A feasibility study of behavioural activation for haemodialysis: The BEACH study protocol.

Chronic illnesses such as hypertension, diabetes mellitus, chronic kidney disease requiring dialysis, and cardiovascular diseases are not characterized by isolated episodes of treatment but instead require long-term management involving continuous monitoring, repeated clinical encounters, and ongoing treatment adjustments [–]. Patients and their families are therefore repeatedly confronted with complex medical decisions, including when to initiate or modify pharmacological therapies, whether to pursue invasive interventions, and how to balance clinical effectiveness with quality-of-life considerations [,]. Consequently, medical decision making in chronic illnesses is embedded within long-term care trajectories characterized by sustained interaction with healthcare systems rather than discrete, one-time choices []. Family caregivers play a central role in these trajectories. Prior research demonstrates that caregivers contribute not only to daily care activities but also to clinical interactions, particularly in the management of chronic and multimorbid conditions [–]. In East Asian contexts, where Confucian traditions emphasize filial piety, interdependence, and family responsibility, caregivers commonly function as intermediaries between patients and healthcare professionals [–]. Their involvement often includes interpreting medical information, coordinating care, and supporting patients’ decision making, particularly when patients are older or experience constraints in direct participation in clinical communication [–]. In such settings, medical decision making frequently occurs not within a dyadic clinician–patient relationship, but through interactions among clinicians, patients, and family members [, ]. Despite this relational complexity, much of the existing literature on shared decision making (SDM) has conceptualized decision making primarily at the individual level. SDM has been widely promoted as a cornerstone of patient-centered care, with dominant frameworks emphasizing patient autonomy, health literacy, patient activation, and direct patient–provider communication [–]. Influential models, including the SDM conceptualization proposed by Charles et al. and the three-talk framework proposed by Elwyn et al., have made important contributions by framing decision making as an interactive and deliberative process rather than a unidirectional transfer of information [,]. These approaches have been instrumental in advancing SDM in collaborative clinical practices.