The History of Palliative Care姑息关怀史

郑秀君/译

British doctor Dame1 Cicely Saunders， founded the modern hospice movement which gave rise to palliative care. In 1948， as a 20-year-old nurse in London， she fell in love with a Polish patient who was dying of cancer. He left her ?500 to start a home or hospital to relieve the physical and emotional suffering of people who were dying. Determined to understand the best ways of controlling pain， Saunders became a doctor， against a backdrop of evolving attitudes to end-of-life care in Britain and America. An active approach was emerging， as people became more aware of the intimate connections between physical and mental states， and sought new， creative ways to care for people until the very end of their lives—and beyond， in the care of the bereaved.

英國医生西塞莉·桑德斯女爵士发起了现代临终关怀运动，姑息关怀由此发展而来。1948年，时年20岁的桑德斯在伦敦当护士，她爱上了一位因身患癌症而生命垂危的波兰病人。那位病人遗赠给她500英镑，用于创办一家疗养院或医院来缓解临终病患的身心痛苦。桑德斯下定决心要掌握控制疼痛的最佳方法，于是她转行成为一名医生。当时，英国人和美国人对临终关怀的态度逐渐转变。人们愈发清楚地意识到身心状态之间存在紧密联系，进而试图寻求创新的方法来照护病人直到其生命的最后一刻，并将这些方法延续到对丧亲者的关怀。在这样的背景下，一种积极的疗护方法逐渐兴起。

In 1967， Saunders opened St Christophers Hospice at Sydenham in south-east London， believing passionately that with the right care， the last days of a persons life could be made dignified and happy. She said： “I once asked a man who knew he was dying what he needed above all in those who were caring for him. He said， ‘For someone to look as if they are trying to understand me. It is impossible to understand fully another person， but I never forgot that he did not ask for success but only that someone should care enough to try.”

1967年，桑德斯在位于伦敦东南部的锡德纳姆创建了圣克里斯托弗临终关怀医院。她坚信，在恰当的照护下，一个人生命的最后时光也可以过得有尊严，过得很快乐。桑德斯说：“我曾问过一个知道自己时日不多的人，问他最需要从照护他的人那里得到什么。他答道：‘最需要有人能让我觉得他们在试着理解我。完全理解另一个人是不可能的，而我永远不会忘记，他也不要求有人能完全理解他，他要的只是有人愿意试着理解他。”

Beating total pain

抗击全方位疼痛

Saunders built a life-affirming phil-osophy around the belief that dying is “as natural as being born”， and death should be free from suffering and pain. By listening carefully to patients stories of illness， disease and suffering， Saunders evolved the concept of “total pain”， which includes not just the physical but also social， emotional and spiritual aspects of suffering. Her approach to pain management was simple： constant pain needs constant control. Analgesics were to be given regularly to prevent pain， rather than alleviate it， and they should be used progressively as needed—from mild through to strong. Each patients needs were individual and specific， and their care was to be developed accordingly， with support extended to their family and carers. “You matter because you are you， and you matter to the last moment of your life，” Saunders is famed for saying.

桑德斯相信死亡是“和出生一样自然的过程”，而且死亡应该是没有折磨和疼痛的。基于这个信念，她构建出一套肯定生命价值的理念。她仔细倾听病人讲述疾病与痛苦，提出了“全方位疼痛”的概念。这一概念不仅涉及躯体疼痛，还包括社会、情感以及精神方面的痛苦。桑德斯管理疼痛的方法很简单：疼痛不止，控制不停。镇痛药应该定期使用以预防疼痛，而不是缓和疼痛，还要按照需求逐步调整剂量（从小剂量到大剂量）。每个病人都有个性化的特定需求，因此疗护方案会根据病人的情况来制订，还会为病人家属和照护者提供支持。桑德斯有句名言：“你很重要，因为你就是你，即使在生命的最后一刻，你依然很重要。”

The speciality of palliative medicine was first recognised in the UK in 1987—a key moment in the wider shift away from “terminal” care towards the concept of palliative care. Alongside the realisation that the benefits of holistic palliative care should be expanded to those with life-limited diseases other than cancer， the impetus emerged to move palliative care to earlier stages in disease progression， integrating it with curative and rehabilitation. The vision of “palliative care for all” emerged as both desirable and achievable.

1987年，英国最先認可姑息关怀为医学专科——这是从“临终”关怀向姑息关怀充分转变的关键时刻。人们意识到，应该让整体性姑息关怀惠及身患癌症以外其他绝症的病人。与此同时，人们开始希望将姑息关怀更多地应用于疾病进展的早期阶段，将其与治疗和康复结合。“为所有人提供姑息关怀”成为既“渴求”又“可求”的愿景。

A global movement

一场全球性运动

The difference palliative care makes to the lives of patients and their families and carers is radical， so its easy to see why palliative care took off and is now an accepted integral part of health care policies globally. St Christophers Hospice quickly became an inspiring model for others， differing significantly from earlier homes for people nearing death by taking a three-pronged approach， combining excellent clinical care， education and research. The success of this approach fuelled palliative care development worldwide， firstly in affluent countries， then in poorer ones too， with Zimbabwes Island Hospice Service （founded in 1979） considered to be the first in a developing country.

姑息关怀能给病人及其家属和照护者的生活带来巨大变化，由此不难看出姑息关怀为何能迅速发展，又为何能成为当今世界各地医疗政策中公认的必要组成部分。圣克里斯托弗临终关怀医院迅速成为启发同行的典范。这家医院与早期为临终病患设立的疗养院明显不同，采用三管齐下的策略，将顶尖的临床护理、教学、研究结合起来。该策略的成功刺激了姑息关怀在全球的发展，先是在富裕国家，随后是在经济较落后的国家。1979年成立于津巴布韦的艾兰临终关怀服务中心被认为是发展中国家的首个姑息关怀机构。

Today there are more than 8，000 hospices working around the world， and many more specialist palliative care units in hospitals. But the principles of hospice care are also practised in many different settings， such as home-based and day-care services. There are also many successful mentoring and twinning arrangements between hospices and palliative care services in developing countries and their counterparts in the West.

今天，全世界已有超过8000家临终关怀医院，综合医院里还有更多专业的姑息关怀科室。临终关怀的原则也在其他诸多场景中得到应用，比如居家护理和日间护理服务。此外，发展中国家的临终关怀医院和姑息关怀服务中心也与西方同行缔结了许多成功的指导协议和结对合作协议。

Ongoing expansion

持续发展

Pioneers of palliative care have worked tirelessly to promote and develop Saunderss approach. Driven by common goals， they have built collaborative networks on national， regional and international levels， and won committed backing from key bodies such as the World Health Organisation. Its now widely accepted that medical specialisation， the integration of palliative care into mainstream health systems and the development of evidence-based practices are crucial to the ongoing reduction of suffering in people with life-limiting illnesses.

姑息關怀的开拓者们不辞辛劳地推广和改进桑德斯的方法。在共同目标的驱动下，他们在国家、地区和国际层面建立了合作关系网，并且获得了世界卫生组织等重要机构的鼎力支持。现在，人们普遍认为，医学专科化、将姑息关怀纳入主流医疗体系、发展循证医学，这三者对持续减轻绝症患者的痛苦至关重要。

The World Health Organisation in 2012 estimated that over 40 million people needed palliative care and that with proper palliative care， the suffering of these people could be prevented. With people living in vast swathes2 of the world still unable to access any sort of palliative care， its vital that the expansion continues.

2012年，世界卫生组织估计有超过4000万人需要姑息关怀，并称恰当的姑息关怀能让他们免受痛苦。由于世界上大多数地区的人们仍然没有途径得到任何形式的姑息关怀，继续扩大姑息关怀的惠及范围至关重要。

（译者为“《英语世界》杯”翻译大赛获奖者；单位：中山大学）