title: Minor cognitive impairments in cancer patients magnify the effect of caregiver preferences on end-of-life care.
abstract: BACKGROUND
  Cognitive impairment commonly affects cancer patients.
  
  
  OBJECTIVE
  To examine whether minor cognitive impairment in patients with advanced cancer is associated with the intensity of end-of-life (EOL) care or modifies the influence of patient and caregiver preferences on the intensity of EOL care.
  
  
  METHODS
  Data were derived from structured interviews with 221 advanced cancer patient-caregiver dyads in the Coping with Cancer Study, a multisite, longitudinal cohort study. Deficits in patients' cognitive function were identified using the Short Portable Mental Status Questionnaire (SPMSQ). Patients and caregivers reported preferences regarding life-extending vs. symptom-directed care. Information regarding EOL care was obtained from postmortem interviews with caregivers. Logistic regression analyses modeled main and interactive effects of patients' cognitive impairment and patients' and caregivers' treatment preferences on intensive EOL care.
  
  
  RESULTS
  Cognitive impairment was associated with less intensive EOL care (odds ratio [OR] = 0.56; 95% confidence interval [CI]: 0.34-0.91). Patients and caregivers had poor agreement regarding preferences for life-extending vs. symptom-directed care (Φ = 0.10; χ(2)=2.32, df = 1, P = 0.13). Patient preference for life-extending care predicted intensive EOL care irrespective of cognitive status (adjusted odds ratio [AOR] = 2.11; 95% CI: 1.04-4.28). For patients with no errors on the SPMSQ, caregiver preference for life-extending care was unrelated to intensive EOL care (AOR = 0.40; 95% CI: 0.09-1.77). However, the association between caregiver preference for life-extending care and intensive EOL care increased by nearly a factor of seven for every error on the SPMSQ (interaction AOR = 6.90; 95% CI: 1.40-34.12).
  
  
  CONCLUSIONS
  Cognitive impairment in patients with advanced cancer is associated with less intensive EOL care. Caregivers' influence on intensive EOL care dramatically increases with minor declines in patients' cognitive function.
authors: Center for Psychosocial Epidemiology and Outcomes Research, Dana-Farber Cancer Institute, Boston, MA, USA.
authors: Xin
authors: X
authors: Gao
authors: Holly G
authors: HG
authors: Prigerson
authors: Eli L
authors: EL
authors: Diamond
authors: Baohui
authors: B
authors: Zhang
authors: Alexi A
authors: AA
authors: Wright
authors: Fremonta
authors: F
authors: Meyer
authors: Paul K
authors: PK
authors: Maciejewski
mesh_terms: D017677:Age Distribution; D001294:Attitude to Health; D001900:Boston / Q000453:epidemiology; D017028:Caregivers / Q000706:statistics & numerical data*; D060825:Cognitive Dysfunction / Q000401:mortality* / Q000451:nursing*; D003657:Decision Making; D004522:Educational Status; D005260:Female; D006801:Humans; D008297:Male; D017533:Marital Status; D008875:Middle Aged; D009369:Neoplasms / Q000401:mortality* / Q000451:nursing*; D010166:Palliative Care / Q000706:statistics & numerical data*; D015995:Prevalence; D012307:Risk Factors; D017678:Sex Distribution; D016019:Survival Analysis; D015996:Survival Rate; D013727:Terminal Care / Q000706:statistics & numerical data*