Placeholder Image

字幕列表 影片播放

已審核 字幕已審核
  • I am a palliative care physician

    我是安寧照護醫師,

  • and I would like to talk to you today about health care.

    今天我想跟大家談談健康照護。

  • I'd like to talk to you about the health and care

    我想跟大家談

  • of the most vulnerable population in our country --

    我國最脆弱的一群人 他們的健康與照護,

  • those people dealing with the most complex serious health issues.

    這群人對抗著 最複雜最嚴重的健康問題。

  • I'd like to talk to you about economics as well.

    我也想跟你們談一談經濟。

  • And the intersection of these two should scare the hell out of you --

    這兩者交會之處應該會把大家嚇死,

  • it scares the hell out of me.

    至少我是怕死了。

  • I'd also like to talk to you about palliative medicine:

    我也想跟大家談談安寧療護:

  • a paradigm of care for this population, grounded in what they value.

    這是基於這群病患的價值觀 而產生的照護模式。

  • Patient-centric care based on their values

    以病人為中心, 根據他們的價值觀而做的照護,

  • that helps this population live better and longer.

    幫助這個族群活得更好更久。

  • It's a care model that tells the truth

    這個照護模式會對病人說實話,

  • and engages one-on-one

    並與他們進行一對一對談,

  • and meets people where they're at.

    並在患者所在之處碰面。

  • I'd like to start by telling the story of my very first patient.

    我想以我第一個病人的故事 來做開場白。

  • It was my first day as a physician,

    那是我當醫師的第一天,

  • with the long white coat ...

    穿著白袍,

  • I stumbled into the hospital

    我一走進醫院,

  • and right away there's a gentleman, Harold, 68 years old,

    就碰到一位先生,海樂,68 歲,

  • came to the emergency department.

    到急診室報到。

  • He had had headaches for about six weeks

    他頭痛了六個星期,

  • that got worse and worse and worse and worse.

    病情愈來愈重,愈來愈難過。

  • Evaluation revealed he had cancer that had spread to his brain.

    診斷發現他有癌症, 而且已經擴散到腦部。

  • The attending physician directed me to go share with Harold and his family

    他的主治醫生指示我去跟海樂和家屬

  • the diagnosis, the prognosis and options of care.

    談他的診斷結果、預後及照護方案。

  • Five hours into my new career,

    我的職業生涯才過了五個小時,

  • I did the only thing I knew how.

    我只能做我唯一會做的事。

  • I walked in,

    我走進去,

  • sat down,

    坐下,

  • took Harold's hand,

    握住海樂的手,

  • took his wife's hand

    握住他太太的手,

  • and just breathed.

    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.

    然後我們開始談話、傾聽、分享。

  • And after a while I said,

    過一陣子之後我說:

  • "Harold, what is it that has meaning to you?

    「海樂,什麼對你最有意義?

  • What is it that you hold sacred?"

    你最看重的東西是什麼?」

  • And he said,

    他說:

  • "My family."

    「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.

    海樂隔天就去釣魚了。

  • He died a week later.

    他在一星期後去世。

  • As I've gone through my training in my career,

    現在我已在職場受到不少訓練,

  • I think back to Harold.

    我就回想起海樂。

  • And I think that this is a conversation

    我在想像這樣的對話

  • that happens far too infrequently.

    太少發生了。

  • And it's a conversation that had led us to crisis,

    這樣的對話帶領我們到危機之處,

  • to the biggest threat to the American way of life today,

    對今天的美式生活產生最大的威脅,

  • which is health care expenditures.

    就是醫療支出。

  • So what do we know?

    所以我們知道什麼?

  • We know that this population, the most ill,

    我們知道這個族群病得最重,

  • takes up 15 percent of the gross domestic product --

    吃掉了 15% 的 國內生產毛額 (GDP),

  • nearly 2.3 trillion dollars.

    將近二兆三千億美金。

  • So the sickest 15 percent take up 15 percent of the GDP.

    所以病得最重的 15% 吃掉 15% 的 GDP。

  • If we extrapolate this out over the next two decades

    照這樣推斷未來二十年,

  • with the growth of baby boomers,

    隨著嬰兒潮逐漸老化,

  • at this rate it is 60 percent of the GDP.

    這個數字會是 60% 的 GDP。

  • Sixty percent of the gross domestic product

    美國 GDP 的 60%──

  • of the United States of America --

    到了這個地步, 已經不再是醫療的問題了,

  • it has very little to do with health care at that point.

    而是變成買牛奶、

  • It has to do with a gallon of milk,

    大學學費的問題。

  • with college tuition.

    這跟我們重視的一切

  • It has to do with every thing that we value

    及我們目前知道的一切有關。

  • and every thing that we know presently.

    這會賭上美國自由市場 及資本主義的成敗。

  • It has at stake the free-market economy and capitalism

    讓我們先擱下統計數字。

  • of the United States of America.

    我們先來談一下花大錢得到什麼。

  • Let's forget all the statistics for a minute, forget the numbers.

    達特茅斯醫療照護地圖集 在大約六年前

  • Let's talk about the value we get for all these dollars we spend.

    看了一下聯邦醫療保險 花掉的每一塊錢,

  • Well, the Dartmouth Atlas, about six years ago,

    大多是這個族群花掉的。

  • looked at every dollar spent by Medicare --

    我們發現有最高 人均醫療費用的病人,

  • generally this population.

    同時也是最受苦、 最痛、最憂鬱的病人。

  • We found that those patients who have the highest per capita expenditures

    而且屢見不鮮,他們也比較快死。

  • had the highest suffering, pain, depression.

    怎麼會這樣呢?

  • And, more often than not, they die sooner.

    我們活在美國,

  • How can this be?

    這裡有地球上最棒的醫療系統。

  • We live in the United States,

    我們花在這些病人身上的錢,

  • it has the greatest health care system on the planet.

    比第二名的國家高出十倍。

  • We spend 10 times more on these patients

    這沒有道理。

  • than the second-leading country in the world.

    但是我們知道的是,

  • That doesn't make sense.

    全球前 50 個

  • But what we know is,

    有醫療保健系統計畫的國家,

  • out of the top 50 countries on the planet

    我們排名第 37 位。

  • with organized health care systems,

    中歐東歐等前東方集團國家 及下撒哈拉非洲國家

  • we rank 37th.

    排名都比我們還高, 品質及價值也比我們好。

  • Former Eastern Bloc countries and sub-Saharan African countries

    每天我看診時都會經歷一件事,

  • rank higher than us as far as quality and value.

    而且我敢保證, 在座很多人自己都經歷過:

  • Something I experience every day in my practice,

    多不代表好。

  • and I'm sure, something many of you on your own journeys have experienced:

    做愈多檢查,

  • more is not more.

    愈精密複雜的儀器,

  • Those individuals who had more tests,

    愈多化療,愈多手術,不管是什麼,

  • more bells, more whistles,

    只要我們在病人身上做愈多,

  • more chemotherapy, more surgery, more whatever --

    就愈降低他們的生活品質。

  • the more that we do to someone,

    而且更常看到的是縮短壽命。

  • it decreases the quality of their life.

    所以我們要怎麼辦?

  • And it shortens it, most often.

    我們要怎麼做?

  • So what are we going to do about this?

    而且為什麼會這樣?

  • What are we doing about this?

    嚴峻的現實是,各位先生女士,

  • And why is this so?

    我們,醫療業界的人 ——穿著白袍的醫師——

  • The grim reality, ladies and gentlemen,

    從你們身上偷東西。

  • is that we, the health care industry -- long white-coat physicians --

    從你們身上偷走

  • are stealing from you.

    選擇如何過活的機會,

  • Stealing from you the opportunity

    不管你得的是什麼病。

  • to choose how you want to live your lives

    我們專注在疾病、病理、手術

  • in the context of whatever disease it is.

    及藥理。

  • We focus on disease and pathology and surgery

    我們沒看到人。

  • and pharmacology.

    我們要怎麼治療這個

  • We miss the human being.

    卻不了解這個的存在?

  • How can we treat this

    我們為此做了許多;

  • without understanding this?

    現在我們必須為這個做點什麼。

  • We do things to this;

    醫療有三重目標:

  • we need to do things for this.

    一,改善患者經驗。

  • The triple aim of healthcare:

    二,改善此族群的健康。

  • one, improve patient experience.

    三,降低照護過程的人均醫療費用。

  • Two, improve the population health.

    我們的安寧照護團隊

  • Three, decrease per capita expenditure across a continuum.

    在 2012 年與病得最重的患者合作,

  • Our group, palliative care,

    癌症、

  • in 2012, working with the sickest of the sick --

    心臟病、肺病、

  • cancer,

    腎臟病、

  • heart disease, lung disease,

    失智等等,

  • renal disease,

    我們如何改善病患經驗?

  • dementia --

    「醫生,我想待在家。」

  • how did we improve patient experience?

    「好,我們會去你家照護你。」

  • "I want to be at home, Doc."

    生活品質提高。

  • "OK, we'll bring the care to you."

    想想人。

  • Quality of life, enhanced.

    第二點:族群健康。

  • Think about the human being.

    我們怎麼用不同的觀點看這個族群,

  • Two: population health.

    在不同的層面、 更深的層次與他們交流,

  • How did we look at this population differently,

    如何將他們以人來看待, 而不是從本位來想?

  • and engage with them at a different level, a deeper level,

    我們怎麼管理這個族群,

  • and connect to a broader sense of the human condition than my own?

    讓我們 94% 的門診病人

  • How do we manage this group,

    在 2012 年都不用進醫院?

  • so that of our outpatient population,

    不是因為他們不能去,

  • 94 percent, in 2012, never had to go to the hospital?

    而是他們不需要去。

  • Not because they couldn't.

    我們把醫療照護帶給他們。

  • But they didn't have to.

    我們維持他們的價值,他們的品質。

  • We brought the care to them.

    第三:人均醫療費用。

  • We maintained their value, their quality.

    對這個族群而言,

  • Number three: per capita expenditures.

    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,

  • For this population,

    我們減低了幾乎 70% 的人均醫療費用。

  • that today is 2.3 trillion dollars and in 20 years is 60 percent of the GDP,

    他們本著自己的價值觀 得到更多自己想要的,

  • we reduced health care expenditures by nearly 70 percent.

    可以活得更好,現在活得更久,

  • They got more of what they wanted based on their values,

    只要三分之一的花費。

  • lived better and are living longer,

    雖然哈樂的時間不多,

  • for two-thirds less money.

    安寧照護卻非如此。

  • While Harold's time was limited,

    安寧照護模式要看顧 從診斷到臨終這整段時間。

  • palliative care's is not.

    可能是幾小時、

  • Palliative care is a paradigm from diagnosis through the end of life.

    幾週、幾個月、幾年、

  • The hours,

    連續整段時間,

  • weeks, months, years,

    有沒有治療都是。

  • across a continuum --

    來看克里斯汀的例子。

  • with treatment, without treatment.

    第三期子宮頸癌,

  • Meet Christine.

    轉移癌,從她的子宮開始,

  • Stage III cervical cancer,

    擴散到整個身體。

  • so, metastatic cancer that started in her cervix,

    她五十幾歲,還活得很好。

  • spread throughout her body.

    我們不是在講臨終,

  • She's in her 50s and she is living.

    我們是在講生命。

  • This is not about end of life,

    我們不只在說老年人,

  • this is about life.

    我們在說人。

  • This is not just about the elderly,

    這位是理查。

  • this is about people.

    肺病末期。

  • This is Richard.

    「理查,你最重視什麼?」

  • End-stage lung disease.

    「我的孩子,老婆和哈雷摩托車。」

  • "Richard, what is it that you hold sacred?"

    (笑聲)

  • "My kids, my wife and my Harley."

    「好!

  • (Laughter)

    我不能騎它載著你到處跑, 因為我連腳踏車都不會騎,

  • "Alright!

    但是來看看能做什麼。」

  • I can't drive you around on it because I can barely pedal a bicycle,

    理查來找我,

  • but let's see what we can do."

    情況很糟。

  • Richard came to me,

    有個小小的聲音告訴他,

  • and he was in rough shape.

    大概只剩幾個星期或幾個月了。

  • He had this little voice telling him

    我們就只是聊聊。

  • that maybe his time was weeks to months.

    我聽著,也試圖去聽言外之意,

  • And then we just talked.

    這兩者有很大的差別。

  • And I listened and tried to hear --

    多聽少說。

  • big difference.

    我說:「好吧!過一天是一天。」

  • Use these in proportion to this.

    就像生命中其它章節一樣。

  • I said, "Alright, let's take it one day at a time,"

    我們天天去理查住的地方。

  • like we do in every other chapter of our life.

    一星期一通或兩通電話,

  • And we have met Richard where Richard's at day-to-day.

    以他肺病末期的狀況而言, 他過得很好。

  • And it's a phone call or two a week,

    現在,安寧照護不只照顧老年人,

  • but he's thriving in the context of end-stage lung disease.

    也不只照顧中年人,

  • Now, palliative medicine is not just for the elderly,

    我們照護每一個人。

  • it is not just for the middle-aged.

    來看看我的朋友強納生。

  • It is for everyone.

    我們很榮幸

  • Meet my friend Jonathan.

    請到強納生和他的父親來到現場。

  • We have the honor and pleasure

    強納生二十多歲,我幾年前遇到他。

  • of Jonathan and his father joining us here today.

    他在與轉移性睪丸癌奮鬥,

  • Jonathan is in his 20s, and I met him several years ago.

    擴散到腦部。

  • He was dealing with metastatic testicular cancer,

    他有過中風,

  • spread to his brain.

    他曾動過腦部手術,

  • He had a stroke,

    做過放療、化療。

  • he had brain surgery,

    在跟他及家人會診時,

  • radiation, chemotherapy.

    他才做完骨髓移植幾星期。

  • Upon meeting him and his family,

    他很仔細聽,

  • he was a couple of weeks away from a bone marrow transplant,

    他們說:「可不可以讓我們 了解一下什麼是癌症?」

  • and in listening and engaging,

    我們怎麼撐到這一步,

  • they said, "Help us understand -- what is cancer?"

    一點都不了解我們到底在對抗什麼?

  • How did we get this far

    我們是怎麼走到這一步, 沒有教育任何人,

  • without understanding what we're dealing with?

    讓他們了解他們到底在對抗什麼,

  • How did we get this far without empowering somebody

    再帶他們走下一步, 讓他們以人類的身分參與,

  • to know what it is they're dealing with,

    明白我們到底該不該那樣做?

  • and then taking the next step and engaging in who they are as human beings

    天知道我們會在你們身上做什麼。

  • to know if that is what we should do?

    但是我們應該做嗎?

  • Lord knows we can do any kind of thing to you.

    你可以不信我的話。

  • But should we?

    但所有跟現今安寧照護有關的證據

  • And don't take my word for it.

    都很確定患者活得更好更久。

  • All the evidence that is related to palliative care these days

    2010 年,新英格蘭醫學雜誌 發表了一篇影響深遠的文章。

  • demonstrates with absolute certainty people live better and live longer.

    我在哈佛的同事好友做了一個研究,

  • There was a seminal article out of the New England Journal of Medicine

    在講末期肺癌:

  • in 2010.

    一組有安寧照護,

  • A study done at Harvard by friends of mine, colleagues.

    另一組沒有。

  • End-stage lung cancer:

    有安寧照護那組的報告說 他們比較不痛,

  • one group with palliative care,

    不那麼沮喪。

  • a similar group without.

    他們比較少住院。

  • The group with palliative care reported less pain,

    而且各位,

  • less depression.

    他們能多活三到六個月。

  • They needed fewer hospitalizations.

    如果安寧照護是治療癌症的藥物,

  • And, ladies and gentlemen,

    地球上每一位癌症醫師都應該 開這種藥給病人。

  • they lived three to six months longer.

    他們為什麼不開呢?

  • If palliative care were a cancer drug,

    再說一次,因為我們這群 穿著白袍的傻瓜醫師

  • every cancer doctor on the planet would write a prescription for it.

    只受過訓練處理這樣的問題,

  • Why don't they?

    不是這樣的問題。

  • Again, because we goofy, long white-coat physicians

    我們遲早都會碰到 (經濟與健康)交會之處,

  • are trained and of the mantra of dealing with this,

    但是今天的演講跟死亡無關,

  • not with this.

    而是跟怎麼活著有關。

  • This is a space that we will all come to at some point.

    基於我們的價值觀而活,

  • But this conversation today is not about dying,

    我們視為神聖的東西,

  • it is about living.

    我們想怎麼寫自己生命的章節,

  • Living based on our values,

    無論是最後一章,

  • what we find sacred

    還是最後五章。

  • and how we want to write the chapters of our lives,

    我們知道的,

  • whether it's the last

    我們已證明的,

  • or the last five.

    就是這樣的對話今天就該發生,

  • What we know,

    不是下星期,也不是明天。

  • what we have proven,

    有危急的是我們今天的生活,

  • is that this conversation needs to happen today --

    及我們老了之後的生活,

  • not next week, not next year.

    還有我們的子子孫孫的生活。

  • What is at stake is our lives today

    不僅是在醫院病房裡,

  • and the lives of us as we get older

    或是家裡的沙發。

  • and the lives of our children and our grandchildren.

    無論我們在哪裡看到什麼都一樣,

  • Not just in that hospital room

    安寧醫護就是答案,將病患視為人,