Oncology Nurses' Narratives About Ethical Dilemmas and Prognosis-Related Communication in Advanced Cancer Patients

Susan M. McLennon, PhD, RN: Margaret Uhrich, BSN, RN, Sue Lasiter, PhD, RN: Amy R. Chamness, BA, Paul R. Helft, MD

Disclosures

Cancer Nurs. 2013;36(2):114-121. 

In This Article

Abstract and Introduction

Abstract

Background: Oncology nurses routinely encounter ethical dilemmas when caring for advanced cancer patients, particularly concerning prognosis-related communications. Nurses experience uncertainty and barriers to providing quality end-of-life care; thus, more information is needed about recognizing and managing these dilemmas and to clarify their role in these situations.

Objective: The purposes of this study were to (1) describe the frequency and types of ethical dilemmas experienced by oncology nurses caring for advanced cancer patients and (2) to summarize their written comments about prognosis-related communications.

Methods: This was a content analysis of narrative comments provided by 137 oncology nurses who completed a mailed national survey of members of the Oncology Nursing Society.

Results: The most frequently reported ethical dilemmas encompassed uncertainties and barriers to truth telling, familial and cultural conflict, and futility. Physician-nurse teams were considered optimal for delivering prognosis-related information. Nurses offered strategies for facilitating these communications. They also expressed the need for more education about how to engage in prognosis-related discussions and for better methods for relaying this information among team members to avoid "working in the dark."

Conclusions: Oncology nurses routinely experience ethical dilemmas, and there is a need for clarification of their role in these circumstances. Healthcare providers would benefit from interdisciplinary education about prognosis-related discussions. Attention to managing familial conflict and understanding cultural variations associated with illness, death, and dying is also needed.

Implications for Practice: Findings reveal new information about ethical dilemmas encountered by nurses and strategies for improving end-of-life communications with advanced cancer patients.

Introduction

Cancer is the second leading cause of death in the United States, with approximately 577 000 people expected to die of cancer in 2012.[1] Because of aging and population growth, the number of new cancer cases is projected to double by the year 2050,[2] underscoring the significant need for expert oncology nurses to provide highquality care for the hundreds of thousands of older adults who die each year of cancer. However, to do so requires a sophisticated skill set to manage complex medical, logistical, emotional, and psychosocial needs surrounding the care of advanced cancer patients. One complexity that has been identified as particularly important––and clearly relevant in the care of advanced cancer patients––is a nurse's ability to recognize and manage the ethical dilemmas that are routinely encountered in this and other healthcare settings.[3,4,5]

Ethics, the rules and principles that guide right behaviors or conduct,[6] are foundational to the field of bioethics, which focuses on ethical issues in healthcare.[7] For nurses, ethical dilemmas may occur when there is tension between a nurse's ability to do what is perceived to be right in a given situation and the views of other healthcare providers.[8] There are a variety of factors that influence a nurse's decisions about courses of action when encountering ethical issues that include power differences,[9] workplace environments,[8] and knowledge of ethical principles.[10] In a study of nurses' descriptions of clinical ethical incidents, Pavlish and colleagues[4] identified the nurses' top 2 areas of patient-care concerns as (1) greater attention to quality of life in the context of pain and suffering (31%) and (2) the promotion of patient autonomy (21%). The authors also revealed that only 42% of the nurses took actions that improved the situation such as advocating on behalf of patients' wishes or improving communication between the healthcare team and patients and families while other nurses continued with routine care. Moreover, many nurses (41%) expressed having regrets about the situations, including not doing enough, failure of the healthcare system, and witnessing patient suffering. The authors concluded that "nursing science on ethicsspecific action has lagged"4(p393) behind advances in modern healthcare.

Ethical dilemmas require nurses to carefully navigate the complexities of the healthcare system to facilitate information delivery and promote effective communication among various team members, patients, and families.[11,12] In a qualitative study of 22 nurses caring for patients with terminal illnesses, Reinke and colleagues[11] identified the various ways that nurses facilitated the delivery of prognostic information in the context of hope. Some actions were initiated independently (eg, determining the meaning of hope, the need for information), whereas others were interdependent (eg, negotiating, coordinating, facilitating, and supporting physicians' communications). A notable challenge associated with the interdependent role was one nurse's concern about how to approach a physician: "I have to go gently into the office and say… 'have you 2 talked about this?' ….But you have to approach the doctor in a way that they're not offended."11(p987) Authors concluded that there is a need for more interdisciplinary communication education. Similarly, others have recommended attention to communication skills education because nurses have identified difficulties with discussing prognosis-related information.[12] These include patients' reluctance or inability to accept prognostic information, beliefs about physician reluctance to discuss prognostic-related topics, nurses' discomfort with the current process, and the desire to maintain hope.

Although the need for education in interdisciplinary communication has been identified, there is also a need for nurses to recognize and manage the various clinical ethical dilemmas that are commonly encountered in healthcare settings.[4,5] The scant research in oncology settings suggests that overly aggressive care, truth telling, patient suffering, family members' role in decision making, maintaining hope, autonomy, and patients rights have been acknowledged by oncology nurses.[12,13,14] In a national survey study of 375 oncology nurses,[13] end-of-life conflicts related to the attitudes and behaviors of families, particularly angry families and those who did not accept negative prognostic information, were identified as the most difficult for the nurses.

In our previously published study,[14] we sought to assess nurses' attitudes, experiences, and views about the quality of prognosis-related communication with advanced cancer patients and their families through a mail survey of Oncology Nursing Society members. We found that a majority of the nurses (96%) thought they had a responsibility to help patients prepare for the end of their lives. They also cited barriers related to physicians who were uncomfortable giving bad news (72%), thought that physicians were primarily responsible for initiating the discussions (85%), felt pressured not to give conflicting information (55%), and felt uncertain about their own role in end-of-life discussions and in providing prognosis-related information (43%). There were also concerns about taking away hope (67%), cultural barriers (43%), and the need for more education in this area (93%). Survey respondents were invited to provide written comments or a story to illustrate their experiences with ethical dilemmas and prognosis-related communication in the survey. Here we present an analysis of the narrative descriptions of their experiences with ethical dilemmas and related comments. The purposes of this content analysis were (1) to more fully describe the frequency and types of ethical dilemmas the nurses experienced and (2) to summarize the written comments about prognosis-related communications that the nurses provided in the original study.

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