although terminal cancer patients could continue living by artificial respiration and cardiopulmonary resuscitation , many of them suffer a variety of painful symptoms and very poor quality of life . this has led to the concept of  death with dignity  ( dwd)the request to stop the medical measures extending their lives and to let them die with calm and dignity . for example , in the united states , dwd is commonly associated with the death with dignity act ( dwda ) , which allows physicians to prescribe a lethal dose of secobarbital that the patient could self - administer . the science council of japan published a report on dwd in 1994 that defined it as the withdrawal or withholding of life - prolonging measures if the patient was terminally ill and expressed an intention to withdraw or withhold such measures in advance . taiwan has a similar definition , although the term  do - not - resuscitate this may be because of some similarities in cultural background between japan and taiwan , including mainland china . during the late 1990s , reverend chuck meyer advocated changing dnr into  allow - natural - death  ( and ) , reflecting an end - of - life philosophy of providing comfort . in fact , the natural death act ( nda ) had already been made law in california in 1977 , after which approximately 40 other states in the united states made similar legislation . the law established the right of a patient to demand his or her physician to withdraw or withhold life - sustaining procedures during terminal illness . in mainland china , a patient confirms a dwd request by filing in  living will  forms in advance . this procedure gives the patient the right to refuse some life - prolonging measures at the end of life . thus , dwd in mainland china is similar to and or nda in america , dnr in taiwan , and dwd in japan . in recent years , an increasing number of chinese advanced cancer patients have asked for dwd , but this concept is not clearly supported by the current laws in mainland china . chinese physicians face a dilemma , as chinese culture is deeply influenced by confucian thoughts , and it is taboo to discuss death . consequently , it is important to investigate chinese oncology physicians ' attitudes toward dwd in order to facilitate its legislation and implementation . after discussion with three oncology and palliative care experts , we designed a special questionnaire to investigate chinese oncology physicians ' attitude toward dwd . the current questionnaire was pilot tested among 12 oncology doctors to ensure that it was easy to understand . the questionnaire included 9 items on respondents ' demographic characteristics and 12 items on their understanding and attitudes toward dwd . in order to avoid any misunderstanding , we gave the definition of dwd in the questionnaire as follows : confirmed by a  living will  form in advance , the patient refuses life - prolonging measures and accepts only those that would create comfort at the end of life . the overall cronbach 's alpha for the questionnaire was 0.75 ; when individual items were deleted one at a time , the resulting cronbach 's alpha was always more than 0.70 . eleven oncology departments in two university hospitals , four tertiary general hospitals , and five urban general hospitals were involved . these hospitals were distributed across seven different regions of mainland china , including one from east china , one from north china , two from southern china , one from central china , one from northeast china , three from southwest china , and two from northwest china . the smallest hospital had more than 300 patient beds including 30 oncology beds , and the largest had 4800 patient beds including 500 oncology beds . those who worked less than one year or did not sign the informed consent form were excluded . all data were analyzed using descriptive analyses by a researcher who was not involved in the data collection . furthermore , the mann - whitney u test and kruskal - wallis test were used to analyze associations between demographic characteristics and understanding and attitudes towards dwd . all statistical analyses were processed by spss 18.0 ( ibm , armonk , ny ) . participants ' median age was 33 years ( range : 2362 years ) and the standard deviation ( sd ) was 8.7 years . characteristics of the oncology physicians ( n  =  223 ) usd 967.7  =  rmb 6000 . most of the participants ( 154/223 , 69.1% ) had received patients ' dwd requests . physicians with higher professional titles ( p  =  0.002 ) , more work experience ( p<0.001 ) , and who were older ( p<0.001 ) received more dwd requests . percentage of answers to the question ,  which is the most important reason for patients making a request for death with dignity ? the understanding of participants toward dwd , including whether dwd was equivalent to euthanasia , is shown in table 2 . those with more work experience ( p<0.001 ) and higher professional titles ( p<0.001 ) had a better understanding of dwd . married physicians ( p  =  0.004 ) and those who were religious ( p  =  0.012 ) understood dwd better . most physicians ( 166/223 , 74.4% ) did not consider dwd as euthanasia ( see table 2 ) . the attitudes of oncology physicians toward the legalization and implementation of dwd are shown in table 2 . physicians ' attitudes were not associated with age , gender , nationality , marital status , religion , education , professional title , work experience , or income . in addition , the attitudes were not influenced by themselves or their family having cancer ( p>0.05 ) . the most important reasons for oncology physicians supporting or rejecting dwd are shown in table 3 . reasons for oncology physicians '  yes  or  no  answers toward death with dignity most oncology physicians ( 69.1% ) in mainland china have received dwd requests from advanced cancer patients ( see fig . a retrospective review of 829 cancer inpatients indicated that the signing rate of dnr orders reached 99.8% in taiwan . most physicians thought the most important reason for a dwd request was the patients ' unwillingness to rely on machines to maintain their survival ( see fig . one - third of the participants thought the most important reason was an unwillingness to suffer from unbearably painful symptoms , which is related to underdeveloped palliative medicine . indeed , many primary hospitals in mainland china still do not have basic analgesic drugs such as oral morphine , and their doctors know little about the standard three - step analgesic ladder . although most participants are familiar with dwd , a fifth of respondents did not know the difference between dwd and euthanasia ; a few even considered dwd as euthanasia ( see table 2 ) . this lack of knowledge led them to express reservations about the legalization of dwd and to worry about  killing  patients ( see table 3 ) . this misunderstanding is evident even in the united states , where and has been legalized for many years , and where medical staff had insufficient knowledge regarding the law . the majority of participants supported the legalization and implementation of dwd ( see table 2 ) . other ethnicity and they all agreed with dwd , which may be related to their religious beliefs . although the legislative yuan of taiwan enacted the hospice and palliative regulation that included the implementation of dwd in 2000 , current laws in mainland china still do not clearly empower physicians to comply with patients ' dwd requests , as family members ' consent is also required . patients ' families tend to conceal the truth of diagnosis and prognosis and want to prolong patients ' lives as much as possible . thus , dwd legalization would be necessary and give patients more autonomy on the medical measures to implement at the end of life ( see table 3 ) . in addition to health care policy , the major differences between mainland china and taiwan may result from  the productivity of the health workforce , in particular doctors and nurses , which are the cornerstone of the health care system .  in 2013 , taiwan had 1.80 doctors and 6.03 nurses per 1000 population , which was higher than mainland china , with 1.65 doctors and 2.01 nurses per 1000 population . moreover , mainland china 's total health care spending per capita was only $ 508 usd adjusted for purchasing power parity ( ppp)far less than taiwan 's $ 2,479 usd ppp . three foundations with religious affiliations have also played an important role in the development of palliative care in taiwan . as the doctor - patient relationship is rather tense in mainland china , it is reasonable that some physicians are afraid of the risk of medical disputes in implementing dwd ( see table 3 ) . however , we believe that dwd implementation could give the patient and family more humane care and help to moderate the relationship between doctors and patients . adding validated assessment of filial piety ( i.e. , virtue of respect for one 's father , elders , and ancestors ) needs to be considered , as this aspect might be important . in conclusion , this study found that chinese oncologists often received dwd requests , and most physicians support dwd legalization in mainland china . because one - fifth of oncology physicians were confused about dwd and euthanasia , it is important to educate them about the crucial difference between dwd and euthanasia . lastly , it is necessary to accelerate the development of palliative care to alleviate terminal patients ' suffering . we especially thank the following persons for their help : wen - xiu yao , md ; ping duan , md ; yan - yu qi , md ; bin ye , md ; and chao yang , md . we also thank editage for providing english language editing .
abstractbackground : death with dignity ( dwd ) refers to the refusal of life - prolonging measures for terminally ill patients by  living wills  forms in advance . 
 more and more oncology physicians are receiving dwd requests from advance cancer patients in mainland china.objective : the study objective was to investigate the attitudes of chinese oncology physicians toward the legalization and implementation of dwd.methods : a questionnaire investigating the understanding and attitudes toward dwd was administered to 257 oncology physicians from 11 hospitals in mainland china.results : the effective response rate was 86.8% ( 223/257 ) . 
 the majority of oncology physicians ( 69.1% ) had received dwd requests from patients . 
 half of the participants ( 52.5% ) thought that the most important reason was the patients ' unwillingness to maintain survival through machines . 
 one - third of participants ( 33.0% ) attributed the most important reason to suffering from painful symptoms . 
 most oncology physicians ( 78.9% ) had knowledge about dwd . 
 a fifth of respondents did not know the difference between dwd and euthanasia , and a few even considered dwd as euthanasia . 
 the majority of oncology physicians supported the legalization ( 88.3% ) and implementation ( 83.9% ) of dwd.conclusions : many chinese oncology physicians have received advanced cancer patients ' dwd requests and think that dwd should be legalized and implemented . 
 chinese health management departments should consider the demands of physicians and patients . 
 it is important to inform physicians about the difference between dwd and euthanasia , as one - fifth of them were confused about it .