A poem by Dylan Thomas written to his father to fight against death: "Do not go gentle into that good night". It consists of both soft melodious tones and harsh tones to contrast between life and death.

Wise Men are philosophers who rage against death because they don't know if they're right on their philosophies therefore they must live until they are proven right. Also since their "words have forked no lightning", they want their philosophies to make a difference, an impact and they want to see the day that it does. So they "rage against the dying of the light".

Good Men are men who do good, puritans who never sin. They have certain beliefs and they rage against death because they might have "danced in the green bay", they would lose potential of doing that if they died. The ocean is a symbol for timelessness.

Wild Men are men who are opposite to the good men. They are hedonists, they did dance in the "green bay". And because they've had so much fun they do not want to die.

Grave Men are men who understand death but are not willing to accept it. They are burdened with this understanding of death. Poets are under the category of grave men. They see with "blinding site" (ie. Milton)

"And you, my father, there on the sad height,
Curse, bless, me now with your fierce tears, I pray
Do not go gentle into that good night.
Rage, rage against the dying of the light."

Friday, nine PM

I stepped onto to the ward. 'Hello, just checking in,' I announced. With me in tow was Justin, the cheery intern who was helping on tonight's admitting shift. I was stopped mid-stride by the strained faces of the nurses who turned towards us, and by a distant shrieking that echoed from far down the hallway. This scene felt all too familiar from similarly disastrous days gone by. Jo, the nursing team leader, looked at me angrily from beneath a sweaty and tightly drawn brow, and she pushed her way towards me through the crowd of her nurses.

'You! I was just about to call you. I might never forgive you for sending that man up to us, he's absolutely impossible. Now you just come with me!'

Jo began stamping her way down the corridor, and we followed. I tried to explain that I had also been unhappy about admitting him under our service, but that I hadn’t been given much choice. Jo didn't seem to be listening. She huffed as we made our way to room nineteen, where the yelling and crying was loudest, though still muffled by the thick door. I recognised Gerard's gravelly voice, cursing and fighting against something yet unseen.


Jo put her hands on her hips with righteous exasperation. ‘And we just did a bladder scan too, it showed nine hundred mils! He’ll need a catheter, and I can tell you right now he's not gonna like that.’

I sighed and opened the door, entering the darkness of that room.

Four hours earlier

I met Gerard in the Emergency Department. He was lying in a resuscitation bed, with no sheets or blankets to cover him, wearing nothing but an adult-sized continence garment. His was thrashing wildly with his right arm and leg as two security guards tried to restrain him. His left side, strangely, wasn't moving at all, except to flop around with deadened weight as he threw his hips up and down. The security guards looked up at me with anger in their faces as I came to the bedside. I took a brief look at Gerard, who was gnashing his teeth with eyelids bunched up tightly, and who didn't seem to notice me at all.


The emergency registrar chirped behind me — 'They've sent him down from the psych unit, I don't think they'll take him back. He's all yours!' I turned and found myself looking over the top of her head; she stood about as tall as my armpit. She smiled up at me sweetly, as if presenting a gift that she had been keeping aside just for me. I sighed and walked over to the bench where his chart was sitting. It was a battered mass of papers stuffed between manila covers, clearly assembled in haste. I scooped it up, along with all the various other paperwork scattered about, and I took them over to a desk where I could sit and do my part. There was no point in talking, so I began putting together his story from everything that had been written about him.

Gerard was fourty-eight years old. Around ten years ago he had been living a normal life — staying with his mother, no job, seeing the mental health team for some unspecified personality issues. Then gradually he started noticing strange tics and shuffles in his movements, little itches that he couldn't help but scratch. At first he continued on with his life, avoiding the gaze of the people who stared at the odd dances he constantly seemed to perform. He wondered whether he was going mad, he hoped that it would pass. But after a year, as the movements slowly got worse and worse, he went to a doctor. The doctor was stumped, they had never seen anything like it. They requested tests, not knowing what they were looking for: his blood counts, electrolytes, thyroid function, vitamin levels, urine drug screening, HIV antibodies, a scan of his brain. When these were all found to be unenlightening, the stumped doctor referred him to a neurologist. The neurologist asked many questions that seemed to be almost at random: Had he ever had tonsillitis? What had his parents died of, and when? Had he ever lived in the UK? Had he received a blood transfusion during that time? Had he any rashes? Did his sister have any rashes? Three months later — after a lumbar puncture, an MRI scan, several more blood tests, and a phone call to his aunt (the family historian) — the neurologist looked at him gravely from across his broad desk and give him his final diagnosis.

Huntington's disease is part of an unhappy family of misfit conditions, all incurable and inexorable, known as the neuro-degenerative diseases. Mostly they affect the elderly: Alzheimer's disease, Parkinson's disease, Lewy Body disease, fronto-temporal dementia, and so on. The most common of them are innocuously embedded in our language, in the way we talk about human existence. We talk of our parents and grandparents going a bit dotty, running out of memory, getting shakey, going off their feet, losing track of things, not taking care of themselves, losing their marbles, et cetera. We see these as part of the natural course of a life, unless one is very lucky and keeps it all together until the dying day. But amidst these supposedly innocent afflictions, Huntington's disease is a rogue. It is a genetic disease that affects the huntingtin protein, an otherwise normal protein which now becomes fragmented and cannot be degraded. It clogs up the brain with a tangled accretion of nonsense building blocks that never fit together into anything useful. The process starts from the day the person is born, but it only begins to manifest years later; first with an odd kind of movement that, much like the protein that is its cause, appears to be something purposeful, though in fact it isn't. The person seems to dance on the spot, turning involuntary jitters into a stroke of the face, a flourish in the wrist, or a rock that has to be shaken about inside their shoe. This is called Huntington's chorea — chorea, choreography — the dance of Dr Huntington. And once this becomes manifest, it continuously worsens over a period of years, gradually giving way to an early and rapidly progressive dementia, derangement of personality, and eventually death from the loss of essential brain functions. The average patient begins to develop symptoms in their thirties, and from that point of onset they will die within about twenty years. Perhaps the worst part is its mode of inheritance: it is autosomal dominant, so that half of the children of any affected person will also be affected, with a phenomenon called genetic anticipation, meaning they will always be affected at a younger age than their parents were. And there is nothing at all that can be done to stop it.

There are very few diagnoses whose mention will strike a bustling handover meeting into sudden solemn reflection, but Huntington's disease is one of them. For those who know anything about it, it holds a place of fearful exclusivity in the imagination. Perhaps this is because its long downward trajectory encapsulates so many of life's great existential threats. The threat of an unending sickness, of a slow disintegration, of the loss of control (first the body, then the mind), of incapacity, of dependency, of our own defects passing silently to our innocent offspring, and, ultimately, of our inescapable death. And perhaps most disturbing of them all is the threat of unwelcome knowledge. These people are cursed with the foreknowledge of everything that is eventually coming their way, and life's long outward gaze becomes dreadfully myopic. Twenty years; perhaps a little more, perhaps a lot less. The path is set at their feet and there is nowhere else to turn, nobody who can provide an escape along the way. Gerard's life was simply a human life playing on fast-forward, on display for everyone to see.


So Gerard received his diagnosis, and his life began falling apart just as the neurologist's textbooks predicted. Then, ten years later, for reasons I couldn't quite figure out, he was locked up in the high-dependency unit of our psychiatric ward. I found no mention of a psychiatric illness in his notes, only the manifestations of his neuronal degeneration. But I supposed that his agitation and aggression were something that the psychiatrists were best-placed to manage, as they know more than any other type of doctor about the various sedatives that are used to control human behaviour. From what I could read into the brief, incomplete, and often illegible notes that filled Gerard's chart, he had spent at least a week up there, being held down by two burly male nurses and dosed with ever-larger amounts of an ever-expanding pharmacopoeia. Because, well, what else could be done? He had already injured two staff members, and smashed several of his own teeth in with a dinner plate. Then today, as often happened, he fell down and hit his head on the floor. He got up and continued swinging his limbs about, whether voluntarily or involuntarily. It was hard to tell. Then, about an hour later, he fell down again, and this time he didn't get up. The left side of his body was flaccid and heavy, though his right side kept on fighting.

He was brought to the Emergency Department, where they ran him through the CT scanner. But before doing that he needed enough tranquilisers to put someone like me to death, just so he would lie still for a few minutes on the gantry. They quickly got the images they needed before he woke up and began shouting again. As he did so, the tiny emergency registrar looked at his scan and saw the cause of his hemiparesis: an encapsulated pool of blood at the right side of his brain, squeezing its way between the layers of tissue that wrap around that mushy grey material, compressing the motor cortex. The entire brain was pushed into the opposite corner, like a child forced to share the bed with a careless older brother. They call this midline shift, and it's never a good thing. The registrar phoned our nearest neurosurgical unit (two hours away, on the coast), who said that his condition was too far gone for them to do anything. They said that if he survived for a week (and it was a big if), then they would consider releasing the pressure with a craniectomy, but in the meantime he should be kept comfortable. Gerard's mother said she didn't want to put him through any more invasive treatments, said she had already accepted that he was going to die. She had put her husband through so many of these things when he was in Gerard's place, and she didn't want to do that again. Gerard himself couldn't take part in the discussions, but I could hear him from across the department as I read about all that had happened so far.


So: psych wouldn't have him back, neurosurg didn't want him, he had nowhere to go. That's how I got involved. That is what my job consists of, for now. My phone rings, I am given the name and date of birth of a patient in the Emergency Department, I am asked to admit them to hospital, I am meant to initiate the medical management of whatever malady they are presumed to be suffering from. That’s all I do. As my father often says, we can only ever be a cog in the system. So the cogs in my own head turned and I made my plan: Admit Gerard to a single room, check no vitals, take no bloods, request no imaging, do nothing with curative intent. I wrote up his usual sedatives, and gave a series of options to control his behaviour whenever needed. I wrote his resuscitation plan on the hospital's designated form, and the plan was to not attempt any resuscitation whatsoever.

I used to think that it was my job to heal people, but now I find that my job is mainly to fill in paperwork. And much of the time, I glumly do my duty. I talk, I examine, I take bloods, I look at x-rays, I make my best guess at a diagnosis, I chart the medications. The charting usually takes the longest, and as I write out the dozens of medications, one after the other in clear capital letters, I often wonder how much difference any of them will ever make. Though of course we can never know. In deciding what treatment to give, I also decide what treatments are off-limits. Every day I speak to worried families and uneasy patients lying in their beds, and I explain what we will be doing and what we will not be doing. Always I tell them that we will not cause them to suffer, if we can help it. More often than not, I also tell that we will not be performing resuscitation. I explain that we will use all our various drugs, instruments, and supportive therapies, but if their body should happen to reject the idea of continued existence, we will not intervene. Rather, we will smooth out the dying pillow.

Almost every day I ask myself whether I am not doing the wrong thing. Is there something more that I have to give? Am I missing something important? Is there a way that I could be a force for good in life, rather than just giving in to death? Is this what a doctor is meant to do? But after seeing a few too many people's final weeks spent in a slow, painful fight against their inevitable death, I truly believe that allowing death to occur is the only humane thing that can be done for most patients in a modern hospital. These are not strapping young people with their whole lives to live; they are mostly frail old men and women, on the slow downhill road to senility and incapacity. Every day they spend in bed is a month's worth of muscle mass they have to regain later, every insult accumulates upon the previous ones, every new prescription added to their endless regimen will grieve them with its side effects and toxicities. They are slipping away all the time, and we cannot stop that.

Dylan Thomas had something to say about old age and dying:

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

I wonder whether old age and dying were different in his time, or whether I've simply lost the fighting spirit that young men should have for these things. Either way, I can count on one hand how many such fights against death I have seen fought and won. And at that moment, staring at the notes as my hand wrote them out (seemingly of its own volition), I couldn't see any future of Gerard’s that was worth raging for, apart from the one where he was drugged into quiet oblivion. So that was the plan I made.


Reading about Gerard, and seeing his muscle-bound body thrashing against those security guards, he felt familiar to me. He represented something: an archetype. To me he stood for a small group of other young men I had treated, who were dying despite the strength of their young bodies. They had all been men, and they had always made an impression on me. Usually they were loud and terrifying. They hated doctors, they berated nurses, they frightened young interns who had to check on them in the night. They were falling to pieces and they wanted to fight it until the last moment, no matter how clearly their future was laid out before everyone else's eyes. They wanted more tests, more chemo, more radiation, more morphine, more life. They seemed to all look the same, too. Tall, skinny, and full of muscle. They had violent tattoos on their chests and their knuckles. They were like bundles of rope, pulled taut and almost ready to break at any point. They were Dylan's raging men, who looked eagerly into the light as it died out before them. Gerard was raging like all those others. Perhaps involuntarily, perhaps unconsciously, but he raged on. He was fourty-eight years old.

Wild men who caught and sang the sun in flight,
And learn, too late, they grieved it on its way,
Do not go gentle into that good night.


I continued writing.

Nine PM again

Room nineteen was warm and humid, like a jungle in the depth of night. It smelled of urine and human crevices. I became very aware of the air moving inside my chest, I felt it was apt to leave droplets of condensation upon my organs. I wanted to leave and clean myself inside and out.


Facing me were the broad backs of two men in hospital uniforms, looking like grizzly bears in powder-blue polo shirts. They were silently wrestling to hold Gerard still, and as I approached the bed I saw him lying there, somehow looking worse than before. His neck was bent backwards at an alarming angle, the muscles pulled tight, the veins all engorged and throbbing, the skin glistening with stale sweat. I recognised him from a painting that makes its way into medical school lectures around the world, of a man contorted in the final agonised throes of tetany. His eyes were wildly rolling about as he gnashed with his broken teeth, babbling and cursing.


The two burly nurses were sub-continental fellows, with neat haircuts and thickets of black hair on their powerful forearms. They chuckled to each other now and then, they held him down as gently as they could, they smiled knowingly at the other staff and me. They spoke kindly to Gerard when they could get a word in edgewise. 'Just calm down Gerard, it's OK,' said one of them. 'Don't worry, why don't you get some sleep now Gerard,' said the other.


'Don't yell now, Gerard, come on now mate.'

I stood and watched, my mind going blank. A pool of blood had formed beneath Gerard’s paralysed left arm, oozing slowly from the spot where he had ripped out his IV line. I reached out with a pad of gauze to put some pressure on the source of that warm spring, and I was surprised as his left leg came up to kick me — it seemed to be only partly paralysed, whereas his left arm was dead weight that flopped about with his turbulent movements. With my free hand I held his half-limp leg that jerked and twisted in vain, and I heard a little splish. I looked down to see the toe of my shoe coated with the ruby-dark shine of his life's essence. I had already had enough of all this.

'Bring me that droperidol,' I commanded Justin. He looked frightened and excited, like a young soldier keen to see some action. As he passed me the syringe, he stretched and leaned to keep himself as distant as possible, clear of Gerard’s lashings. I took a sad little modicum of pride in only reaching my arm out halfway, to make Justin come in closer. I took the syringe and jabbed it into Gerard’s thigh. He didn't seem to notice — he just continued jabbering and shouting, occasionally making a coherent sentence.


We waited, all of us around Gerard’s bed, looking back and forth at each other and at the clock. Jo, the two big nurses, Justin, and me. We each held one of Gerard’s limbs, and we waited. Four minutes. Six minutes.


Jo stroked his forehead with her gloved hand, mother-like. 'We're getting it for you now, it'll only be a minute, OK?'

Nine minutes. No change.


Jo looked at me knowingly, and I nodded in concession. I told Justin to go and bring some more midazolam, which we injected, bolus after bolus, into the thin layer of fat over his taut abdomen. Again, he didn’t seem to notice.


‘It won’t be long, Gerard, we’re bringing you some right now.’


‘It’s OK, Gerard, just be calm.’


'Calm down, Gerard. It'll be OK.'


'You just need to settle down, and we can get you some ice cream soon.'


After the third injection, Gerard’s yelling slowly faded into a continuous nonsensical mumble. His back drifted down onto the mattress. His stronger limbs still fought against us, but they seemed to have lost some of their conviction. We decided to take our chances now. I told one of the younger nurses by the door to bring the catheter kit. The nurses cleaned Gerard’s genitals, they inserted the catheter and hook up the collection bag, securing the tubing to his leg with layers of surgical tape. I watched, slightly dazed, as the urine flowed silently into the bag and formed a meniscus that rose up, and up, past black lines of measurement one after the other.

Jo stepped back from Gerard and clasped her hands together, pleased with a job well done. ‘Seems like an anticlimax now after all that fuss, don’t you think? Ha ha!’

I didn’t think. I looked through the medication chart, and blankly did the sums. I had to check it twice — I couldn't quite believe the volumes of sedative drugs he had soaked up in the past four hours. Twenty milligrams of droperidol, eighty of midazolam, seven of haloperidol, twenty of olanzapine, and a hundred micrograms of fentanyl. I had seen people end up on a ventilator for far less. But here was Gerard, still breathing and muttering and rolling about. I figured the dosages into a twenty-four hour infusion and wrote up the order for a syringe driver. I called out to a nurse from outside to come take the paper away and make up my poisonous concoction. As I passed it to her, I hesitated for a moment. Was it too much, was it wrong, was there some other way? But still I passed it into her hands, and off she went. Jo seemed pleased by this plan. I looked at Gerard and wondered whether there was something else I could do, and came up with nothing. So I beckoned to Justin to follow me out.

When I reached the door, I heard Gerard waking up again. His slurry of words grew louder and louder, he thrashed against the bedrails again. The two big nurses turned to me with a wry smile, and thanked me for coming. I apologised, and thanked them, and apologised again. They laughed and bade me goodnight as they carefully gripped Gerard’s wrists and ankles again.


I left the room and gently closed the door.

Justin and I walked down the fluorescent-lit hallway, dazed by the silence and breathing deeply now that we had left that dark, close, humid room. I tried to slow myself — my heartbeat, my words, my thoughts. Justin didn’t seem so brave now, he kept his eyes on the floor and clutched his notepad to his chest. Even I was able to read those signs. I tried to think of what to say. His shoes tapped against the linoleum, echoing back and forth down the long hallway. I, on the other hand, had learned how to walk silently. I looked at my shoes and remembered Gerard's blood, which was now drying into a cracked layer. We stopped at a sink where I washed my hands — perhaps too thoroughly — and bent down to clean the blood away. I asked him for my things. He handed me the pager, the phone, my admissions book, my stethoscope. He still wouldn't look at me. I tried to remember what my registrar had said to me, way back, what seemed like a lifetime ago, when I had first done CPR and seen a man die before me. I tried to remember how I had felt, and what she had said to me to help make sense of it all. I tried, but I couldn't think of a single thing. It felt like a lifetime ago, or a half-remembered dream from my childhood. Death and suffering and other horrible things no longer seemed to matter, and nowadays when they were over I only felt a sense of tremendous relief. I couldn’t imagine feeling any other way.

'Justin, we have to get back to work pretty soon, but we should also talk about this. How are you feeling?'

'I guess it's just … overwhelming.' There was clearly a lot hidden behind that word. One word could not contain the multitudinous thoughts and emotions that he was bearing.

‘I suppose …’

I stopped myself, not knowing how I might finish that sentence. I didn’t know what exactly it was that I could truthfully suppose about Gerard, about incurable illnesses, about chaos, or about this profession of ours.

As I was walking down that hallway, looking at Justin, thinking about Gerard, and searching for something to say, a rather familiar thing happened. There arose a feeling in my chest, a heavy feeling that seemed apt to burst forth if my skin were not made of such stiff, coarse leather. A yearning, a silent indefinite wanting of so many unspoken things that I knew I could never have. We all want more from life — I’m convinced of that — but we are all stuck here in the realm of possibility, not of fantasy. What I wanted, more than anything else at all, was to not be misunderstood. I wanted Justin to not think of me as cold or inhumane, but rather to see things from my point of view. I wanted him to see that I didn’t just use our many drugs to make Gerard shut up, but that I was doing all I could do to help; and that all I could do to help was pitifully little, such is our lot in life. That Gerard’s life and death were beyond us, that he was merely another feature of the universe we live in. That life is sometimes wonderful, and often dull, but it is only a finite thing and it is not within our means to control it. That death is not a bad outcome, it is the only outcome. That suffering is the only variable that means anything at all in our profession. I wanted to explain all the things I had seen and heard and felt in the time since I was in Justin’s shoes, to explain how and when and why I had begun to doubt the reality of certain things, things that are considered to be universally good. Things like human dignity, beneficence, autonomy, acceptance of the inevitable, the sanctity of life. I wanted to explain why I stopped striving for those things, and therefore why I no longer cared about much at all, other than suffering, and being a man people might admire. And how the things I found myself doing these days, when nobody was around to tell me otherwise, were exactly the things that made such admiration impossible. And I wanted to explain how this would make sense to him too someday, and when it did it would be a kind of death, a death that sits within him and colours everything he sees. I wanted him to know how he would feel akin to the rest of humanity even as he found himself growing separate from it.

But I couldn’t find the words to explain it.

‘I suppose it just gets easier over time. That’s all I can really tell you.’

I am sure Justin saw me as a pillar of certainty. Whatever he might have thought of me and my actions, he surely wouldn't have doubted my convictions. But at times like these, one can't help but wonder whether the problem may actually lie with ourselves, rather than with the patient, or their disease, or the world. My mind raced with questions and doubts: Was Gerard really so unsalvageable? Was his suffering as intense as I imagined, or was it only my own discomfort that I was alleviating? Could I have done it all more delicately, more humanely? Had I gone too far, had I gone beyond my remit? Did I have the expertise, or the authority, or the right to do what I had done? Did I have a choice? Was I a bad doctor, or maybe a bad person? And if so, what then?

I made no mention of my doubts to Justin. I remained silent, only glancing at him as he watched the floor pass under his feet, his eyes fixed like a doll's. Finally he decided to break the silence.

‘Yeah, yeah I suppose it would get easier. Thanks. It’s all a learning experience, isn't it.’


So, regardless of what we thought or felt, we went back to work. There were patients waiting to be seen. As we sat and wrote our notes in Gerard’s chart, I called the on-call consultant to keep her informed of what has transpired. I expected to be chastised, to be told to go back and undo the reckless, inhumane things I had done. But, to my surprise, she told me to go back and add some morphine to the syringe driver. She said that she expected he would need a little more sedation than what I had written up.

Back I went, dutifully so.


I am called into the office of the palliative care consultant — a small, unassuming woman of Eastern European extraction. As I enter the room, three other sets of eyes turned towards me: her registrar, her resident, and her nurse. She tells them to go outside, to ‘go for a walk’, while she and I speak for a few minutes. I sit down, and she proceeds to explain to me how deep her disappointment in me runs, how aghast she had been to read the notes and prescriptions I had written on Friday, how everything I had done was wrong — medically, logically, ethically wrong — how I had acted far beyond my authority as a registrar, how easily I could be prosecuted for murder had Gerard managed to die over the weekend. To illustrate these points, one after the other, she hands me a series of scientific articles and photocopied chapters from palliative care textbooks. The crisp papers pile up in my lap, their weight seeming to increase as each minute passes and my ineptitude is exposed.

‘So this is the day,’ I think to myself, ‘when someone finally realises I don’t know what I am doing.’

I ask her what I should have done instead. She explains to me that palliative care is a technical specialty, just like radiology or neurosurgery. That it must be based on rules, not just on what seems right at the time. That, in particular, a junior registrar must never prescribe more than twenty milligrams of midazolam in one twenty-four period.

‘Even if the patient had already received sixty milligrams in the preceding four hours?’

She says yes. She says these rules exist for a reason: to protect my patients from me, and to protect me from the law.

‘Even if I discussed it with the on-call consultant straight afterwards? And she told me to go back and add even more?’

She asks me, knowing the answer already, whether the consultant I called was a palliative care consultant. I say no. She gestures as if to say, ‘Well, there you have it.’ I ask her what she would have done, had she been in my place.

‘I would probably have done exactly what you did, yes. But that is not the point I am making at all.’

I leave, ever more confused, and I go on with my day. I go to the Emergency Department and admit another four patients to the hospital. They are all simple, unexciting, completely forgettable. I speak and act and write without thinking. I do my job. As I question these patients, reassure them, joke with them, write about them in their charts, I am only thinking about Gerard’s scrambled neurons, hearing his babbling screams, hoping that he will not live much longer. And I decide that all my fine ideas about human suffering are based on nothing at all, that confusion and uncertainty are all I can expect in such a situation. That in life and death and suffering and medicine, I may think and feel, but I will always know next to nothing.

And you, my father, there on the sad height,
Curse, bless, me now with your fierce tears, I pray.
Do not go gentle into that good night.
Rage, rage against the dying of the light.

I feel no rage, no sadness, no dismay. Only a sense of weightlessness, of being suspended above an abyss that cannot be interrogated or explored, that contains more than I can possibly understand.

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