Look, I had second thoughts, really, about whether I could talk about this to such a vital and alive audience as you guys. Then I remembered the quote from Gloria Steinem, which goes, "The truth will set you free, but first it will piss you off." (Laughter) So -- (Laughter)
Dengar, saya sungguh berpikir kembali tentang bisakah saya membicarakan ini kepada kalian semua, yang sangat bersemangat dan hidup. Lalu saya teringat kutipan dari Gloria Steinem, yang berbunyi, "Kebenaran akan membebaskanmu, tapi sebelumnya ia membuatmu kesal dulu." (Tawa) Jadi -- (Tawa)
So with that in mind, I'm going to set about trying to do those things here, and talk about dying in the 21st century. Now the first thing that will piss you off, undoubtedly, is that all of us are, in fact, going to die in the 21st century. There will be no exceptions to that. There are, apparently, about one in eight of you who think you're immortal, on surveys, but -- (Laughter) Unfortunately, that isn't going to happen.
Dengan mengingat itu, saya akan mencoba melakukan hal itu di sini, dan membicarakan kematian di abad ke-21. Hal pertama yang akan membuat Anda kesal adalah fakta bahwa kita semua akan mati di abad ke-21. Takkan ada pengecualian untuk itu. Rupanya, ada satu dari delapan orang dari kalian yang mengira dirinya abadi, menurut survei, tapi -- (Tawa) Sayangnya, itu tidak akan terjadi.
While I give this talk, in the next 10 minutes, a hundred million of my cells will die, and over the course of today, 2,000 of my brain cells will die and never come back, so you could argue that the dying process starts pretty early in the piece.
Selama berbicara, 10 menit ke dapan, 100 juta sel saya akan mati, dan sepanjang hari ini, 2.000 sel otak saya akan mati dan tak pernah kembali, jadi bisa dikatakan proses sekarat dimulai cukup awal.
Anyway, the second thing I want to say about dying in the 21st century, apart from it's going to happen to everybody, is it's shaping up to be a bit of a train wreck for most of us, unless we do something to try and reclaim this process from the rather inexorable trajectory that it's currently on.
Hal kedua mengenai kematian di abad ke-21, selain ia akan dialami semua orang, ialah ia sedikit mirip kecelakaan kereta api bagi sebagian besar kita, kecuali kita mencoba dan merebut kembali proses ini dari lintasan yang agak tak terhindarkan yang tengah berlangsung ini.
So there you go. That's the truth. No doubt that will piss you off, and now let's see whether we can set you free. I don't promise anything. Now, as you heard in the intro, I work in intensive care, and I think I've kind of lived through the heyday of intensive care. It's been a ride, man. This has been fantastic. We have machines that go ping. There's many of them up there. And we have some wizard technology which I think has worked really well, and over the course of the time I've worked in intensive care, the death rate for males in Australia has halved, and intensive care has had something to do with that. Certainly, a lot of the technologies that we use have got something to do with that.
Jadi begitu. Itulah kebenarannya. Anda pasti kesal, tapi lihatlah apa kami bisa membebaskan Anda. Saya tak menjanjikan apapun. Saya bekerja di unit perawatan intensif, dan saya pikir saya telah melewati masa kejayaan perawatan intensif. Jalan berliku, kawan. Pengalaman fantastis. Ada mesin berbunyi ping. Ada banyak mesin itu di sana. Kami punya beberapa teknologi penyihir yang menurut saya telah bekerja dengan sangat baik, dan sepanjang masa kerja saya di UGD, angka kematian laki-laki di Australia telah berkurang separuh, dan ICU berhubungan dengan itu. Tentu, banyak teknologi yang kami gunakan juga berhubungan dengan itu.
So we have had tremendous success, and we kind of got caught up in our own success quite a bit, and we started using expressions like "lifesaving." I really apologize to everybody for doing that, because obviously, we don't. What we do is prolong people's lives, and delay death, and redirect death, but we can't, strictly speaking, save lives on any sort of permanent basis.
Kami mencapai kesuksesan luar biasa, dan kami agak terjebak dalam kesuksesan kami sendiri, sampai kami mulai menggunakan istilah "menyelamatkan nyawa". Sungguh, maafkan kami karena nyatanya kami tak melakukannya. Yang kami lakukan ialah memperpanjang hidup seseorang, dan menunda kematian, dan mengalihkan kematian, tapi kami tak bisa, tegasnya, menyelamatkan nyawa secara permanen.
And what's really happened over the period of time that I've been working in intensive care is that the people whose lives we started saving back in the '70s, '80s, and '90s, are now coming to die in the 21st century of diseases that we no longer have the answers to in quite the way we did then.
Apa yang terjadi selama periode waktu saya bekerja di unit perawatan intensif ialah orang-orang yang hidupnya mulai kami selamatkan di tahun 70-an, '80-an, dan '90-an, kini akan mati di abad ke-21 oleh penyakit yang kita tak lagi punya jawabannya seperti waktu dulu.
So what's happening now is there's been a big shift in the way that people die, and most of what they're dying of now isn't as amenable to what we can do as what it used to be like when I was doing this in the '80s and '90s.
Saat ini ada perubahan besar dalam cara seseorang mati, dan penyebab kematiannya kini sering tak sejalan dengan apa yang bisa kami lakukan seperti dulu saat saya bekerja di tahun 80-an dan 90-an.
So we kind of got a bit caught up with this, and we haven't really squared with you guys about what's really happening now, and it's about time we did. I kind of woke up to this bit in the late '90s when I met this guy. This guy is called Jim, Jim Smith, and he looked like this. I was called down to the ward to see him. His is the little hand. I was called down to the ward to see him by a respiratory physician. He said, "Look, there's a guy down here. He's got pneumonia, and he looks like he needs intensive care. His daughter's here and she wants everything possible to be done." Which is a familiar phrase to us. So I go down to the ward and see Jim, and his skin his translucent like this. You can see his bones through the skin. He's very, very thin, and he is, indeed, very sick with pneumonia, and he's too sick to talk to me, so I talk to his daughter Kathleen, and I say to her, "Did you and Jim ever talk about what you would want done if he ended up in this kind of situation?" And she looked at me and said, "No, of course not!" I thought, "Okay. Take this steady." And I got talking to her, and after a while, she said to me, "You know, we always thought there'd be time."
Jadi kami agak terjebak dengannya, dan kami belum benar-benar jujur dengan kalian tentang apa yang sungguh terjadi kini, dan sudah saatnya kami melakukannya. Saya agak terbangun di bagian ini di akhir tahun 90-an ketika saya bertemu pria ini. Pria ini bernama Jim, Jim Smith, dan dia terlihat seperti ini. Saya dipanggil ke bangsal untuk menemuinya. Dia yang tangannya kecil. Saya diminta menemui Jim oleh dokter respirologi. Dokter berkata, “Ada seorang pria di sini. Dia sakit radang paru-paru, dan sepertinya dia butuh perawatan intensif. Putrinya di sini dan dia ingin segalanya bisa dilakukan.” Ungkapan yang akrab di telinga kami. Saya pergi ke bangsal menemui Jim, kulitnya tembus cahaya seperti ini. Anda bisa melihat tulangnya melalui kulit. Dia kurus sekali, dan dia jelas sakit radang paru-paru. Dia terlalu sakit untuk bicara, jadi saya bicara dengan putrinya Kathleen, dan saya katakan padanya, “Apakah kamu dan Jim pernah berbicara tentang apa yang ingin kamu lakukan jika dia berakhir di situasi seperti ini?" Dan Kathleen menatap saya dan berkata, "Tidak, tentu saja tidak!" Saya berpikir, "Baiklah. Pelan-pelan." Saya berbicara dengannya, dan tak lama, dia berkata, "Anda tahu, kami selalu berpikir waktunya akan tiba."
Jim was 94. (Laughter) And I realized that something wasn't happening here. There wasn't this dialogue going on that I imagined was happening. So a group of us started doing survey work, and we looked at four and a half thousand nursing home residents in Newcastle, in the Newcastle area, and discovered that only one in a hundred of them had a plan about what to do when their hearts stopped beating. One in a hundred. And only one in 500 of them had plan about what to do if they became seriously ill. And I realized, of course, this dialogue is definitely not occurring in the public at large.
Jim berusia 94 tahun. (Tawa) Dan saya sadar bahwa sesuatu tidak terjadi di sini. Tak ada dialog yang terjadi seperti yang saya bayangkan tengah terjadi. Jadi sekelompok dari kami mulai melakukan survei, dan kami meneliti di 4.500 panti jompo yang ada di Newcastle, di daerah Newcastle, dan menemukan bahwa hanya satu dari 100 pasien yang merencanakan apa yang harus dilakukan saat jantung mereka berhenti berdetak. Satu dari seratus. Dan hanya satu dari 500 pasien yang merencanakan apa yang harus dilakukan jika mereka sakit parah. Dan saya sadar, tentu saja, dialog ini pasti tidak terjadi di masyarakat luas.
Now, I work in acute care. This is John Hunter Hospital. And I thought, surely, we do better than that. So a colleague of mine from nursing called Lisa Shaw and I went through hundreds and hundreds of sets of notes in the medical records department looking at whether there was any sign at all that anybody had had any conversation about what might happen to them if the treatment they were receiving was unsuccessful to the point that they would die. And we didn't find a single record of any preference about goals, treatments or outcomes from any of the sets of notes initiated by a doctor or by a patient.
Kini saya bekerja di perawatan akut. Ini Rumah Sakit John Hunter. Dan saya pikir, tentunya, kami melakukan lebih baik dari itu. Jadi, kolega saya dari keperawatan bernama Lisa Shaw dan saya membaca ratusan set catatan di departemen rekam medis melihat apakah ada tanda sama sekali bahwa seseorang pernah membicarakan tentang apa yang bisa terjadi pada mereka jika perawatan yang mereka terima tak berhasil hingga mereka akan mati. Dan kami tak menemukan satu pun catatan preferensi tentang tujuan, perawatan, atau hasil dari kumpulan catatan mana pun yang diprakarsai oleh dokter atau pasien.
So we started to realize that we had a problem, and the problem is more serious because of this.
Jadi kami mulai sadar bahwa kami memiliki masalah, dan masalahnya lebih serius karena hal ini.
What we know is that obviously we are all going to die, but how we die is actually really important, obviously not just to us, but also to how that features in the lives of all the people who live on afterwards. How we die lives on in the minds of everybody who survives us, and the stress created in families by dying is enormous, and in fact you get seven times as much stress by dying in intensive care as by dying just about anywhere else, so dying in intensive care is not your top option if you've got a choice.
Yang kita tahu ialah kita semua jelas akan mati, tapi bagaimana kita mati sebenarnya sangat penting, jelas bukan hanya bagi kita, tapi juga bagi bagaimana kematian itu memengaruhi mereka yang hidup sesudah kita. Cara kita meninggal hidup di benak semua orang yang kita tinggalkan, dan stres yang diciptakan di keluarga karena kematian sangat besar. Faktanya stress Anda 7 kali lebih banyak karena kematian di ICU dibanding meninggal di tempat lain, jadi meninggal di ICU bukanlah pilihan utama Anda jika Anda punya pilihan.
And, if that wasn't bad enough, of course, all of this is rapidly progressing towards the fact that many of you, in fact, about one in 10 of you at this point, will die in intensive care. In the U.S., it's one in five. In Miami, it's three out of five people die in intensive care. So this is the sort of momentum that we've got at the moment.
Dan, jika itu tak cukup buruk, tentu saja, semua ini berkembang pesat menuju fakta bahwa faktanya, sekitar 1 dari 10 orang saat ini, akan meninggal di UGD. Di AS, angkanya 1 dari 5. Di Miami, 3 dari 5 orang meninggal di ICU. Jadi inilah momentum yang kita miliki saat ini.
The reason why this is all happening is due to this, and I do have to take you through what this is about. These are the four ways to go. So one of these will happen to all of us. The ones you may know most about are the ones that are becoming increasingly of historical interest: sudden death. It's quite likely in an audience this size this won't happen to anybody here. Sudden death has become very rare. The death of Little Nell and Cordelia and all that sort of stuff just doesn't happen anymore. The dying process of those with terminal illness that we've just seen occurs to younger people. By the time you've reached 80, this is unlikely to happen to you. Only one in 10 people who are over 80 will die of cancer.
Alasan mengapa ini semua terjadi adalah karena ini, dan saya akan menerangkan. Ada empat cara untuk meninggal. Jadi salah satu darinya akan terjadi pada kita semua. Yang mungkin paling Anda ketahui ialah yang semakin menarik minat sejarah: kematian mendadak. Di acara sebesar ini mati mendadak takkan terjadi pada siapa pun di sini. Kematian mendadak kini langka. Kematian Little Nell dan Cordelia dan semacamnya sudah tidak terjadi lagi. Proses kematian mereka yang sakit parah yang kita lihat terjadi pada orang lebih muda. Di usia 80 tahun, jarang hal ini terjadi pada Anda. Hanya 1 dari 10 orang usia 80 ke atas yang akan meninggal karena kanker.
The big growth industry are these. What you die of is increasing organ failure, with your respiratory, cardiac, renal, whatever organs packing up. Each of these would be an admission to an acute care hospital, at the end of which, or at some point during which, somebody says, enough is enough, and we stop.
Industri pertumbuhan besarnya adalah ini. Alasan kematian Anda ialah meningkatnya kegagalan organ, dengan pernapasan, jantung, ginjal, organ apapun. Setiap mereka akan memasuki perawatan akut rumah sakit, yang akhirnya, atau di titik tertentu, seseorang berkata, cukup sudah, kita hentikan.
And this one's the biggest growth industry of all, and at least six out of 10 of the people in this room will die in this form, which is the dwindling of capacity with increasing frailty, and frailty's an inevitable part of aging, and increasing frailty is in fact the main thing that people die of now, and the last few years, or the last year of your life is spent with a great deal of disability, unfortunately.
Inilah industri dengan pertumbuhan terbesar, dan setidaknya 6 dari 10 orang di ruangan ini akan mati dalam bentuk ini, yaitu berkurangnya kapasitas secara perlahan, dengan meningkatnya kelemahan, dan kelemahan tak terelakkan dari penuaan, dan meningkatnya kelemahan adalah penyebab utama kini seseorang meninggal. Satu atau beberapa tahun terakhir hidup Anda dihabiskan dengan banyak kekurangan jasmani, sayangnya.
Enjoying it so far? (Laughs) (Laughter) Sorry, I just feel such a, I feel such a Cassandra here. (Laughter)
Menikmatinya sejauh ini? (Tertawa) (Tawa) Maaf, saya hanya merasa, saya merasa seperti Cassandra di sini. (Tawa)
What can I say that's positive? What's positive is that this is happening at very great age, now. We are all, most of us, living to reach this point. You know, historically, we didn't do that. This is what happens to you when you live to be a great age, and unfortunately, increasing longevity does mean more old age, not more youth. I'm sorry to say that. (Laughter) What we did, anyway, look, what we did, we didn't just take this lying down at John Hunter Hospital and elsewhere. We've started a whole series of projects to try and look about whether we could, in fact, involve people much more in the way that things happen to them. But we realized, of course, that we are dealing with cultural issues, and this is, I love this Klimt painting, because the more you look at it, the more you kind of get the whole issue that's going on here, which is clearly the separation of death from the living, and the fear — Like, if you actually look, there's one woman there who has her eyes open. She's the one he's looking at, and [she's] the one he's coming for. Can you see that? She looks terrified. It's an amazing picture.
Apa sisi positifnya? Sisi positifnya ini terjadi di usia sangat tua. Kita semua, kebanyakan, hidup untuk mencapai titik ini. Secara historis, kita tak mencapainya. Inilah yang terjadi pada Anda ketika umur Anda panjang sekali, sayangnya, berumur lebih panjang berarti lebih banyak usia tua, bukan lebih muda. Maaf saya mengatakannya. (Tawa) Yang kami lakukan, kami tak terapkan hanya di Rumah Sakit John Hunter. Kami memulai serangkaian proyek demi mencoba melihat apakah kami sungguh bisa melibatkan orang-orang terkait hal-hal yang terjadi pada diri mereka. Tapi kami berurusan dengan masalah budaya, dan ini, saya suka lukisan Klimt ini, makin dilihat, makin banyak Anda mengerti seluruh masalah yang terjadi di sini, yang jelas menjadi pemisahan kematian dari yang hidup, dan rasa takut — Jika cermat dilihat, ada satu wanita di sana yang matanya terbuka. Dialah yang ditatap kematian, dan wanita itu yang kematian cari. Bisakah Anda melihatnya? Dia terlihat ketakutan. Ini gambar yang menakjubkan.
Anyway, we had a major cultural issue. Clearly, people didn't want us to talk about death, or, we thought that. So with loads of funding from the Federal Government and the local Health Service, we introduced a thing at John Hunter called Respecting Patient Choices. We trained hundreds of people to go to the wards and talk to people about the fact that they would die, and what would they prefer under those circumstances. They loved it. The families and the patients, they loved it. Ninety-eight percent of people really thought this just should have been normal practice, and that this is how things should work. And when they expressed wishes, all of those wishes came true, as it were. We were able to make that happen for them. But then, when the funding ran out, we went back to look six months later, and everybody had stopped again, and nobody was having these conversations anymore. So that was really kind of heartbreaking for us, because we thought this was going to really take off. The cultural issue had reasserted itself.
Jadi, kita punya masalah budaya yang besar. Orang tak ingin kami membicarakan kematian, atau, kami pikir begitu. Dengan dana dari Pemerintah Federal serta Layanan Kesehatan setempat, di John Hunter dikenalkan program Menghormati Pilihan Pasien. Kami melatih ratusan orang untuk pergi ke bangsal dan mendiskusikan kematian pada pasien yang akan mendekatinya, serta keinginan mereka dalam keadaan seperti itu. Mereka menyukainya. Keluarga dan pasien, mereka menyukainya. 98% orang sungguh berpikir seharusnya ini praktik normal, dan begitu cara kerjanya. Dan saat mereka mengungkapkan keinginan, semua keinginan itu seolah jadi kenyataan. Kami mampu mewujudkannya untuk mereka. Tapi kemudian, ketika dana habis, kami kembali menengok 6 bulan kemudian, dan semua orang berhenti lagi, dan tak ada yang melakukan percakapan ini lagi. Jadi itu sungguh memilukan bagi kami, karena kami pikir ini akan benar-benar ditinggalkan. Masalah budaya telah menegaskan dirinya kembali.
So here's the pitch: I think it's important that we don't just get on this freeway to ICU without thinking hard about whether or not that's where we all want to end up, particularly as we become older and increasingly frail and ICU has less and less and less to offer us. There has to be a little side road off there for people who don't want to go on that track. And I have one small idea, and one big idea about what could happen.
Jadi inilah puncaknya: saya pikir penting bagi kita untuk tidak langsung masuk ke ICU tanpa berpikir keras tentang iya atau tidak di sana kita mau berakhir, terutama saat kita jadi semakin tua dan lemah dan makin sedikit yang bisa ICU tawarkan pada kita. Harus ada jalan samping kecil di luar sana bagi seseorang yang tak ingin pergi ke jalur itu. Dan saya punya satu ide kecil, dan satu ide besar tentang apa yang bisa terjadi.
And this is the small idea. The small idea is, let's all of us engage more with this in the way that Jason has illustrated. Why can't we have these kinds of conversations with our own elders and people who might be approaching this? There are a couple of things you can do. One of them is, you can, just ask this simple question. This question never fails. "In the event that you became too sick to speak for yourself, who would you like to speak for you?" That's a really important question to ask people, because giving people the control over who that is produces an amazing outcome. The second thing you can say is, "Have you spoken to that person about the things that are important to you so that we've got a better idea of what it is we can do?" So that's the little idea.
Dan ini ide kecilnya. Ide kecilnya adalah, mari kita semua terlibat lebih banyak dengan cara yang telah diilustrasikan oleh Jason. Mengapa kita tak bisa membicarakan ini dengan orang tua sendiri dan orang-orang yang mungkin mendekati kematian? Ada beberapa yang bisa Anda lakukan. Salah satunya adalah, Anda bisa, mengajukan pertanyaan sederhana yang tak pernah gagal ini. "Jika Anda menjadi terlalu sakit untuk berbicara sendiri, siapa yang Anda ingin bisa mewakili Anda?" Pertanyaan itu penting untuk ditanyakan, sebab memberi mereka kendali siapa orangnya memberikan hasil yang luar biasa. Pertanyaan kedua, "Sudahkah Anda bicara padanya tentang hal-hal yang penting bagi Anda supaya kami lebih paham mengenai apa yang bisa kami lakukan?" Jadi itulah ide kecilnya.
The big idea, I think, is more political. I think we have to get onto this. I suggested we should have Occupy Death. (Laughter) My wife said, "Yeah, right, sit-ins in the mortuary. Yeah, yeah. Sure." (Laughter) So that one didn't really run, but I was very struck by this. Now, I'm an aging hippie. I don't know, I don't think I look like that anymore, but I had, two of my kids were born at home in the '80s when home birth was a big thing, and we baby boomers are used to taking charge of the situation, so if you just replace all these words of birth, I like "Peace, Love, Natural Death" as an option. I do think we have to get political and start to reclaim this process from the medicalized model in which it's going.
Gagasan besarnya lebih politis. Saya pikir kita harus membahas ini. Saya sarankan kita menduduki kematian. (Tawa) Istri saya berkata, "Ya, benar, duduk di kamar mayat. Ya, ya. Tentu." (Tawa) Rasanya tak masuk akal, tapi saya terkejut karenanya. Kini, saya <i>hippie </i>yang menua. Entahlah, rasanya saya tak terlihat begitu lagi, tapi ada 2 anak saya yang lahir di rumah di tahun 80-an masa itu melahirkan di rumah adalah hal besar, dan kami <i>baby boomer</i> terbiasa mengambil alih situasi, jadi jika Anda hanya mengganti semua kata kelahiran ini, Saya suka "Damai, Cinta, Kematian Alami" sebagai pilihan. Saya pikir kita harus berpolitik dan mulai merebut kembali proses ini dari model medis di mana pun itu terjadi.
Now, listen, that sounds like a pitch for euthanasia. I want to make it absolutely crystal clear to you all, I hate euthanasia. I think it's a sideshow. I don't think euthanasia matters. I actually think that, in places like Oregon, where you can have physician-assisted suicide, you take a poisonous dose of stuff, only half a percent of people ever do that. I'm more interested in what happens to the 99.5 percent of people who don't want to do that. I think most people don't want to be dead, but I do think most people want to have some control over how their dying process proceeds. So I'm an opponent of euthanasia, but I do think we have to give people back some control. It deprives euthanasia of its oxygen supply. I think we should be looking at stopping the want for euthanasia, not for making it illegal or legal or worrying about it at all.
Kedengarannya seperti memilih eutanasia. Saya ingin mempertegas pada Anda semua, saya benci eutanasia. Saya pikir ia pengalihan isu. Saya tidak merasa eutanasia penting. Sesungguhnya saya pikir, di tempat-tempat seperti Oregon, di mana Anda bisa melakukan bunuh diri dengan bantuan dokter, Anda mengambil dosis racun, hanya 0,5% orang yang pernah melakukan. Saya lebih tertarik dengan apa yang terjadi pada 99,5% orang-orang yang tak mau melakukannya. Saya pikir kebanyakan orang tak ingin mati, tapi saya pikir mereka ingin punya kendali atas bagaimana proses kematian mereka berlangsung. Saya menentang eutanasia, tapi saya kira kita harus berikan orang-orang kendali. Kendali mencabut euthanasia dari pasokan oksigennya. Kita harus hentikan keinginan untuk eutanasia, bukan untuk membuatnya ilegal atau legal atau mencemaskannya sama sekali.
This is a quote from Dame Cicely Saunders, whom I met when I was a medical student. She founded the hospice movement. And she said, "You matter because you are, and you matter to the last moment of your life." And I firmly believe that that's the message that we have to carry forward. Thank you. (Applause)
Ini kutipan dari Dame Cicely Saunders, saya menemuinya saat saya mahasiswa kedokteran. Dia mendirikan gerakan hospis. Dia berkata, “Anda penting karena Anda penting, dan Anda penting sampai saat terakhir hidup Anda." Dengan kuat saya meyakini itulah pesan yang harus kita teruskan. Terima kasih. (Tepuk tangan)