Decisional Capacity Determination in Patients With Cancer

Abstract

Patients with cancer face many difficult decisions and encounter many clinical situations that undermine decisional capacity. For this reason, assessing decision making capacity should be thought of at every medical encounter. The culmination of variable disease trajectories, following patients to the end of life, use of high-risk treatments, and other weighty personal decisions require attention to patients’ ability to engage in decisions. Oncologists develop meaningful relationships with their patients. This familiarity may lead to forgoing the process of diligently assessing a patient’s cognitive ability and/or decisional capacity when important decisions need to be made. While the process may feel like it takes place spontaneously, many subtle and overt details are involved with the decisions around cancer care that require pointed questioning and probing. Thus, there are many ways to fall short in determining decisional capacity. Clinicians are inconsistent in their decisional capacity determinations and generally assume more decisional capacity than the patient has. Consult and referral services such as ethics and psychiatry can help with treatment decisions and with assessing underlying psychosocial and psychiatric conditions. Decisional capacity may fluctuate and requires a variable amount of decisional ability depending on the clinical situation; hence, it is time-specific and decision-specific. This review is intended to provide a summary of key components of decisional capacity while highlighting areas in need of clinical refinement.

Learning about psychiatric aspects of medical assistance in dying: a pilot survey of self-perceived educational needs among assessors in a Canadian academic hospital

“…Another one showed significant cognitive impairments in hospice care patients, despite an absence of documented or clinically obvious impairment, which had the authors recommending assessment of cognition in hospice patients, as it may interfere with decisionmaking capacity (41). Determining capacity to consent to MAiD is an important and complex task since a significant proportion of patients might encounter different clinical situations that undermine or impair decisional capacity in advanced diseased (42). Some researchers have even studied the use of tools in predicting which patient might lose it before the provision of MAiD (11).…”

Psychiatric disorders and self-harm across 26 adult cancers: cumulative burden, temporal variation, excess years of life lost and unnatural causes of deaths

“…In these high-risk patients, a lower threshold for psychiatric consultation and intervention may be beneficial to reduce self-harm risk. Patients with personality disorders are often rigid and inflexible and such behaviours may affect cancer progression either through the maintenance of an unhealthy lifestyle or the inability to cope with cancer, treatments and changes in life 23 . Patients with certain personality traits can feel alienated.…”

“…The number of patients with incident psychiatric disorder were as follow: depression (21,609), anxiety disorder (20,070), schizophrenia (7,679), bipolar disorder (557) and personality disorder (194). The number of matched controls for each psychiatric disorder were as follow: depression (75,087), anxiety disorder (67,887), schizophrenia (23,130), bipolar disorder (1,636) and personality disorder (628) (Figure S1). Patient characteristics of the five diagnostic groups for cases and controls were summarised in Table S1.…”

“…Patients may also experience health anxiety and fear of cancer recurrence, which can be triggered by internal (e.g., physical symptoms) and external cues (e.g., medical consultations, regrets about treatment decisions and media exposure) 22 . Coping with a life-threatening diagnosis of cancer may reinforce abnormal behaviours such as antisocial, narcissistic and obsessive-compulsive tendencies that define personality disorders 23 .…”

Impact of Patient Personality on Adherence to Oral Anti-Cancer Medications: An Opportunity? (Preprint)

“…As in other chronic non-malignant diseases, non-adherence and non-persistence to oral anti-cancer medication can be associated with multiple patient-related factors, some of which may be specific to the type or stage of cancer diagnosis or the duration of the prescribed therapy. The behavioral impact that accompanies a diagnosis of cancer can also have significant effects on the personality of a patient [46][47][48]. Therefore, it is possible that some patients may adopt negative social and affective traits, such as those that define the type D personality.…”