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International Journal of Nursing... Dec 2023Nurses' clinical decision-making, i.e., the data collection, analysis, and evaluation process through which they reach clinical judgements and makes clinical decisions,... (Review)
Review
BACKGROUND
Nurses' clinical decision-making, i.e., the data collection, analysis, and evaluation process through which they reach clinical judgements and makes clinical decisions, is at the core of nursing practice and essential to provide safe and quality care. Instruments to assess nurses' perceptions of their clinical decision-making abilities or skills have been developed for research and education. Thus, it is essential to determine the most valid and reliable instruments available to reflect nurses' self-reported clinical decision-making accurately.
OBJECTIVE
To evaluate the measurement properties of self-reported clinical decision-making instruments in nursing.
METHODS
A systematic review based on the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) was conducted (PROSPERO registration: CRD42022364549). Five bibliographical databases were searched in July 2022 using descriptors and keywords related to nurses, clinical decision-making, and studies on measurement properties. Two independent reviewers conducted reference selection and data extraction. The evaluation of the instruments' measurement properties involved assessing the quality of the studies, the quality of each measurement property (i.e., validity, reliability, responsiveness), and the quality of evidence based on the COSMIN.
RESULTS
Nine instruments evaluated in eleven studies with registered nurses or nursing students from various clinical contexts were identified. Five of the nine instruments were originals; four were translations or adaptations. Most focused on analytical and intuitive decision-making, although some were based on clinical judgment and clinical reasoning theories. Structural validity and internal consistency were the most frequently reported measurement properties; other properties, such as measurement error, criterion validity, and responsiveness, were not assessed for any instruments. A gap was also identified in the involvement of nurses or nursing students in the instrument development process and the content validity assessment. Six instruments appear promising based on the COSMIN criteria, but further studies are needed to confirm their validity and reliability.
CONCLUSIONS
The evidence regarding instruments to assess nurses' self-reported clinical decision-making is still minimal. Although no instruments could be recommended based on the COSMIN criteria, the Nurses Clinical Reasoning Scale had the most robust supporting evidence, followed by the adapted version of the Clinical Decision Making in Nursing Scale. Future efforts should be made to systematically assess content validity through the involvement of the target population and by ensuring that the results of other measurement properties, such as reliability, measurement error, or hypothesis testing, are rigorously assessed and reported.
TWEETABLE ABSTRACT
Despite limited evidence, this COSMIN review identified six promising instruments to assess nurses' clinical #decision-making, especially the Nurses Clinical Reasoning Scale and an adaptation of the Clinical Decision Making in Nursing Scale. #nursingresearch #nursingeducation.
PubMed: 38746590
DOI: 10.1016/j.ijnsa.2023.100122 -
International Journal of Surgery... Mar 2023Efficacy and safety of five common surgical treatments for lower calyceal (LC) stones were assessed for LC stones 20 mm or less. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Efficacy and safety of five common surgical treatments for lower calyceal (LC) stones were assessed for LC stones 20 mm or less.
METHODS
A systematic literature search was conducted up to June 2020 using PubMed, EMBASE, and Cochrane Library. The study has been registered in PROSPERO, CRD42021228404. Randomized controlled trials evaluating the efficacy and safety of five common surgical treatments for LC stones were collected, including percutaneous nephrolithotomy (PCNL), mini-PCNL (MPCNL), ultramini-PCNL (UMPCNL), extracorporeal shock wave lithotripsy (ESWL), and retrograde intrarenal surgery (RIRS). Heterogeneity among studies was assessed by using global inconsistency and local inconsistency. Both pooled odds ratio, along with 95% credible interval (CI) and the surface under the cumulative ranking curve values were calculated to assess the outcomes, paired comparisons of efficacy and safety of five treatments.
RESULTS
Nine peer-reviewed randomized controlled trials, comprising 1674 patients in recent 10 years, were included. Heterogeneity tests showed no statistical significance, and a consistency model was chosen, respectively. The order of surface under the cumulative ranking curve values for efficacy was as follows: PCNL (79.4), MPCNL (75.2), UMPCNL (66.3), RIRS (29), and eSWL (0). For safety: eSWL (84.2), UMPCNL (82.2), RIRS (52.9), MPCNL (16.6), and PCNL (14.1).
CONCLUSION
In the current study, all five treatments are both effective and safe. Many factors must be considered to choose surgical treatments for LC stones 20 mm or less; the results that we separate conventional PCNL into PCNL, MPCNL, and UMPCNL make the questions even more controversial. However, relative judgments are still needed to be used as reference data in clinical management. For efficacy, PCNL>MPCNL>UMPCNL>RIRS>ESWL, ESWL is statistically inferior to the other four treatments, respectively. RIRS is statistically inferior to PCNL and MPCNL, respectively. For safety, ESWL>UMPCNL>RIRS>MPCNL>PCNL, ESWL is statistically superior to RIRS, MPCNL, and PCNL, respectively. RIRS is statistically superior to PCNL. We cannot reach conclusions about which surgical treatment is the best choice for all patients with LC stones 20 mm or less; therefore, tailored treatments based on individual patients still demand more attention than ever before for both patients and urologists.
Topics: Humans; Network Meta-Analysis; Kidney Calculi; Nephrolithotomy, Percutaneous; Lithotripsy; Odds Ratio; Treatment Outcome; Nephrostomy, Percutaneous
PubMed: 36906759
DOI: 10.1097/JS9.0000000000000062 -
Frontiers in Nutrition 2023Management of Crohn's disease (CD) using dietary interventions has become an area of increased research interest. There is a lack of specific research exploring if diet...
BACKGROUND
Management of Crohn's disease (CD) using dietary interventions has become an area of increased research interest. There is a lack of specific research exploring if diet and nutrition interventions are beneficial in patients with strictures, as current dietary recommendations in fibrostenotic CD are often based on clinical judgment. The aim of this systematic review was to assess the impact of dietary interventions in fibrostenotic CD on medical and surgical outcomes.
METHODS
A systematic search of MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), and Cochrane Central Register of Controlled Trials (Ovid) was conducted. Studies reporting dietary interventions or nutritional factors in fibrostenotic CD were included. Outcomes for studies assessing dietary interventions such as enteral nutrition were evaluated as changes in (1) CD symptoms (CD Activity Index), (2) stricture parameters on diagnostic imaging, and (3) rates of surgical or medical intervention following dietary interventions.
RESULTS
Five studies were included in this review. Three studies assessed exclusive enteral nutrition (EEN), one evaluated total parenteral nutrition (TPN), and one studied a liquid diet. All included studies evaluated symptoms as an outcome, while diagnostic imaging parameters and surgical outcomes in the studies were either absent or too heterogeneous to appraise improvement post dietary intervention. Included EEN studies displayed similar efficacy, with approximately 60% of patients having symptom improvement. The included TPN study also reported 75% of patients with symptom improvement, while the liquid diet did not.
CONCLUSION
Exclusive enteral nutrition and total parental nutrition may provide benefit for use as a dietary intervention for fibrostenotic CD. There remains a need for high-quality controlled trials which utilize standardized definitions of strictures.
PubMed: 36895272
DOI: 10.3389/fnut.2023.1017382 -
Frontiers in Oncology 2023Single nucleotide polymorphisms (SNPs) interfere with the function of certain genes and thus may influence the probability of skin cancer. The correlation between SNPs...
BACKGROUND
Single nucleotide polymorphisms (SNPs) interfere with the function of certain genes and thus may influence the probability of skin cancer. The correlation between SNPs and skin cancer (SC) lacks statistical power, however. Therefore, the purpose of this study was to identify the gene polymorphisms involved in skin cancer susceptibility using network meta-analysis and to determine the relationship between SNPs and SC risk.
METHODS
PubMed, Embase, and Web of Science were searched for articles including "SNP" and different types of SC as keywords between January 2005 and May 2022. The Newcastle-Ottawa Scale was used to assess bias judgments. The odds ratio (ORs) and their 95% confidence intervals () were determined to estimate heterogeneity within and between studies. Meta-analysis and network meta-analysis were carried out to identify the SNPs associated with SC. The -score of each SNP was compared to obtain the rank of probability. Subgroup analyses were performed by cancer type.
RESULTS
A total of 275 SNPs from 59 studies were included in the study. Two subgroup SNP networks using the allele model and dominant model were analyzed. The alternative alleles of rs2228570 (FokI) and rs13181 (ERCC2) were the first-ranking SNPs in both subgroups one and two of the allele model, respectively. The homozygous dominant genotype and heterozygous genotype of rs475007 in subgroup one and the homozygous recessive genotype of rs238406 in subgroup two were most likely to be associated with skin cancer based on the dominant model.
CONCLUSIONS
According to the allele model, SNPs FokI rs2228570 and ERCC2 rs13181 and, according to the dominant model, SNPs MMP1 rs475007 and ERCC2 rs238406 are closely linked to SC risk.
PubMed: 36874118
DOI: 10.3389/fonc.2023.1094309 -
International Journal of Clinical... 2022This study aimed at systematically reviewing the clinical success of repaired iatrogenic perforations using different materials in primary teeth. (Review)
Review
AIM
This study aimed at systematically reviewing the clinical success of repaired iatrogenic perforations using different materials in primary teeth.
OBJECTIVES
To compare mineral trioxide aggregate (MTA) with other biomaterials for the repair of iatrogenic perforations in primary molars during endodontic procedures.
SEARCH METHODS
A comprehensive literature search was conducted by using three electronic databases (PubMed, Cochrane Library, Google Scholar) to identify articles that evaluated the different intervention materials for the repair of iatrogenic perforation in primary molars. Selection criteria: The articles reporting perforation repair in primary molars having clinical and radiographic success, as their outcome measures with a follow-up period of at least 1 year were included in this review. Studies and case reports with insufficient or unstated follow-up periods, in vitro, and animal studies were excluded.
DATA COLLECTION AND ANALYSIS
Two reviewers (SM, LM) independently screened all titles and abstracts according to the inclusion and exclusion criteria. Full texts of the selected studies were obtained for the second stage screening. The consensus was achieved by discussion with the third reviewer (AJ). Data extraction included study design, sample size, age of the patient, year of the study, follow-up period, outcome assessment criteria, material for repair, and success and failure.
REVIEW RESULTS
A total of seven publications were included in this review. Of which, one was case series, three were case reports, and three were interventional studies. The combined success rate of MTA (80.55%) was inferior to other materials-premixed bioceramics, Atelocollagen, and calcium-enriched mixture (96.07%); the same being statistically significant ( = 0.011).
CONCLUSION
Within the limitations of our study, it can be concluded that newer biomimetic materials are superior to MTA for iatrogenic perforation repair in primary molars in terms of clinical success.
CLINICAL SIGNIFICANCE
This paper is a first-of-its-kind investigation comparing different materials used in the repair of perforations in primary molars. It can be a foundation for further research on the topic. In absence of any available guidelines, the above study can be applied in clinical situations with appropriate judgment and caution.
HOW TO CITE THIS ARTICLE
Mungekar-Markandey S, Mistry L, Jawdekar A. Clinical Success of Iatrogenic Perforation Repair Using Mineral Trioxide Aggregate and Other Materials in Primary Molars: A Systematic Review and Meta-analysis. Int J Clin Pediatr Dent 2022;15(5):610-616.
PubMed: 36865717
DOI: 10.5005/jp-journals-10005-2038 -
Fertility and Sterility Jul 2023To date, recurrent implantation failure (RIF) has no clear definition and no clearly identified impaired function. Hence, the term RIF is currently used somewhat... (Review)
Review
IMPORTANCE
To date, recurrent implantation failure (RIF) has no clear definition and no clearly identified impaired function. Hence, the term RIF is currently used somewhat haphazardly, on the basis of clinicians' judgment.
OBJECTIVE
International experts in reproductive medicine met on July 1, 2022, in Lugano, Switzerland, to review the different facets of RIF and define the diagnosis and its appropriate management.
EVIDENCE REVIEW
A systematic review without meta-analysis of studies published in English from January 2015 to May 2022.
FINDINGS
Data indicated that RIF has been largely overevaluated, overdiagnosed, and overtreated without sufficient critical assessment of its true nature. Our analyses show that true RIF is extremely uncommon-occurring in <5% of couples with infertility-and that reassurance and continued conventional therapies are warranted in most cases of assisted reproductive technology (ART) failure. Although the true biologic determinants of RIF may exist in a small subset of people with infertility, they elude the currently available tools for assessment. Without identification of the true underlying etiology(ies), it is reasonable not to assign this diagnosis to a patient until she has failed at least 3 euploid blastocyst transfers (or the equivalent number of unscreened embryo transfers, adjusted to the patient's age and corresponding euploidy rate). In addition, other factors should be ruled out that may contribute to her reduced odds of sustained implantation. In such cases, implantation failure should not be the only issue considered in case of ART failure because this may result from multiple other factors that are not necessarily repetitive or persistent. In reality, RIF impacting the probability of further ART success is a very rare occurrence.
CONCLUSION
True RIF is extremely uncommon, occurring in <5% of couples with infertility. Reassurance and continued conventional therapies are warranted in most cases. It would seem reasonable not to assign this diagnosis to a patient until she has failed at least 3 euploid embryo transfers (or the equivalent number of unscreened embryos, adjusted to her age).
RELEVANCE
Given the number of internationally recognized experts in the field present at the Lugano meeting 2022, our publication constitutes a consensus statement.
Topics: Humans; Female; Embryo Implantation; Embryo Transfer; Infertility; Reproductive Techniques, Assisted; Aneuploidy; Retrospective Studies
PubMed: 36822566
DOI: 10.1016/j.fertnstert.2023.02.014 -
Journal of Medical Internet Research Feb 2023Nursing care is increasingly supported by computerized information systems and decision support aids. Since the advent of handheld computer devices (HCDs), there has... (Review)
Review
BACKGROUND
Nursing care is increasingly supported by computerized information systems and decision support aids. Since the advent of handheld computer devices (HCDs), there has been limited exploration of their use in nursing practice.
OBJECTIVE
The study aimed to understand the professional and clinical impacts of the use of mobile health apps in nursing to assist clinical decision-making in acute care settings. The study also aimed to explore the scope of published research and identify key nomenclature with respect to research in this emerging field within nursing practice.
METHODS
This scoping review involved a tripartite search of electronic databases (CINAHL, Embase, MEDLINE, and Google Scholar) using preliminary, broad, and comprehensive search terms. The included studies were hand searched for additional citations. Two researchers independently screened the studies for inclusion and appraised quality using structured critical appraisal tools.
RESULTS
Of the 2309 unique studies screened, 28 (1.21%) were included in the final analyses: randomized controlled trials (n=3, 11%) and quasi-experimental (n=9, 32%), observational (n=10, 36%), mixed methods (n=2, 7%), qualitative descriptive (n=2, 7%), and diagnostic accuracy (n=2, 7%) studies. Studies investigated the impact of HCDs on nursing decisions (n=12, 43%); the effectiveness, safety, and quality of care (n=9, 32%); and HCD usability, uptake, and acceptance (n=14, 50%) and were judged to contain moderate-to-high risk of bias. The terminology used to describe HCDs was heterogenous across studies, comprising 24 unique descriptors and 17 individual concepts that reflected 3 discrete technology platforms ("PDA technology," "Smartphone/tablet technology," and "Health care-specific technology"). Study findings varied, as did the range of decision-making modalities targeted by HCD interventions. Interventions varied according to the level of clinician versus algorithmic judgment: unstructured clinical judgment, structured clinical judgment, and computerized algorithmic judgment.
CONCLUSIONS
The extant literature is varied but suggests that HCDs can be used effectively to support aspects of acute nursing care. However, there is a dearth of high-level evidence regarding this phenomenon and studies exploring the degree to which HCD implementation may affect acute nursing care delivery workflow. Additional targeted research using rigorous experimental designs is needed in this emerging field to determine the true potential of HCDs in optimizing acute nursing care.
Topics: Humans; Computers, Handheld; Mobile Applications; Clinical Decision-Making
PubMed: 36780222
DOI: 10.2196/39987 -
Complex & Intelligent Systems Feb 2023When COVID-19 spread in China in December 2019, thousands of studies have focused on this pandemic. Each presents a unique perspective that reflects the pandemic's main...
Systematic review of MCDM approach applied to the medical case studies of COVID-19: trends, bibliographic analysis, challenges, motivations, recommendations, and future directions.
When COVID-19 spread in China in December 2019, thousands of studies have focused on this pandemic. Each presents a unique perspective that reflects the pandemic's main scientific disciplines. For example, social scientists are concerned with reducing the psychological impact on the human mental state especially during lockdown periods. Computer scientists focus on establishing fast and accurate computerized tools to assist in diagnosing, preventing, and recovering from the disease. Medical scientists and doctors, or the frontliners, are the main heroes who received, treated, and worked with the millions of cases at the expense of their own health. Some of them have continued to work even at the expense of their lives. All these studies enforce the multidisciplinary work where scientists from different academic disciplines (social, environmental, technological, etc.) join forces to produce research for beneficial outcomes during the crisis. One of the many branches is computer science along with its various technologies, including artificial intelligence, Internet of Things, big data, decision support systems (DSS), and many more. Among the most notable DSS utilization is those related to multicriterion decision making (MCDM), which is applied in various applications and across many contexts, including business, social, technological and medical. Owing to its importance in developing proper decision regimens and prevention strategies with precise judgment, it is deemed a noteworthy topic of extensive exploration, especially in the context of COVID-19-related medical applications. The present study is a comprehensive review of COVID-19-related medical case studies with MCDM using a systematic review protocol. PRISMA methodology is utilized to obtain a final set of ( = 35) articles from four major scientific databases (ScienceDirect, IEEE Xplore, Scopus, and Web of Science). The final set of articles is categorized into taxonomy comprising five groups: (1) diagnosis ( = 6), (2) safety ( = 11), (3) hospital ( = 8), (4) treatment ( = 4), and (5) review ( = 3). A bibliographic analysis is also presented on the basis of annual scientific production, country scientific production, co-occurrence, and co-authorship. A comprehensive discussion is also presented to discuss the main challenges, motivations, and recommendations in using MCDM research in COVID-19-related medial case studies. Lastly, we identify critical research gaps with their corresponding solutions and detailed methodologies to serve as a guide for future directions. In conclusion, MCDM can be utilized in the medical field effectively to optimize the resources and make the best choices particularly during pandemics and natural disasters.
PubMed: 36777815
DOI: 10.1007/s40747-023-00972-1 -
Frontiers in Psychology 2022Advances in artificial intelligence (AI) technologies, together with the availability of big data in society, creates uncertainties about how these developments will...
BACKGROUND
Advances in artificial intelligence (AI) technologies, together with the availability of big data in society, creates uncertainties about how these developments will affect healthcare systems worldwide. Compassion is essential for high-quality healthcare and research shows how prosocial caring behaviors benefit human health and societies. However, the possible association between AI technologies and compassion is under conceptualized and underexplored.
OBJECTIVES
The aim of this scoping review is to provide a comprehensive depth and a balanced perspective of the emerging topic of AI technologies and compassion, to inform future research and practice. The review questions were: How is compassion discussed in relation to AI technologies in healthcare? How are AI technologies being used to enhance compassion in healthcare? What are the gaps in current knowledge and unexplored potential? What are the key areas where AI technologies could support compassion in healthcare?
MATERIALS AND METHODS
A systematic scoping review following five steps of Joanna Briggs Institute methodology. Presentation of the scoping review conforms with PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews). Eligibility criteria were defined according to 3 concept constructs (AI technologies, compassion, healthcare) developed from the literature and informed by medical subject headings (MeSH) and key words for the electronic searches. Sources of evidence were Web of Science and PubMed databases, articles published in English language 2011-2022. Articles were screened by title/abstract using inclusion/exclusion criteria. Data extracted (author, date of publication, type of article, aim/context of healthcare, key relevant findings, country) was charted using data tables. Thematic analysis used an inductive-deductive approach to generate code categories from the review questions and the data. A multidisciplinary team assessed themes for resonance and relevance to research and practice.
RESULTS
Searches identified 3,124 articles. A total of 197 were included after screening. The number of articles has increased over 10 years (2011, = 1 to 2021, = 47 and from Jan-Aug 2022 = 35 articles). Overarching themes related to the review questions were: (1) (7 themes) Concerns about AI ethics, healthcare jobs, and loss of empathy; Human-centered design of AI technologies for healthcare; Optimistic speculation AI technologies will address care gaps; Interrogation of what it means to be human and to care; Recognition of future potential for patient monitoring, virtual proximity, and access to healthcare; Calls for curricula development and healthcare professional education; Implementation of AI applications to enhance health and wellbeing of the healthcare workforce. (2) (10 themes) Empathetic awareness; Empathetic response and relational behavior; Communication skills; Health coaching; Therapeutic interventions; Moral development learning; Clinical knowledge and clinical assessment; Healthcare quality assessment; Therapeutic bond and therapeutic alliance; Providing health information and advice. (3) (4 themes) Educational effectiveness of AI-assisted learning; Patient diversity and AI technologies; Implementation of AI technologies in education and practice settings; Safety and clinical effectiveness of AI technologies. (4) (3 themes) Enriching education, learning and clinical practice; Extending healing spaces; Enhancing healing relationships.
CONCLUSION
There is an association between AI technologies and compassion in healthcare and interest in this association has grown internationally over the last decade. In a range of healthcare contexts, AI technologies are being used to enhance empathetic awareness; empathetic response and relational behavior; communication skills; health coaching; therapeutic interventions; moral development learning; clinical knowledge and clinical assessment; healthcare quality assessment; therapeutic bond and therapeutic alliance; and to provide health information and advice. The findings inform a reconceptualization of compassion as a comprising six elements: (1) Awareness of suffering (e.g., pain, distress, risk, disadvantage); (2) Understanding the suffering (significance, context, rights, responsibilities etc.); (3) Connecting with the suffering (e.g., verbal, physical, signs and symbols); (4) Making a judgment about the suffering (the need to act); (5) Responding with an intention to alleviate the suffering; (6) Attention to the effect and outcomes of the response. These elements can operate at an individual (human or machine) and collective systems level (healthcare organizations or systems) as a cyclical system to alleviate different types of suffering. New and novel approaches to human-AI intelligent caring could enrich education, learning, and clinical practice; extend healing spaces; and enhance healing relationships.
IMPLICATIONS
In a complex adaptive system such as healthcare, human-AI intelligent caring will need to be implemented, not as an ideology, but through strategic choices, incentives, regulation, professional education, and training, as well as through joined up thinking about human-AI intelligent caring. Research funders can encourage research and development into the topic of AI technologies and compassion as a system of human-AI intelligent caring. Educators, technologists, and health professionals can inform themselves about the system of human-AI intelligent caring.
PubMed: 36733854
DOI: 10.3389/fpsyg.2022.971044 -
Journal of General Internal Medicine May 2023Physicians treating similar patients in similar care-delivery contexts vary in the intensity of life-extending care provided to their patients at the end-of-life.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Physicians treating similar patients in similar care-delivery contexts vary in the intensity of life-extending care provided to their patients at the end-of-life. Physician psychological propensities are an important potential determinant of this variability, but the pertinent literature has yet to be synthesized.
OBJECTIVE
Conduct a review of qualitative studies to explicate whether and how psychological propensities could result in some physicians providing more intensive treatment than others.
METHODS
Systematic searches were conducted in five major electronic databases-MEDLINE ALL (Ovid), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), and Cochrane CENTRAL (Wiley)-to identify eligible studies (earliest available date to August 2021). Eligibility criteria included examination of a physician psychological factor as relating to end-of-life care intensity in advanced life-limiting illness. Findings from individual studies were pooled and synthesized using thematic analysis, which identified common, prevalent themes across findings.
RESULTS
The search identified 5623 references, of which 28 were included in the final synthesis. Seven psychological propensities were identified as influencing physician judgments regarding whether and when to withhold or de-escalate life-extending treatments resulting in higher treatment intensity: (1) professional identity as someone who extends lifespan, (2) mortality aversion, (3) communication avoidance, (4) conflict avoidance, (5) personal values favoring life extension, (6) decisional avoidance, and (7) over-optimism.
CONCLUSIONS
Psychological propensities could influence physician judgments regarding whether and when to de-escalate life-extending treatments. Future work should examine how individual and environmental factors combine to create such propensities, and how addressing these propensities could reduce physician-attributed variation in end-of-life care intensity.
Topics: Humans; Communication; Death; Pharmaceutical Preparations; Physicians; Terminal Care
PubMed: 36732436
DOI: 10.1007/s11606-022-08011-4