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Analysis of family system can lead to a 'better' death
In the late 19th century, people usually died in bed at home, surrounded by their families.
The physician told the new family patriarch or matriarch that death was imminent, the preacher was called and family members placed their trust in God as they prepared for their loved one's death.
"Dying wasn't easy then," said Robert Houston, M.D., assistant professor at the University of Wyoming family practice residency program in Casper. "But as the family ministered to their dying loved one's needs, they confirmed the new family order."
In the best of circumstances, the grandchildren remembered how grandma said goodbye and blessed them. They remembered how grandpa encouraged them to realize their dreams.
"The children learned their family's dying behaviors, and they received a family legacy," said Houston. "Today, most of these behaviors are nearly extinct."
Houston said faith in medical technology has undermined the traditional peace and wisdom that many dying patients bequeathed to their families.
"Medical technology has provided us with mixed blessings. We live longer, we live with less disability and we rarely experience the death of a loved one," he said. "But medical technology also has made denial the coping style of choice."
It's the job of the family physician to minimize the trauma associated with dying, Houston said.
"We can provide anticipatory guidance to patients and their families," said Houston. "Successful palliative care can allow the dying persons, their children and their grandchildren to rediscover the arts of reconciliation, bonding and saying farewell."
The family is an integral part of how the patient responds to his or her illness.
"The family's response to illness also impacts the patient's ability to cope with changing physical, emotional and environmental needs," Houston said. "At the end of life, the family provides the concerned family physician with the needed context to help the patient and the patient's family conduct a life review and life validation, as well as attempt exoneration and forgiveness."
Family systems and end-of-life care
Family physicians can use the idea of the family system to help patients and their families cope with the end of life.
"The idea of the family system gives the family physician a focus on what you can do to help the survivors," Houston said.
The family system is a way of mapping the emotional milestones in a person's and family's development. It's important for family physicians to note where the patient's family is in the family life cycle. This can help family physicians decide what support is necessary.
The family life cycle comprises six stages:
Leaving home. The family of origin shifts its relational ethics to an adult-to-adult pattern. The young adult develops intimate relationships with peers while striving to achieve financial responsibility and independence. Tightly entangled families sabotage the leaving-home process.
The joining of families: the couple. When two individuals join to form a new family, the values of the two families of origin are merged. All three systems need to negotiate and respect emerging boundaries for the new family unit to remain viable.
Families with young children. New parents review and modify their family-of-origin concepts and values on parenting. Parenting responsibilities and boundaries are formed. Grandparenting entitlement and obligations are negotiated with the two families of origin.
Families with adolescents. Adolescent family members actively redefine the boundaries within the family unit. Adolescents test their adult obligations and entitlements. The parent and child relationship should move from intimacy to respect. Parents should meet their intimacy needs through a strengthened spousal relationship.
Launching children and the family at midlife. Parents now negotiate an adult-to-adult relationship with their children. Responsibility and control is given to the offspring. The mid-life adults change their care focus to their aging parents.
The family in later life. The center of family power shifts from the older generation to the middle one. Grandparenting roles and elder care needs are coordinated and supplemented by the younger generations. Older individuals maximize their functioning in the face of progressive disability.
Family physicians also should recognize that each individual in the family has perceived obligations and entitlements that they protect and maintain within the family system, Houston said.
"And these relationships, obligations and entitlements change as the family system moves through the developmental stages," he said.
Family reconciliation
When individuals don't receive their perceived family or interpersonal entitlements, they usually take action, Houston said.
"Frequently they move to get what they believe they deserve, using threats, manipulation or more dysfunctional behavior," he said. "When a perceived imbalance occurs over a long period, distrust develops within the family relationship."
Family physicians should recognize that each family member has a unique perspective on the family system. The family physician can help the survivors review and understand their family's unique heritage.
"Talking to the family members as well as the patient about the patient's role in the family can give them a sense of belonging," said Houston. "It creates an opportunity for a candid discussion of the family system."
Although this discussion can be difficult for some families, it can lead to forgiveness and an acceptable closure.
"My experience is that attempted closure is better than no closure," said Houston.
FP Report is published by the AAFP News Department. Copyright © 1998 by American Academy of Family Physicians.