sebesar 66,6 95 IK: 50,5 ndash;82,7 . Analisis kesintasan menunjukkan adanya penurunan kesintasan sekitar 30 dan peningkatan risiko terhadap terjadinya kematian sebesar 40 . Usia tua usia > 45 tahun meningkatkan risiko terjadinya kematian sebesar 1,6 kali 95 IK: 1,1 ndash;2,5 dibanding usia dewasa. Enam kategori yang dibahas dalam penelitian kualitatif adalah kebebasan, indikasi masuk dan keluar ICU, kesempatan, kesesuaian, ketersediaan, dan wewenang memutuskan perawatan ICU. Konsep pedoman ICU disusun dengan menitikberatkan pada aspek futilitas tindakan kedokteran yang ditunjukkan dengan skor LODS hari ketiga lebih besar atau sama dengan 12,5. Selanjutnya diperlukan case conference dengan semua pihak dengan mempertimbangkan keenam faktor nonmedis. Kriteria distribusi pelayanan intensif yang adil adalah menjamin ketersediaan tempat di ICU secara proporsional dan melakukan diskursus translasional dengan setiap pihak. Kata Kunci: keadilan distributif, pelayanan intensif, rasionalisasi.

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ABSTRACTThe purposes of intensive care are providing intensive treatment and monitoring. The just enjoyment of this high cost services could be achieved through a thorough rationalization. The goal of this study is to acquire an ICU guidance as an addition to the present regulation. Mixed methods with concurrent transformative strategy was used as study design. Quantitative data were collected from 2015 ICU medical records. Longitudinal retrospective study was used to measure the diagnostic value of the first day APACHE II and first and third day LOD score. Survival analysis and relative risks were also measured. Moral Distress Survey Revised and Hospital Ethical Climate Survey questionnaire were used to measure the moral hazard in intensive care. Qualitative data were obtained from FGD and in depth interview of persons who were involved in intensive care. First day APACHE II and LOD score were found not significant as diagnostic tools. The area under the ROC curve for third day LOD score was 66.6 95 CI 50.5 ndash 82.7 . Survival analysis found a 30 decrease in survivability and a 40 increase in hazard in the third day treatment. Older patient has a 1.6 times higher risk 95 CI 1.1 ndash 2.5 of developing death in intensive care. Six categories were found in qualitative study namely the freedom, in and out indication, opportunity, appropriateness, availability, and the authority to decide. The ethicolegal concept of ICU guidance was developed by emphasizing the medical futility which was shown from the measurement of third day LOD score equal or higher than 12.5. The next step was case conference, considering the six non medical categories.The criteria for distributing a just intensive care are by proportionally guaranteeing the availability of the service and performing the translational discourse with every person involved. Keywords distributive justice, intensive care, rationalization."

"Pengembangan humanisme sebagai inti profesionalisme diperlukan karena dokter profesional masa kini dituntut melakukan pelayanan berpusat pada pasien dan mengesampingkan kepentingan pribadi. Pengembangan humanisme dipengaruhi persepsi mahasiswa terhadap lingkungan pembelajaran terutama di klinik. Meskipun demikian, belum ada instrumen untuk menilai hal tersebut. Tujuan penelitian ini adalah menyusun instrumen penilaian iklim humanis lingkungan pembelajaran klinis.Penelitian ini menggunakan desain sequential exploratory mixed method dan dilakukan di Rumah Sakit dr. Cipto Mangunkusumo (RSCM) pada bulan Januari – Desember 2019. Penelitian dilakukan dalam empat tahap yaitu penyusunan instrumen, uji coba, penyusunan model iklim humanis lingkungan pembelajaran klinis dan implementasi. Tahapan penyusunan instrumen dimulai dengan sintesis konsep iklim humanis lingkungan pembelajaran klinis melalui telaah pustaka, focus group discussion dan wawancara mendalam. Dari penyusunan tersebut diperoleh konsep yang dijadikan rujukan draf instrumen Humanistic Climate Measure (H-CliM) yang terdiri atas 89 butir pertanyaan; 7 domain. Tahap kedua, dilakukan uji coba H-CliM bersama instrumen untuk menilai kompetensi humanisme Integrity Compassion Altruism Respect Empathy (ICARE). Kedua instrumen terbukti valid (r > 0,3) dan reliabel (α-cronbach > 0,7). Dilakukan analisis faktor untuk memvalidasi konstruk dan menghasilkan instrumen H-CliM final (46 butir pertanyaan; 4 domain) serta ICARE final (15 butir pertanyaan; 2 domain). Analisis receiver operating characteristic (ROC) menghasilkan titik potong ≥ 184,5 artinya, skor H-CliM ≥ 184,5 tergolong humanis. Analisis regresi logistik menghasilkan model iklim humanis yang 62% dapat menjelaskan variasi iklim humanis (R2 = 0,62). Model tersebut adalah:Logit P (iklim humanis) = 0,782 (rotasi klinis non-bedah) + 0,048 (kurikulum formal dan informal terkait humanisme) – 0,213 (hidden curriculum) + 0,036 (relasi dan fasilitas yang mendukung humanisme) + 0,044 (pengembangan kepribadian dan profesionalisme) + 0,409 (perempuan) + e.Penelitian ini berhasil mengembangkan instrumen penilaian iklim humanis yang valid dan reliabel yaitu instrumen H-CliM (α-Cronbach = 0,86). Lingkungan pembelajaran non-bedah 2 kali lebih humanis dibanding bedah (p = 0,0001). Persepsi terhadap iklim humanis lingkungan pembelajaran klinis berkorelasi lemah dengan capaian kompetensi humanisme.

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The development of humanism as the core of professionalism is crucial, seeing that professional doctors today are expected to carry through patient-centered services and put aside their personal interests. In clinical setting, cultivating humanism is highly influenced by students 'perceptions on clinical learning climate, therefore, it is necessary to assess that perception. However, to date there is no instrument to assess clinical learning climate. The purpose of this study is to develop an instrument to assess humanistic learning climate.

This study utilizes a sequential exploratory mixed method design and is conducted at the Cipto Mangunkusumo hospital (RSCM) in January - December 2019. The research was conducted in four stages, which are the preparation of instruments, trials, development of humanistic climate models of clinical learning environments and implementation of the instrument. The stages of instrument preparation begin with the synthesis of concept of the humanistic clinical learning climate through literature review, focus group discussions and in-depth interviews. Afterward, the concept that was obtained utilized as a reference for drafting instrument of Humanistic Climate Measure (H-CliM) consisting of 89 questions; 7 domains. The second stage, an H-CliM trial was carried out along with instruments to assess the competence of the Integrity Compassion Altruism Respect Empathy (ICARE).

Both instruments proved to be valid (r > 0.3) and reliable (α-Cronbach > 0.7). Factor analysis was carried out to validate the construct and produce the final H-CliM instrument (46 questions; 4 domains) and the final ICARE (15 questions; 2 domains). Receiver operating characteristic (ROC) analysis resulted in cut-off point of 184.5, which means that the H-CliM score ≥ 184.5 was classified as humanistic climate. Humanistic climate models obtained from the logistic regression analysis could explain 62% of variation of humanistic climate (R2= 0,62). The model is:

Logit P (humanistic climate) = 0.782 (non-surgical clinical rotation) + 0.048 (formal and informal curriculum related to humanism) - 0.213 (hidden curriculum) + 0.036 (relationship and facilities that support humanism) + 0.044 (personality development and professionalism) + 0,409 (female) + e.

This research succeeded in developing a valid and reliable humanistic climate assessment instrument, the H-CliM instrument (α-Cronbach = 0,86). Compare with surgical rotation, the non-surgical learning environment is twice more humanistic (p = 0.0001). Perceptions of the humanistic climate of the clinical learning environment are weakly correlated with the achievement of humanism competencies."