上白木 悦子

オンデマンド型遠隔授業の受講生を対象に先延ばし意識特性尺度に回答を求め，学習履歴から分類した先延ばし学習傾向群間で比較を行った．先延ばし群には前半回のいずれかで先延ばしがあり，先延ばし無し群よりも「状況の楽観視」，「先延ばし前の否定的感情」，「先延ばし中の肯定的感情」の下位尺度得点が高い傾向があった．学生の先延ばし意識特性の事前把握や，授業前半で先延ばししている学生への援助の必要性が示唆された．

(1) Background: To what extent is information manipulation by doctors acceptable? To answer this question, we conducted an exploratory study aimed at obtaining basic data on descriptive ethics for considering this issue. (2) Methods: A self-administered questionnaire survey was conducted on a large sample (n = 3305) of doctors. The participants were queried on (1) whether they consider that information manipulation is necessary (awareness), (2) whether they have actually manipulated information (actual state), and (3) their ethical tolerance. (3) Result: The response rate was 28.7%. Sixty percent of the doctors responded that information manipulation to avoid harm to patients is necessary (awareness), that they have actually manipulated information (actual state), and that information manipulation is ethically acceptable. (4) Conclusion: While the present survey was conducted among doctors in Japan, previous studies have reported similar findings in the United States and Europe. Based on our analysis, we hypothesize that a relationship of trust between patients and medical personnel is crucial and that information manipulation is not needed when such a relationship has been established.

<p>本研究では，緩和ケア・終末期医療の医療ソーシャルワーカー（MSW）の役割に対して，患者による必要性の観点から役割の内実を明らかにすることを目的とする．がん治療中の患者を対象に質問紙調査を行った（188名/回収率77.7％）．このうちMSWへの相談経験のない患者群につき因子分析を行った．結果として5因子に収束し，患者に対する支援計画の策定，意思の確認ができない患者の医療方針の決定に関わる支援，患者の気持ちを医療従事者へ伝達，多職種との情報共有，患者や家族等への精神的支援と命名した．モデル適合度はGFI 0.981, AGFI 0.976であり妥当な水準と評価した．患者が必要と考える，緩和ケア・終末期医療のMSWの役割は5因子構造であった．本研究が明らかとした役割を担うことによりMSWは，人生の最期の生と死に向き合う患者と家族等への支援を行うことの重要性が示唆された．</p>

緩和ケア・終末期医療の医療ソーシャルワーカー(MSW)の役割遂行の構造に関連する要因と因果関係性を明らかにするために、がん診療拠点病院などのMSW 1,134人を対象に質問紙調査を実施した(回収率37.1%)。本研究では、コンピテンシー、コーピング、死に対する態度、職場・職業への適応感は相互に影響し合いながらMSWの役割遂行を規定するという多重指標モデルを作成した。共分散構造分析の結果、有意な推定値が得られ、適合度はGFI=.920、AGFI=.898、RMSEA=.060でありモデルは妥当であると評価した。緩和ケア・終末期医療のMSWの役割遂行の構造(情報共有、ソーシャルワーク実践、代弁、意思決定支援、精神的支援)が本調査により明らかとなり、関連要因を含む仮説は支持された。これら現状の向上・改善は、医療・ケアチームにおけるMSWの至適な役割遂行につながることが示唆された。(著者抄録)

In Japan, physicians are required to report unexpected health care-associated patient deaths to the police. Patients needing to be transferred to another institution often have complex medical problems. If a medical error occurs, it may be either at the final or the referring institution. Some fear that liability will fall on the final institution regardless of where the error occurred or that the referring facility may oppose such reporting, leading to a failure to report to police or to recommend an autopsy. Little is known about the actual opinions of physicians and risk managers in this regard. The authors sent standardised, self-administered questionnaires to all hospitals in Japan that participate in the national general residency program. Most physicians and risk managers in Japan indicated that they would report a patient's death to the police where the patient has been transferred. Of those who indicated they would not report to the police, the majority still indicated they would recommend an autopsy

This article examines what could account for the low autopsy rate in Japan based on the findings from an anonymous, self-administered, structured questionnaire that was given to a sample population of the general public and physicians in Japan. The general public and physicians indicated that autopsy may not be carried out because: (1) conducting an autopsy might result in the accusation that patient death was caused by a medical error even when there was no error (50.4% vs. 13.1%, respectively), (2) suggesting an autopsy makes the families suspicious of a medical error even when there was none (61.0% vs. 19.1%, respectively), (3) families do not want the body to be damaged by autopsy (81.6% vs. 87.3%, respectively), and (4) families do not want to make the patient suffer any more in addition to what he/she has already endured (61.8% vs. 87.1%, respectively).

CONTEXT: Autopsy is a useful tool for understanding the cause and manner of unexpected patient death. However, the attitudes of the general public and physicians in Japan about clinical autopsy are limited. OBJECTIVE: To describe the beliefs of the general public about whether autopsy should be performed and ascertain if they would actually request one given specific clinical situations where patient death occurred with the additional variable of medical error. To compare these attitudes with previously obtained attitudes of physicians practising at Japanese teaching hospitals. DESIGN, SETTING AND PARTICIPANTS: We conducted a cross-sectional study of the general public. We sent standardised questionnaires in 2010 to a randomly selected non-physician adult population using a survey company for participant selection. Respondents gave their opinions about the necessity of autopsy and how they might act given various clinical scenarios of patient death. We compared these results with those of a previous survey of Japanese physicians conducted in 2009. RESULTS: Of the 2300 eligible general adult population, 1575 (68.5%) responded. The majority of the general public indicated they believed an autopsy was necessary. However, in cases of unclear medical error or unclear cause and effect relationship of medical care and patient death, the general public were much less likely to indicate they would actually request an autopsy than were physicians (p<0.0001). Currently in Japan the debate about the role autopsy should play in the case of error related to death is underway. The results from this study will be important in informing related decisions.

BACKGROUND: Patient safety education, including error prevention strategies and management of adverse events, has become a topic of worldwide concern. The importance of the patient safety is also recognized in Japan following two serious medical accidents in 1999. Furthermore, educational curriculum guideline revisions in 2008 by relevant the Ministry of Education includes patient safety as part of the core medical curriculum. However, little is known about the patient safety education in Japanese medical schools partly because a comprehensive study has not yet been conducted in this field. Therefore, we have conducted a nationwide survey in order to clarify the current status of patient safety education at medical schools in Japan. RESULTS: Response rate was 60.0% (n = 48/80). Ninety-eight-percent of respondents (n = 47/48) reported integration of patient safety education into their curricula. Thirty-nine percent reported devoting less than five hours to the topic. All schools that teach patient safety reported use of lecture based teaching methods while few used alternative methods, such as role-playing or in-hospital training. Topics related to medical error theory and legal ramifications of error are widely taught while practical topics related to error analysis such as root cause analysis are less often covered. CONCLUSIONS: Based on responses to our survey, most Japanese medical schools have incorporated the topic of patient safety into their curricula. However, the number of hours devoted to the patient safety education is far from the sufficient level with forty percent of medical schools that devote five hours or less to it. In addition, most medical schools employ only the lecture based learning, lacking diversity in teaching methods. Although most medical schools cover basic error theory, error analysis is taught at fewer schools. We still need to make improvements to our medical safety curricula. We believe that this study has the implications for the rest of the world as a model of what is possible and a sounding board for what topics might be important.

BACKGROUND: Patient safety education is becoming of worldwide interest and concern in the field of healthcare, particularly in the field of nursing. However, as elsewhere, little is known about the extent to which nursing schools have adopted patient safety education into their curricula. We conducted a nationwide survey to characterize patient safety education at nursing schools in Japan. RESULTS: Response rate was 43% overall. Ninety percent of nursing schools have integrated the topic of patient safety education into their curricula. However, 30% reported devoting less than five hours to the topic. All schools use lecture based teaching methods while few used others, such as role playing. Topics related to medical error theory are widely taught, e.g. human factors and theories & models (Swiss Cheese Model, Heinrich's Law) while relatively few schools cover practical topics related to error analysis such as root cause analysis. CONCLUSIONS: Most nursing schools in Japan cover the topic of patient safety, but the number of hours devoted is modest and teaching methods are suboptimal. Even so, national inclusion of patient safety education is a worthy, achievable goal.

診療関連死を対象とする剖検についての意識と行動について検討した。臨床研修プログラムに参加する医師およびリスクマネジャー(RM)を対象とした。回収率は全体47.8%(1065名)で、医師41.9%(466名)、RM53.8%(599名)であった。診療行為と因果関係がある診療関連死が生じた場合、過失が不明であっても、剖検の提案等をしない医師(12.9%)やRM(26.7%)が存在した。診療関連死が生じ、診療行為に過失がある場合、患者の死亡との間の因果関係が不明であっても、剖検の提案等をしない医師(19.2%)やRM(31.3%)が存在した。剖検の必要性の意識については、過失の有無や因果関係の有無との関係から、医師とRMとの間に有意な差はみられなかった。因果関係が不明な場合であっても、剖検を必要でないとする医師(11.8%)やRM(14.6%)が存在した。

診療関連死の剖検に焦点を絞り、臨床研修病院の教育研修責任医師(医師)・医療安全管理者(RM)を対象とした全数調査を行い、剖検の必要性についての意識、遺族への剖検の提案(行動)、意識と行動の相違について実態を調査した。医療行為と因果関係がある診療関連死が生じた場合、過失が不明であっても、剖検を遺族へ提案しない医師(12.9%)や提案を医師へ促さないRM(26.7%)が存在した。診療関連死が生じ、医療行為に過失がある場合、死亡との因果関係が不明であっても、剖検を提案しない医師(19.2%)や提案を医師へ促さないRM(31.3%)が存在した。因果関係が不明な場合であっても、剖検を必要でないとする医師(11.8%)とRM(14.6%)が存在した。剖検を必要と考えていても、遺族への剖検の提案や医師への剖検の促しを、病院長の判断に任せると回答した医師やRMが存在した。

In Japan, healthcare professionals are required by Article 21 of the Medical Practitioner's Law to report "unnatural deaths" to the police in cases of healthcare-associated patient death. The attitudes of medical personnel at the forefront of clinical medicine regarding reporting have not been described. We investigate the attitudes of physicians and risk managers (RMs) regarding reporting to the police under different circumstances. We sent standardized questionnaires to all hospitals in Japan that participate in the National General Residency Program. We asked physicians and RMs to indicate if they would report to the police or not under scenarios including cases where medical error is present, uncertain, or absent. We also asked if they would report when medical error had occurred and the cause-of-death was directly related, possibly related, or unrelated. We found most physicians believe they would report to the police if medical error clearly caused patient death. We found most RMs believe they would advise physicians to report given the same situation. Less but still a large number of participants favor reporting even when cause-of-death is not clearly related to medical care provided. This tendency persisted even when given a scenario where the hospital director opposed the decision to report.

CONTEXT: Autopsy is a useful tool for understanding the manner and cause of death in unexpected patient death. The information about the opinions of physicians and risk managers in Japan regarding autopsy is limited. OBJECTIVE: To describe and evaluate the opinions of physicians and risk managers at Japanese teaching hospitals regarding forensic autopsy. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional study of all residency programme directors and risk managers completing a survey in January 2009. Specific clinical scenarios where autopsy would be essential to determine whether medical error occurred and whether medical care contributed to the death of the patient were presented. Respondents gave their opinion regarding the necessity of autopsy and their beliefs about if they would actually recommend it. RESULTS: Of 1113 eligible physicians and 1113 eligible chief risk management officers, 466 physicians (41.9%) and 599 risk managers (53.8%) responded. The majority of physicians and risk managers reported they would recommend an autopsy in cases of unclear medical error or unclear cause and effect relationship of medical care and patient death; however, 10% or more of physicians and 25% or more of risk managers (depending on the situation) reported that they would not recommend an autopsy. Risk managers were less likely than physicians to recommend and believe that autopsy was necessary. CONCLUSIONS: The majority of physicians and risk managers in Japan would recommend autopsy and believe in its necessity in cases of unexpected patient death.

Recently in Japan, the topic of withdrawing life support is becoming increasingly urgent. The issue of living wills and surrogate decision makers in this process has received little attention. The purpose of this study is to examine recent judiciary decisions in Japan (criminal judgements) and recent guidelines regarding the decision to withdraw life-sustaining treatment based on the living will or surrogate decisions by the patient's family members. We found that most court rulings and all guidelines support withdrawal of life support based on patient wishes stated in a living will. On the other hand, only one judiciary decision supports the use of surrogate wishes in the decision to withdraw support, and the issue of surrogates was not clearly addressed in recent guidelines.

末期医療の現場において、生命維持装置の差し控え・中止についてリビングウイルの作成により事前に自らの希望を表明している場合がある一方で、殆どの患者では事前の意思表示なく、家族などが患者に対する生命維持装置の差し控え・中止を希望する場合がある。前者では事前の意思表示から中止時点の意思を推定し、推定意思に基づき中止などが許容されるかという問題が、後者では患者の意思を忖度した家族などの意向により中止が許容されるかという問題が生じる。そこで末期医療における生命維持装置の差し控え・中止の許容性と患者の意思との関係、患者の意思の推定と代諾の許容性について、日本における関連する裁判例や各種ガイドラインの内容を分析した。その結果、川崎協同病院事件における東京高等裁判所判決のみが、推定意思は許容しない考えを示している以外は、推定を許容していることが明らかとなった。代諾については東海大学安楽死事件における横浜地方裁判所がそれを許容する考えを示したものの、今後、早急に議論を進める必要があると考えられた。

末期医療における治療行為の差し控え・中止については、欧米諸国では既に一定の社会的合意が得られているが、本邦では治療行為の中止等によって患者が死亡した場合、医師に対し刑事介入がなされたり、そのことが広く報道されるなど大きな社会問題になることがある。治療行為の差し控え・中止は患者の死に関わるため、当該患者の利益の点からも、また医師の法的責任の点からも重要な問題である。臨床の現場は、末期医療を行うにあたり、これらの点について事前に関連知識を取得しておくことが不可欠である。差し控え・中止が許容される要件(具体的判断基準)の問題と、末期医療において踏襲すべき手続きの問題について、主として本邦のこれまでの議論を中心に総括した。