Managing Older Adults with Presumed COVID-19 in the Emergency Department: A Rational Approach to Rationing.
Managing Older Adults with Presumed COVID-19 in the Emergency Department: A Rational Approach to Rationing.
复制标题
在急诊室管理疑似患有 COVID-19 的老年人：合理的配给方法。
DOI：
10.1111/jgs.16651
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发表时间：
2020
影响因子：
6.3
通讯作者：
Sanon,Martine
中科院分区：
文献类型：
--
作者：
Rosen,Tony;Ferrante,LaurenE;Liu,ShanW;Benton,EmilyA;Mulcare,MaryR;Stern,MichaelE;Biese,Kevin;Hwang,Ula;Sanon,Martine
美国老年学会（AGS）关于COVID-19时代资源分配策略中与年龄相关的考虑因素的立场文件1和扩展的合理性2强调了在分配稀缺资源时不将年龄作为绝对排斥的重要性。主要使用年龄可能违反公正的道德原则，也意味着年龄歧视。老年人在基线活动和功能、认知和医疗状况方面具有异质性。先前的研究表明，其他脆弱性因素，如虚弱，3功能轨迹，4和多发病5与死亡和不良结局的相关性比实际年龄更强。虽然对COVID-19的研究才刚刚开始，但我们可能会在这种疾病中发现，这些脆弱性因素比实际年龄更能预测不良结果。因此，主要根据实际年龄做出配给决定是非常有问题的，我们认为这是不道德的。AGS的立场文件概述了分配稀缺资源的其他重要考虑因素。这些措施包括讨论护理目标，创建专门用于操作配给决策的分诊团队，并使用多因素策略来评估住院死亡率和限制生命的条件，无论主要分诊评分算法中的急性疾病如何。我们认识到，急诊科（艾德）正在做出许多关于呼吸机、重症监护病房（ICU）床位和医院床位分配的初步决定，以及关于如何治疗危重患者的决定，并可能继续做出这些决定。有鉴于此，我们描述我们目前的经验，并反映如何从AGS的立场文件的想法可能是可操作的ED。我们讨论的大部分也是高度相关的决策后，在住院期间。
The American Geriatric Society’s (AGS) position paper on age-related considerations in resource allocation strategies during the COVID-19 era1 and the expanded rationale2 emphasizes the importance of not using age as a categorical exclusion during the allocation of scarce resources. Using age primarily may violate the ethical principle of justice as well as imply age discrimination. Older adults are heterogeneous in baseline activities and functional, cognitive, and medical status. Prior research has demonstrated that other vulnerability factors, such as frailty, 3 functional trajectory, 4 and multi-morbidity5 are more strongly associated with death and poor outcomes than chronological age alone. Though research on COVID-19 is just beginning, we are likely to find in this disease as well, that these vulnerability factors are more predictive of poor outcomes than is chronological age. As a result, making rationing decisions informed primarily by chronological age is extremely problematic and, we believe, unethical. The AGS position paper outlined additional important considerations for the allocation of scarce resources. These include discussing goals of care, creating triage teams devoted to operationalizing rationing decision-making, and using a multi-factor strategy to assess both in-hospital mortality and conditions that would limit life regardless of the acute illness in the primary triage scoring algorithm. We recognize that many initial decisions about allocation of ventilators, intensive care unit (ICU) beds, and hospital beds, as well as decisions about how to treat critically ill patients are occurring and will likely continue to occur in the Emergency Department (ED). Given this, we describe our current experience and reflect on how ideas from the AGS position paper may be operationalized in the ED. Much of what we discuss is also highly relevant for decision-making later during a hospitalization.