Pros and Cons "Do Not Resuscitate (DNR)" Orders among Terminally Ill Patients

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The primary health care provider goal is to increasing the patients’ life, restrict disability and restore patients' health as possible by maximizing benefits and minimizing harm. Patient who treat consist of many symptoms and diagnosis start from outpatient until the hospitalization patient even there are also the patient who will death. This phenomena often reap the controversy. Life and death of a person not only relationship between his/her with the God but when the people is death, they leave all of them family and other people around them as well as phenomena that occur in Indonesia, especially at hospital. The do not resuscitate's phenomena become never ending subject in this country so this article will discuss about the pros and cons opinions from legal and ethical perspective do not resuscitate order in Indonesia.

A do-not-resuscitate order, or DNR order, is a medical order written by a doctor which instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating and it is created, or set up, before an emergency occurs. Written on Undang Undang No. 29 tahun 2004 Pasal 45 explain that in emergency situation often the approval of action should be done simultaneously with giving life-saving action. Emergency relief must be given by the doctor based on Code of Medical Ethic Pasal 17 explain that every doctor is requires to do emergency help as a manifestation of the task of humanity, except when he believes someone else is willing and able to provide it. The explanation above declare that doctor’s duty to give an emergency help can only fall by some things, one of them is patient who has receive medical decision do not resuscitate.

Accordingly the define of DNR order, the patient allowed to choose whether or not they want CPR in an emergency. When then they pros to do do not resuscitate, it mean that  the patient has convinced that every human being will die and die is the destiny of him/her. According to Al-Qur’an Surah Ali 'Imran that says “Every soul shall have a taste of death” (3:185) and there is another believe every Muslim submits to: “No soul dies except by Allah’s permission” (Qur’an Surah Ali ‘Imran 3:145). In addition, the Regulation Minister of Health Republic Indonesia Number 37 year 2014 about Determination of Death and Use of Donor Organs chapter III about Termination or Delivery of Living Therapy Help Pasal 14 Ayat 1 explain that patient who are in condition that cannot be cured due to illness (terminal state) and medical measures already futile, can be terminate or delay life support therapy. Ayat 2 “the policy about condition the patients’ which is terminal state and the medical measures already futile determined by Director of the hospital”. Ayat 3 “an action plan for termination or suspension life support therapy must be informed and reach an agreement from family of patient or the person who represent the patient”.

On the other hand, the patient who cons the policy of do not resuscitate or asking to be woken up when they die with CPR, must have its own reasons for the choice in accordance with “hak untuk hidup” which is list in Undang Undang Dasar Pasal 28 A Ayat 3 which explained that everyone has the right to live and have the right to survive and live. There are also medical ethic which can strengthen the argument why they cons the police of do not resuscitate.

First, beneficence. Beneficence mean taking actions that serve the best interests of the patients and their families. In this belief, Cardiopulmonary resuscitation (CPR) considered as an effort to restore health and organ function which is aim to reduce patient suffer. Second is non maleficence. The concept of non-maleficence is embodied by the phrase, "first, do no harm," it means that more important not to do harm your patient, than to do them good, which is part of the Hippocratic oath that doctors take and also important to know how likely it is that your treatment will harm a patient. Third, autonomy concept. Autonomy is the the ability of an individual to make a rational and un-influenced decision. As described above, patient have an authority to choose that they pro or con with DNR’s policy. So according the autonomy belief, the patient also choose that they appropriate to given a cardiopulmonary resuscitation. The last is justice. This belief ensure the fulfilment  of patient rights by balance the achievement of social goal. This belief require to reduce inequality of treatment in patient. However, it takes moral value to justify medical care which is given to patient. This belief guarantee all of patient who had cardiac arrest should get Cardiopulmonary resuscitation (CPR).

There are many different opinion about DNR order either agree or not but in here the important thing which must be known is that everyone cannot deny their death time. Although the CPR is the best way to restore the patients’ health but rarely find CPR as effective option if cardiac arrest is because kidney failure or cancer and irreversible cause such as prolonged shock also not recommended to do CPR. A prolonged CPR also giving further pain for the patient. Patient can survive longer but in persistent comma or vegetative status therefore CPR perceived more harm than usefulness. Overall, before the patient make a decision, the doctor must communicate first with them. Doctor should give informed consent related to disease condition, the proposed medical measures, also risks and benefits of the choice and doctor must be sure that the patient in the best condition while making decision.

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