THE MEDICAL PRAXIS IN THE EMERGENCY CARE IN THE PRESENCE OF THE PATIENT WITH CHRONIC SEQUELAE: GUILT, FEAR AND COMPASSION

Abstract What is the relationship between urgencies and chronic care? This question, which is appa-rently paradoxical, was approached in an ethnography conducted at the largest emergency care hospital of a Brazilian metropolis; the ethnography investigated medical care from admission to the confirmation of the clinical and functional condition of the patient with severe sequelae. Between December 2012 and August 2013, we conducted interviews and participant observation with 43 physicians: 25 men and 18 women, aged between 28 and 69 years. The analysis, which was guided by the signs, meanings and actions model, led to the realization that the care varies according to the context: at the ‘gateway’ and at the ‘intensive therapy center’, the struggle to maintain life is intense; at the “chronic patient” sector, care is provided to people who survive, but who have a high degree of dependence. For the physician, ‘life’ means regaining previous function, while survival with dependence would mean a ‘living death.’ The physician refrains from dealing with a highly-limited human being, for he/she feels somehow guilty of the clinical picture, even though he/she feels compassion towards the patient who requires chronic care. The insufficiency of a long-term care network and the lack of palliative training on the part of the physicians cause suffering in those who care and in those who are cared for.

摘要
急症与慢性病照护之间存在何种关联？这一看似矛盾的问题，本研究通过在巴西某大都市规模最大的急诊医院开展的民族志（ethnography）研究展开探讨。该民族志研究覆盖了从患者入院至确诊其存在严重后遗症的临床与功能状态的全流程医疗照护环节。
2012年12月至2013年8月期间，研究团队对43名医师开展了访谈与参与式观察（participant observation）：其中男性25名、女性18名，年龄介于28至69岁之间。本研究以符号、意义与行动模型为分析框架，结果显示照护实践因场景而异：在“急诊入口”与“重症治疗中心”，医护人员为维持患者生命展开高强度救治；而在“慢性病患者专区”，照护对象为已存活但存在高度功能依赖的人群。
对医师而言，“存活”意味着恢复患者既往功能，而仅维持依赖状态的生存则等同于“活着的死亡”。医师会回避照护高度功能受限的患者，尽管他们对需要长期慢性病照护的患者抱有同情，但仍会因患者的临床状况产生某种程度的愧疚感。长期照护服务网络的缺位与医师所欠缺的姑息照护培训（palliative training），同时给照护者与被照护者带来了痛苦。