33 Background: Diagnosis of malignant glioma is catastrophic and standard treatment options remain non-curative. Patients are not guaranteed a good outcome, have significantly decreased QOL and exposure to risk. Shared decision making, is believed to diffuse decisional distress accompanying complex situations. Methods: Semi-structured interviews explored patient, caregiver and physician perceptions of standard of care treatment recommendations following diagnosis. Cognitive, neurological and functional ability was evaluated with neurological examination, Karnofsky Performance Scale (KPS), Trail-Making Test and The Hopkins Verbal Learning Test (HVLT). Physical and emotional distress was scored with the FACT-BR and the MD Anderson Symptom Inventory (MDASI). Results: Common themes emerging from patients’ interviews were identified, characterized and evaluated in comparison to those of treating physicians and caregivers. Several themes pertained to existential concerns, all of which were underappreciated by the physicians and to a lesser extent caregivers. Physicians emphasized the potential advantages of improved survival within a limited lifespan, but this advantage was perceived by patients as a binary life or death construct without differentiation of prognostic subtleties. Physicians and caregivers perceived shared decision making to be occurring to a greater degree than did patients. Cognitive and language dysfunction were not significant barriers to communication in this group of patients. Conclusions: Although physicians believed that shared decision making was occurring, there was poor patient comprehension of the complex situation and patients did not feel empowered or capable to make independent decisions. Patients endorsed moderate to severe distress in the setting of these treatment decisions. Improved physician-patient communication and patient education is needed to support engagement of patients and caregivers in therapy, to address the overwhelming existential crisis that patients face, and to avoid shepherding patients into treatments that are poorly understood, insufficiently explained for informed consent purposes, or accompanied by unrealistic expectations.