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Emergency medicine
Original research
Factors affecting do-not-attempt-resuscitation (DNAR) decisions among adult patients in the emergency department of a general tertiary teaching hospital in China: a retrospective observational study
  1. Chao-Lan Wang,
  2. Yang Liu,
  3. Yu-Lei Gao,
  4. Qing-Song Li,
  5. Yan-Cun Liu,
  6. Yan-Fen Chai
  1. Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
  1. Correspondence to Dr Yan-Fen Chai; chaiyanfen2012{at}126.com; Dr Yan-Cun Liu; yancunliu{at}tmu.edu.cn

Abstract

Objective Do-not-attempt-resuscitation (DNAR) orders are designed to allow patients to opt out of receiving cardiopulmonary resuscitation in the event of a cardiac arrest. While DNAR has become a standard component of medical care, there is limited research available specifically focusing on DNAR orders in the context of emergency departments in China. This study aimed to fill that gap by examining the factors related to DNAR orders among patients in the emergency department of a general tertiary teaching hospital in China.

Design Retrospective observational study.

Setting Emergency department.

Participants This study and analysis on adult patients with DNAR or no DNAR data between 1 January 2022 and 1 January 2023 in the emergency department of a large academic comprehensive tertiary teaching hospital. A total of 689 were included in our study.

Primary outcome measures Whether the patient received DNAR was our dependent variable.

Results Among the total patients, 365 individuals (53.0%) had DNAR orders. The following variables, including age, sex, age-adjusted Charlson comorbidity index (ACCI), primary diagnosis of cardiogenic or cancer related, history of neurological dysfunction or cancer, were independently associated with the difference between the DNAR group and the no DNAR group. Furthermore, there were significant statistical differences observed in the choice of DNAR among patients with different stages of cancer.

Conclusions In comparison to the no DNAR group, patients with DNAR were characterised by being older, having a higher proportion of female patients, higher ACCI scores, a lower number of patients with a primary diagnosis of cardiogenic and a higher number of patients with a primary diagnosis of cancer related, history of neurological dysfunction or cancer.

  • cardiopulmonary resuscitation
  • adult palliative care
  • accident & emergency medicine

Data availability statement

Data are available on reasonable request. The data that support the findings of this study are available from the corresponding author on reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2023-075714

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • This study addresses the limited research available on do-not-attempt-resuscitation orders in the emergency department setting in China, thereby filling a gap in the existing literature.

    • This is a single-centre retrospective observational study, we need multicentre and large-sample studies to provide more comprehensive and robust evidence in this field in the future.

    • The use of patient records as the source of data collection in this study is advantageous as it minimises subjective bias that could potentially be introduced by the researcher.

    Introduction

    With the ageing population and evolving disease spectrum, coupled with the overcrowding of hospital wards and the utilisation of emergency departments as central hubs for managing chronic diseases, it is anticipated that the number of patients experiencing cardiac arrest (CA) in emergency departments will increase in the future.1 2 Cardiopulmonary resuscitation (CPR) is a highly effective method for saving patients experiencing CA.3 The primary goal of CPR is to provide a potential benefit to patients experiencing CA. Nevertheless, it is acknowledged that CPR may result in more harm than benefit in specific cases, particularly those involving irreversible or terminal diseases.4 5 Administering CPR without providing any benefit can lead to unnecessary pain and psychological trauma for the patient and their family members.6

    The term ‘do-not-attempt-resuscitation’ (DNAR) refers to a directive issued by a patient or their guardians prior to the patient experiencing a CA in the hospital. This directive signifies that the patient does not wish to receive aggressive life-saving interventions, such as CPR, in the event of a CA.7 A DNAR order is a decision to restrict the application of CPR during a CA event. In 1974, the American Medical Association became the first organisation to recommend formal documentation of DNAR instructions in patients’ medical records.8 In 1986, an article published in the Journal of American Medical Association (JAMA) emphasised the principle that CPR should be used for sudden and unforeseen deaths rather than for irreversible medical conditions.9

    DNAR orders in adult patients in Chinese emergency departments have been inadequately reported. Proper management of critical patients in emergency departments, avoiding futile medical interventions, reducing the burden on patients’ families and society, and enhancing the quality of life for critical patients are important aspects that deserve attention.10 This study aimed to investigate the prevalence of DNAR orders and the factors affecting their adoption among patients in the emergency department of a major tertiary comprehensive teaching hospital in China.

    Methods

    Study design and setting

    This retrospective observational study focused on adult patients and was conducted between 1 January 2022 and 1 January 2023, within the emergency department of a major tertiary comprehensive teaching hospital.

    Selection of participants

    We included all patients ≥18 years, regardless of whether they had DNAR orders or not. This encompassed not only patients with in-hospital CA (IHCA) but also critical patients without IHCA who had a DNAR order in place. Patients <18 years and those who experienced out-of-hospital CA (OHCA) and were brought to the hospital were excluded from the study.

    Data collection

    The primary objective of the case collection table is to systematically amass pertinent data, encompassing essential variables such as age, resident identity, sex, age-adjusted Charlson comorbidity index (ACCI), primary diagnosis of disease, medical history, as well as the presence or absence of DNAR directives obtained from the medical records. Microsoft Excel was employed as a tool to effectively organise and sort all the collected case data. To extract the required information, a diligent team composed of an associate chief physician and two junior residents conducted a thorough review of medical records, including both paper and electronic files of doctors and nurses. To ensure accuracy and consistency, a chief physician assumed the crucial role of mediating and resolving these differences, thereby facilitating a unified and cohesive analysis.

    In China, DNAR agreements are signed in accordance with the framework established by Chinese law and the rules and regulations established by hospitals. Patients have the right to decide to sign a DNAR. It is important to note that in cases where the patient is unable to express his or her wishes, his or her legal guardian or immediate family members, including parents, children and spouses, have the legal capacity to sign a DNAR agreement on behalf of the patient. Furthermore, it is vital to note that the patient or their representative retains the right to modify their decision regarding DNAR orders at any time. To account for this dynamic nature, we ensure that our analysis incorporates the most up-to-date information regarding the patient’s DNAR status.

    Variable definitions

    OHCA is defined as the cessation of breathing and blood circulation in a patient occurring outside of a healthcare facility. ACCI scores were calculated from previous studies in all patients enrolled.11

    DNAR orders are medical directives that signify a patient’s decision to forego resuscitation efforts without imposing other care restrictions. These orders require the patient or their representative to provide consent to be included in the medical record by signing a document.12 Our study classifies patients according to where they live and divides them into local and non-local residents. Local residents refer to those who have lived in Tianjin for more than 1 year. Non-local residents refer to those who do not reside in Tianjin or those who reside in Tianjin for less than 1 year.

    Sample size calculation and statistical analysis

    With reference to previous research experience, we employed the events per variable (EPV) method, a widely used approach in binary logistic regression models. To ensure robust results, we set the EPV at a minimum of 10.13 14 Based on this assumption (EPV=10) and considering the presence of 20 covariates, the required number of DNAR patients was calculated as 10×20=200. Considering a previous study on the proportion of DNAR patients in China, which reported a proportion of 46.4%.12 We assume that the proportion of DNAR patients is 46.4%, so the total sample size required as 200/0.464=431. Using this assumption, we calculated the total sample size required as 200/0.464=431. Therefore, our study aimed to include a minimum of 200 DNAR patients and at least 231 no-DNAR patients. The sample sizes of both groups satisfied our research requirements.

    The results were presented as n (%) for categorical variables. Descriptive statistics included mean±SD or median with IQR for continuous variables. The Mann-Whitney U test was used for comparing continuous variables between independent samples. For categorical variable analysis, Pearson’s χ2 test or Fisher’s exact test was employed, as appropriate. Statistical analysis was performed by using SPSS software V.26.0 (IBM) and GraphPad Prism9 (GraphPad Software, San Diego, California, USA). The dependent variable was the DNAR orders signed by the patient or their legal guardian, while the selected research factors served as independent variables. Initially, univariate analysis was conducted, followed by the selection of meaningful variables for binary logistic regression analysis using the stepwise screening method. The significance level for variable inclusion was set at p<0.05.

    Patient and public involvement

    Patients or the public were not involved in the design, conduct, reporting or dissemination plans of this study.

    Results

    During the study periods, a total of 887 adult patients with DNAR or no DNAR were treated at the Tianjin Medical University General Hospital. Out of these, 198 cases of OHCAs were excluded, leaving 689 patients included in our study. Among the included patients, 365 (53.0%) had DNAR status, while 324 (47.0%) had no DNAR status (figure 1).

    Figure 1
    Figure 1

    Flow diagram of number of participants in this study. DNAR, do not attempt resuscitation; OHCA, out-of-hospital cardiac arrest.

    As can be seen in figure 2, 208 (57.0%) patients participated in the DNAR decision in the DNAR group, and 77 (23.8%) patients participated in the decision in the no DNAR group. A statistical analysis revealed a significant difference in the participation of patients in DNAR decisions between the two groups (57.0% (208/365) vs 23.8% (77/324); χ2=78.100; p<0.0001) (figure 2A). Figure 2B displays the breakdown of individuals making decisions regarding DNAR orders. The results were as follows: the patient’s own decision accounted for 41.4% (285/689), the spouse’s decision accounted for 12.6% (87/689), the child’s decision accounted for 41.8% (288/689), the parents’ decision accounted for 2.5% (17/689) and the other legal guardian’s decision accounted for 1.7% (12/689).

    Figure 2
    Figure 2

    (A) Patients participation in DNAR orders discussion. (B) The number of people who decide whether to DNAR orders. DNAR, do not attempt resuscitation.

    Table 1 presents a comparison of the detailed baseline characteristics between patients with DNAR and no DNAR. When comparing the DNAR group and the no DNAR group, it was found that patients in the DNAR group had a higher median age (75 (65–83) years vs 72 (61–81) years; U=0.849; p=0.005) and a higher ACCI score (12 (10–13) vs 8 (5–10); U=17.347; p<0.001) compared with the no DNAR group.

    View this table:
    Table 1

    Baseline characteristics of patients with DNAR and no DNAR

    Regarding the history of various conditions, there were no significant differences in the rate composition of patients with DNAR compared with the no DNAR group in terms of hypertension (52.6% (192/365) vs 55.6% (180/324); χ2=0.602; p=0.438), arrhythmia (24.1% (88/365) vs 25.0% (81/324); χ2=0.074; p=0.786), hepatic insufficiency (49.3% (180/365) vs 50.0% (162/324); χ2=0.032; p=0.858), renal insufficiency (47.9% (175/365) vs 47.5% (154/324); χ2=0.012; p=0.913), respiratory insufficiency (87.7% (320/365) vs 90.1% (292/324); χ2=1.040; p=0.308), diabetes mellitus (32.6% (119/365) vs 33.3% (108/324); χ2=0.041; p=0.839).

    However, there were significant differences in the rate composition for sex (56.2% (205/365) vs 64.2% (208/324); χ2=4.613; p=0.032), primary diagnosis of cardiogenic (12.3% (45/365) vs 46.0% (149/324); χ2=96.128; p<0.001), primary diagnosis of cancer-related (26.6% (97/365) vs 2.2% (7/324); χ2=79.832; p<0.001), history of coronary artery disease (80.2% (293/365) vs 72.2% (234/324); χ2=6.187; p=0.013), history of heart failure (72.1% (263/365) vs 60.8% (197/324); χ2=9.794; p=0.002), history of neurological dysfunction (55.6% (203/365) vs 41.0% (133/324); χ2=14.578; p<0.001) and history of cancer (64.7% (236/365) vs 53.7% (174/324); χ2=8.547; p=0.003) between patients with DNAR and those without DNAR.

    The significant variables identified in the univariate analysis were included in the binary logistic regression analysis. Prior to including the variables in the logistic regression model, it was ensured that there was no collinearity (multicollinearity variance inflation factor <5). Through the binary logistic regression analysis, several variables showed significant differences between patients with DNAR and the no DNAR group. These included age (OR 0.977; 95% CI 0.962 to 0.992; p=0.003), sex (OR 1.624; 95% CI 1.062 to 2.483; p=0.025), ACCI (OR 1.615; 95% CI 1.483 to 1.760; p<0.001), primary diagnosis of cardiogenic (OR 0.204; 95% CI 0.126 to 0.330; p<0.001), primary diagnosis of cancer related (OR 8.009; 95% CI 3.287 to 19.518; p<0.001), history of neurological dysfunction (OR 1.561; 95% CI 1.035 to 2.357; p=0.034) and history of cancer (OR 1.657; 95% CI 1.091 to 2.517; p=0.018). These variables demonstrated significant associations with the DNAR status of patients (table 2).

    View this table:
    Table 2

    Multivariable logistic regression for patients with DNAR and no DNAR

    Patients with a history of cancer were classified according to the internationally widely used tumour node metastasis staging system.15 Figure 3 illustrates the distribution of patients with DNAR in different cancer stages. In the DNAR group, 39 patients with cancer (16.5%) were classified as stages 0–I, 76 patients with cancer (32.2%) had stages II–III,and 121 patients with cancer (51.3%) had stage IV. Importantly, there were significant statistical differences observed in the decision to choose DNAR among patients with different stages of cancer.

    Figure 3
    Figure 3

    DNAR selection in patients with different cancer stages. DNAR, do not attempt resuscitation.

    Discussion

    In modern times, emergency departments are assuming an ever more prominent role as the initial point of contact for healthcare services worldwide.2 16 Patients and their families harbour optimistic expectations for swift and efficient care delivery and patient management. As a consequence, the emergency department has emerged as a crucial platform to address DNAR decisions.17 These decisions play pivotal roles in mitigating needless invasive treatments during the end-of-life phase.18 These discussions arise when patients or their family members decline CPR due to a poor prognosis, minimal chances of survival and a significant decline in their quality of life.19 DNAR decisions are indeed a fundamental aspect of emergency medicine practice, and the fast-paced nature of the emergency department introduces various challenges in this regard. However, there is a notable lack of comprehensive data, protocols and guidelines concerning the interactions between doctors, nurses, patients and their families when it comes to DNAR orders.18 Given the specific needs and circumstances of Chinese emergency patients, our study seeks to address the existing gap by investigating the factors that impact the decision to pursue DNAR orders. Through an examination of these factors, we aim to contribute to enhancing the quality of DNAR orders within Chinese emergency departments.

    Among the DNAR patients enrolled in our study, the DNAR rate was 53.0%. It is important to note that signing a DNAR agreement is perceived as a decision to forego life-saving measures, which can be seen as a departure from traditional Chinese cultural norms. In traditional Chinese culture, death is a sensitive and deeply respected topic, and mentioning death can be considered taboo or even disrespectful, which may be a tendency to avoid conversations related to death and end-of-life decisions, including DNAR discussions.20 This cultural context poses unique challenges in the healthcare setting, particularly in the emergency department where decisions rapidly must be made. The reluctance to engage in discussions about death and DNAR orders can impact the communication and decision-making process between healthcare professionals, patients and their families. Healthcare professionals are strongly encouraged to engage in patient-centred communication and take the time to comprehensively explain the concept of DNAR to patients and their families. By patiently addressing their inquiries and concerns, healthcare providers can effectively enhance DNAR acceptance rates. Such open and informative discussions play a crucial role in fostering a clearer comprehension of the implications and benefits of DNAR, ultimately enabling patients and their families to make more informed decisions regarding their medical care.

    In our study, we found that 57.0% of patients participated in DNAR decisions. The European Resuscitation Council Guidelines for 2021 emphasise the importance of ethical considerations in resuscitation and end-of-life decisions. These guidelines aim to maximise the benefits of life-sustaining treatments while preventing related injuries and ensuring equitable access to quality resuscitation care. One key aspect highlighted in the guidelines is the need for clinicians to engage in discussions about DNAR with patients and/or their families.21 By involving patients and their families in DNAR discussions, healthcare providers can promote greater consistency between patients’ wishes and the treatment provided. This collaborative approach respects patients’ autonomy and empowers them to actively participate in decisions about their care. To further promote the use of DNAR and encourage patient engagement, it is essential to raise awareness and educate both healthcare professionals and the general public about the importance of end-of-life discussions. By normalising discussions about end-of-life care, we can encourage more patients to participate in DNAR conversations and make informed decisions about their treatment preferences.

    This study revealed a strong correlation between age and DNAR orders, with older patients and their families being more inclined to choose DNAR. These findings align with previous research.22–24 As the population continues to age, the demand for DNAR orders among emergency end-of-life patients is expected to grow even further.23 25 Age plays a significant role in a patient’s disease prognosis, and elderly individuals generally face poorer prognoses and derive less benefit from CPR.26 Consequently, there is a growing consensus that CPR should not be universally offered to all patients. This perspective takes into account both medical and ethical considerations, including the potential harms associated with CPR, such as compromising dignity, victim awareness and the risk of adverse outcomes for survivors.27 28 However, it remains unclear from existing literature whether the use of age in making these decisions can be deemed as ‘age discrimination’.23 This study underscores the strong association between age and the use of DNAR orders, but further research is necessary to examine whether this constitutes discriminatory practices based on age. It is essential to carefully consider the ethical implications of age in DNAR orders and ensure that decisions are based on individual patient characteristics, values and preferences.

    Health disparities among women are receiving increased attention in contemporary discourse.29 30 Our study revealed a higher likelihood of female patients opting for DNAR compared with the no DNAR group. Several potential explanations for this observation can be analysed. First, persistent disparities in medical resources between men and women in current healthcare practices have been acknowledged, commonly referred to as the ‘Yentl syndrome’.31 32 This phenomenon signifies the unequal medical treatment received by women relative to men. Gender, as a characteristic embedded in society and culture, is intertwined with various factors such as race, economic status, religion and culture, contributing to gender inequality.33 Second, substantial evidence points to gender differences in pain response. Notably, a study revealed that women experienced longer waiting times, averaging 65 min, to receive emergency department analgesics for acute abdominal pain compared with men who waited only 49 min.34 Third, multiple studies have demonstrated that women exhibit a higher propensity than men to choose DNAR due to concerns about burdening their families.35–37 In conclusion, this study sheds light on the higher likelihood of female patients opting for DNAR compared with their male counterparts. This trend can be attributed to persistent disparities in medical resources, gender disparities in pain response and treatment, as well as women’s concerns about burdening their families. Further research is necessary to focus on determining the individual and social factors that affect women’s decisions regarding DNAR.38

    ACCI holds broad usage as an assessment tool for gauging the severity of comorbid conditions and has demonstrated its efficacy in predicting mortality rates among patients experiencing CA.39 40 In our study, we discovered a positive association between higher ACCI scores and an increased propensity for DNAR selection, which aligns with previous investigations.41 The ACCI serves as a significant predictor of mortality, with a higher score indicating a poorer prognosis and an increased risk of mortality.42 43 This association underscores the value of the ACCI in assessing the severity of comorbidities and its ability to offer insights into patient outcomes. To summarise, our study supports the relationship between higher ACCI scores and the increased likelihood of DNAR selection.

    This study has identified a heightened likelihood of patients diagnosed with cardiogenic disease to select CPR as their preferred course of action. This finding aligns consistently with previous retrospective studies.44 Notably, a majority of patients with cardiogenic causes exhibit a shockable initial rhythm when it comes to CA.45 46 Importantly, patients with a shockable initial rhythm demonstrate significantly improved survival rates and more favourable prognoses in terms of neurological function.47 Consequently, patients and their families tend to favour the administration of CPR as a preferred intervention when the primary diagnosis is cardiogenic disease.

    In addition, our investigation revealed a heightened inclination among patients with a primary diagnosis of cancer or a history of cancer to opt for DNAR measures. This observation aligns with earlier research demonstrating the limited efficacy of CPR in patients with cancer and the resulting adverse impact on their quality of life.6 Given the futility associated with resuscitation attempts in such scenarios.48–50 Our study specifically focused on patients with cancer receiving care within the emergency medicine department. Notably, within this population, certain individuals endured a prolonged disease trajectory. Over the course of their cancer treatment, these patients acquired a comprehensive understanding of their condition, actively engaged in decision-making regarding DNAR directives, and elected DNAR orders in accordance with their personal preferences48 51 However, it is important to recognise that some patients with cancer experienced rapid deterioration, rendering them unable to effectively communicate during emergency situations. Additionally, certain patients’ families requested that the patient’s condition remain confidential, a determination typically made in consultation between the family and attending physicians.52 When signing a DNAR decision for a patient with cancer, factors such as the chance of recovery of autonomic circulation, acceptable neurological outcomes after CPR, and the wishes of the patient and his family are taken into account.53

    Our study revealed a heightened inclination among patients with a documented history of neurological dysfunction to opt for DNAR orders. Neurological dysfunction encompasses a range of abnormalities affecting the functioning of the brain, spinal cord and peripheral nervous system, which can manifest as issues with sensory perception, motor control, cognition, language and other functions associated with specific areas of the body.54 Cerebrovascular accidents, traumatic brain injuries, infections and other aetiologies commonly contribute to the development of neurological dysfunction, with severe cases culminating in comatose states or even fatality. Patients with a history of neurological dysfunction often face a poor prognosis and diminished quality of life, placing substantial burdens on both patients and their families.12 55 Consequently, patients and their families are more inclined to select DNAR orders as a means to address these circumstances.

    With the progress of society and the development of policies, more and more attention has been paid to DNAR worldwide. However, there remains ambiguity regarding the optimal timing for initiating hospice discussions and signing DNAR orders in China.56 In Chinese culture, death is viewed as a collective matter that involves the entire family, and DNAR decisions are typically made by doctors in consultation with one or more family members. As a consequence, a consensus on DNAR orders in advance may prove challenging.57 Moreover, when a patient’s condition deteriorates unexpectedly, the DNAR decision often gives rise to conflicts among family members. Strong emotional attachment to the patient can sometimes lead to a sudden rejection of the DNAR order, even when the futility of CPR is acknowledged.58 Effective communication among physicians, patients and all immediate family members is crucial to ensure that the wishes of both patients and their families are respected in DNAR decisions. By fostering open dialogue and understanding, healthcare providers can navigate these complex dynamics and strive to reach a shared understanding that aligns with the best interests and values of the patient and their family.

    Limitations

    The study had several limitations. The study being retrospective observational means that it relied on existing data and didn’t involve direct manipulation or control of variables. This restricts the ability to establish causation and can only establish associations between independent and dependent variables. Besides, it is essential to acknowledge that this study was conducted as a single-centre retrospective investigation, which may limit the generalisability of the findings to other settings due to potential regional, cultural or institutional variations. To enhance the generalisability of the results, future research should involve multicentre studies that include diverse medical institutions and populations.

    Conclusions

    In summary, patients with DNAR were older, more likely to be female, had higher ACCI scores, a lower number of patients with a primary diagnosis of cardiogenic, and a higher number of patients with a primary diagnosis of cancer related, as well as a history of neurological dysfunction or cancer, compared with the no DNAR group. The higher the stage of cancer, the more likely patients were to choose DNAR. These insights contribute to the ongoing exploration of DNAR orders and underscore the importance of improving the quality of discussions surrounding DNAR.

    Data availability statement

    Data are available on reasonable request. The data that support the findings of this study are available from the corresponding author on reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This research was approved by the scientific investigation review board of Tianjin Medical University General Hospital (approval no. IRB2019-076-01) and the need for written informed consent was waived.

    Acknowledgments

    We thank professor Shuzhang Cui of the Emergency Department of Tianjin Medical University General Hospital for the help with the experimental design.

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    Footnotes

    • C-LW and YL contributed equally.

    • Contributors Y-FC and Y-CL: Funding acquisition. C-LW, Y-CL and Y-FC: Planned the study, wrote the protocol, collected the data, performed statistical analyses, and contributed to the writing of the manuscript. C-LW, Q-SL and YL: Helped with data collection, study design, and coordinated the study. YL and Y-LG: Helped with data collection, study design. Y-FC: Participated in the study design, helped to critically revise the manuscript and is the guarantor. All authors read and approved the final manuscript.

    • Funding This work was supported by the National Natural Science Foundation of China (No.81871593, 81701931) and funded by Tianjin Key Medical Discipline (Specialty) Construction Project (TJYXZDXK-007A).

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.