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Ethically speaking: Advance care planning involves nurse advocacy

Wednesday April 16, 2014
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Ms. Klein is a 64-year-old woman newly diagnosed with advanced ovarian cancer. She asks her nurse Kathy about how her disease is likely to progress and about the possibilities for treatment and care at the end of her life. When Kathy mentions this to Ms. Klein’s oncologist, he replies that it’s too early to have this conversation and it will only depress the patient. “Besides, we can always ask her husband what to do if the patient can’t speak for herself.” Troubled, Kathy asks the charge nurse what to do. She becomes more troubled when the charge nurse shrugs and tells her that this is typical behavior for this oncologist.

What the ANA and the Code of Ethics say:

Kathy is right to be concerned about the oncologist ignoring Ms. Klein’s wish to be an involved participant in her treatment and care. Kathy understands that advocacy is central to her professional role and identity. The ANA Code of Ethics for Nurses, provisions 2 and 3, reads: “The nurse’s primary commitment is to the patient, whether an individual, family, group or community. The nurse promotes, advocates for and strives to protect the health, safety and rights of the patient.” The ANA’s “Nursing’s Social Policy Statement: The Essence of the Profession” identifies advocacy as an essential nursing action: “The aims of nursing actions (also nursing interventions) are to protect, promote and optimize health; to prevent illness and injury; to alleviate suffering; and to advocate for individuals, families, communities and populations. Nursing actions are theoretically defined, evidence-based and require developed intellectual competencies.”

Scenario 1

Kathy checks the ANA resources that describe her advocacy responsibilities and checks with her nurse manager to make sure the hospital will support her advocacy actions. She also reviews hospital policy about advanced care planning and sees that nursing clearly has a role in educating patients about ACP. Moreover the hospital recently rolled out a huge patient-centered care initiative with a strong focus on end-of-life care. Since she isn’t familiar with ACP resources she researches this topic and finds numerous helpful resources. Armed, Kathy tells her charge nurse that she is going to talk with the oncologist about Ms. Klein’s right to know more about her disease and to exercise her autonomy to make her own treatment decisions. Kathy is pleasantly surprised when the oncologist invites Kathy to participate in his next conversation with Ms. Klein and to follow up with her about ACP resources. Kathy’s professional integrity is enhanced.

Scenario 2

Kathy accepts the charge nurse’s dismissal of her concerns and concentrates on taking care of Ms. Klein without revisiting her request for more information about her disease and future treatment options. When Ms. Klein repeats her request Kathy tells her that her oncologist will talk with her when it is time. While Kathy doesn’t feel right with this evasion, she has more than enough to keep her busy. Kathy has failed her patient and accepted a work environment that compromises her ability to be an effective patient advocate. Her charge nurse has failed to provide the leadership that might have made the critical difference in this patient’s care and in enhancing Kathy’s advocacy skills.

To see what else is trending in cancer care, visit www.Nurse.com/Cancer.

Advance care planning resources

ABA Commission on Law and Aging. (2005). “Consumer’s Tool Kit for Health
Care Advance Planning” (2nd edition)

National Healthcare Decisions Day - www.NHDD.org/Public-Resources

Coda Alliance’s Go Wish Cards — This card game helps in planning discussions with family members - www.CodaAlliance.org

National Hospice and Palliative Care Organization: Caring Connections - www.CaringInfo.org

The Centers for Disease Control and Prevention’s Advance Care Planning Selected resources for the public - www.CDC.gov/Aging



Carol Taylor, RN, PhD, professor of nursing, Georgetown University School of Nursing and Health Studies, and senior scholar, Kennedy Institute of Ethics. Post a comment below or email specialty@nurse.com.