Implementation of “Do Not Resusitate (DNR)” In Indonesia's

Law and the Study of Ethical Principles of Their

Implementation
Kadek Radhitya Vidianditha1, I Nyoman Bagiastra2, Ria Tri Harini Dwi Rusiawati3
1,2
Faculty of Law, Udayana University
3
Faculty of Medicine Ganesha University of Education
[email protected], [email protected], [email protected]

Abstract Keywords
do not resuscitate (DNR);
This study aims to analyze and examine in depth the implementation
of the " Do Not Resuscitate (DNR)" medical action in the perspective euthanasia; false euthanasia;
of legislation in Indonesia. This study also discusses and examines legislation; ethical principles
the ethical principles in the implementation of " Do Not Resuscitate
(DNR)" as part of Euthanasia and pseudo-euthanasia. This research
uses normative legal research methods, using a statutory approach
(status approach), and a conceptual approach (conceptual
approach). The results of this study are the first with not explicitly
regulated the implementation of " Do Not Resuscitate (DNR)" as
part of Euthanasia or pseudo euthanasia depending on the case and
condition of the patient being treated by medical personnel in
Indonesian legislation, making frequent conflicts both from the side
of the patient or medical personnel. Second, several countries in the
world already have national guidelines to make it easier to do " Do
Not Resuscitate (DNR)", Indonesia, which only relies on ethical
studies, is deemed insufficient for medical personnel to do " Do Not
Resuscitate (DNR)", So there are often ethical dilemmas.

I. Introduction

DNR is a part of a medical procedure which is classified as Euthanasia and/or pseudo-

euthanasia depending on the case and condition of the patient being treated. Based on the
opinion expressed by Kartono Muhamad who is the General Chair of the Indonesian Doctors
Association (IDI) for the period 1991-1994, that Euthanasia can be grouped into several
3parts, namely:
1. Passive Euthanasia, i.e. hastening death by refusing to give/taking usual relief measures,
or stopping regular ongoing help.
2. Active Euthanasia, which is taking actively, either directly or indirectly, which results in
death.
3. Voluntary Euthanasia, i.e. hastening death with the consent or request of the patient.
Involuntary Euthanasia, which is hastening death without the patient's request or consent,
which is often referred to as merey killing .
4. Non-voluntary euthanasia, namely hastening the death of a patient that can be delivered
by or through a third party, or at the decision of the government.
The types of Euthanasia above are the types that are commonly used in the health
sector, but apart from that there is also pseudo-euthanasia. According to MJJ Leenen who is
a Professor of Health Law at the Faculty of Law and the Faculty of Medicine, Van
Amsterdam University stated that the forms of pseudo-eunthanasia consist of:
1. Termination of medical treatment due to symptoms of brain stem death.
______________________________________________________________

DOI: https://doi.org/10.33258/birci.v5i2.5355 14785

 Budapest International Research and Critics Institute-Journal (BIRCI-Journal)
Volume 5, No 2, May 2022, Page: 14785-14794
e-ISSN: 2615-3076 (Online), p-ISSN: 2615-1715 (Print)
www.bircu-journal.com/index.php/birci
email: [email protected]

The human ability to think and feel will be active if the brain organs can work properly,
but if the brain is no longer functioning properly, then intellectual and psychological life
ends even though the respiratory organs and heart rate are normal. The occurrence of
brain death in the process of death is a sign that someone has died.
2. Termination of a person's life due to an emergency because the power is not resisted (
force majeure )
Article 48 of the Criminal Code can be applied in the medical world if there is a case
where a doctor must help two patients, both of whom must receive medical treatment with
the help of a medical device, but only one medical device is available, then the medical
device is attached to the first patient who The former was admitted to the hospital, thus
making the second patient have to die because he did not get medical treatment. Cases
like this cannot be evidence that the doctor has committed a punishable act.
3. Discontinuing a medical treatment that is no longer useful ( zinloos )
According to Leenen, carrying out medical actions that are not useful or can be said to be
legally futile will be seen or considered as persecution. A doctor should not give medical
action if there is no longer a result that can be expected even though the action can cause
the patient to die. Cases like this also cannot be used as evidence that the doctor has taken
action that can be punished, because if medical treatment is no longer useful, then the
doctor will be considered incompetent to take medical care.
4. The patient refuses medical treatment or action against him
The refusal to do treatment or medical action taken by the patient will of course make the
patient die, especially if the patient is in a critical condition. Regarding this matter, it can
be concluded that doctors are not willing to carry out medical treatments or actions
without the patient's permission. For this reason, an agreement is needed (Article 1320 of
the Civil Code), but if a doctor performs treatment or medical action without the patient's
permission, then it can legally be subject to Article 1352 of the Criminal Code regarding
Persecution.
DNR is a difficult thing to do given the many considerations that must be considered
beforehand, therefore there are often pros and cons regarding DNR. Regarding the state of
death or the state of cessation of blood flow as we know so far and has also been regulated
in Government Regulation No. 18 of 1981 concerning Clinical Corpse Surgery and
Anatomical Corpse Surgery and Transplantation of Instruments or Human Tissues
(Government Regulation No. 18 of 1981) which states that the cessation of the function of
the heart and lungs, can no longer be used because resuscitation technology has allowed the
heart and lungs to function again. Assessed from an ethical point of view whether or not
DNR was carried out, seen from cardiac and pulmonary resuscitation measures which were
not limited by legal and technical limitations, but considered bioethical principles, namely
the principle of benefit ( beneficence ), the principle of do not harm ( non-malficence ). , fair
treatment ( justice ) , and the patient 's autonomy ( autonomy ) . Not only that, the rules of
several religions also justify the existence of DNR actions, especially if the CPR/CPR action
is considered futile to be carried out and actually adds to the burden both from the side of
the patient and family or from the side of the medical staff. Most of the hospitals in Indonesia
do not have regulations for conducting DNR, including regarding the marking of DNR
patients with purple bracelets, this regulation is only applied to hospitals on the basis of
fulfilling accreditation. The regulations and/or laws governing DNR actions are not yet clear
in Indonesia, so most of the DNR orders in Indonesia have not been legally documented.
Arrangements regarding the implementation of DNR actions and guidelines (guidelines) or
SPO (Standard Operating Procedures) in carrying out DNR should be clarified again.

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 II. Research Method

This study uses a normative legal research method, using a statutory approach (statue
approach), and a conceptual approach (conceptual approach). The legal materials studied in
this study are primary legal materials, namely: the 1945 Constitution of the Republic of
Indonesia, Law Number 23 of 1847 (KUHPer), Law Number 1 of 1946 (KUHPidana), Law
Number 39 1999 concerning Human Rights, Law Number 36 of 2009 concerning Health,
Law Number 23 of 2002 concerning Child Protection, Law Number 29 of 2004 concerning
Medical Practice, Regulation of the Minister of Health Number 25 of 2014
concerning Health Efforts, Regulation of the Minister of Health Number 37 of 2014
concerning Determination of Death and Use of Organs, as well as secondary legal materials,
namely: a study on “ Do Not Resuscitate (DNR) ”, Euthanasia, False Euthanasia, Legal
protection for children as DNR patients, ethical principles of DNR implementation. The
technique of collecting legal materials by means of a literature study which examines and
reviews books and previous research as a reference and obtains a theoretical basis related to
the problems to be analyzed.

III. Result and Discussion

3.1 Implementation of “Do Not Resuscitate (DNR)” in the Perspective of Legislation in

Indonesia “Do Not Resuscitate (DNR)” in the Perspective of Indonesian Health
Law
As we know, Indonesia does not have regulations that specifically regulate the
implementation of DNR. In fact, DNR medical action can be classified as a form of
euthanasia even though there is no legal certainty about it. For now, Article 1 paragraph (1)
of the Regulation of the Minister of Health Number 37 of 2014 concerning Determination
of Death and Use of Organs states that medical practice is carried out on the basis of an
agreement between a doctor or dentist and a patient in order to maintain, prevent, improve,
treat, and recover. health, so this Article is often used as a basis for carrying out Euthanasia.
Active Euthanasia and Passive Euthanasia which are carried out without the patient's request
or consent will be subject to several articles in the Criminal Code, such as Article 338 of the
Criminal Code. In the event of a brainstem death condition in a patient, the criminal element
committed by a doctor or other medical personnel will also be eliminated if the life support
equipment is removed. This is also reinforced by the opinion of Fred Ameln who stated that
" There is no action against the law if it has been medically confirmed that a medical action
is no longer useful ". Then there is also Article 117 of Law Number 36 of 2009 concerning
Health (Health Law) which states " A person is declared dead if the function of the heart,
circulation system and respiratory system is proven to have stopped permanently, or if brain
stem death has been proven ." this makes the act of euthanasia or pseudo euthanasia cannot
be classified as deprivation of life as stated in articles 334 and 338 of the Criminal Code
because deprivation of life cannot be carried out on people who have been declared and or
are in a dead condition.
Back to the Regulation of the Minister of Health Number 37 of 2014 as a derivative
regulation of Law Number 36 of 2009 concerning Health, which in Article 13 paragraph (1)
of the Minister of Health Number 37/2014 states that " After a person is determined to be
brain stem dead, then all therapies life support must be stopped immediately ”, however, the
only doctor who can determine a patient in a brainstem death state is a doctor, this is in
accordance with Article 9 of the Minister of Health. The Minister of Health Regulation
Number 37/2014 also contains criteria that will distinguish coma and coma caused by brain

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stem death in detail which can be seen in Article 11. Then there is Article 15 of the Minister
of Health Number 37/2014 which also regulates the patient's family as a party who also has
rights. to request the termination of the provision of life support to patients experiencing
brain stem death if: 1) there is a will from the patient; or 2) Patients who have not made a
will, but the family believes that if the patient will agree to discontinue life support
equipment and still be based on the beliefs held.
With the existence of Law Number 36 of 2009 concerning Health and also Regulation
of the Minister of Health Number 37 of 2014 it is the basis for doctors or other medical
personnel to take " Do Not Resuscitate " actions without having to be overshadowed by
criminal elements. Although there are no laws and regulations in Indonesia that clearly
distinguish between Euthanasia and pseudo-euthanasia, by acknowledging brainstem death
as the definition of death, it can guarantee that there will be no punishment if medical
personnel have to perform Ethanasia or pseudo-euthanasia as well as DNR actions. as one
of the actions classified as pseudo euthanasia. We can conclude from the adage " Lex
Specialis derogate Lex Generalis ", Health Law is a special rule ( Lex Specialis ) that
overrides the Criminal Code as a general rule ( Lex Generalis ).

3.2 “Do Not Resuscitate (DNR)” From a Human Rights Perspective

Human rights are often known as rights that have been attached to humans since they
were still in the womb. Article 9 paragraph (1) of Law Number 39 of 1999 concerning
Human Rights regulates the right to life which is owned by humans which may almost have
no right to die, although there are several conditions of death which are often caused by
human rights violations. At first glance, Euthanasia and pseudo-euthanasia can be used as
acts of depriving a patient of the right to life. This will be inversely proportional if the patient
feels he has the right to avoid suffering from the illness he is suffering from and cannot be
cured. Moreover, if the act of Euthanasia or False Euthanasia is requested by the patient
himself. In Indonesia, which is a country that believes that God is the main thing and
Almighty which can be seen in the first precepts of Pancasila, this can raise the possibility
that Euthanasia or pseudo-Euthanasia can be taken for granted, especially if a religion
justifies DNR actions. Not infrequently, euthanasia can be carried out if the court allows it
even though it violates Law Number 39 of 1999 concerning Human Rights in Article 4 and
Article 9 paragraph (1). If then there is a problem regarding the patient's basic right to
determine his own destiny (his body) which is also regulated in Law Number 39 of 1999
concerning Human Rights in Article 21 which states that " Everyone has the right to personal
integrity, both spiritually and physically and therefore it should not be the object of research
without his consent”. The right to determine one's fate includes the right to determine or
refuse health services, the right to choose a health facility or a doctor, the right to view
medical records, including the right to end one's life.
After getting clear information from a competent doctor that a patient can no longer
be cured, then the patient has the right to request for Euthanasia or pseudo euthanasia,
namely " Do Not Resuscitate " medical action, the treatment will stop because the patient
has accepted the risk of losing his life even before his critical period.

3.3 “Do Not Resuscitate (DNR)” in Civil Law Perspective

Legally, Euthanasia has been discussed in several articles of the Civil Code. There are
two forms of liability of doctors in the field of civil law. The first thing is the legal
relationship that occurs because of an agreement and if this agreement is violated it will
create a default as regulated in Article 1238 of the Civil Code. The second thing is an
unlawful act ( onrechtmatigedaad ) in accordance with Article 1365 of the Civil Code. In

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general, in written consent, after a clear and relevant explanation from a competent doctor,
the patient will be given an informed consent form to sign if the patient agrees with the final
decision.
It is important to remember that DNR requests are purely patient requests on their own
behalf. There is no provision that the family can request a decision for a DNR. All aspects
of DNR approval must be carefully considered, both in terms of good and bad effects as a
rescue effort. DNR is used to respect and protect patients' autonomy rights and avoid them
from further suffering during the treatment or treatment period. The assessment made by the
doctor on the results of medical therapy carried out by the patient is not always a reason for
DNR, therefore input from the patient and the patient's family is also still taken into
consideration by doctors and other medical personnel so that unilateral statements do not
occur.
Passive and pseudo-euthanasia actions must clearly be accompanied by informed
consent . Informed consent is an agreement that is needed to take action, while for Active
Euthanasia, most medical personnel still often experience ethical dilemmas because there is
no legal umbrella. Euthanasia or pseudo euthanasia is often judged not to meet the legal
requirements of the agreement on the fourth point, which is a lawful cause . The importance
of communication practices by doctors, especially young doctors to be better able to explain
about DNR to patients, must get serious attention and training in real settings by means of
observation and simulation.
The DNR status of the patient must be clearly written in the document, including the
discussions that took place and the conclusions drawn from the results of the discussion
between the doctor and the patient. Questions and answers that occur between the patient
and the doctor, an explanation of the disease and the pros and cons of DNR must also be
written in the patient's document. The documentation must also contain the patient's
distinctive and special signature that can be recognized by medical personnel at the hospital.
The DNR's decision is not final and rigid. Patients can change the choices that have been
made during the treatment process required thorough documentation. DNR decisions are
subject to change, and these decisions must also be communicated and discussed again with
the parties concerned and immediately remove any marks or statuses that have been made
previously. The DNR document must also contain the conditions that the patient refused, the
action or assistance the patient refused, and also certain things that were excluded. For
example, the patient refuses to perform CPR and the administration of drugs when the patient
is in cardiac arrest, except for cardiac arrest due to complications of the procedure, such as
anaphylactic shock due to administration of drugs, contrast material and compilation of
cardiac catheterization.
The implementation of DNR which has not been clearly regulated makes its
implementation a gray matter for health facilities. If we look at the Regulation of the Minister
of Health Number 37 of 2014 concerning Determination of Death and Organ Utilization in
Article 1 paragraph (1) which states that " Medical practice is carried out based on an
agreement between a doctor or dentist and a patient in an effort to maintain health ". This
provision indirectly categorizes DNR as part of an act of Euthanasia or False Euthanasia,
although the legal certainty is not yet clear. The DNR decision that is directly chosen by the
patient has not yet been clearly regulated, even if the decision is made before undergoing
hospitalization. Patients who have previously chosen to do DNR at the time of previous
treatment or at another hospital cannot sue the doctor if the aim is to save lives. The decision
to do a DNR must take into account the condition and quality of life of the patient.
Documentation of this DNR decision should also be made in a special form so that it
becomes evidence in case of legal problems.

14789
 Regarding legal skills in making an agreement and or agreement is also an important
thing that must be considered. In the case of DNR, if a child or adolescent is the patient, it
can be considered that he is not legally competent and must be represented by a parent or
guardian. The definition of legal competence in Indonesia can be seen from Article 330 of
the Civil Code in conjunction with Law Number 1 of 1974 concerning marriage in Article
47 and Regulation of the Minister of Health Number 25 of 2014 concerning Child Health
Efforts in Article 1 paragraph (7). In accordance with the principle of legal interpretation
lex posterior derogate legi priori , it can be said that Indonesia recognizes that the age of 18
is legally mature and competent. The implication for health services is that Indonesian
children under the age of 18 do not have the right to determine their health services
individually. The absence of the right to determine individual health services for pediatric or
adolescent patients has also become a polemic due to the absence of definite regulations
because they are considered unable to protect the human rights of pediatric or adolescent
patients in determining the choice of medical assistance for their health.

3.4 “ Do Not Resuscitate (DNR )” in Criminal Law Perspective

Judging from the regulations that exist in Indonesia at this time, there is no one that
clearly regulates Euthanasia and pseudo-euthanasia. The problem of Euthanasia and pseudo-
euthanasia that concerns the issue of security and safety of life must be sought at least in
articles that approach the elements of euthanasia and pseudo euthanasia. The only options
that can be used as a legal basis are matters that are regulated in the Criminal Code, especially
those that regulate crimes against human life, including Articles 304, 338, 340, 344, 345,
and 359. Seen in Article 344, there are the sentence " self-declaration expressed with
sincerity " must be stated clearly and earnestly ( ernstig ) otherwise it can be said to be an
ordinary act of murder. The sentence must also get attention, because with the evidence of
the element of sincerity, it can determine whether a person violates Article 344 of the
Criminal Code or not. So that these elements are not misused, it must be determined whether
or not someone has committed a murder due to a firm request ( unitdrukkelijk ) and an
element of sincerity ( ernstig ), which must be proven either by the presence of witnesses or
other evidence.
Judging from the targets of crimes related to legal interests that have been violated,
crimes against human life are divided into 3, namely:
1. Crimes directed against the human soul in general.
2. A crime directed against the soul of a child who is or has just been born
3. A crime directed against the soul of a child still in its mother's womb.
Crimes against human life are divided into five types, namely:
1. Deliberate murder ( doodslag ) in Article 338 of the Criminal Code
2. Premeditated murder ( moord ) in Article 340 of the Criminal Code
3. Murder in a form that can increase the punishment ( gequalificeerde doodslag ) in Article
339 of the Criminal Code
4. Murder committed with a firm request by the victim in Article 344 of the Criminal Code
5. The act of someone who intentionally encourages and helps or gives effort to another
person to commit suicide Article 345 of the Criminal Code.
Regarding Passive Euthanasia which occurs when doctors or other medical personnel
intentionally do not take medical actions that can help extend the patient's life, then Passive
Euthanasia is divided into three:
1. Passive Euthanasia based on the patient's request, will not be punished
2. Passive Euthanasia without the patient's request, subject to Article 304 juncto 306
paragraph (2)

14790
3. Passive Euthanasia without the patient's attitude is subject to Article 304 juncto 359
paragraph (2)
Regarding the implementation of " Do Not Resuscitate " which is regulated in Article
388 of the Criminal Code and Article 340 of the Criminal Code. In the case of Euthanasia
and pseudo euthanasia where the request is made by relatives because the patient is in a state
of unconsciousness that has lasted for a long time (coma) or on the basis of the doctor's own
initiative without the consent of the patient or the patient's family, it can be subject to Article
338 of the Criminal Code or even Article 340 of the Criminal Code. . Judging from the
sounds of the articles that regulate crimes against human life in the Criminal Code which
reveal how important human life is.
Regarding pediatric patients who are DNR patients, their right to decide on all matters
related to the health sector still has to be determined by their guardian ( surrogate ). Decision
making in health services includes DNR orders, which are therapeutic decisions made by the
patient or his representative when the patient is critical before the patient is in a respiratory
or cardiac arrest condition, so that health workers do not perform cardiac arrest without
discontinuing the therapy that has been given. The DNR order for adolescent children is a
social legal case that often occurs in referral public hospitals. Those who are often considered
a minority due to their young age and do not have legal protection to be considered legally
competent in making DNR agreements and are also considered unable to make the right
decisions. Indonesian law regulates the provision of health services to children. Health
services for children are regulated in the 1945 Constitution of the Republic of Indonesia in
Article 28A in conjunction with Law Number 39 of 1999 concerning Human Rights in
Article 62 and Law of the Republic of Indonesia Number 36 of 2009 concerning Health in
Article 5.
Children or teenagers who are often called the nation's next generation and are still
considered to have a very long time to enjoy life are considered taboo to be given DNR
medical treatment. Legal protection for DNR cases where children and adolescents as
patients still has not reached a universal certainty, this is due to:
1. The legal aspects in each country are still different, there are countries that have regulated
the age limit for children and or adolescents to be able to obtain their rights in making
their own decisions for their health, but there are also countries that do not regulate it.
2. The development of the capacity to make decisions involves the cognitive and affective
aspects of reasoning. Assessment of this capacity is difficult to do because of
understanding the short-term and long-term aspects and the consequences that will be
faced, then cognitive and affective development is different for each individual, then the
capacity to predict the consequences of the decisions that have been chosen will be
inhibited by emotions and brain cell growth. .
3. Evaluation and assessment of decision-making abilities carried out by children or
adolescents should be given to competent medical personnel and have direct contact with
patients without ignoring the advice of parents or guardians.
4. Indonesia does not yet have a reference to assess the capacity of children or adolescents
in making decisions in the form of informed consent , informal refusal , do not resuscitate
, or informed assent . There is a tool for assessing the capacity of children and youth
called the MacCAT-T , but it has not been validated and is available in Indonesia.
The provision of legal protection is an effort to protect legal subjects in the form of
preventive or preventive rules, or those that are repressive or restrictive, either verbally or in
writing. Article 28A of the 1945 Constitution in conjunction with Article 62 of Law Number
39 of 1999 concerning Human Rights, Article 5 of the Law of the Republic of Indonesia
Number 36 of 2009 concerning Health, Article 32 paragraph (1) letter (c) of Law Number

14791
44 of 2009 concerning Hospitals which reads " Every patient has the right: to obtain services
that are humane, fair, honest, and without discrimination ", then there is Article 24 of the
Law of the Republic of Indonesia Number 35 of 2014 concerning amendments to Law
Number 23 of 2009 2002 concerning Child Protection which reads " The State, Government,
and Local Government guarantee children to exercise their right to express opinions
according to the age and level of intelligence of the child ". From these rules, it should be
able to provide a child's human rights protection with certainty in making decisions for his
health. There needs to be a law that also regulates DNR with child or adolescent patients to
protect their human rights in determining the medical treatment they get.

3.5 Study of Ethical Principles in Implementation “Do Not Resuscitate (DNR)” as part
of Euthanasia and pseudo euthanasia in Indonesia
DNR which is an effort to resuscitate patients so that the ethical principles are reviewed
regarding the entire effort to provide CPR (Cardiopulmonary Resuscitation) or it can also be
called CPR (Cardiopulmonary Resuscitation). This ethical principle is used when
considering the decisions taken in the DNR case, one example of which is the condition of
the surrounding environment. The environmental conditions referred to here are for example
a group of Asian people who rely heavily on group decisions or the results of deliberation
when the DNR decision will be made, while in the United States it is based on the principle
of individual autonomy that the patient has when the patient makes the decision to do DNR.
Performing CPR/CPR is not only limited to legal and technical rules, but must consider four
bioethical principles, namely the principle of benefit (beneficence), the principle of do not
harm (non-malefience), fair treatment (justice), and also the right to autonomy. patient
(autonomy). The views of a religion also justify DNR actions if indeed CPR/CPR actions
will not give good results and even add to the burden for the patient or family.
The principle of benefit (beneficence) in CPR / CPR is a principle that provides
benefits in the patient's healing efforts. CPR/CPR which is seen as one of the efforts to
restore health and organ function with the aim of relieving pain and suffering of patients.
This principle compels doctors or other medical personnel to take into account the benefits
of CPR/CPR for the patients they treat. Patients with cardiac arrest conditions, administering
CPR / CPR is considered a very efficient action. Patients who are having a heart attack due
to factors such as kidney failure, cancer, or other chronic diseases, it is rare for changes to
improve after being given CPR/CPR and make the patient's life expectancy worse (<5%)
especially if there is no known cause. Irreversible conditions such as prolonged shock,
bleeding, hypotension, and pneumonia indicate that CPR/CPR should not be performed. The
limited implementation of CPR/CPR makes the patient's life expectancy increase by 10.5%
after CPR/CPR is performed, although another 7-10% are postponed to be given CPR/CPR.
The rapid treatment of disease with CPR/CPR of course increases the life expectancy of a
patient by 36%, which is the highest number from current data. In hospitals that have limited
health services, both from human resources and medical equipment, their life expectancy
will be less. It should be remembered that in providing CPR/CPR, the patient's age is not a
contradiction in performing CPR/CPR.
The principle of do not harm ( Non-maleficence ). The level of brain damage that
occurs due to the provision of CPR/CPR varies between 10-83%. One study revealed that
55 out of 60 children died after being given prolonged CPR/CPR. The other five were able
to survive, but in a consistent condition or in a vegetative status in the hospital. As a result,
many patients with severe disabilities accompanied by the occurrence of brain damage are
in a condition tantamount to death. CPR/CPR can be dangerous and damaging when the

14792
patient is at high risk of brain damage. Disturbances in blood flow to the brain or to the heart
can cause severe damage, although CPR/CPR can be said to be successful if done on time.
The principle of autonomy ( autonomy ) which describes the autonomy rights of
patients who must be respected ethically and legally. Requires good communication skills
for doctors and patients to be able to make a decision to approve or reject RJP/CPR. The
decision must also be verified that a patient is able to agree or refuse medical intervention,
including RJP/CPR. The regulations that apply in Indonesia indirectly assume that patients
who are 18 years old are adult patients who are able to make individual decisions and can be
tested. Doctors must provide informed consent , which in writing can show that the patient
can receive and has understood all types of information about the condition of the disease,
prognosis, proposed medical action, alternative medical action, risks and benefits of every
decision taken by the patient. previously explained explicitly by a doctor or competent
medical personnel.
The principle of justice is a principle that can guarantee the rights of patients. In order
to reduce injustice in the treatment or treatment process for patients, the principle of justice
is very necessary. Moral principles are also needed to legitimize the medical care provided
to patients. The principle of justice requires that all patients with heart disease receive
RJP/CPR. The policy of these principles is to ensure fairness, but medical personnel must
first assess whether medical procedures: 1) carry out treatment, prevent, and prolong life; 2)
have less side effects and pain; 3) can provide good benefits for patients; 4) has a greater
positive impact than a negative impact on the patient.
Several countries have national guidelines regarding the implementation of " Do Not
Resuscitate (DNR)" as part of Euthanasia and also pseudo euthanasia depending on the case
and condition of the patient treated by doctors and other medical personnel. Indonesia is one
of the countries that do not widely know and understand the concept of DNR, especially in
existing health facilities. The need for guidelines (guidelines) or SPO (Standard Operational
Procedure) regarding the implementation of DNR as part of Euthanasia and also pseudo-
euthanasia in every health facility owned by Indonesia is also an important matter in addition
to the laws and regulations governing DNR actions in order to reduce ethical dilemmas
experienced by medical personnel.

IV. Conclusion

Indonesian legislation which does not explicitly regulate " Do Not Resuscitate (DNR)"
as part of Euthanasia and/or pseudo euthanasia in accordance with the case or condition of
patients treated by medical personnel makes its implementation still gray or has not found a
bright spot. The implementation of " Do Not Resuscitate (DNR)" is still left entirely to health
facilities in accordance with applicable regulations and refers to national hospital
accreditation standards only. In practice the implementation of " Do Not Resuscitate (DNR)"
only refers to regulations that are closest to and can be used as a reference for accountability
or problem solving in the event of a violation of the law or an unlawful act, Indonesian
legislation must be reaffirmed, either in regulating Euthanasia and also pseudo-euthanasia ,
so that the implementation of DNR no longer makes medical personnel experience ethical
dilemmas, and is not considered to be potentially carried out illegally. The ethical principles
possessed by Indonesia to carry out " Do Not Resuscitate (DNR)" are also deemed
insufficient to deal with the ethical dilemma felt by medical personnel when faced with an
agreement to do a DNR. The need for guidelines ( guidelines ) or SPO (Standard Operating
Procedures) regarding the implementation of DNR as part of Euthanasia and also pseudo-
euthanasia in every health facility owned by Indonesia is also an important matter in addition

14793
to the laws and regulations governing DNR actions in order to reduce the perceived ethical
dilemma. by medical personnel.

References

Irmanti, Riri, & Wahyu Andrianto. (2016). “Analysis of the “Do Not Resuscitate” (DNR)
Command as a Form of Pseudo-Euthanasia (Pseudo-Euthanasia). Faculty of Law,
University of Indonesia
Manik, Judika Atma Togi. (2017). " A Study of Passive Euthanasia in the Perspective of
Indonesian Criminal Law ". University of North Sumatra, Faculty of Law
Minister of Health Regulation Number 25 of 2014 concerning Health Efforts
Minosa, Mona. (2018). “Juridical Analysis of Euthanasia (Right to Die) Based on Article
344 of the Criminal Code and Human Rights”. Junal Inkrach t MH-UB, Vol 2 No. 3
Muhammad, Kartono. (1992). " Medical Technology and its Challenges to Biotics ". Jakarta:
Gramedia Pustaka Utama
Ose, Maria Imaculata. (2017). " Experience of ER Nurses Caring for Do Not Resuscitate
Patients in the Near-Death Care Phase”. Indonesian Journal of Nursing, Vol.20 No. 1
Permatasari, Widya Puspa. 2021. “Do Not Resuscitate (DNR)”. Karangturi National
University, Faculty of Health
Regulation of the Minister of Health Number 37 of 2014 concerning Determination of Death
and Use of Organs
Rizaldi, Faziral. “Do Not Resuscitate Legal Ethics”. Accessed on the page:
https://www.academia.edu/38902890/Etik_Legal_Do_Not_Resucitate.
Shatri, Hamzah, & Edward Faisal, Rudi Ptranto, Budi Sampurna. " Advanced Directives On
Palliative Care ". Indonesian Journal of Internal Medicine, Vol. 7 No. 2
Sutarno, S. (2014). " Health Law Euthanasia, Justice and Positive Law in Indonesia ".
Malang: Equal to Press Shatri, Hamzah, & Edward Faisal, Rudi Ptranto, Budi
Sampurna. " Advanced Directives on Palliative Care ". Indonesian Journal of Internal
Medicine, Vol. 7 No. 2
Wijaya, Yunus Adi, Ni Luh Putu Suardini Yudhawati & Kiki Rizki Fista Andriana. (2022).
“Ethical Dilemma in Do Not Resuscitate (DNR) Management in Indonesia”. Journal
of Nursing Ethics, issued 2
Yustisia, Dewi Asri, & Utari Dewi Fatimah. (2018). “Renewal of Health Laws Against
Euthanasia in Order to Provide Legal Certainty and Legal Protection for Patients and
Doctors”. Journal of Litigation, Vol 19 No. 1 Yustisia, Dewi Asri, & Utari Dewi
Fatimah. 2018. “Renewal of Health Laws Against Euthanasia in Order to Provide
Legal Certainty and Legal Protection for Patients and Doctors”. Journal of Litigation,
Vol 19 No. 1
Jurnal Litigasi, Vol 19 No. 1 Yustisia, Dewi Asri, & Utari Dewi Fatimah. 2018. " Pembaruan
Undang-Undang Kesehatan Terhadap Euthanasia Dalam Rangka Memberikan
Kepastian Hukum dan Perlindungan Hukum bagi Pasien dan Dokter". Jurnal Litigasi,
Vol 19 No. 1

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