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)
Predomišljao sam se da li mogu da govorim o ovome publici koja je ovako puna života, kao vi. A onda sam se setio citata Glorije Stajnem koji kaže: "Istina će vas osloboditi, ali će vas prvo dobro naljutiti." (Smeh) Tako da... (Smeh)
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.
Imajući ovo na umu, to ću vam pokazati tako što ću govoriti o umiranju u 21. veku. Prva stvar koja će vas sigurno naljutiti, je da ćemo svi mi umreti u 21. veku. Bez izuzetaka. Sudeći po anketama, otprilike jedan od osmoro vas misli da je besmrtan, ali... (Smeh) Nažalost, to ne ide tako.
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.
Dok vam budem ovo govorio, u sledećih 10 minuta, 100 miliona mojih ćelija će odumreti, a tokom današnjeg dana, 2000 mojih moždanih ćelija će nepovratno nestati, tako da bi se moglo reći da proces umiranja počinje prilično rano.
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.
U svakom slučaju, druga stvar koju želim da kažem o umiranju u 21. veku, osim toga da nas to sve očekuje, je da taj proces za većinu nas liči na raspad sistema, osim ako uradimo nešto što će ga preusmeriti sa njegove trenutne, nezaustavljive putanje.
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.
Tako da, to je istina. Ne sumnjam da će vas to naljutiti, a sada hajde da vidimo da li može i da vas oslobodi. Ništa ne obećavam. Kao što ste čuli u uvodnom govoru, ja radim na intenzivnoj nezi i mislim da sam na neki način proživeo zlatno doba intenzivne nege. Bila je to prilično luda vožnja. I bilo je fantastično. Imamo svemoguće mašine. I to mnogo njih. I imamo nekakvu magičnu tehnologiju za koju smatram da nas je dobro služila i od kada radim na intenzivnoj nezi, stopa smrtnosti muškaraca u Australiji se upola smanjila, a intenzivna nega imala je udela u tome. Definitivno, mnoge od tehnologija koje koristimo imale su udela u tome.
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.
Tako da smo imali ogroman uspeh i na neki način smo se zaneli tim uspehom i počeli da koristimo izraze poput "spasavanje života". Izvinjavam se svima zvog toga, jer mi to očigledno ne radimo. Ono što mi radimo, je produžavanje života, odlaganje smrti i preusmeravanje smrti, ali ne možemo, u pravom smislu, trajno spasiti živote.
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.
A ono što se stvarno desilo tokom mog rada na intenzivnoj nezi je da ljudi čije živote smo počeli da spašavamo u sedamdesetim, osamdesetim i devedesetim godinama, sada dolaze da umru u 21. veku zbog bolesti na koje više nemamo odgovore onako kako smo ih imali pre.
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.
Ono što se trenutno dešava je velika promena u načinu na koji ljudi umiru i većina uzroka smrti više nije toliko rešiva kao što je to bila onda kada sam se ovim bavio u osamdesetima i devedesetima.
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."
Dakle, malo nas je ovo sve zateklo i nismo bili baš otvoreni sa vama u vezi sa onim što se zapravo dešava trenutno. Ali vreme je da se to promeni. Nekako su mi se otvorile oči u kasnim devedesetima kada sam upoznao ovog čoveka. Njegovo ime je Džim, Džim Smit, i izgledao je ovako. Pozvali su me na odeljenje da ga pogledam. Njegova je ova manja ruka. Dakle, lekar za grudne bolesti pozvao me je da ga pogledam. Rekao mi je: "Slušaj, imamo jednog čoveka ovde. Ima upalu pluća i izgleda mi kao da mu je potrebna intenzivna nega. Njegova ćerka je ovde i želi da uradimo sve što je u našoj moći". A ovo nam je veoma poznata rečenica. I ja odem do odeljenja da pogledam Džima, a njegova koža je providna, kao što možete da vidite. Možete da mu vidite kosti kroz kožu. Veoma, veoma je mršav i zaista je u lošem stanju zbog upale pluća. I previše mu je loše da govori, tako da uzmem da razgovaram sa njegovom ćerkom Ketlin i pitam je: "Da li ste Džim i vi ikada razgovarali o tome šta biste želeli da uradite kad bi on završio u ovakvoj sitaciji?" A ona me je pogledala i rekla: "Ne, naravno da nismo!" Pomislio sam: "Okej. Hajdemo polako." Porazgovarao sam s njom i posle nekog vremena, rekla mi je: "Znate, uvek smo mislili da će biti vremena za to."
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.
Džimu je tada bilo 94 godine. (Smeh) I shvatio sam da je nešto tu nedostajalo. Nije bilo tog razgovora za koji sam mislio da se dešava. Tako da je nekolicina nas počela da sprovodi istraživanja i pregledali smo 4,5 hiljade staračkih domova u Njukaslu i njegovoj okolini. Otkrili smo da samo jedan od sto njih ima plan za trenutak kada srca tih ljudi prestanu da kucaju. Jedan od sto. A samo jedan od petsto njih ima plan ako se neko od njih ozbiljno razboli. I shvatio sam, naravno, ovaj se razgovor uglavnom ne odvija u našem društvu.
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.
E sada, ja radim na akutnoj nezi. Radi se o bolnici Džon Hanter. I pomislio sam, sigurno možemo bolje od toga. Zatim sam sa koleginicom Lisom Šo, koja je negovateljica, prošao kroz stotine i stotine papira u odeljenju medicinskih dosijea ne bismo li pronašli ikakvog traga da je neko imao ikakav razgovor o tome šta bi se moglo desiti sa njima, ako bi terapija koju primaju bila neuspešna i ako bi oni umrli. I nismo našli nijedan dokaz o preferiranim ciljevima, terapiji ili ishodima ni u jednom zapisu lekara ili pacijenta.
So we started to realize that we had a problem, and the problem is more serious because of this.
Počeli smo da shvatamo da imamo problem, a on je još ozbiljniji zbog ovoga. (Važno je kako ćete umreti.)
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.
Ono što znamo je da ćemo zasigurno svi umreti, ali kako ćemo umreti je zapravo veoma važno i to ne samo zbog nas, nego i zbog toga kako će se to odraziti na živote ljudi koji nastavljaju da žive posle toga. Način na koji umremo ostaje u glavama svih koji nas nadžive i stres koji zbog smrti nastaje u porodici je ogroman. Zapravo, taj stres je sedam puta veći ako se umre na intenzivnoj nezi nego ako se umre bilo gde drugde. Tako da, smrt na intenzivnoj nezi ne bi bio vaš prvi izbor, ako biste mogli da birate.
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.
A kao da ovo nije dovoljno loše, sve to brzo napreduje prema činjenici da će mnogi od vas, oko jedan od deset vas, umreti na intenzivnoj nezi. U SAD, to je jedan od pet. U Majamiju, tri od pet ljudi umre na intenzivnoj nezi. Dakle, trenutno imamo porast u ovim brojevima.
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.
Razlog svega toga je ovo što vidite i zaista moram da vam objasnim značenje ovih grafikona. Ovo su četiri načina na koje se umire. Dakle, jedan od ovih će se desiti svima nama. Oni koje možda najbolje poznajete su oni koji sve više postaju od istorijskog značaja: iznenadna smrt. Veoma je verovatno da se iz publike u ovom broju ovakva smrt neće desiti nikome ovde. Iznenadna smrt postala je veoma retka. Smrti Male Nel i Kordelije [iz Kralja Lira] i takve stvari jednostavno se više ne dešavaju. Proces umiranja poput onog kod neizlečivih bolesti koji smo upravo videli dešava se mlađim ljudima. Nakon što dosegnete osamdesetu, malo je verovatno da će vam se to desiti. Tek 1 od 10 ljudi koji imaju preko 80 godina, umire od raka.
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.
U porastu su ove. Ono od čega umirete je otkazivanje organa, gde se vaša pluća, srce, bubrezi, ili koji god organi, predaju. Sve od ovoga znači da biste bili primljeni na akutnu negu u bolnici gde bi na kraju ili u toku nje neko rekao: "što je dosta, dosta je" i mi stajemo.
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 ova ovde je u najvećem porastu od svih i barem 6 od 10 ljudi u ovoj prostoriji umreće ovako, a to je smanjenje kapaciteta sa porastom slabosti. Slabost je neizbežan deo starenja, a porast slabosti je zapravo glavni razlog smrti danas. Poslednjih nekoliko godina ili poslednju godinu svog života, nažalost, ćete provesti, u velikoj meri, nemoćni.
Enjoying it so far? (Laughs) (Laughter) Sorry, I just feel such a, I feel such a Cassandra here. (Laughter)
Uživamo li zasad? (Smeje se) (Smeh) Izvinite, osećam se kao neka zloslutna proročica. (Smeh)
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.
Ono što je pozitivno je da se to sada dešava u veoma kasnim godinama. Većina nas živi da bi dostigla ovu tačku. Znate, u prošlosti, to nismo mogli. To je ono što vam se desi kada doživite te kasne godine, a, nažalost, povećanje dugovečnosti znači dužu starost, ne dužu mladost. Žao mi je što to moram da vam kažem. (Smeh) Ono što smo uradili je da nismo samo sedeli skrštenih ruku u bolnici Džnon Hanter ili negde drugde. Započeli smo čitav niz projekata kako bismo saznali da li možemo mnogo više da uključimo ljude u ono što će im se desiti. Ali smo, naravno, shvatili da imamo posla sa kulturološkim problemima. A ovo je, obožavam ovu Klimtovu sliku, jer što je duže gledate, to bolje shvatate ceo taj problem koji se odvija a to je naravno odvajanje smrti od života, i strah. Na primer, ako se zaista zadubite videćete ovu ženu ovde kojoj su otvorene oči. Ona je ta koju on gleda. Po nju je došao. Vidite li to? Ona izgleda prestravljeno. Neverovatna slika.
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.
U svakom slučaju, imali smo ogroman kulturološki problem. Jasno je da ljudi nisu želeli da pričamo o smrti ili smo mi bar tako mislili. I tako smo sa ogromnom finansijskom podrškom savezne vlade i lokalne zdravstvene službe, u bolnici Džon Hanter predstavili nešto što se zove Poštovanje izbora pacijenta. Obučili smo stotine ljudi da idu po odeljenjima i pričaju sa ljudima o činjenici da će umreti i šta bi voleli da se uradi u tom slučaju. I svidelo im se. I porodicama i pacijetima se izuzetno svidelo. 98 procenata ljudi je stvarno smatralo da to treba da bude uobičajena praksa i da bi tako stvari trebalo da funkcionišu. I kada su izneli svoje želje sve te želje su se ostvarile. Mogli smo to da im omogućimo. Ali onda, kada se finansijska pomoć potrošila vratili smo se da vidimo 6 meseci kasnije i svi su prestali sa tim. Niko više nije vodio ove razgovore. To nas je prilično pogodilo, jer smo mislili da će stvarno postati popularno. Kulturološki problem se ponovo vratio.
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.
Dakle, šta je zaključak: važno je da se ne zaputimo ovim autoputem koji vodi ka intenzivnoj nezi, a da pre toga dobro ne razmislimo da li uopšte želimo tamo da završimo. Posebno pošto postanemo sve stariji i slabiji i intenzivna nega ima sve manje da nam ponudi. Mora da postoji malo skretanje za ljude koji ne žele da idu tim putem. A ja imam jednu malu i jednu veliku ideju o tome šta bi se moglo desiti.
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.
A ovo je mala ideja. Ona predlaže da se svi više uključimo u ovo na način na koji je Džejson prikazao. Zašto ne možemo na ovaj način da razgovaramo sa starijima iz sopstvene okoline i sa ljudima koji se tome bliže? Postoji nekoliko stvari koje možete da uradite. Jedna od njih je da samo pitate ovo prosto pitanje. Ono nikad ne zakaže. "U slučaju da postanete previše bolesni da biste mogli da govorite za sebe, koga biste voleli da govori umesto vas?" To je veoma važno pitanje jer dati ljudima odluku o toj osobi dovodi do neverovatnih rezultata. Druga stvar koju možete da pitate je: "Da li ste razgovarali sa tom osobom o onome što je vama važno, kako bismo imali bolju ideju o tome šta mi možemo da uradimo?" Dakle, to je ta mala ideja.
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.
Mislim da je velika ideja više stvar politike. Mislim da moramo da se posvetimo ovome. Predložio sam nekakav protest za smrt. (Smeh) Moja žena je rekla: "Da, baš, skupljaćemo se u mrtvačnici. Da, da. SIgurno." (Smeh) Tako da mi to baš nije uspelo, ali bio sam dosta pogođen time. Dobro, ja sam ostareli hipik. Ne znam, mislim da ne izgledam tako više, ali dvoje moje dece rođeno je kod kuće u osamdesetima kad je kućni porođaj bio popularan, a mi, deo Bebi-bum generacije navikli smo da preuzimamo kontrolu nad situacijom, tako da, ako samo zamenite svuda gde piše "porođaj", meni se sviđa opcija "Mir, ljubav, prirodna smrt". Mislim da ne moramo da govorimo u političkom smislu i da počnemo da premeštamo ovaj proces iz onog medicinskog modela u kome se nalazi.
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.
Ali slušajte, to zvuči kao da zagovaram eutanaziju. Želim da svima bude apsolutno kristalno jasno da ja mrzim eutanaziju. Mislim da je to sporedna stvar. Mislim da eutanazija nije bitna. Zaista mislim da na mestima poput Oregona gde je moguće izvršiti samoubistvo uz pomoć lekara, gde uzmete otrovnu dozu nečega, samo pola procenta ljudi se odluči na to. Mene više zanima šta se dešava sa 99,5 procenata ljudi koji to ne žele. Mislim da većina ljudi ne želi da umre, ali zato mislim da većina ljudi želi da ima nekakvu kontrolu nad svojim procesom umiranja. Tako da sam ja protivnik eutanazije, ali mislim da moramo da damo ljudima neku kontrolu. Time bismo eutanaziji oduzeli zalihu kiseonika. Mislim da treba da težimo zaustavljanju želje za eutanazijom, a ne tome da ona bude ilegalna ili legalna ili da brinemo uopšte o tome.
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)
Ovo je citat gospođe Siseli Sonders, koju sam upoznao kao student medicine. Ona je osnovala pokret domova za nemoćne. I ona je rekla: "Značajan si jer postojiš, i značajan si do poslednjeg trenutka svog života". I ja čvrsto verujem da je to poruka koju moramo dalje da prenosimo. Hvala vam. (Aplauz)