当医生自己面对癌症和死亡

“医生也会生病？！”

“医生也会患癌？！”

这样的惊叹声没少听，这里人们似乎忽略了一个事实，那就是：医生也是人，是人就会生病。医生也会患癌症，医生也要面对死亡。

医生的死亡也许没有人关心，但当医生自己患上癌症时，他们又会如何选择治疗方案呢？这恐怕是很多人有兴趣、想了解的事。

美国南加州大学家庭医学科副教授、医学博士Ken Murray的一篇关于美国医生自己患癌后的治疗选择文章，引起了网络轰动，在国内广为转载。然鹅，各家报道这相同的文章的标题和内容都大不相同，看过后得到大相径庭甚至穴位相反的观点。

《网易》：“不要抢救：美国医生的临终选择”。

《新浪博客》：“当医者面对自身死亡”

《健康时报》：“美国医生的临终选择”

《中国日报》：“有尊严的长眠――关乎体面 关乎权利”

《文摘》：“无效医疗：医生打死都不会说的秘密”

《人人网》：“How Doctors Die(当医者成为患者)~很有感触~看看吧就当学习......”

陶渊明老先生说过：“奇文共欣赏，疑义相与析”。笔者于是找到了2011年 11月30日发表于英文网站Zocalo public square的这篇文章。

文章原题目为：How Doctors Die--It’s Not Like the Rest of Us, But It Should Be（医生如何面对死亡――虽与众不同，但理应如此）

阅读过英文版原文后，认为作者的观点还是比较中肯的，作者是医生，却不唯医学；作者讲科学道理，却不是科学一切。坊间的译本有点乱，笔者认为最好读原文，以正本清源，让我们看看，洋大夫是怎么处理自己“面对癌症，面对死亡”这个热门话题的。

《How Doctors Die？- It’s Not like the Rest of Us, But It Should Be！》发表在2011年的11月23日，作者是一名医生，叫肯·穆尤睿（Ken Murray），这篇文章发表以后，曾经在美国社会和医学界引起了轰动和辩论。

文章的主要内容是是这样：

肯在文章中回忆说，就在几年前，一位名叫查理的非常有名望的骨科医生发现自己的胃上长了一个肿块，于是他做了一个小手术，没想到诊断结果出来，竟然是癌症杀手——胰腺癌！

给查理做手术的医生是个高手，此公不但医术精湛，而且还发明过一种特别的治疗方法，可以把胰腺癌患者的5年内存活率，从5%增加到15%，即：提高3倍！当然，其生活品质会在医疗过程中大受伤害，用咱们老百姓的话来说就是，遭罪是免不了的。

然而，查理却拒绝了这位名医的治疗方案。第二天回到家，他关掉了自己原本做得很成功的诊所，从此再也没有去过医院。查理把时间全用在了和家人一起享受人生的最后时光上，尽可能地找到最惬意的感觉和状态。他完全没有做化疗和放疗，也没有再做任何手术。

几个月以后，查理在自己的家里病逝，亲人们都陪伴在他的身旁。美国著名的医疗保险制度Medicare 几乎没在他身上花钱。当然，查理不是为了给已经千疮百孔的Medicare 省钱，他是为了自己在人生最后的珍贵时光里，尽量享受生活，少遭罪。

换句话说，在生命的数量和质量之间，查理选择了质量。

毫无疑问，医生也是人，也会面临死亡和病痛的折磨，但似乎从来没有人研究过，这个群体会在死亡的方式上有什么与众不同？

查理的选择揭示了一个不为人知的秘密：虽然为尽天职，医生们不遗余力地挽救病人的生命，可是当医生自己身患绝症时，他们选择的不是“近水楼台先得月”——为自己使用最昂贵的药和最先进的治疗手段。恰恰相反，他们作为一个特定的群体，却选择了最少的治疗！原因正是因为医生们的专业训练，让他们深深明白药物和手术的局限性，以及它们给患者带来的生活品质的摧残和巨大的痛苦。他们在人生的最后关头，集体选择了生活品质！

担心浮躁的读者特别是“看报看题，读书读早题”的“读标题党”没有耐心看完，在文章的主要内容中再摘录重点，提纲挈领一下：

医生也是人，医生也会患癌，也会死亡，不同之处在于医生不会选择过度治疗和无效抢救。因为他们知道治疗效果是有限的，而死亡是必然的。

有不少例子选择高生活质量的生活，有尊严地逝去，而不是在痛苦治疗和抢救中活着。也有更多的是家属和病人在无知彷徨中，选择了过度治疗和无效抢救，步入苟延残喘，劳民伤财的噩梦，毫无生活质量可言。

附：全文

How Doctors Die？

- It’s Not like the Rest of Us, But It Should Be！

BY KEN MURRAY | NOVEMBER 30, 2011

Years ago, Charlie, a highly respected orthopedist 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 percent to 15 percent–albeit with a poor quality of life. 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.

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. 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. 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 CPR (that’s what happens if CPR is done right).

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. 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.

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.

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. 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. 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.

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 portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by the light of a flashlight–or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC.

原文网址：http://www./2011/11/30/how-doctors-die/ideas/nexus/

来源：今日头条 中西科普