Discussion and implications

This scoping review has identified multiple barriers and facilitators across patients, caregivers, clinicians, and health systems that affect SDM for older adults in East Asian healthcare settings. Overall, the findings suggest that SDM in this context is influenced by interrelated factors involving multiple stakeholder groups, rather than solely by the communication between individual patients and clinicians. While several barriers and facilitators resemble those identified in Western healthcare systems, the review highlights the prominent roles of family involvement, clinician authority, and constraints within health systems, such as limited supportive infrastructure and resources, and also reveals that existing evidence is heavily concentrated in EOL, LST, and ACP contexts. Taken together, these findings suggest that while many barriers and facilitators to SDM are broadly shared, their expression and relevance in East Asian healthcare settings are influenced by distinct sociocultural norms, relational dynamics, and system-level constraints.

Several barriers and facilitators identified in this review are consistent with findings from prior systematic reviews conducted predominantly in Western contexts. For example, patient-related barriers, such as declining health status, cognitive or physical impairment, psychological distress, and limited health literacy, closely mirror those reported in a prior systematic review.12 Similarly, challenges related to clinicians, including time constraints, communication difficulties, and discomfort with uncertainty, as well as health system-related barriers such as limited resources and insufficient organizational support, were evident across both Western and East Asian settings.10,12 These overlaps suggest that many foundational challenges to SDM among older adults are shared across healthcare systems, regardless of geographic or cultural context.

However, despite these shared challenges, the current review also highlights important contextual differences in how SDM is enacted in East Asian healthcare settings. In contrast to much of the Western SDM literature, which typically conceptualizes decision-making as a dyadic interaction between patients and clinicians, with caregiver involvement regarded as optional or supplementary,2,5 the studies included in this review suggest that family members often assume a central role in decision-making, sometimes actively influencing or even replacing patient participation in clinical decision-making.23,33,40 Rather than reflecting a simple transfer of decision-making authority, this pattern appears to reflect culturally embedded practices in East Asian societies, where collectivist values and family-centered norms position the family as a key factor in healthcare decisions.7,10 For example, qualitative research among Chinese patients undergoing prostate cancer surgery found that treatment decisions were frequently made by family members, occasionally with limited direct patient involvement.23 Similarly, a recent scoping review of SDM research in the Korean healthcare system reported that strong family involvement and hierarchical patient–clinician relationships were recurring contextual features influencing SDM implementation.10 These findings suggest that family participation is not merely a supplementary element of SDM but represents an important component through which treatment decisions are negotiated in many East Asian healthcare encounters.

The prominence of family involvement observed in this review is consistent with scholarship on Confucian-influenced norms, such as filial piety and family harmony, which emphasize collective responsibility and relational decision-making.7,43 In practice, these norms may encourage families to assume protective roles in medical decision-making, for example, by shaping information disclosure or prioritizing perceived family interests over individual autonomy.9 Across the studies included in this review, family involvement emerged as both a barrier and a facilitator to SDM. In some cases, it appeared to facilitate SDM by supporting patients in articulating their values and preferences33,37; in others, it constrained participation by limiting patients’ opportunities to engage meaningfully in decisions.25,29 These findings suggest that family involvement is neither inherently beneficial nor detrimental to SDM. Rather, its influence appears to depend on how family roles are negotiated during clinical encounters and how clinicians and healthcare systems support these interactions.

Importantly, the dual role of family involvement is not unique to East Asian healthcare systems. A prior systematic review in the United States among racial and ethnic minority patients similarly found that SDM may be shaped by cultural and relational dynamics that can either facilitate or hinder engagement, particularly in the context of serious illness.44 These parallels caution against simplistic East–West dichotomies and underscore the importance of understanding family involvement as a contextual component of decision-making, rather than a categorical deviation from ideal models of SDM.7

In addition to family involvement, our findings also indicate that clinician authority and hierarchical patient–clinician relationships may influence SDM in East Asian healthcare settings. Several studies described clinician-centered decision-making practices, including authoritative behaviors, clinician-driven recommendations, and limited opportunities for interactive communication, which may constrain patient participation.26,27,33,40 These dynamics may limit patients’ opportunities to express preferences and engage actively in decision-making, while also affecting how information is communicated and how decision-making roles are negotiated during clinical encounters.8,9 In some East Asian healthcare settings, hierarchical clinical relationships may therefore be closely associated with how SDM is practiced.

An additional distinction concerns the clinical context in which SDM has been studied. Unlike Western-focused systematic reviews, which synthesize SDM across a broad range of decision types and healthcare settings,12,45 the literature included in this review indicates that SDM and SDM-related concepts in East Asian healthcare systems have been predominantly investigated within the domains of EOL care, LST decisions, and ACP. Notably, several studies applied SDM principles primarily within the context of EOL-related planning and treatment decisions, rather than explicitly framing SDM as a distinct decision-making model. This pattern is consistent with findings from a recent scoping review of SDM research in the Korean healthcare system, which identified EOL care as the most prevalent clinical context examined.10 While EOL settings may render questions about participation, value prioritization, and decision-making authority particularly visible, this concentration also highlights a substantive limitation of the current East Asian SDM literature. The predominance of EOL-focused research may limit the conceptualization of SDM to critical or terminal decisions and constrain the transferability of existing findings to routine outpatient care, chronic disease management, and other non–EOL clinical contexts. In addition, our findings suggest that relatively limited attention has been given to acute or hyperacute clinical scenarios, such as surgical decision-making, which further narrows the scope of current SDM research in East Asian settings. Addressing this imbalance represents an important direction for future SDM research in East Asian healthcare systems.

Implications for future practice, policy, and research

Our findings raise important implications for existing SDM frameworks and implementation strategies. Many widely used SDM models, developed primarily within Western healthcare systems, assume a patient–clinician dyadic focus.5,46,47 While such models provide valuable guidance, the present review suggests that they may be insufficient when applied uncritically to contexts where family involvement and health system constraints play a central role. A broader perspective that incorporates caregiver dynamics and organizational influences may therefore be better suited to capturing the realities of decision-making for older adults in East Asian healthcare systems. Culturally responsive models should treat family participation as a negotiable and potentially supportive component of the decision-making process,18,48 while safeguarding the older person’s preferences and voice.49

From an implementation perspective, the implications of these findings extend beyond individual clinician–patient interactions and suggest the need for coordinated strategies across multiple stakeholders to promote SDM among older adults in East Asia. Interventions focused solely on enhancing patient knowledge or clinician communication skills may have limited impact without parallel efforts to engage family caregivers and address organizational barriers, such as limited consultation time and insufficient decision-support infrastructure. Prior implementation research has described the integration of patient decision aids into routine clinical workflows to facilitate structured communication during consultations.46 Large-scale implementation initiatives, such as the Making Good Decisions in Collaboration (MAGIC) program, have likewise emphasized multilevel approaches targeting clinicians, patients, and healthcare organizations simultaneously to support sustained adoption of SDM.50 For example, the MAGIC program incorporated clinician communication training, patient activation strategies, executive-level organizational support, and adaptation of clinical pathways to embed SDM into routine care. It also emphasized that decision-making is distributed across healthcare teams and family networks rather than confined to a single clinician–patient encounter. These examples illustrate that effective SDM implementation may require not only clinician training, but also organizational support for caregiver engagement and the routine use of decision-support tools within clinical practice.

Strengths and limitations

This review has several limitations. First, only studies published in English were included, and region-specific databases were not searched. As a result, locally published studies may have been excluded, potentially introducing language and publication bias and limiting the comprehensiveness of the evidence base. This restriction may also have contributed to a relative overrepresentation of studies conducted in specific clinical contexts, such as EOL or LST decision-making. Furthermore, although this review focuses on East Asia as a broad regional category, the findings should be interpreted with caution because healthcare systems and sociocultural contexts vary across countries and regions. In addition, the included studies were conducted in a limited number of countries and regions within East Asia, which may not fully capture the diversity of the region. Additionally, the studies reviewed varied in how SDM was conceptualized, with some focusing explicitly on SDM and others examining related practices such as ACP or EOL decision-making. Although this conceptual heterogeneity is consistent with the exploratory scope of a scoping review, it may have limited comparability across studies and complicated the interpretation of barriers and facilitators attributed specifically to SDM. Lastly, most included studies employed cross-sectional designs, which may limit the interpretation of temporal or causal relationships. Nevertheless, by synthesizing evidence across multiple stakeholder groups, this review provides a comprehensive and context-sensitive overview of barriers and facilitators to SDM among older adults in East Asian healthcare systems.