Ethical dilemmas in end-of-life care US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Ethical dilemmas in end-of-life care. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Ethical dilemmas in end-of-life care US Medical PG Question 1: A 29-year-old man is admitted to the emergency department following a motorcycle accident. The patient is severely injured and requires life support after splenectomy and evacuation of a subdural hematoma. Past medical history is unremarkable. The patient’s family members, including wife, parents, siblings, and grandparents, are informed about the patient’s condition. The patient has no living will and there is no durable power of attorney. The patient must be put in an induced coma for an undetermined period of time. Which of the following is responsible for making medical decisions for the incapacitated patient?
- A. The spouse (Correct Answer)
- B. An older sibling
- C. Physician
- D. Legal guardian
- E. The parents
Ethical dilemmas in end-of-life care Explanation: ***The spouse***
- In the absence of a **living will** or **durable power of attorney**, the law typically designates the **spouse** as the primary decision-maker for an incapacitated patient.
- This hierarchy is established to ensure decisions are made by the individual most intimately connected and presumed to understand the patient's wishes.
*An older sibling*
- Siblings are generally further down the **hierarchy of surrogate decision-makers** than a spouse or parents.
- They would typically only be considered if higher-priority family members are unavailable or unwilling to make decisions.
*Physician*
- The physician's role is to provide medical care and guidance, not to make medical decisions for an incapacitated patient when family surrogates are available.
- Physicians only make decisions in **emergency situations** when no surrogate is immediately available and treatment is immediately necessary to save the patient's life or prevent serious harm.
*Legal guardian*
- A legal guardian is usually appointed by a **court** when there is no appropriate family member available or when there is a dispute among family members.
- In this scenario, with a spouse and other close family members present, a legal guardian would not be the first choice.
*The parents*
- While parents are close family members, they are typically considered **secondary to the spouse** in the hierarchy of surrogate decision-makers for an adult patient.
- They would usually only be the decision-makers if the patient were unmarried or the spouse were unavailable.
Ethical dilemmas in end-of-life care US Medical PG Question 2: A 52-year-old man with stage IV melanoma comes to the physician with his wife for a routine follow-up examination. He was recently diagnosed with new bone and brain metastases despite receiving aggressive chemotherapy but has not disclosed this to his wife. He has given verbal consent to discuss his prognosis with his wife and asks the doctor to inform her of his condition because he does not wish to do so himself. She is tearful and has many questions about his condition. Which of the following would be the most appropriate statement by the physician to begin the interview with the patient's wife?
- A. Have you discussed a living will or goals of care together?
- B. We should talk about how we can manage his symptoms with additional chemotherapy.
- C. Why do you think your husband has not discussed his medical condition with you?
- D. What is your understanding of your husband's current condition? (Correct Answer)
- E. Your husband has end-stage cancer, and his prognosis is poor.
Ethical dilemmas in end-of-life care Explanation: ***What is your understanding of your husband's current condition?***
- This statement initiates the conversation by **assessing the wife's current knowledge** and emotional state, which is crucial for delivering sensitive and appropriate information.
- It allows the physician to tailor the discussion to her specific understanding and concerns, ensuring that information is delivered compassionately and effectively.
*Have you discussed a living will or goals of care together?*
- This question is too abrupt and **premature** as an opening, as the wife is clearly distressed and unaware of the full severity of her husband's condition.
- Discussions about end-of-life planning should only occur after the patient's wife has a clear understanding of the diagnosis and prognosis, and has processed this information.
*Your husband has end-stage cancer, and his prognosis is poor.*
- While factual, this statement is **too blunt and lacks empathy** for an opening, especially given the wife's emotional state and lack of prior knowledge.
- Delivering such devastating news directly without first assessing her understanding or providing context can be traumatic and impede effective communication.
*We should talk about how we can manage his symptoms with additional chemotherapy.*
- This statement implies a focus on further aggressive treatment which may not be appropriate given the **new bone and brain metastases** and aggressive prior chemotherapy, suggesting a limited benefit of more chemotherapy.
- It also **diverts from the primary need to discuss the overall prognosis** and the patient's rapidly declining condition, which the doctor has been asked to convey.
*Why do you think your husband has not discussed his medical condition with you?*
- This question is **accusatory** and places blame on either the patient or the wife, which is inappropriate and unhelpful in a sensitive medical discussion.
- It shifts the focus away from providing medical information and empathy towards a speculative and potentially confrontational topic.
Ethical dilemmas in end-of-life care US Medical PG Question 3: An 85-year-old man with terminal stage colon cancer formally designates his best friend as his medical durable power of attorney. After several courses of chemotherapy and surgical intervention, the patient’s condition does not improve, and he soon develops respiratory failure. He is then placed on a ventilator in a comatose condition. His friend with the medical power of attorney tells the care provider that the patient would not want to be on life support. The patient’s daughter disputes this and says that her father needs to keep receiving care, in case there should be any possibility of recovery. Additionally, there is a copy of the patient’s living will in the medical record which states that, if necessary, he should be placed on life support until full recovery. Which of the following is the most appropriate course of action?
- A. Withdraw the life support since the patient’s chances of recovery are very low
- B. Contact other family members to get their input for the patient
- C. Act according to the patient’s living will
- D. The durable medical power of attorney’s decision should be followed. (Correct Answer)
- E. Follow the daughter’s decision for the patient
Ethical dilemmas in end-of-life care Explanation: ***The durable medical power of attorney's decision should be followed***
- The patient designated his friend as his **durable power of attorney for healthcare (DPOA)**, giving him legal authority to make medical decisions when the patient cannot communicate.
- While the living will states life support "until full recovery," the patient has **terminal stage colon cancer** - full recovery is **medically impossible**. The living will's condition cannot be fulfilled.
- When advance directive language is ambiguous or cannot be applied to actual clinical circumstances, the **DPOA's interpretive authority** is essential. The DPOA is expected to apply the patient's values to the real situation.
- The DPOA states the patient would not want to be on life support - this reflects the patient's **values and wishes** as understood by his chosen decision-maker, applied to the actual terminal situation.
- This honors both **patient autonomy** (through his chosen proxy) and the reality that advance directives cannot anticipate every clinical scenario.
*Act according to the patient's living will*
- While a living will expresses patient wishes, it states life support should continue "**until full recovery**" - but the patient has terminal cancer with no possibility of recovery.
- Literal adherence to an advance directive whose conditions are **medically impossible** does not serve the patient's true interests or autonomy.
- Living wills and DPOAs work **together** - the DPOA interprets and applies the living will to actual circumstances, especially when literal application is impossible or the situation wasn't anticipated.
*Withdraw the life support since the patient's chances of recovery are very low*
- While this may align with the DPOA's interpretation of the patient's wishes, unilateral physician decision-making without following the proper **decision-making hierarchy** is inappropriate.
- The physician should work **with the DPOA** rather than make independent decisions about life support withdrawal.
*Contact other family members to get their input for the patient*
- The patient **legally designated** his friend as DPOA, indicating his trust in this person's judgment over family members.
- While family input can be valuable, seeking additional opinions when there is a **legally appointed decision-maker** undermines the patient's explicit choice.
- The daughter has no legal standing to override the DPOA's decisions.
*Follow the daughter's decision for the patient*
- The daughter was **not designated** as the healthcare decision-maker; the friend was explicitly chosen as DPOA.
- Following the daughter's wishes would **violate** the patient's autonomous choice of decision-maker.
- Family relationship alone does not override a formal DPOA designation.
Ethical dilemmas in end-of-life care US Medical PG Question 4: A 68-year-old woman was recently diagnosed with pancreatic cancer. At what point should her physician initiate a discussion with her regarding advance directive planning?
- A. Once she enters hospice
- B. Now that she is ill, speaking about advance directives is no longer an option
- C. Only if her curative surgical and medical treatment fails
- D. Only if she initiates the conversation
- E. At this visit (Correct Answer)
Ethical dilemmas in end-of-life care Explanation: ***At this visit***
- Advance care planning should ideally be initiated as soon as a **serious illness** like pancreatic cancer is diagnosed, while the patient still has the capacity to make informed decisions.
- This allows the patient to clearly state their **wishes** for future medical care and designate a **surrogate decision-maker**.
*Once she enters hospice*
- Delaying discussions until hospice care often means the patient's condition has significantly deteriorated, potentially impacting their ability to actively participate in **decision-making**.
- While advance directives are crucial for hospice patients, starting earlier ensures their preferences guide all stages of their care, not just the end-of-life phase.
*Now that she is ill, speaking about advance directives is no longer an option*
- This statement is incorrect as illness is often the **catalyst** for initiating advance care planning, not a barrier.
- Patients often appreciate the opportunity to discuss their wishes, especially when facing a serious diagnosis, to maintain a sense of **control** and ensure their autonomy.
*Only if her curative surgical and medical treatment fails*
- Waiting until treatment failure is too late as the patient's condition may have worsened to a point where they are no longer able to engage in **meaningful discussions** or have decreased mental capacity.
- Advance care planning is about preparing for potential future scenarios, not just reacting to immediate failures; it provides a framework for care regardless of **treatment outcomes**.
*Only if she initiates the conversation*
- While patient initiation is ideal, it is the physician's responsibility to bring up these important discussions, especially with a new diagnosis of a serious illness like **pancreatic cancer**.
- Many patients may not know about advance directives or feel comfortable initiating such a sensitive conversation, so the physician should proactively offer the **opportunity**.
Ethical dilemmas in end-of-life care US Medical PG Question 5: A 72-year-old woman is brought to the emergency department by ambulance after an unexpected fall at home 1 hour ago. She was resuscitated at the scene by paramedics before being transferred to the hospital. She has a history of ischemic heart disease and type 2 diabetes mellitus. She has not taken any sedative medications. Her GCS is 6. She is connected to a mechanical ventilator. Her medical records show that she signed a living will 5 years ago, which indicates her refusal to receive any type of cardiopulmonary resuscitation, intubation, or maintenance of life support on mechanical ventilation. Her son, who has a durable power-of-attorney for her healthcare decisions, objects to the discontinuation of mechanical ventilation and wishes that his mother be kept alive without suffering in the chance that she might recover. Which of the following is the most appropriate response to her son regarding his wishes for his mother?
- A. “We will take every measure necessary to prolong her life.”
- B. “She may be eligible for hospice care.”
- C. “The opinion of her primary care physician must be obtained regarding further steps in management.”
- D. “Based on her wishes, mechanical ventilation must be discontinued.” (Correct Answer)
- E. “Further management decisions will be referred to the hospital’s ethics committee.”
Ethical dilemmas in end-of-life care Explanation: ***Based on her wishes, mechanical ventilation must be discontinued.***
- A **living will** is a legally binding document that outlines a patient's wishes regarding medical treatment, including **refusal of life support**.
- In this scenario, the patient’s clear and documented wishes in her living will take precedence over the son's objections, even though he holds **durable power of attorney for healthcare** (DPA).
*“We will take every measure necessary to prolong her life.”*
- This statement directly contradicts the patient's **documented wishes** in her living will to refuse intubation and maintenance on mechanical ventilation.
- Ignoring a patient's advance directive can lead to ethical and legal issues, as it undermines the principle of **patient autonomy**.
*“She may be eligible for hospice care.”*
- While hospice care is a relevant consideration for patients with terminal illnesses, suggesting it prematurely without addressing the immediate issue of the **living will** can be dismissive of the patient's explicit directives.
- The primary concern is upholding the patient's autonomy, which includes addressing her advance directive regarding **withdrawal of life support**.
*“The opinion of her primary care physician must be obtained regarding further steps in management.”*
- While the **primary care physician's** input is valuable for understanding the patient's overall health and discussing goals of care, the existence of a clear and legally binding **living will** simplifies the decision-making process concerning life support.
- The patient's advance directive is paramount and generally does not require further medical negotiation unless there's ambiguity or new information suggesting a change in her wishes.
*“Further management decisions will be referred to the hospital’s ethics committee.”*
- An **ethics committee** consultation may be appropriate in cases of ambiguity surrounding an advance directive, conflict among surrogates, or uncertainty about the patient's capacity at the time of signing the directive.
- However, in this case, the **living will** explicitly states her wishes regarding mechanical ventilation, making the patient's intent clear and generally overriding the need for an ethics committee in the initial response.
Ethical dilemmas in end-of-life care US Medical PG Question 6: A 69-year-old woman with acute myeloid leukemia comes to the physician to discuss future treatment plans. She expresses interest in learning more about an experimental therapy being offered for her condition. After the physician explains the mechanism of the drug and describes the risks and benefits, the patient then states that she is not ready to die. When the physician asks her what her understanding of the therapy is, she responds "I don't remember the details, but I just know that I definitely want to try it, because I don't want to die." Which of the following ethical principles is compromised in this physician's interaction with the patient?
- A. Patient competence
- B. Patient autonomy
- C. Decision-making capacity (Correct Answer)
- D. Information disclosure
- E. Therapeutic privilege
Ethical dilemmas in end-of-life care Explanation: ***Decision-making capacity***
- This refers to a patient's ability to **understand information relevant to a medical decision**, appreciate their situation, reason through options, and communicate a choice. The patient's statement indicates a lack of understanding of the details of the complex treatment, despite being explained.
- While she expresses a choice, her inability to recall details suggests she cannot adequately **weigh risks and benefits**, which is central to capacity.
*Patient competence*
- **Competence is a legal determination** made by a court, not by a physician in a clinical setting.
- Physicians assess **decision-making capacity**, which is a clinical judgment, whereas legal competence has broader implications.
*Patient autonomy*
- **Autonomy is the right of a patient to make their own choices** about their medical care. While the patient is attempting to exercise a choice, the issue here is whether she is able to make an adequately informed choice.
- For autonomy to be truly upheld, the patient must have the **capacity to make an informed decision**, which is compromised by her stated lack of understanding.
*Information disclosure*
- The physician *did* disclose information about the drug's mechanism, risks, and benefits, indicating that the act of disclosure itself was performed.
- The problem is not that information was withheld, but that the patient **did not retain or understand the disclosed information** sufficiently.
*Therapeutic privilege*
- **Therapeutic privilege** is when a physician withholds information from a patient if they believe the disclosure would cause significant harm.
- In this scenario, the physician *did* explain the treatment, so information was not withheld under privilege.
Ethical dilemmas in end-of-life care US Medical PG Question 7: A 28-year-old woman is brought to the emergency department after being resuscitated in the field. Her husband is with her and recalls seeing pills beside her when he was in the bathroom. He reveals she has a past medical history of depression and was recently given a prescription for smoking cessation. On physical exam, you notice a right-sided scalp hematoma and a deep laceration to her tongue. She has a poor EEG waveform indicating limited to no cerebral blood flow and failed both her apnea test and reflexes. She is found to be in a persistent vegetative state, and the health care team starts to initiate the end of life discussion. The husband states that the patient had no advance directives other than to have told her husband she did not want to be kept alive with machines. The parents want all heroic measures to be taken. Which of the following is the most accurate statement with regards to this situation?
- A. The physician may be appointed as the patient’s health care surrogate and may make end-of-life decisions on her behalf.
- B. The patient’s parents may be appointed as her health care surrogate and may make end-of-life decisions on her behalf.
- C. The patient’s husband may be appointed as her health care surrogate and may make end-of-life decisions on her behalf. (Correct Answer)
- D. An ethics committee must be appointed as the patient’s health care surrogate and may make end-of-life decisions on her behalf.
- E. A court-appointed guardian may be appointed as the patient's health care surrogate and may make end-of-life decisions on her behalf.
Ethical dilemmas in end-of-life care Explanation: ***The patient’s husband may be appointed as her health care surrogate and may make end-of-life decisions on her behalf.***
- The **hierarchy for healthcare surrogates** typically prioritizes the spouse over parents when there is no advance directive. The husband's recollection of the patient's wishes, although not a formal advance directive, is also relevant.
- State laws generally designate the **spouse as the primary default decision-maker** for incapacitated patients, followed by adult children, parents, and then adult siblings.
*The physician may be appointed as the patient’s health care surrogate and may make end-of-life decisions on her behalf.*
- A physician's role is to provide medical care and guidance, not to act as a **healthcare surrogate** due to potential conflicts of interest.
- Appointing the treating physician as a surrogate undermines the principles of **patient autonomy** and impartial decision-making.
*The patient’s parents may be appointed as her health care surrogate and may make end-of-life decisions on her behalf.*
- While parents are part of the surrogate hierarchy, they are generally ranked below the **spouse** in most jurisdictions.
- The parents' desire for "heroic measures" directly conflicts with the patient's stated wish to her husband, potentially leading to decisions not in the patient's best interest or previously expressed values.
*An ethics committee must be appointed as the patient’s health care surrogate and may make end-of-life decisions on her behalf.*
- An ethics committee's role is to provide **guidance and recommendations** in complex cases, mediate disputes, and ensure ethical principles are upheld, not to act as the primary healthcare surrogate.
- A functional healthcare surrogate takes precedence over an ethics committee in making direct treatment decisions.
*A court-appointed guardian may be appointed as the patient's health care surrogate and may make end-of-life decisions on her behalf.*
- A court-appointed guardian is typically sought only if there is **no clear or willing surrogate** from the established hierarchy, or if there is a dispute among family members that cannot be resolved.
- In this scenario, the husband is the legally recognized next of kin and surrogate by default, making court intervention unnecessary at this stage.
Ethical dilemmas in end-of-life care US Medical PG Question 8: A 23-year-old woman presents to the emergency department with acute alcohol intoxication. Her blood alcohol level is 280 mg/dL. She becomes increasingly agitated and attempts to leave against medical advice. Which of the following determines her capacity to refuse treatment?
- A. Age of the patient
- B. Family's wishes
- C. Blood alcohol level
- D. Understanding of risks and benefits (Correct Answer)
Ethical dilemmas in end-of-life care Explanation: ***Understanding of risks and benefits***
- A patient's capacity to refuse treatment is primarily determined by their **ability to understand the nature of their condition**, the proposed treatment, and the **potential risks and benefits** of both accepting and refusing treatment.
- Even with intoxication, if a patient can demonstrate this understanding, they technically have the capacity to make decisions, though the intoxication itself often impairs this ability.
- Capacity assessment includes four key elements: understanding information, appreciating how it applies to their situation, reasoning through options, and communicating a choice.
*Age of the patient*
- While age is a factor in pediatric care (requiring parental consent for minors), for adults, it does not solely determine capacity; an adult of any age can be deemed to lack capacity for various reasons.
- The patient's age (23 years old) indicates she is legally an adult, but it does not automatically confer or deny treatment capacity, which is assessed based on mental status.
*Family's wishes*
- Family wishes are important for patients who **lack decision-making capacity** and have no advance directives, but they do not override the decisions of a fully capacitated patient.
- In situations where capacity is questionable, family input might be considered, but the direct assessment of the patient's understanding remains paramount.
*Blood alcohol level*
- A high blood alcohol level strongly suggests impaired judgment and cognitive function, making it a red flag for potential lack of capacity, but it is not a direct measure of capacity itself.
- Some individuals may maintain a degree of understanding even with high levels, so a direct assessment of their comprehension is still necessary, not just assuming based on the level alone.
Ethical dilemmas in end-of-life care US Medical PG Question 9: A 76-year-old woman is brought to the physician by her daughter for evaluation of progressive cognitive decline and a 1-year history of incontinence. She was diagnosed with dementia, Alzheimer type, 5 years ago. The daughter has noticed that in the past 2 years, her mother has had increasing word-finding difficulties and forgetfulness. She was previously independent but now lives with her daughter and requires assistance with all activities of daily living. Over the past year, she has had decreased appetite, poor oral intake, and sometimes regurgitates her food. During this time, she has had a 12-kg (26-lb) weight loss. She was treated twice for aspiration pneumonia and now her diet mainly consists of pureed food. She has no advance directives and her daughter says that when her mother was independent the patient mentioned that she would not want any resuscitation or life-sustaining measures if the need arose. The daughter wants to continue taking care of her mother but is concerned about her ability to do so. The patient has hypertension and hyperlipidemia. Current medications include amlodipine and atorvastatin. Vital signs are within normal limits. She appears malnourished but is well-groomed. The patient is oriented to self and recognizes her daughter by name, but she is unaware of the place or year. Mini-Mental State Examination score is 17/30. Physical and neurologic examinations show no other abnormalities. A complete blood count and serum concentrations of creatinine, urea nitrogen, TSH, and vitamin B12 levels are within the reference range. Her serum albumin is 3 g/dL. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?
- A. Prescribe oxycodone
- B. Short-term rehabilitation
- C. Home hospice care (Correct Answer)
- D. Inpatient palliative care
- E. Evaluation for alternative methods of feeding
Ethical dilemmas in end-of-life care Explanation: ***Home hospice care***
- This patient exhibits advanced **dementia** with significant decline in function, frequent aspiration events, and substantial **weight loss**, indicating a prognosis of less than six months. **Hospice care** focuses on comfort and dignity during the end-of-life stage.
- The daughter's recollection of the patient's wishes to avoid life-sustaining measures, combined with the current medical complexity and poor prognosis, supports the transition to **hospice services** to manage symptoms and provide support to both the patient and family.
*Prescribe oxycodone*
- There is no mention of pain in the patient’s presentation; therefore, prescribing an **opioid** like oxycodone is not indicated and could cause adverse effects such as **sedation** and **constipation**, which would further complicate her care.
- While patients with advanced dementia may experience pain, it must be assessed and confirmed before prescribing **analgesics**.
*Short-term rehabilitation*
- Given the patient's advanced dementia, severe functional decline, recurrent aspiration pneumonia, and malnourishment, **short-term rehabilitation** to improve functional status is unlikely to be effective.
- The patient's underlying condition is progressive and irreversible, making restoration of independent function an unrealistic goal.
*Inpatient palliative care*
- While **palliative care** focuses on symptom management and quality of life, **inpatient palliative care** is typically reserved for patients with severe symptoms requiring constant medical attention that cannot be managed at home.
- In this case, the patient's symptoms, while serious, appear amenable to management in a home setting with the comprehensive support offered by **hospice**.
*Evaluation for alternative methods of feeding*
- In advanced dementia, **percutaneous endoscopic gastrostomy (PEG) tube feeding** does not improve survival, reduce aspiration risk, or enhance quality of life.
- Given the patient's advanced stage of disease and the recalled wishes to avoid life-sustaining measures, initiating **artificial feeding** would be contrary to comfort-focused care.
Ethical dilemmas in end-of-life care US Medical PG Question 10: Last night you admitted a 72-year-old woman with severe COPD in respiratory distress. She is currently intubated and sedated and her family is at bedside. At the completion of morning rounds, the patient's adult son asks that you and the team take a minute to pray with him for his mother. What is the most appropriate response?
- A. "I understand what you are experiencing and am happy to take a minute." (Correct Answer)
- B. "I'm sorry, but this is a public hospital, so we cannot allow any group prayers."
- C. "I don't feel comfortable praying for patients, but I will happily refer you to pastoral care."
- D. "While I cannot offer you my prayers, I will work very hard to take care of your mother."
- E. "I also believe in the power of prayer, so I will pray with you and insist that the rest of team joins us."
Ethical dilemmas in end-of-life care Explanation: ***"I understand what you are experiencing and am happy to take a minute."***
- This response demonstrates **empathy** and **compassion**, acknowledging the family's emotional and spiritual needs during a difficult time.
- Participating in a brief prayer when invited by a patient's family, if comfortable, can build **trust** and strengthen the **patient-provider relationship**, showing respect for their beliefs.
*"I'm sorry, but this is a public hospital, so we cannot allow any group prayers."*
- This statement is **factually incorrect**; public hospitals generally permit and often support patients' and families' religious practices.
- It would be perceived as **insensitive** and disrespectful of the family's spiritual needs, potentially damaging the relationship.
*"I don't feel comfortable praying for patients, but I will happily refer you to pastoral care."*
- While referring to **pastoral care** is a good option when one is uncomfortable praying, directly refusing a simple, shared moment of prayer can still feel dismissive to a distressed family.
- The direct refusal, even with a follow-up referral, might not fully address the immediate emotional and spiritual support the family is seeking from the care team.
*"While I cannot offer you my prayers, I will work very hard to take care of your mother."*
- This response, while affirming commitment to medical care, explicitly denies the family's request for a shared moment of prayer, which can be perceived as **unempathetic** or cold.
- It prioritizes medical intervention over the holistic, spiritual needs of the family, potentially creating a distance in the provider-family relationship.
*"I also believe in the power of prayer, so I will pray with you and insist that the rest of team joins us."*
- While participating is appropriate, **insisting** that the entire team join can be coercive and infringe on the individual team members' **religious freedom** or comfort levels.
- Making assumptions about the entire team's beliefs and forcing participation is unprofessional and can lead to discomfort or resentment among staff.
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