Many years ago, there was a popular saying in society that Chinese "cannot afford to live, cannot afford to live, cannot afford to be sick, and cannot afford to die". "Can't afford to die" here refers to the high cost of funeral. With the development of science and technology, the biggest problem faced by doctors is not how to "live", but how to "walk well". To some extent, not dying a "good death" may be the most neglected happiness problem now. China's major cities are releasing happiness indices one after another. But these releases are forgetful – ignoring the fact that "quality of death" is also a core indicator of happiness.
Life is the beginning of death, and death is the end of life. Death is something that everyone has to face, and in terms of the physical aspect, the physiology of the dying person usually presents with various problems. In the midst of all kinds of physical and mental burning, death creates a kind of fear and anxiety. Hence the term "Quality of death". The "Death Quality Index" can see through a country's medical philosophy and humanistic spirit. Hospice care is a symbol of the development of human civilization and a demand for social progress. While we devote too much energy to exploring the "cause of death", perhaps we should think about the cause of life when we are both alive – the "reason for living". Life Care is an inclusive cause, and everyone can make their own unique contribution.
Sometimes, goodbye may be the most affectionate confession. Letting go may be the most profound retention.
About death, this could be an article that turns your perception upside down!
01
In 1999, Mr. Barking became seriously ill and was admitted to the hospital.
After some resuscitation, the life was saved, but the nasogastric tube was inserted from then on. "Feed through a gastric tube and into the stomach six times a day." The tube had to be changed at least every two months, and "the long tube went straight from his nose to his stomach, and he choked on his face every time he changed the tube." After being intubated for a long time, his mouth could not be closed, and Ba Jin's jaw was dislocated, "so he had to cut open his trachea and use a ventilator to maintain breathing."
Ba Jin himself wanted to give up this kind of life-or-death treatment, but he had no choice, because his family and leaders did not agree.
"Everyone who loves him wants him to live!"
Even if it's unconscious, even if it's on a ventilator, as long as the machine shows that there is still a heartbeat. In this way, Ba Jin suffered in his hospital bed for six whole years.
He said: "Longevity is a torture for me".
02
A doctor in Shanghai told such an ordinary thing - the reason why I say ordinary is because such things happen every day in major hospitals.
An 80-year-old man was admitted to the hospital with a cerebral hemorrhage. The family advised: "No matter what, we must let him live!"
After the operation, he survived, his trachea was cut open and a hole was punched in his larynx, where a thick tube was connected to the ventilator.
Occasionally, he would wake up a little and open his eyes painfully. At this time, the family will be extremely excited, take my hand and say, "Thank you for saving him".
His family took turns accompanying him day and night, staring intently at the numbers on the monitor, and at every time he saw a change, he would immediately run to me.
Later, the old man became swollen, his head was like a balloon, and to make matters worse, his airways were bleeding profusely, which made him need to clear his airways more frequently. With each aspiration, the nurse inserts a long tube into his nasal cavity, and blood clots and bloody secretions are sucked out. The process was painful, and I saw him frowning, desperately trying to dodge the tube that was sticking in. But if you clean it repeatedly every day, you can still suck out a lot.
Whenever this happens, his granddaughter always keeps her head down, not daring to look. I asked the family members, "Hold it off or give up?" The granddaughter whispered, "If he dies, I won't have a grandfather."
The treatment became more and more helpless, and he was awake for less time. And the only waking time left is also ruthlessly occupied by sucking and pricking. His death was near, and it was as clear to me as black and white. Then he said to his granddaughter, "Put some lavender at the bedside." She repeatedly, "Okay." We don't understand, listen to you. ”
The next day's rounds, fragrant. Next to his pillow lay a large bunch of lavender. He lay quietly, his expression much softer.
Ten days later, he died. When he died, his complexion became translucent, and he had needle holes and intubations all over his body. Facial edema, no longer the original appearance.
I asked myself, "If I could express myself, would he be willing to ask for these ten days?"
In these 10 days, he has not enjoyed any right to life, what is the meaning of life? Does letting a person live like this for 10 more days proves that we love him very much? Is our love so superficial?
03
Behind all the values is a fundamental outlook on life: Are you willing to live a long life, or are you willing to live well? Are you willing to trade money and pain for a few months of survival, or do you want to leave and say goodbye to your loved ones? We should understand that the reason why people are human beings is because they have the right to choose.
Man cannot choose to live, but he can choose to die. This "death" is not an early death (that is, the so-called "euthanasia"), but it is by no means a postponement of death and not allowing him to die - and the latter is precisely the logical basis of all medical technology and medical ethics now.
As a patient, we must learn to say goodbye, as a relative, we must accept goodbye, as a doctor, we must face goodbye, the international life will movement, DNR (give up rescue) movement, NO-CPR movement, or we Chinese talk about good death, all mean this.
Life comes and should come naturally, and this is our oriental naturalistic view of life. Otherwise, as the author of "Black Swan" Taleb said, "In the face of a terminal illness, nature makes you endure a short period of pain and then die quickly, while medicine makes you endure a long and slow pain before dying."
When a person is dying, in addition to physical pain and psychological fear, there are actually two invisible injuries: one is called iatrogenic injury (injury from medical treatment) and the other is called kinship injury (injury from relatives).
Many family members of patients have a stupid view of filial piety, because I am filial to you, so I will treat you, and you will not be allowed to die, even if you are in great pain before you die. Doctors, on the other hand, have an arrogant view of treatment, because I am a doctor, I must succeed, I must rescue, and I must save lives in addition to helping the wounded, otherwise I will have no sense of professional fulfillment.
In fact, isn't the former a form of loving violence in the name of love? On the surface, he is kind to his parents, but in fact he hates his parents, and after his parents have worked hard all his life, he will torture his parents so that he can show them to others: You see how filial we are! Isn't the latter medical violence in the name of science and technology?
Let's not forget that Dr. Trudeau said that the doctor's job is "sometimes to heal, to help often, but always to soothe." On the edge of life and death, there is too much ambiguity, and at the last moment of life, let another new concept of medical treatment work, let palliative medicine work, let religion work, psychology work, life care work, don't let the concept of foolishness, filial piety and foolishness work. This is the "good end" that we Chinese are pursuing.
04
"Don't cut again, shoot one, die one!".
Since 2015, Zhu Zhenggang, the former president of Shanghai Ruijin Hospital and executive director of the China Anti-Cancer Association, has begun to "block the knife" everywhere like this. He begged doctors on different academic occasions to say, "Don't easily operate on patients with advanced stomach cancer."
Now, as soon as patients with advanced gastric cancer arrive at the hospital, the first choice is to undergo surgery, and then undergo chemotherapy and radiotherapy, "first remove the mountain (the main body of the tumor), and then use chemotherapy and radiotherapy to clean up the surrounding small clods", this treatment concept has been deeply rooted in hospitals of all sizes across the country, "In fact, surgery is not only useless, but also counterproductive." As a result, the immune system of the tumor is stimulated under the blow of surgery, causing them to initiate a stronger counterattack, so many patients with advanced gastric cancer almost do not survive for more than a year after surgery."
At present, many developed countries in Europe and the United States use "conversion therapy", "patients with advanced tumors generally do not take resection surgery, but try to control the lesion as well as possible, so that it can shrink or spread slowly." Not only will the patient die faster, but the rest of the day will be spent in a hospital bed, with almost no quality of life to speak of."
Zhu Zhenggang prefers to call himself an "oncologist", the surgeon is concerned about whether the surgery is not beautiful, and the oncologist is concerned about whether the patient is living well or not, "there is an essential difference."
05
In November 2011, Associate Professor Ken Ken Murray, who published a sensational article in the United States, "How Doctors Die?It's Not Like the Rest of Us, But It Should Be," wrote:
Just a few years ago, Mu Yourui's mentor Charlie, a reputable orthopedic surgeon, found that he had a lump on his stomach, so he had a minor operation, but he didn't expect the diagnosis to come out, and it turned out to be a cancer killer - pancreatic cancer!
The doctor who operated on Charlie was a master of not only being a skilled doctor, but also inventing a special treatment that could increase the five-year survival rate of pancreatic cancer patients from 5% to 15%. Of course, their quality of life can be greatly compromised in the course of medical treatment.
Charlie eventually rejected the famous doctor's treatment plan. He closed the clinic where he had been successful, and spent the last of his days enjoying the last days of his life with his family, trying to find the most comfortable feeling and state possible. He didn't have chemotherapy or radiotherapy at all, and he didn't have any further surgery.
A few months later, Charlie died of illness at his own home, and his family was by his side. Medicare, the famous health insurance system in the United States, paid almost no money to him. Of course, Charlie is not trying to save money on Medicare, which is already in ruins, but to enjoy life as much as possible in the last precious years of his life. In other words, between the quantity and the quality of life, Charlie chose quality.
Mu Yourui found that not only Charlie, but also many American doctors made the same choice after suffering from a terminal illness. "Doctors go out of their way to save patients' lives, but when doctors themselves are terminally ill, they choose not the most expensive drugs and the most advanced surgeries, but the least treatments. ”
At the last moment of their lives, they chose the quality of life.
There are many trained American doctors who have seriously discussed with their families their choices before they become critically ill when death is inevitable. They repeatedly told them that when the "final verdict" came, when they were dying in the world, they should never let anyone break into their homes (they chose not to stay in the hospital), especially when they were giving themselves artificial respiration (CPR, Cardio Pulmonary Resuscitation), and crush their ribs (CPR often leads to rib breakage)!
When a person is taken to the emergency room after losing consciousness, the family is often overwhelmed. When doctors ask if they want to take resuscitation measures, family members often immediately say, "Yes." ”
Thus, the patient's nightmare began.
In order to avoid this kind of nightmare, many American doctors will hang a small "do not rescue" sign around their necks after they are seriously ill to remind themselves not to be rescued when they are dying, and some doctors even tattoo this sentence on their bodies. Because these "medical angels" have been exposed to too much medical "futile care", they deeply know that when a person's life has come to an end, his body is extremely exhausted, and he is about to "run out of oil", he has actually lost his judgment and decision-making power, and "being 'lived' in this way is meaningless except pain." ”
06
Represented by the United Kingdom, many Western countries have put forward suggestions for "palliative treatment" for terminally ill patients.
What is palliative care? "When a person is terminally ill and no treatment can stop the process, soothing therapy is adopted to alleviate the symptoms of the disease, improve the patient's psychological and spiritual state, and make the last journey of life complete and dignified. ”
There are three core principles of palliative care:
1. Acknowledging that death is a normal process;
2. Neither accelerates nor delays death;
3. Provide ways to relieve the pain and discomfort of dying.
In the UK, there are a number of palliative care facilities or wards, and when patients are suffering from incurable diseases, the humane care of palliative care is taken for granted.
At this time, in addition to "providing a solution to the pain and discomfort of dying", the doctor will also make a number of recommendations and requests to the patient's family:
1. Take more time to spend with the patient through the last moments.
2. Let the patient say where he or she would like to die.
3. Listen to patients talk about their lives and record their voices and smiles.
4. Assist patients to make up for all kinds of regrets in life.
5. Help them review their lives and affirm their past achievements.
……
For the families of terminal cancer patients, they can't just seek medical advice and medicine forever, miss the opportunity window to say goodbye to their loved ones, and make lifelong mistakes. Lifelong regret, in addition to the need to learn from Wei Zexi's lessons and improve his ability to find authoritative medical information (this is another necessary ability to survive in China's medical jungle), we must do everything possible to understand our relatives, in the final stage (the international standard is about six months before death), take the initiative to create life memories with him that can be remembered in the future, carefully understand and record his life achievements, affectionate companionship, boldly confide, hold his hand tightly before dying, etc., there are many things that can be done, at least fifteen。
For doctors, in addition to this specialty, sincerely hope to know more about hospice care, understand palliative care, pray that more hospice hospitals can appear in China, admit more terminally ill patients, do not let them have nowhere to go, and sincerely hope that those who do psychology should take a brave step forward lean in, in the L-shaped cliff period of life that every Chinese will encounter, stretch out their hands and soothe people's hearts.
Sometimes, goodbye may be the most affectionate confession. Letting go may be the most profound retention.
While we devote too much energy to exploring the "cause of death", that is, the cause of death, perhaps we should think about the cause of life when we are both alive - the "reason for living". Life Care is an inclusive cause, and everyone can make their own unique contribution.
Original Free Review