CASE STUDY Theory of Dependent-Care
This case study documents an ongoing interaction between a wife and her husband who live in a spacious home in a gated community.
When Dan (now 80) and Jane (now 65) began dating more than 15 years ago, both were emotionally charged to begin their lives anew. Well-educated and financially secure, they had a lot in common. Dan was a protestant minister, and Jane’s deceased husband had been a protestant minister. Both had lost their spouses. Jane’s first husband had suffered a catastrophic cerebral aneurysm 2 years earlier. Dan had conducted the funeral service for Jane’s husband. Dan’s wife had died of terminal cancer a little over a year earlier. Dan’s first wife had been a school counselor; Jane was a school teacher. Both had children in college. They shared a love for travel. Dan was retired but continued part-time employment, and Jane planned to continue teaching to qualify for retirement. Both were in great health and had more than adequate health benefits. Within the year they were married. Summer vacations were spent snorkeling in Hawaii, mountain climbing in national parks, and boating with family. After 7 years, Dan experienced major health problems: a quadruple cardiac bypass surgery, followed by surgery for pancreatic cancer. Jane’s plans to continue working were dropped so she could assist Dan to recover and then continue to travel with him and enjoy their remaining time together. Dan did recover—only to begin to exhibit the early signs and symptoms of Alzheimer’s disease. One of the early signs appeared the previous Christmas as they were hanging outdoor lights. To Jane’s dismay, she noted that Dan could not follow the sequential directions she gave him. As time passed, other signs appeared, such as some memory loss and confusion, frequent repeating of favorite phrases, sudden outbursts of anger, and decreased social involvement. Assessments resulted in the diagnosis of early Alzheimer’s disease. Dan was prescribed donepezil (Aricept), and Jane began to prepare herself to face this new stage of their married life. She read literature about Alzheimer’s disease avidly and organized their home for physical and psychological safety. A kitchen blackboard displayed phone numbers and the daily schedule. Car keys were appropriately stowed. It was noted that she began to savor her time with Dan. Just sitting together with him on the sofa brought gentle expressions to her face. They continued to attend church services and functions but stopped their regular swims at their exercise facility when Dan left the dressing room naked one day. Within the year, Jane’s retired sister and brother-in-law relocated to a home a short walk from Jane’s. Their intent was to be on call to assist Jane in caring for Dan. Dan and Jane’s children did not live nearby so could only assist occasionally. As Dan’s symptoms intensified, a neighbor friend, Helen, began to relieve Jane for a few hours each week. At this time, Jane is still the primary dependent-care agent. She prides herself in mastering a dual shower; she showers Dan in his shower chair first, and then, while she showers, he sits on the nearby toilet seat drying himself. Her girlfriends suggested that this was material for an entertaining home video! Although Jane is cautious in her care for Dan, she often drives a short distance to her neighborhood tennis court for brief games with friends or spends time tending the lovely gardens she and Dan planted. During these times, she locks the house doors and leaves Dan seated in front of the television with a glass of juice. She watches the time and returns home midway through the hour to check on Dan. On one occasion when she forgot to lock the door while she was gardening, Dan made his way to the street, lost his balance, reclined face-first in the flower bed, and was discovered by a neighbor. Jane has given up evenings out and increased her favorite pastime of reading. Her days are filled with assisting Dan in all of his activities of daily living. And, often, her sleep is interrupted by Dan’s wandering throughout their home. At times, when the phone rings, Dan answers and tells callers Jane is not there. Jane, only in the next room, informs him “Dan, I am Jane.” Friends are saddened by Dan’s decline and concerned with the burdens and limitations Jane has assumed as a result of Dan’s dependency.
1. Examine this case study through the dependency cycle model (Fig. 14.3). The outer arrows show a progression through varying stages of dependency. The inner circle represents who can be involved in the dependency cycle. Where are Jane and Dan in this cycle?
2. Using the basic dependent-care system model (Fig. 14.4), assess Dan and Jane. Identify the basic conditioning factors (BCFs) for each. What is the effect of Dan’s BCFs on his self-care agency? Is he able to meet his therapeutic self-care demands? Continue on to diagnose Dan’s self-care deficit and resulting dependent-care deficit. Now assess Jane’s self-care system.
3. Design a nursing system that addresses Jane’s self-care system as she increases her role as dependent-care agent for Dan.
FIG. 14.3 Dependency cycle
FIG. 14.4 Basic dependent-care system. BCF, basic conditioning factors; DCA, dependent-care agency; DCD, dependent-care demand; SCA, self-care agency; SCDF, self-care deficit; SCS, self-care system; TSCD, therapeutic self-care demand.
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Examine this case study through the dependency cycle model (Fig. 14.3). The outer arrows show a progression through varying stages of dependency. The inner circle represents who can be involved in the dependency cycle. Where are Jane and Dan in this cycle?
Based on the details provided, Jane and Dan currently appear to be in the late stage of the dependency cycle. When they first married in their retirement years, they were independent and mutually dependent on each other for companionship and support. However, over time as Dan’s health deteriorated and he was diagnosed with Alzheimer’s disease, he has become increasingly dependent on Jane for his activities of daily living and care needs. Jane has taken on the primary caregiver role to meet Dan’s growing therapeutic self-care demands. They receive some assistance from Jane’s sister and neighbor, showing the expansion of their dependency network.
Using the basic dependent-care system model (Fig. 14.4), assess Dan and Jane. Identify the basic conditioning factors (BCFs) for each. What is the effect of Dan’s BCFs on his self-care agency? Is he able to meet his therapeutic self-care demands? Continue on to diagnose Dan’s self-care deficit and resulting dependent-care deficit. Now assess Jane’s self-care system.
For Dan, his major BCFs currently include his age of 80 years, declining health status due to Alzheimer’s disease, and functional and cognitive limitations caused by his condition. These factors have significantly reduced his self-care agency, meaning his ability to independently engage in self-care actions. Due to his memory loss, confusion, and other symptoms, Dan is no longer able to meet his basic therapeutic self-care demands of dressing, bathing, toileting, meal preparation, safety monitoring, and medication administration without assistance. This has resulted in a self-care deficit for Dan. His dependent-care needs now exceed Jane’s capacity, creating a dependent-care deficit that Jane is striving to meet through her caregiver role.
For Jane, her BCFs include her age of 65 years, good health status, education level as a retired teacher, financial security, and motivation to care for her husband. These factors support her dependent-care agency or ability to provide dependent care. However, her heavy caregiving responsibilities for Dan around the clock have likely started affecting her own self-care, as evidenced by disrupted sleep and stress. While she maintains connections to her support network, she has taken on a demanding caregiving role that could potentially impact her own well-being if not balanced with self-care over the long-term.
Design a nursing system that addresses Jane’s self-care system as she increases her role as dependent-care agent for Dan.
Some elements to consider in a nursing system to support Jane include:
Conducting a comprehensive assessment of Jane’s physical, emotional and psychosocial well-being to monitor signs of caregiver stress or burnout. This could be done periodically through home visits or telehealth check-ins.
Providing education on caregiver stress management techniques like deep breathing, muscle relaxation, and establishing a self-care routine.
Facilitating additional respite support for Jane through expanded hours with Dan’s neighbor helper or engaging a home health aide temporarily.
Screening Jane for depression and making referrals to counseling or support groups as needed.
Ensuring Jane takes regular breaks during the day and week for restorative activities like socializing with friends, hobbies, exercise or simply relaxing alone.
Helping Jane optimize the home environment and safety-proof it to reduce her physical care demands on Dan as his condition progresses.
Maintaining open communication and monitoring any changes in Jane’s health, mood, social engagement or ability to continue caregiving independently for Dan over the long-term. Adjusting the nursing system as needed.
