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INTRODUCTION
Shared decision-making (SDM) is extensively recognized as a fundamental component of patient-centered care, particularly in clinical situations where multiple reasonable options exist for diagnosis, treatment, or management.1 SDM represents a collaborative process where patients and healthcare professionals jointly make decisions that integrate the best available clinical evidence with the patient’s values and preferences.23 A Cochrane review demonstrated that SDM, particularly when facilitated by patient decision aids, significantly enhances patient knowledge and the accuracy of risk perception, while reducing decisional conflict associated with feeling uninformed.4
The concept of SDM was initially articulated by Charles et al.2 as a process involving at least two participants, the patient and clinician, who exchange information, work collaboratively on the preferred treatment, and reach a mutual agreement on its implementation. Makoul and Clayman conducted a systematic review of existing definitions and proposed an integrative model comprising nine essential elements of SDM including defining or explaining the health problem, presenting available options, discussing pros and cons, eliciting the patient’s values and preferences, and either making or explicitly deferring a decision. Elwyn et al.56 further simplified this conceptualization by introducing a “three-talk” model, which delineates the SDM process into three conversational stages: 1) team talk, involving establishing partnership and eliciting goals; 2) option talk, focused on comparing alternatives using risk communication; and 3) decision talk, which supports patients in making informed decisions aligned with their preferences.
Globally, SDM has been increasingly integrated into clinical practice and health policy through initiatives such as national guidelines, clinician training programs, models, measurement tools, and patient decision aids. In the United Kingdom, the National Institute for Health and Care Excellence has issued guidance for facilitating SDM and embedding it into routine care.7 In the United States, the Agency for Healthcare Research and Quality has developed the SHARE approach training curriculum,8 produced decision aids across various clinical conditions,9 and supported the development and validation of SDM measurement tools.10 Similar initiatives have emerged across Europe,111213 Australia,14 and parts of Asia,15 reflecting a global movement to institutionalize SDM within broader health system reforms that emphasize patient autonomy.
In South Korea, a healthcare environment traditionally dominated by physician-led decision-making has gradually evolved toward more patient-centered care.16 This transition has unfolded within a unique sociocultural and clinical landscape, shaped by structural constraints such as high patient volumes17 and brief consultations,18 as well as cultural factors including strong familial involvement in decision-making19 and hierarchical patient–clinician communication.20 These factors may influence how SDM is conceptualized and operationalized across Korean clinical settings.
Building on this, the national interest in SDM in Korea has grown steadily. Previous studies have explored Koreans’ willingness to participate in medical decision-making,21 investigated barriers to SDM in surgical contexts,22 and evaluated the impact of SDM interventions on treatment decisions and decision quality.2324 Notably, SDM has been a major focus in end-of-life (EoL) care, with studies proposing culturally adapted SDM models,19 developing evaluation tools,25 and identifying clinician perspectives.26 These efforts have established an academic foundation for advancing SDM in EoL contexts, particularly following the 2018 implementation of the “Act on Hospice and Palliative Care and Decisions on Life-Sustaining Treatment for Patients at the End of Life” (hereinafter referred to as the “LST Decision Act”).27
Despite this growing interest, no comprehensive synthesis has examined how SDM has been defined, studied, or implemented in the Korean healthcare system. While substantial global literature and policy developments have emerged from Western contexts, conceptualization and implementation in East Asian health systems remain relatively underexplored. Notably, significant differences between Eastern and Western approaches to SDM have been identified, reflecting distinct sociocultural values and institutional frameworks.28 Understanding the current state of SDM research in Korea is therefore essential for enabling context-sensitive implementation and guiding strategies in other systems with similar cultural or structural characteristics.
This scoping review aims to map the breadth of empirical research on SDM in Korean healthcare. Specifically, it aims to identify the types of evidence available, highlight research gaps, and offer evidence-based recommendations for future studies that reflect both Korea’s clinical realities and the broader global movement toward patient-centered decision-making.
METHODS
Study design
This scoping review was conducted to address the following research question: What are the scope, nature, and key characteristics of empirical research on SDM in the Korean healthcare context? The methodological approach was initially guided by the framework proposed by Arksey and O’Malley,29 and subsequently refined in accordance with the Joanna Briggs Institute guidelines for scoping reviews.3031 A research protocol was prospectively developed and registered with the Open Science Framework (https://osf.io/9ty5j).32 This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR).33 The completed PRISMA-ScR checklist is provided in Supplementary Table 1.
Search strategy
A comprehensive literature search was conducted across five English-language databases (PubMed, EMBASE, PsycINFO, CINAHL, and Web of Science) and four Korean databases (KoreaMed, RISS, KISS, and DBpia) from inception to December 31, 2024. The search strategy, developed in consultation with a medical librarian, incorporated both English and Korean search terms relevant to SDM. For English databases, terms included “shared decision making,” “collaborative decision-making,” “participatory decision-making,” and “Korea.” Equivalent Korean search terms were applied across Korean databases. The search strategy was tailored for each database, and the complete search strategy is detailed in Supplementary Table 2. Additionally, we manually reviewed key journals via Google Scholar and screened the reference lists of the included articles and relevant reviews to identify any additional eligible studies not captured by the database search.
All identified citations were exported to EndNote 21 (Clarivate Analytics, Philadelphia, PA, USA) for deduplication and Microsoft Excel (Microsoft, Redmond, WA, USA) for screening management.
Study selection
The Population–Concept–Context framework, as recommended for scoping reviews,31 was used to guide the identification of eligible studies, with details summarized in Table 1. We excluded the following: 1) non-original research (e.g., review articles, editorials, commentaries, and letters); 2) gray literature (e.g., conference abstracts, theses, and dissertations); 3) studies conducted outside the Korean healthcare system or involving non-Korean participants; 4) studies that did not address SDM; and 5) studies with unavailable full-text. Titles and abstracts were independently screened by five reviewers working in pairs (Kwon Y, Nam S, Shin S, Cho Y, and Yoon J). Each record was assessed by two independent reviewers, and disagreements regarding inclusion were resolved by a third reviewer (Yoo SH). Full-text articles that potentially met the inclusion criteria based on screening were subjected to full-text review by pairs of reviewers (Kwon Y, Nam S, Shin S, Cho Y, and Yoon J). Disagreements at this stage were resolved through iterative discussions among the reviewers (Kwon Y, Nam S, Shin S, Cho Y, and Yoon J), with a third reviewer (Yoo SH) consulted when consensus could not be reached.
Table 1
PCC framework used to define the eligibility criteria
Data extraction and analysis
A data extraction form was initially developed based on the study objectives and subsequently refined through pilot testing of five randomly selected studies by two independent reviewers (Kwon Y and Nam S). Two reviewers (Kwon Y and Nam S) independently extracted data from all included articles using a standardized spreadsheet. The extracted data were reviewed by three additional reviewers (Shin S, Cho Y, and Yoon J). Any discrepancies were resolved through consensus or by a third reviewer (Yoo SH) if agreement could not be reached.
The extracted data included 1) study characteristics (e.g., author(s), year of publication, study aim, design, participants, sample size, setting, and disease or condition discussed); 2) SDM elements (e.g., SDM models, measurement tools, and intervention components, if applicable); and 3) key findings related to SDM implementation and factors influencing SDM. We used 2016 and 2018—the years the LST Decision Act was enacted and implemented, respectively—as temporal reference points to distinguish studies published before and after this major policy change in Korea. The Act legally institutionalized patient self-determination in EoL decision-making, offering a meaningful context for examining potential shifts in the focus of SDM research over time. Factors were considered to influence SDM if they were empirically supported or discussed in ways suggesting empirical relevance, even if they were not explicitly identified by the original study authors.
Data were synthesized using both quantitative and qualitative approaches to address the research question comprehensively. Descriptive statistics were used to summarize the general characteristics of the included studies (e.g., study design and setting). For qualitative synthesis, thematic analysis was conducted following the six-phase approach outlined by Kiger and Varpio.34 Codes were generated inductively from the semantic content of the text, and categories were iteratively developed and refined throughout the analysis process. Categorization of disease topics was informed by the classification used by Blanc et al.,35 and the thematic structure of influencing factors was developed with reference to the five-domain framework proposed by Alsulamy et al.36 In line with the scoping review methodology, no formal appraisal of study quality was performed.31
RESULTS
A comprehensive literature search yielded 8,232 records from the databases and 945 records from citation and manual searches. Of the 231 studies that underwent full-text review, 62 were included for the final analysis in this scoping review (Supplementary Table 3 for included studies).2122242526273738394041424344454647484950515253545556575859606162636465666768697071727374757677787980818283848586878889909192 The PRISMA flow diagram illustrates the study selection process (Fig. 1).
Fig. 1
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram illustrating the study selection process.
SDM = shared decision-making.
General characteristics of included studies
Of the 62 included studies, 46 (74.2%) were quantitative studies, seven (11.3%) were qualitative, and nine (14.5%) were mixed-methods studies. The studies were conducted in various settings: multicenter (n = 26, 41.9%), single academic center (n = 13, 21.0%), community-based (n = 13, 21.0%), nationwide (n = 4, 6.5%), and specialized care settings (n = 3, 4.8%). Additional settings included long-term care facilities (n = 1, 1.6%), educational settings (n = 1, 1.6%), and combined hospital and community settings (n = 1, 1.6%). The most prevalent topic of interest was EoL care (n = 15, 24.2%), followed by oncology (n = 8, 12.9%), and family medicine/primary care (n = 7, 11.3%) (Table 2). Among the 15 EoL studies, nine (60%) were published before 2016, when the LST Decision Act was enacted in Korea. Fig. 2 illustrates the temporal distribution of the included studies by year of publication, from 2005 to 2024.
Table 2
General characteristics of included studies (N = 62)
HCP = healthcare professional.
aIncludes studies focused on end-of-life care (n = 1), dental care (n = 1), and neonatal intensive care unit settings (n = 1).
bIncludes combined hospital-based & community-based settings (n = 1), long-term care facilities (n = 1), and academic settings (n = 1).
cIncludes studies focused on older adults (n = 2) and college students (n = 1).
dIncludes studies focused on anesthesiology (n = 1), dentistry (n = 1), endocrinology (n = 1), gastroenterology (n = 1), pediatrics (n = 1), plastic and reconstructive surgery (n = 1), and rheumatology (n = 1).
Fig. 2
Annual publication trend of included studies (2005–2024). The arrow (a) indicates 2016, the year the LST Decision Act was enacted in Korea. Arrow (b) marks 2018, the year the law officially came into effect.
LST = life-sustaining treatment.
These studies have explored diverse aspects of SDM. As shown in Fig. 3, the most frequently addressed theme was patient experience with SDM (n = 34), followed by barriers to and facilitators of SDM (n = 28). Other themes included the SDM experiences of healthcare providers (n = 12), evaluation of SDM-related interventions (n = 12), and decision aids (n = 11).
Models and measurement tools of SDM
Although several studies have incorporated conceptual models or frameworks to define and guide the practice of SDM, our analysis revealed the limited application of established SDM models within the Korean healthcare context. Charles et al.’s model293 was referenced in 15 studies, primarily to conceptualize SDM as a collaborative decision-making process between patients and healthcare providers.242640414550525354697172738086 One study adopted and modified this model to evaluate patient involvement in selecting anesthetic methods for elective surgery.50 Four studies referenced Elwyn et al.’s three-talk model,56 with one intervention study explicitly using the model as a guiding framework to implement SDM for patients with chronic kidney disease.24707178
Several studies have proposed SDM-related models specific to EoL care. A model named the “Korean Shared Medical Decision-Making Model” grounded in King’s Goal Attainment Theory, emphasizes dignity in dying, interprofessional communication, and patient autonomy.43 Koh et al.58 introduced a context-oriented communication model based on a five-step algorithm for engaging terminal cancer patients in EoL decision-making. Similarly, a recent qualitative study proposed a “6C framework” grounded in Korean social and cultural values, aiming to structure the process of SDM for life-sustaining treatment decisions.27
Various instruments were used to evaluate SDM across the included studies. The Decisional Conflict Scale94 was the most frequently utilized, appearing in eight studies to evaluate patients’ decisional uncertainty and related contributing factors.4244546364677381 The Control Preferences Scale,95 which measures patients’ preferred level of involvement in decision-making, was used in six studies.404452656781 Six studies used the 9-item Shared Decision-Making Questionnaire,9697 including five2454647982 that applied the patient version (SDM-Q-9) and one76 that used the physician version (SDM-Q-Doc).
Jo developed and evaluated a culturally tailored instrument—the “Shared Medical Decision-Making Scale” for EoL care—within the Korean context.25 This scale has been used in four subsequent studies to measure attitudes toward SDM.55568092 The scale comprises seven sub-factors that reflect both universal and culturally specific aspects of SDM: 1) sharing information, 2) constructing a system, 3) explanation as a duty, 4) autonomy, 5) capturing time, 6) participation of family, and 7) human respect.25
Tools and interventions to promote SDM
A total of 11 decision aids were identified across the included studies, developed to support SDM in various clinical contexts.4253596367687374757790 These tools targeted diverse populations, including the general public, patients with acute or chronic illnesses, and family caregivers. The decision contexts included advanced care planning (n = 3), surgical treatment (n = 2), cancer screening (n = 2), dialysis modality selection (n = 1), smoking cessation (n = 1), medical treatment for ankylosing spondylitis (n = 1), and dental prosthetic decisions (n = 1). Seven studies either explicitly applied the International Patient Decision Aid Standards (IPDAS) criteria98 or used the IPDAS development process99 during decision aid development.42636768737590 A summary of these decision aids is presented in Table 3.
Table 3
Summary of DA used to promote SDM
| Author, year | Target population | Format | Decision context | Development method |
|---|---|---|---|---|
| Yun et al., 201142 | Family caregivers of terminally ill cancer patients | 20-min take-home DVD + 43-page workbook | Family members’ disclosure of terminal status to the patient | Literature review, 2 focus group interviews (24 caregivers, 5 oncologists); The authors rated the DA using the IPDAS Collaboration criteria |
| Park, 201453 | Patients undergoing dental prosthetic treatment | Web-based application | Selection of dental prosthetic treatment | Ontology-based clinical knowledge structuring, Analytic Hierarchy Process for prioritization |
| Lee et al., 201659 | Current smokers | 7-min animated video (delivered by tablet computer at the clinic) | Use of smoking cessation medication | Literature review, qualitative interviews with Korean smokers, expert opinions from healthcare professionals |
| Gong et al., 201763 | Patients with carpal tunnel syndrome | 6-min cartoon-based videoclip | Surgery for carpal tunnel syndrome | Developed aligning to most of the criteria provided by IPDAS Collaboration |
| Yun et al., 201967 | Advanced cancer patients | 20-min video (delivered via laptop computer at hospital visit; take-home CD provided) + 43-page booklet | ACP and EoL care | Literature review, expert consultations (oncologists), structured discussions of ACP and hospice care (patients); The DA was evaluated using IPDAS criteria |
| Kang et al., 202068 | General healthy population | 20-min video provided via in-home visitations | ACP and EoL care | Literature review; Used IPDAS criteria during the development process |
| Kim and Gong, 202173 | Patients with acute distal radius fractures | 5-min cartoon-based videoclip shown to patients before signing informed consent for surgery | Decision between surgical (volar plate fixation) and nonsurgical treatment for distal radius fractures | Developed in accordance with the IPDAS checklist |
| Kim et al., 202274 | Patients with chronic kidney disease | Questionnaire with 35 self-assessment items | Choosing a dialysis modality (between hemodialysis and peritoneal dialysis) | Literature review, 5 focus group interviews (5 patients in each group), qualitative and quantitative content validity assessment by 5 nephrologists |
| Lee et al., 202377 | Biologics naïve ankylosing spondylitis patients | Web-based; delivered via tablet computer | Biologics treatment for ankylosing spondylitis | Systematic literature review, surveys and in-depth interviews with physicians and patients |
| Jung et al., 202375 | General male population | Web-based | Prostate cancer screening | Semi-structured interviews with multidisciplinary experts, review of existing international guidelines and DAs; Developed in accordance with the IPDAS development process model |
| Jung et al., 202490 | General population aged 40–79 yr | Web-based | Lung cancer screening | Semi-structured interviews with multidisciplinary experts, review of existing international guidelines and DAs; Developed following the IPDAS development process model |
Three decision aids for EoL decision-making were developed based on the IPDAS criteria and evaluated through randomized controlled trials.426768 One intervention, comprising a video and workbook, was designed to support family caregivers of terminally ill cancer patients in initiating discussions regarding their prognosis. This tool significantly reduced decisional conflict and enhanced value clarity, although it did not increase the actual rate of prognosis disclosure.42 Another decision aid, targeting advanced cancer, comprising a video and booklet on advance care planning (ACP), was found to increase preferences for hospice care and decrease preferences for aggressive, life-prolonging treatments, particularly in contexts involving limited life expectancy.67 Building on this intervention, the video was later adapted for the general population to facilitate informed decision-making regarding ACP and EoL care. In a randomized controlled trial, the adapted version significantly improved participants’ knowledge of palliative care and increased their intentions to document ACP.68
In addition to these tools, four studies implemented SDM interventions, including two educational programs and two clinical interventions. The educational programs aimed to enhance SDM-related competencies: one for nurses and another for patients with mental illness. In the first, intensive care unit nurses received training in SDM in the context of EoL care, resulting in significant improvements in moral sensitivity and attitudes toward SDM.56 The second intervention, designed for inpatients with schizophrenia, led to increased self-esteem, problem-solving ability, and quality of life following participation in an SDM-focused training program.61 Although one study evaluated SDM-related education among physicians, the emphasis was on assessing perceptions and prior training experiences rather than direct implementation. In a nationwide survey of nephrologists and internal medicine residents, most respondents recognized the importance of SDM but reported limited training and practical applications. Those with prior SDM education were more likely to report appropriate SDM practices and less likely to cite time constraints and insufficient training opportunities as barriers to SDM.26
The two clinical interventions were embedded within a national pilot project for home-based peritoneal dialysis (PD) management among patients with stage 5 chronic kidney disease and aimed to integrate SDM into routine dialysis decision-making.2482 One study focused on evaluating patients’ experience and decision quality following SDM by using the SDM-Q-9, a patient satisfaction scale, and a disease awareness scale. The intervention involved a structured SDM process comprising patient education, decision coaching, and decision aid use. Among 101 participants, high levels of satisfaction with the decision-making process were observed. SDM-Q-9 scores were significantly higher among patients who selected PD over hemodialysis, suggesting a closer alignment between patient preferences and the selected treatment modality.24 The other study assessed the clinical impact of SDM using claims data and found that patients who decided to undergo PD through the SDM process experienced significantly fewer hospitalization days than those receiving standard care, although no differences were found in mortality or healthcare utilization.82
Factors influencing SDM
Thematic analysis revealed several factors influencing SDM in Korean clinical settings, which were categorized into five interrelated levels of influence: patient/family, provider, interactional, organizational, and systemic. Each level encompasses multiple themes with specific components, as shown in Table 4.
Table 4
Summary of factors influencing SDM
| Level of influence | Theme | Identified factors |
|---|---|---|
| 1. Patient/family level | 1.1. Sociodemographic characteristics | - Age2137474854 |
| - Gender21374748 | ||
| - Education level2137475486 | ||
| - Income5769 | ||
| - Private insurance40 | ||
| 1.2. Health status and healthcare experience | - Disease stage5465 | |
| - Disease severity213740 | ||
| - Diagnosis of a chronic disease83 | ||
| - Number of comorbidities2137 | ||
| - Frequency of hospital visits80 | ||
| - Prior surgical history40 | ||
| - Previous experiences with serious disease45 | ||
| - Psychological status (e.g., anxiety,4748 depression,47 emotional distress27) | ||
| 1.3. Patient capacity | - Limited disease knowledge224578 | |
| - Unfamiliarity with SDM45 | ||
| - Difficulty understanding medical terminology or health information454871 | ||
| - Subjective consumer competency69 | ||
| - Reduced decision-making capacity78 | ||
| - Self-efficacy48 | ||
| - Patient activation70 | ||
| - Communication characteristics72 | ||
| - Health-consciousness69 | ||
| 1.4. Patient attitudes, perceptions, and preferences | - Preferences for participation in treatment decisions224569 | |
| - Illness perception74 | ||
| - Perceived necessity of healthcare consumer rights69 | ||
| - Lack of internal motivation to participate in making decisions85 | ||
| - Interest in obtaining additional information6685 | ||
| - Attitudes related to EoL care (e.g., attitude toward dignified dying,43 attitude toward discontinuing life-sustaining treatment)27 | ||
| 1.5. Family dynamics | - Strong family bonds27 | |
| - Family functioning57 | ||
| - Living arrangements2137 | ||
| - Presence of spouse or caregivers4048 | ||
| - Patient’s and family’s mutual desire for family involvement in decisions65 | ||
| - Perception that family participation facilitates communication and provides psychological support65 | ||
| - Concerns about financial burden on families3878 | ||
| - Patient’s desire to reduce family burden27 | ||
| - Unrealistic needs of family caregivers2671 | ||
| 2. Healthcare provider level | 2.1. Communication skills | - Communication behavior76 |
| - Clarity of physician explanation86 | ||
| - Inadequate provision of information4571 | ||
| - Limited communication skills3845 | ||
| 2.2. SDM competency | - Experience in person-centered education76 | |
| - Clinical decision-making competency92 | ||
| - Eliciting patient values and preferences78 | ||
| - Providing detailed explanations of the pros and cons of treatment optionsa,3372 | ||
| - Allocating sufficient time for deliberation78 | ||
| - Maintaining neutrality in information provisiona 22 | ||
| 2.3. Attitudes and preferences | - Empathic orientation92 | |
| - Person-centered attitude76 | ||
| - Consumer-friendly physician attitude69 | ||
| - Hesitancy to initiate difficult conversations27 | ||
| - Moral sensitivity (in EoL contexts)55 | ||
| - Attitude toward dignified dying (in EoL contexts)55 | ||
| - Ethical conflict in treatment decision-making27 | ||
| - Physician’s personal preference for specific treatment options22 | ||
| 2.4. Decision-making style | - Promoting patient involvement in decision processes78 | |
| - Physician’s dominance in decision-making38 | ||
| - Physician’s persistence of active treatment38 | ||
| - Limiting direct patient involvement2785 | ||
| 2.5. Professional background | - Educational attainment92 | |
| 3. Interactional level | 3.1. Trust and power dynamics | - Nondisclosure of diagnosis to the patient38 |
| - Perceived power imbalance between patient and physician226985 | ||
| - Hierarchical relationship between physician and nurse38 | ||
| - Patient trust in healthcare professionals70 | ||
| - High patient dependence on physicians264485 | ||
| - Belief that physicians hold sole authority in treatment decisions45 | ||
| - Patient faith in physician expertise66 | ||
| 3.2. Interprofessional collaboration and communication | - Limited communication and cooperation between healthcare professionals3856 | |
| - Nurses as mediators of decision-making between patients, families, and physicians78 | ||
| 3.3. Sharing understanding and goals | - Misalignment in perceived treatment goals between patients and physicians66 | |
| - Ambiguity in the timing of decision-making2671 | ||
| - Alignment between patients’ preferred and actual roles in decision-making52 | ||
| - Differences in control preferences among patients, caregivers, and physicians65 | ||
| - Opportunities for patient-initiated inquiry during clinical encounters86 | ||
| 4. Organizational level | 4.1. Protocols and tools to promote SDM | - Limited availability of decision aids4445 |
| - Limited availability of educational materials267172 | ||
| - Limited availability of standardized protocols3872 | ||
| 4.2. Resources and infrastructure | - Hospital system constraints2256 | |
| - Level of healthcare institution utilized (clinic vs. hospital)6986 | ||
| - Geographic setting (rural vs. metropolitan)22 | ||
| 4.3. Education and training | - Insufficient education and training on SDM2671 | |
| 4.4. Institutional culture and hierarchy | - Person-centered care environment76 | |
| - Hierarchical medical culture38 | ||
| - Rigid professional boundaries38 | ||
| 5. Systemic level | 5.1. Structural and policy context | - Consultation time (availability and constraints)26454771728586 |
| - Payment model (i.e., fee-for-service)71 | ||
| - Health insurance system26 | ||
| 5.2. Culture and societal norms | - Paternalistic decision-making38444556 | |
| - Traditional family-centered values27576578 | ||
| 5.3. Standardized guidelines | - Lack of generic SDM models adapted to the Korean context27 | |
| - Guidelines to integrate SDM into practice81 | ||
| 5.4. Legal and regulatory framework | - Laws (in EoL contexts)2756 | |
| - Concerns about medical disputes38 |
Patient and family level
At the patient and family level, five key themes emerged: 1) sociodemographic characteristics, 2) health status and prior medical experiences, 3) patient capacity, 4) patient attitudes, perceptions, and preferences, 5) and family dynamics.212226273738404345474854576566697071727880838586 Sociodemographic variables, such as education level and income, influenced patients’ willingness to participate in decision-making.213740474854576986 Disease severity, comorbidities, and prior healthcare experiences significantly affected patients’ readiness to engage in SDM.2137404580 Patient capacity, including health literacy and self-efficacy, was also found to influence active participation in decision-making.2245486970717278 Additionally, patient preferences regarding their role in treatment decisions varied considerably, directly influencing the degree of engagement in the SDM process.224569 Family dynamics, such as the strength of family bonds, living arrangements, and concerns about financial burden, were particularly salient in Korean contexts, shaping both the extent and nature of SDM involvement.2126273738404857657178
Healthcare provider level
Five major themes emerged at the healthcare provider level: 1) communication skills, 2) SDM competency, 3) attitudes and preferences, 4) decision-making style, and 5) professional background.22273845556971727678858692 SDM was facilitated by a person-centered attitude and provider competency in eliciting patient values and allocating time for deliberation.7678 Conversely, barriers included insufficient explanation of the disease or treatment options, limited communication skills, and physician-dominant decision-making styles.384571 In some cases, clinicians were reluctant to initiate value-sensitive discussions, particularly in EoL care.27
Interactional level
At the interactional level, three themes were identified: 1) trust and power dynamics, 2) interprofessional collaboration and communication, and 3) sharing understanding and goals.2226384445525665666970788586 Patient trust in healthcare professionals was a critical enabler of patient participation, whereas power asymmetries between patients and physicians often undermined the collaborative nature of SDM.2238697085 Poor interprofessional communication and cooperation, as well as mismatches in treatment expectations or decision-making roles, also hindered effective SDM implementation.3852566566
Organizational level
At the organizational level, four distinct themes emerged: 1) protocols and tools to promote SDM, 2) resources and infrastructure, 3) education and training, and 4) institutional culture and hierarchy.2226384445566971727686 Lack of standardized protocols, decision aids, and culturally tailored educational materials was identified as a significant barrier to implementing SDM.263844457172 Similarly, insufficient training opportunities for physicians and hierarchical institutional structures were found to impede the integration of SDM into routine clinical practice.263871
Systemic level
At the systemic level, the analysis revealed four prominent themes: 1) structural and policy context, 2) culture and societal norms, 3) standardized guidelines, and 4) the legal and regulatory framework.26273845475657657172788586 Limited consultation time was consistently identified as a major impediment to SDM, as it restricted opportunities for meaningful dialogue between patients and clinicians.264547717285 Deeply embedded cultural norms favoring physician-led decision-making and traditionally family-centered approaches constrained patient autonomy and engagement.2738444556576578 In addition, legal and regulatory frameworks played an influential role in shaping SDM practices, particularly in the context of EoL care.2756
DISCUSSION
This scoping review identified 62 empirical studies on SDM conducted within the Korean healthcare system, offering a comprehensive delineation of current evidence-based research. Most studies have focused on EoL care as the primary clinical context. The thematic scope centered around patient and family perspectives, followed by investigations into barriers and facilitators of SDM implementation, healthcare provider perspectives, and interventions. The nature of the research revealed an early stage of conceptual and methodological development, with limited application of established international SDM frameworks to guide intervention design or evaluation. The key characteristics of SDM research encompassed a small number of decision aids and interventions, as well as multilevel contextual factors spanning patient/family, provider, interactional, organizational, and systemic domains that collectively influence the practice and feasibility of SDM in Korean clinical settings.
Among the 62 included studies, 15 (24.2%) focused on EoL care and examined culturally adapted SDM models, measurement tools, decision aids, and educational interventions. The predominance of EoL-related research suggests that early academic and clinical engagement with SDM in Korea is concentrated in this domain. This trend was likely shaped by broader national debates on patient autonomy, particularly following two landmark legal cases, the Boramae Hospital case (1998) and the Severance Hospital case (2008), which brought issues of human dignity and self-determination to the forefront of the EoL care discourse.100 Several of these studies preceded the 2016 enactment of the LST Decision Act, indicating active academic interest in patient participation before a legal framework was established.
Following the implementation of the Act in 2018, research began to reflect the evolving legal and ethical landscape surrounding EoL decision-making. Although national data reported an increase in patient-led decisions regarding life-sustaining treatments, two-thirds of cases continued to be based on family statements, highlighting the persistent influence of family-driven decision-making at the EoL.101 A recent qualitative study by Yu et al.,27 involving terminal cancer patients, caregivers, and healthcare professionals, identified ongoing challenges in SDM practice, such as the delayed initiation of discussions until patients’ conditions had significantly deteriorated, cultural taboos around death, and the tendency to prioritize family preferences over patient autonomy. The study proposed a “6C framework” that reflects the complex dynamics, reinforcing the need for culturally sensitive SDM models and improved communication strategies. Collectively, these findings suggest that the Act not only formalized patient rights but also served as a catalyst for advancing context-specific approaches to SDM.
Although EoL care has been emphasized in Korean SDM research, there remains a clear imperative to expand the scope of SDM implementation to other clinical areas where patient preferences also play a critical role. Internationally, SDM has been actively applied across various domains of clinical practice, such as oncology,102 cardiology,103 diabetes management,104 mental health services,105 and maternal health,35 underscoring its broader relevance beyond EoL settings.
This review revealed that most studies primarily focused on patient and family perspectives, along with barriers and facilitators of implementation. Although several studies have cited international SDM models, few have adapted these frameworks to the Korean context or applied them in designing or evaluating interventions. As most of these models were developed in Western contexts,25693 their distinctive relevance in Korean sociocultural and clinical settings may be limited. Evidence from other cultural settings suggest that effective SDM must account for the role of patients’ social networks, including family and community members, which are often integral to decision-making.106 These findings highlight the importance of developing culturally grounded SDM frameworks, tailored to the Korean healthcare environment, an approach aligned with recent proposals for flexible, generic SDM models that are adaptable across diverse clinical and institutional settings.107108
Although physicians play a pivotal role in the implementation of SDM, no study in this review provides evidence for the development of physician-targeted educational programs. Existing efforts have focused on patients and nurses.5661 One study26 reported that 12.3% of physicians had received SDM education during their training. Given that SDM is not formally integrated into Korean medical curricula, such self-reports raise concerns about its validity and suggest conceptual ambiguity around what constitutes SDM. Notably, similar challenges have been reported in international reviews, including in Canada and the UK, where limited training and inconsistent understanding among clinicians have also been identified as barriers.109110 These findings highlight that conceptual clarity and the integration of SDM into formal medical training are foundational to effective practice.
Thematic analyses identified multilevel factors influencing SDM, spanning the patient/family, provider, interactional, organizational, and systemic levels. Patient-level influences, such as age, education, and health status, were associated with preferences for decision-making involvement, consistent with prior international studies.111112 Organizational barriers included limited availability of decision aids, insufficient educational resources, and inadequate clinician training. Systemic challenges included time-constrained consultations, gaps in standardized guidelines, and culturally embedded expectations regarding physician authority.
Time pressure was frequently cited by Korean physicians as a significant barrier to SDM,2671 which aligns with a systematic review in which health professionals identified limited time as the most commonly reported obstacle to SDM implementation.113 Although Veenendaal et al.114 reported that SDM does not necessarily prolong consultation time, this may not apply to the Korean healthcare system, which is recognized internationally for its short outpatient consultation times.115116 In such high-throughput settings, clinicians may reasonably perceive SDM as time-intensive and impractical. Interprofessional approaches that distribute SDM-related tasks across care teams have been suggested to alleviate this burden and are especially relevant for Korea’s high-volume clinical environment.117
Barriers at the organizational and systemic levels highlight the need for research focused on developing culturally appropriate decision aids, educational programs for health professionals, and standardized practice guidelines. Establishing robust methodological frameworks is essential to ensure that these tools are evidence-based, clinically relevant, and feasible for routine implementation. These priorities align with international SDM initiatives that emphasize structured training and rigorous tool development to support the broader integration of SDM into clinical practice.107108118119120121122
To the best of our knowledge, this scoping review represents the first comprehensive synthesis of empirical SDM research in the Korean healthcare context, providing a broad overview of the existing evidence and delineating key research gaps.
This study has some limitations. First, consistent with the scoping review methodology, no formal appraisal of the study quality or risk of bias was performed. Second, although rigorous efforts were made to ensure a systematic and comprehensive synthesis, some studies did not clearly report the factors influencing SDM. In such cases, thematic categorization required reviewer interpretation, which may have introduced a degree of subjectivity. Third, the exclusion of gray literature, such as policy documents, unpublished reports, and conference proceedings, may have limited the comprehensiveness of the findings. To mitigate this limitation, citation tracking and manual searching were conducted in addition to database searches.
Based on these findings, we propose several directions for future research. First, the development and validation of SDM models and measurement tools tailored to the Korean context should be prioritized. These tools must be attuned to the structural constraints of the Korean healthcare system, including limited consultation time. Second, researchers across diverse clinical specialties should design and rigorously evaluate SDM interventions and decision aids that promote patient engagement in value-congruent decision-making. Such efforts should begin by identifying clinical scenarios involving multiple reasonable options for diagnosis, treatment, or management. Findings from such evaluations could inform institutional- and policy-level strategies essential for the sustainable integration of SDM into routine care. Third, health policy research should explore optimal reimbursement models and financial incentives to facilitate SDM implementation. Payment structures aligned with value-based care may enable clinicians to allocate adequate time and resources for SDM processes.123
Overall, this scoping review highlights both foundational advances and ongoing challenges in SDM research and practice in South Korea. Although interest in patient-centered care is growing, Korean SDM research remains fragmented and lacks systematic implementation strategies. Future research should prioritize developing culturally attuned conceptual models, validated measurement tools, and evidence-based interventions while establishing supportive health policies. Insights from the Korean experience may inform SDM implementation efforts in other settings with comparable cultural and healthcare dynamics.
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