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Emergency Department Management of Dyspnea in the Dying Patient

Emergency Department Management of Dyspnea in the Terminal Cancer Patient

Emergency Department Management of Dyspnea in the Dying Patient

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  About This Issue

Up to three quarters of patients with terminal cancer experience dyspnea, and many patients near the end of life will present to the ED seeking help. For emergency clinicians, the goals of care for patients with terminal illness are very different. This issue reviews what emergency clinicians must know to safely, effectively, and sensitively manage the distressing symptoms of shortness of breath.

•  Advance directives explained: What’s the difference between DNR/DNI, living will, and power of attorney?
•  Why you should never ask “Do you want everything done?”
•  How can you tell how close a patient is to death? Does it matter?
•  How can you initiate the conversation about palliative care with family members?
•  Do opioids hasten death? How do you manage dosing in patients who are opioid-naïve and opioid-tolerant?
•  Should you try secretion management, NIPPV, or high-flow nasal cannula?

  Issue Information

Author: Ashley Shreves, MD; Trevor R. Pour, MD

Peer Reviewers: Ethan Cowan, MD, MS; Michael Turchiano, MD

Publication Date: July 1, 2018

CME Expiration Date: July 1, 2021

CME Credits: 4 AMA PRA Category 1 CreditsTM, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2A or 2B Credits. Included as part of the 4 credits, this CME activity is eligible for 2 Ethics credits, 2 Palliative Care credits, 2 End-of-Life Care credits, and 2 Pharmacology credits in pharmacotherapy, subject to your state and institutional approval.

PubMed ID: 29949707

  Issue Features
  Table of Contents
  1. Abstract
  2. Case Presentation
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
  6. Prehospital Care
  7. Emergency Department Evaluation
    1. History
      1. Is this patient dying?
      2. Assessing Goals of Care
      3. History of Present Illness
    2. Physical Examination
      1. Is this patient dying?
      2. Focused Examination
      3. Advance Directives
  8. Diagnostic Studies
    1. Laboratory Testing
    2. Electrocardiogram
    3. Radiographs
    4. Ultrasound
    5. Telemetry
  9. Treatment
    1. Opioids
      1. Do opioids hasten death?
    2. Benzodiazepines
    3. Nonpharmacologic Therapies
    4. Secretion Management
    5. Social Work and Chaplaincy
  10. Special Circumstances
  11. Controversies and Cutting Edge
  12. Disposition
  13. Summary
  14. Risk Management Pitfalls for Dyspneic Patients at the End of Life
  15. Time- and Cost-Effective Strategies
  16. Case Conclusion
  17. Clinical Pathway for Emergency Department Management of Dyspneic Patients at the End of Life
  18. Tables and Figures
    1. Table 2. Terminology of Advance Directives
    2. Table 3. Prognostic Signs in the Dyspneic Patient at the End of Life
    3. Table 4. Opioid Conversion Table
    4. Figure 1. Sample POLST From Oregon
  19. References
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Abstract

Dyspnea is one of the most distressing symptoms experienced by dying patients, and it is a common reason for such patients to seek care in the emergency department. Many underlying disease states and acute illnesses cause shortness of breath at the end of life, and management tends to be symptomatic rather than diagnostic, particularly in those for whom comfort is the most important goal. Opioids are the most effective and widely studied agents available for palliation of dyspnea in this population, while adjuvant therapies such as oxygen, noninvasive positive pressure ventilation, and hand-held fans may also be used. Benzodiazepines may also be helpful in select patients. The early involvement of palliative medicine specialists and/or hospice services for dying patients can facilitate optimal symptom management and transitions of care.

 

Case Presentation

On a quiet overnight shift, you receive a call from EMS. They are en route to your ED with a 55-year-old woman in respiratory distress. You walk to the resuscitation room and prepare for rapid sequence intubation, wondering what catastrophic event might have precipitated this patient’s respiratory failure. When the patient arrives, you notice that she is cachectic and pale, gasping for breath as she tries to pull off the nonrebreather mask on her face. Her distraught husband walks alongside the stretcher, stroking her hair and crying. The patient appears to be terminally ill, and when you ask her husband what’s going on, he says, “She has lung cancer. We just stopped chemo because it wasn’t working anymore. We’re supposed to get hospice, but it hasn’t been set up yet.” Meanwhile, the paramedics read her vital signs out loud: “temp 99°, heart rate 120, respiratory rate 40, pulse ox 90%, blood pressure 100/50.” You briefly wish that it was the middle of the day so your hospital’s newly formed palliative care service would be available. Faced with this clearly uncomfortable, dying patient, the traditional emergency medicine tools of endotracheal intubation and mechanical ventilation seem inappropriate, but what other medical strategies exist to help this distressed, symptomatic patient? You have read that patients often receive morphine at the end of life, but you don’t want to be accused of hastening anyone’s death. Her husband pleads, “Please help her, doctor. I can’t watch her suffer like this.” Despite your desire to do everything possible to make this patient comfortable, you reflect on the unique legal and ethical framework that surrounds care of the dying patient and want to ensure that you do the right thing.

 

Introduction

The American Thoracic Society defines dyspnea as “...a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.”1 Patients suffering from dyspnea or shortness of breath commonly seek care in the emergency department (ED).2 Anticipating the dangerous diagnoses lurking behind this complaint and preventing the associated morbidity and mortality from such conditions has been the primary focus of emergency medicine. Early and aggressive control of derangements in a patient’s airway and breathing often necessitates use of medical devices such as endotracheal tubes, noninvasive positive-pressure ventilation (NIPPV), and mechanical ventilation.

In contrast, for patients with dyspnea in the setting of a terminal condition and limited prognosis, these tools can artificially prolong dying and increase suffering. Nonetheless, these dying patients often have acute needs that require skilled medical interventions. Ensuring that such patients receive high-quality compassionate end-of-life care is increasingly recognized as falling within the domain of emergency medicine.3,4

Despite widespread and increasing utilization of hospice services5 and consistently stated preferences of most terminally ill patients to die in the home,6 many patients visit the ED at the end of life. High rates of ED utilization have been demonstrated in cancer patients, with up to one-third visiting the ED in the last 2 weeks of life.7 A similar trend has been observed in the elderly, with half of Medicare recipients visiting the ED in the last month of their lives.8 About half of the ED visits in the elderly population are associated with a cancer diagnosis and an anticipated death.9 The current rise and predicted trends in geriatric visits to the ED suggest that emergency clinicians will face end-of-life situations with increasing frequency.10

There are a multitude of factors that drive patients who are at the end of life into the acute-care setting. Broadly speaking, in the cancer population, independent predictors of hospital versus home death include non–solid tumor diagnosis, ethnic minority status, and high regional availability of hospitals and inpatient beds.9 At the patient level, however, it is often intense symptoms (particularly dyspnea) coupled with the unavailability of timely support in the outpatient setting that lead patients to the ED.11,12 While these visits are often prompted by an inability to manage distressing symptoms at home, emergency clinicians have expressed discomfort and demonstrated limited knowledge in tending to the nuanced needs of patients with recognized terminal conditions.13-15 It is not surprising, then, that the ED experience of dying patients is often poor.12,16

Dyspnea is one of the most common symptoms that patients encounter at the end of life. In patients with terminal cancer, 70% to 80% experience dyspnea at some time during the last 6 weeks of life, and they commonly experience a significant increase in dyspnea in the last 2 weeks.17,18 In patients with non–cancer terminal diagnoses such as chronic obstructive pulmonary disease (COPD) and congestive heart failure, the severity of dyspnea is highest, but it remains relatively stable until death.18 Dyspnea ranks as one of the most distressing symptoms to the patient and the family, leading to restrictions in quality of life and an increase in anxiety and fear.17,19 This issue of Emergency Medicine Practice reviews the current literature on ED management of adult patients with serious or terminal illnesses who present to the ED with dyspnea, taking into account many of the issues surrounding the end of life and palliative care that arise.

 

Critical Appraisal of the Literature

A PubMed search was conducted with the search terms dyspnea, breathlessness, air hunger, end-of-life, palliative, hospice, emergency, and opiate/opioid, for articles published from 1981 to 2018. A search of the Cochrane Database of Systematic Reviews was also conducted using the search term dyspnea, which identified 17 systematic reviews. ED-related palliative care literature remains sparse and has been published largely within the last decade, while the literature base on inpatient palliative care and hospice care is significantly more robust. Additionally, the bulk of emergency medicine literature concerning end-of-life care focuses on models, perspectives, and education, while nearly the entirety of trial data is drawn from inpatient and hospice populations. As a result, much of the data presented in this issue are drawn from studies conducted outside of the emergency setting. Furthermore, limitations on the quality of evidence for various modes of treatment exist. These limitations arise from the paucity of true randomized controlled trials and the heterogeneity of both medication selection and dosing between currently existing trials. The recommendations made in this issue make reference to the quality of evidence, when appropriate, and recommendations based on expert opinion or current standard of practice are also noted.

 

Tables and Figures

Table 1. Differential Diagnosis of Dyspnea

 

 

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted

  1. Parshall MB, Schwartzstein RM, Adams L, et al. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012;185(4):435-452. (Guideline)
  2. National Hospital Ambulatory Medical Care Survey: 2009 Emergency Department Summary Tables. 2009. (NHAMCS data summary)
  3. Todd KH. Practically speaking: emergency medicine and the palliative care movement. Emerg Med Australas EMA. 2012;24(1):4-6. (Editorial)
  4. Gisondi MA. A case for education in palliative and end-of-life care in emergency medicine. Acad Emerg Med. 2009;16(2):181-183. (Editorial/review)
  5. National Hospice and Palliative Care Organization. NHCPO facts and figures: hospice care in America. Alexandria, VA. 2012:1-18. (Data report)
  6. Higginson IJ, Sen-Gupta GJ. Place of care in advanced cancer: a qualitative systematic literature review of patient preferences. J Palliat Med. 2000;3(3):287-300. (Systematic review)
  7. Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the emergency department near the end of life? CMAJ. 2010;182(6):563-568. (Retrospective Ontario Cancer Registry/database; 91,561 patients)
  8. Smith AK, McCarthy E, Weber E, et al. Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. Health Aff Proj (Millwood). 2012;31(6):1277-1285. (Retrospective health and retirement study and Medicare claims database; 8338 patients)
  9. Gomes B, Higginson IJ. Factors influencing death at home in terminally ill patients with cancer: systematic review. BMJ. 2006;332(7540):515-521. (Systematic review; 58 studies, 1.5 million patients)
  10. Roberts DC, McKay MP, Shaffer A. Increasing rates of emergency department visits for elderly patients in the United States, 1993 to 2003. Ann Emerg Med. 2008;51(6):769-774. (Retrospective NHAMCS database; 1993-2003)
  11. Wallace EM, Cooney MC, Walsh J, et al. Why do palliative care patients present to the emergency department? Avoidable or unavoidable? Am J Hosp Palliat Care. 2013;30(3):253-256. (Retrospective chart review; 30 patients)
  12. Smith AK, Schonberg MA, Fisher J, et al. Emergency department experiences of acutely symptomatic patients with terminal illness and their family caregivers. J Pain Symptom Manage. 2010;39(6):972-981. (Qualitative study with structured interviews; 21 patients and caregivers)
  13. Grudzen CR, Richardson LD, Hopper SS, et al. Does palliative care have a future in the emergency department? Discussions with attending emergency physicians. J Pain Symptom Manage. 2012;43(1):1-9. (Qualitative study with structured interviews; 20 providers)
  14. Meo N, Hwang U, Morrison RS. Resident perceptions of palliative care training in the emergency department. J Palliat Med. 2011;14(5):548-555. (Cross-sectional survey study; 159 emergency medicine residents [70% response rate])
  15. Smith AK, Fisher J, Schonberg MA, et al. Am I doing the right thing? Provider perspectives on improving palliative care in the emergency department. Ann Emerg Med. 2009;54(1):86-93. (Qualitative study focus groups of ED providers; 6 providers)
  16. Bailey C, Murphy R, Porock D. Trajectories of end-of-life care in the emergency department. Ann Emerg Med. 2011;57(4):362-369. (Observation [12-month period, 960 hours] and qualitative study [15 ED provider interviews])
  17. Reuben DB, Mor V. Dyspnea in terminally ill cancer patients. Chest. 1986;89(2):234-236. (Prospective; 1754 patients)
  18. Currow DC, Smith J, Davidson PM, et al. Do the trajectories of dyspnea differ in prevalence and intensity by diagnosis at the end of life? A consecutive cohort study. J Pain Symptom Manage. 2010;39(4):680-690. (Prospective consecutive cohort; 5862 patients)
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  21. Moosavi SH, Golestanian E, Binks AP, et al. Hypoxic and hypercapnic drives to breathe generate equivalent levels of air hunger in humans. J Appl Physiol (1985). 2003;94(1):141-154. (Prospective nonrandomized trial; 16 subjects)
  22. Clemens KE, Klaschik E. Dyspnoea associated with anxiety--symptomatic therapy with opioids in combination with lorazepam and its effect on ventilation in palliative care patients. Support Care Cancer. 2011;19(12):2027-2033. (Prospective nonrandomized trial; 26 patients)
  23. Booth S, Moosavi SH, Higginson IJ. The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic review of pharmacological therapy. Nat Clin Pract Oncol. 2008;5(2):90-100. (Review)
  24. Hickman SE, Sabatino CP, Moss AH, et al. The POLST (Physician Orders for Life-Sustaining Treatment) paradigm to improve end-of-life care: potential state legal barriers to implementation. J Law Med Ethics. 2008;36(1):119-140. (Review)
  25.  Partridge RA, Virk A, Sayah A, et al. Field experience with prehospital advance directives. Ann Emerg Med. 1998;32(5):589-593. (Survey study; 106 prehospital providers [75% response rate])
  26. Silveira MJ, Kim SYH, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13):1211-1218. (Retrospective health and retirement study database; 3746 patients)
  27. Sudore RL, Fried TR. Redefining the “planning” in advance care planning: preparing for end-of-life decision making. Ann Intern Med. 2010;153(4):256-261. (Review)
  28. Stone SC, Abbott J, McClung CD, et al. Paramedic knowledge, attitudes, and training in end-of-life care. Prehospital Disaster Med. 2009;24(6):529-534. (Survey; 236 paramedics [31% response rate])
  29. Fromme EK, Zive D, Schmidt TA, et al. POLST Registry do-not-resuscitate orders and other patient treatment preferences. JAMA. 2012;307(1):34-35. (Retrospective, Oregon POLST registry; 25,142 patients)
  30. Hickman SE, Nelson CA, Moss AH, et al. Use of the Physician Orders for Life-Sustaining Treatment (POLST) paradigm program in the hospice setting. J Palliat Med. 2009;12(2):133-141. (Survey and qualitative study; hospices from 3 states and then 71 hospice staff interviewed)
  31. Gozalo P, Teno JM, Mitchell SL, et al. End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med. 2011;365(13):1212-1221. (Retrospective cohort study, Medicare Minimum data set; 474,829 Medicare decedents)
  32. Wenger NS, Citko J, O’Malley K, et al. Implementation of Physician Orders for Life Sustaining Treatment in nursing homes in California: evaluation of a novel statewide dissemination mechanism. J Gen Intern Med. 2013;28(1):51-57. (Cross-sectional survey; 546 nursing homes)
  33. Morrison RS, Olson E, Mertz KR, et al. The inaccessibility of advance directives on transfer from ambulatory to acute care settings. JAMA. 1995;274(6):478-482. (Chart review; 114 geriatric patients)
  34. Lunney JR, Lynn J, Foley DJ, et al. Patterns of functional decline at the end of life. JAMA. 2003;289(18):2387-2392. (Prospective cohort; 4190 patients)
  35. Lamont EB, Christakis NA. Complexities in prognostication in advanced cancer: “to help them live their lives the way they want to.” JAMA. 2003;290(1):98-104. (Review)
  36. Viganò A, Dorgan M, Buckingham J, et al. Survival prediction in terminal cancer patients: a systematic review of the medical literature. Palliat Med. 2000;14(5):363-374. (Systematic review; 24 studies)
  37. Escalante CP, Martin CG, Elting LS, et al. Identifying risk factors for imminent death in cancer patients with acute dyspnea. J Pain Symptom Manage. 2000;20(5):318-325. (Retrospective random sample; 122 patients)
  38. Teno JM, Gozalo P, Mitchell SL, et al. Survival after multiple hospitalizations for infections and dehydration in nursing home residents with advanced cognitive impairment. JAMA. 2013;310(3):319-320. (Retrospective cohort, Medicare Minimum data set; 1.3 million nursing home residents)
  39. Liberman T, Kozikowski A, Kwon N, et al. Identifying advanced illness patients in the emergency department and having goals-of-care discussions to assist with early hospice referral. J Emerg Med. 2018;54(2):191-197. (Chart review, pre-post study; 82 patients)
  40. Steinhauser KE, Christakis NA, Clipp EC, et al. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000;284(19):2476-2482. (Cross-sectional survey; 1122 patients/families/providers)
  41. Quill TE, Arnold R, Back AL. Discussing treatment preferences with patients who want “everything.” Ann Intern Med. 2009;151(5):345-349. (Review)
  42. Fischer GS, Tulsky JA, Rose MR, et al. Patient knowledge and physician predictions of treatment preferences after discussion of advance directives. J Gen Intern Med. 1998;13(7):447-454. (Cross-sectional interview-based and questionnaire-based survey; 56 patients)
  43. Banzett RB, Lansing RW, Reid MB, et al. “Air hunger” arising from increased PCO2 in mechanically ventilated quadriplegics. Respir Physiol. 1989;76(1):53-67. (Nonrandomized trial; 7 subjects)
  44. Mahler DA, Harver A, Lentine T, et al. Descriptors of breathlessness in cardiorespiratory diseases. Am J Respir Crit Care Med. 1996;154(5):1357-1363. (Prospective observational study and survey; 218 patients)
  45. Moy ML, Woodrow Weiss J, Sparrow D, et al. Quality of dyspnea in bronchoconstriction differs from external resistive loads. Am J Respir Crit Care Med. 2000;162(2 Pt 1):451-455. (Nonrandomized trial; 8 subjects)
  46. Wilcock A, Crosby V, Hughes A, et al. Descriptors of breathlessness in patients with cancer and other cardiorespiratory diseases. J Pain Symptom Manage. 2002;23(3):182-189. (Observational cohort; 261 patients)
  47. Viola R, Kiteley C, Lloyd NS, et al. The management of dyspnea in cancer patients: a systematic review. Support Care Cancer. 2008;16(4):329-337. (3 systematic reviews, 1 with meta-analysis; 2 practice guidelines; 28 controlled trials)
  48. Reeves K. Hospice care in the emergency department. J Emerg Nurs. 2008;34(4):350-351. (Review)
  49. Mercadante S, Valle A, Porzio G, et al. Prognostic factors of survival in patients with advanced cancer admitted to home care. J Pain Symptom Manage. 2013;45(1):56-62. (2 home care programs; 374 consecutive patients)
  50. Morita T, Ichiki T, Tsunoda J, et al. A prospective study on the dying process in terminally ill cancer patients. Am J Hosp Palliat Care. 1998;15(4):217-222. (Prospective cohort; 100 patients)
  51. Beach MC, Morrison RS. The effect of do-not-resuscitate orders on physician decision-making. J Am Geriatr Soc. 2002;50(12):2057-2061. (Randomized trial; 241 physicians)
  52. Cibinel GA, Casoli G, Elia F, et al. Diagnostic accuracy and reproducibility of pleural and lung ultrasound in discriminating cardiogenic causes of acute dyspnea in the emergency department. Intern Emerg Med. 2012;7(1):65-70. (Prospective observational study; 56 patients)
  53. Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED? Chest. 2011;139(5):1140-1147. (Prospective blinded observational study; 404 patients)
  54. Price AS, Leech SJ, Sierzenski PR. Impending cardiac tamponade: a case report highlighting the value of bedside echocardiography. J Emerg Med. 2006;30(4):415-419. (Case report)
  55. Peiffer C. Morphine-induced relief of dyspnea: what are the mechanisms? Am J Respir Crit Care Med. 2011;184(8):867-869. (Editorial)
  56. Bourke DL, Malit LA, Smith TC. Respiratory interactions of ketamine and morphine. Anesthesiology. 1987;66(2):153-156. (Randomized double-blinded trial; 6 patients)
  57. Berkenbosch A, Teppema LJ, Olievier CN, et al. Influences of morphine on the ventilatory response to isocapnic hypoxia. Anesthesiology. 1997;86(6):1342-1349. (Nonrandomized animal model laboratory study; 8 cats)
  58. Barnes H, McDonald J, Smallwood N, et al. Opioids for the palliation of refractory breathlessness in adults with advanced disease and terminal illness. Cochrane Database Syst Rev. 2016;3:CD011008. (Cochrane review; 26 studies, 526 participants)
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  61. Clemens KE, Klaschik E. Effect of hydromorphone on ventilation in palliative care patients with dyspnea. Support Care Cancer. 2008;16(1):93-99. (Prospective nonrandomized trial; 14 patients)
  62. Clemens KE, Klaschik E. Symptomatic therapy of dyspnea with strong opioids and its effect on ventilation in palliative care patients. J Pain Symptom Manage. 2007;33(4):473-481. (Prospective nonrandomized trial; 11 patients)
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Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.

Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 2 Ethics credits, 2 Palliative Care credits, 2 End-of-Life Care credits, and 2 Pharmacology credits in pharmacotherapy, subject to your state and institutional approval.

Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Shreves, Dr. Pour, Dr. Cowan, Dr. Turchiano, Dr. Mishler, Dr. Toscano, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Dr. Jagoda made the following disclosures: Consultant, Daiichi Sankyo Inc; Consultant, Pfizer Inc; Consultant, Banyan Biomarkers Inc; Consulting fees, EB Medicine.

Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.

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