Cassell E J
Weill Medical College, Cornell University, New York, New York, USA.
Ann Intern Med. 1999 Oct 5;131(7):531-4. doi: 10.7326/0003-4819-131-7-199910050-00009.
The alleviation of suffering is crucial in all of medicine, especially in the care of the dying. Suffering cannot be treated unless it is recognized and diagnosed. Suffering involves some symptom or process that threatens the patient because of fear, the meaning of the symptom, and concerns about the future. The meanings and the fear are personal and individual, so that even if two patients have the same symptoms, their suffering would be different. The complex techniques and methods that physicians usually use to make a diagnosis, however, are aimed at the body rather than the person. The diagnosis of suffering is therefore often missed, even in severe illness and even when it stares physicians in the face. A high index of suspicion must be maintained in the presence of serious disease, and patients must be directly questioned. Concerns over the discomfort of listening to patients' severe distress are usually more than offset by the gratification that follows the intervention. Often, questioning and attentive listening, which take little time, are in themselves ameliorative. The information on which the assessment of suffering is based is subjective; this may pose difficulties for physicians, who tend to value objective findings more highly and see a conflict between the two kinds of information. Recent advances in understanding how physicians increase the utility of information and make inferences allow one to reliably use the subjective information on which the diagnosis and treatment of suffering depend. Knowing patients as individual persons well enough to understand the origin of their suffering and ultimately its best treatment requires methods of empathic attentiveness and nondiscursive thinking that can be learned and taught. The relief of suffering depends on physicians acquiring these skills.
减轻痛苦在所有医学领域都至关重要，尤其是在临终关怀中。除非痛苦被识别和诊断出来，否则无法得到治疗。痛苦涉及一些因恐惧、症状的意义以及对未来的担忧而威胁患者的症状或过程。这些意义和恐惧是个人化的，所以即使两名患者有相同的症状，他们的痛苦也会有所不同。然而，医生通常用于诊断的复杂技术和方法针对的是身体而非患者本人。因此，即使在重病情况下，甚至当痛苦明摆在医生面前时，痛苦的诊断也常常被遗漏。面对严重疾病时必须保持高度的怀疑指数，并且必须直接询问患者。倾听患者严重痛苦时的不适所带来的担忧，通常会被干预后的满足感所抵消。通常，只需花费少量时间的询问和专注倾听本身就具有缓解作用。用于评估痛苦的信息是主观的；这可能给医生带来困难，因为医生往往更看重客观发现，并认为这两种信息之间存在冲突。最近在理解医生如何提高信息效用并进行推理方面取得的进展，使人们能够可靠地利用痛苦诊断和治疗所依赖的主观信息。要充分了解患者作为个体，从而理解其痛苦的根源以及最终最佳的治疗方法，需要具备共情专注和非推理思维的方法，这些方法是可以学习和传授的。痛苦的缓解取决于医生掌握这些技能。
