Obstacles and Facilitating Factors in Decision-Making of Elderly Patients’ Living Will in the Chinese Context—A Literature Review

Introduction

In recent years, China’s aging and aging have shown a continuous and rapid development trend. According to the natural law of birth, old age, sickness and death, the elderly are the group closest to “death”. This group may not have advanced disease, but due to old age and weakness, the decline of various physiological functions, there is a high risk of sudden physical deterioration and mental disorders.1 The elderly who suffer from incurable diseases, chronic diseases, fatal diseases and disabling diseases are regarded as groups particularly relevant to the end-of-life medical decision-making. In traditional Chinese concepts, death is a taboo topic and is affected by the concept of filial piety. For example, when an elderly person suffers from an incurable disease, the family usually does not let the elderly know the true condition of the disease, and medical staff are required to continue to conduct a series of “nothing” for the patient. Meaning’ treatment, otherwise it is not filial.2 Once elderly patients begin to lose the ability to make independent decisions, they rarely have their own right to make decisions about end-of-life medical care. Therefore, living will gradually play an increasingly important role in helping them express their wishes for end-of-life medical care. The living will is not only used as an expression document for the patient’s previous decisions, but also as an instruction document for a better understanding of the patient’s previously expressed wishes, which is an instruction on the termination of life care (for example, abandoning a specific treatment). In 1990, the United States emphasized that “death in peace is an important human right”.3 In recent years, people have realized that the meaning of life is not just the extension of time, but more emphasis is on a kind of good death. A prerequisite for “death” has also been paid more and more attention. However, Chinese patients and their families have a relatively low awareness rate of living wills, but the approval rate is more than 50%,3 but in terms of whether to sign relevant documents of living wills, About 30% of the family members expressed their unwillingness to set up life wishes in advance.4 The main reason is that the patient does not want to cause a bad emotional reaction due to thinking about this problem, and the second is that it is unnecessary for the patient and fear that the patient will lose hope. So although both the patient and the family support the living will, these results indicate that certain obstacles still exist.

Materials and Methods

By using “Living Will”, “Advance medical instruction (ACP)”, “advance directives (ADs)”, “Death with Dignity (DWD)” in academic databases such as Cnki, Wanfang date, Weipu, Pubmed, Springer, Elsevier, etc. Retrieval period: Self built database – 31/12/2021, and other keywords are search terms to search for relevant documents and books to understand the connotation and concepts of domestic and foreign elderly patients about living wills, research status, and factors that affect Chinese elderly patients’ signing of living wills.

Overview of Living Wills The Concept of a Living Will

The concept of a living will originated in the United States and was first proposed by Courtner.5 He believed that a living will is equivalent to a legal entrustment of the establishment of property. If the entrustment of the property is If it is legal, then a person’s body should also be protected by the same law. A living will is a legal document and a document about medical care filled out by a person in a healthy mental state. It provides medical staff and the patient’s family with instructions to start or stop rescue intervention when the patient enters an advanced state or a persistent vegetative state. A living will is a formal statement of a capable adult, stating that if he/she suffers from a serious mental or physical illness so that there is no hope of recovery anymore, any life-prolonging procedures should be stopped.6

The Connotation of a Living Will

A living will is one of the two forms of advance directives. It appears in response to modern medical technology and the implementation of active medical treatment when the prognosis of the disease is not clear. The purpose of the living will is Protect the autonomy of the patient in this situation. Ideally, when individuals, especially the elderly, cannot express their wishes due to illness or other reasons, it can play a role in the patient’s choice of medical care.7 At least, a living will can make a useful medical ethical decision for a patient who is unable to express. In addition to being a useful tool to respect the autonomy of the patient, a living will can also be seen as an opportunity to improve communication with patients or healthy people on dying issues.

The Status Quo of the Development of Pre-Mortems in the Context of China

Influenced by traditional Chinese Confucianism and the lack of death education in China, the concept of rebirth and death is deeply ingrained. People often think that “life is priceless and should be rescued at all costs.” There are also life activities, which require a series of traumatic treatments to sustain life.8 The influence of traditional Chinese concept of filial piety can also easily lead to excessively ineffective treatments. For example, when the elderly suffer from incurable diseases, their family members and children usually do not let the elderly know the true condition of the disease, requiring medical staff to continue to use a series of “meaningless” treatments. Methods to treat patients, if you do not do this, it is impious.2 However, when healing is no longer possible, life-prolonging technical interventions often only prolong the death process, causing suffering for patients and surrogate decision-makers, family members, and medical staff encountering moral suffering. And some people think that signing a living will is equivalent to giving up treatment and giving up their lives.9,10 Therefore, the implementation of the living will in China has encountered some obstacles. However, studies have shown that after learning about the living will, most people expressed their willingness to sign and showed great interest.11 However, at the legal level, with the exception of China’s Taiwan and Hong Kong, mainland China has not yet realized the legality of the relevant documents of the living will. But in June 2011, Luo Diandian proposed the first civil living will text in China, and launched the first public welfare website on “choice and dignity”, aiming to promote people’s dignity and death, and you can fill in your own’ on it. In 2017, the former National Health and Family Planning Commission of China also issued a trial document of “Guidelines for the Practice of Peace and Ning Car”. The national level began to pay more attention to this aspect, and the social influence gradually expanded. Some issues still need to be resolved, such as legal protection and ethical obstacles.

Obstacles to the Implementation of the Living Will The Quality of End-of-Life Care is Uncertain

Although the pre-mortem expresses the patient’s good wishes regarding death, studies12 have shown that the quality of end-of-life care, the accuracy of decision-making agents, the effectiveness of the expression of life’s wishes, and the treatment and treatment methods and treatments In terms of costs, the implementation and function of the living will seem to need to be further strengthened and improved. Some people think13 that single-focus interventions such as the “Patient Self-Determination Act” passed in 1990 in the United States and the success rate of pre-order completion will not improve the quality of hospice care. Goodman et al14 found that there is no difference in the care provided to elderly patients with and without a living will. He believes that at present, the basic care received by elderly patients is in line with the meaning of the living will, and there is no need to do so. However, China is currently very concerned about the hospice care of elderly patients. Taking into account the realization of the dignity and death of elderly patients, it is believed that the implementation of peaceful care for dying patients is necessary. In 2017, the “Practical Guidelines for Peaceful Care and Nursing” was issued, which will further to promote the development of living wills, there have been many pilot projects of tranquility treatment in many places, and some results have been achieved. However, the link between the implementation effects of further interventions on living wills and the quality of tranquility treatment is still needed A large number of studies have confirmed that the current evidence is relatively small, so whether the signing of a living will can improve the quality of life of Chinese dying patients needs to be further confirmed.

Ethical Factors

In religious values, life is endowed with sacredness, and any measures to prevent or cancel treatment will cause controversy. However, when the patient’s condition is irreversible and the quality of life has dropped to an imaginable level, how to make reasonable medical and nursing decisions? What kind of decision is legal: stop or refuse life-sustaining treatment, and refuse ineffective medical treatment? If the patient is no longer able to make these decisions, who will make them: doctor, family, ethics committee, or judge? When the situation is irreversible and it is impossible to restore a higher quality of life, should we prolong a person’s life? The emergence of these ethical issues gave birth to the emergence of the living will.

Living wills can ideally serve the autonomy of patients. However, Fagerlin15 and others put forward objections. They believe that only a few people can truly execute the living will, know what the patient really wants, and accurately convey their wishes, and they do not give people a prerequisite for them. Misunderstandings are taken into consideration, and the treatment preferences expressed by individuals may be different when they are healthy and when they are sick. Regarding the choice of surrogate, most studies16 indicate that family members usually make decisions on behalf of elderly patients, but there are also complex issues (such as family discord, family members’ disagreements, issues of interest between family members, such the emotional pressure of the decision).

In China, most elderly patients do not have the opportunity to express their preference for future care. Therefore, the burden of making care and medical decisions will fall on their family members, which will inevitably increase their pain, anxiety and depression, and may also be due to family members. Insufficient communication with medical staff on patient treatment decision-making has resulted in disputes. Therefore, from this perspective, it is necessary for frail elderly people to plan their future care in advance, sign a living will in advance to improve family members’ understanding of their wishes, help resolve family conflicts, and promote communication with their medical staff. Conduct clinical communication. However, some people believe that17 the signing of the living will may weaken the family and medical staff’s sense of responsibility for the patient’s health and the humanistic care for the elderly. The patient may lose confidence in the professional abilities of the medical staff, and the medical staff may give up. Their thoughts, and the worry that medical staff are forced to respect the living will documents in the execution of the living will, they will become the executors of the patient’s wishes without their own judgment ability. And according to Locke,18 any authority should not interfere with a person’s private life. As long as he does not restrict the freedom of others, he can do what he likes freely, and the patient has the right to pursue his or her own concept of happiness. Therefore, there are still many ethical issues in the medical field regarding whether to respect or disrespect the autonomy of elderly patients. However, most of the younger generation in China now support the signing of a living will to express the willingness of elderly patients to make end-of-life treatment decisions.

Lack of Legal Support

In China, many patients with severe cancer are often sent to the intensive care unit for final treatment at the advanced stage, including invasive treatments such as traumatic tracheal intubation, arteriovenous catheterization, and nasal feeding. At this time, in addition to physical pain, patients often I am also experiencing the torment of mentally indignant. At this time, I am eager to receive soothing treatment at the end of life, and even euthanasia. However, under the complicated medical background in China, when some people hope to use medical methods to end their lives in a relatively painless way, but suffer pain, they will always encounter an important question: do people have the right to decide to die? When a doctor is asked to “help someone die”, is he “helping” or “killing”? Therefore, when a patient asks a doctor to “give up treatment”, the doctor will often not give the patient easy palliative treatment because he is afraid of taking responsibility, let alone euthanasia which is not allowed in China.

The emergence of the above-mentioned problems may be able to solve this dilemma. However, at present, mainland China has not yet enacted legislation on the living will, and believes that choosing a living will is a manifestation of giving up treatment and disrespect for life,10 so most People still have doubts about using a living will to make dying decisions. If supported by the law, the quality of life of dying patients will also be improved. However, when the tenth meeting of the Standing Committee of the 13th National People’s Congress of China in 2019 reviewed the draft of the Personal Rights of the Civil Code, the representatives of the National People’s Congress who attended suggested that “euthanasia” should be written into the Civil Code. The draft stipulates that

natural persons shall have the right to life. Have the right to maintain their own life safety and dignity. No organization or individual may infringe on the right to life of others.

The representative suggested that

people with full civil capacity who are medically defined, unable to treat and unable to alleviate their illnesses have the right to independently decide to implement euthanasia in accordance with the law, and no organization or individual shall defraud, induce or coerce natural persons to implement euthanasia. The natural persons consent to euthanasia shall be expressed in written form, and this document can be revoked or withdrawn at any time upon review and approval by relevant departments.

But this is still just a suggestion, and the legislation has not been adopted in the end.

Facilitating Factors for the Implementation of the Living Will Fit People’s Psychological Expectations

Influenced by traditional Chinese culture, living wills do not seem to be suitable for China’s environmental and social background. In particular, elderly people think that it is a taboo to discuss death, including family members, and usually avoid mentioning this topic until it becomes a top priority19. However, Akhtar’s20 survey shows that if a person discusses in an inadvertent way how a person expects to spend his last time, almost everyone expects to die in peace and does not want to be a burden to family and society. At the same time, they do not want to suffer unnecessary pain when they die. They think that rescue technology not only does not make the dying patients feel comfortable, but prolongs their “death”. In particular, terminally ill patients can only receive supportive care when they are in a vegetative state or mentally incapacitated. At this stage, unnecessary treatment to prolong death is tantamount to injury. Mattes21 and other studies also show that if a respondent is diagnosed with a severe incurable disease (estimated life expectancy is 6 months), 97% of people want the doctor to discuss their prognosis with them, and 74% of people do not want to Accept cardiopulmonary resuscitation, even if it is necessary to save their lives (9% want cardiopulmonary resuscitation, 18% are not sure). In this case, 72% prefer to maximize comfort. Targeted supportive care, while 4% of people prefer active treatment with the goal of prolonging life, 24% said that the two are equally important, and the emergence of a living presidency just meets the psychological needs of patients who require relief treatment.

A study22 found that as many as 20% of elderly patients in Hong Kong, China, after knowing the true results of the operation, changed their minds and refused to CPR, hoping to sign documents such as a living will to express their wishes. Many studies have shown23 that when patients are aware of the true survival rate of life-sustaining treatments, they do not want to carry out life-prolonging “meaningless” interventions, believing that pre-mortem orders can help express their willingness to make medical decisions. At the same time, almost all patients hope that there will be no pain at the end of their lives. Therefore, increased pain, poor quality of life, and physical discomfort will make elderly patients choose to sign a living will. If a living will is legal, “a comfortable life without long-term pain” is the most common reason to consider using a living will.22 In a study of elderly patients with advanced chronic obstructive pulmonary disease,24 it was shown that reducing the burden of disease and dignified death are also considered to be the main factors behind the choice of life-sustaining treatment decisions. When Chinese elderly patients with chronic diseases use the living will, good death seems to be the main consideration. Therefore, pre-mortems are more in line with the psychological expectations of elderly patients for death.

Personal Autonomy is Respected

The application of a living will before death is necessary, so that the individual’s wishes in medical decisions can be respected. A study of the deaths of 3746 people aged 60 and over in the United States25 found that among 42.5% of people who need medical decisions, 70% of them cannot express their wishes. It is agreed that respecting patients’ preferences for care and treatment during the life cycle is an important part of high-quality medical care.26 Almost all patients in the intensive care unit are in the predicament of using ventilators and artificial nutrition to prevent the patient from dying prematurely. If a person expresses his desire for what kind of treatment/care he wants, and is respected by the medical staff within the scope of the treatment, this can build trust between the patient and his medical staff.

For Chinese people, they are more inclined to rely on their families rather than individuals. Therefore, families play a more important role than patients in key medical decision-making, but elderly patients with higher status in the family and those who usually do for themselves Elderly patients who make decisions are often given all the information about medical decisions and subsequent prognostic status, so as to make decisions for their future diagnosis and treatment plans.11 In a sample survey of Chinese elderly with chronic diseases,22 it is shown that the family plays an important role in the end-of-life decision: For those respondents who do not consider the use of a living will, if it is legal, “My family will decide for me” is the most common reason (39.1%); for those considering using it, “avoid burdening the family” is the second most common reason (38.9%); If the interviewee wants to discuss with someone about the living will, they most want to talk to their family (91.9%). Traditional Chinese society is strongly family-centered, and medical decisions are often made by families rather than individuals. The principle of autonomy plays a small role in Chinese society.27 It can be seen that the family’s participation in the living will and advance care plan is especially important for Chinese people. However, the emergence and implementation of pre-mortems promoted the communication between patients, relatives, friends, and medical staff, put the right of choice in the hands of patients, and realized the autonomy of patients.

In 1985, Lord Templeman17 believed that after the doctor informed the patient of the recommendations and risks of treatment, the patient had the right to “reject the recommendation, regardless of whether the reason was reasonable or rational”. The implementation of pre-mortems allows the elderly who are gradually losing their decision-making ability to take their own treatment options in their own hands, avoiding relatives and friends from arguing about what the patient wants or relatives and friends adding their own wishes to the patient. In recent years, the Chinese people’s sense of autonomy has become stronger and stronger, which has promoted the development of pre-mortems.

Conducive to the Mental Health of Dying Patients and Their Caregivers

In a randomized controlled trial,28 it was found that a living will plan can improve the satisfaction of patients and their families regarding hospice care, and reduce family stress, anxiety and depression. In addition, studies have shown that8,29 living pre-decision can minimize the desire of elderly patients, maximize comfort for elderly patients, make elderly patients more confident in their decision-making ability, and reduce fear of future life and treatment, Which may prevent certain extreme solutions, such as planning to commit suicide before a person becomes insane. Moreover, it is helpful for the family members to understand the patient’s life will, avoid unnecessary and excessive medical treatment, and reduce the burden on the end-stage patient’s family.30

The Patient is Personally Willing to Accept the Living Will

In China, the attitudes of patients and family caregivers to living wills after explaining relevant information to them mostly showed a positive tendency. Participants were more willing to discuss advance instructions with medical staff. When they are diagnosed with a life-threatening disease, they usually show a preference for refusing to maintain life, increasing the possibility of choosing hospice care.11 When Chinese elderly patients with chronic diseases were told about the details of the living will and life-sustaining treatment, most of them were able to make a certain choice, instead of hesitating, they were more interested in using the living will and passing easing Medical life-sustaining treatment is also generally positive.22 In a German study,31 most patients (56% of 503, 282) also expressed their desire to obtain more information about living wills.

People with higher education have more knowledge and a more positive attitude towards pre-mortems, and prefer to play an active and autonomous role in medical decision-making.32 This high-level education is likely to help patients understand the content and meaning of pre-mortem orders, and is conducive to communicating with families and medical staff about dying decision-making issues. Since family members and friends are an important source of information for understanding the living will, and a close friend or family member has executed the document may also encourage a person to choose to sign the living will.33 Studies have shown that34 elderly patients with higher socioeconomic status and high education are more likely to be prepared for their own deaths, because their self-efficacy is greater, and both can promote elderly patients to plan their own lives. There are also studies35 that have shown that those who have had a living will education, have experience of terminal illness or critical illness, and have higher religious beliefs are more likely to discuss living will or dying decisions with their medical staff.

Suggestions and Measures The State—Improve Relevant Laws

Ethical considerations (different from the law, but generally consistent with the law) are considered to be a more important factor in clinical decision-making.36 According to the “Code of Professional Conduct for Registered Doctors” in Hong Kong, doctors must respect the wishes expressed by patients through living wills, even if these instructions violate their personal beliefs, unless these instructions involve illegal acts such as euthanasia. Taiwan region of China also promulgated the “Hospice Care and Palliative Care Regulations” in 2000, which allows patients to refuse cardiopulmonary resuscitation in the terminal stage of irreversible diseases, stating that terminal patients have the right to sign a living will and can be changed or revoked at any time37. However, there is no relevant law in mainland China that prohibits or supports citizens from signing a living will to express their dying decision-making wishes. Although in June 2011, China’s first private living will text appeared to promote death with dignity, and the first choice and Dignity public service website. In 2017, the Health and Family Planning Commission also issued a trial document for the “Guidelines for the Practice of Hospice care and Nursing”, but there is still a lack of legal documents to regulate the implementation of living wills. This may be related to the concept of rebirth and death in China. A Hong Kong study22 showed that if a living will is legalized in Hong Kong, about half of the respondents (49.3%, 219 people in total) would consider preparing a living will. Kamer et al38 reported that the legislation greatly changed the signing rate of DNR (non-recovery) documents (from 22% to 93%). It can be seen that legal protection is the basis for policy implementation, so the country should promote the country’s legal system construction in terms of tranquility, treatment, and living will.

Society-Promote the Development of Death Education

The formation of attitudes is the result of favorable or unfavorable evaluations of a person, an event, or an event, and it is expected to change with the passage of practice and experience. A correct understanding of death can improve people’s understanding of life. Studies have shown39 that death education has an important effect in improving cancer patients’ anxiety and attitudes towards death and improving the effect of hospice care. A death education intervention group can help reduce the pain related to death and strengthen death preparation. There are almost no courses involving death education in primary and secondary schools in mainland China. Only a few provinces and universities have opened death education courses for medical students, but they have not been popularized. Foreign countries such as the United States have relatively standardized death education systems, which are planned as Regular courses from elementary school to university.40 Our country can learn from the experience of other countries such as South Korea and Japan, and adopt experiential training and education methods, such as visiting funeral homes, writing down feelings of death, and simulating coffin experience, etc., to establish the concept of people’s active life, and enable people to pass the experience of other people’s death As well as their own social and family experiences, people can face death calmly.

Medical Staff To strengthen the reserve and training of relevant knowledge. Nurses are generally recommended as the most suitable professionals to start discussing pre-mortem orders, because they have a close relationship with the patient, and they have established a trust relationship with the patient, and they know to provide what information may be accepted by the patient. Nurses have special communication skills that are very important to elderly patients, especially dying patients, such as listening to the patient’s voice, responding to the emotional needs of elderly patients, and respecting the patient’s cultural and religious beliefs. However, studies have shown41 that Chinese medical staff has a low awareness rate of their related knowledge and lack of information. Most nurses believe that because they do not have enough knowledge to discuss the predecessor with patients, they did not saw it as part of their professional role. Therefore, it is necessary to strengthen the training of relevant professional knowledge for nurses. They need to know what hospice care is, what is a living will, and how to provide relevant hospice care for the special group of elderly patients, all need professional training and practice. Actively understand the cultural values of patients. It is almost impossible for any medical staff to understand the cultural customs of each patient. However, medical staff can improve their cultural capabilities to enable them to engage in constructive conversations about death in the cultural context of elderly patients. Incorporating cultural values into the discussion of living wills can provide a more comprehensive understanding of the medical care preferences of elderly patients. One of the advantages of acquiring cultural values is to help the elderly patient clearly understand what type of medical care he or she wants and why. Another advantage is that medical staff and surrogate decision-makers can give medical care guidance based on the values of elderly patients and respect their willingness to make decisions at the end of life, instead of inferring their values or replacing them with their own values. You can start by asking these questions: 1) What do patients and their families think about death and dying? 2) What is the patient’s wish for care at the end of life? Other key questions include how to deal with death and what are the taboos of the deceased about the funeral and burial ceremony? Later, we can find out the answers to these questions through the participation of patients and family members. Although there is no standard method for this topic, it is possible to provide the necessary care measures for elderly patients by obtaining the cultural values and religious beliefs of them.Family-Encourage Family Members to Drive Patients to Participate in Decision-Making

The Chinese are a family-centered group, and they often regard the family as a decision-making system. A survey in Taiwan42 compared with the elderly in Europe and the United States, the elderly in long-term care institutions in Taiwan have less power to make decisions about their own health. They strongly believe that before making any decisions related to death, All must seek the opinions of family members. Professionals must respect the family-oriented decision-making thinking of elderly patients because it reflects personal choices. Some comments emphasized43 that if family members are unwilling to participate, the promotion of living wills may be difficult. This is especially evident in the case of elderly people suffering from chronic diseases and long-term care, in which case families often become surrogate decision makers. Therefore, families should be encouraged to participate in all aspects of elderly patient care planning. However, in our country, it is often difficult for elderly patients to realize their medical wishes due to filial piety, a sense of responsibility to the family and fear of burdening the family. Some people said that if the death of their loved ones happened “naturally”, they can accept it, but they cannot make a decision to accelerate their death. They believe that signing a living will is equivalent to giving up the life of their family members. Therefore, it is also necessary to popularize the knowledge of living wills and death education for family members, so that family members can promote elderly patients to make terminal decisions.

Discussion

To the best of our knowledge, this review is the first time to summarize the obstacles and facilitating factors in the decision-making of an elderly patient’s living will in a Chinese context. Due to the development of the aging population and the increase in people’s awareness of death, the living will must be Receive attention. We found that there are many obstacles and facilitating factors in the decision-making of elderly patients’ pre-decision in the Chinese context, which can be summarized as personal reasons, social reasons, and national reasons. The poor quality of hospice care, social ethics, and lack of legal support are considered to hinder elderly patients from making decisions about their living will. And conforming to people’s psychological expectations, personal autonomy being respected, conducive to the mental health of dying patients and their caregivers, and patients’ willingness to accept a living will are considered to be contributing factors.

In this review, due to methodological limitations, the searched articles were not systematically reviewed and Meta-analyzed, but only a summary was made, but it also provided strong evidence for the obstacle and promotion of the living will. In particular, a series of suggestions have been put forward in response to these obstacles, so as to promote the development of China’s living will.

Conclusion

A living will is a document about medical intentions filled out by a person in a healthy mental state. It is assumed that at a certain point in the future, a person may not be in a healthy mental state when he can use this document for his own medical treatment. Willing to make decisions, which will help plan treatment for the end of life. As people’s awareness of death increases, the implementation of pre-mortems is also an inevitable trend. However, at present, the research on living will in China is still in an exploratory stage, and there is no relevant document to guarantee it. There is even a lack of intervention research on how to promote the realization of “prejudice” in elderly patients. Due to cultural differences in various countries, it is urgent to develop assessment tools suitable for Chinese culture and national conditions that affect elderly patients’ signing of living wills, determine relevant specific influencing factors, formulate intervention measures, and promote the development of death education in China to ensure gradual progress. Elderly patients who have lost the ability to make independent decisions can have their own right to make decisions at the end of life.

Abbreviations

ACP, Advance medical instruction; Ads, advance directives; DWD, Death with Dignity.

Ethics Approval and Consent to Participate

No ethical approval was required, as this was a review of existing qualitative evidence.

Consent for Publication

All agreed to publish this article.

Acknowledgments

Thanks for the financial support of my work unit.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.

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