Van Nguyen DNP, APRN, AGACNP-BC, FNP-C, PMGT-BC
One of the most rewarding moments in my nursing career came unexpectedly during a routine shift that became anything but routine. I was assigned to care for a 52-year-old male with esophageal cancer, seven days post-op after an esophagectomy. Esophageal cancer accounts for 2.6% of all new cancer cases and 4.6% of cancer-related deaths globally, making it the eleventh most prevalent cancer and the seventh most common cause of cancer-related deaths (Jiang et al., 2024).
Esophagectomy is the standard curative treatment for patients with localized esophageal cancer (Fabbi et al., 2020; Jiang et al., 2024). Two possible complications after esophagectomy include pneumonia and anastomotic leak (Worrell et al., 2023). Among the two, anastomotic leak is the most severe complication, resulting in increased morbidity and mortality for patients after esophagectomy (Fabbi et al., 2020).
Typically, after esophagectomy, patients recover in the post-anesthesia care unit (PACU) and are then transferred to my unit, the Thoracic and Cardiovascular Surgery, for telemetry monitoring for the remainder of their hospital stay. During hospitalization, patients and family members are encouraged to visit, with one visitor allowed to stay overnight. For this patient, his family was actively involved and attentive, providing a strong support system that was a bright spot in an otherwise difficult clinical journey. At the time, my unit had recently implemented bedside shift reports. Although the change was initially met with some resistance, I found it often allowed me to engage more meaningfully with both patients and their loved ones at the start of my shift.
That evening, as I entered the room to receive report and meet the patient and his family, something immediately caught my attention: the fluid in his chest tube had a faint greenish hue. It was subtle, but it was a shade I had never encountered on the unit. I paused and asked the outgoing nurse, who reassured me that this color was “unchanged” and not a cause for concern. Despite her confidence, I could not ignore the sense of unease that lingered in the back of my mind. As I began my initial assessment, I noticed another subtle but significant finding: his heart rate was trending slightly high, in the low 100s.
Fabbi et al. (2020) suggest that patients with an anastomotic leak may initially present with mild symptoms such as tachycardia. The patient was otherwise hemodynamically stable, afebrile, and without chills, shortness of breath, or pain beyond his expected post-surgical discomfort. His surgical incisions appeared healthy and clean, and his white blood cell count remained mildly elevated, consistent with his prior labs. Still, something about the clinical picture did not sit right with me. The subtle light green chest tube output, combined with mild tachycardia and his recent major thoracic surgery, raised a red flag in my mind. I recounted our recent training sessions on recognizing signs of an anastomotic leak, one of the most serious complications following esophagectomy. I mentally reviewed the signs: increased heart rate, change in chest drainage color, and subtle systemic symptoms. Though the patient looked well, I knew better than to be reassured by appearance alone. In fact, according to Fabbi et al. (2020), the presence of gastric contents in the drain is a sign of an anastomotic leak. At that moment, I was guided by the ethical principles of beneficence, the duty to do good, as well as nonmaleficence, the obligation to prevent harm (Beauchamp & Childress, 2019). These core nursing values compelled me to act not only with certainty but with vigilant concern. My responsibility was not just to document what I saw, but instead it was to question, advocate, and protect.
After completing the change-of-shift report for my other patients and ensuring their safety, I decided I could not let it go. I called the on-call physician, presented my findings concisely and in detail, and expressed concern that the patient may have an early anastomotic leak. I emphasized that although the symptoms were subtle, they were atypical enough to warrant further investigation.
When I did not sense the urgency I expected, I escalated my concern to the attending physician and looped in my nursing leadership. This was not just clinical decision-making; it was an ethical act of advocacy. Nurses are the most qualified advocates for patients (Heck et al., 2022). Provision 2 of our Code of Ethics clearly anchors our primary concern to those under our care. Nurses are ethically obligated to speak up, especially when their intuition and critical thinking tell them something is wrong. That night, I chose to honor the patient’s trust in me by being his voice when he could not fully grasp the gravity of what was unfolding. That night, a computed tomography (CT) scan was performed, and the results confirmed what I had feared: the patient had indeed had an anastomotic leak. In this patient’s situation, the gastric content appeared subtle because it was an early anastomotic leak. Thanks to early detection, the surgical team was able to take the patient to the operating room that same night for immediate intervention.
Because of this timely action, the patient avoided a more serious and potentially life-threatening deterioration. The next day, the patient’s wife pulled me aside, tears in her eyes, and said, “You saved my husband’s life.” From that point on, the patient and his family requested that I be his primary nurse for the remainder of his hospital stay. They trusted me. They knew that I would be vigilant, that I would speak up, and that I genuinely cared. That experience left a lasting impact on me. It reaffirmed that nursing is not just about following orders or executing tasks. Instead, it is about upholding our ethical commitment to fidelity: to be faithful to our patients, including advocating on their behalf (Beauchamp & Childress, 2019), to adhere to our professional standards, and to listen to the inner voice that tells us, “something is not right.” Looking back, that day represents one of my proudest moments as a nurse. It was not a day of grand gestures or dramatic interventions. It was a day when quiet observation, moral courage, and a refusal to accept “normal” made all the difference.
It showed me that our most powerful tools as nurses are not only in our hands, but in our eyes, our voices, and our hearts. It also reminded me that ethics is not only about complex dilemmas but also about the daily decisions we make when no one is watching.
References
Beauchamp, T. L. & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.
Fabbi, M., Hagens, E. R. C., Van Berge Henegouwen, M. I., & Gisbertz, S. S. (2020). Anastomotic leakage after esophagectomy for esophageal cancer: definitions, diagnostics, and treatment. Diseases of the Esophagus, 34(1). https://doi.org/10.1093/dote/doaa039
Heck, L. O., Carrara, B. S., Costa Mendes, I. A., & Arena Ventura, C. A. (2022). Nursing and advocacy in health: An integrative review. Nursing Ethics, 29(4), 1014–1034. https://doi.org/10.1177_09697330211062981
Jiang, W., Zhang, B., Xu, J., Xue, L., & Wang, L. (2024). Current status and perspectives of esophageal cancer: a comprehensive review. Cancer Communications, 45(3), 281–331. https://doi.org/10.1002/cac2.12645
Worrell, S. G., Goodman, K. A., Altorki, N. K., Ashman, J. B., Crabtree, T. D., Dorth, J., Firestone, S., Harpole, D. H., Hofstetter, W. L., Hong, T. S., Kissoon, K., Ku, G. Y., Molena, D., Tepper, J. E., Watson, T. J., Williams, T., & Willett, C. (2023). The Society of Thoracic Surgeons/American Society for Radiation Oncology updated clinical practice guidelines on multimodality therapy for locally advanced cancer of the esophagus or gastroesophageal junction. Practical Radiation Oncology, 14(1), 28–46. https://doi.org/10.1016/j.prro.2023.10.001
About Van Nguyen
Van Nguyen is a dual-certified acute and family nurse practitioner with nearly 20 years of oncology nursing experience. She has a strong passion for direct patient care and mentoring the next generation of nurses through education. Van aims to transition from her current role into a full-time faculty position where she can focus on shaping and inspiring future nurses. Her clinical interests include nursing retention and education, postoperative recovery, and early cancer detection. In her free time, she enjoys gardening, traveling, and cooking.