Examining moral distress and injury resulting from the COVID-19 pandemic: Insights from the Ghanaian radiography workforce.

BACKGROUND: Moral distress has been an issue under consideration in healthcare practice. The COVID-19 pandemic became a critical factor that contributed to heightened moral distress and injury among healthcare professionals, including radiographers. Despite the substantial engagement of radiographers in the management of COVID-19 patients, the consequent moral distress and injury states experienced by this critical frontline workforce have not been widely explored. This study investigated the level of moral distress and the coping mechanisms employed by radiographers in Ghana during the pandemic to provide valuable information to support radiographers and prepare the workforce better against any future pandemics. METHODS: Utilising a cross-sectional design, a survey approach was employed for data collection between June 2023 and August 2023 from clinically-active radiographers who worked before and during the pandemic in Ghana. Both descriptive and inferential statistics were generated using Microsoft Excel 2019 and the Statistical Package for the Social Sciences (v.26). RESULTS: Hundred (100) radiographers participated in the study. The result demonstrated that the COVID-19 pandemic escalated the risk of moral distress among radiographers from 22 % (n = 22) to 43 % (n = 43), with 33 % (n = 33) exhibiting signs of moral injury. This escalation impacted the mental health of 12 % (n = 12) of respondents and was reported as a contributor to career-changing decisions among radiographers. Notably, many of those affected did not seek formal support but relied on personal coping strategies and family support. Inadequate resources (69 %, n = 69), particularly regarding consumables, emerged as the primary cause of moral distress. The study underscored that the most effective means of mitigating moral distress in radiographers was through the provision of resources and additional staff support (66 %, n = 66). CONCLUSION: This study sheds light on the state of moral distress and injury among radiographers during the COVID-19 pandemic, impacting the mental health of a minority and contributing to career-changing decisions. The findings emphasise the importance for healthcare institutions to proactively implement systems, such as resource provision, improved staffing, and emotional support, now and during similar future pandemics. This is crucial to address moral distress and cater to the mental health needs of radiographers, ensuring a resilient clinical radiography workforce.

Assessing Generative Pretrained Transformers (GPT) in Clinical Decision-Making: Comparative Analysis of GPT-3.5 and GPT-4.

BACKGROUND: Artificial intelligence, particularly chatbot systems, is becoming an instrumental tool in health care, aiding clinical decision-making and patient engagement. OBJECTIVE: This study aims to analyze the performance of ChatGPT-3.5 and ChatGPT-4 in addressing complex clinical and ethical dilemmas, and to illustrate their potential role in health care decision-making while comparing seniors' and residents' ratings, and specific question types. METHODS: A total of 4 specialized physicians formulated 176 real-world clinical questions. A total of 8 senior physicians and residents assessed responses from GPT-3.5 and GPT-4 on a 1-5 scale across 5 categories: accuracy, relevance, clarity, utility, and comprehensiveness. Evaluations were conducted within internal medicine, emergency medicine, and ethics. Comparisons were made globally, between seniors and residents, and across classifications. RESULTS: Both GPT models received high mean scores (4.4, SD 0.8 for GPT-4 and 4.1, SD 1.0 for GPT-3.5). GPT-4 outperformed GPT-3.5 across all rating dimensions, with seniors consistently rating responses higher than residents for both models. Specifically, seniors rated GPT-4 as more beneficial and complete (mean 4.6 vs 4.0 and 4.6 vs 4.1, respectively; P<.001), and GPT-3.5 similarly (mean 4.1 vs 3.7 and 3.9 vs 3.5, respectively; P<.001). Ethical queries received the highest ratings for both models, with mean scores reflecting consistency across accuracy and completeness criteria. Distinctions among question types were significant, particularly for the GPT-4 mean scores in completeness across emergency, internal, and ethical questions (4.2, SD 1.0; 4.3, SD 0.8; and 4.5, SD 0.7, respectively; P<.001), and for GPT-3.5's accuracy, beneficial, and completeness dimensions. CONCLUSIONS: ChatGPT's potential to assist physicians with medical issues is promising, with prospects to enhance diagnostics, treatments, and ethics. While integration into clinical workflows may be valuable, it must complement, not replace, human expertise. Continued research is essential to ensure safe and effective implementation in clinical environments.

Extending the concept of moral distress to parents of infants hospitalized in the NICU: a qualitative study in Greece.

BACKGROUND: The hospitalization of infants in the neonatal intensive care unit (NICU) is an ethically challenging situation. A limited number of studies have extended the concept of moral distress to parents of infants hospitalized in the NICU. This topic requires further investigation. METHODS: The present prospective qualitative study was conducted from February 2023 to May 2023. Data were collected through semistructured in-depth interviews, which were conducted in-person with fifteen parents of infants who were hospitalized in the NICU at the time of the interviews. Purposive sampling was used. The data were classified and analyzed using thematic analysis. RESULTS: Three themes emerged from the data analysis performed for this empirical study. One intrapersonal dimension featuring two aspects (one dynamic and one static) and another interpersonal dimension focusing on parental moral distress emerged from the data analysis. Furthermore, seven subthemes emerged across these themes: (1) self-directed negative feelings were experienced by parents due to their inability to fulfill their caregiving/parental roles; (2) intense internal conflict was experienced by parents in response to a moral dilemma that was difficult, which was perceived as irresolvable; (3) objectively unjustified, self-directed negative feelings of guilt or failure were experienced by parents; (4) parents experienced moral distress due to the poor image of the ill infants; (5) inadequate information may predispose parents to experience moral distress (6) neonatologists' caring behaviors were unduly perceived by parents as paternalistic behaviors; (7) reasonable or justified institutional rules were unduly perceived by parents as constraint. CONCLUSIONS: In general, the results of this study support the integrated definition of parental moral distress proposed by Mooney-Doyle and Ulrich. Furthermore, the present study introduces new information. The study distinguishes between the dynamic and static aspects of the intrapersonal dimension of the phenomenon of parental moral distress. Moreover, participants experienced moral distress because they unduly perceived certain situations as causing moral distress. In addition, inadequate information may predispose parents to experience moral distress. The findings of this study may contribute promote family-centered care in the NICU context.

Trolleys, crashes, and perception-a survey on how current autonomous vehicles debates invoke problematic expectations.

Ongoing debates about ethical guidelines for autonomous vehicles mostly focus on variations of the 'Trolley Problem'. Using variations of this ethical dilemma in preference surveys, possible implications for autonomous vehicles policy are discussed. In this work, we argue that the lack of realism in such scenarios leads to limited practical insights. We run an ethical preference survey for autonomous vehicles by including more realistic features, such as time pressure and a non-binary decision option. Our results indicate that such changes lead to different outcomes, calling into question how the current outcomes can be generalized. Additionally, we investigate the framing effects of the capabilities of autonomous vehicles and indicate that ongoing debates need to set realistic expectations on autonomous vehicle challenges. Based on our results, we call upon the field to re-frame the current debate towards more realistic discussions beyond the Trolley Problem and focus on which autonomous vehicle behavior is considered not to be acceptable, since a consensus on what the right solution is, is not reachable.

Perceived dilemma between protective measures and social isolation in nursing homes during the COVID-19 pandemic: a mixed methods study among Swiss nursing home directors.

Background: Coronavirus pandemic (COVID-19) particularly affected older adults, with the highest risks for nursing home residents. Stringent governmental protective measures for nursing homes unintendedly led to social isolation of residents. Nursing home directors (NDs) found themselves in a dilemma between implementing protective measures and preventing the social isolation of nursing home residents. Objectives: The objectives of this study were to describe protective measures implemented, to investigate NDs' perception of social isolation and its burden for nursing home residents due to these measures, and to explore experiences of NDs in the context of the dilemma. Methods: Cross-sectional embedded mixed-method study carried out by an online survey between April 27 and June 09, 2022, among NDs in the German-speaking part of Switzerland. The survey consisted of 84 closed-ended and nine open-ended questions. Quantitative findings were analyzed with descriptive statistics and qualitative data were evaluated using content analysis. Results: The survey was completed by 398 NDs (62.8% female, mean age 55 [48-58] years) out of 1'044 NDs invited.NDs were highly aware of the dilemma. The measures perceived as the most troublesome were restrictions to leave rooms, wards or the home, restrictions for visitors, and reduced group activities. NDs and their teams developed a variety of strategies to cope with the dilemma, but were burdened themselves by the dilemma. Conclusion: As NDs were burdened themselves by the responsibility of how to deal best with the dilemma between protective measures and social isolation, supportive strategies for NDs are needed.

Applying AVWEWM to ethical decision-making during autonomous vehicle crashes.

At present, a few scholars studied influencing factors, rules and mechanisms of decision-making in ethical dilemmas. Many factors have been identified, and a few rules and mechanisms have been proposed. However, due to the inability to evaluate the weight and role of each factor in decision-making, it is difficult to establish a computational decision-making model to solve ethical dilemmas. Therefore, entropy weighted method (EWM) and Attribute Value Weighted EWM (AVWEWM) are used to process 84 dilemmas respectively to evaluate the weight and role of each factor in decision-making, then decision-making models based on EWM and AVWEWM are constructed to make decisions during autonomous vehicle (AV) crashes respectively. Lastly, 40 dilemmas are designed to test both decision-making models. The test results indicate that both can make clear decision-making in 40 dilemmas. However, the decision-making by AVWEWM is more consistent with public opinion than EWM. In addition, according to the weight and role of each factor in decision-making, it can also provide a few references for traffic management and legal departments to formulate traffic laws and regulations for AV in the future.

A qualitative study on patients' selection in the scarcity of resources in the COVID-19 pandemic in a communal culture.

The scarcity of resources during the COVID-19 pandemic caused ethical dilemmas in prioritizing patients for treatment. Medical and ethical guidance only emphasizes clinical procedures but does not consider the sociocultural aspect. This study explored the perception of former COVID-19 patients and their families on the decision-making process of the patient's selection at a time of scarcity of resources. The result will inform the development of an ethical guide for allocating scarce resources that aligns with Indonesian culture. We conducted qualitative research with in-depth interviews between May - December 2022 involving sixteen participants from various cities in Indonesia. We transcribed the interviews and analyzed the results using thematic analysis. This study found that doctor's decisions often differed from patient's expectations in allocating scarce resources, and therefore, it should be communicated appropriately. Medical decisions were not sufficiently made ethically, but must also be made communicatively. In Indonesia's strong communal culture, community involvement was essential to distributing limited resources. A better approach to ethical education, including adequate communication skills, is necessary to prepare health professionals for facing unpredictable future pandemics.

Deontological Guilt and Moral Distress as Diametrically Opposite Phenomena: A Case Study of Three Clinicians.

Feelings of guilt are human emotions that may arise if a person committed an action that contradicts basic moral mores or failed to commit an action that is considered moral according to their ethical standards and values. Psychological scholarship distinguishes between altruistic guilt (AG) and deontological guilt (DG). AG results from having caused harm to an innocent victim, either by acting or failing to act, whereas DG is caused by violating a moral principle. Although physicians may be expected to experience frequent feelings of guilt in their demanding and intensive work, it is surprising to find that this issue has not been explored in the professional literature on medical ethics. To that end, we conducted a qualitative study that included personal in-depth interviews with Sunni Muslim gynaecologists. These doctors provide underground infertility care and perform religiously forbidden treatments involving sex selection and gamete donation. They opened their hearts and spoke about the emotionally taxing pangs of conscience they suffer. Analysing their narratives led us to characterize their feelings of guilt as DG. We discuss the causes for their plight and the way they cope with it, compare DG to the concept of moral distress, and call for future research on clinicians' feelings of guilt and pangs of conscience.

Ethical dilemmas faced by healthcare teachers during the COVID-19 pandemic.

BACKGROUND: Previous studies have shown that the rapid transition to emergency remote teaching due to the COVID-19 pandemic was challenging for healthcare teachers in many ways. This sudden change made them face ethical dilemmas that challenged their values and ethical competence. RESEARCH AIM: This study aimed to explore and gain a deeper understanding of the ethical dilemmas healthcare teachers faced during the COVID-19 pandemic. RESEARCH DESIGN: This was an inductive qualitative study using a hermeneutic approach. Semi-structured interviews were conducted and analysed thematically. PARTICIPANTS AND RESEARCH CONTEXT: Healthcare teachers (n = 20) from eight universities and universities of applied sciences in the Nordic and Baltic countries participated. ETHICAL CONSIDERATIONS: This study was based on the research ethics of the Norwegian National Research Ethics Committee for Medicine and Health Sciences and approved by the Norwegian Agency for Shared Services in Education and Research. FINDINGS: Healthcare teachers faced several ethical dilemmas due to restrictions during the COVID-19 pandemic. The analysis revealed three main themes: How should I deal with students' ill-being, and what can I as a teacher do?; What can I demand from myself and my students, what is good teaching?; How do I manage the heavy workload and everyone's needs, and who gets my time? CONCLUSIONS: This study highlights the importance of healthcare teachers' continuous need for pedagogic and didactic education, especially considering new technology and ethical issues. During the pandemic, the ethical consequences of remote teaching became evident. Ethical values and ethical dilemmas should be addressed in healthcare education programmes at different levels, especially in teacher education programmes. In the coming years, remote teaching will grow. Therefore, we need more research on this issue from an ethical perspective on its possible consequences for students and healthcare teachers.

[Characteristics of ethical dilemma and behavior in the support process of older adults and their families among nurses at a community general support center in Japan].

Objectives　This study was aimed at clarifying characteristics of ethical dilemmas and behaviors in the support process of older adults and their families among nurses at community general support centers.Methods　A self-administered questionnaire survey was mailed to 449 nurses at community general support centers in Tokyo. Question items enquired their age, employment license, years of experience as a nurse, the presence of ethics-related organizations, number of cases in which nurses faced difficulties in supporting older adults and their families in decision making over the past year, the ethical dilemmas they experienced and their situations, and ethical behavior in the process of supporting older adults and their families.Results　From the 143 responses (response rate: 31.8%), 135 (valid response rate: 30.1%) nurses were analyzed. Overall, 43.0% and 27.4% of the participants were in their 50s and 40s, respectively. Of these, 77.0% and 23.0% were nurses and public health nurses, respectively. In total, 52 (38.5%) respondents had an ethics-related organization. The average number of cases in which the respondents faced difficulties in supporting older adults and their families in decision making over the past year was 8.3 (standard deviation, 12.5). Of these, the average number of cases in which they faced difficulties in making ethical decisions was 4.1 (standard deviation, 6.0). Regarding the perception of ethical dilemmas, 113 (83.7%) answered "often" or "sometimes." Ethical dilemma situations included "the intentions of the user and family were different, and I had trouble deciding what to respect" 95 (84.1%); "the user's intention was different from my judgment as a professional, and I had trouble deciding what to respect" 64 (56.6%); and "the intention of the user and neighbors were different, and I had trouble deciding what to respect" 56 (49.6%). Ethical behaviors included "I observe the management rules in my organization regarding personal information data" 116 (85.9%); "I provide easy-to-understand explanations appropriate to the user's situation" 115 (85.2%); and "I decide on a support policy with several staff members when self-decision making is difficult due to the user's situation" 113 (83.7%).Conclusion　More than 80% of the nurses perceived ethical dilemmas. Characteristics of the situations were that users and their families, users and professionals, and users and their neighbors had different intentions. Further research should be conducted on ethical issues related to community-based integrated care.

A scoping review of the moral distress of military nurses in crisis military deployment.

BACKGROUND: "Crisis military deployment" was defined as a situation in which military personnel are suddenly ordered to duty to support an operation away from their home station and in a potentially dangerous environment. As a result of complex changes in the global political and economic landscape, military nurses are assuming an increasing number of crisis military deployment tasks. Moral distress has been widely studied among civilian nurses. However, little is known about the moral distress military nurses experience during military deployments in crisis. AIM: This review discussed the current state of research on the phenomenon, unique factors, specific sources, and measurement tools. METHODS: The scope of the study was defined using a framework developed by Arksey and O'Malley. Following English databases were searched: PubMed, CINAHL, Cochrane Library, Web of Science, and Embase, using MeSH terms and free word combinations; furthermore, Chinese databases: CNKI and CBMDisc, were explored using thematic terms from inception until January 20, 2023. Data were selected and defined by the inclusion and exclusion criteria and independently screened by two researchers. ETHICAL CONSIDERATIONS: The scoping review adhered to sound scientific practice and respected authorship and reference sources. RESULTS: Finally, 21 articles were included in the review. The moral distress of military nurses in crisis military deployments had unique and specific sources and reported positive aspects. The deployment environment and nature of the mission, responsibilities and obligations of military nurses, and the limited rights of patients were unique factors. Specific sources included third-party intervention, military triage, resource allocation, futile care, care of the enemy, and return to the battlefield. Military nurses in deployment reported positive aspects. They grow in their inner strength, build deep friendships and gain a greater sense of professional value. CONCLUSION: It is important to understand the unique factors and specific sources of moral distress faced by military nurses in crisis military deployments and to identify the positive aspects. This research will help prepare military nurses for future deployments in advance by providing useful information to mitigate and eliminate moral distress.

Simulation as a key training method for inculcating public health leadership skills: a mixed methods study.

Background: Successful management of public health challenges requires developing and nurturing leadership competencies. We aimed to evaluate the effectiveness of training simulations to assess public health leadership and decision-making competencies during emergencies as an effective learning and training method. Methods: We examined the effects of two simulation scenarios on public health school students in terms of their experience (compared to face-to-face learning) and new skills acquired for dealing with similar emergent situations in the future. A mixed-methods design included developing a validated and pre-tested questionnaire with open-and closed-ended questions that examined the simulation impact and the degree of student satisfaction with the conditions in which it was conducted. Semi-structured in-depth interviews were conducted with the students after going through the simulations. The questionnaire results were evaluated using descriptive analytics. The interviews were analyzed using thematic analyses. All data were collected during June 2022. Results: The questionnaire results indicate that students strengthened their interpersonal communication skills and learned about the importance of listening to the opinions of others before formulating their positions. Four themes emerged from 16 in-depth interviews, according to Kolb's experimental learning cycle. Students emphasized the effectiveness of experiential learning versus traditional classroom learning. The simulation scenarios were felt to realistically convey critical issues regarding leadership, decision-making, and teamwork challenges. They effectively conveyed the importance of building a culture of conducting substantive and respectful discussions. Conclusion: Simulation is a powerful pedagogical training tool for public health leadership competencies. Simulations were seen to be advantageous over face-to-face learning in imparting a range of leadership skills and hands-on practice. We recommend integrating simulations in all public health leadership training programs.

Ethical conflicts associated with COVID-19 pandemic, triage and frailty-unexpected positive disease progression in a 90-year-old patient: A case report.

During the COVID 19 pandemic, advanced age, scoring systems, and a shortage of ICU beds were used as cut-offs for ICU admission. This case report describes the epicrisis of an elderly patient who was almost mistakenly not treated in an ICU.

The dual role dilemma of liver transplantation health care professionals.

BACKGROUND: Similar to many other countries, in Germany patients with alcohol-related liver disease are obliged to prove their abstinence before being accepted on a waitlist for liver transplantation. Health care professionals (HCPs) must both treat patients and ensure that patients have proven their abstinence. The aim of this exploratory study was to develop a deeper understanding of how HCPs deal with this dual role. METHODS: The study used semi-structured interviews as the source of data. 11 healthcare professionals from ten of the 22 German transplant centers were interviewed. After transcription, a qualitative content analysis was performed. RESULTS: We found that these HCPs faced an ethical dilemma, as they must balance the roles of being both a treatment provider (the therapist role) and an assessor (the monitoring role). To solve this dilemma, the strategy seems to be a tendency for the HCPs to take on one dominant role amongst these two roles. HCPs who prefer to take on the therapist role seem to feel burdened by the 6-month abstinence rule and the obligation to monitor their patients. HCPs who prefer to take on the monitoring role tend to have negative assumptions about the patients. HCPs also reported the impression that patients perceive HCPs as more involved in monitoring and less open to the therapeutic role. From this it can be deduced that current regulations and structures lead both to stress for HCPs and to suboptimal therapy for those affected. CONCLUSIONS: The results showed that current transplantation guidelines can have a negative impact on both patient care and the burdens on the HCPs. From our point of view, there are various changes that could be made to the current clinical practice that would help solve this dilemma. For instance, integrating other assessment criteria that are more closely adapted to the health status trajectory and psychosocial background of the individual patient would be both possible and would lead to improvements in practice.

Ethical challenges and dilemmas in the rationing of health commodities and provision of high-risk clinical services during COVID-19 pandemic in Ethiopia: the experiences of frontline health workers.

BACKGROUND: Ethical reasoning and sensitivity are always important in public health, but it is especially important in the sensitive and complex area of public health emergency preparedness. Here, we explored the ethical challenges, and dilemmas encountered by frontline health workers amid the coronavirus disease-19 (COVID-19) pandemic in Ethiopia. METHODS: A nationwide survey was conducted amongst the frontline health workers from nineteen public hospitals. Health workers were invited to respond to a self-administered questionnaire. Data were weighted and analyzed using descriptive statistics. RESULTS: Of the 285 frontline health workers to whom questionnaires were distributed, 217 of them gave their responses (response rate 76.1%). Respondents frequently reported encountering rationing dilemmas on health commodities directly used for the prevention and treatment of COVID-19. Most (83.9%) of the health workers agreed that they encountered ethical challenges very frequently or frequently. Almost all [215(99.1%)] claimed that the limitation of resources was directly used for the treatment and prevention of COVID-19. The frequency of difficulty in the provision of essential clinical services varied between 77% and 98.7% for different services. More than half of the study participants reported that they had encountered difficulty in the provision of clinical care on a daily or weekly basis. Regarding rationing strategies, isolating COVID-19 treatment units and limiting admission were the most frequent rationing strategies used by two-thirds of health workers on a daily or weekly basis. CONCLUSION: Front-line health workers encountered numerous ethically challenging situations during COVID-19. More than half of health workers reported that they encountered ethical challenges in rationing the resources and delivery of different clinical services such as family planning services, maternal and childcare, immunization, and chronic care. With limited resources such as ventilators and hospital beds, healthcare providers have been faced with the difficult task of deciding who gets access to these resources and who doesn't. Overall, the COVID-19 pandemic has presented numerous ethical challenges for healthcare providers, highlighting the importance of ethical considerations in healthcare delivery. By being aware of these dilemmas and having policies in place to address them, healthcare providers can ensure that they are providing the best possible care to their patients while upholding ethical standards.

[Practice of Ethics Education Using a Documentary Film for Pharmacy Students].

In today's world, where clinical options are ever increasing and patients' needs are more diverse, it is not possible to conclude that simply practicing medical care based on pathophysiological data and medical evidence is sufficient for patients, particularly in terms of seeing each patient as an individual. Medical professionals must maintain a close relationship with their patients and seek treatment and care methods that reflect the patient's values and views on life and death, based on their own ethics in medical care. Ethics education should be provided on a continuing basis from the beginning of medical/pharmacy school. However, ethics education in pharmacy departments is often delivered in a lecture format attended by many students and/or as group training using case studies and hypothetical situations, i.e., "paper" patients. With these teaching methods, there are limited opportunities for the students to foster a sense of ethics or to think deeply about their values and views on life and death with respect to the patients they care for. Therefore, in this study, we conducted ethics exercises for pharmacy students in a group study format using a documentary film of real patients who were facing death. By retrospectively analyzing the results of the questionnaires collected before and after the assignments and exercises, we verified the educational effects and changes in the students' sense of ethics from participating in the group learning exercise; moreover, our results revealed the insight gained by the students in examining the experiences and challenges faced by terminally ill patients.

Reducing Moral Stress in Veterinary Teams? Evaluating the Use of Ethical Discussion Groups in Charity Veterinary Hospitals.

This study examines experiences of veterinary moral stress in charity veterinary practice and qualitatively evaluates the role of ethical discussion in reducing veterinary moral stress. Results are drawn from a thematic data analysis of 9 focus groups and 15 individual interviews with veterinary team members from 3 UK charity veterinary hospitals. Moral stress is described as an everyday experience by participants and is caused by uncertainty about their ability to fulfill their ethical obligations. Moral stress is shown to be cumulative and can interact with other forms of stress. Distinct practical and relational barriers to ethical action are identified and proposed as contributors to moral stress, and different team members experience different barriers within their roles. The potential impact of moral stress on team members' quality of life and mental health is highlighted. Results show that regular facilitated ethical group discussions may reduce moral stress in the hospital setting, particularly through familiarization with others' roles and ethical perspectives and through supporting one another's ethical decision-making. The article concludes that moral stress is an important and poorly understood problem in veterinary practice and that further development of regular facilitated ethical group discussion may be of considerable benefit to team members.

NICU nurses' moral distress surrounding the deaths of infants.

BACKGROUND: As Korean neonatal nurses frequently experience the deaths of infants, moral distress occurs when they provide end-of-life care to the infants and their families. Although they need to care for the patients' deaths and consequently experience burnout and turnover due to moral distress from the situation, there is a lack of a support for nurses. Moreover, not much information is available on the moral distress of neonatal nurses. There is a need to better understand Korean neonatal nurses' moral distress to develop and implement appropriate supports. OBJECTIVE: This study aimed to describe nurses' experience of moral distress when they provide end-of-life care to infants and their families in neonatal intensive care units. RESEARCH DESIGN: This is a secondary analysis qualitative study. Content analysis was performed based on Corley's theory of moral distress to develop a codebook and identify themes regarding moral distress among the nurses. PARTICIPANTS AND RESEARCH CONTEXT: Qualitative data were collected from 20 nurses working in two NICUs in Seoul, South Korea. ETHICAL CONSIDERATIONS: The original study obtained permission from a university's institutional review board (IRB). This secondary analysis study obtained the exemption from another university's IRB. Nurses' participation was voluntary and confidential. FINDINGS: The nurses' moral distress was derived when they faced moral constraints and/or moral conflicts. Two distinct categories of moral constraints and four distinct categories of moral conflicts were identified among the neonatal nurses. In addition, impacts of moral distress on patients and nurses were identified. CONCLUSIONS: This study identified occasions neonatal nurses experience moral distress, and thus can guide in developing and implementing effective interventions to decrease their moral distress and improve their resilience in end-of-life care by providing insight into neonatal nurses' needs for support in end-of-life care.

Active Euthanasia for Perinatal Osteogenesis Imperfecta; An Ethical Dilemma in a Tertiary Facility in Southwestern Nigeria: A Case Report.

Managing a newborn with lethal congenital anomalies is challenging but handling a parent's request for doctors under oath to terminate the baby's life is another major ethical dilemma requiring cautious evaluation. We present a term male neonate who presented on the 7th day of life, with a dark-blue sclera, multiple limb deformities, long bone fractures, beaded ribs, a flattened forehead, a narrow chest, and respiratory distress. A Diagnosis of Type II Osteogenesis imperfecta was made and he was managed by a multidisciplinary team including neonatologists, geneticists/endocrinologists, orthopaedic surgeons, nurses, and medical social workers. Supplemental oxygen, intravenous fluids and antibiotics, analgesia, and bisphosphonates were offered as supportive care. The main concern was the challenges of managing a newborn with lethal OI and balancing the demand for euthanasia by the parents to end the baby's misery. In providing care, the rights of the child to life, the morals of the physician, the best interests of the baby, and the family's role in decision-making in a setting of out-of-pocket expenditures must be weighed. Following extensive multidisciplinary team meetings, it was ultimately decided to allow nature to take her course. Baby subsequently had progressive respiratory distress from pulmonary hypoplasia and died of respiratory failure on the twelfth day of life. In Conclusion, Osteogenesis imperfecta of the perinatal type is usually a lethal disease, with death often occurring within the perinatal period. The physician must, therefore, balance the parental rights, the oath of office, and the existing legal framework to avoid charges of murder or manslaughter.