Surrogate Medical Decision-Making in Dementia: A Theory-Informed Integrative Review.

AIM: To synthesize empirical evidence on decision-making factors and emotional outcomes among surrogate medical decision-makers for people with dementia. DESIGN: Integrative review. METHODS: A comprehensive search was conducted following Whittemore and Knafl's integrative review methodology. Eligible studies were appraised using the Mixed Methods Appraisal Tool and synthesized through inductive content analysis, guided by the Transactional Model of Stress and Coping. DATA SOURCES: PubMed, CINAHL, Embase, Scopus and PsycINFO were searched in August 2025. RESULTS: Eighteen studies representing 574 surrogate decision-makers for people with dementia were included. Surrogate decision-making unfolded as an iterative process of evaluating clinical and relational demands, mobilizing coping resources and reappraising earlier judgements as conditions changed, consistent with the Transactional Model of Stress and Coping. Decision-making was influenced by informational needs, communication quality, family dynamics, cultural values and organizational barriers. Emotional outcomes ranged from guilt, anxiety and regret to relief, acceptance and growth. CONCLUSION: Surrogate medical decision-making in dementia reflects an iterative process of appraisal, coping and reappraisal, shaped by contextual, relational and organizational factors that influence emotional outcomes. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Nurses should assess decision-making contexts and provide tailored informational, relational and emotional support throughout the dementia care trajectory. IMPACT: Dementia often requires family members and other surrogates to make complex medical decisions, yet limited synthesis has examined how they appraise and cope with these demands. This review found that surrogate decision-making is an iterative process shaped by evolving appraisals, coping resources and communication quality, leading to varied emotional outcomes. Findings highlight the need for research that examines how surrogate decision-makers with multiple competing roles appraise and cope with decisions across the dementia trajectory. REPORTING METHOD: This review adheres to the PRISMA 2020 reporting guidelines. PATIENT OR PUBLIC CONTRIBUTION: This study did not include patient or public involvement in its design, conduct or reporting.