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)
说实话,我犹豫过 到底应不应该 对你们一群如此有活力的观众讲这个题目。 但我又想起了Gloria Steinem的一句话 她是这样说的 “真相会给你自由, 但它会先令你难受” 所以呢……(笑声)
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.
所以谨记着这一点,我要开始 试图来谈谈这些事 聊一聊21世纪的死亡。 首先,第一件会令你们十分不爽的,毫无疑问的, 就是我们所有人,事实上,都将在 21世纪死去。 这不会有例外吧! 可是根据调查,我们当中每8个人就会有1个 觉得自己可以长生不老,但是…… (笑声) 不幸的是,长生不老是不可能的。
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.
在接下来的这10分钟内,就在我做这个演讲的同时, 我身体里的一亿个细胞将死去, 今天,我的2000个脑细胞会死去 而且永远不会回来。 所以可以说,死亡的过程 其实在这类的日常小事中就开始了。
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.
无论如何,我想说的关于死在21世纪的第二件事是, 除了这件事会发生在每个人的身上以外, 它对大部分人来说,就是一列好好的火车 最终是怎么走向撞车和成为一个残骸的过程。 除非我们做点什么,把这列火车 从它现在正向着的死亡方面前进的轨道上拉回来。
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.
这就是我要告诉你的真相。 毫无疑问,这会让你非常不爽,但现在我们来看看 可不可以让你获得自由并重生。但我不能向你保证什么。 正如你们在介绍中听到的一样,我在ICU (重症监护治疗病房)工作, 而且我想我经历过ICU的黄金时期。 那就像坐过山车一样, 那真的一直都很棒。 我们有很先进的设备。 这照片上就有很多啊。 我们有一些魔术般的技术, 我觉得一直以来都很好用。 在我在ICU工作的时间里, 澳大利亚的男性死亡率减少了一半, 这跟ICU特护是有关系的。 当然,这跟我们采用的许多技术 也有很大的关系。
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.
所以我们取得过巨大的成功, 而我们有点被自己的成功冲昏了头脑, 所以,我们开始用一些像是“挽救生命”之类的词形容自己 为此我真的要对所有人表示歉意, 因为,很明显,我们并不能救命。 我们能做的是延长人们的生命, 让死亡迟一点到来, 让死亡的过程改变一点点,但是严格来说, 从任何永久性的角度看,我们并不能拯救病人的生命。
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.
而从我在ICU这些年的工作经验来看, 事实的真相是, 我们在70年代,80年代, 90年代所救过来的人,现在慢慢开始在21世纪逝去 ——死于我们当时没法治愈 现在也一样没法的治愈的疾病。
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.
而最大的不同点是, 人们死亡的方式发生了巨大的转变。 而大部分让人们致死的疾病 已经和我们当年 在80年代、90年代处理的方法有了很大的不同了。
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."
所以我们也有点困惑 而我们也没有机会和大家分享一下 如今ICU里都在发生什么。现在就让我们来看一下。 我是在90年代后期才思考这个问题的, 当时我遇到了这个人。 他叫做Jim Smith,他当时的样子是这样的。 我被叫到病房去看他。 他的小手可以说是骨瘦如柴。 一名呼吸内科医生 将我叫到他的诊室。 他对我说:“那有个病人” 他得的是肺炎, 看样子他需要入你们的ICU病房。 他的女儿在这, 她希望你们能尽一切办法…… 这是我们常听到的一句话。 所以,我去病房去看Jim Smith. 他的皮肤半透明成了这个样子。 透过他的皮肤,你们以看到他的骨头。 他可是说是瘦骨嶙峋。 他的肺炎已是相当严重了 病得连和我们讲话的力气都没有了 所以,我问他的女儿Kathleen: "你有没有和他谈过" 你会怎么处理这个事, 如果他到了这种地步? 她看了看我,然后说:”没有,当然没有“ 好吧,我当时想,慢慢做她的工作吧。 我和她谈了很久,然后,她对我说: 你知道的,我们也知道,迟早会有那一天的。
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 当时已经94岁了。(笑声) 这件事让我觉得,我们可以为这类病人做些事。 要不是有这件事 我也想象不到我们会不会去做这件事。 所以,我们有一个小组开始做一些调查工作, 我们走访了 Newcastle地区的4500个在养老院生活的老人, 我们发现,他们当中只有1%的人 对他们生理死亡后的事有计划。 仅仅1%。 只有500分之1的老人 会对他们病重时有应对计划。 这个对话使我意识到, 我们生活中的很多人肯定也会对我们的身后事没有计划的。
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.
现在,我在ICU里工作。 我的医院叫“John Hunter”医院。 而过去我一直认为,我们做得比较好。 所以,我和我的同事Lisa Shaw,她来自养老院, 我们一起在医疗档案室 翻看了成千上万本病历, 我们想确认是否有 任何人曾经 就如果他们的治疗失败 而导致他们死亡而作出任何安排的谈话。 可是,我们找不到关于他们的自我选择, 目标、治疗或者最终结果这方面的东西 医生记录或病人自己写的都没有。
So we started to realize that we had a problem, and the problem is more serious because of this.
我这才意识到 我们出了问题, 而正因为这一点,这个问题变得更严重。
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.
我们大家都知道的是很明显,我们都会死去, 但我们以何种方式死去更重要, 很明显,这不仅对我们重要, 这对那些活着的人也很重要。 其实我们会怎样死去, 这在抢救我们的人的心中是心里有数的, 而死亡给一个家庭带来的压力是巨大的, 事实上,死在ICU所带来的压力 是死在其它地方所带来的压力的7倍, 所以,选择在ICU结束自己的生活并不是一个明智的决定 ——如果你有得选择的话。
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.
如果这还不算太糟糕的话,当然 我们很快可以看到另一个数据 很多人,事实上,大约10个人当中就有1个 会死在ICU中。 而在美国,这个数字是每5个人当中有1个。 在迈阿密,这个数字是每5个人当中有3个。 这就是我们目前所看到的 发展势头。
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.
事情会变成这个样子主要是因为这个。 而我要带领大家去一起探讨一下其原因。 21世纪主要有四种死亡形式。 我们所有人都会以其中的一种形式死去。 人们最熟知的死亡方式 也是越来越引起我们关注的一种死亡方式 ——猝死。 在我们这样的观众群中, 可能不会有这种死亡。 猝死现在已经很少见了。 像 Little Nell 或 Condelia 那样猝死的案例 现在已经很少了。 现在因为患绝症而死亡的病人 正如我们刚才看到的一样, 在年轻人中的发病率越来越高了。 到你80岁,这也不可能发生在你身上。 现在80岁年龄层中只有10%的人死于癌症。
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.
而造成死亡最多的因素主要在以下几个方面。 越来越多的人死于器官功能衰竭 如呼吸和心、肾功能衰竭等等。 不管以上那个器官出了问题 病人都要紧急送院治疗, 到最后,或者在治疗过程中的某一时间上 直到有人对我们说不用治了,我们才放弃。
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.
这是我们见得最多的案例, 每10个在这里听演讲的人中就会有6个 将会以这种方式结束我们的一生, 这是因为功能的缺失 造成的生命的脆弱, 而脆弱是老龄化不可避免的进程, 而脆弱事实上就是 现代人死亡的主要原因, 你生命的最后一年或几年时间 你都会在能力缺失中度过,这太不幸了。
Enjoying it so far? (Laughs) (Laughter) Sorry, I just feel such a, I feel such a Cassandra here. (Laughter)
你们还承受得住么?(笑声) (笑声) 对不起,我怎么成了一个卡珊德拉式的预言家了呢。 (笑声)
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.
但积极的一面是 这只发生在老年人当中。 我们大家也都会经历这一时期的。 要知道,以住要活到这么长的人不多的。 这种死亡方式 只会发生在那些高龄人身上, 不幸的是,寿命的延长 延长的不是青春,而是老年的时光。 很遗憾这样说。(笑声) 不管怎么说,我们所做的 我们并不仅仅指那些 在John Hunter 医院逝去的人或在其它地方死去的人。 我们已经开始一系列的项目 尝试去了解我们能否让更多的人 参与到那些可能发生到他们身上去的事。 然而,我们当然意识到 我们要应对一些文化层面的问题, 我喜欢这张克里姆特的画, 这是因为,你越看它, 你越能了解发生在这里的一切, 而这明显是一种死与生, 和恐惧的分隔。比如说,如果你仔细看的话, 你会发现有个女人 她的眼睛是睁着的。 他在看着她, 他就是冲着她来的。你们看到了吗? 她看起来很惊恐。 这是一幅很不错的画。
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.
另外,我们还有一个主要的文化层面的问题。 显而易见,人们并不希望我们和他们谈论死亡, 或者,我们自己如此认为。 所以,在联邦政府和地方卫生部门资金的支持下 我们在John Hunter医院引入了 一个名为“尊重病人的选择”的项目 我们培训了成百上千的工作人员, 派他到病房去告诉别人他们大限将至 然后问他们有什么打算。 此举受到病人和家属的欢迎。 98%的人真的认为 这应该成为一种常态化的做法, 同时,这也是顺应自然的做法。 而当这些病人表达他们的意愿的时候, 所有这些意愿都可以实现。 我们可以帮他们实行他们的意愿。 然而,当这笔资金用完之后中, 六个月后我们再来评估这一项目, 这一做法又被停止了。 也没有人去进行这方面的谈话了。 这是一种很令我们心酸的结局, 因为我们一直以为,这会成为一种常态化的东西。 文化问题又一次得到了体现。
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.
这就是问题所在。 我认为,在我们决定走上去ICU这条路时, 我们真的要想 我们是否真的想死在ICU里, 这点在我们老态龙钟和变得脆弱不堪时尤其重要, 这时,ICU能为我们做的事情是少之又少的。 如果不去ICU,肯定还有其它的选择的 前提是——你不想死在ICU里。 而对于可能发生的事,我有一个“小”主意 我一个“大”主意
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.
我的小主意是: 让我们所有人 更多地象Jason所描述的那样。 我们为什么就不能和Jason一样 和我们的长辈 或者那些正在慢慢变老的人和Jason一样谈一下这个问题呢? 你可以为此做一些事情。 其中一个是, 你只需问一个简单的问题。这是一个很有用的问题。 “万一你病得不能讲话了, 你想让谁代你表达你的心声呢?” 这真是一个非常重要的问题, 这是因为,给予谁这个权利 会给你带来不同的结局。 你可以说的第二个事情是, “你和哪个人谈过了 你认为对你来说是很重要的事吗 那样我们就比较清楚我们能为你做些什么。 这就是我的“小”主意。
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.
我的大主意,我认为更实用。 我认为,我们必须做好一件事。 我建议搞一个“占领死亡”运动(Occupy Death) (笑声) 我妻子对我说,“对,对,到太平间去静坐” 对,应该的。 (笑声) 所以,这个行不通, 但我还是受到一些打击的。 现在,我是一个老嬉皮士。 我不知道,我并不认为我还象一个嬉皮士,但是 在90年代,我的两个小孩都是在家里生产的 那时,在家生小孩是件大事,而我们这帮婴儿潮年代出生的人 已经习惯了处理这些事, 所以,如果你要替换掉这些关于生产的字, 我会选择“和平、爱和自然死亡” 我真的认为,我们必须得面对现实 并且重申这一进程 从我们现行的医疗化模型中解放出来
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.
听走来,好像我又在鼓吹安乐死。 我想向各位澄清一下 我讨厌安乐死。我认为那是一个次要的问题。 我不认为安乐死会有什么好处 事实上, 我认为, 在象Oregon这类地方, 你可以寻求到一些在医生的辅助下的自杀方式, 你可以吃点毒药之类的东西, 可只有0.5%的人做过这样的蠢事。 其实,我对其它的99.5%的 不想通过服毒而死去的人感兴趣。 我想,大多数人都不想死, 但我认为,大多数人都想能够控制 自己死亡的过程。 所以,我反对安乐死, 但我又认为,我们应该给病重的人一些自己控制权。 这能够让安乐死失去理由。 我认为,我们应该去尝试了解病人 想要安乐死背后的原因, 而不只是让它合法代或非法,或者毫不关心。
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)
这是Dame Cicely Saunders的一句话, 我还是一个医学院学生的时候遇过她 她创立了护理所运动。 她说,“你就是你,你是重要的, 直到你生命的最后一刻。“ 我坚定地相信 这是我们应该继续前行的旨意 谢谢(掌声)