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（本文发表于时报观点与评论版面，作者是Sandeep Jauhar。） Like most patients, mine wanted to live as long as possible. So when I brought up the option of a small implantable defibrillator for his failing heart, he immediately said yes. The device would be inserted in his chest to monitor his heartbeat and apply an electrical shock if the rhythm turned into something dangerous. It was like the paddles in the emergency room, I told him, but it would always be inside him. 像大多数患者一样，我的患者也希望尽可能活得长一点。因此，当我建议为他衰竭的心脏装上一个小型植入式除颤器时，他立刻同意了。这个装置将被植入他的胸口，监测他的心跳，如果心律变得危险，将对他施加电击。我告诉他，它就像急诊室里的板子一样，但会一直留在他的体内。 In truth I wasn’t sure if a defibrillator was really such a good idea. My patient was near the end of his life. He might live longer than a year, but certainly no more than five. Patients with heart failure mostly die in one of two ways: either from a sudden, “lights-out” arrhythmia that stops the heart, or from insidious pump failure, in which the heart increasingly fails to meet the metabolic demands of the body. The former, which the defibrillator would help prevent, is quick and relatively painless. The latter, which the defibrillator would make more likely, is protracted and physically agonizing. 然而事实上，我不确定除颤器是否真的是个好主意。我的病人快要走到人生终点了。他的寿命可能超过一年，但是肯定不会超过五年。患有心力衰竭的患者大多以下列两种方式死去：一种是突然“熄灯”的心律失常，会令心脏停跳，另一种是暗中潜伏的衰竭——心脏会愈来愈不能满足身体的代谢需求。前者是快速且相对无痛的，除颤器有助于预防它的发生；后者却旷日持久，令身体非常痛苦，而且除颤器令其更有可能发生。 When the time came, wouldn’t it be better for my patient to die suddenly than to struggle for breath as congestive heart failure filled his lungs with fluid? 当大限将至的时候，我的病人在突然之间死去，而不是因为充血性心力衰竭导致肺部积液，最终窒息而死，这不是更好吗？ It was a difficult thing to bring up with my patient — how he wanted to die — in part because his death wasn’t imminent. But with the rise of technologies like implantable defibrillators, this is a subject with which doctors and patients will increasingly have to grapple: not the inevitability of death, but the manner of one’s demise. 向病人提起这种事——他希望怎样死去——是非常困难的，部分是因为他的死亡并非近在眼前。但是，随着植入式除颤器等技术的兴起，这是医生和患者日益需要应对的问题：不是死亡的必然性，而是死亡的方式。 Sudden cardiac death has always been something of a paradox. It is at once the most desirable way to die and the most feared. Abrupt life-threatening arrhythmias are a leading cause of mortality in the United States. Approximately 350,000 Americans experience them every year, and 90 percent of the victims die before or soon after they get to a hospital. 心脏病猝死一直存在一种悖论。它既是最理想的死亡方式，也是最令人恐惧的方式。在美国，危及生命的突发心律失常是主要死因之一。每年大约有35万美国人经历这种情况，90%的病人在被送入医院之前或之后很快死亡。 My own grandfather was a victim of a sudden fatal arrhythmia on the morning after his 83rd birthday. He woke up complaining of abdominal pain, which he attributed to an excess of food and Scotch the night before. A few minutes later, he emitted a loud groan and went unconscious. Just like that, he was gone. He almost certainly had a massive heart attack, but the heart attack wasn’t what killed him; it was the ensuing arrhythmia, which prevented his heart from sustaining blood flow and life. My mother always said she was sad that he died so suddenly. But she was thankful, too. 我的外祖父在83岁生日翌日早上突发致命性心律失常。他醒来时抱怨腹痛，觉得这是因为他在前一天晚上吃了太多东西，喝了太多苏格兰威士忌。几分钟后，他发出一声响亮的呻吟，昏迷不醒。就这样，他去世了。他几乎肯定是经历了一次大面积心梗，但心梗不是他的死因——随之而来的心律失常导致他的心脏无法维持血液流动，也无法维持他的生命。母亲总是说，他的突然死去令她很伤心。但同时她也很感激。 Sudden deaths like my grandfather’s may become less common. In 2015, about 160,000 defibrillators were implanted in Americans, more than double the number from the decade prior. The population of patients who are eligible for an implantable defibrillator has expanded drastically, too: You used to have to be a survivor of cardiac arrest to be eligible; now the eligible population includes those who have merely an increased risk of sudden death. In America today, if everyone who qualified for a defibrillator were to get one, the costs could reach billions of dollars. 像外祖父这样的突然死亡可能会变得不那么常见。 2015年，美国人植入了大约16万个除颤器，比前十年增加了一倍多。有资格使用植入式除颤器的患者人数也在急剧增加：在过去，只有出现过心脏骤停的幸存者才有资格植入除颤器；现在，只要猝死风险有所增加就可以符合条件。在当今的美国，如果每个有资格使用除颤器的人都能获得一个，那么费用可能达到数十亿美元。 But cost, even with our country’s skyrocketing health care expenditures, is not the main issue. The main issue, in my view, is that defibrillators may send the dying process down a long and winding path that it might not otherwise have taken. No one wants to die prematurely, but when it’s their time, most people want to go quickly and painlessly. Defibrillators can prevent this from happening. They help prevent sudden death, to be sure. But they also can take away the sudden-death option. 但是，即使这令我国的医疗保健支出暴涨，成本也不是最主要的问题。在我看来，最主要的问题是，除颤器可能会使死亡过程沿着本不应有的漫长曲折的道路发展。没人想要过早死去，但是当死亡到来时，大多数人都希望快速而没有痛苦地死去。除颤器可能会阻止这种情况的发生。它们有助于预防猝死。但它们也可以带走突然死亡的选项。 Of course, defibrillators offer many benefits. They are nearly foolproof and are highly effective. Studies have shown that they prolong life in a significant number of cardiac patients. The procedure to implant them is safe. And defibrillators can, in theory, be compatible with a quick death: When a patient’s condition spirals downward, the patient can choose to deactivate the device. 当然，除颤器提供了许多好处。它们几乎万无一失，非常有效。研究表明，它们可以延长大量心脏病患者的生命。植入过程是安全的。而且，从理论上说，除颤器也可以同快速死亡兼容：当患者的病情恶化时，可以选择停用该设备。 However, in my experience, few patients ever deactivate the device. We doctors rarely inform them of this option, and even when we do, patients (and their families) are often reluctant to make a choice that may hasten death. 然而，根据我的经验，几乎没有患者选择停用。我们医生很少会告诉他们这种选择，即使我们这样做了，患者（及其家属）也常常不愿做出可能加速死亡的选择。 I discussed these issues with my patient. I explained that a defibrillator might give him a slightly longer life, but that it might also take away what he wanted from death. He listened to the pros and cons. In the end, he said he wanted to proceed with the defibrillator. We scheduled him to get his device the following week. 我和我的病人讨论了这些问题。我解释说，除颤器可能会稍微延长一点他的生命，但它也可能会排除他所希望的死亡方式。他听取了其中的利弊。最后，他说他想继续使用除颤器。我们安排他在下周安装。 When he was lying on the surgical table, I couldn’t help thinking of another patient of mine who had received a series of painful shocks from her defibrillator when she was in her late 60s. She didn’t want to turn off her device because she believed that it could give her another six months or a year of life. However, she told me, “I say to the Lord, if it’s my time, let me go in my sleep, please.” 当他躺在手术台上时，我忍不住想起我的另一位患者，当她60多岁时，她的除颤器对她进行了一系列令她痛苦的电击。她不想关掉装置，因为她相信它可以让她再多活六个月或一年。然而，她告诉我，“我对主说，如果我的时间到了，请让我在睡梦中死去，拜托了。” Sandeep Jauhar是一名心脏病学家，也是时报的观点作者，他的书《心脏：一部历史》(Heart: A History)即将出版。 翻译：晋其角 下载客户端 安卓：全新安卓客户端可通过Google Play下载安装。 iOS：iOS客户端版本更新，推出搜索等功能。 苹果手机用户可在非中国大陆地区应用商店下载，也可发送邮件至cn.letters@nytimes.com获取新版客户端，或私信时报君获取下载方式。 感谢各位读者的关注和支持！ |
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ARIANNA VAIRO
