Pandemic expediency comes at a cost
Death with dignity has been a solace forsaken in the pandemic era.
The dying hasn’t been gentle for victims or kind to the bereaved as so many have passed in solitude and loneliness, their survivors forbidden an intimate leave-taking.
But in Canada at least we’ve been spared some of the horrors witnessed elsewhere: bodies stockpiled in refrigerated trucks, stored in sheds, hockey rinks turned into temporary morgues, army trucks trundling caskets to distant cities for incineration because local crematoriums couldn’t handle demand, cheap coffins tipped into mass graves.
To that extent, those charged with projecting all possible scenarios and avoiding the worst of them have succeeded. Where cremation was rejected, families have been allowed to bury their loved ones or defer interment to a future date.
“Hospitals were starting to rent facilities,” says Dr. Dirk Huyer, chief coroner for Ontario, recalling how at the onset of the crisis, alarmed by what had so tragically unfolded in Italy, administrators had begun to game plan for warehousing bodies. “We wanted to get to them quickly, tell them: You don’t need to do that.”
The traditional approach in such a massive emergency, Huyer explains, is to build temporary morgues, as has occurred in New York City as well. “We didn’t believe that was the way to go.” With the province’s chief forensic pathologist, Dr. Michael Pollanen, and the bereavement sector, Huyer explored alternative strategies. “How are we going to manage if there’s a surge? Because hospitals are not body storage experts. And frankly, it’s not the most respectful way to care for people.
“We knew that funeral homes have substantial storage capacity because they store over winter. They know how to do it and they do it respectfully. We pushed it a little more quickly than maybe was necessary because it’s a brand new process and there’s thousands of people involved. The hospitals took a while to change their processes. The nursing homes actually were pretty quick.”
In conjunction with funeral homes, the coroner’s office hastily devised new protocols — indeed, protocols at odds with some of the recommendations that arose out of a public inquiry into safety and security of residents in longterm-care homes issued nine months ago. That exercise focused on events that led to crimes committed by serialkiller nurse Elizabeth Wettlaufer, who preyed on elderly patients in her care, and made 91 recommendations to avert it ever again. (Eighteen of those recommendations had been implemented by February.)
“We expedited the time frame,” says Huyer of the quick-step transition that came into effect in April. “Our goal was to make sure we provided timely transfer of people into the aftercare that’s best at doing it. Funeral homes are the best to provide that care.
“We didn’t want temporary storage facilities. By expediting, shortening the time frame, people need to make a decision about a funeral home more quickly. Then the home can come more quickly, transfer them to their care. That was the rationale.”
Quickly might mean as soon as within an hour of death, whether the person dies at home, in a nursing facility or in a hospital. That has been jarring for families, with scarcely time to grieve in the moment before making arrangements. And mortal COVID-19 can hit like a bolt from the blue.
“They don’t have to decide on funeral plans, but they do have to decide on the home they’re going to work with,” says Huyer. “Then funeral home staff are coming at all hours so that there isn’t an overburdening or storage requirement. They were able to change their staffing because they’re not doing visitations, they’re not doing funerals in the same way as pre-pandemic. They had more staff available to do things at night.”
It is fair, however, to ask if transparency and vigorous reporting procedures have been sacrificed on the altar of expediency.
Cause of death on a certificate: COVID-19, under the World Health Organization’s new definition of what constitutes a COVID-19 death, an International Classification
Disease code included on the certificate in order to capture mortality data for the disease.
Unless there’s an exceptional component to the fatality, they all go down as death due to natural causes. And death due to natural causes means there won’t be any consideration of an autopsy, except in rare cases. Even if it’s actually undetermined whether the individual was killed by the disease or some other underlying illness or a domino effect cascading from the coronavirus leading to multiple organ failure.
They’re all included in a broad swath of COVID casualties.
“A coroner is not notified about deaths from natural diseases and therefore we are not investigating the majority of COVID-19-related deaths,” says Huyer.
“They wouldn’t fall into our legislative criteria. Most of the COVID investigations are led by the public health experts. We will work with them as necessary. Early on in the pandemic we were involved in more cases, less now, because we were trying to help understand the pathology and extent of COVID-19 illness in the community.”
The coroner’s office performs about 17,000 investigations and 8,500 autopsies each year — typically when death is unexpected or traumatic — out of some 109,000 deaths annually in the province. Roughly half of the autopsies are performed in hospitals, by pathologists registered with the Ontario Forensic Pathology Service. But hospitals aren’t doing autopsies during the pandemic.
Medical certificates of death are now being issued electronically and directly by coroners, directly to funeral homes, eliminating the need to collect paper copies from hospitals. Funeral home staff no longer have to enter hospital morgues, the bodies brought out to them in body bags that are sanitized before being loaded into a hearse.
The coroner’s office has absorbed some criticism for the lack of autopsies performed on COVID-19 victims. There’s no wide-scale post-mortem COVID-19 testing (swabs) in Ontario. This means there’s no co-ordinated post-mortem strategy to provide a more complete scientific and demographic grasp of how the virus works, who it kills and which underlying medical conditions put people at greater risk. Colin Furness, an infection control epidemiologist at the University of Toronto, has called this vacuum of knowledge “a national embarrassment,” as earlier reported by the Star’s Mary Ormsby.
Further, as freelance investigative journalist (and data skeptic) Rosemary Frei noted in a recent article, one of the Wettlaufer inquiry recommendations called for replacing the standard one-page, yes/no, eight-question Institutional Patient Death Record (IPDR) with an evidencebased resident death record to be filled out by nursing home staff who provided the most direct care before the individual died, with input from physicians, personnel support workers and family members. These would be reviewed by the long-term-care home’s medical director, who would bring any concerns about the death to the coroner’s office and/or the Ontario Forensic Pathology Service.
Instead, writes Frei, the new COVID-19 procedures keep the original one-page IPDR and add a two-page form called the Managing Resident Deaths Report. She alleges that relevant details and circumstances aren’t being appropriately documented, as the Wettlaufer inquiry had recommended, thus reducing transparency around the handling of deaths at both long-term-care homes and hospitals.
The “expedited death response” protocols adopted in mid-April, designed to promote efficiency, also allow for death certificates to be filed electronically. “We sign them, based upon the information provided,” says Huyer. “We don’t review records or evaluate in depth on those cases.”
Huyer emphasizes, again, that the coroner’s role is limited to unusual or suspicious death, framed within the medicolegal parameters of the Coroner’s Act.
“We evaluate to understand the circumstances of death. Talk to families, police, doctors, nurses. We talk to friends.” If the investigation requires, also to fire marshals and children’s aid societies.
Inquests are relatively rare, only between 40 and 50 throughout the province every year.
“You have to step back to one of the important tenets about how we get involved,” says Huyer, explaining the surprisingly low number of COVID-19 autopsies. “We do autopsies in the context of public death investigation.
“If you die of the disease in the hospital or another setting, natural causes, we’re not involved because it does not come into the coroner system. From our point of view, for us to be involved lawfully doing autopsies, you have to first enter our system.” The network of COVID-19 deaths gets barely a foot in the door of that system.
Hardly even a toe tag.