《The Medical Republic》案例分享——圣诞威士忌的秘密

Leon Piterman，蔚文礼（译），刘阳（译），杨辉（译）

【编者按】 澳大利亚的全科医生具有行业自律性，体现在其自行制定行业标准、自主进行资质考核及自主执业等方面，也体现在《The Medical Republic》这一共享平台上。Leon Piterman是医学学士，医学博士，教育学硕士，英国医生学会会员，澳大利亚全科医生学会会员，Monash University副校长、全科医学教授，从事全科医学临床服务近40年，研究兴趣为慢性病管理、心理健康、医学教育。Piterman教授建议我国的全科医生应培养“共和”思想，以为全科医学领域提供更多的平等交流机会。目前Piterman教授定期为《The Medical Republic》撰写文章，本刊深受“医学共和”思想的启发，特邀本刊编委Monash University杨辉教授对Piterman教授的文章进行编译，并进行连载刊登！对于全科医生而言，以患者为中心，正确的做法是要按照一定的接诊方式与患者达成共识。共识意味着要充分考虑患者的意愿，全科医生应了解患者的期望、信仰及对健康/疾病的关注，包括患者愿意选择的治疗方案。本期Piterman教授为我们讲述了一则关于尊重患者患阿尔茨海默病和卒中后不接受复苏治疗的临床接诊故事，以提醒全科医生在工作中应尊重患者的意愿，医患之间应该就治疗计划进行协商，敬请关注！

圣诞节的时候，医生通常会收到患者的礼物，最常见的是一瓶酒。

在做全职全科医生的时候，我会把圣诞节收到的酒，通常是葡萄酒，储藏在酒窖里。可惜的是，酒窖被一次洪水淹没了，大部分的酒损失在这场洪水中。当时，我的妻子一直跟我说酒窖那边有一股怪味，当我终于有时间去查看的时候，才发现酒窖已经埋在了3英尺深的淤泥里。

大约有10年时间，每个圣诞节的早晨，我都会在家门口的台阶上发现一瓶添宝威士忌（Dimple Whisky）。每一年，我都下定决心要早起，然后揭开这位崇拜者的神秘面纱，看看究竟是谁慷慨地赠送了我这份礼物。终于有一次，我撞见了她，被发现时她惊得像弹簧一样跳起来。她叫玛丽，经常到我这来就诊，家住在10 km以外。被发现时，玛丽感到尴尬和不安。我很惊讶，也松了一口气，却有点内疚。

玛丽告诉我说，她非常感谢我，因为我救过她的性命。大约10年前，玛丽发现自己腹部膨胀、体质量增加，这个过程很缓慢，因此她原来的全科医生并没有太在意，给出的诊断是普通肥胖。玛丽当时60岁，饮食方式和锻炼方式一直未改变，30年来体质量变化不大，直到这次，她在6～12个月内体质量增加。给玛丽做完查体后，我给出的疑似诊断是巨大卵巢囊肿，随后的超声检查和CT检查证实了我的诊断。当然，直到切除了这个重达10 kg的卵巢囊肿后，我们才能确定这是良性肿瘤。

成功侦破上述事件后，我仍然会在每年的圣诞节收到添宝威士忌。只不过，酒被直接送到了诊所。这让我的同事们很懊恼，他们只能议论这瓶奇特的酒，但却一口也尝不到。

玛丽70岁的时候，身体开始陆续出现一些常见病，如高血压、骨质疏松症、骨关节炎。但这些都没能妨碍她在草地保龄球锦标赛上获胜，也没能妨碍她照顾患有严重慢性阻塞性肺疾病和心力衰竭的丈夫以及她住在养老院的患有阿尔茨海默病的96岁母亲。

丈夫去世的时候，玛丽75岁。她接管了丈夫的股票投资组合，并且为自己的成功投资感到非常自豪，也经常会在股票的购买上给我一些建议。玛丽80岁的时候，我已经为她和她的家人提供诊疗服务20年了。在此期间，我也喝了不少添宝威士忌。

80岁出头的时候，玛丽告诉我，她可能患上了阿尔茨海默病。我问她出现了哪些症状，她说她会经常忘记自己把东西放在了什么地方，更重要的是她发现自己在选择优势股票方面的能力大不如前了。我对她进行了简易精神状态评价，满分30分的量表她轻松地就得到了28分。之后，我又给她安排了一系列实验室检查，所有的结果都在参考范围内。玛丽告诉我，她的母亲患阿尔茨海默病12年，98岁时病逝，她不想变成母亲那样。玛丽坚持让我在她的病历上明确写下：如果患卒中或者阿尔茨海默病，不要对她施行复苏措施。我同意了她的请求，并让她签署了生前预嘱。

84岁时，玛丽在一次草地保龄球比赛中摔倒了，导致右侧髋关节骨折。她接受了髋关节置换术，康复过程很顺利。4个星期后，玛丽出院，3个月后她已经可以自己开车了。之后的12个月里，我收到了她送的3瓶添宝威士忌。我告诉玛丽，我很高兴能在圣诞节收到添宝威士忌，但这样频繁地送我苏格兰威士忌是没有必要的，也不合适。她说她不记得送给过我这么多威士忌，然后还说：“医生你看，我告诉过你，我得了阿尔茨海默病”。我认真地记住了玛丽的这句话，1个月后她来做常规检查时，又带了一瓶威士忌。我再次对玛丽进行了简易精神状态评价，这次，满分30分的量表她只得20分。CT检查结果显示，玛丽出现了脑萎缩征象，我将玛丽转诊到老年医学专家处，结果证实玛丽确实患有阿尔茨海默病。难道是髋关节骨折和全身麻醉加速了她的病程？谁知道呢？

大约4个月后，我结束了4周的假期回到诊所，得知玛丽发生了脑血管意外，在医院病逝了。玛丽不想像她母亲那样结束生命，这个愿望她实现了。我还有很多库存的添宝威士忌，每当我倒酒时就会想到玛丽。

译 者 注：（1） 生 前 预 嘱（advanced-care directive）：在意识清醒的时候，签署的一份具有法律效力的文书，声明在自己患严重和危及生命的疾病且没有自我判断能力的情况下，停止使用某些没有意义的医学干预措施，特别是损害性介入措施。医务人员和患者家属均需遵照患者的生前预嘱。目前，很多国家的医院都在推行生前预嘱，尊重患者的自我选择并有意义地使用医疗资源。但在中国，生前预嘱并未得到广泛认同。（2）简易精神状态评价（Mini Mental Status Examination，MMSE）：快速筛查患者精神状态的量表。

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》。

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）

（本文编辑：王凤微）