https://orcid.org/0000-0003-1985-2839
Figures
Abstract
Background
Shared decision-making remains underutilized in patients with advanced cancer, despite its proven importance and ongoing efforts to improve its implementation. The influence of communication patterns during consultations on the limited application of shared decision-making in daily clinical practice is not yet well understood. This study explores communication patterns in medical decision-making consultations between patients with advanced cancer and medical oncologists.
Methods
We conducted a qualitative observational study of single consultations between patients with advanced cancer and their medical oncologists in a Dutch tertiary referral center. We used reflexive thematic analysis to generate key themes and categories that characterize communication patterns during these decision-making consultations.
Results
From January to March 2019, our analysis of 16 audio-recorded consultations generated four themes. 1. The medical oncologist is balancing between hope and realism. 2. There is little room for bad news. 3. The medical oncologist’s medical perspective is leading in medical decision-making. 4. The patient and medical oncologist have a shared focus on anticancer treatment.
Citation: Ermers DJ, Engels Y, Schers HJ, Vissers KC, Kuip EJ, Perry M (2026) Communication patterns in decision-making consultations between patients with advanced cancer and medical oncologists: A qualitative observational study. PLoS One 21(4): e0346036. https://doi.org/10.1371/journal.pone.0346036
Editor: Caroline Watts, The University of Sydney, AUSTRALIA
Received: April 1, 2025; Accepted: March 14, 2026; Published: April 7, 2026
Copyright: © 2026 Ermers et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The anonymized data underlying the findings are freely available within the manuscript. However, the raw qualitative data (full transcripts) cannot be shared publicly, as doing so would compromise participant (patients’ as well as medical oncologists’) confidentiality and privacy. Consent for public sharing of raw data was therefore not obtained. Where possible, raw qualitative data will be further anonymized through data aggregation to enable reuse. The anonymized data used for analysis are available from the corresponding author and the research unit in CC (Onderzoek.anes@radboudumc.nl) upon reasonable request.
Funding: This study was financially supported by the Radboud University Medical Centre (https://www.radboudumc.nl) in the form of a grant (RvBI7.52147) received by DE. No additional external funding was received for this study. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Patients with advanced cancer often face complex treatment decisions, weighing the potential benefits of palliative anticancer treatment against the possible harms [1–4]. In guiding these medical decisions, it is essential to consider the likelihood of treatment response, risk of toxicity, and the patient’s personal values and preferences [5]. Shared decision-making has been developed as a strategy to help patients and clinicians align treatment decisions with what matters most to the patient [6].
Several models of shared decision-making have been proposed to support this process. A widely used framework is that of Elwyn et al [6], which distinguishes three key steps: choice talk (making clear that a decision exists), option talk (presenting available options and their pros and cons), and decision talk (supporting patients in exploring preferences and reaching a decision). Stiggelbout et al [7]. have, amongst others, further refined this model by emphasizing deliberation about patient preferences and the patient’s preferred role in decision-making. Despite the availability of such theoretical frameworks, the application of shared decision-making in daily oncology practice remains limited. [1,8–10]
Clear evidence supports the importance of shared decision-making [11–13], and it has been integrated into various clinical guidelines [14], policy documents [15], and medical education programs [16,17]. However, numerous barriers to effective implementation have been identified [10,18,19]. While various initiatives have been proposed to enhance its practice, they often fall short of achieving widespread success [20,21].
Recent insights suggest that a strong emphasis on anticancer treatment significantly influences decision-making in patients with advanced cancer [22–24]. A systematic review with meta-synthesis [22] identified an important driver for this: The Overwhelming Situation of ‘No Choice,’ in which patients, their close ones, and healthcare professionals often feel compelled to pursue aggressive anticancer treatment options, driven by a mutual imperative to combat cancer. An observational study [23] found that while oncologists provide thorough attention to medical aspects, there is an opportunity to focus more on patients’ daily functioning and quality of life. Furthermore, the option of forgoing treatment was frequently described as ‘doing nothing’, which may benefit from reframing.
Nevertheless, research on how this focus on treatment emerges during consultations between patients and medical oncologists is limited, and communication patterns contributing to this focus are poorly understood. Therefore, we aimed to identify such communication patterns in decision-making conversations between patients with advanced cancer and medical oncologists to enable more person-centered palliative care through improved shared decision-making.
Methods
Study design
In this qualitative observational study, we applied reflexive thematic analysis to audio-recorded outpatient consultations of the Medical Oncology department. Reflexive thematic analysis was chosen because it allows for an in-depth exploration of communication processes and the identification of recurring patterns, while acknowledging the active role of the researchers in interpreting meaning. This approach was particularly suited to our aim of understanding how shared decision-making unfolds in consultations with patients with advanced cancer. We used the Consolidated Criteria for Reporting Qualitative Research (COREQ) to guide reporting of this study [25]. In addition, we considered the Reflexive Thematic Analysis Reporting Guidelines (RTARG) to enhance clarity and completeness [26]. The research ethics committee of Radboud University Medical Center judged the study to be fully compliant with the Dutch Medical Research Involving Human Subjects Act (case number 2018–4992).
Setting and participants
Data were collected at a university medical center in the Netherlands from January 10th to March 26th, 2019. Audio recordings were made of single consultations between a medical oncologist or medical oncology fellow and a patient with advanced cancer, along with their close ones when present, during which MRI/CT scan results and treatment decisions were discussed.
Medical oncologists, medical oncology fellows, and nurses approached eligible patients. These were patients with advanced cancer whose practitioner would not be surprised if they were to die within 12 months (Surprise Question [27] answered with no). Exclusion criteria included age under 18, inability to speak Dutch fluently, and inability to complete a questionnaire. Convenience sampling was employed for participant recruitment. Written informed consent was obtained from all patients and medical oncologists involved.
Study team and reflexivity
Team members had diverse research and clinical backgrounds, including primary care, palliative care, and medical oncology (investigator triangulation). The team also included a professor in Meaningful Healthcare with expertise in contextual communication and care. Additionally, all team members had prior experience conducting qualitative research in clinical settings. Further information on the study team and reflexivity is provided in Supplementary 1.
We acknowledge that our perspectives influenced the attention to communication patterns. For example, DE had substantial prior experience observing oncology consultations [28] and conducting a qualitative embedded multiple-case study on shared decision-making [24], which guided the reflexive interpretation of the data. Moreover, the team was largely composed of general practitioners and palliative care physicians, for whom communication is a core element of their clinical practice. To account for these influences, we engaged in reflexive practices throughout the analysis, including notetaking during coding, iterative code review, and multiple team discussions. These strategies helped ensure that the resulting themes were grounded in the data rather than solely shaped by researchers’ preconceptions.
Data collection
Audio recordings and transcriptions.
JvM, a researcher with prior experience as a spiritual caregiver at the department, facilitated audio-recording of the consultations. JvM maintained a non-participatory role to minimize influence on interactions. All recordings were transcribed verbatim and anonymized to protect patient-physician confidentiality and comply with ethical standards.
Consultation context measures and participant characteristics.
To explore the heterogeneity of our convenience sample, we collected quantitative data describing the participants and the consultations. Consultations were assessed in terms of the extent of shared decision-making and participants’ immediate perceptions. Each consultation was scored by the first author (DE) using the OPTION-12 instrument (Supplementary 2) [29]. Immediately following the consultation, patients and medical oncologists (fellows) completed a brief questionnaire assessing their satisfaction with the consultation, including the extent of shared decision-making. Basic characteristics of both patients and medical oncologists were also collected.
Patient Questionnaires included:
- SDM-Q-9 [30,31] to assess the patient’s involvement in decision-making.
- VAS (Visual Analogue Scales) [32] to rate satisfaction with shared decision-making and general satisfaction with the consultation.
Medical Oncologist Questionnaires included:
- VAS scores for satisfaction with shared decision-making and general satisfaction with the consultation.
- Estimates of patient satisfaction with decision-making and general satisfaction with the consultation.
Participant Characteristics documented were:
- Patients: gender, age, type of cancer, educational level [33], and marital status.
- Medical oncologists: gender and work experience.
Data analysis
Content of the consultations.
Transcripts were imported into ATLAS.ti (version 23) for reflexive thematic analysis [34]. DE read all transcripts and inductively coded concepts as closely as possible to the participant’s words to minimize subjectivity. Between October 2023 and February 2024, DE and MP iteratively discussed the codes during weekly meetings until consensus was reached. If new codes emerged, all consultations were reviewed in relation to the latest codes. Next, DE and MP grouped similar concepts into initial categories and themes, resulting in a preliminary codebook. During the first research meeting, the authors reviewed the codes to ensure they reflected the data closely, with minimal interpretation or judgment. In the second meeting, the authors similarly ensured that the creation of categories and themes did not introduce excessive interpretation, and consensus on the final codebook was reached with the full team. Investigator triangulation helped to ensure that the themes reflected the full range and depth of the data [35]. Additionally, we evaluated the consistency of constructed themes across consultations (Supplementary 3) and found that each theme was widely supported, thereby validating the themes created.
Results
Participant characteristics
Sixteen patients, eight medical oncologists and two medical oncology fellows participated. Each patient was accompanied by one or more close ones. Patients had different types of cancer, and their gender, age, educational level, and marital status varied (Supplementary 4). Seven of the medical oncologists and medical oncology fellows were women. The medical oncologists had between 2 and 35 years of experience in the field, while the medical oncology fellows had 6–8 years of overall medical experience.
For clarity, from this point forward, the term “medical oncologists” will be used to refer to both medical oncologists and medical oncology fellows.
Consultation context measures
Sixteen consultations were audio-recorded and analyzed. The median duration of the consultations was 20 minutes (range 5–40).
Table 1 displays contextual information of the consultations. In nine consultations, scan results showed disease stability or remission; in one of these, the treatment strategy changed. In five consultations, scan results indicated progressive disease; the treatment strategy changed in two, while in three it was postponed pending a multidisciplinary meeting or further diagnostics. In two consultations, scan results were ambiguous regarding disease stability or progression; in one case the treatment strategy remained unchanged, and in the other, the decision was postponed. Supplementary 5 provides an overview of consultation content.
OPTION-12 scores were generally low, regardless of whether a treatment decision was made. Patient-reported satisfaction was generally high, including satisfaction with the extent of shared decision-making. Just in one consultation (No. 9), the patient reported lower satisfaction. In this case, the medical oncologist conveyed disease progression and advised against starting immunotherapy.
Communication patterns in decision-making conversations
We generated 118 codes, grouped into 48 axial codes, 15 categories, and 4 themes (Supplementary 6). The themes and categories are described in the following sections, and illustrative quotations per category are provided in Table 2.
Theme 1: The medical oncologist is balancing between hope and realism.
During several consultations, we observed that bad news—such as disease progression, risk of recurrence, or limited life expectancy—was delivered with a balanced or optimistic tone. For example, one medical oncologist expressed hope before delivering bad news and several highlighted the positive effects of ongoing anticancer treatment or the availability of further treatment options afterward. This also happened when addressing patient concerns. Conversely, if a patient or close one appeared overly optimistic about their prognosis or treatment outcomes, the medical oncologist seemed to manage their expectations accordingly.
Theme 2: There is little room for bad news.
In several consultations involving bad news, the information was not always explicitly addressed. In some cases, the bad news was softened or followed by a change in subject. This softening involved medical oncologists using more gentle language, such as diminutives like ‘tiny gland’ or euphemisms. Additionally, some medical oncologists used many words or medical jargon when providing explanations, which could complicate the patient’s understanding of the message. In one case (Consultation No. 5), this appeared to lead to the patient drawing their own conclusion about the bad news (Table 2). In some consultations, patients asked questions later, suggesting that the bad news shared at the start had only just been processed. For example, patients asked questions about scan results and disease progression after the medical oncologist had already proceeded to another subject or at the end of the consultation.
Patients and medical oncologists sometimes seemed to provide little space for negative emotions. In some cases, medical oncologists redirected the discussion or rephrased patient statements when concerns were expressed.
Theme 3: The medical oncologist’s medical perspective is leading in medical decision-making.
The medical oncologist predominantly discussed medical topics, including pathophysiology, diagnostic imaging, clinical outcomes, and treatment efficacy. In several consultations, the patient addressed non-medical subjects, such as personal values, preferences, and quality of life concerns. This suggests that the perspectives of the medical oncologist and patient differ. Consultation No. 6 further illustrates this difference, as the medical oncologist responded to the patient’s psycho-emotional and existential question with factual medical information.
Decision-making appeared to be primarily guided by the medical oncologist, who often suggested treatment options, made decisions, and requested consent without incorporating the patient’s perspective. This seemed to be further compounded by a frequent lack of structure in consultations. For instance, in consultation No. 2, the medical oncologist suggested continuing treatment during a physical examination (Table 2).
Theme 4: The patient and medical oncologist have a shared focus on anticancer treatment.
Most consultations indicated that medical oncologists and patients reinforced each other’s focus on anticancer treatment. In some consultations, patients or their close ones expressed feelings of limited choice and a sense of necessity to pursue treatment. Medical oncologists responded in various ways: some did not address these expressions directly, while others either affirmed or contradicted them. Positive outcomes of prior anticancer treatment were frequently emphasized, with medical oncologists using terms such as “miracle” or encouraging patients to be proud of their efforts (see Table 2).
Theme interrelations: A self-reinforcing cycle unveiled.
Our analysis and the combined quotations in Table 2 suggested an interconnection between the four themes, forming a self-reinforcing cycle (see Fig 1). Efforts by medical oncologists to balance hope and realism influenced how bad news was delivered, often diluting the message. This dilution could make it more challenging for patients to engage as equal partners in decision-making. Consequently, the medical oncologist’s perspective tended to dominate the conversation, likely limiting consideration of the patient’s viewpoint and reinforcing a shared focus on anticancer treatment options. When this focus became overwhelming, medical oncologists appeared to struggle to temper it, which in turn made balancing hope and realism even more challenging in subsequent interactions. This dynamic created a feedback loop, whereby each theme amplified the others, sustaining the cycle over time.
Discussion
In this qualitative observational study, we developed the concept of a self-reinforcing cycle within decision-making consultations that may impede shared decision-making and, consequently, person-centered palliative care. This cycle emerged from four themes: the medical oncologist is balancing between hope and realism, there is little room for bad news, the medical oncologist’s medical perspective is leading in medical decision-making, and the patient and medical oncologist have a shared focus on anticancer treatment, often with insufficient attention to the patient’s personal context. While these themes are consistent with phenomena reported in previous literature [22,23,36], this study is the first to propose that these interactions collectively form a self-reinforcing cycle.
Several psychological and interactional processes likely underpin the four themes and the self-reinforcing cycle, including clinicians’ psychology, patients’ psychology, and their interactional dynamics—for example, collusions between patients and clinicians [37,38]. Understanding how these processes interact, as emphasized in, e.g., (medical) psychology and behavioral science, is crucial and warrants further study, with our observations providing an important initial step toward this goal.
Several limitations should be considered. First, shared decision-making is dynamic and continuous, yet our observations were limited to consultations in which patients received scan results. Consequently, we could not account for earlier discussions between medical oncologists and patients that may have influenced these decisions. Nonetheless, consultations where patients receive scan results are pivotal in initiating the decision-making process regarding whether to continue, discontinue or start treatment. Second, our research team did not include expertise in (medical) psychology or behavioral science, disciplines that have strongly informed medical communication education and could have provided additional perspectives on the psychological and interactional mechanisms underlying the created themes and self-reinforcing cycle. Furthermore, medical education expertise, particularly in medical communication, could have enriched our analysis by illuminating how communication skills are taught, learned, and enacted in practice. We therefore recommend that future research integrate these disciplines alongside clinical and communication-focused expertise, enabling a more comprehensive understanding of the process shaping shared decision-making in oncology consultations.
Despite these limitations, our findings are particularly relevant considering the increasing complexity of shared decision-making due to the expansion of oncological treatment options over the past few decades [39]. Although the median survival gain has remained limited, substantial benefits can still be achieved for individual patients, placing medical oncologists in an even more challenging position of balancing hope with realism. Furthermore, the importance of our findings is also underscored by our hypothesis that this cycle extends beyond oncology and may also affect persons with other life-limiting chronic illnesses, such as COPD, heart failure, renal failure, and dementia. This hypothesis is supported by an observational study [40] that showed a significant portion of patients with cancer and other life-limiting illnesses continued to receive hospital treatment in their final year. Approximately one-third were still hospitalized in the last month of life, despite most people in the Netherlands expressing a preference to die at home. This suggests a prevailing focus on life-extending treatment.
Follow-up to our study offers a valuable opportunity to integrate research with clinical practice and education. Audio- or video-recorded consultations can be reviewed to provide feedback to healthcare professionals, either collaboratively with patients, as demonstrated in studies on medically unexplained symptoms [41], or internally during team review sessions. Previous research shows that patient-collected recordings with structured feedback can enhance physicians’ attention to contextual factors, improve outcomes, reduce hospitalizations, and lower healthcare costs [42]. Beyond feedback, supervision offers a promising avenue for addressing the psychological and interactional dynamics, including mechanisms such as collusion and the psychology of patients and clinicians [37,38]. Further research is needed to determine whether these approaches can effectively disrupt the cycle and strengthen shared decision-making within palliative care. Ultimately, such insights could inform clinical guidelines and medical education, better preparing healthcare professionals for person-centered consultations.
Conclusion
In summary, our study suggests that in decision-making conversations, a self-reinforcing cycle of focus on treatment and hope may hinder shared decision-making and person-centered palliative care. This cycle is likely not confined to oncology alone. Further research is essential to explore the transferability of this cycle to other clinical contexts and determine whether our suggestions can effectively address it and improve care outcomes.
Supporting information
S3 Table. Theme and category presence across consultations.
https://doi.org/10.1371/journal.pone.0346036.s003
(DOCX)
Acknowledgments
AcknowledgmentsWe are grateful to all patients and medical oncologists/fellows who participated in our study. We would like to thank J. van Meurs for collecting the data of this study.
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