<International Circulation>:  There was an interesting and long dialogue in your panel discussion this morning about when to have “the talk”， that is the talk that tells the patient that you， the physician， are beginning to realize that their disease is changing and perhaps progressing into a place that they are maybe not dealing with in reality.  When do you have that talk?

   《国际循环》：今天早上你们就关于何时进行“谈话”开展了一个有趣且长时间的专门小组讨论。“谈话”是指告诉患者，医生已经开始注意疾病正发生变化，也许会进展到实际上无法治疗的地步。那您认为应该何时与患者“谈话”。

　Prof Allen : hat is a great question.  We know that heart failure is a highly morbid and lethal disease and in the United States with average survival rate， once symptoms develop， of 4 to 5 years.  These are patients who are going to need to have that talk that they are often going to get worse and they are going to be confronting much worse symptoms and death.  So approaching that with the patient is， as we discussed， very difficult， and I think the first thing we would say is that there is not one talk.  This is a talk that has to happen multiple times.  In our culture we believe in patient autonomy， we believe that patients should have good information and then make their own decisions.  That may not be true for all cultures， but because we believe in patient autonomy in America we believe that we need to have an open dialogue， a lot of communication. If we continue to give the patient updates about how they are doing， what their choices are， then we have laid the foundation to give them guidance about what the best decisions are as they happen.  We mentioned a few milestones in the discussion we just had about when are good times to have that talk; it is not one time but rather there are many times to consider bringing it up.  Any time somebody is hospitalized it is a good time to talk with the patients about the possibility that the disease is progressing and they may need to think about changing their life and their therapies.  Anytime a defibrillator goes off I think is an excellent time to think about the possibility of advancing disease.  And I think any time that a patient wants to talk about it I think we really have to be sensitive to their needs and not shut them down.

    Dr Allen：这个是很严峻问题，我们知道心力衰竭是一种高度病态的和致命的疾病。在美国，出现症状的心力衰竭患者平均存活率为4-5年。若与这些患者进行“谈话”的话，通常会导致其病情恶化，而且他们将会面临更严重的症状和死亡。所以与这些患者谈话是非常困难，而且我认为首先我们想说的是，这并不是一次“谈话”，这种“谈话”应分几次进行。在我们的文化理念中，我们相信患