慢慢老去是每个生命必须面对的事件，但并不意味着我们都能如智者一样优雅的直面它。事实上，当衰老临近，当事者多已不具备健全的心智，从而让这一进程变成了一个无法独自从容应对的社会学问题。

在今天世界上，科学技术风头无限，科技赋予了现代医学很多神奇的力量。然而，现代医学在处理衰老和死亡上并没有做的贴心、贴切。我们往往滥用了现代医学的力量，将奋斗聚焦在延长生命上，在某种程度上说，是现代医学技术和医疗队伍让生命苟延残喘，屈辱且无人道的挣扎在躯壳与灵魂决裂的痛苦中。

我们习惯于迷信专家的力量，并不是专家没有力量，是我们投错了门子，体面的衰老与死亡不是单靠医疗系统所能保证的。

Atul Gawande所著《Being Mortal》是一本智者的思考，下文翻译一份对Atul Gawande所著《Being Mortal》的评论。让我们一起思考是否应该还衰落和死亡以原貌，在更精神的层面上着眼，归还人文和宗教在其中的地位。

读内部人士讲述医生和老年照护系统对老年人和垂死者处理上的失败感受，Linda Geddes深有感触，从来写下如下评论。

Atul Gawande所著Being Mortal使我整个星期都在流泪，生气，并情不能禁要谈起这一话题。

Gawande的中心论点是从二十世纪中叶起，死亡渐渐转变成为一种医学体验，而多数大夫并没有受到很好的训练来应对这一转变。事实证明这一庞大的实验正在走向失败。正如Gawande所言，如果伴随死亡的医学问题不能够通过医药克服，滥用医药干预将只会招来“无情、残暴和非常的苦难”。

这本书是召唤行动的号角—重新审视生命的意义，包括如何让老年人和病危者活出生命的价值。Gawande指出，要让老年生活更有意义，需要对当前医学和护理学进行一次根本性变革。伴随着2050年美国和欧洲超过65岁人口将比现今翻倍这一严峻形势，这一定时炸弹需要尽快拆除其引爆装置。

当我与一位低年资大夫讨论这本书时，他给我讲述了一次夜班的经历。一位病危者的呼吸降到每分钟三次—可能是为减轻病人疼痛所用吗啡的作用。面对此景，可应对的手段何其凄凉：要么使用药物逆转吗啡的作用，即便是病人很可能已经因低氧而出现不可逆的脑损伤；要么让他（病人先前已经要求不要对他尝试复苏措施）死去。我这位大夫朋友的上司选择了逆转吗啡的作用，但病人还是很快辞世了。

Being Mortal一书中满是此类案例。Gawande自己家庭成员的生死故事构成了这本书的重要叙事情节。作者描述自己的父亲老Gawande如何与脊髓和脑干肿瘤抗争，例如，老Gawande选择手术来降低瘤负荷，而拒接化疗以保持其头脑的思维不受影响。这并非窥伺癖对经历的记述。作为一个外科医生，Gawande自己有充足的素材证明医学院校在训练大夫面对他们垂死病人方面的准备是多么的不足。作者承认自己曾回避这一问题，其所提供的介入式医学程序并没有让病人感到从中受益的现实。

当讨论患不治之症的病人时，Gawande在描述衰老上不惜笔墨，揭示多数大夫常感觉不堪重负，不愿意护理身患多种疾病的老年患者。他认为老年医学专家可提供给实习医生关键的培训课程：关于如何倾听，区分优先次序和介入，通常是通过一些诸如如何活力腿脚以减少摔倒跌伤之类的简单措施，使老年人能保持自理能力。

Gawande常驱动读者去独立思考这些问题，在后文提供答案前让我们思考面对困境如何做出艰难选择，诸如是否让衰老体弱的老年亲人进入匿名机构(让他们在生命的最终时刻面对除了他们的姓名外再无所知的医生和护士们)。在这些让人焦虑的情节中，作者也提供一些历史故事：养老院（Nursing homes）起源于1950年代的美国，用于为正在康复中的病人提供照护，以减轻医院床位压力，并不是为老年人设计以解决其看护问题的长久之计。

Gawande描述位于纽约New Berlin的Chase Memorial养老院在1991年买进了两条狗，四只猫，一百只长尾鹦鹉，一窝兔子和一群鸡，并鼓励养老院的老人照料它们，还建了种植鲜花和蔬菜的花园和职工婴儿看护中心。照看宠物，花园，与孩子交往对老年人大有裨益。Gawande讲述在两年内，老年人所开抓药处方下降到只有临近养老院一半的水平。其它研究也表明豢养宠物有益于心血管并增强社交。Gawande还描述位于马萨诸塞Reading的一处叫Peter Sanborn Place的低收入公寓大楼：那里的侍从，物理治疗师和拜访护士协助老年人洗衣，购物和清洁。

我对这本书的批评之一是Gawande并没有真正感受到这类创新型社区在更大尺度上推广需要多少资金的支持，即没有讨论照护的经济成本。以Peter Sanborn Place为例，它在州财政取得部分资金，但主要是依靠慈善捐赠。这本书也没有涉及养老院中的看护失职事件，或对养老院中弱势老人的故意虐待事件。2012年，国会研究发现美国三分之一的养老院中存在多项严重身体，性和言语虐待事件。

尽管有诸多缺点，却鲜有能如此书触人深思者。对我，此书开启了一扇与近亲讨论他们如何度过晚年的门—无论开头何其艰难，这种对话却注定要进行。

上文作者为Linda Geddesis，Linda Geddesis为英国布里斯托尔自由撰稿的科学作家，New Scientist杂志顾问。e-mail: lindaged@yahoo.com，该文发表在nature上，原文链接http://www.nature.com/nature/journal/v514/n7521/full/514167a.html

Gerontology: Ageing more gracefully

Linda Geddes is moved by an insider’s take on how doctors and geriatric-care systems are failing old people and the dying.

Atul Gawande's Being Mortal left me tearful, angry and unable to stop talking about it for a week. Gawande's central argument is this: since the mid-twentieth century, death has been progressively transformed into a medical experience that the majority of doctors are ill-equipped to deal with. The evidence shows that this giant experiment is failing. As Gawande notes, when the medical problems of the dying cannot be fixed by medicine, “callousness, inhumanity, and extraordinary suffering” can result.

This book is a call to action — a reconsideration of what makes life worth living and how all, including elderly people and those with terminal illnesses, can find access to that. Making old age meaningful, Gawande shows, demands a massive shake-up in medical and nursing care. With the number of over-65s in the United States and Europe expected to double by 2050, this is a time bomb that we need to defuse fast.

When I discussed the book with a junior-doctor friend, he related an episode from a night shift. A terminally ill patient's breathing had dropped to three breaths per minute — possibly as a result of morphine given for pain relief. The choice was stark: administer a drug to reverse the morphine, even though the patient's brain was probably irreversibly damaged from low oxygen intake, or leave the man (who had asked not to be resuscitated) to die. My friend's supervisor stepped in and reversed the morphine; the man ultimately died soon afterwards anyway.

Being Mortal is filled with case studies similar to this. The lives and deaths of various members of Gawande's own family provide the book's overarching narrative. Gawande describes his father's struggle with cancer of the spinal cord and brainstem, for instance, and how Gawande senior opted for surgery to reduce the size of the tumour, avoiding chemotherapy to preserve his mental clarity. But this is no voyeuristic tour. A surgeon himself, Gawande is eloquent about the inadequacy of medical school in preparing doctors to confront the subject of death with their patients. He admits to having skirted around the issue himself, offering invasive medical procedures with little chance of benefit to make the patient feel that he is doing something.

As well as discussing realities for people with terminal illnesses, Gawande dwells on ageing, revealing that many doctors dislike caring for elderly people with multiple health issues, and often find it overwhelming. Geriatricians, he suggests, can offer key lessons to other medics about listening, prioritizing and intervening to enable elderly people to maintain independence, often through simple interventions such as foot care to reduce chances of falling.

Gawande often forces readers to reflect on the issues ourselves. He sets us up to ask our own questions about common dilemmas — such as putting frail elderly relatives into anonymous facilities — before offering answers pages later. Apropos of that vexed phenomenon, among others, he also offers historical context. Nursing homes, he shows, originated in the United States in the 1950s to ease pressure on hospital beds by providing care for recovering patients. They were not designed as a long-term solution for elderly people.

Gawande challenges the idea that the standard US or UK care-home model is the only available choice. He describes the Chase Memorial Nursing Home in New Berlin, New York, which in 1991 brought in 2 dogs, 4 cats, 100 parakeets, a colony of rabbits and a flock of hens, and encouraged residents to care for them. It also established a flower and vegetable garden and on-site childcare for staff. Pet care, gardening and social interaction with the young offer significant benefits, Gawande suggests: within two years, the number of prescriptions per resident fell to half that of a control home nearby. Other studies suggest that pet ownership confers better cardiovascular health and boosts social interaction, for example. Gawande also describes a low-income apartment complex, Peter Sanborn Place in Reading, Massachusetts, where aides, physical therapists and visiting nurses help the ageing residents to assist with laundry, shopping and cleaning.

One criticism I have of the book is that Gawande does not really touch on how such innovative communities could be funded on a larger scale, or discuss the economics of nursing care. Peter Sanborn Place, for instance, gets some state funding but relies mostly on charitable donations. Nor does the book address issues of neglect in nursing homes, or the deliberate abuse of vulnerable residents. A 2012 congressional study found reports of serious physical, sexual or verbal abuse at one in three nursing homes in the United States.

Even so, it is rare to read a book that sparks so much hard thinking. In my case, it has opened the door to discussions with close relatives about how they wish to spend their final days — conversations that we should surely all be having, however difficult they are to start.

Linda Geddesis a freelance science writer in Bristol, UK, and a consultant to New Scientistmagazine. e-mail:lindaged@yahoo.com

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