How to Have Ethical Discussions in Your Practice
By Pamela Bowman, BSN, RN, OCN®
Having an outlet to consider, discuss, and reflect on oncology ethical issues that affect our daily practice is important in caring for each other in our profession. On our solid tumor oncology unit, monthly nursing ethics lunch and learns allow our nurses the opportunity to identify and discuss their concerns with recent patient cases involving ethical issues. Our hospital’s ethics committee chair facilitates the hour-long discussions held on the unit, along with a senior oncology nurse with significant training and background in clinical ethics.
What Ethical Discussions Involve
Our primary goal for starting ethical discussions on the unit was to educate nurses on ethics consult processes and advocate for nurses to place consults, which historically had been done by providers. Ethics consults allow for input from an ethics expert when different parties disagree or cannot resolve the dilemmas of the case. Early in our monthly conversations, we learned that our newer oncology nurses needed a way to discuss difficult end-of-life issues. They were often unaware that their troubling thoughts were ethical dilemmas.
Commonly addressed topics include:
- What are advance directives, and why are they important?
- How do I answer questions when a patient wants to complete an advance directive?
- What happens when a patient doesn’t have an advance directive?
- Who are the patient’s decision makers among the family members or visitors?
- What are the patient’s wishes amid what family members want for the patient?
- Why does the patient want to continue treatment when quality of life will be difficult?
- Why doesn’t a young adult patient want to continue to receive treatments?
- Why is the provider offering more treatment options to an older patient?
- What if the nurse disagrees with an aspect of the patient’s case?
- Is the healthcare team treating each patient with fairness?
- How do we decide who receives treatment when some medications are scarce?
An often-discussed topic is when patients express their wish to discontinue treatment to their care nurse, but their family insists on treatment continuation. Patients may not want to disappoint their family members; however, nurses frequently interpret ordering of treatments or tests as unneeded suffering. Are we honoring patient autonomy? Being a patient advocate is difficult in these cases, and our nurses must talk through their own biases. They may need coaching or support by more experienced nurses to communicate patients’ wishes to the providers, or they may need to help family members understand the changes happening with their loved one.
A Case for Advance Directives
We had a younger couple in their early 50s, where the husband had metastatic disease. He had tried several treatments, but it became clear that hospice was the next step because of his rapid decline. The staff wanted to know why he did not keep fighting. The patient told the nurse that he still wanted to be in control of his plan, and he did have an advance directive. The patient and his wife were so calm about the next steps. They had agreed that he would keep making decisions based on how he felt. He said he would tell his wife when he wanted her to take over. She wanted the advanced directive because it told her what he desired, and she would never second-guess her decisions. She said it gave her strength to make decisions when she really wanted to continue pushing to keep him alive. She knew that was not what he wanted.
In our discussions, we talked about their strength and their advanced planning. Some staff were not sure they would be as strong as his wife. As the healthcare power of attorney, are you able to honor the wishes of someone so close to you?
Sometimes the dilemmas have no resolutions or we do not agree with the patient outcomes, but we have an opportunity to sort through the issues. Sometimes the case changes as different nurses who cared for the patient give their perspectives. These perspectives are invaluable to the nurses who first identified the troubling dilemma, because they learned how the case evolved.
These nursing discussions fulfill important ethical aspects of the American Nurses Association Code of Ethics for Nurses (https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/) and ONS’s Statement on the Scope and Standards of Oncology Nursing Practice (https://www.ons.org/store/books/statement-scope-and-standards-oncology-nursing-practice-generalist-and-advanced-practice). They are one of our unit’s most popular healthy work environment offerings, and nursing staff are eager to attend and provide cases for discussion each month. Both novice and experienced oncology nurses have learned important ethical principles such as autonomy, justice, and fairness.