Commentary on CANO/ACIO 2015 conference presentations cOMMeNtArY S

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reVue CanadIenne de soIns InfIrmIers en onCologIe
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COMMENTARY
Commentary on CANO/ACIO
2015 conference presentations
Medically Assisted Death in
Canada: Careful and Thoughtful
Practice Directions for Oncology
Nurses (CANO/ACIO Session
III-02)
Barbara Fitzgerald, RN, MScN, Barbara
Russell, MBA, PhD, Shari Moura, RN,
MN, CON(C), CHPCN(C)
Presentation abstract (condensed)
In 1993, the Supreme Court of Canada
ruled in a split decision against Sue
Rodriguez, a woman with advanced ALS
wanting medical assistance to end her life.
Twenty-two years later, however, the Court
ruled unanimously in favour of Lee Carter,
a woman with progressive spinal steno-
sis, wanting medical assistance to die. The
Court’s ruling impacts federal and provin-
cial/territorial legislation, as well as pro-
fessional regulations. Recognizing that
governments and professional bodies may
wish to write practice-guiding policies,
the Supreme Court instituted a 12-month
waiting period before its ruling takes
eect. This session [examines] the ruling’s
impact on oncology nurses’ work in hospi-
tal- or community-based interprofessional
settings.
Commentary on the presentation by
Jennifer Stephens
The subject of medically assisted
death is a topic passionately debated in
Canada, even after the February 6, 2015,
ruling of the Supreme Court of Canada
in the Carter v. Canada case in which the
higher court ordered that Criminal Code
prohibitions on assisted suicide and vol-
untary euthanasia violate the Charter of
Rights. Wisely, the Court prohibited the
invalidation for 12 months in order to
allow federal and provincial Parliaments
to write Charter-compliant legislation.
Professional organizations, most notably
the Canadian Medical Association (CMA),
have scrambled in the past few months
to discuss end-of-life care and assisted
dying. At its 148th annual meeting held
in Halifax this August, the CMA agreed
not to support assisted death while at the
same time conrming that physicians
have a duty to provide information on
all options for patients, including access
to medications that can facilitate death
(Sullivan, 2015).The Canadian Nurses
Association (CNA) likewise welcomes
the opportunity to participate in legisla-
tive discussions around medically assisted
dying and how it relates to the Code of
Ethics for Registered Nurses (although
professional nursing organizations such
as CANO/ACIO or CNA have not for-
mally been invited to the table at the fed-
eral level). An early 2015 survey of 700
CNA members revealed that more than
half of nurses support legislation to allow
medically assisted dying (Headley, 2015).
This workshop at the CANO/ACIO
conference was very popular, and attend-
ees poured into the room for several min-
utes after the presentations had started
necessitating the addition of 20-plus
chairs to the back of the room to accom-
modate participants. Using a case study
as the basis for discussion, the three ses-
sion presenters oered an example of
a terminally-ill patient with colon can-
cer who was discussing options for end-
of-life care with his nurse. An expressed
desire to end his life (and suering) was
one of them. Not surprisingly, the presen-
tation pivoted precariously around ethics,
swiveling continuously between patient
needs and nursing clinical practice stan-
dards. Concerns echoed around the room
from nurses who felt they would be chal-
lenged, by legislation or other entities,
to support medically assisted dying. The
presenters utilized the CLEOs framework
(Consideration of the Legal, Ethical, and
Organizational aspects of medicine) to
promote conversations around concepts
pertaining to medically assisted death such
as informed consent, as well as personal
versus professional rights and responsibili-
ties. The overall sense in the room was that
medically assisted dying, even in the oncol-
ogy context, was something requiring con-
tinued discussion from both a nursing and
interprofessional perspective.
Legislation for medically assisted
death (or physician assisted suicide) cur-
rently exist both nationally and interna-
tionally. Within Canada, Quebec Bill 52
becomes eective December 2015. This
legislation frames medically assisted death
within the context of end-of-life care oer-
ing provisions for both terminal pallia-
tive sedation and medical aid in dying
(Hivon, 2013). This Bill is carefully crafted
to reect similar legislation in the United
States (Washington, Oregon, Vermont),
Belgium, and Luxembourg. Within this
legislation, as within international laws
around medically assisted death, the physi-
cian is the touchpoint for decision-making
and access to terminal care. The discus-
sion seems to be intimately linked to a
wavering ethical line between the rights of
persons (patients) and the rights of physi-
cians. Whose rights prevail in the case of
terminal illness? Those of the patient who
desires release from mental and physical
suering or those of a physician who may
be morally opposed to oering assistance
for whatever reason?
Citizens of Oregon tackled these hard
questions in the early 1990s when a ded-
icated grassroots movement successfully
lobbied for the rst death with dignity
legislation in the United States (passed
November 4, 1994, but enacted on October
27, 1997). Simply stated, a physician has no
professional duty to participate in the pro-
vision of lethal medications to patients for
self-administration meant to end their life
at the time of their choosing. Health care
sta, including nurses, pharmacists, phys-
iotherapists, dentists, and the like, have
no obligation to discuss physician assisted
suicide with patients or to provide edu-
cation or referrals. The annual report by
the Oregon government on the Bill states
that in 2014, 155 people were prescribed
lethal medications, and 105 utilized their
ABOUT THE AUTHORS
Jennifer Stephens, MA, PhD(c), RN, OCN
Doctoral Student, School of Nursing, University of
British Columbia, Vancouver, BC, Canada. CIHR
Frederick Banting & Charles Graduate Scholar.
Fellow, UBC School of Graduate Studies
[email protected]
Jacqueline Galica, Doctoral Student, University of
Toronto. [email protected]

91
Canadian OnCOlOgy nursing JOurnal • VOlume 26, issue 1, Winter 2016
reVue Canadienne de sOins infirmiers en OnCOlOgie
FEATURES/RUbRiqUES
prescription (Oregon Health Authority,
2015). A majority of the people (68.6%)
had cancer, second largest group were
people with ALS. 67.6% were over the age
of 65. What do these numbers mean to
us, as Canadians and as oncology nurses?
May I recommend the thoughtful
HBO documentary How to Die in Oregon
(Richardson, 2011) to those colleagues won-
dering what physician assisted suicide actu-
ally looks like in the “real” world. With any
luck, the advisors and politicians currently
crafting Canadian Bill S-225 will also view
this documentary and will consult with
oncology nurses at the frontlines of this
highly contestable, and weighty, discussion.
In brief
What this presentation highlighted:
• Carter v. Canada changes the Canadian
Charter of Rights in February 2016 to
legalize physician assisted death.
• Utilization of the CLEOs framework
(Consideration of the Legal, Ethical,
and Organizational aspects of medi-
cine) to facilitate conversation around
vocabulary and other concepts that
relate to medically assisted death such
as informed consent, as well as per-
sonal versus professional rights and
responsibilities.
• Professional organizations including
the Canadian Medical Association
and the Canadian Nurses
Association are surveying members
and holding meetings to determine
how this legislation will impact prac-
tice and standards of care.
Next steps:
• While nursing’s voice is not at the
federal discussion tables around
Canadian Bill S-225, nurses have
important roles to play in terms of
patient education and collaboration
with physicians and interprofessional
teams around end-of-life care.
• Oncology nurses will be aected by pro-
fessional regulatory changes as well as
changes to palliative and hospice care.
Supportive Care for Cancer
Survivors in the Community: The
Roles of Parish Nurses and Nurse
Practitioners (CANO session:
II-04-A)
Krista Wilkins
Abstract
The expanding cancer survivor pop-
ulation creates complexity for the health
care system. Cancer survivors expe-
rience a number of physical and psy-
chosocial issues, as well as chronic
health problems that greatly aect
quality of life, health and productiv-
ity. Community-based care providers,
including parish nurses and nurse prac-
titioners, are assuming greater respon-
sibility for the ongoing supportive care
sought by cancer survivors. They oer
a health promotion perspective that
may be useful in helping cancer survi-
vors normalize their lives and give them
increased control of their health. Their
perspectives on their ability to provide
supportive care to cancer survivors are
poorly understood. An interpretive,
descriptive qualitative design was
adopted to better understand the care
that is provided to cancer survivors by
parish nurses and nurse practitioners.
This presentation will describe these
experiences of these community-based
care providers in taking care of cancer
survivors in New Brunswick, includ-
ing their professional responsibilities
and their informational needs and pref-
erences in caring for cancer survivors.
Data were captured through semi-struc-
tured interviews. Interviews were tran-
scribed and reviewed for common
themes. While recognizing the unique-
ness of these experiences, the results
of this research may serve as a starting
point for conversations about how to
implement best practices in delivering
ongoing supportive care to cancer survi-
vors in community settings.
Commentary on the presentation by
Jacqueline Galina
As the number of cancer survivors
increases (Canadian Cancer Society’s
Advisory Committee on Cancer
Statistics, 2014), there is a greater need
to care for the unique and complex
needs in cancer survivorship (Hewitt,
Greeneld, & Stovall, 2006; Howell
et al., 2011). Some models of cancer
care have shifted cancer survivorship
care (CSC) from specialized cancer clin-
ics to community care settings (Howell
et al., 2011) where clinicians care for
a spectrum of care needs (Aggarwal
& Hutchison, 2012; Martin-Misener
&Bryant-Lukosius, 2014). Parish nurses
and nurse practitioners are two groups
of community health care professionals
that have received little attention from
oncology researchers. More specically,
the perspectives of parish nurses’ and
nurse practitioners’ roles in survivor-
ship care have been previously unex-
plored. This presentation described two
qualitative studies that used interpretive
description (Thorne, 2013) to ll these
empirical gaps.
Presentation summary
Interviews with six parish nurses
and eight community nurse practi-
tioners sought descriptions of 1) their
role and responsibilities in caring for
REFERENCES
Carter v. Canada. Supreme Court Judgments.
6 Feb. 2015.
Headley, K. (2015, February 9). Canadian
Nurses Association welcomes Supreme Court
of Canada ruling on medically assisted
dying. Retrieved from www.cna-aiic.ca/
en/news-room/news-releases/2015/
canadian-nurses-association-welcomes-
supreme-court-of-canada-ruling-on-
medically-assisted-dying
Hivon, V. (2013, June 12). Bill n°52: An
Act respecting end-of-life care. Retrieved
from www.assnat.qc.ca/en/travaux-
parlementaires/projets-loi/projet-
loi-52-40-1.html
Medical Council of Canada. (2015). CLEO:
Objectives of the Considerations of the Legal,
Ethical and Organizational Aspects of the
Practice of Medicine. Medical Council of
Canada Web site. Retrieved from apps.
mcc.ca/Objectives_Online/objectives.
pl?lang=english&loc=cleo
Oregon Health Authority. (2015, February
2). Oregon’s Death with Dignity Act.
Oregon State Government Web site.
Retrieved from public.health.oregon.
gov/ProviderPartnerResources/
EvaluationResearch/
DeathwithDignityAct/Pages/index.aspx
Richardson, P. (Producer). (2011). How to Die
in Oregon [Documentary]. USA: Clearcut
Productions. Retrieved from http://www.
imdb.com/title/tt1715802/
Sullivan, P. (2015, 25 August). Assisted dying
dominates debate. Canadian Medical
Association Web site. Retrieved from
www.cma.ca/En/Pages/assisted-dying-
dominates-debate.aspx

92 Volume 26, Issue 1, WInter 2016 • CanadIan onCology nursIng Journal
reVue CanadIenne de soIns InfIrmIers en onCologIe
FEATURES/RUbRiqUES
cancer survivors; and 2) their informa-
tional needs to best provide this care.
Interpretive descriptive analyses found
that parish nurses perceived their role
as one that allowed them to speak with
parishioners about their spirituality in
the context of their health. These nurses
regard each parishioner as a unique
component within their family, as well
as the larger congregation to which they
also provided care. Parish nurses iden-
tied that they were limited in their
knowled ge about cancer while wanting
to provide accurate and best care. The
nurse practitioners regarded themselves
as a provider of holistic health care and
that their provision of supportive care to
their patients was lifelong. They iden-
tied that communication with cancer
survivors was challenging and that they
wanted foundational oncology education
in order to feel more prepared and com-
fortable in their primary care setting.
Signicance and relevance to nursing
practice
This presentation adds to our knowl-
edge about how parish nurses and com-
munity nurse practitioners regard their
roles and responsibilities in the care of
cancer survivors and what additional
information they need to best provide
this care. Stemming from and founded
in a nursing worldview, these studies
appropriately used interpretive descrip-
tion (Thorne, 2013) as the method to
analyze interviews with these nurses.
The intention of an interpretive descrip-
tive analysis is to use the clinical wisdom
within the nurse researcher to clarify the
nature of a given health context to build
knowledge and develop future strate-
gies for improvement (Thorne, 2013).
In this context, the ndings from this
study oer important insight into the
care that cancer survivors may receive
when discharged into the community.
Such insights, as well as the guidelines
and recommendations for Canadian can-
cer survivorship care (Howell et al., 2011),
provide complementary information
useful for stakeholders and/or policy-
makers to instill positive change in com-
munity-based cancer survivorship care.
The current Pan-Canadian Guidance on
Survivorship Services (Howell et al., 2011)
identies the importance of an organized
delivery of survivorship services, speci-
cally citing the relevance of partnerships
with community groups. Considering the
increased transfer of cancer survivorship
care into the portfolio of community care
providers (Howell et al., 2011; Martin-
Misener & Bryant-Lukosius, 2014), these
partnerships are more urgently needed
than ever before. Additional literature
outlining the perspectives of cancer sur-
vivors receiving care from these com-
munity care providers would oer an
important supplement to suggested com-
munity practice changes.
The ndings from this study are use-
ful for hospital-based oncology nurses,
and/or specialized oncology nurses, to
understand the informational needs of
non-specialized oncology nurses who
care for cancer patients beyond the hos-
pital-based oncology clinic. Drawing
from the recommendations in the Pan-
Canadian Guidance on Survivorship
Services (Howell et al., 2011), any clini-
cian caring for cancer survivors should
receive education to increase their
awareness of the needs of cancer survi-
vors. Follow-up care providers, such as
parish nurses and nurse practitioners
working in the community, are categor-
ically identied to receive specic survi-
vorship education (Howell et al., 2011).
The ndings highlighted in this presen-
tation, as well as the cited survivorship
care recommendations, call attention to
the value of specialized oncology nursing
knowledge. Specialized oncology nurses
can be empowered to share their exper-
tise with non-specialized clinicians, such
as those providing follow-up cancer care
in the community. This may include
education about common issues for per-
sons post cancer-treatment, survivorship
care planning, or the distribution of rel-
evant survivorship resources. Each of
these nursing roles is vital in the course
of cancer care. As such, avenues for
knowledge exchange to highlight chal-
lenges and informational needs would
improve the overall quality of cancer care
across the cancer care trajectory.
In-Brief
What we already know:
• Cancer survivors continue to have a
number of complex needs beyond the
active treatment phase of cancer.
• Cancer survivorship care is increas-
ingly being provided outside of
oncology clinics, such as primary
and community health settings, by
non-specialized oncology nurses.
What this presentation showed:
• Parish nurses and nurse practitioners
believe they have an important role in
post-treatment cancer survivorship
care.
• These nurses consider themselves as
outsiders to the cancer system and
perceive this is a barrier to the care
that they provide.
Next steps:
• Strategies for knowledge exchange
between nurses that provide care at
various phases of the survivorship tra-
jectory are needed.
• Insight into the perspectives of cancer
survivors receiving survivorship care
from these providers is needed.
REFERENCES
Aggarwal, M., & Hutchison, B. (2012).
Toward a primary care strategy for Canada.
Ottawa: ON. Retrieved from www.ch-
fcass.ca
Canadian Cancer Society’s Advisory
Committee on Cancer Statistics. (2014).
Canadian Cancer Statistics 2014. Canadian
Cancer Statistics. Toronto, ON: Canadian
Cancer Society.
Hewitt, M., Greeneld, S., & Stovall, E.
(2006). From cancer patient to cancer
survivor: Lost in transition. In M.
Hewitt, S. Greeneld, & E. Stovall, (Eds.),
Transition. Washington, DC. Retrieved
from www.nap.edu/catalog/11468.html
Howell, D., Hack, T.F., Oliver, T.K., Chulack,
T., Mayo, S., Aubin, M., … Tompson,
M. (2011). A Pan-Canadian Guidance on
Organization and Structure of Survivorship
Services and Psychosocial-Supportive Care
Best Practices for Adult Cancer Survivors.
Cancer. Toronto, ON. Retrieved from
www.cap.capdf/ENGLISH_Survivorship_
Guideline_Sept2011.pdf
Martin-Misener, R., & Bryant-Lukosius,
D. (2014). Optimizing the Role of Nurses
in Primary Care in Canada. Retrieved
from http://www.cfpna.ca/cms-assets/
documents/184147-364851.cna-
report-2014.pdf
Thorne, S. (2013). Interpretive description.
In C.T. Beck (Ed.), Routledge International
Handbook of Qualitative Nursing Research
(pp. 295–306). New York: NY: Taylor &
Francis.