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(2008). Dementia is ruled out as a candidate for PAD, even if she is terminally ill and suffering terrible and unrelievable pain, which rules out individuals with strong and unwavering desires not to end their life in dementia. *Correspondence: Ravi Philip Rajkumar, ravi.psych@gmail.com, End-Of-Life Care and Physician-Assisted Dying (PAD) in People Living with Dementia: Intersections of Law and Psychiatry, View all Psychiatry Rep. 22, 31. doi:10.1007/s11920-020-01150-7, PubMed Abstract | CrossRef Full Text | Google Scholar, Alsolamy, S. (2014). TABLE 3. (2012). Barriers to Excellent End-Of-Life Care for Patients with Dementia. On the other hand, there was a better fit for non-linear (quadratic or cubic) models than for a linear relationship for life expectancy, individualism/collectivism, masculinity/femininity, and avoidance of uncertainty. 5 0 obj 14, 152170. J. Environ. (2021). (2021). Med. Ther. This case is notable because it is the first case to trigger a criminal investigation since the 2002 Dutch euthanasia law was enacted. (2011). <>20]/P 23 0 R/Pg 44 0 R/S/Link>> and transmitted securely. There is a long-standing condemnation of most or all forms of assisted dying in several global religious traditions, including Orthodox Judaism (Bradley, 2009), Christianity (Baeke et al., 2011), and Islam (Madadin et al., 2020). CMAJ 189, E99E100. Flow diagram showing the selection of articles for conceptual analysis. Due to situations like COVID-19, not everyone can meet with a notary or witness in person. doi:10.1007/978-94-007-4546-9_44, O'Dwyer, S. T., Moyle, W., Taylor, T., Creese, J., and Zimmer-Gembeck, M. J. These four considerations are not purely theoretical, as can be seen from the results of the surveys discussed earlier, which indicate marked ambivalence regarding PAS on the part of both healthcare professionals and elderly individuals themselves (Dening et al., 2013; Bolt et al., 2015; Schuurmans et al., 2021). doi:10.1136/medethics-2017-104644, Mondragn, J. D., Salame, L., Kraus, A., and De Deyn, P. P. (2019). Psychiatry Rep. 19, 64. doi:10.1007/s11920-017-0818-2, Cherry, M. J. Medical Professionalism in China and the United States: a Transcultural Interpretation. 2019 Feb;45(2):92-94. doi: 10.1136/medethics-2018-104951. The purpose of the foregoing analysis was to highlight the marked cross-national variation in attitudes towards PAS in general, and the sociocultural correlates of these variations. Med. doi:10.1371/journal.pone.0239423, D'Anci, K. E., Uhl, S., Giradi, G., and Martin, C. (2019). Euthanasia and assisted suicide. When is he/she not? Neurol. (2019). Paul T. Menzel & Bonnie Steinbock - 2013 - Journal of Law, Medicine and Ethics 41 (2):484-500. details Physician-assisted suicide laws in Oregon and Washington require the person's current competency and a prognosis of terminal illness. It has already been noted that, paradoxically, approval of PAS in cases such as dementia is higher in high-income countries. J. Ageing 38 Suppl 2, 2633. 27, 409417. Its a good idea to note on each copy where the original is stored in case your healthcare provider or any other entity requires it for any reason. doi:10.3233/JAD-180244, Keywords: dementia, assisted suicide, culture, healthcare economics, ethics, religion, Citation: Rajkumar RP (2021) Physician-Assisted Suicide in Dementia: Paradoxes, Pitfalls and the Need for Prudence. jf:{rp#:a There is an urgent need to develop research into the patient's perspective with regard to medical treatment and care-giving in dementia, including end-of-life care, as well as ethical and practical dilemmas created by euthanasia requests in advance directives. [14] Dresser, R. (1995). Favourable attitudes towards PAS appear to be strongly conditioned by cultural and economic conditions and are far from universal. doi:10.1136/jme.2007.024109, Hilliard, M. T. (2011). doi:10.1177/0269216320968517, Meier, D. E. (1997). Systematic Review of Systematic Reviews of Non-pharmacological Interventions to Treat Behavioural Disturbances in Older Patients with Dementia. Aging Ment. (2013). 'Mrs A': a controversial or extreme case? doi:10.1016/j.legalmed.2019.07.007, Cohen-Almagor, R. (2016). However, in more recent times, there have been appeals to extend this practice to patients with other diagnoses, including dementia (Mondragn et al., 2019) and chronic depression or chronic pain disorders (Dees et al., 2011). Would you want to use them if you were permanently unconscious? Pew Res. Maryland: 301-519-8041. The courts efforts to fit incompetent patients to the model of a competent decision-maker are seriously flawed and ultimately threaten harm to many incompetent patients. (2017). doi:10.1177/0969733009102692, Gilhooly, K. J., Gilhooly, M. L., Sullivan, M. P., McIntyre, A., Wilson, L., Harding, E., et al. Autonomy and Identity in Persons Living and Dying with Dementia. It is suggested that the practice of PAS in dementia is not one that can be widely or safely endorsed, on both cultural and ethical grounds, and the medical field should work in collaboration with governmental, social welfare and patient advocacy services to ensure optimal physical, emotional and financial support to this group of patients and their caregivers. Kant on euthanasia and the duty to die: clearing the air. 127. In dementia, economically-driven systemic decisions appear to act as a barrier to the provision of other specific forms of care, such as nursing interventions (Karrer et al., 2020) and may lead to the excessive use of other forms of treatment, such as typical antipsychotics (Stakiaitis et al., 2019) and feeding tubes (Finucane et al., 2007), based on cost considerations rather than evidence. 2 0 obj While 40% of carers in a small sample from a developed country did contemplate the possibility of PAS, the same respondents also mentioned that they would prefer optimal end-of-life care to PAS. Med Health Care Philos. How Can Palliative Care Help Cancer Patients? Advance care planning (ACP) is highly relevant for people with early-stage dementia to communicate their care preferences for serious illness conditions with their family caregivers before they become mentally incapacitated. <><><>3 31 0 R]/P 6 0 R/Pg 44 0 R/S/Link>> Learn more. J. Appl. Bioethics 35, 438445. 80, 380386. %PDF-1.7 % BMC Geriatr. Gerontologist 59, e597e610. <>29 0 R]/P 6 0 R/S/Link>> An undue emphasis on PAS would tend to have a chilling effect on such lines of research and reduce funding for them, potentially depriving patients of effective alternatives or even of adequate palliative care (Hendin et al., 2021). Third, there is evidence that the availability of PAS may compromise the general standard of medical care offered to such patients (Mathews et al., 2021). doi:10.1371/journal.pone.0214724, Verhofstadt, M., Audenaert, K., Van den Broeck, K., Deliens, L., Mortier, F., Titeca, K., et al. Bioethical Implications of End-Of-Life Decision-Making in Patients with Dementia: a Tale of Two Societies. Advance directives: Oral and written instructions about ones future medical care, including the naming of a healthcare agent and acceptable life-sustaining procedures, in case one is unable to speak for oneself. You can review or change your advance directive at any time. In a safe and accessible place in your home. Med. We also recommend checking your state governments website for the most up-to-date forms. 28 0 obj Finally, religiosity was negatively correlated with approval of euthanasia in specific cases. You should discuss changes with your primary care doctor and make sure a new directive replaces Geriatr. WebPhysicianassisted suicide laws in Oregon and Washington require the person's current competency and a prognosis of terminal illness. This could compromise professional integrity and, over time, lead to ambiguities or even erosion of trust in doctor-patient relationships and the healthcare system among patients and their caregivers. CMAJ 189, E101E105. How Patients with Mild Dementia Living in a Nursing home Benefit from Dementia Cafs: a Case-Control Study Focusing on Psychological and Behavioural Symptoms and Caregiver burden. Though faith-based arguments are often critiqued by those who do not share such beliefs (Dcruz, 2021), they should not be discarded outright. To designate an individual, known as your healthcare agent or proxy, to ensure your wishes are honored should you no longer be able to speak for yourself. doi:10.1016/j.acap.2020.09.013, Emanuel, E. J., Fairclough, D. L., Slutsman, J., and Emanuel, L. L. (2000). Psychiatry 11, 622446. doi:10.3389/fpsyt.2020.622446, Johnstone, M. J. A Simple Way to Document the Medical Care. MeSH WebSection 2 (2) of the law allows EAS based on an advance directive, and the euthanasia review committees Code of Practice explains how: a patient aged 16 or over who is decisionally competent in the matter may draw up an advance directive setting out a request for euthanasia. 165, 532. Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe. Alzheimer Dis. Do you define life by the intake of breath and nutrients? Res. Support. The site is secure. Care 2021, 8258597211053088. doi:10.1177/08258597211053088, van der Burg, S., Schreuder, F. H. B. M., Klijn, C. J. M., and Verbeek, M. M. (2019). The following countries were included in the final analysis: Algeria, Azerbaijan, Armenia, Brazil, China, Colombia, Ecuador, Egypt, Georgia, Haiti, Iraq, Kuwait, Lebanon, Libya, Mexico, Netherlands, New Zealand, Pakistan, Peru, the Philippines, Rwanda, Slovenia, South Africa, Sweden, Thailand, Tunisia, Uruguay and Yemen. National Library of Medicine A July 2017 Health Affairs survey found the majority of Americans had not documented their end-of-life wishes in writing, either. Linacre Q. Advocates of PAS in dementia could credibly respond to the three preceding sections by suggesting that the practice should be confined to patients with severe or terminal dementia, where the patients life expectancy is already low and there is little or no scope for improvement (Mondragn et al., 2020). The role of advance euthanasia directives as an aid to communication and shared decision-making in dementia. J. Palliat. 70, 1822. Northern Virginia: 703-691-1888. doi:10.1016/s1474-4422(03)00536-2, Richter, J., Eisemann, M., and Zgonnikova, E. (2001). Persons with dementia often prefer to participate in decisions about their health care, but may be prevented from doing so because healthcare decision-making law facilitates use of advance directives or surrogate decision makers for persons with decisional impairments such as dementia. Innov. doi:10.1503/cmaj.091876, Cheng, S. T. (2017). 2004 Oct;30(5):447-51; discussion 451-2. doi: 10.1136/jme.2002.002857. Ethics 41, 592598. Secondly, social capital was also strongly and positively correlated with approval of euthanasia. endobj Ethics 41, 607610. Hertogh CM, de Boer ME, Dres RM, Eefsting JA. Psychol. Psychogeriatrics 21, 612617. Efficacy of Group-Based Multi-Component Psycho-Education for Caregivers of People with Dementia: a Randomized Controlled Study. Characteristics and Definitions of Ultra-treatment-resistant Schizophrenia - A Systematic Review and Meta-Analysis. Likewise, a more recent study presented Israeli caregivers who had provided end-of-life care to a relative with two end-of-life scenarios, one related to advanced dementia and one to physical disability. Med. (2009). PMC These results are consistent with those of a similar study examining changes in attitudes towards this practice across countries, which also found a positive correlation between higher national income and approval of euthanasia (Inglehart et al., 2021). what We Think about Ending Their Suffering-Attitudes toward Euthanasia for Elderly Suffering from Physical versus Mental Illness. doi:10.1590/s0104-42302009000300016, von Knel, R., Mausbach, B. T., Dimsdale, J. E., Ziegler, M. G., Mills, P. J., Allison, M. A., et al. (2019). doi:10.1080/00243639.2016.1201375, Tanuseputro, P. (2017). 88, 6570. The U.S. Advance Care Plan Registry produces a card for you when you register. Stepwise multivariate linear regression analysis of variables associated with national attitudes towards euthanasia in selected cases. Unable to load your collection due to an error, Unable to load your delegates due to an error. Antibioticsfor infections in the urinary tract, due to bedsores, from aspiration pneumonia, or the like, Artificial nutritionnutrients provided via a tube into the stomach, intestine, or vein, Chemical codepermits the use of drugs, but not cardiopulmonary resuscitation (CPR), for resuscitation, Continuous positive airway pressure/Bilevel positive airway pressure (CPAP/BiPAP)delivery of oxygen through a mask, Cardiopulmonary resuscitationmouth-to-mouth resuscitation, Defibrillator or pacemakera device implanted in the patient to deliver a therapeutic electric shock to treat irregular heartbeats, Do Not Resuscitate orderinstructions not to perform cardiopulmonary resuscitation if heart or breathing stops, Feeding tubenutrition through a tube down your throat, Intravenous (IV) fluidsnutrition via fluid through a vein, Total parenteral nutrition (TPN)nutrition delivered through a needle or catheter placed in a vein. Care 15, 609622. official website and that any information you provide is encrypted Hertogh, C. M. (2009). Access personal subscriptions, purchases, paired institutional or society access and free tools such as email alerts and saved searches. official website and that any information you provide is encrypted J. Med. J. Environ. endobj Medical Ethics Issues in Dementia and End of Life. Cultural factors: Scores for Hofstedes six dimensions of national culture power distance, individualism vs. collectivism, masculinity vs. femininity, uncertainty avoidance, long-term orientation, and indulgence vs. restraint, compiled in the year 2010 and updated with World Values Survey data from the year 2014. A qualitative interview study 2022, BMC Medical Ethics [WjWPBp5Q+. Med. Med. It is important to appoint an alternative healthcare agent or proxy in case yours becomes unavailable to execute their duties when you are dying. WebAn advance directive for dementia as featured in the New York Times. Am. Hospice and Palliative Care Eligibility Guidelines, Medicare Hospice Benefit & Physician Billing, Hospice Puts the Patient and Family in Control. doi:10.1111/j.1559-1816.2002.tb01420.x, Kenning, C., Daker-White, G., Blakemore, A., Panagioti, M., and Waheed, W. (2017). @m[.bE jd>;_)i6>RV}VURVtN2UA@g% >Dm^(Q0HjJMatXc`~L6g)(%qOr3 Perimortal initiatives: issues in foregoing life-sustaining treatment, suicide, and assisted suicide. doi:10.1136/medethics-2013-101781, Cipriani, G., and Di Fiorino, M. (2019). Exploring the Relationship between the Caregiver's Stress Load and Dementia Patient Behavior: A Case Study of Dementia Specialist Outpatient Data from the Southern Medical Center of Taiwan. Epub 2022 Feb 20. The Age gap in Religion Around the World. doi:10.1016/j.jamda.2007.01.007, Finucane, T. E. (1999). <>stream There has been an increasing drive towards the legalization of physician-assisted suicide (PAS) in patients with dementia, particularly in patients with advanced disease and severe cognitive impairment. Appointing a legal guardian for specific tasks, such as financial affairs, might allow a person with Alzheimers disease to maintain a degree of independence over other matters. It has also been noted that, in some cases, those belonging to a higher socio-economic stratum may also be overrepresented among those opting for PAS, again suggesting that simple linear arguments based on caregiver costs do not tell the entire story (Krag, 2014). (You cannot make any directive after you become incapacitated.). Alzheimers Res. Ethics 18, 62. doi:10.1186/s12910-017-0222-9, Tomlinson, E., Spector, A., Nurock, S., and Stott, J. 30 0 obj Additional Choices. Instead, the medical field should work in collaboration with governmental, social welfare and patient advocacy services to ensure optimal physical, emotional and financial support to this group of patients and their caregivers. First prosecution of a Dutch doctor since the Euthanasia Act of 2002: what does the verdict mean? Knows you well. Embracing Slippery Slope on Physician-Assisted Suicide and Euthanasia Could Have Significant Unintended Consequences. Ethics 16, 303318. Religious and spiritual factors: a composite measure of religiosity (affiliation, belief, practice and subjective importance) based on the most recent Pew Research Center survey (2018). and transmitted securely. Advance Directives, Dementia, and Eligibility for Physician-Assisted Death A. Disord. Learn more. (2018). Similarly, a sample of the Dutch general public, 40% of respondents considered PAS unacceptable even in advanced dementia; disapproval was stronger in older subjects and in those with higher self-reported religiosity (Brinkman-Stoppelenburg et al., 2020). 22, 439451. 9, 230236. doi:10.1097/SMJ.0b013e318197f536, Sachs, G. A., Shega, J. W., and Cox-Hayley, D. (2004). Rev Neurol (Paris). This could lead to the further stigmatization of patients with this disorder, and to an undue emphasis on euthanasia or PAS as the solution for those suffering from this illness. IffN|kO'y=% ,%Eu(VaP>:Cw$'>?3,^y @,pOv"?"| Xp|{vG7MT2tv32iQ/"~9 wLoEbeQlUALl44((M]l/!v|JzK^Ag Suicide Risk in Alzheimer's Disease: A Systematic Review. Pew Research Center (2018). A multi-centre, quasi-experimental study was conducted to test the feasibility and acceptability of a theory Sociol. Assisted suicide: where do nurses draw the line? Preferences of the General Public and People with an advance Directive. How to create effective advance directives to avoid living into severe dementia is the focus in this paper: what kinds of care should be withheld and when and the normative force of directives themselves are reviewed. Health Netw. Its called an advance directive, and completing it is one of the best ways to ensure your care preferences are honored. (2021). 2020 Dec;23(4):705-715. doi: 10.1007/s11019-020-09965-0. Conversely, individualism was associated with approval of euthanasia in selected cases. An official website of the United States government. We also recommend checking your state governments website for the Each <>1]/P 15 0 R/Pg 44 0 R/S/Link>> and transmitted securely. BMC Psychiatry 17, 203. doi:10.1186/s12888-017-1369-0, Dominguez, J., Jiloca, L., Fowler, K. C., De Guzman, M. F., Dominguez-Awao, J. K., Natividad, B., et al. Attitudes Toward Physician-Assisted Death From Individuals Who Learn They Have an Alzheimer Disease Biomarker. doi:10.1016/j.jphs.2021.02.006, Dehkhoda, A., Owens, R. G., and Malpas, P. J. Rev. The fear of dementia may lead people to signing an Advance Euthanasia Directive (AED). Am. J. Med. WebAdvance directives, dementia, and physician-assisted death Physician-assisted suicide laws in Oregon and Washington require the person's current competency and a doi:10.1111/j.1525-1497.2004.30329.x, Saragih, I. D., Tonapa, S. I., Lin, C. J., and Lee, B. O. Fifth, there are certain dangers in relying on an advance directive in such cases, because an individuals wishes may vary over time: a patient with early dementia might express a wish for PAS due to psychosocial factors (such as depression or economic hardship) at one point in time, but express a different attitude if such problems are ameliorated (Dcruz, 2021). Have multiple conversations about your wishes and make sure you are heard and understood. Preferences for End-Of-Life Care: a Nominal Group Study of People with Dementia and Their Family Carers. Ethics 45, 9294. (2021). Australas. 20, 127. doi:10.1186/s12877-020-01520-z, Karumathil, A. Conscience Clauses Offer Little protection. - Farr Law Firm. A recent systematic review of studies of older adults underlined this lack of consensus, with only a minority consistently expressing acceptance of PAS, and a significant influence of age, religiosity, education and socio-economic status (Castelli Dransart et al., 2021). It is of course possible that Krags argument would be more applicable to developed and industrialized nations, while concerns related to misuse of PAS in vulnerable groups may be more applicable in lower-income nations with greater economic inequality and resource scarcity. Omega (Westport) 43, 349361. The Journal of Law, Medicine & Ethics, 41 (2), 484-500. Bilchik, G. S. (1996). J. Gen. Intern. Subscribe to our E-Newsletter. Before Prog. Health 25, 420430. Epub 2019 Dec 5. (2021) study raises the possibility of physicians feeling pressured by family members (Wardle, 1993), it is equally conceivable that caregivers could feel pressured for economic, social or other systemic reasons (Kemmelmeier et al., 2002). Unauthorized use of these marks is strictly prohibited. Sci. doi:10.1177/0141076818803452, Fornaro, M., Carvalho, A. F., Fusco, A., Anastasia, A., Solmi, M., Berk, M., et al. 2020 Feb;46(2):71-75. doi: 10.1136/medethics-2019-105877. Lessons from the Dutch debate on euthanasia for patients with dementia. (2010). 32 Nevertheless, some scholars have advocated that patients with advanced dementia should be permitted to request physician-assisted death by advance directive. Public Health 8, 45504562. Elderly people, their caregivers, and healthcare professionals all experience significant ambivalence around the issue, and have flagged several areas where abuse of PAS is a real possibility. General agreements about what he would want help avoid family rifts when a difficult decisionlike resuscitation or feeding tubesmust be decided. L. 60, 278286. 41 0 obj iK?%cb'kl=. J. Alzheimers Dis. The Concept and Management of Acute Episodes of Treatment-Resistant Bipolar Disorder: a Systematic Review and Exploratory Meta-Analysis of Randomized Controlled Trials. The wishes of a person with dementia should be considered whenever possible and until safety becomes an issue. 62, 559569. Federal government websites often end in .gov or .mil. Options to avoid prolonged dying are limited since advanced dementia patients cannot qualify for Medical Aid in Dying. (2018). Ethics 26, 4860. Health Prog. Dealing with requests for euthanasia in incompetent patients with dementia. Am J Geriatr Psychiatry. Following the Money. / . While many of these problems are related to the behavioural problems exhibited by patients with dementia, discussed in the next section, others are not directly correlated with the presence and severity of these behaviours. 8600 Rockville Pike 102, 248250. Open 2, e190828. J. Geriatr. Continuing or Forgoing Treatment at the End of Life? WebThe tenability of maid and death and advance directives dementia physician assisted suicide, as the web site requires in this aper suggests that they are similar. Linacre Q. It may be observed that a number of variables were significantly associated with EU-SELECT in this sample. Int. As information on the mean age and gender distribution of the study samples from each country was not available in the World Values Survey data set, two surrogate markers were used instead: average national life expectancy at birth, and proportion of women per 100 population in each country. WebPhysician-assisted suicide and advance directives concerning life support. 34 0 obj The presence of these symptoms is associated with an increased risk of harm to patients themselves (for example, through wandering away or refusal of food or medications) and their caregivers (for example, in the case of aggression or sexual disinhibition). Neurol. J. doi:10.1177/082585970402000309, Rahmani, E., Lemelle, T. M., Samarbafzadeh, E., and Kablinger, A. S. (2021). The National Notary Association has a state-by-state breakdown of notarization rules. doi:10.2307/3528689, Sharp, R. (2012). 2, 637643. doi:10.1191/0269216303pm673oa, Mathews, J. J., Hausner, D., Avery, J., Hannon, B., Zimmermann, C., and Al-Awamer, A. A correlation matrix of the variables associated with the dependent variable EU-SELECT is presented in Table 2. Geriatr. Economic burdens, both those faced by caregivers and by healthcare systems, have been advanced as a justification for PAS. First, they are based on survey samples which may not be completely representative of the country in question, despite the best efforts of researchers. doi:10.1111/ajag.12654. A qualitative analysis of blog posts made by dementia caregivers found a similar lack of uniformity while themes related to death (n = 73), deterioration (n = 57), hospice care (n = 57) and decision-making (n = 41) were expressed across several posts, explicit references to euthanasia or PAS were much less common (n = 12); even references to suicidal ideation on the part of the caregiver were relatively more frequent (n = 15) (Anderson et al., 2019). application/pdf Doctors' Authoritarianism in End-Of-Life Treatment Decisions. His paper is a response to the argument that assisted dying should not be denied to the marginalized groups because this represents a form of paternalism. His analysis is based on the fact that paradoxically, rich male individuals in developed countries, who are considered to have greater social power and autonomy, may be equally or even more vulnerable to the threats posed by liberal access to euthanasia or PAS because of culturally conditioned social messages that are peculiar to Western countries. WebGale Academic OneFile includes Advance directives, dementia, and physician-assisted de by Paul T. Menzel and Bonnie Steinbock. WebAuthorising euthanasia and assisted suicide with advance euthanasia directives (AEDs) is permitted, yet debated, in the Netherlands. On the Authority of Advance Euthanasia Directives for People with Severe Dementia: Reflections on a Dutch Case. Four of these were raised in a recent review (Cohen-Almagor, 2016). 'We Are (Not) the Master of Our Body': Elderly Jewish Women's Attitudes towards Euthanasia and Assisted Suicide. &Jo>`E^.t->wg?78:?%!+=G^f!g9ZJy3X8 The Expert Working Group on the issue of mental health as a sole underlying condition disagreed on a number of issues. Most Are Deficient, and many Have Been Met with Hostile Judicial Interpretations. Living to the Bitter End? endobj doi:10.1097/HTR.0000000000000656, Rapp, C. (2016). Learn more. Ethics 472020, 257106089. doi:10.1136/medethics-2020-106089, Campana, M., Falkai, P., Siskind, D., Hasan, A., and Wagner, E. (2021). WebGT was clearly able to consent to physician assisted death and the case does not discuss advance directives. Soc. endobj Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India. doi:10.1159/000500183, Mondragn, J. D., Salame-Khouri, L., Kraus-Weisman, A. S., and De Deyn, P. P. (2020). (2021). TABLE 4. 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