アドバンス・ケア・プランニングに関する一考察:‐米国のアドバンス・ディレクティヴに関する取組みを通して‐  [in Japanese] <i>A consideration of the relationship between Advance Care Planning and Advance Directives,Based on evidence from the U.S.A. </i>  [in Japanese]

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Abstract

<p> 近年、専門家の間で人生の終盤期における医療に関する意思決定を考える場合に、アドバンス・ディレクティヴ(以下AD)よりもアドバンス・ケア・プランニング(以下ACP)という言葉が広く用いられるようになっている。しかし両者の違いや関係性は必ずしも明確でない。そこで本稿では、ADの制度化を進めてきた米国の取組みを中心にADの歴史およびその課題を整理し、ACPとの関連性及び可能性について考察する。米国では法制度の中でADを位置づけてきたが、概してAD作成率は期待したより低く推移してきた。その要因として、ADの医療実践上の問題やADに対する患者の期待との相違等の問題が考えられた。問題改善のためには、患者と関係者との継続的な話し合いの必要性、話し合いは患者の価値観やケア目標を含めた内容であること、話し合いによる患者と関係者との信頼関係の構築が含まれる。これらを改善することで結果的にAD作成率の向上につながることが示されている。これら一連のADを実施する上での改善点がACPに含まれる構成要素であり、ADもACPの核をなす構成要素と考えられる。</p>

<p> In recent years medical professionals and academic scholars in Japan have been using the term Advance Care Planning (ACP) in preference to the Advance Directive (AD) when discussing end-of-life care decision-making. However, there is a lack of clarity about the differences between these two terms and/or the relationship between them. This paper examines why ACP is significant and why it, rather than the AD, has appealed to those who study issues concerning decision-making during end-of-life care. Since the concept of the AD was invented and has been implemented in legal systems, this paper mainly reviews practices and discussions regarding the AD and ACP in the U.S.A.  </p><p> Historically, according to some studies, an AD is completed by less than 40% of the adult population of the U.S. This low rate suggests that a significant proportion of patients encounter barriers that deter them from completing an AD. Such barriers include: (1) misconceptions, such as the widespread beliefs that an AD is difficult to execute, that it will not be followed by clinicians, and that proxies for patients cannot apply their preferences in specific medical situations; and (2) discrepancies between patient priorities and the nature of the AD itself, including, for example, the fact that many people are less interested in specific treatment deliberations than in the goals of care and maintaining the integrity of their personal values in decision-making during end-of-life care. Such barriers can be removed by: (1) sustained discussion between the patient, family members, proxies, and medical providers; (2) a broader consideration of topics such as the values of patients in terms of life and death, and the goals of care; and (3) the building of relationships of trust between patients and their stake holders.</p><p> These three strategies, implemented in the context of the AD, can be viewed as equating to the core components of ACP. We conclude that actualizing these components could lead to an increase in the completion rate of the AD, thereby improving decision-making during end-of-life care.</p>

Journal

  • Bioethics

    Bioethics 25(1), 69-77, 2015

    Japan Association for Bioethics

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