FAMILY ASSESSMENT ACTIVITY TABLE OF CONTENTS

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Identifying Family Data………………………………………….……….p. 3-5 Culture and Religion………………………………………….…………..p. 5-6 Family Development…...............................................................................p. 6-7 Environmental Data…………………………………………….………..p. 7-8 Family Structure…………………………………………………….……p. 8-9 Role/Power Structure……………………………………………………p. 9-10 Family Functions………………………………………………………...p. 10-11 Family Coping……………………………………………………………p. 11-12 Summary Statement……………………………………………………..p.13 NANDA…………………………………………………………………..p. 14-16 References….............................................................................................p. 17

FAMILY ASSESSMENT ACTIVITY Identifying Data (Family Composition)

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The Fitzgerald’s immediate family is comprised of Kate, who has acute leukemia, Anna, her younger sister, Jesse, her mother, Sara and her father, Brian and her aunt, Zanne. Anna: Anna’s relationship with her sister and family is the most complex. When Kate was diagnosed with leukemia as a child, her parents used biogenetics to conceive Anna for the specific purpose of providing her older sister with a genetic match for organs and bone marrow. Since she was born, she has been subjected to a myriad of excruciating surgeries and procedures to prolong her sister’s life. Rather than developing resentment towards her Kate, Anna adores her and actually sees her self in terms of who/what she is to her sister. She has completely identified with the fact that her reason for existence is to keep her alive. At the same time, she does struggle with a desire to do her own things- play sports, be with her dad at the fire station- things that would require her to keep her kidney. Despite of this, it is for Kate’s sake and not her own that Anna seeks out medical emancipation from her parents. Through out the book/movie it appears that Anna has become tired of being her sister’s donor but in reality, she is acting on a direct request from Kate who is ready to die and does not want any more life saving actions, especially at additional cost to her little sister. Being in this situation creates guilt and pain for Anna as her mother sees her actions as selfish and cruel. Sara (mom): Sara’s life revolves around being Kate’s mom. From the moment she was diagnosed with leukemia, Sara quit her job as an attorney and took keeping Kate alive with the same fervor she used in the courtroom. Unfortunately, this has led to her

FAMILY ASSESSMENT ACTIVITY focusing on Kate to the exclusion of her other children and even her husband. Sara sees everything in terms of how it will affect Kate and is fiercely protective of her to the

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point of not being able to listen to even Kate herself about her feelings of being ready to die. Sara focuses largely on the physical component of Kate’s health as seen when she loses it when Brian takes Kate out of the hospital for her desired day at the beach. She is so focused on keeping Kate alive she fails to see that quality of life is as much importance as continuing to breathe. Brian (dad): Brian is not all-consumed in Kate- he loves her dearly but also is able to see and hear his other children as well as listen to what Kate’s feeling are. Especially in the book, Anna is drawn more to her father, even going to stay with him at the firehouse when Sara becomes so angry over her request for medical emancipation. Brian is incredibly supportive of Sara but reaches the breaking point when she refuses to let go and allow Kate to live out her last few days as she chooses and even threatens divorce. Jesse: (oldest sibling) Jesse’s role is not played up much in the movie in contrast to the book, where he struggles with feelings of inadequacy and insecurity that lead to him acting out in a destructive fashion. Like Anna, he loves Kate dearly but also identifies himself by how he relates to her. He feels guilt that Anna must bare the burden of helping Kate and that he can’t do anything. In the end, it is Jesse who breaks the secret vow and reveals that it is Kate who wants to die in an attempt to make his mother stop hurting Anna.

FAMILY ASSESSMENT ACTIVITY Kate: Kate’s cancer is the focal point of the story but she has come to accept it rather

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than continue to fight it. She is able to see how her illness has affected her entire family, which is seen when she reads her scrapbook and apologizes to Anna and her brother for the fact that their lives are so caught up in hers. It is because of this in part that Kate is ready to die and set her family free to regain a sense of normalcy in their lives. Kate must struggle against her mother, even using trickery in order to accomplish her wish.

Zanne - The aunt and sister of Sara is a constant companion and caregiver as well. Her presence in the story and support of Sara and her family is another way the book illustrates the bond between sisters. Zanne focuses more on Kate’s happiness, with nail painting and other frivolities.

II. Culture and religion The predominant culture/environment of the book is upper middle class white, suburbia Americans. The family has enough money to support a nice house and expensive medical treatment for their daughter as well as to bio-engineer Anna. Everyone is highly educated and extended family forms a support group for them as well as the community. There were no overt religious preferences in the movie; however, the family has pushed/challenged some traditional concepts on morality and ethics by creating Anna as a designer baby and donor for Kate. In many ways “modern science” or “medicine” is at

FAMILY ASSESSMENT ACTIVITY least what Sara worships. For the rest of the family, life revolves around Kate almost as the religion. Sara expresses outrage when Kate tells her she has “fooled around” with her boyfriend but at the same time seems to want her daughter to have those experiences of normalcy. In the book, Jesse’s rebellion through cigarette smoking (which Anna joins in on) and arson are both a cry for help and a lashing out against that same upper middle class mentality as well as Sara’s obsession with health. III. Family Development

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According to Duval the family should be in the families with teenagers stage where they are balancing freedom with responsibility as the teenagers mature and become more autonomous. This is also the stage where Brian and Sara should be refocusing on marital and career issues and having open communication between parents and children. To some extent, we see that Jesse has autonomy, but more through neglect than actually choice. The same is true with Anna, who manages to go see a lawyer and begin the process of medical emancipation without her parents realizing. Kate is also allowed to date, go on prom and ends up spending the night with her boyfriend without adult supervision. However, Anna is not given the chance to choose whether she wants to donate her kidney, Kate can’t communicate to her mother in the fact that she wants to die, and Jesse turns to setting arson as a way of communicating with his dad. In addition, Brian and Sara are growing further apart as Sara refuses to accept the change in Anna and Brian is forced to look to the good of all of his children and not just

FAMILY ASSESSMENT ACTIVITY Kate. Divorce is even threatened. Sara has put her career totally on hold while Brian spends more and more time away at his. Because of Kate’s illness and Sara’s unwillingness to relinquish control, the family is undergoing a crisis where they are adapting despite of her. As such, the family is growing apart and cracking instead of successfully navigating this obstacle.

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IV. Environmental Data: Support system In the beginning of the movie the fact is mentioned that most of Sara’s family drives her crazy except Zanne, her sister. This relationship is both a contrast/comparison for the one between Kate and Anna as well as the family’s main support system. Zanne mostly interacts as a second mom to Kate, staying with her in the hospital, painting nails, and supporting her sister Sara. Anna seeks out her father and the companionship at the fire station where she is treated like a celebrity. She also enters in the relationship with her attorney, Campbell Alexander, who is drawn to the case because of his own issues with epilepsy as well as his empathy for the little girl. (In the book it details that he actually dated Sara and broke up with her without telling her that it was b/c he had epilepsy and thought she deserved better.) Brian has the support of his co-workers to carry him through and really, it is Jesse who is left without support or a confidant, which is why he turns to arson and other rebellious behavior.

FAMILY ASSESSMENT ACTIVITY

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Kate receives emotional support more from Anna and her Dad than her mom or brother. She also finds solace in her boyfriend, who helps her through the dark days with the understanding of a fellow cancer patient.

V. Family Structure Communication: Secrets and manipulation are the currency of communication in the Fitzgerald household. The family’s communication is dysfunctional with a great deal of subterfuge and nonverbal communication. Sara expresses herself openly while everyone else either suppresses/hides their true thoughts and feelings or expresses them negatively. Brian withdraws from Sara and spends time at work to avoid confrontation, but when forced into it with Sara tells her he will divorce her if she won’t allow him to take Kate to the beach. Anna and Jesse know Kate’s wish to die but keep it hidden from their parents at the expense of Sara taking out her frustration at Anna being selfish in not helping her sister. Jesse again communicates with his father through setting fires – a very particular choice of rebellion with a father who is a fire fighter and is both absent from home and from Jesse.

FAMILY ASSESSMENT ACTIVITY Anna communicates with her sister and in the book, her caseworker and her attorney. Jesse is also a safe place for her, and vise versa for them to be away from Sara and interact both as themselves and as Kate’s siblings. Role/Power Structure: Sara is in essence the head of the family. She makes decisions based on what is best for Kate and expects the whole family to support her in them. She is very singly driven and views her husband and other children in terms of how they help or hurt her attempts to save Kate. Brian seldom challenges this but as the plot culminates with Anna seeking medical emancipation and even Kate challenging Sara’s ideas he is forced to step in and take a leadership role in helping his children. This leads to marital conflict between them. In the beach scene, Sara does back down and join them at the beach but it is a perfect outworking of the constant hidden power struggle between the two of them. Kate struggles with the idea of everyone being so caught up in her and her illness. She recognizes that her brother is struggling with both not being able to help her and being invisible to their parents. She sees that Anna has never had a childhood because of her. She sees the conflict between her parents mounting as well. Her desire is to die and allow everyone else to have their chance to be seen as individuals and not just how they relate to her and her disease. Anna sees herself solely as Kate’s sister. She identifies her very reason for existence as

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being there to help Kate. Without understanding Kate’s pushing Anna to request medical emancipation, it appears that Anna is struggling with guilt at wanting to have a chance to

FAMILY ASSESSMENT ACTIVITY live her own life at the expense of her sisters. While she espouses the desire to have a chance to play sports, be active and to stop being nothing more than Kate’s donor, she

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confesses to Campbell that all she wants in 8 years is to be Kate’s sister. Anna seems the happiest and most carefree when she is at the fire station. It is perhaps the closest to be an individual that she has experienced. Jesse can’t help Kate medically and feels guilt for both having needs of his own when Kate is dying and his inability to help her. Because all the attention is focused on Kate, the sensitive older brother acts out destructively in a very specific fashion that addresses his need for more male attention from his father as he matures into a young man. He feels resentment towards his mother, especially for her treatment of Anna and does his best to support the emotional needs of both his sisters.

VI. Family Functions. This has been mentioned in previous sections as to how each member functions in conjunction with Kate. In short, Sara sees only Kate’s needs and expects everyone else to support her ideas on what is best for Kate. Brian focuses more on the emotional needs of his entire family and is more perceptive but also avoids conflict with Sara as much as possible by withdrawing. Anna is completely dedicated to her sister, even showing footage of her bathing and caring for her sister at a young age, tasks that would not normally be left to a 13 year old. By her proficiency it is apparent that Anna not only has offered her body up to Kate but also emotionally exists to do whatever Kate needs. Kate loves her family but is tired of fighting her illness and tired of what it is doing to her

FAMILY ASSESSMENT ACTIVITY

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family. Jesse supports the counter-Sara efforts and does his best to be a brother to both of them. Because of Sara’s dogmatic approach to saving Kate regardless, the opinion and feelings of everyone around her, including Kate are pushed into the background. Sara is oblivious to the things that are happening around her – Jesse’s pain, Kate’s desire to stop fighting, and Anna’s true motivation for requesting medical emancipation.

VII. Family coping The stress of dealing with an illness like leukemia is multi-faceted. It’s both a blessing and a curse that the ability for a complete remission exists, making it possible to hope for recovery but with the full knowledge that the opposite is also true: the disease can return at anytime. It makes it impossible to really come to terms with dying or living, and for a mother, especially one like Sara, who is intelligent, driven and has financial resources- it creates almost an obsession with keeping her daughter alive no matter the stakes. It is to that end that she and Brian have Anna genetically engineered as a match for Kate and implanted. To that end that she allows 2-year old Anna to be dragged screaming for bone marrow transplants. That she quits her job to devote every moment to Kate. And she loses the ability to be a wife and a mother to her other children. Because the focus is on Kate, any desires or deviation from what is best for her brings with it a heavy burden of guilt. For Jesse, needing attention is to feel guilty for not

FAMILY ASSESSMENT ACTIVITY

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being selfless towards his sister. For Brian, desiring Sara to be a wife as well as a mother is construed as selfish. For Anna it is the worst because she was actually created, not out of love but as a donor for her sister. Amazingly, this resilient little girl could be so bitter and disenfranchised but instead pours herself into her family without complaint. Even Kate chooses to focus on the beauty that is her life and on the preciousness of her family and the experiences she has had rather than her life being squelched at before it’s begun. Sara’s approach is almost militant but has kept her family together and has provided a quality of life for Kate she would not have otherwise known. The love among siblings is unprecedented, showing bonds that run deep with a silent vow to protect one another regardless of cost to self. So many of the families strengths are also their weaknesses – the force that keeps them moving forward makes it impossible to let go, the love that holds them together compromises individual needs and so on and so forth. The willingness of Anna to sacrifice herself for Kate and vice versa is a beautiful picture of love. This is seen moreover in the book where Anna dies after being awarded medical emancipation and Kate goes on to receive the transplant and live six more years. To love so selflessly is again, both the strength and weakness of the family and is in my opinion, the epitome of coping- not black and white, but found in the gray area of struggling back and forth with the needs of an individual over a collective whole.

FAMILY ASSESSMENT ACTIVITY X. Summary and Evaluation Summary Statement

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The Fitzgerald family operates fluidly from a medical standpoint of physical health only. Since Kate’s diagnosis of leukemia, the family has utilized every resource available to prolong Kate’s life and improve her chances of remission. That dedication included the bioengineering of a genetic match, Anna to provide cord blood, bone marrow and other organs as needed. That well-oiled machine came to a crash when Kate’s leukemia began progressing and she needed a kidney from her 13-year old sister. The crisis became if ethically and morally when Sara decided Anna should donate a kidney without considering the implications for her younger daughter. This highlighted the fact that while the family has been handling the physical needs of Kate that emotionally, the family is on the verge of collapse with the question of how far will Sara go to save Kate in terms of Anna’s own health. While it looks like Sara is the one holding the family together, it is actually the emotional bonds between the siblings and even their father that allows them to come together with a silent understanding that is the true coping. While the entire family is doing their best, emotional and grief counseling is needed for all members of the family, including Sara, in helping her to accept and open her arms to the needs of her husband and other children in addition to Kate.

FAMILY ASSESSMENT ACTIVITY

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NANDA Disturbed personal identity related to situational crisis and impaired stages of development. (Physical, psychosocial, psychological) 1. Disturbed relationships as evidenced by Sara’s focus on Kate to the exclusion of the rest of her family and especially Anna. (Physical, psychosocial, psychological) 2. Fluctuating feelings about self as evidenced by Jesse’s feeling guilty about his needs and acting out through destructive behavior with providing care for his sisters. As evidenced by Anna’s guilt over wanting to be more than just Kate’s sister with her desire for Kate’s well- being. (Physical, psychosocial, psychological) 3. Uncertainty about ideological values as evidenced by Sara’s willingness for Anna to be Kate’s donor without contemplating ethical limits (would it be different if it was a vital organ) and Anna’s uncertainty about whether it is selfish to want to keep her kidney, and Brian struggling with seeing both Kate and Anna’s needs. (Physical, psychosocial, psychological) 4. Ineffective coping as evidenced by Sara’s unwillingness to let Kate go or see her desire to die. As evidenced by Jesse setting fires and smoking. As evidenced by Brian withdrawing to work. As evidenced by Kate pushing her sister to not give her the kidney v/s confronting mom.

FAMILY ASSESSMENT ACTIVITY Dysfunctional family processes related to inadequate coping skills (Teaching/Learning) (Socio-cultural) (Psychological) 1. Altered role function as evidenced by Kate and her siblings having to force their

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mother to stop life-saving treatment. As evidenced by Anna having to sue her mother for medical emancipation. 2. Family does not demonstrate respect for individuality of its members as evidenced by Anna’s conception as a donor child, lack of concern for Anna’s well being, Sara’s view of Kate being the only important focus, Jesse setting fires, Brian stepping down as husband/head of household. 3. Ineffective spousal communication as evidenced by Brian having to threaten divorce to take Kate to the beach, Sara’s refusal to listen to Brian about the needs/perspective of Anna. 4. Closed communication system as evidenced by inability to communicate to Sara what family members want (Kate telling Anna to file for medical emancipation,) Kate telling her Dad she wants to go to the beach w/o Sara’s approval, Jesse’s inability to communicate to his Dad the need for mentorship so he sets fires. Compromised family coping related to temporary family role changes, prolonged disease, situational crisis. (282) (Psychological, teaching/learning, spiritual, sociocultural) 1. Significant person displays protective behavior disproportionate to client’s abilities as evidenced by Sara’s unwillingness to allow Kate to go to the beach or decide if she wants life-saving measures such as kidney transplant.

FAMILY ASSESSMENT ACTIVITY 2. Client expresses complaint about significant person’s response to health

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problem as evidenced by Kate requesting Anna file medical emancipation to stop her mother from continuing life saving measures. 3. Significant person describes preoccupation with client’s needs as evidenced by inability to see Anna separately from how she helps Kate, focus on Kate to the exclusion of other children and husband.

FAMILY ASSESSMENT ACTIVITY REFERENCES

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Ackley, B. J., & Ladwig, G. B. (2006). Nursing diagnosis handbook, a guide to planning care. (Ninth ed., pp. 282-283, 350-352, 190-191). Mosby Inc.

Picoult, J. (2004). My sister's keeper, a novel. New York: Atria Books.

Potts, N. L., & Mandleco, B. L. (2011). Pediatric nursing, caring for children and their families. (Third ed., p. inclusive). Delmar Pub.

SparkNotes Editors. (2010). SparkNote on My Sister’s Keeper. Retrieved October 31, 2011, from http://www.sparknotes.com/lit/my-sisters-keeper/

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