“Ethical issues and dilemmas are inherent in the care we provide to our patients and their families across the life span,” Joyce Neumann, PhD, APRN, AOCN®, BMTCN®, FAAN, from the University of Texas MD Anderson Cancer Center in Houston, said during a session on April 22, 2021, for the 46th Annual ONS Congress™. “We have a responsibility to speak up and speak out individually, through our professional organizations like ONS and the American Nurses Association (ANA), and internationally, when possible, to advocate to resolve ethical issues.”

Moral and Ethical Issues Have Never Been More Complex

Ethical dilemmas occur throughout all phases of cancer, from the time of diagnosis through survivorship or end of life. The ANA Code of Ethics’ nine provisions are intended to guide nursing practice, but Neumann said that they can sometimes seem in conflict, particularly in the new situations presented by the pandemic.

For example, protecting a patient from potential exposure to the virus may supersede the need to receive treatments, or vice versa. Although keeping visitors limited to prevent spread of the virus is a moral responsibility, it may increase stress for loved ones and professional caregivers.  

“Nurses, individually and collectively, are responsible to serve as advocates for the resolution of ethical issues,” Neumann said. “Nurses have never practiced in a time when there have been so many complex ethical issues. We need to be willing to bring issues forward in thoughtful and meaningful ways that speak for us as people, our profession, and our patients.”

It Begins With Education

Patients need to understand at the beginning of treatment the kinds of issues they may face throughout their journey. Oncology nurses should educate them about advance care planning, the difference between standard of care and research protocol, and informed consent.  

But nurses aren’t expected to know how to do that without training. Resources are available to help nurses become more comfortable having those conversations with patients and families, including ELNEC courses or the Institute for Healthcare Improvement’s How to Talk to Your Patient About End-of-Life Care Conversation Ready toolkit.   

Nurses can also use Five Wishes to guide their conversations about advance care planning. It covers:

  • The person who will make decisions for the patient when they can’t
  • The types of medical treatments the patient wants or does not want
  • How comfortable the patient wants to be
  • How the patient wants to be treated
  • What the patient wants their loved ones to know

Additional documents that may be useful for patients and families include Respecting Choices, Physician’s Orders for Life-Sustaining Treatment Choices, and Prepare for Your Care.

Nurses Have Even More Opportunities to Speak Out

Neumann provided advice for identifying and documenting other measures nurses may initiate to address ethical dilemmas and advocate for patients, such as organizing patient care conferences, requesting ethics consultation, volunteering to serve on the ethics committee, initiating ethics rounds or journal club, and working with a mentor. She also shared the consequences of leaving ethical issues unresolved: providing unwanted or nonbeneficial care, decreasing healthcare provider morale, and moral distress.