How Culture and Structure Shape Shared Decision-Making Among Healthcare Professionals: "Practicing Tai Chi" in Neurocritical Stroke Care in China

How Culture and Structure Shape Shared Decision-Making Among Healthcare Professionals: "Practicing Tai Chi" in Neurocritical Stroke Care in China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article How Culture and Structure Shape Shared Decision-Making Among Healthcare Professionals: "Practicing Tai Chi" in Neurocritical Stroke Care in China Hui Zhang, Carmel Davies, Chunhai Su, Deirdre O'Donnell This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8711713/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Shared decision-making (SDM) is widely recommended in neurocritical stroke care due to prognostic uncertainty and the high-stakes nature of treatment decisions. However, SDM is shaped by sociocultural and healthcare system contexts, and evidence from non-Western settings remains limited. This study explored how and why contextual mechanisms influence SDM experiences and practices in Chinese neurocritical stroke care. Methods Underpinned by critical realism (CR), this interpretive qualitative study was conducted at a major tertiary medical center in central China. Semi-structured interviews were undertaken with 18 healthcare professionals (HCPs) involved in neurocritical stroke care. Data were analyzed using Fryer’s CR-informed thematic analysis to identify event-level patterns and infer underlying generative mechanisms. Results The analysis produced a multi-level conceptual model comprising a core experiential metaphor, seven descriptive event-level codes, and two interrelated mechanisms. The core experiential metaphor—“Practicing Tai Chi”—captured HCPs’ adaptive and strategically calibrated communication during SDM encounters, aimed at maintaining dialogue while reducing conflict and professional risk. SDM was typically family-led, with limited patient involvement, and was further shaped by relational and material constraints, including family dynamics, perceived trust, and financial pressures. These patterns were interpreted as arising from two intertwined mechanisms: familialism, which legitimizes family-centered decision norms, and a market-embedded healthcare system, which amplifies economic pressures and reinforces tension and mistrust between clinicians and families. Conclusions SDM in Chinese neurocritical stroke care is shaped by the interaction of cultural values and structural conditions. By identifying the mechanisms underpinning SDM practices, this study contributes a culturally grounded and theoretically robust perspective to the global SDM literature and highlights the need for context-sensitive approaches to SDM in neurocritical care. Stroke Shared decision-making Neurocritical care Qualitative study Critical realism Culture Healthcare system Figures Figure 1 Introduction Stroke remains a leading cause of death and long-term disability worldwide, imposing a substantial burden on patients, families, and healthcare systems 1,2 . Patients with severe stroke frequently require neurocritical care, where intensive monitoring and advanced life-sustaining treatments (LSTs) are provided in the context of considerable prognostic uncertainty 3 . The abrupt onset of stroke, uncertainty regarding prognosis, and frequent reliance on family surrogate decision-makers render decision-making in neurocritical care particularly complex 4,5 . These decisions often involve whether to initiate, continue, or limit LSTs, typically under time pressure and with major implications for survival and functional outcomes 3,6 . Given these high-stakes circumstances, shared decision-making (SDM) is increasingly recommended to promote care that is ethically sound and aligned with patients’ values and goals 7-10 . Healthcare professionals (HCPs) play a central role in SDM. They must communicate evolving clinical information amid uncertainty, provide emotional support while maintaining realistic expectations, and remain attentive to cognitive biases that may shape clinical judgement 11-14 . HCPs are also responsible for integrating patients’ values into clinical deliberations and managing disagreements within families or between families and clinicians 15,16 . Understanding how HCPs experience and enact SDM in real-world neurocritical care practice is therefore essential. Importantly, SDM is embedded within sociocultural and structural contexts. Our previous qualitative meta-synthesis in neurocritical stroke care demonstrated that contextual factors can substantially influence SDM processes and outcomes, while also highlighting limited representation of culturally diverse perspectives in the SDM literature 5 . Building on this prior synthesis, the present study offers an empirical, context-specific examination of SDM by exploring the mechanisms that may shape HCPs’ decision-making work in Chinese neurocritical stroke care. The Chinese context is particularly relevant. Cultural traditions in China often emphasize relational harmony, collective responsibility, and family-centered ethical obligations in healthcare decision-making 17-19 . Within this broader moral framework, family members may be viewed as legitimate and necessary participants in decision-making, particularly in situations involving severe illness, uncertainty, and high-stakes treatment choices. In parallel, China’s healthcare system has undergone rapid reform and achieved near-universal insurance coverage; however, structural challenges persist, including misaligned incentives, uneven quality, and relatively low public satisfaction 20-22 . Together, these sociocultural and system-level conditions may influence how SDM is negotiated and enacted in high-stakes neurocritical settings. Although international research has examined key aspects of SDM in severe stroke care, including prognostic communication and professional roles 11,12,14,15,23-25 , evidence remains limited on how SDM is enacted by HCPs within China’s distinct sociocultural and healthcare system context. Guided by critical realism (CR) 26 , this study aims to identify the underlying causal mechanisms that shape SDM experiences and practices among HCPs in Chinese neurocritical stroke care. Rather than focusing solely on how SDM unfolds, the study seeks to explain why it takes particular forms—specifically, how the interplay between culturally embedded values and systemic structures may generate observed SDM patterns. In doing so, it offers a theoretically robust and culturally grounded contribution to the global SDM literature, with implications for advancing context-sensitive SDM practice in neurocritical care. Methods Study Design This study adopted an interpretive qualitative design underpinned by CR as its philosophical framework. CR extends beyond describing subjective experiences and observable phenomena to identify the underlying causal mechanisms that generate them 27 . This approach provides a theoretically coherent foundation for examining how and why SDM takes particular forms in neurocritical stroke care in China. This manuscript is reported in accordance with the COREQ checklist 28 (Supplementary File). Recruitment and sampling This study was conducted at a major tertiary medical center in central China, with a capacity of 5,000 beds across three campuses. As a regional referral hospital, it includes six neurology wards and four neurosurgery wards (approximately 500 beds in total), admitting around 8,000 stroke patients annually. Neurocritical care is delivered across four general intensive care units (ICUs) and two specialized neurological ICUs, all equipped to provide advanced LSTs. Eligible participants were HCPs who: (1) had at least one year of experience caring for neurocritical stroke patients, and (2) were employed as physicians, surgeons, nurses, or rehabilitation therapists. Interns, trainees, fellows, and residents in standardized training programs were excluded. Purposive sampling was used to achieve variation in professional role, unit setting, clinical experience, and gender. Recruitment was facilitated through departmental gatekeepers (unit directors). Following approval, the primary researcher (HZ, female) attended departmental meetings to introduce the study and distribute participant information sheets. Interested HCPs contacted HZ directly to discuss participation and provide written informed consent. No participants withdrew after consent was obtained. HZ holds an administrative role within the hospital and has over 10 years of experience in general ICU and neurocritical care. Although HZ was professionally acquainted with participants, no direct supervisory relationships existed, minimizing potential power imbalances or conflicts of interest. Data Collection The semi-structured interview guide was developed collaboratively by the core research team (HZ, DOD, CD), informed by the conceptual model generated in the team’s prior qualitative meta-synthesis 5 . The initial version of the guide is provided in Supplementary Table S1. This guide was refined iteratively throughout data collection, with adjustments to question wording, sequencing, and depth based on reflective appraisal after each interview. Data were collected through one-on-one semi-structured interviews conducted between December 2024 and May 2025, in a private office at times convenient for participants. No non-participants were present during the interviews. All interviews were audio-recorded using a KDDI H1pro digital recorder. Detailed field notes were taken to capture contextual details, non-verbal cues, and reflexive observations. Where appropriate, selected transcripts were returned to participants for clarification and brief comment; however, this was not undertaken systematically for all interviews. An initial target sample size of 20 was set, with the final sample determined by data saturation (i.e., when no new relevant information emerged). Repeat interviews were not conducted. Data Analysis Data analysis followed Fryer’s CR-informed thematic analysis, comprising five iterative steps 26 . Unlike other approaches underpinned by CR that emphasize the ontological domains of reality—empirical, actual, and real 29 , Fryer’s framework focuses on three interrelated analytical levels: experiences, events, and causal mechanisms. “Experiences” are embedded within participants’ accounts; “events” are captured through descriptive codes representing observable patterns; and “themes” reflect the underlying causal mechanisms that explain how and why these experiences and events occur. The first step involved refining the central research question: How and why do contextual mechanisms influence SDM for HCPs caring for neurocritical stroke patients in China? The second step entailed repeated reading of transcripts for familiarization and the recording of reflective notes. In the third step, transcripts were imported into NVivo 12 for systematic coding 30 . Descriptive codes were iteratively refined, standardized, and consolidated to enhance analytical coherence. In the fourth step, higher-order themes were developed to explicate causal mechanisms, followed by a final step of integrating findings and drafting the analytical report. Throughout, analysis remained iterative, involving continuous movement between data, codes, and themes. While selected transcripts were returned to participants for clarification, participants were not asked to review the final analytic findings. Rigor was strengthened through iterative analysis, reflexive documentation, and team-based interpretation. Given the cross-cultural nature of the research, translation was a key methodological consideration. As recommended in the literature, when data are collected in one language but analyzed and reported in another, translation may occur during analysis rather than as a discrete step 31 . Accordingly, a structured data management plan was implemented (Table 1). A bilingual Chinese researcher (CHS), fluent in English, supported transcription, translation, and initial coding to ensure linguistic accuracy and cultural sensitivity. Ethics approval Ethical approval was obtained from the Ethics Committee of the study hospital (Approval No. KYLL-202312-223) and the Research Ethics Committee of University College Dublin (Reference No. LS-24-72-Zhang-ODon). Results Participant Characteristics A total of 18 HCPs participated in the interviews, including six neurosurgeons, two neurological intensivists, three neurosurgical intensivists, two general ICU physicians, four nurses, and one rehabilitation therapist. Twelve participants were male and six were female. The mean participant age was 42.5 years, with a mean of 16.2 years of clinical experience. Interviews lasted 27–65 minutes (mean 45.6 minutes). To protect anonymity and minimize risk of identification, Table 2 reports participants’ discipline and interview duration only. Decision Types Participants described SDM as occurring across multiple stages of neurocritical stroke care, including acute interventions (e.g., surgical decompression, intravenous thrombolysis, arterial thrombectomy), intensive care decisions (e.g., intubation, mechanical ventilation, tracheostomy, and prevention/treatment of deep vein thrombosis), and end-of-life decisions (e.g., withholding or withdrawing LSTs). Decisions perceived as strongly supported by established evidence were generally described as less challenging. CR Thematic Analysis Following Fryer’s CR thematic analysis approach 26 , findings are presented across three linked conceptual levels, progressing from lived experience to underlying causality. Data were coded to identify observable event-level patterns (events), which were then interpreted to generate higher-order explanatory themes (generative mechanisms). For clinical readability, we use the terms “events” and “mechanisms” throughout this paper. We begin with the central metaphorical experience of “practicing Tai Chi,” which captures participants’ accounts of SDM in neurocritical stroke care. We then present the event-level patterns that describe the key actions and interactional dynamics shaping SDM in practice, alongside the inferred generative mechanisms that help explain why these patterns occur in this context. The Central Experience of SDM – “Practicing Tai Chi” “Practicing Tai Chi” emerged as the central metaphorical experience of SDM in the participants’ accounts. Participants described SDM as occurring primarily with patients’ family members and as a dynamic, iterative process rather than a linear exchange. HCPs reported continuously monitoring family members’ emotional responses, attitudes, and implicit intentions, and strategically adjusting their tone, emphasis, and framing to maintain dialogue while avoiding overt confrontation. You have to adjust constantly during the conversation—the tone can shift very quickly. At first, you speak from professional judgement, but as you sense the family’s real intentions, you emphasize what supports their choice—whether it’s benefits, costs, or risks. There’s no way around it—that’s the reality. (P11, Neurological Intensivist) Through repeated conversations, we can pick up the underlying messages in family members’ words. If they are open to treatment, I talk more about treatment options. If I sense they’re leaning toward refusing treatment, I emphasize how severe the bleeding is and how poor the prognosis might be. (P9, Neurosurgeon) One participant vividly likened this communicative strategy to “practicing Tai Chi,” drawing on the martial art’s principles of yielding, deflection, and responsiveness to external force. Within this metaphor, HCPs described carefully navigating discussions by shifting responsibility in response to family expectations, thereby reducing exposure to blame or legal risk. Some families say, “I don’t care what I choose, I just want it to be a good option.” Then we can’t offer advice; we can only let them make the choice. While they have this right, they also have to bear the consequences of their choice. It feels like practicing Tai Chi, constantly deflecting responsibility back to them. (P16, General ICU Physician) Some family members don’t want to think or take risks themselves. They want me to tell them exactly what will work. I tell them honestly that I don’t know either. If the outcome is bad, they’ll say, “We followed your advice.” So, I push the decision back to them and make them think it through themselves. (P12, Neurosurgeon) The Events and Generative Mechanisms of SDM Practice Seven event-level patterns were identified, capturing the characteristic features of SDM described by participants and substantiating the central experience of “practicing Tai Chi.” These events were interpreted as being shaped by two interrelated generative mechanisms: a cultural mechanism of familialism and a structural mechanism associated with a market-embedded healthcare system. Cultural Mechanism-Familialism Familialism refers to a cultural orientation in which family integrity, collective responsibility, and relational obligations are prioritized, positioning relatives as the most legitimate decision-makers in serious illness. The following four events illustrate how this mechanism shaped SDM practices in neurocritical stroke care. Event 1: Family Members as Dominant Decision-Makers All participants consistently reported that family members were not merely surrogate decision-makers but functioned as the primary decision-makers in practice, taking responsibility for final treatment choices. The ultimate decision-making power lies with the family. We present the options, but the choice is theirs. In the end, the family decides what to do and what not to do. (P6, Nurse) Participants described this dominance as closely linked to a strong desire to preserve family integrity. Consequently, families often pursued aggressive treatment even when the prognosis was poor. For many families, the attitude is, “As long as I still have this person (the patient), that’s enough.” Even if the patient is bedridden or severely disabled, they want them alive. It’s emotional—about keeping the family whole. (P5, Neurosurgical intensivist) Under the influence of familialism, some families were described as resolute in pursuing treatment regardless of medical advice, with decisions sometimes appearing predetermined. Some families are determined to treat no matter what. We recently had a patient in a very serious condition. The doctor explained that surgery wouldn’t help, but the family insisted. Even if the patient would die soon, they felt it still had to be done. They didn’t need the doctor’s advice—they had already decided.( P3, Nurse) Beyond emotional attachment, participants described treatment persistence as a moral obligation, allowing families to fulfil perceived duties and avoid guilt or social criticism. We had a patient with bilateral dilated pupils. The prognosis was extremely poor, but the family insisted on surgery. Later, the patient died. What is the family’s mentality? “I did everything I could, so I won’t feel guilty anyway.’’ (P13, Neurosurgeon) Event 2: Patients Remain Largely Absent from Decision-Making In contrast to the dominant role of family members, patients were described as largely absent from SDM. Participants attributed this pattern to cultural taboos surrounding death and the limited uptake of advance care planning. What decisions will patients make themselves when they become seriously ill? No family member has ever discussed with me about that. This might happen abroad, but almost never in China. (P5, Neurosurgical intensivist) Some participants emphasized that, even when patients expressed preferences, these wishes were rarely upheld due to limited legal recognition and strong family authority in decision-making. Patients rarely make health plans when they’re well. How do they plan? Even if they do, their children may not follow them. Families feel it’s their responsibility to do everything possible — that’s generally how it works.” (P16, General ICU physicians) Some older patients, while still conscious, might have expressed, “If I get sick, I don’t want to be in the ICU, I don’t want to be hooked up to tubes.” But once they lose consciousness, their families, desperate to prolong life, usually ignore or forget those wishes. (P10, Neurological intensivist) Participants also described situations in which conscious patients’ stated preferences were overridden, indicating that patients often functioned as passive recipients rather than active participants in SDM. I communicated with the patient several times. When we extubated him yesterday, he wanted to be transferred out of the ICU. He didn’t want to continue treatment because he also had cancer. But I just tried to comfort him. He still had to stay here and continue treatment, because his family and doctors insisted on aggressive measures. ( P7, Nurse ) Event 3: Family Relationship Quality Shapes Treatment Choices Participants emphasized that the quality of family relationships strongly influenced treatment decision-making. Cohesive families were described as more likely to act collectively and commit to ongoing care, whereas strained relationships were associated with delayed decisions, disputes, and shifts in responsibility among relatives. I think the family atmosphere matters a lot. Some families are very united and committed to treating the patient. Others may have many children, but each one avoids responsibility—arguing about who will pay and who will provide care. This is not uncommon in hospitals. (P2, Neurosurgical intensivist) A key observation was that relatives’ willingness to pursue treatment often appeared contingent on the patient’s fulfilment of expected familial roles. Participants noted that treatment decisions could reflect implicit moral judgements regarding the patient’s perceived “value” within the family—whether the patient was seen as “worth saving,” and how much effort and resources should be invested. We’ve seen young patients with cerebral hemorrhage who clearly had surgical indications, but their families refused surgery. When that happens, our first reaction is: does he smoke, drink, or abuse his family? Sometimes relatives even say directly, “He’s lazy and violent—I wouldn’t treat him even if I had money.” (P10, Neurological intensivist) Participants also highlighted that access to a stable family support network was viewed as essential for sustaining active treatment. Patients lacking such support—such as those who were divorced—were perceived as more likely to receive conservative care or forgo treatment altogether. Look at patients who are divorced—many of them end up having treatment withdrawn. No one is willing to go to such great lengths to save them. There’s no one to care for them, right? (P12, Neurosurgeon) Event 4: Family Collective Interests Take Precedence Beyond the patient’s prognosis, participants emphasized that treatment decisions were often shaped by consideration of the family’s collective interests, including caregiving capacity, financial sustainability, and longer-term family stability. In our department, we had to consider more than just the patient . Recovery is only one part. After a stroke, in some cases, the best outcome may still be severe disability. We also have to consider the impact on the whole family. (P1, Neurosurgeon) Participants described how family members frequently weighed multiple and competing responsibilities, evaluating how different treatment pathways might affect broader family functioning and well-being. Many people these days are only children. They have no siblings to share caregiving responsibilities, and at the same time they must raise their own children. This reality can’t be ignored—it has to be factored in. (P9, Neurosurgeon) Even in emotionally close families, aggressive treatment could be reconsidered over time when it conflicted with other pressing family obligations, such as supporting children’s education or caring for older relatives. In such circumstances, relatives were described as gradually re-evaluating priorities and shifting toward more conservative approaches. At first, families often try everything possible. But as time passes, they begin to think, “I need to save something for my children. If I spend everything on the patient, I won’t be able to care for them (children), and he (the patient) might not improve anyway.” That’s when they may start to consider giving up. (P4, Nurse ) Structural Mechanism-Market-Embedded Healthcare System A market-embedded healthcare system refers to structural conditions in which economic pressures, service commodification, and strained clinician–patient relationships influence clinical communication and treatment decision-making. The following three events demonstrate how this mechanism shaped HCPs’ engagement in SDM within the study setting. Event 5: Perceived Trust Shapes HCP Engagement in SDM Participants reported that families typically expected clear treatment recommendations from HCPs. Many HCPs described responding proactively to this expectation, viewing recommendation-giving as both a professional duty and a tangible way of participating in SDM. Families often ask, “Doctor, if it were you, what would you choose?” I try to see it from their perspective, empathize with them, and give a recommendation. I don’t just list options A, B, and C and leave them to choose. (P5, Neurosurgical intensivist) Given the inherent prognostic uncertainty in neurocritical care, participants described adopting a “subtle” or “guided” approach to communication. Rather than issuing direct instructions, HCPs reported framing information strategically to support families toward what they regarded as the most appropriate clinical option. I don’t openly direct the discussion, but I can influence it subtly. For example, if I think surgery would be most beneficial, I emphasize it more, say less about conservative treatment, and highlight how poor the prognosis would be without intervention. (P17, Neurosurgeon) Notably, the extent and clarity of HCPs’ recommendations were strongly influenced by their perceived level of trust. When participants sensed openness and trust, they were more willing to engage actively and provide clearer guidance. In contrast, when they perceived defensiveness, suspicion, or potential conflict, they often adopted a more neutral stance, focusing on information provision to reduce professional risk. In such circumstances, worst-case outcomes were frequently emphasized to manage expectations and limit future disputes. You can usually sense whether a family is looking for someone to blame. If their tone feels hostile, I become very cautious. I may have wanted to help, but their words make me unwilling to get involved in their decisions. (P18, Neurosurgeon) If we feel trusted, we’re more confident and engaged. But if the family is defensive or unfriendly, we may step back and just stress the worst possible prognosis. (P4, Nurse) Across accounts, trust was described as a prerequisite for meaningful SDM engagement. Participants emphasized that trust enabled clinicians to participate more fully in decision-making discussions, particularly in situations involving uncertainty and clinical risk. There’s a saying we often hear: “The more you trust a doctor, the more risks they might be willing to take for you.” And that’s exactly how it is. (P5, Neurosurgical intensivist ) Event 6: Aligning with Families to Avoid Accountability Risks Participants reported that although treatment recommendations are typically grounded in clinical judgment, strained doctor–patient relationships often lead HCPs to prioritize alignment with family members’ wishes. In these contexts, complying with family preferences was described as a pragmatic strategy to minimize professional, social, and legal accountability risks. Based purely on imaging or the patient’s condition, I might initially lean toward one option. But my position changes depending on the family. If you don’t respect their wishes, you may end up bearing the consequences—this is the reality of healthcare in China right now. (P9, Neurosurgeon) Sometimes you have to abandon your own judgement and go along with what the family wants. Let them have their way. (P12, Neurosurgeon) Several participants described a related phenomenon in which families transfer patients from local hospitals to tertiary centers not primarily for advanced medical treatment, but to alleviate social pressure and avoid being perceived as “unfilial.” Once HCPs recognized this underlying motivation, they sometimes emphasized poor prognosis to help families legitimize decisions to withhold or withdraw treatment. Some participants referred to this practice as a form of “doctor–family collusion.” Some families don’t really want the procedure, but they fear what neighbors or relatives might say, so they get referred from the county hospital to us. When you talk to them, it’s obvious they don’t want surgery. At that point, I go along with their wishes, and they decide quite quickly. Sometimes it feels like I’m catering to them.” (P17, Neurosurgeon) They’ve already seen doctors in their county, who also recommended surgery. Why families come to us? Often, it’s just to show they’ve tried everything. Some even bring other relatives and say, “Doctor, please explain it to them.” They actually want us to convince their family members. In these cases, we usually choose to cooperate. (P18, Neurosurgeon) Event 7: Financial Capacity as a Rigid Constraint Nearly all participants identified affordability as a decisive factor in family treatment decisions. Families’ economic capacity was consistently described as a primary determinant of whether aggressive interventions could be initiated or sustained. The most critical factor is financial—whether families can afford treatment and the long-term care that follows. I’d say finances account for about 70–80% of the reasons behind decisions. (P17, Neurosurgeon) A patient’s financial situation largely defines their options. Wealthier families can pursue almost any treatment, but poorer families often refuse invasive procedures. We always have to take this into account. (P11, Neurological Intensivist) Although recent healthcare reforms have expanded insurance coverage and reduced some out-of-pocket costs, participants emphasized that financial pressure remains the most immediate and significant challenge for many families. Things are much better now. In the past, without insurance or “pay-after-treatment” policies, medical costs were like a bottomless pit. How much could a rural family earn in a year? I’ve seen many families insist on treatment at first, but they often can’t sustain it for even a week. (P15, Neurosurgical Intensivist) Recognizing the central role of financial considerations, many HCPs reported actively guiding families to assess their capacity and weigh treatment costs against expected outcomes, to avoid what participants described as “losing both lives and money. ” Some families haven’t really thought through the financial burden. I tell them: if the patient stays in a vegetative state, it could cost about 2,000 yuan a day—almost a million a year. Even with insurance, how much would you still have to pay? And that doesn’t include lost income. Do the math before deciding. (P12, Neurosurgeon) In practice, clinicians also described helping families establish time- or cost-based thresholds to guide decision-making. This illustrates how economic considerations have become structurally embedded within clinical reasoning and SDM processes. For some patients, especially older ones, I suggest setting a “cutoff point”—either a time limit or a spending limit. For example, stopping treatment after 10 days or after spending 100,000 yuan. You need boundaries. You can’t pour all your resources into a hopeless situation. (P2, Neurosurgical Intensivist) Importantly, participants noted that financial constraints often intersected with family relationships, jointly shaping decision trajectories. The most distressing situations were described as those in which strong emotional bonds coexisted with limited financial resources. Family finances and relationships influence each other. When both are strong, families tend to pursue treatment. When both are weak, families often give up. The hardest cases are when emotional bonds are strong, but the money simply can’t support the treatment. (P1, Neurosurgeon ) Conceptual Model Figure 1 presents the conceptual model of SDM among HCPs in Chinese neurocritical stroke care. E1–E7 correspond to Events 1–7 described above. The model integrates three analytical levels: a core experiential metaphor SDM as “practicing Tai Chi”, seven event-level patterns representing key SDM practices and interactions, and two interrelated generative mechanisms that explain why these patterns occur in this context. The cultural mechanism of familialism legitimizes family members as primary decision-makers, often positioning the family—rather than the patient—as the central actor in SDM. The structural mechanism of a market-embedded healthcare system intensifies economic pressures and contributes to tension and mistrust between HCPs and families, shaping decision-making encounters. These mechanisms are mutually reinforcing, as economic considerations become embedded within the collective-interest logic of familialism and form a core component of family deliberation. Under the combined influence of these mechanisms, HCPs navigate complex SDM interactions across the identified events. This negotiation gives rise the central metaphorical experience of “practicing Tai Chi,” reflecting strategic communication to maintain dialogue, avoid conflict, redistribute responsibility, and mitigate perceived professional risk. Discussion This study adopted a critical realist approach to interpret HCPs’ accounts of SDM in Chinese neurocritical stroke care. By linking observed SDM events and practices to generative explanations, the analysis identified two interrelated mechanisms shaping SDM in this context: the cultural mechanism of familialism and the structural mechanism of a market-embedded healthcare system. Our findings suggest that familialism exerts a profound and pervasive influence on SDM. Within this cultural context, family members typically dominate decision-making, while the patient—the nominal focus of care—remains largely absent. This pattern aligns with prior research in Chinese intensive care settings, which indicates that SDM for critically-ill patients is often grounded in family members’ values, preferences, and moral responsibilities rather than the patient’s expressed wishes 32,33 . This contrasts with many Western healthcare systems, which have institutionalized mechanisms such as advance directives, substituted judgement, and supported decision-making to safeguard individual self-determination 34-37 . In China, however, Confucian traditions emphasize the family as a moral community and the ethical foundation of society 17 . Within this worldview, patients’ identities are frequently embedded within their familial roles, and relatives are positioned as the “natural” primary decision-makers. Existing scholarship further suggests that when Western SDM frameworks are applied in Eastern sociocultural contexts, the “individual” often yields to the “family”, as reflected in concepts like family autonomy 38 , family decision-making 39 , family-centered decision-making 40 , and family-centered care 18 . Although this orientation challenges individualistic notions of autonomy, the emotional bonds and collective responsibility embedded in familial relationships may also serve protective functions that support patient welfare 24 . Promoting family involvement may therefore be culturally and ethically appropriate, particularly in severe neurological conditions where relatives carry substantial financial and caregiving burdens and are direct stakeholders in treatment outcomes. As previous studies have argued, serious illness exposes the reality of social interdependence and relational autonomy, and disregarding caregivers’ pressures is neither ethically defensible nor practically sustainable 24,35,41 . Nevertheless, it remains essential to recognize that the family itself is not a rights-bearing entity; fundamental rights ultimately reside with the individual patient 42 . Advancing SDM in China therefore requires a careful balance between protecting patient autonomy and acknowledging the cultural legitimacy and moral necessity of family participation. Notably, nearly all participants in this study reported that patient involvement in decision-making was “rarely” considered, highlighting the need to strengthen public awareness of patient autonomy and to support HCPs in facilitating patient participation whenever possible. In addition to cultural influences, our findings indicate that China’s market-embedded healthcare system decisively shapes SDM processes and outcomes. Over recent decades, China has established the world’s largest system of universal health coverage, serving more than 1.3 billion people 43 . However, constrained public funding and the sheer scale of demand mean that healthcare services are not fully free at the point of use. Patients covered by resident insurance schemes continue to pay approximately 30–40% of costs out-of-pocket 44 , while limited government investment (approximately 10% in 2022) has left public hospitals largely self-financing 45 . Although this model has improved service availability and efficiency, it has also reinforced revenue-driven incentives within public healthcare institutions 46,47 . Within this structural context, patients and families increasingly perceive themselves as consumers of medical services, with heightened expectations regarding outcomes and stronger emphasis on rights assertion 48 . Combined with high financial stakes and prognostic uncertainty, this shift contributes to mistrust between doctors and patients and to strained relationships, frequent disputes, and, in extreme cases, violence against medical staff 49,50 . HCPs may adopt defensive communication strategies, avoid explicit recommendations, and transfer responsibility for high-stakes decisions to families. This dynamic is captured in the central metaphorical experience of “practicing Tai Chi” in our study. While such strategies may provide short-term self-protection for clinicians, they may also increase families’ emotional and moral burden, potentially reinforcing mistrust and perpetuating a self-reinforcing cycle 51 . Nearly all participating HCPs emphasized that rebuilding mutual trust is fundamental to effective SDM. Trust was described as a prerequisite for clinicians’ meaningful engagement and for improving SDM quality. Addressing trust deficits requires coordinated, multi-level interventions. At the governmental level, continued efforts are needed to advance supply-side reforms, strengthen the public welfare orientation of hospitals, and curb excessive market-driven incentives 47 . At the societal level, initiatives should foster respect for medical professionals, improve public health literacy, and promote realistic expectations of healthcare outcomes 50 . At the professional level, further training and guidance are needed to support HCPs in practicing SDM, strengthening communication and humanistic competencies, and maintaining empathy and transparency while avoiding defensive practices that erode trust 50,52 . Taken together, familialism and the market-embedded healthcare system shape SDM in China in ways that differ markedly from Western contexts, particularly in how prognostic uncertainty is interpreted and managed. In Western practice, prognostic uncertainty is central to SDM and often prompts deliberation about acceptable quality of life, including engagement with concepts such as the “disability paradox” and “clinical nihilism” 14,53-55 . Professional guidelines therefore commonly recommend time-limited trials—often around two weeks—to reduce the risk of premature withdrawal of LSTs 7,9 . In contrast, our findings indicate that Chinese families do not necessarily view prognostic uncertainty as the primary challenge. Even with a favorable prognosis, financial strain or competing family obligations may lead to treatment withdrawal. Conversely, poor prognosis may not preclude aggressive treatment if familial ethics and resources support continued intervention. This pattern suggests persistent gaps in public understanding of life, death, and end-of-life care. Palliative care and advance care planning remain underdeveloped in China 56-58 , highlighting the need for broader societal dialogue about death and for contemporary reinterpretations of traditional concepts such as “filial piety. ” Concurrently, healthcare reforms should expand access to palliative care options to meet diverse needs. Neuro-palliative care, a well-established discipline in Western systems 59 , remains under-recognized in China. In addition, given the high uncertainty associated with severe stroke prognosis, artificial intelligence–based prognostic models and structured decision aids may offer future opportunities to support families and clinicians, strengthening both the scientific basis and humanistic quality of SDM 60,61 . Treatment decisions in neurocritical care directly affect survival, prognosis, and quality of life, requiring particularly careful deliberation. Although many interviewees demonstrated limited explicit awareness of SDM, the interviews prompted reflection on routine decision-making practices. As China’s healthcare system continues to evolve, there is a timely need to re-examine and strengthen decision-making models in neurocritical care. SDM research in this field remains at an early stage, underscoring the importance of developing a contextually appropriate and operational SDM framework. Such a framework may not only address key gaps in China but also enrich global understandings of decision-making in critical care. Strengths and Limitations This study has several strengths and limitations. A key strength is its CR design, which enabled mechanism-based explanation of how SDM is shaped by cultural and structural influences in Chinese neurocritical stroke care. In addition, the study was conducted in a major regional medical center located in the birthplace of Confucius, offering a contextually rich setting for examining the role of Confucian-informed values in high-stakes clinical decision-making. Several limitations should also be noted. First, participants were recruited from a single hospital, which may limit the transferability of findings to other regions and healthcare settings. Second, the primary researcher (HZ) held an insider position and a professional background in neurocritical care. This facilitated rapport-building and enhanced interpretive depth, but also introduced potential risks of bias related to prior experience and institutional relationships. To mitigate these risks, HZ maintained reflective journals and engaged in regular supervision and critical dialogue with the research team (DOD, CD), supporting reflexivity and analytical rigor. Finally, this study focused on HCPs perspectives; future research should incorporate patient and family experiences to build a more comprehensive account of SDM in this context. Conclusions Using a critical realist approach, this study examined SDM in Chinese neurocritical stroke care from the perspective of HCPs. Findings suggest that SDM is shaped by the interaction of cultural and structural mechanisms, resulting in a practice pattern characterized by family-dominant decision-making, limited patient involvement, and defensive clinician engagement. Improving SDM in this setting will likely require context-sensitive and system-level strategies that support meaningful communication, strengthen trust, and balance patient autonomy with culturally legitimate family participation and professional responsibility. These insights contribute to ongoing international efforts to advance ethically grounded, patient-centered decision-making in neurocritical care. Declarations We confirm that this manuscript adheres to the Neurocritical Care Instructions for Authors . Author contributions: All authors made substantial intellectual and practical contributions to this study. HZ, DOD, and CD jointly prepared the ethics applications and developed the interview guide. HZ conducted the interviews and, together with CHS, undertook preliminary coding and translated selected transcripts. HZ, DOD, and CD completed the final analysis and interpretation of findings. HZ drafted the manuscript, and DOD and CD provided critical revisions. All authors meet the authorship criteria and have read and approved the final version of the manuscript. This manuscript is reported in accordance with the COREQ checklist. The completed checklist has been uploaded as a supplementary file. This manuscript has not been published elsewhere and is not currently under consideration by another journal. Ethical approval was granted by the Ethics Committee of Jining No.1 People’s Hospital (Approval No. KYLL-202312-223) and the Research Ethics Committee of University College Dublin (Reference No. LS-24-72-Zhang-ODon). All figures, tables, and materials included in this manuscript are original and created by the authors. No permissions were required for reuse. This study received no external funding. We declare that there are no conflicts of interest associated with this study. References Feigin VL, Abate MD, Abate YH, et al. Global, regional, and national burden of stroke and its risk factors, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021. The Lancet Neurology 2024;23(10):973-1003. Feigin VL, Brainin M, Norrving B, et al. World stroke organization: global stroke fact sheet 2025. International Journal of Stroke 2025;20(2):132-144. Simonetto M, Stieg PE, Segal AZ, Ch'ang JH. Neurocritical care in 2024: where are we headed? 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Lorenc T, Khouja C, Harden M, Fulbright H, Thomas J. Defensive healthcare practice: systematic review of qualitative evidence. BMJ open 2024;14(7):e085673. Barton JL, Kunneman M, Hargraves I, et al. Envisioning shared decision making: a reflection for the next decade. SAGE Publications Sage CA: Los Angeles, CA; 2020:2381468320963781. Lim MJR, Tan J, Neo AYY, Ng BCJ, Asano M. Acceptance of disability in stroke: A qualitative metasynthesis. Journal of Health Psychology 2025;30(4):599-621. Munakomi S, Agrawal A. Advancements in managing intracerebral hemorrhage: transition from nihilism to optimism. Medical Science and Research: Springer; 2019:1-9. Mavaddat N, Sadler E, Lim L, et al. What underlies the difference between self-reported health and disability after stroke? A qualitative study in the UK. BMC neurology 2021;21(1):315. Zhang X, Jeong SYS, Chan S. Advance care planning for older people in mainland China: an integrative literature review. International Journal of Older People Nursing 2021;16(6):e12409. Yang M, Li N, Mei Y. Advance Care Planning in Patients With Stroke: A Scoping Review. Nursing & Health Sciences 2025;27(2):e70085. Pan H, Shi W, Zhou Q, Chen G, Pan P. Palliative care in the intensive care unit: not just end-of-life care. Intensive Care Research 2023;3(1):77-82. Lau WK, Fehnel CR, Macchi ZA, et al. Research Priorities in Neuropalliative Care: A Consensus Statement From the International Neuropalliative Care Society. JAMA neurology 2025. Yeo M, Kok HK, Kutaiba N, et al. Artificial intelligence in clinical decision support and outcome prediction–applications in stroke. Journal of medical imaging and radiation oncology 2021;65(5):518-528. Calderone A, Latella D, Bonanno M, et al. Towards transforming neurorehabilitation: the impact of artificial intelligence on diagnosis and treatment of neurological disorders. Biomedicines 2024;12(10):2415. Tables Table1 Data management and translation plan When What Language Who Before data collection Develop and finalize the interview guide English to Chinese DOD, CD, HZ Data collection Conduct one-to-one semi-structured interviews Chinese HZ Transcription Transcribe audio recordings and verify accuracy Chinese HZ, CHS Transcript translation Translate selected transcripts (covering all professional roles) Chinese to English HZ, CHS Translation review Review translations and confirm contextual equivalence English DOD, HZ, CHS Initial analysis (Fryer’s Steps 1–3) Familiarization and descriptive coding (event-level patterns) Chinese HZ, CHS Translation of analytical outputs Translate codes and selected illustrative quotations Chinese to English HZ, CHS Formal thematic analysis (Fryer’s Steps 3–5) Refine codes, develop themes (mechanisms), and generate conclusions English DOD, CD, HZ Manuscript preparation Draft and revise manuscript for publication English DOD, CD, HZ Table 2 Participant characteristics Codename Discipline Interview duration (minute) P1 Neurosurgeon 50 P2 Neurosurgical intensivist 56 P3 Nurse 45 P4 Nurse 42 P5 Neurosurgical intensivist 46 P6 Nurse 27 P7 Nurse 45 P8 General ICU physicians 65 P9 Neurosurgeon 40 P10 Neurological intensivist 34 P11 Neurological intensivist 52 P12 Neurosurgeon 43 P13 Neurosurgeon 38 P14 Rehabilitation therapist 44 P15 Neurosurgical intensivist 42 P16 General ICU physicians 53 P17 Neurosurgeon 36 P18 Neurosurgeon 62 Supplementary Files COREQchecklist.docx COIdisclosureHuiZhang.docx TableS1Initialversionoftheinterviewguide.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 30 Jan, 2026 Reviewers invited by journal 30 Jan, 2026 Editor invited by journal 29 Jan, 2026 Editor assigned by journal 29 Jan, 2026 First submitted to journal 28 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8711713","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":583063071,"identity":"fc900833-dd37-4de2-8de0-38a8787aca3f","order_by":0,"name":"Hui Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIiWNgGAWjYBACAwbGBhBiYGBvPsDAwAaXkCBCC8+xBISWA3i1AAFYi0SOAbIW3MBcIrmB8ecOuzx5h5xvEj/K7OTMpZsPfv7AYCGHS4vljMQGBskzycWGB85uk+w5l2xsOedYsgTQYcY4HXYDqMWwjTlxY2PvNmnGtgOJG27kmIH8ktiAT0tiW33ixmaeZ1At+d9AWurxajnYdjhxPhsPG8wWNpCWBJwOO/Ow4WBj2/HEDTxsxpYgvxjcSDOWOGMgYYjTluPpDx/+bKtOnD//8cMboBAzuJH88ENFRZ08LltA4ABY7wFUo/BpgAJ5XO4YBaNgFIyCUQAAjR1d4f0A/K8AAAAASUVORK5CYII=","orcid":"https://orcid.org/0009-0002-1771-3069","institution":"University College Dublin","correspondingAuthor":true,"prefix":"","firstName":"Hui","middleName":"","lastName":"Zhang","suffix":""},{"id":583063072,"identity":"9ba3474c-b16d-47dd-9437-08c0c9f6f0dd","order_by":1,"name":"Carmel Davies","email":"","orcid":"","institution":"University College Dublin","correspondingAuthor":false,"prefix":"","firstName":"Carmel","middleName":"","lastName":"Davies","suffix":""},{"id":583063073,"identity":"ba62d6e4-db2a-464f-a8fc-a595c8f8f877","order_by":2,"name":"Chunhai Su","email":"","orcid":"","institution":"Jining No 1 People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chunhai","middleName":"","lastName":"Su","suffix":""},{"id":583063074,"identity":"2370ed85-9637-4180-bc9f-cc07ac852417","order_by":3,"name":"Deirdre O'Donnell","email":"","orcid":"","institution":"University College Dublin","correspondingAuthor":false,"prefix":"","firstName":"Deirdre","middleName":"","lastName":"O'Donnell","suffix":""}],"badges":[],"createdAt":"2026-01-27 14:36:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8711713/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8711713/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101789411,"identity":"7b9af257-cf82-48fe-ba32-04d983a831df","added_by":"auto","created_at":"2026-02-03 15:57:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":87664,"visible":true,"origin":"","legend":"\u003cp\u003eA conceptual model of SDM among HCPs in neurocritical stroke care in China\u003c/p\u003e\n\u003cp\u003eThis critical realist conceptual model summarizes findings across three linked analytical levels: experiences, events, and generative mechanisms. The core experiential metaphor, “Practicing Tai Chi,” reflects HCPs’ accounts of adaptive and strategically calibrated communication during SDM encounters in neurocritical stroke care. Seven event-level patterns (E1–E7) illustrate how SDM was enacted in practice. These events were interpreted as being shaped by two interrelated mechanisms: a cultural mechanism of familialism and a structural mechanism associated with a market-embedded healthcare system, which together influence family-led decision-making and clinicians’ navigation of professional and relational risk.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8711713/v1/07ad5621594402749c245d68.png"},{"id":101943234,"identity":"ab7a5341-9bf3-4d64-bcc1-e32ace3ba7fd","added_by":"auto","created_at":"2026-02-05 09:41:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":925840,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8711713/v1/1ca4eb78-870f-4666-9eb9-e33448b044a9.pdf"},{"id":101789413,"identity":"e3f3d419-c62d-4415-be3f-03be14d9583d","added_by":"auto","created_at":"2026-02-03 15:57:23","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27801,"visible":true,"origin":"","legend":"","description":"","filename":"COREQchecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-8711713/v1/23eebf7cf34b66de904cca53.docx"},{"id":101789415,"identity":"1b77a8a3-60b9-4108-aaaf-5642edbc7333","added_by":"auto","created_at":"2026-02-03 15:57:24","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":35811,"visible":true,"origin":"","legend":"","description":"","filename":"COIdisclosureHuiZhang.docx","url":"https://assets-eu.researchsquare.com/files/rs-8711713/v1/724f50017a22ab007ba4dda4.docx"},{"id":101789414,"identity":"b68828e8-ec9a-43bb-8106-75985bb38b35","added_by":"auto","created_at":"2026-02-03 15:57:24","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":22816,"visible":true,"origin":"","legend":"","description":"","filename":"TableS1Initialversionoftheinterviewguide.docx","url":"https://assets-eu.researchsquare.com/files/rs-8711713/v1/d227a30dd546035d1496b2f5.docx"}],"financialInterests":"","formattedTitle":"How Culture and Structure Shape Shared Decision-Making Among Healthcare Professionals: \"Practicing Tai Chi\" in Neurocritical Stroke Care in China","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStroke remains a leading cause of death and long-term disability worldwide, imposing a substantial burden on patients, families, and healthcare systems \u003csup\u003e1,2\u003c/sup\u003e. Patients with severe stroke frequently require neurocritical care, where intensive monitoring and advanced life-sustaining treatments (LSTs) are provided in the context of considerable prognostic uncertainty \u003csup\u003e3\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe abrupt onset of stroke, uncertainty regarding prognosis, and frequent reliance on family surrogate decision-makers render decision-making in neurocritical care particularly complex \u003csup\u003e4,5\u003c/sup\u003e. These decisions often involve whether to initiate, continue, or limit LSTs, typically under time pressure and with major implications for survival and functional outcomes \u003csup\u003e3,6\u003c/sup\u003e. Given these high-stakes circumstances, shared decision-making (SDM) is increasingly recommended to promote care that is ethically sound and aligned with patients\u0026rsquo; values and goals \u003csup\u003e7-10\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eHealthcare professionals (HCPs) play a central role in SDM. They must communicate evolving clinical information amid uncertainty, provide emotional support while maintaining realistic expectations, and remain attentive to cognitive biases that may shape clinical judgement \u003csup\u003e11-14\u003c/sup\u003e. HCPs are also responsible for integrating patients\u0026rsquo; values into clinical deliberations and managing disagreements within families or between families and clinicians \u003csup\u003e15,16\u003c/sup\u003e. Understanding how HCPs experience and enact SDM in real-world neurocritical care practice is therefore essential.\u003c/p\u003e\n\u003cp\u003eImportantly, SDM is embedded within sociocultural and structural contexts. Our previous qualitative meta-synthesis in neurocritical stroke care demonstrated that contextual factors can substantially influence SDM processes and outcomes, while also highlighting limited representation of culturally diverse perspectives in the SDM literature \u003csup\u003e5\u003c/sup\u003e. Building on this prior synthesis, the present study offers an empirical, context-specific examination of SDM by exploring the mechanisms that may shape HCPs\u0026rsquo; decision-making work in Chinese neurocritical stroke care.\u003c/p\u003e\n\u003cp\u003eThe Chinese context is particularly relevant. Cultural traditions in China often emphasize relational harmony, collective responsibility, and family-centered ethical obligations in healthcare decision-making \u003csup\u003e17-19\u003c/sup\u003e. Within this broader moral framework, family members may be viewed as legitimate and necessary participants in decision-making, particularly in situations involving severe illness, uncertainty, and high-stakes treatment choices. In parallel, China\u0026rsquo;s healthcare system has undergone rapid reform and achieved near-universal insurance coverage; however, structural challenges persist, including misaligned incentives, uneven quality, and relatively low public satisfaction \u003csup\u003e20-22\u003c/sup\u003e. Together, these sociocultural and system-level conditions may influence how SDM is negotiated and enacted in high-stakes neurocritical settings.\u003c/p\u003e\n\u003cp\u003eAlthough international research has examined key aspects of SDM in severe stroke care, including prognostic communication and professional roles\u0026nbsp;\u003csup\u003e11,12,14,15,23-25\u003c/sup\u003e, evidence remains limited on how SDM is enacted by HCPs within China\u0026rsquo;s distinct sociocultural and healthcare system context. Guided by critical realism (CR) \u003csup\u003e26\u003c/sup\u003e, this study aims to identify the underlying causal mechanisms that shape SDM experiences and practices among HCPs in Chinese neurocritical stroke care. Rather than focusing solely on how SDM unfolds, the study seeks to explain why it takes particular forms\u0026mdash;specifically, how the interplay between culturally embedded values and systemic structures may generate observed SDM patterns. In doing so, it offers a theoretically robust and culturally grounded contribution to the global SDM literature, with implications for advancing context-sensitive SDM practice in neurocritical care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study adopted an interpretive qualitative design underpinned by CR as its philosophical framework. CR extends beyond describing subjective experiences and observable phenomena to identify the underlying causal mechanisms that generate them \u003csup\u003e27\u003c/sup\u003e. This approach provides a theoretically coherent foundation for examining how and why SDM takes particular forms in neurocritical stroke care in China. This manuscript is reported in accordance with the COREQ checklist \u003csup\u003e28\u003c/sup\u003e (Supplementary File).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitment and sampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted at a major tertiary medical center in central China, with a capacity of 5,000 beds across three campuses. As a regional referral hospital, it includes six neurology wards and four neurosurgery wards (approximately 500 beds in total), admitting around 8,000 stroke patients annually. Neurocritical care is delivered across four general intensive care units (ICUs) and two specialized neurological ICUs, all equipped to provide advanced LSTs.\u003c/p\u003e\n\u003cp\u003eEligible participants were HCPs who: (1) had at least one year of experience caring for neurocritical stroke patients, and (2) were employed as physicians, surgeons, nurses, or rehabilitation therapists. Interns, trainees, fellows, and residents in standardized training programs were excluded.\u003c/p\u003e\n\u003cp\u003ePurposive sampling was used to achieve variation in professional role, unit setting, clinical experience, and gender. Recruitment was facilitated through departmental gatekeepers (unit directors). Following approval, the primary researcher (HZ, female) attended departmental meetings to introduce the study and distribute participant information sheets. Interested HCPs contacted HZ directly to discuss participation and provide written informed consent. No participants withdrew after consent was obtained.\u003c/p\u003e\n\u003cp\u003eHZ holds an administrative role within the hospital and has over 10 years of experience in general ICU and neurocritical care. Although HZ was professionally acquainted with participants, no direct supervisory relationships existed, minimizing potential power imbalances or conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe semi-structured interview guide was developed collaboratively by the core research team (HZ, DOD, CD), informed by the conceptual model generated in the team\u0026rsquo;s prior qualitative meta-synthesis \u003csup\u003e5\u003c/sup\u003e. The initial version of the guide is provided in Supplementary Table S1. This guide was refined iteratively throughout data collection, with adjustments to question wording, sequencing, and depth based on reflective appraisal after each interview.\u003c/p\u003e\n\u003cp\u003eData were collected through one-on-one semi-structured interviews conducted between December 2024 and May 2025, in a private office at times convenient for participants. No non-participants were present during the interviews. All interviews were audio-recorded using a KDDI H1pro digital recorder. Detailed field notes were taken to capture contextual details, non-verbal cues, and reflexive observations. Where appropriate, selected transcripts were returned to participants for clarification and brief comment; however, this was not undertaken systematically for all interviews. An initial target sample size of 20 was set, with the final sample determined by data saturation (i.e., when no new relevant information emerged). Repeat interviews were not conducted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analysis followed Fryer\u0026rsquo;s CR-informed thematic analysis, comprising five iterative steps \u003csup\u003e26\u003c/sup\u003e. Unlike other approaches underpinned by CR \u0026nbsp;that emphasize the ontological domains of reality\u0026mdash;empirical, actual, and real \u003csup\u003e29\u003c/sup\u003e, Fryer\u0026rsquo;s framework focuses on three interrelated analytical levels: experiences, events, and causal mechanisms. \u0026ldquo;Experiences\u0026rdquo; are embedded within participants\u0026rsquo; accounts; \u0026ldquo;events\u0026rdquo; are captured through descriptive codes representing observable patterns; and \u0026ldquo;themes\u0026rdquo; reflect the underlying causal mechanisms that explain how and why these experiences and events occur.\u003c/p\u003e\n\u003cp\u003eThe first step involved refining the central research question: How and why do contextual mechanisms influence SDM for HCPs caring for neurocritical stroke patients in China? The second step entailed repeated reading of transcripts for familiarization and the recording of reflective notes. In the third step, transcripts were imported into NVivo 12 for systematic coding \u003csup\u003e30\u003c/sup\u003e. Descriptive codes were iteratively refined, standardized, and consolidated to enhance analytical coherence. In the fourth step, higher-order themes were developed to explicate causal mechanisms, followed by a final step of integrating findings and drafting the analytical report. Throughout, analysis remained iterative, involving continuous movement between data, codes, and themes. While selected transcripts were returned to participants for clarification, participants were not asked to review the final analytic findings. Rigor was strengthened through iterative analysis, reflexive documentation, and team-based interpretation.\u003c/p\u003e\n\u003cp\u003eGiven the cross-cultural nature of the research, translation was a key methodological consideration. As recommended in the literature, when data are collected in one language but analyzed and reported in another, translation may occur during analysis rather than as a discrete step \u003csup\u003e31\u003c/sup\u003e. Accordingly, a structured data management plan was implemented (Table 1). A bilingual Chinese researcher (CHS), fluent in English, supported transcription, translation, and initial coding to ensure linguistic accuracy and cultural sensitivity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Ethics Committee of the study hospital (Approval No. KYLL-202312-223) and the Research Ethics Committee of University College Dublin (Reference No. LS-24-72-Zhang-ODon).\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 18 HCPs participated in the interviews, including six neurosurgeons, two neurological intensivists, three neurosurgical intensivists, two general ICU physicians, four nurses, and one rehabilitation therapist. Twelve participants were male and six were female. The mean participant age was 42.5 years, with a mean of 16.2 years of clinical experience. Interviews lasted 27\u0026ndash;65 minutes (mean 45.6 minutes). To protect anonymity and minimize risk of identification, Table 2 reports participants\u0026rsquo; discipline and interview duration only.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDecision Types\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described SDM as occurring across multiple stages of neurocritical stroke care, including acute interventions (e.g., surgical decompression, intravenous thrombolysis, arterial thrombectomy), intensive care decisions (e.g., intubation, mechanical ventilation, tracheostomy, and prevention/treatment of deep vein thrombosis), and end-of-life decisions (e.g., withholding or withdrawing LSTs). Decisions perceived as strongly supported by established evidence were generally described as less challenging.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCR Thematic Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing Fryer\u0026rsquo;s CR thematic analysis approach \u003csup\u003e26\u003c/sup\u003e, findings are presented across three linked conceptual levels, progressing from lived experience to underlying causality. Data were coded to identify observable event-level patterns (events), which were then interpreted to generate higher-order explanatory themes (generative mechanisms). For clinical readability, we use the terms \u0026ldquo;events\u0026rdquo; and \u0026ldquo;mechanisms\u0026rdquo; throughout this paper.\u003c/p\u003e\n\u003cp\u003eWe begin with the central metaphorical experience of \u0026ldquo;practicing Tai Chi,\u0026rdquo; which captures participants\u0026rsquo; accounts of SDM in neurocritical stroke care. We then present the event-level patterns that describe the key actions and interactional dynamics shaping SDM in practice, alongside the inferred generative mechanisms that help explain why these patterns occur in this context.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Central Experience of SDM \u0026ndash; \u0026ldquo;Practicing \u0026nbsp;Tai Chi\u0026rdquo;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Practicing Tai Chi\u0026rdquo; emerged as the central metaphorical experience of SDM in the participants\u0026rsquo; accounts. Participants described SDM as occurring primarily with patients\u0026rsquo; family members and as a dynamic, iterative process rather than a linear exchange. HCPs reported continuously monitoring family members\u0026rsquo; emotional responses, attitudes, and implicit intentions, and strategically adjusting their tone, emphasis, and framing to maintain dialogue while avoiding overt confrontation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYou have to adjust constantly during the conversation\u0026mdash;the tone can shift very quickly. At first, you speak from professional judgement, but as you sense the family\u0026rsquo;s real intentions, you emphasize what supports their choice\u0026mdash;whether it\u0026rsquo;s benefits, costs, or risks. There\u0026rsquo;s no way around it\u0026mdash;that\u0026rsquo;s the reality. (P11, Neurological Intensivist)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThrough repeated conversations, we can\u003c/em\u003e \u003cem\u003epick up the underlying messages in family members\u0026rsquo; words.\u003c/em\u003e \u003cem\u003eIf they are open to treatment, I talk more about treatment options. If I sense they\u0026rsquo;re leaning toward refusing treatment, I emphasize how severe the bleeding is and how poor the prognosis might be. (P9, Neurosurgeon)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOne participant vividly likened this communicative strategy to \u0026ldquo;practicing Tai Chi,\u0026rdquo; drawing on the martial art\u0026rsquo;s principles of yielding, deflection, and responsiveness to external force. \u0026nbsp;Within this metaphor, HCPs described carefully navigating discussions by shifting responsibility in response to family expectations, thereby reducing exposure to blame or legal risk.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSome families say, \u0026ldquo;I don\u0026rsquo;t care what I choose, I just want it to be a good option.\u0026rdquo; Then we can\u0026rsquo;t offer advice; we can only let them make the choice. While they have this right, they also have to bear the consequences of their choice. It feels like practicing Tai Chi, constantly deflecting responsibility back to them. (P16,\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eGeneral ICU Physician)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSome family members don\u0026rsquo;t want to think or take risks themselves. They want me to tell them exactly what will work. I tell them honestly that I don\u0026rsquo;t know either. If the outcome is bad, they\u0026rsquo;ll say, \u0026ldquo;We followed your advice.\u0026rdquo; So, I push the decision back to them and make them think it through themselves. (P12, Neurosurgeon)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Events and Generative Mechanisms of SDM Practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeven event-level patterns were identified, capturing the characteristic features of SDM described by participants and substantiating the central experience of \u0026ldquo;practicing Tai Chi.\u0026rdquo; These events were interpreted as being shaped by two interrelated generative mechanisms: a cultural mechanism of familialism and a structural mechanism associated with a market-embedded healthcare system.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCultural Mechanism-Familialism\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFamilialism refers to a cultural orientation in which family integrity, collective responsibility, and relational obligations are prioritized, positioning relatives as the most legitimate decision-makers in serious illness. The following four events illustrate how this mechanism shaped SDM practices in neurocritical stroke care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvent 1:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFamily Members as Dominant Decision-Makers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants consistently reported that family members were not merely surrogate decision-makers but functioned as the primary decision-makers in practice, taking responsibility for final treatment choices.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe ultimate decision-making power lies with the family. We present the options, but the choice is theirs. In the end, the family decides what to do and what not to do.\u003c/em\u003e \u003cem\u003e(P6, Nurse)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described this dominance as closely linked to a strong desire to preserve family integrity. Consequently, families often pursued aggressive treatment even when the prognosis was poor.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFor many families, the attitude is, \u0026ldquo;As long as I still have this person (the patient), that\u0026rsquo;s enough.\u0026rdquo; Even if the patient is bedridden or severely disabled, they want them alive. It\u0026rsquo;s emotional\u0026mdash;about keeping the family whole.\u003c/em\u003e \u003cem\u003e(P5, Neurosurgical intensivist)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eUnder the influence of familialism, some families were described as resolute in pursuing treatment regardless of medical advice, with decisions sometimes appearing predetermined.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSome families are determined to treat no matter what. We recently had a patient in a very serious condition. The doctor explained that surgery wouldn\u0026rsquo;t help, but the family insisted. Even if the patient would die soon, they felt it still had to be done. They didn\u0026rsquo;t need the doctor\u0026rsquo;s advice\u0026mdash;they had already decided.( P3, Nurse)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBeyond emotional attachment, participants described treatment persistence as a moral obligation, allowing families to fulfil perceived duties and avoid guilt or social criticism.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe had a patient with bilateral dilated pupils. The prognosis was extremely poor, but the family insisted on surgery. Later, the patient died. What is the family\u0026rsquo;s mentality? \u0026ldquo;I did everything I could, so I won\u0026rsquo;t feel guilty anyway.\u0026rsquo;\u0026rsquo; (P13, Neurosurgeon)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvent 2: Patients Remain Largely Absent from Decision-Making\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn contrast to the dominant role of family members, patients were described as largely absent from SDM. Participants attributed this pattern to cultural taboos surrounding death and the limited uptake of advance care planning.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWhat decisions will patients make themselves when they become seriously ill? No family member has ever discussed with me about \u0026nbsp;that. This might happen abroad, but almost never in China. (P5, Neurosurgical intensivist)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome participants emphasized that, even when patients expressed preferences, these wishes were rarely upheld due to limited legal recognition and strong family authority in decision-making.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatients rarely make health plans when they\u0026rsquo;re well. How do they plan? Even if they do, their children may not follow them. Families feel it\u0026rsquo;s their responsibility to do everything possible\u003c/em\u003e\u0026mdash;\u003cem\u003ethat\u0026rsquo;s generally how it works.\u0026rdquo; (P16, General ICU physicians)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSome older patients, while still conscious, might have expressed, \u0026ldquo;If I get sick, I don\u0026rsquo;t want to be in the ICU, I don\u0026rsquo;t want to be hooked up to tubes.\u0026rdquo; But once they lose consciousness, their families, desperate to prolong life, usually ignore or forget those wishes. (P10, Neurological intensivist)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants also described situations in which conscious patients\u0026rsquo; stated preferences were overridden, indicating that patients often functioned as passive recipients rather than active participants in SDM.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI communicated with the patient several times. When we extubated him yesterday, he wanted to be transferred out of the ICU. He didn\u0026rsquo;t want to continue treatment because he also had cancer. But I just tried to comfort him. He still had to stay here and continue treatment, because his family and doctors insisted\u003c/em\u003e \u003cem\u003eon aggressive measures. ( P7, Nurse\u003c/em\u003e\u003cem\u003e)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvent 3: Family Relationship Quality Shapes Treatment Choices\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants emphasized that the quality of family relationships strongly influenced treatment decision-making. Cohesive families were described as more likely to act collectively and commit to ongoing care, whereas strained relationships were associated with delayed decisions, disputes, and shifts in responsibility among relatives.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think the family atmosphere matters a lot. Some families are very united and committed to treating the patient. Others may have many children, but each one avoids responsibility\u0026mdash;arguing about who will pay and who will provide care. This is not uncommon in hospitals.\u003c/em\u003e \u003cem\u003e(P2, Neurosurgical intensivist)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA key observation was that relatives\u0026rsquo; willingness to pursue treatment often appeared contingent on the patient\u0026rsquo;s fulfilment of expected familial roles. Participants noted that treatment decisions could reflect implicit moral judgements regarding the patient\u0026rsquo;s perceived \u0026ldquo;value\u0026rdquo; within the family\u0026mdash;whether the patient was seen as \u0026ldquo;worth saving,\u0026rdquo; and how much effort and resources should be invested.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe\u0026rsquo;ve seen young patients with cerebral hemorrhage who clearly had surgical indications, but their families refused surgery. When that happens, our first reaction is: does he smoke, drink, or abuse his family? Sometimes relatives even say directly, \u0026ldquo;He\u0026rsquo;s lazy and violent\u0026mdash;I wouldn\u0026rsquo;t treat him even if I had money.\u0026rdquo; (P10, Neurological intensivist)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants also highlighted that access to a stable family support network was viewed as essential for sustaining active treatment. Patients lacking such support\u0026mdash;such as those who were divorced\u0026mdash;were perceived as more likely to receive conservative care or forgo treatment altogether.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLook at patients who are divorced\u0026mdash;many of them\u003c/em\u003e \u003cem\u003eend up having treatment withdrawn. No one is willing to go to such great lengths to save them. There\u0026rsquo;s no one to care for them, right? (P12, Neurosurgeon)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvent 4:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFamily Collective Interests Take Precedence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBeyond the patient\u0026rsquo;s prognosis, participants emphasized that treatment decisions were often shaped by consideration of the family\u0026rsquo;s collective interests, including caregiving capacity, financial sustainability, and longer-term family stability.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIn our department, we had to consider more than just the patient\u003c/em\u003e. \u003cem\u003eRecovery is only one part. After a stroke, in some cases, the best outcome may still be severe disability. We also have to consider the impact on the whole family. (P1, Neurosurgeon)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described how family members frequently weighed multiple and competing responsibilities, evaluating how different treatment pathways might affect broader family functioning and well-being.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMany people these days are only children. They have no siblings to share caregiving responsibilities, and at the same time they must raise their own children. This reality can\u0026rsquo;t be ignored\u0026mdash;it has to be factored in. (P9, Neurosurgeon)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEven in emotionally close families, aggressive treatment could be reconsidered over time when it conflicted with other pressing family obligations, such as supporting children\u0026rsquo;s education or caring for older relatives. In such circumstances, relatives were described as gradually re-evaluating priorities and shifting toward more conservative approaches.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAt first, families often try everything possible. But as time passes, they begin to think, \u0026ldquo;I need to save something for my children. If I spend everything on the patient, I won\u0026rsquo;t be able to care for them (children), and he (the patient) might not improve anyway.\u0026rdquo; That\u0026rsquo;s when they may start to consider giving up.\u003c/em\u003e \u003cem\u003e(P4, Nurse\u003c/em\u003e\u003cem\u003e)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStructural Mechanism-Market-Embedded Healthcare System\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA market-embedded healthcare system refers to structural conditions in which economic pressures, service commodification, and strained clinician\u0026ndash;patient relationships influence clinical communication and treatment decision-making. The following three events demonstrate how this mechanism shaped HCPs\u0026rsquo; engagement in SDM within the study setting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvent 5: Perceived Trust Shapes HCP Engagement in SDM\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported that families typically expected clear treatment recommendations from HCPs. Many HCPs described responding proactively to this expectation, viewing recommendation-giving as both a professional duty and a tangible way of participating in SDM.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFamilies often ask, \u0026ldquo;Doctor, if it were you, what would you choose?\u0026rdquo; I try to see it from their perspective, empathize with them, and give a recommendation. I don\u0026rsquo;t just list options A, B, and C and leave them to choose. (P5, Neurosurgical intensivist)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGiven the inherent prognostic uncertainty in neurocritical care, participants described adopting a \u0026ldquo;subtle\u0026rdquo; or \u0026ldquo;guided\u0026rdquo; approach to communication. Rather than issuing direct instructions, HCPs reported framing information strategically to support families toward what they regarded as the most appropriate clinical option.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI don\u0026rsquo;t openly direct the discussion, but I can influence it subtly. For example, if I think surgery would be most beneficial, I emphasize it more, say less about conservative treatment, and highlight how poor the prognosis would be without intervention. (P17, Neurosurgeon)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNotably, the extent and clarity of HCPs\u0026rsquo; recommendations were strongly influenced by their perceived level of trust. When participants sensed openness and trust, they were more willing to engage actively and provide clearer guidance. In contrast, when they perceived defensiveness, suspicion, or potential conflict, they often adopted a more neutral stance, focusing on information provision to reduce professional risk. In such circumstances, worst-case outcomes were frequently emphasized to manage expectations and limit future disputes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYou can usually sense whether a family is looking for someone to blame. If their tone feels hostile, I \u0026nbsp;become very cautious. I may have wanted to help, but their words make me unwilling to get involved in their decisions.\u003c/em\u003e\u003cem\u003e\u0026nbsp;(P18, Neurosurgeon)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf we feel trusted, we\u0026rsquo;re more confident and engaged. But if the family is defensive or unfriendly, we may step back and just stress the worst possible prognosis. (P4, Nurse)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAcross accounts, trust was described as a prerequisite for meaningful SDM engagement. Participants emphasized that trust enabled clinicians to participate more fully in decision-making discussions, particularly in situations involving uncertainty and clinical risk.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThere\u0026rsquo;s a saying we often hear: \u0026ldquo;The more you trust a doctor, the more risks they might be willing to take for you.\u0026rdquo; And that\u0026rsquo;s exactly how it is. (P5, Neurosurgical intensivist\u003c/em\u003e\u003cem\u003e)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvent 6: Aligning with Families to Avoid Accountability Risks\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported that although treatment recommendations are typically grounded in clinical judgment, strained doctor\u0026ndash;patient relationships often lead HCPs to prioritize alignment with family members\u0026rsquo; wishes. In these contexts, complying with family preferences was described as a pragmatic strategy to minimize professional, social, and legal accountability risks.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBased purely on imaging or the patient\u0026rsquo;s condition, I might initially lean toward one option. But my position changes depending on the family. If you don\u0026rsquo;t respect their wishes, you may end up bearing the consequences\u0026mdash;this is the reality of healthcare in China right now. (P9, Neurosurgeon)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSometimes you have to abandon your own judgement and go along with what the family wants. Let them have their way. (P12, Neurosurgeon)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral participants described a related phenomenon in which families transfer patients from local hospitals to tertiary centers not primarily for advanced medical treatment, but to alleviate social pressure and avoid being perceived as \u0026ldquo;unfilial.\u0026rdquo; Once HCPs recognized this underlying motivation, they sometimes emphasized poor prognosis to help families legitimize decisions to withhold or withdraw treatment. Some participants referred to this practice as a form of \u0026ldquo;doctor\u0026ndash;family collusion.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSome families don\u0026rsquo;t really want the procedure, but they fear what neighbors or relatives might say, so they get referred from the county hospital to us. When you talk to them, it\u0026rsquo;s obvious\u003c/em\u003e \u003cem\u003ethey don\u0026rsquo;t want surgery. At that point, I go along with their wishes, and they decide quite quickly. Sometimes it feels like I\u0026rsquo;m catering to them.\u0026rdquo; (P17, Neurosurgeon)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThey\u0026rsquo;ve already seen doctors in their county, who also recommended surgery. Why families come to us? Often, it\u0026rsquo;s just to show they\u0026rsquo;ve tried everything. Some even bring other relatives and say, \u0026ldquo;Doctor, please explain it to them.\u0026rdquo; They actually want us to convince their family members. In these cases, we usually choose to cooperate. (P18, Neurosurgeon)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvent 7: Financial Capacity as a Rigid Constraint\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNearly all participants identified affordability as a decisive factor in family treatment decisions. Families\u0026rsquo; economic capacity was consistently described as a primary determinant of whether aggressive interventions could be initiated or sustained.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe most critical factor is financial\u0026mdash;whether families can afford treatment and the long-term care that follows. I\u0026rsquo;d say finances account for about 70\u0026ndash;80% of the reasons behind decisions. (P17, Neurosurgeon)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eA patient\u0026rsquo;s financial situation largely defines their options. Wealthier families can pursue almost any treatment, but poorer families often refuse invasive procedures. We always have to take this into account. (P11, Neurological Intensivist)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAlthough recent healthcare reforms have expanded insurance coverage and reduced some out-of-pocket costs, participants emphasized that financial pressure remains the most immediate and significant challenge for many families.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThings are much better now. In the past, without insurance or \u0026ldquo;pay-after-treatment\u0026rdquo; policies, medical costs were like a bottomless pit. How much could a rural family earn in a year?\u003c/em\u003e \u003cem\u003eI\u0026rsquo;ve seen many families insist on treatment at first, but they often can\u0026rsquo;t sustain it for even a week.\u003c/em\u003e \u003cem\u003e(P15, Neurosurgical Intensivist)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRecognizing the central role of financial considerations, many HCPs reported actively guiding families to assess their capacity and weigh treatment costs against expected outcomes, to avoid what participants described as \u0026ldquo;losing both lives and money. \u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSome families haven\u0026rsquo;t really thought through the financial burden. I tell them: if the patient stays in a vegetative state, it could cost about 2,000 yuan a day\u0026mdash;almost a million a year. Even with insurance, how much would you still have to pay? And that doesn\u0026rsquo;t include lost income. Do the math before deciding. (P12, Neurosurgeon)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn practice, clinicians also described helping families establish time- or cost-based thresholds to guide decision-making. This illustrates how economic considerations have become structurally embedded within clinical reasoning and SDM processes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFor some patients, especially older ones, I suggest setting a \u0026ldquo;cutoff point\u0026rdquo;\u0026mdash;either a time limit or a spending limit. For example, stopping treatment after 10 days or after spending 100,000 yuan. You need boundaries. You can\u0026rsquo;t pour all your resources into a hopeless situation.\u003c/em\u003e\u003cem\u003e\u0026nbsp;(P2, Neurosurgical Intensivist)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eImportantly, participants noted that financial constraints often intersected with family relationships, jointly shaping decision trajectories. The most distressing situations were described as those in which strong emotional bonds coexisted with limited financial resources.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFamily finances and relationships influence each other. When both are strong, families tend to pursue treatment. When both are weak, families often give up. The hardest cases are when emotional bonds are strong, but the money simply can\u0026rsquo;t support the treatment. (P1, Neurosurgeon\u003c/em\u003e\u003cem\u003e)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConceptual Model\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 1 presents the conceptual model of SDM among HCPs in Chinese neurocritical stroke care. \u0026nbsp;E1\u0026ndash;E7 correspond to Events 1\u0026ndash;7 described above. The model integrates three analytical levels: a core experiential metaphor SDM as \u0026ldquo;practicing Tai Chi\u0026rdquo;, seven event-level patterns representing key SDM practices and interactions, and two interrelated generative mechanisms that explain why these patterns occur in this context.\u003c/p\u003e\n\u003cp\u003eThe cultural mechanism of familialism legitimizes family members as primary decision-makers, often positioning the family\u0026mdash;rather than the patient\u0026mdash;as the central actor in SDM. The structural mechanism of a market-embedded healthcare system intensifies economic pressures and contributes to tension and mistrust between HCPs and families, shaping decision-making encounters. These mechanisms are mutually reinforcing, as economic considerations become embedded within the collective-interest logic of familialism and form a core component of family deliberation. Under the combined influence of these mechanisms, HCPs navigate complex SDM interactions across the identified events. This negotiation gives rise the central metaphorical experience of \u0026ldquo;practicing Tai Chi,\u0026rdquo; reflecting strategic communication to maintain dialogue, avoid conflict, redistribute responsibility, and mitigate perceived professional risk.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study adopted a critical realist approach to interpret HCPs\u0026rsquo; accounts of SDM in Chinese neurocritical stroke care. By linking observed SDM events and practices to generative explanations, the analysis identified two interrelated mechanisms shaping SDM in this context: the cultural mechanism of familialism and the structural mechanism of a market-embedded healthcare system.\u003c/p\u003e\n\u003cp\u003eOur findings suggest that familialism exerts a profound and pervasive influence on SDM. Within this cultural context, family members typically dominate decision-making, while the patient\u0026mdash;the nominal focus of care\u0026mdash;remains largely absent. This pattern aligns with prior research in Chinese intensive care settings, which indicates that SDM for critically-ill patients is often grounded in family members\u0026rsquo; values, preferences, and moral responsibilities rather than the patient\u0026rsquo;s expressed wishes \u003csup\u003e32,33\u003c/sup\u003e. This contrasts with many Western healthcare systems, which have institutionalized mechanisms such as advance directives, substituted judgement, and supported decision-making to safeguard individual self-determination \u003csup\u003e34-37\u003c/sup\u003e. In China, however, Confucian traditions emphasize the family as a moral community and the ethical foundation of society \u003csup\u003e17\u003c/sup\u003e. Within this worldview, patients\u0026rsquo; identities are frequently embedded within their familial roles, and relatives are positioned as the \u0026ldquo;natural\u0026rdquo; primary decision-makers.\u003c/p\u003e\n\u003cp\u003eExisting scholarship further suggests that when Western SDM frameworks are applied in Eastern sociocultural contexts, the \u0026ldquo;individual\u0026rdquo; often yields to the \u0026ldquo;family\u0026rdquo;, as reflected in concepts like family autonomy \u003csup\u003e38\u003c/sup\u003e, family decision-making \u003csup\u003e39\u003c/sup\u003e, family-centered decision-making \u003csup\u003e40\u003c/sup\u003e, and family-centered care \u003csup\u003e18\u003c/sup\u003e. Although this orientation challenges individualistic notions of autonomy, the emotional bonds and collective responsibility embedded in familial relationships may also serve protective functions that support patient welfare \u003csup\u003e24\u003c/sup\u003e. Promoting family involvement may therefore be culturally and ethically appropriate, particularly in severe neurological conditions where relatives carry substantial financial and caregiving burdens and are direct stakeholders in treatment outcomes. \u0026nbsp;As previous studies have argued, serious illness exposes the reality of social interdependence and relational autonomy, and disregarding caregivers\u0026rsquo; pressures is neither ethically defensible nor practically sustainable \u003csup\u003e24,35,41\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNevertheless, it remains essential to recognize that the family itself is not a rights-bearing entity; fundamental rights ultimately reside with the individual patient \u003csup\u003e42\u003c/sup\u003e. Advancing SDM in China therefore requires a careful balance between protecting patient autonomy and acknowledging the cultural legitimacy and moral necessity of family participation. Notably, nearly all participants in this study reported that patient involvement in decision-making was \u0026ldquo;rarely\u0026rdquo; considered, highlighting the need to strengthen public awareness of patient autonomy and to support HCPs in facilitating patient participation whenever possible.\u003c/p\u003e\n\u003cp\u003eIn addition to cultural influences, our findings indicate that China\u0026rsquo;s market-embedded healthcare system decisively shapes SDM processes and outcomes. Over recent decades, China has established the world\u0026rsquo;s largest system of universal health coverage, serving more than 1.3 billion people \u003csup\u003e43\u003c/sup\u003e. However, constrained public funding and the sheer scale of demand mean that healthcare services are not fully free at the point of use. Patients covered by resident insurance schemes continue to pay approximately 30\u0026ndash;40% of costs out-of-pocket \u003csup\u003e44\u003c/sup\u003e, while limited government investment (approximately 10% in 2022) has left public hospitals largely self-financing \u003csup\u003e45\u003c/sup\u003e. Although this model has improved service availability and efficiency, it has also reinforced revenue-driven incentives within public healthcare institutions \u003csup\u003e46,47\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eWithin this structural context, patients and families increasingly perceive themselves as consumers of medical services, with heightened expectations regarding outcomes and stronger emphasis on rights assertion \u003csup\u003e48\u003c/sup\u003e. Combined with high financial stakes and prognostic uncertainty, this shift contributes to mistrust between doctors and patients and to strained relationships, frequent disputes, and, in extreme cases, violence against medical staff \u003csup\u003e49,50\u003c/sup\u003e. HCPs may adopt defensive communication strategies, avoid explicit recommendations, and transfer responsibility for high-stakes decisions to families.\u0026nbsp;This dynamic is captured in the central metaphorical experience of \u0026ldquo;practicing Tai Chi\u0026rdquo; in our study. While such strategies may provide short-term self-protection for clinicians, they may also increase families\u0026rsquo; emotional and moral burden, potentially reinforcing mistrust and perpetuating a self-reinforcing cycle\u0026nbsp;\u003csup\u003e51\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eNearly all participating HCPs emphasized that rebuilding mutual trust is fundamental to effective SDM. Trust was described as a prerequisite for clinicians\u0026rsquo; meaningful engagement and for improving SDM quality. Addressing trust deficits requires coordinated, multi-level interventions. At the governmental level, continued efforts are needed to advance supply-side reforms, strengthen the public welfare orientation of hospitals, and curb excessive market-driven incentives\u0026nbsp;\u003csup\u003e47\u003c/sup\u003e. At the societal level, initiatives should foster respect for medical professionals, improve public health literacy, and promote realistic expectations of healthcare outcomes \u003csup\u003e50\u003c/sup\u003e. At the professional level, further training and guidance are needed to support HCPs in practicing SDM, strengthening communication and humanistic competencies, and maintaining empathy and transparency while avoiding defensive practices that erode trust \u003csup\u003e50,52\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eTaken together, familialism and the market-embedded healthcare system shape SDM in China in ways that differ markedly from Western contexts, particularly in how prognostic uncertainty is interpreted and managed. In Western practice, prognostic uncertainty is central to SDM and often prompts deliberation about acceptable quality of life, including engagement with concepts such as the \u0026ldquo;disability paradox\u0026rdquo; and \u0026ldquo;clinical nihilism\u0026rdquo; \u003csup\u003e14,53-55\u003c/sup\u003e. Professional guidelines therefore commonly recommend time-limited trials\u0026mdash;often around two weeks\u0026mdash;to reduce the risk of premature withdrawal of \u0026nbsp;LSTs \u003csup\u003e7,9\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn contrast, our findings indicate that Chinese families do not necessarily view prognostic uncertainty as the primary challenge. Even with a favorable prognosis, financial strain or competing family obligations may lead to treatment withdrawal. Conversely, poor prognosis may not preclude aggressive treatment if familial ethics and resources support continued intervention. This pattern suggests persistent gaps in public understanding of life, death, and end-of-life care. Palliative care and advance care planning remain underdeveloped in China \u003csup\u003e56-58\u003c/sup\u003e, highlighting the need for broader societal dialogue about death and for contemporary reinterpretations of traditional concepts such as \u0026ldquo;filial piety. \u0026rdquo; Concurrently, healthcare reforms should expand access to palliative care options to meet diverse needs. Neuro-palliative care, a well-established discipline in Western systems \u003csup\u003e59\u003c/sup\u003e, remains under-recognized in China. In addition, given the high uncertainty associated with severe stroke prognosis, artificial intelligence\u0026ndash;based prognostic models and structured decision aids may offer future opportunities to support families and clinicians, strengthening both the scientific basis and humanistic quality of SDM \u003csup\u003e60,61\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eTreatment decisions in neurocritical care directly affect survival, prognosis, and quality of life, requiring particularly careful deliberation. Although many interviewees demonstrated limited explicit awareness of SDM, the interviews prompted reflection on routine decision-making practices. As China\u0026rsquo;s healthcare system continues to evolve, there is a timely need to re-examine and strengthen decision-making models in neurocritical care. SDM research in this field remains at an early stage, underscoring the importance of developing a contextually appropriate and operational SDM framework. Such a framework may not only address key gaps in China but also enrich global understandings of decision-making in critical care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several strengths and limitations. A key strength is its CR design, which enabled mechanism-based explanation of how SDM is shaped by cultural and structural influences in Chinese neurocritical stroke care. In addition, the study was conducted in a major regional medical center located in the birthplace of Confucius, offering a contextually rich setting for examining the role of Confucian-informed values in high-stakes clinical decision-making.\u003c/p\u003e\n\u003cp\u003eSeveral limitations should also be noted. First, participants were recruited from a single hospital, which may limit the transferability of findings to other regions and healthcare settings. Second, the primary researcher (HZ) held an insider position and a professional background in neurocritical care. This facilitated rapport-building and enhanced interpretive depth, but also introduced potential risks of bias related to prior experience and institutional relationships. To mitigate these risks, HZ maintained reflective journals and engaged in regular supervision and critical dialogue with the research team (DOD, CD), supporting reflexivity and analytical rigor. Finally, this study focused on HCPs perspectives; future research should incorporate patient and family experiences to build a more comprehensive account of SDM in this context.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eUsing a critical realist approach, this study examined SDM in Chinese neurocritical stroke care from the perspective of HCPs. Findings suggest that SDM is shaped by the interaction of cultural and structural mechanisms, resulting in a practice pattern characterized by family-dominant decision-making, limited patient involvement, and defensive clinician engagement. Improving SDM in this setting will likely require context-sensitive and system-level strategies that support meaningful communication, strengthen trust, and balance patient autonomy with culturally legitimate family participation and professional responsibility. These insights contribute to ongoing international efforts to advance ethically grounded, patient-centered decision-making in neurocritical care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eWe confirm that this manuscript adheres to the \u003cem\u003eNeurocritical Care Instructions for Authors\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eAuthor contributions: All authors made substantial intellectual and practical contributions to this study. HZ, DOD, and CD jointly prepared the ethics applications and developed the interview guide. HZ conducted the interviews and, together with CHS, undertook preliminary coding and translated selected transcripts. HZ, DOD, and CD completed the final analysis and interpretation of findings. HZ drafted the manuscript, and DOD and CD provided critical revisions.\u003c/li\u003e\n \u003cli\u003eAll authors meet the authorship criteria and have read and approved the final version of the manuscript.\u003c/li\u003e\n \u003cli\u003eThis manuscript is reported in accordance with the COREQ checklist. The completed checklist has been uploaded as a supplementary file.\u003c/li\u003e\n \u003cli\u003eThis manuscript has not been published elsewhere and is not currently under consideration by another journal.\u003c/li\u003e\n \u003cli\u003eEthical approval was granted by the Ethics Committee of Jining No.1 People\u0026rsquo;s Hospital (Approval No. KYLL-202312-223) and the Research Ethics Committee of University College Dublin (Reference No. LS-24-72-Zhang-ODon).\u003c/li\u003e\n \u003cli\u003eAll figures, tables, and materials included in this manuscript are original and created by the authors. No permissions were required for reuse.\u003c/li\u003e\n \u003cli\u003eThis study received no external funding.\u003c/li\u003e\n \u003cli\u003eWe declare that there are no conflicts of interest associated with this study.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eFeigin VL, Abate MD, Abate YH, et al. Global, regional, and national burden of stroke and its risk factors, 1990\u0026ndash;2021: a systematic analysis for the Global Burden of Disease Study 2021. The Lancet Neurology 2024;23(10):973-1003.\u003c/li\u003e\n \u003cli\u003eFeigin VL, Brainin M, Norrving B, et al. World stroke organization: global stroke fact sheet 2025. International Journal of Stroke 2025;20(2):132-144.\u003c/li\u003e\n \u003cli\u003eSimonetto M, Stieg PE, Segal AZ, Ch\u0026apos;ang JH. Neurocritical care in 2024: where are we headed? World Neurosurgery 2025;193:330-337.\u003c/li\u003e\n \u003cli\u003eGoostrey K, Muehlschlegel S. 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Asian Bioethics Review 2020;12(1):27-36.\u003c/li\u003e\n \u003cli\u003eSeeber AA, Pols AJ, Hijdra A, Willems DL. How Dutch neurologists involve families of critically ill patients in end-of-life care and decision-making. Neurology: Clinical Practice 2015;5(1):50-57.\u003c/li\u003e\n \u003cli\u003eFryer T. A critical realist approach to thematic analysis: producing causal explanations. Journal of Critical Realism 2022;21(4):365-384.\u003c/li\u003e\n \u003cli\u003eDanermark B, Ekstr\u0026ouml;m M, Karlsson JC. Explaining society: Critical realism in the social sciences: Routledge, 2019.\u003c/li\u003e\n \u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International journal for quality in health care 2007;19(6):349-357.\u003c/li\u003e\n \u003cli\u003eWiltshire G, Ronkainen N. A realist approach to thematic analysis: making sense of qualitative data through experiential, inferential and dispositional themes. Journal of critical realism 2021;20(2):159-180.\u003c/li\u003e\n \u003cli\u003eNVivo. NVivo 12 Software. QSR International Pty Ltd.; 2018.\u003c/li\u003e\n \u003cli\u003eYunus NA, olde Hartman T, Lucassen P, et al. Reporting of the translation process in qualitative health research: a neglected importance. International Journal of Qualitative Methods 2022;21:16094069221145282.\u003c/li\u003e\n \u003cli\u003eLei Y, Sui W, Chen L, Zhou Q, Zhuang Y. The experience of surrogate decision‐making and deciphering critically ill patient values: A qualitative study. Nursing in Critical Care 2025;30(3):e13171.\u003c/li\u003e\n \u003cli\u003eLu Q, Ji J, Lu X-y, Yin Q-H, Yang Y-Q. Conversations Between Family Members and Physicians in Intensive Care Unit During Shared Decision-Making: A Qualitative Observational Study. Journal of Multidisciplinary Healthcare 2025:4535-4550.\u003c/li\u003e\n \u003cli\u003eHigel T, Alaoui A, Bouton C, Fournier JP. Effect of living wills on end‐of‐life care: a systematic review. Journal of the American Geriatrics Society 2019;67(1):164-171.\u003c/li\u003e\n \u003cli\u003eO\u0026prime; Donnell D, Davies C, Christophers L, N\u0026iacute; Sh\u0026eacute; \u0026Eacute;, Donnelly S, Kroll T. An examination of relational dynamics of power in the context of supported (assisted) decision‐making with older people and those with disabilities in an acute healthcare setting. Health Expectations 2023;26(3):1339-1348.\u003c/li\u003e\n \u003cli\u003eDowling T, Kennedy S, Foran S. Implementing advance directives\u0026mdash;An international literature review of important considerations for nurses. Journal of nursing management 2020;28(6):1177-1190.\u003c/li\u003e\n \u003cli\u003eDavies C, Fattori F, O\u0026rsquo;Donnell D, et al. What are the mechanisms that support healthcare professionals to adopt assisted decision-making practice? A rapid realist review. BMC health services research 2019;19(1):960.\u003c/li\u003e\n \u003cli\u003eAkhtar MU, Bhatti ME, Fredericks S. What factors influence patient autonomy in healthcare decision-making? A systematic review of studies from the Global South. Nursing ethics 2025;32(3):875-891.\u003c/li\u003e\n \u003cli\u003eLi E-C, Wen C-F. Should the Confucian family-determination model be rejected? A case study. Journal of Medicine and Philosophy 2010;35(5):587-599.\u003c/li\u003e\n \u003cli\u003eLee E-J, Lam C, Ditchman N. Self-determination and cultural considerations: An Asian perspective. \u0026nbsp;2015.\u003c/li\u003e\n \u003cli\u003eG\u0026oacute;mez-V\u0026iacute;rseda C, De Maeseneer Y, Gastmans C. Relational autonomy: what does it mean and how is it used in end-of-life care? A systematic review of argument-based ethics literature. BMC medical ethics 2019;20(1):76.\u003c/li\u003e\n \u003cli\u003eRaposo VL. Lost in \u0026lsquo;Culturation\u0026rsquo;: medical informed consent in China (from a Western perspective). Medicine, Health Care and Philosophy 2019;22(1):17-30.\u003c/li\u003e\n \u003cli\u003eYi B. An overview of the Chinese healthcare system. Hepatobiliary surgery and nutrition 2021;10(1):93.\u003c/li\u003e\n \u003cli\u003eHanjue W, Vadeveloo T. An overview of the structure and future prospects of China\u0026rsquo;s Urban and Rural Resident Pension Insurance (URRPI). Journal of Administrative Science 2025;22:171-186.\u003c/li\u003e\n \u003cli\u003eCommission NH. China Health Statistics Yearbook. 2025. Available at https://www.nhc.gov.cn/mohwsbwstjxxzx/tjtjnj/202601/4c453cf4278941ab8465846d1dc90e08.shtml.\u003c/li\u003e\n \u003cli\u003eHe AJ, Qian J. Explaining medical disputes in Chinese public hospitals: the doctor\u0026ndash;patient relationship and its implications for health policy reforms. Health Economics, Policy and Law 2016;11(4):359-378.\u003c/li\u003e\n \u003cli\u003eJakovljevic M, Chang H, Pan J, et al. Successes and challenges of China\u0026rsquo;s health care reform: a four-decade perspective spanning 1985\u0026mdash;2023. Cost Effectiveness and Resource Allocation 2023;21(1):59.\u003c/li\u003e\n \u003cli\u003eChen J, Zhou M-y, Liu Q-y, et al. High time for ease the doctor-patient relationship in China. Journal of forensic and legal medicine 2020;72:101961.\u003c/li\u003e\n \u003cli\u003eLin L, Zhang X, Wang P. Interconnected stressors and Well-being in healthcare professionals. Applied Research in Quality of Life 2025:1-23.\u003c/li\u003e\n \u003cli\u003eHe Y, Holroyd E, Koziol-McLain J. Understanding workplace violence against medical staff in China: a retrospective review of publicly available reports. BMC health services research 2023;23(1):660.\u003c/li\u003e\n \u003cli\u003eLorenc T, Khouja C, Harden M, Fulbright H, Thomas J. Defensive healthcare practice: systematic review of qualitative evidence. BMJ open 2024;14(7):e085673.\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Barton JL, Kunneman M, Hargraves I, et al. Envisioning shared decision making: a reflection for the next decade. SAGE Publications Sage CA: Los Angeles, CA; 2020:2381468320963781.\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Lim MJR, Tan J, Neo AYY, Ng BCJ, Asano M. Acceptance of disability in stroke: A qualitative metasynthesis. Journal of Health Psychology 2025;30(4):599-621.\u003c/li\u003e\n \u003cli\u003eMunakomi S, Agrawal A. Advancements in managing intracerebral hemorrhage: transition from nihilism to optimism. \u0026nbsp;Medical Science and Research: Springer; 2019:1-9.\u003c/li\u003e\n \u003cli\u003eMavaddat N, Sadler E, Lim L, et al. What underlies the difference between self-reported health and disability after stroke? A qualitative study in the UK. BMC neurology 2021;21(1):315.\u003c/li\u003e\n \u003cli\u003eZhang X, Jeong SYS, Chan S. Advance care planning for older people in mainland China: an integrative literature review. International Journal of Older People Nursing 2021;16(6):e12409.\u003c/li\u003e\n \u003cli\u003eYang M, Li N, Mei Y. Advance Care Planning in Patients With Stroke: A Scoping Review. Nursing \u0026amp; Health Sciences 2025;27(2):e70085.\u003c/li\u003e\n \u003cli\u003ePan H, Shi W, Zhou Q, Chen G, Pan P. Palliative care in the intensive care unit: not just end-of-life care. Intensive Care Research 2023;3(1):77-82.\u003c/li\u003e\n \u003cli\u003eLau WK, Fehnel CR, Macchi ZA, et al. Research Priorities in Neuropalliative Care: A Consensus Statement From the International Neuropalliative Care Society. JAMA neurology 2025.\u003c/li\u003e\n \u003cli\u003eYeo M, Kok HK, Kutaiba N, et al. Artificial intelligence in clinical decision support and outcome prediction\u0026ndash;applications in stroke. Journal of medical imaging and radiation oncology 2021;65(5):518-528.\u003c/li\u003e\n \u003cli\u003eCalderone A, Latella D, Bonanno M, et al. Towards transforming neurorehabilitation: the impact of artificial intelligence on diagnosis and treatment of neurological disorders. Biomedicines 2024;12(10):2415.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable1 \u0026nbsp;Data management and translation plan\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhen\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLanguage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWho\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eBefore data collection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eDevelop and finalize the interview guide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eEnglish to Chinese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eDOD, CD, HZ\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eData collection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eConduct one-to-one semi-structured interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eChinese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eHZ\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eTranscription\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eTranscribe audio recordings and verify accuracy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eChinese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eHZ, CHS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eTranscript translation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eTranslate selected transcripts (covering all professional roles)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eChinese to English\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eHZ, CHS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eTranslation review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eReview translations and confirm contextual equivalence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eEnglish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eDOD, HZ, CHS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eInitial analysis\u003c/p\u003e\n \u003cp\u003e(Fryer\u0026rsquo;s Steps 1\u0026ndash;3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eFamiliarization and descriptive coding (event-level patterns)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eChinese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eHZ, CHS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eTranslation of analytical outputs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eTranslate codes and selected illustrative quotations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eChinese to English\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eHZ, CHS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eFormal thematic analysis\u003c/p\u003e\n \u003cp\u003e(Fryer\u0026rsquo;s Steps 3\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eRefine codes, develop themes (mechanisms), and generate conclusions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eEnglish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eDOD, CD, HZ\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eManuscript preparation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eDraft and revise manuscript for publication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eEnglish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eDOD, CD, HZ\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 \u0026nbsp;Participant characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCodename\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiscipline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterview duration (minute)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eP1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003eNeurosurgeon\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eP2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003eNeurosurgical intensivist\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eP3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003eNurse\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eP4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003eNurse\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eP5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003eNeurosurgical intensivist\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eP6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003eNurse\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eP7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003eNurse\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eP8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003eGeneral ICU physicians\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eP9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003eNeurosurgeon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eP10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003eNeurological intensivist\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n 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\u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eP17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003eNeurosurgeon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eP18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003eNeurosurgeon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"neurocritical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"neca","sideBox":"Learn more about [Neurocritical Care](http://link.springer.com/journal/12028)","snPcode":"12028","submissionUrl":"https://www.editorialmanager.com/neca/default2.aspx","title":"Neurocritical Care","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Stroke, Shared decision-making, Neurocritical care, Qualitative study, Critical realism, Culture, Healthcare system","lastPublishedDoi":"10.21203/rs.3.rs-8711713/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8711713/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Background\n\nShared decision-making (SDM) is widely recommended in neurocritical stroke care due to prognostic uncertainty and the high-stakes nature of treatment decisions. However, SDM is shaped by sociocultural and healthcare system contexts, and evidence from non-Western settings remains limited. This study explored how and why contextual mechanisms influence SDM experiences and practices in Chinese neurocritical stroke care.\n\nMethods\n\nUnderpinned by critical realism (CR), this interpretive qualitative study was conducted at a major tertiary medical center in central China. Semi-structured interviews were undertaken with 18 healthcare professionals (HCPs) involved in neurocritical stroke care. Data were analyzed using Fryer’s CR-informed thematic analysis to identify event-level patterns and infer underlying generative mechanisms.\n\nResults\n\nThe analysis produced a multi-level conceptual model comprising a core experiential metaphor, seven descriptive event-level codes, and two interrelated mechanisms. The core experiential metaphor—“Practicing Tai Chi”—captured HCPs’ adaptive and strategically calibrated communication during SDM encounters, aimed at maintaining dialogue while reducing conflict and professional risk. SDM was typically family-led, with limited patient involvement, and was further shaped by relational and material constraints, including family dynamics, perceived trust, and financial pressures. These patterns were interpreted as arising from two intertwined mechanisms: familialism, which legitimizes family-centered decision norms, and a market-embedded healthcare system, which amplifies economic pressures and reinforces tension and mistrust between clinicians and families.\n\nConclusions\n\nSDM in Chinese neurocritical stroke care is shaped by the interaction of cultural values and structural conditions. By identifying the mechanisms underpinning SDM practices, this study contributes a culturally grounded and theoretically robust perspective to the global SDM literature and highlights the need for context-sensitive approaches to SDM in neurocritical care.","manuscriptTitle":"How Culture and Structure Shape Shared Decision-Making Among Healthcare Professionals: \"Practicing Tai Chi\" in Neurocritical Stroke Care in China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-03 15:57:18","doi":"10.21203/rs.3.rs-8711713/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2026-01-30T16:20:44+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-30T13:23:37+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Neurocritical Care","date":"2026-01-29T16:00:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-29T11:05:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"Neurocritical Care","date":"2026-01-28T15:39:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"neurocritical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"neca","sideBox":"Learn more about [Neurocritical Care](http://link.springer.com/journal/12028)","snPcode":"12028","submissionUrl":"https://www.editorialmanager.com/neca/default2.aspx","title":"Neurocritical Care","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"9a7048b0-c683-4158-a2f6-5c422522fea0","owner":[],"postedDate":"February 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T08:05:19+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-03 15:57:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8711713","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8711713","identity":"rs-8711713","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}