MEDICO LEGAL ASPECT IN WITHDRAWAL OF

VENTILATOR ON BRAIN DEATH PATIENTS

(ASPEK MEDIKOLEGAL PELEPASAN ALAT BANTU
PERNAFASAN PADA PASIEN MATI BATANG OTAK)
Fachri Setiawan
(UNDIP)
Marcellinus Triyuono D
(UNDIP)
Sylvia Wahyu R (UPN)
Aprillia Tri Noorharsanti
(UNDIP)
Che Wan Nur Hajar
binti Saimi
(UKRIDA)
Dewi Yulianti
(UPN)
Melissa Elperide Damery
(UPN)
Dosen
Oktavianus Gilbert
(UPN) penguji:
dr. Arif Rahman
Sadad, Sp.F, S.H, Msi.Med, DHM
Elsa Alamanda
(UNDIP)
Muhammad Syafiq
(UKRIDA)

Residen pembimbing:
dr. Suryo Wijoyo, MH (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

BRAIN DEATH

Definitions of Brain
Death

Harvard Criteria- Harvard ad hoc group defined cerebral or

brain death in 1968

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.

Allows for determination at the discretion of the

physician.

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

Diagnosis Brain Stem Death

Neurologi Examination
Clinical Prerequisites:
Known Irreversible
Cause

1. Evaluation Coma

2. Absent Brain Stem

Reflexes

Exclusion of Potentially
Reversible Conditions
Core Body temperature
> 32 C

3. Apnea Test

4. Confirmatory Test

COMA

No Response to Painful Stimulus

Nail Bed Pressure
Sternal Rub
Supra-Orbital Ridge Pressure

Absence of Brain Stem

Reflexes

Pupillary Reflex
Eye Movements
Facial Sensation and Motor Response
Pharyngeal (Gag) Reflex
Tracheal (Cough) Reflex

1. Pupillary Refleks

2. Eye movements

3. Facial sensory & motor responses

Corneal Reflex
Jaw Reflex
Grimace to Supraorbital or
Temporo-Mandibular Pressure
Pharyngeal and tracheal reflexes

APNEA TEST

(American Academy of Neurology)

Pre-requisite
Core body tempeature > 32C

Systolic Blood Pressure 90 mm Hg

Normal Electrolytes
Normalize PO2,PCO2 if possible

1. Pre-Oxygenation
100% Oxygen via Tracheal Cannula
PO2 = 200 mm Hg

2.
3.
4.

Monitor PCO2 and PO2 with pulse oximetry

Disconnect Ventilator
Observe for Respiratory Movement until PCO2 = 60 mm
Hg
5. Discontinue Testing if BP < 90, PO2 saturation
decreases, or cardiac dysrhythmia observed

Confirmatory Testing

EE
G

erebral Angiography

Electrocerebral
Silence

No Intracranial
Flow

Technetium-99 Isotope Brain Scan

Transcranial
Ultrasonography

Step Determination
of Brain Stem Death
Diagnosis

Removal of
medical conditions
that can interfere
with the clinical
assessment,
particularly
Neurological
electrolyte
examination to
disturbances, acid
determine whether
- base, or
a person has
absence of severe
endocrine.
suffered brain
hypothermia,
death or not can
defined as a
be made only if
temperature
the following
greater than or
requirements are
equal to 32oC.
No
evidence
met
of drug
intoxication,
poison, or
agent of
neuromuscul

Steps determination of brain stem death

include the following:
1. Evaluation of cases of coma
2. Provide an explanation to the patient's family about the
current state
3. The initial clinical assessment of brain stem reflexes
4. The period of observation intervals
a. Up to the age of 2 months, the period of observation
intervals of 48 hours
b. Age more than 2 months - <1 year, 24-hour period of
observation intervals
c. More than 1 year of age - <18 years, 12-hour period
of observation intervals
d. Age 18 years and above, the period of observation
intervals ranging from 6 hours
5. Clinical assessment on brain stem reflexes
6. Test apnea
7. confirmatory examination if there are indications
8. Preparation of suitable accommodation
9. Certification of brain stem death
10. Termination advocates cardiorespiratory

VENTILATOR

Definition of Mechanical
Ventilator
Ventilator mekanik adalah alat
yang dapat membantu atau
mengambil pertukaran gas di
dalam paru untuk
mempertahankan kehidupan.
(SOP RSUP DR.Kariadi. Semarang, 2008)

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

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.

General Term
Fi02 - Inspired oxygen
concentration.
Peak Inspiratory
Pressure (PIP)
Positive end-expiratory
pressure (PEEP)
Respiratory Rate (RR)
I:E Ratio (InspiratoryExpiratory ratio)
Flow Rate

Procedure of Medical Ventilator

Application
1.
2.
3.
4.

5.
6.

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 :

7.

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.

Ventilator
Weaning
gradual
withdrawal
of
ventilatory
support.
to induce
spontaneou
s ventilation

Ventilator
Withdrawal
Immediate
discontinuation
of mechanical
ventilation
Rapid Reduction
(dialing down the
ventilator
settings stepwise
for Fi02, PEEP,
respiratory rate,
and volume or
pressure)

Ventilator Withdrawal
1.
2.
3.

4.

Reduce alarm settings (apnea, heat, etc.) to minimal settings or,

if possible, turn them off.
Over 0-5 minutes, reduce FiO2 to room air and PEEP to zero.
You may want to wait a while at this point, expecting the patient
to expire, or you can proceed over 0-15 minutes to reduce the
respiratory rate and tidal volume or target pressure on the
ventilator to 0.
Concerning the airway:
Extubate patient to room air, wrapping the ET tube, or
Remove connection to the ventilator, keeping the ETT or tracheostomy
in place.

5.
6.

If tracheal secretions are bothersome, an in-line suction catheter

can be attached to the ETT without supplemental O2 or humidity.
Note time of death, if it occurs.

. Determine if premedication is necessary: if the patient is

capable of experiencing distress or if distress is likely during the
withdrawal procedure, continue current analgesia and sedation

Legal
aspect

Ethical
aspect

Withdrawal of
Mechanical
Ventilator on
Brain Death
Patient in
Malaysia

Legal
Aspect

Guideline of
The Malaysian
Medical
Council tahun
2006

Brain
Death

- Biological
death
- Is a clinical
diagnosis

Withdrawa
l of
ventilator
on brain
death
patient

Is not an
euthanasi
a

No
criminal
sanction

Is one of the
indicators of
ventilator
withdrawal

Brai
n
deat
h
Consensus on
Withdrawal and
Withholding of life
support in The Critically
Ill year 2004

Ethical Aspect :
Consensus on Withdrawal and
Withholding of life support in The
Critically Ill year 2004
Preservation of life
which is frequently
tempered by the
second principle

Relief of suffering

first do no harm

Respect the
autonomy of
patients

Concept of a just
allocation of
medical resources

To be truthful to
the patients and
family about
patients condition

What Malaysia said about Brain

Death?
According to the Guideline Brain Death
issued by the Malaysian government in
2006, patients with brain death is
considered as biological death.
Brain death is a clinical diagnosis

Withdrawal of life support is lawful at the

patients request at common law and in
a few countries by legal statute

Withdrawal of mechanical
ventilator on brain death patient
Malaysia
Guideline Brain
Death yang
diterbitkan oleh
pemerintah
Malaysia pada
tahun 2006

DIFFEREN
CES IN
MEDICOLEGAL ?

NO

Indonesia

definisi kematian
menurut UU
Kesehatan No. 36
tahun 2009 pasal 117
dan fatwa IDI nomer
231/7/.4/90

Brain Death = Biological

death
= Passive