| Sumario: | Purpose Japanese society often recommends the elderly to choose a 'natural death' when it becomes difficult for them to eat orally and when their ability to make decisions declines1. Caregivers can, however, opt for tube feeding to be administered to the elderly, who have little time to live, so that they can spend more time with their family members2. Our study was aimed at clarifying the decision-making process involved in introducing tube feeding to an elderly person by focusing on the relationships between him, his family, and his caregiver. Method A fieldwork survey was carried out from November 25, 2013 to January 8, 2014 (ongoing) at an adult day care center. Field notes were taken about the relationship between an elderly person and his caregiver. The relationships between the elderly person, relatives, and a caregiver were investigated through semi-structured and informal interviews. We described the ethnography of the collected data, analyzed it by focusing on the relationship between the stakeholders, and synthesized the results of analysis on the decision-making process. Results X was the caregiver, who took care of Y. X was also a nurse and care manager who ran an adult day care center. Y was 74 years old and an elder brother of Z, to whom X had been a friend for 20 years. Y and Z had long been distanced. Y was passed around in 2011 from hospital to hospital due to his impaired cognition caused by hydrocephalus. X tried to move Y from a hospital to a nursing home near Z's house to support Z and his wife. However, he was not admitted to the nursing home because the staff refused to take him in after meeting him. X could not help to take care of Y at her adult day care center and lived with him until another nursing home was found. At that time, X agreed with Z and his wife that they would not have life-sustaining treatments administered to Y. However, he gradually improved due to X's care, and humane relations were formed between X and Y. The relationship between X and Z (including his wife) also evolved as a result, i.e., their relationship was transformed from a relationship between a family and a caregiver to a relationship between a family and Y's primary caregiver. When it became difficult for Y to orally ingest nutrients due to aspiration pneumonia in the summer of 2013, Z and his wife wished for a 'natural death' as they had agreed in advance. However, X proposed gastrostomy tube feeding on the grounds that Y's physical and cognitive states were being restored. Z, his wife, and X concluded Y be fitted with a nasal tube through discussions with a physician. Y's condition improved due to nutrients administered through the tube, and he was then able to ingest nutrients through only being fed orally. Discussion This study analyzed the process of decision-making in medical technology with a focus on relationships. As a result, we observed the process in which a caregiver participated in a discussion on decision-making with a family and a family doctor and caused a change in the relationships between the caregiver, an elderly person, and his family. Families are substitute decision-makers for elderly with cognitive difficulties in Japan, and a common practice by caregivers is to help families accordingly. However, the choice of medical technologies that is discarded in common practice is picked up by primary caregiver who participate discussions on an equal basis. This suggests that it is important not to be tied to relations based on a framework, and to discuss issues as equals based on specializations. We consider that this conclusion is beneficial as a suggestion to practitioners in the field of medical care.
|
|---|