The good, the bad and the ugly: pandemic priority decisions and triage
The good, the bad and the ugly: pandemic priority decisions and triage
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DOI：
10.1136/medethics-2020-106489
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发表时间：
2021-12-01
影响因子：
4.1
通讯作者：
DeLange, Dylan W.
中科院分区：
文献类型：
--
作者：
Flaatten, Hans;Van Heerden, Vernon;DeLange, Dylan W.
在本分析中，我们讨论了从重症监护的角度来看，在COVID-19等大流行病的三个不同阶段，患者分诊标准的变化。重症监护病床的可用性已成为一个热门话题，在许多国家，我们看到临时重症监护病床容量大幅增加。然而，医院可能会耗尽资源来提供重症护理，这在很大程度上依赖于训练有素的工作人员、临床消耗品和药物的及时供应链以及先进设备。在第一（良好）阶段，我们仍然可以根据重症监护和辅助治疗的需要，像往常一样进行临床优先级排序和决策：在生存和生活质量方面取得良好结果的几率是多少。在下一个阶段（坏阶段），资源基本上是可用的，但由于许多病人在短时间内到达医院，而且医院不同地方的辅助病床被使用，系统受到了压力。我们可能不得不放弃对预后不确定的病人的治疗。在最后（丑陋的）阶段，通常的医疗分流和优先级设置可能不足以减少流入，可能没有足够的重症监护病房床位。在这一阶段，必须采用不同的标准，使用功利主义的方法进行分类。我们认为，这是一个重要的转变，社会，而不是医生，必须提供指导，以支持分流，不再是基于医疗优先事项。
In this analysis we discuss the change in criteria for triage of patients during three different phases of a pandemic like COVID-19, seen from the critical care point of view. Availability of critical care beds has become a hot topic, and in many countries, we have seen a huge increase in the provision of temporary intensive care bed capacity. However, there is a limit where the hospitals may run out of resources to provide critical care, which is heavily dependent on trained staff, just-in-time supply chains for clinical consumables and drugs and advanced equipment. In the first (good) phase, we can still do clinical prioritisation and decision-making as usual, based on the need for intensive care and prognostication: what are the odds for a good result with regard to survival and quality of life. In the next (bad phase), the resources are mostly available, but the system is stressed by many patients arriving over a short time period and auxiliary beds in different places in the hospital being used. We may have to abandon admittance of patients with doubtful prognosis. In the last (ugly) phase, usual medical triage and priority setting may not be sufficient to decrease inflow and there may not be enough intensive care unit beds available. In this phase different criteria must be applied using a utilitarian approach for triage. We argue that this is an important transition where society, and not physicians, must provide guidance to support triage that is no longer based on medical priorities alone.