1
|
Lavecchia M, Myers J, Bainbridge D, Incardona N, Levine O, Steinberg L, Schep D, Vautour J, Kumar SJ, Seow H. Education modalities for serious illness communication training: A scoping review on the impact on clinician behavior and patient outcomes. Palliat Med 2024; 38:170-183. [PMID: 37424275 PMCID: PMC10865772 DOI: 10.1177/02692163231186180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
BACKGROUND Several clinician training interventions have been developed in the past decade to address serious illness communication. While numerous studies report on clinician attitudes and confidence, little is reported on individual education modalities and their impact on actual behavior change and patient outcomes. AIM To examine what is known about the education modalities used in serious illness communication training and their impact on clinician behaviors and patient outcomes. DESIGN A scoping review using the Joanna Briggs Methods Manual for Scoping Reviews was conducted to examine studies measuring clinician behaviors or patient outcomes. DATA SOURCES Ovid MEDLINE and EMBASE databases were searched for English-language studies published between January 2011 and March 2023. RESULTS The search identified 1317 articles: 76 met inclusion criteria describing 64 unique interventions. Common education modalities used were: single workshop (n = 29), multiple workshops (n = 11), single workshop with coaching (n = 7), and multiple workshops with coaching (n = 5); though they were inconsistently structured. Studies reporting improved clinician skills tended to be in simulation settings with neither clinical practice nor patient outcomes explored. While some studies reported behavior changes or improved patient outcomes, they did not necessarily confirm improvements in clinician skills. As multiple modalities were commonly used and often embedded within quality improvement initiatives, the impact of individual modalities could not be determined. CONCLUSION This scoping review of serious illness communication interventions found heterogeneity among education modalities used and limited evidence supporting their effectiveness in impacting patient-centered outcomes and long-term clinician skill acquisition. Well-defined educational modalities and consistent measures of behavior change and standard patient-centered outcomes are needed.
Collapse
Affiliation(s)
- Melissa Lavecchia
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, McMaster University, Hamilton, ON, Canada
| | - Jeff Myers
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Daryl Bainbridge
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Nadia Incardona
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Oren Levine
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Leah Steinberg
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Daniel Schep
- Division of Radiation Oncology, Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Joanna Vautour
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
2
|
McDarby M, Silverstein HI, Rosa WE, Parker PA, Carpenter BD. Patient and caregiver questions and clinician responses during initial outpatient neuropalliative care appointments. PEC INNOVATION 2023; 3:100207. [PMID: 37700766 PMCID: PMC10494256 DOI: 10.1016/j.pecinn.2023.100207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 08/23/2023] [Accepted: 08/30/2023] [Indexed: 09/14/2023]
Abstract
Objective Open communication during appointments exemplifies person-centered care. The current study characterized questions asked by persons with neurologic illnesses and their caregivers-and clinicians' responses to those questions-during initial outpatient palliative care appointments. Methods We coded type (direct or indirect) and topic of questions stated by patients and their caregivers in audio recordings from 38 initial outpatient palliative care appointments. We also coded the completeness and quality features of clinicians' responses. Results Patients and caregivers stated 556 total questions; most were direct questions (79.7%) and primarily about symptoms, treatment, and lifestyle issues. Clinicians responded to more than 90% of all questions. Responses to both question types were similar in completeness and quality, but clinicians more frequently offered support in response to direct questions and gave recommendations in response to indirect questions. Conclusion Persons with neurologic illnesses and their caregivers use different question types to obtain information about symptoms and treatment during initial palliative care appointments. Results may guide clinician training and patient education for optimizing information exchange in palliative care. Innovation This study is the first to explore patient and caregiver use of indirect questions in neuropalliative care appointments and the quality of clinicians' responses to those questions.
Collapse
Affiliation(s)
- Meghan McDarby
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Hannah I. Silverstein
- Department of Psychological and Brain Sciences, Washington University in St. Louis, St. Louis, MO, United States of America
| | - William E. Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Patricia A. Parker
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Brian D. Carpenter
- Department of Psychological and Brain Sciences, Washington University in St. Louis, St. Louis, MO, United States of America
| |
Collapse
|
3
|
Mori M, Lin CP, Cheng SY, Suh SY, Takenouchi S, Ng R, Chan H, Kim SH, Chen PJ, Yuen KK, Fujimori M, Yamaguchi T, Hamano J, Kizawa Y, Morita T, Martina D. Communication in Cancer Care in Asia: A Narrative Review. JCO Glob Oncol 2023; 9:e2200266. [PMID: 37364221 PMCID: PMC10497295 DOI: 10.1200/go.22.00266] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 04/28/2023] [Accepted: 04/28/2023] [Indexed: 06/28/2023] Open
Affiliation(s)
- Masanori Mori
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Cheng-Pei Lin
- Institute of Community Health Care, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, King's College London, United Kingdom
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Sang-Yeon Suh
- Department of Family Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
- Department of Medicine, Dongguk University Medical School, Seoul, South Korea
| | - Sayaka Takenouchi
- Department of Nursing Ethics, Division of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Raymond Ng
- Palliative and Supportive Care, Woodlands Health, Singapore, Singapore
| | - Helen Chan
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Sun-Hyun Kim
- Department of Family Medicine, School of Medicine, Catholic Kwandong University, International St Mary's Hospital, Incheon, South Korea
| | - Ping-Jen Chen
- Department of Family Medicine, Division of Geriatrics and Gerontology, Kaohsiung Medical University Hospital and School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, United Kingdom
| | - Kwok Keung Yuen
- Department of Clinical Oncology, Queen Mary Hospital, Hong Kong, China
| | - Maiko Fujimori
- Division of Supportive Care, Survivorship and Translational Research, National Cancer Center Institute for Cancer Control, Tokyo, Japan
| | - Takashi Yamaguchi
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Jun Hamano
- Department of Palliative and Supportive Care, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative and Supportive Care, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Diah Martina
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Internal Medicine, Division of Psychosomatic and Palliative Medicine, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
- Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| |
Collapse
|
4
|
Harnischfeger N, Rath H, Alt-Epping B, Brand H, Haller K, Letsch A, Rieder N, Thuss-Patience P, Bokemeyer C, Bergelt C, Oechsle K. Effects of a communication training for oncologists on early addressing palliative and end-of-life care in advanced cancer care (PALLI-COM): a randomized, controlled trial. ESMO Open 2022; 7:100623. [PMID: 36356411 PMCID: PMC9808464 DOI: 10.1016/j.esmoop.2022.100623] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 09/28/2022] [Accepted: 10/05/2022] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION In advanced cancer care, early communication about palliative care (PC) and end-of-life (EoL)-related issues is recommended, but is often impeded by physicians' communication insecurities. We investigated the effect of a newly developed compact communication skills training 'PALLI-COM' on oncologists' competencies to early address PC/EoL-related issues. MATERIALS AND METHODS We conducted a randomized, controlled trial (RCT) with an intervention group (IG; 2 × 90 min training) and a wait list control group (CG) at five sites. At two assessment points, participating oncologists led videotaped medical consultations with simulated patients (SPs) via a privacy compliant video conference platform. SPs were represented by trained actors. The taped conversations were rated for primary outcome (communication skills assessed by adapted COM-ON-checklist and COM-ON-coaching rating scales) by raters blinded for study group. Secondary outcomes included oncologists' self-reported communication skills (Self-Efficacy in Palliative Care Scale, Thanatophobia-Scale, Communication about End of Life Survey, study-specific items) as well as external rating of the SPs. Univariate analyses of covariance with baseline adjustment were used to analyze intervention effects. RESULTS A total of 141 oncologists [age: mean (standard deviation) = 32.7 (6.3) years, 60% female (nIG = 73, nCG = 68)] participated. Following intervention, the IG showed significantly more improvement in four out of five assessed communication skills: 'reacting to emotions and showing empathy', 'pointing out opportunities and giving hope', 'addressing the EoL' and 'explaining the concept of PC'. IG participants also improved more than CG participants in almost all secondary outcomes assessed by participants and SPs: oncologists' self-efficacy, attitudes towards caring for terminally ill patients, communication strategies and confidence in dealing with PC/EoL-related issues as well as communication quality from the SPs' perspective. CONCLUSION Findings indicate that the compact communication skills training PALLI-COM increases oncologists' competencies in early addressing PC/EoL-related issues from different perspectives. Implementation in routine oncology residency might improve advanced cancer care by strengthening these communication skills.
Collapse
Affiliation(s)
- N. Harnischfeger
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Correspondence to: Nele Harnischfeger, Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - H.M. Rath
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - B. Alt-Epping
- Department of Palliative Medicine, Heidelberg University Hospital, Heidelberg, Germany,Department of Palliative Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - H. Brand
- Department of Hematology, Oncology and Tumor Immunology, Campus Kiel, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - K. Haller
- Department of Hematology, Oncology and Cancer Immunology, Campus Virchow-Klinikum, Charité – University Medicine Berlin, Berlin, Germany
| | - A. Letsch
- Department of Hematology, Oncology and Tumor Immunology, Campus Kiel, University Medical Center Schleswig-Holstein, Kiel, Germany,Department of Hematology, Oncology and Cancer Immunology, Campus Benjamin Franklin, Charité – University Medicine Berlin, Berlin, Germany
| | - N. Rieder
- Department of Palliative Medicine, Heidelberg University Hospital, Heidelberg, Germany,Department of Palliative Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - P. Thuss-Patience
- Department of Hematology, Oncology and Cancer Immunology, Campus Virchow-Klinikum, Charité – University Medicine Berlin, Berlin, Germany
| | - C. Bokemeyer
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - C. Bergelt
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Department of Medical Psychology, University Medicine Greifswald, Greifswald, Germany
| | - K. Oechsle
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
5
|
Ryan RE, Connolly M, Bradford NK, Henderson S, Herbert A, Schonfeld L, Young J, Bothroyd JI, Henderson A. Interventions for interpersonal communication about end of life care between health practitioners and affected people. Cochrane Database Syst Rev 2022; 7:CD013116. [PMID: 35802350 PMCID: PMC9266997 DOI: 10.1002/14651858.cd013116.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Communication about end of life (EoL) and EoL care is critically important for providing quality care as people approach death. Such communication is often complex and involves many people (patients, family members, carers, health professionals). How best to communicate with people in the period approaching death is not known, but is an important question for quality of care at EoL worldwide. This review fills a gap in the evidence on interpersonal communication (between people and health professionals) in the last year of life, focusing on interventions to improve interpersonal communication and patient, family member and carer outcomes. OBJECTIVES To assess the effects of interventions designed to improve verbal interpersonal communication about EoL care between health practitioners and people affected by EoL. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018, without language or date restrictions. We contacted authors of included studies and experts and searched reference lists to identify relevant papers. We searched grey literature sources, conference proceedings, and clinical trials registries in September 2019. Database searches were re-run in June 2021 and potentially relevant studies listed as awaiting classification or ongoing. SELECTION CRITERIA This review assessed the effects of interventions, evaluated in randomised and quasi-randomised trials, intended to enhance interpersonal communication about EoL care between patients expected to die within 12 months, their family members and carers, and health practitioners involved in their care. Patients of any age from birth, in any setting or care context (e.g. acute catastrophic injury, chronic illness), and all health professionals involved in their care were eligible. All communication interventions were eligible, as long as they included interpersonal interaction(s) between patients and family members or carers and health professionals. Interventions could be simple or complex, with one or more communication aims (e.g. to inform, skill, engage, support). Effects were sought on outcomes for patients, family and carers, health professionals and health systems, including adverse (unintended) effects. To ensure this review's focus was maintained on interpersonal communication in the last 12 months of life, we excluded studies that addressed specific decisions, shared or otherwise, and the tools involved in such decision-making. We also excluded studies focused on advance care planning (ACP) reporting ACP uptake or completion as the primary outcome. Finally, we excluded studies of communication skills training for health professionals unless patient outcomes were reported as primary outcomes. DATA COLLECTION AND ANALYSIS Standard Cochrane methods were used, including dual review author study selection, data extraction and quality assessment of the included studies. MAIN RESULTS Eight trials were included. All assessed intervention effects compared with usual care. Certainty of the evidence was low or very low. All outcomes were downgraded for indirectness based on the review's purpose, and many were downgraded for imprecision and/or inconsistency. Certainty was not commonly downgraded for methodological limitations. A summary of the review's findings is as follows. Knowledge and understanding (four studies, low-certainty evidence; one study without usable data): interventions to improve communication (e.g. question prompt list, with or without patient and physician training) may have little or no effect on knowledge of illness and prognosis, or information needs and preferences, although studies were small and measures used varied across trials. Evaluation of the communication (six studies measuring several constructs (communication quality, patient-centredness, involvement preferences, doctor-patient relationship, satisfaction with consultation), most low-certainty evidence): across constructs there may be minimal or no effects of interventions to improve EoL communication, and there is uncertainty about effects of interventions such as a patient-specific feedback sheet on quality of communication. Discussions of EoL or EoL care (six studies measuring selected outcomes, low- or very low-certainty evidence): a family conference intervention may increase duration of EoL discussions in an intensive care unit (ICU) setting, while use of a structured serious illness conversation guide may lead to earlier discussions of EoL and EoL care (each assessed by one study). We are uncertain about effects on occurrence of discussions and question asking in consultations, and there may be little or no effect on content of communication in consultations. Adverse outcomes or unintended effects (limited evidence): there is insufficient evidence to determine whether there are adverse outcomes associated with communication interventions (e.g. question prompt list, family conference, structured discussions) for EoL and EoL care. Patient and/or carer anxiety was reported by three studies, but judged as confounded. No other unintended consequences, or worsening of desired outcomes, were reported. Patient/carer quality of life (four studies, low-certainty evidence; two without useable data): interventions to improve communication may have little or no effect on quality of life. Health practitioner outcomes (three studies, low-certainty evidence; two without usable data): interventions to improve communication may have little or no effect on health practitioner outcomes (satisfaction with communication during consultation; one study); effects on other outcomes (knowledge, preparedness to communicate) are unknown. Health systems impacts: communication interventions (e.g. structured EoL conversations) may have little or no effect on carer or clinician ratings of quality of EoL care (satisfaction with care, symptom management, comfort assessment, quality of care) (three studies, low-certainty evidence), or on patients' self-rated care and illness, or numbers of care goals met (one study, low-certainty evidence). Communication interventions (e.g. question prompt list alone or with nurse-led communication skills training) may slightly increase mean consultation length (two studies), but other health service impacts (e.g. hospital admissions) are unclear. AUTHORS' CONCLUSIONS Findings of this review are inconclusive for practice. Future research might contribute meaningfully by seeking to fill gaps for populations not yet studied in trials; and to develop responsive outcome measures with which to better assess the effects of communication on the range of people involved in EoL communication episodes. Mixed methods and/or qualitative research may contribute usefully to better understand the complex interplay between different parties involved in communication, and to inform development of more effective interventions and appropriate outcome measures. Co-design of such interventions and outcomes, involving the full range of people affected by EoL communication and care, should be a key underpinning principle for future research in this area.
Collapse
Affiliation(s)
- Rebecca E Ryan
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Michael Connolly
- School of Nursing, Midwifery and Health Systems, University College Dublin and Our Lady's Hospice and Care Services, Dublin, Ireland
| | - Natalie K Bradford
- Centre for Children's Health Research, Cancer and Palliative Care Outcomes at Centre for Children's Health Research, Queensland University of Technology (QUT), South Brisbane, Australia
| | - Simon Henderson
- Department of Aviation, The University of New South Wales, Sydney, Australia
| | - Anthony Herbert
- Paediatric Palliative Care Service, Children's Health Queensland, Hospital and Health Service, South Brisbane, Australia
- Centre for Children's Health Research, Queensland University of Technology, South Brisbane, Australia
| | - Lina Schonfeld
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Jeanine Young
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Sippy Downs, Australia
| | | | - Amanda Henderson
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Sippy Downs, Australia
| |
Collapse
|
6
|
Harnischfeger N, Rath HM, Oechsle K, Bergelt C. Addressing palliative care and end-of-life issues in patients with advanced cancer: a systematic review of communication interventions for physicians not specialised in palliative care. BMJ Open 2022; 12:e059652. [PMID: 35715185 PMCID: PMC9207918 DOI: 10.1136/bmjopen-2021-059652] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To identify and summarise evaluated interventions aiming to improve the communication of palliative care (PC) and end-of-life (EoL) issues in physicians caring for cancer patients. Such interventions are needed with regard to the aim of an earlier communication of those issues in oncology daily practice, which is associated with a range of benefits for patients and caregivers but is often impeded by physicians' communication insecurities. DESIGN Systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES Relevant publications were systematically searched in MEDLINE, PsycINFO, CINAHL and Web of Science databases in September 2020 with an update in July 2021. ELIGIBILITY CRITERIA We included publications reporting a quantitative evaluation of a communication intervention on one or more PC/EoL issues with a communication-related main outcome. Target group had to be physicians caring for cancer patients non-specialist in PC. DATA EXTRACTION AND SYNTHESIS Two independent raters extracted intervention characteristics, publication characteristics and publication quality. Results were narratively synthesised. RESULTS 24 publications reporting 22 interventions were included. 13 publications reported randomised controlled trials. A majority of the interventions addressed one specific PC/EoL issue, most often breaking bad news. Teaching strategies mostly involved role-plays. Target group were mainly oncologists. In addition to self-reported outcome measurements for evaluation, most publications also reported the use of external rating data. All but one publication reported significant intervention effects on at least one outcome parameter. Publication quality was overall moderate. CONCLUSIONS The empirically tested communication interventions on PC/EoL issues seem to effectively improve physicians' communication. Future interventions should focus on other issues than breaking bad news, such as preparing for the future. Target group should also be organ-specific oncologists, as all primary caring physicians are responsible for timely communication. Our risk-of-bias assessment revealed some weaknesses, indicating that more high-quality studies for evaluation are needed. PROSPERO REGISTRATION NUMBER CRD42020191054.
Collapse
Affiliation(s)
- Nele Harnischfeger
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hilke M Rath
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karin Oechsle
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Corinna Bergelt
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Medical Psychology, University Medicine Greifswald, Greifswald, Germany
| |
Collapse
|