Comunicado 007 / Communiqué 007

1. Las organizaciones firmantes aclaramos que no hacemos parte de partido político alguno, por lo que seguiremos manteniendo nuestra autonomía e independencia y aportando desde lo técnico, científico, académico, gremial y social para que se garantice el derecho fundamental a la salud para todos los residentes en Colombia. 2. Con respecto a la Ponencia para Segundo Debate, destacamos algunos de los avances más importantes que acogen propuestas que hemos presentado

Ética do uso de escores prognósticos em unidade de terapia intensiva: revisão integrativa / Ethics in the use of prognostic scores in intensive care units: an integrative review / Ética del uso de puntajes pronósticos en una unidad de cuidados intensivos: una revisión integradora

Resumo O enfrentamento da covid-19 suscitou uma série de problemas na área da saúde, em razão do aumento da demanda de cuidados intensivos. Para solucionar a crise causada pela escassez de recursos de alta complexidade, a tomada de decisão tem se norteado por escores prognósticos, porém esse processo inclui uma dimensão moral, ainda que esta seja menos evidente. Mediante revisão integrativa, este artigo buscou refletir sobre a razoabilidade da utilização de indicadores de gravidade para definir a alocação de recursos escassos na saúde. Observou-se que o trabalho realizado em situações de escassez de recursos provoca sobrecarga moral, convergindo para busca por soluções padronizadas e objetivas, como a utilização de escores prognósticos. Conclui-se que seu uso isolado e indiscriminado não é eticamente aceitável e merece avaliação cautelosa, mesmo em situações emergenciais, como a da covid-19.

Abstract Facing COVID-19 caused many problems in the healthcare field, due to the rise in the intensive care demand. To solve this crisis, caused by the scarcity of resources of high complexity, decision-making has been guided by prognostic scores; however, this process includes a moral dimension, although less evident. With na integrative review, this article sought to reflect on the reasonability of using severity indicators to define the allocation of the scarce resources in healthcare. We observed that the work carried out on resource scarcity situations causes moral overload, converging to the search for standard and objective solutions, such as the use of prognostic scores. We conclude that their isolated and indiscriminate use is not ethically acceptable and deserves cautious evaluation, even in emergency situations, such as COVID-19.

Resumen La lucha contra el Covid-19 implicó una serie de problemas en el área de la salud, debido al aumento de la demanda de cuidados intensivos. Para solucionar la crisis provocada por la escasez de recursos de alta complejidad, la toma de decisiones estuvo orientada por puntuaciones pronósticas, pero este proceso incluye una dimensión moral aún menos evidente. A partir de una revisión integradora, este artículo buscó reflexionar sobre la razonabilidad de utilizar indicadores de gravedad para definir la asignación de recursos escasos en salud. El trabajo realizado en situaciones de escasez de recursos genera sobrecarga moral, llevando a la búsqueda de soluciones estandarizadas y objetivas, como el uso de puntuaciones de pronóstico. Se concluye que su uso aislado e indiscriminado no es éticamente aceptable y merece una cuidadosa evaluación, incluso en situaciones de emergencia, como la del Covid-19.

Distortions of parliamentary amendments to the equitable allocation of federal resources to the PAB / Distorções das emendas parlamentares à alocação equitativa de recursos federais ao PAB

ABSTRACT OBJECTIVE Analyze the implications of parliamentary amendments (EP) for the model of equitable allocation of resources from the Fixed Primary Care Minimum (PAB-Fixo) to municipalities in the period from 2015 to 2019. METHODS A descriptive and exploratory study was conducted on allocating federal resources to the PAB-Fixo and on the increment in the PAB by parliamentary amendment. The municipalities were classified into four groups according to degrees of socioeconomic vulnerability defined by the Ministry of Health for the allocation of PAB-Fixo resources. The transfers from the Ministry by parliamentary amendment were identified. The proportions of municipalities benefiting per group were analyzed by resources allocated from the PAB-Fixo and increment to the minimum by EP. RESULTS There were reduced resources allocated to the PAB-Fixo (from R$ 6.04 billion to R$ 5.51 billion, -8.8%) and increased increment to PAB by parliamentary amendment (from R$ 95.06 million to R$ 5.58 billion, 5.767%) between 2015 and 2019. The participation of municipalities by the group of those favored by EP was similar to that in the PAB-Fixo. In the proportion of resources for amendments, the municipalities of group I (most vulnerable) had more participation, and those of group IV had less participation if compared to the allocation of the PAB-Fixo. The distribution of resources by the parliamentary amendment did not cover all municipalities, even the most vulnerable ones, i.e., belonging to groups I and II. There was great inequality of resources per capita according to the groups of municipalities. CONCLUSION The EP distorted the model of equitable allocation of resources proposed by the Ministry of Health for the PAB-Fixo, by allocating resources in a much more significant proportion to the municipalities of group I and much less to those of group IV, which is in disagreement with this model. Furthermore, this distribution by amendments does not benefit all municipalities, not even the most vulnerable.

RESUMO OBJETIVO Analisar as implicações das emendas parlamentares (EP) para o modelo de alocação equitativa de recursos do Piso da Atenção Básica Fixo (PAB-Fixo) aos municípios no período de 2015 a 2019. MÉTODOS Realizou-se um estudo descritivo e exploratório da alocação de recursos federais para o PAB-Fixo e para incremento ao PAB por emenda parlamentar. Os municípios foram classificados em quatro grupos, segundo graus de vulnerabilidade socioeconômica definidos pelo Ministério da Saúde para destinação de recursos do PAB-Fixo. Os repasses do ministério por emenda parlamentar foram identificados, analisando-se as proporções de municípios beneficiados em cada grupo por recursos alocados do PAB-Fixo e do incremento ao piso por EP. RESULTADOS Verificou-se redução dos recursos alocados ao PAB-Fixo (de R$ 6,04 bilhões para R$ 5,51 bilhões, -8,8%) e aumento do incremento ao PAB por emenda parlamentar (de R$ 95,06 milhões para R$ 5,58 bilhões, 5.767%) entre 2015 e 2019. A participação dos municípios por grupo dos que foram favorecidos por EP foi semelhante à dos municípios do PAB-Fixo. Na proporção de recursos por emendas, os municípios do grupo I (mais vulneráveis) tiveram maior participação e os do grupo IV, menor participação, se comparada à alocação do PAB-Fixo. A distribuição de recursos por emenda parlamentar não contemplou todos os municípios, mesmo aqueles mais vulneráveis, pertencentes aos grupos I e II. Houve grande desigualdade de recursos per capita segundo os grupos de municípios. CONCLUSÃO As EP distorceram o modelo de alocação equitativa de recursos proposto pelo Ministério da Saúde para o PAB-Fixo, ao destinar recursos em proporção muito maior para os municípios do grupo I e muito menor para os do grupo IV, o que está em desacordo com esse modelo, além disso essa distribuição por emendas não beneficia a todos os municípios, nem mesmo aos mais vulneráveis.

SUS: avaliação da eficiência do gasto público em saúde / SUS: evaluation of the efficiency of public health spending

Após a fase aguda da pandemia de covid-19, que originou uma crise sanitária mundial, matando aproximadamente 700 mil pessoas no Brasil, parece importante refletir sobre a necessidade de se aumentar os recursos destinados ao Sistema Único de Saúde (SUS). Criado na Constituição federal de 1988, o SUS sofreu desde seu nascedouro com o esvaziamento do orçamento da seguridade social e o subfinanciamento das ações e serviços públicos de saúde. A partir de 2016, após a queda da presidente Dilma Rousseff, essa situação se agravou, provocando, entre outros, um processo de desfinanciamento do SUS, no contexto do aumento da pobreza e da desigualdade. Neste cenário, a 'eficiência' aparece como panaceia administrativa, a qual, em nosso caso, acaba servindo para reforçar a ideia de que os problemas do SUS resultam da falsa dicotomia entre financiamento e gestão ­ quando é plausível admitir, que boa parte de seus problemas de gestão, tenham decorrido em razão de um quadro de restrição orçamentária.

Relación entre la tasa de letalidad por COVID-19 y los recursos hospitalarios / Relation between COVID-19 fatality rate and hospital resources

Introducción: La tasa de letalidad por COVID-19 ha generado mucha preocupación entre los ciudadanos y los medios de comunicación con respecto a los números oficiales proporcionados por distintos gobiernos. La salud pública en la actualidad debe hacer frente a la pandemia más significativa del siglo xxi. Objetivo: Analizar la tasa de letalidad por COVID-19 y su relación con recursos hospitalarios críticos, en el contexto de la pandemia de la COVID-19. Métodos: Se analizó la tasa de letalidad sobre la base de datos oficiales. Se subestimó el número de casos para obtener una estimación más real del alcance de la infección, de los indicadores de recursos hospitalarios importantes (críticos) en transición pandémica que podrían elevar la tasa de letalidad posterior al estudio. Se emplearon curvas de tendencia exponencial doblemente suavizadas, distribución S y técnicas de regresión. Resultados: La curva que mejor explicó el comportamiento de fallecidos por COVID-19 en Chile fue una ecuación de regresión cúbica. La variable hospitalización básica se distribuyó como una curva S. Las variables hospitalización media, pacientes críticos, unidad tratamiento intensivo, unidad cuidado intensivo, ventiladores mecánicos totales y ventiladores mecánicos ocupados; se pudieron explicar mediante regresiones cúbicas. En todos los casos, los valores de R2 fueron superiores al 95 por ciento. Conclusiones: El número de fallecidos seguirá en aumento. Se sugiere fortificar las unidades de hospitalización básica para imposibilitar el colapso de la red sanitaria. Es necesario seguir creciendo en términos de hospitalización de media complejidad, unidad tratamiento intensivo, unidad cuidado intensivo y número total de ventiladores mecánicos para asegurar el soporte sanitario(AU)

Introduction: The fatality rate by COVID-19 has generated a lot of concern among citizens and the media regarding the official numbers provided by different governments. Public health today must cope with the most significant pandemic of the twenty-first century. Objective: Analyze the fatality rate due to COVID-19 and its relation with critical hospital resources, in the context of the COVID-19 pandemic. Methods: The fatality rate was analyzed on the basis of official data. The number of cases was underestimated to obtain a more real estimate of the extent of the infection, of the indicators of important (critical) hospital resources in pandemic transition that could raise the post-study fatality rate. Double-smoothed exponential trend curves, S-distribution and regression techniques were used. Results: The curve that best explained the behavior of COVID-19 deaths in Chile was a cubic regression equation. The basic hospitalization variable was distributed as an S-curve. The variables called mean hospitalization, critical patients, intensive treatment unit, intensive care unit, total mechanical ventilators and busy mechanical ventilators could be explained by cubic regressions. In all cases, R2 values were greater than 95percent. Conclusions: The number of deaths will continue to rise. It is suggested to fortify the basic hospitalization units to prevent the collapse of the health network. It is necessary to continue growing in terms of medium complexity hospitalization, intensive treatment unit, intensive care unit and total number of mechanical ventilators to ensure health support(AU)

Recomendaciones bioéticas para la pandemia. Una perspectiva personalista / Bioethical recommendations for the pandemic. a personalistic perspective / Recomendações bioéticas para a pandemia. uma perspectiva personalista

Resumen La emergencia sanitaria por la pandemia del covid-19 puso en evidencia limitaciones en los sistemas de salud a nivel mundial, lo que hizo necesario un marco bioético que brinde herramientas para orientar la toma de decisiones de los profesionales de la salud ante la escasez de recursos sanitarios. Modelos bioéticos como el principialismo, el utilitarismo y la bioética centrada en la persona buscan enfocar las decisiones clínicas con base en el respeto de los derechos y la dignidad de las personas, a fin de salvaguardar la práctica médica. La bioética centrada en la persona brinda un enfoque dirigido hacia el respeto de su dignidad en situaciones de urgencia sanitaria, para evitar dar un sentido material al hombre. Se requieren criterios de decisión para afrontar los conflictos bioéticos presentes en la práctica clínica, que reduzcan la carga legal, emocional y ética de la toma de decisiones en situaciones de pandemia.

Abstract The health emergency due to the COVID-19 pandemic revealed limitations in health systems worldwide, making it necessary to establish a bioethical framework that provides tools to drive health professionals' decision-making amid scarce health resources. Bioethical models such as principlism, utilitarianism, and personalism seek to focus clinical decisions on respect for people's rights and dignity, thus protecting the medical practice. Personalism provides a person-centered approach to respect for human dignity during health emergencies to avoid giving material meaning to the individual. Decision criteria are required to face bioethical conflicts in clinical practice, reducing the legal, emotional, and ethical burden of decision-making in pandemic situations.

Resumo A emergência sanitária devido à pandemia ocasionada pela covid-19 colocou em evidência limitações nos sistemas de saúde de todo o mundo. Isso levou à necessidade de um referencial bioético que ofereça ferramentas para orientar a tomada de decisões dos profissionais da saúde ante a escassez de recursos sanitários. Modelos bioéticos como o principialismo, o utilitarismo e a bioética centralizada na pessoa procuram enfocar as decisões clínicas com base no respeito dos direitos humanos e da dignidade das pessoas, preservando a prática médica. A bioética centralizada na pessoa oferece uma abordagem dirigida ao respeito a sua dignidade em situações de emergência sanitária, para evitar dar um sentido material ao homem. São exigidos critérios de decisão para enfrentar os conflitos bioéticos presentes na prática clínica que reduzam a carga legal, emocional e ética da tomada de decisões em contextos de pandemia.

El triaje en pandemia: fundamentos éticos para la asignación de recursos de soporte vital avanzado en escenarios de escasez / Pandemic triage: ethical foundations for the allocation of advanced life support resources in scarcity scenario

Las pandemias y otras catástrofes de alto impacto sanitario azotan periódicamente a la humanidad, aumentando desproporcionadamente la demanda por atención en servicios de urgencia, unidades de cuidados intensivos y medios de soporte vital avanzado. Este desequilibrio obliga a una compleja toma de decisiones en que se deben asignar recursos proporcionalmente escasos en relación a una gran demanda. Así, los equipos clínicos asistenciales necesitan actuar bajo criterios consensuados, que orienten sus decisiones y alivien la pesada carga moral de seleccionar pacientes para terapias, en detrimento de otros. El triaje es una estrategia que permite establecer, bajo racionalidades propias a cada escenario, objetivos y criterios que faciliten la toma de decisiones complejas para el logro del mejor resultado. Estas estrategias deben considerar el marco de valores intangibles que apreciamos y que nos identifican cultural y socialmente, como son el respeto a la vida, la igualdad, la justicia y la libertad. Sin embargo, en escenarios excepcionales como el de la actual pandemia COVID-19, en que el sistema sanitario puede no dar abasto, deberán establecerse objetivos prioritarios, como salvar la mayor cantidad de vidas, del modo más humano, justo y eficiente posible. A la vez, deberán redefinirse jerarquías en los valores y principios clásicos de la práctica clínica cotidiana, adecuadas a la catástrofe sanitaria, bajo una ética propia de la salud pública, el mayor bien para la mayoría y el mejor cuidado de los que no pueden ser curados.

Pandemics and other global disasters regularly overwhelm humankind. These catastrophic events suddenly increase demand for health-care in emergency services, intensive care units, and for advanced life support devices. This imbalance requires complex decision-making in which scarce resources must be allocated in relation to high demand. Thus, health-care teams need to act under consensus criteria that guide their decisions and alleviate the heavy moral burden of selecting patients for therapies, excluding others. Triage is a strategy that allows to establish, under appropriate rationalities, objectives and criteria that facilitate complex decisions to achieve the best results. These strategies should consider the framework of intangible values that we appreciate and identify us culturally and socially, such as respect for life, equity, justice and freedom. However, in exceptional scenarios such as the current COVID-19 pandemic, where the health system may be overcome, priority goals should focus in order to save as many lives as possible and by mean the most humane, fair and efficient way possible. At the same time, hierarchies of classical values and principles of daily clinical practice should be redefined in an appropriate way to face this catastrophic scenario, under an ethics for public health, the greatest good for the most and the best care of those who cannot be cured.

Experiencia cubana en planificación de los recursos humanos de enfermería en la epidemia por COVID-19 / Cuban experience in human resources planning for epidemic nursing COVID-19

Introducción: la pandemia por el virus SARS-CoV-2 ha provocado numerosas víctimas en el plano mundial. A partir de los primeros casos diagnosticados en Cuba, la máxima Dirección del Estado y el Ministerio de Salud Pública dispusieron el reordenamiento de los servicios del Sistema Nacional de Salud para garantizar la atención a los pacientes confirmados con la enfermedad y los programas priorizados con el aseguramiento de los recursos humanos de enfermería, además del desarrollo de acciones para garantizar la continuidad y calidad de las prestaciones proporcionadas. Desarrollo: se organizaron grupos de pesquisa diaria del 100% de la población en las viviendas para identificar a pacientes sintomáticos y se crearon centros para la vigilancia de acuerdo con la clasificación del paciente, ya fuera con- tacto, sospechoso o confirmado. En estos centros, el personal de enfermería mantiene una vigilancia para la detección oportuna de síntomas o agravamiento del estado de salud y efectúa el control de las pruebas diagnósticas por PCR evolutiva y el cumplimiento de los tratamientos médicos hasta su alta. En los hospitales se atienden los casos confirmados y sospechosos de alto riesgo de COVID-19. En estas instituciones se estableció un sistema de trabajo-vigilancia-descanso con el objetivo de garantizar la atención con el personal estrictamente necesario. Conclusiones: este trabajo permite compartir las experiencias vivenciales en la planificación del recurso humano de enfermería en cada una de las etapas y destaca la colaboración médica como muestra de solidaridad y humanismo que caracteriza a la sociedad. Los resultados obtenidos permitirán establecer líneas de trabajo con una clara visión de este fenómeno, con utilización óptima de los recursos materiales y humanos, además de contribuir a la preparación de los profesionales para el intercambio y la experiencia con otros países.

Introduction: The pandemic caused by the SARS-CoV-2 virus has hit numbers of victims worldwide, from the first cases diagnosed in Cuba, the highest state administration and the Ministry of Public Health provides the reorganization of the services of the National System of Health, guaranteeing care for patients confirmed with the disease and prioritized programs with the assurance of nursing human resources and the development of actions to guarantee the continuity and quality of the services provided for what the purpose is outlined. Development: Daily investigation groups of 100% of the population were organized in the homes to detect symptomatic patients, surveillance centers were created according to the classification of the patient as contact, suspect and confirmed, in these centers the nurse maintains a surveillance for the timely detection of symptoms or worsening of their health, controls the performance of the evolutionary PCR and compliance with medical treatments until discharge. In hospitals, confirmed and suspected high-risk cases of COVID-19 are treated. In these institutions, a work-surveillance-rest system was established in order to guarantee care with the strictly necessary personnel. Conclusions: In this article we share the experiential experiences in the planning of the nursing human resource in each of the stages and medical collaboration stands out as a sign of solidarity and humanism that characterizes our society. The results obtained will allow establishing lines of work with a clear vision of this phenomenon with optimal use of material and human resources, as well as contributing to the preparation of professionals with a view to exchange and experience with other countries.

Rationing of nursing care and its relationship to nurse practice environment in a tertiary public hospital

@#<p style="text-align: justify;"><strong>Objectives:</strong> The purpose of the study is to determine the level of rationing of nursing care and its relationship to nurses' perception of their practice environment.</p><p style="text-align: justify;"><strong>Methods:</strong> The study employed a descriptive, cross-sectional study design. The Basel Extent of Rationing of Nursing Care (BERNCA) was administered to assess the level of care rationing while the Practice Environment Scale of the Nursing Work Index (PES-NWI) was used to describe nurses' practice environment. A total of 147 nurses participated in the study. Multiple regression analysis was conducted to determine the effect of various respondent characteristics and nurse practice environment on care rationing.</p><p style="text-align: justify;"><strong>Results:</strong> Only practice environment total score was significantly associated with rationing of care total scores (B = -0.20, p < 0.05). Results of the regression show that for every unit increase in nurse practice environment total score, indicating a better work environment, there is a 0.20 unit decrease in rationing of nursing care total score, which indicated less rationing of care. Respondent characteristics are not significantly related.</p><p style="text-align: justify;"><strong>Conclusion:</strong> Nurses most frequently rationed tasks in the areas of caring/support and monitoring. The less frequently rationed tasks involved medical, technical, and therapeutic aspects of care. The identification of rationing predictors can aid in determining starting points for hospital policy reforms. Prevalence levels can indicate when care rationing exceeds identified thresholds, if any. Nursing administrators can use implicit rationing of nursing care as a crucial indicator of the impact of strategies and changes in the nurse practice environment (e.g., changes in staffing levels, skill mix, and other resources).</p><p style="text-align: justify;"><strong>Key Words:</strong> Health Care Rationing, Health Facility Environment, Nursing Care</p>

Bioética e a alocação de recursos nos cuidados paliativos durante a pandemia de covid-19: percepção de profissionais de saúde / La bioética y la asignación de recursos en cuidados paliativos durante la pandemia del covid-19 - percepción de los profesionales de la salud / Bioethics and the allocation of resources in palliative care during the covid-19 pandemic: the perception of health professionals

Objetivo: Analisar a percepção de profissionais de saúde sobre as questões bioéticas na tomada de decisão acerca dos recursos escassos, no contexto dos Cuidados Paliativos (CP), durante a pandemia de COVID-19 no Brasil. Métodos: Estudo transversal, descritivo e de abordagem quantitativa, realizado por meio de um questionário on-line, contendo quatro afirmativas sobre os dilemas éticos para que os participantes pudessem concordar ou não com elas, totalizando um escore máximo de 20 pontos. Os dados foram tabulados e analisados, por meio de estatística descritiva, utilizando-se o software Statistical Package for Social Sciences (SPSS), versão 25.0. Resultados: Participaram 190 profissionais de saúde, 45,3% (86) enfermeiros, 23,7% (45) médicos, 10,5% (20) dentistas e 12,6% (24) outros profissionais de saúde. Identificaram-se os seguintes percentuais de erros: restrição do acesso a Unidades de Terapia Intensiva (UTIs) (93 - 48,9%), disponibilização de ventiladores (117 - 61,6%), decisão de triagem para recursos escassos (158 ­ 83,2%), interrupção do atendimento a pacientes crônicos e paliativos na pandemia (11 ­ 5,8%). Conclusão: Os resultados demonstraram que os profissionais ainda apresentam conhecimento insuficiente sobre critérios de justiça e equidade na alocação de recursos escassos e que há necessidade de educação permanente no assunto voltado à temática.(AU)

Objective: To analyze the perception of health professionals about bioethical issues in decision-making processes about scarce resourcesfor Palliative Care (PC) during the COVID-19 pandemic in Brazil. Methods: This is a cross-sectional, descriptive study with a quantitative approach, carried out through an online questionnaire containing four statements about ethical dilemmas for participants to agree or disagree on, totaling a maximum score of 20 points. The data were tabulated and analyzed using descriptive statistics, on software Statistical Package for Social Sciences (SPSS), version 25.0. Results: 190 health professionals participated, 45.3% (86) nurses, 23.7% (45) doctors, 10.5% (20) dentists and 12.6% (24) other health professionals. The following percentages of errors were identified: restriction of access to Intensive Care Units (ICUs) (93 - 48.9%), availability of ventilators (117 - 61.6%), screening decision for scarce resources (158 - 83.2%), interruption of care for chronic and palliative patients in the pandemic (11 - 5.8%). Conclusion: The results demonstrate that the professionals still have insufficient knowledge about the criteria of justice and equity in the allocation of scarce resources and that there is a need for permanent education on the subject(AU)

Objetivo: Analizar la percepción de los profesionales de la salud sobre temas bioéticos en la toma de decisiones sobre recursos escasos en el contexto de Cuidados Paliativos (CP) durante la pandemia de COVID-19 en Brasil. Métodos: Estudio descriptivo transversal con enfoque cuantitativo, realizado a través de un cuestionario online que contiene cuatro afirmaciones sobre dilemas éticos para que los participantes estén de acuerdo o en desacuerdo con ellos, totalizando una puntuación máxima de 20 puntos. Los datos fueron organizados y analizados mediante estadística descriptiva, utilizando el software Statistical Package for Social Sciences (SPSS), versión 25.0. Resultados: Participaron 190 profesionales de la salud, 45,3% (86) enfermeras, 23,7% (45) médicos, 10,5% (20) odontólogos y 12,6% (24) otros profesionales de la salud. Se identificaron los siguientes porcentajes de errores: restricción de acceso a Unidades de Cuidados Intensivos (UCI) (93 - 48,9%), disponibilidad de ventiladores (117 - 61,6%), decisión de selección de recursos escasos (158 - 83,2%), interrupción de la atención de pacientes crónicos y paliativos en la pandemia (11 - 5,8%). Conclusión: Los resultados demuestran que los profesionales aún tienen un conocimiento insuficiente sobre los criterios de justicia y equidad en la asignación de recursos escasos y que existe la necesidad de una educación permanente en la materia enfocada en el tema(AU)

Problemas éticos en la asignación de recursos escasos y cuidado intensivo en la atención de la pandemia por SARS-CoV-2 Una reflexión desde los principios, criterios, derechos y deberes / Ethical problems in the assignment of scarce resources and intensive care in SARS-CoV-2 pandemic healthcare Thoughts based on principles, criteria, rights and responsibilities

Resumen Este documento tiene como finalidad identificar algunos problemas éticos de los procesos de atención en el contexto de la pandemia por SARS-CoV-2 en Colombia, y proponer un conjunto de principios y criterios éticos que permitan a las instituciones y los trabajadores de la salud la toma de decisiones éticamente sustentables y jurídicamente factibles, con un especial enfoque en la protección del núcleo de los derechos fundamentales de pacientes y trabajadores, en un contexto extraordinario caracterizado por la inequidad estructural y la discrepancia entre la oferta y la demanda de bienes, recursos y servicios de salud, con el objetivo de mitigar el estrés moral, maximizar los beneficios derivados de la utilización de los recursos escasos y modular los riesgos éticos y jurídicos asociados.(Acta Med Colomb 2020; 45. DOI:https://doi.org/10.36104/amc.2020.1952).

Abstract The purpose of this document is to identify some ethical problems in healthcare processes within the context of the SARS-CoV-2 pandemic in Colombia, and propose a collection of ethical principles and criteria which will allow healthcare institutions and workers to make ethically supported and legally feasible decisions. These decisions should especially focus on protecting the core of the fundamental rights of patients and workers, in an extraordinary context characterized by structural inequity and a discrepancy between the supply and demand of healthcare goods, resources and services. Ultimately, this will mitigate moral stress, maximize the benefits derived from the use of scarce resources, and modulate the associated ethical and legal risks.(Acta Med Colomb 2020; 45. DOI:https://doi.org/10.36104/amc.2020.1952).

La relación médico-paciente en tiempos de pandemia / The doctor-patient relationship in times of pandemic / A relaçao médico paciente em tempos de pandemia

El presente artículo refiere a determinados problemas bioéticos y jurídicos en marcados en la crisis global generada por el COVID-19. En ese sentido se abordan cuestiones tales como la asignación de recursos limitados, las limitaciones al ejercicio de la autonomía en general, y del derecho a no saber y el egreso contra voluntad médica en particular; y la protección de la confidencialidad de los datos sanitarios; en el contexto de la pandemia señalada (AU)

This article refers to certain bioethical and legal problems framed in the global crisis generated by COVID-19. In this sense, issues such as the allocation of limited resources, limitations to the exercise of autonomy in general, and the right to not to know and discharge against medical will in particular are addressed; and the protection of the confidentiality of health data; in the context of the indicated pandemic (AU)

Este artigo refere-se a certos problemas bioéticos e legais enquadrados na crise global gerada pelo COVID-19. Nesse sentido, são abordadas questões como a alocação de recursos limitados, limitações ao exercício da autonomia em geral e o direito a não conhecer e dispensar a vontade médica em particular; e a proteção da confidencialidade dos dados de saúde; no contexto da pandemia indicada (AU)

Bioética y pandemia / Bioethics and pandemic

Se describen las recomendaciones y los principios éticos para la asignación de recursos en la organización y práctica de la salud pública en el marco de pandemias originadas por enfermedades infecciosas. Durante las pandemias, las capacidades humanas y los recursos materiales disponibles para dar respuesta a las necesidades suelen verse sobrepasados. En este escenario se deberán adoptar múltiples decisiones, muchas de ellas difíciles, acerca de cómo, dónde, cuándo y a quién asignar esos recursos. Para ayudar a los médicos a sortear estos desafíos, las instituciones deberían contar con personal abocado al triage, comités de expertos y de ética que ayuden a aplicar estas recomendaciones, asistir en la toma de decisión o realizar elecciones, liberando al médico de esa pesada carga.

Recommendations and ethical principles for the allocation of resources in the organization and practice of public health in the context of pandemics caused by infectious diseases are described. During pandemics, the human capacities and material resources available to respond to needs are often overwhelmed. In this scenario, multiple decisions will have to be made, many of them difficult, about how, where, when and to whom to allocate those resources. To help physicians overcome these challenges, institutions should have triage staff, expert and ethics committees to help implement these recommendations, assist in decision-making or make choices, freeing the physician from that heavy burden.

Guías éticas para la atención durante la pandemia COVID-19: Recomendaciones multisocietarias para asignación de recursos / Ethical guides, criteria for admission in intensive care, palliative care. Multi-society recommendations for allocation of resources during the COVID-19 pandemic

Se presentan las guías sobre ética de asignación de recursos, procesos de triaje con criterios de ingreso y egreso de unidades de cuidados críticos y atención paliativa durante la pandemia. El panel interdisciplinario y multisocietario que las preparó estuvo representado por bioeticistas y por especialistas vinculados al fin de la vida: clínicos, geriatras, emergentólogos, intensivistas, expertos en cuidados paliativos y en reanimación cardiopulmonar. La información disponible indica que aproximadamente 80% de las personas con COVID-19 desarrollarán síntomas leves y no requerirán asistencia hospitalaria, mientras que 15% precisará cuidados intermedios o en salas generales, y el 5% restante requerirá de asistencia en unidades de cuidados intensivos. La necesidad de pensar en justicia y establecer criterios éticos de asignación surgen en condiciones de superación de los recursos disponibles, como en brotes de enfermedades y pandemias, siendo la transparencia el principal criterio para la asignación. Estas guías recomiendan criterios generales de asignación de recursos en base a consideraciones bioéticas, enraizadas en los Derechos Humanos y sustentadas en el valor de la dignidad de la persona humana y principios sustanciales como la solidaridad, la justicia y la equidad. Las guías son recomendaciones de alcance general y su utilidad consiste en acompañar y sostener las decisiones técnicas y científicas que tomen los distintos especialistas en la atención del paciente crítico, pero dado el carácter dinámico de la pandemia, debe asegurarse un proceso de revisión y readaptación permanente de las recomendaciones.

Guidelines on resource allocation, ethics, triage processes with admission and discharge criteria from critical care and palliative care units during the pandemia are here presented. The interdisciplinary and multi-society panel that prepared these guidelines represented by bioethicists and specialists linked to the end of life: clinicians, geriatricians, emergentologists, intensivists, and experts in palliative care and cardiopulmonary resuscitation. The available information indicates that approximately 80% of people with COVID-19 will develop mild symptoms and will not require hospital care, while 15% will require intermediate or general room care, and the remaining 5% will require assistance in intensive care units. The need to think about justice and establish ethical criteria for allocation patients arise in conditions of exceeding available resources, such as outbreaks of diseases and pandemics, with transparency being the main criterion for allocation. These guides recommend general criteria for the allocation of resources relies on bioethical considerations, rooted in Human Rights and based on the value of the dignity of the human person and substantial principles such as solidarity, justice and equity. The guides are recommendations of general scope and their usefulness is to accompany and sustain the technical and scientific decisions made by the different specialists in the care of critically ill patients, but given the dynamic nature of the pandemic, a process of permanent revision and adaptation of recommendations must be ensured.

Recomendaciones para la gestión de recursos en las unidades de cuidados intensivos durante la pandemia de COVID-19 / Recommendations for resource management in intensive care units during the COVID-19 pandemi

El presente documento tiene como fin proporcionar recomendaciones basadas en la evidencia para estimar los equipos de proteccion personal (EPP), los dispositivos médicos y los medicamentos comúnmente utilizados en la Unidad de Cuidados Intensivos durante la pandemia de COVID-19. Se llevó a cabo una revisión sistemática de la literatura y evaluación de la literatura gris. La evidencia se clasificó utilizando la metodología GRADE. Luego, se construyó un modelo predictivo para apoyar la estimación de recursos durante 30 días de la pandemia. En el desarrollo de estas recomendaciones se incluyeron 33 publicaciones con calidad de evidencia variable (calidad baja a muy baja), acerca del uso de EPP según el riesgo de exposición; manejo y re-uso de EPP, y las necesidades de fármacos y dispositivos médicos para la atención de pacientes con COVID-19. Es destacable lo difícil que resulta estimar y administrar la cantidad de suministros y equipos esenciales necesarios durante una pandemia. El modelo nos permitió predecir los recursos necesarios para proporcionar cuidados críticos durante 30 días de actividad pandémica. Dada la evolución constante de COVID-19, estas recomendaciones pueden cambiar a medida que evolucione la evidencia.

This document aims to provide evidence-based recommendations to estimate the personal protective equipments (PPE), medical devices, and drugs commonly used in the Intensive Care Unit during the COVID-19 pandemic. A systematic literature review and gray literature assessment was performed, and the evidence was categorized using the GRADE methodology. Then a predictive model was built to support the estimation of resources needed during 30 days of the pandemic. In the development of these recommendations, 33 publications were included, with variable quality of evidence (low to very low quality). They refer to the use of PPE according to the risk of exposure; management and reuse of PPE, and the stock of drugs and medical devices needed for the care of patients with COVID-19. It is important to remark the difficult in estimating and managing the number of essential supplies and equipment required during a pandemic. The model allowed us to predict the resources required to provide critical care during 30 days of pandemic activity. Given the constant evolution of COVID-19, these recommendations might change as evidence evolves.

Orientaciones éticas para la toma de decisiones médicas en el contexto de la pandemia de COVID-19 en Chile / Ethical guidelines for medical decision-making during COVID-19 pandemic in Chile

The catastrophic emergency experienced by many countries with the COVID-19 pandemic emphasized the importance of bioethics for decision-making, both at the public health (equitable and effective policies) and at the clinical level. At the clinical level, the issues are the fulfillment of medical care demand with adequate health care teams, infrastructure, and supplies, and to cover critical care demands that surpass the available resources. Therefore, ethically correct approaches are required for the allocation of life sustaining resources. There are recommendations for the allocating life support during disasters based on multiple considerations, including ethical ones. However, the ethical criteria of existing guidelines are variable. Ethical principles usually considered are saving the greatest number of lives, saving the greatest number of years of life and the principle of the life cycle or the goal to give each individual equal opportunity to live through the various phases of life. However, the centrality of the human being and the search for the common good should be considered. Knowledge of public perspectives and moral benchmarks on these issues is essential. A successful assignment effort will require everyone's trust and cooperation. Decision making should be planned and discussed in advance, since in-depth deliberation will be extremely complex during the disaster. Our goal is to help the health care teams to wisely allocate resources in shortage periods.

Practical Considerations for Converting Operating Rooms and Post-anaesthesia Care Units into Intensive Care Units in the COVID-19 Pandemic - Experience from a Large Singapore Tertiary Hospital

COVID-19 has spread globally, infecting and killing millions of people worldwide. The use of operating rooms (ORs) and the post-anaesthesia care unit (PACU) for intensive care is part of surge response planning. We aim to describe and discuss some of the practical considerations involved in a large tertiary hospital in Singapore. Firstly, considerations for setting up a level III intensive care unit (ICU) include that of space, staff, supplies and standards. Secondly, oxygen supply of the entire hospital is a major determinant of the number of ventilators it can support, including those on non-invasive forms of oxygen therapy. Thirdly, air flows due to positive pressure systems within the OR complex need to be addressed. In addition, due to the worldwide shortage of ICU ventilators, the US Food and Drug Administration has granted temporary approval for the use of anaesthesia gas machines for patients requiring mechanical ventilation. Lastly, planning of logistics and staff deployment needs to be carefully considered during a crisis. Although OR and PACU are not designed for long-term care of critically ill patients, they may be adapted for ICU use with careful planning in the current pandemic.

Ethical dilemmas in COVID-19 times: how to decide who lives and who dies?

SUMMARY The respiratory disease caused by the coronavirus SARS-CoV-2 (COVID-19) is a pandemic that produces a large number of simultaneous patients with severe symptoms and in need of special hospital care, overloading the infrastructure of health services. All of these demands generate the need to ration equipment and interventions. Faced with this imbalance, how, when, and who decides, there is the impact of the stressful systems of professionals who are at the front line of care and, in the background, issues inherent to human subjectivity. Along this path, the idea of using artificial intelligence algorithms to replace health professionals in the decision-making process also arises. In this context, there is the ethical question of how to manage the demands produced by the pandemic. The objective of this work is to reflect, from the point of view of medical ethics, on the basic principles of the choices made by the health teams, during the COVID-19 pandemic, whose resources are scarce and decisions cause anguish and restlessness. The ethical values for the rationing of health resources in an epidemic must converge to some proposals based on fundamental values such as maximizing the benefits produced by scarce resources, treating people equally, promoting and recommending instrumental values, giving priority to critical situations. Naturally, different judgments will occur in different circumstances, but transparency is essential to ensure public trust. In this way, it is possible to develop prioritization guidelines using well-defined values and ethical recommendations to achieve fair resource allocation.

RESUMO A doença respiratória provocada pelo coronavírus 2019 (COVID-19) é uma pandemia que produz uma grande quantidade simultânea de doentes com sintomas graves que necessitam de cuidados hospitalares especiais, sobrecarregando a infraestrutura dos serviços de saúde. Todas essas demandas geram a necessidade de racionar equipamentos e intervenções. Diante desse desequilíbrio, como, quando e quem decide, há o impacto dos sistemas estressores dos profissionais que se encontram na linha de frente do atendimento e, em segundo plano, questões inerentes à subjetividade humana. Nesse percurso, surge ainda a ideia do uso de algoritmos da inteligência artificial para substituir o profissional de saúde nessa tomada de decisão. Nesse contexto, fica o questionamento ético de como gerenciar as demandas produzidas pela pandemia. O objetivo deste trabalho é refletir, do ponto de vista da ética médica, sobre princípios basilares das escolhas executadas pelas equipes de saúde, no enfrentamento da pandemia da COVID-19, cujos recursos são escassos e as decisões ocasionam angústia e inquietação. Os valores éticos para o racionamento de recursos de saúde em uma epidemia devem convergir para algumas propostas embasadas em valores fundamentais, como maximizar os benefícios produzidos por recursos escassos, tratar as pessoas de forma igualitária, promover e recomendar os valores instrumentais, dar prioridade para situações críticas. Naturalmente ocorrerão julgamentos diferentes em circunstâncias distintas, mas é fundamental que haja transparência para garantir a confiança pública. Desse modo, é possível elaborar diretrizes de priorização utilizando valores e recomendações éticas bem delineados para atingir procedimentos justos de alocação de recursos.

Asignación ética de recursos sanitarios escasos en el contexto de crisis por COVID-19 / Ethical allocation of scarce health care resources in the context of the COVID-19 crisis

La actual pandemia por COVID-19 tiene el potencial de sobrepasar la capacidad de hospitales y unidades de cuidados intensivos en Chile y América Latina. Por lo tanto, las autoridades locales tienen la obligación ética de estar preparadas mediante la implementación de medidas tendientes a evitar una situación de racionamiento de recursos sanitarios escasos, y a través de la definición de criterios éticamente aceptables y socialmente legítimos para la asignación de estos recursos. Este artículo presenta una respuesta a orientaciones éticas recientes emitidas por una institución académica chilena y analiza los principios éticos relevantes para la fundamentación ética de criterios de racionamiento. Se argumenta que, frente a circunstancias excepcionales como la actual pandemia, la moral centrada en el paciente de la medicina tradicional necesita ser ponderada con principios éticos formulados desde una perspectiva de salud pública, incluyendo los principios de utilidad social, justicia social y equidad, entre otros. Se concluye con algunas recomendaciones sobre cómo llegar a acuerdo sobre criterios de racionamiento y sobre la implementación de estos en la práctica clínica.

The current COVID-19 pandemic has the potential to overwhelm the capacity of hospitals and Intensive Care Units in Chile and Latin America. Thus local authorities have an ethical obligation to be prepared by implementing pertinent measures to prevent a situation of rationing of scarce healthcare resources, and by defining ethically acceptable and socially legitimate criteria for the allocation of these resources. This paper responds to recent ethical guidelines issued by a Chilean academic institution and discusses the main moral principles for the ethical foundations of criteria for rationing during the present crisis. It argues that under exceptional circumstances such as the current pandemic, the traditional patient-centered morality of medicine needs to be balanced with ethical principles formulated from a public health perspective, including the principles of social utility, social justice and equity, among others. The paper concludes with some recommendations regarding how to reach an agreement about rationing criteria and about their implementation in clinical practice.