Considerations for Evaluating Older Adults with Cancer for Depression: A Qualitative Survey of Experts.

OBJECTIVES: The objective of this study was to engage national experts in geriatric psychiatry and oncology in qualitative interviews to develop consensus regarding how older adult cancer survivors (OACS) experience depressive symptoms, and how best to assess OACs for depression. METHODS: Expert clinicians in geriatric oncology disciplines were interviewed about approaches to assessing depression in OACs. Interviews were audio-recorded and transcribed, and conducted until thematic saturation was achieved. Thematic Content Analysis was utilized to identify key themes. RESULTS: Experts (N = 8) were board certified geriatric psychiatrists and oncologists with specialization in geriatric medicine. Two conceptual domains were identified: Key indicators of depression in OACs (e.g. anhedonia; loss of meaning and purpose; loneliness and social withdrawal) and unique considerations for depression assessment in OACs (e.g. alternative phrasing to "depression," disentangling mood and cancer or treatment-related side effects). CONCLUSIONS: The approaches identified tended to depart from traditional diagnostic criteria for depression. CLINICAL IMPLICATIONS: Results provide additional insight into the limitations of existing depression measures for OACs. The themes and practices identified in the present study suggest that a revised measure of depression for OACs may be useful. Future research will continue to shed light on best practices for depression assessment in OACs.

Meaning-centered psychotherapy training program for cancer care clinicians: Efficacy and impact of the first 5 years.

Meaning-Centered Psychotherapy (MCP) is a manualized, evidence-based intervention designed to help cancer patients to find meaning and alleviate distress. Meaning-Centered Psychotherapy Training (MCPT) is a multicomponent program for cancer care clinicians that consists of didactics, group experiential learning, and role-plays with simulated patients to learn MCP and acquire skills to deliver it in real-world oncology settings. The efficacy and impact of MCPT for multidisciplinary cancer care clinicians to learn and disseminate MCP is described and evaluated. A multilevel evaluation based on the RE-AIM framework was utilized to assess the efficacy of the MCPT program over the initial 5 years of the program. The outcomes of the evaluation supported MCPT goals. Three hundred forty-two participants attended MCPT. Overall satisfaction measured in the post-training assessment was high. Significant increases in MCP skills were demonstrated by participants over the course of the role-play sessions, and participants showed significant improvements in pre/post-training MCP knowledge assessment scores, as well as significant increases in self-reported overall MCP skills and core competencies. Follow-up survey responses indicate that MCP trainees were utilizing MCP, had made changes to their clinical practice, and progressed on individual implementation goals. During the first 5 years, the MCPT program was successfully developed, established, implemented, and shown to be effective in the dissemination of MCP across the RE-AIM domains. Future directions for training and implementation research include increasing diversity of providers and investigating the impact of the program on patient outcomes.

Meaning-Centered Psychotherapy (MCP) is a manualized brief intervention designed to help cancer patients to find meaning and alleviate distress. Meaning-Centered Psychotherapy Training (MCPT) is a program for cancer care clinicians, consisting of lectures, group exercises, and practice with simulated patients to learn MCP and the skills to deliver it in real-world oncology settings. Participants were evaluated with a multi-assessment approach to establish the efficacy and impact of the program over the initial 5 years. Results demonstrated that the MCPT program met its goals. In total, 342 clinicians from diverse clinical and geographic cancer settings attended. Overall satisfaction with the training after participation in MCPT was high. Significant increases in MCP skills were demonstrated by participants over the course of the practice sessions, participants showed significant improvements in MCP knowledge assessment scores, as well as in self-reported overall MCP skills and core competencies. Surveys sent at 3, 6, and 12 months after participation indicated that most trainees were utilizing MCP, changed their clinical practice, and made progress on their training goals. During the first 5 years, the MCPT program was successfully developed, implemented, and shown to be effective to facilitate the dissemination of MCP for wider use in clinical settings.

Cognitive effects of long-term androgen deprivation therapy in older men with prostate cancer.

OBJECTIVE: Androgen deprivation therapy (ADT) is a common treatment for prostate cancer (PCa), with increasing numbers of men on ADT for longer. Limited evidence suggests ADT impacts cognition. This study addressed gaps in the literature by focusing on older men with PCa and assessing ADT usage longer than 1 year. METHODS: This study of 133 men ≥65 years of age with PCa included two groups: (1) men on ADT for 1-3 years (ADT-exposed), and (2) a comparison group of men with PCa not on ADT (ADT-unexposed). Group comparisons on individual neuropsychological test scores are reported, as well as effect sizes (Cohen's d). RESULTS: Half (n = 67) of the sample was ADT-exposed and half (n = 66) were unexposed. The average age was 72 years, most were White, and over 50% had at least secondary education. There were no statistically significant differences between groups by age, race, or education. Unadjusted analyses showed the ADT-exposed group, compared with the ADT-unexposed group, performed significantly lower in domains of verbal learning (d = 0.45-0.52, p = 0.01 to <0.01), verbal recall (d = 0.33-0.54, p = 0.06 to <0.01), and possible effects in visuospatial construction (d = 0.33, p = 0.08 to 0.06). When controlling for age and education, similar patterns emerged. The ADT exposed-group performed significantly lower in domains of verbal learning (d = 0.45-0.52, p = 0.06 to 0.03) and verbal recall (d = 0.33-0.54, p = 0.11 to 0.03), and possible effects in visuospatial construction d = 0.33, p = 0.18 to 0.13. CONCLUSIONS: This study suggests long-term ADT exposure impacts verbal learning, verbal recall, and possibly visuospatial abilities in older men (≥65) with PCa. The potential cognitive effects of ADT should be discussed with older patients considering long-term use of ADT.

Protocol for a randomized controlled trial of brief behavioral activation among older adult cancer survivors.

INTRODUCTION: As many as 35% of older adult cancer survivors (OACS; i.e., ≥65 years old) have clinically significant depression. OACS often experience fatigue, mild cognitive impairment, and increased medical comorbidities post-cancer that make them susceptible to depression. Behavioral activation (BA) is an empirically supported depression treatment in geriatric psychiatry that guides individuals to reengage in pleasurable and rewarding activities and has great potential for addressing the needs of OACS. This manuscript presents the protocol for a pilot randomized controlled trial (RCT) testing the efficacy of a brief BA intervention adapted to address the needs of OACS (BBA-OACS) by telephone and videoconference delivery. MATERIALS AND METHODS: An RCT will be conducted at Memorial Sloan Kettering Cancer Center (MSK) in New York City. Participants will be randomized to either BA as a target intervention or supportive psychotherapy (SP) as a standard of care control intervention for outpatient oncology. The target intervention includes 10 weekly sessions of BA consisting of psychoeducation about depression and the rationale for BA, life areas and values assessment, compilation of a list of enjoyable and important activities across values, activity scheduling, and self-monitoring of satisfaction and mood. The standard of care control intervention includes 10 weekly sessions of SP consisting of reassurance, guidance, encouragement, and support for patients with cancer. OACS who have a history of cancer, report elevated depressive symptoms, are fluent in English, and can communicate via telephone or videoconference will be recruited from the MSK Survivorship Clinics across all disease types. Seventy participants will be recruited for the study (10 training cases, 30 in each RCT arm). The primary aim is to evaluate implementation outcomes (i.e., acceptability, feasibility, and fidelity) of BA, relative to SP, for cancer survivorship. The secondary aim is to determine the preliminary effects of BA on depressive symptoms (primary outcome), anxiety, coping, and increased activity level (secondary outcomes) compared to SP. Participants will be asked to complete a set of three surveys pre- and post-intervention. DISCUSSION: If successful, BBA-OACS would provide frontline clinicians with an accessible, evidence-based treatment for OACS. Future research will evaluate the efficacy of BA in a larger trial and its impact on depression and other healthcare outcomes. TRIAL REGISTRATION: This study is registered under ClinicalTrials.gov (ID NCT05574127).

A survey of statistical methods utilized for analysis of randomized controlled trials of behavioral interventions.

OBJECTIVES: Given the many statistical analysis options used for randomized controlled trials (RCTs) of behavioral interventions and the lack of clear guidance for analysis selection, the present study aimed to characterize the predominate statistical analyses utilized in RCTs in palliative care and behavioral research and to highlight the relative strengths and weaknesses of each of these methods as guidance for future researchers and reform. METHODS: All RCTs published between 2015 and 2021 were systematically extracted from 4 behavioral medicine journals and analyzed based on prespecified inclusion criteria. Two independent raters classified each of the manuscripts into 1 of 5 RCT analysis strategies. RESULTS: There was wide variation in the methods used. The 2 most prevalent analyses for RCTs were longitudinal modeling and analysis of covariance. Application of method varied significantly by sample size. SIGNIFICANCE OF RESULTS: Each statistical analysis presents its own unique strengths and weaknesses. The information resulting from this research may prove helpful for researchers in palliative care and behavioral medicine in navigating the variety of statistical methods available. Future discussion around best practices in RCT analyses is warranted to compare the relative impact of interventions in a more standardized way.

Psychosocial well-being among patients with malignant pleural mesothelioma.

OBJECTIVES: The investigators conducted a psychosocial needs assessment of mesothelioma patients through self-report measures of quality of life (QOL), coping, depression, and social support. METHODS: Patients with malignant pleural mesothelioma (MPM) (N = 67) completed a battery of assessments at a single timepoint after being approached during routine medical oncology clinic appointments or by letter. RESULTS: Participants were predominately male (70.0%; n = 47) and ranged in age from 35 to 83 years old (M = 65.61, SD = 9.71). Most participants were white (88.0%; n = 59), and 10.0% (n = 7) were identified as Hispanic. The majority were married or living with a partner (93.0%; n = 62) and had some college or more education (64.0%; n = 43). Fourteen percent of participants (n = 11) endorsed significantly elevated depression symptoms. No significant demographic or clinical differences in depressed compared to nondepressed participants were observed, with a trend toward those identifying as Hispanic and those who were divorced as being more likely to be depressed. For the total sample, the most frequently endorsed coping strategies were active coping, emotional support, and acceptance. SIGNIFICANCE OF RESULTS: The present study did not identify any clear correlates of depression or QOL among patients with MPM. This research contributes to the small literature on psychosocial functioning in patients with MPM and provides putative directions for future larger studies and the development of interventions to provide appropriate support to diverse patients with MPM.

How patients with advanced cancer conceptualize prognosis: A phenomenological qualitative inquiry.

BACKGROUND: Despite the importance of accurate prognostic understanding in patients with advanced cancer, there is little consensus around how to conceptualize and measure the multidimensional construct. Most studies focus on single aspects of prognostic understanding (e.g., curability) that clinicians have identified as important; no previous research has asked patients how they define "prognosis." AIM: The present study examined how patients with advanced cancer conceptualize their "prognosis." It also explored how patients assigned value to prognostic information and the impact of prognosis on life perspectives. DESIGN: A phenomenological approach was used to analyze semi-structured interviews with individuals with advanced cancer to examine how patients define prognosis. SETTING/PARTICIPANTS: English and Spanish-speaking patients with advanced cancer (N = 29) were recruited from ambulatory clinics at a comprehensive cancer center in New York City. RESULTS: To conceptualize prognosis, patients focused on concrete medical data, anticipated survival and quality of life, impact on meaningful life events, uncertainty, and physician affect. They discussed the importance of maintaining normalcy despite prognosis, knowledge as a form of coping, information reframing, and altered decision-making as means of coping with prognostic information. CONCLUSIONS: Given the range of ways patients define prognosis and assign value to prognostic information, clinicians should incorporate a thorough assessment of patient information preferences, values, and coping styles when engaging in end-of-life discussions. Trainings should emphasize the importance of nonverbal cues (i.e., affect management, body language) in prognostic disclosure.

On taking up space: a qualitative inquiry of depression in older adults with cancer.

OBJECTIVE: To identify the phenomenology of depression in older adults with cancer (OACs) in order to improve the accuracy of depression screening for this population. METHOD: Inclusion criteria were: ≥70 years old, history of cancer, no cognitive impairment or severe psychopathology. Participants completed a demographic questionnaire, a diagnostic interview, and a qualitative interview. Using a Thematic Content Analysis framework, critical themes, passages, and phrases used by patients to describe their perceptions of depression and how it is experienced were identified. Particular attention was paid to divergences between depressed and non-depressed participants. RESULTS: Among 26 OACs (13 depressed, 13 non-depressed), qualitative analyses revealed four major themes indicative of depression (i.e. anhedonia, reduction in social relationships/loneliness, lack of meaning and purpose, lack of usefulness/feeling like a burden) and four minor themes (i.e. attitude towards treatment, mood, regret/guilt, physical symptoms/limitations). Themes of adaptation and acceptance of symptoms also emerged. CONCLUSIONS: Of the eight themes identified, only two overlap with DSM criteria. This supports the need to develop assessment methods of depression in OACs that are less reliant on DSM criteria and distinct from existing measures. This may improve the ability to identify depression in this population.

Cancer and aging: Reflections for elders- Expressive writing intervention: A pilot study.

OBJECTIVES: The Cancer and Aging: Reflections for Elders Expressive Writing Intervention (CARE-Express) was developed to enhance coping and minimize psychological distress in older adults with cancer. The aim of the current study is to evaluate the feasibility and initial efficacy of CARE-Express. MATERIALS AND METHODS: Seventy-one distressed older adults (≥70) with cancer were assigned to CARE-Express (n = 41) or the Enhanced Social Work Control (ESWC) arm (n = 30). Participants completed five telephone sessions over seven weeks and were assessed on psychosocial variables at baseline, post-intervention, and four months post study enrollment. Feasibility was assessed by examining rates of eligibility, acceptance, retention, assessment, and fidelity. Initial efficacy was evaluated using standardized effect sizes. RESULTS: Adequate rates of acceptance (29%), eligibility (66%), retention (90%), assessment (70% at post-intervention, 63% at four month follow-up), and fidelity (97%) were observed. At post-intervention, participants receiving CARE-Express reported less depression compared to ESWC (d = 0.69, p = 0.01) and lower demoralization (d = 0.50, p = 0.06). A small/moderate effect was demonstrated for increased total spirituality scores (d = 0.41, p = 0.07), meaning/peace (d = 0.32, p = 0.20) and faith (d = 0.35, p = 0.07). The CARE-Express group reported greater reductions in behavioral disengagement (d = 0.44, p = 0.06), while ESWC demonstrated a small effect for active coping (d = 0.21, p = 0.31). At four months, differential effects of CARE-Express had attenuated, though small/moderate, effects in favor of CARE-Express remained. CONCLUSION: Results support the feasibility of CARE-Express and its potential positive impact on psychological well-being. TRIAL REGISTRATION: Registered at the US National Institutes of Health (ClinicalTrials.gov) #NCT00984321 on September 25, 2009.

Implementation of a Meaning-Centered Psychotherapy training (MCPT) program for oncology clinicians: a qualitative analysis of facilitators and barriers.

The Meaning-Centered Psychotherapy training program (MCPT) is a multimodal, intensive, in-person program that trains cancer care providers in the evidence-based psychosocial treatment Meaning-Centered Psychotherapy (MCP). This analysis aimed to identify barriers and facilitators to clinical implementation (CI) at 1 year post-training. Trainee feedback regarding CI was collected via a mixed-methods questionnaire, including rating the ease of CI and free-text response identifying facilitators and barriers to CI. Descriptive statistics and thematic content analysis of follow-up data from the first five MCPT training cohorts (n = 55) were performed to assess CI and its facilitators and barriers. One third of participants indicated that it was at least somewhat difficult to implement MCP in clinical practice. Trainee-identified facilitators and barriers to CI were characterized within four main categories: program, patient, treatment, and institution. Within each of these factors, clinicians reported a variety of components that contributed to or hindered their ability to implement MCP. MCPT itself was reported as a facilitator. Patient access and interest were simultaneously identified as facilitators for some and barriers for others. Some trainees found the MCP treatment structure helpful in addressing important patient psychosocial needs, while others felt it was too restrictive. Institutional support played an important role in whether trainees felt hindered or helped to implement MCP. These initial results provide important insight into the program's strengths and have fostered improvements to the MCPT program to better facilitate CI. Further study of MCPT CI is warranted, and theme refinement will be possible with a larger sample.

Prognostic implications of depression and inflammation in patients with metastatic lung cancer.

Background: Lung cancer-related inflammation is associated with depression. Both elevated inflammation and depression are associated with worse survival. However, outcomes of patients with concomitant depression and elevated inflammation are not known. Materials & methods: Patients with metastatic lung cancer (n = 123) were evaluated for depression and inflammation. Kaplan-Meier plots and Cox proportional hazard models provided survival estimations. Results: Estimated survival was 515 days for the cohort and 323 days for patients with depression (hazard ratio: 1.12; 95% CI: 1.05-1.179), 356 days for patients with elevated inflammation (hazard ratio: 2.85, 95% CI: 1.856-4.388), and 307 days with both (χ2 = 12.546; p < 0.001]). Conclusion: Depression and inflammation are independently associated with inferior survival. Survival worsened by inflammation is mediated by depression-a treatable risk factor.

Health Information Preferences and Curability Beliefs Among Patients With Advanced Cancer.

CONTEXT: Accurate prognostic understanding is associated with increased advance care planning, symptom control, and patient autonomy in oncology. The impact of prognostic understanding on patients' health information preferences (HIPs) and prognostic information preferences is unknown and has important implications for health care communication. OBJECTIVES: The present study characterized the HIPs of patients with advanced cancer; examined differences in HIPs between patients with varying curability beliefs; and identified differences in the characteristics and psychological well-being of patients with varying curability beliefs. METHODS: This cross-sectional study used a secondary data analysis of baseline data (prerandomization) for patients enrolled in a large randomized controlled psychotherapy trial. 206 participants were recruited from outpatient clinics at a single facility. Inclusion criteria included: 18 years and older; English speaking, Stage IV solid tumor cancer, and Distress Thermometer score of ≥4. RESULTS: Most participants preferred as many details as possible about their diagnosis and treatment (69.4%; n = 143), and the likely outcome of their disease (72.3%; n = 149). Most participants accurately described their cancer as unlikely curable or incurable (62.6%; n = 129). There were no significant differences in HIPs based on level of prognostic understanding. Poorer prognostic understanding was associated with religiosity and better quality of life and existential well-being. CONCLUSION: In the present study, prognostic understanding (i.e., curability beliefs) was not associated with HIPs. Therefore, oncology clinicians must individually and interatively evaluate patients' interest and preferences for receiving information. Future research should further clarify preferences for the framing and content of prognostic information from providers and improve the measurement of prognostic understanding to facilitate patient-centered end-of-life care.

Confirmatory Factor Analysis of the Center for Epidemiologic Studies Depression Scale in Oncology With Examination of Invariance Between Younger and Older Patients.

Accurate measurement of depressive symptoms in the cancer setting is critical for ensuring optimal quality of life and patient outcomes. The present study compared the one-factor, correlated two-factor, correlated four-factor, and second-order factor models of the Center for Epidemiologic Studies Depression Scale (CES-D), a commonly used measure in oncology settings. Given the importance of adequate psychometric performance of the CES-D across age groups, a second aim was to examine measurement invariance between younger and older adults with cancer. Participants (N = 663) were recruited from outpatient clinics at a large cancer center. Over one-fourth of the sample endorsed clinically significant depressive symptoms (25.9%, n = 165). Confirmatory factor analysis of the CES-D supported the hypothesized correlated four-factor model as the best fit. The second-order factor also demonstrated good fit, but interpretations of the factors were more complex. Factors were highly correlated (range = .38-.91). There was also support for full scalar invariance between age groups, suggesting that regardless of age, respondents endorse the same response category for the same level of the latent trait (i.e., depression) on the CES-D. Taken together, the results suggest that the CES-D is a viable depression screening option for oncology settings and does not require scoring adjustments for respondent age.

Are we accurately evaluating depression in patients with cancer?

Depression remains poorly managed in oncology, in part because of the difficulty of reliably screening and assessing for depression in the context of medical illness. Whether somatic items really skew the ability to identify "true" depression, or represent meaningful indicators of depression, remains to be determined. This study utilized item response theory (IRT) to compare the performance of traditional depression criteria with Endicott's substitutive criteria (ESC; tearfulness or depressed appearance; social withdrawal; brooding; cannot be cheered up). The Patient Health Questionnaire (PHQ-9), ESC, and Center for Epidemiologic Studies Depression Scale (CES-D) were administered to 558 outpatients with cancer. IRT models were utilized to evaluate global and item fit for traditional PHQ-9 items compared with a modified version replacing the 4 somatic items with ESC. The modified PHQ-9 ESC scale was the best fit using a partial credit model; model fit was improved after collapsing the middle 2 response categories and removing psychomotor agitation/retardation. This improved model showed satisfactory scale precision and internal consistency, and was free from differential item functioning for gender, age, and race. Concurrent and criterion validity were supported. Thus, as many have speculated, utilizing the ESC may result in more accurate identification of depressive symptoms in oncology. Depressed mood, anhedonia, and suicidal ideation retained their expected properties in the modified scale, indicating that the traditional underlying syndrome of depression likely remains the same, but the ESC may provide more specificity when assessing patients with cancer. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Latent Profile Analyses of Depressive Symptoms in Younger and Older Oncology Patients.

The aging of America will include a significant increase in the number of older patients with cancer, many of whom will experience significant depressive symptoms. Although geriatric depression is a well-studied construct, its symptom presentation in the context of cancer is less clear. Latent profile analysis was conducted on depressive symptoms in younger (40-64 years) and older (≥65 years) patients with cancer (N = 636). The sample was clinically heterogeneous (i.e., included all stages, dominated by advanced stage disease). Participants completed questionnaires including the Center for Epidemiological Studies Depression Scale, which was used for the latent profile analysis. A four-class pattern was supported for each age group. However, the four-class pattern was significantly different between the younger and older groups in terms of the item means within each corresponding latent class; differences were primarily driven by severity such that across classes, older adults endorsed milder symptoms. An unexpected measurement issue was uncovered regarding reverse-coded items, suggesting that they may generate unreliable scores on the Center for Epidemiological Studies Depression Scale for a significant subset of patients. The results indicate that cancer clinicians can expect to see depressive symptoms along a continuum of severity for patients of any age, with less severe symptoms among older patients.

Is screening for psychosocial risk factors associated with mental health care in older adults with cancer undergoing surgery?

BACKGROUND: Surgery is a notable stressor for older adults with cancer, who often are medically and psychosocially complex. The current study examined rates of preoperative psychosocial risk factors in older adults with cancer who were undergoing elective surgery and the relationship between these risk factors and the provision of mental health services during the postoperative hospitalization. METHODS: A total of 1211 patients aged ≥75 years who were referred to the geriatrics service at a comprehensive cancer center were enrolled. Patients underwent elective surgery with a length of stay of ≥3 days and were followed for at least 30 days after surgery. A comprehensive geriatric assessment was administered as part of routine preoperative care. Bivariate relationships between demographic and surgical characteristics and the preoperative comprehensive geriatric assessment and the receipt of mental health services during the postoperative hospitalization period were examined. Characteristics with bivariate relationships that were significant at the level of P < .10 were entered into a multivariable regression predicting postoperative mental health service use. RESULTS: Approximately one-fifth of the total sample (20.6%) received postoperative mental health services. In multivariable analyses, high distress (P = .007) and poor social support (P = .02) were found to be associated with a greater likelihood of the receipt of mental health services. Of those patients with high distress and poor social support, only approximately one-quarter (24.6%-25.5%) received mental health care. CONCLUSIONS: Distressed older adults and those with low levels of support preoperatively were found to be more likely to receive mental health services after surgery. Nevertheless, less than one-third of these patients received inpatient postoperative mental health care, indicating that barriers to translating screening into the provision of psychosocial services remain.

Psychotherapy at the End of Life.

Dr. Elisabeth Kübler-Ross is credited as one of the first clinicians to formalize recommendations for working with patients with advanced medical illnesses. In her seminal book, On Death and Dying, she identified a glaring gap in our understanding of how people cope with death, both on the part of the terminally ill patients that face death and as the clinicians who care for these patients. Now, 50 years later, a substantial and ever-growing body of research has identified "best practices" for end of life care and provides confirmation and support for many of the therapeutic practices originally recommended by Dr. Kübler-Ross. This paper reviews the empirical study of psychological well-being and distress at the end of life. Specifically, we review what has been learned from studies of patient desire for hastened death and the early debates around physician assisted suicide, as well as demonstrating how these studies, informed by existential principles, have led to the development of manualized psychotherapies for patients with advanced disease. The ultimate goal of these interventions has been to attenuate suffering and help terminally ill patients and their families maintain a sense of dignity, meaning, and peace as they approach the end of life. Two well-established, empirically supported psychotherapies for patients at the end of life, Dignity Therapy and Meaning Centered Psychotherapy are reviewed in detail.

Neuropsychological Predictors of Decision-Making Capacity in Terminally Ill Patients with Advanced Cancer.

OBJECTIVE: The purpose of this cross-sectional study was to identify the neuropsychological underpinnings of decision-making capacity in terminally ill patients with advanced cancer. METHOD: Participants were 108 English-speaking adults. More than half (n = 58) of participants had a diagnosis of advanced cancer and were receiving inpatient palliative care; the rest were healthy adults. Participants completed a measure of decision-making capacity that assesses four legal standards of capacity (Choice, Understanding, Appreciation, and Reasoning), and several measures of neuropsychological functioning. RESULTS: Patients with terminal cancer were significantly more impaired on measures of capacity and neuropsychological functioning. Surprisingly, in the terminally ill sample, there were no significant correlations between neuropsychological functioning and decision-making capacity. CONCLUSION: The terminally ill sample exhibited high levels of neuropsychological impairment across multiple cognitive domains. However, few of the measures of neuropsychological functioning were significantly associated with performance on the decisional capacity subscales in the terminally ill sample. It is possible that end-of-life decisional capacity is governed by general, rather than domain-specific, cognitive abilities.