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TEDxNewy

Peter Saul: Let's talk about dying

ピーター・サウル:死に方を話し合おう

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Views 884,921

「死ぬこと自体は変えられないが、『死を占拠』することはできる」というのはピーター・サウル博士の言葉です。終末期医療について希望を明確にすることを勧め、そのきっかけとなる2つの問いかけを提案しています。(TEDxNewy にて収録)

- Doctor, intensive care specialist
Over the past 35 years Peter Saul has been intimately involved in the dying process for over 4,000 patients. He is passionate about improving the ways we die. Full bio

Look, I had second thoughts, really,
実はかなり迷いました
00:16
about whether I could talk about this
皆さんのような元気な人達を前に
00:18
to such a vital and alive audience as you guys.
こんな話をしてもいいものか
00:20
Then I remembered the quote from Gloria Steinem,
グロリア・スタイネムの 言葉です
00:23
which goes,
グロリア・スタイネムの 言葉です
00:26
"The truth will set you free,
「真実は貴方を解放する
00:27
but first it will piss you off." (Laughter)
しかし その前に
まず貴方を怒らせるだろう」
00:29
So -- (Laughter)
ということで(笑)
00:33
So with that in mind, I'm going to set about
それを念頭において お話しするのは
00:35
trying to do those things here,
それを念頭において お話しするのは
00:38
and talk about dying in the 21st century.
21世紀の死です
00:39
Now the first thing that will piss you off, undoubtedly,
腹の立つ真実の一つ目は
00:41
is that all of us are, in fact, going to die
私達はみんな21世紀中に
00:43
in the 21st century.
死ぬこと
00:46
There will be no exceptions to that.
例外はありません
00:47
There are, apparently, about one in eight of you
調査によると8人に一人は
00:50
who think you're immortal, on surveys, but --
不死身だと思っていますが
00:52
(Laughter)
(笑)
00:55
Unfortunately, that isn't going to happen.
残念ながら
そういう訳には行きません
00:57
While I give this talk, in the next 10 minutes,
今から10分間
私が話す間にも
01:01
a hundred million of my cells will die,
1億もの細胞が死んでいき
01:03
and over the course of today, 2,000 of my brain cells
今日中に2千の脳細胞が
01:07
will die and never come back,
死んでしまうので
01:09
so you could argue that the dying process
死の過程は早くから 始まると言えます
01:11
starts pretty early in the piece.
死の過程は早くから 始まると言えます
01:13
Anyway, the second thing I want to say about dying in the
21世紀の死について
2つ目は
01:16
21st century, apart from it's going to happen to everybody,
死は不可避である上に
01:18
is it's shaping up to be a bit of a train wreck
やや悲惨な様相を 呈していることです
01:20
for most of us,
やや悲惨な様相を 呈していることです
01:23
unless we do something to try and reclaim this process
容赦ない軌道に乗っている
死の過程を
01:25
from the rather inexorable trajectory that it's currently on.
改善しなければならない
01:28
So there you go. That's the truth.
それが真実です
01:32
No doubt that will piss you off, and now let's see
頭には来ますが
01:33
whether we can set you free. I don't promise anything.
自由にはなれるでしょうか
01:35
Now, as you heard in the intro, I work in intensive care,
集中治療が私の仕事です
01:38
and I think I've kind of lived through the heyday
集中治療の全盛期を経験しました
01:40
of intensive care. It's been a ride, man.
色々なことがあって
01:44
This has been fantastic.
最高でした
01:46
We have machines that go ping.
モニターとか音の鳴る機械が
01:47
There's many of them up there.
たくさんある職場です
01:48
And we have some wizard technology which I think
すごい技術のおかげで
01:50
has worked really well, and over the course of the time
私が働き始めてから
01:53
I've worked in intensive care, the death rate
オーストラリア男性の死亡率が
01:55
for males in Australia has halved,
半減しました
01:58
and intensive care has had something to do with that.
集中治療の成果です
02:00
Certainly, a lot of the technologies that we use
さまざまな技術を駆使した
02:02
have got something to do with that.
おかげでもあります
02:04
So we have had tremendous success, and we kind of
大変な成功を収めて
02:06
got caught up in our own success quite a bit,
すっかり浮かれてしまい
02:08
and we started using expressions like "lifesaving."
「救命」などという言葉を
使い始めてしまいました
02:11
I really apologize to everybody for doing that,
誤解を招いたことを
02:14
because obviously, we don't.
お詫びします
02:16
What we do is prolong people's lives,
私達がするのは延命で
02:18
and delay death,
死を先延ばしにし
02:20
and redirect death, but we can't, strictly speaking,
遠回りさせる事は出来ても
02:22
save lives on any sort of permanent basis.
永続的な救命は
できないのです
02:25
And what's really happened over the period of time
集中治療で働いていて
02:28
that I've been working in intensive care is that
目の当たりにしていることですが
02:30
the people whose lives we started saving back in the '70s,
70年代から90年代にかけて
02:33
'80s, and '90s, are now coming to die in the 21st century
私達が命を救った人達は
21世紀になって
02:36
of diseases that we no longer have the answers to
当時とは違う
解決策のない病気で
02:41
in quite the way we did then.
死んでいこうとしています
02:44
So what's happening now is there's been a big shift
人の死に方に
大きな変化が
02:47
in the way that people die,
起きているのです
02:49
and most of what they're dying of now isn't as amenable
現在の死因の多くは
02:50
to what we can do as what it used to be like
80年代や90年代のように
02:53
when I was doing this in the '80s and '90s.
治療が可能なものではありません
02:56
So we kind of got a bit caught up with this,
この対応に追われていて
02:59
and we haven't really squared with you guys about
いま何が起こっているのか
03:02
what's really happening now, and it's about time we did.
きちんと説明していませんでした
03:05
I kind of woke up to this bit in the late '90s
90年代後半にこの人に出会って
03:09
when I met this guy.
目が覚めました
03:13
This guy is called Jim, Jim Smith, and he looked like this.
彼の名前は
ジム・スミスといいます
03:15
I was called down to the ward to see him.
細い方が彼の手です
03:19
His is the little hand.
彼の様子を見るよう
03:22
I was called down to the ward to see him
呼吸科医に
03:24
by a respiratory physician.
呼ばれました
03:25
He said, "Look, there's a guy down here.
「肺炎に罹った患者がいる
03:26
He's got pneumonia,
「肺炎に罹った患者がいる
03:28
and he looks like he needs intensive care.
集中治療が必要だ
03:30
His daughter's here and she wants everything possible
娘さんは あらゆる手を
03:33
to be done."
尽くしてくれと言っている」
03:35
Which is a familiar phrase to us.
私達には聞き慣れた言葉です
03:37
So I go down to the ward and see Jim,
病室に様子を見に行くと
03:40
and his skin his translucent like this.
皮膚が透けて
03:42
You can see his bones through the skin.
骨が見えるほどです
03:43
He's very, very thin,
やせ細って
03:46
and he is, indeed, very sick with pneumonia,
重度の肺炎に罹っていました
03:47
and he's too sick to talk to me,
話は無理なので
03:50
so I talk to his daughter Kathleen, and I say to her,
娘のキャスリーンに向かって
こう聞きました
03:52
"Did you and Jim ever talk about
「こういう状況になった時
03:57
what you would want done
どうしたいのか
04:00
if he ended up in this kind of situation?"
話し合ったことは?」
04:02
And she looked at me and said, "No, of course not!"
彼女は私を見て
「ある訳ないでしょう!」
04:04
I thought, "Okay. Take this steady."
「落ち着かせなきゃ」と思いました
04:07
And I got talking to her, and after a while, she said to me,
しばらくして
彼女はこう言いました
04:13
"You know, we always thought there'd be time."
「まだ先のことだと思ってた」
04:15
Jim was 94. (Laughter)
ジムは94歳でした
(笑)
04:18
And I realized that something wasn't happening here.
それで気づきました
何かが欠けている
04:22
There wasn't this dialogue going on
あるはずの
04:25
that I imagined was happening.
対話が持たれていない
04:26
So a group of us started doing survey work,
そこで調査を始めて
04:29
and we looked at four and a half thousand nursing home
ニューカッスル周辺の
04:32
residents in Newcastle, in the Newcastle area,
養護施設に住む
4,500人に当たりました
04:34
and discovered that only one in a hundred of them
心停止の際のプランがあるのは
04:37
had a plan about what to do when their hearts stopped beating.
100人のうち1人だけでした
04:40
One in a hundred.
100人中1人ですよ
04:43
And only one in 500 of them had plan about what to do
重体になった際
どうするか考えている人は
04:44
if they became seriously ill.
500人中たったの1人だけ
04:48
And I realized, of course, this dialogue
この対話は社会全般では
04:51
is definitely not occurring in the public at large.
全くなされていない
と気がつきました
04:54
Now, I work in acute care.
現職は救急医療です
04:58
This is John Hunter Hospital.
ジョン・ハンター病院です
05:00
And I thought, surely, we do better than that.
我々の病院ではこんなはずではないと
05:02
So a colleague of mine from nursing called Lisa Shaw and I
同僚のリサ・ショウと一緒に
05:06
went through hundreds and hundreds of sets of notes
何百もの診療記録を
05:09
in the medical records department
調べました
05:11
looking at whether there was any sign at all
受けている治療が効かず
05:13
that anybody had had any conversation about
死ぬ可能性がある場合
05:15
what might happen to them if the treatment they were
患者の希望を話し合ったような
05:18
receiving was unsuccessful to the point that they would die.
会話の記録を探しましたが
05:19
And we didn't find a single record of any preference
医師や患者が始めた記録の
どこにも
05:23
about goals, treatments or outcomes from any
目標や治療や成果についての
05:26
of the sets of notes initiated by a doctor or by a patient.
希望は一つも
書いてありませんでした
05:30
So we started to realize
これは問題だと
05:34
that we had a problem,
やっと気づきました
05:37
and the problem is more serious because of this.
問題は更に深刻です
というのも
05:39
What we know is that obviously we are all going to die,
誰でも死ぬ事は知っていますが
05:44
but how we die is actually really important,
死に方も大切だからです
05:47
obviously not just to us, but also to how that
本人だけでなく 
先立たれた人達の
05:50
features in the lives of all the people who live on afterwards.
人生にも影響するからです
05:54
How we die lives on in the minds of everybody
残された人達の心に
05:57
who survives us, and
死に様が生き続けるのです
05:59
the stress created in families by dying is enormous,
死による
家族のストレスは甚大で
06:02
and in fact you get seven times as much stress by dying
集中治療室で死ぬ場合のストレスは
06:06
in intensive care as by dying just about anywhere else,
他で死ぬ場合の7倍です
06:09
so dying in intensive care is not your top option
選べるなら 集中治療室では
06:11
if you've got a choice.
死なない方がいい
06:14
And, if that wasn't bad enough, of course,
ところが残念ながら
06:17
all of this is rapidly progressing towards the fact that
集中治療室で死ぬ人は
急速に増えていて
06:19
many of you, in fact, about one in 10 of you at this point,
10人に一人は集中治療室で
06:22
will die in intensive care.
死ぬことになりそうです
06:24
In the U.S., it's one in five.
アメリカでは
06:26
In Miami, it's three out of five people die in intensive care.
5人に一人
マイアミは5人に3人
06:27
So this is the sort of momentum
そういう勢いです
06:31
that we've got at the moment.
これが現状です
06:33
The reason why this is all happening is due to this,
その理由はこれです
06:35
and I do have to take you through what this is about.
説明しましょう
06:37
These are the four ways to go.
4つの死に方です
06:39
So one of these will happen to all of us.
誰もがこの一つで死にます
06:41
The ones you may know most about are the ones
よくご存知なのは
06:44
that are becoming increasingly of historical interest:
その重要性が
過去のものとなりつつある
06:46
sudden death.
突然死でしょう
06:49
It's quite likely in an audience this size
ここにいる位の人数だと
06:50
this won't happen to anybody here.
突然死する人はいません
06:52
Sudden death has become very rare.
突然死は稀になりました
06:54
The death of Little Nell and Cordelia and all that sort of stuff
悲劇のヒロインのような死は
06:56
just doesn't happen anymore.
もう起きません
06:59
The dying process of those with terminal illness
この末期疾患の
07:00
that we've just seen
死に方は
07:03
occurs to younger people.
若い人に多く
07:04
By the time you've reached 80, this is unlikely to happen to you.
80歳以上では少ないです
07:05
Only one in 10 people who are over 80 will die of cancer.
80歳以上で癌で死ぬのは
10人に一人だけ
07:08
The big growth industry are these.
大幅に増加している
死因はこちらです
07:12
What you die of is increasing organ failure,
臓器不全で死ぬ人が増えています
07:16
with your respiratory, cardiac, renal,
呼吸器 心臓 腎臓など
07:20
whatever organs packing up. Each of these
臓器の機能が止まったら
07:22
would be an admission to an acute care hospital,
救急病院に入院です
07:24
at the end of which, or at some point during which,
そして もう十分だと言われるまで
07:26
somebody says, enough is enough, and we stop.
治療を続けます
07:28
And this one's the biggest growth industry of all,
そして これが最大の成長分野
07:30
and at least six out of 10 of the people in this room
今日お集まりの10人中6人は
07:33
will die in this form, which is
これが理由で死にます
07:36
the dwindling of capacity
衰弱がひどくなることに伴う
07:38
with increasing frailty,
身体能力の衰えです
07:42
and frailty's an inevitable part of aging,
衰えは老化において
避けられませんが
07:44
and increasing frailty is in fact the main thing
だんだん衰弱することが
07:47
that people die of now,
現代人の主な死因です
07:49
and the last few years, or the last year of your life
残念ながら晩年は
07:50
is spent with a great deal of disability, unfortunately.
かなりの障害をもって
過ごすことになります
07:52
Enjoying it so far? (Laughs)
楽しんでます?(笑)
07:56
(Laughter)
(笑)
08:00
Sorry, I just feel such a, I feel such a Cassandra here.
悲劇の預言者みたいな気分だ
08:03
(Laughter)
(笑)
08:06
What can I say that's positive? What's positive is
明るい話をしましょう
08:11
that this is happening at very great age, now.
衰弱するほど高齢まで
08:13
We are all, most of us, living to reach this point.
長生きする人が多いということです
08:15
You know, historically, we didn't do that.
昔は違いました
08:18
This is what happens to you
長生きすれば
08:20
when you live to be a great age,
こういう死に方になるのです
08:21
and unfortunately, increasing longevity does mean
延びるのは老年期だけで
08:24
more old age, not more youth.
若年期は増えません
08:25
I'm sorry to say that. (Laughter)
残念な事ですが(笑)
08:27
What we did, anyway, look, what we did,
私たち病院などの関係者は
08:33
we didn't just take this lying down
死についての問題を
08:35
at John Hunter Hospital and elsewhere.
見過ごしませんでした
08:37
We've started a whole series of projects
不測の事態の備えに
08:38
to try and look about whether we could, in fact, involve
もっと関わってもらおうと
08:40
people much more in the way that things happen to them.
一連のプロジェクトを
始めました
08:43
But we realized, of course, that we are dealing
もちろん
08:46
with cultural issues,
文化上の問題も承知でした
08:48
and this is, I love this Klimt painting,
クリムトの絵です
08:50
because the more you look at it, the more you kind of get
よく見ると 本質的なことが
08:52
the whole issue that's going on here,
描かれています
つまり―
08:54
which is clearly the separation of death from the living,
生と死は
はっきり分かれるということ
08:56
and the fear — Like, if you actually look,
そして恐怖
09:00
there's one woman there
目を開けた
09:01
who has her eyes open.
女性がいます
09:03
She's the one he's looking at,
死神は彼女を
09:05
and [she's] the one he's coming for. Can you see that?
狙っています
見えますか?
09:06
She looks terrified.
彼女は怯えている
09:10
It's an amazing picture.
素晴らしい絵です
09:11
Anyway, we had a major cultural issue.
ともかく文化上の理由で
09:13
Clearly, people didn't want us to talk about death,
人は死の話を聞きたがらない
09:15
or, we thought that.
そう予想しました
09:17
So with loads of funding from the Federal Government
そこで政府と公共医療機関から
09:18
and the local Health Service, we introduced a thing
予算をもらい
09:20
at John Hunter called Respecting Patient Choices.
我々の病院で
事前ケア計画を導入しました
09:22
We trained hundreds of people to go to the wards
研修を受けた数百人が
09:25
and talk to people about the fact that they would die,
病棟を訪ね
患者たちに死の話をして
09:28
and what would they prefer under those circumstances.
終末期の希望を聞きました
09:31
They loved it. The families and the patients, they loved it.
患者も家族も大変喜びました
09:33
Ninety-eight percent of people really thought
98%がこれを
普通の診療として
09:36
this just should have been normal practice,
あるべき形と
09:39
and that this is how things should work.
思ってくれました
09:40
And when they expressed wishes,
伝えられた希望は
09:43
all of those wishes came true, as it were.
全て叶いました
09:45
We were able to make that happen for them.
実現できたのです
09:47
But then, when the funding ran out,
しかし予算が底をつき
09:49
we went back to look six months later,
半年後に確認したら
09:51
and everybody had stopped again,
打ち切りになっていました
09:53
and nobody was having these conversations anymore.
誰もこの対話をしなくなり
09:55
So that was really kind of heartbreaking for us,
とても残念なことでした
09:58
because we thought this was going to really take off.
うまくいくと思ったのに
10:01
The cultural issue had reasserted itself.
死を嫌う文化の問題は
根強かったんです
10:03
So here's the pitch:
本題です
10:07
I think it's important that we don't just get on this freeway
ICU行きの高速に
乗ってもいいのか
10:08
to ICU without thinking hard about whether or not
真剣に考えることが
10:12
that's where we all want to end up,
とても大切です
10:15
particularly as we become older and increasingly frail
老い衰えるほど
10:17
and ICU has less and less and less to offer us.
ICUで出来る事は少ないのです
10:19
There has to be a little side road
その道を望まない
10:23
off there for people who don't want to go on that track.
人達のための
横道がないといけません
10:25
And I have one small idea,
将来に関して 私には
10:29
and one big idea about what could happen.
小さいアイデアと
大きなアイデアがあります
10:32
And this is the small idea.
小さい方は
10:36
The small idea is, let's all of us
ジェイソンの提案のように
10:37
engage more with this in the way that Jason has illustrated.
ローテクな方法で
参加しましょう
10:40
Why can't we have these kinds of conversations
こういう会話を
10:44
with our own elders
お年寄りや
10:46
and people who might be approaching this?
死が近い人と持ちましょう
10:48
There are a couple of things you can do.
できる事が2つ
10:50
One of them is, you can,
1つ目はシンプルで
10:52
just ask this simple question. This question never fails.
誰でもできる
失敗のない問いかけです
10:54
"In the event that you became too sick to speak for yourself,
「重体で意思伝達が
できなくなったら
10:57
who would you like to speak for you?"
誰に代弁してほしいですか?」
11:01
That's a really important question to ask people,
大事な質問です
11:04
because giving people the control over who that is
誰に代弁を頼むかという決定権を
11:06
produces an amazing outcome.
本人が持つことで
結果が違ってきますからね
11:08
The second thing you can say is,
2つ目は
11:11
"Have you spoken to that person
「何が大切か
11:12
about the things that are important to you
私達にも伝わるよう
11:14
so that we've got a better idea of what it is we can do?"
代弁者の方に
言い残してありますか?」
11:16
So that's the little idea.
それが小さいアイデアです
11:20
The big idea, I think, is more political.
大きい方は
11:22
I think we have to get onto this.
皆で力を合わせて
11:24
I suggested we should have Occupy Death.
「死を占拠」するべきです
11:26
(Laughter)
(笑)
11:29
My wife said, "Yeah, right, sit-ins in the mortuary.
妻は「あーはいはい
11:32
Yeah, yeah. Sure." (Laughter)
死体安置所で座り込みね」(笑)
11:34
So that one didn't really run,
そうは行きませんでしたが
11:37
but I was very struck by this.
ピンと来ました
11:39
Now, I'm an aging hippie.
実は 私はヒッピーです
11:40
I don't know, I don't think I look like that anymore, but
この歳ではそう見えないでしょうが
11:42
I had, two of my kids were born at home in the '80s
うちの子達は
80年代に 当時話題だった
11:45
when home birth was a big thing, and we baby boomers
自宅出産で生まれました
ベビーブーマー世代なので
11:47
are used to taking charge of the situation,
何でも自分主導でやりたくて
11:51
so if you just replace all these words of birth,
あの頃の「誕生」を
「死」に置き換えるわけです
11:53
I like "Peace, Love, Natural Death" as an option.
「平和 愛 自然死」
なんていいと思います
11:57
I do think we have to get political
現行の医療重視の
12:00
and start to reclaim this process from
モデルからプロセスを
12:01
the medicalized model in which it's going.
取り戻すべきです
12:04
Now, listen, that sounds like a pitch for euthanasia.
安楽死肯定に聞こえるが
12:06
I want to make it absolutely crystal clear to you all,
はっきり言います
12:08
I hate euthanasia. I think it's a sideshow.
安楽死は大嫌いです
12:10
I don't think euthanasia matters.
実際大した問題でもないと
12:13
I actually think that,
思っています
12:15
in places like Oregon,
医師のほう助による
12:17
where you can have physician-assisted suicide,
自殺ができる
オレゴン州でも
12:20
you take a poisonous dose of stuff,
毒を摂取するのは
12:23
only half a percent of people ever do that.
0.5%の人だけです
12:25
I'm more interested in what happens to the 99.5 percent
99.5%は
それを望まなかった
12:27
of people who don't want to do that.
私はそちらに興味があります
12:30
I think most people don't want to be dead,
人は死にたくないが
12:32
but I do think most people want to have some control
自分の死の過程は
12:34
over how their dying process proceeds.
自分でコントロールしたい
12:36
So I'm an opponent of euthanasia,
安楽死には反対です
12:39
but I do think we have to give people back some control.
本人に決定権を戻すべきです
12:40
It deprives euthanasia of its oxygen supply.
そうすることで
安楽死を廃止するのです
12:43
I think we should be looking at stopping
安楽死が必要だという考えを
12:46
the want for euthanasia,
安楽死が必要だという考えを
12:47
not for making it illegal or legal or worrying about it at all.
なくすべきです
違法か合法かは問題ではありません
12:48
This is a quote from Dame Cicely Saunders,
学生の時に出会った
シシリー・ソンダース博士の
12:53
whom I met when I was a medical student.
言葉です
12:57
She founded the hospice movement.
ホスピス活動創始者です
12:58
And she said, "You matter because you are,
「貴方は貴方ゆえ大切なのです
13:01
and you matter to the last moment of your life."
貴方の人生の
最後の瞬間まで大切です」
13:03
And I firmly believe that
このメッセージを
13:06
that's the message that we have to carry forward.
推進すべきと
固く信じています
13:08
Thank you. (Applause)
ありがとう(拍手)
13:11
Translated by Kyoko Florendo
Reviewed by Emi Kamiya

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About the speaker:

Peter Saul - Doctor, intensive care specialist
Over the past 35 years Peter Saul has been intimately involved in the dying process for over 4,000 patients. He is passionate about improving the ways we die.

Why you should listen

Dr. Peter Saul is a Senior Intensive Care specialist in the adult and pediatric ICU at John Hunter Hospital, and Director of Intensive Care at Newcastle Private Hospital in Australia.  After spending time as the Head of Discipline for Medical Ethics at Newcastle University, he is now a leading adviser to the State and Federal health departments.

More profile about the speaker
Peter Saul | Speaker | TED.com