and I would like to talk to you today about health care.

今天我想跟大家談談健康照護。

I'd like to talk to you about the health and care

我想跟大家談

of the most vulnerable population in our country --

我國最脆弱的一群人 他們的健康與照護，

those people dealing with the most complex serious health issues.

這群人對抗著 最複雜最嚴重的健康問題。

I'd like to talk to you about economics as well.

我也想跟你們談一談經濟。

And the intersection of these two should scare the hell out of you --

這兩者交會之處應該會把大家嚇死，

it scares the hell out of me.

至少我是怕死了。

I'd also like to talk to you about palliative medicine:

我也想跟大家談談安寧療護：

a paradigm of care for this population, grounded in what they value.

這是基於這群病患的價值觀 而產生的照護模式。

Patient-centric care based on their values

以病人為中心， 根據他們的價值觀而做的照護，

that helps this population live better and longer.

幫助這個族群活得更好更久。

It's a care model that tells the truth

這個照護模式會對病人說實話，

and engages one-on-one

並與他們進行一對一對談，

and meets people where they're at.

並在患者所在之處碰面。

I'd like to start by telling the story of my very first patient.

我想以我第一個病人的故事 來做開場白。

It was my first day as a physician,

那是我當醫師的第一天，

with the long white coat ...

穿著白袍，

I stumbled into the hospital

我一走進醫院，

and right away there's a gentleman, Harold, 68 years old,

就碰到一位先生，海樂，68 歲，

came to the emergency department.

到急診室報到。

He had had headaches for about six weeks

他頭痛了六個星期，

that got worse and worse and worse and worse.

病情愈來愈重，愈來愈難過。

Evaluation revealed he had cancer that had spread to his brain.

診斷發現他有癌症， 而且已經擴散到腦部。

The attending physician directed me to go share with Harold and his family

他的主治醫生指示我去跟海樂和家屬

the diagnosis, the prognosis and options of care.

談他的診斷結果、預後及照護方案。

Five hours into my new career,

我的職業生涯才過了五個小時，

I did the only thing I knew how.

我只能做我唯一會做的事。

I walked in,

我走進去，

sat down,

坐下，

took Harold's hand,

握住海樂的手，

took his wife's hand

握住他太太的手，

and just breathed.

然後就一直呼吸。

He said, "It's not good news is it, sonny?"

他說：「不是什麼好消息， 對吧，小夥子？」

I said, "No."

我說：「不是。」

And so we talked and we listened and we shared.

然後我們開始談話、傾聽、分享。

And after a while I said,

過一陣子之後我說：

"Harold, what is it that has meaning to you?

「海樂，什麼對你最有意義？

What is it that you hold sacred?"

你最看重的東西是什麼？」

And he said,

他說：

"My family."

「我的家人。」

I said, "What do you want to do?"

我說：「那你想怎麼辦？」

He slapped me on the knee and said, "I want to go fishing."

他拍拍我的膝蓋說： 「我想去釣魚。」

I said, "That, I know how to do."

我說：「這個簡單， 我知道該怎麼做。」

Harold went fishing the next day.

海樂隔天就去釣魚了。

He died a week later.

他在一星期後去世。

As I've gone through my training in my career,

現在我已在職場受到不少訓練，

I think back to Harold.

我就回想起海樂。

And I think that this is a conversation

我在想像這樣的對話

that happens far too infrequently.

太少發生了。

And it's a conversation that had led us to crisis,

這樣的對話帶領我們到危機之處，

to the biggest threat to the American way of life today,

對今天的美式生活產生最大的威脅，

which is health care expenditures.

就是醫療支出。

So what do we know?

所以我們知道什麼？

We know that this population, the most ill,

我們知道這個族群病得最重，

takes up 15 percent of the gross domestic product --

吃掉了 15% 的 國內生產毛額 (GDP)，

nearly 2.3 trillion dollars.

將近二兆三千億美金。

So the sickest 15 percent take up 15 percent of the GDP.

所以病得最重的 15% 吃掉 15% 的 GDP。

If we extrapolate this out over the next two decades

照這樣推斷未來二十年，

with the growth of baby boomers,

隨著嬰兒潮逐漸老化，

at this rate it is 60 percent of the GDP.

這個數字會是 60% 的 GDP。

Sixty percent of the gross domestic product

美國 GDP 的 60%──

of the United States of America --

到了這個地步， 已經不再是醫療的問題了，

it has very little to do with health care at that point.

而是變成買牛奶、

It has to do with a gallon of milk,

大學學費的問題。

with college tuition.

這跟我們重視的一切

It has to do with every thing that we value

及我們目前知道的一切有關。

and every thing that we know presently.

這會賭上美國自由市場 及資本主義的成敗。

It has at stake the free-market economy and capitalism

讓我們先擱下統計數字。

of the United States of America.

我們先來談一下花大錢得到什麼。

Let's forget all the statistics for a minute, forget the numbers.

達特茅斯醫療照護地圖集 在大約六年前

Let's talk about the value we get for all these dollars we spend.

看了一下聯邦醫療保險 花掉的每一塊錢，

Well, the Dartmouth Atlas, about six years ago,

大多是這個族群花掉的。

looked at every dollar spent by Medicare --

我們發現有最高 人均醫療費用的病人，

generally this population.

同時也是最受苦、 最痛、最憂鬱的病人。

We found that those patients who have the highest per capita expenditures

而且屢見不鮮，他們也比較快死。

had the highest suffering, pain, depression.

怎麼會這樣呢？

And, more often than not, they die sooner.

我們活在美國，

How can this be?

這裡有地球上最棒的醫療系統。

We live in the United States,

我們花在這些病人身上的錢，

it has the greatest health care system on the planet.

比第二名的國家高出十倍。

We spend 10 times more on these patients

這沒有道理。

than the second-leading country in the world.

但是我們知道的是，

That doesn't make sense.

全球前 50 個

But what we know is,

有醫療保健系統計畫的國家，

out of the top 50 countries on the planet

我們排名第 37 位。

with organized health care systems,

中歐東歐等前東方集團國家 及下撒哈拉非洲國家

we rank 37th.

排名都比我們還高， 品質及價值也比我們好。

Former Eastern Bloc countries and sub-Saharan African countries

每天我看診時都會經歷一件事，

rank higher than us as far as quality and value.

而且我敢保證， 在座很多人自己都經歷過：

Something I experience every day in my practice,

多不代表好。

and I'm sure, something many of you on your own journeys have experienced:

做愈多檢查，

more is not more.

愈精密複雜的儀器，

Those individuals who had more tests,

愈多化療，愈多手術，不管是什麼，

more bells, more whistles,

只要我們在病人身上做愈多，

more chemotherapy, more surgery, more whatever --

就愈降低他們的生活品質。

the more that we do to someone,

而且更常看到的是縮短壽命。

it decreases the quality of their life.

所以我們要怎麼辦？

And it shortens it, most often.

我們要怎麼做？

So what are we going to do about this?

而且為什麼會這樣？

What are we doing about this?

嚴峻的現實是，各位先生女士，

And why is this so?

我們，醫療業界的人 ——穿著白袍的醫師——

The grim reality, ladies and gentlemen,

從你們身上偷東西。

is that we, the health care industry -- long white-coat physicians --

從你們身上偷走

are stealing from you.

選擇如何過活的機會，

Stealing from you the opportunity

不管你得的是什麼病。

to choose how you want to live your lives

我們專注在疾病、病理、手術

in the context of whatever disease it is.

及藥理。

We focus on disease and pathology and surgery

我們沒看到人。

and pharmacology.

我們要怎麼治療這個

We miss the human being.

卻不了解這個的存在？

How can we treat this

我們為此做了許多；

without understanding this?

現在我們必須為這個做點什麼。

We do things to this;

醫療有三重目標：

we need to do things for this.

一，改善患者經驗。

The triple aim of healthcare:

二，改善此族群的健康。

one, improve patient experience.

三，降低照護過程的人均醫療費用。

Two, improve the population health.

我們的安寧照護團隊

Three, decrease per capita expenditure across a continuum.

在 2012 年與病得最重的患者合作，

Our group, palliative care,

癌症、

in 2012, working with the sickest of the sick --

心臟病、肺病、

cancer,

腎臟病、

heart disease, lung disease,

失智等等，

renal disease,

我們如何改善病患經驗？

dementia --

「醫生，我想待在家。」

how did we improve patient experience?

「好，我們會去你家照護你。」

"I want to be at home, Doc."

生活品質提高。

"OK, we'll bring the care to you."

想想人。

Quality of life, enhanced.

第二點：族群健康。

Think about the human being.

我們怎麼用不同的觀點看這個族群，

Two: population health.

在不同的層面、 更深的層次與他們交流，

How did we look at this population differently,

如何將他們以人來看待， 而不是從本位來想？

and engage with them at a different level, a deeper level,

我們怎麼管理這個族群，

and connect to a broader sense of the human condition than my own?

讓我們 94% 的門診病人

How do we manage this group,

在 2012 年都不用進醫院？

so that of our outpatient population,

不是因為他們不能去，

94 percent, in 2012, never had to go to the hospital?

而是他們不需要去。

Not because they couldn't.

我們把醫療照護帶給他們。

But they didn't have to.

我們維持他們的價值，他們的品質。

We brought the care to them.

第三：人均醫療費用。

We maintained their value, their quality.

對這個族群而言，

Number three: per capita expenditures.

現在的花費是二兆三千億美元， 二十年後是 60% 的國內生產毛額，

For this population,

我們減低了幾乎 70% 的人均醫療費用。

that today is 2.3 trillion dollars and in 20 years is 60 percent of the GDP,

他們本著自己的價值觀 得到更多自己想要的，

we reduced health care expenditures by nearly 70 percent.

可以活得更好，現在活得更久，

They got more of what they wanted based on their values,

只要三分之一的花費。

lived better and are living longer,

雖然哈樂的時間不多，

for two-thirds less money.

安寧照護卻非如此。

While Harold's time was limited,

安寧照護模式要看顧 從診斷到臨終這整段時間。

palliative care's is not.

可能是幾小時、

Palliative care is a paradigm from diagnosis through the end of life.

幾週、幾個月、幾年、

The hours,

連續整段時間，

weeks, months, years,

有沒有治療都是。

across a continuum --

來看克里斯汀的例子。

with treatment, without treatment.

第三期子宮頸癌，

Meet Christine.

轉移癌，從她的子宮開始，

Stage III cervical cancer,

擴散到整個身體。

so, metastatic cancer that started in her cervix,

她五十幾歲，還活得很好。

spread throughout her body.

我們不是在講臨終，

She's in her 50s and she is living.

我們是在講生命。

This is not about end of life,

我們不只在說老年人，

this is about life.

我們在說人。

This is not just about the elderly,

這位是理查。

this is about people.

肺病末期。

This is Richard.

「理查，你最重視什麼？」

End-stage lung disease.

「我的孩子，老婆和哈雷摩托車。」

"Richard, what is it that you hold sacred?"

（笑聲）

"My kids, my wife and my Harley."

「好！

(Laughter)

我不能騎它載著你到處跑， 因為我連腳踏車都不會騎，

"Alright!

但是來看看能做什麼。」

I can't drive you around on it because I can barely pedal a bicycle,

理查來找我，

but let's see what we can do."

情況很糟。

Richard came to me,

有個小小的聲音告訴他，

and he was in rough shape.

大概只剩幾個星期或幾個月了。

He had this little voice telling him

我們就只是聊聊。

that maybe his time was weeks to months.

我聽著，也試圖去聽言外之意，

And then we just talked.

這兩者有很大的差別。

And I listened and tried to hear --

多聽少說。

big difference.

我說：「好吧！過一天是一天。」

Use these in proportion to this.

就像生命中其它章節一樣。

I said, "Alright, let's take it one day at a time,"

我們天天去理查住的地方。

like we do in every other chapter of our life.

一星期一通或兩通電話，

And we have met Richard where Richard's at day-to-day.

以他肺病末期的狀況而言， 他過得很好。

And it's a phone call or two a week,

現在，安寧照護不只照顧老年人，

but he's thriving in the context of end-stage lung disease.

也不只照顧中年人，

Now, palliative medicine is not just for the elderly,

我們照護每一個人。

it is not just for the middle-aged.

來看看我的朋友強納生。

It is for everyone.

我們很榮幸

Meet my friend Jonathan.

請到強納生和他的父親來到現場。

We have the honor and pleasure

強納生二十多歲，我幾年前遇到他。

of Jonathan and his father joining us here today.

他在與轉移性睪丸癌奮鬥，

Jonathan is in his 20s, and I met him several years ago.

擴散到腦部。

He was dealing with metastatic testicular cancer,

他有過中風，

spread to his brain.

他曾動過腦部手術，

He had a stroke,

做過放療、化療。

he had brain surgery,

在跟他及家人會診時，

radiation, chemotherapy.

他才做完骨髓移植幾星期。

Upon meeting him and his family,

他很仔細聽，

he was a couple of weeks away from a bone marrow transplant,

他們說：「可不可以讓我們 了解一下什麼是癌症？」

and in listening and engaging,

我們怎麼撐到這一步，

they said, "Help us understand -- what is cancer?"

一點都不了解我們到底在對抗什麼？

How did we get this far

我們是怎麼走到這一步， 沒有教育任何人，

without understanding what we're dealing with?

讓他們了解他們到底在對抗什麼，

How did we get this far without empowering somebody

再帶他們走下一步， 讓他們以人類的身分參與，

to know what it is they're dealing with,

明白我們到底該不該那樣做？

and then taking the next step and engaging in who they are as human beings

天知道我們會在你們身上做什麼。

to know if that is what we should do?

但是我們應該做嗎？

Lord knows we can do any kind of thing to you.

你可以不信我的話。

But should we?

但所有跟現今安寧照護有關的證據

And don't take my word for it.

都很確定患者活得更好更久。

All the evidence that is related to palliative care these days

2010 年，新英格蘭醫學雜誌 發表了一篇影響深遠的文章。

demonstrates with absolute certainty people live better and live longer.

我在哈佛的同事好友做了一個研究，

There was a seminal article out of the New England Journal of Medicine

在講末期肺癌：

in 2010.

一組有安寧照護，

A study done at Harvard by friends of mine, colleagues.

另一組沒有。

End-stage lung cancer:

有安寧照護那組的報告說 他們比較不痛，

one group with palliative care,

不那麼沮喪。

a similar group without.

他們比較少住院。

The group with palliative care reported less pain,

而且各位，

less depression.

他們能多活三到六個月。

They needed fewer hospitalizations.

如果安寧照護是治療癌症的藥物，

And, ladies and gentlemen,

地球上每一位癌症醫師都應該 開這種藥給病人。

they lived three to six months longer.

他們為什麼不開呢？

If palliative care were a cancer drug,

再說一次，因為我們這群 穿著白袍的傻瓜醫師

every cancer doctor on the planet would write a prescription for it.

只受過訓練處理這樣的問題，

Why don't they?

不是這樣的問題。

Again, because we goofy, long white-coat physicians

我們遲早都會碰到 （經濟與健康）交會之處，

are trained and of the mantra of dealing with this,

但是今天的演講跟死亡無關，

not with this.

而是跟怎麼活著有關。

This is a space that we will all come to at some point.

基於我們的價值觀而活，

But this conversation today is not about dying,

我們視為神聖的東西，

it is about living.

我們想怎麼寫自己生命的章節，

Living based on our values,

無論是最後一章，

what we find sacred

還是最後五章。

and how we want to write the chapters of our lives,

我們知道的，

whether it's the last

我們已證明的，

or the last five.

就是這樣的對話今天就該發生，

What we know,

不是下星期，也不是明天。

what we have proven,

有危急的是我們今天的生活，

is that this conversation needs to happen today --

及我們老了之後的生活，

not next week, not next year.

還有我們的子子孫孫的生活。

What is at stake is our lives today

不僅是在醫院病房裡，

and the lives of us as we get older

或是家裡的沙發。

and the lives of our children and our grandchildren.

無論我們在哪裡看到什麼都一樣，

Not just in that hospital room

安寧醫護就是答案，將病患視為人，

or on the couch at home,

改變我們都要面對的旅程，

but everywhere we go and everything we see.

而且要變得更好。

Palliative medicine is the answer to engage with human beings,