Terminal Stages Of Illness Research Articles

Unitary caring: Marlaine Smith’s new theory

The notion of care has been prominently emphasized in nursing literature and has been posited as the fundamental core of nursing by renowned nursing scholars like Leininger, Watson, Rogers, Newman, and others [1]. The concept of care serves as a pivotal element within the discipline of nursing, setting it apart from other healthcare professions. Nonetheless, certain experts argue that care isn't exclusive to nursing but represents a fundamental pillar across various health disciplines, underpinning the ethos and principles of numerous healthcare institutions and organizations [2]. Care is delineated as the cornerstone of nursing, intricately linked with the four metaparadigm concepts of the field. This central position of care in nursing has prompted the formulation of several care theories [3]. Among these theories are Smith's unitary care theory, which draws its foundational assumptions from Rogers' science of unitary humans, Newman's theory of health as expanding consciousness, and Watson's transpersonal care theory [4]. Marilyn Smith's unit care theory encapsulates several core concepts: 1) Manifesting Intentions: Before administering nursing care, the nurse is urged to ascertain and prioritize intentions, striving to actualize them. This intentional focus aims to foster a healing environment through the nurse's authentic presence at the patient's bedside during unit care. 2) Appreciating Pattern: Recognizing the interconnected and distinctive nature of human field patterns, which interplay with environmental fields, reveals insights into illness, unwellness, and emotions. Nurses are encouraged to consciously identify these patterns during unit care, collaborating with patients to devise effective care strategies based on observed patterns. 3) Attuning to Dynamic Flow: Nurses are advised to attune themselves to the patient's vibrational frequency during unit care. This entails discerning appropriate moments for silence, smiles, dialogue, or physical contact, emphasizing the nurse's genuine presence in each interaction. Nurses are encouraged to hone these skills through sensory perception, attentive listening, genuine presence, concentration, and intuition. 4) Experiencing the Infinite: Establishing a profound, transcendent relationship between nurse and patient beyond physical constraints, akin to a spiritual connection, is advocated during unit care. Within this caring context, healing miracles may manifest, furthered by spiritual practices such as prayer or meditation. 5) Inviting Creative Emergence: Nurses are tasked with creating a nurturing space that encourages the emergence of innovative, novel patterns by supporting, educating, and instilling confidence in patients. This fosters spiritual growth and inner peace. For instance, encouraging patients to document their concerns as a means of emotional regulation [3]. Overall, the unit care theory predominantly focuses on abstract mental and spiritual facets of patient care, necessitating the nurse's physical presence at the bedside. This approach holds potential applicability across diverse patient populations and age groups [5], particularly benefiting those in terminal stages of illness, experiencing depression, anxiety, or requiring palliative care [6]. However, patients who do not align with spiritual beliefs may encounter limitations with this theory. To illuminate the theory's positive outcomes, it is recommended that researchers and nurses incorporate it into their investigative endeavors.

Between Life and Death: How do Muslim Terminal Patients in Pakistan cope with Hepatitis C utilizing their Beliefs and Social Support?

Life-threatening events including terminal illness intensify the search for meaning and incite individuals to get closer to religion. Terminal patients canoften findreligious practices as helpful as medical therapy for bettering both physical and mental health. The present research aims to explain the interaction between religion, spirituality, and social support in coping with terminal illness among Muslim hepatitis C patients in Pakistan. A semi-structured open-ended interview guide was utilized to collect the data. Participants expressed that the deployment of religious and spiritual beliefs along with socio-emotional support during illness fostered medical therapy. Participants also revealed that belief in God provided them the strength to be steadfast during the terminal stage of the disease. Religious beliefs enabled terminal participants to accept death as an eventual reality and a normal part of their lives. Furthermore, participants put forward their longing for those kinds of religious practices that terminal diseases usually restrained them from receiving.The emotional support stemming from social relationships also improved resilience to cope with the terminal stage of illness. The study concludes that the interplay of religion, spirituality, and social support normalizes the fear of death, lessens pain, and improves resilience among Muslim hepatitis C patients in Pakistan.

Syrian Health Providers' Knowledge of Palliative Care: An Online Cross‑Sectional Study in Syria

Background: Palliative care is a method to alleviate pain and enhance the quality of life for patients suffering from the consequences of a life-threatening illness. The knowledge of palliative care among healthcare professionals is poor; therefore, training programs are needed to offer patients appropriate treatment and improve their health. In Syria, as palliative care programs are rarely applied, we aim to evaluate the knowledge regarding palliative care among healthcare workers.
 
 Methods: This is an online cross-sectional study conducted between July 24 and August 28, 2022 to measure palliative care knowledge and its applications among Syrian healthcare workers. The questionnaire for the study was designed in light of a previous study, and the inclusion criteria were Syrian healthcare workers, including physicians and nurses, as well as medical and nursing students. The four sections of the questionnaire included sociodemographic information in the first part, while the second, third, and fourth parts assessed experience, knowledge, and attitude toward palliative care among healthcare workers, respectively. Data were analyzed in IBM SPSS V. 28.0 using descriptive and multivariate logistic regression analysis.
 
 Results: Among 602 participants, 66.2% of participants were females. Most respondents were medical students (72.9%), while residents and nurses or nursing students represented 18.8% and 8.3%, respectively. The majority of participants (84%) answered the question about pain treatment goals correctly, while a small percentage (5.3%) answered the question about whether or not long-term opioid use is addictive correctly. No significant difference in the overall knowledge score was shown among geographical areas, genders, and different specialties. Regarding the knowledge questions related to palliative care, only 14 participants were considered knowledgeable. The three most responses that received agreement regarding the attitudes towards palliative care were “Pain relievers should be given as needed to terminally ill patients” (89.7%), “Spiritual care must include counseling for the terminally ill patient” (84.3%), “Patients have the right to determine their own degree of psychosocial intervention” (81%). A significant difference existed between urban and rural residents in terms of the attitude score. When comparing first-year students to those in their fifth year, students in their fifth year were 8.06 times more likely to have a positive attitude. 
 
 Conclusions: Our results demonstrated that healthcare professionals have inadequate knowledge about palliative care. There is an urgent need to introduce palliative care to the health system in Syria in order to improve the quality of life of these patients in their terminal stages of illness and to provide care for patients who need it.

Lumbosacral DREZotomy for oncologic pain treatment: a case-based review.

To present 3 cases of oncologic pain treated by DREZotomy in the pediatric population and to review the literature published about this procedure. The permanent literature about oncologic pain treatment in children and the applicability of DREZotomy was reviewed. Three cases treated at our institution were reviewed and presented. In the pediatric population, the DREZotomy has been extensively applied for the treatment of spasticity and spasticity-related pain. Currently, there are no reports of oncologic pain treated by means of a DREZotomy in children. We presented 3 cases coursing the terminal stage of illness, presenting predominantly neuropathic, oncologic pain that were successfully managed after a DREZotomy was performed. In well-selected patients, with a good general condition and life expectancy to withstand an open neurosurgical procedure, DREZotomy is an excellent tool to treat neuropathic oncologic pain.

Characteristics and Resource Utilization Associated with Frequent Users of Emergency Departments.

Background Frequent emergency department (ED) users place a huge influence and burden on healthcare systems and medical costs. In Taiwan, citizens have very easy access to medical services and the national health insurance (NHI) puts very few restrictions on the frequency and facilities which the patients go to. However, there is still a certain percentage of frequent ED users in Taiwan, and yet, there are few research studies investigating the features of such users and their impact on the healthcare system. We conducted this study to investigate the prevalence and characteristics of the repeated ED users in a tertiary care medical center with more than 80000 emergency visits in a year and hypothesized that frequent ED users have unique medical and social characteristics and results in increased medical expense. Methods We searched the integrated medical database of an urban tertiary medical center in 2017. We compared frequent ED users (≧4 visits/year) with nonfrequent users (<4 visits/year) with regards to the medical history, distance from home to the hospital, main visiting purposes, whether patients had used outpatient care or other medical resources at the same time, and the charge to the patients for each visit. Results In 2017, 2191 patients (3.37%) were listed as frequent users and accounted for 12166 visits (14.20%). Most of the frequent users were over 65 years old (53.1%) and more than half of them had suffered from cancer (55.1%). The most significant features of frequent ED users were male, educational attainment below university, low-income households, drug or food allergies, terminal stage of illness, possession of IC Cards for Severe Illness, hospitalization in the past year, multiple outpatient visits in same year, and with certain medical history including anemia, cerebrovascular accident, congestive heart failure, peptic ulcer disease, ileus, cirrhosis, chronic obstructive pulmonary disease, and psychiatric disease. There were significant differences between frequent and nonfrequent users in disposition and median charge per visit (US$137 vs. $117, p < 0.001). Conclusions Frequent users of ED are a heterogeneous group who usually suffer from multiple chronic diseases. There were higher rates of hospital admission and medical costs among frequent ED users compared to nonfrequent users. In addition to emergency services, frequent users also utilized outpatient resources heavily.

A Pilot Study on the Quality of Sexual Life of Patients Receiving Home Palliative Care in Poland

Background: Quality of life, physical, psychic, and social functioning assessments in patients suffering from chronic, progressive, and incurable diseases are one of the most significant aims of the palliative care home teams. Sexuality and intimacy can be one of the most important elements of a person’s life, even at the end of it. Unfortunately, there is very little interest in this topic among medical staff of palliative care units. The objective of the study: The aim of this study was to assess the health status, the quality of life, the quality of sexual life, and the recognition and resolution of sexual problems by the palliative care team in adult patients in the advanced stage of terminal illness, who were receiving home palliative care. Research methods: The study involved 342 adult patients in the advanced stage of incurable, progressive disease, covered by home palliative care in 15 facilities in Poland. A generic EuroQoL 5-Dimension 3-Level health and quality of life assessment questionnaire and a questionnaire developed by the researchers, including questions about sexual problems, were used in this prospective study. Results: The presented results are the part of the more extensive study. The assessment of health status and quality of life of the study patients showed that the evaluation was the lowest for performing ordinary daily activities. The quality of sexual life after diagnosis in more than half of the study patients has worsened. Almost half of the respondents felt that the palliative care team did not recognize or address their sexual concerns. Patients indicated nurses and physicians as the members of the palliative care team most helpful in identifying and addressing sexual concerns. Conclusions: Members of the palliative care team should receive training in communication with patients concerning their sexual life, their needs and expectations and have knowledge about options for obtaining specialized sexological care. It is necessary to prepare and validate simple tools that will facilitate the initiation of appropriate communication between patients and members of the medical staff. It will be important to conduct more detailed and targeted research on sexuality and intimacy in the Polish palliative care patient population.

Inappropriate hemodialysis treatment and palliative care

Abstract The paper discusses inappropriate (futile) treatment by analyzing the casuistics of palliative patients in the terminal stage of illness who are hospitalized at the Department of Internal Medicine and Geriatrics of the Faculty hospital with policlinic (FNsP). Our research applies the principles of palliative care in the context of bioethics. The existing clinical conditions of healthcare in Slovakia are characteristic of making a taboo of the issues of inappropriate treatment of palliative patients. Inductive-deductive and normative clinical bioethics methods of palliative care and ethical strategy are applied for defining issues found in inappropriate hemodialysis treatment. An algorithm of hemodialysis treatment requires the definition of those lege artis criteria which, in the context of a patient’s autonomy and his/her decision, precondition the avoidance of the situation in which hemodialysis treatment is inappropriate (futile). Futile treatment in a terminal condition is ethically inappropriate medical treatment that extends the suffering of patients and their relatives. Its definition is determined by the relevant legislation and the methods of bioethics. An active palliative strategy is aimed at managing the process of incurable diseases in the patient’s bio-psycho-socio-spiritual continuity in the process of special bioethics. The global bioethical objective of general bioethics for palliative care is based on the paradigm of social harmony and solidarity in the context of an authentic modus of the patient’s existence as a constitutive principle for the phenomenon of the patient’s being to finite being (death).

Mortality patterns and risk among older men and women with intellectual disability: a Swedish national retrospective cohort study

BackgroundSweden has closed all institutions and imposed legislation to ensure service and support for individuals with intellectual disability (ID). Understanding mortality among older individuals with ID is essential to inform development of health promotion and disease control strategies. We investigated patterns and risk of mortality among older adults with ID in Sweden.MethodsThis retrospective cohort study compared older adults aged 55 years and older with ID with a control population. Participants were followed during 2002–2015 or death, and censored if they moved out of Sweden. Individuals with ID were identified from two national registers: one covering all specialist health-care visits (out-patient visits and hospitalisation) and the other covering people accessing social/support services. Individuals with ID (n = 15,289) were matched with a control population by sex, birth year, and year of first hospitalisation/out-patient visit/access to LSS services. Cause-of-death data were recorded using International Classification of Diseases, Tenth Revision. Cox proportional hazards regression were conducted to assess if overall and cause-specific mortality rate among individuals with ID was higher than in the Swedish population.ResultsThe overall mortality rate among individuals with ID was 2483 per 100,000 people compared with 810 in the control population. Among those who died, more individuals with ID were younger than 75 years and unmarried. Leading causes of death among individuals with ID were circulatory diseases (34%), respiratory diseases (17%) and neoplasms (15%). Leading causes of death in a sub-sample with Down syndrome (DS) were respiratory diseases (37%), circulatory diseases (26%) and mental/behavioural disorders (11%). Epilepsy and pneumonitis were more common among individuals with ID than controls. Alzheimer’s disease was common in the control population and individuals with DS, but not among those with ID when DS was excluded. Individuals with ID had a higher overall mortality risk (hazard ratio [HR] 4.1, 95% confidence interval [CI] 4.0–4.3) and respiratory disease death risk (HR 12.5, 95% CI 10.9–14.2) than controls.ConclusionOlder adults with ID in Sweden carry a higher mortality risk compared with the general population, mainly attributable to respiratory, nervous and circulatory diseases. Care for this group, particularly during the terminal stage of illness, needs to be tailored based on understanding of their main health problem.

Decline of Physical Activity in Terminally Ill Patients Could Be Useful for Predicting Short-Term Survival.

Although it is recommended that all terminally ill patients receive advance care planning (ACP), this is occasionally challenging because of the difficulty in predicting survival. There are some indexes for predicting survival, but few are accurate, especially at the terminal stages of illness. Twenty-two patients at the terminal stages of cancer were retrospectively analyzed. We assessed their physical activity and condition using activities of daily living (ADL) scores for 1 month before the death. The ADL scores included 7 items: walking, bathing, grooming, dressing, eating, transferring, and toileting. Survival time after the first decline of physical activity was calculated (median: 13 days, 95% confidence interval [95% CI]: 5.6-20.4 days). Survival time after the second (median: 5 days, 95% CI: 0-10.9 days), third (median: 5 days, 95% CI: 0-13.4 days), and fourth (median time: 1 day, 95% CI: not applicable due to small size) decline of physical activity was also calculated. Change in physical activity seems helpful for estimating survival time, especially at the end of life, and this index could be useful for coordinating final ACP.

Social factors of under-five mortality in rural Agra

Background: Very limited recent data is available on the causes of child deaths in India.Most of the available studies do not accurately reflect the socio factors related to these deaths. Identifying and assessing the factors affecting the child mortality could be the first step in planning to reduce the mortality and promoting the society health and life expectancy. Therefore the present study was undertaken to find out the socio factors of deaths among children under 5 years of age. Methods: The present cross-sectional survey was conducted among under five children and their parents residing within the selected villages in a community Development Block Sainyan, District Agra using Multistage random sampling technique. Participatory learning action technique was used. Data was analyzed and presented in form of percentages. Results: Diarrhoea was the most common cause of under five children mortality followed by acute respiratory tract infection and pyrexia. Delay in recognition of problem followed by delay in decision making at family level, delay in seeking of health provider and delay in arranging transport were the main social causes of deaths. Most children were attended by local rural medical practitioners both at initial and terminal stages of illness. Conclusions: Efforts to prevent diarrhoea and acute respiratory tract infection must be intensified. Awareness about the services provided by the government and their utilization should be strengthened.

Deaktivace kardiostimulátorů a kardioverterů v terminálním stádiu onemocnění

Aim: The aim of the present study was to seek out expert knowledge concerning the direct experience of care providers of the deactivation of pacemakers or ICDs in patients in the terminal stage of illness. Another goal was to describe the possibilities of deactivation of pacemakers and ICDs in the Czech Republic. Design: The research had the character of a systematic overview. Methods: Articles focusing on the problem area of interest were searched by means of a systematic trawl through various databases using the relevant terms. The search was limited to articles in English issued between 2000 and 2013. Results: In total, five papers satisfying the basic criteria were found. Conclusion: The deactivation of pacemakers and ICDs in patients in the terminal stage of illness is a topic that continues to be overlooked. Studies focusing on care providers’ direct experience of deactivation of the two devices in patients in the terminal stage are exceptional. However, with respect to the increasing number of patients with implanted pacemakers and ICDs, this problem area should be addressed.

Aspiration Pneumonia in the Geriatric Population

Aspiration pneumonia is a common infection in older adults and has a high mortality rate. Oropharyngeal dysphagia is the major mechanism leading to aspiration pneumonia in the older adult. Many conditions that are prevalent in the older adult population such as stroke, parkinsonism, dementia, and institutionalization have an increased incidence of oropharyngeal dysphagia. Aspiration pneumonia is a bacterial pulmonary infection which is dependent upon the amount of bacterial inoculum, the virulence of the organism, and the host immune system. It is treated with antibiotic therapy that is similar to therapies for traditional community-acquired or health-care-associated pneumonia. In the advanced stages of terminal illness, a palliative care approach may be most appropriate. This review seeks to look at aspiration pneumonia focusing on oropharyngeal dysphagia, the microbiology of aspiration pneumonia and the palliative care aspects.

Special Considerations for Endoscopists on PEG Indications in Older Patients

Undernutrition in frail elderly people is a pathological condition that needs to be recognized and addressed early. Neurological dysphagia is among the most frequent causes of this condition in the elderly but should be considered a terminal event in Alzheimer-type dementias. Tube feeding is an important resource for facilitating metabolic recovery in cachectic patients and is particularly successful in “bridging” and stabilizing therapies prior to major treatment able to cure the patient. Clinical management of tube feeding in “incurable” conditions is complex and becomes part of the palliative care and comfort provided in the terminal stages of illness. Non-specialized physicians are often unfamiliar with the theory and practice of end-of-life interventions, and the resulting decisions are in many cases actually contrary to patient comfort. These problems deserve to be more carefully addressed when the patient is unable to cooperate or express his/her preferences and needs. The success of percutaneous endoscopic gastrostomy has led to increasingly frequent referrals for placement in critically ill elderly patients. Endoscopists therefore become a key figure in stimulating rational, correct treatment of these patients.

In praise of the literary eponym--Henry V sign

The use of eponyms in medicine is often discouraged. However, the literary eponym should be an exception as it is not linked with many of the difficulties associated with conventional eponyms and offers descriptive brevity and accuracy. Here, we illustrate the point with Henry V sign, which will be familiar to many who have cared for patients in the terminal stage of illness.

Masticator space metastasis from a male breast carcinoma: A case report

The aim of this case report is to highlight the importance of clinical examination, the correct treatment modalities and effectiveness of multidisciplinary approach in managing a metastatic jaw tumour with poor prognosis.A 60 year old male patient reported with complaints of trismus and pain in the Lt side of the face for the past eight months. Patient gave history of multiple teeth extraction. Case was initially diagnosed as chronic osteomyelitis mandible secondary to submasseteric infection. The lump in the left breast was a suspicious finding which was further investigated using US and FNAC. The cytomorphological picture was suggestive of infiltrating ductal carcinoma. The 99mTc-MDP bone scan was done and showed multiple bony metastasis. The case was diagnosed as metastatic tumour of masticator space from carcinoma breast. The patient was in his terminal stage of illness with widespread metastasis. Palliative treatment was then instituted to reduce the pain. Patient's condition became worse and finally he succumbed to his illness.Metastatic tumours to the jaws and oral tissues are uncommon and represent less than 1% of all malignant tumours affecting the oral cavity. The breast being a primary site for metastasis to a jaw bone in a male patient is a rare entity and less documented.

Benefits of using the liverpool care pathway in end of life care.

The Liverpool Care Pathway (LCP) is an integrated care pathway used to manage terminally ill patients in their final days or hours of life. It was developed by the Marie Curie Palliative Care Institute Liverpool to incorporate 'gold standard' care associated with the hospice setting into mainstream healthcare. The LCP has been advocated by the National Institute for Health and Clinical Excellence and the Department of Health for use in the care of dying patients. A literature review was undertaken to determine whether there is sufficient evidence that the LCP represents best practice in end of life care and whether patients cared for using the LCP receive better end of life care. Eight research articles were selected for inclusion in the review. The key themes of symptom management, communication and documentation were identified, and the research surrounding these themes was analysed. The analysis showed that use of the LCP promotes better care for patients in the terminal stage of illness; however, some weaknesses in the research were identified and recommendations have been made for further research and future practice.

Benefits of using the Liverpool Care Pathway in end of life care

The Liverpool Care Pathway (LCP) is an integrated care pathway used to manage terminally ill patients in their final days or hours of life. It was developed by the Marie Curie Palliative Care Institute Liverpool to incorporate 'gold standard' care associated with the hospice setting into mainstream healthcare. The LCP has been advocated by the National Institute for Health and Clinical Excellence and the Department of Health for use in the care of dying patients. A literature review was undertaken to determine whether there is sufficient evidence that the LCP represents best practice in end of life care and whether patients cared for using the LCP receive better end of life care. Eight research articles were selected for inclusion in the review. The key themes of symptom management, communication and documentation were identified, and the research surrounding these themes was analysed. The analysis showed that use of the LCP promotes better care for patients in the terminal stage of illness; however, some weaknesses in the research were identified and recommendations have been made for further research and future practice.

Constraining the use of antibiotics: applying Scanlon's contractualism

Decisions to use antibiotics require that patient interests are balanced against the public good, that is, control of antibiotic resistance. Patients carry the risks of suboptimal antibiotic treatment and many...

Palliative Sedation in End-of-Life Care and Survival: A Systematic Review

Palliative sedation is a clinical procedure aimed at relieving refractory symptoms in patients with advanced cancer. It has been suggested that sedative drugs may shorten life, but few studies exist comparing the survival of sedated and nonsedated patients. We present a systematic review of literature on the clinical practice of palliative sedation to assess the effect, if any, on survival. A systematic review of literature published between January 1980 and December 2010 was performed using MEDLINE and EMBASE databases. Search terms included palliative sedation, terminal sedation, refractory symptoms, cancer, neoplasm, palliative care, terminally ill, end-of-life care, and survival. A manual search of the bibliographies of electronically identified articles was also performed. Eleven published articles were identified describing 1,807 consecutive patients in 10 retrospective or prospective nonrandomized studies, 621 (34.4%) of whom were sedated. One case-control study was excluded from prevalence analysis. The most frequent reason for sedation was delirium in the terminal stages of illness (median, 57.1%; range, 13.8% to 91.3%). Benzodiazepines were the most common drug category prescribed. Comparing survival of sedated and nonsedated patients, the sedation approach was not shown to be associated with worse survival. Even if there is no direct evidence from randomized clinical trials, palliative sedation, when appropriately indicated and correctly used to relieve unbearable suffering, does not seem to have any detrimental effect on survival of patients with terminal cancer. In this setting, palliative sedation is a medical intervention that must be considered as part of a continuum of palliative care.

終末期の事前指示に対する医師の考え方と対応に関する検討―医師の年齢の影響を中心に―

We distributed 282 questionnaires to doctors to ascertain their opinions on obtaining the advance directives regarding the end-of-life treatment of patients at the terminal stage. We received 136 (48%) responses. A total of 62% of the respondents stated a desire for patients to indicate their advance directives "if at all possible". Only 36% stated that the need for advance directives "depended on the circumstances". A total of 80% of doctors aged under 40 wished patients to provide advanced directives "if at all possible", while 59% of doctors over 61 wanted advanced directives "depending on the circumstances" (p=0.008). A large number of doctors stated a desire for patients to indicate their preference in writing, particularly directives regarding the "use of a ventilator to prolong life" (76%) or the "use of artificial nourishment through a gastric fistula etc. as part of a proactive approach to sustaining life" (67%). Regarding the optimal timing of this declaration, 59% chose "at the first diagnosis of a terminal illness", and 47% chose "at the diagnosis of a chronic illness", regardless of whether it could become terminal. Of those respondents under 40, 32% believed that doctors should strictly follow the patients' advance directives, while only 11% of doctors over 61 years old believed the same. There was a statistically significant relationship between aging and dealing with advance directives of patients in the terminal stages of illness (p=0.002). These results suggest that doctors under 40 years of age should focus on how to correctly interpret the wishes of the patients expressed in the directives, while doctors over 61 should concentrate on the importance of the clinical application of advance directives, and how to balance the need to make qualified medical decisions on treatment in compliance with the wishes of end-stage terminal patients.