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2015.04.27 宮道スライド改
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Ryosuke Miyamichi
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2015年4月27日のターミナルケアカンファレンスのスライドです。
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2015.04.27 宮道スライド改
1.
救急医療と アドバンス・ケア・プランニング 救急部 宮道亮輔 旧約聖書「列王記」下巻4章; Frederic
Leighton 紀元前9世紀、預言者エリシアがシュネムの婦人の子供 を生き返らせた。
2.
当院救急外来の現状 項目 人数/件数 救急外来受診 43,299人 救急車受け入れ
10,148件 三次救急受け入れ 976件 (平成26年度)
3.
救急医療は 究極の 慢性期医療や
4.
ところで皆さん自身は… 延命を希望しますか? 救命は希望しますか?
5.
とある救急患者さん 78歳女性、自室で倒れているのを家族が発見 救急隊到着時は心肺停止状態 胸骨圧迫、人工呼吸、AED装着 病院到着時も心肺停止状態 胸骨圧迫、気管挿管、ルート確保 ERで自己心拍再開(心停止時間60分) 意識JCS300、自発呼吸なし CCM入室し、呼吸循環管理 人工呼吸管理、昇圧薬使用 経管栄養開始 その後も意識は回復せず 気管切開施行、人工呼吸器が必要
6.
DN(A)Rと終末期医療 DNR患者さんが発熱した! DNRとは癌の末期,老衰,救命の可能性がない患者などで, 本人または家族の希望で心肺蘇生法をおこなわないこと [日本救急医学会 用語集より抜粋] 「救急・集中治療における終末期」とは、集中治療室等で 治療されている急性重症患者に対し適切な治療を尽くして も救命の見込みがないと判断される時期である。 一連の過程において、すでに装着した生命維持装置や投与中の薬剤な どへの対応として、①現在の治療を維持する(新たな治療は差し控え る)、②現在の治療を減量する(すべて減量する、または一部を減量あ るいは終了する)、③現在の治療を終了する(全てを終了する)、④上 記の何れかを条件付きで選択するなどが考えられる。 [救急・集中治療における終末期医療に関するガイドラインより抜粋]
7.
とある救急患者さん 78歳女性、自室で倒れているのを家族が発見 救急隊到着時は心肺停止状態 胸骨圧迫、人工呼吸、AED装着 病院到着時も心肺停止状態 胸骨圧迫、気管挿管、ルート確保 ERで自己心拍再開(心停止時間60分) 意識JCS300、自発呼吸なし CCM入室し、呼吸循環管理 人工呼吸管理、昇圧薬使用 経管栄養開始 その後も意識は回復せず 気管切開施行、人工呼吸器が必要 どこまで 救命の 可能性あり?
8.
我々のスタンス 医学的適応 患者の意向 ・客観的に救命の可能性を 考慮 ・治療の目標について検討 ・本人には聞けない! 「本人ならこの状況をどう考 えると思いますか?」 と家族に問いかける QOL 周囲の状況 ・生活復帰の可能性を考慮 ・患者が失うものを考慮 ・家族の意向を考慮 ・社会的・経済的要因を考慮 [Jonsen
AR他著.赤林朗他監訳『臨床倫理学 第5版』新興医学出版社 より抜粋] 答えはそれぞれ違う、寄り添い一緒に考える
9.
Advance Care Planningへの期待 “救命の可能性”について論ずる 窒息,VFなどは救命の可能性あり? 我々のスタンスは、やってみないと分からない 自宅で心停止した時の対応 救急要請? 救急隊は救命のための隊→CPRを行う 死を意識することで生を意識する 人は必ず死ぬ 生き方、家族に伝えたいことなどを考える
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