One-Quarter of Cancer Patients Lack Capacity to Make Medical Decisions

Decision-making incapacity is an under-recognized problem among older adults with cancer, according to a recent study published on PLoS One. 

Toru Okuyama (Nagoya City University Hospital, Nagoya, Japan) led a study to look at 114 patients age 65 and older with malignant lymphoma or multiple myeloma admitted to Nagoya City University Hospital in Japan for inpatient treatment. They assessed patients’ decision-making capacity using the Structured Interview for Competency and Incompetency Assessment Testing and Ranking Inventory-Revised (SICIATRI-R) and also evaluated cognitive impairment, depressive symptoms, and other factors possibly associated with decision-making.

One in 4 patients ranked as having some extent of decision-making incapacity according to the SICIATRI-R, researchers reported. The findings are consistent with previous research that suggested 26% of the general medical population has decision-making incapacity.

Interestingly, patients’ attending physicians rarely detected the incapacity, the researchers noted. 

“We also found that physicians have difficulty with evaluating patient competency levels, and are more likely to overestimate the patients’ competency, consistent with a previous study,” they wrote. “One of the reasons for physician overestimation
of patient capacity may be that patients who were judged to be incompetent in this study did not refuse the anti-cancer treatment suggested by physicians.”

When researchers looked at characteristics linked with participants’ decision-making incapacity, they found a significant association between incapacity and higher levels of cognitive impairment as well as older age.

“The association between older age and incompetency, independent from cognitive impairment, may be due to sensory decline, low medical literacy, or passive communication style, all of which have been linked to aging,” they wrote. “Exploring the factors underlying this association could deepen the understanding of how medical decision-making capacity may be linked to the aging process.”

Sufficient capacity to make decisions about medical treatment is essential for informed consent, researchers wrote. With cancer, patients should understand the extent and life-threatening nature of their disease and the effectiveness and side effects of treatment options. This information allows them to make choices about their treatment that align with their priorities in life.

Although no standardized strategy is available to identify patients at increased risk of decision-making incapacity, researchers said their study provides early evidence that age and cognitive impairment assessment could help.

“To maximize patient autonomy, further research is required to develop an appropriate brief assessment or screening tool for physicians to evaluate medical decision-making capacity,” they concluded (https://bit.ly/1VsCZBF).—Jolynn Tumolo