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

Introduction: 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. Methods: 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. Results: 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. Conclusions: 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.


Introduction
The literature on pandemic planning and responses suggests that response to public health emergencies should be guided by specific ethical norms and considerations, in addition to medical and military logistical skills [1,2].Lessons learned from past pandemics and epidemics such as SARS (2003) have demonstrated the reasons for and ways in which incorporating ethical concerns into pandemic plans and policies may have made and can still make a substantial impact in resolving many ethical issues that a pandemic crisis may present.Researchers have argued that there are ethical concerns identified in almost every aspect of pandemic planning, including allocating healthcare resources, prioritising the distribution of services, resolving conflicts between patient and community rights, and balancing healthcare workers' professional and personal obligations.The World Health Organisation's [3] guidance document "Ethical considerations in developing a public health response to pandemic influenza" was created to help member states include ethical values and considerations in pandemic planning.There were several alleged advantages of incorporating moral principles into pandemic response plans, from lowering death rates to increasing public collaboration [1,4].Nonetheless, a study demonstrated that differential pandemic planning existed, and ethical value inclusion also varied between countries; some made notable efforts to include ethical principles in their pandemic plans and policies, while others lagged behind [5].
The study conducted from 2009 to 2011 [1] in the context of South Asian nations, specifically India, Nepal, Bangladesh, and Sri Lanka, revealed that while many nations had actually been able to put together a national pandemic plan or draft during the last pandemic, the use of ethical language and the process of including ethical values or considerations in their pandemic plans and policies were at an early stage.India, for instance, experienced A H5N1 (Avian Influenza, 2006-2006) and A H1N1 (Human Influenza, 2009) and created two plans: the Influenza Pandemic Preparedness and Response Plan to mitigate avian influenza in 2005 and the Action Plan, Pandemic Preparedness and Response for Managing Novel Influenza (AH1N1) (earlier called Swine flu) (or that arising from any other novel strain of Influenza) in 2009.However, a study revealed that India used shockingly little ethical language, far less than some of its much smaller bordering countries.Additionally, both the Indian pandemic plans [2005,2009] acknowledged the livelihood risks and the vulnerability of the immune-compromised people, but had the oversight of the Social Determinants of Health (SDH), and the heightened risk of excess morbidity and mortality due to the SDH among certain social and economic strata of the society during the pandemics [1].The 2009-2011 study maintained that within these lacunae lay the scope of health inequities, which needed to be addressed urgently.It argued that in order to address these lacunae, and particularly to address the need for extending equitable protection to those who may need it most, pandemic planning in India should take guidance from the ethical precepts of social justice theories.With this backdrop, the present study revisits the ethical principles guiding patient prioritisation during disaster triage in the Indian subcontinent and attempts to look for triaging principles with consideration of social justice in the Indian subcontinent.
Triage is a dynamic and complex decision-making process to prioritise access to medical care, both healthcare treatments and hospital care.It involves an ethical element to secure fair access to available healthcare facilities and resources and has been the subject of many debates [6].Intensive Care Units (ICUs) might be considered as free from triage due to the sensitivity and criticality of patient conditions; however, triage was actually conducted in ICUs during COVID-19 pandemic where these units were overwhelmed with critical cases and resources were limited despite the pandemic preparedness of countries [7].A deeper look into the ICU triaging principles revealed that countries developed ICU guidelines to deal with mass casualties and with a great variance in principles: saving the maximum number of lives through medical prognosis, adopting age, life expectancy, quality of life, etc. [7].This variance had been a concern for some researchers as the adopted triage process had overlooked the existing health inequities and contributed to widening the health gap in societies [8].
With the backdrop of COVID-19 in the Indian subcontinent, this study revisits the ethical pandemic planning in the subcontinent with specific focus on the guidelines and guiding ethical principles for ICU triaging.

Methodology and Protocol
This study is founded on qualitative research based on secondary data.The literature was searched for using the following: (a) electronic databases (see Table 1); (b) reference lists of included articles; (c) national and regional pandemic guidelines and policies; (d) ministry/department of health websites of India, Nepal, Bangladesh, Sri Lanka, Pakistan, and Bhutan (the Bhutan plan was finally excluded for non-availability on the website) for pandemic preparedness documents; and (e) grey literature [9][10][11][12][13][14]. Search keywords included but were not limited to "COVID 19"; "Critical Care"; "Ethics"; "ICU"; "Pandemic"; "Prioritisation"; "Rationing"; "Social Justice"; "Sub-continent"; and "Triage" and included Boolean operators "AND" and "OR".
Setting (S), Population (Perspective), Intervention (I), Comparator (C), Evaluation (E) or the SPICE framework was used to identify the literature.Preferred Studying Items for Systematic Reviews [15,16] and Meta Analysis (PRISMA) (Figure 1) standard was applied to screen the appropriate literature.The relevant literature search has been limited to only English language articles published between 2015-2022; literature with explicit mention of ethical guidelines used for pandemic triage was included.The initial search identified 226 articles and after initial screening, 140 articles were included in this study.The application of inclusion and exclusion criteria led to 59 articles which were then included for eligibility assessment.With the removal of duplicates, 40 articles were included after the initial screening (Table 1).Total following removal of duplicates and application of inclusion/exclusion criteria 59 40 The final assessment, after screening and eligibility check, resulted in n = 6 with n = 53 being excluded for not having a focus on Indian subcontinent and/or not referring to ethical ICU triage as shown in Figure 1.

Data Abstraction and Synthesis
Data were abstracted, drafted, and refined.Two kinds of methods were used for data abstraction: (a) identifying the literature prioritising the ICU triage process in the South Asian context and conducting a critical appraisal, and (b) reviewing the ethical contents in the country-specific documents as sourced from the governmental websites.The tables were cross checked twice to achieve consistency and to add missing information (e.g., Reference Location; Need of ethics for ICU triage; Ethical Framework; and Open and Transparent Protocol for ICU).Table 2 summarises this abstraction and Table 3 summarises the general critical appraisal.Since the methodology also involved the exclusion criteria, Table A1 summarises the articles with the justified usage of the exclusion criteria.The final assessment, after screening and eligibility check, resulted in n = 6 with n = 53 being excluded for not having a focus on Indian subcontinent and/or not referring to ethical ICU triage as shown in Figure 1.

Data Abstraction and Synthesis
Data were abstracted, drafted, and refined.Two kinds of methods were used for data abstraction: (a) identifying the literature prioritising the ICU triage process in the South Asian context and conducting a critical appraisal, and (b) reviewing the ethical contents in the country-specific documents as sourced from the governmental websites.The tables were cross checked twice to achieve consistency and to add missing information (e.g., Reference Location; Need of ethics for ICU triage; Ethical Framework; and Open and Transparent Protocol for ICU).Table 2 summarises this abstraction and Table 3 summarises the general critical appraisal.Since the methodology also involved the exclusion criteria, Table A1 summarises the articles with the justified usage of the exclusion criteria.Due to the heterogeneity of data resulting from the scoping searches, a narrative (thematic) synthesis and qualitative appraisal was undertaken.Table 2 presents the summary of these.
Table 2 summarises to what extent the referred guides agree and disagree on the broad themes about ICU triage and admissions.This abstraction and broad thematic analysis were needed to proceed further with the critical appraisal and in-depth thematic analysis.

Critical Appraisal
Collected data have been appraised for methodological and quality assessment according to Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II) [17].AGREE II was adopted for critical quality appraisal of documents for (a) it is designed to assess guidelines developed by local, regional, national, or international groups or affiliated governmental organisations; (b) it is generic and can be applied to guidelines in any health or disease area targeting any step in the healthcare continuum, including those for health promotion, public health, screening, diagnosis, treatment, or intervention [18].Scores were used on the main guidelines, policies, and plans to calculate domain scores for AGREE II.A score of 1 was used to indicate the presence of information in the guidelines (see Table 3).Table 3 summarises the critical appraisal with appraiser score, and it highlights that Nepal and Pakistan guidelines score better than the other neighbouring countries.
The second approach was to review the ethical contents in the country-specific documents as sourced from official websites.A previous study [5] identified the existence of few ethical terms in the South Asian influenza pandemic plans.This study further investigates if those ethical terms/expressions have been used to deal with the ICU triage process during the COVID-19 pandemic and if there is any enhanced awareness and consideration of the social justice framework.Table A5 summarises the findings from this study, whereas previous findings have been reported in Tables A2-A4.Sentences containing the ethical phrases of concern were extracted first.They were further investigated to see if the terms were employed with an ethical meaning in their respective contexts.That is, in addition to a mechanical key term search, the usage of the terms was subjected to a semantic assessment to determine whether or not it has ethical value in its particular context.When no such significance was discovered, this was also reported in this study.The analysis also omitted partial occurrences of terms in separate words.The terms "moral" in the "femoral", "fair" in the "affair", "ICU" in "difficulties", and "open" in "propensity", for example, were eliminated from this study, in addition to phrases with primarily medical/clinical implications.For instance, "exhaled air spreads through. .." was omitted.Extracted phrases were appraised for their ethical meanings for further analysis.As mentioned above, Table A5 shows this study's findings as well as the frequency with which the term was employed.

Findings
The PRISMA flow diagramme (Figure 1) illustrates the process of selection and identification of articles.Of the articles, one concerned ethical decision making for ICU triage, one is concerned with lessons learned from COVID-19, and one is concerned with the containment plan.At least eight of these were guidelines at the national level and were produced by government bodies; one was produced by the Bioethics Commission.Narrative synthesis identified seven broad themes across these articles and guidelines, which are summarised in Table 2.As Table 2 summarises, while country documents mentioned the need for open and transparent ICU protocols, no guideline demonstrated complete coverage of all themes.However, the Nepal guidelines are relatively better at matching the themes than the others.Results specific to each theme are described below.
No guidelines and/or articles were excluded for their quality.However, from the quality assessment perspective, the Nepal and Pakistan guidelines scored better than the others for significantly specifying different stakeholders to be involved in decision making and the implementation stage.While documents were prepared by the governments, only Pakistan's document was published by the National Bioethics Committee and the Sri Lankan document was prepared in collaboration with the physicians as shown in the documents.

Theme 1: Need of Ethics for ICU Triaging during Pandemics
In the context of the need of ethics for ICU triaging, there are areas of agreement in the literature that indicate that scarce medical resources of the ICU such as beds, ventilators, etc. are to be distributed fairly and reasonably during a pandemic [19][20][21].Literature also specifies that resources are to be distributed fairly and reasonably to make them accessible to all.However, there is limited understanding of standard ethical principles in ICU triage decision making, especially in South Asian countries [20].Out of the five countries, only the Pakistan guidelines explicitly mention the need of ethical principles for ICU triaging during pandemics like COVID-19 ( [22], p. 4).Nepal's plan, on the other hand, implicitly indicates how differential groups such as migrants, people with co-morbidities, etc. are not to be overlooked for disease screening, but these undermined groups have been mentioned only for the public health screening and not for the ICU admission protocol ( [23], p. 46).Hence, no consistent awareness or concern of the need of ethics for ICU triaging has been noticed in the South Asian guidelines.

Theme 2: Disagreements on the (Ethical) Framework
There is disagreement on the rationale principle behind the just allocation during the crisis [24][25][26][27][28].A requirement of strengthened national guidance for the protocol and policy for ICU triaging [29] was highlighted.To conduct a deeper assessment, ICU triage frameworks for the South Asian countries were revisited.
In general, a variety of criteria were given for ICU admissions to inform decisions on who should be admitted to the ICU based on the parameters of respiratory rate, SPO2 level, probability of survival, co-morbidities, and age.All of the guidelines agreed that components of these characteristics should be utilised in combination in ICU admission decision making, and the onus remains on the clinical teams led by physicians to assess the final admission criteria for individual patients.However, when it comes to an ethical ICU triage process, it is only Pakistan's guidelines which mention using a compassionate, respectful, and empathetic approach ( [22], p. 5).The Nepal guidelines specify different socioeconomically vulnerable groups, but these groups have been undermined in the context of ICU admission and treatment.Hence, no consistent guideline on ethical triaging or need of ethical framework for ICU triaging has been found in the relevant South Asian documents.

Theme 3: ICU Triage Protocols Are to Be Transparent
ICU triage protocols are expected to be transparent, built upon trust, to be inclusive, and to include public health values [24].Multiple ethical values need to be balanced for various interventions and circumstances to develop prioritisation guidelines and standard operating protocols [30].There are limited data which support advanced ethical consultation and reflection to make the process more inclusive and value-based in the South Asian guidelines and plans.The importance of open and transparent information sharing had been hinted at by the Nepal and Pakistan guidelines (Table A5).The Pakistan guideline, specifically, highlights that Standard Operating Procedures (SOPs) need to be more coherent ( [22], p. 4).On the other hand, the Bangladesh plan used the term "open" but with different connotations, such as "Do not go near any open flames when using oxygen. .." ( [31], p. 33).Hence, no indication of clear, transparent, and standardised ethical ICU protocol could be identified in the plans and guidelines.

Theme 4: ICU Triaging Needs Equitable Approach with Consideration of Underlying Health Inequities
ICU triaging needs an equitable consideration safeguarding the right to health of all [32].However, the main and generic focus of equity has been utilitarian-saving maximum lives; lottery-based rationing thereby overlooks the underlying health inequities.Hence, a just and fair approach with consideration of an equitable framework is desirable for the ICU triage decision-making during pandemics.In this context, only Nepal's guidelines have mentioned equity (Table A5), but this has not been extended to set the criteria for ICU admissions and treatment.
Four fundamental ethical values, obtained from previous pandemic models, are usually popular in ICU triaging: Maximising the benefits produced by scarce resources; Treating people equally; Promoting and rewarding instrumental value; Giving priority to the worst off [30].In some plans and guidelines of South Asian countries, although these concepts have been used, they have been used for different contexts, such as for general health care and public health concerns, but not specifically for ICU triaging.The Pakistan plan, though, encourages not overlooking other patients for ICU admissions; in all countries, the ICU admission criteria are founded on the basis of medical conditions, overlooking socioeconomic and health inequities.Hence, more research is needed to incorporate the perspective of existing health inequities in just and fair ICU rationing during pandemics.

Theme 5: Need of Regional Mapping of Capacities and Better Modelling
With lessons learnt from past pandemics, the literature recommends maintaining a central database of ICU resources in order to evaluate health system performance, both within and between countries, which may help to develop related health policy [33].Regional modelling is needed to cope with the pandemic pressure for the ICU [24,34].As a pandemic respects no borders, ICUs of the region can also be overwhelmed at the same time with no capacity to transfer patients and COVID-19 has shown evidence of this.While Nepal mentions inter-country and regional collaboration (Table A5), nothing has been remarkably highlighted for mapping regional capacities in any other plans.Hence, there is a need to have a better insight into the regional ICU triaging process.
Recently, COVID-19 has highlighted that pandemic preparedness, including ICU preparation in a South Asian context, needs to be founded on a better framework [24,34].However, there is an oversight of the framework recommendation with insights of underlying health inequities.Therefore, there is a need for research to revisit the framework recommendation, which is founded on equitable rationalisation.
In addition to these thematic analyses, inclusion of ethical terms/expressions were searched for in the South Asian guideline and plans for the second time.In general, the usage of ethical language in the guidelines and plans, once again, is said to be low.None of the plans, except Pakistan's, has a separate section on ethical considerations; whatever ethical terms have been found are used as part of the content of the plan in general.
Out of the 18 terms searched for, the common terms used for COVID-19 are communication, protection, and responsibility.The terms which have not been found in any COVID-19 plans' guidance are Accountability, Fair/Fairness, and Responsiveness.
Collaboration signifies working together.However, it is only the Nepal and Pakistan guidelines which mention intersectoral collaboration and collaborative decisions.
Ethics, the other term, appears again in Nepal's and Pakistan's guidelines which use the term to promote better public health interventions and the rational allocation of healthcare resources.
The Nepal plan has shown concern for equity but for public health measures, not particularly for ICU triage.It has also used strategies to boost the morale of the healthcare workers.It is the only plan to use the context of rights (human rights).
Minimising risk of transmission was the most used expression in the Sri Lanka plan and has been used to designate areas to prevent a COVID-19 spread.
The expression Reasonableness was used in the Bangladesh plan and has been used in the context of rationale imagination but not in relation to reasonable ICU allocation.
Representation/represent was used in the Nepal, Sri Lanka, and India plans to indicate intersectoral representations in the COVID-19 prevention team.However, no representations of the vulnerable groups have been mentioned in any documents.
Finally, the context of Transparency and Trust were mentioned in the Nepal and Pakistan guidelines to indicate open sharing of information and building rapport among the teams and community.Importantly, although the COVID-19 pandemic led to many issues and challenges in relation to the ICU, with the exception of the Pakistan guidelines, no other plans use the term ICU prioritisation, though they discuss vaccination strategies.

Discussion
This study reveals several traits which may contribute to regional pandemic planning and ethical ICU triage in a South Asian context.From the synthesis and analysis of this study, it can be said that the guidelines and plans prepared by the five South Asian countries have been rapid with less or no consideration given to the existing socioeconomic determinants, health inequities, and social justice.Neither has this been observed in the deciding factors of ICU triage in the individual countries.
The similarity between the countries is mainly shown by setting up the medical assessments for ICU admissions.Regarding ethics, once again, the usage of expressions is low.While this portrays the individual and collective effort to be ethically concerned and to be aware of pandemic situations, it also implies that these countries do not appear to be adequately and ethically prepared to address pandemic-like disasters.Relatively, Nepal and Pakistan used more ethical terms than others.However, for regional pandemic preparedness, individual countries should have been better ethically prepared for COVID-19.The plans have also not explicitly mentioned, or implicitly suggested, the need for any ethical framework, or values, as guiding principles for ethical ICU decision making as part of pandemic preparedness, especially, involving socioeconomically vulnerable communities in these countries.There is also no overt attempt to identify probable major ethical issues, such as how to ensure 'fair' access to a limited number of ICUs.There is also no special effort visible in any of the plans to indicate procedural guidelines about how to ensure that ICU decision making could be ethically sound involving more stakeholders.
In certain circumstances, an ethical word is used, but the usage does not appear to be properly thought through.For example, the word "protection" appears quite frequently.However, none of the strategies emphasise the significance of protecting socioeconomically vulnerable individuals.It is also worth noting that none of the plans mention the ethical word "fairness", despite the region's great diversity in religious, cultural, and political beliefs, as well as noticeable socioeconomic inequities.Apart from a huge population living below the poverty line, the majority of the countries in question also have a sizable marginal population, which includes minorities, tribes, and nomads.There should have been better efforts to indicate how the vulnerability of the marginal people will be protected during a pandemic, especially in the context of ICU triage by incorporating the social justice framework in pandemic guidelines and plans of the subcontinent.

Conclusions and Recommendations
ICU triaging in five South Asian neighbouring 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, and usage of those terms was found to be significantly low.A discussion shows that the plans and guidelines have the scope to improve the ethical ICU triaging in the countries and in the region.After analysing different ethical guidelines, this study emphasises that there is a need for a just and fair framework, mainly a social justice-based framework, in ICU triage in the subcontinent to address the existing health inequities.
In the crisis hours of a pandemic, an open and transparent ethical ICU triage can help avert many irrational strategies impacting the service delivery and can also save many unwanted and premature deaths.Inequalities in society are unavoidable.However, if they are thoughtfully incorporated in the pandemic planning, many real-time disasters can be averted.And for this, more research, with a vision of social justice, is needed in this domain.

Limitations
This study has the limitation to conduct the systematic review on the secondary literature and grey literature.Additionally, the present work is disclosure-based and thus is limited to only what is disclosed on the website of the Ministry of Health or on the official websites.No direct, extensive primary data collection has been undertaken.Moreover, this study uses a mixture of guidelines, articles, and plans to conduct the synthesis and analysis.

Table 1 .
List of databases searched.

Table 2 .
Summary of references for the COVID-19 ICU admissions and allocation.

Reference Location Need of Ethics Ethical Framework (Explicit/ Implicit) Open and Transparent Protocol for ICU ICU Triaging Needs Equitable Approach Suitability of Existing Rationing Strategy for Pandemic ICU TriageTable 3 .
Summary of the quality appraisal of included articles.