Departmental Bulletin Paper 超高齢者の終末期医療における家族の代理意思決定に対する看護師の臨床判断
Clinical decision making of nurses in support of a family member with power of attorney in palliative care for the extremely aged
チョウ コウレイシャ ノ シュウマツキ イリョウ ニ オケル カゾク ノ ダイリ イシ ケッテイ ニ タイスル カンゴシ ノ リンショウ ハンダン

矢野, 真理

 本研究は超高齢者の終末期医療で、家族が代理意思決定する際、看護師はどのような手がかりによって臨床判断を行っているかを明らかにすることを目的とした。看護師3 名を対象に半構成的面接を実施し、質的統合法(KJ 法)で分析した。その結果、看護師は表面的な感情表出では伝えきれない超高齢者の思いを大切に、専門的に捉えた認知症の感情表出の意味を手がかりに終末期という状況など複数の側面から判断しており、徐々に変化する患者に対して家族の距離間やスキンシップを手がかりに家族の理解状況や医師との調整の必要性について判断をしていた。また、看護師は高齢者の食べたい・自宅へ帰りたいという思いを手がかりに、医師への代弁者となれるような判断をしていた。これらの結果より、超高齢者が加齢とともに身体的精神的な機能低下をきたし、認知症と診断されていなくても自分の意思を伝えることが困難になる特徴を認識し関わる臨床判断や家族や医師との調整を図る中で成り行きを推測し、患者の家族に意図的な支援を行うまでの無意識的な臨床判断が明らかにできたと言える。さらに、看護師は超高齢者の死の尊厳を守り、家族にもよい余韻を残すケア、納得のいく看取りの支援を重視することで、看護師は患者や家族の意向を十分に汲み取り、支援の手がかりを得ていることを明らかにできたと考える。
This study is aimed at revealing how nurses make clinical decisions as they interact with family members with Power of Attorney who are involved in the palliative care of extremely old patients. I interviewed three registered nurses and analyzed the results with Qualitative Synthesis method (KJ method). The analysis revealed Nurse was focusing on the feelings of the very old patients, which are difficult to comprehend by mere superficial expression. She was found to be interpreting the expressions of dementia professionally and analyzing what they really mean in the contexts of terminal care. Nurse was probing the understanding level of the family members by assessing the distance between them and the patients in order to coordinate communication with physicians. Nurse was capturing the old patients’ desire to eat well, to go home, and to make decisions enabling them to relate these feelings to the physicians. These findings suggest that it is empirical to understand the fact that very old patients tend to become clumsy in expressing themselves as they physically and mentally deteriorate with aging even if they are not yet diagnosed as technically demented. It was obvious that nurses have been making subconscious clinical decision by recognizing this feature and coordinating the communications between family members and physicians. This study also revealed that nurses are picking up the clues to assist the patients by fully understanding what they or their family members wish; and this can only be achieved by always honoring the dignity of death of the very old patients as well as providing the care that will be remembered by the loved ones.

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