The Lancaster Family Sinthia Reynoso Ramirez
California State University San Marcos, School of Nursing N480 Family Nursing Theory & Practice Dr. Monica Sprague, APRN, FNP-BC, MSN, PHN, Ph. D. Figure 1
A FAMILY LIVING WITH CANCER Figure 2
The Lancasters are a traditional middle-class nuclear family that lives in the suburbs of Indianapolis. The family includes the father, Michael, the mother, Frannie, and their teenage daughter, Hazel Grace. As such, the Lancasters are currently in the 5th stage of Duvall’s Family Development Theory which denotes “families with adolescents” (Kaakinen et al, 2015). This stage focuses on both planning for the future as well as the growing independence and identity formation of the teen– while still ensuring their place within the family through assigning responsibilities and setting limits (Kaakinen et al, 2015; Lang, 2020). Unfortunately, the Lancasters are living with a serious chronic illness that afflicts their daughter. Hazel was diagnosed with Stage 4 thyroid cancer when she was thirteen. While an experimental medication is keeping the progression of the tumors in her lungs at bay, her breathing capacity is greatly compromised and she requires the constant use of oxygen, which she carries with her at all times in a rolling backpack. Although the prognosis is typically excellent for most children with this type of cancer, the disease remains stable in only ⅓ of children with metastasis in the lungs (American Thyroid Association, 2017). Even with their difficult circumstance, the Lancasters are a close family, yet the complexities of adolescence coupled with a terminal disease results in significant barriers in communication between Hazel and her parents.
THE LANCASTERS Hazel Grace– An only child, Hazel is a 17-year-old girl who’s battled
thyroid cancer for three years, which has now spread to her lungs. She is in Erikson’s Identity vs. Identity Confusion adolescent stage of psychosocial development (Orenstein & Lewis, 2020). Although Hazel accepts her condition’s prognosis, she takes antidepressants and reluctantly agrees to attend a support group for youth with cancer. Here, Hazel becomes friends with Isaac and falls in love with Augustus, who inspires and supports her in accomplishing her dream of meeting her favorite book’s author. Hazel also has the unwavering support from her parents throughout the journey that takes her all the way to Amsterdam.
Frannie– Hazel’s mother is likely in her 40s which places her in Erikson’s Generativity vs. Stagnation/Self-Absorption stage of
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psychosocial development (Orenstein & Lewis, 2020). Frannie has been Hazel’s primary caregiver since she became ill and, while devastated at the thought that she will no longer be a mom at some point, she does everything in her power to make Hazel’s life better and as close to that of an average teenager’s. Ever there for her daughter, Frannie also joins Augustus and Hazel on their trip to Amsterdam.
● Pencil ● Journal Michael– Hazel’s father is also in his 40s, placing him in Erikson’s Generativity vs. Stagnation/Self-Absorption stage of psychosocial Pen of financial support development like his wife (Orenstein & Lewis, 2020). Because Frannie takes care of Hazel, Michael is the●sole source for the family, yet he remains fully devoted to his wife and daughter and is present through the highs and lows they experience as Hazel ●in welcoming Do your continues to fight cancer. Also wanting Hazel to experience an normal adolescence, Michael joins Frannie Augustus to their home as hazel’s boyfriend. homework
Although the Lancasters don’t appear to celebrate typical American holidays, they do recognize International Goji Berry Day with a special dinner Frannie prepares. They sit together as a family for dinner and engage in casual conversation every evening. They don’t follow any religious denomination, but Hazel is open to the belief that God exists. Hazel’s support group also meets in a Episcopal church basement where the teens joke about being in the “literal heart of Jesus”, which is a large rug everyone sits around (Augustus Waters, personal communication, 2014).
CULTURE
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&
RELIGION
CHALLENGES & STRENGTHS
The Lancasters undergo difficult challenges in the face of a terminal illness. The parents remain hopefully optimistic– almost in denial, and cannot verbally acknowledge the impending death of their daughter. There is a struggle to accept the inevitability of death and reconciling that with the numerous efforts to stem it. Furthermore, the family retains a deep sense of guilt from powerlessness, but for varying reasons. Hazel laments on how the situation is unfair to her parents, and even to Augustus, while her parents cannot shake the feeling of impotence at not being able to stop Hazel’s suffering. Finally, the Lancasters have difficulty integrating and managing Hazel’s physical limitations with her living her life as a regular teenager. The family’s strengths are largely connected to their closeness and deep love for one another. Both parents are loving to each other, remain united when receiving new medical information and in advocating for their daughter and her wishes. Michael and Frannie remain positive, live in the moment, and strive to keep routines and a sense of normalcy for Hazel. When it comes to parenting an adolescent, both parents demonstrate an authoritative parenting style which complements their daughter’s developmental stage.
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COMMUNICATION
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The Lancasters express their love to each other quite easily using both verbal acknowledgements and physical shows of affection. Michael and Frannie hug or hold each other’s hands in times of stress and fear like when Hazel is in the hospital. The family uses humor to make light of or even deflect serious feelings, like the guilt Hazel has in her belief of being a burden to her parents. However, certain things are not communicated to one another in an effort to avoid inflicting pain. Examples include Hazel not clarifying to her mother that her “depression” stems from the thought of death, not having cancer, or Frannie hiding her pursuit of a Master’s Degree in Social Work from Hazel for fear of making her feel abandoned by the thought of life moving forward without her. Both parents run to Hazel and remain in close proximity to her for support as she suffers the loss of her boyfriend Augustus. Throughout their current circumstance as a family, both parents attempt to maintain the lines of communication with their daughter open, but given Hazel’s developmental stage, regardless of her illness, it proves difficult because she’s still an adolescent that’s developing her identity as separate from her parents. Complete honesty and openness with her parents are conditional and not guaranteed at this point.
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THE CHRONIC ILLNESS FRAMEWORK Rolland’s Chronic Illness Framework serves as a vital tool that helps nurses assess and understand the psychosocial effects of chronic illness in families to better serve their needs, starting from the time of a diagnosis (Kaakinen et al, 2015).
Illness Type
Onset–Gradual: Hazel’s treatment process follows a long trajectory starting from when she was 13; however, her initial medical demands following the advanced cancer diagnosis necesitate drastic changes in the family, such as Frannie adjusting to her new role as Hazel’s primary caregiver. Course–Progressive: If available cancer treatment is curative, illness progression will cease with its successful use. Hazel’s thyroid cancer metastasized to her lungs, signaling the continuation of the disease and the progression of the physiologic changes that go along with it. By this point, Hazel requires the constant use of oxygen via nasal cannula and her physical energy is further diminished– leading to closer care and monitoring from her mother, especially on her trip to Amsterdam. Outcome–Trajectory & Incapacitation: Because Hazel’s cancer is diagnosed as a stage 4, it is greatly understood that its trajectory will result in a shorter life span. The family’s stress from this knowledge revolves around the tentative effectiveness of her treatment and the uncertainty of when an unresolved physical decline will manifest. As mentioned before, Hazel’s incapacitation lies in her increased energy expenditure stemming from her compromised lungs.
THE CHRONIC ILLNESS FRAMEWORK –CONTINUED Time Phase
Mid-Time Phase: In this phase the family finds itself constantly adjusting to the “new normal”. Key matters Rolland ties to this intermediate phase include: staving off burnout, keeping relationships stable, maintaining autonomy, following family development as it normally progresses, and preserving intimacy (Rolland, 2005). Frannie wards off caretaker burnout by focusing on furthering her education to allow her to help other families as a social worker. The parents strive to maintain a sense of normalcy through verbal and physical affirmations of love, consistent co-parenting, keeping routines, and encouraging Hazel to make friends, have a relationship, and overall live the life of a regular teenager. This phase also sees a more integrated partnership with the healthcare team, like when the family sits with Hazel’s doctors to discuss the possibility of her traveling to another country. The Lancasters experience the greatest stress, within this new normal, from Hazel’s health emergencies such as the sudden dyspnea caused by the rapid fluid accumulation in her lungs, leading to prolonged hospital stays.
Family Functioning
Illness Demands: Stress imparted on the family from Hazel’s illness is dependent on its stability. The Lancasters adapt to her need for oxygen support and its associated physical limitations by driving her to support group and doctor’s appointments. They also have to be ready to seek medical help for any sudden deteriorations in her health. Strengths & Vulnerabilities: The family’s strength comes from their love, unity, and support for one another. Because their love is so deep, each member seeks to protect the others by not fully disclosing their thoughts and feelings. Hazel wants to openly talk about death, but holds herself back so as to not affect her parents’ hopes. Frannie does not tell Hazel about her studies because she doesn’t want Hazel to feel that her parents are already moving on with life without her. What makes the Lancaster family’s bond both strong and vulnerable is the extent of what they communicate with each other.
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APPLICATION OF THE NURSING PROCESS
Family Problems: lack of complete and honest communication & members at different stages of death acceptance NANDA- Compromised family coping related to denial of reality regarding Hazel’s health problem as evidenced by unrealistic future planning and reluctance to discuss her thoughts regarding the progression of her illness.
Interventions
Outcomes
Support the parents by engaging and collaborating with them in the care of their daughter. This can help enhance communication and the parent-healthcare professional relationship in order to facilitate exploring their fears regarding the future. Rationale: This encompasses a valuable framework for determining parental knowledge and providing support services that relate to the family’s needs (Smith & Kendall, 2018).
Frannie and Michael will verbalize their knowledge and understanding of Hazel’s illness, including its progression and ultimate outcome.
Recognize and support positive family coping efforts, both as individuals and as a unit. Rationale: Positive feedback strengthens beneficial coping behaviors within the family (Ackley et al, 2020).
The Lancasters will develop and maintain appropriate coping behaviors that benefit both every member individually and the family as a whole.
Provide the parents psychosocial interventions and references to support and education groups for additional opportunities to obtain coping resources and learn new parenting skills that reflect their daughter’s needs in relation to her developmental level. Rationale: These forms of support help parents find meaning, develop helpful coping mechanisms, and improve resilience in the face of a serious illness (Rosenberg et al, 2019).
After recognizing the need for and seeking outside support, Frannie and Michael will verbalize internal resources and coping strategies that help them adjust their parenting approach to better support Hazel’s needs.
REFERENCES Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnosis handbook: an evidence-based guide to planning care. Twelfth edition. St. Louis, Missouri: Elsevier. American Thyroid Association (ATA). (2017, July 27). Pediatric differentiated thyroid cancer. https://www.thyroid.org/pediatric-differentiated-thyroid-cancer/ Boon, J. (Director). (2014). The Fault in Our Stars [Film]. Fox 2000 Pictures, Temple Hill Entertainment, TSG Entertainment. Kaakinen, J., Duff-Gedaly, V., Hanson, S. & Coelho, D. (2015) Family health care nursing: Theory, practice and research (5th ed.). F.A. Davis: Philadelphia. ISBN-13: 9780803639218 Lang, D. (2020). Parenting and family diversity issues. Iowa State University Digital Press. https://iastate.pressbooks.pub/parentingfamilydiversity/chapter/the-family-life-cycle-theory/ Orenstein, G. A. & Lewis, L. (2020, November 22). Eriksons stages of psychosocial development. StatPearls. StatPearls Publishing. Rolland, J. S. (2005). Cancer and the family: An integrative model. Cancer Supplement, 104(11), 2584-2595. Rosenberg, A. R., Bradford, M. C., Junkins, C. C., Taylor, M., Zhou, C., Sherr, N., Kross, E., Curtis, J. R., & Yi-Frazier, J. P. (2019). Effect of the promoting resilience in stress management intervention for parents of children with cancer (PRISM-P): A randomized clinical trial. JAMA network open, 2(9), e1911578. https://doi.org/10.1001/jamanetworkopen.2019.11578 Smith, J., & Kendal, S. (2018). Parents' and health professionals' views of collaboration in the management of childhood long-term conditions. Journal of pediatric nursing, 43, 36–44. https://doi.org/10.1016/j.pedn.2018.08.011
IMAGE REFERENCES Figure 1. Corral, R. (2012). The Fault in Our Stars [Book Cover]. Wikipedia. http://en.wikipedia.org/wiki/File:The_Fault_in_Our_Stars.jpg Figure 2. Hazel Grace [Online image]. (2014). Retrieved from https://www.kqed.org/pop/12589/sick-lit-whats-with-our-morbid-fascination-for-stories-like-the-fault-in-our-stars Figure 3. The Lancasters [Online image]. (2014). Retrieved from https://www.wsj.com/articles/SB10001424052702304547704579564041085529608 Figure 4. Literal Heart of Jesus [Online image]. (2014). Retrieved from https://www.timetoast.com/timelines/the-fault-in-our-stars-69bb6a97-f726-4971-991b-471034ef1812 Figure 5. Hazel and Frannie [Online image]. (2014). Retrieved from https://www.wsj.com/articles/SB10001424052702304547704579564041085529608 Figure 6. Michael and Beautiful Family Sign [Online image]. (2014). Retrieved from https://weheartit.com/entry/139458056 Figure 7. Michael Comforting Hazel [Online image]. (2014). Retrieved from https://www.scmp.com/magazines/48hrs/article/1562491/film-review-tear-jerker-fault-our-stars-romantic-withoutbeing Figure 8. Michael Carrying Hazel [Online image]. (2014). Retrieved from https://textingthecity.wordpress.com/2014/09/13/the-fault-in-our-stars/