Psychological Implications in Families with a Nursing-dependent Family Member BY
Yakob Abdul Rahman Wilhelm Scholer
Home Nursing is a fledging program in our country (Malaysia) and perhaps in Asia.
While it is regarded in most European countries as a solid Pillar of the Health System, here, mobile home nursing is a rather un-systemized, with various forms of home nursing care, and its importance for the future is grossly under estimated.
We are faced with a series of difference although the pure nursing aspect and the patients’ needs do not differ from that in other countries, or anywhere in the world.
Let me highlight a few differences between the mobile nursing here and those in the European countries.
Finance
In Europe
The cost is borne by the insurance system or public health care funds, or welfare aid.
In Asia
The cost of mobile nursing services has to be borne exclusively by the clients or their families.
Medical Home-Care
In Europe
Family (house) doctors are compelled to visit and attend to very sick people even in their home setting – during regular working time. Some doctors even set aside an afternoon a week to make regular house calls to chronically ill patients and impaired Senior Citizens.
In Asia
There is no regulated house-call system and doctors are generally reluctant or even refuse outright to visit patients in their home, even if the same doctor has attended them in the clinic for decades.
Family System
In Europe
Most senior citizens live in their own residence alone, and their children are wage earners, staying away from the city or region.
In Asia
There is still a common practice of extended family system where 2 to 4 generations live under the same roof. The role of the matriarchal/patriarchal system is not to be underestimated.
Treatment Regime
In Europe
The majority of patients receive treatment according to “Western Medicine” standard medical procedures
In Asia
Still a lot of patients follow traditional medicines and customs, simultaneously or intermittently also the classical western approach of “Western Medicine”
These factors alone have enough potential for conflicting situations, since the more ambiguous situations exist the more space is available for conflicts.
Case descriptions
(All Names have been changed)
Case 1
En Mokhtar, an 84 year old patient suffering of multiple strokes, dementia and diabetes was admitted to a Private Hospital, for removing of slough from a bed sore at the sacrum. The Private Hospital requested the family to contact us for further wound management. Initially we met only two of the daughters of the patient. On discharge from the hospital the rest of the family “surfaced”, lastly the only son who was a medical Doctor. The Patient had developed multiple bedsores, 6 all together. The family of one of the daughters where the patient put up could be described as a real caring “motherly type”. Always interested in what was needed to be done. The wife of the patient being the “matriarch” of the family (after the incapacitation of her husband) would rather listen to the son, “who as a medical doctor is most qualified to judge on medical aspects”. However, this son hardly ever appeared on the scene and met with the nursing staff only after more than 7 months since HNP has taken over the nursing of the father.
The female siblings noting the lack of interest of the brother and the total absence of monetary responsibility, could hardly accept that for any issue of nursing care, the mother would consult the son, who without seeing the father would give some “pacifying advice to the mother” usually agreeing to her opinion, and thereby giving the mother the needed lever to direct whatever kind of nursing and wound management was suppose to be ‘appropriate’.
The modern style of moist wound treatment was for her not acceptable (“it caused smell”) and on pestering the son to change it to a method of drying out the wounds, he finally consented and used “a traditional Indonesian treatment” to dry out the wounds only to terminate the same again 4 days later after noticing the increase of tissue damage caused by the herbal application on the wounds, which were indeed dry, but also caused additional tissue damage. As time went by and the patient suffered a few more minor strokes, the issue of sufficient nutrition consumption arose and to the nursing opinion enteral feeding was pertinent and was recommended by the Hospital on discharge.
However here again the mother/son bond went against the professional opinion of the consulting doctor and the nursing team, causing stress to the rest of the siblings who could observe the decline of their father’s condition and were helpless, as the mother would not allow the insertion of a Ryle’s tube. Ironically, only when the condition became imminently serious, did the mother attempt to ask her son to come and do the needful to improve the condition. Despite of several days of pleading the son did not turn up and only arrive when the cortege had left the house.
Comment
Much suffering of hunger and thirst by Mr. Mokhtar could have been avoided if the family, the son in particular, would have liaison with the nursing team. The atmosphere of tension in the house could be much lessened and be more conducive to the patient’s condition.
Case II
Mr. Firuz is another patient with multiple strokes, diabetes, Parkinson’s, dementia and bedsore.
His children are highly educated and holding responsible position in the society.
Mr. Firuz actually lives in a neighbour state, but due to his illness and the age of his wife the children decided to take him in their own home setting.
We were called by the son with the hope to assist in the professional care of the father.
After the Assessment we made out a plan for a twice-weekly visit, which would include a full bath (shower), colonic washout (due to chronic constipation) and mobilization.
Every family member was agreeable. The request for a hospital bed and a special wheelchair on hire was complied with. The intention was to provide optimal professional nursing care. Due to his mental state Mr. Firuz would scream at the slightest touch on his body, sometimes even before reaching his body.
The procedures of bathing, colonic washout and mobilization were accordingly accompanied by the “obligatory” screams of the patient. In many tests I showed the family that his screaming was not related to the actual procedures but rather part of his mental state.
While the children could observe the situation and were accepting the explanation, the devoted wife was showing her doubts. While the patient refused to sit in the wheelchair the wife insisted on a headrest to provide more “comfort”, and get his cooperation for mobilization. The patient however would only sit “normally” in the wheelchair when the attending nurse places him in it, he refuses to sit in the wheelchair when the family members wanted to place him inside - he refuses to bend his knees and hang in like a “pole”. This caused the family to return the wheelchair plus the special head support on the request of the wife, who did not want the husband to be under “stress”. Expectedly the service of the nurse was terminated, so as to conform to his wishes and the wife’s request. Only a short period later Mr. Firuz decided that decided that sleeping on the floor would please him more than on a hospital bed. Again the “devoted wife” would consent to the “wish of her husband” and requested the return of the hospital bed. The children were under quite a lot of duress created by this: for them it was illogical to conform to the father’s demands yet were unable to influence against the demand and desire of their parents. The attending nurse found himself in a conflict of nursing requirement and the demands of an irrational patient and devotion of the wife.
Consequently we had to withdraw from nursing the patient and allow the family to manage the case as best as possible.
Comment
Over devotion of the wife and the filial cultural mentality of the children were over ruling any sensible and appropriate nursing care. There was no question that the children disagreed with the father’s demand and the mother’s request. But not breaking with the culture and resisting parental request, they would rather allowed the matter to be left to the parents’ control.
Case III
Mrs. Lim, a lady in her early seventies, with unstable diabetes and multiple strokes (on medication) was discharged from hospital and stayed with youngest daughter. Her eldest daughter-in-law called in for our service for regulating the lady’s blood pressure, blood sugar and mobilization. The lady has been unable to swallow properly. We suggested naso-gastric tube feeding but the idea was rejected. However, the youngest daughter is a staunch believer in traditional Chinese medicine/treatment. She took matters into her own hands and stopped all medications from hospital, gave her mother ‘normal’ soft diet (porridge), which she could hardly swallow. One afternoon the maid found the lady unconscious and foaming slightly from the mouth. An emergency call was made to us and we found the lady in a severe hypoglycaemic state. We managed to revive the lady after emergency nursing administration rendered. Only then the youngest daughter consented to her mother to have a naso-gastric tube. Things went on well for a while. After a couple of weeks the old lady went into another crisis - aspirated pneumonia. Apparently the youngest daughter was ‘advised’ by a ‘traditional healer’ to remove the naso-gastric tube, believing that it was the cause that the old lady could not swallow and the tube would cause infection to the stomach. The young lady followed the advice and the mother ended up in a hospital.
The family conflict in traditional and modern medical management became so bad that the eldest daughter-in-law gave up (in order not to be blamed should anything happen to the mother-in-law) and curtailed our service.
Comments
Traditional believes and interpersonal siblings’ altered rolls was making it impossible to provide appropriate nursing that could have helped the patient to ensure a certain degree of life quality.
Summary
Most families here are still a closely-knit entity, where the role of each family member is not always as clear-cut as one may assume. This leads to certain conflicts, particularly when different siblings manage the needs and wishes of the patient and the financial aspect. This is especially so when the nursing requirements and financial limitations do not correspond.
Sibling-rivalry and family conflict may manifest when the issue of nursing care, and medical approaches are an unresolved entity. While on one hand a sibling may have to carry the sole financial burden, the other members of the family may not spare the making of suggestions and remarks as to how best the situation could be dealt with.
The position of a maid who may have made ‘in-road’ into the family system and the skillfully manipulates the family environment to her own end, placing the family at times in a position of being threatened and/or at her mercy.
The nurse, being subjected to manipulation, and solicited by the various sources must survive in this “emotional mine-fields”, perform one’s professional duty without getting entangled in the family dispute or conflict.
Evaluation/Response
The nursing personnel in a mobile-nursing setting must be made aware of these potential dangers and needs information on potential conflicts and guidance in dealing with such situations. To stay neutral and restrain her/his own emotional feelings a nursing agency must have a system where the nursing personnel can turn to in conflicting situations and get the needful guidance such as supervision, group session and individual counseling.
At the end of the day it is the patient who needs the care, and is mostly unable to intervene or make decisions.
Surely this problem is not limited to Malaysian families alone, but will always manifest in situations where:
A. A decision making member of the family has not been appointed,
B. Where money responsibilities play a role,
C. Where neurotic personalities are involved,
D. Where cultural aspects are abused for ones own end
If you are looking for A MOBILE NURSING SERVICE OR A MOBILE DOCTOR PLEASE CONTACT US www.hnp-mobilenursing.com or
nursing@hnp-mobilenursing.com or Phone +603 78777202
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