Family Theory Case StudyDr. Deborah Witt Sherman “Mrs. Mendez”

Mrs. Maria Mendez is a 72-year-old Hispanic patient with advanced left breast cancer with metastasis to the lungs and bones.She is referred to your home care agency for wound care services.She has seven children: five daughters and two sons (all living in California).Her five daughters live within the Los Angeles area.Her eldest son lives in San Diego and the younger son has been distant from the family and has not had contact with the family for the last 18 months.Mrs. Mendez’s husband died seven years ago of lung cancer.Since that time she has lived with her youngest daughter, Maria.

Initially, Mrs. Mendez discovered the breast lump herself but did not seek medical care for over a year.When Mrs. Mendez was diagnosed, her disease was considered advanced.She refused to have a mastectomy based in part by her cultural belief that the soul resides in the breast and should not be removed.At the urging of her children, she did undergo chemotherapy but recently has experienced increased bone pain and decided to discontinue the treatment regimen.The tumor in the left breast is now approximately the size of an orange with malodorous, purulent drainage.Home care was initiated for wound care and other symptom management services.Under the terms of her managed care/Medicare insurance plan, her care is referred back to her family care practitioner in her local community rather than her oncologist since she is no longer receiving cancer treatment.

Mrs. Mendez’s condition continues to decline and her physician encourages her to seek hospice care.Mrs. Mendez has become very close to the home care nurses who provided the wound care and requests that her care continue with the home care agency rather than a referral to hospice.At this time, changes in her living arrangements are also made.Living with Maria over the last seven years has been very positive, but Maria has three young children and the intensive care of her mother at this stage of the illness is becoming a problem.The family emphasizes that Mrs. Mendez should move in with her eldest daughter, Gloria, who no longer has children living at home.Although her daughters have always been close to their mother and more involved in her care, the eldest son of the family, José, who resides in San Diego, is consulted for all decisions and has been the father figure of the family since Mr. Mendez’s death.Mrs. Mendez’s managed care plan allows for only two RN visits per week and must be reevaluated every three weeks by the case manager. In addition to the symptom management provided by the home care agency, Mrs. Mendez and her daughters use many alternative therapies which includes “cat’s claw”, herbs, and visits by a healer.Mrs. Mendez is religious and uses prayer to help cope with her illness.Her middle daughter, Christina, is devout in her religion and is in absolute denial that her mother will die.Christina comes nightly and holds a prayer vigil with her mother and also brings herbs and remedies that “will cure the disease”.Mrs. Mendez becomes increasingly withdrawn as conflicts arise among her children.Gloria and Christina are at odds because Gloria is most accepting of her

mother’s impending death.Gloria was also the primary caregiver during her father’s illness with lung cancer.

After three weeks of care by the home care agency (HCA), Gloria calls requesting that a nurse come as soon as possible because her mother’s pain is worse.On physical assessment, the nurse notes that the breast tumor remains dry, however the tumor mass has increased and the breast is inflamed.The pain is described by Mrs. Mendez as an intense pressure pain at the site of the tumor in the base of the breast.She also describes a sharp stabbing pain in the left upper quadrant of the breast.In addition, Mrs. Mendez complains of intense pain in her mid-back which has made it very difficult to lay in bed and she has been unable to sleep for the last week.She has been taking one to two Vicodin every four hours PRN although yesterday Gloria reports that out of desperation the Vicodin was given approximately every two hours until Mrs. Mendez became extremely nauseated.The nurse recalls that morphine was ordered for the patient a few weeks ago in anticipation of increased pain not controlled with the Vicodin.Upon questioning, the daughter states that they have not used the morphine as they were “Saving it for the end.”Gloria also reports that the family is trying to minimize the use of the medicine since their mother is extremely constipated.Gloria continues to relate that the reason her mother is constipated is because Mrs. Mendez has not been able to continue her herbal remedies due to nausea.Mrs. Mendez appears very stoic with minimal expression of pain.Her only complaint is that she no longer is able to have her grandchildren over to visit due to her declining condition.

Mrs. Mendez is initiated on a regimen of long-acting morphine, 60 mg at bedtime with 15 mg morphine immediate release (MSIR) for rescue dose.Over the next week, the longacting morphine is increased to 120 mg BID supplemented with Imipramine 50 mg BID and Ibuprofen 800 mg TID.Christina has now moved into Gloria’s home and continues her evening prayer vigils.José calls several times a day to dictate his wishes regarding his mother’s care but has not been able to visit often from San Diego as he is in risk of losing his job.Gloria seems increasingly burdened with her mother’s care and her siblings’ involvement.Gloria follows the home care nurse to the car weeping because of the stress.

Approximately one week later, the nurse receives a call from Gloria reporting that her mother has seemed to decline rapidly over the weekend.Mrs. Mendez awoke during the night with difficulty breathing and has been terrified of the possibility of suffocation.On exam, the nurse notes that Mrs. Mendez has developed extreme shortness of breath.She is also increasingly fatigued and the combination of exhaustion, dyspnea, and general decline has resulted in minimal intake of foods or fluids.José called this morning with strict orders that his sisters continue to feed their mother at all costs.He hopes to be able to come up from San Diego the following weekend to visit.Mrs. Mendez relates to the nurse that she knows she is dying and does not want to continue being a burden to her family.

Mrs. Mendez’s physical condition has greatly improved due to aggressive symptom management by the HCA.The morphine dose has increased to 240 mg BID

supplemented with 40 mg of MSIR approximately every two hours for dyspnea.With her breathing improved, she as been able to take sips of water and occasional amounts of other liquids.Mrs. Mendez’s condition, however, continues to decline and the home care nurse anticipates that she will die within the next two weeks.The HCA schedules a meeting with the primary nurse and social worker to discuss the growing tension in the family.Four of the daughters are now present in the home taking shifts to be at Mrs. Mendez’s bedside at all times.To make the family situation more difficult, Jose has learned that the young brother Pablo is living in Los Angeles and asks Pablo that he please visit his mother before she dies.Christina continues her prayer vigils and has asked members of her church to visit daily to hold prayer meetings with her mother.Mrs. Mendez tells the nurse that she cannot discuss her impending death with her family because they do not want to talk about it or hear that she is dying.At this point, Mrs. Mendez is very withdrawn and has little interaction with her family.Mrs. Mendez has now developed a pressure ulcer on her buttocks and requires a Foley catheter due to incontinence, which has intensified the physical care demands of her care.

The HCA receives a call on Saturday evening requesting assistance with Mrs. Mendez as her condition is declining rapidly.The younger son, Pablo, arrived two days ago and has had a very tearful reunion with his mother and his sister, Gloria.The social worker and the nurse were very successful in the family meeting with facilitating communication among the children and establishing common goals for Mrs. Mendez’s comfort.All of the children with the exception of Christina, seem accepting of the impending death.Gloria’s husband, Michael, has been quite supportive of his mother-in-law’s care throughout her illness, but has strong feelings against death occurring within his home.

The priest is called to give Mrs. Mendez communion and the Anointing of the Sick.The extended family is at Mrs. Mendez’s bedside, except for Christina who is in the kitchen crying.

Source:HOPE: Home care Outreach for Palliative care Education Project. (1998). Funded by the National CancerInstitute. B. R. Ferrell, PhD, FAAN, Principal Investigator.

Mrs. Mendez Case Study Questions

1. Assess each family member.

2. Assess the functioning of the whole family

3. Identify the larger suprasystem and the subsystems and discuss their interactions.

4. What are the positive and negative feedback loops?

5. Is this family self-reflective working toward goals?

6. Is the family able to create a balance between change and stability?

7. What patterns are observed for the family?

8. Is Gloria self-differentiated?

9. What communication and interaction patterns are observed?

10. What constitutes first and second order change in this family?

11. What are the contextual constraints for change in this family?

12. What values are being passed down through the generations?

13. How you would describe this family based on Olson’s Model of family?

14. What plan would you develop for this family based on Theory Based Family problem solving?

15. How is this family responding to stress?Are they crisis prone?

16. What behavioral therapies may be of value to this family?