Heller Axel R, Wurmb Thomas, Franke Axel
Klinik für Anästhesiologie und operative Intensivmedizin, Medizinische Fakultät an der Universität Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Sektion Notfall- und Katastrophenmedizin, Universitätsklinikum Würzburg, Würzburg, Deutschland.
Unfallchirurgie (Heidelb). 2025 Aug 5. doi: 10.1007/s00113-025-01614-6.
In health crises marked by severe resource scarcity, such as during the COVID-19 pandemic and in anticipated scenarios of national or state defence, hospitals face the challenge of maintaining the best possible medical care under ethically and legally responsible conditions. This article analyzes the ethical, legal and operational foundations of resource allocation in clinical disaster medicine. Central to this are the principles of utility maximization, fairness and transparency, which necessitate a shift from standard individual-centered care to a population-oriented crisis response. Medical indication forms the cornerstone of any treatment and must be evidence-based and patient-centered, even under crisis conditions. Therapeutic goals and prognostic assessment within the given resource constraints serve as key criteria for prioritization and allocation decisions. The use of triage category IV (blue) and the implementation of tertiary (ex-post) triage within hospitals are only conceivable under conditions of existential scarcity and require clear legal and ethical justification. Clinical ethics committees and independent triage teams play a pivotal role in decision-making and communication. The legal interpretation, particularly in the context of § 5c of the German Infection Protection Act, remains controversial and demands nuanced evaluation. The article underlines the necessity of consistent decision-making processes, structured documentation and the inclusion of vulnerable populations in crisis planning. Finally, operational strategies, such as tactical abbreviated surgical care (TASC), are presented as resource-efficient approaches to care. The overarching goal is to enable as many patients as possible to access the best achievable medical care, even under extreme conditions, while upholding ethical standards.
在以资源严重短缺为特征的健康危机中，例如在新冠疫情期间以及在国家或国防的预期情景下，医院面临着在符合伦理和法律责任的条件下维持尽可能最佳医疗护理的挑战。本文分析了临床灾难医学中资源分配的伦理、法律和操作基础。其中的核心是效用最大化、公平和透明原则，这需要从标准的以个体为中心的护理转向以人群为导向的危机应对。医疗指征是任何治疗的基石，即使在危机情况下也必须以证据为基础且以患者为中心。在给定的资源限制内，治疗目标和预后评估是优先级和分配决策的关键标准。只有在生存资源极度稀缺的情况下，才可以考虑在医院使用四级（蓝色）分诊类别以及实施三级（事后）分诊，这需要明确的法律和伦理依据。临床伦理委员会和独立分诊团队在决策和沟通中发挥着关键作用。法律解释，特别是在德国《感染保护法》第5c条的背景下，仍然存在争议，需要进行细致入微的评估。本文强调了一致的决策过程、结构化记录以及在危机规划中纳入弱势群体的必要性。最后，介绍了诸如战术简化手术护理（TASC）等操作策略，作为资源高效的护理方法。总体目标是即使在极端条件下，也要使尽可能多的患者能够获得可实现的最佳医疗护理，同时坚持伦理标准。
