Group 11CAbuan, RyanMarquez, CharmaineMeollo, Arejenald Merencilla, Rupert Morillo, LaurencePagdanganan, Simeon Arni

THE FAMILY ILLNESS TRAJECTORY- PASSAGE THRU SUFFERINGSNormal course of the psychosocial aspects of disease for the patient and the familyKnowledge of trajectory allows the physician to predict, anticipate , and deal with a familys response to illnessIndicates normal and pathologic response thus enabling family physicians to formulate special therapeutic plan

THE STAGE IN FAMILIY ILLNESS TRAJECTORY ARE:STAGE I Onset of illness to diagnosisSTAGE II Impact phase- Reaction to diagnosisSTAGE III Major therapeutic effortsSTAGE IV Recovery phase- early adjustment to outcomeSTAGE V Adjustment to permanency of the outcome

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

Nature of IllnessNature of OnsetCharacteristics of ExperienceImpact on FamilyAcute/Rapid illness/accidentRapid, clear onsetProvide little time for physical and psychological adjustmentShort period between onset, diagnosis and management thereby leaving little time to remain in state of uncertaintyCaught up in suddennessDeal with immediate decisionOften with little support from within and outside the family unitIf less threatening, may be dramatic but less crisis oriented problem for the familyChronic especially debilitatingGradual onsetSuffer from state of uncertainty over meaning and symptomVague apprehension and anxietyFearful fantasies over denial of seriousness of symptoms and possible implication

RESPONSIBILITIES OF THE PHYSICIANExplore routinely the explanatory model and fear that patients bring to the Clinical set-upWithin inappropriate label of illness, acknowledge and explore conflict the patient maybe experiencingExplore several aspects of pre-diagnostic phase of patient and families

STAGE II- REACTION TO DIAGNOSIS: IMPACT PHASEThe 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 patients level of comprehension and understanding. Unnecessary frightening anxiety may occur if information are not understood.

1. Given his present level of anxiety or shock. *

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 careInterpret findings which are misunderstoodOffer advise and encouragementAnd clarify meaning and specialists message and outcome of illness and operation

3. if the diagnosis is particularly traumatic and the patient and his family may be unable to receive so much*

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

EMOTIONAL PLANECOGNITIVE PLANEDuring onset of illness, initially there is denial, disbelief and anxiety protest diffuse directly over unfairness (minutes to hours)

This is followed by emotional upheaval characterized by strong emotions such as anxiety, anger and depression depends on disrupted roles and channels (period of weeks)PHASE I- initially there is tension and confusion with probable lack of capacity for problem solving threat sets in motion tension reduction mechanismPHASE II- repeated failure in deriving the diagnosis may lead to exacerbation of tension and increase distress *resort to prayers * still earn capacity to problem solve

*

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

EMOTIONAL PLANECOGNITIVE PLANEThe last phase is accommodation during which the patient and the family learn to accommodate and accept the diagnosis this is very important for the implementation of therapeutic plans PHASE III- increasing assessment and receptivity of family to new approach for relief of distress *some go doctor shopping *some are willing and capable for active participation *time for real opportunity for the physician and other health workers to assist family in realigning roles and expectations, learn new skills and make adjustment *willing to accept responsibility

PHASE IV- eventual acceptance of diagnosis will enable them to mobilize resources and recognize the family *quality of family reorganization *if there is no movement towards this phase, family will be inefficient in achieving healthy adaptation to the crisis and reorganize at more dysfunctional level

RESPONSIBILITIES OF THE PHYSICIANAnticipate 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 IllnessMaintains OppennessAllows sharing and supportNon-sharing and silenceLimit openness and spontaneityIsolation and Abandonment

-The family should from the very beginning be encouraged to make clear to each other and to the patient the nature of the illness by helping family maintain openness that allows sharing and support. Pattern of non-sharing/silence limit the openness and spontaneity of families and hampers their ability to share and openly support each other. Process of isolation is more terrifying and may be perceived as abandonment by the patient *

-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 patients 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

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 familys denial and inability to accept reality.

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

CRITICAL ISSUES IN CHOOSING THERAPEUTIC PLANPsychological 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

-if the patients belief system and trust in therapeutic modality is at variance with that of physician, he may resist attempt at education and reassurance. Thus, the physician should investigate for signs of non-compliance

some of patients families are not emotionally equipped to undertake some form of therapy so other professional help should be obtained*

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

-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 patients 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

-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

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

RESPONSIBILITIES OF THE PHYSICIANRemain open to the family, indicate that they will not be abandoned, provide them informationDeal with multiple variables; consider all factors in planningWork in harmony with patient and familyCoordinate all aspects of therapyAnticipate 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

STAGE IV- EARLY ADJUSTMENT TO OUTCOMES- RECOVERYReturn 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 familyExperience 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.

- 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

RESPONSIBILITIES OF THE PHYSICIAN:Deal with immediate effects of traumaAlleviate anxiety and assure adequate restPsychological support can be given through understanding and repeated reassuranceExplore 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

STAGE V- ADJUSTMENT TO THE PERMANENCY OF THE OUTCOMEThis point to the familys adjustment to crisisThe 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 patients 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.

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 personFor 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.

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

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

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.

Family Reaction to DeathIn after prolonged severe illness and adaptation and reaction are already accomplishedDeath comes swiftly and MD to assist family to copea. Stage of denial- few days to few weeksIf prolonged- premorbid pattern of abnormal behaviorb. Angerc. Depressiond. Bargaininge. Acceptance

1. Given his present level of anxiety or shock. *3. if the diagnosis is particularly traumatic and the patient and his family may be unable to receive so much*

*-The family should from the very beginning be encouraged to make clear to each other and to the patient the nature of the illness by helping family maintain openness that allows sharing and support. Pattern of non-sharing/silence limit the openness and spontaneity of families and hampers their ability to share and openly support each other. Process of isolation is more terrifying and may be perceived as abandonment by the patient *-if the patients belief system and trust in therapeutic modality is at variance with that of physician, he may resist attempt at education and reassurance. Thus, the physician should investigate for signs of non-compliance

some of patients families are not emotionally equipped to undertake some form of therapy so other professional help should be obtained*