C r i t i c a l C a re N u r s i n g i n t h e

P h i lippin es
Historical Past, Current Practices, and Future
Directions

Rudolf Cymorr Kirby P. Martinez, PhD, MA, RNa,b,*,

Maria Isabelita C. Rogado, MA, RNa,c,
Diana Jean F. Serondo, RN, SCRN, NVRN-BCc,
Gil P. Soriano, MHPEd, RNb,d, Karen Czarina S. Ilano, RN, SCRN
c

KEYWORDS
 Critical care nursing  End of life and palliative care  Family involvement
 Pain management  Patient rehabilitation
 Interprofessional communication and collaboration  Quality and safety  Philippines

KEY POINTS
 The field of critical care nursing is widely recognized as a nursing specialty; however, there
is no standardized national certification program for critical care nursing in the Philippines.
 The patient admitted in the intensive care unit (ICU) requires complex care and needs
technologically advanced monitoring and resources; however, this has become a chal-
lenge in the Philippines because of insufficient national and local health funding and the
prevailing health care financing system.
 There is a need to increase on the competencies of critical care nurses pertaining to pain
and delirium management, provision of palliative and end-of-life care, communication,
and interprofessional collaboration.
 Despite the central roles that critical care nurses play within the ICU, their active partici-
pation during medical/interprofessional rounds or patient case analysis is still lacking.

a
Graduate School of Nursing, Arellano University Juan Sumulong Campus, 2600 Legarda St,
Sampaloc, Manila 1008, Philippines; b College of Nursing, San Beda University, 638 Mendiola
St., San Miguel, Manila 1005, Philippines; c Critical Care Nurses Association of the Philippines,
Inc., 3rd floor, Edificio Enriqueta, 422 NS Amoranto St. Corner D. Tuazon St., Quezon City 1114,
Philippines; d Graduate School, Wesleyan University- Philippines, Mabini Extension, Cab-
anatuan City, Nueva Ecija 3100, Philippines
* Corresponding author. College of Nursing, San Beda University, 638 Mendiola St., San Miguel,
Manila, Philippines, 1005.
E-mail address: [email protected]

Crit Care Nurs Clin N Am 33 (2021) 75–87

https://doi.org/10.1016/j.cnc.2020.11.001 ccnursing.theclinics.com
0899-5885/21/ª 2020 Elsevier Inc. All rights reserved.
76 Martinez et al

BRIEF HISTORICAL BACKGROUND

Critical care as a specialty practice in the Philippines was strengthened in the early
1970s. This was the time when then First Lady Imelda R. Marcos spoke about eradi-
cating the country’s top 3 killers (heart disease) by harnessing the advances of medical
science. This was realized when the Philippine Heart Center (PHC) for Asia was inau-
gurated on February 14, 1975, with the goal of serving not only the Philippines but the
entire Asian region.1
The beginning of this state-of-the-art PHC paved the way to strengthen not only the
medical practice of cardiology but also the specialization in critical care. Soon after,
specialty tertiary hospitals, like the National Kidney and Transplant Institute and
Lung Center of the Philippines, were built, further enhancing the practice of critical
care in the Philippines.
To complement the practice of critical care medicine, nurses working in the critical
care units were trained initially with orientation, on-the-job, and preceptorial educa-
tion. In approximately 1977, the PHC Nursing Service, Division of Nursing Education,
crafted a 2-month postgraduate curriculum in critical care nursing designed to provide
nurses with the concepts of critical care practice, such as cardiac monitoring, hemo-
dynamics, mechanical ventilation, arterial blood gas interpretation, nutritional support,
and Basic and Advanced Cardiac Life Support, among others. Although the original 2-
month course was focused on cardiovascular pathologies, the integrated concepts of
critical care were adapted by its trainees to enhance the critical care practice in their
respective hospitals.
In February 1977, nurses from different hospitals, such as PHC, Philippine General
Hospital, National Orthopedic Hospital, and Cardinal Santos Medical Center, repre-
sented by Amelia Baldovino-Lopez (founding president, Critical Care Nurses Associ-
ation of the Philippines, Inc. [CCNAPI]), Deogracia M. Valderrama, Eufemia Rueda,
and Ester Romano, convened to organize the CCNAPI. The CCNAPI has become
instrumental in assisting the hospitals outside metropolitan areas to set up their
own critical care units and has helped educate the nurses by providing various training
programs relevant to critical care practice.
Currently, critical care nursing is practiced as one of the recognized nursing spe-
cialties that uses the nursing process to deal with potential and actual life-
threatening conditions requiring organ support and invasive monitoring. It focuses
on restorative, curative, rehabilitative, maintainable, or palliative care, based on iden-
tified patient needs, in a challenging and fast-paced environment.2,3 The practice of
critical care nursing in the Philippines involves a multidisciplinary, interprofessional,
and a holistic patient-centered approach given in a timely manner.

CURRENT PRACTICE
The Critical Care Nurse
Critical care nurses in the Philippines are registered nurses trained and qualified to
practice critical care nursing. They carry out interventions and coordinate patient
care activities to address life-threatening situations that will meet patient’s biological,
psychological, cultural, and spiritual needs.2 Within the current system, most critical
care nurses have previous experience in the general ward before their exposure to
the critical care setup.
Training for nurses who desire to practice in the critical care setting are usually pro-
vided by the nurses’ respective institutions where the training curriculum is designed
by their respective training offices or is collaboratively done with a recognized spe-
cialty organization, such as CCNAPI. The training usually includes a combination of
 Critical Care Nursing in the Philippines 77

didactic (lectures, seminars, orientations) and hands-on clinical components (precep-

torship, mentoring).
Certification in critical care nursing indicates that the nurse has mastered the skills
and knowledge base necessary to effectively care for acutely ill patients. Currently,
there is no national certification for critical care nurses in the Philippines. Standards
are in the process of being implemented in the Philippines.

Health Care Financing and Intensive Care Unit Capacity

Health care in the Philippines is mostly institution-based given through either public or
private medical institutions. Metropolitan areas like Metro Manila, have a higher num-
ber of medical institutions compared with nonmetropolitan areas. Funding for hospi-
talization is paid by the national health insurance program managed by PhilHealth,
private health insurance (PHI), out-of-pocket payments, or a combination of these.
PhilHealth covers private and public hospitals with 30% to 60% of hospitalization
cost; 50% to 70% for public medical institutions, and only 30% or less for some pri-
vate medical facilities.4 The rest are taken on by the patient either through PHI or out of
their own pocket. These private PHIs mostly cater to selected private medical institu-
tions and some public hospitals as well. Hospitalization in private hospitals arguably
costs more than public hospitals and is mostly accessible only to those who can afford
the out-of-pocket expenses. Patients declared as medically indigent are channeled to
other sources of financing, and in some cases, fully accommodated by the govern-
ment hospitals, with little to no financial burden to the patient and their family.
Most government hospitals rely on government funding, either through the central
government or their respective local government units. Funding from the central gov-
ernment is relatively less affected by politics compared with their local government
counterparts. To augment their funds, some government hospitals have been con-
verted to government-owned and controlled corporations, allowing them to conduct
commercial and noncommercial activities, such as allowing the patient the choice
to be admitted either as a paying patient or a regular patient.5
The hospital’s classification is reflected in the organization of its departments or
attached intensive care units (ICUs). All hospitals in the Philippines are classified ac-
cording to their service capability: level 1 hospitals have an average of 41-bed capac-
ity, level 2 hospitals have 97, and level 3 hospitals have 318 average bed capacity.4
Within this system, hospitals with higher level of classification can accommodate pa-
tients with more complex needs, and it is implied that they have more advanced tech-
nologies compared with those with lower level of classifications. The study done by
Phua and colleagues6 reported that there are a total of 2315 critical care beds among
the 450 ICUs surveyed in the Philippines, with an additional 20 Intermediate Care Unit
(IMCU) beds in 2 IMCUs, which roughly translates to 2.2 critical care beds available
per current 100,000 population. Most ICUs are running near or on their limit even
before the surge of cases brought about by the coronavirus disease 2019 (Covid-
19) pandemic, which stresses and overwhelms an already overrun system even
more.7 With the current system, some patients requiring ICU admission are denied
because of the unavailability of beds, forcing some of them to prolong their stay in
the emergency department (ED), be admitted to a regular room modified to assist in
their needs, or seek treatment elsewhere.

The Milieu of the Intensive Care Unit

Although there are IMCUs, often termed as intermediate care units or “step-down”
units, most critical care nurses in the Philippines work in the ICU. These ICUs can
78 Martinez et al

be categorized according to age groups (neonatal, pediatric, adult) or medical spe-

cialties (surgical, cardiovascular, neurocritical, etc.).6,8
Patients referred to the ICU are those with potential or established organ dysfunc-
tion needing focused care and treatment. A patient may be admitted to the ICU via ED
admission, transfer from the general ward, transfer from another hospital, or from a
special or complex operation such as heart surgeries. Admission to the ICU is decided
by the case of the patient, the availability of beds, the attending physician and critical
care physician’s collaborative management, and sometimes the demands of the pa-
tient’s family who will shoulder the hospital expenses. There are instances wherein
moribund patients, whose clinical outcomes may not be improved by ICU manage-
ment, are still admitted to the ICU so long as there is an availability of beds and is
done with the approval of the patient’s attending physicians and their family. Patients
admitted in the ICU are generally classified using varied patient care acuity tools
depending on institutional preference.
Operation within these ICUs can be classified as open, closed, or a combination of
both. In an open system, admission and patient management is the primary and sole
responsibility of the attending physicians. Other physicians, such as the intensivist or
critical care specialist provides advice only on the patient’s management. The
attending physician has the sole prerogative on the direction of the patient’s manage-
ment. Under the closed system, the intensivist or critical care specialist provides the
decision on patient management. Once referral is done by the previous attending or
admitting physician, the intensivist or critical care specialist will take over patient
management.2
Regardless of the type of operation, a team of critical care nurses is always present
to provide direct patient care as part of the multidisciplinary team. Critical care nurses
are usually led clinically by a charge nurse and administratively by a head nurse.
Although each critical care nurse works independently as they work under primary
nursing, the charge nurse provides bedside clinical support if needed, whereas the
head nurse answers for administrative concerns. Patient assignment and staffing
are collaboratively done by both the charge and head nurses. At times, the charge
and the head nurses are the same person, as many ICUs have concerns with low staff-
ing. The decreased number of critical care nurses working in the ICU is attributed to
the high attrition rate, as many will resign to seek greener pasture abroad, and to
the low uptake of new critical care nurses, as most systems allow only those with
bedside experience to be trained in the ICU setup, compounded by the fact that the
application for any nursing post is generally low.
Staffing in the ICU is generally based on the availability of limited critical care
nurses rather than the patient’s acuity of care. The ideal ratio of 1 nurse to 1 to 3
patients in the ICU2,9 is achieved only if there is sufficient staff available on the floor.
Because the ICU is considered as a highly specialized unit, there is difficulty of
“floating” nurses from other wards when staffing is low, thus patient assignment
among critical care nurses present within the shift will be higher than the ideal ratio.
With these, the possibility of an overtime duty among critical care nurses is a daily
reality. Shifts may vary from an 8-hour to 12-hour duty per day with a required min-
imum of 40 hours per week for a full-time post. Almost all critical care nurses work
full-time. This less-than-ideal staffing setup significantly contributes to the perceived
unfavorable and frustrating work environment among critical care nurses along with
their heavy workload, perceived lack of mentorship, and standardized national
training guidelines.10
Patient assignments are generally given during shift handover, often referred to in
the Philippines as “endorsement.” Although the process of handover varies from
 Critical Care Nursing in the Philippines 79

different institutions, the same goal of a complete handover of care from the outgoing
to the incoming shift is still attained. The handover among physicians and among
nurses happens at different times because of the variation in their shifting schedules.
Tools used during handover vary across different ICU units, but are consistent among
related institutions, such as hospital conglomerates.
Patients admitted in the ICU needing transport to and from a different part of the
hospital or from another medical institution are accompanied by at least 1 physician,
1 nurse trained in critical care, and various support personnel, such as nursing aide,
respiratory therapist, and other allied health care personnel depending on the need
and equipment attached to the patient during transport. Interinstitutional patient trans-
fer, often referred to as “conduction,” is mostly done if the needed diagnostics are not
present in the institution, as is often the case in government hospitals, or if the patient
decides to change hospitals for better care, or because of lack of funding. During
these interinstitutional transfers, a medical technician and/or a paramedic may be pre-
sent depending on the circumstances. Although transport policies and guidelines
markedly vary within medical institutions, the role of critical care nurses during these
transports is seemingly consistent.
Discharge from the ICU is facilitated once the critical care issues are resolved and
the discharge criteria are met. The patient is then transferred to either a step-down
unit, if institutionally available, or to the general ward, depending on its availability.
The choice of room among those that are available is highly dependent on the financial
capacity of the patient and family and their attending physician’s preference. Although
there are cases in which patients are discharged directly from the ICU, those are ex-
emptions rather than the general trend.

Issues Within the Critical Care Unit

The complexities of cases present and the multidisciplinary approach used in the crit-
ical care unit generate unique issues within these units. Critical care nurses acting as
patient advocates and providing most bedside care are at times witness to these is-
sues. From the perspective of critical care nurses and within the context of the ICU
and the Philippine health care system, the following are some of the prevalent issues
within the critical care units.

Pain management
Pain is one of the most common signs seen and expected to be present in the ICU.
It may arise from the patient’s disease condition, present condition, or procedures
done to the patient. Although the management of pain is one of the functions of crit-
ical care nurses, critical care nurses in the Philippines tend to use pharmacologic
measures to alleviate pain, which is heavily reliant on the physician’s management
and orders. There seems to be an underutilization of nonpharmacologic measures
and overreliance on drugs to control pain. This is further compounded by the prac-
tice of assessing only the severity of the pain, leaving behind the other aspects of
the pain experience. Although there is a preference for pharmacologic pain manage-
ment, there is a still a prevailing culture among Filipino health care providers of
undermedicating patients who are experiencing pain. The inclination to use drugs
found at the lower levels of the World Health Organization pain ladder and the
underuse of opioids for pain management is still commonplace.11,12 Although pain
is a common occurrence in the ICU, little nursing research has been done to explore
this phenomenon, its nature, management, and nursing implications, in the
Philippines.
80 Martinez et al

Management of delirium
Delirium is characterized by a disturbance in consciousness resulting in severe confu-
sion and reduced awareness of surroundings.13 It is often associated with poor health
outcomes, neurocognitive impairment, prolonged length of stay in the ICU, prolonged
mechanical ventilation, greater risks to safety related to self-extubation and falls,
reduced health-related quality of life, as well as higher overall mortality rate.14,15
Despite being a condition of growing concern in the ICU setting, especially for me-
chanically ventilated patients, little is still known about the prevalence of delirium
among patients in ICUs in the Philippines. Although different tools for assessment
are available for delirium, such as the Confusion Assessment Method for the ICU,
its screening is still not part of routine care in the local ICU setting, thus delirium is
frequently underdiagnosed.16,17

Provision of sleep
Disturbance of sleep in the ICU setting is influenced by illumination, noise (ie,
alarms, monitors, staff voices), discomfort, anxiety, and various interventions done
to the patient. The essentiality of sleep for the regeneration of the body is hampered,
thus affecting the patient’s recovery process and resulting in possible disorienta-
tion.18 Although critical care nurses continuously monitor changes in the sleep
pattern of patients in the ICU, there is no standard tool used in most of the units
and most often these observations are merely endorsed to the incoming shift rather
than properly documented in the patient’s chart. Critical care nurses play an essen-
tial role in minimizing sleep disturbance by maximizing all activities to be done dur-
ing daytime; bathing the patient before midnight; controlling room temperature,
noise, and light; and positioning the patient based on their preference, which will
promote a restful sleep. These activities are ideally done if the circumstances within
the units permit, as some ICUs in government hospitals are not as spacious, well lit,
and noise free as their private hospital counterparts. Administration of drugs solely
to induce and fix the sleeping pattern is rarely done.

Patient rehabilitation
Within the setup among the ICUs in the Philippines, patients needing physical
rehabilitation are formally referred to a rehabilitation team often led by a physician
and composed mostly of physical and occupational therapists. Rehabilitation is
often initiated as soon as the patient is stabilized and ready for therapy. Passive
range-of-motion exercises are often done with the patient, whereas mobility and
ambulation are rarely an occurrence within the ICU. These exercises are delegated
to the physical rehabilitation team that visits the unit for each session. The critical
care nurses seldom perform an active role during the therapy sessions except for
preparing the patient by adjusting equipment and activities within the day and per-
forming handover before and after the therapy session. During the active therapy
session of their patient, critical care nurses will focus on their other patients, as
they are assigned more than 1 patient most of the time. With the limitations of
health care professionals conducting rehabilitation sessions and the emergence
of Covid-19, telerehabilitation, a branch of telemedicine in which teleconference
with the therapist on one side and the nurse tasked to assist the patient on the
other, is slowly beginning to develop. Although this will increase the engagement
of the nurse with patient’s rehabilitation therapy, it will inevitably increase the
nurse’s workload as well. Institutions offering telerehabilitation are still limited in
the country.19,20
 Critical Care Nursing in the Philippines 81

Respiratory rehabilitation is always led by a physician, with nurses and the respira-
tory therapist acting as support personnel. Respiratory rehabilitation is achieved by
various ventilatory weaning strategies based on protocols and physician’s preference.
Although other countries have established nurse-led ventilation-weaning protocols,
with much success and good clinical outcomes,21 its practice in the Philippines has
yet to be observed or reported.

Quality and safety

With the promulgation of the Republic Act 7875 or the National Health Insurance Act
of the Philippines, hospital institutions were mandated to establish quality assurance
programs,22 which has significantly led to the strict adherence to national standards
as set by PhilHealth. International accreditations, such as the Joint Commission In-
ternational, Canadian Hospital Accreditation, and Pathway to Excellence, were also
sought by some hospitals on top of those given by Philhealth.23 Most of these insti-
tutions are private hospitals. Although there are quality assurance and hospital-wide
accreditations in place, there is none distinct for critical care units except if these
units are part of “centers” especially built for specific diseases or medical condi-
tions. Exemplars of these are the neurocritical care unit (NCCU) of Brain Specialty
Centers designated by the Department of Health. These Brain Specialty Centers
are projected to be on par with international standards, and will have a separate
NCCU on top of their other ICUs.24 Among these hospitals, few have started with
their technological updates and have already acquired advance machine technolo-
gies, such as those used for targeted temperature management for improved neuro-
logic outcomes.25
More recently, emphasis on health care provider safety from exposure to infection
during handling and transport of patients has been raised. Health care providers are
required to don appropriate personal protective equipment (PPE) as mandated by
their hospital’s infection control service. Departments in which the patient is to be
transferred are alerted ahead of time of incoming patients to allow their staff ample
time to don their own PPE. The shortest routes to these areas are used, and are usually
cordoned off so that people, especially patients and visitors, are kept from crossing
paths with suspected COVID-19 cases. It is also mentioned that portable diagnostic
equipment, rather than patient transport to diagnostic areas, is given priority to mini-
mize the exposure of others to possible infection.

Technology in Critical Care

Technology and its utilization in critical care varies from unit to unit and institution to
institution. Advances in state-of-the-art technology still press an issue in the practice
of most critical care nursing.3 Advanced technologies, such as hemodynamic moni-
tors, ventilators, and specialized equipment, such as extracorporeal membrane
oxygenation, continuous electrocardiogram (cEEG), continuous renal replacement
therapy, intracranial pressure (ICP) monitors, cooling and warming devices, perfusion
machines, automated medicine cabinets, and nursing informatics are more widely
available and used in private institutions as compared with government hospitals.
Inside the ICU units, each patient’s headboard is equipped with inlets/outlets for
oxygenation, and suctioning. Patients needing mechanical ventilation (MV) can be
set up inside the room if rooms are available or beside the bed within their confined
space. A small portable MV can be used as well during patient transport. Private
ICUs have automated handheld ear thermometers and can be used with disposable
ear probes. Since the pandemic, most hospitals acquired gun thermometers for their
use.
82 Martinez et al

Individual ICU beds are equipped with at least a bedside monitor for continuous vital
signs, heart rhythm, and oxygen saturation tracking. Each monitor is connected to a
central monitor that is visible in the nurse’s station and most often monitored by the
head nurse or a trained telemetry nurse if there is one in the institution,6 whereas in
other ICUs, the monitors are individualized per patient and there is no central moni-
toring system.6 These monitors can be switched to a portable device when necessi-
tating transport from one unit to another.
In light of the pandemic, a Filipino innovation for patient monitoring, called
RxBox biomedical monitoring devices, was used in some government facilities hand-
ing patients with COVID-19. This portable device can provide monitoring comparable
to other branded monitoring devices.26
Brain monitoring devices, such as ICP monitors and cEEGs, are now accessible in
some ICUs, mostly from private institutions. ICP monitoring can be done invasively
and noninvasively via a multidisciplinary facet. Invasive ICP monitoring with the appli-
cation of monitoring devices can be applied if the device is available and warranted.
Such devices can show numbers and ICP waves to monitor trends in pressures. Crit-
ical care nurses are part of the team that monitors these ICP readings, but nurses
seem to be more reliant on the numerical values of the reading than the meaning of
the waves and its trends, as some are not trained for this competency.
Several private institutions and a few government facilities are equipped with
computerized medication management systems that are a part of their hospital infor-
mation system (HIS). Most HISs also have integrated picture archiving and communi-
cations systems (PACS) in which members of the multidisciplinary team can view
images of the diagnostic procedures, such as radiographs and scans. Some PACS
vendors allow mobile access that is convenient for physicians to view their diagnostic
images even if they are outside the hospital through a secured network.

Interprofessional Communication and Collaboration

The critical care team in most ICUs in the Philippines are primarily composed of phy-
sicians (intensivists, critical care specialists, residents) and nurses (bedside, charge,
and head nurses). There is no advanced practice nurse in the Philippines, but all
nurses working in the ICU are trained in basic critical care by either their respective
institution or through other noninstitutional trainings. Other ICUs have respiratory ther-
apists and clinical pharmacists as part of their team. Other health care professionals,
such as rehabilitation therapists, dieticians, and medical technologists are called
depending on the patient’s needs and concerns. Social workers and chaplains are
available for the whole hospital and are called depending on the request of the pa-
tient’s family and the attending physicians. Social workers are often called to assist
in locating additional funding for the patient, whereas chaplains are, most often than
not, lay ministers from a Christian denomination either hired by the institution or
serving on a voluntary basis. Although there are a significant number of non-
Christian patients admitted in the ICU, provisions for referral for pastoral care from
their religious denomination are lacking. With these, if the family wished for a non-
Christian pastoral service, referrals need to be facilitated by them from outside the
hospital. Individual ICUs have different guidelines on allowing persons not connected
with the institution to perform chaplaincy within their unit; some allow it, whereas
others prohibit it, citing safety, privacy, and infection control issues.
Given the complexity of care present in these units, interprofessional collaboration
between various health care professionals is essential and has been found to signif-
icantly decrease mortality and morbidity rate among patients admitted in the ICU.27
Critical care nurses in the Philippines play an instrumental role in maintaining the
 Critical Care Nursing in the Philippines 83

openness and collaborative atmosphere between and among various health care
professionals caring for the patient. They provide significant input to other health
care professionals managing the patient; their collective information provides a
more holistic understanding of the patient’s condition that is not viewed solely
through each professional’s disciplinary perspective. As nurses provide the longest
bedside interaction and presence with the patient, they manage the schedules of
other health care professionals so conflicts of schedules are prevented and all ac-
tivities are bundled to provide more rest period for the patient. All referrals to other
health care professionals will pass through the nurses and notification for referrals
will be sent by them. Despite these vital roles that critical care nurses play within
the ICU, their active participation during medical/interprofessional rounds or patient
case analysis is still lacking. Most often, during these instances, the voices of the
critical care nurses will be heard only when a question, commonly about a patient’s
vital signs, is directly asked of them.28 Critical care nurses’ communication with
other health care providers outside the ICU team is limited to referral and endorse-
ment with the patient’s scheduled activities. In this sense, interprofessional commu-
nication seems to be present but active collaboration by the nurses needs further
improvement.

Family involvement, end-of life choices, and palliative care

Most of the ICUs in the Philippines do not allow family members to stay with their pa-
tient but instead have a fixed visiting hour where they can check on their relatives. In
most instances, family members stay in another private room, if they can afford it, or a
room dedicated for all family members of all patients admitted in the ICU, or a spot in
and/or around the hospital premises where announcements can be heard where they
could be called in to provide decisions or personal provisions that the hospital cannot
provide for. The first is common in private hospitals, whereas the last are almost exclu-
sively found in government health institutions. This system seems to add to the overall
burden and anxiety felt by the families of patients admitted in the ICU.29,30
During visitation hours, the critical care nurse assigned to the patient is often the
health professional who gives updates to the patient’s family. Most of the information
conveyed within this interaction involves the patient’s status, vital signs, and proced-
ure done within the shift. Information deemed as “serious” by the nurse is not divulged
to the family member but is referred to the available physician handling the patient so
the information will be coming directly from the physician. This information may
include the prognosis of the patient given the current situation, the current overall sta-
tus of the patient, the professional advice for end-of-life decisions, and possibility of
organ donation.28–30
The practice of organ donation varies among individual critical care units. Although
there are laws and promulgations that facilitate its process, dilemmas usually occur
when the living relative of the patient does not consent for harvesting of the organ
to proceed.31,32 In the absence of a last will or an advanced directive from the patient,
the family would rather have the patient “intact and complete” than go through the
process of organ donation.
Although there exists a presidential promulgation for the integration of palliative and
hospital care in the Philippines, palliative care provisions are not functionally inte-
grated in most local ICUs.33 Most hospitals do not have a separate specialized
team that specifically provides palliative care, and palliative care, as practiced in the
ICU, is focused mostly on pain control and management. Provisions and referral for
palliative care are not routinely coordinated or deliberately offered with the patient’s
family in the early stage of management, but they are usually informed by the time it
84 Martinez et al

involves end-of-life decisions.29,30 For this reason, the Philippines is categorized as

belonging to group 3a, those that have isolated provisions of palliative care.34 This
is one of the factors contributing to why the Philippines was considered as one of
the worst countries to die in, ranking 78th of 80 countries in the 2015 Quality of Death
study index.35 This, along with insufficiency of public information, lack of training
among health professionals, low interest in the field of palliative care, unwillingness
of doctors to refer patients, absence of legal basis supporting palliative care, and scar-
city of government stream for hospice funding, contribute to the current situation of
palliative care in the Philippines, and is very much reflected in various local ICU units.36
Because of this prevailing system, end-of-life decisions within the critical care units
are more heavily influenced by the physician’s medical opinion rather than the result of
the active participation of the patient’s family members. This is compounded by the
reality that most Filipinos do not have a living will or advance directive, owing to the
prevailing belief that death is a taboo topic, thus the possibility of death is not openly
discussed with their families.37 End-of-life decisions are rarely discussed until such
time when withdrawal of treatment is beginning to be considered.
The option for withdrawal of treatment is mostly decided by the patient’s medical
prognosis and the family’s prevailing belief on the morality of withdrawing treatment.
In the Philippines, where euthanasia is not legal and Christianity is a dominant religion,
simple acts or measures, such as turning off the ventilator and giving opioids, could be
perceived as tantamount to killing the patient. A common dilemma among family
members who decided to withdraw treatment is who will turn off the patient’s mechan-
ical ventilator. These, among other misconceptions, serve as barriers in deciding to
limit life-sustaining therapy in a dying patient.29,30,38 Ultimately, the financial difficulties
and burden brought about by high hospital bills will inevitably play a more significant
role in deciding when to withdraw the treatment.

IMPLICATIONS AND FUTURE DIRECTIONS

A holistic approach is needed to continually uplift critical care nursing practice in the
Philippines. Laws need to be created to promulgate the advancement of its practice
and affect systemic change in the country’s health care system that directly affects
the processes inherent in various critical care units. Appropriate funding, prioritization
for health, and directives on a national level are greatly needed. Albeit the practice of
critical care nursing in the Philippines follows the international and regional standards,
and the current lack of national competencies for critical care nurses may be one of
the reasons for its delayed professional growth. Luckily, this lacking national standard
is now being created through the collaborative efforts of critical care nurses, nursing
leaders, and government instrumentalities.
Although critical care nurses in the Philippines are skilled in the technicalities of
technologies in the ICU, and are competent in caring for the patient, there is a need
to focus and improve their competencies on pain management, delirium recognition,
interprofessional collaboration, and end-of-life decisions. Critical care nurses’ training
also should include communication skills, conflict resolution, and palliative care for
them to become better empowered to fully fulfill their roles as a collaborative clinician
and an active patient advocate.

DISCLOSURE

The authors have nothing to disclose.

 Critical Care Nursing in the Philippines 85

REFERENCES

1. Porciuncula C, Blanco-Limpin ME, San Juan BG, et al, editors. Philippine Heart
Center 30 years of heart care and compassion coffee table book. Quezon City:
Philippine Heart Center; 2005.
2. Critical Care Nurses Association of the Philippines. Critical care nursing guide-
lines, standards and competencies. 2014. Available at: http://www.ccnapi.org/
news-and-events/critical-care-nursing-guidelines-standards-and-competencies/.
Accessed October 18, 2020.
3. Paguio JT, Banayat AC. Commentary on challenges to critical care nursing prac-
tice in the Philippines. sgrwfccn 2018;12(1):8–11.
4. Dayrit MM, Lagrada LP, Picazo OF, et al. The Philippines health system review.
World Health Organization. India: Regional Office for South-East Asia; 2018.
Available at: https://apps.who.int/iris/bitstream/handle/10665/274579/
9789290226734-eng.pdf?sequence51&isAllowed5y.
5. Picazo OF. Public hospital governance in the Philippines. In: Hort K, editors. Pub-
lic Hospital Governance in Asia and the Pacific. Comparative Country Studies.
World Health Organization; 2015:186-221. Available at: https://books.google.
com.ph/books?id=WRiYjgEACAAJ.
6. Phua J, Faruq MO, Kulkarni AP, et al. Critical care bed capacity in Asian Coun-
tries and regions. Crit Care Med 2020;48(5):654–62.
7. UP COVID-19 Pandemic Response. Estimating local healthcare capacity to deal
with COVID-19 case surge: analysis and recommendations. University of the
Philippines Website; 2020. Available at: https://www.up.edu.ph/estimating-local-
healthcare-capacity-to-deal-with-covid-19-case-surge-analysis-and-
recommendations/. Accessed October 20, 2020.
8. Marshall JC, Bosco L, Adhikari NK, et al. What is an intensive care unit? A report
of the task force of the World Federation of Societies of Intensive and Critical Care
Medicine. J Crit Care 2017;37:270–6.
9. DOH-Philippines. Revised organizational structure and staffing standards for
government hospitals. 2013. Available at: https://www.dbm.gov.ph/wp-content/
uploads/Issuances/2013/Joint Circular 2013/DOH/Manual RSSGH_ 3 levels.pdf.
Accessed October 1, 2020.
10. Samuelsson C, Thach Q. Nurses experiences on work-related health in the
Philippines. 2018;(June):1-22. Available at: http://www.diva-portal.org/smash/
get/diva2:1210360/FULLTEXT01.pdf. Accessed September 27, 2020.
11. Javier FO, Calimag MP. Opioid use in the Philippines - 20 years after the introduc-
tion of the WHO analgesic ladder. Eur J Pain Suppl 2007;1(1):19–22.
12. Galanti GA. Filipino attitudes toward pain medication. A lesson in cross-cultural
care. West J Med 2000;173(4):278–9.
13. Cavallazzi R, Saad M, Marik PE. Delirium in the ICU: an overview. Ann Intensive
Care 2012;2(1):1–11.
14. Gulay C, Saranza G, Tuble G, et al. Neurocognitive outcome of patients with
delirium in the intensive care units at a tertiary government hospital. Philipp J
Chest Dis 2017;18(2):14–21.
15. Ofquila RM, Ybanez A, Llamedo M, et al. Health-related quality of life and cogni-
tive functioning of intensive care unit (ICU) survivors with delirium and non-
delirium states from a Philippine Provincial Hospital. Int J Health Sci Res 2016;
6(6):301–6. Available at: https://www.ijhsr.org/IJHSR_Vol.6_Issue.6_June2016/
49.pdf.
86 Martinez et al

16. Tuble GC, Saranza GM, Albay AB, et al. Prevalence of delirium in patients
admitted at intensive care units of Philippine General Hospital. Philipp J Chest
Dis 2015;16(3):27–33.
17. Tanuatmadja AP, Vea JR. Prevalence of delirium and its clinical outcome in adult
Filipino patients admitted in the intensive care unit. J Med Health 2019;2(4):
920–9.
18. Miranda-Ackerman RC, Lira-Trujillo M, Gollaz-Cervantez AC, et al. Associations
between stressors and difficulty sleeping in critically ill patients admitted to the
intensive care unit: a cohort study. BMC Health Serv Res 2020;20(1). https://
doi.org/10.1186/s12913-020-05497-8.
19. Leochico CFD, Espiritu AI, Ignacio SD, et al. Challenges to the emergence of tele-
rehabilitation in a developing country: a systematic review. Front Neurol 2020;11.
https://doi.org/10.3389/fneur.2020.01007.
20. Carl CF. Adoption of telerehabilitation in a developing country before and during
the COVID-19 pandemic. Ann Phys Rehabil Med 2020;11. https://doi.org/10.
1016/j.rehab.2020.06.001.
21. Hirzallah FM, Alkaissi A, do Céu Barbieri-Figueiredo M. A systematic review of
nurse-led weaning protocol for mechanically ventilated adult patients. Nurs Crit
Care 2019;24(2):89–96.
22. Maramba J. Conference report first national meeting on quality assurance in
healthcare in the Philippines. Int J Qual Health Care 1997;9(5):381–2.
23. Asinas-Tan M, Leonardo J, Aldana E, et al. Implementation of quality improve-
ment strategies for better patient care. Int J Integr Care 2016;16(6):20.
24. Health Systems Development and Management Support Division, Health Facility
Development Bureau. Stakeholder’s consultation: expanding access to brain
specialty care. 2019. Available at: http://caro.doh.gov.ph/wp-content/uploads/
2019/11/Brain-Centers-lecture-materials.pdf. Accessed September 26, 2020.
25. HealthSolutions installs first-ever BARD Arctic Sun at QMMC. The Manila Times.
Available at: https://www.manilatimes.net/2019/03/20/public-square/
healthsolutions-installs-first-ever-bard-arctic-sun-at-qmmc/528088/. 2019.
26. Sambatyon E. UP and DOST-developed RxBox vital signs monitor for COVID-19
patients now in use at Philippine General Hospital. Good News Pilipinas. Avail-
able at: https://www.goodnewspilipinas.com/up-and-dost-developed-rxbox-
vital-signs-monitor-for-covid-19-patients-now-in-use-at-philippine-general-
hospital/. 2020. Accessed September 27, 2020.
27. Curtis JR, Cook DJ, Wall RJ, et al. Intensive care unit quality improvement: a
“how-to” guide for the interdisciplinary team. Crit Care Med 2006;34(1):211–8.
28. Martinez RCKP. “Of technical competence, perceived autonomy and relational
expertise”: Understanding professional identity among nurses working in a stroke
unit. 2019. https://doi.org/10.31235/osf.io/dh65f.
29. Berdeguel RE, Martinez RCKP. “Hope Within Hopelessness”: The lives of families
whose member is on {DNR} (Do Not Resuscitate) Status. 2019. https://doi.org/10.
31235/osf.io/geusd.
30. Sumaguingsing R, Martinez RCKP. “Swinging Pendulum”: Lives of Family Mem-
bers Caring for A Dying Relative. 2019. https://doi.org/10.31235/osf.io/tqzp6.
31. Organ donation act of 1991. Congress of the Philippines. 1992. Available at:
https://www.officialgazette.gov.ph/1992/01/07/republic-act-no-7170/. Accessed
October 1, 2020.
32. Department of Health. National policy on palliative and hospice care in the
Philippines. Philippines. 2015. Available at: https://www.doh.gov.ph/sites/
default/files/health_programs/AO2015-0052. Accessed September 26, 2020.
 Critical Care Nursing in the Philippines 87

33. World Health Organization. Global atlas of palliative care at the end of life. World-
wide Palliative Care Alliance 2014. Available at: https://www.who.int/nmh/Global_
Atlas_of_Palliative_Care.pdf. Accessed September 26, 2020.
34. Worldwide Palliative Care Alliance, World Health Organization. Global atlas of
palliative care at the end of life. Worldwide Palliative Care Alliance; 2014. Avail-
able at: https://www.who.int/nmh/Global_Atlas_of_Palliative_Care.pdf.
35. The 2015 quality of death index. 2015. Available at: https://eiuperspectives.
economist.com/sites/default/files/images/2015 Quality of Death Index Country
Profiles_Oct 6 FINAL.pdf. Accessed October 2, 2020.
36. Department of Health. Palliative and hospice report Philippines. 2008. Available
at: https://www.doh.gov.ph/sites/default/files/health_programs/Palliative and
Hospice Report Philippines.pdf. Accessed October 2, 2020.
37. Soriano GP, Calong KAC. Religiosity, spirituality, and death anxiety among Fili-
pino older adults: a correlational study. J Death Dying 2020. https://doi.org/10.
1177/0030222820947315. 003022282094731.
38. Manalo MFC. End-of-life decisions about withholding or withdrawing therapy:
medical, ethical, and religio-cultural considerations. Palliat Care Res Treat
2013;7:1–5. PCRT.S10796.