Patient-Centered, Family-Focused, Community-Approach to Health PDF

DISEASE PREVENTION AND CONTROL: LE 2 | TRANS 1 Patient-Centered, Family-Focused, Community-Approach to Health, Introduction to Clinical Family and Community Medicin...

DISEASE PREVENTION AND CONTROL: LE 2 | TRANS 1 Patient-Centered, Family-Focused, Community-Approach to Health, Introduction to Clinical Family and Community Medicine (Biopsychosocial Approach) LISSA LUZ C. CALIMAG, MD, MPM-HSD, DFM | 09/17/2024 OUTLINE The human body is a complex entity divided into: → Organ systems > Organs > Tissues > Cells > I. Biomedical Model B. Family Organelles > Molecules > Atom > Subatomic particles A. Definition of Health Assessment Tools II. Biopsychosocial C. Family Life Cycle Model D. Two Levels of A. Important Times Orders of for Psychosocial Magnitude of Intervention Change III. Biological Factors E. Illness Trajectory A. Demographic and the Impact of Profile Illness on the B. Genetic Patient and Family Characteristics F. Hospice and C. Lifestyle Palliative Medicine Characteristics VI. PFC Approach IV. Psychological Factors (Patient-Centered, Figure 1. Biomedical model A. Modalities of Family-Focused, Filipino Healing B. Primary Care Community-Oriented) A. Patient-Centered 📣 The biomedical model seeks to understand the human body using this framework in order to make the patient Counseling B. Family-Focused healthy. V. Social Factors C. Community-Orient A. Definition of ed A. DEFINITION OF HEALTH Family VII. Review Questions World Health Organization definition: Health is defined as VIII. References the highest possible level or state of complete physical, mental, and social well-being and not merely the absence SUMMARY OF ABBREVIATIONS of disease. ECM Emotionally critical misperceptions II. BIOPSYCHOSOCIAL MODEL CEA Catharsis - Education - Action Dr. George Engel CIA Catharsis - Insight - Action Neither disease nor illness is understandable only in terms APGAR Adaptation, Partnership, Growth, Affection, of smaller and smaller biologic components Resolve A person’s response to a disease requires consideration of PFC Patient-Centered, Family-Focus, Community factors such as the social and cultural environment, the -Oriented individual's psychological resources, and the ❗️ 📣 📖 📋 Must know Lecturer Book Previous Trans biochemistry and genetics of the disorder in the population. You can then analyze patients not just in terms of their component parts but through this macro scale of: LEARNING OBJECTIVES → Biosphere, society, culture, community, family, two ✔ Differentiate the biomedical model and the persons, person biopsychosocial model The biopsychosocial approach does not attempt to ✔ Identify biological, psychological, and social replace the traditional way of approaching medicine but factors that influence health tries to go further by taking a whole person approach ✔ Apply the biopsychosocial approach to the holistic (i.e., holistic approach) to manage patients and their care of a patient and his/ her family and community various medical conditions. (i.e., patient-centered, family-focused, A. IMPORTANT TIMES FOR PSYCHOSOCIAL community-oriented health care) INTERVENTION I. BIOMEDICAL MODEL Natural transition in the family life cycle Traditional medical model When patient compliance or lifestyle issues impinge on Rooted in the practice 4 centuries ago when physicians health were allowed to dissect the human body Dramatic change in patient symptoms Understanding a complex entity can be achieved by Significant medical diagnosis precipitating psychosocial analyzing its component parts crisis Can be studied and explained by the methods and in the Patients living with chronic illness require sensitive languages of physics and chemistry psychosocial care → They would study the human body with physics and chemistry. LE 2 TRANS 1 TG-A1 & A2: A. Abergas, I. Abesamis, J. Aceveda, C. Acol, K. TE: I. Abesamis, J. Aceveda, AVPAA: B. Asuncion, J. Page 1 of 15 Abante, D. Abjelina, G. Abrigo, L. Abanilla, N. Accad, A. Acosta, A. Acosta, F. Alcancia Cadano N. Adalin, R. Aguilar, S. Al-Ismail, V. Alagadan, G. Alano, F. Alcancia, C. Alcantara, S. Alcantara  III. BIOLOGICAL FACTORS ▪ E.g., Patients refuse taking medications because of Demographic profile their fear of kidney-damage and that herbal → Age, sex, race, educational background, occupation medications are safer because they are natural. Genetic characteristics − Inform them of safe dosages of medicines that → Familial/ hereditary diseases have been clinically studied and won’t cause Lifestyle characteristics kidney diseases. → Exercise, diet, vices (smoking, alcoholism, illicit drug A. MODALITIES OF FILIPINO HEALING use) Babaylan/ mumbaki A. DEMOGRAPHIC PROFILE Orasyon (bulong) Having the following characteristics are associated with Albularyo reduced mortality from nearly all diseases → Pagtatapal → Female sex → Dinalisay (herbal medicine) → Marital status: married ▪ Lack further studies and may have the highest risk → Higher socioeconomic status among other modalities → Greater number of social ties Manghihilot → Masahe (therapeutic massage) AGE → Paligo (gulgol) Older age → Bone-setter (chiropractic) → Hypertension, Diabetes, Coronary Artery Disease, Traditional birth attendant Chronic Kidney Disease, and most cancers Mangluluop (diviners) Younger age Manggagaway (sorcerers) → Streptococcal throat infection, many infectious diseases → Mangbabarang (hence we have the Expanded Program of → Mangkikitang Immunization), and certain types of leukemia → Mangkukulam at pagtatawas SEX/ GENDER Suob/tuob (steam inhalation) Disease that come with menopause Bintusa (ventosa) → Cardiovascular disease, osteoporosis B. PRIMARY CARE COUNSELING Men can have prostate cancer Face-to-face psychoeducation method Women can have breast cancer → Brings out psychological concerns that result from a PARITY misperception of reality that hinders appropriate behavior (i.e., emotionally critical misperceptions / Nulliparity (having never given birth) ECMs) 📣 → Associated with increased risk of breast cancer ▪ E.g., Patient believes medicine causes kidney → The risk factors were studied only in terms of damage. association but it is not necessarily a cause and effect → If ECMs are addressed appropriately, barriers are lifted, situation. Grand Multiparity (5 or more births) → Associated with adverse maternal outcomes ❗️ and educational inputs are better received. Forms of Primary Care Counseling derived from Carl Roger’s person-centered psychotherapy ▪ May also be due to older age → CEA Counseling: Catharsis – Education – Action B. GENETIC CHARACTERISTICS → CIA Counseling: Catharsis – Insight – Action Genetic characteristics predispose us to certain diseases In these forms of counseling: Newborn screening program is used to facilitate early → Ask the patient’s thoughts, feelings and fears about their interventions in the Philippines illness (Catharsis). → Congenital hypothyroidism (CH) → Identify the ECM, and educate the patient (for CEA) or → Congenital adrenal hyperplasia (CAH) allow them to get the insight on their own (for CIA). → Galactosemia (GAL) → Together, create an action plan on the behaviors that 📣 → Phenylketonuria (PKU) will be corrected by the patient. → Homocystinuria (HCY) There are many cases that the CEA counseling will not C. LIFESTYLE CHARACTERISTICS be effective. If you’ve already done the CEA, let the patient 📣 have more time to mull over what you discussed. The following lifestyle characteristics predispose us to But if the case is urgent, you can also try talking to the various diseases: other family members and ask them to discuss the matter → Alcoholism 📣 with the patient. → Substance use and abuse In the end, the patient always has autonomy and you → Smoking still need to respect their final decision and get their → Lack of exercise consent. → Diet (overnutrition and undernutrition) Importance of Catharsis: IV. PSYCHOLOGICAL FACTORS → Helps patients release their fears and more likely Affective (feelings), Cognitive (Beliefs & Expectations), believe when they’re educated Behavioral Dimensions → Allows for the identification of their ECM Coping styles and defense mechanisms Counselors must show genuineness, unconditional → Influence health and illness positive regard (letting go of judgment towards the → Health beliefs influence health-seeking behaviors patient), and empathy, and employ active listening skills → Identify the health beliefs of patients, correct any (non-verbal cues). existing misperception regarding their illnesses, and improve behavior. DISEASE PREVENTION AND CONTROL Patient-Centered, Family-Focused, Community-Approach to Health, Introduction to Clinical Family and Page 2 of 15 Community Medicine (Biopsychosocial Approach)  V. SOCIAL FACTORS → One parent working outside the Philippines (i.e., Social Systems → Family Characteristics 📖overseas Filipino worker) Communal / Corporate Family → Group of individuals which is formed for specific ▪ Structure ▪ Family Assessment Tools ideological or societal purposes ▪ Family Life Cycle ▪ e.g., Amish community in Lancaster county in → Impact of Illness and Illness Trajectory Pennsylvania These social factors affect the quality of life of FAMILY: CLINICAL CORRELATES individuals. Single parents Importance of family characteristics → Higher death rates due to: → WHO recognizes the family as the primary social ▪ Cardiovascular disease agent in the promotion of health and well-being, as well ▪ Malignancies as disease prevention. ▪ Infectious diseases → The family influences a person’s health beliefs and ▪ Accidents health-related behaviors. ▪ Homicides ▪ It is common for health beliefs and behaviors to be ▪ Suicides shared across the family, whether positive or Widowed: negative. → Four times higher age-specific death rates compared to − E.g., Diet and exercise practice, doctor visits married individuals → The family can be a source of stress and emotional Divorced men support. → Increased rates of A. DEFINITION OF FAMILY ▪ Depression-suicides Classical definition ▪ Domestic violence → Biological and marital kinship and patterns of Stepchildren/ children of single parents reciprocal obligations → Developmental delay ▪ Biologically related, married, or people taking care of ▪ (i.e., autism spectrum disorder, attention deficit each other hyper-reactive disorder) → Emphasis is given on the biologic and procreative → Depression relationships, as well as the child-rearing structure → Adjustment disorders Modern definition B. FAMILY ASSESSMENT TOOLS → A small social system made up of individuals related to Used to study and describe the family each other by reason of strong reciprocal affections and Studied by family physicians during residency training loyalties and comprising a permanent household that when they want to focus on a particular family with familial persists over years and decades (Berman, 1978). problems. → Examples: ▪ Same sex couples with children FAMILY GENOGRAM 📖 ▪ Unmarried couples with children Also known as family tree ▪ Couples with stepchildren Graphic representation of both the genetic pedigree of ▪ Single parents with children the family and key psychosocial and interactional data FAMILY STRUCTURE using standardized symbols Nuclear Family → Parents and their dependent children → Occupies a separate dwelling not shared with members → 📖 of the family of origin / orientation of either spouse Economically dependent Extended Family → 3 generations → 📖 → Grandparents, parents, and children in one household Family centered, lives together as a group → Can be unilateral or bilateral ▪ Unilateral: One side of the family ▪ Bilateral: Both sides of the family have grandparents living with them Blended Family → 📖 → Stepparents and stepchildren Caused by divorce, annulment with remarriage, and 📖 separation Single-Parent Family → Children less than 17 years of age living with a single parent, another relative, or non-relative → Results from loss of spouse by death, divorce, annulment, separation, desertion → Out of wedlock birth of a child → Adoption Figure 2. Symbols used in Family Genogram DISEASE PREVENTION AND CONTROL Patient-Centered, Family-Focused, Community-Approach to Health, Introduction to Clinical Family and Page 3 of 15 Community Medicine (Biopsychosocial Approach)  In the genogram, symbols for the diseases, especially FAMILY A.P.G.A.R. 📖 hereditary diseases are highly important It represents the three components of the family: → Family Tree Assesses family function Table 1. APGAR ▪ It consists of three or more generations, and each Adaptation Family’s utilization of the resources generation is identified by Roman numerals. available within and outside of the familial ▪ The first born of each generation is farthest to the left, system when significant life events pose a with siblings following to the right in order of birth. crisis. (e.g., Is the family able to adapt by ▪ The family name is placed above each major family collecting finances to support the unit; given names and respective ages are written hospitalized family member?) below each symbol. ▪ One member of the family is of greater medical Partnership Sharing of the family members in significance because of an illness and he is known as decision-making and responsibilities. the index patient who is identified with an arrow. Physical and emotional growth attained by Growth ▪ Date is indicated when the chart was developed so each family member from the family's that ages could be adjusted over time. ability to support and guide (i.e., family → Functional Chart members should not be stagnant, but they ▪ A more dynamic image of the family, especially the should be supportive). relationship of members. It allows one to judge the totality of the family unit, its strengths and Affection Reflects the satisfaction with emotional weaknesses, its ability to withstand future stressful relationships and intimacy within the family. situations. Commitment of family members to devote Resolve → Family Illness/History time to support each other’s physical and ▪ Denotes the presence of inherited diseases or emotional growth. It also pertains to the familial tendencies indicating potential problems in sharing of wealth and space. 📖 the family It is a very excellent tool to learn about family structure. Advantages: 📖 However, its role is limited in assessing family function. → Rapid screening for family function It is impractical in routine clinic visits as it takes → Good reliability and validity to measure individual 📖 10-15 minutes to construct a family genogram. satisfaction with family relationships Basic structure of the genogram is initially placed in the Disadvantages chart to shorten time consumption and then to be → Needs little time to complete (i.e, the family APGAR → 📖 completed on succeeding visits/consults. Advantages ▪ Records names and roles of each family member → Score is the average score of the index patient and at least one other family member) ▪ Separates extended family into several household ▪ Documents medical problems of each member → 📖 ▪ Documents significant dates in family history Disadvantages ▪ Limited value in assessing family function Figure 4. Family APGAR Questions FAMILY MAP Tool designed to reflect family relationships and interaction Figure 3. Sample Family Genogram of a Blended Family patterns 📣 Knowing these illnesses that are present in the family, Very important for primary care physicians in obtaining a therapeutic ally for the delivery of care in the family there may be a need to screen the children of this index patient for hypertension and other metabolic diseases due Provides a schematic description on whom to ask for assistance in making decisions for the patient 📣 to the history of the family. Family Genogram can help identify allies in health that Utilizes common symbols can take care of the index patients. ▪ Suggests family dynamics Describes the relationship between family members and boundaries between each member → Boundaries ▪ Rigid ▪ Clear − Good ▪ Diffuse ▪ Coalition − Between members against another family member DISEASE PREVENTION AND CONTROL Patient-Centered, Family-Focused, Community-Approach to Health, Introduction to Clinical Family and Page 4 of 15 Community Medicine (Biopsychosocial Approach)  ▪ Conflict FAMILY LIFELINE ▪ Detouring Summarizes the individual or the family’s significant ▪ Overinvolvement experiences in a chronologically sequenced manner Includes how the family has coped with these stressful life events → Example (see table below) ▪ In a patient that has been suffering from chronic headache, it was noted that certain life stressors exacerbated the headache. − Highest severity of headache was due to academic, work-related, and marital problems Figure 5. Symbols of Family Structure [PPT] FAMILY S.C.R.E.E.M. Family SCREEM (Social, Cultural, Religious, Economic, Educational, and Medical) → Represents the family resources → Commonly used when the need for care is long or lasts a lifetime 📖 ▪ E.g., chronically/terminally ill, hospice care patients It is a tool where the primary care physician helps family members identify and assess their resources to meet a crisis. However, the lack of resources can also 📖 serve as a kind of pathology in certain situations. It can also be used to assess the resources of difficult and non-compliant patients. Figure 6. Timeline of Significant Life Events and Their Impact on Headache Severity[PPT] C. FAMILY LIFE CYCLE Example → Social resources ▪ Neighbor 📖 Represent composite of the individual developmental changes of family members ▪ Community Shows the evolution of the marital relationship → Cultural Presents cyclic development of the evolving family unit ▪ Cultural beliefs Shows the ability of the family to transcend the emotional − E.g., bayanihan process of transitions → Religious Key element: Adaptation ▪ Specific religious beliefs that help them cope with → Everytime they go from one stage to another, they have their illness to fulfill that transition or adaptation ▪ Religious institutions (church) → Economic WHY DO WE STUDY THE FAMILY LIFE CYCLE? 📖 ▪ State of finances Provides a predictable, chronologically oriented sequence → Educational of events in family life with which family physicians and ▪ Educational status/attainment other health professionals are already familiar with ▪ How well they are able to understand their illness Involves a sequence of stressful changes that require ▪ How well they are able to understand the things they compensating or reciprocal readjustments by the family to need to do to manage their illness maintain viability → Medical Events of the family life cycle can be related to clinical ▪ Nearby hospitals, clinics, specialists, primary care events and to health maintenance of the family physicians, etc. that the patient has access to 6-STAGE FAMILY LIFE CYCLE 📋 SCREEM FAMILY RESOURCE SURVEY Unattached Young Adult (S.C.R.E.E.M.-RES) Newly Married Couple ***See Table 9 in the appendix Family with Young Children 12-item self-administered survey in Filipino. Family with Adolescent Modification of the original S.C.R.E.E.M. Launching Family Used to assess the family’s capacity to participate in health Family in Later Years care provision or to cope with crises. Interpretations based on the sum of the score: → 0-6 points: Severely inadequate resources 📖 📖 1. UNATTACHED YOUNG ADULT Start of the family life cycle → 7-12 points: Moderately inadequate resources → 13-18 points: Adequate resources 📋 “Between families” When a person leaves their family of origin to live by themselves independently DISEASE PREVENTION AND CONTROL Patient-Centered, Family-Focused, Community-Approach to Health, Introduction to Clinical Family and Page 5 of 15 Community Medicine (Biopsychosocial Approach)  Young adults have come to terms with family of origin and 📖 Adolescents to teenagers, parents to middle age, ❗️Emotional process of transition/ key principle: are formulating personal goals in developing as an grandparents to later years ❗️ individual including forming a new family. Emotional process of transition/key principle: → Accepting parent-offspring separation increasing flexibility of boundaries to include children’s independence and grandparents’ frailties → Accepting financial and emotional responsibility for → When a married couple has adolescent children, their oneself parents’ are usually older so they’re getting sick at that 2. THE NEWLY MARRIED COUPLE stage so they have to take care of their parents as well. 📋 Differentiation from family of origin When a young adult gets married, they form a family 📖 5. LAUNCHING FAMILY Launching of Adult Children 📖 with their spouse Transition stage of the couple from individual to couple living Launching family stage occurs when the original family’s eldest child grows further into an adult and eventually leaves the nest. ❗️ Making room for spouse with family and friends Emotional process commitment to the new system of transition/key principle: → The one who left the family will start their own life cycle as an unattached young adult. Begins when the first child leaves home Table 2. Stages of Marriage 📖 Ends when the last child leaves home STAGES EMOTIONAL ISSUES CRITICAL TASKS ❗️ Launched children start their own families Emotional process of transition/ key principle: accepting a multitude of entries intro and exits from Honeymoon Commitment to Differentiation the family system Stage the marriage from family origin → Intros and Exits examples: (less than 2 Making room for ▪ Intros years) spouse with − Daughter-in-law family and friends − Son-in-law Early Maturation of Keeping romance − Manugang Marriage the relationship in the marriage ▪ Exits Stage Balancing − The elderly parents of the original couple who may (2-10 years) “separateness” pass away and “togetherness” 6. FAMILY IN LATER YEARS Middle Post-care Adjusting to Occurs once they launched all their children Marriage review midlife changes Should be preparing for death and bereavement. Stage Re-negotiating Begins with departure of last child (10-25 years) marriage Continues through retirement of one or both of the couple Long Term Marriage “Farewells” and planning Maintaining couple ❗️ Ends when both are dead Emotional process of transition/ key principle: accepting the shifting of generational goals Stage functioning (more than 25 Closing of → When you’re an elderly couple, you turnover the years) adapting family authority of being the head of the family and being the home decision maker to your adult kids due to increasing Coping with frailty. 📖 death of the D. TWO LEVELS OF ORDERS OF MAGNITUDE OF spouse CHANGE 3. FAMILY WITH YOUNG CHILDREN Starts with the pregnancy for the first child to emergence of → 📋 First Order Changes Change in “ability” → Involves increments of mastery and adaptation 📋 adolescents They would need to adapt to the responsibilities of this ▪ 📋 → A “need to do” something new e.g., A baby first learns how to crawl followed by a 📋 stage primarily adjusting to parenting. Defines new family status New roles: series of steps, then finally running → No change in the main structure of the family → Wife to mother → No change in the family’s identity and self-image → Husband to father ▪ e.g., change of residence, employment (i.e., young adults), establishing a place to call their own (i.e., ❗️ Conflict to home and school regulations Emotional process of transition/ key principle: accepting new members into the system newly married couple), working out money matters (i.e., family with young children) → New members: young children Second Order Changes → New role: as a parent and responsibilities → Involves transformation of an individual’s status and meaning 4. FAMILY WITH ADOLESCENTS When children grow up to be teenagers → Teenagers have different needs as compared to young ▪ 📋 → A “need to be” something new e.g., Role reversal: A child who was taken care of will take care of his/her caregiver in the future children. → There is change in the role and identity of family 📖 → They need more independence. members. 📋 Identity crisis stage → Change occurs between stages of the family life cycle ( Intergenerational Connectedness) DISEASE PREVENTION AND CONTROL Patient-Centered, Family-Focused, Community-Approach to Health, Introduction to Clinical Family and Page 6 of 15 Community Medicine (Biopsychosocial Approach)  ▪ e.g., change when a family moves from newly meaning of Fearful fantasies married to family with young children; husband symptoms and anxiety over becomes father and wife becomes mother the denial of seriousness of E. ILLNESS TRAJECTORY AND THE IMPACT OF symptoms and 📖 📖 ILLNESS ON THE PATIENT AND FAMILY Discover the meaning of illness for the family Investigate disease: examine clinical and laboratory possible implications 2. IMPACT PHASE/ REACTION TO DIAGNOSIS 📖 evidence of biologic and psychophysiologic dysfunction When they consult a doctor and get diagnosed, they go Investigate illness: exploring the meaning of disease to to the impact phase/ reaction to diagnosis phase. 📖 the patient and the patient’s family → E.g., Patient with rectal bleeding and constipation got Major illnesses involve loss of: diagnosed with colorectal cancer. → Body parts Where they deal with all the anguish and turmoil of the → Ability to carry out normal and treasured activities diagnosis → Sense of self-esteem → Dreams and plans for the future Table 4. Reaction to Diagnosis 📖 → Sense of invulnerability for one’s self and loved ones EMOTIONAL PLANE COGNITIVE PLANE that keeps fears of impending death and separation at During onset of illness, Phase I: initially tension bay there may be initially confusion with probably denial, disbelief, and lack of capacity for 📖 THE FAMILY ILLNESS TRAJECTORY anxiety problem solving Normal course of the psychosocial aspects of disease Followed by emotional Phase II: repeated failure for the patient and the family upheaval (i.e., anger, in deriving diagnosis may Knowledge of the trajectory allows the primary care anxiety, depression) lead to exacerbation of physician to Last phase is tension and increase → Predict, anticipate, and deal with the family’s response accommodation and distress to the illness acceptance of diagnosis Phase III: increasing 📖 → Formulate individualized therapeutic plans. Indicates normal and pathologic responses assessment and receptivity of family to STAGES OF FAMILY ILLNESS TRAJECTORY new approach for relief or distress 1. ONSET OF ILLNESS TO DIAGNOSIS Phase IV: acceptance of When the patient starts to feel any symptoms but they the diagnosis enables the haven’t consulted a doctor yet family to mobilize → E.g., The patient has constipation and rectal bleeding resources for one month with no check up. Medical beliefs and previous experiences influence the 3. MAJOR THERAPEUTIC EFFORTS meaning of illness. The patient, with the help of their family, is focused on the → E.g., “What could be the meaning of this?” or “Am I treatment (ex. Surgery, chemotherapy, other medications). sick?” Critical issues in choosing the therapeutic plan Warning sign → Things you can consider when talking to the patient → Malaise is the preliminary stage of the illness trajectory. when deciding → Stage experienced prior to contact to medical care ▪ Example questions: providers − Are you doing surgery or chemotherapy or → Nature of onset may play an important role on impact of palliative care? illness on a family − Are you going to hospitalize the patient or home Table 3. Onset of illness to Diagnosis Onset 📖 care? → Psychological and preparedness state of the patient and Nature of Characteristics Impact on the family of Illness of Experience Family → Assumption of responsibility for care, responsibilities of Illness Acute, Rapid, Little time for Caught up in each party rapid clear physical and suddenness → Economy of the therapeutic plan psychological adjustment Short period Deals with immediate decisions → 📖 → Lifestyle and cultural characteristics of the a family Hospitalization gives rise to stressful logistic problem between stages, Often with little 4. RECOVERY PHASE - EARLY ADJUSTMENT TO little time to support within OUTCOME remain in state and outside of After therapeutic efforts, the patient either recovers and of uncertainty the family unit goes to the recovery phase, or they have a bad outcome If less (e.g., disability or bedridden). threatening, may Family will have to support the patient in that outcome. be dramatic but Experience of recovery of adjustment to the illness less crisis- oriented problem outcome varies according to type of outcome anticipated: for the family → Return to full health Chronic, Gradual Suffer from state Vague ▪ Simplest, gains from illness experience debilitating of uncertainty apprehension ▪ E.g., regaining health after community-acquired regarding and uncertainty pneumonia → Partial recovery DISEASE PREVENTION AND CONTROL Patient-Centered, Family-Focused, Community-Approach to Health, Introduction to Clinical Family and Page 7 of 15 Community Medicine (Biopsychosocial Approach)  ▪ Followed by period of waiting to learn if disease will ▪ Active listening skills return or fear of death, maintain constant sense of − Used by the primary care physician to understand vulnerability how a patient sees the world and how he ▪ E.g., cancer in remission; completing six-month perceives the problematic reality for which he is regimen for anti-Koch’s infection consulting → Permanent disability o Attending skills ▪ E.g., S/P below the knee amputation (BKA) for a o Bracketing skills neuroischemic foot ulcer o Leading skills: direct and indirect leads 5. ADJUSTMENT TO PERMANENCY OF THE OUTCOME o Reflecting skills: content, feeling, experience o Focusing skills Continued unwillingness to incorporate reality of o Probing skills permanency or outcome may be a sign of pathology Prolonged Grief Disorder F. HOSPICE/PALLIATIVE MEDICINE → Family members have a difficulty in accepting the death Hospice and Palliative Medicine of a loved one or moving on from the death of a loved → Emphasizes providing support and care for terminally-ill one. patients and their families How well a family can deal with the death of a family → Goal is for them to live as fully and as comfortably as member can depend on whether the illness was acute, possible chronic, or terminal → To attain a degree of mental and spiritual preparation for 📣 Second crisis occurs as family realizes that they must death accept and adjust to the permanent disability Example of palliative care: Family must accept that life goes on → Patient having stage 4 cancer so there are no more For acute illness curative management and the focus is on giving the 📣 → Potential for crisis when the routine of the family is patient comfort suspended Hospice and nursing homes are similar but: ▪ E.g., If the affected person was the breadwinner of → Hospice is more of end-of-life care the family, the family might be at a loss for how to → Nursing homes can be for geriatric or elderly patients 📣 support themselves. who need more help → Emotions are high and can lead to anger especially if End-of-life care and Palliative care are not exactly the medical care is perceived to be inadequate. same: ▪ E.g., a patient died during childbirth from eclampsia → Palliative care and that was an unexpected outcome in the eyes of ▪ Comfort/holistic care for patients with severe or the family members, leading them to blame medical chronic illness workers → End-of life care → Medical professionals must be more empathetic when it ▪ Under palliative care comes to the family members of the deceased person and anticipate those emotions. → 📋 Advanced Directives Whether or not to be intubated or have CPR or For chronic illness → Prolonged fear and anxiety can cause higher incidence 📋resuscitation done to them Surrogate Decision Makers of illness in other members of the family ▪ Caregivers also become sick due to prolonged anxiety 📋 → When the patient cannot decide on their own → Orthothanasia ▪ Humane way of allowing patients to die with dignity → Brings about additional burden, feelings of guilt ▪ Patient is provided with psychosocial support and is ▪ Especially if the patient was previously neglected helped to achieve a level of comfort until their last over indulgence towards sick member’s feelings of overwork, anger, resentment, and guilt ▪ Some caregivers experience feelings of guilt as well 📋 breath → Euthanasia ▪ “Mercy-killing” For terminal illness ▪ Physician-assisted suicide is not promoted → Initial response is of shock and overwhelming anxiety VI. PFC APPROACH (PATIENT-CENTERED, → Highly emotional and devastating FAMILY-FOCUSED, COMMUNITY-ORIENTED) → Grief reaction of a family ▪ If the family is functional, family members are drawn A. PATIENT-CENTERED HEALTH CARE closer. ▪ If the family is dysfunctional, the grief can be a seed healthcare 📖 Table 5. A summary of the PFC Approach to patient-centered Plans for Patient-Centered Health for family discord and breakdown. Category → Medical professionals can aid the family in providing Care efficient and functional readjustment as well as History and physical A survey or interview of the patient’s exam (The medical fears, doubts, concerns, and providing quality care. component) predicaments ▪ Home care is best. STEPS IN FAMILY SYSTEMS APPROACH 📖 Analysis Primary working impression or a differential diagnosis Stage of illness 1. Recognize the family function Impact of the illness → Graphic representation of the family members Plan of management Diagnostics, therapeutics, 2. Understand the normal family function non-pharmacologic advice → Dynamic image of relationships in the family Counseling 3. Learn to assess family structure and function in Follow-up consult clinical practice Referrals → Family physician should listen more and talk less DISEASE PREVENTION AND CONTROL Patient-Centered, Family-Focused, Community-Approach to Health, Introduction to Clinical Family and Page 8 of 15 Community Medicine (Biopsychosocial Approach)  B. FAMILY FOCUSED HEALTH CARE ▪ Difficulty with ambulation, inability to express Table 6. A summary of the PFC Approach to family-focused health needs, emotions, thoughts care ▪ Anger and frustrations Category Plans for Patient-Centered Health Care ▪ May benefit from counseling; screening for Data Analysis Family Determinants and Resources Caregiver Issues Family Assessment Tools − 📣 depression and anxiety Frustrated, hopeless, depressed. Being unable to speak they are unable to express Family Life Cycle Impact of Illness − 📣 their needs, emotions, and thoughts These patients can benefit from counseling or refer them to a psychiatric service, palliative Plan of Capability Building of Caregivers management Health Education for Family Family Counseling − 📣 care, or family medicine You can also screen for depression and anxiety, with PHQ-9 and GAD-7 C. COMMUNITY-ORIENTED HEALTH CARE → Family-Focused Table 7. A summary of the PFC Approach towards ▪ Total dependence on the wife (risk for caregiver community-oriented health care strain) Category Plans for Patient-Centered Health Care ▪ Altered roles of family members; re-assignment of Data Home or work environment (e.g., tasks within the household (e.g breadwinner role) Sanitation) Social Determinants of Health Building blocks of health systems − 📣 ▪ Financial and emotional burden The wife could be the breadwinner while the siblings of the patient or wife and/or other Health Laws relatives take on the care-giver role or Epidemiologic data Analysis Plan of Enablers and barriers to care Networking and linkages − 📣 parenting role, vice versa A functional family can support each other through difficult times management Referral system → Community-Oriented Interprofessional / multidisciplinary ▪ Mobilization of rehabilitation services; support of team approach medical teams (e.g., physical/occupational CASE SCENARIO therapy, etc.) A 62-year-old male office clerk was rushed to the ▪ Social support (e.g., neighbors and friends, UERMMMCI-ER due to right-sided weakness and slurring PCSO, politicians, and Philhealth) of speech. The patient is a known hypertensive with poor − Senior Citizens Act of 2010 (RA 9994) compliance to his maintenance medications due to financial constraints. ▪ 📣 − Persons With Disability (PWD) Act (RA 10754) You can refer them to DSWD in their city or barangay. The patient is the sole breadwinner of the family. He and his wife have three young children. ❗️ For the exam: Focus on the counseling and illness trajectory On physical examination, his BP was 180/100 mmHg. He III. REVIEW QUESTIONS was awake but aphasic. Motor and sensory deficits were 1. In which STAGE OF MARRIAGE will maturation of the apparent in the right side of the body. marital relationship be noted, and balancing “separateness” and “togetherness” becomes a He was subsequently admitted for cerebrovascular critical issue? accident (CVA)/stroke, left middle cerebral artery (MCA) a. Middle marriage stage occlusion. He lost functional capacity and ability to b. Long-term marriage stage communicate needs and emotions. He was advised c. Early marriage stage rehabilitation. d. Honeymoon stage 2. Which of the following exemplifies a SECOND ORDER BIOMEDICAL ASPECT CHANGE? → Cellular/Molecular Level: a. A 15-year-old junior high school teen prepares her ▪ Nerve cells die (ischemic cell change) and 10-year-old brother’s laptop computer for his daily disappear and are replaced by fibrillary gliosis online classes amidst the COVID-19 pandemic → Tissue/Organ Level: b. A 17-year-old teen lovingly attends to all the health ▪ Occlusion of Left Middle Cerebral Artery (LMCA) needs of his 50-year-old father who is in chronic leading to decreased blood supply vegetative state after suffering from a recent brain ▪ Ischemic damage to nerve tissue attack secondary to a ruptured cerebral aneurysm → Organ System/Person/Patient-Centered c. A 19-year-old college student learns to use food art as ▪ Cerebral infarct causes paralysis on the a marketing strategy to promote his mother’s contralateral side of the body, aphasia, and homemade gourmet “tuyo” online business sensory deficits. d. A 75-year Professor Emeritus officially leaves her ▪ Management: Anti-hypertensives, Anti-platelet, academic work in a private academic institution and Statin, Rehabilitation, etc. flies to different continents to enjoy her retirement with her husband PSYCHOSOCIAL ASPECT 3. Tham and Type are gay men in their late 20s, both → Patient-Centered Thai nationals currently residing in Bangkok, and have legally registered for same-sex domestic DISEASE PREVENTION AND CONTROL Patient-Centered, Family-Focused, Community-Approach to Health, Introduction to Clinical Family and Page 9 of 15 Community Medicine (Biopsychosocial Approach)  partnership. They are in the process of officially adopting a 7-year-old orphan, named Fighter. Once the adoption is legalized in Thailand, what will be their FAMILY STRUCTURE? a. Nuclear family b. Blended family c. Single-parent family d. Communal family 4. In which of the FAMILY LIFE CYCLE is “increasing flexibility to include grandparents’ frailties” the main emotional process of transition? a. Family in later years b. Launching family c. Family with adolescents d. Newly married couple 5. The family genogram and family map are graphic representations of both the genetic pedigree of the family and interactional data using standardized international symbols. The following data may be documented objectively using these 2 family assessment tools, EXCEPT: a. Family structure b. Family medical history c. Family dynamics and relationships ANSWER KEY 1. C A critical task during the early marriage stage is balancing “separateness” and “togetherness” 2. B Exemplifies ‘role reversal’ 3. A Members consist of parents and their dependent children, occupying a separate dwelling not shared with members of the family of origin 4. C “Increasing flexibility to include grandparents’ frailties” is a key principle of family with adolescents 5. B Family medical history used in family A.P.G.A.R. VIII. REFERENCES DPC Manual Powerpoint presentation → https://uerm.instructure.com/courses/15404/files/1051328?wra p=1 Lecture Video DISEASE PREVENTION AND CONTROL Patient-Centered, Family-Focused, Community-Approach to Health, Introduction to Clinical Family and Page 10 of 15 Community Medicine (Biopsychosocial Approach)  VI. APPENDIX Figure 7. Family Genogram Sample [DPC Manual] DISEASE PREVENTION AND CONTROL Patient-Centered, Family-Focused, Community-Approach to Health, Introduction to Clinical Family and Page 11 of 15 Community Medicine (Biopsychosocial Approach)  Table 8. Family A.P.G.A.R. [DPC Manual] DISEASE PREVENTION AND CONTROL Patient-Centered, Family-Focused, Community-Approach to Health, Introduction to Clinical Family and Page 12 of 15 Community Medicine (Biopsychosocial Approach)  Table 9. Filipino Family A.P.G.A.R. [DPC Manual] DISEASE PREVENTION AND CONTROL Patient-Centered, Family-Focused, Community-Approach to Health, Introduction to Clinical Family and Page 13 of 15 Community Medicine (Biopsychosocial Approach)  Table 10. S.C.R.E.E.M.Family Resource Survey [DPC Manual] DISEASE PREVENTION AND CONTROL Patient-Centered, Family-Focused, Community-Approach to Health, Introduction to Clinical Family and Page 14 of 15 Community Medicine (Biopsychosocial Approach)  Table 11. Example of Family S.C.R.E.E.M 📖 Resource Pathology Social Social interaction is evident among family members. Family Family members are isolated from extra-familial members have well-balanced lines of communication with social groups. Problem of over-commitment may be extra-familial social groups, such as friends, sports, clubs, evident. and other community groups. Cultural Cultural pride or satisfaction can be identified, especially in Family members may experience ethnic/cultural distinct ethnic groups. inferiority Religious Religion offers satisfying spiritual experiences as well as Family members may observe very rigid contacts with an extra-familial support group. dogmas/religious rituals. Economic Economic stability is sufficient to provide both reasonable Family members experience economic deficiency satisfaction with financial status and an ability to meet with inappropriate economic planning. economic demands of normative life events. Educational Education of family members is adequate to allow members Family members are handicapped to comprehend to solve or comprehend most of the problems that arise important issues/details. within the format of the lifestyle established by the family. Medical Health care is available through channels that are easily Family members fail to utilize available health care established and have previously experienced in a facilities and resources. satisfactory manner. Figure 8. Family Map Sample [DPC Manual] DISEASE PREVENTION AND CONTROL Patient-Centered, Family-Focused, Community-Approach to Health, Introduction to Clinical Family and Page 15 of 15 Community Medicine (Biopsychosocial Approach)