The amount of disruption in a family can often be predicted by:

1. The family position of the serious ill, dying or dead family member.  For example, if the incapacitated or deceased family member was the only wage earner, the family is likely to experience significant stress as surviving members struggle with financial difficulties.
2. The number and type of roles held by the family member.  For example, the deceased was the family's only nurturer and communicators, cook, "chauffer." social planner, and peace-maker, remaining family member may feel particularly isolated until they learn how to communicate directly with one another instead of through the "communicator".
3. The ability of family members to perform tasks essential to the continuity of family life.  If other family members are unable to fulfill the roles vacated by the deceased, for example the family will experience a great deal of disruption as it learns to adjust.  Illness, handicaps, lack of education or skills, or lack or physical strength can interfere with surviving family member's abilities to fill a vacant role.
4. The degree of scapegoating.  Many dysfunctional families identify one of its members as the problem person in the family.  The identification of a problem person or scapegoat allows the family to direct its energy to dealing with  problems created by the scapegoat instead of focusing on its own dysfunctional patterns of behavior.  On an unspoken level, the family is afraid any recognition of its own dysfunction may result in the dissolution, or "death" of the family system.  To avoid that, the family maintains its balance and existence by focusing on the scapegoat, whose role is to act as a diversion and allow the family to maintain its own denial of any problems.

Family Rules
Each family, like any other group or system, has rules governing how its members act, what they are allowed to say, and what kinds of relationships they are permitted to have both within the family and with the outside world.  Virginia Satir indicates open family systems acknowledge family rules and allow them to be discussed and altered as as necessary. Closed systems prohibit any discussion or acknowledgement of the family rules.

Satir has identified rules common to open family systems.  Some of the rules that can help family members adjust to a death:

• Feelings are important
• We can work it out
• You are a special person

A closed family system's rules often interfere with a family's adjustment.  Some rules that hinder family members' adjustment include:

• Don't raise your voice
• Don't talk about ____'s illness or death
• Children must be protected from painful experiences, e.g., funerals
• To ask for what I want is selfish
• Never make mistakes
• We can't talk about or acknowledge our family secrets

A terminal illness and death require changes in family rules.  A rule against accepting help from the government may need to be adjusted to allow acceptance of the Hospice Medicare Benefit.  A rule to never use drugs must be reassessed during the treatment of the terminal illness.  "Don't let anyone know our business" will need some adjustments to allow for home care visits by the hospice team.

Because open family systems are better able to adapt to changing situations, members of such systems tend to have less difficulty coping with the illness and death of a family member. Open family systems still experience great stress as they adapt to the death of a family member, but they are more likely to manage successful adaptation because they can alter family rules that need to be changed.  Closed family systems, with their hidden rules and prohibitions against attempts to discuss or alter outdated rules, are more like to have difficulty adapting.

Intimacy Patterns

• Isolation:
  White suggests the crises of a terminal illness and death in the family is likely to affect the ability of family members to provide support for one another.  Isolated within the confines of their own grief, members of the family may not have the emotional energy to support anyone, including themselves.
  Multiple deaths in a family are especially likely to result in family isolation.  To protect themselves from the pain of another death in the family, family members may withdraw from one another.  Multiple deaths can also result in surviving family members withdrawing from all close personal relationships.
  
  When isolation occurs, the entire family systems needs support until adequate functioning is restored.  If families become isolated, members of the hospice team, in particular the bereavement team, can provide an invaluable service to the family by temporarily providing support for each family member and the family system as a whole.
  
• Changes in Relationship Patterns
  White notes a death can sometimes create close emotional ties among family members where none had existed before.  On other occasions a death may cause the disintegration of family relationships that had been close.  Often a crisis can lead to temporary changes in relating, such as greater closeness immediately after the death, which gradually revert to former patterns of relating.
  
• Touch
  An illness can affect patterns of intimacy in may other ways.  Most people feel a strong sense of "skin hunger" and need the reassurance and emotional healing a caring touch can provide.  Unfortunately a long, serious illness often results in a lack of touching.
  
  We need to remind family members about the patient's continued need to be touched.  Gentle massage, stroking, or holding the patient's hand can calm a troubled spirit.  However, we need to take our clues from the patient and remember that levels of intimacy, whether a pat on the arm or a long hug, must be determined by the patient.  Some people are uncomfortable with almost any touch.  Skilful assessment is the key to individual patient care.
  
  A protracted illness often leads to lack of privacy for long talks, cuddling, prayer or sexual intimacies.  The entire hospice team needs to encourage couples to establish private times, particularly during inpatient stays.
  
• Changes in the Nature of Families and The Patient Without a Family
  Families have always come in many different models.  High maternal mortality rates, which existed until quite recently, meant children were often sent to live with grandparents or aunts and uncles.  Men frequently had a succession of wives, each of whom became a surrogate mother to all the living children.
  
  Although families have always existed in many forms, the cultural changes of the past fifty years have resulted in greater numbers of nontraditional family models.  High divorce rates have resulted in many single parent families with their own special needs.  Today more married couples are choosing not to have children.  Homosexual union have become more open.  Each family model has its own special needs.