SERENITY realist synthesis questions.

IntroductionPatients with cancer are at increased risk of thrombotic complications from both the disease and its treatments, with antithrombotic therapy (ATT) usually continued in the last phase of life where the benefit is less clear and there is high risk of harms. Physiological changes toward the end of life increase the risk that ATT will cause serious bleeding events, but discussion between clinicians and patients of ATT risks and benefits is sub-optimal. This realist synthesis explores shared decision-making (SDM) to: (a) provide insights into why prescribing continues in end-of-life care; (b) build a conceptual platform for optimizing ATT prescribing for persons living with cancer towards end-of-life.Methods and findingsWe conducted a realist synthesis using context-mechanism-outcome configurations and ‘if…then’ statements. A total of 17,036 citations identified across 10 databases (Medline, EMBASE, APA PsycInfo, CINAHL Complete, CDSR, CENTRAL, EPISTEMONIKOS, Web of Science Core Collection, Assia, Google Scholar). Ninety-one papers included following reverse chronology quota record screening (from: database searches (n = 56), consortium experts (n = 35)). Included papers: quantitative (n = 40), qualitative (n = 17), mixed-methods (n = 2), evidence syntheses (n = 16), commentaries (n = 9), case reports (n = 7). Exclusion criteria: persons ConclusionImplementation of ATT deprescribing is enabled or constrained by (a) the meaning of medications to patients; (b) clinician engagement and understanding; (c) multi-disciplinary clinical decision-making processes (including support tools); (d) patient empowerment; (e) organizational investment. Addressing these multi-level factors, including the development of SDM tools, can address the prescribing inertia that may cause devastating impacts on patients and their families as well as moral distress amongst healthcare staff. This study was performed as part of the Horizon-Europe funded SERENITY project.