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Moral distress within neonatal and paediatric intensive care units: a systematic review
  1. Trisha Prentice1,2,
  2. Annie Janvier3,
  3. Lynn Gillam2,4,
  4. Peter G Davis5,6
  1. 1Neonatal Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria, Australia
  2. 2Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
  3. 3Division of Neonatology and Clinical Ethics, University of Montreal, Montreal, Quebec, Canada
  4. 4Children's Bioethics Centre, Royal Children's Hospital, Melbourne, Victoria, Australia
  5. 5Department of Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
  6. 6Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
  1. Correspondence to Dr Trisha Prentice, Neonatal Intensive Care Unit, Royal Children's Hospital, 50 Flemington Road, Parkville, Melbourne 3051, Australia; prenticet{at}


Objective To review the literature on moral distress experienced by nursing and medical professionals within neonatal intensive care units (NICUs) and paediatric intensive care units (PICUs).

Design Pubmed, EBSCO (Academic Search Complete, CINAHL and Medline) and Scopus were searched using the terms neonat*, infant*, pediatric*, prematur* or preterm AND (moral distress OR moral responsibility OR moral dilemma OR conscience OR ethical confrontation) AND intensive care.

Results 13 studies on moral distress published between January 1985 and March 2015 met our inclusion criteria. Fewer than half of those studies (6) were multidisciplinary, with a predominance of nursing staff responses across all studies. The most common themes identified were overly ‘burdensome’ and disproportionate use of technology perceived not to be in a patient's best interest, and powerlessness to act. Concepts of moral distress are expressed differently within nursing and medical literature. In nursing literature, nurses are often portrayed as victims, with physicians seen as the perpetrators instigating ‘aggressive care’. Within medical literature moral distress is described in terms of dilemmas or ethical confrontations.

Conclusions Moral distress affects the care of patients in the NICU and PICU. Empirical data on multidisciplinary populations remain sparse, with inconsistent definitions and predominantly small sample sizes limiting generalisability of studies. Longitudinal data reflecting the views of all stakeholders, including parents, are required.

  • Moral Distress
  • Ethics
  • Intensive Care
  • Palliative Care
  • Decision-making

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