University of Manchester, Oxford Road, Manchester, M13 9PL, UK.
Med Health Care Philos. 2021 Jun;24(2):227-233. doi: 10.1007/s11019-020-09994-9. Epub 2021 Jan 15.
Time-limited trials of intensive care have arisen in response to the increasing demand for intensive care treatment for patients with a low chance of surviving their critical illness, and the clinical uncertainty inherent in intensive care decision-making. Intensive care treatment is reported by most patients to be a significantly unpleasant experience. Therefore, patients who do not survive intensive care treatment are exposed to a negative dying experience. Time-limited trials of intensive care treatment in patients with a low chance of surviving have both a small chance of benefiting this patient group and a high chance of harming them by depriving them of a good death. A 'rule of rescue' for the critically unwell does not justify time-limiting a trial of intensive care treatment and overlooks the experiential costs that intensive care patients face. Offering time-limited trials of intensive care to all patients, regardless of their chance of survival, overlooks the responsibility of resource-limited intensive care clinicians for suffering caused by their actions. A patient-specific risk-benefit analysis is vital when deciding whether to offer intensive care treatment, to ensure that time-limited trials of intensive care are not undertaken for patients who have a much higher chance of being harmed, rather than benefited by the treatment. The virtue ethics concept of human flourishing has the potential to offer additional ethical guidance to resource-limited clinicians facing these complex decisions, involving the balancing of a quantifiable survival benefit against the qualitative suffering that intensive care treatment may cause.
限时重症监护试验是为了应对越来越多的低存活率危重症患者对重症监护治疗的需求,以及重症监护决策中固有的临床不确定性而产生的。大多数患者报告称,重症监护治疗是一种非常不愉快的体验。因此,没有从重症监护治疗中存活下来的患者会经历负面的临终体验。对低存活率患者进行限时重症监护治疗试验,既有使这一患者群体受益的小机会,也有通过剥夺他们善终的机会而使他们受到伤害的高机会。对于病重患者的“救援规则”并不能为限时重症监护治疗试验辩护,也忽视了重症监护患者所面临的体验成本。为所有患者提供限时重症监护治疗试验,而不考虑他们的生存机会,忽视了资源有限的重症监护临床医生对其行动造成的痛苦所承担的责任。在决定是否提供重症监护治疗时,进行患者特异性的风险效益分析至关重要,以确保不会对那些更有可能受到伤害而不是受益于治疗的患者进行限时重症监护治疗试验。有限资源的重症监护临床医生在面对这些复杂决策时,可能会从美德伦理概念中的人类繁荣中获得额外的道德指导,涉及对可量化的生存获益与重症监护治疗可能引起的定性痛苦进行平衡。