The New England Journal of Medicine Highlights Patient Care Issues During
Emergencies
(Posted: 01/07/2008)
Following are excerpts from the January 3, 2008 New England Journal of
Medicine which Dr. Pou believes should be of interest to website viewers.
Dr. Pou and the Hurricane ‹ Implications for Patient Care during Disasters
Susan Okie, M.D.
During the flood after Hurricane Katrina in August 2005, health care
providers in marooned New Orleans hospitals worked in almost unimaginably
difficult conditions while awaiting rescue. Nowhere was the situation more
desperate than at Memorial Medical Center, where for 4 days a small staff
struggled to care for critically ill patients in a dark building with no
electric power, no fresh water, a flooded first floor, a nonfunctional
sanitation system, and an interior temperature above 100°F.
Dr. Anna Maria Pou, a cancer surgeon on the faculty of Louisiana State
University School of Medicine, was supervising residents at Memorial when
Katrina hit on Monday, August 29, and she remained at the hospital after the
storm. Pou, 51, is a New Orleans native whom colleagues describe as a
dedicated, hardworking physician who, though physically small, "had a huge
presence."1 At least 34 patients died at Memorial during and after the
storm, and shortly thereafter, media reports began to suggest that some had
been euthanized. In July 2006, Louisiana's attorney general, Charles Foti,
shocked the country by arresting Pou and two nurses, accusing them of
administering morphine and midazolam to kill four elderly patients on
September 1, 2005, the day patient evacuation was completed. In a television
interview aired in September 2006, Pou denied the accusation, stating, "I
did not murder those patients. . . . I do not believe in euthanasia. I don't
think it's anyone's decision to make when a patient dies. However, what I do
believe in is comfort care, and that means that we ensure that they do not
suffer pain."
A grand jury considered possible murder charges in the deaths of these four
patients plus five others on the same floor, and the attorney general agreed
not to pursue charges against the nurses in exchange for their testimony
against Pou. Many New Orleans residents rallied to Pou's support, calling
her a hero for remaining on duty when other doctors had fled, and numerous
medical organizations issued statements in her defense. This past August,
the grand jury refused to indict Pou, but she still faces three civil suits
that have been brought by relatives of patients who died. After the grand
jury's decision, she acknowledged in an interview that she had administered
morphine and midazolam to the nine patients knowing that their deaths might
be hastened, but she said that she did not intend to kill them. "God strike
me dead ‹ what we were trying to do was help," she said.2
What precisely happened? And what lessons does the episode hold for health
care workers, hospital administrators, and policymakers as they prepare for
natural disasters, terrorist attacks, or epidemics?
Memorial was a private, for-profit hospital owned by Dallas-based Tenet
Healthcare Corporation. The patients in question died on the seventh floor,
where LifeCare Hospitals of Plano, Texas, leased space and operated a
separately licensed long-term acute care facility for elderly patients with
multiple medical problems. The staff apparently decided that nine could not
be rescued, but it is unclear who made that decision and whether it was
based on the patients' medical conditions, their resuscitation status (five
of the nine reportedly had do-not-resuscitate [DNR] orders), or other
considerations. According to written responses that Pou provided for this
article, "The standard of rescue [had] changed from Tuesday to Thursday;
initially the sickest patients were evacuated first. When we realized that
help was not imminent, . . . the standard of rescue changed to that of
reverse triage. It was recognized that some patients might not survive, and
priority was given to those who had the best chance of survival. On Thursday
morning, only category 3 patients [the most gravely ill] remained on the
LifeCare unit."
Still, the decision is puzzling to many in light of the eventual evacuation
of about 200 patients from Memorial, including patients from the intensive
care unit, premature infants, critically ill patients who required dialysis,
patients with DNR orders, and two 400-lb men who could not walk. The story
so far is incomplete; testimony before the grand jury was secret, and since
Pou, other health care workers, and the two companies still face litigation,
they have not publicly discussed details of the events.
The version we have comes from an affidavit that was issued at the time of
Pou's arrest by the Louisiana Department of Justice and from a summary of
evidence that was released by that department last July. These documents
cite statements by LifeCare employees but do not provide the full statements
or indicate whether they were sworn depositions. According to the documents,
Susan Mulderick, the Memorial "incident commander" who oversaw patient care
and evacuation during and after Katrina, allegedly told employees at a
meeting on the morning of September 1 that she did not expect LifeCare's
nine critically ill patients to be evacuated. Later, she allegedly told
three LifeCare employees that the plan was not to leave any living patients
behind.
Dr. John Skinner, Memorial's director of pathology, stated that because of
plans to finish the evacuation and lock down the hospital by 5 p.m., he made
rounds throughout the hospital during the afternoon of September 1 to
document all deaths and to make sure no one had been left behind. He said he
encountered Dr. Pou on the seventh floor with a patient who appeared to be
alive and offered to help her evacuate the patient, but she said she wanted
to talk with an anesthesiologist first. Skinner said he returned to the
seventh floor around 3:30 p.m. and found that all the patients there were
dead.
Establishing the causes of the deaths of the nine patients was problematic.
The bodies lay in the sweltering hospital for 10 days before they were
recovered, and autopsies were not performed for another week or more. This
past February, after considering the opinions of multiple experts, Orleans
Parish coroner Frank Minyard announced that he could not determine whether
the patients had died from natural causes or homicide. On the autopsy
reports, the classification of the deaths has been left blank.3 Toxicology
studies of liver and purge fluid documented the presence of significant
levels of morphine in all nine patients and of midazolam in seven; levels of
one or both drugs in brain tissue were also measured in eight patients.
However, because of the extent of decomposition, these results may not
accurately reflect what the levels were when the patients died.
The patients, four men and five women, ranged in age from 61 to 90 and had
varied medical problems. Richard Deichmann, Memorial's chief of medicine,
said in an interview that some LifeCare patients were dependent on
ventilators and others had chronic, nonhealing wounds or required tube
feeding or hyperalimentation. However, as hospital conditions deteriorated,
many patients got sicker or became dehydrated ‹ for example, Ireatha Watson,
one of the nine patients, was coded and resuscitated after developing a
temperature of 105°F and probable aspiration.
About 2000 people ‹ patients, staff members, family members, and neighbors ‹
had taken shelter at Memorial, which put a strain on the supplies of food
and water. To obtain medications, staff members had to walk through
pitch-dark hallways and stairways to the pharmacy. In Code Blue, his
harrowing Katrina memoir, Deichmann describes "dozens of people sprawled on
the floors and corridors of the hospital, lifting their voices to ask for
water and assistance."4 Routines for tasks such as drug ordering and
charting broke down; the approximately 25 physicians in the hospital,
assigned to nurses' stations, were to sort patients into triage categories
so that sicker patients could be evacuated first. To evacuate nonambulatory
patients, employees had to carry them on stretchers down multiple flights of
stairs to the second floor, pass them through a narrow opening in a wall
into the parking garage, and then either transport them to the helipad on
the garage roof or load them onto boats. "Our intention was that we were
going to evacuate all the patients, [but] we decided early on that the
patients that were `no codes' . . . were going to be lower on the priority
list," Deichmann said. "Lots of no-code patients were evacuated. Some of
them died awaiting evacuation."
Wednesday night or early Thursday morning, hospital administrators received
word that no government rescue was forthcoming. Staff morale plummeted.
Although Tenet officials in Dallas had spent Wednesday hiring private
transport to evacuate the company's New Orleans hospitals, they had no way
of communicating their plans to Memorial, said Tenet spokesperson Steven
Campanini. In his book, Deichmann writes that Susan Mulderick, the incident
commander, asked him on Wednesday whether euthanasia should be considered
for some patients with DNR orders but that he immediately dismissed the
idea.4 (Mulderick could not be reached for comment for this article.)
Deichmann said that the topic of euthanasia never arose at any of the
twice-daily meetings he attended: "We never discussed anything except
evacuating everybody." On Thursday, staff members and rescuers managed to
round up a fleet of private fishing boats that evacuated scores of patients,
and helicopter flights resumed. Late that day, Deichmann watched as the last
three surviving patients were loaded onto choppers before boarding one
himself. He said that when the media reported the allegations of euthanasia,
"I was as surprised as anybody. . . . I just can't reconcile that."
On her lawyer's advice, Pou declined to answer questions about the events of
September 1. She told Newsweek that the decision to sedate the remaining
LifeCare patients was made by a group of staff members on Thursday morning
after the announcement that no rescue was coming, and that it was agreed
that she would administer the drugs. "It was a group decision. I didn't
really volunteer for anything," she said.2 Campanini, the Tenet
spokesperson, said that LifeCare "had its own evacuation plan," although its
administrators would have coordinated with Mulderick. The decision not to
evacuate the nine LifeCare patients "was not a Tenet decision," he said. "I
can't speak for the employees on the ground but . . . that is not a decision
that would be supported by the company." Rosemary Plorin, a spokesperson for
LifeCare Hospitals, said she didn't know how the decision was made and
refused to comment on the deaths. "As far as the specifics of that
particular day and what those discussions entailed, I think only the people
involved and the authorities have access to that information," she said.
Although New Orleans hospitals had participated with the Federal Emergency
Management Agency and state agencies during 2004 in planning for a
catastrophic hurricane, there was no organized plan for evacuation of the
hospitals; government officials assumed that they would be self-sufficient
for 5 to 7 days, said James Aiken, medical director for emergency
preparedness at LSU University Hospital. At the public Charity Hospital,
where Aiken was on duty during Katrina, "we got our job done with a
combination of resources" from state and other sources; private, for-profit
hospitals like Memorial were "left to their own devices." At Charity, "there
was no discussion that I was a part of as to what we would do if we couldn't
get somebody out," added Aiken, noting that "triage, by definition, is a
sorting of patients for care ‹ something we would never do on a day-to-day
basis." The effort to prosecute Pou and the nurses, he predicted, will have
a chilling effect on the willingness of medical professionals to volunteer
during disasters ‹ though Pou still says, "As for me, I would stay to care
for my patients if I was needed."
As a doctor responsible for patients who, it had apparently been determined,
were not going to be rescued, Pou was faced with a dire choice, noted R.
Alta Charo, a professor of law and bioethics at the University of Wisconsin.
"From her perspective, these people are now terminal ‹ because of their
biological status, their medical condition, and the environmental context .
. . and they're terminal under particularly terrifying conditions: extreme
discomfort, [probably] panic, and the prospect of being abandoned while
helpless," said Charo. If Pou could not save them, then her next obligation
"would seem to be palliation . . . to give them enough medicine that they're
not in any pain and they're not in any panic and it may or may not hasten
their deaths." If her intent was to relieve suffering, Charo added, "then I
don't think anybody in the ethics community would bat an eye. If it [was]
specifically to hasten death . . . then it becomes a little more
questionable." Furthermore, Pou had a duty to inform any conscious,
competent patients of the circumstances and offer them a choice about
accepting the medications ‹ "not a choice," noted Charo, that "we are
willing to take away from people capable of making it."
Timothy Quill, director of palliative care at the University of Rochester
Medical Center, said that the drugs Pou gave are typically used for
palliation, not euthanasia. "There were no paralytics, no barbiturates ‹
which are the usual things people give if they are really trying to end
life." Moreover, he said, "the drug levels are comparable to those used in
palliative care, although many of these people had never been on opioids
before. Is it possible they were given an overdose? Yes. But it's also just
as possible that they were suffering, that she came through and gave some
kind of dose that she thought was appropriate." Quill believes "she was
trying to do the right thing in an awful situation and was doing the best
she could."
One lesson of Pou's experience is the need for community discussions about
what care should be provided during a disaster that strains medical
resources, said Marianne Matzo, a professor of nursing at the University of
Oklahoma and coauthor of a report on the subject.5 Katrina left many
survivors while disabling a city's health care network; another storm, a
disastrous earthquake, or a severe epidemic could create a similar scenario.
"There are people who, as a result of the disaster, are steps away from
death," Matzo said. "As a community we have to say, what are we going to do
if we don't have the resources" to evacuate or treat everyone?
But hospitals and communities are unlikely to confront such questions
without leadership from government, medical schools, and medical specialty
organizations, because discussion of changing standards of care involves
"not only liability but political risks," said Craig Llewellyn, professor
emeritus of military and emergency medicine at the Uniformed Services
University of the Health Sciences (USUHS). Currently, he said, governors can
declare a state of emergency during disasters, "suspending some of the
normal standards without giving any idea of what the alternative standards
ought to be," and medical professionals who care for disaster victims are
not protected from lawsuits or criminal prosecution by such declarations.
Pou's case has triggered discussion about whether laws are needed to
indemnify such volunteers.
Pou argues that "the conditions faced were similar to battlefield
conditions" and that civilian medical training does not prepare physicians
for such circumstances: "There's nothing that teaches reverse triage,
military evacuation strategies, or how to prepare oneself for the feelings
of helplessness and sorrow that come when there is little to do for a
patient based on lack of resources." However, USUHS has experience training
medical students to make triage decisions in such conditions: they
participate in exercises in which the demand for treatment exceeds available
resources, with volunteers playing the parts of injured soldiers, civilians,
enemy prisoners, and so on. "You have to prioritize who gets on the
operating table or who gets the one vacant litter position on the only
helicopter you're liable to see for the next 4 hours," Llewellyn said, which
forces students to confront "difficult clinical, ethical, and moral issues."
Without a similar focus on altered standards of care in extreme situations
in civilian medicine, Llewellyn said, doctors will face disasters
unprepared, and citizens will be unaware of the choices that may be
required. But with expanded training and public debate about triage,
communication, and decision making when resources are limited, caregivers
may be better equipped for the kind of ordeal that Pou and her colleagues
faced after the deluge.
Source Information
Dr. Okie is a national correspondent for the Journal.
References
1. Konigsmark AR. La. affidavit describes alleged `mercy killings': state
accuses 3 of taking `law into their own hands.' USA Today. July 19, 2006:3A.
2. Scelfo J. A doctor says she didn't murder her patients. Newsweek.
September 3, 2007.
3. Bradley CW Jr. Autopsy and toxicology reports. October 22, 2007
(letter). (Accessed December 12, 2007, at
http://www.nola.com/katrina/files/102107_memorial_autopsy.pdf.)
4. Deichmann RE. Code blue: a Katrina physician's memoir. Bloomington,
IN: Rooftop Publishing, 2007.
5. Phillips SJ, Knebel A, eds. Mass medical care with scarce resources: a
community planning guide. Rockville, MD: Agency for Healthcare Research and
Quality, February 2007. (AHRQ publication no. 07-0001.) (Accessed December
12, 2007, at http://www.ahrq.gov/research/mce/.
