ASPEK ETIK DAN HUKUM

KEGAWATDARURATAN
DIVISI BIOTIKA, MEDIKOLEGAL DAN
HUMANIORA
FK USU
RESPECT FOR PERSON
Ethical Decisions are Ultimately Concerned with Life
and Death
Definition of Life and Death in Bioethics Determine
the Financial Burden of Health Care
- Science and Technology
- Culture
- Ethnic
- Local Belief
- Religion
Influence the Concept of Death
BRAIN DEATH OR BRAIN STEM
DEATH

CONSCIOUSNE
SS
Cerebrum
The quality of
consciousness
Brain Stem
off on
consciousness
Qualitative Quantitative
GRADE / SCALES OF CONSCIOUSNESS
(Glasgow)
(E, V, M Response)
Alert 4 5 6 (15)
Somnolent (13 14)
Soporous (9 12)
Comatous (3 8)
COMA
Unarousable unresponsiveness
May be caused by systemic causes
metabolic drugs, or cns damage
Reversible or irreversible
May ensue to BD/BSD/PVS

Coma
BD/BSD
UK BRAIN DEATH CRITERIA
Three preconditons
Patient on a ventilator

Coma due to irremedial structural brain damage

No - Depressant or neuromuscular blocking drugs

- Primary hypothermia
- Metabolic or endocrine abnormalities

Five tests
No pupillary response to light
No tracheal, gag or cough reflex
No response to facial and peripheral pain
No cold caloric responses
No respiratory effort after achieving a PaCO2 of 50
mmHg for 10 min or more
Avoid premature diagnosis of BD / BSD
REAL CASE OF BD
Marlon Ploch, F, 18yr pregnant of 14 weeks
Got car crash, severe brain damage, presented in ER,
already intubaled, respirated
3 days later stated as BD

Q:
Should the fetus be aborted
Let the life support be maintained until the fetus viable?
Could a dead body deliver a healthy baby?

40 days after / 19 week pregnancy spont. aborted

BEGINNING AND END
OF LIFE Beginning
Viewpoint End
Philosophical Ensoulment Separation of
soulbody
Physiological Conception Irreversible
(Classic) function stop of
respiration /
cardiac
Physiological Conception BD / BSD
(Modern) Some time after
Conception
VEGETATIVE STATE
Three clinical criteria all be fulfilled
1. No evidence of awareness of self or
environment. No volitional response to
visual, auditory, tactile or noxious stimuli.
No evidence of language comprehension or
expression
2. Cycles of eye closure and opening
simulating sleep and waking
3. Sufficiently preserved hypothalamic and
brain stem function to maintain respiration
and circulation
 VEGETATIVE STATE
Other clinical features
1. Incontinence of bladder and bowel. Spontaneous
blinking and usually retained pupillary and corneal
responses. Conjugate or dyconjugate tonic response
to ice-water caloric testings
2. No nystagmus to caloric testing. No visual fixation,
tracking of moving objects whit eyes or response to
menace
3. May be occasional movements of head and eyes
towards sound or movement, and of trunk and limbs
in purposeless way. May have startle myoclonus.
May smile; may grimace to pain. May have roving
eye movements

(Royall College of Physicians Working Group, 1996)

 VEGETATIVE STATE
One year outcomes of patients in VS after head
injury
Duration of VS n Dead Vegetati Consciou Independe
(%) ve s nt
(%) (%) (%)
1 month 140 51 11 36 10
3 months 49 49 31 20 0
6 months 30 52 16 0
B. Jennet, 2002
 VEGETATIVE STATE
AGE
Independence at 1 year from patients in VS 1
month after head injury

Age n % Independent
< 20 years 53 21
20 39 years 46 9
> 40 years 41 0
B. Jennet, 2002
ETHICAL PROBLEMS ON PVS
How long should VS be stated as
PERSISTENT
How long could a patient in VS live
Could we limit/withdraw the treatment
once a VS is declared permanent
6 months ? 12 months ?
IDI =
if the treatment is no more useful,
contrary to the goal of medicine. it may
be discontinued.
(questionable, debatable, Darmadipura 2008)
INDONESIAN MEDICAL
ASSOCIATION STATEMENT &
RECOMMENDATION
(IDI 231/PB/A.4/07/90)
Death is a process. Not all cells of the body are of the same
vulnerable to hypoxia / anoxia
Definition of death
Spontaneous arrest of resp. & cardiac
functions that is ananimous and
irreversible
Brain dead
(consistent to Gvt. Decree 18/1981)
 Indonesian Medical Association
Statement & Recommendation
(IDI 231/PB/A.4/07/90)
For the sake of organ transplantation the
definition of BD is used. All medical treatments
are maintained, to perfuse and maintain the
functions
Recommendation : in a certain condition in which
therapeutic / palliative treatment is not useful
anymore, that its maintaining is contrary to the
goal of medicine, it may be discontinued. The
cessation of it is recommended be consulted to at
leas one other doctor
INDONESIAN LEGISLATION
THE GREAT BOOK OF
CRIMINAL
CAUSING DEATHLAW (KUHP)
Either : - Intentional
- Unintentional (by mistake, error, or
negligence)
- Upon Request
- Provoke other to Suicide
- Help other to Suicide
are prohibited
(Art. No. 338, 340, 344, 345)
He is Who gives life and causes death and
to Him you (all) shall return
(Yunus, 10:56)

Only Allah has the right to take ones life

ASKING TO DIE IS PROHIBITED

Asking to die (ISLAM)

Committing suicide (ISLAM, LAW/KUHP)
Praying for dying (ISLAM)
Helping someone to die (KUHP)
Helping someone to commit suicide (KUHP)
SUMMARY
The beginning and the end of life is most closely
related to the principle of respect for person
1. Brain Death (BD), or more accurately Brain
Stem Death is largely accepted as one of the
definitions of death. But still ethically and
philosophically problematic
2. Persistent Vegetative State (PVS) is
debatable on the discontinuation of
therapeutic efforts
3. Any murder (causing death) either
intentional, unintentional, helping other to
die or suicide is criminal
 REFERENSI TTG PENENTUAN MATI &
WITH-DRAWING/WITH-HOLDING

Lokakarya IDI-PKGDI 1985 tentang

mati
Lokakarya IDI-PKGDI 1986 tentang
eutanasia pasif
Badan Legislasi Medis IDI 1986
tentang mati, eutanasia pasif dsb
Muktamar IDI 1987 pensyahan
keputusan Badan Legislasi Medis
IDI
Fatwa IDI 1988, 1990 ttg mati &
REFERENSI TTG
PENENTUAN MATI & WITH-
DRAWING/WITH-HOLDING
PP no 18 thn 1981 ttg bedah mayat
klinis & bedah mayat anatomis serta
transplantasi alat dan atau jaringan
tubuh manusia
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
Sedang dalam proses untuk dijadikan
SK PERMENKES RI
SK Direktur RSCM Maret 2006 ttg
penentuan mati dan with-
drawing/with-holding life supports
 Lebih baik

Mati dng cepat

Ps dng (mati klasik)
harapan akan ICU
Kondisi tdk tertolong
sembuh lagi, menunggu ajal

MO/MBO
KAPAN MENGAKHIRI
RESUSITASI JANGKA
PANJANG?
Mati batang otak
Stadium terminal penyakit
yang sudah tidak dapat
disembuhkan lagi
misalnya mati sosial
PEDOMAN ETIK SP
ANESTESIOLOGI & REANIMASI
INDONESIA
Pasal 3
setiap SpAn tidak akan mengupayakan
pengakhiran kehidupan manusia ataupun
memperpanjang proses kematian pada
pasien-pasien yang akan meninggal alamiah
 KONDISI PS TELAH
MENJADI 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
~ PEDOMAN ETIK SpAn
 STATUS VEGETATIF
(SINDROMA APALIKA, MATI
SOSIAL)
Kerusakan otak berat ireversibel pd ps
yg tetap tdk sadar & tdk responsif
Harus dibedakan dari mati serebral &

dari MBO/MO
Belum mati !!! mungkin ada daur :

sadar-tidur
EEG masih aktif, bbrp refleks masih

utuh
Mungkin dpt dilakukan with-drawing/

with-holding life supports

FATWA IDI NO
231/PB/.4/07/90
Pd ps belum mati, namun tindakan
terapeutik /paliatif tdk ada gunanya lagi,
shg bertentangan dng tujuan ilmu
kedokteran, maka tindakan2 tsb dpt
dihentikan !!!
Penghentian tsb sebaiknya dikonsultasikan

dng minimal 1 dokter lain (Lokakarya

DepKes RI 2005/SK Dir RSCM 2006: 2 dokter
lain)
FATWA IDI NO
231/PB/.4/07/90
Keputusan utk menghentikan life supports

merupakan keputusan medis

Dibuat oleh dr yg berpengalaman yg
memahami kasus secara keseluruhan
Sebaiknya sesudah konsultasi dng DSp yg
berpengalaman (Sp An, intensivis & SpS)
Dipertimbangkan keinginan ps & sikap
keluarga & kualitas hidup terbaik yg
diharapkan , tetapi keluarga tdk diminta
membuat keputusan membiarkan mati
FATWA IDI NO
231/PB/.4/07/90
Bila diputuskan ps diberi kesempatan utk
mati secara wajar dgn mematikan ventilator :
Sesudah mesin dimatikan, dicoba utk
mengembalikan nafas spontan.
Bl gagal th/ ventilator tdk lagi diberikan & ps
dibiarkan mati
Bl secara tdk terduga ps dpt bernafas lagi
upaya menyelamatkan ps dilanjutkan kembali
TINDAKAN LUAR BIASA UTK
LIFE SUPPORTS
( 1. LOKAKARYA DEPKES RI, IDSAI, PKGDI, PERDICI , ORGANISASI PROFESI KLINIS
LAINNYA DALAM NAUNGAN IDI 2005, 2. SK DIREKTUR RSCM MARET 2006 TTG
PENENTUAN MATI DAN WITH-DRAWING/WITH-HOLDING LIFE SUPPORTS )

Rawat di ICU
RJP
Pengendalian disritmia
Intubasi trakeal
Ventilasi mekanis
Vasoaktif kuat
Nutrisi parenteral total
TINDAKAN LUAR BIASA UTK LIFE SUPPORTS
( 1. LOKAKARYA DEPKES RI, IDSAI, PKGDI, PERDICI , ORGANISASI PROFESI KLINIS
LAINNYA DALAM NAUNGAN IDI 2005, 2. SK DIREKTUR RSCM MARET 2006 TTG
PENENTUAN MATI DAN WITH-DRAWING/WITH-HOLDING LIFE SUPPORTS )

Organ artifisial
Transplantasi

Transfusi darah

Monitor invasif

Antibiotika

Pipa enteral (untuk makan)

Infus cairan dasar (NS, D5W, D5R dsb)

 Eutanasia : tindakan aktif dan
langsung utk mengakhiri kehidupan;
di kebanyakan negara tidak dapat
diterima kecuali di Holland, Belgia,
Luxembourgh, 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
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
WITH-DRAWING VS WITH-HOLDING

Etis& teoritis sama

Banyak bukti menyokong

asumsi bahwa kedua hal tsb

tdk sama
With-draw: aktif, with-hold:

pasif
With-draw: kematian hampir

pasti dan segera

 WHY WITH-DRAWING?
Jika tdk: ICU penuh dgn ps tanpa harapan dgn
th/ mahal melawan 4 prinsip dasar etis
Jika tdk: timbul keraguan dlm bertindak
ketika waktu menjadi penting
Ps dgn gagal nafas akut: ragu utk intubasi &
ventilasi mekanis krn tdk yakin ttg riwayat ps
& ingin pasti tdk memulai th/ yg mungkin sia-
sia, tapi yg kemudian tdk dpt with-drawing
Jika tdk: Melanggar kode etik SpAn & Fatwa
IDI
ETHICS IN CCM IS BASED
ON
Beneficence: obligation to do
good for pt
Non-maleficence: have to avoid
harm
Autonomy: respect for pts self-
determination
Justice: fair for allocation of
health care resources
 JIKA TDK ADA OPSI
WITHDRAWING
MELANGGAR ETIKA DASAR
Beneficence: apa manfaat meneruskan th/?
CCM
Non-maleficence: meski dgn analgo-sedasi
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
sayuran yg menjadi beban kel?
Justice: meneruskan th/ yg tdk efektif berarti
memblok bed ICU shg ps lain tdk bisa masuk;
beaya lebih utk kepentingan lain
PROBLEMA DI LAPANGAN
Seorang pasien di ICU sudah dalam
keadaan terminal, tidak ada harapan
pulih/sembuh, yang merupakan
kandidat untuk dilakukan
penghentian/penundaan bantuan
hidup. Namun, keluarga pasien
minta untuk terus dipasang
ventilator dan terapi bantuan hidup
lainnya. Jadi di sini dokter
memperpanjang proses kematian
yang bertentangan dengan tujuan
ilmu kedokteran yaitu
memperpanjang kehidupan.
 PROBLEMA DI

LAPANGAN
Dengan demikian dokter yang merawat melanggar fatwa IDI
tentang penghentian/penundaan bantuan hidup, melanggar
kode etik dokter spesialis anestesiologi Indonesia,
melakukan hal yang sia-sia (medical futility), tidak etis karena
mendapat honor untuk memperpanjang proses kematian.
Selain itu, setelah akhirnya pasien meninggal, terjadilah
tambahan biaya perawatan di ICU yang cukup besar. Pada
kenyataannya bila pasien meninggal, kebanyakan sulit
pembayarannya, yang ujung-ujungnya tidak mau/mampu
membayar penuh seluruh beaya pengobatan/perawatan RS.
Ini tentu saja merugikan rumah sakit
DOKTER TIDAK DIHARUSKAN
UNTUK MEMBERI ASUHAN
(CARE) YANG DIANGGAP SIA-
SIA SECARA FISIOLOGIS
MESKIPUN PASIEN ATAU
KELUARGA PASIEN MEMINTA
DENGAN SANGAT
MEMATIKAN
VENTILATOR
SAATselalu
Tdk PS MASIH HIDUP
salah secara moral
Jika kondisi ps tdk ada
harapan lagi maka
pemakaian ventilator akan
sia-sia
Keputusan yg berat, dibuat

setelah cukup konsultasi !

HUBUNGAN YG JELAS:
VENTILATOR DIMATIKAN PS MATI

Memberi kesan sengaja membunuh

Yg dituju bukan mengakhiri nyawa ttp
menghentikan prosedur sulit yg sia-sia
Play God ?!? Bukan!

Krn sadar tdk kuasa melawan hkm Tuhan,

maka kita serahkan ps pd Tuhan yg dlm hal
ini memenangkan penyakit !
WITH-DRAWING/WITH-
HOLDING ADALAH KEPUTUSAN
MEDIS & ETIS (LOKAKARYA DEPKES RI 2005, SK
Oleh2006
DIR RSCM sebuah
): tim yg terdiri dari 3 (tiga)
orang dokter yg kompeten
Sebelum keputusan penghentian /
penundaan bantuan hidup dilaksanakan
, tim dokter wajib menjelaskan kepada
keluarga ps tentang keadaan ps &
keputusan tim dokter
Dalam hal tidak dijumpai adanya kel ps,
maka harus diperoleh persetujuan dari
pimpinan Rumah Sakit atau Komite
Medis Rumah Sakit
PS & KEL DAPAT MINTA DOKTER
UTK
WITH-DRAWING LIFE SUPPORTS
Ps masih mampu membuat keputusan
(kompeten) & menyatakan keinginannya
itu sendiri
Ps tidak kompeten tetapi telah
mewasiatkan pesannya tentang hal ini
(advanced directive) yg dapat
berupa:
Pesan spesifik yg menyatakan agar dilakukan
with-drawing/with-holding apabila mencapai
keadaan futility (kesia-siaan)
Pesan yg menyatakan agar keputusan
didelegasikan kepada seseorang tertentu
(surrogate decision maker)
PS & KEL DAPAT MINTA DOKTER UTK
WITH-DRAWING LIFE SUPPORTS

Ps yg tidak kompeten & belum

berwasiat, namun kel yakin
bahwa seandainya ps kompeten
akan memutuskan seperti itu,
berdasarkan
kepercayaannya & nilai-nilai yg
selama ini dianutnya
Permintaan tersebut harus

dipenuhi
Kel ps dapat meminta dokter utk
melakukan penghentian
penggunaan peralatan life supports
karena sebab apapun (khusus
untuk ps yg belum memenuhi
syarat utk penghentian bantuan
hidup). Permintaan harus di atas
formulir bermaterai, & dicantumkan
dalam catatan medis & dijelaskan
risiko akibat penghentian life-
supports. Setelah kel mengerti
sepenuhnya maka baru permintaan
dapat dipenuhi.
MEDICAL PROGRESS IN
SUPPORT THX
enable organ fnc to be maintained while a pt
recovers from serious illness is indeed
remarkable should be used for those in whom
it is appropriate

should not be abused to maintain life that is w/o

quality or meaning indefinitely against all 4 of
the basic ethical laws
 ESSENTIALS
WHEN WITH-
DRAWING THX :
good communication and explicit
decision
end of life decisions should be
made in advance if possible
difficult issues
 CONCLUSION
end of life decision making is an
important and widely accepted
with-drawal of thx should be
permitted and may even be
preferable to withholding thx
if our treatment does not benefit
the pt (futile thx) we are duty
bound to stop it w/o undue delay
CONCLUSION
continuing MV or extracorporeal renal support in a
pt who has no real chances of recovering a
meaningful life is of no use and should be stopped,
exactly as it should not be started if there is no
chance that it will be benefit the pt
we as doctors are privileged to be able to assist our
pts in their final journey through the dying process
CONCLUSION
we have a duty to ensure that
our pts die with dignity
though we may stop active
treatment, we must never stop
pt care
with-drawal of thx does not
mean with-drawal of care
53