急性期病院の熟練看護師が行うエンド・オブ・ライフケアにおける超高齢者の療養場所選択についての意思決定支援の構造

Structure of Decision Support for the Oldest Old by Expert Nurses in the Selection of Care Location During End of Life Care in Acute Hospitals

要旨

　目的：本研究は，エンド・オブ・ライフケアにおける超高齢者の療養場所選択に対する意思決定支援を行うために，急性期病院の熟練看護師が超高齢者と家族の意思をどのようにくみ取り，意思決定支援を実践しているかについての構造を明らかにする．

　方法：研究参加者10名に半構造化面接を行い質的統合法（KJ法）にて分析した．

　結果：熟練看護師は，【超高齢者への理解の追求】と【家族への理解の追求】の両面から【療養場所決定の中にある本人の尊厳】を尊重していた．さらに，【超高齢者側から見た最適医療】のために超高齢者の価値観や体験の理解をし，【医療者側から見た最適医療】を見定める調整をして【病院医療依存の中にある本人の尊厳】を守り【希望療養場所の実現可能性支援】を行っている構造が明らかとなった．

　結論：熟練看護師は，超高齢者の尊厳の追求を中心に据え，超高齢者医療のあり方への挑戦を実践していることが示唆された．

　Aim: The present study aimed to clarify the framework for how expert nurses at acute care hospitals comprehend the intentions of oldest-old patients and their families and implement decision-making support with regard to the selection of care location of end-of-life care for oldest-old.

　Method: Semi-structured interviews conducted on 10 participants were analyzed using qualitative synthesis method (KJ method).

　Results: Expert nurses respected “the dignity of the person at the center of the decision about the selection of care location” from the perspectives of “seeking to understand the oldest-old” and “seeking to understand the family”. They understood the values and an experience of the oldest-old in order to provide “optimal medical care from the oldest-old perspective” and they made adjustments to determine “optimal medical care from the medical care providers' perspective”. While protecting “the dignity of the person at the center of dependency on hospital medical care”, they provided “support for the feasibility of the desired location of care”. Based on the above results comprised the framework for decision-making support by expert nurses.

　Conclusion: The present findings suggest that expert nurses take on the challenge of medical care for oldest-old while maintaining dignity for these patients.