More Thoughts On The Increase In Morphine and Midazolam Use in UK Care Homes in Early 2020.

I made a grievous error in my last post. I did not explore the root cause of all the excess deaths which I think was from the blanket issuing of policies intended for use in mass casualty situations.

I made an error in my post by not exploring the root cause of the deaths as I was simply trying to rebut the idea that providers suddenly decided to use medicines to euthanize patients.

My hypothesis as to the “root cause” of the excess deaths is that as the chaos of the first wave of the Wuhan variant unfolded, policy makers made an assessment that they were in a “mass casualty” scenario. Policies were hastily created which removed care opportunities to care home patients. The seemingly blanket DNR policies and “do not hospitalize” policies in the homes they were following for a time is what I suspect was the proximate cause of the excessive dying (not the medicines), as sick residents were forced to stay in the homes and proper Covid care could not be provided there.

In that first wave in New York (I was not in the UK), I saw a lot of ethically troubling ideas and even actions borne of fear as well as ignorance as to how much capacity they had or would be able to be created or even how many patients would need to be cared for. Could we handle a 1,000 admissions a day at my hospital? No way.

Again, my hypothesis is that the hasty attempt at creating "rationing" policies in the UK was catastrophic. It seems they were trying to "ration" or "prioritize" care for certain classes of citizens with a priority for the non-elderly, non-disabled(?) as if they were in a mass casualty event. Although I am not an expert in the management of mass casualties, I do know that in mass casualty events one of the first steps is to triage care (triage=ration?) to those most likely to survive or benefit from medical intervention. If you read the below, I think it supports my hypothesis that those extremely destructive policies were informed by “mass casualty” thinking.

From the Mayo Clinic: According to a 2016 issue of World Journal of Emergency Surgery, a mass casualty incident refers to an event that overwhelms the local healthcare system, with number of casualties that vastly exceeds the local resources and capabilities in a short period of time."

Sort, Assess, Lifesaving Interventions, Treatment/Transport (SALT) applies in incidents with five or more patients, such as a large motor vehicle crash. In this circumstance, first responders need to assess people quickly to determine who needs treatment in what order and then alert the receiving hospital so that medical staff can prepare for them.

In both SALT and START, responders classify each victim involved in a mass casualty incident into the following categories for treatment needs:

• Green (minimal)

• Yellow (delayed)

• Red (immediate)

• Black (dead)

• SALT also includes a new category, Gray status, meaning that responders expect the victim to die. This eliminates previous consternation when a patient was dying, but not yet deceased.

  "If you label someone black and someone else walks by and sees the victim breathing, that's confusing," says Juntunen. "A Gray tag means there's not any hope and that responders need to concentrate efforts elsewhere. I have encountered a victim in this status personally, and I had to move to another patient for whom we had resources."

It seems that UK policy makers, for a time, assigned a “grey status”.. to all the UK care home patients? I have not done a deep dive into what the actual hospital capacity for care was to even remotely justify such a policy, but from what I have read, these policies were not justified by a catastrophic lack of capacity. Given that reality, the policies, in hindsight(?) were outright violations of proper medical care but I still have trouble ascribing them with a primary intent to cause death, although those erroneous policies did cause excess death for sure.

My personal experience in that first wave was that there was outright chaos in some places, it truly was disorienting and scary and that is where policies come from - to bring order out of chaos (and presumably to ensure the right thing happens for the most people like in a mass casualty event).

However, even if the situation approximated a “mass casualty”, a blanket assigning of “grey status” to all care home residents is extremely disturbing versus trying to do so on an individual basis.

The reason why I am reluctant to accept there was a primary intent to cause death is that I just can’t. I have been exposed to so much fraud and corruption and ignorance within the medical system through Covid, with what now seems like systematic depravity around the vaccines, but I can’t believe any suggestion that health care providers systematically began to practice euthanasia or homicide in the early pandemic. Or that the policies were formed with a primary intent to cause excess death in care homes. I just can’t do it. And won’t, because if I do, then the world is lost to me.

The seeming perception of policy makers that they were in a mass casualty when it appears they were not led the care home residents to die of Covid at needlessly excessive rates due to lack of access to hospital support devices. Which then led to many developing severe breathlessness in the home with the only available care options to be those of "comfort meds." It seems the reason why they put in a medication protocol as part of their policies, is that they knew they would be needed as a result of insufficient hospital capacity with inability to make available the use of non-invasive and invasive ventilators and high-flow oxygen devices.

Again, my hypothesis is that UK policy makers had come to the conclusion that there was not enough hospital resources for everyone. My point is that my prior post did not address this as what I think was the "real" problem - the blanket issuing of DNR and do-not-hospitalize policies which created a situation where large increases in the use of comfort meds was observed.

Further, these policies likely explain so many of the troubling reports by patients and their families of being denied care and thus causing the premature death of patients. But again, I believe (although I was not there, I have read some of the investigations into what happened) that it was the policies that caused the excess deaths, not the meds (although I suppose one could argue there is little difference given that the meds were part of the policy, but I personally do see a distinction - the meds were secondary, albeit an unfortunate and ugly part of the whole mess in that early wave).

A second “correction” to my post is that my skills and approach to end-of-life care, prognosticating, and following ethical principles are mine and were formed from a decade and a half of practice in busy, urban ICU's as well as my study of medical ethics and the tutoring by some incredible mentors. I have to acknowledge the wide variability amongst providers in this knowledge and skill set as I have heard too many horror stories of improper actions of doctors to think we all have the same understanding and application of the principles of medical ethics.

But again, although terrible actions were taken by some providers out of fear and confusion as to what the "right" thing to do was, I cannot ascribe the intent of murder or euthanasia systematically to a population of health care providers. Although I, like many others, recognize that individual providers in certain situations may have "lost their minds”,, a.k.a “ethical bearings" and thus may have actually committed those acts out of some combination of ethical ignorance and fear but I refuse to accept they did it out of malice.

P.S. I also want to apologize for my “stay in your lane” comment - egregious and arrogant, not sure what I was thinking. I removed it.

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