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Kwon MK, Jung KH, Choi S, Kim H, Woo CY, Lee M, Ji JG, Son HJ. Antibiotics use patterns in end-of-life cancer patients and medical staff's perception of antimicrobial stewardship programs. Korean J Intern Med 2023; 38:758-768. [PMID: 37586810 PMCID: PMC10493437 DOI: 10.3904/kjim.2023.160] [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] [Received: 04/05/2023] [Revised: 05/19/2023] [Accepted: 06/05/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND/AIMS While most cancer patients with end-of-life (EOL) care receive antibiotic treatments, antibiotic use should be decided appropriately considering the benefits, side effects, resistance, and cost effects. Antimicrobial stewardship programs (ASP) are important for patients with EOL care, but there is limited study analyzing actual antibiotic use in EOL care and the perceptions of Korean medical staff. METHODS Electronic medical records of 149 deceased cancer patients hospitalized in the medical hospitalist units at Asan Medical Center in Seoul from May 2019 to September 2021 were reviewed. Basic information, antibiotic use, duration, and changes were investigated. We surveyed medical staff's perceptions of antibiotics in cancer patients with EOL. RESULTS Of the 149 cancer patients with EOL care, 146 (98.0%) agreed with physician orders for life-sustaining treatment (POLST). In total, 143 (95.9%) received antibiotics, 110 (76.9%) received combination antibiotic treatment, and 116 (81.1%) were given antibiotics until the day of death. In a survey of 60 medical staff, 42 (70.0%) did not know about ASP, and 24 (40.0%) thought ASP was important in EOL care. Nineteen doctors (31.7%) discussed the use or discontinuation of antibiotics with patients or caregivers when writing POLST, but only 8 patients (5.6%) stopped antibiotics after POLST. CONCLUSION Most cancer patients with EOL care continue to receive antibiotics until just before their death. A careful approach is needed, considering the benefits and side effects of antibiotic use, and the patient's right to self-decision. It is necessary to actively improve awareness of ASP and its importance for medical staff.
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Affiliation(s)
- Min Kwan Kwon
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Kyung Hwa Jung
- Department of Infectious Diseases, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu,
Korea
| | - Sungim Choi
- Division of Infectious Diseases, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang,
Korea
| | - Hyeonjeong Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Chang-Yun Woo
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Mingee Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Jeong Geun Ji
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Hyo-Ju Son
- Department of Infectious Diseases, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu,
Korea
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Kim YJ, Kim SH. Advance Care Planning in South Korea. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 180:68-73. [PMID: 37353427 DOI: 10.1016/j.zefq.2023.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 06/25/2023]
Abstract
South Korea is an Asian country with a very low birth rate and a large elderly population. Nearly half of deaths are in the elderly over the age of 80, and cancer is the leading cause of all deaths. As the aging population increases, interest in end-of-life (EOL) care and quality of death is growing, but South Korea is one of the Asian countries that traditionally feels burdened by discussing death openly. In particular, even when a person is suffering from an incurable disease and is about to die, it is customary for the family members to make decisions without directly informing the patient of the disease status or discussing life-sustaining treatment (LST). However, due to a series of social events, the importance of individual autonomy, good death, discontinuation of LSTs, and advance care planning (ACP) gradually spread, and eventually the Life-Sustaining Treatment Decisions Act was implemented in 2018. With the enactment of this law, patients' autonomy was enhanced in a short period of time, and a legal basis was established to discontinue LST at the EOL. However, there are still many areas to be improved, and it is fundamentally necessary to spread the concept of 'ACP' within society.
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Affiliation(s)
- Yu Jung Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Sun-Hyun Kim
- Department of Family Medicine, International St. Mary's Hospital, College of Medicine, Catholic Kwandong University, Incheon, Republic of Korea.
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Hwang IY, Han Y, Kim MS, Kim KH, Cho B, Choi W, Kim Y, Yoo SH, Lee SY. Preferred versus Actual Place of Care and Factors Associated with Home Discharge among Korean Patients with Advanced Cancer: A Retrospective Cohort Study. Healthcare (Basel) 2023; 11:1939. [PMID: 37444773 DOI: 10.3390/healthcare11131939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/27/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
Respecting the preference for a place of care is essential for advance care planning in patients with advanced cancer. This retrospective study included adult patients with cancer referred to an inpatient palliative care consultation team at a tertiary acute care hospital in South Korea between April 2019 and December 2020. Patients' preference for place of care and demographic and clinical factors were recorded, and the actual discharge locations were categorized as home or non-home. Patients discharged home but with unintended hospital visits within 2 months were also investigated. Of the 891 patients referred to the palliative care consultation team, 210 (23.6%) preferred to be discharged home. Among them, 113 (53.8%) were discharged home. No significant differences were found between patients who preferred home discharge and those who did not. Home discharge was higher among female patients (p = 0.04) and lower in those with poor oral intake (p < 0.001) or dyspnea (p = 0.02). Of the 113 patients discharged home, 37 (32.8%) had unintended hospital visits within 2 months. Approximately one-quarter of hospitalized patients with advanced cancer preferred to be discharged home, but only half of them received the home discharge. To meet patients' preferences for end-of-life care, individual care planning considering relevant factors is necessary.
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Affiliation(s)
- In Young Hwang
- Public Healthcare Center, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Family Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Yohan Han
- Public Healthcare Center, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Family Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Min Sun Kim
- Public Healthcare Center, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Pediatrics, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Kyae Hyung Kim
- Public Healthcare Center, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Family Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Belong Cho
- Public Healthcare Center, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Family Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Wonho Choi
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Yejin Kim
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Shin Hye Yoo
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Sun Young Lee
- Public Healthcare Center, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
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Kim GL, Lee SH, Kim YJ, Lee JG, Yi YH, Tak YJ, Ra YJ, Lee SY, Cho YH, Park EJ, Lee YI, Choi JI, Lee SR, Kwon RJ, Son SM. Utilization of End-of-Life Care Rooms by Patients Who Died in a Single Hospice Unit at a National University Hospital in South Korea. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2023; 26:60-68. [PMID: 37753508 PMCID: PMC10519721 DOI: 10.14475/jhpc.2023.26.2.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/10/2023] [Accepted: 04/26/2023] [Indexed: 09/28/2023]
Abstract
Purpose For the dignity of patients nearing the end of their lives, it is essential to provide end-of-life (EoL) care in a separate, dedicated space. This study investigated the utilization of specialized rooms for dying patients within a hospice unit. Methods This retrospective study examined patients who died in a single hospice unit between January 1, 2017, and December 31, 2021. Utilizing medical records, we analyzed the circumstances surrounding death, the employment of specialized rooms for terminally ill patients, and the characteristics of those who received EoL care in a shared room. Results During the 1,825-day survey period, deaths occurred on 632 days, and 799 patients died. Of these patients, 496 (62.1%) received EoL care in a dedicated room. The average duration of using this dedicated space was 1.08 days. Meanwhile, 188 patients (23.5%) died in a shared room. Logistic regression analysis revealed that a longer stay in the hospice unit was associated with a lower risk of receiving EoL care in a shared room (odds ratio [OR]=0.98, 95% confidence interval [CI] 0.97~0.99; P=0.002). Furthermore, a higher number of deaths on the day a patient died was associated with a greater risk of receiving EoL care in a shared room (OR=1.66, 95% CI 1.33~2.08; P<0.001). Conclusion To ensure that more patients receive EoL care for an adequate duration in a private setting, additional research is necessary to increase the number of dedicated rooms and incorporate them into the hospice unit at an early stage.
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Affiliation(s)
- Gyu Lee Kim
- Department of Family Medicine, Pusan National University Hospital, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Seung Hun Lee
- Department of Family Medicine, Pusan National University Hospital, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Yun Jin Kim
- Department of Family Medicine, Pusan National University Hospital, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
- Department of Family Medicine, Pusan National University School of Medicine, Yangsan, Korea
| | - Jeong Gyu Lee
- Department of Family Medicine, Pusan National University Hospital, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
- Department of Family Medicine, Pusan National University School of Medicine, Yangsan, Korea
| | - Yu Hyeon Yi
- Department of Family Medicine, Pusan National University Hospital, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
- Department of Family Medicine, Pusan National University School of Medicine, Yangsan, Korea
| | - Young Jin Tak
- Department of Family Medicine, Pusan National University Hospital, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
- Department of Family Medicine, Pusan National University School of Medicine, Yangsan, Korea
| | - Young Jin Ra
- Department of Family Medicine, Pusan National University Hospital, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Sang Yeoup Lee
- Department of Medical Education, Pusan National University School of Medicine, Yangsan, Korea
- Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Young Hye Cho
- Department of Family Medicine, Pusan National University School of Medicine, Yangsan, Korea
- Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Eun Ju Park
- Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Young In Lee
- Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jung In Choi
- Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sae Rom Lee
- Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ryuk Jun Kwon
- Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soo Min Son
- Department of Family Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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Im HS, Lee I, Kim S, Lee JS, Kim JH, Moon JY, Park BK, Lee KH, Lee MA, Han S, Hong Y, Kim H, Cheon J, Koh SJ. Experience and perspectives of end-of-life care discussion and physician orders for life-sustaining treatment of Korea (POLST-K): a cross-sectional study. BMC Med Ethics 2023; 24:18. [PMID: 36882795 PMCID: PMC9993746 DOI: 10.1186/s12910-023-00897-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/02/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND This study aimed to identify the healthcare providers' experience and perspectives toward end-of-life care decisions focusing on end-of-life discussion and physician's order of life-sustaining treatment documentation in Korea which are major parts of the Life-Sustaining Treatment Act. METHODS A cross-sectional survey was conducted using a questionnaire developed by the authors. A total of 474 subjects-94 attending physicians, 87 resident physicians, and 293 nurses-participated in the survey, and the data analysis was performed in terms of frequency, percentage, mean and standard deviation using the SPSS 24.0 program. RESULTS Study results showed that respondents were aware of terminal illness and physician's order of life-sustaining treatment in Korea well enough except for some details. Physicians reported uncertainty in terminal state diagnosis and disease trajectory as the most challenging. Study participants regarded factors (related to relationships and communications) on the healthcare providers' side as the major impediment to end-of-life discussion. Study respondents suggested that simplification of the process and more staff are required to facilitate end-of-life discussion and documentation. CONCLUSION Based on the study results, adequate education and training for better end-of-life discussion are required for future practice. Also, a simple and clear procedure for completing a physician's order of life-sustaining treatment in Korea should be prepared and legal and ethical advice would be required. Since the enactment of the Life-Sustaining Treatment Act, several revisions already have been made including disease categories, thus continuous education to update and support clinicians is also called for.
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Affiliation(s)
- Hyeon-Su Im
- Division of Hematology and Oncology, Department of Internal Medicine, Ulsan University Hospital, Ulsan University College of Medicine, 877, Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, Republic of Korea
| | - Insook Lee
- Department of Nursing, Changwon National University, 20 Changwon daehak-ro, Uichang-gu, Changwon, 51140, Republic of Korea.
| | - Shinmi Kim
- Department of Nursing, Changwon National University, 20 Changwon daehak-ro, Uichang-gu, Changwon, 51140, Republic of Korea
| | - Jong Soo Lee
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Korea
| | - Ju-Hee Kim
- Division of Hematology and Oncology, Department of Internal Medicine, Ulsan University Hospital, Ulsan University College of Medicine, 877, Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, Republic of Korea
| | - Jae Young Moon
- Department of Internal Medicine, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Byung Kyu Park
- Division of Gastroenterology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Kyung Hee Lee
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Myung Ah Lee
- Division of Medical Oncology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Sanghoon Han
- Department of Hematology and Oncology, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
| | - Yoonki Hong
- Department of Internal Medicine, Kangwon National University Hospital, Kangwon National University College of Medicine, Chuncheon, Korea
| | - Hyeyeoung Kim
- Division of Hematology and Oncology, Department of Internal Medicine, Ulsan University Hospital, Ulsan University College of Medicine, 877, Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, Republic of Korea
| | - Jaekyung Cheon
- Department of Medical Oncology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Su-Jin Koh
- Division of Hematology and Oncology, Department of Internal Medicine, Ulsan University Hospital, Ulsan University College of Medicine, 877, Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, Republic of Korea.
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6
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An HJ, Jeon HJ, Chun SH, Jung HA, Ahn HK, Lee KH, Kim MH, Hee Kim J, Cheon J, Koh SJ. Discussing POLST-facilitated hospice care enrollment in patients with terminal cancer. Support Care Cancer 2022; 30:7431-7438. [PMID: 35622149 DOI: 10.1007/s00520-022-07143-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE A multicenter prospective study to evaluate the feasibility of Physician Orders for Life-Sustaining Treatment (POLST) in oncology practice was conducted between June and December 2017. Factors associated with POLST completion and follow-up outcomes were analyzed. METHODS Patients with terminal cancer, aged ≥ 20 years and capable of communicating, were enrolled from seven hospitals. Demographic data were collected and updated in February 2021. Descriptive statistics and logistic regression analyses were conducted. RESULTS Among 336 patients, 105 (31.3%) completed POLST, which was more common in male (p = 0.029), patients with better performance (p < 0.001), longer duration of follow-up (p = 0.037), and those living with children (p = 0.023). Male (odds ratio [OR], 2.30; 95% confidence interval [CI], 1.17-3.51; p = 0.012), having good performance status (OR, 2.38; 95% CI, (1.35-4.19); p = 0.003), transferred from other departments (OR, 0.50; 95% CI, (0.26-0.98); p = 0.045), and living with children (OR, 1.94; 95% CI, (1.11-3.47); p = 0.020) were significant predictors of POLST completion. Patients who completed POLST were more likely to enroll in hospice care (p = 0.012) or experience out-of-hospital death (p = 0.016) at end-of-life (EOL). POLST completion showed a strong association with hospice enrollment at EOL (OR, 2.61; 95% CI, (1.08-6.32); p = 0.033). CONCLUSION Gender, patient performance, timing of POLST discussion, and type of household were associated with POLST completion. Earlier discussions on POLST could reinforce hospice enrollment or non-aggressive EOL care.
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Affiliation(s)
- Ho Jung An
- Department of Medical Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hyun Jeong Jeon
- Department of Internal Medicine, Seoul Medical Center, Seoul, South Korea
| | - Sang Hoon Chun
- Division of Medical Oncology, Department of Internal Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Hyun Ae Jung
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Dongtan, South Korea
| | - Hee Kyung Ahn
- Division of Medical Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, South Korea
| | - Kyung Hee Lee
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, South Korea
| | - Min-Ho Kim
- Ewha Institute of Convergence Medicine, Ewha Womans University Mokdong Hospital, Seoul, South Korea
| | - Ju Hee Kim
- Department of Hematology and Oncology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, 877, Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - Jaekyung Cheon
- Department of Hematology and Oncology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, 877, Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - Su-Jin Koh
- Department of Hematology and Oncology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, 877, Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea.
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Heo DS, Yoo SH, Keam B, Yoo SH, Koh Y. Problems Related to the Act on Decisions on Life-Sustaining Treatment and Directions for Improvement. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2022; 25:1-11. [PMID: 37674892 PMCID: PMC10180009 DOI: 10.14475/jhpc.2022.25.1.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/18/2021] [Accepted: 12/23/2021] [Indexed: 09/08/2023]
Abstract
The Act on Decisions on Life-Sustaining Treatment has been in effect since 2018 for end-of-life patients. However, only 20~25% of deaths of terminally ill patients comply with the law, while the remaining 75~80% do not. There is significant confusion in how the law distinguishes between those in the terminal stage and those in the dying process. These 2 stages can be hard to distinguish, and they should be understood as a single unified "terminal stage." The number of medical institutions eligible for life-sustaining treatment decisions should be legally expanded to properly reflect patients' wishes. To prevent unnecessary suffering resulting from futile life-sustaining treatment, life-sustaining treatment decisions for terminal patients without the needed familial relationships should be permitted and made by hospital ethics committees. Adult patients should be permitted to assign a legal representative appointed in advance to represent them. Medical records can be substituted for a patient's judgment letter (No. 9) and an implementation letter (No. 13) for the decision to suspend life-sustaining treatment. Forms 1, 10, 11, and 12 should be combined into a single form. The purpose of the Life-sustaining Medical Decisions Act is to respect patients' right to self-determination and protect their best interests. Issues related to the act that have emerged in the 3 years since its implementation must be analyzed, and a plan should be devised to improve upon its shortcomings.
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Affiliation(s)
- Dae Seog Heo
- Patient-Centered Clinical Research Coordinating Center, National Evidence-based Healthcare Collaborating Agency, Korea
| | - Shin Hye Yoo
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Korea
| | - Bhumsuk Keam
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Korea
- Department of Internal Medicine, Seoul National University Hospital, Korea
| | - Sang Ho Yoo
- Department of Medical Humanities and Ethics, Hanyang University College of Medicine, Korea
| | - Younsuck Koh
- Department of Internal Medicine, Asan Medical Center, Seoul, Korea
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Kim D, Yoo SH, Seo S, Lee HJ, Kim MS, Shin SJ, Lim CY, Kim DY, Heo DS, Lim CM. Analysis of Cancer Patient Decision-making and Health Service Utilization after Enforcement of the Life-Sustaining Treatment Decision-Making Act in Korea. Cancer Res Treat 2021; 54:20-29. [PMID: 33848413 PMCID: PMC8756111 DOI: 10.4143/crt.2021.131] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/09/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose This study aimed to confirm the decision-making patterns for life-sustaining treatment (LST) and analyze medical service utilization changes after enforcement of the Life-Sustaining Treatment Decision-Making Act. Materials and Methods Of 1,237 patients who completed legal forms for life-sustaining treatment (hereafter called the LST form) at three academic hospitals and died at the same institutions, 1,018 cancer patients were included. Medical service utilization and costs were analyzed using claims data. Results The median time to death from completion of the LST form was three days (range, 0 to 248 days). Of these, 517 people died within two days of completing the document, and 36.1% of all patients prepared the LST form themselves. The frequency of use of the intensive care unit, continuous renal replacement therapy, and mechanical ventilation was significantly higher when the families filled out the form without knowing the patient’s intention. In the top 10% of the medical expense groups, the decision-makers for LST were family members rather than patients (28% patients vs. 32% family members who knew and 40% family members who did not know the patient’s intention). Conclusion The cancer patient’s own decision-making rather than the family’s decision was associated with earlier decision-making, less use of some critical treatments (except chemotherapy) and expensive evaluations, and a trend toward lower medical costs.
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Affiliation(s)
- Dalyong Kim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Shin Hye Yoo
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea
| | - Seyoung Seo
- Department of Oncology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hyun Jung Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Min Sun Kim
- Department of Pediatrics, Seoul National University Hospital, Seoul, Korea
| | - Sung Joon Shin
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Chi-Yeon Lim
- Department of Biostatistics, Dongguk University College of Medicine, Goyang, Korea
| | - Do Yeun Kim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Dae Seog Heo
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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9
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Cheng SY, Lin CP, Chan HYL, Martina D, Mori M, Kim SH, Ng R. Advance care planning in Asian culture. Jpn J Clin Oncol 2020; 50:976-989. [PMID: 32761078 DOI: 10.1093/jjco/hyaa131] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 07/20/2020] [Indexed: 11/14/2022] Open
Abstract
Ageing has been recognized as one of the most critically important health-care issues worldwide. It is relevant to Asia, where the increasing number of older populations has drawn attention to the paramount need for health-care investment, particularly in end-of-life care. The advocacy of advance care planning is a mean to honor patient autonomy. Since most East Asian countries are influenced by Confucianism and the concept of 'filial piety,' patient autonomy is consequently subordinate to family values and physician authority. The dominance from family members and physicians during a patient's end-of-life decision-making is recognized as a cultural feature in Asia. Physicians often disclose the patient's poor prognosis and corresponding treatment options to the male, family member rather to the patient him/herself. In order to address this ethical and practical dilemma, the concept of 'relational autonomy' and the collectivism paradigm might be ideally used to assist Asian people, especially older adults, to share their preferences on future care and decision-making on certain clinical situations with their families and important others. In this review article, we invited experts in end-of-life care from Hong Kong, Indonesia, Japan, South Korea, Singapore and Taiwan to briefly report the current status of advance care planning in each country from policy, legal and clinical perspectives. According to the Asian experiences, we have seen different models of advance care planning implementation. The Asian Delphi Taskforce for advance care planning is currently undertaken by six Asian countries and a more detailed, culturally sensitive whitepaper will be published in the near future.
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Affiliation(s)
- Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Cheng-Pei Lin
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Helen Yue-Lai Chan
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Central Ave, Hong Kong
| | - Diah Martina
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Division of Psychosomatic and Palliative Medicine, Department of Internal Medicine Universitas Indonesia, Jakarta Pusat, Indonesia
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Sun-Hyun Kim
- Department of Family Medicine, International St. Mary's Hospital, College of Medicine, Catholic Kwandong University, Incheon, Republic of Korea
| | - Raymond Ng
- Department of Palliative Medicine, Tan Tock Seng Hospital, Jln Tan Tock Seng, Singapore
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10
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Hong YA, Chung S, Park WY, Bae EJ, Yang JW, Shin DH, Kim SW, Shin SJ. Nephrologists' Perspectives on Decision Making About Life-Sustaining Treatment and Palliative Care at End of Life: A Questionnaire Survey in Korea. J Palliat Med 2020; 24:527-535. [PMID: 32996855 DOI: 10.1089/jpm.2020.0248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Nephrologists commonly engage in decision making regarding the withholding or withdrawal of dialysis and palliative care in patients at end of life (EoL). However, these issues remain an unsolved dilemma for nephrologists. Objective: To explore nephrologists' perceptions on the decision-making process about withholding or withdrawing dialysis and palliative care in Korea. Design: A nationwide 25-item questionnaire online survey via e-mail. Setting/Subjects: A total of 369 Korean nephrologists completed the survey. Results: The proportions of respondents who stated that withholding or withdrawing dialysis at EoL is ethically appropriate were 87.3% and 86.2%, respectively. A total of 72.4% respondents thought that withdrawal of dialysis in a maintenance dialysis patient is ethically appropriate. Responses regarding patient features that should be considered to withhold or withdraw dialysis were as follows: dialysis intolerance (84.3%), poor performance status (74.8%), patient's active request (47.2%), age (28.7%), very severe dementia (27.1%), and several comorbidities (16.5%). Among those nephrologists who responded to the question about the minimum age, at which dialysis should be withheld or withdrawn, most specified an age between 80 and 90 years (94.3%). Fifty-eight percent of respondents stated that terminally ill dialysis patients should be allowed to use palliative care facilities. In addition, a number of nephrologists thought that adequate palliative care facilities, specific treatment guidelines, enough time to manage patients, financial support, and adequate medical experts are necessary. Conclusions: Korean nephrologists thought that withholding or withdrawing dialysis at EoL is ethically appropriate, even in maintenance dialysis patients. Therefore, consensus guidelines for palliative care after withholding or withdrawal of dialysis are needed.
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Affiliation(s)
- Yu Ah Hong
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sungjin Chung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Woo Yeong Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Eun Jin Bae
- Department of Internal Medicine, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - Jae Won Yang
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Dong Ho Shin
- Department of Internal Medicine, College of Medicine, Hallym University, Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Sang Wook Kim
- Gwangmyeong Soo Clinic Center, Gwangmyeong, Republic of Korea
| | - Sung Joon Shin
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
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11
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Lee J, Lee JE. A Palliative Care Program for Volunteers in a Community Setting: A Mixed-Methods Pilot Study. Am J Hosp Palliat Care 2020; 37:455-464. [PMID: 31859524 DOI: 10.1177/1049909119895213] [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: 11/16/2022] Open
Abstract
BACKGROUND The objective of community-based palliative care is to improve the quality of life of patients and their families and to share the responsibility of caregiving. However, the evidence of the efficacy of volunteer services in community-based palliative care is insufficient. PURPOSE This pilot study sought to uncover the feasibility and efficacy of a volunteer program in palliative care. METHODS The study used a sequential mixed-methods design. A total of 19 volunteers participated in the training program, and 6 trained volunteers provided services for a period of 10 weeks to 5 families. Quantitative data were collected on death anxiety, coping with death, and meaning in life for volunteers before and after the training and after completing their services. Qualitative data were collected about volunteering experiences. RESULTS Significant increases in coping with death and meaning in life after training and in meaning in life after providing services were observed among volunteers. Three categories ("Volunteer's growing influence at home," "Discovering meaning-in-life through volunteering," and "Death as the final journey in life") emerged from the qualitative findings. The caregivers' satisfaction score was high. CONCLUSIONS A palliative care program was found to be useful for volunteers in finding meaning in life, motivating continued volunteering. Moreover, caregivers were satisfied with the palliative care service of volunteers.
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Affiliation(s)
- Jiwon Lee
- College of Nursing, Ajou University, Suwon, Republic of Korea.,College of Nursing, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong-Eun Lee
- College of Nursing, The Catholic University of Korea, Seoul, Republic of Korea
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12
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Kim JW, Choi JY, Jang WJ, Choi YJ, Choi YS, Shin SW, Kim YH, Park KH. Completion rate of physician orders for life-sustaining treatment for patients with metastatic or recurrent cancer: a preliminary, cross-sectional study. BMC Palliat Care 2019; 18:84. [PMID: 31640677 PMCID: PMC6806497 DOI: 10.1186/s12904-019-0475-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/02/2019] [Indexed: 11/24/2022] Open
Abstract
Background “End of life” is a difficult topic of conversation in East Asian cultures, even among patients and doctors who share a good rapport. In 2016, the Hospice, Palliative Care, and Life-Sustaining Treatment Decision-Making Act, which took the form of “Physician Orders for Life-Sustaining Treatment,” was introduced in South Korea. This study was conducted to investigate the completion rate of Physician Orders for Life-Sustaining Treatment in patients with advanced cancer on the active recommendation of physicians, as well as patients’ general attitudes toward end-of-life care. Methods We conducted a preliminary, cross-sectional descriptive survey on patients with advanced cancer. A total of 101 patients with advanced solid cancer agreed to participate in the study. The primary endpoint was the rate of completion of Physician Orders for Life-Sustaining Treatment based on a doctor’s suggestion. Written interviews were conducted to understand the perceptions and factors influencing patients’ decisions. Results Of the 101 patients, 72 (71.3%) agreed to prepare Physician Orders for Life-Sustaining Treatment. Patients who had an educational level of high school or higher were more likely to agree to complete Physician Orders for Life-Sustaining Treatment documentation as compared to the lower educational status group. More than half of the respondents who completed Physician Orders for Life-Sustaining Treatment documentation reported that they had more than a fair understanding of “life-sustaining care” or “Physician Orders for Life-Sustaining Treatment.” Participants’ reasons for Physician Orders for Life-Sustaining Treatment completion were diverse. Conclusions We found that highly educated patients, who understood the concept behind the policy well, tended to accept Physician Orders for Life-Sustaining Treatment without hesitation. Better education, information shared through the media, and conversations with health care providers might improve understanding of Physician Orders for Life-Sustaining Treatment in patients with cancer.
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Affiliation(s)
- Ju Won Kim
- Division of Oncology/Hematology, Department of Internal medicine, Korea University Anam Hospital, 73 Goryeodae-ro Seongbuk-gu, Seoul, 02841, South Korea
| | - Jung Yoon Choi
- Division of Oncology/Hematology, Department of Internal medicine, Korea University Anam Hospital, 73 Goryeodae-ro Seongbuk-gu, Seoul, 02841, South Korea
| | - Won Jin Jang
- Division of Oncology/Hematology, Department of Internal medicine, Korea University Anam Hospital, 73 Goryeodae-ro Seongbuk-gu, Seoul, 02841, South Korea
| | - Yoon Ji Choi
- Division of Oncology/Hematology, Department of Internal medicine, Korea University Anam Hospital, 73 Goryeodae-ro Seongbuk-gu, Seoul, 02841, South Korea
| | - Youn Seon Choi
- Department of Family Medicine, Korea University Guro Hospital, 97 Guro-dong Gil, Guro-gu, Seoul, 08308, South Korea
| | - Sang Won Shin
- Division of Oncology/Hematology, Department of Internal medicine, Korea University Anam Hospital, 73 Goryeodae-ro Seongbuk-gu, Seoul, 02841, South Korea
| | - Yeul Hong Kim
- Division of Oncology/Hematology, Department of Internal medicine, Korea University Anam Hospital, 73 Goryeodae-ro Seongbuk-gu, Seoul, 02841, South Korea
| | - Kyong Hwa Park
- Division of Oncology/Hematology, Department of Internal medicine, Korea University Anam Hospital, 73 Goryeodae-ro Seongbuk-gu, Seoul, 02841, South Korea.
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13
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Kwon KT. Implementation of Antimicrobial Stewardship Programs in End-of-Life Care. Infect Chemother 2019; 51:89-97. [PMID: 31270988 PMCID: PMC6609743 DOI: 10.3947/ic.2019.51.2.89] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Indexed: 12/17/2022] Open
Abstract
Many terminal patients at the end-of-life have been receiving antimicrobial therapy despite concerns including futile use, potential lack of efficacy, increased patient burden, excess costs, high risk of adverse effects, and increased antimicrobial resistance. Thus, the implementation of antimicrobial stewardship programs (ASPs) in end-of-life care needs to be discussed. But, the topics of antimicrobial therapy and ASPs have not been addressed in the Life-Sustaining Treatment Decision Act enacted in the Korea in February 2016. Antimicrobial therapy should be included in the decision-making framework for end-of-life care similar to other life-sustaining treatment decisions. If the antimicrobial therapy is legally considered as a life-sustaining treatment which can be withdrawn or withheld in patients at the end-of-life, the feasibility of implementing ASPs among this patient population may improve. Various researches on antimicrobial therapy for patients at the end-of-life need to be conducted and collaborations are required between ASPs professionals and many other concerned parties involved in the legislative process of the Life-Sustaining Treatment Decision Act. This review aims to summarize previous studies on the use of antimicrobials for end-of-life care and reveal important aspects for applying ASPs to this population in Korea.
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Affiliation(s)
- Ki Tae Kwon
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
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14
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An HJ, Jeon HJ, Chun SH, Jung HA, Ahn HK, Lee KH, Kim MH, Kim JH, Cheon J, Kim J, Koh SJ. Feasibility Study of Physician Orders for Life-Sustaining Treatment for Patients with Terminal Cancer. Cancer Res Treat 2019; 51:1632-1638. [PMID: 30999720 PMCID: PMC6790857 DOI: 10.4143/crt.2019.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/16/2019] [Indexed: 11/21/2022] Open
Abstract
PURPOSE Physician Orders for Life-Sustaining Treatment (POLST) form is a legal document for terminally ill patients to make medical decisions with physicians near the end-of-life. A multicenter prospective study was conducted to evaluate the feasibility of POLST administration in actual oncological practice. Materials and Methods Patients with terminal cancer, age ≥ 20 years, and capable of communicating were eligible. The primary endpoint was the completion rate of POLST. Data about physicians' or patients' barriers were also collected. RESULTS From June to December 2017, 336 patients from seven hospitals were eligible. Median patient age was 66 years (range, 20 to 94 years); 52.7% were male; and 60.4% had poor performance status. Primary cancer sites were hepato-pancreato-biliary (26.2%), lung (23.2%), and gastrointestinal (19.9%). Expected survival duration was 10.6±7.3 weeks, with 41.2% receiving hospice care, 37.9% showing progression after cancer treatment, and the remaining patients were under active treatment (15.8%) or initially diagnosed with terminal cancer (5.1%). POLST forms were introduced to 60.1% of patients, and 31.3% signed the form. Physicians' barriers were reluctance of family (49.7%), lack of rapport (44.8%), patients' denial of prognosis (34.3%), lack of time (22.7%), guilty feelings (21.5%), and uncertainty about either prognosis (21.0%) or the right time to discuss POLST (16.6%). The patients' barriers were the lack of knowledge/understanding of POLST (65.1%), emotional discomfort (63.5%), difficulty in decision-making (66.7%), or denial of prognosis (14.3%). CONCLUSION One-third of patients completed POLST forms, and various barriers were identified. To overcome such barriers, social engagement, education, and systematic support might be necessary.
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Affiliation(s)
- Ho Jung An
- Department of Medical Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Hyun Jeong Jeon
- Department of Internal Medicine, Seoul Medical Center, Seoul, Korea
| | - Sang Hoon Chun
- Division of Medical Oncology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Hyun Ae Jung
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Hee Kyung Ahn
- Division of Medical Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Kyung Hee Lee
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Min-Ho Kim
- Ewha Institute of Convergence Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Ju Hee Kim
- Department of Hematology and Oncology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Korea
| | - Jaekyung Cheon
- Department of Hematology and Oncology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Korea
| | - JinShil Kim
- College of Nursing, Gachon University, Incheon, Korea
| | - Su-Jin Koh
- Department of Hematology and Oncology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Korea
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