The "Code Status" Conversation

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An evidence-based review of the evidence and guidelines behind the "code status" conversation in the hospital. Geared towards medical students & residents.

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  • Image: http://4.bp.blogspot.com/_xUWGKWvCTb0/TNo-U5yKJ6I/AAAAAAAAAFk/nAVmBi6oSqU/s1600/2204241-3-black-and-white-tree-lake-hume.jpg (Accessed 1.29.11)
  • Originally called “Closed Chest Cardiac Massage” and was performed on all patients with presumed consent until early 70s

    POTUS Commission: policies based on three value considerations: self-determination (based on competent patient’s preference), well-being (decision to withhold can be justified if it won’t benefit pt) and equity (all patient’s should have equitable access without consideration of cost-benefit).

    PSDA: Effective on December 1, 1991, this legislation required many hospitals, Nursing Homes, home health agencies, hospice providers, HMOs, and other health care institutions to provide information about advance health care directives to adult patients upon their admission to the healthcare facility.

    Developed following Nancy Cruzan case (MVC in 1983PVSfeeding tube out in 1990).
  • Lack of empathy
    No discussion of prognosis
    Treats it as an consent conversation without offering all the information

    Image: http://4.bp.blogspot.com/_SPYHXFtLYDk/TOSEb9IOprI/AAAAAAAAAGE/vzlcyaZ8aiU/s320/finished%2Bcube.jpg
  • One conveys a powerful subconscious message to the patient and one is a roundabout way of giving your opinion as to what the patient should choose to do…

    These are commonly found in the conversations of both residents and attending physicians when studied.

    Image: http://www.age-of-e.com/hypnosis/ConsiousMind.jpg
  • Often these decisions will not be made alone but rather in concert with the family. While it is not imperative that the family agree with the patient’s decision, we must ensure that the patient’s decision will be honored and this is easier done if the family is on board before deterioration.

    Prigerson (Socialization to Dying): the geriatric patient demonstrates an overall preference for the goals of palliative care; the care that is provided, however, is predicted by the preferences of the family and the provider.

    **Therefore, to understand this, we need to look at the preexisting expectations of these groups…
  • Social and situational knowledge…

    “97 episodes of three popular television medical shows in the 1990s depicted 60 CPR attempts. The depicted TV show survival and hospital discharge rate was 67 percent.”

    Further inadequacies: completeness of interventions, depth of compressions, etc.
  • Pt’s are not likely to start this conversation on their own.

    Image: http://www.amphetamobile.com/wp-content/uploads/icons/chest.png
  • Amount of control afforded to providers differs based upon how moral the decision seems to patients
    Demonstrates that therapeutic paternalism has a limit with regard to what are considered highly moral choices.
    Also indicates a need for providers to frame options in a proper light (medical vs. moral)
    limit choices proactively to those that are medically reasonable.
    “Life-sustaining/supporting” vs. “death-prolonging”
    I.E. when the long-term family caregivers of patients are asked about…“The term ‘life-sustaining treatment measures’ was often interpreted differently than how it would be defined medically. ANH or administration of antibiotics was not seen as a medical but ‘normal’ or ‘basic’ treatment by the family caregivers in this study.” (Kuehlmeyer et al., 2012.)
  • CPR occurs in 1% of hospital admissions.

    Only 19% of those requiring CPR had documented code status conversation (therefore it is most commonly performed on patients without their foreknowledge or consent).

    More likely to be documented: care facility transfer

    Image: http://www.scumdoctor.com/images/What-Are-Resuscitation-Code-Status.jpg
  • Diagnosis of: CA, Depression, Hx CVA, CAD or CHF
    Those having: POA and/or living will
    Those on Medicare

    (In this study, these differences were less powerful than the differences between the hospitals in the study, suggesting a significant hospital culture bias.)

    Education: self reported highest level.

    **If these are our expectations, how do they align with reality?

    Image: http://eldercareabcblog.com/wp-content/uploads/2009/08/elderlaw.jpg
  • We are taking “a value-laden medical decision” and “camouflaging as a depersonalized, hypothetical one.”

    **So what are the guidelines…?
  • So if you start with 10,000 code arrests  3000 will have CPR  1200 will have return of circulation  12 will live to d/c  3 will live to 5 years

    Another meta-analysis found that only 13% live to one month and 5% live to one year after CPR.

    The numbers depend upon how you stratify the patients and if you separate them by prognostic indicators (i.e. age).
  • 4-year multi-center prospective observational study
    2060 cardiac arrests>330survivors (16%)>101 completed two-phase interviews
    67% men, mean age 64yo; no other provided demographic information
    NDE (near-death experience): defined Greyson NDE Scale, validated 16-scale (0-3 Likert) with 7/32=NDE
  • Those with explicit recall: both with Vfib, in-hospital, non-acute settings; 1 too ill for f/u interview; 57yo man described watching from the corner ceiling and accurately described the people and interventions used during the code; attempts to more objectively validate this type of report were made in the study with the installation of 1000 shelves (single, varied picture on the top and triangle on bottom) across participating hospitals, but not OOB experiences happened in these rooms

    Image credit: http://th03.deviantart.net/fs71/PRE/i/2010/169/3/f/Dont_Walk_Towards_The_Light_by_InfektedAutumn.jpg
  • Additionally, CEJA recommends that you establish capacity first.

    As you can see, what we do (and what we have been taught to do) is only the middle part of this recommendation.

    I think this is partially vestigial, left over from the days when it was assumed that the admitting doc had already done the first part in the office; the third part fell off as the pendulum of medical care swung wildly away from paternalism and forgot that we should be paid to provide our opinions…
  • You may be asking yourself some questions:

    How do we establish this relationship, convey this information, control the ensuing emotion and reach a conclusion when we have 4 other admissions waiting?

    Can this conversation be postponed to allow time for a longitudinal relationship?

    How do I tell patients their prognosis??

    **Let’s break the conversation down by recommendation…
  • Amer J Medicine. Cardiopulmonary Resuscitation and Do-Not-Resuscitate Orders: A Guide for Clinicians

    Acknowledge most common fears: pain, suffering, indignity, abandonment, the unknown.

    Image: http://farm4.static.flickr.com/3221/2655264220_464b7d4115_o.jpg
  • Encourage the patient to discuss their desires with their MPOA (and choose an MPOA that will honor their wishes)!!!

    **So what about prognosis?

    Image: http://images03.olx.com/ui/10/50/03/1292455745_147094703_3-CPR-certification-Miami-Broward-NBRC-certification-reviews-Miami-Broward-Hialeah-1292455745.jpg
  • >51000 patients in 366 hospitals.
    13 pre-arrest variables
    It identified the likelihood of a good outcome as very low in 9.4%of patients (good outcome in 0.9%), low in 18.9%(good outcome in 1.7%), average in 54.0% (good outcome in 9.4%), and above average in 17.7%(good outcome in 27.5%). Overall, the score can identify more than one-quarter of patients as having a low or very low likelihood of survival to discharge, neurologically intact or with minimal deficits after IHCA (good outcome in 1.4%).
  • “We can revisit your decision at any time, it is not permanent.”

    **We cannot expect that this conversation will be the end. There are situations when it is appropriate to revisit the patient’s decision…

    Image: http://t2.gstatic.com/images?q=tbn:ANd9GcQysOoXVZEkDNnyffCm7XfXu3u09Y_vAVL67ybgrxks65Oa0BqZdw&t=1
  • Goals categories: cure, return to baseline, improve survival, improve function, relieve symptoms, allow natural death.

    Always linked to time-limited trial.
  • **Now let’s look at a couple of the questions that may come up during this conversation. If your patient asks for a partial order…

    Image: http://4.bp.blogspot.com/-6HOm5r2NStU/TVXO42k9UwI/AAAAAAAABcM/zsIlO-pDE7U/s1600/AAHPM+Palliative+Doctors.JPG
  • Additionally, CEJA recommends that you establish capacity first.

    As you can see, what we do (and what we have been taught to do) is only the middle part of this recommendation.

    I think this is partially vestigial, left over from the days when it was assumed that the admitting doc had already done the first part in the office; the third part fell off as the pendulum of medical care swung wildly away from paternalism and forgot that we should be paid to provide our opinions…
  • Think: DNR orders only apply when the patient is unresponsive and pulseless.

    Without a thorough discussion with the patient, you can rule out no specific pre-arrest intervention.

    It also differs from the standard practice in our hospital…

    Image: http://www.alleganpublicschools.org/allhs/curric/28-Time-Management.gif
  • Literature review (noted limited research into partial status).

    **If your patient says “you can put the tube down my throat, doc, but only if I’m going to live”…
  • “Futility” = medically non-beneficial treatment (UCSD MCP 531.1 definition " no realistic chance of returning the patient to a level of health that permits survival outside the acute care setting“)

    Invite other family members into the conversation and to have the patient describe his own understanding of his medical condition.

    Physician statement that CPR would not be medically appropriate. If no resolution, then Ethics assistance. Unilateral DNARs are controversial.

    Image: http://thebizcoachblog.com/wp-content/uploads/2011/01/The-4-Keys-To-Breaking-The-Online-%E2%80%9CDeath-Spin%E2%80%9D-Of-Marketing-Futility-dead-end.jpg
  • AND/DNR orders apply only when patients are unresponsive and pulseless.

    Elective cardioversion is not the same as cardioversion for cardiac arrest.

    Her change in clinical status provides an opportunity to clarify the patient’s care goals and to ask about a health care surrogate decision-maker.

    Image: http://drsvenkatesan.files.wordpress.com/2008/09/cepbasicspresentation_004-001.png
  • There are parallels between interventions used for CPR and those used by anaesthesia.

    Cardiopulmonary arrest in the operating room might be induced by anesthetics, and resuscitation generally has higher rates of success.

    It is appropriate to reconsider AND/DNR orders before operation.

    If the patient elects to suspend the AND/DNR then the specific time that it again takes effect should be documented.

    Image: http://www.freefoto.com/images/21/19/21_19_60---Road-Closed-and-Diversion-Signs_web.jpg?&k=Road+Closed+and+Diversion+Signs
  • Reality: survival is poor especially for those older and sicker.
    Positive: younger, healthier, angina before; Negative: older, sicker, CHF during
    Likelihood = 0%!
    Guidelines…

    Image: http://www.motifake.com/image/demotivational-poster/0907/objectives-strawberry-fields-of-flanders-demotivational-poster-1247846409.jpg
  • It is our job to align the ethical goals for CPR with those of our patients; to do so in a way that involves all of those whom the patient would like to involve in the conversation; to respect that wishes and goals change with time and medical burden and to not be afraid to provide our opinion when the time is right.
  • Caveat: on the whole, today’s discussion will be related to the code status as part of the hospital admission rather than in the office setting or the more general conversation regarding advanced directives.

    Talk about present process to change SJHMC language to AND.

    Image: http://4.bp.blogspot.com/_xUWGKWvCTb0/TNo-U5yKJ6I/AAAAAAAAAFk/nAVmBi6oSqU/s1600/2204241-3-black-and-white-tree-lake-hume.jpg (Accessed 1.29.11)
  • The "Code Status" Conversation

    1. 1. 1 The “Code Status” Conversation: Evidence and Guidelines Kyle P. Edmonds, MD Assistant Clinical Professor Doris A. Howell Palliative Care Service Director, SOMI 421, Subinternship in Palliative Medicine UC Health System
    2. 2. 2 Objectives • List one reality of CPR. • What are the guidelines for the code conversation? • Name a positive and negative prognostic factor for a patient status post CPR. • What was the likelihood of survival for patients with a “partial” code?
    3. 3. 3 • Elam, Safar & Gordon demonstrate CPR techniques in a surgical populationMid-1950s • AMA recommends documentation of code status1974 • First hospital policies drafted1976 • President’s Commission on Bioethics Guidelines (still standing)1983 • Patient Self Determination Act1990 • AMA CEJA Report on End-of-Life Decision Making (still standing)1991 Timeline
    4. 4. 4 “I need to ask you some questions that we ask all patients who are very sick. These questions are about CPR, or cardiopulmonary resuscitation. I need to know your preferences. “If your hearts stops beating, do you want us to use electrical shocks and chest compressions to try to get your heart beating again? Or if you stop breathing, do you want us to put a tube down your throat into your lungs and attach you to a breathing machine to help you breathe?” The usual Balaban, 2000.
    5. 5. 5 • Lack of empathy • No discussion of prognosis • Treats it as an “informed choice” conversation without offering all the information Inadequacies of the usual
    6. 6. 6 Variations on the usual • Do you frame CPR as “normal”? “Normally, if someone’s heart stops…” • Do you ever use “shock talk”? “We smash on your chest and break your ribs…stick a tube in your throat…”
    7. 7. 7 Patient FamilyProvider Rosow’s Decision matrix
    8. 8. 8 Patient Expectations • TV survival and discharge rate = 67%
    9. 9. 9 Patient Expectations • 37% did not want code status discussion • Less likely to want if: • Older • More functionally impaired • No partner • BUT: 5 times more likely if conversation perceived as relevant Heyland et al, 2006
    10. 10. 10 Patient Expectations: Meaning making Johnson et al., 2011.
    11. 11. 11 Provider Expectations • 27% eventually requiring CPR judged stable at admit • CPR conversation less likely to be documented on: • Direct admissions • Surgical admissions • Hospital transfers Mirza et al., 2005
    12. 12. 12 Provider expectations • More likely to have documented discussion: • Older • White • More educated • Residing in care facility • Hospitalized in last 12 months • Difficulties with ADLs/iADLs Auerbach et al, 2008
    13. 13. 13 “The experiences of our participants indicate that residents primarily adopt a model of informed choice in their discussions about life-sustaining treatment...in employing this approach, what may actually be a value-laden medical decision is camouflaged as a depersonalized, hypothetical...” – Deep et al, 2008
    14. 14. 14 …Provider Expectations: Informed Consent • “Mandatory Autonomy” • Pt Role: decide • Doc Role: • Provide info • Execute Decision
    15. 15. 15 Reality of CPR: By the Numbers Loertscher et al, 2010
    16. 16. 16 101 Participants No Memories (54%) Memories (46%) Memories, no NDE, no recall (33%) Memories, NDE, no recall (9%) Memories, NDE, Recall (2%) Reality of CPR: Conscious Awareness?... Parnia et al, 2014
    17. 17. 17 …Conscious Awareness? • Memories (46) • A bright light • Animals & plans • Déjà vu • Fear • Recalling post-code events • Seeing family • Violence / persecution • NDEs (9) • Explicit intra-code recall (2) Parnia et al, 2014
    18. 18. 18 Unchanged from 1983… • Begin with a discussion of prognosis and general values, goals and preferences; • Discuss CPR as an intervention including likelihood, risks, benefits and outcomes; check for comprehension; • Physician makes a recommendation consistent with the patient’s values and goals as discussed previously. • (For GME: Replication of discussion by attending if (1) DNR status or (2) high likelihood of patient requiring CPR) Guidelines
    19. 19. 19 “Discussions that do not include the recommended elements yield, at best, a decision for full code, the default without a discussion. At worst, brief discussions may reinforce misinformation about the effectiveness of CPR which may negatively impact future discussions.” –Anderson et al, 2010
    20. 20. 20 • Begin with a discussion of prognosis and general values, goals and preferences; • Discuss CPR as an intervention including likelihood, risks, benefits and outcomes; check for comprehension; • Physician makes a recommendation consistent with the patient’s values and goals as discussed previously. Guidelines
    21. 21. 21 Understand the Patient • Categorize : Low or high risk • Eliminate distractions • Patient comfort level • Who is this PERSON? • Patient’s understanding (Dx, Px) Adapted from: Loertscher et al, 2010
    22. 22. 22 • Begin with a discussion of prognosis and general values, goals and preferences; • Discuss CPR as an intervention including likelihood, risks, benefits and outcomes; check for comprehension; • Physician makes a recommendation consistent with the patient’s values and goals as discussed previously. Guidelines
    23. 23. 23 Provide context • Emphasize routineness • “If you were to die while here in the hospital…” • Describe CPR as a package Adapted from: Loertscher et al, 2010
    24. 24. 24 Provide Context: Prognosis… Favorable • Healthy baseline • Younger age • Witnessed arrest • Initial cardiac rhythm = VFib • CPR duration <10 minutes • Respiratory arrest (rather than cardiac) Poor • Age >70 • Sepsis • Metastatic cancer • ESLD or ESRD • GI Bleeding Adapted from Mirza et al, 2005 & Loertscher et al, 2010
    25. 25. 25 • Good Outcome Following Attempted Resuscitation →gofarcalc.com …Prognosis Ebell MA et al, 2013
    26. 26. 26 • Begin with a discussion of prognosis and general values, goals and preferences; • Discuss CPR as an intervention including likelihood, risks, benefits and outcomes; check for comprehension; • Physician makes a recommendation consistent with the patient’s values and goals as discussed previously. Guidelines
    27. 27. 27 Own Your Degree • Offer recommendation based on: • Condition (“medically appropriate”) • Goals/priorities • “We want to do anything we can to help you live longer and better, but CPR in our opinion would only hurt you, so I don’t recommend it.” • Clarify you will never abandon • Develop a plan based on the discussion Adapted from: Loertscher et al, 2010
    28. 28. 28 Goals of Care Hopes Fears Values A brief aside on “Goals of Care” Code Status Patient/Family Us
    29. 29. 29 Goals / Plan of Care Alive Code Status Dead When the Usual Doesn’t Work
    30. 30. 30 The fine print: Proof of the conversation • Document in GOALS OF CARE NOTE • Who was there? • Context • Patient/Family goals & values • Your medical recommendation & if you shared it • Outcome
    31. 31. 31 • Begin with a discussion of prognosis and general values, goals and preferences; • Discuss CPR as an intervention including likelihood, risks, benefits and outcomes; check for comprehension; • Physician makes a recommendation consistent with the patient’s values and goals as discussed previously. Guidelines
    32. 32. 32 The fine print: Pre-arrest management • Ethical recommendations on DNAR: • Should not preclude aggressive pre-arrest care • Should not preclude ICU care • May not preclude short term ventilator support
    33. 33. 33 The fine print: “partial” status • Overall survival to discharge: 15-23% • Survival for those with partial code status: 0% “Choosing to include or exclude one element of a larger combination of treatments may inadvertently prevent what otherwise would be a successful resuscitation.” Sanders et al, 2011
    34. 34. 34 Clinical Scenario one • 67 yoM with widely metastatic lung CA • Poor oral intake • Admission Dx: ARF • Wishes to remain full code Loertscher et al, 2008
    35. 35. 35 Clinical Scenario two • 82 yoF with DM and CKD who has a POLST listing DNAR status • p/w Afib with RVR • Elects for cardioversion • Is this okay? Do you rescind the DNAR? Loertscher et al, 2008
    36. 36. 36 Clinical scenario three • 73 yoF w/ metastatic colon CA in hospice w/ severe abd pain  LBO • Rec: palliative diverting colostomy • Wants to maintain DNAR during surgery • Surgical team wants DNAR suspended
    37. 37. 37 Conclusion When formulating your defensive strategies, keep in mind that the strawberry you’re so concerned about keeping is of absolutely no interest whatsoever to mittens.
    38. 38. 38 • Guidelines in establishing code status: • Discuss prognosis & goals of care • Discuss CPR as an intervention to revive • Provide your recommendation • (Document!) Conclusion
    39. 39. 39 The “Code Status” Conversation: Evidence and Guidelines Kyle P. Edmonds, MD SOMI 421, Subinternship in Palliative Medicine kpedmonds@ucsd.edu
    40. 40. 40 • Anderson, Wendy G., Rebecca Chase, Steven Z. Pantilat, James A. Tulsky, and Andrew D. Auerbach. "Code Status Discussions between Attending Hospitalist Physicians and Medical Patients at Hospital Admission." Journal of General Internal Medicine (2010): 1-8. Web. 10 Jan. 2011. <springerlink.com>. • Auerbach AD, Katz R, Pantilat SZ, et al. Factors associated with discussion of care plans and code status at the time of hospital admission: results from the Multicenter Hospitalist Study. J Hosp Med. 2008;3(6):437–45. • Back, A. L., R. M. Arnold, W. F. Baile, K. A. Fryer-Edwards, S. C. Alexander, G. E. Barley, T. A. Gooley, and J. A. Tulsky. "Efficacy of Communication Skills Training for Giving Bad News and Discussing Transitions to Palliative Care." Archives of Internal Medicine 167.5 (2007): 453-60. Print. • Balaban, Richard B. "A Physician's Guide to Talking about End-of-life Care." Journal of General Internal Medicine 15 (2000): 195-200. Print. • Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987). A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis, 40(5): 373-383. References
    41. 41. 41 • Cotter, P. E., M. Simon, and S. T. O'Keeffe. "Changing Attitudes to Cardiopulmonary Resuscitation in Older People: A 15-year Follow-up Study." Age and Ageing 38 (2009): 200-05. Print. • Council on Ethical and Judicial Affairs, American Medical Association: Guidelines for the appropriate use of do-not-resuscitate orders. JAMA 1991; 265:1868–1871. • De Vos, Rien, Rudolph W. Koster, Rob J. De Haan, Hans Oosting, Poll A. Van Der Wouw, and Angela J. Lampe-Schoenmaeckers. "In-hospital Cardiopulmonary Resuscitation: Pre-arrest Morbidity and Outcome." Archives of Internal Medicine 159 (1999): 845-50. Print. • Deep, Kristy S., Charles H. Griffith, and John F. Wilson. "Communication and Decision Making about Life-sustaining Treatment: Examining the Experiences of Resident Physicians and Seriously-ill Hospitalized Patients." Journal of General Internal Medicine 23.11 (2008): 1877-882. Print. • Ebell MA et al, Development and Validation of the Good Outcome Following Attempted Resuscitation (GO-FAR) Score to Predict Neurologically Intact Survival After In-Hospital Cardiopulmonary Resuscitation JAMA Internal Medicine November 11, 2013 Volume 173, Number 20 • Ebell MH, Kruse JA: A proposed model for the cost of cardiopulmonary resuscitation. Med Care. 1994; 32(6): 640-649. • Heyland, D. K., Chris Frank, Dianne Groll, Deb Pinchora, Peter Dodek, Graeme Rocker, and Amiram Gafni. "Understanding Cardiopulmonary Resuscitation Decision Making: Perspectives of Seriously Ill Hospitalized Patients and Family Members." Chest 130.2 (2006): 419-28. Web. 10 Jan. 2011. <http://chestjournal.chestpubs.org/content/130/2/419.full.html>. References
    42. 42. 42 • Kass-Bartelmes BL, Hughes R, Rutherford MK. Advance care planning: preferences for care at the end of life. Rockville (MD): Agency for Healthcare Research and Quality; 2003. Research in Action Issue #12. AHRQ Pub No. 03-0018. • Loertscher, Laura, Darcy A. Reed, Michael P. Bannon, and Paul S. Mueller. "Cardiopulmonary Resuscitation and Do-no-resuscitate Orders: A Guide for Clinicians." American Journal of Medicine 123 (2010): 4-9. Print. • Mirza A, Kad R, Ellison NM. Cardiopulmonary resuscitation is not addressed in the admitting medical records for the majority of patients who undergo CPR in the hospital. Am J Hosp Palliat Care. 2005;22(1):20–5. • Morrison, Laurie J., Gerald Kierzek, Douglas S. Diekema, Michael R. Sayre, Scott M. Silvers, Ahamed H. Idris, and Mary E. Mancini. "Part 3: Ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care."Circulation 122 (suppl 3) (2010): S665-675. Web. 10 Jan. 2011. <circ.ahajournals.org>. • Parnia S, Spearpoint K et al. (2014). AWARE-AWAreness during Resuscitation: A prospective study. Resuscitation. ePub ahead of print. • Prigerson HG. Socialization to dying: social determinants of death acknowledgement and treatment among terminally ill geriatric patients. J Health Soc Behav. 1992;33(4):378–95 References
    43. 43. 43 • Sanders, Alan, Melissa Schepp, and Marianne Baird. "Partial Do-not- resuscitate Orders: a Hazard to Patient Safety and Clinical Outcomes?" Critical Care Medicine 39.1 (2011): 14-18. Print. • Smith, Alexander K., Angela P. Ries, Baohui Zhang, James A. Tulsky, Holly G. Prigerson, and Susan D. Block. "Resident Approaches to Advance Care Planning on the Day of Hospital Admission." Archives of Internal Medicine 166.15 (2006): 1597-602. Print. References

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