The Hidden Power of Palliative Care姑息关怀的潜在力量

萨钦·H. 贾殷　商裴裴/译

Susan is 98 years old. Shes been diagnosed with hypertension and memory loss. She experiences frequent pain spells and， like many people her age， shes at risk of falling， especially when she becomes tired. Five years ago， Susan fell， fractured her pelvis and spent an unhappy month in a skilled nursing facility. Physicians like myself often see patients like Susan in hospitals across the country. Typically， we treat them and send them on their way. And just as typically， patients like Susan often reappear in the hospital， either with new ailments or when the old ones show up again.

苏珊，98岁，患有高血压并表现出记忆丧失。她经常突发疼痛，而且与很多同龄人一样，她容易跌倒，疲劳时更是如此。五年前，因摔倒造成骨盆骨折，苏珊在专业护理机构住了一个月，那一个月过得可不舒服。像我这样的医生经常在全国各地的医院里碰到像苏珊这样的病人。通常情况下，我们救治患者，帮助他们康复回家。可像苏珊这样的患者经常会因为患上新病或旧病复发再次来到医院，这种情况同样时有发生。

But not Susan. She has not been inside a hospital in more than a year. In fact， these days youll find her drinking coffee with her daughter in the comfort of her San Fernando Valley home， completely unaware that she represents the future of palliative care.

但苏珊没有。她已经一年多没进过医院了。如今，你會发现她在圣费尔南多谷舒适的家里和女儿喝咖啡，完全没有意识到自己代表的正是姑息关怀的未来。

When I was a medical student， I believed in the infinite power of medical interventions to save lives. Lately， however， my thoughts have changed somewhat. As I watch my patients， my parents， and some of my close friends age， Ive begun to think that， when it comes to people nearing the end of their lives， perhaps we put too much emphasis on curing diseases—and not enough on humanely helping our patients accept their diagnoses， counseling them on how to find enjoyment in their remaining days， and providing them with the knowledge they need to make informed end-of-life care decisions.

读医期间，我坚信医疗手段拥有无穷力量，能挽救生命。最近，我的想法却略有改变。看着我的患者、父母，还有几个好友渐渐老去，我开始思考，对即将走到人生尽头的人，我们可能过于强调怎么治好疾病，却不够重视人道主义关怀，比如帮助患者接受诊断结果，就如何乐享余生提供建议，并告知他们所需信息，以便他们在知情的前提下选择临终护理。

Truth be told， if you look back at the history of medicine， the profession was always more concerned with symptom management than curing disease. Hippocrates is known as the “father of medicine，” but perhaps a better title for him would be the “father of palliative care.” Though his belief in balancing the bodys four “humors1” was off the mark2， he nevertheless understood the primal importance of comforting patients by alleviating their symptoms， which in his case usually involved the use of herbal medicines.

说实话，如果你回顾一下医学发展史，就会发现这个行业一向更关注管理症状，而非治愈疾病。希波克拉底，人称“医学之父”，但也许更恰当的称谓是“姑息关怀之父”。他认为人体应该维持四种“体液”的平衡，虽然说得不够准确，但他清楚地知道通过缓和症状来安抚病患至关重要，他本人就常常使用草药来缓和病人的症状。

In the modern world， our focus has shifted primarily to curative medicine. In many cases， this is the correct approach. From plague to heart disease to many forms of cancer to cystic fibrosis， we can now cure an astonishing array of illnesses， allowing people to live longer， healthier lives than ever before.

到了现代社会，我们基本已经把注意力转向了治疗医学。在许多情况下，这是正确的做法。现在，我们能够治愈一系列疾病，包括瘟疫、心脏病、多种癌症、囊性纤维化，可治愈的种类之多，令人惊叹，人们也因此比以往任何时候都更长寿、更健康。

And yet， for many seniors， no medicine or treatment of any kind can effectively stave off3 the inevitable. TV shows about hospitals have burned images into our brains of heroic doctors helping their patients outwit death. But in reality， it rarely works this way. As seniors age and experience deteri-orating health， many bounce in and out of emergency departments， general and geriatric wards， and intensive care units. The time they spend in hospitals， hooked up to a myriad of tubes and subjected to a litany of tests， is rarely pleasant for them or their families—or even in accordance with their wishes. Eighty percent of Americans say they would like to die at home. And yet， about 60% of Americans ultimately pass away in hospitals， with 20% spending their final days in an ICU.

然而，對很多老人来说，该来的迟早会来，任何药物或治疗手段都回天无力。以医院为题材的电视剧里，医生帮助病人战胜死亡，这种英雄形象深深地印刻在我们的脑海里。可在现实中，这样的场景极其少见。随着年岁渐长，身体每况愈下，很多老人会频繁出入急诊室、普通病房、老年病房和重症监护室。他们在医院里插上一大堆管子，忍受一连串检查，无论对他们还是他们的家属而言都极不舒服，甚至不符合他们的意愿。80%的美国人表示希望死在家里。可是，约60%的美国人最终在医院离世，其中有20%在重症监护室里走完了人生的最后时光。

This presents a problem not just for patients and their families， but for the health system as a whole. One-quarter of Medicare spending goes toward caring for people in their final year of life. Moreover， a study of family members of patients who died from cancer found that only half felt their loved one had received excellent end-of-life care. Altogether， this suggests that we as a whole are directing valuable health care resources toward hospital-based end-of-life care that few people want—and that many people say is inadequate.

这给病人及其家属，乃至整个医疗体系带来一个难题。美国国家老年人医疗保险25%的支出都用在了病人临终前一年的护理上。此外，针对已离世癌症病人的家属，一项研究发现仅半数认为他们的挚亲得到了优质的临终关怀。总之，这表明我们整个社会都在将宝贵的医疗卫生资源投入到以医院为依托的临终护理，可是几乎没有人想要这种护理，而且很多人也说这种护理不够好。

But there is an alternative. Physicians could put less emphasis on trying to cure late-stage illnesses in hospital settings and instead focus on the avoidance of suffering， and helping our patients make informed decisions about how they want to spend their final days. This， in a nutshell， is the goal of quality palliative care. Unfortunately， palliative care has often been seen as a hospital-based transition to hospice care. But an increasing body of evidence suggests that， when provided in the patients home， good palliative care can lead people to live a high-quality end-of-life.

其实还有一个选择。医生可以少关注怎样在医院里治好晚期疾病，而把重点放在如何避免痛苦，以及帮助病人就自己想怎样走完最后的日子作出知情决策。简单来说，这就是高质量姑息关怀的目标。可惜，人们往往认为姑息关怀依托于医院，是病人转向临终关怀的过渡阶段。但越来越多的证据表明，如果在家接受优质的姑息关怀，患者便可拥有高质量的临终生活。

Which brings us back to Susan. Shes a patient of Aspire Health， a company I lead. Under Aspires care model， people like Susan receive home-based care from a specialized team of clinicians whose goals are to provide their patients with quality medical care， keep them out of the hospital， and offer them counsel in their final years. Seventy-one percent of Aspire patients engage in advance care planning4 discussions， allowing them and their families to make informed choices before they end up in the hospital， connected to tubes.

让我们回过头再看看苏珊的故事。她是由我领导的阿斯皮尔健康公司的患者。在阿斯皮尔的护理模式下，像苏珊这样的病人可以获得来自专业医生团队的居家护理。他们旨在为患者提供优质的医疗护理，避免患者出入医院，在患者生命的最后几年里提供咨询服务。阿斯皮尔71%的患者可以参与预先护理计划的讨论，在全身插着管子躺在医院之前，他们得以和家人共同作出知情决策。

On a recent afternoon， Susan sat at her kitchen table with her daughter， Jenny， and Liz Garcia， an Aspire nurse practitioner who visits Susan in her home every four to six weeks. Susan sipped coffee， nibbled a muffin and gazed at the view of the valley while Liz took her blood pressure. Nearby， Rufus， Susans dog， slept in the sun. Susan told Liz that she fell the night before， so she checked her legs for signs of bruising and offered to connect her with a service to evaluate her home for safety. “The goal is for you to be here at home， to be taken care of，” Liz explained.

前几天的一个下午，苏珊和女儿珍妮坐在餐桌前，和她们在一起的还有阿斯皮尔的执业护师利兹·加西亚，她每四到六周会去苏珊家里探望。利兹给苏珊量血压的时候，苏珊一边小口喝着咖啡、吃着松饼，一边凝视着山谷的风光。旁边，苏珊的狗鲁弗斯正躺在阳光下睡大觉。苏珊告诉利兹，自己昨晚摔倒了，于是利兹检查她的双腿，看看有没有淤青。利兹还主动提出要为苏珊联系家庭安全状况评估服务。“我们的目标就是让你居家生活、有人照护。”利兹说。

Care models like Aspires not only provide patients like Susan with a dignified experience， they reduce costs. Aspire patients are two-thirds less likely than other people to experience expensive hospitalizations， which results in significant cost savings.

类似阿斯皮尔这样的护理模式不仅让苏珊这样的患者感觉活得体面，还为他们节约了开支。阿斯皮尔的患者需要花大钱住院的可能性减少了三分之二，这大大降低了费用。

Of course， I recognize that theres a tension here. Our job as physicians， I believe， is to offer our patients hope. Nevertheless， that isnt our only job. It is also incumbent upon us to be honest comforters， to help our patients avoid suffering， and to have difficult discussions with them about the most delicate of subjects.

当然，我清楚这份工作存在一个矛盾。作为医生，我相信我们要给患者带去希望。可是，这不是我们唯一的职责。我们也有责任坦诚地宽慰病人，帮助他们避免痛苦，并与他们就最敏感的话题进行艰难的讨论。

After Liz updated Susans medical record， she closed her laptop and got up to leave. But first， Susan wanted to show her the two Oscars her late husband won for set design. As Liz held the gold statuettes， Susan pointed out the Christmas tree she keeps year-round in the living room to remind her of her husband， who loved Christmas and died in late December. “Hes still with me，” Susan said adding， “I have my dog. I have my view. And I have my neighbors. Im happy to be home.”

利茲更新完苏珊的病历，合上笔记本电脑，起身准备离开。临走前，苏珊想给她看看丈夫生前凭借布景设计获得的两座奥斯卡奖杯。正当利兹拿起小金人奖杯，苏珊说客厅里的那棵圣诞树放了整整一年，为的就是能让她时常想起自己的丈夫。她丈夫喜欢圣诞节，又死于12月底。“他还在我身边。”苏珊接着说，“我还有狗，还有风景，还有邻居。住在家里真好！”

（译者为“《英语世界》杯”翻译大赛获奖者）