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  • Translator: Joseph Geni Reviewer: Morton Bast

    各位,我本來還在猶豫

  • 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 fearLike, 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

  • So that was really kind of heartbreaking for us,

    因為我們以為這件事已經上了軌道

  • because we thought this was going to really take off.

    文化爭議再次現身聲明立場

  • The cultural issue had reasserted itself.

    我的想法是:

  • So here's the pitch:

    在一路衝進加護病房之前,我們應該要仔細思考

  • I think it's important that we don't just get on this freeway

    到底有沒有這個必要,讓每個人都以這種方式結束生命

  • to ICU without thinking hard about whether or not

    我認為這很重要

  • that's where we all want to end up,

    尤其是當我們老的時候,越來越虛弱

  • particularly as we become older and increasingly frail

    而加護病房能幫到我們的地方越來越少

  • and ICU has less and less and less to offer us.

    對於那些不想走這條路的人

  • There has to be a little side road

    我們必須再開一條小路給他們選

  • off there for people who don't want to go on that track.

    對於未來可能發生的事

  • And I have one small idea,

    我有兩個見解,一大一小