I am a palliative care physician and I would like to talk to you today about health care. I'd like to talk to you about the health and care of the most vulnerable population in our country -- those people dealing with the most complex serious health issues. I'd like to talk to you about economics as well. And the intersection of these two should scare the hell out of you -- it scares the hell out of me.
Ja sam lekar palijativne nege i hteo bih da danas razgovaram sa vama o zdravstvenoj zaštiti. Hteo bih da razgovaram sa vama o zdravlju i nezi najranjivijeg stanovništva naše zemlje - ljudi koji se suočavaju sa najsloženijim ozbiljnim zdravstvenim problemima. Takođe bih hteo da razgovaramo o ekonomiji. Ukrštanje ta dva bi trebalo da vas užasno plaši. Mene strašno plaši.
I'd also like to talk to you about palliative medicine: a paradigm of care for this population, grounded in what they value. Patient-centric care based on their values that helps this population live better and longer. It's a care model that tells the truth and engages one-on-one and meets people where they're at.
Takođe bih voleo da govorimo o palijativnoj medicini, o paradigmi nege za ovu populaciju, utemeljenoj u onome u šta oni veruju, o nezi orijentisanoj na pacijenta zasnovanoj na njegovim vrednostima koja pomaže da ova populacija živi bolje i duže. To je model nege koji govori istinu, angažuje se jedan na jedan i izlazi u susret ljudima tamo gde se nalaze.
I'd like to start by telling the story of my very first patient. It was my first day as a physician, with the long white coat ... I stumbled into the hospital and right away there's a gentleman, Harold, 68 years old, came to the emergency department. He had had headaches for about six weeks that got worse and worse and worse and worse. Evaluation revealed he had cancer that had spread to his brain. The attending physician directed me to go share with Harold and his family the diagnosis, the prognosis and options of care.
Hteo bih da započnem tako što ću ispričati priču o svom prvom pacijentu. Bio je to moj prvi dan kao lekara, sa dugačkim belim mantilom. Doteturao sam se u bolnicu i odmah je tu bio gospodin, Herold, od 68 godina, koji je došao u hitnu službu. Imao je glavobolje oko šest nedelja koje su se sve više pogoršavale. Pregled je otkrio da ima rak koji se proširio na njegov mozak. Nadležni lekar me je uputio da sa Haroldom i njegovom porodicom podelim djagnozu, prognozu i opcije za negu.
Five hours into my new career, I did the only thing I knew how. I walked in, sat down, took Harold's hand, took his wife's hand and just breathed.
Pet sati od ulaska u novu karijeru, uradio sam jedino što sam umeo. Ušao sam, seo, uzeo Haroldovu ruku, uzeo ruku njegove žene i samo sam disao.
He said, "It's not good news is it, sonny?"
Rekao je: „Nisu dobre vesti, zar ne, sine?“
I said, "No."
Odgovorio sam: „Ne.“
And so we talked and we listened and we shared. And after a while I said, "Harold, what is it that has meaning to you? What is it that you hold sacred?"
Tako smo pričali, slušali i razmenjivali. Nakon izvesnog vremena sam upitao: „Harolde, šta je to što za tebe ima smisla? Šta smatraš za svetinju?“
And he said, "My family."
Odgovorio je: „Moju porodicu.“
I said, "What do you want to do?"
Upitao sam: „Šta želiš da radiš?“
He slapped me on the knee and said, "I want to go fishing."
Potapšao me je po kolenu i rekao: „Želim da idem na pecanje.“
I said, "That, I know how to do."
Uzvratio sam: „To znam kako da ostvarim.“
Harold went fishing the next day. He died a week later.
Harold je otišao na pecanje narednog dana. Preminuo je nedelju dana kasnije.
As I've gone through my training in my career, I think back to Harold. And I think that this is a conversation that happens far too infrequently. And it's a conversation that had led us to crisis, to the biggest threat to the American way of life today, which is health care expenditures.
Dok sam nastavljao sa obukom u svojoj karijeri, osvrtao sam se na Harolda. Mislim da je ovo razgovor koji se dešava previše retko. To je razgovor koji nas je doveo do krize, do najveće pretnje američkom načinu života danas, a to su troškovi zdravstvene zaštite.
So what do we know? We know that this population, the most ill, takes up 15 percent of the gross domestic product -- nearly 2.3 trillion dollars. So the sickest 15 percent take up 15 percent of the GDP. If we extrapolate this out over the next two decades with the growth of baby boomers, at this rate it is 60 percent of the GDP. Sixty percent of the gross domestic product of the United States of America -- it has very little to do with health care at that point. It has to do with a gallon of milk, with college tuition. It has to do with every thing that we value and every thing that we know presently. It has at stake the free-market economy and capitalism of the United States of America.
Šta je to što znamo? Znamo da na ovu populaciju najbolesnijih odlazi 15 odsto bruto domaćeg proizvoda, skoro 2,3 biliona dolara. Dakle, na najbolesnijih 15 procenata odlazi 15 posto BDP. Ako to prenesemo na sledeće dve decenije sa porastom bejbi bum generacije, ovom stopom, to je 60 posto BDP-a. Šezdeset odsto bruto domaćeg proizvoda Sjedinjenih Američkih Država - to u tom trenutku ima vrlo malo veze sa zdravstvenom zaštitom. Ima veze sa litrom mleka, sa školarinom za fakultet. Ima veze sa svime što cenimo i svačim za šta trenutno znamo. Stavlja na kocku ekonomiju slobodnog tržišta i kapitalizam Sjedinjenih Američkih Država.
Let's forget all the statistics for a minute, forget the numbers. Let's talk about the value we get for all these dollars we spend. Well, the Dartmouth Atlas, about six years ago, looked at every dollar spent by Medicare -- generally this population. We found that those patients who have the highest per capita expenditures had the highest suffering, pain, depression. And, more often than not, they die sooner.
Zaboravimo sve statističke podatke na trenutak, zaboravimo brojeve. Hajde da razgovaramo o vrednosti koju dobijamo za dolare koje potrošimo. Pa, projekat Darmut Atlas je, pre oko šest godina, razmotrio svaki dolar koji je potrošilo osiguranje Mediker uopšte na ovu populaciju. Otkrili smo da su ti pacijenti koji imaju najveće izdatke po glavi stanovnika prolaze kroz najviše patnje, bolova i depresije. Takođe, u većem broju slučajeva, oni umiru ranije.
How can this be? We live in the United States, it has the greatest health care system on the planet. We spend 10 times more on these patients than the second-leading country in the world. That doesn't make sense. But what we know is, out of the top 50 countries on the planet with organized health care systems, we rank 37th. Former Eastern Bloc countries and sub-Saharan African countries rank higher than us as far as quality and value.
Kako je to moguće? Živimo u Sjedinjenim Državama koje imaju najbolji sistem zdravstvene zaštite na planeti. Trošimo 10 puta više na te pacijente od druge po redu vodeće zemlje sveta. To nema nikakvog smisla. Međutim, ono što znamo je da, od 50 zemalja na planeti koje su u vrhu po organizovanim sistemima zdravstvene zaštite, nalazimo se na 37. mestu. Zemlje bivšeg Istočnog bloka i zemlje podsaharske Afrike imaju bolji rang od nas u pogledu kvaliteta i vrednosti.
Something I experience every day in my practice, and I'm sure, something many of you on your own journeys have experienced: more is not more. Those individuals who had more tests, more bells, more whistles, more chemotherapy, more surgery, more whatever -- the more that we do to someone, it decreases the quality of their life. And it shortens it, most often.
Nešto što doživljavam svakog dana u svojoj praksi, a siguran sam da su to mnogi od vas iskusili na svojim putovanjima - dodatno ne znači više. Ti pojedinci koji su imali dodatne testove, dodatne skupe naprave, dodatne hemoterapije, operacije, šta god - što više uradimo nekome, to umanjuje kvalitet njegovog života i najčešće ga skraćuje.
So what are we going to do about this? What are we doing about this? And why is this so? The grim reality, ladies and gentlemen, is that we, the health care industry -- long white-coat physicians -- are stealing from you. Stealing from you the opportunity to choose how you want to live your lives in the context of whatever disease it is. We focus on disease and pathology and surgery and pharmacology. We miss the human being. How can we treat this without understanding this? We do things to this; we need to do things for this.
Pa, šta ćemo preduzeti po tom pitanju? Šta radimo u vezi sa ovim? Zašto je to tako? Surova realnost, dame i gospodo, je da mi, industrija zdravstvene zaštite - lekari u dugim belim mantilima - krademo od vas. Krademo od vas mogućnost da odaberete kako želite da provedete svoje živote u kontekstu bolesti koja je u pitanju. Usmereni smo na bolest, patologiju, hirurgiju i farmakologiju. Propuštamo ljudsko biće. Kako možemo lečiti ovo bez razumevanja ovoga? Radimo stvari ovome; treba da radimo stvari za ovo.
The triple aim of healthcare: one, improve patient experience. Two, improve the population health. Three, decrease per capita expenditure across a continuum. Our group, palliative care, in 2012, working with the sickest of the sick -- cancer, heart disease, lung disease, renal disease, dementia -- how did we improve patient experience?
Trostruki cilj zdravstvene zaštite - prvo, poboljšati iskustvo pacijenta. Drugo, poboljšati zdravlje populacije. Treće, smanjiti potrošnju po glavi stanovnika duž kontinuuma. Naša grupa, palijativna nega, 2012. godine, kroz rad sa najbolesnijima među bolesnicima - rak, bolesti srca i pluća, bubrežne bolesti, demencija - kako smo poboljšali iskustvo pacijenta?
"I want to be at home, Doc."
„Želim da budem kod kuće, doktore.“
"OK, we'll bring the care to you."
„U redu, dovešćemo negu kod vas.“
Quality of life, enhanced. Think about the human being.
Kvalitet života je poboljšan. Razmislite o ljudskom biću.
Two: population health. How did we look at this population differently, and engage with them at a different level, a deeper level, and connect to a broader sense of the human condition than my own? How do we manage this group, so that of our outpatient population, 94 percent, in 2012, never had to go to the hospital? Not because they couldn't. But they didn't have to. We brought the care to them. We maintained their value, their quality.
Pod dva - zdravlje populacije. Kako smo drugačije sagledavali ovu populaciju, angažovali se oko njih na drugačijem, dubljem nivou, i povezali se u širem smislu ljudskog stanja od sopstvenog? Kako rukovodimo ovom grupom, pa od naše populacije na vanbolničkom lečenju 94 posto njih 2012. godine uopšte nije moralo da ide u bolnicu? Ne zato što nisu mogli, već nisu morali da idu. Doveli smo negu kod njih. Sačuvali smo njihove vrednosti, njihov kvalitet.
Number three: per capita expenditures. For this population, that today is 2.3 trillion dollars and in 20 years is 60 percent of the GDP, we reduced health care expenditures by nearly 70 percent. They got more of what they wanted based on their values, lived better and are living longer, for two-thirds less money.
Broj tri - izdaci po glavi stanovnika. Kod ove populacije na koju danas odlazi 2,3 biliona dolara, a za 20 godina 60 odsto BDP-a, umanjili smo troškove zdravstvene zaštite za gotovo 70 procenata. Dobili su više od onoga što su hteli na osnovu svojih vrednosti, živeli su bolje i duže, za dve trećine manje novca.
While Harold's time was limited, palliative care's is not. Palliative care is a paradigm from diagnosis through the end of life. The hours, weeks, months, years, across a continuum -- with treatment, without treatment.
Dok je Haroldovo vreme bilo ograničeno, vreme palijativne nege to nije. Palijativna nega je paradigma od postavljanja dijagnoze do kraja života. Sati, nedelje, meseci, godine, duž kontinuuma - sa lečenjem, bez lečenja.
Meet Christine. Stage III cervical cancer, so, metastatic cancer that started in her cervix, spread throughout her body. She's in her 50s and she is living. This is not about end of life, this is about life. This is not just about the elderly, this is about people.
Upoznajte Kristinu. Treći stadijum raka grlića materice dakle, metastatski rak koji je otpočeo u grliću materice proširio se kroz njeno telo. U pedesetim je godinama i živi. Ovde se ne radi o kraju života, već o životu. Ne radi se samo o starijima, radi se o ljudima.
This is Richard. End-stage lung disease.
Ovo je Ričard. Krajnji stadijum bolesti pluća.
"Richard, what is it that you hold sacred?"
„Ričarde, šta je to što smatraš svetinjom?“
"My kids, my wife and my Harley."
„Moja deca, žena i moj Harli.“
(Laughter)
(Smeh)
"Alright! I can't drive you around on it because I can barely pedal a bicycle, but let's see what we can do."
„U redu! Ne mogu da vas vozim unaokolo na njemu jer jedva da umem da vozim bicikl, ali hajde da vidimo šta možemo.“
Richard came to me, and he was in rough shape. He had this little voice telling him that maybe his time was weeks to months. And then we just talked. And I listened and tried to hear -- big difference. Use these in proportion to this.
Ričard je došao kod mene i bio je u teškom stanju. Mali glas u njemu mu je govorio da možda njegovo vreme dolazi za nekoliko nedelja ili meseci. Zatim smo samo pričali. Ja sam slušao i pokušavao da čujem; velika razlika. Koristite ovo srazmerno ovome.
I said, "Alright, let's take it one day at a time," like we do in every other chapter of our life. And we have met Richard where Richard's at day-to-day. And it's a phone call or two a week, but he's thriving in the context of end-stage lung disease.
Rekao sam: „U redu, hajde da se bavimo ovim dan za danom“, kao što to radimo u svakom drugoj oblasti života. Izlazili smo u susret Ričardu tamo gde se on nalazio iz dana u dan. U pitanju je jedan ili dva telefonska poziva nedeljno, ali on napreduje u kontekstu krajnjeg stadijuma bolesti pluća.
Now, palliative medicine is not just for the elderly, it is not just for the middle-aged. It is for everyone.
Palijativna medicina nije samo za starije osobe, niti je samo za osobe srednjih godina. Ona je za svakog.
Meet my friend Jonathan. We have the honor and pleasure of Jonathan and his father joining us here today. Jonathan is in his 20s, and I met him several years ago. He was dealing with metastatic testicular cancer, spread to his brain. He had a stroke, he had brain surgery, radiation, chemotherapy. Upon meeting him and his family, he was a couple of weeks away from a bone marrow transplant, and in listening and engaging, they said, "Help us understand -- what is cancer?"
Upoznajte mog prijatelja Džonatana. Imamo čast i zadovoljstvo da su nam se Džonatan i njegov otac danas pridružili ovde. Džonatan je u svojim dvadesetim i upoznao sam ga pre nekoliko godina. Borio se sa metastatskim rakom testisa koji se proširio na njegov mozak. Doživeo je šlog, imao je operaciju na mozgu, radijaciju, hemoterapiju. Po mom upoznavanju sa njim i njegovom porodicom, imao je par nedelja do transplantacije koštane srži, a tokom slušanja i uključenosti, rekli su: „Pomozite nam da razumemo - šta je to rak?“
How did we get this far without understanding what we're dealing with? How did we get this far without empowering somebody to know what it is they're dealing with, and then taking the next step and engaging in who they are as human beings to know if that is what we should do? Lord knows we can do any kind of thing to you. But should we?
Kako smo dospeli tako daleko bez razumevanja o tome sa čim imamo posla? Kako smo dospeli toliko daleko bez osnaživanja osobe da zna sa čime se suočava, a zatim preduzimanja sledećeg koraka i bavljenja time ko je kao ljudsko biće tako da znamo da li je to ono što treba da radimo? Sam bog zna da možemo da vam svašta uradimo. Ipak, da li bi trebalo?
And don't take my word for it. All the evidence that is related to palliative care these days demonstrates with absolute certainty people live better and live longer. There was a seminal article out of the New England Journal of Medicine in 2010. A study done at Harvard by friends of mine, colleagues. End-stage lung cancer: one group with palliative care, a similar group without. The group with palliative care reported less pain, less depression. They needed fewer hospitalizations. And, ladies and gentlemen, they lived three to six months longer. If palliative care were a cancer drug, every cancer doctor on the planet would write a prescription for it. Why don't they? Again, because we goofy, long white-coat physicians are trained and of the mantra of dealing with this, not with this.
Nemojte mi verovati na reč. Svi dokazi u poslednje vreme vezani za palijativnu negu pokazuju sa apsolutnom sigurnošću da ljudi žive bolje i duže. Bio je jedan plodonosni članak u Medicinskom časopisu Nove Engleske iz 2010. godine. Studija koju su na Harvardu sproveli moji prijatelji, kolege. Krajnji stadijum raka pluća - jedna grupa sa palijativnom negom, slična grupa bez nje. Grupa sa palijativnom negom je saopštavala da ima manje bolova, manje depresije. Ređe im je bila potrebna hospitalizacija. Takođe, dame i gospodo, živeli su tri do šest meseci duže. Kada bi palijativna nega bila lek protiv raka, svaki doktor za rak na planeti bi propisivao recepte za nju. Zašto to ne rade? Još jednom, zato što smo mi, smešni lekari u dugim belim mantilima, obrazovani i imamo mantru za bavljenje ovim, a ne ovim.
This is a space that we will all come to at some point. But this conversation today is not about dying, it is about living. Living based on our values, what we find sacred and how we want to write the chapters of our lives, whether it's the last or the last five. What we know, what we have proven, is that this conversation needs to happen today -- not next week, not next year. What is at stake is our lives today and the lives of us as we get older and the lives of our children and our grandchildren. Not just in that hospital room or on the couch at home, but everywhere we go and everything we see. Palliative medicine is the answer to engage with human beings, to change the journey that we will all face, and change it for the better.
Ovo je mesto na koje ćemo svi doći u nekom trenutku. Međutim, ovaj razgovor danas nije o umiranju, već o življenju. O življenju na osnovu naših vrednosti, onome što smatramo svetim i načinu na koji želimo da ispišemo poglavlja svog života, bilo da je u pitanju poslednje ili poslednjih pet. Ono što znamo, ono što smo dokazali, jeste da ovaj razgovor mora da se dogodi danas - ne naredne nedelje, ne naredne godine. U pitanju je naš život danas, naši životi kada ostarimo, životi naše dece i naših unuka. Ne samo u toj bolničkoj sobi ili na kauču kod kuće, već gde god da odemo i šta god da vidimo. Palijativna medicina je odgovor za bavljenje ljudskim bićima, za promenu putovanja sa kojim ćemo se svi suočiti, i to promenu nabolje.
To my colleagues, to my patients, to my government, to all human beings, I ask that we stand and we shout and we demand the best care possible, so that we can live better today and ensure a better life tomorrow. We need to shift today so that we can live tomorrow.
Od svojih kolega, od svojih pacijenata, od svoje vlade, od svih ljudskih bića, tražim da ustanemo, uzviknemo i zahtevamo najbolju moguću negu, tako da možemo da živimo bolje danas i obezbedimo bolji život sutra. Moramo da napravimo preokret danas da bismo mogli da živimo sutra.
Thank you very much.
Hvala vam mnogo.
(Applause)
(Aplauz)