Nurses' Responses to Ethical Challenges in Oncology Practice: An Ethnographic Study

Abstract

Oncology nurses encounter increasingly complex ethical challenges in clinical practice. This ethnographic study explored 30 oncology nurses' descriptions of ethical situations and 12 key informants' perspectives on factors that influence the development of ethically difficult situations. Nurses described the goals of preventing patient suffering and injury, being honest with patients, and contributing meaningfully to patient improvement and stated goals. Nurses experienced six primary challenges in meeting their goals: being the eyes and arms of patient suffering, experiencing the precariousness of competing obligations, navigating the intricacies of hope and honesty, managing the urgency caused by waiting, straining to find time, and weighing risks of speaking up in hierarchal structures. Nurse actions included addressing concerns, creating other avenues, murmuring to one another, staying silent, and looking away. Several factors influenced nurses' responses to ethical challenges. Results imply a contextual model of moral action that reveals a need for altering practice environments in addition to improving nurses' ethics skills. Nurses are very aware of their moral responsibilities in ethically difficult situations and need work environments conducive to interprofessional collaboration and open dialogue.

Ethical and Legal Issues in Palliative Care

“…Nurses reported challenges such as ''administering treatments that cause suffering, being honest without removing hope, and considering the risks of speaking up.'' 10 In addition, they described nine types of ethically difficult situations: end-of-life situations with futility as a major concern; end-of-life situations with patient autonomy as a primary issue; fidelity to RN obligations but medical team not listening; end-of-life situation with honesty about prognosis a concern; patient capacity to provide informed consent for clinical trial; pain management when drug-seeking behavior is suspected; adolescent patients with cancer above age 18 years but parents continue to make all decisions; mental health capacity to comply with complex treatments; justice issues with insurance company refusal to cover treatment. 10,11 …”

“…This obligation to the patient comes into play in the following situations: the patient and family disagree on the goals of care; the family and patient disagree on code status; the family attempts to override the patient's advance directives; the family attempts to interfere with symptom management, especially around the use of opioids; the family does not want the patient to know their diagnosis (''don't tell mama''); or the family's voice drowns out that of the patient, who's voice is lost. [9][10][11] The importance of nurses' moral sensitivity and advocacy in recognizing and addressing these issues is clear. 12,13 CASE The patient is a 76-year-old man who was diagnosed at a community hospital with neuroendocrine cancer with metastases to the liver.…”

Passer à l’action : une exploration des actions des infirmières et infirmiers en oncologie exemplaires dans les situations où un sentiment d’impuissance et de futilité est éprouvé par le personnel infirmier dans le cadre du diagnostic, du traitement et de la phase palliative

“…» et ils y répondaient presque tout le temps par l'affirmative (Boyle, 2000, p. 916). Des sentiments de regret apparaissaient souvent (Pavlish et al, 2011;Beng et al, 2013;Pavlish et al, 2012). Dans la recherche d'actions de rechange et de meilleurs résultats pour les patients, les infirmières et infirmiers voient leur force et leur courage rudement mis à l'épreuve (Kerfoot, 2012).…”

Barriers to Innovation

“…Providing aggressive therapies may be indicated in some cases; however, health care providers need to question whether this practice has become routine in our current health care system without adequate attention to the ethical dimensions of treatment decisions. 10,24 Avoiding or delaying difficult conversations about prognosis and treatment increases the probability of aggressive and sometimes unwanted treatment for patients with serious and life-limiting conditions. 20 This suggests that health care providers need to have honest conversations with patients and their families about prognosis and treatment options including palliative care.…”