ETHICAL, MORAL AND LEGAL ISSUES IN

ONCOLOGY NURSING

INTRODUCTION

• Ethics is the attempt to identify norms or standards of right or good behaviour. The ethical practices that govern modern oncology nursing are non-malfeasance, beneficence, respect each person as a person and respect individual autonomy, treat people as they have a right to be treated and treated people fairly (i.e. principles of distributive justice).

END OF LIFE CARE• INTRODUCTION

Providing excellent care for a dying patient is something all patients deserve. It is important to remember that most patients want to prepare for death, if at all possible. Everyone does this his or her own way, but oftentimes concern about pain and symptom management interferes with this very involved and valuable process.

DEFINITION

• End-of-life (EOL) care is defined as an active, compassionate approach that treats, comforts, and supports persons who are living with, or dying from progressive or chronic life threatening conditions (Ross, 2000).

TODAY'S TRENDS IN END-OF-LIFE CARE

• The need for improvement in communication with patients and family, and the need of more education and support in nursing are important issues in providing EOL care. Nursing practice, education, and research must embrace and respond to these changing demographics, and nurses must focus on spiritual-psychosocial health as well as the physical health of the population (Heller, 2001).

• Undergraduate education provides the foundation for nursing care, including EOL care. Educational programs should focus on addressing the problem of stable misinformation.

• In addition, education should offer didactic information and role modelling to skilfully incorporate EOL care planning into clinical practice.

• Health care providers are much better at saving lives than helping patients know when life is at its end.

• Research results indicate that nurses most often selected discussion of the dying process with patients and their families as the number one core competency about which they would like to have had more education (White, 2001).

• Satisfaction at the end of life has been positively correlated with EOL care, where emphasis is placed on palliation.

• Stable misinformation is another inadequacy identified which can be particularly resilient to educational strategies because people are unaware of their knowledge deficit and therefore do not seek accurate information. Continued efforts should be made to define and improve communication techniques in professional and continuing educational programs.

ETHICAL ISSUES IN END OF LIFE CARE

• Oncology is the stream which deals with care of the cancer clients. As medical knowledge and technology increase, so do options for healthcare. When decisions arise concerning the treatment of dying patients, these options present complex ethical dilemmas. Oncology nursing practitioners should be aware of the present scenario of oncology patients.

• Lack of access to Hospice Care

• Lack of palliative care facilities

• Advance Directives

• Medical power of attorney or durable power of attorney

Withholding and Withdrawing Medical Treatment

• Resuscitation• Mechanical ventilation use• Nutrition and Hydration

Medical Futility

• Medically futile treatments are those that are highly unlikely to benefit a patient. Ethical decisions to forgo or withdraw life-sustaining treatments are accompanied by an assessment that such treatments would be medically futile.

Terminal Sedation

• For some dying patients, profound pain that occur when dying may not be relievable by any means other than terminal sedation. This uses sedatives to make a patient unconscious until death occurs from the underlying illness.

Euthanasia • Euthanasia is an act where a third party,

usually implied to be a physician, terminates the life of a person—either passively or actively. The modern concept of euthanasia is based on the fact that patients alive who are living in a situation that they consider to be worse than death, are in a coma or are in a persistent vegetative state (PVS) can be relieved from their pain and misery.

Physician Assisted Suicide

• With physician assisted suicide, a doctor provides a patient with a prescription for drugs that a patient could use to end his or her life. The main distinction between physician assisted suicide and active euthanasia is that the doctor is not the person physically administering the drugs.

Communication: Patients and Healthcare Professionals

• Good communication at the end of life is vital to good healthcare. If communication breaks down, mistrust and conflict can arise, resulting in inappropriate or unwanted treatment.

ETHICAL DELEMAS IN END OF LIFE CARE

• Nurse needs look at both the ethical and moral issues; to weigh the burdens and benefits of particular treatments and take into consideration the clients values and preferences

• Extra ordinary versus ordinary• Withholding versus withdrawing

Forgoing life sustaining therapies include withholding and withdrawing

• Foreseen versus intended

It is known as the principle of double effect. Treatments have multiple possible consequences (some good and some bad) may still be justified.

Active versus passive

• It is used to distinguish between actions that are not justified in leading to a client’s death (boluses of potassium) and omissions (sometimes reffered to as “allowing to die”) that are justified.

FOCUS AREAS FOR IMPROVEMENT IDENTIFIED IN END OF LIFE CARE• Spiritual-Psychosocial Health

Areas of spiritual-psychosocial health of dying patients have been identified as weaknesses among nurses in their fundamental education.

• Examination of focus areas identified for improvement in spiritual-psychosocial includes: anxiety, delirium, depression, and communication.

Anxiety

• Anxiety is common in the dying, as patients face their fears and concerns about their impending death. However, anxiety is not a normal, inevitable consequence of dying and should be managed aggressively. Risk factors for anxiety include organic mental disorders, concurrent life events or social difficulties, lack of support and understanding from one's family and friends, and apprehension and worry.

Delirium

• Delirium is a state of decreased cognitive abilities. It usually has a quick onset and is considered to be a potentially reversible process. Changes in patients sleep and wake cycle occur with fluctuating levels of consciousness.

Depression

• Sadness is common in patients with life-threatening disease. It is a myth that feeling helpless, hopeless, and depressed is inevitable. Sadness usually responds to supportive interventions.

Communication

• There is evidence that communication with the dying and their families is less than optimal, and that few nurses receive adequate training in appropriate communication skills. It has been concluded that nurses may neglect their communication with patients who are very ill, tending to rely instead on families to communicate with the dying. (Ross, 2000).

Physical Health

• Healthcare professionals’ inadequate knowledge of physical health including: pain management, symptom control, and other dimensions of terminal-illness care have been cited as a key barrier to good EOL care.

• Pain

• Dyspnoea

• Gastrointestinal Symptoms

• Anorexia/Cachexia

• Asthenia

ROLE OF THE NURSE IN END OF LIFE CARE

• Educate client and family• Refer client to an appropriate resource

for imitating a living will or medical power of attorney

• Ensure that the health care team is aware of the existence and content of the living will or medical power of attorney

• Respect the cultural values of the dying client and family members

• Promote independent decision making through treatment by encouraging clients and family members to communicate openly with the health care team

• Ensure a clear understanding between family members, client and physician regarding DNR orders

• Refer client and family members to resort to spiritual care

END OF LIFE CARE PROVIDERS• Many healthcare professionals can be

involved in providing end of life care, depending on the needs.

• Hospital doctors and nurses, general practitioners, community nurses, hospice staff and counsellors might all be involved, as well as social services, religious ministers, physiotherapists or complementary therapists.

OVERVIEW OF END OF LIFE CARE

• When end of life care begins depends on the client’s needs.

• The General Medical Council considers that patients are approaching the end of life when they are likely to die within the next 12 months. This includes patients who are expected to die within the next few hours or days, and those with advanced incurable conditions.

According to National Cancer Institute end of life care is :

• When a patient's health care team determines that the cancer can no longer be controlled, medical testing and cancer treatment often stop. But the patient's care continues. The care focuses on making the patient comfortable.

• Either way, services are available to help patients and their families with the medical, psychological, and spiritual issues surrounding dying. A hospice often provides such services. The time at the end of life is different for each person.

• Each individual has unique needs for information and support. The patient's and family's questions and concerns about the end of life should be discussed with the health care team as they arise.

GRIEF AND GRIEVING PROCESS

Definition• Grief: Deep mental and emotional

anguish that is the response to the subjective experience of loss of something significant. Or Grief is a multi-faceted response to loss, particularly to the loss of someone or something to which a bond was formed.

Risk factors of grief

• Disease related and treatment related: It includes poor diagnosis of cancer, poor prognosis, uncertain outcome, likelihood of reoccurrence. It arises due to changed body structures and functions

• Situational and social: e.g. loss of the dear one, breach of the relationship

• Developmental: loss of desires, dreams, autonomy etc

Types of Grief Reactions

Anticipatory Grief• Anticipatory grief occurs when a death

is expected, but before it happens. It may be felt by the families of people who are dying and by the person dying. Anticipatory grief helps family members get ready emotionally for the loss.

Normal Grief–Normal or common grief begins

soon after a loss and symptoms go away over time.

• During normal grief, the bereaved person moves toward accepting the loss and is able to continue normal day-to-day life even though it is hard to do.

Complicated Grief

• There is no right or wrong way to grieve, but studies have shown that there are patterns of grief that are different from the most common. This has been called complicated grief.

STAGES OF GRIEF

• New grief stages. These are the three phases of the New Grief Stages:

• SHOCK• SUFFERING• RECOVERY

THE MANAGEMENT OF GRIEF

• Individual or family psychotherapy• Spirtiual counselling• Pharmacological management of symptoms-

anoxiolytics, antidepressant, sedatives• Complementary therapy- homeopathic

therapy• Behavioural and cognitive interventions-

support groupa and relaxion techniques• Occupational and recreational therapy

ISSUES RELATED TO GRIEF AND BEREAVEMENT:

• After a person dies, the family, loved ones, and friends will experience grief and bereavement. For some people, viewing the body helps grieving and acceptance.

• Medical professionals can facilitate this by arranging a private and pleasant environment. Some believe that the medical profession has a duty to acknowledge the surviving family members after a patient’s death and that this obligation has a potential to be rewarding.

• This respect for people’s individuality in grieving and in their decision making reflects the fundamental ethical principle of autonomy.

• Living will and durable power of attorney• Euthanasia• The Price of Life-Sustaining Care

BEREAVEMENT

Definition• Bereavement is the period after a

loss during which grief is experienced and mourning occurs. The time spent in a period of bereavement depends on how attached the person was to the person who died, and how much time was spent anticipating the loss

Difference between grieving and bereavement

– Bereavement is the period of sadness after losing a loved one through death.

– Grief and mourning occur during the period of bereavement. Grief and mourning are closely related. Mourning is the way we show grief in public. The way people mourn is affected by beliefs, religious practices, and cultural customs. People who are grieving are sometimes described as bereaved.

Process of bereavement

• Shock and numbness

• Yearning and searching

• Disorganization and despair

• Reorganization

Theory of bereavement

• Bereavement care is part of a comprehensive palliative / hospice care programme.

• Bereavement is a human experience occurring with the death of a loved

Nursing Diagnosis

Dysfunctional grieving.

Goal:• Family completes the tasks of

bereavement.

Nursing Assessment

• Assess family for risk factors associated with unresolved grief.

• Evaluate family members for manifestations of grief.

• Assess social support available to family

CARE OF NURSES WHO CARE FOR THE DYING• The care of the dying client and his family is

a process in which the nurse provides supportive care to the patient and family. The main goals that affect the care of the dying are:– Relieve the dying person's pain– Keep the patient comfortable– help the patient to a peaceful death

• Care after death

• Comfort the family and let them grieve.

ROLE NURSES PLAY IN IMPROVING THE CARE OF THE DYING• When cure is no longer possible, dying

people primarily need good nursing care. Nurses witness firsthand the plight of patients throughout the dying process and are able to recognize and appreciate their complex needs.

Specifically, nurses can contribute to fundamental reform of systems to provide end-of-life care by: • Developing creative partnerships with

patients, health care professionals, policy makers, and others to make care of the dying a priority.

• Documenting the comprehensive needs of dying patients and families and identifying individual, professional, organizational, and societal barriers to quality end-of-life care.

• Participating as members of interdisciplinary groups within specialty areas, institutions, or communities to devise specific solutions to address barriers and develop standards for quality end-of-life care

• Advocating for systems of accountability for comprehensive and holistic end-of-life care that includes professional guidelines, protocols, and standards to meet the needs of the dying

• Participating in the development of interdisciplinary pre-service and inservice curriculums that provide students and practitioners with the tools and skills necessary to provide optimal end-of-life care.

• Collaborating with patients and potential patients to promote public and professional understanding of the realities that surround end-of-life care.

ASSESSMENT - WHERE AM I (NURSE) ON THE JOURNEY:

• In order to be an effective Care giver to the dying patient and the significant others, nurses must come to terms and their own mortality and views on dying and death. Death is inevitable.

• Nurses are encouraged to maintain composure when caring for patients. However professionalism for the nurses with this context does not require that the nurse deny emotional engagement with the patient and significant are the others during the dying process and bereavement period.

Common responses to grief

• Physical• Psychological• Shortness of breath• Depression• Insomnia• loneliness• Loss of appetite• Anger and hastines• Fear of God

Personal Experiences with death

• Personal Experiences with death and dying influences how nurses give care to those who are dying and their significant others. E.g. examining nurses personal experiences can help nurses understand their own fears and anxieties related to dying and death. Understanding the meaning and significance of relationship helps put the loss in perspective.

• The nurse’s ability to articulate feelings regarding a good or a bad death is important while working with individuals who are dying. Exploring individuals valued and biases can enhance the nurse’s competence; this helps the nurse to better understand the individual’s health care attitudes and behaviour. (Warren 1999)