高齢者の看取りにおける人工的水分・栄養補給法（AHN）の差し控え・中止をめぐる家族介護者の代理意思決定プロセス：修正版グラウンデッド・セオリー・アプローチ（M-GTA）

Decision-Making Process of Family Caregivers on Withholding or Withdrawing Artificial Hydration and Nutrition in End-Of-Life Care of Older Adults: A Modified Grounded Theory Approach

要旨

　目的：高齢者の看取りにおけるAHNの差し控え・中止をめぐる家族介護者の代理意思決定プロセスを明らかにする．

　方法：9名の家族介護者へインタビューを行いM-GTAにより分析した．

　結果：AHNの差し控え・中止をめぐる代理意思決定を行った家族介護者は，〈医療選択を迫られる動揺〉のなかで〈手がかりの探索〉を行い，〈胃ろう選択の回避〉や〈看取りの決心をかき乱す声〉から【いのちを見捨てるような自責】を抱え，〈時間を延ばすための点滴〉が〈治療なのか，延命なのか〉と自問しながら，『自然で穏やかな最期という望み』をもって，代理意思決定者としてではなく〈ただ家族であること〉から高齢者の最期を見守り，【不確かさと共に続く生活】のなかで代理意思決定の経験を意味づけようとしていた．

　結論：家族介護者はAHNの代理意思決定に苦悩と葛藤を抱きながら高齢者を看取り，それぞれの関係性のなかで自身の代理意思決定の経験を意味づけようとしていた．

　Objective: To identify family caregivers' surrogate decision-making processes regarding withholding or withdrawing artificial hydration and nutrition in the end-of-life care of older adults.

　Methods: Nine family caregivers were interviewed, and the data were analyzed using a modified grounded theory approach.

　Results: Family caregivers searched for meaning in the turmoil of having to make medical decisions but felt distress when others' voices disrupted their decision-making about the patient's gastrostomy and end-of-life care. Respondents reported experiencing remorse, and the feeling that they were abandoning the patient's life. Caregivers questioned whether the provision of intravenous fluids constituted a cure or a life extension, but they had hope for a natural and peaceful end to the patient's life. Caregivers made sense of their experience of surrogate decisionmaking in an uncertain life, not as surrogate decision-makers but simply as family members watching over an older adult in their final days.

　Conclusion: Family caregivers experienced anguish and conflict when making surrogate decisions about withholding or withdrawing artificial hydration and nutrition for older adult family members, and they tried to make sense of these difficult experiences in the context of their relationships with those family members.