The Family Illness Trajectory -Passage Thru Sufferings

1. The Family Illness Trajectory-Passage Thru Sufferings Group 11C Abuan, Ryan Marquez, Charmaine Meollo, Arejenald Merencilla, Rupert Morillo, Laurence Pagdanganan, Simeon Arni

2. THE FAMILY ILLNESS TRAJECTORY- PASSAGE THRU SUFFERINGS • Normal course of the psychosocial aspects of disease for the patient and the family • Knowledge of trajectory allows the physician to predict, anticipate , and deal with a family’s response to illness • Indicates normal and pathologic response thus enabling family physicians to formulate special therapeutic plan

3. THE STAGE IN FAMILIY ILLNESS TRAJECTORY ARE: 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 permanency of the outcome

4. Stage I- ONSET OF ILLNESS • The stage experienced prior to contact with medical care providers. Medical beliefs and previous experiences provide influence to meaning of illness • The warning sign of malaise which initiates preliminary stage of the illness trajectory • Nature of onset may play an important role on impact of illness on a family and some meaning of experiences are formulated here

6. RESPONSIBILITIES OF THE PHYSICIAN • Explore routinely the explanatory model and fear that patients bring to the Clinical set-up • Within inappropriate label of illness, acknowledge and explore conflict the patient maybe experiencing • Explore several aspects of pre-diagnostic phase of patient and families

7. STAGE II- REACTION TO DIAGNOSIS: IMPACT PHASE • The physician who presents the diagnosis is responsible for making a clinical judgment about the amount of information the patient can absorb. • It is important that the physician elicits explanatory model of diagnosis to patient if disease is not life threatening and patient is liable to be unduly alarmed. • Disease and appropriate treatment can be described according to the patient’s level of comprehension and understanding. Unnecessary frightening anxiety may occur if information are not understood.

8. 3. Give small doses of information over time 4. If the diagnosis is confusing and stressful and shuttering, the family physician must: • Provide support and continuity of care • Interpret findings which are misunderstood • Offer advise and encouragement • And clarify meaning and specialist’s message and outcome of illness and operation

9. 2 plane or areas by which family and patient react and adjust:

10. 2 plane or areas by which family and patient react and adjust:

11. RESPONSIBILITIES OF THE PHYSICIAN • Anticipate number of problems and help families to cope and adapt more through family conference, discussion with parents, etc. • Specifically: • Encourage to elucidate clearly to each other the nature of the Illness • Maintains Oppenness • Allows sharing and support • Non-sharing and silence • Limit openness and spontaneity • Isolation and Abandonment

12. -The physician should know that feeling of guilt is a natural response to stress of grief and loss -Family members may have the irrational feeling that they personally caused the patient’s disease -The physician should help family members anticipate such feelings and make realistic efforts to relieve patient of self-blame through careful explanation of etiology

13. 3. Assess the likely effect of the illness on the family, predict problems likely to arise; develop plans for realistically coping with them; and assess the family capabilities to deal with such stress. 4. The physician should briefly help the family understand some of the problems as well as benefits to be expected from family and friends who offer support. 5. Offer alternative interpretation of proposed therapeutic-bolster family’s denial and inability to accept reality.

14. STAGE III- MAJOR THERAPEUTIC EFFORTS -management/therapy represents one of the most challenging and rewarding part of medical practice -the physician should deal with multiple variables, works in harmony of the wishes of the patient and family and coordinates all aspects of therapy which involve specialist and others

15. CRITICAL ISSUES IN CHOOSING THERAPEUTIC PLAN • Psychological state and preparedness of the patient and family -belief system and trust • Thus, the physician should investigate for signs of non-compliance -not emotionally equipped to undertake some form of therapy so other professional help should be obtained

16. 2. Assumption of responsibility for care very early in the treatment plan. Thus, we have to establish and define responsibilities of each party. Give realistic role to everyone. 3. Economy of therapeutic plan-> Of what good is therapy if family cannot afford it. The sickness will have devastating effects on the family economically speaking. -diligence on the part of physician in keeping costs down by involving family in all major decisions which affect the patient as in-request for tests/referrals which are really necessary

17. -economic impact of illness: a. emotional trauma b. social dislocation c. economic catastrophe- wipes out family savings 4. Lifestyle and cultural characteristics of a family are important in choosing a therapeutic plan. 5. Effects of hospitalization, surgery and other major therapeutic method are emotionally stressful for the patient’s family. There is fear and concern in the families who are still essentially helpless, unable to participate in the suffering or need to relieve the constant discomfort or anguish

18. -Hospitalization gives rise to stressful logistic problem a. Father- special economic burden b. Mother- greatest impact on the family members. It poses high risk of family dysfunction. c. Children- special syndrome of emotional problems of families. Hostility, abandonment d. Parents- helpless, guilt, frustrated, or hurt e. Geriatric- vulnerable to fears of death, rejection, abandonment, loneliness, and helplessness

19. -Hospitalization *loss of member- reserve position upon return *conflict between family and hospital staff- intrussion

20. RESPONSIBILITIES OF THE PHYSICIAN • Remain open to the family, indicate that they will not be abandoned, provide them information • Deal with multiple variables; consider all factors in planning • Work in harmony with patient and family • Coordinate all aspects of therapy • Anticipate pathologic response. Such response of family members occur when there is severe emotional symptom of deep depression; psychological reaction and organic symptoms behavioral problem like addiction to alcohol work inhibition and pathologic acting out

21. STAGE IV- EARLY ADJUSTMENT TO OUTCOMES- RECOVERY • Return from the hospital or major therapy initiates a period of gradual movement from the role of being sick to some form of recovery or adaptation with corresponding adjustments of relation within family • Experience of recovery or adjustment to the illness outcome is an important phase for patients and families. It varies according to the type of outcome anticipated.

22. - simplest outcome is return to full health *gains from illness experience *patient nurtured and allowed to take over the abandoned obligation. New responsibilities and privileges when sick - partial recovery followed by a period of waiting to learn if disease will return or fear of death because of long period of waiting. They maintain constant sense of vulnerability. - recovery is quite different if it requires acceptance of a known permanent disability

23. RESPONSIBILITIES OF THE PHYSICIAN: • Deal with immediate effects of trauma • Alleviate anxiety and assure adequate rest • Psychological support can be given through understanding and repeated reassurance • Explore level of understanding of patient and family. Call on other members of family for means of support. Try to find out how members understand what happened, what kind of labeling do they have. Do they label person as still ill or do they label him as once again well or has returned to health

24. STAGE V- ADJUSTMENT TO THE PERMANENCY OF THE OUTCOME • This point to the family’s adjustment to crisis • The second crisis occurs as family realizes that they must accept and adjust to a permanent disability. The whole family must begin and give hope for the patient’s full return to health. They have to accept that life must go forward and pattern believed to be temporary must be accepted as permanent. The family physician should be aware that the continued unwillingness to incorporate that reality of the permanency of the loss may be sign of pathology.

25. Coping mechanism is developed during earlier stage of family adjustment. *person who is sick continued to be treated as sick and he is treated as patient and not reintegrated into the family *treat patient as recovered, full, responsible person • For acute illness: There is potential for crisis especially when family routines are suspended. Emotions are high and can lead to anger especially if the family perceives that the care given by the doctor is not satisfactory. Because of suddenness of illness, family may find it difficult to face the stress.

26. What the family physician can do is to facilitate healthy response or Acceptance of diagnosis and recognize danger signals such as delayed or prolonged reaction -For chronic Illness: Because of prolonged fear and anxiety there is higher incidence of illness in other members of the family. If the chronic burden brings about additional burden and sometimes feeling of guilt especially if the sick member was previously neglected then as a result of this feeling the family becomes over-indulgent toward the sick and this will later result into feeling of overwork. Thus anger and resentment toward sick member sets in leading back to feeling of guilt later

27. What the physician can do is to encourage ventilation of feelings, give reassurance and reinforcement for care -For Terminal Illness: This is highly emotional and potentially devastating. The moment of diagnosis of a major debilitating or terminal disease is often remembered by patient in their families as the single most difficult time of the entire illness experience. A a reaction to shattering diagnosis, the patient and his family anticipate grief reaction. If the family is functional, members will be drawn close together to provide care and support to the patient and to each other. If the family is dysfunctional, it can be the seed for future family discord and breakdown

28. The initial response in diagnosis of terminal illness is that of shock and overwhelming anxiety. As they respond to the pain with denial and disbelief, the patient may say. “This could not be happening to me” The physician can: • Assist the patient and the family in relating to health care system. • Aid the patient and the family in efficient and functional readjustment. • Provide quality care. Home care is the best and most accepted and the least demanding, thus it should be facilitated.

29. Family Reaction to Death In after prolonged severe illness and adaptation and reaction are already accomplished Death comes swiftly and MD to assist family to cope a. Stage of denial- few days to few weeks If prolonged- premorbid pattern of abnormal behavior b. Anger c. Depression d. Bargaining e. Acceptance