经济学人19:温和地走入那个良夜

 　　Books and Arts; Book Review;Terminal care;

　　文艺；书评;临终关怀;
　　Go gentle into that good night;
　　温和地走入那个良夜;
　　The Best Care Possible: A Physician's Quest to Transform Care Through the End of Life. By Ira Byock.
　　《可能是最好的医护手段：一位内科医生试图改革生命尽头的医护方法。》Ira Byock著作。
　　Asked where they would like to spend their last days, Americans almost always say at home, surrounded by people they love. In real life, though, only one in five achieves that. More than 30% die in a nursing home, where almost no one wants to be, and over half end up in a hospital, often in an intensive-care unit, heavily sedated 1 and attached to life-saving equipment until their doctors give up the battle.
　　对大多数美国人来说，倘若最后的时光能在家中度过，周围环绕着挚爱亲朋，便是走也能走得称心了。然而，只有五分之一的人能实现这个愿望。谁也不想去疗养院，可却有超过三成的人死在那里；另外有超过半数的人死在医院的重症监护室里，身上注射了大量镇定剂，连接在生命维持设备上，直到医生宣布投降。
　　Death is a difficult subject for anyone, but Americans want to talk about it less than most. They have a cultural expectation that whatever may be wrong with them, it can be fixed 2 with the right treatment, and if the first doctor does not offer it they may seek a second, third or fourth opinion. Litigation is a constant threat, so even if a patient is very ill and likely to die, doctors and hospitals will still persist with aggressive treatment, paid for by the insurer or, for the elderly, by Medicare. That is one reason why America spends 18% of its GDP on health care, the highest proportion in the world.
　　死亡对所有人来说都是个难题，相比之下美国人却很少谈起死亡。在他们的文化里，大家都觉得不管生了什么病，只要医治得当就能安然无恙；如果一个医生不行，他们就会去找第二个，第三个，第四个……他们还常常威胁着要起诉医生，所以就算有人病入膏肓，行将就木，医院和医生也会坚持实施高强度治疗，反正年轻人有保险公司付账，老人也有医疗保险撑腰。所以，美国的医疗支出占GDP的18%，高居全球之首。
　　That does not mean that Americans are getting the world's best health care. For the past 20 years doctors at the Dartmouth Institute for Health Policy and Clinical Practice in New Hampshire have been compiling the “Dartmouth Atlas 3 of Health Care”, using Medicare data to compare health-spending patterns in different regions and institutions. They find that average costs per patient during the last two years of life (when health spending is heaviest) in some regions can be almost twice as high as in others, yet patients in the high-spending areas do not survive any longer or enjoy better health as a result.
　　花了最多的钱，未必就能得到最好的卫生保健服务。20年来，新罕布什尔州达特茅斯卫生政策与临床实践学院一直在编纂《达特茅斯卫生保健地图册》。该学院使用医保数据，比较了不同的地区和医疗机构卫生保健支出之间的差异。研究者发现，虽然在生命最后两年中（医疗支出最大），有些地区病人的平均支出可达其它地区的两倍，但是他们的寿命没有延长，健康状况也不比其它地方好。
　　Ira Byock is the director of palliative medicine at Dartmouth-Hitchcock Medical Centre and a professor at Dartmouth Medical School. His book is a plea for those near the end of their life to be treated more like individuals and less like medical cases on which all available technology must be let loose. With two decades' experience in the field, he makes a good case for sometimes leaving well alone and helping 4 people to die gently if that is what they want.
　　Ira Byock是美国达特茅斯希契科克医疗中心的姑息疗法主管，也是达特茅斯医学院教授。他在书中恳请人们把那些生命尽头的人当做“人”来看待，别把他们当成冷冰冰的医疗个案，也别把他们当成各种医疗措施的跑马场。Ira Byock从业已有二十载，在书中为姑息疗法做了强有力的辩护。如果人们只想走得安详些，便不应该徒生枝节，而应该帮助他们满足心愿。
　　That does not include assisted suicide, which he opposes. But it does include providing enough pain relief to make patients comfortable, co-ordinating their treatment among the different specialists, keeping them informed, having enough staff on hand to see to their needs, making arrangements for them to be cared for at home where possible—and not officiously keeping them alive when there is no hope.
　　但是要满足病人的心愿，并不意味着帮助他们自杀，Ira Byock也反对自杀。相反，姑息疗法应该为遭受剧痛折磨的病人缓解痛苦，与其它医疗专家协同合作治疗病人，让病人了解治疗情况，保证有充足的人手为病人服务，还尽可能为病人提供上门服务。当大限到来之时，也不将病人强留于世。
　　This is slippery territory. The Medicare Hospice Benefit act, passed by Congress 30 years ago, offers palliative care to those expected to die within six months, but requires that once they take it up, treatment for their condition must stop. That puts many patients off. And when they hear “palliative care” and “hospice”, their usual reaction is, “I'm not that far gone yet.” Yet hospice patients typically last only two or three weeks. As Dr Byock says, this has become “brink-of-death care”.
　　姑息疗法处境尴尬。美国国会30年前通过了《临终关怀医疗保障法案》，为那些预期寿命只有6个月的病人提供姑息疗法。但是根据该法案，病人一旦选择了姑息疗法，就不得再接受对其病症的治疗，使得许多病人望而却步。而且人们听到“姑息疗法”或者“临终关怀”，总会觉得：“我的情况还没有那么糟吧。”所以，大多数接受临终关怀的病人往往只能生存两到三周。正如Byock所说，这成了“死亡边缘的关怀”。
　　Nor is it easy to decide when to stop making every effort to save someone's life and allow them to die gently. The book quotes the case of one HIV-positive young man who was acutely ill with multiple infections. He spent over four months in hospital, much of the time on a ventilator, and had countless 5 tests, scans and other interventions 6. The total bill came to over $1m. He came close to death many times, but eventually pulled through and has now returned to a normal life. It is an uplifting story, but such an outcome is very rare.
　　究竟何时可以不再尽一切努力挽救病人的生命，而是放手让他们从容走向死亡？很难判断。书中便举出了一个例子：从前，有一位青年身患艾滋病，病情危重，并发多种感染。他在医院里度过了四个月，大多数时间都连在呼吸机上，做了许多次检测、扫描和其它干预治疗，最后医疗总账单超过了100万美元之巨。他曾一次次濒临死亡，最终却挺了过来，过上了正常的生活。这是个让人振奋的故事，但是如此美好的结局很少出现。
　　Dr Byock's writing style is not everybody's cup of tea. The patients' personal stories are told in minute detail, leaving the reader gagging at the degree of physical and psychological suffering that is most people's lot towards the end of their lives. And the author gets rather messianic, advocating a more caring society that shows no sign of materialising. But he is surely right to suggest better management of a problem that can only get worse. As life expectancy 7 keeps on rising, so will the proportion of old people in the population. And with 75m American baby-boomers now on the threshold of retirement 8, there is a limit to what the country can afford to spend to keep them going on and on.
　　Byock博士的写作风格可能不会合所有人的胃口。他把病人的故事事无巨细地一一写出，让读者对多数人死亡前将要面对的心理和生理折磨感到窒息。作者也有些以救世主自居，在书里宣扬一个不太可能出现的更有爱心的社会。不过，他说要妥善处理一个必将越来越严重的问题，这是对的：随着预期寿命不断提高，老年人口的比重也会越来越大。如今，美国婴儿潮中出生的7500万人即将退休，国家财力有限，无法在生命的路途中将他们送上一程一程又一程。