Peter Saul: Let's talk about dying

Translator: Joseph Geni Reviewer: Morton Bast

譯者: Ho-chung Chou 審譯者: FU SHIUNG KE

Look, I had second thoughts, really,

各位，我本來還在猶豫

about whether I could talk about this

該不該跟你們這些

to such a vital and alive audience as you guys.

充滿活力與精力的觀眾討論這件事

Then I remembered the quote from Gloria Steinem,

然後我想到Gloria Steinem說過的話

which goes,

她說：

"The truth will set you free,

"真相能讓你自由，

but first it will piss you off." (Laughter)

但是你會先被惹毛。"（笑聲）

So -- (Laughter)

所以．．．（笑聲）

So with that in mind, I'm going to set about

這句話我銘記在心，所以等一下我要做的

trying to do those things here,

就是遵循這個忠告，

and talk about dying in the 21st century.

然後談論21世紀對死亡的看法

Now the first thing that will piss you off, undoubtedly,

無庸置疑，現在第一個讓你們不爽的事情就是

is that all of us are, in fact, going to die

即使已到了21世紀

in the 21st century.

我們所有人還是難逃一死

There will be no exceptions to that.

沒有人能例外

There are, apparently, about one in eight of you

根據統計，你們之中大概每八個就有一個

who think you're immortal, on surveys, but --

認為自己是不死之身，但是．．．

(Laughter)

(笑聲)

Unfortunately, that isn't going to happen.

很抱歉，沒這種事

While I give this talk, in the next 10 minutes,

接下來我在演講的這十分鐘內

a hundred million of my cells will die,

我體內的細胞會死掉一億個

and over the course of today, 2,000 of my brain cells

今天一整天下來，我的腦細胞

will die and never come back,

會死掉兩千個，而且不會再復活

so you could argue that the dying process

所以我們可以這樣說，死亡的過程

starts pretty early in the piece.

很早就開始了

Anyway, the second thing I want to say about dying in the

總之，關於21世紀對死亡的看法

21st century, apart from it's going to happen to everybody,

我要說的第二件事是， 除了所有人都難逃一死之外

is it's shaping up to be a bit of a train wreck

就是死亡對於我們大多數的人而言，有點像是

for most of us,

火車事故

unless we do something to try and reclaim this process

除非我們試圖改變現況而有所作為

from the rather inexorable trajectory that it's currently on.

讓火車離開這條直直朝災難而去的軌道

So there you go. That's the truth.

你們看。這就是真相

No doubt that will piss you off, and now let's see

難怪你會被惹毛，接下來我們來看看

whether we can set you free. I don't promise anything.

你能不能獲得自由。這我可不敢保證

Now, as you heard in the intro, I work in intensive care,

好，你們剛剛在簡介裡聽到了，我在加護病房工作

and I think I've kind of lived through the heyday

而且我經歷過加護病房的全盛時期

of intensive care. It's been a ride, man.

說真的，那很不得了

This has been fantastic.

那種感覺很棒

We have machines that go ping.

我們有鏗鏘作響的機器

There's many of them up there.

照片裡面就有一堆

And we have some wizard technology which I think

我們也有傑出的技術，我認為

has worked really well, and over the course of the time

那些技術的效果很好，我在加護病房

I've worked in intensive care, the death rate

工作的那段時間，澳洲男性的

for males in Australia has halved,

死亡率降了一半

and intensive care has had something to do with that.

這有些要歸功於加護病房

Certainly, a lot of the technologies that we use

當然，很多我們採用的科技

have got something to do with that.

都有助於降低死亡率

So we have had tremendous success, and we kind of

也因此我們的成就相當可觀

got caught up in our own success quite a bit,

而且我們也沉浸在成功的喜悅之中

and we started using expressions like "lifesaving."

然後我們開始使用 “拯救生命” 這種字眼

I really apologize to everybody for doing that,

為此，我必須跟各位道歉

because obviously, we don't.

因為我們根本沒有 “拯救生命”

What we do is prolong people's lives,

我們只是延長人們的壽命

and delay death,

延遲死亡的到來

and redirect death, but we can't, strictly speaking,

避開死亡這個結局，但嚴格說來，我們辦不到

save lives on any sort of permanent basis.

我們無法違背這些恆久不變的原則，拯救生命

And what's really happened over the period of time

而事實上這段期間發生的事

that I've been working in intensive care is that

也就是我在加護病房工作的時候

the people whose lives we started saving back in the '70s,

當初我們在70、80和90年代所拯救的性命

'80s, and '90s, are now coming to die in the 21st century

到了21世紀都一一離開人世了

of diseases that we no longer have the answers to

一些疾病讓我們束手無策

in quite the way we did then.

無法像以前一樣醫治他們

So what's happening now is there's been a big shift

所以現況是，人們的死亡方式

in the way that people die,

產生了極大的轉變

and most of what they're dying of now isn't as amenable

80、90年代時，大多數病患的死因

to what we can do as what it used to be like

我們都還能掌控

when I was doing this in the '80s and '90s.

但是現在我們卻束手無策

So we kind of got a bit caught up with this,

可以說我們陷入困境了

and we haven't really squared with you guys about

而且對於現在發生的事

what's really happening now, and it's about time we did.

我們之間還沒取得共識，不過現在是好時機

I kind of woke up to this bit in the late '90s

90年代末期，我遇到了這個人

when I met this guy.

他讓我有了這種想法

This guy is called Jim, Jim Smith, and he looked like this.

他叫Jim，Jim Smith，這是他的照片

I was called down to the ward to see him.

我被叫去病房看他

His is the little hand.

這隻小手是他的

I was called down to the ward to see him

是一名呼吸科醫生

by a respiratory physician.

叫我去病房看他的

He said, "Look, there's a guy down here.

他說：“聽我說，樓下有個

He's got pneumonia,

得了肺炎的人

and he looks like he needs intensive care.

看起來應該需要特別的監護

His daughter's here and she wants everything possible

他的女兒在這裡，她希望我們

to be done."

盡全力照顧他”

Which is a familiar phrase to us.

這句話聽起來很耳熟

So I go down to the ward and see Jim,

所以我到樓下的病房看Jim

and his skin his translucent like this.

他的皮膚像這樣，是半透明的

You can see his bones through the skin.

你可以看到皮膚底下的骨頭

He's very, very thin,

他非常非常瘦

and he is, indeed, very sick with pneumonia,

當然，他也被肺炎折磨得很慘

and he's too sick to talk to me,

虛弱到連跟我說話的力氣都沒有

so I talk to his daughter Kathleen, and I say to her,

所以我跟她的女兒Kathleen說，我對她說

"Did you and Jim ever talk about

“妳和Jim有沒有聊過

what you would want done

如果他就這樣過世

if he ended up in this kind of situation?"

妳會怎麼處裡嗎？”

And she looked at me and said, "No, of course not!"

然後她看著我，她說：“沒有，當然沒有！”

I thought, "Okay. Take this steady."

我心想：“好吧。別刺激她。”

And I got talking to her, and after a while, she said to me,

然後我跟她聊了這件事，過了一會兒，她跟我說

"You know, we always thought there'd be time."

“你知道嗎，我們都一直以為還有時間。”

Jim was 94. (Laughter)

Jim已經94歲了。（笑聲）

And I realized that something wasn't happening here.

然後我才發現，有些事情並沒有實現

There wasn't this dialogue going on

如果我想像的事情實現了

that I imagined was happening.

我們就不會有這種對話了

So a group of us started doing survey work,

所以我們的團隊開始著手考察

and we looked at four and a half thousand nursing home

然後我們仔細研究了4500間的看護之家

residents in Newcastle, in the Newcastle area,

位於Newcastle的，Newcastle地區的

and discovered that only one in a hundred of them

然後發現他們只有百分之一

had a plan about what to do when their hearts stopped beating.

有針對病患的心跳停止後的應變計畫

One in a hundred.

百分之一

And only one in 500 of them had plan about what to do

他們之中只有五百分之一 有針對病情惡化的

if they became seriously ill.

應變計畫

And I realized, of course, this dialogue

然後我才了解，當然啦

is definitely not occurring in the public at large.

這種話題是不會在公開場合討論的

Now, I work in acute care.

我現在在重症病房工作

This is John Hunter Hospital.

這間是John Hunter醫院

And I thought, surely, we do better than that.

然後我想，對啊，我們的作法比較完善

So a colleague of mine from nursing called Lisa Shaw and I

所以我看護所的同事Lias Shaw和我

went through hundreds and hundreds of sets of notes

仔細研究了成千上萬份的紀錄

in the medical records department

收在醫療紀錄部裡面的

looking at whether there was any sign at all

我們想找出任何蛛絲馬跡

that anybody had had any conversation about

到底有沒有人曾經討論過

what might happen to them if the treatment they were

萬一他們正在進行的那些療程一直沒有效果

receiving was unsuccessful to the point that they would die.

而病人也只剩一口氣了，要怎麼辦？

And we didn't find a single record of any preference

但是這麼多份醫生或病患的紀錄裡

about goals, treatments or outcomes from any

關於這些情況的治療目標，治療方式或結果

of the sets of notes initiated by a doctor or by a patient.

卻連一項都沒有提到

So we started to realize

因此我們才了解

that we had a problem,

我們有問題

and the problem is more serious because of this.

而這個問題之所以那麼嚴重，是因為

What we know is that obviously we are all going to die,

我們都很清楚，人遲早一死

but how we die is actually really important,

而死因為何，對我們真的非常重要

obviously not just to us, but also to how that

不僅對我們很重要，對所有曾目睹死亡

features in the lives of all the people who live on afterwards.

的在世者而言，這種形象也非常重要

How we die lives on in the minds of everybody

我們死亡的形象，仍然存活在所有

who survives us, and

在世者的心中

the stress created in families by dying is enormous,

而目睹死亡會對家人產生極大的壓力

and in fact you get seven times as much stress by dying

事實上，處以重症看護的彌留病患

in intensive care as by dying just about anywhere else,

承受的壓力是其他環境的七倍之多

so dying in intensive care is not your top option

所以死於重症看護並不是你的最佳選擇

if you've got a choice.

如果你有選擇餘地的話

And, if that wasn't bad enough, of course,

當然，如果你覺得這樣還不夠慘

all of this is rapidly progressing towards the fact that

所有我們採取的作法都讓情況急速惡化了

many of you, in fact, about one in 10 of you at this point,

目前，你們會有很多人，事實上是十分之一

will die in intensive care.

死於重症看護

In the U.S., it's one in five.

在美國，比例是五分之一

In Miami, it's three out of five people die in intensive care.

在邁阿密，有五分之三的人死於重症看護

So this is the sort of momentum

所以這就是我們

that we've got at the moment.

現在所處的態勢

The reason why this is all happening is due to this,

這就是這些事情會發生的原因

and I do have to take you through what this is about.

所以我必須帶你們深入探討這件事

These are the four ways to go.

我們有四個選擇

So one of these will happen to all of us.

我們會遇上其中一項

The ones you may know most about are the ones

你們最熟悉的那個死因

that are becoming increasingly of historical interest:

也是醫療界越來越多人研究的

sudden death.

猝死

It's quite likely in an audience this size

如果以現場觀眾人數的比例而言

this won't happen to anybody here.

你們當中不會有人猝死

Sudden death has become very rare.

猝死變得相當罕見

The death of Little Nell and Cordelia and all that sort of stuff

類似Little Nell和Cordelia的死因

just doesn't happen anymore.

再也沒出現過了

The dying process of those with terminal illness

我們剛剛看到的，罹患這種極嚴重病症的

that we've just seen

死亡過程

occurs to younger people.

發生在年紀比較輕的人身上

By the time you've reached 80, this is unlikely to happen to you.

等你活到80歲的時候，這種事不太可能發生在你身上

Only one in 10 people who are over 80 will die of cancer.

超過80歲的人，只有十分之一死於癌症

The big growth industry are these.

比例大幅攀升的是這塊區域

What you die of is increasing organ failure,

你的死因是器官逐漸衰竭

with your respiratory, cardiac, renal,

呼吸系統，心臟病，腎臟

whatever organs packing up. Each of these

隨便哪個器官都行。每一個症狀都是

would be an admission to an acute care hospital,

你進入醫院加護病房的通行證

at the end of which, or at some point during which,

到了最後，或是這期間的某個時刻

somebody says, enough is enough, and we stop.

有人會說，我受夠了，到此為止

And this one's the biggest growth industry of all,

這是攀升幅度最大的區塊

and at least six out of 10 of the people in this room

今天現場的人，至少有十分之六

will die in this form, which is

會有這種死法，那就是

the dwindling of capacity

體力越來越差

with increasing frailty,

身體越來越虛弱

and frailty's an inevitable part of aging,

而虛弱是不可逆轉的老化過程

and increasing frailty is in fact the main thing

其實，日漸衰敗的身體才是

that people die of now,

現代人最主要的死因

and the last few years, or the last year of your life

最後那幾年，或是說你生命中最後那幾年

is spent with a great deal of disability, unfortunately.

都困在重度失能的狀態，這很可悲

Enjoying it so far? (Laughs)

目前為止還不錯吧 (笑聲)

(Laughter)

(笑聲)

Sorry, I just feel such a, I feel such a Cassandra here.

不好意思，我只是覺得，我覺得現在變 Cassandra (希臘神話報噩耗的預言家)了

(Laughter)

(笑聲)

What can I say that's positive? What's positive is

這怎麼能稱上得上是件好事？這種好事是指

that this is happening at very great age, now.

在現代社會，這發生在很老很老的人身上

We are all, most of us, living to reach this point.

我們都能，我們大多數都能，活到那種歲數

You know, historically, we didn't do that.

你知道嗎，根據歷史紀載，我們以前沒辦法

This is what happens to you

當你活了一大把歲數

when you live to be a great age,

這種事就會發生在你身上

and unfortunately, increasing longevity does mean

不幸的是，平均壽命增加表示的是

more old age, not more youth.

老人會越來越多，不是年輕人

I'm sorry to say that. (Laughter)

很遺憾宣佈這種消息 (笑聲)

What we did, anyway, look, what we did,

總之，我們以前的做法，注意，我們以前的做法

we didn't just take this lying down

我們以前不會束手待斃

at John Hunter Hospital and elsewhere.

不管是在John Hunter醫院或是任何地方

We've started a whole series of projects

我們推行了一連串的計畫

to try and look about whether we could, in fact, involve

試著找出我們是否能做些甚麼，其實

people much more in the way that things happen to them.

這些嘗試涉及的人更多，包括那些不久於人世的

But we realized, of course, that we are dealing

但是我們明白，當然，我們處裡的是

with cultural issues,

文化上的爭議

and this is, I love this Klimt painting,

還有這個，我喜歡這幅Klimt的畫

because the more you look at it, the more you kind of get

因為你們思考得越多，你們應該就越能了解

the whole issue that's going on here,

今天主要的議題是甚麼

which is clearly the separation of death from the living,

在生與死之間，畫出一條清晰的界線

and the fear — Like, if you actually look,

還有恐懼 - 比如說，如果你仔細看

there's one woman there

畫裡有個女人

who has her eyes open.

她的眼睛是張開的

She's the one he's looking at,

他在看的就是她

and [she's] the one he's coming for. Can you see that?

他就是為她而來的。你們看到沒有？

She looks terrified.

她的樣子嚇呆了

It's an amazing picture.

這幅畫很不可思議

Anyway, we had a major cultural issue.

總之，以前我們最常遇見的文化爭議

Clearly, people didn't want us to talk about death,

顯然就是，沒有人想跟我們談論死亡

or, we thought that.

或許是我們的誤解

So with loads of funding from the Federal Government

所以聯邦政府撥出了一堆基金

and the local Health Service, we introduced a thing

在地的健康機構也是，我們跟你們介紹

at John Hunter called Respecting Patient Choices.

John Hunter醫院稱之為 “病患選擇優先權”

We trained hundreds of people to go to the wards

我們訓練了好幾百人，走進病房

and talk to people about the fact that they would die,

告訴他們，其實他們來日不多了

and what would they prefer under those circumstances.

然後問他們，事到如今，他們的想法是甚麼

They loved it. The families and the patients, they loved it.

他們喜歡這種做法。病人和家屬，他們都喜歡

Ninety-eight percent of people really thought

百分之九十八的人認為

this just should have been normal practice,

這應該納入例行手續

and that this is how things should work.

本來就應該這樣做

And when they expressed wishes,

他們表達意願之後

all of those wishes came true, as it were.

這些願望都實現了，都比照辦理

We were able to make that happen for them.

我們曾經有能力幫他們達成

But then, when the funding ran out,

但是，基金用完了

we went back to look six months later,

六個月之後，我們回去看的時後

and everybody had stopped again,

所有人又回歸起點

and nobody was having these conversations anymore.

再也沒人討論這些問題了

So that was really kind of heartbreaking for us,

所以我們真的覺得很失望

because we thought this was going to really take off.

因為我們以為這件事已經上了軌道

The cultural issue had reasserted itself.

文化爭議再次現身聲明立場

So here's the pitch:

我的想法是：

I think it's important that we don't just get on this freeway

在一路衝進加護病房之前，我們應該要仔細思考

to ICU without thinking hard about whether or not

到底有沒有這個必要，讓每個人都以這種方式結束生命

that's where we all want to end up,

我認為這很重要

particularly as we become older and increasingly frail

尤其是當我們老的時候，越來越虛弱

and ICU has less and less and less to offer us.

而加護病房能幫到我們的地方越來越少

There has to be a little side road

對於那些不想走這條路的人

off there for people who don't want to go on that track.

我們必須再開一條小路給他們選

And I have one small idea,

對於未來可能發生的事

and one big idea about what could happen.

我有兩個見解，一大一小

And this is the small idea.

這是比較簡單的作法

The small idea is, let's all of us

簡單的做法是，因為Jason

engage more with this in the way that Jason has illustrated.

為我們指出了方向，所以我們都應該投入這場戰役

Why can't we have these kinds of conversations

我們為什麼不能和自己的長輩

with our own elders

那些大限將至的人

and people who might be approaching this?

討論這些問題？

There are a couple of things you can do.

有兩件事你們都做得到

One of them is, you can,

第一件事是，你們可以

just ask this simple question. This question never fails.

問個簡單的問題。這個問題每試必靈

"In the event that you became too sick to speak for yourself,

" 萬一你虛弱到連話都說不出來，

who would you like to speak for you?"

你希望誰幫你說話？"

That's a really important question to ask people,

提出這個問題真的很重要

because giving people the control over who that is

因為如此能讓人們獲得自我的控制權

produces an amazing outcome.

產生的效果非常驚人

The second thing you can say is,

第二件事，你們可以問：

"Have you spoken to that person

" 你有沒有跟那個人說過

about the things that are important to you

對你而言很重要的事？

so that we've got a better idea of what it is we can do?"

這樣我們才能更了解你，提供幫助會更有效。"

So that's the little idea.

這是從小處看的見解

The big idea, I think, is more political.

從大處來看，我覺得，要從政治著手

I think we have to get onto this.

我認為我們必須開始行動

I suggested we should have Occupy Death.

我建議我們應該攻佔死亡 (死星)

(Laughter)

(笑聲)

My wife said, "Yeah, right, sit-ins in the mortuary.

我老婆說: " 是啊，沒錯，在太平間靜坐抗議

Yeah, yeah. Sure." (Laughter)

是啊，是啊。當然啦。" (笑聲)

So that one didn't really run,

所以這想法沒有真的執行

but I was very struck by this.

但是這真的啟發了我

Now, I'm an aging hippie.

現在，我是個老嬉皮了

I don't know, I don't think I look like that anymore, but

我不知道，我覺得自己不像從前那樣了，可是

I had, two of my kids were born at home in the '80s

我有兩個在自家接生，80年代的小孩

when home birth was a big thing, and we baby boomers

那時候自家接生是件大事，我們是嬰兒潮世代

are used to taking charge of the situation,

對這種情況已經駕輕就熟了

so if you just replace all these words of birth,

如果你試試，把"生產"換成其他字

I like "Peace, Love, Natural Death" as an option.

我喜歡選 “和平，愛，自然死”

I do think we have to get political

我真的認為我們應該推動政策

and start to reclaim this process from

然後針對現行的醫療模式

the medicalized model in which it's going.

著手開始進行改造

Now, listen, that sounds like a pitch for euthanasia.

現在，注意，這些話很像是對安樂死的訴求

I want to make it absolutely crystal clear to you all,

我要完全明確地告訴你們

I hate euthanasia. I think it's a sideshow.

我討厭安樂死。我認為那是無聊的把戲

I don't think euthanasia matters.

我不認為安樂死有用

I actually think that,

我真的這樣想

in places like Oregon,

像是Oregon (美國州名) 這種地方

where you can have physician-assisted suicide,

你可以請醫生幫你自殺

you take a poisonous dose of stuff,

你喝下一劑有毒的東西

only half a percent of people ever do that.

只有百分之零點五的人這樣做

I'm more interested in what happens to the 99.5 percent

我對另外百分之九十九點五的人比較有興趣

of people who don't want to do that.

那些不想這樣做的人

I think most people don't want to be dead,

我認為大多數的人都不想死

but I do think most people want to have some control

但我認為大多數的人都想要控制

over how their dying process proceeds.

自己的死亡過程

So I'm an opponent of euthanasia,

所以我反對安樂死

but I do think we have to give people back some control.

但是我認為我們應該要還一些控制權給人們

It deprives euthanasia of its oxygen supply.

如此一來，安樂死就沒有容身之處了

I think we should be looking at stopping

我認為我們的焦點應該是

the want for euthanasia,

研究如何停止人們對於安樂死的需要

not for making it illegal or legal or worrying about it at all.

至於它合不合法，這問題我們根本不用去擔心

This is a quote from Dame Cicely Saunders,

這是Dame Cicely Saunders說過的話

whom I met when I was a medical student.

我還是醫學院讀書的時候遇到她

She founded the hospice movement.

她創辦了安寧照顧基金會

And she said, "You matter because you are,

然後她說，"你很重要，因為你就是你

and you matter to the last moment of your life."

你的生命直到最後一刻都很重要。"

And I firmly believe that

我堅決相信這一點

that's the message that we have to carry forward.

這就是我們要傳遞下去的訊息

Thank you. (Applause)

謝謝大家 (掌聲)