10 ms·

Doctors' Secret Language for Assisted Suicide

197 points by nitin_flanker 10y ago

Daneel_ 10y ago
My heart just aches for the poor woman who had to inject her husband.. I can't even begin to imagine having to do this with my partner. For every person talking about it openly now, I'm sure there are literally hundreds more dealing with this in secret, and that's a terrible shame. I really hope euthanasia laws progress globally to allow these poor people some peace.
- PantaloonFlames 10y ago
  Funny, i thought the exact opposite. "How lucky!" She was so fortunate to be there at the end and have the ability to take action. Watching a loved one die, slowly, while you stand by helplessly observing their pain... that is much worse.
  - scott_s 10y ago
    She obviously did not feel this way. She had no support from the medical establishment she was surrounded by. I imagine it was isolating, and made a painful moment worse.
  - Daneel_ 10y ago
    Lucky in the sense that she could help her husband, but unlucky in that she had no support, mentally or medically, for her actions. I can't imagine how lonely she must have felt in a time when she so desperately needed others around her.
- fixermark 10y ago
  I think there are quite a few people who enter into lifelong marriage commitments without realizing that when you say "sickness and health..." Yes, that's what you're signing up for. There may come a time when you're the only person your partner trusts to make those calls.
deleted 10y ago
[deleted]
draugadrotten 10y ago
The doctor said to my relative, "Here is the morphine injection device. If you press this button once, you will get a small dose of strong morphine. If you are in severe pain you can press it twice. Never press it more than three times, as you would die for sure at five or six presses." He had terminal cancer, severe pains and he died peacefully thanks to the hint.
- elthran 10y ago
  Not having been in this situation, and (potentially relevant) being in the UK, are the family/patient really allowed to administer drugs like this? It seems to me that administering potent drugs such as morphine would be controlled by medical staff who have the knowledge around safe doses.
  - chiph 10y ago
    If you're on hospice, you're typically at home, with a caregiver coming by once or twice a day to see how you're doing, clean up, etc., and to check on the automatic IV drip machines. These machines come with a remote that lets the patient request additional pain meds, and they're supposed to have limits on how often the button can be pressed in a certain time period. But if you're on hospice, with stage IV pancreatic cancer or other no probability of survival and extremely painful illness, those limits are sometimes not set. Source: A friend's mom was a hospice nurse who ended up going into hospice herself.
  - jevinskie 10y ago
    When my grandmother was in hospice care at home, there were bottles of liquid morphine in her refrigerator. Her family was free to administer it as needed, for pain.
- shultays 10y ago
  Is this like a syringe or a machine? I thought those machines would limit the output
  - golemotron 10y ago
taneq 10y ago
Having gone through the death of a grandparent following a stroke, the magic words we had to use were "I think he's in pain." He was well and truly gone by then, but his body was still battling on despite that. Any questions regarding whether we could give him something to let him down easy were met with legally-mandated "no, we can't give him anything... unless you think he's in pain." It took us a few rounds of this before we cottoned on and completed the dance: "Yes, I think he's in pain."
- bryanlarsen 10y ago
  Confirmation from the article: "It is legal for people to take or give large doses of narcotics to relieve pain, even if a known side effect is that it may hasten death." -- Stanford medical ethicist David Magnus
pcrh 10y ago
Another process that "assists" dying is withdrawal of fluids while someone is heavily sedated. The ensuing death is "natural", but inevitable.
- mikeash 10y ago
  It's insane that we think this is reasonable. It's little different from simply suffocating the person, except much longer and more agonizing.
- sago 10y ago
  Allowing someone to die of dehydration (a process that takes many hours and involves gradual shut down of organ function) might be marginally more kind than letting someone die more slowly, but is only fractionally so. Fortunately most doctors have more empathy and ethics. The difficulty comes with conditions that aren't immanently terminal. Campaigner Debbie Purdy took eighteen months to starve herself to death after she reached the point where she did not want to continue with her progressive MS. That's just insane and barbaric, but fewer doctors will step in at that point. We need better laws, as a matter of civil rights. If I have the right to life, I should have the right to relinquish it.
  - pcrh 10y ago
    I suppose the only saving grace of this "natural" death by thirst, which is not an uncommon occurrence, is that it is done while the person is heavily sedated. Otherwise it would be incredibly painful, I imagine.
  - draugadrotten 10y ago
    > If I have the right to life, I should have the right to relinquish it. That statement needs better justification than sounding good. For assisted suicide, It is necessary but not sufficient that the person wishes suicide. Just because someone wants to die doesn't mean that we should let them die. And even if someone wants to die, it doesn't imply that that person have a right to demand someone else to kill them - you do not even have the right to demand that someone else kills you by looking the other way when you kill yourself. The criteria for when someone should be allowed to help someone else to die is complex and requires a lot of safeguards.
shermozle 10y ago
The problem with this being a secret, behind-the-scenes thing is that there's plenty of scope of serial killers. Harold Shipman got away with being the most prolific serial killer of all time because he was knocking off old people. This is the argument that needs to be made, because euthanasia is and will go on anyway.
- beobab 10y ago
  Good point, shermozle. And the problem with it being allowed and acceptable is that older people "don't want to be a burden", and younger people with inheritances in the balance might make a decision based more on greed than on wanting to help. It's a difficult and emotive subject, and you can easily argue both sides convincingly.
- sangnoir 10y ago
  > The problem with this being a secret, behind-the-scenes thing is that there's plenty of scope of serial killers. How large is the serial killer market? How about a Tinder-like app[1] that matches serial killers to hospice patients on a morphine-only contract. The 'killers' get to pay a fee[2], and part of it goes to the clients' estate. 1. This is a rather macabre thought experiment. My apologies if you are/have a loved one going through hospice care and this offends you. 2. How many laws would this disruptive arrangement break? Sadly the law is behind the curve
shermozle 10y ago
The problem with this being a secret, behind-the-scenes thing is that there's plenty of scope of serial killers. Harold Shipman got away with being the most prolific serial killer of all time because he was knocking off old people. This is the argument that needs to be made, because euthanasia is and will go on anyway.
nkoren 10y ago
The first assisted-suicide advocate I ever met left an impression I will never forget. He had the most romantic life story. He was an Indian from Gujarat who had moved to America in the 1960s to become a hippy. Then one day he found a flier for an Indian dance troupe that was coming through town. In the back row of the group photo he saw a face that he instantly recognised as the love of his life. He followed her back to India, where he courted and they fell in love. Her parents refused permission to marry, so he got a haircut and a job in the civil service, and the parents accepted. They married and soon had two small, beautiful children. Then she got breast cancer. "At the end, she was in so much pain. It lasted so long. I would have done anything, anything to make that easier for her. But I could only watch while the cancer slowly tortured her to death." He was still broken from the experience. It had been 30 years. Life-sized portraits of her were hung throughout the house. The mythic quality of their love was undiminished, not only for him but for anybody who entered that house. What their love needed was a quiet, peaceful, comfortable death. That would have been good and right and true. It's worth fighting for.
- jpatokal 10y ago
  > the cancer slowly tortured her to death With the help of the Indian government, which makes it extremely difficult for people to get access to opioids, even if they're terminally ill patients. http://www.newyorker.com/tech/elements/an-epidemic-of-pain-in-india http://www.newyorker.com/tech/elements/an-epidemic-of-pain-i...
  - MichaelGG 10y ago
    Wow that's evil. The war on opiates is unethical. The fear of people enjoying a vice overrules compassion, which is just sick.
  - nkoren 10y ago
    Absolutely worth highlighting, yes.
deleted 10y ago
[deleted]
cisstrd 10y ago
Also on assisted suicide and interesting: "By the time you read this, I’ll be dead - Between 1999 and 2001, I helped eight people die, including the poet Al Purdy. Now, as I prepare to take my own life, I’m ready to tell my story" by John Hofsess http://torontolife.com/city/life/john-hofsess-assisted-suicide http://torontolife.com/city/life/john-hofsess-assisted-suici... I also recommend the Documentary "Choosing to die" with Terry Pratchett http://www.dailymotion.com/video/xnu340_terry-pratchett-choosing-to-die_shortfilms http://www.dailymotion.com/video/xnu340_terry-pratchett-choo... Very powerful and thought provoking
briffle 10y ago
Oregon was the first state to approve physician assisted suicide.. but last year, after a stroke left a relative in a coma with no possibility of recovery, my family got to learn that the state recently passed a law making it illegal to disable a pacemaker.. So even though we requested that they unplug her, they were not able to turn off the one thing that was still keeping her going for a day or so longer..
LCDninja 10y ago
I accidentally euthanised my father because I misunderstood the conversation I was having with a nurse. He had a stroke and was in intensive care, we were told he probably wouldn't live - and if he did - he'd require care for the rest of his life. He had fallen into a coma when the nurse kept asking me if I thought he was in pain and needed more morphine. She kept giving him more, returning to ask the same question and doing it over and over. I can't remember how many times. He began Cheyne–Stokes breathing, and eventually died. I remember feeling strange about the situation, and years later I connected the dots between the amount of morphine given, the breathing (symptomatic of morphine overdose), and his subsequent death. Understanding that I was responsible was something that took a long time to cope with. My mother faced terminal cancer a few years ago, and I found myself in exactly the same situation. Thankfully I understood what was happening. The decision to take her off fluids and to "help her along," was made by a team of medical staff with myself deeply involved in the discussion (which looking back, was a desperate attempt for me to negotiate any way I could for her life). At least Mum understood she was going to die, and I'm glad my eyes were open to what was happening. I feel that the economics of hospital beds have a lot to do with this. Beds in the oncology ward are in demand, as of those in intensive care. I've seen all of my families previous generation die of cancer in either in the same way - in hospital, in oncology or intensive care, always assisted death. It makes me think that if I ever go down that road I don't want to be anywhere near the medical industrial complex.
- mfoy_ 10y ago
  Reading this, and other comments, makes me realize there is a secret assisted-dying dance in play in the medical system. If you say the magic words "I think he is in pain" repeatedly, then the medical staff can legally administer a coincidentally lethal amount of morphine. If assisted-dying was legal, regulated, and a well accepted practice there would be none of this "Do you think he is in pain? wink" nonsense and they could directly ask whether or not you would like to have him humanely euthanized. Then no one else would ever have to begin a comment with "I accidentally euthanized my father" ever again. That is just too tragic. Even if it was honestly the best course of action, I'd want to at least be cognizant of my decision, not to just piece it together years later. :(
CaptSpify 10y ago
I had a similar 'secret language' experience, though not at all related to AS. I have a diabetic pet, and the vet was explaining how to use insulin. Naturally, one of our concerns was cost. He kept mentioning how he'd seen many people use insulin for months after it's expiration-date. He was clear that you should "always follow the instructions", but that occasionally he'd seen people use old insulin, and, as long as they were consistently checking their glucose, it worked fine for them. We finally figured out his message: The insulin expiration date might or might not be valid. Testing is better than going by the bottle's expiration date, within reason of course. He couldn't tell us to ignore the date, but he could tell us about when he'd seen it work past the date.
wmeredith 10y ago
The heartbreaking stories in this article, as well as several from the comments, all seem to be the symptoms of an overly litigious climate in our healthcare system. Health workers are afraid to speak plainly. It's gross.
- scott_s 10y ago
  I don't think that's the case. I think the primary factor is the laws which govern how medical professionals can act - and I think that has more support from the article, and by people's comments.
mdturnerphys 10y ago
"Just over 3 percent of U.S. doctors said they have written a prescription for life-ending medication, according to an anonymous survey published in The New England Journal of Medicine in 1998. Almost 5 percent of doctors reported giving a patient a lethal injection." That seemed really high, given that most physicians aren't in relevant specialties. Clicking through to the article, it actually says: "The sample was drawn from 10 specialties, selected on the basis of previous surveys as those in which physicians are likely to receive requests from patients for assistance in hastening death." Further, it was clear that there were self-selection biases in the responses.
fixermark 10y ago
I've seen a terminal cancer patient breathe her last after the nurse (with doctor authorization) overrode the safeties on the infusion system to give her an overdose of painkillers. She wasn't ever getting out of that room alive, and everybody knew it. She died with her family and loved ones at her side. I think what a lot of people (in America) may not understand about the national euthanasia discussion is that in the absence of firm policy, we don't have no euthanasia; we have ad-hoc, case-by-case, absolutely-functionally-necessary euthanasia. The notion that doctors can always do no harm is a polite fantasy that blinds people to the messy realities near the boundary of human life and death. Similarly to the abortion question, end-of-life euthanasia is something people find medically necessary sometimes, and in the absence of a society-wide consensus that allows for it, doctors, nurses, and patients are left doing the best they can and bearing the moral responsibilities alone. Unlike the abortion question, absolutely everyone is going to be in a place where they are either caring for someone who is dying or dying themselves.

197 points by nitin_flanker 10y ago

My heart just aches for the poor woman who had to inject her husband.. I can't even begin to imagine having to do this with my partner. For every person talking about it openly now, I'm sure there are literally hundreds more dealing with this in secret, and that's a terrible shame. I really hope euthanasia laws progress globally to allow these poor people some peace.

PantaloonFlames 10y ago
Funny, i thought the exact opposite. "How lucky!" She was so fortunate to be there at the end and have the ability to take action. Watching a loved one die, slowly, while you stand by helplessly observing their pain... that is much worse.
- scott_s 10y ago
  She obviously did not feel this way. She had no support from the medical establishment she was surrounded by. I imagine it was isolating, and made a painful moment worse.
- Daneel_ 10y ago
  Lucky in the sense that she could help her husband, but unlucky in that she had no support, mentally or medically, for her actions. I can't imagine how lonely she must have felt in a time when she so desperately needed others around her.
fixermark 10y ago
I think there are quite a few people who enter into lifelong marriage commitments without realizing that when you say "sickness and health..." Yes, that's what you're signing up for. There may come a time when you're the only person your partner trusts to make those calls.

deleted 10y ago

[deleted]

draugadrotten 10y ago

The doctor said to my relative, "Here is the morphine injection device. If you press this button once, you will get a small dose of strong morphine. If you are in severe pain you can press it twice. Never press it more than three times, as you would die for sure at five or six presses." He had terminal cancer, severe pains and he died peacefully thanks to the hint.

elthran 10y ago
Not having been in this situation, and (potentially relevant) being in the UK, are the family/patient really allowed to administer drugs like this? It seems to me that administering potent drugs such as morphine would be controlled by medical staff who have the knowledge around safe doses.
- chiph 10y ago
  If you're on hospice, you're typically at home, with a caregiver coming by once or twice a day to see how you're doing, clean up, etc., and to check on the automatic IV drip machines. These machines come with a remote that lets the patient request additional pain meds, and they're supposed to have limits on how often the button can be pressed in a certain time period. But if you're on hospice, with stage IV pancreatic cancer or other no probability of survival and extremely painful illness, those limits are sometimes not set. Source: A friend's mom was a hospice nurse who ended up going into hospice herself.
- jevinskie 10y ago
  When my grandmother was in hospice care at home, there were bottles of liquid morphine in her refrigerator. Her family was free to administer it as needed, for pain.
shultays 10y ago
Is this like a syringe or a machine? I thought those machines would limit the output
- golemotron 10y ago

taneq 10y ago

Having gone through the death of a grandparent following a stroke, the magic words we had to use were "I think he's in pain." He was well and truly gone by then, but his body was still battling on despite that. Any questions regarding whether we could give him something to let him down easy were met with legally-mandated "no, we can't give him anything... unless you think he's in pain." It took us a few rounds of this before we cottoned on and completed the dance: "Yes, I think he's in pain."

bryanlarsen 10y ago
Confirmation from the article: "It is legal for people to take or give large doses of narcotics to relieve pain, even if a known side effect is that it may hasten death." -- Stanford medical ethicist David Magnus

pcrh 10y ago

Another process that "assists" dying is withdrawal of fluids while someone is heavily sedated. The ensuing death is "natural", but inevitable.

mikeash 10y ago
It's insane that we think this is reasonable. It's little different from simply suffocating the person, except much longer and more agonizing.
sago 10y ago
Allowing someone to die of dehydration (a process that takes many hours and involves gradual shut down of organ function) might be marginally more kind than letting someone die more slowly, but is only fractionally so. Fortunately most doctors have more empathy and ethics. The difficulty comes with conditions that aren't immanently terminal. Campaigner Debbie Purdy took eighteen months to starve herself to death after she reached the point where she did not want to continue with her progressive MS. That's just insane and barbaric, but fewer doctors will step in at that point. We need better laws, as a matter of civil rights. If I have the right to life, I should have the right to relinquish it.
- pcrh 10y ago
  I suppose the only saving grace of this "natural" death by thirst, which is not an uncommon occurrence, is that it is done while the person is heavily sedated. Otherwise it would be incredibly painful, I imagine.
- draugadrotten 10y ago
  > If I have the right to life, I should have the right to relinquish it. That statement needs better justification than sounding good. For assisted suicide, It is necessary but not sufficient that the person wishes suicide. Just because someone wants to die doesn't mean that we should let them die. And even if someone wants to die, it doesn't imply that that person have a right to demand someone else to kill them - you do not even have the right to demand that someone else kills you by looking the other way when you kill yourself. The criteria for when someone should be allowed to help someone else to die is complex and requires a lot of safeguards.

shermozle 10y ago

The problem with this being a secret, behind-the-scenes thing is that there's plenty of scope of serial killers. Harold Shipman got away with being the most prolific serial killer of all time because he was knocking off old people. This is the argument that needs to be made, because euthanasia is and will go on anyway.

beobab 10y ago
Good point, shermozle. And the problem with it being allowed and acceptable is that older people "don't want to be a burden", and younger people with inheritances in the balance might make a decision based more on greed than on wanting to help. It's a difficult and emotive subject, and you can easily argue both sides convincingly.
sangnoir 10y ago
> The problem with this being a secret, behind-the-scenes thing is that there's plenty of scope of serial killers. How large is the serial killer market? How about a Tinder-like app[1] that matches serial killers to hospice patients on a morphine-only contract. The 'killers' get to pay a fee[2], and part of it goes to the clients' estate. 1. This is a rather macabre thought experiment. My apologies if you are/have a loved one going through hospice care and this offends you. 2. How many laws would this disruptive arrangement break? Sadly the law is behind the curve

shermozle 10y ago

nkoren 10y ago

The first assisted-suicide advocate I ever met left an impression I will never forget. He had the most romantic life story. He was an Indian from Gujarat who had moved to America in the 1960s to become a hippy. Then one day he found a flier for an Indian dance troupe that was coming through town. In the back row of the group photo he saw a face that he instantly recognised as the love of his life. He followed her back to India, where he courted and they fell in love. Her parents refused permission to marry, so he got a haircut and a job in the civil service, and the parents accepted. They married and soon had two small, beautiful children. Then she got breast cancer. "At the end, she was in so much pain. It lasted so long. I would have done anything, anything to make that easier for her. But I could only watch while the cancer slowly tortured her to death." He was still broken from the experience. It had been 30 years. Life-sized portraits of her were hung throughout the house. The mythic quality of their love was undiminished, not only for him but for anybody who entered that house. What their love needed was a quiet, peaceful, comfortable death. That would have been good and right and true. It's worth fighting for.

jpatokal 10y ago
> the cancer slowly tortured her to death With the help of the Indian government, which makes it extremely difficult for people to get access to opioids, even if they're terminally ill patients. http://www.newyorker.com/tech/elements/an-epidemic-of-pain-in-india http://www.newyorker.com/tech/elements/an-epidemic-of-pain-i...
- MichaelGG 10y ago
  Wow that's evil. The war on opiates is unethical. The fear of people enjoying a vice overrules compassion, which is just sick.
- nkoren 10y ago
  Absolutely worth highlighting, yes.

deleted 10y ago

[deleted]

cisstrd 10y ago

Also on assisted suicide and interesting: "By the time you read this, I’ll be dead - Between 1999 and 2001, I helped eight people die, including the poet Al Purdy. Now, as I prepare to take my own life, I’m ready to tell my story" by John Hofsess http://torontolife.com/city/life/john-hofsess-assisted-suicide http://torontolife.com/city/life/john-hofsess-assisted-suici... I also recommend the Documentary "Choosing to die" with Terry Pratchett http://www.dailymotion.com/video/xnu340_terry-pratchett-choosing-to-die_shortfilms http://www.dailymotion.com/video/xnu340_terry-pratchett-choo... Very powerful and thought provoking

briffle 10y ago

Oregon was the first state to approve physician assisted suicide.. but last year, after a stroke left a relative in a coma with no possibility of recovery, my family got to learn that the state recently passed a law making it illegal to disable a pacemaker.. So even though we requested that they unplug her, they were not able to turn off the one thing that was still keeping her going for a day or so longer..

LCDninja 10y ago

I accidentally euthanised my father because I misunderstood the conversation I was having with a nurse. He had a stroke and was in intensive care, we were told he probably wouldn't live - and if he did - he'd require care for the rest of his life. He had fallen into a coma when the nurse kept asking me if I thought he was in pain and needed more morphine. She kept giving him more, returning to ask the same question and doing it over and over. I can't remember how many times. He began Cheyne–Stokes breathing, and eventually died. I remember feeling strange about the situation, and years later I connected the dots between the amount of morphine given, the breathing (symptomatic of morphine overdose), and his subsequent death. Understanding that I was responsible was something that took a long time to cope with. My mother faced terminal cancer a few years ago, and I found myself in exactly the same situation. Thankfully I understood what was happening. The decision to take her off fluids and to "help her along," was made by a team of medical staff with myself deeply involved in the discussion (which looking back, was a desperate attempt for me to negotiate any way I could for her life). At least Mum understood she was going to die, and I'm glad my eyes were open to what was happening. I feel that the economics of hospital beds have a lot to do with this. Beds in the oncology ward are in demand, as of those in intensive care. I've seen all of my families previous generation die of cancer in either in the same way - in hospital, in oncology or intensive care, always assisted death. It makes me think that if I ever go down that road I don't want to be anywhere near the medical industrial complex.

mfoy_ 10y ago
Reading this, and other comments, makes me realize there is a secret assisted-dying dance in play in the medical system. If you say the magic words "I think he is in pain" repeatedly, then the medical staff can legally administer a coincidentally lethal amount of morphine. If assisted-dying was legal, regulated, and a well accepted practice there would be none of this "Do you think he is in pain? wink" nonsense and they could directly ask whether or not you would like to have him humanely euthanized. Then no one else would ever have to begin a comment with "I accidentally euthanized my father" ever again. That is just too tragic. Even if it was honestly the best course of action, I'd want to at least be cognizant of my decision, not to just piece it together years later. :(

CaptSpify 10y ago

I had a similar 'secret language' experience, though not at all related to AS. I have a diabetic pet, and the vet was explaining how to use insulin. Naturally, one of our concerns was cost. He kept mentioning how he'd seen many people use insulin for months after it's expiration-date. He was clear that you should "always follow the instructions", but that occasionally he'd seen people use old insulin, and, as long as they were consistently checking their glucose, it worked fine for them. We finally figured out his message: The insulin expiration date might or might not be valid. Testing is better than going by the bottle's expiration date, within reason of course. He couldn't tell us to ignore the date, but he could tell us about when he'd seen it work past the date.

wmeredith 10y ago

The heartbreaking stories in this article, as well as several from the comments, all seem to be the symptoms of an overly litigious climate in our healthcare system. Health workers are afraid to speak plainly. It's gross.

scott_s 10y ago
I don't think that's the case. I think the primary factor is the laws which govern how medical professionals can act - and I think that has more support from the article, and by people's comments.

mdturnerphys 10y ago

"Just over 3 percent of U.S. doctors said they have written a prescription for life-ending medication, according to an anonymous survey published in The New England Journal of Medicine in 1998. Almost 5 percent of doctors reported giving a patient a lethal injection." That seemed really high, given that most physicians aren't in relevant specialties. Clicking through to the article, it actually says: "The sample was drawn from 10 specialties, selected on the basis of previous surveys as those in which physicians are likely to receive requests from patients for assistance in hastening death." Further, it was clear that there were self-selection biases in the responses.

fixermark 10y ago

I've seen a terminal cancer patient breathe her last after the nurse (with doctor authorization) overrode the safeties on the infusion system to give her an overdose of painkillers. She wasn't ever getting out of that room alive, and everybody knew it. She died with her family and loved ones at her side. I think what a lot of people (in America) may not understand about the national euthanasia discussion is that in the absence of firm policy, we don't have no euthanasia; we have ad-hoc, case-by-case, absolutely-functionally-necessary euthanasia. The notion that doctors can always do no harm is a polite fantasy that blinds people to the messy realities near the boundary of human life and death. Similarly to the abortion question, end-of-life euthanasia is something people find medically necessary sometimes, and in the absence of a society-wide consensus that allows for it, doctors, nurses, and patients are left doing the best they can and bearing the moral responsibilities alone. Unlike the abortion question, absolutely everyone is going to be in a place where they are either caring for someone who is dying or dying themselves.