日本臨床麻酔学会 vol.36

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1 308 Vol.36 No.3/May 2016 日本臨床麻酔学会第 35 回大会招待講演日臨麻会誌 Vol.36 No.3, , 2016 日本臨床倫理学会による POLST(DNAR 指示を含む ) 作成指針 作成の経緯と今後の展望 *1 3 箕岡真子 [ 要旨 ] 多くの病院で日常的に DNAR 指示 (= Do Not Attempt Resuscitation) が出されている. しかし, 患者の自己決定権の尊重が不十分であったり, また,DNAR 指示の解釈が医療者個人個人で異なり,DNAR 指示によって CPR 以外の生命維持治療も制限されてしまい, 実質的な延命治療の差し控え 中止となってしまっている可能性がある. そこで, このような DNAR 指示実践における混乱を改善するために, 日本臨床倫理学会はワーキンググループを発足させ, 日本中の医療機関で使用可能な DNAR 指示の作成指針の雛形を発表した. 当指針は 基本姿勢 書式 ガイダンス よりなり,CPR 以外の他の医療処置に関する具体的指示も含んだ POLST = Physician Orders for Life Sustaining Treatment という形式を採用することにし, 正式名称は POLST (DNAR 指示を含む ) 作成指針 とした. キーワード : DNAR 指示,POLST, 自己決定, 事前指示, 代理判断 Ⅰ 臨床現場における DNAR 指示実践の混乱 DNAR Do Not Attempt Resuscitation DNAR DNAR CPR cardiopulmonary resuscitation DNAR CPR DNAR DNAR Ⅱ DNAR 指示に関する倫理的論点 DNAR

2 309 DNAR DNAR DNAR DNAR DNAR DNAR Ⅲ POLST(DNAR 指示を含む ) 作成指針 生命を脅かす疾患 に直面している患者の 医療処置 ( 蘇生処置を含む ) に関する医師による指示書 DNAR DNAR CPR CPR POLST Physician Orders for Life Sustaining Treatment POLST DNAR 1. 基本姿勢 Autonomy - DNAR DNAR 2. 書式 POLST DNAR Physician s Order Patient s Instruction A CPR Resuscitate Full Code Do Not Attempt Resuscitation B CPA a Comfort Measures b Full Treatment c C

3 310 Vol.36 No.3/May 2016 D E 3. ガイダンス 6 1 POLST DNAR 2 CPA 3 4 POLST DNAR 5 POLST DNAR 6 POLST DNAR Ⅳ 倫理的に適切な意思決定プロセス, および アドバンスケアプラニング (Advance Care Planning) の重要性 DNAR DNAR Advance Care Planning DNAR POLST

4 311 Advance Care Planning Advance Care Planning DNAR POLST Advance Care Planning 3 DNAR POLST DNAR POLST DNAR htm 参考文献 1) 箕岡真子 : 私の四つのお願い 医療のための事前指示書. ワールドプランニング, 東京,2011 2) 箕岡真子 : 蘇生不要指示のゆくえ 医療者のための DNAR の倫理. ワールドプランニング, 東京,2012 3) 箕岡真子 : 正しい看取りの意思確認. ワールドプランニング, 東京,2015

5 312 Vol.36 No.3/May 2016 Japanese Version of POLST(DNAR)by Japan Association for Clinical Ethics: Ethics for End of Life Care Masako MINOOKA *1 Executive Director of Japan Association for Clinical Ethics *2 Department of Biomedical Ethics, University of Tokyo, Graduate School of Medicine *3 Minooka Clinic The Japan Association for Clinical Ethics(JACE)organized a working group on DNAR order to discuss the ethics of the decision making process and issued a Japanese version of POLST(DNAR)in March, Until recently, consensus regarding DNAR was lacking, with different interpretations among different individual physicians. As a result, various life-sustaining medical treatments other than CPR were withdrawn or withheld. The Japanese version of POLST(DNAR)has 3 parts:1. Basal Concept, 2. Guidance(with check sheets), and 3. Form. Regarding guidance, the following six reference points are considered relevant:chap.1. Communication with patient, family members and medical staffs;chap.2. Autonomy:respect for patient s wishes and values;chap.3. Substituted judgment:respect for family member s opinions and ethically adequate process of proxy consent;chap.4. Medical matters in consideration of POLST (DNAR);Chap.5. Procedual justice of decision making on POLST(DNAR);Chap.6. Consideration for the patient and family members after POLST(DNAR)is made. To reduce and resolve ethical dilemmas relating to end-of-life care, Advance Care Planning is proposed as being of paramount importance. To this end, we advocate the implementation of ethically appropriate POLST(DNAR). Key Words : DNAR order, POLST, Autonomy, Advance directive, Proxy(surrogate)judgment The Journal of Japan Society for Clinical Anesthesia Vol.36 No.3, 2016

日本臨床倫理学会 日本版 POLST(DNAR 指示を含む ) 作成指針 POLST(Physician Orders for Life Sustaining Treatment) 生命を脅かす疾患 に直面している患者の 医療処置 ( 蘇生処置を含む ) に関する医師による指示書 これは日本臨床倫理

日本臨床倫理学会 日本版 POLST(DNAR 指示を含む ) 作成指針 POLST(Physician Orders for Life Sustaining Treatment) 生命を脅かす疾患 に直面している患者の 医療処置 ( 蘇生処置を含む ) に関する医師による指示書 これは日本臨床倫理 日本版 POLST(DNAR 指示を含む ) 作成指針 POLST(Physician Orders for Life Sustaining Treatment) 生命を脅かす疾患 に直面している患者の 医療処置 ( 蘇生処置を含む ) に関する医師による指示書 これはによる POLST(DNAR 指示を含む ) の作成指針です. 患者さんのために POLST(DNAR 指示を含む ) を作成する医師であれば,

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日本臨床倫理学会 Ⅱ POLST(DNAR 指示を含む ) 作成に関するガイダンス 生命を脅かす疾患 に直面している患者の 医療処置 ( 蘇生処置を含む ) に関する医師による指示 現在, 広く DNAR 指示 (Do Not Attempt Resuscitation Order) という言葉が用

日本臨床倫理学会 Ⅱ POLST(DNAR 指示を含む ) 作成に関するガイダンス 生命を脅かす疾患 に直面している患者の 医療処置 ( 蘇生処置を含む ) に関する医師による指示 現在, 広く DNAR 指示 (Do Not Attempt Resuscitation Order) という言葉が用 Ⅱ POLST(DNAR 指示を含む ) 作成に関するガイダンス 生命を脅かす疾患 に直面している患者の 医療処置 ( 蘇生処置を含む ) に関する医師による指示 現在, 広く DNAR 指示 (Do Not Attempt Resuscitation Order) という言葉が用いられていますが, DNAR 指示は心肺停止 (Cardio Pulmonary Arrest;CPA) の際に, 心肺蘇生術

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