Abstract
Background: Effective shared decision-making (SDM) for life-sustaining treatment (LST) requires alignment between physicians and surrogates. However, discrepancies in perceptions and communication may hinder ethically sound decisions. This study aimed to compare the perceptions and attitudes of physicians and surrogates toward SDM for LST in a Chinese hospital setting. Methods: This pre-planned secondary analysis included data from two cross-sectional surveys administered to physicians and surrogates. Participants were 325 surrogates of critically ill adult patients admitted to the Emergency Intensive Care Unit (EICU) of a tertiary teaching hospital and 351 physicians from hospitals in Beijing. Survey items assessed triggers and preferred models of decision-making, disclosure practices, perceived decisional capacity, and factors influencing LST decisions. Statistical comparisons were performed using appropriate tests for categorical data. Results: Although a majority in both groups nominally preferred SDM (physicians: 52.7%; surrogates: 44.3%; p = 0.155), significant discrepancies emerged across other domains. Physicians were more likely than surrogates to initiate LST discussions earlier (88.0% vs. 75.3%; p < 0.001). Perceived understanding differed markedly: 87.7% of surrogates rated their comprehension as "good" or "excellent", whereas 73.8% of physicians rated surrogate understanding as "fair" or "poor" (p < 0.001). Surrogates expressed a stronger preference for receiving quantitative prognostic information and decision-support tools. Most physicians (94.9%) reported directing consent discussions primarily to families, with limited patient involvement. Priorities for LST decisions diverged: physicians emphasized clinical indicators such as prognosis (96.0%) and comorbidities (91.7%), whereas surrogates emphasized patient age (72.0%). Conclusions: Marked discordances exist between physicians and surrogates in their perceptions and practices regarding SDM for LST in China. Differences in communication strategies, informational expectations, and decision-making priorities underscore the need for contextually adapted interventions, such as structured communication tools and culturally sensitive clinician training, to bridge these gaps and support ethically aligned decision-making.