Cultural and socioeconomic determinants of family satisfaction with ICU care across the globe: a scoping review

Abstract

Objective:

To map evidence on global cultural and socioeconomic determinants of family satisfaction with care in the intensive care unit (ICU), including assessment, the influence of cultural beliefs and practices, and the impact of socioeconomic status on family satisfaction.

Study design:

This scoping review followed the Joanna Briggs Institute (JBI) guidelines and was reported in accordance with PRISMA-ScR. A comprehensive search of English-language studies was conducted across multiple databases. Studies were included if they examined the impact of cultural and socioeconomic factors on shared or end-of-life decision-making among family members, or if they explored the relationship between these factors and psychological outcomes (e.g., anxiety, depression, insomnia) in caregivers during ICU stays—provided that family satisfaction was also assessed. Two independent reviewers screened all studies, and data were extracted using a customized form to ensure consistency and relevance to the research question.

Results:

A total of 2,121 articles were identified from PubMed (n = 68), Scopus (n = 475), Embase (n = 1,436), Web of Science (n = 138), Cochrane (n = 4), and other sources (n = 10). After removing duplicates, 1,772 articles underwent title and abstract screening, with 101 full texts evaluated. Seventeen studies met the inclusion criteria. Data extraction focused on family characteristics (e.g., religion, race, education, kinship, prior ICU experience), sociocultural and economic factors, end-of-life practices, and ICU-related elements influencing family satisfaction. Findings were narratively synthesized to provide a comprehensive overview of these contextual influences. The review revealed that prioritizing patient symptoms, fostering effective communication to support shared decision-making, and showing compassion toward family needs significantly enhanced family satisfaction. However, a major gap was identified in research from low- and middle-income countries (LMICs). Further studies are needed to understand how diverse cultural and socioeconomic factors affect caregiver satisfaction in these settings and to develop tailored strategies that improve family experiences and outcomes in intensive care units globally.

Conclusion:

This review comprehensively mapped the available evidence and noted that addressing the cultural, socioeconomic, religious, and spiritual needs of the family, including comfort-based care interventions in the ICU, may improve family perceptions of ICU care and satisfaction. Further studies are required, especially in LMIC settings, to address diverse races, religions, and ethnicities in this context.

Systematic review registration:

https://osf.io/5xusk.

1 Introduction

Family satisfaction has emerged as a critical metric in evaluating the quality of care provided in ICUs. Families of severely ill patients often act as “surrogate decision-makers” and are central to patient-centered care models. Their experiences, perceptions, and satisfaction levels can significantly impact both the quality of care provided and their psychological outcomes, including the risk of anxiety, depression, and post-traumatic stress disorder after an ICU stay (1, 2).

Cultural factors profoundly shape family expectations, preferences, and satisfaction with ICU care. Variations in beliefs about illness, death, and medical decision-making across cultures influence communication styles, preferences for “shared decision-making,” and perceptions of empathetic care (3, 4). Religious and spiritual practices often intersect with palliative care, further influencing how families perceive the adequacy of emotional and spiritual support provided by healthcare teams (5).

Socioeconomic factors, including income, education, and occupational status, also play a pivotal role. These determinants influence how families interact with ICU processes, comprehend medical information, and assess the quality of care. Lower socioeconomic status has been linked to limited health literacy, poorer healthcare experiences, and feelings of exclusion from critical decision-making (6). In resource-limited or culturally diverse settings, these disparities can further hinder effective communication and erode trust in healthcare providers (7).

Considering the “global commitment to Universal Health Coverage and Sustainable Development Goal 3.8 (access to quality essential health services),” there is growing recognition of the need to understand sociocultural determinants in ICU care (8). An in-depth understanding of how cultural and socioeconomic aspects influence family satisfaction is crucial for developing equitable, person-centered critical care practices. Mapping the existing evidence in this area can identify priority areas for culturally sensitive interventions and inform policies to reduce inequities in ICU experiences.

Scoping reviews offer a robust method for addressing these complex, context-dependent questions. By systematically identifying, mapping, and synthesizing existing research, this review provides a detailed overview of the existing evidence base. It also highlights key gaps, guiding future research and informing ICU practices that are responsive to diverse cultural and socioeconomic needs.

2 Material and methodology

This scoping review adhered to the methodological framework established by the Joanna Briggs Institute (JBI) for conducting scoping reviews (9). The final report was prepared in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist (10). Owing to the broad and diverse nature of the literature on communication between patients, families, and caregivers, a scoping review was considered the most suitable method for capturing and synthesizing evidence across diverse study types and international contexts. Unique Identifier: https://osf.io/5xusk (registered with OSF on 08.07.2025) URL of publicly accessible website: https://osf.io/. A formal protocol was not published for this review (Appendix 1).

2.1 Eligibility criteria

2.1.1 Data sources and search strategy

An extensive literature search was performed to gather studies examining the cultural and socioeconomic determinants of family satisfaction with ICU care across global settings. The search strategy was designed to capture diverse study methodologies—including qualitative, quantitative, and mixed-methods research—across diverse cultural and socioeconomic contexts.

The databases searched included PubMed/MEDLINE, Embase, the Cochrane Library, Scopus, and Web of Science. All search strategies included both controlled vocabulary (e.g., MeSH terms in PubMed, Emtree in Embase) and relevant free-text terms to ensure comprehensive coverage and sensitivity (see Table 1).

Search terms.

were organized around four core conceptual domains, consistent with the Population–Concept–Context (PCC) framework:

• ICU setting (e.g., “intensive care units,” “critical care,” “ICU”)

• Cultural factors (e.g., “culture,” “cross-cultural,” “ethnicity,” “religion”)

• Socioeconomic factors (e.g., “income,” “education,” “socioeconomic status,” “employment”)

• Family satisfaction (e.g., “family satisfaction,” “patient satisfaction,” “family experience,” “FS-ICU 24R”).

Boolean operators (AND, OR) and appropriate truncation were applied to integrate and expand search terminologies across the four domains. The initial search technique was developed for PubMed and subsequently adapted for each additional database, accounting for differences in syntax and controlled vocabulary. The complete database-specific search strategies are provided in Appendix 2.

2.1.2 Data extraction and management

Search results across databases and additional records from other sources were transferred to Rayyan (11), and duplicates were removed.

2.1.3 Study selection

Two reviewers independently selected studies through a two-stage screening process.

During the first stage, two reviewers screened titles and abstracts to determine relevance according to predefined inclusion criteria. Studies that appeared eligible were advanced to the second stage; any disagreement between the two reviewers was resolved through a consensus-based discussion. Studies that appeared eligible advanced to the next stage, where full-text articles were reviewed by two reviewers to determine suitability for inclusion. Articles meeting the inclusion criteria were then subjected to a final eligibility check to ensure conformity with the predefined framework. Any conflicts between the two reviewers concerning study eligibility were addressed through consensus with a third reviewer. All disagreements were resolved through discussion. The primary reasons for excluding full-text articles were documented in the PRISMA 2020 flow diagram (Figure 1).

Figure 1

2.1.4 Data charting

A pretested coding framework was employed, including detailed variables such as citation details, study objectives, research design, country, setting, population characteristics, cultural and socioeconomic factors, family satisfaction measures or other tools, and reported outcomes. Data charting was carried out independently by two reviewers (Tables 2, 3).

2.1.5 Critical appraisal

As this was a scoping review, no formal quality assessment of the studies included was undertaken, in line with JBI and PRISMA-ScR recommendations.

2.1.6 Synthesis of results

Charted data were organized in tables and summarized using descriptive statistics and narrative synthesis. Data were grouped by key study characteristics and themes to map the breadth of evidence and highlight the patterns and gaps across the literature.

3 Results

Data presentation and interpretation were organized under the following subheadings (Table 4).

3.1 Country

The review included 17 studies in total, of which United States contributed the largest proportion (41.2%, seven studies), followed by Brazil, Canada, and India (11.8% each, two studies each), and single studies from Germany (5.9%), Lebanon (5.9%), Saudi Arabia (5.9%), and the Republic of Korea (5.9%), suggesting a gap in evidence from lower- and middle-income countries (LMIC).

3.2 Study design

When classified by study design, the largest category comprised observational, survey-based prospective studies (35.3%, six studies), conducted across multiple countries, including Canada, Brazil, South Korea, and India. Other survey-based designs, such as cross-sectional studies (11.8%, two studies) and questionnaire-based longitudinal observational studies (11.8%, two studies), were also frequently used. Cohort studies accounted for 11.8% (two studies), while before–after interventional trials also represented 11.8% (two studies), both mainly from the United States and Europe. Less frequently reported designs included a cluster-randomized trial (5.9%, one study), a qualitative phenomenological study (5.9%, one study) from Saudi Arabia, and a secondary exploratory analysis (5.9%, one study) from the United States. Overall, the evidence base is dominated by observational survey methodologies (58.9% combined), with fewer interventional and qualitative designs. This highlights a reliance on descriptive and exploratory approaches in the existing literature, with relatively limited experimental or randomized evidence to guide practice.

3.3 Religion/race/ethnicity

Of the 17 studies reviewed, only 9 (52.9%) explicitly reported the religion, race, or ethnicity of study populations. Religion was reported in four studies (23.5%), with Christianity being the most frequently cited (17.6%), followed by Islam (5.9%). Race and ethnicity were reported frequently, with White populations forming the majority (35.3%), while Hispanic/Latino populations were reported in 11.8% of studies. Other groups, including Black, Mediterranean, East Asian, non-white (general), other races, and unknown race, were each represented in a single study (5.9% each). Overall, these findings indicate limited reporting of cultural, racial, and religious characteristics, with a predominance of studies focusing on White and Christian populations. There is a clear need for studies involving populations of different religions, races, and ethnicities to better examine the influence of cultural and social determinants, highlighting a gap in the evidence.

3.4 Factors addressed

The studies were further classified according to whether they addressed cultural, socioeconomic, or both factors. Out of 17 studies, the majority (12–24) (n = 13, 76.5%) explored an interplay between cultural and socioeconomic influences on family satisfaction with ICU care. A smaller proportion of studies (25–27) (n = 3, 17.6%) focused exclusively on cultural factors, while only one study (28) (5.9%) examined socioeconomic factors in isolation. (Table 4).

3.5 Tools used

A diverse array of assessment tools was utilized across the 17 studies included in the review, with the Family Satisfaction in the Intensive Care Unit (FS-ICU) scale being the most widely employed, applied in 10 studies (58.8%) to evaluate family perspectives on ICU care and end-of-life care. Psychological distress was assessed in two studies (11.8%) using the Hospital Anxiety and Depression Scale (HADS), while bereavement stress was captured in one study using the Impact of Event Scale–Revised (IES-R). Other tools were applied in single studies (5.9% each), including the Quality of Dying and Death (QODD) questionnaire, the End-of-Life Satisfaction (EOLS) Survey, the Critical Care Family Needs Inventory (CCFNI), the Critical Care Family Satisfaction Survey (CCFSS), the Modified Patient Judgement of Hospital Quality (PJHQ) Questionnaire, the Quality of Communication (QOC) questionnaire, and a structured End-of-Life Communication tool. Additionally, one qualitative study utilized in-depth interviews.

3.6 Thematic description

Across the 17 studies reviewed, five major thematic domains emerged in relation to family satisfaction with ICU care.

3.6.1 Shared decision-making and role of communication

This was addressed in eight studies (38.1%). These investigations consistently emphasized the role of honest, consistent, and empathetic communication in shaping family satisfaction. While Curtis et al. (16) (USA) and Johnson et al. (20) (USA) demonstrated that structured communication interventions improved family engagement in care decisions, studies such as Atri et al. (13) (India), Bhatt et al. (14) (India), Chuang et al. (15) (USA), Jones et al. (21) (USA), Nayfeh et al. (27) (Canada), and Schwarzkopf et al. (24) (Germany) highlighted that communication often outweighed clinical outcomes or ICU length of stay in determining overall satisfaction.

3.6.2 Emotional, psychological, and spiritual support

Observed in four studies (19.04%), this finding highlighted the importance of addressing the family’s emotional and mental wellbeing alongside patient care. Amass et al. (12) (USA & Italy) demonstrated that structured rituals reduced post-traumatic stress in family caregivers, while Al Mutair et al. (25) (Saudi Arabia) and Hajj et al. (19) (Lebanon) highlighted the significance of spiritual and psychosocial support to the family members. Similarly, Fumis et al. (17) (Brazil) showed that open visitation policies improved family satisfaction by alleviating distress.

3.6.3 Cultural and religious sensitivity

A comparable proportion of studies (19.04%) emphasized cultural and religious sensitivity as a determinant of family satisfaction. Al Mutair et al. (25) (Saudi Arabia) highlighted the centrality of religious practices in end-of-life care for Muslim families, while Nayfeh et al. (27) (Canada) revealed differences in experiences across White, Mediterranean, and East Asian families. Min et al. (23) (South Korea) described how Confucian traditions shaped prognosis communication, and Hajj et al. (19) (Lebanon) underscored the importance of culturally attuned information sharing.

3.6.4 ICU environment and institutional policies

Reported in four studies (19.04%), Gerstel et al. (18) (USA) noted the impact of institutional culture on family perceptions, while Hajj et al. (19) (Lebanon) identified dissatisfaction with environmental comfort, particularly in waiting areas. Fumis et al. (17) (Brazil) highlighted the benefits of open visitation policies, and Johnson et al. (20) (USA) suggested that institutional reforms may be required to ensure significant improvements in family satisfaction.

3.6.5 Clinical care processes and outcomes

Addressed in four studies (19.4%), findings consistently showed that families valued aspects such as symptom management, clear communication about prognosis, and alignment of care with patient wishes over purely clinical outcomes. Heyland et al. (26) (Canada) and Curtis et al. (16) (USA) demonstrated that caregiver satisfaction correlated more strongly with communication quality than with survival outcomes. Amass et al. (12) (USA and Italy) further revealed that structured interventions could enhance alignment of care with family expectations, while Min et al. (23) (South Korea) showed that extubation practices and discontinuation of life support in the ICU influenced satisfaction with both care and decision-making.

4 Discussion

This scoping review aimed to provide a comprehensive overview by mapping global evidence on the sociocultural and economic determinants that influence family satisfaction in the context of critically ill and palliative care in the ICU. The diverse factors influencing family satisfaction are often rooted in the sociocultural context of families, which shapes their involvement in clinical care, educational status, capacity to bear healthcare expenses, and the variability of healthcare infrastructure across different global settings (13, 19, 25). These findings underscore the need to recognize and address contextual factors and to tailor strategies to the distinct needs and expectations of family members within specific healthcare environments to ensure satisfaction. Key approaches involve simple yet impactful measures, such as addressing patients’ symptom relief, creating a safe ICU environment, implementing flexible visitation policies, ensuring honest and transparent communication with families to support shared or surrogate decision-making, providing emotional support, offering palliative care interventions, and attending to spiritual needs during palliative care.

This review noted that a significant proportion of the evidence originated from the United States and Canada, accounting for approximately 53% of the total. In contrast, there was a relative paucity of data from other regions of the world, despite the considerable variations in population demographics, race and ethnicity, sociocultural contexts, and economic factors across countries. However, the mapped evidence provides valuable insights into cultural and socioeconomic factors, as described below.

4.1 Cultural aspects

Cultural factors influencing family satisfaction were assessed in 94.1% of the included studies. A consistent finding across the included studies, mainly from North American countries, was that clear and frequent communication from the healthcare team, with due attention to the family’s spiritual and cultural needs, led to higher family satisfaction (12, 20, 21). This included providing families with complete information to support structured decision-making, providing emotional and psychological support to distressed and bereaved caregivers, and ensuring access to spiritual and chaplaincy services for patients at the end of life.

4.1.1 Religious and spiritual beliefs surrounding health, illness, and death

Perceptions of families regarding health, illness, death, and grieving can be different depending on the religion and can influence family satisfaction (12, 25).

Irrespective of denomination (Catholic or Evangelical), Christians generally view illness and death not as an end, but as a passage to eternal life with God, depending on the good or bad deeds committed during one’s lifetime. Grieving families seek spiritual services, such as the presence of a pastor, to pray for the dying person and offer spiritual absolution. The sick person is anointed with holy oils and receives holy water, symbolizing the “body and blood of Christ” (29).

In Islam, illness is often viewed as a means of spiritual purification, and death is regarded as the beginning of the afterlife. In line with the “five pillars of Islam,” Muslims are encouraged to approach death with prayer, patience, recitation of the Qur’an, and reflection. Death is considered predestined, and families often strive to help their loved one recite the Shahadatain—the testimony of faith—at the end of life (25).

Similarly, Hindus see illness as a result of karma—actions from this life or past lives—and view death as a transition from one life to the next through reincarnation. Hindu families feel it is their sacred duty to assist the dying person at the end of life by reciting passages from sacred scriptures to provide spiritual comfort (30). Buddhists believe in the afterlife, with the ultimate goal of attaining “nirvana,” defined as freedom from the cycle of suffering and rebirth. Medications that can alter one’s state of mind at the end of life, such as narcotics, are often discouraged, as they may affect “one’s life transition and rebirth” (31). The available evidence predominantly reflects ICU practices and interventions from Christian-majority countries, with a noticeable focus on attending to the religious and spiritual demands of families within that context. There remains a substantial gap in research from other regions and non-Christian religious contexts, where caregiver perspectives remain underrepresented. This highlights an urgent need for prospective studies and randomized controlled trials in diverse healthcare environments to generate robust evidence to support best approaches aligned with caregivers’ local linguistic, religious, and spiritual needs.

This review also noted the positive impact of palliative care interventions directed at supporting end-of-life decision-making, resulting in higher family satisfaction (12, 13, 16, 18, 20, 27, 28). This highlights the value of integrating tailored end-of-life practices that cater to the diverse religious and spiritual requirements of families worldwide.

4.1.2 Family role and dynamics

Patient’s ICU stay is a period of emotional upheaval for the families (17, 22). “Spiral of maintaining situational awareness, cognitive integration of facts, and difficult decision making” often requires collective effort from both families and the healthcare team. Interpersonal dynamics in caregiver families also play an important role in stress coping, grieving during bereavement, and end-of-life care situations (21, 28). The composition of families, interpersonal dynamics, and expectations surrounding filial responsibility differ markedly across global regions, shaped by distinct cultural, religious, and societal frameworks (32). While studies have shown a significant association between proactive participation of more educated families in shared decision-making for ICU care planning (28), the situation differs in LMIC. Studies from LMIC (13, 14) highlight how sociocultural contexts uniquely shape family satisfaction with ICU care. Families in many LMICs often come from rural backgrounds, have lower educational attainment, and live in larger household units, which influences their expectations and interactions with treating healthcare teams (13). These factors frequently shift the burden of surrogate decision-making onto clinicians, as relatives may feel less prepared or empowered to participate in complex medical decision-making (13, 14, 19). At the same time, strong extended-family networks can provide emotional support that enhances distress coping but may also create divergent opinions that lead to conflict (13). Together, these contextual elements underscore why family satisfaction dynamics in LMICs differ significantly from those in high-income settings.

Additionally, family support systems for patient care vary considerably across the globe depending on patient companion status (single/married//divorced), cohabitation (nuclear/joint family), and family dynamics related to filial responsibilities, distress coping, and shared decision-making. As most of the existing literature originates from Western ICU settings, its relevance in other diverse healthcare setups cannot be assumed. Existing evidence remains limited in scope, and future research should focus on examining how these contextual factors influence family satisfaction in multicultural settings.

4.1.3 ICU environment and institutional policies

The ICU environment can be distressing for conscious patients and visiting family members (23–25). Noisy alarms from the monitors, the sight of multiple tubes and infusions, the physical and psychological distress of patients, and other grieving families nearby can all negatively impact a caregiver’s perception of ICU care, ultimately affecting their overall satisfaction.

However, several simple and targeted quality improvement initiatives can address these concerns and enhance satisfaction. These include ensuring optimal patient sensorium during visiting hours through appropriate sedation breaks; maintaining a calm and peaceful ICU environment during visitation periods; training bedside nurses to communicate effectively with families and address their queries; promptly attending to patients’ physical and psychological needs; providing comfortable and private spaces for grieving families; implementing flexible visitation hours to support family involvement; and creating a well-maintained and supportive ICU waiting room environment (13, 14, 17, 22, 25, 26). Additionally, timely multidisciplinary family meetings, early integration of end-of-life care services for terminally ill patients, and the presence of a dedicated medical social worker or psychologist to support distressed or grieving families are crucial steps toward delivering truly patient- and family-centered care (21, 22).

4.2 Socioeconomic aspects

4.2.1 Healthcare expenditure and insurance coverage

Financial burden associated with ICU care, such as high treatment costs and long-term financial repercussions, can negatively affect family satisfaction, especially when there is a significant gap between medical costs and insurance coverage (33, 34). There is considerable variation in public awareness of healthcare expenditure and in the proportion of a nation’s gross domestic product (GDP) allocated to healthcare. These disparities can significantly impact out-of-pocket expenses (OOPEs) for caregivers and adversely affect overall family satisfaction with care (34). Caregivers may also face loss of income, as they are required to remain with patients in the hospital for prolonged periods, further increasing their financial burden.

This review identified significant gaps and a lack of evidence specifically examining the economic factors that influence family satisfaction with ICU care, thereby overlooking several important dimensions. Family satisfaction with healthcare can vary significantly in countries such as India and Lebanon (with healthcare spending of 3.3 and 6% of gross domestic product, respectively, and less developed government or private insurance coverage supplementation) as compared to nations such as the United States and Canada (with higher health expenditure—approximately 17 and 12.3% of GDP, respectively—well-supported universal or mandated coverage systems) (35). In settings with low public awareness of healthcare costs and limited government-sponsored health coverage, families often face highly variable and sometimes catastrophic OOPEs. The wide rich–poor divide in LMICs further amplifies these disparities, leaving vulnerable families particularly exposed during episodes of critical illness. Strengthening government-backed comprehensive health coverage and improving public understanding of financial risk protection mechanisms are, therefore, crucial steps in the LMIC context. Such measures can substantially enhance family satisfaction by reducing financial distress during ICU admissions.

There is an urgent necessity for high-quality research that specifically explores how financial burden influences caregiver satisfaction with ICU care, especially in LMICs. Such evidence is essential for policymakers at both national and international levels.

4.2.2 Educational aspects

Active family participation in ICU decision-making depends on various factors such as caregivers’ educational status, understanding of the illness, and the number of decision-makers in the family. This review noted that young, educated relatives of patients often require clear, honest, and frequent communication from the healthcare team to support shared decision-making (19, 26). In contrast, less educated families often prefer the treating team to make surrogate decisions on their behalf (13, 14). Novel interventions, such as educational initiatives for the families of ICU patients regarding the ICU environment, routine ICU procedures, the multidisciplinary team approach for patient care, infection control, end-of-life care, and common issues such as pain and sedation, have shown promise in reducing anxiety and improving family satisfaction (36). However, more studies are required to explore approaches that improve family satisfaction across diverse educational backgrounds.

4.3 Strengths and limitations

This scoping review’s strength lies in its detailed and comprehensive approach. It uniquely considers the geographical, economic, sociocultural, and religious contexts in which care is delivered. The facilitation of respectful and meaningful terminal care through palliative, comfort-based services in ICUs has been gaining global attention. This review represents one of the first comprehensive efforts to evaluate how end-of-life care practices affect family satisfaction within varying sociocultural and spiritual frameworks. A rigorous search strategy, using carefully constructed search terms across five major databases, further broadened the scope and depth of this review. This review also had several limitations. The literature review revealed that a significant proportion of the evidence originated in North America, potentially limiting the generalizability of the findings to other regions. Additionally, the review was limited to studies published in English, potentially overlooking relevant studies in other languages. The included studies were heterogeneous, encompassing diverse methodologies, from randomized controlled trials and observational studies to qualitative research, and were subject to inherent methodological limitations. Measures of family satisfaction with ICU care varied considerably, ranging from objective tools such as the FS-ICU, CCFNI, and IES-R scales to qualitative approaches, such as family interviews. Finally, despite comprehensive efforts to develop an inclusive search strategy, it is possible that some pertinent studies were unintentionally overlooked.

4.4 Policy and practice implications

This scoping review provides insights to guide the development of future practice and policy measures at multiple levels, as outlined below.

• At the individual level:

Clinician training to recognize diverse religious beliefs, cultural norms, and family expectations surrounding illness and death.

Use of culturally appropriate language and communication strategies during family meetings.

Implementation of structured assessment frameworks to routinely assess sociocultural and economic factors that affect families’ perceptions and satisfaction with ICU care (such as religious needs, healthcare cost constraints, decision-making capacity, and stress-coping mechanisms).

Tailoring decision-making discussions based on the family’s preferred level of involvement, filial responsibilities, literacy, and stress-coping abilities.

Provision of social work consultations and financial counseling for psychological and economic support.

• At the institutional level:

Implementation of flexible ICU visitation policies that align with patient and family needs.

Creation of a supportive ICU environment by providing waiting areas with amenities, private rooms for family discussions, and quiet spaces for prayer.

Establishment of feedback systems for families to report concerns, dissatisfaction, or cultural mismatches and use of these data for continuous quality improvement in family-centered ICU care.

Incorporation of communication skills training and cultural competence as a part of capacity-building initiatives.

• At the national policy level:

Strengthening national healthcare coverage through policies that guarantee access to essential medical services, thereby reducing financial barriers to ICU care.

5 Conclusion

Holistic, patient- and family-centered care in the ICU has become an urgent priority worldwide. When evaluating caregiver satisfaction in the ICU, it is essential to consider the influence of diverse cultural, religious, and socioeconomic contexts. However, there remains a critical lack of evidence from LMICs, limiting the ability to fully inform and guide practice in these settings.

References

• 1.

  Azoulay E Pochard F Kentish-Barnes N Chevret S Aboab J Adrie C et al . Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. (2005) 171:987–94. doi: 10.1164/rccm.200409-1295OC,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 2.

  Pochard F Azoulay E Chevret S Lemaire F Hubert P Canoui P et al . Symptoms of anxiety and depression in family members of intensive care unit patients: ethical hypothesis regarding decision-making capacity. Crit Care Med. (2001) 29:1893–7. doi: 10.1097/00003246-200110000-00007,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 3.

  Davidson JE Aslakson RA Long AC Puntillo KA Kross EK Hart J et al . Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Crit Care Med. (2017) 45:103–28. doi: 10.1097/CCM.0000000000002169

  • CrossRef
  • Google Scholar

• 4.

  Secunda KE Kruser JM . Patient-centered and family-centered care in the intensive care unit. Clin Chest Med. (2022) 43:539–50. doi: 10.1016/j.ccm.2022.05.008

  • CrossRef
  • Google Scholar

• 5.

  Curtis JR Engelberg RA Wenrich MD Shannon SE Treece PD Rubenfeld GD . Missed opportunities during family conferences about end-of-life care in the intensive care unit. Am J Respir Crit Care Med. (2005) 171:844–9. doi: 10.1164/rccm.200409-1267OC

  • CrossRef
  • Google Scholar

• 6.

  Loving BA Hazy AJ Salari KF Ye H Sivapalan S Oyeniyi JF et al . Socioeconomic disadvantage and its impact on patient satisfaction at a multi-site radiation oncology center. Tech Innov Patient Support Radiat Oncol. (2024) 32:100276. doi: 10.1016/j.tipsro.2024.100276

  • CrossRef
  • Google Scholar

• 7.

  Maharlouei N Md Akbari M PhD Akbari M Ms Lankarani KB Md . Socioeconomic Status and Satisfaction with Public Healthcare System in Iran. Int J Community Based Nurs Midwifery. (2017) 1:22–29.

  • Google Scholar

• 8.

  United Nations . Transforming our world: the 2030 agenda for sustainable development. United Nations. 2025. Available online at: https://sdgs.un.org/2030agenda (Accessed September, 2025).

  • Google Scholar

• 9.

  Peters MDJ Marnie C Tricco AC Pollock D Munn Z Alexander L et al . Updated methodological guidance for the conduct of scoping reviews. JBI Evid Synth. (2020) 18:2119–26. doi: 10.11124/JBIES-20-00167

  • CrossRef
  • Google Scholar

• 10.

  Tricco AC Lillie E Zarin W O’Brien KK Colquhoun H Levac D et al . PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. (2018) 169:467–73. doi: 10.7326/M18-0850

  • CrossRef
  • Google Scholar

• 11.

  Ouzzani M Hammady H Fedorowicz Z Elmagarmid A . Rayyan—a web and mobile app for systematic reviews. Syst Rev. (2016) 5:210. doi: 10.1186/s13643-016-0384-4

  • CrossRef
  • Google Scholar

• 12.

  Amass TH Villa G S OM Badger JM Mc Fadden R Walsh T et al . Family care rituals in the ICU to reduce symptoms of post-traumatic stress disorder in family members—a multicenter, multinational, before-and-after intervention trial. Crit Care Med. (2020) 48:176–84. doi: 10.1097/CCM.0000000000004113,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 13.

  Atri V Bhatt MT Chaudhuri S Mitra A Maddani SS Ravindranath S . Family’s perceived needs and satisfaction with intensive care services: a questionnaire-based prospective observational study. Indian J Crit Care Med. (2024) 28:483–94. doi: 10.5005/jp-journals-10071-24621,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 14.

  Bhatt MT Chaudhuri S Ravindranath S Atri V Maddani SS Vishwas P et al . Impact of shared decision-making on family satisfaction with intensive care services: “share with care” has a new meaning in ICU. Am J Hosp Palliat Med. (2024) 42:889–98. doi: 10.1177/10499091241287861

  • CrossRef
  • Google Scholar

• 15.

  Chuang E Fiter RJ Sanon OC Wang A Hope AA Schechter CB et al . Race and ethnicity and satisfaction with communication in the intensive care unit. Am J Hosp Palliat Care. (2020) 37:823–9. doi: 10.1177/1049909120916126,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 16.

  Curtis JR Nielsen EL Treece PD Downey L Dotolo D Shannon SE et al . Effect of a quality-improvement intervention on end-of-life Care in the Intensive Care Unit. Am J Respir Crit Care Med. (2011) 183:348–55. doi: 10.1164/rccm.201006-1004OC

  • CrossRef
  • Google Scholar

• 17.

  Fumis RRL Ranzani OT Faria PP Schettino G . Anxiety, depression, and satisfaction in close relatives of patients in an open visiting policy intensive care unit in Brazil. J Crit Care. (2015) 30:440.e1–6. doi: 10.1016/j.jcrc.2014.11.022

  • CrossRef
  • Google Scholar

• 18.

  Gerstel E Engelberg RA Koepsell T Curtis JR . Duration of withdrawal of life support in the intensive care unit and association with family satisfaction. Am J Respir Crit Care Med. (2008) 178:798–804. doi: 10.1164/rccm.200711-1617OC,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 19.

  Hajj M Gulgulian T Haydar L Saab A Dirany F Badr LK . The satisfaction of families in the care of their loved ones in CCUs in Lebanon. Nurs Crit Care. (2015) 22:203–11. doi: 10.1111/nicc.12195,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 20.

  Johnson JR Engelberg RA Nielsen EL Kross EK Smith NL Hanada JC et al . The Association of Spiritual Care Providers’ activities with family members’ satisfaction with care after a death in the ICU. Crit Care Med. (2014) 42:1991–2000. doi: 10.1097/CCM.0000000000000412,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 21.

  Jones C Puntillo K Donesky D McAdam JL . Family members’ experiences with bereavement in the intensive care unit. Am J Crit Care. (2018) 27:312–21. doi: 10.4037/ajcc2018262

  • CrossRef
  • Google Scholar

• 22.

  Midega TD Oliveira HSBD Fumis RRL . Satisfaction of family members of critically ill patients admitted to a public hospital intensive care unit and correlated factors. Rev Bras Ter Intensiva. (2019) 31:147–55. doi: 10.5935/0103-507X.20190024,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 23.

  Min J Kim Y Lee JK Lee H Lee J Kim KS et al . Survey of family satisfaction with intensive care units: a prospective multicenter study. Medicine. (2018) 97:e11809. doi: 10.1097/MD.0000000000011809,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 24.

  Schwarzkopf D Behrend S Skupin H Westermann I Riedemann NC Pfeifer R et al . Family satisfaction in the intensive care unit: a quantitative and qualitative analysis. Intensive Care Med. (2013) 39:1071–9. doi: 10.1007/s00134-013-2862-7,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 25.

  Al Mutair A Al Shaer A Al Ghamdi F Al Ghamdi A . The experiences of Muslim family members of critically ill patients during end-of-life care in Saudi Arabia: a qualitative phenomenological study. Clin Nurs Res. (2018) 29:375–81. doi: 10.1177/1054773818788969

  • CrossRef
  • Google Scholar

• 26.

  Heyland DK Rocker GM Dodek PM Kutsogiannis DJ Konopad E Cook DJ et al . Family satisfaction with care in the intensive care unit: results of a multiple center study. Crit Care Med. (2002) 30:1413–8. doi: 10.1097/00003246-200207000-00002,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 27.

  Nayfeh A Yarnell CJ Dale C Conn LG Hales B Gupta TD et al . Evaluating satisfaction with the quality and provision of end-of-life care for patients from diverse ethnocultural backgrounds. BMC Palliat Care. (2021) 20:145. doi: 10.1186/s12904-021-00841-z,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 28.

  Kaufer M Murphy P Barker K Mosenthal A . Family satisfaction following the death of a loved one in an Inner City MICU. Am J Hosp Palliat Med. (2008) 25:318–25. doi: 10.1177/1049909108319262,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 29.

  Sharma H Jagdish V Anusha P Bharti S . End-of-life care: Indian perspective. Indian J Psychiatry. (2013) 55:293. doi: 10.4103/0019-5545.105554

  • CrossRef
  • Google Scholar

• 30.

  Firth S . End-of-life: a Hindu view. Lancet. (2005) 366:682–6. doi: 10.1016/S0140-6736(05)67141-3,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 31.

  Bauer-Wu S Barrett R Yeager K . Spiritual perspectives and practices at the end-of-life: a review of the major world religions and application to palliative care. Indian J Palliat Care. (2007) 13:53. doi: 10.4103/0973-1075.38900

  • CrossRef
  • Google Scholar

• 32.

  Wu X Tang Y Chen J . The Association of Filial Piety and Financial Toxicity with Surrogate Decisional Conflict among Adult Children of ICU patients with Cancer. J Pain Symptom Manag. (2025) 70:437–46. doi: 10.1016/j.jpainsymman.2025.07.023,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 33.

  Kamath S Jeffin Maliyekkal Raj A Varshini RJ Brand H Sirur A et al . Understanding out-of-pocket expenditure in India: a systematic review. Front Public Health. (2025) 13:1594542. doi: 10.3389/fpubh.2025.1594542

  • CrossRef
  • Google Scholar

• 34.

  Reshmi B Unnikrishnan B Rajwar E Parsekar SS Vijayamma R Venkatesh BT . Impact of public-funded health insurances in India on health care utilisation and financial risk protection: a systematic review. BMJ Open. (2021) 11:e050077. doi: 10.1136/bmjopen-2021-050077

  • CrossRef
  • Google Scholar

• 35.

  Giplaye H . Healthcare delivery system in developed, developing and underdeveloped countries. Texila Int J Nurs. (2019) 2019:1–7. doi: 10.21522/TIJNR.2015.SE.19.01.Art009,

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 36.

  Haack TDSR Rosa RG Teixeira C Sganzerla D Robinson CC Eugênio CS et al . Does an educational website improve psychological outcomes and satisfaction among family members of intensive care unit patients?Crit Care Sci. (2023) 35:31–6. doi: 10.5935/2965-2774.20230113-en

  • CrossRef
  • Google Scholar