Joyce Neumann discusses ethical challenges nurses face in oncology care and uses case studies as examples of how to apply ethical decision making when faced with complex cases.
Back to Symposium Page » Hi. Welcome back, everyone from your break. I would like to introduce myself. My name is Jen Vaux. I am the system wide oncology nurse educator here at Scripps Health in San Diego, California And I will be your moderator for the last half of this symposium. I have the privilege to introduce our next guest who is going to be talking on ethical considerations. Dr. Joyce Newman received her bachelor's and master's of science and nursing from DePaul University in Chicago and her PhD in nursing research from Texas Woman's University in Houston. She's received two national certifications by the Oncology Nursing Certification Corporation of um Oncology Nursing Society as an advance oncology, certified nursing and blood marrow transplantation Certified nurse. Her major professional experience has been an advanced practice. Registered nurse in a stem cell transplant and graft versus host disease. Clinic manager of 26 nurse practitioners and as program director and stem cell transplantation at M. D. Anderson Cancer Center. She's also had nine years of experience as a nurse educator at all levels of nursing programs and has served as an adjuvant ethicist in the institutional section of integrated ethics for over 10 years. Her professional presentations consists of topics on oncology, nursing, nurse, nursing s ethics, stem cell transplant, nursing and GBH D have been given nationally and internationally in Japan, Saudi Arabia, Brazil, Korea, Singapore and Australia. Research and publications. Focus has been on ethical issues and oncology care, stem cell transplant patients, quality of life and experience treatment for GBH D, moral distress, compassion, fatigue and burnout of stem cell transplant care providers. She has a principal investigator on a protocol with the National Marrow Donor Program, examining the prevalence of work related distress, work, life balance and career satisfaction among nurses, N. P. P. A s pharmacist positions and social workers. She's also received the Ethel Fleming Arsenal Outstanding Nurse Oncologist Award at M. D. Anderson Cancer Center in 2000 and one clinical excellent awards from Oncology Nursing Society in 2000 and 13 and American Society of Blood and Bone Marrow Transplantation in 2000 and 17 and is to be inducted as a fellow in the American Academy of Nursing and fall of this year. Please help me welcome Dr Joyce Newman. Thank you very much. Done. I really appreciate your, uh, very humbling, uh, introduction, and, uh, The induction to the American Academy of Nursing was actually last weekend. So this has been a kind of a world wind experience over the last couple of weeks. So thank you very much for that introduction. It's an honor for me to be able to present this topic for consideration at this wonderful scripts meeting. And if we could go to the next slide, please. Okay, um, these are the objectives that we have for today's presentation. And I would like to just say that we will be reviewing the a n a code of ethics, um, and just a few slides and will be discussing that and what has been under consideration related to Cove it. I was able to listen to Bette Farrell's wonderful lecture yesterday about advance care planning. Can you hear me? Okay, um, and we'll also talk about the ethical challenges nurses face in oncology care. And then finally, we'll discuss the case study and apply some ethical decision making. Next slide, please. So, ethics of nursing practice. We know that ethical issues and dilemmas are inherent within our practice setting, and especially in oncology, and to provide patients and their families across the lifespan, especially at the end of life. And I think Dr Farrell did a wonderful job yesterday of talking about that Professional codes and standards. Servas are assisting to resolve those ethical issues and also direct us in our practice. We need to individually and collectively we're responsible to continue to advocate for our patients and the resolution of ethical issues. Aziz. They present themselves within practice so the next slide will talk about the code of ethics. So the code of ethics was This second version was put out in recently in 2015. The original first ah code of ethics by the American Nurses Association was put out in 2000 and one within the ethics code of ethics. There are nine provisions, and this is just a copy of the interpretive guides of those nine provision. But and really, this is again meant to guide our practice and help us in decision making. I'm gonna particularly focus on provisions to five and eight because I think in our current issues related to our oncology practice and with co vet thes air, these provisions are especially important. But you can see on the slide that provisioned one and our main focus is the practice with compassion, respect for inherent dignity, worth and unique attributes of every person provisions to then focuses us on. Our primary commitment is to the patient, whether it's the individual family, group, community or population, and then you can read the other provisions for yourself. But I want to focus on provisioned five because I think this is where we have may have some issues when we're especially when we're talking about Cove it. So we owe our to ourselves the same duty as to others. And that includes the responsibility to promote health safety, preserve wholeness of character integrity, maintain, um competencies and continue with personal professional growth. So this is telling us on day this has really been more highlighted in this in this more recent version of the code of ethics. But this really highlights for us. The fact that we do need to take care of ourselves so that we can take care of our patients. The next slide will go Thio, discuss the provision six through nine. I want to bring your attention to Provision eight, which really talks about collaborating with other health professionals and the public to protect the human rights, promote health diplomacy and reduce health disparity. And we'll talk a little bit later in a few minutes about the A, an American Academy of Nursing, um, statement that they put out on August 4th about the, uh, issues related to this. But you can see in many times, and when we're caring for patients now in this cove it era where we have to focus on what's safest for the community and not just the individual. So we all know how important it is for families and visitations and all that. But we know that there's been changes related to policy because of the co vet issues. The next slide then talks about the ethical princes, which is kind of the bedrock of our nursing practice and medical practice. And the first one is you all remember from your ethics course in training and also dealing with the daily is that we've beneficence is the ability to benefit or to help a person, and that's not always clear. There may be uncertainty in terms of what medical care is most likely to benefit, especially in co vet and in many of our trials for patients, uh, related Thio Oncology care. We're we're doing randomized controlled trials because we're not sure and phase one trials because we're not sure what will likely benefit the patient. So we brings us to the second principle, which is non malfeasance, which is to promote or prevent or avoid harm. First, do no harm with the vaccination testing that's going on now with co vet This, uh, Speed and the rigors of our experiments and and finding the best vaccinate the vaccines is sometimes in conflict. Justice is the professional. Have a duty with to get to act with fairness, giving every individual there do. Professionals have may have to decide who is likely to benefit if not every person can be given. So if we get into a crisis situation, um, we may have to make some tough decisions. Personal autonomy that is again very much at the forefront of our Western culture in the U. S. Asst. Faras the individual has capacity or a surrogate has the right to decide for or against treatment professionals need. Thio may need to decide who is likely to benefit if every person cannot be given the same again in a crisis mode. When we're talking about ventilators, I see you beds, etcetera, and then the sanctity of life that human life is held in high regard and respect and saving lives at all. Costs may not be possible in certain situations, and then benefit and burden. We wanna Onley provide medical treatment that provides more benefit than burden in its ethically mandated. So again uncertainty We're not. We may not be sure what is the best treatment and who would benefit the most. The next lie talks about some additional moral considerations that we have in our society, so the norm ing of family lives. We know how important family relationships are in the moral responsibility. When we visit limit visitors and the current crisis pandemic, we know there's increased stress for loved ones and professional caregivers. Likewise, there's relation the relationship between clinicians and patients. We have a fiduciary responsibility to holistically care for the patient, and there's a mutual trust. We know that that trust maybe, um, you know, interrupted because of that face to face limit we have in certain cases were doing telemedicine. There may be some PPE limitations in terms of contacting patients and affecting report with our patients Professional integrity of conditions. We have no responsibility to offer treatment that is not medically indicated and care of givers. Maybe exhausted, uh, and increase moral distress when we're providing care That may not change the course, or it's unlikely to change the course. We're also curing for the most vulnerable populations. Having a cancer diagnosis is a very vulnerable situation, as you all know and then doing. Being good stewards of our resource is systems with limited resources and allocation priorities, figuring out the most appropriate and what costs and making those decisions if we're in a search situation, like many places have been around the country and with related to I C. U and ventilator use, and then the cultural religious Variations. And Dr Farrell mentioned that also yesterday, where we have patients from different cultural beliefs and norms that may create disparity and the values and principles that we may hold, you know, sacred. But the patient may be from a different cultural background. So my next my first polling question, and I think we'll get to those get to your answers at the end of our end of this presentation. But the first polling question is you Have you ever called in ethics, Consul? And so I gave you some choices. No, I have not experienced any ethical issues. No, I'm not sure how to do that. No, but I know how to call for one if needed. And yes, and it helped in resolving this situation or issue and yes, but it did not help the situation. So if you would answer that polling question and again will discuss these at the end of the presentation. So this is, um if you've been on a consultation service or you do ethics Consul Tieu know that this method of looking at ethical decision making is one that's been well versed in the literature and this Johnson and Johnson and three other authors have. This is taken from the clinical journal practical approach to clinical ethical decisions in clinical medicine. This was from 2010 addition. But when we look at ethical decision making, we want to make sure that we get information that will help us make the best decision with patients. And we need to look at and consider these four areas. And the first is the medical indications. So When we do start a concert, we may start talking about the medical situation at hand, and that may be done with a physician. We may ask the patient, What is your understanding of the medical Indian medical condition or your medical condition? We want to make sure we address patient preferences. And again, what? What are the patient's wishes? What do they want in this situation? We don't want to, you know, start the conversation by asking the patient, What do you want us to do? You want? I see you or intubation? That really doesn't bode well in terms of doing a shared decision model. So we want to take into consideration the patient preferences. But we won't don't want it to be a case where we're asking the patient to make that decision, because we we want to make that decision together. Quality of life is another area. What what is the patients? How does the patient divine their quality of life? What's important to them? What are some other values and beliefs that help help us define or help them to find their what their quality of life is? And then we also may have contextual features social, legal, economic, institutional circumstances, stances which all may help to contribute to this decision. So when we do an ethics consul to or we have a care conference where we discuss the ethical issues as well as the others, we wanna make sure that we cover all these bases and talk about these issues with our patients so that we're making the best decision for them. The next Live done talks about translating principles to practice a nurse's face, as we said, ethical scenarios on a daily basis, including, but not limited thio. Things like patient and caregiver provider. Disagreement on the Plan of care. What are the goals of care? What is the plan of care and so patients that we've been in situations where patients are requested research tri ALS. But they don't meet the eligibility criteria. So we need to decide whether we're going to do, um, you know, admit them on that trial or not, which is why an F and research ethics we need toe. Make sure the eligibility criteria set there may be differences between the caregivers and a patient, or providers and caregivers, and then the extent treatment is unlikely to provide quality or quantity of life. So there may be a difference in terms of the medical team in the nursing team I once was in a ethics conference and an Hamrick who's very well known. Unfortunately, she passed away this year, but she's done a lot of work with moral distress, and she was giving a talk and and to restate what she said. Her paraphrase, she said. You know, physicians come from the perspective of the success of one and their history with no understanding or remembering the sex. The success of that one patient, whereas nursing sometimes we is, uh, may focus or may have the perspective of the suffering of many. And so we not there's not one right or wrong. It's just understanding that we come from a different perspective and that we have to respect and have a discussion and talk about what our differences might be, and then the culture within the patient is not. And if the patients not the primary decision maker, so sometimes we'll get into very difficult cases if the patients on life sustaining treatment in the I C. U. For example, and we get to the point where it's very clear that we need to transition to comfort measures or comfort and withdraw life sustaining treatment. And that's very I think some of our most challenging patient situations has been in the I C. U. Where the patient may be from a Middle Eastern culture, different culture. And that's not within their purview of doing that. Withdrawing life sustaining treatment and then patients consenting to particular clinical trials as a viable curative option. That therapeutic misconception when we're enrolling patients on ah, Phase one clinical trial is certainly takes, uh, takes over and maybe an issue that, um, we we have to grapple with in oncology setting, especially so the next slide. I have another question for you. And if you could answer this question, what has been the most challenging, ethically challenging aspects of co vid pandemic for you and your nursing practice? Has it been the safety of nurses, patients, colleagues and families? Allocation of scarce resource is, or the change in relationship with patients and families, So if you could answer that and then we will again review these at the end of the presentation. So we recently did a, uh, a ethics discussion or ethics rounds, which I've been doing for many, many years now on the transplant unit with the nurses working on during the day shift in the night shift. We do it at three in the afternoon and a 10 p.m. And we've been doing them monthly. We had a we suspended for the last few months because of the co vet and we're now setting up. But But a few weeks ago, we did a ethics rounds or just discussion with the whole institution and how I do those is We pick an article or topic that we will discuss and then, um, we have the literature Thio, help support the discussion, and we will talk about what that is. And the article there on the right, which is from the Hasting Center report on Covic. Ethical challenges for nursing is what we used several weeks ago when we had our ethics and we were successful. About 200 nurses really joined in in our ethics rounds at that time, and and so we use this article to kind of frame our discussion and, um uh, in the article on the left is also recently found, and I'm not sure it's still impressed. But it was also another excellent article on that. Some of the challenges and lessons learned I'm going to focus a little bit more on that article on the right, which is the co vet. 19 and ethical challenges for nursing three authors. Air Well known, a nurse ethicist Morally, the first author is in the Cleveland Clinic. By the way, these references air in my in the reference list at the end of the presentation. Morley's at the Cleveland Clinic. Dr. Christine Grady is the head of bioethics at the N. I. H. The National Institutes of Health. Ah, center. She also happens to be married to Anthony Fauci, who we all know. Dr. Fauci, Um, McCarthy is also a nurse ethicist from the UK and from Ireland. And then the last author with old bridges from University of Pennsylvania, is associate professor of bioethics and nursing. And so we're going to talk a bit about that. I also want the next slide. I also want to bring you to the tension of this, also very recently published article that talks about vaccine trials. And again, Dr Grady is the principal author on this trial with other authors from the From the N. I H. As well as Um Cornell in New York and Chicago. But she talks about this tension between the speed and the rigors of science. So some of the issues ethical issues related to vaccine trials, I think, is very well documented in this article. The confidence in the trials and generalize ability of the data, the feasibility, speed and cost, the risk of participants and the social risks and distrust of vaccines Number one are all mentioned in this trial. So you might want to take a look at this article, too, if you're interested. I'm going to go on, though, and talk about the next slide. Please talk about the three ethical issues this article the High Stings Center article talks about, and they talk about the safety of nurses and patients, colleagues and families. Allocation of scarce resource is and change in the relationship with patients and families. And so the next slide will talk. Talk about the first one, which is the safety of nurses and patients and colleagues and how that has been affected. We all know that nurses and health care providers face substantial and in a risks when we go to work every day, especially working in oncology, where we're giving chemotherapeutic agents and which is why I O. N s and has come out on OSHA standards have come out with using safe practices for Mr When we're setting up to administer chemotherapy. We also know with co vet, then there's a lot of inadequately or under misunderstood risks that are associated with. We've learned more and more over the months as we learn more about the covert virus. This isn't new, however. So for the last 50 years, or Mawr, healthcare personnel nurses especially have been an A, P. P S and physicians have been had increased risk. We remember the HIV AIDS epidemic. Dr. Mason this morning talked about bizarre swine flu and the czar's We know Ebola has been in the area. Um, even as a child, my dad was a physician and used to go on house calls. And during the polio epidemic epidemic of I, of course, was not around that back then. I'm joking. But the polio epidemic in the 19 fifties, where you know, we didn't know actually vaccines it was interesting. An article on vaccines that I just mentioned that polio vaccine came through some stops and starts because of finding that there were bad lots or risks with different lots. So it's been around for a long time that we've been in a situation of risks and we really need to balance the obligation for to benefit the patient and duty of care with the rights and responsibilities to address the health care systems. And so we have a duty again, going back to number five provisioned duty to protect ourselves and our loved ones also, and so we owe that same duty to ourselves. So it's really a balancing act between making sure we're taking taking care of our patients well but also protecting ourselves. We don't want to pass the virus on potentially to another patient or saw another situation. We also recognize that there's difficulty in denying or delaying treatment. I know the change in a C. L s, and when we're doing a code situation and the changes with codes we've been in ingrained in us that we need to do that rescue, breathing and now that has changed in the initial stage and and we need that Ambu bag that has the HEPA filter on after the filters. So we don't, um, have secretions. We know because we've been professionally socialized Thio Rescue and to Dio to jump in there and do what we need to do. We have some expectations professionally and are enormous to save lives. And then we want to make sure we relieve suffering. We don't want to abandon patients. And I think this is one of the hardest things with the co vet, because we feel like we're not spending that contact with time with the patient. And that closeness of holding patients hands and and being always being there at the bedside organization or some many organizations have helped with that. Moral distress and psychological distress and and really post traumatic stress syndrome is going to be something that we're going to be dealing with for some time, I think. But we'll talk a little bit in a few minutes about some other resource is that we may see may have the next lied, then talks about the second point, which is the allocation of scarce resource is and, uh, you know, nurses have been inconsistently included in this decision making and all voices need to be heard. I think, um, in our institution here, we're fortunate that we have had the ability to have nurses at the table and nursing has taken ah leadership role in many things and that Z to be, you know, shared and encouraged in all institutions. I think to make sure that the nurses at the bedside in the forefront are making are at the table making some decisions. We have a shift in balance from ethical concerns and needs of the individual to needs of the community. When we limit visitors were doing that because we want to, we're concerned about the spread of co vet Onda. Also needing Thio focus more on community needs Many institutions have triage guidelines and and with another group who will remove the burden from the provider at the bedside and really look more critically at what the patients overall expectations are in terms of treatment. I think this is especially difficult for cancer patients because we want to make sure that we're doing things that are going to benefit them. And if they're, uh at a high risk group that we may need to consider that one, we're triaging or doing trying to figure out who will benefit, especially if we're in a search situation. Then there there may be conditional treatment offered on the basis of goals and limited time. Try a where again, the patient may be transferred to the unit with the idea that will do a try a war time trial of certain aspects. But you may get into a situation of withdrawing or withholding treatment, and I think it's much more difficult for nurses and everyone in healthcare. When we're doing when we have to withdraw or we're doing Asus, we can see that there is not going to be any benefit to continued ventilation or continued. I see you and there's a decision to withdraw treatment versus withholding. Nurses, as you know, are asked to perform other duties and their nursing certain nurses air, not infinite resource. And so we need to make make sure that they're safe and doing it safely in a with proper PPE and and develop and make sure that they're trained to do these other duties. And then there's moral distracts and conflict, uncertainty about appropriate actions to take, and I think that we're gonna see that in our health care providers in situation. Certainly we've seen it in cancer care already that you know. And if you work in a research hospital, you know that offering treatment that we're not really certain whether it's going to benefit that patient or not, eyes something that we deal with healthcare workers, then priorities for testing for treatment for vaccinations, triaging eyes, another issue that we're grappling with in terms of as the vaccine becomes available, you know, where will health care providers and workers frontline workers be giving being given the vaccine? So there's a lot of things involved. Relationship with patients is another aspect that we have Thio grapple with. So we know that nurses are the most trusted profession it's been for several decades now. Um, and as I said before, we know that during this time with PPE and all the protections that our relationship and the level of trust with our patients may be interrupted and uh, maybe affected in our our ability to have report with our patients and then I said said, already moving from a patient centered, community focused model practice, we also need to be imaginative in terms of solutions and make sure we don't sacrifice compassion and respect on the altars of safety and efficacy. I know we're using a lot of I pads on our covert unit as well as on are impatient stem cell transplant unit on making those available to patients so that they can communicate with their families and face time and has some connection, even though it can't be physical. And then we also know that there's this relationship may have long term effects on nursing on health care. A swell as our society. So my next question for you as faras polling questions And since the start of covert pandemic, how would you rate the intensity or frequency of ethical dilemmas that you have experienced on your your daily practice? Very frequently meaning daily frequently several times a week, occasionally maybe once every 1 to 2 weeks or none at all. So if you would answer that again, hopefully we'll have time at the end. Thio. Talk more about this. I want to turn the focus a little bit to advance care planning, and I don't Dr Farrell. If you were ableto to hear her presentation yesterday, she did a wonderful job of talking about advance care planning, but I really want to focus in on that and really talk about how this has changed the dynamic of care and how Cove it has changed. I don't want to say a positive aspect of co vet or effective co vet has been that we I think we have been much more, um, proactive in having these advanced care planning and discussions on goals of care. And, um, you know, I think, you know, in a general rule of pre co vet we we really needed to have these discussions. The goal Concorde, Ian care, the next slide we talked about. This is taken again. This is on the reference list at the end of the my presentation, but it's really been heightened our our need or desire to have heightened goal Concorde ian care has been increased. Goals of care discussion should be, ah, high priority right now. It should have been should be a high priority before this, too. We want to make sure we avoid unwanted treatments in the time of health care capacity. Stress, especially and then providing unwanted or non beneficial high intensity care, can put others at risk. Also during the cove it time. It also causes, I think, a lot of moral distress for nurses when they're asked to provide this high end, you know, care that they don't feel may not feel is unwanted or unnecessary. So Dr Ferrell gave us a definition yesterday of advanced care planning. I want to share these two definitions. That one is taken from our policy. Met, uh, institutional policy at M. D. Anderson related Thio Advanced Care Planning and Dr Farrell stressed yesterday, which I totally agree with is an ongoing process of communication. Ah, lot of people will say gold advanced care planning is advanced directives, and that's certainly not true. Advanced care planning is that conversation that we have with patients about their prognostic information, therapeutic options that they may have but also very importantly about patients, goals, values and wishes for further treatment, and to make sure that they're understood and address so that we can honor those patients preferences. Goals of care is the evolving, ongoing discussion again very similar, intended to be regularly re evaluated to ensure care can be realistically provided, and it's aligned with the patients preferences, so there may be a difference between what we feel from a medical or nursing standpoint and what the patient desires again. Then you can see goals of care or advanced care. Planning allows the patient to state what's important to them and share those goals and wishes and decide the types of life sustaining treatment that's available. Who will make decisions? That's an important point. If they do not have the capacity to make decisions themselves, it may and hopefully will include advanced care plan, advanced directives. One measure of it. Advanced care planning has been the presence of advanced directives, and I've looked at this over the last 15 or so years in our transplant patients population and and really find that patients coming in for a transplant which is life threatening, potentially life threatening treatment for their life threatened diagnosis that Onley the national. It's it's slightly higher than the national average, which I think Dr Farrell mentioned yesterday was. About 20 or 30% of individuals have advanced directives in our transplant patient population. With certain activities we've done, we've gotten it around 50%. But you know, when a living wills and a patient decision making 1991 when the Patient Self Determination Act was found was passed in legislation. You know, it was very clear we can't provide or deny care based upon whether they have advanced directives. So I think having advanced direct is important. But again, advanced care planning covers much more than that. And then we all have a responsibility to review the information from time to time in the in your reference list. There's also a study by Grant back and debt mire that talks about from recently published in the Journal of Palliative Medicine. The talks about pre Covad review of studies. And they reviewed 12 studies with over 9000 participants. And they examined advanced Care planning, payload of Karen Hospice and as faras advanced Care planning. They noted that 80 to 90% reported of the participants reported their familiar with advanced care planning. But on Lee, about 10 to 41% in these studies had completed the documents again, which are advanced directives. The next slide then, and it's a very busy slide and I apologize. But this if you go to our if you can't go thio m. D. Anderson inside page, which not everybody has access to that unless you work here it m d. Anderson. But this is a model of care, and this was in response again to co vet and, um, we we understood and acknowledged and and saw that there was some situations that need to occur. And there are many times patients will come in without having advanced care, planning, discussions or documentation of those. And so, based upon how the patient's physically doing, um, they developed this models for having these conversations. And so, um, they're encouraged. We're encouraging all patients to get admitted for their primary oncologist toe, have this goals of care conversation and then make sure that's documented so that others can see in the chart that it's been done. If the patient's condition really deteriorates and the goals of care discussion needs toe go a little bit further in terms of identifying things, then way have what we call co managed goals of care discussion and in that the oncologist again will lead the discussion. But we may also ask for palliative care and social work and others to participate in the discussion, and again, we want to make sure that this is document. If we're really in a tough situation, and it needs to be addressed urgently. We also have what's called Rapid Response Team, and I just want to share this with you to say, you know, there, there this rapid response team then has ethics involved social work involved and the palliative care team Azaz well is the primary oncologist, and it's really almost like the merit team or the team that comes in rapid response of the patients deteriorating medically. And it's really to try to address the issue and make clear. Now we've been fortunate that we haven't been in that crisis. We've been in a contingency mode here, a TMD Anderson with our covert patients and situations. But we haven't been in a situation where we've had a surgeon and uh, and have to have these conversations but who have limited resource is like other places in the country have had but this rapid response team that has really meant to help facilitate those conversations. So next live, please. So again, the importance it's important to remember certain things DNA does not mean do not treat or do not, you know, continue care. We kind of have to levels of DNA in our institution, DNA or DNA, where we may have patients continuing with aggressive care all the way upto I see you are intubation, but then we also have DNA with comfort. Care is the goal of care, so it does not go of care. And those conversations does not automatically mean DNA or hospice. We're just trying to address what the patient's wishes might be, and then how what's most of medically appropriate? And so the models are listed there, too, and that was on the last table that I just showed you. So advanced care. Advanced Directives again is a measure of those goals of maybe an outcome of the advanced care planning conversations, and that includes living will with the wishes. If the patient is in a terminal or irreversible state. Here in Texas, the patient has the option thio to choose if their wishes might be even in a terminal or irreversible condition. They want full court press or they want continued, UH, a medical care. They can indicate that on their advanced directive or they're living will power of attorney would be substituted just judgment if the patient does not have the capacity to make those decisions. It's not a matter of competency, but its capacity to make decisions. Then family or friend might be, um, so and then out of hospital DNA is the third advance directive that we have in this very state, the state. So knowing what your stages. But I want to bring your attention to other documents, and Dr Ferrell mentioned some of these yesterday in her discussion. But five wishes identifies who will make decisions. It's much more involved than just, um that what do I want? If I'm in a terminal reversible state? It talks about the kinds of treatments, how comfortable the patient wants to be or the person wants to be. What would they want to tell their loved ones and that, And so I would encourage you to look at that five On the next slide, we have some of the websites respecting choices is another document that I think is especially helpful, and that's been come out of Wisconsin, actually, and that's been around for quite a while, respecting choices. And that's again another decision. Aid for making choices about care respecting pulsed, which is physician orders for life sustaining treatment. And that's another document that can be used, and it really details much more than a D. N R. Order typically will detail the type of medical care and then prepare for your care. And this is very 10 plus page document. But it really helps the patient going through kind of that decision making process and a good details about medical care on what's desired. The next slide then, has some of those websites for respecting choices. Prepare for your care and five wishes. And so any one of these documents may be helpful for patients if they seem there in a quandary about what? What, making those decisions and what you may pull those documents and preparing for care actually does. Can substitute for a living Will Medical Power of Attorney? It does have a place for a notary or the two witnesses, which is required, at least in Texas. That's required on our documents, uh, to having two witnesses or it can be notarized. Don't need a lawyer to fill those out, but you may find that thes resource is air helpful to have those discussions with patients. So now the next slide I'm going to give you a situate. Another situation that hopefully we'll have time to talk about it. Just have a few more minutes. Toe talk. Mary is a 78 year old woman patient with relapse leukemia, and she's emitted with a positive covert tests. She's neutral Penick and on oxygen, so she has relapse. Leukemia. Family cannot visit because of the co vet, and she may be transferred to the I C U to do to her declining condition. There is no advance care planning or goals of care documentation in our chart, and so my question is, What are you going to do? So the first option is talk with Mary and her family on the phone. Call her attending medical team and let them handle it. Look for Mary's Advanced Directive a D, and call the team with recent information. Or call the medical team help coordinator, calling the rapid response team to talk with Mary and her family. So I will let you answer that question and we'll move on. Um, the next question is, she's widowed. The same scenario. Clinical scenario. She has three adult Children. She has no medical power of attorney document or living will. Who should we talk to about her wishes. So this oldest adult child, all the Children, talk with Mary if she has capacity to make decisions called social work or all of the above. And one more question, what do you think is the most appropriate action in Mary's care? Send Mary to the I. C. U and see what happens. Have a goals of care conversation with Mary and family to find out her values and wishes. Call on ethics Consul Tin Plan of Care Conference for next week and support the medical team's decision to place the DNA a DNA order on Mary's chart. Yes, so in the last few minutes, I just want to call to your attention. Some resource is that you have. This was a journal of the American Nurses Association a month or two ago, and it really on the cover was quite profound. Covert 19 forever changed reluctant heroes, life saving experts and caring providers. And there was an article within this about the ethical protecting yourself and your patients, which is similar to the article that we just discussed from the Hasting Center. I also want you to know that American Nurses Association has put out a call for social justice to address racism and health and equity and communities of color. And so this American Nurses Association and the American Academy of Nursing put out a joint statement in August. And it really does a fine job of talking about the inequity within health care. And this has certainly been highlighted in the Cove at times, we know that the incidents of co vet and the mentality of co vet is higher in communities of color. And so we need toe, bring this up and do as much as we can changing policy and and resource is, so you may want to take a look at that. If you look up A and A and, uh, call for action and social justice. It's a great, um, paper Quick read. Yeah, and then measures you've taken, um, indicating the situation in these issues. So these this is from our inside page. Here it M. D. Anderson. There's a whole center. We also have a document Covad 19 Wellness Resource Guide, which has great material in it for helping us help patients and taking care of ourselves. The next slide is in a covert resource site, which American Nurses Nurses Association has. This site, which is has a lot of resource, is, uh, suggestions mindfulness training, Relax, ation training things to help us again care for patients. And it's certainly true in oncology nursing that we have increased ethical issues or or things that we need to take care of ourselves. And we need those Resource is to take ourselves within that page is the next slide, please, is, uh, within that covert resource center pages. Ah, whole section on, well being initiatives. And it has also put out a call for action paper a few years ago on resiliency. And, um, I was part of that group across the country who came up with that, Um, and they have some great resource is and suggested programs around the country that have been used to help with nurse resiliency. So my next question is, you have been working 48 hours this week to help cover your unit and the Collins. You're physically, mentally emotionally exhausted, your short tempered with your family. Which of the following actions might be the least helpful for you to do. And so the options we gave you are focused on getting tasks done at work. Don't get involved. Take a vacation to a yoga camp, Call Employees Assistance Program and Review Resource is on professional websites. And then I just want Thio. Just open this up for any discussion. I know we only have a few minutes, but if you experience any of these issues as an advanced practice provider nurse, if there's administrative nurse research nurses and then my last question for use have you changed your pattern of self care activities to help you cope with covert pandemic. And that's a yes or no question so that the next line is the references. But I would like toa open it up for discussion if we can. And thank you. Thank you, Joyce, for your excellent presentation. You touched on important at the coal issues, How Cove it has changed that landscape and re emphasized the importance of advance care planning. I really enjoyed you incorporating the interactive pull everywhere questions into your presentation to assess how our audience would respond in those situations and in the interest of time. I want to go over those poll responses, so let me just pull that up here. It looks like the first question was, Have you called an ethics console to? And it looks like that the majority of the answers are or no, I am not sure how to do that. That was 33% and 29% was No. But I do know how to call for one if needed. 29% on that question. Yes, for that particular choice. And the other answer choices were about 17%. No, I have not experienced any ethical issues. And then the other one was yes, and it helped in resolving the issue and then 4% yes, but it did not help the situation. That's unfortunate the situation. But I think a lot of us go into an ethics console thinking that we're going to resolve the issue. And as we know many of these issues, it's a process. And as patients are coming thio e think Betty Ferrell said yesterday, You know that it's new diagnosis for patients, and so it's a process. Those answers are very similar to what we we got in our poll of our 200 or so nurses that were involved in our meeting a couple months ago. You want to go on to the next question. Sure, the next question was what has been the most ethical challenging aspect of the cove. It pandemic for you and your nursing practice. It looks like the majority 68% answered safety of nurses, patients, colleagues and family. It looks like 32% the remaining. It said It was a change in relationships with patients and families again, that's very similar to what we got when we did this presentation here at M. D Anderson a few weeks ago. Uh, 55% of our audience said safety related to patients, families and others, so 68% is right or wrong the same same measure. I'm gonna go on. Okay, So next question was, since the start of the Cove in 19 Pandemic, How would you rate the intensity or frequency of ethical dilemmas you have experienced in your daily nursing practice? It was kind of split down everywhere here, very frequent daily. 14% said that a Sfar as frequent several times per week, that was 24%. The majority was with e answer choice. Occasionally, maybe once every 1 to 2 weeks. That was 38% and then 24% said none at all. Okay, so that I think that that nurses are facing especially those nurses we have that are when the patient enters into the hospital are they're trying to explain to visitors why they can't come in and and do that. So we have nurses who are at those stations in the hospital, and I think that that makes it very difficult. So it varies. There's no right answer here. There's just, you know, what has been your experience. So it sounds like frequently, maybe once or once every 1 to 2 weeks mhm. Looks like our next question was about Mary and the fact that there was no, uh, advanced care provider Documentation in your chart. What are you going to dio? Majority, 64% said Call the medical cuttin help coordinate calling rapid response team to talk with Mary and her family. That is great. That's kind of the answer that we want to not now, understanding that not every institution certainly has a rapid response team. But, yeah, something to do more on the more immediate, uh, meet immediate time frame in terms of, you know, getting getting the discussion going and, uh, making that decision before the especially the night nurses there, you know, waiting for that answer to be had, Whether you're gonna send the patient the next question. Well, it looks like we actually run out of time. I'm so sorry, but for you attendees out there that have any questions for Dr Newman, you can email her any remaining questions or enquiries. Her email is in the slides. However, I have it here for you is Jay Newman. So J and E u M a n n at m d Anderson dot org's okay. It looks like there are no questions at this point. I think we had enough pull everywhere questions for the interactivity. So thank you so much, Dr Joyce Newman. Thank you. Appreciate having this opportunity and be happy to answer any questions. If you want to email me and have a good rest of your day