What we can do to die well | Timothy Ihrig

Prevodilac: Ivana Krivokuća Lektor: Tijana Mihajlović

I am a palliative care physician

Ja sam lekar palijativne nege

and I would like to talk to you today about health care.

i hteo bih da danas razgovaram sa vama o zdravstvenoj zaštiti.

I'd like to talk to you about the health and care

Hteo bih da razgovaram sa vama o zdravlju i nezi

of the most vulnerable population in our country --

najranjivijeg stanovništva naše zemlje -

those people dealing with the most complex serious health issues.

ljudi koji se suočavaju sa najsloženijim ozbiljnim zdravstvenim problemima.

I'd like to talk to you about economics as well.

Takođe bih hteo da razgovaramo o ekonomiji.

And the intersection of these two should scare the hell out of you --

Ukrštanje ta dva bi trebalo da vas užasno plaši.

it scares the hell out of me.

Mene strašno plaši.

I'd also like to talk to you about palliative medicine:

Takođe bih voleo da govorimo o palijativnoj medicini,

a paradigm of care for this population, grounded in what they value.

o paradigmi nege za ovu populaciju, utemeljenoj u onome u šta oni veruju,

Patient-centric care based on their values

o nezi orijentisanoj na pacijenta zasnovanoj na njegovim vrednostima

that helps this population live better and longer.

koja pomaže da ova populacija živi bolje i duže.

It's a care model that tells the truth

To je model nege koji govori istinu,

and engages one-on-one

angažuje se jedan na jedan

and meets people where they're at.

i izlazi u susret ljudima tamo gde se nalaze.

I'd like to start by telling the story of my very first patient.

Hteo bih da započnem tako što ću ispričati priču o svom prvom pacijentu.

It was my first day as a physician,

Bio je to moj prvi dan kao lekara,

with the long white coat ...

sa dugačkim belim mantilom.

I stumbled into the hospital

Doteturao sam se u bolnicu

and right away there's a gentleman, Harold, 68 years old,

i odmah je tu bio gospodin, Herold, od 68 godina,

came to the emergency department.

koji je došao u hitnu službu.

Imao je glavobolje oko šest nedelja

He had had headaches for about six weeks

koje su se sve više pogoršavale.

that got worse and worse and worse and worse.

Evaluation revealed he had cancer that had spread to his brain.

Pregled je otkrio da ima rak koji se proširio na njegov mozak.

The attending physician directed me to go share with Harold and his family

Nadležni lekar me je uputio da sa Haroldom i njegovom porodicom podelim

the diagnosis, the prognosis and options of care.

djagnozu, prognozu i opcije za negu.

Five hours into my new career,

Pet sati od ulaska u novu karijeru,

I did the only thing I knew how.

uradio sam jedino što sam umeo.

I walked in,

Ušao sam,

sat down,

seo,

took Harold's hand,

uzeo Haroldovu ruku,

took his wife's hand

uzeo ruku njegove žene

and just breathed.

i samo sam disao.

He said, "It's not good news is it, sonny?"

Rekao je: „Nisu dobre vesti, zar ne, sine?“

I said, "No."

Odgovorio sam: „Ne.“

And so we talked and we listened and we shared.

Tako smo pričali, slušali i razmenjivali.

And after a while I said,

Nakon izvesnog vremena sam upitao:

"Harold, what is it that has meaning to you?

„Harolde, šta je to što za tebe ima smisla?

What is it that you hold sacred?"

Šta smatraš za svetinju?“

And he said,

Odgovorio je:

"My family."

„Moju porodicu.“

I said, "What do you want to do?"

Upitao sam: „Šta želiš da radiš?“

He slapped me on the knee and said, "I want to go fishing."

Potapšao me je po kolenu i rekao: „Želim da idem na pecanje.“

I said, "That, I know how to do."

Uzvratio sam: „To znam kako da ostvarim.“

Harold went fishing the next day.

Harold je otišao na pecanje narednog dana.

He died a week later.

Preminuo je nedelju dana kasnije.

As I've gone through my training in my career,

Dok sam nastavljao sa obukom u svojoj karijeri,

I think back to Harold.

osvrtao sam se na Harolda.

And I think that this is a conversation

Mislim da je ovo razgovor

that happens far too infrequently.

koji se dešava previše retko.

And it's a conversation that had led us to crisis,

To je razgovor koji nas je doveo do krize,

to the biggest threat to the American way of life today,

do najveće pretnje američkom načinu života danas,

which is health care expenditures.

a to su troškovi zdravstvene zaštite.

So what do we know?

Šta je to što znamo?

We know that this population, the most ill,

Znamo da na ovu populaciju najbolesnijih

takes up 15 percent of the gross domestic product --

odlazi 15 odsto bruto domaćeg proizvoda,

nearly 2.3 trillion dollars.

skoro 2,3 biliona dolara.

So the sickest 15 percent take up 15 percent of the GDP.

Dakle, na najbolesnijih 15 procenata odlazi 15 posto BDP.

If we extrapolate this out over the next two decades

Ako to prenesemo na sledeće dve decenije

with the growth of baby boomers,

sa porastom bejbi bum generacije,

at this rate it is 60 percent of the GDP.

ovom stopom, to je 60 posto BDP-a.

Sixty percent of the gross domestic product

Šezdeset odsto bruto domaćeg proizvoda

of the United States of America --

Sjedinjenih Američkih Država -

to u tom trenutku ima vrlo malo veze sa zdravstvenom zaštitom.

it has very little to do with health care at that point.

It has to do with a gallon of milk,

Ima veze sa litrom mleka,

with college tuition.

sa školarinom za fakultet.

It has to do with every thing that we value

Ima veze sa svime što cenimo

i svačim za šta trenutno znamo.

and every thing that we know presently.

It has at stake the free-market economy and capitalism

Stavlja na kocku ekonomiju slobodnog tržišta i kapitalizam

of the United States of America.

Sjedinjenih Američkih Država.

Let's forget all the statistics for a minute, forget the numbers.

Zaboravimo sve statističke podatke na trenutak, zaboravimo brojeve.

Let's talk about the value we get for all these dollars we spend.

Hajde da razgovaramo o vrednosti koju dobijamo za dolare koje potrošimo.

Well, the Dartmouth Atlas, about six years ago,

Pa, projekat Darmut Atlas je, pre oko šest godina,

looked at every dollar spent by Medicare --

razmotrio svaki dolar koji je potrošilo osiguranje Mediker

generally this population.

uopšte na ovu populaciju.

We found that those patients who have the highest per capita expenditures

Otkrili smo da su ti pacijenti koji imaju najveće izdatke po glavi stanovnika

had the highest suffering, pain, depression.

prolaze kroz najviše patnje, bolova i depresije.

And, more often than not, they die sooner.

Takođe, u većem broju slučajeva, oni umiru ranije.

How can this be?

Kako je to moguće?

We live in the United States,

Živimo u Sjedinjenim Državama

it has the greatest health care system on the planet.

koje imaju najbolji sistem zdravstvene zaštite na planeti.

We spend 10 times more on these patients

Trošimo 10 puta više na te pacijente

than the second-leading country in the world.

od druge po redu vodeće zemlje sveta.

That doesn't make sense.

To nema nikakvog smisla.

But what we know is,

Međutim, ono što znamo je da,

out of the top 50 countries on the planet

od 50 zemalja na planeti koje su u vrhu

with organized health care systems,

po organizovanim sistemima zdravstvene zaštite,

we rank 37th.

nalazimo se na 37. mestu.

Zemlje bivšeg Istočnog bloka i zemlje podsaharske Afrike

Former Eastern Bloc countries and sub-Saharan African countries

rank higher than us as far as quality and value.

imaju bolji rang od nas u pogledu kvaliteta i vrednosti.

Something I experience every day in my practice,

Nešto što doživljavam svakog dana u svojoj praksi,

and I'm sure, something many of you on your own journeys have experienced:

a siguran sam da su to mnogi od vas iskusili na svojim putovanjima -

more is not more.

dodatno ne znači više.

Those individuals who had more tests,

Ti pojedinci koji su imali dodatne testove,

more bells, more whistles,

dodatne skupe naprave,

more chemotherapy, more surgery, more whatever --

dodatne hemoterapije, operacije, šta god -

the more that we do to someone,

što više uradimo nekome,

it decreases the quality of their life.

to umanjuje kvalitet njegovog života

And it shortens it, most often.

i najčešće ga skraćuje.

So what are we going to do about this?

Pa, šta ćemo preduzeti po tom pitanju?

What are we doing about this?

Šta radimo u vezi sa ovim?

And why is this so?

Zašto je to tako?

The grim reality, ladies and gentlemen,

Surova realnost, dame i gospodo,

je da mi, industrija zdravstvene zaštite - lekari u dugim belim mantilima -

is that we, the health care industry -- long white-coat physicians --

are stealing from you.

krademo od vas.

Stealing from you the opportunity

Krademo od vas mogućnost

to choose how you want to live your lives

da odaberete kako želite da provedete svoje živote

in the context of whatever disease it is.

u kontekstu bolesti koja je u pitanju.

We focus on disease and pathology and surgery

Usmereni smo na bolest, patologiju, hirurgiju

and pharmacology.

i farmakologiju.

We miss the human being.

Propuštamo ljudsko biće.

How can we treat this

Kako možemo lečiti ovo

without understanding this?

bez razumevanja ovoga?

We do things to this;

Radimo stvari ovome;

we need to do things for this.

treba da radimo stvari za ovo.

The triple aim of healthcare:

Trostruki cilj zdravstvene zaštite -

one, improve patient experience.

prvo, poboljšati iskustvo pacijenta.

Two, improve the population health.

Drugo, poboljšati zdravlje populacije.

Three, decrease per capita expenditure across a continuum.

Treće, smanjiti potrošnju po glavi stanovnika duž kontinuuma.

Our group, palliative care,

Naša grupa, palijativna nega,

in 2012, working with the sickest of the sick --

2012. godine, kroz rad sa najbolesnijima među bolesnicima -

cancer,

rak,

heart disease, lung disease,

bolesti srca i pluća,

renal disease,

bubrežne bolesti,

dementia --

demencija -

how did we improve patient experience?

kako smo poboljšali iskustvo pacijenta?

„Želim da budem kod kuće, doktore.“

"I want to be at home, Doc."

"OK, we'll bring the care to you."

„U redu, dovešćemo negu kod vas.“

Quality of life, enhanced.

Kvalitet života je poboljšan.

Think about the human being.

Razmislite o ljudskom biću.

Two: population health.

Pod dva - zdravlje populacije.

How did we look at this population differently,

Kako smo drugačije sagledavali ovu populaciju,

and engage with them at a different level, a deeper level,

angažovali se oko njih na drugačijem, dubljem nivou,

and connect to a broader sense of the human condition than my own?

i povezali se u širem smislu ljudskog stanja od sopstvenog?

How do we manage this group,

Kako rukovodimo ovom grupom,

so that of our outpatient population,

pa od naše populacije na vanbolničkom lečenju

94 percent, in 2012, never had to go to the hospital?

94 posto njih 2012. godine uopšte nije moralo da ide u bolnicu?

Not because they couldn't.

Ne zato što nisu mogli,

But they didn't have to.

već nisu morali da idu.

We brought the care to them.

Doveli smo negu kod njih.

We maintained their value, their quality.

Sačuvali smo njihove vrednosti, njihov kvalitet.

Number three: per capita expenditures.

Broj tri - izdaci po glavi stanovnika.

For this population,

Kod ove populacije

that today is 2.3 trillion dollars and in 20 years is 60 percent of the GDP,

na koju danas odlazi 2,3 biliona dolara, a za 20 godina 60 odsto BDP-a,

we reduced health care expenditures by nearly 70 percent.

umanjili smo troškove zdravstvene zaštite za gotovo 70 procenata.

They got more of what they wanted based on their values,

Dobili su više od onoga što su hteli na osnovu svojih vrednosti,

lived better and are living longer,

živeli su bolje i duže,

for two-thirds less money.

za dve trećine manje novca.

While Harold's time was limited,

Dok je Haroldovo vreme bilo ograničeno,

palliative care's is not.

vreme palijativne nege to nije.

Palliative care is a paradigm from diagnosis through the end of life.

Palijativna nega je paradigma od postavljanja dijagnoze do kraja života.

The hours,

Sati,

weeks, months, years,

nedelje, meseci, godine,

across a continuum --

duž kontinuuma -

with treatment, without treatment.

sa lečenjem, bez lečenja.

Meet Christine.

Upoznajte Kristinu.

Stage III cervical cancer,

Treći stadijum raka grlića materice

so, metastatic cancer that started in her cervix,

dakle, metastatski rak koji je otpočeo u grliću materice

spread throughout her body.

proširio se kroz njeno telo.

She's in her 50s and she is living.

U pedesetim je godinama i živi.

This is not about end of life,

Ovde se ne radi o kraju života,

this is about life.

već o životu.

This is not just about the elderly,

Ne radi se samo o starijima,

this is about people.

radi se o ljudima.

This is Richard.

Ovo je Ričard.

End-stage lung disease.

Krajnji stadijum bolesti pluća.

"Richard, what is it that you hold sacred?"

„Ričarde, šta je to što smatraš svetinjom?“

"My kids, my wife and my Harley."

„Moja deca, žena i moj Harli.“

(Laughter)

(Smeh)

"Alright!

„U redu!

I can't drive you around on it because I can barely pedal a bicycle,

Ne mogu da vas vozim unaokolo na njemu jer jedva da umem da vozim bicikl,

but let's see what we can do."

ali hajde da vidimo šta možemo.“

Richard came to me,

Ričard je došao kod mene

and he was in rough shape.

i bio je u teškom stanju.

He had this little voice telling him

Mali glas u njemu mu je govorio

da možda njegovo vreme dolazi za nekoliko nedelja ili meseci.

that maybe his time was weeks to months.

And then we just talked.

Zatim smo samo pričali.

And I listened and tried to hear --

Ja sam slušao i pokušavao da čujem;

big difference.

velika razlika.

Use these in proportion to this.

Koristite ovo srazmerno ovome.

I said, "Alright, let's take it one day at a time,"

Rekao sam: „U redu, hajde da se bavimo ovim dan za danom“,

like we do in every other chapter of our life.

kao što to radimo u svakom drugoj oblasti života.

And we have met Richard where Richard's at day-to-day.

Izlazili smo u susret Ričardu tamo gde se on nalazio iz dana u dan.

And it's a phone call or two a week,

U pitanju je jedan ili dva telefonska poziva nedeljno,

but he's thriving in the context of end-stage lung disease.

ali on napreduje u kontekstu krajnjeg stadijuma bolesti pluća.

Now, palliative medicine is not just for the elderly,

Palijativna medicina nije samo za starije osobe,

it is not just for the middle-aged.

niti je samo za osobe srednjih godina.

It is for everyone.

Ona je za svakog.

Meet my friend Jonathan.

Upoznajte mog prijatelja Džonatana.

We have the honor and pleasure

Imamo čast i zadovoljstvo

da su nam se Džonatan i njegov otac danas pridružili ovde.

of Jonathan and his father joining us here today.

Jonathan is in his 20s, and I met him several years ago.

Džonatan je u svojim dvadesetim i upoznao sam ga pre nekoliko godina.

He was dealing with metastatic testicular cancer,

Borio se sa metastatskim rakom testisa

spread to his brain.

koji se proširio na njegov mozak.

He had a stroke,

Doživeo je šlog,

he had brain surgery,

imao je operaciju na mozgu,

radiation, chemotherapy.

radijaciju, hemoterapiju.

Upon meeting him and his family,

Po mom upoznavanju sa njim i njegovom porodicom,

he was a couple of weeks away from a bone marrow transplant,

imao je par nedelja do transplantacije koštane srži,

and in listening and engaging,

a tokom slušanja i uključenosti,

they said, "Help us understand -- what is cancer?"

rekli su: „Pomozite nam da razumemo - šta je to rak?“

How did we get this far

Kako smo dospeli tako daleko

without understanding what we're dealing with?

bez razumevanja o tome sa čim imamo posla?

How did we get this far without empowering somebody

Kako smo dospeli toliko daleko bez osnaživanja osobe

to know what it is they're dealing with,

da zna sa čime se suočava,

and then taking the next step and engaging in who they are as human beings

a zatim preduzimanja sledećeg koraka i bavljenja time ko je kao ljudsko biće

to know if that is what we should do?

tako da znamo da li je to ono što treba da radimo?

Lord knows we can do any kind of thing to you.

Sam bog zna da možemo da vam svašta uradimo.

But should we?

Ipak, da li bi trebalo?

And don't take my word for it.

Nemojte mi verovati na reč.

All the evidence that is related to palliative care these days

Svi dokazi u poslednje vreme vezani za palijativnu negu

demonstrates with absolute certainty people live better and live longer.

pokazuju sa apsolutnom sigurnošću da ljudi žive bolje i duže.

There was a seminal article out of the New England Journal of Medicine

Bio je jedan plodonosni članak u Medicinskom časopisu Nove Engleske

in 2010.

iz 2010. godine.

A study done at Harvard by friends of mine, colleagues.

Studija koju su na Harvardu sproveli moji prijatelji, kolege.

End-stage lung cancer:

Krajnji stadijum raka pluća -

one group with palliative care,

jedna grupa sa palijativnom negom,

a similar group without.

slična grupa bez nje.

The group with palliative care reported less pain,

Grupa sa palijativnom negom je saopštavala da ima manje bolova,

less depression.

manje depresije.

They needed fewer hospitalizations.

Ređe im je bila potrebna hospitalizacija.

And, ladies and gentlemen,

Takođe, dame i gospodo,

they lived three to six months longer.

živeli su tri do šest meseci duže.

If palliative care were a cancer drug,

Kada bi palijativna nega bila lek protiv raka,

every cancer doctor on the planet would write a prescription for it.

svaki doktor za rak na planeti bi propisivao recepte za nju.

Why don't they?

Zašto to ne rade?

Again, because we goofy, long white-coat physicians

Još jednom, zato što smo mi, smešni lekari u dugim belim mantilima,

are trained and of the mantra of dealing with this,

obrazovani i imamo mantru za bavljenje ovim,

not with this.

a ne ovim.

This is a space that we will all come to at some point.

Ovo je mesto na koje ćemo svi doći u nekom trenutku.

But this conversation today is not about dying,

Međutim, ovaj razgovor danas nije o umiranju,

it is about living.

već o življenju.

O življenju na osnovu naših vrednosti,

Living based on our values,

what we find sacred

onome što smatramo svetim

i načinu na koji želimo da ispišemo poglavlja svog života,

and how we want to write the chapters of our lives,

whether it's the last

bilo da je u pitanju poslednje

or the last five.

ili poslednjih pet.

What we know,

Ono što znamo,

what we have proven,

ono što smo dokazali,

is that this conversation needs to happen today --

jeste da ovaj razgovor mora da se dogodi danas -

not next week, not next year.

ne naredne nedelje, ne naredne godine.

What is at stake is our lives today

U pitanju je naš život danas,

and the lives of us as we get older

naši životi kada ostarimo,

and the lives of our children and our grandchildren.

životi naše dece i naših unuka.

Not just in that hospital room

Ne samo u toj bolničkoj sobi

or on the couch at home,

ili na kauču kod kuće,

but everywhere we go and everything we see.

već gde god da odemo i šta god da vidimo.

Palliative medicine is the answer to engage with human beings,

Palijativna medicina je odgovor za bavljenje ljudskim bićima,

to change the journey that we will all face,

za promenu putovanja sa kojim ćemo se svi suočiti,

and change it for the better.

i to promenu nabolje.

To my colleagues,

Od svojih kolega,

to my patients,

od svojih pacijenata,

to my government,

od svoje vlade,

to all human beings,

od svih ljudskih bića,

I ask that we stand and we shout and we demand

tražim da ustanemo, uzviknemo i zahtevamo

the best care possible,

najbolju moguću negu,

so that we can live better today

tako da možemo da živimo bolje danas

and ensure a better life tomorrow.

i obezbedimo bolji život sutra.

We need to shift today

Moramo da napravimo preokret danas

so that we can live tomorrow.

da bismo mogli da živimo sutra.

Thank you very much.

Hvala vam mnogo.

(Aplauz)

(Applause)