WITH DRAWING, WITH HOLDING

WHEN & WHY

Anang Achmadi
Department of Anesthesiology & Intensive Care
Santosa Hospital Bandung Central
What % of US deaths are preceded by withholding
or withdrawing life-sustaining treatment?

1.  Less than 20%

2.  Less than 40%
3.  About half
4.  60 to 80%
5.  More than 80%
Intensive Care Med 2012;38:1886-96. Two hospitals one high, one low treatment,
173 patients over 65, interviews of 4 attendings, staff and families
 Non
maleficence

Autonomy Justice

Beneficence Honesty

Dignity
 The Role Of The Intensivist

•  A Manager Of Resources
•  }
•  A ‘referee’ or ‘judge’ caught in the conflict
between the principles and the models of
medical ethics
 SCCM Guidelines
“…both philosophical and legal analyses have
emphasized that clinicians should make no
distinction between decisions to withhold or to
withdraw.”

“…whether any therapy is initiated or continued

should be based solely on an assessment of its
benefits vs. burdens and the preferences of the
patient.”

Truog R. Crit Care Med. 2008

 SCCM Guidelines
•  "... baik analisis filosofis dan hukum telah
menekankan bahwa dokter tidak boleh membuat
perbedaan antara keputusan untuk menahan
atau menarik.”

•  "... apakah terapi apa pun dimulai atau

dilanjutkan harus didasarkan hanya pada
penilaian manfaatnya vs beban dan preferensi
pasien."
Truog R. Crit Care Med. 2008
•  Kapan mulai, tidak memulai dan
mengakhiri resusitasi
•  Penundaan atau pengakhiran
bantuan hidup
•  Penentuan mati
 Dasar mengambil keputusan

•  norma-norma etis & kultural

•  Aturan hukum
•  Dokter harus berperan dlm keputusan
resusitasi serta end of life care à
keputusan medis
 Prinsip autonomi pasien

•  Diterima secara etis dan legal

•  advance directives, living wills, patient
self-determination
•  bila pilihan tdk pasti, kondisi darurat
diatasi saja sampai pilihan pasien menjadi
pasti
 Prinsip kesia-siaan medis
(futility)
•  Bila tujuan penanganan medis tdk dpt dicapai

•  Intervensi tdk dpt mempertahankan

kehidupan atau meningkatkan kualitas hidup
 Kondisi Pasien
tidak ada harapan lagi…
•  With-drawing : seringkali tepat utk menghentikan
sebagian/seluruh th/ yg sudah terlanjur diberikan

•  With-holding : tanpa menghentikan th/ yg sedang

diberikan, tdk lagi memberi th/ baru yg
dipertanyakan manfaatnya
Ingat
~ ICU MAHAL & TERBATAS
~ Medical Futility
•  Eutanasia : tindakan aktif dan langsung utk
mengakhiri kehidupan; di kebanyakan negara
tidak dapat diterima kecuali di Belanda, Belgia,
Luxembourg, masyarakat autonom Andalusia di
Spanyol, Swiss, Oregon dan Washington USA,
Thailand
•  With-drawing/with-holding : dapat diterima dan
dibenarkan bilamana penanganan medis
hanya memperpanjang proses kematian
 EUTANASIA DALAM KITAB HUKUM
UNDANG-UNDANG PIDANA
•  Pasal 344 KUHP secara tegas menyatakan : (Moeljatno,
2005 : 116) “Barang siapa merampas nyawa orang lain
atas permintaan orang itu sendiri yang jelas dinyatakan
dengan kesungguhan hati diancam dengan pidana
penjara paling lama dua belas tahun”

•  Pasal 304 KUHP dinyatakan:“Barang siapa dengan

sengaja menempatkan atau membiarkan seorang dalam
keadaan sengsara,padahal menurut hukum yang
berlaku baginya atau karena persetujuan dia wajib
memberi kehidupan,perawatan atau pemeliharaan
kepada orang itu,diancam dengan pidana penjara paling
lama dua tahun delapan bulan atau pidana denda paling
banyak empat ribu lima ratus rupiah”
 EUTANASIA DALAM KITAB HUKUM
UNDANG-UNDANG PIDANA
•  Pasal 340 KUHP dinyatakan :“ Barang siapa dengan
sengaja dan dengan rencana lebih dulu merampas
nyawa orang lain diancam, karena pembunuhan
berencana, dengan pidana mati atau pidana penjara
seumur hidup atau selama waktu tertentu paling
lama dua puluh tahun”

•  Pasal 356 (3) KUHP yang juga dinyatakan :

“Kejahatan yang dilakukan dengan memberikan
bahan yang berbahaya bagi nyawa dan kesehatan
untuk dimakan atau diminum”.
 Penghentian bantuan hidup...

•  Tdk berarti meninggalkan ps

•  Menghentikan th/ yg tdk efektif
•  Dapat disertai dng th/ yg lebih tepat :
membuat nyaman, meredakan nyeri, sedasi
dsb
 Definition
•  With-holding of treatment : patients for whom a
specific treatment limitation (eg, mechanical
ventilation or cardiovascular support) or “do not
resuscitate” orders were documented in the
medical record in the days before death;

•  With-drawing of treatment : patients in whom life-

sustaining treatments were discontinued, and
palliative care was initiated.

Brieva J, Cooray P, Rowley M. Withholding and withdrawal of life-sustaining therapies in

intensive care: an Australian experience, Crit Care Resusc 2009; 11: 266–268
 Referensi ttg penentuan mati &
with-drawing/with-holding

•  Lokakarya IDI-PKGDI 1985 tentang mati

•  Lokakarya IDI-PKGDI 1986 tentang eutanasia
pasif
•  Muktamar IDI 1987 pensyahan keputusan
Badan Legislasi Medis IDI tentang mati dan
eutanasia pasif
•  Fatwa IDI 1988, 1990 ttg mati & eutanasia pasif
 Referensi ttg penentuan mati &
with-drawing/with-holding

•  Lokakarya penerapan ttg mati & with-drawing / with-

holding (21 Mei 2005)
DEPKES RI bekerja sama dgn IDSAI, PKGDI, PERDICI
dan Perhimpunan Profesi Klinis di lingkungan IDI

•  UU Kesehatan no 36 th 2009 (ps 117)

•  Permenkes no 37 thn 2014 tentang Penentuan

Kematian dan Pemanfaatan Organ Donor
 Withdrawing vs withholding

•  Etis & teoritis sama

•  Withdraw: aktif
•  withhold: pasif
•  Withdraw: kematian hampir pasti dan
segera
 Why Withdrawing?

•  Keterbatasan Tempat tidur di ICU

•  Tidak memberi harapan dgn th/ mahal → melawan 4

prinsip dasar etis

•  Melanggar kode etik Intensive Care & Fatwa IDI

} Five scenarios where the withdrawal or
withholding of life sustaining medical treatments
may be considered : (The Royal College of
Paediatrics and Child Health)
1.  The “Brain Dead” Child
2.  The “Permanent Vegetative State”
3.  The “No Chance” Situation
4.  The “No purpose” Situation
5.  The “Unbearable” Situation
 Jika tdk ada opsi withdrawing →
melanggar etika dasar Critical Care

•  Beneficience: apa manfaat meneruskan th/?

•  Non-maleficience: meski dgn sedasi analgesi
optimal meneruskan th/ yg tdk efektif → distres &
tdk nyaman (pengisapan dsb)
•  Autonomy: siapa mau tetap diberi bantuan artifisial
bila tdk ada harapan lagi? Mau jadi seperti
tumbuhan yg menjadi beban kel ?
•  Justice: meneruskan th/ yg tdk efektif berarti
menghalangi ps lain tdk bisa masuk; biaya lebih utk
kepentingan lain
Dokter tidak diharuskan untuk memberi asuhan
(care) yang dianggap sia-sia secara fisiologis
(futility treatment)
meskipun
pasien atau keluarga pasien meminta
dengan sangat
 Withdrawing/ withholding adalah
keputusan medis & etis (Permenkes 37 tahun 2014)

•  Oleh sebuah tim dokter yg merawat

•  berkonsultasi dgn tim yg ditunjuk komite medik
( situasional )

•  Sebelum keputusan penghentian / penundaan

bantuan hidup dilaksanakan , tim dokter wajib
menjelaskan keputusan tim dan mendapat
persetujuan keluarga pasien.
 Essentials when
withdrawing & withholding thx :

•  Good communication and explicit decision

•  Patient/ relatives consent
•  End of life decisions should be made in
advance if possible
•  Difficult issues
 Quality Measures for
End-of-Life Care

•  Patient and Family-Centered Decision

Making
•  Continuity of Care
•  Symptom Management and Comfort
Care
•  Spiritual Support for Patients and
Family
Major Religions’ Views on WH & WD

“The bioethics committee of the Church of Greece has stated: “There is

always the possibility of an erroneous medical appraisal or of an
unforeseen outcome of the disease, or even a miracle” [27]. Therefore,
as a principle the withholding and withdrawing of therapy is not allowed.”

Hans-Henrik. Intens Care Med. 2008

 Clinician Death Anxiety & Terminal Care
1/3 of MDs are uncomfortable
discussing terminal care with patients
1/10 after discussing these issues with
family.
Arch Int Med 1990:150:653-58. See also CMAJ
2000;163:1255-9.
1990
1998
MDs with á death anxiety:
•  Treat more aggressively.
•  Less tolerant of clinical uncertainty.
•  Like elderly patients less.
•  Greater interest in specialties.
Psychol Rep 1998;83:123-8.
Doctors, nurses, SWs with higher fear of death less
likely to:
•  Disclose prognosis P. <004
•  Assist in selecting proxy decisionmaker P< .000
•  Collaborate with team on advance planning P<.003
Death Studies 2007;31:563-72. N= 135, one
institution.
2007
2011
A six day HCW course in how to face
and cope with death anxiety,
•  Decreased burnout.
•  Decreased death anxiety.
•  Improved job satisfaction, esp in
relationships with eol patients.
J Palll Care 20111;27:287-95.
 Family ICU Distress in ICUs 2010

57% mod to severe traumatic stress

80% borderline anxiety
70% borderline depression. PTSD: 10-19%. Depression: 14-24%
>80% mod to severe fatigue, sadness, fear Correlates of above
More severe symptoms: Knowing patient for shorter time
Younger age, female, and non-white relative. PTSD, P = .003 Depression, P = .04
Young patient was only variable associated with
symptom severity.
Discord between fam' DM prefs v their DM roles
Despite symptoms, most relatives coping at
and functioning at high levels during the ICU PTSD, P=.005 Depression, P= .05
experience.
Crit Care Med 2010;38:1078-85. Prospective,
cross-sectional study, 3 ICUs at 1 AHC. 74 Chest 2010;137:280-7. Prosp, multivar, 226
relatives 74 patients at high risk for dying after ICU
families
stay >72 hrs on vent.

2010
Family Satisfaction with EoL Conferences

•  Family spoke 30%, MDs 70%

•  % Family speaking time correlated with
–  Perceived quality of MD information,
–  MD listening,
–  MD understanding of issues,
–  Meeting needs, and
–  Conflict resolution.
•  Crit Care Med 2004;32:1284-88. Tapes of 51 meetings with 51 families,
214 relatives, 4 hospitals, 36 MDs. 111 potential meetings, 36 families
excluded because of MD pref. 46% of approached families consented
to taping. Mean meeting time 32 min SD=15 min.
•  See also Arch Int Med 2004;164:1999-2004.

So, LISTEN UP!

 Family meeting tips
•  Accommodate extended families.
•  Include family clergy in preference to hospital chaplains
(consider pre-contact with clergy).
•  Minimize staff in room.
•  Sit down.
•  Take time.
•  Private space.
•  Give a business card with your cell phone on it when the
situation is close to death.
 Take Home Message
•  Pengambilan keputusan akhir kehidupan Pasien adalah
penting dan dapat diterima oleh semua pihak

•  with–holding & with-drawing adalah pilihan

•  jika perawatan kita tidak menguntungkan pasien (sia-sia)

→ kewajiban kita untuk menghentikannya tanpa
penundaan yang tidak semestinya

•  Intensivist & Team memiliki kewajiban untuk memastikan

bahwa pasien mati dengan bermartabat
Hatur nuhun