Delirium Management: Mr. De Jong's Case and Best Practices
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This report provides a comprehensive review of delirium management, focusing on a case study of Mr. Lars De Jong, a 69-year-old patient who developed delirium following mechanical ventilation. The report begins with an introduction to delirium, emphasizing its significance as a serious medical condition with high morbidity and mortality, particularly in elderly hospitalized patients. It then analyzes Mr. De Jong's case, identifying his risk factors, including age, mechanical ventilation, and elevated creatinine levels. The report reviews literature on the prevention and management of delirium, highlighting the importance of multi-component interventions, including formal assessments, non-pharmacological strategies (such as reorientation, mobility exercises, and managing sleep patterns), and medication reviews. It critiques the care provided to Mr. De Jong, noting the absence of formal assessments and the omission of key preventive strategies. The report recommends that nurses conduct regular cognitive assessments, manage sedation, and address hydration and sleep patterns. Finally, it concludes that multi-component interventions targeting risk factors are most effective in preventing delirium and underscores the need for a holistic approach to patient care, especially in critically ill patients like Mr. De Jong. The report references several clinical guidelines and research papers to support its findings and recommendations.
Running head: DELIRIUM
Delirium
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Delirium
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1DELIRIUM
Introduction:
Delirium is a serious medical condition associated with impaired cognitive function and
reduced ability to focus and pay attention. The diagnosis of dementia is associated with
significant morbidity, persistent decline in function, increased medical cost and high mortality. It
is also a risk factor of later onset of dementia. Despite being preventable, delirium is a major
burden as it remains a common complication in hospitalized elderly patients (Pezzullo et al.
2019). Delirium can be prevented by implementation of best practices related to dementia care
and management. The main aim of this essay is to undertake a review of the literature to identify
best practices related to delirium care and compared this evidence with the case of Mr. Lars De
Jong who suffered from delirium during hospital stay. The essay will critically assess risk factors
for Mr. De Jong Lars and evaluate how delirium could be managed in the case.
Review of risk factors for Mr. De Jong:
Based on the review of the case study, it has been found that Mr. Lars De Jong is a 69
years old man who developed symptoms of delirium following mechanical ventilation during
hospital stay. He was brought to the hospital by his daughter Hanna as he was found to
unresponsive and breathless. He remained in mechanical ventilation for more than three days and
he was displaying unusual behaviors. For example, he looked agitated and restless. He avoided
eye contact and appeared withdrawn. According to the review of high level of evidence on risk
factors of dementia, age greater than 70 years, pre-existing cognitive impairment, use of
indwelling catheter, abnormal sodium, visual impairment and use of three or more medications
during hospitalization increases the risk of delirium (Department of Health and Ageing 2011,
ACSQHC 2016). Age was one of the factors linked to high risk. In addition, indwelling catheter
Introduction:
Delirium is a serious medical condition associated with impaired cognitive function and
reduced ability to focus and pay attention. The diagnosis of dementia is associated with
significant morbidity, persistent decline in function, increased medical cost and high mortality. It
is also a risk factor of later onset of dementia. Despite being preventable, delirium is a major
burden as it remains a common complication in hospitalized elderly patients (Pezzullo et al.
2019). Delirium can be prevented by implementation of best practices related to dementia care
and management. The main aim of this essay is to undertake a review of the literature to identify
best practices related to delirium care and compared this evidence with the case of Mr. Lars De
Jong who suffered from delirium during hospital stay. The essay will critically assess risk factors
for Mr. De Jong Lars and evaluate how delirium could be managed in the case.
Review of risk factors for Mr. De Jong:
Based on the review of the case study, it has been found that Mr. Lars De Jong is a 69
years old man who developed symptoms of delirium following mechanical ventilation during
hospital stay. He was brought to the hospital by his daughter Hanna as he was found to
unresponsive and breathless. He remained in mechanical ventilation for more than three days and
he was displaying unusual behaviors. For example, he looked agitated and restless. He avoided
eye contact and appeared withdrawn. According to the review of high level of evidence on risk
factors of dementia, age greater than 70 years, pre-existing cognitive impairment, use of
indwelling catheter, abnormal sodium, visual impairment and use of three or more medications
during hospitalization increases the risk of delirium (Department of Health and Ageing 2011,
ACSQHC 2016). Age was one of the factors linked to high risk. In addition, indwelling catheter
2DELIRIUM
use and mechanical ventilation were identified as other links for risk factors of delirium. The
study by Bulic et al. (2017) investigated about the risk of delirium after mechanical ventilation in
intensive care units (ICU) and revealed that delirium risk increase due to sedation, mechanical
ventilation and lack of sleep. Toft et al. (2019) highlighted that delirium develops in patient
within 72 hours of ICU admission and Mr. Lars was found to have such symptoms in the same
interval. The study indicated that high level of serum markers like creatinine level increases the
risk of delirium. In the case study, change in the creatinine level for Mr. Lars was observed as his
creatinine value was 20 mg/Dl. Hence, it can be concluded that mechanical ventilation and long
period of hospitalization exposed Mr. Lars to risk of delirium.
Literature review on prevention and management of delirium:
In the case study, the nurse suspected Mr. Lars to be suffering from delirium and started
non-pharmacological protocols to control and manage his symptoms. However, the drawback of
the nursing action is that no formal assessment was conducted to confirm the risk of delirium.
According to clinical practice guidelines for management of delirium, there is a need to use
structured process for screening and diagnosing the condition using assessments tools like
Confusion Assessment Method (CAM). In case of high risk patient, formalized process of
screening is suggested by means of regular cognitive assessment and using the DSM-V
diagnostic criteria for detection of the disease (ACSQHS 2019, Department of Health and
Ageing 2011). In case of the case study, it has been found that formal assessment method was
missing.
Mr. Lars was a high risk patient considering his age and long duration of hospitalization.
Considering this, it was important for the nurse to implement preventive strategies related to
use and mechanical ventilation were identified as other links for risk factors of delirium. The
study by Bulic et al. (2017) investigated about the risk of delirium after mechanical ventilation in
intensive care units (ICU) and revealed that delirium risk increase due to sedation, mechanical
ventilation and lack of sleep. Toft et al. (2019) highlighted that delirium develops in patient
within 72 hours of ICU admission and Mr. Lars was found to have such symptoms in the same
interval. The study indicated that high level of serum markers like creatinine level increases the
risk of delirium. In the case study, change in the creatinine level for Mr. Lars was observed as his
creatinine value was 20 mg/Dl. Hence, it can be concluded that mechanical ventilation and long
period of hospitalization exposed Mr. Lars to risk of delirium.
Literature review on prevention and management of delirium:
In the case study, the nurse suspected Mr. Lars to be suffering from delirium and started
non-pharmacological protocols to control and manage his symptoms. However, the drawback of
the nursing action is that no formal assessment was conducted to confirm the risk of delirium.
According to clinical practice guidelines for management of delirium, there is a need to use
structured process for screening and diagnosing the condition using assessments tools like
Confusion Assessment Method (CAM). In case of high risk patient, formalized process of
screening is suggested by means of regular cognitive assessment and using the DSM-V
diagnostic criteria for detection of the disease (ACSQHS 2019, Department of Health and
Ageing 2011). In case of the case study, it has been found that formal assessment method was
missing.
Mr. Lars was a high risk patient considering his age and long duration of hospitalization.
Considering this, it was important for the nurse to implement preventive strategies related to
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delirium much before. However, the nurse initiated non-pharmacological interventions after
observing sign and symptoms of delirium. The review of research literature gives many ideas
regarding how preventive care strategies should have been implemented for delirium. The review
of literature on preventive strategies for delirium particularly in critically ill and mechanically
ventilated patient revealed managing dose of drugs and sedation to prevent risk. This is said
based on link between different sedation agents and development of delirium. The study by
Bulic, Bennet and Shehabi (2015) conducted a review of literature to identify risk of delirium in
ICU unit and examines the role of sedation in promoting this disorder. The key finding from this
paper was that use of y-aminobutyric acid (GABA) receptor agonists like propofol and
benzodiazepines increase the occurrence of delirium. This study gave the indication for
implementing balanced approach to analgesia and sedation to minimize side-effects and risk for
Mr. Lars. However, such dose management and assessment for sedative agent was missing in the
case study.
There are multiple preventive strategies for delirium. This involved looking at addressing
all those factors that increase the risk of dementia. After identifying risk of delirium, there is a
need to assess and manage the hydration and nutrition status of patient, pain, cognitive
impairment, immobility and falls, bowel and bladder, sleep patterns, environment and sensory
aids to prevent delirium (ACSQHS 2019, NSW Government 2019). In case of Mr. Lars such
multi-component preventive step was missing which was major drawback of his care provided
during hospital stay. Due to lack of fall assessment, he fell and injured his left elbow. As elderly
hospitalized patients are at risk of fall, it is necessary to assess fall risk and ensure safe
environment by lowering their bed and providing mobility aid or support while going to toilet.
Fall assessment is part of the delirium care pathway too. Medication review and management of
delirium much before. However, the nurse initiated non-pharmacological interventions after
observing sign and symptoms of delirium. The review of research literature gives many ideas
regarding how preventive care strategies should have been implemented for delirium. The review
of literature on preventive strategies for delirium particularly in critically ill and mechanically
ventilated patient revealed managing dose of drugs and sedation to prevent risk. This is said
based on link between different sedation agents and development of delirium. The study by
Bulic, Bennet and Shehabi (2015) conducted a review of literature to identify risk of delirium in
ICU unit and examines the role of sedation in promoting this disorder. The key finding from this
paper was that use of y-aminobutyric acid (GABA) receptor agonists like propofol and
benzodiazepines increase the occurrence of delirium. This study gave the indication for
implementing balanced approach to analgesia and sedation to minimize side-effects and risk for
Mr. Lars. However, such dose management and assessment for sedative agent was missing in the
case study.
There are multiple preventive strategies for delirium. This involved looking at addressing
all those factors that increase the risk of dementia. After identifying risk of delirium, there is a
need to assess and manage the hydration and nutrition status of patient, pain, cognitive
impairment, immobility and falls, bowel and bladder, sleep patterns, environment and sensory
aids to prevent delirium (ACSQHS 2019, NSW Government 2019). In case of Mr. Lars such
multi-component preventive step was missing which was major drawback of his care provided
during hospital stay. Due to lack of fall assessment, he fell and injured his left elbow. As elderly
hospitalized patients are at risk of fall, it is necessary to assess fall risk and ensure safe
environment by lowering their bed and providing mobility aid or support while going to toilet.
Fall assessment is part of the delirium care pathway too. Medication review and management of
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4DELIRIUM
dose of sedative drug is an important strategy too. Hanison and Conway (2015) gave evidence
for the effectiveness of clinical practices like reduction in the use of drugs like benzodiazepines,
opioids and targeting lighter levels of sedation to minimize risk for patient. Such changes
resulted in improvement in rates of delirium. This evidence suggests that multimodal preventive
efforts are more successful in preventing delirium compared to other interventions.
In the case study, the nurse implemented many non-pharmacological interventions for
management of delirium and preventing progression of the disease. This included reorientation
strategy, visible daylight, mobility activities and range of motion exercises. From the review of
best practices related to management of delirium, these steps are part of multi-component
intervention. However, other important elements that were missing in Mr. Lars care pathway was
management of hydration, sleep patterns and visual problems. The ACQHS standard for
dementia management mentions reorientation, therapeutic activity, reduction in psychoactive
drugs, early mobilization, hydration and nutrition and visual aids as part of successful multi-
component intervention to prevention of delirium (ACSQHS 2019). Reorientation strategy
mainly involves orienting patient to the environment, place and time by communication skills.
This involves asking the patient who they are, where they are and their daily work. It also
involves making changes to the environment such as introducing provision of clock and
calendar, maintaining appropriate lighting to reduce disorientation (Slooter, Van De Leur and
Zaal 2017).
In case of Lars, the nurse introduced visible daylight and reorientation strategy to
minimize disorientation. The effectiveness of environmental stimulation and re-orientation
strategy has been proved by a two-stage prospective observation study by Colombo et al. (2012).
The researcher conducted research with patients admitted to the ICU units. After the Delirium
dose of sedative drug is an important strategy too. Hanison and Conway (2015) gave evidence
for the effectiveness of clinical practices like reduction in the use of drugs like benzodiazepines,
opioids and targeting lighter levels of sedation to minimize risk for patient. Such changes
resulted in improvement in rates of delirium. This evidence suggests that multimodal preventive
efforts are more successful in preventing delirium compared to other interventions.
In the case study, the nurse implemented many non-pharmacological interventions for
management of delirium and preventing progression of the disease. This included reorientation
strategy, visible daylight, mobility activities and range of motion exercises. From the review of
best practices related to management of delirium, these steps are part of multi-component
intervention. However, other important elements that were missing in Mr. Lars care pathway was
management of hydration, sleep patterns and visual problems. The ACQHS standard for
dementia management mentions reorientation, therapeutic activity, reduction in psychoactive
drugs, early mobilization, hydration and nutrition and visual aids as part of successful multi-
component intervention to prevention of delirium (ACSQHS 2019). Reorientation strategy
mainly involves orienting patient to the environment, place and time by communication skills.
This involves asking the patient who they are, where they are and their daily work. It also
involves making changes to the environment such as introducing provision of clock and
calendar, maintaining appropriate lighting to reduce disorientation (Slooter, Van De Leur and
Zaal 2017).
In case of Lars, the nurse introduced visible daylight and reorientation strategy to
minimize disorientation. The effectiveness of environmental stimulation and re-orientation
strategy has been proved by a two-stage prospective observation study by Colombo et al. (2012).
The researcher conducted research with patients admitted to the ICU units. After the Delirium
5DELIRIUM
assessment of patient using the Confusion Assessment Method, patients were provided re-
orientation and environmental stimulation intervention. By the review of outcomes related to rate
of delirium post intervention, it was found that reorientation was the strongest protective
predictors of delirium. The study revealed statistically significant improvement in occurrence of
delirium after timely reorientation strategy. Hence, the nurse use of timely reorientation is
commendable. Early mobilization and range of motion exercise is also part of evidence based
management of delirium. According to Department of Health and Ageing (2011) dementia care
pathways, regular mobilization and massage can promote sufficient sleep and relaxation. A
systematic review by Hshieh et al. (2015) also gave evidence for use of early mobilization during
multi-component non-pharmacological delirium interventions. Such intervention was found to be
cost effective in preventing delirium and functional decline.
Based on critical review of research literature related to delirium care and management, it
is recommended that nurse should first conduct regular cognitive assessment of Mr. Lars
followed by non-pharmacological intervention. As the nurse missed paying attention to effects of
sedation, sleep patterns and hydration on delirium risk, it is recommended that the nurse include
hydration, nutrition strategies and sleep strategies in the care plan too. Early hydration is part of
evidence based interventions like the Hospital Elder Life program, which included 6 delirium
risk factors such as sleep deprivation, dehydration, immobility, visual, cognitive and hearing
impairment in the care protocol. The significance of this resource is that it gives systematic steps
to implement non-pharmacological intervention which can be easily followed by nurse. For
example, for sleep deprivation, the study suggested providing relaxing night environment and
noise reduction strategies. Systematic mobility and range of motion exercise at least 3 times
daily and systems to main hydration and nutrition was suggested too. Such evidence adequately
assessment of patient using the Confusion Assessment Method, patients were provided re-
orientation and environmental stimulation intervention. By the review of outcomes related to rate
of delirium post intervention, it was found that reorientation was the strongest protective
predictors of delirium. The study revealed statistically significant improvement in occurrence of
delirium after timely reorientation strategy. Hence, the nurse use of timely reorientation is
commendable. Early mobilization and range of motion exercise is also part of evidence based
management of delirium. According to Department of Health and Ageing (2011) dementia care
pathways, regular mobilization and massage can promote sufficient sleep and relaxation. A
systematic review by Hshieh et al. (2015) also gave evidence for use of early mobilization during
multi-component non-pharmacological delirium interventions. Such intervention was found to be
cost effective in preventing delirium and functional decline.
Based on critical review of research literature related to delirium care and management, it
is recommended that nurse should first conduct regular cognitive assessment of Mr. Lars
followed by non-pharmacological intervention. As the nurse missed paying attention to effects of
sedation, sleep patterns and hydration on delirium risk, it is recommended that the nurse include
hydration, nutrition strategies and sleep strategies in the care plan too. Early hydration is part of
evidence based interventions like the Hospital Elder Life program, which included 6 delirium
risk factors such as sleep deprivation, dehydration, immobility, visual, cognitive and hearing
impairment in the care protocol. The significance of this resource is that it gives systematic steps
to implement non-pharmacological intervention which can be easily followed by nurse. For
example, for sleep deprivation, the study suggested providing relaxing night environment and
noise reduction strategies. Systematic mobility and range of motion exercise at least 3 times
daily and systems to main hydration and nutrition was suggested too. Such evidence adequately
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6DELIRIUM
informs nursing practitioners regarding the appropriate way to manage delirium in seriously ill
hospitalized patients like Mr. Lars (Kostas, Zimmerman and Rudolph 2013).
Conclusion:
From the review of clinical guidelines and literatures on prevention and management of
delirium, it can be concluded that multi-component interventions targeting risk factors are most
effective in preventing delirium. In case of Mr. Lars, ICU conditions and mechanical ventilation
increased the risk of delirium. Several non-pharmacological interventions were implemented to
manage his symptoms. However, other vitals steps like limiting use of sedation, moderating
sleep patter and assessment of hydration was not done. This essay recommends nurse to pay
special emphasis to implementation of multi-component protocols so that complication is
minimized and there is no need to implement pharmacological interventions for patient.
informs nursing practitioners regarding the appropriate way to manage delirium in seriously ill
hospitalized patients like Mr. Lars (Kostas, Zimmerman and Rudolph 2013).
Conclusion:
From the review of clinical guidelines and literatures on prevention and management of
delirium, it can be concluded that multi-component interventions targeting risk factors are most
effective in preventing delirium. In case of Mr. Lars, ICU conditions and mechanical ventilation
increased the risk of delirium. Several non-pharmacological interventions were implemented to
manage his symptoms. However, other vitals steps like limiting use of sedation, moderating
sleep patter and assessment of hydration was not done. This essay recommends nurse to pay
special emphasis to implementation of multi-component protocols so that complication is
minimized and there is no need to implement pharmacological interventions for patient.
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7DELIRIUM
References:
ACSQHC (The Australian Commission on Safety and Quality in Health Care) 2016. Delirium
Clinical Care Standard to improve care and prevention. Retrieved from:
https://www.safetyandquality.gov.au/media_releases/delirium-clinical-care-standard-to-improve-
care-and-prevention
Australian Commission on Safety and Quality in Health Care (ACSQHS) 2019. A better way to
care Safe and high-quality care for patients with cognitive impairment or at risk of delirium in
acute health services. Retrieved from:
https://www.safetyandquality.gov.au/sites/default/files/2019-06/sq19-
026_acsqhc_bwtc_d21.sk_june-3_accessible_pdf.pdf
Bulic, D., Bennett, M. and Shehabi, Y., 2015. Delirium in the intensive care unit and long-term
cognitive and psychosocial functioning: literature review. Australian Journal of Advanced
Nursing, The, 33(1), p.44.
Bulic, D., Bennett, M., Rodgers, H., Nourse, M., Rubie, P., Looi, J. C., and Van Haren, F. 2017.
Delirium After Mechanical Ventilation in Intensive Care Units: The Cognitive and Psychosocial
Assessment (CAPA) Study Protocol. JMIR research protocols, 6(2), e31.
Colombo, R., Corona, A., Praga, F., Minari, C., Giannotti, C., Castelli, A. and Raimondi, F.,
2012. A reorientation strategy for reducing delirium in the critically ill. Results of an
interventional study. Minerva anestesiologica, 78(9), p.1026
References:
ACSQHC (The Australian Commission on Safety and Quality in Health Care) 2016. Delirium
Clinical Care Standard to improve care and prevention. Retrieved from:
https://www.safetyandquality.gov.au/media_releases/delirium-clinical-care-standard-to-improve-
care-and-prevention
Australian Commission on Safety and Quality in Health Care (ACSQHS) 2019. A better way to
care Safe and high-quality care for patients with cognitive impairment or at risk of delirium in
acute health services. Retrieved from:
https://www.safetyandquality.gov.au/sites/default/files/2019-06/sq19-
026_acsqhc_bwtc_d21.sk_june-3_accessible_pdf.pdf
Bulic, D., Bennett, M. and Shehabi, Y., 2015. Delirium in the intensive care unit and long-term
cognitive and psychosocial functioning: literature review. Australian Journal of Advanced
Nursing, The, 33(1), p.44.
Bulic, D., Bennett, M., Rodgers, H., Nourse, M., Rubie, P., Looi, J. C., and Van Haren, F. 2017.
Delirium After Mechanical Ventilation in Intensive Care Units: The Cognitive and Psychosocial
Assessment (CAPA) Study Protocol. JMIR research protocols, 6(2), e31.
Colombo, R., Corona, A., Praga, F., Minari, C., Giannotti, C., Castelli, A. and Raimondi, F.,
2012. A reorientation strategy for reducing delirium in the critically ill. Results of an
interventional study. Minerva anestesiologica, 78(9), p.1026
8DELIRIUM
Department of Health and Ageing 2011. Delirium Care Pathways. Retrieved from:
https://www1.health.gov.au/internet/main/publishing.nsf/Content/FA0452A24AED6A91CA257
BF0001C976C/$File/D0537(1009)%20Delirium_combined%20SCREEN.pdf
Hanison, J., and Conway, D. 2015. A multifaceted approach to prevention of delirium on
intensive care. BMJ quality improvement reports, 4(1), u209656.w4000.
doi:10.1136/bmjquality.u209656.w4000
Hshieh, T.T., Yue, J., Oh, E., Puelle, M., Dowal, S., Travison, T. and Inouye, S.K., 2015.
Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-
analysis. JAMA internal medicine, 175(4), pp.512-520.
Kostas, T. R., Zimmerman, K. M., and Rudolph, J. L. 2013. Improving delirium care:
prevention, monitoring, and assessment. The Neurohospitalist, 3(4), 194–202.
doi:10.1177/1941874413493185
NSW Government 2019. Preventative Strategies for Delirium. Retrieved from:
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0003/181623/Delirium-Prevention.pdf
Pezzullo, L., Streatfeild, J., Hickson, J., Teodorczuk, A., Agar, M.R. and Caplan, G.A., 2019.
Economic impact of delirium in Australia: a cost of illness study. BMJ open, 9(9), p.e02751
Slooter, A.J.C., Van De Leur, R.R. and Zaal, I.J., 2017. Delirium in critically ill patients.
In Handbook of clinical neurology (Vol. 141, pp. 449-466). Elsevier.
Toft, K., Tontsch, J., Abdelhamid, S., Steiner, L., Siegemund, M., and Hollinger, A. (2019).
Serum biomarkers of delirium in the elderly: a narrative review. Annals of intensive care, 9(1),
76.
Department of Health and Ageing 2011. Delirium Care Pathways. Retrieved from:
https://www1.health.gov.au/internet/main/publishing.nsf/Content/FA0452A24AED6A91CA257
BF0001C976C/$File/D0537(1009)%20Delirium_combined%20SCREEN.pdf
Hanison, J., and Conway, D. 2015. A multifaceted approach to prevention of delirium on
intensive care. BMJ quality improvement reports, 4(1), u209656.w4000.
doi:10.1136/bmjquality.u209656.w4000
Hshieh, T.T., Yue, J., Oh, E., Puelle, M., Dowal, S., Travison, T. and Inouye, S.K., 2015.
Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-
analysis. JAMA internal medicine, 175(4), pp.512-520.
Kostas, T. R., Zimmerman, K. M., and Rudolph, J. L. 2013. Improving delirium care:
prevention, monitoring, and assessment. The Neurohospitalist, 3(4), 194–202.
doi:10.1177/1941874413493185
NSW Government 2019. Preventative Strategies for Delirium. Retrieved from:
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0003/181623/Delirium-Prevention.pdf
Pezzullo, L., Streatfeild, J., Hickson, J., Teodorczuk, A., Agar, M.R. and Caplan, G.A., 2019.
Economic impact of delirium in Australia: a cost of illness study. BMJ open, 9(9), p.e02751
Slooter, A.J.C., Van De Leur, R.R. and Zaal, I.J., 2017. Delirium in critically ill patients.
In Handbook of clinical neurology (Vol. 141, pp. 449-466). Elsevier.
Toft, K., Tontsch, J., Abdelhamid, S., Steiner, L., Siegemund, M., and Hollinger, A. (2019).
Serum biomarkers of delirium in the elderly: a narrative review. Annals of intensive care, 9(1),
76.
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