Meadow William
Department of Pediatrics, University of Chicago, Chicago, IL, USA.
J Pediatr Gastroenterol Nutr. 2007 Dec;45 Suppl 3:S215-7. doi: 10.1097/01.mpg.0000302975.98491.7f.
Over the past 30 years, I have noted 4 epidemiological points, each of which, I believe, must inform future conversations between neonatal intensive care unit (NICU) physicians, parents, and policy makers. First, there are no credible arguments against NICU care that rely on invoking cost or distributive justice. NICU dollars are remarkably well targeted to children who will ultimately survive to be discharged, as opposed to die in the NICU. If any rationing arguments are to be made, then they should be directed against sick adults in intensive care units. Second, the vast majority of infants admitted to the NICU, even infants sick enough to require mechanical ventilation, will survive to be discharged home-and every caretaker knows this, every day. Again, these findings stand in sharp contrast to adult patients in intensive care, where discordant predictions of survival are the norm, not the exception. Third, medical caretakers are remarkably poor at predicting which infants will die in the NICU, using either serial illness severity algorithms or serial intuitions. Nearly half of all babies predicted to die in the NICU by either strategy will survive to be discharged nonetheless. Fourth, and finally, medical caretakers seem remarkably good at identifying burdensome outcomes (either death or survival with permanent serious neurological disability) while babies are still sick enough that an alternative (ie, withdrawal of the ventilator) is ethically possible. Only 5% of ventilated extremely low birth weight babies receiving ventilation who are predicted to die before NICU discharge will be alive and neurologically unscathed at 2 years of age.
在过去30年里，我注意到4个流行病学要点，我认为每一点都必须为新生儿重症监护病房（NICU）医生、患儿父母和政策制定者未来的讨论提供依据。第一，没有任何基于成本或分配正义的可靠论据反对NICU护理。NICU的资金显著地精准用于那些最终能够存活并出院的儿童，而不是死于NICU的儿童。如果要提出任何配给论据，那么它们应该针对重症监护病房中的成年患者。第二，绝大多数入住NICU的婴儿，即使是病重到需要机械通气的婴儿，也能存活并出院回家——每位护理人员每天都知道这一点。同样，这些发现与重症监护病房中的成年患者形成鲜明对比，在那里，对生存的不一致预测是常态，而非例外。第三，医疗护理人员在使用连续疾病严重程度算法或连续直觉来预测哪些婴儿会在NICU死亡方面表现得非常糟糕。通过这两种策略预测会在NICU死亡的婴儿中，近一半最终仍能存活并出院。第四，也是最后一点，医疗护理人员似乎非常善于在婴儿病情仍然严重到在伦理上可以选择其他方案（即撤掉呼吸机）时，识别出沉重的结局（死亡或存活但伴有永久性严重神经残疾）。预计在NICU出院前死亡且正在接受通气的极低出生体重婴儿中，只有5%在2岁时能够存活且神经功能未受损害。
