終末期がん患者の輸液を減量・中止する際に看護師が行う合意形成支援プロセス

The Process by Which Nurses Build a Consensus to Reduce or Cease Fluids for Patients with Terminal Cancer

要旨

　本研究の目的は，終末期がん患者の輸液を減量・中止する際に看護師が行う合意形成支援プロセスを明らかにすることである．機縁法により選定されたがん看護経験年数5年以上の看護師10名を対象に半構成的面接を行い，修正版グラウンデッド・セオリー・アプローチを用いて分析した．

　分析の結果，看護師は，日々の患者との関わりで得られる輸液に関連した苦痛やQOLの情報から【輸液の意味の自問自答】を行い，【多職種での減量・中止の吟味】を図っていた．また，吟味された輸液の減量・中止を患者・家族に提案する際，『飢餓と悪液質との違いの説明』を基にした【輸液認識のパラダイムシフト】と〈揺れる思いへの寄り添い〉を円環的に行い合意形成へと向かっていた．これらには，減量・中止に『難色を示す家族への共感』や治療が少なくなっていく中での『見放され感への配慮』という【見捨てないことの保証】を行っていた．また，このプロセス全体を促進させる要因として，【変化する終末期の情報提供】や【可能な限りの経口摂取の促し】を行っていた．

　看護師は，終末期だからとやみくもに減量・中止の検討を進めるのではなく，多様に出現している苦痛やQOLの低下と輸液との関連性について考え判断することが重要である．また，輸液の減量や中止が行われた後も，それに伴う効果や変化を伝えていくこと，家族がどう捉えているかを確認していくことも必要である．

　The aim of the current study was to ascertain the process by which nurses build a consensus to reduce or cease fluids for patients with terminal cancer. Semi-structured interviews were conducted with 10 nurses with at least 5 years of experience in oncology nursing who were identified by snowball sampling. Interview data were analyzed using a modified grounded theory approach.

　Because of their daily interaction with patients, nurses sensed patient distress related to receiving fluids and they received information on patient QOL. Based on this input, nurses “pondered the point of fluids” and they sought to “consider reducing or ceasing fluids with other medical professionals”. When nurses suggested reducing or ceasing fluids to patients and their families, they sought to build a consensus by fostering “a paradigm shift regarding attitudes towards providing fluids” based on ‘an explanation of the difference between starvation and cachexia’ and by thoroughly “addressing wavering opinions”. While “empathizing with families who were reluctant to reduce or cease fluid and reducing treatment”, nurses “assured families that they were not being forsaken”, i.e. nurses ‘addressed family concerns about being cast aside’. In addition, “nurses provided information on changes in the final stages of life” and they “promoted oral intake to the extent possible”； these actions were factors that promoted the reaching of a consensus regarding reducing or ceasing fluids.

　Nurses must not blindly consider reducing or ceasing fluids for terminal patients simply because they are in the final stages of disease. Instead, they must reach a decision based on the relationship between providing fluids and various forms of distress and a diminished QOL. Moreover, nurses must inform family members of results and changes that will occur once fluids are reduced or ceased and determine how family members will perceive those results and changes.