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临终关怀我们能做什么

What we can do to die well | Timothy Ihrig

我是一名临终关怀医师
I am a palliative care physician
今天我想和你们聊聊医疗保健
and I would like to talk to you today about health care.
我想和你们谈谈我们国家中最脆弱的人所获得的医疗和 保健
I’d like to talk to you about the health and care of the most vulnerable population in our country —
那些正面临着最复杂最严重的健康问题的人们
those people dealing with the most complex serious health issues.
我也想和你们聊聊经济学
I’d like to talk to you about economics as well.
而这两者的交集应该会 让你们感到很恐惧
And the intersection of these two should scare the hell out of you —
它已经吓坏我了
it scares the hell out of me.
我也想和你们谈谈临终关怀:
I’d also like to talk to you about palliative medicine:
一个基于这群人价值观的治疗方法
a paradigm of care for this population, grounded in what they value.
基于他们的价值观 以病人为中心
Patient-centric care based on their values
这一方法帮助这类人群活得更好 更久
that helps this population live better and longer.
它主张与病人诚实相待 与病人建立一对一的联系 提供上门服务
It’s a care model that tells the truth and engages one-on-one and meets people where they’re at.
我将从讲述我第一个病人的故事开始
I’d like to start by telling the story of my very first patient.
那是我成为医生的第一天
It was my first day as a physician,
穿着白大褂
with the long white coat …
我走进了医院
I stumbled into the hospital
马上就有一名68岁叫哈罗德的男士
and right away there’s a gentleman, Harold, 68 years old,
来到了急诊科
came to the emergency department.
他已经头疼了大约六周
He had had headaches for about six weeks
而且变得越来越严重
that got worse and worse and worse and worse.
诊断显示他得了癌症 已经扩散到大脑
Evaluation revealed he had cancer that had spread to his brain.
他的主治医师建议我 告诉哈罗德和他的家人
The attending physician directed me to go share with Harold and his family
诊断结果 病情预测和护理选项
the diagnosis, the prognosis and options of care.
我新事业才开始了5小时
Five hours into my new career,
我做了我唯一会做的事情
I did the only thing I knew how.
我走进病房
I walked in,
坐了下来
sat down,
握住哈罗德的手
took Harold’s hand,
拿起他妻子的手
took his wife’s hand
深呼吸
and just breathed.
他问 “孩子 不是什么好消息对吧?”
He said, “It’s not good news is it, sonny?”
我说 “是的”
I said, “No.”
于是我们进行了沟通 互相倾听 分享想法
And so we talked and we listened and we shared.
过了一会儿 我问道
And after a while I said,
“哈罗德 对你来说什么是有意义的事情?
“Harold, what is it that has meaning to you?
什么事情你觉得是神圣的?”
What is it that you hold sacred?”
他说
And he said,
“我的家人”
“My family.”
“你接下来想做什么?”
I said, “What do you want to do?”
他拍拍我的膝盖说: “我想去钓鱼”
He slapped me on the knee and said, “I want to go fishing.”
我说 “这个我知道怎么做”
I said, “That, I know how to do.”
第二天哈罗德去钓鱼了
Harold went fishing the next day.
一周后他去世了
He died a week later.
在我在职业生涯中的培训后
As I’ve gone through my training in my career,
我总回想起哈罗德
I think back to Harold.
我认为这种对话
And I think that this is a conversation
太少了
that happens far too infrequently.
是这种对话导致我们走向了危机
And it’s a conversation that had led us to crisis,
那就是对美国现代生活最大的威胁
to the biggest threat to the American way of life today,
即医疗保健支出
which is health care expenditures.
那么我们知道些什么?
So what do we know?
我们清楚这群病入膏肓的人
We know that this population, the most ill,
耗费了15%的国内生产总值——
takes up 15 percent of the gross domestic product —
大约2.3万亿美元
nearly 2.3 trillion dollars.
病得最重的15%的人 占用了15%的GDP
So the sickest 15 percent take up 15 percent of the GDP.
如果我们以此来推断二十年后
If we extrapolate this out over the next two decades
随着婴儿潮一代人的变老
with the growth of baby boomers,
这个比率会是60%的GDP
at this rate it is 60 percent of the GDP.
60%的美国GDP
Sixty percent of the gross domestic product of the United States of America —
在那个时候已经和医疗保健关系不大了
it has very little to do with health care at that point.
而是和一加仑的牛奶有关
It has to do with a gallon of milk,
和大学学费有关
with college tuition.
它与每一件我们重视的事情
It has to do with every thing that we value
和每一件我们现在已知的事情有关
and every thing that we know presently.
这会让美国的市场经济和资本主义制度陷入泥潭
It has at stake the free-market economy and capitalism of the United States of America.
让我们暂时忘记那些统计数据
Let’s forget all the statistics for a minute, forget the numbers.
让我们来谈谈从所有这些开销中得到的价值
Let’s talk about the value we get for all these dollars we spend.
大概六年前 达特茅斯阿特拉斯项目
Well, the Dartmouth Atlas, about six years ago,
查看了医疗保险支出的每一分钱
looked at every dollar spent by Medicare —
通常就是这群人
generally this population.
我们发现那些人均支出最高的病人
We found that those patients who have the highest per capita expenditures
承受着最严重的病痛和绝望
had the highest suffering, pain, depression.
但是他们往往更早离世
And, more often than not, they die sooner.
为什么会这样?
How can this be?
我们生活在美国
We live in the United States,
拥有全球最好的医疗保健系统
it has the greatest health care system on the planet.
我们在这些病人身上花的钱比世界第二大国多10倍
We spend 10 times more on these patients than the second-leading country in the world.
这不合理
That doesn’t make sense.
但是我们知道的是
But what we know is,
在全球前五十拥有
out of the top 50 countries on the planet
有组织的医疗保健系统的国家中
with organized health care systems,
我们排第三十七位
we rank 37th.
原东欧集团国家和撒哈拉以南非洲国家
Former Eastern Bloc countries and sub-Saharan African countries
在质量和价值上都比我们排名更高
rank higher than us as far as quality and value.
有件事我每天都能在实践中感受到
Something I experience every day in my practice,
我也确信这是你们中的很多人在生命旅程中感受过:
and I’m sure, something many of you on your own journeys have experienced:
更多不等于更好
more is not more.
那些做过更多检查的病人
Those individuals who had more tests,
更多次陷入紧急情况的病人
more bells, more whistles,
做过更多化疗 更多手术的病人
more chemotherapy, more surgery, more whatever —
我们对他们做得越多
the more that we do to someone,
他们的生活质量就降低得越多
it decreases the quality of their life.
他们的寿命也通常越短
And it shortens it, most often.
那我们该怎么办呢?
So what are we going to do about this?
我们现在是怎么做的?
What are we doing about this?
为什么事情是这样的?
And why is this so?
严峻的现实是 女士们先生们
The grim reality, ladies and gentlemen,
我们整个医疗保健业 长白大褂的医生们
is that we, the health care industry — long white-coat physicians —
正在偷取你们的东西
are stealing from you.
窃取了你们自己选择自己的生活的机会
Stealing from you the opportunity to choose how you want to live your lives
不论你们得了什么病
in the context of whatever disease it is.
我们关注病症 病理 手术
We focus on disease and pathology and surgery
以及药理学
and pharmacology.
我们却忘了人本身
We miss the human being.
我们没有了解这个
How can we treat this
又怎么能治疗呢?
without understanding this?
我们只关注医疗
We do things to this;
但我们需要对人本身做些事情
we need to do things for this.
医疗保健的三个目标是:
The triple aim of healthcare:
一 改善病人体验
one, improve patient experience.
二 改善人民健康
Two, improve the population health.
三 减少周期性的人均消费
Three, decrease per capita expenditure across a continuum.
我们的临终关怀团队
Our group, palliative care,
在2012年服务了病得最重的人——
in 2012, working with the sickest of the sick —
癌症患者
cancer,
心脏病患者 肺部疾病患者
heart disease, lung disease,
肾脏疾病患者
renal disease,
痴呆症患者
dementia —
我们如何改善病人体验的呢?
how did we improve patient experience?
“我想待在家里 医生”
“I want to be at home, Doc.”
“可以 我们会上门治疗”
“OK, we’ll bring the care to you.”
生活提高了
Quality of life, enhanced.
想想人类本身
Think about the human being.
二 人群健康
Two: population health.
我们是怎样从新的角度看待这类人群
How did we look at this population differently,
怎样更深入地和他们打交道
and engage with them at a different level, a deeper level,
怎样了解比原有更多的病况的呢?
and connect to a broader sense of the human condition than my own?
我们是怎样管理这类人群
How do we manage this group,
从而使我们的病人
so that of our outpatient population,
在2012年 有94%都不需要去医院的呢?
94 percent, in 2012, never had to go to the hospital?
他们不去并不是因为他们不能
Not because they couldn’t.
而是因为他们没有必要
But they didn’t have to.
我们会上门治疗
We brought the care to them.
我们维护了他们的尊严 维持了他们的生活质量
We maintained their value, their quality.
三 人均支出
Number three: per capita expenditures.
对这类人群而言
For this population,
现在是2.3万亿美元 20年后是60%的GDP
that today is 2.3 trillion dollars and in 20 years is 60 percent of the GDP,
我们降低了近70%的医疗保健支出
we reduced health care expenditures by nearly 70 percent.
他们收获了更多符合他们价值观的 他们想要的东西
They got more of what they wanted based on their values,
活得更好 也活得更久
lived better and are living longer,
而且少花了三分之二的钱
for two-thirds less money.
虽然哈罗德的时间是有限的
While Harold’s time was limited,
但临终关怀不是
palliative care’s is not.
临终关怀这一治疗方式从诊断贯穿至生命的终结
Palliative care is a paradigm from diagnosis through the end of life.
日复一日
The hours,
周复一周 月复一月 年复一年
weeks, months, years,
跨过一个周期
across a continuum —
接受或没接受治疗的
with treatment, without treatment.
来认识一下克里斯汀
Meet Christine.
宫颈癌三期
Stage III cervical cancer,
转移性肿瘤开始从她的子宫
so, metastatic cancer that started in her cervix,
蔓延至她的全身
spread throughout her body.
她已经50多岁了而且她还活着
She’s in her 50s and she is living.
这不是关于生命的终结
This is not about end of life,
这关乎生命
this is about life.
这也不是只关乎于老年人
This is not just about the elderly,
而是关乎全人类
this is about people.
这是理查德
This is Richard.
肺癌晚期
End-stage lung disease.
“理查德 你觉得什么东西是神圣的?”
“Richard, what is it that you hold sacred?”
“我的孩子们 我的妻子和我的哈雷”
“My kids, my wife and my Harley.”
(笑声)
(Laughter)
“好吧!
“Alright!
我无法骑哈雷载着你到处去 因为我几乎连自行车都不会骑
I can’t drive you around on it because I can barely pedal a bicycle,
但我们会尽力满足你的心愿的”
but let’s see what we can do.”
理查德找到我
Richard came to me,
他看起来糟透了
and he was in rough shape.
他脑海中有一把微弱的声音 告诉他
He had this little voice telling him
也许他只有几个星期到几个月的时间了
that maybe his time was weeks to months.
于是我们就聊天
And then we just talked.
我倾听 并试图去理解
And I listened and tried to hear —
这是很大的不同
big difference.
听和说要成比例
Use these in proportion to this.
我说 “好的 我们一天一天慢慢来”
I said, “Alright, let’s take it one day at a time,”
就像我们在生命其他篇章中所做的一样
like we do in every other chapter of our life.
我们在理查德平时待的地方见面
And we have met Richard where Richard’s at day-to-day.
和他保持一周一到两次的通话
And it’s a phone call or two a week,
他却在肺癌晚期精神焕发
but he’s thriving in the context of end-stage lung disease.
临终关怀的对象不仅限于老人
Now, palliative medicine is not just for the elderly,
也不仅限于中年人
it is not just for the middle-aged.
它是面向所有人的
It is for everyone.
见见我的朋友乔纳森
Meet my friend Jonathan.
很荣幸今天能邀请到乔纳森和他的父亲来到这里
We have the honor and pleasure of Jonathan and his father joining us here today.
乔纳森20多岁 我在几年前就遇见他了
Jonathan is in his 20s, and I met him several years ago.
他得了转移性睾丸癌
He was dealing with metastatic testicular cancer,
扩散到了他的脑部
spread to his brain.
他中风了
He had a stroke,
他做了脑部手术
he had brain surgery,
放疗 化疗
radiation, chemotherapy.
在见到他和他的家人时
Upon meeting him and his family,
他的骨髓移植还有几个星期
he was a couple of weeks away from a bone marrow transplant,
在沟通中
and in listening and engaging,
他们说 “帮我们理解一下 什么是癌症?”
they said, “Help us understand — what is cancer?”
为什么我们走了这么远 却还一头雾水?
How did we get this far without understanding what we’re dealing with?
我们怎么能在这个阶段
How did we get this far
还让病患还对自己病情一头雾水
without empowering somebody to know what it is they’re dealing with,
还不去深入了解 作为人 他们到底是怎么想的呢?
and then taking the next step and engaging in who they are as human beings
如果不这样 我们怎么知道应该做些什么?
to know if that is what we should do?
谁知道呢 医生对病人做什么都可以
Lord knows we can do any kind of thing to you.
但是我们应该吗?
But should we?
你们可以不相信我
And don’t take my word for it.
但最近所有和临终关怀相关的数据
All the evidence that is related to palliative care these days
都证明了临终关怀能帮助病人活得更好和更久
demonstrates with absolute certainty people live better and live longer.
2010年《新英格兰医学杂志》刊登了一篇意义重大的文章
There was a seminal article out of the New England Journal of Medicine in 2010.
是关于我的朋友兼同事在哈佛大学的一项实验的
A study done at Harvard by friends of mine, colleagues.
在一群肺癌末期患者中
End-stage lung cancer:
一组接受临终关怀
one group with palliative care,
一个对照组不接受
a similar group without.
接受临终关怀的那组 感受到的痛苦更少
The group with palliative care reported less pain,
抑郁也更少
less depression.
对住院治疗的需求也更小
They needed fewer hospitalizations.
女士们先生们
And, ladies and gentlemen,
他们多活了三到六个月
they lived three to six months longer.
如果临终关怀是一种癌症药物
If palliative care were a cancer drug,
地球上的每一位癌症医生都会开这个处方
every cancer doctor on the planet would write a prescription for it.
他们为什么不呢?
Why don’t they?
因为我们这些愚蠢的白大褂医生们
Again, because we goofy, long white-coat physicians
是被训练来治病的
are trained and of the mantra of dealing with this,
而不是救人
not with this.
死亡是一个我们都会碰到的时刻
This is a space that we will all come to at some point.
但今天这个对话不是关于死亡
But this conversation today is not about dying,
而是关于活着
it is about living.
以符合自己价值观的方式活着
Living based on our values,
为我们的信仰而活
what we find sacred
书写自己生活的篇章
and how we want to write the chapters of our lives,
无论这是最后一章
whether it’s the last
还是最后五章
or the last five.
我们知道的是
What we know,
我们已经证明的是
what we have proven,
这种对话今天就需要发生
is that this conversation needs to happen today —
不是下个星期 不是明年
not next week, not next year.
我们今天的生活就已深陷危机
What is at stake is our lives today
还有我们的老年生活
and the lives of us as we get older
和我们孙子和曾孙的生活都面临危机
and the lives of our children and our grandchildren.
不只是在病房里
Not just in that hospital room
或者家里的沙发上
or on the couch at home,
而是随时随地
but everywhere we go and everything we see.
临终关怀才能真正帮助人们
Palliative medicine is the answer to engage with human beings,
改变我们生命最后的旅程
to change the journey that we will all face,
而且是将它改善
and change it for the better.
我的同事们
To my colleagues,
我的病人们
to my patients,
我的政府
to my government,
所有的人类
to all human beings,
我请求你们去主张 呼吁 要求
I ask that we stand and we shout and we demand
获得尽可能好的治疗
the best care possible,
所以我们可以在今天活得更好
so that we can live better today
并确保明天更好的生活
and ensure a better life tomorrow.
我们今天就需要改变
We need to shift today
这样明天才可以生活
so that we can live tomorrow.
非常感谢
Thank you very much.
(掌声)
(Applause)

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视频概述

对于一个垂死的病人来说,困在病房里头,接受药物治疗、手术治疗,这些真的是他们想要的吗?我们应该怎样让接近死亡的人尽可能快乐地离开这个世界?

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视频来源

https://www.youtube.com/watch?v=5qaktKVL_zM

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