緩和ケア病棟入院中で余命3週間程度と予測されている終末期がん患者の1日の過ごし方に対する意思決定の内容

The Details of Decision-Making Regarding How to Spend Daily Life among Terminally Ill Cancer Patients in the Palliative Care Unit with Life Expectancies of Approximately Three Weeks

要旨

　本研究の目的は，緩和ケア病棟入院中で余命3週間程度と予測されている終末期がん患者の1日の過ごし方に対する意思決定の内容を明らかにし，患者が自己の意思決定にしたがって最期まで良質な1日を過ごすことを支援する看護への示唆を得ることである．対象は，緩和ケア病棟に入院し，余命3週間程度と予測されているがん患者18名である．研究は，研究協力施設の承認および任意による研究参加の同意を得て，対象者の体調に配慮して行った．データ収集は，参加型参加観察法および半構造化面接法を用いて行い，Krippendorffの内容分析の手法により分析した．分析の結果，緩和ケア病棟入院中で余命3週間程度と予測されている終末期がん患者の1日の過ごし方に対する意思決定の内容は，【時の仕切りをして，今日1日を生きるという過ごし方をする】【あらかじめ何かをしようとは決めず状況に応じた過ごし方をする】【体力が維持できるような過ごし方をする】【形あるものを残せるような過ごし方をする】【楽しみを取り入れた過ごし方をする】【つらさは家族以外の他者に吐き出して平穏に過ごす】【今も死後においても大切な人との絆を断ち切らないような過ごし方をする】【残された命を他者のために使えるような過ごし方をする】【人として尊厳ある過ごし方をする】であった．

　必要な看護として，身体的苦痛を緩和する，1日1日の生活が患者にとって最良の日となるようケアする，計画を立てないで過ごすことも患者の意思決定として尊重する，達成可能で身近な目標を患者とともに掲げたり「ものづくり」や季節的行事の実施などにより希望を維持し育む契機を用意する，聴き手になる，患者自身が他者のために何かができるような関わりをする，可能な限り患者自身で身の周りのことができるよう環境を整える，などが示唆された．

Abstract

　The purposes of this study were to clarify the details of decision-making among terminally ill cancer patients with life expectancies of approximately three weeks in the palliative care unit on how they would spend their remaining days, and to consider the role of nursing in ensuring that the decisions made by the patients were supported to maintain their quality of daily life.

　Participant observation(participant-as-observer)and semi-structured interviews were conducted with 18 terminally ill cancer patients admitted to the palliative care unit with life expectancies of approximately three weeks. Data were obtained with careful consideration of each participant's health status. The data were analyzed using Krippendorff's content analysis method. The institutional ethics committee approved this study and each patient provided an informed consent.

　We found that patients wanted to spend their remaining days by doing the following : live each day with each moment in time as a separate compartment ; live each day as it is without planning ahead of time ; live life by conserving physical strength ; create or leave something that can be left behind as a memento ; spend time doing something enjoyable ; talk about the frustrations and pain with people other than family and live in tranquility ; live in such a way that bonds with special people will last even after death ; do something for others with what's left of their life ; and maintain dignity as a human being.

　Through the results, it became clear that for nurses to support patients' decisions, alleviating pain is of course a crucial issue, but most importantly, nurses should provide the best support for their patients to help them spend their precious days so that each day is the best day of their life. Nurses should actively listen to the patient ; respect the patient's decision even if the patient has no plans set for the day ; respect the desire of patients who want opportunities to maintain hope by holding craft workshops and/or seasonal events and by setting achievable goals with other patients ; be someone they can talk to, and lastly, create an environment enabling patients to become as independent as possible by taking care of themselves, and allowing the opportunity for the patients themselves to help other patients.