Leon Piterman，梁艷嫦（譯），楊輝（譯）

【編者按】 澳大利亞的全科醫(yī)生具有行業(yè)自律性，體現(xiàn)在其自行制定行業(yè)標(biāo)準(zhǔn)、自主進(jìn)行資質(zhì)考核及自主執(zhí)業(yè)等方面，也體現(xiàn)在《The Medical Republic》這一共享平臺(tái)上。Leon Piterman是醫(yī)學(xué)學(xué)士，醫(yī)學(xué)博士，教育學(xué)碩士，英國(guó)醫(yī)生學(xué)會(huì)會(huì)員，澳大利亞全科醫(yī)生學(xué)會(huì)會(huì)員，Monash University副校長(zhǎng)、全科醫(yī)學(xué)教授，從事全科醫(yī)學(xué)臨床服務(wù)近40年，研究興趣為慢性病管理、心理健康、醫(yī)學(xué)教育。Piterman教授建議我國(guó)的全科醫(yī)生應(yīng)培養(yǎng)“共和”思想，以為全科醫(yī)學(xué)領(lǐng)域提供更多的平等交流機(jī)會(huì)。目前Piterman教授定期為《The Medical Republic》撰寫(xiě)文章，本刊深受“醫(yī)學(xué)共和”思想的啟發(fā)，特邀本刊編委Monash University楊輝教授對(duì)Piterman教授的文章進(jìn)行編譯，并進(jìn)行連載刊登！根據(jù)2018年世界家庭醫(yī)生組織家庭暴力特殊利益團(tuán)體（WONCA Special Interest Group on Family Violence）發(fā)出的公告，過(guò)去1年里有近1/6的老年人遭受了各種形式的虐待。虐待老年人主要包括軀體虐待、心理虐待、經(jīng)濟(jì)虐待及漠不關(guān)心4種常見(jiàn)形式，經(jīng)濟(jì)虐待是指監(jiān)護(hù)人不正當(dāng)?shù)貞?yīng)用老年人的收入和經(jīng)濟(jì)來(lái)源，或者未使用可得到的資金或經(jīng)濟(jì)來(lái)源來(lái)維持或恢復(fù)老年人的健康、幸福。本期Piterman教授為我們講述了一例遭受財(cái)務(wù)方面虐待的老年人的故事，以提醒全科醫(yī)生在為老年人提供健康服務(wù)時(shí)，應(yīng)以家庭為單位，關(guān)注其與家庭成員間的關(guān)系以及是否遭受了虐待，敬請(qǐng)關(guān)注！

湯姆和安妮是我所執(zhí)業(yè)診所的長(zhǎng)期就診患者，20世紀(jì)50年代初結(jié)婚時(shí)，他們搬進(jìn)了墨爾本東南郊區(qū)的多面磚房。墨爾本東南郊區(qū)在劃分成為住宅區(qū)之前，是蔬菜瓜果的種植地。那個(gè)時(shí)候幾乎不用擔(dān)心城市綠化帶的問(wèn)題，鐵路線(xiàn)和火車(chē)站也都建設(shè)得很到位，沒(méi)有現(xiàn)在面臨的基礎(chǔ)設(shè)施“追趕”不上都市擴(kuò)張速度的問(wèn)題。畢竟，這個(gè)郊區(qū)距離墨爾本的中央商務(wù)區(qū)僅16 km，不像現(xiàn)在的城市地鐵要向外延伸超過(guò)50 km。

湯姆和安妮的家庭，也跟著他們的社區(qū)一起成長(zhǎng)。他們的3個(gè)孩子，2個(gè)女兒、1個(gè)兒子，都是由我所在診所的全科醫(yī)生在當(dāng)?shù)厣鐓^(qū)醫(yī)院接生的?，F(xiàn)在，這家社區(qū)醫(yī)院已經(jīng)變成了腫瘤中心，悲傷的是，它已經(jīng)不再是新生命誕生的地方，而是很多人離世的地方。而在這個(gè)醫(yī)院里，也已經(jīng)沒(méi)有全科醫(yī)生可以施展的地方。

湯姆是一個(gè)高大、強(qiáng)壯、英俊的男子。在第二次世界大戰(zhàn)的太平洋戰(zhàn)場(chǎng)服過(guò)兵役，回國(guó)后做了木匠學(xué)徒。湯姆是一個(gè)有潛力的運(yùn)動(dòng)員，戰(zhàn)爭(zhēng)結(jié)束后，收到了好幾家足球俱樂(lè)部的邀請(qǐng)。如果換作現(xiàn)在，湯姆可能會(huì)成為球星，然后簽下利潤(rùn)豐厚的合同。但當(dāng)時(shí)，因?yàn)榻Y(jié)婚后孩子們相繼出生，湯姆選擇了木匠職業(yè)來(lái)養(yǎng)家糊口。

安妮現(xiàn)在70多歲，已經(jīng)開(kāi)始出現(xiàn)阿爾茨海默病的早期癥狀。湯姆說(shuō)安妮記不住自己把東西放在了什么地方，他不放心讓安妮一個(gè)人購(gòu)物或者做飯，而且要經(jīng)常提醒她去洗澡。安妮去老年病專(zhuān)家處就診過(guò)幾次，接受了一系列的檢查，最終被確診為阿爾茨海默病。

這時(shí)，他們的大女兒茱伊主動(dòng)提出，會(huì)帶安妮每周出去購(gòu)物1～2次，然后利用這些外出機(jī)會(huì)與母親一起喝咖啡、吃三明治。湯姆非常感激女兒的幫助，這樣他就可以有時(shí)間收拾花園，或者去退伍軍人俱樂(lè)部找老戰(zhàn)友回憶往事。茱伊的妹妹珍妮絲、弟弟埃里克也很高興，因?yàn)樗麄兌加腥毠ぷ?，沒(méi)有時(shí)間照顧安妮。

這樣的安排一直愉快地持續(xù)了8、9個(gè)月，直到有一天湯姆接到了銀行的電話(huà)。銀行雇員詢(xún)問(wèn)湯姆，是否知情儲(chǔ)蓄賬戶(hù)的額度已經(jīng)快消耗殆盡。這個(gè)儲(chǔ)蓄賬戶(hù)綁定了安妮的信用卡，近6個(gè)月來(lái)，賬戶(hù)里的額度通過(guò)定期取現(xiàn)、信用卡支付給在線(xiàn)賭博公司的方式，減少了35 000澳元，目前賬戶(hù)僅剩下5 000澳元。

湯姆來(lái)找我，淚流滿(mǎn)面、渾身顫抖、震驚、羞愧。他說(shuō)，他質(zhì)問(wèn)過(guò)茱伊，茱伊承認(rèn)自己賭博，并且承諾會(huì)把錢(qián)還回來(lái)。茱伊的妹妹和弟弟希望警察能介入這件事，但湯姆不能接受與親人對(duì)簿公堂，因?yàn)槟菢涌赡軙?huì)讓茱伊被關(guān)進(jìn)監(jiān)獄。茱伊提出，會(huì)和丈夫詹姆斯一起在12個(gè)月內(nèi)把錢(qián)還回來(lái)，湯姆接受了她的方案。但這個(gè)家庭的生活，不會(huì)再恢復(fù)到以前的樣子了。

隨著人口老齡化進(jìn)程的加快，虐待老年人的事件逐漸增多。目前年齡為65歲及以上的老年人口數(shù)約占15%，而在80歲及以上的老年人中約20%患有某種形式的意識(shí)障礙，虐待老年人的潛在風(fēng)險(xiǎn)較高。虐待老年人不僅局限在家庭里面，在養(yǎng)老機(jī)構(gòu)也常有發(fā)生。維多利亞州皇家家庭暴力委員會(huì)（Royal Commission into Family Violence）根據(jù)維多利亞警方和維多利亞老年人權(quán)益局提交的重要報(bào)告數(shù)據(jù)，提出了虐待老年人這一問(wèn)題的重要性［1］。

虐待可以發(fā)生在生理、性、情感、財(cái)務(wù)等很多方面，比如安妮遭遇的情況。當(dāng)虐待發(fā)生在家庭環(huán)境中時(shí)，通常很少會(huì)向警方報(bào)告，多數(shù)老年人只能默默忍受。據(jù)估計(jì)，5%～6%的澳大利亞老年人可能會(huì)遭到某種形式的虐待，且女性受害者多于男性。一般來(lái)說(shuō)，男性是施虐者，但50～54歲的女性成為施虐者的可能性也較大。安妮的女兒茱伊52歲，符合維多利亞老年人權(quán)益局報(bào)告中描述的施虐者類(lèi)型。多數(shù)被虐待的老年人年齡為70～84歲，多數(shù)施虐者的年齡為35～54歲。92%的施虐者與受害者具有一定關(guān)系，其中40%為受虐者的兒子，27%為受虐者的女兒，5%為受虐者的丈夫［1］。

很多全科醫(yī)生的老年患者遭受過(guò)虐待，或未來(lái)會(huì)遭受虐待。重要的是，在某些特定情況下，我們可以通過(guò)一些簡(jiǎn)單的提問(wèn)，婉轉(zhuǎn)地向老年患者提出這些問(wèn)題：你家庭成員的關(guān)系怎么樣？你和子女相處得怎么樣？你自己管理財(cái)務(wù)嗎？你有安排委托人嗎？湯姆信任他的女兒茱伊，但茱伊辜負(fù)了父親的信任，并導(dǎo)致了家庭關(guān)系的永久性破壞。在接下來(lái)的6個(gè)月里，湯姆的健康狀況急轉(zhuǎn)直下，安妮被送進(jìn)了養(yǎng)老機(jī)構(gòu)。1年后，湯姆和安妮相繼離世。我不知道他們的死亡證明書(shū)上，是否表明了真正死因。

譯 者 注：（1） 多 面磚 房（triple-front brick veneer），澳大利亞戰(zhàn)后（1050—1970年）的民居建筑風(fēng)格。特點(diǎn)為：正面有多個(gè)房間，錯(cuò)落排列，窗戶(hù)面對(duì)前院；墻壁是單層磚，黃色或棕色；房頂傾斜；窗子為鋁合金框；房間內(nèi)有地板，墻壁上少有裝飾。這種磚房是澳大利亞的“經(jīng)濟(jì)適用房”，造價(jià)較低，缺乏藝術(shù)感，是為了適應(yīng)戰(zhàn)后人口激增、住房需求快速增長(zhǎng)的情況。（2）蔬菜瓜果種植地（market-garden territory），一般位于城市郊區(qū)，每日向城市供應(yīng)新鮮蔬菜和水果。但隨著城市化，這些種植地被改建為住宅區(qū)，種植地逐漸外移。（3）綠色帶（green wedges），是城市的生態(tài)肺。（4）全科醫(yī)生在社區(qū)醫(yī)院接生孩子。澳大利亞傳統(tǒng)的全科醫(yī)生是在社區(qū)醫(yī)院里接生孩子或進(jìn)行小手術(shù)的，但目前這種傳統(tǒng)的全科醫(yī)生在城市地區(qū)基本不存在，部分農(nóng)村地區(qū)仍然存在。（5）退伍軍人俱樂(lè)部（RSL），澳大利亞的退役和服務(wù)聯(lián)盟，為從世界大戰(zhàn)戰(zhàn)場(chǎng)歸國(guó)的退伍軍人、犧牲軍人家屬提供同情和支持的社會(huì)組織。

志謝：特別感謝原文出版者《The Medical Republic》同意將此文編譯后刊登于《中國(guó)全科醫(yī)學(xué)》。

［1］Royal Commission into Family Violence.Royal commission into family violence full report［J］.Summary and Recommendations，2016，5（27）：1353-1384.

Tom and Annie were long-standing patients at our clinic.They had moved into their triple-front brick veneer in the south-eastern suburb of Melbourne when they married in the early 1950s.

This suburb was market-garden territory until the subdivisions hit.There was little or no talk of green wedges at that time，and a railway line and station were already in place，unlike some of the infrastructure "catch up" problems we now face in our ever-expanding metropolis.After all，this suburb is only 16 km from the CBD，unlike the current outer-metro sprawl which extends beyond 50 km.

Tom and Annie's family grew，as did their community.Their three children（two daughters and a son） were all delivered in the local hospital by GPs from our clinic.This community hospital is now a cancer centre.Babies no longer enter the world in this place；sadly，many people leave it.GPs have no role to play in this organisation.

Tom was a tall，strong，good-looking man who had completed a carpentry apprenticeship after returning from the Second World War where he served in the Pacific.He was a talented athlete whose skills were sought by several football clubs immediately after the war.Had he lived today，he may well have played football at an elite level and would have secured a lucrative contract.Recently married and soon with a growing family，Tom instead turned to his vocation as a carpenter to earn a living and support his family.

In her mid-70s，Annie began to show early signs of dementia.Tom highlighted the difficulty she was having remembering where she placed things，she could no longer be trusted to go shopping on her own or cooking meals and progressively needed reminding about showering.A series of tests and visit to a geriatrician confirmed the diagnosis of Alzheimer's dementia.

It was at this stage that Joy，their eldest daughter stepped in to help.She offered to take her mother shopping on a regular basis，once or twice a week，sharing coffee and sandwiches on these outings.Tom was very appreciative as it gave him time to spend in the garden or share some memories with old mates at the local RSL.

Joy's siblings，Janice and Eric，were also happy，particularly as they had full-time jobs and could not afford the time to care for Annie.

This arrangement continued happily for eight or nine months，until Tom received a call from the bank asking him if he was aware that their savings account which was linked to Annie's credit card had been progressively depleted over the past six months with $35 000 being removed over this time，through a mixture of regular cash withdrawals and credit card payments to an online betting agency.There was now only $5 000 left in the account.

Tom came to see me.He was tearful，shaking，shocked and mortified.He had confronted Joy，who admitted to a gambling problem and promised to pay the money back.Her siblings wanted the matter reported to the police.Tom could not bear the thought of a court case and the possibility of Joy spending time in jail.He agreed to accept Joy's offer，who，together with her husband James，undertook to pay the money back over a 12-month period.Life for the family was never the same again.

Elder abuse is becoming increasingly common as our population ages.With almost 15% of the population aged over 65，and up to 20% of people aged over 80 expected to suffer some form of dementia，the potential for elder abuse increases.

Elder abuse is not confined to family settings and often takes place in institutional settings.The Victorian Royal Commission into Family Violence devoted a section to elder abuse with important submissions from Victoria Police and Senior Rights Victoria.

Abuse may be physical，sexual，emotional or financial in nature，as was the case with Annie.When it occurs in family settings，it is often under-reported to police.Shame takes over.It is estimated that 5% to 6% of elder Australians may be affected by some form of abuse，with women affected more than men［1］.

Generally，males are the perpetrator，with the exception of perpetrators in the 50-54 year age group where women are more likely to be perpetrators［1］.

Joy，Annie's daughter was 52.Joy fits nicely the pattern described in The Senior Rights Victoria Study.Most elder abuse victims are aged 70-84，most perpetrators are aged 35 to 54，92% of perpetrators are related to the victim，40% are sons of the victim and 27% are daughters.Only 5%are husbands.

Many GPs will have older patients who have been abused，or will be abused in the future.

It is important that，in certain circumstances，we tactfully raise the subject with elderly patients by asking some simple questions：（1）How are relations in your family?（2）How do you get on with your children?（3）Do you manage your own finances?（4）Have you arranged power of attorney?

Tom trusted his daughter.That trust was misplaced and abused and family relations were permanently destroyed.

Tom's health deteriorated rapidly over the next six months and Annie was admitted to nursing home.A year later both were dead.

I was left wondering what to write on the death certificates as the true cause of death.Reference

［1］Royal Commission into Family Violence.Royal commission into family violence full report［J］.Summary and Recommendations，2016，5（27）：1353-1384.