Table 3:

Representative Quotes of the Two Themes Influencing Physician Decision-making for Treatment in Patients with MCI

Theme 1: Physicians assume that the decreased cognitive ability of MCI patients will impact treatment.

Impaired Independent Decision Making

• “The patient themselves might not fully understand or be able to balance the risks and benefits of surgery when it comes to manipulating complex numbers and knowing how they do or don’t apply to them.” (MD4, internist).

• “It’s often in those cases I’ll ask - like I had one case where I actually asked to see the document, the consent. I can find it in the computer and then I went over it with a family member who was with them at the visit…I said, “Did you see this form,” and she said, “Well no, they let him [MCI patient] sign it,” and I said, “He’s not been declared legally incompetent to sign documents,” but they didn’t know that actually he doesn’t understand a lot of the language.” (MD12, internist)

Inability to Adhere to Treatment

• “Here’s what’s happening; they’re actually not taking their medicines like they say they are. They don’t do anything; they just sit in a chair and watch TV all day.” (MD2, cardiologist)

• “The less somebody is able to understand and be part of their recovery, the rockier that course is going to be.” (MD9, cardiologist)

• “With that [electroencephalogram, EEG] there is often a lot of electrodes on the head and that can be quite bothersome to a patient. If they’re not understanding why they’re there they might be pulling at the EEG leads.” (MD13, neurologist)

Inability to Communicate Treatment Preferences

• “I think a lot of that comes from clinicians being busy, consulting services being busy, and there’s a real risk of anchoring bias for what the patient sort of first says to you or what their first impression is… I think with mild cognitive impairment, that’s the type of diagnosis that I think can often be somewhat glossed over and maybe it would not, you know, trip the threshold for the consulting service to say, well, we should really pressure test the statement of, ‘I don’t want to have surgery’.” (MD8, internist)

Theme 2: Physicians assume that the poor health status and physical functioning of MCI patients will impact treatment.

Poor Health, Life Expectancy and Functional Status

• “I would not put those devices [defibrillators] in if there’s an older patient where the life expectancy would be limited because I feel like they wouldn’t get benefit from it at all…It’s more age than cognitive but they go together very frequently” (MD3, internist)

• “If there are three or four different factors and there’s MCI, I might be more conservative and less aggressive in recommending surgery…MCI in that particular case would tip you over to not do something, I think.” (MD14, neurologist)

Increased Risks and Burden from Treatment

• “If they had mild cognitive impairment and now we’re concerned they’re going to become much more impaired than it might make their surgical decision making more conservative.” (MD16, internist)

• “If somebody like, for whatever reason gets tested, is found to have [carotid] narrowing but has not had a stroke or a TIA, I’m in general pretty disinclined to recommend those patients ever go for surgery, unless it’s the perfect circumstance. And MCI might be a variable that I could talk myself into being a non-perfect circumstance.” (MD11, neurologist)