Objective To explore the status quo of treatment decisional conflict in elderly inpatients with solitary pulmonary nodules (SPN) and analyze its influencing factors. Methods A total of 148 elderly inpatients with SPN admitted to our hospital from February 2023 to February 2025 were enrolled, and finally 146 valid questionnaires were collected. Decisional conflict scale (DCS) was used to investigate the treatment decisional conflict of patients. According to the DCS score, 146 participants were divided into a high score group (score ≥37.5 points, 37 cases) and a non-high score group (score <37.5 points, 109 cases). SPSS 25.0 was employed for data processing, and t test or χ² test was applied for comparison between groups depending on data type. Multivariate logistic regression analysis was performed to identify the influencing factors for severe decisional conflict in elderly SPN inpatients. ResultsAmong the 148 patients, 146 questionnaires were effectively recovered, with an effective rate of 98.65%. The final total score of DCS was (29.42±5.09) points in the 146 participants. There were 69 cases (47.26%) with effective decision, 77 cases (52.74%) with decisional conflict, and 37 cases (25.34%) with severe decisional conflict. The high score group exhibited significantly larger proportions of patients with anxiety tendency, depression tendency, frailty and poor family function, while smaller proportions of history of lung disease and asymptomatic condition than the non-high score group (P<0.05). Multivariate logistic regression analysis suggested that anxiety tendency (OR=3.031,95%CI 1.686-5.450; P<0.05), depression tendency (OR=4.047,95%CI 2.604-6.290; P<0.05), frailty (OR=5.562,95%CI 3.645-8.488; P<0.05) and poor family function (OR=4.660,95%CI 3.054-7.111; P<0.05) were risk factors of severe decisional conflict in elderly SPN inpatients, and history of lung disease (OR=0.384,95%CI 0.020-0.811; P<0.05) and asymptomatic condition (OR=0.375,95%CI 0.017-0.799; P<0.05) were protective factors. Conclusion The situation of decisional conflict is severe in elderly SPN inpatients. Clinically, it is necessary to assess decisional conflict by evaluating the anxiety tendency, depression tendency, frailty, family function, history of lung disease and clinical symptoms, and implement the decisional conflict support strategy in time to improve the decision-making quality.