薬物療法中に複数の症状を抱えた転移・再発乳がん患者の予後を見据えた外来看護の実践と困難

Investigation on the Performance and Dfficulties of Outpatient Nurses Engaging in Prognosis of Patients with Metastatic/recurrent Breast Cancer who Have Multiple Symptoms and are Undergoing Outpatient Pharmacotherapy

要旨

　目的：本研究の目的は，外来薬物療法中に複数の症状を抱えた転移・再発乳がん患者の予後を見据えた外来看護の実践と困難を明らかにすることである．

　方法：都内の2施設の乳腺外科外来あるいは外来化学療法室に勤務する看護師6名に半構造化面接を実施し，質的帰納的に分析した．

　結果：薬物療法中に複数の症状を抱えた転移・再発乳がん患者の予後を見据えた外来看護の実践は，【身体的苦痛の塊から核となる症状を明確にする】【自宅療養の継続に向けて優先すべきケアを整理する】【再発告知から死を意識する時期に至る患者・家族に伴走する】であった．薬物療法中に複数の症状を抱えた転移・再発乳がん患者の予後を見据えた外来看護の困難は【悪い知らせを受けた患者との対峙に戸惑う】【心身ともに脆弱化した患者の急変を予測しにくい】【死が迫った患者と家族の動揺に巻き込まれる】であった．

　考察および結論：外来看護師は，診察までの待ち時間という限られた時間で患者の複数症状の整理とケア方略の見極めを円環的に実践していることが推察された．一方，外来看護師の実践上の困難から，緩和ケア主体の医療への転換期の患者に対する外来での「終末期の話し合い」の効果的な実施，患者の自宅療養継続に向けた外来と在宅の看護連携に課題があると考えられた．今後は，本研究の知見を基に，薬物療法中の転移・再発 乳がん患者の予後を見据えた外来看護支援の体系化が必要である．

　Purpose: This study aimed to investigate the performance and difficulties of outpatient nurses engaging in prognosis of patients with metastatic/recurrent breast cancer who have multiple symptoms and are undergoing outpatient pharmacotherapy.

　Methods: Semi-structured interviews were conducted with six nurses working in the department of outpatient breast surgical oncology or outpatient chemotherapy in two facilities in Tokyo. Data from the interviews were analyzed qualitatively and inductively.

　Results: The practice of outpatient nurses engaging in prognosis of patients with metastatic/recurrent breast cancer who have multiple symptoms and are undergoing outpatient pharmacotherapy consisted of “clarification of core symptoms based on the cluster of physical pain,” “organization of priority care with the aim of continuation of home care,” and “accompanying patients/family members from time of notice of recurrence to period of consciousness of death.” The difficulty of outpatient nurses engaging in prognosis of patients with metastatic/recurrent breast cancer who have multiple symptoms and are undergoing outpatient pharmacotherapy consisted of “confusion regarding facing a patient who has received bad news,” “difficulty in predicting sudden changes in patients who are physically and mentally vulnerable,” and “dealing with a patient facing death and family members who are upset.”

　Discussion and Conclusion: We inferred that outpatient nurses sorted patients' multiple symptoms and determination of care strategies in a circular manner within the limited waiting time for medical examination. Some of the practical difficulties faced by outpatient nurses were problems regarding the effective implementation of outpatient end-of-life discussions for patients during the transitional phase to palliative care-oriented medical care and the cooperation between outpatient and home nursing for the continuation of home care for patients. Based on these findings, we recommend the creation of a specific set of guidelines for outpatient nursing support to better perform prognosis of patients with metastatic/recurrent breast cancer during pharmacotherapy.