Background/rationale: Rates of cancer treatment refusal are relatively low, yet in the Pacific island of Guam, the authors have recently received several referrals to provide psycho-oncology care to patients who declined treatment services. The majority of these patients are from low SES backgrounds, low education levels, and ethnic minority groups, suggesting that treatment refusal may stem in part from socioeconomic, educational, cultural, and language barriers. Methods: The first step in our service protocol for patients who refuse treatment is to establish trust and rapport, a process that often takes several sessions. Our second step is to explore misunderstandings that underlie treatment refusal, as well as belief systems that conflict with biomedical frameworks. Our third step is to outline treatment options in a way that is easy to understand. This includes an honest discussion of potential benefits, risks, and side effects, taking into account the patient's age, overall health, and lifestyle, as well as addressing the patient’s questions and concerns about each treatment option. The fourth step is to set up meaningful opportunities for patients to access treatment services, including introducing them to medical, surgical, and radiation oncologists at cancer support group sessions. Impact on practice: The support and guidance provided have led some of our patients to pursue treatment in order to prolong their life. For those who ultimately refuse treatment, we focus our services on maintaining quality of life, including helping patients to meaningfully engage with others and find a sense of purpose as they go through their cancer journey. Discussion: Discussion focuses on navigating the complexities of shared decision making—a challenging process whereby the clinician must demonstrate compassion and respect for patient preferences, while also helping patients to understand the treatment options available to them.