死亡来临是一种怎样的感受

You and I, one day we’ll die from the same thing. We’ll call it different names: cancer, diabetes, heart failure, stroke.

将来有一天，我们都会因同样的问题而死去。我们对它有不同的称呼：癌症、糖尿病、心力衰竭，或中风。

One organ will fail, then another. Or maybe all at once. We’ll become more similar to each other than to people who continue living with your original diagnosis or mine.

一个器官将会衰竭，然后是另一个。也可能同时衰竭。与那些跟你我的最初诊断相同却继续存活的人相比，我们与彼此更加相似。

Dying has its own biology and symptoms. It’s a diagnosis in itself. While the weeks and days leading up to death can vary from person to person, the hours before death are similar across the vast majority of human afflictions.

死亡有自己的生理机制和症状。它是对自己的诊断。虽然死亡前的数周和数日可能因人而异，但对绝大多数疾病来说，死亡前的几个小时都差不多。

Some symptoms, like the death rattle, air hunger and terminal agitation, appear agonizing, but aren’t usually uncomfortable for the dying person. They are well-treated with medications. With hospice availability increasing worldwide, it is rare to die in pain.

有些症状，比如濒死喉声、空气饥渴和临终烦躁，似乎十分痛苦，但对濒死之人来说，通常不是那么难受。可以通过药物进行治疗。随着世界各地出现越来越多的临终关怀医院，现在很少有人在痛苦中死去。

While few of us will experience all the symptoms of dying, most of us will have at least one, if not more. This is what to expect.

虽然我们中极少有人会经历所有这些濒死症状，但我们大多数人将至少经历其中一种。下面是可能出现的一些情况。

The Death Rattle

濒死喉声

“The graves are full of ruined bones, of speechless death-rattles” (Pablo Neruda)

“坟墓里充满腐烂的骨头，和无语的濒死喉声”（巴勃罗·聂鲁达）

We suspected the patient wouldn’t survive off the ventilator. A blood clot had crawled up one of the vessels in the back of his brain, blocking blood flow to the area that controlled alertness. He would die from not being awake enough to cough.

我们怀疑这个病人无法靠人工呼吸机活下去。一个血栓堵住了他大脑后部的一根血管，导致血液无法流向控制警觉的区域。他会因为不够清醒，不去咳嗽而死亡。

The beat of the death rattle began when the breathing tube was removed and continued until life was done. It was a gurgling, crackling sound, like blowing air through a straw at the bottom of a cup of water. The average time between the onset of death rattles to death itself is 16 hours. For him, it was six.

濒死喉声从气管被移除开始，到生命结束终止。它是一种汩汩、嘎嘎的声音，就像用吸管对着一杯水的底部吹气。从濒死喉声开始到死亡的平均时间是16个小时。对他来说，是6个小时。

The death rattle is a symptom of swallowing dysfunction. Normally, our tongue rises to the top of the mouth and propels saliva, liquid or food backward. The epiglottis, a flap in the throat, flops forward to protect the swallowed substance from entering the airway.

濒死喉声是吞咽功能障碍的一个症状。正常情况下，我们的舌头会升到嘴巴上部，将唾液、液体或食物向后推动。喉部的组织片“会厌”向前扇动，防止咽下的物质进入气管。

In the dying process, the symphony of swallowing becomes a cacophony of weak and mistimed movements. Sometimes the tongue propels saliva backward before the epiglottis has time to cover the airway. Other times, the tongue fails to push at all and saliva trickles down the airway to the lungs in a steady stream. The death rattle is the lungs’ attempt to breathe through a layer of saliva.

在濒死过程中，吞咽协作变成了一些虚弱的、不合时机的运动。有时，舌头会在会厌挡住气管之前推动唾液向后走。还有些时候，舌头完全没有推动，导致唾液沿着气管不断慢慢流入肺部。濒死喉声是肺努力透过一层唾液呼吸的声音。

Despite the sound’s alarming roughness, it’s unlikely that the death rattle is painful. The presence of a death rattle doesn’t correlate with signs of respiratory distress.

尽管濒死喉声听起来特别艰难，但它不大可能是痛苦的。濒死喉声并不一定意味着呼吸困难。

As often happens in medicine, we treat based on intuition. To lessen the volume of the death rattle, we give medications that decrease saliva production. Sometimes, we are successful in silencing the rattle. More of the time, we placate our instinctive concern for a noise that probably sounds worse than it feels. Without hurting our patients, we treat the witnesses who will go on living.

在医学中，我们常常根据直觉进行治疗。为了降低濒死喉声的音量，我们会使用一些减少唾液产生的药物。有时，我们能成功消除这种声音。更多的时候，我们是在安抚对这种很可能听起来比感觉上更难受的声音的本能关切。在不伤害患者的前提下，我们要治疗那些还要继续活下去的旁观者。

Air Hunger

空气饥渴

“You villain touch! What are you doing? My breath is tight in its throat” (Walt Whitman)

“你这恶棍的触碰！你在干什么？我的喉咙发紧”（沃尔特·惠特曼）

The patient was a wiry woman in her 80s who had smoked for seven decades. Cigarettes turned her lungs from a spongelike texture to billowing plastic bags that collapsed on themselves when she exhaled. It was like trying to scrunch all the air out of a shopping bag. Air got trapped.

这位患者是一名80多岁的精瘦女人，她吸了70年烟。烟草把她的肺部从海绵状结构变成了鼓胀的塑料袋，她呼气时，塑料袋就塌陷了。这就像试图把一个购物袋里的空气都挤出去。空气被困在了里面。

Air hunger — the uncomfortable feeling of breathing difficulty — is one of the most common end-of-life symptoms that doctors work to ease.

空气饥渴——呼吸困难的不舒服感觉——是医生们努力缓解的最常见临终症状之一。

The treatment? Opiates, usually morphine.

治疗方法是什么呢？麻醉剂，通常是吗啡。

People sometimes ask why the treatment for painful breathing is a medication that can depress breathing. You’d guess that opiates would worsen air hunger.

人们有时会问，为什么治疗痛苦的呼吸困难的药物是一种会抑制呼吸的药物。你可能会觉得，麻醉剂会加重对空气的渴求。

The answer hinges on defining why air hunger is uncomfortable in the first place.

答案的关键在于弄清为什么空气饥渴让人不舒服。

Some researchers think the discomfort of air hunger is from the mismatch between the breathing our brain wants and our lungs’ ability to inflate and deflate. Opiates provide relief because they tune our brain’s appetite for air to what our body can provide. They take the “hunger” out of “air hunger.”

有些研究者认为，空气饥渴的不适源于大脑想要的呼吸量与肺部吸气和呼气的能力不相匹配。麻醉剂的作用在于它微微调整了大脑对空气的需求量，使之与身体能够提供的量相匹配。它将“空气饥渴”中的“饥渴”去除了。

Others believe that the amount of morphine needed to relieve air hunger may have little effect on our ability to breathe. Since air hunger and pain activate similar parts of the brain, opiates may simply work by muting the brain’s pain signals.

还有些人认为，缓解空气饥渴所需的吗啡量对呼吸能力几乎没有影响。因为呼吸渴求和疼痛激活的是大脑的类似部位，麻醉剂的作用可能只是消除了大脑的痛苦信号。

The patient traded her cigarettes for a breathing mask when she came to the hospital. She quit smoking for the umpteenth time and made plans to go home and live independently again. A few days later, her thin frame tired. She died in hospice.

这位患者到医院时，用呼吸面罩取代了香烟。这是她第无数次戒烟，她还准备着回家重新开始独立的生活。几天后，她消瘦的身体疲倦了，她在临终关怀中去世。

Terminal Agitation

临终烦躁

“Do not go gentle into that good night” (Dylan Thomas)

“不要温和地走进那个良夜”（狄兰·托马斯）

My grandfather screamed two days before he died. “Open that door and let me out! Right now! It’s a travesty! Open that door!”

我祖父去世前尖叫了两天。“打开那扇门，让我出去！现在！这太荒唐了！打开那扇门！”

It was the scream of a lost child. My grandfather’s eyebrows, which had been lost over the years from the outside inward so that only a centimeter of long gray hairs near the middle remained, tilted toward each other.

那是一个迷失的孩子的尖叫。祖父的眉毛这些年从外往里慢慢脱落，只留下中间那一厘米灰色长毛，向彼此倾斜。

Until then, we were preparing for missing and absence. Not for an agitated delirium. Not for rage.

在那之前，我们都准备好面对思念以及他离去后留下的空白。没人料到他会出现烦躁的精神错乱。没人料到他会狂怒。

A famous poet once wrote that “dying is an art, like everything else.” For hospice doctors, the artists of death, terminal agitation is the subject’s revolt against the shaper. It’s uncommon, but it can be difficult to watch when it happens.

一位著名的诗人曾经写道，“死亡是一种艺术，和其他任何事物一样。”临终关怀医生就是死亡艺术家，对他们来说，临终烦躁是作品对塑造者的反抗。它不常见，但发生时，看着很难受。

Instead of peacefully floating off, the dying person may cry out and try to get out of bed. Their muscles might twitch or spasm. The body can appear tormented.

濒死者不是平静地离去，而是可能大喊大叫，想要下床。他们的肌肉可能会抽动或痉挛。他们的身体可能看起来极度痛苦。

There are physical causes for terminal agitation like urine retention, shortness of breath, pain and metabolic abnormalities. There are medications that quell it. Yet it’s hard to discount the role of the psyche and the spiritual.

临终烦躁有一些身体上的原因，比如尿潴留，呼吸困难，疼痛和新陈代谢紊乱。有些药物可以缓解烦躁。不过很难不去考虑心理和精神上的因素。

People who witness terminal agitation often believe it is the dying person’s existential response to death’s approach. Intense agitation may be the most visceral way that the human body can react to the shattering of inertia. We squirm and cry out coming into the world, and sometimes we do the same leaving it.

见过临终烦躁的人经常认为，它是濒死者面对死神的来临而做出的求生反应。剧烈的烦躁可能是人的身体对惯性改变的最本能反应。我们哭喊着来到这个世界，有时我们也同样哭喊着离开。