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October 24, 1990, Vol 264, No. 16 >
ARTICLE | October 24, 1990

Life-Sustaining Therapy: Title and subTitle BreakA Model for Appropriate Use FREE

Donald J. Murphy, MD; David B. Matchar, MD
[+] Author Affiliations

Reprint requests to Intensive Care Research Unit, George Washington University Medical Center, 2300 K St NW, Washington, DC 20037 (Dr Murphy).


JAMA. 1990;264(16):2103-2108. doi:10.1001/jama.1990.03450160073032
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Published online
Article
References

New strategies are needed to curb the proliferation of life-sustaining therapies that rarely benefit patients. We propose a model for appropriate use of such therapies that incorporates effectiveness, utility, and marginal costs. If a therapy is rarely effective and rarely desirable, it is considered medically inappropriate. If the marginal cost-effectiveness ratio is inordinately high, it is considered economically inappropriate. If a therapy is either medically or economically inappropriate, it should not be automatically offered. The model provides an operational definition of futility and is illustrated with an analysis of out-of-hospital cardiopulmonary resuscitation for chronically ill older people. Advance directives, explicit health care rationing, and defining futile therapy based on survival predictions are alternatives to the appropriate care model, but are insufficient strategies to solve the problem of inappropriate life-sustaining care.

(JAMA. 1990;264:2103-2108)

REFERENCES

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Weinstein MC, Fineberg HV. Clinical Decision Analysis . Philadelphia, Pa: WB Saunders Co; 1980;.
2 +
Sox HC, Blatt MA, Higgins MC, Marton KI. Medical Decision Making . Stoneham, Mass; Butterworths; 1988;.
3 +
Kahneman D, Tversky A.  The psychology of preference . Sci Am. 1982;;246:160-173.
4 +
Williams S.  The limit of quantitative ethics . Med Decis Making . 1987;;7:121-123.
5 +
Benatar SR.  Fatal asthma . N Engl J Med. 1986;; 314:423-429.
6 +
Ottinger LW.  Ruptured arteriosclerotic aneurysms of the abdominal aorta: reducing mortality . JAMA . 1975;;233:147-150.
7 +
Wachter RM, Luce JM, Lo B, Raffin TA.  Life-sustaining treatment for patients with AIDS . Chest . 1989;;95:647-652.
8 +
Steinbrook R, Lo B, Moulton J, et al.  Preferences of homosexual men with AIDS for life-sustaining treatment . N Engl J Med. 1986;;314:457-460.
9 +
Friedman Y, Franklin C, Rackow EC, Weil MH.  Improved survival in patients with AIDS, Pneumocystis carinii pneumonia, and severe respiratory failure . Chest . 1989;;96:862-866.
10 +
Luce JM, Wachter RM, Hopewell PC.  Intensive care of patients with the acquired immunodeficiency syndrome: time for a reassessment . Am Rev Respir Dis. 1988;;137:1261-1263.
11 +
Detsky AS, Naglie IG.  A clinician's guide to cost-effectiveness analysis . Ann Intern Med. 1990;;113:147-154.
12 +
Durbin M.  Bone marrow transplantation: economic, ethical, and social issues . Pediatrics . 1988;;82:774-783.
13 +
Wagner DP.  Economics of prolonged mechanical ventilation . Am Rev Respir Dis. 1989;;140:S14-S18.
14 +
Crawshaw R, Garland M, Hines B, Anderson B.  Developing principles for prudent health care allocation: the continuing Oregon experiment . West J Med. 1990;;152:441-446.
15 +
Schuster DP, Marion JM.  Precedents for meaningful recovery during treatment in a medical intensive care unit: outcome in patients with hematologic malignancy . Am J Med. 1983;;75:402-408.
16 +
Denardo SJ, Oye RK, Bellamy PE.  Efficacy of intensive care for bone marrow transplant patients with respiratory failure . Crit Care Med. 1989;; 17:4-6.
17 +
Knaus WA, Draper EA, Wagner DP, Zimmerman JE.  Prognosis in acute organ-system failure . Ann Surg. 1985;;202:685-693.
18 +
Pinzani M, Zipser RD.  The hepatorenal syndrome . Intensive Care Med. 1987;;13:148-153.
19 +
Gibson RM, Stephenson GC.  Aggressive management of severe closed head trauma: time for reappraisal . Lancet . 1989;;2:369-371.
20 +
Lantos JD, Miles SH, Silverstein MD, Stocking CB.  Survival after cardiopulmonary resuscitation in babies of very low birth weight: is CPR futile therapy? N Engl J Med. 1988;;318:91-95.
21 +
Murphy DJ, Murray AM, Robinson BE, Campion EW.  Outcomes of cardiopulmonary resuscitation in the elderly . Ann Intern Med. 1989;;111:199-205.
22 +
Applebaum GE, King JE, Finucane TE.  The outcome of CPR initiated in nursing homes . J Am Geriatr Soc. 1990;;38:197-200.
23 +
Bachman JW, McDonald GS, O'Brien PC.  A study of out-of-hospital cardiac arrests in northeastern Minnesota . JAMA . 1986;;256:477-483.
24 +
Kellermann AL, Staves DR, Hackman BB.  Inhospital resuscitation following unsuccessful prehospital advanced cardiac life support: 'heroic efforts' or an exercise in futility . Ann Emerg Med. 1988;;17:589-594.
25 +
Murphy DJ.  Do-not-resuscitate orders: time for reappraisal in long-term care institutions . JAMA . 1988;;260:2098-2101.
26 +
Shmerling RH, Bedell SE, Lilienfeld A, Delbanco TL.  Discussing cardiopulmonary resuscitation: a study of elderly outpatients . J Gen Intern Med. 1988;;3:317-321.
27 +
Wagner A.  Cardiopulmonary resuscitation in the aged: a prospective survey . N Engl J Med. 1984;;310:1129-1130.
28 +
Finucane TE, Denman SJ.  Deciding about resuscitation in a nursing home: theory and practice . J Am Geriatr Soc. 1989;;37:684-688.
29 +
Zweibel NR, Cassel CK.  Treatment choices at the end of life: a comparison of decisions by older patients and their physician-selected proxies . Gerontologist . 1989;;29:615-621.
30 +
Volicer L, Rheaume Y, Brown J, et al.  Hospice approach to the treatment of patients with advanced dementia of the Alzheimer type . JAMA . 1986;;256:2210-2213.
31 +
Emanuel LL, Emanuel EJ.  The medical directive: a new comprehensive advance care document . JAMA . 1989;;261:3288-3293.
32 +
Uhlmann RF, Clark H, Pearlman RA, et al.  Medical management decisions in nursing home patients: principles and policy recommendations . Ann Intern Med. 1987;;106:879-885.
33 +
Bedell SE, Pelle D, Maher PL, Cleary PD.  Donot-resuscitate orders for critically ill patients in the hospital: how are they used and what is their impact? JAMA . 1986;;256:233-237.
34 +
Blackhall LJ, Cobb J, Moskowitz MA.  Discussions regarding aggressive care with critically ill patients . J Gen Intern Med. 1989;;4:399-402.
35 +
Frankl D, Oye RK, Bellamy PE.  Attitudes of hospitalized patients toward life support: a survey of 200 medical inpatients . Am J Med. 1989;;86:645-648.
36 +
Ende J, Kazis L, Ash A, Moskowitz MA.  Measuring patients' desire for autonomy: decision making and information-seeking preferences among medical patients . J Gen Intern Med. 1989;;4:23-30.
37 +
Iserson KV.  Prehospital DNR orders . Hastings Cent Rep. 1989;;19:17-19.
38 +
Annas GJ.  Precatory prediction and mindless mimicry: the case of Mary O'Connor . Hastings Cent Rep. 1988;;18:31-33.
39 +
High DM.  All in the family: extended autonomy and expectations in surrogate health care decision-making . Gerontologist. 1988;;28( (suppl) ):46-52.
40 +
Ouslander JG, Tymchuk AJ, Rahbar B.  Health care decisions among elderly long-term care residents and their potential proxies . Arch Intern Med. 1989;;149:1367-1372.
41 +
Uhlmann RF, Pearlman RA, Cain KC.  Physicians' and spouses' predictions of elderly patients' resuscitation preferences . J Gerontol. 1988;;43: M115-M121.
42 +
Youngner SJ.  Do-not-resuscitate orders: no longer secret, but still a problem . Hastings Cent Rep. 1987;;17:24-33.
43 +
Evans RW.  Health care technology and the inevitability of resource allocation and rationing decisions: part II . JAMA . 1983;;249:2208-2219.
44 +
Aaron H, Schwartz WB.  Rationing health care: the choice before us . Science . 1990;;247:418-422.
45 +
Thurow LC.  Medicine versus economics . N Engl J Med. 1985;;313:611-614.
46 +
Lamm RD.  Critical decisions in medical care: birth to death . South Med J. 1989;;82:822-824.
47 +
Churchill LR.  Should we ration health care by age? J Am Geriatr Soc. 1988;;36:644-647.
48 +
Grumet GW.  Health care rationing through inconvenience: the third party's secret weapon . N Engl J Med. 1989;;321:607-611.
49 +
Callahan D. What Kind of Life—the Limits of Medical Progress . New York, NY: Simon & Schuster Inc; 1990;.
50 +
Caper P.  Solving the medical care dilemma . N Engl J Med. 1988;;318:1535-1536.
51 +
Callahan D.  Old age and new policy . JAMA . 1989;;261:905-906.
52 +
Schneider EL.  Options to control the rising health care costs of older Americans . JAMA . 1989;;261:907-908.
53 +
Daniels W.  Why saying no to patients in the United States is so hard: cost containment, justice, and provider autonomy . N Engl J Med. 1986;;314: 1380-1383.
54 +
Hammond J, Ward CG.  Decision not to treat: 'do not resuscitate' order for the burn patient in the acute setting . Crit Care Med. 1989;;17:136-138.
55 +
Taffet GE, Teasdale TA, Luchi RJ.  In-hospital cardiopulmonary resuscitation . JAMA . 1988;;260: 2069-2072.
56 +
Lo B, Raffin TA, Cohen NH, et al.  Ethical dilemmas about intensive care for patients with AIDS . Rev Infect Dis. 1987;;9:1163-1167.
57 +
Youngner SJ.  Who defines futility? JAMA . 1988;;260:2094-2095.
58 +
Lantos JD, Singer PA, Walker RM, et al.  The illusion of futility in clinical practice . Am J Med. 1989;;87:81-84.
59 +
Schneiderman LJ, Jecker NS, Jonsen AR.  Medical futility: its meaning and ethical implications . Ann Intern Med. 1990;;112:949-954.
60 +
Chang RWS.  Individual outcome prediction models for intensive care units . Lancet . 1989;;2:143-146.
61 +
Dobkin JE, Cutler RE.  Use of APACHE II classification to evaluate outcome of patients receiving hemodialysis in an intensive care unit . West J Med. 1988;;149:547-550.
62 +
Hanley JA, Lippman-Hand A.  If nothing goes wrong, is everything all right? interpreting zero numerators . JAMA . 1983;;249:1743-1745.
63 +
Poe RH, Wahl GW, Qazi R, Kallay MC, Utell MJ, Morrow GR.  Predictors of mortality in the immunocompromised patient with pulmonary infiltrates . Arch Intern Med. 1986;;146:1304-1308.
64 +
Wachter RM, Luce JM, Turner J, Volberding P, Hopewell PC.  Intensive care of patients with the acquired immunodeficiency syndrome: outcome and changing patterns of utilization . Am Rev Respir Dis. 1986;;134:891-896.
65 +
Froberg DG, Kane RL.  Methodology for measuring health-state preferences, I: measurement strategies . J Clin Epidemiol. 1989;;42:345-354.
66 +
Mulley AG.  Assessing patients' utilities: can the ends justify the means? Med Care. 1989;;27: S269-S281.
67 +
Froberg DG, Kane RL.  Methodology for measuring health-state preferences, IV: progress and a research agenda . J Clin Epidemiol. 1989;;42:675-685.
68 +
Thurow LC.  Learning to say 'no.' N Engl J Med. 1984;;311:1569-1572.
69 +
Engelhardt HT Jr, Rie MA.  Intensive care units, scarce resources, and conflicting principles of justice . JAMA . 1986;;255:1159-1164.
70 +
Blackhall LJ.  Must we always use CPR? N Engl J Med. 1987;;317:1281-1285.
71 +
Carlon GC.  Just say no . Crit Care Med. 1989;;17:106-107.
72 +
Weir RF. Abating Treatment With Critically Ill Patients: Ethical and Legal Limits to the Medical Prolongation of Life . New York, NY: Oxford University Press Inc; 1989;.
73 +
Lomas J, Anderson GM, Domnick-Pierre K, et al.  Do practice guidelines guide practice? the effect of a consensus statement on the practice of physicians . N Engl J Med. 1989;;321:1306-1311.
74 +
Brook RH.  Practice guidelines and practicing medicine: are they compatible? JAMA . 1989;;262: 3027-3030.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Weinstein MC, Fineberg HV. Clinical Decision Analysis . Philadelphia, Pa: WB Saunders Co; 1980;.
2 +
Sox HC, Blatt MA, Higgins MC, Marton KI. Medical Decision Making . Stoneham, Mass; Butterworths; 1988;.
3 +
Kahneman D, Tversky A.  The psychology of preference . Sci Am. 1982;;246:160-173.
4 +
Williams S.  The limit of quantitative ethics . Med Decis Making . 1987;;7:121-123.
5 +
Benatar SR.  Fatal asthma . N Engl J Med. 1986;; 314:423-429.
6 +
Ottinger LW.  Ruptured arteriosclerotic aneurysms of the abdominal aorta: reducing mortality . JAMA . 1975;;233:147-150.
7 +
Wachter RM, Luce JM, Lo B, Raffin TA.  Life-sustaining treatment for patients with AIDS . Chest . 1989;;95:647-652.
8 +
Steinbrook R, Lo B, Moulton J, et al.  Preferences of homosexual men with AIDS for life-sustaining treatment . N Engl J Med. 1986;;314:457-460.
9 +
Friedman Y, Franklin C, Rackow EC, Weil MH.  Improved survival in patients with AIDS, Pneumocystis carinii pneumonia, and severe respiratory failure . Chest . 1989;;96:862-866.
10 +
Luce JM, Wachter RM, Hopewell PC.  Intensive care of patients with the acquired immunodeficiency syndrome: time for a reassessment . Am Rev Respir Dis. 1988;;137:1261-1263.
11 +
Detsky AS, Naglie IG.  A clinician's guide to cost-effectiveness analysis . Ann Intern Med. 1990;;113:147-154.
12 +
Durbin M.  Bone marrow transplantation: economic, ethical, and social issues . Pediatrics . 1988;;82:774-783.
13 +
Wagner DP.  Economics of prolonged mechanical ventilation . Am Rev Respir Dis. 1989;;140:S14-S18.
14 +
Crawshaw R, Garland M, Hines B, Anderson B.  Developing principles for prudent health care allocation: the continuing Oregon experiment . West J Med. 1990;;152:441-446.
15 +
Schuster DP, Marion JM.  Precedents for meaningful recovery during treatment in a medical intensive care unit: outcome in patients with hematologic malignancy . Am J Med. 1983;;75:402-408.
16 +
Denardo SJ, Oye RK, Bellamy PE.  Efficacy of intensive care for bone marrow transplant patients with respiratory failure . Crit Care Med. 1989;; 17:4-6.
17 +
Knaus WA, Draper EA, Wagner DP, Zimmerman JE.  Prognosis in acute organ-system failure . Ann Surg. 1985;;202:685-693.
18 +
Pinzani M, Zipser RD.  The hepatorenal syndrome . Intensive Care Med. 1987;;13:148-153.
19 +
Gibson RM, Stephenson GC.  Aggressive management of severe closed head trauma: time for reappraisal . Lancet . 1989;;2:369-371.
20 +
Lantos JD, Miles SH, Silverstein MD, Stocking CB.  Survival after cardiopulmonary resuscitation in babies of very low birth weight: is CPR futile therapy? N Engl J Med. 1988;;318:91-95.
21 +
Murphy DJ, Murray AM, Robinson BE, Campion EW.  Outcomes of cardiopulmonary resuscitation in the elderly . Ann Intern Med. 1989;;111:199-205.
22 +
Applebaum GE, King JE, Finucane TE.  The outcome of CPR initiated in nursing homes . J Am Geriatr Soc. 1990;;38:197-200.
23 +
Bachman JW, McDonald GS, O'Brien PC.  A study of out-of-hospital cardiac arrests in northeastern Minnesota . JAMA . 1986;;256:477-483.
24 +
Kellermann AL, Staves DR, Hackman BB.  Inhospital resuscitation following unsuccessful prehospital advanced cardiac life support: 'heroic efforts' or an exercise in futility . Ann Emerg Med. 1988;;17:589-594.
25 +
Murphy DJ.  Do-not-resuscitate orders: time for reappraisal in long-term care institutions . JAMA . 1988;;260:2098-2101.
26 +
Shmerling RH, Bedell SE, Lilienfeld A, Delbanco TL.  Discussing cardiopulmonary resuscitation: a study of elderly outpatients . J Gen Intern Med. 1988;;3:317-321.
27 +
Wagner A.  Cardiopulmonary resuscitation in the aged: a prospective survey . N Engl J Med. 1984;;310:1129-1130.
28 +
Finucane TE, Denman SJ.  Deciding about resuscitation in a nursing home: theory and practice . J Am Geriatr Soc. 1989;;37:684-688.
29 +
Zweibel NR, Cassel CK.  Treatment choices at the end of life: a comparison of decisions by older patients and their physician-selected proxies . Gerontologist . 1989;;29:615-621.
30 +
Volicer L, Rheaume Y, Brown J, et al.  Hospice approach to the treatment of patients with advanced dementia of the Alzheimer type . JAMA . 1986;;256:2210-2213.
31 +
Emanuel LL, Emanuel EJ.  The medical directive: a new comprehensive advance care document . JAMA . 1989;;261:3288-3293.
32 +
Uhlmann RF, Clark H, Pearlman RA, et al.  Medical management decisions in nursing home patients: principles and policy recommendations . Ann Intern Med. 1987;;106:879-885.
33 +
Bedell SE, Pelle D, Maher PL, Cleary PD.  Donot-resuscitate orders for critically ill patients in the hospital: how are they used and what is their impact? JAMA . 1986;;256:233-237.
34 +
Blackhall LJ, Cobb J, Moskowitz MA.  Discussions regarding aggressive care with critically ill patients . J Gen Intern Med. 1989;;4:399-402.
35 +
Frankl D, Oye RK, Bellamy PE.  Attitudes of hospitalized patients toward life support: a survey of 200 medical inpatients . Am J Med. 1989;;86:645-648.
36 +
Ende J, Kazis L, Ash A, Moskowitz MA.  Measuring patients' desire for autonomy: decision making and information-seeking preferences among medical patients . J Gen Intern Med. 1989;;4:23-30.
37 +
Iserson KV.  Prehospital DNR orders . Hastings Cent Rep. 1989;;19:17-19.
38 +
Annas GJ.  Precatory prediction and mindless mimicry: the case of Mary O'Connor . Hastings Cent Rep. 1988;;18:31-33.
39 +
High DM.  All in the family: extended autonomy and expectations in surrogate health care decision-making . Gerontologist. 1988;;28( (suppl) ):46-52.
40 +
Ouslander JG, Tymchuk AJ, Rahbar B.  Health care decisions among elderly long-term care residents and their potential proxies . Arch Intern Med. 1989;;149:1367-1372.
41 +
Uhlmann RF, Pearlman RA, Cain KC.  Physicians' and spouses' predictions of elderly patients' resuscitation preferences . J Gerontol. 1988;;43: M115-M121.
42 +
Youngner SJ.  Do-not-resuscitate orders: no longer secret, but still a problem . Hastings Cent Rep. 1987;;17:24-33.
43 +
Evans RW.  Health care technology and the inevitability of resource allocation and rationing decisions: part II . JAMA . 1983;;249:2208-2219.
44 +
Aaron H, Schwartz WB.  Rationing health care: the choice before us . Science . 1990;;247:418-422.
45 +
Thurow LC.  Medicine versus economics . N Engl J Med. 1985;;313:611-614.
46 +
Lamm RD.  Critical decisions in medical care: birth to death . South Med J. 1989;;82:822-824.
47 +
Churchill LR.  Should we ration health care by age? J Am Geriatr Soc. 1988;;36:644-647.
48 +
Grumet GW.  Health care rationing through inconvenience: the third party's secret weapon . N Engl J Med. 1989;;321:607-611.
49 +
Callahan D. What Kind of Life—the Limits of Medical Progress . New York, NY: Simon & Schuster Inc; 1990;.
50 +
Caper P.  Solving the medical care dilemma . N Engl J Med. 1988;;318:1535-1536.
51 +
Callahan D.  Old age and new policy . JAMA . 1989;;261:905-906.
52 +
Schneider EL.  Options to control the rising health care costs of older Americans . JAMA . 1989;;261:907-908.
53 +
Daniels W.  Why saying no to patients in the United States is so hard: cost containment, justice, and provider autonomy . N Engl J Med. 1986;;314: 1380-1383.
54 +
Hammond J, Ward CG.  Decision not to treat: 'do not resuscitate' order for the burn patient in the acute setting . Crit Care Med. 1989;;17:136-138.
55 +
Taffet GE, Teasdale TA, Luchi RJ.  In-hospital cardiopulmonary resuscitation . JAMA . 1988;;260: 2069-2072.
56 +
Lo B, Raffin TA, Cohen NH, et al.  Ethical dilemmas about intensive care for patients with AIDS . Rev Infect Dis. 1987;;9:1163-1167.
57 +
Youngner SJ.  Who defines futility? JAMA . 1988;;260:2094-2095.
58 +
Lantos JD, Singer PA, Walker RM, et al.  The illusion of futility in clinical practice . Am J Med. 1989;;87:81-84.
59 +
Schneiderman LJ, Jecker NS, Jonsen AR.  Medical futility: its meaning and ethical implications . Ann Intern Med. 1990;;112:949-954.
60 +
Chang RWS.  Individual outcome prediction models for intensive care units . Lancet . 1989;;2:143-146.
61 +
Dobkin JE, Cutler RE.  Use of APACHE II classification to evaluate outcome of patients receiving hemodialysis in an intensive care unit . West J Med. 1988;;149:547-550.
62 +
Hanley JA, Lippman-Hand A.  If nothing goes wrong, is everything all right? interpreting zero numerators . JAMA . 1983;;249:1743-1745.
63 +
Poe RH, Wahl GW, Qazi R, Kallay MC, Utell MJ, Morrow GR.  Predictors of mortality in the immunocompromised patient with pulmonary infiltrates . Arch Intern Med. 1986;;146:1304-1308.
64 +
Wachter RM, Luce JM, Turner J, Volberding P, Hopewell PC.  Intensive care of patients with the acquired immunodeficiency syndrome: outcome and changing patterns of utilization . Am Rev Respir Dis. 1986;;134:891-896.
65 +
Froberg DG, Kane RL.  Methodology for measuring health-state preferences, I: measurement strategies . J Clin Epidemiol. 1989;;42:345-354.
66 +
Mulley AG.  Assessing patients' utilities: can the ends justify the means? Med Care. 1989;;27: S269-S281.
67 +
Froberg DG, Kane RL.  Methodology for measuring health-state preferences, IV: progress and a research agenda . J Clin Epidemiol. 1989;;42:675-685.
68 +
Thurow LC.  Learning to say 'no.' N Engl J Med. 1984;;311:1569-1572.
69 +
Engelhardt HT Jr, Rie MA.  Intensive care units, scarce resources, and conflicting principles of justice . JAMA . 1986;;255:1159-1164.
70 +
Blackhall LJ.  Must we always use CPR? N Engl J Med. 1987;;317:1281-1285.
71 +
Carlon GC.  Just say no . Crit Care Med. 1989;;17:106-107.
72 +
Weir RF. Abating Treatment With Critically Ill Patients: Ethical and Legal Limits to the Medical Prolongation of Life . New York, NY: Oxford University Press Inc; 1989;.
73 +
Lomas J, Anderson GM, Domnick-Pierre K, et al.  Do practice guidelines guide practice? the effect of a consensus statement on the practice of physicians . N Engl J Med. 1989;;321:1306-1311.
74 +
Brook RH.  Practice guidelines and practicing medicine: are they compatible? JAMA . 1989;;262: 3027-3030.

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