Objective <p>To examine a moderated mediation model in which shared decision-making (SDM) mediates the association between patient–physician communication (PPC) and two key diabetes outcomes—medication adherence and diabetes distress— while physician empathy moderates the pathways from PPC to SDM and from SDM to outcomes.</p> Methods <p>A cross-sectional survey of 1300 adults with diabetes was conducted at a specialty clinic in Tehran, Iran. Participants completed validated measures of PPC, SDM, physician empathy, medication adherence, and diabetes distress. Analyses used latent moderated structural equation modeling in Mplus to test direct, indirect, and conditional indirect effects.</p> Results <p>SDM significantly mediated the effects of both ‘hurried communication’ and ‘explained results’ (two aspects of PPC) on adherence and distress (all 95% CIs excluded zero). Empathy significantly moderated these indirect effects. The negative indirect effect of hurried communication on adherence through SDM was weaker at high empathy (B= -0.83, p &lt; 0.001) than at low empathy (B= -1.13, p &lt; 0.001). A similar pattern was found for distress, where the positive indirect effect of hurried communication was weaker at high empathy (B = 0.29, p &lt; 0.001) than at low empathy (B = 0.39, p &lt; 0.001). Conversely, the positive indirect effect of explained results on adherence through SDM was stronger at high empathy (B = 2.95, p &lt; 0.001) than at low empathy (B = 1.35, p = 0.001).</p> Conclusion <p>Physician empathy may act as a relational resource that sustains SDM when communication is hurried and enhances its benefits when treatment rationales are clearly explained. These findings have important implications for the design of communication and empathy-training interventions, suggesting that enhancing physician empathy may be a key target for improving self-management and emotional well-being in diabetes care.</p>