PONE-D-24-35495Factors influencing the participation of surrogate decision-makers for advanced cancer patients in advance care planning: A cross-sectional studyPLOS ONE

Dear Dr. Ma,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jan 03 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
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• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Xiong Xingyu, M.D.

Academic Editor

PLOS ONE

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Additional Editor Comments:

Actually, the peer reviewers have proposed many serious problems, and one of the experts recommended to reject your manuscript. After careful consideration, we decide to give authors a chance to comprehensively improve your paper by replying to all the reviewers' feedbacks. If these questions are properly addressed by authors and approved by reviewers, editors would like to reconsider the decision for publication.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

Reviewer #3: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1:  The authors have clearly identified surrogate decision-making as an important subject especially for patients with advanced cancer and the need for education and policy development in China. However, there are three main reasons why this article is not suitable for publication in its present form:

1) The English language is currently not up to publication standard and requires considerable editing. Also, there are incorrect facts in the Introduction about advance care planning in different countries, for example, Australia does not have federal laws regulating advance care planning, this is a Sate responsibility.

2) The research method does not address the key principle of surrogate decision-making, that is, what would the patient want, even though it is mentioned in the Introduction when defining Advance Care Planning, “… which aims to respect the patient’s values … “. There is no mention of this fundamental reason for surrogate decision making in the Aim or Methods. The authors note there are limitations with the research including no interviews, but do not address how the participants would know or understand the decisions the patient would want. This is the basic principle underpinning advance care planning and as the authors mention will require interviews to understand the complex issues involved.

3) Although the authors have not clearly explained their quantitative methodology, it is unclear how the participants were approached to be involved with this research. Were they given the questionnaire to complete, or were they assisted by one of the researchers. (As a qualitative methods research fellow, I have not commented on the quantitative results).

Reviewer #2:  Title: Factors influencing the participation of surrogate decision-makers for advanced cancer patients in advance care planning: A cross-sectional study.

Thank you for allowing me to review this important manuscript.

General feedback:

Overall, very well written manuscript and a well thought study.

Recommend using tenses consistently. Please have the manuscript reviewed for grammatical and sentence structure errors to bring more clarity to the content.

Recommend changing the term, “propaganda” as it has a negative connotation.

Abstract: Concise and well written. However, please identify the age group of patients you are focusing on.

Introduction: The flow of ideas is clear leading to your research question.

Methods and results:

Very thorough and well presented.

Discussion:

Please expand on your point regarding optimistic surrogate decision makers. Are you suggesting that people should be optimistic so healthcare providers can better engage them in ACP discussions? I think this is too much to ask from them when they are already dealing with cancer diagnosis and treatments. What can be done from the perspectives of healthcare providers and researchers to increase the uptake of ACP?

Conclusion:

Make conclusion concise and move future suggestions in research and practice implications as well as limitations to the discussion.

I recommend changing, “cognitive error” to another better term to describe your point.

Reviewer #3:  Comments:

Thank you for offering the opportunity to review the manuscript titled “Factors influencing the participation of surrogate decision-makers for advanced cancer patients in advance care planning: A cross-sectional study”.

I believe the dataset of this study have valuable and important figures that worth dissemination. However, the quality of the current manuscript is far below the standard ready to publish. Here is an overall comment to address:

1) Please justify why the chosen study population “surrogate decision-maker of patients with advanced cancer” is important to study in the Chinese context. There should be more elaboration about how the Chinese culture affecting medical decisions and the dynamic between family caregivers and doctors. This would highlight the significance of this study.

2) The statistical tests performed in inferential analyses were not clearly reported. It is unclear about how the missing data was treated, and the completion rate of each outcome measure. The result tables do not clearly describe if mean (SD) is reported or not.

3) The discussion is superficial to add new knowledge to the field of study. Consider comparing the results with the following papers:

- WANG, T., WANG, W., SHEN, W., & SHI, B. (2022). Participation in Advance Care Planning and Associated Factors among Surrogate Decision Makers of Patients with Hematologic Malignancies. Chinese General Practice, 25(07), 859.

- Liu, X., Chen, H., Zhang, L., Zhang, Q., Feng, T., & Liu, D. (2022). Advance care planning engagement among family members of community-dwelling elderly patients with chronic diseases in China: a mixed-methods study. Journal of Hospice & Palliative Nursing, 24(2), E26-E34.

Please refer to the attached PDF file marked with in-text comments for more specific comments about the methods, analysis, and results. Thank you!

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

**********

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: ACP in cancer.docx

Attachment

Submitted filename: PONE-D-24-35495_reviewer comment.pdf

PONE-D-24-35495R1Factors influencing the participation of surrogate decision-makers for advanced cancer patients in advance care planning: A cross-sectional studyPLOS ONE

Dear Dr. Ma,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Mar 23 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Xiong Xingyu, M.D.

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

Reviewer #3: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

Reviewer #3: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors do not fully explore the principles behind advance care planning and substitute decision making. Their analysis largely ignores the fundamental issues of patient autonomy and of decision makers needing to implement the patient’s wishes. The authors mention that these are Western concepts that are new to China, but they do not make pay substantial attention to that point. The authors’ conclusions are sound, but the design of the study did not fully explore the points made in the conclusion. The research design was not the most appropriate design for this topic.

Reviewer #2: There are major areas that need revision to strengthen the manuscript for publication. These have been highlighted in the attached file.

Reviewer #3: The first and most crucial comment is to send your manuscript to professional editing before getting published. There were many grammatical mistakes and inconsistent use of terms, such as SDMs vs SMDs, severely affect readers’ understanding. More specific comments are as below:

Section 1: introduction

• The connection between ACP & AD was not highlighted, despite the two concepts were compared. Why promoting ACP is significant and how does it relate to the completion of AD? Please explain.

Section 2: Background

• Consider using the term “individual” instead of “patient” to minimize stigmatization.

Section 3: Aim

• Suggest moving the last sentence of this paragraph to the background section. It highlights the significance of the study rather than aim of this study.

Section 4.1: Study design

• Please state that this is a cross-sectional survey.

• Please clarify the duration of data collection period. It is not necessary to mention the period of evaluation (i.e. from July 2023 to January 2024).

• Please state the data collection approach. Whether participants were invited to complete a self-report questionnaire or assisted by research assistants.

Section 4.2: Participant selection

• Please clarify how SDM is appointed in your study setting. The phrase “appointed according to relevant regulations” is ambiguous.

Section 4.3: Measurements

• Please cite the references that support your choice of exploring factors under the three dimensions.

Section 4.3.3 to 4.4.5: Instruments

• The description of scoring methods was lengthy. Consider delete it as long as the total score is reported for analysis. Showing the direction of total score is adequate.

Section 4.4 Statistical analysis

• The term “cancer characteristics of SDMs” are ambiguous. The SDMs are not cancer patient. Do you mean “the characteristics of cancer of their care recipients”.

• Please state clearly if an independent t-test or paired t-test was used.

• When stating the p-value. Please consider if a small letter “p” or a capital letter “P” should be used.

• Consider addressing how missing data was treated in this section.

Section 5.2: Factors influencing the ACP engagement of SDMs

• This section reported the results of univariate analyses. The heading should be “factors associated with the ACP engagement of SDMs”

• The section heading should not be the same for section 5.2 and 5.3

Table 2:

• The heading of columns were not aligned with the heading of table. If subscale score is reported, please indicate these are the three subscale component of ACP engagement.

• In the column heading, please indicate “mean (SD)” was reported in the table.

• The choice of statistical tests for certain variables were queried. Please review the test being used for “marital status”, “experience of making medical decision”

• Please state the level of significance at the bottom of the table.

Table 3:

• Please clarify whether the construct reported here should be named as "life orientation" or "optimism"? Please align with section 4.3.5.

• What was the variable “attitudes” reported here? It was not described in section 4.3

Section 5.3

• The section heading should not be the same as section 5.2.

• Please check the presentation format of table 5. The collinearity statistics, TOL and VIF should be included in the table. Values for the constant is not necessarily to be reported.

• Please add the level of significance/ removal standard at the bottom of the table

Section 6: Discussion

• The conclusion “The univariate analyses showed that older SDMs had higher ACP engagement” was not supported by the statistics. From table 2, the mean ACP engagement score of the age group 18-40 is the highest among all. Please update your discussion.

• The discussion between educational level, cognitive ability and knowledge of ACP was not logical. People having higher educational level doesn’t mean they have higher cognitive ability, as they may suffer from cognitive problem such as memory problem. The discussion followed cannot address the need of the less educated group. Please revise the implication drawn from this finding.

• The discussion made based on the result of table 3 was not logical. Please explain why people having higher treatment expenditure reported higher level of ACP engagement; and why people having higher level of uncertainty of disease reported lower level of ACP engagement. Followed by the discussion of their implications.

• The recommendations made (public education and legal support) were not drawn from the study findings. Please tailored your recommendation specifically to a specific population that need extra attention and support to enhance their ACP engagement. And suggest what components should be included in the ACP intervention. Recommendations should be discussed in Section 6 instead of section 7.

• Please clarify the meaning of “validation studies”.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: Revised manuscript (clean copy)_reviewer comment.docx

Attachment

Submitted filename: Reviewers in-text comment.pdf

Attachment

Submitted filename: PLOS One Jan 2025.docx

PONE-D-24-35495R2Factors influencing the participation of surrogate decision-makers for advanced cancer patients in advance care planning: A cross-sectional studyPLOS ONE

Dear Dr. Ma,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by May 10 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Xiong Xingyu, M.D.

Academic Editor

PLOS ONE

Additional Editor Comments:

Peer experts still point out many serious problems, and there is always a rejection recommendation in each round of peer review. Especially, language problems were proposed by each reviewer. Thus, this revision decision is the last chance to improve you manuscript for potential publication in PLOS ONE. I hope your next ammendments can meet the standard of the experts. I look forward to your revisions. Thanks for the chance to consider your work.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Partly

Reviewer #3: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: No

Reviewer #3: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Review

Title: Factors influencing the participation of surrogate decision-makers for advanced cancer patients in advance care planning: A cross-sectional study.

General Comments

- Thank you for allowing me to review this manuscript for the third time. Most of the comments have been responded to however there are still some points that need addressing.

- Multiple grammatical errors, and flow of ideas, need to be reviewed and edited throughout the manuscript. Please have the manuscript reviewed for grammatical and sentence structure errors to bring more clarity to the content.

Major Comments

Background:

- Last paragraph of this section talks a lack of existing research on ACP engagement by SDMs. But it is still unclear if authors are referring to the need for the SDMs to engage in ACP with or without their patients (family members).

- It is unclear how will you use the findings of this study apart from education. Who will be the target for the education

- You have mentioned education, but what is your opinion on reducing/addressing the hierarchy existing between elders and physicians. How will knowing SDMs’ perspective help with removing barriers related to hierarchy?

Discussion:

- Your rationalization on yours and Liu study differences are not very clear.

- Its unclear what you mean by “new things” as a prerequisite for participation in ACP, please elaborate.

- You talk about the role of government, media and hospital in establishing theoretical framework. I don’t believe that’s their role. But I am also wondering if you are referring to policies instead of theoretical framework.

- Your point regarding higher financial burden leading to high participation in ACP by SDMs is contradictory to the actual philosophy of ACP, which must involve the patient. It appears you are referring to care decisions made by SDMs only.

- You talk about patients playing a central role in developing ACP and suggest healthcare providers should be sensitive to culture, religion etc., these are generic suggestions. I am interested to know recommendations related to the Mainland China.

Reviewer #3: The authors' effort in improving the writing is well acknowledged. Despite two rounds of extensive review from multiple reviewers, the article is still not ready to be published. First, the academic writing skills were beyond standard, which highly affected readers' understanding. More than one reviewer requested professional editing to improve clarity, yet the recommendation has not been taken. Secondly, inconsistent information was noted; careful proof-reading is required. The discussion fairly brings out new insights into the subject matter, as the discussion is rather superficial or lacks logic. Some suggestions or implications of the study were not supported by the findings. Please refer to the attachment for detailed comments.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #2: No

Reviewer #3: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: PONE-D-24-35495_R2_reviewer comment.pdf

Attachment

Submitted filename: PLOS One Mar 2025.docx

PONE-D-24-35495R3Factors influencing the participation of surrogate decision-makers for advanced cancer patients in advance care planning: A cross-sectional studyPLOS ONE

Dear Dr. Ma,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 07 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
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Kind regards,

Xiong Xingyu, M.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2:  Authors have satisfactorily responded to the reviewers' comments and hence can be considered for publication.

Reviewer #3:  1. Background

In the 4th paragraph, I believe the meaning of “there are few studies focusing on the ACP engagement of SDMs with patients in mainland China” is deviated from your original meaning. Please consider rewrite it as “there are few studies related to ACP involving both SDMs and patients in mainland China.

In the last paragraph of section 2, the elaboration on literature gap closely resembles the discussion section, which sounds duplicated and a preconception before investigation.

To address the literature gap, please consider citing the following reference to highlight the complexity of implementing ACP in mainland China.

McMahan, R. D., Tellez, I., & Sudore, R. L. (2021). Deconstructing the Complexities of Advance Care Planning Outcomes: What Do We Know and Where Do We Go? A Scoping Review. Journal of the American Geriatrics Society, 69(1), 234–244. https://doi.org/10.1111/jgs.16801

2. Methods

In section 4.1 and 4.2, the handling of missing data has been reported in section 4.4. Please delete it from here.

3. Results

In section 5.1, according to the figure in table 1, only 8.7% of advanced cancer patients were fully independent.

Please clarify if the author would like to emphasize that over 90% of them require ADL support? It sounds more logical to emphasize the caregiver burden in this way than emphasizing that two-thirds of them could take care of themselves.

4. Discussion

In the 7th paragraph, please consider citing references to support the first two recommendations (involving SDMs in ACP and developing decision aids), especially literature related to the Chinese cultural context:

Yeung, C. C. Y., Ho, K. H. M., & Chan, H. Y. L. (2023). A dyadic advance care planning intervention for people with early-stage dementia and their family caregivers in a community care setting: a feasibility trial. BMC geriatrics, 23(1), 115.

In the 8th pagraph, please consider citing the following reference to support the importance of healthcare provider training:

Mills, J., Kim, S. H., Chan, H. Y., Ho, M. H., Montayre, J., Liu, M. F., & Lin, C. C. (2021). Palliative care education in the Asia Pacific: challenges and progress towards palliative care development. Progress in Palliative Care, 29(5), 251-254.

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Reviewer #2: No

Reviewer #3: No

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Attachments

Attachment

Submitted filename: reviewers comment.pdf

Factors influencing the participation of surrogate decision-makers for advanced cancer patients in advance care planning: A cross-sectional study

PONE-D-24-35495R4

Dear Dr. Ma,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Xiong Xingyu, M.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thanks for the authors' efforts to comprehensively improve your manuscript according to editor's and reviewers' comments. I am pleased to inform you that your paper can be accepted for publication now. Thanks for the chance to assess your interesting and important work. Additionally, many thanks for all the reviewers' precious inputs.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: No

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: Thank you for having me in this review exercise. Your efforts in addressing the comments are much appreciated.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #3: No

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