Leon Piterman，蔚文禮（譯），劉陽（譯），楊輝（譯）

【編者按】 澳大利亞的全科醫(yī)生具有行業(yè)自律性，體現(xiàn)在其自行制定行業(yè)標準、自主進行資質(zhì)考核及自主執(zhí)業(yè)等方面，也體現(xiàn)在《The Medical Republic》這一共享平臺上。Leon Piterman是醫(yī)學學士，醫(yī)學博士，教育學碩士，英國醫(yī)生學會會員，澳大利亞全科醫(yī)生學會會員，Monash University副校長、全科醫(yī)學教授，從事全科醫(yī)學臨床服務近40年，研究興趣為慢性病管理、心理健康、醫(yī)學教育。Piterman教授建議我國的全科醫(yī)生應培養(yǎng)“共和”思想，以為全科醫(yī)學領域提供更多的平等交流機會。目前Piterman教授定期為《The Medical Republic》撰寫文章，本刊深受“醫(yī)學共和”思想的啟發(fā)，特邀本刊編委Monash University楊輝教授對Piterman教授的文章進行編譯，并進行連載刊登！對于全科醫(yī)生而言，以患者為中心，正確的做法是要按照一定的接診方式與患者達成共識。共識意味著要充分考慮患者的意愿，全科醫(yī)生應了解患者的期望、信仰及對健康/疾病的關(guān)注，包括患者愿意選擇的治療方案。本期Piterman教授為我們講述了一則關(guān)于尊重患者患阿爾茨海默病和卒中后不接受復蘇治療的臨床接診故事，以提醒全科醫(yī)生在工作中應尊重患者的意愿，醫(yī)患之間應該就治療計劃進行協(xié)商，敬請關(guān)注！

圣誕節(jié)的時候，醫(yī)生通常會收到患者的禮物，最常見的是一瓶酒。

在做全職全科醫(yī)生的時候，我會把圣誕節(jié)收到的酒，通常是葡萄酒，儲藏在酒窖里?？上У氖?，酒窖被一次洪水淹沒了，大部分的酒損失在這場洪水中。當時，我的妻子一直跟我說酒窖那邊有一股怪味，當我終于有時間去查看的時候，才發(fā)現(xiàn)酒窖已經(jīng)埋在了3英尺深的淤泥里。

大約有10年時間，每個圣誕節(jié)的早晨，我都會在家門口的臺階上發(fā)現(xiàn)一瓶添寶威士忌（Dimple Whisky）。每一年，我都下定決心要早起，然后揭開這位崇拜者的神秘面紗，看看究竟是誰慷慨地贈送了我這份禮物。終于有一次，我撞見了她，被發(fā)現(xiàn)時她驚得像彈簧一樣跳起來。她叫瑪麗，經(jīng)常到我這來就診，家住在10 km以外。被發(fā)現(xiàn)時，瑪麗感到尷尬和不安。我很驚訝，也松了一口氣，卻有點內(nèi)疚。

瑪麗告訴我說，她非常感謝我，因為我救過她的性命。大約10年前，瑪麗發(fā)現(xiàn)自己腹部膨脹、體質(zhì)量增加，這個過程很緩慢，因此她原來的全科醫(yī)生并沒有太在意，給出的診斷是普通肥胖?，旣惍敃r60歲，飲食方式和鍛煉方式一直未改變，30年來體質(zhì)量變化不大，直到這次，她在6～12個月內(nèi)體質(zhì)量增加。給瑪麗做完查體后，我給出的疑似診斷是巨大卵巢囊腫，隨后的超聲檢查和CT檢查證實了我的診斷。當然，直到切除了這個重達10 kg的卵巢囊腫后，我們才能確定這是良性腫瘤。

成功偵破上述事件后，我仍然會在每年的圣誕節(jié)收到添寶威士忌。只不過，酒被直接送到了診所。這讓我的同事們很懊惱，他們只能議論這瓶奇特的酒，但卻一口也嘗不到。

瑪麗70歲的時候，身體開始陸續(xù)出現(xiàn)一些常見病，如高血壓、骨質(zhì)疏松癥、骨關(guān)節(jié)炎。但這些都沒能妨礙她在草地保齡球錦標賽上獲勝，也沒能妨礙她照顧患有嚴重慢性阻塞性肺疾病和心力衰竭的丈夫以及她住在養(yǎng)老院的患有阿爾茨海默病的96歲母親。

丈夫去世的時候，瑪麗75歲。她接管了丈夫的股票投資組合，并且為自己的成功投資感到非常自豪，也經(jīng)常會在股票的購買上給我一些建議?，旣?0歲的時候，我已經(jīng)為她和她的家人提供診療服務20年了。在此期間，我也喝了不少添寶威士忌。

80歲出頭的時候，瑪麗告訴我，她可能患上了阿爾茨海默病。我問她出現(xiàn)了哪些癥狀，她說她會經(jīng)常忘記自己把東西放在了什么地方，更重要的是她發(fā)現(xiàn)自己在選擇優(yōu)勢股票方面的能力大不如前了。我對她進行了簡易精神狀態(tài)評價，滿分30分的量表她輕松地就得到了28分。之后，我又給她安排了一系列實驗室檢查，所有的結(jié)果都在參考范圍內(nèi)?，旣惛嬖V我，她的母親患阿爾茨海默病12年，98歲時病逝，她不想變成母親那樣。瑪麗堅持讓我在她的病歷上明確寫下：如果患卒中或者阿爾茨海默病，不要對她施行復蘇措施。我同意了她的請求，并讓她簽署了生前預囑。

84歲時，瑪麗在一次草地保齡球比賽中摔倒了，導致右側(cè)髖關(guān)節(jié)骨折。她接受了髖關(guān)節(jié)置換術(shù)，康復過程很順利。4個星期后，瑪麗出院，3個月后她已經(jīng)可以自己開車了。之后的12個月里，我收到了她送的3瓶添寶威士忌。我告訴瑪麗，我很高興能在圣誕節(jié)收到添寶威士忌，但這樣頻繁地送我蘇格蘭威士忌是沒有必要的，也不合適。她說她不記得送給過我這么多威士忌，然后還說：“醫(yī)生你看，我告訴過你，我得了阿爾茨海默病”。我認真地記住了瑪麗的這句話，1個月后她來做常規(guī)檢查時，又帶了一瓶威士忌。我再次對瑪麗進行了簡易精神狀態(tài)評價，這次，滿分30分的量表她只得20分。CT檢查結(jié)果顯示，瑪麗出現(xiàn)了腦萎縮征象，我將瑪麗轉(zhuǎn)診到老年醫(yī)學專家處，結(jié)果證實瑪麗確實患有阿爾茨海默病。難道是髖關(guān)節(jié)骨折和全身麻醉加速了她的病程？誰知道呢？

大約4個月后，我結(jié)束了4周的假期回到診所，得知瑪麗發(fā)生了腦血管意外，在醫(yī)院病逝了?，旣惒幌胂袼赣H那樣結(jié)束生命，這個愿望她實現(xiàn)了。我還有很多庫存的添寶威士忌，每當我倒酒時就會想到瑪麗。

譯 者 注：（1） 生 前 預 囑（advanced-care directive）：在意識清醒的時候，簽署的一份具有法律效力的文書，聲明在自己患嚴重和危及生命的疾病且沒有自我判斷能力的情況下，停止使用某些沒有意義的醫(yī)學干預措施，特別是損害性介入措施。醫(yī)務人員和患者家屬均需遵照患者的生前預囑。目前，很多國家的醫(yī)院都在推行生前預囑，尊重患者的自我選擇并有意義地使用醫(yī)療資源。但在中國，生前預囑并未得到廣泛認同。（2）簡易精神狀態(tài)評價（Mini Mental Status Examination，MMSE）：快速篩查患者精神狀態(tài)的量表。

志謝：特別感謝原文出版者《The Medical Republic》同意將此文編譯后刊登于《中國全科醫(yī)學》。

Doctors commonly receive gifts from their patients at Christmas time，very often in the form of an alcoholic beverage.

When I was in full-time practice these bottles，usually of wine，generously stocked my cellar.Sadly，a large proportion of them were lost when the cellar flooded.My wife had kept telling me there was a bad smell in the vicinity of the cellar.When I finally explored it，the cellar was under three feet of mud.

For 10 years or so each Christmas morning，as I opened my front door at home，I discovered a bottle of Dimple Whisky on my doorstep.Each year，I determined to unravel the mystery of my secret admirer and resolved to wake early to identify the source of this generous gift.

Finally it happened.She was sprung.It was Mary，one of my regular patients，who lived about 10 km away.She was embarrassed and uncomfortable.I was surprised and relieved，but somewhat guilt-ridden also.

Mary proceeded to tell me how grateful she was because I had saved her life.Some 10 years earlier，Mary noticed abdominal swelling and weight gain.This was slow and progressive，and had been brushed off by her usual GP as obesity.

Mary was aged 60 at the time.She had not changed her diet or exercise pattern and had maintained the same weight for 30 years until the recent weight gain over the past six to 12 months.

When I examined Mary，I discovered what I thought was a large ovarian cyst.This was confirmed on ultrasound and CT scan.Of course，it was not until this 10 kg cyst was removed that its benign nature was established.

The regular Christmas Dimple continued after my detective work，only this time it was presented to me at the clinic——much to the chagrin of my colleagues，who could only boast the odd bottle of wine.

In her 70s，Mary developed a range of minor illnesses，including hypertension，osteoporosis and osteoarthritis.But none of these stopped her from winning bowling tournaments，caring for her husband，who had severe COPD and cardiac failure，and caring for her demented mother，who，at the age of 96，was placed in an aged-care facility.

When her husband died，Mary was 75 and took over the management of his share portfolio.She took great pride in boasting of her success in this arena，frequently giving me advice on which shares I should purchase.

By the time Mary turned 80，I had been looking after her and various family members for 20 years.

Much Dimple had been consumed over these two decades.

In her early 80s Mary informed me that she was becoming demented.I asked her what evidence she had for this and she explained that she kept forgetting where she put things.But more importantly，she was proving to be far less adept at picking winners on the stockmarket.

I undertook a mini mental examination and she comfortably scored 28 out of 30.I arranged a number of blood tests，all of which were normal.

She repeatedly told me that she did not wish to go the same way as her mother，who lived for 12 years with progressive dementia and died aged 98.

She insisted that I make it clear in her medical records that she did not wish to be resuscitated if she had a stroke or became demented.I agreed to this and arranged for her to sign an advanced- care directive.

At the age of 84，Mary fell during a game of bowls and fractured her right hip.Hip replacement and rehabilitation were successful and she was back at home after four weeks and driving her car after three months.

Over the next 12 months，I received three bottles of Dimple.I pointed out to Mary that while I was happy to receive her traditional Christmas Dimple，presenting me with Scotch more frequently was both unnecessary and inappropriate.

She told me that she could not remember giving me so much whisky，adding："You see doctor? I told you I was getting dementia."

I took this remark seriously when，a month later，a further Dimple arrived with her next routine visit.I repeated the mini mental.This time the score was only 20 out of 30.

A CT scan showed signs of cerebral atrophy and a visit to a geriatrician confirmed Mary's worst fears.She had Alzheimer's dementia.Did the hip fracture and the general anaesthetic accelerate the process? Who knows?

Some four months later，I returned from four weeks leave to the news that Mary had suffered a CVA and died in hospital.She did not wish to end life like her mother and this wish was granted.

I still have surplus stocks of Dimple and I am reminded of Mary each time I pour a glass.

（收稿日期：2018-03-01）

（本文編輯：王鳳微）