I am excited about the year 2022 and committed to looking forward to a bright future with endless possibilities. But I must make one exception and look back for a moment as I reflect on a wonderful time with family this past holiday season. Our family has a 30-year tradition of “meeting up” for the holiday season and it has been restricted to “family only”. This year’s gathering had a lively discussion on “who determines family?” This question inspired further discussions around family losses during the COVID-19 pandemic years and the resulting “family realignments”.

Melanie Prince

As I connected with friends and peers during this time, I asked the question about the definition of family and “who should decide”. These discussions were fascinating and provocative. One of my friends is estranged from her only living relative and relies on an adult companion to help with activities of daily living, finances and social interactions. Their platonic, committed relationship is more akin to family than her living relative. She shared the challenges she has had with navigating “family-only access” during times of illness or medical procedures because of institutional definitions of family in the context of COVID restrictions.

Another friend is raising two children whose parents died of COVID-19. He is working toward legal guardianship but has faced hurdles due to court backlogs, state-required investigations, and other family dynamics. In the meantime, the children are not entitled to “family benefits” or have access to “family-only attendance” for school events. These are only two examples of several discussions around “who decides who is family”.

I am intrigued by the implications for social support systems in the context of health care. One would think that the patient/client determines who is their social support system. This system may be family, friends, clergy, social groups (i.e., Fraternity or Sorority) or anyone who provides support to that individual. However, the limitations and restrictions of the past two years for safety and infection control reasons evoked “formal” definitions of family that may have not always been consistent with how the individual patient/client perceived “family”. This phenomenon seemed to vary as I collected anecdotes from friends and colleagues in various regions of the U.S. Thus, I sought a national/federal definition of family as a possible answer to “who determines family”.

The Code of Federal Regulations (CFR), Title 5 amended December 23, 2021, defined family for the primary purpose of establishing family leave/absences rules for employers/employees. The verbatim definition reads as follows:

Family member  means an individual with any of the following relationships to the employee:

(1) Spouse, and parents thereof; (2) Sons and daughters, and spouses thereof; (3) Parents, and spouses thereof; (4) Brothers and sisters, and spouses thereof; (5) Grandparents and grandchildren, and spouses thereof; (6) Domestic partner and parents thereof, including domestic partners of any individual in paragraphs (2) through (5) of this definition; and (7) Any individual related by blood or affinity whose close association with the employee is the equivalent of a family relationship.

The seventh descriptor was germane to the “who determines family” discussion, but I wondered how the decision was ultimately made. The CFR further noted that the scope of “immediate family” was not defined, however there is exclusionary wording. The verbatim paragraph is as follows:

780.308 Definition of immediate family. The Act does not define the scope of “immediate family.” Whether an individual other than a parent, spouse or child will be considered as a member of the employer's immediate family, for purposes of sections 3(e)(1) and 13(a)(6)(b), does not depend on the fact that he is related by blood or marriage. Other than a parent, spouse or child, only the following persons will be considered to qualify as part of the employer's immediate family: Step-children, foster children, step-parents and foster parents. Other relatives, even when living permanently in the same household as the employer, will not be considered to be part of the “immediate family.” https://www.ecfr.gov/current/title-5/chapter-I/subchapter-B/part-630

The CFR definition of family has a specific purpose, but I wanted to explore the meaning of a family from other sources. Literature in the social sciences defined the word “family” as Traditional Nuclear Families, Blended Families, Extended Families, Single Parent Families, Same-sex Parent Families, Childless Families, Census Family, Employment Leave Family & the Family you choose.

As I reflected on this admittedly unscientific collection of information gleaned from peer discussions and compared it to the information from an abbreviated literature review, I realized that there is no right or wrong way to answer the question of “who decides what is normally considered family”.  Families are unique, unrestricted to rules of tradition and rooted in love and support. Maybe, the definition of family should be based on how individuals commit to each other through shared goals, values and interdependency.

Why is this entire ponderance around family relevant? These past two years of living within the impact and constraints of a global pandemic, has resulted in families that evolved from circumstances. Looking forward, will society, and more specifically, the U.S. healthcare system adapt to new perspectives around the definition of family? Of course, there must be boundaries for legal, employer and benefit entitlement reasons; but can patients/clients enjoy the benefit of defining that “family member” who provides the kind of support necessary for healing, recovery and well-being? Will institutional “norms” around family definitions be flexible enough to engage support systems that have a different composition? My summary comment to a colleague was: “time for a study on familial definitions and its impact on Social Determinants of Health”.  Any takers?

Interested in digging deeper into SDoH? Check out Issue 5 of CMSA Today: https://www.cmsatoday-digital.com/cmsq/1221_issue_5__2021/MobilePagedArticle.action?articleId=1706136#articleId1706136