Best Evidence for Life-Sustaining Treatment Decision-Making Assessment in Hospitalized Adults with Advanced Cancer in Chinese Clinical Practice

Summary

This study synthesizes the best available evidence to guide life-sustaining treatment (LST) decision-making assessments in patients with advanced cancer, evaluates their applicability within the Chinese cultural context, and proposes an evidence-based clinical strategy to support high-quality end-of-life nursing practice.

Abstract

This study aimed to retrieve, appraise, and synthesize the best available evidence for life-sustaining treatment (LST) decision-making assessment in patients with advanced cancer and to explore its applicability within the Chinese clinical and cultural context. Systematic searches were conducted in BMJ Best Practice, UpToDate, DynaMed, JBI, GIN, NICE, SIGN, NCCN, Cochrane Library, MEDLINE, CINAHL, Embase, China National Knowledge Infrastructure, Wanfang Data, and SinoMed from March 3, 2019, to March 3, 2024, with additional retrospective searches. Eligible evidence sources included clinical decision-support resources, guidelines, expert consensus documents, evidence summaries, systematic reviews, and meta-analyses. Two reviewers independently screened the literature, appraised methodological quality, and extracted evidence, with disagreements resolved through consensus and, when necessary, adjudication by a senior third reviewer. Eight documents were included: two guidelines, one evidence summary, three clinical decision-support resources, and two systematic reviews. Nine evidence items were generated and assessed using the FAME framework, covering patient identification, prognosis and palliative care needs, family-system assessment, decision-making capacity, structured assessment tools, communication about LST preferences, documentation, and dynamic reassessment near the end of life. Evidence-based LST decision-making assessment may help reduce overtreatment and support high-quality end-of-life care for patients with advanced cancer. By translating the summarized evidence into a culturally adapted workflow, this study provides a practical reference for integrating patient preferences, family participation, and clinical assessment in Chinese palliative care practice.

Introduction

The 2022 Lancet Commission reported that current healthcare systems often overemphasize life extension through aggressive end-of-life (EOL) treatments, with millions of people worldwide receiving LSTs such as mechanical ventilation and chest compressions in their final days¹. LSTs encompass the use of advanced medical technology or procedures to sustain the lives of critically ill patients or those experiencing organ failure, including cardiopulmonary resuscitation, mechanical ventilation, nutritional support, pacemakers, and hemodialysis². Recent global evidence further supports this concern. GLOBOCAN 2022 estimated approximately 20.0 million new cancer cases and 9.7 million cancer-related deaths worldwide, with new cases projected to exceed 35 million by 2050. Recent systematic reviews also showed that aggressive end-of-life care remains common among patients with cancer, while only about one-third of cancer patients globally receive palliative care^3,4. Statistics indicate that around 3 million people in China succumb to cancer annually, with this group predominantly confronting prolonged suffering⁵. In a study of secondary qualitative analysis of 423 outpatient encounters, only 21 encounters (5%) included EOL discussions about LSTs' choices⁶. Thus, responding inadequately to patient concerns about disease progression or dying, engaging in overly optimistic future talk to address patient worries, or expressing undue concern over treatment discontinuation culminates in a diminished quality of death⁷. Consequently, healthcare professionals must perform meticulous assessments to ascertain optimal timings and strategies for engaging terminal cancer patients and their families in meaningful discussions about LST options, thereby facilitating a high-quality end-of-life experience.

Current guidelines predominantly offer recommendations from a palliative care perspective. For instance, there is research advice that evaluations of decisions for terminal cancer patients should be conducted early, ensuring that advance directives and DNR (Do Not Resuscitate) orders are in place to minimize the risk of overtreatment at EOL⁸. A guideline recommends carrying out a comprehensive, all-stage palliative care assessment for terminal patients to continually assess the end-of-life needs of both patients and their families⁹. While existing guidelines address some aspects of LST decision-making assessment in patients with advanced cancer, the evidence remains piecemeal and has not been systematically synthesized, which impedes the implementation of structured assessment in clinical palliative care practice. This study aimed to generate a defined best-evidence summary and a culturally adapted clinical workflow for assessing life-sustaining treatment decision-making in hospitalized adults with advanced cancer in Chinese clinical practice, based on systematic retrieval, quality appraisal, and synthesis of recent guidelines, clinical decision-support resources, evidence summaries, and systematic reviews. However, existing recommendations rarely explain how patient preferences, family participation, decision-making capacity, and culturally embedded family-centered communication should be assessed together before LST discussions in Chinese clinical settings. To facilitate the adaptation of LST decision-making to the Chinese cultural context, a clinical practice workflow was proposed.

Protocol

This study was based exclusively on the review and synthesis of previously published evidence and did not involve the recruitment of participants, collection of individual patient data, or implementation of clinical interventions. As no human subjects were directly involved, approval from an institutional ethics committee and informed consent were not required. Protocol registration was not undertaken because the study aimed to develop a best-evidence summary and clinical assessment workflow using published and pre-appraised evidence rather than to conduct a conventional systematic review evaluating intervention effectiveness. All the tools used for this study are listed in the Table of Materials.

Literature search

A comprehensive literature search was conducted using the 6S evidence hierarchy framework, which prioritizes pre-appraised evidence before primary research studies. The search covered the following electronic databases and evidence resources: Chinese National Knowledge Infrastructure (CNKI), Wanfang Data, SinoMed, CINAHL, Embase, MEDLINE, Joanna Briggs Institute (JBI), Cochrane Library, BMJ Best Practice, UpToDate, DynaMed, National Comprehensive Cancer Network (NCCN), National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), and Guidelines International Network (GIN).

The search period extended from March 2019 to March 2024. This timeframe was selected to capture the most recent and valid evidence because guidelines, evidence summaries, and clinical decision-support resources in palliative care are updated regularly. Earlier publications were retained only when they provided important background information, validated assessment tools, or conceptual support identified through reference-list screening. Search strategies were developed using a combination of controlled vocabulary terms, including Medical Subject Headings (MeSH) where applicable, and free-text keywords. The main search terms included “life-sustaining treatment,” “life support treatment,” “do not resuscitate,” “DNR,” “advance directives,” and “advance care planning.” Boolean operators (AND and OR) were applied to adapt the search strategy to the indexing structure of each database. Searches were limited to studies published in English or Chinese. Detailed search strategies, database-specific terms, date restrictions, and search procedures are presented in Supplementary Table 1.

All retrieved records were exported to reference-management software for organization and duplicate removal. To ensure a comprehensive search and minimize the risk of missing relevant evidence, additional manual searches were performed by reviewing the reference lists of included documents and examining related guidelines, evidence summaries, and clinical decision-support resources available on the source websites. Controlled vocabulary and free-text terms were combined according to the indexing requirements of each database, and supplementary reference checking was conducted to identify any additional eligible evidence.

Screen and select eligible studies

Following the removal of duplicate records, all remaining citations were independently screened by two reviewers. Title and abstract screening were performed to exclude publications that were clearly unrelated to the assessment of life-sustaining treatment decision-making in patients with advanced cancer. Full-text articles were subsequently obtained for all potentially relevant records and assessed for eligibility. Studies were considered eligible if they involved hospitalized adults aged 18 years or older with advanced cancer and an estimated life expectancy of six months or less. Evidence addressing the assessment of life-sustaining treatments (LSTs) in inpatient settings caring for patients with advanced cancer was included. Eligible evidence sources comprised clinical practice guidelines, expert consensus statements, evidence summaries, clinical decision-support resources, systematic reviews, and meta-analyses. Only publications available in English or Chinese and published within the previous five years were considered. Evidence sources were excluded if they represented updated or duplicate versions of previously published guidelines or recommendations. Publications with incomplete information, insufficient methodological details, or unavailable full-text articles were also excluded. Any disagreements regarding study eligibility were resolved through discussion and consensus between the reviewers.

Appraise the quality of included evidence

The methodological quality of the included evidence was evaluated using appraisal instruments appropriate to each evidence source. Clinical practice guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. For evidence summaries, the original supporting studies were traced and critically appraised using the assessment tool corresponding to their study design. Systematic reviews were evaluated using the Joanna Briggs Institute (JBI) critical appraisal checklist for systematic reviews, whereas clinical decision-support resources were assessed using the Critical Appraisal for Summaries of Evidence (CASE) tool. All quality assessments were performed independently by two reviewers who were trained in evidence appraisal methods. The reviewers examined each evidence source according to predefined criteria and documented their assessments separately. Any differences in appraisal results were resolved through discussion and consensus. When necessary, additional review and clarification were undertaken to ensure consistency and accuracy in the final quality ratings.

Define the criteria for considering studies

The scope of the evidence search was defined using the PIPOST framework, which considers Population, Intervention, Professionals, Outcomes, Setting, and Type of evidence. This framework was used to formulate the clinical questions and establish clear eligibility criteria for identifying evidence related to the assessment of life-sustaining treatment (LST) decision-making in hospitalized adults with advanced cancer. The PIPOST elements also guided the screening process and ensured consistency in study selection. Evidence sources were considered eligible if they involved hospitalized patients aged 18 years or older with advanced cancer and an estimated life expectancy of six months or less. Studies focusing on the assessment of life-sustaining treatments within inpatient settings caring for patients with advanced cancer were included. Eligible evidence types comprised clinical practice guidelines, expert consensus statements, evidence summaries, clinical decision-support resources, systematic reviews, and meta-analyses. Only articles published in English or Chinese during the previous five years were considered for inclusion. Evidence sources were excluded if they represented duplicate, superseded, or updated versions of previously published recommendations or guidelines. Publications with incomplete information, insufficient methodological details, or inaccessible full-text articles were also excluded from the final evidence synthesis.

Study selection, data extraction, and quality assessment

Study selection, quality appraisal, and data extraction were conducted independently by two reviewers according to predefined eligibility criteria. Following title and abstract screening, full-text articles were retrieved and assessed for inclusion. Final eligibility decisions were made independently by both reviewers. Any disagreements were resolved through discussion and consensus, and unresolved issues were referred to a senior member of the evidence-based research team for adjudication. The methodological quality of the included evidence was evaluated using appraisal tools appropriate for each evidence type. Clinical practice guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Evidence summaries were appraised by tracing their original evidence sources and applying the corresponding appraisal tools. Systematic reviews were evaluated using the Joanna Briggs Institute (JBI) critical appraisal checklist for systematic reviews, whereas clinical decision-support resources were assessed using the Critical Appraisal for Summaries of Evidence (CASE) tool. Relevant data were extracted independently by the same two reviewers using a standardized extraction form. Evidence published in languages other than English was translated prior to synthesis. The synthesis process prioritized recommendations supported by methodologically robust and internally consistent evidence. Complementary findings from different sources were integrated based on their conceptual and clinical relevance, while conflicting recommendations were resolved by giving preference to higher-quality evidence. Finally, all included evidence was classified according to the 2014 Joanna Briggs Institute evidence pre-grading system, with evidence levels ranging from Level 1 (highest quality) to Level 5 (lowest quality).

Results

Basic characteristics of the included literature

A total of eight documents were selected for inclusion: two guidelines, one evidence summary, three clinical decision-support resources, and two systematic reviews. The small number of included documents reflects the strict eligibility criteria of this best-evidence summary. Of the 1,657 records initially identified, 150 duplicates were removed, leaving 1,507 records for title and abstract screening. After screening, 1,494 records were excluded, and 13 full-text articles were assessed for eligibility. Six full-text articles were excluded because of no available full text (n = 1), conference report (n = 2), non-advanced cancer population (n = 1), or lack of decision-making assessment content (n = 2). Seven documents were included after full-text review, and one additional document was identified through reference screening. Finally, eight documents were included in the evidence summary. The literature selection process is depicted in Figure 1, while the fundamental characteristics of the included articles are outlined in Table 2.

Quality assessment of the included guideline

This study utilized the AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument to assess the quality of the two included guidelines. The tool comprises six assessment domains with a total of 23 items. Each item is rated on a 1–7 scale (1 = strongly disagree, 7 = strongly agree). Domain scores are calculated as the sum of all item scores within a domain, expressed as a percentage of the domain's maximum possible score. For clarity, Table 3 presents the standardized scores (actual score/maximum possible score) for each domain and the corresponding domain score percentage. Generally, domain scores ≥60% indicate good quality, ≥30% represent moderate quality, and <30% suggest low quality. Two reviewers independently scored the guidelines, and average scores were used to determine the overall recommendation grade (A = strongly recommended, B = recommended, C = not recommended). As indicated in the newly added Final Recommendation Grade column in Table 3, both included guidelines received a final recommendation grade of A and were therefore retained for evidence synthesis. Given their high quality, both guidelines were selected for inclusion. Domain-wise interpretation showed that both guidelines clearly defined their scope, target population, and clinical questions. The rigor of development and clarity of presentation supported the reliability and usability of their recommendations, whereas applicability was considered the key domain requiring local adaptation because implementation barriers, resource needs, and clinical workflow may differ across healthcare settings. Editorial independence was also reviewed to assess whether the recommendations were likely to be influenced by competing interests.

Quality assessment of included clinical decision-support resources

A total of three clinical decisions were analyzed, all sourced from UpToDate. In the clinical decisions by Harman et al.¹⁰ and Okon & Christensen¹¹. One reviewer assessed the following items: item 3, "Is the transparency of the summary reviewers/editors ensured?", item 4, "Is the search methodology transparent and comprehensive?", and item 5, "Is the evidence graded, and is the grading system transparent and translatable?" as 'No'. Additionally, this reviewer rated item 9, "Is the summary free from potential bias?" as 'Unclear', while the other two reviewers rated it 'Yes'. In the clinical decision by Silveira et al., besides item 2, "Is the transparency of the summary's authors ensured?" and item 3, which one reviewer rated as 'Unclear', one reviewer rated items 4 and 5 as 'Unclear', and another rated them as 'No', whereas the other two rated these items as 'Yes'. In the clinical decision by Harman et al., aside from items 2, 3, 5, and 7-'Are the recommendations appropriately cited?'-which one reviewer rated 'No', both reviewers rated item 4 'No'. One reviewer rated item 10, "Can this summary be applied to your patients?" as 'Unclear', while the other two reviewers rated it 'Yes'. Overall, the quality of the three clinical decisions was deemed moderate and met the inclusion criteria. The two systematic reviews included in the final evidence set were appraised separately using the JBI Critical Appraisal Checklist for Systematic Reviews.

Quality assessment of included systematic reviews

The quality of the two included systematic reviews was assessed using the JBI Critical Appraisal Checklist for Systematic Reviews, which comprises 11 items¹². Because only two systematic reviews were included, the detailed appraisal results are described in the main text rather than presented in a separate table. Two reviewers independently assessed both systematic reviews. The appraisal focused on the clarity of the review question, the appropriateness of the inclusion criteria, the search strategy, the critical appraisal process, data extraction, the synthesis methods, and the assessment of publication bias. Overall, both systematic reviews were judged to have moderate methodological quality and were retained in the final evidence set.

Evidence aggregation and generation

In this study, nine pieces of evidence were generated, as shown in Table 4. The five members of the evidence-based team analyzed, evaluated, and screened extracted evidence according to the FAME principles¹². The assessment of evidence includes the following dimensions. Feasibility (F): Evaluate whether the application of each piece of evidence is viable in theoretical, technical, and local cultural contexts‌; Appropriateness (A):‌ assess the suitability of evidence implementation by integrating the interests of healthcare providers, nurses, patients, and family members, adhering to the ethical principle of non-maleficence‌1; Meaningfulness (M): Determine whether the evidence benefits clinical decision-making or advances the practice of palliative care‌; Effectiveness (E):‌ Evaluate whether the evidence originates from high-quality research and its anticipated outcomes‌. The nine evidence items were not assigned numerical weights. They were prioritized according to evidence level, source hierarchy, methodological quality, consistency across sources, direct relevance to LST decision-making assessment, and feasibility within the Chinese clinical context. When evidence addressed different stages of care, it was organized according to the clinical sequence of assessment, communication, documentation, and reassessment. Evidence statements with overlapping meanings were merged when they addressed the same assessment objective, target population, clinical timing, or implementation procedure. When findings were inconsistent, priority was given to higher-level evidence, more recent sources, and documents with stronger methodological quality. Evidence certainty was standardized using the 2014 JBI evidence pre-grading system before the final evidence summary was generated.

DATA AVAILABILITY:

No primary datasets were generated or analyzed during this study. This work was based exclusively on the retrieval, appraisal, and synthesis of previously published evidence, including clinical practice guidelines, evidence summaries, clinical decision-support resources, and systematic reviews. All sources used to support the findings of this study are cited in the reference list. Detailed search strategies and evidence retrieval methods are provided in Supplementary Table 1. Therefore, no additional datasets are available.

Figure 1: Study selection and inclusion process. A total of 1,657 records were identified from electronic databases and evidence resources, and 150 duplicates were removed. After title and abstract screening, 13 full-text documents were assessed for eligibility. Seven documents met the inclusion criteria after full-text review, and one additional document was identified through reference screening. Finally, eight documents were included in the evidence summary, comprising two guidelines, one evidence summary, three clinical decision-support resources, and two systematic reviews. Please click here to view a larger version of this figure.

Figure 2: Culturally adapted life-sustaining treatment (LST) decision-making assessment workflow for hospitalized adults with advanced cancer in the Chinese clinical context. The workflow illustrates a stepwise assessment process beginning with patient identification, survival estimation using the Palliative Performance Scale (PPS), and determination of palliative care eligibility, followed by psychological assessment, evaluation of decision-making capacity, identification of key family members, comprehensive palliative care assessment using the Integrated Palliative Care Outcome Scale (IPOS) with PEACE as a local implementation framework when appropriate, assessment of patient and family preparedness for LST discussions, multidisciplinary determination of discussion readiness, documentation of patient-family preferences and agreed care goals, and repeated reassessment when the patient's condition, prognosis, or decision-making context changes¹⁷. Please click here to view a larger version of this figure.

Line	Search
#1:	“life sustaining treatment” OR “life support treatment” OR “do not resuscitate “
#2:	“DNR” OR“ advance directives” OR“ advance care planning”
#3:	#1 OR #2
#4	“advanced” OR “Late-stage” OR “Terminal” OR “dying” OR “end of life” OR “palliative”
#5	“cancer” OR “tumor”
#6	#4 OR #5
#7	#3 AND #6
#8	“assessment” OR “measurement” OR “method” OR “approach” OR “strategy” OR “progress” OR “procedure”
#9	“participate” OR “decision making” OR “choice” OR “knowledge” OR “attitude” OR “skill”
#10	“guideline” OR “protocol” OR “evidence summary” OR “Evidence-based synthesis” OR “Systematic review” OR “Meta-analysis”
#11	#7 AND #8 AND #9 AND #10

Table 1: Search strategy in MEDLINE. MEDLINE search strategy used to identify evidence on LST decision-making assessment in patients with advanced cancer. Search terms covered LSTs, advanced cancer, assessment methods, decision-making, and evidence-source types.

Included study	Publication date	Study types	Database	Study topic
[7]	2019	Guideline	NICE	End of life care for adults: service delivery
[6]	2021	Guideline	NCCN	Palliative Care
[15]	2022	Evidence summary	JBI	Palliative Care: Communication and Decision-Making
[16]	2019	Clinical decision-making	UpToDate	Palliative care: The last hours and days of life
[17]	2021	Clinical decision-making	UpToDate	Overview of comprehensive patient assessment in palliative care
[18]	2022	Clinical decision-making	UpToDate	Advance care planning and advance directives
[15]	2023	Systematic review and meta-analysis	Palliative Medicine	Performance of the Palliative Prognostic Index for cancer patients
[26]	2013	Systematic review	Reference-list screening / American Journal of Hospice and Palliative Medicine	Prevalence of signs of impending death and symptoms in the last 2 weeks of life

Table 2: Characteristics of the eight included documents. The table summarizes two guidelines, one evidence summary, three clinical decision-support resources, and two systematic reviews by publication year, evidence type, database or source platform, and topic, providing an overview of the evidence base used for final synthesis.

Inclusion in the		Standardized score for each field (%)/Evaluation and Score						Quality level	Final Recommendation Grade
literature		Scope purpose	Participants	Rigor	Clarity	Applicability	Independence
[7]	#1	6/7/2006	6/6/2006	6/6/5/5/6/5/5/6	6/5/2006	6/6/6/6	5/4	A	A
	#2	6/7/2007	5/5/2003	4/4/4/5/6/4/7/6	5/4/2006	5/5/4/5	5/5	A	A
	#3	7/7/2006	5/4/2004	4/5/5/6/6/5/7/6	5/4/2005	6/5/5/6	5/5	A	A
	#4	5/5/2006	7/6/2005	7/5/6/5/5/6/6/7	6/5/2007	5/6/6/5	7/5	A	A
		87.50%	69.40%	74.50%	72.20%	78.10%	68.80%	A	A
	#1	6/6/2006	6/6/2006	6/6/6/6/6/6/5/5	6/6/2007	6/6/6/5	6/6	B	A
[6]	#2	6/6/2007	6/6/2005	6/6/5/6/6/6/7/6	6/6/2007	7/6/6/7	6/6	B	A
	#3	6/7/2006	7/6/2005	6/6/6/7/7/6/7/7	6/7/2007	6/6/5/6	5/5	A	A
	#4	7/7/2007	6/5/2006	7/7/6/7/5/6/7/7	7/6/2007	6/7/5/7	6/7	A	A
		90.30%	80.60%	86.50%	91.70%	88.50%	81.20%	A	A

Table 3: Results of the quality evaluation of the guidelines. AGREE II domain scores are presented as standardized percentages. Scores ≥60% indicate good quality, scores of 30–59% indicate moderate quality, and scores <30% indicate low quality. Recommendation grades were assigned according to the overall domain performance and methodological quality. Quality evaluation of the included guidelines using the AGREE II instrument. Six domains were assessed, including scope, participants, rigor, clarity, applicability, and editorial independence, with final recommendation grades assigned according to overall quality.

Evidence No.	Evidence category	Assessment category	Evidence description			Evidence level
Evidence 1	Basic evaluation	Patient assessment	Healthcare professionals should accurately identify patients with advanced cancer and those in the dying phase, and estimate the patient’s survival time.			1b
Evidence 2	Basic evaluation	Family member assessment	Healthcare professionals and social workers should collaborate to assess and identify the patient’s caregiver and other important family members.			2c
Evidence 3	Basic evaluation	Patient decision-making capacity assessment	Healthcare professionals should assess the patient’s decision-making capacity, particularly whether the patient can understand the benefits and burdens of potential LSTs in future emergency situations. If necessary, an alternative decision-maker should be identified, and use of a decision-making capacity assessment form is recommended.			1a
Evidence 4	LST assessment guided by the palliative care stage	Assessment goals	A comprehensive palliative care assessment should be patient-centered and family-oriented throughout the palliative care phase, with particular attention to the patient’s treatment goals, including goals related to LST decision-making.			2b
Evidence 5	LST assessment guided by the palliative care stage	Guided decision-making structured assessment	The structured assessment should include: a) assessment of the patient’s psychological, mental, spiritual, and cognitive status, including exclusion of patients with severe depression and assessment of spiritual needs; b) assessment of the patient’s personal support system; c) discussion of prognosis and evaluation of personalized care goals; and d) assessment of the coordination and continuity of medical services.			1b
Evidence 6	LST assessment guided by the palliative care stage	Family assessment	Caregivers’ and other important family members’ understanding of the patient’s disease status, prognosis, and treatment effects should be assessed.			2c
Evidence 7	LST assessment guided by the palliative care stage	Assessment tools	The Integrated Palliative care Outcome Scale (IPOS) is recommended as a structured reference for pre-assessment in palliative care.			2b
Evidence 8	LST assessment guided by the palliative care stage	End-of-life assessment	Healthcare professionals should assess the end-of-life expectations of dying patients, determine and document the care goals and LST preferences of patients and their families, with particular emphasis on discussions about LSTs.			1b
Evidence 9	LST assessment guided by the palliative care stage	Dynamic reassessment	Healthcare professionals should assess whether the patient’s current physiological and psychological state allows participation in discussions about LST decisions, and repeat the assessment when the patient’s condition, prognosis, or decision context changes.			1b

Table 4: Evidence summary derived from the eight included documents. Nine evidence items were organized by assessment category, evidence description, and evidence level, covering patient identification, family assessment, decision-making capacity, palliative care assessment, assessment tools, and end-of-life reassessment.

Supplementary Table 1: Complete search strategies for major databases. Raw search-strategy data file for major databases and evidence resources. This supplementary raw data file provides the complete database-specific search strategies used in this study. Search strategies were tailored to each database's indexing rules. The search period was March 3, 2019, to March 3, 2024. MEDLINE searches used MeSH terms where applicable, and Chinese databases used corresponding Chinese subject and free-text terms.Please click here to download this file.

Discussion

Evidence 1 in Table 4 is essential for identifying patients with advanced cancer, evaluating their survival, and determining their eligibility for palliative care interventions. Widely recognized survival assessment tools, such as the Palliative Performance Scale (PPS)¹³, Karnofsky Performance Status (KPS)¹⁴, which scores patients' daily activity abilities on a 0-100 scale, with higher scores indicating better functional status, and Palliative Prognostic Index (PPI)¹⁵, offer a preliminary estimation of a patient's survival time. Furthermore, studies have confirmed the accuracy of the terminal illness assessment scale in predicting the survival duration of terminally ill patients, affirming its utility in evaluating patients in the dying phase^16,17,18. When it is determined that a patient's survival duration is less than six months and both the patient and their family members clearly understand the impending approach of death, it becomes more suitable to guide discussions about decisions concerning LSTs.

Evidence 2 in Table 4 highlights the need to evaluate the family system, identifying the primary caregiver and other key family members involved in decision-making. This step is pivotal in determining the feasibility of discussions regarding LST's decisions. Within the context of China's traditional 'family-centered' culture, the assessment and identification of family system members prior to discussions about LST's decisions are crucial, as most significant end-of-life decisions are made by family members¹⁹. Evidence 3 emphasizes the importance of assessing a patient's decision-making capacity, particularly their understanding of potential LSTs in future emergencies. It is advisable to utilize a decision-making capacity assessment form to aid this evaluation²⁰. Assessing the patient’s decision-making capacity and identifying the key family members helps standardize the preparatory steps before initiating discussions about LSTs. This approach not only respects the patient’s rights in LST discussions but also underscores the importance of family participation in these dialogues within the Chinese cultural context, leading to LST decisions that reflect the family's collective preferences. Evidence 4–6 in Table 4 elaborates on the preliminary decision-making evaluation framework for patients with advanced cancer entering the palliative care stage. These segments include the assessment's goals and content, with a focus on the patient and family system. The assessment objectives indicate that decisions regarding LSTs during the palliative care phase are dynamic and ongoing. The foundational principle centers on patient-centered care, prioritizing the patient’s treatment objectives, including decisions about LSTs, while also emphasizing the guiding role of family members’ opinions. Thus, medical staff should evaluate the attitudes of key family members towards the patient’s disease progression, prognosis, and subsequent treatments. Through a comprehensive assessment of both the patient and their family members, discussions about LSTs should be progressively facilitated to aid in timely decision-making. Discussions surrounding LSTs face challenges such as decision conflicts and ethical dilemmas. The structured assessment process indicates that prior to discussing treatment decisions with patients in the palliative care phase, it is essential to first evaluate their physical symptoms, psychological, mental, and cognitive conditions to prevent safety and ethical issues. Palliative care practices are centered on patient needs, assessed across physical, psychological, social, and spiritual dimensions, thereby facilitating an understanding of patients’ perceptions of disease progression. In Evidence 7 regarding LST decision-making assessment during the palliative care phase, the Integrated Palliative Care Outcome Scale (IPOS) is recommended for pre-assessment to facilitate structured patient evaluation. IPOS amalgamates the most pertinent elements from the Palliative Care Outcome Scale (POS) with symptom management, creating a 17-item multidimensional tool for assessing patients' physical, emotional, and spiritual symptoms, along with care practices issues²¹. Studies have demonstrated that IPOS is particularly suitable for patients with advanced cancer and is extensively utilized in clinical settings for comprehensive and continuous evaluations during palliative care^21,22. IPOS is available in both patient self-assessment and proxy versions for healthcare professionals and family members. It has been translated into several languages and validated by research, including English²³, French²⁴, Portuguese²⁵, and Japanese²². However, there is a dearth of IPOS Chinese-language tools tailored to China’s specific conditions. In regions without a locally validated IPOS version, its use may be limited by linguistic equivalence, cultural interpretation of symptom and spiritual-care items, uncertain cut-off values, and insufficient evidence on local reliability and responsiveness. Therefore, IPOS should be used cautiously as a structured reference until translation, cultural adaptation, and psychometric validation are completed. Future research could focus on enhancing the comprehensive assessment of palliative care stages for advanced cancer patients by either developing or adapting existing tools. Moreover, the evaluation of coordination and continuity of medical services is also suggested in the comprehensive assessment of palliative care stages, to ensure timely delivery of in-hospital palliative care and the feasibility of external referrals. Evidence 8 and Evidence 9 in Table 4 highlight the need to document patient-family LST preferences and to conduct dynamic reassessment before or during LST discussions near the end of life^8,26. According to the evidence, as the patient approaches the terminal stage, the assessment increasingly focuses on clarifying decisions about LSTs. For those with predetermined LST decisions, the assessment at this stage highlights dynamic changes in the content of decision-making. The assessment encompasses the patient’s and family’s end-of-life expectations and care objectives, addressing LST measures that align with these goals^27,28. It is also essential for healthcare providers and family members to collaboratively evaluate the patient’s current physical and mental state, including for those patients and families who have made prior decisions, to ascertain the appropriateness of further LST discussions.

As previously reported, Chinese traditional culture emphasizes family-centered collective decision-making, which differs from the Western patient autonomy model¹⁹. In non-Chinese or Western contexts, this framework should be adapted by placing explicit patient autonomy at the outset of the assessment. Clinicians should first ask whether, how, and to what extent the patient wishes family members to be involved in LST discussions. Family-system assessment can then be retained when it is consistent with the patient’s preferences. Compared with many Western shared decision-making and advance care planning models, which usually begin with individual autonomy, informed preferences, advance directives, and legally authorized surrogates, the present framework places greater emphasis on early assessment of family structure and family communication patterns. This does not mean that patient autonomy is weakened; rather, the framework attempts to identify how autonomy is expressed, negotiated, or supported within the family context. In non-Chinese healthcare systems, family-centered components should therefore be used flexibly, only after confirming the patient’s preferred level of family involvement. Although IPOS is recommended as the structured reference for palliative care assessment in Evidence 7, it does not specifically address family decision-making conflicts, and a locally validated mainland Chinese version remains unavailable. Therefore, the workflow in Figure 2 retains IPOS as the evidence-based structured reference and uses PEACE as an operational framework for local implementation, rather than replacing IPOS. Each workflow step corresponds to the numbered evidence items in Table 4: Steps I–III correspond to Evidence 1; Step VI corresponds to Evidence 2; Step V corresponds to Evidence 3; Steps IV, VII, VIII, IX, and X correspond to Evidence 4–6; Step VII also reflects Evidence 7; and Step XII corresponds to Evidence 8 and Evidence 9 by integrating final multidisciplinary determination, documentation of patient-family LST preferences and agreed care goals, and repeated assessment when the patient’s condition, prognosis, or decision context changes. The workflow has not yet undergone formal expert validation or prospective pilot implementation; therefore, it should be interpreted as an evidence-informed framework that requires further feasibility testing and clinical validation.

In conclusion, this summary consolidates nine pieces of evidence on how to conduct a basic, structured assessment of LSTs' decision-making during the palliative care phase; see Table 4. It should be clarified that, although Table 4 presents 8 assessment dimensions, the "LST Assessment Guided by Palliative Care Stage" dimension contains 4 sub-items (a–d), yielding a total of 9 evidence entries. The evidence includes the goals, content, tools, and key points of LST's decision-making assessments at different stages. Palliative care professionals can use this evidence to further refine and implement the assessment process, devising practical evaluation plans for LSTs in patients with advanced cancer. This approach facilitates comprehensive physical, psychological, spiritual, and compassionate care, thereby supporting patients and their families in making high-quality decisions and helping patients die with dignity. Finally, this study proposed a "Culturally Adapted LST Decision-Making Assessment Flowchart for the Chinese Clinical Context" to facilitate clinical practice.

Before interpreting this workflow for clinical use, the limitations should be distinguished at two levels. First, evidence-synthesis limitations arise from the search strategy and available evidence base, including restriction to Chinese- and English-language publications, exclusion of gray literature, reliance on a limited number of eligible documents, and variable transparency in clinical decision-support resources. Second, workflow implementation may face practical barriers in real clinical settings, including insufficient clinician training in LST communication, limited time for structured family-system assessment, inconsistent documentation of patient preferences, potential conflicts between patient autonomy and family-centered decision-making, and the lack of locally validated assessment tools, such as a mainland Chinese version of IPOS. Therefore, pilot testing, staff training, documentation standardization, and iterative troubleshooting are needed before the proposed workflow can be widely implemented.

This evidence summary inevitably has some limitations. Firstly, although an effort was made to identify recent articles pertinent to assessing LSTs in patients with advanced cancer, excluding gray literature may have led to the omission of relevant studies, potentially biasing our interpretation of the results. The five-year restriction may also have excluded earlier primary studies or conceptual work that remains relevant, although retrospective reference checking was used to identify foundational sources when necessary. Secondly, the review was restricted to studies published in Chinese and English, introducing a language bias that could affect the reliability of the combined findings. This restriction may also limit the generalizability of the findings to healthcare systems with different legal, religious, and cultural approaches to end-of-life decision-making. In addition, omitting gray literature and local institutional protocols may have underrepresented practice-based strategies used clinically but not published in indexed sources. Thirdly, only eight documents met the eligibility criteria, which may still limit the breadth of the evidence base despite the focused scope of this best-evidence summary. Fourthly, potential publication bias cannot be fully excluded because unpublished evidence and negative or less conclusive implementation experiences may not have been captured. Fifthly, three included documents were clinical decision-support resources from UpToDate; although these sources are widely used in clinical practice, their search and updating processes may be less transparent than those of formal systematic reviews or guidelines. Finally, the proposed workflow has not yet been prospectively validated or pilot-tested in clinical practice, and its feasibility, acceptability, and impact on patient-family-clinician decision-making require further evaluation. Despite these limitations, this evidence summary adhered rigorously to the criteria and incorporated high-quality research reports. Notably, it is the first to synthesize how patients with advanced cancer, their family members, and healthcare professionals make decisions about LSTs using an evidence-based approach, providing a valuable reference for healthcare professionals to guide end-of-life decision-making in palliative care.

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
6S evidence hierarchy model	McMaster University / evidence-based medicine methodology	6S model; no catalog number; URL: https://www.ebm.med.ualberta.ca/teaching/6s.htm	Used to guide the search sequence by prioritizing pre-appraised evidence, including guidelines, evidence summaries, and clinical decision-support resources.
AGREE II instrument	AGREE Enterprise / AGREE Research Trust	AGREE II; no catalog number; URL: https://www.agreetrust.org/resource-centre/agree-ii/	Used to appraise the methodological quality of clinical practice guidelines.
BMJ Best Practice	BMJ Publishing Group Ltd.	Online clinical decision-support database; URL: https://bestpractice.bmj.com	Used as an evidence-based clinical decision-support source for retrieving relevant palliative care and LST decision-making evidence.
CINAHL	EBSCO Information Services	CINAHL database via EBSCOhost; URL: https://www.ebsco.com/products/research-databases/cinahl-database	Used as an international nursing and allied health bibliographic database for literature retrieval.
CNKI	China Academic Journals (CD Edition) Electronic Publishing House Co., Ltd. / Tongfang Knowledge Network Technology Co., Ltd.	China National Knowledge Infrastructure; URL: https://www.cnki.net	Used as a major Chinese database for retrieving Chinese-language literature.
Cochrane Library	Cochrane / John Wiley & Sons Ltd.	Cochrane Library; URL: https://www.cochranelibrary.com	Used to retrieve systematic reviews and evidence-based resources related to palliative care and LST decision-making.
Critical Appraisal for Summaries of Evidence (CASE) tool	Medical Library Association / Journal of the Medical Library Association	CASE tool; no catalog number; DOI: 10.3163/1536-5050.101.3.008	Used to evaluate clinical decision-support resources and summaries of evidence.
DynaMed	EBSCO Information Services	DynaMed clinical decision-support database; URL: https://www.dynamed.com	Used as a clinical decision-support database for retrieving pre-appraised evidence.
Embase	Elsevier B.V.	Embase biomedical database; URL: https://www.embase.com	Used as an international biomedical database for systematic literature retrieval.
EndNote	Clarivate Analytics	EndNote 20; URL: https://endnote.com	Used for importing retrieved records, managing references, and removing duplicate records.
FAME framework	Joanna Briggs Institute (JBI), University of Adelaide	Feasibility, Appropriateness, Meaningfulness, and Effectiveness framework; no catalog number; URL: https://jbi.global	Used to assess the feasibility, appropriateness, meaningfulness, and effectiveness of evidence items before synthesis.
Guidelines International Network (GIN)	Guidelines International Network	International Guidelines Library; URL: https://g-i-n.net/international-guidelines-library/	Used as an international guideline repository for retrieving relevant clinical practice guidelines.
Integrated Palliative care Outcome Scale (IPOS)	Cicely Saunders Institute, King’s College London / POS Development Team	IPOS 17-item scale; URL: https://pos-pal.org/maix/ipos/	Recommended as a structured multidimensional tool for assessing physical, emotional, spiritual, and care-related needs in palliative care.
JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses	Joanna Briggs Institute (JBI), University of Adelaide	JBI critical appraisal checklist; URL: https://jbi.global/critical-appraisal-tools	Used to assess the methodological quality of included systematic reviews.
JBI Database of Systematic Reviews and Implementation Reports	Joanna Briggs Institute (JBI), University of Adelaide / Wolters Kluwer Ovid	JBI evidence-based practice database; URL: https://jbi.global	Used to retrieve evidence summaries, systematic reviews, and implementation-related evidence.
JBI Levels of Evidence and Grades of Recommendation	Joanna Briggs Institute (JBI), University of Adelaide	2014 JBI evidence pre-grading system; URL: https://jbi.global	Used to classify the level and certainty of included evidence from Level 1 to Level 5.
Karnofsky Performance Status (KPS)	Public-domain clinical performance scale / original Karnofsky scale	KPS 0–100 scale; no catalog number	Used as a functional performance assessment tool to support survival estimation in patients with advanced cancer.
MEDLINE / PubMed	U.S. National Library of Medicine, National Institutes of Health	MEDLINE via PubMed; URL: https://pubmed.ncbi.nlm.nih.gov	Used as a major biomedical database for retrieving English-language evidence.
Microsoft Excel	Microsoft Corporation	Microsoft Excel for Microsoft 365; URL: https://www.microsoft.com/microsoft-365/excel	Used to construct standardized extraction forms, manage extracted evidence, and prepare supplementary tables.
National Comprehensive Cancer Network (NCCN) Guidelines	National Comprehensive Cancer Network	NCCN Clinical Practice Guidelines in Oncology; URL: https://www.nccn.org/guidelines	Used as a guideline source for palliative care and end-of-life decision-making recommendations.
National Institute for Health and Care Excellence (NICE) Guidance	National Institute for Health and Care Excellence	NICE Guidance; URL: https://www.nice.org.uk/guidance	Used as a guideline repository for end-of-life care and palliative care recommendations.
Palliative Performance Scale (PPS)	Victoria Hospice Society	PPS version 2; URL: https://victoriahospice.org	Used as a survival and functional status assessment tool for patients receiving palliative care.
Palliative Prognostic Index (PPI)	Public-domain prognostic index / original Morita scale	PPI score; no catalog number	Used as a prognostic tool to estimate survival in patients with advanced or terminal cancer.
PEACE framework	Wolters Kluwer / UpToDate clinical decision-making framework	Adapted clinical decision-making framework; no catalog number; URL: https://www.uptodate.com	Used to inform the culturally adapted LST decision-making assessment workflow.
PIPOST framework	Evidence-based healthcare methodology / Joanna Briggs Institute-related evidence summary framework	PIPOST framework; no catalog number	Used to define the evidence scope, including Population, Intervention, Professionals, Outcomes, Settings, and evidence Types.
Scottish Intercollegiate Guidelines Network (SIGN)	Healthcare Improvement Scotland	SIGN Guidelines; URL: https://www.sign.ac.uk	Used as a guideline repository for retrieving clinical practice guidelines.
SinoMed	Institute of Medical Information, Chinese Academy of Medical Sciences and Peking Union Medical College	Chinese Biomedical Literature Service System; URL: https://www.sinomed.ac.cn	Used as a Chinese biomedical database for retrieving Chinese-language literature.
UpToDate	Wolters Kluwer	UpToDate clinical decision-support database; URL: https://www.uptodate.com	Used to retrieve clinical decision-support resources related to palliative care, advance care planning, and LST decision-making.
Wanfang Data	Beijing Wanfang Data Co., Ltd.	Wanfang Data Knowledge Service Platform; URL: https://www.wanfangdata.com.cn	Used as a major Chinese database for retrieving Chinese-language literature.