Setting Up a Just and Fair ICU Triage Process during a Pandemic: A Systematic Review

Triage is a dynamic and complex decision-making process to determine fair access to medical care in mass casualty situations. Triage takes place through healthcare settings including Intensive Care Units (ICUs). Triage governing principles have been subject to ethical debates for a long time specifically with the recent global pandemic of COVID-19. This study aims to revisit the ethical principles guiding patient prioritisation during recent COVID-19 disaster triage in the Indian subcontinent and attempts to look for principles with consideration of social justice.

Key electronic databases such as WHO, EMBASE, and DOAJ were used to access published literature relating to ICU triage in the Indian subcontinent. Literature on and from 2015-2022 were included in this study. The SPICE framework was used to identify the literature. The Inclusion criteria were as follows: Literature with ethical connotations focusing on India and neighbouring countries, and in an ICU setting during pandemics. The Exclusion criteria were as follows: Literature focusing on other countries, without ethical foundations, hospital admissions, and non-COVID-19 ICU admissions. The PRISMA standard was applied to screen the appropriate literature. The BOOLEAN operator "OR" was used to enhance the literature search. Finally, six papers were found suitable for this study and thus were included in the literature review. Additionally, for the second time, the frequency of certain ethical phrases was reassessed in the plans and guidelines to check the changed awareness of ethical pandemic planning, if any. A thematic analysis was applied to analyse the data and generate findings and new knowledge.

The findings highlight gaps in knowledge around ICU triaging in the region which indicates the scope of better ethical pandemic preparation at the regional level. The findings show that there is a debate between researchers on prioritisation from available resources and ethical perspectives and principles associated with fair access to healthcare even during pandemic times. The literature also highlights enhancing the regional capacity and building equitable approaches to reduce existing health inequities and the need of the social justice framework for ICU triaging during a pandemic.

ICU triaging in five South Asian neighbour nations was studied for the presence of a guided ethical framework. Additionally, for the second time, certain ethical phrases were reassessed in the plans and guidelines; however, usage of those terms was found to be significantly low. The discussion shows that the plans and guidelines have the scope to improve ethical ICU triaging in these countries and in the specific region. After analysing different ethical guidelines, this study emphasises that there is a need for a just and fair framework, specifically a social justice framework in ICU triage in the subcontinent to address the underlying health inequities.