Assessment of Institutional Palliative Care Availability and End-of-Life Practices within Critical Care Settings in Indonesia

Assessment of Institutional Palliative Care Availability and End-of-Life Practices within Critical Care Settings in Indonesia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of Institutional Palliative Care Availability and End-of-Life Practices within Critical Care Settings in Indonesia Gezy Weita Giwangkancana, Annisa Isfandiary Ismandiya, Gian Ruzbihan Al Afghani, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8645592/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Palliative care and end-of-life (EOL) support are increasingly recognized as core components of high-quality health systems and are embedded within international human rights and hospital accreditation standards. However, in many low- and middle-income countries, including Indonesia, palliative care integration in intensive care units (ICUs) remains limited, with substantial gaps in institutional structure and clinician training. Given that ICUs are common settings for death and dying, understanding factors associated with EOL practices in critical care is essential. Aim This study aimed to assess whether the availability of institutional palliative care services is associated with EOL communication practices and care processes among anesthesiologists working in ICUs in Indonesia. Methods We conducted a cross-sectional analytical survey among anesthesiologists practicing in West Java Province, Indonesia. The questionnaire was adapted from a validated national survey and assessed institutional palliative care availability, clinician training, and ICU EOL practices. Descriptive analyses were performed, followed by unadjusted and multivariable logistic regression analyses guided by a Donabedian structure–process–outcome framework. Adjusted models controlled for clinician palliative care training, and model fit was assessed using the Hosmer–Lemeshow test. Results A total of 300 anesthesiologists were included in the analysis. Formal palliative care services were available in 53.3% of respondents’ hospitals, while only 26.7% reported prior palliative care training. In unadjusted analyses, palliative care service availability was significantly associated with several ICU process indicators, including palliative/EOL screening, living-will discussions, and standardized sedation and analgesia protocols. In adjusted models with acceptable fit, institutional palliative care availability remained independently associated with palliative/EOL screening (adjusted OR 5.00), sedation and analgesia protocols (adjusted OR 6.32), and living-will discussions (adjusted OR 4.83). Routine symptom monitoring was not associated with structural availability. Several outcomes, including family involvement and discharge disposition, demonstrated poor model fit and were excluded from adjusted analyses. Conclusion Institutional palliative care availability is associated with more consistent implementation of key EOL processes in Indonesian ICUs, particularly those requiring formal protocols and structured support. However, not all EOL practices are explained by institutional structure alone, underscoring the need for combined system-level development and clinician education to strengthen palliative care integration in critical care settings. Palliative care End-of-life care Intensive care unit Health systems Anesthesiology Figures Figure 1 Figure 2 Introduction Palliative care and end-of-life (EOL) support are increasingly recognized as fundamental components of universal health coverage and are currently considered basic human rights by international organizations such as the World Health Organization (WHO) and the World Palliative Care Alliance. As a result, standards related to palliative care integration have also been incorporated into hospital accreditation systems, including the Joint Commission International (JCI) hospital design framework. 1 – 3 While these concepts are well established in the Northern Hemisphere, particularly in North America and Europe, they remain underdeveloped in the Southern Hemisphere, where curative health care is prioritized and often lacks formal palliative care infrastructure or training. 2 , 4 In the southern hemisphere, such as Indonesia, palliative care is seldom introduced in undergraduate or postgraduate medical education. In Brazil, nearly half of medical residency applicants reported never receiving any palliative care education during their training. In Thailand, a national hospital survey found that one-quarter of facilities providing palliative care lacked staff with formal palliative care training, and only 17% met the minimum training standards. In Indonesia, a cross-sectional study of 516 primary healthcare providers reported a mean palliative care knowledge score of 7.8 ± 3.3 out of 20 and a mean comfort score of 1.6 ± 2.7 out of 10, underscoring limited exposure to formal palliative or end-of-life education among healthcare professionals. 5 – 8 In addition to this educational gap, the discussion of death and dying in Indonesian culture remains a sensitive topic. It is often considered socially inappropriate, a tendency that aligns with broader patterns observed across many Asian societies. In Indonesia, death is commonly regarded not as a natural phase of life. Still, as a potential reflection of insufficient effort, faith, or familial responsibility. 9 Families frequently interpret the continuation of medical intervention as an expression of devotion. In contrast, withdrawal or acceptance of death may be viewed as neglect. Consequently, healthcare providers—who share similar cultural and social frameworks—may delay or avoid discussions regarding treatment futility, perceiving death as a medical shortcoming rather than an element of care. Although an Indonesian survey indicated that 94% of healthcare providers were willing to discuss end-of-life issues, fewer than 10% had received formal education in palliative or end-of-life care, and approximately 75% of the general population preferred to avoid such discussions, leading to communication gaps and inconsistent decision-making. 8,9 In Indonesia, where hospitals are commonly chosen as places of dying, critical care units (ICUs) provide much of this end-of-life care, highlighting the need to implement end-of-life care specifically tailored for these settings. This necessity has also been emphasized by the World Health Organization (WHO) and JCI. This cultural dynamic of gap between deaths un critical care unit and lack of knowledge among clinicians an cultural barriers, contributes to a continued emphasis on aggressive treatment approaches, even when the likelihood of clinical benefit is minimal, and highlights the challenges faced in implementing patient-centred end-of-life care within intensive care settings. 4 , 8 , 9 Anesthesiologists in Indonesia serve as critical care specialists, taking on the responsibility of managing life support and guiding treatment goals for critically ill patients, including those nearing end-of-life in the ICU. However, many anesthesiologists find it challenging to navigate the complexities of end-of-life decision-making without adequate palliative education, supportive institutional policies, or access to emotional support. This lack of resources can hinder their ability to provide compassionate care during these crucial moments. 2 , 3 , 9 , 10 Studies demonstrate that hospitals with structured palliative care units or consult teams achieve better patient outcomes and communication quality. A meta-analysis found that hospital-based specialist palliative care significantly improved outcomes and patients satisfaction compared with usual care in patients with advanced illness. 11 These models provide standardized pathways and ethical frameworks that support earlier end-of-life discussions. Consistent with this evidence, Joint Commission International (JCI) accreditation standards require hospitals to implement organized end-of-life care processes that ensure comfort, dignity, and family involvement. 12 To explore this issue in the Indonesian context, we conducted a cross-sectional survey among anaesthesiologists in West Java, the province with the highest density of anaesthesiologists and intensive care units in the country. West Java represents a diverse healthcare landscape, encompassing government, private, referral, and teaching hospitals, making it a relevant microcosm of Indonesia’s critical care environment. The primaryaim of this study is to assess whether the availability of institutional palliative care services is associated with end-of-life (EOL) communication practices among anaesthesiologists. Methodology Study Design and Setting This study employed a cross-sectional analytical design using an online survey to assess the relationship between institutional palliative care availability and end-of-life (EOL) communication practices among anaesthesiologists in West Java, Indonesia. Data collection was conducted between July and August 2025 following ethical approval from the Health Research Ethics Committee of Universitas Padjadjaran, Bandung (Approval No. 409/UN6.KEP/EC/2025). The survey was disseminated through the West Java Association of Anesthesiologists, which includes anesthesiologists working in public, private, teaching, and referral hospitals. West Java was selected as the study site because it represents the largest provincial cluster of anesthesiologists in Indonesia and encompasses diverse healthcare settings reflective of the national critical-care landscape. The writing of this paper follows the C hecklist for R eporting R esults of I nternet E - S urveys (CHERRIES) guidelines. 14 2. Population and Sampling The study population comprised all registered anesthesiologists practicing in West Java Province, totalling 354 members according to the West Java Association of Anesthesiologists (2024 membership data). The required minimum sample size was calculated using Slovin’s formula for finite populations at a 95% confidence level and 5% margin of error, yielding a minimum of 188 respondents. After accounting for an anticipated 10% non-response rate, the final target sample size was 210. A total population sampling approach was employed. We included registered members of the West Java Association of Anesthesiologists and were currently practicing as anesthesiologists in hospitals within West Java Province at the time of the survey. We excluded questionnaires with missing data on the primary exposure (availability of a palliative care unit) or primary outcomes (end-of-life communication items). We also removed duplicate entries submitted under the same name and entries in which the respondent’s name and email did not match the official association database. 3. Instrument The questionnaire used in this study was adapted from a previously validated nation-wide survey of Italian anesthesiologists on palliative care and end-of-life issues in the intensive care unit developed in Italy. 13 The original instrument consists of closed-ended items covering respondent characteristics, institutional features, palliative care availability, and end-of-life decision-making practices. For validation in the Indonesian context, the questionnaire was translated from English into Bahasa Indonesia by a professional language agency and then backtranslated into English by a second independent agency. The review research team evaluated discrepancies between the original and back-translated versions, ensuring conceptual equivalence rather than literal translation. We then tested the Bahasa Indonesia version with a pilot group of five anesthesiologists working in West Java to assess clarity, comprehensibility, and cultural appropriateness. Based on their feedback, we made minor wording adjustments, but no novel items were added or deleted. We maintained the structure and content domains of the original instrument. Data were collected using an online questionnaire distributed via a secure link created through Google Forms (GFORM, USA) and shared across the Association’s official communication channels (email and WhatsApp groups). Participation was voluntary and anonymous, and we obtained electronic informed consent before respondents could access the survey and no incentives were offered. 4.Variables The independent variable was the availability of a formal palliative care unit in the respondent’s hospital (Q1). The dependent variables represented end-of-life (EOL) communication practices: whether the physician routinely discusses EOL issues with families (Q2), whether the physician asks patients about resuscitation preferences (Q3), and whether the ICU has a Do-Not-Resuscitate (DNR) policy (Q4). Potential confounding variables included years of experience, hospital type (public/private), ICU bed capacity, and previous palliative care training. Questionnaire items, measurements and their coding are provided in the Supplementary Appendix. 5. Analysis We analysed data using IBM SPSS Statistics (Version 25.0, IBM Corp., Armonk, NY, USA). Descriptive statistics were applied to summarize respondent characteristics and institutional variables, presented as frequencies and percentages for categorical data and means ± standard deviations or medians (interquartile ranges) for continuous variables, depending on distribution. Bivariate associations between the availability of a palliative care unit (independent variable) and each end-of-life communication outcome (dependent variables: Q2–Q4) were evaluated using the Chi-square test or Fisher’s exact test when appropriate. Confounding variables—years of experience, hospital type, ICU bed capacity, and prior palliative care training—were tested for associations with both the exposure and the outcome.Variables with p < 0.10 in bivariate analysis were entered into a multivariate logistic regression model to identify independent predictors of end-of-life communication practices. Adjusted odds ratios (aOR) with 95% confidence intervals (95% CI) were reported. All tests were two-tailed, and statistical significance was set at p < 0.05. We conceptualized end-of-life (EOL) practices in the intensive care unit using a Donabedian-based framework, which classifies quality of care into three interrelated domains: structure, process, and outcomes. Structural indicator, reflecting the organizational capacity to support end-of-life care. End-of-life practices—including palliative and EOL screening, discussion of patient preferences (e.g., living wills), routine symptom management, use of standardized sedation and analgesia protocols, multidisciplinary decision-making, and family involvement—were categorized as process indicators, reflecting clinician behaviors and care-delivery practices within the ICU. Selected downstream indicators, such as family involvement in decision-making and disposition following EOL decisions, were considered outcome-related measures. This conceptual framework guided variable selection, analytical strategy, and interpretation of findings Results Of the 331 respondents, we retained 300 eligible questionnaires after applying data-cleaning procedures, exceeding the minimum required sample size of 180 for the analysis. (Fig. 1 ) A total of 300 anesthesiologists participated in the survey, with a median age of 43.50 years. Regarding clinical experience, 26.67% had fewer than 5 years of anesthesiology practice, 23.33% had 5–10 years, and 50.00% had more than 10 years. In terms of ICU involvement, 60.00% reported working ≤ 40 hours per week in the ICU, while 40.00% reported working more than 40 hours per week. Respondents were distributed across government-owned hospitals (43.33%) and private hospitals (56.67%). ICU bed capacity varied: 6.66% in units with fewer than 5 beds, 36.67% in units with 5–10 beds, and 56.67% in units with more than 10 beds. Formal palliative-care training was reported by 26.67% of respondents, while 73.33% indicated no prior training. (Table 1 ) Table 1 Epidemiology of Respondents Variable Results (n = 300) Age (years) 43.50 (32–71) Experience (years after graduation) 10 50.00% ICU weekly duration (hours/week) ≤ 40 60.00% >40 40.00% Hospital Type Government owned 43.33% Privately Owned 56.67% ICU capacity (beds) 10 56.67% Palliative care training Yes 26.67% No 73.33% In the unadjusted analysis (Table 2 ), the availability of palliative care services in a hospital was significantly associated with several process indicators within the ICU. Hospitals with a palliative care service demonstrated higher odds of conducting palliative and end-of-life (EOL) screening (OR 3.21, 95% CI 1.99–5.24, p < 0.0001) and of screening and discussing living wills (OR 3.60, 95% CI 2.06–6.50, p < 0.0001). The presence of a palliative service was also associated with higher odds of implementing routine sedation and pain protocols for EOL care (OR 4.71, 95% CI 2.85–7.94, p < 0.0001) and of having a palliative care protocol specifically for ICU settings (OR 17.50, 95% CI 9.83–32.45, p < 0.0001). No significant association was observed between palliative service availability and routine monitoring of pain, dyspnoea, and anxiety as part of general patient care (OR 1.20, 95% CI 0.71–2.00, p = 0.4855) or routine multidisciplinary discussions regarding EOL choices (OR 1.03, 95% CI 0.62–1.69, p = 0.90). For outcome indicators, palliative service availability was associated with increased family involvement in EOL decision-making (OR 2.50, 95% CI 1.1519–5.7582, p = 0.02). No significant association was noted between palliative service availability and the place of discharge following an EOL decision (OR 1.22, 95% CI 0.75–1.97, p = 0.41). Multicollinearity among independent variables was assessed prior to multivariable logistic regression and was not found to be problematic. Table 2 Unadjusted Model Analysis of the Relationship Between Palliative Service Availability and Process and Outcome Parameters in the Intensive Care Unit Dependent Variables Palliative Care Service Availability OR 95% CI p-value Process Indicators Screening for Palliative and EOL in ICU 3.21 (1.99–5.24) < 0.0001** Screening and discussion of living will 3.60 (2.06–6.50) < 0.0001** Routine pain, dypnea and anxiety monitoring as part of general patient care 1.20 (0.71–2.00) 0.48 Routine sedation and pain protocol for EOL care 4.71 (2.85–7.94) < 0.0001** Routine Multidisciplinary Discussion for EOL choices 1.03 (0.62–1.69) 0.90 Palliative Care Protocol for ICU 17.50 (9.83–32.45) < 0.0001** Output Family Involvement in EOL 2.50 (1.15–5.75) 0.02** Place of Discharge after EOL decision 1.22 (0.75–1.97) 0.41 Legend : Intensive Care Unit (ICU), EOL ( End of Life), OR (Odds Ratio), CI (Confidence Interval),. A forest plot (Fig. 2 ) was constructed to visualize the adjusted associations between palliative care service availability and selected ICU process indicators. Only outcomes for which multivariable logistic regression models demonstrated acceptable goodness-of-fit (Hosmer–Lemeshow p > 0.05) were included. For these models, adjusted odds ratios and 95% confidence intervals were plotted to illustrate the independent effect of palliative care unit availability, controlling for clinician palliative care training. Several outcomes had poor model fit, that is palliative care provision in ICU, multidisciplinary decision-making, family involvement, and place of discharge. The lack of model fit suggests that these outcomes are driven by non-structural determinants such as culture, family norms, and institutional ethics climates. These models were excluded from the figure to ensure that only statistically valid and interpretable estimates were displayed. The resulting forest plot provides a visual summary of the adjusted effect sizes for the four process indicators that met model validity criteria. In the adjusted analysis evaluating the independent association between palliative care unit availability and ICU practice indicators, several process variables demonstrated statistically significant relationships. The presence of a palliative care unit was associated with higher odds of conducting palliative and end-of-life (EOL) screening within the ICU (adjusted OR 5.00, 95% CI 2.89–8.95, p < 0.0001). Similarly, hospitals with a palliative care unit had greater odds of implementing routine sedation and analgesia protocols for EOL care (adjusted OR 6.32, 95% CI 3.64–11.40, p < 0.0001). The availability of a palliative care unit was also significantly associated with screening or discussing living will preferences (adjusted OR 4.83, 95% CI 2.64–9.26, p < 0.0001). Routine monitoring of pain, dyspnoea, and anxiety as part of general patient care did not show a significant association with palliative care unit availability in the adjusted model (adjusted OR 1.06, 95% CI 0.62–1.79, p = 0.8301). (Fig. 2 ) Discussion To our knowledge, this is the first study to systematically describe palliative care availability and end-of-life practices among anesthesiologists in Indonesia. The main findings of this study demonstrate that just over half of anesthesiologists reported working in institutions with a formal palliative care service, while fewer than one-third had received any structured palliative or end-of-life training. The presence of an institutional palliative care unit was strongly associated with several key ICU process measures, including routine screening for palliative and end-of-life needs, discussion of living-will preferences, and implementation of standardized sedation and analgesia protocols for end-of-life care. In contrast, practices such as routine symptom monitoring and multidisciplinary decision-making were not consistently associated with institutional palliative care availability, suggesting that these behaviors may be driven by broader ICU culture or individual clinician factors rather than formal service structure alone. In depth, 300 anesthesiologists from 354 members of the West Java Anesthesiology Association, or 84.7%, Hospital type and ICU bed capacity were assessed descriptively but were not included as covariates in the multivariable models. The distribution of respondents across hospital ownership and ICU sizes was relatively homogeneous, and preliminary inspection showed no meaningful variability by these characteristics. (Table 1 ) Consequently, neither variable met criteria as a potential confounder, and inclusion did not improve model fit or alter effect estimates. These outcomes likely require additional contextual variables—such as family expectations, institutional norms, and cultural drivers—that were beyond the scope of the current model From the survey, our respondents were of the mean age of participants was 43.50 years, representing a predominantly mid- to late-career cohort and consistent with this age distribution; 50% of respondents reported more than 10 years of anesthesiology practice. With respect to critical care involvement, 60% of anesthesiologists reported spending ≤ 40 hours per week in the ICU. This finding reflects the typical Indonesian practice model, also observed in the United States and several European countries, in which anesthesiologists have dual training and often maintain dual clinical responsibilities, dividing their time between the operating room and the ICU rather than practicing as dedicated intensivists. 15 , 16 The remaining 40% reported working more than 40 hours per week in the ICU, indicating a subset with more continuous critical-care roles. As was expected, only 26.67% of respondents reported having received formal palliative-care training, underscoring the limited penetration of structured palliative education among anesthesiologists despite their central role in end-of-life decision-making within the ICU. 4 , 6 , 7 The findings of this study demonstrated three distinct behavioural patterns in the implementation of palliative care processes within the ICU. First, several practices—namely palliative and EOL screening, use of sedation and analgesia protocols for EOL care, and living-will discussions—were strongly associated with both the availability of a palliative care unit and clinician training, indicating that these behaviours rely on the alignment of institutional structure and individual competence. Second, routine symptom monitoring for pain, dyspnoea, and anxiety appeared to be independent of institutional palliative care structures and was influenced only by individual training, suggesting that this activity reflects established ICU clinical norms rather than palliative care system factors. Third, outcomes such as palliative care delivery in the ICU, multidisciplinary EOL discussions, family involvement in EOL decision-making, and disposition location did not demonstrate adequate model fit, indicating that these behaviours are shaped by additional system-level or cultural factors not captured by the two primary predictors. Together, these three categories highlight the varying degrees of structural, educational, and contextual influence on palliative care practices in Indonesian ICUs. This study has several limitations. First, its cross-sectional design precludes causal inference regarding the relationships among palliative care service availability, clinician training, and ICU practice patterns. Second, data were derived from self-reported questionnaires, which may be subject to recall or social desirability bias. Third, although the adjusted models focused on palliative care unit availability and clinician training, other system-level determinants—such as institutional culture, family expectations, hospice accessibility, and reimbursement structures—were not measured and may influence certain end-of-life practices. This is reflected in the inadequate model fit for outcomes related to family involvement, multidisciplinary decision-making, and discharge disposition, which were therefore excluded from the adjusted analyses. Taken together, our findings suggest that palliative care in the intensive care setting should be understood not as a discrete intervention, but as a continuous clinical process that requires sustained organizational stewardship. The presence of a formal palliative care unit appears to provide an immediate structural scaffold for end-of-life practices that depend on protocols, ethical support, and interdisciplinary coordination, resulting in measurable improvements within hospital care. However, the incomplete alignment between structural availability and several end-of-life behaviors underscores that institutional infrastructure alone is insufficient. End-of-life care unfolds at the intersection of organizational systems, clinician capability, and deeply embedded cultural norms surrounding death and decision-making. Establishing a dedicated, functional palliative care body within hospitals may therefore serve as a necessary foundation for improving in-hospital end-of-life care, while simultaneously creating the conditions for ongoing education, cultural adaptation, and iterative quality improvement. In this sense, palliative care integration represents not a one-time implementation, but a dynamic process that evolves through continuous alignment between structure, practice, and context.T Conclusion In Indonesia, palliative care is inconsistently integrated into intensive care, with formal services and clinician training limited to a subset of hospitals. Institutional palliative care availability is associated with more consistent implementation of key end-of-life practices, including screening, advance care planning, and standardized sedation and analgesia. However, not all end-of-life behaviours are explained by structural availability alone, highlighting the need for combined system-level development and clinician education to strengthen palliative care integration in IndonesianICUs. Declarations Funding The publication charge is funded by Universitas Padjadjaran through the Indonesia Endowment Fund for Education (LPDP) on behalf of the Indonesian Ministry of Higher Education, Science and Technology and managed under EQUITY program (contract no 4303/B3/DT.03.08/2025 and 3927/UN6.RKT/HK.07.00/2025) Conflicts of interest/Competing interests No competing interests Availability of data and material Data supporting the findings of this study are not publicly available due to institutional and patient confidentiality policies. However, they are available from the corresponding author upon formal request and subject to appropriate approvals. Authors' contributions Gezy Weita Giwangkancana: conceptualization, methodology, data analysis, writing the original draft. Anni sa Isfandiary Ismandiya : data collection and analysis, ethical evaluation, investigation, original draft preparation. Gian Ruzbihan Al Afghani: survey preparation, data collection, Budiana Rismawan: data curation, resources, writing-reviewing and editing. Marina Ma: reviewing and editing. Erwin Pradian: reviewing and editing, Andrea Cortegiani: reviewing and editing Ethics approval Health Research Ethics Committee of Universitas Padjadjaran, Bandung (Approval No. 409/UN6.KEP/EC/2025) and this study adhered to the Declaration of Helsinki for human data and/or material. Consent to participate Written informed consent for participation was obtained from all participants prior to enrolment Consent for publication Written informed consent for publication was obtained from all participants prior to enrolment Artificial Intelligence Disclosure The authors used Grammarly AI and ChatGPT to support language refinement and improve readability. The authors have complete control over the study design, data interpretation, and scientific conclusions, and we accept complete responsibility for the content of this manuscript. Acknowledgement None References Ezer T, Lohman D, de Luca GB. Palliative care and human rights: a decade of evolution in standards. J Pain Symptom Manag. 2018;55(2):S163–9. Connor SR, Gwyther E. The worldwide hospice palliative care alliance. J Pain Symptom Manag. 2018;55(2):S112–6. Paiva CF, Silva CP, Santos TC, Augusto PD, Ennes LD, Almeida Filho AJ. Oncology nursing and palliative care in a reference institution (2005–2006). 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8645592","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":586609518,"identity":"e073d77c-2e89-43aa-be03-93157a65c352","order_by":0,"name":"Gezy Weita Giwangkancana","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAklEQVRIiWNgGAWjYBADHgYG5gMgBmMDiExgI0ILDwNbAmlagNbwGCC0MODRIu/e/kyCsc1Gxp79zDfpwh12sg3shx8wPCjDrcXwzIE0oJY0Hh6e3G3SM88kGzfwpBkwJJzDo2VGwjEJxm2HgX4BauFtY05sYMhhYEhsw6Nl/sM2oJb/PDz8b54BtdQnNvC/wa9FXoKZDajlAA+PRA4bUMvhxAYJArYY8KQxWyT+S+bhufHM2Jr3zHHjNolnBgfw+UW+/fjDGx/O2Nmz9yc/vM27o1q2nz/54cMfeELM4AADi0QCjAeKFFCMHMCtAWhLAwPzBzgPGo+jYBSMglEwClAAAIqnSy4zIQ48AAAAAElFTkSuQmCC","orcid":"","institution":"Padjadjaran University","correspondingAuthor":true,"prefix":"","firstName":"Gezy","middleName":"Weita","lastName":"Giwangkancana","suffix":""},{"id":586609523,"identity":"11e4352b-a8bd-44af-b667-07f8ae8f5f2e","order_by":1,"name":"Annisa Isfandiary Ismandiya","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Annisa","middleName":"Isfandiary","lastName":"Ismandiya","suffix":""},{"id":586609524,"identity":"ec845724-971c-4ea4-8012-424463b54e30","order_by":2,"name":"Gian Ruzbihan Al Afghani","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Gian","middleName":"Ruzbihan Al","lastName":"Afghani","suffix":""},{"id":586609526,"identity":"f0b6ec90-88d8-4fa9-b3e1-dfc7d5ebcef7","order_by":3,"name":"Budiana Rismawan","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Budiana","middleName":"","lastName":"Rismawan","suffix":""},{"id":586609527,"identity":"0d75780c-9d25-4c5e-b25e-7348ff8b1c38","order_by":4,"name":"Marina Ma","email":"","orcid":"","institution":"Baylor College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Marina","middleName":"","lastName":"Ma","suffix":""},{"id":586609531,"identity":"569b24da-09de-4590-b73f-ef1ced00d052","order_by":5,"name":"erwin pradian","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"erwin","middleName":"","lastName":"pradian","suffix":""},{"id":586609532,"identity":"c4b6fc88-837e-44fd-a767-a8cb318fffff","order_by":6,"name":"Andrea Cortegiani","email":"","orcid":"","institution":"Azienda Ospedaliera Universitaria Policlinico \"Paolo Giaccone\" di Palermo","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Cortegiani","suffix":""}],"badges":[],"createdAt":"2026-01-20 06:23:48","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8645592/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8645592/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102295258,"identity":"b6007df4-289a-496a-aebb-74ce1eb3b5a9","added_by":"auto","created_at":"2026-02-10 10:10:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":108668,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8645592/v1/e3e3888d09639635fa54684b.png"},{"id":102022552,"identity":"97720a36-2a6e-40e9-a64f-29a7f1ebd78b","added_by":"auto","created_at":"2026-02-06 09:01:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":64595,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdjusted Associations Between Palliative Care Unit Availability and ICU Process Measures Controlling for Clinician Training\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8645592/v1/8872a41309441ef84d2bc44e.png"},{"id":102298741,"identity":"33cfd7b6-58f2-4794-81dd-d2cd20bfe0b4","added_by":"auto","created_at":"2026-02-10 10:59:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":871502,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8645592/v1/7c688289-fbe6-40d0-b4bc-d14772816cd9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of Institutional Palliative Care Availability and End-of-Life Practices within Critical Care Settings in Indonesia","fulltext":[{"header":"Introduction","content":"\u003cp\u003e Palliative care and end-of-life (EOL) support are increasingly recognized as fundamental components of universal health coverage and are currently considered basic human rights by international organizations such as the World Health Organization (WHO) and the World Palliative Care Alliance. As a result, standards related to palliative care integration have also been incorporated into hospital accreditation systems, including the Joint Commission International (JCI) hospital design framework.\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhile these concepts are well established in the Northern Hemisphere, particularly in North America and Europe, they remain underdeveloped in the Southern Hemisphere, where curative health care is prioritized and often lacks formal palliative care infrastructure or training.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e In the southern hemisphere, such as Indonesia, palliative care is seldom introduced in undergraduate or postgraduate medical education. In Brazil, nearly half of medical residency applicants reported never receiving any palliative care education during their training. In Thailand, a national hospital survey found that one-quarter of facilities providing palliative care lacked staff with formal palliative care training, and only 17% met the minimum training standards. In Indonesia, a cross-sectional study of 516 primary healthcare providers reported a mean palliative care knowledge score of 7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3 out of 20 and a mean comfort score of 1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 out of 10, underscoring limited exposure to formal palliative or end-of-life education among healthcare professionals.\u003csup\u003e\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn addition to this educational gap, the discussion of death and dying in Indonesian culture remains a sensitive topic. It is often considered socially inappropriate, a tendency that aligns with broader patterns observed across many Asian societies. In Indonesia, death is commonly regarded not as a natural phase of life. Still, as a potential reflection of insufficient effort, faith, or familial responsibility.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Families frequently interpret the continuation of medical intervention as an expression of devotion. In contrast, withdrawal or acceptance of death may be viewed as neglect. Consequently, healthcare providers\u0026mdash;who share similar cultural and social frameworks\u0026mdash;may delay or avoid discussions regarding treatment futility, perceiving death as a medical shortcoming rather than an element of care. Although an Indonesian survey indicated that 94% of healthcare providers were willing to discuss end-of-life issues, fewer than 10% had received formal education in palliative or end-of-life care, and approximately 75% of the general population preferred to avoid such discussions, leading to communication gaps and inconsistent decision-making. \u003csup\u003e8,9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn Indonesia, where hospitals are commonly chosen as places of dying, critical care units (ICUs) provide much of this end-of-life care, highlighting the need to implement end-of-life care specifically tailored for these settings. This necessity has also been emphasized by the World Health Organization (WHO) and JCI. This cultural dynamic of gap between deaths un critical care unit and lack of knowledge among clinicians an cultural barriers, contributes to a continued emphasis on aggressive treatment approaches, even when the likelihood of clinical benefit is minimal, and highlights the challenges faced in implementing patient-centred end-of-life care within intensive care settings.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Anesthesiologists in Indonesia serve as critical care specialists, taking on the responsibility of managing life support and guiding treatment goals for critically ill patients, including those nearing end-of-life in the ICU. However, many anesthesiologists find it challenging to navigate the complexities of end-of-life decision-making without adequate palliative education, supportive institutional policies, or access to emotional support. This lack of resources can hinder their ability to provide compassionate care during these crucial moments.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eStudies demonstrate that hospitals with structured palliative care units or consult teams achieve better patient outcomes and communication quality. A meta-analysis found that hospital-based specialist palliative care significantly improved outcomes and patients satisfaction compared with usual care in patients with advanced illness.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e These models provide standardized pathways and ethical frameworks that support earlier end-of-life discussions. Consistent with this evidence, Joint Commission International (JCI) accreditation standards require hospitals to implement organized end-of-life care processes that ensure comfort, dignity, and family involvement.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTo explore this issue in the Indonesian context, we conducted a cross-sectional survey among anaesthesiologists in West Java, the province with the highest density of anaesthesiologists and intensive care units in the country. West Java represents a diverse healthcare landscape, encompassing government, private, referral, and teaching hospitals, making it a relevant microcosm of Indonesia\u0026rsquo;s critical care environment. The primaryaim of this study is to assess whether the availability of institutional palliative care services is associated with end-of-life (EOL) communication practices among anaesthesiologists.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis study employed a cross-sectional analytical design using an online survey to assess the relationship between institutional palliative care availability and end-of-life (EOL) communication practices among anaesthesiologists in West Java, Indonesia. Data collection was conducted between July and August 2025 following ethical approval from the Health Research Ethics Committee of Universitas Padjadjaran, Bandung (Approval No. 409/UN6.KEP/EC/2025).\u003c/p\u003e \u003cp\u003eThe survey was disseminated through the West Java Association of Anesthesiologists, which includes anesthesiologists working in public, private, teaching, and referral hospitals. West Java was selected as the study site because it represents the largest provincial cluster of anesthesiologists in Indonesia and encompasses diverse healthcare settings reflective of the national critical-care landscape. The writing of this paper follows the \u003cb\u003eC\u003c/b\u003ehecklist for \u003cb\u003eR\u003c/b\u003eeporting \u003cb\u003eR\u003c/b\u003eesults of \u003cb\u003eI\u003c/b\u003enternet \u003cb\u003eE\u003c/b\u003e-\u003cb\u003eS\u003c/b\u003eurveys (CHERRIES) guidelines.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003e2. Population and Sampling\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe study population comprised all registered anesthesiologists practicing in West Java Province, totalling 354 members according to the West Java Association of Anesthesiologists (2024 membership data). The required minimum sample size was calculated using Slovin\u0026rsquo;s formula for finite populations at a 95% confidence level and 5% margin of error, yielding a minimum of 188 respondents. After accounting for an anticipated 10% non-response rate, the final target sample size was 210. A total population sampling approach was employed. We included registered members of the West Java Association of Anesthesiologists and were currently practicing as anesthesiologists in hospitals within West Java Province at the time of the survey. We excluded questionnaires with missing data on the primary exposure (availability of a palliative care unit) or primary outcomes (end-of-life communication items). We also removed duplicate entries submitted under the same name and entries in which the respondent\u0026rsquo;s name and email did not match the official association database.\u003c/p\u003e \u003cp\u003e \u003cb\u003e3. Instrument\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe questionnaire used in this study was adapted from a previously validated nation-wide survey of Italian anesthesiologists on palliative care and end-of-life issues in the intensive care unit developed in Italy.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e The original instrument consists of closed-ended items covering respondent characteristics, institutional features, palliative care availability, and end-of-life decision-making practices. For validation in the Indonesian context, the questionnaire was translated from English into Bahasa Indonesia by a professional language agency and then backtranslated into English by a second independent agency. The review research team evaluated discrepancies between the original and back-translated versions, ensuring conceptual equivalence rather than literal translation. We then tested the Bahasa Indonesia version with a pilot group of five anesthesiologists working in West Java to assess clarity, comprehensibility, and cultural appropriateness. Based on their feedback, we made minor wording adjustments, but no novel items were added or deleted. We maintained the structure and content domains of the original instrument. Data were collected using an online questionnaire distributed via a secure link created through Google Forms (GFORM, USA) and shared across the Association\u0026rsquo;s official communication channels (email and WhatsApp groups). Participation was voluntary and anonymous, and we obtained electronic informed consent before respondents could access the survey and no incentives were offered.\u003c/p\u003e \u003cp\u003e \u003cb\u003e4.Variables\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe independent variable was the availability of a formal palliative care unit in the respondent\u0026rsquo;s hospital (Q1). The dependent variables represented end-of-life (EOL) communication practices: whether the physician routinely discusses EOL issues with families (Q2), whether the physician asks patients about resuscitation preferences (Q3), and whether the ICU has a Do-Not-Resuscitate (DNR) policy (Q4). Potential confounding variables included years of experience, hospital type (public/private), ICU bed capacity, and previous palliative care training. Questionnaire items, measurements and their coding are provided in the Supplementary Appendix.\u003c/p\u003e \u003cp\u003e5. \u003cb\u003eAnalysis\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWe analysed data using IBM SPSS Statistics (Version 25.0, IBM Corp., Armonk, NY, USA). Descriptive statistics were applied to summarize respondent characteristics and institutional variables, presented as frequencies and percentages for categorical data and means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations or medians (interquartile ranges) for continuous variables, depending on distribution. Bivariate associations between the availability of a palliative care unit (independent variable) and each end-of-life communication outcome (dependent variables: Q2\u0026ndash;Q4) were evaluated using the Chi-square test or Fisher\u0026rsquo;s exact test when appropriate. Confounding variables\u0026mdash;years of experience, hospital type, ICU bed capacity, and prior palliative care training\u0026mdash;were tested for associations with both the exposure and the outcome.Variables with p\u0026thinsp;\u0026lt;\u0026thinsp;0.10 in bivariate analysis were entered into a multivariate logistic regression model to identify independent predictors of end-of-life communication practices. Adjusted odds ratios (aOR) with 95% confidence intervals (95% CI) were reported. All tests were two-tailed, and statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eWe conceptualized end-of-life (EOL) practices in the intensive care unit using a Donabedian-based framework, which classifies quality of care into three interrelated domains: structure, process, and outcomes. Structural indicator, reflecting the organizational capacity to support end-of-life care. End-of-life practices\u0026mdash;including palliative and EOL screening, discussion of patient preferences (e.g., living wills), routine symptom management, use of standardized sedation and analgesia protocols, multidisciplinary decision-making, and family involvement\u0026mdash;were categorized as process indicators, reflecting clinician behaviors and care-delivery practices within the ICU. Selected downstream indicators, such as family involvement in decision-making and disposition following EOL decisions, were considered outcome-related measures. This conceptual framework guided variable selection, analytical strategy, and interpretation of findings\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 331 respondents, we retained 300 eligible questionnaires after applying data-cleaning procedures, exceeding the minimum required sample size of 180 for the analysis. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e A total of 300 anesthesiologists participated in the survey, with a median age of 43.50 years. Regarding clinical experience, 26.67% had fewer than 5 years of anesthesiology practice, 23.33% had 5\u0026ndash;10 years, and 50.00% had more than 10 years. In terms of ICU involvement, 60.00% reported working\u0026thinsp;\u0026le;\u0026thinsp;40 hours per week in the ICU, while 40.00% reported working more than 40 hours per week. Respondents were distributed across government-owned hospitals (43.33%) and private hospitals (56.67%). ICU bed capacity varied: 6.66% in units with fewer than 5 beds, 36.67% in units with 5\u0026ndash;10 beds, and 56.67% in units with more than 10 beds. Formal palliative-care training was reported by 26.67% of respondents, while 73.33% indicated no prior training. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEpidemiology of Respondents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResults (n\u0026thinsp;=\u0026thinsp;300)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43.50 (32\u0026ndash;71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExperience (years after graduation)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26.67%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23.33%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eICU weekly duration (hours/week)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le; 40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital Type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGovernment owned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43.33%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivately Owned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56.67%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eICU capacity (beds)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.66%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36.67%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56.67%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePalliative care training\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26.67%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73.33%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the unadjusted analysis (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), the availability of palliative care services in a hospital was significantly associated with several process indicators within the ICU. Hospitals with a palliative care service demonstrated higher odds of conducting palliative and end-of-life (EOL) screening (OR 3.21, 95% CI 1.99\u0026ndash;5.24, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and of screening and discussing living wills (OR 3.60, 95% CI 2.06\u0026ndash;6.50, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). The presence of a palliative service was also associated with higher odds of implementing routine sedation and pain protocols for EOL care (OR 4.71, 95% CI 2.85\u0026ndash;7.94, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and of having a palliative care protocol specifically for ICU settings (OR 17.50, 95% CI 9.83\u0026ndash;32.45, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). No significant association was observed between palliative service availability and routine monitoring of pain, dyspnoea, and anxiety as part of general patient care (OR 1.20, 95% CI 0.71\u0026ndash;2.00, p\u0026thinsp;=\u0026thinsp;0.4855) or routine multidisciplinary discussions regarding EOL choices (OR 1.03, 95% CI 0.62\u0026ndash;1.69, p\u0026thinsp;=\u0026thinsp;0.90). For outcome indicators, palliative service availability was associated with increased family involvement in EOL decision-making (OR 2.50, 95% CI 1.1519\u0026ndash;5.7582, p\u0026thinsp;=\u0026thinsp;0.02). No significant association was noted between palliative service availability and the place of discharge following an EOL decision (OR 1.22, 95% CI 0.75\u0026ndash;1.97, p\u0026thinsp;=\u0026thinsp;0.41). Multicollinearity among independent variables was assessed prior to multivariable logistic regression and was not found to be problematic.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnadjusted Model Analysis of the Relationship Between Palliative Service Availability and Process and Outcome Parameters in the Intensive Care Unit\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDependent Variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003ePalliative Care Service Availability\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eProcess Indicators\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScreening for Palliative and EOL in ICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1.99\u0026ndash;5.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScreening and discussion of living will\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2.06\u0026ndash;6.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoutine pain, dypnea and anxiety monitoring as part of general patient care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.71\u0026ndash;2.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoutine sedation and pain protocol for EOL care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2.85\u0026ndash;7.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoutine Multidisciplinary Discussion for EOL choices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.62\u0026ndash;1.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePalliative Care Protocol for ICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(9.83\u0026ndash;32.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOutput\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily Involvement in EOL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1.15\u0026ndash;5.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.02**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlace of Discharge after EOL decision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.75\u0026ndash;1.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eLegend\u003c/b\u003e : Intensive Care Unit (ICU), EOL ( End of Life), OR (Odds Ratio), CI (Confidence Interval),.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA forest plot (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) was constructed to visualize the adjusted associations between palliative care service availability and selected ICU process indicators. Only outcomes for which multivariable logistic regression models demonstrated acceptable goodness-of-fit (Hosmer\u0026ndash;Lemeshow p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) were included. For these models, adjusted odds ratios and 95% confidence intervals were plotted to illustrate the independent effect of palliative care unit availability, controlling for clinician palliative care training. Several outcomes had poor model fit, that is palliative care provision in ICU, multidisciplinary decision-making, family involvement, and place of discharge. The lack of model fit suggests that these outcomes are driven by non-structural determinants such as culture, family norms, and institutional ethics climates. These models were excluded from the figure to ensure that only statistically valid and interpretable estimates were displayed. The resulting forest plot provides a visual summary of the adjusted effect sizes for the four process indicators that met model validity criteria.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn the adjusted analysis evaluating the independent association between palliative care unit availability and ICU practice indicators, several process variables demonstrated statistically significant relationships. The presence of a palliative care unit was associated with higher odds of conducting palliative and end-of-life (EOL) screening within the ICU (adjusted OR 5.00, 95% CI 2.89\u0026ndash;8.95, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Similarly, hospitals with a palliative care unit had greater odds of implementing routine sedation and analgesia protocols for EOL care (adjusted OR 6.32, 95% CI 3.64\u0026ndash;11.40, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). The availability of a palliative care unit was also significantly associated with screening or discussing living will preferences (adjusted OR 4.83, 95% CI 2.64\u0026ndash;9.26, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Routine monitoring of pain, dyspnoea, and anxiety as part of general patient care did not show a significant association with palliative care unit availability in the adjusted model (adjusted OR 1.06, 95% CI 0.62\u0026ndash;1.79, p\u0026thinsp;=\u0026thinsp;0.8301). (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e To our knowledge, this is the first study to systematically describe palliative care availability and end-of-life practices among anesthesiologists in Indonesia. The main findings of this study demonstrate that just over half of anesthesiologists reported working in institutions with a formal palliative care service, while fewer than one-third had received any structured palliative or end-of-life training. The presence of an institutional palliative care unit was strongly associated with several key ICU process measures, including routine screening for palliative and end-of-life needs, discussion of living-will preferences, and implementation of standardized sedation and analgesia protocols for end-of-life care. In contrast, practices such as routine symptom monitoring and multidisciplinary decision-making were not consistently associated with institutional palliative care availability, suggesting that these behaviors may be driven by broader ICU culture or individual clinician factors rather than formal service structure alone.\u003c/p\u003e \u003cp\u003eIn depth, 300 anesthesiologists from 354 members of the West Java Anesthesiology Association, or 84.7%, Hospital type and ICU bed capacity were assessed descriptively but were not included as covariates in the multivariable models. The distribution of respondents across hospital ownership and ICU sizes was relatively homogeneous, and preliminary inspection showed no meaningful variability by these characteristics. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) Consequently, neither variable met criteria as a potential confounder, and inclusion did not improve model fit or alter effect estimates. These outcomes likely require additional contextual variables\u0026mdash;such as family expectations, institutional norms, and cultural drivers\u0026mdash;that were beyond the scope of the current model\u003c/p\u003e \u003cp\u003eFrom the survey, our respondents were of the mean age of participants was 43.50 years, representing a predominantly mid- to late-career cohort and consistent with this age distribution; 50% of respondents reported more than 10 years of anesthesiology practice. With respect to critical care involvement, 60% of anesthesiologists reported spending\u0026thinsp;\u0026le;\u0026thinsp;40 hours per week in the ICU. This finding reflects the typical Indonesian practice model, also observed in the United States and several European countries, in which anesthesiologists have dual training and often maintain dual clinical responsibilities, dividing their time between the operating room and the ICU rather than practicing as dedicated intensivists.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e The remaining 40% reported working more than 40 hours per week in the ICU, indicating a subset with more continuous critical-care roles. As was expected, only 26.67% of respondents reported having received formal palliative-care training, underscoring the limited penetration of structured palliative education among anesthesiologists despite their central role in end-of-life decision-making within the ICU.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe findings of this study demonstrated three distinct behavioural patterns in the implementation of palliative care processes within the ICU. First, several practices\u0026mdash;namely palliative and EOL screening, use of sedation and analgesia protocols for EOL care, and living-will discussions\u0026mdash;were strongly associated with both the availability of a palliative care unit and clinician training, indicating that these behaviours rely on the alignment of institutional structure and individual competence. Second, routine symptom monitoring for pain, dyspnoea, and anxiety appeared to be independent of institutional palliative care structures and was influenced only by individual training, suggesting that this activity reflects established ICU clinical norms rather than palliative care system factors. Third, outcomes such as palliative care delivery in the ICU, multidisciplinary EOL discussions, family involvement in EOL decision-making, and disposition location did not demonstrate adequate model fit, indicating that these behaviours are shaped by additional system-level or cultural factors not captured by the two primary predictors. Together, these three categories highlight the varying degrees of structural, educational, and contextual influence on palliative care practices in Indonesian ICUs.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, its cross-sectional design precludes causal inference regarding the relationships among palliative care service availability, clinician training, and ICU practice patterns. Second, data were derived from self-reported questionnaires, which may be subject to recall or social desirability bias. Third, although the adjusted models focused on palliative care unit availability and clinician training, other system-level determinants\u0026mdash;such as institutional culture, family expectations, hospice accessibility, and reimbursement structures\u0026mdash;were not measured and may influence certain end-of-life practices. This is reflected in the inadequate model fit for outcomes related to family involvement, multidisciplinary decision-making, and discharge disposition, which were therefore excluded from the adjusted analyses.\u003c/p\u003e \u003cp\u003eTaken together, our findings suggest that palliative care in the intensive care setting should be understood not as a discrete intervention, but as a continuous clinical process that requires sustained organizational stewardship. The presence of a formal palliative care unit appears to provide an immediate structural scaffold for end-of-life practices that depend on protocols, ethical support, and interdisciplinary coordination, resulting in measurable improvements within hospital care. However, the incomplete alignment between structural availability and several end-of-life behaviors underscores that institutional infrastructure alone is insufficient. End-of-life care unfolds at the intersection of organizational systems, clinician capability, and deeply embedded cultural norms surrounding death and decision-making. Establishing a dedicated, functional palliative care body within hospitals may therefore serve as a necessary foundation for improving in-hospital end-of-life care, while simultaneously creating the conditions for ongoing education, cultural adaptation, and iterative quality improvement. In this sense, palliative care integration represents not a one-time implementation, but a dynamic process that evolves through continuous alignment between structure, practice, and context.T\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn Indonesia, palliative care is inconsistently integrated into intensive care, with formal services and clinician training limited to a subset of hospitals. Institutional palliative care availability is associated with more consistent implementation of key end-of-life practices, including screening, advance care planning, and standardized sedation and analgesia. However, not all end-of-life behaviours are explained by structural availability alone, highlighting the need for combined system-level development and clinician education to strengthen palliative care integration in IndonesianICUs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe publication charge is funded by Universitas Padjadjaran through the Indonesia Endowment Fund for Education (LPDP) on behalf of the Indonesian Ministry of Higher Education, Science and Technology and managed under EQUITY program (contract no 4303/B3/DT.03.08/2025 and 3927/UN6.RKT/HK.07.00/2025)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest/Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData supporting the findings of this study are not publicly available due to institutional and patient confidentiality policies. However, they are available from the corresponding author upon formal request and subject to appropriate approvals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGezy Weita Giwangkancana: conceptualization, methodology, data analysis, writing the original draft. \u0026nbsp;Anni \u0026nbsp; \u0026nbsp; \u0026nbsp; sa Isfandiary Ismandiya : data collection and analysis, ethical evaluation, investigation, original draft preparation. \u0026nbsp;Gian Ruzbihan Al Afghani: survey preparation, data collection, Budiana Rismawan: data curation, resources, writing-reviewing and editing. Marina Ma: reviewing and editing. Erwin Pradian: reviewing and editing, Andrea Cortegiani: reviewing and editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth Research Ethics Committee of Universitas Padjadjaran, Bandung (Approval No. 409/UN6.KEP/EC/2025) and this study adhered to the Declaration of Helsinki for human data and/or material.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for participation was obtained from all participants prior to enrolment\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from all participants prior to enrolment\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eArtificial Intelligence Disclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors used Grammarly AI and ChatGPT to support language refinement and improve readability. The authors have complete control over the study design, data interpretation, and scientific conclusions, and we accept complete responsibility for the content of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEzer T, Lohman D, de Luca GB. Palliative care and human rights: a decade of evolution in standards. J Pain Symptom Manag. 2018;55(2):S163\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConnor SR, Gwyther E. The worldwide hospice palliative care alliance. J Pain Symptom Manag. 2018;55(2):S112\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaiva CF, Silva CP, Santos TC, Augusto PD, Ennes LD, Almeida Filho AJ. Oncology nursing and palliative care in a reference institution (2005\u0026ndash;2006). 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Aust J Prim Health. 2020;26(6):472\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1071/PY20111\u003c/span\u003e\u003cspan address=\"10.1071/PY20111\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEng V, Hewitt V, Kekalih A. Preference for initiation of end-of-life care discussion in Indonesia: a quantitative study. BMC Palliat Care. 2022;21(1):6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12904-021-00872-z\u003c/span\u003e\u003cspan address=\"10.1186/s12904-021-00872-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRao SR, Salins N, Joshi U, Patel J, Remawi B, Simha S, et al. Palliative and end-of-life care in intensive care units in low- and middle-income countries: A systematically constructed scoping review. 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Interrelation between anaesthesiology and intensive care medicine training in Europe: An ESAIC National Anaesthesiologists Societies Committee survey. Eur J Anaesthesiology| EJA. 2025;42(2):173\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTankard K, Shelton K. The future of cardiac critical care: an anesthesia perspective. Annals Translational Med. 2023;11(9):324.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Palliative care, End-of-life care, Intensive care unit, Health systems, Anesthesiology","lastPublishedDoi":"10.21203/rs.3.rs-8645592/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8645592/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePalliative care and end-of-life (EOL) support are increasingly recognized as core components of high-quality health systems and are embedded within international human rights and hospital accreditation standards. However, in many low- and middle-income countries, including Indonesia, palliative care integration in intensive care units (ICUs) remains limited, with substantial gaps in institutional structure and clinician training. Given that ICUs are common settings for death and dying, understanding factors associated with EOL practices in critical care is essential.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThis study aimed to assess whether the availability of institutional palliative care services is associated with EOL communication practices and care processes among anesthesiologists working in ICUs in Indonesia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a cross-sectional analytical survey among anesthesiologists practicing in West Java Province, Indonesia. The questionnaire was adapted from a validated national survey and assessed institutional palliative care availability, clinician training, and ICU EOL practices. Descriptive analyses were performed, followed by unadjusted and multivariable logistic regression analyses guided by a Donabedian structure\u0026ndash;process\u0026ndash;outcome framework. Adjusted models controlled for clinician palliative care training, and model fit was assessed using the Hosmer\u0026ndash;Lemeshow test.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 300 anesthesiologists were included in the analysis. Formal palliative care services were available in 53.3% of respondents\u0026rsquo; hospitals, while only 26.7% reported prior palliative care training. In unadjusted analyses, palliative care service availability was significantly associated with several ICU process indicators, including palliative/EOL screening, living-will discussions, and standardized sedation and analgesia protocols. In adjusted models with acceptable fit, institutional palliative care availability remained independently associated with palliative/EOL screening (adjusted OR 5.00), sedation and analgesia protocols (adjusted OR 6.32), and living-will discussions (adjusted OR 4.83). Routine symptom monitoring was not associated with structural availability. Several outcomes, including family involvement and discharge disposition, demonstrated poor model fit and were excluded from adjusted analyses.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eInstitutional palliative care availability is associated with more consistent implementation of key EOL processes in Indonesian ICUs, particularly those requiring formal protocols and structured support. However, not all EOL practices are explained by institutional structure alone, underscoring the need for combined system-level development and clinician education to strengthen palliative care integration in critical care settings.\u003c/p\u003e","manuscriptTitle":"Assessment of Institutional Palliative Care Availability and End-of-Life Practices within Critical Care Settings in Indonesia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-06 09:00:52","doi":"10.21203/rs.3.rs-8645592/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"297601868199750549625518254285753934216","date":"2026-05-11T04:42:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80270011162192867930173666739260406586","date":"2026-04-12T04:45:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-11T23:44:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319824034798836653323390301049164624441","date":"2026-03-04T18:19:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-20T16:58:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277544945751421504681145626299182761848","date":"2026-02-09T16:49:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-03T20:51:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-02T11:54:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-30T13:07:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2026-01-30T11:41:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fa37200e-267a-43bf-afe6-3cc6e59d4fda","owner":[],"postedDate":"February 6th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"297601868199750549625518254285753934216","date":"2026-05-11T04:42:04+00:00","index":85,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-06T09:00:52+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-06 09:00:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8645592","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8645592","identity":"rs-8645592","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}