As if at a magic show, we have been sitting in a darkened room and the spotlight has been directed, not to white gloves, cups and balls, but to graphs and projections, hospitalization and death rates. We are captivated and yet our attention span is short. Early on, we checked the rising case counts daily; latterly it is the percentage of the population vaccinated or the global rise and fall of Omicron. With so many numbers crossing our screens it’s easy to lose track of the ball.
There is, however, one set of figures that should have caught and kept our attention: the shocking proportion of Covid-19 deaths that took place in Canada’s long-term care facilities (LTCFs) during the pandemic’s first wave. This proportion was high everywhere, but Canada’s numbers were in a class by themselves. At the end of May 2020, Canada was reporting that 81 percent of the country’s Covid-19 deaths took place in LTCFs. This compared to an average of 38 percent in the other 37 OECD countries. That proportion has fallen, but a December 2021 report by the Canadian Institute for Health Information noted that LTCFs still accounted for 43 percent of Covid-19 deaths.
In one sense, the high numbers are not entirely surprising. Although residents of LTCFs represent fewer than three percent of those aged over 65, they are the weakest and most vulnerable among us. And Covid-19, like other respiratory infections, preys especially on the elderly and infirm. Protecting the vulnerable aged was the reason governments worldwide gave to justify restrictive pandemic policies. The Don’t Kill Granny campaign first emerged in Preston, England, in August 2020, when the city banned social mixing between households. “Don’t kill your gran” was quickly adopted by the U.K.’s then health minister, Matt Hancock, and used to encourage young people to limit their social interactions.
But much remains opaque about the circumstances and nature of the many thousands of reported deaths in Canada’s LTCFs. There have been commissions and reports, but in Canada, only one province – Quebec, which suffered the highest percentage of long-term care Covid-19 deaths – has had public hearings to examine those circumstances. Revelations from that inquiry and an evaluation of measures taken in other places suggest that the real question should be, “What did kill gran?”
Besieged During the Fearsome First Wave
Between February and April of 2020, nursing homes became islands whose residents were marooned in a viral sea of SARS-CoV-2. Nurses and personal aides were sent home because of infection, and the intensifying climate of fear meant many healthy staff did not report for work. Staffing had long been a problem in Canada’s nursing homes and no one in the health and social services sector was surprised to witness an already weak system buckle in some provinces under the pressure. To make matters worse, lockdown policies barred family caregivers and close friends, who often provided daily support to their loved ones, from the facilities. And not just physically, for family members often spent weeks unable even to contact their loved ones or staff.
Louise Langlois experienced the anxiety and frustration of the situation firsthand. Her mother, Viviane, was a resident of the CHSLD Herron in Dorval, Quebec. (CHSLD is the French-language equivalent to LTCF.) On March 12 the home’s receptionist called to tell her that the Herron was under lockdown. There would be “no ins and outs, and we will keep in touch.” But they did not keep in touch. For a period of two weeks, Louise was unable to speak with her mother or even to reach staff. Although Viviane had a telephone in her room, her dementia meant that she did not know to answer when it rang.
Louise is certain her mother wasn’t being properly fed or looked after in those initial weeks of lockdown. She believes that, as a matter of self-protection, Viviane put up a “carapace” to survive. She’s now happily resettled in another CHSLD but when Louise tries to talk to her about “Covid-19 time” or “lockdown,” her mother looks at her uncomprehendingly. With so many LTCF residents suffering some form of dementia, and with family caregivers, doctors and even police unable to enter the facilities for weeks, there are few witnesses to the reality in the nursing homes during that crucial period. Much of the data has not been retrieved; most of the stories remain untold.
In late April, the siege was broken. Military personnel were deployed to five LTCFs in Ontario and five CHSLDs in Quebec. “Operation Laser” was quickly scaled up in Quebec; by May 7, 20 CHSLDs were receiving support and some 1,300 Canadian Armed Forces members were in the homes. The reports published at the end of their mission gave the Canadian public its first real glimpse into the situation.
To read Brigadier General C.J.J. Mialkowski’s report about the Ontario homes is to read a document that conveys in the precise, meticulous language of a soldier the horror the military personnel felt. It reads as dispatches from a new kind of battlefield. There were common themes across the five facilities: lack of permanent, trained, and coordinated staff; misuse of narcotics; shortage of supplies; inadequate nutrition and hydration of residents. Personal support workers, said one note, are “often rushed and leave food on table but patients often cannot reach or cannot feed themselves (therefore they miss meals or do not receive a meal for hours.)” In another centre, “forceful feeding observed by staff causing audible choking/aspiration [and] forceful hydration causing choking/aspiration” were reported. At the same residence, patients were “observed crying for help with staff not responding,” sometimes for over two hours.
But even more than the military reports, in Quebec it was the work of journalist Aaron Derfel – and specifically his April 10 Montreal Gazette article about CHSLD Herron – that laid bare the grim conditions. A year later, a coroner’s inquest began in Quebec, examining deaths in seven CHSLDs between March 12 and May 1, 2020. Testimony at the inquest would raise more questions about what factors, other than the virus itself, might account for the staggering death rate.
Why Did So Many Elderly Patients Die?
There has been one sizable roadblock hindering attempts to answer: reliable data on cause of death was not always collected. An auxiliary nurse, whose identity is protected by a publication ban, testified before the Quebec inquest that many of the deaths at her facility were labelled as suspected Covid-19 cases because “it would be easier to blame the virus than to acknowledge the hard truth that these people suffered from malnourishment and dehydration.” Why was this so? “I felt,” she added, “that it was a way to escape culpability.”
If this was true in one beleaguered facility, it is reasonable to conclude that it could also be true in others. Despite inaccurate, missing or compromised data, the question must therefore be pressed: what actually happened in the LTCFs in the spring of 2020?
In Quebec, the most common explanation is a term used both by Premier François Legault and Quebec’s coroner, Géhane Kamel – “organizational negligence.” Poor coordination, lack of proper lines of communication and command, scarcity of personal protective equipment, inadequate funding and staffing – all have been identified as systemic weaknesses.
But there is reason to believe that nursing home residents suffered not just from a broken-down system, but from a deliberate effort to protect the healthcare system at the expense of vulnerable LTCF residents. The rationale for the latter plan is easy to grasp. It was feared that, as was happening in northern Italy, pandemic patients with acute illness would flood the hospitals. To ensure sufficient beds, staff and respirators to care for them, a restriction on non-urgent patients would be necessary, as well as protocols to determine which patients would receive care and which would be placed on “end-of-life pathways.”
The strategic underpinning for such decisions is a concept known as population triage – or disaster triage. In a 2019 article on this topic, Michael Christian, a specialist in emergency preparedness, wrote that disaster triage is concerned with “allocating scarce resources in order to ‘do the greatest good for the greatest number.’” While this utilitarian maxim “easily slips off the tongue,” he warns that “many overlook its profound implications” as the focus of decision-making shifts from “individual patient outcomes to population-level outcomes.”
Following China’s lead, nations around the world engaged in an exercise of population triage never before attempted or even conceived. The lockdowns meant to slow the spread of infections so hospitals could prepare for the onslaught were part of disaster triage. In England, the ubiquitous advice was “Stay Home – Protect the NHS – Save Lives.” That message was on every government minister’s lips and on billboards everywhere. The National Health Service, not the individual patient, was prioritized.
Hospitals were to prepare for the reception of Covid-19 patients: triage in advance. As the elderly in the care homes were deemed least likely to benefit from Covid-19 care offered in hospitals, transfer of sick patients from the long-term care facilities to the hospitals was discouraged. Quebec’s Health Ministry issued a directive on March 19 – barely a week after the global pandemic had been declared – instructing nursing homes not to send residents to hospitals unless in exceptional circumstances. Conversely, hospital patients who were not in critical condition were to be either sent home or transferred to care homes. This practice was adopted in multiple jurisdictions: Quebec, Ontario, several U.S. states including New York and New Jersey, and in England.
On March 17 Danielle McCann, Quebec’s Minister for Health and Social Services, announced that by offering alternative locations for hospital patients and postponing elective surgeries, the province would be able to free up 6,000-8,000 of the province’s 18,000 hospital beds. According to the minister, the number of beds expected to be needed was based on data emerging from Italy.
Quebec’s projection, like so many others, turned out to be a grotesque overestimation. Nearly a month later the number of people hospitalized for Covid-19 was only 733. Covid-19 hospitalizations would peak in mid-May with a seven-day average of 1,600.
On November 18, 2021, McCann testified at the inquest that only a few hundred hospital patients were actually transferred to the nursing homes. But that was not without cost. That same day, Kamel noted that one elderly patient transferred to Herron in the early days of the pandemic was found dead two days after the transfer. His family believe he had been abandoned in the confusion. How many other similar cases might there have been?
The same was happening in New York, where then-Governor Andrew Cuomo issued a directive that drove thousands of hospital patients to nursing homes. The directive forbade the homes from turning away patients who tested positive for Covid-19, and it would later be learned that many were not tested in any event. Cuomo, a left-leaning and highly popular Democrat, effectively created a series of super-spreader events among his state’s most vulnerable population. The state’s health department originally reported the transfer of 6,327 patients and recorded 8,500 deaths among long-term care residents. The true numbers – 9,056 transfers and some 15,000 deaths – were only revealed much later, under pressure from the New York State Bar Association’s Task Force on Nursing Homes.
Just How Far Did “Population Triage” Go?
The truth about these population triage measures becomes still more troubling when we learn more about their actual scope.
In the U.K., it did not end at withholding advanced care from elderly Covid-19 patients who were deemed unlikely to survive. Instead, “Do not resuscitate” (DNR) orders for residents of care homes became standard. A DNR stipulates that “neither basic (heart compressions and ventilation) nor advanced (defibrillator or medicines) CPR should be performed.” Care homes were asked by the NHS managers to issue a blanket DNR for all residents.
Similarly, for five months first responders of Urgences-Santé, a Quebec ambulance service, were instructed not to resuscitate those whose hearts had stopped. “During the summer and spring, we just modified our protocol to protect the paramedic, to protect the health system, to protect the people – all people – because we didn’t know…how to protect ourselves, how contagious it was,” said Pierre-Patrick Dupont, director of care at Urgences-Santé.
Hospital medical staff were advised to prepare to ration intensive care beds and ventilators. The first to be treated were those who had the best diagnostic outcome. If too many candidates qualified, priority should be given first to those who are of “un stade moins avancé,” or those who have more life to live; second, to healthcare professionals; and finally, to those chosen by lottery, “la randomisation.” While that did not prove necessary, in the nursing homes a catalogue of horrors – neglect and isolation, malnutrition and dehydration, and death upon death – was unfolding.
The Quebec coroner’s inquest that began last June revealed that as non-critical patients were being transferred from the hospitals to the LTCFs, family members of residents were being contacted and advised to revise the end-of-life instructions attached to their relative’s file. A Health Department document filed at the inquest recommended that residents who had been classified as recipients of A or B-level care (that is, as receiving treatment to prolong life) “should move towards C and D levels,” as those who would now receive only “comfort care,” subject to end-of-life protocols.
The CHSLD Sainte-Dorothée lost nearly half its residents, but the coroner’s inquest focused on one death in particular. Anna José Maquet, a 94-year-old resident, died on April 3. (It is unclear whether Maquet had tested positive for Covid-19; either she was never tested or the results were not recorded.) According to the testimony of her son, Jean-Pierre Daubois, the family had a phone conversation with their mother on the evening prior, during which she said she was feeling fine. The next morning, she choked while drinking a liquid and later threw up her medication. At 12:45 p.m., morphine was administered. By nightfall she was dead.
Maquet’s death does not seem to be a result of careless or indiscriminate use of narcotics such as the military observed in Ontario nursing homes. In fact, morphine was part of a “respiratory distress protocol” that nurses at Sainte-Dorothée had been instructed to use, a protocol apparently issued by the local health authority, the CISSS Laval.
Sylvie Morin, assistant chief nurse at CHSLD Sainte-Dorothée, testified to the use of the protocol: “They made us put them all on the respiratory-distress protocol…morphine, scopolamine, Ativan.” Morin recalled that in early March her unit leader was visibly agitated. In a conversation with Morin, the unit leader said that if Covid-19 entered the nursing home it would empty the facility. “She had 250 death certificates [and] 250 forms for the respiratory distress protocol.” Morin pushed back, telling her boss, “Come now, they’re not all going to die.” Later, however, she would come to believe that “it was all set up ahead of time.” Not all residents who were administered the protocol died, “but most did.”
A Legitimate Treatment, or Stealth Euthanasia?
A respiratory distress protocol (RDP) may sound perfectly appropriate in the context of a SARS virus. After all, a small proportion of those who contract SARS-CoV-2 develop a form of pneumonia that can cause acute respiratory distress syndrome, which requires special attention and treatment. But the RDP described by Sylvie Morin is not such a treatment.
What is it, then? It is a combination of drugs deployed in end-of-life care, particularly in the last days or hours of life. Scopolamine is given to help control airway secretions; Ativan (lorazepam) or another benzodiazepine like Versed (Midazolam) to manage agitation and delirium; morphine for pain control. While the layperson might suppose that the protocol is used to assist a patient to breathe, the main effect is to reduce the urgent drive to breathe. Used in combination, these drugs have a very narrow therapeutic window. It is a fine balance between administering a dose that successfully manages the pain and agitation of a dying patient and one that actually causes death. The drugs must be dosed carefully and the patient monitored closely.
A Montreal neurologist interviewed for this article noted that RDPs are used almost exclusively after consultation with a palliative-care team or when it has been established that the level of intervention is consistent with a palliative approach. He said he found it hard to believe such a protocol would be a standing order.
Michael Ferri, Chief of Psychiatry at Pembroke Regional Hospital in Ontario, echoed that concern: “It does not surprise me that it is part of a protocol for respiratory distress especially in palliative care, supported by palliative care physicians. What is disturbing, however, is the apparent intent to use this protocol widely, in situations without careful palliative physician oversight and without accountability for outcomes.”
More distressing news about the protocols came out last month. On February 2, 2022, Radio-Canada reported that its journalists had obtained the RDPs developed for Covid-19 patients in 20 Quebec health authorities. They asked a panel of 12 physicians from the Quebec Association of Palliative Care Physicians (SQMDSP) to examine those protocols. The doctors’ findings were disturbing. In five health authorities, including the CISSS Laval where CHSLD Sainte-Dorothée is located, the physicians found that the Covid-19-specific protocols recommended doses that were too high.
In low doses, the combination of benzodiazepines, morphine and scopolamine achieves the aim of relief from anxiety and pain. In higher doses, the result is typically respiratory depression and death. As mentioned, the “therapeutic window” is narrow. In light of their findings, the SQMDSP informed the Fédération des Médecins Omnipatriciens du Québec (FMOQ) that the Covid-19-related protocols were inappropriate and that any training based on them should be immediately withdrawn. Hours before publication of the Radio-Canada article, the FMOQ announced it had withdrawn the online training.
A number of important questions arise from the SQMDSP report. It is clear that there were two sets of protocols being used in the spring of 2020: one for Covid-19 patients and one for non-Covid-19 patients. The dosing was higher in the Covid-19 protocols. The Radio-Canada article notes that, “No protocols with potentially excessive doses were identified by the Society in the respiratory distress protocols for non-Covid-19 patients.” We also know that, in at least the case of Anna José Maquet, a patient whose Covid-19 status was in doubt was administered an RDP issued by the health authority. Were there two sets of protocols in use at the CHSLD Sainte-Dorothée? If so, which one did Anna José receive?
Another question is the use of RDPs in a non-clinical setting. As noted by Ferri, careful oversight and clinical reasoning are required in the administration of these palliative-care protocols. They are typically used in carefully monitored hospital or hospice settings. Was any use of them in the LTFCs even appropriate? If administered by teams who are undertrained and unfamiliar with the protocols, is the practice consistent with a recognized standard of care? Questions about these kinds of protocols are emerging, and need to be pursued, in other jurisdictions as well.
In April 2020, members of the U.K.’s House of Commons Health & Social Care Committee questioned Health Secretary Matt Hancock at a virtual meeting. Luke Evans, a Conservative MP and physician, prefaced his questions by suggesting something was missing from the Covid-19 “battle plan.” For some people, he said, death is an inevitability and there should be provision for those who would not make it to intensive care units. “A good death needs three things. It needs equipment, it needs medication, and it needs staff to administer it.” He then asked, “Do you have enough syringe drivers? Do you have enough medication, particularly midazolam and morphine?” Hancock answered yes to both questions. The MP’s questions and the Health Minister’s ready response suggest that the U.K. government had already prepared to impose end-of-life protocols on patients who had been deemed too old or frail to receive treatment.
The Prodigious Use of Killer Drugs
The prodigious use of such drugs raises further questions. Midazolam, for instance, a quick-acting benzodiazepine used for sedation and muscle relaxation, facilitates intubation in the emergency department and in operating rooms. It is used in palliative care to provide rapid relief for agitation and air hunger. (In Canada, it’s used in Medical Assistance in Dying (MAiD) protocols, and in the U.S. as part of the process for administering the death penalty through lethal injection.)
In England, the five-year monthly average prescription total for midazolam was 15,000 – but in April 2020 this figure leaped to 38,353 prescriptions. Accord Healthcare, one of the drug’s five manufacturers, reported it had sold two years’ worth of stock to U.K. wholesalers in March and that by the end of April those supplies had been depleted. In May, the country’s pharmaceutical regulator gave Accord approval for a further 22,000 packs of French label stocks to be sold into the NHS.
The subject is an uncomfortable one, to be sure. In a July 2020, Daily Mail Online article, Patrick Pullicino, a retired neurologist and neuroscientist who held multiple senior academic and clinical positions over a long career, suggested that the triage protocols consigned vulnerable patients to end-of-life care. In Pullicino’s view, this result was unintentional. As he wrote, “This flow-chart encouraged use of end-of-life sedation with midazolam – effectively resulting in euthanasia pathways.” The Association for Palliative Medicine of Great Britain and Ireland, however, disputed Pullicino’s evaluation. “I absolutely do not believe,” declared the association’s president, Amy Proffitt, “That there have been cases of euthanasia in care homes related to Covid-19.”
Such a position is increasingly difficult to maintain, however. It is belied both by facts on the ground and by the striking similarities between procedures in diverse jurisdictions. A Wired U.K. article suggests that Sweden may have been on a parallel track. It notes both the non-admission of the elderly and infirm to intensive care units and the administering of “a palliative cocktail of morphine and midazolam, because the homes were not equipped to administer oxygen,” as well as the fact that this protocol was not restricted to Covid-19-positive patients. According to Andrew Ewing, a professor at the University of Gothenburg, “A person who got a urinary tract infection and required hospitalisation, for example for IV antibiotic or fluids, would not get that care either. They received palliative medicine instead.”
From the very beginning of the pandemic, it seems, there were plans in several countries to implement a system of population triage that included the administration of end-of-life drugs to those considered too old or frail for intensive (or, in some cases, even standard) Covid-19 medical treatment. We know that the associated protocols can induce death, and that they were sometimes employed on residents in public care who were not in immediate danger of death or even Covid-19-positive.
Neither the extent of these measures nor their justification has been properly examined as yet, despite deeply disturbing indicators that they amount to a kind of involuntary euthanasia. Like many other public health policies introduced during the Covid-19 pandemic, these protocols and their implementation demand strict legal investigation and close public scrutiny. That in the early going “granny” very often died unexpectedly is not in doubt. We owe it to her to find out why.
Anna Farrow is a Montreal-based director of a non-profit organization representing English-speaking Catholics in Quebec who has written for Mercatornet, Catholic World Report, the Catholic Register and other publications.
Source of main image: Shutterstock.