Legal and Ethical Issues among Oncology Nurses Toward End of Life Care

Background: Near end of life cancer patients are suffering from multiple distress that can affect their quality of life. Oncology nurses as primary care givers of cancer patients are committed to provide high quality care considering complex ethical issues to this extremely delicate and sensitive patient and their families. Purpose: To evaluate the ethical commitments of oncology nurses practice during the end of life period. Methods: After the usage of different electronic database with specific key words, the number of the found articles was 31 articles, but only six articles were met the inclusion criteria and were used for the current review. Results: This integrative review found that the oncology nurses are not completely adhere with ethical practice for terminally ill cancer patients. Lack of proper forms and documents combined with poor knowledge and understanding of nurses about ethical sensitivity was the major factors which led to poor end of life quality care and outcomes. The oncology nurse managers and their team members need to seriously take more responsibility with honesty and dignity to improve the situation. The oncology nurses should have the capability to identify the different needs of each patient specifically towards the late stage of disease progress. Implications and Recommendations: In order to maintain a high quality care at the end of life which is critically important to manage the symptoms as soon as possible, and for more enhancements, the oncology nurses need comprehensive programs to increase their awareness about the importance of ethical practice and care.


Introduction
Ethics is the basic component to guide nurses' professional practice. Worldwide, nurses have the responsibility to meet the standards of ethical practice. Lachman has defined ethics "as the philosophy of investigating, through analytical thinking, the values at the basis of relations between humans and the characteristics of the moral terms of good/bad and right/wrong" [1]. This characteristic distinguishes ethics from morals: ethics refers to a system of thought, while moral refers to the set of values that develop on their own with the rise and fall of different societies. Ethics guides how people view the relevance of each decision made in the field of health and is separated into two subcategories: theoretical (philosophical) and applied. Theoretical ethics is concerned with the subject, meaning, and purpose behind philosophical ethics and examines its areas of responsibility, while applied ethics helps in deciding on what is right and wrong [2].
Nurses who are unable to understand and apply the ethical values during patient care struggle in their role as a professional and more likely suffer from moral distress. The majority of conflict in nursing care is associated with cancer patients who are near the end of life [3,4]. End of life (EOL) is a period of time that is characterized by severe deterioration in physical, psychological and/or psychosocial status of patients resulting from underlining irreversible disease which require comprehensive care, which may lead to death [5]. The EOL term might be used interchangeably with other related terms such as terminal stage, palliative care, and hospice care and the specific meaning of each concept might be different. On the other hand, all terms reflect the end of life period.
In the last two decades, health care organizations have focused on the quality of care. The quality of care is not only associated with skilled and knowledgeable nurses; the ability to adhere with code of ethics during patient care has an enormous impact to achieve high quality of care mainly during terminal stage of cancer patients [6][7][8].
Rosenkoetter and Milstead, emphasized on the Florence Nightingale Pledge as the first ethical code for the medical profession and a guide for nurses. Terminologies such as "I will do all in my power to maintain and elevate the standard of my profession and I will abstain from whatever is deleterious and mischievous. I will not take or knowingly administer any harmful drug" was certainly a great help in orienting nurses to the purpose of nursing profession. Since then, nursing has become increasingly acknowledged as a profession with unique values and principles [9].
However, incorporating technology and scientific developments in medicine has changed the several approaching ways to the end of life care and mandated few amendments to the initial code of ethics. The American Nurses' Association (ANA) and the International Council of Nursing (ICN, 1953) reviewed the ethical codes and established new versions. These new values guide nurses in their activities and decision making, as well as how they should disseminate health information to the general public. The ethical principles established by contemporary medical ethics fall into four categories, as follows: autonomy, beneficence, non-maleficence, justice [10].
The number of studies which have explored the theoretical nature of ethical topics and it has been increased in the recent year's professional bodies such as the International Council of Nurses (ICN) addresses new code of ethics for nurses to guide their practice during the end of life period [3].
However, the majority of studies have focused on theoretical part of ethical practice and guidelines related to the actual practical guides to assist nurses in real life situations remains scarce.
To fill the gap between philosophical ideas and practices, and for nurses to practice their ethical values in clinical settings, it is critical to have a clinical evaluation that reflect the ethical practice of oncology nurses, and this evaluation should be associated with educational program to increase the nurse's ethical commitment during clinical practicing [11].
Patients going through the end stage of cancer disease usually suffer from multiple deterioration in their physical, psychological, cognitive, and social aspects of life Therefore it is not clear that how the nursing staff dealing with palliative and hospice patients would be able to provide care considering ethical commitment and provide the highest possible quality of care when dying is imminent.

Methods
In order to achieve the purpose of the current review; the studies were obtained through an electronic search of the literature using the databases PubMed, Ovid and EBSCO. The included studies published from 2001 to 2016 and the following search terms were used alone and in combination: "end of life", "ethics practice", "practice", "nurse, and nursing", in addition to their alternatives. Additional articles were found through Google search. Since there is a paucity of data regarding the EOL outcomes in relation to ethical commitment, studies that included the EOL issues regarding ethical practice were used in this review [6]. Initial selection took place by assessing the title and abstract. When these appeared to meet the inclusion criteria, full-text articles were obtained, read extensively, and assessed in depth according to the criteria mentioned earlier. From 31 articles that found in relation to search terms; only eight articles met the inclusion criteria for this review. Duplicated articles were excluded as were abstracts that did not meet the inclusion criteria.

Methodological characteristics
The eight studies were quantitative studies, four studies applied a non-experimental and cross-sectional design, one was longitudinal study, two were prospective and the last one was a distinctive study in which a prospective approach was used with a large sample size. The six quantitative articles were used multiple models and theoretical frameworks with different instruments to measure and define the variables in operational manner.
The eligible articles were focused mainly on four variables or concepts, these concepts were included; ethical practice, commitment, end of life and palliative care. For measurements, analysis and interpretations various scales were used. Individual meeting with employees on a regular basis perhaps once every few months or a couple of times per year. Personal interviews were a useful tool in assessing attributes, such as communication skills, problems solving skills, ability to work in groups and other characters.
Another measurable tool was to evaluate employees' demonstrated work ethics against a checklist. Employee Performance Appraisal (EPA) that included sections entitled judgment, integrity and attendance, availability and dependability were part of the checklist. It is easier to evaluate and measure concepts, such as integrity, in others when those concepts are broken down into individual traits, such as sensitivity to confidentiality and compliance with procedural standards of conduct.

Sample characteristics
The sample size in eight studies was ranged from 80 to 220 participants, with the age range between 18 to 65 years old, the participants were either patients or nurses depend on the study purpose. The nurse participants in studies were working in different departments with variation in their experiences from one year to 10 years. While the patient participants were diagnosed with different types of cancers, different stages and they were varied in their educational level. In terms of gender there were 47% male and 53% female in all the selected articles.

Result Nurses ethical practice
Oncology nurses facing difficulties in their daily practice mainly when the cancer patients become near end of life. The transition period for the patients to obtain highest level of quality of life near the end of life, a comprehensive ethical approach in practice is needed to be placed [5,11]. The end of life care is multidimensional care. Both physical symptoms such as pain and psychological distress such as depression should be managed in an ethical manner. Oncology nurse managers and their team members must take this responsibility with honesty and dignity [6,12].
Lzumi [3] reflected on a study which examined new and experienced nurses' knowledge in dealing with the end of life ethical issues. Although the study revealed a good knowledge and background on the narrative part of the ethical practice among nurses, lack of ethical sensitivity was highly noticeable among them. Ethical sensitivity helps nurses to identify the prominent concerns regarding ethical practice. That means they are able to distinguish if the practice care is good or bad [3]. The new graduated nurses -who work directly with patients near the end of life-are not trained in facing the moral dilemmas and distress.
On the other hand, another study reflected that health organizations have a responsibility regarding nurse's ethical practice. The lack of fixed documents and coherent models is a major factor lead to lack of nurses ethical practice. The main of unregulated or undocumented issues are specific cultural settings, patient-centered variables, and family specificity [13].

End of life care outcomes
For patients diagnosed with an advanced cancer, as death approaches, optimal health care would shift from life prolonging therapy to supportive care and symptoms control which means they are focusing on having a peaceful end of life. The current findings suggest that the medical staff should consider the most appropriate and preferred decision-making model according to disease stage and the individual's characteristics, especially age, and that a passive or paternalistic decision-making model. Sometimes it contributes to achieving a good death for patients, especially elderly adults, although the influence of cultural differences between countries must be considered when discussing these findings. Because large differences in individual values and preferred physician-patient relationships exist between these countries [3,13].
According to a study conducted by Fang et al. a culturally and spiritually sensitive end of life care is critical in providing a highquality care for end stage cancer patients. The authors have examined primary barriers to EOL care. The several barriers include but not limited to cultural differences between healthcare providers, those who approach EOL and family members; under-utilization of culturallysensitive models. Also, Language barriers; lack of awareness of cultural and spiritual diversity issues; exclusion of families in the decision-making process; personal, racial and religious discrimination and lack of culturallytailored EOL information to facilitate decision-making are among major contributing factors to the issue [14]. In support of the abovementioned study Selman et al. has suggested that more holistic models of care are required, integrating the experience of ill health and conceptualizations of the meaning of EOL care which are intrinsically imbued with cultural and spiritual meaning [15].
The findings sufficiently support evidence of gaps in end-of-life care for patients with cancer to warrant further initiatives by our nascent palliative care team. A high number of uncontrolled symptoms and a great amount of physical and psychological distress have been reported for patients who are nearing the end of life.
Although the literature examining Quality of Life (QOL) in patients near the end of life is small, patients in palliative care have been found to experience problems that affect all areas of their lives. Early work found that patients experience a dramatic decline in their QOL as they approach the end of life [5,6,12].
Every single thing that lead to deterioration in patient's end of life outcomes can reflect nurses practice mainly regarding ethical issues. For example, suffering due to unrelieved pain and unavailability of morphine are recognized as negligence of human rights [11].
Several findings represents evidence of poor outcomes in advanced cancer patients which is due to inability of oncology nurses to understand the patients symptoms experiences (either physical or psychological symptoms); lack of fixed documents that regulate the staff practice mainly in dilemma situations; and the oncology nurses lack to ethical sensitivity regarding their daily practice (that means the nurses are unable to identify the good verses bad practice even with narratives documents) [6,13].

Conclusion
The significance of this appears in two dimensions. First, that oncology nurses are first line care providers for cancer patients. Therefore, they must be able to understand all aspects regarding patients and families care. This reflects on their abilities to be equipped with ethical concerns of terminal patients.
Second, to achieve better care for dying patients is to decrease suffering through control of symptoms and understand their differences and their needs. Therefore, the health care provider especially the oncology nurses have major responsibilities in understanding the physical, psychological, social, and financial distress to avoided poor outcomes in the care provided.

Recommendations
In order to ease transition of patients to be smooth during the period of end of life, the oncology nurses have to understand all aspects of ethical care. Nursing ethics should have taught primarily in the classroom, focusing on philosophical arguments and justification of decisions using bioethical principles.