1.       Introduction

The development of biotechnology and medicine has renewed the definition of human natural nature, life and death, and has shown new ethical problems that challenge the preconditions of traditional ethics by showing that domination and manipulation of nature are possible [1]. As a result of these changes, ethical problems cannot be solved by the oath or code of ethics because ethical rules and personal ethics perceptions can vary in various nursing situations. Therefore, nurses are required to present the criteria for how to resolve ethical conflicts that are encountered variously as professional practitioners on a philosophical basis, and it is necessary to establish the ethical value system of nurses themselves. Nursing is an activity that directly helps individuals, families and communities to acquire the knowledge, energy, and hope resources necessary for recovery of health, prevention of disease, maintenance and promotion of health [2]. This definition implies that nursing has the ethical purpose of promoting the patient's well-being, and the judgments and decisions in nursing practice are ethical judgments about what is for the subject. Essential ethical questions in nursing are considered to be a sub-scope of broader bioethics domains. The consequences of a moral dilemma involving life and death experienced by medical practitioners are often related to bioethics and to problems and practices based on nursing practice [3].

In general, the ethical questions faced by nurses are classified into four types according to the types of nurses' relationships: patient relations, physician relations, fellow nurses, and relationships with other health professionals. Most ethical problems arise [4]. In other words, the nurse experiences ethical problems while performing nursing activities through various relationships centering on the patient in the clinical field. In particular, the intensive care unit is limited in the number of medical personnel who care for patients other than those prohibited by DNR(Do-Not-Resuscitate), and the nurses' focus on care for acute care patients is limited to the time spent on holistic nursing, differentiated nursing from acute phase patients is performed and results in accepting death as a routine task [5]. The ethical problems faced by nurses who do not benefit from DNR are that the ethical problems experienced by the nurse are related to the need to abandon their work in situations where they know what they are supposed to do but they cannot do anything and their value conflicts with the expectations of a professional or medical institution. It is difficult to take appropriate action due to confusion about the ethical value of the individual, and it appears as physical exhaustion [6], conflict and agony about turnover, and ethical dilemma [7]. Although these ethical problems frequently occur in the nursing field and are an obstacle to nursing work. The difficulty of resolving ethical problems is justified, and there is no institutional support for ethical problems. It does not provide specific directions for problem solving. Therefore, situations related to ethics are stressful to nurses, and ethical stresses are emotional and occupational stresses due to moral suffering [8]. In addition, nurses tend to act and become more self - defensive in situations of ethical problems. The negative image of nurses on these ethical issues is an impediment to the development of individual and nursing professions to nurses who do not have firm nursing beliefs [9].

According to previous studies on DNR decision-related perceptions, nurses felt that 99% of the need for DNR was necessary. The reason for this is that DNR determination is necessary for decent death (53%), and 94.5% of the DNR guidelines require sympathy [10]. The reason for determining DNR is to reduce the economic and psychological burden of the patient's family, to consider the input and effectiveness of medical services, [11] to relieve the pain of end-of-life patients who are unable to recover, Respectively [12]. Age was the most important determinant of DNR inhibition, rather than disease severity or prognosis [13]. In the study of Kim [14], the factors considered by the medical staff when deciding on the cardiopulmonary resuscitation of cancer patients were age, disease severity, cardiopulmonary resuscitation, long duration, economic burden, patient pain relief and dignified death.

In the meantime, the advancement of the nursing profession for high-quality research into ethical dilemmas in the nursing but died in ICU patients, 78.8% [15] DNR prohibited for patient ethical problems, and for that matter, have a value and the nurses study, saying the action was not yet underway. The ethical value in the issue is not only about what is important to the patient, but also about what is important both nurse's personal and professional [5]. Clarified ethical values for nurses influence the patient care situation in an environment surrounding unhealthy patients. Therefore, nurses need to be aware of individual values and patient values. Therefore, through this study, ethical problems related to patient nursing with DNR in the intensive care unit are identified, and how nurses are experiencing and coping with ethical problems by identifying the ethical values ​​and behaviors of the nurses related to the problem.

2.       Design and Sample

This study was to identify the ethical problems experienced by the nurses in the ICU nurse and to understand the ethical value of the nurses. The research method is qualitative research using inductive content analysis method. The study participants consisted of 13 nurses in ICU nurses who have experienced DNR patients and experienced ethical problems for 4 years or more.  Data collection was conducted from June 23, 2013 to August 13, 2017, and individual interviews were conducted using semi-structured questionnaires on the ethical problems experienced during DNR patients nursing.

3.       Ethical Considerations

Data collection was conducted with the approval of KU Bioethics Review Committee [KWNUIRB-2017-05-004-001]. This study explains the purpose of the study to the research participants, explains the confidentiality and anonymity of the participants, and can withdraw the research participation whenever they want. During the interview, I explained that the recorded contents were only used for research purpose. The information collected at the end of the research was discarded and the above contents were obtained after the written consent of the participants.

4.       Results

The results of the analysis were as follows: 1) ethical problem situations 2) reason for ethical problem 3) behavior in ethical problem situation 4) reason for not being consistent in value and behavior. Each derived main category is as follows.

1) The main category of the ethical problem situation is 'decision to death that is too easy to select' and 'life that cannot be respected'. The subcategories of 'the decision on death so easily selected' are 'A decision on death that excludes a patient' and 'DNR determined with sufficient understanding and lack of explanation' (Table 1).

2) The main category of reasons for thinking as an ethical problem are the two values: 'Death that the will of the patient and the caregiver should be respected', and 'Treatment that must be done to the end' (Table 2).

3) The main categories of behavior in ethical problem situations are two behaviors: 'To act according to their own values' and 'To follow passively in situations' (Table 3).

4) The main categories for why their values ​​and behaviors are inconsistent are 'To do what they want', 'Not to go beyond the scope of doctors rather than follow my values',' Followed by three categories (Table 4) 

5.       Discussion

The purpose of this study is to discuss ethical problems, reason for ethical problems, behavior in ethical problems of nurses, reason for not cooperating with oneself value, and comprehensive discussion.

5.1.  Situation of Ethical Problems and Value of Nurses

Looking at the category of 'Too easy choice of death', the most ethical problem faced by nurses is the fact that in many cases the decision to prohibit DNR for patients is made too easily because of family economic problems. This requires that the family be exhausted and exhausted at the end of the patient's life, and that the patient should be given minimal passive treatment in order to speed up the time to death [15,16]. The results in the category of 'unrequited life' were perceived as an ethical problem for both active and discontinued treatments for DNR patients. In particular, ICU nurses recognized that they were more sensitive to ethical problems than the general wards. The value of nurses has also shown that they have two values: the value of sustaining treatment for the dignity of life, and the opposition to longevity therapy for a comfortable death. This result shows that nurses have different values for death and DNR, they are confused themselves

5.2.  Behaviors and Reasons According to Ethical Problems

Nurses' behaviors in the ethical problem situation were largely classified into 2 kinds of behaviors according to their own values or passive behavior in the context. First, behaviors according to their values show that they act based on the sense of duty as a nurse and their own values. These behaviors are not by the doctor's prescription but by the autonomous will and beliefs of the nurses. The second behavior is　'follow-through passively in situations' showed most nurses stepping away from ethical problems according to their doctor's prescription. The reason for this is that in Korea, the subject of decision to prohibit DNR is mainly doctors and caregivers [7], and this can be attributed to the characteristics of family-centered Korean culture. All decisions are discussed and verified through the main protector. Nurses must consider the structural and cultural characteristics of patients with consciousness, which require the consent of the guardian to proceed with the treatment.

Because doctors are ultimately responsible for the treatment of patients, the nurses themselves are perceived to be involved in doctor's work and are reluctant to object to the doctor' s prescription [17]. And the reason for passively following a doctor's prescription in an ethical problem situation may be due to the mutual non - collaborative relationship with the nurse - doctor.　However, on the other hand, the passive attitude of these nurses to doctors is considered to be difficult for nurses to communicate with doctors themselves, and it is necessary to take a passive attitude do. It may also be intended to prevent unnecessary friction with the doctor in advance. Nurses also showed contradictory behaviors that followed the practices of their seniors in the nursing organization they belonged to while valuing life and dignified death. The reason for this is that nursing organizations place a priority on hierarchical and relationship-oriented ones that emphasize the existing procedures and rules while emphasizing the efficiency within the organization on a stable basis [18]. However, ICU nurses recognize that seniors need to be aware of unidirectional communication for early work and efficient nursing due to the nature of ICU. These results show that the relationship with the nurse and the nurse is unequal and the communication is not smooth.

5.3.  Recognition and Coping with Ethical Problems of Nurses

The results of this study indicate that the value of treatment and death for ICU nurses, In the case of ethical problems experienced while nursing patients who are prohibited DNR, is not firmly established and changes according to the patient 's situation.  First, as a nurse, the perception of ethical problems and ethical values ​​are not clear. The results showed that the clinical nurses were 10.1% of those who said their ethical values ​​were firm [19]. The results suggest that ethical awareness and values ​​of ethics should be prioritized through planned and systematic ethics education. Ethics is being taught in nursing curriculum during college education. However, ethics education through actual ethical problems should be provided to students who have experienced clinical practice, and sensitivity to ethical problems should be raised in nursing practice through education.

The second reason nurses perceive the confusion of ethical values ​​according to the patient's specific situation is that there are situations that cannot be solved by ethical value only in face of various problems of human life. The reason is that the patient-related problems are related to unplanned, unexpected ethics. Also, it is complicated because it is accompanied by moral uncertainty and dilemma [20], and it can be difficult to solve as a nurse. The role of a nurse in a clinical setting is a nurse who has to experience nursing care while experiencing frustration and torture while taking care of the patient [21]. However, the reality that nurses have no authority or role to solve ethical problems is considered institutional problem.

In the area of ​​communication with doctors, nurse's ethical expertise should be raised. It may be that the ethical problems faced by the nurse have a negative attitude toward the physician, or an ethical problem between the nurse and the physician, for reasons such as the nurse's ability to work, problem solving ability, lack of communication skills with the doctor. Proper information sharing between nurses and physicians is an important part of the nurse's position to address ethical problems surrounding patient care. Therefore, in order to solve ethical problems, it is necessary to try various methods for communication between nurse and doctor in order to respect the active attitude for the relationship with the doctor and the role of each other.

It is also important to think about the fact that hospitals are not seriously aware of the importance of bioethics problems for patients' lives and deaths. Although doctors may have guidelines, do not pay much attention to them, and do not want to apply ethical guidelines in the field of health care, despite their 'medical ethics guidelines', this is the result of supporting this part [22]. Therefore, there is a need to regularly conduct training on bioethics for medical practitioners at the association or academia level. Ethical problems related to bioethics may be more difficult to solve or more difficult to solve by themselves. In order to solve these problems, efforts should be made to publicize ethical problems in the nursing organization and solve problems together by sharing the nurses' opinions.

Another problem is that there is a negative aspect that nurses do not perform patient-centered nursing that recognizes the patient's individuality in situations where they cannot actively solve ethical problems [23]. This may be due to the nursing delivery system. There are hospitals where individual patient care is provided for each nurse, but in hospitals where there are not enough nursing personnel, tasks are divided according to the job. Therefore, it is necessary to carry out the nursing work for the whole patient in the case of the actress nurse, so there is a limit to the whole nursing considering the individuality of the patient and the importance of the ethical problem is not considered. Also, it is necessary to prevent the intensive care unit admission in the aspect of efficient nursing service allocation and to make other institutional devices related to care when maintaining nonsensical lifetime treatment.

In addition, ethics advisory committees have been set up in large hospitals, but actual ethics advisory committees have not been active due to lack of cases or lack of financial support [24]. Therefore, it is necessary to establish system and institutional support for effective operation of ethical advisory committee and resolve specific problems.

6.       Conclusion

Through this study, it is expected that the value of ethical problems of the ICU nurses caring for patients at the end of their life will be specified and it will be helpful to present the direction of the desired nursing according to the value.

Table 1:  Situation of ethical problems.

Table 2: Reasons for ethical problems: Value of nurses.

Table 3: Behavior in ethical problem situations.

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