A scoping review of the moral experiences of children with medical complexity in Brazil.

OBJECTIVES
The aim of this review was to identify and summarize how the moral experiences of children with medical complexity are being expressed within the Brazilian health-related literature and discuss research gaps and directions for future research.


METHODS
A scoping review was performed using the methodological framework of Arksey and O'Malley and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Systematic searches were conducted on Medline, CINAHL, Scopus, and Embase databases. Articles were included if using qualitative methodologies, having children as participants, and published in Brazil.


RESULTS
In total, 6,360 articles were retrieved from databases. Sixteen studies were selected for the analysis.


FINAL CONSIDERATIONS
The studies were not primarily focused on children's moral experiences. Yet, the studies demonstrate morally relevant accounts concerning children's capacity to reason and interpret their lived experiences, expressing deep concerns about isolation, suffering, future aspirations, and feelings of normality.


INTRODUCTION
Children with medical complexity are a heterogeneous group of children who have severe and chronic health conditions, substantial health service needs, functional limitations, and high health resource utilization (1) . This population of children have complex chronic conditions that affect their everyday lives (2) . In Brazil, over last 20 years, these children are a new reality after the significant decrease in child mortality rates and subsequent survival of children with complex health conditions, such as extreme prematurity and congenital malformations (3) .
Brazilian nursing research has shown that these children and their families are living in vulnerable conditions which create barriers to health-care services and decrease their quality of care and life (4) . These vulnerable conditions lead to significant ethical concerns such as health inequities and discrimination, inadequate public policies, and exclusion of children from decisions that affect them (4,5) .
From an ethical perspective, legal documents and standards in Brazil have described the importance of children's participation in decisions involving them (6) . Brazilian legislation stresses that children must be included, and their views must be taking into consideration in decisions such as medical treatments (6) . In addition, the recognition of children's perspectives and preferences have been described in the childhood research field as a strategy to promote more inclusive practices that can meet their needs and promote equitable care (7) . In addition, studies have shown that to illuminate the multiple facets of children's experiences, healthcare professionals and researchers should draw on frameworks that acknowledge children's capacity to act as agents, reasoning and interpreting their own lived experiences (8) . These interpretations, which are rooted in collective notions of what is good, just, and right, can be explored through the use of a moral experiences framework (9) . This framework focuses on how persons live out their moral lives. Moral experiences have been defined by Hunt and Carnevale (9) as "a person's sense that values that he or she deems important are being realized or thwarted in everyday life, including interpretations of a lived encounter, or a set of lived encounters, that fall on spectrum of right-wrong, good-bad or just-unjust" (p. 659).
There is therefore emerging evidence in the childhood research field about the importance of the analysis of children's moral experiences to understand their moral lives (7) . However, we know little about how the health-related literature is reporting the moral experiences of children with medical complexity in Brazil. Thus, the objective of this review was to (a) identify and summarize how the moral experiences of children with medical complexity are being expressed within the Brazilian health-related literature, and (b) discuss research gaps and directions for future research.

OBJECTIVE
To (a) identify and summarize how the moral experiences of children with medical complexity are being expressed within the Brazilian health-related literature, and (b) discuss research gaps and directions for future research.

METHODS
Because moral experience is an emerging framework in healthrelated research, a scoping review synthesis method, based upon the model of Arksey and O'Malley (10) was chosen as a methodology. Scoping review methodology allows an assessment of emerging evidence, thereby providing significant foundation for future research (11) . As a comprehensive methodology to examine relevant literature on a research area, scoping reviews have the aim of examining the extent, range, and nature of research activity as well as identifying research gaps in the existing literature (10) . This methodology includes five essential steps: 1) identification of the research question; 2) identification of relevant studies; 3) selection of studies for review; 4) charting the data; and 5) collating, summarizing, and reporting the results. The steps were conducted as follows: Step 1: Identification of the research question Given that there is some available literature on the moral experiences of children with medical complexity in Brazil, but it has not yet been summarized or synthesized, the research question was: What is known from the existing health-related literature in Brazil about the moral experiences of children with medical complexity?

Step 2: Identification of relevant studies
The studies were identified through a systematic search initially completed in May 27, 2015. The searches were rerun in July 10, 2018 with entry date from May 27, 2015 onwards. Four computerized databases were used: CINAHL, Ovid Medline, Embase, and Scopus. The search strategy was developed with input from a health sciences research librarian. The search strategy included terms related to health, children, and qualitative studies. The complete description of the search strategy is presented in Chart 1.

Step 3: Selection of studies for review
Articles were selected based on the following inclusion criteria: 1. Children were included as participants in the study. This criterion was used in order to ascertain that the examination of children's views and perspectives was done through the analysis of their own accounts.
2. Empirical, qualitative studies. Hunt and Carnevale (9) suggest that, because of the hermeneutical nature of the concept of moral experience (e.g., the aim of understanding a particular phenomenon through interpretation of the different aspects that shape people's experiences), studies on moral experiences should be primarily qualitative. Therefore, qualitative studies were included in this analysis to ensure they were confirming with the aspects of moral experiences.
3. Studies conducted in Brazil. According to Hunt and Carnevale (9) , the particular social context in which experiences are lived has an important influence on people's choices and preferences. Therefore, the moral experiences of children with medical complexity in Brazil will have significant characteristics that must be addressed within the particularities of the Brazilian health context. 4. Articles published in Portuguese, English, and Spanish languages between the years 1994 and 2018. The year 1994 was chosen in consideration of the approval of the Brazilian Child and Adolescent Statute by the decree 1.302, which stated, for the first time in Brazil's democratic regime, the rights of all children across the nation (12) .
The definition used in this analysis for the term "children" drew on the United Nations Conventions on the Rights of the Child, which refers to children as all minors from 0 to 17 years of age.
Medical complexity was identified by matching participants' health conditions with the definition of medical complexity described by Cohen et al (1) as "children who have clinical conditions that require health care needs such as medical care, specialized therapy, and educational needs with high utilization of health resources due to chronic conditions or functional limitations. "

Scopus
( TITLE-ABS-KEY ( "mental capacity" OR "mental competen*" OR "decision making" ) AND TITLE-ABS-KEY ( ethic* OR "informed consent" OR "moral development" OR moral* ) AND (experience* or perspective* or perception* or belief* or attitude* or meaning* or understanding)).tw. 19. 7 and 11 and 18 20. ((lived or life or personal or patient$2 or survivor*) adj3 (experience* or perspective* or perception* or belief* or attitude* or meaning* or understanding)).ti,ab,kw. PRISMA Extension for Scoping Reviews (PRISMA-ScR) was used to organize the systematic process of including articles in the analysis (13) . Articles selected for the analysis were screened by their titles in order to have a more comprehensive list of the literature. 86 articles were then selected for complete reading and further screening for relevance. 70 articles were excluded because they were reporting children's experiences through data collected with parents, included people with more than 18 years of age in the sample, or were not focus on the experiences of children. Therefore, the final selection included 16 articles. All 16 articles were included in the review. The selection of articles is presented in a flow diagram (Figure 1).
Step 4: Charting the data Information from the selected articles was organized for analysis using the following categories: authors, year of publication, child's medical condition, aims of the study, specific methodology (e.g., how children's voices were accessed by the study), results and interpretation of the studies analyzed (e.g., how children's moral experiences are being expressed by the study), and themes related to the results of the analysis. Complete data charting information is presented in Chart 2.
Step 5: Collating, summarizing, and reporting the results The articles analyzed in this review were first summarized according to the information gathered from the data charting. Following, a thematic analysis was conducted using the framework of moral experiences to identify relevant themes, analyze and interpret the data. (Chart 2). After the primary scanning of the articles' abstracts, we noticed that none of the studies explicitly conceptualized the experiences of children as moral experiences. However, across all the retained studies we noted investigations of children's morally relevant experiences. For example, there were statements from researchers that expressed the importance of recognizing children's voices in relation to health experiences.
Because of this lack of explicit use of the framework of moral experiences, for the purposes of this analysis children's moral experiences were explored very broadly. The moral experiences of children were primarily interpreted via expressions of "meaningful" experiences. By meaningful, we refer to the experiential significance (14) which children attributed to their experiences. Therefore, our analysis is focused on demonstrating how the authors expressed moral experiences of children with medical complexity through the identification of the described health experiences that were most meaningful for children, touching on questions associated with their health conditions and notions of what is right, just, and good (9) . These experiences were described by our analysis in situations in which children were able to express interpretations, concerns, and preferences related to their complex health conditions.

RESULTS
In total, 6,360 articles were retrieved from CINAHL (n=2,257 articles), Medline (n=2,891), Embase Brazil (n=486), and Scopus (n=726). After the removal of duplicate articles and the application of the inclusion criteria, 16 studies were retained for analysis ranging from the years 2000 to 2014. Regarding children's medical conditions, the studies explored the lived experiences of children living with HIV (n=7), hemodialysis (n=2), cancer (n=2), sickle cell anemia (n=1), and diabetes (n=4). Children's ages ranged from 3 to 18 years. 15 studies were conducted by nursing researchers, and one by a physician. Articles were published in Portuguese.
Studies used unique terms to describe the experiences of children with medical complexity. Most of the terms used were related to the daily experiences of children; that is, how children perceive their daily lives within the perspectives of their clinical conditions. Terms used included: (translated from Portuguese) children's choices, responsibilities, meanings that children attribute to their conditions, lived experiences of children, lived suffering during an illness process, children's perceptions of the illness process, children's understandings about situations related to the illness, children's emotions as distress, and children's report on the implications of their conditions. Importantly, studies were not primarily focused on children's moral experiences, demonstrating a research gap that will be presented in the discussion section of this article. The data of the studies is charted in Chart 2, including title, authors, year of publication, medical condition, child's age, aim, specific methodological approach, and important results.

DISCUSSION
In relation to the results of the studies selected, four themes were identified that are related to children's moral experiences: being "normal"; social isolation and stigma; existential distress: fear and loneliness; and benefits beyond illness: valuing the ends. For the purposes of clarity, we have separated children's moral experiences into unique themes; however, because of the complex aspects of their everyday lives, aspects of children's experiences described in these themes may overlap. Themes are presented in the following discussion. The themes, selected articles, and specific health problems are charted in Chart 3.

Being "normal"
In the studies analyzed, children with medical complexity showed their capacity to reflect and value their experiences regarding their feelings of normality (A16; A15; A9; A4; A2). The normal aspects were expressed by the studies as the possibilities of having future wishes, going to school, having friends, and playing. Studies (A16; A15; A9; A4; A2) demonstrated that the children consider their lives normal when they felt able to do things other children could do, despite their limitations. Furthermore, children described families and health-care providers as having an important role in keeping their 'normality' by promoting activities that can prevent their isolation (A16; A9; A4; A2).
The complex relation between children and families was described in the articles, with important implications for children's moral experiences. Social values transmitted to children by parents and caregivers were highlighted as important aspects to promote the feeling of normality in their lives. These values were associated with the families' fears of discrimination and prejudice, which led to a protective behavior that could isolate children. For example, articles reported that parents did not permit their child to participate in leisure activities in the school. Children's narratives expressed their perception of less negative implications of their health condition when they could enact usual actions like other children in their social environment, promoting feelings of 'being normal' (A1; A15; A16).

Social isolation and stigma
The articles demonstrated children's capacity to be aware and to articulate meaningful worries and experiences in situations related to their health condition, such as isolation and discrimination (A5; A7). Although authors did not explicitly report children's choices as moral, their studies illustrated how children could value their own lived experiences as well as their capacity to understand meaningful experiences.
Negative feelings such as discrimination, prejudice, and sadness were associated with the implications of having a complex clinical condition that required constant care, hospitalizations, and medications, precluding children from interacting with others (A7; A5). Articles reported that the stigma of having a life-threatening disease such as HIV or cancer led children to isolation, causing feelings of loneliness and sadness (A7; A5).
Body changes caused by chemotherapy such as alopecia (A7) or dealing with a stigmatized condition such as HIV (A5), reflected negatively on children's self-identity, consequently creating uncertainties about their future, anguish, and isolation from others (A7; A5). Menossi & Lima (A7) described that adolescents chose to avoid school because they felt ashamed of their hair loss. Participants also described negative feelings resulting from the impossibility of having a 'normal' romantic relationship because of their health condition (A15; A7; A5).
Children chose not to socialize with others or not to go to school to prevent feeling different from friends and avoid discrimination (A15; A6). Also, children were isolated from others during school activities because they felt incapable of performing activities in the same way as others. Growing up and developing with a complex illness was considered a burden to children in these cases (A15; A10; A8; A6). Some articles (A6; A4; A3; A1) illustrated how families provide care focused on protecting their children from discrimination. For instance, parents organized the times for taking medications when the child was at home, to prevent others from knowing their condition (A6; A4; A3; A1). Children felt afraid of exposing their diagnosis to their peers because they feared being labeled and bullied (A6; A4; A3; A1). Keeping children's diagnosis undisclosed from the child was considered by some parents as a way to protect their children from prejudice. Parents created stories such as "little animals fighting inside the child's stomach" (A6) or used a substitute condition, such as problems in the bone system, to justify the need for medications (A1).

Existential distress: death and loneliness
Articles reported children's expression of existential distress about their complex conditions (A13; A11; A8; A7). Children questioned the reasons why the complicated illness was happening to them (A13; A11; A8; A7), what were the implications for their future lives (A13), sought justifications for the illness (A13; A11) and feared of being alone and dying (A13; A11).
Experiences of sadness about the uncomfortable side effects of medications (A13; A11) the frequent hospitalizations with consequent breakdown of their daily routines (A13), loneliness and distance from family and friends (A7) were described negatively by these children. Hospitalization was viewed as necessary by some children because of the complexity of the treatment they required (A11; A7). Feelings of loneliness were constant during hospitalizations because of detachment from people they liked, as well as the fear of being left alone in the hospital (A11; A8; A7).
Children's reflections about the possibility of dying demonstrated their existential suffering about having their lives threatened by a disease (A13). The fear of death and the perception of being too young to die created feelings of anxiety and sadness. Children also felt impotent toward death, and their fear increased when other children in the ward, such as a friend, died (A10).

Benefits beyond illness: valuing the ends
Studies presented that unpleasant means, or strategies, such as the use of medication, were accepted by children in consideration of the good results provided by these means. Examples of positive results described by children include possibilities for relieving pain, staying alive, cure, feeling healthy, going home, and being able to go to school and play. These situations were all described by the authors as positive implications that helped children to manage negative experiences, such as unpleasant taste of the medications, side effects, and painful health procedures (A14; A12; A11; A10; A9; A7; A6; A4; A3). Thus, children demonstrated their capacity to deliberate about meaningful situations and to reflect on their health experiences (A9; A7; A6; A4; A3).
Studies with children living with HIV highlighted the experiences of children in relation to their antiretroviral treatment. These experiences ranged from negative feelings related to discomforts caused by the side effects of these medications, discrimination, and fear of death (A4), to the positive feelings of staying alive and avoiding hospitalization and death (A9; A7; A6; A3). In these situations, children were able to demonstrate of that something bad (use of medication) was justified in relation to something good (staying alive). This situation increased their adherence to treatment (A12; A6; A4; A3).
Health experiences of children with cancer included difficulties concerning their hospitalization and clinical condition, such as physical pain and being alone (A7). Besides such problems, children described the possibilities of diminishing suffering and cure that came from their medical care and hospitalizations. This understanding about the good ends of the process of chemotherapy and hospitalization led children to cooperate with health practices and to better accept the treatment (A10; A7).

Limitations of study
This study has limitations considering the use of articles only written in Portuguese and English language. Another limitation is that this review was conducted in one limited setting regarding the Brazilian perspectives on children's moral experiences. Besides, as we understand Brazil as a vast country with many cultural, social, and economic differences, not including information on the specific region of Brazil where researchers conducted these studies is another limitation. Importantly, though we provided here an important reflection on the Brazilian's perspectives, we cannot anticipate how the results would translate in different settings. To conclude, the selection and screening of the final articles included in the analysis were done by only one reviewer, constituting a further limitation to this study.

Contributions to health-related research
The evidence synthesized in this review is a first step in the development of research concerned with the moral lives of children with medical complexity, and how the different social contexts shape these experiences. The results showed the importance of understanding children's experiences in relation to their own views and interpretations in order to provide care that can meet their needs. In addition, we suggest that the use of a more explicit framework to address the moral concerns of children with medical complexity can foster understanding of their preferences. Such a framework can help orient health researchers, as well as other researchers from interdisciplinary perspectives, to elicit and understand children's views, values, and interpretations.

FINAL CONSIDERATIONS
The evidence about the moral experiences of children with medical complexity within Brazilian health-related research is limited. Despite that, our analysis found many morally relevant accounts within this literature. Researchers regarded children as participants in their studies, engaging with the analysis of children's lived experiences through the children's own voices. These studies have also emphasized the importance of giving children space to display their experiences. In their accounts, children demonstrated their capacity to reflect on moral concerns related to the illness process, engaging with conversations about complex matters, such as stigma, loneliness, and fear of death.
Importantly, although the studies were describing morally relevant accounts of children with medical complexity, none of the articles presented a clear framework for addressing children's experiences. Frameworks used came primarily from nursing research and qualitative research in general.
The identified studies focused primarily on children's experiences regarding their illness process in a broad approach. Thus, the knowledge about the moral implications of the health experiences of children with medical complexity is still restricted in Brazilian health-related literature. Further work is needed to address the moral concerns regarding the lives of children with medical complexity through the development of studies using an explicit conceptualization of moral experiences.
Another research gap found in our analysis was the limited interdisciplinary scope of the literature analyzed. In our analysis, 15 of the 16 articles were nursing studies. Therefore, we suggest that future interdisciplinary research is needed to improve health research and health-care practices by uncovering children's views on moral concerns from multiple perspectives. It is hoped that this exploration of moral experiences of children with medical complexity in Brazil will foster the interest of researchers from various disciplinary fields in understanding and exploring this important dimension of child care.