不確実性の中での決断―無症候性脳血管障害患者の診断から予防的手術への決断のプロセス

Decision Making under the Uncertainty；Process of Decision from Diagnosis to Preventive-Operation in Patient with Asymptomatic Cerebrovascular Diseases

要旨

　本研究の目的は，無症候性脳血管障害患者の予防的手術への決断のプロセスを検討することである．無症候性脳血管障害に対する予防的治療はいまだ不確実性の多い領域であり，手術の有効性や妥当性の証明が急がれる一方で，患者の体験の実態はほとんどわかっていない．15名の対象者から聞き取った内容を分析した結果，決断のプロセスには時間的経過の中で変化する時間的カテゴリーと，そのプロセスに絡む要因的カテゴリーの2つの軸で説明できた．時間的カテゴリーは『混乱』『迷い／揺らぎ』『見込みの吟味』『賭けに出る決断』であり，要因的カテゴリーは内的に生じる《病気との距離感》《一時的な病人化》と外的な人的資源との関係から生じる《医師とのつながり感》《家族機能へのこだわり感》であった．また，患者は診断後に直感的に発症の予感を強く抱き，不確実性の中で厳しい決断を下し手術に立ち向かっていた．しかし，この決断のプロセスを支援する看護師の存在はきわめて希薄であった．今後，無症候性脳血管障害患者は増えると予測されている．看護師は患者を取り巻く人的資源として医師や家族とは別にその役割を明確に示していく必要がある．

Abstract

　The purpose of this study was to investigate the processes of decision making for the preventiveoperation in the patients with asymptomatic cerebrovascular diseases.

　In the domain of preventive surgical treatment for asymptomatic cerebrovascular diseases, there are still many uncertain and controversial elements. Meanings of the experiences of patients who undergo the preventive-operation are not known. Using qualitative method, we analyzed open-ended interviews of 15patients who underwent the preventive-operation, it was found that the process of decision making has two main dimensions. One was explained as category of sequential process, and another was explained as category relevant to the process. In the sequential process-category, ‘confusion,’‘hesitation / fluctuation,’‘examination of the prospect,’and ‘decision making which is like a bet /at the risk’were accrued sequentially. The elements-category consisted of internal emotions and experiences of the interpersonal to external human resources. The internal emotions included ‘perception of distance from illness’and ‘perception of becoming a sick person temporarily.’And experiences in the interpersonal to external human resources ‘perception of being connected with the doctor’and ‘adhering to the family functions.’Those patients intuitively felt presentiment that they might have an attack right of the diagnosis. In this study, we revealed that patients made a decision under the serious uncertainty.

　However, nurses had hardly participated in their hard situation to support the process of the decision-making. Since it is expected that patients with asymptomatic cerebrovascular diseases will increase, nurses need to establish the additional role to support the decision making of these patient.