– Bilingual Lyrics Chinese/English

Lyrics & Translation

[English]

Hello everyone

I am Chen Yishan, the editor-in-chief of Tianxia Magazine

Welcome to the 130th episode of Decision Maker Listens to the World

...

You can see this episode

There is a new cover story here

It talks about the required courses in the super-aged society

Practice hospice well

I think

This is a big initiative that I feel

I remember when I first became the chief editor

I launched a topic called Lonely Death

It should be a media in Taiwan that used lonely death as a cover very early

...

After a few years

In fact, it has reached a new social stage

In fact, it should be this month

If nothing unexpected happens

This month Taiwan will move towards

Super-aged society

This month

is our population over 65 years old

which will probably account for more than 20% of the total population

Then in the first half of this year

In fact, the life choice of the famous writer Qiong Yao

actually once again caused society's anxiety about

good death

We discovered a somewhat abnormal phenomenon

In fact, the quality of Taiwan's hospice care

is ranked first in Asia

in the latest evaluation, and actually third in the world

And it has very good and very friendly health insurance

We also have Asia's first

Patient Autonomy Rights Act

But our signature rate is not high enough

Then I think there are several contradictory phenomena

Including Ms. Qiong Yao's choice

Then her anxiety

In fact, I think

this required course

may be something that this society should urgently

do

So we made a cover like this in this issue

...

We have also seen several phenomena

Our hospice environment

Our prevalence of nasogastric tubes

There are also how individuals can make some preparations for physical and mental

finances and medical care

Then I will publish this new issue and online

immediately

Then I also particularly recommend

that everyone should read our charts carefully

This time our article

has many touching stories

But on the charts

we have prepared a lot of manuals

This review list

I think is worth keeping

I remember when this issue was published

almost everyone told me

There are elders in the family

who are going through such a stage

So I think this is a very practical issue

I hope it can help everyone

Today's decision-makers

are also very different from the past.

In the past

Most of us invited an expert and scholar

to introduce the cover of our issue

But this time

I specially invited two

experts with different positions

Regarding the current situation of fasting and end-of-life care and hospice care

Let’s have a discussion

I want to be the first

I want to invite Taichung City first

The director of the Municipal Rehabilitation Hospital

Dr. Bi Liuying Bi says hello to everyone

She is also the author of Fasting for a Good Death

Hello everyone

The second one is

The director of the Jinshan Branch of National Taiwan University Hospital

President Cai Zhaoxun Cai

Hello everyone

President Cai has also served as the president of the

Taiwan Hospice and Palliative Medicine Association.

After three years

The dean also published a book this year

called Life and Death

I think this is also a very important book

The two of them coincidentally

published these books within two years

In fact, they are all related to the so-called death

...

So this conversation originated from

The fasting and good death

published by Dr. Bi immediately became a bestseller

I heard that it was also beyond Dr. Bi's expectation

I didn't expect that

many elders would want to adopt this method

Because this method is so common

that

the Hospice and Palliation Association issued a statement

Opposing fasting and a good death

in April this year

My wording

I don’t know if it is right

But it seems that the opinions of both sides

are very, very different

But

I have always hoped that it is the role of the media

In fact, I think the most important thing of the media is to allow

people with different opinions to have a space to gather

That I have always felt

I read their books

and also watched their videos

Then my own thoughts are

In fact, both of them are

I hope everyone can have a good death

This is our common wish

So maybe there are some differences

Maybe there are some similarities

So thank you both for coming this time

Then I heard that this is a pioneering work

The two sat together

to talk about such a thing

I think there are many, many things

It should be about concepts

I can really take this opportunity to clarify

What are the differences between the two opinions

...

That is the reason for this difference

There must be some social phenomena behind it

Maybe it's a problem with the system

I think we can have a deeper discussion

instead of just saying that the two are completely opposite

different parties

Then I think today

let's start today's discussion

The first one I want to say

is actually because fasting and good death are very common

Many people have heard this term

But I still want to ask Dr. Bi to talk about it

How would you explain this concept

What concept do you want to emphasize

I should talk about my mother's example first

When she was completely paralyzed

She couldn't even turn over

It's easy to choke when eating

In Taiwan

The general practice would be to insert a nasogastric tube

But my cousin

He was intubated and bedridden for eight years before leaving.

So of course my mother knew that

she would not make such a choice.

This is also something Taiwan's Patient Law

is promoting. Another case in that book

...

...

...

...

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is that he had this degenerative disease of the brain

He has been unable to take care of himself for nine years

He inserted a gastrostomy hole

This situation has been going on for five years

Then he did not want to continue this situation

So later his family asked me for help

They said they wanted to remove the gastroesophageal tube

That is actually a hospice and palliation regulation

According to the law with the patient,

the family can represent the patient

to make this decision to withdraw life-sustaining medical care

Such a decision

What surprised me

was that the first three doctors I found

all refused

The reason for the rejection was that they believed

that the patient would only need to continue to have a nasogastric tube

He just can continue to live

He only applies palliative care to terminal patients

So he defines him as not a terminal patient

But later

this patient still found a doctor to remove the tube

Then why is this doctor willing

Because this doctor thinks that this patient

As long as he does not have this life-sustaining medical care

he will actually die naturally

So he is actually in a terminal state

He thought

that he had no way

to express his wishes

and no way to express it in words

Then he fed like this for a long time

and his gastrointestinal function was not good

so he decided that he was a terminal patient

so he had to withdraw the tube

For me,

because I know Dr. Chen Xiudan

and help withdraw the tube on the Internet

Until now

If there is a patient who has no way to take it home

I can only ask her

Then I saw

that there are hundreds of thousands of people in Taiwan

unconsciously intubated and bedridden

I am very touched by this

because I was in a Fujian hospital

after seeing the National Health Insurance

There are more and more people like this

Let's calculate about 400,000

Right

Then I feel

I feel sorry for them like this

But I always thought that the media said

90% is because the family members don't let go

Then why did I meet the first patient who asked for help

It was the doctor who didn't let go

That's why I mentioned it at the back of the book

...

After my book was published

I want to do extubation hospice

Promote extubation movement

So the origin is like this

But in the past three years

I have helped more than 300 people leave

Then

among them, you see who will come to me

and you will know why this society

needs help in this certain aspect

Of course, those who have been well taken care of

or acute emergency

doctors know how to let go

They don't need to come to me

Those who come to me all have problems

Of which 55%

are the so-called unconscious intubated bedridden

Most of them remove the nasogastric tube

A few remove the respirator and nasogastric tube

For the other 25%

I was surprised that he just suffered from fatigue

Then the more he slept, the more he ate, the less he ate

The family members would rush to send him to the hospital.

As a result, he was given an intravenous drip and a nasogastric tube was inserted

Then I quickly told him that you wanted to apply

Automatically discharged and went home

Then this is what I did

After it has been exposed like this for a long time

I now have many patients

They already know how to deal with

I all say that they are too old to eat, drink, sleep and walk

So 25% of the patients I help

This should be almost 100 cases

These people know that these are called terminal symptoms

We don't want to send them to the hospital

and they also know how to take care of them at home

So in total, they are like my mother

She has a sense of autonomy

And the number of patients who decide to fast and leave

is actually only 20%

I will go to South Korea at the end of this month to report

I just want to report these 61 patients

What diseases do they have?

Basically, they all have severe symptoms

cannot be treated

Then most of them are getting worse

Yes

Then he has the expression of autonomous consciousness

Expressing that he does not want to prolong such a painful life

So these 61 patients

are like my mother's method

which is to fast independently

So

why do you get this

Great repercussions in society

I think it is because of the past 30 years

In the past 30 years after the National Health Insurance

There are too many people

Intubation and bed rest may last 10 years on average

Then think about it

How many people have such people in their families

Have taken care of such people

or are taking care of them now

There are 300,000 to 400,000 such people

There are also people who are afraid that they will be treated like this by their children in the future because of seeing these things

...

So these people will know that

In fact, it turns out that we have another way

We can refuse unnecessary nasogastric tubes

If these life-sustaining medical treatments are inserted

and the patient will not recover

Then we still have it

The right to terminate

The other one is to say

In case the disease is difficult to control

When you can’t eat it

or your family can’t eat it

We don’t force it

It’s okay if we don’t want to eat it

Leave peacefully

In fact, I think when the doctor was talking just now

Dr. Bi had two words when he was talking

What I will always emphasize is

The first is the patient owner's law

The second is the tranquility and palliation regulations

It seems that in your suggestion

this regulation is actually quite important

One basis

is

Then I don't know what the dean thinks of this

Some examples of Dr. Bi just now

This explanation of Professor Bi

is quite impressive

Let me mention six important words first

The first is the object is the severity of the condition

The second is autonomy

The third is the intention of our

measures for medical care

This is very important

So these examples mentioned by Teacher Bi

I think

use this palliative care regulations

or the recent Patient Autonomy Rights Act

should be able to take care of these patients

For example, if there are two

not nationwide

two related specialists

to evaluate this patient

If he is in the terminal stage

the family members can make some

medical decisions on their behalf

This is what I will explain first

It is that we do not want it

Treat the end of this life

as a method of good death

This is what I want to explain

It's because we always feel that

is not a sign of life

The end is called a good death

Then think about it

If a person can live

or a person can eat

then he doesn't want to live or eat

Then you let him end his life

Then is this called a good death?

These are some opinions I must put forward

There is a mention here that

is actually a good death. My Chinese proficiency is not that good

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...

I'm going to look up the dictionary

What does a good death mean?

What it puts forward is also very specific

As far as the dictionary is concerned, it means to live a long life

Die peacefully

My personal interpretation is that

It is a natural death

Cherishing life is what we can live

Just keep living

The second one mentioned

is this happy ending

I think this is also very important

It is the balance of life and death

It was also mentioned recently

Not only the patients and their families

In fact, caregivers are also very important

Because we take care of these patients with heart and affection

There will also be sadness

So this is not just the patient himself

Of course, this funeral

It is to do the best to grieve

This is the description in the dictionary

I think it is quite consistent

Your dictionary is so complicated

Just write this

I think it makes sense

Just from my perspective

This is a sorrow consolation

The whole funeral is a sorrow consolation

Then I think it is also explained in a smooth manner

Then there is this international document

Let us also explain

What is the word "good death"

How to describe this matter

Then there are four projects we have looked for in the past

One is to understand the nearness of time

Be calm and accept

The aftermath has been explained and arranged

The time is right, just don't be too hasty

Be prepared

Then we later added it to the fifth item

That means the body must be cared for

The pain of the body must be relieved and taken care of

So now we basically use these five indicators

to evaluate the results of a patient's care

Whether there is a good death

This has also received international recognition

Now Japan also uses these five indicators

It is quite simple to do

Then recently I found a book

which was also told to me by a colleague called the death of old age

The decline of weakness and the death of death

Then this colleague also grew from this book

Share it with me

It says in this definition

High-quality death

What does it mean by high-quality death

It writes a

I think it is also very good from my experience

It says that it must meet the expectations of patients and family members

Then use this clinical medical experience

and this cultural and ethical method

An acceptable method

Let the patient, family members and caregivers

This way there are three parties

Patients, family members, caregivers

Including the medical team

Everyone can die in trouble and pain

A liberating death

This is called a high-quality death

I think it is quite good

So what I must mention here is

because the word "fasting" is quite attractive

But I still want people to think about it again

Because the process of our care has just been mentioned

Fasting does not mean a good death

A good death does not necessarily require fasting

Because we take care of a lot of patients

We can still eat when we can

We are not forced

Because in our care

we actually care a lot

The patient has a nasogastric tube inserted and a gastric photo taken

Because this will affect the quality of the patient's life

But we also emphasize

When we feed him

he still eats

We feed him one bite at a time

He can eat

We still eat

That is what we think

Saying it is not necessary means

stopping it based on human planning

It is natural

So actually the two views are

In fact, Dr. Bi mentioned it at the beginning

It is actually a regulation

And if you can get the support of doctors

you will try your best to win the support of

doctors to help

Can I say this

For example, there are a few doctors

who are willing to admit the patient to the hospital

Then remove the respirator or nasogastric tube

Most of those doctors are

doctors from the Department of Hospice and Palliative Care

So in this process

of course they will provide good

physical and mental care, not only for the patients

but also for their families

As the dean just said

this tripartite

everyone is really calm

Then if they go to the hospital

they are very lucky

They can go home

If possible,

I will try to find a home medical

medical staff to assist

for

They have also received tranquility training

So we will try our best to follow the principles

Dean Cai just mentioned

to take care of them and their families

There are some patients

because we are

now Resources for medical treatment at home

There are not enough resources for peace and quiet

Or it is very rural

They can't find it

At that time

I was responsible for stabilizing their body and mind

Such a job

So in order to do such a thing

In fact, I read nearly a hundred books

Related to this life and death

Or hospice and palliative care

Then

because my original rehabilitation department is

a holistic medical background

Then I am like this

In the process of accompanying them

They are all my teachers

So I learned a lot

So the key points that Dean Cai just talked about

What is called a good death

I have also described this in detail in the book

So there are currently some family members

They can just read my book

and they will know how to accompany them on the last journey

Then thank my book

for helping them afterwards

Because if you think about it, in the past

maybe fifty years ago

most of the elderly and severe patients

died at home

So at that time people had the ability to take care of

patients who died of natural causes at home

But because in the past few decades

many of our patients died in hospitals

So our society has collectively lost this ability

and there is too much fear about natural death

or death from severe old age

...

They are afraid to send him to the hospital

But they don't know how to send him to the hospital

If he is not taken good care of as a dying patient

In fact, the appearance of death in the end is very scary

In fact, the director

I think you mentioned a few points just now

Then I think Dr. Bi also mentioned a point

which is quite important

That is, you must go to the hospital to stay in the hospice ward

Or actually staying at home for hospice

is also an option

Can you talk about it

Now on these two ratios

or

What kind of phenomena have you seen

That is to say, what Dr. Bi just talked about about staying at home

was actually before there was no health insurance

Most people stayed at home more

Now I feel that

health insurance has really

changed the appearance of many lives in Taiwan

So can you talk about peace

Now let’s talk about the promotion of staying at home

What is the situation

And I don’t know enough nurses

So in fact, the current bed occupancy rate

is not very difficult to open all beds

Then the issue of volume

What do you think about this matter now

This is very important

Because I have been talking about this terminal care

The concept of hospice and palliative care

It is a concept

It is

Not limited to the venue

I think correct care can be done anywhere

...

Proper care

Even in the hospital

In the hospice ward of the hospital

In the emergency room of the general ward ICU

I think it can be done

Of course it can also be done at home

Our past research also found that

the quality of care at home

It's not necessarily worse than the hospital

This patient feels at ease and at ease at home

Indeed

One of the issues we have discovered now is whether

can get

a professional medical care at home

This is what we attach great importance to

Because now the government is vigorously promoting

Aging in place and hospice at home

These are all good directions

The problem is

Have we prepared these personnel

to take on this important matter

In fact, the government has also seen this problem

So we are also actively

preparing and training personnel

We hope to implement this policy

We must implement good policies

It is true that people are a big problem

Then I must explain it here

In fact, in the face of death

It is a very difficult thing

We usually think that people will die naturally

But from my experience with so many patients

In fact, it is very difficult for people to face death

You will only know when you encounter it

So this is really not that easy

Most people will still feel uneasy

There are many people who don’t want to die or are unwilling to die

These all need to be taken care of

Of course, for medical staff

I think it is also a necessary education and training

That is, the family members of patients and medical staff

need to do life education

so that medical staff can know

how to take care of patients at what stage

Do not overuse these ineffective life-sustaining medical treatments

This is what we have been working hard

We also hope to be like

A senior like Professor Bi

in her different professional fields

can help us promote

such a care model

Why is it because to be honest

the patient is not in the hands of our

hospice and palliative care physician all of a sudden

He is in other specialties in front

So sometimes we also feel

The previous doctor

also had difficulty communicating and discussing this matter

So these communication skills

It's also very necessary

I just mentioned that you forced him to do this

When he can't cope with it mentally

He is also injured and a difficulty

We have also encountered in the past

patients come to the hospice ward

Take care of a patient

After the resident doctor took care of one

he said he wanted to leave his job

He couldn't face this matter

So this is the education of life we talk about

How can we change from the traditional

active treatment

to avoid patient death

to say that when we face

these critically ill and terminal patients

we have to think again

so as not to overuse life-sustaining medical care

and let this increase unnecessary suffering

This is really bad

Let's take a break at this stage

Be back soon

I want to discuss with you two later

I mentioned life education just now

In fact, I feel it myself too

During our interview this time, we discovered that

doctors are actually a group that needs

retraining and education

and even some enlightenment

We may come

Because both of them graduated from medical school

Maybe you can talk about your own mental journey

Why you can change from active treatment

to making everyone change

I think there is a new turning point

Then you can share your own experience

We will take a break and come back soon

Welcome everyone back

We are here with Dean Cai Zhaoxun

and our doctor Bi Liuying

The two have never sat together

and talked about the issue of death

I think what I just mentioned

is quite important to talk about.

In fact, when we arrive at the hospital

In fact, the doctor has to go to the peaceful place

Then it may really be the family members who come to ask for help

Before Dr. Bi

In fact, there is a very important

discussion with the doctor

The process of your elders or your own life status

In fact, both of you graduated from medical school

and both received orthodox medical education

How did you change your mind from

Must actively treat

to later

It is a more from the perspective of human life

to change and say

You may have some different ideas about how to treat this patient

...

Would you like two of you to talk about your own experiences

Like you went from home medicine to Anning

Do you want to tell us about your experience

This feels a lot better

I will talk about learning medicine from the beginning

The beginning of clinical internship

In fact, I have formed an indissoluble bond with Anning Palliative Medicine

...

That’s probably because internship

My ability does not mean that I am good at taking care of patients.

Then I just started my internship

and soon I had the opportunity to do an internship in the hospice ward. The abdomen is as distended as a bulge

...

...

...

...

...

...

...

...

The limbs are skin and bones

She cannot sit as easily as we can

She can sit

She is in a wheelchair

She needs a special wheelchair to support

Her neck

She has to lift her legs because of the swollen abdomen

Then my ability at the time

could not take care of such a patient

Because of the very limited medical ability

But I visited her almost three times a day

Morning, noon and evening

Then I pushed her outside to bask in the sun

Blow the air

I cared about her condition

I greeted her and chatted with her

What moved me very much

was after she passed away

Because we take care of patients equally

She passed away in only two or three weeks.

Her father brought a tie and gave it to me.

He said that the daughter confessed that

this must be given to me. But it may be helpful to her

...

...

...

...

...

...

So this feeling

is that not only drugs and other treatments

can be helpful to patients

When we can say that medicine has no effect

Under this medical limit

it is actually quite important to be more caring and caring

...

to bring peace to patients

At the same time, it also reduces the grief for family members

Because the loved ones have passed away well

The grief of the family members can naturally be reduced and shortened

The family can rebuild the function of family life as soon as possible

This is very important to me

The other one is the continuation

I am a resident in my first year

Because I am a medical doctor

so I have to go everywhere for training

I also go to the Department of Hepatobiliary Gastroenterology

Then we know about liver cancer

If hepatocellular liver tumor

invades the hepatic portal vein

Our previous knowledge is

He will pass away within about half a year

This should also be medical evidence

I was very impressed.

At that time, I met a patient who was still able to walk. This affects hepatic portal vein embolism

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...

...

...

...

...

It means that the cancer cells have already reached this blood vessel

Then he doesn't need to do anything at the moment

Then let him be discharged

At that time, I was also in great shock

Why because we can understand

Family members and patients are also full of expectations

I came to National Taiwan University Hospital

just to cure this disease

Last hope

Then how can I talk to him

Your disease cannot be cured

And I was very cute at that time

I knew he would try this

so-called alternative therapy remedy

That must be understandable

I also suggested this to him at the time

If you want to find this

this other alternative auxiliary therapy

how to find it

He is relatively capable of this level and has this reputation

You still make this kind of suggestion

Because of human nature

I know that from the perspective of Western medicine

there is nothing we can do to help him

But I clearly know that he will look everywhere

This is human nature

So I still

gave him this suggestion very tactfully

So I learned from the beginning

Two histories of medicine

In fact, it has a huge impact on me.

We encounter bottlenecks in medicine.

How to do these things?

Instead of ignoring him.

Go straight ahead.

Do whatever you can to the end.

In fact, it will bring unnecessary pain to the patient.

There is no way to help the patient.

Let the family members suffer more.

Is this kind of medical education

you usually receive

or do you think you are a special case

because you entered the field of internship

There are these two cases

Basically I can’t say that I am special

That is to say

Maybe I am more subtle about this observation

But now I have become a teacher

So no matter how busy I am

Let's go back to bedside teaching

Then why should we go back to bedside teaching

That is, we have to take students to see

What we want to see depends on how we interact with these patients

interact with their families

how to turn a very difficult situation

into taking care of him

and turn it into a smooth one

Because what we are most afraid of is that students have no sense of these things

What is no sense is hopelessness?

There is no way to treat it

I am not a god

It has nothing to do with me

In fact, we are very concerned

At least I think this medicine always needs to be perfect

Under this limit

It is still necessary to complete these things

to be perfect

Although there is no way to cure him

But we can do this well

So this is Dean Cai's turning point

I have had this experience since I was a medical student

Dr. Na Bi

I should have a lot to do with my work in the rehabilitation department

...

Because but the turning point should be health insurance

Before health insurance

People who need rehabilitation have no money

Unless they have labor insurance or public insurance or rural insurance

So ordinary children, women, and the elderly

They have no way to do rehabilitation

Since the introduction of health insurance

We have begun to see the so-called

patients with no rehabilitation potential

For example, severe brain injuries

He is simply in a vegetative state

And then there are severe cerebral palsy like children

Maybe they were at home before, I don’t know

But now

He will bring us to our outpatient clinic for rehabilitation

So I will see wow

This person was born with severe cerebral palsy

These parents have to take care of him for the rest of his life

So I gradually see

There are more and more

very advanced medical technologies

The lives left behind

But they are very hardworking

Their family members

A child like that taken care of by his mother

He has no self at all

I sympathize very much with these caregivers

So I gradually feel it

This medical treatment is too advanced

In addition to more and more life-saving technologies

getting better and better

This is its bright side

But its dark side is

We don’t know when to let go

Sometimes it’s the family members who don’t want to let go

Sometimes it’s the doctors who don’t know to let go

But

Another influencing factor

should also be affected by some

Inspiration from senior An Ning Ren

For example, I heard about Professor Zhao Keshi very early

When he was in the 78th year of the Republic of China

His father had dementia and was on a ventilator

The doctor said it was illegal to withdraw the tube

But he just signed the case

Said his daughter Zhao Keshi

I said that the case should be turned into an antique

Very valuable

After she signed,

she personally helped her father

to remove the respirator

So she is very courageous

The other is that she saw

in the cancer ward

At the same time, several patients committed suicide and died, so

...

she felt it and said

It turns out that our medical care is like just now

Dean Cai's words have limits

So

she found out about the knowledge of tranquility and relaxation

She went abroad for further study when she was forty years old

In addition, in 2010

I also saw a book by Dr. Huang Shengjian

Mysteries of Life and Death

and Dr. Chen Xiudan's

It's Cruel

That means we may think that people die.

But it is actually cruel

So they talked about it a lot in the book

When first aid is not needed

We don’t need first aid

When it’s time to let go

We have to persuade the family to let go

That’s especially Dr. Chen Xiudan

Later I was in the video

I saw her personally helping the patient to withdraw from the tube

How to communicate with the patient

How to explain to family members

That process

may be what Dr. Cai often does

But for me

that is a very shocking scene

Yes

Later I also read the book by myself

and then watched other videos

So I also learned how to communicate with patients

...

and communicate with family members

So I think

should be the predecessor of Taiwan's tranquility and relaxation

I have made a lot of efforts in the past few decades

Part of it has

been influencing me invisibly

Another most important factor

should be that I have seen too much in the hospital

What is more, it should be true

My father-in-law has been intubated and bedridden for 12 years for dementia.

The same goes for his younger brother

He has been in bed with intubation for 12 years due to dementia

My husband's sister's father-in-law is also the same

He has been in bed with intubation for dementia

My

My husband's sister's father-in-law has Parkinson's disease

He has been in bed with intubation

My cousin has cerebellar atrophy and has been in bed with intubation

So I am alone

There are so many relatives around me

So you can imagine

These impacts will make us think

How to live

What is truly called a meaningful life

Those people

It is he who said it himself

In case there is no consciousness in the future

I am paralyzed and I need to be intubated

The longer you stay in bed, the better

Nope

There are even many people

He has actually explained it

For example, if my mother-in-law saw my father-in-law like this

Of course she will tell me that I will do this in the future

Don't help me intubate

So I assisted 180 people in the removal of tubes

There are many people here

He has explained it before

Yes, although he had no time to sign the patient's signature

It’s too late to sign this tranquility ordinance

In fact, I think Dr. Bi talked about a

very important point now

Because most Taiwanese people in Taiwanese society

Even I think overseas

did not expect that they would live so old

So they did not expect

Dementia is a new issue for many people

In fact, the disease-preserving method has not been around for many years.

And everyone still doesn’t know how to get familiar with it.

So it is true that

our generation will also encounter it. The examples mentioned by Teacher Bi

...

...

...

...

...

...

My personal opinion is that

if his condition is of a certain severity

then based on our current

two laws

he has not written the documents by himself before

Probably we will choose

The

method of palliative care regulations

is evaluated by two relevant specialists

It is in the terminal stage

Then the family can make the decision on their behalf

Then proceed in this way

I think everyone feels more at ease compared to this

What is important now is

why do we need to do education and training

is what Teacher Bi mentioned just now

Then some doctors

agree

Some doctors

may not agree with the method I just mentioned

It means that regarding the determination of terminal evaluation

Some doctors will have doubts

So we have to educate this matter

It means

at what stage

This patient should be able to assess that he is terminal

The family members will act as substitutes

Express his opinion

So

the education and training of medical personnel is very important

It is not just doctors

Because

there are other professionals in the medical team

For example

In the past, we also encountered doctors who were willing

but respiratory therapists who were unwilling

Why did you write a will

I have to turn off the respirator

They think he is the executioner

So this matter

Of course doctors are an important key

But a team

So why did I just talk about

Why does high-quality death require

Patients, family members, medical staff

This all requires a consensus

It will be smoother

Otherwise, if you give the example of a respiratory therapist and he is not willing

What should this doctor do?

We are also very difficult

I'm afraid there will be problems

So this is not only for the whole people

This life education and death awareness

The education of medical personnel is still very important

I think this is really rarely mentioned

It is the education of medical personnel

I heard that the younger generation is slightly better now

But I heard that it is more senior doctors

I always want to try it

There always seems to be a chance

What is the key to this

Why can't we let go

The key is our medical education

The previous few years have emphasized

We go from ignorance to understanding

How to save this life

Prolong it as much as possible

Avoid death

We used to be in the hospital

Teacher Bi must have a lot of experience

The death of this patient needs to be reviewed

There needs to be a meeting to discuss

Why this patient died

Is there any negligence

So this habit will become to say

The death of this patient

has become a bad result

He must review

to avoid the same problem happening next time

This is of course a manifestation of valuing life.

But what we just mentioned is that

medicine has its limits

Some patients are inevitably going to die

But if this is not as good as

,

he will think that I will try again

Maybe there is a chance

Then it will become a fuel

No brakes

He doesn’t know when to make a stop loss point

So we are constantly doing these educations

It’s not that

My hair

Most of it is lost because of this education

Because it is not easy to educate this matter

Because it is difficult to educate doctors

Sorry

I am offensive to the two doctors

I think this phenomenon is not unique to Taiwan

Even if I am looking for an American doctor to write such a book

He will also talk about it

Our medicine only saves lives through education

But our medicine does not have education

How to let go

So when he sees the patient

he only thinks about what he lacks

What data he needs to correct

He doesn't think about it

This person is actually already going

He cannot be saved and has to face death

So there is a lack of death education in medical education

This is true

What about the other

You just mentioned, for example,

why people

in different eras are different

This should be caused by the culture of the entire society

Because our

Eastern society is relatively

more taboo about death

so there is usually no discussion

Then I also think that death is this person

If it is eliminated and lost

we will no longer have this person

For example, if there are family members, he will say

There are also doctors who say this

At least my mother is lying

You still have your mother to see

There are also patients who say that my mother is lying here

Then at least I still have my mother

I would say that your mother has been with you for 80-90 years

Why is she not physically present

You will feel that you do not have a mother

But this is his sincere feeling

Yes, so it is our understanding of death

Is there any

In fact, the entire society has to change slowly

For example, the Dalai Lama

He is very simple in one sentence

It is our physical body

It is borrowed from the earth

So if this clothes

has been worn out and worn out

and can no longer be used, you have to change it

Just put it down and change it to another piece of clothing

So you will not be obsessed with

You only have the physical body in this life on earth

So this physical body cannot be used

There is really no need to force it

But your soul can move forward freely

So I will believe in the concept of eternal soul

and will not be attached to

my body

I must not let it die

I think there is a point

I was watching your

video or information

I think the dean is actually worried about one thing

which is over-emphasis on fasting and good death

In fact, there may be issues such as accelerated death

instead of natural death

I think what Teacher Bi really wants

is to be more natural

Within this boundary

And then the matter of autonomy

How to handle this

How to have a better process

Let me briefly explain

The patients I help now can be divided into two categories

One is that he has autonomous consciousness

That autonomous consciousness

This means that he will not eat or want to eat

You should not force him to eat without giving him a gastrointestinal tube

Then he is too sad because of the disease

It is too painful

Like my mother, she decided

that she should not wait until it becomes aspiration pneumonia

before leaving the intensive care unit

She has to stop eating in advance

just stop eating

Because she is choking and coughing every day and it is very painful

Well, for

Dean Cai and some people,

they think that my mother is hastening her death

For that

I believe why they have such a belief

is because peace and tranquility has been relaxed for decades.

There is a very important purpose

that is, we do not speed up or delay death

Then I would think

If you have such a belief,

if you support such a belief,

then you should try your best

when you are in your final stage.

For example, take Stephen Hawking

. His living situation is

worse than that of my mother.

But he feels that his life is meaningful.

So he can still live until

It's the concept of autonomy

He thinks his life is meaningful

But my mother thinks it's enough

Although you don't agree with accelerated death

but I will respect this patient

He has to choose to accelerate death

There is no heinous crime in accelerated death

So we just have to learn to respect

Respect everyone

But I want

The dean may not agree with this view

I want to borrow this part

Teacher Bi's picture is very important

Let me explain this picture

In fact, this picture is very important

This is the time of natural death

That part is where we just

have a huge consensus

We should not use meaningless and ineffective medical treatment

To prolong the patient's death process

This is just unnecessary suffering

This is what we have been working hard on

Then there is basically no big problem in the more severe and terminal stages

...

The Patient Rights Act, etc.

are all paying attention to this matter

Aging terminal stage

So there are three parts in this one

If we talk about our current situation

It is the

patient's independent severity of illness

that he mentioned just now. Is his intention to do this

to end his life?

According to two laws

basically we can take care of these things

but just emphasized

our education needs to be further strengthened

to do this

But in fact the biggest worry is here

These four words

are what we are worried about

It means those who are severely disabled

For example, if he has a stroke

and is relatively disabled

then he is unwilling

If he is unwilling

Basically we also respect his wishes

Because everyone has his own wishes

We cannot put a knife to his neck

But what I want to explain is here

In order to clarify this issue,

I drew a picture myself

It is the same as Teacher Bi's.

This time of natural death

We don’t want to do this unnecessary life-sustaining medical care

Adding unnecessary suffering

This is very bad

What we emphasize is that in accordance with two laws

Our current view is

We want to die naturally

If this patient

is due to his illness

He gradually cannot eat

Then we don’t want him to be in a serious condition

Why force-feed him?

But we won't say that he can still eat

In order for him to still eat

we will stop him

It is probably impossible to do this

So we emphasize

It is because the patient's condition naturally stops eating

It is our view that he can eat if he can

If he can't eat, he can't eat naturally

But he has a dilemma

He has a nasogastric tube

Can he eat by himself

The natural eating I am talking about is oral feeding

That is, he can eat

If he can eat by himself, of course he should continue eating

We feed her like the old grandma

She has severe dementia

But you feed her

She can still eat

Then we should feed her

Eat

As the condition progresses

she will gradually eat less

Then we don't

insert her nasogastric tube again

and don't do gastric scans

It is closer to what we call natural death

It is because of the condition that she naturally stops eating

Then we won't

Use this explanation called fasting

Then this part

Now I think it will cause

Maybe the misunderstanding we are worried about is

euthanasia

We know better

He ended his life earlier

Maybe everyone can understand

Then our current teacher Bi initiated

this fasting

The spectrum will be larger

There is a part here

Basically we don't have a big problem

What I am more worried about is

the part I mentioned just now

In a state of severe disability

accelerated death

Our colleagues will be more worried

Because now there are at least two laws

that do not have a concept of these four words

So I shared this with my colleagues

I drew this picture

It means

how we take care of the suffering patients

This is my experience

It means that this assessment is very important

Regarding the severity of the condition I just mentioned

We need to evaluate his condition

Assume that this person can express

If he is conscious, he can express

He does not want to eat

What should we do?

Let's evaluate his condition

Is it because of the seriousness of his condition? The most important thing for us is here

...

...

...

...

...

...

...

...

...

He can eat but he told you

I won't eat

This is where I think

The place that needs care and care is here

So it is not a question of peace

but a comparison

Healing his heart

Look at his mentality

Because this is a place that I think is very important

That is to say, because the previous one is related to the condition

Then do what needs to be done

If he does not meet the severity of the condition

We will suggest him to use this so-called

artificial nutritional fluid stomach

to see if he is willing to accept it

If he is not willing to accept it

We have no choice

But we have always maintained a caring attitude

This is something I emphasize very much

For example, this can be eaten

He may say that I don't want to eat

Wait a minute I can use an example

to show that I don't want to eat

Then what do we want

Support care and see the follow-up results

That assumes that he can no longer express

Like what I just said, he has dementia

There is no way to say it, no way to express it

We still look at his condition

So my line is very important

That is, he needs to evaluate the patient's condition

to make the follow-up direction

If it is in line with his original patient care

The direction of the peace and relaxation regulations

Then we will do it in this way

The important thing is

This is also what we are most concerned about

What I just said

He can eat by himself

If you feed him he can still eat

Then we have to continue feeding him

I won’t say it’s because he has dementia

Maybe I think he has no function

Then let's stop him

In fact, we have to explain this matter

Because such doubts do arise

We also encountered that

This patient had discussed with his son

not to eat

As a result, he was hungry for five days

Hungry for five days

He was too hungry

He asked the nursing colleague,

Can I eat

The nursing colleague said yes, you can eat

But I have promised my son not to eat anymore

My son will scold me

That is because of family financial problems

So this is a situation

We need to understand the problem behind him

And for example, she has cancer

but it is only in the second stage

She can still hear voices, she

can trace the voice of people

Indicates that she is still conscious

As a result, the child told her about mother

Long-term pain is worse than short-term pain

That is also some of the things that have appeared to us

that make us more worried

So we have to explain these things clearly

How to do it

How to do it

How to do care

We have to do care

I want to add

This kind of situation is not only encountered by them

I also encountered

but I will not regard it as a problem

so I should not promote hospice

I will think that

these people need different help from me

For example, he is suffering from depression

He just wants to fast

I will tell him directly that you are in good health

You can't succeed

Then I will tell him

What else can you do

What kind of medical treatment can you try to find

Like what he just said is that the patient has dementia

Seeing him living like this

is very painful

But he can still eat

So I will say

You have to be very sure

He knows that you are not feeding him

He wants to die

We are going to do it

But if he doesn't know

what life and death are

what is a good death

He just has biological instincts and he still wants to eat

Then you must feed

I will tell the family

Otherwise he will die unjustly

You have different methods

In fact, we are facing the same

Even what Teacher Bi meant just now

he would also object to them

That is, if someone mentions that they are family members

and want to help their parents get rid of this situation

Yes, so I won't

Because when I meet such family members

I think what I am doing is wrong

We have to stop

But I know that they need a different approach from me

So actually I said

I may have helped more than 300 people

but I didn't count it carefully

The number I refused must be at least more than 100

Yes

So I will judge

what situation is actually a misjudgment by the family

and then really have to implement it

We all understand it very clearly

You really know that you don't want to eat

Some people will say that I don't want to live anymore

I said you have to communicate with him well

Only then will you know that he doesn't want to live

Is it just that he needs others to care

Or is he actually just expressing that he is in pain

Or does he really don't want to live

This requires a lot of communication

It's not that simple

Say you come to me

OK, I will help you fast

There is absolutely no such thing

This makes me feel too relaxed.

Yes, so we need to do this kind of assessment

and then we must really understand

what is the mentality of the family members

and then the patient

what is his state

This requires a lot of effort

It is really a lot of effort

So

clinical assessment is quite important

so it should be Teacher Bi

Her approach is to evaluate by herself

The dean is sure about this

You may not know it

You have done a lot of self-evaluation

This is indeed the most helpless place for me at the moment

For example, America is like a person with dementia

A person with Parkinson's disease

If he feels

His quality of life is very bad now

He wants to fast on his own

In the United States, they will send him to the hospital

to do fasting

But

they will have

doctors from the psychiatry department

doctors from the hospice department

or doctors from the department of his original disease

...

Let's all negotiate with him

Right

Then really evaluate it

Then make sure there is really no better way for you

Are you sure this is your right?

Then they will take him in and take care of him

But Taiwan is very pitiful now

Now if you mention this to An Ningxuan

you will be shot

You will be said that you are not qualified

You are not good at this

Yes

But there may be a few doctors

who will bring the family members

Let's have a good family meeting

But most of them are rejected

When I was rejected

they came to me

So I had to rely on my own experience

And then add

I also have some hospice doctors with me

We have the same idea

We can discuss this case together

Can you tell us

Why do you think this is the case

Then Dean, you can also tell us

Why they

There will be cases of rejection

Let me say something briefly

Because they think accelerated death is not allowed

Yes, but accelerated death is not impossible

Because my mother decided that I would not eat

I decided that I would not insert a nasogastric tube

This is the human right given to her by the constitution

The human rights given to us by our constitution

That is, I can refuse all medical treatment

I feel that it is not necessary

But I can also refuse to eat

The Constitution does not have any legal provisions

How many meals do you have to eat

How much do you want to eat

So these people decide that they have to stop eating

To hasten death

This is his human rights

At least in European and American countries

In 2014, the Netherlands already had clinical guidelines for voluntary fasting

...

It believes that all doctors and nurses

need to understand

Because they have 8% of patients who died

They were due to voluntary fasting

or due to withdrawal

So 8% of the dead

did not eat in the last two weeks

So they think

medical staff should understand

But in Taiwan

now some doctors are willing to help me

Come to help patients like this

But

the Hospice Association made a public statement against

and called these patients suicide

Then you use this English word for voluntary fasting

You check all the foreign literature

All the literature is definitely more than 90%

They are all very clear

Voluntary fasting is not suicide

My uncle strangled his neck to death with a wire

...

committed suicide like this

My mother was 21 days old

We are well accompanied by relatives

My mother's death

How could it be the same as suicide

So it is important for me to emphasize one thing

The patient decides independently

He wants to end his life

This is his personal autonomy

So we shouldn't say they committed suicide

Because you said he committed suicide

You also said that his family members or helpers

These medical staff assisted in suicide

It may be illegal

In this way, in society

This is a very incorrect

A very bad concept

But Teacher Bi just mentioned one

It is very important that it is international.

They will send people who want to fast on their own

after evaluation

There may be a process

I think this is Taiwan

It is very different from now

We also have

It’s just that we compare

How to say

Relatively simple and simplified

Let me give you an example

Of course this person has his rights

But let me talk about an important point first.

In fact, I still believe that

people have the right to be cared for and cared for.

This is also emphasized by the World Health Organization in the recent

hospice and palliative care explanation.

...

...

...

...

...

This patient is about 50 years old

He is the first one I met

He just told me that he read Teacher Bi's book

She is going to fast and die

I also arranged for her to be hospitalized

Because she is about 50 years old

Head and neck nasopharyngeal cancer

This is a very painful disease

Because although she can still walk and talk

It’s just that her speech is not clear

She has difficulty swallowing and sometimes chokes

So she has physical functions and disabilities

Furthermore, because her husband passed away a few years ago

The unexpected death is also sad

The mother also has lung cancer

The father also has cancer

So her function gradually deteriorates

So I asked my younger brother to stay on without pay

to take care of him

and become a burden to others

In fact, the patient is quite miserable

Then come the fear

She had thoughts of committing suicide

She didn't dare to jump when she walked to the river

Do you think this person is suffering?

Suffering

But we arranged for her to be admitted to the hospital

You said she told me on the first day of hospitalization

I'm going to fast tomorrow

I'm going to fast tomorrow

Post a sign on the bedside

Don't ask me if I'm hungry again

I just want to eat

That's also the focus of my teaching

Our interaction with these patients

requires an attitude of empathy and acceptance

To establish a relationship with him

Then this patient is a very important turning point

It is a learning

Because after I had a little interaction with her

she asked me

Because I asked her about her experience in learning Buddhism

She asked me in turn

Dr. Cai, please share your experience in learning Buddhism

I took the opportunity

to share my experience with her

I said this person needs to continue to learn

Then bring back the essence of kindness in your past

Bring it back

Because when people are in pain

Forget how good he was before

This is what we are talking about, she is very compassionate

Because when I asked her to come to the hospital

she didn't even want to be hospitalized

She said I didn't need to waste medical resources anymore

I would be fine at home

Then I told her

Your compassion is very important

Did you bring this Buddhist scripture?

She said she was going to die.

What Buddhist scriptures to bring

Later I turned her to

her motivation to study Buddhism

She turned to

and ignored me

Why

She was chanting Buddha

She was chanting Buddha

It meant that she had caught that one again

That one supported

So I came to help her with this life review

Self-affirmation

Resolving conflicts

Some misunderstandings with her family

This is Teacher Bi, who seems to be a lucky person

Did you meet the dean, right?

This is what I want to say

Then I will bring something special today

This is very touching

She printed this and gave it to me

Then I was very touched and said

Your printing is very beautiful

As a result, she printed a hundred copies

and put them in the Buddhist hall to share with others

This is compassion and joy

She not only continued to go by herself

but also shared with others

So you say this person

If it is difficult

Of course I think it is easy

Because I have been doing this

So what is the importance of this education

Why would I teach this

Six Steps, Ten Key Points and Five Good Prescriptions

I just hope that

our medical staff must be able to do this

Only then can they avoid the use of ineffective medical treatment

The first is to avoid ineffective medical treatment

But like what Teacher Bi said

when he wants to die

In fact, it may be a physical inability

or it may be a psychological dilemma

Then this all needs some help

It looks like this

I think what Dr. Cai just mentioned

is really a good thing

For doctors who are like this and very compassionate

Then the patient can also find a way

So I changed my mind

But life, old age, illness and death

are really many situations and many aspects

So we don’t want to say that we are bent on death

We just don’t care about them

Because we are

They actually

are not so easy to make such a decision

They have gone through a long struggle

Family members

Think about it

Someone in the family said that I want to fast and pass away

What is the reaction of the family members

The initial reaction is to persuade

and they will try their best to care

So I think they all care

But not all of them

As long as you care for him

His life seems to change from black and white

There is a way to change it into color

Of course it is good

But I believe most people have this heart

I want to try this first

But I must also say that I have encountered many examples

...

It all changed naturally after caring

We didn't tell him with a knife

You want to change

He will just do it naturally

You have made a lot of good relationships

Good people form good relationships

He changed

Because I am a teacher

I am not just a doctor

Didn't you just ask how students change

I am doing this educational work

I take things that I think are easy

so that our students can learn this matter

to avoid ineffectiveness

Why can't he let go

Just don't do these things

Right

In fact, my last question

In fact, the two of you just now

I think this discussion is very, very exciting

But I think

Dr. Bi mentioned something just now

He is abroad

When you meet someone who wants to fast on their own and die

In fact, the medical system will have some intervention or

but we don't seem to have this

In fact, what I really want to ask is

Is there any way to do this?

I just talked about it from the perspective of the dean

Is there any way to do this abroad?

...

...

...

...

...

...

He said he wanted to fast independently

He has a clinic

Then we can come and discuss

Can I do this

Is there such an opportunity

Because I want to discuss later

It is this hospice treatment

This energy issue

Because when we did this topic this time

You said you accepted him

It is not necessary to enter tranquility

But at least there is a chance

to diagnose his condition

Basically

What I just said is that he can eat naturally

Then basically we will eat naturally

The so-called natural eating means that he eats by mouth

If he cannot eat by mouth

Basically we will not force him to do it

From the perspective of tranquility care

We will not force him to insert a nasogastric tube

Do this gastric photo

Basically we will not do these things

Just eat if you can

But we will not say that he can eat

Or deliberately stop him

It won't be like this

This is what I just emphasized

It is due to the condition

He will stop naturally

But what the teacher just said

Teacher Bi just talked about is abroad

There is such an experience

He will have a companion

Then there is a

He is a formal medical system

Because what they say is the same

Patients have the right to refuse medical treatment and diet

But the medical community has to take a responsibility

That is, we have to evaluate it carefully

He is really desperate

There is no other way to improve his current predicament

So we need to confirm

Confirm that his self-judgment is correct

The clinical evaluation just mentioned by the dean

Now this part of the clinical evaluation

is for example, other departments

feel there is a situation

Did they send him here

Or should he go to the hospice clinic on his own?

I refer to our general medical staff

How to face patients

The matter of eating or not eating

He needs to evaluate

Just now, Teacher Bi mentioned that

people have the right to stop eating

I can't deny this

We can't help him if he doesn't eat

But I emphasize that we care for him

Often he will eat

This is my experience

For example, the lady just now did the same

She said she wanted to fast

As a result, there were drinks on the bedside

Then we can understand and we can’t talk about it

Let’s talk about the more difficult part now

This is Teacher Bi’s point of view

I think most people in the medical community

It’s still more difficult

Because the current law is the patient-owner law

Follow the Ning Ning Palliative Medical Regulations

As for the four words just mentioned to accelerate death

The teacher believes that

people have the right to hasten death

But there seems to be no consensus yet

When there is no such consensus

It turns out that we hope that medical staff

should let go when this patient is in the terminal stage

It is very difficult

We just mentioned that it is very difficult

So it means that the teacher is a bit advanced

That's basically the case

But it is more difficult at present

This is regulated in law

But I just emphasized that

the four words "accelerated death"

are basically not in our current laws

So it will be more difficult than now to promote

reducing ineffective health care

Taiwan is actually still dismantling

ineffective health care

and they are all still struggling

So why my book is so shocking

is because I directly refused

Now it is even necessary to dismantle

My family is not willing to let go

Or the doctor is unwilling to let go

In my mother's case, I directly refused

So her situation is really

ahead of Taiwan

But my concept comes from Japan

So the Japanese did not say

For example, they have some documents that you have seen

There is still a certain proportion of Japanese medical staff

who have taken care of patients who fasted on their own

Let alone European and American countries

So I want to say

From today's interview, we can see that

In fact, our stage is really

The stage of the entire society

In fact, it is still slowly

There is a need for death

It is a stage of great learning

Then I think the last thing I want to ask is

which is hospice care

We mentioned this time

In fact, peace at home

I think it is a project that should be promoted in the future

But the current situation of this

I think maybe I can ask the dean to talk

This is of course very important

Because people often ask me

You don’t have enough beds in the hospice ward

Then I always use this explanation

Hospice ward

You compare the number of deaths with the number of wards

Of course it is not enough

But what I want to say is

Let’s see if the bed occupancy rate is full

We found that there are still empty beds, right

Then what I want to express is

I also said just now that

this matter of death is difficult for everyone

so we must strengthen

this life education

It is a problem for the whole people, a problem for the whole medical field

a problem for the whole society and the whole country

It is not just this tranquility

that is responsible for this matter

So I was also

like our teacher Bi, a rehabilitated senior

There should be so many

people with lofty ideals to promote this matter

to influence various medical associations

As a physician in my family medicine department

I cannot break into

the world of internal medicine and surgery

It is very difficult

We were not scolded by teachers before

How did I teach you before

How can you give up on patients now

We are all suffering

So this is

We need to work together

to reduce this ineffective medical treatment

Now our government has also seen this matter

Home medical care continues to be a long-term policy

Hope is blooming everywhere

So we now also have a responsibility

That is to train personnel

Then what are you teaching

That's what I just said

Only by teaching these caring care

can we avoid the use of this ineffective medical treatment

He knows how to take good care of these patients

and it will be smoother

Of course

the payment of health insurance is a very important encouragement to us

...

We do these things

Good quality saves our health care resources

So after saving

We should give back to our patients

Good quality of life and good care

Part of it is to give back to our medical staff

Because the savings

are what we save by doing care

So we should give back to

those of us who work hard to do interactive communication

These medical staff

can do a good job

So the payment of this health insurance

We must be able to provide

Otherwise we will be hungry and do meritorious deeds

This is also very important

I want to help Dean Cai explain this

You know this

We spend more than 800 billion a year

Among the health insurance expenses

more than 200 billion are spent on ineffective medical treatment

Like those who just lie there using respirators

30 billion is used a year

But An Ning only uses 1.7 billion a year

And then Home Animation only uses 160 million

You know, just like me before

I got to know some home medical practitioners because of this promotion of hospice

...

They are really doing meritorious deeds and riding motorcycles

They come and go on the street like this

The maximum payment for seeing a patient is one hour

He went in and helped him get it out

Three hours

Then 24 hours online

If he has a question

you have to answer him immediately

Hold this family meeting

These are not paid

So the payment method of our health insurance

really needs to be changed a lot

The only way to find a way is to reduce ineffective medical care

Then An Ning uses the spirit

It uses the mental effort and the result is no payment

Then you buy that very expensive respirator

and put it there

You give him a payment of hundreds of thousands per month

So the payment values the machine

but not our people's mental strength

This is An Ning

They are facing a lot of trouble now

The government knows that hospice care should be promoted at home

But if you don’t have so many people

willing to go and get home care

How do you recommend hospice at home

The current payment is too poor

They are really doing merit

Really, we actually interviewed a lot of people this time

What impressed me deeply was Chengda Hospital

The hospice ward of Chengda Hospital

There is also a mage

And then they also want

to teach the neighbors

which is the clinic below them

There are many clinics that can join forces to do this

I guess

These may be in the process of promotion

They are also doing merit

Let me give you another example:

Because this patient talked about this

Use a respirator in the acute stage

After the first aid, he stayed for a month

...

spent one million in the intensive care unit

But later his family members found out

The doctor also said he would not recover

So he transferred to Yilan to see Dr. Chen Xiudan

Came in at 4pm to remove the respirator

Left at 4am to be discharged the next day

The cost of applying for health insurance was 5,000 yuan

He spent so much effort

Organizing this companionship with his family

And holding this family meeting

Help him do such a meritorious thing

The application fee for him and the health insurance is 5,000 yuan

But if you save it to the end

it will cost 1 million a month

This is very strange

A very paradoxical phenomenon

So today it is actually possible

In today's discussion

In fact, I feel very grateful to you two

for coming on my show today

And then I am really

This process can be roughly clarified

In fact, it is about the matter of accelerated death

Taiwan has not yet passed laws and regulations

In fact, foreign countries say

that it is already a human rights issue

In fact, we can take a step forward

But the most realistic problem

In fact, very basic things have not been done yet

Our life education

In fact, the life education system in Taiwan, including the medical profession

and the public

as well as the health insurance payment system

Although it is recommended

, I feel that everyone is facing death

The degree of consensus or discussion

should start with discussion

and then there will be consensus

It should be seriously inadequate

So I hope today

This time our cover story

can arouse this issue

Then thank you both for participating in today's discussion

Because I think it is a very meaningful discussion

It is rare

The two of us sat together

One is

You are not the chairman now

You are the current chairman

issued a statement against fasting

But Teacher Bi will also

We can all sit together and talk

In fact, there is a lot of consensus on life

and how to let everyone live well

In fact, we talk about a point in this book

That is, a good death

must be a good life

It is the stage in front of you

You must do well

Only then will you have the possibility of a good death

That includes the thoughts of people who have reached the stage of life

Many things will undergo great changes

So today I would like to thank the two doctors again

and then come and share with us

Thank you

Thank you very much

Finally, I want to share Tianxia Learning with the audience

A new program of Podcast

Called the CEO’s training ground

When the general environment changes rapidly

CEOs must be confused and struggling

Without CEO

Editor-in-Chief is often confused and struggling

I think the dean is also there

But how are they actually

These CEOs who come on the show

How to adhere to values and beliefs

This show is personally hosted by the co-CEO of Tianxia

...

Through sincere communication with other CEOs

To the audience friends in the workplace

Some strength and inspiration

Invite you to click on the information column below

to listen to the confusion and persistence of CEOs

I am Chen Yishan

I hope you like today's decision-maker Tingtianxia

Welcome to leave us a five-star evaluation message

Tell us what you think about the program

The update time of the next program

is November 27th

Let’s see you next time and thank you

Thank you two doctors again

Thank you

[Chinese]

大家好

我是天下雜誌總編輯陳一姍

歡迎收聽決策者聽天下

第130集的節目

這一集的節目大家可以看到

這邊有一個新的封面故事

談的是超高齡社會的必修課

善終練習好好走

我想

這是一個我自己覺得蠻大的創舉

我記得我剛開始當總編輯的時候

我推出了一個題目叫做孤獨死

應該是台灣很早

就以孤獨死做封面的一個媒體

隔了這幾年

其實又到了一個新的社會的階段

其實應該是這個月

如果不出意外的話

這個月台灣就會邁向

超高齡的社會

就是這個月

就是我們的高齡65歲以上的人口

大概會佔總人口超過兩成以上

那今年上半

事實上名作家瓊瑤的生命選擇

其實再度引起社會對於

善終的一個焦慮

我們發現了一個有點反常的現象

其實台灣的安寧的療護的品質

最新的評比是亞洲第一

其實是全球第三

而且它有很好很親民的健保

那我們也有亞洲第一個

病人自主權利法

但是我們的簽署率不夠高

然後我覺得有好幾個矛盾的現象

包含瓊瑤女士的選擇

然後她的那個焦慮感

其實我會覺得說

這個東西這個必修課

可能是這個社會現在應該很急迫

要做的這件事情

所以我們特別在這一期

做了這樣子的封面

我們也看到幾個現象

我們的善終環境

我們的鼻胃管盛行率

還有個人如何在身心靈

財務跟醫療照護上面做一些準備

然後我在這集新刊和網路上

我們都會立刻就會發布了

那我也特別特別建議

大家要仔細看我們的圖表

這次我們的文章

有非常多感人的故事

但在圖表上面

我們準備了大量的手冊

跟這個檢視的清單

我覺得很值得大家保留

我記得這刊出刊的時候做的時候

就幾乎每一個人都告訴我

家裡有長輩

在經歷這樣的階段

所以我想這是一個很實用的一刊

希望可以對大家提供幫助

那今天的決策者

也跟以往非常的不同

過往

我們大部份都是請一個專家學者

導讀我們這一期的封面

但這一次

我特別請來兩個

立場不太相同的專家

針對斷食善終跟安寧照護的現狀

我們來進行一個討論

我想第一位

我想先請前台中市

市立的復健醫院的院長

畢柳鶯畢醫師跟大家打個招呼

她也是斷食善終的作者

大家好

第二位是

臺大醫院金山分院的院長

蔡兆勳蔡院長

大家好

蔡院長之前也擔任過

台灣安寧緩和醫學會的理事長

當了三年的時間

那院長今年也出了一本書

叫做生死兩相安

我想這也是一個蠻重要的書

兩位在不約而同

在兩年內出了這些書

其實都跟所謂的死亡

是有關的

那這個對談是源起於

畢醫師出的這個斷食善終

馬上就變成暢銷書

我聽說也是出乎畢醫師的意料之外

沒有想到

那很多長輩想要採取此法

因為這個方法實在太普遍了

以至於

安寧緩和協會在今年的四月份

出了一個聲明

反對斷食善終

我這樣的措詞

我不知道對不對

但是看起來兩邊的意見

是非常非常不同的

那但是

我一直很希望是作為媒體的角色

其實我覺得媒體最重要的事情是讓

不同意見人有一個匯聚的空間

那我一直覺得

我看了兩位的書

也看了兩位的影片

然後我自己的感想是

其實兩位都是

希望大家能夠在善終好好走

這是大家共同的心願

所以也許有一些不同

也許有一些相同

所以這次特別謝謝兩位能夠來

然後聽說這是創舉

兩位坐在一起

來聊聊這樣的一件事情

我想有很多很多的東西

應該是觀念上面

真的可以趁這個機會釐清

然後兩位的意見

到底有哪些不同

那是這個不同的原因

背後一定有一些社會的現象

也許是制度面的問題

我想反而可以做更深層的探討

而不是停留在說兩人是完全對立

不同的一個一方

那我想今天

我們就開始今天的討論

第一個我想說

其實因為斷食善終非常的普遍

很多人有聽到這個名詞

但是我還是想請畢醫生聊一聊

你會怎麼講這個概念

你想要強調的概念是什麼

應該是我先講我媽媽的例子就說

當她已經全身癱瘓

連翻身都不可以

吃東西很容易嗆咳

那在台灣

一般的做法會建議插鼻胃管

但是我的表弟

就是插管臥床八年才離開的

所以我媽媽當然知道

她不會做這樣的選擇

那這個也是台灣病主法

在推動的一個事情

當生命品質不好的時候

可以拒絕用維生醫療來延長

這樣子的不正常的生命

或者是說沒有尊嚴的

這個品質的生活

那在那本書裡面另外一個案例

是他得了這個也是大腦的退化的疾病

他已經生活無法自理九年了

插這個用胃造孔

這樣子的情況已經有五年了

那他不想要繼續這樣的狀況

所以後來家屬請我協助

就說想要撤掉這個胃食管

那這個其實也是安寧緩和條例

跟病主法裡面就是說

家屬是可以代理這個病人

來做這個撤除維生醫療的

這樣子的一個決定

那可是我很意外的是

發現我找到的

前面的三位醫師都是拒絕

那拒絕的理由就是他們認為

這個病人只要繼續插鼻胃管

他就是還可以繼續活

他把安寧緩和只適用於末期病人

所以他把他界定是他不是末期病人

但是後來

這個病人還是有找到醫師撤管

那為什麼這個醫師又願意

因為這個醫師認為這個病人

他只要沒有這個維生醫療

他其實就是會自然死亡

所以他其實是在一種末期狀態

他認為

他都已經也沒有辦法

表達他的意願了

也沒有辦法語言表達了

然後長期這樣餵食

腸胃功能也不好

所以他認定他是末期病人

所以有撤管

那對我來講

因為我認識陳秀丹醫師

在網路上幫忙撤管

那到現在

假如有病人沒有辦法帶回家

我也是只能拜託她

那我看到

這個台灣有幾十萬人

無意識插管臥床

這件事情我很有感

因為我在福建醫院裡面

是看到健保以後

這樣的人口愈來愈多

我們算一下大概四十萬

對

那我是很覺得

這樣子替他們感到難過

但是我一直以為媒體說

90%是因為家屬不放手

那怎麼我遇到第一位求助的病人

就是醫師不放手

所以我才會在那本書的後面

就提到說

那我書出版了以後

我要來做拔管善終

推廣拔管運動

所以這個起源是這樣

但是到現在這三年多來

我已經幫忙三百多個人離開了

那這個

其中你看看什麼人會來找我

就會知道為什麼這個社會

需要這某方面的幫忙

當然已經得到安寧很好照顧的

或者是急性急救

醫生就懂得放手的

他們就不需要來找我

那來找我的都是有問題

那其中55%

都是所謂的無意識插管臥床的

那大部份是撤除鼻胃管

少數是撤除呼吸器和鼻胃管

對那另外25%

我很意外的是他只是勞衰

然後愈睡愈多 愈吃愈少

那家屬會急著把他送到醫院去

結果就被打點滴 被插鼻胃管

那我趕快告訴他你要辦理

自動出院回家

那這個事情我這樣子

一直長期的這樣曝光以後

我現在很多病人

他們已經懂得碰到

我都說老衰不吃不喝睡睡走

所以我幫忙的25%的病人

這樣應該是快要100例

這些人就是知道這個叫做臨終症狀

我們不要送醫

然後也懂得如何在家裡照顧

所以總共像我媽媽這樣子

她有自主意識

而決定要斷食離開的病人

其實只有20%

我這個月底要去韓國報告

我就是要報告這61位病人

他們是因為哪一些疾病

基本上都是有重症

無法治療

然後他大部份都是愈來愈惡化的

對

然後他有自主意識表達

表達他不要再延長這樣痛苦的生命

所以這61位病人

是像我媽媽的方法

就是自主斷食

所以

為什麼這個會得到

社會的很大迴響

我覺得就是因為這30年來

健保以後的這30年來

有太多人

插管臥床平均可能10年

那你想想看

有多少人家裡有這樣子的人

有照顧過這樣的人

或現在正在照顧

30-40萬這樣的人

還有人因為看了這些事情

很害怕自己未來被子女這樣子急救

所以這些人會知道說

其實原來我們還有一個方法

我們可以拒絕沒有必要的鼻胃管

萬一插了這些維生醫療的話

病人不會復原

那我們也還是有可以

終止的這個權利

那另外一個就是說

萬一這個病很難控制的時候

自己吃不下的時候

或家人吃不下

我們不要勉強

我們不要吃就可以了

安詳地離開

其實我覺得剛才醫生在講的時候

畢醫生在講的時候有兩個

我會一直強調的是

第一個是病主法

第二個是安寧和緩條例

看起來你的建議裡面

這個法規其實是一個蠻重要的

一個依據

是

那我不知道院長怎麼看這個

剛剛畢醫生的一些例子

這個畢教授的這個說明

是蠻讓人有感的

那我先提六個重要的字

第一個是對象就是病情的嚴重度

第二個字是自主

第三個是我們做這個醫療照護的

措施的意圖

這是很重要

所以畢老師講的這些例子例子

我都覺得

用這個安寧緩和醫療條例

或者最近的病人自主權利法

應該是可以來照顧這些病人

譬如說如果是有兩位

不是全國

兩位相關專科醫師

來評估這個病人

他是末期的話

家屬是可以代為做一些

醫療的決策的決定

這是我先說明的地方

就是我們比較不希望

把這個生命的結束

當成是一個善終的方法

這是我要說明的地方

就是因為我們一直覺得

不是生命跡象

結束就叫做善終這件事

那你想一想說

如果一個人他可以活

或者一個人還可以吃

那他就不想活不想吃

那這樣你就讓他結束生命

那這樣是不是叫做善終

這是我必須提出來的一些看法

那這裡有提到說

其實是一個善終的那個意涵

就是剛才提到的

不是生命結束就叫做善終

所以我在這裡也提出來是說

其實我之前

國文造詣不是那麼好

我要去查字典

說什麼叫善終

它提出來的也很具體

就字典講的就是能享天年

安詳而逝

那這個我個人的解讀是說

它是一個自然死亡

珍惜生命就是我們能夠活的

就繼續活

那第二個它提到說

是這個美滿的結局

那這個我覺得也很重要

就是生死兩相安

那最近也提到

不僅是病人跟家屬

其實照顧者也很重要

因為在照顧這些病人都是用心用情

也會有悲傷

所以這個也不是只有病人本身

當然就是說這個喪禮

就是要盡其善盡其哀

這是字典上面的描述

那我覺得都蠻符合

你的字典好複雜

就是寫這個

我覺得是蠻有道理

就是在我的角度看起來

這個就是悲傷撫慰

整個喪禮就是一個悲傷撫慰

那我覺得也講得四平八穩

那另外就是這個國際文獻

我們也去了解說

究竟這個善終兩個字

怎麼去描述這個事情

那我們過去找的有四個項目

一個就是了解時之將近

心平氣和接受

後事有交代有安排

時間恰當就是不要太匆忙

有所準備

那我們後來把它加入第五項

就是說這個身體的照顧必須得到

身體的痛苦必須得到緩解跟照顧

所以我們現在基本上用這五個指標

在評估一個病人照顧的結果

有沒有善終

那這個也得到國際的肯定

現在日本也用了這五個指標

也算蠻簡單地來做了

那最近我發現有一本書

也是同仁告訴我的叫做老衰死

衰弱的衰 死亡的死

那這個同仁也是從這本書得到成長

跟我分享

它說這個定義裡面

高品質的死亡

它說什麼叫做高品質的死亡

它就寫了一個

我覺得從我的經驗也是很好

它說要符合病人跟家屬的期待

那同時運用這個臨床醫療的經驗

跟這個文化跟倫理的方法

可以接受的方法

讓這個病人跟家屬以及照顧者

這樣有三方

病人 家屬 照顧者

包括醫療團隊

大家都能夠在煩惱痛苦中

解放的死亡

這叫做高品質的死亡

我覺得講得也蠻好的

所以我這裡必須提到的是說

因為這個斷食兩個字蠻吸引人的

但是我還是想讓民眾再想一想說

因為我們照顧的過程剛才提到

斷食不等於善終

善終也不見得要斷食

因為我們照顧很多的病人

還是可以吃就吃

我們也沒有強迫

因為我們的這個照顧裡面

其實蠻在意

病人插鼻胃管放這個胃照

因為這會影響病人的生活的品質

但是我們也強調說

我們餵他能夠吃的時候

他還是吃

我們一口一口餵他

他能夠吃

我們還是吃

那這個是我們覺得

說不需要就是

就人的規劃去把它停止下來

就是自然的

所以其實兩位的看法是

其實像畢醫生一開始就有提到

就是其實法規

然後如果說可以得到醫生的支持

你還會是盡力地去爭取

醫生的支持來協助

我可以這樣講嗎

譬如說有少數幾位醫師

他是願意把病人收住院

再來撤除呼吸器或者是鼻胃管

那些醫生大部份都是

安寧緩和科的醫師

所以這個過程

當然他們會有提供很好的

身心靈的照顧不只照顧病人

也會照顧到家屬

像剛才院長講的

這個三方各方的這個

大家是真心的平靜

那假如是不是到醫院

是很幸運的

他們是可以回家

那回家的話可以的話

我也會盡量找到居家醫療的

這個醫護人員去協助

對

他們也是受過安寧的訓練

所以我們也會盡量照剛剛

蔡院長講的這樣子的原則

在照顧他們和家屬

那有一部份的病人

因為我們現在

在宅醫療的資源

安寧的資源是不太夠的

或者是很偏鄉

他們沒有辦法找到

那時候

我就負責來做安穩他們的身心

這樣子的一個工作

所以我為了要做這樣的事情

其實我看了將近一百本書

跟這個生死有關

或者安寧緩和照顧

然後

因為我本來復健科本來就是

一個全人的醫療的背景

然後我這樣子的

陪伴他們的過程當中

他們都是我的老師

所以我學到很多

所以剛剛蔡院長講的這一些重點

所謂什麼叫做善終

這個我在書上也都有很詳細的描述

所以目前有一些家屬

他們可以只看我的書

自己就知道怎麼陪伴最後一路

然後事後再來感謝我的書

對他們的幫忙

因為你想想看在以前

也許五十年以前

大部份的老衰重症的病人

都是在家裡往生

所以那個時候民眾是有照顧

這個在家自然死亡病人的這種能力的

但是因為這幾十年來

大家很多病人在醫院死亡

所以我們社會集體失去這個能力

而對於自然死亡

或是老衰重症的死亡

都有過多的恐懼

他們是害怕把他送到醫院去

但是他們不曉得送到醫院

假如沒有被當作臨終的病人好好照顧

其實最後死亡的樣貌是非常恐怖的

其實院長

我想你剛剛有提到了幾個點

然後我覺得畢醫生也提到了一個點

是蠻重要的

就是一定要到醫院去住安寧病房

還是其實在宅安寧

也是個選項

可以講一講

現在這兩個比例上

或者說

你們看到了一些什麼樣的現象嗎

就是說剛才畢醫生講的在宅

其實真的是在沒有健保之前

大部份人是在宅比較多

那現在的我是覺得

健保真的

改變了台灣很多生命的樣態

所以你可不可以講講就是安寧

現在就是說在宅推廣的

怎麼樣的狀況

然後護理師我知道不夠

所以其實現在的佔床率

也不是很沒有辦法開全床

那這個量的問題

到底你現在是怎麼想這件事情

這個就非常重要了

因為我一直在講這個末期照顧

安寧緩和醫療的理念

它是一個理念

是

不限於場地

我想任何地方

都可以進行正確的照顧

適當的照顧

就是在醫院也好

在醫院的安寧病房也好

在一般病房ICU的急診

我覺得都是可以進行的

在家裡當然也是可以進行的

我們過去的研究也發現

在家裡照顧的品質

不見得比醫院差

這個病人在家裡安心自然自在

確實

我們現在發現的一個問題就是說

是不是在家裡能夠得到

一個專業的醫療的照顧

是我們重視的

因為現在政府極力的推動

在地老化在宅善終

這些都是很好的方向

問題是

我們有沒有準備好這些人員

能夠來承接這個重要的事情

其實政府也看到這個問題了

所以我們也積極

在做人員的籌備跟訓練

希望能夠落實這個政策

好的政策我們要去落實

確實人是很大的問題

那我也必須在這裡說明

其實面對死亡

它是一個很困難的事情

我們平常都覺得說人自然會死

但是從我跟這麼多病人相處的經驗

其實人面對死亡是很困難的

遇到的才會知道

所以這個真的不是那麼容易

多數的還是會不安

不想死 不願意死都很多了

這些都是需要去照顧的

當然對於醫療人員

我覺得也是一個必要的教育跟訓練

就是病人的家屬以及醫療人員

都需要去做生命的教育

來能夠讓醫療人員知道說

什麼階段的病人應該怎麼去做照顧

不要過度使用這些無效的維生醫療

這是我們一直在努力

那也希望像

畢教授畢老師這樣的一個前輩

在她不同的專業的領域

能夠幫我們去推廣

這樣的一個照顧模式

為什麼因為說實話

病人不是一下子就在我們

安寧緩和醫療醫師的手上

他都在前面的其他各專科

所以有時候我們也覺得

前面的醫師

他也很困難去溝通討論這個事情

所以這些溝通的能力

也是很需要的

剛才提到你勉強他去做這個事情

他心理上過不去的時候

他也是一個受傷也是一個困難

我們過去也是有遇到

病人來安寧病房

照顧一個病人

那個住院醫師照顧一個以後

他就說要離職

他沒辦法去面對這個事情

所以這個都是我們講的生命的教育

怎麼讓我們從原來傳統上

積極救治

避免病人死亡的一個教育

轉成說我們面對

這些重症晚期末期的病人的時候

要重新地去思維

才不會過度地使用維生醫療

讓這個徒增無謂的痛苦

這是真的很不好

我們這一階段先休息一下

馬上回來

後面我想跟兩位討論到

剛才提到生命教育

其實我自己也有感覺

我們這次在採訪的時候發現

醫生其實也是一個需要

被重新訓練和教育

甚至有點啟蒙的團體

我們也許會來

因為兩位都是醫學院畢業的

也許可以講一講自己的心路歷程

為什麼可以從積極救治

到讓大家改變

我覺得有一個新的轉折也許

然後可以分享一下大家自己的經驗

我們休息一下馬上回來

歡迎大家回來

在我們現場的是蔡兆勳院長

還有我們畢柳鶯醫師

兩位從來沒有坐在一起

談過死亡這個議題

我想剛才提到的一個

蠻大的重點在講的事情是說

其實到了醫院

其實醫生要到安寧的之前

然後可能真的是家屬來求助

畢醫師之前

其實有一段很重要的

就是跟醫生討論

自己的長輩或自己的生命的狀態的過程

那其實兩位都是醫學院畢業

也都是受過正統的醫學教育

你們怎麼轉念的就是從

一定要積極救治

到後來

是一個比較從人生命的觀點

去轉變說

你對於這個病人的對待

可能有一些不同的想法

要不要兩位講講自己的經驗

像你是從家醫科到安寧

你要不要說說你的經驗好

這個感受良多了

我就講從開始學習醫學

臨床實習的開始

其實就讓我跟安寧緩和醫療

結下不解之緣

那因為實習大概也

能力也不是說很會照顧病人

那我剛開始實習

就很快有機會到安寧病房去實習

那這個就遇到

一位當時年紀比我

稍長的一位大姐

她是大概四十幾歲

這個未婚的女士一個小姐

那她是一個肝癌

肝癌就是腫瘤很大腹水

腹脹如鼓

四肢就皮包骨

她要坐著不像我們這麼輕鬆

能夠坐的

她坐在輪椅上

還要特殊的輪椅來撐住

她的這個脖子

兩隻腿要抬起來因為這個腹腫

那我當時的能力

也沒辦法去照顧這樣病人

因為很有限的醫學的能力

但是我每天幾乎去看她三次以上

早中晚

然後推她到外面去曬曬太陽

吹吹風

關心她的這個狀況

跟她噓寒問暖陪陪她聊天

讓我非常感動的

就是在她往生之後

因為我們平均照顧病人

她只有兩三個禮拜就往生了

她的父親就拿了一個領帶來送給我

他說這個女兒交代

這個一定要送給我

那我對這個

醫學生那時候還沒畢業

滿大的衝擊

就是說在這個醫學的極限之下

那我們能夠做的不多

但是就是可能對她有幫忙

所以這個感受到

就是不是只有藥物這些治療處置

對病人才有幫助

當我們這個可以說是藥石罔效

這個醫學極限之下

能夠多去關懷照顧

其實是蠻重要的

帶給病人的一個平靜

同時也是帶給家屬的一個悲傷的減少

因為親人走得好

家屬的悲傷自然能夠減少跟縮短

家庭可以盡早重建家庭生活的功能

這是我覺得蠻重要

另外一個就是接續的

我在第一年住院醫師

我因為是家醫科

所以要到處去受訓

也是到肝膽腸胃科

那我們知道肝癌

如果說肝細胞肝腫瘤

去侵犯肝門靜脈的話

我們以前的知識就是

大概半年之內他會過世

這應該也是醫學的證據

我印象很深刻

那時候就遇到一位還能夠走路

外表看起來都還好的病人

他就是住院

要來做檢查要做治療

結果檢查完這個電腦斷層

我的指導老師就跟我說了

明天讓他出院

因為答案已經知道了

沒有辦法治療了

他這個影響到肝門靜脈栓塞

就是這個癌細胞已經跑到這個血管了

那他就目前也不需要做什麼

那就讓他出院

那時候我也是很大的衝擊

為什麼因為我們可以體會

家屬病人也是滿懷期待

我來台大醫院

就是要把這個病治好

最後希望

那我怎麼開口去跟他講說

你這個病不能治

然後我那時候還很可愛

我知道他會去試這個

所謂的另類療法偏方

那一定可以理解的

我還當時跟他這個建議說

你如果要找這個

這個其他的另類輔助療法

可能要怎麼樣去找

比較能夠這個有水準有這個風評

你還做這種建議

因為人心

我知道我們從這個西醫的角度

沒辦法幫他什麼

但我明明知道他會到處尋找

這個人之常情

所以我還是很

很委婉地跟他這個建議

所以是從一開始學習的

醫學的兩個歷史

其實對我是蠻大的影響是說

我們遇到醫學的瓶頸

怎麼去做這些事情

而不是這個不管他

直衝直撞

拼到最後無所不用其極

其實是帶來這個病人無謂的痛苦

沒有辦法幫助病人

讓這個家屬更痛苦

那你這樣的醫學教育

是平常就會接受到

還是你覺得你是很特殊的例子

因為你進到實習的場域

有這兩個案例

基本上我不能說我特殊

就是說

或許是我對這個觀察比較細微

但是現在我變成是老師

所以我再怎麼忙

還是回到床邊的教學

那為什麼要回到床邊的教學

就是我們要帶著學生去看

看什麼看我們怎麼去跟這些病人

跟家屬互動

怎麼去把一個很困難的情境

把他照顧

轉化變成一個順利

因為我們最怕的是學生對這些無感

什麼叫無感就是沒救了

沒辦法治療了

我又不是神

跟我沒關係

其實是我們很關心

至少我覺得這個醫學總是要圓滿

在這個極限之下

還是要把這些事情把它完整

才能夠圓滿

雖然沒有辦法把他救治回來

但是我們把這個事情做好

所以這是蔡院長的轉折

就是從醫學生的時候就有這個經驗

那畢醫生

我應該是跟我復健科的工作

很有關係

因為但是轉折點應該是健保

在健保以前

是應該需要復健的人也沒有錢

除非他有勞保或公保或者是農保

所以一般的小孩 婦人 老人

他們是沒有辦法做復健的

自從有健保了以後

我們就開始出現所謂

沒有復健潛能的病人

譬如說很嚴重的腦傷

他根本就是植物人的狀態

然後像小孩子很嚴重的腦性麻痺

以前可能他們在家裡我不知道

可是現在

他會帶來我們的門診做復健

所以我會看到哇

這出生就重度腦麻

這父母要照顧他一輩子

所以我逐漸看到

有愈來愈多

被就很先進的醫療科技

留下來的人命

可是他們非常辛苦

他們的家屬

像媽媽照顧那樣的小孩

他完全沒有自己

我非常同情這些照顧者

所以我是逐漸有感受到

這個醫療因為太進步

除了救命的技術愈來愈多

愈來愈好

這個是它的光明的一面

可是它的黑暗面是

我們不知道要放手的時候

有時候是家屬不肯放手

有時候是醫生不知道要放手

但是

另外一個影響的因素

應該是也是受到一些

安寧緩和前輩的啟發

譬如說我很早就聽說趙可式教授

他在民國七十八年的時候

他的爸爸失智插著呼吸器

醫生說不能撤管這樣違法

可是他就是在病例上面簽名

說他的女兒趙可式

我說那份病例應該可以變成古董

很寶貴

她簽了名以後

她自己親自幫她的爸爸

去撤除這個呼吸器

所以她是很有膽識的一個

另外一個是她看到

這個癌症病房裡面

同一段時間裡面

就有好幾個病人自殺死亡所以

她有感受到說

原來我們的醫療像剛剛

蔡院長講的有極限

所以

她就因此查到有安寧緩和這本學問

她是四十歲才出國進修

另外在2010年

我就同時看到黃勝堅醫師的一本

生死謎藏

還有陳秀丹醫師的

就是殘酷

就是說我們可能是以為人死

可是其實是殘酷

所以他們在書裡面有講到很多

不需要急救的時候

我們不要急救

應該要放手的時候

我們要勸家屬放手

那尤其是陳秀丹醫師

到後來我在影片上面

我看到她親自幫病人撤管之前

如何去跟病人溝通

如何跟家屬解釋

那個過程

可能就是蔡院長經常在做的事情

但是對我來講

那個是一個很震撼的一個畫面

對

後來我也自己再去看書的

然後再去看別的影片

所以我也學會就是說

如何跟病人做這樣的溝通

跟家屬做這樣的溝通

所以我想

應該是台灣的安寧緩和的前輩

這幾十年來做了很多的努力

其中有一部份就是已經

已經無形之中在影響我

另外一個最重要因素

應該就是我在醫院裡面看太多了

還有再說的話應該是實際上

我的公公是失智症插管臥床十二年

他的弟弟也是一樣

失智症插管臥床十二年

我先生的姐姐的公公也是一樣

失智症插管臥床

我的

先生的妹妹的公公是巴金森氏症

插管臥床

我的表弟小腦萎縮症也是插管臥床

所以我一個人而已

我身邊就有這麼多親人

所以你可以想像

這些衝擊都是會讓我們來思考

到底怎麼樣活著

才是真正叫做有意義的活著

那這些人

是他自己有說

萬一將來沒有意識

我癱瘓了我要插管

臥床躺越久越好嗎

沒有耶

甚至有很多人

他其實是有交代過

譬如說我婆婆看到我公公這樣

她當然會交代我未來這樣

你們不要幫我插管

所以我協助撤管的180個人

這裡面有很多人

他以前有交代過

對雖然他來不及簽病主法

來不及簽這個安寧條例

其實我想畢醫生講到一個

現在蠻重要的重點

因為台灣社會應該大部份的台灣人

甚至我覺得國外也是

都沒有想到自己會活得這麼老

所以也沒有想到

失智對很多人來講是一個新的議題

那病主法其實沒有太多年

然後大家也還不知道怎麼熟悉

所以的確

像我們這一輩也都會遇到

已經開始遇到父母失智

然後他也沒辦法自主表達意見的時候

這件事情到底要怎麼解決

這個我的建議是這樣

剛才所講的

那個畢老師講的這些例子

我個人的己見就是說

如果他病情有一定的嚴重度

那依照我們現在的

這個兩個法律當作基礎的話

他沒有之前自己去文件的書寫

大概我們會選擇

這個安寧緩和醫療條例的

方法的方式的規範

由兩位相關的專科醫師來評估

他是末期的階段

那就可以家屬代為作為決定

那以這樣的方式來進行

我想是比較這個大家比較安心

那現在重要的是

我們為什麼要去做教育訓練

就是剛才畢老師提到的

那有些醫師

他認同

有些醫師

他不見得認同我剛才講的方法

意思是說就對於末期的評估的判定

有些醫師他會有疑慮

所以我們要去教育這個事情

是說

進入到什麼階段的時候

這個病人應該是可以評估他是末期

那家屬來作為代為

表達他的意見

那所以

這個醫療人員的教育訓練是很重要

也不是只有醫師

因為醫療團隊裡面

還有其他的專業人員

譬如說

以前我們也遇到了醫師願意

呼吸治療師不願意

為什麼你開遺囑

我要去把呼吸器關掉

他們覺得他是劊子手

所以這個事情

當然醫師是一個重要的關鍵

但是一個團隊

所以我剛才為什麼會講說

為什麼高品質的死亡要

病人 家屬 醫療人員

這都是要有一個共識

會比較順利

不然你說舉例呼吸治療師他不願意

那這個醫師怎麼辦

我們也是很困難

我怕會有問題

所以這個不僅是全民的

這個生命教育 死亡識能

醫療人員的教育還是很重要

我覺得這塊是真的很少人提到

就是醫療人員的教育

聽說現在年輕一輩稍微好一點

但是聽說反而是比較資深的醫生

總是想要試試看

好像總會有一點機會

這個的關鍵是什麼

為什麼大家沒有辦法放手

關鍵就是我們的醫學教育

前面幾年都是在強調

我們從無知到認識

到怎麼把這個命把它保住

把它盡量地延長

避免死亡

以前我們在醫院裡面

畢老師一定很多經驗

這個病人死亡要檢討的

要這個開會討論

為什麼這個病人會死

有沒有哪裡疏忽

所以這個習慣上就會變成說

這個病人死亡

變成是一個不好的結果

他必須要檢討

而避免下一次發生同樣的問題

那這個當然是重視生命的一個表現

但是我們剛才提到的就是

醫學是有極限的

有些病人是不可避免走向死亡的

但是這個還沒有

那麼好的一個認知了解的話

就會他又覺得我再試看看

或許有機會

那這樣就變成有加油

沒有煞車

他不曉得什麼時間做一個停損點

所以我們不斷的在做這些教育

不是沒有

我的頭髮

大部份是因為這個教育掉的

因為是不容易教育這個事情

因為醫生是不是很難教育

對不起

對兩位醫生有所冒犯

我想這個現象不是只有台灣會出現

就算我在看美國的醫師來寫這樣書

他也會講

我們的醫學只有教育救命

可是我們的醫學沒有教育

如何放手

所以他可能看到病人

就只想到他缺什麼

他需要矯正什麼數據

他就沒有去想說

這個人其實是就是已經要

已經救不回來要面對死亡

所以醫學教育裡面缺少死亡教育

這個是真的

那另外一個

你剛剛提到說譬如

為什麼不同的這個年代的人

有不太一樣

這個應該是整個社會的文化造成的

因為我們

我們東方社會相對

對死亡是比較忌諱的

所以平常比較沒有討論

然後也認為好像死亡就是這個人

消滅了失去了

我們就沒有這個人了

譬如說有家屬他會說

也有醫生這樣說

就是媽媽至少躺著

你還有媽媽可以看

那也有病人說媽媽在這邊躺著

那我至少還有媽媽

我會說你媽媽已經陪你80-90年了

為什麼她肉身不在

你會覺得你沒有媽媽

可是他這是他真摯的感情

對所以是我們對死亡的認知

有沒有

其實這整個社會要慢慢要改變

譬如說達賴喇嘛

他就是很簡單一句話

就是我們這個肉身

是來地球借用的

所以假如這個衣服

已經穿破了舊了

不能用了你就要換

就把它放下要換另外一件衣服

所以你不會執著於

你只有在地球這一世的肉身

所以這個肉身不能用

真的不用勉強

而是你的靈魂可以自由再往前走

所以我會相信靈魂永生這個觀念

而不會執著在

我這個肉身

絕對不能讓它消亡

我想有一個點

我就是在看兩位的

這個影片或者資料的時候

我覺得院長其實很擔心一件事情

就是過度強調斷食善終

其實有可能會有加速死這樣的問題

而不是自然死

我想畢老師其實真心想要的

就是比較是自然的

對那這個界線當中

然後自主這件事情

這個要怎麼樣來拿捏

怎麼樣有一個比較好的這個流程

我簡單講

我現在幫忙的病人可以分成兩類

一類就是他有自主意識

那自主意識

這個就是他不會吃不想吃

你不要勉強他吃不要他胃管

然後他因為這個病太難過

太痛苦了

像我媽媽她決定

她不要等到變成吸入性肺炎

加護病房再走

她要提前

就是直接不吃了

因為她每天都在嗆咳很痛苦

那這個對

蔡院長他們可能某些人來講

就認為我媽媽這樣子是加速死亡

對那這個

我相信他們為什麼會有這樣信念

是因為安寧緩和數十年來

有一個很重要的宗旨

就是我們不加速也不延遲死亡

那我會認為

你有這樣的信念可以

你支持這樣的信念

那你在很末期的時候

你都還是盡量努力

譬如說這個史蒂芬霍金

他在生活情況

比我媽媽還慘的情況之下

可是他有覺得他的生命是有意義的

所以他還可以活到

就是自主這個概念

是他認為他的生命是有意義的

但是我媽媽覺得夠了

那雖然你們不贊成加速死亡

但是我會尊重這個病人

他要選擇加速死亡

加速死亡並沒有什麼滔天大罪

所以我們只是要學會尊重

尊重每個人

但我想

院長可能不太認同這個看法

這部份我想借重這個

畢老師這個圖就很重要

這個圖我來說明一下

其實這個圖是很重要的

這邊就是自然死亡的時間

那這一部份是我們剛才是

蠻大的共識的地方

我們不要用無義無效的醫療

去延長病人死亡的過程

這個徒生無謂的痛苦

這是我們一直在努力的事情

那接下來這邊比較重症末期的

基本上也沒有很大的問題

病人自主權利法等等

都有在注意這個事情

老衰 末期

所以這一個部份三個

如果說以我們目前的狀況

就是剛才提到的

病人自主病情嚴重度

他這個處置的意圖

是不是在以結束他的生命

這個按照兩個法律

基本上我們是可以照顧這些事情

但是就是剛才強調

我們這個教育要再加強

來做這個事情

但是其實最大的擔心點是在這裡

這個就這個四個字

是我們擔憂的地方

就是說這些重症失能的

譬如他是中風

比較失能的

那他不願意

如果他不願意

基本上我們也尊重他的意願

因為每個人有他的意願

我們不可能拿刀子去抵著他脖子

但是我要說明的是在這裡

這個我為了澄清這個問題

我自己畫了一個圖

就是同樣的跟畢老師這個是類似

這個自然死亡的時間

我們不要去做這個無謂的維生醫療

增加無謂的痛苦

這個是很不好

那我們強調的是說按照兩個法律

我們現在的看法是

我們要自然死亡

如果這個病人

他是因為病情的關係

他漸漸就不能吃東西了

那我們不要在他嚴重的情況之下

還要去強制的給他灌食幹嘛

但是我們不會說他還能夠吃

為了他還可以吃

我們就把他停下來

大概也不可能這樣做

所以我們是強調

是因病人的病情自然停止飲食

是我們的看法就是可以吃就吃

不能吃就自然就不能吃了

可是他有一個困境

就是在插鼻胃管

算不算可以自己吃

我講的自然吃是經口進食

就是他可以吃

可以自己吃那當然是繼續吃

我們餵她像那個老阿嬤

她失智很嚴重

但是你餵她吃

她還能夠吃

那我們應該是餵她吃才對

吃一吃

因為病情進行了

她漸漸吃的量就會減少了

那我們到最後就不要

再去插她鼻胃管了

也不要再去做胃照了

就是比較接近我們所謂的自然死亡

是因為病情的關係自然停止飲食

那我們不會了

用這個叫做斷食這樣的說明

那這一部份

現在我看起來會引起

可能我們擔心的誤會的地方是說

安樂死

我們比較清楚

他比較提早結束生命

大概是大家可以理解

那我們現在這個畢老師倡議的

這個斷食

就光譜會比較大一點

有一部份是這裡

基本上我們沒什麼大問題

比較擔心的是

剛才提到的這個

重度失能的狀態下

加速死亡這一部份

我們同仁會比較擔心

因為現在這個至少兩個法律

沒有這四個字的一個概念

所以我為了這個跟同仁分享

我畫了這個圖

就是說

我們這些苦痛的病人怎麼去做照顧

這是我的經驗

意思是說這個評估很重要

就我剛才講的病情的嚴重度

我們要評估他的狀況

假設這個人他是可以表達

意識清楚可以表達

他不想吃

那我們怎麼辦

我們去評估他的病情

是不是因為病情嚴重

他沒辦法自然進食

所謂自然進食

是經口進食

如果他符合我們現在

這個兩個法律的規範

他有之前表達的意見

那我們當然按照他的意見

來做進行

我們最重要的是這裡

他可以吃但是他跟你講

我不吃了

這個是我覺得

需要照顧關懷的地方是在這裡

所以不是一個安寧的問題

而是一個比較是

醫他的心

看他的這個心態

因為這裡是我覺得很重要的地方

就是說因為前面那個是病情的關係

那去做該做的事情

他如果不符合病情的嚴重度

我們會建議他用這個所謂

人工營養流體的胃

看他願意不願意接受

他不願意接受

我們也沒辦法

但是我們一直保持一種關懷

這個是我很強調的事情

那舉例來講這個可以吃

他就可能表明我不吃了

等一下我可以用一個例子

表明不吃了

那我們要什麼

支持關懷看後續的結果

那假設是他已經沒辦法表達

像我剛才講的已經失智了

沒辦法說了沒辦法表達

我們還是看他的病情

所以我這一條線很重要

就是他要評估病人的狀況

來做後續的這個走向

那如果是符合他原來這個病主法

安寧和緩條例的方向

那我們就按照這樣的做

重要的是

在這裡也是我們最關心的

剛才講的

他可以自己吃

你餵他他還可以吃

那我們還是要繼續餵

不會說因為他失智了

可能覺得他沒有功能

那我們就把他停下來

其實我們要說明這個事情

因為確實會出現這樣的疑慮

我們也遇到說

這個病人跟兒子商量好了

就不要吃東西

結果餓了五天

餓了五天

肚子太餓了

他問這個護理同仁說

我能不能吃

護理同仁說可以你可以吃

但是我已經答應兒子不再吃了

兒子會罵我

那是因為家庭經濟的問題

所以這個是一種情況

我們要瞭解他的背後的問題

還有譬如說她癌症

但是只有二期

她還可以聽聲音她

可以追尋人的那個這個聲音

表示她還是有意識

結果這個子女跟她講說媽媽

你長痛不如短痛

那這也是我們出現的一些

讓我們比較擔心的事情

所以是要把這些事情講清楚而已

該是怎麼樣做

我們怎麼去做

該怎麼去做照護的

我們要去做照護

我要補充一下

這種狀況不會只有他們碰到

我也碰到

但是我不會把它當成這個是困擾

所以我不應該再推廣善終

我會認為

這些人需要我不一樣的協助

譬如說他憂鬱症而已

他就是想要斷食

我會直接告訴他你身體健康

你不可能成功

然後我會告訴他

你還是可以做些什麼努力

你可以嘗試去尋找什麼醫療

像他剛剛講的就是病人失智症了

他看他活得這樣

很痛苦

可是他還會吃

所以我會說

你要很確認

他是知道你不餵他

他是想要死亡的狀態之下

我們才要進行

可是假如他根本不知道

什麼是生死

什麼叫做善終

他就是有生物的本能他還想要吃

那你一定要餵

我會告訴家屬說

不然他會變冤死

你有不同的方法

其實在面對一樣的

就是剛才畢老師意思

他也會反對他們

就是如果人家提到是家屬

想要幫助父母親解脫這樣子

對所以我不會

因為碰到這樣子的家屬

我就認為那我做的事情不對了

我們要停止

而是我知道他們需要我不同的方法

所以其實我說

我幫忙的可能是三百多個

可是我是沒有認真去算

我拒絕的有多少至少一百多個吧

對

所以我會去判斷

什麼情況其實是家屬錯判

然後真的要執行的

我們都是很清楚地去了解

你是真的知道你不想吃了

有的人會說我不想活了

我說你要好好跟他溝通

你才會知道不想活的

只是他需要人家關心

還是說他其實只是在表達他很痛苦

還是他是真的不想活

這中間需要很多的這個溝通

這不是那麼簡單

說你來找我

好我就幫你斷食

絕對沒有這種事

這樣我就太輕鬆了

對所以我們是要做這樣子評估

然後也要真的去了解

家屬你是什麼心態

然後病人

他是什麼狀態

這個是需要很多的心力

真的是一個很大的心力

所以就是

臨床評估這件事情是蠻重要的

所以應該是畢老師

她的做法是她自己來評估

那院長肯定這一塊

大家可能比較不知道

你做了很多這個自己評估的

這個確實是我目前最無奈的地方

譬如說美國就像失智症的人

巴金森氏症的人

他假如覺得

他現在的生活品質很不好了

他想要自主斷食

美國的是會把他送到醫院裡面

去做斷食

但是

他們之前會有會有

這個精神科的醫師

安寧科的醫生

或者他本來的那個病

的那個科的醫生

大家一起來跟他協商

對

然後真的好好去評估

以後確定真的沒有對你更好的路了

你確定這個是你的權利的

那他們就會把他收進來照顧

可是台灣現在很可憐

現在是你只要去跟安寧緩和提這個

你就是會被打槍

你就會被說你這個不符合

你這個不行

對

但是也許有少數的醫生

他會把家屬找來

我們來好好做家庭會議

但是大部份他們都是被拒絕的

被拒絕的時候

他們來找我

所以我只好根據我自己的經驗

然後再加上

我也有一些安寧緩和醫師跟我

我們是理念相同的

我們可以一起來討論這個案例

可不可以講講

你自己覺得為什麼會這樣

那院長你也可以講講

為什麼他們

會有被拒絕的狀況

我先簡單講一句

因為他們認為加速死亡就是不行了

對但是加速死亡沒有不行

因為我媽媽決定我不吃

我決定我不插鼻胃管

這是憲法給她的人權

我們的憲法給我們的人權

就是我可以拒絕所有

我覺得沒有必要的醫療

但是我也可以拒絕飲食

憲法沒有任何的法律規定

你這個人一定要吃幾餐

你要吃多少

所以這些人決定他自己要停止進食

要加速死亡

這個是他的人權

至少在歐美國家

人家2014年荷蘭就有

已經有自主斷食的臨床指引

它認為所有的醫生護士

都要瞭解

因為他們有8%死亡的病人

他是因為自主斷食

或者是因為撤管離開

所以死亡人口裡面有8%

最後兩個禮拜是沒有吃到

所以他們認為

醫護人員應該要瞭解

但是在台灣

現在有部份的醫生願意協助我

來幫忙這樣子的病人

但是

安寧緩和協會是出公開聲明反對

而稱這些病人為自殺

那但是你用這個自主斷食的英文

你去查所有國外的文獻

所有的文獻絕對是90%以上

都是很明確的說

自主斷食不是自殺

我的舅舅是用電線

把自己的脖子勒死

這樣子自殺

我的媽媽是二十一天

我們這樣子親人好好的陪伴

我媽媽的死亡

怎麼會跟自殺是一樣的

所以我很重要一定要強調一件事情

病人自主決定

他要結束他的生命

這是他個人的自主權

所以我們不應該說他們是自殺

因為你說他是自殺

又說他的家屬或幫忙的

這些醫護人員是協助自殺

有可能犯法

這樣子在社會上來講

這是一個很不正確的

很不好的一個觀念

不過畢老師剛剛有提到一個

很重要就是國際上面

他們會把想要自主斷食的人

經過評估以後送

可能有一個過程

我想這是台灣

跟現在很不一樣的地方

我們也是有

只是我們比較

怎麼講

比較簡單比較簡化

我舉個例子

這個人當然是有他的權利

但是我先說一個重點就是說

其實我還是認為

人有被照顧跟關心的權利

這也是世界衛生組織在最近的

安寧緩和醫療的說明裡面

強調的

提供給這個病人的照顧關懷

是基本的人權

那為什麼會強調這個

我一個印象很深刻的例子

這個病人大概50歲了

他是我遇到第一位

就是跟我說他看了畢老師的書

她要來斷食善終

我也是安排她來住院

因為她50歲左右

頭頸部鼻咽癌

這是蠻痛苦的一個病

因為她雖然還可以走路講話

只是講話不太清楚

吞咽會有些困難有時候會嗆到

所以她有身體上的功能跟障礙

再來因為她的先生幾年前也過世

意外過世也是個悲傷

那媽媽也是一個肺癌

那父親也得癌症

所以她漸漸的功能上比較退化

所以要弟弟留職停薪

來照顧他

成為別人的負擔

這其實病人是蠻苦的

那再來恐懼

她有輕生的念頭

走到河邊不敢跳下去

你說這個人苦不苦

苦

但是我們安排她來住院

你說住院她第一天跟我講

比手畫腳我明天就要斷食

我明天就要斷食

貼一個告示牌在床頭嗎

你不要再問我肚子會不會餓

我就是一心求食

那這個也是我的教學的重點

我們對這些病人的互動

是要同理心接納的態度

去跟他建立關係

那這個病人一個很重要的轉折點

就是一個學習

因為我跟她有一點互動關係以後

她問我

因為我是問她這個學佛的那個經驗

她反過來問我

蔡醫師那你分享你的學佛的經驗

我就抓到機會

跟她分享一下我的經驗

我說這人是要不斷的去學習

那把你過去的這個善良這個本質

把它再找回來

因為人在痛苦的時候

忘記他以前的好

這是我們講的這個她很慈悲

因為我要找她來住院的時候

她都不想住院

她說我不需要再浪費醫療資源

我在家裡就好了

那我跟她講說

你這個慈悲是很重要的

那你這個佛經帶來了沒有

她說來就是要死

帶什麼佛經

後來我把她轉成

她去學佛的這個積極

她轉向了

都不理我了

為什麼

她都在念佛了

她在念佛了

表示她又抓到那個

那個支持了

所以來協助她這個生命回顧

自我肯定

化解衝突

跟她的家人的一些誤會

這是畢老師看起來這是運氣好的人

遇到院長對不對

這個就是我要說的是這裡

那我今天要特別帶來

這個很有感

她印這個送給我了

那我非常感動我說

你這個印得很漂亮

結果她印了一百張

放在佛堂分享給別人

這是慈悲喜捨

她不僅自己繼續走了

也分享別人

所以你說這個人

如果是困難

我是當然覺得簡單

因為我都在做這個事

所以這個教育重要是在哪裡

我為什麼會去教這個

六步驟十重點五良方

就是希望說

我們醫療人員要能夠會做這個事情

他才能夠避免無效醫療的使用

第一個是避免無效醫療

但像畢老師講的這個

當他一心求死的時候

其實有可能是生理的不能

也有可能是心理的困境

那這個都需要一些幫忙

看起來是這樣子

我想蔡院長剛剛提的這個

真的是一個善緣

對有這樣子很慈悲心的醫生

然後那個病人也都有辦法

因此就轉念

但是人生的生老病死

真的是很多種狀況很多種面向

所以我們也不要說這個一心求死

我們就是沒有關懷他們

因為我們是

他們其實

不是這麼容易做這樣的決定

他們是有經過很長久的掙扎

家屬

你想想看

家裡有一個人說我要斷食往生

家屬的反應是什麼

一開始的反應都是會勸解

都會盡量關心

所以我認為他們都有做關心

但是不是不是所有的人

只要你再給他關懷

他的生命好像就從黑白

就有辦法變彩色

有的話當然是很好

但是我相信大多數人都有這個心

想要先這樣試試看

但是我也必須說我遇到

好多的例子

都是關懷之後就自然改變了

我們不是拿刀子跟他說

你要改的

他就自然

你結了很多善緣

善人結善緣

他變了

因為我是老師

我不只是醫師

你剛才不是問嗎學生怎麼轉變

我是在做這個教育工作

我把我認為容易的事情

讓我們的學生能夠去學習這個事情

才能夠避免無效

為什麼他不能放手

就是不會做這些事情

對

其實我最後一個問題

其實剛才兩位

我覺得這個討論非常非常精彩

但我想

剛才畢醫生有提到一個事情

就在國外

當你遇到有人要自主斷食善終的時候

其實醫療體系會有一些介入或者是

但我們好像沒有這個

那其實我就很想問的是說

這個東西有沒有辦法做

就是從院長的角度剛才講說

國外的這個事情有沒有辦法做

他就會也會避免掉

畢醫生的這個困擾

就是也避免掉安寧緩和的困擾

就是說他真的有一個

做什麼

他如果自主斷食

他說他想要自主斷食

他有一個門診

然後可以來討論說

我可不可以來做這個事情

有這樣子的機會嗎

因為我後面想要討論

就是這個安寧治療的

這個能量的問題

因為我們這次做這個題目的時候

你說接受他那個

不一定要進到安寧

但是起碼有一個機會

診斷一下他到底是什麼狀況

基本上

我剛才講的就是說他能夠自然吃

那基本上我們會就是自然吃

所謂自然吃就是他經口進食

如果他沒辦法經口進食

基本上我們不會強迫去跟他做

以安寧照顧的角度

我們不會強迫去跟他插鼻胃管

做這個胃照

基本上是不會去做這些事情

就是可以吃就吃

但是我們不會說可以吃

還是故意把他停下來

不至於這樣子

這就是我剛才強調

是因病情的關係

他自然就停止

不過老師剛才講

畢老師剛才講的是國外

有一個這樣的經驗

他會有一個陪伴

然後有一個

他是一個正規的醫療體系

因為他們的說法也是

病人就是有拒絕醫療跟飲食的權利

但是醫界要負起一個責任

就是我們要好好去評估

他真的已經絕望

沒有別的路可以改善他現在的困境

所以我們是要確認

確認他的自我判斷是正確的

剛才院長講的那個臨床評估

現在臨床評估的這個部份

都是譬如說其他的科室

覺得有狀況

把他送過來的嗎

還是說他自己可以去做安寧門診

我指的是我們普遍的醫療人員

怎麼去面對病人

吃與不吃這件事情

他是要評估

那剛才畢老師提到說

人有自己停止飲食的權利

那這個我不能去否認

他不吃我們也沒辦法

但是我是強調我們去關懷他

經常他會吃

這是我的經驗

那譬如剛才那個小姐也是

她說要斷食

結果床頭都是飲料

那我們看得懂不能講破

那以現在會比較困難的地方說

這個畢老師這樣的一個觀點

我覺得醫界上可能多數

還是比較困難是

因為現在的法律就是病主法

跟安寧緩和醫療條例

那對於剛才提到的四個字加速死亡

老師認為說

人有加速死亡的權利

但是現在似乎還沒有這個共識

那沒有這個共識的時候

原來我們希望醫療人員

在這個病人末期的時候要放手

都很困難

剛才我們提到很困難

所以意思是老師有點先進

對基本上是這樣

但是目前上是比較困難是

這個法律上是這樣規範

不過我剛才也強調

這個加速死亡這四個字

基本上不在我們現在的法令裡面

所以會比現在去推動

減少無效的衛生醫療會更困難

就是台灣其實還在撤除

無效的衛生醫療

都還在掙扎的情況之下

所以我的書為什麼很震撼

是因為我是直接拒絕的

現在是連接受要撤除

家屬都還不願意放手

或醫生不願放手

而我媽媽的案例是我直接拒絕

所以她的情況真的是

走在台灣的前面

但是我的觀念是從日本來的

所以日本人並沒有說

他們譬如說有一些文獻你們看到

日本的醫護人員還是有一定的比例

都照顧過自主斷食的病人

那歐美國家就更不要講了

所以我想說

從今天的訪談裡面可以看到

其實我們的階段還真的

整個社會的階段

其實是還在慢慢的

對死亡這件事情有需要

很大的學習的一個階段

那我想最後一個就是想問一下

就是安寧療護

我們這次有提到

其實居家的安寧

我覺得是未來應該要推廣的項目

但是這個的目前的狀況

我想可能也許請院長聊聊

這個當然是很重要

因為經常有人問我

你這個安寧病床不夠

那我都是用這樣一個說明

安寧病房

你從死亡的人數去跟病房數來對比

當然是不夠

但是我要提出來的是說

我們去看這個佔床率有沒有滿

我們發現還是有空床對不對

那我要表達的是

剛才我也講過了

這個死亡這件事情對所有人都困難了

所以我們必須要去加強

這個生命教育

它是全民的問題全醫界的問題

全社會全國家的問題

不是只有這個安寧的

這個事情的責任

所以我剛才也是

像我們畢老師這個復健的前輩

那應該是有這麼多的

這個有志之士來推動這件事情

去影響各醫學會

以我這個家醫科的醫師來講

我不可能打入

這個內科 外科的世界去

很困難

我們以前不被老師罵說

我以前怎麼教你的

你現在怎麼可以放棄病人

我們都很痛苦

所以這個是

要有志一同

來減少這個無效醫療

再來我們政府現在也看到這件事情

居家醫療不斷地在政策上長照上面

希望遍地開花

所以我們現在也負責一個責任

就是要去培訓人員

那你說在教什麼

就是我剛才講的

就教這些關懷照顧

才能夠避免這個無效醫療的使用

他知道怎麼照顧好這些病人

還會比較順暢

當然

健保的給付對我們是

很重要的一個鼓勵

我們做這些事情

好的品質是節省我們的健保資源

所以節省了來之後

應該要回饋給我們的病人

好的生活的品質好的照顧

一部份是要回饋給我們醫療人員的

因為為什麼會節省

是我們去做照顧所節省下來的

所以應該要回饋給

我們這些辛苦去做互動溝通的

這些醫療人員

才做得好

所以這個健保的給付

確實要能夠提供

不然我們會餓肚子都在做功德

這個也是很重要

這點我要幫蔡院長講一下

這個你知道

我們一年八千多億的這個

健保費用裡面

用在無效醫療是兩千多億

像那些只是使用呼吸器躺在那裡的

一年用掉300億

可是安寧一年才用掉17億

然後居家安寧才1.6億

你知道說像跟我以前

我是因為做這個推廣善終的關係

才認識的一些跑居家醫療的

他們真的是在做功德騎著摩託車

在街上這樣子來來往往的

看一個病人給付最多一個小時

他進去幫他弄完出來

三個小時

然後二十四小時線上要

他有問題

你就要馬上回答他

開這個家庭會議

這些都沒有給付

所以我們的健保的這個給付辦法

實在要做很大的改變

要想辦法是減少無效醫療

然後安寧用的是精神

用的是心力結果沒有給付

然後你買了那個很昂貴的呼吸器

放在那裡

你每個月給他十幾萬的給付

所以這個給付重機器

而不重我們的人的心力

這個是安寧

它們現在面對很大的困擾

那政府知道要推在宅善終

可是你假如沒有那麼多人

願意下去做在宅的醫療

你是要怎麼推在宅善終

現在的給付太差了

他們真的是在做功德

真的我們這次其實採訪了很多人

我印象很深的是成大醫院

成大醫院的這個安寧病房

還有法師

然後他們還要

就是還要教鄰居

就是他們下面的診所

有很多診所可以聯合起來一起做

我猜測

這些可能在推廣的過程

也都是做功德

對我再講一個例子就是說

這個病人因為講這個

急性期用呼吸器

急救到底

住了一個月

在加護病房花了一百萬

可是後來家屬知道

醫生也說他不會復原

就轉到宜蘭找陳秀丹醫師

下午四點進來拔掉呼吸器

半夜四點離開第二天辦出院

健保申請的費用是5千塊

他花了這麼多心力

跟家人辦這個陪伴

還有開這個家庭會議

幫他做一個這麼有功德的事情

他跟健保申請費用是5千塊

但是前面你救到底

一個月就花掉1百萬

這就是很奇怪的

很吊詭的一個現象

所以今天其實可以

在今天的這個討論裡面

其實我覺得很謝謝兩位

今天來上我的節目

然後我真的也很

就是把這個過程大概可以理清楚

其實就是對加速死這件事情

台灣的法規還沒有過

然後其實國外表示

覺得是已經是一個人權的問題

其實是可以往前再走一步

但是最現實的問題

其實很基本的事情都還沒有做好

我們的生命教育

其實全台灣的包含醫界的生命教育

還有民眾

還有健保的給付的這個系統

雖然在推了

但是我覺得大家在面臨死亡

這件事情的共識度或討論度

應該是從討論開始

然後才會有共識

應該是嚴重不足的

所以我希望今天

這次我們的這個封面故事

可以把這個議題喚起

那也謝謝兩位參加今天的討論

因為我覺得很有意義的討論

就是也很難得

兩位坐在一起

一個是

你現在不是理事長

是你的現任理事長

發了一個聲明反對斷食善終

但是畢老師還會

我們大家可以坐在一起談

那其實有很多共識就是對於生命

然後對於怎麼樣讓大家活得好

那其實我們在這本裡面講到一個點

就是善終的

一定是善生

就是你前面的階段

一定要做好

你才會有善終的可能性

那包含走到生命階段的人的轉念

很多的事情都要有很大的變化

所以今天再次謝謝兩位醫生

然後來跟我們分享

謝謝

好謝謝謝謝

最後想跟聽眾分享天下學習

Podcast的一個新節目

叫CEO的修煉場

當大環境的快速變化

CEO一定會有迷惘跟掙扎

不用CEO

總編輯就常常迷惘跟掙扎

我想院長也有

但他們其實怎麼樣

這些來上節目的這些CEO

怎麼樣堅持價值跟信念

這個節目是由天下的

共同執行長親自主持

透過跟其他的CEO的真誠交流

給職場的聽眾朋友

一些力量跟啟發

邀請你點擊下方的資訊欄

聽聽CEO們的迷惘跟堅持

我是陳一姍

希望你喜歡今天的決策者聽天下

歡迎給我們五星的評價留言

說說你對節目的想法

下一個節目的更新時間

是11月27號

讓我們下次見也謝謝

再次謝謝兩位醫生

謝謝