{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,12]],"date-time":"2026-09-12T16:09:31Z","timestamp":1789229371133,"version":"build-2803163510"},"reference-count":25,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2026,3,30]],"date-time":"2026-03-30T00:00:00Z","timestamp":1774828800000},"content-version":"unspecified","delay-in-days":29,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100009104","name":"Department of Health Research, India","doi-asserted-by":"publisher","award":["DHR\u2013ICMR Young Faculty PhD Program (2024-25)"],"award-info":[{"award-number":["DHR\u2013ICMR Young Faculty PhD Program (2024-25)"]}],"id":[{"id":"10.13039\/501100009104","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,3,10]]},"published-print":{"date-parts":[[2026,3]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Intensive care units (ICUs) operate at the intersection of advanced technology, complex ethical decision-making and resource-intensive care. While many high-income countries have developed institutional governance mechanisms\u2014such as Clinical Ethics Committees, structured triage policies and formal palliative care consultation pathways\u2014to support ethical deliberation and accountability in ICUs, the applicability, structure and reported outcomes of such frameworks in low- and middle-income countries (LMICs) remain unclear and dispersed across disciplines.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>This scoping review aims to map existing governance frameworks and ethical decision-making models guiding ICU practices globally, with particular attention to their relevance and reported application in LMIC contexts.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>The review will follow the Joanna Briggs Institute methodology and be reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) standards. Searches will be conducted across MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Scopus, Web of Science, PsycINFO and Global Health. Grey literature will be identified through Google Scholar, WHO Global Index Medicus and professional society websites (eg, Indian Society of Critical Care Medicine (ISCCM), Indian Association of Palliative Care (IAPC) and European Society of Intensive Care Medicine (ESICM)). Eligible sources will include empirical research, policy documents, guidelines and institutional reports published in English from 2000 onwards. Data will be charted using a structured template and synthesised through descriptive mapping and thematic analysis across domains, including structural design, decision processes, communication pathways, integration with palliative care, ethical-legal considerations and reported outcomes. The review is planned to be conducted between December 2025 and April 2026, including database searches, screening, data extraction and synthesis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethics and dissemination<\/jats:title>\n                    <jats:p>\n                      Ethical approval is not required. Findings will be disseminated through peer-reviewed publications and conference presentations. OSF registration:\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/osf.io\/tkcav\">https:\/\/osf.io\/tkcav<\/jats:ext-link>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2026-117708","type":"journal-article","created":{"date-parts":[[2026,3,31]],"date-time":"2026-03-31T04:55:38Z","timestamp":1774932938000},"page":"e117708","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Governance frameworks and decision-making models for intensive care units in low- and middle-income countries: a scoping review protocol"],"prefix":"10.1136","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9975-2568","authenticated-orcid":false,"given":"Arunangshu","family":"Ghoshal","sequence":"first","affiliation":[{"name":"Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India- 576104"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4469-0846","authenticated-orcid":false,"given":"Anuja","family":"Damani","sequence":"additional","affiliation":[{"name":"Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India- 576104"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shwethapriya","family":"Rao","sequence":"additional","affiliation":[{"name":"Department of Critical Care, Kasturba Medical College,Manipal Academy of Higher Education, Manipal, Karnataka, India- 576104"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cherian","family":"Varghese V","sequence":"additional","affiliation":[{"name":"Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India- 576104"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Naveen","family":"Salins","sequence":"additional","affiliation":[{"name":"Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India- 576104"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,3,30]]},"reference":[{"key":"2026033021551281000_16.3.e117708.1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jcrc.2006.09.008"},{"key":"2026033021551281000_16.3.e117708.2","unstructured":"Rubenfeld GD . The structure of intensive care. In: Sibbald WJ , Bion JF , eds. Evaluating critical care: using health services research to improve quality. Berlin, Heidelberg: Springer, 2002: 23\u201340."},{"key":"2026033021551281000_16.3.e117708.3","doi-asserted-by":"publisher","DOI":"10.1177\/096853320700800302"},{"key":"2026033021551281000_16.3.e117708.4","doi-asserted-by":"crossref","unstructured":"Sarto F . Hospital governance. In: Encyclopedia of sustainable management. Cham: Springer, 2023: 1875\u201382.","DOI":"10.1007\/978-3-031-25984-5_882"},{"key":"2026033021551281000_16.3.e117708.5","doi-asserted-by":"crossref","unstructured":"Parkin M , Quinn T . Patient safety and clinical governance. In: Tubaro M , Vranckx P , Bonnefoy-Cudraz E , et al , eds. The ESC textbook of intensive and acute cardiovascular care. Oxford University Press, 2021.","DOI":"10.1093\/med\/9780198849346.003.0005"},{"key":"2026033021551281000_16.3.e117708.6","unstructured":"Pastores SM , Kvetan V . Governance. In: Oropello JM , Pastores SM , Kvetan V , eds. Critical care. New York, NY: McGraw-Hill Education 1 AD, 2017."},{"key":"2026033021551281000_16.3.e117708.7","doi-asserted-by":"crossref","first-page":"154981","DOI":"10.1016\/j.jcrc.2024.154981","article-title":"The interplay between organizational culture and burnout among ICU professionals: A cross-sectional multicenter study","volume":"85","author":"Kok","year":"2025","journal-title":"J Crit Care"},{"key":"2026033021551281000_16.3.e117708.8","doi-asserted-by":"crossref","DOI":"10.1186\/s13054-020-2784-z","article-title":"Burnout and Joy in the Profession of Critical Care Medicine","volume":"24","author":"Kerlin","year":"2020","journal-title":"Crit Care"},{"key":"2026033021551281000_16.3.e117708.9","doi-asserted-by":"publisher","DOI":"10.1136\/jme.27.suppl_1.i36"},{"key":"2026033021551281000_16.3.e117708.10","doi-asserted-by":"crossref","first-page":"759","DOI":"10.31729\/jnma.3703","article-title":"An Audit of An Intensive Care Unit of A Tertiary Care Hospital","volume":"56","author":"Acharya","year":"2018","journal-title":"JNMA J Nepal Med Assoc"},{"key":"2026033021551281000_16.3.e117708.11","doi-asserted-by":"crossref","first-page":"412","DOI":"10.25259\/IJPC_267_2022","article-title":"Initiation of Palliative Care Referral from the Intensive Care Unit for Advanced Stage Metastatic Cancer Patients: A Quality Improvement Process from a Tertiary Referral Cancer Institute from South India","volume":"29","author":"Balakrishna","year":"2023","journal-title":"Indian J Palliat Care"},{"key":"2026033021551281000_16.3.e117708.12","doi-asserted-by":"crossref","first-page":"15","DOI":"10.5005\/ijccm-17-S1-15","article-title":"Critical care delivery in intensive care units in India: Defining the functions, roles and responsibilities of a consultant intensivist","volume":"17","author":"Divatia","year":"2020","journal-title":"Indian J Crit Care Med"},{"key":"2026033021551281000_16.3.e117708.13","doi-asserted-by":"crossref","first-page":"216","DOI":"10.4103\/0972-5229.180042","article-title":"Intensive Care in India: The Indian Intensive Care Case Mix and Practice Patterns Study","volume":"20","author":"Divatia","year":"2016","journal-title":"Indian J Crit Care Med"},{"key":"2026033021551281000_16.3.e117708.14","doi-asserted-by":"crossref","first-page":"1093","DOI":"10.5005\/jp-journals-10071-23965","article-title":"Intensive Care in India in 2018\u20132019: The Second Indian Intensive Care Case Mix and Practice Patterns Study","volume":"25","author":"Divatia","year":"2022","journal-title":"Indian J Crit Care Med"},{"key":"2026033021551281000_16.3.e117708.15","doi-asserted-by":"crossref","DOI":"10.1186\/s40560-021-00574-4","article-title":"The story of critical care in Asia: a narrative review","volume":"9","author":"Phua","year":"2021","journal-title":"J Intensive Care"},{"key":"2026033021551281000_16.3.e117708.16","doi-asserted-by":"crossref","first-page":"76","DOI":"10.4103\/0972-5229.114822","article-title":"Economic analysis of costs associated with a Respiratory Intensive Care Unit in a tertiary care teaching hospital in Northern India","volume":"17","author":"Shweta","year":"2013","journal-title":"Indian J Crit Care Med"},{"key":"2026033021551281000_16.3.e117708.17","doi-asserted-by":"crossref","first-page":"237","DOI":"10.5005\/jp-journals-10071-24442","article-title":"Need Analysis of Indian Critical Health Care Delivery in Government Sectors and Its Impact on the General Public: A Time to Revamp Public Health Care Infrastructure","volume":"27","author":"Prabu","year":"2023","journal-title":"Indian J Crit Care Med"},{"key":"2026033021551281000_16.3.e117708.18","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1017\/S0266462316000398","article-title":"Cost of intensive care in India","volume":"32","author":"Peter","year":"2016","journal-title":"Int J Technol Assess Health Care"},{"key":"2026033021551281000_16.3.e117708.19","first-page":"554","article-title":"Initiating and Documenting Goals of Care Discussion in Patients with Advanced Pancreatic and Colorectal Cancers: A Quality Improvement Project in a Low Resource Setting","volume":"6","author":"Joseph Thangasamy","year":"2025","journal-title":"Palliat Med Rep"},{"key":"2026033021551281000_16.3.e117708.20","doi-asserted-by":"crossref","first-page":"200","DOI":"10.5005\/jp-journals-10071-24661","article-title":"Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit","volume":"28","author":"Mani","year":"2024","journal-title":"Indian J Crit Care Med"},{"key":"2026033021551281000_16.3.e117708.21","doi-asserted-by":"crossref","unstructured":"Sasidharan S , Dhillon H . Ethics of Futile Care: Who Decides When Enough Is Enough?-A Commentary From the Indian Context on Moral Distress in ICU Staff. 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