Decision Making in Geriatric Oncology: Supported Versus Assisted Decision Making

Abstract

DuMontier et al 1 have performed a comprehensive overview on a broad range of medical, ethical, and legal aspects to be considered regarding decision making connected with older patients with cancer. We would like to add two points which seem relevant from our clinical experience and an ethical perspective to further improve decision making with older adults.

Reply to S. Sommerlatte et al

“…2 In particular, the authors focus on ethical concerns, expanding on two points inherent in our framework for decision making: (1) a concern about assigning decisional capacity prematurely and (2) the distinction between assistance with and substitution for capacity. 1 We are pleased by the degree of agreement between our views, and we believe our framework can accommodate the expressed concerns.…”

“…We thank Sommerlatte et al 1 for their comments on our article on clinical decision making for older adults with cancer. 2 In particular, the authors focus on ethical concerns, expanding on two points inherent in our framework for decision making: (1) a concern about assigning decisional capacity prematurely and (2) the distinction between assistance with and substitution for capacity.…”

“…6,7 The need for supported decision making in the context of disability reinforces a fundamental point of our review: Optimal decision making for older adults with cancer requires a geriatric assessment to assess for prevalent aging-related vulnerabilities like sensory losses and cognitive impairment that often go undetected in routine oncology examinations. Sommerlatte et al 1 appropriately highlight that interventions targeting these deficits (eg, allowing extra time to discuss choices in an older adult with hearing or cognitive impairment) help ensure that older patients are able to receive, use, and communicate information regarding cancer treatments in the decision-making process.…”

“…The geriatric assessment also best allows clinicians to determine when health deficits that impair decision-making capacity are not modifiable—eg, an older patient with advanced dementia who can neither process nor recall the risks of intensive versus less intensive cancer treatment strategies. Sommerlatte et al 1 provide justifiable caution that invoking surrogate decision makers risks overlooking patient preferences and adding burden to those requested to make decisions on behalf of the impaired patient. However, moving forward with treatments without involving health care proxies in an older patient who truly does lack capacity equally risks missing patient preferences that can result in overtreatment or undertreatment.…”

“…However, moving forward with treatments without involving health care proxies in an older patient who truly does lack capacity equally risks missing patient preferences that can result in overtreatment or undertreatment. Accordingly, the caution expressed by Sommerlatte et al 1 implores us to commit time early and often toward eliciting health care preferences and values from older patients, while encouraging them to communicate these preferences and values to their health care proxy before impairment leads to incapacity. Indeed, Wendler and Rid's 8 systematic review on the effects on surrogates of making treatment decisions for others found that knowing the patients' previously communicated preferences reduced stress on surrogates, providing motivation for older patients to complete advance directives.…”