Legal Aspects and Ethical

Problems in Emergency
Dr. Elizeus Hanindito dr. SpAn KIC KAP
Dept Anesthesiology & Reanimation
Faculty of Medicine Airlangga University – dr Soetomo General
Hospital
 Ethics
• Ethics deals with the “rightness” or
“wrongness” of human behavior
• Concerned with the motivation
behind the behavior
• Bioethics is the application of these
principles to life-and-death issues
Ethical Principles
• Autonomy
• Nonmaleficence
• Beneficence
• Justice
• Fidelity
• Confidentiality
• Veracity
• Accountability
 Autonomy
• The freedom to make decisions about oneself
• The right to self-determination
• Healthcare providers need to respect patient’s rights to make
choices about healthcare, even if the healthcare providers do not
agree with the patient’s decision.
 Nonmaleficence
• Requires that no harm be caused to an individual, either
unintentionally or deliberately
• This principle requires nurses to protect individuals who are unable to
protect themselves
 Beneficence
• This principle means “doing good” for others
• Nurses need to assist clients in meeting all their needs
• Biological
• Psychological
• Social
 Justice
• Every individual must be treated equally
• This requires nurses to be nonjudgmental
Case 1
• 25 yrs old man, motorcycle accident, multitrauma.
• No blood pressure, pulse or spontaneous respiration
• Paramedics transport the patient to ED while performing CPR
• The patient has had no vital signs for at least 10 minutes
• The patient could be resuscitated and kept alive
• How do you manage the patient in hospital ?

NO VITAL SIGNS AT THE SCENE  HAVE A LESS THAN 1% CHANCE OF BEING RESUSCITATED AND
LEAVING THE HOSPITAL
Diagnosis of Death

“permanent cessation of all vital

functions”

• cardiac and respiratory function

Apnea – breathing support –
tracheal intubation
Death – an event or a process ?
* 22nd World Medical Assembly 1968 - Sidney

CPR
Cellular death

Biological death
BRAIN DEATH – BRAIN STEM DEATH - PVS

BRAIN PERSISTENT
DEATH VEGETATIVE
STATE

BRAIN BRAIN STEM

DEATH DEATH
Pons Midbrain
Cranial Nerves IV, V, VI Cranial Nerve III
 conjugate eye movement  pupillary function
 corneal reflex  eye movement

Medulla
Cranial Nerves IX, X
 Pharyngeal (Gag) Reflex
 Tracheal (Cough) Reflex
Respiration & Cardiovascular
Reticular Activating System
 Receives multiple sensory
inputs
 Mediates wakefulness &
awareness
The Apnea Test
• Preconditions
• Normothermia.
• Systolic BP > 100 mm Hg.
• Euvolemia (positive fluid balance).
• Eucapnia (PaCO2 35-45 mmHg).
• No evidence for CO2 retention (COPD, severe obesity,
severe OSA).
The Apnea Test (cont.)

• Preoxygenate for 10 minutes to PaO2 >200 mm Hg.

• Reduce ventilation frequency to 10 bpm and PEEP to 5 cm
H2O.
• If pulse oximetry remains > 95%, check baseline ABG.
• Disconnect ventilator and preserve oxygenation with 100%
O2 @ 6-10 lpm via catheter through the ET at level of
carina.
The Apnea Test (cont.)
• Watch closely for respiratory movements (abdominal or chest
excursions).
• If no respiratory efforts, draw ABGs at 3-5 minutes and again at 7-10
minutes.
• If arterial PaCO2 is 60 mm Hg or greater or if >20 mmHg over
baseline, the test is positive.
• If inconclusive, may extend to 10-15 minutes if clinically stable.
The Apnea Test (cont.)
• Abort Apnea Test for:
• Spontaneous respiratory effort.
• Significant cardiac ectopy.
• Pulse oximetry <90%.
• Systolic blood pressure < 90 mmHg.
Harvard Criteria
“to determine the characteristics of a permanently nonfunctioning
brain”
1. Unreceptivity and unresponsitivity
2. No movements or breathing
3. No reflexes
4. Flat electroencephalogram

Exclusion of hypothermia or CNS depressants

All of the above 4 tests shall be repeated at, at least 24 hours, with
no change.
Glasgow Outcome Scale (Quality of Life)
• Good recovery: patient can lead a full and independent life with or without
minimal neurological deficit
• Moderately disabled: patient has neurological or intellectual impairment but
is independent
• Severely disabled: conscious but totally dependent on others to get through
daily activities
• Vegetative : unconscious , totally dependent
• Dead
Spectrum of Brain Injury
Vegetative State*

• Severe brain damage (kerusakan berat otak)

• Coma
• State of wakefulness (buka mata)
• Without awareness (tanpa kesadaran)

*Wikipedia Encyclopedia
Case 2
• Mr. M, 82 years old presented to ER in severe respiratory distress.
• History : heavy tobacco use for 50 years.
• He had 3 hospital admissions for respiratory failure in the previous
year, two of which required mechanical ventilation.
• He was intubated and was placed on a ventilator
• Over the next several days he was improved , off the ventilator he
became restless, agitated and severe shortness of breath

WHAT WILL YOU DO TO THIS PATIENT ?

Ethical Criteria:
Withholding/Withdrawing treatment
• When can person refuse potentially life-prolonging
treatment
• Without aiming at or intending death?
• When treatment judged to be
• Useless
• Futile: will likely not achieve intended results
• Excessively burdensome to the patient
• Little expected benefits, high burdens/risks
Useless/Burdensome Treatments
• Ethical jargon: “extraordinary” (vs. ordinary)
• or “disproportionate” (vs. proportionate)
• Refusing useless treatment
• Not choosing death, but choosing another sort of life
• Refusing excessively burdensome treatment
• Not rejecting life as such, but life with added burdens of low-yield
interventions
• Choosing not death, but one of several possible lives open to
us
• Even if a foreshortened life
 The physician discussed various option with mr. M and his family :
• Do everything
• Do something
• Do nothing

• All agreed that continued long-term reliance on the ventilator was burdensome, and
that his condition was terminal.
• Mr. M. was fully alert and competent; he and his family understood fully the
implications of his illness.
• A “do not resuscitate” (DNR) order was entered in the chart, with the agreement of
Mr. M. and his wife.
• A strict “do not intubate / do not resuscitate” order was given, and the patient was
left on supplemental oxygen.
• Twelve hours after discontinuing ventilator support, and with his family present, the
patient died.
Questions:
1. Was the cessation of therapy for Mr. M. justified?
2. Could this be an example of assisted suicide or of euthanasia?
3. What ethical principles are involved here?

1. A terminal condition is a disease or process that will result eventually in a

patient’s death, no matter what treatment is given.
2. “Letting die” may seem to be more acceptable, though it can be just as
unethical as active killing.
3. “Letting die” can be morally justifiable in medicine if a particular intervention
is truly futile, or if a patient or her authorized surrogate refuses it.
A Living Will

DNAR
Situasi klinis  DNAR Order
• Angka keberhasilan pengobatan rendah
• Resusitasi hanya menunda proses kematian alamiah
• Pasien tidak sadar secara permanen
• Pasien dalam kondisi terminal
• Kelainan/disfungsi kronis, sehingga resusitasi mengakibatkan lebih
banyak kerugian
Isi Perintah DNAR
• Diagnosis dan alasan untuk melakukan perintah DNR
• Kemampuan pasien untuk membuat keputusan
• Dokumentasi bahwa status DNR telah ditetapkan dan oleh siapa

(Perintah DNR dapat dibatalkan oleh pasien sendiri/wali yang sah atau
oleh dokter)
Case 3
• 88 year old male with history of pancreatic cancer, with metastases to liver
and abdominal wall.
• Patient has end stage renal disease on regular hemodialysis, recurrent
respiratory failure.
• He has now been hospitalized for close to 6 months, mostly in the ICU on
mechanical ventilation and sedation and artificial nutrition.
• Exam shows evidence of tumor invasion of abdominal wall with ulceration.
Patient unresponsive and unable to decide for himself.
 MEDICAL FUTILITY

Futile treatment is any course of treatment that provides no beneficial outcome

or is medically ineffective or even harmful to the patient. It is usually contrary to
generally accepted standards of care

A treatment may have an effect on the patient but may not benefit the patient

Treating the disease and not treating the patient

Treating the numbers and not treating the patient

Do Not Attempt Resuscitation
• A written physician’s order instructing health care providers not to
attempt CPR
• Often requested by family
• Must be signed my a physician to be valid
• Several types of CPR decisions can be made, including:
• Full code
• Chemical code
• DNR or “no code”
• Out-of-hospital DNR
Physical symptom of terminally ill/suffering
• Pain - anxiety
• Dyspnea
• Anorexia
• Malaise EUTHANASIA ?
• Nausea - vomiting DO NOT ATTEMPT RESUSCITATE ?
• Constipation
• Dehydration - shock
• Incontinence
Definition of euthanasia

Webster Dictionary/Wikipedia :
• the deliberate, painless killing of persons who suffer from a painful and
incurable disease or condition, or who are aged and helpless
• the practice of terminating the life of a person because they are perceived as
living an intolerable life, in a painless or minimally painful way either by lethal
injection, drug overdose, or by the withdrawal of life support
• ‘the painless inducement of quick death’
Auto-euthanasia
Dr. Jack Kevorkian
"suicide machine“ – The “Thanatron”

Michigan Feb. 6, 1991

Indonesia
Pasal 344 KUHP

• “Barangsiapa menghilangkan nyawa orang

atas permintaan sungguh – sungguh orang itu
sendiri dipidana dengan pidana penjara
selama – lamanya duabelas tahun”.
Legalized of Euthanasia
1994 - the Oregon Death with Dignity Act was passed, which legalized
assisted suicides.
Other states such as California, Michigan, Maine, Hawaii, Arizona, and
Vermont have tried to pass similar bills. All attempts have been
unsuccessful.
2002 – Euthanasia is legalized in Belgium
2005 – “Netherlands set to give the go-ahead to child euthanasia.”
Goals of Care
Curative (“beating it”)
• Cure or durable remission
• Prognosis: years
Palliative (“living with disease, anticipating death”)
• Disease incurable and progressive
• Prognosis: weeks, months (but can be years)
Terminal (“dying very soon”)
• Death imminent
• Prognosis: hours or days
Ashby M, Stoffell B.
Therapeutic ratio and defined phases: proposal of ethical framework for palliative care.
BMJ 1991; 302: 1322-1324
Mr. M
The “Comfort Care Only” patient
• Death is anticipated
• Goal: Alleviate suffering
• CPR and other treatments withheld  Do Not Attempt Resuscitation
DNAR
Are there situations in which it is ethical not to
initiate resuscitation ? (withholding resuscitation)

• Gestational age of less than 22 weeks’ gestation

• Severe congenital malformations
• Chromosomal anomalies
The primary consideration for decision regarding life-sustaining
treatment for seriously ill newborns should be what is best for
the newborn

Factors that should be weight are as follows :

1. The chance that the therapy will succeed
2. The risks involvement with treatment and nontreatment
3. The degree to which the therapy, if successful, will extend life
4. The pain and discomfort associated with the therapy
5. The anticipated quality of life for the newborn with and without
treatment
Ethical Analysis
• Etical analysis begin with an orderly review of four basic topics :
Medical indications
Patient preferences
Quality of life
Contextual features
 Medical indications
THE PRINCIPLES OF BENEFICENCE & NONMALEFICENCE
• What is the patient’s medical problems ? History ?
Diagnosis ? Prognosis ?
• Is the problems acute ? Chronic ? Critical ? Emergent ?
Reversible ?
• What are the goals of treatment ?
• What are the probabilities of success ?
• What are the plans in case of therapeutic failure ?
• In sum, how can this patient can be benefited by medical
and nursing care , and how can harm be avoided ?
Patient preferences
PRINCIPLES OF RESPECT FOR AUTONOMY
• Is the patient mentally capable and legally competent ? Is
there evidence of incapacity ?
• If competent, what is the patient stating about preferences
for treatment ?
• Has the patient been informed of benefit and risk,
understood this information and given consent ?
• If incapacitated, who is the appropriate surrogate ? Is the
surrogate using appropriate standards for decision making ?
• Has the patient expressed prior preferences, e.g. Advance
Directive ?
• Is the patient unwilling or unable to cooperate with medical
treatment ? If so, why ?
• In sum, is the patient’s right to choose being respected to
the extent possible in ethics and law ?
 Quality of life
THE PRINCIPLES OF BENEFICENCE-NONMALEFICENCE &
RESPECT FOR AUTONOMY
• What are the prospect, with or without treatment for
return to normal life ?
• What physical, mental and social deficits is the patient
likely to experience if treatment succeds ?
• Are there biases that might prejudice the provider’s
evaluation of the patient’s quality of life ?
• Is the patient’s present or future condition such that his
or her continued life might be judged undesirable ?
• is there any plan and rationale to forgo treatment ?
• Are there plans for comfort and palliative care ?
Contextual features
THE PRINCIPLES OF LOYALTY & FAIRNESS
• Are there family issues that might influence treatment
decisions ?
• Are there provider (physicians and nurses) issues that might
influence treatment decisions ?
• Are there financial and economic factors ?
• Are there religious or cultural factors ?
• Are there limits on cofidentiality ?
• Are there problems of allocation of resources ?
• How does the law affect treatment decisions ?
• Is clinical research or teaching involved ?
• Is there any conflict of interests on the part of the providers
or the institution ?
Legal issues in emergency medicine
• Informed consent • Duty of care
• Confidentiality • Negligance
• Competence • Transfer of responsibility
• Documentation • Refusing treatment
• Medical error
Kodeki gawat darurat
• Wajib melakukan pertolongan gadar sbg tugas kemanusiaan.
• Melakukan profesi dg ukuran tertinggi.
• Wajib melindungi hidup insani.
• Bersikap tulus ikhlas.
• Merujuk bila tdk mampu & ada yg lbh ahli.
• Tdk ada kepentingan pribadi.
• Bekerjasama dg tenaga kesehatan/nonkes.
• Memberi kesempatan pasien berhubungan dg keluarga,ibadat,masalah
lain.
Kasus2 Gawat Darurat
(kaitannya dg etik dan pidana)
 Tidak datang saat diminta memeriksa  pasien meninggal.
 Merujuk pasien ke RS lain tanpa melakukan pertolongan pertama 
pasien meninggal dlm perjalanan.
 Menunda pertolongan krn blm bayar uang muka.
 Permenkes No 585 th 1989 pasal 11 :
Dalam hal pasien tdk sadar dan tdk didampingi keluarga,memerlukan tindakan
terapi maupun diagnostik untuk menyelamatkan jiwa/cacad,tdk perlu
persetujuan dari siapapun.
 Laws are set of rules which are legislated by an authentic and
legitimate authority which can force and obligate others to do
something or leave

Ethics is the set of rules and norms that is efficient and effective to get
in the way of perfection
Medical ethics are related to the practice and delivery of medical care.
Your understanding of medical ethics must be consistent with the codes of your
profession.
Emergency Department
Tugas unik penanganan gawatdarurat :
* Pasien gawat-darurat  terapi segera!
* Pasien tdk bisa komunikasi
* Pasien tidak mengenal tenaga kesehatan
* Petugas kesehatan UGD multidisiplin
* Tugas – CPR,praRS,bencana,wabah,dll
Case analysis in clinical ethics
• Clinical ethics is a practical discipline that provides a structured approach for
identifying, analysing & resolving ethical issues in clinical medicine.
• Medicine, even at its most technical & scientific, is an encounter between
human beings, and the physician’s work of diagnosing disease, offering advice
and providing treatment is embedded in a moral context.
• The willingness of physician and patient to endorse moral values, such as
mutual respect, honesty, trustworthiness, compassion and commitment to
pursue shared goals, usually ensures a sound ethical relationship between
patient and physician.
Modern medical ethics
• Moral principles in clinical ethics :
• Autonomy
• Beneficence
• Nonmaleficence
• Justice
• However, clinical medicine is intensely practical. It consists of
particular cases, a multitude of circumstances & a variety of
values.
Death – an event or a process ?
* 22nd World Medical Assembly 1968 - Sidney

CPR
Cellular death

Biological death
APA PASIEN GAWAT DARURAT ITU ?

Adalah pasien yang perlu pertolongan

CEPAT-TEPAT-CERMAT
untuk mencegah kematian / kecacatan

Doktrin dasar :
Time saving is life saving
Waktu adalah nyawa

Keberhasilan :
Response time
(Waktu tanggap)
 WHAT IS A MEDICAL EMERGENCY ?

IS ANY MEDICAL PROBLEM THAT COULD CAUSE

DEATH OR PERMANENT INJURY

IF NOT TREATED QUICKLY-PROPERLY-ACCURATELY

Time saving is life saving

(Response time)
CEPAT ! TEPAT ! CERMAT?
QUICKLY ! PROPERLY ! ACCURATELY ?
Trimodal Trauma Mortality
Distribusi saat kematian korban trauma
Int. Anesthesiol Clin 1987;25:1-18

50 early
45
40
35
30 immediate
25
20
15
late
10
5
0
0-1 jam 1- 4 jam 2-6 minggu

Kerusakan Perdarahan Infeksi dan

SSP, jantung, banyak gagal organ ganda
pemb darah besar
Kasus gawat darurat
Pria usia muda  kecelakaan lalu lintas di UGD :
• Cedera otak berat
• Patah tulang paha terbuka & beberapa iga
• Perdarahan banyak  syok , nadi tak teraba
• Koma  tidak ada respon

Tidak ada keluarga yang mendampingi.

Bagaimana sikap anda sebagai

tenaga medik ?
1. OTONOMI PENDERITA
(RESPEK PENDERITA SBG MANUSIA)
2. BENEFICIENCE
(TINDAKAN HARUS ADA MANFAATNYA)
3. NON MALEFICENCE
(MANFAAT HARUS LEBIH BESAR DARI PENYULIT)
4. JUSTICE
(SARANA/SDM HARUS DIMANFAATKAN DGN ADIL)

APLIKASINYA :
1. Hormati kehidupan sebagai anugerah Tuhan.
2. Tetapi kemampuan manusia bertahan hidup dan kemampuan
tenaga kesehatan mempertahankan kehidupan ada batasnya –
kondisi gawat darurat dan terminal
1. OTONOMI PENDERITA
(RESPEK PENDERITA SBG MANUSIA)
2. BENEFICIENCE
(TINDAKAN HARUS ADA MANFAATNYA)
3. NON MALEFICENCE
(MANFAAT HARUS LEBIH BESAR DARI PENYULIT)
4. JUSTICE
(SARANA/SDM HARUS DIMANFAATKAN DGN ADIL)

APLIKASINYA :
1. Hormati kehidupan sebagai anugerah Tuhan.
2. Tetapi kemampuan manusia bertahan hidup dan kemampuan
tenaga kesehatan mempertahankan kehidupan ada batasnya –
kondisi gawat darurat dan terminal
 Otonomi
• Hak penderita untuk menentukan sendiri :
Pilihan-pilihan perawatan yang dikehendaki
atau tidak dikehendaki, tanpa purbasangka
• Mutlak perawatan dilaksanakan dengan persetujuan tindakan
kedokteran (informed consent) setelah mendapat penjelasan
(information for consent)
• Dalam perawatan bayi-anak/tidak kompeten dipertimbangkan oleh
orangtua/keluarga

79
 INFORMED CONSENT

HAK PASIEN

Hak atas informasi

Hak untuk memberikan persetujuan
Hak atas rahasia kedokteran
Hak atas pendapat kedua (second opinion)
Persetujuan Tindakan Kedokteran
Persetujuan Tindakan Kedokteran yaitu persetujuan yang diberikan
pasien atau keluarga atas dasar penjelasan yang memadai
mengenai tindakan medik yang akan dilakukan terhadap pasien
tersebut.
Dasar Hukum :
• Permenkes No. 290 Tahun 2008 Psl 1
• UU No.29 Th 2004 psl 45 (tentang praktek kedokteran-
penyelenggaran praktek kedokteran)
• Pasal 68 ayat 1 UU Tenaga Kesehatan
UNSUR-UNSUR (yang perlu dijelaskan)

• Prosedur yang akan dilakukan

• Risiko yang mungkin terjadi
• Manfaat dari tindakan yang akan dilakukan
• Alternatif tindakan yang dapat dilakukan
Jenis persetujuan tindakan kedokteran
Persetujuan Tindakan Medik (Informed Concent)
dapat terdiri dari :
1. Yang dinyatakan (expressed), yakni secara lisan (oral) atau
tertulis (written)
2. Dianggap diberikan (Implied atau tocit concent), yakni dalam
keadaan biasa (normal) atau dalam keadaan darurat
(emergency).
Intubasi trakhea

Tindakan invasive  pada kondisi gawat darurat tidak

perlu persetujuan pasien/keluarga
Pembedahan laparoscopy

Tindakan terrencana untuk pembedahan terrencana

(misalnya pembedahan batu empedu)
Tindakan non-invasif
YANG BERHAK MEMBERIKAN PERSETUJUAN

• Pasien dewasa
( telah berumur > 18 tahun atau sudah menikah )
yang berada dalam keadaan sadar dan sehat mental
• Pasien dewasa yang berada di bawah pengampuan (
curate ) persetujuan diberikan oleh wali / curator
• Pasien dibawah umur 18 tahun dan tidak mempunyai
orang tua / wali dan atau ortu/ wali berhalangan,
persetujuan diberikan oleh keluarga terdekat atau
induk semang.
1. OTONOMI PENDERITA
(RESPEK PENDERITA SBG MANUSIA)
2. BENEFICIENCE
(TINDAKAN HARUS ADA MANFAATNYA)
3. NON MALEFICENCE
(MANFAAT HARUS LEBIH BESAR DARI PENYULIT)
4. JUSTICE
(SARANA/SDM HARUS DIMANFAATKAN DGN ADIL)

APLIKASINYA :
1. Hormati kehidupan sebagai anugerah Tuhan.
2. Tetapi kemampuan manusia bertahan hidup dan kemampuan
tenaga kesehatan mempertahankan kehidupan ada batasnya –
kondisi gawat darurat dan terminal
Nonmaleficence – primum non nocere (first of all do no
harm)

tindakan2 darurat untuk penyelamatan  tdk

menimbulkan penyulit yang serius.

Contoh kasus :
perdarahan ditelapak kaki karena menginjak pecahan
gelas  torniket dipasang untuk menghentikan
perdarahan, tetapi akibat dipasang torniket
menyebabkan jaringan dibawahnya nekrosis
Balancing Beneficence and Non-maleficence
• One of the most common ethical dilemmas arises in the balancing of
beneficence and non-maleficence.
• This balance is the one between the benefits and risks of treatment and
plays a role in nearly every medical decision such as whether to order a
particular test, medication, procedure, operation or treatment.
• By providing informed consent, physicians give patients the information
necessary to understand the scope and nature of the potential risks and
benefits in order to make a decision.
• Ultimately it is the patient who assigns weight to the risks and
benefits. Nonetheless, the potential benefits of any intervention must
outweigh the risks in order for the action to be ethical.
• Pria 51 tahun nyeri abdomen kanan bawah, dibawa ke klinik kecil. Dokter
bedah yang kebetulan disitu memeriksa dan mengusulkan pembedahan
appendectomy.
• Beneficence :
o pasti bermanfaat karena appendicitis perforasi harus segera dilakukan
pembedahan appendectomy.
• Nonmaleficence :
o Risiko infeksi karena klinik kecil tidak disiapkan untuk appendectomy
o Peralatan tidak memadai untuk appendectomy
o Tindakan yang tidak proporsional, kecuali di pedalaman
Fasilitas IRD/ICU terbatas

JUSTICE (ADIL)
Justice
Justice is a concept intended to promote fair and equitable treatment
of individuals within populations

• Procedural Justice :
if you are waiting to see your physician, did others get to go ahead of
you without any clear medical reason ?
• Distributive Justice :
resource allocation issues.
• Justice : (Fairness)
bersikap adil thd siapa saja yg dirawat
tdk memandang tk sosialekonomi,kultur,
ras,usia,gender,agama
tidak merawat secara substandar
alokasi sumber daya yg terbatas  triage , penentuan ‘policy’ RS.
 Perbedaan Kasus Darurat & Non Darurat
DARURAT
 Ambulans atau polisi
 Tdk memilih tenaga kesehatan
 ‘Trust’ tidak ada
 Tdk kenal pasien & kel
 Penyakit akut,berat
 Nyeri,cemas.
 Keputusan segera
 Keputusan dokter dominan
 Dr mewakili institusi
 Lingkungan kerja terbuka &
kurang terkontrol
 Situasi kerja lbh stressful
NON DARURAT
 Px menentukan sendiri
 Pasien memilih tenaga kesehatan
 Ada ‘trust’ thd dr,prwt
 Tenaga kes kenal pasien
 Penyakit kronis,ringan
 Nyeri & cemas tdk ada/minimal
 Banyak waktu diskusi
 Dr punya waktu utk konsultasi
 Mewakili diri sendiri
 Lingkungan ‘private’ & terkontrol.
 Jadwal kerja teratur
Hubungan hukum dengan pelayanan gawat darurat

• Doktrin “Good Samaritan Law”

• Melindungi penolong yang secara suka-rela & beritikad baik.
• Kesukarelaan dibuktikan dengan tidak ada keinginan penolong untuk
memperoleh kompensasi apapun.
• Itikad baik dinilai dari apa yang dilakukan penolong.
Kodeki gawat darurat
• Wajib melakukan pertolongan gadar sbg tugas kemanusiaan.
• Melakukan profesi dg ukuran tertinggi.
• Wajib melindungi hidup insani.
• Bersikap tulus ikhlas.
• Merujuk bila tdk mampu & ada yg lbh ahli.
• Tdk ada kepentingan pribadi.
• Bekerjasama dg tenaga kesehatan/nonkes.
• Memberi kesempatan pasien berhubungan dg keluarga,ibadat,masalah
lain.
Kasus2 Gawat Darurat
(kaitannya dg etik dan pidana)
 Tidak datang saat diminta memeriksa  pasien meninggal.
 Merujuk pasien ke RS lain tanpa melakukan pertolongan pertama 
pasien meninggal dlm perjalanan.
 Menunda pertolongan krn blm bayar uang muka.
 Permenkes No 585 th 1989 pasal 11 :
Dalam hal pasien tdk sadar dan tdk didampingi keluarga,memerlukan tindakan
terapi maupun diagnostik untuk menyelamatkan jiwa/cacad,tdk perlu
persetujuan dari siapapun.
RS keberatan & menolak pasien ?

Pasal 32 UU no 36 tahun 2009 tentang Kesehatan : dilarang

menolak pasien & minta uang muka.
Kemajuan bidang kedokteran
• Resusitasi jantung – paru – otak (RJPO)
• Ventilasi mekanik & cardiac thumper
• Dialisis renal , hepar MASALAH ETIKA
• Transplantasi organ tubuh MEDIS
• Reproduksi buatan
• Stem cell
Kasus gawat darurat terminal
• Wanita 90 tahun Alzheimer stadium akhir.
(flexion contractures, tracheostomy,Foley cath,
enteral feeding 2 tahun)
• Dalam 3 bulan masuk rumah sakit 3 kali.
• Terakhir mengalami sepsis karena pneumonia – sesak dan syok.

Oleh keluarga dibawa ke UGD  bagaimana sikap anda ?

Keluarga minta terapi maximal termasuk intubasi &

respirator , antibiotik , dialysis , nutrisi parenteral dan jika
cardiac arrest diresusitasi.
Tujuan Terapi Kedokteran
Curative (“beating it”)
• Penyakit bisa disembuhkan secara total.
• Prognosis: sehat kembali.
• Terapi : causal , harapan sembuh
Palliative (“living with disease, anticipating death”)
• Penyakit tidak bisa sembuh & progresif (memberat)
• Prognosis: mati dalam minggu, bulan (kadang2 tahun)
• Terapi : Comfort , Pain free , Stress free.
• Menghadapi kematian yang bermartabat & tenang
Goals of Care
Curative (“beating it”)
• Cure or durable remission
• Prognosis: years
Palliative (“living with disease, anticipating death”)
• Disease incurable and progressive
• Prognosis: weeks, months (but can be years)
Terminal (“dying very soon”)
• Death imminent
• Prognosis: hours or days
Ashby M, Stoffell B.
Therapeutic ratio and defined phases: proposal of ethical framework for palliative care.
BMJ 1991; 302: 1322-1324
Palliative Care
Palliative Care
• Relieve symptoms
• Improve the quality of living
• Improve the quality of dying,
for a person &/or family living with a life threatening illness
The term ‘palliative care’ is increasingly used with regards to diseases other
than cancer, such as :
 Chronic progressive pulmonary disorders
 Renal disease
 Chronic heart failure
 HIV/AIDS
 Progressive neurological conditions
Potential palliative care intervention
Kasus penyakit terminal
• Wanita usia 58 tahun , kanker ovarium metastase luas. Telah
dilakukan pembedahan 5 tahun yang lalu. Saat ini nyeri hebat , telah
diberi obat anti nyeri (morphin 20 mg/jam) , tetapi tetap menderita
sakit. Hipotensi dan nafasnya terganggu (cepat dan dangkal).
• Apa yang anda lakukan?
Pilihannya
A. Bolus intravena 100 mg morphin ?
B. Lanjutkan morphin tanpa perubahan ?
C. Berikan naloxone ?
D. Bolus intravena 2-4 mg morphin dan naikkan morphin drip secara
titrasi 10% dosis/jam ?
Alasan Pilihan Terapi
A. Efek yang kita inginkan disertai efek yang tidak diinginkan (pain
control could be achieved by shooting the person, too!)
B. Dengan dosis sekarang tidak menolong...!!
C. Nyeri akan semakin hebat, pilihan yang sangat tidak manusiawi...
!!!
D. Jika tujuan kita murni untuk menghilangkan rasa nyeri , mungkin ini
pilihan yang paling baik.
Masalah Etika Penderita Gawat & Kondisi Terminal

• Keputusan untuk tidak melakukan resusitasi (DNR Order) – withold

resuscitation
• Keputusan menghentikan resusitasi (mis.:penderita dinyatakan sudah
mati-brain death) – withdraw resuscitation
• Keputusan untuk tidak melanjutkan terapi yang tidak bermanfaat –
futile (sia-sia)
• Keputusan memakai terapi ‘high-tech’ & tindakan invasif – mahal ,
tdk terjangkau
• Diagnosa mati (MBO vs status vegetatif)
Do Not Resuscitate (DNR)
DNR Order :
 Perintah yang ditujukan kepada semua tenaga medis
 Dituliskan oleh dokter untuk pasien
 Untuk tidak melakukan resusitasi bila nafas dan jantung pasien
berhenti
 Harus tertulis di rekam medik & catatan pasien sendiri
 Menghormati keinginan pasien & keluarga ,setelah dijelaskan
dokter
 DNR Order bisa dibatalkan
TANDA KHUSUS
Withdrawing

• Keputusan untuk menghentikan terapi penunjang kehidupan.

• Menghentikan ventilasi mekanik , pemberian oksigen , infus vasopressor
, tidak lagi dialysis.
• Ex: brain death, fase terminal penyakit mematikan , status agonal.
• Keputusan harus melibatkan keluarga (prinsip AUTONOMI)
Withholding

Keputusan tidak memulai terapi penunjang kehidupan.

Do Not Attempt Resuscitation jika mati klinis.
Tidak memberi vasopressor pada hipotensi
Tidak melakukan RRT pada gagal ginjal
Keputusan ini didasari pemahaman, jika dilakukan tdk akan
bermanfaat , tdk merubah outcome.
 Tidak
Tidak melakukan
melakukan resusitasi
resusitasi
dapat diterima pada keadaan:
dapat diterima pada keadaan:
Masa gestasi < 23 mgg atau
BB < 400 gram
Anensefali
Terbukti trisomi 13 atau 18
Death – an event or a process ?
* 22nd World Medical Assembly 1968 - Sidney
KRITIS
VF Mati klinis

asystole
RJPO
obstruksi nafas Mati seluler

gagal nafas Mati biologis

CARDIAC
hipoksia ARREST
perdarahan
shock
coma

normal neurol vegetatif MBO

defisit
Kematian
Mati klinis : jantung berhenti

Resusitasi

Mati biologis : otak nekrosis 

Mati otak atau mati batang otak (MBO)
Nafas berhenti - Nafas buatan - Intubasi trakhea
Tanda mati batang otak (MBO)
• Terjadi koma (unresponsive/GCS 3)
• Tidak ada sikap abnormal (dekortikasi , decerebrasi)
• Tidak ada sentakan epileptic
• Tidak ada refleks batang otak
• Tidak ada nafas spontan
Penegakan diagnosis MBO
• Dilaksanakan oleh tim dokter , terdiri dari 3 dokter yang kompeten
• Harus melibatkan dokter spesialis anestesi dan saraf
• Pemeriksaan dilakukan secara mandiri & terpisah
• MBO pada calon donor organ, tim dokter penegakan diagnose MBO
tidak melibatkan dokter yang berkepentingan dalam transplantasi
• Penegakan diagnosis MBO harus dilakukan di ICU
Persyaratan untuk menegakkan diagnosis
MBO
• Prakondisi berupa koma dan apnea oleh karena kerusakan struktur
otak yang menetap akibat gangguan yang potensial merusak struktur
otak.
• Tdak ada penyebab koma dan henti nafas yang sifatnya tidak menetap
 obat2an
 intoksikasi
 gangguan metabolit
 hipotermia
Prosedur menegakkan diagnosis MBO
• Memastikan areflexia batang otak
• Memastikan henti nafas yang menetap
• Bila tes areflexia batang otak dan tes henti nafas hasilnya positif, tes harus
diulang dalam waktu 25 menit sampai 24 jam
• Bila tes ulangan tetap positif, pasien dinyatakan mati batang otak (walau
jantung masih berdenyut)
• Bila pada waktu tes henti nafas, timbul artimia yang mengancam nyawa,
tes harus dihentikan ,ventilator disambung ke pasien. Diagnosis MBO
belum bisa ditegakkan.
• Penetapan jam kematian adalah saat diagnosis MBO sudah ditetapkan
Vegetative State*

• Severe brain damage (kerusakan berat otak)

• Coma
• State of wakefulness (buka mata)
• Without awareness (tanpa kesadaran)

*Wikipedia Encyclopedia
BRAIN DEATH – BRAIN STEM DEATH - PVS

BRAIN PERSISTENT
DEATH VEGETATIVE
STATE

BRAIN BRAIN STEM

DEATH DEATH
 Breaking Bad News
Setiap dokter pernah menangani pasien :
Prognosis jelek
Pasien ingin tahu masalah penyakitnya, namun akan stress/syok jika
mengetahui
Dokter bimbang akan memberitahu atau tidak

Masalah sering timbul dari sikap dokter :

Bersikap ‘overacting’ (menunjukkan luasnya pengetahuan dokter)
Tidak memberi informasi yang memuaskan
Membohongi pasien/keluarga
Menakuti pasien/keluarga
Kesalahan yang sering dilakukan dokter
• Memberi harapan yang tidak rasional
• Memberi gambaran yang berlebihan
• Menyembunyikan informasi tentang prognosis yang buruk
Strategi yang bisa dilakukan :
• Menahan sebagian informasi yang potensial membuat pasien stres
• Memberitahu secara tersamar bhw pasien menderita penyakit serius
yang sulit diobati
• Untuk keluarga mungkin perlu diberitahu lengkap
Kubler Ross reaction to terminal illness/death