Revisiting the equity debate in COVID-19: ICU is no panacea
Revisiting the equity debate in COVID-19: ICU is no panacea
复制标题
DOI：
10.1136/medethics-2020-106460
复制
发表时间：
2020-10-01
影响因子：
4.1
通讯作者：
Towns, Cindy
中科院分区：
文献类型：
--
作者：
Ballantyne, Angela;Rogers, Wendy A.;Towns, Cindy
在整个二零二零年三月及四月，面对日益严重的COVID-19疫情，有关如何以最佳方式分配有限的重症监护病房（ICU）资源的争论激烈。这场辩论主要是基于效用的论点，即挽救最多的生命或生命年。这些论点被基于公平的担忧所缓和，即仅仅基于预后的分类将加剧现有的健康不公平，使弱势患者的情况更糟。这场辩论的核心是这样一个假设，即在大流行的背景下，ICU入院是一种宝贵但稀缺的资源。在本文中，我们认为，在ICU分流实现公平的关注是有问题的原因有两个。首先，重症监护室可能是徒劳的，延长或加剧痛苦，而不是改善它。这可能是尤其是在新冠肺炎患者与新的数据显示，大多数谁接受呼吸机仍然会死亡。当重症监护违背患者的最大利益时，将预后指标较差的患者送入ICU以达到公平目标是没有价值的。其次，对ICU入院的关注转移了对COVID-19护理重要方面的关注，这些方面有更大的机会减轻痛苦和加强公平护理。我们建议，在大流行期间，应扩大对公平问题的关注，使之包括向所有需要的人提供尽可能高标准的临终关怀。这就需要在以下相互关联的领域关注文化上安全的护理：姑息治疗、沟通和决策支持以及先进的护理规划。
Throughout March and April 2020, debate raged about how best to allocate limited intensive care unit (ICU) resources in the face of a growing COVID-19 pandemic. The debate was dominated by utility-based arguments for saving the most lives or life-years. These arguments were tempered by equity-based concerns that triage based solely on prognosis would exacerbate existing health inequities, leaving disadvantaged patients worse off. Central to this debate was the assumption that ICU admission is a valuable but scarce resource in the pandemic context. In this paper, we argue that the concern about achieving equity in ICU triage is problematic for two reasons. First, ICU can be futile and prolong or exacerbate suffering rather than ameliorate it. This may be especially true in patients with COVID-19 with emerging data showing that most who receive access to a ventilator will still die. There is no value in admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. Second, the focus on ICU admission shifts focus away from important aspects of COVID-19 care where there is greater opportunity for mitigating suffering and enhancing equitable care. We propose that the focus on equity concerns during the pandemic should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care. This requires attention to culturally safe care in the following interlinked areas: palliative care, communication and decision support and advanced care planning.