02 Legal and Ethical Aspect of Medical Emergencies - Dr Herkutanto SH, FACLM

8/6/2019 02 Legal and Ethical Aspect of Medical Emergencies - Dr Herkutanto SH, FACLM

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LEGAL AND ETHICAL ASPECTLEGAL AND ETHICAL ASPECTOF MEDICAL EMERGENCIESOF MEDICAL EMERGENCIES

Dr.Herkutanto, SH, FACLM Dr.Herkutanto, SH, FACLM


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HH erkutantoerkutanto Department of Forensic Medicine & Medicolegal Department of Forensic Medicine & Medicolegal

Faculty of Medicine University of IndonesiaFaculty of Medicine University of IndonesiaPh.D in Forensic MedicinePh.D in Forensic MedicineFellow of Australian College of Legal MedicineFellow of Australian College of Legal Medicine

Medical & Medicolegal QualificationsMedical & Medicolegal Qualifications

University of IndonesiaUniversity of Indonesia Faculty of Medicine Faculty of Medicine Monash University Monash University , Australia, Australia Faculty of Medicine Faculty of Medicine Netherland School of Public Health Netherland School of Public Health , The Netherland, The Netherland

Qualifications in Health LawQualifications in Health LawUniversity of IndonesiaUniversity of Indonesia Faculty of Law Faculty of Law

La Trobe University, Australia La Trobe University, Australia - - School of LawSchool of Law

International AssignmentsInternational Assignments Medicolegal ConsultantMedicolegal ConsultantWorld Health OrganizationWorld Health Organization 19891989United Nation Funds for Populations ActivitiesUnited Nation Funds for Populations Activities 1992, 19941992, 1994

John Hopkins University, 2003 John Hopkins University, 2003


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OBJECTIVES

1) To understand Ethical and Legal

Aspect in a medical emergencies andits circumstances

2) To understand the scope of duties and

obligations in medical emergencies3) To understand consent in medical

emergencies


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EMERGE NCY ( definition )

Any conditions that in the opinion of thepatient, his family, or whoever assumes theresponsibility of bringing the patient to thehospital requires immediate medicalattention . This condition continues until adetermination has been made by a

healthcare professionals that the patientslife or wellbeing is not threatened.

American Hospital Association


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EMERGENCY PHASE

Pre Hospital HospitalPublic >> Medical PersonelGood Samaritan Doc P-P Relationship

voluntarism (- )pre-existing (- )

Public Good Private Good

All Aid in Emergency Phase FINISH

Avoid the loss of chance to survive


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ROLE OF MEDICAL FIRSTROLE OF MEDICAL FIRSTRESPONDER RESPONDER

ACCESS TO THE VICTIMAND COMMUNICATIONSAFETY AND SECURITYASSISTING THE VICTIMSASSISTING OTHER MEDICAL EMEREGINCYPERSONNELSDATA PROTECTINGTRANSPORTATION

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 thecompetence Reliability & Confidenti-ality medical informationVehicle & transportationroute


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SCOPE OF ASSISTANCE

Knows the limit of competence

DO NO FURTHER HARM


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LEGA L CONCERN LEGA L CONCERN IN MEDICA L EMERGENCIESIN MEDICA L EMERGENCIES

Is there any legal obligation in medical emergencycircumstances? Who are obliged? every person? Are there any limitation to act?

Are there any legal consequences for persons who helpsanother 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 ( E mergency Medical Treatment and Labor Act ) -

USA

COBRA ( Consolidated Omnibus Budget Reconciliation Act )


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ETHICA L CONCERN ETHICA L CONCERN IN MEDICA L EMERGENCIESIN MEDICA L EMERGENCIES

Is there any basic moral principle in medical emergencycircumstances? What basic moral principle are? What ethical conduct for medical emrgencies

Are there any legal consequences for persons who helpsanother 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 ( E mergency Medical Treatment and Labor Act ) -

USA

COBRA ( Consolidated Omnibus Budget Reconciliation Act )


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MEDICAL PRACTICE ACT2004 ( Indonesia )

Article 5 1

(d) Medical practitioners shall have theobligation to provide humanitarianemergency medical assistance , except that they convince that

another competent person isavailable to provide such assistance , ..


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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 negligencecreated the danger , will not be charged withcontributory negligence unless the rescue

attempt is an unreasonable one or the rescuer acts unreasonably in performing the attemptedrescue


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CONFIDENTIALITYMANDATORY-REPORTING

RIGHT TO P RIVACYDuty to medical secrec y

RE P ORT TO PU B LIC AGENCYP o lice

CHI LD AB USENo manda to r y ob liga t io n inI nd o nesia


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SPECIFIC CIRCUMSTANCESSPECIFIC CIRCUMSTANCESIN MEDICAL EMERGENCIESIN MEDICAL EMERGENCIES

S HORT OB SE RVATION TIM E

SUDDE N & U N EXPEC T ED CL INI C A L MANIF ES TATION

HIGH MOBI L ITY OF H E A L THPE R S ONN EL

IN SU FFI C IE NT INFORMATION TO

ES TAB L IS H CL INI C A L J UD G E M E NT

HIGH RISK!!


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LEGA L CONCERN IN EMERGENCY-TRA UM A

CONSENTREFUSAL OFTREATMENTCONFIDENTIALITYMANDATORY-REPORTING

INFORMED CONSENT

EMERGENCY DOCTRINE

GOOD SAMARITAN D.

PATIENTS COMPETENCY

ASSAULT & BATTERY

RIGHT TO PRIVACY

REPORT TO PUBLIC AGENCY

CHILD ABUSE

CHAIN OF CUSTODY


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CONSENT TO TREATMENT

Every action must be consented by thecompetent patient or the next of kin(w hen the patient is incompetent )

Expressed ConsentImplied Consent the patient is unconscious

medical treatment is urgent no next of kin present


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CONSENT IN MEDICAL EMERGENCY &CONSENT IN MEDICAL EMERGENCY &CONSENT COULDNOT BE OBTAINEDCONSENT COULDNOT BE OBTAINED

No ConsentNo ConsentNeededNeeded

Good FaithGood Faith

Patients BestPatients BestInterestInterest


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CONFIDENTIALITYMANDATORY-REPORTING

RIGHT TO P RIVACYDuty to medical secrec y

RE P ORT TO PU B LIC AGENCYP o lice

CHI LD AB USENo manda to r y ob liga t io n inI nd o nesia


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LEGA L CONCERN IN EMERGENCY-TRA UM A

NEGLIGENCE

DEATH / DNR

PATIENTSPROPERTY

MEDICAL

CERTIFICATION

LIABILITY

STANDARD OF CARE

ABANDONMENT

PATIENTS TRANSFERS

DEFINITION OF DEATH

DNR INDICATIONS

WITHHOLDING&WITHDRAWAL TREATMENT

UNCLAIMED DEATH BODIES

CHAIN OF CUSTODY


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NEGLIGENCE

LIABI LITYSTANDARD OF CARE

ABANDON MENTP ATIENTS TRANSFERS


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ABANDONMENT

Terminating an on-going emergencyassistance regardless the absence of a more competent health personnel


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NEGLIGENCENEGLIGENCE

RecklessnessForeseeable

Preventable


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DEATH / Do Not Resuscitate

DEFINITION OF DEATHC linicalB rain St em D ea th

DNR INDICATIONSTh e dea th h as b een declared

UNC LAI MED DEATH BODIES

S en t to th e ci ty m o rg u e


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PATIENTS PROPERTY

CHAIN OF CUSTODY


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MEDICAL CERTIFICATEMEDICAL CERTIFICATE

PURPOSE

LEGAL CONSEQUENCES


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MEDICOLEGAL ASPECT OFMEDICOLEGAL ASPECT OFEMERGENCIESEMERGENCIES

According to Causes

TRAUMA

NON-TRAUMA

According to the Number of Victims

Individual Casualty

Mass Casualty

Criminal Act?

Medicolegal

Certification

IdentificationR ights of victims


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DISCUSSION


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ISSUES TO BE EXPLORED

Dont know his/her limitation of competenceNegligenceDifferent opinion amongst the helpersPatients consent

Refuse of treatment by the patientEtc, etc


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DISCUSSION PROCEDURES

1. What kinds of conflicts that possible to bearisen when a MFR helps a victim?

2. Play the role of two parties in conflict3. Identify potential problems

4. Develop options to solve the problems

5. What is the theoretical background?


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POTENTIAL CONFLICT.

.

POSSIBLE SOLUTION


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POTENTIAL CONFLICTPasien tidak mau ditolong , tidak mau di RJ P, Keluarganyaminta agar dilakukan tindakan (bertentangan dengankemauan pasien) , & butuh RJ P, tidak ditolong , pasienmeninggal. Keluarga menuntut.

.

POSSIBLE SOLUTION


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S ikap dokter (merespon permintaan pasien):analisis kondisi mental pasien(sehat:turuti pasien)

S ikap dokter (merespon keluarga ygminta RJ P):menjelaskan kpdkeluarga , menunjukkan surat

pernyataan sikap pasienDN R adalah advance directive , sejauh alasan dpt diterima , dokter menuruti kehendak pasien


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Dokter punya kewajiban utk menolong sesamaDokter tetap melakukan RJ Pmeskipun permintaan pasien menolak RJ P. Krn RJ P life-saving. Lebih baik dituntut krn melakukan perbuatan yg

baik.


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Advance directive:dokter harusmemastikan bhw pasien benar-benar memahami keadaan dirinya.Dr.amal:tetap mengikuti keinginan

pasien krn hak otonomi pasien


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R espon keluarga:marah krn next of kin minta RJ P tapi dokter tdk mengabulkan permintaan keluarga.

pasien hrs dinilai apakah dpt menilaihak2nya sendiri


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Dokter hrs menjelaskan krn pasien belum tentu dpt mengerti kondisinyayg sebenar2nya.


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POTENTIAL CONFLICTDi tengah jalan ,dokter bertemu seseorang yg tertembak.Dokter menelpon ambulans ,tetapi datangnya lama. Klinik terdekat fasilitasnya tidak lengkap. Jadi ,menungguambulans atau menolong di klinik (kemungkinan tertolongkecil)

.

POSSIBLE SOLUTION


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Dr.anton:ditolong dulu di klinik danmeminta ambulans menjemput diklinik

Adakah dilema moralnya?Apa yg terbaik utk korban? (asas

beneficence ,non-maleficence)

Mana yg lbh mencelakakan pasien?Mana yg lbh menolong pasien?

B enefit/ R isk ratio?


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POTENTIAL CONFLICTDitengah jalan bertemu wanita bercadar (tdk boleh kontak fisik dg lawan jenis) yg saat itu mengalami serangan

jantung. S edangkan dokter penolong laki-laki.

.

POSSIBLE SOLUTION


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Mencari orang lain (perempuan) utk memeriksa korban

S ebagai pasien ,saya terima penolongapabila juga perempuanDlm agama diijinkan utk menolongmeskipun lawan jenis.


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POTENTIAL CONFLICT.

.

POSSIBLE SOLUTION


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POTENTIAL CONFLICT.

.

POSSIBLE SOLUTION


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KEMUNGKINAN KONFLIK

1. Menolak pengobatan (belakangan ) setelah pengobatan dilakkan dalam keadaan tidak sadar

2. Menolak pengobatan karena masalah kultural3. 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 dandinomorduakan.


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KEMUNGKINAN KONFLIK

1. Menolak pengobatan meninggal , oranglain menuduh penolong tidak bersediamelakukan pertolongan

2. Akses ke korban terhalang , konflik denganmasyarakat ketika akan melakukan akseskepada korban

3. Masalah ekonomi. Pasien tidak punya biaya.Konflik dengan tenaga kesehatan.


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KEMUNGKINAN KONFLIK

1. Ada 2 orang korban . S alah satu satu penjahat. Fasilitas saat itu hanyamenungkinkan untuk menolong satu orangsaja. S iapakah yang harus ditolong?

2. Tenaga medis dalam situasi pertempuran /konflik. Apakah tenaga medis itu dianggap

netral , ataukah memang bertugas menolongsalah satu pihak saja?


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KEMUNGKINAN KONFLIK

1. Korban yang mati secara klinis. Apkaahakan dilakukan resusitasi? Pertimbangan:

1. B ila dilakukan resusitasi , korban akanmengalami sequele (cacat)

2. B ila tidak ditolong , keluarga marah

2. Penolong dituduh lalai melakukan tindakan

pertolongan sehingga menyebabkankematian.


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1. Menolong pernafasan buatanterhadap jenis kelamin lain,ada hambatan agama. Bilamencari orang lain, tidak sempat, korban meninggal.

2. Dokter salah diagnosis, denganakibat salah terapi.

3. Korban massal, petugas terlalu

letih, tak mampu menolonglagi

4. Dalam keadaan perang, kitadikejar lawan, padahal adayang perlu ditolong

1. Hambatan kultural.Dalam situasi tersebut ,

jangan membayangkandengan pikiran non-medis. Membedakanlaki2 & perempuan..?

2. Tanggung guggat.S tandard Op Precedurevs S tandar Profesi ..?

3. Di R S : unacceptable4. Tenaga medis:

combatant & non-combatant

KEMUNGKINAN KONFLIK


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5. Seorangtua menyeberang, tiba2 jatuh dan tak sadar ditengah jalan. Ada penyeberang lain ygmengaku sebagai mhs ked /tenaga medis tanpa

memperlihatkan jati diri. Yangdilakukan dianggap salah,haruskah kita menegur?

6. Korban tabrak lari. Apakahmenolong, dengan segalakonsekuensinya?

7. Anak menderita leukemiamyeblast akut, perlu transfusidarah. Padahal ia menganut

sekte yg tidak boleh dilakukan

1. Bekerjasama!! Bilatidak yakin dgtindakan org lain,komunikasi dg baik.

KEMUNGKINAN KONFLIK


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8 . Ada 2 pasien di I G D , datang berbarengan. Penolongkekurangan tenaga , pada halkeduanya dalam keadaan

darurat.9. Tabrak lari malam hari. Ketikaakan menolong , ternyata kitamempunyai keperluanmendadak yang lain (keadaan

gawat).10. Dr. PTT ke daerah , hanya ada 1R S . Terjadi konflik sosial. Dr.mendapat ancaman agar tidak menolong kelompok lainnya.

KEMUNGKINAN KONFLIK

02 Legal and Ethical Aspect of Medical Emergencies - Dr Herkutanto SH, FACLM

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Transcript of 02 Legal and Ethical Aspect of Medical Emergencies - Dr Herkutanto SH, FACLM