Clinical Advances in Hematology & Oncology
June 2014, Volume 12, Issue 6
As soon as I began my journey through those dark pages, I knew that this book would be the one. Five Days At Memorial by Dr Sheri Fink was clearly the most provocative book we had read for our book club for fellows (and others). The Côtes du Rhône and chilled Vermentino facilitated discussions of ponderous ethical issues that went on long after the hour was over.
The author detailed the plight of patients and doctors at Memorial Hospital in New Orleans in the devastating aftermath of Hurricane Katrina. The gods of chaos, miscommunication, and fear created an environment in which decisions were made that led to the indictment of 2 nurses and 1 doctor. These health professionals had stayed behind to care for patients awaiting boats or helicopters to rescue them from a hospital left without electricity, air conditioning, or running water. Rumors of armed marauders outside further contributed to the fear. The corporation that owned the hospital did little to provide aid.
We were all amazed by the poor preparedness for such a disaster in a city below sea level. Not only did Hurricane Katrina occur after 9/11, but the hospital had suffered a flood years earlier without making plans to deal with a subsequent catastrophe.
The book provided serious ethical, moral, and medical dilemmas. Many decisions had to be made, yet it was never clear who was in charge. Who should have come to the rescue? Certainly the Tenet Healthcare Corporation, which owned and profited from the hospital, yet provided no assistance during the crisis. But what was the responsibility of the government, which also failed its citizens?
Who should have determined the order of triage for patients to leave the hospital, and on what basis should triage have been done? I asked my charges which patients should have been evacuated first: those who were most fit, or those at the other end of the health spectrum? For most of us, the decision largely boiled down to whether we thought that help was imminent. If so, then the more debilitated should have been evacuated first because the healthier patients were more likely to survive the delay. Given the uncertainties of the situation, however, and after several days without power or water in stifling heat, the sickest were left for last. What was not known at the time was that the supposed “safe havens”—the Superdome and the various parking lots for the evacuees—were perhaps more dangerous than the hospital from which patients were being rescued.
And then there were those considered too ill to be moved at all, even after all the rest had gone. They certainly could not just be left behind. Their fate was left in the hands of exhausted health care providers including Dr Anna Pou, a head and neck surgeon who was depicted as caring and compassionate. When evacuations were finally done, 45 patients had died, including 23 who were found to have elevated blood levels of morphine and/or midazolam that had not been prescribed for them in most cases.
The crucial question was whether it was right to inject patients who were unable to be moved with lethal doses of painkillers. Where is the line between making a terminally ill patient comfortable and euthanasia? Do patients having agonal breathing actually experience pain? Here there was disagreement among our group. Some felt that life should be preserved at all costs, regardless of quality. Others felt that it was more humane to prevent terminally ill patients from suffering a lonely death after abandonment. Clearly, whether there was an end in sight factored into the decision. And there was none. Should the rules of ethics change in a crisis situation? Perhaps to some degree, but the limits were unclear.
Another thing that shocked and disturbed our group was all of the healthy pets who were brought to the hospital for protection, but who ended up unnecessarily being put to death.
It was truly ironic that the adjacent cancer center had electricity and water, yet was not being used for the care of any patients or the refuge of most of the doctors.
The story concludes with the events and thoughts leading up to the final question: should Dr Pou and her 2 nurses have been convicted of murder? Read this exceptional book for yourself and see whether you agree with the verdict.
Until next month . . .
Bruce D. Cheson, MD