ETIKA PELAYANAN

DI RUMAH SAKIT
BUDI SAMPURNA
RSUPN Dr Cipto Mangunkusumo /
Fakultas Kedokteran Universitas
Indonesia
Bolehkah Pasien merekam
gambar, suara atau video di

1
lingkungan rumah sakit?
Isu:
- Keterbukaan Informasi Publk
- Privasi dan Rahasia Kedokteran
- Hak Pasien memperoleh informasi
- Kewajiban RS menjaga hak pasien lain
- Hak Dokter atas kenyamanan kerja
 ETIKA PELAYANAN
DI RUMAH SAKIT
Etika dalam bersikap perilaku
sebagai insan rumah sakit

Etika dalam bersikap dan

perilaku profesi.

Etika dalam membuat

keputusan klinis, secara
individu ataupun secara tim
 ETIKA BERSIKAP-
PERILAKU SEBAGAI INSAN
RUMAH SAKIT
• Pedoman Perilaku atau
Code of Conduct
• Peraturan Disiplin
Pegawai
• Kode Etik Rumah Sakit
• Peraturan Rumah Sakit
• Peraturan Per-UU-an
komitmen terhadap visi-misi dan budaya RS, mutu dan keselamatan pasien,
Komunikasi-informasi-edukasi yang efektif, pelayanan yang bermartabat,
privasi pasien dan rahasia informasi medik, hubungan antar insan rumah sakit,
aset dan properti rumah sakit, keselamatan lingkungan, menghindari benturan
kepentingan, melakukan fungsi pendidikan dan penelitian
ETIKA BERSIKAP DAN
PERILAKU PROFESI
• Kode Etik masing2 Profesi
dan Cabang Profesi
• Peraturan Konsil
• Standar dan Pedoman
• Rekomendasi Organisasi
Profesi
• Tata-tertib akademis
• Peraturan Per-UU-an
• Norma Profesi yang
berlaku internasional/
universal
ETIKA PEMBUATAN
KEPUTUSAN KLINIS
1) Berbasis bukti
2) Kepentingan terbaik
pasien
3) Preferensi pasien/keluarga

Memanfaatkan:
1) Teori Etika
2) Kaidah Dasar Bioetika
3) Clinical Ethics
 A RM NO M
H ARG
ST D O NO Penerapan IN, N
O MI
FIR SSIO
KDB dalam RS N
isu etika perilaku:
• bersikap ramah, penuh
perhatian, dan peduli;
• berkomunikasi dengan
efektif, informatif dan
edukatif;
• fokus dan tidak terpecah
perhatiannya dengan alat
komunikasi dan gadget;
• tidak membicarakan hal-
ihwal yang tidak ada
hubungan dengan pasien
Antar Profesional
• saling menghormati secara
keprofesian,
• bersikap informatif dan
kooperatif,
• berkolaborasi dalam
memberikan pelayanan.
• tidak memburukkan tenaga
kesehatan lain di depan
pasien,
• jujur dan tidak berbohong
Keputusan • mempertimbangkan indikasi
Klinis ? (beneficence),
• kontra-indikasi dan efek
samping (non-maleficence),
persetujuan pasien
(autonomy),
• pertimbangan cost-benefit,
• pilihan tindakan dengan
variasi sumber daya,
• pilihan sumber daya,
• pilihan kualitas hidup yang
ditargetkan
penilaian atas:
• indikasi medis,
• patient preference,
• quality of life, dan
• contextual features
(clinical ethic s dari Jonsen
and Siegler)
 Keputusan klinis kadang sulit
DILEMMA diputuskan karena adanya
pertentangan nilai etika
antara dua atu lebih pilihan
keputusan (dilemma etik).
Pada keadaan tersebut
harus di-dialog-kan terlebih
dahulu pilihan-pilihan
tersebut dengan
membandingkan argumen
etik sebagaimana di atas.
HUKUM mempermudah
atau mempersulit
Keputusan Klinis???
• Aborsi karena mendahulukan
kepentingan kehidupan IBU
• Apakah kehamilan akan
membahayakan IBU?

• Aborsi pada kehamilan akibat

perkosaan
• Harus dilakukan selambat-
lambatnya usia 6 minggu
• Mungkinkah membuktikan
akibat perkosaan saat itu?
HUKUM mempermudah
atau mempersulit
Keputusan Klinis???
• Transplantasi Organ harus
sukarela dan tidak diskriminatif
• tidak boleh atas dasar JUAL-BELI
(ada transaksi finansial),
• Hanya boleh utk yg related (darah)

• Apakah ucapan terima kasih

tidak dibolehkan?
• Apakah saudara atau teman
tidak boleh menyumbang?
• Apakah resipien tidak boleh
membayari pendonor?
 - bagaimana insan rumah sakit
Etika Pelayanan Umum
bersikap dalam melayani
pasien dan/atau keluarganya
- di poliklinik rawat jalan,
pelayanan penunjang, rawat
inap, ruang rawat darurat,
intensif, kamar operasi,
pemulihan

- general consent, advance

directive, informed consent,
rekam medis,
jaminan/asuransi, surat
keterangan, family meeting,
keluhan atau komplain
Etika pelayanan pediatri, lanjut
usia, pelayanan gawat darurat,
pelayanan intensif, pelayanan
paliatif, pelayanan dengan
ventilator, pelayanan kesehatan
reproduksi, pelayanan berupa
tindakan atau intervensi tertentu,
pelayanan berisiko tinggi,
pelayanan berbiaya tinggi,
pelayanan anestesi dan animasi,
bedah plastik, estetika, Pengembangan Etika
pelayanan transplantasi, Pelayanan Khusus
pelayanan sel punca
ANTAR PROFESI Setiap tenaga kesehatan wajib
menghormati profesi tenaga
kesehatan lainnya sebagai
profesional,
mereka harus berkomunikasi
dengan baik dan jelas.

Kerjasama dapat dalam

bentuk kerja dalam satu
team, dimana masing-masing
harus saling menghormati
dan memahami peran dan
kapasitas serta
tanggungjawab masing2
ANTAR PROFESI
Kerjasama dapat dilakukan
dalam bentuk kerja bersama
berupa pendelegasian
(tanggungjawab tetap
berada di tangan pemberi
delegasi), perujukan
(pemindahan
tanggungjawab), dengan
memperhatikan proses
serah terima pekerjaan
tersebut.
 Ethical and
Medico-legal
Aspects in Hospital
Services:
Beginning and End
of Life
 KAIDAH DASAR BIOETIKA
 AUTONOMY
 Menghormati hak otonomi pasien
 BENEFICENCE
 Ditujukan
untuk kebaikan pasien
 Tetap mempertimbangkan benefit dg risk
 NON MALEFICENCE
 tidak memperburuk, primum non nocere
 JUSTICE
 fairness, distributive justice
 Isu Klasik yg Universal
 Hak Pasien
 Kode Etik Profesi
 Rahasia Kedokteran
 Pelepasan Informasi Kesehatan
 Pembuatan Keputusan berdasar Informasi
 Penolakan perawatan/pengobatan
 Kontrasepsi, Aborsi, SC atas permintaan
 Pasangan dengan HIV
 etc
 Hak Pasien
Specific Issues :
• Bukan pasien (mis imunisasi, masyarakat
sekitar), tapi ber-risiko
• Promosi dan pencegahan, sekaligus deteksi dini
risiko dan manajemen risiko
• Persalinan bukan "tindakan medis", pilihan
pasien
 It is believed that:
 All patients are presumed to have medical
decision-making capacity unless
determined otherwise
 Mentally competent adults have the right
to accept or reject treatment, even if such
decisions result in harm or death
 All medical interventions require implied or
explicit informed consent

But NOT to say: “patient should get what he/she want”

 When the patient lacks
decision-making capacity
 The surrogate makes the decision (usually
a next-of-kin). Problems raised when:
 Family members are divided over treatment
decisions
 No designated surrogate
 Patient preferences are unknown
 Competent patient can execute an
advance directive document:
 Definethe type and extent of end-of-life care
 Delegate to someone to decide
Etik pada awal
kehidupan
 ISU DOMINAN
 PRA-KONSEPSI
 FGM, Genetic counseling, therapy, contraception,
sterilization
 KONSEPSI
 Assisted conception, non traditional parentage
 PASCA KONSEPSI
 Prenatal injuries, abortion, paternity, discrimination
based on pregnancy
 PERSALINAN
 Wrongful birth, wrongful life, on request caesarian
section
FIGO, 2006
 FGM menurut WHO
1. mengangkat seluruh atau sebagian klitoris, atau
mengangkat preputium,
2. Mengangkat seluruh atau sebagian klitoris dan
labia minora, dengan atau tanpa memotong labia
mayora,
3. menyempitkan pintu masuk vagina (infibulasi)
dengan cara memotong dan mereposisi labia,
dengan atau tanpa mengangkat klitoris,
4. Lain-lain tindakan yang berbahaya terhadap
genitalia tanpa indikasi medik, seperti menusuk,
menindik, menyayat, mengerok (scraping) atau
mengkauter (membakar).
 Sex selection
 The international context of sex selection is
grounded in a setting where the majority of
women are disadvantaged in enjoyment of
economic, social, educational, health, and
other rights.
 Sex selection is of particular ethical concern
when it is driven by value differences
ascribed to each sex or that arise from
pervasive gender stereotypes.
 The use of sex selection to avoid sex
linked genetic disabilities is generally
considered justifiable on medical grounds.
FIGO, 2006
 DONATION OF GENETIC MATERIAL
FOR HUMAN REPRODUCTION
 The donation of genetic material whether sperm, oocyte
or preembryo, in order to create a child raises a number
of ethical as well as social, religious, and legal issues.
 The donation of genetic material should be altruistic and
free from commercial exploitation. Reasonable
compensation for legitimate expenses is appropriate.
 No genetic material should be used for donation without
the formal written consent of the donor, the recipient
and the recipient’s legal partner (except in the case of
single women). Withdrawal of consent must be accepted
in certain circumstance (e.g. divorce).
 INDONESIA: Tidak diperkenankan, kecuali dari
suami dan isteri yang sah
FIGO, 2006
 THE USE OF EMBRYONIC OR FETAL TISSUE
FOR THERAPEUTIC CLINICAL APPLICATIONS

 The use of embryonic or fetal tissue or cell

transplants for improving or curing disease
should be regarded with the same rules
pertaining to therapeutic transplantation in
general.
 RI: the use of embryonic tissue/cell
is not allowed

FIGO, 2006
 SURROGATE MOTHERHOOD
 The Committee was concerned that
surrogacy generally might violate certain
family values.
 Surrogacy can be applied only in cases of
very limited special indications (majority
opinion).
 The autonomy of the surrogate mother
should be respected and the surrogate
arrangement should not be commercial
(organized by agencies).
 INDONESIA: not allowed FIGO, 2006
 Bagaimana dg transplantasi uterus?
 HIV & Reproductive
 Physicians have a duty, therefore, to provide not
only individual counsel and care for patients but
also public advocacy to protect them from unfair
and punitive actions.
 The mother to child transmission (MCT) risk can
be reduced from 15 – 35% to below 2% with
ARV treatment, particularly during the third
trimester, the avoidance of breast feeding, and a
carefully timed and planned mode of delivery.
 Important: Informed decision
FIGO, 2006
 Mother and fetus
 Once a pregnant woman has been declared
dead because of brain death, or death is
imminent due to lack of circulatory and
respiratory functions, the life and well-being
of her fetus become a matter of urgent
consideration.
 Among the issues to be considered are:
 a) the viability of the fetus
 b) the probable health status of the fetus
 c) any wish expressed by the mother
 d) the views of her partner and/or family
members.
FIGO, 2006
 SC for non medical reasons
 The medical profession throughout the world
has been concerned for many years at the
increasing rate of Caesarean delivery. Many
factors, medical, legal, psychological, social and
financial have contributed to this increase.
Efforts to reduce the excessive use of this
procedure have been disappointing.
 available evidence suggests that normal
vaginal delivery is safer in the short and
long term for both mother and child.
Surgery on the uterus also has
implications for later pregnancies and
deliveries
FIGO, 2006
 Severely malformed fetus
 The Committee agreed that a woman carrying
a severely malformed fetus had the ethical
right to have her pregnancy terminated.
 The qualification ‘severe’ is used in this context
to indicate malformations that are either
potentially lethal or whose nature is such that
even with medical treatment they are likely, in
the view of the parents and their medical
advisors, to result in unacceptable mental
and/or physical disability.
FIGO, 2006
 Severely malformed fetus
 In multiple pregnancies involving both
malformed and normal fetuses, the right of
the normal fetus to survive should take
precedence in decision making, except of
course in the rare instance of the mother’s
health being put at risk.
 The decision to terminate a pregnancy
should rest primarily with the parents. No
medical or governmental coercion for
financial or demographic reasons should be
brought to bear on them.
FIGO, 2006
 Anencephaly and transplantation
 When an infant is born with signs of life but has
no forebrain (anencephaly) and hence has no
prospect of survival, this infant may be
declared brain dead, and with parental
permission may be placed on a ventilator
for the purpose of organ donation.
 Local legal definitions of death are binding
but it is felt that these have to be reviewed to
catch up with scientific development.

FIGO, 2006
 Collection of cord blood
 The discovery that umbilical cord-blood provided
a rich source of haemopoietic stems cells used in
transplantation in diseases such as leukaemia,
has led to the organised collection of blood from
this source and its retention in cord-blood banks
until required.
 In some countries the process of collecting,
(private) banking and using the cord-blood of
term infants has been commercialized.
 Public banking should be encourage
 Etik: Jaminan apa bagi penyimpan ? FIGO, 2006
 Severely malformed newborn infant
 The Committee recognised that newborn
infants with severe malformations
have the right to be allowed to die
with dignity, without inappropriate or
futile medical intervention when it is the
considered view of both the parents and
their doctors that this course is in the
child’s best interest.
 Analogi (?) : indikasi kedaruratan medis
aborsi (pasal 75 UU Kes) FIGO, 2006
 CONTRACEPTION
 Everyone has the right to decide on the
number and spacing of their children.
 Hysterectomy solely for the purpose of
sterilisation is inappropriate, because of the
disproportionate risks and costs.
 Acceptable sterilisation services are those which
are delivered in a way that ensures that the
person gives their fully informed consent,
respects their dignity, guarantees confidentiality
and is sensitive to their needs and perspectives

FIGO, 2006
 STERILIZATION
 Sterilisation should be available to any person
who has reached the age of majority.
 No minimum or maximum number of children
may be used as a criteria for access to
sterilisation.
 The partner’s consent must not be
obligatory (PP Kespro: pasangan sah wajib
mendukung pilihan metode kontrasepsi)
 Some physicians may, because of their
own beliefs, object to sterilisation
FIGO, 2006
 ABORTION
 An anti-progestin has been marketed as a
safe and effective method for the medical
termination of pregnancy. However its
introduction has been associated with
widespread controversy.
 Unsafe abortion of an unwanted
pregnancy is estimated to be
responsible for the death of a woman
every three minutes throughout the
world
FIGO, 2006
 INDUCED ABORTION
FOR NON-MEDICAL REASONS
 Abortion is very widely considered to be
ethically justified when undertaken
for medical reasons to protect the life
and health of the mother in cases of molar
or ectopic pregnancies and malignant
disease.
 Most people would also consider it to be
justified in cases of incest or rape, when
the conceptus is severely malformed, or
when the mother’s life is threatened by
other serious disease.
FIGO, 2006
 INDUCED ABORTION
FOR NON-MEDICAL REASONS

 The use of abortion for other social

reasons remains very controversial
because of the ethical dilemmas
 Abortions for non-medical reasons when
properly performed, particularly during the
first trimester when the vast majority take
place, are in fact safer than term
deliveries.

FIGO, 2006
 Pasal 75 UU Kes
 Aborsi dilarang
 Pengecualian pada:
 indikasikedaruratan medis, baik bagi ibu atau
anak, termasuk cacat atau kelainan yang
membahayakan atau tidak dapat hidup
 akibat perkosaan
 dilakukan melalui konseling
 Pasal 76 UU Kes
 Aborsi sbgmn pada pasal 75 dilakukan:
 dilakukan oleh nakes yang kompeten dan
berwenang
 atas persetujuan si ibu hamil
 dengan izin suami, kecuali korban perkosaan
 sebelum usia 6 minggu, kecuali kedaruratan
medis
 di fasyankes yang memenuhi persyaratan
yang ditetapkan Menteri
Baca : Peraturan Pemerintah tentang Kesehatan
Reproduksi
 ISU UTAMA pada aborsi:
 Kapankah dimulainya suatu kehidupan
manusia ?

 Fakta: IUD dan Bayi tabung

 Sumpah Dokter: bergeser dari menghormati
kehidupan manusia “sejak konsepsi” menjadi
“sejak awal kehidupan”
 Agama Islam:
5 Alam kehidupan manusia : alam ruh, alam
rahim, alam dunia, alam barzah, alam akherat.
 Awal kehidupan: Mulai ditiupkannya ruh
 CLONING
Pengertian:
 “mereproduksi aseksual”
 “membuat copy genetik atau serangkaian
copy dari suatu organisme”, atau
 “fusi atau insersi suatu inti sel diploid ke
dalam sebuah sel telor (oocyte)”.

Macam:
 molecular cloning, cellular cloning dan
embryonic cloning
CLONING UNTUK REPRODUKSI?
 Ancaman thd individualitas
Kitcher “There will never be
 Philip
another you ”
 Playing God
 Reproduksi tidak melalui cara yang
biasa / layak (aseksual)
 Hak anak atas masa depan yang terbuka
 Anak dianggap telah diarahkan
pertumbuhan dan perkembangannya
 Kebebasan keinginan (free will)
 Autonominya hilang karena diatur
pembuat kloning
 AGAMA MENGAJARKAN
REPRODUKSI “LUAR BIASA”
 Penciptaan manusia dari tanah
 Penciptaan Hawa dari tulang rusuk Adam
 Penciptaan Isa Almasih tanpa peran
sperma

Apakah itu sekedar “mujizat” ataukah

petunjuk kepada manusia untuk reproduksi
dengan cara yg “luar biasa” ?
End of Life
Care
Indonesian Penal (Criminal) Code
Article 338
 The person who with deliberate intent
takes the life of another person, being
guilty of manslaughter, shall be
punished by a maximum imprisonment
of fifteen years.
Barang siapa dengan sengaja merampas nyawa orang lain, diancam
karena pembunuhan dengan pidana penjara paling lama lima belas
tahun

Withholding and withdrawing ?

Stopping futile treatment ?
 Penal (Criminal) Code

Article 344
 Any person who takes the life of
another person at his explicit and
earnest desire, shall he punished by a
maximum imprisonment of twelve
years.
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.

Euthanasia ?
 Penal (Criminal) Code
Article 345
 Any person who with deliberate intent
instigates another to commit suicide, aids
him thereby or provides him with the
means thereto, if the suicide ensues, shall
be punished by a maximum imprisonment
of four years.
Barang siapa sengaja mendorong orang lain untuk bunuh diri, menolongnya
dalam perbuatan itu atau memberi sarana kepadanya untuk itu, diancam
dengan pidana penjara paling lama empat tahun kalau orang itu jadi bunuh
diri.
Physician Assisted suicide ?
 FACTS :
 Some countries criminalize suicide and
similar acts
 Some other countries legalize suicide,
physician assisted suicide, euthanasia,
living will, nutrition and hydration
termination, withdrawing & withholding
life supporting treatments, etc
 Some beliefs allow certain kind of suicide
 Potential Legal Exposures

 Forgoing (withholding or
withdrawing) life-sustaining treatment
 Stopping futile treatment
 Assisted suicide and euthanasia
 Failure to adequately treat pain
 Care of Patients in ICU
 Patients who are hospitalized in the ICU should
have a care conference to define the goals
of care within 5 days of admission, and
have such meetings every 7 days during their
stay in the ICU, not to discuss “withdrawal of
support” but rather to focus on the
complexity of multidisciplinary care
 It is morally and ethically permissible to
withhold a treatment or withdraw a treatment
once started if it is not consistent with a
patient’s goals of care
 Dampak penghentian “terapi tertentu”

There is a distinct difference between hospice and palliative care in that palliative
care can be provided at any point in the continuum of illness and is not synonymous
with dying or “giving u
 Common practices
 An adult with decision making capacity
may choose to forgo life sustaining
therapy
 An advance directive serves to legally
express the patient’s wishes when he or
she is no longer able to do so
 In the event there is no advance directive,
the patient’s surrogate decision maker
makes the decision

SY Tan, University of Hawaii, 2006

 Common practices
 Disputes tend to arise when:
 the legitimate decision maker is not
well identified,
 the wishes of the patient are unclear;
 the patient is not terminally ill; and
 the decision concerns “ordinary
treatment” such as artificial nutrition
and hydration

SY Tan, University of Hawaii, 2006

 Diskusi
 Apakah tindakan forgo (withholding and
withdrawing) dan menghentikan
pengobatan yang sia-sia dapat dikatakan
sebagai tindakan euthanasia?
 Benarkah tindakan membiarkan pasien
yang menderita “nyeri yang berlebihan”
dapat dianggap sebagai pelanggaran hak
asasi manusia?
 Euthanasia
 Euthanasia is the intentional premature
termination of another person's life either
by direct intervention (active euthanasia)
or by withholding life-prolonging measures
and resources (passive euthanasia), either
at the express or implied request of that
person (voluntary euthanasia), or in the
absence of such approval (non-voluntary
euthanasia)
 WMA, Sept 1987
 Euthanasia, that is the act of deliberately
ending the life of a patient, even at the
patient’s own request or at the request of
close relatives is unethical.

 It does not prevent the physician from

respecting the desire of a patient to allow
the natural process of death in the terminal
phase of sickness
 WMA, Sept 1992
 Physician assisted suicide, like euthanasia,
is unethical and must be condemned by the
medical profession

 However, the right to decline medical

treatment is a basic right of the patient and
the physician does not act unethically even
if respecting such a wish resulting in the
death of the patient.
 Withholding / Withdrawing
Stopping a futile treatment
 In this case, the death of the patient is not
the result of the action, but merely as the
natural consequence of the diseases or
the underlying medical conditions, which
are untreatable and the patient is
terminally ill.
 The better terminology is “Letting die
naturally”
Just like the other medical intervention / treatment, this action
need an adequate written consent from the authorized persons
 Penuhi persyaratan
 Syarat :
 Terminal
 Medis: futile
 Tim, konsul Komdik & KEH
 Diinformasikan dan memperoleh persetujuan kel
 Keputusan direktur
 Permintaan pasien: advanced directive,
atau
 Permintaan/persetujuankeluarga: Informasi
adekuat, Keputusan keluarga dengan
memperhatikan “keinginan pasien”
 Yg dapat dihentikan/ditunda
 Rawat di Intensive  Organ artifisial;
Care Unit;  Transplantasi;
 Resusitasi Jantung  Transfusi darah;
Paru;  Monitoring invasif;
 Pengendalian  Antibiotika; dan
disritmia;  Tindakan lain yang
 Intubasi trakeal; ditetapkan dalam
 Ventilasi mekanis; standar pelayanan
 Obat vasoaktif; kedokteran.
 Nutrisi parenteral;
 Yg tidak boleh dihentikan
 oksigen,
 nutrisi enteral dan
 cairan kristaloid (hidrasi).
 Opinion of the Indonesian
Medical Ethics
 In a living patient, where a therapeutic
or palliative treatment is no more
useful, it will be against the aim of the
medical science, then the treatment
can be withdrawn
 Those decisions should be consulted with
at least another physician.

FATWA IDI NO 231/PB/.4/07, 1990

 Assisted suicide & Euthanasia
 The intention is to take the life of
another.
 The death of the patient is the direct
result of the action
 The patient request proves that the
intention is to make the patient die as
requested, either by committing suicide or
by being euthanized
Considered as Unethical and Illegal Actions
Common Issues :

Do Not Resuscitate
 Issues
 In which case DNR can be applied / advised?
 With whom should DNR status be discussed?
 Who should discuss DNR status, and when?
 What should be discussed?
 How should the discussion be documented?
 What if the patient refuses a DNR status?
 Can the patient’s surrogate decision-maker
override a previously expressed desire for DNR
status?
 Reasons
 Studies have shown that although some
patients with metastatic cancer may
initially respond to cardiopulmonary
resuscitation (CPR), the chances of
survival to discharge are minimal to nil.
 The procedure may be physically
traumatic, and may lead to the patient
spending his or her final hours or days in
an intensive care setting.
 Information
 DNR should be addressed in the
context of a broader discussion about
the patient’s understanding of his or
her illness and prognosis, and goals
of care.
 In order to be able to make an informed
decision, the patient should be made
aware of the benefits and burdens of CPR.
 It should be clarified that agreement to
DNR status does not preclude other
supportive measures
 Documentation
 It is not necessary for the patient to
sign consent to DNR status.
 Rather, documentation should be made of
the names and relationships of those who
participated in the discussion, the content
of the discussion, and the decision
Common Issues

Determination of Death
 Facts
 Increasing ability of the medical
community to resuscitate people with no
heart beat, respiration or other visible
signs of life
 The use life support equipments, which
can maintain body functions indefinitely
 Rising capabilities and demand for organ
transplantation, incl. heart beating and
non-heart beating brain death
 Indonesia
 The Law Nr 36 year 2009 reg Health (Art 117):
 Seseorang dinyatakan mati apabila fungsi
sistem jantung- sirkulasi dan sistem pernafasan
terbukti telah berhenti secara permanen, atau
apabila kematian batang otak telah dapat
dibuktikan.
 SK IDI No 336/PB/A.4/88 and Fatwa in 1990 :
 someone is declared death if irreversible cease
of spontaneous cardiac and respiratory
functions are proved, or if a brain death is
proved
 Ethical and legal issues

 When the death of somebody can be

declared ?
 What is the criteria ?
 How to determine ?
 Who is authorized to do that ?
(particularly on brainstem-death cases)

Failure to determine the death could lead to situation,

in that a medical procedure is killing or futile in nature
 Diagnosis of Brainstem Death
 Declared by a team of 3 competent
physicians, should include SpAn and SpS,
exclude transplantation team member
 Each physician do the test separately
 The test shall be done in ICU
 Inclusive and exclusive criteria and test
procedures as stated in Permenkes.

Further reading: Permenkes 37/2014

 Take Home Message
 If the hospital staffs maintain their ethical
and personal responsibilities to their
patient and are diligent in the
performance of their functions, they are
maintaining the obligations established by
law and ethics.
 Their activities must be supported by a
continuing concern for the welfare of the
patient.
TERIMA
KASIH