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)
Viete, uvažoval som nad tým, naozaj, či sa mám o tomto rozprávať práve s takými vitálnymi a živými divákmi ako ste vy. Vtedy som si spomenul na citát Glorie Steinem, ktorý znie: "Pravda ťa oslobodí, ale najprv ťa naserie." (smiech) (smiech)
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.
S týmto na vedomí, pokúsim sa urobiť to isté aj tu a porozprávam Vám o zomieraní v 21. storočí. Bezpochyby, prvá vec, ktorá Vás nahnevá je, každý jeden z nás raz zomrie. V skutočnosti, zomrieme v 21. storočí. Každý jeden, bez výnimky. Hoci, podľa ankety, 1 z 8 prítomných si myslí, že je nesmrteľný, ale (smiech) bohužiaľ, to sa nestane.
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.
Počas môjho vystúpenia, počas najbližších 10 minút, zomrie až 100 miliónov buniek v mojom tele. Počas celého dnešného dňa zomrie 2 000 mojich mozgových buniek a už nikdy sa nevrátia. Mohli by ste teda tvrdiť, že proces zomierania začína už na bunkovej úrovni.
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.
Ďalšou vecou, ktorú som chcel povedať o umieraní v 21. storočí je, okrem toho, že sa jej nik z nás nevyhne, bude to trochu pripomínať haváriu vlaku pre väčšinu z nás, ak sa o niečo nepokúsime a presmerujeme ho z jeho terajšej neúprosnej dráhy.
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.
Takto to je, toto je pravda. Niet pochýb, že vás to nepoteší. Teraz sa zamerajme na to, či sa z toho dá nejako oslobodiť. Nič však nesľubujem. Ako ste počuli v úvode, pracujem na intenzívnej starostlivosti a myslím, že som tam zažil skoro všetko. Bola to riadna jazda, verte mi. Bolo to úžasné. Máme prístroje, ktoré cinkajú. Tu ich zopár vidíte. Taktiež máme fascinujúcu techniku, ktoré funguje veľmi dobre. Postupom času, ako pracujem na intenzívnej starostlivosti, úmrtnosť mužov sa v Austrálii znížila na polovicu. Zapríčinila sa o to aj jednotka intenzívnej starostlivosti. Nepochybne, technológie, ktoré využívame tomu veľmi dopomohli.
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.
Zožali sme veľký úspech a trochu sme sa tým nechali uniesť a začali používať výrazy ako "zachrána života". Za toto sa chcem každému ospravedlniť, pretože je zrejmé, že to tak nie je. V skutočnosti predlžujeme ľudské životy, oddiaľujeme smrť, presmerujeme ju. Avšak, presnejšie povedané, nezachraňujeme životy natrvalo.
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.
Čo sa naozaj udialo počas môjho pôsobenia na intenzívnej starostlivosti je, že ľudí, ktorých sme zachránili ešte v 70., 80. a 90. rokoch, zomrú v 21. storočí na choroby, na ktoré už dávno nemáme odpovede tak, ako sme ich vtedy mali.
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.
To, čo sa deje teraz je, že nastala veľká zmena v tom, ako ľudia zomierajú a s tým, na čo dnes umierajú, sa ťažko bojuje a lieči v porovnaní s tým, ako sme to riešili v 80. a 90. rokoch.
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."
Trochu sme sa v tom zamotali ešte sme to s vami neurovnali ohľadom toho, čo sa teraz deje a je najvyšší čas, aby sme to napravili. Ja som si uvedomil na konci 90. rokov, keď som stretol tohto chlapíka. Volal sa Jim, Jim Smith a vyzeral takto. Zavolali ma na oddelenie, aby som sa naňho pozrel. Tá malá ruka je jeho. Na oddelenie, aby som sa naňho pozrel, ma zavolal pľúcny lekár. Povedal: "Pozri, dole je jeden pán, ktorý má zápal pľúc a asi by potreboval intenzívnu starostlivosť." Je tu s ním jeho dcéra a chce, aby sa preňho spravilo všetko, čo sa len dá. Pre nás to je už dobre známa fráza. Zišiel som na oddelenie, aby som sa s ním stretol. Jeho koža bola asi takto priesvitná. Mohli ste vidieť jeho kosti. Bol priveľmi chudý a v skutku, veľmi chorý na zápal pľúc. Až taký chorý, že nevládal rozprávať. Rozprával som sa s jeho dcérou Kathleen a povedal som jej: "Rozprávali ste sa s Jimom niekedy o tom, čo by ste spravili, keby sa dostal do takejto situácie?" Pozrela sa na mňa a odpovedala: "Samozrejme, že nie!" Pomyslel som si, musím byť pokojný. Porozprával som sa s ňou a po chvíli mi povedala: "Viete, vždy sme si mysleli, že máme čas."
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 mal 94 rokov. (smiech) Vtedy som si uvedomil, že tu niečo chýba. Nebol tu ten dialóg, ktorý som si myslel, že bude. Preto skupinka z nás začala pracovať na prieskume. Skúmali sme 4500 opatrovateľských ústavov v meste Newcastle, v jeho okolí a zistili sme, že iba v 1 zo 100 majú plán na riešenie situácie, keď ľudia zomrú. 1 zo 100. A len v 1 z 500 mali plán čo robiť, keď pacienti vážne ochorejú. Uvedomil som si, že tento dialóg sa celkom určite nerozoberá na verejnosti vo veľkosť.
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.
Teraz pracujem na akútnej starostlivosti. Toto je nemocnica Johna Huntera. Pomyslel som si, s istotou, vieme to robiť aj lepšie. Preto moja kolegyňa zo starostlivosti, Lisa Shaw a ja sme prešli stovky a stovky poznámok v oddelení lekárskych záznamov. Zameral som sa na akýkoľvek náznak konverzácie medzi ľuďmi o tom, čo by sa im mohlo stať, keby liečba, ktorú podstupujú nebola účinná a mohli by zomrieť. Nenašli sme ani jednu zmienku o tom, o cieľoch, liečbe alebo závery z iných záznamov, ktoré boli iniciované doktorom alebo pacientom.
So we started to realize that we had a problem, and the problem is more serious because of this.
Začali sme si uvedomovať, že tu máme problém. Problém ktorého závažnosť rastie.
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.
Všetci sme si vedomí toho, že raz zomrieme, ale ako zomrieme, je naozaj veľmi dôležité. Nielen kvôli nám, ale aj kvôli tomu, ako to ovplyvní ľudí z nášho okolia. To, ako zomrieme, zostáva v mysli každého, koho sme opustili a stres, ktorý tým v rodine vzniká, je enormný. V skutočnosti, smrť na intenzívnej starostlivosti spôsobuje 7-krát väčší stres, ako keď smrť nastane hocikde inde. Preto zomrieť na jednotke intenzívnej starostlivosti nie je najlepším výberom, ak si môžete vybrať.
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.
Ako keby to už samo o sebe nebolo zlé, všetko to rýchlo smeruje k tomu, že veľa z vás, vlastne asi 1 z 10 v vás, zomrie na jednotke intenzívnej starostlivosti. V USA je to 1 z 5. V Miami sú to 3 z 5. Toto je asi približne rýchlosť, ktorú tu v tomto smere teraz máme.
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.
Dôvod, prečo sa to deje je práve tento a teraz s vám poviem, o čom to vlastne je. Existujú 4 spôsoby. Jeden sa stane každému z nás. Tie, ktoré asi poznáte, sú tie, ktoré sú zaujímavé z historiského hľadiska: náhla smrť. Je celkom pravdepodobné, že pri publiku takejto veľkosti sa nikomu nič takéto nestane. Náhla smrť sa stala veľkou raritou. Smrť malého Nella (<i>Dickens - Starožitnícky obchod) a Cordelie (</i>Shakespeare - Kráľ Lear) a podobné príbehy sa už nestávajú. Umieranie na smrteľné choroby, aké sme práve videli, sa objavujú u mladých ľudí. Je veľmi nepravdepodobné, že keď budete mať 80 rokov, takto ochoriete. Len 1 z 10 ľudí, ktorí má viac ako 80, zomrie na rakovinu.
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.
Rozmach majú hlavne choroby ako je zlyhanie orgánu, dýchacieho, srdcového či obličkového, čokoľvek, čo robia. Každé z nich vám zabezpečí prijatie na akútnej starostlivosti, na konci ktorej alebo počas ktorej niekto povie, že už stačilo a my prestaneme.
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.
A toto je jeden z najväčších nárastov zo všetkých a minimálne 6 z 10 vás prítomných zomrie touto formou, čo je znižovanie kapacity s oslabovaním zdravia. Oslabenie zdravia je neodľučiteľnou súčasťou starnutia a jeho zvyšovanie je v skutočnosti hlavnou príčinou, prečo dnes ľudia zomierajú a posledné roky alebo posledné roky vášho života strávite, bohužiaľ, s ťažkou invaliditou.
Enjoying it so far? (Laughs) (Laughter) Sorry, I just feel such a, I feel such a Cassandra here. (Laughter)
Stále si to ešte užívate? (smeje sa) (smiech) Prepáčte, ale pripadám si tu ako Kassandra (*grécka mytológia - veštica, ktorej nik neveril) (smiech)
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.
Čo je na tom pozitívne? Pozitívne je to, že sa to deje až vo veľmi vysokom veku. Všetci, prípadne väčšina, sa toho dožijeme. Viete, v histórii to tak nebolo. Toto sa vám stane, ak sa dožijete vysokého veku a bohužiaľ, zvyšovanie dlhovekosti znamená viac staroby, nie viac mladosti. Nehnevajte sa, že som to povedal. (smiech) To, čo sme spravili, v každom prípade, sme neurobili ležiac v nemocnici Johna Huntera alebo inde. Začali sme s celou sériou projektov, skúsili a zisťovali sme, či by sme mohli zapojiť ľudí viac do toho, čo sa im môže stať. Samozrejme, uvedomili sme si, že sa zaoberáme s kultúrnymi otázkami. A toto je, zbožňujem maľby od Klimta, pretože čím viac sa na ne pozeráte, tým viac sa dostanete podstaty toho, čo sa tam deje, čo je jednoznačne oddelenie smrti od života, strachu, ako, keď sa pozorne pozriete, je tam jedna žena, ktorá má otvorené oči. Práve na ňu sa pozerá a ona je tá, po ktorú si ide. Vidíte to? Vyzerá vystrašene. Je to neuveriteľný obraz.
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.
Takže, mali sme dôležitú kultúrnu otázku. Išlo o to, že ľudia nechceli, aby sme rozprávali o smrti. Aspoň sme si to mysleli. S obrovskou finančnou podporou federálnej vlády a miestneho zdravotníctva, predstavili sme v nemocnici Johna Huntera vec s názvom "Rešpektujeme výber pacienta". Vycvičili sme stovky ľudí, ktorí potom šli na oddelenie a rozprávali sa s ľuďmi o tom, že by mohli zomrieť a čo by si za daných okolností vybrali. Zbožňovali to. Rodiny, pacienti, každému sa to páčilo. 98% ľudí si myslelo, že toto by malo byť súčasťou praxe a že takto by sa to malo robiť. Keď za zverili so svojimi želaniami, každé jedno sa naplnilo, tak ako chceli. Boli sme schopní to pre ich urobiť. Avšak potom, ako sa minula finančná podpora, vrátili sme sa do čias spred 6 mesiacov a všetko skončilo, nikto sa o tomto nerozprával. Veľmi nás to mrzelo, pretože sme si mysleli, že sa to udrží. Kultúrna otázka sa znovu presadila.
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.
Takže, tu je ponuka: Je potrebné vedieť, nedostaneme sa na cestu smerujúcu na jednotku intenzívnej starostlivosti len tak bez rozmysllu či to je, alebo nie je miesto, kde všetci chceme skončiť. Najmä, keď budeme starší a náchylní na choroby a toto miesto nám toho môže ponúknuť stále menej a menej. Musí tu byť aj odbočka pre tých, ktorí týmto smerom nechcú ísť. Mám jeden malý nápad a jeden väčší o tom, čo by sa mohlo stať.
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.
Toto je ten malý nápad. Zaoberajme sa všetci viac tým, čo nám bližšie priblížil Jason. Prečo by sme nemali o tom rozprávať s našimi staršími členmi rodiny a s ľuďmi, ktorých by sa to mohlo týkať? Existuje niekoľko vecí, ktoré môžete urobiť. Jednou z nich je, že sa spýtate prostú otázku. Tá nikdy nesklame. "V prípade, ak by si bol veľmi chorý a nevedel by si za seba rozprávať, koho by si si vybral, aby rozprával v tvojom mene?" Toto je naozaj veľmi dôležitá otázka, pretože umožniť ľuďom, aby mali nad niekým takúto moc, zapríčiňuje ohromný výsledok. Druhou možnosťou, ktorú sa môžete spýtať, je: "Rozprávali ste sa s tou konkrétnou osobou o veciach, ktoré sú pre vás dôležité a vďaka ktorým by sme mohli získať lepší obraz o tom, čo by sme mohli urobiť?" To bol ten menší nápad.
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.
Ten väčší je viac politickejší. Myslím, že sa k tomuto musíme dostať. Navrhujem, aby sme spravili "Occupy smrti". (smiech) Moja žena mi na to povedala: "Iste, samozrejme, na protest obsaďme márnicu. Pravdaže." (smiech) Tento mi teda moc nevyšiel, aj keď ma to oslovilo. Teraz som už starnúci hipík. Neviem, nemyslím si, že tak ešte vyzerám, ale obe moje deti sa narodili doma, v 80. rokoch, keď rodiť doma bola veľká vec a my, narodení počas populačnej explózie, sme sa radi chopili iniciatívy. Takže, ak by ste nahradili všetky slová o narodení, mne sa páči "mier, láska, prirodzená smrť" ako možnosť. Naozaj si myslím, že by sme mali byť politickejší a vytrhnúť tento proces z lekárskej predlohy, v ktorej momentálne je.
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.
Trochu to znie ako boj za eutanáziu. Aby som to ujasnil, nemám rád eutanáziu. Je to len okrajová možnosť. Nemyslím si, že je podstatná. Skôr som toho názoru, že v miestach ako je Oregon, kde máte možnosť asistovanej samovraždy, užijete jedovatú látku, len polovica percenta ľudí k tomu pristúpi. Skôr ma zaujíma to, čo sa stane s 99,5% ľudí, ktorí to nechcú urobiť. Myslím si, že väčšina ľudí nechce zomrieť. Aj keď väčšina z nich určite chce mať nejakú kontrolu nad tým, ako budú zomierať. Som proti eutanázii, ale ľuďom by sme mali vrátiť určitú kontrolu. Pripravuje to eutanáziu o jej zásoby kyslíka. Mali by sme zaoberať zastavením potreby eutanázie, nie tým, že bude nelegálna či legálna alebou za ňou vôbec zaoberať.
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)
Toto je citát dámy Cicely Saunders, ktorú som stretol ako študent medicíny. Založila hospicové hnutie. Ten citát znie: "Záleží na tebe, lebo ty si ty. Záleží na tebe do posledného momentu tvojho života." Pevne verím, že toto je správa, ktorú musíme niesť ďalej. Ďakujem. (potlesk)