Impact of Illness

on the Family
Mek Villafuerte-Solana, MD, DPAFP
FCH I
Sept. 15, 2009
1
 Objectives of the
Session
 Differentiate between disease and illness
 Determine reasons why impact of illness
on a family should be studied
 Learn the stages of the family illness
trajectory and the responsibilities of the
physician in each stage

2
 Why study impact of
illness?
 Sickness of a patient causes suffering and
severe disruption for the patient’s family
 Illness sets in motion processes that are
disruptive and hazardous to health of
family members
 Role reversal, income loss
 Prolonged and complicated illnesses result
in structural change within the family
system to a point that leads to different
roles and functions

3
 Problems Contributing to
the Disease Process
 Poverty
 Unemployment
 Other sickness in

the family
 Chronic family
 dispute
 Poor nutritional habit
 Inadequate housing
condition
4
 Disease vs Illness
Disease Illness
 Primary biologic  Includes the
psychophysiologi sufferer’s
c disorder experience of the
 Laboratory values disease
 Deeply embedded
in the social,
cultural, & family
context of the
person who is ill
 Meaning of illness
to the patient and
his family 5
 How is investigation
done?
Explore the patient’s explanatory
models
Explore for patient’s understanding of
the following issues:
› Etiology
› Pathophysiology
› Trajectory and outcome of his illness
› Appropriate treatment
6
 The Family Illness
Trajectory-Passage Thru
Sufferings
 Natural course of the psychosocial
aspects of disease
 Knowledge of the trajectory allows the
physician to predict, anticipate, and deal
with a family’s response to illness
 Indicates normal and pathologic
responses thus enabling physicians to
formulate special therapeutic plans
7
 Major Illnesses Involves
Loss of the Following
 Body parts
 Ability to carry out normal and treasured
activities
 Sense of self-esteem
 Dreams and plans for the future
 Sense of invulnerability of one’s self and in
love ones that keep existential fears of
impending death and separation at bay
8
 Stages in Family Illness
Trajectory
Stage I Onset of Illness to Diagnosis
Stage II Impact Phase-Reaction to
Diagnosis
Stage III Major Therapeutic Efforts

Stage IV Recovery Phase- Early

Adjustment to Outcome
Stage V Adjustment to the Permanency
of the Outcome

9
Stage I
ONSET OF
ILLNESS

10
 Stage I- ONSET OF
ILLNESS
Warning sign of malaise which
initiates preliminary stage of the
illness trajectory
Stage experienced prior to contact
with medical care providers
Nature of illness may play an
important role on impact of illness

11
 Case # 1

 Roberto, 32, father of 3 small

children, applied as a seaman
1 year ago. After 6 months of
being away from his family, he
died of fatal arrhythmia while
aboard his ship.
12
 Case # 1

 Nature of illness  Acute, rapid

 Nature of onset  Rapid, clear onset
 Characteristics of  Provide little time
experience for
physical/psycholog
 Impact on family ical adjustments
 Caught up in
suddenness
 Immediate
decision
 Little support w/in
and outside family
13
 Case # 2
Nilo, 26, father of 2, sole provider,
worked as a messenger for 2 years.
He encountered a motorcycle
accident 1 year ago which left half of
his body, from the waist down,
paralyzed. His wife accepts laundry
work from neighbors in order to feed
their family and take care of Nilo’s
needs and medications.
14
 Case # 2
 Nature of illness  Chronic,
 Nature of onset debilitating
 Characteristics of  Gradual onset
experience  Suffer from state
of uncertainty
over meaning and
symptom
 Impact on family  Vague
apprehension and
anxiety
 Fear, denial of
seriousness of
symptoms and
possible
implications 15
 What will your
responsibilities as a
physician be?
Explore fear that the patients/ family
bring up in the clinic
With inappropriate label of illness,
acknowledge and explore conflicts
the patient and family may be
experiencing
Explore aspects of pre-diagnostic
phase of patients and families
16
Stage II
REACTION TO
DIAGNOSIS:
IMPACT PHASE

17
2 PLANES OR AREAS BY
WHICH A PATIENT/FAMILY
REACT AND ADJUST

EMOTIONAL PLANE
 Denial, disbelief, anxiety (min to hrs)
 Emotional upheaval such as anger,
anxiety and depression (wks)
 Accommodation and acceptance

18
 2 PLANES OR AREAS BY
WHICH A PATIENT/FAMILY
REACT AND ADJUST
COGNITIVE PLANE

 Phase 1: Tension and confusion, lack of

capacity for problem solving
 Phase 2: Repeated failure in deriving the
diagnosis leading to increased distress
 Phase 3: Receptivity of family to new
approach for relief of distress
 Phase 4: Eventual acceptance of
diagnosis
19
 Case # 3
Mae, 21, with a 18 month old old child, was
diagnosed with Lymphoma 6 months ago. Due
to lack of funds, her mother, who is also the
caregiver, has tried several faith healers and
other therapeutic modalities to comfort Mae’s
symptoms.
When asked about Mae’s family history of
cancer, her mother said that her husband, Mae’s
father, died of liver CA in the hospital where Mae
was diagnosed with Lymphoma. She expressed
her fears regarding the management and the
appropriateness of care in the hospital.

20
Case # 3
Mae continued to have anorexia
and vomiting, back pain, cough, and
difficulty of breathing.
Also, she has been depressed for
the last three months because aside
from her illness, her husband was
rumored to be having another girl,
limiting his time in caring for Mae.

21
 Emotional  Anxietyand
plane where depression
the patient is
now
 Phase 2 to 3
 Phase in the Failure to derive
cognitive the diagnosis
plane where Trial of different
the patient is approaches to
now relieve stress

22
Responsibilities of the
Physician
 Anticipate problems and help family cope and
adapt through family meetings/ discussion
 Make clear about the nature of illness by
helping the family maintain openness that
allows sharing and support
 Know that the feeling of guilt is a natural
response to stress of grief and loss, anticipate
such feelings, and make realistic goals to
correct the feeling

23
Responsibilities of the
Physician
 Help the family assess the likely
effect of the illness on the family
Assess the capability of the
family to cope with stress
Offer alternative interpretation
of proposed therapeutics

24
 Describe disease and treatment
according to patient’s level of
comprehension and understanding
 Make a clinical judgment about the
amount of information to give and be
absorbed by the patient
 Give small doses of information over time
 If diagnosis is confusing or stressful
› Provide support and continuity of care
› Interpret findings
› Offer advise and encouragement

25
Stage III
MAJOR
THERAPEUTIC
EFFORTS

26
Stage III- Major
Therapeutic Efforts
Represents one of the most
challenging and rewarding part
of medical practice
Physician should deal with
multiple variables
› work in harmony with the wishes of the
patient and family
› Coordinate all aspect of the therapy
27
 Therapeutic Triangle

Family

Physician Patient
Doherty & Baird
28
WORKING WITH FAMILIES

METHODS:

Family-oriented
approach with individual
patient
Involving family
members in routine office
visits
Family conference/
meeting
29
 Involving Family
Members in Routine
Office Visits
 One or more family members are present
 Common medical Situation: Well-child and
prenatal care, diagnosis of a chronic
illness
 Length of visit: 15-20 min
 How scheduled: Request family member
attendance
 Family Interviewing

30
Involving Family Members
in Routine Office Visits
DO’s DON’Ts
 Greet each family  Don’t let any one
member person monopolize
 Acknowledge any the conversation
emotions expressed  Don’t allow family
 Encourage family members to speak
members to be for each other
specific  Don’t offer
 Maintain an interpretations
empathic and non early in the
critical stance with interview
each person
31
Involving Family Members
in Routine Office Visits

DO’s DON’Ts
 Emphasize  Don’t breach
individual and patient
family strengths confidentiality
 Block persistent  Don’t take sides
interruptions in a family
conflict

32
 Family Conferences
 A specially arranged meeting requested by
the physician, patient or family to discuss
the patient’s health problem in more depth
than can be addressed during a routine
office visit
 Medical Situation: Terminal Illness

Institutionalization
 Length of visit: 30-40min

33
Phases of Family
Conferences
 Joining Phase- develop rapport with
family
› create a sense of trust
 GoalSetting- why the family has been
convened

34
Phases of Family
Conferences
 Information Exchange- Ask what the
family knows about the patient’s illness;
Educate family about the illness
 Establishing a Plan- develop a mutually
agreed upon treatment plan and clarify
each person’s role in carrying it out

35
CRITICAL ISSUES IN
CHOOSING
THE THERAPEUTIC PLAN
 Psychological state and preparedness of
the patient and family
 Assume responsibility of care very early in
the treatment plan. Define roles
 Economic status
› Economic impact of illness
a. Emotional trauma
b. Social dislocation
c. Economic catastrophe

36
CRITICAL ISSUES IN
CHOOSING
THE THERAPEUTIC PLAN
 Lifestyle and cultural
characteristics of the family
 Effects of hospitalization,
surgery, and other therapeutic
methods are emotionally
stressful to the family

37
CRITICAL ISSUES IN
CHOOSING
THE THERAPEUTIC PLAN
 Hospitalization gives rise to stressful logistic
problems
› Father- special economic burden
› Mother- greatest impact on other family members;
high risk of family dysfunction
› Children- syndrome of emotional problems;
hostility, abandonment
› Parents- helpless, guilt, frustrated, or hurt
› Geriatric- vulnerable to fears of death, rejection,
abandonment; loneliness and helplessness

38
 RESPONSIBILITIES OF THE
PHYSICIAN
Remain open and work in harmony
with the patient and his family
Deal with multiple variables; consider
all factors when planning
Coordinate all aspects of therapy
Anticipate pathologic responses and
be able to deal with them
39
 Case # 4
56/M, married with 3 children, came in
due to cough for 1 month.
CXR: Cavitary lesion at right apex
Diagnosis: Pulmonary Tuberculosis
Tx: 2 months HRZE, 4 months HR
How will you tell this patient that he has
PTB and convince him to take his medications?

40
Stage IV
EARLY ADJUSTMENT
TO OUTCOMES-
RECOVERY

41
 Stage IV-Early Adjustment
to Outcomes-Recovery
 Return from the hospital or major therapy
 Gradual movement from the role of being
sick to some form of recovery or
adaptation
 Adjustment of relation within the family

42
 Types of Outcomes
 Return to full health
› Gains from illness experience
› Patient allowed to take over abandoned
obligation
 Partial recovery
› Followed by a period of waiting to see if
illness will return
› Fear of death
› Constant sense of vulnerability
 Permanent disability
43
RESPONSIBILITIES OF THE
PHYSICIAN
 Deal with immediate effects of
trauma
 Alleviate anxiety and assure
adequate rest
 Psychological support
 Explore level of understanding of
patient and family
44
Stage V
ADJUSTMENT TO
THE PERMANENCY
OF THE OUTCOME

45
 Stage V- Adjustment to
the Permanency of the
Outcome
 Family’s adjustment to crisis
 Second crisis occurs as family realizes
that they must accept and adjust to a
permanent disability
 FOR ACUTE ILLNESS: Potential for
crisis when routines are suspended
› Physician can facilitate acceptance of
diagnosis
46
Stage V- Adjustment to
the Permanency of the
Outcome
 FOR CHRONIC ILLNESS: Prolonged
fear and anxiety leads to higher
incidence of illness in other members of
the family
› Feeling of guilt brings about anger and
resentment
› Physician should encourage ventilation of
feelings, give reassurance and
reinforcement of care
47
Stage V- Adjustment to
the Permanency of the
Outcome
 FOR TERMINAL ILLNESS: Highly
emotional and potentially devastating
› Single most difficult time of the entire illness
experience
› If family is functional: members are drawn
close together
› If family is dysfunctional: seed for future
family discord and breakdown
› Physician should provide quality home care
48
49
50
Questions?

51
 Group activity

Form groups of 5 members each

Discuss a given case and answer
the questions that follows
Submit answers at the end of the
session

52
 Case# 5
49/M, married with 4 children, works as a
seaman. He was supposed to board back
to his ship when his agency did not allow
him him due to high blood sugar
FBS: 235mg/dl
History:polyuria, polydipsia, polyphagia
Family History of DM
How will you present your diagnosis, and
educate the patient about the disease?
How will you present your management
and convince the patient to adhere
to the prescribed medicines? 53