わが国の新生児医療における治療拒否 : 概念分析 <総説>

「わが国のNICUにおける治療拒否」について, 親-医療者問の話し合いの方法を導くために, Rodgersの方法を参考に概念分析した. その結果, 治療拒否には, 子どもが負う苦痛の正当性および人の幸福に関する信念の対立を含む「親-医療者間の不一致」と, 「医療パターナリズム」が含まれた。先行因子として, 「新生児の病状の特徴」, 「親の心理社会的状況と考え方の特徴」, 「意思決定過程の特徴」があった. 帰結は, 「決定者および決定機関」は4つに分類され, 「決定内容に伴う関係性の変化」が親-医療者間, 親子間に生じていた.

「治療拒否」は, 新生児の親のアドボカシーの観点から慎重に用いるべき概念であった. 「治療拒否」という概念は, 医療者が親と同等の立場に立ち, 意思決定過程に生じるジレンマを抱えた親の葛藤を理解し, 最後まで養育の責任を負う者としての親の意見を尊重する医療に変われば, 親の「治療選択」の概念に変わるだろうと考えられた. これらの結果をもとに, 新生児看護に対して1)緊急状況であっても親の意思決定過程へのケアを重視する, 2)看護者としての自己の態度を分析する, 3)合意にならない場合であっても親の人権を擁護し医療者間で建設的に協働する, 4)治療拒否という概念を慎重に用いる組織づくりをすることを提案した.

This review aimed to clarify the concept of 'CHIRYOKYOHI', withdrawing treatment in neonatal intensive care unite in Japan, to facilitate discussion between parents and medical staff. This concept analysis is based on a literature review using Rodgers' evolutionary method. It was found that attributes were "disagreement between parents and medical staff", including disagreements on the validity of infant distress and conflict of beliefs about the definition of 'well-being', and "medical paternalism". Antecedents were "characteristics of infant disease condition", "parents' psychosocial situation and features of reaction" and "features of the decision making process". Consequences were "decision maker or decision institution" and "change in relationship as an outcome of decision" for patient-medical staff and parent-child relationships. Related concepts were "informed consent" and "shared decision making". A surrogate term for withholding and withdrawing of treatment was "choice of treatment".

CHIRYOKYOHI is a concept that should be used cautiously from the parent advocacy perspective. If medical staff consider parents' viewpoints and recognized patients' dilemmas during the decision making process, and if medical care can be modified to respect parents' responsibility for their children and their opinions in decision making, CHIRYOKYOHI should be adopted as the 'choice of treatment'. Based on the above analysis, we propose that neonatal nursing 1) attach importance to parents' decision making process even in emergency situations, 2) analyze the own attitudes as a nurse, 3) advocate patients' human rights and collaborate with other medical staff in a constructive manner if there is a conflict, and 4) develop a system that carefully incorporates CHIRYOKYOHI.