“Ethical issues and dilemmas are inherent in our practice, especially at the end of life. Fortunately, we have professional codes and standards that serve to assist,” stated Joyce Neumann, PhD, APRN, AOCN, BMTCN, FAAN, Program Director, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, who spoke at the virtual Scripps MD Anderson Cancer Center’s 2020 Cancer Care Symposium.
“Nurses, individually and collectively, are responsible to serve as advocates for the resolution of ethical issues,” she said.
Dr Neumann pointed out that the COVID-19 pandemic has sharpened the focus on ethical issues in caring for patients with cancer.
The American Nursing Association Code of Ethics has 9 provisions meant to guide practice and help in ethical decision-making (www.nursingworld.org). Dr Neumann said the following 3 provisions are particularly important in the era of COVID-19:
- Provision 2. Primary commitment is to the patient, whether individual, family, group, community, or population.
- Provision 5. The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.
- Provision 8. Collaborate with other professionals and the public to protect human rights, promote health diplomacy, reduce health disparities.
Dr Neumann went on to say that there are 4 topics that need to be considered in ethical decision-making in oncology practice: medical indications, patient preferences, quality of life, and contextual features.
“We want to make sure we cover these bases to help make the best decision for each patient,” she said.
Nurses must incorporate ethics into dealing with patients on a daily basis, including, but not limited to, patient-caregiver/provider disagreements on plans of care. There are situations in which extending treatment is unlikely to improve quality or quantity of life, and the patient and his or her family members need to agree. However, a patient may come from a culture in which the patient is not the primary decision maker.
“For example, if it becomes clear that we need to withdraw life-sustaining treatment for an [intensive care unit] patient, the family may disagree. Some of our biggest dilemmas occur in the [intensive care unit],” Dr Neumann explained.
Challenges in the COVID-19 Era
Advance care planning has always been an important but difficult conversation to have with patients and families, and the COVID-19 pandemic has made this even more pressing.
“Goal-concordant care has been heightened during this period. These discussions should be a high priority and should have been before this. We want to be sure we avoid unwanted treatment or nonbeneficial high-intensity care,” Dr Neumann stated.
Once advance directives are in place, communication is ongoing as the prognosis and course of treatment evolve. These discussions must take into consideration the patient’s goals, values, and preferences.
“We need to regularly re-evaluate advance care directives and make sure this is in alignment with the patient’s preference, which may differ from what we feel,” she explained.
The University of Texas MD Anderson Cancer Center has developed a model for conversations about goals of care during COVID-19 for all patients admitted to the hospital.
“If the patient deteriorates and the goals of care need to change, we have co-managed goals of care discussions. We may request palliative care and a social worker, and we document this,” Dr Neumann said.
“We have a rapid response team for tough situations that incorporates ethics, social work, palliative care, and the primary oncologist as part of a contingency mode,” she said. “Fortunately, we have not been in a crisis mode as other centers have been.”
Dr Neumann also explained that documentation should include a living will, medical power of attorney, and out-of-hospital do not resuscitate orders. Additional documents that may be useful for patients include Five Wishes, Respecting Choices, Physician’s Orders for Life-Sustaining Choices, and Prepare for Your Care, a 10-page document that helps patients with details of medical care if desired.