What do Japanese residents learn from treating dying patients? The implications for training in end-of-life care

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Title

What do Japanese residents learn from treating dying patients?

The implications for training in end-of-life care( 内容と審査の要

旨(Summary) )

Author(s)

荒井, 和子

Report No.(Doctoral

Degree)

博士(医学) 甲第1056号

Issue Date

2018-01-17

Type

博士論文

Version

ETD

URL

http://hdl.handle.net/20.500.12099/75194

※この資料の著作権は、各資料の著者・学協会・出版社等に帰属します。

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Ặ ྡ 㸦 ᮏ ⡠ 㸧 Ⲩ ஭ ࿴ Ꮚ 㸦ᮾி㒔㸧 Ꮫ ఩ ࡢ ✀ 㢮 ༤ ኈ㸦་Ꮫ㸧 Ꮫ ఩ ᤵ ୚ ␒ ྕ ⏥➨ ྕ Ꮫ ఩ ᤵ ୚ ᪥ ௜ ᖹᡂ ᖺ ᭶ ᪥ Ꮫ ఩ ᤵ ୚ せ ௳ Ꮫ఩つ๎➨㸲᮲➨㸯㡯ヱᙜ Ꮫ ఩ ㄽ ᩥ 㢟 ┠ :KDWGR-DSDQHVHUHVLGHQWVOHDUQIURPWUHDWLQJG\LQJSDWLHQWV" 7KHLPSOLFDWLRQVIRUWUDLQLQJLQHQGRIOLIHFDUH ᑂ ᰝ ጤ ဨ 㸦୺ᰝ㸧ᩍᤵ ሯ⏣ ᩗ⩏ 㸦๪ᰝ㸧ᩍᤵ ሷධ ಇᶞ ᩍᤵ Ṋෆ ᗣ㞝 ㄽ ㄽ ᩥ ෆ ᐜ ࡢ せ ᪨ ୡ⏺ⓗ࡟㧗㱋♫఍ࡀ㐍⾜ࡍࡿ୰࡛㸪་ᖌࡀ㐺ษ࡞࢚ࣥࢻ࣭࢜ࣈ࣭ࣛ࢖ࣇࢣ࢔ࢆᥦ౪ࡍࡿࡇ࡜㸪ࡑࡢ ࡓࡵ࡟◊ಟ་࣭་Ꮫ⏕࡟ᑐࡋ࡚㐺ษ࡞ᩍ⫱ᣦᑟࢆ⾜࠺ࡇ࡜ࡣᴟࡵ࡚㔜せ࡛࠶ࡿࡀ㸪◊ಟ་ࡀ㸪Ṛ࡟ࡺ ࡃᝈ⪅ࡢデ⒪ࢆ㏻ࡌ࡚㸪࡝ࡢࡼ࠺࡞Ꮫ⩦య㦂࣭ឤ᝟య㦂ࢆࡋ࡚࠸ࡿࡢ࠿㸪ࡲࡓࡑࢀࡽࡀ་ᖌ࡜ࡋ࡚ࡢ ࢔࢖ࢹࣥࢸ࢕ࢸ࢕ᙧᡂ࡟࡝ࡢࡼ࠺࡞ᙳ㡪ࢆཬࡰࡋ࡚࠸ࡿࡢ࠿࡟ࡘ࠸࡚ࡣ༑ศ࡟ゎ᫂ࡉࢀ࡚࠸࡞࠸ࠋᮏ ◊✲࡛ࡣ㸪㉁ⓗ◊✲ࡢᡭἲࢆ⏝࠸㸪ᡃࡀᅜࡢ◊ಟ་ࡀ㸪⤊ᮎᮇᝈ⪅ࡢデ⒪࡟㝿ࡋ࡚㸪࡝ࡢࡼ࠺࡞ឤ᝟ ࡛ྥࡁྜ࠸㸪ఱࢆ࡝ࡢࡼ࠺࡟Ꮫࡧ㸪ࡑࡢ⤒㦂ࢆ㏻ࡋ࡚་ᖌ࡜ࡋ࡚ࡢ࢔࢖ࢹࣥࢸ࢕ࢸ࢕ࢆ࡝࠺ᙧᡂࡋᾰ 㣴ࡉࡏ࡚࠸ࡿࡢ࠿࡟ࡘ࠸࡚ศᯒࡋࡓࠋ ࠙ᑐ㇟࡜᪉ἲࠚ ◊ಟ་ࡢ⤒㦂㸪┬ᐹ㸪ᴫᛕ໬㸪ィ⏬ࡢࣉࣟࢭࢫࢆ㉁ⓗ࡟᫂ࡽ࠿࡟ࡍࡿࡓࡵ㸪.ROE ࡢ⤒㦂Ꮫ⩦⌮ㄽ ([SHULHQWLDO /HDUQLQJ 7KHRU\(/7ࢆศᯒࡢ⌮ㄽⓗᯟ⤌ࡳ࡜ࡋ࡚◊✲ィ⏬ࢆ❧᱌ࡋࡓࠋ౽ᐅⓗࢧࣥ ࣉࣜࣥࢢἲࢆ⏝࠸࡚༞ᴗᚋ 㹼 ᖺ┠ࡢᚋᮇ◊ಟ་ ྡ㸦⏨ᛶ ྡ㸪ዪᛶ ྡ㸧ࢆເࡾ㸪◊✲ཧຍࡢ ྠពࢆᚓࡓᚋ㸪༙ᵓ㐀໬࢖ࣥࢱࣅ࣮ࣗࢆ⏝࠸࡚㉁ⓗࢹ࣮ࢱࢆ཰㞟ࡋࡓࠋ࢖ࣥࢱࣅ࣮ࣗ࡟ඛ❧ࡕ㸪ཧຍ ⪅ࡢ⫼ᬒ᝟ሗࢆࣇ࢙࣮ࢫࢩ࣮ࢺ࡛཰㞟ࡋࡓࠋ࢖ࣥࢱࣅ࣮࡛ࣗࡣ㸪ஸࡃ࡞ࡗࡓཷࡅᣢࡕᝈ⪅ࡢ࠺ࡕ༳㇟ ῝࠿ࡗࡓ⑕౛㸦㸯౛㸧ࢆཧຍ⪅࡟㑅ࢇ࡛ࡶࡽ࠸㸪ࡑࡢ⤒㦂ࢆ࢖ࣥࢱࣅ࣮ࣗ࢞࢖ࢻ࡟ἢࡗ࡚㉁ၥࡋ㸪᣺ ࡾ㏉ࡗࡓࠋ࢖ࣥࢱࣅ࣮ࣗ࢞࢖ࢻࡣ (/7 ࡢࢧ࢖ࢡࣝ㸦ලయⓗ⤒㦂Ѝ┬ᐹⓗほᐹЍᢳ㇟ⓗᴫᛕ໬Ѝィ⏬࣭ ᐇ㊶㸧࡟ᇶ࡙࠸࡚సᡂࡋ㸪⤊ᮎᮇᝈ⪅ࡢデ⒪࡟࠶ࡓࡗ࡚ᢪ࠸ࡓឤ᝟࣭ᛮ⪃ࡢኚ໬㸪ᣦᑟ་࣭ࢥ࣓ࢹ࢕ ࢝ࣝ࡜ࡢ㛵ࢃࡾ㸪⑕౛࠿ࡽᚓࡓᏛࡧ㸪ᑗ᮶㸪ᣦᑟⓗ❧ሙ࡜࡞ࡗࡓ㝿ࡢ⤊ᮎᮇᝈ⪅デ⒪࡟ᑐࡍࡿ⪃࠼᪉ ࡞࡝ࡢㄆ㆑ࢆ᥈⣴ࡋࡓࠋ࢖ࣥࢱࣅ࣮ࣗࡣ⏦ㄳ⪅.$ࡀ༢⊂࡛⾜࠸㸪◊✲ཧຍ⪅ࡀヰࡋࡸࡍ࠸ࡼ࠺࡟⎔ ቃ࡟㓄៖ࡋ㸪ಶᐊ࡛ ྡࡎࡘ ࠥ ศ࠿ࡅ࡚ᐇ᪋ࡋࡓࠋ࢖ࣥࢱࣅ࣮ࣗࡣ ,& ࣞࢥ࣮ࢲ࣮࡛㘓㡢ࡋ㸪㏲ㄒ㘓ࢆసᡂࡋࡓࠋࢹ࣮ࢱࡢศᯒࡣ୺㢟ศᯒἲࢆ⏝࠸㸪㏲ㄒ㘓ࢆ ྡࡢ◊✲⪅.$76<6ࡀ⊂❧ࡋ࡚ ศᯒࡋ㸪ࡑࡢ⤖ᯝࢆ㞟⣙ࡋࡓࡢࡕ㸪௚ࡢ◊✲⪅ ྡ5,&..)࡜࡜ࡶ࡟⤖ᯝࡢጇᙜᛶ࣭ಙ៰ᛶ㸪࠾ ࡼࡧࢹ࣮ࢱ㣬࿴ࢆ᳨ドࡋࡓࠋ ࠙⤖ᯝࠚ (/7 ࢆ⌮ㄽⓗᯟ⤌ࡳ࡜ࡋ࡚㸪୺㢟ศᯒἲࢆ⏝࠸࡚ศᯒࡋࡓ⤖ᯝ㸪 ✀㢮ࡢほⅬ࠿ࡽ㸪㡯┠࡟ࢃࡓࡿ ◊ಟ་ࡢ⤒㦂࣭┬ᐹ࣭ᴫᛕ໬ࡀ᫂ࡽ࠿࡜࡞ࡗࡓࠋ

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ほⅬϨ⤊ᮎᮇᝈ⪅ࡢࢣ࢔ࢆ㏻ࡋ࡚ࡢឤ᝟ⓗᅔᝨ㸦(/7 ලయⓗ⤒㦂㸧㸸⤊ᮎᮇ་⒪⌧ሙ࡟࠾ࡅࡿ୙ ☜ᐇᛶࡸ⑌ᝈ἞⒪୺⩏࡟ᑐࡍࡿᅔᝨ㸪ࢫࢺࣞࢫࣇࣝ࡞≧ἣୗ࡛ᝈ⪅ࡸ་⒪ࢳ࣮࣒࡜ࡢ࣑ࢫࢥ࣑ࣗ ࢽࢣ࣮ࢩࣙࣥࡀ⏕ࡌ⮬ᕫຠຊឤࡀࡺࡽࡄࡇ࡜㸪ே࡜ࡋ࡚་ᖌ࡜ࡋ࡚ࡢ⨥ᝏឤ࡜↓ຊឤ㸪࡞࡝ࡢឤ ᝟࡜⤒㦂ࡀ᫂ࡽ࠿࡜࡞ࡗࡓࠋ ほⅬϩ⤊ᮎᮇᝈ⪅ࡢࢣ࢔࡟ᑐࡍࡿ᣺ࡾ㏉ࡾ㸦(/7 ┬ᐹⓗほᐹ㸧㸸ᝈ⪅ࡸᐙ᪘㸪ࡑࡋ࡚⮬ศ⮬㌟ࡢឤ ᝟࡟ྥࡁྜ࠺ࡇ࡜ࡢព⩏㸪ಶ࠿ࡽከ⫋✀ࢳ࣮࣒࡟ࡼࡿࢥ࣑ࣗࢽࢣ࣮ࢩࣙࣥ࡜࠸࠺ど㔝ࡢᗈࡀࡾ㸪 ⤊ᮎᮇᝈ⪅࡟ᑐࡍࡿⱞ③⦆࿴ࡢ㔜せᛶࡢព⩏㸪ࢆ┬ᐹࡋ࡚Ꮫࢇ࡛࠸ࡓࠋ ほⅬϪ㸬࢚ࣥࢻ࣭࢜ࣈ࣭ࣛ࢖ࣇࢣ࢔࡟ᑐࡍࡿㄆ㆑ࡢ෌ᵓ⠏㸦(/7 ᢳ㇟ⓗᴫᛕ໬࣭ィ⏬㸧㸸ඛࢆㄞࡳ ࡞ࡀࡽᝈ⪅࣭ᐙ᪘࡜ࢥ࣑ࣗࢽࢣ࣮ࢩࣙࣥࡍࡿࡇ࡜ࡢ㔜せᛶ࡜ᝈ⪅୰ᚰ་⒪࡬ࡢᚿྥ㸪⫋ᴗ࢔࢖ࢹ ࣥࢸ࢕ࢸ࢕ࡢ῝໬࡜⥅⥆ⓗ⬟ຊ㛤Ⓨ࡬ࡢෆⓎⓗືᶵ࡙ࡅࡀಁ㐍ࡉࢀ࡚࠸ࡓࠋ ࠙ ࠙⪃ᐹࠚ ᮏ◊✲ࡣ .ROE ࡢ (/7 ࢆ⌮ㄽⓗᯟ⤌ࡳ࡜ࡋ࡚㸪⤊ᮎᮇᝈ⪅ࡢデ⒪⤒㦂࠿ࡽ㸪◊ಟ་ࡢឤ᝟ኚ໬㸪་ ⒪ࢳ࣮࣒ࡸᝈ⪅࣭ᐙ᪘࡜ࡢࢥ࣑ࣗࢽࢣ࣮ࢩࣙࣥ㸪௒ᚋࡢ⌮᝿࡜ࡍࡿ⮫ᗋ་ീࡸ࢚ࣥࢻ࣭࢜ࣈ࣭ࣛ࢖ࣇ ࢣ࢔ࡢ࠶ࡾ᪉࡟↔Ⅼࢆᙜ࡚㸪◊ಟ་ࡢㄆ㆑࡟ࡘ࠸࡚ศᯒࡋࡓࠋ(/7 ࡛ࡣ㸪⤒㦂࡜ࡣᏛࡧࡢ➨୍Ṍ࡛࠶ ࡾ㸪⌧≧ࡢ▱㆑࣭᝟ሗ࣭ࢫ࣭࢟ࣝ⪃࠼᪉࠿ࡽ㐍ࢇ࡛᪂ࡓ࡞⾜ືࢆ⏕ࡳฟࡍࡓࡵࡢฟⓎⅬ࡜఩⨨௜ࡅࡽ ࢀ࡚࠸ࡿࡀ㸪ᮏ◊✲࡛ࡣ㸪◊ಟ་ࡣᵝࠎ࡞㝜ᛶឤ᝟ࡸ⮬ᕫຠຊឤࡢࡺࡽࡂ࡞࡝ࢆ⤒㦂ࡋࡘࡘࡶ㸪┬ᐹ ࢆ⤒࡚࢚ࣥࢻ࣭࢜ࣈ࣭ࣛ࢖ࣇࢣ࢔࡟ᑐࡍࡿㄆ㆑ࡢ෌ᵓ⠏ࢆ⾜࠺࡜ྠ᫬࡟㸪་ᖌ࡜ࡋ࡚ࡢ࢔࢖ࢹࣥࢸ࢕ ࢸ࢕ࡢ῝໬࡟ࡶࡘ࡞ࡀࡗ࡚࠸ࡗࡓࠋࡇࢀࡽࡢ⤖ᯝࡣ࢚ࣥࢻ࣭࢜ࣈ࣭ࣛ࢖ࣇࢣ࢔ᩍ⫱ࢆ⪃࠼ࡿୖ࡛㔜せ ࡞▱ぢ࡛࠶ࡾ㸪་⒪ࡢ୙☜ᐇᛶ࡜㝈⏺ࡢᩍ⫱㸪ከ⫋✀ࢳ࣮࣒࡬ࡢ᭦࡞ࡿཧ⏬㸪࣮ࣟࣝࣔࢹࣝ࡜࡞ࡿᣦ ᑟ་ࡢᏑᅾ㸪◊ಟ་ࡢឤ᝟㠃࡬ࡢ㓄៖࡜┬ᐹࡢಁ㐍㸪࢔࢖ࢹࣥࢸ࢕ࢸ࢕ࢆᾰ㣴ࡍࡿࡓࡵࡢྲྀ⤌࡞࡝ࡀ ᚲせ࡜⪃࠼ࡽࢀࡓࠋ ࠙⤖ㄽࠚ .ROE ࡢ (/7 ࢆ⌮ㄽⓗᯟ⤌ࡳ࡜ࡋࡓ㉁ⓗศᯒ࡟ࡼࡗ࡚㸪◊ಟ་ࡣ⤊ᮎᮇᝈ⪅ࡢデ⒪ࢆ㏻ࡌ࡚㸪ᵝࠎ ࡞㝜ᛶឤ᝟ࡸ⮬ᕫຠຊឤࡢࡺࡽࡂࢆ⤒㦂ࡋࡘࡘࡶ㸪┬ᐹࢆ⤒࡚࢚ࣥࢻ࣭࢜ࣈ࣭ࣛ࢖ࣇࢣ࢔࡟ᑐࡍࡿㄆ ㆑ࡢ෌ᵓ⠏ࢆ⾜࠺࡜ྠ᫬࡟㸪་ᖌ࡜ࡋ࡚ࡢ࢔࢖ࢹࣥࢸ࢕ࢸ࢕ࡢᙧᡂࡸᾰ㣴࡟ࡶࡘ࡞ࡀࡗ࡚࠸ࡿࡇ࡜ࢆ ᫂ࡽ࠿࡟ࡋࡓࠋ ㄽ ᩥ ᑂ ᰝ ࡢ ⤖ ᯝ ࡢ せ ᪨ ⏦ㄳ⪅ Ⲩ஭࿴Ꮚࡣ㸪⤊ᮎᮇᝈ⪅ࡢデ⒪࡟࠾࠸࡚㸪◊ಟ་ࡀᵝࠎ࡞㝜ᛶឤ᝟ࡸ⮬ᕫຠຊឤࡢࡺࡽࡂࢆ ⤒㦂ࡋ㸪┬ᐹࢆ⤒࡚࢚ࣥࢻ࣭࢜ࣈ࣭ࣛ࢖ࣇࢣ࢔࡟ᑐࡍࡿㄆ㆑ࡢ෌ᵓ⠏ࢆ⾜࠸㸪་ᖌ࡜ࡋ࡚ࡢ࢔࢖ࢹࣥ ࢸ࢕ࢸ࢕ࢆᾰ㣴ࡉࡏ࡚࠸ࡿࡇ࡜ࢆ᫂ࡽ࠿࡟ࡋࡓࠋᮏ◊✲ࡢᡂᯝࡣ㸪་Ꮫᩍ⫱࡜࢚ࣥࢻ࣭࢜ࣈ࣭ࣛ࢖ࣇ ࢣ࢔ᩍ⫱ࡢⓎᒎ࡟ᑡ࡞࠿ࡽࡎᐤ୚ࡍࡿࡶࡢ࡜ㄆࡵࡿࠋ 㹙୺ㄽᩥබ⾲ㄅ㹛 .D]XNR$UDL7DNX\D6DLNL5LQWDUR,PDIXNX&KLKLUR.DZDNDPL.D]XKLNR)XMLVDNL <DVX\XNL 6X]XNL :KDW GR -DSDQHVH UHVLGHQWV OHDUQ IURP WUHDWLQJ G\LQJ SDWLHQWV" 7KH LPSOLFDWLRQV IRUWUDLQLQJLQHQGRIOLIHFDUH