TANTANGAN ETIK DAN HUKUM RUMAH SAKIT DI ERA PANDEMI

COVID-19

BUDI SAMPURNAKOMPARTEMEN HUKUM ADVOKASI MEDIASI & PERSI

JAKARTA, 1 NOVEMBER 2020

SISTEMATIKA

• SITUASI DAN KONDISI PANDEMI COVID-19 YANG MEMPENGARUHI PELAYANAN DI RUMAH SAKIT

• POTENSI PERMASALAHAN ETIK DAN HUKUM

• TANTANGAN ETIK DI ERA PANDEMI COVID-19

• TANTANGAN HUKUM DI ERA PANEMI COVID-19

• CATATAN AKHIR

SITUASI-KONDISI PANDEMI COVID-19 YANG MEMPENGARUHI MANAJEMEN, PROFESI DAN PELAYANAN DI RUMAH SAKIT

• Informasi tentang Penyakit dan Tata-Laksananya yang terbatas: Virus penyebab, Cara penularan, Gejala danTanda, Patofisiologi, Uji Diagnostik, Terapi, Pencegahan, Vaksin, Kekebalan, dll. Sehingga “NSPK” tidak konsisten

• Sifat Kedaruratan Kesehatan Masyarakat yang mengakibatkan “kebolehan” di banyak hal, dan di sisi lain dilakukan “penghentian aktivitas” dengan segala dampak

• Secara natural, situasi-kondisi tersebut berpotensitimbulkan pelanggaran dan kriminalitas tertentu

Informasi Penyakit

• Sifat Virus Penyebab: • Mati dengan cuci pakai sabun dan pelarut lemak (alkohol),

bertahan di permukaan benda, terakhir dapat aerosol danbertahan di udara. Masuk ke manusia melalui hidung, mulut, mata, umumnya menyerang saluran pernafasan, tapi dapat juga di system lain. Postmortem, virus ditemukan di saluran nafas, paru, dan berbagai organ lain.

• Cara Penularan: • Berkembang, dari hanya droplet dan kontak erat, bertambah

dengan aerosol, serta potensi airborne dan faeco-oral.• Akibatnya pencegahan berkembang, dari hanya yg sakit yg pakai

masker, menjadi semua harus pakai masker, ventilasi udara harusbaik untuk cegah airborne.

Penyakit dan Tata-Laksana

• Gejala/Tanda dan Patofisiologi

• Kriteria klasifikasi orang sakit berkembang, Gejala/Tandaberkembang, Patofisiologi kematian berkembang, “Sebabkematian akibat Covid-19” untuk tujuan surveilans jadi luas.

• Uji Diagnosis, Isolasi, Terapi

• Dimulai mengandalkan hasil laboratorium (PCR), hingga juga mengakui kriteria diagnostic klinis, Perkembangan juga menunjukkan rendahnya sensitivitas uji diagnostic.

• Karena persentase OTG tinggi, maka diagnosis dengan PCR mulai diragukan (overestimate), potensi bergeser ke diagnosis klinis. Demikian pula kematian akibat Covid.

• Terapi mulai diberikan kepada orang dengan gejala.

Masalah Etik dan Hukum

• Informasi yg harus diberikan• Upaya pencegahan penularan

(distancing, masker, cuci) • Deteksi Terkena Covid-19

• Uji Diagnostik yg diperlukan, • Isolasi perlukah? (#HAM) • Isolasi difasyankes? (admisi

non volunter),

• Kapan mulai dengan obat?

• Ranap/karantina paksa?

• Tidak ada obat standar, ataubelum terregistrasi, dll

• Prioritas pada keterbatasansumber daya?

• Perlukah resusitasi atau DNR pada lansia atau orang dg komorbiditas yg kritis?

• Kapan dipulangkan?

• Keadilan akses dan distribusi

Masalah Etik dan Hukum

HAK PASIEN• Hak atas Privasi

• Hak atas Informasi

• Kerahasiaan info-kes

• Hak autonomi

• Hak ditengok/ditunggukeluarga

• Hak dilayani sesuai standar

• Hak dilayani secara adil

• Hak tidak didiskriminasi

NSPK• Kriteria Terkena Covid-19

• Kriteria Diagnostik Covid-19

• Standar Penanganan Pasien

• Standar Pemulasaraan

• Prosedur KIE

• Prosedur Informed Consent

• Prosedur DNR, WW,

• Prosedur Keluhan / Klaim

Tantangan Etik & Hukum

• Tantangan dalam mendiagnosis Covid-19

• Tantangan Pemeriksaan, Karantina, dan Pengobatan Covid-19, baik suspek ataupun konfirmasi

• Tantangan menghadapi beban sistem kesehatan

• Tantangan atas potensi tidak tertanganinya pasien non Covid-19

• Tantangan untuk mengatasi beban tenaga kesehatan yang berlebih

• Kebutuhan perlindungan tinggi

• Disrupsi rantai pasokan obat dan alkes, termasuk pelanggaranadministratif dan pidana

Tantangan etik dan hukum

• Triage (strategi prioritasi)

• life support decision, (withhold atau withdraw)

• Limitation or prohibition of family visit

• Quality of end of life care

• Pemalsuan APD dan alkes testing

• Non voluntary admission

• Disrupsi diagnosis dan Fraud

Total since

first

publication

1617 1152 465 28.8%

While the total proportion of COVID-19 death certificates not featuring COVID-19 as the

underlying cause of death is only 7.8%, this figure has stood at almost 30% (465 of

1,617 deaths in total) over the time period that PHE have published the weekly mortality

report.

This is broadly in line with figures published by the National Records of Scotland

[https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/general-publications/weekly-and-

monthly-data-on-births-and-deaths/deaths-involving-coronavirus-covid-19-in-

scotland#:~:text=The%20NRS%20weekly%20data%20is,Scottish%20Government's%20Covid%2D19%20dashboard.&text=As%20

at%209%20August%2C%20there,mentioned%20on%20the%20death%20certificate.] indicating that COVID-19 was

the underlying cause in 94.6% of death certificates with any such mention until week

21, but only 76.3% from week 22 to week 32.

While death certification is rightly regarded as a gold standard for the ascertainment of

cause of death, it is important to be able to distinguish between deaths where COVID-

19 was a contributory cause from those where COVID-19 was the underlying cause of

death. It appears that, over the course of the epidemic, a change to the respective

composition of deaths in this regard has taken place.

The distinction between the underlying cause of death and any other mention on the

death certificate will be increasingly important as we enter the autumn and winter

months, where increases in respiratory illness are observed annually. This is particularly

so since the ONS’s weekly release of data includes a breakdown of deaths featuring

COVID-19 according to whether it appeared in any mention on the death certificate, and

of a broad classification of ICD-10 codes only according to whether any featured as the

underlying cause of death.

Daniel Howdon is a Senior Research Fellow in Health Economics, Leeds Institute of

Health Sciences. Bio here [https://medicinehealth.leeds.ac.uk/medicine/staff/447/dr-dan-howdon]

Jason Oke [https://www.phc.ox.ac.uk/team/jason-oke] is a Senior Statistician at the Nuffield

Department of Primary Care Health Sciences and Module Coordinator for Statistical

Computing with R and Stata [https://www.conted.ox.ac.uk/courses/statistical-computing-with-r-and-stata] (EBHC

Med Stats), and Introduction to Statistics for Health Care Research

[https://www.conted.ox.ac.uk/courses/introduction-to-statistics-for-health-care-research] (EBHC), as part of the

Evidence-Based Health Care Programme [https://www.cebm.net/study-with-us/] .

Howdon D, Oke J, Henegan C. Death Certificate Data: Covid19 as the underlying cause of death. CEBM, Oxford Univ, downloaded Sept 16, 2020.

25%-30%

KERUMITAN PENENTUAN SEBAB KEMATIAN

MENGGUNAKAN “UNDERLYING DISEASE”

Certificate of Cause of Death

Chain of Events

4

C- CHAIN OF EVENTS

Specification of the causal sequence leading to death in Part 1 of the certificate is important. For

example, in cases when COVID-19 causes pneumonia and fatal respiratory distress, both pneumonia

and respiratory distress should be included, along with COVID-19, in Part 1. Certifiers should include

as much detail as possible based on their knowledge of the case, as from medical records, or about

laboratory testing.

Here, on the International Form of Medical Certificate of Cause of Death, is an example of how to

certify this chain of events for deaths due to COVID-19 in Part 1:

Frame A: Medical data: Part 1 and 2

1

Report disease or condition

directly leading to death on line a

Report chain of events in due to

order (if applicable)

State the underlying cause on the

lowest used line

Cause of death Time interval from onset

to death

a Acute respiratory distress syndrome 2 days

b Due to:

Pneumonia 10 days

c Due to:

COVID-19 (test positive) 14 days

d Due to:

2 Other significant conditions contributing to death (time

intervals can be included in brackets after the condition)

Manner of death:

Disease Assault Could not be determined

Accident Legal intervention Pending investigation

Intentional self harm War Unknown

Note: This is a typical course with a certificate that has been filled in correctly. Please remember to

indicate whether the virus causing COVID-19 had been identified in the defunct.

D- COMORBIDITIES

There is increasing evidence that people with existing chronic conditions or compromised immune

systems due to disability are at higher risk of death due to COVID-19. Chronic conditions may be

non-communicable diseases such as coronary artery disease, chronic obstructive pulmonary disease

(COPD), and diabetes or disabilities. If the decedent had existing chronic conditions, such as these,

they should be reported in Part 2 of the medical certificate of cause of death.

Underlying cause of death Due to Covid-19

COVID-19 - GUIDELINES FOR DEATH CERTIFICATION AND CODING

5

Here, on the International Form of Medical Certificate of Cause of Death, are examples of how to

certify this chain of events for deaths due to COVID-19 in Part 1, with comorbidities reported in

Part 2:

Frame A: Medical data: Part 1 and 2

1

Report disease or condition

directly leading to death on line a

Report chain of events in due to

order (if applicable)

State the underlying cause on the

lowest used line

Cause of death Time interval from onset

to death

a Acute respiratory distress syndrome 2 days

b Due to:

Pneumonia 10 days

c Due to:

Suspected COVID-19 12 days

d Due to:

2 Other significant conditions contributing to death (time intervals can be included in brackets after the condition)

Coronary artery disease [5 years], Type 2 diabetes [14 Years], Chronic

obstructive pulmonary disease [8 years]

Manner of death:

Disease Assault Could not be determined

Accident Legal intervention Pending investigation

Intentional self harm War Unknown

Note: This is a typical course with a certificate that is filled in correctly. COVID-19 cases may have

comorbidity. The comorbidity is recorded in Part 2.

Frame A: Medical data: Part 1 and 2

1

Report disease or condition

directly leading to death on line a

Report chain of events in due to

order (if applicable)

State the underlying cause on the

lowest used line

Cause of death Time interval from onset

to death

a Acute respiratory distress syndrome 2 days

b Due to:

Pneumonia 10 days

c Due to:

COVID-19 10 days

d Due to:

2 Other significant conditions contributing to death (time

intervals can be included in brackets after the condition)

Cerebral palsy [10 Years]

Manner of death:

Disease Assault Could not be determined

Accident Legal intervention Pending investigation

Intentional self harm War Unknown

Note: This is a typical course with a certificate that has been filled in correctly. COVID-19 cases may

have comorbidity. The comorbidity is recorded in Part 2.

Underlying cause of death

Underlying cause of death

6

E- OTHER EXAMPLES

Frame A: Medical data: Part 1 and 2 1

Report disease or condition directly

leading to death on line a

Report chain of events in due to

order (if applicable)

State the underlying cause on the

lowest used line

Cause of death Time interval from

onset to death

a Respiratory failure 2 days

b Due to:

Pneumonia 8 days

c Due to:

Pregnancy complicated by COVID-19 12 days

d Due to:

2 Other significant conditions contributing to death (time

intervals can be included in brackets after the condition)

Manner of death:

Disease Assault Could not be determined

Accident Legal intervention Pending investigation

Intentional self harm War Unknown

For women, was the deceased pregnant? Yes No Unknown

At time of death Within 42 days before the death

Between 43 days up to 1 year before death Unknown

Did the pregnancy contribute to the death? Yes No Unknown

Note: This is a typical course with a certificate is filled in correctly. In case of a pregnancy,

puerperium or birth leading to death in conjunction with COVID-19, please record the sequence of

events as usual, and remember to enter the additional detail for pregnancies in frame B of the

certificate of cause of death.

Frame A: Medical data: Part 1 and 2 1

Report disease or condition directly

leading to death on line a

Report chain of events in due to

order (if applicable)

State the underlying cause on the

lowest used line

Cause of death Time interval from

onset to death

a

Acute respiratory distress syndrome 3 days

b Due to:

COVID-19 One week

c Due to:

d Due to:

2 Other significant conditions contributing to death (time

intervals can be included in brackets after the condition)

HIV disease [5 years]

Manner of death:

Disease Assault Could not be determined

Accident Legal intervention Pending investigation

Intentional self harm War Unknown

Note: This is a typical course with a certificate that is filled in correctly. The certifier has identified

HIV disease as contributing to the death and recorded it in Part 2.

Underlying cause of death

Underlying cause of death

VARIASI:

• Ventricular Fibrilation

• Myocardiac Infarct

• ARDS

• COVID-19

• Syok sepsis

• ARDS

• Pneumonia Viral

• COVID-19

COMMON COMPLICATIONs

• ARDS & Airway Obstruction

• Thrombosis & Hypercoagulation ➔ PAD, CVD

• Cardiac Injury

• Sepsis & Septic Shock

• Acute Kidney Injury

• Diabetic Keto Acidosis

• Diabetic Keto Acidosis

• Handicap in Optimal Glycemic Control

• Hypercoagulation

• Cytokine Storm

• COVID-19

• PAD, CVD, Pulmonary emboly, MCI

• Hypercoagulation & thrombosis

• Endothelial dysfunction

• COVID-19 + Comorbid

Bukan KematianAkibat Covid-19

CATATAN AKHIR

• Coercion and restraint are highly problematic and controversial interventions in the treatment of patients during periods of pandemic, so that it is emphasized important general principles such as legitimacy, necessity, effectiveness, proportionality, and fairness.

• it was suggested that ethical and legal issues related to the pandemic require a dynamic framework that is constantly re-evaluated and refined according to the latest available information, with considering the five key values in the ethical process have been identified: Accountability, Inclusiveness, Openness and Transparency, Reasonableness, and Responsiveness.