Five Days at Memorial by Sheri Fink. (2/2)
Title: Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital.
Author: Sheri Fink.
Genre: Non-fiction, ethics, medicine, law, journalism.
Country: U.S.
Language: English.
Publication Date: 2013.
Summary: After Katrina struck and power failed, amid rising floodwater and heat, exhausted staff at Memorial Medical Center designated certain patients last for rescue. Months later, a doctor and two nurses were criminally accused of injecting some of those patients with life-ending drugs. The book, developed out of a 2009 news article and the culmination of six years of reporting, unspools the mystery, bringing the reader inside a hospital fighting for life and into the most charged questions in health care: which patients should be prioritized, and can health professionals ever be excused for hastening death? Transforming our understanding of human nature in crisis, the book exposes the hidden dilemmas of end-of-life care and reveals how ill-prepared we are for large-scale disasters-and how we can do better (Refer to PART 1 for rest of the quotes).
My rating: 7.5/10
My review:
♥ Rider often lay awake the night before an arrest, wondering if what she was about to do was wrong. Whether by surprise or self-surrender, she knew it would change the suspect's life forever. In this case, evidence to warrant the arrests before a judge had been present for months. It was time for justice to advance.
Schafer did not wrestle with his conscience over prosecuting the women. Given what he knew about what happened at Memorial, he felt, absolutely, it was right.
♥ Why, in the end, had more than a thousand died immediately in New Orleans-many of them in medical facilities, and many others poor and elderly-and an unknown number of others suffered and died in the aftermath due to stress and disruption of health care? So many reasons. The mayor's delayed evacuation order. The lack of buses and drivers to move people out of town who had no cars of their own. Stubborn decisions to stay by people with the means to leave. Uncoordinated rescue efforts. Confusion and turf battles between different agencies and levels of government. Poor communications, not interoperable. Hospitals and nursing homes that didn't evacuate before the storm and had not invested in backup power systems and backup water systems robust enough to withstand a prolonged emergency. Alarm over lawlessness, which interrupted rescues. It soon became clear that the fear of violence outweighed the actual violence, and that fear itself had compounded tragedy, as when fi0rst responders, including medical workers at the Superdome, were instructed to abandon their posts and their patients out of concern for their own safety. "Most of the worst crimes reported at the time never happened," Times-Picayune reporters asserted in an investigative story, part of a group that won a Pulitzer Prize.
Although real and troubling lawlessness and several murders and violent crimes occurred, rumors of homicidal gangs and "zombies" that had swirled from WWL to the rescue boat pilots to the halls of Memorial were revealed as overblown. Looters were sometimes foragers, searching for food and water. Gunshots assumed to have been aimed at rescuers may have been gunshots aimed, however misguidedly, at alerting those rescuers to the presence of desperate survivors. In the wake of the rumors, journalists began uncovering real and troubling evidence of several white vigilante attacks on unarmed black men after the storm, and of police misconduct, questionable shootings, and a cover-up.
Underlying the official response to the crisis was a lack situational awareness-a view of the larger picture of what was happening and what needed to be done.
All of this had occurred against the backdrop of the knowledge, for years, that exactly such a scenario could occur. The Times-Picayune had written about it. The Hurricane Pam exercises had modeled it.
The hospital was a microcosm of these larger failures, with compromised physical infrastructure, compromised operating systems, and compromised individuals. And also instances of heroism.
The scenario was familiar to students of mass disasters around the world. Systems always failed. The official response was always unconscionably slow. Coordination and communication were particularly bad. These were truths Americans had come to accept about other people's disasters. It was shocking to see the scenario play out at home.
Life and death in the critical first hours of a calamity typically hinged on the preparedness, resources, and abilities of those in the affected community with the power to help themselves and others in their vicinity. Those who did better were those who didn't wait idly for help to arrive. In the end, with systems crashing and failing, what mattered most and had the greatest immediate effects were the actions and decisions made in the midst of a crisis by individuals.
♥ Writer DM Edwards of Marrero, who described having worked at another New Orleans hospital, during the disaster, wondered exactly whose pain the medical workers had been trying to relieve: "Our whole purpose for being here was to aid the patients; not to kill them because we wanted them out of our misery."
♥ The NBC Television news magazine Dateline carried an anniversary report about Memorial's sister hospital, Tenet-owned Lindy Boggs Medical Center. The conditions had been similar to those at Memorial-no power, almost no communications, delayed rescue. Water had poured over the hospital's floodgates with the drama and variegation of a natural waterfall.
With no helipad and no assurance of ambulances a boat ride away on dry ground, hospital staff at first ferried only able-bodied non-patients from Lindy Boggs. On Wednesday, firefighters arrived and began directing drivers of the small dinghies and pleasure boats to take patients to a berm by a nearby post office to be picked up by helicopters. The roughly 150 patients were divided into categories: A, B, and C. Some doctors and nurses thought the C's, the most critical patients, should be rescued first. But the doctors and firefighters in charge decided to leave them for last. The concern might have been that there would not be medical care for them at the drop points. For the Dateline story, reporter Hoda Korb asked firefighter Chris Shamburger the reason for the triage protocol. He offered little explanation: "That's the way things are done."
Dr. Glenn Johnson, acting chief of staff, described drawing letters on people's foreheads with a permanent marker. "I'm just having horrible thoughts, like, 'Is this what happened, like, at Auschwitz or something?' You know, where people were just marked like cattle."
Johnson took pity on a paralyzed patient whose husband offered to carry her-Johnson turned her C into an A, "my one act of mercy for the day."
..The criminal inquiry centered on what had happened after nearly all of the 175 staff members escaped. At the fire officials' suggestion, they had put on gowns and drawn the triage symbol "C" on themselves to look like patients so they could be evacuated by military helicopter. Some took pictures of one another grinning, patient gowns tied loosely over their scrubs, bright-red triage letters marking their chests, hands, and foreheads.
♥ Riopelle, a past president of the state humane society coalition, had quietly decided earlier in the day to disobey the authorities and stay. There was no way he was leaving behind the sixty or seventy pets at the hospital, including his own, just because some twenty-year-old fireman from Shreveport had ordered him to go. He'd made a pledge to himself years earlier, after touring the Holocaust concentration camp Dachau, to refuse to comply with misdirection. Two other hospital staff members with pets-a nurse director and a respiratory therapist-decided to stay behind with him.
♥ The stories from Memorial, Lindy Boggs, and Touro hospitals stood in contrast to the reaction of staff at New Orlean's public Charity Hospital. Charity had flooded; lost power, functioning plumbing, computers, telephones, and elevators; lacked a helipad; and had no corporate overseers to assist, however belatedly. It had taken until Friday afternoon, September 2, to transfer all the patients from there, compared with Thursday, September 1, at Memorial. Approximately twice as many patients were present at the public hospital's two campuses as compared with Memorial, with a lower ratio of staff to patients. However, fewer than ten patients died.
Doctors said that staff continued to provide medical care to patients in their rooms until the end, despite similar or even worse conditions of existential threat, including a gunman reported to be on a nearby roof, disrupting the evacuation, and the presence of more than a hundred psychiatric patients inside. People urinated on stair landings. Convoys attempting to reach the hospital over water were reportedly shot at and looted. News reports suggested the hospital had been evacuated when it hadn't. Soldiers had brought additional ventilator-dependent patients to the hospital.
In articles and conversations, hospital workers chalked up their resilience to a number of factors, including morale building-leaders held meetings every four hours in the lobby for everyone from doctors to janitorial staff. They put on a talent show by flashlight. The painted and laughed.
Hospital officials had drilled for as Category Three hurricane and levee failure and purchased, with the help of federal preparedness funds made available after the 9/11 attacks, several portable generators, oxygen-powered ventilators, and a ham radio system. Special disaster training had been provided to hospital security officers.
The Charity staff was populated by crusty characters accustomed to the comparatively Spartan, chaotic, and occasionally threatening conditions of an inner-city government hospital. Workers included Vietnam War-era ER doctors known for their bravado and machismo. Nearly everyone had experience getting creative with all-too-common resource limitations.
At Charity, workers siphoned gas from cars to fuel ten small portable generators. These were used to power ventilators and cardiac monitors in the ICUs, keeping critically ill people alive, including a very premature baby. This contrasted with Memorial, where patients were ventilated by hand with Ambu-bags after the power failed, as two similar generators were only later put to use for powering lights and fans in common areas and the helipad, not medical equipment.
Charity staff also kept up the hospital routine despite the bizarre conditions. They kept patients in their rooms, continued to provide services like physical and occupational therapy, and encouraged workers to maintain shifts and a regular sleep schedule. This signaled that the situation was under some degree of control and kept panic to a minimum. There was an active effort to stem rumors. "You can only say it if you've seen it," staff were told.
Perhaps most important, Charity's leaders avoided categorizing a group of patients as too ill to rescue. The sickest were taken out first instead of last.
♥ Asked by Safer if she ever lost hope, Pou was indignant. As a cancer specialist, she said, "I am hope."
♥ Minyard was proud of his office and its history and liked to tell people that "coroner" meant "keeper of the crown," the person who collected money for the king when someone died. "It's in the Magna Carta," he'd say. He considered his job to be different from that of medical examiners or pathologists who use "pure science with blinkers" to draw conclusions about the causes and manner of suspicious deaths. He, being elected, was a man of the people.
♥ As a local nonprofit hospital chain, Ochsner Health System, completed its purchase of Memorial and partially reopened it under the Baptist name, Richard Deichmann sent a letter of appreciation to Memorial's medical staff. This incensed Baltz, particularly given that he himself had not received an invitation to the anniversary memorial ceremony. His pointed, two-page reply to Deichmann began by calling his compliments "kind, but inappropriate." Baltz had worked at Baptist for every hurricane except Betsy, when he had volunteered at a high school medical station. To him, service in a disaster was pro forma, not "valorous or uncommon."
True valor would have been to oppose euthanasia; to lock all narcotics and sedatives securely; to erase all order "DNR"; to dissuade naive nurses enlisted to execute orders that ordinarily would have been rejected; to assure that evacuees have secure destinations before being dispatched; to adhere to professional ethics at all times; to guard against aberrant behavior of staff members; to demand the Chief Executive Officer and staff be held responsible and visible; and to pray that Divine guidance grace us with sound judgement, serenity, and composure.
The scenario at Memorial, he wrote, was a horror, but an instance of the horror others faced throughout the Central Gulf Coast region. "Our situation was not unique, but somehow our reactions and responses regrettably were," he wrote. "Other hospitals with similar stress had more success than we. Was there some inherent flaw in our leadership? Look to ourselves and our behavior. Don't indict government abandonment, while ignoring corporate neglect. Don't cite the dread of lawlessness surrounding the hospital, when internally dreadful disregard for law and ethics may have become endorsed policy."
♥ The evolving discipline of biomedical ethics helped define moral choices in American medical practice. A popular conception, first described in 1979, rested on the balance of four principles: respect for patients' informed decisions, the duty to treat patients in ways that benefit them and that do not harm them, and the importance of distributing resources justly. While the latter principle traced back to Aristotle, the field of secular medical ethics was also influenced by concepts of morality rooted in religious law and developed theologians of various faiths, including Catholicism, Judaism, Islam, Protestantism, and others.
Caplan knew that the history of thought, law, and policy on aid in dying could be arrayed along two axes. One was whether or not the patient had requested to die, making him or her either a voluntary or involuntary participant. The other was whether the aid in dying came in an active form, such as the giving of drugs, versus what was referred to as "passive" withdrawal or non-initiation of life-sustaining treatment. The poles of these two axes were known as voluntary, involuntary, active, and passive euthanasia.
Whether killing someone who wished to be killed was an act of mercy or an act of murder was a question that had divided humanity from ancient times, millennia before the advent of critical care medicine focused the modern mind on it. In a story related in the Bible, King Saul, injured in battle, asked his armor bearer to finish him off. He refused, "for he was sore afraid." Saul then fell on his own sword and called out to a passing young man, "Stand over me and kill me! I am in the throes of death, but I'm still alive." The young man did so and later told the story to King David, saying, "I knew that after he had fallen he could not survive." David condemned the young man to death for his actions.
Physician involvement in killing had also long divided opinion, back to the time of ancient Greece and Rome. Hippocrates's thoughts eventually held sway, and many medical schools still honor his tradition by having graduating doctors swear an oath descended from the one attributed to him: "I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan..."
This marked an important transition in medicine. "For the first time in our tradition there was a complete separation between killing and curing," anthropologist Margaret Mead told the eminent psychiatrist Maurice Levine, who recounted their conversation in a widely quoted 1961 lecture reprinted in his book Psychiatry & Ethics. "Throughout the primitive world, the doctor and the sorcerer tended to be the same person. He with the power to kill had power to cure, including specially the undoing of his own killing activities. He who had the power to cure would necessarily also be able to kill [...] With the Greeks the distinction was made clear. One profession, the followers of Asclepius, were to be dedicated completely to life under all circumstances, regardless of rank, age or intellect-the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child."
Mead added: "This is a priceless possession which we cannot afford to tarnish, but society always is attempting to make the physician into a killer-to kill the defective child at birth, to leave the sleeping pills beside the bed of the cancer patient." Mead was convinced, Levine said, that "it is the duty of society to protect the physician from such requests."
The Christian acceptance of mortal suffering as redemptive only solidified the Hippocratic stance. In notable historical cases even the exigencies of the battlefield could not shake doctors' exclusive commitment to preserve life. After Napoleon Bonaparte's troops were struck by plague in Jaffa, in May of 1799 he told his army's chief medical officer, René-Nicolas Dufriche Desgenettes, that if he were a doctor, he'd put an end to the sufferings of the plague patients and the danger they represented to the army. He would give them an overdose of opium, a product of poppies that contains the opiate painkiller morphine. Bonaparte would, he said, want the same done for him. The doctor recalled later in his memoirs that he disagreed, in part on principle and in part because some patients survived the disease, "My duty is to preserve life," he wrote.
Less than two weeks later, Turkish troops closed in on their position. Bonaparte ordered that those in the hospital not strong enough to join the retreat be poisoned with laudanum, a tincture of opium. Dr. Desgenettes refused. The remaining fifty or so patients in the hospital, seemingly close to death, were poisoned instead by the chief pharmacist, but apparently he gave an insufficient dose. The Turks found several alive in the hospital and protected them.
Although stories of wartime mercy killings of injured soldiers frequently appear in fictional novels and movies, it is extrenmely difficult to find a real, documented case of physician involvement. In the nineteenth century, however, a movement arose to challenge the physicians' absolutist views on preserving life. In the United States and Europe, some non-physicians criticized doctors' penchant for prolonging lives at all costs. They advocated using anesthetic drugs developed in the 1800s not only to ease the pain of dying but also to help it along. Known as "euthanasiasts," these advocates called their proposal "euthanasia"-a Greek-derived term (eu = "good," thanatos = "death") that English-language speakers had for centuries used to mean "a soft quiet death, or an easy passage out of this world."
Many doctors argued against the proposed use of their skills to bring about dying, fearing the public would lose trust in the profession. Allowing death to claim patients naturally struck them as far different from causing those deaths. "To surrender to superior forces is not the same thing as to lead an attack of the enemy upon one's own friends," editors of the Boston Medical and Surgical Journal opined in 1884.
Still, the movement for euthanasia grew in the United States and Europe, and it morphed. Some advocates noted the great burdens the sick, mentally ill, and dying placed on their families and society. Helping them die would be both merciful and a contribution to the greater collectivist good. Why not, some asked, extend to terminally ill people what few would deny their sick animals, regardless of whether they were capable of expressing the wish to die? These were lives not worthy of living.
These ideas found particular resonance at a time of wide-spread economic privation, suffering, and hunger in post-World War I Germany. Attention focused on the costs of caring for the elderly, disabled, mentally ill, and other dependent individuals, many warehoused in church-run asylums. (Also couched in terms of public health was the growing international support for eugenics-improving the gene pool of the society-and these individuals were seen as a threat to the purity and superiority of the German race.)
In an effort to save money and resources during wartime in the early 1940s, the Nazis took the ideas to their logical extreme and implemented programs of involuntary "euthanasia" of these populations. By some counts up to 200,000 people with mental illnesses or physical disabilities were executed, the Darwinian notion of survival of the fittest employed to justify the murders. After these programs were shut down, their administrators were sent to orchestrate the genocidal mass killings of Jews and others in extermination camps in Poland during the Holocaust.
Doctor and nurse mass murderers of more recent ilk, some who have killed many dozens of patients before being stopped-Harold Shipman, Michael Swango, and Arnfinn Nesset among them-have similarly targeted the very sick and elderly, as well as those unable to communicate and neglected by their families. On arrest, some have invoked similar justifications, claiming to have euthanized suffering patients to put them out of their misery.
Psychiatrists have profiled these killers, identifying them as grandiose narcissists who tend to bristle at criticism, or to see themselves as saviors or gods unable to do wrong, or who get a thrill out of ending suffering and deciding that somebody should die.
Decades after World War II, arguments for legalizing voluntary euthanasia again gained traction in several European countries. In 1973, a Dutch court ruled that euthanasia and physician-assisted suicide (whereby a doctor provides medicine that a person can take to commit suicide) were not punishable under certain circumstances, and imposed only a symbolic, suspended sentence. These acts were decriminalized in the 1980s and formally legalized by a vote of the Dutch parliament in 2001. Similar laws passed in Belgium in 2002 and Luxembourg in 2009. In Belgium, one pharmacy chain made home euthanasia kits available for about €45, complete with the sedative drug used at Memorial, midazolam; along with the anesthetic drug sodium theopental (Pentothal), which Dr. Ewing Cook used at Memorial to euthanize pets; and a paralyzing agent that stops breathing. The kits were intended for use by doctors in patients' homes. Doctors could prescribe them for specific patients who had signed a request for euthanasia at least a month in advance, after having discussed it with two independent doctors. The Dutch and Belgian laws did not require a terminal medical condition for a euthanasia request to be granted.
In each country, legality rested on different guidelines, which at first appeared to offer important safeguards. For example, in the Netherlands, euthanasia was supposed to be limited to people who made repeated requests to die and were experiencing, as certified by two doctors, unbearable suffering without the possibility of improvement. However, a study of the program showed these rules were not always followed, and a small proportion of people were killed each year without having made an explicit request. There were few prosecutions in these cases. Were the Dutch merely more honest about their practices? Or did the legalization of one form of euthanasia bleed, inevitably, into the other, darker kind?
While it was a problem that some ill or injured people had no option of participating in the program because they could not speak for themselves and had not let their wishes be known, involuntary, active euthanasia was, at the time Caplan made his review of the LifeCare deaths, not legal anywhere. Taking the life of someone who had not expressed the wish to die would contravene the principle that people have a right to decide what doctors can do to their bodies. It would also put the physician or other decision maker in the position of judging what quality of life is acceptable to another human being. The possibility of abuse (for example, insurance payouts for family members) was too great.
However, while not legal, in practice what was considered acceptable in the Netherlands had expanded to include this type of active euthanasia. The 2002 Groningen Protocol for Euthanasia in Newborns, devised by leading Ditch medical authorities, outlined conditions for taking the lives of very ill or brain-damaged babies with the substituted consent of their parents. While this was not explicitly legal, doctors who followed the guidelines were not prosecuted. Babies-sick, disabled babies, but babies nonetheless-were being euthanized openly again in Europe.
The Netherlands' premier advocacy and counseling organization for euthanasia and choice in dying, the NVVE, promoted social acceptance of euthanasia under conditions that were not yet legal in the hopes that they someday would be. People, particularly the elderly, who were reasonably healthy, but who were becoming an increasingly dependent burden on their families, had a profoundly diminished "quality of life," and felt "after many years on this earth, life has been completed," should be entitled to aid in dying, according to the group. So, too, should people with dementia and difficult-to-treat chronic psychiatric illnesses. A Dutch court approved of euthanasia for a woman with advanced dementia who repeatedly communicated her wish to die.
In contrast with the European countries that formally legalized euthanasia in the first decade of the twenty-first century, in the United States, intentionally ending a life to relieve suffering remained illegal. The American Medical Association's influential Code of Medical Ethics continued to prohibit active euthanasia.
The debate in the United States focused instead on what some call passive euthanasia, the withdrawal of life support and withholding of medical treatment. In 1975, not long after the widespread adoption of high-tech intensive care medicine and only a decade and a half after the trial of Nazi leader Adolf Eichmann in Jerusalem had focused attention on the horrors of mass euthanasia, the parents of a comatose young woman, Karen Ann Quinlan, asked doctors in New Jersey to remove her from a ventilator. She had stopped breathing and suffered brain damage after taking the sedative Valium and drinking several gin and tonics with friends. She was not expected to recover, and friends and family recalled her having said she would never want to be kept alive that way. Doctors refused to discontinue life support, but the New Jersey Supreme Court ruled that this could be done on the basis of Quinlan's constitutional rights to privacy and liberty, as exercised by her father. The respirator was turned off.
Quinlan breathed on her own and survived nine more years, but her case became a landmark. Subsequently, state courts ruled in other cases that the right to refuse treatment flowed from established rights to privacy, liberty, self-determination, and informed consent. The right to refuse treatment had already been established, in the case of some Jehovah's Witnesses, on the basis of freedom of religion.
The climate of American medicine had changed since the Clarence Herbert case Dr. Baltz and his colleagues had discussed at Memorial in the 1980s. Doctors treating the comatose Mr. Herbert had been charged with murder for withdrawing life support and intravenous fluids, even as they contended that this accorded with his prior wishes and the requests of his family members, who did not want him on "machines." A California appeals court decided the case should be dismissed because the burdens to Mr. Herbert of continued treatment, although minimal, outweighed its benefits to him, as his prognosis was "virtually hopeless for any significant improvement in condition." Stopping treatment, the court ruled, taking its lead from a presidential ethics commission, was indistinct from never having started it and was not in this case equivalent to active euthanasia. Shutting off an ordinary IV, the court likewise decided, was no different from shutting off a ventilator, as long as the treatment was legitimately refused by a patient or surrogate decision maker.
The case set a binding precedent only in part of California, but these concepts had gained wide acceptance by the time of Katrina. The US Supreme Court in 1990 considered the case of thirty-three-year-old Nancy Cruzan, severely brain damaged in a Missouri car accident years earlier, whose parents sought to remove the feeding tube that nourished her. The Court agreed by a five-to-four margin that the right to liberty included the right to refuse life-sustaining medical care and die. However, the ruling allowed states to require clear and convincing proof of the patient's wishes to discontinue care, not just what was believed to be in the patient's best interest. A Missouri judge allowed Cruzan's nutrition to be discontinued after acquaintances gave evidence this would have been her wish. The case led to increased adoption of living wills and advance directives that documented treatment preferences prior to a catastrophe.
The next battleground was assisted suicide: whether it should be legal for doctors to prescribe drugs certain patients could take to end their lives. Having the option of a painless death at a time of one's choosing could ease the sense of terror, loss of control, and suffering experienced by people with grave progressive diseases such as metastatic cancer, advocates argued. They questioned why only people who relied on life support or medical treatments that could be withdrawn should have the freedom to choose a dignified death with medical assistance.
Opponents countered that removing life support allows nature to take its course whereas assisting suicide is intended to shorten life, long considered unethical and akin to active euthanasia. Hundreds of years after sorcery's amputation from medicine, did Americans want doctors again to conjure death? Could the societal embrace of suicide for terminally ill or disabled people lead members of those groups to feel more worthless, devalued, and abandoned? Would it discount the meaning to be had from family reconnections, insights, and various forms of spiritual enrichment and personal growth that may accompany death's approach? Did it not violate all manner of secular and religious moral proscriptions?
Physician-assisted suicide became legal in Oregon in the 1990s (and later in Washington and Vermont, and was deemed by Montana's state supreme court as not legally forbidden there, as other states began considering the matter), but at the time of Caplan's review, most American doctors continued to reject the practice as unethical. To address the very real issues of pain and suffering in the last stages of deadly illnesses, hospitals and doctors increasingly offered palliative and hospice care programs. These employed an array of medical treatments, counseling, and support to address symptoms and keep patients comfortable rather than to attempt to cure them. Hospice was considered a philosophy and a movement to care for the terminally ill and their families, which took root in the United States in the 1970s after being developed in Britain. Because patients had to agree to forgo treatments aimed at extending their lives, caring for them was thought to be cheaper, too, and Medicare covered hospice care beginning in 1982.
For the minority of patients whose suffering failed to yield even to the most determined efforts to treat it, another strategy had emerged: terminal sedation. The idea was to render patients unconscious until death. A proposal that would have explicitly legalized the practice upon request of "mortally injured and diseased persons" had been made and voted down by the Ohio legislature in the first decade of the 1900s, but interest in it surged again in the 1990s.
Terminal sedation seemingly fulfilled the goal of relieving terminally ill patients' discomfort without intending to kill them, but it did not do away with all ethical bugbears. A sedated person was unable to eat and drink, which would eventually lead to death, and unless the drugs were withdrawn and the patient awakened, it would be impossible to know whether the symptoms had abated. Still, in a 1997 decision that there was no constitutional right to physician-assisted suicide, the US Supreme Court supported the legality of terminal sedation. While Dr. Minyard deliberated about Memorial, the American Medical Association's top ethics body was considering a proposal to endorse terminal sedation as a last resort under the more palatable term "palliative sedation." (It later backed the practice in 2008.)
..Ethicist Arthur Caplan concluded that what had happened at Memorial did not fit within the purview of palliative sedation precisely because of these guidelines. If the accused women had intended solely to ease pain and discomfort on Tuesday, September 1, then he would expect at least some documentation that the medicines were given gradually and with care. The fact that doctors, including Pou, had recorded some medication orders by hand throughout the disaster before midday on Tuesday meant that, while difficult, this was not impossible. Even war hospitals kept records. The apparently rapid introduction of large amounts of drugs known to be lethal, without any proper use in these patients, concerned him. It also disturbed him that at least some of the patients did not appear to have been terminally ill. No effort seemed to have been made to consult with the family members who were present at Memorial.
He was unconvinced that the sole option to relieve any pain or suffering was to kill.
Caplan had told CNN viewers that judges and juries rarely convinced physicians and non-physicians for murder when they believed the motive for hastening a death was compassionate. Studies in 1973 and in 1987 of twenty cases of alleged euthanasia found that only three resulted in prison sentences, and those were marked by unusual circumstances, including that the victim may not have been terminally ill and suffering. Similarly, juries have acquitted-sometimes on technicalities-physicians who have intentionally killed patients with air emboli, potassium chloride lethal injection, and expired Amytal Sodium sedatives. One of the few doctors to see jail time was Jack Kevorkian. He escaped conviction for first-degree murder several times in the 1990s, even as he hooked up more than 100 suicidal patients to his death machines. Kevorkian finally goaded a judge to send him to prison for second-degree murder after he videotaped himself injecting drugs into Lou Gehrig's disease patient Thomas Youk in 1998 to put him to sleep, paralyze his muscles, and stop his heart, killing him. Previously the patients themselves, not Kevorkian, would press a button or handle on his machines to release a sequence of deadly drugs or carbon monoxide gas. Kevorkian later said he wanted to go to jail to make a point and shift public debate from assisted suicide to euthanasia.
♥ The headline of the February 1, 2007, New Orleans daily newspaper the Times-Picayune reported that coroner Frank Minyard had made his decision on the Memorial cases: "N.O. coroner finds no evidence of homicide."
..Rider slapped the paper on Minyard's desk. She sat down before him in tears. She was convinced by everything he'd told her that he believed the deaths were homicides. "How could you do this?" she asked. "How could you say this?"
There was so much local support for Pou, Minyard explained. A public homicide declaration would stir the media into a frenzy. That would look bad for the city.
What will it look like for New Orleans when this all comes out, Rider asked, when the world knows that the truth was swept under the rug? A corner's job was to discover and report the truth!
Minyard told her he had to consider what was best for his city, whose reputation had already suffered so much damage.
But did his own reputation concern him more?
Rider had never witnessed the level of politics that she had seen in this case.
♥ In one of their bull sessions in the smoking area outside of the office, Schafer called her a "naïve little girl." The way he saw it, she was used to going into a nursing home, finding someone stealing out of purses, and arresting that person. This wasn't a case of investigate, arrest, and you're done. Look at the overall picture here, he'd tell her: a city underwater, politics in the background, multimillion-dollar corporate interests, the medical profession on trial. He had tried to warn her not to get emotionally involved, that the case would tear her heart out. And now it had.
The truth was that he greatly respected her. He watched her cry, a woman who'd been to the police academy, who toted two pistols, who had many years of experience as an investigator, whose quality of work on this case had been peerless all the way.
She had collected overwhelming evidence of homicides. She had earned the right to be disappointed, to be devastated.
Rider began applying for new jobs, a dozen in one week. On Valentine's Day she had a promising meeting that evolved into an offer. Schafer didn't see the emotion behind her departure as much as he saw that it would make her money and give her the chance to become a CPA. She had ambition. He thought the move made good sense for her career. In the end Schafer wasn't Cary Grant, fighting to rekindle the passion of his jaded girl Friday for the work she clearly still loved. He let her go.
♥ Some attorneys in New Orleans believed that poor patients had less wherewithal to sue their doctors. LSU had not reopened Charity Hospital in New Orleans after Katrina, lobbying instead for state and federal support to build a long-hoped-for new hospital, and Earl K. Long was picking up some of the slack. The air conditioner in the operating room didn't work reliably, and Pou operated sometimes under the light of hinting headlamps. Pou questioned her surgical academy's practice of sending surgeons overseas when Louisiana was, to her mind, "as Third World as any place you want to visit."
The state medical board had not sanctioned or investigated Pou. She even received something of a promotion, being named director of Louisiana State University's residency training program for her specialty, which required the approval of national medical organization.
♥ "Well, there was the problem with the Coast Guard," Pou asserted. "The Coast Guard do not fly at night. When you have a disaster, you need people who can fly at night. That's absurd that that can't happen, in my opinion."
Of course the contention wasn't true. In the days after Katrina, Coast Guard air crews had donned night-vision equipment and risked tangling themselves in power lines to land on rooftops, hack into attics, and rescue people, including patients at Memorial. The Coast Guard had specific policies and procedures for flying at night.
Pou could fix on an idea and be absolutely convinced of it, and convince others of it, even without all the evidence. "Trust me, they don't fly at night," she said to the audience.
♥ A few hours later in the transformed hotel basement ballroom, a former colleague of Pou's welcomed around two hundred guests who had donated up to $2,000 per couple to attend and support her. "Doing the right thing sometimes isn't the most popular thing to do," he said into a microphone. "But it certainly is not a crime. And so I think all of us are here today to celebrate doing the right thing. So that's what I want the emphasis of this evening to be, is to be a celebration."
..The event raised close to $100,000..
♥ A presenter read a quote from the World Medical Association, an organization founded after World War II to set ethical guidelines for doctors. In a disaster, "patients whose condition exceeds the available therapeutic resources," the organization said, "may be classified as 'beyond emergency care.'" Rather than maintaining their lives at all costs, "the physician must show such patients compassion and respect for their dignity, for example by separating them from others and administering appropriate pain relief and sedatives."
♥ They also took to calling the concept "reverse triage," as in the reverse of what a layperson would expect. The term was used, albeit rarely, to refer to theoretical wartime situations where treating the most able-bodied first to get them back on the battlefield could help ensure the group's survival.
♥ The AMA delegates voted to create model legislation to shield disaster doctors from civil and criminal prosecution. Members would be encouraged to lobby nationwide for a new standard for conviction that would require proving a doctor set out with malice to hurt a patient. The AMA would also strengthen existing efforts to oppose criminal prosecution of doctors, with an emphasis on doctors in emergencies.
Without a jury or a judge having yet ruled on Pou's case, without Pou having shared publicly what she had done, organized medicine's main response to the alleged murders at Memorial was to close ranks and defend itself.
♥ Someone asked him, "What would you have done if you were working at the hospital under those conditions?" And he knew exactly what "those conditions" were, could imagine them from his four days trapped at the courthouse in the heat, hustling for water and food, smelling urine, his bare feet slipping on the damp floor, his boots stuck back in his flooded truck.
What would he have done? He would have done what he thought was best for each person. And, by his ethic, sick people came before non-sick people. One thing he wouldn't do if they told him to leave the hospital, that they were closing it down at five p.m., everybody out, he wouldn't walk around with two syringes and shoot up nine people to kill them because they couldn't get them off the seventh floor. "I know I wouldn't do that," he said. Not that he was saying Pou had done it.
♥ He looked out at the jurors and imagined he saw the larger public sentiment reflected in their eyes. Pou was Mother Teresa. Florence Nightingale. He looked into these citizens' hearts and saw they were not interested in bringing charges against her. That was how he would later describe it.
♥ Dr. Horace Baltz resented the thrust of what he began calling the "euthanasia rally." By warning that an indictment would lead medical professionals to leave New Orleans, Pou's supporters were threatening to abandon their patients if the issue wasn't resolved to their satisfaction. It was ridiculous, irrational. It undermined the trust of society in the medical profession. How dare these educated professionals hold a gun to the head of the community and say, "You do what we want!" Never had he seen such a constructed, hysterical response to serious allegations.
♥ He insisted he didn't feel one way or another about the outcome of the case, didn't care. The abiding lesson he took from it was the need to evacuate in advance of future storms.
♥ Pou continued to practice surgery and went on to become a popular national lecturer on "ethical considerations" in disaster medicine. In her talks, she rewrote history. "FEMA called us and said we're taking the airboats at noon," she said as the keynote speaker at a conference registering nearly a thousand California hospital executives and health professionals, who gave her a long ovation. "So whatever you can get out of the hospital get out because they can no longer stay." In all the months Virginia Rider and Butch Schafer had investigated events at Memorial, and in all the years of stories journalists had written about the disaster, nobody had made that claim.
Standing on stage, her voice booming through the large hall, Pou said that in addition to no running water there was "no clean water" at Memorial-though investigators found a large amount of bottled water left over after the evacuation-and she asked audience members to put themselves in the position of deciding who should get the last bottle of drinking water-an employee or a patient, "Who gets it? Who gets the one bottle of water?"-a decision that was never necessary at Memorial.
"The Coast Guard helicopters did arrive," she said, "late Thursday afternoon." She spoke as if helicopters had not arrived early on Tuesday morning. Their presence that morning was documented by the pilots themselves, and the cacophony they caused was later recalled by LifeCare staff members present as Pou gathered drugs and supplies to inject the patients (asked about this, Pou's attorney, Rick Simmons, countered in a letter: "The obvious effect of that type of contention would be that the helicopters were awaiting right outside and ready to evacuate patients. This is just not so." He added: "We flatly deny this new contention of 'loud helicopters' during the morning hours.") Pou also did not slay that the Coast Guard came to rescue patients on Tuesday afternoon, the day the floodwaters rose, and throughout Tuesday night, and into Wednesday morning-despite Memorial employees having tried repeatedly to send the helicopters away after deciding it was too dangerous to conduct the evacuation in the dark and that staff needed rest. "I should note that, something I didn't know: Helicopters cannot fly at night," Pou told the audience, years after a colleague at her Houston fund-raiser had gently tried to relieve her of this mumpsimus.
Embellishing the profound hardships she experienced might have been inconsequential except for the fact that as Pou lectured to medical groups around the country, she used these stories-juxtaposed with the fact of her arrest-to convince her audiences of the need to crusade for immunity laws that would prevent people from suing and prosecuting medical professionals in future emergencies. In her talks, Pou sometimes flashed her mug shot on the screen, but she did not say that she was arrested for having allegedly murdered patients, not for having made the challenging and controversial triage decisions she discussed. In fact, she left out mention of injecting patients entirely. In lectures to hospital executives in Sacramento, disaster preparedness planners in Chicago, doctors in Texas, and attorneys ion New Orleans, she did not discuss or explain the decision she and her colleagues made to medicate at least nineteen patients on Tuesday, September 1, all of whom died as helicopters and boats emptied Memorial.
Pou took issue with the AMA's ethical directive for doctors to serve in emergencies "even in the face of greater than usual risk." Pou said, "The duty to care sounds easy, great. It's not always so; it's more romantic on paper." Pou concluded her Sacramento talk by sharing her views on handling the media in disasters: "Restrict them and use them to the best of your ability."
♥ It took until 2013 for the checks to be distributed-more than seven years after Katrina, in a case some referred to as a "full employment act" for disaster-struck New Orleans attorneys. Many families objected in court to what they considered meager compensation for the suffering they and their loved ones endured.
In order to receive money, those eligible had to submit a notarized claim form indicating whether physical or emotional injuries were suffered. Funds were divided among three categories: patients who died, patients who survived, and non-patients. Each claim effectively reduced the payout to other claimants in the same category.
Anna Pou opted in for a share of the settlement. According to the guidelines, she qualified for $2,090.37 for each day she was at Memorial.
♥ What was it about death in the United States? Why did it seem like Americans were so unprepared for it when it occurred? She had seen it again and again working in the ICU. People often did not want to talk about death with the dying, or be there with a relative when it happened.
Why did we celebrate every milestone in life except this one? she wondered. Everyone wanted to be there to witness the beginning of life, but the ratio of birth to death was one to one. She would ask, "If your best one got on the slow boat to China, you would not be at the dock saying good-bye? ..We're so frightened of 'euthanasia,'" she would say. "It's the race card of medicine. It's like the word 'lynching.'" She wanted that to change.
♥ Forensic Expert Cyril Wecht did not care if Pou was punished. What he cared about was the truth and what could be learned from it. For heaven's sake, he thought, Memorial wasn't on a goddamn battlefield with enemy shells coming in. This was New Orleans, and there were helicopters and boats. And really, were they saying they couldn't get patients off the seventh floor? Given a choice, would someone rather die a painless death or live after being lowered, however uncomfortably, from a window? A great disservice was being done to the field of medicine, because the events were covered up and medical leaders reacted emotionally, without knowledge about what had happened. For now the lessons seemed to be that in a disaster if you're a doctor, you're in charge. If you feel giving large doses of morphine and Versed are appropriate, go ahead. It's your call. "Is this what we want young doctors to learn?" he asked. "It's a goddamn precedent, a very dangerous, bad precedent."
♥ King had worked closely with Anna Pou throughout the disaster, switching off caring for patients on the second floor. He'd thought she was doing yeoman's job. What troubled him later was how easily someone with whom he'd had a cordial relationship could be turned to do something so horrible. No matter how tired a doctor was, the initial reaction to the proposal should have been to take a step back and say, "Are you kidding me? Oh no, that just doesn't sound right." He wondered what words someone could possibly have used to make Pou and others say instead, in essence, "We know this is not how we usually function, but today we're going to do it and pretend it never happened." He could not wrap his mind around it. And he could not believe that Pou was allowed to continue practicing medicine.
♥ Pou had genuflected to thank God that she wasn't going to prison? He longed to hear that she had taken to her knees to do something different: beg forgiveness for having violated the commandment "Thou shalt not kill."
♥ "I felt like I was on the Titanic," she told the Texas Medical Association in 2012, where she received a standing ovation. She has referred to what happened at Memorial and her subsequent arrest as a "personal tragedy." In arrangements with meeting organizers, Pou has often prevented journalists from attending her lectures about Katrina.
♥ Yet incredibly, just as in the lead-up to Katrina, some staff members said they had never pondered or planned for what they would do in case of a failure of the backup plan to the backup plan-a complete loss of power. This was true not just there, but also in many places where I have reported since Katrina. Emergencies are crucibles that contain and reveal the daily, slower-burning problems of medicine and beyond-our vulnerabilities; our trouble grappling with uncertainty, how we die, how we prioritize and divide what is most precious and vital and limited; even our biases and blindnesses.
♥ In 2008, citing the arrests of the Memorial health professionals and fears that a severe influenza outbreak could emerge and force providers, again, into making life-and-death choices between patients, New York planners published a protocol for rationing ventilators. The guidelines, devised by experts in disaster medicine, bioethics, and public policy, were designed to go into effect if the United States was ever struck by a pandemic comparable to the 1918 Spanish flu outbreak, which sickened more than a quarter of the population, overwhelmed hospitals, and killed an estimated 50 million people worldwide-the most deadly disease event in recent history.
When state health department officials ran exercises based on scenarios involving H5N1 avian influenza-a strain of "bird flu" that had caused deadly outbreaks in humans around the world and that experts feared might mutate into a form that could spread easily between people-questions about how New York hospitals would handle massive demand for life support equipment rose.
"They kept running out of ventilators," said Dr. Tia Powell, former executive director of the New York State Task Force on Life and the Law, which was asked to address the problem. "They immediately recognized this is the worst thing we've ever imagined. What on earth are we going to do?"
First the experts recommended ways that hospitals could stretch supply, for example by canceling all elective surgeries during a severe pandemic. New York also purchased and stockpiled additional ventilator-enough to deal with a moderate pandemic but orders of magnitude fewer than would be needed in a severe outbreak of 1918 scale.
Officials realized those two measures alone would not be nearly enough to meet demand in the most dire scenario. Ventilators were costly, required highly trained operators, and used oxygen, which could be limited in a disaster-so the group drew up the rationing plans. The goal, participants said, was to save as many lives as possible while adhering to an ethical framework. This represented a departure from the usual medical standard of care, which focuses on doing everything possible to save each individual life. Setting out guidelines in advance of a crisis was a way to avoid putting exhausted, stressed frontline health professionals in the position of having to come up with criteria for making tough decisions in the midst of a crisis, as the ragged staff at Memorial Medical Center had to do after Hurricane Katrina.
The New York group based its plan, in part, on a 2006 rationing proposal developed by health officials in Ontario, Canada, responding to the severe acute respiratory syndrome (SARS) pandemic. The Canadians took a tool that doctors use to track the progress of ICU patients, known as the Sequential Organ Failure Assessment (SOFA) score, and used it to help guide which patients would-and would not-be allotted ICU care in a severe emergency.
The SOFA score was not designed to predict survival and was not validated for assessing the health status of children, but the experts adopted it in the absence of an appropriate alternative.
The New York protocol calls for denying some of the sickest patients with the highest scores access to scarce ventilators. Hospitals are also to withhold ventilators from patients with serious chronic conditions, such as kidney failure, cancers that have spread and have a poor prognosis, or "severe, irreversible neurological" conditions that are likely to be deadly.
♥ Take the Flood Control Act of 1928, the massive legislative initiative resulting from the devastating 1927 Mississippi River floods. It tasked the Army Corps of Engineers with improving levee and flood-control systems, but protected the Corps from liability from any damages that might result from this work. That included the levee failures after Katrina. "This story-50 years in the making-is heart-wrenching," wrote US District Court Judge Stanwood Duval Jr., who presided over cases attempting to hold the Corps accountable for what the judge called the levee system's "tragically flawed," knowingly inadequate construction. "The Corps' lassitude and failure to fulfill its duties resulted in a catastrophic loss of human life and property in unprecedented proportions," he wrote. However, because legislators had passed immunity provisions that were interpreted as virtually absolute, more than a half million post-Katrina flood victims lost their fight for billions of dollars in compensation. "Often, when the King can do no wrong, his subjects suffer the consequences. Such is the case here," Duval wrote, reluctantly delivering verdicts denying the claims against those "tasked with the protection of life and property."
♥ A year after Pou's campaign, and again three years later after consulting with emergency responders across the country, a group of disaster experts convened by the Institute came down unequivocally on the question of euthanasia in guidance to policymakers and the public on medical care during disasters: "Neither the law nor ethics," they wrote, "support the intentional hastening of death, even in a crisis."
A bioethicist uninvolved with the group shared a similar view. "Rather than thinking about exceptional moral rules for exceptional moral situations," Harvard Dr. Lachlan Forrow, who is also a palliative care specialist, wrote, "we should almost always see exceptional moral situations as opportunities for us to show exceptionally deep commitment to our deepest moral values."
♥ Many of the plans are based on the Ontario and New York ventilator guidelines. The US Veterans Health Administration-which has 144 medical centers across the country-also drafted similar protocols.
However, mounting evidence suggests that the plans would not accurately direct care to patients who are most likely to survive with treatment, as is often presumed. Several researchers have studied how groups of ICU patients might fare under these emergency protocols. They asked doctors to categorize the patients in their ICUs during the relatively mild H1N1 "swine flu" pandemic as if it were an emergency and they needed to ration. The results were disturbing. The majority of patients who would have been tagged as "expectant" (i.e., likely to die or unable to be saved with the resources available; analogous to Memorial's "category 3") and been designated for withdrawal of ICU care and ventilator support in fact actually survived with continued treatment and were discharged from the hospital. In some cases, their ventilators would likely have been reassigned to a group of patients whose survival rate turned out to be lower. Even with clear guidelines to follow, triage officers often disagreed and lacked confidence in their categorization decisions.
In other words, there was slim if any evidence that taking away ventilators or other resources from patients with a lower triage priority actually would have saved more lives. Moreover, in some instances just the opposite appeared to have been the case. "A new model of triage needs to be developed," British researchers who tested a version of the protocols wrote in a medical journal article in 2009.
New models have been proposed, including prioritizing patients along a scale with a sliding cutoff point rather than categorically excluding members of certain groups; patients assigned a low priority would then be provided treatment if it became available. But six years later, in 2015, many disaster plans on the books across the country had not been modified, and some additional state plans-newly required for certain federal preparedness grants-were being adopted based on the faulty model.
♥ At Connecticut Hospice in Branford, which evacuated in haste as Sandy approached, the staff did consult with patients and their families. They discovered something surprising. Hospice leaders had planned to move the sickest patients first. But those patients and their families chose to allow the healthier patients to go first.
Involving patients and their families in these decisions is all too rare. Triage is typically seen as the preserve of medical professionals. The ventilator rationing protocols that have been developed around the country have not been publicized, perhaps out of fears of how the public will react; even many medical professionals aren't aware that their states or hospitals have them in place.
Reluctance to draw public attention to the plans is understandable. They outline the creation of what could, in all fairness, be called death panels: groups of doctors who would decide which patients are given a higher chance to survive. Similar fears surround health-care reform in the United States-when insurance coverage is expanded to more people, what services, to which people, will be cut? Whether the disaster protocols reflect the values of the larger public simply isn't known. In an age of extreme sensitivity over health-care rationing, almost no one has dared to find out.
♥ As the medical control chief of the Office of Emergency Management at Johns Hopkins Hospital, a 1,059-bed tertiary referral hospital and the cornerstone of the $6.5 billion Johns Hopkins Medicine enterprise, she was asked to help design a pandemic plan. In discovering how inadequate even this well-endowed hospital system's supplies were in relation to expected demand, she recognized an acute analog to the chronic resource dilemmas she had seen in other countries.
♥ Both Schultz and Knebel make vital points. What will save the most lives in an overwhelming emergency probably won't be refining how a set number of patients is triaged, essentially shuffling the same deck of cards so that different numbers and suits come up on top. What will save more lives will be doing everything possible to avoid having to deal the hand, by taking steps to minimize the need to compromise standards, and promote the ability to rebound as quickly as possible to normalcy. One of the greatest tragedies of what happened at Memorial may well be that the plan to inject patients went ahead at precisely the time when the helicopters at last arrived in force, expanding the available resources.
♥ Still, sometimes there is no substitute for the highest standards of medical care when it comes to saving lives in a disastrous epidemic, as the Ebola outbreak that was declared in West Africa in 2014 demonstrated. Only foreigners were sometimes whisked away for sophisticated care. They grappled with guilt over the disparity in treatment they received versus that they had provided as aid workers. Of the twenty-six patients known to have been cared for in hospitals in the United States and Europe, fewer than 20 percent died. That contrasted with a fatality rate of well over half of patients in many treatment units in West Africa, where thousands were treated.
Many familiar themes concerning preparedness and triage emerged during the epidemic. Although Ebola was identified in 1975, had been up to 90 percent fatal in previous outbreaks in rural Africa, and was viewed as a potential bioterrorist threat, experimental vaccines and treatments were in an early stage of development when the epidemic was recognized in early 2014. Public health surveillance systems throughout the world remained weak and underfunded. The World Health Organization, forced to decrease its budget during a global financial crisis, had cut its epidemic response units disproportionately.
When the epidemic began raging out of control in the spring and summer of 2014 in Guinea, Sierra Leone, and Liberia, even basic protection-gloves, gowns, running water-was frequently unavailable in hospitals. Nurses, doctors, and other health workers died.