Luce J M
University of California, San Francisco.
QRB Qual Rev Bull. 1991 Feb;17(2):42-7. doi: 10.1016/s0097-5990(16)30423-7.
Critical care units have proliferated over the past three decades and the cost of care in these units has increased dramatically during that period. These units have flourished despite a surprising lack of adequate data to support their overall efficacy, and indeed a number of studies suggest that many patients admitted to these units are either too ill or too healthy to benefit. Dr Luce reviews recent changes in the organization and delivery of critical care and argues that the utilization and quality of critical care units can be improved through a combination of strategies. He advocates two strategies to decrease the demand for, or increase the supply of, critical care beds: more efficient use of intermediate care units and the development of clear institutional guidelines regarding the termination of treatment. In addition, although nominally eschewing the use of "formal" rationing policies, he advocates the development of admission and discharge policies to guide physicians during periods of low bed availability. Finally, he advocates greater leadership roles for professional critical care unit directors. This final suggestion has great merit but, as Dr Luce recognizes, a heightened role for critical care unit directors raises ethical and legal issues about the autonomy of both patients and physicians that need to be explored thoroughly.
在过去三十年里，重症监护病房数量激增，在此期间这些病房的护理成本大幅上升。尽管令人惊讶地缺乏足够数据来支持其整体疗效，但这些病房仍蓬勃发展，事实上，多项研究表明，许多入住这些病房的患者要么病情过重，要么病情过轻，无法从中受益。卢斯博士回顾了重症监护在组织和提供方面的近期变化，并认为通过一系列策略可以提高重症监护病房的利用率和质量。他主张采取两种策略来减少对重症监护病床的需求或增加其供应：更有效地利用中级护理病房，并制定关于终止治疗的明确机构指南。此外，尽管名义上避免使用“正式”的配给政策，但他主张制定入院和出院政策，以便在病床供应不足期间指导医生。最后，他主张重症监护病房专业主任发挥更大的领导作用。这最后一条建议有很大的价值，但正如卢斯博士所认识到的，重症监护病房主任角色的强化引发了关于患者和医生自主权的伦理和法律问题，需要进行深入探讨。
