Episode 293: Access to Care: How to Manage Moral Dilemmas and Advocate for Your Patients

"I can think of examples where I have two patients. They have the same diagnosis, but they have two different insurance companies, treatment plan's the same. 'Patient A' isn't going to get the optimal treatment plan because their insurance company won't approve it. 'Patient B' is going to get the Cadillac version of this treatment plan, and what am I supposed to do about it," Lucia D. Wocial, PhD, RN, FAAN, HEC-C, senior clinical ethicist in the John J. Lynch Center for Ethics at the MedStar Washington Hospital Center in Washington, DC, told Jaime Weimer, MSN, RN, AGCNS-BS, AOCNS®, manager of oncology nursing practice at ONS, during a discussion about how access-to-care issues can produce moral dilemmas for nurses and how to manage this. You can earn free NCPD contact hours after listening to this episode and completing the evaluation linked below. Music Credit: " Fireflies and Stardust " by Kevin MacLeod Licensed under Creative Commons by Attribution 3.0 The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. Learning outcome: The learner will report an increase in knowledge in moral dilemmas in nursing practice. Episode Notes The NCPD activity for this episode has expired, but you can still earn NCPD through many other ONS Podcast episodes. Find a full list of opportunities . How to advocate for your patients . ONS position statement: Access to Quality Cancer Care Oncology Nursing Podcast : Episode 222: Ethical and Moral Dilemmas of Futility in Cancer Care and Treatment Episode 253: The Ethics of Caring for People You Know Personally Episode 277: Futility in Care: How to Advocate for Your Patients and Prevent Ethical Distress ONS Voice articles: Four R's and Resilience Approach Help Oncology Nurses Respond to Morally Distressing Challenges It Takes a Team to Confront Moral Distress Cope With Moral Distress by Focusing on the Possibilities The Case of the Blurred Boundaries Clinical Journal of Oncology Nursing articles: Moral Distress: A Qualitative Study of Experiences Among Oncology Team Members Moral Distress: Identification Among Inpatient Oncology Nurses in an Academic Health System Moral Distress: One Unit's Recognition and Mitigation of This Problem The Role of Oncology Nurses as Ethicists: Training, Opportunities, and Implications for Practice Oncology Nursing Forum article: Ethical Challenges Encountered by Clinical Trials Nurses: A Grounded Theory Study Reducing Compassion Fatigue in Inpatient Pediatric Oncology Nurses Moral Resilience Moral Resilience ONS Huddle Card American Cancer Society: Road to Recovery American Nurses Association position statement: The Nurse's Role When a Patient Requests Medical Aid in Dying (ONS endorsed) Dr. Lorna Breen Heroes' Foundation: Improving Licensure and Credentialing Applications Toolkit Guttmacher Institute: Roe v. Wade Overturned: Our Latest Resources General ethics resources: Center for Practical Bioethics Harvard Implicit Association Test Johns Hopkins Berman Institute of Ethics Markkula Center for Applied Ethics at Santa Clara University The John J. Lynch, MD Center for Ethics: MedStar Washington Hospital Center To discuss the information in this episode with other oncology nurses, visit the ONS Communities . To find resources for creating an ONS Podcast Club in your chapter or nursing community, visit the ONS Podcast Library . To provide feedback or otherwise reach ONS about the podcast, email pubONSVoice@ons.org . Highlights From Today's Episode "When people think of a moral dilemma, sometimes what I think they're considering is what I call a 'moral temptation.' So, that's a situation where there's one right and clearly a wrong answer. And usually, the wrong thing is about doing something that benefits you." TS 2:50 "An ethical dilemma is a situation in which you are compelled to make a choice between two or more actions—I say two or more; it's very rarely just two—that will affect the well-being of someone else, usually. So, the actions that you're considering can be reasonably justified, both of them, as being good or bad. Neither action is obviously good or obviously bad, and maybe the goodness of the action is uncertain. So, sometimes people will say choices between two equally good choices, and sometimes people say between equally bad choices. But the fact is you have to pick one." TS 4:13 "Even stories with happy endings sometimes have a really bumpy road on the way to that happy ending. Some people also think of this as what's called a 'vicarious secondary trauma.' 'I was there. I walked through this patient's journey, and I know the patient was traumatized by it, but so was I.' You know, sometimes people will experience compassion fatigue when they feel unable to help someone overcome the barriers that are keeping them from getting better." TS 6:18 "Meet your social worker. Be as nice as possible as you can to them. They, like you, are not paid enough for what they do. Know and become familiar with resources that are available in the community. The American Cancer Society, for example, has a wealth of resources for cancer patients, including rides to clinic appointments. Knowing how to tap into them is really, really important." TS 14:52 "Fourteen states ban abortion outright. Just think about that. It is not uncommon, and I know your nurses know this, for cancer to be diagnosed during pregnancy. And there are women who are faced with the decision of initiating chemo or terminating a pregnancy or initiating chemo and risking the teratogenic effects of the chemo. Most physicians would really struggle with that. So, they have to choose, literally choose between themselves and a fetus. In some states, the laws are quite clear. People who assist individuals getting termination of pregnancy can be criminally prosecuted. That's a big deal, and it weighs pretty heavily on folks." TS 21:09 "Many people do not realize that Planned Parenthood, as a resource, the bulk of their work is screening. It's screening and contraception and other things which, you know, think about vaccination to prevent viruses that we know can lead to cervical cancer. And when those organizations are forced to close, that limits access, and that means, usually, you will see an increased incidence of cancers that could have been prevented or detected earlier." TS 23:57 "I do know people who are making choices with their feet. Those who are able to, they're moving and leaving states, and the data is clear about that. States that have significant restrictions on abortion are seeing an exodus of healthcare providers. So, it is a really complicated issue. It's going to be a difficult time until it works itself out. Hopefully it will work itself out. I think there will be a clear distinction between states that have access and states that don't." TS 24:44 "All of your patients are at risk for financial ruin. Insurance companies change their enrollment practices. People whose spouses who carry them on their insurance lose their jobs. Everybody's at risk. The best thing you can do is to acknowledge it upfront and figure out how you're going to cope with the inequities that exist in our healthcare system. It's not a pretty answer, and it's not an easy answer for me to say out loud." TS 27:29 "There are things to not do. So, there are times when you care for a patient, and you form a special bond, and the patient hits some hard times. Please don't give them money. I know you're tempted, and I know it seems really easy—like a cup of coffee, that's not a big deal. Now, this is where frequently, from a professional ethics standpoint, people ask me like, 'What's a boundary crossing? What's a violation?' Like when people are in trouble is when nurses are most vulnerable because they're the most compassionate people I know. And they really, really, really want to help." TS 32:24 "You need to be able, as a bedside nurse, to say, 'Hey, have you reached out to our financial office? Have you reached out to this? Have you done this? And oh, I know it's really hard for you to ask, but we have a program for families who have this sort of circumstances. I really encourage you to apply.' I think that's the other thing about this is we still are in a society where it's shameful to not have money. I wish we could fix that one, but we can't. So, you know, the best thing nurses can do, really, is to help normalize the experience of not having enough resources to get what you deserve." TS 34:26 "I will say for nurses who have a deep philosophical opposition to medical aid in dying, if one of your patients asks you about it, the most graceful thing you can say is, if you're in a state where it's legal, 'I would encourage you to talk to your doctor about that. And going forward, I may not be a nurse who can take care of you in that circumstance.' You don't have to say why. You just have to say it may not be possible. If you're opposed to it and a patient approaches you about it, the thing not to say is, 'You know, that's morally wrong.' If you struggle with it, then it's your opportunity to connect the patient with someone who can talk to them about it." TS 37:44 "The data on systemic racism in health care is overwhelming, and it makes me sad every time I look at it. I don't work with people who I know would intentionally not provide good care to someone because they were of a different color or had a different financial background. And yet, the data is really clear. So, that means we all have to get a big, fat mirror and look at it, and it's painful." TS 44:55