In this issue of ISNCC Academic Express, we highlight a qualitative study published in Cancer Nursing by a research team in Türkiye, exploring the ethical dilemmas experienced by pediatric oncology nurses during end-of-life (EOL) care. The study brings nurses’ voices to the forefront, examining how they navigate complex tensions among medical decisions, children’s dignity, family needs, and organizational constraints.
The findings highlight challenges including uncertainty around potentially futile treatment, limited nursing authority in decision-making, ethical silence, and the emotional burden of EOL care. This study provides valuable insights for the global cancer nursing community and underscores the importance of clear EOL care standards, interdisciplinary shared decision-making, ethics support, and emotional preparation for nurses. Strengthening these areas can help advance compassionate, patient- and family-centred pediatric cancer care across diverse health systems.
Why We Chose This Research Topic?
Despite remarkable progress in pediatric cancer survival, many children still progress to end-of-life care, one of the most emotionally and ethically demanding areas of pediatric oncology nursing. While ethics in adult oncology and palliative care are well documented, qualitative evidence capturing pediatric nurses' own voices remained limited. We wanted to understand, from nurses themselves, how they navigate the tension between medical necessity, children's dignity, and family needs when difficult decisions must be made.
What We Discovered?
We conducted three online focus groups with 13 pediatric oncology nurses across Türkiye, most with five or more years of experience in university hospitals. Using Braun and Clarke's thematic analysis, three overarching themes emerged. The first, Ethical Issues in End-of-Life Clinical Care, captured nurses' uncertainty about continuing interventions perceived as futile, decisions about place of care and quality of life, tension between honesty and preserving hope, and system-imposed constraints such as bed shortages and the absence of dedicated palliative spaces. The second, Lack of Authority in Decision-Making Mechanisms and Ethical Silence, revealed that although nurses hold rich, continuous knowledge of children and families, physician-centered hierarchies and unclear institutional or legal frameworks often leave them unable to voice their concerns. The third, The Emotional and Professional Cost of Ethical Conflicts, described the cumulative helplessness, guilt, and exhaustion nurses carry, often far beyond working hours.
What struck me most was how consistently nurses described feeling caught between conscience and institutional rules, with no structured way to consult about what they believed was ethically right.
Implications for Cancer Care
1. Strengthen Institutional EOL Standards: Most participating nurses reported no clear end-of-life protocol. Standardized, child-centered EOL guidelines and expanded pediatric palliative care services can reduce the uncertainty falling on individual nurses.
2. Create Space for Nursing Voice: Because nurses' day-to-day knowledge of children and families is rarely integrated into formal decisions, embedding ethics consultation and shared decision-making structures into EOL care could translate nursing insight into actionable care planning.
3. Invest in Ethical and Emotional Preparedness: Structured training on truth-telling, moral distress, and complex EOL communication may strengthen nurses' confidence in difficult moments, while organizational psychosocial support can help sustain compassionate care and protect against burnout.
Ultimately, ethical dilemmas in pediatric oncology EOL care are shaped by relational, organizational, and institutional contexts together, not isolated clinical events. Listening to nurses, and giving them a genuine role in ethical decision-making, is essential to sustaining dignity-oriented care for children and families facing the end of life.
Source：
Şahin, R. S., Sümengen, A. A., Ercan-Koyuncu, İ., Tekinyildiz, E., Güneş, E., Savaş, E. H., . . . Ay, A. (2025). Under the shadow of ethical dilemmas: A qualitative study of pediatric oncology nurses’ end-of-life care experiences. Cancer Nursing. Advance online publication. https://doi.org/10.1097/NCC.0000000000001599
Author:
By Remziye Semerci Şahin, RN, MSN, PhD, School of Nursing, Department of Pediatric Nursing, Koç University, Istanbul, Türkiye
