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)
各位,我本來還在猶豫 該不該跟你們這些 充滿活力與精力的觀眾討論這件事 然後我想到Gloria Steinem說過的話 她說: "真相能讓你自由, 但是你會先被惹毛。"(笑聲) 所以...(笑聲)
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.
這句話我銘記在心,所以等一下我要做的 就是遵循這個忠告, 然後談論21世紀對死亡的看法 無庸置疑,現在第一個讓你們不爽的事情就是 即使已到了21世紀 我們所有人還是難逃一死 沒有人能例外 根據統計,你們之中大概每八個就有一個 認為自己是不死之身,但是... (笑聲) 很抱歉,沒這種事
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.
接下來我在演講的這十分鐘內 我體內的細胞會死掉一億個 今天一整天下來,我的腦細胞 會死掉兩千個,而且不會再復活 所以我們可以這樣說,死亡的過程 很早就開始了
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.
總之,關於21世紀對死亡的看法 我要說的第二件事是, 除了所有人都難逃一死之外 就是死亡對於我們大多數的人而言,有點像是 火車事故 除非我們試圖改變現況而有所作為 讓火車離開這條直直朝災難而去的軌道
So there you go. That's the truth. 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.
你們看。這就是真相 難怪你會被惹毛,接下來我們來看看 你能不能獲得自由。這我可不敢保證 好,你們剛剛在簡介裡聽到了,我在加護病房工作 而且我經歷過加護病房的全盛時期 說真的,那很不得了 那種感覺很棒 我們有鏗鏘作響的機器 照片裡面就有一堆 我們也有傑出的技術,我認為 那些技術的效果很好,我在加護病房 工作的那段時間,澳洲男性的 死亡率降了一半 這有些要歸功於加護病房 當然,很多我們採用的科技 都有助於降低死亡率
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.
也因此我們的成就相當可觀 而且我們也沉浸在成功的喜悅之中 然後我們開始使用 “拯救生命” 這種字眼 為此,我必須跟各位道歉 因為我們根本沒有 “拯救生命” 我們只是延長人們的壽命 延遲死亡的到來 避開死亡這個結局,但嚴格說來,我們辦不到 我們無法違背這些恆久不變的原則,拯救生命
And what's really happened over the period of time 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.
而事實上這段期間發生的事 也就是我在加護病房工作的時候 當初我們在70、80和90年代所拯救的性命 到了21世紀都一一離開人世了 一些疾病讓我們束手無策 無法像以前一樣醫治他們
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.
所以現況是,人們的死亡方式 產生了極大的轉變 80、90年代時,大多數病患的死因 我們都還能掌控 但是現在我們卻束手無策
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."
可以說我們陷入困境了 而且對於現在發生的事 我們之間還沒取得共識,不過現在是好時機 90年代末期,我遇到了這個人 他讓我有了這種想法 他叫Jim,Jim Smith,這是他的照片 我被叫去病房看他 這隻小手是他的 是一名呼吸科醫生 叫我去病房看他的 他說:“聽我說,樓下有個 得了肺炎的人 看起來應該需要特別的監護 他的女兒在這裡,她希望我們 盡全力照顧他” 這句話聽起來很耳熟 所以我到樓下的病房看Jim 他的皮膚像這樣,是半透明的 你可以看到皮膚底下的骨頭 他非常非常瘦 當然,他也被肺炎折磨得很慘 虛弱到連跟我說話的力氣都沒有 所以我跟她的女兒Kathleen說,我對她說 “妳和Jim有沒有聊過 如果他就這樣過世 妳會怎麼處裡嗎?” 然後她看著我,她說:“沒有,當然沒有!” 我心想:“好吧。別刺激她。” 然後我跟她聊了這件事,過了一會兒,她跟我說 “你知道嗎,我們都一直以為還有時間。”
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已經94歲了。(笑聲) 然後我才發現,有些事情並沒有實現 如果我想像的事情實現了 我們就不會有這種對話了 所以我們的團隊開始著手考察 然後我們仔細研究了4500間的看護之家 位於Newcastle的,Newcastle地區的 然後發現他們只有百分之一 有針對病患的心跳停止後的應變計畫 百分之一 他們之中只有五百分之一 有針對病情惡化的 應變計畫 然後我才了解,當然啦 這種話題是不會在公開場合討論的
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.
我現在在重症病房工作 這間是John Hunter醫院 然後我想,對啊,我們的作法比較完善 所以我看護所的同事Lias Shaw和我 仔細研究了成千上萬份的紀錄 收在醫療紀錄部裡面的 我們想找出任何蛛絲馬跡 到底有沒有人曾經討論過 萬一他們正在進行的那些療程一直沒有效果 而病人也只剩一口氣了,要怎麼辦? 但是這麼多份醫生或病患的紀錄裡 關於這些情況的治療目標,治療方式或結果 卻連一項都沒有提到
So we started to realize that we had a problem, and the problem is more serious because of this.
因此我們才了解 我們有問題 而這個問題之所以那麼嚴重,是因為
What we know is that obviously we are all going to die, 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.
我們都很清楚,人遲早一死 而死因為何,對我們真的非常重要 不僅對我們很重要,對所有曾目睹死亡 的在世者而言,這種形象也非常重要 我們死亡的形象,仍然存活在所有 在世者的心中 而目睹死亡會對家人產生極大的壓力 事實上,處以重症看護的彌留病患 承受的壓力是其他環境的七倍之多 所以死於重症看護並不是你的最佳選擇 如果你有選擇餘地的話
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.
當然,如果你覺得這樣還不夠慘 所有我們採取的作法都讓情況急速惡化了 目前,你們會有很多人,事實上是十分之一 死於重症看護 在美國,比例是五分之一 在邁阿密,有五分之三的人死於重症看護 所以這就是我們 現在所處的態勢
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.
這就是這些事情會發生的原因 所以我必須帶你們深入探討這件事 我們有四個選擇 我們會遇上其中一項 你們最熟悉的那個死因 也是醫療界越來越多人研究的 猝死 如果以現場觀眾人數的比例而言 你們當中不會有人猝死 猝死變得相當罕見 類似Little Nell和Cordelia的死因 再也沒出現過了 我們剛剛看到的,罹患這種極嚴重病症的 死亡過程 發生在年紀比較輕的人身上 等你活到80歲的時候,這種事不太可能發生在你身上 超過80歲的人,只有十分之一死於癌症
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.
比例大幅攀升的是這塊區域 你的死因是器官逐漸衰竭 呼吸系統,心臟病,腎臟 隨便哪個器官都行。每一個症狀都是 你進入醫院加護病房的通行證 到了最後,或是這期間的某個時刻 有人會說,我受夠了,到此為止
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.
這是攀升幅度最大的區塊 今天現場的人,至少有十分之六 會有這種死法,那就是 體力越來越差 身體越來越虛弱 而虛弱是不可逆轉的老化過程 其實,日漸衰敗的身體才是 現代人最主要的死因 最後那幾年,或是說你生命中最後那幾年 都困在重度失能的狀態,這很可悲
Enjoying it so far? (Laughs) (Laughter) Sorry, I just feel such a, I feel such a Cassandra here. (Laughter)
目前為止還不錯吧 (笑聲) (笑聲) 不好意思,我只是覺得,我覺得現在變 Cassandra (希臘神話報噩耗的預言家)了 (笑聲)
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.
這怎麼能稱上得上是件好事?這種好事是指 在現代社會,這發生在很老很老的人身上 我們都能,我們大多數都能,活到那種歲數 你知道嗎,根據歷史紀載,我們以前沒辦法 當你活了一大把歲數 這種事就會發生在你身上 不幸的是,平均壽命增加表示的是 老人會越來越多,不是年輕人 很遺憾宣佈這種消息 (笑聲) 總之,我們以前的做法,注意,我們以前的做法 我們以前不會束手待斃 不管是在John Hunter醫院或是任何地方 我們推行了一連串的計畫 試著找出我們是否能做些甚麼,其實 這些嘗試涉及的人更多,包括那些不久於人世的 但是我們明白,當然,我們處裡的是 文化上的爭議 還有這個,我喜歡這幅Klimt的畫 因為你們思考得越多,你們應該就越能了解 今天主要的議題是甚麼 在生與死之間,畫出一條清晰的界線 還有恐懼 - 比如說,如果你仔細看 畫裡有個女人 她的眼睛是張開的 他在看的就是她 他就是為她而來的。你們看到沒有? 她的樣子嚇呆了 這幅畫很不可思議
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.
總之,以前我們最常遇見的文化爭議 顯然就是,沒有人想跟我們談論死亡 或許是我們的誤解 所以聯邦政府撥出了一堆基金 在地的健康機構也是,我們跟你們介紹 John Hunter醫院稱之為 “病患選擇優先權” 我們訓練了好幾百人,走進病房 告訴他們,其實他們來日不多了 然後問他們,事到如今,他們的想法是甚麼 他們喜歡這種做法。病人和家屬,他們都喜歡 百分之九十八的人認為 這應該納入例行手續 本來就應該這樣做 他們表達意願之後 這些願望都實現了,都比照辦理 我們曾經有能力幫他們達成 但是,基金用完了 六個月之後,我們回去看的時後 所有人又回歸起點 再也沒人討論這些問題了 所以我們真的覺得很失望 因為我們以為這件事已經上了軌道 文化爭議再次現身聲明立場
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.
我的想法是: 在一路衝進加護病房之前,我們應該要仔細思考 到底有沒有這個必要,讓每個人都以這種方式結束生命 我認為這很重要 尤其是當我們老的時候,越來越虛弱 而加護病房能幫到我們的地方越來越少 對於那些不想走這條路的人 我們必須再開一條小路給他們選 對於未來可能發生的事 我有兩個見解,一大一小
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.
這是比較簡單的作法 簡單的做法是,因為Jason 為我們指出了方向,所以我們都應該投入這場戰役 我們為什麼不能和自己的長輩 那些大限將至的人 討論這些問題? 有兩件事你們都做得到 第一件事是,你們可以 問個簡單的問題。這個問題每試必靈 " 萬一你虛弱到連話都說不出來, 你希望誰幫你說話?" 提出這個問題真的很重要 因為如此能讓人們獲得自我的控制權 產生的效果非常驚人 第二件事,你們可以問: " 你有沒有跟那個人說過 對你而言很重要的事? 這樣我們才能更了解你,提供幫助會更有效。" 這是從小處看的見解
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.
從大處來看,我覺得,要從政治著手 我認為我們必須開始行動 我建議我們應該攻佔死亡 (死星) (笑聲) 我老婆說: " 是啊,沒錯,在太平間靜坐抗議 是啊,是啊。當然啦。" (笑聲) 所以這想法沒有真的執行 但是這真的啟發了我 現在,我是個老嬉皮了 我不知道,我覺得自己不像從前那樣了,可是 我有兩個在自家接生,80年代的小孩 那時候自家接生是件大事,我們是嬰兒潮世代 對這種情況已經駕輕就熟了 如果你試試,把"生產"換成其他字 我喜歡選 “和平,愛,自然死” 我真的認為我們應該推動政策 然後針對現行的醫療模式 著手開始進行改造
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.
現在,注意,這些話很像是對安樂死的訴求 我要完全明確地告訴你們 我討厭安樂死。我認為那是無聊的把戲 我不認為安樂死有用 我真的這樣想 像是Oregon (美國州名) 這種地方 你可以請醫生幫你自殺 你喝下一劑有毒的東西 只有百分之零點五的人這樣做 我對另外百分之九十九點五的人比較有興趣 那些不想這樣做的人 我認為大多數的人都不想死 但我認為大多數的人都想要控制 自己的死亡過程 所以我反對安樂死 但是我認為我們應該要還一些控制權給人們 如此一來,安樂死就沒有容身之處了 我認為我們的焦點應該是 研究如何停止人們對於安樂死的需要 至於它合不合法,這問題我們根本不用去擔心
This is a quote from Dame Cicely Saunders, 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)
這是Dame Cicely Saunders說過的話 我還是醫學院讀書的時候遇到她 她創辦了安寧照顧基金會 然後她說,"你很重要,因為你就是你 你的生命直到最後一刻都很重要。" 我堅決相信這一點 這就是我們要傳遞下去的訊息 謝謝大家 (掌聲)