Chuang Elizabeth, Cuartas Pablo A, Powell Tia, Gong Michelle Ng
Department of Family and Social Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA.
Albert Einstein College of Medicine, New York, New York, USA.
AJOB Empir Bioeth. 2020 Jul-Sep;11(3):148-159. doi: 10.1080/23294515.2020.1759731. Epub 2020 May 5.
The COVID-19 pandemic has highlighted health care systems' vulnerabilities. Hospitals face increasing risk of periods of scarcity of life-sustaining resources such as ventilators for mechanical respiratory support, as has been the case in Italy as of March, 2020. The National Academy of Medicine has provided guidance on crisis standards of care, which call for the reallocation of scarce medical resources to those who will benefit most during extreme situations. Given that this will require a departure from the usual fiduciary duty of the bedside clinician, we determined and mapped potential barriers to the implementation of the guidelines from stakeholders using an implementation science framework. A protocol was created to operationalize national and state guidelines for triaging ventilators during crisis conditions. Focus groups and key informant interviews were conducted from July-September 2018 with clinicians at three acute care hospitals of an urban academic medical center. Respiratory therapists, intensivists, nursing leadership and the palliative care interdisciplinary team participated in focus groups. Key informant interviews were conducted with emergency management, respiratory therapy and emergency medicine. Subjects were presented the protocol and their reflections were elicited using a semi-structured interview guide. Data from transcripts and notes were categorized using a coding strategy based on the Theoretical Domains Framework. Participants anticipated that implementing this protocol would challenge their roles and identities as clinicians including both their fiduciary duty to the patient and their decision-making autonomy. Despite this, many participants acknowledged the need for such a protocol to standardize care and minimize bias as well as to mitigate potential consequences for individual clinicians. Participants identified the question of considering patient quality of life in triage decisions as an important and unresolved ethical issue in disaster triage. Clinicians' discomfort with shifting roles and obligations could pose implementation barriers for crisis standards of care.
2019年冠状病毒病（COVID-19）大流行凸显了医疗保健系统的脆弱性。医院面临维持生命资源（如用于机械呼吸支持的呼吸机）短缺时期的风险不断增加，就像2020年3月意大利的情况那样。美国国家医学院已就危机护理标准提供了指导意见，该意见要求将稀缺的医疗资源重新分配给在极端情况下受益最大的人。鉴于这将需要背离床边临床医生通常的信托责任，我们使用实施科学框架确定并梳理了利益相关者在实施这些指南时可能遇到的障碍。制定了一项方案，以实施国家和州关于在危机情况下对呼吸机进行分诊的指南。2018年7月至9月，对一家城市学术医疗中心的三家急症医院的临床医生进行了焦点小组讨论和关键信息人访谈。呼吸治疗师、重症监护医生、护理领导人员和姑息治疗跨学科团队参加了焦点小组讨论。对应急管理、呼吸治疗和急诊医学方面的人员进行了关键信息人访谈。向受试者介绍了该方案，并使用半结构化访谈指南引出他们的看法。根据理论领域框架，采用编码策略对转录本和笔记中的数据进行分类。参与者预计，实施该方案将挑战他们作为临床医生的角色和身份，包括他们对患者的信托责任和决策自主权。尽管如此，许多参与者承认需要这样一个方案来规范护理并尽量减少偏见，同时减轻对个体临床医生的潜在影响。参与者认为，在分诊决策中考虑患者生活质量的问题是灾难分诊中一个重要且未解决的伦理问题。临床医生对角色和义务转变的不适可能会对危机护理标准的实施构成障碍。
