Non-Beneficial Life Prolonging Interventions

Oct 29, 2026 at 05:32 pm

 

Editor's note: The following is the complete article from the October/November 2026 issue's condensed version of "Non-Beneficial Life Prolonging Interventions" Thanks and credit to JAMANetwork.com

 

 

 

Decision-Making Approaches Used to Limit Potentially Nonbeneficial Life-Prolonging Intevrentions

 

 
Key Points

Question  What decision-making approaches do clinicians use to limit potentially nonbeneficial life-prolonging interventions?

Findings  In this qualitative study of 101 clinician interviews conducted at 3 academic medical centers, respondents reported facing challenges limiting interventions using the approaches recommended in professional society policy statements (ie, shared decision-making, institutional processes addressing disagreement with patients or surrogates). Respondents described alternate approaches (eg, stating a plan to limit interventions, explicitly not offering interventions, not mentioning interventions) in which clinicians limited interventions without a shared decision or institutional process.

Meaning  Clinicians face challenges in limiting potentially nonbeneficial life-prolonging interventions via recommended approaches, which may lead them to resort to alternate approaches.

 
Abstract

Importance  Professional society policy statements recommend that clinicians limit (ie, withhold or withdraw) potentially nonbeneficial life-prolonging interventions by (1) achieving a shared decision with patients or surrogates or (2) initiating an institutional process to address disagreement with patients or surrogates. However, in the context of a health care system with a default tendency toward life prolongation, it is unclear whether clinicians rely entirely on these recommended approaches or resort to alternate approaches.

Objective  To characterize the range of decision-making approaches clinicians report using to limit potentially nonbeneficial life-prolonging interventions.

Design, Setting, and Participants  This qualitative study was conducted at 3 tertiary academic medical centers in Washington and California. Clinicians were sampled from emergency department, medical ward, medical intensive care unit, geriatrics, and palliative care services between February 2018 and June 2022 for in-depth, semistructured interviews. Results were analyzed between August 2023 and May 2025.

Main Outcomes and Measures  After qualitatively analyzing interviews to identify decision-making approaches, we developed a framework of approaches that categorized each as a recommended or alternate approach.

Results  We conducted 101 interviews (53 attending physicians [52%], 16 trainee physicians [16%], 6 advanced practice clinicians [6%], 21 nurses [21%], 3 chaplains [3%], and 2 social workers [2%]; 59 women [58%], 42 men [42%]; mean age, 42 years [range, 27-74 years]; mean years of experience, 14 [range, 1-52]). We identified 6 decision-making approaches: (1) providing an informed choice regarding interventions, (2) making a recommendation to limit interventions, (3) stating a plan to limit interventions, (4) explicitly not offering interventions, and (5) not mentioning interventions. In rare cases of intractable conflict, clinicians reported using an option of last resort: (6) invoking an institutional process to limit interventions. Respondents reported challenges with limiting interventions via the recommended approaches of shared decision-making (approaches 1-3) and institutional processes (approach 6), which sometimes discouraged the use of these approaches. While respondents recounted successfully using alternate approaches (approaches 3-5), they described interclinician and interhospital practice variation, as well as ethical and practical uncertainties.

Conclusions and Relevance  In this qualitative study, clinicians reported substantial challenges using recommended approaches to limit potentially nonbeneficial life-prolonging interventions. Some clinicians reported using alternate approaches that are not supported in professional society policy statements.

 
 
Introduction

US hospitals, particularly academic medical centers, exhibit a default tendency toward life prolongation.1-3 Life-prolonging interventions include life-sustaining treatments (eg, mechanical ventilation, vasopressors), transfer to higher levels of care (eg, intensive care unit [ICU]), and invasive procedures (eg, hemodialysis catheter placement, bronchoscopy, extracorporeal membrane oxygenation [ECMO] cannulation). Life-prolonging interventions are often initiated, continued, and escalated by default until clinicians become concerned interventions are potentially nonbeneficial1,3,4—that is, clinicians believe interventions are unlikely to improve patient outcomes or quality of life and may cause harm.5 Because the default tendency toward life prolongation is generated and reinforced by systems-level factors,1-3 clinicians may unintentionally reach the point of providing potentially nonbeneficial life-prolonging interventions.

Concerns about the default use of life-prolonging interventions have been raised in medical and lay press,6-8 especially for patients with chronic critical illness or nearing the end of life.9 In addition to direct patient harm from unnecessary or unwanted interventions,10 other harms include financial toxicity to patients and families,11 increased emotional distress for the bereaved,10 increased health care expenditures,12 poor allocation of hospital resources,13 and clinician moral distress and burnout.14,15 Yet clinicians frequently report difficulties in limiting potentially nonbeneficial life-prolonging interventions.16 In resource-rich environments like US academic medical centers, surveyed clinicians report that up to one-tenth of critically ill patients receive life-prolonging interventions that should not be provided.12,17,18

Policy statements published by professional critical care societies recommend 2 approaches for limiting (ie, withholding or withdrawing) potentially nonbeneficial interventions: (1) achieving a shared decision-making with patients and/or surrogates,19 or (2) institutional processes that addresses disagreement with patients and/or surrogates (eg, medical futility or unilateral do-not-resuscitate policies).20,21 However, in practice, both approaches are inconsistently used, sometimes ineffective, and may be insufficient to counter the default tendency toward life prolongation.22-27 Clinicians may also use alternate approaches: They may limit life-prolonging interventions without a shared decision or an institutional process, such as when a clinician declares that a patient is not a candidate for an intervention or does not offer it.28-31

It is critical to understand how decisions to limit life-prolonging interventions are made in practice, especially if clinicians encounter challenges using recommended approaches. We conducted a multi-institutional qualitative interview study that aimed to describe the full range of decision-making approaches clinicians use to limit potentially nonbeneficial interventions for patients in medical wards or ICUs. By synthesizing clinicians’ reports of decision-making approaches used on the ground, we illuminate tensions between ethical ideals articulated in policy statements and clinician perceptions. This offers suggestions to inform clinical practice, ethical inquiry, empirical research, and the design of policies and guidelines.

 
Methods
 
Study Design

The qualitative study draws from a larger multi-institutional ethnographic project conducted at 3 tertiary academic medical centers on the US West Coast. Sites were purposively selected to reflect variation in end-of-life treatment intensity (one low-, medium-, and high-intensity site), as measured by the Dartmouth Atlas of Health Care.32 Between February 2018 and June 2022, we conducted interviews at these centers to explore institutional culture and decision-making practices near the end of life. This study was approved by the University of California, San Francisco institutional review board and adhered to the Standards for Reporting Qualitative Research (SRQR) reporting guideline.

 
Data Collection

We recruited clinician respondents through group email solicitations, individual interview requests, and snowball sampling. We purposively sampled physicians from multiple services (emergency medicine, hospital medicine, critical care, geriatrics, and palliative care) along with nonphysician clinicians (eg, advanced practice clinicians, nurses, and social workers) likely to observe physician decision-making approaches, ensuring triangulation in reported approaches. We collected self-reported demographic data including age, years of practice, professional role, and gender because we sought diversity in respondents.

A hospitalist and sociologist (E.W.D.) conducted semistructured in-depth interviews using an interview guide2 examining decision-making regarding potentially nonbeneficial life-prolonging interventions. Interviews were conducted in person, with written informed consent, until the COVID-19 pandemic; videoconferencing, with verbal informed consent, was used thereafter. All interviews were audio-recorded, transcribed, and deidentified for qualitative data analysis.

 
Initial Thematic Analysis

Initial analysis of the interview transcripts was conducted between January 2019 and December 2022. Several research team members (including E.W.D. and J.N.B.) conducted line-by-line thematic coding on a subset of interviews to develop a preliminary codebook. Code definitions were refined through team-based discussion. Next, several team members (including L.M.P. and J.N.B.) double-coded 20% of the entire dataset, adjudicating all code applications to consensus and finalizing the codebook. Two team members (including L.M.P.) used the final codebook to code the remainder of the dataset using ATLAS.ti software, version 24.2.0 (ATLAS.ti Scientific Software Development).

 
Development of Framework

Secondary analysis of the interview transcripts was conducted between August 2023 and May 2025. Using the applied codes, we extracted all excerpts in which the respondent reported an approach used by a physician to limit a life-prolonging intervention. We analyzed these descriptions to develop a preliminary conceptual framework of clinician-reported approaches to limiting life-prolonging interventions. Drawing on clinical and bioethics literature, we began with a deductive framework (eAppendix in Supplement 1) that provided initial language and concepts to categorize reported approaches. Four investigators (J.N.B., S.W.G., A.A.N., and H.O.C.) independently reviewed and categorized each excerpt. Each excerpt was discussed in team meetings using constant comparative methods to revise the framework iteratively.33 Disconfirming cases helped challenge and revise preliminary categories from the literature until all reported approaches could be accounted for.34 To represent the framework, all identified approaches were visually organized and summarized in a figure. A core team (J.N.B., S.W.G., and J.K.A.) drafted a finalized framework, which was refined and validated by additional team members (A.A.N., H.O.C., J.A.B., J.M.K., and E.W.D.) with diverse backgrounds in hospital medicine, geriatrics, palliative care, critical care, procedural subspecialties, and bioethics for its consistency with interview data and interpretability in light of existing literature (eAppendix in Supplement 1).

 
Analysis of Recommended and Alternate Approaches

We categorized each approach as a recommended approach or an alternate approach based on the critical care society policy statements that address decision-making regarding life-prolonging interventions.19-21 We recognized an approach as a recommended approach if it relied (1) on shared decision-making19 or (2) on an institutional process to limit an intervention.20,21 To verify the latter, we collected hospital policy documents describing institutional processes at each site.

We aimed to understand clinician perspectives regarding when and why they might deviate from recommended approaches. Therefore, we conducted a directed thematic analysis to identify challenges clinicians encountered using recommended approaches. Since alternate approaches are not clearly described in professional society policy statements, we used inductive thematic analysis to explore clinicians’ general perspectives regarding these approaches as they emerged in interviews.

Results

We recruited 101 clinician respondents with approximately equal representation from each site (hospital A: 34, B: 35, C: 32), whose demographics are reported in Table 1. Our sample included 53 attending physicians (52%), 16 trainee physicians (16%), 6 advanced practice clinicians (6%), 21 nurses (21%), 3 chaplains (3%), and 2 social workers (2%), with approximately equal proportion of women (59 [58%]) and men (42 [42%]) and a wide range of ages (mean, 42 [range, 27-74] years) and experience (mean, 14 [range, 1-52] years).

 

 

 

Framework of Clinician-Reported Decision-Making Approaches

Respondents described a range of decision-making approaches physicians use to influence patients and surrogates toward limiting potentially nonbeneficial life-prolonging interventions. Based on these descriptions, we developed a conceptual framework of 6 approaches that categorized each approach as a recommended or alternate approach (Figure). While no individual respondent articulated all 6 approaches, each was represented across sites by physician and nonphysician clinicians.

 

 

  

 

 

 

The 6 decision-making approaches are identified from left to right across the center of the Figure. In the boxes above, each decision-making approach is categorized as an approach that is recommended in professional society policy statements (ie, shared decision-making, institutional process addressing disagreement with patients/surrogates), or as an alternate approach. Approach 3 can be either a recommended or an alternate approach, depending on how it is enacted. For the discussion-based approaches (approaches 1-5), the alterations that physicians make to tailor the degree of influence toward limiting interventions (eg, altering what information is presented, altering how choice is offered) are described below in arrow-shaped boxes.

Respondents described approaches 1 through 5 as discussion-based approaches, in which physicians tailor the degree of influence they provide toward limiting interventions by altering the way they present information or offer choice (Figure). In contrast, respondents described approach 6 as a shift from attempting to limit interventions through discussion with the patient or surrogate to involving the institution in a policy-supported manner (Figure).

 
Description of Decision-Making Approaches

Each approach is described below, with quotations shown in Table 2.

 

 

 

  1. Providing an informed choice regarding interventions: The physician presents multiple options to the patient or surrogate, including at least 1 that limits life-prolonging interventions (Q1). The physician contextualizes these options to support an informed choice (eg, by describing expected quality of life, probability of survival to hospital discharge, etc) (Q2). Respondents felt this framing could influence patients and surrogates to limit interventions (Q3). Some respondents contrasted this approach with offering interventions without any guidance or intention of limiting interventions (Q4).

  2. Making a recommendation to limit interventions: The physician presents multiple options to the patient or surrogate and conveys a professional recommendation to limit interventions (Q5). Respondents provided examples of explicit recommendations (Q6) and discussed other ways recommendations could be conveyed (Q7). Respondents noted that the physician allowed the patient or surrogate to choose options differing from the recommendation (Q8).

  3. Stating a plan to limit interventions: The physician states a plan to limit interventions in the presence of known alternatives (Q9) and proceeds unless the patient or surrogate dissents (Q10). Physicians differed in the degree to which they explicitly offered a choice to defer to physician judgment or object to the plan (Q9-Q11). Respondents felt this approach guided the patient or surrogate toward limiting interventions by easing their decision-making burden (Q10-Q12).

  4. Explicitly not offering interventions: The physician states a final decision to limit interventions without providing a choice to the patient or surrogate (Q13). The decision not to offer an intervention is not responsive to objections from the patient or surrogate (Q14). Respondents explained that this approach guided the patient or surrogate by removing options from consideration (Q15).

  5. Silently withholding interventions: The physician omits mention of a life-prolonging intervention, thereby offering neither information nor choice (Q16). Some physicians described how this could be accomplished by not consulting physicians who might offer the intervention (Q17). Respondents saw this approach as a way to avoid introducing new interventions as options (Q18).

  6. Initiating an institutional process to limit interventions: The physician activates an institutional policy to limit interventions over the objections of the patient or surrogate (Q22). Most physicians described a process that involved other hospital personnel in positions of authority (eg, ethics consultants, risk management, the chief medical officer) (Q23). It was consistently described as an option of last resort that was rarely used (Q24).

 

Recommended Approach: Shared Decision-Making

In approaches 1 through 3 (providing an informed choice regarding interventions, making a recommendation to limit interventions, stating a plan to limit interventions), the physician guides the patient or surrogate toward limiting interventions but proceeds only if a shared decision is reached, conforming to recommendations in professional society policy statements.

Respondents identified challenges to limiting interventions using shared decision-making (Table 3). Respondents described how patients and surrogates experienced extreme difficulties in making potentially life-ending decisions (Q22), resulting in time-consuming and distressing decision-making experiences for all parties (Q23). During prolonged decision-making, respondents expressed alarm about unnecessary patient suffering or harm (Q24) and moral distress for the clinical team (Q25). Some respondents acknowledged that such challenges influenced them to avoid shared decision-making in certain situations (Q26).

 

 

 

 

Recommended Approach: Institutional Processes

Approach 6 (initiating an institutional process to limit interventions) also conforms to recommendations in professional society policy statements. Respondents identified challenges with using this approach (Table 3). Respondents felt that, while this approach was sometimes necessary, it was likely to worsen clinicians’ relationship with the patient or surrogate, causing resentment or suffering (Q27). Respondents feared downstream negative consequences such as legal action or media scrutiny (Q28). Respondents felt that the success of this approach depended on a unified team and administrative support, which was not always present (Q29). Some respondents acknowledged that such challenges deterred them from using institutional processes to limit interventions (Q30).

 
Alternate Approaches

In approaches 4 and 5 (explicitly not offering interventions, not mentioning interventions), the physician limits interventions without a shared decision or an institutional process. In most descriptions of approach 3 (stating a plan to limit interventions), the patient or surrogate is not offered an opportunity to object to the stated plan, and thus the physician limits interventions without a shared decision. These approaches are not recommended in professional society policy statements.

While respondents recognized that these alternate approaches were sometimes used (Q30) (Table 4), they described substantial practice variation in the use of alternate approaches among individuals (Q30 and Q31) and across institutions (Q32). Respondents felt that physicians differed in their ethical beliefs about alternate approaches (Q33), with some questioning (Q34) and others endorsing (Q35) the ethical permissibility of alternate approaches. Respondents used various rationales to justify alternate approaches, such as lack of impact on patient outcome, potential for harm, medical ineffectiveness, or medical futility (Q36). Respondents also described specific uncertainties regarding the permissibility of alternate approaches, depending on the nature of the intervention (Q36) or the physician’s specialty or role (Q37). These ethical uncertainties were closely intertwined with practical uncertainties, including how such approaches might be received by patients and surrogates or consulting teams and the potential for negative downstream consequences (Q36 and Q37).

 

 

 

Discussion

This multi-institutional qualitative interview study with clinicians across 3 academic medical centers characterizes the full range of approaches physicians use to limit potentially nonbeneficial life-prolonging interventions (Figure). The 6 approaches identified in this study were reported across hospitals that varied in geographic location and end-of-life treatment intensity, suggesting that clinicians across institutions navigate similar decisional pressures, likely shaped by a shared default tendency toward life prolongation in the US.1-4 Respondents at all sites perceived a need to mitigate the harms associated with this default by influencing the patient or surrogate toward limiting potentially nonbeneficial interventions.

This study provides 2 central contributions to the clinical and bioethics literature. First, it introduces a framework that organizes the decision-making approaches physicians use to influence a patient or surrogate to limit life-prolonging interventions, offering a structured set of approaches and shared language for coordinating sensitive conversations. The framework highlights how deliberations about life-prolonging interventions do not occur in a neutral space but rather in the context of a default tendency to initiate, continue, and escalate life-prolonging interventions. In this study, respondents described how physicians intentionally disrupt this default pathway by using decision-making approaches that influence patients and surrogates toward limiting potentially nonbeneficial life-prolonging interventions.

Second, this study provides evidence that physicians sometimes limit life-prolonging interventions without a shared decision or an institutional process. Respondents described how physicians resorted to these alternate approaches when life-prolonging interventions were highly unlikely to provide net benefit, but recommended decision-making approaches appeared burdensome or ineffective. In this way, alternate approaches could be viewed as pragmatic workarounds.35,36 In the sociological literature, workarounds are defined as “shortcuts or fixes for when work rules don’t match work realities.”36 Physicians resorted to alternate approaches when there were no other routes for addressing the problem of potentially nonbeneficial life-prolonging interventions. Recognizing alternate approaches as pragmatic workarounds underscores the limitations of professional society policy statements in a health care system that tends to intervene by default.

Respondent descriptions of the challenges associated with recommended approaches (Table 3) offer suggestions for ways forward. Respondents described shared decision-making as ineffective when patients or surrogates struggled to make potentially life-ending decisions, in agreement with prior literature.37-40 In these situations, respondents framed alternate approaches as strategies to reduce the emotional burden of a decision by reshaping choice architecture or pre-empting a difficult choice altogether.41-43 Similarly, respondents described institutional processes as burdensome, costly, and risky—especially when clinical team or administrative consensus could not be achieved, also aligning with prior literature.22,26 By incorporating clinicians’ experiences of these constraints, hospital-level interventions, hospital policies, and professional society statements might be designed to better support ethical decision-making.

Examining the conceptual boundaries between the recommended and alternate decision-making approaches is also instructive. First, policy statements recommend not offering or not mentioning interventions only in situations of physiologic futility when interventions cannot meet their intended goal (eg, providing antifungals for a myocardial infarction).20,21 In the present study, clinicians reported not offering or not mentioning interventions that had at least some chance of prolonging life, suggesting that physiologic futility may be too rigorous to address everyday clinical challenges. While policy statements allow exceptions in time-pressured situations,20,21 some clinicians reported not offering or not mentioning interventions without apparent time pressure.

Second, policy statements and other literature describe informed assent and nondissent as forms of shared decision-making only if patients and surrogates are informed of other options, understand that they are deferring to physician judgment, and can object to the plan of care.19,44-47 In the present study, most reports of stating a plan did not consistently meet these requirements, suggesting that that these requirements are challenging to implement for clinicians facing the high-stakes, emotionally laden discussions that engender use of this approach.

When physicians limit life-prolonging interventions without a shared decision, they risk imposing physician values and biases on vulnerable patients for preference-sensitive, high-stakes decisions.20,48 While some patients and surrogates prefer clinician-directed approaches, others prefer to direct decision-making themselves,19,49,50 inconsistent with the alternate approaches identified. This study points to a need for additional ethical inquiry and multidisciplinary professional consensus around when, if ever, alternate approaches are permissible.28,29 This need is especially pronounced given the confusion noted by respondents around the ethical permissibility of alternate approaches, particularly concerning the nature of the intervention (eg, not offering mechanical ventilation vs ECMO) and the role and specialty of the physician (eg, consulting surgeon vs hospitalist). Although it is well accepted that surgeons and other proceduralists can not offer interventions, it is unclear whether similar professional discretion should be extended to hospitalists, intensivists, and other medical subspecialists.28,29 At present, the alternate approaches described in this study are not supported by professional policy statements, and there is no explicit consensus regarding their ethical permissibility.

Limitations

This study has several limitations. Our analysis is based on clinician reports rather than observed behavior, which limits our ability to understand clinical context and may introduce reporting bias. However, we triangulated findings across institutions and a varied sample of clinicians to strengthen the validity of our framework. Further work, likely in the form of ethnographic observation, is needed to better understand how and when clinicians resort to alternate approaches. Additionally, semistructured qualitative interviews cannot support a comparative analysis among hospitals or clinicians, although some respondents reported interhospital or interclinician variation.

Conclusions

In this multi-institutional qualitative study, respondents reported facing challenges limiting interventions using the approaches recommended in professional society policy statements (ie, shared decision-making and institutional processes addressing disagreement with patients and surrogates). Use of alternate approaches (eg, stating a plan to limit interventions, explicitly not offering interventions, and not mentioning interventions) can be viewed as pragmatic attempts to navigate decision-making challenges surrounding life-prolonging interventions. Strategies are needed to help clinicians balance the ethical ideals articulated in professional societal policy statements with the potential harms imposed by the default tendency toward life prolongation in US hospitals.

 
Article Information

 

Accepted for Publication: December 28, 2025.

Published: February 20, 2026. doi:10.1001/jamanetworkopen.2025.60260

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2026 Batten JN et al. JAMA Network Open.

Corresponding Author: Jason N. Batten, MD, MA, UCLA Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Ste 3325, Los Angeles, CA 90095 (jbatten@mednet.ucla.edu).

Author Contributions: Drs Batten and Dzeng had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Batten, Kruser, Dzeng.

Acquisition, analysis, or interpretation of data: Batten, Weiss Goitiandia, Axelrod, Chernicoff, Nichol, Pereira, Blythe, Kruser, Dzeng.

Drafting of the manuscript: Batten, Weiss Goitiandia, Axelrod.

Critical review of the manuscript for important intellectual content: Batten, Weiss Goitiandia, Axelrod, Chernicoff, Nichol, Pereira, Blythe, Kruser, Dzeng.

Statistical analysis: Dzeng.

Obtained funding: Dzeng.

Administrative, technical, or material support: Weiss Goitiandia, Axelrod, Chernicoff, Nichol, Dzeng.

Supervision: Batten, Dzeng.

Conflict of Interest Disclosures: Dr Batten reported receiving funding from the National Institutes of Health during the conduct of the study. Dr Dzeng reported receiving grants from the California Department of Public Health, National Institutes of Health, and National Palliative Care Research Center during the conduct of the study. No other disclosures were reported.

Funding/Support: The research reported in this article was supported by an Alzheimer’s Disease Research Award from the California Department of Public Health (Dr Dzeng) and grants from the National Institute of Nursing Research (3R01NR018161-02S1), the National Institute on Aging (1K76AG074906-01A1), and the National Institute of General Medical Sciences (T32GM148369).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: This content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Data Sharing Statement: See Supplement 2.

Additional Contributions: We thank the study respondents who took the time to provide us with their insights. We also thank Catherine Burke, MD (University of California, San Francisco); Steven Chang, MD, PhD (University of California, Los Angeles); J. Randall Curtis, MD, MPH (University of Washington); Solomon Liao (University of California, Irvine); Daniel Dohan, PhD (University of California, San Francisco); Thea Matthews, MFA (no affiliation); Lorraine Pereira, BA (Harvard Medical School); Amy Rosenwohl-Mack, PhD (University of California, San Francisco); Neil Wenger, MD, MPH (University of California, Los Angeles); and Sherry Xu, MSN (University of California, Los Angeles) for their assistance with the project. Mses Matthews and Rosenwohl-Mack were compensated for their contributions; the others were not.

 
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