[An acute care response to chronic care: the American perspective]

American medical care has been characterized by an acute care and surgical orientation. This acute care focus has been reinforced by advances in infectious diseases and cardiology in the years since World War II. The success in acute care medicine, however, has resulted in a larger number of Americans who are older and suffering from chronic disease. Despite these demographic developments, there is a general inattention to chronic and long term care in medical education. Such a focus is needed because unlike acute care medicine which is dependent upon diagnostic categories, the provision of long term care is dependent upon functional status. Ethical considerations in long term care are also different than acute care. While the autonomy ethic is predominant in acute care settings, the needs of the chronically ill might be better addressed with a communitarian ethic of care. The autonomy ethic distorts the doctor-patient relationship most notably in chronic care by isolating the dependent patient from a community of care. The current euthanasia debate in the United States is symptomatic of the health care system's inability to provide adequate chronic, long term and palliative care to patients in great need.