ABSTRACT
INTRODUCTION: Suicide in physicians outlines a public health problem that deserves more consideration. A recently performed meta-analysis and systematic review evaluated suicide mortality in physicians by gender and investigated several related risk factors. It showed a post-1980 suicide mortality ratio 46% higher in female physicians than women in the general population and a 33% lower risk in male physicians than men in general, despite an overall contraction in physicians' mortality rates in both genders. METHODS: This narrative review was conducted through a search and analysis of relevant articles/databases to address questions raised by the meta-analysis, and how they may be affected by COVID-19. The process included unstructured searches on physician suicide, burnout, medicine judicialization, healthcare organization and COVID-19 on Pubmed, and Google searches for relevant databases, medical society, expert and media commentaries on these topics. We focus on three factors critical to address physician suicides: epidemiological data limitations, psychiatric comorbidities, and professional overload. RESULTS: We found relevant articles on suicide reporting, physician mental health, effects of healthcare judicialization and organization on physician and patient health, and how COVID-19 may impact such factors. This review addresses information sources, underreporting/misreporting of physicians' suicide rates, inadequate diagnosis and management of psychiatric comorbidities and chronic effects on physicians' work capacity, and finally, medicine judicialization and organization failure increasing physician "burnout". We discuss these factors in general and in relation to the COVID-19 pandemic. CONCLUSIONS: We describe an overview of the above factors, discuss possible solutions, and specifically address how COVID-19 may impact such factors.
ABSTRACT
Resumen: Introducción: la pandemia provocada por el SARS-CoV-2 genera un importante desafío para el sistema sanitario y especialmente para la Medicina Intensiva. Es necesario prepararse en múltiples aspectos. Además, considerar plausible una demanda extraordinaria de camas críticas que puede llevar a un desbalance entre las necesidades clínicas y la disponibilidad efectiva de los recursos sanitarios. Objetivos: realizar un análisis bioético para brindar una orientación en la atención a los pacientes críticos. Objetivos específicos: 1) Analizar los principios bioéticos fundamentales en este contexto. 2) Apoyar a los clínicos en la toma de decisiones difíciles. 3) Hacer explícitos los criterios de asignación de recursos. 4) Definir líneas de acción ante un posible escenario de "desastre sanitario". Método: la SUMI ha generado un ámbito de trabajo colectivo cuyo método de trabajo fue la deliberación. En la documentación se utiliza la revisión bibliográfica y los protocolos ya existentes. Resultados: el trabajo plantea un análisis teórico documentado sobre los principios bioéticos involucrados en el contexto de pandemia, sobre los escenarios de demanda asistencial y sobre la fundamentación para un cambio en los criterios éticos ante un escenario de saturación del sistema. Conclusión: se plantean recomendaciones prácticas para: 1) Toma de decisiones de ingreso y egreso en demanda controlada. 2) Criterios de acción ante el aumento de la demanda estableciendo definiciones de los diferentes escenarios. 3) Recomendaciones para aplicar en un escenario de saturación del sistema.
Summary: Introduction: the pandemic caused by SARS-CoV2 constitutes a significant challenge for the health system, and especially for Critical Care Units, so we need to prepare in many aspects. Likewise, we need to consider there could be an extraordinary demand for beds in critical care units, what would lead to an imbalance between clinical needs and the effective availability of health resources. Objectives: the study aims to perform a bioethical analysis that could provide guidelines for the assistance of patients in critical care. Specific objectives: 1) to analyse the main bioethical principles in this context, 2) to support clinicians in the making of difficult decisions, 3) to make the resource allocation criteria specific, 4) to define action lines upon a potential "health's disastrous" scenario Method: the Uruguayan Society of Intensive Care has generated a space for collective work based on discussion processes. Documents include a bibliographic review and the existing protocols. Results: the study presents a theoretical analysis that is backed up by the bioethical principles involved in the pandemic context on the scenarios of demand for assistance and, by the arguments calling for a change in the ethical criteria upon the saturation of the health system. Conclusion: practical recommendations are made: 1) for the making of decisions about admission and discharge in a controlled demand. 2) to define action criteria upon an increase in demand, clearly defining the different scenarios, 3) to apply upon the saturation of the health system.
Resumo: Introdução: a pandemia causada pelo SARS-CoV2 gera um importante desafio para o sistema de saúde e principalmente para a Medicina Intensiva. É preciso se preparar em vários aspectos. Além disso, considera plausível uma demanda extraordinária por leitos críticos, que pode levar a um desequilíbrio entre as necessidades clínicas e a disponibilidade efetiva de recursos de saúde. Objetivos: realizar uma análise bioética para orientar o cuidado ao paciente crítico. Objetivos específicos: 1) Analisar os princípios bioéticos fundamentais neste contexto, 2) Apoiar os médicos na tomada de decisões difíceis, 3) Tornar explícitos os critérios de alocação de recursos, 4) Definir linhas de ação perante um possível cenário de " desastre de saúde ". Métodos: a SUMI gerou um ambiente de trabalho coletivo cujo método de trabalho era deliberativo. A documentação usa a revisão da literatura e os protocolos existentes. Resultados: o trabalho propõe uma análise teórica documentada sobre os princípios bioéticos envolvidos no contexto da Pandemia, sobre os cenários da demanda de saúde e sobre os fundamentos para uma mudança de critérios éticos em um cenário de saturação do sistema. Conclusão: são propostas recomendações práticas para: 1) tomada de decisão para admissão e alta sob demanda controlada. 2) critérios de atuação frente ao aumento da demanda, estabelecendo definições dos diferentes cenários. 3) recomendações a serem aplicadas em um cenário de saturação do sistema.