Moral distress within neonatal and paediatric intensive care units: a systematic review

par Dr Annie Janvier
Moral Distress


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.

Keywords: Decision-making; Ethics; Intensive Care; Moral Distress; Palliative Care.



Institut de Biologie Moléculaire et Cellulaire, Plateforme Protéomique Strasbourg –
Esplanade, CNRS FRC1589, Université de Strasbourg, 2, allée Konrad Roentgen, F67084 Strasbourg (France)

SARS-CoV-2 coronavirus is responsible for Covid-19 pandemic. In the early phase of
infection, the single-strand positive RNA genome is translated into non-structural
proteins (NSP). One of the first proteins produced during viral infection, NSP1, binds
to the host ribosome and blocks the mRNA entry channel. This triggers translation
inhibition of cellular translation. In spite of the presence of NSP1 on the ribosome,
viral translation proceeds however. The molecular mechanism of the so-called viral
evasion to NSP1 inhibition remains elusive. Here, we confirm that viral translation is
maintained in the presence of NSP1 and we show that the evasion to NSP1-inhibition is mediated by the cis-acting RNA hairpin SL1 in the 5’UTR of SARS-CoV-2. Only the
apical part of SL1 is required for viral translation. We further show that NSP1 remains
bound on the ribosome during viral translation. We suggest that the interaction
between NSP1 and SL1 frees the mRNA accommodation channel while maintaining
NSP1 bound to the ribosome. Thus, NSP1 acts as a ribosome gatekeeper, shutting
down host translation and fostering SARS-CoV-2 translation in presence of the SL1 
5’UTR hairpin. SL1 is also present and necessary for translation of sub-genomic RNAs in the late phase of the infectious program. Consequently, therapeutic strategies targeting SL1 should affect viral translation at early and late stages of infection. Therefore, SL1 might be seen as a genuine ‘Achille heel’ of the virus. 


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