Betty, age 70, was diagnosed with metastatic colon cancer and started treatment with FOLFOX.
Her medical oncologist changed the treatment to capcitabine after Betty developed grade 3 peripheral neuropathy. Because of disease progression, bevacizumab was added to her treatment plan. She lives with her daughter, is insured by Medicare, and receives $800 per month from Social Security.
Prior to Betty signing a treatment consent form, Myra, RN, uses the teach-back method to confirm Betty’s understanding of the risks, benefits, and side effects associated with bevacizumab and the palliative goal of treatment. At their next encounter, Betty tells Myra that she signed the consent form and then tearfully says, “I wanted to tell my doctor that I didn’t want any more treatment, but my daughter told me if I don’t keep fighting I will have to find another place to live.”
What Would You Do?
Oncology nurses may be asked to document patients’ consent to treatment. Although it is the oncology provider’s legal responsibility to discuss the necessary information patients need to make an informed decision—risks, benefits, and alternatives (including no treatment)—nurses mutually share ethical accountability for determining patients’ understanding of the recommended treatment and ensuring patients’ treatment goals and preferences are honored prior to initiating cancer therapy. The ethical provisions stated in the American Nursing Association’s Code of Ethics for Nurses can empower oncology nurses to promote, advocate for, and protects the rights, health, and safety of patients.
Betty expresses a clear understanding of the benefits and risks involved in the treatment and autonomously signs the consent form. However, her self-determination—free choice without external coercion—appears to be threatened.
Persuasion becomes coercion when verbal threat or forcible action is used to intimidate people into doing something against their will. This case study demonstrates a possible act of coercion on the part of the patient’s daughter, and the patient’s claim must be investigated further.
Myra asks Betty for additional details about her relationship with her daughter and learns that Betty attends all of her medical appointments alone and has not disclosed the seriousness of her diagnosis with anyone, including her daughter. Over the course of the conversation, Betty’s account of what her daughter said changes: “She said we would need to move into a house without stairs if I get sicker.” Betty ultimately decides to postpone the treatment until she and her daughter meet with the oncologist the following week.
Oncology nurses can advocate for patients’ treatment goals and preferences by recognizing situations that question patients’ understanding, autonomy, and self-determination.