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The NHS aspires to place patients’ needs wishes and preferences at the heart of a clinical decision-making; however it is not clear how this can be routinely implemented. One example is the patient clinical care pathway for patients diagnosed with advanced non-small cell lung cancer (NSCLC) where there may be misunderstanding of the extent of disease prognosis and aims of treatment.To understand how treatment decisions are made for NSCLC patients and map the decisions pathway.PACT is a prospective multi-centre multi-methods five-stage qualitative study. Non-participant observation of MDT meetings (n=12) determined patients’ allocation to treatment. Non-participant observation of patient-clinician consultations (n=14) explored communication of treatment options and decision-making. Interviews with patients/companions and clinicians (n=27) explored perception of treatment options and involvement in decision-making. Mediated discourse thematic framework and narrative analysis were used to analyse the data. An expert consensus meeting (n=33) finalised the content and format of a proposed intervention.For NSCLC patients decision making was a process rather than a single event. Patients’ priorities and preferences were not routinely or intrinsically part of the clinical pathway and arose according to the skills/attitudes of the clinician and the confidence/awareness of the patient. The interviews illustrate the uncertainty for patients around treatment considerations and highlighted the importance of knowing patients’ priorities and preferences.Current pathway for NSCLC patients focuses on clinical management at the expense of patient-centred care. However clinicians’ attitude towards hope for patients with non-curative diagnosis is instrumental to any process change.