From the day you began your career as an oncology nurse, it is quite likely that two main principles were ingrained into every aspect of your training and practice: infection prevention for our very susceptible patient population and using safe handling to reduce the risk of exposure to chemotherapy and other hazardous agents. 

But what happens when following one principle puts the other in jeopardy? Chances are you've cared for a confused or incontinent patient who was then ordered to initiate chemotherapy. At that point the care team is faced with a decision—catheter placement to contain contaminated body fluids but increase the risk for infection, or avoid introducing a urinary catheter but risk contaminating the environment with body fluids contaminated by hazardous drugs. 

This is frequently the case when patients are diagnosed with Central Nervous System Lymphoma. The disease causes confusion, disorientation, and—should the tumors affect the spinal cord—may also result in incontinence. Patients need chemotherapy initiated in order to treat the disease and possibly see improvement in neurological and cognitive function. The literature is scarce regarding evidence to guide nurses and practitioners through managing the conflict of infection prevention and optimizing safe handling practices once chemotherapy is initiated. 

This instance is complicated by the fact that this disease is often treated with high-dose steroids and high-dose methotrexate. Methotrexate will require aggressive hydration and is known to be present in body fluids of those receiving the drug. Even further complicating the case, steroids at a high dose may agitate and confuse a patient with pathologic neurologic and cognitive deficits.

The evidence is clear however, that linens contaminated by body fluids with traces of hazardous drugs should be treated as a potential chemotherapy spill, and health care workers need to use personal protective equipment in handling them. ONS's Safe Handling of Hazardous Agents lists strategies to limit contamination from body fluids and includes using patient weight to monitor intake and output, weighing urinary drainage bags, and encouraging the use of toilets as opposed to bedpans and urinals when feasible. However, these are not always viable options for nurses and patients when weighing risks and benefits and planning the treatment and monitoring plan. 

Given the lack of research in this area, what’s important to keep in mind in these instances is that each patient and treatment plan should be developed on a case-by-case basis. No two patients and treatment plans should be considered the same. An interdisciplinary care team collaborating together can weigh risks and benefits of the treatment plan and the best supportive measures for the patient and care team alike. 

Regardless of the course of action taken, safe handling principles and the need for personal protective equipment should be shared with clinical and ancillary staff in order to minimize exposure and environmental contamination. Nurses can certainly advocate for their patients, as well as for their own safety. It's a delicate, but vital, balance, and one that likely will not be encountered too frequently in your practice.