NURS 6521 Week 1 EmmaGarcia Ethical and Legal Aspects of Prescribing Example SolutionEthical and Leg

NURS 6521 Week 1 EmmaGarcia Ethical and Legal Aspects of Prescribing Example Solution

Ethical and Legal Implications of Prescribing Drugs

As an advanced practice nurse prescribing drugs, you are responsible for the safety of your patients each day. The prescriber is responsible for ensuring that any medical intervention they propose will align with the ethical and legal guidelines. The nurse practitioner must be knowledgeable about the most recent rules governing advanced practice nurses with the power to prescribe.

According to Rosenthal and Burchum (2021), writing prescriptions should prioritize patient safety and minimize medication errors through thorough assessment, clear documentation, electronic prescribing systems, and ongoing monitoring. The prescriber should ensure that any intervention taken has to account for the patient’s wishes and those of the family members and the primary caregivers.

Ethical and Legal Implications

1. Prescriber:

From the scenario, as an advanced nursing practitioner, prescribing medication makes the nurse face ethical and legal responsibilities. Ethically, the prescriber must prioritize AC’s best interests and respect his autonomy. The prescriber should consider the principle of beneficence by providing appropriate and necessary treatment.

They should also respect AC’s autonomy by ensuring his values and wishes are considered, even without advanced directives (Rosenthal & Burchum, 2021). Legally, the prescriber must follow applicable laws and regulations regarding informed consent, decision-making capacity, and end-of-life care.

2. Pharmacist:

The pharmacist has ethical and legal obligations as well. Ethically, the pharmacist should prioritize patient welfare and respect the autonomy of AC. They should ensure that the prescribed medications are appropriate, safe, and effective. The pharmacist may also play a role in counseling the patient’s family about the potential benefits, risks, and alternatives to treatment options. Legally, the pharmacist must adhere to laws and regulations related to medication dispensing, patient privacy, and confidentiality (Rosenthal & Burchum, 2021).

3. Patient (AC):

Although unresponsive and unable to communicate, AC has the ethical right to receive appropriate and compassionate care. The ethical principle of autonomy requires that AC’s values and wishes, as expressed by his family, be considered (American Geriatrics Society, 2019). If AC had previously expressed his wishes regarding end-of-life care, those should be respected. The healthcare team must act in his best interests if his wishes are unknown.

4. Patient’s Family (wife and daughter):

The wife and daughter have emotional and ethical involvement in AC’s care. Ethically, the wife’s belief that AC would not want to live in his current state should be respected, as it aligns with the principle of autonomy. The daughter’s belief that AC should be kept alive raises questions about the balance between hope and futility. Ethical discussions and family meetings can help address their concerns, consider AC’s values, and reach a consensus regarding his care.

Strategies to Address Disclosure and Non-disclosure

1. Open communication and shared decision-making: Engage in open dialogue with the wife, daughter, and other relevant stakeholders. Discuss the prognosis, treatment options, and potential outcomes. Please encourage them to express their concerns, values, and beliefs. By involving them in decision-making, you promote shared decision-making and respect for their autonomy (Rosenthal & Burchum, 2021).
2. Respecting patient confidentiality: Maintain patient confidentiality and privacy throughout the discussions. Ensure that sensitive information is only shared with individuals who have a legitimate need to know. Familiarize yourself with the laws specific to your state regarding patient confidentiality and privacy, such as the Health Insurance Portability and Accountability Act (HIPAA) in the United States, and adhere to them.
3. Exploring legal frameworks: Familiarize yourself with the legal framework in your state regarding disclosure and nondisclosure in healthcare. Laws may vary, but generally, healthcare professionals have a duty to disclose information to patients or their surrogates that is relevant to the patient’s condition and treatment decisions. However, laws also recognize exceptions where disclosure may not be appropriate, such as when it could cause serious harm to the patient or if the patient has explicitly requested nondisclosure (Rosenthal & Burchum, 2021).
4. Involving an ethics committee or legal counsel: In complex situations with conflicting views, involving an ethics committee or seeking legal counsel can provide guidance and ensure compliance with legal and ethical obligations. These resources can help navigate the specific laws in your state and provide recommendations on how to address disclosure and nondisclosure appropriately.

Strategies to Guide My Decision Making

1. Ethical reflection and consultation: Engaging in ethical reflection allows for a thoughtful examination of the situation, weighing the principles of autonomy, beneficence, and non-maleficence. Consulting with colleagues, an ethics committee, or a supervisor can provide different perspectives and support in decision-making. Discussing the ethical dilemma of disclosing the error with trusted individuals can help ensure a well-considered decision.
2. Adherence to professional standards and guidelines: Utilizing professional standards, such as those set forth by nursing organizations, can provide a framework for decision-making. These standards emphasize the importance of patient safety, communication, and accountability. In this scenario, disclosing the error may align with professional standards and guidelines, as it promotes transparency, fosters trust with the patient and family and allows for shared decision-making.

Whether to disclose the error should be carefully considered, considering the potential impact on the patient, their family, and the healthcare team. Justification for disclosing the error may include promoting transparency, maintaining trust, and involving the patient and family in decision-making (Rosenthal & Burchum, 2021). However, it is important to consult legal and institutional policies to ensure compliance with disclosure requirements specific to the jurisdiction.

The Process of Writing Prescriptions

1. Patient assessment and diagnosis: Conduct a thorough assessment of the patient, including their medical history, current symptoms, and any allergies or contraindications. Accurate diagnosis is crucial for prescribing the appropriate medication (Shojaei & Salari, 2020).
2. Selecting the medication: Choose the most appropriate medicine based on the patient’s diagnosis, considering efficacy, safety, dosage form, and patient-specific factors (e.g., age, comorbidities).
3. Determine dosage and frequency: Calculate the correct dosage and frequency of administration based on the patient’s age, weight, renal or hepatic function, and other relevant factors. Double-check calculations and refer to reliable references or prescribing guidelines.
4. Write clear and legible prescriptions: Use clear and concise language when writing prescriptions, including the medication name, strength, dosage form, instructions for use, and duration of treatment. Avoid abbreviations or ambiguous terminology to minimize confusion.
5. Electronic prescribing systems: Utilize electronic prescribing systems whenever possible, as they can help reduce errors by providing decision support, alerts for potential interactions or allergies, and automated dose calculations.
6. Double-check and review: Review the prescription for accuracy and completeness before transmitting or handing it to the patient. Ensure there are no potential drug-drug interactions, duplications, or contraindications (Shojaei & Salari, 2020).
7. Communication and patient education: Clearly communicate the prescription instructions to the patient or caregiver, ensuring they understand the medication regimen, potential side effects, and any necessary precautions.
8. Ongoing monitoring: Regularly assess the patient’s response to the medication, monitor for adverse effects, and adjust the prescription as needed.

Conclusion

The case scenario presented ethical and legal implications for all stakeholders involved, including the prescriber, pharmacist, patient, and patient’s family. The conflicting perspectives regarding end-of-life care highlighted the importance of open communication, shared decision-making, and respecting patient autonomy. Strategies such as ethical reflection, adherence to professional standards, and consultation with ethics committees or legal counsel can guide decision-making in complex situations.

Additionally, the process of writing prescriptions should prioritize patient safety and minimize medication errors through thorough assessment, clear documentation, electronic prescribing systems, and ongoing monitoring. By considering the ethical and legal aspects while implementing strategies to minimize errors, healthcare professionals can provide compassionate and appropriate care in challenging situations.

NURS 6521 Week 1 EmmaGarcia Ethical and Legal Aspects of Prescribing References

American Geriatrics Society. (2019). Beers Criteria Update Expert Panel. (2019). American Geriatrics Society 2019 updated AGS Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society Download Journal of the American Geriatrics Society, 67(4), 674–694. https://doi.org/10.1111/jgs.15767

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier. https://evolve.elsevier.com/cs/product/9780323554954

Shojaei, A., & Salari, P. (2020). COVID-19 and off-label use of drugs: an ethical viewpoint. DARU Journal of Pharmaceutical Sciences, 28, 789-793. https://www.mdpi.com/1383694

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NURS 6521 WEEK 1: AT A GLANCE BASIC PHARMACOTHERAPEUTIC CONCEPTS/ETHICAL AND LEGAL ASPECTS OF PRESCRIBING

INTRODUCTION

How do beta-blockers work? What exactly do antibiotics do to the bacteria they target? What effects does an anti-depressant have on blood flow?

Questions like these are related to the underlying pharmacokinetic and pharmacodynamic processes of pharmacotherapeutics. As an advanced practice nurse, understanding these fundamental pharmacotherapeutic concepts is important to ensure that the prescription drugs you recommend for your patients will be safe and effective to treat and/or manage their symptoms. Additionally, as the advanced practice nurse, it is your responsibility to ensure that when prescribing prescription drugs, you adhere to the ethical and legal principles set forth for prescribing drugs as an added layer of protection and safety for the patients you will treat.

This week, you will analyze factors that may influence pharmacokinetic and pharmacodynamics processes of a patient and assess the details of a personalized plan of care that you develop based on influencing factors and patient history. You will also evaluate and analyze ethical and legal implications and practices related to prescribing drugs, including disclosure and nondisclosure, and analyze the process of writing prescriptions to avoid medication errors.

LEARNING OBJECTIVES

Students will:

• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients
• Assess patient factors and history to develop personalized plans of care
• Evaluate ethical and legal implications related to prescribing drugs
• Analyze ethical and legal practices of prescribing drugs
• Analyze strategies to address disclosure and nondisclosure
• Justify advanced practice nurse strategies to guide prescription drug decision-making
• Analyze the process of writing prescriptions to avoid medication errors

LEARNING RESOURCES

Required Readings

• Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants(2nd ed.) St. Louis, MO: Elsevier.
  • Chapter 1, “Prescriptive Authority” (pp. 1–3)
  • Chapter 2, “Rational Drug Selection and Prescription Writing” (pp. 4–7)
  • Chapter 3, “Promoting Positive Outcomes of Drug Therapy” (pp. 8–12)
  • Chapter 4, “Pharmacokinetics, Pharmacodynamics, and Drug Interactions” (pp. 13–33)
  • Chapter 5, “Adverse Drug Reactions and Medication Errors” (pp. 34–42)
  • Chapter 6, “Individual Variation in Drug Response” (pp. 43–45)
• American Geriatrics Society 2019 Beers Criteria Update Expert Panel. (2019). American Geriatrics Society 2019 updated AGS Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics SocietyDownload Journal of the American Geriatrics Society, 67(4), 674–694. doi:10.1111/jgs.15767

American Geriatrics Society 2019 updated AGS Beers criteria for potentially inappropriate medication use in older adults by American Geriatrics Society, in Journal of the American Geriatrics Society, Vol. 67/Issue 4. Copyright 2019 by Blackwell Publishing. Reprinted by permission of Blackwell Publishing via the Copyright Clearance Center.

This article is an update to the Beers Criteria, which includes lists of potentially inappropriate medications to be avoided in older adults as well as newly added criteria that lists select drugs that should be avoided or have their dose adjusted based on the individual’s kidney function and select drug-drug interactions documented to be associated with harms in older adults.

• Drug Enforcement Administration. (2021). CFR – Code of Federal Regulations Title 21. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFRPart=1300

This website outlines the code of federal regulations for prescription drugs.

• Drug Enforcement Administration. (n.d.). Mid-level practitioners authorization by state. Retrieved May 13, 2019 from http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html

This website outlines the schedules for controlled substances, including prescriptive authority for each schedule.

• Institute for Safe Medication Practices. (2017). List of error-prone abbreviations, symbols, and dose designations. Retrieved from https://www.ismp.org/recommendations/error-prone-abbreviations-list

This website provides a list of prescription-writing abbreviations that might lead to misinterpretation, as well as suggestions for preventing resulting errors.

• Sabatino, J. A., Pruchnicki, M. C., Sevin, A. M., Barker, E., Green, C. G., & Porter, K. (2017). Improving prescribing practices: A pharmacist?led educational intervention for nurse practitioner students. Journal of the American Association of Nurse Practitioners, 29(5), 248–254. https://doi:10.1002/2327-6924.12446

The authors of this article assess the impact of a pharmacist?led educational intervention on family nurse practitioner (FNP) students’ prescribing skills, perception of preparedness to prescribe, and perception of pharmacist as collaborator.

Required Media

Introduction to Advanced Pharmacology

• Meet Dr. Terry Buttaro, associate professor of practice at Simmons College of Nursing and Health Sciences as she discusses the importance of pharmacology for the advanced practice nurse.

Time Estimate: 8 minutes

• Speed Pharmacology. (2016). Pharmacology – Adrenergic receptors & agonists.(MADE EASY) [Video]. https://www.youtube.com/watch?v=KtmV-yMDYPI&t=372s

Note: This media program is approximately 18 minutes.

• Speed Pharmacology. (2017). Drugs for Hyperlipidemia (Made Easy)Links to an external site.[Video]. https://www.youtube.com/watch?v=Of1Aewx-zRM&t=24s

Note: This media program is approximately 14 minutes.

NURS 6521 Week 1 Discussion

To prepare:

• Review the Resources for this module and consider the principles of pharmacokinetics and pharmacodynamics.
• Reflect on your experiences, observations, and/or clinical practices from the last 5 years and think about how pharmacokinetic and pharmacodynamic factors altered his or her anticipated response to a drug.
• Consider factors that might have influenced the patient’s pharmacokinetic and pharmacodynamic processes, such as genetics (including pharmacogenetics), gender, ethnicity, age, behavior, and/or possible pathophysiological changes due to disease.
• Think about a personalized plan of care based on these influencing factors and patient history in your case study.

BY DAY 3 OF WEEK 1

Post a description of the patient case from your experiences, observations, and/or clinical practice from the last 5 years. Then, describe factors that might have influenced pharmacokinetic and pharmacodynamic processes of the patient you identified. Finally, explain details of the personalized plan of care that you would develop based on influencing factors and patient history in your case. Be specific and provide examples.

Week 1 Discussion Sample

While working at a medical ward in my 4th year of practice, I encountered a 72-year-old male named Mr. Smith. The patient had been in the ward for over a month and presented with hypertension and chronic kidney disease. His blood pressure was through the roof as he had a history of non-compliance with medication regimens and a significant genetic predisposition to drug metabolism variations. The patient has been on antihypertensives but has no detectable elevated blood pressure changes.

Factors That May Have Influenced Mr. Smith’s Pharmacokinetic and Pharmacodynamic Responses

1. Genetics and Pharmacogenetics: Mr. Smith may have had changed drug metabolism and clearance rates due to genetic differences in drug-metabolizing enzymes, such as cytochrome P450 enzymes. Higher medication concentrations and a higher likelihood of negative consequences may follow (Rosenthal & Burchum, 2021).
2. Age: Given Mr. Smith’s age of 65, changes in drug absorption, distribution, metabolism, and excretion due to aging may take place. For instance, decreased renal function in CKD may impact medication clearance, potentially causing drug buildup and protracted effects.
3. Pathophysiological Changes: Mr. Smith’s chronic kidney disease may have changed his pharmacokinetic characteristics, particularly for medications whose main route of elimination are the kidneys. Medication clearance may be lowered, and medication exposure may rise due to impaired renal function (American Geriatrics Society, 2019).
4. Non-Compliance: The effectiveness of Mr. Smith’s prescription antihypertensive medicine may have been harmed by his prior history of non-compliance with medication regimens. Drug levels in the body can fluctuate due to inconsistent drug use, which can lessen the intended therapeutic effects.

Individualized Plan of Care:

Mr. Smith could have the individualized plan of care listed below based on the patient’s medical history and contributing factors:

1. Pharmacogenetic testing should be carried out to find particular genetic variants that could affect medication metabolism. The likelihood of adverse drug reactions can be decreased by using this information to help with dosage modifications and medication selection.
2. Individualized Dosing: Change the antihypertensive drug dosage based on Mr. Smith’s renal function and pharmacokinetic data. Regular medication level monitoring and renal function testing are essential for appropriate dosing.
3. Patient Education and Counseling: Stress to Mr. Smith the value of drug compliance. Inform him of the dangers of disobeying instructions and the advantages of constantly following his prescribed drugs (Rosenthal & Burchum, 2021).
4. Use a multidisciplinary approach to manage Mr. Smith’s chronic kidney illness and monitor his renal function. The effectiveness of the treatment should be checked frequently, and the prescription schedule should be changed as necessary.

References

American Geriatrics Society (2019). Beers Criteria Update Expert Panel. (2019). American Geriatrics Society 2019 updated AGS Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society Download Journal of the American Geriatrics Society, 67(4), 674–694. https://doi.org/10.1111/jgs.15767

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier. https://evolve.elsevier.com/cs/product/9780323554954

NURS 6521 Week 1 Assignment 2 ETHICAL AND LEGAL IMPLICATIONS OF PRESCRIBING DRUGS

What type of drug should you prescribe based on your patient’s diagnosis? How much of the drug should the patient receive? How often should the drug be administered? When should the drug not be prescribed? Are there individual patient factors that could create complications when taking the drug? Should you be prescribing drugs to this patient? How might different state regulations affect the prescribing of this drug to this patient?

These are some of the questions you might consider when selecting a treatment plan for a patient.

As an advanced practice nurse prescribing drugs, you are held accountable for people’s lives every day. Patients and their families will often place trust in you because of your position. With this trust comes power and responsibility, as well as an ethical and legal obligation to “do no harm.” It is important that you are aware of current professional, legal, and ethical standards for advanced practice nurses with prescriptive authority.

Additionally, it is important to ensure that the treatment plans and administration/prescribing of drugs is in accordance with the regulations of the state in which you practice. Understanding how these regulations may affect the prescribing of certain drugs in different states may have a significant impact on your patient’s treatment plan. In this Assignment, you explore ethical and legal implications of scenarios and consider how to appropriately respond.

Please use the following scenario for this assignment:

• AC is a 72-year-old male who is admitted to your ICU after suffering a massive stroke that has left him unresponsive and unable to communicate.  He is currently on a ventilator.  His wife of 48 years is available along with their one adult daughter.  The wife informs you that they don’t have any advanced directives, but she is “pretty sure her husband would not want to live like this.”  However, their daughter is adamant her dad would want to be kept alive in case there is any chance to come out of this.

Talk to you all soon!

To Prepare:

• Review the Resources for this module and consider the legal and ethical implications of prescribing prescription drugs, disclosure, and nondisclosure.
• Review the scenario assigned by your Instructor for this Assignment.
• Search specific laws and standards for prescribing prescription drugs and for addressing medication errors for your state or region, and reflect on these as you review the scenario assigned by your Instructor.
• Consider the ethical and legal implications of the scenario for all stakeholders involved, such as the prescriber, pharmacist, patient, and patient’s family.
• Think about two strategies that you, as an advanced practice nurse, would use to guide your ethically and legally responsible decision-making in this scenario, including whether you would disclose any medication errors.

BY DAY 7 OF WEEK 1

Write a 2- to 3-page paper that addresses the following:

• Explain the ethical and legal implications of the scenario you selected on all stakeholders involved, such as the prescriber, pharmacist, patient, and patient’s family.
• Describe strategies to address disclosure and nondisclosure as identified in the scenario you selected. Be sure to reference laws specific to your state.
• Explain two strategies that you, as an advanced practice nurse, would use to guide your decision making in this scenario, including whether you would disclose your error. Be sure to justify your explanation.
• Explain the process of writing prescriptions, including strategies to minimize medication errors.

Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The College of Nursing Writing Template with Instructions provided at the Walden Writing Center offers an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632.). All papers submitted must use this formatting.

Rubric – NURS_6521_Week1_Assignment_Rubric

NURS_6521_Week1_Assignment_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeExplain the ethical and legal implications of the scenario you selected on all stakeholders involved such as the prescriber, pharmacist, patient, and the patient’s family.

25 to >22.25 pts

Excellent

The response accurately and thoroughly explains in detail the ethical and legal implications of the scenario selected on all stakeholders involved. … The response includes accurate, clear, and detailed explanations as to how these implications affect the prescriber, pharmacist, patient, and the patient’s family.

22.25 to >19.75 pts

Good

The response explains the ethical and legal implications of the scenario selected on all stakeholders involved. … The response includes accurate explanations as to how these implications affect the prescriber, pharmacist, patient, and the patient’s family.

19.75 to >17.25 pts

Fair

The response inaccurately or vaguely explains the ethical and legal implications of the scenario selected for all stakeholders involved. … The response includes vague explanations as to how these implications affect the prescriber, pharmacist, patient, and the patient’s family.

17.25 to >0 pts

Poor

The response vaguely and inaccurately explains the ethical and legal implications of the scenario selected for all stakeholders involved, or the response is missing. … The response vaguely and inaccurately explains how these implications affect the prescriber, pharmacist, patient, and the patient’s family, or is missing.

25 pts

This criterion is linked to a Learning OutcomeDescribe strategies to address disclosure and nondisclosure as identified in the scenario selected. Be sure to reference laws specific to your state.

20 to >17.8 pts

Excellent

An accurate, detailed, and clear description of strategies to address disclosure and nondisclosure as identified in the scenario selected is provided. … The response includes specific, detailed, and accurate reference to state laws related to the scenario.

17.8 to >15.8 pts

Good

An accurate description of strategies to address disclosure and nondisclosure as identified in the scenario selected is provided. … The response includes accurate reference to state laws related to the scenario.

15.8 to >13.8 pts

Fair

A vague or inaccurate description of strategies to address disclosure and nondisclosure as identified in the scenario selected is provided. … The response includes inaccurate or vague reference to state laws related to the scenario.

13.8 to >0 pts

Poor

A vague and inaccurate description of strategies to address disclosure and nondisclosure as identified in the scenario selected is provided, or is missing. … The response includes vague and inaccurate reference to state laws related to the scenario, or is missing.

20 pts

This criterion is linked to a Learning OutcomeExplain two strategies that you, as an advanced practice nurse would use to guide your decision making in this scenario, including whether you would disclose your error. Be sure to justify your explanation.

20 to >17.8 pts

Excellent

The response accurately and thoroughly explains in detail at least two strategies that an advanced practice nurse would use to guide decision making in the scenario. … The response accurately and completely explains whether they would disclose the error, including an accurate, detailed, and clear justification for the explanation provided.

17.8 to >15.8 pts

Good

The response accurately explains at least two strategies that an advanced practice nurse would use to guide decision making in the scenario. … The response accurately explains whether they would disclose the error, including an accurate justification for the explanation provided.

15.8 to >13.8 pts

Fair

The response inaccurately or vaguely explains at least two strategies that an advanced practice nurse would use to guide decision making in the scenario, or only explains one strategy. … The response inaccurately or vaguely explains whether they would disclose the error, including a justification that is vague, inaccurate, or misaligned to the explanation provided.

13.8 to >0 pts

Poor

The response inaccurately and vaguely explains only one strategy that an advanced practice nurse would use to guide decision making in the scenario, or is missing. … The response inaccurately and vaguely explains whether they would disclose the error, with no justification provided, or is missing.

20 pts

This criterion is linked to a Learning OutcomeExplain the process of writing prescriptions including strategies to minimize medication errors.

20 to >17.8 pts

Excellent

The response provides an accurate, detailed, and thorough explanation of the process of writing prescriptions, including detailed strategies to minimize medication errors.

17.8 to >15.8 pts

Good

The response provides an accurate explanation of the process of writing prescriptions, including some strategies to minimize medication errors.

15.8 to >13.8 pts

Fair

The response provides an inaccurate or vague explanation of the process of writing prescriptions, including inaccurate or vague strategies to minimize medication errors.

13.8 to >0 pts

Poor

The response provides an inaccurate and vague explanation of the process of writing prescriptions, including inaccurate and vague strategies to minimize medication errors, or is missing.

20 pts

This criterion

Solution: