The Fitzgerald Family
Kate Fitzgerald
Meet The
Kate Fitzgerald is a 15-year-old who was diagnosed with acute promyelocytic leukemia at a very young age. She is strong willed and very brave and maintains a positive outlook on life despite her condition. She spends most of her time in hospitals and when she isn’t she just “waits for something that makes her go back.” She feels morally guilty that her illness has caused her to require all the attention in the family and feels like a burden at times. She understands that her condition is deteriorating and that her time is limited so she hasn’t made any plans for the future. She struggles with depression for a time after her boyfriend passes away from acute myeloid leukemia, however she overcame it and now looks forward to seeing him again once it is her time to go. Developmental stage: Identity vs. Role confusion – Kate demonstrates a positive outcome, she knows who she is and how she fits in the world. She embraces her condition as an inherent part of who she is, but she has grown tired and knows she will die soon. She subsequently decides to refuse any further treatment options.
Acute Promyelocytic Leukemia (APL) Acute promyelocytic leukemia is a subtype of acute myeloid leukemia caused by a specific chromosome abnormality (t15;t17). Immature white blood cells (promyelocytes) collect in the bone marrow, the overgrowth of it results in normal platelet, white & red blood cells shortages causing the signs and symptoms (pale complexion, excessive bleeding, infection). Treatments for APL include: stem cell transplantation, chemotherapy, radiation (NIH, 2017) As long as Kate can remember, she’s been sick. She exhibits the classic symptoms for APL (constant infection, frequent nosebleeds, and pale complexion), she also lost her hair during chemotherapy. She was in remission for some time, following radiation but ultimately the leukemia came back and she went into renal failure that turned systemic. Although they have utilized every treatment possible in the past, she and her family have been fighting her illness for a long while and she is tired and knows that she is going to die soon. Therefore, she makes the decision to forgo further treatment options.
Fitzgerald Family
Sara Fitzgerald
Sara is in her mid-30’s and primary caretaker of Kate. She quit her job as a lawyer when Kate got sick to be able to take care of her full time. Her life is dedicated to keeping Kate alive. Although she is very devoted to taking care of Kate, she has tunnel vision when it comes to Kate, focusing only on what it will take to ensure that her daughter lives. Developmental stage: Intimacy vs. isolation. Sara demonstrates a positive outcome, she is in a committed relationship, and loves her family
Brian Fitzgerald Brian is in his mid-30’s and is the sole source of income for the family. He is also very involved in Kate’s care, however he is not home all the time because he works full time as a firefighter for the city of Los Angeles. He is the voice of reason in the household, taking into everyone into account, and trying his best to ensure that his kids are able to live “normal lives” as much as possible. Developmental stage: intimacy vs. isolation. Brian demonstrates a positive outcome through his sense of love and commitment.
The Fitzgerald’s are a traditional nuclear family in Duvall’s 5th stage: families with adolescents. The developmental tasks in this stage include: allowing adolescents to establish their own identities, thinking about the future, and increasing the roles of adolescents in the family (Kaakinen et. al., 2015)
Jesse Fitzgerald Jesse is 17 and the eldest sibling. He loves his family very much, and helps take care of Kate. However, he is frustrated, feeling isolated, invisible, and alone in his family because he feels like he is the only one without a specific role (Kate is sick, and Anna is the savior baby). He is dyslexic, however he was diagnosed late because his parents were so focused on Kate’s well being. Developmental stage: Identity vs. role confusion. Jesse demonstrates a negative outcome because he is unsure of who he is and how he fits in.
Anna Fitzgerald Anna is an 11-year-old conceived through in vitro fertilization as a “savior sister,” a perfect chromosomal match to be “spare parts” for Kate. Anna is immensely devoted to Kate, and would do anything for her. She is suing her parents for medical emancipation (so she won’t have to donate her kidney) at the request of Kate. At times she feels like she was only brought into the world because her parents wanted to save Kate. Developmental Stage: Industry vs. inferiority. She has a positive outcome as she is independent.
Culture & Tradition
The Fitzgerald family hold very traditional familial values and roles. They have a strong bond with each other as they are all dedicated to Kate and hold nothing but love for one another. They foster a culture of mutual respect, love, and hope within their family. They always make time for each other: eating meals together, having table time, holding family meetings, and going on outings. The Fitzgerald’s are very focused on Kate’s condition and treatments that they don’t have time for much else (i.e., practicing religion, going out in social circles).
The family communicates verbally and nonverbally, however there are issues in family communication. This is because Sara is very closed off when it comes to Kate’s health focused only on doing what it takes to get her daughter better rather than asking Kate what she wants. Her tunnel vision makes it difficult for her children to approach her when Kate decides to stop treatments. Sara is also heavily influenced by her emotions which dictate her actions (slapping Anna due to her anger at being sued). On the other hand, the Fitzgerald children feel like they don’t have too much of a voice because they don’t want to take attention away from Kate, and they know that their mother won’t hear what she doesn’t want to hear.
Communication
Strengths & Challenges Strengths: • The Fitzgerald’s have an incredibly strong bond with each other • Everyone helps take care of Kate • They have immense love for one another. Challenges: • Sara has a hard time accepting Kate’s decision • Kate has all the attention, taking bits away from others who need it • The dynamics of the family will change once Kate passes away
Family Genogram
Family Ecomap
Chronic Illness Framework Illness Type Onset of Illness: Gradual Family adaptation occurs over a prolonged period of time, Kate was diagnosed with APL at a very young age so over the past 10 years, the family has had to manage and adapt. Course of Disease: Chronic and progressive; Kate’s leukemia was diagnosed as a chronic illness and has progressed over time in severity. Trajectory of Illness: chronic illness with a fatal outcome that results in a shortened life span; Kate’s APL continued to deteriorate her condition despite treatment. Degree of Incapacitation: Energy production/expenditure; Kate’s condition and treatment gradually wore her down.
Time Phase The family has been living in the mid time phase but they are gradually moving into the terminal phase as Kate’s renal failure turned systemic. They were successful in overcoming the various challenges during the “long haul,” however as time wore on and Kate’s condition worsened they had to make re-adapt and readjust their family life. When they move into the termination phase the family dynamic will drastically change. The deterioration of Kate’s condition put a lot of stress on the family especially with the addition of her decision to stop treatment. It added a tension that was not part of the family dynamic prior. Anna mentions how she feels like “everyone is mad at her” since she does not want to donate her kidney at Kate’s request.
Family Functioning The demands of managing Kate’s illness are absolute; every family member is affected. Sara: Quit her job as a lawyer to take care of Kate full time. She is great at it, however she is intent on making sure that Kate does not die. Brian: Head of the household but is also the only source of income for the family so works all the time. Jesse: Oldest child, feels left out because all the attention is on Kate Anna: Youngest child, devoted to Kate and taking care of her, however she has undergone many procedures to have her parts harvested in order to save Kate/prolong her life.
The chronic illness framework promotes understanding of how chronic illness can affect a family. It helps nurses to think about the various factors associated with illness and how they influence the functioning of the family (Kaakien et. al., 2015). Strengths of the Chronic Illness Framework: This framework shows the complexity of chronic illness and the myriad of family responses to it (Kaakien et. al., 2015). Weaknesses of the Chronic Illness Framework: The framework depicts the progression of the illness from a more medical standpoint and is not predictive. Therefore it is easy focus only on the medical aspect of the model and forget to take into account the aspect of the family as a whole (Kaakien et. al., 2015).
Interventions for the Fitzgerald Family Decisional conflict r/t selection to discontinue treatment Respect personal preferences, values, needs, and rights. EB: Denial of this right of autonomy and self-determination may worsen the individual’s physical and existential suffering (Ackley, 2015).
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Kate’s decision should be respected, she knows her body and understands that she is going to die soon.
Facilitate communication between client and family members regarding the final decision EBN: There is less decisional conflict when end of life preferences are discussed with loved ones. • Kate and her family should
talk about the options and her decision as a family since it affects everyone.
Compromised family coping r/t unwillingness to discuss impending death Encourage family members to verbalize feelings, spend time with them, sit down and make eye contact, and offer coffee and other nourishment (Ackley, 2015). • A conversation with Sara could be initiated so she could relay her feelings to Kate and the family. Since the compromised coping interferes with the ability to support the client’s treatment plan, referral to psychiatric home health care services for family counseling (Ackley, 2015). • Sara’s reaction to Kate’s decision is causing turmoil and tension within the family.
Outcomes The Fitzgerald’s will be able to state the advantages and disadvantages of various options and take into account all those who are affected by the decision (Sara, Brian, Kate, Anna, and Jesse). Sara will provide support and assistance to Kate as needed The Fitzgerald’s will express feelings, identify ways to cope effectively, and use appropriate support systems.
Interrupted family processes r/t situational crisis of death Acknowledge the range of emotions and feelings that may be experienced when the health status of a family member changes EBN: Nurses can better support caregivers regarding their perceptions of family support and expressive family functioning (Ackley, 2015)
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The Fitzgerald’s are experiencing a wide range of emotions due to Kate’s deterioration.
Encourage family members to find meaning in a serious illness. EBN: Letting go before the death of a loved one involves a shift in thinking in which there is acknowledgment of impending loss without impeding its natural progression (Ackley, 2015) • The Fitzgerald’s are slowly
coming to terms with Kate’s decision.
References Ackley, B. J., & Ladwig, G. B. (2014). Nursing Diagnosis Handbook (10th ed.). Maryland Heights, MO: Elsevier. Acute Promyelocytic Leukemia. (2017, October). In National Institute of Health. Retrieved November 4, 2017, from https://ghr.nlm.nih.gov/condition/acute-promyelocytic-leukemia#synonyms Kaakinen, J. R., Coehlo, D. P., Steele, R., Tabacco, A., & Hanson, S. H. (2014). Family Health Care Nursing: Theory, Practice, and Research (5th ed.). Philadelphia, PA: F.A. Davis Company.