Objectives
This systematic review examines how design methodologies support Shared Decision Making (SDM), identifies the most suitable for future use, explores types of methodologies used, challenges faced, and the impact on patients, clinicians, and care pathways.

Methods
Studies were searched on Medline, Web of Science, Scopus and grey literature (Google Scholar, CORDIS) up to July 2024, following PRISMA guidelines.

Results
were analysed to identify patient involvement, design strategies, SDM solutions, and their impact on care paths, professionals, and patients.

Results
Out of 2499 studies and 39 grey literature projects identified, 22 studies (reported in 35 publications) were selected, primarily from the USA and Europe (2015 onward). User-Centered Design predominated, involving health professionals more than patients. IPDAS standards were common. Evaluations showed improved patient experience and SDM role, with a potential increase in healthcare professionals' workload.

Conclusion
Although design methodologies are used in SDM implementation, improvement is needed. Service Design can enhance implementation by analysing the entire SDM process, while co-creative approaches develop patient-focused solutions that integrate smoothly into health professionals' workflows.

Practical implications
Introducing SDM in healthcare is complex, but design methodologies can help by analysing stakeholder needs, providing a broader care path view, and facilitating SDM implementation.

Purpose: Solutions to improve the implementation of shared decision making (SDM) in oncology often focus on the consultation, with limited effects. In this study, we used a service design perspective on the care path of locally advanced pancreatic cancer (LAPC). We aimed to understand how experiences of patients, their significant others, and medical professionals over the entire care path accumulate to support their ability to participate in SDM. Participants and methods: We used qualitative interviews including design research techniques with 13 patients, 13 significant others, and 11 healthcare professionals, involved in the diagnosis or treatment of LAPC. The topic list was based on the literature and an auto-ethnography of the illness trajectory by a caregiver who is also a service design researcher. We conducted a thematic content analysis to identify themes influencing the ability to participate in SDM. Results: We found four interconnected themes: (1) Decision making is an ongoing and unpredictable process with many decision moments, often unannounced. The unpredictability of the disease course, tumor response to treatment, and consequences of choices on the quality of life complicate decision making; (2) Division of roles, tasks, and collaboration among professionals and between professionals and patients and/or their significant others is often unclear to patients and their significant others; (3) It involves “work” for patients and their significant others to obtain and understand information; (4) In “their disease journey,” patients are confronted with unexpected energy drains and energy boosts, that influence their level of empowerment to participate in SDM. Conclusion: The service design perspective uncovered how the stage for SDM is often set outside the consultation, which might explain the limited effect currently seen of interventions focusing on consultation itself. Our findings serve as a starting point for (re)designing care paths to improve the implementation of SDM in oncology.