Ethical Considerations in the Neonatal Intensive Care Unit

Lisa J. Sundean, RN, MSN, MHA; Jacqueline M. McGrath, PhD, RN, FNAP, FAAN


NAINR. 2013;13(3):117-120. 

In This Article

Recommendations for Practice

Although ethical issues in the NICU can be challenging and ambiguous, practice recommendations assist nurses and physicians by offering guidelines from a common knowledge and evidence base. These recommendations derive from professional and government organizations, and include both clinical guidelines and legal mandates. To manage ethical dilemmas in the NICU consistently and proactively, and to assist families with ethical decision-making, familiarity with current best evidence, practice, and legal guidelines is important.[1–3] Providers must understand the four principles of ethics and how they apply to neonatal care. Recognizing how the ethical principles apply to ethical dilemmas in the NICU prepares providers to respond to complex situations with forethought. SeeTable 2 for a summary of recommendations for practice.

To begin, surveying personal ethical beliefs and values helps neonatal nurses and physicians discover areas of potential ethical conflict and areas of alignment with others. Additionally, providers must begin to understand ethical beliefs and values of differing cultures. Considering the changing multicultural mix of the United States, understanding cultural ethical differences helps reduce ethical conflicts in the NICU. Surveying personal ethical beliefs and values and developing respect for cultural ethical differences enable providers to communicate better with colleagues and families and resolve ethical conflicts collaboratively.[3]

Staying abreast of current clinical treatment options and outcomes data ensure providers offer the best information to families during ethical decision-making discussions.[3] Utilizing current clinical knowledge and questioning clinical practices also helps providers improve and test care to ensure high quality and best ethical practices.[1] Combining clinical information with ethical perspectives offers a broad and more holistic view of care options.

Complex ethical issues in the NICU can lead to lingering moral distress among nurses and physicians. When ethical issues arise, debriefing sessions can be helpful to staff. Debriefing can provide a source of emotional support and learning to aid the process of ethical decision-making in the future.[7]

Fortunately, neonatal care providers do not need to engage in ethical decision-making without the support of national standards. From professional best practices to government directives and laws, many ethical decisions are prescribed via guidelines, precedents, and mandates. For example, The American Nurses Association Code of Ethics provides ethical standards and expectations for all nurses. More specifically, the National Association of Neonatal Nurses and the American Academy of Pediatrics provide ethical guidelines for practice. Although ethical decision-making sometimes requires considerations on the basis of case circumstances, laws, federal guidelines, and professional best practices ensure a more consistent approach.[3]

True for all best practices in health care, clear and transparent communication with families regarding ethical issues in the NICU is essential. Providers must offer information in a way that is current, accurate, compassionate, respectful, culturally sensitive, and family-centered.[1] Assisting families with difficult ethical decisions is an important component of the role of neonatal nurses and physicians. Providers must engage families as equal partners in the decision-making process in a way that gives families the most respect and control over care decisions for their babies. Finally, consider the development and regular use of an ethics committee comprised of all stakeholders including families. The ethics committee serves an advisory role when confronted with challenging ethical issues in the NICU.[8]