262 Seminars in Oncology Nursing, Vol 28, No 4 (November), 2012: pp 262-270

TARGETING COMMUNICATION
INTERVENTIONS TO DECREASE
CAREGIVER BURDEN
ELAINE WITTENBERG-LYLES, JOY GOLDSMITH, DEBRA PARKER OLIVER, GEORGE DEMIRIS,
AND ANNA RANKIN

OBJECTIVES: To describe family communication patterns that give shape to

four types of family caregivers: Manager, Carrier, Partner, and Loner.
DATA SOURCES: Case studies of oncology family caregivers and hospice patients
selected from data collected as part of a larger, randomized controlled trial
aimed at assessing family participation in interdisciplinary team meetings.
CONCLUSION: Each caregiver type demonstrates essential communication
traits with nurses and team members; an ability to recognize these caregiver
types will facilitate targeted interventions to decrease family oncology
caregiver burden.
IMPLICATIONS FOR NURSING PRACTICE: By becoming familiar with caregiver
types, oncology nurses will be better able to address family oncology
caregiver burden and the conflicts arising from family communication
challenges. With an understanding of family communication patterns and its
impact on caregiver burden, nurses can aid the patient, family, and team to
best optimize all quality-of-life domains for patient and family caregiver.
KEY WORDS: Family caregiver, Communication, Family caregiver types,
Family communication patterns

Elaine Wittenberg-Lyles, PhD: Associate Professor, This project was supported by Award No.
University of Kentucky, Markey Cancer Center and R01NR011472 from the National Institute of Nursing
Department of Communication, Lexington, KY. Joy Research. The content is solely the responsibility of the
Goldsmith, PhD: Associate Professor, Department of authors and does not necessarily represent the official
Communication, Young Harris College, Young Harris, views of the National Institute of Nursing Research of
GA. Debra Parker Oliver, MSW, PhD: Associate Professor, the National Institutes of Health.
Curtis W. and Ann H. Long Department of Family and Address correspondence to Elaine Wittenberg-Lyles,
Community Medicine, University of Missouri, PhD, Associate Professor, University of Kentucky, Mar-
Columbia, MO. George Demiris, PhD: Professor. Bio- key Cancer Center and Department of Communication,
behavioral Nursing and Health Systems, School of 741 S. Limestone, B357 BBSRB, Lexington, KY
Nursing & Biomedical and Health Informatics, School 40506-0509. e-mail: [email protected]
of Medicine, University of Washington, Seattle, WA. Ó 2012 Elsevier Inc. All rights reserved.
Anna Rankin, MA: Doctoral Student, Department of 0749-2081/2804-$36.00/0.
Communication, University of Kentucky, Lexington, KY. http://dx.doi.org/10.1016/j.soncn.2012.09.009
 TARGETING COMMUNICATION INTERVENTIONS TO DECREASE CAREGIVER BURDEN 263

cancer with each other.9 As a result, nurse assess-

C
LINICAL communication with care-
givers is considered instrumental in es- ment of the caregiver’s knowledge of the disease
tablishing and promoting caregiver trajectory can be difficult because it may be
quality of life.1 As other articles in this different among family members within the same
issue highlight, cancer care impacts all four dimen- family, and in many cases there is a conflict in
sions of the caregiver’s quality of life: physical, informational needs between the patient and the
psychological, social, and spiritual well-being.2,3 family.10 Because of the variation in the type of
Physical well-being involves the caregiver’s ability communication valued within a family, the impact
to perform caregiving tasks and includes strength, of how family members talk to each other about
fatigue, and appetite. Psychological well-being cancer varies as well.9 Determining appropriate
reveals cognitive changes, such as observable interventions for family members may be depen-
depression, anxiety about being able to provide dent on the family system and its impact on the
quality care, and distress from caregiving burden. family caregiver.
Similarly, social well-being characterizes changes
in roles or relationships and variation in affection
or appearance. A caregiver’s spiritual well-being THE CLIMATE OF FAMILY COMMUNICATION
encompasses both religiosity and transcendence
or can include feelings of hopelessness. This article The Family Communication Patterns Theory
will present family communication patterns details how family conversation and family confor-
theory as a lens for investigating family communi- mity range from high to low to form specific family
cation and propose four family caregiver types. communication patterns.11-15 First, families have
Each type will be illustrated through a case study rules that govern appropriate topics for family
analysis of an oncology family caregiver caring conversation. Family conversation can vary from
for a hospice cancer patient. free, spontaneous interaction between family
members (high) to limitations on family topics
and time spent communicating with each other
THE CHALLENGES OF FAMILY CAREGIVER (low).16 Families with high family conversation
COMMUNICATION patterns talk openly about death, dying, cancer,
and illness. Families with high communication
Family caregivers are important collaborators before the disease will maintain the pattern
during cancer care because they often provide throughout the illness as the situation highlights
patient information (eg, medical history, patient pre-existing interaction patterns.17 On the other
preferences), receive directions from the team hand, families with low family conversation
(eg, medication instructions, care tasks to be patterns do not engage in discussions about illness
done), and facilitate communication between the and are able to make decisions without talking
patient, health care providers, and other family about the disease. By avoiding talk about cancer,
members.4 Family members look to oncology some family caregivers feel they are protecting
nurses for information and are more likely to the patient from sad conversations.9 Families
receive cancer information from health care who have a prior history of family communication
providers than patients themselves.5,6 Typically, constraints are more likely to experience family
conversations with caregivers about cancer focus conflict during cancer care.18
on the medical treatment plan, the circumstances The second dimension of the family communi-
surrounding the cancer and prognosis, and psycho- cation pattern is family conformity, which is
social reactions.7 A nurse’s goals include commu- established by a hierarchy within the family struc-
nicating caring and ensuring that the family ture. Family members with high family conformity
understands and follows recommendations.7 have uniform beliefs and family values that
Although a relational approach with caregivers emphasize family harmony. However, conformity
has been recommended to ensure shared in family communication does not always equate
decision-making between clinicians, patients, with family agreement or open communication.19
and family caregivers,8 communicating with Hierarchical roles within the family are often
family members can be problematic. Following emphasized over conversation and disclosure.
a cancer diagnosis, some family members avoid Family caregivers of lung cancer patients reported
discussing emotional and information issues about that avoiding the topic of cancer was one way of
264 E. WITTENBERG-LYLES ET AL

maintaining family standards, recognizing that the conversation frequency and topic variability. A
family’s history of communication influenced Partner caregiver is part of a family that shares
their approach to communicate about cancer.9 low conformity or high diversity in attitudes and
In some instances, the emotional toll of the situa- beliefs, and also high conversation in terms of
tion was considered an unacceptable display of topic diversity and frequency of interaction. A
family communication.9 Alternatively, families family very low in conformity as well as conversa-
with low family conformity have little emphasis tion produces the Loner caregiver.19 Each of these
on obedience to parents/elders.20 For example, patterns of communication is best supported
avoiding communication about cancer is a tactic through different approaches by clinical staff to
used by some families to exclude certain family facilitate family decision-making about clinical
members from decision-making.9 decisions. Case studies depicting each caregiver
type are presented to identify essential character-
istics of clinical communication and distinguish
FOUR FAMILY CAREGIVER TYPES interventions appropriate for each type.

Our early work examined hospice family care-

giver talk about family-related concerns during Methods
caregiving.19 Caregiver talk revealed burdens re-
sulting from family communication patterns, Case studies presented here were selected from
advancing a typology for the ways caregivers expe- data collected as part of a randomized controlled
rience caregiving responsibility within their family trial funded by the National Institute of Nursing
setting. We examined two dimensions of family Research (R01NR011472, Parker Oliver, PI)
communication, conformity and conversation, aimed at assessing the clinical benefits of family
and used them to identify four patterns (Fig. 1). participation in hospice team meetings. Family
Namely, Manager, Carrier, Partner, and Loner caregivers, patients, and staff were recruited
caregiver types emerged as a result of the burden from a hospice agency in the Midwestern United
produced by family communication patterns. States. The Institutional Review Board of the sup-
The Manager is derived from a family that values porting university approved the study.
high conformity of attitudes, values, and behavior, Hospice staff provided referrals to a Graduate
and also engages in frequent conversation. Research Assistant (GRA) who then contacted
However, high conformity for the Manager’s family patients and caregivers for consent. Upon consent,
limits the range of conversational topics. For baseline measures were taken and caregivers
example, the family roles and structure, as well randomized for the intervention were provided
as homogenous attitudes and beliefs, will trump with a webcam (when necessary) and a password
the presence of topics that threaten these aspects to access Web-based video-conferencing software.
of family climate. The Carrier also comes from Caregivers were invited to use video conferencing
a high-conformity family, but one that is low in to participate in team meetings hosted by hospice

High
Conversation

Manager Partner
• Makes decisions swiftly and • Engages in a process of care
independently with team and family
• Restricts other family from • Navigates conflict and
illness process multiple perspectives
High Low
Conformity Carrier Loner Conformity
• Overperforms caregiving • Survives alone in caregiving
• Seeks affirmation for efforts
caregiving • Focuses intensely on one
aspect of care

Low
Conversation

FIGURE 1. Overview of Oncology Family Caregiver Types.

 TARGETING COMMUNICATION INTERVENTIONS TO DECREASE CAREGIVER BURDEN 265

staff. The goal of the meeting was to review the Mrs. Glenn had some college education and was
patient’s plan of care and facilitate questions and retired. Mr. Bee completed a GED and was still
answers between caregivers and staff. A random working part-time. Both siblings were married.
selection of videoconferences were recorded and
transcribed. A grounded theory approach was Quality-of-life and family network measures.
used to review the transcripts.21 A total of six repeated measures using the
Two instruments were used to measure care- CQOL-R and LSNS were taken. Mrs. Glenn’s first
giver outcomes. The Caregiver Quality of Life three assessments (time 1, 2, and 3) on the
Index Revised (CQOL-R) was used to measure CQOL-R yielded an average score of 6.0, which
caregivers’ quality of social life, with lower scores indicated moderate quality of social life, but time
reflecting lower quality social life.22 A three-item 4 measure (4.0) indicated a substantially lower
family subscale from the Lubben Social Network quality of social life. Meanwhile, Mr. Bee’s first
Scale (LSNS) was used to measure primary family three assessments (time 1, 2, and 3) on the
networks, with higher scores representing larger CQOL-R yielded an average score of 7.6, with his
family networks.23 According to the LSNS, a score time 4 assessment (8.0) depicting a much higher
of 6 or less represents fewer than two family quality of social life than his sibling counterpart.
members who can be counted on for support and Average assessment at time 5 and 6 demonstrated
are considered socially isolated. Caregivers report- higher quality of social life for Mrs. Glenn (7.5);
ing scores of 12 or more had nine or more family yet lower quality of social life for Mr. Bee (5.5).
members for support. Repeated measures on the CQOL-R over the dura-
The GRA contacted caregivers every 15 days to tion of the study suggest a negative correlation
repeat the measures. Additionally, the GRA con- between the two caregivers, with Mrs. Glenn’s
ducted a bereavement interview 15 days after the quality of social life improving and Mr. Bee’s
patient’s death. As part of the bereavement inter- quality of social life worsening.
view, caregivers were asked to use a scale of 0 to Likewise, Mrs. Glenn’s first three assessments
10, with 10 being the best, to rate their overall satis- on the LSNS yielded an average score of 11.4
faction with the hospice team’s pain management for compared with Mr. Bee’s average of 10.0, depicting
their loved one. Demographics were also collected. that she reported a slightly stronger family
To select case studies, we reviewed family care- network than Mr. Bee. At time 4 assessment,
givers of cancer patients who participated in Mrs. Glenn’s reported family network decreased
videoconferences. At the time of manuscript prep- to its lowest level (9.0) and her brother’s family
aration, 10 cases were identified. Three steps were network increased to its highest level (12.0).
used to initially identify caregivers who could be Average assessment scores for time 5 and 6 de-
typed as one of four caregivers: Manager, Carrier, picted a return to original assessment levels for
Partner, and Loner. First, we examined LSNS Mrs. Glenn (11.5) and Mr. Bee (10.0). Although
scores to determine each caregiver’s primary time 4 assessment showed the biggest difference
family network. Second, we examined the care- between the two siblings over the duration of the
giver’s reported quality of social life. By comparing study, Mrs. Glenn reported an overall stronger
LSNS and CQOL-R scores, we were able to gauge family network than Mr. Bee.
family networks in terms of number and
frequency of contact, as well as the quality of the Clinical communication with health care
interactions. Finally, we reviewed bereavement team. Mr. Bee and Mrs. Glenn participated
interviews and recorded interactions with hospice together in two team meetings. During team meet-
staff and considered caregiver demographics. In all ings, hospice staff inquired about the patient’s
cases, caregiver names have been changed to quality-of-life domains. Questions were asked
protect confidentiality. about their mother’s adjustment to a new nursing
home (psychological) and signs of pain (physical),
Results and staff also shared reports that their mother
spent time in the television room (social) and
Case 1 – The Manager Caregiver that a local pastor planned to visit the patient
Mr. Bee and Mrs. Glenn are Caucasian siblings, (spiritual). However, information about Mr. Bee
brother (64 years) and sister (67 years), caring and Mrs. Glenn’s quality of life during hospice
for their mother who resided in a nursing home. caregiving was limited. When asked about her
266 E. WITTENBERG-LYLES ET AL

mother’s transition to the nursing home, Mrs. had attended college, and was separated from her
Glenn commented: ‘‘I’m better with things. Those partner. To provide care for her sister, Ms. Wilson
days I talked to you were not good for me. It wasn’t relocated her sister to her home.
about her. It was me.’’ However, staff did not ques-
tion her further about this reference to distress. Quality-of-life and family network measures.
Generally, Mr. Bee and Mrs. Glenn did not initiate Two repeated measures were taken for Ms. Wilson.
concerns and only asked for clarification or On her initial assessment (time 1), her average
provided their own updates on patient care. Mrs. score on the CQOL-R for social quality of life was
Glenn positioned herself as the dominant commu- 10.0, which indicates high quality, but time 2
nicator, both verbally and nonverbally, telling the (9.0) was slightly lower. Repeated measures on
team: ‘‘My brother is here with me and we have no the LSNS over the duration of the study showed
questions.’’ Although Mr. Bee was present for both no change, with her average score (10.0) depicting
team meetings, he did not say anything and sat in a moderate family network consisting of three to
the seat furthest from the camera and micro- four family members.
phone, positioning his sister to speak for him.
Clinical communication with health care
Discussion. Mrs. Glenn emerged as the domi- team. Ms. Wilson participated in one team
nant family figure during clinical communication meeting with hospice staff. The focal point of the
with hospice staff. She served as self-appointed discussion was her sister’s ‘‘uncontrollable’’
family spokesperson, providing decisive decision- anxiety and staff questioned Ms. Wilson about
making and limiting open family communication her sister’s fear of dying (psychological well-
with Mr. Bee. With an emphasis on family struc- being), people she may need/want to see (social
ture, Mr. Bee emphasized family obligations work and spiritual issues), and reviewed pain
(conformity) over conversation. His need to management (physical well-being). Ms. Wilson
communicate was diminished by the preservation shared that her sister’s anxiety stemmed from
of existing family patterns. When asked if he was her inability to be in her own home. Although
able to pose questions during team conferences, Ms. Wilson shared that she often prays with her
Mr. Bee reported that his ‘‘sister did most of it’’ sister to help calm her down, the hospice team
and that he ‘‘was just there to kinda help her out did not address Ms. Wilson’s own spiritual, psycho-
a little bit.’’ Not surprisingly, Mrs. Glenn reported logical, physical, or social burden. In her commu-
an overall stronger family network than Mr. Bee. nication with staff, Ms. Wilson tended to default to
She continued to use ‘‘we’’ language about care- others in her decision-making or make a decision
giving responsibilities, but was the self-appointed and then seek social support from the hospice
family spokesperson in all clinical communication team. Unlike the Manager Caregiver, she ex-
with staff. pressed concern and asked questions about her
Summary of Key Points: duties as a caregiver. She was also unique from
other caregiver types by immediately initiating
 Manager Caregivers may have other family
a concern rather than waiting to be asked if she
members present but disallow their participa-
had any concerns. She mainly used ‘‘I’’ language
tion by dominating communication. Disparities
in describing caregiving and made it clear to the
in educational achievement between family
team that she needed support, as she was uncer-
members may influence this pattern.
tain about her caregiving role.
 As dominant family spokesperson, Manager
Caregivers prioritize swift decision-making.
Discussion. While Ms. Wilson reported
 Staff should initiate participation of other
a moderate family network of three or four people,
family members present, particularly those
she conveyed that she was the primary caregiver
who remain silent during clinical interactions.
for her sister by focusing only on her role as care-
giver and disclosing little about assistance from
Case 2 – The Carrier Caregiver other family members. Unique to the Carrier
Ms. Wilson is an African-American woman in her Caregiver, her caregiving burden came from
sixties caring for her sister who was under hospice efforts to follow directions from her sister and
care for lung cancer with brain metastases. She make arrangements for her sister to visit
had some outside employment responsibilities, her home. Decision-making about care was up to
 TARGETING COMMUNICATION INTERVENTIONS TO DECREASE CAREGIVER BURDEN 267

her sister and Ms. Wilson’s job was to carry out her ical well-being) were among the topics shared
sister’s wishes. As a result, most Carrier Care- about her mother. Mrs. Terry inferred that
givers are acutely aware of their ability to meet although she had child care responsibilities for
patient needs and seek confirmation from hospice her grandchildren, she had arranged a daily visit
staff assessing his or her performance. With an to her mother and this was very positively affirmed
emphasis on preservation of family, conformity by various team members—and in so doing Mrs.
outweighed family conversation and Ms. Wilson Terry’s psychological and social well-being as
reported that her main concern was maintaining caregiver was included in this meeting. Similarly,
her sister’s dignity throughout the dying process. Mrs. Terry’s conflict with her brother, Tom, was
Self-imposed pressure to do well resulted in a lower integrated in the team meeting by the chaplain,
quality of life for Ms. Wilson as her sister became providing Mrs. Terry further opportunity to share
more ill. Ms. Wilson’s obligation to family confor- family conflicts about choosing a hospice agency
mity likely resulted in her position as caregiver. with the team (social well-being). She presented
Summary of Key Points developments and concerns, but initiated few
questions.
 Evidence of over-performance of the caregiver
role is highlighted by Carrier Caregivers who
work to demonstrate excellent caregiver Discussion. Mrs. Terry was positioned as
performance. a teammate with the hospice staff and reported
 Carrier Caregivers focus almost exclusively on the highest family network of all other caregiver
support needs as they attempt to meet the types. She considered challenges and decisions
requests of the patient. with the team, and included the perspectives—
 Staff should provide accolades and reassurance even if divergent—of family members not present.
about the quality of caregiving being provided The Partner Caregiver holds perspective in pursuit
by the caregiver. Respite care and the provision of the best patient care possible, knowing that this
of care resources, including family mediation, is not something that can be sought or achieved
will be important for the Carrier Caregiver who without the entire family and health care team.
attempts to meet every patient care goal alone. This caregiver type becomes a partner not only
within her own family, but also with the team.
Mrs. Terry used a variety of names and pronouns
Case 3 – The Partner Caregiver
in describing her mother, her family, and herself.
Mrs. Terry is a Caucasian woman in her late
Their identities were not usurped into that of the
fifties caring for her mother who resided in
caregiver, as they are in the Manager Caregiver
a nursing home following a diagnosis of advanced
type, or excluded from the cause, as they are
OVCA with metastases to the lung. Mrs. Terry
with the Carrier. Her father’s painful cancer death
had a graduate degree, was married, and retired.
17 years earlier, plus family interaction patterns
that supported high conversation and low confor-
Quality-of-life and family network measures.
mity, allowed Mrs. Terry to experience the least
Only one measure of the CQOL-R and LSNS
burdensome type of caregiving.
were taken for Mrs. Terry. On the CQOL-R she re-
Summary of Key Points
ported high quality of social life (9.0 out of 10.0)
and high family network of five to eight family  Partner caregivers engage in processes of
members (11.0 out of 15.0). problem-solving with other family members
and health care team members.
Clinical communication with health care  Partner caregivers use ‘‘I’’, ‘‘we’’, as well as
team. Mrs. Terry participated in one team meeting specific name identifiers as they acknowledge
with hospice staff. Happiness with the patient’s and see the burdens that family and team are
transition to a new place of care (psychological distributing to achieve optimal patient care.
well-being), increased comfort with more frequent  Staff should focus on including the caregiver in
attention from health care professionals (social care planning, engaging in dialogue about
and spiritual well-being), and attention to the decision-making, rather than providing infor-
patient’s disinterest in drinking, inability to mation. The opportunity to be part of the care
swallow pain medication in pill form, diminishing team compliments the Partner Caregiver’s
strength, and effects of disease progression (phys- family communication pattern.
268 E. WITTENBERG-LYLES ET AL

Case 4 – The Loner Caregiver Caregiver primarily experiences care as one acute
Mrs. Salley is a Caucasian woman in her seven- crisis moment after another; this dynamic is
ties overseeing care for her husband who lived in heightened by their perceived isolation. The
a nursing home. She had an undergraduate college burden for this caregiver is redoubled because of
degree and was retired. her inability to enter into ongoing discussion
about multiple care matters, as there is a proclivity
Quality-of-life and family network measures. to fixate on one quality-of-life domain at the
Two repeated measures were taken for Mrs. Salley. expense of others, as well as the caregiver’s own
At initial assessment (time 1) on the CQOL-R, quality of life. There is no demonstrated effort
Mrs. Salley reported a 3.0, indicating low quality placed on family conversation or conformity, as
of social life, which was only slightly higher at the Loner views these variables as unreliable or
the time 2 assessment (4.0). Similarly, her average simply not present in his or her family system.
score on the LSNS at time 1 produced a 6, which As a result, Mrs. Salley performed exclusively as
indicates fewer than 2 family members in her the caregiver, according to her descriptions upon
family social network. While this initial score bereavement.
suggests social isolation, Mrs. Salley’s time 2 Summary of Key Points
assessment did increase (8.0).
 Loner Caregiver questions care surrounding
one quality of life dimension rather than initi-
Clinical communication with health care
ating their own problem-solving processes
team. Based on her bereavement interview, we
about holistic care.
know that Mrs. Salley participated in at least
 Family members are identified as separates in
two team meetings. While reflecting on her own
caregiver descriptions (ie, ‘‘they’’).
communication and presence in team meetings,
 Staff should consistently engage this caregiver
this caregiver remained transfixed on the physical
in one-on-one interactions to integrate quality
well-being of her dying spouse. Concerns about
of life domains for patient and caregiver,
a port, CT scan results, steroids, and brand of
increasing health literacy.
pain medication prompted extensive question
and answer periods with various team members
during her husband’s care. In describing her RESEARCH IMPLICATIONS AND FUTURE NEEDS
husband’s level of peace upon dying (spiritual
and psychological well-being), she noted an 8 Family caregivers interact regularly with the
out of 10–the lowest number provided by any of health care team, providing and receiving
our caregiver types during bereavement inter- information from health care providers, deliv-
views. She described bringing a specific complaint ering daily care, and influencing treatment
and question to the team, depicting the team decisions.5
‘‘doing things’’ and explaining that she worked to Some family caregivers avoid talking about
‘‘have a say’’ in these actions. This communica- cancer because they feel that they cannot do it
tion suggests that Mrs. Salley interacted with the well and lack self-efficacy to have a family conver-
team as a disempowered person, awaiting deliber- sation about cancer.9 Avoiding the topic of cancer
ations over her anxious concerns. Mrs. Salley is often the caregiver’s attempt to reduce psycho-
used descriptions of her family that revealed their logical distress and prohibit uncomfortable discus-
separateness from her in caregiving and loss (ie, sions with the patient or other family members.24
‘‘they got some answers to questions they were Family caregivers also struggle with the competing
asking’’). needs of open communication and avoidance
within the family, with the communication divide
Discussion. Mrs. Salley’s initial report of two or possible between the patient and family or among
less family members and a consistently low quality family members.9 These complexities can seem
of social life in relation to the family network is impenetrable for nurses and health care teams
consonant with her lack of disclosure about any pursuing the best care and goal planning for
caregiver support provided by other family during oncology patients.
the illness experience. Distinctive to this caregiver During cancer care, several barriers exist that
is the inability to identify as part of a team with prohibit discussions about transitions in care.
family or health care professionals. The Loner For example, nurses must decide which team
 TARGETING COMMUNICATION INTERVENTIONS TO DECREASE CAREGIVER BURDEN 269

member should initiate conversations, when it escapes these stressors. But our work in this
is appropriate to suggest a transition in care, area and the much longer history of Family
whether or not the patient is eligible for transi- Communication Patterns Theory indicates that
tion, and consider treatment options that may families with less strict conformity patterns
prolong aggressive treatments.25 Nurses have and high conversation are more adaptable and
a unique clinical role that makes them the most flexible. Likewise, the Partner caregiver (low
accessible care provider on the care team, privy conformity/high conversation) emerges from
to family conversations and ongoing family families better able to distribute stressors and
communication throughout the care trajectory. process decisions and changes along the cancer
Recognizing the indicators of a specific family trajectory. Future research should address
caregiver type or communication pattern within whether caregiver types vary in terms of resil-
a family enables early identification of at-risk ience, social support needs, use and function of
caregivers in need of multiple interventions. Iden- social support systems, and whether or not
tifying a specific caregiver type should help nurses bereavement is impacted by the role family
and their teams most appropriately target inter- that caregivers play within their family. Re-
ventions that will support family oncology search findings in these areas could inform clini-
caregivers. cian identification of less adaptable and less
The four caregiver types (Manager, Carrier, flexible family units. Additionally, variance
Partner, and Loner) explicated here should be among caregiver types should be explored for
further studied to assess impact on nursing and the quality and quantity of patient discussion
team goal planning as well as caregiver burden. about end-of-life wishes. Finally, mediating vari-
As these cases reveal, every caregiver type faces ables such as family size and family-of-origin
some of the most taxing stressors of life during communication patterns should be considered
cancer care for a loved one. No type of caregiver in future work.

REFERENCES
1. Tamayo GJ, Broxson A, Munsell M, et al. Caring for the communication at the end of life. J Hospice Palliat Nurs
caregiver. Oncol Nurs Forum 2010;37:E50–57. 2010;12:59-68.
2. Kitrungroter L, Cohen MZ. Quality of life of family care- 11. Koerner AF, Fitzpatrick MA. Family communication
givers of patients with cancer: a literature review. Oncol Nurs patterns theory: a social cognitive approach. In: Braithwaite D,
Forum 2006;33:625-632. Baxter L, eds. Engaging theories in family communication:
3. Ferrell B. From research to practice: quality of life assess- multiple perspectives. Thousand Oaks, CA: Sage; 2006: pp.
ment in medical oncology. J Support Oncol 2008;6: 50-65.
230-231. 12. Harris J, Bowen DJ, Badr H, et al. Family communication
4. Li H, Stewart BJ, Imle MA, et al. Families and hospitalized during the cancer experience. J Health Commun 2009;14
elders: a typology of family care actions. Res Nurs Health (suppl 1):76-84.
2000;23:3-16. 13. Ritchie L, Fitzpatrick MA. Family communication
5. Bevan JL, Pecchioni LL. Understanding the impact of patterns: Measuring interpersonal perceptions of interpersonal
family caregiver cancer literacy on patient health outcomes. relationships. Commun Res 1990;17:523-544.
Patient Educ Counsel 2008;71:356-364. 14. Fitzpatrick MA, Ritchie L. Communication schemata
6. Koutsopoulou S, Papathanassoglou ED, Katapodi MC, within the family: multiple perspectives on family interaction.
et al. A critical review of the evidence for nurses as informa- Human Commun Res 1994;20:275-301.
tion providers to cancer patients. J Clin Nurs 2010;19: 15. McLeod J, Chaffee S. Interpersonal approaches to
749-765. communication research. Am Behav Sci 1973;16:469-499.
7. Brataas HV, Thorsnes SL, Hargie O. Themes and goals in 16. Fitzpatrick MA. Family Communication Patterns
cancer outpatient-cancer nurse consultations. Eur J Cancer Theory: observations on its development and application. J
Care 2010;19:184-191. Family Commun 2004;4:167-179.
8. Hubbard G, Illingworth N, Rowa-Dewar N, et al. Treatment 17. Syren SM, Saveman BI, Benzein EG. Being a family in
decision-making in cancer care: the role of the carer. J Clin Nurs the midst of living and dying. J Palliat Care 2006;22:
2010;19:2023-2031. 26-32.
9. Caughlin JP, Mikucki-Enyart S, Middelton A, et al. Being 18. Kramer BJ, Kavanaugh M, Trentham-Dietz A, et al.
open without talking about it: a rhetorical/normative approach Predictors of family conflict at the end of life: the experience
to understanding topic avoidance in families after a lung cancer of spouses and adult children of persons with lung cancer.
diagnosis. Commun Monographs 2011;78:409-436. Gerontologist 2010;50:215–225.
10. Kirk I, Kirk P, Kuziemsky C, et al. Perspectives of Vancou- 19. Wittenberg-Lyles E, Goldsmith J, Demiris G, et al. The
ver Island Hospice Palliative Care team members on barriers to impact of family communication patterns on hospice family
270 E. WITTENBERG-LYLES ET AL

caregivers: a new typology. J Hosp Palliat Nurs 2012;14: 23. Lubben J, Gironda M. Social support networks. In:
25-33. Osterweil D, Brummel-Smith K, Beck J, eds. Comprehensive
20. Koerner AF, Fitzpatrick MA. Toward a theory of family geriatric assessment. Columbus, OH: McGraw Hill; 2000: pp.
communication. Commun Theory 2002;12:70. 121-137.
21. Glaser B, Strauss A. The discovery of grounded theory: 24. Zhang AY, Siminoff LA. Silence and cancer: why do fami-
strategies for qualitative research. Chicago, IL: Aldine; 1967. lies and patients fail to communicate? Health Commun
22. Courtney K, Demiris G, Oliver DP, et al. Conversion of 2003;15:415-429.
the Caregiver Quality of Life Index to an interview instrument. 25. Hill KK, Hacker ED. Helping patients with cancer prepare
Eur J Cancer Care 2005;14:463-464. for hospice. Clin J Oncol Nurs 2010;14:180-188.