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James R, Carroll RS, Miller JM. Analysis of 20 Years of Ethics Consultations at a U.S. Children's Hospital. THE JOURNAL OF CLINICAL ETHICS 2024; 35:107-118. [PMID: 38728694 DOI: 10.1086/729417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
AbstractEmpirical studies of pediatric clinical ethics cases are scant in the biomedical and bioethics literature. In this study, more than 100 detailed records of clinical ethics consultations spanning from 2000 to 2020 at a moderately sized U.S. Mid-Atlantic children's hospital were abstracted and analyzed. Findings of the analysis were generally consistent with other studies in pediatric clinical ethics, with additional insight into aspects of moral distress associated with cases, family engagement with consultations, and other characteristics of interest also documented. Over the 20-year time frame, ethics consults were completed on average twice a year, with a detectable upward trend. Consultations were requested across the spectrum of services and units within the hospital, with critical care environments represented most frequently and genetic and neurological conditions being the most common primary diagnoses. Ethical analysis most commonly related to questions around the principles of autonomy and beneficence.
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Kovancı MS, Atlı Ozbas A. Turkish Adaptation of the Moral Distress Scale-Revised for Pediatric Nurses: A Validity and Reliability Study. J Nurs Meas 2023; 31:336-346. [PMID: 37558249 DOI: 10.1891/jnm-2021-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
Background and Purpose: Recent studies have demonstrated the adverse effects that moral distress experienced by nurses has on nurses, patients, and the healthcare system. This study aims to analyze the validity and reliability of the Turkish version of the Moral Distress Scale-Revised (MDS-R, pediatric). Methods: This study was conducted with 210 pediatric nurses. Results: Explanatory factor analysis was conducted, and a five-factor structure emerged. The Cronbach's α value of the scale was found to be 0.865, and the correlation-based item analysis showed that the values were within the acceptable range, and the discrimination of the items was adequate. Conclusions: Analyses conducted revealed that the Turkish version of the MDS-R (pediatric), consisting of 21 items and five subdimensions, is a valid and reliable measurement tool for the Turkish culture and language.
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Affiliation(s)
- Mustafa Sabri Kovancı
- Hacettepe University, Faculty of Nursing, Department of Psychiatric Nursing, Altındağ, Ankara, Turkey
| | - Azize Atlı Ozbas
- Hacettepe University, Faculty of Nursing, Department of Psychiatric Nursing, Altındağ, Ankara, Turkey
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Weaver MS, Sharma S, Walter JK. Pediatric Ethics Consultation Services, Scope, and Staffing. Pediatrics 2023; 151:e2022058999. [PMID: 36720710 PMCID: PMC9979255 DOI: 10.1542/peds.2022-058999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES National standards and guidelines call for a mechanism to address ethical concerns and conflicts in children's hospitals. The roles, responsibilities, and reach of pediatric ethics consultation services (PECS) remain unmeasured. The purpose of this study is to quantify staffing, structure, function, scope, training, and funding of PECS. METHODS Cross-sectional online survey was shared with an ethics informant at 181 children's hospitals in the United States from March to June 2022. Data were summarized descriptively and with semantic content analyses. RESULTS One hundred seventeen surveys were received from individual children's hospitals in 45 states and Washington DC (response rate 65%), with 104 qualifying for survey completion. Almost one-quarter of settings received 50 or more pediatric ethics consults in the past 12 months. On average, 7.4 people at each institution have responsibility for completing ethics consults. Estimated full-time equivalent salary support for ethics is on average 0.5 (range 0-3, median 0.25). One-third (33%) of facilities do not offer any salary support for ethics and three-quarters do not have an institutional budget for the ethics program. Clinical staff primarily initiate consults. End-of-life, benefits versus burdens of treatments, and staff moral distress were the most frequently consulted themes. Almost one-quarter (21%) of children's hospitals do not receive any consults from patients or families. CONLUSIONS The findings from this study reveal wide variation in PECS practices and raise concern about the lack of financial support provided for PECS despite substantial workloads.
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Affiliation(s)
- Meaghann S. Weaver
- Pediatric Palliative Care, University of Nebraska Medical Center, Omaha, Nebraska
- National Center for Ethics in Healthcare, Washington, District of Columbia
| | - Shiven Sharma
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jennifer K. Walter
- Department of Medical Ethics and Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Weaver MS, Wichman C, Sharma S, Walter JK. Demand and Supply: Association between Pediatric Ethics Consultation Volume and Protected Time for Ethics Work. AJOB Empir Bioeth 2022; 14:135-142. [PMID: 36574230 DOI: 10.1080/23294515.2022.2160512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
BACKGROUND Despite national increase in pediatric ethics consultation volume over the past decade, protected time and resources for healthcare ethics consultancy work has lagged. METHODS Correlation study investigating potential associations between ethics consult volume reported by recent national survey of consultants at children's hospitals and five programmatic domains. RESULTS 104 children's hospitals in 45 states plus Washington DC were included. There was not a statistically significant association between pediatric ethics consult volume and hospital size, rurality of patient population, or number of consultants. Academically-affiliated children's hospitals had fewer ethics consults compared to nonacademically affiliated. Association was found between full-time equivalent (FTE) hours and number of ethics consults (p < 0.0001). Spearman rank correlation between ethics consult volume and FTE was 0.5. CONCLUSIONS While the results of this study should be interpreted with caution, investment in protected time for ethics consultancy work may translate into increased volume of pediatric ethics consults.
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Affiliation(s)
- Meaghann S Weaver
- Department of Pediatrics, Pediatric Palliative Care, University of Nebraska Medical Center, Omaha, NE, USA
- Veterans Health Affairs, National Center for Ethics in Healthcare, Washington, DC, USA
| | - Christopher Wichman
- College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Shiven Sharma
- Department of Medical Ethics and Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer K Walter
- Department of Medical Ethics and Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Marathe PH, Zhang H, Blackler L, Stetson PD, Voigt LP, Friedman DN. Ethics Consultation Requests After Implementation of an Electronic Health Record Order. JCO Oncol Pract 2022; 18:e1505-e1512. [PMID: 35749678 PMCID: PMC9509102 DOI: 10.1200/op.22.00174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/22/2022] [Accepted: 05/19/2022] [Indexed: 09/03/2023] Open
Abstract
PURPOSE As the role of clinical ethics consultation in health care advances, there are calls to standardize the process of consultation. The Ethics Committee at Memorial Sloan Kettering Cancer Center (MSK) hypothesized that the process of requesting an ethics consultation could be improved by instituting an electronic health record (EHR) order for consultation requests. This report summarizes the impact of adopting an EHR order for ethics consultation requests at MSK. METHODS This retrospective review of all clinical ethics consultations requested at a tertiary cancer center from May 2017 to February 2020 spans 17 months before and after implementation of an electronic order for consultation requests. Summary statistics are presented using Pearson chi-square analyses with a significance level of 0.05. RESULTS There was a significant increase in the total number of consultation requests placed after implementation of the EHR order (n = 165, 0.08% of total patients) compared with before (n = 108, 0.05% of total patients; P = .007). The number of consults requested by providers from inpatient (P = .02) and outpatient (P = .04) settings significantly increased. The proportion of consults placed by medical versus nonmedical providers remained unchanged (P = .32). CONCLUSION In this large single-institution retrospective study, implementation of an EHR order for ethics consultation requests was associated with a significant increase in the number of consultation requests. Implementation of an electronic order may decrease barriers to ethics consultation in diverse practice settings. Further longitudinal, multicenter studies are needed to assess strategies to improve access to clinical ethics consultation for oncology patients.
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Affiliation(s)
- Priya H. Marathe
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hao Zhang
- Department of Anesthesiology, Pain, and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Liz Blackler
- Office of the Physician-In-Chief, Memorial Sloan Kettering Cancer Center, New York, NY
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Peter D. Stetson
- Office of the Physician-In-Chief, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Louis P. Voigt
- Department of Anesthesiology, Pain, and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Anesthesiology, Weill Cornell Medical College,New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Danielle Novetsky Friedman
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Pediatrics, Weill Cornell Medical College, New York, NY
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Madrigal VN, Curry K. Pediatric Ethics Consults for Caregivers: Anybody Home? Hosp Pediatr 2022; 12:e306-e308. [PMID: 35934746 DOI: 10.1542/hpeds.2022-006734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Vanessa N Madrigal
- Pediatric Ethics Program, Children's National Hospital, Washington, DC.,Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University, Washington, DC
| | - Kara Curry
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University, Washington, DC
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Fox E, Danis M, Tarzian AJ, Duke CC. Ethics Consultation in U.S. Hospitals: A National Follow-Up Study. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:5-18. [PMID: 33769216 DOI: 10.1080/15265161.2021.1893547] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
A 1999-2000 national study of U.S. hospitals raised concerns about ethics consultation (EC) practices and catalyzed improvement efforts. To assess how practices have changed since 2000, we administered a 105-item survey to "best informants" in a stratified random sample of 600 U.S. general hospitals. This primary article details the methods for the entire study, then focuses on the 16 items from the prior study. Compared with 2000, the estimated number of case consultations performed annually rose by 94% to 68,000. The median number of consults per hospital was unchanged at 3, but more than doubled for hospitals with 400+ beds. The level of education of EC practitioners was unchanged, while the percentage of hospitals formally evaluating their ECS decreased from 28.0% to 19.1%. The gap between large, teaching hospitals and small, nonteaching hospitals widened since the prior study. We suggest targeting future improvement efforts to hospitals where needs are not being met by current approaches to EC.
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Affiliation(s)
- Ellen Fox
- Altarum Institute
- Fox Ethics Consulting
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Nathanson PG, Walter JK, McKlindon DD, Feudtner C. Relational, Emotional, and Pragmatic Attributes of Ethics Consultations at a Children's Hospital. Pediatrics 2021; 147:peds.2020-1087. [PMID: 33674461 PMCID: PMC8015157 DOI: 10.1542/peds.2020-1087] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pediatric ethics consultations are important but understudied, with little known about consultations' contextual attributes, which may influence how ethically problematic situations are perceived and addressed. METHODS We analyzed data regarding 245 pediatric clinical ethics consultations performed between 2013 and 2018 at a large children's hospital. Prespecified data elements included 17 core problematic issues that initiate consultations, 9 ethical considerations identified by the consultation service, and 7 relational, emotional, and pragmatic contextual attributes of the consultation. The main process measure was the cumulative consultation process, ranging from one-on-one discussions with the requestor, to meeting with the clinical team, separate meetings with the patient or family and the clinical team, or combined meeting with the patient or family and the clinical team. RESULTS The most-prevalent core problematic issues were intensity or limitation of treatment (38.8%) and treatment adherence and refusal (31%). Common pertinent ethical considerations were best interest (79.2%), benefits versus harms of treatment (51%), and autonomy and decision-making (46.5%). A total of 39.2% of consults culminated with a meeting with the clinical team, 9.4% with separate meetings, and 8.2% with a meeting with all parties. Common contextual attributes were discord (43.3%), acknowledged dilemma (33.5%), and articulate disagreement (29.8%). In exploratory analyses, specific contextual attributes were associated with the core problematic issue that initiated the consultation and with how the consultative process culminated. CONCLUSIONS Pediatric ethics consultations have contextual attributes that in exploratory analyses are associated with specific types of problems and, to a lesser degree, with the cumulative ethics consultation process.
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Affiliation(s)
- Pamela G. Nathanson
- Department of Medical Ethics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Jennifer K. Walter
- Department of Medical Ethics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Department of Pediatrics, Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donna D. McKlindon
- Department of Medical Ethics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Chris Feudtner
- Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and .,Department of Pediatrics, Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Ethics Consultation in Surgical Specialties. HEC Forum 2021; 34:89-102. [PMID: 33674985 PMCID: PMC7934986 DOI: 10.1007/s10730-021-09447-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 11/24/2022]
Abstract
Multiple studies have been performed to identify the most common ethical dilemmas encountered by ethics consultation services. However, limited data exists comparing the content of ethics consultations requested by specific hospital specialties. It remains unclear whether the scope of ethical dilemmas prompting an ethics consultation differ between specialties and if there are types of ethics consultations that are more or less frequently called based on the specialty initiating the ethics consult. This study retrospectively assessed the incidence and content of ethics consultations called by surgical vs. non-surgical specialties between January 1, 2013 to December 31, 2018 using our RedCap Database and information collected through the EMR via our Clinical and Translational Science Center. 548 total ethics consultations were analyzed (surgical n = 135, non-surgical n = 413). Our results demonstrate that more surgical consults originated from the ICU, as opposed to lower acuity units (45.9% vs. 14.3%, p ≤ 0.001), and surgical patients were more likely to have a DNR in place (37.5% vs. 22.2%, p = 0.002). Surgical specialties were more likely to call about issues relating to withholding/withdrawing life-sustaining treatment (p ≤ 0.001), while non-surgical specialties were more likely to call about issues related to discharge planning (p = 0.001). There appear to be morally relevant differences between consults classified as the “same” that are not entirely captured by the usual ethics consultations classification system. In conclusion, this study highlights the unique ethical issues experienced by surgical vs. non-surgical specialties. Ultimately, our data can help ethics consultation services determine how best to educate various hospital specialties to approach ethical issues commonly experienced within their field.
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KOVANCI MS, HİÇDURMAZ D. Ahlaki Cesaret: Tanımı, Ahlaki Sıkıntı ve Ahlaki Duyarlılık İle İlişkisi ve Geliştirilmesi. DÜZCE ÜNIVERSITESI SAĞLIK BILIMLERI ENSTITÜSÜ DERGISI 2020. [DOI: 10.33631/duzcesbed.683548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Orzechowski M, Schochow M, Steger F. Clinical Ethics Consultation in the Transition Countries of Central and Eastern Europe. SCIENCE AND ENGINEERING ETHICS 2020; 26:833-850. [PMID: 31587148 DOI: 10.1007/s11948-019-00141-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 09/24/2019] [Indexed: 06/10/2023]
Abstract
Since 1989, clinical ethics consultation in form of hospital ethics committees (HECs) was established in most of the transition countries of Central and Eastern Europe. Up to now, the similarities and differences between HECs in Central and Eastern Europe and their counterparts in the U.S. and Western Europe have not been determined. Through search in literature databases, we have identified studies that document the implementation of clinical ethics consultation in Central and Eastern Europe. These studies have been analyzed under the following aspects: mode of establishment of HECs, character of consultation they provide, and their composition. The results show that HECs in the transition countries of Central and Eastern Europe differ from their western-European or U.S. counterparts with regard to these three aspects. HECs were established because of centrally imposed legal regulations. Little initiatives in this area were taken by medical professionals interested in resolving emerging ethical issues. HECs in the transition countries concentrate mostly on review of research protocols or resolution of administrative conflicts in healthcare institutions. Moreover, integration of non-professional third parties in the workings of HECs is often neglected. We argue that these differences can be attributed to the historical background and the role of medicine in these countries under the communist regime. Political and organizational structures of healthcare as well as education of healthcare staff during this period influenced current functioning of clinical ethics consultation in the transition countries.
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Affiliation(s)
- Marcin Orzechowski
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, Parkstraße 11, 89073, Ulm, Germany.
| | - Maximilian Schochow
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, Parkstraße 11, 89073, Ulm, Germany
| | - Florian Steger
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, Parkstraße 11, 89073, Ulm, Germany
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Navin MC, Wasserman JA, Jain S, Baughman KR, Laventhal NT. When Do Pediatricians Call the Ethics Consultation Service? Impact of Clinical Experience and Formal Ethics Training. AJOB Empir Bioeth 2020; 11:83-90. [PMID: 32207383 DOI: 10.1080/23294515.2020.1737983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background: Previous research shows that pediatricians inconsistently utilize the ethics consultation service (ECS). Methods: Pediatricians in two suburban, Midwestern academic hospitals were asked to reflect on their ethics training and utilization of ECS via an anonymous, electronic survey distributed in 2017 and 2018, and analyzed in 2018. Participants reported their clinical experience, exposure to formal and informal ethics training, use of formal and informal ethics consultations, and potential barriers to formal consultation. Results: Less experienced pediatricians were more likely to utilize formal ethics consultation and more likely to have formal ethics training. The most commonly reported reasons not to pursue formal ECS consultation were inconvenience and self-reported expertise in pediatric ethics. Conclusions: These results inform ongoing discussions about ethics consultation among pediatricians and the role of formal ethics training in both undergraduate and graduate medical education.
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Affiliation(s)
- Mark C Navin
- Department of Philosophy, Oakland University, Rochester, Michigan, USA
| | - Jason Adam Wasserman
- Department of Foundational Medical Studies and Department of Pediatrics, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Susanna Jain
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Katie R Baughman
- Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Naomi T Laventhal
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA.,Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, USA
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