STATEGI IDENTIFIKASI MASALAH KESEHATAN

KELUARRGA

Dosen: Uki Noviana,S.Kep.,Ns.,MNSc.,Ph.D

Disusun oleh:
Nur Isnaini NIM: 21/484946/SKU/00881

PROGRAM DOKTOR ILMU KEPERAWATAN

FAKULTAS KEDOKTERAN, KESEHATAN MASYARAKAT DAN KEPERAWATAN

UNIVERSITAS GADJAH MADA
YOGYAKARTA
2021-2022
1. Latar Belakang
Keluarga adalah sebuah unit terkecil dari masyarakat yang terdiri atas kepala
keluarga dan beberapa orang yang berkumpul dan tinggal di suatu tempat di bawah
satu atap dalam keadaan saling bergantungan. Keluarga memiliki pengaruh yang
penting tehadap pembentukan identitas individu, status kesehatan dan perasaan harga
diri individu. Sistem pendukung yang vital bagi individu adalah keluarga, dimana
keluarga berfungsi untuk memenuhi kebutuhan-kebutuhan anggota keluarga dengan
menjalankan fungsi biologi, fungsi pendidikan, fungsi psikis, fungsi sosiokultural,
serta fungsi kesehatan1 . Aktivitas anggota keluarga dalam menjalankan fungsi kesehatan
dan kesimbangan antara anggota keluarga adalah bagian dari lima tugas dalam perawatan
kesehatan keluarga yaitu; mampu mengenal masalah kesehatannya, mampu
mengambil keputusan yang tepat untuk mengatasi kesehatannya, mampu melakukan
tindakan keperawatan untuk anggota keluarga yang memerlukan bantuan
keperawatan, mampu memodifikasi lingkungan sehingga menunjang upaya
peningkatan kesehatan, mampu memanfaatkan sarana pelayanan kesehatan yang ada.
Keluarga menjadi point penting dalam upaya mencapai kesehatan
masyarakat secara optimal karena memiliki keterkaitan dengan masalah kesehatan,
memiliki fungsi utama dalam masyarakat dan lembaga yang menyangkut kehidupan
masyarakat. Peran keluarga sebagai kelompok keluarga dapat melakukan aktivitas
pencegahan, pemeliharaan, menimbulkan, memperbaiki ataupun mengabaikan masalah
kesehatan yang ada di dalam kelompok atau keluarga. Keluarga berperan sebagai pengambil
keputusan dalam memelihara kesehatan anggota keluarganya, yang dapat diambil
kesimpulan keluarga dapat menjadi faktor penentu kondisi sehat-sakitnya anggota keluarga,
yang akan berdampak pada munculnya berbagai masalah kesehatan anggota keluarga.
Keluarga menjadi unit pelayanan kesehatan yang terdepan dalam meningkatkan derajat
kesehatan komunitas. Apabila setiap keluarga sehat, akan tercipta komunitas yang sehat
pula. Masalah kesehatan yang dialami oleh salah anggota keluarga dapat mempengaruhi
anggota keluarga yang lain, mempengaruhi sistem keluarga, komunitas setempat bahkan
 komunitas global. Dengan demikian kesehatan dan kemandirian keluarga merupakan kunci
utama pembangunan kesehatan masyarakat.
Strategi identifikasi masalah kesehatan keluarga tidak lepas dari tahapan Proses
keperawatan yang diawali dengan pengkajian individu dan anggota keluarga terkait status
kesehatan dan apa yang menjadi masalah kesehatan di dalam keluarga tersebut. Makalah ini
betujuan untuk menganalisa strategi apa saja yang dilakukan pada dua artikel yang dipilih
sesuai kata kunci pencarian.

2. Metode Pemilihan Artikel

Pemilihan atikel diawali dengan menuliskan kata kunci yang dipilih melalui pencarian
kata kunci : (((strategy) AND (identify)) AND (health problems)) AND (family) Filters: in the
last 5 years. (("strategie"[All Fields] OR "strategies"[All Fields] OR "strategy"[All Fields] OR
"strategy s"[All Fields]) AND ("identifiable"[All Fields] OR "identifiably"[All Fields] OR
"identifie"[All Fields] OR "identified"[All Fields] OR "identifier"[All Fields] OR "identifiers"[All
Fields] OR "identifies"[All Fields] OR "identify"[All Fields] OR "identifying"[All Fields]) AND
(("health"[MeSH Terms] OR "health"[All Fields] OR "health s"[All Fields] OR "healthful"[All
Fields] OR "healthfulness"[All Fields] OR "healths"[All Fields]) AND ("problem"[All Fields] OR
"problem s"[All Fields] OR "problems"[All Fields])) AND ("familialities"[All Fields] OR
"familiality"[All Fields] OR "familially"[All Fields] OR "familials"[All Fields] OR "familie"[All
Fields] OR "family"[MeSH Terms] OR "family"[All Fields] OR "familial"[All Fields] OR
"families"[All Fields] OR "family s"[All Fields] OR "familys"[All Fields])) AND (y_5[Filter]). Dari
pencarian tersebut didapatkan 976 artikel dan dipilih 2 artikel untuk dianalisa.
Pencarian Artikel yang kedua dengan menuliskan kata kunci : (((strategy) AND
(identify)) AND (health problems)) AND (family) AND Genogram
3. Hasil
a. Hilding, U., Allvin, R., & Blomberg, K. (2018). Striving for a balance between leading and
following the patient and family–nurses’ strategies to facilitate the transition from life-
prolonging care to palliative care: an interview study. BMC palliative care, 17(1), 1-8.
 b. Roni Peleg, M. D., Biderman, A., & Press, Y. Developing a Comprehensive Geriatric
Genogram Assessment Tool. Sat, 13, 21.

4. Pembahasan & Analisa

Peningkatan PTM di negara berkembang dilihat sebagai konsekuensi dari kombinasi
transisi demografi peningkatan harapan hidup dan peningkatan proporsi populasi pada
kelompok usia yang lebih tua dan transisi epidemiologi; ketersediaan imunisasi dan
pengobatan untuk penyakit menular mengurangi dampak langsung dari banyak penyakit
tersebut. Sebaliknya, perubahan gaya hidup yang berhubungan dengan urbanisasi dan
"westernisasi", seperti diet, merokok, aktivitas fisik dan peningkatan tingkat stres,
menyebabkan peningkatan faktor risiko PTM membutuhkan strategi perawat untuk
melakukan upaya promotif. Upaya promotif membutuhkan strategi yang efektif agar pesan
yang disampaikan dapat dipahami oleh pasien maupun keluarga.
Penelitian dari artikel pertama dengan desain kualitatif dengan pengambilan sampel
yang bertujuan digunakan untuk memasukkan RN dengan berbagai pengalaman dari
pertanyaan penelitian [15]. Kriteria inklusi adalah RN dengan setidaknya 1 tahun
pengalaman bekerja di PC. Lima belas RN, dipilih oleh manajer unit, secara pribadi diminta
untuk berpartisipasi dalam penelitian. Semua peserta memberikan persetujuan tertulis.
Sebanyak 14 RN diintervensi, satu pria dan 13 wanita berusia 27 64 tahun (median 43 tahun).
Mereka memiliki antara 2 dan 32 tahun pengalaman bekerja di PC. Satu hanya bekerja pada
jam malam, empat bekerja pada shift malam dan siang, dan sembilan hanya bekerja pada
siang hari. Penelitian ini untuk menentukan keseimbangan antara pekerjaan perawat, pasien
dan keluarga pada kondisi paliatif care.
Tema yang pertama
a. Mengenal pasien dan menciptakan hubungan Untuk membangun kepercayaan dan
memfasilitasi dialog
RN berusaha untuk mengenal pasien dan keluarga. RN mempertimbangkan aspek
fisik, psikologis, sosial, dan eksistensial selama proses ini. Mereka fokus untuk melihat
orang di balik penyakit dan apa yang dianggap paling penting oleh pasien. Ketika waktu
perawatan singkat, atau ketika RN tidak menemui pasien sebelum penyakitnya lanjut,
digambarkan lebih sulit untuk menjalin hubungan dengan pasien dan keluarga.
b. Memberikan dukungan
Berbagai jenis dukungan baik untuk pasien dan keluarga digambarkan sebagai
pusat. Dukungan diberikan dengan cara yang berbeda, tergantung pada gejala dan situasi
pasien. Salah satu jenis dukungan melibatkan mengidentifikasi dan memenuhi kebutuhan
pasien untuk meredakan gejala, dan mengoordinasikan tindakan yang berbeda untuk
menangani masalah medis dan sosial.
c. Beradaptasi dengan kebutuhan individu
Strategi yang mereka gunakan adalah memperjelas arti dari konsep PC (Paliatif
Care). RN di bangsal berusaha keras untuk melihat pasien sebagai individu, dan juga
keluarga, dan membuat mereka merasa seolah-olah berada di rumah. Menjadi tersedia
dan memberikan waktu yang cukup untuk pasien dan keluarga dipandang penting.
d. Aktifkan percakapan
RNS mengambil pendekatan proaktif ketika berbicara dengan pasien mereka.
Mengajukan pertanyaan terbuka dan mengajukan pertanyaan lanjutan ketika pasien
memulai pembicaraan adalah strategi umum. Mereka memfasilitasi percakapan melalui
penangkapan. Perawat terdaftar memiliki peran unik untuk mendukung pasien dan
keluarga dalam transisi dari perawatan yang memperpanjang hidup ke PC untuk pasien
dengan penyakit yang tidak dapat disembuhkan. RN menggunakan strategi yang
memerlukan pemahaman dan pengetahuan tentang proses transisi, kemampuan untuk
mengenali dan memahami kebutuhan unik pasien terkait transisi. dan pengalaman
bagaimana memenuhi kebutuhan tersebut. Selanjutnya, RN perlu menyesuaikan strategi
mereka dan berusaha untuk mengevaluasinya dengan berkonsultasi dengan individu
dalam perawatan mereka dan keluarga mereka.

Artikel yang kedua membahas terkait identifikasi masalah kesehatan keluarga dengan
menggunakan CGGAT (Comperhensif Geriatric Genogram Assesment Tools) Yang
didalamnya terdapat alat pengkajian komperhensif yang berguna untuk meringkas status
pasien lanjut usia di beberapa domain termasuk medis, fisik, psikologis, mental, nutrisi,
kognitif, sosial, ekonomi, dan lingkungan. Ada banyak manfaat potensial untuk
mengintegrasikan CGGAT ke dalam bidang kedokteran geriatri. CGGAT dapat menangkap
informasi sejarah pasien serta status fisik dan fungsional dalam satu penggambaran grafis.
Penggunaan gambar untuk presentasi visual kondisi medis adalah metode yang diterima
yang melengkapi laporan kesehatan klien. Genogram ini adalah sebuah diagram seperti
sebuah pohon keluarga. Genogram dapat menggambarkan hubungan keluarga untuk dua
atau tiga generasi (untuk menggambarkan lebih dari tiga generasi akan menjadi sangat
 komplek). Beberapa informasi yang termasuk di dalam genogram ini antara lain adalah :
umur, jenis kelamin, status perkawinan dan komposisi keluarga, struktur keluarga dan
hubungan keluarga (misalnya anak kandung, anak angkat, orangtua dan sebagainya); Situasi
pekerjaan dan tanggung jawab, kegiatan sosial dan minat/bakat; dam karakter yang
mengikuti anggota keluarga yang bersangkutan. Berikut adalah contoh genogram pada
wawancara awal.
Genogram ini dapat digunakan untuk memverifikasi apakah ada pola hubungan
berulang dan gangguan emosional atau fisik. Genogram berasal dari disiplin penilaian
keluarga dan terapi keluarga, dan telah disesuaikan dengan kebutuhan pengaturan
perawatan kesehatan lainnya seperti risiko genetik, seksualitas, forensik, identifikasi risiko
kardiovaskular, evaluasi kebutuhan, sumber daya di akhir kehidupan, situasi dan duka, dan
perawatan pasien dengan demensia. Selain Genogram pada artikel ini juga terdapat
pengembangan Tools dengan memasukan Eco Map yang bisa menjelaskan kondisi
seseorang atau suatu keluarga di dalam suaru konteks sosial. Informasi yang termasuk di
dalamnya antara lain adalah : keluarga inti, asosiasi formal (misalnya keanggotaan dalam
aktivitas keagamaan, partisipasi dalam organisasi dan sebagainya). Sumber-sumber yang
mendukung atau bahkan membuat stress dalam interaksi sosial (antara seseorang dengan
sistem komunitasnya); penggunaan sumber-sumber yang terdapat di lingkungan serta
sumber-sumber yangt erdapat di lingkungan serta sumber-sumber informal dan lingkungan
pendukung (keluarga besar, kerabat, teman, tetangga dan kelompok bantu diri).
5. Kesimpulan Dan Saran
Strategi identifikasi masalah kesehatan dalam keluarga dapat dilakukan oleh perawat
melalui komunikasi efektif dan terapeutik pada individu, keluarga juga dengan lingkungan
sekitar dari individu tersebut. Identifikasi dibantu dengan alat ukur yang memadai yang
dapat memotret kondisi kesehatan individu dalam keluarga tersebut yang salah satunya
dengan Genogram dan Ecomap seperti yang tercantum pada jurnal kedua dari artikel yang
ditemukan. Genogram adalah alat yang berharga untuk penilaian situasi yang kompleks.
Sebuah symbol dicocokkan dengan setiap domain berdasarkan karakteristik domain (hasil
tes, keadaan fungsional, dan hubungan emosional). Simbol genogram biasa digunakan untuk
 mewakili struktur keluarga, riwayat keluarga, anggota rumah tangga, tanggal penting, dan
hubungan antar anggota keluarga.

6. Daftar Pustaka

Hilding, U., Allvin, R., & Blomberg, K. (2018). Striving for a balance between leading and
following the patient and family–nurses’ strategies to facilitate the transition from
life-prolonging care to palliative care: an interview study. BMC palliative care, 17(1),
1-8.

Roni Peleg, M. D., Biderman, A., & Press, Y. Developing a Comprehensive Geriatric Genogram
Assessment Tool. Sat, 13, 21.

Souza, Í. P. D., Bellato, R., Araújo, L. F. S. D., & Almeida, K. B. B. D. (2016). Genogram
and eco-map as tools for understanding family care in chronic illness of the young.
Texto & Contexto-Enfermagem, 25.

Gonçalves Barbosa, N., Guidorizzi Zanetti, A. C., & de Souza, J. (2021). Genogram and
ecomap as ludic strategies for teaching nursing in Primary Health Care. Revista
Brasileira de Enfermagem, 74(3).
Hilding et al. BMC Palliative Care (2018) 17:55
https://doi.org/10.1186/s12904-018-0311-7

RESEARCH ARTICLE Open Access

Striving for a balance between leading and

following the patient and family – nurses’
strategies to facilitate the transition from
life-prolonging care to palliative care: an
interview study
Ulrika Hilding1, Renée Allvin2,3 and Karin Blomberg1,3*

Abstract
Background: The transition from life-prolonging to palliative care (PC) can be challenging often characterized by
psychical, physiological, social and existential changes. Knowledge of how to support the patient and family in this
specific care phase is lacking, and this area needs to be further explored. The aim of this study was to investigate
strategies that registered nurses (RNs) use to ease the transition from life-prolonging care to PC for patients with
incurable disease.
Methods: The study has a descriptive design. Fourteen RNs working in a specialized PC unit were interviewed.
The data were analysed using content analysis.
Results: The RNs’ strategies can be described under the categories “Getting to know the patient and creating a
relationship”, “Providing support”, “Adapting to individuals’ needs” and “Enabling conversations”.
Conclusion: The findings show that the RNs in this population used strategies that not only took time but also
required knowledge about the transition process and required the ability to identify and meet patients’ and families’
unique needs. Patients’ difficult and exposed situation needs to be addressed through a structured follow-up after
informing about the change from life-prolonging care to PC. RNs have a unique role of supporting both the patient
and the family in the transition from life-prolonging care to PC for patients with incurable disease.
Keywords: Interviews, Palliative nursing care, Qualitative research

Introduction by physiological, social and existential changes due to loss

Palliative care (PC) has changed during the last decades of roles and functions that effect self-image [2–4], often
and today the patient and family are involved in the PC occurring in parallel with physical suffering [5]. This situ-
process in a much more direct way compared with previ- ation is challenging, and the patient and their family need
ously. The patient’s role has been strengthened, as the to be supported. However, knowledge of how to support
health care team are obliged to inform patients of their the patient and family in this specific phase is lacking, and
prognosis, be open for a discussion about any change in this needs to be further explored.
goals and plan the care in line with the individual patient’s
wishes [1]. The end of a person’s life is often characterized
Background
The transition to PC is associated with the experience of
* Correspondence: karin.blomberg@oru.se leaving a predictable and entering a new, unpredictable
1
Örebro University Hospital, Örebro, Sweden situation [6]. Family caregivers describe the transition to PC
3
Faculty of Medicine and Health, School of Health Sciences, Örebro
University, S-70182 Örebro, Sweden as bringing a constant awareness of death, which increases
Full list of author information is available at the end of the article in times of deterioration of symptoms or when waiting for
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Hilding et al. BMC Palliative Care (2018) 17:55
test results or information from the doctors [7]. Studies
show that information about incurable cancer and impend-
ing death can triggered existential issues and angst [2] and
the transition from discussing a cure to enter PC can cause
emotional distress to the patient, the family and even health
professionals [8, 9]. At this point the patient and family
enter a very special and vulnerable time and the role of reg-
istered nurses (RNs) is to support them during this process.
Several studies have described the importance of
receiving honest and sincere information about life being
limited. This communication enables the patient and
their family to prepare and plan for the end of life and
focus on what is important in the remaining time. This
is a meaningful and valuable part of the grieving process
of the family, both during the PC and after the death [1].
Kirby et al. report that Australian palliative specialists
find families’ situation critical when it comes to transi-
tioning to PC [10]. They stress the importance of a new
focus on training and education, including cultural com-
petence education, of health professionals to enable a
more comprehensive understanding of the patient’s family
and the challenging changes in their needs.
In Sweden, PC is based on WHO’s definition [11], as a
means to improve the quality of life of patients facing life-
threatening illness and of their families, regardless of diag-
nosis or age, including both at an early stage of serious
illness and the late phase of end-of life. PC is not merely
given in a specialized palliative clinic, but also in general
care such as municipal care or at hospitals, where RNs
have a central role. The Swedish guidelines [12] emphasize
the need to inform the patient and family when the med-
ical situation changes and cure no longer is an option.
The information may be summarized by the treating doc-
tor. Crucial for the upcoming care is that the patient and
family understand the new direction of care.
Warnock emphasizes that transitions in health care
constitute time points and a process where the RN has an
important role, of taking part in giving information, and
preparing and helping the patient to receive and cope with
the information [13]. In describing the role of the RN and
the challenges in breaking the bad news Griffiths et al.
show that, of all the health care workers, RNs are the ones
who are close to the patient and their family during the
final period of life [14]. They have to face with patient’s
existential issues and angst. However, they often feel
unprepared and are in need of tailored education to be
able to give optimal care at the end of life [14].
To summarize, the complex transition to PC is not
fully explored, and the transition to PC distinguishes
from other care transitions as it includes; the emotional
component in facing death, the concern of timing the
transition, and patient’s and family’s understanding of
the process [9]. There is a lack of studies that focus on
the role of the RN and the strategies RNs use to facilitate
Page 2 of 8
the transition to PC. Increased knowledge would give a
better understanding that could contribute to develop-
ment of supportive care in this phase of the illness
trajectory irrespectively the disease has evolved over
years or is a sudden change in health. Therefore, the aim
of this study was to describe strategies RNs employ in
facilitating the transition from life-prolonging care to PC
for patients with incurable disease.
Method
The study has a descriptive design [15]. Individual inter-
views were conducted with RNs working in a hospital-
based specialized PC unit, including both inpatient care
and advanced home care, at a university hospital in
Sweden. Ethical approval was obtained from the Regional
Ethics Board in Uppsala (Reg.no. 2013/244).
Participants and procedure
A purposeful sampling was used to include RNs with a
range of experience of the research question [15]. The
inclusion criterion was RNs with at least 1 years’ experience
of working in PC. Fifteen RNs, selected by the manager of
the unit, were personally asked to participate in the study.
All participants gave written informed consent. A total of
14 RNs were interviewed, one man and 13 women 27–
64 years old (median 43 years). They had between 2 and
32 years’ experience of working in PC. One worked only
night hours, four worked both night and day shifts, and
nine only worked during daytime.
Data collection
Individual semi-structured interviews [16] were conducted
by the first author using an interview guide designed
according to the aim of the study. The interviews started
with an open-ended question: “How do you facilitate the
transition from life-prolonging care to palliative care for
your patients?” Afterwards more specific questions were
asked, for example: “Can you explain how you follow up
after breaking the bad news to the patient and their
family?” To reach a deeper understanding, probing ques-
tions were asked, such as “Could you describe that in
more detail?”
Two pilot interviews were conducted to test the inter-
view guide. This resulted in a few revisions of the ques-
tions by changing the initial question to give the RNs
even more opportunity to speak freely. These interviews
were included in the data analysis. Demographic data
were collected at the beginning of each interview. All
RNs chose to be interviewed during their scheduled time
at their workplace. The interviews were audio-recorded
and lasted between 20 and 60 min. All the interviews
were transcribed verbatim.
Hilding et al. BMC Palliative Care (2018) 17:55
Data analysis
The data were analysed using qualitative content analysis
[17]. As a first step, the transcribed interviews were read
thoroughly several times to get an overview of the
content, and to identify meaning units supporting the
aim of the study. The meaning units were condensed to
give a more manageable material without losing the
essence of the text. Out of the condensed units, codes
were extracted, consisting of words or a short sentence.
For example, codes might represent specific actions or
an approach that the RNs described in the interviews.
During the analysis, we attempted to create codes that
were close to the text, although more concise as well as
abstracted to a higher logical level (see Table 1). To
minimize the risk of interpretation errors the researchers
paid special attention to the context of the meaning unit
during the condensing and coding process. The codes
were sorted into subcategories based on similarities and
differences in the RNs’ strategies. From the subcategor-
ies, four categories were abstracted describing RNs’ strat-
egies to facilitate and ease the transition process for
patients. Finally, the underlying meaning (i.e. the latent
content) was formulated into a theme. During the ana-
lysis, discussions about categorization were held between
all researchers to increase trustworthiness. In the follow-
ing, quotations have been used to illustrate the findings.
Results
The analysis resulted in the theme “Striving for a balance
between leading and following the patient and family”.
The theme is based on four main categories (presented
below) depicting the RNs’ descriptions of strategies used
to facilitate the transition from life-prolonging care to PC
(Table 2).
The theme can be understood as the core of the RN’s
work during the specific phase of a patient’s life. During
this period, the RN cautiously tries to reach out to the
patient and their family, and to find out how well
informed they are about the patient’s situation. The RNs
also tries to establish how the information about the
illness and its progress is comprehended. The RNs
described how they took repeated initiatives to invite the
patient and their family to dialogue. During the progress
of the illness the RNs were available to meet and satisfy
patients’ differing needs. They strived to show respect
and share concerns, at the same time as they gently tried
to build reality awareness.
Table 1 Example of a meaning unit, condensed meaning unit and codes
Meaning unit
… still, I strive to be as honest as possible all the time,
you strive towards being honest and telling what you
maybe think they need
Page 3 of 8
… do you see … how ill your mother is? That it’s
different from yesterday? So maybe tell the daughter
that her mother can’t keep the food; she is that ill …
it’s not possible to be much more ill than this.
(RN 10, inpatient care)
Getting to know the patient and creating a relationship
To build trust and facilitate dialogue, the RNs strived to get
to know the patient and the family. The RNs considered
physical, psychological, social, and existential aspects during
this process. They focused on seeing the person behind the
illness and what patients considered as most important.
When the time of care was short, or when the RNs did not
meet the patient before the illness had advanced, it was
described more difficult to establish a relationship with the
patient and family.
One of the RNs described how she wanted to be
confident with the patient before speaking about bad
news. For her, the point in time for initiating existential
matters was crucial. Mutual interests were used to start a
dialogue and create a common base. One RN described
how she actively directed the dialogue to progressively
turn to what was important. If the patient was giving
vague answers this was a complicating factor. According
to the RNs, this was hard, because it might lead to misun-
derstandings. The RN was then unsure whether the
patient understood more than they showed – or whether
the opposite applied. To find out what, and how much, a
patient wanted to know was seen as a delicate task.
… even if you have this diagnosis you might not want
to know all about it, and how medically literal can
you be? … it might sound pretty hard if you read from
a medical record. You have to choose your words.
(RN 7, advanced home care)
Some of the RNs described themselves as straightfor-
ward when getting to know the patient. Others tried to
be more cautious and careful.
… sort of try to listen and see where the person is …
(RN 11, inpatient care)
The RNs generally considered that family participation
eased the patient’s situation. The RNs took care of giving
the family the opportunity to prepare for the loss of a
family member. If the patient agreed, the family were
Condensed meaning unit Codes
… strive to be as honest as possible. Nurse strives to be as honest as possible.
Strive towards telling what you think Nurse tells what she thinks patients need.
they need.
Hilding et al. BMC Palliative Care (2018) 17:55
Table 2 The final subcategories, categories and theme
Subcategories Categories
Getting close to the patient Getting to know the patient and creating a relationship
Exploring where the patient is emotionally
Involving family
Identifying and meeting needs Providing support
Informing and explaining
Emotional support
Family support
Responsiveness Adapting to individuals’ needs
Adherence
Consideration and respect
Facilitating talk Enabling conversations
Reality checking
given the opportunity to receive information, and to take
part in making decisions. However, RNs described that
sometimes the family expressed a denial to the patient’s
situation and were unable to take in information. These
situations were described as a challenge for the RNs in
order to establish a relationship to the family.
Providing support
Different kinds of support both to the patient and the
family was described as central. The support was given in
different ways, depending on the patient’s symptoms and
situation. One type of support involved identifying and
meeting patient needs of symptom relief, and coordinating
different actions to deal with both medical and social
issues. The RNs also provided information about the care
of the patient, the course of the illness, and the plans for
patient and family. The type of information they handled
varied, but mostly concerned answering questions from
patients and family. They explained what was going on
with the patient. Sometimes they had to give information
without being asked any questions. The RNs described
how they strived to be responsive, and give information in
manageable amounts, being well aware that some patients
did not want to be fully informed. Therefore, to give
support and mediate a sense of safety, all patients had to
be asked about how much they wanted to know about
their illness and its progress. To be able to follow up after
bad news, exploring previously given information and
how it was perceived, was described as central. The RNs
used different strategies to find out how well informed the
patient was, and how well they understood the situation.
Several RNs noted that sometimes the patient and/or
family did not grasp the information although it was given
repeatedly. One of the RNs described that just knowing
that bad news had been received made it easier for her to
communicate with the patient. She valued having
Page 4 of 8
Theme
Striving for a balance between leading
and following the patient and family
something to relate to in her conversations with the pa-
tient and family.
… you must help the patient in all ways, you should
relieve symptoms – focus on that instead of curative
treatment. (RN 8, inpatient care)
Support was provided through listening to the patient
and letting them talk, as well as confirming and meeting
different emotions. To give time and be there for the
patient was described as emotional support. One of the
RNs described how she let her patients pass through
their stages of anger and guilt just by following them in
the process. Others described taking one day at a time
with their patients. Hope was considered to be precious
to the patients, and the RNs strived to let them preserve
their hope.
I don’t want to take all hope away, because this hope
might be the one and only reason why they wake up
one more morning. (RN 13, advanced home care)
The RNs tried to help the patients to focus on what could
be done, instead of what could not. It was considered
easier for both the patient and the family if the patient
accepted the situation and the RNs described that these
patients often experienced a better last period.
Support was also given to the family, which the RNs
saw as equally important to giving support to the pa-
tient. This support covered both practical information
and supportive conversations. One RN stressed the im-
portance of relieving the family from guilt with respect
to the patient. She reported that many family members
expressed conflicting interests, and did not feel that they
were as physically present as they would have wanted.
The RNs tried to ease their burden by reassuring them
Hilding et al. BMC Palliative Care (2018) 17:55
that they were looking after the patient, and that the
family members could come and go as they wanted and
were able.
… you have to release them from debt, help them to
not feel guilty. (RN 12, inpatient care)
The RNs understood that family members who took care
of the patient in their home mostly needed practical sup-
port from the home care service and/or the occupational
therapist; but they also needed confirmation that they
were going through a hard time.
Adapting to individuals’ needs
The RNs strived to be responsive by showing respect and
adapting to individual patients’ needs. A strategy they used
was to be clear about the meaning of the concept PC. The
RNs on the ward made great efforts to see the patient as
an individual, and also the family, and to make them feel
as if they were at home. Being available and giving enough
time to the patient and family were seen as important.
Considering the follow up after the bad news, all RNs
described that having an empathetic approach was of
utmost importance, although the initiatives they took
varied depending on individual patients and families. The
RNs also showed patients and their families consideration
and respect when existential questions were discussed.
They described how they tried to meet individual needs:
… sort of invited to help during the hardest times and
then you are open-minded and try to meet people and
accept them the way they are. (RN 12, inpatient care)
Flexibility was considered important and the RNs adapted
their actions based on factors such as patients’ diagnosis,
personality and age. Nurses used different tactics to make
a hard situation easier, sometimes tried distraction without
detracting from the seriousness of the situation. One RN
told that she tried to use humor when appropriate:
Even if you are dying, you have to laugh and often you
can actually attract it, even in the most difficult, sad
situations... And it’s liberating … you may think things
are fun yet. You cannot just sit and think about dying.
You live today, today we are here, and do not be afraid
to laugh…That (humor) is an weapon, even for our
patients (RN 3, advanced home care)
Enable conversations
The RNs took a proactive approach when talking to their
patients. Asking open-ended questions and posing follow-
up questions when patients initiated talk were common
strategies. They facilitated conversations through catching
Page 5 of 8
the right moment. One RN used to initiate conversations
while she performed her everyday practice, without focus-
ing on the talk itself. Patients’ understanding of bad news
information was eased through conversations, so it was
important not to back off from difficult talks. Sometimes
the RNs would bounce questions back to the patients, by
asking about their feelings and thoughts. Also, it was im-
portant to make it easier for patients and families to start
talking. One RN made a point of paying extra attention to
patients with an introvert personality:
You have to try to catch people – invite yourself.
They can be shy or something. (RN 12, inpatient care)
Several of the RNs described how patients and family
often tried to protect each other, and that it could be diffi-
cult for them to speak openly in front of each other. The
RNs emphasized the importance of making the patients
understand that they could be totally honest with them.
… because he doesn’t have to pretend to us, but maybe
he has to pretend in front of his wife and daughter.
(RN 3, inpatient care)
Conversation was also used to give the patient and family
a reality check about the illness and its progress. Accord-
ing to the RNs, this was essential in families where neither
part took the situation in. The RNs tried to be empathetic,
albeit honest in their conversations, and repeated the
information several times because these patients and/or
their families could have difficulties to take in or under-
stand all the information at the same time. Some RNs
stressed the importance of being totally honest to create a
trust between the patient and the RN. It was described as
important not to pretend or making false promises to the
patient. A balance between respecting patients’ defence
mechanisms and the RNs need to be honest was described.
They don't want anything else and then I think
that one has to step back. But on the other hand,
you can't promise anything: never make promises.
(RN 3, inpatient care)
Discussion
The findings show the complexities and dynamics of RNs’
work to facilitate patients’ transitioning between life-
prolonging care and PC. The RNs in this study said they
aimed for a balance between leading and following the
patient and family. Their striving towards this balance can
be seen as central to RNs’ work with patients who have just
received information regarding their disease and the change
in care from life-prolonging care to PC. The strategies the
RNs used to facilitate transition were getting to know and
Hilding et al. BMC Palliative Care (2018) 17:55
creating a relationship with the patient, providing different
forms of support, for example through enabling conversa-
tions, and taking different approaches to individuals’ needs,
which could seen as central for providing PC. In a study
about experiences of comfort among persons in need of
PC, Coelho et al. found that patients felt more comfortable
when healthcare was based on compassion, hope, interper-
sonal, transpersonal and intrapersonal relationships [18].
The findings further show that RNs used a range of
strategies, but all RNs stressed that they always focused on
what was best for the patient to facilitate the transition be-
tween life-prolonging care and PC. It has been noted that
RNs are less able to meet a patient’s needs if the patient is
not participating, or where communication is insufficient
[19, 20]. In the present study the importance of respon-
siveness and respect for the patient’s wishes concerning
prognostic information was emphasized. The patient’s
needs for information can vary, ranging from a wish to
know nothing at all to wanting to know all the details.
According to Reinke et al. RNs give prognostic informa-
tion by establishing what the patient already knows and
then based on the patient’s wishes regarding the informa-
tion [19]. The findings from this study showed same strat-
egies, but some ethical dilemmas were mentioned, such as
when the patient had one wish and the family another.
This was described as a challenge and difficult to handle
by the RNs. This need to be further explored for under-
standing of how RNs dealt with these dilemmas to further
improve education and practice in PC.
Benzein et al. describes the characteristics and means of
hope of persons with advanced cancer [21, 22]. Hope can
be described as reconciliation with life and death and is
central in palliative care [21–24]. Reconciliation was some-
thing the RNs in the present study described as an import-
ant task to help patients with. One strategy RNs used was
to find out where the patient was emotionally and how the
information they had been given had been received. This
was done during conversations focus on the impending
death, where the patient was invited to take the lead, both
regarding the content and in terms of time. This finding
highlights the need for creating a space, a culture where the
patients and their families feel safe to express existential
concerns as well as aspects of spirituality [2, 6, 25]. As men-
tioned, the RNs tried to meet every individual’s wishes with
respect to what information and how many details patients
wanted. According to Griffiths et al. it is not only hard to
determine what information to give but it is also difficult to
judge when is the right time for information [14]. To give
prognostic information too early could “close doors” to
further talk – and to give it too late could mean that there
is no time to prepare for death. Even if the essential of com-
munication in PC is highlighted in literature and guidelines,
errors related to PC are experienced by patients as commu-
nication and information errors and errors associate to
Page 6 of 8
trust/empathy. Warnock has put down guidelines and
advice for giving patients’ bad news [13]. One of the guide-
lines stresses, as the RNs in the present study have done,
that it is important to have both formal and informal talks.
It is not always pre-booked and planned time that provides
conditions for the best talk. Instead, staff have to make the
most of the times when the patient or family hint they want
to talk.
To explain different events to the patient and the family,
as well as facilitate families’ participation, both in the talks
and in the care, were other examples of ways to give
support. Bloomer et al. confirm that family participation
in planning end of life care is sufficient to give the patient
the care he or she wants [26]. A family that is involved
can also give the sense of meaning and closeness to the
patient. RNs thought that planning end of life care is a
process taking place during several meetings where pa-
tient and family attendance is a necessity. In our findings,
RNs perceived it to be important to involve the family and
give them support. Discussion of prognostic uncertainty is
of importance for family members [27]. Often, the RNs
wished for more open communication between the pa-
tient and the family, but they met barriers. They described
guiding the patient and family through the challenging
and vulnerable phase by being responsive, considerate and
respectful; and by being honest while giving continuous
support. Lundberg et al. state that a family’s emotional
experience of support is more important than the support
itself [28].
Registered nurses are uniquely positioned to support pa-
tients during this difficult time of transition. It encompasses
not only what the RNs do, but also how they see the person
in need of palliative care [29]. However, support given by
health care personnel is valuable only when considered so,
which suggests that RNs may need to adapt their strategies
further and, moreover, that they need to strive to evaluate
their strategies in consultation with the individuals in their
care and their families.
Strengths and limitations
To increase trustworthiness of the study we strived for
detailed descriptions of the study context, selection,
participants’ characteristics, data collection and analysis.
The findings are illustrated with appropriate quotes to
further enhance trustworthiness [15, 17]. Data collection
was done in a specialized PC unit. This needs to be
taken into consideration when translating the findings to
contexts outside of specialized care units, but our
findings are probably applicable even to general PC. If
not transferable, the findings could hopefully even give
some support and guidance when caring for patients
with incurable diseases outside PC. However, we used a
qualitative design with the intent to seek information on
and understanding of RNs’ strategies, rather than make
Hilding et al. BMC Palliative Care (2018) 17:55
generalizations to a larger population. In the analysis,
continuous discussions about how to categorize the find-
ings were held between all the authors. The authors have
different expertise (including clinical expertise in PC, in-
tensive care and anaesthesiology, as well as education
and research), which gives different perspectives and
opportunities for analytical discussions of the findings.
Conclusion
Patients’ difficult and exposed situation needs to be
addressed through a structured follow-up after informing
about the change from life-prolonging care to PC. Regis-
tered nurses have a unique role of supporting both the pa-
tient and the family in the transition from life-prolonging
care to PC for patients with incurable disease. RNs use
strategies that require understanding and knowledge of
the transition process, the ability to recognize and under-
stand patients’ unique needs concerning the transition,
and experience of how to meet those needs. Furthermore,
RNs need to adapt their strategies and to strive to evaluate
them in consultation with the individuals in their care and
their families.
Clinical implications
Patients’ difficult and exposed situation during the transi-
tion from life-prolonging care to PC needs to be addressed.
Studies have shown that RNs often meet patients or
families who have not fully understood the information that
they have been given or why the decision to transition to
PC has been made. Guidelines to help increase patients’
understanding and participation in decision making would
improve the situation of patients and families. The findings
of this study could be used in educational settings and
discussions with students, newly employed nurses and RNs
working outside of specialized units. In this way, optimal
care for PC patients and their families may be achieved.
Abbreviations
PC: Palliative Care; RN: Registered Nurse; RNs: Registered Nurses
Acknowledgements
The study was supported by Örebro University as the research time for KB
was funded.
Availability of data and materials
Because of the small size of the study population, where the individual
subjects are mostly familiar with each other, data cannot be shared for
reasons of integrity.
Authors’ contributions
UH, RA and KB designed the study and UH conducted the interviews, as well as
leading the data analysis. All authors were involved in the analysis and writing
the final manuscript. The final manuscript was approved by all authors.
Authors’ information
Ulrika Hilding, is a registered nurse at Örebro University Hospital, Örebro in
Sweden and have experiences of working with palliative care, both specialized
(in a palliative care unit) and general palliative care (in municipally care). Renée
Allvin, registered nurse, PhD, and research supervisor at the Clinical Skills Centre,
Örebro University Hospital, Sweden. Karin Blomberg is also a registered nurse,
Page 7 of 8
Associate Professor at the School of Health Sciences, Örebro University. She
has long experiences of palliative care, both as a nurse but also in educating
healthcare professionals in palliative care.
Ethics approval and consent to participate
The study was conducted in accordance with the Declaration of Helsinki and
has been approved by an ethical review board of Uppsala, Sweden (reg.no
2013/244). All participants gave written informed consent before participation.
Consent for publication
Not applicable as the paper does not include any details about individuals.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Örebro University Hospital, Örebro, Sweden. 2Clinical Skills Centre, Örebro
University Hospital, Örebro, Sweden. 3Faculty of Medicine and Health, School
of Health Sciences, Örebro University, S-70182 Örebro, Sweden.
Received: 27 December 2016 Accepted: 22 March 2018
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ORIGINAL ARTICLES
Developing a Comprehensive Geriatric Genogram
Assessment Tool
Tali Samson MSW PhD1,2, Roni Peleg MD1,2, Aya Biderman MD1,2 and Yan Press MD1,2,3
1
Department of Family Medicine, Siaal Research Center for Family Medicine and Primary Care Research Center, Faculty of Health Sciences, Ben-Gurion University of the Negev,
Beer Sheva, Israel
2
Comprehensive Geriatric Assessment Unit, Clalit Health Services, Southern District, Beer Sheva, Israel
3
Department of Geriatrics, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
ABSTRACT: Background: The use of graphic depictions (pictorials) to
represent medical conditions is an accepted method that
can complement standard methodology of comprehensive
geriatric assessment.
Objectives: To use the clinical pathway method to develop a
comprehensive geriatric genogram assessment tool (CGGAT),
which could supplement a written summary letter and recom-
mendations.
Methods: We used the critical paths method to develop a tool
to facilitate implementation of the comprehensive geriatric
assessment recommendations. A multidisciplinary group of
clinicians used the critical pathways method to develop a
CGGAT.
Results: We used the CGGAT to depict the physical and
functional status of patients and to complement the textual
historical information, family dynamics, and current patient
issues. CGGAT is a simple instrument that provides a visual
structure and it can facilitate the sharing of information
among team members, encourage interdisciplinary dialogue,
enhance understanding and adherence on the part of patients
and professionals, and reduce the burden on the clinicians
who conduct the initial comprehensive geriatric assessment.
Conclusions: We showed the benefits and obstacles related to
the adaptation of this new tool and provide recommendations
for further development.
IMAJ 2019; 21: 796–800
KEY WORDS: clinical pathway, comprehensive geriatric assessment
(CGA), elderly, genogram
comprehensive geriatric assessment (CGA) is defined as a
A multidimensional interdisciplinary diagnostic process used
to delineate the medical, functional, psychosocial, nutritional,
and environmental needs of an elderly patient. A CGA also is
used to develop a comprehensive plan for care and long-term
follow-up [1].
A CGA requires contributions from many healthcare pro-
fessionals. The core team should consist of a geriatrician, a
nurse, and a social worker. Following a brief initial assessment
796
,0$-ǯ92/21ǯ'(&(0%(52019
or screening tests for central assessment domains, the team
decides whether to refer the patient to an expanded team. This
expanded team should include physical and occupational thera-
pists, nutritionists, pharmacists, and psychiatrists.
During the CGA, patients undergo various tests, including
a functional assessment of basic activities of daily living (e.g.,
the Barthel Index [2]), assessment of instrumental activities of
daily living (e.g., the Older Americans Resources and Services
Activity of Daily Living scale [3]), a cognitive assessment (e.g.,
the Mini-Mental State Examination [4] or Clock Drawning Test
[5]), an assessment of symptoms of depression (e.g., the Patient
Health Questionnaire [6]), a nutritional assessment (e.g., the
Mini Nutritional Assessment [7]), a balance and mobility
assessment (e.g., Timed Up and Go test [8]), and co-morbidity
indices (e.g., the Charlson Comorbidity Index [9]). In addition,
the caregiver’s burden is often evaluated by the Zarit Burden
Inventory (ZBI [10]). An essential part of the process is the
medication reconciliation [11].
The implementation of CGA recommendations can benefit
both patients and the healthcare system. However, the CGA
process is challenging and difficult because of its length, the
scope of domains, the duration, and the diversity of profession-
als involved in the process. While a large body of important
information can be gathered during the process, different stud-
ies have shown that the adherence rates for CGA recommenda-
tions are as low as 49–79% [12-14]. Thus, a critical challenge is
to convey CGA recommendations to healthcare providers in a
manner that facilitates their implementation.
PATIENTS AND METHODS
We used the critical paths (CP) method to develop a tool to
facilitate implementation of the CGA recommendations. The
CP method involves two steps. First, critical tasks and interdis-
ciplinary processes are identified. Second, standardized key ele-
ments are documented to ensure standard of care for patients
and provide an overview of the entire care process. This step
includes different sources of information such as the results of
assessments, consultations and diagnostic tests, and outcomes
,0$-ǯ92/21ǯ'(&(0%(52019 ORIGINAL ARTICLES

of interventions [15]. The CP method is considered the best

practice tool for organizing and integrating different levels of Figure 1. Comprehensive geriatric genogram worksheet
healthcare. Using the CP method, our multidisciplinary group Comprehensive Geriatric Genogram worksheet
developed a Comprehensive Geriatric Genogram Assessment Patient Name: __________________________ Address: _______________________________
tool (CGGAT), which can supplement the CGA written sum- Phone No: ____________________ Referrer: ___________________ Date: _______________
mary letter and list of recommendations. Our group included
Legal issues:
a geriatric physician, two family physicians, and a healthcare
social worker. We identified critical tasks, diagnostic tests, and
interdisciplinary processes related to the medical, functional,
psychosocial, nutritional, and environmental state of the
elderly patient. A symbol was matched to each domain based
Medical issues:
on domain characteristics (test result, functional state, and Draw the patient genogram and ecomap here
emotional relationship). The usual genogram symbols [1] were
used to represent family structure, family history, household
members, significant dates, and relationships among family
members [16].
Functional issues:

RESULTS Date / Date / Date / Geriatric

Figure 1 shows our CGGAT worksheet and Figure S1 shows
the symbols that were included in our CGGAT. All icons were
downloaded (with permission) from Flaticon (www.flaticon.
com). The genogram was drawn using the GenoPro software
program (https://www.genopro.com/). GenoPro can facilitate
the presentation of essential information about the patient
and other family members by integrating both the genogram
technique, which describes family structure and relationships
among family members [16], and a series of symbols that
describe fundamental geriatric conditions. The medical geno-
gram can then be used for recording information about patients
and families. It has a standard format to present family his-
tory and structure for at least three generations and to identify
the type of bonds between family members and nonrelative
household members and the individual characteristics of key
family members. The genogram includes the primary medical
problems of all family members; dates of marriages, divorces,
deaths; and cause of death.
A genogram can also be used to verify whether there are
recurrent relationship patterns and emotional or physical
disruptions. The genogram originated within the discipline of
family assessment and family therapy, and has been adapted to
the needs of other healthcare settings such as genetic risk, sexu-
ality, forensics, identification of cardiovascular risk, evaluation
of needs, resources in end-of-life situations and bereavement,
and care of patients with dementia [17-23]. There is a general
consensus that the genogram is a valuable tool for assessments
of complex situations.
HYPOTHETICAL CASE STUDY
We demonstrated the use of the CGGAT with a hypotheti-
cal case study. In our hypothetical case, Mr. David Cohen,
was referred for CGA by his family physician due to memory
Test score score score syndrome Date
MMSEa
CTDb
Financial issues: PHQ9c
Barthel Index
IADLd
TU&Gf
Environmental
& Social issues: MNAe
Charlson’s Score
ZBIg
aMini-Mental State Examination, bClock Drowning Test,
cPatient Health Questionnaire, dInstrumental Activities of Daily Living,
eMini Nutritional Assessment, fTimed Up and Go test, gZarit Burden
Inventory
All icons were downloaded (with permission) from “Flaticon” (www.flaticon.com)
problems, general deterioration in everyday coping abilities,
and recurrent falls. During the first visit David was assessed
by a nurse, a social worker, an occupational therapist, and a
geriatric physician. Figure 2 shows how the CGGAT was used
to present the information collected at the first CGA.
In the genogram Mr. Cohen, a 78-year-old patient, is repre-
sented by a double square figure at his first visit to the geriatric
clinic. As shown by the curved line under his name, he married
Rebecca in 1961, after both immigrated to Israel. The Cohen
couple’s parents died, as shown by the cross and the year above
their names, indicating both the fact that they are deceased and
the year they died. The Cohen couple have two adult children
(Rachel and Josef). Their son is divorced and their daughter
is married and has one daughter. Mr. Cohen, his wife, and
his son, live in the same house, as depicted by the dotted line
surrounding them. Their daughter lives with her family in a
separate house.

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Figure 2. Sample CGGAT worksheet, first visit summary

circled “No,” linked to the treatment preference symbol reflects
that his end-of-life treatment preferences were not clarified.
Comprehensive Geriatric Genogram worksheet During the interview, it became clear that Rebecca was
Cohen David
Patient Name: __________________________ Beer Sheva
Address: _______________________________ David’s primary caregiver, as shown in the ecomap [Figure 2].
08-1111111
Phone No: ____________________ Family Physician
Referrer: ___________________ 06/2016
Date: _______________ This information is encoded by indicating her name beside the
Legal issues: primary caregiver symbol. The ZBI score signifies a mild to
moderate burden. The current structure of the document sup-
Rebeca
ports the presentation of information about Rebecca, the plan-
ning of interventions, and the formulation of recommendations
based on her ZBI score.
Medical issues:
MEDICAL ASPECTS
Tables of the diagnoses and tests are presented below the
genogram, providing current medical information [Figure 2].
Cognitive impairment, hearing loss, recurrent falls, and risk for
malnutrition are the geriatric syndromes diagnosed. The icon
Functional issues:
for stumbling is circled on the left, representing an increased
Date / Date / Geriatric
Test 06/16 score score syndrome Date risk for falls. Mr. Cohen has limited mobility, as indicated by
MMSEa 23/30
Cognitive Impairment- 16/06/15 the circled walker symbol, and uses a hearing aid.
m/p Dementia
The Cohens live in a rented apartment. Their income is
CTDb 5/10 Hearing Loss 16/06/15
c
above the average in Israel, as indicated by the circled sign that
PHQ9 5/27 Recurrent Falls 16/06/15
Financial issues: is linked to the income symbol. The Cohen’s live in an apart-
Barthel Index 70/100
ment on the third floor without an elevator, as indicated by the
IADLd 3/14
circled stairs symbol. The number that is linked to the income
TU&Gf 24
symbol indicates the floor where they live.
Environmental MNAe 9
& Social issues: Based on this assessment, the apartment needs to be
Charlson’s Score 6 adjusted to David’s physical condition, as indicated by the
3
ZBIg 23
circled repair house icon.
9.75 aMini-Mental State Examination, bClock Drowning Test,
cPatient Health Questionnaire, dInstrumental Activities of Daily Living,
eMini Nutritional Assessment, fTimed Up and Go test, gZarit Burden SOCIAL ISSUES
Inventory David is a Holocaust survivor, as indicated by the circled Star of
David on the left. In Israel, this guarantees him unique rights if
All icons were downloaded (with permission) from “Flaticon” (www.flaticon.com) he becomes disabled; therefore, this information is important
for all of his healthcare providers. He is entitled to 9.75 hours
The ecomap is a diagram that shows the social and personal of home nursing care each week, as part of his right to long-
relationships of an individual with his or her environment. In term insurance. This benefit is indicated by the circle around
our example the ecomap shows that Rebecca was the primary the nursing symbol. The numbers besides the symbol represent
caregiver. Their relationship focused on David’s needs, as the level of his entitlement. The Barthel test result and the other
manifested by the arrow in the genogram. David had a close functional information presented indicate the need to submit a
relationship with their daughter, Rachel, while Rebecca had claim for supplemental rights.
a close relationship with their son-in-law and a more distant
relationship with Josef, their son. Rebecca also had a close rela- RECOMMENDATIONS AND FOLLOW-UP BASED ON THE OUTCOME
tionship with her son’s ex-wife who lived nearby. The nature of OF THE CGGAT
the relationship between David and his son is not clear at this At the end of the assessment process, several recommendations
stage of the assessment. The ecomap indicates that the son and were made to the family and the primary care team. These sug-
daughter might find it difficult to support their parents in light gestions related to environmental and social issues, including
of the challenges posed by David’s condition. psychosocial interventions aimed at strengthening relationships
Gathering the medical, functional, environmental, social, among family members and providing support for Rebecca as
and financial information at the CGA is presented together on the primary caregiver.
the left side of the CGGAT [Figure 2]. Figure 3 shows the CGGAT of the follow-up visit 6 months
David has no legal guardian or medical power of attorney, later. Comparing the two schemes, it is clear that major changes
as shown by the empty blank lines linked to both symbols. The occurred. First, the relationship between Josef and Rebecca

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improved and Josef became a source of support for his mother. Figure 3. Sample CGGAT workout, second visit
Rachel was more involved as David’s end-of-life treatment pref-
erences were clarified, and she assumed the role of his medical Comprehensive Geriatric Genogram worksheet
power of attorney. The ecomap indicates that Rachel’s relation- Cohen David
Patient Name: __________________________ Beer Sheva
Address: _______________________________
08-1111111
Phone No: ____________________ Family Physician
Referrer: ___________________ 01/2017
Date: _______________
ship with both of her parents became much closer. Although
Rebecca remained David’s primary caregiver, the present eco- Legal issues:
map indicates that the children became involved and supportive.
Rebeca
While the couple lived in a rented apartment, the circles
around the repaired house symbol and the stairs symbol were
removed, which indicated that the present apartment fits
David’s needs and there were not accessibility issues. David’s Medical issues:
entitlement to homecare within the framework of long-term
insurance was increased to 19 hours per week, which addressed
his state of physical deterioration and increased dependency.
David’s daily routine included visits to a geriatric daycare cen-
ter. An emergency call button was installed in the apartment.
Functional issues:
At the second visit [Figure 3], Rebecca’s ZBI score reflects
Date / Geriatric
the benefits of the changes initiated after the first visit, as she Test 06/16 01/17 score syndrome Date
shows a lower level of caregiver burden. MMSE a
23/30 22/30
Cognitive Impairment- 16/06/15
m/p Dementia

CTDb 5/10 5/10 Hearing Loss 16/06/15

DISCUSSION Financial issues: PHQ9c 5/27 3/27 Recurrent Falls 16/06/15

Barthel Index 70/100 70/100 Dementia- Alzheimer’s 01/17

The CGGAT is a useful tool to summarize the status of elderly Disease
IADLd 3/14 2/14
patients in several CGA domains including medical, physical,
TU&Gf 24 22
psychological, mental, nutritional, cognitive, social, economic,
Environmental MNAe 9 11
and environmental. There are many potential benefits to inte- & Social issues:
grating CGGAT into the field of geriatric medicine. The CGGAT Charlson’s Score 6 6

can capture a patient’s historical information as well as the phys- ZBIg 23 18

ical and functional status in one graphic depiction. The use of
pictorials for the visual presentation of medical conditions is an
accepted method that complements written reports. In addition,
it can provide the medical staff with a tool that can help with
the preparation of written reports [24], enhance communication
between professionals and patients, and provide other medical
staff members with a tool to recall verbal messages.
Successful implementation of CGA recommendations
requires that both patients and caregivers understand the impor-
tance of making changes and the potential benefits. The use of
pictorials to supplement written or spoken text, when compared
to text alone, is a useful way to enhance patient comprehension
of the recommendations by increasing their attention to health-
related information [25]. The CGGAT pictorials could also serve
to help healthcare providers who conduct the CGA to remember
the multiple aspects of the patient’s life and health concerns.
Since the CGA is a multidisciplinary assessment, use of a
shared file to summarize the findings allows healthcare provid-
ers to use the information that was collected and, at the same
time, provide new information. Seeing graphic illustrations of
the main issues that should be considered during the CGA can
also assist in identifying information gaps, determining needs
and available resources to meet those needs, and setting treat-
ment options. The systematic use of CGGAT could identify
19 aMini-Mental State Examination, bClock Drowning Test,
cPatient Health Questionnaire, dInstrumental Activities of Daily Living,
eMini Nutritional Assessment, fTimed Up and Go test, gZarit Burden
Inventory
All icons were downloaded (with permission) from “Flaticon” (www.flaticon.com)
details that might have been omitted during the interview and
clarify them when possible. The CGGAT can be repeated as
treatment progresses, documenting how the family adapts to
changes over time.
LIMITATIONS
Although the CGGAT has important potential benefits, there
also may be obstacles to its implementation. The integration
of new techniques into clinical practice involves education
and practice. Using the CGGAT might be a frustrating and
time-consuming task at first. To make productive use of the
pictorials and the genogram, a training period is required in
which staff members can learn the new method and practice
its use. In the future, a computerized version of the CGGAT
could be integrated into the medical record. The advantages of
a computerized version might include linking the pictorial and
written versions, thus enabling users to understand the meaning
of a specific icon or a specific issue by linking to the assessment

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Figure S1. Geriatric symbol key
Medical issues Primary caregiver aspects
Recurrent falls Primary caregiver name
____
Incontinence Environmental & Social issues
Entitlement for daily home
care within the framework
Drug sensitivity of long term insurance. The
number indicates level of
entitlement
Repeated hospitalization Entitlement for home care
long term insurance - 24
hours’ assistance.
Resident in a building
Polypharmacy without an elevator. The
number beside the icon
___ indicates the apartmentfloor
Functional issues
Adjustment of housing
Cane dependent conditions is required
Emergency call-button at
home
Walker dependent
Holocaust survivor
Wheelchair dependent
Visiting a Geriatric day
care center as part of the
entitelment of long term
Bed ridden insurance
Permanent residence in a
nursing home
Hearing aid dependent
Legal issues
Vision limitation
End of life treatment
Correspondence
Dr. T. Samson
Dept. of Family Medicine, Faculty of Health Sciences, Ben-Gurion University
of the Negev, Beer Sheva 84105, Israel
Phone: (972-8) 647-7433, Fax: (972-8) 647-7636, email: samsont@bgu.ac.il
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medical information. It is a short, user-friendly way to discuss
recommendations with patients, their primary care teams, and
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primary care physicians and families, thus improving imple-
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