死亡來臨是一種怎樣的感受

You and I, one day we’ll die from the same thing. We’ll call it different names: cancer, diabetes, heart failure, stroke.
將來有一天，我們都會因同樣的問題而死去。我們對它有不同的稱呼：癌症、糖尿病、心力衰竭，或中風。

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.
一個器官將會衰竭，然後是另一個。也可能同時衰竭。與那些跟你我的最初診斷相同卻繼續存活的人相比，我們與彼此更加相似。

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.
死亡有自己的生理機制和症狀。它是對自己的診斷。雖然死亡前的數週和數日可能因人而異，但對絕大多數疾病來說，死亡前的幾個小時都差不多。

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.
有些症狀，比如瀕死喉聲、空氣飢渴和臨終煩躁，似乎十分痛苦，但對瀕死之人來說，通常不是那麼難受。可以通過藥物進行治療。隨着世界各地出現越來越多的臨終關懷醫院，現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.
雖然我們中極少有人會經歷所有這些瀕死症狀，但我們大多數人將至少經歷其中一種。下面是可能出現的一些情況。

The Death Rattle
瀕死喉聲

“The graves are full of ruined bones, of speechless death-rattles” (Pablo Neruda)
“墳墓裏充滿腐爛的骨頭，和無語的瀕死喉聲”（巴勃羅·聶魯達）

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.
我們懷疑這個病人無法靠人工呼吸機活下去。一個血栓堵住了他大腦後部的一根血管，導致血液無法流向控制警覺的區域。他會因爲不夠清醒，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.
瀕死喉聲從氣管被移除開始，到生命結束終止。它是一種汩汩、嘎嘎的聲音，就像用吸管對着一杯水的底部吹氣。從瀕死喉聲開始到死亡的平均時間是16個小時。對他來說，是6個小時。

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.
瀕死喉聲是吞嚥功能障礙的一個症狀。正常情況下，我們的舌頭會升到嘴巴上部，將唾液、液體或食物向後推動。喉部的組織片“會厭”向前扇動，防止嚥下的物質進入氣管。

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.
在瀕死過程中，吞嚥協作變成了一些虛弱的、不合時機的運動。有時，舌頭會在會厭擋住氣管之前推動唾液向後走。還有些時候，舌頭完全沒有推動，導致唾液沿着氣管不斷慢慢流入肺部。瀕死喉聲是肺努力透過一層唾液呼吸的聲音。

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.
儘管瀕死喉聲聽起來特別艱難，但它不大可能是痛苦的。瀕死喉聲並不一定意味着呼吸困難。

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.
在醫學中，我們常常根據直覺進行治療。爲了降低瀕死喉聲的音量，我們會使用一些減少唾液產生的藥物。有時，我們能成功消除這種聲音。更多的時候，我們是在安撫對這種很可能聽起來比感覺上更難受的聲音的本能關切。在不傷害患者的前提下，我們要治療那些還要繼續活下去的旁觀者。

Air Hunger
空氣飢渴

“You villain touch! What are you doing? My breath is tight in its throat” (Walt Whitman)
“你這惡棍的觸碰！你在幹什麼？我的喉嚨發緊”（沃爾特·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.
這位患者是一名80多歲的精瘦女人，她吸了70年煙。菸草把她的肺部從海綿狀結構變成了鼓脹的塑料袋，她呼氣時，塑料袋就塌陷了。這就像試圖把一個購物袋裏的空氣都擠出去。空氣被困在了裏面。

Air hunger — the uncomfortable feeling of breathing difficulty — is one of the most common end-of-life symptoms that doctors work to ease.
空氣飢渴——呼吸困難的不舒服感覺——是醫生們努力緩解的最常見臨終症狀之一。

The treatment? Opiates, usually morphine.
治療方法是什麼呢？麻醉劑，通常是嗎啡。

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.
人們有時會問，爲什麼治療痛苦的呼吸困難的藥物是一種會抑制呼吸的藥物。你可能會覺得，麻醉劑會加重對空氣的渴求。

The answer hinges on defining why air hunger is uncomfortable in the first place.
答案的關鍵在於弄清爲什麼空氣飢渴讓人不舒服。

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.”
有些研究者認爲，空氣飢渴的不適源於大腦想要的呼吸量與肺部吸氣和呼氣的能力不相匹配。麻醉劑的作用在於它微微調整了大腦對空氣的需求量，使之與身體能夠提供的量相匹配。它將“空氣飢渴”中的“飢渴”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.
還有些人認爲，緩解空氣飢渴所需的嗎啡量對呼吸能力幾乎沒有影響。因爲呼吸渴求和疼痛激活的是大腦的類似部位，麻醉劑的作用可能只是消除了大腦的痛苦信號。

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.
這位患者到醫院時，用呼吸面罩取代了香菸。這是她第無數次戒菸，她還準備着回家重新開始獨立的生活。幾天後，她消瘦的身體疲倦了，她在臨終關懷中去世。

Terminal Agitation
臨終煩躁

“Do not go gentle into that good night” (Dylan Thomas)
“不要溫和地走進那個良夜”（狄蘭·托馬斯）

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兩天。“打開那扇門，讓我出去！現在！這太荒唐了！打開那扇門！”

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.
那是一個迷失的孩子的尖叫。祖父的眉毛這些年從外往裏慢慢脫落，只留下中間那一釐米灰色長毛，向彼此傾斜。

Until then, we were preparing for missing and absence. Not for an agitated delirium. Not for rage.
在那之前，我們都準備好面對思念以及他離去後留下的空白。沒人料到他會出現煩躁的精神錯亂。沒人料到他會狂怒。

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.
一位著名的詩人曾經寫道，“死亡是一種藝術，和其他任何事物一樣。”臨終關懷醫生就是死亡藝術家，對他們來說，臨終煩躁是作品對塑造者的反抗。它不常見，但發生時，看着很難受。

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.
瀕死者不是平靜地離去，而是可能大喊大叫，想要下牀。他們的肌肉可能會抽動或痙攣。他們的身體可能看起來極度痛苦。

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.
臨終煩躁有一些身體上的原因，比如尿瀦留，呼吸困難，疼痛和新陳代謝紊亂。有些藥物可以緩解煩躁。不過很難不去考慮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.
見過臨終煩躁的人經常認爲，它是瀕死者面對死神的來臨而做出的求生反應。劇烈的煩躁可能是人的身體對慣性改變的最本能反應。我們哭喊着來到這個世界，有時我們也同樣哭喊着離開。