The Future of Palliative Care姑息關懷的未來

瑪格麗特·迪雷恩　唐昉/譯

Medical advancements are occurring in artificial intelligence （AI） and information and communications technology （ICT） and in the fields of biotechnology and precision medicine， which can tailor medications and ther-apies to the unique biological makeup of the individual. These developments are revolutionising health care now and will continue to do so into the future.

醫學進步漸漸在人工智能、信息通信技術以及生物技術和精準醫療領域顯現，其成果在于可以根據個體獨特的生理結構定制藥物和療法。目前，這些發展成果正在徹底改變醫療保健領域，而且未來還會持續引發行業變革。

Palliative care is not immune from these changes and clinicians working in palliative care will find themselves working with new technologies and data sources to inform their practice and care of palliative patients.

姑息關懷也難免受到這些變化的影響。姑息關懷科的臨床醫生勢必會使用新技術、利用新數據源，指導自己的醫療行為和對患者的姑息關懷。

Looking forward to the next 10 or so years， patients and consumers will have access to a range of data that has not previously been available to them. Health professionals will increasingly need to adapt their service models to include the patient as a key resource in health decision making， acknowledging that patients will have more information about their own health at their fingertips. Smart technology will be used to monitor a persons health and well-being. Smart technology will routinely measure heart rate， blood pressure， breathing， weight， activity levels and could potentially predict when people are at risk of stroke， heart attack or other diseases and conditions.

展望未來十年左右的時間，患者和消費者將能獲取一系列他們以前無法獲取的數據。醫技人員將越來越需要調整自身服務模式，讓患者成為醫療決策的關鍵參與者，認識到患者將掌握更多關于自身健康的信息。智能技術將用于監測個人的身心健康——定期測量心率、血壓、呼吸、體重、活動水平，并有可能預測人們何時會面臨中風、心臟病發作或其他疾病和健康問題的風險。

Access to remote monitoring of health data will increase and this will mean that where individuals want this option， their data collected through smart technology will also be available to their health care teams. Clinicians can then be alerted earlier to a change in diagnosis or a need to change treatment options.

遠程監控健康數據的機會將會增加，這意味著如果人們需要這種服務，那么智能技術收集的個人健康數據也將提供給他們的醫療保健團隊。如此一來，臨床醫生可以更早地收到提示信息，知曉病情診斷的變化或治療方案的變更需求。

Not only will there be more data at the individual level， data collected at the macro level will also have implications for diagnosis and treatment options. Big data and artificial intelligence will have a greater role to play in medical forecasting and treatment.

不僅會有更多的個人數據，收集到的宏觀數據也會對診斷和治療方案產生影響。大數據和人工智能將在醫學預測和治療方面發揮更大的作用。

What can this mean in practice？ According to the Australian Council of Learned Academies （ACOLA） there will be “increasing ability to collect and codify clinical and laboratory data in aggregate through the use of big data tools—including supercomputing capacity， cloud storage and automated biometric， diagnostic and therapeutic data collection—allowing association of genomic and related information with biomarkers， diagnosis and clinical outcome.” This will enable patients to have a real-time medical condition assessment， which will lead to point-of-care interventions and predictive analytics for clinical decision-making. Based on this information， health and support services can be more preparative and responsive and less reactive.

這對醫療行為意味著什么呢？澳大利亞學術研究院委員會表示，“通過使用大數據手段（包括超級計算能力、云存儲，以及自動收集生物特征信息、診斷和治療數據），收集和整理所有臨床與實驗室數據的能力將不斷提高，從而使基因組數據以及與之相關的信息得以和生物標志物、診斷、臨床結局聯系起來。”這將使患者能夠實時接受病情評估，進而能為患者提供即時干預，為臨床決策提供預測分析。基于上述信息，醫療和配套服務更能未雨綢繆，更能積極主動地作出響應，而非被動應對。

In a similar vein1， the computing power of artificial intelligence will assist scientists and pharmaceutical clinicians develop new and responsive medications that are directly related to a persons biological system and specific disease symptoms.

同樣，人工智能的計算能力將幫助科學家和臨床藥師研發與人體生理系統和特定疾病癥狀直接相關的新型特效藥。

This is the area where clinicians will see the biggest change—the tailoring of treatments to meet the biological make-up of their patients. The emerging field of biotechnology and precision medicine will mean that life-limiting illness is easier to predict and biological markers will provide a clearer indication of life expectancy for many people with varying diagnoses. As noted by the ACOLA， precision medicine is “the ability to ana-lyse disease in terms of an individuals make-up， when compared with and studied alongside aggregated clinical and laboratory data from healthy and diseased populations. Although medicine has always had personal and predictive aspects， precision medicine allows health and disease to be viewed at an increasingly fine-grained resolution， attuned2 to the complexities of both the biology of each individual and vari-ation within the population.” In other words， there will be an increasing move away from a one size fits all approach for disease treatment and prevention to very tailored individual treatment and prevention plans.

這是臨床醫生將見證最大變化的領域——量身定制治療方案以適應患者的生理特性。生物技術與精準醫療領域的興起將意味著絕癥更容易預測，生物標志物將為眾多患有不同疾病的人提供更明確的預期壽命指標。正如澳大利亞學術研究院委員會所指出的，精準醫療指“能夠通過對健康人群和患病人群的臨床與實驗室匯總數據進行比較和研究，根據個體的具體情況分析疾病。雖然醫學總是涉及個體差異和預測因素，但精準醫療能越來越精細地解析健康和疾病，適應每個個體生物學特征的復雜性和群體內個體差異的復雜性”。換句話說，疾病的治療與預防將漸漸從“一刀切”的方法，轉向量身定制的個體治療與預防方案。

This will mean that the treatment of life-limiting illnesses such as cancer or neurodegenerative3 diseases will be managed using knowledge about an individuals biological system to increase the efficacy of treatment outcomes. This will include immunotherapy4， which enables a person to use their own immune system to fight off a disease. This could reduce the need for radiotherapy5， chemo-therapy or surgery. If a person does need chemotherapy， the emerging field of nanotechnology will increasingly be used to target cancer cells without the current side effects.

這意味著針對癌癥或神經系統變性疾病等絕癥的治療，將基于有關個體生理系統的信息，以此提高治療效果。治療方法將包括免疫療法，即讓病人能夠利用自身免疫系統對抗疾病，可減少對放療、化療或手術的需求。如果病人確實需要化療，新興的納米技術將越來越多地用于靶向癌細胞，而不會產生現有的副作用。

So what does this all mean for palliative care clinicians？

那么，這對姑息關懷科的臨床醫生意味著什么呢？

Emerging treatment and interventions using advanced biotechnological options and incorporating the benefits of big data and artificial intelligence will mean that many people will be kept alive for longer and where they need ser-ious treatment， the side effects should be less physically diminishing than in the past and currently.

新興的治療和干預方法運用先進的生物技術，結合了大數據和人工智能的優勢。這意味著許多患者將活得更久，即使他們需要高強度治療，副作用對身體的損害也會比過去和現在更小。

So while all these advances are generally positive， the fact remains that people will still have life-limiting illness and will need help living with the symptoms of their illness while also preparing for their death. It is also known that the dominant illnesses accounting for growth in palliative care need will be dementia and cancer. According to the CSIRO6， there will be an increase in neurodegenerative disorders， and a changing spectrum of cancers as the common cancers become more survivable… the associated increasing lifespans will see more individuals develop rare and less common cancers such as pancreatic7 and renal8.

因此，盡管上述醫學發展成果大體是積極的，現實卻與以往無異——人們仍然會身患絕癥，依舊需要有人幫他們在帶病生存的同時做好死亡的準備。眾所周知，導致姑息關懷需求增長的主要疾病將是失智癥和癌癥。根據澳大利亞聯邦科學與工業研究組織的說法，神經系統變性疾病的病例將會增加，而且隨著常見癌癥的生存率提高，癌癥譜系將不斷變化……隨之而來的壽命延長可能會讓更多人患上罕見和不常見的癌癥，比如胰腺癌和腎癌。

Comorbidity9 will be significant factor in palliative care. Many people will live with more than one comorbid condition. “This means that the complexity of palliative care need is likely to grow due to the high symptom burden， complex healthcare needs and high hospitalisation rates of patients with multimorbidity.”

共病將是姑息關懷的重要因素。許多病人可能患有不止一種共存性疾病。“這意味著由于多重疾病患者的癥狀負擔大、醫療需求復雜、住院率高，姑息關懷需求的復雜性可能會加劇。”

To manage all of these factors will require a sophisticated array of skills. Consumers will expect their health practitioners to be able to work with the latest technological advancements and incorporate biotechnology and precision medicine into care and treatment options and to minimise negative side-effects. Specifically for palliative care， patients and their carers will depend on the skills， knowledge and experience of palliative care clinicians in interpreting the data and assessing the multitude of treatment options to determine the best care path available.

要想控制好上述因素，需要一系列復雜巧妙的技能。消費者期望醫療從業者能夠利用技術發展的最新成果，將生物技術和精準醫療融入護理和治療方案，并最大限度地減少不良反應。具體到姑息關懷，患者及其照護者將依賴姑息關懷科臨床醫生根據自己的專業技能、知識和經驗來解讀數據，并評估多種治療選擇，最終確定可行的最佳療護方案。

In addition to the changes that emerging medical advances and technologies will have for the care options available to people with life-limiting illness， palliative care clinicians will increasingly be called on to advise patients about when enough is enough for treatment proposed by other medical clinicians. The growing accessibility of biotechnology options will run the risk of more people being on a treatment treadmill and there will always be a point where further treatment will be too burdensome or non-beneficial. Palliative care expertise will be needed more than ever to advise patients about when to stop more active treatments and interventions and to ensure patients have quality of life and avoid unnecessary pain and distress.

逐漸顯現的醫學進步和新興技術將為患有絕癥的病人帶來療護方案的變化。除此之外，越來越多的病人將要求姑息關懷科的臨床醫生給出建議，告訴他們其他科室臨床醫生提出的治療何時該停。生物技術的日益普及可能會使更多病人處于持續治療的狀態，而治療終有一天會變得徒勞無功。未來將比以往任何時候都更需要姑息關懷專家向患者提供建議——何時停止積極治療和干預，如何確保生活質量，怎樣避免不必要的疼痛和苦惱。

It is important that palliative care remains a human service within the context of this changing world. Technology needs to be balanced with the counterforce of human contact and kindness together with the expertise to advise and guide people about what is best for them. In addition to the high quality medical care and treatment provided by palliative care clinicians， palliative care will continue to provide high quality psychosocial， emotional and spiritual care for the person receiving palliative care along with grief and bereavement10 support for family and loved ones.

重要的是，在這個不斷變化的世界中，姑息關懷仍然是一項人性化服務。運用技術的同時要兼顧與之相抵的人際交往和懷善之心，還要搭配專業知識，以建議和指導病人怎么做才是最適合他們的。除了姑息關懷科臨床醫生提供的高質量護理和治療外，姑息關懷還將持續為接受這項服務的病人提供高質量的社會心理、情感和精神關懷，并為其親屬提供悲痛安撫和喪親支持服務。

We are entering a new age where some things will change dramatically but the core essence of what palliative care offers now will be needed more than ever into the future.

我們漸漸邁入一個新時代，有些事情將會發生巨大變化，但未來將比以往任何時候都更需要姑息關懷所呈現出的核心本質。

（譯者為“《英語世界》杯”翻譯大賽獲獎者）