The History of Palliative Care姑息關懷史

鄭秀君/譯

British doctor Dame1 Cicely Saunders， founded the modern hospice movement which gave rise to palliative care. In 1948， as a 20-year-old nurse in London， she fell in love with a Polish patient who was dying of cancer. He left her ?500 to start a home or hospital to relieve the physical and emotional suffering of people who were dying. Determined to understand the best ways of controlling pain， Saunders became a doctor， against a backdrop of evolving attitudes to end-of-life care in Britain and America. An active approach was emerging， as people became more aware of the intimate connections between physical and mental states， and sought new， creative ways to care for people until the very end of their lives—and beyond， in the care of the bereaved.

英國醫生西塞莉·桑德斯女爵士發起了現代臨終關懷運動，姑息關懷由此發展而來。1948年，時年20歲的桑德斯在倫敦當護士，她愛上了一位因身患癌癥而生命垂危的波蘭病人。那位病人遺贈給她500英鎊，用于創辦一家療養院或醫院來緩解臨終病患的身心痛苦。桑德斯下定決心要掌握控制疼痛的最佳方法，于是她轉行成為一名醫生。當時，英國人和美國人對臨終關懷的態度逐漸轉變。人們愈發清楚地意識到身心狀態之間存在緊密聯系，進而試圖尋求創新的方法來照護病人直到其生命的最后一刻，并將這些方法延續到對喪親者的關懷。在這樣的背景下，一種積極的療護方法逐漸興起。

In 1967， Saunders opened St Christophers Hospice at Sydenham in south-east London， believing passionately that with the right care， the last days of a persons life could be made dignified and happy. She said： “I once asked a man who knew he was dying what he needed above all in those who were caring for him. He said， ‘For someone to look as if they are trying to understand me. It is impossible to understand fully another person， but I never forgot that he did not ask for success but only that someone should care enough to try.”

1967年，桑德斯在位于倫敦東南部的錫德納姆創建了圣克里斯托弗臨終關懷醫院。她堅信，在恰當的照護下，一個人生命的最后時光也可以過得有尊嚴，過得很快樂。桑德斯說：“我曾問過一個知道自己時日不多的人，問他最需要從照護他的人那里得到什么。他答道：‘最需要有人能讓我覺得他們在試著理解我。完全理解另一個人是不可能的，而我永遠不會忘記，他也不要求有人能完全理解他，他要的只是有人愿意試著理解他。”

Beating total pain

抗擊全方位疼痛

Saunders built a life-affirming phil-osophy around the belief that dying is “as natural as being born”， and death should be free from suffering and pain. By listening carefully to patients stories of illness， disease and suffering， Saunders evolved the concept of “total pain”， which includes not just the physical but also social， emotional and spiritual aspects of suffering. Her approach to pain management was simple： constant pain needs constant control. Analgesics were to be given regularly to prevent pain， rather than alleviate it， and they should be used progressively as needed—from mild through to strong. Each patients needs were individual and specific， and their care was to be developed accordingly， with support extended to their family and carers. “You matter because you are you， and you matter to the last moment of your life，” Saunders is famed for saying.

桑德斯相信死亡是“和出生一樣自然的過程”，而且死亡應該是沒有折磨和疼痛的。基于這個信念，她構建出一套肯定生命價值的理念。她仔細傾聽病人講述疾病與痛苦，提出了“全方位疼痛”的概念。這一概念不僅涉及軀體疼痛，還包括社會、情感以及精神方面的痛苦。桑德斯管理疼痛的方法很簡單：疼痛不止，控制不停。鎮痛藥應該定期使用以預防疼痛，而不是緩和疼痛，還要按照需求逐步調整劑量（從小劑量到大劑量）。每個病人都有個性化的特定需求，因此療護方案會根據病人的情況來制訂，還會為病人家屬和照護者提供支持。桑德斯有句名言：“你很重要，因為你就是你，即使在生命的最后一刻，你依然很重要。”

The speciality of palliative medicine was first recognised in the UK in 1987—a key moment in the wider shift away from “terminal” care towards the concept of palliative care. Alongside the realisation that the benefits of holistic palliative care should be expanded to those with life-limited diseases other than cancer， the impetus emerged to move palliative care to earlier stages in disease progression， integrating it with curative and rehabilitation. The vision of “palliative care for all” emerged as both desirable and achievable.

1987年，英國最先認可姑息關懷為醫學專科——這是從“臨終”關懷向姑息關懷充分轉變的關鍵時刻。人們意識到，應該讓整體性姑息關懷惠及身患癌癥以外其他絕癥的病人。與此同時，人們開始希望將姑息關懷更多地應用于疾病進展的早期階段，將其與治療和康復結合。“為所有人提供姑息關懷”成為既“渴求”又“可求”的愿景。

A global movement

一場全球性運動

The difference palliative care makes to the lives of patients and their families and carers is radical， so its easy to see why palliative care took off and is now an accepted integral part of health care policies globally. St Christophers Hospice quickly became an inspiring model for others， differing significantly from earlier homes for people nearing death by taking a three-pronged approach， combining excellent clinical care， education and research. The success of this approach fuelled palliative care development worldwide， firstly in affluent countries， then in poorer ones too， with Zimbabwes Island Hospice Service （founded in 1979） considered to be the first in a developing country.

姑息關懷能給病人及其家屬和照護者的生活帶來巨大變化，由此不難看出姑息關懷為何能迅速發展，又為何能成為當今世界各地醫療政策中公認的必要組成部分。圣克里斯托弗臨終關懷醫院迅速成為啟發同行的典范。這家醫院與早期為臨終病患設立的療養院明顯不同，采用三管齊下的策略，將頂尖的臨床護理、教學、研究結合起來。該策略的成功刺激了姑息關懷在全球的發展，先是在富裕國家，隨后是在經濟較落后的國家。1979年成立于津巴布韋的艾蘭臨終關懷服務中心被認為是發展中國家的首個姑息關懷機構。

Today there are more than 8，000 hospices working around the world， and many more specialist palliative care units in hospitals. But the principles of hospice care are also practised in many different settings， such as home-based and day-care services. There are also many successful mentoring and twinning arrangements between hospices and palliative care services in developing countries and their counterparts in the West.

今天，全世界已有超過8000家臨終關懷醫院，綜合醫院里還有更多專業的姑息關懷科室。臨終關懷的原則也在其他諸多場景中得到應用，比如居家護理和日間護理服務。此外，發展中國家的臨終關懷醫院和姑息關懷服務中心也與西方同行締結了許多成功的指導協議和結對合作協議。

Ongoing expansion

持續發展

Pioneers of palliative care have worked tirelessly to promote and develop Saunderss approach. Driven by common goals， they have built collaborative networks on national， regional and international levels， and won committed backing from key bodies such as the World Health Organisation. Its now widely accepted that medical specialisation， the integration of palliative care into mainstream health systems and the development of evidence-based practices are crucial to the ongoing reduction of suffering in people with life-limiting illnesses.

姑息關懷的開拓者們不辭辛勞地推廣和改進桑德斯的方法。在共同目標的驅動下，他們在國家、地區和國際層面建立了合作關系網，并且獲得了世界衛生組織等重要機構的鼎力支持。現在，人們普遍認為，醫學專科化、將姑息關懷納入主流醫療體系、發展循證醫學，這三者對持續減輕絕癥患者的痛苦至關重要。

The World Health Organisation in 2012 estimated that over 40 million people needed palliative care and that with proper palliative care， the suffering of these people could be prevented. With people living in vast swathes2 of the world still unable to access any sort of palliative care， its vital that the expansion continues.

2012年，世界衛生組織估計有超過4000萬人需要姑息關懷，并稱恰當的姑息關懷能讓他們免受痛苦。由于世界上大多數地區的人們仍然沒有途徑得到任何形式的姑息關懷，繼續擴大姑息關懷的惠及范圍至關重要。

（譯者為“《英語世界》杯”翻譯大賽獲獎者；單位：中山大學）