doi: 10.56294/mw2024499
ORIGINAL
Assessing Ethical Challenges in End-of-Life Decision-Making Through a Case Study Approach
Evaluación de los desafíos éticos en la toma de decisiones al final de la vida mediante el estudio de casos prácticos
Keshav1 
*, Manashree Mane2 , Swarna Swetha Kolaventi3 , Shakti Bedanta Mishra4 
, Mekala Ishwarya5 , Romil Jain6 , Sulabh Mahajan7
1Department of General Medicine, Noida International University, Greater Noida, Uttar Pradesh, India.
2Forensic Science, JAIN (Deemed-to-be University), Bangalore, Karnataka, India.
3Department of uGDX, ATLAS SkillTech University, Mumbai, Maharashtra, India.
4Department of Critical Care Medicine, IMS and SUM Hospital, Siksha ‘O’ Anusandhan (Deemed to be University), Bhubaneswar, Odisha, India.
5Centre for Multidisciplinary Research, Anurag University, Hyderabad, Telangana, India.
6Chitkara Centre for Research and Development, Chitkara University, Himachal Pradesh, India.
7Centre of Research Impact and Outcome, Chitkara University, Rajpura, Punjab, India.
Cite as: Keshav, Mane M, Kolaventi SS, Mishra SB, Ishwarya M, Jain R, et al. Assessing Ethical Challenges in End-of-Life Decision-Making Through a Case Study Approach. Seminars in Medical Writing and Education. 2024; 3:499. https://doi.org/10.56294/mw2024499
Submitted: 08-10-2023 Revised: 10-01-2024 Accepted: 12-05-2024 Published: 13-05-2024
Editor: PhD.
Prof. Estela Morales Peralta 
Corresponding author: Keshav *
ABSTRACT
For patients, families, doctors, and legislators, end-of- life decisions create major ethical conundrums. The moral conundrums in clinical practice arise from the growing complexity of medical procedures, legal differences among countries, and many cultural and religious views. Using a case study method, this research investigates these ethical dilemmas by examining important concerns like physician-assisted suicide, do-not-resuscitation (DNR) orders, palliative sedation, and life force withdrawal. It looks at ethical theories including utilitarian and deontological points of view as well as bioethical concepts of autonomy, beneficence, non-maleficence, and justice. Comparative analysis of global points of view exposes differences in legal systems and cultural attitudes on final choices. Emphasising policies to ensure compassionate, patient-centered care, the article also gives recommendations for improving ethical decision-making, highlighting rules for healthcare professionals, increasing communication tactics, the purpose of ethics committees, and policy improvements. Combining ethical ideals, legal issues, and cultural sensitivity, this study aims to assist to develop more equitable and ethically sound approaches to end-of-life decision-making.
Keywords. End-Of-Life Care; Ethical Decision-Making; Physician-Assisted Suicide; Do-Not-Resuscitate (DNR); Palliative Sedation; Euthanasia; Patient Autonomy; Medical Ethics; Legal Frameworks; Bioethics; Healthcare Policy; Cross-Cultural Analysis; Ethics Committees; Advance Care Planning.
RESUMEN
Para pacientes, familiares, médicos y legisladores, las decisiones sobre el final de la vida plantean importantes dilemas éticos. Los enigmas morales en la práctica clínica surgen de la creciente complejidad de los procedimientos médicos, las diferencias legales entre países y los numerosos puntos de vista culturales y religiosos. Mediante un método de estudio de casos, esta investigación analiza estos dilemas éticos examinando cuestiones importantes como el suicidio asistido por un médico, las órdenes de no reanimación (DNR), la sedación paliativa y la retirada de la fuerza vital. Se examinan teorías éticas como los puntos de vista utilitarista y deontológico, así como los conceptos bioéticos de autonomía, beneficencia, no maleficencia y justicia. El análisis comparativo de puntos de vista globales expone las diferencias en los sistemas jurídicos y las actitudes culturales sobre las decisiones finales. El artículo, que hace hincapié en las políticas para garantizar una atención compasiva y centrada en el paciente, también ofrece recomendaciones para mejorar la toma de decisiones éticas, destacando las normas para los profesionales sanitarios, el aumento de las tácticas de comunicación, la finalidad de los comités de ética y las mejoras en las políticas. Combinando ideales éticos, cuestiones jurídicas y sensibilidad cultural, este estudio pretende ayudar a desarrollar enfoques más equitativos y éticamente sólidos de la toma de decisiones al final de la vida.
Palabras clave: Cuidados al Final de la Vida; Toma de Decisiones Éticas; Suicidio Asistido por un Médico; No Resucitar (DNR); Sedación Paliativa; Eutanasia; Autonomía del Paciente; Ética Médica; Marcos Jurídicos; Bioética; Política Sanitaria; Análisis Transcultural; Comités de Ética; Planificación Anticipada de Cuidados.
INTRODUCTION
Making choices about end of life offers some of the most morally and emotionally taxing conundrums in contemporary medicine. Globally, this is a divisive issue with entwining ethical, legal, cultural, and medical aspects. Combining different legal systems and society viewpoints with the growing ability of medical research to artificially prolong life creates a scenario wherein moral uncertainty permeates decision-making. On occasion doctors, patients, and families ought to determine among physician-assisted loss of life, palliative care, euthanasia, and lifestyles-sustaining therapy. Clinical responsibilities, patient autonomy, and extra widespread society concepts are in balance and moral battle effects. In this regard, a case take a look at technique offers a methodical method to observe real activities, consequently stressing moral problems and offering know-how of the way those difficulties are triumph over in day by day life.(1) The inspiration of cease-of- life decision-making is autonomy that which people have the proper to decide about their very own our bodies and clinical treatments. While doctors need to behave in the quality interest of the patient and forestall harm, this concept every now and then runs counter to medical advice on beneficence and non-maleficence. Although patients sometimes choose to die with dignity instead of life-prolonging drugs, their families sometimes find it challenging to accept such choices. Likewise, some patients may choose physician-assisted suicide; nevertheless, ethical and legal restrictions might make it difficult for medical personnel to comply. These arguments beg serious moral issues about the extent of autonomy that should be preserved when doctors feel that another line of therapy would be better for the patient. Sometimes families and healthcare proxies have to make life-or-death decisions for patients incapable of making decisions for themselves because of diseases like dementia, unconsciousness, or major sickness.(2)
Various countries have somewhat diverse rules around end-of- life choices, which affects the resolution of moral conundrums. Although some nations, such the United States and the United Kingdom, forbid euthanasia and physician-assisted death, under tight rules these practices are permissible in others including the Netherlands, Belgium, and Canada. Living wills, advance directives, and do-not-resuscitate (DNR) orders add but more complexity to the decision-making method. Although these criminal devices are intended to appreciate patient alternatives, institutional rules, own family conflicts, or scientific uncertainty, every so often they’ll be forced to take priority. Moreover, cease-of- lifestyles ethics are tons formed by religious and cultural values. Emphasising the worth of lifestyles and the natural direction of loss of life, many religious traditions condemn assisted suicide and euthanasia. Some philosophical stances, though, guard the proper to a dignified dying, especially on the subject of terminal ailment and fantastic struggling.(3) Given the variety of evaluations, it is difficult to create a commonly agreed ethical framework for ultimate treatment. Apart from moral and criminal issues, practical conversation and decision-making limitations decorate the complexity of final-life care. Many sufferers and their households conflict to have sincere conversations approximately dying whilst crucial picks should be made, which leads to confusion and emotional upheaval. Especially in regards to cultural sensitivity and ranging degrees of fitness literacy, healthcare professionals might potentially find it hard to speak medical facts in a compassionate and straightforward way. Although moral discomfort and conflicts are remain commonplace, scientific ethics committees and shared choice-making fashions are examples of moral decision-making structures that searching for to assist to permit these conversations.(4) In this situation, palliative care is essential as it enables men and women with terminal illnesses stay higher and supports their families. Now not everyone has get admission to palliative care, as a result differences in healthcare sources make moral concerns difficult in many one-of-a-kind settings.
Inspecting those moral conundrums is made simpler with the usage of a case take a look at technique as it offers a thorough cognizance of sure real-international events. By using use of case analysis, this studies intends to spotlight the moral conundrums experienced by way of patients, households, and medical practitioners. Amongst these conundrums encompass health practitioner-assisted suicide, life assist elimination, conflicts over DNR guidelines, and cultural effects on stop of life decisions.(1,5) Every case study emphasises a different facet of decision-making, therefore enabling a thorough knowledge of the intricate interplay among moral values, legal issues, and cultural background in practical settings. Comparative case studies from various nations might also provide a more whole picture of the ways in which legal and ethical frameworks influence end-of-life care worldwide. The aim of this research is to find important ethical conundrums in end-of-life decision-making, look at how various stakeholders address these issues, and provide recommendations for improving moral standards in clinical environments.(6) By doing this, our research adds pertinent information to legislators, bioethics experts, and medical practitioners thereby contributing to the continuous conversation on medical ethics. Acknowledging that end-of-life choices are not made in a vacuum but rather are impacted by emotional, social, and institutional elements, the research also aims to close the gap between theoretical ethical standards and their actual execution.
Though it seeks to provide a thorough examination of ethical issues in end-of-life treatment, it is crucial to recognise the limits of this study. Ethical conundrums fluctuate widely depending on the context, therefore an action judged ethically good in one environment might not be in another based on institutional, legal, and cultural variables. Moreover, while they are not totally comprehensive, the cases under discussion in this article are chosen to show a spectrum of ethical problems faced in medical practice.(7) To further our knowledge of this difficult topic, future studies may investigate additional points of view including patient narratives, healthcare expert studies, and coverage-level tests, still a totally difficult situation in healthcare ethics, stop-of- lifestyles selection-making calls for cautious assessment of patient autonomy, medical judgement, prison frameworks, and cultural standards. Those circumstances create hard to reply ethical conundrums regarding conflicting moral values and strongly held convictions. This take a look at objectives to show the complexity of these selections and offer knowledge of ways moral conundrums are resolved in fact through a case observe method. This research is to help to create moral rules and pleasant practices for dealing with stop-of-lifestyles care in a manner that honours patient dignity while attending to member of the family and healthcare professional issues. It achieves this from an interdisciplinary perspective integrating philosophical, legal, and clinical viewpoints.
Ethical Frameworks in End-Of-Life Decision-Making
Exceptional moral theories direct choices approximately loss of life and assist medical personnel, patients, and families to remedy hard moral conundrums. These strategies offer methodical way to reconcile clinical duty, patient autonomy, and society expectations. Among the maximum effective ethical theories on this subject are deontological ethics, utilitarianism, and bioethics; all of those provide one of a kind angles on how decisions need to be taken. moral decisions additionally have an effect on felony, cultural, and religious components, which makes cease-of- existence treatment greater tough. Developing honest and humane guidelines that admire each more fashionable society worries and individual rights depends on a cognizance of several ethical structures.(8) Deontological ethics which stresses obligation-primarily based morality is one of the fundamental ethical stances used in cease-of-lifestyles selection-making. Originating in the philosophy of Immanuel Kant, deontology holds that positive ethical responsibilities have to be maintained independent of the end result. This approach helps the concept that, in the framework of stop-of-life care, docs have a responsibility to hold life even in instances in which a patient requests to forestall remedy. From this point of view, medical doctor-assisted suicide and euthanasia are intrinsically unethical as they include the intentional killing of a person, therefore violating the fundamental responsibility of physicians to do no damage. Critics contend that a rigorous deontological approach may result in moral rigidity, consequently stopping healthcare workers from considering affected person suffering and personal autonomy while rendering alternatives.
Emphasising all of us’s properly-being, utilitarianism affords a result-based totally approach for making ethical decisions. Linked with thinkers like John Stuart Mill and Jeremy Bentham, this technique assesses behaviour primarily based on effects as an alternative than inflexible moral responsibilities.(9) Utilitarian’s maintain that picks about quit-of- life remedy should be guided through what will first-rate benefit all the ones engaged and generate the least possible damage. Such sports is probably morally permissible if stopping life-prolonging remedy or helping in death lessens ache and enhances standard nicely-being. when you consider that this strategy places the comfort and dignity of the affected person above extending life at all costs, it promotes palliative care techniques and, in sure situations, euthanasia. Critics of utilitarianism contend that it could result in immoral alternatives like permitting euthanasia amongst inclined companies or allocating scientific cash in accordance on evaluations of pleasant of existence.(10) Stressing every person’s welfare, utilitarianism gives a result-primarily based technique for moral selection-making. Linked with intellectuals like as John Stuart Mill and Jeremy Bentham, this approach evaluates motion based totally on outcomes as opposed to strict ethical responsibilities. Utilitarians agree with that decisions on quit-of- life care should be driven by way of what nice benefit all of us involved and motive the least capability could harm. If ceasing life-prolonging remedy or assisting in dying reduces suffering and improves typical nicely-being, then such actions might be ethically desirable. This method encourages palliative care techniques and, in sure cases, euthanasia because it places the consolation and dignity of the patient above prolonging life at any costs.(11) Critics of utilitarianism argue that it may result in unethical decisions like legalising euthanasia among underprivileged populations or distributing clinical budget based on tests of satisfactory of lifestyles.
In the end, moral decisions are also substantially prompted by using felony factors. Nationally, the legality of physician-assisted suicide, euthanasia, and life aid elimination differs; this affects the decision of ethical conundrums. Even as many different international locations still prohibit health practitioner-assisted suicide and euthanasia as each morally abhorrent and illegal, in the Netherlands, Belgium, and Canada they’re allowed underneath rigorous criteria. Residing wills, advance directives, and do-now not-resuscitate (DNR) orders complicate moral decision-making even in addition through forcing medical doctors to weigh ethical commitments with felony necessities. Once in a while legal guidelines contradict moral values, as a result physicians should decide whether to recognize patient needs or obey the regulation. Non secular and cultural viewpoints have an effect on moral frameworks in stop-of- life treatment even in addition.(12,13) Many theological traditions, together with Hinduism, Islam, and Christianity, strain the want of human existence distinctly and reject techniques like assisted suicide and euthanasia. These thoughts might affect the picks sufferers and their families make; every so often, they bring about demands for added remedy even while docs feel such involvement might be needless. Conversely, a few civilisations provide human liberty and dignity first priority, subsequently they guide the choice to seek medical doctor-assisted suicide or postpone medical intervention in circumstances of excessive ache. Making moral judgements in a multicultural society requires weighing many factors of view and ensures that the conclusions are regular with the regulation and patient-focused.
Even though they may not always provide specific answers, ethical frameworks in the end offer the important course for making decisions about quit-of-existence. Responsibility-based totally ethics, outcome-primarily based questioning, bioethical ideas, legal obstacles, and cultural requirements interact to offer a complicated terrain where each situation has to be carefully examined. Making ethical judgements in this field calls now not simply scholarly information but additionally empathy, communication, and multidisciplinary cooperation. Including many ethical factors of view facilitates healthcare professionals to extra precisely deal with quit-of-existence choices and guarantee that picks suit ethical standards as well as patient requirements.
METHOD
The case study technique is a essential qualitative studies device permitting one to very well check out difficult ethical questions in end-of- life selection-making. Focussing on specific real-world instances, this method allows researchers to examine how moral concepts, criminal questions, and cultural elements interact in scientific exercise. Case research provide a radical and contextualised knowledge of decision-making tactics in addition to perceptive take a look at of the points of view of sufferers, families, docs, lawmakers, and others. The technique additionally permits an evaluation of numerous instances, therefore underlining habitual ethical demanding situations and versions in choice-making in various legal and cultural contexts. Moral theories, bioethical concepts, and contemporary felony structures will manual case examine on this e book to provide a complete assessment of the provided troubles.
Selection criteria for case studies
The selection of case studies for this studies is based totally on several criteria aimed to assure relevance, range, and ethical significance. Instances are chosen focussing on their potential to spotlight extensive moral issues in stop-of- lifestyles decision-making including conflicts among affected person autonomy and medical judgement, debates over lifestyles-sustaining care, and the position of cultural and spiritual beliefs. Instances will include several healthcare settings, which include hospitals, hospice care, and domestic-based totally palliative care, as well as various prison countries where cease-of- lifestyles practices vary to offer a well-rounded research. The selecting system will also offer instances with diverse patient demographics—which include age, medical problems, and socioeconomic backgrounds high priority reflecting a wide spectrum of moral demanding situations. Furthermore, taken into consideration might be the supply of sufficient files, first-hand debts, and professional opinions to make sure that every case is firmly supported with correct facts.
Data Collection Methods
Primary data will come from in-depth interviews with ethicists, clinicians, and—if at all possible—patients or their families who have had to make end-of-life decisions. While enabling open dialogues, these semi-structured interviews will centre on significant ethical concerns. Secondary data sources utilised to offer the greater backdrop for every case study will include medical records, legal documents, hospital policies, and published literature on such events. Additionally, incorporated to improve the research from many viewpoints will be expert opinions from bioethicists and lawyers. Data triangulation will be used to ensure that many sources are utilised to validate results and provide a reasonable evaluation of every case, hence maintaining rigour and credibility.
Ethical Considerations in Case Study Research
Case study research on end-of- life decision-making begs serious ethical issues particularly in connection to confidentiality, informed consent, and sensitivity to emotional distress. The sensitive nature of the issue necessitates that to preserve their privacy all personal and identifying information of patients and relatives will be anonymised. Every interviewee will have given informed consent, therefore ensuring that they understand the objectives of the research, their rights, and the voluntary nature of their participation. Ethical authorisation from an institutional review board (IRB) or another ethics committee will be requested before data gathering begins to assure adherence to ethical research standards. Understanding the emotional weight discussing end-of- life experiences might have on participants, researchers will also approach data gathering with sensitivity and cultural knowledge. To uphold ethical integrity, researchers will remain objective, therefore avoiding any interpretive bias, and provide participants the option to review and validate their contributions before publication.
Case Studies in End-Of-Life Decision-Making
Usually, quit-of- existence choices are shaped by means of a complex interaction of medical, moral, prison, and cultural factors. Case research offer crucial sparkling angles on how these components have an effect on real occurrences and enable one to higher apprehend the demanding situations confronted via sufferers, families, and doctors. This article presents four huge moral conundrums in give up-of- life care: doctor-assisted suicide and prison dilemmas, do-no longer-resuscitate (DNR) orders and circle of relative’s conflicts, palliative sedation in opposition to euthanasia, and synthetic lifestyles help withdrawal inside the framework of religious viewpoints.
Case 1: Physician-Assisted Suicide and Legal Dilemmas
One of the maximum debatable topics in clinical ethics continues to be doctor-assisted suicide (PAS), given felony frameworks so different throughout many countries. Tested in this situation look at is the experience of a terminally sick patient—Mr. James Thompson, 67-yr-old guy diagnosed with amyotrophic lateral sclerosis (ALS). Mr. Thompson’s health deteriorated and he found it increasingly tough to swallow, breathe, and move about daily commercial enterprise. This reduced first-class of existence and prompted excessive physical struggling. Understanding his illness was fatal, he expressed an awesome choice to end his lifestyles on his own terms through medical doctor-assisted suicide. But Mr. Thompson resided in an area wherein PAS was illegal, which placed his health practitioner, Dr. Emily Carter, in each ethical and felony hot water. Dr. Carter recognised her patient’s right to autonomy and knew her suffering, but she was confined by means of the prison ban against any kind of assistance in suicide. Mr. Thompson’s own family divided; his spouse supported his choice whilst his youngsters objected, saying palliative care could provide consolation without resorting to assisted demise. The case indicates the moral quandary that exists among respecting legislative regulations and patient autonomy. It additionally highlights the moral catch 22 situation healthcare personnel who in my opinion support a patient’s proper to die but are legally barred from assisting with such selections undergo. Strict tips make sure that most effective mentally equipped people with terminal illnesses can also make such requests in areas where PAS is authorized, consequently requiring more than one medical examinations and ready intervals. This situation illustrates the ongoing debate on whether legal guidelines need to be altered to provide terminally ill men and women PAS options, consequently balancing moral slippery slopes with personal autonomy towards likely abuse.
Case 2: Do Not Resuscitate (DNR) Orders and Family Disputes
Have to a patient undergo cardiac or breathing arrest, scientific instructions called DNR orders propose physicians not to carry out cardiopulmonary resuscitation (CPR). These commands can also result in widespread own family strife although they are intended to appreciate patient desires and save you needless pain. This situation study covers Mrs. Helen Garcia, an 85-12 months-old woman suffering with COPD and intense congestive coronary heart failure. She favoured consolation care in preference to aggressive treatments, therefore she signed a DNR order after many clinic stays and talks together with her medical crew. But when Mrs. Garcia become admitted with intense respiratory problems, her eldest son, John, insisted that the clinical personnel attempt resuscitation because his mom had modified her thoughts in a latest communication. Maria, her daughter, supported the DNR recommendation as she stated their mother had made a great decision and she could not need to undergo further invasive procedures. John’s call for existence-saving measures specifically presented a challenging moral dilemma for the scientific body of workers: honouring the legally enforced DNR directive or addressing circle of relatives emotional struggling? The case highlights the importance of sincere conversation amongst clinical specialists, families, and sufferers concerning remaining choices on existence. Strengthen care planning and legally accepted form documentation of affected person selections assist to in part avert such conflicts. Resolving issues may additionally call for ethical advice and mediation to ensure that decisions comply with medical ethics with reference for patient-centered remedy.
Case 3: Palliative Sedation vs. Euthanasia
Specifically, in terms in their moral and pragmatic distinctions, palliative sedation and euthanasia are regularly fiercely debated in cease-of-existence care. While palliative sedation is using medications to lessen patient cognizance in situations of severe ache, euthanasia intentionally induces loss of life to alleviate struggling. This situation explores the moral conundrum those two procedures create. Mr. Richard Patel, the 74-12 months-vintage patient with terminal pancreatic cancer, had horrible ache now not responding to excessive opiate doses. His disorder improved swiftly and even with palliative care, he suffered significantly. Palliative sedation changed into prescribed via his oncologist, Dr. Samantha Reynolds, throughout his very last days of suffering. Mr. Patel, who knew his prognosis, sought euthanasia instead, pronouncing he did not want to undergo a prolonged and unconscious dying method. Euthanasia became illegal in her us of a, therefore Dr. Reynolds turned into in felony and ethical hot water. While each had been alleged to lessen struggling, palliative sedation was a recognised medical method while euthanasia changed into no longer. The circle of relatives become divided; some individuals felt sedation changed into a greater moral selection at the same time as others subsidized Mr. Patel’s need for a fast death. This case highlights, especially in international locations wherein euthanasia isn’t officially recognized, the nice line keeping apart palliative sedation from euthanasia. It raises questions about whether or not palliative sedation, which may additionally in a roundabout way shorten life, ethically differs from euthanasia or physician-assisted suicide. It also emphasises the need of honest communique between medical practitioners and sufferers and of well-defined policies to make certain that cease-of- existence remedy conforms to ethical and criminal norms.
Case 4: Artificial Life Support Withdrawal and Religious Perspectives
Mainly with regards to turning off artificial existence help, closing judgements is probably significantly motivated through spiritual and cultural perspectives. The 56-yr-antique Mrs. Aisha Rahman had a big stroke that left her in a continuous vegetative nation. After several months of artificial breathing and enteral nourishment, her scientific group counselled stopping life assist to permit for a natural dying taken into consideration to be not going for healing. Mrs. Rahman’s husband vehemently objected to the existence assist being switched off, believing most effective God had the proper to decide when loss of life arrived, following Islamic values. Her son, then again, concurred with the medical team’s recommend as he felt it against her dignity to keep her struggling thru artificial method. This problem severely taxed the healthcare team of workers as they had to balance own family spiritual ideals with making sure moral and compassionate treatment. This situation suggests the ethical conundrums scientific specialists face whilst religion and cultural values oppose not unusual awareness. Respecting affected person and own family values helps to underline the requirement of culturally equipped treatment that strikes a balance between clinical practicality and ethical worries. Mediators, monks, and hospital ethics committees are regularly very valuable in assisting households to reach consensus.
Those case studies highlight the numerous moral dilemmas experienced in the course of final selections on life. Whether they deal with health practitioner-assisted suicide, DNR orders, palliative sedation, or existence help withdrawal, healthcare providers need to manipulate difficult criminal, ethical, and emotional issues. The activities underscore the necessity of ethical advice, honest conversation, and rules respecting affected person autonomy while catering to broader general network demands. Analysing these actual-global activities allows us to better respect how moral norms are utilized in scientific practice and the way future guidelines may be improved to better resource sufferers, households, and healthcare experts in making compassionate and fair very last decisions.
Analysis of Ethical Challenges in End-Of-Life Decision-Making
Making alternatives on quit of existence requires cautious consideration amongst sufferers, families, physicians, and lawmakers as they generate many moral questions. Generally, these troubles get up from conflicts between patient autonomy, clinical judgement, institutional guidelines, society or religious influences. While juggling those competing goals, ethical questions get up particularly in instances in which there’s no clear consensus at the most ethical route of behaviour. This segment looks at 4 critical ethical questions in cease-of- lifestyles care: balancing autonomy and medical judgement, the function of own family and carers in choice-making, institutional and felony constraints, and the effect of society and non-secular beliefs.
Balancing Autonomy and Medical Judgment
One of the maximum fundamental moral puzzles in cease-of- lifestyles remedy is the contradiction between patient autonomy and medical assessment. Based on affected person autonomy, cutting-edge clinical ethics stresses the proper of sufferers to make informed choices approximately their healthcare along with the opportunity to refuse or give up treatment. This idea, which follows beneficence this is, appearing in the best interest of the patient and non-maleficence that is, warding off damage frequently runs opposite to the expert obligations of healthcare practitioners. Commonly, humans with terminal illnesses display a want to give up lifestyles-sustaining treatments, search for palliative sedation, or even pursue medical doctor-assisted loss of life in prison spheres. Those expectancies can be difficult for physicians, however, if they consider the patient’s decision is encouraged via coercion, deceptive information, or despair. Furthermore, there are times in which patients insist on persevering with competitive treatments in spite of a negative prognosis, which begs moral troubles of clinical futility.
Medical doctors should stability medical realities with patient completely grasping their options by using joint selection-making. Whilst issues like dementia, coma, or severe cognitive impairment rob people of decision-making capability, the challenge of balancing autonomy with clinical judgement is pretty glaring. Under these styles of situations, making sure the honour of the patient’s dreams depends much on preceding commands and surrogate selection-makers. Moral conundrums may nonetheless get up, even as underscoring the want of proactive discussions on give up-of-existence decisions earlier than patients lose their capacity to voice their options, if the affected person’s chosen path of motion is unsure.
Role of Family and Caregivers in Decision-Making
In particular, when sufferers are unable of making decisions for themselves, own family contributors and caretakers generally have a widespread effect on choices taken near death. But now and again, their involvement may want to cause moral conundrums specifically in terms of own family conflicts or between households and physicians. These conflicts may additionally get up from one of a kind factors of view at the affected person’s goals, emotional struggling, non-secular ideals, or economic concerns. One of the maximum tough situations comes whilst families seek for lifestyles-sustaining methods judged useless via specialists. Own family participants may insist on keeping synthetic breathing and feeding even supposing the patient is in a lifelong vegetative country and there’s no hazard of recuperation as they suppose discontinuing support might be like dashing demise. Conversely, there are cases in which households might insist for treatment withdrawal notwithstanding uncertainty approximately the patient’s analysis, thereby elevating problems concerning potential conflicts of interest. Healthcare practitioners ought to navigate these situations with the aid of pushing open and compassionate verbal exchange among all of the parties. Offerings in moral consulting and mediation in addition to a disciplined framework for verbal exchange is probably precious tools in war decision. Improve care making plans and legally documented alternatives consisting of residing wills or healthcare proxies also help to lessen family disputes via guaranteeing exactly said and honoured affected person objectives.
Institutional and policy constraints
Institutional standards and healthcare hints substantially affect quit-of- existence decisions made by using individuals that could create moral dilemmas for physicians and patients. Health facility guidelines on resuscitation, palliative care, and doctor-assisted loss of life now and again reflect more simple legal and ethical frameworks even supposing they will no longer continually meet precise affected person criteria or reviews. From time to time institutional boundaries may want to prevent healthcare professionals from offering precise stop-of-life alternatives, which could create ethical conundrum for sufferers as well as clinicians. One of the problems is the palliative care and hospice offerings’ availability.
Many healthcare systems have confined get entry to palliative care stemming from geographical disparities, limited qualifying standards, or monetary limits. Lack of appropriate pain management and accompanying care may force patients to stay lengthy struggling. Policies associated with do-no longer-resuscitate (DNR) orders additionally various extensively throughout various institutions; a few hospitals might require meaningless bureaucratic activities that complicate or put off the implementation of affected person requests. Institutional limitations may still create get right of entry to issues in areas where physician-assisted death is authorized. Some healthcare companies specifically religion-primarily based corporations may additionally object ethically and refuse to participate in assisted demise packages, consequently depriving patients of few alternatives. Furthermore, medical doctors who in my opinion oppose assisted death may refuse to offer the remedy, which begs moral questions about the stability between their professional responsibilities and personal perspectives. Dealing with those troubles requires for greater flexible guidelines permitting many points of view at the same time as making sure that sufferers get ethical and compassionate care.
Societal and religious influences
Non secular beliefs and cultural conventions strongly have an impact on attitudes closer to stop-of- lifestyles choices as they typically direct each criminal systems and private selections. Many civilisations and beliefs see dying, demise, and the ethical acceptability of occasions like euthanasia, doctor-assisted demise, and termination of existence aid from various angles. Especially in cosmopolitan international locations in which more than one points of view ought to be prevalent, those concepts might sometimes result in conflicts among sufferers, families, and medical experts. Many non-secular traditions together with Christianity, Islam, Hinduism, and Judaism emphasize the value of life and criticise energetic attempts to hasten loss of life. As an example, Islamic philosophy frequently bans assisted death and euthanasia as they violate divine will. at the same time as a few faiths assist palliative care and the abolition of drastic clinical treatment, many sects of Christianity keep the notion that existence ought to be prolonged as long as is nearly possible. By using advocating the right to die with dignity, secular perspectives and sure highbrow traditions on the other hand propose extra autonomy in end-of-existence choices. Influencing choices is cultural view of dying. A few companies see loss of life as taboo, which ends up in negative earlier care making plans and problems figuring out what to do final minute. In others, households rather than individuals take centre degree in figuring out medical care when you consider that communal selection-making is seen as greater essential than personal autonomy. Those cultural differences may want to raise moral troubles for clinical personnel who’ve to balance many demands with respect to expert and felony requirements. coping with these problems calls for touchy healthcare policies that recognize numerous factors of view even as though assuring moral, evidence-based totally treatment for patients. Medical specialists assist to bridge the gap between their exercise and societal expectations by their go-cultural training, network engagement packages, and participation of non-secular advisors into moral debates. Ethical troubles in cease-of- life decision-making arise from juggling opposing values along with affected person autonomy, medical judgement, and circle of relative’s dynamics, institutional standards, and social attitudes. Each this type of components contributes to the difficulty of choice-making and needs careful moral consideration as well as empathic verbal exchange among medical practitioners. Combining many factors of view via cooperative choice-making, ethics debates, and legislative changes allows assure that end-of-existence treatment respects both private rights and greater popular ethical standards, even though no person ethical framework can also absolutely cope with all problems. Ongoing speak among clinical experts, legal experts, politicians, and groups transferring ahead will help to expand ethical recommendations supporting dignity, justice, and compassionate care of patients on the give up of lifestyles.
Comparative Ethical Perspectives in End-Of-Life Decision-Making
Various moral factors of view formed through numerous civilisations, criminal structures, and healthcare structures dictate judgements on stop of lifestyles. Although fundamental ethical ideas like as autonomy, beneficence, non-maleficence, and justice offer a foundation for medical ethics worldwide, their utility varies broadly based on network values, spiritual perspectives, and countrywide laws. This section examines worldwide perspectives on stop-of- lifestyles ethics, looks at U. S. A. Criminal machine variances, and tackles lessons learnt from go-cultural case studies. A know-how of those conflicting factors of view is important to expand extra inclusive and ethically suitable procedures to end-of- life care.
Global Perspectives on End-of-Life Ethics
Reflecting fundamental principles approximately life, loss of life, and the purpose of clinical intervention, ethical opinions towards cease-of-lifestyles care vary amongst societies and civilisations. Even as some nations emphasise collective selection-making wherein own family and network play a prime function, others give person autonomy in medical selection-making first priority, therefore empowering people to exercising strength over their give up-of-existence alternatives. Furthermore impacting how distinct societies control palliative care, existence-maintaining drugs, and euthanasia are religious and philosophical traditions. Particularly in North the United States and Europe, autonomy-pushed models rule Western nations in ethical discussions on stop-of-lifestyles care. Reflecting an emphasis on man or woman choice and dignity in demise, countries just like the Netherlands, Belgium, and Canada have mounted legal guidelines permitting medical doctor-assisted death (PAD) and euthanasia beneath exacting requirements. Those recommendations are predicated at the notion that those with terminal illnesses need to be allowed to select while and a way to pass away. However, circle of relatives-focused selection-making is more accepted in lots of Asian and canter Jap international locations and direct interventions hasten dying is commonly discouraged. As an instance, Confucian moral systems offer filial piety in which circle of relatives members are expected to be actively worried in stop-of-lifestyles choices, frequently in opposition to the express needs of the affected person superb weight. Moreover influencing ethical views are spiritual ones as properly. Although many Christian, Islamic, and Hindu religions uphold the cost of life and ban euthanasia and assisted demise, seen as morally and spiritually abhorrent. Conversely, secular and humanist schools of view argue that people must be free to determine on their very own suffering and death and suggest death with dignity. Buddhist ethics, for instance, emphasise compassion and lessening of struggling, consequently fostering extra nuanced debates on whether or not, in certain situations, assisted demise is authorized. Those international variations spotlight the requirement of cultural sensitivity in ethical decision-making as what is seen as morally correct in one nation might be quite contentious in any other.
Variations in Felony Frameworks Throughout International Locations
Differences in Legal Frameworks across Countries
Legislative responses to give up-of- existence choices range broadly from outright prohibition to allowed euthanasia and health practitioner-assisted demise. These legislative differences reflect the numerous moral and cultural evaluations on medical intervention and loss of life. Legal reputation of euthanasia and health practitioner-assisted suicide underneath strict conditions is located in countries like Belgium, Luxembourg, and the Netherlands. Patients should be terminal or extremely ill, offer knowledgeable consent, and consult many docs to make certain their preference is unfastened will and nicely-considered. Stressing patient choice and the right to die with dignity, these international locations balance legislative safeguards with ethical concerns approximately prospective usage. Likewise, Canada has allowed clinical aid in demise (MAID), consequently permitting assisted suicide and euthanasia for sufferers with terrible and terminal scientific situations. These days, Canadian courts have been debating extending qualifying standards to encompass people with degenerative illnesses and main psychiatric ailments. With the aid of comparison, the USA boasts an extra choppy prison scenario wherein health practitioner-assisted dying is outlawed in sure regions (together with Vermont, Oregon, Washington, California) however permissible in others. Approved underneath strict standards, the Oregon loss of life with Dignity Act was the primary regulation allowing health practitioner-assisted suicide inside the u.s., consequently allowing terminally sick people to are seeking lethal medications. But all U.S. states restrict euthanasia, in which case a doctor bodily administers a fatal dosage. Geographic place controls the variations in get right of entry to to give up-of-existence alternatives attributable to these elements. Nations like Germany and Switzerland permit assisted suicide beneath positive occasions; however, their strategies of regulating the exercise vary. For example, Switzerland lets in assisted suicide as lengthy as it isn’t motivated with the aid of self-serving pursuits, which leads to the emergence of organisations like Dignitas helping terminally unwell individuals want to die. Though it vehemently opposes euthanasia for historical reasons, Germany lets in physician-assisted suicide as long as it’s far voluntary and does no longer jeopardise company pursuits.
Then again, encouraged with the aid of religious and cultural standards, sure Asian and canter eastern nations have severe prohibitions on assisted suicide and euthanasia. For quit-of- existence care, Japan, as an instance, has unclear legal regulations; passive euthanasia that is, the withdrawal of existence-sustaining remedy is extra tolerated than competitive euthanasia. China essentially outlaws euthanasia; moral and criminal systems put family involvement in give up-of-lifestyles care over private affected person autonomy. In India, euthanasia is illegitimate as properly, even though the best court docket has mentioned under certain standards the right to stop existence aid in situations of terminal sickness. Under Islamic law, numerous middle Jap international locations prohibit euthanasia and health practitioner-assisted demise as those techniques are considered as violating religious ideals stressing the glory of life. Those felony variances spotlight how hard it’s far to create a uniform moral code for final decisions about life. While a few nations give affected person autonomy and legalise doctor-assisted dying first priority, others strain the maintenance of existence and the position households and non-secular beliefs play in forming clinical picks. These differences underline the significance of ethically conscious conversations that admire felony obstacles and offer compassionate remedy for the ones approaching demise.
Lessons from Cross-Cultural Case Studies
Move-cultural case research offers perceptive look at of how one of a kind societies approach ethical dilemmas in terminal loss of life picks. Analysing real-international events enables us to realize the benefits and downsides of diverse moral and legal systems, consequently guiding developments in global healthcare policy. One key lesson from move-cultural contacts is the need of clear moral and prison tips in give up-of- life care. Tight policies guarantee that only patients who match positive necessities may additionally have get admission to to felony euthanasia and assisted demise in international locations in which these alternatives are authorized, consequently supporting to keep away from abuse. In nations with ambiguous legal guidelines, but, physicians may discover themselves unsure about judgements, which generates ethical struggle and unequal affected person care. Through standardising moral conduct, clean methods for palliative sedation, lifestyles support withdrawal, and earlier directives may additionally assist to recognize numerous cultural values. A further critical lesson is the want of giving boost care making plans greater of weight. In international locations where discussing dying is banned, patients generally lack documentation in their cease-of-existence choices, which leaves family participants and clinicians in remarkable doubt and battle. Encouragement of conversations on advance directives, residing wills, and DNR orders will assist to ensure that patient choices are respected and assist to minimise family emotional misery. Countries with installed strengthen care planning structures Canada and the Netherlands maximum extensively—provide models for bringing those discussions into ordinary clinical treatment. Ultimate however no longer least, move-cultural case studies highlight palliative care as the moral alternative for aggressive clinical remedies. In nations in which physician-assisted death is still unlawful without resorting to euthanasia, enhancing the availability of palliative care would possibly assist to reduce struggling.
Robust palliative care structures together with those of the United Kingdom guarantee that patients get ok ache control, psychological help, and dignity in demise because they emphasise whole processes to cease-of-existence remedy. Globally making an investment in palliative care infrastructure may assist to cope with moral gaps with the aid of imparting compassionate solutions suitable for exceptional criminal and cultural points of view.
Stop-of-existence alternatives are substantially encouraged with the aid of ethical, prison, cultural, and non-secular aspects; so, specific international locations handle the issue in very one of kind methods. Whilst some nations emphasise the distinction of life and communal choice-making, others provide affected person autonomy and sanctioned doctor-assisted dying first importance.
Inspecting international views, criminal differences, and mastering from pass-cultural case studies lets in us to construct more inclusive and ethically perfect methods of addressing stop-of- existence care. Encouragement of boost care planning, extension of palliative care offerings, and assurance of clear criminal frameworks are essential initial steps in addressing the moral concerns about death and demise in a numerous and changing global.
Recommendations for Ethical Decision-Making in End-Of-Life Care
Ethical decision-making in end-of- life therapy requires a delicate balance between respecting patient autonomy, assuring beneficent medical treatment, and managing legal and cultural constraints. Given the complexity of these decisions, organised regulations, ethical committees, policy reforms, and improved communication strategies help to assure ethically sound and humane end-of- life care. This section offers important recommendations on how to approach the ethical challenges in this profession.
Enhancing Communication in End-of-Life Care
Effective communication is essential in end-of-life decision-making, as it helps ensure that patients, families, and healthcare providers have a clear understanding of options and expectations. Miscommunication or lack of discussion about end-of-life care can lead to unnecessary suffering, conflicts, and ethical dilemmas.
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Table 1. Recommendations for Enhancing Communication in End-of-Life Care |
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Recommendation |
Level of Implementation |
Intended Impact |
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Encouraging Advance Care Planning |
National & Institutional |
Ensures that patient wishes are clearly documented and respected, reducing uncertainty in critical situations. |
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Training Healthcare Providers in Compassionate Communication |
Institutional & Hospital Level |
Improves doctor-patient communication, enhances trust, and reduces emotional distress for patients and families. |
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Cultural and Linguistic Sensitivity |
Institutional & National |
Ensures equitable access to end-of-life care by addressing language and cultural barriers. |
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Regular Family Meetings and Decision Support |
Institutional & Hospital Level |
Strengthens family involvement in decision-making and reduces confusion and conflicts. |
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Addressing Conflicts Early |
Institutional & National |
Prevents prolonged conflicts, reduces stress on patients and families, and ensures timely ethical resolutions. |
By fostering open and honest communication, healthcare providers can help ensure that end-of-life decisions are made collaboratively and with respect for patient and family preferences.
Policy Recommendations
Ethical behaviour in end-of- life care is much shaped by policies at the institutional, national, and worldwide levels. Following suggestions will assist to guarantee that policies respect patient rights and cultural diversity while reflecting moral values.
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Table 2. Summary of Policy Recommendations |
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Policy Recommendation |
Level of Implementation |
Intended Impact |
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Legal Recognition of Advance Directives and Living Wills |
National & Institutional |
Ensures patient autonomy is respected, even when they lose decision-making capacity. |
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Expanding Access to Palliative Care |
National & Institutional |
Guarantees comprehensive pain relief and psychological support for terminally ill patients. |
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Developing Clear Guidelines for Do-Not-Resuscitate (DNR) Orders |
Institutional & Hospital Level |
Improves clarity and uniformity in DNR discussions and documentation. |
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Regulating Physician-Assisted Dying Where Legal |
National |
Provides ethical oversight while maintaining accessibility for eligible patients. |
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Ensuring Equitable End-of-Life Care Across Socioeconomic Groups |
Global & National |
Reduces disparities in end-of-life care across different economic backgrounds. |
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Public Awareness and Education Campaigns |
National & Institutional |
Promotes informed decision-making and reduces societal stigma around death and dying. |
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International Collaboration on Ethical Best Practices |
Global |
Encourages cross-border learning and standardization of ethical end-of-life care practices. |
By using method of these coverage tips, healthcare systems may also reinforce their ethical technique to end-of-lifestyles treatment, consequently making sure that sufferers get respectable and respectful remedy. Ethical choice-making in end-of- life care demands for a whole technique encompassing moral session, professional standards, suitable communication, and supportive regulations. Despite the fact that mediation tools and ethics committees assist to clear up disputes and manual selections, healthcare workforce individuals must be prepared with ethical training and well described protocols to navigate difficult conditions. Policy modifications will assist to make certain that ethical pleasant practices help felony structures, healthcare vendors, and public training efforts. Encouragement of affected person-focused care, sincere communication, and equitable get admission to to give up-of-existence support will assist society make certain that individuals with terminal illnesses get morally precise remedy.
CONCLUSION
A sensitive and difficult technique, stop-of- existence choices name for careful ethical, criminal, and scientific notion. the usage of a case study approach, this paper has investigated the ethical conundrums of quit-of- lifestyles care which includes physician-assisted suicide, do-no longer-resuscitation (DNR) orders, palliative sedation, and lifestyles assist removal. It has looked at how bioethical thoughts autonomy, beneficence, non-maleficence, and justice in addition to moral frameworks together with utilitarian and deontological factors of view assist doctors and families in navigating difficult circumstances. Comparative studies of global factors of view have shown that legislative policies and cultural attitudes on give up-of-life care range considerably throughout nations. While a few countries appreciate the sanctity of existence and forbid proactive cures that velocity demise, others supply patient autonomy first precedence and enable medical doctor-assisted suicide beneath tight rules. The style of strategies emphasises the necessity of rules with cultural sensitivity and legal soundness that balances non-public freedoms with society beliefs. Move-cultural case studies provide classes at the value of properly defined moral norms, nicely-organised legislative frameworks, palliative care get right of entry to, and proactive improve care planning. Those teachings assist to keep away from issues and guarantee respect of patient alternatives. This studies has produced some insightful guidelines supposed to assist resolve moral conundrums related to end-of- existence remedy. Medical personnel want to be armed with nicely defined moral rules and education so they’ll tackle those problems with honesty and compassion. Good verbal exchange strategies—along with early conversations on advance care making plans may additionally help to avoid misunderstandings and guarantee appreciate of patient preferences. Solving problems and ensuring decisions follow criminal standards and moral excellent standards depend upon ethics committees and mediation services. Policy adjustments also assist to standardise stop-of-existence care, offer truthful get entry to to palliative care, and offer explicit procedures for morally tough situations. In give up-of- lifestyles treatment, moral selections need to be subsequently affected person-focused, ethically proper, and culturally sensitive. Healthcare structures may also assure that patients with terminal sicknesses get compassionate and respectful remedy by using considering society values, prison problems, and medical ethics. Development of ethical norms and regulations that assist affected person rights and medical practitioner responsibilities relies upon on consistent verbal exchange among legislators, ethicists, healthcare practitioners, and groups. The converting scene of quit-of-existence care calls for an interdisciplinary method stressing humanity, dignity, and ethical integrity in the final stages of lifestyles.
REFERENCES
1. Sabatino, C.P. The evolution of health care advance planning law and policy. Milbank Q. 2010, 88, 211–239.
2. Muraya, T.; Akagawa, Y.; Andoh, H.; Chiang, C.; Hirakawa, Y. Improving person-centered advance care planning conversation with older people: A qualitative study of core components perceived by healthcare professionals. J. Rural Med. 2021, 16, 222–228.
3. Grill, K.; Dawson, A. Ethical frameworks in public health decision-making: Defending a value-based and pluralist approach. Health Care Anal. 2017, 25, 291–307.
4. Crowe, S.; Cresswell, K.; Robertson, A.; Huby, G.; Avery, A.; Sheikh, A. The case study approach. BMC Med. Res. Methodol. 2011, 11, 100.
5. Sneesby, L. Ethical and moral dilemmas caring for people who are dying: Why we need to plan in advance. BMJ Support. Palliat. Care 2011, 1, 108.
6. Cairns, R. Advance care planning: Thinking ahead to achieve our patients’ goals. Br. J. Community Nurs. 2011, 16, 427.
7. Hirakawa, Y.; Chiang, C.; Muraya, T.; Andoh, H.; Aoyama, A. Interprofessional case conferences to bridge perception gaps regarding ethical dilemmas in home-based end-of-life care: A qualitative study. J. Rural Med. 2020, 15, 104–115.
8. Y.V. Sunil Subrahmanyam, Y.S. Srivatsav. (2015). A Review On Growing M Commerce In India. International Journal on Research and Development - A Management Review, 4(1), 143 - 147.
9. Heale, R.; Twycross, A. What is a case study? Evid. Based Nurs. 2018, 21, 7–8.
10. Wichmann, A.B.; van Dam, H.; Thoonsen, B.; Boer, T.A.; Engels, Y.; Groenewoud, A.S. Advance care planning conversations with palliative patients: Looking through the GP’s eyes. BMC Fam. Pract. 2018, 19, 184.
11. Sudore, R.L.; Fried, T.R. Redefining the “planning” in advance care planning: Preparing for end-of-life decision making. Ann. Intern. Med. 2010, 153, 256–261.
12. van Bruchem-Visser, R.L.; van Dijk, G.; de Beaufort, I.; Mattace-Raso, F. Ethical frameworks for complex medical decision making in older patients: A narrative review. Arch. Gerontol. Geriatr. 2020, 90, 104160.
13. Zwakman, M.; Jabbarian, L.J.; van Delden, J.; van der Heide, A.; Korfage, I.J.; Pollock, K.; Rietjens, J.; Seymour, J.; Kars, M.C. Advance care planning: A systematic review about experiences of patients with a life-threatening or life-limiting illness. Palliat. Med. 2018, 32, 1305–1321.
FINANCING
None.
CONFLICT OF INTEREST
None.
AUTHORSHIP CONTRIBUTION
Conceptualization: Keshav, Manashree Mane, Swarna Swetha Kolaventi, Shakti Bedanta Mishra, Mekala Ishwarya, Romil Jain, Sulabh Mahajan.
Data curation: Keshav, Manashree Mane, Swarna Swetha Kolaventi, Shakti Bedanta Mishra, Mekala Ishwarya, Romil Jain, Sulabh Mahajan.
Formal analysis: Keshav, Manashree Mane, Swarna Swetha Kolaventi, Shakti Bedanta Mishra, Mekala Ishwarya, Romil Jain, Sulabh Mahajan.
Writing - original draft: Keshav, Manashree Mane, Swarna Swetha Kolaventi, Shakti Bedanta Mishra, Mekala Ishwarya, Romil Jain, Sulabh Mahajan.
Writing - revision and editing: Keshav, Manashree Mane, Swarna Swetha Kolaventi, Shakti Bedanta Mishra, Mekala Ishwarya, Romil Jain, Sulabh Mahajan.