Barriers to critical care utilization in low-resource settings: A multicenter study of family perspectives

INTRODUCTION: Low- and middle-income countries (LMICs), including Pakistan, face a high burden of critical illness but limited intensive care unit (ICU) capacity, compounded by financial and cultural barriers. Families play a central role in ICU decision-making, yet little is known about their perceptions. This study aims to explore Pakistani families' perceptions of intensive care and identify barriers affecting ICU utilization. METHODS AND ANALYSIS: Six focus group discussions were held with 38 family members across 10 public hospitals in three provinces. A semi-structured guide explored perceptions of ICU care, decision-making, affordability, and end-of-life experiences. Data were analyzed thematically using an inductive approach. RESULTS: Three themes and sixteen subthemes emerged. Families viewed ICU admission as a sign of impending death, causing significant psychological distress. While ventilators were understood as lifesaving, some associated them with harm. Major barriers included public bed shortages and prohibitive private costs, though insurance has improved access. Families prioritized active involvement in patient care but faced poor communication, mistrust in private hospitals, and discomfort with trainees. Conversely, 24-h senior physician coverage provided reassurance. Spiritual beliefs heavily influenced end-of-life decisions, often prompting care withdrawal to prevent suffering. CONCLUSION: Family perceptions of ICU care in Pakistan are defined by fear, financial constraints, spiritual values, and a strong desire for active participation. To build trust and support patient-centered care in low-resource settings, health systems must improve communication, facilitate family engagement, and ensure timely access to quality services.