在宅がん終末期ケアに従事する訪問看護師が重要と判断したケア

Dimensions of End-of-Life Care Deemed Important by Home-Visit Nurses

要　旨

　本研究では，最期1カ月にある療養者と家族に対して訪問看護師が重要と判断したケアを明らかにすることを目的とした．対象者は在宅でがん療養者の看取りを重点的に行っている訪問看護師7名とした．方法は，半構造化面接法による質的帰納的研究デザインであり，面接内容は看取りまでの最期1カ月にあるがん療養者および家族に対して重要と判断したケアについてである．

　分析の結果，死亡前1カ月から1週間までは6カテゴリ【療養者や家族の変化をとらえ介護負担の軽減に努める】【家族と看護師間の共通認識に向け看取りへの準備をサポートする】【療養者の病状や生活背景を考慮した医療の提供や管理を行う】【訪問時の状況から安全・安楽な日常生活を支える】【思いを尊重し療養者が最期まで自分らしく生き抜くために寄り添う】【多職種間の連携を強化する】が抽出された．死亡前1週間未満から看取り直後までは7カテゴリが抽出され，新たに【グリーフケアとして在宅看取りを認め家族に寄り添う】が見出された．

　訪問看護師は，療養者の生活状況や病状，予後に加えて，療養者や家族の発言だけでなく表情などの小さな変化に気づくことで，介護負担の軽減や自分らしく生き抜くための支援につなげていた．また，家族の看取りの準備の調整，グリーフケアを見据えた支援，多職種連携の調整が重要と判断していた．

　The aim of this study was to clarify the care that visiting nurses determined to be important for home care patients with one month to live and their families. The participants were seven visiting nurses who focus on providing end-of-life care at home for cancer patients. The method is a qualitative inductive study design using semi-structured interview, and the content of the interviews covers care that has been determined to be important for cancer patients with a month to live and their families.

　Analysis results extracted six categories from a month to a week before death: “capturing the changes of the patients and their families and striving to reduce their nursing care burden”, “supporting preparation for a common understanding between family members and nurses”, “providing and managing medical care that takes into account the medical condition and life background of the patient”, “strengthening cooperation among various professionals”, “supporting safe and comfortable daily life based on the situation at the time of the visit”, and “respecting the patient's thoughts and approaching them empathetically so they can be true to themselves until the end”. Seven categories were extracted from less than one week before passing to immediately after passing, with “acknowledging dying at home as grief care and providing emotional support for family members” newly discovered.

　Home-visit nurses help reduce the burden of long-term care and comforting of patients by observing small changes in facial expressions as well as listening to statements made by patients and their families. Also, they are sensitive to aspects of the living situation, medical conditions, and prognosis of the patient. Finally, our study concludes that it is crucial to coordinate multidisciplinary collaboration in preparation for family support while keeping in mind the likely need for grief care at the time of the patient's passing.