The Nature of Ethical Conflicts and the Meaning of Moral Community in Oncology Practice

Abstract

Practice environments as moral communities could foster comfortable dialogue about moral differences and prevent or mitigate ethical conflicts and the moral distress that frequently follows.

Ethical Issues Experienced by Hospice and Palliative Nurses

“…1,2,5,[8][9][10][11][12] Leuter and colleagues 11 found that most nurses experienced recurrent ethical problems and did not feel effectively supported by the health care system. These include futile or nonbeneficial care, pain management, patient autonomy (lack of decisional capacity, patient confidentiality or privacy), advance care planning (disregard of patients' wishes), communication difficulties, conflicts between patients/families and health providers, and conflicts between nurses and colleagues.…”

“…Approximately 60% of ethical dilemmas were associated with truth telling. 1,5,9,11,12,16 Futile treatments may lead to increased pain, loss of dignity, and patient's decreased quality of life. Barriers to truth telling included physicians' avoidance of discussing ethical issues, fear of destroying a patient's hope, and patient's lack of decisional capacity.…”

“…The need for nurses to have formal education and training in communication skills when working with patients with progressive diseases or who are at EOL is well supported in the literature. 2,8,9,18 Although most health care providers respect a competent patient's wishes over families' wishes when those wishes are conflicted, 18 when patients lose decisional capacity, two-thirds of health care providers (60%) override the patient's wishes and honor the family's wishes even if the patient's previously expressed wishes are known. 13,14 Nurses, however, rank communication as one of the most important competencies to their clinical practice, and communication has been shown to be a cornerstone to improving a patient's quality of care and quality of life.…”

Ethical and Legal Issues in Palliative Care

“…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.…”