Decisional capacity determination and serious mental illness in oncology: Implications for equitable and beneficent care

Abstract

Background: Patients with Serious Mental Illness (SMI) have worse survival compared to cancer patients without SMI after controlling for delayed diagnosis.Decision-making capacity (DMC) may be impaired in both populations (cancer or SMI). DMC may be further impaired based on coupled vulnerability factors that challenge Shared Decision Making (SDM) for patients with cancer and SMI.Methods: Psychiatric consultations for DMC in hospitalized patients with cancer (n = 97) were consecutively evaluated across a single institution cancer center. SMI data, demographic, and cancer-related variables were obtained from the medical record. Descriptive data were contrasted in patients with and without DMC and used for logistic regression modeling.Results: Overall, 42% had DMC with no significant differences based on SMI (χ 2 = 2.60, p = 0.11). Patients with SMI were younger, receiving anticancer treatment, and were less likely facing end of life issues. Age (OR 1.03, p = 0.05) and no recent anticancer treatments (OR 0.34, p = 0.02) were associated with decisional incapacity. At 3 months post discharge, almost two-thirds were dead with no difference based on SMI (χ 2 = 0.01, p = 0.91). But End of Life (EOL) concerns were documented in 63% of non-SMI patients and only 36% of SMI patients (χ 2 = 5.63, p = 0.02). Healthcare proxy (16%), four determinates of DMC (22%), and repeated psychiatric DCM assessments (35%) were documented with no differences based on SMI. Conclusion:SDM is not equitable for cancer patients with SMI. Advanced directives and a robust effort to provide value-congruent care for patient with SMI who develop cancer may lessen this health inequity for cancer patients with SMI.

Disparities and inequalities in cancer care and outcomes in patients with severe mental illness: Call to action

“…The study found that there were barriers to cancer care provision for patients affected by SMI: fragmentation of care; healthcare providers' understanding of SMI; complex nature of presentation; and specialized care needs. In a Japanese study, by analyzing the responses of 439 professionals, Etoh et al 23 A very specific and important point was raised by McFarland et al 25 in the USA. In a series of psychiatric consultations for patients with SMI and cancer, they found that shared decision making was often a problem.…”