Current Use of Carbon-Based Materials for Biomedical Applications—A Prospective and Review

Biomaterials for Targeting Endoplasmic Reticulum in Cancer

Endoplasmic reticulum (ER) is one of the most important sub-cellular organelles which controls myriads of biological functions including protein biosynthesis with proper functional folded form, protein misfolding, protein transport into Golgi body for secretion, Ca2+ homeostasis and so on. Subsequently, dysregulation in ER function leads to ER stress followed by disease pathology like cancer. Hence, targeting ER in the cancer cells emerged as one of the futuristic strategies for cancer treatment. However, the major challenge is to selectively and specifically target ER in the sub-cellular milieu in the cancer tissues, due to the lack of ER targeting chemical moieties to recognize the ER markers. To address this, in the last decade, numerous biomaterials were explored to selectively impair and image ER in cancer cells to induce ER stress. This review outlines those biomaterials which consists of carbon and silicon materials, lipid nanoparticles (liposomes and micelles), supramolecular self-assembled nanostructures, cell membrane-coated nanoparticles and metallic nanoparticles. Moreover, we also discuss the challenges and possible solutions of this promising field to usher the readers towards next-generation ER targeted cancer therapy.

Disposable electrochemical biosensors for the detection of bacteria in the light of antimicrobial resistance

Persistent and inappropriate use of antibiotics is causing rife antimicrobial resistance (AMR) worldwide. Common bacterial infections are thus becoming increasingly difficult to treat without the use of last resort antibiotics. This has necessitated a situation where it is imperative to confirm the infection to be bacterial, before treating it with antimicrobial speculatively. Conventional methods of bacteria detection are either culture based which take anywhere between 24 and 96 hor require sophisticated molecular analysis equipment with libraries and trained operators. These are difficult propositions for resource limited community healthcare setups of developing or less developed countries. Customized, inexpensive, point-of-care (PoC) biosensors are thus being researched and developed for rapid detection of bacterial pathogens. The development and optimization of disposable sensor substrates is the first and crucial step in development of such PoC systems. The substrates should facilitate easy charge transfer, a high surface to volume ratio, be tailorable by the various bio-conjugation chemistries, preserve the integrity of the biorecognition element, yet be inexpensive. Such sensor substrates thus need to be thoroughly investigated. Further, if such systems were made disposable, they would attain immunity to biofouling. This article discusses a few potential disposable electrochemical sensor substrates deployed for detection of bacteria for environmental and healthcare applications. The technologies have significant potential in helping reduce bacterial infections and checking AMR. This could help save lives of people succumbing to bacterial infections, as well as improve the overall quality of lives of people in low- and middle-income countries.

Single Atom-Dispersed Silver Incorporated in ZIF-8-Derived Porous Carbon for Enhanced Photothermal Activity and Antibacterial Activities

Purpose

Recently, Single-atom-loaded carbon-based material is a new environmentally friendly and stable photothermal antibacterial nanomaterial. It is still a great challenge to achieve single-atom loading on carbon materials.

Materials and Methods

Herein, We doped single-atom Ag into ZIF-8-derived porous carbon to obtain Ag-doped ZIF-8-derived porous carbon(AgSA-ZDPC). The as-prepared samples were characterized by XRD, XPS, FESEM, EDX, TEM, and HAADF-STEM which confirmed that the single-atom Ag successfully doped into the porous carbon. Further, the photothermal properties and antimicrobial activity of AgSA-ZDPC have been tested.

Results

The results showed that the temperature increased by 30 °C after near-infrared light irradiation(1 W/cm2) for 5 min which was better than ZIF-8-derived porous carbon(ZDPC). It also exhibits excellent photothermal stability after the laser was switched on and off 5 times. When the AgSA-ZDPC concentration was greater than 50 µg/mL and the near-infrared irradiation was performed for 5 min, the growth inhibition of S. aureus and E. coli was almost 100%.

Conclusion

This work provides a simple method for the preparation of single-atom Ag-doped microporous carbon which has potential antibacterial application.

Carbon Quantum Dots: Properties, Preparation, and Applications

Carbon quantum dots are a novel form of carbon material. They offer numerous benefits including particle size adjustability, light resistance, ease of functionalization, low toxicity, excellent biocompatibility, and high-water solubility, as well as their easy accessibility of raw materials. Carbon quantum dots have been widely used in various fields. The preparation methods employed are predominantly top-down methods such as arc discharge, laser ablation, electrochemical and chemical oxidation, as well as bottom-up methods such as templates, microwave, and hydrothermal techniques. This article provides an overview of the properties, preparation methods, raw materials for preparation, and the heteroatom doping of carbon quantum dots, and it summarizes the applications in related fields, such as optoelectronics, bioimaging, drug delivery, cancer therapy, sensors, and environmental remediation. Finally, currently encountered issues of carbon quantum dots are presented. The latest research progress in synthesis and application, as well as the challenges outlined in this review, can help and encourage future research on carbon quantum dots.

Nanoparticles loaded with Daunorubicin as an advanced tool for cancer therapy

Nowadays, with the advent of cutting-edge technologies in the field of biotechnology, some highly advanced medical methods are introduced to treat cancers more efficiently. In the chemotherapy processes, anti-cancer drugs can be encapsulated in a stimuli-responsive coating which is capable of being functionalized by diverse ligands to increase the biocompatibility and control drug release behavior in a targeted drug delivery system. Nanoparticles (NPs) are playing an important role as nanocarriers in chemotherapy procedures, recently, numerous novel drug delivery systems have been studied which employed diverse types of NPs with remarkable structural features like porous nanocarriers with active and extended surface areas to enhance the drug loading and delivery efficacy. In this study, Daunorubicin (DAU) as an effective anti-cancer drug for treating various cancers introduced, and its application for novel drug delivery systems either as a single chemotherapy agent or co-delivery alongside other drugs with diverse NPs has been reviewed.

Smart Nanomaterials in Cancer Theranostics: Challenges and Opportunities

Cancer is ranked as the second leading cause of death globally. Traditional cancer therapies including chemotherapy are flawed, with off-target and on-target toxicities on the normal cells, requiring newer strategies to improve cell selective targeting. The application of nanomaterial has been extensively studied and explored as chemical biology tools in cancer theranostics. It shows greater applications toward stability, biocompatibility, and increased cell permeability, resulting in precise targeting, and mitigating the shortcomings of traditional cancer therapies. The nanoplatform offers an exciting opportunity to gain targeting strategies and multifunctionality. The advent of nanotechnology, in particular the development of smart nanomaterials, has transformed cancer diagnosis and treatment. The large surface area of nanoparticles is enough to encapsulate many molecules and the ability to functionalize with various biosubstrates such as DNA, RNA, aptamers, and antibodies, which helps in theranostic action. Comparatively, biologically derived nanomaterials perceive advantages over the nanomaterials produced by conventional methods in terms of economy, ease of production, and reduced toxicity. The present review summarizes various techniques in cancer theranostics and emphasizes the applications of smart nanomaterials (such as organic nanoparticles (NPs), inorganic NPs, and carbon-based NPs). We also critically discussed the advantages and challenges impeding their translation in cancer treatment and diagnostic applications. This review concludes that the use of smart nanomaterials could significantly improve cancer theranostics and will facilitate new dimensions for tumor detection and therapy.

Biocompatibility Evaluation of Carbon Nanohorns in Bone Tissues

With the advent of nanotechnology, the use of nanoparticles as drug delivery system (DDS) has attracted great interest. We aimed to apply carbon nanohorns (CNHs) as DDS in the development of new treatments for bone diseases. We evaluated the in vitro and in vivo cellular responses of CNHs in bone-related cells compared with carbon blacks (CBs), which are similar in particle size but differ in surface and structural morphologies. Although in vitro experiments revealed that both CNHs and CBs were incorporated into the lysosomes of RAW264-induced osteoclast-like cells (OCs) and MC3T3-E1 osteoblast-like cells (OBs), no severe cytotoxicity was observed. CNHs reduced the tartrate-resistant acid phosphatase activity and expression of the differentiation marker genes in OCs at noncytotoxic concentrations, whereas the alkaline phosphatase activity and differentiation of OBs increased. Under calcification of OBs, CNHs increased the number of calcified nodules and were intra- and extracellularly incorporated into calcified vesicles to form crystal nuclei. The in vivo experiments showed significant promotion of bone regeneration in the CNH group alone, with localized CNHs being found in the bone matrix and lacunae. The suppression of OCs and promotion of OBs suggested that CNHs may be effective against bone diseases and could be applied as DDS.

Biofilms: Formation, Research Models, Potential Targets, and Methods for Prevention and Treatment

Due to the continuous rise in biofilm-related infections, biofilms seriously threaten human health. The formation of biofilms makes conventional antibiotics ineffective and dampens immune clearance. Therefore, it is important to understand the mechanisms of biofilm formation and develop novel strategies to treat biofilms more effectively. This review article begins with an introduction to biofilm formation in various clinical scenarios and their corresponding therapy. Established biofilm models used in research are then summarized. The potential targets which may assist in the development of new strategies for combating biofilms are further discussed. The novel technologies developed recently for the prevention and treatment of biofilms including antimicrobial surface coatings, physical removal of biofilms, development of new antimicrobial molecules, and delivery of antimicrobial agents are subsequently presented. Finally, directions for future studies are pointed out.

Production and Biomedical Applications of Bioactive Compounds

The development of drug resistance to presently available synthetic medicines leads us to investigate naturally produced small bioactive molecules to treat drug-resistant diseases, such as cancer and other diseases [...]

Carbon nanostructures: a comprehensive review of potential applications and toxic effects

There is no doubt that nanotechnology has revolutionized our life since the 1970s when it was first introduced. Nanomaterials have helped us to improve the current products and services we use. Among the different types of nanomaterials, the application of carbon-based nanomaterials in every aspect of our lives has rapidly grown over recent decades. This review discusses recent advances of those applications in distinct categories, including medical, industrial, and environmental applications. The first main section introduces nanomaterials, especially carbon-based nanomaterials. In the first section, we discussed medical applications, including medical biosensors, drug and gene delivery, cell and tissue labeling and imaging, tissue engineering, and the fight against bacterial and fungal infections. The next section discusses industrial applications, including agriculture, plastic, electronic, energy, and food industries. In addition, the environmental applications, including detection of air and water pollutions and removal of environmental pollutants, were vastly reviewed in the last section. In the conclusion section, we discussed challenges and future perspectives.

Nanoscale Technologies in the Fight against COVID-19: From Innovative Nanomaterials to Computer-Aided Discovery of Potential Antiviral Plant-Derived Drugs

The last few years have increasingly emphasized the need to develop new active antiviral products obtained from artificial synthesis processes using nanomaterials, but also derived from natural matrices. At the same time, advanced computational approaches have found themselves fundamental in the repurposing of active therapeutics or for reducing the very long developing phases of new drugs discovery, which represents a real limitation, especially in the case of pandemics. The first part of the review is focused on the most innovative nanomaterials promising both in the field of therapeutic agents, as well as measures to control virus spread (i.e., innovative antiviral textiles). The second part of the review aims to show how computer-aided technologies can allow us to identify, in a rapid and therefore constantly updated way, plant-derived molecules (i.e., those included in terpenoids) potentially able to efficiently interact with SARS-CoV-2 cell penetration pathways.

Fluorescent Biosensors for the Detection of Viruses Using Graphene and Two-Dimensional Carbon Nanomaterials

Two-dimensional carbon nanomaterials have been commonly employed in the field of biosensors to improve their sensitivity/limits of detection and shorten the analysis time. These nanomaterials act as efficient transducers because of their unique characteristics, such as high surface area and optical, electrical, and magnetic properties, which in turn have been exploited to create simple, quick, and low-cost biosensing platforms. In this review, graphene and two-dimensional carbon material-based fluorescent biosensors are covered between 2010 and 2021, for the detection of different human viruses. This review specifically focuses on the new developments in graphene and two-dimensional carbon nanomaterials for fluorescent biosensing based on the Förster resonance energy transfer (FRET) mechanism. The high-efficiency quenching capability of graphene via the FRET mechanism enhances the fluorescent-based biosensors. The review provides a comprehensive reference for the different types of carbon nanomaterials employed for the detection of viruses such as Rotavirus, Ebola virus, Influenza virus H3N2, HIV, Hepatitis C virus (HCV), and Hepatitis B virus (HBV). This review covers the various multiplexing detection technologies as a new direction in the development of biosensing platforms for virus detection. At the end of the review, the different challenges in the use of fluorescent biosensors, as well as some insights into how to overcome them, are highlighted.

How to evaluate the potential toxicity of therapeutic carbon nanomaterials? A comprehensive study of carbonized nanogels with multiple animal toxicity test models

Carbon-based nanomaterials have great potential in medical applications, especially in the treatment of infectious diseases and even tumors. However, to safely execute the application of carbon nanomaterials in human treatments, conducting safety assessments and establishing suitable evaluation criteria are necessary. In this study, lysine-carbonized nanogels (Lys-CNGs) that display antibacterial and antiviral abilities were employed in a comprehensive evaluation of their toxicity profiles through assessments in different animal models and growth stages. It was observed that zebrafish at the embryo and eleutheroembryo stages experienced significant toxic effects at a concentration of 15-fold the recommended dosage (0.5 ppm), whereas adult zebrafish following long-term consumption of fodder containing Lys-CNGs presented no adverse effects. Further microbiota analysis indicated that Lys-CNGs did not cause significant changes in the composition of the intestinal bacteria. In contrast, in the toxicity assessments with mammalian animal models, the Lys-CNGs showed no adverse effects, such as weight loss, dermal irritation, and skin sensitization responses in rabbits and guinea pigs, even at a high dose of 2000 mg/kg body weight. Our study revealed that Lys-CNGs have different toxic effects on different growth stages of zebrafish. Researchers in this field should carefully consider the implications of these toxicity profiles during the development of therapeutic carbon-based nanomaterials and for comparison of studies.

Carbon-Based Materials in Photodynamic and Photothermal Therapies Applied to Tumor Destruction

Within phototherapy, a grand challenge in clinical cancer treatments is to develop a simple, cost-effective, and biocompatible approach to treat this disease using ultra-low doses of light. Carbon-based materials (CBM), such as graphene oxide (GO), reduced GO (r-GO), graphene quantum dots (GQDs), and carbon dots (C-DOTs), are rapidly emerging as a new class of therapeutic materials against cancer. This review summarizes the progress made in recent years regarding the applications of CBM in photodynamic (PDT) and photothermal (PTT) therapies for tumor destruction. The current understanding of the performance of modified CBM, hybrids and composites, is also addressed. This approach seeks to achieve an enhanced antitumor action by improving and modulating the properties of CBM to treat various types of cancer. Metal oxides, organic molecules, biopolymers, therapeutic drugs, among others, have been combined with CBM to treat cancer by PDT, PTT, or synergistic therapies.

Synthesis and Characterization of Nanoporous Carbon Carriers for Losartan Potassium Delivery

Losartan potassium is most commonly used for the treatment of hypertension. In recent years, new applications of this drug have emerged, encouraging the design of novel nanoporous carriers for its adsorption and release. The purpose of this study was to synthesize ordered mesoporous carbon vehicles via a soft-templating method altered with the use of nitrogen precursors and via a hard-templating method followed by chitosan functionalization. As a result, the materials obtained differed in nitrogen content as well as in the number of total surface functional groups. The impact of the modification on the physicochemical properties of carbon carriers and their interaction with losartan potassium during adsorption and release processes was examined. The materials were characterized by various morphologies, specific surface areas (101–1180 m² g⁻¹), and the amount of acidic/basic oxygen-containing functional groups (1.26–4.27 mmol g⁻¹). These features, along with pore sizes and volumes, had a key effect on the sorption capacity of carbon carriers towards losartan potassium (59–161 mg g⁻¹). Moreover, they contributed to the differential release of the drug (18.56–90.46%). Losartan potassium adsorption onto the surface of carbonaceous materials was mainly based on the formation of hydrogen bonds and π–π interactions and followed the Langmuir type isotherm. It has been shown that the choice of the method of carbon carriers’ synthesis and their modification allows for the precise control of the kinetics of the losartan potassium release from their surface, resulting in rapid or sustained drug liberation.

Nanotechnology against COVID-19: Immunization, diagnostic and therapeutic studies

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in early 2020 soon led to the global pandemic of Coronavirus Disease 2019 (COVID-19). Since then, the clinical and scientific communities have been closely collaborating to develop effective strategies for controlling the ongoing pandemic. The game-changing fields of recent years, nanotechnology and nanomedicine have the potential to not only design new approaches, but also to improve existing methods for the fight against COVID-19. Nanomaterials can be used in the development of highly efficient, reusable personal protective equipment, and antiviral nano-coatings in public settings could prevent the spread of SARS-CoV-2. Smart nanocarriers have accelerated the design of several therapeutic, prophylactic, or immune-mediated approaches against COVID-19. Some nanovaccines have even entered Phase IΙ/IIΙ clinical trials. Several rapid and cost-effective COVID-19 diagnostic techniques have also been devised based on nanobiosensors, lab-on-a-chip systems, or nanopore technology. Here, we provide an overview of the emerging role of nanotechnology in the prevention, diagnosis, and treatment of COVID-19.

Biocompatible, Electroconductive, and Highly Stretchable Hybrid Silicone Composites Based on Few-Layer Graphene and CNTs

In this paper, we report a cost-effective and scalable approach to produce highly homogeneous graphene and CNT-based silicone composites with potential applications in diverse fields of research, including biosensors and wearable electronics. This approach includes the fabrication of hybrid fillers based on few-layer graphene and CNTs by water solution blending and manufacturing of graphene/CNT/PDMS composites through calendering in a three-roll mill. The influence of processing parameters, the graphene/CNT ratio, and hybrid filler loading was thoroughly investigated, and the optimal parameters for producing hybrid composites with superior electrical and mechanical properties were found. It was also confirmed that the graphene/CNT hybrid system exhibits a synergistic effect of non-covalent interactions between graphene sheets and CNT sidewalls. This synergistic effect prevents the aggregation of graphene sheets, facilitates the dispersion of graphene and CNTs in the silicone matrix, and contributes to the superior properties of hybrid composites compared to composites with either of these fillers alone.

Drug Delivery With Carbon-Based Nanomaterials as Versatile Nanocarriers: Progress and Prospects

With growing interest, a large number of researches have been conducted on carbon-based nanomaterials (CBNs). However, their uses are limited due to comprehensive potential environmental and human health effects. It is often confusing for researchers to make an informed choice regarding the versatile carbon-based nanocarrier system and its potential applications. This review has highlighted emerging applications and cutting-edge progress of CBNs in drug delivery. Some critical factors like enzymatic degradation, surface modification, biological interactions, and bio-corona have been discussed here. These factors will help to fabricate CBNs for effective drug delivery. This review also addresses recent advancements in carbon-based target specific and release controlled drug delivery to improve disease treatment. The scientific community has turned their research efforts into the development of novel production methods of CBNs to make their production more attractive to the industrial sector. Due to the nanosize and diversified physical properties, these CBNs have demonstrated distinct biological interaction. Thus long-term preclinical toxicity study is recommended before finally translating to clinical application.

Advances in Drug Delivery Nanosystems Using Graphene-Based Materials and Carbon Nanotubes

Carbon is one of the most abundant elements on Earth. In addition to the well-known crystallographic modifications such as graphite and diamond, other allotropic carbon modifications such as graphene-based nanomaterials and carbon nanotubes have recently come to the fore. These carbon nanomaterials can be designed to help deliver or target drugs more efficiently and to innovate therapeutic approaches, especially for cancer treatment, but also for the development of new diagnostic agents for malignancies and are expected to help combine molecular imaging for diagnosis with therapies. This paper summarizes the latest designed drug delivery nanosystems based on graphene, graphene quantum dots, graphene oxide, reduced graphene oxide and carbon nanotubes, mainly for anticancer therapy.

Ibandronate-Loaded Carbon Nanohorns Fabricated Using Calcium Phosphates as Mediators and Their Effects on Macrophages and Osteoclasts

Carbon nanohorns (CNHs), a type of nanocarbon, have been studied for the application of drug delivery systems (DDSs) because they are easily functionalized, support bone regeneration, can be used to perform photohyperthermia, have low toxicity, and are easily phagocytosed by macrophages. To take advantage of these features of CNHs, we developed a DDS for the local treatment of bone metastasis by loading the antibone resorption drug ibandronate (IBN) onto CNHs. The poor adsorption of IBN onto CNHs due to the weak hydrophilic-hydrophobic interaction was overcome by using calcium phosphates (CaPs) as mediators. In the fabrication process, we used oxidized CNH (OxCNH), which is less hydrophobic, onto which IBN was coprecipitated with CaP from a labile supersaturated CaP solution. OxCNH-CaP-IBN composite nanoparticles exerted stronger cell-suppressive effects than OxCNH and IBN in both murine macrophages (RAW264.7 cells) and osteoclasts (differentiated from RAW264.7 cells). OxCNH-CaP-IBN composite nanoparticles were efficiently phagocytosed by macrophage cells, where they specifically accumulated in lysosomes. The stronger cell-suppressive effects were likely due to intracellular delivery of IBN, i.e., the release of IBN from OxCNH-CaP-IBN composite nanoparticles via dissociation of CaP in the acidic environment of lysosomes. Our findings suggest that OxCNH-CaP-IBN composite nanoparticles are potentially useful for the local treatment of metastatic bone destruction.

Methods to Scale Down Graphene Oxide Size and Size Implication in Anti-cancer Applications

Despite considerable progress in the comprehension of the mechanisms involved in the origin and development of cancer, with improved diagnosis and treatment, this disease remains a major public health challenge with a considerable impact on the social and economic system, as well as on the individual. One way to improve effectiveness and reduce side effects is to consider responsive stimuli delivery systems that provide tailor-made release profiles with excellent spatial and temporal control. 2D nanomaterials possess special physicochemical properties (e.g., light, ultrasonic and magnetic responses) and biological behaviors such as endocytosis, biodistribution, biodegradation, and excretory pathways, which lead to their use in various biomedical applications. In particular, among 2D nanomaterials, graphene and its derivatives, namely graphene oxide (GO) nanomaterials, have attracted enormous attention in cancer diagnosis and therapy because they combine, in a unique material, extremely small size, NIR absorption, delocalized electrons, extremely high surface area, and versatile surface functionality. Taking into account the fundamental role played by GO size, in this review, we summarize the main methods employed to reduce and homogenize in nanometric scale the lateral dimensions of graphene oxide produced by chemical exfoliation of graphite, as well as post-synthesis separation techniques to uniform the size. We also discuss the implication of the small size in cancer treatment by exploiting GO nanocarriers as an effective theranostic tool.

Current State of Porous Carbon for Wastewater Treatment

Porous materials constitute an attractive research field due to their high specific surfaces; high chemical stabilities; abundant pores; special electrical, optical, thermal, and mechanical properties; and their often higher reactivities. These materials are currently generating a great deal of enthusiasm, and they have been used in large and diverse applications, such as those relating to sensors and biosensors, catalysis and biocatalysis, separation and purification techniques, acoustic and electrical insulation, transport gas or charged species, drug delivery, and electrochemistry. Porous carbons are an important class of porous materials that have grown rapidly in recent years. They have the advantages of a tunable pore structure, good physical and chemical stability, a variable specific surface, and the possibility of easy functionalization. This gives them new properties and allows them to improve their performance for a given application. This review paper intends to understand how porous carbons involve the removal of pollutants from water, e.g., heavy metal ions, dyes, and organic or inorganic molecules. First, a general overview description of the different precursors and the manufacturing methods of porous carbons is illustrated. The second part is devoted to reporting some applications such using porous carbon materials as an adsorbent. It appears that the use of porous materials at different scales for these applications is very promising for wastewater treatment industries.

End-of-Life Recycling Options of (Nano)Enhanced CFRP Composite Prototypes Waste-A Life Cycle Perspective

Life cycle assessment is a methodology to assess environmental impacts associated with a product or system/process by accounting resource requirements and emissions over its life cycle. The life cycle consists of four stages: material production, manufacturing, use, and end-of-life. This study highlights the need to conduct life cycle assessment (LCA) early in the new product development process, as a means to assess and evaluate the environmental impacts of (nano)enhanced carbon fibre-reinforced polymer (CFRP) prototypes over their entire life cycle. These prototypes, namely SleekFast sailing boat and handbrake lever, were manufactured by functionalized carbon fibre fabric and modified epoxy resin with multi-walled carbon nanotubes (MWCNTs). The environmental impacts of both have been assessed via LCA with a functional unit of '1 product piece'. Climate change has been selected as the key impact indicator for hotspot identification (kg CO2 eq). Significant focus has been given to the end-of-life phase by assessing different recycling scenarios. In addition, the respective life cycle inventories (LCIs) are provided, enabling the identification of resource hot spots and quantifying the environmental benefits of end-of-life options.