【生死教育第三講】
講題 Title:預設醫療指示與預設照顧計劃 Advance Directive and Advance Care Planning
報名鏈接Registration Link: https://bit.ly/3tE9RgE
日期 Date:12/6/2021(Sat)
時間 Time:3:00-4:30pm
地點 Venue:沙田澤祥街12號香港中文大學鄭裕彤樓地下演講廳1A (LT1A)
Lecture Theatre 1A, Level 1, Cheng Yu Tung Building, The Chinese University of Hong Kong, 12 Chak Cheung Street, Shatin, N.T.
講者 Speaker:陳裕麗教授 Prof Helen Chan / 鍾一諾教授 Prof Roger Chung
主持 Moderator:伍桂麟先生 Mr Pasu Ng
講座內容 Synopsis:
現今醫療科技發達,很多疾病均可治癒或受控制。當疾病到了末期,醫療科技有時只能提供維持生命治療,但延長死亡過程對病人可能沒有意義,甚至增加痛楚。面對這情況,病人、家屬和醫護人員可以商討是否中止對生活質素沒有幫助的維持生命治療,讓病人安詳離世。香港中文大學醫學院那打素護理學院副教授陳裕麗博士和香港中文大學公共衛生及基層醫療學院助理教授鍾一諾博士會在由中大公共衞生及基層醫療學院主辦的公眾「生死教育」四講系列的第三講和大家分享『預設醫療指示』 (Advance Directive)和『預設照顧計劃』(Advance Care Planning)的概念與應用。這兩種健康護理選擇不但可以免卻家屬決定病者死時所受到的困難和壓力,減少作出決定後感到矛盾和內疚的機會,亦體現對病者生命和意願的尊重。
Thanks to the advancement of medical technology, most diseases can be cured or subsided. However, there are times that medical technology could only prolong one’s life but could not cure the terminal illness. Facing such situation, patients, family members, and medical staff can discuss whether to withhold or withdraw from life-sustaining treatments that may not help improve patients’ quality of life so that they can die peacefully. Professor Helen Chan, Associate Professor from The Nethersole School of Nursing and Professor Roger Chung, Assistant Professor of the School of Public Health and Primary Care of the Chinese University of Hong Kong, will share with us the concepts and values behind Advance Directive and Advance Care Planning in the third public seminar of the four-lecture series on life and death education organized by the School of Public Health and Primary Care, CUHK. These two health care options aim not only to reduce the pressure faced by patients’ family when making end-of-life healthcare decision, but also show respect to patients’ will.
講者介紹:
Professor Helen Chan’s research interests focus on end-of-life care, gerontology as well as care ethics. She has conducted a number of research projects on promoting palliative and end-of-life care, especially advance care planning, among older adults and people with advanced progressive diseases.
陳裕麗教授的主要研究範疇集中在臨終護理、老年病學和護理倫理學上。她的研究項目包括推廣有關老人和晚期疾病患者的紓緩照顧和臨終護理服務,尤其是預設照顧計劃。
Professor Roger Chung’s research aims to empirically inquire into the social determinants of health inequalities, as well as aging‐related issues on multimorbidity and long‐term/end‐of‐life care, and to utilize such evidence to inform health services and policy, domestically and beyond.
鍾一諾教授的主要研究範疇為健康不平等的社會決定因素,與老年有關的多重疾病,和晚期與臨終護理政策,並運用研究成果為本地及國際公共衛生服務和政策提供意見。
生死教育 X 伍桂麟
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#史泡泡 今天 蘇怡寧醫師愛碎念 貼了那個「換肚」藥的事情,「換肚」應該是現代的說法,古代稱為「轉胎」,更精確地說,是「轉女為男」,李貞德教授的《女人的中國醫療史》中已經明快地總結了唐代以前對於轉胎的態度可分成:方術與藥方兩種,時間都必須在懷孕的前三個月,這點跟現代所謂吃「換肚」藥應該有一樣的理路。
方術大概都是拿一些有男性象徵的東西給孕婦或讓孕婦看,像是在孕婦床下放斧頭、讓孕婦佩戴弓弦宜男花(似乎是金針花?)一類的東西,基本上,就是一種內外感應.....
藥物就是吃金針花、吃蠶大便、喝一堆奇怪的東西......甚至是喝老公衣帶燒成的灰,千金方中有一個方子就是這種轉女成男方:
「丹參 續斷 芍藥 白膠 白术 柏子人各二兩 人參 芎藭 乾薑各三十銖 當歸 橘皮 吳茱萸各一兩十八銖 白芷 冠纓燒灰各一兩 蕪荑十八銖 乾地黃一兩半 甘草二兩 犬卵一具乾 東門上雄雞頭一枚。
右十九味末之。蜜和丸。酒服十丸。日再。稍加至二十丸如梧子大。」
以上是貞德老師的研究,所有對生小孩有興趣的人都應該買一本來看,真的好看,千年傳統到現在還是一堆人很信:
*傳送門:女人的中國醫療史:漢唐之間的健康照顧與性別
https://www.books.com.tw/products/0010859086
------
簡單說,轉胎這件事由來已久,古代醫書也一直有記載,大家好像也都很相信,但到底實驗成功有多少還真不好說。
不過,到了元代,滋陰派的大師朱震亨卻開始有點懷疑,他在〈胎感論〉這篇文章中,說以前的人都相信南朝褚氏遺書的說法:
「男女之合,二情交暢,陰血先至,陽精後沖,血開裹精,精入為骨,而男形成矣;陽精先入,陰血後參,精開裹血,血入居本,而女形成矣。」
但朱震亨認為這個說法不大正確,他參考了另一個醫者的說法後,認為不是什麼陰血跟陽精比賽衝鋒,誰先到就決定生男或生女,來自母親的陰血與來自父親的陽精,是一起到子宮之後,陰血形成胎兒的血肉、陽精形成骨頭。
那性別怎麼決定,朱震亨認為這跟受孕的時間點比較有關係,他說經期結束的一兩日內,子宮排掉了舊的經血、新的血還沒匯聚時,這時「精勝於血」,容易生男,再過四五天,新血匯聚,就是「血勝於精」,容易生女。但這裡還要加上受孕的時間是否ok、受孕在左邊的子宮還是右邊的子宮(當時的人認為子宮有左右,但以現在的看法,可能是左邊或右邊的輸卵管),換言之,算日期這件事,朱震亨算的受孕期是正確的,但是在左邊或右邊這就不好說,另外,整個受孕過程中,其實還是有很多不確定的因素。
重要的是,朱震亨在胎感論中排除掉了轉胎的討論,他自己編著的丹溪醫集中,提到的轉女為男也是配戴東西而已,不再服藥,就只是傳抄孫思邈的方法而已。多年後,替他整理文獻的明代醫家虞摶非常讚賞朱的說法,順便巴了那些轉胎藥一巴掌,他說:
「是知男女之分,已定於萬物資始乾元之際,陰陽交姤之時。昧者不悟是理,妄有轉女為男之法,惑矣。」
不知道是不是中醫後來終於認清了轉女為男這件事真的很困難,後代的醫者好像也就放生了,明清之後基本上沒有發明什麼新藥方,大概就是用雄黃或蠶大便之類的東西、配戴東西或者在床下放斧頭之類的事情而已。
我並不是做這個研究的專家,只是簡單看了一下資料,但總結來看,不管是「轉胎」、「轉女為男」或者「換肚」,都已經是千年來屢經實驗但顯然沒有太多進步的傳說,假如哪一個方法有效,肯定有更多的精進跟改良,就因為沒有,也就漸趨保守、無害,像配戴東西或放斧頭,真的不會死人,吃蠶大便,在中醫上也有一些療效。
但有些東西在現代已證明有害,比如雄黃,在古代是讓孕婦配戴之外也服用,但雄黃的毒性會造成砷中毒,在現代中醫給一般人內服都必須謹慎使用,更是孕婦忌用的東西,隨便亂吃是會出人命的。
那些吃來路不明換肚藥的女人,是拿命在賭,賭的不是兒子,是賭對方有沒有良心、有沒有給她們一些無關痛癢的東西、有沒有亂添加了會有害的藥物。
就算我烏鴉嘴好了,吃這些東西能不能生男還未定,但亂吃東西導致孕婦死亡、重病或者生出了雖然有雞雞但有各種問題的孩子,真的比較好?
medical care中文 在 Roger Chung 鍾一諾 Facebook 的最佳貼文
今早為Asian Medical Students Association Hong Kong (AMSAHK)的新一屆執行委員會就職典禮作致詞分享嘉賓,題目為「疫情中的健康不公平」。
感謝他們的熱情款待以及為整段致詞拍了影片。以下我附上致詞的英文原稿:
It's been my honor to be invited to give the closing remarks for the Inauguration Ceremony for the incoming executive committee of the Asian Medical Students' Association Hong Kong (AMSAHK) this morning. A video has been taken for the remarks I made regarding health inequalities during the COVID-19 pandemic (big thanks to the student who withstood the soreness of her arm for holding the camera up for 15 minutes straight), and here's the transcript of the main body of the speech that goes with this video:
//The coronavirus disease 2019 (COVID-19) pandemic, caused by the SARS-CoV-2 virus, continues to be rampant around the world since early 2020, resulting in more than 55 million cases and 1.3 million deaths worldwide as of today. (So no! It’s not a hoax for those conspiracy theorists out there!) A higher rate of incidence and deaths, as well as worse health-related quality of life have been widely observed in the socially disadvantaged groups, including people of lower socioeconomic position, older persons, migrants, ethnic minority and communities of color, etc. While epidemiologists and scientists around the world are dedicated in gathering scientific evidence on the specific causes and determinants of the health inequalities observed in different countries and regions, we can apply the Social Determinants of Health Conceptual Framework developed by the World Health Organization team led by the eminent Prof Sir Michael Marmot, world’s leading social epidemiologist, to understand and delineate these social determinants of health inequalities related to the COVID-19 pandemic.
According to this framework, social determinants of health can be largely categorized into two types – 1) the lower stream, intermediary determinants, and 2) the upper stream, structural and macro-environmental determinants. For the COVID-19 pandemic, we realized that the lower stream factors may include material circumstances, such as people’s living and working conditions. For instance, the nature of the occupations of these people of lower socioeconomic position tends to require them to travel outside to work, i.e., they cannot work from home, which is a luxury for people who can afford to do it. This lack of choice in the location of occupation may expose them to greater risk of infection through more transportation and interactions with strangers. We have also seen infection clusters among crowded places like elderly homes, public housing estates, and boarding houses for foreign domestic helpers. Moreover, these socially disadvantaged people tend to have lower financial and social capital – it can be observed that they were more likely to be deprived of personal protective equipment like face masks and hand sanitizers, especially during the earlier days of the pandemic. On the other hand, the upper stream, structural determinants of health may include policies related to public health, education, macroeconomics, social protection and welfare, as well as our governance… and last, but not least, our culture and values. If the socioeconomic and political contexts are not favorable to the socially disadvantaged, their health and well-being will be disproportionately affected by the pandemic. Therefore, if we, as a society, espouse to address and reduce the problem of health inequalities, social determinants of health cannot be overlooked in devising and designing any public health-related strategies, measures and policies.
Although a higher rate of incidence and deaths have been widely observed in the socially disadvantaged groups, especially in countries with severe COVID-19 outbreaks, this phenomenon seems to be less discussed and less covered by media in Hong Kong, where the disease incidence is relatively low when compared with other countries around the world. Before the resurgence of local cases in early July, local spread of COVID-19 was sporadic and most cases were imported. In the earlier days of the pandemic, most cases were primarily imported by travelers and return-students studying overseas, leading to a minor surge between mid-March and mid-April of 874 new cases. Most of these cases during Spring were people who could afford to travel and study abroad, and thus tended to be more well-off. Therefore, some would say the expected social gradient in health impact did not seem to exist in Hong Kong, but may I remind you that, it is only the case when we focus on COVID-19-specific incidence and mortality alone. But can we really deduce from this that COVID-19-related health inequality does not exist in Hong Kong? According to the Social Determinants of Health Framework mentioned earlier, the obvious answer is “No, of course not.” And here’s why…
In addition to the direct disease burden, the COVID-19 outbreak and its associated containment measures (such as economic lockdown, mandatory social distancing, and change of work arrangements) could have unequal wider socioeconomic impacts on the general population, especially in regions with pervasive existing social inequalities. Given the limited resources and capacity of the socioeconomically disadvantaged to respond to emergency and adverse events, their general health and well-being are likely to be unduly and inordinately affected by the abrupt changes in their daily economic and social conditions, like job loss and insecurity, brought about by the COVID-19 outbreak and the corresponding containment and mitigation measures of which the main purpose was supposedly disease prevention and health protection at the first place. As such, focusing only on COVID-19 incidence or mortality as the outcomes of concern to address health inequalities may leave out important aspects of life that contributes significantly to people’s health. Recently, my research team and I collaborated with Sir Michael Marmot in a Hong Kong study, and found that the poor people in Hong Kong fared worse in every aspects of life than their richer counterparts in terms of economic activity, personal protective equipment, personal hygiene practice, as well as well-being and health after the COVID-19 outbreak. We also found that part of the observed health inequality can be attributed to the pandemic and its related containment measures via people’s concerns over their own and their families’ livelihood and economic activity. In other words, health inequalities were contributed by the pandemic even in a city where incidence is relatively low through other social determinants of health that directly concerned the livelihood and economic activity of the people. So in this study, we confirmed that focusing only on the incident and death cases as the outcomes of concern to address health inequalities is like a story half-told, and would severely truncate and distort the reality.
Truth be told, health inequality does not only appear after the pandemic outbreak of COVID-19, it is a pre-existing condition in countries and regions around the world, including Hong Kong. My research over the years have consistently shown that people in lower socioeconomic position tend to have worse physical and mental health status. Nevertheless, precisely because health inequality is nothing new, there are always voices in our society trying to dismiss the problem, arguing that it is only natural to have wealth inequality in any capitalistic society. However, in reckoning with health inequalities, we need to go beyond just figuring out the disparities or differences in health status between the poor and the rich, and we need to raise an ethically relevant question: are these inequalities, disparities and differences remediable? Can they be fixed? Can we do something about them? If they are remediable, and we can do something about them but we haven’t, then we’d say these inequalities are ultimately unjust and unfair. In other words, a society that prides itself in pursuing justice must, and I say must, strive to address and reduce these unfair health inequalities. Borrowing the words from famed sociologist Judith Butler, “the virus alone does not discriminate,” but “social and economic inequality will make sure that it does.” With COVID-19, we learn that it is not only the individuals who are sick, but our society. And it’s time we do something about it.
Thank you very much!//
Please join me in congratulating the incoming executive committee of AMSAHK and giving them the best wishes for their future endeavor!
Roger Chung, PhD
Assistant Professor, CUHK JC School of Public Health and Primary Care, @CUHK Medicine, The Chinese University of Hong Kong 香港中文大學 - CUHK
Associate Director, CUHK Institute of Health Equity
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