Evaluation Of Decision-making Capacity Research Articles

Age-bias in assessments of medical decision-making capacity: a cross-sectional experimental vignette study

Accurate assessments about medical decision-making capacity (DMC) are vital but could be susceptible to age-bias. We examined if client age impacts on DMC likelihood assessment. One hundred and forty-seven adults were trained to identify four cognitive abilities (i.e., understanding, appreciation, reasoning, expression). Six experimental vignettes described a person making a diabetes treatment decision with systematic variation of client age (unspecified, 50-, or 95-years-old) and abilities (demonstrated vs uncertain). The dependent variable was DMC likelihood. Standardised tests of explicit (Kogan’s Attitudes Toward Old People scale) and implicit age-bias (IAT) were administered. There was a statistically significant effect of abilities on DMC likelihood. DMC was judged more likely when cognitive abilities were demonstrated. There were no other significant effects. Age-bias, measured implicitly and explicitly, did not influence DMC likelihood. Contrary to the hypothesis, DMC likelihood was unaffected by client age. This suggests that training can mitigate age-bias in simulated clinical DMC evaluation.

Capacity Assessment Instrument – Health: Pilot Study of a New Tool for Adults with Dementia

ABSTRACT Objectives This research comprises a pilot study of the CAI-Health, a new tool for the evaluation of decision-making capacity in healthcare. It aims to analyze the instrument’s indicators of reliability and internal validity to conclude its final version. Methods A total of 89 participants were included, of which 22 had Alzheimer’s Disease; 32 had mild cognitive impairment, and 35 were controls. Cronbach’s alpha and the intercorrelation matrix were used as indicators of reliability and internal validity as well as to identify items for elimination. Repeated-measures ANOVA allowed for the analysis of differences between the vignettes that comprise CAI-Health. Results The internal consistency results were acceptable, and no items were proposed for elimination. A repeated-measures ANOVA revealed that the vignettes were unexpectedly equivalent. Despite the procedures used to develop clinical vignettes with increased levels of complexity in assessing decision-making capacity, this study showed no differences in the vignettes’ level of demand. Conclusions The extensive application of CAI-Health compromises its clinical usefulness and viability. To reduce its length while maintaining a thorough assessment of each ability, it was decided to eliminate two vignettes and retain all interview items. The final version of the CAI-Health comprises a clinical vignette and a capacity interview. Clinical implications CAI-Health was designed for the assessment of medical decision-making capacity in older adults.

Risk-Sensitive Assessment of Decision-Making Capacity: A Comprehensive Defense.

Should the assessment of decision-making capacity (DMC) be risk sensitive, that is, should the threshold for DMC vary with risk? The debate over this question is now nearly five decades old. To many, the idea that DMC assessments should be risk sensitive is intuitive and commonsense. To others, the idea is paternalistic or incoherent, or both; they argue that the riskiness of a given decision should increase the epistemic scrutiny in the evaluation of DMC, not increase the threshold for DMC. We respond to the critics' main concerns by providing a comprehensive account of how risk-sensitive DMC is coherent, avoids paternalism, and best fulfills the epistemic goal of DMC evaluations.

Functional MRI to Assess Decision-Making Capacity of Older Adults With Dementia: A Proof of Concept Study

Assessment of decision-making capacity is essential to respect older adult dignity, particularly concerning major decision such as ageing in place. To date, it is the clinician's assessment, based on a global analysis of his clinical evaluation and neuropsychological tasks, which enables decision-making assessment. Given the difficulty it represents, and the ethical and societal issues raised, the research question concerns the contribution of neuro-imaging technologies as an aid to the evaluation of decision-making capacity. We included in our proof-of-concept study 4 healthy older patients and 2 older patients with dementia (mild stage) followed in a memory clinic. Each of the participants completed neuropsychological tests with a focus on executive functions, anosognosia and judgemental skills. Next, they performed a decision-making task, the Balloon Assessment Risk Task (BART) in functional MRI, and, finally, they participated in a semi-structured interview completed with interview of their caregiver. For both patients, their referring geriatrician was questioned a priori on his assessment of their decision-making capacity. The results showed a common activation pattern in functional MRI between the patient considered competent in decision-making and the healthy subjects, unlike the patient who was not clinically competent. The qualitative analysis highlighted major anosognosia in both pathological situations, but decision-making in everyday life situations differed between the 2 patients. This study shows the feasibility, on a sensitive topic, to explore the potential contribution of functional neuroimaging and semi-directed interviews as tools. It also demonstrates the value of conducting mixed research, combining neurosciences and social science to explore complex clinical issues.

End-of-Life Decision-Making Capacity in Older People With Serious Mental Illness.

Background: The study's main aim was to assess the end-of-life decision-making capacity and health-related values of older people with serious mental illness.Methods: A cross-sectional, observational study, was done at Weskoppies Psychiatric Hospital, Gauteng Province, South Africa that included 100 adults older than 60 years of age and diagnosed with serious mental illness. The Mini-Cog and a semi-structured clinical assessment of end-of-life decision-making capacity was done before a standardized interview, Assessment of Capacity to Consent to Treatment, was administered. This standardized instrument uses a hypothetical vignette to assess decision-making capacity and explores healthcare-related values.Results: The Assessment of Capacity to Consent to Treatment scores correlated (p < 0.001) with the outcomes of the semi-structured decision-making capacity evaluation. Significant correlations with impaired decision-making capacity included: lower scores on the Mini-Cog (p < 0.001); a duration of serious mental illness of 30–39 years (p = 0025); having a diagnosis of schizophrenia spectrum disorders (p = 0.0007); and being admitted involuntarily (p < 0.0001). A main finding was that 65% of participants had decision-making capacity for end-of-life decisions, were able to express their values and engage in advance care discussions.Discussion and Conclusion: Healthcare providers have a duty to initiate advance care discussions, optimize decision-making capacity, and protect autonomous decision-making. Many older patients with serious mental illness can engage in end-of-life discussions and can make autonomous decisions about preferred end-of-life care. Chronological age or diagnostic categories should never be used as reasons for discrimination, and older people with serious mental illness should receive end-of-life care in keeping with their preferences and values.

Elder Financial Abuse and Electronic Financial Instruments: Present and Future Considerations for Financial Capacity Assessments

Personal economic stability is one of the core social determinants of health and longevity, and managing one's finances is an instrumental activity of daily living. Impaired financial decision-making can lead to poor health, emotional distress, and loss of independence and safety. Older adults in the United States lose billions of dollars annually to elder financial abuse (EFA), which may be preceded by a decline of capacity to make financial decisions. A literature review regarding EFA, electronic financial instruments (EFI), medical and financial decision-making capacity evaluations, and biomedical ethics was performed. Currently, there is no gold standard clinical assessment tool for evaluating financial capacity. The instruments in use have yet to formally integrate modern EFI that present novel mechanisms through which EFA can occur. This article summarizes the current state of EFA in the United States, risk factors and strategies for prevention, and offers a clinician administered screening questionnaire for addressing EFI use along with a semi-structured approach to clinical financial capacity assessments.

Capacity Assessment Training and Competency Evaluation Tool

Given the complex interplay of ethical, clinical, and legal factors, evaluating capacities in older adults is an important competency for geropsychologists. However, the amount of quality of training in this area varies, and geropsychology trainees report less confidence in their capacity evaluation skills. To date, only the Pikes Peak Self-Assessment Tool includes items measuring competency and growth in decisional capacity evaluations. However, it is a broad self-report measure assessing general geropsychology competencies. We developed a performance-based measure of decision-making capacity evaluations, the “Capacity Assessment Training and Competency Evaluation Tool (CATCET).” Using the ABA/APA Assessment of Older Adults with Diminished Capacity as a guide, expert panels created two clinical cases across 5 capacity domains. This presentation will discuss the creation of the CATCET, its application as a training and evaluation tool, and initial performance data among psychology graduate students, intern, and fellows across settings.

Psychiatric Illness and Medical Decision-Making Capacity: A Retrospective Study in Medical Settings

Determination of medical decision-making capacity (DMC) is one of the common encounters in Consultation-Liaison Psychiatry (CLP) services. It is a common misbelief that patients with “psych history” lack capacity more often than patients without mental illness. The study aims to examine the relationship between mental illness and DMC in patients presented to acute medical settings. The study is a retrospective chart review, where data were collected from the patients admitted to the medical units and assessed for capacity by a psychiatrist. Clinical and demographic characteristics were compared between two groups (patients having capacity and lacking capacity) using t-tests or chi-square tests, as appropriate. The commonest reason for DMC evaluation requests was for the patients who wanted to leave the hospital against medical advice. Overall, 53% (52/98) of the patients evaluated for DMC were found to lack capacity. Group of patients lacking DMC had a significantly higher percentage of males (58% vs. 35%) but were significantly less employed (8% vs. 10%). No significant difference was observed in other demographic characteristics and primary psychiatric diagnoses (past and current) among the two groups. However, patients lacking capacity were found to have a significantly more occurrence of current (48% vs. 11%) and past (23% vs. 4%) history of neurocognitive disorder, and larger trend significance (31% vs. 15%) of active psychiatric symptoms. We conclude that patients with neurocognitive disorders and active psychiatric symptoms might have poor DMC but not all patients who have psychiatric diagnoses lack medical DMC. Larger studies especially in outpatient psychiatric settings are suggested to derive more conclusive results.

Decision-making capacity evaluations: the role of neuropsychological assessment from a multidisciplinary perspective

Decision-making capacity (DMC) in aging adults has become increasingly salient as the number of older adults, life expectancy, and the amount of wealth to be transferred from older generations have all increased. The accurate and reliable determination of older adults’ DMC is a particularly important topic given its implication in legal, financial, and health decisions. Based upon the four-ability DMC model promulgated by Appelbaum and Grisso in the 1980’s, a number of MacArthur Competence Assessment Tools have been developed and widely utilized. However, these tools do not include cognitive testing or other sources of objective data and have limited validity in a medico-legal setting, necessitating additional options for the evaluation of DMC. This is significant from the perspective of the patient because they have a vested interest in accurate and objective assessment of their DMC across domains.Given the disparities in the assessment of DMC, the authors propose, through this debate article, that the evaluation of DMC in the aging adult population utilize a combination of traditional interview and domain specific instruments and neuropsychological testing. To achieve a consensus on the issue, medical experts in a number of fields related to capacity evaluation, including psychiatry, neurology, neuropsychology, and general medicine were consulted and recruited as authors. Experts in Swiss law and ethics were also consulted and provided input.A tendency to focus on a single capacity, and in particular, the ability to consent to medical treatment, arose in the literature. Similarly, there are many instruments purporting to evaluate a single capacity (e.g., consenting to medical treatment, managing finances), while other areas important to the evaluation of DMC received little attention (e.g., activities of daily living, the ability to live independently, to marry, to resist undue influence, and to make a will or advanced care directive). Medical and legal experts in the multidisciplinary group agreed that there is a clear need for more consistency across evaluation of DMC domains and that a combined approach of traditional methods and neuropsychological testing provides a more thorough evaluation and better serves the patient.

Evaluation of decision-making capacity in patients with dementia: challenges and recommendations from a secondary analysis of qualitative interviews

BackgroundEvaluation of decision-making capacity to consent to medical treatment has proved to be difficult in patients with dementia. Studies showed that physicians are often insufficiently trained in the evaluation of decision-making capacity. In this study, we present findings from a secondary analysis of a qualitative interviews with physicians. These interviews were initially used to assess usability of an instrument for the evaluation of decision-making capacity. By looking at difficult cases of decision-making capacity evaluation in patients with dementia, we provide recommendations for such evaluations in clinical practice.MethodsWe used thematic coding to analyse physicians’ narratives of problematic decision-making capacity evaluations in patients with dementia to uncover challenging issues of decision-making capacity evaluation.ResultsIn this study, decision-making capacity evaluations in patients with dementia were mainly perceived as challenging when they pertained to treatment refusals and treatment unrelated circumstances, such as psychiatric consultation, advance directives, and new living arrangements. Furthermore, the physicians reported training needs regarding situation-independent challenges with decision-making capacity evaluation.ConclusionsUpon further examining self-reported training needs and challenging cases, we have developed recommendations to improve decision-making capacity evaluations in clinical practice. In these recommendations, we argue that being able to evaluate decision-making capacity is an integral part of the informed consent process.

Decision-making capacity: from testing to evaluation.

Decision-making capacity (DMC) is the gatekeeping element for a patient's right to self-determination with regard to medical decisions. A DMC evaluation is not only conducted on descriptive grounds but is an inherently normative task including ethical reasoning. Therefore, it is dependent to a considerable extent on the values held by the clinicians involved in the DMC evaluation. Dealing with the question of how to reasonably support clinicians in arriving at a DMC judgment, a new tool is presented that fundamentally differs from existing ones: the U-Doc. By putting greater emphasis on the judgmental process rather than on the measurement of mental abilities, the clinician as a decision-maker is brought into focus, rendering the tool more of an evaluation guide than a test instrument. In a qualitative study, the perceived benefits of and difficulties with the tool have been explored. The findings show on the one hand that the evaluation aid provides basic orientation, supports a holistic perspective on the patient, sensitizes for ethical considerations and personal biases, and helps to think through the decision, to argue, and to justify one's judgment. On the other hand, the room for interpretation due to absent operationalisations, related ambiguities, and the confrontation with one's own subjectivity may be experienced as unsettling.

OTHR-01. USING COGNITION TO PREDICT RISK OF MEDICAL DECISION-MAKING IMPAIRMENT IN BRAIN CANCER

BACKGROUND: Medical decision-making capacity refers to the ability to make informed decisions about medical treatment. Understanding is the most cognitively demanding aspect of medical decision-making and requires the ability to comprehend medically-related information and then use that information to make decisions about diagnosis, prognosis, and treatment options. In previous papers, we have shown that knowledge about specific cognitive abilities that affect understanding in brain cancer could be used to construct actuarial equations designed to help clinicians identify persons with brain cancer or brain metastases at risk of understanding impairment. METHODS: In total, 184 participants (67 with brain metastasis, 41 with non-brain metastasis, 29 with malignant glioma, and 47 healthy controls) were recruited. All participants were administered a neuropsychological battery that included a performance-based measure of medical decision-making capacity. Impairment cutoffs were calculated from control group performance. Using the cognitive scores that were most highly associated with understanding, logistic and linear regression models were used to construct actuarial equations designed to predict intact/impaired understanding and understanding scores, respectively. RESULTS: As expected, both brain cancer groups had poorer understanding than controls and approximately 50% of both brain cancer groups exhibited impaired understanding. Over 24% of the non-brain metastasis group exhibited impaired understanding. Significant associations were found between understanding and all administered cognitive variables, with the strongest correlations noted as between understanding and measures of executive function, verbal memory, and verbal fluency. Using these cognitive variables, we were able to construct predictive equations that showed strong psychometric properties. CONCLUSIONS: These data demonstrate how cognitive measures can estimate medical understanding in persons with cancer. Clinically, these findings suggest that poor verbal memory, executive function, and/or phonemic fluency function could serve as “red flags” for reduced consent capacity in this patient population, and thus signal that a more comprehensive medical decision-making capacity evaluation is warranted.

Evaluating Decision-Making Capacity

Abstract. The study identified factors that make an evaluation of decision-making capacity (DMC) difficult for clinicians in their daily work. Semistructured interviews were carried out with 24 healthcare professionals from Switzerland and subsequently thematically analyzed. The challenges they faced when evaluating DMC stemmed from three main concerns: patient characteristics that impede DMC evaluation; differing opinions and consequences of DMC evaluation; and familial and legal situations that complicate such evaluations. Physicians must be adequately trained to evaluate DMC as it is closely related to basic ethical principles of respect for patients’ autonomy and beneficence. Extensive training on DMC evaluation and the legal concept of capacity should be part of pre- and postgraduate education.

Medical Decision-Making Capacity

Abstract. Decision-making capacity (DMC) is a prerequisite for informed consent to medical treatments. However, little is known about the knowledge, attitudes, and evaluation of DMC among physicians in Croatia. A survey was conducted among 180 general practitioners and psychiatrists in Croatia. Although from a legal perspective DMC is a dichotomous concept, about 90% of physicians indicated that they understand DMC to be a gradual concept. A majority of physicians considered themselves responsible and qualified to conduct DMC evaluations, though some physicians considered themselves insufficiently qualified. General practitioners considered themselves less responsible and less qualified than psychiatrists. Almost all participants indicated that they would welcome official guidelines and training.

An algorithm for managing adults who refuse medical treatment in New South Wales.

The assessment and management of a patient who refuses medical treatment requires clinical skill, and consideration of the relevant law and the patient's decision-making capacity. Psychiatrists are often asked to advise in these situations. We aimed to develop an algorithm describing the relevant legal pathways to assist clinicians, especially psychiatrists, working in New South Wales (NSW), Australia. We reviewed the academic literature on treatment refusal, relevant legislation, judicial rulings and NSW Health policy directives and guidelines. We consulted with clinicians and representatives of relevant tribunals. We developed an algorithm for managing patients who refuse medical treatment in NSW. The algorithm emphases the evaluation of decision-making capacity and tracks separate pathways depending upon a person's status under the Mental Health Act 2007 (NSW). The algorithm provides a clear decision tree for clinicians responding to a patient refusing medical treatment in NSW.

Capacity Evaluation Requests in the Medical Setting: A Retrospective Analysis of Underlying Psychosocial and Ethical Factors

Psychosocial and ethical variables influence physicians in requesting decision-making capacity (DMC) evaluations. Previous authors have classified certain DMC evaluation requests as "unwarranted" when there is no explicit suspicion or evidence that the patient might lack DMC. To explore psychosocial and ethical reasons motivating both "warranted" and "unwarranted" DMC evaluation requests by physicians in the medical setting. A retrospective electronic health record review was approved by the institutional review board. All psychiatric consultation requests identified as DMC evaluation requests between January 1, 2012 and December 31, 2012 were assessed independently by 2 reviewers. Each reviewer identified each DMC evaluation request as "warranted" vs "unwarranted." Unwarranted DMC evaluation requests were defined as those lacking explicit suspicion that the patient might lack DMC or those with explicit evidence of a patient with blatantly impaired DMC. We hypothesized that most (over half) DMC evaluation requests would be deemed unwarranted. Descriptive statistics, chi-square/Fisher exact tests, and t-test/ANOVA were used. A total of 146 DMC evaluations were reviewed, and 83 (56.8%) of these were deemed unwarranted. Of these, most were likely driven by a previous neuropsychiatric disturbance (p < 0.001). Various other psychosocial and ethical patterns were identified (i.e., the practice of defensive medicine and guardianship concerns). Over half of DMC evaluation requests in a general medical setting were unwarranted. Many such requests were motivated by unarticulated psychosocial and ethical factors. DMC evaluation requests appear to serve as a means for indirectly resolving various psychosocial and ethical dilemmas beyond assessing DMC itself. Implications and future directions are discussed.

Shedding Light on Implicit Processes and the Inherent Vagueness of Decision-Making Capacity

Shedding Light on Implicit Processes and the Inherent Vagueness of Decision-Making Capacity Helena Hermann (bio), Manuel Trachsel (bio), and Nikola Biller-Andorno (bio) We are grateful to Paul S. Appelbaum and Wayne Martin for their thoughtful remarks on our paper. Among the various aspects that we might address and refute in return, we have decided to focus on just two issues that we believe have potential to advance the debate. According to Appelbaum, the “assessment of an intuitive process is being predicated on a patient having the ability to reflect on determinants of which he may be completely unaware.” In this passage, he points to an apparently “self-evident paradox.” Also, Martin is skeptical about the assessment of intuitive reasoning ability. We agree that relying entirely on unarticulated gut feelings is problematic in terms of decision-making capacity (DMC). However, we do not regard the mentioned paradox as unresolvable. It might be true that something that is implicit cannot be explicit, but that the implicit can be made explicit. In this transition—which is, in part, a self-reflective process—intuitions or feelings are experienced, verbalized, and assessed. We are not convinced that the operationalization of reasoning in the MacCAT-T is able to fully account for this process. Moreover, the assessment of intuitive processes illustrates why the provision of support is fundamentally important in DMC evaluations and should not be separated from the assessment. A counterpart is needed to identify the implicit, unconscious elements and/or help articulate them. Rather than looking at paradigms used in experimental psychology to measure the intuitive reasoning, as Martin proposed, we suggest learning from psychotherapeutic approaches that facilitate the transition from implicit, unconscious processes to explicit content, referred to as clarification-focused interventions (Grawe, 1997). In psychoanalytic theory, for example, two basic principles have been formulated enabling a grasp of unconscious elements: “free association” on the side of the patient, and “evenly-suspended attention” on the side of the clinician (Freud, 1912). If the patient reports whatever comes into his or her mind without actively censoring it and the clinician listens impartially and attaches no preconceived relevance to single elements of the [End Page 333] patient’s discourse, but is instead receptive to the order in which things are said, the fluency and omissions in the speech of the patient, and the manner and emotional tone by which they express themselves verbally and nonverbally, the subtexts in the patient’s speech will become hearable, and implicit elements can be identified (e.g., Mertens, 2015). Moreover, implicit experiences that have not yet been symbolized in language are often acted out nonverbally, evoking feelings, sensations, and images in the clinician, also known as “counter-transferences” (e.g., Mertens, 2015). Such counter-transferences provide additional insights that can help the patient recognize and verbalize the unconscious elements. Emotion-focused therapy (Greenberg, 2010) offers strategies to empathically foster the expression and articulation of emotions and to direct the patient’s attention to the present through techniques such as paraphrasing, repetition, exaggeration, and mirroring (Engle & Arkowitz, 2006). We regard it more pertinent for DMC (assuming that the patient understands the medical situation, including the risks and benefits of the treatment alternatives) that the patient is able to assign personal significance and meaning to the situation by means of self-reflection than to (merely) “identify the comparative consequences of the options” (Appelbaum, 2017, p. 327). Moreover, in affirming the potential of these techniques for DMC evaluation, we stress again the importance of addressing not only the definition of relevant criteria but the “how” of the assessment. Our second remark addresses the commentators’ criticism that the terms intuitive decision making or ability to self-reflect are too vague, poorly operationalized, and therefore incur a potential “risk of arbitrarily designating patients as incapable.” Indeed, it is worth thinking about vagueness in the context of DMC. Along with criteria too generally formulated, a different sort of vagueness is immanent in DMC, which evolves from a requirement to categorize people as either competent or incompetent. Although there are people who clearly fall into one or another category, there are also borderline cases, which are much more difficult to allocate. The question...

Decision-making capacity evaluation in adult guardianship: a systematic review.

Evidence of impaired decision-making capacity is a legal requirement for adult guardianship. To understand the quality of the evidence health professionals commonly provide in reports submitted to guardianship courts, a systematic review was undertaken to appraise the design and methodological quality of the published literature on health professionals' written reports of decision-making capacity and to describe the content of these reports. Electronic searches from 1980 to 2015 identified 1183 articles of which 11 met the inclusion criteria where each evaluated quantitatively the content of health professionals' written reports submitted to adult guardianship proceedings. Methodological quality of the selected studies was rated using a critical appraisal tool. Nine studies sourced files from courts in the U.S. and one from Sweden; another reported on guardianship decisions from Australia. Four studies were rated as moderately strong or strong. Strengths included the use of comparison groups and a reliable and valid instrument to code reports. The review showed a person's medical condition was often cited as evidence of impaired decision-making capacity. Cognitive, psychiatric and functional abilities were less often described, and a person's values and preferences were rarely recorded. It is recommended health professionals describe the process by which a person makes a particular decision (their ability to understand, appreciate, reason and communicate) in addition to providing medical information, including cognitive, psychiatric and functional abilities. This approach provides support for a professional's opinion and evidence for a court. International studies of health professionals' approach to decision-making capacity evaluation are needed.

Physicians’ personal values in determining medical decision-making capacity: a survey study

Decision-making capacity (DMC) evaluations are complex clinical judgements with important ethical implications for patients’ self-determination. They are achieved not only on descriptive grounds but are inherently normative and, therefore, dependent...

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

Medical decision-making capacity is a higher-order functional skill that refers to a patient's ability to make informed, sound decisions related to care and treatment. In a medical context, understanding is the most cognitively demanding consent standard and refers to a patient's ability to comprehend information to the extent that informed decisions can be made. The association between reasoning and cognition was examined using data from 41 patients with diagnosed brain metastasis. All diagnoses were made by a board-certified radiation oncologist and were verified histologically. In total, 41 demographically matched, cognitively healthy controls were also included to aid in classifying patients with brain metastasis according to reasoning status (ie, intact or impaired). Results indicate that measures of simple attention, verbal fluency, verbal memory, processing speed, and executive functioning were all associated with understanding, and that verbal memory and phonemic fluency were the primary cognitive predictors. Using these two primary predictors, equations can be constructed to predict the ability to understand treatment decisions in patients with brain metastasis. Although preliminary, these data demonstrate how cognitive measures can estimate understanding as it relates to medical decision-making capacities in these patients. Clinically, these findings suggest that poor verbal memory and expressive language function could serve as "red flags" for reduced consent capacity in this patient population, thus signaling that a more comprehensive medical decision-making capacity evaluation is warranted.