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Revista Iberoamericana de la Educación, Vol - 8 No. 4, October - December 2024
e-ISSN: 2737-632x
Pgs 37-52
*Bachelor's Degree in Nursing
(Universidad Estatal de Bolívar)
silvhana@hotmail.es
https://orcid.org/0000-0001-9289-
8089
* Bachelor's Degree in Nursing
(Universidad Estatal de Bolívar)
thaliasegura123@gmail.com
https://orcid.org/0009-0003-5095-
4435
* Bachelor's Degree in Nursing
(Universidad Estatal de Bolívar)
valenciamelissa386@gmail.com
https://orcid.org/0009-0007-6845-
6636
Received: July, 2024
Approved: September, 2024
DOI:
https://doi.org/10.31876/
ie.v8i12.280
http://www.revista-
iberoamericana.org/index.
php/es
How to cite:
López, X., Silva, S.,
Valencia, E. (2024)
Formative processes in
nursing intervention in
palliative care in internal
medicine service patients.
Revista Iberoamericana De
educación, 8 (4).
Formative processes in nursing
intervention in palliative care in internal
medicine service patients
Procesos formativos en la intervención de enfermería en cuidados paliativos
en pacientes de servicio de medicina interna
Processos de formação na intervenção de enfermagem em cuidados
paliativos em doentes de medicina interna
Ximena Silvana López Paredes*
Sharon Thalía Silva Segura*
Erika Melisa Valencia Aguay*
Abstract
The purpose of the research project was to determine the nursing
intervention in palliative care in patients of the Internal Medicine
service of the Alfredo Noboa Montenegro Hospital during the period
October 2023- February 2024, since nursing professionals are
exposed to social, health and service changes, whose deficiency or
lack of knowledge can limit an integral, personalized and quality
intervention that allows care from individuality, flexibility,
continuity, accessibility and polyvalence. A descriptive, cross-
sectional, bibliographic and field method was applied with a
quantitative approach, whose research design was non-experimental
and cross-sectional, applying a sample by convenience with a total of
17 nursing professionals working in the internal medicine service, in
addition, a survey of 29 questions distributed in four dimensions was
used to collect the information; actions, education, psycho-emotional
support, spiritual and grief. According to the results, it was possible
to demonstrate the deficiencies of nursing professionals, especially
in the identification of palliative needs, symptom assessment,
intervention processes, use of tools to assess psychoemotional and
spiritual needs, pharmacological approach and information on
bereavement, which made it necessary to establish a palliative care
guide focused on nursing professionals, to be subsequently socialized
with all personnel.
Keywords: palliative care, terminal illness, nursing, quality of life,
symptom control.
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Training processes in palliative care nursing intervention in internal medicine patients
38
Resumen
El proyecto investigativo tuvo la finalidad de determinar la
intervención de enfermería en cuidados paliativos en pacientes de
servicio de Medicina Interna del Hospital Alfredo Noboa
Montenegro durante el periodo octubre 2023- febrero 2024, ya que
los profesionales en enfermería están expuestos a cambios sociales,
sanitarios y de servicio, cuya deficiencia o desconocimiento puede
limitar una intervención integral, personalizada y de calidad que
permita un cuidado desde la individualidad, flexibilidad,
continuidad, accesibilidad y polivalencia. Se aplicó un método
descriptivo, transversal, bibliográfico y de campo con un enfoque
cuantitativo, cuyo diseño de investigación fue no experimental y de
corte transversal, aplicando una muestra por conveniencia con un
total de 17 profesionales de enfermería que laboran en el servicio de
medicina interna, además, para recolectar la información se utilizó
una encuesta de 29 preguntas distribuidas en cuatro dimensiones;
acciones, educación, apoyo psicoemocional, espiritual y duelo. De
acuerdo a los resultados se pudo evidenciar las deficiencias que
presentan los profesionales de enfermería, especialmente en la
identificación de necesidades paliativas, valoración de síntomas,
procesos de intervención, utilización de herramientas para evaluar las
necesidades psicoemocionales y espirituales, abordaje farmacológico
e información sobre el duelo, lo cual fue necesario establecer una
guía de cuidados paliativos enfocados en los profesionales de
enfermería, para posteriormente ser socializado con todo el personal.
Palabras Clave: Cuidados paliativos, enfermedad terminal,
enfermería, calidad de vida, control de síntomas.
Resumo
O projeto de pesquisa teve como objetivo determinar a intervenção
de enfermagem em cuidados paliativos em pacientes do serviço de
Medicina Interna do Hospital Alfredo Noboa Montenegro no
período de outubro de 2023 a fevereiro de 2024, uma vez que os
profissionais de enfermagem estão expostos a mudanças sociais, de
saúde e de serviços, cuja deficiência ou falta de conhecimento pode
limitar uma intervenção abrangente, personalizada e de qualidade
que permita cuidados baseados na individualidade, flexibilidade,
continuidade, acessibilidade e polivalência. Foi aplicado um método
descritivo, transversal, bibliográfico e de campo com uma
abordagem quantitativa, cujo desenho de pesquisa foi não-
experimental e transversal, aplicando uma amostra por conveniência
com um total de 17 profissionais de enfermagem que trabalham no
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Training processes in palliative care nursing intervention in internal medicine patients
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serviço de medicina interna, além disso, foi utilizado um inquérito
de 29 questões distribuídas em quatro dimensões para recolher a
informação; acções, educação, apoio psico-emocional, espiritual e
luto. De acordo com os resultados, foi possível demonstrar as
deficiências dos profissionais de enfermagem, especialmente na
identificação das necessidades paliativas, avaliação de sintomas,
processos de intervenção, utilização de ferramentas para avaliar as
necessidades psico-emocionais e espirituais, abordagem
farmacológica e informação sobre o luto, o que foi necessário para
estabelecer um guia de cuidados paliativos centrado nos
profissionais de enfermagem, a ser posteriormente socializado com
todo o pessoal.
Palavras-chave: Cuidados paliativos, doença terminal,
enfermagem, qualidade de vida, controlo de sintomas.
INTRODUCTION
The role of nursing in palliative care is very indispensable, since they
are the health professionals who spend more time with patients,
therefore, their responsibility and protagonism are incalculable and
openly grateful in achieving the objectives of the patient's well-being,
being necessary a care focused on the administration of drugs and the
relief of pain, discomfort, fear and all the negative symptoms
presented by the sick in the last stage of their lives (Alborea, 2021).
Currently, there is an increase in chronic degenerative diseases that
are related to terminal states, being necessary the implementation of
palliative care through specialized medical care by nursing
professionals, in order to treat the emotional, social, practical and
spiritual problems that the disease poses (Souza et al., 2021).
Globally, it is estimated that 40 million people need palliative care,
of which only 14% have received such care, with pain being one of
the main symptoms presented by patients, becoming a constraint for
people with terminal illnesses, since the lack of training by health
professionals has hindered improvement programs in palliative care
(World Health Organization , 2020).
According to the Institute of Culture and Society of the University of
Navarra (2021) in their study carried out in 17 Latin American
countries, they revealed that only 7% of people have access to
palliative care, due to the fact that there are only 1,562 specialized
teams in the entire region, which means an insufficient rate of 2.6 per
million inhabitants. This problem is increasing due to the increase in
cardiovascular pathologies or non-communicable diseases such as
cancer, in addition to the aging of the population.
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Training processes in palliative care nursing intervention in internal medicine patients
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According to Pozo and Fernandez (2017) state that in Ecuador 35%
of deaths require palliative care, and it is necessary to strengthen this
service to allow its integration in all medical areas; therefore, health
professionals should know palliative care so that they can provide
patients with a better quality of life during their treatment.
According to a report issued by the Ministry of Economic and Social
Inclusion (2018) states that, in Bolivar Province there are a total of
3,825 elderly people who have chronic degenerative diseases in
progressive and advanced stage, in which they do not have adequate
care due to their social situation and lack of economic resources that
has limited timely medical care.
In this geographical context, the Alfredo Noboa Montenegro
Hospital in the city of Guaranda presents problems of medical care
in palliative care, especially in the area of Internal Medicine, since
the intervention processes by the nursing staff have not been carried
out correctly, which has led to limited humanized and comprehensive
care in patients with chronic and degenerative diseases (García and
Ramos, 2018).
According to Calderón et al. (2020) the deficiencies presented by
nursing professionals regarding palliative care are due to the lack of
training from the academy, since there are not enough professionals
specialized in palliative care, which causes feelings of frustration,
anguish and insecurity that they must face in their work activities,
being an impediment to provide a quality service.
For Codorniu (2019) nursing professionals are exposed to social,
health and service changes, whose deficiency or lack of knowledge
limits a comprehensive, personalized and quality intervention that
allows care from individuality, flexibility, continuity, accessibility
and polyvalence. Therefore, it is necessary for nurses to acquire
knowledge in health technology, clinical ethics and interpersonal
relationships in order to efficiently face the demands of patients and
the challenges of the profession itself.
In this sense, the study was conducted in order to determine the
nursing intervention in palliative care in patients of the Alfredo
Noboa Montenegro Internal Medicine service during the period
October 2023 - February 2024. Therefore, it is important to carry out
the study since a correct intervention in patients with terminal
illnesses will allow knowing their current situation, in this way it will
be possible to provide the appropriate medications to contribute to
their spiritual and emotional needs to obtain a better diagnosis of their
illness, making pertinent decisions for an efficient coordination with
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Training processes in palliative care nursing intervention in internal medicine patients
41
the Internal Medicine staff and taking care of their physical,
emotional and social state.
The project will contribute to know the reality in which nursing
professionals find themselves in relation to palliative care, since the
increase of chronic degenerative diseases has caused a considerable
demand of patients at the Alfredo Noboa Montenegro Hospital,
which is essential to guarantee the rights of terminally ill patients to
alleviate pain and suffering, in addition to addressing physical, social
and emotional aspects.
The beneficiaries of the project will be all nursing professionals
working in the internal medicine area, as well as patients with
terminal illnesses, whose care will allow active, continuous,
comprehensive, empathetic, supportive and quality care, alleviating
their physical, psychological and social needs in order to improve
their quality of life, respecting their will and their right to health.
MATERIALS AND METHODS
The study was carried out at the Alfredo Noboa Montenegro
Hospital, specifically in the area of Internal Medicine and focused
on nursing intervention in palliative care, for which a methodology
with a quantitative approach was used, thus identifying the
knowledge that nursing professionals possess in relation to palliative
care, In addition, the research has a descriptive, cross-sectional,
bibliographic and field level, whose research design was non-
experimental and cross-sectional, since the variables under study
were not manipulated and it was mainly based on direct observation
of the phenomenon as it occurs in its natural context. Since the
sample is small, the entire study population was taken into
consideration, considering 11 nurses and 6 auxiliary nurses who
work rotating shifts in the Internal Medicine area.
The technique used in this research was through a survey directed to
nursing professionals working in the Internal Medicine area, whose
questionnaire consisted of 29 questions with Likert-type answers,
being the main instrument that allowed identifying the knowledge
that nursing professionals have regarding palliative care. Likewise,
a palliative care guide was prepared focusing on the assessment of
palliative needs, common symptoms, pharmacological and non-
pharmacological approach, subcutaneous route, ethical aspects of
nursing, psychosocial, spiritual and communication aspects.
It is worth mentioning that the research instrument was validated by
three nursing professionals, obtaining an approval criterion of
acceptable and very acceptable, likewise, the participants signed an
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Training processes in palliative care nursing intervention in internal medicine patients
42
informed consent form, so that the information obtained is
confidential, whose information was used only for the analysis of the
research work. The information was processed through the statistical
program SPSS of the company IBM Spanish version, in which
statistical tables and graphs were made for the analysis and
interpretation of results, in addition to using the Word program
version 2016 to process the information of the palliative care guide
and its respective socialization with the nursing staff.
RESULTS
Table 1. Identification of the level of nursing staff knowledge of
palliative care in Internal Medicine patients.
Questions
Never
Very
rare
Sometimes
Regularly
Always
Do you apply the
nursing care process
(assessment, diagnosis,
planning,
implementation and
evaluation) to the
patient?
0%
5,88%
17,65%
47,06%
29,41%
In assessing the
symptoms of palliative
care patients do you
work with a patient,
caregiver/family
focus?
0%
5,88%
23,53%
41,18%
29,41%
The following tools are
used to identify the
needs of patients
requiring palliative
care: "Gold Standards
Framework
Prognostics Indicator
Guide, NECPAL 1?0 -
NECPAL CCOMS -
ICO, NECPAL 3.0"?
0%
5,88%
23,53%
11,76%
17,65%
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Training processes in palliative care nursing intervention in internal medicine patients
43
To measure the
intensity of pain and
other symptoms in
patients with diseases
requiring palliative
care, the following
tools are used: "Visual
analog scale, numerical
pain intensity scale,
simple descriptive pain
intensity scale?
0%
29,41
41,18%
11,76%
17,65%
Does it meet the
physical needs of
patients with chronic,
progressive and
terminal illnesses?
0%
11,76%
23,53%
47,06%
17,65%
Do you consistently
observe signs of
dehydration and its
complications?
0%
5,88%
11,76%
52,94%
29,41%
Does it provide
complete and clear
information about care
to the patient and
caregiver/family?
0%
11,76%
17,65%
58,82%
11,76%
Do you apply active
listening during
communication with
the patient and
caregiver/family
members?
0%
11,76%
5,82%
64,71%
17,65%
Do you inform the
patient and
caregiver/family before
administering a
medication?
0%
17,65%
58,82%
17,65%
5,88%
Does it assess the
psychoemotional needs
of patients in need of
palliative care and their
caregiver/family?
0%
5,82%
29,41%
52,94%
11,76%
Do you assess the
patient's spiritual
needs?
5,88%
17,65%
41,18%
29,41%
5,88%
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Does it provide basic
emotional support to
the patient and
caregiver/family
member after receiving
bad news?
0%
11,76%
64,71%
17,65%
5,88%
Prepared by; (Valencia and Silva, 2024).
According to the surveys conducted among nursing professionals, it
was found that 47% apply nursing processes on a regular basis, which
shows a certain deficiency which in turn limits the organization of
their work to evaluate changes and progress in the improvement of
the patient's state of wellbeing. These results are similar to those
obtained by Miranda et al. (2020) where they showed that the
intervention of nursing processes allows providing comprehensive
care to patients from the initial experience as a daily activity of care
and with a positive projection to the world of work, not exempt from
restrictions in its application to the hospital environment. Likewise,
41% rate symptoms regularly, and it is necessary for the professional
to know and assume the patient's point of view in order to increase
their satisfaction and the quality of health care. The results of this
survey are similar to those obtained by Ponti et al. (2019) where they
showed that only 12% of respondents expressed knowledge and
appreciation of palliative care symptoms, which may affect decision
making during patient assessment.
Forty-one percent of respondents sometimes use tools to identify the
needs of patients, which needs to be improved in this aspect to
generate positive results in the identification of needs and the timely
recognition of the points that require greater palliative intervention.
In this regard, Tripodoro et al. (2020) conducted a research study to
improve these shortcomings, where they applied the NECPAL tool
to identify palliative needs, the results of which allowed improving
the comprehensive care of patients by 94%. With regard to pain
intensity measurement scales, 41% of respondents use them on
certain occasions, which may cause the assessment acquired to
present inconsistencies in measuring the pain and sensations
presented by the patient, as shown in a study by Uriel et al. (2023)
where measurement scales such as the luminous analog, Luesher's
gray scale, Downie's numerical scale and simple descriptive scale
were applied, which allowed therapeutic decisions to be made in a
timely manner, efficacy in the administration of analgesia and
evaluation of results to measure pain intensity correctly.
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On the other hand, 47% meet their physical needs on a regular basis,
and it is essential to prioritize these needs so that the patient can
receive good hygiene, food, mobilization, rest and relief from pain
derived from the disease. As stated by Ayala et al. (2023) in their
research study, whose results showed that it is essential that they
receive good hygiene, personal grooming, food, mobilization, rest
and relief of the main pains derived from the disease, thus improving
the quality of life during the terminal stage. In relation to the signs of
dehydration, 53% of those surveyed observed constant dehydration,
which is important for regulating body temperature so that nutrients
and oxygen can be transported to the patient's cells. These results are
similar to those obtained by Maset (2021) where it is evident that
poor care by nursing professionals to constantly hydrate the patient
can cause irritability, dizziness, vomiting, constipation and headache,
therefore, it is important that professionals keep patients constantly
hydrated during palliative care, so that in this way body temperature
can be regulated and nutrients and oxygen can be transported to the
patient's cells to maintain their physical well-being.
In reference to information about patient care, 59% provide complete
information on a regular basis, which information is essential to
restore the patient and family's emotional stability, as demonstrated
by Sierra et al. (2019) in their study on communication in palliative
care, the results of which made it possible to contribute to alleviating
the patient's suffering, accompanying them until the last stage of their
illness. In the same context, 65% regularly apply active listening
during communication with the patient, which is essential to better
cope during the terminal stage. With regard to information for
administering medication, this is demonstrated by a study conducted
by Subiela et al. (2019) whose findings allowed better coping during
the patient's terminal stage, using more than one sense, in addition to
eye contact, body movements, position and relevant messages for the
patient's family.
On the other hand, 59% informed the patient and family about its
administration on certain occasions, so it should be considered that
their information becomes a pharmacotherapeutic link. These results
are similar to those obtained by Tapiero (2021) where it was found
that 85% of the respondents expressed the inconvenience of
informing the patient prior to the administration of a drug, therefore,
it is essential that patients know about the drugs, since it is a
pharmacotherapeutic link in which the necessary aspects to achieve
the success of the pharmacological therapy are addressed. In relation
to psychoemotional needs, 53% evaluate on a regular basis, therefore
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this component should be considered within palliative care, since
situations that produce anguish, sadness and pain to the patient
should be addressed, as shown by the findings obtained by Guijar
(2018) whose results evidenced that the nursing staff were not in an
ideal position to detect the emotional needs of the patient, therefore,
they present problems to face the situations that produce anguish,
sadness and pain to the patient, caused by the burden of symptoms
that affect their daily life.
Likewise, 41% sometimes evaluate the spiritual needs of the patient,
therefore, they should consider their spiritual expression and
religious manifestation to promote and facilitate practices that
generate peace and tranquility in the patient and family. With regard
to emotional support after receiving bad news, this is shown in a
study by Jara (2020) where she witnessed deficiencies during the
assessment of spiritual needs, which is necessary for nursing
professionals to put aside their own expectations and focus on the
spiritual needs of the patient, considering their spiritual expression
and religious manifestations to facilitate and promote practices that
generate tranquility and peace in the patient and family. In addition,
65% sometimes provide emotional support, being necessary to gather
all available information from the patient, providing information
according to the patient's needs and desires, as shown in a study by
Miranda et al. (2022) where they emphasize adequate
communication during bad news, so that the nursing professional
gathers all available information about the patient's disease,
providing information according to the patient's wishes and needs, to
reduce the emotional impact of both the patient and his family after
receiving bad news.
Once the nursing professionals had been surveyed, a nursing
intervention guide was prepared, based on the manuals established
by the Ministry of Public Health and documents published by
international health institutions, in order to provide technical and
scientific support for the preparation of the guide, which consisted of
several components focused on the assessment of palliative needs,
common symptoms, pharmacological approach, ethical aspects,
advance planning, psychosocial, spiritual and bereavement aspects.
Subsequently, the intervention guide was socialized through a
chronogram of activities, in which the objective, the description of
the activity, those responsible and the dates of socialization were
determined, whose purpose was focused on improving palliative
care.
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Table 2. Socialization of the guide with nursing professionals
Socialization
Target
Activity
Participants
Responsible
Jan-24
1 wk
2 sem
3 sem
4 sem
perform a
multidimensional
assessment to identify
any type of need that
arises in the disease
process.
Palliative needs
assessment
Internal
medicine
nursing
professionals
Éricka
Valencia and
Thalía Silva
(UEB
Students)
early identification of
symptoms in various
life-limiting conditions
in adult and pediatric
patients.
Common
palliative care
symptoms
Internal
medicine
nursing
professionals
Éricka
Valencia and
Thalía Silva
(UEB
Students)
To achieve adequate
symptom control and
pharmacological
interventions for the
patient and possible
drug-drug interactions.
Pharmacological
approach in
palliative care
Internal
medicine
nursing
professionals
Éricka
Valencia and
Thalía Silva
(UEB
Students)
Facilitate the proper,
safe and effective use
of the subcutaneous
route for nursing
professionals.
Subcutaneous
route in palliative
care
Internal
medicine
nursing
professionals
Éricka
Valencia and
Thalía Silva
(UEB
Students)
To learn about non-
pharmacological
interventions that
include psychological
and physical strategies
to reduce pain.
Non-
pharmacological
approach in
palliative care
Internal
medicine
nursing
professionals
Éricka
Valencia and
Thalía Silva
(UEB
Students)
To raise awareness of
the ethical principles
that govern the nursing
profession in order to
provide adequate
palliative care.
Ethical aspects in
palliative nursing
Internal
medicine
nursing
professionals
Éricka
Valencia and
Thalía Silva
(UEB
Students)
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Review the patient's
condition and
prognosis in the event
of a crisis, in order to
prepare the patient
through timely
decisions in medical
treatment
Advance
palliative care
planning
Internal
medicine
nursing
professionals
Éricka
Valencia and
Thalía Silva
(UEB
Students)
To have the ability to
cope with situations of
anguish, sadness and
pain generated in the
patient that limit the
rhythm of his/her daily
life.
Psychosocial
aspects of
palliative care
Internal
medicine
nursing
professionals
Éricka
Valencia and
Thalía Silva
(UEB
Students)
Provide a constant
presence, listening and
compassionate support
for all that arises during
the disease process and
the patient's end of life.
Palliative care and
spirituality
Internal
medicine
nursing
professionals
Éricka
Valencia and
Thalía Silva
(UEB
Students)
Prepared by: (Valencia and Silva, 2024)
CONCLUSIONS
According to the surveys conducted, it could be seen that the level of
knowledge of nursing professionals is at a regular level, presenting
deficiencies in the processes of nursing intervention with 47%,
symptom assessment with 41%, scarce use of tools to identify with
41%, scarce administration of medications with 59%, scales of
measurement of intensity of measurement with 41%, in addition to
presenting psychoemotional deficiencies with 53%, spiritual with
41%, In addition to presenting psychoemotional deficiencies (53%),
spiritual deficiencies (41%), deficiencies in providing complete
information on palliative care (65%) and deficiencies in providing
information on bereavement and available resources (41%), it was
also evident that there are deficiencies in providing information on
bereavement and available resources (41%).
A nursing intervention guide was prepared based on the manuals
established by the Ministry of Public Health and documents
published by international health institutions, in order to provide
technical and scientific support for the preparation of the guide,
which consisted of several components focused on the assessment of
palliative needs, common symptoms, pharmacological approach,
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Training processes in palliative care nursing intervention in internal medicine patients
49
ethical aspects, advance planning, psychosocial, spiritual and
bereavement aspects.
The intervention guide was socialized through a chronogram of
activities, in which the objective, the description of the activity, those
responsible and the dates of socialization were determined, whose
purpose was focused on improving palliative care, so that nursing
professionals can perform an adequate assessment of palliative
needs, in addition to identifying the common symptoms of terminally
ill patients, as well as the appropriate approach to pharmacological
use during the administration of medications, ethical aspects during
palliative care, and the correct assessment of physical, psychological
and spiritual needs through appropriate tools that allow a proper
diagnosis and treatment during the patient's illness.
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