Family Medicine and Community Health I

Semester
IMPACT OF ILLNESS
LEOPANDO, MD | 07 10 2017

Investigate disease Investigate illness
I.INTRODUCTION Examining clinical and Exploring the meaning of illness
v Disease affects the person body laboratory evidences of to the patient and the patient’s
v These effect are manifested in the body in the form of sign biologic and psycho- family
and symptoms and physical abnormality physiologic dysfunction
v It is these effect the physicians look at to make a diagnosis
of the disease IMPACT OF ILLNESS
v Illness affects the person’s emotion, his mental and social ü Training on medical school should focus on treatment of
well-being disease problems and management of illness problems
v It can affect the way he acts, he thinks and/or he deals with ü Medical care should result in treatment of the disease
the people around him which technologically brilliant as well as adequate
v It can also affect his family, its functions, its relation with treatment of illness
the members ü Ancient form of healing focused on the experience of the
v That is why the family physician is trained to not only look patient and his family providing them with meaning and
at the person’s bodily problems but his psyche’s problem as hope, relieving the sufferer’s sense of despair, impatience
well and isolation should be revived
v He must understand the person’s disease and illness as well
v And it should be clear by now the distinction between and WHY DO WE NED TO STUDY IMPACT OF ILLNESS?
illness ü Sickness of patient causes suffering and severe disruption
v Disease affects the bodily; illness affects the psyche, i.e., the for the patient’s family (way of life and ability to function).
soul, the mind and the personality of the person ü Particular illness sets in motion processes that re disruptive
v And illness also affects the family of family life and hazardous to the health of family
members.
DISEASE VS ILLNESS ü Patient’s disease is embedded in a whole matrix of difficult
family problems that contribute to the disease process itself
DISEASE o Poverty
o a pathology of the body. o Unemployment
ü And the physician looks for this abnormality when confront o Other sickness in the family
with a person with the disease o Chronic family dispute
ü The physician after history taking, physical examinations, o Poor nutritional habit
and sometimes or oftentimes orders laboratory o Inadequate housing condition
examinations to arrive at a diagnosis and subsequently o Part of structured inequality in society that he
treatment cannot change
ILLNESS ü The interaction that takes place between the health care
ü affects the emotion, the perception, the mind and the social system and the patient and his family are affected by:
aspects of the person o Setting of care
ü The physician who recognize only the bodily aspect of the o Type of care
disease and forgets his illness will not be able to give o Ability to pay
comprehensive management of the person’s health o Flexibility/responsiveness of the health care
problem system
ü Impact of illness minimized by personalized care that is
Disease Illness highly responsive and flexible to the patient and the family
ü Primarily biologic ü Includes the members
and psycho- sufferer’s experience ü Prolonged and complicated illness
physiologic disorder of the disease and
ü Clinical perspective the broad range of o Study have shown that
dislocations felt by § There are psychological and social
both the sufferer and effects on the family of a patient with
his family chronic or life threatened illness
ü Deeply embedded in § There are effects on parents and sibling
the social cultural of illness of a child
and family context of § Severe illness in parent’s place children
the person who is ill of family at greater risk

HOW IS INVESTIGATION DONE?
THE PHYSICIAN:
• Explores the patient’s explanatory models because the
belief held by a person explains the nature of illness

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• Explore the patient’s understanding of ff. issues: • Sense of self-esteem
• Etiology of his illness • Dreams and plans for the future
• Its pathophysiology • Sense of invulnerability of one’s self and in loved
• Trajectory and outcome of illness ones that keep existential fears of impending
• Appropriate treatment death and separation at bay

THE PHYSICIAN STAGES IN THE FAMILY ILLNESS TRAJECTORY
• This should be the basis of communication • no single interpersonal relationship in a family exist in
• Explore patient’s isolation from other relationship within family
o Perception
o Reaction to symptoms STAGE 1: ONSET OF ILLNESSS
o How and why he seeks medical advice and care • warning sign of malaise which initiates
o Follow-up regimen and care for himself preliminary stage of the illness trajectory
THE PHYSICIAN: • stage experienced prior to contact with medical
• This should be the basis for communication care providers. Medical beliefs and previous
• the belief: experiences provide influence to meaning of
ü scientific medicine illness
ü religious beliefs • nature of onset may play an important role on
ü ancient healing sciences impact of illness on a family and some meaning of
ü popular accounts experiences are formulated here
ü healing groups NATURE OF NATURE CHARACTERISTICS IMPACT ON
THE PHYSICIAN: ILLNESS OF ONSET OF EXPERIENCE FAMILY
• investigate the broader set of experiences and concerns ACUTE: Rapid Provide little time Caught up in
that patient associate with their illness RAPID ONSET clear for physical and suddenness
o derived from past experience with therapy onset psychological Deal with
o personal meaning associated with disease and adjustment immediate
form of therapy decision
o self-consciousness about tacit meanings of ACCIDENT Short period Often with
certain disease and disabilities between onset, little support
o meaning of illness for other members of the diagnosis and from within
family and their vulnerability management and outside
• Kleinman suggest the ff. questions to learn how your thereby leaving the family
patient sees his or her illness: little time to unit
o What do you think caused the problem? remain in the If less
o What do you think it started when it did? state of threatening,
o What do you think your sickness does to you? uncertainty may be
o How severe is your sickness? Do you think it will dramatic but
last a long time, or will it better soon in your less crisis
opinion? oriented
o What are the chief problems your sickness has problem for
caused for you? family
o What do you fear about your illness? CHRONIC: GRADUAL Suffer from a state Vague
o What kind of treatment do you think you should DELIBIRATING ONSET of uncertainty apprehension
receive? over meaning and and anxiety
o What are the most important results you hope to symptom Fearful
get from treatment? fantasies over
THE FAMILY ILLNESS TRAJECTORY denial of
HIP Passage through sufferings seriousness
ü Normal course of psychosocial aspects of disease for the
patent and the family RESPONSIBILITIES OF THE PHYSICIAN
ü Knowledge of trajectory allows the physician to predict,
anticipate and deal with a family’s response to illness 1. Explore routinely the explanatory model and fear that the
ü Indicate normal and pathologic responses thus enabling patient brings into the clinic set-up
family physicians to formulate special therapeutic plan 2. With inappropriate label of illness, explore conflict the
MAJOR ILLNESSES INVOLVING LOSS OF: patient may be experiencing
• Body parts 3. Explore several aspect of pre-diagnostic phase of patients
and families
• Ability to carry out normal and

treasures activities

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• If there is no
STAGE II: REACTION TO DIAGNOSIS: IMPACT PHASE movement towards
the phase, family
• The physician who present the diagnosis is responsible for will inefficient in
making a clinical judgment about the amount of achieving healthy
information the patient can absorb given his present level adaptation to the
of anxiety or shock crisis and organize
• It is important that the physician elicits explanatory model at more
of diagnosis to patient if disease is not life threatening and DYSFUNCTIONAL
patient is liable to be undue harmed LEVEL
• Disease and appropriate treatment can be described
according to the patient’s level of comprehension and Responsibilities of the Physician
understanding ü ANTICIPATE number of problems and help families to
• Unnecessary frightening anxiety may occur if information is cope and adapt more through family conference,
not understood discussion with parents.
• Give small doses of information over time if the diagnosis is ü ENCOURAGE
particularly traumatic and the patient and his family may • Make clear to each other and to the patient the
unable to receive so much nature of the illness by helping family maintain
If diagnosis is confusing and stressful and shattering the gamily
openness that allowed sharing and support.
physician must:
• Pattern of non-sharing/ silence limit the openness
• Provide support, and continuously of care
and spontaneity of families and hampers their
• Interpret findings which are misunderstood
ability to share and openly support each other.
• Offer advise and encouragement
• And clarify meaning of specialist’s message and outcome of • Process of isolation is more terrifying and may
illness and operation perceived as abandonment by the patient
EMOTIONAL PLANE (REACT) COGNITIVE PLANE (THINK) ü KNOW
During onset of illness, Phase I: initially there is • That feeling of guilt is a natural response to stress
initially there is denial, tension and confusion with of grief and loss
disbelief and anxiety probable lack of capacity for • Family members may have the irrational feeling
problem solving that they personally caused the patient’s disease.
This followed by emotional Phase II: repeated failure in • To anticipate such feelings and make realistic
upheaval characterized by deriving the diagnosis may efforts to relieve patient of self-blame through
strong emotions such as lead to EXACERBATION of careful explanation of etiology.
ANGER, ANXIETY and tension and increase distress
ü HELP
DEPRESSION
• Family asses the likely effect of the illness on the
The last phase is Phase III: increasing
ACCOMODATION during assessment and RECEPTIVITY family
which during which the of the family to new approach • Predict problems likely to arise
patient and the family learn for RELIEF DISTRESS • Develop plans for realistically coping with them
to accommodate and accept • Some go doctor and assess the family capabilities to deal with
the diagnosis shopping stress
This is very important for the • Some are willing for • Understand problems as well as benefits to the
implementation of active participation expected from family and friends who offer the
therapeutic plans. • Willing to accept support.
responsibility ü OFFER
• Alternative interpretation of proposed
therapeutics
• Rational explanation to alleviate family’s inability
Phase IV: eventual
to accept reality.
ACCEPTANCE of diagnosis will
enable them to mobilize
STAGE III: MAJOR THERAPEUTIC EFFORTS
resources and recognize the
ü Management/ therapy represents one of the MOST
family
• Quality of the family CHALLENGING AND REWARDING part of medical practice
reorganization ü The physician should deal with multiple variables
ü Works in harmony of the wishes of the patient and family
ü Coordinates all aspects of the therapy which involve
specialist and others.

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ü Critical issues in choosing therapeutic plan RESPONSIBILITIES OF THE PHYSICIAN
ü Psychosocial state and preparedness of the patient and ü Remain open to the family, indicate they will NOT BE
family determined the choice of therapeutic plan as well as ABADONED, provide them information
the alternative choices ü Deal with multiple variables, CONSIDER ALL FACTORS IN
• If the patient belief system and trust in PLANNING
therapeutic modality is at variance with that of ü Work in HARMONY with patient and family
the physician, he may resist attempt at education ü COORDINATE all aspects of therapy
and reassurance. ü ANTICIPATE pathologic response
• Thus, the physician should investigate for signs of • Severe emotional symptoms of deep depression
non-compliance • Psychological reaction and organic symptoms
• Some of patient’s families are not emotionally behavioural problem like addiction to alcohol
equipped to undertake some form of therapy so work inhibition and pathological acting out.
other professional help should be obtained
STAGE IV: EARLY ADJUSTMENT TO OURCOMES RECOVERY
ü Assumption of responsibility for care very early in the
• Simplest outcome is RETURN to full health
treatment plan
o Gains from illness experience
ü Establish and define responsibilities of each party
o Patient nurtured and allowed to take over the
ü Give realistic role to everyone abandoned obligation, new responsibilities and
ü Economy therapeutic plan privileges when sick
“Of what good is therapy if family cannot afford PARTIAL RECOVERY
it” • Period of waiting to learn if disease will return or fear of
ü The sickness will have devastating effects on the family death, because of long period of waiting
economically speaking • They maintain constant sense of vulnerability
ü DILIGENCE on the part of the physician in keeping costs • Recovery is quite different if it requires acceptance of a
down by involving family in all major decisions which affect known permanent disability
the patient. Request for TEST/REFFERALS which are really
necessary RESPONSIBILITIES OF THE PHYSICIAN
• Deal with immediate EFFECTS of trauma
ECONOMIC IMPACT OF ILLNESS • ALLEVIATE anxiety and assure adequate rest
a. EMOTIONAL TRAUMA • Psychological SUPPORT can b given through understanding
b. SOCIAL DISLOCATION and repeated assurance
c. ECONOMIC CATASTROPHE – WIPES OUT FAMILY SAVING • Explore level of UNDERSTANDING of patient and family
• Call on other members of family for means of SUPPORT
ü Lifestyle and cultural characteristics of a family are • Try to find out how members understand what happened,
important in choosing a therapeutic plan what kind of LABELLING do they have
ü Effects of hospitalization, surgery and other major o Do they label person as still ill or do they label him
therapeutic method are emotionally stressful for the as once again well or has returned to health
patient’s family • Initiates a period of gradual movement from the role of
ü Fear and concern in the families who are still essentially being sick to some form of recovery or adaptation
helpless • Important phase for patients and families
ü Unable to participate in the suffering or need to relieve the • Varies according to the type of outcome anticipated
discomfort or anguish • This points to the family’s adjustment to crisis
• SECOND CRISIS occurs as family realizes that they must
HOSPITALIZATION GIVE RISE TO STRESSFULL LOGISTIC PATTERN accept and adjust to a permanent disability
FATHER – Special economic burden • Family must BEGIN AND GIVE UP HOPE for patient’s full
MOTHER – greatest impact on other family members. It poses high return to health
risk for family dysfunction • ACCEPT that life must go forward and pattern believed to
CHILDREN - special syndrome of emotional problems of families, be temporary must be accepted as permanent
hostility, abandonment. • Physician should be aware that continued unwillingness to
PARENTS – helpless, guilt, frustrated or hurt. incorporate that reality of the permanency of the loss may
GERIATRIC – vulnerable to fears of death, rejection, abandonment, be a sign of PATHOLOGY
loneliness and helplessness • Coping mechanism is developed during earlier stage of
family adjustment
o Person who is sick continue to be treated as sick
and he is treated as patient and not reintegrated
into the family

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o Treat patient as recovered, full, responsible FAMILY IN CRISIS
person
ACUTE ILLNESS • Family is crisis when it moves into a state of disequilibrium
• There is potential for crisis especially when family routines in response to any situation or event that cannot resolve
are suspended by use of available problem solving skills, behaviour or
• Emotions are high and can lead to anger especially if the resources
family perceives that the care given by the doctor is not • When illness is perceived as threat to its equilibrium a
satisfactory crisis response is set in motion
• Because of suddenness of illness, family may find it difficult
to face stress EVALUATING FAMILY IN CRISIS
CHRONIC ILLNESS
Assess family history of coping with problem and stressor
• Because of prolonged fear and anxiety there is higher
• BOILING POINT AT WHICH CRISIS RESPONSE IS ET IN
incidence of illness in other members of the family MOTION
• Additional burden and sometimes feeling of guilt especially o Affected by uniqueness of internal and external
if the sick member was previously neglected factors
• The family becomes over-indulgent toward the sick o Stresses are sufficient in numbers or intensity to
member and this will later result into feeling of overwork disturb family equilibrium
• Anger and resentment toward sick member set in leading o Family psychosocial history provides information
back to feeling guilt later regarding capacity of family to cope with illness
and other missions
FOR TERMINAL ILLNESS o Quality of family life mobilize their own strength
• This is HIGHLY EMOTIONAL and potentially devastating and resources to cope adequately with stress
• The moment of diagnosis of debilitating or terminal disease • DETERMINE STYLE OF FAMILY DEVELOPMENT
is often remembered by patient in their families as the o Anticipatory guidance
SINGLE MOST DIFFICULT time of entire illness experience o Timelines of illness or problem affects family’s
• Patient and his family anticipate GRIEF REACTION ability to cope
• If the family is FUNCTIONAL members will be drawn close • ROLE OF THE PATIENT IN THE FAMILY
together to provide care and support to the patient and to o Members providing financial support (financial
each other problem)
• If the family is DYSFUNCTIONAL, it can be the seed for o Member plays critical role in the family
future family discord and breakdown emotional life, ex: mom who nurtures, emotional
• The initial response is that of shock and overwhelming support (most serious impact in family when she
anxiety. gets sick). Impact: feeling of guilt and self blame
• As they respond to the pain with denial and misbelief, the o Child (other sibling deprived, develop
patient may say “this could not be happening to me” resentment towards the ill sibling
• MONITOR ROLE DISRUPTION
The physician can: o Assessment and monitors effect of role
• Assist the patient and the family in relating to health care disruption
system o Identifies gap in family role that exists or the
• Aid the patient and the family in efficient and functional results of the illness and helps the family explore
adjustment options for filling those gaps from within and
• Provide quality care. Home care is the best and most outside of the family
accepted and the least demanding, thus it should be o Sick role as perceived by patient and family
facilitated

FAMILY REACTION TO DEATH
• In prolonged severe illness and adaptation and reaction are
already accomplished
• Death comes swiftly. Physician should assist family to cope
• Stage of denial- few days to few weeks
• If prolonged – premorbid pattern of abnormal behaviour
• Denial, Anger, Bargaining, Depression, Acceptance (DABDA)

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