ターミナル期にあるがん患者の自己決定支援に関する看護師の価値観─経験を積んだ看護師に焦点を当てて

Nurses' Value Judgments on Support Provided for Decision-making by Terminal Cancer Patients : A Study Focusing on Experienced Nurses

要旨

　本研究の目的は，ターミナル期がん患者の看護実践経験を積んできた看護師が患者の自己決定支援に関して持ち合わせている価値観を明らかにし，患者の自己決定支援への示唆を得ることである．ターミナル期にある成人がん患者の看護実践経験が4年以上の看護師16名を対象に，半構成的面接を行い質的帰納的に分析した．分析の結果，【患者が最期まで自分の意思で決定する】，【患者が決定したことを何としても実現させるためにチームに働きかける】，【患者が希望すれば残りの時間を自宅で過ごせるよう支援する】，【家族が患者の意思を尊重して最期の治療・処置に関する代理決定ができるよう支援する】，【患者の自己決定への揺らぎを共有し，何度でも自己決定をやり直せるよう支援する】，【残りの時間を考慮して患者の自己決定を尊重できるようケアを工夫する】，【患者の自己決定内容の実現が及ぼす負の影響を考慮してケアを実践する】の7つの価値観が明らかとなった．患者の自己決定支援への示唆として，患者が正しい病状認識のもとで最期まで自己決定できることを重視し，代理決定や医療チームへの働きかけを含めた多様な方法で自己決定を尊重すること，患者が自宅での療養を希望した場合には，在宅療養を可能にするための要である家族に対して社会資源と医療者のサポート体制について十分な情報提供を行うこと，さらに，患者の自己決定内容の実現が及ぼす負の影響を考慮し，患者の安全を保証するケアを提供したうえで患者の自己決定内容実現を支援すること，が得られた．

Abstract

　The purpose of this research was to understand the value judgments of nurses with practical experience of nursing patients with terminal cancer, regarding support provided for decision making by these patients. Semi-structured interviews were carried out with 16 nurses having at least 4 years’ practical experience of nursing adult patients with terminal cancer, and qualitative functional analysis of the interview content was performed. Analysis of the research results identified seven value judgments held by these nurses：‘a patient should make his own decisions until the end,’ ‘a patient should be able to approach and appeal to the medical team so that his decision is realized at all costs,’ ‘a patient should be given support to enable him to spend the remainder of his life at home if he wishes,’ ‘the family should respect the decisions of the patient and should be supported so that they can make treatment and other related decisions on the patient’s behalf more easily during the final stages,’ ‘when a patient changes his decision, the information should be shared and supported so that he may change his decision as many times as required,’ ‘considering the amount of time the patient has left, care should be taken to respect the patient’s decision,’ and ‘care should be taken to minimize the burden on the patient in realizing the content of his decision.’ The suggestions given regarding the support provided for decision-making included emphasizing the ability of patients to make their own decisions until the end based on correct recognition of their condition and respecting their decisions in a variety of ways, including approaching and appealing to the substitute decision maker and/or medical team；providing sufficient information regarding social resources and medical staff support systems to the patients’ families to allow for home care if the patients wish to receive treatment at home；taking into account the burden on the patients in realizing the content of their decision；and supporting the realization of their decision while providing care to ensure their safety.