LEGAL AND ETHICAL ASPECT OF MEDICAL EMERGENCIES

Dr.Herkutanto, SH, FACLM

Herkutanto
Department of Forensic Medicine & Medicolegal Faculty of Medicine University of Indonesia
Ph.D in Forensic Medicine Fellow of Australian College of Legal Medicine Medical & Medicolegal Qualifications University of Indonesia ± Faculty of Medicine Monash University, Australia ± Faculty of Medicine University, Netherland School of Public Health, The Netherland Health, Qualifications in Health Law University of Indonesia ± Faculty of Law La Trobe University, Australia - School of Law International Assignments ± Medicolegal Consultant World Health Organization ± 1989 United Nation Funds for Populations Activities ± 1992, 1994 John Hopkins University, 2003

OBJECTIVES
1) To understand Ethical and Legal Aspect in a medical emergencies and its circumstances 2) To understand the scope of duties and obligations in medical emergencies 3) To understand consent in medical emergencies

EMERGENCY (definition)
Any conditions that in the opinion of the patient, his family, or whoever assumes the responsibility of bringing the patient to the hospital ± requires immediate medical attention. This condition continues until a determination has been made by a healthcare professionals that the patient¶s life or wellbeing is not threatened.

American Hospital Association

EMERGENCY PHASE
Pre Hospital
Public >> Good Samaritan Doc

Hospital
Medical Personel P-P Relationship voluntarism (-) pre-existing (-) ³Private Good´

³Public Good´

All Aid in Emergency Phase

FINISH

Avoid the loss of chance to survive

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ROLE OF MEDICAL FIRST RESPONDER ‡ ACCESS TO THE VICTIM AND COMMUNICATION ‡ SAFETY AND SECURITY ‡ ASSISTING THE VICTIMS ‡ ASSISTING OTHER MEDICAL EMEREGINCY PERSONNELS ‡ DATA PROTECTING ‡ TRANSPORTATION ‡ Access to communication facilities 118. 113 ‡ Access to the victim and environment assessment ‡ Access to security personnel ‡ Victim and self Personal protection ‡ Assists the victim according to the competence ‡ Reliability & Confidentiality medical information ‡ Vehicle & transportation route . 110.

SCOPE OF ASSISTANCE ‡ Knows the limit of competence DO NO FURTHER HARM .

LEGAL CONCERN IN MEDICAL EMERGENCIES ‡ Is there any legal obligation in medical emergency circumstances? ± Who are obliged? every person? ± Are there any limitation to act? ‡ Are there any legal consequences for persons who helps another person in emergencies? ± Is there any protection for a person who is in good faith voluntarily helps other people in medical emergencies? ± Are there legal liability to the helpers? ‡ What about the costs of treatment? ± EMTALA (Emergency Medical Treatment and Labor Act) USA ± COBRA (Consolidated Omnibus Budget Reconciliation Act) .

ETHICAL CONCERN IN MEDICAL EMERGENCIES ‡ Is there any basic moral principle in medical emergency circumstances? ± What basic moral principle are? ± What ethical conduct for medical emrgencies ‡ Are there any legal consequences for persons who helps another person in emergencies? ± Is there any protection for a person who is in good faith voluntarily helps other people in medical emergencies? ± Are there legal liability to the helpers? ‡ What about the costs of treatment? ± EMTALA (Emergency Medical Treatment and Labor Act) USA ± COBRA (Consolidated Omnibus Budget Reconciliation Act) .

.MEDICAL PRACTICE ACT 2004 (Indonesia) Article 51 (d) Medical practitioners shall have the obligation to provide humanitarian emergency medical assistance. . except that they convince that another competent person is available to provide such assistance. «.

GOOD SAMARITAN DOCTRINE ³The principle that a person who is injured while attempting to aid another in imminent danger and who the sues the one whose negligence created the danger. will not be charged with contributory negligence unless the rescue attempt is an unreasonable one or the rescuer acts unreasonably in performing the attempted rescue´ .

CONFIDENTIALITY MANDATORY-REPORTING    RIGHT TO PRIVACY  Duty to medical secrecy Police No mandatory obligation in Indonesia REPORT TO PUBLIC AGENCY  CHILD ABUSE  .

SPECIFIC CIRCUMSTANCES IN MEDICAL EMERGENCIES ‡ SHORT OBSERVATION TIME ‡ SUDDEN & UNEXPECTED CLINICAL MANIFESTATION ‡ HIGH MOBILITY OF HEALTH PERSONNEL ‡ INSUFFICIENT INFORMATION TO ESTABLISH CLINICAL JUDGEMENT HIGH RISK!! .

PATIENT¶¶S COMPETENCY ASSAULT & BATTERY RIGHT TO PRIVACY REPORT TO PUBLIC AGENCY CHILD ABUSE CHAIN OF CUSTODY .LEGAL CONCERN IN EMERGENCY-TRAUMA  CONSENT  REFUSAL OF TREATMENT  CONFIDENTIALITY  MANDATORYREPORTING          INFORMED CONSENT EMERGENCY DOCTRINE GOOD SAMARITAN D.

CONSENT TO TREATMENT ‡ Every action must be consented by the competent patient or the next of kin (when the patient is incompetent) ‡ Expressed Consent ‡ Implied Consent ± the patient is unconscious ± medical treatment is urgent ± no next of kin present .

CONSENT IN MEDICAL EMERGENCY & CONSENT COULDNOT BE OBTAINED No Consent Needed Good Faith Patient¶s Best Interest .

CONFIDENTIALITY MANDATORY-REPORTING    RIGHT TO PRIVACY  Duty to medical secrecy Police No mandatory obligation in Indonesia REPORT TO PUBLIC AGENCY  CHILD ABUSE  .

LEGAL CONCERN IN EMERGENCY-TRAUMA  NEGLIGENCE  DEATH / DNR  PATIENT¶S PROPERTY  MEDICAL CERTIFICATION          LIABILITY STANDARD OF CARE ABANDONMENT PATIENT¶S TRANSFERS DEFINITION OF DEATH DNR INDICATIONS WITHHOLDING&WITHDRA WAL TREATMENT UNCLAIMED DEATH BODIES CHAIN OF CUSTODY .

NEGLIGENCE LIABILITY  STANDARD OF CARE  ABANDONMENT  PATIENT¶S TRANSFERS  .

ABANDONMENT Terminating an on-going emergency assistance regardless the absence of a more competent health personnel .

NEGLIGENCE ‡ Recklessness ‡ Foreseeable ‡ Preventable .

DEATH / Do Not Resuscitate  DEFINITION OF DEATH Clinical  Brain Stem Death    DNR INDICATIONS  The death has been declared Sent to the city morgue UNCLAIMED DEATH BODIES  .

PATIENT¶S PROPERTY  CHAIN OF CUSTODY .

MEDICAL CERTIFICATE  PURPOSE  LEGAL CONSEQUENCES .

MEDICOLEGAL ASPECT OF EMERGENCIES According to Causes ‡TRAUMA ‡NON-TRAUMA According to the Number of Victims ‡Individual Casualty Criminal Act? ‡Mass Casualty Identification Rights of victims Medicolegal Certification .

.

DISCUSSION .

ISSUES TO BE EXPLORED ‡ ‡ ‡ ‡ ‡ ‡ Don¶t know his/her limitation of competence Negligence Different opinion amongst the helpers Patient¶s consent Refuse of treatment by the patient Etc. etc .

Play the role of two parties in conflict 3. What kinds of conflicts that possible to be arisen when a MFR helps a victim? 2. Identify potential problems 4. What is the theoretical background? .DISCUSSION PROCEDURES 1. Develop options to solve the problems 5.

POTENTIAL CONFLICT ‡ . POSSIBLE SOLUTION ‡ . .

. Keluarganya minta agar dilakukan tindakan (bertentangan dengan kemauan pasien). & butuh RJP. POSSIBLE SOLUTION ‡ .POTENTIAL CONFLICT ‡ Pasien tidak mau ditolong. tidak mau di RJP. pasien meninggal. Keluarga menuntut. tidak ditolong.

menunjukkan surat pernyataan sikap pasien ‡ DNR adalah advance directive.‡ Sikap dokter (merespon permintaan pasien):analisis kondisi mental pasien (sehat:turuti pasien) ‡ Sikap dokter (merespon keluarga yg minta RJP):menjelaskan kpd keluarga. dokter menuruti kehendak pasien . sejauh alasan dpt diterima.

‡ Dokter punya kewajiban utk menolong sesama ‡ Dokter tetap melakukan RJP meskipun permintaan pasien menolak RJP. . Lebih baik dituntut krn melakukan perbuatan yg baik. Krn RJP life-saving.

‡ Dr.‡ Advance directive:dokter harus memastikan bhw pasien benar-benar memahami keadaan dirinya.amal:tetap mengikuti keinginan pasien krn hak otonomi pasien .

‡ pasien hrs dinilai apakah dpt menilai hak2nya sendiri .‡ Respon keluarga:marah krn next of kin minta RJP tapi dokter tdk mengabulkan permintaan keluarga.

‡ Dokter hrs menjelaskan krn pasien belum tentu dpt mengerti kondisinya yg sebenar2nya. .

POTENTIAL CONFLICT ‡ Di tengah jalan. Jadi.tetapi datangnya lama. . Klinik terdekat fasilitasnya tidak lengkap.menunggu ambulans atau menolong di klinik (kemungkinan tertolong kecil) POSSIBLE SOLUTION ‡ . Dokter menelpon ambulans.dokter bertemu seseorang yg tertembak.

‡ Dr.non-maleficence) ‡ Mana yg lbh mencelakakan pasien? ‡ Mana yg lbh menolong pasien? ‡ Benefit/Risk ratio? .anton:ditolong dulu di klinik dan meminta ambulans menjemput di klinik ‡ Adakah dilema moralnya? ‡ Apa yg terbaik utk korban? (asas beneficence.

Sedangkan dokter penolong laki-laki. . POSSIBLE SOLUTION ‡ .POTENTIAL CONFLICT ‡ Ditengah jalan bertemu wanita bercadar (tdk boleh kontak fisik dg lawan jenis) yg saat itu mengalami serangan jantung.

‡ Mencari orang lain (perempuan) utk memeriksa korban ‡ Sebagai pasien.saya terima penolong apabila juga perempuan ‡ Dlm agama diijinkan utk menolong meskipun lawan jenis. .

. POSSIBLE SOLUTION ‡ .POTENTIAL CONFLICT ‡ .

POSSIBLE SOLUTION ‡ .POTENTIAL CONFLICT ‡ . .

Menolak pengobatan karena masalah kultural 3. Penolong dijadikan saksi dan direpotkan: 1. Korban merasa ditelantarkan dan dinomorduakan. Multiple korban. tidak semua bisa ditolong sekaligus. Konflik antara penolong dengan pihak lain yang berkepentingan untuk menyelesaikan perkara tersebut (keadaan hukum) 5.KEMUNGKINAN KONFLIK 1. orang lain menuduh penolong tidak bersedia melakukan pertolongan 4. Menolak pengobatan (belakangan ) setelah pengobatan dilakkan dalam keadaan tidak sadar 2. . Menolak pengobatan ± meninggal.

. orang lain menuduh penolong tidak bersedia melakukan pertolongan 2. Konflik dengan tenaga kesehatan. Masalah ekonomi. konflik dengan masyarakat ketika akan melakukan akses kepada korban 3. Menolak pengobatan ± meninggal. Akses ke korban terhalang. Pasien tidak punya biaya.KEMUNGKINAN KONFLIK 1.

KEMUNGKINAN KONFLIK 1. ataukah memang bertugas menolong salah satu pihak saja? . Fasilitas saat itu hanya menungkinkan untuk menolong satu orang saja. Ada 2 orang korban. Salah satu satu penjahat. Siapakah yang harus ditolong? 2. Apakah tenaga medis itu dianggap netral. Tenaga medis dalam situasi pertempuran / konflik.

Bila dilakukan resusitasi. korban akan mengalami sequele (cacat) 2. keluarga marah 2. Apkaah akan dilakukan resusitasi? Pertimbangan: 1. Bila tidak ditolong. . Penolong dituduh lalai melakukan tindakan pertolongan sehingga menyebabkan kematian.KEMUNGKINAN KONFLIK 1. Korban yang mati secara klinis.

jangan membayangkan dengan pikiran nonmedis. korban meninggal. 2. 3.KEMUNGKINAN KONFLIK 1. Hambatan kultural.? Di RS: unacceptable Tenaga medis: combatant & noncombatant 2. Dokter salah diagnosis.? Tanggung guggat. 4. tidak sempat. Bila mencari orang lain. kita dikejar lawan. . Membedakan laki2 & perempuan. dengan akibat salah terapi. Korban massal. padahal ada yang perlu ditolong 1. Dalam keadaan perang. Menolong pernafasan buatan terhadap jenis kelamin lain. 3.. tak mampu menolong lagi 4. petugas terlalu letih. Dalam situasi tersebut. Standard Op Precedure vs Standar Profesi .. ada hambatan agama.

Anak menderita leukemia myeblast akut. Yang dilakukan dianggap salah. Padahal ia menganut sekte yg tidak boleh dilakukan transfusi 1. Korban tabrak lari. tiba2 jatuh dan tak sadar ditengah jalan.KEMUNGKINAN KONFLIK 5. Seorangtua menyeberang. dengan segala konsekuensinya? 7. Ada penyeberang lain yg mengaku sebagai mhs ked / tenaga medis tanpa memperlihatkan jati diri. Bekerjasama!! Bila tidak yakin dg tindakan org lain. komunikasi dg baik. Apakah menolong. haruskah kita menegur? 6. perlu transfusi darah. .

9. Ketika akan menolong.KEMUNGKINAN KONFLIK 8. ternyata kita mempunyai keperluan mendadak yang lain (keadaan gawat). pada hal keduanya dalam keadaan darurat. Dr. hanya ada 1 RS. Ada 2 pasien di IGD. 10. datang berbarengan. mendapat ancaman agar tidak menolong kelompok lainnya. Tabrak lari malam hari. . Terjadi konflik sosial. Dr. Penolong kekurangan tenaga. PTT ke daerah.

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