Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study

doi:10.1136/bmj.320.7233.469

BMJ 2000;320:469-473 ( 19 February )

Papers

Nicholas A Christakis, associate professor, ^a Elizabeth B Lamont, fellow. ^b

^a Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA, ^b Robert Wood Johnson Clinical Scholars Program, University of Chicago Medical Center

Correspondence to: N A Christakis nchrista{at}medicine.bsd.uchicago.edu

Objective: To describe doctors' prognostic accuracy interminally ill patients and to evaluate the determinants of thataccuracy.
Design: Prospective cohortstudy.
Setting: Five outpatient hospice programmes inChicago.
Participants: 343 doctors provided survival estimates for468 terminally ill patients at the time of hospicereferral.
Main outcome measures: Patients' estimated and actualsurvival.
Results: Median survival was 24 days. Only 20% (92/468)of predictions were accurate (within 33% of actual survival);63% (295/468) were overoptimistic and 17% (81/468) were overpessimistic.Overall, doctors overestimated survival by a factor of 5.3. Fewpatient or doctor characteristics were associated with prognosticaccuracy. Male patients were 58% less likely to have overpessimisticpredictions. Non-oncology medical specialists were 326% more likelythan general internists to make overpessimistic predictions. Doctorsin the upper quartile of practice experience were the most accurate.As duration of doctor-patient relationship increased and timesince last contact decreased, prognostic accuracydecreased.
Conclusion: Doctors are inaccurate in their prognosesfor terminally ill patients and the error is systematically optimistic.The inaccuracy is, in general, not restricted to certain kindsof doctors or patients. These phenomena may be adversely affectingthe quality of care given to patients near the end oflife.

© BMJ 2000

CiteULike

Complore

Connotea

Del.icio.us Add to Digg

Digg

StumbleUpon Add to Technorati

Technorati What's this?

Relevant Articles

Describing the road to death: Joanne Roberts
BMJ 2005 331: E364-E365. [Full Text] [PDF]

Doctors are overoptimistic in predicting survival for patients with cancer
BMJ 2000 320: 0. [Full Text]

This article has been cited by other articles:

Younis, T., Milch, R., Abul-Khoudoud, N., Lawrence, D., Mirand, A., Levine, E. (2009). Length of Survival in Hospice for Cancer Patients Referred From a Comprehensive Cancer Center. AM J HOSP PALLIAT CARE 26: 281-287 [Abstract]
Larochelle, M., Rodriguez, K., Arnold, R., Barnato, A. (2009). Hospital staff attributions of the causes of physician variation in end-of-life treatment intensity. Palliat Med 23: 460-470 [Abstract]
Finlay, E., Casarett, D. (2009). Making Difficult Discussions Easier: Using Prognosis to Facilitate Transitions to Hospice. CA Cancer J Clin 59: 250-263 [Abstract] [Full text]
Mack, J. W., Wolfe, J., Cook, E. F., Grier, H. E., Cleary, P. D., Weeks, J. C. (2009). Peace of Mind and Sense of Purpose as Core Existential Issues Among Parents of Children With Cancer. Arch Pediatr Adolesc Med 163: 519-524 [Abstract] [Full text]
Monturo, C. (2009). The Artificial Nutrition Debate: Still an Issue... After All These Years. Nutr Clin Pract 24: 206-213 [Abstract] [Full text]
Teno, J. M., Connor, S. R. (2009). Referring a Patient and Family to High-Quality Palliative Care at the Close of Life: "We Met a New Personality . . . With This Level of Compassion and Empathy". JAMA 301: 651-659 [Abstract] [Full text]
Bruera, E., Hui, D. (2008). Practical Model for Prognostication in Advanced Cancer Patients: Is Less More?. JCO 26: 5843-5844 [Full text]
Daugherty, C. K., Hlubocky, F. J. (2008). What Are Terminally Ill Cancer Patients Told About Their Expected Deaths? A Study of Cancer Physicians' Self-Reports of Prognosis Disclosure. JCO 26: 5988-5993 [Abstract] [Full text]
Setoguchi, S., Earle, C. C., Glynn, R., Stedman, M., Polinski, J. M., Corcoran, C. P., Haas, J. S. (2008). Comparison of Prospective and Retrospective Indicators of the Quality of End-of-Life Cancer Care. JCO 26: 5671-5678 [Abstract] [Full text]
Brook, L, Hain, R (2008). Predicting death in children. Arch. Dis. Child. 93: 1067-1070 [Abstract] [Full text]
Stone, P, Kelly, L, Head, R, White, S (2008). Development and validation of a prognostic scale for use in patients with advanced cancer. Palliat Med 22: 711-717 [Abstract]
Walling, A., Lorenz, K. A., Dy, S. M., Naeim, A., Sanati, H., Asch, S. M., Wenger, N. S. (2008). Evidence-Based Recommendations for Information and Care Planning in Cancer Care. JCO 26: 3896-3902 [Abstract] [Full text]
Reith, M., Lucas, C. (2008). Questioning the Evidence for Service Assumptions: Audit of Transfers from a Hospice to Nursing Home Care. Journal of Social Work 8: 233-245 [Abstract]
Barbot, A.-C., Mussault, P., Ingrand, P., Tourani, J.-M. (2008). Assessing 2-Month Clinical Prognosis in Hospitalized Patients With Advanced Solid Tumors. JCO 26: 2538-2543 [Abstract] [Full text]
Twomey, F., O'Leary, N., O'Brien, T. (2008). Prediction of Patient Survival by Healthcare Professionals in a Specialist Palliative Care Inpatient Unit: A Prospective Study. AM J HOSP PALLIAT CARE 25: 139-145 [Abstract]
Ferrand, E., Jabre, P., Vincent-Genod, C., Aubry, R., Badet, M., Badia, P., Cariou, A., Ellien, F., Gounant, V., Gil, R., Jaber, S., Jay, S., Paillaud, E., Poulain, P., Regnier, B., Reignier, J., Socie, G., Tardy, B., Lemaire, F., Brun-Buisson, C., Marty, J., for the French Mort-a-l'Hopital Group, (2008). Circumstances of Death in Hospitalized Patients and Nurses' Perceptions: French Multicenter Mort-a-l'Hopital Survey. Arch Intern Med 168: 867-875 [Abstract] [Full text]
Wijnia, J. W., Corstiaensen, I. J. P. M. (2008). A Poor Prognosis: Guide or Misleading?. AM J HOSP PALLIAT CARE 25: 5-8 [Abstract]
Lewis, C. L., Moore, C. G., Golin, C. E., Griffith, J., Tytell-Brenner, A., Pignone, M. P. (2008). Resident Physicians' Life Expectancy Estimates and Colon Cancer Screening Recommendations in Elderly Patients. Med Decis Making 28: 254-261 [Abstract]
Back, A. L., Arnold, R. M., Tulsky, J. A. (2008). Discussing Prognosis. Am Soc Clin Oncol Ed Book 2008: 135-138 [Abstract] [Full text]
Mehra, M. R, Uber, P. A, Ventura, H. O (2007). Death messengers. BMJ 335: 1296-1297 [Full text]
Workman, S. (2007). A communication model for encouraging optimal care at the end of life for hospitalized patients. QJM 100: 791-797 [Abstract] [Full text]
Torres, M. B., Rao, N. (2007). Disclosure and Truth in Physician-Patient Communication An Exploratory Analysis in Argentina, Brazil, India and the United States. Journal of Creative Communications 2: 279-305 [Abstract]
Noble, S (2007). The challenges of managing cancer related venous thromboembolism in the palliative care setting. Postgrad. Med. J. 83: 671-674 [Abstract] [Full text]
Gripp, S., Moeller, S., Bolke, E., Schmitt, G., Matuschek, C., Asgari, S., Asgharzadeh, F., Roth, S., Budach, W., Franz, M., Willers, R. (2007). Survival Prediction in Terminally Ill Cancer Patients by Clinical Estimates, Laboratory Tests, and Self-Rated Anxiety and Depression. JCO 25: 3313-3320 [Abstract] [Full text]
Kelly, L, White, S, Stone, P. (2007). The B12/CRP index as a simple prognostic indicator in patients with advanced cancer: a confirmatory study. Ann Oncol 18: 1395-1399 [Abstract] [Full text]
Stone, P., Lund, S (2007). Predicting prognosis in patients with advanced cancer. Ann Oncol 18: 971-976 [Abstract] [Full text]
Munday, D., Dale, J., Murray, S. (2007). Choice and place of death: individual preferences, uncertainty, and the availability of care. JRSM 100: 211-215 [Full text]
Cartoni, C., Brunetti, G. A., D'Elia, G. M., Breccia, M., Niscola, P., Marini, M. G., Nastri, A., Alimena, G., Mandelli, F., Foa, R. (2007). Cost analysis of a domiciliary program of supportive and palliative care for patients with hematologic malignancies. haematol 92: 666-673 [Abstract] [Full text]
Volandes, A. E., Lehmann, L. S., Cook, E. F., Shaykevich, S., Abbo, E. D., Gillick, M. R. (2007). Using Video Images of Dementia in Advance Care Planning. Arch Intern Med 167: 828-833 [Abstract] [Full text]
Mack, J. W., Cook, E. F., Wolfe, J., Grier, H. E., Cleary, P. D., Weeks, J. C. (2007). Understanding of Prognosis Among Parents of Children With Cancer: Parental Optimism and the Parent-Physician Interaction. JCO 25: 1357-1362 [Abstract] [Full text]
Kee, F, Owen, T, Leathem, R (2007). Offering a prognosis in lung cancer: when is a team of experts an expert team?. J. Epidemiol. Community Health 61: 308-313 [Abstract] [Full text]
Casarett, D. J., Quill, T. E. (2007). "I'm Not Ready for Hospice": Strategies for Timely and Effective Hospice Discussions. ANN INTERN MED 146: 443-449 [Abstract] [Full text]
Workman, S. (2007). Researching a good death. BMJ 334: 485-486 [Full text]
Zapka, J. G., Carter, R., Carter, C. L., Hennessy, W., Kurent, J. E., DesHarnais, S. (2006). Care at the End of Life: Focus on Communication and Race. J Aging Health 18: 791-813 [Abstract]
Back, A. L., Arnold, R. M. (2006). Discussing Prognosis: "How Much Do You Want to Know?" Talking to Patients Who Are Prepared for Explicit Information. JCO 24: 4209-4213 [Full text]
Matsuyama, R., Reddy, S., Smith, T. J. (2006). Why Do Patients Choose Chemotherapy Near the End of Life? A Review of the Perspective of Those Facing Death From Cancer. JCO 24: 3490-3496 [Abstract] [Full text]
Borgsteede, S. D, Deliens, L., Francke, A. L, Stalman, W. A., Willems, D. L, van Eijk, J. T., van der Wal, G. (2006). Defining the patient population: one of the problems for palliative care research. Palliat Med 20: 63-68 [Abstract]
Hudson, P. L, Toye, C., Kristjanson, L. J (2006). Would people with Parkinson's disease benefit from palliative care?. Palliat Med 20: 87-94 [Abstract]
Hutton, J L, Pharoah, P O D (2006). Life expectancy in severe cerebral palsy.. Arch. Dis. Child. 91: 254-258 [Abstract] [Full text]
Earle, C. C., Ayanian, J. Z. (2006). Looking Back From Death: The Value of Retrospective Studies of End-of-Life Care. JCO 24: 838-840 [Full text]
Henderson, R, Keiding, N (2005). Individual survival time prediction using statistical models. J. Med. Ethics 31: 703-706 [Abstract] [Full text]
McMahon, M. M., Hurley, D. L., Kamath, P. S., Mueller, P. S. (2005). Medical and Ethical Aspects of Long-term Enteral Tube Feeding. Mayo Clin Proc. 80: 1461-1476 [Abstract]
Maltoni, M., Caraceni, A., Brunelli, C., Broeckaert, B., Christakis, N., Eychmueller, S., Glare, P., Nabal, M., Vigano, A., Larkin, P., De Conno, F., Hanks, G., Kaasa, S. (2005). Prognostic Factors in Advanced Cancer Patients: Evidence-Based Clinical Recommendations--A Study by the Steering Committee of the European Association for Palliative Care. JCO 23: 6240-6248 [Abstract] [Full text]
Bailey, F. A., Burgio, K. L., Woodby, L. L., Williams, B. R., Redden, D. T., Kovac, S. H., Durham, R. M., Goode, P. S. (2005). Improving Processes of Hospital Care During the Last Hours of Life. Arch Intern Med 165: 1722-1727 [Abstract] [Full text]
Roberts, J. (2005). Describing the road to death. BMJ 331: E364-E365 [Full text]
Hagerty, R. G., Butow, P. N., Ellis, P. M., Dimitry, S., Tattersall, M. H. N. (2005). Communicating prognosis in cancer care: a systematic review of the literature. Ann Oncol 16: 1005-1053 [Abstract] [Full text]
(2005). Statement on Home Care for Patients with Respiratory Disorders. Am. J. Respir. Crit. Care Med. 171: 1443-1464 [Full text]
Shah, S. H (2005). Integrated care pathway for the last days of life. Palliat Med 19: 351-352
Oi-Ling, K., Man-Wah, D. T., Kam-Hung, D. N. (2005). Symptom distress as rated by advanced cancer patients, caregivers and physicians in the last week of life. Palliat Med 19: 228-233 [Abstract]
van der Steen, J. T., Ooms, M. E., van der Wal, G., Ribbe, M. W. (2005). Withholding or Starting Antibiotic Treatment in Patients with Dementia and Pneumonia: Prediction of Mortality with Physicians' Judgment of Illness Severity and with Specific Prognostic Models. Med Decis Making 25: 210-221 [Abstract]
Hagerty, R. G., Butow, P. N., Ellis, P. M., Lobb, E. A., Pendlebury, S. C., Leighl, N., Mac Leod, C., Tattersall, M. H.N. (2005). Communicating With Realism and Hope: Incurable Cancer Patients' Views on the Disclosure of Prognosis. JCO 23: 1278-1288 [Abstract] [Full text]
Brandt, H. E., Deliens, L., Ooms, M. E., van der Steen, J. T., van der Wal, G., Ribbe, M. W. (2005). Symptoms, Signs, Problems, and Diseases of Terminally Ill Nursing Home Patients: A Nationwide Observational Study in the Netherlands. Arch Intern Med 165: 314-320 [Abstract] [Full text]
Bach, P. B., Schrag, D., Begg, C. B. (2004). Resurrecting Treatment Histories of Dead Patients: A Study Design That Should Be Laid to Rest. JAMA 292: 2765-2770 [Abstract] [Full text]
Bradley, E. H., Prigerson, H., Carlson, M. D.A., Cherlin, E., Johnson-Hurzeler, R., Kasl, S. V. (2004). Depression Among Surviving Caregivers: Does Length of Hospice Enrollment Matter?. Am. J. Psychiatry 161: 2257-2262 [Abstract] [Full text]
Gagnon, B., Mayo, N. E., Hanley, J., MacDonald, N. (2004). Pattern of Care at the End of Life: Does Age Make a Difference in What Happens to Women With Breast Cancer?. JCO 22: 3458-3465 [Abstract] [Full text]
Kostopoulou, O, Wildman, M (2004). Sources of variability in uncertain medical decisions in the ICU: a process tracing study. Qual Saf Health Care 13: 272-280 [Abstract] [Full text]
Mertens, W. C., Hoople, N. E., Rodrigues, C., Lindenauer, P. K., Benjamin, E. M. (2004). Association of admission date with cancer patient survival at a regional hospice: Utility of a statistical process control analysis. AM J HOSP PALLIAT CARE 21: 275-284 [Abstract]
Marcin, J P, Pretzlaff, R K, Pollack, M M, Patel, K M, Ruttimann, U E (2004). Certainty and mortality prediction in critically ill children. J. Med. Ethics 30: 304-307 [Abstract] [Full text]
Shanafelt, T. D., Loprinzi, C., Marks, R., Novotny, P., Sloan, J. (2004). Are Chemotherapy Response Rates Related to Treatment-Induced Survival Prolongations in Patients With Advanced Cancer?. JCO 22: 1966-1974 [Abstract] [Full text]
Hagerty, R. G., Butow, P. N., Ellis, P. A., Lobb, E. A., Pendlebury, S., Leighl, N., Goldstein, D., Lo, S. K., Tattersall, M. H.N. (2004). Cancer Patient Preferences for Communication of Prognosis in the Metastatic Setting. JCO 22: 1721-1730 [Abstract] [Full text]
Yabroff, K R., Mandelblatt, J. S, Ingham, J. (2004). The quality of medical care at the end-of-life in the USA: existing barriers and examples of process and outcome measures. Palliat Med 18: 202-216 [Abstract]
Paice, J. A., Muir, J. C., Shott, S. (2004). Palliative care at the end of life: Comparing quality in diverse settings. AM J HOSP PALLIAT CARE 21: 19-27 [Abstract]
Maltoni, M., Tassinari, D. (2004). Prognostic assessment in terminally ill cancer patients: from evidence-based knowledge to a patient-physician relationship and back. Palliat Med 18: 77-79
Norton, S. A., Tilden, V. P., Tolle, S. W., Nelson, C. A., Eggman, S. T. (2003). Life Support Withdrawal: Communication and Conflict. Am J Crit Care 12: 548-555 [Abstract] [Full text]
Glare, P., Virik, K., Jones, M., Hudson, M., Eychmuller, S., Simes, J., Christakis, N. (2003). A systematic review of physicians' survival predictions in terminally ill cancer patients. BMJ 327: 195- [Abstract] [Full text]
Lamont, E. B., Christakis, N. A. (2003). Complexities in Prognostication in Advanced Cancer: "To Help Them Live Their Lives the Way They Want to". JAMA 290: 98-104 [Abstract] [Full text]
Smith, T. J. (2003). Tell It Like It Is. JCO 21: 12s-16 [Full text]
Daugherty, C. K., Steensma, D. P. (2003). Overcoming Obstacles to Hospice Care: An Ethical Examination of Inertia and Inaction. JCO 21: 42s-45 [Full text]
McCarthy, E. P., Burns, R. B., Davis, R. B., Phillips, R. S. (2003). Barriers to Hospice Care Among Older Patients Dying With Lung and Colorectal Cancer. JCO 21: 728-735 [Abstract] [Full text]
Von Roenn, J. H., von Gunten, C. F. (2003). Setting Goals to Maintain Hope. JCO 21: 570-574 [Full text]
Lohiya, G.-S., Tan-Figueroa, L., Crinella, F. M. (2003). End-of-Life Care for a Man with Developmental Disabilities. J Am Board Fam Med 16: 58-62 [Abstract] [Full text]
Toffler, W. L. (2003). The Challenge of Caring for the Severely Disabled. J Am Board Fam Med 16: 78-80 [Full text]
Cowie, M.R. (2002). The fine art of prognostication. Eur Heart J 23: 1804-1806 [Full text]
WERTH, J. L. Jr., BLEVINS, D. (2002). Public Policy and End-of-life Care. American Behavioral Scientist 46: 401-417 [Abstract]
HICKMAN, S. E. (2002). Improving Communication Near the End of Life. American Behavioral Scientist 46: 252-267 [Abstract]
Smith, T. J., Staats, P. S., Deer, T., Stearns, L. J., Rauck, R. L., Boortz-Marx, R. L., Buchser, E., Catala, E., Bryce, D. A., Coyne, P. J., Pool, G. E. (2002). Randomized Clinical Trial of an Implantable Drug Delivery System Compared With Comprehensive Medical Management for Refractory Cancer Pain: Impact on Pain, Drug-Related Toxicity, and Survival. JCO 20: 4040-4049 [Abstract] [Full text]
George, L. K. (2002). Research Design in End-of-Life Research: State of Science. Gerontologist 42: 86-98 [Abstract] [Full text]
Drought, T. S., Koenig, B. A. (2002). "Choice" in End-of-Life Decision Making: Researching Fact or Fiction?. Gerontologist 42: 114-128 [Abstract] [Full text]
Gibbs, J S R, McCoy, A S M, Gibbs, L M E, Rogers, A E, Addington-Hall, J M (2002). Living with and dying from heart failure: the role of palliative care. Heart 88: ii36-39 [Full text]
Plettau, L. L., Palmer, C. (2002). High-Tech Care in a Hospice Setting. Home Health Care Management Practice 14: 335-337 [Abstract]
Tassinari, D., Maltoni, M., Amadori, D. (2002). Reply: Prediction of survival in terminally ill cancer patients: why we cannot avoid an evidence-based palliative medicine. Ann Oncol 13: 1322-1323 [Full text]
Tanneberger, S., Malavasi, I., Mariano, P., Pannuti, F., Strocchi, E. (2002). Planning palliative or terminal care: the dilemma of doctors' prognoses in terminally ill cancer patients. Ann Oncol 13: 1320-1322 [Full text]
Curtis, J. R., Wenrich, M. D., Carline, J. D., Shannon, S. E., Ambrozy, D. M., Ramsey, P. G. (2002). Patients' Perspectives on Physician Skill in End-of-Life Care* : Differences Between Patients With COPD, Cancer, and AIDS. Chest 122: 356-362 [Abstract] [Full text]
Daugherty, C. K., Steensma, D. P. (2002). Overcoming Obstacles to Hospice Care: An Ethical Examination of Inertia and Inaction. JCO 20: 2752-2755 [Full text]
Fallowfield, L J, Jenkins, V A, Beveridge, H A (2002). Truth may hurt but deceit hurts more: communication in palliative care. Palliat Med 16: 297-303 [Abstract]
Shadbolt, B., Barresi, J., Craft, P. (2002). Self-Rated Health as a Predictor of Survival Among Patients With Advanced Cancer. JCO 20: 2514-2519 [Abstract] [Full text]
Lo, B., Dornbrand, L., Wolf, L. E., Groman, M. (2002). The Wendland Case -- Withdrawing Life Support from Incompetent Patients Who Are Not Terminally Ill. NEJM 346: 1489-1493 [Full text]
Farquhar, M, Grande, G, Todd, C, Barclay, S (2002). Defining patients as palliative: hospital doctors' versus general practitioners' perceptions. Palliat Med 16: 247-250 [Abstract]
Abrahm, J. L., Hansen-Flaschen, J. (2002). Hospice Care for Patients With Advanced Lung Disease. Chest 121: 220-229 [Abstract] [Full text]
Lee, S. J., Back, A. L., Block, S. D., Stewart, S. K. (2002). Enhancing Physician-Patient Communication. ASH Education Book 2002: 464-483 [Abstract] [Full text]
Hayward, R. A., Hofer, T. P. (2001). Estimating Hospital Deaths Due to Medical Errors: Preventability Is in the Eye of the Reviewer. JAMA 286: 415-420 [Abstract] [Full text]
Schneider, S. M., Raina, C., Pugliese, P., Pouget, I., Rampal, P., Hebuterne, X. (2001). Outcome of Patients Treated with Home Enteral Nutrition. JPEN J Parenter Enteral Nutr 25: 203-209 [Abstract]
Lamont, E. B., Christakis, N. A. (2001). Prognostic Disclosure to Patients with Cancer near the End of Life. ANN INTERN MED 134: 1096-1105 [Abstract] [Full text]
Casarett, D., Abrahm, J. L. (2001). Patients With Cancer Referred to Hospice Versus a Bridge Program: Patient Characteristics, Needs for Care, and Survival. JCO 19: 2057-2063 [Abstract] [Full text]
Llamas, K J, Pickhaver, A M, Piller, N B (2001). Mainstreaming palliative care for cancer patients in the acute hospital setting. Palliat Med 15: 207-212 [Abstract]
Quill, T. E. (2000). Initiating End-of-Life Discussions With Seriously Ill Patients: Addressing the "Elephant in the Room". JAMA 284: 2502-2507 [Abstract] [Full text]
Smith, T. J. (2000). Tell It Like It Is. JCO 18: 3441-3445 [Full text]
Billings, J A. (2000). Recent advances: Palliative care. BMJ 321: 555-558 [Full text]

Rapid Responses:

Read all Rapid Responses

Patient's perspective: Sue Meeuwissen
bmj.com, 22 Feb 2000 [Full text]
Predicting the death of patients: A Oakley John
bmj.com, 3 Mar 2000 [Full text]
Honesty not Statistics: Andrea Husain
bmj.com, 23 Feb 2000 [Full text]
EXTENT AND DETERMINANTS OF ERROR OF DOCTORS PROGNOSES IN TERMINALLY ILLPATIENTS; PROSPECTIVE COH: C K Connolly
bmj.com, 9 Mar 2000 [Full text]
Survival in terminal illness may be long and makes predicting prognosis difficult: Sean Weaver
bmj.com, 17 Mar 2000 [Full text]
Doctors' prognoses vs statistical models; Why not combine the two?: Margaret Jones
bmj.com, 11 Apr 2000 [Full text]