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Objectives This study aimed to explore the experience of decision conflict among surrogate decision-makers for patients with critical illness undergoing neurosurgery.Design A qualitative descriptive research design was used. Participants were selected using a purposive sampling method, and semi-structured interviews were conducted to collect data, which were then analysed using Colaizzi’s seven-step analysis method.Setting The study was conducted in a tertiary hospital in China.Participants This study included 15 surrogate decision-makers for patients with critical illness undergoing neurosurgery as interview participants.Results In this interview study, two main themes and nine subthemes were identified：(a) core conflict in the decision-making process: conflicts between the quality of life and the length of life, conflict between patient and surrogate preferences and conflict between the expected and realistic treatment outcomes; and (b) complex causes of decisional conflict: the burden of decision-making in critical care, inadequate decision-making information, erosion of patient-physician trust, socio-cultural pressures, overwhelming financial burden and negative emotional distress.Conclusions Surrogate decision-makers for patients with neurological critical illness often experience complex decision conflicts during the clinical decision-making process. This underscores the need for healthcare providers to identify high-risk individuals for decision conflicts early on and provide personalised decision support strategies to mitigate such conflicts and enhance decision quality.