Between Hope and Harm: A Meta‐Synthesis of Family Decision‐Making Agonies in ECMO Initiation Crossroads

ABSTRACT Background Family members making decisions about ECMO initiation face high‐stakes uncertainty, emotional stress and cultural–ethical dilemmas. However, existing research lacks a synthesised understanding of these decision‐making experiences across contexts. Aims To synthesise qualitative evidence on the experiences of family decision‐makers during the pre‐ECMO phase and develop a context‐sensitive theoretical framework. Study Design A meta‐synthesis was conducted following PRISMA 2020 guidelines. Six qualitative studies from 2011 to 2025 were included, spanning diverse cultural settings. Thematic synthesis and Gioia‐informed coding were used to extract core patterns and reconstruct decision‐making pathways. Results Five overarching themes emerged: (1) clinical decision urgency, (2) cognitive overload, (3) cultural and financial tensions, (4) intra‐family dynamics and (5) the dual role of clinical communication. Families often experienced informational imbalance and emotional distress, intensified by cultural obligations and systemic constraints. Conclusions We propose the ECMO Family Decision‐Making Ecological Model, which emphasises the interactive influence of information processing, cultural values and institutional systems. The model offers a foundation for developing culturally tailored, human‐centred decision support strategies in critical care. Relevance to Clinical Practice The central role of families in ECMO decision‐making was emphasised, and a context‐sensitive model was proposed to support clinicians in delivering more humanised, culturally informed critical care. Trial Registration: This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD420250652437