Wolfson Institute of Population Health, Queen Mary University of London, London, UK.
Soc Sci Med. 2022 Jan;292:114532. doi: 10.1016/j.socscimed.2021.114532. Epub 2021 Nov 3.
Primary care management of patients with multimorbidity in the UK is underpinned by clinical guidelines, quality standards and measurable targets which govern practices of risk management and disease control. There is concern that standardised approaches may not always be appropriate for older patients living with multimorbidity. Using a narrative approach, we elicited the voices of older people living with multiple conditions in order to rethink chronicity, and consider what their accounts might mean for reconfiguring care practices. Within an ethnographic study of multimorbidity and polypharmacy, we conducted in-depth interviews, based on the Biographical Narrative Interpretive Method, with 24 participants aged 65 to 94. Participants were recruited from three general practices in England. All had two or more chronic conditions and were prescribed ten or more medicines. Our analysis draws on Bakhtinian theory, tracing the multiple ways in which participants voiced living with multimorbidity. In this paper, we focus on 'keeping in balance' which emerged as a key meta-conceptualisation across our dataset. Adopting the metaphor of the 'multimorbidity tightrope' we explore the precarity of patients' experiences and show their struggle to create coherence from within a deeply ambiguous living situation. We consider how and to what extent participants' narrative constructions co-opt or resist normative biomedical framings of multimorbidity. Our analysis foregrounds the complex ways in which patients' voices and values may sometimes be at odds with those promoted within professional guidelines. Narrative approaches may offer significant potential for reorienting healthcare towards enabling patients to live a flourishing life, even when facing significant adversity.
在英国，对患有多种疾病的患者的初级保健管理以临床指南、质量标准和可衡量的目标为基础，这些标准规范了风险管理和疾病控制的实践。人们担心标准化方法并不总是适用于患有多种疾病的老年患者。我们采用叙述方法，倾听了患有多种疾病的老年人的声音，以便重新思考慢性病，并考虑他们的叙述可能对重新配置护理实践意味着什么。在对多种疾病和多种药物治疗进行的民族志研究中，我们对来自英格兰三个全科医生诊所的 24 名年龄在 65 岁至 94 岁之间的参与者进行了深入访谈，这些参与者的访谈都是基于传记叙事解释方法进行的。所有参与者都患有两种或两种以上的慢性疾病，并服用十种或更多的药物。我们的分析借鉴了巴赫金理论，追溯了参与者表达患有多种疾病的多种方式。在本文中，我们关注的是“保持平衡”，这是我们整个数据集的一个关键元概念化。我们采用“多种疾病平衡木”的隐喻，探索了患者体验的脆弱性，并展示了他们在一个充满深刻歧义的生活情境中努力创造一致性的挣扎。我们考虑了参与者的叙述结构如何以及在何种程度上认同或抵制多种疾病的规范生物医学框架。我们的分析突出了患者的声音和价值观有时可能与专业指南中所倡导的价值观不一致的复杂方式。叙述方法可能为重新调整医疗保健方向以帮助患者过上繁荣的生活提供重要潜力，即使他们面临重大逆境。
