National University Hospital, Singapore.
Architectural Association School of Architecture, London, United Kingdom.
J Hepatol. 2020 Oct;73(4):873-881. doi: 10.1016/j.jhep.2020.05.023. Epub 2020 May 23.
BACKGROUND & AIMS: The outbreak of COVID-19 has vastly increased the operational burden on healthcare systems worldwide. For patients with end-stage liver failure, liver transplantation is the only option. However, the strain on intensive care facilities caused by the pandemic is a major concern. There is an urgent need for ethical frameworks to balance the need for liver transplantation against the availability of national resources.
We performed an international multicenter study of transplant centers to understand the evolution of policies for transplant prioritization in response to the pandemic in March 2020. To describe the ethical tension arising in this setting, we propose a novel ethical framework, the quadripartite equipoise (QE) score, that is applicable to liver transplantation in the context of limited national resources.
Seventeen large- and medium-sized liver transplant centers from 12 countries across 4 continents participated. Ten centers opted to limit transplant activity in response to the pandemic, favoring a "sickest-first" approach. Conversely, some larger centers opted to continue routine transplant activity in order to balance waiting list mortality. To model these and other ethical tensions, we computed a QE score using 4 factors - recipient outcome, donor/graft safety, waiting list mortality and healthcare resources - for 7 countries. The fluctuation of the QE score over time accurately reflects the dynamic changes in the ethical tensions surrounding transplant activity in a pandemic.
This four-dimensional model of quadripartite equipoise addresses the ethical tensions in the current pandemic. It serves as a universally applicable framework to guide regulation of transplant activity in response to the increasing burden on healthcare systems.
There is an urgent need for ethical frameworks to balance the need for liver transplantation against the availability of national resources during the COVID-19 pandemic. We describe a four-dimensional model of quadripartite equipoise that models these ethical tensions and can guide the regulation of transplant activity in response to the increasing burden on healthcare systems.
COVID-19 的爆发使全球医疗系统的运营负担大大增加。对于终末期肝功能衰竭的患者来说，肝移植是唯一的选择。然而，大流行对重症监护设施造成的压力是一个主要的关注点。迫切需要制定伦理框架，在肝移植的需求与国家资源的可获得性之间取得平衡。
我们对移植中心进行了一项国际多中心研究，以了解 2020 年 3 月为应对大流行而对移植优先次序进行政策调整的演变。为了描述在这种情况下出现的伦理紧张局势，我们提出了一种新的伦理框架，即四分平衡（QE）评分，适用于在有限的国家资源背景下进行肝移植。
来自四大洲 12 个国家的 17 个大型和中型肝移植中心参与了这项研究。十个中心选择限制移植活动以应对大流行，倾向于采用“病情最严重者优先”的方法。相反，一些较大的中心选择继续常规的移植活动，以平衡等待名单上的死亡率。为了模拟这些和其他伦理紧张局势，我们使用 4 个因素（受者结局、供体/移植物安全、等待名单死亡率和医疗资源）为 7 个国家计算了 QE 评分。QE 评分随时间的波动准确反映了大流行期间围绕移植活动的伦理紧张局势的动态变化。
这种四分平衡的四维模型解决了当前大流行中的伦理紧张局势。它为指导在医疗系统负担不断增加的情况下对移植活动的监管提供了一个普遍适用的框架。
在 COVID-19 大流行期间，需要制定伦理框架来平衡肝移植的需求与国家资源的可获得性。我们描述了一种四分平衡的四维模型，该模型可以模拟这些伦理紧张局势，并可以指导在医疗系统负担不断增加的情况下对移植活动的监管。
