Look, I had second thoughts, really,

該不該跟你們這些

about whether I could talk about this

充滿活力與精力的觀眾討論這件事

to such a vital and alive audience as you guys.

然後我想到Gloria Steinem說過的話

Then I remembered the quote from Gloria Steinem,

她說：

which goes,

"真相能讓你自由，

"The truth will set you free,

但是你會先被惹毛。"（笑聲）

but first it will piss you off." (Laughter)

所以．．．（笑聲）

So -- (Laughter)

這句話我銘記在心，所以等一下我要做的

So with that in mind, I'm going to set about

就是遵循這個忠告，

trying to do those things here,

然後談論21世紀對死亡的看法

and talk about dying in the 21st century.

無庸置疑，現在第一個讓你們不爽的事情就是

Now the first thing that will piss you off, undoubtedly,

即使已到了21世紀

is that all of us are, in fact, going to die

我們所有人還是難逃一死

in the 21st century.

沒有人能例外

There will be no exceptions to that.

根據統計，你們之中大概每八個就有一個

There are, apparently, about one in eight of you

認為自己是不死之身，但是．．．

who think you're immortal, on surveys, but --

(笑聲)

(Laughter)

很抱歉，沒這種事

Unfortunately, that isn't going to happen.

接下來我在演講的這十分鐘內

While I give this talk, in the next 10 minutes,

我體內的細胞會死掉一億個

a hundred million of my cells will die,

今天一整天下來，我的腦細胞

and over the course of today, 2,000 of my brain cells

會死掉兩千個，而且不會再復活

will die and never come back,

所以我們可以這樣說，死亡的過程

so you could argue that the dying process

很早就開始了

starts pretty early in the piece.

總之，關於21世紀對死亡的看法

Anyway, the second thing I want to say about dying in the

我要說的第二件事是， 除了所有人都難逃一死之外

21st century, apart from it's going to happen to everybody,

就是死亡對於我們大多數的人而言，有點像是

is it's shaping up to be a bit of a train wreck

火車事故

for most of us,

除非我們試圖改變現況而有所作為

unless we do something to try and reclaim this process

讓火車離開這條直直朝災難而去的軌道

from the rather inexorable trajectory that it's currently on.

你們看。這就是真相

So there you go. That's the truth.

難怪你會被惹毛，接下來我們來看看

No doubt that will piss you off, and now let's see

你能不能獲得自由。這我可不敢保證

whether we can set you free. I don't promise anything.

好，你們剛剛在簡介裡聽到了，我在加護病房工作

Now, as you heard in the intro, I work in intensive care,

而且我經歷過加護病房的全盛時期

and I think I've kind of lived through the heyday

說真的，那很不得了

of intensive care. It's been a ride, man.

那種感覺很棒

This has been fantastic.

我們有鏗鏘作響的機器

We have machines that go ping.

照片裡面就有一堆

There's many of them up there.

我們也有傑出的技術，我認為

And we have some wizard technology which I think

那些技術的效果很好，我在加護病房

has worked really well, and over the course of the time

工作的那段時間，澳洲男性的

I've worked in intensive care, the death rate

死亡率降了一半

for males in Australia has halved,

這有些要歸功於加護病房

and intensive care has had something to do with that.

當然，很多我們採用的科技

Certainly, a lot of the technologies that we use

都有助於降低死亡率

have got something to do with that.

也因此我們的成就相當可觀

So we have had tremendous success, and we kind of

而且我們也沉浸在成功的喜悅之中

got caught up in our own success quite a bit,

然後我們開始使用 “拯救生命” 這種字眼

and we started using expressions like "lifesaving."

為此，我必須跟各位道歉

I really apologize to everybody for doing that,

因為我們根本沒有 “拯救生命”

because obviously, we don't.

我們只是延長人們的壽命

What we do is prolong people's lives,

延遲死亡的到來

and delay death,

避開死亡這個結局，但嚴格說來，我們辦不到

and redirect death, but we can't, strictly speaking,

我們無法違背這些恆久不變的原則，拯救生命

save lives on any sort of permanent basis.

而事實上這段期間發生的事

And what's really happened over the period of time

也就是我在加護病房工作的時候

that I've been working in intensive care is that

當初我們在70、80和90年代所拯救的性命

the people whose lives we started saving back in the '70s,

到了21世紀都一一離開人世了

'80s, and '90s, are now coming to die in the 21st century

一些疾病讓我們束手無策

of diseases that we no longer have the answers to

無法像以前一樣醫治他們

in quite the way we did then.

所以現況是，人們的死亡方式

So what's happening now is there's been a big shift

產生了極大的轉變

in the way that people die,

80、90年代時，大多數病患的死因

and most of what they're dying of now isn't as amenable

我們都還能掌控

to what we can do as what it used to be like

但是現在我們卻束手無策

when I was doing this in the '80s and '90s.

可以說我們陷入困境了

So we kind of got a bit caught up with this,

而且對於現在發生的事

and we haven't really squared with you guys about

我們之間還沒取得共識，不過現在是好時機

what's really happening now, and it's about time we did.

90年代末期，我遇到了這個人

I kind of woke up to this bit in the late '90s

他讓我有了這種想法

when I met this guy.

他叫Jim，Jim Smith，這是他的照片

This guy is called Jim, Jim Smith, and he looked like this.

我被叫去病房看他

I was called down to the ward to see him.

這隻小手是他的

His is the little hand.

是一名呼吸科醫生

I was called down to the ward to see him

叫我去病房看他的

by a respiratory physician.

他說：“聽我說，樓下有個

He said, "Look, there's a guy down here.

得了肺炎的人

He's got pneumonia,

看起來應該需要特別的監護

and he looks like he needs intensive care.

他的女兒在這裡，她希望我們

His daughter's here and she wants everything possible

盡全力照顧他”

to be done."

這句話聽起來很耳熟

Which is a familiar phrase to us.

所以我到樓下的病房看Jim

So I go down to the ward and see Jim,

他的皮膚像這樣，是半透明的

and his skin his translucent like this.

你可以看到皮膚底下的骨頭

You can see his bones through the skin.

他非常非常瘦

He's very, very thin,

當然，他也被肺炎折磨得很慘

and he is, indeed, very sick with pneumonia,

虛弱到連跟我說話的力氣都沒有

and he's too sick to talk to me,

所以我跟她的女兒Kathleen說，我對她說

so I talk to his daughter Kathleen, and I say to her,

“妳和Jim有沒有聊過

"Did you and Jim ever talk about

如果他就這樣過世

what you would want done

妳會怎麼處裡嗎？”

if he ended up in this kind of situation?"

然後她看著我，她說：“沒有，當然沒有！”

And she looked at me and said, "No, of course not!"

我心想：“好吧。別刺激她。”

I thought, "Okay. Take this steady."

然後我跟她聊了這件事，過了一會兒，她跟我說

And I got talking to her, and after a while, she said to me,

“你知道嗎，我們都一直以為還有時間。”

"You know, we always thought there'd be time."

Jim已經94歲了。（笑聲）

Jim was 94. (Laughter)

然後我才發現，有些事情並沒有實現

And I realized that something wasn't happening here.

如果我想像的事情實現了

There wasn't this dialogue going on

我們就不會有這種對話了

that I imagined was happening.

所以我們的團隊開始著手考察

So a group of us started doing survey work,

然後我們仔細研究了4500間的看護之家

and we looked at four and a half thousand nursing home

位於Newcastle的，Newcastle地區的

residents in Newcastle, in the Newcastle area,

然後發現他們只有百分之一

and discovered that only one in a hundred of them

有針對病患的心跳停止後的應變計畫

had a plan about what to do when their hearts stopped beating.

百分之一

One in a hundred.

他們之中只有五百分之一 有針對病情惡化的

And only one in 500 of them had plan about what to do

應變計畫

if they became seriously ill.

然後我才了解，當然啦

And I realized, of course, this dialogue

這種話題是不會在公開場合討論的

is definitely not occurring in the public at large.

我現在在重症病房工作

Now, I work in acute care.

這間是John Hunter醫院

This is John Hunter Hospital.

然後我想，對啊，我們的作法比較完善

And I thought, surely, we do better than that.

所以我看護所的同事Lias Shaw和我

So a colleague of mine from nursing called Lisa Shaw and I

仔細研究了成千上萬份的紀錄

went through hundreds and hundreds of sets of notes

收在醫療紀錄部裡面的

in the medical records department

我們想找出任何蛛絲馬跡

looking at whether there was any sign at all

到底有沒有人曾經討論過

that anybody had had any conversation about

萬一他們正在進行的那些療程一直沒有效果

what might happen to them if the treatment they were

而病人也只剩一口氣了，要怎麼辦？

receiving was unsuccessful to the point that they would die.

但是這麼多份醫生或病患的紀錄裡

And we didn't find a single record of any preference

關於這些情況的治療目標，治療方式或結果

about goals, treatments or outcomes from any

卻連一項都沒有提到

of the sets of notes initiated by a doctor or by a patient.

因此我們才了解

So we started to realize

我們有問題

that we had a problem,

而這個問題之所以那麼嚴重，是因為

and the problem is more serious because of this.

我們都很清楚，人遲早一死

What we know is that obviously we are all going to die,

而死因為何，對我們真的非常重要

but how we die is actually really important,

不僅對我們很重要，對所有曾目睹死亡

obviously not just to us, but also to how that

的在世者而言，這種形象也非常重要

features in the lives of all the people who live on afterwards.

我們死亡的形象，仍然存活在所有

How we die lives on in the minds of everybody

在世者的心中

who survives us, and

而目睹死亡會對家人產生極大的壓力

the stress created in families by dying is enormous,

事實上，處以重症看護的彌留病患

and in fact you get seven times as much stress by dying

承受的壓力是其他環境的七倍之多

in intensive care as by dying just about anywhere else,

所以死於重症看護並不是你的最佳選擇

so dying in intensive care is not your top option

如果你有選擇餘地的話

if you've got a choice.

當然，如果你覺得這樣還不夠慘

And, if that wasn't bad enough, of course,

所有我們採取的作法都讓情況急速惡化了

all of this is rapidly progressing towards the fact that

目前，你們會有很多人，事實上是十分之一

many of you, in fact, about one in 10 of you at this point,

死於重症看護

will die in intensive care.

在美國，比例是五分之一

In the U.S., it's one in five.

在邁阿密，有五分之三的人死於重症看護

In Miami, it's three out of five people die in intensive care.

所以這就是我們

So this is the sort of momentum

現在所處的態勢

that we've got at the moment.

這就是這些事情會發生的原因

The reason why this is all happening is due to this,

所以我必須帶你們深入探討這件事

and I do have to take you through what this is about.

我們有四個選擇

These are the four ways to go.

我們會遇上其中一項

So one of these will happen to all of us.

你們最熟悉的那個死因

The ones you may know most about are the ones

也是醫療界越來越多人研究的

that are becoming increasingly of historical interest:

猝死

sudden death.

如果以現場觀眾人數的比例而言

It's quite likely in an audience this size

你們當中不會有人猝死

this won't happen to anybody here.

猝死變得相當罕見

Sudden death has become very rare.

類似Little Nell和Cordelia的死因

The death of Little Nell and Cordelia and all that sort of stuff

再也沒出現過了

just doesn't happen anymore.

我們剛剛看到的，罹患這種極嚴重病症的

The dying process of those with terminal illness

死亡過程

that we've just seen

發生在年紀比較輕的人身上

occurs to younger people.

等你活到80歲的時候，這種事不太可能發生在你身上

By the time you've reached 80, this is unlikely to happen to you.

超過80歲的人，只有十分之一死於癌症

Only one in 10 people who are over 80 will die of cancer.

比例大幅攀升的是這塊區域

The big growth industry are these.

你的死因是器官逐漸衰竭

What you die of is increasing organ failure,

呼吸系統，心臟病，腎臟

with your respiratory, cardiac, renal,

隨便哪個器官都行。每一個症狀都是

whatever organs packing up. Each of these

你進入醫院加護病房的通行證

would be an admission to an acute care hospital,

到了最後，或是這期間的某個時刻

at the end of which, or at some point during which,

有人會說，我受夠了，到此為止

somebody says, enough is enough, and we stop.

這是攀升幅度最大的區塊

And this one's the biggest growth industry of all,

今天現場的人，至少有十分之六

and at least six out of 10 of the people in this room

會有這種死法，那就是

will die in this form, which is

體力越來越差

the dwindling of capacity

身體越來越虛弱

with increasing frailty,

而虛弱是不可逆轉的老化過程

and frailty's an inevitable part of aging,

其實，日漸衰敗的身體才是

and increasing frailty is in fact the main thing

現代人最主要的死因

that people die of now,

最後那幾年，或是說你生命中最後那幾年

and the last few years, or the last year of your life

都困在重度失能的狀態，這很可悲

is spent with a great deal of disability, unfortunately.

目前為止還不錯吧 (笑聲)

Enjoying it so far? (Laughs)

(笑聲)

(Laughter)

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

Sorry, I just feel such a, I feel such a Cassandra here.

(笑聲)

(Laughter)

這怎麼能稱上得上是件好事？這種好事是指

What can I say that's positive? What's positive is

在現代社會，這發生在很老很老的人身上

that this is happening at very great age, now.

我們都能，我們大多數都能，活到那種歲數

We are all, most of us, living to reach this point.

你知道嗎，根據歷史紀載，我們以前沒辦法

You know, historically, we didn't do that.

當你活了一大把歲數

This is what happens to you

這種事就會發生在你身上

when you live to be a great age,

不幸的是，平均壽命增加表示的是

and unfortunately, increasing longevity does mean

老人會越來越多，不是年輕人

more old age, not more youth.

很遺憾宣佈這種消息 (笑聲)

I'm sorry to say that. (Laughter)

總之，我們以前的做法，注意，我們以前的做法

What we did, anyway, look, what we did,

我們以前不會束手待斃

we didn't just take this lying down

不管是在John Hunter醫院或是任何地方

at John Hunter Hospital and elsewhere.

我們推行了一連串的計畫

We've started a whole series of projects

試著找出我們是否能做些甚麼，其實

to try and look about whether we could, in fact, involve

這些嘗試涉及的人更多，包括那些不久於人世的

people much more in the way that things happen to them.

但是我們明白，當然，我們處裡的是

But we realized, of course, that we are dealing

文化上的爭議

with cultural issues,

還有這個，我喜歡這幅Klimt的畫

and this is, I love this Klimt painting,

因為你們思考得越多，你們應該就越能了解

because the more you look at it, the more you kind of get

今天主要的議題是甚麼

the whole issue that's going on here,

在生與死之間，畫出一條清晰的界線

which is clearly the separation of death from the living,

還有恐懼 - 比如說，如果你仔細看

and the fear — Like, if you actually look,

畫裡有個女人

there's one woman there

她的眼睛是張開的

who has her eyes open.

他在看的就是她

She's the one he's looking at,

他就是為她而來的。你們看到沒有？

and [she's] the one he's coming for. Can you see that?

她的樣子嚇呆了

She looks terrified.

這幅畫很不可思議

It's an amazing picture.

總之，以前我們最常遇見的文化爭議

Anyway, we had a major cultural issue.

顯然就是，沒有人想跟我們談論死亡

Clearly, people didn't want us to talk about death,

或許是我們的誤解

or, we thought that.

所以聯邦政府撥出了一堆基金

So with loads of funding from the Federal Government

在地的健康機構也是，我們跟你們介紹

and the local Health Service, we introduced a thing

John Hunter醫院稱之為 “病患選擇優先權”

at John Hunter called Respecting Patient Choices.

我們訓練了好幾百人，走進病房

We trained hundreds of people to go to the wards

告訴他們，其實他們來日不多了

and talk to people about the fact that they would die,

然後問他們，事到如今，他們的想法是甚麼

and what would they prefer under those circumstances.

他們喜歡這種做法。病人和家屬，他們都喜歡

They loved it. The families and the patients, they loved it.

百分之九十八的人認為

Ninety-eight percent of people really thought

這應該納入例行手續

this just should have been normal practice,

本來就應該這樣做

and that this is how things should work.

他們表達意願之後

And when they expressed wishes,

這些願望都實現了，都比照辦理

all of those wishes came true, as it were.

我們曾經有能力幫他們達成

We were able to make that happen for them.

但是，基金用完了

But then, when the funding ran out,

六個月之後，我們回去看的時後

we went back to look six months later,

所有人又回歸起點

and everybody had stopped again,

再也沒人討論這些問題了

and nobody was having these conversations anymore.

所以我們真的覺得很失望