Naidoo Reshania, Naidoo Kantharuben
Centre for Global Health and Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
Department of Family Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, KwaZulu-Natal, South Africa.
BMC Med Ethics. 2021 Mar 22;22(1):28. doi: 10.1186/s12910-021-00596-5.
The worsening COVID-19 pandemic in South Africa poses multiple challenges for clinical decision making in the context of already-scarce ICU resources. Data from national government and the last published national audit of ICU resources indicate gross shortages. While the Critical Care Society of Southern Africa (CCSSA) guidelines provide a comprehensive guideline for triage in the face of overwhelmed ICU resources, such decisions present massive ethical and moral dilemmas for triage teams. It is therefore important for the health system to provide clinicians and critical care facilities with as much support and resources as possible in the face of impending pandemic demand. Following a discussion of the ethical considerations and potential challenges in applying the CCSSA guidelines, the authors propose a framework for regional triage committees adapted to the South African context.
Beyond the national CCSSA guidelines, the clinician has many additional ethical and clinical considerations. No single ethical approach to decision-making is sufficient, instead one which considers multiple contextual factors is necessary. Scores such as the Clinical Frailty Score and Sequential Organ Failure Assessment are of limited use in patients with COVID-19. Furthermore, the clinician is fully justified in withdrawing ICU care based on medical futility decisions and to reallocate this resource to a patient with a better prognosis. However, these decisions bear heavy emotional and moral burden compounded by the volume of clinical work and a fear of litigation.
We propose the formation of Provincial multi-disciplinary Critical Care Triage Committees to alleviate the emotional, moral and legal burden on individual ICU teams and co-ordinate inter-facility collaboration using an adapted framework. The committee would provide an impartial, broader and ethically-sound viewpoint which has time to consider broader contextual factors such as adjusting rationing criteria according to different levels of pandemic demand and the latest clinical evidence. Their functioning will be strengthened by direct feedback to national level and accountability to a national monitoring committee. The potential applications of these committees are far-reaching and have the potential to enable a more effective COVID-19 health systems response in South Africa.
南非日益恶化的新冠疫情给本就稀缺的重症监护病房（ICU）资源背景下的临床决策带来了多重挑战。来自国家政府的数据以及最近公布的全国ICU资源审计表明资源严重短缺。虽然南部非洲危重症医学会（CCSSA）指南为面对不堪重负的ICU资源时的分诊提供了全面指导方针，但此类决策给分诊团队带来了巨大的伦理和道德困境。因此，面对即将到来的疫情需求，卫生系统为临床医生和重症监护设施提供尽可能多的支持和资源非常重要。在讨论了应用CCSSA指南中的伦理考量和潜在挑战后，作者提出了一个适用于南非情况的区域分诊委员会框架。
除了国家CCSSA指南外，临床医生还有许多其他伦理和临床考量。单一的伦理决策方法并不足够，相反，需要一种考虑多种背景因素的方法。诸如临床衰弱评分和序贯器官衰竭评估等评分在新冠患者中的用途有限。此外，临床医生基于医疗无效性决定撤回ICU护理并将该资源重新分配给预后较好的患者是完全合理的。然而，这些决策承载着沉重的情感和道德负担，临床工作量大以及对诉讼的恐惧更是雪上加霜。
我们提议成立省级多学科重症监护分诊委员会，以减轻各个ICU团队的情感、道德和法律负担，并使用一个经过调整的框架来协调机构间的合作。该委员会将提供一个公正、更广泛且符合伦理的观点，有时间考虑更广泛的背景因素，例如根据不同程度的疫情需求调整配给标准以及最新的临床证据。通过直接向国家层面反馈以及对国家监督委员会负责，它们的运作将得到加强。这些委员会的潜在应用影响深远，有可能使南非在应对新冠疫情的卫生系统方面更有效。
