Many years ago, there was a popular saying in the society that Chinese people "cannot afford to live, live, get sick, or die". The term "unable to die" here refers to the high funeral expenses. Today, with the development of science and technology, the biggest problem faced by doctors is not how to "live" the patients, but how to "walk well". To some extent, not to "die well" may be the most neglected happiness problem. China's major cities are releasing happiness index in succession. But these announcements were forgetful - ignoring that "quality of death" is also a core indicator of happiness index.
Life is the beginning of death, and death is the end of life. Death is something everyone has to face. As far as the body is concerned, the physiology of the dying person usually has various problems. In a variety of physical and mental burning, death causes fear and anxiety. Thus, the theory of "Quality of death" came into being. The "death quality index" can see through a country's medical philosophy and humanistic spirit. Hospice care is a sign of the development of human civilization and a demand for social progress.
When we put too much energy into exploring the "cause of death", perhaps we should think about the living cause when we are both alive - the "cause of life". Life care is a universal cause, and everyone can make their own unique contributions.
Sometimes, farewell may be the most affectionate confession. Letting go may be the most profound retention.
Only by facing death squarely can we truly embrace life
Figure | Escher
01
In 1999, Mr. Ba Jin was seriously ill.
After some rescue, life was saved, but since then, a nasal feeding tube was inserted. "Eating through the stomach tube, six times a day into the stomach". The tube had to be replaced at least once every two months. "The long tube went straight from the nose to the stomach, and every time he changed the tube, he was choked and flushed". After a long time of intubation, Ba Jin's mouth could not be closed and his jaw dislocated. "We had to cut the trachea and use a ventilator to maintain breathing".
Ba Jin himself wanted to give up this treatment, but he did not have the right to choose, because his family members and leaders did not agree.
"Everyone who loves him wants him to live!"
Even if you are in a coma, even if you rely on the 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 years. He said:
“ Longevity is a torture to me ”。
02
A doctor in Shanghai said such an ordinary thing - the reason why it is ordinary is that such things happen every day in major hospitals.
An 80 year old man was hospitalized due to cerebral hemorrhage. Family members told: "No matter what, we must let him live!"
After the operation, he survived. His trachea was cut and a hole was made in his throat. There was a long and thick pipe connected to the ventilator.
Occasionally, he would wake up slightly and open his eyes painfully. At this time, the family will be very excited, holding my hand and saying, "Thank you for saving him".
His family took turns to accompany him day and night, staring at the numbers on the monitor. Every time they saw a change, they would immediately come to me.
Later, the old man became swollen, and his head looked like a blown up balloon. What's worse, his airway was bleeding constantly, which made him need to clean the airway more frequently. Each time, the nurse put a long tube into his nasal cavity, and blood clots and bloody secretions were sucked out. The process was very painful. He frowned and tried desperately to avoid the pipe. It can be cleaned repeatedly every day, but it can still suck out a lot.
At this time, his granddaughter always lowered her head and dared not look. I asked the family members, "Do you want to postpone or give up?". The granddaughter whispered, "If he died, I would have no grandfather.".
The treatment became more and more helpless, and his waking time was shorter. The only remaining waking time is also mercilessly occupied by aspiration and needling. His death is coming, and my heart is as clear as black and white. He said to his granddaughter, "Put some lavender on the bed." She said repeatedly, "OK. We don't understand. We listen to you."
The next day's rounds were filled with fragrance. Beside his pillow, there was a big bunch of lavender. He lay quietly, his expression softened a lot.
Ten days later, he died. At the time of death, the skin color became translucent, with needle eyes and cannula all over the body. Facial edema has disappeared.
In my heart, I asked myself, "If he can express himself, will he want these ten days?"
In these ten days, he has no right to enjoy any life. What is the meaning of life? Let a person live for ten more days. Does that prove that we love him very much? Is our love so superficial?
03
Behind all values, there is a fundamental outlook on life: do you want to live long or do you want to live well? Are you willing to trade money and pain for a few months of life, or leave and bid farewell to your relatives? We should understand that people are human because they have the right to choose.
Man cannot choose to live, but he can choose to die. This "death" is neither premature death (also known as "euthanasia"), nor delayed death, which is the logical basis of all medical technology and medical ethics.
As a patient, we should learn to say goodbye, as a family member, we should accept the farewell, as a doctor, we should face the farewell. The international life prediction movement, DNR (give up rescue) movement, NO-CPR movement, or what we Chinese say about a good ending, all mean that.
Life comes naturally, and it should also go naturally. This is our oriental naturalistic view of life. Otherwise, as Taleb, the author of Black Swan, said“ In the face of incurable diseases, nature makes you suffer a short time and then die quickly, while medicine makes you suffer a long and slow time before dying ”。
At the end of life, in addition to physical pain and psychological fear, there are actually two kinds of hidden injuries: one is called iatrogenic injuries (injuries from medical treatment), and the other is called parental injuries (injuries from relatives).
Many patients' families have a foolish filial piety view. Because I am filial to you, I will treat you and forbid you to die, even if you are in great pain before your death. The doctor has an arrogant view of treatment. Because I am a doctor, I must succeed, rescue, and save my life in addition to helping the injured. Otherwise, I have no sense of professional achievement.
In fact, isn't the former the violence of love in the name of love? They are good to their parents on the surface, but hate their parents in fact. After their parents' hard life, they have to torture their parents on their deathbed to show others how filial we are! Isn't the latter a medical violence in the name of technology?
Don't forget Dr. Trudeau said that the duty of a doctor is "sometimes to heal, often to help, but always to comfort". On the edge of life and death, there is too much ambiguity. At the last moment of life, let another new medical concept work, let soothing medicine work, let religion work, psychology work, and life care work. Don't let the concept of filial piety and foolish governance work. This is the "good ending" that we Chinese pursue.
04
"Don't operate any more, open one, and die one!".
Since 2015, Zhu Zhenggang, the former president of Shanghai Ruijin Hospital and the executive director of China Anti Cancer Association, has been "blocking knives" everywhere. He begged doctors on different academic occasions to say, "Do not operate on patients with advanced gastric cancer easily".
Now, when patients with advanced gastric cancer arrive at the hospital, the first choice is surgery, followed by chemotherapy and radiotherapy. "First remove the mountains (the main body of the tumor), and then use chemotherapy and radiotherapy to remove the surrounding small lumps of soil." This treatment concept has been deeply rooted in hospitals across the country“ In fact, cutting is not only useless, but also counterproductive. The late stage tumors spread widely, and the metastatic foci often could not be opened cleanly. As a result, under the impact of surgery, the tumor's own immune system was stimulated, which led them to launch a stronger fight back. Therefore, many patients with advanced gastric cancer could not survive nearly one year after surgery ”。
Now, many developed countries in Europe and the United States have adopted "transformation therapy". "For patients with advanced tumors, we generally do not take resection, but try to control the focus well and let it shrink or spread slowly. Because surgery will not only make patients die faster, but also spend the rest of their lives in hospital beds, almost without any quality of life".
Zhu Zhenggang prefers to call himself a "tumor doctor", Surgeons are concerned about whether the operation is beautiful, while oncologists are concerned about whether the patient is alive or not. "There is an essential difference" 。
05
In November 2011, Ken Murray, an associate professor at the University of Southern California, published a sensational article - How Doctors Die? It’s Not like the Rest of Us, But It Should Be）， The article wrote:
Just a few years ago, Mu Yourui's mentor Charlie, a prestigious orthopedic doctor, found a lump on his stomach, so he had a small operation. Unexpectedly, the diagnosis turned out to be a cancer killer - pancreatic cancer!
The doctor who operated on Charlie was an expert. He not only had excellent medical skills, but also invented a special treatment method, which could increase the 5-year survival rate of pancreatic cancer patients from 5% to 15%. Of course, their quality of life will be greatly damaged in the medical process.
Charlie finally rejected the famous doctor's treatment plan. He closed the clinic that he had successfully built, and spent his last time enjoying life with his family to find the most comfortable feeling and state as far as possible. He did not receive chemotherapy or radiotherapy at all, nor did he undergo any surgery.
A few months later, Charlie died of illness at his home, with his relatives beside him. Medicare, the famous American medical insurance system, hardly spent money on him. Of course, Charlie is not trying to save money for Medicare, which is already full of holes. He is trying to enjoy life in the last precious time of his life. In other words, between quantity and quality of life, Charlie chose quality.
Muyurui found that not only Charlie, but also many American doctors made the same choice after encountering terminal illness. “ Doctors spare no effort to save the lives of patients, but when doctors themselves suffer from incurable diseases, they choose the least treatment instead of the most expensive medicine and the most advanced surgery. ”
They chose the quality of life at the last moment of their lives.
Many trained American doctors have seriously discussed with their families their choice before dying when death is inevitable. They repeatedly told that when the "final judgment" came, when they were dying in the world, they should never let anyone break into their homes (they could not choose to live in the hospital), especially when giving themselves artificial respiration (i.e. CPR, Cardio Pulmonary Resuscitation) to crush their ribs (CPR often leads to rib fracture)!
When a person loses consciousness and is sent to the emergency room, usually the family members will become confused. When the doctor asks "whether to take rescue measures", the family members often immediately say: "Yes."
So the patient's nightmare began.
In order to avoid this nightmare, many American doctors will hang a "don't rescue" tag on their neck after serious illness to remind them not to be rescued when they are dying. Some doctors even tattooed this sentence on their bodies. Because these "medical angels" have been exposed to too much medical "futile care", they know deeply 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 and light out", he has actually lost his judgment and decision-making power. "Being alive like this is meaningless except for pain."
06
With Britain as the representative, many western countries have proposed "palliative treatment" for terminally ill patients.
What is palliative treatment?
“ When a person is suffering from an incurable disease and no treatment can stop this process, he or she will take soothing treatment to alleviate the symptoms of illness, improve the psychological and mental state of the patient, and make the last step of life complete and dignified. ”
There are three core principles of palliative care:
1. Acknowledge that death is a normal process;
2. Neither accelerates nor delays death;
3. Provide methods to relieve pain and discomfort at the end of life.
In Britain, many palliative medical institutions or wards have been established. When patients have incurable diseases, the humanistic care of palliative medical care is taken for granted as the basic choice.
At this time, in addition to "providing ways to relieve pain and discomfort at the end of life", the doctor will also put forward a number of suggestions and requirements to the patient's family members:
1. Spend more time with the patient at the last moment.
2. Let the patient say where he hopes to die.
3. Listen to patients talk about life and record their faces and voices.
4. Assist the patient to make up for all kinds of regrets in life.
5. Help them review their life and affirm their past achievements.
For the family members of patients with advanced cancer, they can't just ask for medicine and medicine, miss the window of opportunity to say goodbye to their relatives, and become lifelong mistakes and regrets. In addition to the need to learn from Wei Zexi and improve their ability to find authoritative medical information (this is another necessary ability to survive in China's medical jungle), We must try our best to know more about our relatives. In the final stage (the international standard is about six months before death), we should actively create life memories with him that can be remembered in the future, carefully understand and record his life achievements, accompany him with deep feelings, talk boldly, hold his hand tightly before death, and so on. There are many things we can do, at least 15.
For doctors, apart from their majors, they sincerely hope that they can learn more about hospice care and palliative medicine, and pray that more hospice care hospitals will appear in China to treat more terminally ill patients, so that they will not have nowhere to go. At the same time, they sincerely hope that those who do psychology should bravely move forward, At the L-shaped cliff stage of life that every Chinese will encounter, extend your hands to comfort people.
Sometimes, farewell may be the most affectionate confession. Letting go may be the most profound retention.
When we devote too much energy to exploring the "cause of death", that is, the cause of death, we should probably think about the living cause when we are both alive - "the cause of life". Life care is a universal cause, and everyone can make their own unique contributions.
