Results

Study selection

The literature search across 6 databases identified 2008 records, of which 967 duplicates were removed. After title and abstract screening, 132 articles remained for full-text reviews. As a result, 20 studies were included in the final review and analysis. The study selection process is summarized in the PRISMA flow diagram (Figure 1).

Figure 1: PRISMA flow diagram.

Study characteristics

As shown in Table 1, the 20 included studies were published between 2011 and 2025. Although the eligibility criteria allowed studies from East Asian countries and regions, the included studies were conducted in China (_n = _8),23–30 Taiwan (_n = _5),31–35 Japan (_n = _4),36–39 South Korea (_n = _2),40,41 and Hong Kong (_n = _1).42 The included studies employed diverse designs, including qualitative studies (_n = _8),23,25–27,29,33,34,40 quantitative observational studies (_n = _11),24,30–32,35–39,41,42 and 1 mixed-method study.28 Sample sizes ranged from 12 to 1600 participants, and the reported mean or median age of participants ranged from 65 to 86.9 years. Regarding the primary focus of decision-making, the studies addressed SDM in treatment decisions (_n = _9),23,25–27,33,37,38,40,41 advance care planning (ACP) (_n = _4)28,34–36 or advance directives (AD) (_n = _2),32,42 end-of-life (EOL) care (_n = _4),24,29,31,39 and life-sustaining treatment (LST) decision (_n = _1).30 Further details on study characteristics are provided in Supplementary Table 1.

References | Country or region (setting) | Study design | Study population (sample size) | Mean or median age | Primary focus of decision-making
Cao et al.23 | China (tertiary hospital) | Qualitative | Patients with prostate cancer (n =34)Medical and nursing staff (n =16) | 65.3 (mean) | Treatment decision (prostate cancer surgery)
Chen et al.31 | Taiwan (tertiary public hospital) | Quantitative (secondary analysis) | Patients with cancer who died in a hospital (n =1338) | 66.8 (mean) | End-of-life care (terminal cancer care)
Chong et al.40 | South Korea (university hospital) | Qualitative | Patients underwent kidney transplantation (n =12) | 67.4 (mean) | Treatment decision (kidney transplantation)
Chu et al.32 | Taiwan (public hospital) | Quantitative (secondary analysis) | Patients with chronic life-limiting illness or functional impairment (n =1411) | 78.2 (mean) | Advance directive
Chu et al.42 | Hong Kong (nursing homes) | Quantitative | Older adults residing in nursing homes (n =1600) | 82.4 (mean) | Advance directive
Chuang et al.33 | Taiwan (regional hospital) | Qualitative | Patients with degenerative joint disease (n =21) | 69.9 (mean) | Treatment decision
Fang et al.24 | China (nursing home) | Quantitative | Older adults with disability, dementia, or those over 80 years (n =571) | 86.9 (mean) | End-of-life care
Guo et al.25 | China (tertiary hospital) | Qualitative | Patients with stroke (n =31) | Not reporteda | Treatment decision (rehabilitation)
Hsu et al.34 | Taiwan (community center) | Qualitative | Patients with chronic disease (n =13)Family caregivers (n =12)Community nurses (n =11) | 71.7 (mean) | Advance care planning
Kanakubo et al.36 | Japan (medical institutions) | Quantitative | Patients undergoing hemodialysis (n =453) | 69 (mean) | Advance care planning
Komatsu et al.37 | Japan (communities) | Quantitative (secondary analysis) | Older adults covered by long-term care insurance (n =643)Primary caregivers (n =643) | Not reportedb | Treatment decision (long-term care)
Lin et al.35 | Taiwan (communities) | Quantitative | Patients receiving home-based medical care (n =408) | 80.4 (mean) | Advance care planning
Liu et al.26 | China (tertiary hospital) | Qualitative | Patients with multiple comorbidities (n =12)Caregivers (n =9)Healthcare professionals (n =7) | 65 (mean) | Treatment decision
Shibagaki et al.38 | Japan (medical institutions) | Quantitative | Patients with chronic kidney disease (n =475) | 67.4 (mean) | Treatment decision (renal replacement therapy)
Shin et al.41 | South Korea (hospitals) | Quantitative | Patients with cancer (n =358)Family caregivers (n =358) | 71.1 (mean) | Treatment decision
Shinada et al.39 | Japan (tertiary hospitals) | Quantitative | Caregivers who experienced the loss of older patients with cardiovascular disease (n =266) | 82 (median) | End-of-life care
Wang et al.27 | China (tertiary hospitals) | Qualitative | Patients who have undergone coronary artery bypass grafting (n =19) | 72.2 (mean) | Treatment decision (cardiac rehabilitation)
Yang et al.28 | China (communities) | Mixed-method | Patients with chronic diseases-survey (n =471)-interview (n =14) | Not reporteda | Advance care planning
Ye et al.29 | China (nursing homes) | Qualitative | Patients with chronic diseases or cancer (n =20) | 77.8 (mean) | End-of-life care (hospice and palliative care)
Zhu et al.30 | China (communities) | Quantitative | Patients with chronic conditions (n =150)Family caregivers (n =150) | 71 (mean) | Life-sustaining treatment decision

Conceptualization of shared decision-making

Table 2 summarizes the stakeholder groups considered in the SDM process (patients, caregivers, clinicians, and the health system) and how SDM was described across the included studies. The studies were further categorized according to their primary decision-making focus (treatment decisions, ACP/AD, and EOL/LST decisions). About half of the studies (_n = _8) considered all 4 stakeholder groups in the SDM process,23,25–27,29,31,34,40 while 3 studies focused only on patient-related factors.24,35,42

References | Stakeholder groups considered | Description of SDM
Studies addressing treatment decisions (n = 9)
Cao et al.23 | Patients, caregivers, clinicians, system | A deliberative process involving access to information, shared treatment goals, and understanding of treatment consequences between patients and clinicians
Chong et al.40 | Patients, caregivers, clinicians, system | An approach involving active support for patients in making decisions that reflect their autonomy and values, thereby maximizing their right to self-determination.
Chuang et al.33 | Patients, caregivers, clinicians | A patient-centered approach involves patient-clinician communication to clarify evidence-based practice and consider patients’ preferences.
Guo et al.25 | Patients, caregivers, clinicians, system | A collaborative approach involving patients and clinicians that integrates the best evidence, patient preferences, and values to help patients make informed health decisions.
Komatsu et al.37 | Patients, caregivers | A process involving patients’ participation and engagement in daily care decisions and choices in receiving care.
Liu et al.26 | Patients, caregivers, clinicians, system | A process involving the participation of patients and healthcare professionals in decision-making, considering patients’ values, preferences, and actual circumstances.
Shibagaki et al.38 | Patients, system | A collaborative approach involving clinicians and patients in choosing treatment options, considering patients’ circumstances, values, and goals.
Shin et al.41 | Patients, caregivers | A process involving patients’ ability to understand and use medical information to make treatment decisions aligned with their values and preferences.
Wang et al.27 | Patients, caregivers, clinicians, system | A collaborative approach involving patients and healthcare professionals in decision-making, considering patients’ background, goals, values, and preferences to achieve desired treatment outcomes.
Studies addressing ACP/AD (n = 6)
Chu et al.32 | Patients, system | A process involving AD discussions as part of ACP for patients who may lose decision-making capacity.
Chu et al.42 | Patients | A process involving AD discussions about the type of health care patients would want if they are no longer competent.
Hsu et al.34 | Patients, caregivers, clinicians, system | A process involving ACP to understand patients’ preferences, improve symptom management, and provide patient-centered care.
Kanakubo et al.36 | Patients, clinicians | A process involving ACP discussions and documentation of patients’ goals and preferences for future medical care.
Lin et al.35 | Patients | A process involving ACP discussions to clarify patients’ medical decisions and respect their voices in treatment and care preferences, thereby facilitating patient-centered care.
Yang et al.28 | Patients, caregivers, system | A process involving ACP that requires patients to express their preferences for treatment and care in case their condition deteriorates, based on their life experiences and values.
Studies addressing EOL care/LST (n = 5)
Chen et al.31 | Patients, caregivers, clinicians, system | A process involving DNR orders, assuming prior disclosure of terminal status and end-of-life options, and using a signed DNR letter of intent as an indicator of patient autonomy.
Fang et al.24 | Patients | A process involving EOL care that is influenced by both clinical and psychosocial factors, as well as individuals’ perceived control over treatment outcomes.
Shinada et al.39 | Patients, caregivers | Not reported
Ye et al.29 | Patients, caregivers, clinicians, system | Not reported
Zhu et al.30 | Patients, caregivers | A process involving LST discussions as part of ACP, enabling patients to discuss their goals and preferences for future care with their families and clinicians.

Among studies focusing on treatment decisions,23,25–27,33,37,38,40,41 SDM was commonly described as a collaborative, patient-centered process involving information exchange, deliberation between patients and clinicians, and the alignment of treatment decisions with patients’ goals, preferences, and values. In studies examining ACP or AD,28,32,34–36,42 decision-making was conceptualized primarily as preparation for future medical decisions, active engagement in planning discussions, and the documentation or completion of AD to ensure care that aligns with patients’ values and preferences. Studies addressing EOL or LST decisions24,29–31,39 conceptualized decision-making through constructs such as patient autonomy, involvement of family caregivers, and deliberation regarding treatment options within EOL contexts.

Barriers and facilitators to shared decision-making

Table 3 presents a simplified summary of barriers and facilitators to SDM across key stakeholder groups (patients, caregivers, clinicians, and the health system) in the included studies. Detailed items are provided in Supplementary Table 2.

Stakeholder groups | Barriers | Facilitators
Patient | Limited information, health literacy, and understandingPersonal health, situational, and resource-related challengesPsychological and emotional distressConstrained autonomy and interactions with cliniciansAvoidance or reluctance toward EOL discussion | Greater individual capacity and self-efficacyPersonal health, situational, and resource-related supportInformation preferences, access, and learning opportunitiesSupportive social discussionPrior experience-based awarenessPersonal values favoring dignity in care
Caregiver | Family-led decision-making dynamicsAvoidance and limited supportLack of caregiver preparedness, knowledge, and health | Shared involvement and respect for patientsDetailed communication and understanding of the clinical situation
Clinician | Lack of communication skills and discomfort with uncertaintyClinician-centered decision-making practicesLimited interaction and emotional supportDelayed timing of EOL decisions | Patient-centered communication practicesContinuity of care
Health system | Lack of decision-support infrastructureResource and structural constraintsFragmentation and lack of care integrationInformation barriers and complexityCare-setting constraints | Palliative care and multidisciplinary supportCommunity integrationHigh facility capacity or volumeQuality and stability of the care environment

Patient-related factors

Among patient-related factors, barriers to SDM were commonly related to patients’ limited information, health literacy, and understanding of their disease and treatment options,23,25–27,29,31,40 along with other personal health, situational, and resource-related challenges, such as complex health and care needs or financial burden.26,29,31,37–40,42 Psychological and emotional distress23,25,27,28,40 and constrained autonomy and interactions with clinicians25–27,33,40 were also highlighted as limiting patients’ ability to actively engage in decision-making. In a few studies, avoidance or reluctance toward EOL discussion due to religious beliefs or attitudes toward death was also reported.29,34,40

Patient-related facilitators were frequently associated with greater individual capacity and self-efficacy, such as high educational level or self-care ability,24,26,28,35,41,42 as well as several personal health, situational, and resource-related supports, including healthy status and financial burden.30,32,34,36,39,41 Additionally, preferences for disease- and treatment-related information, access to multiple information sources, opportunities for learning through personal or vicarious experiences,25,33,42 and supportive social discussion with family members, friends, or community groups,33,34,42 as well as awareness gained through prior personal experience with LST or functional decline,24,28,34 appeared to support patient engagement in SDM. Personal values and preferences regarding death or care, such as favoring dignity in death and incorporation of individual preferences, were also identified as facilitators.28–30

Across the included studies, several patient-related characteristics—including complex health and care needs (eg, severe illness, high care burden) and financial burden—were reported as influencing engagement in SDM in different ways depending on the context.

Caregiver-related factors

Among caregiver-related factors, barriers to SDM were primarily related to family-led decision-making dynamics, including situations in which family members made decisions on behalf of patients, exerted pressure to decide, or imposed pressure related to filial piety.23,25,29,31,34,40 Avoidance of conversations about dying and limited family support further constrained SDM.27–29 In a few studies, caregiver characteristics, such as lack of preparedness for bereavement, limited knowledge about disease management, and poorer physical or psychological health, were reported as barriers.26,39

Caregiver-related facilitators included shared involvement of patients and family members in decision-making and respect for patients’ decisions.23,33,37 In addition, detailed communication with clinicians and a better understanding of the clinical situation, through awareness of treatment ineffectiveness and caregivers’ higher educational level, were also identified as factors that could support caregiver participation in SDM.29,30,41

Clinician-related factors

Among clinician-related factors, major barriers to SDM included a lack of communication skills, discomfort in managing uncertainty, and unclear explanations.23,25,27,34,40 Clinician-centered decision-making practices, including pressure to make decisions and authoritative behaviors,26,27,33,40 as well as limited interaction and emotional support,23,25,27 were also identified. Additionally, one study reported that EOL decisions made close to death—indicated by first DNR orders issued within 29 days before death—limited opportunities for SDM.31

Clinician-related facilitators included patient-centered communication practices and respect for patient preferences.29,33,36 Continuity of care, including involvement of family medicine practitioners or primary care providers, was also reported as supportive of SDM among older adults.31,34

Health system–related factors

Among health system-related factors, barriers to SDM were frequently related to a lack of decision-support infrastructure, such as decision-support systems, training or consultation opportunities, or psychological support.23,26–29,40 Additional barriers reflected resource and structural constraints, including inconsistency in resources across institutions, limited financial support or insurance coverage,23,25,34 and fragmentation and lack of care across settings and specialities.25–27 In several studies, difficulty identifying appropriate disease-related information, the complexity of decision-making processes,25,34 and specific care-setting constraints, such as last admissions to an intensive care unit or high annual treatment volume,31,38 were also reported to impede SDM.

Health system-related facilitators included the availability of hospital palliative care and the involvement of social workers,31,32 as well as the integration of community leadership and local activities.34 High-capacity facilities,38 consistent, high-quality care, and comfortable care environments29 were also identified as supportive.

Results summary

Overall, the findings indicate that barriers and facilitators to SDM among older adults in East Asian healthcare settings arise from multiple, interrelated influences. Factors related to patients, caregivers, clinicians, and the health system collectively shaped opportunities for discussing options, deliberating on treatment decisions, and incorporating patients’ values and preferences into clinical decisions, rather than functioning in isolation. Figure 2 summarizes these interacting factors and illustrates their dynamic relationships across stakeholder groups. Table 3 presents the detailed subcategories of barriers and facilitators identified in this review.

Figure 2: Stakeholder-related factors influencing shared decision-making among older adults in East Asian healthcare settings.