認知機能低下を伴う高齢がん患者に対するがん疼痛アセスメント

Pain Assessment in Elderly Cancer Patients with Cognitive Impairment

要旨

　本研究の目的は，看護師が認知機能低下を伴う高齢がん患者のがん疼痛をどのようにアセスメントしているのかを明らかにすることである．対象者は，5年以上の臨床経験があり，認知機能低下を伴う高齢がん患者の疼痛緩和の経験がある看護師7名である．方法は半構造化面接法と参与観察法を用い質的帰納的に分析した．結果，看護師が実践する認知機能低下を伴う高齢がん患者に対するがん疼痛アセスメントは【取り繕いの奥にある“つらさ”を推しはかる】【定まらない痛みの表現と向き合う】【時間をかけて痛みによる変化の裏付けを探す】【病態を基点に目に見えない痛みを予測する】【生活の中から“いつもの患者”を見直す】【記憶に働きかけ居心地を整える】という6つのカテゴリに集約された．

　認知機能低下を伴う高齢がん患者に対して看護師が実践するがん疼痛アセスメントでは，患者の微細な変化を捉え，その変化の原因と内容を察知する能力が必要であることが示唆された．さらに，看護師自身の患者への関わり方についても検証し，患者の表現が痛みによる変化であるのかを複合的に判断していく必要性が示唆された．

　Background: Because pain management is complex, a comprehensive approach to assessment and management using validated tools is necessary for optimal care. There is strong evidence that the pain of elderly cancer patients with cognitive impairment is underdetected and that leads to poor management. This study was designed to identify how palliative care nurses evaluate pain in clinical settings to identify the needs for better assessment.

　Method: Semi-structured interviews and participant observations were conducted involving nurses with experience in providing care for elderly cancer patients with cognitive impairment. The content of the interviews was supplemented by the data obtained by participation observation. Interviews were audio-taped and the contents were transcribed verbatim. The data obtained was analyzed qualitatively and inductively.

　Result: The 7 nurses interviewed used the following methods for assessing pain: The coded interview data yielded 20 codes, 6 categories: inferring the suffering of patients who pretend not to be suffering pain; continuing to listen to patients' inaccurate verbal expressions of pain; taking the time to find confirming evidence that changes in the patients' behaviors or verbal expressions are caused by pain; referring to the patients' clinical conditions in order to judge their pain; assessing pain based on their usual behaviors; reminding the patients of their previous pain care that was effective, and eliminating physical factors that make the patients uncomfortable.

　Conclusion: The nurses assumed that they could not depend on verbal expressions of pain alone in accurately assessing pain in patients with cognitive impairment. When these nurses realized unnoticeable changes in the patients' behaviors, they tried various interventions in order to determine whether the changes were caused by pain. Simultaneously, it was revealed that the nurses assessed pain tentatively based on their knowledge of cancer nursing and on the clinical conditions. The analysis results suggest the importance of using various techniques in order to adequately understand changes in the behaviors and verbal expressions of elderly cancer patients with cognitive impairment.