Case Study of Palliative Care for Bowel Cancer

Mrs Cheng has a 2 years history of bowel cancer recently being complicated by liver metastases. Doctors had given her a prognosis of about one month left to live. She is admitted to the medical ward for palliative care.

Social

Mrs Cheng is the sole survivor of the Boxing Day Tsunami in her family. She has thus no viable support system to speak of.

Ethical

From a palliative care perspective, it may seem appropriate to assist the patient in meeting her special needs during the final days of her life.

Legal

The hospital prohibits smoking by law. Thus Mrs Cheng is allowed smoking only at a garden outside of the hospital.

2. Get the facts

Pathophysiology

Bowel cancer is presented with a growth of a malignant tumor in the colon or rectum (Realtime Health, 2010). It is currently the third most commonly diagnosed cancer in Australia (Cancer Council Australia, 2010).

The final stage of the bowel cancer often denotes that the cancer has spread to other organs, for example the liver. Currently, there is no known effective treatment available for stage 4 bowel cancer (Cancer Council Australia, 2010).

In Mrs Cheng’s case, her bowel cancer has been further complicated by liver metastases. This is unfortunate but typical in patients with end-stage bowel cancer.

Palliative care

As defined by World Health Organization (WHO) (2010), Palliative care is an approach that improves the quality of life of terminally-ill patients and their families by recognizing the needs of a terminally-ill patient, and focusing on making them comfortable (Palliative Care Victoria, 2007).

It is important for nurses to understand that patient care must continue until the end of life and that everything within the means of the healthcare team be done to ensure that the patient’s death will be peaceful and dignified (Cancer.Net, 2010).

Palliative Care Australia recognizes the importance of palliative care, and affirms that it should be considered a core competency for all health care professionals (Palliative Care Australia, 2008).

Patient’s understanding

It is important to ascertain Mrs Cheng’s level of understanding towards the ‘no-smoking policy’, the manpower situation and unhappiness of the staff. Without proper clarification, being a patient, Mrs Cheng may be ignorant of the issues which had arisen. It is thus the responsibility of the team to ensure that she fully understands the inconveniences imposed.

Patient advocacy

Patient advocacy, as stated in the Australian Nursing and Midwifery Council (ANMC) Code of Ethics for Nurses in Australia, is the obligation of the nurses to question nursing care which they may regard as potentially unethical or illegal (ANMC, 2008).

Ironically, due to the presence of manpower shortage, nurses advocating in the interest of Mrs Cheng may experience an ethical dilemma as they may find difficulty distributing equal amount of attention and nursing care to the rest of the patients. Likewise, the opposite would be true if advocacy is to be in the interest of the other patients.

Patient’s support

Being the sole survivor of the Boxing Day tsunami in her family, Mrs Cheng has inordinately poor social support. It is not known if Mrs Cheng has any extended family members.

The presence of a kin is most favorable in palliative care. A family member may be able to render a higher level of emotional support to Mrs Cheng, and also provide her some positive and healthy distraction away from her smoking habit.

Thus, the aid of social workers should be enlisted in tracing possible extended family members of Mrs Cheng.

Staff disagreement

Some of the staff had demonstrated dissatisfaction by threatening resignation. To mitigate the matter, the nursing unit manager needs to interview the affected staff, to gain a clearer understanding of the problem and any other precipitating factors that might have led the staff to the point of threatening resignation.

Manpower

As Mrs Cheng smokes about 25 cigarettes daily, and each smoking trip would take up 12 minutes of the accompanying staff’s working time. As such, approximately 300 minutes of manpower would be taken up daily, to see to this particular need of Mrs Cheng.

Staffing is a factor which often inhibits the quality of care, and limits the time available for nursing care delivery to each patient (Irurita, 1999). The issue of both the manpower wastage and shortage needs to be address.

Disruption of care

Mrs Cheng’s smoking habit requires extended periods of attention from the healthcare professionals. It is thus inevitable that attention is being deprived from the rest of the patients in the ward. This needs to be looked into, as negligence may result from such disruption of care.

Passive smoking

By accompanying Mrs Cheng to the garden for cigarette smoking, it is inevitable for the accompanying nurse to be exposed to harmful passive smoking. As Mrs Cheng smokes heavily, the exposure of the nursing staff to the harmful fumes, are relatively immerse. Thus, measures should be taken to safeguard the well-being of the staff.

3. Consider the four principles

Autonomy

Autonomy is referred to as the exercise of one’s free will, which should be deemed as acceptable, as long as it does not affect the rights of others adversely (Staunton & Chiarella, 2008, p. 31). Being mentally competent, Mrs Cheng should possess the free will to smoke cigarettes for as much as she wishes.

Beneficence

Beneficence is often described as the principle of ‘above all, do good’ (Staunton & Chiarella, 2008, p. 32). It affirms that the healthcare professional should always act, with the best interest of the patient in mind (Dominick, 1999). Thus, advocating Mrs Cheng to quit smoking may be an act of ‘beneficence’, as smoking is an unhealthy habit and induces undesirable health outcomes.

Non-maleficence

Non-maleficence is the principle of ‘above all, do no harm’ (Staunton & Chiarella, 2008, p. 32). Thus from the ‘non-maleficence’ perspective, one should not forbid Mrs Cheng from indulging in cigarette smoking as it may affect her negatively, with regards to her emotional health and stability.

Justice

Justice refers to the obligation of the healthcare professionals to treat all patients with equality and fairness (eNotes.com, 2006). An example of justice, particularly in countries where racism is evident in many aspects of life, is when nurses demonstrate equal and unbiased care and treatment towards all patients, regardless of age, sex, and ethnicity.

Value statement 3 of the Australian Nursing and Midwifery Council (ANMC) Code of Ethics for Nurses in Australia states that nurses should value and respect the diversity of people (ANMC, 2008). While conduct statement 4 of the ANMC Code of Professional Conduct for Nurses in Australia states to respect the dignity, culture, ethnicity, values and beliefs of people receiving care and treatment (ANMC, 2008).

As a palliative patient in the ward, it is perchance that Mrs Cheng’s special needs are more so taken care of than the rest of the patients in the unit. One could argue that, in spite of Mrs Cheng’s plight, it is equitable that equal attention and care should be rendered to all the patients in the unit.

4. Identify ethical conflicts

Beneficence versus Non-maleficence

Beneficence versus Non-maleficence is one of the most apparent ethical dilemmas which are pertinent to Mrs Cheng’s smoking habit. Beneficence, here, may refer to protecting Mrs Cheng from the ill effects of smoking by advocating her to lead a smoke-free life; while non-maleficence, may refer to respecting Mrs Cheng’s wishes by approving her requests to smoke.

The healthcare team needs to weigh the benefits and losses of adopting either principle. Being a medical ward, it is dubious if all the nurses on the unit understand the crux of palliative nursing. It is therefore of eminent importance that the entire team gain a better understanding of palliative care. As such, a higher level of empathy and a more humanitarian approach may be invoked in the nurses caring for Mrs Cheng.

In spite of being one of the most preventable causes of ill health and death (HealthInsite, 2010), it is somewhat irrelevant to discuss about the issues of health awareness with a dying patient. It is also uncompassionate to have a terminally-ill patient cut down on or to quit smoking during the final days of her life, as withdrawal symptoms may result from abstinence from smoking, causing more discomfort to Mrs Cheng, and in turn, further compromises her quality of life.

Autonomy versus Beneficence

Despite being a terminally-ill patient, Mrs Cheng is mentally able and competent. Thus her autonomy as an individual should be respected. Mrs Cheng indulges in, and draws enjoyment from smoking cigarettes. An ethical conflict arises when Mrs Cheng’s autonomy disharmonizes with the healthcare professional’s principle of beneficence.

An effort to preserve Mrs Cheng’s autonomy would mean assisting her in meeting her needs of getting her cigarette smokes; while on the contrary, one with the principle of beneficence in mind would discredit such an act.

The writer feels that the principle of beneficence should not overwrite that of the patient’s autonomy. Value statement 2 of the Singapore Nursing Board code of ethics and professional conduct, states to respect and promote the patient’s autonomy and rights for self-determination (SNB, 2006). Thus restricting Mrs Cheng from smoking should be deemed as unethical and unprofessional.

Nevertheless, any concerned nurse may educate Mrs Cheng on the adverse effects of smoking and advice her on the option of Nicotine Replacement Therapy (NRT), by doing so ensures that she is fully aware of the undesirable health outcomes of smoking and the options available.

However, it is also important to ensure that this is not done in a domineering manner. Clause 2.1 of the Australian Nursing and Midwifery Council (ANMC) national competency standards for the registered nurse, states to ensure that personal values and attitudes are not imposed on others (ANMC, 2006).

Should Mrs Cheng choose to continue smoking, her autonomy should be respected and preserved, for as long as she is mentally competent of making her own decisions.

5. Consider the Law

Smoking is prohibited by law in the hospital. Nonetheless, being mentally able, Mrs Cheng should retain the autonomy of making her own decisions. In this instance, carrying out the act of cigarette smoking, so long she does not do it within the hospital.

It is not said if Mrs Cheng possesses the physical abilities to maneuver herself about in a wheelchair. Nonetheless, should she require any assistance, it is the duty of the nurse to assist her in the aspect of her mobility. Clause 1.2 of the ANMC National Competency Standards for the Registered Nurse states to fulfill the duty of care towards patients (ANMC, 2006). In Mrs Cheng’s case, a duty of care would involve accompanying her to the garden for cigarette smoking.

There is no clear ethical or legal bill that protects the interest of the nurses. However, in Australia, the importance of nurses protecting themselves was discussed in a guideline titled ‘The Responsibilities of Nurses and Midwives in the Event of a Declared National Emergency’.

Owing to the duty of care, it may be the liability of the nurses to escort Mrs Cheng for cigarette smoking. Nevertheless, nurses should not be oblivious to the fact that they are being exposed to passive smoking in the process, and take protective measures, such as donning a face mask to prevent unnecessary and excessive inhalation of harmful fumes (ANMC, 2008).

6. Making the ethical decision

The writer believes that Mrs Cheng should retain her right to smoke cigarettes. As a palliative patient, Mrs Cheng’s needs should not be compromised.

It is perhaps lucid that the nurses in the medical unit feels frustrated over caring for Mrs Cheng. Apart from manpower shortage, they also lack specialized knowledge and hence may find difficulty in empathizing with Mrs Cheng’s needs. Thus, it is perchance that majority of the nurses would be inclined to caring more for the medical patients, for whom they are able to render nursing care more confidently.

The manager should enquire with the palliative unit of the hospital regarding the possibility of transferring Mrs Cheng to a palliative ward, where she may receive more individualized nursing care from trained palliative nurses. By doing so, would concurringly, solve the issue of the manpower shortage, and also the dissatisfaction amongst the affected nurses.

In the event that a transfer is not possible, the manager may explore the possibility of enlisting the help of a palliative volunteer, to tend to this special need of Mrs Cheng. This would alleviate the burden on the healthcare team. There are several palliative volunteer programmes in Australia, one of which is Victoria’s Palliative Care Program (Victorian Government Department of Human Services, 2007).

7. Document the decision

Documentation is essentially an integral element in nursing care, as it serves as an important tool for communication between members of the healthcare team. Nurses need also be aware that the patient’s progress notes could be commanded as legal documents in the event of a legal prosecution, thus it is important that entries are concise and factual (Hansebo, Kihlegren, and Ljunggren, 1999).

Clause 10.2 of the ANMC National Competency Standards for the Registered Nurse states the importance of nurses to documents all forms of communication, nursing interventions and individual/group responses, precisely and as soon as possible (ANMC, 2006).

The manager should assume the responsibility of documenting the complaints of the nurses, so as to better facilitate an analysis of the possible root causes of the problem. Upon arriving at the ethical decision, points agreed upon by the team needs to be clearly recorded, to ensure that everyone on the unit is aware of the decision.

Nurses should educate Mrs Cheng on the harmful effects of smoking, and have it documented in the notes. Mrs Cheng’s requests to proceed to the garden to smoke should also be recorded, likewise for each and every journey made.

It is also important for the nurse to state that Mrs Cheng has been accompanied by a nurse or certified volunteer throughout her journey to the garden; this is particularly true if Mrs Cheng is physically frail and requires assistance with mobility.

8. Evaluation the decision

Clauses 4.1, 7.6, and 8.1 of the ANMC National Competency Standards for the Registered Nurse state the importance of nursing care evaluation.

The manager needs to review and assess staff satisfaction on a regular basis, to minimize any amassment of discord or unhappiness amongst the members of the healthcare team. This would also provide chance for ventilation and early intervention, and in turn prevent issues from escalating to an immitigable state.

Nurses on the ward should review the safety and comfort of Mrs Cheng with the palliative volunteer, if any. While it is advantageous to have a volunteer to see to the needs of Mrs Cheng, her safety and wellbeing must not be compromised.