Patients with advanced cancer must make important decisions even after the point at which their disease has progressed beyond the possibility for cure. These decisions can have important legal and ethical consequences. However, patients with advanced cancer are vulnerable to impairments in decision-making capacity. Additionally, anti-cancer treatments and the disease itself have been linked to impairment in neuropsychological functioning that may underlie decision-making ability. The proposed study aims to aid clinicians by identifying patterns of decisional impairment in terminally ill cancer patients so that they can better assess and enhance patient decision-making capacity. Study participants will be recruited from Calvary Hospital, an inpatient care facility dedicated to providing palliative care to advanced cancer patients during their final months and weeks of life. A healthy comparison sample will be recruited from the community. Participants will complete a standardized measure of treatment decision-making capacity (the MacCAT-T) designed to tap decision-making abilities about relevant end-of life issues (i.e., artificial nutrition and hydratin for the treatment of cachexia). This measure has been pilot tested in a sample of terminally ill cancer patients drawn from Calvary Hospital to ensure its feasibility and relevance. Participants will also complete several measures of neuropsychological functioning hypothesized to predict decision-making ability, including premorbid IQ, semantic fluency, learning and memory and executive function.
Specific aims of this study are: a) to characterize the nature of decision-making capacity impairments in terminally ill cancer patients relative to the four most commonly accepted legal standards for competency: ability to express a choice, understanding, appreciation, and reasoning;b) to identify the most useful items and subscales of the MacCAT-T for assessing decision-making capacity using Item Response Theory with the goal of developing a shortened version of the measure;c) to identify the relationship between neuropsychological functioning and decision-making abilities in terminally ill cancer patients. The long-term objectives of this study include the development of improved clinical capacity assessments, informed consent procedures, and cognitive remediation strategies for cancer patients.
Due to impairments in decision-making capacity, many terminally ill cancer patients are at risk of making decisions that may result in harm. Improved understanding of impairment and measures are needed to accurately assess decision-making capacity in this vulnerable population. The identification of patterns of decision-making impairment, cognitive abilities related to decision- making capacity, and items that most accurately identify decision-making impairment will result in improved quality of life for terminaly ill cancer patients and their caregivers.