Sedation, Not Salvation (Part 1)

An analysis of the use of "chemical restraints" and "COVID-19 deaths" in Australia in 2020.

In 2020, approximately 75% of Australia’s “COVID-19 deaths” occurred in residential aged-care facilities (RACFs), with more than 40% of these deaths occurring in just ten of these homes; nine of which were in Victoria.¹

During Australia’s two COVID-19 waves in 2020, shortages for sedatives caused by “unexpected consumer demand” occurred. These corresponded with surges in prescribing for sedatives, suggesting a potential link between their expanded use and increases in deaths caused by COVID-19 and dementia.

As we will show, sedation at the time was both permitted and recommended by treatment protocols for COVID-19 patients and those unable to follow COVID-19 infection mitigation controls in RACFs.

The evidence we present in this article, suggests that these recommendations were followed.

In other words, two shots to slow the spread: Midazolam and Morphine.

“COVID-19 Deaths” in 2020

By the end of 2020, prior to the commencement of the world’s largest ever clinical trial, Australia had recorded only 909 “COVID-19 deaths”, 678 of which were in RACFs.

These deaths were not, however, shared equally between the RACFs across Australia. Department of Health statistics reveal that there were only four States (Victoria, New South Wales, South Australia and Tasmania) which had COVID-19 outbreaks in 2020 (defined as having two or more COVID-19 “cases”) and among these four States, Victoria experienced 123 of the 129 listed in the Department of Health’s “COVID-19 Outbreaks in Australian Residential Aged-Care Facilities” final report for 2020.²

These 678 “COVID-19 deaths” in RACFs occurred from a mere 2,027 RACF resident “COVID-19 cases”, revealing a case-fatality rate (CFR) of 33.45%.

In contrast, among 2,238 RACF staff COVID-19 cases, only one death was recorded, resulting in a CFR of just 0.04%.³

The age and general health of RACF staff likely explain these differences, but the statistic remains striking; highlighting COVID-19’s limited lethality in 2020, except among older, comorbid, or chemically restrained individuals.

Yet, the reasons for the significant disparities in COVID-19 management outcomes among Victorian RACFs remain unclear.

One possible explanation for these variable resident COVID-19 outcomes could be the different “treatment” provided to residents of certain RACFs and not others. Sedatives, or “chemical restraints”, were recommended for some residents who tested positive to COVID-19. If their COVID-19 disease was critical, then doing so would could have hastened their deaths “from COVID-19”.

A second possibility is that residents already in an advanced stage of illness, who tested positive for COVID-19, were placed on an “end-of-life” care plan involving chemical restraints, potentially hastening their deaths “from COVID-19”.

The third possible explanation for these variable COVID-19 outcomes for RACFs in 2020 is that sedatives were used for “wanderers”; primarily dementia patients unable to adhere to infection mitigation strategies in RACFs. If sedatives were used as infection control measures in RACFs, it could explain why some had far superior COVID-19 outcomes than others. The counterpoint here is that if sedation was used for these types of patients, then sedation could have harmed their respiratory function, potentially hastening their deaths from causes like dementia.

In the end, 2020 was still a low “COVID-19 deaths” year for Australia. With the exception of the shockingly poor performance of these few RACFs, primarily in Victoria, Australia sailed through the pandemic without “vaccination”, or restricted access to vital early treatments like hydroxychloroquine.

In this article, therefore, we investigate how and why only a select few RACFs might have failed so poorly with its COVID-19 management resulting in these elevated “COVID-19 deaths” and we draw attention to how deaths from other causes might have also been elevated in these RACFs because of these policies promoting isolation and chemical restraint.

As the evidence in this article will show, the chemical restraint of patients in RACFs was allowed and even recommended.

Sedation was allowed

Despite restrictions on the use of sedatives, or chemical restraint for residents in aged-care facilities, they were still widely used and actually permitted under Australian law. In 2021, Australia’s “Aged Care Quality and Safety” Royal Commission reported how chemical restraint was an overused practice in RACFs, even before the pandemic. Following the Royal Commission, the regulatory requirements for RACFs in their use of chemical restraints were strengthened, however, chemical restraint continued to be used in RACFs.

A Human Rights Watch review of non-compliance reports for aged-care facilities across Australia from 1 July 2020 to 30 June 2021 found use of chemical restraints in more than 150 aged care facilities, despite recommendations to minimise their use.⁴

Similarly, in an explosive report in The Australian from August 2020, it was revealed that hospitals were refusing to admit seriously ill COVID-19 residents and sending them back to RACFs, where they were sedated:

“Another facility – the Glenlyn Aged Care in Glenroy – told the families of residents that Royal Melbourne Hospital ‘would not be accepting (residents) and they were to remain at the facility and be placed on end of life care and/or be sedated if they were wandering’.”⁵

As shocking as these reports were, they were all probably lawful applications of chemical restraint if certain loose conditions were met. The first condition was if “informed consent” was obtained by the medical or nurse practitioner (given by the resident or their representative). The second condition was if chemical restraint was used only as a “last resort”.

Incredibly, under these strengthened restrictions, informed consent could even be obtained after the chemical restraint was applied:

“Under the Principles, the aged care provider must inform the consumer or their representative about the use of the chemical restraint. The aged care service must provide this information before commencing the chemical restraint if it is practicable to do so, or immediately after.”⁶ [emphasis added]

Consider the absurdity of obtaining “consent” after the event. Consent, by definition, must precede the intervention, otherwise, it is simply a retrospective notification of actions already taken.

It is even more ludicrous to pretend that a patient considered for chemical restraint as a “last resort” could meaningfully give informed consent, because by reaching that “last resort” threshold, they would likely be beyond a state of clear decision-making.

Unsurprisingly, we found that these new restrictions were not always followed. A July 2021 report revealed that 90% of residents in one NSW RACF had been given psychotropic medication without evidence of informed consent:

“The report showed that 35 of the 39 residents were being given psychotropic medication . . . there was no written consent from family for the residents to take the medication.”⁷

The notion of the “last resort” was also a vague idea ripe for exploitation. It could conceivably have been interpreted as meaning it was imperative to protect the health of the community at the expense of the individual: at all costs. By this thinking, it would be permissible to sedate a resident in an aged-care facility if that would prevent the spread of COVID-19 in the RACF, even if that sedation had the effect of hastening that resident’s death. The problem is that once the use of chemical restraint is framed in utilitarian terms, like maximising overall safety “for the greater good”, then the threshold for what qualifies as a “last resort” becomes dangerously flexible.

Yet, this was how sedation was allowed under Australian law, and was also likely exploited in RACFs.

Those at risk of harming themselves or others, could lawfully be chemically restrained and, not only was it lawful, it was recommended.

Sedation was recommended

In April 2020, the Australian New Zealand Society of Palliative Medicine (ANZSPM) published one of the first palliative care guidance documents in the pandemic. Its “Essential Palliative and End-of-Life Care in the COVID-19 Pandemic” publication recommended medicines such as Midazolam, Morphine, Metoclopramide, Hydromorphone, Clonazepam and Glycopyrrolate for patients receiving palliative and “end-of-life” care:

Source: ANZSPM “Essential Palliative and End-of-Life Care in the COVID-19 Pandemic” (archive link)

It is important to note, that ANZSPM guidance did not distinguish “palliative” from “end-of-life” care. This is important because the former is directed toward improving the quality of life for those suffering from “life-limiting illnesses”, whereas the latter is about providing care to those in the final stages of their life.

Was COVID-19 considered a “life-limiting illness” or something that placed an aged-care resident in their “final stages of life”, particularly if that resident was aged 85+ and had other comorbidities?

In the end, it didn’t matter.

The treatment plan was the same.

If you were an aged-care resident suffering from dsypnoea, or pain, or cough, you could get your Morphine, or the super-charged “Hydromorphone”.

A bit of agitation?

Let’s throw in some Midazolam.

Did you have to be on an “end-of-life” plan to get these wonder-drugs?

No, because the ANZSPM guidance was for palliative care and “end-of-life” care.

We have good reasons to believe that this ANZSPM protocol became the default national protocol for COVID-19 palliative care in Australia too. In September 2020, Australia’s peak COVID-19 expert group, citing evidence from the ANZSPM expanded on ANZSPM’s recommendations with its guidance document “Management of People with COVID-19 Who Are Receiving Palliative Care”. The advice in this document was for:

“[P]eople with COVID-19 whose prognosis due to co-existing advanced progressive disease is limited or uncertain, or people with critical COVID-19 illness where recovery is not expected.”⁸ [emphasis added]

Once more, these vague directives could be open to interpretation and, perhaps in this earlier stage of the pandemic, our understanding (and the refusal of many to try to better understand) how to treat COVID-19 might have led to COVID-19 patients being prematurely placed on an “end-of-life” treatment plan which hastened their deaths. All that was required was the “uncertainty” of a patient’s prognosis to have them placed on a palliative or “end-of-life” care plan.

The National COVID-19 Clinical Evidence Taskforce’s (NCCET) guidance is a harrowing reminder of how residents would have been treated in RACFs in 2020.⁹ Their guidance includes recommendation such as:

• How to provide palliative care using baby monitors, or via video tablets from outside the patient’s room “with masks down”; acknowledging (and denying at the same time) the importance of face-to-face communication in palliative care¹⁰;

• Ways to minimise staff interaction with residents to “support infection control” by dosing residents up with “immediate release medications” to knock them out, or with slow release medications to minimise the need for medical or nurse practitioners to repeatedly risk visiting their rooms:

  • “In patients with COVID-19, every interaction (such as providing medication) has an important opportunity cost for nursing staff, and many medications can be omitted, stopped or converted to a once daily formulation (for some drugs given more than once a day) during COVID-19 illness”¹¹;

• Sedating COVID-19 patients as a “last resort” with the lowest possible dose, for the shortest possible duration; all of which, could be open to wildly variable interpretations:

  • “In people with COVID-19, delirium can increase risk to other patients and staff as it may impact on the person’s capacity to understand and follow infection control measures and maintain isolation. . . For pharmacological prevention and management of delirium and agitation, follow guidance as per usual care”.¹²

• Managing breathlessness and cough with sedatives:

  • “For management of the symptoms of breathlessness or cough, use opioids as per usual care. Consider the addition of a benzodiazepine (for example Midazolam) if breathlessness persists.”¹³

Aside from the horrors of using chemical restraint of COVID-19 infected patients as an infection control measure or, as some earlier legacy media reports stated, to manage understaffing at RACFs, doing so could have made their COVID-19 condition far worse. The use of opioids or benzodiazepines can cause harm due to their potential to suppress respiration, depressing the central nervous system and exacerbating respiratory issues caused by COVID-19. These concerns set aside the significant problems associated with opioid use in “opioid naive” populations.¹⁴

In sum, we know that not only was chemical restraint in RACFs lawful, but that it was also recommended.

We also know that sedatives were used.

Shortages and prescriptions data shows sedatives were used

Aside from the few media reports alleging the use of chemical restraint in RACFs, we also have very good data suggesting that these protocols were applied in RACFs and sedative use surged in 2020.

First, data from the Therapeutic Goods Administration’s (TGA) “Medicines Shortage Reports Database” reveals that three of these six recommended palliative care medicines were all affected by shortages in 2020, many of which were driven by “unexpected increase[s] in consumer demand”.

As shown above, both the timing and duration of these shortages neatly correlate with the two COVID-19 waves in 2020 and were driven by “unexpected consumer demand”.¹⁵

We propose that the surge in demand for these sedatives was likely the result of increased palliative and “end-of-life” prescribing combined with their increased use as chemical restraints for infection control, as discussed in the previous section of this article.

These shortages are highly unlikely to have been driven by “unexpected consumer demand” in the nation’s hospitals either. On 24 March 2020, Australia’s Health Protection Principal Committee (AHPPC) announced a temporary suspension of all elective surgeries and this ban was slowly lifted with a phased resumption of surgeries a month later in late April 2020. These measures reduced elective surgeries in public hospitals by 8.3% and 5.2% in private hospitals in the period comparing 2018-19 to 2019-20.¹⁶ Fewer surgeries would have caused a reduction in sedative use, and so, it could only be assumed that the “unexpected consumer demand” would have had other, non-hospital causes.

Second, data from Australia’s Pharmaceutical Benefits Scheme (PBS) also shows that the number of prescriptions for these same palliative and “end-of-life” care medicines surged during these waves of “COVID-19 deaths” in 2020. It is important to note that these data do not include medicines administered to “inpatients” in private or public hospitals, and therefore, the increased usage observed is not affected by “COVID-19 hospitalisations” which were relatively small in 2020 anyhow. For the same reasons, the increased sedative use is also not explained by increased use of mechanical ventilation in hospitals for major surgeries or as part of “COVID-19 ICU admission” (though they could impact the TGA Shortages Database data).

As a “COVID-19 death” did not provide time for a planned and sustained nature of treatment, doctors would have likely prescribed these palliative and “end-of-life care” medicines when visiting these RACFs under these emergency scenarios. In doing so, they would have been likely to have prescribed them under the “Prescriber Bag Schedule”, which offers free medicines for emergency or initial treatment.¹⁷

Our analysis, therefore, focused on changes in the total number of prescriptions for these recommended palliative and “end-of-life” care medicines for COVID-19 patients, prescribed under the “Prescriber Bag Schedule” (click the image below to open the graph in a new window):

As the evidence shows, there are clearly visible spikes for all of these palliative and “end-of-life” care medicines, especially the quite significant spikes for Midazolam, Morphine and Metoclopramide, corresponding with, if not slightly preceding the the first wave of “COVID-19 deaths” of approximately March to May in Australia.

The use of these sedatives preceding the “COVID-19 deaths” is expected because it could have set aged-care residents on a pathway that caused their health to deteriorate, where to a point almost 2-3 weeks later (on average) they succumbed to a “COVID-19 death” or death from other leading causes such as dementia. This reflects a potential “pull-forward effect”, where increased sedation hastened mortality among vulnerable individuals who might have otherwise survived longer.

In the second wave, occurring from July to October, there are surges in prescriptions for Midazolam and Morphine which, though evident, are not as pronounced as all the surges for these and other palliative care prescriptions in the first COVID-19 wave (with the exception of the surge in Chlorpromazine prescriptions in the second wave).

The observed drop in Morphine prescriptions in the data is explained by prescribing restrictions which were imposed by the TGA in June 2020. It is estimated that restrictions which reduced pack-sizes, altered indications for opioid use and modified authority requirements resulted in many more private prescriptions being issued as sales data for these opioids showed little change throughout this period.¹⁸ Therefore, we have reason to believe that the the Morphine prescriptions data might be a significant underestimate and the elevated prescribing for Morphine likely continued in the second COVID-19 wave too.

Deaths by other causes

Deaths by causes (not “COVID-19 deaths”) also reveal the likely harmful effects of the increased use of chemical restraints in RACFs in 2020. Though often regarded as Australia’s “low mortality year” owing to the coincidental disappearance of influenza, there were elevated deaths by leading causes such as dementia in the months corresponding with the COVID-19 waves in 2020 (click the image to open the graph in a new window):

As the data shows, compared against the 2015-19 baseline average, dementia deaths in the first COVID-19 wave were even beyond those of the “worst flu season on record” in 2019. It is anticipated that there is usually an uptick of dementia deaths during bad influenza seasons and this is observed with the surge in these deaths in 2019 (the blue line) in the winter months. The trajectory is similar across all of the mortality lines showing a noticeable rise in the winter months, but two important distinctions with the 2020 line are noted:

1. No evident mortality displacement from this “worst flu season on record” from 2019 to 2020; and,

2. Despite the near total absence of influenza in Australia at the time, dementia deaths in 2020 exceeded those in 2019 between January-April and November-December.

It is plausible that the excess prescribing and shortages discussed earlier in this article for palliative and “end-of-life” care medicines might have also hastened deaths by dementia which could explain the elevated mortality observed during these months in 2020.

Conclusion

Chemical restraint was a practice widely used in RACFs before the pandemic and one which continued in 2020.

The law allowed it as a “last resort” but the evidence shows that residents in aged-care facilities could be placed on palliative or “end-of-life” care if their COVID-19 outcome was simply “uncertain”.

In the national plan, there was no distinction between a palliative and “end-of-life” treatment and it is highly likely that many of Australia’s “COVID-19 deaths” and dementia deaths in RACFs in 2020 were hastened by the application of these protocols and the use of chemical restraints.

As alarming as these revelations might be, the surge in the use of sedatives pales in comparison to the prescribing of these same sedatives in June 2021 onwards.

Something made Australia sicker in 2021 and palliative care prescribing soared from mid-2021 onwards.

We will explore this in our next article.

Thank you for reading.

1. In all of our articles, when we write “COVID-19 deaths” and “COVID-19 cases” we have intentionally placed these terms in inverted commas to emphasise their ambiguity and the potential for them to be misleading. There are very good reasons to distrust the accuracy of PCR-testing. We have previously addressed the dodgy data from PCR-testing methodology. See here: https://www.shiftedparadigms.org/i/137653276/the-world-health-organisation-who-guidance or for more expert commentary read the excellent “Where are the Numbers” Substack.

2. Department of Health, “COVID-19 outbreaks in Australian residential aged care facilities”, https://www.health.gov.au/sites/default/files/documents/2020/12/covid-19-outbreaks-in-australian-residential-aged-care-facilities-30-december-2020-covid-19-outbreaks-in-australian-residential-aged-care-facilities-30-december-2020.pdf, archive link, p. 1, accessed 5 January 2024.

3. Ibid.

4. Human Rights Watch, “Australia: Chemical Restraint Persists in Aged Care”, https://www.hrw.org/news/2022/03/30/australia-chemical-restraint-persists-aged-care, accessed 1 March 2025.

5. The Australian, “Coronavirus: ‘Hospital Does Not Want Them’, Say Relatives”, https://www.theaustralian.com.au/nation/politics/coronavirus-hospital-does-not-want-them-say-relatives/news-story/d0b5bab2dcf94051e4a49e4ccbabfd17?amp&nk=3d692fd2d53bab022bb399f026ff8bf5-1717377006, archive link, accessed 1 March 2025.

6. Aged Care Quality and Safety Commission, “Regulatory Bulletin: Regulation of Physical and Chemical Restraint”, https://www.agedcarequality.gov.au/sites/default/files/media/rb_2019-08_regulation_of_physical_and_chemical_restraint_0.pdf, p. 7, accessed 1 March 2025.

7. Hellocare, “90% Of Residents Sedated Without Consent As Nursing Home Fails Accreditation”, https://hellocare.com.au/90-of-residents-sedated-without-consent-as-nursing-home-fails-accreditation/, accessed 1 March 2025.

8. National COVID-19 Clinical Evidence Taskforce, “Management Of People with COVID-19 Who Are Receiving Palliative Care”, https://web.archive.org/web/20200914145458/https://covid19evidence.net.au/wp-content/uploads/FLOWCHART-9-PALLIATIVE-CARE.pdf, accessed 1 March 2025.

9. As an aside, check and see what’s happened with the NCCET today.

Here’s their webpage:

https://covid19evidence.net.au/

Apparently the funding for the pivotal “National Clinical Evidence Taskforce” was discontinued in mid-2023, and one of the first items on the scrapheap was the domain. The original page is explorable using the Internet Wayback Machine, however, it appears most of the original content has been migrated to a new site called “Australian Living Evidence Collaboration” which purports to provide “Australia’s healthcare professionals with continually updated, evidence-based clinical guidelines”.

10. Ibid., p. 1.

11. Ibid.

12. Ibid., p. 2.

The “as per usual care” refers to the use of chemical restraints as a “last resort” as discussed earlier.

13. Ibid.

14. Delaney, L.D., Bicket, M.C., Hu, H.M., et al., “Opioid and Benzodiazepine Prescribing after COVID-19 Hospitalisation”, Journal of Hospital Medicine, 2022; 17: 539-544. doi:10.1002/jhm.12842.

15. Acknowledging that not all of the medicines recommended in the ANZSPM guidance document appear in the same dosage here. For example, Metoclopramide was affected by shortages in its tablet, not injection form.

16. AIHW, “Australia's Hospitals at a Glance 2020-21”, https://www.aihw.gov.au/getmedia/ded358b4-ca09-4559-bcfc-df050f5ec206/australia-s-hospitals-at-a-glance-2020-21.pdf.aspx, p. 17, accessed 7 March 2025.

17. In 2020, the average mortality timeline for a COVID-19 patient was 18.1 days, and by comparison, patients with terminal illnesses might be on a palliative care pathway for much longer than this.

Marschner, I.C., “Estimating Age-Specific COVID-19 Fatality Risk and Time to Death by Comparing Population Diagnosis and Death Patterns: Australian Data”, BMC Medical Research Methodology, 21, 126 (2021). https://doi.org/10.1186/s12874-021-01314-w

The analysis focused on confirmed COVID-19 cases and included all reported COVID-19 deaths in the surveillance system, meaning it likely considered both deaths from and with COVID-19 under the same umbrella, as long as they met the loose definition of a “COVID-19 case”.

18. Koch, F.C., Olivier, J., Brett, J., Buckley, N.A., Gisev, N., Pearson, S. and Daniels, B., The Impact of Tightened Prescribing Restrictions for Pbs-subsidised Opioid Medicines and the Introduction of Half-pack Sizes, Australia, 2020–21: an Interrupted Time Series Analysis”, The Medical Journal of Australia, 220: 315-322. https://doi.org/10.5694/mja2.52257.