allocation of medical resources in the lifeboat课件

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1、JonStanger,MD,MDiv,MHSEthicsChairContraCostaRegionalMedicalCenterAllocationofMedicalResourcesintheLifeboatTheClinician’s“Hippocratic”EthicA48year-oldmanwitharecentdiagnosisofincurablecancerhasaprognosisoflessthan6monthstolive.Hepresentstotheemergency

2、departmentwithpneumoniaandrespiratoryfailure.Theemergencyphysicianplacesthepatientonaventilator,startsantibiotics,andadmitshimtotheICU.Theattendingphysicianintheunitadvisesthefamilythattheventilatorsupportshouldbediscontinuedbecauseitismedicallyfutil

3、eandaninappropriateuseofscarceresources.Thefamilyobjects.UnrestrictedAdvocacyRestrictedAdvocacyJustlyRestricted(orProportional)AdvocacyAfterJeckeretal.JusticeattheBedsideThreeModelsofPhysicianAdvocacy“Lifeboat”EthicsApreviouslyhealthy34year-old,singl

4、emotherofthreeisintheICUwithsepsisandmulti-organfailure.SheisonCRRTandhasaroughly20%chanceofsurvivaltodischarge.A67year-oldhomelessmansustainedmultipleinjuriesfromanassault.HehasdevelopedrenalfailureandrequiresCRRT.Withtreatment,hehasa60%chanceofsurv

5、ivaltodischarge.ThereisonlyoneCRRTunitavailable.Neitherpatientisstablefortransfer.Definingthe“Good”AllocationGuidelinesGUIDELINETRIAGECRITERIABeauchamp&ChildressConstituencyMedicalUtility(need+likelihoodofsuccess)QueuingorLotteryNYSWorkgroup+OHPIPE

6、xclusionCriteria(cardiacarrest,metastaticcancer,severburn,endstageorganfailure,severeneurocondition)SOFAScoreTaskForceforMassCriticalCareExclusionCriteria(asabove+>85yearsold+severebaselinecognitiveimpairment)SOFAScoreWhiteetal(UCSF)LivesSaved(SOFA

7、)+Life-YearsSaved(comorbidconditions)+LifeCyclePrincipleSocialJusticeintheLifeboatYouhavebeenaskedtoparticipateintheprocessofformulatingacounty-widemedical“disasterplan”forapandemicthatfarexceedsavailablemedicalresources.NorthCountyishometoawell-to-d

8、opopulation.SouthCountyisalargelypoor,minoritypopulation.Thereare5privatehospitalsinNorthCounty(total50ICUbeds).SouthCountyhasonepublichospital(10ICUbeds),servinganequivalentpopulation.Atotalof120ventilatorswillbeavailabletothecounty.Howshouldthevent