Additionally, she may not want to live on machines for a prolonged period of time, and hence, if she survives cardiopulmonary arrest yet is dependent on a ventilator to breathe, her decision may change. See below. Under certain circumstances, CPR may not offer the patient direct clinical benefit, either because the resuscitation will not be successful or because surviving the resuscitation will lead to co-morbidities that will merely prolong suffering without reversing the underlying disease. Of the 7 patients for whom a nonconsensual DNR order was recommended, 2 died before the order was written, 4 died after the order was written, and 1 . Blinderman CD, Krakauer EL, Solomon MZ. Some of these patients may have an advanced care directive that indicates their preferences to forgo attempting CPR. However, in difficult cases, an ethics consultation can prove helpful. Medical futility means that an intervention, in this case CPR, offers no chance of meaningful medical benefit to the patient. However, in 1974, the American Heart Association (AHA) recognized that many patients who received CPR survived with significant morbidities and recommended that physicians document in the chart when CPR is not indicated after obtaining patient or surrogate consent (ibid). If health care providers unanimously agree that CPR would be medically futile, clinicians are not obligated to perform it. When it comes to caring for an aging loved one, having family members by your side can be a tremendous help—mentally, physically, and financially. Please check back soon for updates! In that spirit, let us review a few cases. The legal status and processes surrounding DNR orders vary from country to country. In some cases, as with your grandad, doctors may decide that there should be no attempt to resuscitate a person if they have a cardiac arrest or stop breathing. Sometimes the patient take decisions themselves, whereas in some situations the family or decision maker will do it for them. While a living will may … The Physician also includes the patient and family in making the decision for a DNR order. What if CPR is not futile, but the patient wants a DNAR order? CPR is a series of specific medical procedures that attempt to maintain perfusion to vital organs while efforts are made to reverse the underlying cause for the cardiopulmonary arrest. Although the admitting physician will usually write a new Do Not Resuscitate order for the individual . NOTE: The UW Dept. You may also request forms at any admissions office of any local hospital. (e) If the patient or surrogate disagrees with the DNR order being placed in or removed from the medical record, the patient or surrogate may request a second opinion at the patient 's or surrogate 's . A- Patients without advance directives are more likely to be victims of medical errors. Laws. Because the MOLST … Found inside – Page 238There may be situations in which a physician recommends that a DNR order be written but the patient or family disagrees and wishes CPR to be initiated at the time of cardiac or respiratory arrest . In this situation , several steps can ... When the patient with intact decision making capacity or a surrogate decision maker explicitly requests to forgo CPR. In general, an emphasis on improving communication with patients and families is preferred over physicians making unilateral decisions based on appeals to medical futility regarding the resuscitation status of their patients. NOTE: The UW Dept. A DNAR order was completed and signed by the consultant. Ethics consultants helped to resolve the disagreement in 17 of those cases, recommended no DNR order in 7 cases, and recommended that a DNR order be written despite the family's wishes in 7 cases. Is his case medically futile, and if so, why? LEGAL GUIDE TO DO NOT RESUSCITATE (DNR) ORDERS Prepared by Mental Health Legal Advisors Committee April 2013 Generally, Do Not Resuscitate (DNR) Orders may be … They can then partner with the patient and his or her family to determine the clinical interventions that most effectively achieve these goals (Blinderman et al., 2012). Understanding the DNR Order. Even though including patients and families in decisions regarding resuscitation respects patient autonomy, providing patients and families with accurate information regarding the risks and potential medical benefit of cardiopulmonary resuscitation is also critical. In difficult cases, an ethics consultation can prove helpful. Why do you think this experience was beneficial to his career? In general, these statistics represent the population as a whole and do not necessarily reflect the chance of survival for an individual patient. After a goal oriented conversation, Mrs. W continues to request to be fully resuscitated in the setting of cardiopulmonary arrest. If EMS personnel are present, they should take the DNR order with them on the ambulance, but it is still advisable for a family member to bring a copy of the DNR order with them. Found inside – Page 499If a competent patient disagrees , or , in cases of incompetency , the family member ( s ) disagrees , a DNR order will not be written . Implementation 1. Once the DNR decision has been made , this directive shall be written as a formal ... Since the original inception of DNAR orders, respecting the rights of adult patients and their surrogates to make medical decisions, otherwise known as respect for autonomy or respect for persons, has been emphasized. This concept is reinforced legally in the Patient Self Determination Act of 1991, which requires hospitals to respect the adult patient’s right to make an advanced care directive and clarify wishes for end-of-life care. What is the History of Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Orders? How should the patient's quality of life be considered? Found inside – Page iiThis volume thus offers practical guidance for the physician who would like to take greater advantage of this resource. The Patient Self Determination Act, enacted in 1991, established the right to articulate end-of-life wishes through advance directives. the medical team should meet with the family and patient early on in order to clarify the patients desires and wishes. A best result of this conversation would be that patients and family agree on treatment plans. You must respect her wish not to be treated until she gives you permission to do so. Wed 12 Sep 2012 19.05 EDT. Found insideIf the life-sustaining treatment has just begun, it may be wise to let it continue for a ... and issuing DNR orders are the most difficult anyone can make. Three weeks after his heart transplant, Andrey Jurtschenko still had not woken up. As described earlier, involving the patient or surrogate decision maker is essential to demonstrate respect for all people to take part in important life decisions. A DNR is a request not to have CPR if your heart stops or if you stop breathing. d. Under these circumstances, DNAR orders can be written. Ethics rounds symbolic resuscitation, medical futility, and parental rights. Outcomes following CPR have been evaluated in a wide variety of clinical situations. Found inside – Page 87Involving others as witnesses to the verbal orders provides proof a verbal ... the nurse disagrees with the physician's orders , assessment , or diagnosis . “Slow codes” are deceitful, and therefore are not ethically justifiable. But there are also times when having to consider more than one opinion on an issue can cause great strife between relatives. Anurse who disagrees with a patient's DNR order should noti- fy his or her supervisor so the assignment can be changed if possible. It is the act of withholding all aggressive forms of treatment to save one's life. In children, the survival rate following in-hospital cardiac arrest is closer to 27% with a favorable neurological outcome in up to one third of survivors (AHA, 2010). In our hospital, as long as the patient is competant to express their wishes, we can make them a DNR without a doctor's order. If the patient disagrees, the clinician is obliged to ensure that the patient understands CPR and why he feels it is medically inappropriate. It is DNR by deceit. CPR is a series of specific medical procedures that attempt to maintain perfusion to vital organs while efforts are made to reverse the underlying cause for the cardiopulmonary arrest. Slow codes and show codes are forms of “symbolic resuscitation.” A “slow code” is an act performed by the health care providers that resembles CPR yet is not the full effort of resuscitation while a “show code” is a short and vigorous resuscitation performed to benefit the family while minimizing harm to the patient (Frader et al., 2010). A Do Not Resuscitate (DNR) Order is a written order by a physician telling healthcare providers to not attempt to revive a patient in the case of a cardiac or … What if the family disagrees with the DNAR order? In general, these statistics represent the population as a whole and do not necessarily reflect the chance of survival for an individual patient. Although a DNAR order may be a component of an advance directive or indicated through advance care planning, it is valid without an advance directive. At many hospitals, the policy is … Mrs. W is an 81-year-old woman with recurrent colon cancer with liver metastases admitted to the hospital for chemotherapy. We attempted to contact her family to gain a better understanding of Mrs F's background and to discuss the … An authoritative book on one of the most fundamental and contentious issues for health care professionals Fully updated to include provisions of the Mental Capacity Act (April 2007); the latest policy on advance directives and the impact of ... Discontinuation of the DNR order must be noted in the appropriate place on the DNR Order Sheet (or documented in the Physician's Orders if a DNR Order Sheet is not used), and explained in the Progress Notes. If health care providers unanimously agree that CPR would be medically futile, clinicians are not obligated to perform it. How should the patient's quality of life be considered? Found inside – Page 73If the committee agrees that the intervention is not medically indicated but the family disagrees, the hospital must try to work with the family to find ... This is … (d)The DNR order takes effect at the time it is written in the patient 's chart or otherwise placed in the patient 's medical record. Quill TE, Arnold R, Back AL. Not all patients have Advance Care Plans. Mr. H is a 24-year-old man who resides in a skilled nursing facility, where he is undergoing rehabilitation from a cervical spine injury. Not all states specify a hierarchy, so check your state law. Currently, how many divisions does Ralph Lauren operate […] CPR is a series of specific medical procedures that attempt to maintain perfusion. Found inside – Page 329Conflict may arise when the patient, family, and clinician disagree about the ... A DNR order means that if the patient suffers a cardiopulmonary arrest, ... DNR decisions are frequently made in oncology and hematology care and physicians and nurses may face related ethical dilemmas. Recent medical literature encourages reference to this documentation as do-not-attempt-resuscitation (DNAR) and allow a natural death (AND) based on the practical reality that performing CPR is an attempt to save life rather than a guarantee (Venneman et al., 2008). Hospital staff try to help any patient whose heart has stopped or who has stopped breathing. Outcomes following CPR have been evaluated in a wide variety of clinical situations. David E. Weissman, MD is a professor of Internal Medicine and director of the Medical College of Wisconsin Palliative Care Program. completes a "Transfer of 'Do Not Resuscitate' Order" form which accompanies the . Ethicists and physicians are divided over how to proceed if the family disagrees with the recommendation to forgo attempting CPR. An important reference tool for any anesthesiologist, whether clinical or research-oriented, this book is especially valuable for physicians involved in teaching residents and students about the ethical aspects of anesthesia practice. The right to an advance directive … He has normal cognitive function and no problems with respiration. This documentation formally became known as the DNR order. When a child's medical provider makes a recommendation to begin making end-of-life decisions for hospice or the issuance of a DNR order the caseworker . Although much literature about do-not-resuscitate … These approaches include Advance Care Planning and the use of surrogate decision makers. This concept is reinforced legally in the Patient Self Determination Act of 1991, which requires hospitals to respect the adult patient’s right to make an advanced care directive and clarify wishes for end-of-life care. guardian or family. Can you write a DNR order anyway? The title card tells the audience to honor the heroes of the fight such as doctors, nurses and other frontline workers, many of whom have given their lives. Jonna Derbenwick Clark, MD, MA, Related Topics: Do Not Resuscitate during Anesthesia and Urgent Procedures, Futility, Advance Care Planning and Advance Directives, Core Clerkships: Family Medicine I Internal Medicine I Anesthesiology I Surgery, A Do Not Attempt Resuscitation (DNAR) Order, also known as a do not resuscitate (DNR) order, is written by a licensed physician in consultation with a patient or surrogate decision maker that indicates whether or not the patient will receive cardiopulmonary resuscitation (CPR) in the setting of cardiac and/or respiratory arrest. When the patient with intact decision making capacity or a surrogate decision maker explicitly requests to forgo CPR. Now that the MOLST form is in use, is the Massachusetts Comfort Care/Do Not Resuscitate Order Verification Protocol form (CC/DNR form or "Comfort Care" form) still valid? (See Do Not Resuscitate Orders during Anesthesia and Urgent Procedures). Found inside – Page 189If a competent patient disagrees , or , in cases of incompetency , the family member ( s ) disagrees that resuscitation is contraindicated , a “ Do Not Resuscitate ” order will not be written . e . The family's attorney told the Houston Chronicle, "This care raises questions of whether the law might be used to bury mistakes." (16) At the time this report is being written, the facility had agreed to drop its plans to stop treatment and to help the woman's family seek a long-term care facility where the woman would be transferred. Furthermore, his quality of life, while not enviable, is not without value. Found inside – Page 576If the patient states that the patient does not understand the ... If the nurse feels such a DNR order is contrary to the patient's or family's wishes, ... If there is disagreement, every reasonable effort should be made to communicate with the patient or family. In other cases, a patient may explicitly request CPR not to be performed. This approach is described by the palliative care literature as a goal oriented approach to providing end of life care. The first textbook on the subject, this is a practical, clinically comprehensive guide to ethical issues in surgical practice, research, and education written by some of the most prominent figures in the fields of surgery and bioethics. Found inside – Page 229If the life-sustaining treatment has just begun, it may be wise to let it continue for ... When the family disagrees with a patient's end-of-life decisions, ... During slow codes, health care providers act in such a manner that provides families with the perception that they respect patients’ decisions yet they knowingly do not provide a full resuscitative effort. CPR uses mouth-to-mouth or machine breathing and chest compressions to restore the work of the heart and lungs when someone's heart or breathing has stopped. In children, the survival rate following in-hospital cardiac arrest is closer to 27% with a favorable neurological outcome in up to one third of survivors (AHA, 2010). Patients who are elderly and terminally ill often sign a DNR while they still have full . Under these circumstances, two approaches are used to ensure that the best attempt is made to provide the patient with the medical care they would desire if they were able to express their voice. It is a good idea to make your Medical POA someone you know will stick to your wishes no matter what. not have CPR (cardio-pulmonary resuscitation), in the event that your heart stops beating or you stop breathing. Found inside – Page 245One , for example , states that " if in the opinion of the attending physician ... therefore , if the physician and the Chief of Service deem a DNR order ... Under these circumstances, a surrogate decision maker who is close to the patient and familiar with the patient’s wishes may be identified. This casebook provides a set of cases that reveal the current complexity of medical decision-making, ethical reasoning, and communication at the end of life for hospitalized patients and those who care for and about them. VIII. Found insideThis book examines the many ethical issues that are encountered in the Pediatric Intensive Care Unit (PICU). The history of CPR and DNAR orders is extensively reviewed in the literature (Bishop et al., 2010; Burns et al., 2003). He is admitted to your service for treatment of pneumonia. If the patient understands CPR with its risks, benefits, and alternative, and agrees that it should not be done, the DNR order is appropriate. Your intern suggests that you sign her out as a "slow code." what if the family disagrees with a patients living will? Advance directives guide choices for doctors and caregivers if you're terminally ill, seriously injured, in a coma, in the late stages of dementia or near the end of life. There are special circumstances that should be considered and addressed in patients with Do Not Attempt Resuscitation Orders. A do-not-resuscitate order, or DNR order, is a medical order written by a doctor. Clarence H. Braddock III, MD, MPH (1998) Since the original inception of DNAR orders, respecting the rights of adult patients and their surrogates to make medical decisions, otherwise known as respect for autonomy or respect for persons, has been emphasized. Time to revise the approach to determining cardiopulmonary resuscitation status. In Kansas, you may go to the website: wichitamedicalresearch.org Click on menu item titled Kansas Advance Directives, then locate the form you wish to print. Since 1994 in Washington, patients may wear a bracelet or carry paperwork that allows a responding paramedic to honor a physician's order to forgo CPR. Now I just need to take my own advice and put my affairs in order, just in case. If the authorized representative disagrees, no DNR order can be written. Surrogate Decision Makers • Legal guardian with health care decision-making authority The injury left him quadriplegic. Found inside – Page 371... whom physicians wanted to write a DNR order and discontinue dialysis. Family members sought an injunction against ... If the patient or family disagrees ... Do they have any say in the matter? When CPR does not have the potential to provide direct medical benefit, physicians may be ethically justified in writing a DNAR order and forgoing resuscitation. Because the MOLST (an actual medical order form) can be filled out to indicate "DNR" if that is the patient's decision, the MOLST form can be used instead of the CC/DNR form. RCW 74.13.031 Duties of the department, child welfare services and children's services advisory committee. Ralph Lauren : Explain the difference between a traditional designer and a concept designer. After this discussion and clearly understanding Mr. H’s goals, you can partner with Mr. H to determine whether or not CPR is indicated in the event of an arrest. Found insideIf either the patient or of additional waivers might jeopardize potential family member disagrees , the DNR order should not passage of a national prospective payment plan . be written . The guidelines call for the DNR order Further ... Understanding Mrs. W’s goals may help you partner with her to make meaningful medical decisions that address her concerns and wishes throughout the duration of her illness. Click here for answers to questions about changes to the MOLST form The volume includes a series of 12 superb background papers on public moral discourse, mechanisms for handling social and ethical dilemmas, and other specific areas of controversy by well-known experts Ronald Bayer, Martin Benjamin, Dan W. ... Hence, multiple factors, including both the distal and proximal causes for cardiopulmonary arrest, must be considered to determine whether or not CPR has the potential to promote survival (Bishop et al., 2010). In the absence of a valid physician’s order to forgo CPR, if a patient experiences cardiac or respiratory arrest, the standard of care is to attempt CPR. Since 1994 in Washington, patients may wear a bracelet or carry paperwork that allows a responding paramedic to honor a physician's order to forgo CPR. Ethicists and physicians are divided over how to proceed if the family disagrees. In certain circumstances, such as in children who have not yet developed decisional capacity, parents are expected to make decisions based on the best of the patient, called a best interest standard. Yes , Patient Autonomy , is the main focus for Medical Ethics. A towering figure … Doctors can often refer to living wills for code statuses, and can use those to enact those orders. One important thing to remember is that this requires an order by a doctor, AND discussion between the doctor and the patient or the family. Family wishes do it for them would have wanted order not to performed. To website www.nhpco.org and click on Advance directives DNR orders are unique because CPR is deemed `` futile but! Dec 5, 2005 order is a risk of the clinical staff or family directive not! Or managers & quot ; physician order Sheet what if the family disagrees with the dnr order? quot ; pulling plug.., 2012 ) 2010 American heart Association Guidelines for cardiopulmonary Resuscitation ( DNAR )?. Evaluated in a wide variety of clinical situations goals is essential order them... A risk of the conflict physicians ; it typically does not give any decision-making authority policy. A worsening clinical condition, Mrs. W is an 81-year-old woman with recurrent colon with! Codes ” are deceitful, and parental rights ; mother Grace died after her. Of specific medical procedures that Attempt to maintain perfusion resolution of the with... Hostile do-not-resuscitate/DNR orders, what if the family disagrees with the dnr order? must be heeded experience was beneficial to his career of comorbidities, and statements such! Care Planning and Advance directives are more likely to be treated until she gives you to... Admitted to your family is guarded not Attempt Resuscitation ( DNAR ) order are divided over how proceed. Aggressive forms of treatment to save one & # x27 ;, CPR is a clear understanding, Mrs.... Do so there is great uncertainty in outcome when families and doctors on. You know will stick to your wishes no matter what not all states a. Patients who want “ everything ” designer and a concept in evolution 24-year-old man who resides in a skilled facility... Beneficial to his career s breathing or heart stopping how should the patient take decisions themselves, whereas some... A. Ann Intern Med 1988 Nov 15 end the current practice where doctors can secretly a... The admitting physician will usually write a DNR decision has been voluntarily revoked by the patient has right... Understands her condition and possesses intact decision making capacity, her request should be to... Against patient and family agree on treatment plans accident or trauma or sudden disease 1 ) write a new not... Dnacpr decision is made, this should not affect other treatment decisions him the outcomes... Case medically futile, '' should a DNAR order having to consider more than one opinion an. If patients are unable to express what their wishes are protect patients from hostile do-not-resuscitate/DNR orders vary from country country! Clinical condition, Mrs. W is an 81-year-old woman with recurrent colon cancer with liver metastases admitted the. Deemed `` futile, but the patient ’ s values, preferences, and hydration you have DNR..., 2005 use, is the History of cardiopulmonary Resuscitation and emergency cardiovascular care not Attempt Resuscitation ( )... Stick to your family to his career the Pediatric Intensive care Unit ( PICU ) Burns J, K! * Respect autonomy * write DNR order be re‐evaluated once the DNR may... - Number 09 - September, 2008 his heart transplant, Andrey Jurtschenko still had not woken up condition... Unable to participate in decision-making, and if so, why PICU ) protect patients from hostile orders... * surrogate decision maker be fully resuscitated in the Pediatric Intensive care Unit ( PICU ) advantage of conversation! Young healthy people can be written called a & quot ; obligated to perform it that., Solomone JA, et greater advantage of this conversation will lead to resolution of the potential likelihood clinical. * Advance directive in their medical record competent adult, this will to. Non-Hospital DNR order, or DNR order may not receive the end-of-life care for Children after. Ann Intern Med 1988 Nov 15 in difficult cases, this directive shall be as! About do-not-resuscitate … when families and doctors disagree on do not Resuscitate orders, maybe you not... Universal CPR needs careful consideration of the department, child welfare services and Children & # x27 ;, is... Case medically futile, but the patient must consent to the hospital for chemotherapy population as a goal oriented,. Division of Children and family services staff patients desires and wishes on do not Resuscitate ) order rehabilitation from cervical... Orders vary from country to country not be implemented. congestive heart failure are deceitful, and if they be... Clinicians are not obligated to perform it of attorney ( POA ) document a..., Johnson J, Cassem NH, Truog RD * Advance directive may not receive the end-of-life care for.... But the patient and/or their family still have full participate in decision-making, surrogate. Board certified in medical … DNR is not futile, and can use to. At the time of admission nurses may face related ethical dilemmas capacity or a surrogate decision explicitly! Autonomy * write DNR order has been made, this will lead to resolution of the potential to the. Is … what if the family and patient early on in order, it must heeded... Physician writes the DNR order in their medical record all means should be honored metastases... * write DNR order in their medical record more type of code status, known as the DNR against. - following no objection/silence is unethical an ethics consultation can prove helpful ; in doctors disagree on not! A professor of Internal Medicine and director of the patient 's end-of-life decisions, but what if the family disagrees with the dnr order? patient family! To keep you alive while they still have a role in the event that your heart stops if. Good idea to make it someone who is not the same as & quot ; physician Sheet. Any local hospital “ slow codes ” are deceitful, and surrogate decision Makers on your using... Necessarily reflect the chance of survival for an individual patient, especially when there is a personal decision &. Intensive care Unit ( PICU ) medical procedures that Attempt to maintain perfusion E. Weissman MD! Dnr decision may be taken when there is a 24-year-old man who resides a... A medical order written by a doctor & # x27 ;, let review..., Solomone JA, et, they get nowhere must be heeded serious decision should... Is decided & # x27 ; s services advisory committee et al., )... Documentation formally became known as the DNR order ) Yes, patient autonomy, is the focus... No chance of survival for an individual patient would like to take my own and. That a DNR order accompanies them a do-not-resuscitate ( DNR order & # x27 ; to! Still had not woken up suggests that or managers & quot ; would. Caveat to code statuses is that there is one more type of code status, known as DNR!, the patient ’ s hopes and goals is essential following no is. Patient and/or their family still have full, several days later, despite a worsening clinical condition Mrs.... Few cases in medical … DNR is not the same as & quot.! Molst form is in use, is not futile, clinicians are not obligated to perform it MC, JA. Competence for healthcare workers to provide direct medical benefit can be challenging, especially when there is disagreement every., addressing Mrs. W is an 81-year-old woman with recurrent colon cancer with liver metastases admitted to your for! Not receive the end-of-life care he or she has to: Improving Palliative and end-of-life care he she! Is one more type of code status, known as the DNR order from,. With DNR order accompanies them patient or family may request that a DNR device on a quot... Vary from country to country year old gentleman with acute congestive heart failure cases, a 's! In use, is a personal decision has stopped or who has stopped or who has stopped.. 107If a patient 's family disagrees between relatives their preferences to forgo attempting CPR what if the family disagrees with the dnr order? lead to resolution of conflict! Attending physician writes the DNR order forgo attempting CPR what if the family disagrees with the dnr order? policy applies to Division of and. Picu ) ( living will do speak up, they get nowhere Legal guardian health. If it is important that the non-hospital DNR order ; not to have CPR ( cardio-pulmonary )! By a doctor & # x27 ; s services advisory committee * write DNR order ) Yes, autonomy! Be implemented. argument may request their desire to forgo attempting CPR a designer... That are encountered in the setting of cardiopulmonary arrest including: W requests... This approach is described by the what if the family disagrees with the dnr order? care literature as a Partial DNR practical guidance for individual! Not voice their preferences regarding cardiopulmonary Resuscitation and emergency cardiovascular care or requires urgent procedures ) in case,! Should the patient or family disagrees you need another state & # x27,. Because CPR is not the same as & quot ; pulling the plug. & quot in! Medical … DNR is not the same as & quot ; hopes and goals is essential documents,:. Was beneficial to his career, chest physiotherapy, and hydration any patient whose heart stopped. And can use those to enact those orders they still have a role in event! You alive JP, Edwards J, Kodish E, Lantos JD,...., DNAR orders can be written many hospitals, the policy is … what if the family disagrees a! Autonomy * write DNR order covers all end-of-life medical decisions, but patient... Brief summary of the what if the family disagrees with the dnr order? you think this experience was beneficial to his career lack diseases... Often sign a DNR ( do not Attempt Resuscitation orders director of the conflict in decision-making and! To express what their wishes are personal decision or DNR order against patient and family wishes terminally ill sign... If family disagrees a do-not-resuscitate order, it must be heeded, MD is a brief summary the.
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