Nurses Participate in Ethics Rounds at M. D. Anderson Cancer Center

August 1, 2001

HOUSTON-Cancer patients receiving aggressive treatment often face difficult decisions. Nurses will often help patients and their families through them-but the nurses may need support themselves, says a nurse who co-authored a study looking at nurse utilization of hospital ethics rounds.

HOUSTON—Cancer patients receiving aggressive treatment often face difficult decisions. Nurses will often help patients and their families through them—but the nurses may need support themselves, says a nurse who co-authored a study looking at nurse utilization of hospital ethics rounds.

The study was presented during a poster session of the Oncology Nursing Society’s 26th Annual Congress in San Diego.

Case History: What the Nurses Knew

This case, altered to protect the confidentiality of the patient, was discussed during ethics rounds at the M.D. Anderson Cancer Center BMT Unit. It illustrates the need for nurses in some cases to initiate ethics consults.

A 60-year-old woman with lymphoma who had had an autologous bone marrow transplant 4 months earlier developed a herpes zoster blister and later a fever. She was admitted to the BMT unit with fever and increasing bilirubin.

A biopsy resulted in a percutaneous capsular hemorrhage. The woman was transferred to the ICU for 24 hours. The biopsy report said she had graft-vs-host disease, although in fact she probably had an infectious or chemotherapy-related toxicity. Her bilirubin level had increased to 37 mg/dL.

The patient had asked her doctor what would happen if her liver failed, but had not received a clear answer, and the nurses queried the physicians as to whether the patient and the family understood the bleak prognosis. The patient had no advance directives.

"The nurses knew her bilirubin was rising and that she would not be lucid or able to make decisions at the end," Joyce Neumann, RN, told ONI at the ONS annual congress. "Nurses with years of experience know that with certain complications, the likelihood of a patient being able to recover and go home is slim."

Four days later, after a brief response to steroids and without making any decisions about terminal care, her mental status deteriorated. A debate ensued among family members, but eventually they opted for DNR and comfort care with IV pain medication and oxygen.

Whereas the physician on medical rounds examines the patient and then leaves to go on to the next patient, "the nurse is the person who spends the majority of time at the patient’s bedside," said Joyce Neumann, RN, MS, AOCN, a clinical nurse specialist and bone marrow transplantation (BMT) clinical coordinator, Hematology Center, M.D. Anderson Cancer Center.

Consequently, she said, "nurses often have privileged information that the patient gives them—their fears and concerns—and it’s really up to the nurse to make sure that these concerns are communicated to the health care team."

Ms. Neumann, with Rebecca Pentz, PhD, and Anne Flamm, JD, surveyed nurses at her institution who had taken part in ethics rounds. The program was started 2 years ago in the BMT unit to enhance nurses’ knowledge of ethical principles, provide a forum for discussion, and encourage nurse participation in clinical decision-making.

Nearly all (99%) of the nurses who attended the ethics rounds reported that the experience helped them in their practice; 92% reported that they had a better understanding of ethical principles; 80% said that they had a better understanding of advance directives; and 88% reported feeling better prepared to speak with physicians about ethical issues.

In the survey, the most frequently cited reason nurses gave for not asking for an ethical consult was fear of conflict with the medical team.

When a patient’s condition is deteriorating, a nurse or other practitioner needs to make sure the patient is given an honest opinion of the situation so that he or she can make decisions about end-of-life care. "Do they want to be intubated? Do we need to send them to hospice?" she said. 

After the BMT unit began holding ethical rounds, the lymphoma unit followed, Ms. Neumann said, and there are plans to extend it to the leukemia service as well.

"The hospital wants to support the nurse as an advocate and as a caregiver. It is very emotionally draining for the nurse not only to do the physical care of the patient but also some of the psychosocial care," Ms. Neumann said.