For anyone in health care, Sheri Fink's award-winning Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital is a must-read-and a haunting one. At times I found myself unable to put the book down; at others, reading it was so painful that I had to stop.
The book is divided into two parts. The first, "Deadly Choices," recounts events in August 2005 at Memorial Medical Center in New Orleans during and after Hurricane Katrina, including allegations that patients deemed difficult to evacuate were euthanized by staff on the fifth day after landfall. The second, "Reckoning," details the investigation into those accusations, focusing largely on Dr. Anna Maria Pou, a Memorial physician universally acknowledged as exceptionally caring with patients.
A grand jury later failed to indict Pou (or any other staff member) on criminal charges, even though "[A] juror was convinced-and, she believed, all of her fellow jurors were too-that a crime had occurred on that fifth day at Memorial." Therein lies the ethical nut that Fink wants readers to crack: if patients were euthanized at Memorial Hospital, were these acts of mercy or murder? As I read, I found it increasingly hard to answer that question, or even to know what moral certainty would mean amid such disorder and turmoil.
Grasping what life in New Orleans was like immediately after the hurricane is crucial to understanding the events at Memorial. Fink thoroughly paints a portrait of a hospital and a city out of control. After the levees burst, the hospital's electricity failed, meaning there was no air-conditioning during sweltering weather in a hospital lacking windows that opened. No electricity also meant no elevators. Many patients who were successfully evacuated were first wrapped in sheets and then carried up and down two sets of stairs to the hospital helipad.
There were other complicating factors. Because of flooding, no one could enter or leave the hospital without a boat. Memorial's corporate bosses provided little assistance to the hospital's nurses and physicians, and the federal government's response to Katrina was slow and inexcusably chaotic. Exaggerated news reports about declarations of martial law and gangs of killers roving the city left hospital workers frightened. Some hospital staff didn't know how their own family members had fared during and after the storm. Their growing anxiety, coupled with the oppressive heat and the demands of patient care, meant that many slept poorly, if at all. Sleep deprivation must have affected their functional and reasoning abilities.
Memorial had no triaging rules for evacuating patients in an emergency. Soon after Katrina struck, a decision was made to have the most unstable or difficult-to-move patients-most of whom had do-not-resuscitate (DNR) orders-evacuated last. Fink depicts how a small group of staff became convinced that these patients would never be evacuated. Pets that had been brought to the hospital were being euthanized as acts of mercy. After witnessing such acts, that small group purportedly decided to end the lives of patients with DNRs rather than surrender them to ugly, lingering deaths.
I imagine myself as a nurse in that situation-exhausted, dirty, panicked about my family, unsure if I could provide good care-and wonder whether my sense of what my patients needed would have become very conditional. Rescue efforts were sporadic and poorly coordinated citywide; many evacuated patients ended up without adequate care in improvised drop-off sites, including a crowded highway intersection. To a staff that felt increasingly hopeless, giving the sickest patients permanent relief might have seemed like the best of the terrible options. Indeed, though I've never given pain-relieving drugs with the intent to kill, I have given morphine to dying cancer patients suffering from air hunger, and it's possible the drug hastened their deaths.
There's the rub, and Five Days at Memorial brings us back to it repeatedly: was injecting certain patients at Memorial with lethal drug cocktails a crime that should be punished? Or was it an act of mercy, the moral equivalent of pushing morphine for a dying patient struggling to breathe?
Five Days at Memorial will make you ask yourself what you'd have done-and how, in an environment of city-wide pandemonium, your normally clear clinical judgment might blur.