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 Netherland School of Public Health, The Netherland 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 patients 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 (-) Private Good

Public Good

All Aid in Emergency Phase FINISH Avoid the loss of chance to survive

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; 110; 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

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

The 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!!

LEGAL CONCERN IN EMERGENCY-TRAUMA

CONSENT REFUSAL OF TREATMENT CONFIDENTIALITY MANDATORYREPORTING
INFORMED CONSENT EMERGENCY DOCTRINE GOOD SAMARITAN D. PATIENTS COMPETENCY ASSAULT & BATTERY RIGHT TO PRIVACY REPORT TO PUBLIC AGENCY CHILD ABUSE CHAIN OF CUSTODY

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

Patients 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 PATIENTS PROPERTY MEDICAL CERTIFICATION

LIABILITY STANDARD OF CARE ABANDONMENT PATIENTS TRANSFERS DEFINITION OF DEATH DNR INDICATIONS WITHHOLDING&WITHDRA WAL TREATMENT UNCLAIMED DEATH BODIES CHAIN OF CUSTODY

NEGLIGENCE

LIABILITY STANDARD OF CARE ABANDONMENT PATIENTS 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 The death has been declared Sent to the city morgue

DNR INDICATIONS

UNCLAIMED DEATH BODIES

PATIENTS 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
Mass Casualty Identification Rights of victims

Criminal Act? Medicolegal Certification

DISCUSSION

ISSUES TO BE EXPLORED

Dont know his/her limitation of competence Negligence Different opinion amongst the helpers Patients consent Refuse of treatment by the patient Etc, etc

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

POTENTIAL CONFLICT
.

POSSIBLE SOLUTION
.

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

POSSIBLE SOLUTION
.

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

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

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

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

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

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

POSSIBLE SOLUTION
.

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

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

POSSIBLE SOLUTION
.

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

POTENTIAL CONFLICT
.

POSSIBLE SOLUTION
.

POTENTIAL CONFLICT
.

POSSIBLE SOLUTION
.

KEMUNGKINAN KONFLIK
1. Menolak pengobatan (belakangan ) setelah pengobatan dilakkan dalam keadaan tidak sadar 2. Menolak pengobatan karena masalah kultural 3. Menolak pengobatan meninggal, orang lain menuduh penolong tidak bersedia melakukan pertolongan 4. Penolong dijadikan saksi dan direpotkan:
1. Konflik antara penolong dengan pihak lain yang berkepentingan untuk menyelesaikan perkara tersebut (keadaan hukum)

5. Multiple korban, tidak semua bisa ditolong sekaligus. Korban merasa ditelantarkan dan dinomorduakan.

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

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

KEMUNGKINAN KONFLIK
1. Korban yang mati secara klinis. Apkaah akan dilakukan resusitasi? Pertimbangan:
1. Bila dilakukan resusitasi, korban akan mengalami sequele (cacat) 2. Bila tidak ditolong, keluarga marah

2. Penolong dituduh lalai melakukan tindakan pertolongan sehingga menyebabkan kematian.

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

2.
3.

2.

3. 4.

4.

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

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