Digital Twins are evolving from passive virtual representations into closed-loop systems that continuously synchronize with physical assets and drive real-time decisions. Yet predictive modeling, machine learning (ML), uncertainty quantification (UQ), and decision-making have been studied as separate capabilities, leaving limited understanding of their integration and maintenance during online operation. This narrative review, scoped by the functional requirements of real-time decision-making rather than by Digital Twin terminology alone, examines how such decisions are generated and sustained in engineering Digital Twins. We first examine foundational decision-making architectures and representative engineering applications, followed by methods that address their limitations across the decision loop. We identify optimization-based, policy-based, and knowledge-based approaches as the major pathways from virtual representation to action. Across them, ML plays three roles in decision-making: enabling efficient surrogate modeling, transforming heterogeneous physical feedback into decision-relevant information, and accelerating or directly generating decisions. UQ supports uncertainty-aware decisions and model adaptation, while continual validation, drift detection, and adaptation help maintain reliable operation as the physical system evolves. Together, these findings underscore the need for a shift from a model-centric to a system-centric perspective on Digital Twins, where its performance depends on the interactions with sensing, state estimation, computation, decision-making, and adaptation rather than on their standalone performance. Therefore, future research should shift from isolated algorithm development toward system-level co-design, scalable decision-making, and approaches to design, and data-efficient continual adaptation and validation for AI-enabled autonomous systems.

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