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未契約
書籍名 蘇生不要指示のゆくえ 医療者のためのDNARの倫理
出版社 ワールドプランニング
発行日 2012-10-25
著者
  • 箕岡真子(著)
ISBN 9784863510524
ページ数 131
版刷巻号 第1版
分野
閲覧制限 未契約

DNAR指示という言葉は知っている。しかし、その本当の意味とはなにか?そして、いつ、どこで、いったい誰が出すのか?この「蘇生不要」という言葉は、人生の最期にどのような意味と影響を与えるのだろうか!?

目次

  • 表紙
  • はじめに
  • 目次
  • 第1章 DNAR指示
    P.11閲覧
    • I. なぜDNAR指示について考えなければならないのか
      • 1. 患者本人の意向が尊重されていない
      • 2. 医師と家族だけで決めている
      • 3. DNAR指示を出すにあたって, 適切な手続きが踏まれていない
      • 4. DNAR指示の内容について, 医療者間でコンセンサスがない
    • II. DNARとDNRの違い
      • 1. DNAR / DNRの概念
        • 1) 疾病の末期に救命の可能性のない患者に対して
        • 2) 本人または家族の要望によって
        • 3) 心肺蘇生術 (CPR) を行わないこと
      • 2. DNARとDNRの違い
    • III. DNARの歴史
      • 1. 1960年代
      • 2. 1970〜1990年
      • 3. 1991年〜
    • IV. DNAR指示の適切使用のためのガイドライン (1991)
    • V. DNAR指示はだれが決めるのか
      • 1. 【ケース 1】患者の事前指示によってDNAR指示を決めた場合
        • 1) 生命倫理の4原則
        • 2) 意思能力
        • 3) インフォームドコンセント
          • (1) インフォームドコンセントの構成要素
          • (2) 開示すべき情報
          • (3) インフォームドコンセント訴訟
        • 4) 患者はDNAR指示について医療者と十分に話し合う機会を与えられていない
        • 5) 患者は医療者とDNAR指示について話し合いたいと思っている
        • 6) 患者に提供すべきCPRの有効性についての知識
      • 2. 【ケース 2】家族による本人意思の推定によりDNAR指示を決めた場合
        • 【ケース 3】家族の申し出によって家族と医師が決めた場合
        • 1) 代理判断の手順
          • (1) 事前指示 (アドバンスディレクティブ)
          • (2) 代行判断
          • (3) 最善の利益判断
        • 2) だれが代理判断者になるか
          • (1) 家族による代理判断は適切か
          • (2) 家族による患者意思の推定が許される場合 : 東海大学事件判決
          • (3) 家族による患者意思推定は慎重に : 川崎協同病院事件控訴審判決
      • 3. 【ケース 4】医師が単独でDNARを決め, 家族に伝えた場合
        • 1) 医療者は, DNAR指示について患者と話し合っていない
        • 2) 医療者は, 患者はDNAR指示についての話し合いを望んでいないと思っている
        • 3) DNAR指示についての話し合いが必要となったとき, すでに患者は意思能力がなくなっている
        • 4) 家族や医療者によるDNAR指示に関する決定は, 患者本人の意向と一致しない
        • 5) 医療者が患者とDNAR指示についての話し合いをしない理由
        • 6) DNAR指示についての意思決定では, 医師個人の価値観を押しつけすぎてはならない
    • VI. DNAR指示を出すための適切なプロセスとはどのようなものか
      • 1. Assessment (評価)
      • 2. Disclosure (情報提供)
        • 1) わかりやすい情報の提供を心掛ける
      • 3. Discussion (話し合い)
        • 1) 早い段階からの率直なコミュニケーションが重要
        • 2) 回数を重ね, ていねいに話し合い (面談) をすることが大切
        • 3) コミュニケーションの内容
        • 4) 話し合いに参加するスタッフは患者 (家族) と信頼関係がある人を
        • 5) DNAR指示についてのコミュニケーション不足がある
      • 4. Consensus (合意の形成) ; DNAR指示を出す
        • 1) 記録の重要性
      • 5. DNAR指示後も話し合いを繰り返す
      • 6. コンフリクト (意見の不一致) の解決
        • 1) 時間をかけディスカッションを繰り返す
        • 2) セカンドオピニオン
        • 3) 合意に向けた対話を促進
        • 4) トライアル・ピリオドを設ける
        • 5) 倫理コンサルテーション (ethics support)
        • 6) 倫理委員会 (interdisciplinary ethics committee)
        • 7) 主治医の交代・転院
        • 8) ADR裁判外紛争解決
        • 9) 法的介入
      • 7. その他のDNAR指示の手続きに関する問題
        • 1) 持続的DNAR指示 (durable DNAR order)
        • 2) DNAR指示が出ている患者に麻酔をかける場合
        • 3) DNAR指示の有無が不明の場合
        • 4) DNAR指示と事前指示の関係
    • VII. DNAR指示によって差し控えられたり, 中止される医療的処置の内容とは
      • 1. DNAR指示によって差し控えられる, あるいは中止される治療の内容 ; DNAR指示はCPR以外の治療方針に影響を与えてはならない
        • 1) CPRに含まれる治療手技
        • 2) CPR以外の治療手技
          • (1) 海外における実状
          • (2) 日本における実状
          • (3) 制限されるCPR以外の治療を明確にするために
        • 3) DNRからNo CPRへ
        • 4) DNARはCPRをしないという事前指示である
      • 2. DNAR指示後の緩和ケア
        • 1) Cure sometimes, Comfort always (時に治療 - 常に快適ケア)
      • 3. DNAR指示後の治療の"差し控え"と"中止"の違い
    • VIII. DNAR指示はいつ出すのか
      • 1. DNAR指示についての話し合いが必要となったとき, 患者はすでに意思能力がないことが多い
      • 2. DNAR指示が出される時期
        • 1) 患者あるいは家族からCPRを望まないという申し出があったとき
        • 2) 主治医がCPRを無益 (=futile) であると判断したとき
          • (1) 無益性 (futility) の概念についての議論
    • IX. 適切なDNAR指示の実践を目指して
      • 1. ディスカッションの重要性
      • 2. DNAR指示によって制限される治療内容を明確にする
        • 1) Procedure-specific DNAR orderとGoal-directed DNAR order
        • 2) DNAR指示のガイドラインに含まれることが望ましい内容
        • 3) アメリカにおけるDNAR指示に関するガイドライン
      • 3. 意思決定プロセスの公正性
        • 1) 終末期医療に関する意思決定プロセスのアルゴリズム
        • 2) DNAR指示は"延命治療の差し控え・中止"のガイドラインに沿ってなされる必要がある
  • 第2章 終末期の延命治療の差し控え・中止
    P.81閲覧
    • I. 終末期延命治療に関する最近の出来事
      • 1. 富山県射水市民病院の事例 (2005)
      • 2. 岐阜県立多治見病院の事例 (2006)
      • 3. 亀田総合病院の事例 (2008)
    • II. 適切な"看取り" (延命治療の差し控え・中止) をするために考慮すべき要素
      • 1. 医学的視点
        • 1) 終末期の定義
        • 2) 治療の無益性
      • 2. 本人の意思
        • 1) 自己決定権
        • 2) 事前指示アドバンスディレクティブ
      • 3. 家族の意思
        • 1) 家族などによる代理判断の手順
        • 2) だれが代理判断者になるか
      • 4. 意思決定のための手続き的公正性
      • 5. 法的視点
      • 6. 社会的コンセンサス
    • III. 海外の終末期延命治療に関する法的判断
      • 1. カレン・クィンラン裁判 (米・1976)
      • 2. クラレンス・ハーバート裁判 (米・1982)
      • 3. ウィリアム・バートリンク裁判 (米・1984)
      • 4. コンロイ裁判 (米・1985)
      • 5. エリザベス・ボービア裁判 (米・1986)
      • 6. ナンシー・クルーザン裁判 (米・1990)
      • 7. テリー・シャイヴォ (Theresa Schiavo "Terri") 裁判 (米・2005)
      • 8. トニー・プラント裁判 (英・1992)
    • IV. 日本の終末期延命治療に関する法的判断
      • 1. 東海大学事件 (横浜地裁 平成7年3月28日, 殺人被告事件)
      • 2. 川崎協同病院事件 (2005・2007・2009)
    • V. 社会的コンセンサスとしてのガイドライン
      • 1. 終末期医療に関するガイドライン
      • 2. 終末期医療の決定プロセスに関するガイドライン (厚生労働省 ; 平成19年5月)
        • 1) 終末期医療およびケアの在り方
        • 2) 終末期医療およびケアの方針の決定手続
          • (1) 患者の意思の確認ができる場合
          • (2) 患者の意思の確認ができない場合
          • (3) 複数の専門家からなる委員会の設置
      • 3. イギリスのガイドライン
      • 4. オーストラリアのガイドライン
      • 5. フランスのガイドライン
  • 第3章 事前指示
    P.105閲覧
    • I. 患者の自律 (自己決定権) と事前指示
    • II. 事前指示が有用である理由
    • III. 事前指示作成に際して留意すること
      • 1. 事前指示 (以前の意思) の内容が現在の最善の利益と一致しない場合
      • 2. よい事前指示書の書き方
        • 1) 事前指示は適切な状況で書く (What, When, with Whom, Where)
        • 2) 事前指示書は"こころ"で書く
        • 3) 信頼関係のある医療・ケア関係者の立会いのもとで書く
        • 4) 同居の家族だけでなく, すべての関係者に理解を促す
        • 5) 事前指示作成時には疼痛のコントロールを
        • 6) 事前指示の作成により家族関係が修復されることがある
        • 7) 事前指示書の内容を再確認する
        • 8) 終末期の医療ケアについて皆で話し合う
    • IV. 事前指示書『私の四つのお願い』
      • 1. 私のお願い1
      • 2. 私のお願い2
      • 3. 私のお願い3
      • 4. 私のお願い4
  • あとがき
    P.117閲覧
  • 奥付

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あとがき

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