4．ICUにおける予後情報を用いた意思決定の方法—shared decision makingとは？

Decision-making regarding life-sustaining treatments in the ICU using prognostic information

ダイナミックな臨床経過をたどり不確定要素の多いICU患者において，医師と患者や代理意思決定者が協調し診療方針を創り出してゆく共同の意思決定shared decision making（SDM）の過程は極めて重要である。SDMでは，特にICU入室早期から予後，患者の価値観，延命治療で得られる利益・害について頻回かつ定期的に話し合い，両者が合意したケア目標を定めることが重要である。ケア目標を定める際には，予後予測モデルやtime-limited trial（TLT）を活用することで，両者の合意がより得られやすくなる可能性がある。また，ICUを今後より有効活用してゆくためには，事前の意思表示〔アドバンス・ケア・プランニング（ACP）〕を一般市民へ普及させることが大切である。

Many patients in the ICU follow a dynamic clinical course, and their prognosis is quite uncertain. Under such circumstances, the process of shared decision making （SDM） as a collaborative effort including physicians, patients, and surrogate decision makers to reach the goal of care is important. The important aspect of SDM is to decide what to discuss from the time of ICU admission （prognosis, values, benefits / disadvantages following life-prolonging treatment） and hold these discussions frequently and regularly. Once they reached agreement, final goal of care should be clearly set. When goal of care is decided upon, the use of prognostic indicators and time-limited trial （TLT） would be useful to reach mutual agreement. In order to reduce futile medical treatment and accelerate the effective use of the ICU, to initiate goal of care discussions using TLT from the early stage of ICU admission is important. Dissemination of the concept of ACP （Advance Care Planning） to the general public is also important.