MEDICOLEGAL ASPECTS IN

WITHDRAWAL OF MECHANICAL
VENTILATOR ON BRAIN DEATH PATIENT
Arum Nurlatifah
Chairizal Meiristica Yanha
Imam Fahri Rizki
Noer Rizky Helga
Ronald Van Basten Hutagaol
Sondang Virginia
Dosen penguji:
dr. Arif Rahman Sadad, Sp.F, S.H, Msi.Med, DHM
Residen pembimbing:
dr. Elisa Rompas M.Kes

BACKGROUND
In the modern era,
the determination of
death became
indefinite.

Advanced
development of
medical
technologies

Withdrawal of lifesupport devices e.g.

Ventilator presumed as
euthanasia

WHAT DOES IT MEAN BY.....

TERMINAL CONDITION,
BRAIN DEATH, AND
VENTILATOR

Terminal Condition/End
of Life
An incurable and irreversible condition
caused by injury, disease, or illness that
would cause death within a reasonable
period of time in accordance with
accepted medical standards, and where
the application of life-sustaining treatment
would serve only to prolong the process of
dying.

Acute

Respiratory

Respiratory

Failure

Failure

Hypercapnia

Others

Hypoxemia
Acute

Chronic

Restrictive

Respiratory

Obstructive

Lung Disease

Distress

Pulmonary

Syndrome

Disease

(ARDS)
Acute Lung

Asthma

Oedema
Flail Chest

Pneumothorax

Unilateral
Lung Disease

Guillain Barre

The increase

Syndrome

of TIK

BRAIN
DEATH
Uniform Determination of Death Act, 1980:
An individual who has sustained either
(1)irreversible cessation of circulatory and respiratory
functions or
(2) irreversible cessation of all functions of the entire
brain, including the brainstem, is dead. A determination
of death must be made in accordance with accepted
medical standards.
Harvard Medical school, 1985
Not respond to intensive noxius stimulation
(unresponsive coma).
Loss of the ability to breathe spontaneously.
Loss of brain stem and spinal reflexes.
Loss of postural activities like decerebration.
Flat EEG.

The main
considerations in the
diagnosis of brain
death :
1) The loss of
cerebral function
2) The loss of
brainstem function
including
spontaneous
respiration
3) As irreversible.
Sunatrio S. Penentuan Mati .
Bagian Anestesiologi
:FKUI/RSCM ,2006

Clinical Criteria for Brain

Death in Adults and Children

Coma
Absence of motor
response
Absence of pupillary
responses to light and
pupils at midposition.
Absence of corneal
reflexes
Absence of caloric
responses

Absence of gag
reflex
Absence of
coughing in
response to
tracheal suctioning
Absence of
respiratory drive at
PaCo2 that is
60mmHg or
20mmHg above
normal baseline

VENTILATO
R
A machine that supports
breathing. It helps to get oxygen
into the lungs, and remove
carbon dioxide from the lung.
Ventilator can fully/partially
supports the ventilation for
people who have lost all ability to
breathe on their own to maintain
the oxygenation.

Goals of using ventilator to patients:

Provide adequat alveolar ventilation
Improving the oxygenation procces
reducing respiratory work

Indication
1.

Respiratory failure
Respiratory failure is a syndrome in which the respiratory system fails in one or
both of its gas exchange functions: oxygenation and carbon dioxide elimination.
hence intubation, with subsequent mechanical ventilation is considered.

2.

Cardiac insufficiency
In some cardiac insufficiency such as cardiogenic shock or CHF, the use of
mechanical ventilator helps to reduce respiratory systems loads.

3.

Neurological dysfunction
Patients with GCS< 8 have a bigger risk to recurrent apneu.

4.

Surgery
In surgery, the use of ventilator supports anesthesia and sedative administration.

Procedure of Medical Ventilator Application

1.
2.
3.
4.
5.
6.

7.
8.

The mode of ventilation should be tailored to the needs of the patient.

FiO2 is started from 1,0, and can be reduced depends on patients O2 saturation.
Tidal volume : 8-10 ml/KgBB ( Volume cycle ), PIP 20 cm H2O ( Pressure cycle ).
Adjust the respiratory rate. A respiratory rate (RR) of 8-12 breaths per minute is
recommended for patients who are not requiring hyperventilation for the
treatment of toxic or metabolic acidosis, or intracranial injury.
Applying PEEP. 3-5 cm H2 O is common to prevent decreases in functional residual
capacity in those with normal lungs.
If the inspiratory pressure reduction is needed, these following strategies can be
used :
- By decreasing the flow rate.
- By decreasing the tidal volume
If the mode of ventilation requires flow rate settings, a proper rate is needed to
prevents respiratory gases accumulation.
Monitor following parameters to evaluate oxygen delivery: Hb, cardiac output,
SP02.

ETHICAL ASPECT
WITHDRAWAL OF MECHANICAL
VENTILATOR ON BRAIN DEATH
PATIENT

BIOETHICS
An interdisciplinary study of the
problems posed by development in
biology and medicine, not only paying
attention to the problems that occurs in
the present, but also take into account
the problems in the future.
F. Abel

Bioethic rule is
an absolute law
for a doctor

Indonesian Medical Council

Indonesian medical practice refers
to 4 basic rules of morality are often
also referred to the basic rules of
medical ethics, like:
Beneficence
Non-maleficence
Justice
Autonomy

Beneficence
The role of the physician to provide patient convenience and pleasure steps to maximize the
results than a bad thing.
Non-Maleficece
A doctor doesn't acts which aggravate the patients and choose a treatment that the smallest risk
for patients treated or treated by him.
Justice
A physician shall respect the dignity and human rights. Every individual should be treated as
human beings who have the rights of self-determination. The patient is given the right to thinki
logically and make his/her own choice.
Autonomy
A doctor is obliged to provide equal and fair treatment for the happiness and comfort of the
patient. Differences in levels of economics, political views, religion, nationality, and social
differences to stand and citizenship shall not change attitudes and physician services to patients.

Legal
aspect

Ethical
aspect

Withdrawal of
Mechanical
Ventilator on
Brain Death
Patient

ETHICAL ASPECTS

Pada Kode Etik Kedokteran Indonesia Bab II tentang kewajiban dokter

terhadap pasien, tidak memperbolehkan mengakhiri penderitaan dan hidup
orang sakit, yang menurut pengetahuan dan pengalaman tidak akan
sembuh lagi (euthanasia) (Kode Etik Kedokteran, 2002).

Dalam pasal 9 Bab II Kode Etik Kedokteran

Indonesia tentang kewajiban dokter kepada
pasien, disebutkan bahwa seorang dokter
harus senantiasa mengingat akan
kewajiban melindungi hidup makhluk insani

Dokter tidak diperbolehkan mengakhiri hidup

seorang yang sakit meskipun menurut
pengetahuan dan pengalaman tidak akan sembuh
lagi. Tetapi apabila seperti contoh pasien sudah
dipastikan mengalami kematian batang otak atau
kehilangan fungsi otaknya sama sekali, maka
pasien tersebut secara keseluruhan telah mati
walaupun jantugnya maih berdenyut.

EUTHANASI
A

pasal 9 Bab II Kode Etik

Kedokteran Indonesia

LEGAL ASPECT
WITHDRAWAL OF MECHANICAL
VENTILATOR ON BRAIN DEATH
PATIENT

EUTHANASIA

EUTHANASIA

1. ACTIVE
2. PASSIVE
3. AUTO-EUTHANASIA
Hanafiah, M. Jusuf, Amri Amir. Etika Kedokteran & Hukum Kesehatan Ed. 3. 1999. Jakarta: EGC. Hal.107

Pasal 338
KUHP
Pasal 340
KUHP
EUTHANASIA

Pasal 344
KUHP
Pasal 345
KUHP
Pasal 359
KUHP

Hanafiah, M. Jusuf, Amri Amir. Etika Kedokteran & Hukum Kesehatan. 1999. Jakarta: EGC.

Pasal 340 KUHP

Pasal
359
KUHP
Pasal
338
KUHP

Barangsiapa dengan sengaja &

Menyebabkan
matinya
direncanakan
Barang
siapa
dengan
sengaja
lebih
dahulu
menghilangkan
seseorang
jiwa
orang lain,karena
karena
bersalah
menghilangkan
jiwakesalahan
orang lainatau
kelalaian,
dipidana dengan
melakukan
pembunuhan
berencana,
karena
pembunuhan
biasa,
pidana
penjara
selama-lamanya
dipidana
dengan
pidana
mati atau
penjara
dihukum dengan hukuman
penjara
limahidup
tahunatau
ataupenjara
pidana sementara
kurungan
seumur
selama-lamanya
lima
belas
tahun.
selama-lamanya
satu tahun.
selama-lamanya
duapuluh
tahun.

Passive
Euthanasia
Barang siapa dengan sengaja menempatkan atau membiarkan
seorang dalam keadaan sengsara, padahal menurut hukum
yang berlaku baginya atau karena persetujuan dia wajib
memberi kehidupan, perawatan atau pemeliharaan kepada
orang itu, diancam dengan pidana penjara paling lama dua
tahun delapan bulan atau pidana denda paling banyak empat
ribu lima ratus rupiah.

PASAL 304 KUHP

Ari Yunanto dan Helmi , 2010, Hukum Pidana Malpraktek Medik, C.V Andi, Yogyakarta,
hal.92.

RELEASING OF VENTILATOR ON
BRAIN DEATH PATIENT
Definition of
Death :
UU Kesehatan
No. 36 tahun
2009 pasal 117
dan
SK PB IDI No.
231/PB.A.4/07/90

UU
No. 36 tahun
SK Kesehatan
PB IDI
2009
pasal 117
No.231/PB.A.4/07/90
Seseorang
dikatakan
mati,
bila
Seseorang
dinyatakan
mati
apabila
fungsi
spontan
pernapasan
dan
fungsi
sistem
jantung
sirkulasi dan
jantung
telah berhenti
sistem
pernafasan
terbuktisecara
telah pasti
(irreversibel),
atau terbukti
berhenti
secara permanen,
atautelah
apabila
kematian
batang otak
telah dapat
terjadi kematian
batang
otak.
dibuktikan

Brain Death = Biological death

= Passive Euthanasia

VS
RELEASING OF VENTILATOR ON BRAIN
DEATH PATIENT

Is Not An Euthanasia

NO CRIMINAL SANCTION

BPJS

HEALTH CARE PLOT

PATIENT
Primary health
care

HOSPITAL

Emergency

CLAIM

BPJS
Branch Office

REFERENCE

LEGAL BASIS
PERATURAN PEMERINTAH REPUBLIK INDONESIANO. 101 TAHUN 2012
TENTANG PENERIMA BANTUAN IURAN
PERATURAN PRESIDEN REPUBLIK INDONESIA
NOMOR 12 TAHUN 2013, TENTANG JAMINAN KESEHATAN
PERATURAN PRESIDEN REPUBLIK INDONESIA NOMOR 111 TAHUN 2013
TENTANG PERUBAHAN ATAS
PERATURAN PRESIDEN REPUBLIK INDONESIA
NOMOR 12 TAHUN 2013, TENTANG JAMINAN KESEHATAN
PERATURAN PEMERINTAH REPUBLIK INDONESIA NO. 86 TAHUN 2013
TENTANG TATA CARA PENGENAAN SANKSI ADMINISTRATIF KEPADA PEMBERI
KERJA SELAIN PENYELENGGARA NEGARA DAN SETIAP ORANG, SELAIN
PEMBERI KERJA, PEKERJA, DAN PENERIMA BANTUAN IURAN DALAM

BPJS and VENTILATOR

Diagram between BPJS, Hospital and Patient

BPJS
Patient
Hospital

Regional 1 Type A Hospital

Regional 1
Type B
Hospital

Regional 1 Type C Hospital

Kode INACBG
J-1-01-I

J-1-01-II

J-1-01-III

J-1-02-I

J-1-02-II

J-1-02-III

Deskripsi Kode INA-CBG

Tarif Kelas 3

Tarif Kelas 2

Tarif Kelas 1

PROSEDUR VENTILASI MEKANIKAL

LONG TERM DENGAN TRAKEOSTOMI
RINGAN
PROSEDUR VENTILASI MEKANIKAL
LONG TERM DENGAN TRAKEOSTOMI
SEDANG
PROSEDUR VENTILASI MEKANIKAL
LONG TERM DENGAN TRAKEOSTOMI
BERAT
PROSEDUR VENTILASI MEKANIKAL
LONG TERM TANPA TRAKEOSTOMI
RINGAN
PROSEDUR VENTILASI MEKANIKAL
LONG TERM TANPA TRAKEOSTOMI
SEDANG
PROSEDUR VENTILASI MEKANIKAL
LONG TERM TANPA TRAKEOSTOMI
BERAT

18.705.922

22.447.107

26.188.291

20.377.880

24.453.455

28.529.031

36.906.033

44.287.240

51.668.446

8.770.331

10.524.398

12.278.464

10.088.019

12.105.623

14.123.227

16.464.073

19.756.887

23.049.702

Regional 1 Type D Hospital

CASE REPORT
An 18 year old girl was brought to the accident and emergency
department of our hospital in suspicion of overdose. She was
transferred to hospital, where a cardiac output was achieved after
further defibrillation. We estimated that she had been without
spontaneous cardiac output for at least 30 minutes. She was
transferred to the intensive care unit for full ventilatory and
inotropic support. Activated charcoal was given nasogastrically.
From the beginning of treatment the family was made aware of
the patient's poor prognosis and the high probability of her death

After 72 hours blood concentrations of the ingested drug had

fallen to the lower end of the thera peutic range, and two sets of
brain stem tests were performed according to national
guidelines. The family had been kept fully informed of the
patient's condition up to this point and were aware that brain
stem testing was being performed.

However, after the declaration of death the family refused to allow

the ventilator to be switched off. The family were unable to accept
that the patient was dead while her heart was still beating. The
hospital was contacted by a lawyer acting for the family and
threatened with an injunction to prevent us from switching off the
ventilator. The doctor sought advice from the management of the
hospital, the hospital's legal advisers, and a medical defence union.
They all advised us not to stop artificial ventilation. Only after 48
hours, and after discussions with representatives of the family and
their general practitioner, did the patient's family eventually agree
to allow us to switch off the ventilator.

CONCLUSION
Medicolegal

aspects of the release of a respirator in

Indonesia in patients with brain stem death is an act
Withdrawing life support. The release of a respirator in
patients with brain stem death in Indonesia is not classified
to the action of passive euthanasia. It is based on the
Health Act number 36 of 2009 Article 117 and fatwa IDI
number 231/7 / .4 / 90.