Work

Decision vacuum and prepared delegation in cancer end-of-life decision-making: a scoping review

Year: 2026

Type: review

Abstract: CONTEXT: End-of-life (EOL) decision-making profoundly shapes the quality of dying for advanced cancer survivors and the long-term psychological well-being (e.g., mitigating persistent decisional regret) of their bereaved families. While decision-making styles range from individual autonomy to clinician delegation across clinical and cultural contexts, their structural process determinants remain poorly synthesized. OBJECTIVES: To synthesize international (English-language) and Japanese evidence clarifying how EOL decision-making processes and timing influence psychological and economic outcomes in oncological care. METHODS: Following PRISMA-ScR guidelines, we searched PubMed and Ichushi-Web for studies published from 2016 to 2026. Inclusion criteria focused on advanced cancer decision-making (involvement or delegation) and multi-dimensional outcomes, including psychological (satisfaction, regret, conflict), clinical (aggressiveness of care), and economic outcomes (financial toxicity, healthcare resource utilization). Narrative synthesis was performed on all 136 included studies (detailed matrix provided in Supplementary Table S1). RESULTS: From 1,813 records, 136 studies were included. Physician-led decisions without prior value validation were associated with significantly higher decisional regret (p = - 0.400) and lower quality-of-life evaluations. A lack of preparedness contributed to a clinical "decision vacuum"-a state where unarticulated patient preferences lead to decision-making dictated by external system drivers or paternalism-frequently pushing vulnerable families toward non-evidence-based therapies, resulting in "Financial Toxicity" and inappropriate aggressiveness of care. Three key process moderators-validation of values, information transparency, and multidisciplinary coordination-were identified as essential for transforming delegation into a high-quality, value-concordant process ("prepared delegation"). CONCLUSION: EOL support must transcend the rigid dichotomy between individual autonomy and delegation. Implementing the "prepared delegation" model through early intervention and multidisciplinary validation can eliminate the "decision vacuum," thereby preventing persistent decisional regret and protecting family economic and psychological well-being across the survivorship trajectory.

Source: Supportive Care in Cancer

DOI: 10.1007/s00520-026-11394-3

Authors: Seiichiro Kuroda, Yohei Iimura, Masako Kuroda

Institutions: IMSUT Hospital, Institute of Medical Science, The University of Tokyo, The University of Tokyo

Language: English

Topic: Palliative Care and End-of-Life Issues

Subfield: Public Health, Environmental and Occupational Health

Field: Medicine

Domain: Health Sciences

SDG: Good health and well-being

Open Access status: hybrid

Estimated APC paid: $4,690