How Doctors die. It’s not like the rest of us (2016)

How Doctors Die. It’s not like the rest of us (2016)

医生是如何离世的？他们与我们截然不同（2016）

This hard-hitting blogpost by Ken Murray, a retired Los Angeles family doctor, helped open up discussions about why doctors routinely administer treatments to dying patients that they would adamantly refuse for themselves. 这篇由洛杉矶退休家庭医生肯·默里（Ken Murray）撰写的重磅博文，引发了人们对于一个现象的讨论：为什么医生经常给垂死的病人提供他们自己绝对会拒绝的治疗方案？

Years ago, Charlie, a highly respected orthopaedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds – from 5% to 15% – albeit with a poor quality of life. 多年前，我的一位导师查理（Charlie）是一位备受尊敬的骨科医生，他在腹部发现了一个肿块。他请了一位外科医生进行探查，诊断结果是胰腺癌。这位外科医生是全国顶尖的专家，甚至发明了一种针对该癌症的新手术，能将患者的五年生存率提高三倍——从5%提高到15%——尽管这会以牺牲生活质量为代价。

Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him. 查理对此毫无兴趣。第二天他就回了家，关掉了诊所，从此再也没有踏进医院一步。他专注于陪伴家人，并尽可能让自己感觉舒适。几个月后，他在家中去世。他没有接受任何化疗、放疗或手术治疗。医疗保险在他身上并没有花费太多。

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. 虽然这不是一个常被讨论的话题，但医生也会死亡。而且他们的离世方式与我们其他人不同。他们的特别之处不在于他们比大多数美国人接受了多少治疗，而在于他们接受的治疗是多么少。尽管他们终其一生都在努力挽救他人的生命，但当面对自己的死亡时，他们往往表现得相当平静。

They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently. Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. 他们清楚地知道将会发生什么，了解所有的选择，并且通常能获得他们想要的任何医疗服务。但他们选择平静地离去。当然，医生也不想死，他们也想活下去。但他们对现代医学了解得足够多，知道它的局限性。他们也足够了解死亡，知道人们最恐惧的是什么：在痛苦中死去，以及孤独地死去。

They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen – that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with cardiopulmonary resuscitation (that’s what happens if CPR is done right). 他们会与家人讨论这些问题。他们想确保当那一刻来临时，不会有任何“英雄式”的抢救措施——他们绝不希望在人生的最后时刻，有人为了进行心肺复苏（CPR）而压断他们的肋骨（如果CPR操作正确，这确实会发生）。

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. 几乎所有的医疗专业人员都见过我们所说的“无效医疗”。那是医生将尖端技术应用于生命垂危的病人身上。病人会被切开身体、插满管子、连接上机器，并被药物“狂轰滥炸”。这一切都发生在重症监护室（ICU），每天花费数万美元。而这换来的，却是我们甚至不忍施加给恐怖分子的痛苦。

I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo. 我数不清有多少次，同行们用大同小异的话对我说：“答应我，如果我变成那样，请杀了我。”他们是认真的。一些医务人员佩戴刻有“NO CODE”（拒绝抢救）字样的奖章，以告知医生不要对他们进行心肺复苏。我甚至见过有人把它纹在身上。

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice. 提供让病人受苦的医疗服务是令人痛苦的。医生受过训练，在收集信息时不能流露个人情感，但在私下里，在同行之间，他们会发泄。“怎么有人能对自己的家人做这种事？”他们会这样问。我怀疑这就是为什么医生群体的酗酒和抑郁比例高于大多数其他行业的原因之一。我知道，这也是我职业生涯最后10年停止参与医院护理工作的原因之一。

How has it come to this – that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system. To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. 事情怎么会变成这样——医生提供了如此多他们自己都不想要的治疗？简单（或者说并不简单）的答案是：病人、医生和医疗体系。要了解病人在其中扮演的角色，想象一下某人失去意识被送进急诊室的情景。通常情况下，没有人为此做过预案，惊慌失措的家属发现自己陷入了选择的迷宫。他们不知所措。当医生问他们是否要“尽一切努力”时，他们回答“是”。于是，噩梦开始了。

Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not. The above scenario is a common one. 有时，家属确实是指“尽一切努力”，但更多时候他们只是指“尽一切合理的努力”。问题在于，他们可能不知道什么是合理的，而且在困惑和悲伤中，他们也不会去询问，或者听不进医生在说什么。而医生在被要求“尽一切努力”时，无论是否合理，都会照做。上述场景非常普遍。

Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a ‘tension pneumothorax’), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions. 导致这一问题的还有对医生能力不切实际的期望。许多人认为心肺复苏是一种可靠的救命手段，但事实上，其效果通常很差。在急诊室，我见过数百名接受过心肺复苏后被送来的病人。其中只有一个人——一个没有心脏病史的健康男性（具体来说，他患的是“张力性气胸”）——活着走出了医院。如果病人患有重病、高龄或绝症，心肺复苏带来良好结果的几率微乎其微，而遭受痛苦的几率却极大。知识匮乏和错误的期望导致了许多糟糕的决定。

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment. Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portraye… 当然，造成这种情况的不仅仅是病人。医生也起到了推波助澜的作用。问题在于，即使是那些厌恶实施无效医疗的医生，也必须找到一种方法来回应病人及其家属的意愿。再次想象一下急诊室里那些悲痛欲绝、甚至歇斯底里的家属。他们不认识医生。在这种情况下建立信任是一件非常微妙的事情。人们往往倾向于认为医生动机不纯，是为了省时间、省钱或省事，尤其是当医生建议停止进一步治疗时。有些医生比其他人更善于沟通，有些医生更坚定，但他们面临的压力是相似的。当我面对涉及临终选择的情况时，我采取的方法是尽可能早地只列出我认为合理的方案（就像我在任何情况下所做的那样）。当病人或家属提出不合理的选择时，我会用通俗易懂的语言讨论这个问题，并描述……