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.
我是安寧照護醫師, 今天我想跟大家談談健康照護。 我想跟大家談 我國最脆弱的一群人 他們的健康與照護, 這群人對抗著 最複雜最嚴重的健康問題。 我也想跟你們談一談經濟。 這兩者交會之處應該會把大家嚇死, 至少我是怕死了。
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.
我也想跟大家談談安寧療護: 這是基於這群病患的價值觀 而產生的照護模式。 以病人為中心, 根據他們的價值觀而做的照護, 幫助這個族群活得更好更久。 這個照護模式會對病人說實話, 並與他們進行一對一對談, 並在患者所在之處碰面。
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.
我想以我第一個病人的故事 來做開場白。 那是我當醫師的第一天, 穿著白袍, 我一走進醫院, 就碰到一位先生,海樂,68 歲, 到急診室報到。 他頭痛了六個星期, 病情愈來愈重,愈來愈難過。 診斷發現他有癌症, 而且已經擴散到腦部。 他的主治醫生指示我去跟海樂和家屬 談他的診斷結果、預後及照護方案。
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.
我的職業生涯才過了五個小時, 我只能做我唯一會做的事。 我走進去, 坐下, 握住海樂的手, 握住他太太的手, 然後就一直呼吸。
He said, "It's not good news is it, sonny?"
他說:「不是什麼好消息, 對吧,小夥子?」
I said, "No."
我說:「不是。」
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?"
然後我們開始談話、傾聽、分享。 過一陣子之後我說: 「海樂,什麼對你最有意義? 你最看重的東西是什麼?」
And he said, "My family."
他說: 「我的家人。」
I said, "What do you want to do?"
我說:「那你想怎麼辦?」
He slapped me on the knee and said, "I want to go fishing."
他拍拍我的膝蓋說: 「我想去釣魚。」
I said, "That, I know how to do."
我說:「這個簡單, 我知道該怎麼做。」
Harold went fishing the next day. He died a week later.
海樂隔天就去釣魚了。 他在一星期後去世。
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.
現在我已在職場受到不少訓練, 我就回想起海樂。 我在想像這樣的對話 太少發生了。 這樣的對話帶領我們到危機之處, 對今天的美式生活產生最大的威脅, 就是醫療支出。
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.
所以我們知道什麼? 我們知道這個族群病得最重, 吃掉了 15% 的 國內生產毛額 (GDP), 將近二兆三千億美金。 所以病得最重的 15% 吃掉 15% 的 GDP。 照這樣推斷未來二十年, 隨著嬰兒潮逐漸老化, 這個數字會是 60% 的 GDP。 美國 GDP 的 60%── 到了這個地步, 已經不再是醫療的問題了, 而是變成買牛奶、 大學學費的問題。 這跟我們重視的一切 及我們目前知道的一切有關。 這會賭上美國自由市場 及資本主義的成敗。
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.
讓我們先擱下統計數字。 我們先來談一下花大錢得到什麼。 達特茅斯醫療照護地圖集 在大約六年前 看了一下聯邦醫療保險 花掉的每一塊錢, 大多是這個族群花掉的。 我們發現有最高 人均醫療費用的病人, 同時也是最受苦、 最痛、最憂鬱的病人。 而且屢見不鮮,他們也比較快死。
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.
怎麼會這樣呢? 我們活在美國, 這裡有地球上最棒的醫療系統。 我們花在這些病人身上的錢, 比第二名的國家高出十倍。 這沒有道理。 但是我們知道的是, 全球前 50 個 有醫療保健系統計畫的國家, 我們排名第 37 位。 中歐東歐等前東方集團國家 及下撒哈拉非洲國家 排名都比我們還高, 品質及價值也比我們好。
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.
每天我看診時都會經歷一件事, 而且我敢保證, 在座很多人自己都經歷過: 多不代表好。 做愈多檢查, 愈精密複雜的儀器, 愈多化療,愈多手術,不管是什麼, 只要我們在病人身上做愈多, 就愈降低他們的生活品質。 而且更常看到的是縮短壽命。
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.
所以我們要怎麼辦? 我們要怎麼做? 而且為什麼會這樣? 嚴峻的現實是,各位先生女士, 我們,醫療業界的人 ——穿著白袍的醫師—— 從你們身上偷東西。 從你們身上偷走 選擇如何過活的機會, 不管你得的是什麼病。 我們專注在疾病、病理、手術 及藥理。 我們沒看到人。 我們要怎麼治療這個 卻不了解這個的存在? 我們為此做了許多; 現在我們必須為這個做點什麼。
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?
醫療有三重目標: 一,改善患者經驗。 二,改善此族群的健康。 三,降低照護過程的人均醫療費用。 我們的安寧照護團隊 在 2012 年與病得最重的患者合作, 癌症、 心臟病、肺病、 腎臟病、 失智等等, 我們如何改善病患經驗?
"I want to be at home, Doc."
「醫生,我想待在家。」
"OK, we'll bring the care to you."
「好,我們會去你家照護你。」
Quality of life, enhanced. Think about the human being.
生活品質提高。 想想人。
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.
第二點:族群健康。 我們怎麼用不同的觀點看這個族群, 在不同的層面、 更深的層次與他們交流, 如何將他們以人來看待, 而不是從本位來想? 我們怎麼管理這個族群, 讓我們 94% 的門診病人 在 2012 年都不用進醫院? 不是因為他們不能去, 而是他們不需要去。 我們把醫療照護帶給他們。 我們維持他們的價值,他們的品質。
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.
第三:人均醫療費用。 對這個族群而言, 現在的花費是二兆三千億美元, 二十年後是 60% 的國內生產毛額, 我們減低了幾乎 70% 的人均醫療費用。 他們本著自己的價值觀 得到更多自己想要的, 可以活得更好,現在活得更久, 只要三分之一的花費。
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.
雖然哈樂的時間不多, 安寧照護卻非如此。 安寧照護模式要看顧 從診斷到臨終這整段時間。 可能是幾小時、 幾週、幾個月、幾年、 連續整段時間, 有沒有治療都是。
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.
來看克里斯汀的例子。 第三期子宮頸癌, 轉移癌,從她的子宮開始, 擴散到整個身體。 她五十幾歲,還活得很好。 我們不是在講臨終, 我們是在講生命。 我們不只在說老年人, 我們在說人。
This is Richard. End-stage lung disease.
這位是理查。 肺病末期。
"Richard, what is it that you hold sacred?"
「理查,你最重視什麼?」
"My kids, my wife and my Harley."
「我的孩子,老婆和哈雷摩托車。」
(Laughter)
(笑聲)
"Alright! I can't drive you around on it because I can barely pedal a bicycle, but let's see what we can do."
「好! 我不能騎它載著你到處跑, 因為我連腳踏車都不會騎, 但是來看看能做什麼。」
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.
理查來找我, 情況很糟。 有個小小的聲音告訴他, 大概只剩幾個星期或幾個月了。 我們就只是聊聊。 我聽著,也試圖去聽言外之意, 這兩者有很大的差別。 多聽少說。
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.
我說:「好吧!過一天是一天。」 就像生命中其它章節一樣。 我們天天去理查住的地方。 一星期一通或兩通電話, 以他肺病末期的狀況而言, 他過得很好。
Now, palliative medicine is not just for the elderly, it is not just for the middle-aged. It is for everyone.
現在,安寧照護不只照顧老年人, 也不只照顧中年人, 我們照護每一個人。
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?"
來看看我的朋友強納生。 我們很榮幸 請到強納生和他的父親來到現場。 強納生二十多歲,我幾年前遇到他。 他在與轉移性睪丸癌奮鬥, 擴散到腦部。 他有過中風, 他曾動過腦部手術, 做過放療、化療。 在跟他及家人會診時, 他才做完骨髓移植幾星期。 他很仔細聽, 他們說:「可不可以讓我們 了解一下什麼是癌症?」
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?
我們怎麼撐到這一步, 一點都不了解我們到底在對抗什麼? 我們是怎麼走到這一步, 沒有教育任何人, 讓他們了解他們到底在對抗什麼, 再帶他們走下一步, 讓他們以人類的身分參與, 明白我們到底該不該那樣做? 天知道我們會在你們身上做什麼。 但是我們應該做嗎?
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.
你可以不信我的話。 但所有跟現今安寧照護有關的證據 都很確定患者活得更好更久。 2010 年,新英格蘭醫學雜誌 發表了一篇影響深遠的文章。 我在哈佛的同事好友做了一個研究, 在講末期肺癌: 一組有安寧照護, 另一組沒有。 有安寧照護那組的報告說 他們比較不痛, 不那麼沮喪。 他們比較少住院。 而且各位, 他們能多活三到六個月。 如果安寧照護是治療癌症的藥物, 地球上每一位癌症醫師都應該 開這種藥給病人。 他們為什麼不開呢? 再說一次,因為我們這群 穿著白袍的傻瓜醫師 只受過訓練處理這樣的問題, 不是這樣的問題。
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.
我們遲早都會碰到 (經濟與健康)交會之處, 但是今天的演講跟死亡無關, 而是跟怎麼活著有關。 基於我們的價值觀而活, 我們視為神聖的東西, 我們想怎麼寫自己生命的章節, 無論是最後一章, 還是最後五章。 我們知道的, 我們已證明的, 就是這樣的對話今天就該發生, 不是下星期,也不是明年。 有危急的是我們今天的生活, 及我們老了之後的生活, 還有我們的子子孫孫的生活。 不僅是在醫院病房裡, 或是家裡的沙發。 無論我們在哪裡看到什麼都一樣, 安寧醫護就是答案,將病患視為人, 改變我們都要面對的旅程, 而且要變得更好。
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.
給我的同事, 我的病患, 我的政府, 及所有人類, 我要大家都站起來、呼喊、要求 最好的照護, 讓我們今天能活得更好, 並確保明天的生活更好。 我們今天就要改變, 明天才能享受人生。
Thank you very much.
謝謝各位!
(Applause)
(掌聲)