I love being an oncology nurse navigator on most days, but then there are those times when a treatment decision is made for one of my patients that concerns me. This happens seldom I’m happy to report, but when it does, I’m forced to deal with it in one way or another. I believe many oncology nurses will have their own stories of times they experience moral distress because of a decision made for one of their patients that makes them feel uncomfortable.
I remember a case I had a long time ago that I caused me a lot of moral distress. The patient was in her seventies. I’ll call her “Sylvia.” She presented with a new diagnosis of widely metastatic adenocarcinoma of the lung. Sylvia was angry about her diagnosis; she told me she felt that her body had “failed her.” She was filled with regrets, mostly about decisions she had made in the course of her life that had ended relationships with her family. She wanted to get the opportunity to put things right with her family now that she was so ill.
A few days after our conversation, Sylvia had a respiratory arrest in the hospital and was intubated in the ICU for a few days. She had no friends or family to sit by her bed. Essentially, we nurses were her only advocates.
Her ICU team managed to get her off the ventilator, but she was very weak after that and had no energy to start repairing relationships. The oncologist who saw her in the hospital decided she would benefit from chemotherapy; he was adamant that this was the best course of action, despite hearing reservations from her oncology nurses. We were worried she was too frail to tolerate very toxic chemotherapy.
Chemotherapy was started as ordered by the oncologist, and Sylvia’s condition deteriorated further in a very short time. A week later when Sylvia went into renal failure, the hospitalist and the oncologist decided all treatment should be stopped. Sylvia was placed on comfort care and passed away 24 hours later.
I worried that we — her medical team — had deprived Sylvia of the opportunity to make amends with her family before she passed away. I was sad for the family left behind who would now never know that Sylvia had wanted to say she was sorry. I had difficulty working through these feelings once Sylvia passed away.
So what can we do as nurses when we’re faced with moral distress?
There’s a great article about moral distress in the July 2016 issue of Oncology Nursing Forum magazine. In the article, titled “Coping With Moral Distress in Oncology Practice: Nurse and Physician Strategies,” the authors define moral distress as “an experience of dissonance that may arise when a caregiver has the moral opinion about what is appropriate care in a given context, while, because of internal or external constraints, acting upon it is perceived as difficult or impossible.”
There are a few suggestions on what may help moral distress, put forward by providers who were interviewed for this article:
- Use the situation as a learning opportunity where there is a lecture on why the decision was made by the provider in the first place.
- Organize a debriefing for all providers involved in the care of the patient.
- Have regular coordinated team meetings to discuss treatment decisions for patients.
- Set up “Schwartz Rounds” (which we hold at our facility), which are a great way to discuss feelings we providers may have about a difficult patient case. Obviously not every sad case discussed in Schwartz Rounds causes moral distress, but in those rare cases, the Schwartz Rounds are a great way to work through what a case has meant to you.
I’ll end this column with a quote from Margaret Thatcher: “You may have to fight a battle more than once to win it.” As nurse navigators, we need to pick ourselves up and work through our moral distress when we experience it. This is how we can carry on. There are many opportunities ahead for us to advocate for our patients, and we need to be ready to “get back into the battle” for them!
About the Author
Jenny Marais, RN, BN, OCN, is an oncology nurse navigator for a West Coast health system and author of “Navigating Your Cancer Journey: A Handbook for Cancer Patients and Caregivers by an Oncology Nurse Navigator.” She obtained her associate of nursing degree in South Africa in 1988 at the age of 21. She has years of experience working with cancer patients. She has a bachelor’s of nursing degree through a distance learning program from the University of Dundee in Scotland, and is oncology nurse certified in the United States. She has applied her 27-plus years of nursing experience to the world of oncology nursing, where she shares her insight into the complexity of cancer care in the United States.