FAMILY IN STRESS, ILLNESS & CRISIS

A crisis

What occurs when a person and/or family is confronted with a critical incident or stressful event perceived as overwhelming despite traditional coping strategies?

Any stressful event perceived as overwhelming

What may trigger a crisis?

The appraisal of the event as serious, uncontrollable, and beyond the patient’s and families’ resources for coping

What primarily triggers a crisis response, rather than the stressful event itself?

To provide examples of critical incidents or stress events

What is the purpose of Table 1?

Developmental, Existential, Environmental, Medical, Psychiatric, Situational

What are the six types of critical incidents or stress events listed in Table 1?

Birth of child, graduation from college, midlife career change, retirement

What are examples of Developmental life-transition events that may trigger a crisis?

Inner conflicts and anxieties related to purpose, responsibility, independence, freedom or commitment

What characterizes Existential critical incidents?

Realization that one will never make a significant impact on one’s profession, remorse that one has never married or had children, despair that one’s life has been meaningless

What are examples of Existential crises?

Natural or man-made disasters

What are examples of Environmental critical incidents?

Tornado, earthquake, floods, hurricanes, forest or grass fires

What are examples of Environmental disasters that may trigger a crisis?

A newly diagnosed medical condition or an exacerbation of a current medical problem

What type of event is classified as a Medical critical incident?

Multiple sclerosis, human immunodeficiency virus infection, infertility, myocardial infarction, cancer, medical problems that result in partial or total disability

What are examples of Medical critical incidents?

Actual syndromes and those that affect coping

What type of events fall under Psychiatric critical incidents?

Depression or suicidal thoughts, events precipitating acute or post-traumatic stress disorder

What are examples of Psychiatric critical incidents?

Uncommon, situation-specific events

What defines Situational critical incidents?

Loss of job, vehicular accident, divorce, rape

What are examples of Situational critical incidents?

Kavan, M. et al. A Practical Guide to Crisis Management. American Family Physician. October 2006

What is the source for Table 1, listing critical incidents and stress events?

Medical conditions are stressful events that may trigger a crisis

Why must physicians understand how medical conditions affect patients and families?

Physiological abnormalities taking place in the patient’s body

What does DISEASE refer to?

The person’s perceptions, emotions, and experiences of the disease, as well as the suffering and changes the patient and the family have to undergo in the presence of that disease

What does ILLNESS encompass?

Creates stress and requires a certain degree of adjustment

What is the impact of illness on the individual afflicted and their family?

Understand and support them and their families as they cope with the illness

What is a part of managing patients for physicians, related to illness?

Knowledge of the illness timeline and typology of disease as well as its trajectory

What knowledge can help physicians predict the impact of illness and decide on interventions?

A scheme that defines and classifies illnesses

What is Typology of illness?

Acute or chronic

How do some literature categorize illnesses according to their nature?

Rapid with clear onset, provides little time for physical and psychological adjustment

What characterizes an ACUTE illness?

Gradual onset, could be incapacitating or debilitating, can bring prolonged fear and anxiety from uncertainty over meaning and symptoms

What may characterize a CHRONIC illness?

Some chronic illness could also have acute or sudden onset

Why might acute and chronic illness categories sometimes superimpose?

Onset, Course, Outcome, and Incapacitation

What are the four broad categories or attributes used to classify illness, especially chronic illness, in typology?

Acute, Gradual

What are the sub-categories for the ONSET typology of illness?

Progressive, Constant, Episodic

What are the sub-categories for the COURSE typology of illness?

Fatal, Non-fatal

What are the sub-categories for the OUTCOME typology of illness?

Severity (Mild-Moderate-Severe), Type (Physical-Cognitive-Others)

What are the sub-categories for the INCAPACITATION typology of illness?

Developing interventions for patients and their families

Why is knowledge of illness typology important?

Illness which strikes quickly places the entire family into immediate crisis, with major readjustments compressed into a very short period

What is the psychosocial impact of an Acute onset illness?

Allows families some time for adjustment to illness and time for family adaptation, potentially requiring significant alteration of roles

What is the psychosocial impact of a Gradual onset illness?

Family members are faced with a symptomatic family member whose condition is steadily worsening, constantly challenged to adapt roles and reorganize family structures

What is the psychosocial impact of a Progressive course illness?

Families can stabilize the care for the chronically ill member after an initial period of crisis and adjustment

What is the psychosocial impact of a Constant course illness?

Requires families to change roles back and forth, depending on the current health status, adding tremendous stress due to uncertainty and frequent role changes

What is the psychosocial impact of an Episodic course illness?

These diseases create an undercurrent of anticipatory grief and separation and a sense of impending doom which affect all phases of family adaptation

What is the psychosocial impact of a Fatal outcome illness?

Family adaptation must focus on long-term adjustments and stable, permanent realignment of roles

What is the psychosocial impact of a Non-fatal outcome illness?

Impairment of functioning due to a defect or severe disability

What does Incapacitation refer to?

Impaired cognition, movement, or energy level, or physical deformities or other medical causes of stigmas

What can incapacitation result from?

The type and severity of incapacitation

What is a very significant factor in determining the stress experienced by families?

Combined physical and cognitive effects

What type of incapacitation can stress the family more than an injury affecting only energy production while retaining cognitive faculties?

Rolland (1989)

Who described the natural history of illness within three time phases?

To illuminate critical transition points in the natural developmental phases of an illness

What is the purpose of Rolland's three time phases for illness?

The crisis phase, the chronic phase, the final/terminal phase

What are the three time phases of illness described by Rolland?

Initiated with the first symptom onset and extends through diagnosis

When is the crisis phase of illness initiated and how long does it extend?

High stress, shock, anger, unpreparedness for role changes and family adjustments

What does the crisis phase create for families?

From initial diagnosis through the treatment and readjustment

When is the chronic phase of illness?

Prolonged adjustments and the establishment of a level of family normality to deal with the illness

What does the chronic phase require?

Life under the abnormal conditions of chronic illness

What is the key task for the family during the chronic phase?

When death becomes apparent

When does the final, terminal phase of illness occur?

Separation, death, grief and resolution of mourning

What marks the final/terminal phase?

A basis for family assessment and a framework to relate disease with psychosocial tasks of the family

What does the interaction of illness time phases and typology provide?

To anticipate different responsibilities of the attending physician in each stage

What can the framework provided by illness time phases and typology help with?

The normal course of the psychosocial aspects of disease for the patient and the family

What is the Family Illness Trajectory?

It indicates normal and pathologic responses

What does the Family Illness Trajectory indicate that enables family physicians to formulate a therapeutic plan?

To predict, anticipate and deal with a family’s response to illness

What does knowledge of the trajectory allow the physician to do?

Table 3

What table shows the stages of the family illness trajectory and physician responsibilities?

Onset of symptoms/illness

What is Stage 1 of the Family Illness Trajectory called?

Period from the time the patient demonstrates physical symptoms or feels something is wrong to when consultation is sought, prior to contact with health care providers

Describe Stage 1 of the Family Illness Trajectory.

Medical beliefs and previous experiences

What influences the meaning of illness in Stage 1?

The nature of onset

What may play an important role on the impact of illness on a family and some meaning of experiences in Stage 1?

Elicit the patient’s explanatory models of illness and fears

What should the physician do in Stage 1, even if not actively involved, to guide them to the second stage?

Acknowledge and explore conflict the patient may be experiencing with inappropriate label of illness (emotionally critical misperception)

What should a physician do if a patient has an inappropriate label of illness in Stage 1?

Catharsis-Education-Action (CEA) model of counseling

What model of counseling may be highly applicable in Stage 1?

Impact Phase – Reaction to Diagnosis

What is Stage 2 of the Family Illness Trajectory called?

When initial contact with the physician is usually established

When does Stage 2 of the Family Illness Trajectory typically begin?

Acceptance and immediate movement to the third stage of major therapeutic efforts

What is the likely reaction to a diagnosis of curable diseases or chronic, non-debilitating illnesses?

Denial, anger, bargaining, depression to acceptance, resulting in a protracted second stage

What might be the range of reactions to a debilitating or terminal illness diagnosis?

When the family wishes to withhold the truth from the patient

What is another source of dilemma in the Filipino setting regarding terminal illness, seen in Stage 2?

Explore first what the patient and his/her family already know and ask what they still want to know

What is the first step a physician should take when disclosing a diagnosis in Stage 2?

Hinder rather than help treatment

What can bombarding the patient and family with medical jargon do?

Provide small doses of truthful information that they need to make decisions

What is essential for physicians to provide to patients and families in Stage 2?

Diagnostic information regarding one’s body and life belongs to the person to whom it refers, not to the family or physicians

What is an important principle regarding diagnostic information?

A patient’s wish to know or not to know the truth

What is the most important determining factor regarding disclosing the truth to a patient (Fetherstonhaugh, 1997)?

Major Therapeutic Efforts

What is Stage 3 of the Family Illness Trajectory called?

Management or treatment

What represents one of the most challenging and rewarding parts of medical practice?

The period of great mobilization when the family pursues avenues for treatment and palliation

Describe Stage 3 of the Family Illness Trajectory.

A good support system and wealth of resources

What helps the family go through Stage 3?

Offer family options that are effective at a cost they can afford and are acceptable to the patient and family’s belief systems

What is a physician's responsibility in Stage 3 regarding treatment options?

A therapeutic ally

How should a physician best view the family in Stage 3?

Explore the patient and family’s reactions to the therapy and how it is proceeding, and make necessary interventions if dissatisfied

What should a physician do in Stage 3 from the perspective of the family as a therapeutic ally?

Recovery Phase – Adjustment to Outcome

What is Stage 4 of the Family Illness Trajectory called?

Disappearance of symptoms

What marks Stage 4 for acute, self-limiting illnesses?

A return to the home environment and some degree of functionality

What marks Stage 4 for chronic illnesses?

Several factors

What does adjustment to outcomes depend on in Stage 4?

Minimal problems

What is anticipated when full recovery without incapacity is expected in Stage 4?

The family experiences some form of crisis

What happens when partial recovery, permanent disability, or even death is expected in Stage 4?

Prepare the family for the potential outcomes of a disease

What is a physician's responsibility in Stage 4 to help families cope?

A readjustment of roles

What might be needed in Stage 4 to accommodate the new status of the ill member?

Continually provide support and guidance to the family, educate the caregiver, and arrange for home care, if necessary

What should a physician do for chronically ill patients in Stage 4?

Interplay of Illness Typology, Illness Timeline & Family Illness Trajectory

What does Figure 1 illustrate?

An upset in a steady state (or homeostasis) causing a disruption or breakdown in a family’s usual pattern of functioning

What is a crisis in a family?

When families encounter a transition they cannot handle with their usual coping skills and problem-solving methods

When does crisis occur in families?

Two or more

How many elements contributing to a crisis must interact for a family to move into a state of crisis?

Experiencing a stress-producing situation, having difficulty coping, showing a chronic inability to meet basic family responsibilities, having no apparent sources of support

What are the four elements contributing to a family crisis?

HeadStart Early Childhood Learning & Knowledge Center

What is the source for Figure 2 and Table 4, which discuss elements contributing to a family crisis?