Comments: How do we view the doctor-patient relationship and the series of conflicts and entanglements arising therefrom? The author entered the first-line medical department, In-depth interviews with doctors and patients, At the edge of life and death, She carefully analyzed this sensitive issue. With vivid strokes, It tells many stories about the first line of medical treatment, And moments of life and death. With the progress of science, Great changes have taken place in the duties of doctors, In the struggle between doctors and diseases, doctors are becoming more and more [strong], but this cannot [kill] all diseases. The problem of doctor-patient relationship arises from this. Today, medicine is not strong enough to solve any problem. How to face death is a common confusion between doctors and patients. This article is thrilling in its calm narration.
Medicine is an effort to respond to the pain of others. Medical care can only be carried out with humility, trust and respect when doctors understand the patient’s experience to some extent. However, when doctors are alert to the boundaries of technology, they see more room for action.
I thought I was going to tell a thrilling story: pain, struggle, ups and downs of hope, and final despair. Unexpectedly, the rhythm of the story itself is much softer and calmer than I imagined.
In order to understand the group of doctors, I entered the geriatric department of Peking Union Medical College Hospital and the oncology department of Beijing Military Region General Hospital. In my understanding, Geriatrics and oncology must be at war with geriatric and incurable diseases, There are always many unwilling lives that have to end here. In the relatively closed space of hospital departments, the pain brought by diseases to human beings, the urgent desire for survival of human beings, the acme and boundary of medical technology, the feeling of dying people crossing life and death, the psychological trauma of caring for companions, and the cramped people have nowhere to dodge.
And because of the doctor’s profession, Make them bearers of all the ties that connect them. They are expected to cure their ailments. Trying to pull the weakening body back from the line of death, However, many times they have to become professional ferrymen, ferrying their sick bodies to another world we do not know well. Sometimes, doctors will tell you that they are a few healthy people living in the majority of patients, which makes them feel lonely. This is also their sense of mission.
Liu Duanqi, former director of oncology department of Beijing Military Region General Hospital, told me, Medical students often experience a huge psychological gap. When they studied surgery in the first two or three years of medical school, There will be an omnipotent sense of victory, [If there is something wrong with your body, just cut off the pain]. When I was studying internal medicine next, I suddenly found that except for a few diseases that can be cured, most diseases are incurable, [the “black holes” of medicine are one after another. Although science and technology are progressing rapidly, doctors can still do very limited things before aging and diseases caused by cancer].
Patients find that they move from one specialist, one treatment procedure to another specialist, another treatment procedure, They may have received enough attention technically, but they feel abandoned when facing the consequences and fears of the disease. If only relying on science, medicine cannot help patients find the meaning of disease and death when fighting the disease.
Patients who die within one month of oncology or geriatrics, Probably more patients than any other department have died in a year. Here, Doctors have touched the limitations of technology most deeply, but they also feel most strongly that treatment technology cannot afford all the meaning in the face of disease and death. Disease is revealing secrets, showing the conflicts and contradictions between people’s survival and dying, and they also show the sincerity and courage of patients and refine their self-identity.
There is no cure for the disease, But it doesn’t mean there is no treatment. Although seeing the same end point for patients, But how to make the patient and the disease live together, How to make every person in his late life have his unique value, Become a new direction for doctors to strive for. The clock of life rings in everyone’s ear, I saw in the wards of Peking Union Medical College Hospital and Beijing Military Region General Hospital, Doctors are trying to make patients at the end of their lives less painful and less unnecessary treatment. Conform to nature when the body is full of oil and the lamp is dry. Calm to the end. A person should not die in the emergency room with various instruments, but in the warmth of his relatives. Only then did I understand that the gentleness and restraint, peace and tranquility I felt reached a new balance of emotion and comfort after exploration and reflection by medicine and its practitioners.
How noble is the peace on the edge of illness and death.
[Elephants in the House]
On February 15 this year, when 71-year-old Zhang Shunian (alias) was admitted to the geriatrics department of Peking Union Medical College Hospital, his family told him: “You have been admitted to history.”
The geriatric ward is in the old building of Concorde Hospital. This group of palatial buildings built 95 years ago, Cornices and vaults, green tiles and grey walls, colorful carved beams, They are located in Dongdan, the most prosperous area in Beijing. Hidden but not clear. During the Republic of China, U.S. Oil magnate Rockefeller donated 48 million U.S. Dollars, This best hospital has been established in Peiping. The bronze statues of Lin Qiaozhi, founder of China’s Obstetrics and Gynecology Department, and Zhang Xiaoqian, founder of China’s Gastroenterology Department, are located on the first floor. Behind the bronze statue of Zhang Xiaoqian, It records the history of Sun Yat-sen, Feng Yuxiang, Chiang Kai-shek, Pu Yi and others who lived here. From the outside, The old building is more than a dozen independent classical buildings, but the internal corridor and courtyard corridor connect the whole building complex, which also makes people who have just entered feel like crossing a maze and easily get lost. The story that happened here seems to be as deep and tortuous as the corridor of the old building.
Zhang Shunian’s mood is very complicated, He was reluctant to spend money for himself, Don’t talk about Beijing coming to cure diseases, Just for the travelling expenses to Beijing, Let him, a Jiangxi farmer, feel distressed. But after an appendectomy in a small local hospital at the end of 2014, His illness is getting worse and worse. Zhang Shunian has resentment towards the local hospital. In addition, his granddaughter in her early 20s and her boyfriend are studying in Peking Union Medical College. Holding the expectation of going to the best hospital to cure the disease, Zhang finally made up his mind and made his first trip to Beijing in his life.
As soon as I saw the attending doctor Qu Xuan, Zhang Shunian said clearly: I am the master of the family, My disease is what, you can tell me.] Although Zhang Shunian is a farmer, he has read junior high school and is half a cultural person at his age. He told the doctor that it was not easy for him and his family to come out for a trip. He specially collected some money to see a doctor. Although he is old, he is still one of the two strong laborers in the family of nine.
From the point of view of doctor Qu Xuan, Zhang Shunian is a person who has arrangements for his life. From Zhang Shunian’s statement, See clear expectations and measures: He has to bear the life of a large family, Whether you come to Beijing for treatment or not, For Zhang Shunian, it is not only related to health, but also a matter that needs to be measured [input-output ratio] at the economic level. If the disease can be cured and he can go home to earn money, then the cost this time is probably worth it. The dedication of the old farmer to his family and careful economic considerations make Qu Xuan respect this [seemingly sensible person].
But for Zhang Shunian’s granddaughter and granddaughter’s boyfriend Tong Ning (alias), The story has different expressions. Zhang Shunian underwent not a simple appendix operation in 2014. During the operation, doctors, Accidentally found that Zhang Shunian had colon cancer, and the tumor was not removed cleanly. After the operation, the whole family knew that Zhang Shunian had colon cancer, but the old man himself was completely unaware of it. In 2015, local doctors found that Zhang Shunian’s tumor had abdominal metastasis.
The family did not dare to tell the news to the hale and hearty old man. When he came to Beijing for treatment, Zhang Shunian was kept in the dark: his illness was not serious either. Why was the level of the local hospital so poor that the more treatment was made, the more trouble it became?
Ning Xiaohong, deputy chief physician of the Department of Geriatrics of Concorde Hospital, is an advocate of palliative care. She was in her early 40s, outspoken, When expressing their opinions unequivocally, Walking like a gust of wind forward. She has an obvious decisiveness, this kind of courage to take on the momentum is easy to trust. In addition to receiving patients, Ning Xiaohong also taught in Concorde Medical College, teaching students medical ethics, doctor-patient relationship and doctor-patient communication, and also teaching palliative care concepts and operation methods.
Palliative care is also called palliative care, It is for patients with incurable serious diseases and end-stage chronic diseases, Pay close attention to their emotional, spiritual and spiritual needs. Alleviate the suffering of patients, improve the quality of life, To help patients and their families achieve their wishes. In late November 2012, Ning Xiaohong and 10 doctors and nurses from the mainland went to Taiwan to learn more about palliative care. They were very touched to see how the terminal patients died peacefully and peacefully under the warm care of the medical care. An older doctor sighed with emotion and said, “I will come to Taiwan to die in the future.” Ning Xiaohong blurted out, “Don’t do this, we will work hard when we go back, and we can die there with dignity later.”
In order to [not let the small flames in my heart go out], Ning Xiaohong returned to Concorde and began to promote palliative care. At that time, she was a doctor in the oncology department of Concorde Hospital. In 2014, she was pulled to this 7-year-old department by Liu Xiaohong, director of the geriatric department, to jointly promote the concept of palliative care in the process of practicing geriatric medicine.
Attending physician Qu Xuan conducted a series of examinations on Zhang Shunian, He invited other departments to consult, only to find that Zhang Shunian’s condition was more serious than expected: his tumor had metastasized to the abdominal cavity and pelvic cavity, and intestinal cell lymph nodes had multiple metastases. For doctors, the elderly have actually lost the opportunity for radical treatment of cancer, and palliative care is more meaningful to him.
However, when Qu Xuan needed to determine the plan with the patient and his family members, things got stuck. The family members did not want to let Zhang Shunian know about the illness, but they could not do the main thing for the treatment. The paradox Qu Xuan faced was that each family member said that he could not do the main thing, but did not let Zhang Shunian, who could make the decision, know about it.
As doctors know, Patients willing to be hospitalized, They are basically people with a positive attitude towards treatment. The patient’s deep expectation, It has become cruel pressure on doctors and their families. Outside the ward, The early spring in Beijing began to attract people’s attention. Tiananmen Square and the Forbidden City are two or three kilometers away. They hold many outsiders’ imagination of Beijing. However, Zhang Shunian felt extremely uncomfortable with intestinal obstruction caused by cancer metastasis. Don’t say walking, even a day without pain is an extravagant hope. Nearly a month after he was hospitalized, instead of getting better, he became weaker and weaker. In the ward, everything became subtle, the language was no longer transparent, and words or silence had extra meaning.
The ceiling of the old building of Concorde Hospital is extremely high. The sun shone through the large green wooden lattice window. The tiny dust jumping in the beam, Showing the most carefree vitality. The pattern of the ward is still the same as that of the Republic of China. Yellow partitions, A white curtain was drawn between each two. Zhang Shunian on the sickbed gradually weakened. In addition to physical pain, More importantly, The deep meaning of life has changed. Now there are restrictions, anxieties, forced separation in his life. Although his family did not inform him of his illness, they felt that he must have guessed that he might be planning for the end of his life. Every patient wants to be himself before he gets sick, but they are forced to receive medical care from healthy strangers.
On Friday, March 11, geriatric doctors routinely made a weekly round. They spent the whole morning discussing difficult medical records in the doctor’s office instead of going directly to the patient’s bed for discussion. On the one hand, doctors need to protect the patient’s privacy; On the other hand, every patient and his family have a special psychological condition, and too many things cannot be said clearly. It was when I was attending this ward round that I learned about Zhang Shunian.
Qu Xuan reported on the difficulties he encountered, The family members who can communicate with her cannot be the master. Liu Xiaohong, director of the geriatric department, is a gentle and petite woman. Her youthful face conceals more than 30 years of medical experience, But when expressing their views, Her rich experience immediately showed up. [The biggest problem with this medical record is that The patient’s hospitalization goals and treatment goals are not clear.] She told doctors again, [When we treat patients, we should make it clear that the average time they stay in hospital here is two weeks. As soon as they arrive, we will evaluate them and then jointly reach a treatment plan to see what kind of treatment goals we can achieve in these two weeks. If the goal is not clear, everyone will fall into confusion.]
However, it is difficult to reach a treatment plan because the advanced patients do not know the condition of the disease. It is too common in Chinese hospitals. Another attending physician reported his difficulties. An old man he admitted last weekend, He was hospitalized for septic shock. The tumor caused perforation, The patient has been having a fever, After the surgeon saw it, Believing that the old man had lost the chance to undergo surgery, Can only receive treatment to improve symptoms. The attending physician said, Before, the family members of the elderly have been very active in treatment and are willing to do all traumatic treatment, but now they understand that the elderly have really run out of time and are very tangled. The doctor thinks that the old man is a wise man, and he should be able to treat his illness rationally and prepare for his death, but his wife just won’t let the doctor tell the truth.
The attending doctor pulled the patient’s wife out of the ward and asked, “If it is you, do you want to know your condition?” ] My wife said, “Of course I want to know.” But she immediately and firmly instructed the doctor: “He is different from me, he is weaker than me, he cannot know.”
After listening to the attending doctor’s story, Director Liu Xiaohong sighed with emotion: “There is an elephant in the room. Everyone saw it, whether the patient or the family, but they just didn’t say it!” ]
An informant of bad news
After coming into contact with the concept of palliative care, Ning Xiaohong felt that he was concerned about how to communicate with patients and their families, With a deeper understanding, Ning Xiaohong said during the ward round discussion that in fact many patients guessed the condition of their illness, but they were not willing to pierce this layer of paper. [If I asked the patients what was wrong, they would complain: I hurt, I have a fever. But why didn’t they ask me: Doctor, after all this time, why am I still in pain? Why do I still have a fever? They don’t ask, probably they don’t want to face it at all.]
This hidden fact, It will lead to a deadlock in treatment. Zhang Daqing, director of the Institute of Medical Humanities at Peking University, told me. In the Chinese culture of taboo to talk about death, doctors to a large extent bear the responsibility of informing bad news. When patients and their families are unprepared for death in cultural cognition, it is difficult for people to suddenly admit that death is the proper meaning in the process of life.
According to Rita Cullen of Columbia University School of Medicine, Patients have their own concept of death, Everyone’s experience of contact with death is different. Someone witnessed the death in the army, Some are in hospitals, Some have been hit by the death of their families, Some people have experienced death from political violence or natural disasters. Because of these different experiences, Some people regard death as the enemy of the individual, while others think it is a distant and abstract concept. She put forward the concept of “narrative medicine”, hoping that narrative medicine can answer many accusations against medical practice and training-impersonal, fragmented, indifferent, supremacy of medical interests, lack of social responsibility, etc.
In Rita Cullen’s view, patients and caregivers enter the process of pain and treatment as a whole-their bodies, lives, families, beliefs, values, experiences and hopes for the future all enter the process. Efforts to restore health and help others improve cannot be separated from the deepest part of life.
For patients, The process of illness is full of negative emotions such as shame, blame and fear. These psychological activities add to the pain caused by the disease. Although people around you try to comfort the patient, However, healthy people cannot really feel the pain of patients. Just like when people are not afraid, I can’t imagine fear. The patient has the pain of illness. Family members need to face the pain of losing their loved ones. Doctors sometimes feel deep and painful feelings, but these pains cannot be completely combined. In these clinics, the difference between patients and healthy people is staged. In Susan Sontag’s words, patients will realize that [disease is the night of life, a heavier identity].
Wang Li, an oncologist at the General Hospital of the Beijing Military Region, told me, She was particularly understanding, Why do patients always want to avoid illness? Many people after serious illness, Don’t want to tell others. Because these patients think, They have become people with no future. [Some of them worry that they will be discriminated against. Some people worry that partners will not look for themselves again. Some people are worried that there will be no filial son in front of the hospital bed for a long time.] The patient felt that, Serious illness has cut their lives off from the social ties of the past. [Not even harassing phone calls, not even those selling fake invoices called me]. Some patients finally accepted the reality of their illness after hard work, but when relatives, friends and colleagues came to visit, they would constantly mention their illness out of concern, [for patients, it is often a feeling that scars are constantly being uncovered].
Although there will be extremely negative psychological feelings, However, if these feelings cannot be openly told and discussed to the patient, Without facing the pain of patients, patients are actually isolated from their own environment. Patients have the right to know and are protected by law. Some countries such as the United States have legislated to protect patients’ right to know, but China is still a long way from this step. Ning Xiaohong hopes patients will get the right to know, but she will be very careful to test patients.
When discussing the condition with the patient, Ning Xiaohong will show a very different style from normal times. She treats young children with a soothing tone and extremely meticulous emotional balance. She told me that serious illness can make people feel very helpless, which makes patients feel like children. She will tilt her head and gently ask the patient: “Have you ever wondered why you have been uncomfortable for this period?” She would also ask: What do you think of a good day? You want me to be what for you? ]
Some patients would stop her: “Doctor, I don’t understand these medical things, please tell my son.” Sometimes the family members would interrupt her urgently: “Doctor Ning, my father feels quite good.” Sometimes the patient was silent, and she would ask, “Do you still have what to ask me? Although patients should have the right to know about the disease, Ning Xiaohong knows better that whether to break this window or not, one must also respect the wishes of the patients themselves and their families.
Dr. Zhang Ning told me, The Concorde Geriatric Team conducted a survey of more than 1,000 elderly people in Chaoyang District of Beijing. More than 78% of the elderly want to know the truth when they get sick. More than 56% of the elderly want to make a decision on their own treatment plan. Only 8.9% of the elderly are willing to receive traumatic rescue in the final stage of life. [For the elderly with sound cognitive function, they are fully capable of making medical decisions independently. Family members should return this right to patients.]
A 90-year-old man sent away by Zhang Ning just two months ago, Is a senior intellectual, lung cancer multiple metastases. The two daughters are very filial and require doctors to actively treat them, but they cannot tell the old man about their illness. The family has been deceiving the old man that he is benign meningioma, plus a little pneumonia. One day the old man suddenly showed anger in front of Zhang Ning. How can a simple disease not be cured? Zhang Ning asked the old man, “Do you want to know the whole situation?” ] The old man replied that he would like to know, but the family members on one side hurriedly pulled Zhang Ning away. After the old man died, one day, the old man’s daughter told Zhang Ning on WeChat that now they regret their decision at that time. If the father knew that he was leaving soon, he should have his own wish.
Regarding Zhang Shunian’s situation, Ning Xiaohong suggested that the attending doctor Qu Xuan push forward. Ning Xiaohong asked: “Did his family tell you clearly that he must not know about his illness?” Qu Xuan said: [I didn’t say I couldn’t, they thought he should have guessed it.] Ning Xiaohong suggested that doctors should take more responsibilities and push things forward at this time. Some patients don’t want to pierce their illness, but people like Zhang Shunian who are accustomed to making decisions are better off knowing the situation.
After the morning round discussion on March 11, Qu Xuan thought she had found a good time to tell bad news. She also agreed with Ning Xiaohong’s judgment. Zhang Shunian is a sensible person, He has his own plan for the life of the whole family, If he knew his time was running out, he should have some wishes to fulfill. The first day he had a serious abdominal pain, Qu Xuan gave analgesic treatment. With the obvious relief of pain, Zhang Shunian wrinkled Ba’s mood also relaxed. Qu Xuan called Tong Ning to the outside of the ward and persuaded Tong Ning and her to tell the truth frankly to Zhang Shunian.
Zhang Shunian seemed very calm. Indeed, as everyone speculated, he had already understood his situation.
When Qu Xuan asked him about his plans for what, he said: I want to go home.
Although telling the truth makes many people feel [cruel], the care and kindness behind it actually relieved everyone in the room.
Tong Ning later told me that the old man had asked him to buy a train ticket to go home and decided to go back to the place for some supportive treatment. He felt that since the doctors in Concorde all felt that his illness could not be cured, [the end], there was no need to go over and over again to see a doctor. It might be a better choice to go home for some treatment and calmly accept the end of his life.
On March 21, Tong Ning sent a text message to tell me that the old man had already seen a doctor in the local hospital and was ready to undergo some routine chemotherapy. He would decide the next treatment according to his body’s tolerance. [Although he was in a low mood, he was still a man who could see through the whole.]
The suffocating three minutes
How to tell patients bad news, It is a real problem faced by most doctors. For the average person, Going to the hospital is a frustrating experience: Crowded crowds, professional and obscure words in medicine, doctors’ limited patience and thin sympathy. Zhang Daqing, director of Peking University’s Institute of Medical Humanities, told me. The core meaning of patients going to the hospital is to get treatment for the disease, which is also the focus of doctors’ attention. If the disease is cured, the indifference shown by the hospital as an institution is tolerable. However, if the disease is not cured well, all places in the hospital that are not humane enough, the indifference and indifference of medical staff become unacceptable.
Chinese traditional culture always has the image of “magic doctor”, People mentioned that the words they like to use to cure diseases are “medicine to cure diseases” and “wonderful hands to revive spring”. Liu Duanqi, an oncologist at the Beijing Military Region General Hospital, mentioned that This concept of deifying the role of doctors tends to make people place particularly high expectations on doctors. [Westerners often say to their children that “it is best not to get sick, even doctors cannot help you when you are ill”, which is closer to reality.]
The patient showed the expectation of getting rid of the disease, With the hardships and lengths of the actual medical process, It often forms a sharp contrast. Zhang Daqing said, This also has a lot to do with the change of disease spectrum. Over a long period of history, Medicine mainly deals with infectious diseases, acute diseases, The treatment of these diseases is indeed easy to show the characteristics of [medicine to disease]. With the rapid progress of medical technology in the 19th century, Especially with the rapid development of surgery, It has solved the three major problems of surgery in disinfection and corrosion prevention, anesthesia and analgesia, and blood transfusion. By the 20th century, Surgical operation [opening all three chambers], Doctors can perform craniotomy, thoracotomy and abdominal surgery. People’s life expectancy has been significantly prolonged. Doctors’ ability to deal with diseases has greatly improved. So that for a long time to come, He has gained parental authority. The disease spectrum also ranges from infectious diseases, acute diseases to infectious diseases. Chronic diseases and degenerative diseases are the main diseases. These chronic diseases and degenerative diseases are intertwined with lifestyle and even life. However, most people’s ideas still remain on the idea of treating acute diseases and lack the psychological preparation to resist chronic diseases. Once the doctor shows that there is nothing he can do, which falls short of the patient’s expectations, the patient’s most likely complaint is: “You didn’t listen to me at that time, you didn’t care about me, so you didn’t cure the disease.”
Zhang Jianwei, a doctor in the oncology department of the Beijing Military Region’s chief doctor, said that when he told patients that a disease was difficult to treat, patients often did not agree: “Really? Is it not your hospital? You don’t know the situation, do you? Now that science and technology are so developed, medicine is so advanced, and there are still diseases that cannot be cured? I’m going to XX Hospital to have another look! ]
Zhang Jianwei told me, This reminded him of the situation described in “The King of All Diseases”. Medicine made rapid progress in the 1940s. After the war, the economy also achieved steady development, various antibiotics emerged in medicine, and many diseases that were helpless in the past were treated. Against this background, once the doctor told the patient that he had an incurable disease, the patient’s response was often: “Really? Aren’t new drugs invented every day now, and are there any diseases that can’t be cured? ]
With the development of economy and the rapid development of science, people often forget that there are still problems that medicine cannot solve. Disease and death are part of life. However, the uncertainty of treatment, the risks of medicine and its boundaries have always been problems that doctors must face.
When the patient is faced with the fact that the disease is much more cruel than expected, A medical setting that is not humane enough, It makes patients feel more intense pain. Zhang Daqing believes that The scientific nature of medicine does not take into account the individuality of patients. Science pursues universality, Not paying attention to individual cases, The patient’s feelings about the disease are very personal. Rita Cullen, the initiator of narrative medicine, said: [It is difficult to describe what is missing in medicine is what, And how to make up for these deficiencies. Some people accuse that doctors’ innate empathy, respect for the pain of others and ethical recognition ability have been artificially weakened in the process of medical training. In the process of educating doctors, they have witnessed more pain and hardened their hearts.]
In such a deep conflict, the bad news told by doctors may become the last straw to crush patients and their families. Of course, doctors need to muster up their courage.
Chen Yingqian is an intern at Concorde Hospital. She experienced an impressive patient in 2015, felt deeply helpless, and also saw the space that medicine can work hard. At the beginning of 2015, Chen Yingqian practiced in urology and handled dozens of patients every month. She thought she would not remember the name of any of the patients.
The patient who impressed her deeply was a middle-aged lawyer from a large international law firm. When she was admitted to the hospital for more than half a month due to frequent and urgent urination, she was diagnosed as [acute cystitis] in the outer hospital. The patient and his family flew to Beijing and were soon admitted to the special needs ward. They wanted to repeat cystoscopy, with a little treatment, and could go home in a week or two.
However, when urologists saw the medical information he brought from the outer court, they all got a fright: “What kind of acute cystitis is this?” ] A large area of aquatic plants and blister-like objects in the bladder, and a small tumor on the anterior wall of the bladder can be seen on abdominal CT. Obviously, the local hospital also noticed this and tried to carry out puncture biopsy on the tumor, but pathology only suggested chronic inflammation of the bladder wall.
The patient became weaker and weaker. Within a week, the frequency of urination increased significantly. Symptoms of urinary incontinence occurred. The body was too weak to walk on the ground, could not eat much, and his stomach became swollen day by day, but his weight was rubbing off. After a series of examinations, the doctor understood that the patient’s tumor could not escape, but was the tumor the source of what? How to treat it? Urologists, while supporting the treatment of patients, quickly contacted the consultation of relevant internal medicine departments. However, everyone said that no department could work out an active treatment plan before obtaining pathological confirmation.
The doctor looked very embarrassed, The patient had a bladder puncture at the local hospital, No new findings were found in the pathology consultation, As the mass is outside the bladder, The danger of puncture again is very great. After fully explaining with the family members, the doctor did abdominal puncture for the patient, and the ascites was passed out and the tumor cells were examined. The pathological results showed cancer. Chen Yingqian described it as cancer. For the doctor, what could not do it either. They advised the patient to go home and spend the last time.
The patient’s family members and friends came to a large group and all asked the doctor to actively treat them. The attending doctor, associate professor, professor and director of urology took turns to talk about the disease with the family members, moving with emotion and understanding with reason, and suggested taking the patient home. However, the relatives of the patient still put forward the same requirements every day: 1. Don’t inform the patient; 2. Actively find out the cause of the disease and actively treat it.
Patients are weakening day by day at an alarming rate. Chen Yingqian said that facing the end-stage patients is not what urologists are good at. Although everyone is doing his best and does not hesitate to work overtime, everyone’s eyebrows are deeply wrinkled as soon as he arrives at the door of the ward every day.
At this moment, Chen Yingqian thought of Ning Xiaohong. The palliative care she advocated may be useful to the patient. Ning Xiaohong first met the patient’s wife and younger brother outside the ward. They repeatedly asked not to tell the patient’s condition.
Ning Xiaohong first spent half an hour introducing the actual situation of the patient in detail with the patient’s family members: Malignant tumor abdominal metastasis, renal failure, family members understand the situation, agreed to let Ning Xiaohong see the patient, Ning Xiaohong invited them to walk to the patient’s bedside together. She bent down, close to the patient, let the patient feel her attention and kindness. Gently said to the patient: “Why are you not feeling well now?” ] [I have a stomachache, swelling, don’t want to eat, can’t sleep, and now I have no urine…] [What do you think of my illness? ]
The patient showed a dismissive appearance and replied, “They said it was acute cystitis. They were discharged from the hospital after doing cystoscopy and taking medicine.”
Ning Xiaohong was not unhappy with the patient’s indifference. She said: “I know you are experiencing pain. You have stomachache, can’t eat, can’t sleep well, and urinate a lot.” Then she asked: “Do you think we need to do some what for your discomfort? [At this moment, the patient turned his head for the first time and confided some of his symptoms, saying: “If only abdominal distension and frequent urination could not be so serious.”
Ning Xiaohong said that it could relieve the discomfort of the patient. She asked softly, “Do you still need to ask us about your illness and what?” ] She still kept her initial posture, with gentle eyes, looking at the patient whose eyes were gradually flashing tears.
Chen Yingqian recalled that the patient fell into deep meditation. [Those three minutes seemed to be the longest I had spent. Family members, patients and teacher Ning were silent. The room was so quiet that the sound of the wall clock could be heard. I just felt that the air in the room was getting more and more dignified and breathless, making me feel like I wanted to escape.]
Ning Xiaohong later told me that This moment of silence, It takes the doctor’s courage and patience. Sometimes when a patient is silent for ten seconds, the doctor opens his mouth to break the silence or flees. In fact, everyone needs more courage to face such a notification moment. The patient’s eyes are flashing with complicated thoughts. He hesitates many times, but finally what does not ask. [No, thank you.]
Chen Yingxi described the unforgettable scene: [We finally stepped out.]
Ning Xiaohong said, Although she is eager to help tell the patient the truth, But respecting the patient’s wishes is the first thing. The three minutes of silence, It doesn’t seem to have any verbal information, but it actually has a profound meaning. What she wants to do is not to give the patient any pressure, so she asks a lot of questions and gives the patient enough choice. [We will never say that you need chemotherapy or surgery for this disease. What if the patient doesn’t want to? So I will always give patients more than two plans, and I will tell them that death is also a plan, and you will always have a choice.]
For the rest of the day, Ning Xiaohong had in-depth communication with the patient’s family. [The patient is so young, And so knowledgeable, If we let him leave in a muddle-headed way, I don’t think so. He must have his own wishes, Why don’t you ask him what his wishes are? Once he has dialysis here, The patient inserted the tube, It is impossible to go home.] Ning Xiaohong said, Doctors not only treat diseases, The eyes should not only see organs, but also pay attention to the overall feelings of patients. The same is true for family members. When medical skill is unable to return to heaven, it is very important not to just think about treatment and treatment, but also to help patients realize their wishes. The doctor’s duty is not only the operator of medical technology, but also the ability to respond to patients’ pain in various ways.
Although the family grief, or quickly accepted Ning Xiaohong’s advice. Ning Xiaohong accompanied them to sign the agreement to refuse the operation and also discussed the transfer. She also prescribed painkillers and drugs to relieve the symptoms of the patient’s digestive tract and urinary system. Family members said at that time that as long as there was a glimmer of hope, they still did not want to leave Concorde.
But early the next morning, the family told the doctors that they had held a family meeting at night and told the patient about his illness. The patient was calm and expressed his wish to go home for supportive treatment, so they decided to leave for home that night.
Chen Yingqian later wrote in her article: After work that night, I went to the special ward to find his wife, Said some comforting words to her, And the blessing of weakness. The woman who has always been strong and has always been the backbone of the family, For the first time in front of me, I could not help but shed tears. She said: “With those drugs, he feels much better. It is good that he does not suffer. We will leave at night. Thank you for your care.” That night, they left quietly. Despite the complicated procedures and the large number of family members, they hardly disturbed the doctors and nurses. The room seemed as if no one had lived in it.
After a few months, careful Chen Yingqian, I also made a phone call, I want to know that this patient went to how. She called the patient’s cell phone. It’s down. She called the patient’s wife again, His wife said, After returning to the area, the patient took some traditional Chinese medicine. Had dialysis several times, She left peacefully in less than a month. She said, It is regrettable that the patient did not receive effective treatment. However, I still thank the doctors for their explanation and good communication during the consultation. Chen Yingqian sighed with emotion and said: [The patient was in his prime and lost his life in two months, which was hard for anyone to accept. I admire his wife for respecting his wishes and not letting the patient suffer unnecessary treatment pain. I am already satisfied with her evaluation of us as a doctor.]
This experience reminds Chen Yingqian of the epitaph of American doctor Trudeau, which may be the essence of medicine-[sometimes to cure, often to help, always to comfort.]
The fragmented disease and its vector
The palliative care that Ning Xiaohong came into contact with is one of the latest and fastest-growing disciplines in medicine. For western medicine, the rapidly advancing technology has brought people a strong sense of pressure. The more people believe in technology, the more vulnerable they are to problems that technology cannot solve.
What happened in the doctor’s office was very complicated. But the two sides involved did not make what preparations for these clinical encounters. Patients feel that doctors do not think much of their pain. Doctors don’t trust them when describing symptoms, They are materialized by cold medical treatment. Doctors live in a scientific world: In academic ideals, scientific competitive pressures, professional superiority and ambition to express one’s own skills, Often obscure the main goal of medicine-service. Patients have to choose between the care and ability of doctors, empathy and science. Medical treatment cannot reverse the consequences of unhealthy behavior, bad choices, contingency and bad luck. But the [scientific world] in which doctors live, And the gap between the patient’s [life world], more and more need effective fillers.
The current specialist model of medicine, the situation of “seeing diseases but not seeing people”, Facing severe challenges. Li Hongying, an expert in oncology department of Beijing Military Region General Hospital, recalled to me, In the past, after tumor patients had undergone surgery, Often I don’t know where to go next for treatment. Apart from a few specialized oncology hospitals, The tumor patient felt helpless in the general hospital. After the surgeon removed the tumor, Many patients face the problems of short-term recurrence, cancer cell metastasis and short survival time. But in every department, The doctors in this department only treat the patients according to their own thinking, [Surgery is surgery, When I get to the radiology department, I will take photos. The disease is cut into pieces to correspond to the existing department. What kind of treatment is the best for the patient in general, In the 1990s, the state required 3A general hospitals to establish oncology departments to deal with this problem. In oncology departments, each patient’s condition has a sense of history and overall situation. Doctors consider from the comprehensive perspective of the patient’s body, and what targeted treatment should be implemented at different stages.
Liu Xiaohong was a professor in the Department of Digestive Internal Medicine of Concorde Hospital and has been engaged in the clinical work of the Department of Digestive Internal Medicine for nearly 30 years. She said that all departments of the hospital used to basically treat [single disease]. The patient has stomach problems and goes to the digestive department. If there is a heart problem, go to the Department of Cardiology. The liver is not good, Then go to the digestive department. Specialists only consider the treatment of one disease. Often neglect the patient’s comprehensive condition. She said that once there was an old professor of medicine, Her wife had an acute myocardial infarction, He was sent to the hospital for rescue. The old professor told the doctor, His wife’s kidney function is problematic, No antiplatelet drugs are needed. However, according to the guidelines for the treatment of acute myocardial infarction, Standardized use of antiplatelet drugs, The patient suffered from massive hemorrhage in the digestive tract, No treatment. Liu Xiaohong remembered the old professor’s grief: “If my wife died of heart disease, I have nothing to say. But he died of gastrointestinal hemorrhage, I can’t accept it.” Liu Xiaohong said that since then, she felt the defects of specialized diagnosis and treatment, but for individuals, it is still difficult to rise to the system level and propose particularly effective improvement measures.
In the sixties and seventies of the 20th century, The emerging bio-psychological-social medical model in the West, as well as bioethics and doctors’ professional spirit, It broadens doctors’ narrow vision of focusing only on biological diseases, Encourage them to understand the emotional, psychological, social and family needs of patients. In the past 20 to 30 years, Medical schools, resident training and medical professional societies have responded to the call for humanization of medicine. In addition to equipping doctors and medical students with exquisite medical knowledge and technology, medical education is also committed to promoting empathy, trust and attention to individual patients in medical practice.
After Liu Xiaohong was suddenly appointed as the director of the geriatric department of Concorde Hospital in 2010, She came into contact with the most advanced medical concepts. When the elderly demonstration ward of Peking Union Medical College Hospital was prepared in 2006, He cooperated with Johns Hopkins University School of Medicine in the United States to try to introduce modern western geriatric concepts into China. Coincidentally, Rockefeller copied Concorde more than 90 years ago when he was building Peking Union Medical College Hospital according to the model of the most advanced Hopkins University School of Medicine at that time.
A special department is set up for the elderly patients. It embodies the different concept from other specialized departments. What troubles the elderly is basically not [single disease], But a mixture of several chronic diseases. According to the survey data of the elderly in the United States, Among the elderly over 65 years old, 90% suffer from a chronic disease, More than 50% of people suffer from three or more chronic diseases at the same time. The goal of geriatrics is not to simply prolong life span, But to extend healthy life expectancy with quality of life, With the goal that the elderly can live independently in the community as their goal, geriatrics embodies a concept of “whole-person management”, in which the elderly patients are treated as a whole, and doctors choose the most beneficial scheme for the patients after comprehensive consideration. Medical technology is only one of the means to help achieve this goal.
Zhu Minglei, chief physician of geriatrics, told me, for example, In the past, doctors’ treatment ideas, It is often to treat a disease to the extreme. For example, for patients with lung cancer and multiple organ metastases, Whole body chemotherapy, and possibly follow-up chemotherapy. Once on chemotherapy, let the patient must finish this course of treatment. Now he is more inclined to consider the patient’s feelings, whether the patient’s body is tolerant to the treatment, if the side effects are too serious, can he rest for a while? Make a trade-off between prolonging life and ensuring the quality of life.
Liu Xiaohong said, The proportion of elderly people who die from non-cancer is higher, Such as heart, lung, kidney, liver and other important organ failure, Dementia, advanced Parkinson’s disease, etc. Generally, it is relatively easy to estimate the life expectancy of cancer patients. The expected life expectancy is shorter than 6 months, and you can consider entering the nursing care program. However, non-cancer patients may live for a long time every time they are rescued, so it is more important to decide whether to enter or not according to the needs of the elderly.
Liu Xiaohong said that when the disease is incurable, there is no better way. In this case, the wishes of the patients come first. It is necessary to see that doctors can do some what for patients and their families and try their best to help achieve their wishes, instead of just doing what medical technology can do.
Disease is a loss of balance between the body’s defense system and external stress, For the weak elderly, the body is like a paper boat and a clay flowerpot, which cannot withstand blows. If we are still chasing after diseases for diagnosis and treatment at this time, doctors cannot run away from those diseases. Therefore, our focus is not on diseases, but on maintaining the functions of the elderly and improving the quality of life.]
When I was out of the clinic in Ning Xiaohong, I fully felt this kind of thinking in geriatrics. On the morning of March 16, Ning Xiaohong an old patient to see a doctor. 76-year-old woman ovarian cancer advanced, after the operation and found metastasis, now has cancer metastasis for a year and a half. The old man and his family have accepted the fact that they no longer do anti-cancer treatment. She occasionally came to see the concorde geriatric clinic and got some supportive treatment.
This morning, The old lady in a bright orange down jacket was pushed into the clinic in a wheelchair. Her son said loudly to Ning Xiaohong: You see how strong our old lady is, I came to see the doctor myself.] Ning Xiaohong, like talking to a child, Gently asked the old man what was wrong with him, He fell down and touched the old man’s abdomen. He squatted down and touched her legs and feet. Ning Xiaohong paid attention to the problem that the elderly were most concerned about at the moment. The patient himself cares most about what. The old lady has already looked very dull. There was not much reaction to her question. Her wife said, If we can solve the problems of fecal incontinence and unstable sleep, That’s good. [Fecal incontinence is probably caused by tumor compressing nerves.] Ning Xiaohong said to his family, [Don’t give the old lady CT, even if found out the tumor and how, there is no need to let the old man endure the pain of examination.] She prescribed some drugs for the old man, instructed the family to nurse frequently, don’t let the old man retting bedsore. This diagnosis and treatment is over. She told me that making the patient feel better is what she can do for the old man at this stage.
Another mother and daughter seeking medical treatment, It was for the 88-year-old woman in the family. The old man was hospitalized in another hospital because he suspected Alzheimer’s disease. But I’ve been in hospital for three months, In the past half month, not only has the fever not subsided, More and more abdominal water. The mother and daughter came to ask Ning Xiaohong, What should I do? Ning Xiaohong said that the cause of abdominal water accumulation may be inflammation or malignant tumor. Anti-inflammation has not been used for so long, and it is estimated that the possibility of malignant tumor is large. [But the old man is 88 years old, even if it is found to be malignant tumor, do you think you still hope to do surgery or chemotherapy? If we don’t do all this, then we don’t need to check whether she has a malignant tumor, and the examination itself will bring pain to the elderly.] The mother and daughter froze a little and asked, “Do you want to smoke ascites? ]
Ning Xiaohong said, if ascites hasn’t made her very uncomfortable yet, don’t smoke. [Three months in hospital is too long, have you ever thought about letting the old man go home? Hospitals are not a good place in what. Many old people are getting weaker and weaker as they live. Hospital infection is also a problem.]
The mother and daughter asked again, How can they judge whether the elderly can be discharged from the hospital?
Ning Xiaohong said: “If you can’t get through without leaving the hospital, you can consider leaving the hospital. If the elderly’s body temperature is stable at 37 ~ 38 ℃, there is no special discomfort, and they can be cared for at home. However, you should also be prepared for the elderly’s short time.]
Body: Shelter for Patients
When a patient is notified of hospitalization, Guo Xinying, head nurse of the geriatric department of Concorde Hospital, will specially tell the family members: Ask the patient to bring something he is familiar with. Don’t forget to bring hearing aids for patients with poor hearing. Patients who do not sleep well can bring their own pillows. If you are willing to bring photos of your family to the hospital, It is also a very good choice. They hope that the patient can be accompanied by his family on the first night of hospitalization to help the patient eliminate the fear in the strange environment. But what puzzled her was: [It is not that we do not allow family members to accompany them now, but that there are too many empty nest families, and almost half of the elderly do not receive much family support.]
Director Liu Xiaohong has clear requirements for the ward, They put up calendars in conspicuous places to let patients notice what day of the month and what day of the week it is today. She asked the ward to turn off the lights at night, [the ward should be bright during the day and dark at night]. Because if the bright headlights are always on in the clinic, the patient will not feel the circulation between day and night, feel isolated and afraid, and be prone to delirium.
When the physician puts the patient’s wishes first, Their concerns will change greatly. In addition to the body, There are also important social roles. Liu Xiaohong said: [If a person is intubated, He was confined to bed, Even at home, He was unable to eat at the table, The actual status at home will change.] So she is very careful not to let the ward restrict the patient’s mobility. [All factors that restrict (restrict people’s movement) should be avoided as much as possible. In some departments, The patient was catheterized as soon as he came in, The patient could have been able to move before he was hospitalized, Finally, I had to lie down and go out.] Liu Xiaohong said, The geriatric patients are already very weak, Inserting a catheter restricts the patient’s movement, It can also cause lung infections. [Treating diseases can also cause diseases. We should avoid iatrogenic injuries. We encourage patients to get out of bed, help them control pain, and teach their families how to give them physical therapy. Some patients come in in wheelchairs, but they can walk out when they leave the hospital. Once they regain their mobility, they feel very different about life.]
Attending doctor Ge Nan told me that Treatment of geriatric diseases is not absolutely conservative. If a certain treatment can significantly improve the quality of life of patients, They may be more active in advocating treatment than doctors in other departments. A 98-year-old man whom she attended earlier, After the fracture of his right leg, There was another comminuted fracture in the middle of the right thigh. After the orthopaedic doctor saw it, I think the old man is so old, There is also a precursor to myocardial infarction, Don’t do surgery. But the geriatric department after comprehensive judgment of various factors, if do not do surgery, pain, bed rest and other conditions will lead to the old man to live for not more than a month, and lost most of the ability to move. So after consultation, it is suggested to operate on the old man. Now the old man has finished the operation for more than four months, and his physical condition is still OK.
Unlike the general profession, Medical workers have the right and privilege to touch other people’s bodies and interfere with them, which may cure them. Because of this, In fact, they also have an obligatory responsibility. Acknowledge that the patient’s body is the patient’s self, Recognizing that the body is an important refuge for everyone’s self. Many issues involved in bioethics and health law, It is related to the owners, guardians, managers and protectors of the body. One of Liu Xiaohong’s ways of respecting patients’ bodies is to protect their bodies as little as possible. If the disadvantages brought by treatment outweigh the benefits, he will discuss the benefits and risks of several schemes with his family members and patients and change his thinking.
When I attended the ward rounds of the University of Geriatrics on March 11, after the attending doctor reported the condition of a patient, Liu Xiaohong would ask: [Does the patient’s society support how? ] Attending doctors, head nurses, nurses or social workers are all likely to answer this question. In the 30 square meters of space in the doctor’s office, I saw a rich level: a medical team composed of doctors, nurses and social workers, as well as attention to patients from various aspects of disease, spirit, psychology and family.
For example, a 76-year-old patient [who had cerebral infarction in 2003], After losing his spouse in 2014, The mood has been very depressed. My daughter is busy with her work, Although he has a daughter and son-in-law living at home, However, communication is relatively small, and nursing workers have been taking care of them recently. When I was first admitted to hospital, I had some delirium, saying that it was 1960 and I was only 48 years old, etc.]. Liu Xiaohong reminded that the old man had the risk of falling into bed and must pay attention to it. His thinking is sometimes unclear, so he should ask his family if the old man has any financial problems to account for to ensure his financial safety.
The attending doctor mentioned that This time I was hospitalized because the old man fell down. He fell when the nurse was holding him. Liu Xiaohong confessed: [You observe the movements of the nursing workers. Many nursing workers treat the confused old people roughly. The correct care method you should teach nursing workers is what.] She also reminded that the history of the elderly’s medication should be made clear to see if the elderly have recently added new drugs and whether it is possible that the new drugs have caused unconsciousness.
Liu Xiaohong mentioned several times that To find the reversible factors of the problem, which can be improved technically through treatment and which need to strengthen social support. [Starting from the admission of patients to hospital, we must think about where they go after going out and which factors can be improved. For example, if the elderly are prone to fall down, it is better not to live alone. Can they move to their daughter’s house? Can his daughter’s house pack up the small carpet on the ground and hide the line of the desk lamp so as not to prevent the old man from falling down again? Is there anyone in the family who can eat with the old man? Don’t let the old man eat alone. Only when two people eat together can they have an appetite.]
For patients who are already dying, She stressed that medical staff must be able to judge people’s near-death symptoms. [If family members and patients know in advance, We can help the patient fully wish. Maybe he has some problems to explain to his family, maybe he wants to go home and die. If the patient dies in a muddle, it is a permanent regret to them and the family. If the patient needs rescue, be sure to inform the family of the possible cost.]
After discussing the patient’s condition, A few more people came into the doctor’s office. They are doctors in the Department of Medical Psychology and Rehabilitation of Peking Union Medical College Hospital, as well as pharmacists. They started the most distinctive multidisciplinary team rounds in the Department of Geriatrics of Peking Union Medical College Hospital. Everyone expressed their own opinions and made suggestions from their respective professional perspectives to ensure the patient’s emotional stability, medication safety and effective nutritional support.
Attending this big round, There is also a medical team from another well-known hospital in Beijing. They encountered a very difficult problem. Some elderly people from well-to-do families used the ventilator for various reasons before they died. [After the ventilator was put on, even if the patient had no meaning of prolonging his life and some had already died of brain death, it was a big problem for the department to unplug the ventilator. No one can bear the responsibility of unplugging the ventilator].
In recent decades, Medical technology is increasingly involved in dying, The process of death is greatly prolonged, Constantly deviating from nature. Zhang Daqing said, Originally, there were three recognized medical purposes. It was proposed by Francis Bacon: Promote health, reduce diseases and prolong life span. As medicine intervenes more and more in normal deaths, [How to Die] Becomes a Medical Ethical Issue. In the 1990s, Under the leadership of the United States, 14 countries, including China, launched the “Re-examine the Purpose of Medicine” campaign. They put forward the fourth purpose of medicine-to promote dignified and peaceful death. The geriatrics department and oncology department I interviewed both faced the problem of how to promote dignified death.
Liu Xiaohong said: [Put on the ventilator and pull out the ventilator, They are all the same in ethics. To prolong life meaninglessly, The patient himself is very painful, But they often do not have the ability to express themselves. The UN Health Organization has long made it clear that Artificially and meaninglessly prolonging life, Is inhumane. If the family decides to pull out the ventilator, After the family members sign, it should be carried out by the medical staff. If, in order to avoid the responsibility, the family members are allowed to pull out the ventilator themselves, it is likely that the family members will have nightmares all their lives and will be pulling out the ventilator of their relatives. Our doctors should assume their due responsibilities. The care object of hospice palliative care also includes the family members of the patients.]
Listening and Farewell
When head nurse Guo Xinying was just transferred from ICU ward to geriatric ward, I didn’t get used to it for a while. In the ICU ward, Critically ill patients are barely able to communicate, Most of the time there is only the monotonous sound of machines in the ward. But in geriatrics, many patients are full of desire to communicate. [One patient wants to pull me to talk for an hour every day. We are already very busy and have a lot of things to do, so I feel very collapsed at first and don’t understand: Why is he telling me this? But Guo Xinying quickly changed his view. [When I feel annoyed by patients, I actually feel that patients do not abide by the rules of our ward. But I think again from their standpoint, why must they abide by my rules? ]
Guo Xinying slowly realized the value of patients telling themselves. After they were closed into the ward, changed into hospital gown, Before the label [patient] is affixed, Everyone has a unique past. To a large extent, Suddenly cutting off people’s past, even the patient himself feels that he has become a person who has no future and floats on the real life. Taking care of the terminal patients is not an easy job. When the patient is terminally ill and the doctor is already unable to recover, a very small wound may cause the patient’s pain. Some people have mental breakdown and extreme depression. Some people are extremely cynical and often hurt people with bad words. There are also people who become like spoiled children. Neither how can meet his endless demands. Some doctors mentioned that for these patients, the morning rounds are a psychological challenge.
But Wang Li, a doctor in the oncology department of the Beijing Military Region, said that after working long hours, she found that patients who are difficult to deal with often do not solve their own problems. They are not having opinions about doctors, but are still in the process of accepting their own diseases, or because there are difficult problems within the family.
Guo Xinying found that By chatting with patients, Those who wear the same gown, There was a vivid personality in her eyes. Some patients are always asking, In fact, they are too lonely, Wishing to get attention, So Guo Xinying and the nurses went to shake when they were okay, Say a few words to the patient. Patients with good family support, Often very few additional requests are made. Some patients are willing to talk to doctors, Some feel that they are too heavy to talk to doctors and prefer to talk to nurses. Ning Xiaohong’s social work interns from the university’s social work major have also played a very good role in communicating with patients. Guo Xinying said: “Our teams have formed a close cooperative group and have a three-dimensional understanding and support for patients.”
If we do not pay attention to the communication between doctors and patients, It is easy to feel the barrier on both sides. The doctor’s intuition is to simplify complicated things. The patient’s intuition is to complicate simple things, so the two situations have conflicts. Medical reductionism restricts what it wants to see and eliminates all the things in the patient’s complicated life that have nothing to do with the biology of the disease. It can be said that medicine is de-metaphorization, sacrificing the uniqueness of the patient’s life in this conflict.
While listening to patients, It is originally a medical procedure, Only its importance is more and more obscured. Wu Dong, a digestive doctor at Concorde Hospital, told me. The United States has done research, If the doctor does not interrupt the patient, Three-quarters of the patients will only stop talking for two minutes. The median length of the patient’s talk is 92 seconds. In other words, The vast majority of patients do not talk as much as doctors worry. Listening to medical history is helpful for doctors to treat. Doctors try not to interrupt patients. Let the patient have a complete description, which can not only comfort the patient psychologically, but also will not lose important clues. Therefore, when a disease is difficult to diagnose, in addition to doing various examinations, you should also return to the patient’s side and find more clues through chatting.
Wu Dong once met a male patient in his 40s in the emergency room, The fever did not subside, Antibiotics can’t cure it, Check blood again found white blood cells are not high, let him very confused. Later he returned to the patient’s side to chat with him, the patient usually sells wonton at a stall in Beijing. Wu Dong asked him if he had poor sanitary conditions in his home and whether there were mice. Again associated with the epidemic hemorrhagic fever spread by animals, it was finally determined that the patient had typhus and tetracycline could be cured.
Zhang Songlun, vice president of Beijing Henghe Hospital, told me that When he was young, he treated the common people at the grassroots level. The medical conditions are very poor, and there is often a shortage of doctors and medicines. Therefore, when the common people come, he spends a lot of time chatting with them. [I call it “love and love”, talking about the illness and showing concern. This is a helpless move, but I slowly found out that I can find clues of diseases from this kind of chat. Some diseases do not need special urgent treatment, and can get better by waiting for observation.]
This kind of telling and listening, It is also the essence of [seeing a doctor]. Disease is an event that happens to people. Sometimes for identifiable reasons, And occur at a specific time and in a specific context, It is told by one person to another person from a specific angle. Only by understanding how the patient suffers from the pain, Only doctors can provide effective clinical help to patients. But this requires doctors to enter the patient’s world. Even if it is only through imagination and from the patient’s point of view and understanding of the world. When the patient tells the symptoms, even the fear of the disease, the process of healing has actually begun. The patient often talks to himself first, then to his relatives, and finally to the medical workers.
Listen to the patient’s complete description of his or her experience in this ordeal, Hearing their own conclusion is what means what, which of those terrible things they fear most. In this way, doctors and patients can jointly try to face up to the uncertainty that any action may bring, including not taking therapeutic action. Listening to patients is also an important way to know their wishes.
When Zhang Songlun was a postdoctoral student in Canada’s medical school, he worked part-time in a large local nursing institution. In the hospice ward, all the patients clearly expressed their intention for hospice treatment. Therefore, the patient’s medical records are divided into four colors, representing their different wishes: full rescue in case of emergency; Agree to rescue, but do not agree to traumatic rescue; Agree to maintenance treatment, but do not take rescue measures; Abandon invasive treatment completely. In this way, the medical staff can clearly implement the opinions of the patients.
However, in China, the vast majority of people have not had living wills. Liu Xiaohong said: “This is something that should be talked about in the living room. When the patient is admitted to the ward, it is no longer a good time to talk about it. This will alert the patient: Am I not able to do it? So we still have a lot of work outside the ward. We need to go deep into the community and let people know how to protect their medical rights.]
Sometimes, patients die in the ward. Head nurse Guo Xinying will help complete a small ceremony. When the patient is dying, She will advise family members to accompany them gently. Some family members will take off their sick clothes and put on their own clothes. She will tell family members that when a person is on the verge of death, the motor and sensory functions of the limbs will decline first. In the process of gradually losing vision, people can still vaguely hear external sounds, and the hearing and subconscious mind will eventually lose.
If a person has to hear the noise of doctors’ rescue and the sad cries of relatives repeatedly at the last moment of his life, and his body and mind have to continue to endure the torture brought by treatment methods such as needle insertion and enema, then the patient must be very unsafe when he [leaves].
Liu Xiaohong said, Many people don’t know, In fact, on his deathbed, he was half hungry and half dehydrated. Endorphin secretion in the body, It will produce a sense of pleasure. At this time, even if it is an infusion, Will destroy this pleasure. The deceased’s hearing finally disappeared, They hope that the family members will whisper in the patient’s ears, encourage and praise the patient, and help them through the last time. This review of the patient’s life can help the patient and the family members find the meaning of various past experiences and realize the value and love. The joy of life and the calm of death all become signs of the perfection of life.
After the patient left, Guo Xinying will send a flower to their pillow. Liu Xiaohong said, The move is also meaningful to the medical staff, and it is also an emotional relief. Everyone has put their grief here, and when they get home, it is another world. When the family members leave the hospital, the medical staff in the geriatric department also sent them a signed card praising them for bravely accompanying their loved ones to die.
For the medical staff who see the cruelty of the disease and still strive to make the patients feel comfortable and dignified, it may be suitable for Roman Rolland’s words-there is only one real heroism in this world, that is, they still love it after recognizing the truth of life.