Understanding Decision-Making Dynamics Among Families of Frail Elderly ICU Patients: A Qualitative Study

Family members of frail elderly intensive care unit (ICU) patients shoulder complex surrogate decisions under prognostic uncertainty, cultural expectations and moral strain-particularly in Middle Eastern settings where collective responsibility and religion shape choices.

To explore how families experience and navigate ICU decision-making for frail elderly relatives and to identify culturally distinctive mechanisms.

Qualitative descriptive study using reflexive thematic analysis.

Fifteen Arabic-language, in-depth interviews (45-90 min) with family decision-makers in Saudi Arabia were audio-recorded, transcribed, translated and analysed following Braun and Clarke's six phases. Rigour was supported by memoing, interpretive meetings and an audit trail. Sample adequacy was justified via information power (sufficiency at n = 13 with two confirming interviews). Three themes emerged: (1) Burden of Decision-emotional paralysis, moral ambivalence about withholding/withdrawing life-sustaining treatment and episodic isolation within surrogate roles; (2) Consultative Family Deliberation (shūrā)-distributed roles, intergenerational negotiation and prioritisation of family harmony; and (3) Faith-Driven Acceptance-tawakkul (trust in divine will), prayer/ritual as anchors and reframing death as a spiritual transition rather than treatment failure. Frailty (Clinical Frailty Scale ≥ 5) heightened uncertainty and, for some, oriented preferences towards comfort-focused care.

Family decision-making for frail elderly ICU patients is culturally embedded, relational and spiritually mediated.

Nurse-led, culturally responsive supports-structured inclusive family meetings, Arabic values-clarification aids and facilitation of spiritual needs-may reduce decisional burden, enhance trust and align care with family values.