PDF Summary:Five Days at Memorial, by Sheri Fink

In August 2005, Hurricane Katrina struck New Orleans, leaving Memorial Medical Center flooded and without power. In Five Days at Memorial, journalist Sheri Fink examines what happened during those five days when medical staff faced impossible decisions about patient care and evacuation priorities. The crisis exposed failures in disaster preparedness, from vulnerable electrical systems to inadequate emergency plans that hadn't anticipated the reality of a major flood.

Fink explores the ethical and legal questions that emerged when doctors decided which patients to evacuate first and how to care for those left behind. She discusses the controversial medical decisions made under extreme conditions, the subsequent investigations and legal proceedings, and the broader implications for medical ethics and disaster policy. This summary provides insight into how systemic failures, resource scarcity, and crisis conditions intersect with medical decision-making and the legal standards that govern care.

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Crisis Response, Ethical Dilemmas, and Lawful Consequences

Fink discusses how the crisis at the hospital in Memorial highlighted ethical dilemmas in triage and patient care decisions. Doctors determined that patients with DNR directives would be evacuated last, based on the belief that these patients had less to lose. This decision wasn’t communicated to patients or their relatives, leading to distress when they discovered their loved ones were being left behind. The decision to prioritize patients with the best chance of survival over those in critical condition was based on a utilitarian approach, aiming to maximize benefits for as many people as possible. However, this approach raised ethical questions about whether it was just to sacrifice people who most needed care.

(Shortform note: Bioethicists like Tom Beauchamp and James Childress, authors of Principles of Biomedical Ethics, argue that the utilitarian approach to triage, which prioritizes patients with the best chance of survival, is based on the principle of beneficence. This principle emphasizes maximizing benefits for the greatest number of people. However, this approach can conflict with the principles of respect for persons and justice, which emphasize the importance of treating each individual with dignity and fairness. The decision to sacrifice people who most needed care raises ethical questions about whether it’s just to prioritize the needs of the many over the needs of the few.)

The circumstances at Memorial Hospital reflected broader systemic failures in disaster preparedness and response, including inadequate infrastructure, poor communication, and lack of coordination among agencies. These failures contributed to the difficult decisions faced by medical staff and the suffering of patients and families.

(Shortform note: Ask your local emergency management office for a copy of your community’s emergency operations plan. Use the problems at Memorial as a checklist: inadequate infrastructure, poor communication, and lack of coordination among agencies. Then, calmly ask officials at public meetings to explain how those weaknesses are addressed in your area.)

Fink notes that legal and ethical standards were challenged by the choices made during the crisis. The decision to prioritize DNR patients last for evacuation was based on a misunderstanding of the law and a value judgment about their lives. The law doesn’t mandate that DNR patients must have an incurable or irreversible illness, and there’s no evidence that they would object to being rescued even if it cost other lives. The choice wasn't communicated to the patients or their loved ones, and in some instances, this was done intentionally. The decision to hasten the deaths of patients wasn’t supported by law or ethics, even in a crisis.

(Shortform note: In Resolving Ethical Dilemmas, Bernard Lo explains that a DNR order is a request to not be resuscitated in the event of cardiac or respiratory arrest. It doesn’t mean that the patient wants to die or that they don’t want to be rescued from danger. It also doesn’t mean that the patient wants to be euthanized or that they want to be given a lethal dose of medication. A DNR order is a specific request to not be resuscitated in the event of cardiac or respiratory arrest, and it doesn’t give doctors the right to make decisions about the patient’s life or death.)

The decision to reduce the quality of care was criticized by some experts, who argued that the aim should be to deliver the best possible care given the situation. Reducing the quality of care can be dangerous because it can lead to a slippery slope where the standard is lowered even further in non-emergent situations.

(Shortform note: The Institute of Medicine (IOM) has published a series of reports on crisis standards of care, which are guidelines for how to allocate scarce resources during a disaster. The IOM argues that in a crisis, it may be necessary to depart from the usual standard of care in order to maximize the overall benefit to the population.)

Let’s explore the immediate crisis conditions and actions at Memorial Hospital, along with the ethical, legal, and policy ramifications of the crisis.

Immediate Crisis Conditions and Actions

Fink describes how Memorial Hospital faced immediate crisis conditions after Hurricane Katrina, including rising floodwaters and a lack of resources. The hospital's leadership declared a change from "assault mode" to "survival mode." Due to looting in the vicinity, the hospital went on lockdown while other hospitals began evacuating. Despite the heat, the hospital was running nearly as usual. The maintenance team cleared debris, dismantled floodgates, and fixed the roof's holes.

(Shortform note: According to some disaster preparedness and response researchers, hospitals can create problems for themselves by locking down too early and switching to “survival mode.” In an academic book, the authors explain that hospitals that lock down too early can cut off lines of communication and coordination with outside agencies. This can delay or complicate evacuation support, leaving patients and staff trapped in a deteriorating situation. Additionally, the shift to “survival mode” is often informal and vaguely defined, which can lead to confusion and inconsistent decision-making.)

Kitchen staff were distributing food, and the lead pharmacist was working to arrange a supply drop from his vendor to replenish the shrinking stock of medications. The leadership group sought nurses experienced in conducting dialysis for renal patients. Dialysis centers in the city had shut down, and their patients were arriving at the hospital. The dialysis process required water, but reports said the city water was so heavily contaminated with chemicals and bacteria that bathing in it would be dangerous. The doctor had a choice to make: patients needed dialysis to survive, but the timing of their transfer from Memorial was uncertain. The hospital's heliport had been out of use for many years. The heliport hadn't been used since a 1987 drill that coincided with the Pope's visit to New Orleans.

How Dialysis Works

Dialysis is a process that removes waste products and excess fluid from the blood when the kidneys are no longer able to do so. There are two main types of dialysis: hemodialysis and peritoneal dialysis. In hemodialysis, the patient's blood is pumped through a machine called a dialyzer, which acts as an artificial kidney. Inside the dialyzer, the blood flows through thin fibers made of a semi-permeable membrane. On the other side of this membrane is a special fluid called dialysate, which is made by mixing purified water with chemicals that help draw waste products out of the blood. The dialysate is constantly refreshed during the treatment, and the patient's blood never actually mixes with the dialysate. However, the blood and dialysate are separated only by a thin membrane, so any impurities in the water used to make the dialysate can easily pass into the patient's bloodstream.

Memorial faced several operational and logistical challenges during the crisis. We’ll explore these challenges and how they affected patient prioritization and sorting decisions.

Operational Breakdown and Logistical Challenges

Fink says that Memorial Hospital faced significant communication and logistical challenges during the evacuation process. Communication with state authorities for emergencies was difficult, and the facility lost reliable connection to the outside world. Tenet lacked existing agreements with companies for medical transport or a system for command in emergency incidents. Additionally, communications at the federal, state, and local levels couldn't work together, and the software authorities were using to manage the disaster couldn't sort data for sharing. Fink adds that various agencies and officials seemed to be managing distinct lists of evacuation priorities for the hospital, and no one had a central leadership role. Essential Tenet executives were bewildered by the convoluted bureaucracy, which filled them with panic.

(Shortform note: Since the publication of Fink’s book, disaster communication and evacuation requirements for hospitals have evolved. Hospitals are now expected to participate in regional incident-command systems that coordinate communication and resource allocation during disasters. These systems establish clear lines of authority and communication protocols, reducing confusion and ensuring a coordinated response. Hospitals are also required to have prearranged agreements with medical transport companies and to participate in regional planning efforts that establish evacuation priorities before a crisis occurs. These changes aim to prevent the kind of disorganized response that occurred at Memorial Hospital by ensuring that hospitals are integrated into a larger emergency management framework.)

The hospital evacuated its critical care patients via airlift on Tuesday evening, and the rest of the patients were transported by helicopter and boat. The police opposed using a second boat launch, citing security concerns, and said they'd be leaving at 5 p.m. due to unrest in New Orleans, so everyone had to vacate the hospital. The police refused to remain at the hospital past that time to guard it.

(Shortform note: The “security concerns” and “unrest in New Orleans” that the police cited at Memorial Hospital were part of a larger breakdown in law enforcement after Hurricane Katrina. Rumors of violence and looting spread quickly, leading to confusion and fear among both residents and law enforcement. Police officers were being pulled from guard posts across the city to focus on roving security operations, which may have contributed to the decision to evacuate Memorial Hospital by 5 p.m.)

Patient Prioritization and Triage Decisions

Fink discusses patient prioritization and decisions regarding triage. Triage methods aim to determine which patients ought to be prioritized based on the severity of their condition, with the goal of saving as many lives as possible. However, she notes that these approaches are not consistently effective. There's minimal research on whether triage procedures are truly life-saving, and some studies suggest they may not be effective whatsoever.

Triage protocols can be biased and inaccurate. Different medical professionals may classify the same patient differently, and a patient's condition can change over time. This means that individuals who could potentially survive may be wrongly classified as unsalvageable and abandoned to die. Some triage systems also exclude certain patients from receiving care, such as seniors, individuals with orders to avoid resuscitation, or those with serious neurological damage. This raises ethical concerns about who deserves treatment during a disaster.

The Effectiveness of the START Triage System

While Fink notes that there is little research on the effectiveness of triage procedures, some researchers have found that certain triage systems can be effective. For example, emergency medicine researchers have found that the START (Simple Triage and Rapid Treatment) system, which is used in mass-casualty incidents, can be effective in identifying patients who need immediate care. In a study of 1,219 patients treated at a hospital after a mass-casualty incident, researchers found that only 2.3% of patients were under-triaged, meaning they were classified as less severe than they actually were. This suggests that the START system can be effective in identifying patients who need immediate care. However, the researchers also note that the START system is not perfect and that there is still room for improvement.

Fink adds that predicting patient outcomes is difficult and can be subjective. Doctors often disagree about which patients have the best chance of survival. In one study, doctors were tasked with sorting patients in their intensive care units during the H1N1 pandemic under the assumption that resources needed to be rationed. Most of the individuals who would have been labeled "expectant" (meaning they weren't expected to survive with the available resources) were released from the hospital after surviving through ongoing care.

The H1N1 Pandemic and the Push for Crisis Standards of Care

The H1N1 pandemic of 2009-2010 was a major turning point in disaster medicine, as it forced hospitals to confront the reality of resource scarcity and the need for triage protocols. The study Fink references, in which doctors misclassified patients as "expectant," highlights the difficulty of predicting patient outcomes in a crisis. This finding has been used to argue that bedside rationing is unreliable and that crisis standards of care frameworks, like those outlined in the Institute of Medicine's Crisis Standards of Care, are necessary to guide decision-making during disasters.

Ethical, Legal, and Policy Ramifications

Fink notes that the ethical and legal implications of euthanasia and aid in dying are complex and controversial. Euthanasia refers to deliberately causing a person's death to alleviate suffering, while assisted suicide involves providing the means for a person to end their own life. In the U.S., euthanasia is illegal, and the widely respected Code of Medical Ethics by the American Medical Association still bans active euthanasia.

(Shortform note: Various contributors disagree with the view that euthanasia and aid in dying should remain prohibited in U.S. medical ethics and law. For example, Compassion & Choices, a nonprofit organization, advocates for the legalization of medical aid in dying, arguing that terminally ill patients should have the right to end their suffering on their own terms. They contend that current laws force patients to endure unnecessary pain and suffering, and that allowing aid in dying respects individual autonomy and dignity.)

The debate in the US focuses on passive euthanasia, which involves removing life-sustaining interventions and withholding medical treatment. In 1990, the US Supreme Court ruled that the right to liberty encompassed the choice to decline life-preserving treatment and choose death, but states can mandate clear, convincing evidence of the patient's desire to cease care. This prompted more people to use documents expressing their wishes regarding treatment. In 1997, the US Supreme Court supported the legality of rendering patients unconscious until death, which is called terminal sedation.

(Shortform note: In The Right to Die, a comprehensive legal treatise on end-of-life law, the authors clarify that the Supreme Court’s decisions addressing physician-assisted suicide in the late 1990s, particularly Washington v. Glucksberg and Vacco v. Quill, treat the provision of aggressive pain relief and even sedating levels of analgesia as practices to be evaluated under existing state law and professional standards, not as newly recognized federal constitutional rights. The Court’s favorable references to strong pain control simply acknowledge that a physician may lawfully administer medication needed to relieve suffering, even if it foreseeably hastens death, while leaving it to the states, medical boards, and clinical ethics to determine when extreme measures such as continuous deep sedation at the end of life are permissible.)

Fink explains that Dutch guidelines on euthanasia intended to restrict it to those who made continual death requests and suffered unbearably without hope of improvement, with confirmation from two doctors. However, a study of the program showed that these rules were not always followed, and a small proportion of people were killed each year without having made an explicit request. Prosecutions were infrequent in these cases.

(Shortform note: The study Fink refers to was conducted by sending questionnaires to doctors and linking their responses to death certificates. The study found that a small percentage of deaths in the Netherlands were caused by doctors deliberately ending a patient’s life without an explicit request from the patient.)

In 2002, the Groningen Protocol established guidelines for ending the lives of severely ill or brain-damaged infants with parental consent given on their behalf. Although this wasn't technically legal, doctors adhering to the guidelines faced no prosecution. The leading Dutch group advocating for euthanasia and end-of-life choices, the NVVE, encouraged public acceptance of euthanasia under then-illegal conditions, hoping for eventual legality. The group believes that individuals, especially older adults, who are in relatively good health but increasingly depend on family for support and whose "quality of life" has significantly declined, feeling that "having spent a long time living, life has come to a close," should have the right to assistance in dying. Additionally, individuals with dementia and challenging chronic psychiatric disorders should also be eligible. A Dutch court approved of euthanasia for a woman with advanced dementia who repeatedly communicated her wish to die.

Opposition to Euthanasia

The Nederlandse Patiëntenvereniging (NPV), a Christian patients’ association, opposes euthanasia for people whose lives are deemed to lack sufficient “quality.” The NPV argues that dependence and cognitive decline don’t diminish a person’s claim to care. They believe that every human life, from conception to natural death, has equal and inviolable worth that doesn’t depend on health, self-reliance, or mental functioning. The NPV’s position is rooted in a theological view of human dignity, arguing that intentionally ending a human life can never be regarded as a form of good care. Instead, they advocate for relieving suffering as far as possible, staying faithfully alongside the sick and vulnerable, and respecting their life until its natural end.

Let’s explore medication administration and clinical judgment at Memorial Hospital, along with the investigations, legal proceedings, and policy responses that followed.

Medication Administration and Decisions in Care

Fink explains that administering midazolam and morphine requires careful clinical judgment due to their potential to suppress breathing and hasten death. Morphine serves as a powerful narcotic used to manage intense pain or discomfort, while midazolam is a sedative. Both drugs can reduce respiration, and high doses can be lethal.

Whether giving a drug is murder or medical care typically depends on the provider's intent. The purpose may be to alleviate suffering, yet the outcome might accelerate death. Distinguishing between ethics and illegality can be subtle.

The Doctrine of Double Effect

Bioethicists often analyze cases like this through the “doctrine of double effect,” a centuries-old principle that says an action with both good and bad effects can be morally permissible if the bad effect is not intended. In modern medicine, this doctrine has been adapted to justify aggressive symptom relief at the end of life, even if it may hasten death. Sulmasy, a prominent bioethicist, argues that this approach allows clinicians to provide compassionate care without crossing ethical lines, provided they meet specific criteria.

Investigations, Legal Proceedings, and Changes in Procedure

Fink notes that legal proceedings were initiated against Dr. Pou and others, but the grand jury declined to bring an indictment. The district attorney's office put together ten counts in a bill of indictment against Pou for the grand jury's review. This included a charge of second-degree murder for Emmett Everett and nine charges of conspiring to commit second-degree murder—one for each of the LifeCare patients on the seventh floor, including Everett. The grand jury had to determine if the evidence was convincing enough to prove that Pou possessed "a specific intent to kill," an element in Louisiana's second-degree murder definition. The grand jury decided against indicting Pou on any of the charges, and the case was over.

(Shortform note: In Louisiana, “a specific intent to kill” is a higher standard than “general intent.” General intent means that the accused intended to do the act that resulted in the crime, but not necessarily that they intended the crime itself. For example, if someone fires a gun into a crowd, they may have had the general intent to fire the gun, but not the specific intent to kill anyone. Specific intent, on the other hand, means that the accused had the conscious objective or purpose to achieve a particular result. In the context of second-degree murder, this means that the accused must have had the specific intent to kill the victim. This can be proven through direct evidence, such as statements made by the accused, or through circumstantial evidence, such as the accused's actions or the circumstances surrounding the crime.)

The attorney general condemned the grand jury for not hearing testimony from experts or from the deceased patients' relatives. He wrote an editorial for USA Today, stating that he would support the value of life and people affected by crime. He failed to be reelected. Federal authorities halted their involvement in the collaborative probe into the hospital and nursing home, citing the Memorial and St. Rita's cases as "unsuccessful."

(Shortform note: These outcomes are significant because they may have influenced how future disasters were handled. The attorney general’s failure to be reelected may have signaled to other politicians that aggressively prosecuting medical professionals after disasters is politically risky. The federal authorities’ decision to halt their involvement in the probe may have signaled to other law enforcement agencies that such cases are legally fragile.)

Fink adds that this case spurred discussions about ethical issues in medicine and policy changes for future disasters. The American Medical Association (AMA) conducted a public discussion on modifying typical medical guidelines during emergencies. The AMA delegates decided to draft model laws to protect doctors in disasters from civil or criminal prosecution. Participants would be urged to advocate across the country for a conviction standard that would demand evidence of a doctor's malicious intent to harm a patient.

The Pros and Cons of the AMA’s Model Laws

While the AMA’s model laws would protect doctors from prosecution, they could also make it difficult to hold clinicians accountable for reckless or grossly negligent conduct. For example, if a doctor administered a lethal dose of medication to a patient without proper justification, it might be challenging to prove that the doctor acted with malicious intent. This could create a situation where doctors are effectively immune from legal consequences, even in cases of gross negligence or misconduct.