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 recor...

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 Prognosti...

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.