《The Medical Republic》案例分享——给老年人做计划：若非今日，更待何时？Planning for the Ages——If Not Now，Then When？

Leon Piterman，黄文静（译），杨辉（译）

故事发生在一个忙碌的周六早晨，当时正值流行性感冒多发季节。诊所的候诊室里挤满了患者，接诊员在电话里告诉我：“大家只能站着”。接诊员还说：“里昂医生，韦伯先生正在与诊所进行电话连线，他是乔治医生的一位患者。韦伯先生听上去很忧虑，需要马上与医生联系，但他不愿意告诉我事情的原委”。

我永远忘不了和比尔（即韦伯先生，全名为比尔·韦伯）接通电话时，他甩给我的那段开场白。他说：“医生，如果你现在不来为我的岳母伊迪丝做些什么的话，那我的下一个电话就会打到谋杀专案组，告诉他们我杀了那个老太太”。后来，我终于弄明白，原来是比尔和他的妻子在照顾伊迪丝时遇到了极端的困难。于是，我答应他要在午饭时间去他家做一次上门访视。

我在比尔家的前门见到了他。那是一幢普通的20世纪50年代建筑风格的双面贴砖房，这种建筑风格的住宅在墨尔本东南区的城区街道上随处可见。在那个年代，房地产商会把蔬果和花卉的种植园分割出一部分，用于建造住宅。这种建筑风格已经被艺术家霍华德·阿克利栩栩如生地展现了出来，如果感兴趣的话可以到谷歌上去搜索一下他的绘画作品，现在他的画几乎和他画的房子一样值钱。

比尔·韦伯，72岁，身材高大，体格魁梧，年轻时可能是一名体育健将。但他的外表掩盖了他同时患有2型糖尿病、高血压、缺血性心脏病的事实，2年前他还接受了3次冠状动脉旁路移植术。比尔带我进到厨房，他的妻子薇拉坐在那里，泪流不止、神情凄苦。我以前没有见过薇拉，但从她的双手可以明显看出，她患有类风湿关节炎。

比尔向我解释到，他和妻子7年来一直在照顾伊迪丝。现在，伊迪丝已经96岁了，患有阿尔茨海默病，二便失禁，大多数时间都在床上度过。比尔时常会出现胸痛的症状，薇拉因为类风湿关节炎而不能做事情，所以大部分搬运沉重物品的任务就落在比尔的肩上。伊迪丝已经在一家公立养老院的排队名单上等了2年，但现在看来想要得到一个床位的期望与当初刚报名时一样渺茫。比尔对现在的医疗照护系统感到非常失望，虽然地方政府和地段护理服务组织为他们提供了家庭照护服务，但这并不能满足他们日益增大的照护需求。同时，家庭内部的变动也是雪上加霜。最近他们的女儿离婚了，成了单身母亲，需要照顾2个正处在青春期的男孩，而且儿女手头拮据，需要经济支持。

我被带进卧室，然后见到了伊迪丝。伊迪丝的块头不小，可能有90 kg。很明显，她缺乏定向力，意识不清。整个卧室里弥漫着小便的恶臭味。在给伊迪丝做体格检查的时候，我注意到她的臀部有一个早期褥疮。薇拉表示，近两天伊迪丝的意识混乱情况越来越严重了。我怀疑伊迪丝存在尿路感染，应该安排她紧急住院治疗。当时，我可以安排伊迪丝住进当地社区医院的公立病房，现在那家社区医院已经改成了肿瘤中心。

如果是现在，而且伊迪丝足够幸运的话，她可能会被安排到大型公立医院的“短住病房”。在那里她可以接受相应的实验室检查和治疗，也会有住院医师为她提供服务。现在，很多老年人被安排住进了这种“短住病房”，但实际上，“短住病房”就是不知道“何去何从”的委婉说法而已。

我很感激比尔请我到他家里去阻止了一场“谋杀”，但这远不及比尔和薇拉对我的感激。目前，社区老年人的数量越来越多，照护需求越来越大，上述案例中反映的问题将会越来越突显。60～70岁的老年人本该在退休后享受生活，但他们却不得不去照顾年纪非常大的父母。虽然他们中的很多人存在健康问题，但还是不得不把自己划归到上有老、下有小的“三明治一代”行列里。这夹在中间的一代人既要服侍80～90岁的年迈父母，又要关照30～40岁的寄居子女，有些会突然面临家庭危机。

作为全科医生，我们需要照顾一个家庭里的好几代人，我们既要为他们提供急症服务，也要为他们提供持续性服务。全科医生的诊断和管理措施，不仅要针对患者个体，还要针对家庭和社区。随着年龄的增长，人们对家庭和社区资源的依赖会逐渐增加，因此我们现在就要为这些可能会发生的事情做好计划。若非今日，更待何时？

志谢：特别感谢原文出版者《The Medical Republic》同意将此文编译后刊登于《中国全科医学》。

It was a busy Saturday morning at the clinic in the midst of a major influenza epidemic. The waiting room was "standing room only" when I received a call from my receptionist.

"Leon, it's Mr Webber on the phone. He's one of George's patients. He seems distressed and needs to speak to a doctor urgently. He won't tell me what it is about."

I will never forget Bill's opening remarks when we were connected. "Doctor, if you don't come now and do something about my mother in law, Edith, my next phone call will be to the homicide squad to report a murder."

I managed to ascertain that he and his wife were finding it extremely difficult to manage Edith and promised to do the home visit at lunch time.

I was met at the front door of a modest 1950s doublefront brick-veneer home. It was much the same as many in the street created during the subdivision of market gardens into residential real estate in the inner south-east of Melbourne. The style was beautifully captured by the artist Howard Arkley (suggest you Google him for picture) whose paintings are now worth almost as much as the houses he painted.

Bill Webber, aged 72, was a tall, solidly built man,possibly a sportsman in his day. His appearance, however,disguised the fact that he suffered from type 2 diabetes,hypertension and ischaemic heart disease and had triple coronary bypass two years ago.

He ushered me into the kitchen where his wife Vera sat,tearful and forlorn. I had not previously met Vera, however it was apparent from looking at her hands that she was afflicted with rheumatoid arthritis.

Bill explained that he and his wife had been caring for Edith for the past seven years. She was now aged 96, suffered from dementia, was frequently incontinent and spent much of her time in bed.

Bill was still getting chest pains, and with Vera incapacitated with arthritis most of the heavy lifting fell on his shoulders.

Edith had been on the waiting list for a public nursing home for two years, but the promise of a bed seemed just as elusive as ever.

Bill felt let down by the system. Home help from the council and district nursing were helpful, but did little to alleviate the day-to-day caring needs.

The family situation was further complicated by the recent marriage break up of their daughter who now, as a single mother, was caring for two teenage boys and needed financial support.

I was led to the bedroom where I met Edith. She was a large woman, possibly over 90 kg.

She was clearly disoriented and confused and the smell of urine seemed to permeate the room. In the course of examining her, I noted an early bed sore on her buttock. Vera felt that the confusion had got worse over the past two days.

I suspected a urinary-tract infection and felt urgent hospital admission was warranted. This was at a time when I had access to public-hospital beds at the local community hospital (now a cancer centre).

In the current climate, with a bit of luck, she would be admitted to the "short-stay unit" of a large public hospital while investigation and treatment were implemented and placement organised. Many elderly now crowd these socalled "short stay" places, a euphemism for "where to from here".

I was grateful to be able to prevent a homicide, but not nearly as grateful as Bill and Vera.

This case illustrates a problem that will become increasingly more common as our community grows older,resources for care of the elderly become more and more stretched, and people in their late 60s and 70s, who should be retired and enjoying life, find themselves caring for their very old loved ones.

Many, despite their own ill health, may fill the ranks of the "sandwich generation" where they care both for their elderly parents as well as their 30- to 40-year-old children,some of whom are suddenly facing domestic crises.

As GPs, we care for several generations within one family. We provide both acute care as well as ongoing care.

Our diagnostic and management processes focus not just on the individual, but also on the family and the community.

As we age, the dependence on family and community resources will only increase. We need to plan for these eventualities now.

For if not now, then when?