When Intensive Care is Perceived as a Place of Death: Family Decision Delay, Trust, and Financial Barriers to Timely Acceptance of ICU Admission in Somalia

Abstract: This article is an evidence-informed commentary and conceptual reflection on delays in accepting intensive care unit (ICU) admission or escalation in Somalia, informed by contextual clinical experience and relevant literature rather than primary empirical measurement. In some families, ICU transfer may be interpreted not as a setting for advanced monitoring and potentially life-saving support, but as a sign that death is imminent. Such interpretations may be influenced by prior bereavement experiences, fear of separation from the patient, uncertainty about care quality and outcomes, financial barriers within a predominantly out-of-pocket system, and family-centered decision structures in which elders or household heads may authorize major care decisions. ICU services and workforce capacity have expanded gradually in urban Somali settings, including Mogadishu, yet public understanding of ICU purpose and processes may remain limited. We propose a context-informed conceptual pathway of ICU decision delay and outline a practical response framework emphasizing clear family explanation, structured communication and trust-building, respectful counseling of fear and grief, and feasible approaches to reduce immediate financial barriers at the point of escalation decisions to support timely acceptance of ICU admission or escalation when indicated. Keywords: Somalia, intensive care unit, critical care, family decision making, treatment delay, health financing, trust, communication, low resource settings