Capacity of patients with brain metastases to make treatment decisions

Abstract

OBJECTIVE To investigate medical decision-making capacity (MDC) in patients with brain metastasis. METHODS Participants were 41 adults with brain metastases with Karnofsky Performance Status scores ≥70 were recruited from an academic medical center and 41 demographically-matched controls recruited from the community. We evaluated MDC using the Capacity to Consent to Treatment Instrument (CCTI) and its four clinically relevant consent standards (expressing a treatment choice, appreciation, reasoning, and understanding). Capacity impairment ratings (no impairment, mild/moderate impairment, and severe impairment) on the consent standards were also assigned to each participant with brain metastasis using cutoff scores derived statistically from the performance of the control group. RESULTS The brain metastases patient group performed significantly below controls on consent standards of understanding and reasoning. Capacity compromise was defined as performance ≤1.5 standard deviations (SD) below the control group mean. Using this definition, approximately 60% of the participants with brain metastases demonstrated capacity compromise on at least one MDC standard. CONCLUSION When defining capacity compromise as performance ≤1.5 SD below the control group mean, over half of patients with brain metastases have reduced capacity to make treatment decisions. This impairment is demonstrated shortly after initial diagnosis of brain metastases and highlights the importance of routine clinical assessment of MDC following diagnosis of brain metastasis. These results also indicate a need for the development and investigation of interventions to support or improve MDC in this patient population.

Cognitive predictors of understanding treatment decisions in patients with newly diagnosed brain metastasis

“…In total, 41 demographically-matched, cognitively healthy controls were included. Healthy controls were only evaluated for the purpose of classifying the brain metastasis group as exhibiting intact or impaired reasoning (see Data Analyses for details) and have been described in detail elsewhere [10]. …”

“…Off-study guidelines for radiosurgical treatment at UAB followed maximum tolerated doses outlined in RTOG 9005 [10]. …”

“…In a previous study [10], we noted that brain metastases patients were impaired in relation to healthy controls on the CCTI core consent standard of understanding. Consequently, these analyses focused on this consent standard.…”

“…Although corticosteroids can sometimes improve cognitive functioning by reducing edema, many treatments of brain metastases (e.g., corticosteroids, anticonvulsants, and radiotherapy), can cause impairments in executive functioning, memory, sustained attention, and other cognitive abilities [9]. Patients with brain metastases have also shown significantly poorer understanding compared to demographically matched healthy controls, with nearly 50% classified as impaired in their understanding of medical decisions in one study [10]. Given the complexities of treating brain metastases in combination with the high likelihood of cognitive dysfunction, medical decision-making capacity has significant implications for these patients and their healthcare providers.…”

Neurosurgical management of brain metastases

“…75 Over half of patients with brain metastases have capacity compromise in making medical treatment decisions. 76 Therefore determining the ideal treatment plan for a brain metastasis patient requires integration of understanding the primary disease biology, systemic therapy treatment, sophisticated prognostication, treatment options and most importantly the patients' desires and guidance from their loved-ones.…”