During the chaotic time in early 2020 when COVID-19 swept through the Sainte-Dorothée nursing home, two physicians made decisions that may have hastened the death of one resident and left others struggling to breathe, a Quebec coroner’s inquest heard this week.
Nguyen Tu Anh was questioned about her decision to prescribe morphine to a patient who later died, while Thérèse Nguyen addressed concerns about her decision to administer oxygen to six patients using a low-flow method that provided them with less air than they would have received by other methods.
Dr. Nguyen Tu Anh said that the morphine she prescribed was intended to comfort a person who had little chance to survive. Her colleague said the lower-flow oxygen she authorized made it safer for nurses, enabling them to work without N95 respirators.
The inquest is looking at the impact of COVID-19 on Quebec’s long-term care facilities, where more than 4,000 seniors died during the first wave of the virus last year.
The two doctors at the nursing home located in Laval, north of Montreal, were operating in a pandemic context where the province, trying to protect emergency wards and intensive-care units, had issued guidelines that made it harder to hospitalize ailing nursing home residents. Protective equipment was rationed, and doctors discouraged from visiting nursing homes in person.
The inquest heard this week how 102 Sainte-Dorothée residents died after the pandemic’s first wave hit the nursing home.
Coroner Géhane Kamel’s hearings are focusing on the fate of one of the 102 victims: Dr. Nguyen Tu Anh’s patient, Anna José Maquet.
The 94-year-old was having difficulty swallowing. Early on April 3, 2020, her condition worsened after she gagged while drinking water, then vomited up her medication. A staff member contacted her physician, Dr. Nguyen Tu Anh, by phone. The doctor prescribed morphine.
The inquest heard that the Quebec Health Department had told doctors to consult by phone as much as possible, out of fear that they would carry the virus between facilities.
Nursing home doctors had also been ordered to revise the care levels of their elderly patients. Families were urged to reclassify their loved ones to C or D levels. At those levels, only comfort care would be provided in the event of a medical crisis. A patient who had been classified in this way would not be hospitalized to prolong their life.
Dr. Nguyen Tu Anh said she prescribed morphine because Ms. Maquet had an acute breathing problem. She said the only other option would have been to intubate Ms. Maquet in a hospital. But Ms. Maquet had been reclassified to a care level that precluded moving her out of Sainte-Dorothée.
“There was no prognosis. We tried a dose of morphine to relieve her pain. She was continuously out of breath,” Dr. Nguyen Tu Anh testified.
Jacques Ramsay, a physician who is acting as an expert assessor in the inquest, asked Dr. Nguyen Tu Anh whether she was comfortable prescribing morphine when she wasn’t there in person.
“We often did that, whether there was COVID or not,” she replied.
The inquest heard previously that, until that day, Ms. Maquet had been lucid and in good health. Reading from the medical file, Dr. Ramsay noted that Ms. Maquet was breathing fast but without wheezing.
“You didn’t give the patient a chance,” he told Dr. Nguyen Tu Anh.
Ms. Maquet died in her third-floor room that evening. At the same time, there was another crisis on the ground floor, in a makeshift “hot zone” for infected residents.
Six of the 18 residents in the hot zone needed supplemental oxygen using CPAP and Ventimask breathing devices. Their nurses were worried because a public-health advisory had recommended workers wear N95 respirators when using CPAP and Ventimask, because the machines could generate virus-carrying aerosols.
Three nurses refused to work unless they had N95 respirators. The inquest heard that Sainte-Dorothée had no such devices. If there was an aerosol-generating procedure requiring an N95, the patient had to be hospitalized.
Dr. Thérèse Nguyen testified that, as the physician on duty, she authorized using nasal cannulas, a system that delivers oxygen at a lower flow rate than the CPAP or Ventimask, through a tube in a patient’s nostrils.
“I was worried for the safety of the personnel,” she said.
Dereck Cyr, an emergency nurse and union official, testified on Tuesday that he had concerns about the switch to cannulas because the lower oxygen flow had the potential to harm patients.
“When your blood oxygen rate decreases, you compensate by increasing your blood circulation and your breathing ... You’ll breathe faster, your body will protect your vital organs,” he said.
Dr. Thérèse Nguyen said patients in the hot zone were at C and D levels, and were receiving comfort care.
She said that on that same day, the staff had begun training on a new protocol for breathing distress that relied on administering morphine through a pump.
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