FEU NRMF

Institute of Medicine
PREVMED PRELIMS ⦿Section 2J ⦿2017-2018

TABLE OF CONTENTS ○ Illness sets in motion processes that are

Impact Of Illness On The Family 1 disruptive and hazardous to the health of
Psychosocial Typology Of Illness 3 family members
Breaking the Bad News 6 ○ Decreased physical well-being among
Family CEA 8 family members living with and caring for
Dysfunctional Families 9 chronically ill
Long Term Care ● Disease is embedded in a whole matrix of difficult
Index family problems that contribute to the disease
process itself
Impact of Illness on the Family ○ Poverty, poor nutritional habit, poor
Objectives: education, poor health habits, etc poor
● Importance of looking into the impact of illness on health outcomes
the family
● Discuss the important aspects of the ILLNESS AFFECTS THE PATIENT AND THE FAMILY
● Family Illness trajectory ● Assessment of the impact of illness can help
○ Enumerate the different stages physicians…
○ Describe the characteristics of each stage ○ plan interventions that can mobilize the
○ Discuss the responsibilities of the family
physician in each stage ○ help the family cope and adapt
○ lessen the burden brought about by the
Disease vs Illness disease
○ support the patient
Disease Illness
FAMILY ILLNESS TRAJECTORY
● Primary biologic; ● Includes the sufferers ● Normal course of the psychosocial aspects of
psycho-physiologic experience of the
disease for the patient and the family
disorder disease
● Allows the physician to predict, anticipate and
● Investigation: clinical ● Deeply embedded in deal with the family’s response to illness
and laboratory social, cultural & ● Enable the physician to formulate specific
evidence family context
therapeutic plans.
● Investigation: Stage I – Onset of Illness
exploring the Stage II – Impact Phase (Reaction to Diagnosis)
meaning of illness to
Stage III – Major Therapeutic Efforts
the patient and the
Stage IV – Adjustment to the Outcome of Disease
family (Stage V – Adjustment to the permanency of the outcome
of disease )
Why study Impact of Illness?
● BIOPSYCHOSOCIAL APPROACH to care physical STAGE I - ONSET OF ILLNESS
symptoms (biomedical) anxiety/stress due to the ● Stage prior to contact with medical care providers
symptoms (psychosocial) ● Health beliefs and previous experiences help
● HOLISTIC CARE shape what patients and their families do at this
● Stress, illness and the family are linked stage and how soon they seek consult.self-
○ Stress is frequently followed by illness medication;health-seeking behavior
○ Family support protects from stress ● Nature of onset play an important role on the
○ Illness has an effect on the family impact of illness
○ Family has an impact on illness Acute
● Sickness causes suffering and severe disruption ❏ Rapid, clear
for the patient and his family ❏ Little time for adjustment (physically &
○ Way of life and ability to function are psychologically)
altered
○ Role reversal, income loss, disruption of Chronic
activities ❏ Gradual onset

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Institute of Medicine
PREVMED PRELIMS ⦿Section 2J ⦿2017-2018
❏ family stays in a prolonged state of
uncertainty
● Effect on the Family
Acute
❏ Potential crisis when resources are
limited
❏ Anxiety
❏ No time to remain in uncertainty
❏ Rapid, clear
Chronic
❏ Burden long term need for resources
❏ Anxiety
❏ Drained resources
❏ Uncertain of meaning of symptoms
/outcome of treatment
❏ Denial of seriousness of illness and
possible complications
● Physicians are not actively involved at this stage
● Explanatory models of illness can be used as guide
on how to best approach the second phase
○ Illness perception (medical, psychosocial
stress; moral/ karma; spiritual/religious;
witchcraft)
○ Awareness/understanding of what is
happening
○ Explore how the patient and family view
of the illness to help you during the Stage
2 ○ Impact: emotional and cognitive
STAGE II – IMPACT PHASE (REACTION TO DIAGNOSIS)
● Initial contact with physician
● Reactions/impact depend on:
○ Understanding
○ Awareness
○ Perceptions
○ Outcome
○ Readiness / preparedness
● Onset: Acute distress
Chronic distress / relief
● Diagnosis of curable or chronic non-debilitating
➔ disease lead to better acceptance and immediate
movement to Stage III
● Debilitating or terminal disease -
○ Grief reactions
○ Prolonged stage II
○ Family collusion
PLEASE SEE TABLE 1.1 AT PAGE 20
● Explore patient and family illness understanding
what they already know, what else they want to
know…
● PROPER DISCLOSURE
● Deal with family collusion (patient autonomy)
● If diagnosis is confusing & stressful, must:
○ Provide support & continuity of care
○ Interpret findings
○ Offer advise & encouragement
● Anticipate problems & help family cope & adapt
(family conference)
RESPONSIBILITIES OF THE PHYSICIAN
● Assess likely effect/impact of the illness
● Assess capabilities to deal with stress.
● Help understand some problems as well as
benefits from support of family & friends
● Support family’s denial & inability to accept
reality
● Plan realistically based on your assessment
STAGE III – MAJOR THERAPEUTIC EFFORTS
● One of the most challenging & rewarding part of
medical practice
● Physicians deal with multiple variables: works
with wishes of patient/family, coordinate all
aspects of therapy (specialists, paramedical
support, etc.)
CRITICAL ISSUES IN CHOOSING THE THERAPEUTIC PLAN
● Psychological state and preparedness of the
patient and family
○ Signs of non-adherence or non-
compliance
○ Patient and family belief system and
trust in the therapeutic modality
● Responsibility of care -- should be made clear in
the treatment plan.
○ Realistic roles
○ Duties & responsibilities of each family
member
● Cost of therapy -- should be kept at reasonable
level
○ Economic status
○ Economic impact of illness
* Of what good is therapy if the family could
not afford it?
● Lifestyle and cultural characteristics of the family
are important
● Effects of hospitalization, surgery, and other
therapeutic methods -- may be emotionally
(financially) stressful to the family
● Offer options that are
○ effective at a cost they can afford
○ acceptable to their belief system
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Institute of Medicine
PREVMED PRELIMS ⦿Section 2J ⦿2017-2018
● Remain open and work in harmony with the
patient and family
● Deal with multiple variables consider all factors
when planning
● Coordinate all aspects of therapy
● View the patient and family as therapeutic ally-
not merely as recipient of care
● Explore reactions to therapy
STAGE IV – ADJUSTMENT TO THE OUTCOME OF DISEASE
● Return from role of being sick to some form of
recovery or adaptation
● Varies according to the type of outcome
anticipated.
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
● Death
FOR ACUTE ILLNESS:
❖ Potential for crisis when routines are suspended
❖ Emotions are high especially when they feel that
there was inadequate / unsatisfactory care given
❖ Deal with immediate effects of trauma
❖ Explore level of understanding of patient &
❖ Family
➢ how family members understand what
has happened
❖ Alleviate anxiety
➢ Provide psychological support
➢ Understanding & repeated reassurance.
FOR CHRONIC ILLNESS:
❖ Prolonged fear and anxiety leads to higher
incidence of illness in other members of the
family
❖ Physician should encourage ventilation of
feelings, give reassurance and reinforcement of
care
FOR TERMINAL ILLNESS:
❖ Highly emotional and pote0ntially devastating
❖ Single most difficult time of the entire illness
experience
❖ If family is functional -- members are drawn closer
together
❖ If family is dysfunctional-- seed for future family
discord and breakdown
❖ Assist patient & family in relating to health care
system
❖ Aid patient & family in efficient & functional
readjustment
❖ Provide quality care
➢ Home care is the best & most accepted &
least demanding
❖ Preparation for death (early grief)
CLINICALLY “RED FLAGS” (what to WOF)
1. Injury or surgery that alters body image
2. Excessive reaction to an illness by a patient or
family member
3. Symptoms similar to those of the patient & family
member
4. Suicidal ideation
5. History of prior psychotic episodes (patient or
family)
6. Excessive use of alcohol or other drugs
7. Sudden change in behavior
8. Scapegoating of a family member
9. History of poor family coping patterns
PSYCHOSOCIAL TYPOLOGY OF ILLNESS
Objectives:
At the end of the session, the student will be able to:
○ Describe the psychosocial types of illness
○ Describe the time phases of illness
○ Discuss the clinical applications of the
psychosocial and time phases of illness
○ Discuss the importance and role of family
caregivers
○ Identify the issues encountered by family
caregivers and the interventions to address
them.
DISEASE AND ILLNESS: Biopsychosocial Approach
IMPACT OF ILLNESS
2 frameworks:
Family Illness Trajectory
➢ Normal course of psychosocial aspects of
disease
➢ Normal and pathological response to illness
➢ Enables the physician to predict, anticipate and
deal with the family’s response to illness and
formulate a specific therapeutic plan
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Institute of Medicine
PREVMED PRELIMS ⦿Section 2J ⦿2017-2018
Psychosocial Typology of Illness
➢ Character of chronic illness in psychosocial
terms over time
➢ Psychosocial demands of chronic illness across
time phases; developmental tasks of the family
➢ Enables the physician to predict, anticipate and
support the family going through the course of
a chronic illness
PSYCHOSOCIAL TYPOLOGY OF ILLNESS
Provides a framework for assessment and clinical
intervention of individuals and families facing a
chronic or life-threatening illness
- Rolland, 1994
TWO DIMENSIONS:
1. PSYCHOSOCIAL TYPE
❖ Significant characteristics of chronic illnesses and
and their corresponding psychosocial demands on
the ill individual and his/her family.
❏ Onset – acute or gradual
❏ Course – progressive, constant, relapsing
❏ Incapacitation – incapacitating or non-
incapacitating
❏ Outcome – fatal, non-fatal, possibly fatal
PLEASE SEE TABLE 2.1 ON PAGE 20
2. TIME PHASE OF ILLNESS
❖ Chronic Illness timeline
❖ Point at which the patient and family are in the
illness life cycle.
❖ Chronic illness is an ongoing process with
landmarks, transitions and changing demands
❖ Timing of family psychosocial check-ups are
important during key transition points
❖ Each has its own unique psychosocial
developmental tasks, that require significantly
different strengths, attitudes or changes from a
family.
❖ Crisis, Chronic, Terminal
PLEASE SEE FIGURE 2.1 ON PAGE 16
Crisis Phase
➢ includes symptomatic period before diagnosis and
the initial period of adjustment - Stage/s of in the
Illness Trajectory
➢ Psychosocial Type
Onset: Acute or Gradual
Acute onset
● Reactions compressed into a
● short time.
● Requires more rapid mobilization
of crisis management skills
● Limited resources
Gradual onset
● Family coping is more prolonged
● More time to cope and adjust
● Prolonged anticipatory anxiety
DEVELOPMENTAL TASKS:
1. Learn to deal with pain, incapacitation, or other illness-
related symptoms
2. Learn to deal with the hospital environment and any
disease-related treatment procedures
3. Establish and maintain workable relationships with the
health care team.
4. Pull together to undergo short-term crisis reorganization
(functional)
5. Move toward a position of acceptance of permanent
change
6. In the face of uncertainty, develop a system flexibility
toward future goals
7. Create a meaning for the illness event that
maximizes a preservation of a sense of mastery and
competency;
• explore existential purposes;
• gain control of the situation
8. Grieve for the loss of the pre-illness family identity
Characteristics of families capable of coping and adjusting
to acute illness:
● Able to tolerate highly charged emotional states
● Exchange clearly defined roles flexibly
● Open and direct communication
● Problem-solve effectively
● Use outside resources
Chronic Phase
• Time phase between diagnosis and readjustment period
and the 3rd phase when issues of death predominates
• "the long haul,"
• phase of "day-to-day living with chronic illness."
PSYCHOSOCIAL TYPES:
1. COURSE
a. Progressive
➢ Persistently or generally symptomatic patient
➢ Continuous deterioration as the illness progresses
in severity
➢ Minimal relief for caregivers from the demands of
the illness
➢ Continuous adaptation and role changes in the
family
○ Activities of daily living
○ Need for new equipment / medications
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Institute of Medicine
PREVMED PRELIMS ⦿Section 2J ⦿2017-2018
○ Occurrence of new illnesses/problems
➢ Increasing strain on family caretakers due to risks
of:
○ exhaustion
○ addition of new caretaking
○ tasks over time
○ expenses
○ decision-making
➢ Progressive illnesses
❏ Alzheimer's disease
❏ Emphysema
❏ Cancer
❏ Uncontrolled cardiovascular diseases
❏ Amyotrophic Lateral Sclerosis (ALS)
b. Constant
➢ An initial event occurs, followed by stabilization of
the biological course of illness
➢ Initial period of recovery then a chronic phase,
characterized by deficit or residual, functional
limitation.
➢ Semi-permanent change: stable and predictable
over a considerable time
➢ Potential for family exhaustion exists without the
strain of new role demands over time
➢ Recurrences can occur - anxiety
➢ Controlled diabetes mellitus
➢ Controlled hypertension
➢ Post CVA / Post MI
➢ Hyperthyroidism
➢ Cancer in remission
➢ Spinal cord injury
c. Relapsing / Episodic
➢ Alternation of stable periods of varying length
characterized by a low level or absence of
symptoms, and with periods of flare-up or
exacerbation.
➢ Strain on the family system due to:
○ Frequency of transitions between crisis
and non-crisis
○ Ongoing uncertainty of when a
recurrence will occur.
➢ Requires family flexibility
➢ Wide psychological discrepancy between periods
of normalcy (asymptomatic) versus illness
(exacerbation)
➢ Relapsing or Episodic Illnesses
❏ Uncontrolled Bronchial Asthma
❏ COPD
❏ Systemic Lupus Erythematosus
❏ Rheumatoid / Osteoarthritis
❏ Seasonal Allergy
❏ Insulin-induced hypoglycemia
2. INCAPACITATION
a. Incapacitating
b. Non-Incapacitating
Incapacitation
➢ May result from impairment of :
○ Cognition (Alzheimer's, stroke, dev’t
delay in CP)
○ Sensation (blindness, deafness)
○ Movement (stroke with paralysis,
multiple sclerosis)
➢ Impairment of :
○ Energy production (cardiovascular
disease; CHF),
○ Disfigurement (severe burns, leprosy)
➢ Associated with social stigma (TB, HIV, AIDS).
➢ Degree of stress on the family depends on
extent, type and timing of incapacitation
➢ Stroke versus spinal-cord-injury
○ Combined motor and cognitive
impairment in
○ stroke requires more family role
reallocation
○ Worse in the early onset, may improve
thru time (or further worsen)
➢ Stroke vs. Parkinson’s
➢ Incapacitation is worse in the onset or worse at
later time
➢ Alzheimer’s (Progressive, Incapacitating
➢ disease)
○ Disability is an increasing problem in
later phases of the illness
○ Family has more time to prepare for
anticipated changes
○ Patient has the opportunity to
participate in disease-related family
planning
DEVELOPMENTAL TASKS:
1. Maintain semblance of normalcy or normal life with
chronic illness and heightened uncertainty
2. Maintain maximal autonomy for all family
members in the face of a pull toward mutual dependency
and care-taking
• Anticipate exhaustion and ambivalence with caregiving
demands
• Expect depletion of emotional and financial resources
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Institute of Medicine
PREVMED PRELIMS ⦿Section 2J ⦿2017-2018

Chronic Phase ◆ Chronic illness with unpredictable course

● Time phase between diagnosis and readjustment ◆ Future planning, adapting and coping are
period and the 3rd phase when issues of death hindered by anticipatory anxiety and
predominates ambiguity
● The individual and family that is able to cope and ◆ What to do?
adjust to the chronic illness ➔ Guidance from physicians and assurance of
○ have accepted psychologically and/or continuity of care are important for families to be
organizationally the changes presented able to adapt and cope
by a chronic illness ◆ Illness understanding
○ have devised an ongoing modus ◆ Anticipatory care
operandi. ➔ Management considerations that affect family
Terminal Phase adaptation:
● Includes pre-terminal stage of an illness ◆ Complexity, frequency and efficacy of a
where the inevitability of death becomes ◆ treatment regimen
apparent or dominates family life ◆ Amount of home vs. hospital-based care
Psychosocial Type: required by the disease
Outcome – fatal, non-fatal, possibly fatal ◆ Frequency and intensity of symptoms
◆ Regimens that require significant
(FOR CHRONIC AND TERMINAL PHASE, PLEASE SEE ON financial resources and caregiving time
FIGURE 2.1 ON PAGE 18) and energy
** Knowledge on outcome and treatment options are very
OUTCOME: important physician –dependent)
FATAL: Likely to cause death ➔ Crucial predictors of long-term home treatment
❏ Metastatic cancer compliance:
❏ AIDS ◆ Degree of emotional support
❏ Amyotrophic Lateral Sclerosis (ALS) ◆ Role flexibility
NON-FATAL ◆ Effective problem-solving
● No predictable timeline of demise ◆ Effective communication
● No assurance that the chronic illness will be the ➔ Home-based treatments for chronically-ill
principal cause of death patients place heavier responsibility on patient
❏ Spinal Cord Injury and family.
❏ Cerebral palsy ➔ Paradoxically, a family’s hope to resume a normal
❏ Alzheimer’s / Parkinson’s Disease life cycle might only be realized after the death of
the patient
TASKS: ◆ Highly debilitating but not fatal illness
Address issues of exhausting problem- “without an end”
• Separation ◆ Potentially fatal illness- “Living in limbo”,
• Death “Survivor guilt”
• Grief ◆ A “normal” life cycle resumes only after
• Resolution of mourning the death of the patient - “Wishing for
• Resolution of normal life beyond the loss death”
• Anticipated outcomes dictate how the family will react to PLEASE SEE FIGURE 2.2 ON PAGE 18
the illness.
• Possibility of imminent death makes way for:
• overprotection by the family BREAKING THE BAD NEWS
• powerful secondary gains for the ill member eg Objectives:
childhood illnesses ● At the end of the session the students will be
able to:
REFLECTION POINTS: ○ Understand the principles in
➔ Families unable to put long-term uncertainty into communicating bad news
perspective are at high risk for exhaustion and ○ Learn the process involved in
dysfunction. communicating bad news
◆ Unknown illness; crisis (Stage1&2)

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Institute of Medicine
PREVMED PRELIMS ⦿Section 2J ⦿2017-2018

○ Acquire the skill of proper disclosure of ○ Verbal/voice of compassion

bad news ○ Eye contact
○ Relaxed
What is “Bad News”? ○ Seating arrangement
“Any news that drastically and negatively alters a patient’s
view of his or her future” PERCEPTION
➢ Bracketing
BREAKING BAD NEWS ➢ Leading
❖ One of the physician’s most difficult duties ➢ Reflecting
➢ Fear of how the patient might react ➢ Probing
➢ Sense of failure or guilt ➢ Focusing
X No formal preparation ➢ Summarizing
X Lack of communication skills and ❖ Reflect content, feelings, experience
technique ❖ Check perception
❖ Brings sense of unpleasantness ❖ Paraphrase
❖ May lead physicians to emotionally disengage ❖ Clarify
from their patients ❖ Empathize

Breaking bad news is seldom a question of whether Emotionally Critical→ Catharsis Education
“to tell or not to tell”, but more of a matter of “when and Misperceptions Action
how to tell”. (ECM) (CEA)

Studies show that most patients generally INVITATION

● Want to know what is wrong with them ➢ Ensure that the patient is prepared to receive the
● Desire frank and empathic disclosure news
● Prefer disclosure of bad news to come from their ➢ Ask permission to give the bad news
doctors ➢ Ask the patient how much he/she wants to know
Studies reveal that most patients generally Examples:
● Become relieved when they finally know “How would you like me to give you information about…”
● Become angry when they discover collusion “Are you the type of person who…”
● Disagree that disclosure of bad news/poor
prognosis will destroy hope KNOWLEDGE
➢ Warn the patient that you are proceeding with
HOW DO YOU BREAK THE BAD NEWS? the bad news
6-Step Protocol (University of Texas, MD Anderson Cancer ➢ Impart the message
Center) ➢ Avoid medical jargon
S etting ➢ Avoid excessive bluntness
P erception ➢ Give information in small pieces
I nvitation ➢ ALWAYS assess understanding
K nowledge ➢ Tailor the delivery to the patient’s response
E mpathize (address Emotions) ➢ Acknowledge all responses
S trategize and S ummarize
EMPATHIZE
SETTING ➢ Encourage and validate emotions
➢ Arrange privacy ○ Observe for emotions
○ Non-distracting environment ○ Identify the emotion
○ Quiet place ○ Identify the reason behind the emotion
○ Curtains ➢ Allow the patient to experience the feeling and
➢ Involve significant others respond empathically
➢ Mental and physical preparedness Emotions people experience after receiving bad news
➢ Attending skills Denial
○ Lean forward Anger
○ Open posture Bargaining

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 FEU NRMF
Institute of Medicine
PREVMED PRELIMS ⦿Section 2J ⦿2017-2018

Depression WHY?
Acceptance ➢ Family influence on health
○ Values, beliefs and attitudes are imbibed
Examples: and behaviors are learned in the context
“I can see how upsetting this is to you” of family
“I can tell you weren’t expecting to hear this” ○ Family as a resource / therapeutically vs.
“I’m sorry to have to tell you this” obstacle to health care
“I was also hoping for a better result” ■ Indecision / poor illness
understanding / misperceptions
STRATEGY AND SUMMARY (ECMS), etc.
➢ Ask the patient if he/she is ready to ➢ Family interventions are more effective than
discuss prognosis and management individual approach.
➢ Make a plan
○ Explain and collaborate with the LEVELS OF PHYSICIAN INVOLVEMENT WITH FAMILIES
patient(and family) • LEVEL 1: Minimal involvement of the family (focus on the
➢ Discuss goals individual)
➢ Offer realistic hope based on the patient’s goals • LEVEL 2: Focus is on health education of patient and
○ “Hope for the best but prepare for the family
worst…” • LEVEL 3: HEALTH EDUCATION + IMPACT OF ILLNESS
➢ Summarize main ideas PROVISION OF EMOTIONAL SUPPORT
➢ Assess understanding • LEVEL 4: Assessment of family dynamics & how it
➢ Set up succeeding appointments affects the illness;
(Intervention→ restructuring)
THE IRISH HOSPICE FOUNDATION • LEVEL 5: Family therapy
BREAKING THE BAD NEWS IN A COMPASSIONATE WAY
● Can improve the patient’s and family’s ability to WHEN?
plan and cope When is it imperative / essential to convene the family?
● Encourage realistic goals and autonomy ROUTINELY CONVENE THE FAMILY:
● Support the patient emotionally 1. Hospitalization
● Strengthen the physician-patient relationship 2. Obstetrical & well-child care
● Foster collaboration among the patient, family 3. Terminal illness & death
physicians, and other professionals. 4. Serious chronic illness
CONSIDER CONVENING THE FAMILY:
Hope… 1. Serious illness
“May pag-asa hangga’t humihinga.” 2. Compliance problem
You matter because you are you. You matter to the last 3. Poor control of a chronic illness
moment of your life, and we will do all we can not only to 4. High utilization of medical services
help you die peacefully, but also to help you live until you 5. Somatization, anxiety, depression
die.” 6. Substance abuse
Dame Cicely Saunders 7. Marital & sexual difficulties
Mother of Modern Hospice
WHO?
FAMILY: All emotionally significant people bound together
FAMILY CEA by enduring ties
Objectives Family intervention – involves at least 2 members
• To discuss:
•Why family meetings are important WHAT?
•When family meetings are required o Educate
•Who should attend family meetings o Illness understanding and management
•What is done during family meetings o Assistance with problem solving / decision-
• How family meetings are conducted making
•To apply active listening skills and CEA in o Provide psychological support
convening the family

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Institute of Medicine
PREVMED PRELIMS ⦿Section 2J ⦿2017-2018
o Empathy, opportunity to share feelings,
assistance in coping
HOW?
C – CATHARSIS
E – EDUCATION
A – ACTION
STEPS:
1. Discuss the clinical problem
• Reason for consult
• Medical history
Family members serve as additional source
to verify the medical history
2. Define the clinical problem
•Explore the patient and family’s health understanding
• Identify ECMs that cause
• greatest emotional upset
• greatest obstacle to treatment
• Probe / Reflect
CATHARSIS (patient and family)
•What do you call the illness / disability?
•What do you understand about the illness?
•What do you think has caused the illness?
•What does your sickness do to you?
•What can you no longer do that you would like to do?
•How do you feel about your sickness?
•How does your family react to you because of your
illness?
•How do you feel about their reaction?
(Family)
•How does his / her sickness affect you?
•How do you feel about his / her illness?
(Both)
• What do you think will happen to the illness in the
future?
• What do you fear most about the illness?
•What is the worst thing that could happen?
3. Correct misperception/s
CORRECT THE MISPERCEPTION/S (EDUCATE)
• Share your findings with the patient and family
• Address the ECMs first
• Provide other information that the patient and
family needs
IMPORTANT POINTS:
•Remain neutral
• Give equal time / equal chance to speak
• Reflect: Paraphrase / perception check
• Summarize
• Empathize (validate emotions)
• Switch from directive facilitator (biomedical physician) to
non-directive listener
4. Address patient’s problem
(ACTION/TREATMENT)
• Explain the recommended treatment and elicit
their perceptions and feelings about it
• Address ECMs about treatment
(BOTH)
• How do you feel about the treatment plan that I have
just
explained to you?
• What important results do you expect from this
treatment?
(PATIENT)
• What might make the treatment difficult for you to
follow?
•What would you like your doctor to do for you?
reflect, summarize, address ECMs
INVOLVE THE PATIENT AND FAMILY in the
MANAGEMENT PLAN
• Explicitly state what each needs from one another
• Agree about the things that they will do for each other
(PATIENT) “What would you like your family to do for
you?”
(FAMILY) “What would you like him to do for you?”
(BOTH) “Will each of you state what you are willing to do
for each other in response to the needs expressed?
TREATMENT PLAN:
Include tasks of the patient and family members in relation
to the behavioral contract set during the meeting (what
each family member is willing to do for the other)
5. Closing & follow-up
• DO A FEELINGS CHECK
• SET SPECIFIC DATE AND TIME FOR FOLLOW-UP
• Involve the family as early as possible
• Explain that it is a routine procedure
• Emphasize the importance of family as a resource
• Identify the obstacles (if any)
• Stress the benefits of family meeting
• Instruct on who and how to invite
DYSFUNCTIONAL FAMILIES
Objectives:
At the end of the session, the student
should be able to:
● Assess dysfunctional family behaviors
● Describe different forms of family violence
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Institute of Medicine
PREVMED PRELIMS ⦿Section 2J ⦿2017-2018
● Discuss the different types of abuse
● Discuss the prevention of abuse and
● violence.
FAMILY – the individuals best support system
FAMILY PHYSICIAN – should be able to recognize
when the family is stressed…
FAMILY AND STRESS ↔ FAMILY DYSFUNCTION
Being able to identify family dysfunction allows
for timely and appropriate interventions.
What is Family Dysfunction?
State in which the family demonstrates destructive
behavior in response to an inability to manage internal or
external stressors due to inadequate resources OR
ineffective family coping
When Does Family Dysfunction occur?
- When status of family is altered
● Incomplete family- illegitimacy
● Willed dissolution – annulment, separation,
divorce, desertion
● Absence of a member due to: death – distant
death, incarceration
● Empty nest
- Presence of severe chronic problems:
● Addiction
● Mental Illness
● Abuse / Family Violence
Major Defining Characteristics of a Dysfunctional Family..
1. Neglectful care of the patient
2. Neglectful relationship with other family
members
3. Decisions/actions are made which are
detrimental to economic and social well
being (addiction, control, overprotection,
unrealistic expectations, enabler,
scapegoat, etc)
How to Assess Family
Dysfunction..
I. What are the sources of stress in the family?
• Stressors can affect the person negatively (distress) or
positively (eustress)
•Stress – may lead to CRISIS
•Inability to adapt/ be flexible
•Reaction to stress related to previous coping mechanisms
(failed attempts)
II. How adaptable or rigid is the family?
ADAPTABILITY:
• the family’s ability to respond flexibly, to modify
interaction patterns in the face of stress
• Key to coping
• Clear boundaries→ negotiable rules and roles open
communication
III. How cohesive is the family?
•Support system of the family: balanced, overly cohesive,
non-cohesive
• Members support one another emotionally and
physically while holding on to some degree of autonomy
(balance between “family” and “self”)
Enmeshed or Disengaged
Enmeshed– too much cohesiveness
Family members are overprotective and
over reactive to one another’s pain
• Members speaking for one another
• Interruptions when one is speaking
• High levels of emotionality
• Unwillingness to discuss conflict
• Family members flare up angrily with slight
provocation
Disengaged- Non-cohesiveness
Boundaries are rigid & impermeable
• “Go on their own separate ways”
• Do not respond quickly to emergencies
• Emotionally unreactive to one another
• Sense of abandonment
IV. What are the family’s repeating interactional patterns
related to the problem?
• Analyze the interactional context of dysfunctional
behavior
• What is the repeating sequence of family interactions?
• Who relates to whom, how and when
INTERACTIONAL PATTERNS… (ROLES)
Scapegoating
• one member bears the blame for the problems
confronting the family
• Acts out in anger and defiance - delinquent
Enabling
• any conscious or unconscious behavior that encourages
an individual to continue acting in a specific manner –
shielding a person from the
consequence of the behavior
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Pattern of communication
• Direct (Indirect)
• Congruent (Incongruent)
• verbal and non-verbal communication are sending the
same message
What are the Physiological Variables?
Assess family for signs of physical health problems (aside
from structure & function)
ABUSE – common in dysfunctional families
• Substance abuse: alcohol & drugs
• Neglect
• Family or Domestic violence
PLEASE SEE TABLE 5.1 ON PAGE 21
ABUSE
Exhibits key characteristics of dysfunction:
• disrespect of other’s boundaries (perpetrator)
• inadequate or missing boundaries for self/ tolerating
inappropriate treatment from others (victim)
• denial / refusal to acknowledge abusive behavior
(enabling)
• blaming one person for misfortunes (scapegoating)
Domestic violence
• Domestic violence may refer to all aspects of family
violence.
• 95% of intimate partner violence involves a man abusing
his female partner.
• The outcome results in injury and fear in the female
partner.
• Such cases are underreported and unrecognized by
clinicians.
In the US…
• 52% of female murder victims in 1990
were killed by a current or former partner
• Men kill their female partners more than
twice as often as women kill their male
partners
• Battery is the single greatest cause of injury to women
In the Philippines…
• Information was collected on spousal violence -
covering all forms of VAW:
1) physical violence
2) sexual violence
3) emotional violence
4) economic violence
(the 3rd and 4th forms of VAW were grouped together in
the survey as "other forms of violence").
• The NDHS revealed that 1 in 5 women aged 15-49 has
experienced physical violence since age 15
• 14.4 % of married women have experienced
physical abuse from their husbands;
• 37% of separated or widowed women have
experienced physical violence domestic violence could be
the reason for separation or annulment
• 1 in 25 women age 15-49 who have ever had
sex experienced forced first sexual intercourse
• 1 in 10 women age 15-49 ever experienced
sexual violence
• 4% of women who have ever been pregnant have ever
experienced physical violence during pregnancy Incidence:
• ↑slightly with number of living children
• ↓slightly with age
• ↓with education level
• ↑declines steadily with wealth
Emotional and other forms of nonphysical violence are the
most common types of spousal violence in 23% of ever
married women
• 1 in 7 ever-married women experienced physical
violence by their husbands while 8% experienced
sexual violence by their husbands.
Clinical presentation
• Repeated, increasingly severe physical injuries
• Bilateral and covered by clothing
• Contusions, lacerations, abrasions
• Pain without obvious tissue injury
• Evidence of injuries of different ages
• Evidence of rape
• Self-abuse
• Psychosocial problems
• Depression, drug or alcohol abuse, suicide
attempts
• 1 in 10 victims attempts suicide.
• 9-fold increased risk for drug abuse
• 16-fold increased alcohol use
Presence of one factor should initiate
questions about the others.
Abused women
• Divorced or separated
• Young
• Low socio-economic status
Isolation, power imbalance and alternating abusive and
kind behaviors predispose victims to the formation of
strong attachments to their abusers
* Cycle of violence (PLEASE SEE FIGURE 5.1 ON PAGE 18)
Goal of Abuse:
power and control
•components of domestic violence
• tactics employed by batterers
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• ultimately enforced by threat of or
Actual physical & sexual violence.
PLEASE SEE FIGURE 5.2 ON PAGE 19
Abusive men
• Batterers do not lose control, they take control.
• Partners are dependent on them
• Jealous of their partners
• Believe in traditional gender roles
• Extreme need for control, hostile, trust issues
• Refuse to accept responsibility for violent behaviors
• 90% have NO criminal record
Children & Domestic Violence
• 45-60% of child abuse cases, there is concurrent
domestic violence
• Symptoms manifested by a child witnessing spousal
abuse fall into 3 categories:
1. Internalizing behavior- sadness, withdrawal,
somatic complaints, fear and anxiety
2. Externalizing behavior- aggression, cruelty to animals,
defiance of authority, destructiveness
3. Defects in social competence- poor school achievement,
peer relations and participation in sports and other
extracurricular activities
Children caught in domestic violence – become
perpetrators or victims
Diagnosis
● The single most important step physicians can
take is to ASK every woman if she is being or has
been abused.
● Questioning communicates to the patient that the
problem is not trivial, shameful or irrelevant.
● It conveys to all women the physician’s belief that
it is important to talk about the abuse.
MANAGEMENT
PLEASE SEE TABLE 5.2 AND 5.3 ON PAGE 20 &21
CONTINUING CARE
Composition of physician’s treatment of
domestic violence:
1. Continued support
2. Validation
3. Risk assessment
4. Documentation
Focus on the process of empowerment
rather than the outcome of leaving.
Battered woman can:
1. Take civil actions- protective order,
injunction or restraining order.
2. File criminal charges- battery,
harassment, intimidation, or attempted
murder
Empowerment or Advocacy Wheel ways healthcare
providers can help victims of domestic violence become
empowered and change their lives. Developed by the
Domestic Violence Project of Kenosha Wisconsin
PLEASE SEE FIGURE 6. 3 ON PAGE
PREVENTION
Primary: challenging the roles of violence and patriarchy in
society
Secondary: interruption and elimination of
intergenerational abuse of all kinds
Tertiary: identifying the victims and their abusers and
helping each one
Physicians and other health care givers are mandated by
law to report cases of abuse
RA 9262: "Anti-Violence Against Women and their Children
(VAWC) Act of 2004.
RA 7610: The Special Protection for a Child against Abuse,
Exploitation and Discrimination Act
CHILD ABUSE and NEGLECT
Common disorders identified in adults who were abused
as children:
• Chemical dependence
• Eating disorders
• Affective disorders
• Dysfunctional relationships
• Violence
• Post traumatic stress disorder
Children at Increased Risk for Abuse
• Live in dysfunctional homes
• Roles and boundaries are poorly defined
• Live without a natural parent
• Low self-esteem
• Physical, mental or behavioral problems
Abused Child
• Rarely voluntarily disclose abuse
• May tell a trusted friend, teacher, relative
• Behavioral indicators may cue a physician to pursue the
history
• Caregiver cannot give a reasonable
explanation for injuries
• Injuries not compatible with PE findings
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• Delays in seeking treatment for injuries • Expectations not compatible with growth and
• Contradictions in the history development (unrealistic)
• Excessive responsibility
Behavioral Indicators Associated with Neglect and Abuse • Demeaning comments
of Children and Adolescents: • Attitude conveying that the child’s presence is a
• Clinging burden
• Irritability
• Regression: bowel/bladder, withdrawal, thumb sucking Signs of Emotional Abuse
• Night terrors, sleep walking, afraid to sleep alone Excessive seriousness
• Eating disorders or difficulties • Lack of spontaneity
• Change in school performance • Lack of confidence
• Acting out among peers • Aggression
• Restricted social life • Acting out

• Suicide, depression, anxiety, phobic disorders 2. Physical

• Decreased self-esteem • Not the most common form of child maltreatment
• Overt abnormal sexual activity for age • Easiest to identify
• Delinquency, running away • Recognition of injury patterns warrants investigation
• Substance abuse • Dermatological manifestations
• Prostitution • Ocular injuries
• Psychosomatic complaints gastrointestinal or • CNS injuries
genitourinary • Skeletal injury
• Visceral trauma
NEGLECT
• Failure of a parent or guardian to provide Dermatological Manifestations
for the child’s basic needs • BRUISING from belts, buckles, looped cords, sticks,
• Lack adequate food, clothing, shelter, medical care, whips, fly swatters, coat hangers, spatulas, spoons,
education, safety and nurturing brushes combs, teeth and hands
• Most common form of child maltreatment • BURNS
• Under reported • Intentional scald burns
Difficult to diagnose unless there are
Signs of Neglect discrepancies in the history
• Malnutrition - child must be developmentally
• Poor hygiene capable of producing the injury
• Inadequate clothing appropriate for environment - Burn patterns: thrown at the child
• Related to lack of supervision child was immersed
• Poor school attendance Common sites of ACCIDENTAL splash burns: head,
• Exploitation: child is asked to beg or steal chest, abdomen
• Repeated ingestion of toxic substances INTENTIONAL immersion burns uniform in depth
• Excessive home responsibilities symmetrical glove and stocking pattern
• Caring for siblings
• Housework • Immersion burns
• Role reversal • Mechanical burns
• Lack of appropriate medical care Skin comes in contact with a hot object
• Lack of immunizations - Burns take the shape of the heated
• Poor dental care object easy to recognize
• Failure to thrive - Cigarette burns typically 0.7cm; held
against a the skin results in a 1.0 cm
CHILD ABUSE round lesion
1. Emotional • Rope burns
• Family dynamics undermine the • BITES
development of a child’s healthy self-esteem

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CNS INJURIES • Physicians must recognize the behavioral, medical and

• Cause of most deaths related to physical abuse
• Shaken baby syndrome
• Common in infants <6months old
• No external evidence of trauma
• Child presents with lethargy, vomiting, seizures,
coma, bulging fontanel, enlarging head
SKELETAL INJURIES
• 56% of fractures in infants <1 year old are found to be
non-accidental
• Indicators of fracture: crying, swelling, bruising favoring
an arm or leg
• Metaphyseal fractures of the long bones are diagnostic
of abuse.
• Caused by: twisting or pulling using the arm or leg as
handle for shaking direct blow
metaphysis – growing plate at each end
of long bones; piece of cartilage that
only fully ossifies in adulthood
VISCERAL TRAUMA
• 2nd to head injuries for causing death to abused children
• Victims are often infants no evidence of bruising or other
marks
• Often involve multiple organs:
• Ruptured liver, spleen
• Transection of the pancreas
• Bowel obstruction secondary to hematoma
• SUSPECT IF:
• History is vague or misleading
• There was delay in seeking medical attention
Other forms of Physical Abuse
• Passive inhalation of drugs
• Intentional drownings
• Suffocation
• Gunshot wounds
• Poisonings
• MUNCHAUSEN SYNDROME
• Illness of a child inflicted by the parent or
guardian for the adult’s secondary gains
• Repeated evaluations, hospitalizations and
procedures
• Child becomes well when separated from the
parent or guardian
3. Sexual
Child Sexual Abuse
• Exploitation of children for sexual gratification or profit
of an adult or a person in position of power (older child or
adolescent)
physical signs of sexual abuse
Medical Signs and Symptoms Indicating Sexual Abuse
• Unexplained genital irritation, injury or scarring
• Bruising, scratches, or bites not consistent with history
• Sperm on clothing
• Grasp marks
• Blood stains on underwear
• Enuresis, encopresis, or both
• Penile swelling, discharge, or both
• Recurrent atypical abdominal pain
• Unexplained recurrent urinary tract infections
• Proctitis
• Any sexually transmitted disease
• Pregnancy in a pubescent girl
Child Abuse Alert Checklist: PARENT
• Expresses fear or shows evidence of losing control
• Shows detachment from the child
• Shows indication of abuse of alcohol/drugs
• States that the child is “always injuring self”
• Complains that there is no one to “bail him/her out when
uptight with the child
• Is reluctant to answer questions, is defensive
and becomes angry with questions
• Indicates that he/she was raised in a “motherless,” harsh
way
• Shows unrealistic expectations of the baby/ child,
indicating lack of knowledge of normal development
• Shows marked lack of concern for child’s welfare and
little or no remorse
• Treats siblings differently, with obvious preference and
dislike for one child
• Appears to be under considerable stress but does not
seek help.
Child Abuse Alert Checklist: CHILD
• Has injury or marks which are unexplained or
inadequately explained
• Has received no apparent medical attention for an injury
• Is unusually fearful of adults (perhaps of one sex more
than the other)
• If a baby shows a “frozen watchfulness” with adults
• Shows failure to thrive
• Shows unusual apprehension when an adult
approaches
• Is frequently overtired and/or inappropriately dressed
for the weather
• Is unusually aggressive, disruptive or nervous
• Arrives early at school, leaves late, and indicates that the
parent/s won’t care about absence

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• Has difficulty in sitting, has genital area discomfort, • History of alcoholism or substance abuse
shows resistance to being touched by an adult • Alone in the caregiving role
• Craves attention and affection but is easily hurt and • Prolonged or burdensome caregiver role
mistrustful. • Unrealistic expectations
• Previous insecure relationships
Physician’s role
• Provide support Abuse in the elderly should be suspected:
• Express belief in the child’s statement • Significant weight loss or dehydration
• Protect the child • Unexplained or recurrent trauma
• Report the abuse to the proper authorities • Delays in seeking medical attention
• Multiple visits to the emergency room
ELDER ABUSE • Poor hygiene
• Physical Neglect • Misuse of medications (overdosing or
• Passive : inexperience or impairment of the caregiver noncompliance)
(individual who is suppose to be caring for the older
person) results in neglect Prevention
• Active : necessities of daily life are intentionally withheld • Identify situations of increased risk
• Physical abuse: • Behavioral or other problems in the potential
• beating, hitting, slapping, sexual assault, victim
restraining • Part of periodic health assessments
• Psychological abuse: • Actively follow-up
• Frightening, intimidating, humiliating,
threatening, demeaning, isolating, insulting, Physicians are in a unique position to interrupt the cycle of
infantilizing, name-calling violence and to effect positive change in the lives of
victims, abusers and children involved in domestic violence.
• Fiscal and Material Abuse:
• Theft or misuse of financial or material
Resources Long Term Care
• Not using resources for the benefit or with the Objectives:
approval, of the older person ● Define long term care (LTC)
• Violation of Rights: ● Identify the people who benefit from LTC
• Evicting or forcing a move to a nursing home or ● Identify the factors contributing to the need
another dwelling without forewarning, ● for LTC
explanation, or input into the decision; ● Discuss factors that affect care of the
inappropriate confinement ● Filipino elderly
● Enumerate the different types of LTC services
Characteristics of Elderly that ● Discuss LTC services in the Philippines
may Increase Risk for Abuse
• Female Long-term Care
• Very old ➢ Variety of services and support
• Dependent on other for care and protection ○ To meet a person's health needs and/or personal care
• Dependent on ADLs needs
• Suffering dementia ○ For people unable to perform activities on their own.
• Exhibiting “difficult behaviors” known to induce caregiver
stress Health Needs
• Disturbed nights, aggressive or belligerent,
➢ Skilled nursing
resistive or impulsive behavior, incontinence,
➢ Physical /Occupational therapy
wandering
➢ Pain Management
Caregiver characteristics that may increase risk for abusive ➢ Wound care
behavior ➢ Prescription management
• History of abusive behavior toward family members, ➢ Medical consult -- Symptom/ illness management
spouse

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Personal Care Needs: Activities of Daily Living (ADL) d. Developmental Disabilities

❏ Everyday functions and activities individuals usually e. Mental illness
do without help. f. Spinal Cord Injury / Trauma
Instrumental activities of daily living (IADLs)
❏ Complex skills needed to successfully live Family Circumstances and Support systems
independently Asian cultures→ customary for the family elder to be cared
for by his children or other relatives.
Who needs long-term care? ➢ Out of gratitude for raising them
★ 70% of people expect to use some form of LTC by ➢ Out of respect
the age of 65 years ➢ Filipino culture
Traditionally, family takes care of family
a. Challenges Facing Seniors
Frailty – clinically recognizable state of increased Factors that affect elderly care in the Philippines
vulnerability resulting from aging- associated decline in Physical separation of parents and children as a result of
reserve and function migration and urbanization
Any acute illness in the older person can be life- ➢ Children spend less time receiving guidance from
threatening their parents
➢ Ideational change→ guidance through mass media
Having multiple comorbid diseases is associated with: and schooling
• Higher rates of morbidity/death
• Disability Consequences:
• Higher rates of adverse effects to treatments and Children may feel less indebted to their parents.
interventions Break down the traditional values and norms relating to
• Exacerbations of Illnesses are always life-threatening the family
• Greater use of hospital resources
• Institutionalization FACTORS THAT INCREASE THE NEED FOR LONG TERM CARE
• Decreased/Poor quality of life. SERVICES
➔ Migration and urbanization
b. Common Medical Disorders that Contribute to Frailty ◆ Physical separation
❏ Hypertension ◆ Breakdown in traditional values
❏ Coronary Artery ➔ Greater longevity / increased survivorship
❏ Disease ➔ Declines in fertility
❏ Asthma ➔ Increased participation of women in economic
❏ Pneumonia activities outside the home
❏ Arthritis
❏ Osteoporosis Providers of LTC
❏ Diabetes ● Informal caregivers
❏ Malnutrition ○ skilled but not trained provide unpaid care
❏ Cancer out of love, respect, obligation or
❏ Anemia friendship
○ family, friends, neighbors or church
❏ Alzheimer’s disease
members
❏ Cataracts ● Formal caregivers
❏ Hearing disorders ○ trained care providers
❏ Anxiety disorders ○ typically paid care providers
❏ Depression ○ may also be volunteers
○ MD, nurses, caregivers and other allied
c. Disabled medical professions
Disability refers to any restriction or lack of ability
(resulting from an impairment) to perform an activity in
the manner or within the range considered normal for
human being.

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TYPES of LONG TERM CARE (4)
❖ Home-Based Care
➢ Services given in one’s own home
➢ Health, personal, and support services
➢ Care mostly provided by informal caregivers
➢ Formal caregivers are preferred for more complex care
needs
➢ Home visits by professionals: doctors, nurses, PT/OT,
Nutritionists, etc
❖ Community-based Care
➢ Supplement other services provided at home.
➢ Often provided by a local government, social service
agency, or private company.
Adult Day Programs
➢ provide individualized day care in a protective setting
➢ personal care services, supervision, or assistance with
ADLs
Adult Day Health Care:
➢ provides medical, rehabilitative and social services
through an individualized plan of care
Senior centers
➢ Offer a variety of services: meals, recreation, social
services, and classes.
➢ Provide information and referrals to help people find
the care and services they need.
➢ Generally for healthy older adults without cognitive
problems
♢REPUBLIC ACT NO. 7876: "Senior Citizens Center Act of
the Philippines."
♢An act establishing a senior citizens center in all cities
and municipalities of the Philippines
Long-term Care
Sustained provision of comprehensive programs and
services to Senior Citizens with the view of enabling them
to have dignified, healthy and secured lives
Meal Programs
➢ Services that deliver meals to homebound people
➢ ("Meals on Wheels").
➢ Group meals at senior centers, places of worship, and
other locations.
➢ Not yet available in the Philippines
Transportation Services
➢ help people get to and from medical appointments,
shopping centers, and other places in the community.
➢ Not yet available in the Philippines
❖ Facility-based Care
Independent living
➢ single-family homes, condos, apartments
➢ Family home no longer maintained for practical reasons
➢ Children have lives of their own
Assisted living
➢ People who need help with daily care, but not as much
help as a nursing home
➢ Own apartments or rooms Assisted Living Services:
➢ 3 meals a day;
➢ assistance with personal care;
➢ help with medications,
➢ housekeeping, and laundry;
➢ 24-hour supervision, security,
➢ onsite staff; and social and recreational activities.
Skilled Nursing Facilities
➢ Commonly known as nursing homes
➢ Provide both skilled nursing and personal care services.
➢ Residents usually have medical problems
■ DSWD Haven for the Elderly
HOSPICE CARE UNIT
➢ For the dying person with less than 6
months to live
❖ Hospice and PalliativeCare
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INDEX

FIGURE 2.1

FIGURE 2.2

FIGURE 5.1

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FIGURE 5.2

FIGURE 5.3

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TABLE 1.1

TABLE 2.1

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TABLE 5.1

TABLE 5. 2

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TABLE 5.3

22