家族(代理決定人)は望み薄の予後告知を希望するか

昨日レジデントと食事に行って,脳梗塞後の麻痺がほぼ固定したと思われる人にその後の回復の見込みを伝えるかという話になりました.

そこで出た話でやっぱりあんまり厳しい話はいえないよね~みたいな結論でしたが,今朝タイムリーにわたしの情報源に流れていました.

abstractまでのレビューです

Latifat Apatira et al. Hope, Truth, and Preparing for Death: Perspectives of Surrogate Decision Makers. Ann Int Med.149(12), 2008, pp. 861-868

93%の代理決定人が,たとえ望みを絶ちきられるとしても予後の見込みについて伝えないのはunacceptable(ありえない)と考えている.

あくまで,米国,人工呼吸器につながれて5日目という条件ですが.

理由はやはり
感情的にも,物理的にも準備がいるから
患者のサポートを適切にやりたい
嘘の希望を伝えることのモラルの問題
医者からはあくまで真実(科学的データ?)だけがほしい,希望は別のところから見つける.

ということのようです.

(6 of 179) 5.6%は患者への心理的ダメージが大きいから伝えるべきではないと考えていた.

TPOV (teaching point of view)

米国でも20人に1人は否定的に考える.ー>一方的に伝えることもよくないー>やはり事前指示(絶望的な状況でも予後を知りたいか)を健康なとき,比較的状態のよいときに聞いておくこと

日本ではどうか? よい研究テーマ

Background: Although many physicians worry that openly discussing a poor prognosis will cause patients and families to lose hope, surrogate decision makers’ perspectives on this topic are largely unknown.

Objective: To determine surrogate decision makers’ attitudes toward balancing hope and telling the truth when discussing prognosis.

Design: Prospective, mixed-methods cohort study.

Setting: 4 intensive care units at the University of California, San Francisco, Medical Center, San Francisco, California.

Participants: 179 surrogate decision makers for incapacitated patients at high risk for death.

Measurements: One-on-one, semistructured interviews with surrogates were conducted on the patients’ 5th day of receiving mechanical ventilation. Constant comparative methods were used to inductively develop a framework to describe participants’ responses. Validation methods included multidisciplinary analysis and member checking.

Results: Overall, 93% (166 of 179) of surrogates felt that avoiding discussions about prognosis is an unacceptable way to maintain hope. The main explanatory theme was that timely discussion of prognosis is essential to allow family members to prepare emotionally and logistically for the possibility of a patient’s death. Other themes that emerged included surrogates’ belief that an accurate understanding of a patient’s prognosis allows them to better support the patient and each other, a moral aversion to the idea of false hope, the perception that physicians have an obligation to discuss prognosis, and the notion that some surrogates look to physicians primarily for truth and seek hope elsewhere. A few surrogates (6 of 179) felt that physicians should withhold prognostic information because of a belief that discussing death could be emotionally damaging to the family or could negatively affect the patient’s health.

Limitation: The authors did not longitudinally assess whether early disclosure about prognosis predicts fewer adverse bereavement outcomes.

Conclusion: Most surrogates of critically ill patients do not view withholding prognostic information as an acceptable way to maintain hope, largely because timely discussions about prognosis help families begin to prepare emotionally, existentially, and practically for the possibility that a patient will die.

レビューから

Patients’ Surrogates Want to Discuss Prognosis, Even at the Risk of Extinguishing Hope

Surrogates of incapacitated patients at high risk for death want to talk about prognosis, according to a study in Annals of Internal Medicine.

A researcher interviewed some 180 surrogate decision makers of high-risk intensive care patients who were on mechanical ventilation. Surrogates were asked: “Do you think physicians should avoid discussing prognosis in order to maintain hope?” Almost 95% felt that avoiding such discussions in order to preserve hope was unacceptable.

Many felt that discussions about prognosis would allow them the time to prepare emotionally for the patient’s death. Another advantage, according to the surrogates, was in planning, such as making funeral arrangements and having the time to notify relatives and friends in advance of the patient’s death.

Only about 3% of surrogates favored withholding information to avoid emotional damage to the family.

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