서론

인간생명에 대한 존중과 인간권리에 대한 존중은 조직화된 간호전문직이 그 구성원들에게 대상자를 위한 간호제공 시 충실해야 한다고 강조하는 두 가지 근원적 가치이다.  말기 환자 간호에 있어서 간호사는 간호 중재 시 어떻게 가치 판단을 해야 할지에 대해 인식할 필요가 있다. 간호사는 실무 수행 시 자주 윤리적인 문제의 한가운데에 놓이게 된다. 윤리적 갈등은 가장 단순하고 평범한 간호수행, 즉 체위변경, 식사보조, 목욕 등과 같은 업무 중에도 유발 할 수 있다.  많은 경우 의사, 환자 및 그 가족들은 어떤 결정을 내려야만 하고, 간호사들은 가치 판단을 하여 선택한 것을 수행하도록 요청 받는다. 간호사들은 관(tube)이나 링거(lines)의 제거 혹은 모르핀 관리 등과 같은 업무를 수행할 때, 가치판단과 선택을 하여야 한다. 의사들은 때때로 아무런 의논도 없이 간호사에게 영원한 무의식 상태나 생명의 종료 상태를 가져 올 수 있는 중재를 하도록 지시할 수 있다. 다른 이들에 의한 이러한 결정은 간호사에게 심각한 도덕적인 혼란을 가져온다. “간호사들이 도덕적 고뇌(moral distress)를 경험하는 것은 그들이 도덕적 선택을 도덕적인 행동으로 옮길 수 없거나 간호에서의 가치가 무시되었을 때”,  혹은 어떻게 행동하는 것이 옳은지 알고 있지만 그 옳은 것을 따르는 것이 불가능 할 때, 또한 여러 가지 제약 즉, 개인의 신념과 가치에 위배되는 방식의 행위를 요구 당할 때이다.  

그러므로 도덕적 문제를 명명하고 명료화 하는 것은 간호사의 중요한 간호 역할에 속한다. 간호사는 항상 “이 사람과 가족을 위해 할 수 있는 좋은 일이 무엇인가? 이것이 이 사람이 원하는 것인가?” 라는 질문들을 목소리를 높여 할 필요가 있다. 이러한 질문들은 간호사가 도덕적 용기를 갖기 위해 반드시 필요하다.

따라서 본 강의에서는 임상에서 발생하는 다양한 윤리 문제 가운데 말기환자 간호와 관련된 윤리적 원칙, 의무와 행동들을 선행, 자율성 존중, 진실 말하기 중심으로 논의하고, 또한 가톨릭 교회의 가르침을 인용하여 설명하고자 한다.   

Sung-Suk Han
Kangnam St. Mary's Hospital,
the Catholic University of Korea

Introduction
  Respect for human life and respect for human rights are two basic values which the organized nursing profession has urged its members to adhere to in their service of mankind. To nurse at the end of life, you need to become conscious of how value laden the choice of medical and nursing interventions can be. We practice in the middle of an ethical minefield. Even the most ordinary nursing measures, such as nursing, feeding and bathing can elicit ethical conflicts. Physicians families, patients, and a combination thereof make decisions. Nurses are often the ones asked to carry out their values laden choices. Sometimes, without discussion physicians order us to intervene in ways that may end life or cause permanent unconsciousness. Decisions made by reasons such as these create great moral confusion in nurses. "Nurses experience moral distress when they are unable to translate their moral choices into moral action or when they feel that nursing virtues are undermined". Or when they know how they should act morally but that act is deemed impossible, among other restraints namely when individual's beliefs and self worth are being demanded.
Therefore, naming and clarifying ethical issues is a permanent nursing role at the end of life. Nursing must constantly question: "Is what we are doing good for this person and family? Is this what the person wants? These are questions that the nurse must ask in order to gain moral courage and not fall into despair.
Moreover, more principles, duties such as moral conduct, beneficence, respect for autonomy and veracity that relates to my work with palliative care patients will be explained. Where there is a variety of occurring clinical problems; with a focus on respect for autonomy and veracity in particular.

Moral principles and the nurse's duties

   1.Doing good, beneficence
Doing good to others involve being virtuous and extending goodness to them. At the end of life, beneficence is expressed through attentive listening, knowing the patient as a person, inquiring about well-being, and persistently trying to relieve suffering. However, nurses are often confronted with fear that interferes with this goal. For example, when the nurse stop listening attentively to patients, it can be said that the nurse is afraid to alleviate the patients' suffering. We might fear comforting because we are afraid that medicating to relieve suffering will kill the patient. Therefore, beneficent nursing practice requires courage to confront our own fears.

   2.respect for autonomy
Respect for autonomy is usually under the moral sphere of the patient's right to self-determination. In the ICN Code of Ethical (2001) states "the nurse ensures that the individual receives sufficient information on which to base consent for care and related treatment". Nurses should understand that "in order to advocate the autonomy of the patient, the patient must be informed of and understand the nature of treatments and results." Also, only under voluntary consent can the patient be administered a treatment or care". For example, when an ethical dilemma is presented by a patient refusing his or her food 'when the patient's autonomy is respected, there is no intervention in part by the nurse and the situation is left alone' The nurse's dilemma lies in his or her duties to respect the patient's autonomy, and liabilities stemming from failure to provide care for the patient. The study of Um (1994) showed that the values nurses gave greatest importance to were 'saving life' and "maintaining care", and the next most important value was respecting the patient's autonomy/self determination.
Therefore, the nurse must judge whether or not the patient has the ability to make rational decisions. When a patient has the ability to make rational decisions on life sustaining treatments involving resuscitation, artificial respiration, diet, transfusion, dialysis, chemotherapy, operations or antibiotics, decisions upon refusal or such treatments should be consulted with the patients' family and caregivers.
Decisional capacity usually deteriorates at the end of life, due to both disease and medication evaluating decisional capacity entails asking the following.

       1) Can the person understand and communicate information?
       2) Is the person able to reason and deliberate about a decision?
       3) Can the person identify personal values and goals?

When the patient's decisional capacity is impaired, family members or legally appointed surrogates make decisions in the patient's decision in the patient's stead.
But in Christian perspective autonomy does, however, not have the first nor the last wore but it exists thanks to "creatural" solidarity and is necessary condition for the fulfillment of this solidarity.

   3. veracity
The term veracity relates to the practice of telling the truth. Truthfulness is widely accepted as a universal virtue. Nursing literature promotes honesty as a virtue and truth telling as an important function of nurses. We can support nurses' practice of telling the truth in many ways. Truth telling engenders respect, open communication, trust and shared responsibilities. It is promoted in all professional codes of nursing ethics.
To inform someone that they are dying is a difficult tasks for anyone. However, "this difficulty is not to be mistaken as a right to bypass the duty to be truthful. Death is too essential an event for the envisioning of it to be avoided." Would depriving end of life patients with their rights to know the truth be in their best interest, and respecting the patient's dignity? Do you think it is acceptable to deceive a patient in order to prevent unnecessary suffering? However, to what extent can nurses answer end of life patients' questions directly? To what extent do nurses provide a context in which patients can ask these questions? In addition to clinical settings the reality is that the responsibility of informing the patient of the nature of his or her disease lies in the doctor, and in the case that the doctor has not informed the patient of his or her prognosis, the nurse is not in the position of informing the patient. Actually self-determination is not possible without knowing the truth.

The importance of nurses' responsibilities

I would like to conclude this paper with Cor Unum's writing. "Despite the fact that many doctors tend to look upon them as purely auxiliary, nurses have a fundamental role of medication between doctors and patients. Although nurses are, it is true, by no means free of danger of avoiding the patients during the final stages of his illness, they are nevertheless responsible for actions that can be often be of crucial importance. They must decide, for example, whether or not to call the doctor when they find that the patient has suddenly become worse; or must decide whether or not to give the patient a calming substance the doctor has left it up to their judgment to use appropriate moment, etc…." Therefore doctors and nurse' close collaboration is essential to the relief and proper care of each patient."