CASE STUDY 1

Patient Y is a married woman, 76 years of age. She emigrated from China to the United States with her husband 53 years ago. They have three children: a daughter who lives near them; a son who lives in the same city; and a son who lives out of state. They also have eight grandchildren. Patient Y is a homemaker. She and her husband have lived in the same neighborhood, in the same house for more than 40 years. Patient Y speaks little English and depends on family members to translate for her when the need arises. Recently, she became ill, complaining of dizziness, shortness of breath, being tired all the time, and loss of appetite. During a visit, her daughter noticed that she looked pale and had lost strength in her left arm. She convinced her mother to go to the hospital and accompanied her; Patient Y was diagnosed as having had a mild heart attack and was admitted to the hospital for tests and observation. On the second day following hospitalization, Patient Y suffered a second, more serious heart attack and was admitted to the intensive care unit (ICU). Her condition was guarded and other family members were notified, including the son who lived out of state.

The hazardous event in this case scenario is the onset of the illness and the symptoms. It usually occurs when the family receives news of the diagnosis. Rolland's trajectory phases of illness chronicle the natural history of chronic diseases [18]. Rolland's first phase is the crisis stage, which includes the onset of symptoms, learning about the diagnosis, and the initial adjustment period. During this stage, the patient and family assimilate the news of the diagnosis, attempt to comprehend the meaning of the disease, and begin grieving the loss that the disease will bring. Eventually, there is a movement toward acceptance and gradual equilibrium in the family system. In crisis theory jargon, the hazardous events in this case study are the initial diagnosis of the first attack, and later, the diagnosis of chronic heart disease and Patient Y slipping into a coma. Patient Y's family will learn of the diagnosis and begin to comprehend the enormity and gravity of the situation.

Although visiting in the ICU was strictly limited, a family member was allowed to stay with Patient Y most of the time due to her anxiety about hospitals and the staff's limited ability to converse with her. Patient Y continued to refuse to eat, and IVs were maintained. Her condition was guarded, although she insisted through her husband and children that she was fine and just wanted to go home to prepare for Thanksgiving.

The younger son was contacted due to the seriousness of his mother's condition and arrived the night after her second heart attack. The daughter organized the family to take turns being with Patient Y, and the grandchildren and other extended family members provided transportation, cooked, cleaned the home, and met her basic needs.

After three days in the ICU, Patient Y was transferred to the telemetry unit. The crisis situation began taking its toll on the family. The younger son argued with his sister that his mother should be allowed to go home to familiar surroundings, familiar foods, and family care. He was angry about his mother's condition and blamed his father and siblings for not taking better care of her. Patient Y's husband ignored him and refused to discuss any future plans with him or the other children. The long days and nights and his worry about his wife were obviously affecting this quiet man whose wife had always looked after him and dealt with the children.

The daughter took over and met with physicians and the hospital social worker and organized family resources to assure her father's care. She arranged for a family member to always be present with Patient Y and arranged with the hospital to allow the family to bring more familiar foods to her mother. She quietly and competently mobilized family resources to meet new and different demands and began gathering information about available resources for when (and if) her mother was able to leave the hospital, in spite of her father's denial and her brother's unrealistic optimism.

Crisis theory is helpful in normalizing the crisis event and the responses evoked by Patient Y's illness. In this case study, the son's anger and the calm, methodical, and systematic responses of the daughter are not viewed in a pathologic perspective. Instead, they are viewed in light of the crisis and from the perspective that a range of emotions and reactions are normal. The range of responses on the part of the patient and/or family members may include: (1) a biophysical response (e.g., the patient's experience of pain and discomfort); (2) the range of emotional responses (e.g., anger, sorrow, shock, loss, helplessness, anxiety about welfare of children, spouse), fear of death, and other emotions; (3) the cognitive response (e.g., fears, belief systems about how illness will affect the future); and (4) the behavioral response (e.g., the patient and the family's adjustment to medical regimen, hospital rules if hospitalized, assimilation of diagnosis) [10]. Because of the crisis event, the family system freezes, requiring an altering of family functions and roles. In this case scenario, the daughter's role was redefined as she mobilized the family to meet the various demands of her mother's illness. The grandchildren assumed various caretaking roles including cooking, cleaning, and transporting Patient Y's husband to and from the hospital. Because the stress was a threat to the ongoing functions of the family, its members mobilized its energy to establish new equilibrium.

CASE STUDY 2

The family in this case consists of a mother, a father, and three children: a daughter 39 years of age; a son, Patient J, 38 years of age; and a daughter 32 years of age. Patient J has recently made contact with his family after an absence of 16 years. During this time, he has lived in another state and has had no contact with his father and older sister. He has been in touch sporadically with his mother and younger sister, although without the knowledge of his father and older sister. Nine years ago, Patient J was diagnosed with HIV and 11 months ago was diagnosed with AIDS. His health is deteriorating, and he will most likely be unable to care for himself within a few months. Patient J has been in a stable relationship for about seven years, and his partner is both willing and able to care for him throughout the course of his illness. Patient J would like to reconcile with his father and older sister and move back to his hometown. His partner, a successful writer who works from their home, is willing to accompany him. They have purchased a home approximately six miles from Patient J's family home and have arranged to transfer his medical treatment to a local physician. All of this has been accomplished with the assistance of Patient J's younger sister and mother, both of whom are eager to have the patient near them but are apprehensive about the reception he will receive from his father and older sister.

In this scenario, we see how the diagnosis of HIV and AIDS has estranged Patient J from both his father and older sister. Although Patient J has made repeated attempts to bridge the gap, his attempts have been rebuffed. The patient's mother and younger sister have worked to bring him home, with much disapproval from his father and older sister. We can imagine the conflict that must have transpired within the marital dyad and perhaps between the two sisters. We can also see how AIDS has affected the lives of Patient J and his partner. Patient J's partner, who is committed to him, has taken on the responsibility of providing the day-to-day care for the patient. He is also willing to sacrifice his professional writing career, deciding to relocate with Patient J to their new home.

CASE STUDY 3

Mr. and Mrs. P have long anticipated their retirement years. They have plans to travel the country in the RV they purchased last year and have spent many evenings studying maps and brochures about campgrounds. With their two children grown and relatively stable, they look forward to having time to devote to each other and to their shared interest in travel. Their friends tease them about their pending "second honeymoon" and are planning a surprise retirement party for Mrs. P, who will retire from her career as an elementary school teacher in one week, at the end of the school year. Mr. P has been retired for two years. Both are eagerly anticipating the freedom that Mrs. P's retirement will allow and have been caught giggling together on more than one occasion. Future plans include taking their two grandchildren to the Grand Canyon and Disneyland, but they first plan to spend six months alone just going wherever they please and getting used to the RV lifestyle.

Neither has anticipated the total disruption to their lives that the telephone call from the hospital brings. Their daughter has been involved in an auto accident and has suffered severe brain damage. She is currently in a coma in intensive care and the prognosis is not good. Their son-in-law asks if one of them can pick up their 7-year-old grandson from school and take him to a neighbor who sometimes babysits for the parents. They decide that Mr. P will do this and then meet Mrs. P at the hospital.

Later in the evening Mr. and Mrs. P, their son-in-law, and their other daughter meet with the neurologist who is attending their injured daughter. The neurologist reports that the damage is extensive and, at best, they can expect several weeks of hospitalization followed by months of rehabilitation. Suddenly, everyone's plans have changed and the future no longer seems so carefree.