Covid-19 Pandemisinde Yoğun Bakım Triyajı Bağlamında Hazırlanan Klinik Etik Rehberlerin Normatif Analizi ve Etik Değerlendirmesi

Yıl 2021, , 19 - 36, 31.10.2021

Esra Aksoy , Merve Nur Koçak Öztürk , İlhan İlkılıç

https://doi.org/10.26650/JARHS2021-945971

Öz

Covid-19 Pandemisi sürecinde vaka sayılarının belli dönemlerde hızla yükselmesi yoğun bakım ünitelerinde yüksek doluluk oranlarına sebep olmuştur. Hasta sayısında yaşanan bu ani ve hızlı yükseliş karşısında tıbbi kaynakların yetersiz kalması ihtimali ve tecrübeleri yoğun bakım hizmetlerinde kaynakların acil ve adil dağıtımı ile ilgili etik tartışmaları başlatmıştır. Bu durum sadece etik tartışmalara ivme kazandırmakla kalmamış aynı zamanda Avrupa’daki birçok tıbbi meslek kuruluşu yoğun bakım triyajı için etik kriterler içeren rehberler yayınlamıştır. Bu çalışmada Avrupa’da yayınlanan bazı klinik-etik triyaj rehberleri normatif analize tabi tutularak etik açıdan değerlendirilmiştir. Amaç: Almanya, Avusturya, Belçika, Fransa, İngiltere, İsviçre ve İtalya’nın yoğun bakım derneklerinin triyaj için yayınlamış olduğu rehberlerin içerdikleri genel parametreleri ve normatif kavramları belirlemek ve bunların eleştirel bir değerlendirmesinden ortaya çıkan sonuçları tespit etmektir. Gereç ve Yöntem: Yukarıda adı geçen ülkelerin yoğun bakım ve anestezi derneklerinin Covid-19 pandemisi bağlamında yayınladıkları triyaj rehberlerinin eleştirel normatif analizi ve etik prensiplere göre değerlendirilmesi. Bulgular: İncelenen triyaj rehberleri ortak parametreler ve benzer normatif kavramlar kullanmış olmasına rağmen, birbirleri arasında önemli farklar bulunmaktadır. Bu farklılıkların kullanılan triyaj kriterleri, triyaj hedefleri, yaş faktörü, bazı sosyal gruplara öncelik verilmesi, ilk müdahale yapılması ve Covid-19 hastalarına farklı uygulama yapılması alanlarında olduğu tespit edilmiştir. Sonuç: Triyaj rehberlerini yayınlayan Avrupa ülkeleri aynı kültür geleneğinden gelse bile triyaj rehberlerinde kullandıkları kriterlere ve normatif kavramlara farklı değerler atfedilmiş ve farklı öncelikler verilmiştir. Bu farklılıkların oluşmasında güncel siyasi yaklaşımlar ve geçerli etik kültür etkili olabildiği gibi, o ülkenin hali hazırdaki maddi ve sosyo-kültürel kaynakları ve bu kaynakların kullanılmasındaki stratejileri de önemlidir. Bu bağlamda ülkemizde etik triyaj rehberlerine ihtiyaç duyulduğunda acilen hazırlanmalı ve hazırlanma sürecinde tüm bu noktalar göz önüne alınmalıdır.

Anahtar Kelimeler

Covid-19, triyaj, kısıtlı kaynakların adil dağıtımı, etik rehberler, yoğun bakım

Destekleyen Kurum

İstanbul Üniversitesi, Bilimsel Araştırma Projeleri

Proje Numarası

36837

Teşekkür

Proje toplantılarında çalışmamıza görüş ve eleştiriyle katkı sağlayan projenin danışman hocalarına ve çalışma arkadaşlarımız Ayşenur Daldaban, Dr. Orhan Önder ve Tuğba Doğan’a teşekkür ederiz.

Normative Analysis and Ethical Evaluation of Clinical Ethical Guidelines Published in the Context of Intensive Care Triage During Covid-19 Pandemic

Öz

Throughout the COVID-19 pandemic, the rapid increase in the number of cases during certain periods has caused a high occupancy rate in intensive care units. Faced with a sudden and rapid increase in the number of patients, a lack of medical resources or its possibility led to ethical discussions on the immediate and equitable distribution of resources in intensive care units. This has not only given impetus to the ethical debate, but many medical professional organisations in Europe have published guidelines for triage of critical care which contain ethical criteria. In this study, some of the ethical triage guides have been normatively analyzed and ethically evaluated. Objective: The aim of this study is to identify and determine the parameters and normative concepts contained in the guidelines for triage published by the intensive care associations of Germany, Austria, Belgium, France, England, Switzerland and Italy. The results of this investigation were also critically and ethically evaluated and reflected. Materials and Methods: Critical normative analysis and ethical evaluation of clinical ethical guidelines published by intensive care and anaesthesia associations of the above-mentioned countries. Results: Although the studied triage guides used common parameters and similar normative concepts, there are significant differences between them. These differences were determined to be related to the triage criteria used, triage objectives, age factor, priority given to certain social groups and the application of different treatments to Covid-19 patients. Conclusion: Although the European countries that have published triage guides come from the same cultural tradition, the normative criteria and concepts they used in the triage guides are considered different values and priorities in their rankings. These differences may be due to the current political and ethical culture, also to the current economic and socio-cultural resources and their strategies for using their resources. Because of these facts and the reasons which we found, they should be considered in the preparation of ethical triage guidelines in Turkey.

Anahtar Kelimeler

Covid-19, triage, resource allocation, ethical guidelines, intensive care

Proje Numarası

36837

Kaynakça

• 1. World Health Organization. Coronavirus (COVID-19) Dashboard 2021, [31.05.2021], Available from: https://covid19.who.int/.
• 2. İlkılıç İ. Covid-19 Sürecinde Etik Sorun Alanları. SD Sağlık Düşüncesi ve Tıp Kültürü Dergisi. 2020;56:112-5.
• 3. Schaupp W, Kröll W, Ruckenbauereditor HW.editors. Bioethik in Wissenschaft und Gesellschaft. In: Lintner MM, Das Triage- Problem in Italien während der COVID-19- Pandemie. Nomos Verlagsgesellschaft mbH & Co. KG.2020.p.87.
• 4. Centre National de Ressources Textuelles et Lexicales. CNDRTEL. Trier. Available from: https://www.cnrtl.fr/definition/triage.
• 5. Baker R, Strosberg M. Triage and equality: An historical reassessment of utilitarian analyses of triage. Kennedy Inst Ethics J. 1992;2(2):103-23.
• 6. Ellebrecht N. Triage. Charakteristika und Gegenwart eines ordnungsstiftenden Verfahrens. Sociologia Internationalis 2009;47(2):229.
• 7. Mathwig F. 10 questions - 10 réponses Le malheur ne doit pas créer l’injustice -Regard éthique sur le triage aux soins intensifs pendant la pandémie de Covid-19. Église évangélique réformée de Suisse. 2020. Available from: https://www.diaconie.ch/ wp-content/uploads/sites/2/2020/11/EERS_10- questions-10-reponses_Triage_20201127-1.pdf.
• 8. Deutscher Ethikrat. Solidarität und Verantwortung in der Corona-Krise Adhoc- Empfehlung. Berlin 2020. Available from: https://www.ethikrat.org/fileadmin/ Publikationen/Ad-hoc-Empfehlungen/deutsch/ ad-hoc-empfehlung-corona-krise.pdf
• 9. Lewandowski K, W. SK. Beatmung, Triage und Scoring - Anmerkungen zur Situation in Europa zu Beginn der COVID-19-Pandemie In: Woesler Martin SH-M, editor. Medizin und Ethik in Zeiten von Corona. Münster ; Berlin: LIT; 2020. p. 35-52.
• 10. Piscitello GM, Kapania EM, Miller WD, Rojas JC, Siegler M, Parker WF. Variation in ventilator allocation guidelines by US state during the coronavirus disease 2019 pandemic: a systematic review. JAMA network open 2020;3(6):e2012606.
• 11. British Medical Association. COVID-19 – ethical issues. A guidance note 2020. Available from: https://www.bma.org.uk/media/2226/ bma-covid-19-ethics-guidance.pdf.
• 12. Harvey D, Gardiner D, McGee A, DeBeer T, Shaw D. CRITCON-Pandemic levels: A stepwise ethical approach to clinician responsibility. J Intensice Care Soc. 2020;0(0):1-8. doi. org/10.1177/1751143720950542
• 13. Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin. Entscheidungen über die Zuteilung von Ressourcen in der Notfall- und der Intensivmedizin im Kontext der COVID-19- Pandemie, Version 2.16.04.2020, Available from: https://www.divi.de/ joomlatools-files/docman-files/publikationen/ covid-19-dokumente/200417-divi-covid-19- ethik-empfehlung-version-2.pdf
• 14. Österreichische Gesellschaft für Anaesthesiologie, Reanimation und Intensivmedizin. Allokation intensivmedizinischer Ressourcen aus Anlass der Covid-19-Pandemie. Klinisch-ethische Empfehlungen für Beginn, Durchführung und Beendigung von Intensivtherapie bei Covid- 19-PatientInnen.17.03.2020, Available from: https://www.oegari.at/web_files/cms_daten/ covid-19_ressourcenallokation_gari-statement_ v1.7_final_2020-03-17.pdf
• 15. Belgian Society of Intensive care medicine. Ethical principles concerning proportionality of critical care during the 2020 COVID-19 pandemic in Belgium. 2020. Available from: https://www.zorgneticuro.be/sites/default/files/ general/COVID-19-ethical_final_c.cleaned.pdf
• 16. Montgomery J, Stokes-Lampard HJ,Griffiths MD,Gardiner D, Harvey D, Suntharalingam G. Assessing whether COVID-19 patients will benefit from critical care, and an objective approach to capacity challenges during a pandemic: an intensive care Society clinical guideline. J Intensive Care Soc 2021;22(3):204- 10.
• 17. Schweizerische Akademie der Medizinischen Wissenschaften. Covid-19-Pandemie: Triage von intensivmedizinischen Behandlungen bei Ressourcenknappheit Version 3. 04.11.2020, Available from:samw.ch/de/coronavirus
• 18. Vergano, M., Bertolini, G., Giannini, A. et al. Clinical ethics recommendations for the allocation of intensive care treatments in exceptional, resource-limited circumstances: the Italian perspective during the COVID-19 epidemic. Crit Care 2020;24:165
• 19. Académie suisse des sciences médicales. Pandémie Covid-19: Triage des traitements de soins intensifs en cas de pénurie des ressources. 2020, Available from: https://sfar.org/download/ pandemie-covid-19-triage-des-traitementsde- soins-intensifs-en-cas-de-penurie-desressources/? wpdmdl=25743&refresh=616 ab208896351634382344
• 20. Comité Consultatif National d’Ethique. COVID-19 contribution du comité consultatif national d’éthique: enjeux éthiques face à une pandémie.13.03.2020, Available from:https:// www.ccne-ethique.fr/sites/default/files/ publications/reponse_ccne_-_covid-19_def.pdf
• 21. Gelinsky K. Triage-Empfehlungen grenzüberschreitend betrachtet - Eine Befragung europäischer Intensivmediziner Konrad Adenauer Stiftung. 2020. Available from: https:// www.kas.de/de/einzeltitel/-/content/triageempfehlungen- grenzueberschreitend-betrachtet.
• 22. Hübner J, Schewe DM, Katalinic A, Frielitz F-S. Rechtsfragen der Ressourcenzuteilung in der COVID-19-Pandemie–Zwischen Utilitarismus und Lebenswertindifferenz. Deutsche Medizinische Wochenschrift (1946). 2020;145(10):687.
• 23. White DB, Lo B. A framework for rationing ventilators and critical care beds during the COVID-19 pandemic. JAMA. 2020;323(18):1773-4.
• 24. Marckmann G. Triage – wer wird behandelt, wer nicht? 2020. Available from: https://grueneeuropa. de/files/doc/docs/890899b2c778046003c c2b419e8912b3.pdf.
• 25. Bundesärztekammer. Orientierungshilfe der Bundesärztekammer zur Allokation medizinischer Ressourcen am Beispiel der SARS-CoV-2-Pandemie im Falle eines Kapazitätsmangels.Dtsch Arztebl 2020; 117(20): A-1084 / B-912
• 26. Sante et Service Sociaux Québec.Triage pour l’accès aux soins intensifs (adultes et pédiatriques) et l’allocation des ressources telles que les respirateurs en situation extrême de pandémie. 01.04.2020, Available from: https://publications. msss.gouv.qc.ca/msss/fichiers/directives-covid/ archives/1-Protocole_national_triage_aux_ Soins_intensifs-pandemie.pdf
• 27. Emanuel EJ, Wertheimer A. Who should get influenza vaccine when not all can? Science 2006;312(5775):854-5.
• 28. White DB, Katz MH, Luce JM, Lo B. Who should receive life support during a public health emergency? Using ethical principles to improve allocation decisions. Ann Intern Med. 2009;150(2):132-8.
• 29. Wang K, Zhang Z, Yu M, Tao Y, Xie M. 15- day mortality and associated risk factors for hospitalized patients with COVID-19 in Wuhan, China: an ambispective observational cohort study. Intensive Care Med. 2020;46(7):1472-4.
• 30. İ lkılıç İ. Yoğun Bakım Ünitelerindeki Kararlarda Yaşlılığın Normatif Anlamı. Türkiye Klinikleri J Med Ethics Law Hist-Special Topics 2016;2(2):18- 26.
• 31. Deutsche Gesellschaft für Osteogenesis imperfecta (Glasknochen) Betroffene e. V. Stellungnahme der DOIG zur aktuellen Diskussion über die Zuteilung von Ressourcen Triage in der Notfall- und Intensivmedizin bei Covid-19-Erkrankten. 2020, Available from: https://abilitywatch.de/ wp-content/uploads/2020/04/PM_Triage_OIGesellschaft- 20.04.2020.pdf
• 32. Maves RC, Downar J, Dichter JR, Hick JL, Devereaux A, Geiling JA, et al. Triage of scarce critical care resources in COVID-19: an implementation guide for regional allocation An expert panel report of the Task Force for Mass Critical Care and the American College of Chest Physicians. Chest 2020;158(1):212-25.
• 33. Goold SD. The COVID-19 pandemic: Critical care allocated in extremis. Am J Bioeth. 2020;158(1):212-25.
• 34. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, et al. Fair allocation of scarce medical resources in the time of Covid-19. N Engl J Med 2020;382(21):2049-55.
• 35. Rehmann-Sutter C. Ethik der Triage bei überforderter Intensivpflege. Triage – Priorisierung intensivmedizinischer Ressourcen unter Pandemiebedingungen. 24.03.2020. Available from: https://www.ethikrat.org/ fileadmin/PDF-Dateien/Veranstaltungen/fb- 2021-03-24-transkription.pdf
• 36. Nuffield Council on Bioethics. Ethical Considerations in Responding to the COVID-19 Pandemic. 20202020. Available from: https:// www.nuffieldbioethics.org/publications/ethicalconsiderations- in-responding-to-the-covid-19- pandemic#:~:text=People%20should%20be%20 treated%20as,and%20self%2Disolation%20 are%20implemented.
• 37. Joebges S, Biller-Andorno N. Ethics guidelines on COVID-19 triage—an emerging international consensus. Crit Care 2020;24(1):201.)