The name of our discipline—family practice—implies that “family” is the focus of care.1 The definition of family varies with the clinical situation and has important clinical implications. Some family physicians care for multiple family members of differing ages. The traditional approach to treatment is to focus on the individual patient, with minimum consideration of the family. Other physicians focus on the patient in the context of the family environment, while others focus on the family as the unit of care.2 In this issue of American Family Physician, Lang and associates3 discuss the challenges and opportunities of conducting an office visit when additional family members are present.
There are many definitions of family. One that is widely accepted is the U.S. Census Bureau's description of a family as “a group of two or more people related by blood, marriage or adoption.”4 This definition is often used in clinical practice as the basis for family charting. It is an inclusive definition that allows for dual-parent, single-parent, grandparent, adoptive, and gay and lesbian families. In clinical situations, however, the definition and focus of care needs to be flexible depending on the illness type, disease stage, and life-cycle stage of the patient and family. In addition, some definitions of family include members who may not be related by blood, marriage, or adoption.
Primary Definitions: Biologic, Household, and Functional Families
The biologic, household, and functional family definitions are primary family configurations seen daily in clinical practice.
BIOLOGIC FAMILY—GENETIC AND FAMILIAL ASPECTS OF DISEASE
When a genetic or familial disposition to an illness is evident, the relevant unit of care is the biologic family. The most effective way to gather historical information is by using a family tree or genogram.5 Cancers of the ovary, breast, and colon, and premature heart attacks, migraines, hypertension, and asthma are examples of disease conditions known to have familial patterns of genetic origin.
Understanding a patient's biologic family history often helps to diagnose unusual or rare conditions, and the use of DNA testing and other laboratory screening tests can identify high-risk family members. Intensive measures can then be taken to make early diagnoses or even prevent the disease in an effort to reduce morbidity and mortality.
When gathering information for a family tree, it is important to inquire about adoptees because they might not know details about their biologic family.
Illustrative Case. A 36-year-old woman initially presented with a three-month history of abdominal distress, which was diagnosed as irritable bowel syndrome. The patient had been treated but did not experience relief of her symptoms. Her family history revealed several first-degree relatives with ovarian or breast cancer. Following this lead, the patient was found to have cancer of the left ovary with peritoneal metastases. While she received chemotherapy, discussions ensued with other family members about genetic testing.
Household Family—Infectious Disease Considerations
When an infectious disease is suspected, physicians should focus on the inhabitants of the household. All persons who are residing in the home or visiting (e.g., friends, babysitter) around the time of disease onset should be included in the diagnostic consideration. Inquiring about sleeping arrangements is important because infections are more easily transmitted to persons sharing a bed or bedroom.6 Obtaining knowledge about the household is advantageous to identifying the infection source and developing a plan to prevent its spread.
Illustrative Case. A two-year-old child with acute tonsillitis and otitis media had been infected by his babysitter. Despite routine hand washing, the infection spread to his six-year-old brother with whom he shared his bedroom, and to his parents. His two sisters, who had their own bedrooms, were not infected.
FUNCTIONAL FAMILY—IMPACT OF CHRONIC ILLNESS ON FAMILY FUNCTION
In dealing with patients with chronic disease, it is important to identify the functional family (i.e., the group involved in dealing with the everyday affairs of the patient and family). The functional family may include the caregiver and persons who help with finances or household chores. Different people may fulfill different functions during the course of a chronic disease, which is described as a series of crises interspersed with relatively stable periods.7
Illustrative Case. Mary, who was diagnosed with juvenile type 1 diabetes at 10 years of age, was followed by her family physician for 20 years. Roles within her functional family changed as she progressed through different disease stages and life-cycle transitions. Key support roles were played by different people at different stages of her disease: by her parents as she initially adjusted to the disease; by herself at college; by a roommate when she was single; and by her husband after marriage.
Secondary Definitions: Crisis, Bereaved, Cultural, and Relationship Families
The crisis, bereaved, cultural, and relationship families are secondary conceptual definitions, which usually emerge from the primary family types. Occasionally, they become the central focus of care.
CRISIS FAMILY—CRISIS SITUATION
During a crisis such as a sudden death, heart attack, stroke, or accident, the group dealing with the patient may be called the crisis family. This includes persons actively involved in any aspect of the crisis and might include members of the immediate family, relatives, friends, and neighbors.
Illustrative Case. A 56-year-old woman who was the caregiver of her 82-year-old, disabled, widowed mother, felt unable to continue care-giving after her mother developed urinary incontinence following a stroke. She wanted her mother to be institutionalized, but sisters living in distant cities strongly objected. A family conference resolved the conflict by securing the services of a friend and a home health aide, who became integral parts of the crisis family.
The bereaved family usually develops following a sudden death or within the functional family dealing with a chronic illness. Bereavement often begins during a terminal disease phase and continues after the patient's death. A spouse is particularly vulnerable during the first six to 12 months after the death,8 during which time the attention of the family physician can be especially important. Without adequate support, the spouse can become the “hidden patient,” being at risk for illness or death.9
CULTURAL FAMILY—CULTURAL AND RELIGIOUS BELIEFS
Sometimes religious and cultural values and beliefs affect medical decision-making. Physicians must understand these perspectives in order to negotiate appropriate patient care. In some cases, religious or cultural groups may exert more influence on the patient's beliefs than family members.
|Family definition||Major family situation||Clinical significance|
|Census definition (blood, Marriage, adoption)||Routine contact with all new patients||Inventory of family morbidity, mortality, and biologic relationships|
|Biologic||Genetic and/or familial disorder||Diagnosis of family/genetic transmission; identification of high-risk members and their early treatment or prevention|
|Household||Infectious diseases||Determine the origin of infection; prevent, ameliorate, or treat contacts|
|Functional||Chronic disease or illness||Identify caregiver and support system of patient and caregiver to help with care at that particular time.|
|Crisis||Sudden death, illness, or accident||Identify key members to participate with physician in dealing with situation.|
|Bereaved||Terminal phase of disease and following death of patient||Prepare patient and family for death and continue follow-up, especially of spouse, after death of patient.|
|Cultural||Cultural beliefs of patient impact medical decisions and care||Determine beliefs and reasons for behavior in order to negotiate treatment and care.|
|Relationship||Conflicted relationships leading to violence, abuse, psychosomatic problems, depression, and unclear results of treatment||Evaluate relationships within family in order to directly treat or make appropriate referral.|
Illustrative Case. As a medical resident, JHM watched helplessly along with his patient's parents as their 24-year-old son rejected treatment based on his religious beliefs. The patient died of a bleeding duodenal ulcer.
RELATIONSHIP FAMILY—FAMILY INTERACTIONS AND CONFLICTS
In the majority of primary configurations, the patient-family relationship supports the doctor's care. However, the relationship can sometimes become an impediment. In situations where family violence or abuse exists, the relationship situation becomes the primary problem. The physician should then identify the problem and deal with it directly or make an appropriate referral.
Medalie and colleagues10 reported that 92 percent of family physicians pay attention to the families of their patients in some fashion. These physicians know that clinically, family configuration and roles vary according to disease type and stage, the patient's reaction to the disease, and the relationship between patient and family. The primary and secondary family configurations commonly seen in clinical work are summarized in the accompanying table. It is essential for family physicians to determine their patients' family configurations so that appropriate family members become part of the physician-patient-family health care team.