A purposive sampling strategy was employed to recruit lung cancer patients undergoing chemotherapy at a tertiary care hospital in Jiangxi Province, China, between October and December 2024. Maximum variation sampling (11) was implemented, incorporating key demographic variables including gender, age, cultural background, occupation, and marital status.

The implementation of the shared decision-making program occurred within the thoracic surgery department of the Second Affiliated Hospital of Nanchang University.

Inclusion criteria comprised: (a) histopathologically or cytologically confirmed primary lung cancer (12); (b) age ≥ 18 years; (c) active chemotherapy regimen with ≥3 months since diagnosis; (d) intact verbal communication capacity; (e) voluntary participation with full diagnostic awareness. Exclusion criteria included: (a) severe sensory deficits (visual/auditory), psychiatric comorbidities, or cognitive dysfunction; (b) uncontrolled comorbidities contraindicating study participation.

Participants were recruited via purposive and snowball sampling. Eligible patients meeting the inclusion criteria were contacted through their attending physicians. Upon agreement, researchers provided study details and confirmed participation within one week to minimize recall bias. Written informed consent was obtained prior to interviews.

To ensure the accuracy and completeness of the interview guide, we initially drafted it based on the research objectives through reviewing relevant literature and group meetings with project team members. Subsequently, we conducted pilot interviews with two patients and revised the guide again according to the interview results (e.g., simplifying jargon, changing the interview place from the ward to a quiet room, inviting family members to accompany them, etc.), forming the final interview guide. The interview questions are shown in Table 1. The interviews were conducted face-to-face in a demonstration classroom where conversations could take place without interruption. Face-to-face talks were held with the respondents within the agreed time, with each interview lasting 30–45 minutes. Data collection continued until thematic saturation was achieved. Saturation was defined as the point at which three consecutive interviews (participants 12, 13, and 14) yielded no new thematic insights and all identified themes were sufficiently developed and nuanced. This was independently verified by two researchers (QW and JX), confirming that no further interviews were necessary.

Within 24 hours after each interview, two researchers independently transcribed the recordings into text and added records of non-verbal behaviors without altering or deleting any content to ensure the authenticity of the data. The transcribed interviews were then numbered and imported into NVivo12.0 for data analysis and processing. To ensure coding consistency and objectivity, an inter-coder reliability analysis was conducted using the coding comparison function in NVivo. The Cohen’s Kappa coefficient was calculated at 0.82, demonstrating excellent agreement (13). The panelists confirmed that participants had reviewed the subject summaries to obtain written/verbal feedback. Colaizzi’s (14) seven-step analysis method was employed to analyze the data. Colaizzi’s seven-step procedure was strictly followed:

Guided by Colaizzi’s phenomenological approach, our data analysis was further informed by Hofstede’s cultural dimensions theory as an overarching theoretical framework (15). This lens, particularly the dimensions of collectivism (versus individualism), high power distance (acceptance of hierarchical order), and long-term orientation (emphasis on future rewards and persistence), provided a structured perspective to interpret how broader cultural values shape patients’ decision-making experiences and interactions with healthcare providers.

Meanwhile, this study employed NVivo 12 qualitative analysis software for coding, using manual coding to systematically analyze and categorize data. After abstracting and naming the findings, the research progressively identified primary and secondary themes. To ensure methodological rigor and manage potential bias, the research team engaged in reflexivity practices throughout the study. As the research team primarily consists of oncology nurses (MHP, AQQ, YJ, WHQ), we acknowledged our pre-understanding and potential bias towards focusing on nursing interventions and patient compliance. To mitigate this, we held pre-study reflexive discussions to document our presuppositions, maintained reflective journals during data collection and analysis, and actively sought disconfirming evidence and alternative interpretations of the data during team meetings.

This study was conducted in accordance with the ethical guidelines of the Helsinki Declaration and obtained approval from the Ethics Committee of the Second Affiliated Hospital of Nanchang University (I-Medical Research Review [2024] No. (38)).

The first author conducted semi-structured interviews with lung cancer patients receiving chemotherapy from October to December 2024. All patients were hospitalized for chemotherapy, with an average age of 62.79 years, and had been diagnosed with lung cancer for at least three months. Participant characteristics are summarized in Table 2.

The analysis of the interview data from participants yielded a total of four main themes and 13 sub-themes. All themes are listed in Table 3.

This qualitative study demonstrates that shared decision-making mitigates information gaps and enhances engagement in treatment choices among advanced lung cancer patients through multifaceted information support. Sociocultural and familial support systems are pivotal, alongside sustained patient-provider communication to address psychological distress and emotional burdens. In parts of China, persistent misconceptions and sociocultural barriers rooted in religious beliefs and traditional norms hinder palliative care implementation for advanced lung cancer patients and their families.

Studies have shown that (18) patients with a lack of treatment information often feel regret or remorse about their decisions after receiving treatment. Therefore, during the treatment decision-making stage, patients should be provided with comprehensive and easily understandable knowledge introductions to enhance information sharing and support, helping patients clearly understand the disease, treatment, and related data. In this study, most patients were in the advanced stages of lung cancer and were older. Faced with various tumor treatments and chemotherapy regimens, the majority of patients reported insufficient information. To address this, decision-making tools such as videos and guidebooks can be utilized to provide personalized support, enabling patients to fully understand the comparisons, potential outcomes, and benefits of different treatment plans within a limited time. Additionally, due to the hidden nature of early-stage lung cancer symptoms, patients often seek treatment only in the late stages of the disease. Influenced by the traditional paternalistic decision-making model, patients tend to accept the doctor’s diagnostic and treatment recommendations passively. Meanwhile, the brief consultation time limits the amount of information patients can obtain from doctors. Moreover, due to differences in the cognitive levels and health literacy of the interviewees, some patients struggle to understand professional medical terminology and can easily feel confused when faced with a large amount of treatment information. They may even fail to understand the content provided fully. Insufficient or excessive information leads to patients’ repeated indecision, increasing the difficulty of decision-making. In the future, a professional information support team should be established, the capabilities of oncology-specialized nurses should be valued, and peer support and diversified information support should be provided.

With the evolution of the social medical environment and the improvement of people’s knowledge levels and health awareness, the traditional treatment decision-making model is gradually being replaced. Shared Decision-Making (SDM) is bound to become the trend. SDM deepens the ‘patient-centered’ healthcare model. In 2012, Elwyn G et al. (19) proposed a three-talk model for SDM comprising three steps: introducing choice, describing options (typically through patient decision support tools), and helping patients explore preferences and make decisions. In 2017, Elwyn G et al. (20) further refined this model into three components: team talk (providing decision support when patients recognize the need to choose while eliciting their decision goals), option talk (using risk communication principles to help patients compare risks/benefits of alternatives in balanced detail with easily understandable methods), and decision talk (listening to patients’ perspectives as they consider impacts on themselves/family while guiding preference-aligned decisions based on clinicians’ expertise). A survey study in the United States showed (21) that in the decision-making process, 39% of cancer patients prefer to play an “actively cooperative” role, and 34% of patients tend to “make decisions jointly”. Patients are more inclined to make decisions based on the provider’s suggestions or to make decisions jointly with the provider. Research has shown (22) that cancer patients’ involvement in treatment decision-making can not only make them more familiar with disease-related knowledge but also enhance their satisfaction with medical care, subjective happiness, and compliance with medical advice. It can also enable patients to form a reasonable expectation of treatment outcomes, make treatment choices that meet their personal preferences, thereby improving their quality of life, and achieve the best diagnostic and treatment results. This is an important way to enhance doctor-patient trust and meet patients’ health needs. In the future, patients and their families should be encouraged to ask questions, and their concerns should be fully listened to and addressed to effectively establish a trust relationship with patients, improve their fear of chemotherapy, and enhance treatment compliance. The SDM model can reduce conflicts and misunderstandings between doctors and patients. In future SDM implementation, a three-phase communication framework should be adopted. During the diagnostic phase, oncology-specialized nurses provide treatment overviews detailing modalities and pros/cons of each option; in the decision phase, multidisciplinary team (MDT) meetings explain risks/benefits; during the treatment phase, ongoing symptom management communication occurs (23). Through in-depth communication and decision-making with patients, doctors can better explain the benefits and risks of treatment plans. This allows patients to have a clearer understanding of the causes, development process, treatment options, and prognosis of their disease, enhancing their sense of participation and responsibility in the treatment process. Moreover, this model promotes information sharing and communication between doctors and patients, avoiding doctor-patient conflicts and disputes caused by information asymmetry, and thus establishing a better doctor-patient relationship.

The complexity of lung cancer treatment, the uncertainty of prognosis, and the high cost of treatment can easily lead to feelings of fear and anxiety in patients. These factors not only reduce patients’ quality of life and physical and mental health levels but may also affect treatment compliance and effectiveness. Due to the nature of the disease itself and the impact of chemotherapy, patients are highly susceptible to varying degrees of negative emotions (such as anxiety, depression, or feeling overwhelmed), and may even experience decision-related regret, which in turn affects the effectiveness of chemotherapy and quality of life (39). A meta-analysis showed (40) that 30% to 40% of cancer patients in hospitals have anxiety or depressive emotional disorders, a proportion much higher than that in the general population. Anxiety can cause patients to overly focus on the poor efficacy of chemotherapy regimens and potential side effects, leading to higher levels of decisional conflict. Long-term negative emotions can weaken patients’ immune function and increase the risk of cancer recurrence, metastasis, and high mortality (41). Therefore, clinical nurses need to closely monitor the emotional states and psychological responses of lung cancer patients and provide timely psychological guidance. Medical staff should have a sense of humanistic care, maintain continuous and effective communication with patients, and also guide patients’ caregivers to use methods such as encouragement, guidance, and empathy to help patients reduce emotional suppression behaviors and promptly alleviate inner distress. Future research can explore ways to help patients relax and actively face illness and treatment through social and psychological support, cognitive-behavioral therapy, exercise therapy, or Baduanjin, avoiding excessive preoccupation with existing problems and instead actively seeking solutions and allowing sufficient time for decision-making. Additionally, incorporating standardized assessment tools like the DRSc (16) into routine psychosocial care, leveraging its psychometric properties to measure individual decisional regret in the clinical setting, which successfully differentiates patients exhibiting varying levels of regret about medical decisions, can facilitate early intervention and evaluate the effectiveness of supportive strategies aimed at mitigating this specific emotional burden. In addition, patients should be taught methods to alleviate anxiety, such as pausing to think, taking deep breaths, and relaxing muscles when emotional issues arise, in order to ease emotions, reduce the excitability of the sympathetic nervous system, and thus improve emotions, reduce symptoms of depression, anxiety, and stress, and enhance physical and mental functions (42).

Our findings elucidate decision-making processes that are profoundly shaped by collectivist values and hierarchical trust, which are prevalent in many societies worldwide. The experiences of our participants in China provide a critical case study for understanding and enriching the global SDM paradigm, highlighting the urgent need to develop culturally-adapted frameworks that integrate, rather than overlook, these fundamental social forces. Table 4 details the comparison of decision-making models between Western countries and collectivist countries represented by China. Our findings allow for a theoretical operationalization of key Confucian values. Filial piety manifested as a mechanism of intergenerational responsibility transfer, where children assumed decision-making roles as a moral duty. Family harmony operated through protective information filtering, where family members withheld distressing medical information to preserve emotional stability. Respect for authority was enacted as deferential compliance with physicians’ recommendations, reflecting the high power distance prevalent in the clinical context. Theoretically, this constitutes family-centric decision-making, which is distinct from family involvement in Western SDM. In the former, the family unit often acts as the primary decision agent, practicing a form of relational autonomy—a well-established bioethical concept defining individuals as situated within social relationships, rather than in isolation, as the foundation of identity and decision-making (43). In contrast, the Western model typically treats the family as a supportive resource to an ultimately individual-centric autonomous choice.