What we can do to die well | Timothy Ihrig

翻译人员: Jiani Wu 校对人员: Conway Ye

I am a palliative care physician

我是一名安宁护理医师，

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

今天我想和你们聊聊医疗保健。

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

我和你们谈谈健康和理疗

of the most vulnerable population in our country --

关于我们国家中最脆弱的人群——

those people dealing with the most complex serious health issues.

解决最复杂最严重的健康问题的人们。

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

我也想和你们聊聊经济学，

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

而这两者的交集应该会 让你们感到很恐惧，

it scares the hell out of me.

它已经吓坏我了。

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

我也想和你们谈谈安宁护理：

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

一个基于一类人群价值观念的治疗方法，

Patient-centric care based on their values

基于他们的价值观，以病人为中心，

that helps this population live better and longer.

帮助了这类人群活得更好，更久。

It's a care model that tells the truth

是一个告诉我们事实，

and engages one-on-one

并与病人一对一，

and meets people where they're at.

并于他们实地接触的治疗方式。

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

我将从讲述我第一个病人的故事开始，

It was my first day as a physician,

那是我成为医生的第一天，

with the long white coat ...

穿着白大褂，

I stumbled into the hospital

我走进了医院

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

马上就有一名68岁叫哈罗德的男士，

came to the emergency department.

来到了急诊科。

He had had headaches for about six weeks

他已经头疼了大约六周，

that got worse and worse and worse and worse.

而且变得越来越严重。

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

诊断显示他得了癌症， 已经扩散到大脑。

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

他的主治医师建议我 告诉哈罗德和他的家人

the diagnosis, the prognosis and options of care.

诊断、预后和护理选项。

Five hours into my new career,

在我新事业开始的5小时，

I did the only thing I knew how.

我做了我唯一知道该怎么做的事。

I walked in,

我走进病房，

sat down,

坐了下来，

took Harold's hand,

握住哈罗德的手，

took his wife's hand

拿起他妻子的手，

and just breathed.

接着就只是呼吸，

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

他问 “孩子，不是什么好消息对吧？”

I said, "No."

我说 “是的”

And so we talked and we listened and we shared.

于是我们与对方沟通、倾听和分享。

And after a while I said,

过了一会儿，我问道

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

“哈罗德，对你来说什么是 有意义的事情？

What is it that you hold sacred?"

什么事情你觉得是神圣的？”

And he said,

他说，

"My family."

“我的家人。”

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

“你接下来想做什么？”

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

他拍拍我的膝盖说： “我想去钓鱼。”

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

我说 “这个我知道怎么做。”

Harold went fishing the next day.

第二天哈罗德去钓鱼了。

He died a week later.

一周后他去世。

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

在我在职业生涯中的培训后，

I think back to Harold.

我总回想起哈罗德。

And I think that this is a conversation

我认为这种对话

that happens far too infrequently.

发生得过于频繁。

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

是这种对话导致我们走向了危机，

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

那就是对美国现代生活最大的威胁，

which is health care expenditures.

即医疗保健支出。

So what do we know?

那么我们知道些什么？

We know that this population, the most ill,

我们清楚这群病入膏肓的人

takes up 15 percent of the gross domestic product --

耗费了15%的国内生产总值——

nearly 2.3 trillion dollars.

大约2.3万亿美元。

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

病得最重的15%的人 占用了15%的GDP。

If we extrapolate this out over the next two decades

如果我们以此来推断二十年后，

with the growth of baby boomers,

随着婴儿潮一代人的变老，

at this rate it is 60 percent of the GDP.

这个比率是60%的GDP。

Sixty percent of the gross domestic product

整个美国

60%的国内生产总值

of the United States of America --

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

在那个时候已经和医疗保健关系不大了。

It has to do with a gallon of milk,

它和一加仑牛奶，

with college tuition.

大学学费有关，

It has to do with every thing that we value

它与每一件我们重视的事情，

and every thing that we know presently.

和每一件我们现在已知的事情有关。

It has at stake the free-market economy and capitalism

这和美国岌岌可危的

自由市场经济和资本主义有关。

of the United States of America.

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

让我们忘记那些统计数据一分钟，

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

让我们来谈谈从所有 花出去的钱中得到的价值。

Well, the Dartmouth Atlas, about six years ago,

大概六年前， 达特茅斯阿特拉斯项目，

looked at every dollar spent by Medicare --

查看了医疗保险支出的每一分钱，

generally this population.

通常就是这群人。

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

我们发现那些人均支出最高的病人，

had the highest suffering, pain, depression.

承受着最严重的病痛和绝望，

And, more often than not, they die sooner.

但是他们往往更早离世。

How can this be?

为什么会这样？

We live in the United States,

我们生活在美国，

it has the greatest health care system on the planet.

拥有全球最好的医疗保健系统。

We spend 10 times more on these patients

我们花费在这些病人上的，

than the second-leading country in the world.

比世界第二大国多10倍。

That doesn't make sense.

这不合理。

But what we know is,

但是我们知道的是，

out of the top 50 countries on the planet

在全球前五十拥有

with organized health care systems,

有组织的医疗保健系统的国家中，

we rank 37th.

我们排第三十七位。

Former Eastern Bloc countries and sub-Saharan African countries

原东欧集团国家和 撒哈拉以南非洲国家，

rank higher than us as far as quality and value.

在质量和价值上都比我们排名更高。

Something I experience every day in my practice,

有件事我每天都能在实践中感受到，

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

我也确信这是你们中的 很多人在生命旅程中感受过：

more is not more.

更多不等于更好。

Those individuals who had more tests,

那些做了更多的测试的人，

more bells, more whistles,

更多钟声与哨声，

more chemotherapy, more surgery, more whatever --

做了更多的化疗、更多的手术等等，

the more that we do to someone,

我们对某人做得越多，

it decreases the quality of their life.

他们的生活质量就减少得越多。

And it shortens it, most often.

也常常缩短了他们的生命。

So what are we going to do about this?

那么我们该做些什么呢？

What are we doing about this?

我们该怎么做？

And why is this so?

为什么事情是这样的？

The grim reality, ladies and gentlemen,

严峻的现实是，女士们先生们，

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

我们，整个医疗保健业， 长白大褂的医生们，

are stealing from you.

正在偷取你们的东西。

Stealing from you the opportunity

窃取了你们机会，

to choose how you want to live your lives

自己选择自己的生活，

in the context of whatever disease it is.

不论你们得了什么病。

We focus on disease and pathology and surgery

我们关注病症、病理、手术

and pharmacology.

以及药理学。

We miss the human being.

我们却忘了人本身。

How can we treat this

我们没有了解这个

without understanding this?

又怎么能治疗呢？

We do things to this;

我们对人的疾病做了很多，

we need to do things for this.

但我们需要对人本身做些事情。

The triple aim of healthcare:

医疗保健的三个目标是：

one, improve patient experience.

一，改善病人体验。

Two, improve the population health.

二，改善人民健康。

Three, decrease per capita expenditure across a continuum.

三，减少周期性的人均消费。

Our group, palliative care,

我们的安宁护理团队

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

在2012年研究最严重的病症——

cancer,

癌症，

heart disease, lung disease,

心脏病、肺部疾病，

renal disease,

肾脏疾病，

dementia --

痴呆。

how did we improve patient experience?

我们如何改善病人体验的呢？

"I want to be at home, Doc."

“我想待在家里，医生。”

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

“可以，我们会把治疗带给你。”

Quality of life, enhanced.

生活提高了。

Think about the human being.

想想人类本身。

Two: population health.

二，人群健康。

How did we look at this population differently,

我们怎样不同地看待这类人群，

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

怎样和他们在不同且更深层面打交道，

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

怎样了解比原有更多的病况？

How do we manage this group,

我们怎样管理这类人群，

so that of our outpatient population,

而使我们的病人，

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

94%在2012年不需要去医院？

Not because they couldn't.

并不是因为他们不能，

But they didn't have to.

而是因为他们没有必要。

We brought the care to them.

我们把治疗带去给他们。

We maintained their value, their quality.

我们维持着他们的 价值、他们的生活质量。

Number three: per capita expenditures.

三，人均支出。

For this population,

对这类人群而言，

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

现在是2.3万亿美元， 20年后是60%的GDP。

we reduced health care expenditures by nearly 70 percent.

我们降低了近70%的医疗保健支出。

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

基于他们的价值观，他们收获了更多，

lived better and are living longer,

活得更好，也活得更久，

for two-thirds less money.

只用了三分之一的钱。

While Harold's time was limited,

虽然哈罗德的时间是有限的，

palliative care's is not.

但安宁护理的不是。

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

安宁护理是从诊断到死亡的治疗方式。

The hours,

日复一日，

weeks, months, years,

周复一周，月复一月，年复一年。

across a continuum --

跨过一个周期，

with treatment, without treatment.

接受或没接受治疗的。

Meet Christine.

来认识一下克里斯汀。

Stage III cervical cancer,

宫颈癌三期，

so, metastatic cancer that started in her cervix,

转移性肿瘤开始从她的子宫

spread throughout her body.

蔓延至她的全身

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

她已经50多岁了而且她还活着。

This is not about end of life,

这不是关于生命的终结，

this is about life.

这关乎生命。

This is not just about the elderly,

这也不是只关乎于老年人，

this is about people.

而是关乎全人类。

This is Richard.

这是理查德，

End-stage lung disease.

肺病终末期。

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

“理查德，你觉得 什么东西是神圣的？”

"My kids, my wife and my Harley."

“我的孩子们、 我的妻子和我的哈雷。”

(Laughter)

（笑声）

"Alright!

“好吧！

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

我无法骑哈雷载着你， 因为我几乎不会骑自行车。

but let's see what we can do."

但是我们看看能做什么。”

Richard came to me,

理查德找到我，

and he was in rough shape.

他的身体很疲倦。

He had this little voice telling him

有个微小的声音告诉他

that maybe his time was weeks to months.

也许他只有几个星期 到几个月的时间了。

And then we just talked.

于是我们就聊天，

And I listened and tried to hear --

我倾听，并试图去理解，

big difference.

这是很大的不同，

Use these in proportion to this.

听和说要成比例。

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

我说， “好的，一天一天地过。”

like we do in every other chapter of our life.

像我们在生命其他篇章中做的一样。

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

我们见到了理查德平常的样子，

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

一周一到两次的通话，

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

他却在肺病终末期的情况下精神焕发。

Now, palliative medicine is not just for the elderly,

现在安宁护理已经不仅限于老人，

it is not just for the middle-aged.

也不仅限于中年人。

It is for everyone.

这适合所有人。

Meet my friend Jonathan.

见见我的朋友乔纳森。

We have the honor and pleasure

我们很荣幸和快乐，

of Jonathan and his father joining us here today.

乔纳森和他的父亲今天也在场。

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

乔纳森20多岁， 我在几年前就遇见他了。

He was dealing with metastatic testicular cancer,

他得了转移性睾丸癌，

spread to his brain.

扩散到了他的脑部。

He had a stroke,

他中风了，

he had brain surgery,

他做了脑部手术，

radiation, chemotherapy.

放疗、化疗。

Upon meeting him and his family,

在见到他和他的家人时，

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

他的骨髓移植还有几个星期，

and in listening and engaging,

他认真地听着，

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

他们说， “帮帮我们理解，什么是癌症？”

How did we get this far

我们是怎么走到这步

without understanding what we're dealing with?

却并不了解我们在和什么打交道的？

How did we get this far without empowering somebody

我们是怎么走到这步却不授予

to know what it is they're dealing with,

人们对病情的知情权，

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

然后采取下一个步骤， 让他们知道作为人类他们是谁

to know if that is what we should do?

并知道他们该做什么？

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

上帝知道我们能对你做任何事情。

But should we?

但是我们应该吗？

And don't take my word for it.

不要相信我的话。

All the evidence that is related to palliative care these days

最近所有和安宁护理相关的证据

demonstrates with absolute certainty people live better and live longer.

论证了人们绝对活得更好和更久。

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

一篇在“新英格兰医学杂志”上的 开创性的文章，

in 2010.

在2012年。

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

一项我的朋友同事在哈佛大学的实验，

End-stage lung cancer:

肺病终末期，

one group with palliative care,

一组做安宁护理，

a similar group without.

一个对照组不做。

The group with palliative care reported less pain,

做了安宁护理的那组 报告了更少的痛苦，

less depression.

更少的抑郁。

They needed fewer hospitalizations.

他们需要较少的住院治疗，

And, ladies and gentlemen,

女士们先生们，

they lived three to six months longer.

他们多活了三到六个月。

If palliative care were a cancer drug,

如果安宁护理是一种癌症药物，

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

地球上的每一位 癌症医生都会开这个处方。

Why don't they?

他们为什么不呢？

Again, because we goofy, long white-coat physicians

因为我们这些愚蠢的白大褂医生们

are trained and of the mantra of dealing with this,

是被训练来治病的，

not with this.

而不是救人。

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

这是一个我们都会碰到的时刻。

But this conversation today is not about dying,

但今天这个对话不是关于死亡，

it is about living.

而是关于活着。

Living based on our values,

活着为了价值观和我们珍惜的东西，

what we find sacred

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

和我们想如何去书写人生篇章，

whether it's the last

无论这是最后一篇，

or the last five.

或者最后五篇。

What we know,

我们知道的是，

what we have proven,

我们已经证明的是，

is that this conversation needs to happen today --

这种对话今天就需要发生，

not next week, not next year.

不是下个星期，不是明年

What is at stake is our lives today

面临危机的的是我们现在的生活，

and the lives of us as we get older

我们老了以后的生活，

and the lives of our children and our grandchildren.

和我们孙子和曾孙的生活。

Not just in that hospital room

不只是在病房里，

or on the couch at home,

或者家里的沙发上，

but everywhere we go and everything we see.

而是我们遇见的所有地方和事情。

Palliative medicine is the answer to engage with human beings,

安宁护理是与人类接触，

to change the journey that we will all face,

改变我们都会面临的旅程，

and change it for the better.

并把它变得更美好的答案，

To my colleagues,

向我的同事们，

to my patients,

我的病人们，

to my government,

我的政府，

to all human beings,

所有的人类，

I ask that we stand and we shout and we demand

我请求你们去主张、呼吁、要求

the best care possible,

尽可能的最好的治疗，

so that we can live better today

所以我们可以在今天活得更好

and ensure a better life tomorrow.

并确保明天更好的生活。

We need to shift today

我们需要改变今天，

so that we can live tomorrow.

所以我们才可以生活在明天。

Thank you very much.

非常感谢。

(Applause)

（掌声）