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Ethics in CPR

Eddy Rahardjo

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Apakah jantung yang berhenti berdenyut itu
tanda akhir dari kehidupan ?

• Dulu, ya !
• Sekarang, belum tentu.
• Ada resusitasi jantung paru
(cardio-pulmonary resuscitation)

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• Dari 100 pasien cardiac arrest, hanya
5-10% bisa pulang hidup dari RS
• 50% dari mereka menderita sequellae
yang mengurangi kwalitas hidup mereka
• Jadi apakah etis usaha kita me-resusitasi?

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Resusitasi

Tenggelam 30 menit,
tidak sadar, tidak bernafas,
dingin, biru

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Apakah coma, tidak sadar, itu tanda akhir
dari kehidupan ?

• Dulu, ya !
• Sekarang, belum tentu.
• Ada resusitasi jantung paru otak
(cardio-pulmonary-cerebral resuscitation)

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When a patient's brain falls completely silent, and
electrical recordings devices show a flat line,
reflecting a lack of brain activity, doctors consider
the patient to have reached the deepest stage of a
coma.

However, new findings suggest there can be a


coma stage even deeper than this flat line —
and that brain activity can ramp up again from
this state.

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• Etik profesi dokter mewajibkan kita
berusaha menolong seseorang yang
terancam jiwanya agar hidup kembali

1. Kapan kewajiban itu dimulai?

2. Kapan kewajiban itu berakhir?


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Kapan kewajiban itu dimulai?

1. Proses itu bisa ditolong dan kita mampu


menolong
2. Proses itu mungkin bisa ditolong dan kita
mungkin bisa menolong
3. Tidak ada pesan penolakan pertolongan
yang disampaikan oleh penderita atau
oleh “wakil”nya (surrogate) sesuai
ketentuan hukum

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CPR ? YES (hak hidup pasien)

1. ALL patients in cardiac arrest


should receive CPR

2. ALL patients in coma should


continue treatment

3. When can a patient be allowed


to discontinue treatment?

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Kapan kewajiban itu berakhir?

1. Jika penderita sudah dipastikan meninggal


2. Jika penolong sudah tidak mampu
menolong lebih jauh (keterbatasan fisik)
3. Jika surrogates meminta penghentian

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Ethics is not mathematics, not a physical science.
It is life values generated in a society
It differ between different societies

Differences in ethical approaches around the world


depend on the intrinsic differences in culture,
resources, demand, and level of development.
Even in the same institution, health care workers
of different ethnic and religious backgrounds may
have significantly different views.
INTERNATIONAL PERSPECTIVES ON ETHICS IN CRITICAL CARE
Critical Care Clinics - Volume 13, Issue 2 (April 1997)

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Prinsip Dasar Etik

1. Do good
“Saya senantiasa mengutamakan kesehatan pasien”
2. Do no harm
3. Veracity / Honesty
– Memberi informasi yang benar & arif
4. Autonomy
5. Confidentiality
6. Justice
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Principles of medical ethics
Adopted by the AMA's House of Delegates June 17, 2001.

I. A physician shall be dedicated to


providing competent medical care,
with compassion and respect for human
dignity and rights.
IX. A physician shall support access to
medical care for all people.

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Medical ethics is a system of moral
principles that apply values and
judgements to the practice of medicine.

edisi 2012

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Apakah CPR yang kita berikan ini akan berhasil?

1. time to CPR • None of these


2. time to defib factors alone or in
3. initial arrest rhythm combination is
clearly predictive of
4. co-morbids outcome
5. pre-arrest state

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meta-analysis on 11 studies, 1914 patients

• 4 of 5 strong predictors detectable at 24


to 72 hours post CPR
1. Absent corneal reflexes at 24 H
2. Absent pupillary response at 24 H
3. Absent withdrawal response to pain at 24 H
4. No motor response at 24 H
5. No motor response at 72 H (3 days!!)
• Withdrawal of life support is then
ethically permissible

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No professional should make a judgement about
the present or future quality of life of
a cardiac arrest victim
on the basis of
current or anticipated neurological status

AHA, CPR Guidelines 2005


p IV-8

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Withholding and withdrawing CPR

1. Patient shows signs of irreversible death


– rigor mortis, dependent lividity (lebam mayat)
2. No physiological benefit can be expected
despite maximal therapy
3. Patient has valid DNR

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Principles of futility (sia-sia)
• CPR dianggap “futile” bila:
– tidak memperpanjang hidup (length of life)
– tidak meningkatkan kwalitas hidup
(quality of life)
• Semua ini harus dijelaskan sampai
difahami dan disetujui oleh keluarga /
surrogate pasien

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Withdrawal of Life Support
• emotionally complex decision
• witholding and withdrawing is ethically equal
• justifiable when
– patient is determined to dead,
– physician, patient or surrogate agree that
treatment goals can not be met
– if burden to the patient exceeds any benefit

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1990

The case of Terri Schiavo, 25 years old, previously healthy woman


After CPR following cardiac arrest, she sustained PVS (1990)
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Suami minta pengadilan menghentikan Nasogastric feeding
supaya Terri mati
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Court decision : stop further feeding. Gastric tube was removed.

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BUT, is Schiavo still “a person” ?

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PERATURAN MENTERI KESEHATAN
REPUBLIK INDONESIA
NOMOR 37 TAHUN 2014
TENTANG
PENENTUAN KEMATIAN DAN
PEMANFAATAN ORGAN DONOR

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PENGHENTIAN ATAU PENUNDAAN TERAPI
BANTUAN HIDUP
Pasal 14
(1) Pada pasien yang berada dalam keadaan yang
tidak dapat disembuhkan akibat penyakit yang
dideritanya (terminal state) dan tindakan
kedokteran sudah sia-sia (futile) dapat dilakukan
penghentian atau penundaan terapi bantuan hidup.
(2) Kebijakan mengenai kriteria keadaan pasien
yang terminal state dan tindakan kedokteran yang
sudah sia-sia (futile) ditetapkan oleh Direktur atau
Kepala Rumah Sakit.
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(3) Keputusan untuk menghentikan atau menunda
terapi bantuan hidup tindakan kedokteran
terhadap pasien sebagaimana dimaksud pada
ayat (1) dilakukan oleh tim dokter yang menangani
pasien setelah berkonsultasi dengan tim dokter
yang ditunjuk oleh Komite Medik atau Komite Etik.
(4) Rencana tindakan penghentian atau
penundaan terapi bantuan hidup harus
diinformasikan dan memperoleh persetujuan dari
keluarga pasien atau yang mewakili pasien.

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From Medscape Medical Ethics
Exclusive Ethics Survey:

"Should I Keep This Patient Alive?"


Shelly M. Reese Posted: 11/16/2010

Medscape electronic survey on 10,000 physicians


representing all specialties.
Nearly 5300 answered the question

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"Would you ever recommend or give life-sustaining
1. therapy when you judged that it was futile?"

• 24% yes, would recommend or continue to


give care they knew to be futile
• 37% would not
• 39% would depend on the circumstances

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yes, would
recommend
24%

depends "Would you recommend


39% or give life-sustaining
therapy when you
judged that it was futile?"

would not
37%

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“Would you ever consider
2. halting life-sustaining therapy
because the family demanded it,
even if you believed that it was premature?”

• 55% would not discontinue care,


• 16% would discontinue
• 29% depends on the situation.

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“Would you consider
halting life-sustaining therapy
depends because the family
29% demanded it,
even if you believed that it
was premature?”

continue care
55%

stop
16%

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"Who am I to say what's futile?"

Nancy Berlinger, PhD,


an ethicist specializing in end-of-life issues
at The Hastings Center,
a bioethics research institution in Garrison, New York

Ini orang di Barat sana


yang banyak menganut faham sekuler

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Kita yang Muslim sudah mendapat perintah
lebih dari 1500 tahun yang lalu

……. Barangsiapa memelihara kehidupan


seorang manusia, maka seakan-akan dia
telah memelihara kehidupan semua
manusia…….
Al Maidah : 32

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Jadi, jika pasien
nampak mati

CPR YES?
or CPR NO?

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end

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