Uncertain Obligations

For Susan Brownell, there was never a question that she would help care for her two parents and two stepparents when they all became ill with cancer over an eight-year period starting in 1992. Both of Brownell’s parents remarried shortly after divorcing when she was just 4 years old.

"If the ties are strong and there has been a reasonably good adaptation to the new family structure, you're going to find the adult kids taking care of a [stepparent] who may not be their blood relative, but a realtive by virtue of having become that."

More serious disagreements can revolve around who will be charged with making health care decisions for the patient, especially if end-of-life care becomes necessary, and the patient can’t make those decisions.

To prevent these kinds of conflicts from surfacing in the first place, having legal documents, such as an advance directive, in place is key. If there are no documents in place and the patient’s wishes are unclear, experts suggest holding a family meeting to try and come to a mutual decision about who will be responsible for medical and financial decisions, and even to assign duties to various family members to help in the everyday care of the patient.

“The difficulty is that these are emotionally charged situations,” says Davey, “and it’s hard for family members to maintain a sense of objectivity and detachment that lets you have a reasonable, rational conversation about what’s best for the person who actually needs care. If everyone can get those ideas on the table in a nonthreatening, nonjudgmental way, that’s important.”

If that effort fails, it may be necessary to engage the help of a hospital social worker, mental health professional, or clergy member to mediate the conflict.

Coping with the responsibility of caring for an ill stepparent as part of a blended family is largely uncharted territory for society, but experts say it can provide new opportunities to improve nontraditional family ­relationships.

In blended families, Holland says, “if the ties are strong and there has been a reasonably good adaptation to the new family structure, you’re going to find the adult kids taking care of a [stepparent] who may not be their blood relative, but a relative by virtue of having become that.”

Read a blog from editor-at-large Kathy LaTour on how the new family dynamic is changing caregiving at www.curetoday.com/blog/kathylatour/family_dynamic.

“My stepfather raised me,” says Brownell, 61. “I would see my father and stepmother a couple of times a year, so I really didn’t know my dad or stepmother very well.”

Still, when Brownell’s father was diagnosed with colon cancer shortly after her mother died from lung cancer, Brownell didn’t hesitate to make the 130-mile journey from her home in Sparta, Wisconsin, to help care for him. The experience, she says, not only brought her closer to her father but also gave her new insight into her stepmother as well.

“My stepmother was never one to show affection easily, but she changed so much after my father’s illness. She took very good care of him, and I came to admire and respect her for all she did for him, because it was a tough job,” says Brownell.

While Brownell’s commitment to care for her parents and stepparents when they became ill was unwavering, research is showing that a sense of obligation of adult children toward aging and sick parents and stepparents is becoming increasingly rare. And a high divorce rate in the U.S. is often cited as the reason. Although data from the Centers for Disease Control and Prevention’s National Center for Health Statistics put the divorce rate in the U.S. at around 43 percent, some researchers say that figure is actually hovering closer to 50 percent. Plus, statistics show, two-thirds of remarriages end in divorce.

All of these familial shakeups are raising the societal question of what is the responsibility of adult children from these unions who find themselves in the position of having to care for multiple sets of ailing, divorced parents and stepparents? The answer can be as complicated as the situations themselves.

Major factors that come into play include living far away from parents, not being able to get time off from work, and simply not being able to afford the financial costs of providing full-time or part-time care. (Find articles addressing these issues at www.curetoday.com/caregiving.) And recent research is providing some other clues as well.

Experts say the age of the children when parents remarry after a divorce or the death of a spouse plays a role in how willing the grown children are to care for the parents and stepparents when they become ill with cancer and other diseases.

“The same marital transition affects every child in the family differently, and when in that child’s life it occurs can greatly affect whether it’s a positive or negative event,” says Adam Davey, PhD, director of the doctoral program in health ecology at Temple University in Philadelphia, and lead author of a recent study, published in the journal Advances in Life Course Research, that looked at parental marital transitions and assistance between generations. The longer a child has had a relationship with a stepparent, says Davey, the more that person becomes a “naturalized” parent to that child. But even that scenario doesn’t guarantee that stepchildren will want to provide care for their ailing stepparent when the time comes.

“We also found that stepchildren were only half as likely as biological children to provide assistance to parents. There are a lot of situations we come across where there just aren’t very clear norms or social expectations about what someone ought to do. Stepchildren and stepparent relationships [are] one big area,” says Davey.

However, being the biological child of an aging and ailing parent is no guarantee that he or she will automatically feel obliged to care for that parent, says Lawrence Ganong, PhD, co-chair and professor in the department of human development and family studies at the University of Missouri in Columbia.

“One of the least ambiguous situations is when a divorced [biological] parent, who walked off into the sunset when the child was young, reappears at some point later and says, ‘I need some help,’ ” says Ganong, who has conducted research on the obligations to stepparents acquired later in life. “That’s really not an issue for [adult children]. They don’t feel as much guilt about saying ‘no’ because the closeness is not there; there’s no sense of ‘I have to pay this person back.’ ”

Despite the potential emotional landmines some caregivers face, as Susan Brownell found, one of the often overlooked benefits of caregiving is the opportunity to forge better relationships with estranged loved ones. “Caregiving is not just all a burden,” says Jimmie C. Holland, MD, the chair of psychiatric oncology at Memorial Sloan-Kettering Cancer Center in New York City. “When you’re dealing with someone who’s ill, there’s a chance for closeness that you might not have had if the person had stayed healthy.”

There’s also the added benefit of being able to create a caregiver team by enlisting the aid of step- and half-siblings and other extended family members who can provide some relief and a bigger financial and emotional resource pool for the primary caregiver.

But caregiving can also create conflict among blended family members. When a serious illness like cancer strikes, “the real issue is how well a family has blended,” says Holland. “For example, how well a new spouse interacts with the adult stepchildren can be a very contentious issue because the adult children may harbor fears that the new spouse is going to take all the money, or that their mom or dad is going to give away the house to the newcomer. So there is a lot of possibility for conflict.”