Moral Distress,Workplace Health,and Intrinsic Harm

Moral distress is now being recognized as a frequent experience for many health care providers, and there's good evidence that it has a negative impact on the health care work environment. However, contemporary discussions of moral distress have several problems. First, they tend to rely on inadequate characterizations of moral distress. As a result, subsequent investigations regarding the frequency and consequences of moral distress often proceed without a clear understanding of the phenomenon being discussed, and thereby risk substantially misrepresenting the nature, frequency, and possible consequences of moral distress. These discussions also minimize the intrinsically harmful aspects of moral distress. This is a serious omission. Moral distress doesn't just have a negative impact on the health care work environment; it also directly harms the one who experiences it. In this paper, I claim that these problems can be addressed by first clarifying our understanding of moral distress, and then identifying what makes moral distress intrinsically harmful. I begin by identifying three common mistakes that characterizations of moral distress tend to make, and explaining why these mistakes are problematic. Next, I offer an account of moral distress that avoids these mistakes. Then, I defend the claim that moral distress is intrinsically harmful to the subject who experiences it. I conclude by explaining how acknowledging this aspect of moral distress should reshape our discussions about how best to deal with this phenomenon.     

Moral Distress and its Interconnection with Moral Sensitivity and Moral Resilience: Viewed from the Philosophy of Viktor E. Frankl

The interconnection between moral distress, moral sensitivity, and moral resilience was explored by constructing two hypothetical scenarios based on a recent Swedish newspaper report. In the first scenario, a 77-year-old man, rational and awake, was coded as “do not resuscitate” (DNR) against his daughter’s wishes. The patient died in the presence of nurses who were not permitted to resuscitate him. The second scenario concerned a 41-year-old man, who had been in a coma for three weeks. He was also coded as “do not resuscitate” and, when he stopped breathing, was resuscitated by his father. The nurses persuaded the physician on call to resume life support treatment and the patient recovered. These scenarios were analyzed using Viktor Frankl’s existential philosophy, resulting in a conceivable theoretical connection between moral distress, moral sensitivity, and moral resilience. To substantiate our conclusion, we encourage further empirical research.     

Notes On the Crow-Hidatsa Schism

Abstract

Three lines of evidence bearing on the Crow-Hidatsa separation provide different dates for that separation, but dates which are consistent with the following generalizations: (1) The Crow began to diverge linguistically from the various Hidatsa groups no less than five centuries ago, and perhaps even earlier. (2) The Crow movement onto the Northwestern Plains was accomplished gradually, perhaps by band-by-band movement, rather than as one precipitous migration away from the Hidatsa. (3) Archaeological evidence from sites of the Mandan/Hidatsa continuum in the Missouri Valley suggest that the Hagen site, at least, probably dates at about A.D. 1675 – although alternative explanations for related sites suggest that the Crow moved into the Northwestern Plains several centuries earlier. (4) Ethnohistorical data suggest that the Crow separation dates from the mid-1700s. Rather than dating the initial separation of the two groups, the ethnohistorical data probably reflect the final severing of ties with the Hidatsa – a separation made final by the adoption of the horse.     

Neonatal Euthanasia: Why Require Parental Consent?

The Dutch rules governing neonatal euthanasia, known as the Groningen Protocol, require parental consent for severely disabled infants with poor prognoses to have their lives terminated. This paper questions whether parental consent should be dispositive in such cases, and argues that the potential suffering of the neonate or pediatric patient should be the decisive factor under such unfortunate circumstances.     

Moral Distress: An Innovative and Important Subject to Study in Brazil

There have been recurrent reports of fragilities in the Brazilian health system, especially in public institutions. In this commentary, I argue that moral distress in nursing in Brazil can still be considered an innovative and important subject of study. I also highlight the relevance of engaging educational institutions in the development of policies about environmental sustainability. It is relevant to continue studying moral distress in nursing and in health care generally in order to contribute to the transformation of reality by confronting the multiple common situations in the work environment that are recognized by many as morally problematic because they infringe upon the rights of people, patients, and health care professionals and are an affront to environmental health.     

A Reflection on Moral Distress in Nursing Together With a Current Application of the Concept

The concept of moral distress can be extended from clinical settings to larger environmental concerns affecting health care. Moral distress—a common experience in complex societies—arises when individuals have clear moral judgments about societal practices, but have difficulty in finding a venue in which to express concerns. Since health care is large in scale and climate change is proving to be a major environmental problem, scaling down health care is inevitably a necessary element for mitigating climate change. Because it is extremely challenging to discuss these concerns in health care settings, those concerned about climate change and health care experience distress. This article outlines some philosophical concepts and perspectives that may be useful in mitigating this distress.     

Neonatal Cardiac Distress—A Practical Approach to Recognition,Diagnosis, and Management

The death rate among neonates with cardiovascular disease is 50 percent during the first six months, with the majority dying during the first month. With early diagnosis most of these babies could be saved. In approaching the diagnosis of cardiac distress in the newborn, it is important to remember that the types of cardiovascular disease which cause symptoms and death early in life are quite different from those in older children. Lesions such as hypoplasia of the left heart, transposition of the great arteries, endocardial fibroelastosis, pulmonary atresia, mitral atresia, tricuspid atresia and truncus arteriosus are common, not rare, causes of cardiac distress in the newborn.A classification of neonatal cardiovascular diseases into seven pathophysiological groups is presented as a basis for an effective, practical approach to the differential diagnosis of the potentially lethal lesions. This approach is simplified further since over 90 percent of babies with cardiac distress have one of three lesions: (1) Large left-to-right shunt (characterized by the presence of massive plethora on the chest roentgenogram), (2) Large right-to-left shunt (association with intense cyanosis) or (3) Severe obstruction (including hypoplasia of the left heart, which is the most common cause of death due to cardiac distress during the first week of life).     

NAVA模式与SIMV模式在新生儿呼吸窘迫综合症中的应用效果对比

目的:观察和比较神经调节辅助通气(NAVA)模式与同步间歇指令通气(SIMV)模式在新生儿呼吸窘迫综合症中的应用效果。方法:选择2015年3月至2017年3月我院接诊的94例呼吸窘迫综合征患儿,根据治疗方式不同分为观察组(n=47)和对照组(n=47),均使用西门子公司生产的Servo-i呼吸机治疗,对照组使用SIMV模式,观察组使用NANA模式,连续治疗7天。比较两组治疗前后血氧分压(PaO_2)、二氧化碳分压(PaCO_2)、氧合指数(PaO_2/FiO_2)的变化,临床疗效及并发症的发生情况。结果:治疗后,两组PaO_2、PaO_2/FiO_2均较治疗前显著升高,PaCO_2较治疗前显著降低(P0.05),观察组PaO_2、PaO_2/FiO_2明显高于对照组[(69.12±4.10)vs.(55.74±3.65) mmHg,(256.81±28.11) vs.(212.75±26.35) mmHg],PaCO_2明显比对照组低[(45.81±3.04)mmHg vs.(50.03±3.15)mmHg](P0.05)。观察组临床疗效总有效率明显高于对照组[93.62%(44/47) vs. 74.47%(35/47)](P0.05)。两组气漏综合征、死亡发生率比较无显著差异(P0.05),观察组呼吸机相关性肺损伤炎发生率明显低于对照组[4.26%(2/47)vs21.28%(10/47)](P0.05)。结论:和SIMV机械通气模式比较,NAVA模式用于呼吸窘迫症患儿的效果更加显著,其有助于改善血气分析,且可减少并发症的发生率。     

两种肺表面活性物质治疗新生儿呼吸窘迫综合症的临床疗效比较

目的:比较珂立苏与固尔苏两种肺表面活性物质(PS)治疗新生儿呼吸窘迫综合症(NRDS)的临床疗效.方法:选择2011年2月～2012年12月在我院确诊并接受治疗的NRDS患儿58例,在患儿家长知情同意的情况下,随机分为A组(n=26例)和B组(n=32例).在给予相同基础治疗措施的情况下,A组患儿采用珂立苏治疗,B组患儿采用固尔苏治疗,比较两组患儿治疗24h后的机械通气参数与血气指标的变化,并比较两组患儿症状缓解时间、机械通气时间、吸氧治疗时间及住院时间.结果:治疗24h后,两组患儿的呼气末正压(PEEP)、吸氧峰压(PIP)、平均气道压力(MAP)和氧浓度(FiO2)比较,均较治疗前显著降低,且B组以上指标均显著低于A组,差异均具有统计学意义(P＜0.05);两组患儿的血PaO2和pH值均较治疗前显著升高,而血PaCO2、氧合指数(OI)均较治疗前显著降低,且B组血PaO2、pH值和OI均显著高于A组,而血PaCO2显著低于A组,差异具有统计学意义(P＜0.05).此外,B组患儿经治疗后的症状缓解时间、机械通气时间、吸氧治疗时间及住院时间均较A组患儿显著缩短,差异均具有统计学意义(P＜0.05).结论:积极给予固尔苏治疗NRDS,可促进患儿机械通气参数与血气指标的改善,并缩短临床治疗时间,其效果优于珂立苏.     

高频振荡呼吸机治疗呼吸窘迫综合征致呼吸机相关性肺损伤的疗效观察

目的:观察高频振荡呼吸机在治疗呼吸窘迫综合征(NRDS)致呼吸机相关性肺损伤(VALI)患儿的临床疗效。方法:选择我院2012年6月~2014年10月收治的NRDS致VALI患儿83例为研究对象,采用随机数字表法将患者随机分为研究组(45例)和对照组(38例)。两组均进行一般治疗,在此基础上对照组采用常规机械通气,研究组采用高频振荡呼吸机行高频通气。观察两组患者治疗24 h后p H值、二氧化碳分压(Pa CO2)、氧分压(Pa O2)、血压(BP)、心率(HR)及并发症情况。结果:两组患者治疗24 h后p H值、Pa CO2、Pa O2及BP比较,差异均无统计学意义(P0.05),研究组HR心率低于对照组,差异存在统计学意义(P0.05);研究组纵膈气肿、肺损伤、间质气肿及气胸的发生率均低于对照组,差异有统计学意义(P0.05)。结论:高频振荡呼吸机治疗NRDS致VALI患儿能够明显改善其症状及减少并发症的发生率,是治疗NRDS致VALI的有效的方式。     

Efficacy of a Low-Cost Bubble CPAP System in Treatment of Respiratory Distress in a Neonatal Ward in Malawi

Background

Respiratory failure is a leading cause of neonatal mortality in the developing world. Bubble continuous positive airway pressure (bCPAP) is a safe, effective intervention for infants with respiratory distress and is widely used in developed countries. Because of its high cost, bCPAP is not widely utilized in low-resource settings. We evaluated the performance of a new bCPAP system to treat severe respiratory distress in a low resource setting, comparing it to nasal oxygen therapy, the current standard of care.

Methods

We conducted a non-randomized convenience sample study to test the efficacy of a low-cost bCPAP system treating newborns with severe respiratory distress in the neonatal ward of Queen Elizabeth Central Hospital, in Blantyre, Malawi. Neonates weighing >1,000 g and presenting with severe respiratory distress who fulfilled inclusion criteria received nasal bCPAP if a device was available; if not, they received standard care. Clinical assessments were made during treatment and outcomes compared for the two groups.

Findings

87 neonates (62 bCPAP, 25 controls) were recruited. Survival rate for neonates receiving bCPAP was 71.0% (44/62) compared with 44.0% (11/25) for controls. 65.5% (19/29) of very low birth weight neonates receiving bCPAP survived to discharge compared to 15.4% (1/13) of controls. 64.6% (31/48) of neonates with respiratory distress syndrome (RDS) receiving bCPAP survived to discharge, compared to 23.5% (4/17) of controls. 61.5% (16/26) of neonates with sepsis receiving bCPAP survived to discharge, while none of the seven neonates with sepsis in the control group survived.

Interpretation

Use of a low-cost bCPAP system to treat neonatal respiratory distress resulted in 27% absolute improvement in survival. The beneficial effect was greater for neonates with very low birth weight, RDS, or sepsis. Implementing appropriate bCPAP devices could reduce neonatal mortality in developing countries.     

Ethnic Differences in Neonatal Body Composition in a Multi-Ethnic Population and the Impact of Parental Factors: A Population-Based Cohort Study

Background

Neonates from low and middle income countries (LAMIC) tend to have lower birth weight compared with Western European (WE) neonates. Parental height, BMI and maternal parity, age and educational level often differ according to ethnic background, and are associated with offspring birth weight. Less is known about how these factors affect ethnic differences in neonatal body composition.

Objectives

To explore differences in neonatal body composition in a multi-ethnic population, and the impact of key parental factors on these differences.

Methods

A population-based cohort study of pregnant mothers, fathers and their offspring, living in Oslo, Norway. Gender- and gestational-specific z-scores were calculated for several anthropometric measurements, with the neonates of WE ethnic origin as reference. Mean z-scores for neonates with LAMIC origin, and their parents, are presented as outcome variables.

Results

537 singleton, term neonates and their parents were included. All anthropometric measurements were smaller in neonates with LAMIC origin. Abdominal circumference and ponderal index differed the most from WE (mean z-score: −0.57 (95% CI:−0.69 to −0.44) and −0.54 (−0.66 to −0.44), and remained so after adjusting for parental size. Head circumference and skin folds differed less, and length the least (−0.21 (−0.35 to −0.07)). These measures became comparable to WEs when adjusted for parental factors.

Conclusions

LAMIC origin neonates were relatively “thin-fat”, as indicated by reduced AC and ponderal index and relatively preserved length and skin folds, compared with neonates with WE origin. This phenotype may predispose to type 2 diabetes.     

早产儿血清炎性因子与生长发育指标的关系及对新生儿呼吸窘迫综合征的预测研究

摘要 目的：分析早产儿血清炎性因子与生长发育指标的关系及对新生儿呼吸窘迫综合征（RDS）的预测效能。方法：选择2018年1月至2020年10月在我院出生的98例早产儿作为研究对象,根据是否并发RDS,分为RDS组（58例）和非RDS组（40例）。检测两组血清白细胞介素-1β（IL-1β）、IL-6、IL-8、肿瘤坏死因子-α（TNF-α）、降钙素原（PCT）水平,记录生长发育指标,通过Pearson相关性分析早产儿血清炎性因子与生长发育指标的关系,使用受试者工作特征曲线（ROC）分析血清炎性因子对新生儿呼吸窘迫综合征的预测效能。结果：RDS组血清IL-1β、IL-6、IL-8、TNF-α、PCT水平均高于非RDS组（P＜0.05）;RDS组胎龄、出生体重均小于非RDS组（P＜0.05）;经Pearson相关性分析,早产儿血清IL-1β、IL-6、IL-8、TNF-α、PCT水平均与胎龄、出生体重呈负相关（P＜0.05）;经多因素Logistic回归分析,IL-1β、IL-6、IL-8、TNF-α、PCT均是早产儿并发新生儿呼吸窘迫综合征的独立危险因素（P＜0.05）;经ROC曲线分析,IL-1β、IL-6、IL-8、TNF-α联合PCT预测早产儿并发新生儿呼吸窘迫综合征的AUC为0.910。结论：早产儿血清IL-1β、IL-6、IL-8、TNF-α均与胎龄及出生体重密切相关,这些炎性因子联合预测RDS发生的效能较好,值得临床予以重视应用。     

肺脏超声对新生儿呼吸窘迫综合征的诊断价值及肺超声评分的评估价值分析

目的:探讨肺脏超声对新生儿呼吸窘迫综合征(NRDS)的诊断价值,并分析肺超声评分的临床应用价值。方法:本研究选择2017年5月至2018年5月于我院确诊的NRDS患儿45例作为观察组,选择同期于我院就诊的非肺病患儿45例作为对照组,所有患儿均行肺脏超声检查。分析NRDS患儿肺脏超声特征性征象,比较肺脏超声对两组患儿各种征象的检出率,分析肺脏超声对NRDS的诊断价值,比较两组肺超声评分。结果:NRDS患儿全部存在肺实质征象,超声下肺组织回声呈肝样伴支气管充气征,轻度的NRDS患儿于肺脏超声下表现为局灶性的肺实质,且支气管充气征不明显;重度的NRDS患儿于肺脏超声下表现为肺实质范围的进一步扩大,且支气管充气征随病情的加重而愈发明显。观察组肺实质、胸膜线异常、A线消失、弥漫性肺水肿、支气管充气征等征象的检出率显著高于对照组(P0.05),两组B线存在征象的检出率比较无统计学差异(P0.05)。肺实质、胸膜线异常和A线消失三种特征征象同时存在时对NRDS诊断的灵敏度和特异性均为100.00%,肺实质、胸膜线异常和支气管充气征三种特征征象同时存在时对NRDS诊断的灵敏度为80.00%,特异性为100.00%。观察组双肺、左肺、右肺、双侧肺、双肺底肺超声评分均高于对照组(P0.05)。结论:肺脏超声对NRDS的诊断价值较高,且肺超声评分可以评估NRDS患儿的病情严重程度,有助于指导患儿的治疗。     

血清IL-6、CAR联合NLR对新生儿呼吸窘迫综合征患儿病情和预后的评估价值

摘要 目的：探讨血清白细胞介素-6（IL-6）、C-反应蛋白与白蛋白比值（CAR）联合中性粒细胞与淋巴细胞比值（NLR）对新生儿呼吸窘迫综合征（NRDS）患儿病情和预后的评估价值。方法：选取2020年12月～2022年4月我院收治的102例NRDS患儿（NRDS组）,根据病情严重程度分为轻度亚组23例、中度亚组38例、重度亚组41例,根据28 d治疗后结局分为死亡组37例和存活组65例,另选取同期57名健康新生儿（对照组）。检测血清IL-6、CAR、NLR,多因素Logistic回归分析NRDS患儿预后不良的影响因素,采用受试者工作特征（ROC）曲线分析血清IL-6、CAR、NLR对NRDS患儿预后不良的评估价值。结果：NRDS组血清IL-6、CAR、NLR均高于对照组（P均＜0.001）。轻度、中度、重度亚组血清IL-6、CAR、NLR依次升高（P均＜0.001）。死亡组血清IL-6、CAR、NLR高于存活组（P均＜0.001）。多因素Logistic回归分析显示,胎龄和5min Apgar评分增加为NRDS患儿预后不良的独立保护因素,IL-6、CAR、NLR升高为独立危险因素（P均＜0.05）。ROC曲线分析显示,血清IL-6、CAR、NLR联合评估NRDS患儿预后不良的曲线下面积（AUC）大于各指标单独评估（P均＜0.05）。结论：NRDS患儿血清IL-6、CAR、NLR升高与病情加重和预后不良密切相关,血清IL-6、CAR联合NLR评估NRDS患儿预后不良的价值较高。