A culture of avoidance: voices from inside ethically difficult clinical situations.

BACKGROUND Healthcare providers experience many ethical challenges while caring for and making treatment decisions with patients and their families. OBJECTIVES The purpose of this ethnographic study was to examine the challenges and circumstances that surround ethically difficult situations in oncology practice. METHODS The authors conducted six focus groups with 30 oncology nurses in the United States and interviewed 12 key informants, such as clinical ethicists, oncologists, and nurse administrators. FINDINGS The authors found that many healthcare providers remain silent about ethical concerns until a precipitating crisis occurs and ethical questions can no longer be avoided. Patients, families, nurses, and physicians tended to delay or defer conversations about prognosis and end-of-life treatment options. Individual, interactional, and system-level factors perpetuated the culture of avoidance. These included the intellectual and emotional toll of addressing ethics, differences in moral perspectives, fear of harming relationships, lack of continuity in care, emphasis on efficiency, and lack of shared decision making. This information is critical for any proactive and system-level effort aimed at mitigating ethical conflicts and their frequent companions-moral distress and burnout.