美國醫(yī)院正在為誰應(yīng)該優(yōu)先獲得治療而制定方案

美國醫(yī)院正在為誰應(yīng)該優(yōu)先獲得治療而制定方案

As COVID-19 spreads rapidly through the United States, many American doctors could soon be making the decisions that overwhelmed health care workers in Italy are already facing: Which patients get lifesaving treatment, and which ones do not?

隨著COVID-19在美國的迅速傳播，許多美國醫(yī)生可能很快就會做出早已讓意大利醫(yī)護(hù)人員不知所措的決定:哪些病人會得到挽救生命的治療，哪些病人不會得到?

Every accredited hospital in the U.S. is required to have some mechanism for addressing ethical issues like this — typically, an ethics committee made up of not just medical professionals but often also social workers, pastors and patient advocates. Sometimes in partnership with hospital triage committees, they create guidelines for prioritizing patient care if there's a resource shortage.

在美國，每一家獲得認(rèn)證的醫(yī)院都被要求有某種機(jī)制來處理這樣的倫理問題——通常情況下，一個倫理委員會不僅由醫(yī)學(xué)專業(yè)人士組成，而且通常還包括社會工作者、牧師和患者維權(quán)人士。有時，他們與醫(yī)院的分類委員會合作，制定出在資源短缺時優(yōu)先照顧病人的指導(dǎo)方針。

As the number of coronavirus cases rises in the U.S., hospitals have a new urgency in revisiting and updating those guidelines.

隨著美國冠狀病毒病例數(shù)量的增加，醫(yī)院在重新審視和更新這些指南方面有了新的緊迫性。

They vary from hospital to hospital, but their overall goal is usually to save the most lives. So hospitals consider a combination of factors: age, life expectancy, how severe a patient's illness is, how likely treatment is to help and whether a patient has additional illnesses that could shorten the person's life span, such as cancer or heart disease. Hospitals can then use those factors to develop scoring systems or clinical scores to prioritize care.

每個醫(yī)院的情況各不相同，但他們的總體目標(biāo)通常是挽救最多的生命。因此，醫(yī)院會綜合考慮以下因素：年齡、預(yù)期壽命、患者病情有多嚴(yán)重、治療有多大可能有幫助，以及患者是否患有其他可能縮短其壽命的疾病，如癌癥或心臟病。然后，醫(yī)院可以利用這些因素來開發(fā)評分系統(tǒng)或臨床評分，以優(yōu)先護(hù)理。

In early March, as the coronavirus outbreak worsened in Italy, an Italian medical association issued guidelines finding that doctors might have to prioritize younger COVID-19 patients over older ones. "It may be necessary to place an age limit" on access to intensive care, the guidelines advised, with the goal of preserving limited health care resources for patients more likely to survive.

3月初，隨著意大利冠狀病毒疫情的惡化，意大利一家醫(yī)學(xué)協(xié)會發(fā)布了一項(xiàng)指導(dǎo)方針，指出醫(yī)生可能必須優(yōu)先考慮年輕的COVID-19患者，而不是老年患者。”指導(dǎo)方針建議，可能有必要對“獲得重癥監(jiān)護(hù)的機(jī)會”設(shè)定年齡限制，以期為更有可能存活的患者保留有限的醫(yī)療資源。

But age is rarely the only factor in such decision-making. For example, a 20-year-old will not always get priority over a 60-year-old, especially if that 20-year-old has additional health problems that could mean the 60-year-old is likely to live longer anyway. Scoring systems can disadvantage older patients, because as people age they become more susceptible to disease, which can hurt their clinical scores.

但年齡很少是做決定的唯一因素。例如，一個20歲的人并不總是比60歲的人更有優(yōu)先權(quán)，特別是如果這個20歲的人有額外的健康問題，這可能意味著60歲的人無論如何都可能活得更長。評分系統(tǒng)可能對老年患者不利，因?yàn)殡S著年齡的增長，他們更容易患病，這可能會影響他們的臨床評分。

Another potential factor is "social usefulness," a concept that might favor, for example, a sick nurse because that person could go on to save other lives.

另一個潛在的因素是“社會有用性”，這個概念可能有利于，例如，一個生病的護(hù)士，因?yàn)檫@個人可以繼續(xù)拯救其他人的生命。

"Some people think that people who are in a position to help address a crisis in the future if they were to recover, like health care workers and first responders, maybe should receive some sort of priority in triaging scarce resources," said Emily Rubin, a pulmonary and critical care physician at Massachusetts General Hospital in Boston and a co-chair of the hospital's ethics committee.

埃米莉·魯賓說：“有些人認(rèn)為，像醫(yī)療工作者和急救人員一樣，如果他們能夠康復(fù)，有能力幫助解決未來危機(jī)的人，也許應(yīng)該在篩選稀缺資源方面獲得某種優(yōu)先權(quán)，波士頓馬薩諸塞州總醫(yī)院的一名肺和危重病護(hù)理醫(yī)生，也是該醫(yī)院倫理委員會的聯(lián)合主席。

Wynia said most hospitals should operate on the principle that every human life has equal worth, so patients are clinically evaluated the same regardless of their employment, gender, race or insurance, or whether they have children.

懷尼亞說，大多數(shù)醫(yī)院都應(yīng)該按照每個人的生命都有同等價值的原則來運(yùn)作，因此不管患者的就業(yè)、性別、種族或保險，也不管他們是否有孩子，臨床評估都是一樣的。

Hospitals could adopt a lottery or first-come-first-served system for triaging patients, but that might mean someone less sick is treated before someone more sick, potentially failing to achieve the goal of saving the most lives. Hospitals could treat worse-off patients first, but if those people are unlikely to survive, doctors might be better off focusing on people who are less ill.

醫(yī)院可以采用抽簽或先到先得的制度來對病人進(jìn)行分類，但這可能意味著，病情較輕的病人會在病情較重的病人之前得到治療，這可能無法達(dá)到挽救最多生命的目標(biāo)。醫(yī)院可以先治療病情較重的病人，但如果這些病人不太可能活下來，醫(yī)生最好還是關(guān)注病情較輕的病人。