タグ別アーカイブ: JC

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.

広告

早食い,腹一杯食いは肥満と関係あるか?

日本ではよく言われますね.それは本当か?そんなところから臨床研究は始まります.
以下は,そんな日本人ならではの研究です.(海外では既に研究があるようです)

Maruyama K et al. The joint impact on being overweight of self reported behaviours of eating quickly and eating until full: cross sectional survey.
BMJ. 2008 Oct 21;337:
Comment in: BMJ. 2008;337:a1926.

全文はこちら(pdf)

critical appraisalは何となくしかやっていません.(まあ,良さそうです)

対象:日本の法律で対象となる心血管リスク調査に参加した4140名の成人(30-69才)
過去1ヶ月の食習慣についてのアンケート 
除外:心血管疾患のある人,4000kcal以上や,500kcal未満の食事の人
肥満を BMI25以上と定義

質問の仕方
お腹一杯まで食べるかどうか :はい・いいえ
食べるスピード: とてもゆっくり,ゆっくり,ふつう,はやい,とてもはやい  の5段階
両方とも既に評価された(validated)質問紙を使用 (本人の自己申告のスピードは,友達による評価と相関するそうです)
スピードのとても速い,早いを1つのグループに(早食いグループ),残り3つを1つのグループに(荘でないグループ)
早食いかそうでないか,腹一杯食べるかそうでないかで2×2の4種類の集団に分けて分析

結果
回答率 88%
以下 男女の順で

男性
全体の平均のBMI 25
平均カロリー摂取 2236
喫煙率 47.4%

女性
全体の平均のBMI 22.8
平均カロリー摂取 1773
喫煙率 10.0%

肥満の有病率    33.8% 21.8%
腹一杯まで食べる人 50.9% 58.4% (女性の方が多い!)
早食い       45.6% 36.3%

腹一杯食べることの肥満へのリスク 2.00(95%CI 1.53 to 0.62)   1.92 (1.53 to 2.40)
早く食べることの肥満へのリスク  1.84 (1.42 to 2.38)      2.09(1.69 to 2.59)

どちらの習慣もない人たちに比べて,両方の習慣(早食い+腹一杯)のひとの肥満であるリスク
                 3.13 (2.20 to 4.45)     3.21 (2.41 to 4.29)

早食い+腹一杯グループがもっとも平均身長,体重,BMI,摂取カロリーが多かった
両方の習慣が存在する場合に加算的ではなく,それ以上のリスク増加.

コメント:あくまで相関(association)を示した論文なので,そういう食習慣の人が太るのか,太るとそういう食習慣になるかは不明.ただ,おおざっぱに片方の食習慣で2倍,両方で3倍というのは患者さんには説明しやすい.

以下abstract

Published 21 October 2008, doi:10.1136/bmj.a2002
Cite this as: BMJ 2008;337:a2002

Research

The joint impact on being overweight of self reported behaviours of eating quickly and eating until full: cross sectional survey

Koutatsu Maruyama, graduate student1,2, Shinichi Sato, director2,3, Tetsuya Ohira, associate professor1,2, Kenji Maeda, chief physician2, Hiroyuki Noda, research fellow1,4, Yoshimi Kubota, graduate student1,2, Setsuko Nishimura, dietitian2, Akihiko Kitamura, director2, Masahiko Kiyama, director2, Takeo Okada, director2, Hironori Imano, chief physician2, Masakazu Nakamura, director2, Yoshinori Ishikawa, deputy president2, Michinori Kurokawa, dietitian5, Satoshi Sasaki, professor6, Hiroyasu Iso, professor1
1 Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Yamadaoka, 2-2 Suita-shi, Osaka, Japan 565-0871, 2 Osaka Medical Center for Health Science and Promotion, Osaka, Japan, 3 Chiba Prefectural Institute of Public Health, Chiba-City, Japan, 4 Harvard Center for Population and Development Studies, Harvard University, MA, USA, 5 Division of Health and Welfare, Osaka Prefecture, Japan, 6 Department of Social and Preventive Epidemiology, School of Public Health, University of Tokyo, Japan
Correspondence to: H Iso fvgh5640@mb.infoweb.ne.jp

Objective: To examine whether eating until full or eating quickly or combinations of these eating behaviours are associated with being overweight.

Design and participants: Cross sectional survey.

Setting: Two communities in Japan.

Participants: 3287 adults (1122 men, 2165 women) aged 30-69 who participated in surveys on cardiovascular risk from 2003 to 2006.

Main outcome measures: Body mass index (overweight 25.0) and the dietary habits of eating until full (lifestyle questionnaire) and speed of eating (validated brief self administered questionnaire).

Results: 571 (50.9%) men and 1265 (58.4%) women self reported eating until full, and 523 (45.6%) men and 785 (36.3%) women self reported eating quickly. For both sexes the highest age adjusted mean values for height, weight, body mass index, and total energy intake were in the eating until full and eating quickly group compared with the not eating until full and not eating quickly group. The multivariable adjusted odds ratio of being overweight for eating until full was 2.00 (95% confidence interval 1.53 to 2.62) for men and 1.92 (1.53 to 2.40) for women and for eating quickly was 1.84 (1.42 to 2.38) for men and 2.09 (1.69 to 2.59) for women. The multivariable odds ratio of being overweight with both eating behaviours compared with neither was 3.13 (2.20 to 4.45) for men and 3.21 (2.41 to 4.29) for women.

Conclusion: Eating until full and eating quickly are associated with being overweight in Japanese men and women, and these eating behaviours combined may have a substantial impact on being overweight.

© 2008 BMJ Publishing Group Ltd.