最後の標準治療を伝えられた再発・進行がん患者の揺らぎから自己決定に至るプロセス

The Process Through Which Fluctuating Feelings Lead to Self-Determination in Patients with Advanced/Recurrent Cancer Who Received the Last Standard Treatment

要　旨

　本研究の目的は，最後の標準治療を医師から伝えられた再発・進行がん患者の揺らぎから自己決定に至るプロセスを明らかにし，有効な看護支援について検討することである．

　外来化学療法を受けている患者14名に半構造化面接を実施し，修正版グラウンデッド・セオリー・アプローチ（M-GTA）を用いて質的記述的に分析した．その結果，最後の標準治療を伝えられた再発・進行がん患者の揺らぎから自己決定に至るプロセスは，〔医師からがんの進行を告げられ，治療変更の説明を受ける〕ことから始まり，【身体感覚と説明の違いによる混乱と葛藤】を体験する．〔今までの治療継続〕をしながら，『暗闇の迷路をさまよう』中でさまざまな思いを巡らせる．〈気持ちが行ったり来たりする〉ことを経て，〈治療過程への自己のかかわりを内省する〉ことが転換点となり〈感情が堰を切ってあふれ出す〉．これを機に，揺らぎから抜け出し【最後の治療という現実との対峙】から自己決定に至っていた．

　看護支援は，患者が揺らぐことは折り合いをつけていくための第一歩であると認識することから始まる．そして，看護師は患者の語りに耳を傾け，真摯に受けとめながら患者の内省を促し，十分な感情の表出ができるよう環境を整える必要がある．加えて，患者と家族などの重要他者の関係性を強めるための支援や，ピアサポーターなどによる社会的支援システムの構築が重要である．

　The purpose of this study was to clarify the process through which fluctuating feelings lead to self-determination in patients with advanced/recurrent cancer who received the last standard treatment and to investigate effective nursing support.

　Semi-structured interviews were conducted with 14 patients receiving outpatient chemotherapy and were analyzed qualitatively and descriptively using a modified grounded theory approach (M-GTA).

　In the process through which fluctuating feelings lead to self-determination in patients with advanced/recurrent cancer who received the last standard treatment, the affected patients first are informed by a physician of the progression of their cancer and an explanation is given as to why their treatment is to be changed and then experience confusion and conflict due to the difference between physical sensation and explanation content. While continuing to receive the same treatment, they ‘wander in the dark’ while turning everything over in their minds. And then becomes a turning point. The patients take this opportunity to escape from their fluctuating feelings and follow the process of self-determination beginning with facing reality, i.e., the last stage of treatment.

　Nursing support begins with recognizing that the patient's fluctuating feelings is the first step towards making an internal compromise. Furthermore, nurses should listen to the patient's narratives, encourage patient introspection while accepting them seriously, and prepare the environment so that feelings can be expressed adequately. In addition, it is important to support the strengthening of the relationship between patients and loved ones such as their families, and to construct social support systems such as peer supporters.