Meadow William, Hall Jesse, Frain Laura, Ren Yaya, Pohlman Anne, Plesha-Troyke Susan, Gresens Winnifred, Lantos John
Department of Pediatrics and Critical Care Medicine, MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL 60637, USA.
Semin Perinatol. 2003 Dec;27(6):471-9. doi: 10.1053/j.semperi.2003.10.006.
We compared 560 adults hospitalized in our Medical Intensive Care Unit (MICU) to 245 ventilated babies hospitalized in our Neonatal ICU (NICU). Both ICUs had comparable mortality rates--roughly 1 patient in 5 died. The average length of hospitalization for nonsurvivors versus survivors was disproportionately short for NICU babies (13d v 33d) and long for MICU adults (15d v 12d). This phenomenon resulted in a redistribution of ICU bed-days and resources in favor of survivors for NICU babies (approximately 9 of every 10 NICU beds were devoted to babies who survived), and nonsurvivors for MICU adults (roughly 1 MICU bed in 2). Both ICUs had comparable percentages of patients predicted to die--roughly 1 patient in 3. The predictive power of an intuition of die was comparable--and not all that great. Almost one third of patients in both ICUs with a single prediction of "die in hospital" survived to be discharged. However, the likelihood of finding a neurologically normal NICU survivor after a prediction of "die" was only 5 in 100. To the extent that informed decisions can be made with 95% certainty, we may have found a foothold on the slippery ethical slope of benefit/burden calculations in the NICU. Unfortunately, we have no comparable data for MICU survivors.
我们将在我院医学重症监护病房（MICU）住院的560名成人与在我院新生儿重症监护病房（NICU）住院的245名使用呼吸机的婴儿进行了比较。两个重症监护病房的死亡率相当——大约每5名患者中有1人死亡。对于NICU的婴儿，非幸存者与幸存者的平均住院时间差异很大（13天对33天），而对于MICU的成人，非幸存者的平均住院时间较长（15天对12天）。这种现象导致重症监护病房的床日数和资源重新分配，有利于NICU婴儿中的幸存者（每10张NICU床位中约有9张用于存活的婴儿），以及MICU成人中的非幸存者（大约每2张MICU床位中有1张）。两个重症监护病房预计死亡的患者百分比相当——大约每3名患者中有1人。死亡直觉的预测能力相当——而且并不是特别强。两个重症监护病房中，单次预测“死于医院”的患者中，几乎有三分之一存活并出院。然而，在预测“死亡”后，找到神经功能正常的NICU幸存者的可能性仅为100分之5。在能够以95%的确定性做出明智决策的程度上，我们可能在NICU利益/负担计算这一棘手的伦理斜坡上找到了一个立足点。不幸的是，我们没有MICU幸存者的可比数据。
