INTRODUCTION

Metastatic cancers, characterized by the spread of malignant cells from the primary tumor to distant tissues, are a leading cause of treatment failure and mortality across multiple cancer types [1,2]. Surgical and systemic interventions, including surgery and chemotherapy, often produce limited therapeutic benefit in certain metastatic cancers and may substantially diminish patients’ quality of life [3]. Concurrently, the economic burden of cancer continues to rise. The World Economic Forum projects that, by 2030, cancer treatment costs in the United States will reach US$246 billion [4]. In Iran, approximately 85 000 new cancer cases are diagnosed annually, imposing a financial burden exceeding 60 trillion rials on the healthcare system [5].

However, a subset of patients with advanced cancer elects to discontinue active treatment. Significant ethical and clinical controversy persists regarding the initiation, continuation, or withdrawal of treatment at the end of life [6]. This situation creates profound ethical dilemmas, requiring individuals to choose between burdensome and often ineffective therapies and the continuation of non-beneficial care [7]. To date, clinical guidelines have not established a clear threshold for discontinuing active treatment and transitioning to palliative care [8].

The International Council of Nurses recognizes patient autonomy—including the right to accept or refuse treatment—as a fundamental principle of nursing practice. This principle is embedded within a broader framework of ethical rights, including confidentiality, respect, informed consent, and freedom from degrading treatment, all of which uphold patient dignity [9,10]. Although these principles have advanced person-centered care, conflicts in decision-making may still arise. Such conflicts frequently stem from differences in values between patients and healthcare professionals and may inadvertently compromise patient autonomy. Nevertheless, healthcare professionals aim to preserve patient independence and protect patients’ best interests [11]. Patients’ values, cultural backgrounds, and personal beliefs substantially shape their attitudes toward treatment decisions and influence the quality of care they receive [12]. Consequently, decisions to accept or refuse treatment are complex and are often informed by deeply held philosophical, cultural, and spiritual beliefs [6].

Patients with advanced and incurable cancer experience complex physical, psychological, social, and spiritual consequences of both disease and treatment. Decisions regarding treatment withdrawal are frequently influenced by cultural factors [3]. In Iranian culture, religion and spirituality play a central role in coping with illness; however, these influences may vary across different cultural contexts [13]. Given the profound influence of culture and the limited availability of in-depth research in this area, qualitative inquiry is particularly well suited to explore this phenomenon [14]. Although previous studies have examined treatment withdrawal in various settings, the lived experience of this decision within collectivist and spiritually oriented cultures, such as Iran, remains insufficiently understood. In particular, the influence of beliefs in divine destiny, conceptualizations of death as spiritual transition, and the negotiation between individual suffering and familial responsibility warrant further exploration. Therefore, this qualitative study aimed to explore the factors influencing decisions to withdraw treatment among Iranian patients with metastatic cancer.

METHODS

Study Design

This qualitative study using conventional content analysis was conducted from September 2024 to April 2025 in Fars Province, Iran. Qualitative content analysis allows for multifaceted descriptions and interpretations that aim to understand and convey individuals’ experiences, particularly in contexts with limited prior knowledge [15]. This approach provides a valuable means of addressing critical clinical issues with a primary emphasis on participant perspectives [16]. This study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

Research Question and Conceptual Definitions

Research question: “What are the reasons for deciding to withdraw treatment in Iranian patients with metastatic cancer?”

Treatment withdrawal: Refers to a patient-initiated decision to cease curative or disease-modifying therapies (specifically chemotherapy, radiotherapy, and targeted systemic therapies) intended primarily to extend life or achieve remission. This definition excludes discontinuation of purely palliative treatments aimed at symptom control (e.g., pain management and palliative radiotherapy for pain). The decision is characterized as a voluntary choice made by a patient with decisional capacity after a period of receiving such treatments.

Participants and Setting

Purposive sampling with maximum variation was used to capture a wide range of experiences. Participants were recruited from 3 settings—hospitals, palliative care centers, and patients’ homes—and were approached face-to-face by the researcher. Inclusion criteria were (1) adults (≥18 years) with a physician-confirmed diagnosis of metastatic cancer, (2) having made a personal decision to withdraw treatments such as chemotherapy, and (3) ability to communicate in Persian and provide informed consent. Variation was sought in age, sex, cancer type, and treatment history. Recruitment continued until data saturation was reached after 13 participants. To confirm saturation, 1 additional interview was conducted, which yielded no new concepts, codes, or thematic insights [17]. The final sample size was therefore determined by thematic saturation. Data collection and preliminary analysis occurred concurrently. The final sample consisted of 14 participants (8 females, 6 males) with a mean age of 51 years (range: 28–78). Most participants were married (n=11). Participants had a range of metastatic cancer diagnoses (Table 1).

Data Collection

The first author (FA), a researcher at Kerman University of Medical Sciences (female, PhD), trained in qualitative methods and interviewing techniques, conducted all interviews. A semi-structured interview guide (Table 2), developed from the literature and pilot-tested, was used. Interviews began with an open-ended invitation: “Could you tell me the story of your journey that led to the decision to stop your cancer treatment?” Follow-up probes were used to explore participants’ narratives in depth. All interviews were conducted privately, audio-recorded with written consent, and lasted 30–60 minutes. Only the participant and the researcher were present during interviews. The interviewer had no therapeutic or personal relationship with any participant. Participants were informed that the interviewer was a researcher, not a member of their direct clinical care team, to minimize perceived power dynamics and social desirability bias. To support data quality, the interviewer practiced reflexivity through journaling, and the interview guide was discussed and refined in team meetings. Preliminary findings were also member-checked with available participants. Data were coded and categorized using MAXQDA 2020 (VERBI, Berlin, Germany) software.

Data Analysis

The qualitative content analysis approach described by Graneheim and Lundman [18] was applied in 3 steps: (1) selecting meaning units, (2) condensing and coding, and (3) creating categories and themes at different levels of abstraction. This approach enables researchers to derive meaningful insights from raw textual data through systematic condensation and categorization into higher-order constructs. Themes were derived inductively from the data. Content analysis facilitates in-depth interpretation of textual data through structured categorization, coding, and identification of thematic patterns [18]. After each interview, the audio-recording was transcribed verbatim. The transcripts were then read several times to obtain an overall understanding of the content. Meaning units and codes were grouped into subcategories based on similarities. The first author (FA) performed the initial coding. The resulting codes, subcategories, and categories were reviewed, discussed, and agreed upon by the full research team (FA, SN, CR, MB) through iterative consensus meetings.

Trustworthiness and rigor of the study

Trustworthiness was established using Lincoln and Guba [19]’s criteria: credibility, dependability, confirmability, authenticity, and transferability. Confirmability was supported through maintenance of a detailed audit trail (including transcripts, field notes, and analytic memos) and through reflexivity, with preconceptions documented and bracketed. Credibility was strengthened through peer debriefing within the team and with an external expert, as well as member checking with participants when feasible. Transferability was supported by sampling for diversity. Authenticity was supported by obtaining informed consent, respecting participants’ statements, attending to interpersonal dynamics, and clearly explaining the research methods to participants.

Ethics Statement

The study was approved by the Ethics Committee of Kerman University of Medical Sciences (IR.KMU.REC.1403.291). Written informed consent was obtained from all participants. Ethical procedures included explaining the study purpose, obtaining permission to audio-record, sharing study findings in aggregate form, ensuring anonymity, and informing participants of their right to withdraw at any time. The study adhered to the Declaration of Helsinki [20].

RESULTS

The analysis generated 1 main theme, 4 categories, and fifteen subcategories. A comprehensive overview of the categories and subcategories is provided in Table 3. The analytic structure of the findings is summarized in a conceptual map (Figure 1).

Main Theme: Finding the Meaning of Life, and Freedom From Cycles of Suffering

Understanding life’s meaning enabled patients to contextualize their illness within a larger purpose, often connecting them to a transcendent source and affirming life’s intrinsic value beyond survival. This motivation coincided with a desire to end cycles of suffering, suggesting that identifying deeper meaning in existence was central to achieving peace and liberation from pain.

Category 1. Social and Family Influences

The findings indicate that strong family and social support can help patients accept their illness and continue treatment by strengthening resilience and adherence. In contrast, limited support may reduce patients’ capacity to cope with suffering and diminish their desire to continue living. This category comprised the following subcategories.

Financial and insurance challenges

Insufficient governmental social support and inadequate health insurance coverage were important factors in decisions to withdraw treatment, particularly when patients exhausted their family’s financial resources and lacked alternative sources of financial support.

“Chemotherapy drugs are extremely expensive, and most of them are not covered by insurance. The treatment costs are truly backbreaking; all of our income and living expenses are spent on medications.” (40-year-old man with intestinal cancer)

Inadequate family support

The absence of familial support, particularly limited spousal involvement in treatment management, contributed to feelings of hopelessness. This emotional state appeared to reinforce acceptance of death and the decision to withdraw treatment.

“Ever since I was diagnosed with cancer, my husband has completely neglected me. For a while, he even claimed it was contagious and kept saying nonsense like, ‘I need to marry another woman.’ These kinds of remarks only made me more distressed. I was deeply hurt. My husband shows no care for me at all, as if cancer is some kind of highly dangerous, untouchable disease.” (56-year-old woman with intestinal cancer)

Acquaintances’ experiences of treatment failure

Participants often drew on relatives’ and acquaintances’ treatment experiences when making their own decisions. Accordingly, observations of unsuccessful treatment outcomes within one’s social network appeared to influence decisions to withdraw therapy.

“Everyone I’ve seen who underwent chemotherapy only got worse. The drugs themselves weaken the body; they are completely useless. I’ve seen many cases, even Mr. Ali, if you know him. He was hospitalized right here. He was a relative of ours. After so much chemotherapy, his body deteriorated faster, and he died.” (40-year-old man with liver cancer)

Guilty feelings following dependent care

Prolonged treatment regimens could increase dependency and reduce functional autonomy while imposing substantial burdens on family members. Participants described resulting distress and guilt, and some appeared to withdraw treatment to reduce the caregiving burden on their families, prioritizing a lower care burden over a longer lifespan.

“I swear to God, what upsets me the most is having to stay in the hospital, making two or three of my children suffer because of me. I feel ashamed for burdening them. They are all stuck caring for me.” (78-year-old man with leukemia)

Category 2. Physical Health Factors

Patients generally expressed willingness to endure pain and chemotherapy-related side effects when treatment was perceived as effective. However, when therapy appeared to provide only marginal life prolongation without curative benefit—particularly when severe adverse effects compromised independence and physical functioning—participants were more likely to withdraw treatment. This category comprised the following subcategories.

Prioritizing quality of life over quantity

A central finding was the prioritization of quality of life over length of survival. Participants consistently conveyed that survival without the ability to enjoy ordinary aspects of life was unsatisfactory. Many indicated a preference for a shorter life characterized by less pain rather than a prolonged life accompanied by significant suffering.

“Whether I live for two months or two years, I want to live properly. At the very least, I don’t want to have a colostomy bag attached to me. I want to be independent, not dependent on anyone. I want to be able to manage my own affairs and not become bedridden. I want to live, not merely survive.” (56-year-old woman with intestinal cancer)

Death as liberation from suffering

The data indicated that acceptance of death and diminished fear of dying were influential in participants’ decision-making. Many described death as a means of escaping physical pain associated with both disease and treatment.

“When someone dies and is buried, I see it as a relief. I’m not afraid of death. Whenever I visit a grave and see the deceased lying there, I think to myself, ‘Wow, they’re sleeping so peacefully.’ It looks so restful; no one bothers them, and no one disrespects them. I just want to die and be free, to sleep peacefully like that. To me, death means a serene sleep, freedom from all this pain and suffering.” (43-year-old man with liver cancer)

Failed treatment experiences

Following disease recurrence and previous ineffective treatments, participants often expressed reluctance to resume therapy due to disappointment with prior outcomes. This hesitation was reinforced when treatment-related adverse effects significantly compromised physical well-being.

“If this chemotherapy had any effect, then why did the disease return after I first underwent chemotherapy ten years ago? Why did I not feel better? What’s the point of treatment now if the disease might just return in a few years, causing the same pain and suffering again?” (31-year-old woman with leukemia)

Category 3. Psychological Determinants

Psychological determinants refer to internal cognitive and emotional processes that influence perceptions, behaviors, and decision-making. Unlike external social or economic influences, these factors operate within an individual’s internal framework and shape responses to illness. In the context of health, they may predispose individuals toward specific health-related behaviors or outcomes. This category comprised the following subcategories.

Love and hope as the meaning of life

Analysis indicated that love and hope were fundamental to sustaining participants’ will to live. When individuals perceived a lack of affection—particularly from spouses or family members—their motivation to continue treatment diminished. For these participants, life’s meaning was closely tied to experiencing love and maintaining hope for the future.

“Whether my condition improves or worsens, it no longer matters to me. I do not want to see another day of this life, a life that is cold, devoid of affection, and without love. Without love, life has no value. Life must be filled with love and attention. In fact, this illness has only driven me further away from my husband; it has brought no positive changes, only negative ones. The worst part is that my husband has become so distant from me.” (56-year-old woman with intestinal cancer)

Reconciling with terminal prognosis

Chemotherapy-related suffering emerged as a prominent subcategory. Many participants expressed the view that accepting a shortened lifespan was preferable to enduring severe pain, fatigue, and treatment-related distress.

“The doctor told me that even if I undergo chemotherapy, I will only live a little longer. But that does not mean my illness will be completely cured. Given this, why would I want to unnecessarily torment myself when, in any case, I will eventually die? It is better to spend whatever time I have left without enduring unnecessary pain or undergoing chemotherapy for no reason.” (33-year-old woman with leukemia)

Alterations in self-perception and bodily integrity

Changes in body image, particularly among women, appeared to influence decisions to discontinue treatment. Adverse effects such as hair loss and sexual dysfunction were described as distressing and contributed to dissatisfaction. Feelings of shame and diminished bodily integrity reduced motivation to continue therapy.

“The last time I underwent chemotherapy, all my hair fell out, and I became extremely thin and unattractive. When I looked at myself in the mirror, it was deeply distressing. That is why I do not want to undergo chemotherapy again, at least not if it means looking this way. I would rather have a shorter life than die looking so hideous.” (38-year-old woman with ovarian cancer)

Prioritizing autonomy and self-sufficiency

A recurrent subcategory was the importance of having one’s autonomy respected during decision-making. Participants emphasized the need for their personal wishes to be acknowledged and honored. Respect for autonomy appeared to be a significant factor influencing decisions to withdraw treatment.

“Honestly, life is not worth suffering so much for. I have reached a point where I realize that the only thing that truly matters is myself. At this stage, it is better to make my own decisions based on what I want, without being dependent on anyone else.” (45-year-old woman with breast cancer)

Category 4. Divine and Spiritual Beliefs

Divine and spiritual beliefs refer to faith in a higher power or an ultimate purpose that provides meaning to life, suffering, and death. Although often linked to organized religion, spirituality may also represent a personal existential framework. In the Iranian context—where belief in a higher power (Allah) is widespread—these beliefs significantly shaped participants’ interpretations of illness and treatment decisions. This category comprised the following subcategories.

Death as a passage to spiritual tranquility

Many participants conceptualized death not as an end, but as a transition from physical to spiritual existence. The belief that the afterlife would be free of suffering contributed to acceptance of death and withdrawal from treatment perceived as futile.

“We exist on multiple levels, one of which is the physical body, but in reality, we are part of the divine spirit. Death is not an end but a transition from one stage of existence to another.” (40-year-old man with intestinal cancer)

Conviction in a transcendent power to heal

Some participants expressed a strong belief in divine healing, which directly influenced their decision to discontinue medical treatment. They maintained that divine authority superseded medical intervention and that recovery would occur if divinely ordained.

“God and the Prophet Muhammad assist me, and I do not need these medications or treatments. I am confident that God will heal me, for with God, all things are possible.” (78-year-old man with leukemia)

Disease as a path to increase consciousness

Participants described illness as a catalyst for spiritual growth and heightened awareness. Facing a life-threatening diagnosis prompted existential reflection and reinterpretation of suffering as meaningful or divinely guided.

“When someone falls ill, they must look inward and ask themselves, ‘What caused this event? What lesson am I meant to learn from this that will help me complete my soul’s journey?’ From this world, which is filled with pain and suffering, I understand that life is merely a game, and I must finish this game to become aware of the divine presence within myself.” (43-year-old man with liver cancer)

Belief in divine destiny

A recurring belief among participants was that the timing of death was predetermined by divine will. They expressed the conviction that medical intervention could not alter this predetermined outcome.

“Outwardly, it may seem that we are responsible for our illness, but according to the word of God, as stated in the Holy Quran, we did not choose for these events to happen to us. Rather, God has chosen us to follow this path. This means that God has already planned our lives, and an individual’s fate is unchangeable. For instance, if I am meant to die young, that is what will happen. If I am meant to live longer, then cancer will not take my life. My purpose is simply to learn the lessons that life’s suffering offers.” (35-year-old woman with uterine cancer)

DISCUSSION

This study identified key factors influencing decisions to withdraw treatment among Iranian patients with metastatic cancer. The analysis indicated that determinants spanned 4 interrelated domains: physical, social, psychological, and spiritual. This multidimensional framework is consistent with the World Health Organization’s holistic model of health [21]. The findings suggest that when advanced cancer substantially disrupts well-being across these domains, patients’ motivation to pursue aggressive treatment may diminish. Instead, participants appeared to shift toward accepting death, prioritizing comfort, and avoiding the burdens associated with toxic or non-beneficial therapies such as chemotherapy [22]. These findings are consistent with those of Khankeh et al. [23], who highlighted the role of resilience in treatment decision-making. When patients’ multifaceted needs remain unmet, resilience may erode, leading to emotional exhaustion and decisions to discontinue treatment.

Within the centralized family structure characteristic of Iranian culture, adult children often maintain close emotional and practical ties to their parents, even after marriage. This interdependence strongly shapes medical decision-making [24]. Patients’ decisions are rarely made in isolation but are influenced by perceived impacts on family well-being. When patients believe that continued treatment imposes substantial financial, emotional, or caregiving burdens on their families, they may elect to discontinue therapy as an act intended to reduce family suffering. Similar patterns have been reported in other contexts. For example, Dhotre et al. [25] observed that patients may withdraw treatment to alleviate family hardship, and Yu et al. [26] likewise reported comparable findings.

Newman’s theory of health as expanding consciousness proposes that disruptions such as illness can catalyze personal transformation and heightened awareness [27]. This theoretical framework aligns with the present findings, in which some participants interpreted their suffering as divinely meaningful, facilitating spiritual growth and a deeper understanding of life’s purpose. Many also expressed the belief that lifespan is predetermined by divine will and that medical intervention cannot alter its duration, a perspective similarly reported by Yu et al. [26]. In contrast, research conducted in Kenya found that some parents discontinued pediatric cancer treatment due to beliefs in witchcraft, perceiving modern medicine as ineffective against supernatural forces [28]. These cross-cultural comparisons highlight the importance of contextual belief systems in shaping treatment decisions. The findings also underscore the significant roles of hope and love in shaping treatment decisions. Participants who described diminished experiences of love or hope appeared more likely to disengage from treatment. These findings suggest that hope and emotional connectedness may function as motivational resources in sustaining engagement with care [29]. This interpretation resonates with philosophical perspectives, including those attributed to Plato, which conceptualize love as central to meaningful existence. From a Platonic viewpoint, the value of human life is realized through the soul’s ascent toward beauty and goodness, a journey grounded in love [30].

A further pragmatic consideration involved participants’ evaluation of treatment utility relative to burden. Many described a perceived tipping point at which therapies were viewed as ineffective and as exacerbating suffering through adverse effects. This appraisal led to prioritization of quality of life over longevity [31,32]. Participants articulated a desire to preserve autonomy and functional independence—”to live, not merely survive” [33]. When chemotherapy was perceived as threatening these valued states by increasing dependency, discontinuing treatment was framed as a rational means of maintaining dignity and control during the remaining lifespan [34].

The Pervasive Role of Cultural Context

The findings are deeply embedded within the socio-cultural and religious context of Iran. The prominence of divine and spiritual beliefs reflects the influence of Islamic values, which provide a framework for interpreting suffering and legitimizing acceptance of death. Similarly, the familistic orientation of Iranian society reshapes autonomy into a relational construct in which decisions are negotiated within the family unit. Within this context, experiences of illness and suffering are interpreted through culturally specific narratives of sacrifice, spiritual testing, and transcendence.

Suggestions and Limitations

This study has several limitations. First, as a qualitative study using purposive sampling within a specific socio-cultural context (Iran), the findings are not statistically generalizable. However, the in-depth data provide conceptual insights that may be transferable to similar contexts.

Second, the sample included only patients who had already decided to withdraw treatment. The perspectives of family caregivers and oncology professionals were not examined; including these stakeholders in future research would provide a more comprehensive understanding of the decision-making process.

Third, the physical and emotional frailty of some participants limited the duration and depth of 2 interviews, which may have reduced the richness of the data. Although follow-up interviews were attempted—either at a later time or in shorter sessions —this limitation may still have influenced data completeness.

Fourth, researchers’ perspectives may have influenced participant interactions and thematic interpretation despite efforts to enhance reflexivity and peer debriefing. Although rigorous strategies were implemented to mitigate this influence, complete neutrality cannot be assumed.

Implications of the Study

At the micro level of clinical nursing practice, nurses serve as frontline caregivers. Their role should include comprehensive assessments extending beyond physical symptoms to systematically explore patients’ spiritual beliefs, family dynamics, financial stressors, and personal values related to quality of life. Such holistic assessments may facilitate shared decision-making. When patients prioritize autonomy or express concern about burdening family members, nurses may need to shift from advocating continued treatment to supporting a dignified transition to palliative care.

At the meso level, healthcare institutions—including hospitals and oncology centers—should develop structured protocols and staff training programs to support patients contemplating treatment withdrawal. Multidisciplinary teams comprising oncologists, nurses, psychologists, social workers, and chaplains may be particularly valuable in addressing the multifaceted needs identified in this study. Integrating financial counseling into routine oncology care may also mitigate economic pressures that influence withdrawal decisions.

At the macro level of national health policy, policymakers should consider these findings when designing palliative and supportive care frameworks. Expanding universal health insurance coverage may alleviate financial burdens that contribute to difficult treatment decisions. Additionally, public and professional education initiatives may help reframe treatment withdrawal not as abandonment of care but as a legitimate, values-consistent choice aimed at preserving dignity and quality of life at the end of life.

In summary, the findings indicate that social and family influences, physical health factors, psychological determinants, and divine and spiritual beliefs are central factors shaping decisions to withdraw treatment among patients with metastatic cancer. These insights provide a foundation for healthcare administrators and policymakers to develop targeted strategies aimed at reducing barriers to supportive care and improving end-of-life care. Future research should further examine mechanisms underlying treatment withdrawal and evaluate interventions designed to support patient-centered decision-making. Such understanding is essential for designing contextually appropriate interventions that align with patients’ values and preferences.

Data Availability

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

This study was supported by the Vice Chancellor for Research of Kerman University of Medical Sciences.

Acknowledgements

We would like to express our sincere gratitude to all individuals who contributed to this research.

Author Contributions

Conceptualization: Abadi F, Bijani M, Nouhi E, Rohani C. Data curation: Abadi F, Bijani M, Nouhi E, Rohani C. Formal analysis: Abadi F, Bijani M, Nouhi E, Rohani C. Funding acquisition: Abadi F, Nouhi E. Methodology: Abadi F, Bijani M, Nouhi E, Rohani C. Project administration: Nouhi E, Bijani M, Rohani C. Visualization: Abadi F, Bijani M, Nouhi E, Rohani C. Writing – original draft: Abadi F. Writing – review & editing: Abadi F, Bijani M, Nouhi E, Rohani C.

Figure 1

A conceptual map of categories and subcategories.

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