Assessment of institutional palliative care service and end-of-life practices within critical care settings in Indonesia

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, the integration of palliative care in intensive care units (ICUs) remains limited, with substantial gaps in institutional structures 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. A secondary analytical objective was to evaluate the influence of clinician palliative care training on ICU EOL practices. 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 service, 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. Institutional palliative care service was available in 53.3% of respondents’ hospitals, while only 26.7% reported prior palliative care training. In unadjusted analyses, institutional palliative care service (IPCS) 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 IPCS 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 the integration of palliative care in critical care settings.