進行がん患者の終末期の話し合いへの病棟看護師の同席を阻害している要因

Barriers to Attending End of Life Discussions with Advanced Cancer Patients as Perceived by Ward Nurses

要旨

　【目的】進行がん患者の意思決定支援を行ううえで，終末期の話し合い（End-of-Life discussion：EOLD）の有効性が確認されているが，看護師がEOLDに同席することが困難な現状にある．そこで本研究は，進行がん患者のEOLDへの看護師の同席を阻害している要因を明らかにする．

　【方法】A県の3つのがん診療拠点病院に勤務し，がん看護を実践している8名の病棟看護師を対象にEOLDへの同席を阻害している要因について半構造化インタビューを実施し，Krippendorffの内容分析法を用いて質的帰納的分析を行った．

　【結果】対象者は男性3名，女性5名であり，臨床経験年数は，5〜24年であった．インタビューから155コードが抽出され，14サブカテゴリー，5カテゴリーに集約された．EOLDへの病棟看護師の同席を阻害している要因は【話し合いへの同席の必要性の認識不足】【医療者間の連携不足】【同席するためのシステムの不足】【話し合いにおける役割認識やコミュニケーションスキルの不足】【患者と家族の特性に応じた関わりの難しさ】であった．

　【考察】進行がん患者のEOLDへの看護師の同席を促進するためには，EOLDに看護師が同席する必要性の認識を統一することが重要である．さらに，看護師のEOLDについての知識やコミュニケーションスキルの教育をすること，感情的な患者への対応や倫理的葛藤が生じる事例においては他職種との連携を図ることが重要である．

　[Objective]: Patients with advanced cancer must make difficult decisions as their disease progresses. End of Life Discussion (EOLD) has been shown to be effective in the decision-making process. However, nurses are not currently able to attend EOLD adequately. Therefore, our aim of this study is to clarify the factors that prevent nurses from attending the EOLD of patients with advanced cancer.

　[Methods]: The subjects were eight ward nurses who were engaged in cancer nursing practice at three designated cancer hospitals in A Prefecture. Semi-structured interviews were conducted on the factors preventing their attendance at the EOLD, and the data obtained were analyzed qualitatively and inductively using Krippendorff's content analysis method.

　[Results]: The subjects were three males and five females with 5-24 years of clinical experience. From the verbatim record, 155 codes, 14 subcategories, and five categories were created. Factors that prevented ward nurses from attending the EOLD were “lack of awareness of the need to attend the EOLD”, “lack of collaboration between health care providers”, “lack of a work system to attend the EOLD”, “lack of role awareness and communication skills in the EOLD”, and “difficulty in engaging with patients' families according to their characteristics”.

　[Discussion]: To promote the attendance of nurses in the EOLD for patients with advanced cancer, the following three solutions are proposed: unified awareness of the need for nurses to attend the EOLD, improved knowledge about the EOLD and communication skills of nurses, and collaboration with the team and experts in difficult cases that may make patients emotional or create ethical conflicts after serious notification.