AbstractPatients without capacity or a surrogate decision maker are known as unrepresented. These patients are highly vulnerable and frequently encountered in healthcare settings, though there is little consensus regarding how medical decisions should be made on these patients' behalf. Several states now require a second nontreating physician (SNTP) to evaluate nonemergent medical decisions for unrepresented patients. This article examines the legal and ethical challenges faced by SNTPs in the dual-physician authorization process, including biases in SNTP selection, time constraints, power dynamics, and accountability concerns. We propose a checklist to guide SNTPs in the care of unrepresented patients while minimizing biases and conducting rigorous risk-benefit assessments. Institutional strategies to address the challenges faced by SNTPs include systematic SNTP selection processes, protected time for evaluations, peer review panels, training to mitigate implicit bias, and iterative review for quality improvement. By providing an ethical framework for dual-physician authorization and actionable processes for minimizing bias, we seek to promote fair and thoughtful decision-making on behalf of unrepresented patients.

AbstractWhen patients are unable to make decisions for themselves, medical teams often turn to surrogate decision makers to help identify what the patient would have wanted. Unless a patient has designated a surrogate, teams must rely on statutory hierarchies that often prioritize legal and biological ties. When cases arise in which patients do not want their legal surrogate to be their medical decision maker, they must take steps to exclude that person. Unfortunately, people often are not aware of this until they are unable to make complex medical decisions for themselves. While much has been said about the capacity to appoint surrogates, comparatively little has been said about excluding surrogates. In current practice, a patient's decision to exclude a surrogate would not be respected when they do not have capacity. It is our view that this blanket inclusion of surrogates can be seriously harmful and potentially violating. Our goals in this article are twofold. First, we aim to carve out the decision to exclude a surrogate as distinct from the decision to appoint one. Second, we argue that respecting an incapacitated patient's exclusion to some degree is morally appropriate. We will conclude by offering suggestions about how to respect the preference to exclude while considering the risks that may come with exclusion.

Background: Understanding the factors influencing food choice is critical for developing effective strategies to promote healthier eating habits and creating policies that support public health. Attentional bias, the inclination to focus attention on specific stimuli, plays a significant role in shaping food preferences by affecting how individuals perceive and react to various food-related elements. Various methodologies exist to examine attentional bias, including the dot-probe task, which measures reaction times to probes appearing after paired stimuli (eg, novel vs familiar food images); eye-tracking, which tracks gaze patterns and fixations to determine visual attention; and electroencephalography, which records brain activity, capturing early and late neural responses (eg, N100, P300) linked to attention processing; however, integrated approaches combining these methods to assess bias toward familiar versus novel foods remain underexplored.

Objective: This study aims to examine differences in attention toward familiar versus novel food stimuli using integrated eye-tracking, dot-probe, and electroencephalography methods, and to explore associations with self-reported food choice.

Methods: A total of 40 healthy adult participants will be recruited. Participants will be presented with pairs of familiar or novel food images, while their visual attention and brain activity are recorded concurrently. Eye-tracking metrics, including time to first fixation and total fixation duration, will be used to assess visual attention. Electroencephalography data will be collected to measure the amplitude of event-related potential components, such as P300 and N100, associated with attentional processing. Reaction times will also be recorded as a behavioral measure of attentional engagement with familiar versus novel food items. Data analysis will involve repeated measures ANOVA to examine the effects of food familiarity and novelty on attentional bias metrics. Correlation analyses will also be conducted to explore the relationships between eye-tracking, electroencephalography, and dot-probe measures.

Results: This study was approved by the Ethics Committee of the Iran University of Medical Sciences in February 2021 and funded in January 2022. Data collection began in November 2022 and is expected to be completed in July 2025. As of the submission of this study, 36 individuals have been recruited. Data analysis has not yet commenced, but it is planned to begin upon the completion of data collection. The results are anticipated to be published by December 2025. The protocol was registered with the Open Science Framework in September 2024.

Conclusions: The main outcome of this study is identifying differences in attentional bias metrics toward familiar versus novel food stimuli at different presentation times. These findings will provide preliminary data on the application of an integrated approach for capturing attentional bias to food-based stimuli based on their familiarity or novelty, and how these biases may be linked to food choice behaviors.

International registered report identifier (irrid): DERR1-10.2196/69541.

The rapid advancement of Large Language Models (LLMs) and their potential integration into autonomous driving systems necessitates understanding their moral decision-making capabilities. While our previous study examined four prominent LLMs using the Moral Machine experimental framework, the dynamic landscape of LLM development demands a more comprehensive analysis. Here, we evaluate moral judgments across 52 different LLMs, including multiple versions of proprietary models (GPT, Claude, Gemini) and open-source alternatives (Llama, Gemma), to assess their alignment with human moral preferences in autonomous driving scenarios. Using a conjoint analysis framework, we evaluated how closely LLM responses aligned with human preferences in ethical dilemmas and examined the effects of model size, updates, and architecture. Results showed that proprietary models and open-source models exceeding 10 billion parameters demonstrated relatively close alignment with human judgments, with a significant negative correlation between model size and distance from human judgments in open-source models. However, model updates did not consistently improve alignment with human preferences, and many LLMs showed excessive emphasis on specific ethical principles. These findings suggest that while increasing model size may naturally lead to more human-like moral judgments, practical implementation in autonomous driving systems requires careful consideration of the trade-off between judgment quality and computational efficiency. Our comprehensive analysis provides crucial insights for the ethical design of autonomous systems and highlights the importance of considering cultural contexts in AI moral decision-making.

Background: The burgeoning rise in social media use has revolutionized information dissemination, rendering social media a vital tool for promoting health campaigns and enhancing 2-way health communication between senders and users. Health planners and policy makers consider social media platforms (SMPs) vital for transferring useful health information to the public. However, there are important concerns about the decision makers' perceptions of the evolving role of social media in health promotion and education campaigns.

Objective: This qualitative study explored how decision makers perceive the role of social media in health promotion and education. We aimed to shed light on strategic efficacy, real-world challenges, and valuable prospects of using social media for health communication.

Methods: We adopted a qualitative research method involving in-depth, semistructured, face-to-face interviews. We included 13 participants from government and private health care sectors in the Al-Qassim region of Saudi Arabia, who were key players and decision makers in health care programs and reforms. Data were recorded, transcribed verbatim, and analyzed using thematic analysis to identify key themes and patterns.

Results: Five main themes were identified: (1) use of social media (frequency, type of content, target audience, purpose of communication), (2) perceptions of decision makers (how social media influences public health behavior), (3) benefits, (4) challenges, and (5) implications for future use. Participants recognized the positive role of SMPs in spreading health information, particularly in health promotion and awareness campaigns. Communication emerged as a key concept, and WhatsApp, X (Twitter), and Facebook were recognized as major platforms for digital health literacy. The participants used these applications extensively for communication with colleagues, patients, and the public, intending discussion, information exchange, and health promotion campaigns. Content inaccuracy and reliability were identified as major challenges. Furthermore, misinformation and social inequalities were identified as barriers to effective communication. Participants suggested that social media influencers play a more effective role in information dissemination than the health care staff. Far-reaching audiences, visually appealing and engaging content using videos and graphics, and assessing campaign effectiveness using metrics, such as views, shares, likes, and comments, were recognized as major benefits of social media. Participants stressed the promising role of social media in the future as technological advancements in eHealth could revolutionize health care.

Conclusions: SMPs play a vital role in sharing information about health-related initiatives. This research highlights the complexities and potential challenges of using social media for health promotion in Saudi Arabia. It emphasizes the need to develop strategies to combat misinformation, address privacy and confidentiality concerns, and ensure compliance with legal and ethical standards. Encouraging communication among key stakeholders, including health promotion experts, government organizations, social media companies, and the general public, can help establish effective guidelines and protocols to overcome the challenges.

Delay discounting is the tendency for people to devalue future rewards as the time required to obtain them increases over time. Self-control is the ability to regulate behavior, emotions and cognition to achieve goals or adhere to social norms despite temptations, impulses or distractions. Previous studies have found that self-control was negatively correlated with delay discounting. However, the neural mechanism underlying the relationship between self-control and delay discounting remains unclear. To address this question, we examined the neural basis of the relationship between self-control and delay discounting using voxel-based morphometry(VBM) and resting-state functional connectivity analysis(RSFC). The behavioral results demonstrated a negative correlation between delay discounting and self-control. Furthermore, the voxel-based morphometry results showed a positive correlation between self-control and gray matter volume in the dorsolateral prefrontal cortex(dlPFC). Moreover, self-control was positively correlated with functional connectivity between the medial prefrontal cortex(mPFC) and the dorsolateral prefrontal cortex. More importantly, the association between self-control and delay discounting was shown to be partially mediated by the functional connectivity between the dlPFC and mPFC. These findings suggested that dlPFC-mPFC functional connectivity could be the neural basis underlying the association between self-control and delay discounting, which provided novel insights into how self-control affected delay discounting and offered new explanations from a neural perspective.

In negotiation, individuals collaborate to achieve a shared goal and reach a mutual agreement by understanding their partner's intentions and adapting to them. Unlike most social cognition studies that investigate brain activity in individuals separately, this study employed an innovative hyperscanning approach, which is able to explore the inter-brain synchronization during negotiation. 26 students, divided into 13 dyads, participated in a negotiation decision-making task, requiring convergence on a shared course of action. The interaction was segmented offline into three phases: opener (sharing of individual opinions), central (negotiation), and final phase (shared decision). Electrophysiological (EEG delta, theta, alpha, beta and gamma bands) and hemodynamic (oxygenated-OHb and deoxygenated-HHb hemoglobin) data were collected. Higher HHb levels were observed during the central phase compared to the final phase, suggesting a relative decrease in frontal activation, potentially due to a shift in cognitive processing toward temporoparietal regions, as indicated by EEG findings. Increased delta, theta, and alpha activity was reported in the frontal area, suggesting the engagement of emotional and motivational systems as well as cortical resources for information processing. Finally, beta and gamma bands showed higher activity in the temporo-central and parieto-occipital areas, indicating the activation of perspective-taking. This study highlights how hyperscanning reveals the neural mechanisms of negotiation, where emotional, cognitive, and perspective-taking processes converge.

Women's representation in science has grown, yet they still comprise only about a third of the global scientific community. While women are the majority in fields like social, biological, and health sciences, they remain underrepresented in others, such as exact sciences and engineering, from training stages to senior positions. Beyond gender-related challenges, motherhood introduces additional barriers. In this study, we analyzed the perceptions of research productivity fellows from the National Council for Scientific and Technological Development in the fields of physics and nursing regarding their academic-scientific trajectories. These fields present contrasting professional landscapes: women are a minority in physics and a majority in nursing. Data collected in 2020 from fellows active in 2019 revealed that being a woman and, in particular, being a mother impacts scientific careers differently across disciplines. In physics, participants perceived significant obstacles, including gender-based challenges and the disruption caused by motherhood. In nursing, however, motherhood was seen as more integrated into the academic journey. These findings underscore how the academic environment, shaped by the gender composition of a field, profoundly influences career experiences. Addressing these disparities requires context-specific strategies to create equitable and inclusive scientific environments.

Background: Numerous new treatments for atopic dermatitis (AD) have been approved in recent years, but it is unknown whether published patient, caregiver and healthcare provider preferences are biased by industry funding.

Objectives: To investigate funding sources and their putative influence on patients, caregivers and healthcare providers' reported preferences with regard to different properties of therapies and treatment outcomes of AD.

Methods: This descriptive systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines. PubMed and EMBASE were searched. Studies were included if they reported data on AD patients', caregivers' and/or healthcare providers' preferences of therapy and/or treatment outcomes.

Results: A total of 8346 studies were identified, and 42 were included for data synthesis (participants, 19,839; females, 62.2%). Nineteen and twenty-three studies were pharma-sponsored and non-pharma-sponsored, respectively. The pharma-sponsored studies were of recent dates, had larger patient populations and included discrete choice experiments. Efficacy was of great importance to patients, caregivers and healthcare providers, and this finding was mainly driven by pharma-sponsored studies. Moreover, patients were more willing to accept the risk of side effects or adverse events to achieve other treatment goals in pharma-sponsored studies. Studies sponsored by companies producing Janus kinase inhibitors showed that patients preferred the least invasive administration route despite increased administration frequency. Studies evaluating preferred topical treatment attributes were often non-pharma-sponsored.

Conclusions: The findings of this study indicate that preference research may be biased. Therefore, healthcare providers should be cautious when employing treatment needs and preferences research to support decision-making.

Background: Spinal muscular atrophy (SMA) is a rare, progressive neuromuscular disease associated with a significant burden of illness to both patients and caregivers; however, there is little evidence available regarding how patients and caregivers evaluate potential treatment benefit-risk profiles. As access to SMA disease-modifying therapies increases, it is imperative to understand which treatment attributes drive treatment choices.

Objective: To identify which treatment attributes drive treatment choices in adults with SMA and caregivers of children with SMA across nine countries in Latin America.

Methods: A discrete choice experiment (DCE) survey was developed for market research using data collected via qualitative interviews and consultations with medical experts. Adults with Type 2/3 SMA and caregivers of children with Types 1-3 SMA were recruited by patient advisory groups and physician referrals. Respondents completed a 30-min, online survey that collected patient demographics, disease-specific information, and quality of life data (via the EQ-5D-5L), and included the DCE, in which respondents were asked to choose between 14 sets of hypothetical treatment profiles. Data were pooled for analysis, as the country-level sample sizes were small. Raw data were aggregated in Microsoft Excel. Statistical testing was performed using data tables and SPSS (as appropriate). Demographic data were summarized descriptively.

Results: A total of 143 respondents (45 adults with SMA and 98 caregivers) completed the online survey. Most respondents were from Argentina (35.0%) or Brazil (19.6%). Breathing function outcome was the most important treatment attribute for caregivers, while adults with SMA placed greater importance on motor function outcome. Both adults with SMA and caregivers placed the greatest importance on improvements in function compared with worse or stable outcomes.

Conclusions: Understanding treatment attribute preferences at a regional level will improve shared medical decision-making for individuals with SMA.

Background: Shared decision-making (SDM) implementation remains limited in psychosis management, particularly within antipsychotic prescribing. When and why prescribers engage in SDM within these contexts is largely unknown. Part 1 of this two-part realist review aimed to understand the impact of structural and contextual factors on prescriber engagement in SDM within antipsychotic prescribing.

Study design: CINAHL Plus, Cochrane Library, Embase, PsycINFO, PubMed, Scopus, Sociological Abstracts, Web of Science, and Google Scholar were searched for evidence to develop realist program theories outlining the relationship between macro-level contexts and their impact on prescriber behaviors.

Study results: From 106 included documents, five program theories explaining relationships between (i) leadership and governance, (ii) workforce development, and (iii) service delivery contexts and their impact on reducing prescriber engagement with behaviors required of SDM application were developed. No facilitative macro-level contexts were identified. Key mechanisms reducing prescriber engagement in desired behaviors include fear of individual blame for adverse outcomes and exposure to liability, pressure from service environments to prioritize decreasing risk of harm, devaluing of experiential knowledge, and beliefs that SDM conflicts with duties of beneficence and non-maleficence.

Conclusion: Even empirically efficacious interventions will be difficult to implement at scale within real-world settings due to misalignment with complex cultural, legal, and professional realities prominent therein. Mechanisms responsible for reducing prescriber engagement in SDM should be the target of structural interventions necessary to support contextual integration into psychosis management. Part 2 outlines features of service delivery contexts, workforce development, and technology that can increase prescriber engagement in SDM.

Background: Shared decision-making (SDM) implementation remains limited in psychosis management, particularly within antipsychotic prescribing. When and why prescribers engage in SDM within these contexts is largely unknown. Part 2 of this 2-part realist review aimed to understand what SDM intervention strategies and local implementation contexts are responsible for successful prescriber engagement and why.

Study design: CINAHL Plus, Cochrane Library, Embase, PsycINFO, PubMed, Scopus, Sociological Abstracts, Web of Science, and Google Scholar were searched for evidence to develop realist program theories explaining relationships between meso- and micro-level contexts and impact on prescriber behaviors.

Study results: From 106 included documents, 5 program theories were developed explaining mechanisms responsible for increasing prescriber engagement with desired behaviors, alongside facilitative features within service delivery contexts and workforce development. Key mechanisms included reducing prescriber fear of sole responsibility for harm, reducing the perceived burden of SDM, increasing prescriber confidence in their ability to productively negotiate treatment consultations and their confidence to safely increase patient autonomy within decision-making. These mechanisms should be the focus of those interested in designing SDM interventions to increase prescriber engagement and those responsible for translating results of effective interventions into real-world settings to ensure facilitative contexts are maintained.

Conclusion: Intervention strategies that should be prioritized for scale-up include attempting SDM within existing therapeutic relationships, adopting a multidisciplinary team (MDT) responsibility for SDM implementation, and workforce training in skillsets required of effective SDM application. Efforts to standardize psychosis care via MDTs and systematically reduce discontinuity and fragmentation of care are required at policy-level.

Private ambulance services play a vital role in healthcare systems across Europe, supplementing public emergency services and providing essential medical transportation. However, managing these services presents significant challenges, including resource allocation, regulatory compliance, service quality, technological integration, workforce management, and financial sustainability. This study employs the Analytical Hierarchy Process (AHP) as a strategic decision-making tool to optimize the management of private ambulance services in Germany, Spain, and the United Kingdom. To achieve this, data were collected from 20 participants across the three countries (Germany: 7, Spain: 6, United Kingdom: 7), comprising ambulance service administrators, emergency medical personnel, and regulatory experts. A purposive sampling method was used to ensure the inclusion of key stakeholders with direct experience in the sector. Participants completed structured questionnaires involving pairwise comparisons of key decision criteria. Results reveal that Regulatory Compliance is the highest priority across all countries (Germany: 0.25, Spain: 0.22, UK: 0.20), followed by Service Quality, which is particularly emphasized in the UK (0.22) and Germany (0.20). Technological Integration is important in Spain (0.20), reflecting the need for advancements in underserved areas. While Workforce Management and Financial Sustainability rank slightly lower, they remain critical for operational efficiency. The study highlights country-specific challenges and regulatory differences and provides actionable recommendations for optimizing resource allocation, improving service quality, and ensuring compliance. Despite limitations such as potential biases and a narrow geographic focus, the findings offer valuable insights for refining management practices and enhancing the sustainability of private ambulance services across Europe.

When personality psychologists examine political behaviour, including voting, they usually focus on a narrow range of variables, thereby undermining the breadth of our knowledge. We asked 280 participants who they voted for (or would have) in the 2020 US presidential election and inquired as to their 'dark' personality (i.e., psychopathy, sadism, narcissism, and Machiavellianism) and 'light' (i.e., Kantianism, humanism, and faith in humanity) personality traits, political attitudes (i.e., social dominance orientation, right-wing authoritarianism, and left-wing authoritarianism), and how many times people chose each of the six moral foundations (i.e., care, fairness, loyalty, purity, liberty, and hierarchy). We found that personality traits (as distal systems) were negligibly important in presidential choice, moral choices (as parallel-yet-related choices) had some utility especially in relation to voting for a third-party candidate, and political attitudes (as proximal predictors) had the broadest and strongest associations. In addition, we found that third-party voters showed stronger concerns for purity than Biden supporters, and greater concerns for fairness than Trump supporters. Our results focus on how dispositional measures can add to standard sociodemographic predictors used by pollsters, politicians, and pundits.

Background: This study aimed to examine the association between health literacy and illness perception among Chinese patients with chronic disease in the community through a national cross-sectional study.

Methods: This cross-sectional study was conducted in China from June 20, 2022, to August 31, 2022, and used a multistage sampling approach to select patients with chronic diseases. The study included 5,525 participants from 15 provinces, drawn from the Psychology and Behavior Investigation of Chinese Residents in 2022. We constructed univariate analysis, smooth curve fitting, threshold saturation effect analysis, and forest plot of subgroup analysis to evaluate the association between health literacy and illness perception.

Results: The analysis revealed an inverted J-shaped association between health literacy and illness perception (P < 0.001). Moreover, the identified inflection point was 22.22. When the health literacy score was below 22.22, illness perception exhibited a positive association with health literacy (β = 0.12, 95%CI = 0.03, 0.21, P = 0.009). When the health literacy score was higher than 22.22, illness perception decreased with the increasing health literacy (β=-0.23, 95%CI=-0.27, -0.19, P < 0.001). The significant association between health literacy and illness perception did not differ significantly across subgroups, except for the Hukou subgroup.

Conclusions: This study determined a threshold of health literacy that was associated with the illness perception of Chinese chronic disease patients. Additionally, an inverted J-shaped association between health literacy and illness perception was observed, suggesting that targeted health literacy intervention measures should be tailored to specific chronic disease groups rather than a uniform approach.

Clinical trial number: Not applicable.

Background: Video feedback interventions have been designed to improve maternal sensitivity by reducing the negative effects of maternal depression symptoms on the quality of mother-infant interaction during the postnatal period. However, little is known about how these interventions may indirectly influence a mother's sense of identity or who she understands herself to be.

Methods: Eight Australian women, with signs of perinatal depression, participated in a 3-session Video Interaction Guidance (VIG) intervention and a follow-up interview. Their interview responses were qualitatively analysed with a constructivist, inductive thematic analysis.

Results: VIG showed potential to support positive maternal self-concept, through its strengths-based approach. Women reported positive benefits, and their responses engaged with broader cultural discourses of "good" motherhood, which they both reflected and challenged. This process was supported by both the external evidence of the video clips and the insider validation of "seeing" the preferred sense of motherhood identity in action.

Conclusions: Findings expand the scope of VIG from its original aim of increasing maternal sensitivity, to that of indirectly assisting mothers with forming a more positive and durable sense of motherhood identity. Clinical implications and suggestions for the role of video feedback interventions in maternal depression are discussed, including the need for further research on VIG interventions in this group.

Introduction: Menopausal women often face challenges in choosing appropriate interventions to mitigate distressing menopause symptoms, primarily due to concerns about treatment suitability. Therefore, the present study aimed to assess the effect of shared decision-making (SDM) on conflict and regret in menopause symptoms management.

Method: This interventional study was conducted on 44 menopausal women aged ≥ 45 years in Tabriz, Iran, from September 2020 to January 2021. Subjects were randomly assigned to the intervention (n = 22), which received SDM-based counseling along with a decision aid (DA) booklet, and control (n = 22) groups. The data were collected using a socio-demographic and obstetric characteristics checklist, awareness of the menopause symptoms management strategies, decisional conflict, and regret. The intergroup differences were compared employing an independent t-test and ANCOVA.

Results: The mean score of decision conflict [Mean difference (MD): -2.07, 95% CI: -29.65 to -11.92, P = 0.001] and decision regret [MD: -1.25, 95% CI: -1.64 to 0.64, P = 0.03] significantly reduced in the intervention group compared to the control group after the intervention. Additionally, a statistically significant increase in the mean score of women's awareness was observed in the intervention group compared to the control group following the intervention [(Hormone Therapy: MD: 3.38, 95% CI: 1.01 to 5.57, P = 0.006) (Natural Products: MD: 2.44, 95% CI: 0.93 to 3.94, P = 0.002)].

Conclusion: The results indicated the effect of SDM-based counseling on improving women's awareness of the menopause symptoms management strategies and reducing the decisional conflict and regret.

Background: In hospital, nurses are often the first to identify patients in cardiorespiratory arrest and must decide whether to call a CODE BLUE and commence cardiopulmonary resuscitation (CPR). In Australia, there are no legal or policy obligations to commence CPR when unequivocal signs of death are present. The use of CPR where it cannot provide any benefit to a patient raises profound questions about decision-making and ethical practice. The aim of this empirical ethics study was to describe hospital-based nurses' decision-making, perspectives, and experiences of initiating CPR in hospitalised patients who have unequivocal signs of death but lack a Do-Not-Resuscitate (DNR) order.

Methods: The study was a multisite cross-sectional descriptive survey conducted between October 2023-April 2024. Nurses were presented with two clinical scenarios in which patients were found to have no signs of life: Mr. D, an 84-year-old male with cancer, and Mr. G, a 35-year-old male post-motor vehicle accident. Eligible participants were all nurses working in in-patient units. Descriptive statistics, Pearson Chi-square or Fisher's exact tests, McNemar test, and binomial logistic regression were used to analyse the data.

Results: 531 nurses completed the survey. For Mr D, 61.5% (n = 324) would call a CODE BLUE, 24.1% (n = 127) would perform limited CPR. Only 14.4% (n = 76) would confirm death. For Mr G, 93.9% (n = 492) would call a CODE BLUE, 4.4% (n = 23) would perform limited CPR, and 1.7% (n = 9) would confirm death. The major reasons why nurses initiate a CODE BLUE were 'In the absence of an DNR order, there is no option but to begin CPR', 'I am required by hospital policy to do so', 'I am required by law to do so' and 'It is what I was trained to do'.

Conclusions: Most nurses would commence CPR in patients with clear signs of death in the absence of a DNR order. This seems most likely related to ignorance or misunderstanding of law, policy and/or the misapplication or professional norms. These results raise important questions about the drivers of nurses understanding of and engagement with CPR. This highlights ethical concerns for care and treatment of patients at the end of their life and underscores the need to examine ethical practice, agency, and professionalism and supports review of policy, practices and education regarding ethical end-of-life decision making and care.

Background: There is a worldwide shortage of general practitioners (GPs). The aim of this study is to explore the perspectives of GP trainees and to understand their motivators and career priorities to inform future GP workforce planning.

Methods: A qualitative study, consisting of one-to-one, semi-structured interviews was conducted with GP trainee participants and data were analysed thematically. Every GP trainee currently enrolled in vocational training nationally was invited to participate. 'Social Cognitive Career Theory' and 'Sociocultural Theory' were used as theoretical frameworks to inform the interview guide and its analysis.

Results: Seventeen GP trainees were interviewed. One meta-theme was identified from interviews: 'Sustainable work as part of a fulfilling life'. This meta-theme of sustainability threads through each of the five related subthemes: Family, stability and support, burnout aversion, role-modelling, and well supported portfolio careers in practice.

Conclusion: Understanding priorities and motivators of GP trainees will inform future healthcare planning, in particular, the type of role to which trainees aspire and the type of health service they in which they will work.

Since our first understanding of the nature of pathogen and parasite transmission, avoidance of infectious diseases has been an essential component of public health and epidemic suppression. Avoidance reduces an individual's risk of contacting pathogens. Humans are not the only host organisms that avoid their pathogens and parasites, though. In nature, infection avoidance is widespread in vertebrates, invertebrates, and even plants. Examining avoidance from this unified taxonomic perspective gives insights into its function, form, evolution, and application. In this Primer, we functionally define avoidance, outline its taxonomic breadth, provide an overview of what is known about its mechanisms and evolution, and identify applications of basic avoidance knowledge across fields as diverse as public health, conservation, and agriculture. We also highlight key open questions directing research into the future.