Diets of reef-dwelling labrids (Choerodon species) vary with body size, season and habitat: influence of foraging ability, specialization and opportunism.

Contemporary multivariate statistics were used to test the hypotheses that the dietary compositions of three populations of labrids on the west Australian coast are related to body size and undergo seasonal changes and to elucidate the relative extents and basis for any dietary differences within and between those populations. Gut content analyses determined the dietary compositions of Choerodon rubescens in marine waters of the outer reefs in the World Heritage Area of Shark Bay (26° S; 114° E) and of Choerodon schoenleinii in inner protected reefs of that large embayment. The dietary compositions of C. rubescens and C. schoenleinii differed significantly among length classes, progressed serially with increasing body size, both overall and almost invariably in each season and were more closely related to body size than season, whose effect was at best minimal. The size-related dietary change in C. rubescens involved, in particular, a shift from crustaceans and non-mytilid bivalves to mytilid bivalves and echinoid echinoderms. Although the diet of C. schoenleinii followed similar size-related changes, it contained a greater volume of gastropods when the fish were small and mytilids when large and only a small volume of echinoids. The dietary composition of C. rubescens in the Abrolhos Islands, 300 km to the south of Shark Bay, was related both to length class and season and differed from that of this labrid in Shark Bay with the ingestion of lesser volumes of mytilids and greater volumes of echinoids. The size-related changes in diet imply that these species shift from foraging over soft substrata to over reefs as their very well-developed jaws become sufficiently strong to remove attached and larger prey. The dietary compositions of C. rubescens and C. schoenleinii in Shark Bay and of C. rubescens at the Abrolhos Islands were related far more to habitat-locational differences than to length class and season. The above intraspecific and interspecific differences in diet are consistent with qualitative accounts of the relative abundances of the main prey in their respective environments, supporting the view that, despite specializations in their feeding apparatus, these labrids can feed opportunistically to a certain extent and could thus potentially respond to moderate changes in the composition of their prey caused by climate change and other anthropogenic effects.

Reliability and validity of the instrument for scoring clinical outcomes of research for epidermolysis bullosa (iscorEB).

BACKGROUND: Epidermolysis bullosa (EB) is a group of rare and currently incurable genetic blistering disorders. As more pathogenic-driven therapies are being developed, there is an important need for EB-specific validated outcomes measures designed for use in clinical trials. OBJECTIVES: To test the reliability and construct validity of an instrument for scoring clinical outcomes of research for EB (iscorEB), a new combined clinician- and patient-reported outcomes tool. METHODS: We conducted an observational study consisting of independent 1-day assessments (six assessors) at two academic hospitals. The assessments consisted of iscorEB clinician (iscorEB-c), Birmingham Epidermolysis Bullosa Severity (BEBS) and global severity assessment for physicians; and iscorEB patient (iscorEB-p), Quality of Life evaluation in Epidermolysis Bullosa and Children's Dermatology Life Quality Index for patients. Construct validity and intraclass correlation coefficients (ICCs) for interobserver, intraobserver and test-retest reliability were calculated. RESULTS: Overall, 31 patients with a mean age of 19·5 years (1·8-45·2) were included. Disease severity was mild in 42% of cases, moderate in 29% and severe in 29%. The interobserver ICC was 0·96 for both the clinician-reported section of iscorEB-c and BEBS. The ICC for intraobserver reliability was 0·91 and 0·70 for the skin and mucosal domains of iscorEB-c, respectively. Cronbach's alpha for iscorEB-c was 0·89. The test-retest reliability of iscorEB-p was 0·97 and Cronbach's alpha was 0·84. The clinical score differentiated between subjects with mild, moderate and severe disease, and both clinical and patient subscores discriminated between recessive dystrophic EB and other EB subtypes. CONCLUSIONS: iscorEB has robust reliability and construct validity, including strong ability to distinguish EB types and severities. Further studies are planned to test its responsiveness to change.

Real-time PCR validation of visually identified snapper Chrysophrys auratus (Sparidae) eggs.

In this study, a total of 212 eggs were visually identified as snapper Chrysophrys auratus. Real-time PCR confirmed visual identification in 69% of cases but corroboration varied widely among plankton samples. The use of molecular tools to support visual identification prior to adopting daily egg production stock assessment methods should be considered.

Breathing life into fisheries stock assessments with citizen science.

Citizen science offers a potentially cost-effective way for researchers to obtain large data sets over large spatial scales. However, it is not used widely to support biological data collection for fisheries stock assessments. Overfishing of demersal fishes along 1,000 km of the west Australian coast led to restrictive management to recover stocks. This diminished opportunities for scientists to cost-effectively monitor stock recovery via fishery-dependent sampling, particularly of the recreational fishing sector. As fishery-independent methods would be too expensive and logistically-challenging to implement, a citizen science program, Send us your skeletons (SUYS), was developed. SUYS asks recreational fishers to voluntarily donate fish skeletons of important species from their catch to allow biological data extraction by scientists to produce age structures and conduct stock assessment analyses. During SUYS, recreational fisher involvement, sample sizes and spatial and temporal coverage of samples have dramatically increased, while the collection cost per skeleton has declined substantially. SUYS is ensuring sampling objectives for stock assessments are achieved via fishery-dependent collection and reliable and timely scientific advice can be provided to managers. The program is also encouraging public ownership through involvement in the monitoring process, which can lead to greater acceptance of management decisions.

Do the maximum sizes, ages and patterns of growth of three reef-dwelling labrid species at two latitudes differ in a manner conforming to the metabolic theory of ecology?

The size and age data and patterns of growth of three abundant, reef-dwelling and protogynous labrid species (Coris auricularis, Notolabrus parilus and Ophthalmolepis lineolata) in waters off Perth at c. 32° S and in the warmer waters of the Jurien Bay Marine Park (JBMP) at c. 30° S on the lower west coast of Australia are compared. Using data for the top 10% of values and a randomization procedure, the maximum total length (L(T) ) and mass of each species and the maximum age of the first two species were estimated to be significantly greater off Perth than in the JBMP (all P < 0.001) and the maximum ages of O. lineolata in the two localities did not differ significantly (P > 0.05). These latitudinal trends, thus, typically conform to those frequently exhibited by fish species and the predictions of the metabolic theory of ecology (MTE). While, in terms of mass, the instantaneous growth rates of each species were similar at both latitudes during early life, they were greater at the higher latitude throughout the remainder and thus much of life, which is broadly consistent with the MTE. When expressed in terms of L(T), however, instantaneous growth rates did not exhibit consistent latitudinal trends across all three species. The above trends with mass, together with those for reproductive variables, demonstrate that a greater amount of energy is directed into somatic growth and gonadal development by each of these species at the higher latitude. The consistency of the direction of the latitudinal trends for maximum body size and age and pattern of growth across all three species implies that each species is responding in a similar manner to differences between the environmental characteristics, such as temperature, at those two latitudes. The individual maximum L(T), mass and age and pattern of growth of O. lineolata at a higher and thus cooler latitude on the eastern Australian coast are consistent with the latitudinal trends exhibited by those characteristics for this species in the two western Australian localities. The implications of using mass rather than length as the indicator variable when comparing the maximum sizes of the three species and the trends exhibited by the instantaneous growth rates of those species at different latitudes are explored. Although growth curves fitted to both the L(T) and masses at age for the males of each species lay above those for their females, this would not have influenced the conclusions drawn from common curves for both sexes.

Implications of the divergent use of a suite of estuaries by two exploited marine fish species.

Biological characteristics of the marine species King George whiting Sillaginodes punctatus and Australian herring Arripis georgianus in three seasonally open estuaries (Broke, Irwin and Wilson Inlets), one permanently open estuary (Oyster Harbour) and one normally closed estuary (Wellstead Estuary) on the south coast of Western Australia have been determined and compared. Sillaginodes punctatus enters the seasonally and permanently open estuaries early in life and reaches total lengths (L(T)) >280 mm at which it can be legally retained and thus contributes to commercial and recreational fisheries in these systems. This sillaginid almost invariably emigrates from these estuaries before reaching its typical size at maturity (L(T50)) and does not return after spawning in marine waters. In contrast, virtually all female A. georgianus (≥ 98%) in the three seasonally open estuaries and the majority in the normally closed (89·5%) and permanently open estuaries (83%) exceeded the L(T50) of this species at maturity, reflecting the fact that the nursery areas of this species are predominantly located much further to the east. Although adult females of A. georgianus in seasonally open and normally closed estuaries had developed mature ovaries by autumn, at which time they were prevented from migrating to the sea by closure of the estuary mouths, this species did not spawn in those estuaries. The oocytes in their ovaries were undergoing extensive atresia, a process that had been incipient prior to oocyte maturation. As the adult females of A. georgianus in the permanently open Oyster Harbour at this time all possessed resting gonads, i.e. their oocytes were all previtellogenic, the adults that were present in that estuary earlier and were destined to spawn in autumn must have emigrated from that permanently open estuary to their marine spawning areas prior to the onset of gonadal recrudescence. The body masses at length of A. georgianus, which were almost invariably higher in summer and autumn than in winter and spring, were greater in the very productive environments of the seasonally open and normally closed estuaries than in the less productive and essentially marine environment of Oyster Harbour and coastal marine waters. In general, the same pattern of differences between water bodies was exhibited by the growth of A. georgianus and by the more restricted data for body mass at L(T) and growth of S. punctatus. Despite an increase in anthropogenic activities in Wilson Inlet over the last two decades, the growth of both species was very similar to that recorded 20 years earlier. The fisheries implications of the results for the two species are discussed.

To what extent are the dietary compositions of three abundant, co-occurring labrid species different and related to latitude, habitat, body size and season?

This study demonstrated that the dietary composition of each of three abundant reef-associated labrid species in temperate Western Australia differed significantly with latitude and changed with increasing body size and almost invariably differed among those species when they co-occurred. These results were derived from comparisons and multivariate analyses of volumetric dietary data, obtained from the foregut contents of Coris auricularis, Notolabrus parilus and Ophthalmolepis lineolatus from the Jurien Bay Marine Park (JBMP) and waters off Perth, 250 km to the south. Latitudinal differences in the dietary compositions of each species in exposed reefs typically reflected greater contributions by large crustaceans, bivalve molluscs, echinoids and annelids to the diets in the waters off Perth than in the JBMP, whereas the reverse was true for gastropods and small crustaceans. The diet of each species exhibited similar, but not identical, quantitative changes with increasing body size, with the contributions of small crustaceans declining and those of large crustaceans and echinoids increasing, while that of gastropods underwent little change. Within the JBMP, the dietary compositions of both C. auricularis and N. parilus were similar in exposed and sheltered reefs and the same was true for N. parilus in the sheltered reefs and interspersed areas of seagrass. The latter similarity demonstrated that, in both of those divergent habitat types, N. parilus feeds on prey associated with either the sand or the macrophytes that cover and lie between the reefs. Although the main dietary components of each species were the same, i.e. gastropods, small crustaceans (mainly amphipods and isopods), large crustaceans (particularly penaeids and brachyuran crabs) and echinoids, their contributions varied among those species, which accounts for the significant interspecific differences in diet. Coris auricularis had the most distinct diet, due mainly to an ingestion of greater volumes of small crustaceans, e.g. amphipods and isopods, and lesser volumes of large crustaceans, e.g. brachyuran crabs, which was associated with a relatively narrower mouth and smaller teeth and the absence of prominent canines at the rear of the jaw. The above intra and interspecific differences in dietary composition would reduce, on the south-west coast of Australia, the potential for competition for food among and within these three abundant labrids, each of which belongs to different genera within the Julidine clade.

The functional assessment of cancer therapy-BRM (FACT-BRM): a new tool for the assessment of quality of life in patients treated with biologic response modifiers.

PURPOSE: This paper reports on the development and validation of two biologic response modifier (BRM) subscales for use with the Functional Assessment of Cancer Therapy-General (FACT-G) quality of life (QOL) questionnaire. METHODS: Using the FACT-G as a base, 17 additional questions related to symptoms common to interferon and retinoid therapy were developed. Data collected at baseline (n = 191) and week 2 (n = 168) in a randomized trial of interferon +/- 13-cis-retinoic acid in advanced renal cell carcinoma patients were used to validate this measure. RESULTS: Using a combined empirical and conceptual approach, the 17 questions were reduced to 13 questions consisting of two subscales: 'BRM-physical' (7 items; baseline coefficient alpha(alpha) = 0.70; week-2 alpha = 0.75) and 'BRM-mental' (6 items; baseline alpha = 0.79; week-2 alpha = 0.78). Internal consistency of the trial outcome index (TOI) combining physical well-being, functional well-being and the BRM subscales, was 0.91 for baseline assessments and 0.92 for week 2. Discriminant validity was demonstrated for the TOI by its ability to differentiate among prognostic risk groups, and for the total FACT-G, TOI and total FACT-BRM scores by their ability to distinguish between groups differing in performance, response and toxicity status. CONCLUSIONS: The 'BRM-physical' and 'BRM-mental' subscales can be combined with the FACT-G to form the 'FACT BRM' scale, useful for measuring QOL in cancer patients who are receiving treatment with biologic response modifiers.

Evaluation of quality of life in a clinical trial with nonrandom dropout: the effect of epoetin alfa in anemic cancer patients.

Quality of life (QOL) endpoints from a randomized, placebo-controlled trial of anemic cancer patients treated with nonplatinum-containing chemotherapy who received epoetin alfa or placebo were subjected to a sensitivity analysis. Three QOL instruments were used: the Functional Assessment of Cancer Therapy-Anemia (FACT-An), the Cancer Linear Analog Scale (CLAS), and the Medical Outcomes Study Short Form-36 (SF-36). The seven primary endpoints chosen a priori for analysis were: the Functional Assessment of Cancer Therapy-General (FACT-G) Total, FACT-An fatigue subscale, CLAS energy, CLAS daily activities, CLAS overall QOL, and the SF-36 physical and mental component summary scales. Lower QOL scores were reported for patients who discontinued early, suggesting a nonrandom dropout process. Significant correlations (ranging from 0.37 to 0.77) between individual rates of change and the time to early termination of therapy or death supported this conclusion. Estimates of within-treatment-arm QOL change over time are more conservative with the missing not at random (MNAR) assumption as compared with the more optimistic estimates with the assumption that missing QOL data are missing at random (MAR). However, the between-treatment-arm comparisons were consistent across analyses, demonstrating statistically significant differences in favor of the epoetin alfa arm for four of the seven outcome measures.

A randomized trial of a brief intervention to increase fruit and vegetable intake: a replication study among callers to the CIS.

BACKGROUND: Results are reported from a large randomized trial designed to increase fruit and vegetable consumption among callers to the National Cancer Institute's Cancer Information Service (CIS) (n = 1,717). METHODS: CIS callers assigned to the intervention group (n = 861) received a brief proactive educational intervention over the telephone at the end of usual service, with two follow-up mailouts. Key educational messages and print material derived from the NCI 5 A Day for Better Health program were provided to intervention participants. Participants were interviewed by telephone at 4 weeks (n = 1,307), 4 months (n = 1,180), and 12 months for follow-up (n = 1,016). RESULTS: Results obtained from a single-item measure of fruit and vegetable consumption indicate a significant intervention effect of 0.88 servings per day at 4 weeks follow-up (P < 0.001), 0.63 servings per day at 4 months follow-up (P < 0.001), and 0.43 servings per day at 12 months follow-up (P < 0.001). Using a 7-item food frequency measure, an intervention effect of 0.63 servings per day was obtained at 4 weeks follow-up (P < 0.001), compared with 0.39 servings per day at 4 months follow-up (P = 0.002) and 0.44 servings per day at 12 months follow-up (P = 0.002). A 24-h recall assessment included in the 4-month interviews also yielded a significant intervention effect of 0.67 servings per day (P = 0.015). The vast majority of callers (90%) endorsed the strategy of providing 5 A Day information proactively within the CIS. CONCLUSIONS: This brief educational intervention was associated with higher levels of self-reported fruit and vegetable intake at both short- and long-term follow-up. Additional research is recommended to test this or a similar intervention in diverse populations.

Understanding the experience of pain in terminally ill patients.

BACKGROUND: Terminally ill patients commonly experience substantial pain. Unresolved pain has been cited as evidence that end-of-life care is of poor quality. However, the data on which that conclusion is based are limited. We aimed to provide additional data on the experience of pain in such patients. METHODS: We interviewed 988 terminally ill patients from six randomly selected US sites. We asked them who had treated their pain in the previous 4 weeks (primary-care physician, pain specialist, or both), and whether they wanted more pain medication than they were receiving, or why they did not want more. FINDINGS: 496 (50%) terminally ill patients reported moderate or severe pain. 514 (52%) individuals had seen a primary-care physician for treatment of pain in the previous 4 weeks and 198 (20%) saw a pain specialist. Of those who had been treated by their primary-care physician, 287 (29%) wanted more therapy, 613 (62%) wanted their pain therapy to remain the same, and 89 (9%) wanted to reduce or stop their pain therapy. Several reasons for not wanting additional therapy were offered-fear of addiction, dislike of mental or physical side-effects, and not wanting to take more pills or injections. We saw no association between disease and amount of pain between disease and the desire for more treatment. Black patients were more likely to seek additional pain therapy, see a pain specialist, and refuse additional medication because of fear of addiction than other populations. INTERPRETATION: Although half of terminally ill patients experienced moderate to severe pain, only 30% of them wanted additional pain treatment from their primary-care physician. The number of patients experiencing pain remains too high. However, the number is not as large as perceived. Additionally, most are willing to tolerate pain. Furthermore, the experience of pain is constant across major terminal diseases.

Discrepancies between patient and physician estimates for the success of stem cell transplantation.

CONTEXT: Stem cell transplantation is associated with considerable morbidity and mortality. The extent to which patients and their physicians correctly estimate these risks is unknown. OBJECTIVE: To measure the expectations of patients and physicians prior to stem cell transplantation and correlate them with actual outcomes after transplantation. DESIGN: Prospective cohort study with baseline questionnaire administered July 1996 through November 1999 and follow-up to May 2000. SETTING: Tertiary care transplant center in the United States. PARTICIPANTS: Of 458 surveys mailed, evaluable returned surveys were included for 313 autologous and allogeneic stem cell transplantation patients and their physicians. MAIN OUTCOME MEASURES: Patient and physician expectations prior to transplantation (measured on 6-point Likert scales) of treatment-related mortality, cure with transplantation, and cure without transplantation; actual treatment-related mortality and disease-free survival among patients with at least 1 year of follow-up after transplantation (n = 263). RESULTS: Both patients and physicians were fairly accurate in estimating treatment-related mortality when actual mortality was less than 30%. However, in situations in which mortality was higher than 30%, such as with allogeneic transplantation for intermediate or advanced disease, physician expectations were lower, while patients remained optimistic. Similarly, physicians provided lower estimates of disease-free survival in cases of intermediate or advanced disease while patient expectations remained high and constant regardless of disease stage. CONCLUSIONS: Patients and their physicians have the most concordant and accurate expectations when the outcome of stem cell transplantation is likely to be favorable. However, patients with more advanced disease fail to recognize the higher risks associated with their situations.

Attitudes and practices among pediatric oncologists regarding end-of-life care: results of the 1998 American Society of Clinical Oncology survey.

PURPOSE: In 1998, the American Society of Clinical Oncology (ASCO) surveyed its membership to assess the attitudes, practices, and challenges associated with end-of-life care of patients with cancer. In this report, we summarize the responses of pediatric oncologists and the implications for care of children dying from cancer. METHODS: The survey consisted of 118 questions, covering eight categories. All ASCO members in the United States, Canada, and the United Kingdom were mailed a survey, which was completed by 228 pediatric oncologists. Predictors of particular attitudes and practices were identified using stepwise logistic regression analysis. Potential predictors were age, sex, religious affiliation, importance of religious beliefs, recent death of a relative, specialty, type of practice (rural or urban, academic or nonacademic), amount of time spent in patient care, number of new patients in the past 6 months, and number of patients who died in the past year. RESULTS: Pediatric oncologists reported a lack of formal courses in pediatric palliative care, a strikingly high reliance on trial and error in learning to care for dying children, and a need for strong role models in this area. The lack of an accessible palliative care team or pain service was often identified as a barrier to good care. Communication difficulties exist between parents and oncologists, especially regarding the shift to end-of-life care and adequate pain control. CONCLUSION: Pediatric oncologists are working to integrate symptom control, psychosocial support, and palliative care into the routine care of the seriously ill child, although barriers exist that make such comprehensive care a challenge.

Recovery after stem-cell transplantation for hematologic diseases.

PURPOSE: Although the number of autologous and allogeneic stem-cell transplantations (SCT) is increasing, relatively little information about recovery after transplantation is available. Quantitative information appropriate for patient counseling is difficult to discern from the literature. We sought to suggest reasonable expectations for recovery and symptoms after SCT for hematologic malignancies and other disorders using the following measures: (1) objective measures of health status, such as frequency of clinic visits, need for rehospitalization, medication usage, work status, and overall and event-free survival; (2) qualitative assessment of quality of life, such as returning to a normal life, resumption of normal activities, satisfaction with appearance, and whether recovery has occurred; and (3) quantification of specific bothersome symptoms. PATIENTS AND METHODS: Autologous and allogeneic SCT recipients at a tertiary-care transplant center participated in the prospective, longitudinal questionnaire study. RESULTS: Three hundred twenty patients were studied. Questionnaire response rates at 6, 12, and 24 months range from 85% to 88% among survivors. Although autologous patients had better event-free and overall survival, fewer symptoms, and more complete recovery at 6 months, these advantages had largely equalized by 12 months. Specific bothersome symptoms were reported by less than 24% of patients after transplantation, except for fatigue and financial and sexual difficulties, which were more prevalent. CONCLUSION: These findings may help counsel patients considering transplantation and educate them about reasonable expectations for recovery. Overall, the low level of bothersome symptoms and continued recovery through the first year after transplantation are encouraging.

Attitudes and desires related to euthanasia and physician-assisted suicide among terminally ill patients and their caregivers.

CONTEXT: Euthanasia and physician-assisted suicide (PAS) are highly controversial issues. While there are studies of seriously ill patients' interest in euthanasia and PAS, there are no data on the attitudes and desires of terminally ill patients regarding these issues. OBJECTIVE: To determine the attitudes of terminally ill patients toward euthanasia and PAS, whether they seriously were considering euthanasia and PAS for themselves, the stability of their desires, factors associated with their desires, and the proportion of patients who die from these interventions. DESIGN: Prospective cohort of terminally ill patients and their primary caregivers surveyed twice between March 1996 and July 1997. SETTING: Outpatient settings in 5 randomly selected metropolitan statistical areas and 1 rural county. PARTICIPANTS: A total of 988 patients identified by their physicians to be terminally ill with any disease except for human immunodeficiency virus infection (response rate, 87. 4%) and 893 patient-designated primary caregivers (response rate, 97. 6%). MAIN OUTCOME MEASURES: Support for euthanasia or PAS in standard scenarios; patient-expressed considerations and discussions of their desire for euthanasia or PAS; hoarding of drugs for suicide; patient death by euthanasia or PAS; and patient-reported sociodemographic factors and symptoms related to these outcomes. RESULTS: Of the 988 terminally ill patients, a total of 60.2% supported euthanasia or PAS in a hypothetical situation, but only 10. 6% reported seriously considering euthanasia or PAS for themselves. Factors associated with being less likely to consider euthanasia or PAS were feeling appreciated (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.52-0.82), being aged 65 years or older (OR, 0.52; 95% CI, 0.34-0.82), and being African American (OR, 0.39; 95% CI, 0. 18-0.84). Factors associated with being more likely to consider euthanasia or PAS were depressive symptoms (OR, 1.25; 95% CI, 1.05-1. 49), substantial caregiving needs (OR, 1.09; 95% CI, 1.01-1.17), and pain (OR, 1.26; 95% CI, 1.02-1.56). At the follow-up interview, half of the terminally ill patients who had considered euthanasia or PAS for themselves changed their minds, while an almost equal number began considering these interventions. Patients with depressive symptoms (OR, 5.29; 95% CI, 1.21-23.2) and dyspnea (OR, 1.68; 95% CI, 1.26-2.22) were more likely to change their minds to consider euthanasia or PAS. According to the caregivers of the 256 decedents, 14 patients (5.6%) had discussed asking the physician for euthanasia or PAS and 6 (2.5%) had hoarded drugs. Ultimately, of the 256 decedents, 1 (0.4%) died by euthanasia or PAS, 1 unsuccessfully attempted suicide, and 1 repeatedly requested for her life to be ended but the family and physicians refused. CONCLUSIONS: In this survey, a small proportion of terminally ill patients seriously considered euthanasia or PAS for themselves. Over a few months, half the patients changed their minds. Patients with depressive symptoms were more likely to change their minds about desiring euthanasia or PAS. JAMA. 2000;284:2460-2468.

Attitudes and practices of U.S. oncologists regarding euthanasia and physician-assisted suicide.

BACKGROUND: The practices of euthanasia and physician-assisted suicide remain controversial. OBJECTIVE: To achieve better understanding of attitudes and practices regarding euthanasia and physician-assisted suicide in the context of end-of-life care. DESIGN: Cohort study. SETTING: United States. PARTICIPANTS: 3299 oncologists who are members of the American Society of Clinical Oncology. MEASUREMENTS: Responses to survey questions on attitudes toward euthanasia and physician-assisted suicide for a terminally ill patient with prostate cancer who has unremitting pain, requests for and performance of euthanasia and physician-assisted suicide, and sociodemographic characteristics. RESULTS: Of U.S. oncologists surveyed, 22.5% supported the use of physician-assisted suicide for a terminally ill patient with unremitting pain and 6.5% supported euthanasia. Oncologists who were reluctant to increase the dose of intravenous morphine for terminally ill patients in excruciating pain (odds ratio [OR], 0.61 [95% CI, 0.48 to 0.77]) and had sufficient time to talk to dying patients about end-of-life care issues (OR, 0.79 [CI, 0.71 to 0.87]) were less likely to support euthanasia or physician-assisted suicide. During their career, 3.7% of surveyed oncologists had performed euthanasia and 10.8% had performed physician-assisted suicide. Oncologists who were reluctant to increase the morphine dose for patients in excruciating pain (OR, 0.58 [CI, 0.43 to 0.79]) and those who believed that they had received adequate training in end-of-life care (OR, 0.86 [CI, 0.79 to 0.95]) were less likely to have performed euthanasia or physician-assisted suicide. Oncologists who reported not being able to obtain all the care that a dying patient needed were more likely to have performed euthanasia (P = 0.001). CONCLUSIONS: Requests for euthanasia and physician-assisted suicide are likely to decrease as training in end-of-life care improves and the ability of physicians to provide this care to their patients is enhanced.