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How should neonatal clinicians act in the presence of moral distress?
  1. Trisha M Prentice1,2,3,
  2. Lynn Gillam2,4,
  3. Annie Janvier5,
  4. Peter G Davis6,7
  1. 1Neonatal Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
  2. 2Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
  3. 3Neonatal Research, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
  4. 4Children’s Bioethics Centre, The Royal Children’s Hospital, Melbourne, Victoria, Australia
  5. 5Pediatrics and Clinical Ethics, University of Montreal, Montreal, Québec, Canada
  6. 6Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
  7. 7Newborn Research, The Royal Women's Hospital, Parkville, Victoria, Australia
  1. Correspondence to Dr Trisha M Prentice, Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville VIC 3052, Australia; trisha.prentice{at}

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Hannah was born at23+1weeks. At2 weeksof age, Hannah developed severe necrotising enterocolitis requiring extensive resection of her small bowel. She remains ventilated and dependent on inotropes. Additionally, Hannah is known to have bilateral gradeIVintraventricular haemorrhages. The doctors and nurses caring for her believe that it is very unlikely she will survive and if she does, major disability is almost inevitable. The treating team hascommunicateditsconcerns to her parents several times over the past48 hoursand hassuggested discontinuing life-sustaining interventions. Her parents understand the recommendation but have requested thateverything be done to save their baby’s life. This leads to considerable distressamongmany team members who believe ongoing life-sustaining treatment is no longer in Hannah’s interests.

Moral distress is increasingly recognised as an important issue affecting the well-being of clinicians. It is the anguish that occurs when clinicians are prevented from acting in accordance with their moral judgements.1 Most commonly, moral distress reflects the belief that a child is receiving disproportionate care (‘doing too much’) that is not in his or her interests,2 as in the case of Hannah. Historically, moral distress has often been framed as an institutional failing3 where medical hierarchy enforces nurses and medical residents to provided futile care against their better judgement and without a viable pathway for their concerns to be heard. The term ‘moral distress’ has therefore become something of a buzzword, used to demand action to overcome these perceived institutional failings, to empower distressed clinicians and thereby to eliminate moral distress within the institution. Within paediatric acute care settings, literature on moral distress generally implies that, to optimally address moral distress, the management plan for a patient needs to …

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  • Contributors All authors have made substantial contributions to the conception of this article, revising it critically and approving the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.

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