Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.
Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.
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DOI：
10.1164/rccm.202010-3809cp
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发表时间：
2021-02-01
影响因子：
24.7
通讯作者：
Lo B
中科院分区：
文献类型：
--
作者：
White DB;Lo B
新型冠状病毒病（COVID-19）大流行的负担不成比例地落在弱势群体身上，包括穷人和黑人、拉丁裔和土著社区。有大量的关注，使用现有的ICU分诊协议分配稀缺的呼吸机和重症监护资源，其中大部分是为了挽救尽可能多的生命，可能会加剧这些不公平。随着政府和卫生系统在资源短缺的背景下重新审视其分诊指南，学者们提倡一系列替代分配策略，包括使用随机抽签，让所有有需要的患者有平等的机会接受ICU治疗。然而，拯救最多生命的方法和随机分配都存在严重缺陷。在这个角度来看，我们认为，ICU分诊政策应同时促进人口健康的结果，减轻健康不公平。这些伦理目标有时会发生冲突，这就需要在最大限度地挽救生命和在全社会公平分配健康福利这两个目标之间取得平衡。我们建议采取三种策略来减轻ICU分诊期间的健康不平等：在患者的分诊评分中引入校正因子，以减少基线结构不平等的影响;高度优先考虑从事基本高风险职业的个人;拒绝使用长期预期寿命和分类排除作为分配标准。我们提出了一个实用的分诊框架，结合这些战略，并出席促进人口健康和社会正义的双重公共卫生目标。
The burdens of the coronavirus disease (COVID-19) pandemic have fallen disproportionately on disadvantaged groups, including the poor and Black, Latinx, and Indigenous communities. There is substantial concern that the use of existing ICU triage protocols to allocate scarce ventilators and critical care resources—most of which are designed to save as many lives as possible—may compound these inequities. As governments and health systems revisit their triage guidelines in the context of impending resource shortages, scholars have advocated a range of alternative allocation strategies, including the use of a random lottery to give all patients in need an equal chance of ICU treatment. However, both the save-the-most-lives approach and random allocation are seriously flawed. In this Perspective, we argue that ICU triage policies should simultaneously promote population health outcomes and mitigate health inequities. These ethical goals are sometimes in conflict, which will require balancing the goals of maximizing the number of lives saved and distributing health benefits equitably across society. We recommend three strategies to mitigate health inequities during ICU triage: introducing a correction factor into patients’ triage scores to reduce the impact of baseline structural inequities; giving heightened priority to individuals in essential, high-risk occupations; and rejecting use of longer-term life expectancy and categorical exclusions as allocation criteria. We present a practical triage framework that incorporates these strategies and attends to the twin public health goals of promoting population health and social justice.