Ethics in CPREddy Rahardjo 1 Apakah jantung yang berhenti berdenyut itu tanda akhir dari kehidupan ? • Dulu, ya ! • Sekarang, belum tentu. • Ada resusitasi jantung paru (cardio-pulmonary resuscitation) 2 • 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? 3 Resusitasi Tenggelam 30 menit, tidak sadar, tidak bernafas, dingin, biru 4 5 Apakah coma, tidak sadar, itu tanda akhir dari kehidupan ? • Dulu, ya ! • Sekarang, belum tentu. • Ada resusitasi jantung paru otak (cardio-pulmonary-cerebral resuscitation) 6 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. 7 • Etik profesi dokter mewajibkan kita berusaha menolong seseorang yang terancam jiwanya agar hidup kembali 1. Kapan kewajiban itu dimulai? 2. Kapan kewajiban itu berakhir? 8 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 9 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? 10 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 11 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) 12 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 13 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. 14 Medical ethics is a system of moral principles that apply values and judgements to the practice of medicine. edisi 2012 15 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 16 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 17 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 18 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 19 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 20 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 21 1990 The case of Terri Schiavo, 25 years old, previously healthy woman After CPR following cardiac arrest, she sustained PVS (1990) 22 Suami minta pengadilan menghentikan Nasogastric feeding supaya Terri mati 23 Court decision : stop further feeding. Gastric tube was removed. 24 BUT, is Schiavo still “a person” ? 25 PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA NOMOR 37 TAHUN 2014 TENTANG PENENTUAN KEMATIAN DAN PEMANFAATAN ORGAN DONOR 26 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. 27 (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. 28 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 29 "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 30 yes, would recommend 24% depends "Would you recommend 39% or give life-sustaining therapy when you judged that it was futile?" would not 37% 31 “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. 32 “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% 33 "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 34 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 35 Jadi, jika pasien nampak mati CPR YES? or CPR NO? 36 37 end 38