Online ISSN: 2187-2988 Print ISSN: 0911-1794
特定非営利活動法人日本小児循環器学会 Japanese Society of Pediatric Cardiology and Cardiac Surgery
Pediatric Cardiology and Cardiac Surgery 36(3): 215-222 (2020)


こんな症例をセカンドオピニオンに出しました治療方針決定が困難な症例におけるshared decision makingの効果Lessons Learned from Our Second Opinion Cases: Advantages of Shared Decision Making for Complex Heart Diseases

独立行政法人地域医療機能推進機構 中京病院中京こどもハートセンターJapan Community Health Care Organization, Chukyo Hospital, Chukyo Children’s Heart Center ◇ Nagoya, Japan

発行日:2020年10月1日Published: October 1, 2020

先天性心疾患領域ではどの治療方針が正解か明言することが困難な状況にも遭遇する.我々の施設では治療方針の決定に難渋した症例,他施設と治療方針が異なる可能性がある症例,施設によって手術成績が異なる症例について,shared decision makingの観点から家族にセカンドオピニオンを勧めるケースがある.修正大血管転位症の症例では,ダブルスイッチ手術に進むべきかどうかの検討を行い,家族はダブルスイッチ手術を行う施設での治療を希望された.大血管転位症,肺動脈閉鎖症の症例では,ラステリ手術,大動脈基部転位術,フォンタン手術が治療の選択肢となり,当院とセカンドオピニオン施設ともラステリ手術を勧められ当院でラステリ手術を施行した.総肺静脈還流異常合併左心低形成症候群の母胎紹介例では当院ではフォンタン到達例の経験がなく,フォンタン到達例の経験ある施設での治療を希望され母体搬送を行った.混合型総肺静脈還流異常を合併した機能的単心室について当初手術適応のない症例であるとされたが,経過中に手術適応となりセカンドオピニオンを行ったのち,他施設でも同様の意見と理解され当院で総肺静脈還流異常修復術を施行した.これらの経験は我々と患者および家族の“shared decision making”であり,非常に有益であった.最善な医療を提供するために適切な情報提供を行い,率直な態度をとることはあらゆるレベルの医師に必要である.

In the field of congenital heart surgery, it is often difficult to determine the best treatment option. For patients with complex heart disease or operative factors, we recommend obtaining a second opinion from the viewpoint of shared decision-making. In this study, we describe four second opinion cases, relating to congenitally corrected transposition of the great arteries (ccTGA): Transposition of the great arteries (TGA), TGA and pulmonary atresia (PA), hypoplastic left heart syndrome (HLHS) with total anomalous pulmonary venous connection (TAPVC), and a functional single ventricle with mixed TAPVC. In the ccTGA case, the patient preferred a double switch operation to conservative observation. The patient with TGA and PA underwent a Rastelli operation, which was the treatment option offered by the second opinion institution. In the HLHS with TAPVC case, the patient’s mother preferred treatment at another hospital, which had a previous Fontan survivor with the same disease. In the last case, the family felt embarrassed because the operation was considered impossible at first, but the patient was later told that surgery would be appropriate. Consequently, the family requested a second opinion from another hospital, where they were told that surgery could be performed, which they agreed to. All four cases relied on shared decision-making. Our findings show that information-sharing, and a sincere attitude towards patients is necessary for all medical workers.

Key words: shared decision making; second opinion

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