Decision vacuum and prepared delegation in cancer end-of-life decision-making: a scoping review.
- 1Department of Pharmacy, The IMSUT Hospital, The Institute of Medical Science, The University of Tokyo, 4-6-1, Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan. [email protected].
- 2Department of Pharmacy, The IMSUT Hospital, The Institute of Medical Science, The University of Tokyo, 4-6-1, Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan.
- 3Kuroda Pharmacy, Hirai, Edogawa-ku, Tokyo, Japan.
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.
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BibTeX
@article{kuroda2026decision,
title = {{Decision vacuum and prepared delegation in cancer end-of-life decision-making: a scoping review.}},
author = {Seiichiro Kuroda and Yohei Iimura and Masako Kuroda},
journal = {Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer},
year = {2026},
month = oct,
doi = {10.1007/s00520-026-11394-3},
url = {https://europepmc.org/article/MED/42970182},
note = {CC BY},
}
RIS
TY - JOUR
TI - Decision vacuum and prepared delegation in cancer end-of-life decision-making: a scoping review.
AU - Seiichiro Kuroda
AU - Yohei Iimura
AU - Masako Kuroda
PY - 2026
DA - 2026/10/30
JO - Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer
DO - 10.1007/s00520-026-11394-3
UR - https://europepmc.org/article/MED/42970182
AB - 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.
SN - 0941-4355
SN - 1433-7339
ER -