Assessment of Decision-Making Capacity in 97 Hospitalized Patients With Cancer: A Call for Standardization

Abstract

Hospitalized patients with cancer face pivotal decisions that will affect their cancer care trajectory and quality of life, but frequently lack decision making capacity (DMC). Standardization is conspicuously missing for inpatient oncology teams and for consultation-liaison psychiatrists performing DMC assessments for patients with cancer. This study sought to characterize a single institutional experience of psychiatric consultations to assess DMC. We conducted a retrospective chart review of 97 consecutive psychiatric consultations for DMC from 2017 to 2019. Demographic, hospital-based, and psychiatry consult differences were assessed based on the reasons for DMC evaluation (uncertainty, patient refusal, and emergency) and whether patients had decisional capacity. Out of 97 consultations, 56 (59%) hospitalized patients with cancer were unable to demonstrate capacity. Consultations came from medical services almost exclusively. Only 5% of primary teams documented their own DMC evaluation. Only 22% of DMC evaluation by consultation-liaison psychiatrists documented four determinates of DMC. Few commented on reversibility or tenuousness of DMC, and the identification of agents/surrogates; however, psychiatry consultants were more likely to follow up on patients without DMC. One-third of patients died in the hospital and two-thirds of patients were deceased 3 months after the consult. Given the substantial heterogeneity in the documentation of DMC evaluations in this retrospective chart review, we call for more rigor and standardization in documentation of DMC evaluations.