OMEGA, Vol. 67(4) 329-361, 2013

THE END-OF-LIFE EXPERIENCES OF 9/11 CIVILIANS: DEATH AND DYING IN THE WORLD TRADE CENTER

M. SARA ROSENTHAL, PH.D. University of Kentucky Program for Bioethics

ABSTRACT

This bioethics analysis of trapped civilians in the World Trade Center (WTC) on September 11, 2001, is based on a review of materials in the public domain. Death and dying experiences are divided into three major groups: sudden death, of which there was virtually no suffering or foreknowledge; deaths in which there was a maximum of 102 minutes of suffering; and death by falling or jumping, in which an autonomous decision may have been exercised as a palliative approach. A content analysis of publicly available records of this event reveals many types of end-of-life decisions were being made within the 102-minute time frame from aircraft impact to collapse. Many WTC occupants experienced intensified suffering directly consequent to unprepared emergency dispatchers and inaccurate instructions. Truthtelling and appropriate end-of-life dialogues could have reduced loss of life, suffering, and led to qualitatively improved dying experiences.

INTRODUCTION This is a bioethics analysis of the death and dying experiences of some of the civilians caught in the events of September 11, 2001 (9/11). This analysis is informed by clinical ethics frameworks in end-of-life discourse, which comprise decision-making, truth-telling, and autonomous preferences regarding managing pain and suffering (Jonsen, Siegler, & Winslade, 1998). 329 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/OM.67.4.a http://baywood.com

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To date, within the health arena, 9/11 scholarship has focused on the public health effects related to exposures to dust and debris from Ground Zero, the site of the World Trade Center (WTC) collapse. See, for example, Jordan, Brackbill, et al. (2011); Jordan, Stellman et al. (2011); Levy and Sidel (2011); Perlman et al. (2011); Wisnivesky et al. (2011); Zeig-Owens et al. (2011). There have been studies that looked at birth outcomes in exposed survivors (Lipkend, Curry, Huynh, Thorpe, & Matte, 2010; Ohlsson et al., 2011). Another explored area involves the mental health and post-traumatic stress effects on the survivors and the grief-stricken, exemplified by Digrande, Neria, Brackbill, Pulliam, and Galea (2011); Galea et al. (2002); Henriksen, Bolton, and Sareen (2010); and Berninger et al. (2010). There are over 150 papers focusing on this aspect of 9/11. There is now consensus that traditional models of psychological counseling were largely inapplicable to dealing with 9/11 survivors and bereaved (NPR, 2011a). This punctuates the need to treat 9/11 as a distinct area of scholarship. In the immediate aftermath period, biomedical inquiry focused on the living; there was an urgent need to clarify occupational exposures of the first responders in order to pass necessary health legislation. Bioethics exploration into 9/11 has been mostly limited to military medical ethics and issues involving torture. Only one bioethics paper looked at some of the health effects of 9/11 on exposed survivors and first responders (Wahlert & Fiester, 2011). This exploration is based on a content analysis of publicly available materials. Civilians who faced death in the WTC present a unique demographic; these civilians were primarily young, mobile, fully autonomous, and decisional. Males outnumbered women two to one (NIST, 2005); they were reported to represent 77% of the deaths in 2002 (Schwartz, Li, Berenson, & Williams, 2002). The mean and median ages were 39-45 (NIST, 2005; Schwartz et al., 2002). About 79% were born in the United States, and 67% had undergraduate or post-graduate degrees. Of the males, 61% were described as non-Hispanic White males; 15% of females were described as non-Hispanic White females; while 23% were male and female civilians of Hispanic, African American, and Asian descents (Schwartz et al., 2002). End-of-life decisions by civilians in these demographics provide a unique opportunity for analysis. In this demographic, telecommunications technology served a critical role in decision-making. These civilians, caught in an attack on native soil, used cell phones and voicemail to communicate with an array of critical players in this event. Core Documents and Archival Material By 2002, there was pressure for an inquiry into the WTC collapse (Dwyer, 2002; Glanz & Lipton, 2001), which resulted in a preliminary report by the Federal Emergency Management Association (FEMA) recommending further investigation (FEMA, 2002). Additionally, family members of 9/11 civilian victims began to lobby for a wider public inquiry into their deaths, which resulted

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in formation of the National Commission on Terrorist Attacks Upon the United States, or the 9/11 Commission. Testimony included many of the civilian calls made to emergency dispatchers. The Commission released its final report in 2004, known as the 9/11 Commission Report. Although this work was also criticized for being a work of “postmodern pastiche,” which imitates popular fiction, reads like a spy novel, and is not a work of scholarship (Nadel, 2011a; Warren, 2007), it nonetheless remains a core report for the public record on which one can reasonably track events. In 2005, the National Institute of Standards and Technology (NIST) released its Final Report on the Collapse of the World Trade Center Towers (NIST, 2005), an exhaustive report, comprising hundreds of interviews and supporting documents on the details of the WTC collapse and “Human Activity” that morning. This report superseded FEMA’s early report; the National Construction Safety Team (NCST) Act of 2002 (15 U.S.C. 7301 et seq.) gave NIST the authority to collect and demand evidence. Another substantial qualitative work presented detailed accounts of conditions inside the WTC towers the morning of 9/11 (Dwyer & Flynn, 2005). These documents present disturbing conclusions that point to layers of systemic problems, building code lapses, inadequate communications, and unpreparedness that cost lives. In many cases, trapped or dying civilians in the WTC were put on hold, transferred to other call centers, asked to repeat information, or provided with inaccurate information or inappropriate instructions. Escape was stymied by inadequate stairwell or roof access that Dwyer and Flynn compare to the 1912 Titanic disaster, in which safety codes during construction are bent to maximize profits, while mythology permeates about indestructible structures. The 9/11 Commission Report (2004) concluded that future survival in a similar event would depend on civilian preparedness in the private sector, which must consider that government may not be able to rescue or protect civilians in the midst of disaster or an attack. It was noted, for example, that journalists and television viewers had more information about the attack and the location of fires in the WTC towers than the dispatchers handling the calls from civilians inside the towers. Private-sector preparedness was also a critical factor in survival. In 2006, Freedom of Information Act (FOIA) requests by the press led of the release of 1,600 calls into the public domain, with the “caller” portion of the recordings withheld because of confidentiality issues (Stout & Lewis, 2006). Enough information may be gleaned from the “emergency dispatcher” portions of these calls to demonstrate profound problems with the dialogue exchanges. Three of these calls (Tables 1, 2, and 3) were released in their entirety as evidence in the 2006 Moussaoui trial to demonstrate the extent of victims’ suffering. Two of these calls record prolonged discussion, as well as the deaths of the callers while on the phone with emergency dispatchers. Mellissa Doi, in WTC 2 on the 83rd floor (Table 2) states, “I’m going to die, aren’t I. . . . Stay on the line with me please, I feel like I’m dying” to an unprepared dispatcher; Kevin

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Table 1. Transcript of Call from Chris Hanley, WTC 1, 106th Floor* Time: 8:57:02 Speaker

Transcript

Dispatcher 1886

Police operator 1886, what is your emergency?

Chris Hanley

I’m on the 106th floor of the World Trade Center. We just had an explosion on the like 105th floor.

Dispatcher 1886

The 1-0-6 floor?

Chris Hanley

Yes.

Dispatcher 1886

1-0-6, okay, umm

Chris Hanley

We have a conference up here and there’s about a hundred people up here.

Dispatcher 1886

What is your last name?

Chris Hanley

Hanley. H-a-n-l-e-y.

Dispatcher 1886

H-a-–?

Chris Hanley

We have smoke and it’s pretty bad.

Dispatcher 1886

(typing is heard) This is on the 1-0-6 floor, right?

Chris Hanley

Hello?

Dispatcher 1886

Okay, we have the job. Let me connect you with the Fire, okay?

Chris Hanley

Yes, there is fire, smoke.

Dispatcher 1886

You have. Hold on, let me connect with the Fire, okay?

Chris Hanley

We have about a hundred people here. We can’t get down the stairs.

Dispatcher 1886

Hold on. Let me connect you with fire.

note

phone rings six times, the dispatcher is heard muttering “Come on now . . .” before the transfer takes place

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Table 1. (Cont’d.)

Speaker

Transcript

Fire Dept 408

Fire Department 408. Where’s the fire?

Chris Hanley

Yeah, hi. I’m on the 106th floor of the World Trade Center. We just had an explosion up here.

Fire Dept 408

Okay, 1-0-6th floor, what building are you in, sir? One or two?

Chris Hanley

That’s one World Trade.

Fire Dept 408

Alright.

Chris Hanley

(interrupting) One?

Fire Dept 408

Yeah.

Chris Hanley

Yeah, there’s smoke, and we have about a hundred people up here.

Fire Dept 408

Sit tight. Do not leave, okay? There’s a fire or an explosion or something in the building. Alright, I want you to stay where you are.

Chris Hanley

Yes.

Fire Dept 408

Alright, what’s your phone number there?

Chris Hanley

We’re on the 106th, the 106th floor.

Fire Dept 408

What’s your phone number sir, your phone number?

Chris Hanley

646-752-1436

Fire Dept 408

Alright, we’re there. We’re coming up to get you.

Chris Hanley

I can see the smoke coming up from outside the windows down . . .

Fire Dept 408

All right, we’re on the way.

Chris Hanley

Huh?

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Table 1. (Cont’d.)

Speaker

Transcript

Fire Dept 408

We’re on the way, sir.

Chris Hanley

Okay, please hurry.

Fire Dept 408

Alright, just keep some windows open if you can open up windows and just sit tight. It’s going to be a while because there’s a fire going on downstairs.

Chris Hanley

We can’t open the windows unless we break them.

Fire Dept 408

Okay, just sit tight.

Chris Hanley

Okay.

Fire Dept 408

All right. Just sit tight. We’re on the way.

Chris Hanley

Alright, please hurry.

*An audio of the call is available at this link (New York Times, 2006a): http://www. nytimes.com/2006/03/29/nyregion/30tape-transcript.html

Cosgrove, in WTC 2 on the 105th floor (Table 3) states to another unprepared dispatcher, “We’re young men . . . we’re not ready to die, but it’s getting bad. . . . I’ve got young kids.” The historical archive from 9/11 is also informed by the private sector; families have released voicemail recordings and oral histories recounting the discussions they had with trapped civilian family members (History Channel, 2011). Oral histories from WTC survivors have also become important sources of information regarding civilian death experiences. Some of their accounts span multiple interviews across different years and media, demonstrating remarkable consistency and validity (History Channel, 2011; September 11 Television Archive, 2011). Data and archives from the private sector demonstrate that many family members were key informants, who facilitated appropriate decisionmaking that led to better death experiences. Family members communicated to the civilians what they were seeing on the news, estimates of what floors the fires appeared to be on, as well as activities of the firefighters below, some of which were being actively reported on the news. These information exchanges led, in some cases, to civilians self-evacuating, rescuing others, deciding to jump

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(Dwyer & Flynn, 2005; Junod, 2009; 9/11 Commission, 2004; NIST, 2005), or staying on the phone comforted by their loved one(s) as they died (Dwyer, 2006; History Channel, 2011). Ultimately, a myriad of end-of-life decisions were being made that led to qualitatively different death and dying experiences among those trapped in the same circumstances. These experiences are analyzed using traditional clinical ethics frameworks. Historical Context And Considerations As the 9/11 Commission Report states, the bias and painful lens of hindsight must be taken into consideration in any post-analysis of 9/11. In 2000, the fear of a terrorist attack was of such insignificance to the American public, it was not even asked about on any national surveys or election polls (9/11 Commission, 2004). This archive presents a rare snapshot of the emerging role of technology in death and dying experiences. Cell phone usage in 2001 was just beginning to become mainstream; 110 million Americans used cell phones in 2001, compared to approximately 285 million in 2012 (approximately 90% of the population), out of which 46% of cell phones are now smartphones with Internet access (Foresman, 2010; Gaudin, 2001; Smith, 2012). For the civilian population at the WTC that day, cell phones already had become an indispensible communication tool. Some of the photographs released in WTC staircases were snapped from cell phone cameras; cell phones, in some cases, were used to light the way to escape. Cell phone coverage was also an issue, as cellular phone use increased precipitously that day, overwhelmed the system, and ultimately shut down. Many WTC civilians made multiple calls and eventually got through to either family members or emergency dispatchers. Voicemails from WTC civilians left on answering machines were also an important technological tool that day; many last words were recorded on voicemail to loved ones, who have since turned these voicemails into MP3 files, which are frequently transferred to computers, MP3 players, or smartphones (History Channel, 2011). The recordings, in some cases, were played several times a day by widowed spouses or other surviving family members during their grieving periods. These behaviors point to a need for new frameworks to understand death and dying in the digital age (Walter, Hourizi, Moncur, & Pitsillides, 2012). In 2001 the Blackberry (launched in 1999) was also used by some inside the tower, as 10,000 companies worldwide were using Blackberry devices at that time. A few text messages were also sent, in addition to emails (Blackberry, 2001). More notably, “social networking” was not yet developed; early social networking sites, such as MySpace (launched 2003), Facebook (launched 2004) and Twitter (launched 2006) had not yet been invented. YouTube (launched 2005) was not yet invented, but has become an important archival tool in post-9/11 analysis. Since YouTube’s launch, several eyewitnesses to 9/11 began releasing

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Table 2. Transcript of Call from Melissa Doi, WTC 2, 83rd Floor* Time: 9:17 AM** Speaker

Transcript

Melissa Doi

(muttering to herself) . . . Holy Mary Mother of God.

Dispatcher 8695

8695, good morning, unintelligible good day

unidentified

Hi, what’s your number again please?

Dispatcher 8695

8-6-9-5

Melissa Doi

Oh my God, I’m on the 83rd floor! I’m on the 83rd floor!

unidentified

86 . . . what?

Melissa Doi

I’m on the 83rd floor!

unidentified

Ma’am, stop that, 86-what?

Dispatcher 8695

8-6-9-5

unidentified

unintelligible . . . somebody’s having difficulty breathing on the 83rd floor.

Dispatcher 8695

Hi there ma’am, how’re you doing?

Melissa Doi

Is it . . . is it . . . are they going to be able to get somebody up here?

Dispatcher 8695

Well of course ma’am, we’re coming up to you.

Melissa Doi

Well, there’s no one here yet, and the floor’s completely engulfed. We’re on the floor and we can’t breathe . . .

Dispatcher 8695

unintelligible

Melissa Doi

And it’s very, very, very hot.

Dispatcher 8695

It’s very . . . are the lights still on?

Melissa Doi

The lights are on, but it’s very hot.

Dispatcher 8695

Ma’am, now m’am . . .

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Table 2. (Cont’d.)

Speaker

Transcript

Melissa Doi

VERY hot! We’re all on the other side of Liberty, and it’s very, very hot.

Dispatcher 8695

Well the lights, can you turn the lights off?

Melissa Doi

No, no the lights are off.

Dispatcher 8695

Okay good, now everybody stay calm, you’re doing a good job . . .

Melissa Doi

Please!

Dispatcher 8695

Ma’am listen, everybody’s coming, everybody knows, everybody knows what happened, okay . . . they have to take time to come up there, you know that. You got to be very careful.

Melissa Doi

It’s very, very hot.

Dispatcher 8695

I understand. You’ve got to be very, very careful . . . how they approach you, okay? Now you stay calm. How many people where you’re at right now?

Melissa Doi

There’s like, five people here with me.

Dispatcher 8695

All up on the 83rd floor?

Melissa Doi

83rd floor

Dispatcher 8695

with five people . . . unintelligible, everybody’s having trouble breathing?

Melissa Doi

Everybody’s having trouble breathing, some people are worse . . . than others.

Dispatcher 8695

Anybody’s unconscious, everybody’s awake?

Melissa Doi

So far yes, but it’s . . .

Dispatcher 8695

Listen, listen, everybody’s awake?

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Table 2. (Cont’d.)

Speaker

Transcript

Melissa Doi

Yes, so far.

Dispatcher 8695

Conscious? And it’s very hot there, but no fire, right?

Melissa Doi

I can’t see because it’s too hot.

Dispatcher 8695

No, no, very hot, no fire for now, and no smoke right? No smoke, right?

Melissa Doi

OF COURSE THERE’S SMOKE!

Dispatcher 8695

Ma’am, ma’am, you have to stay calm.

Melissa Doi

There is smoke! I can’t breathe!

Dispatcher 8695

Okay, stay calm with me, okay? I understand . . .

Melissa Doi

I think there is fire because it’s very hot.

Dispatcher 8695

Okay, it’s . . .

Melissa Doi

It’s very hot, everywhere on the floor.

Dispatcher 8695

Okay, I know you don’t see it and all, but I’m, I’m . . . stumbles over words . . . I’m gonna, I’m documenting everything you say, okay? And it’s very hot, you see no fire, but you see smoke, right?

Melissa Doi

It’s very hot, I see . . . I don’t see any air anymore!

Dispatcher 8695

Okay . . .

Melissa Doi

All I see is smoke.

Dispatcher 8695

Okay dear, I’m so sorry, hold on for a sec, stay calm with me, stay calm, listen, listen, the call is in, I’m documenting, hold on one second please . . .

Melissa Doi

I’m going to die, aren’t I?

Dispatcher 8695

No, no, no, no, no, no, no, say your, ma’am, say your prayers.

Melissa Doi

I’m going to die, aren’t I?

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Table 2. (Cont’d.)

Speaker

Transcript

Dispatcher 8695

No, no, no. You gotta think positive, because you gotta help each other get off the floor.

Melissa Doi

I’m going to die.

Dispatcher 8695

Now look, stay calm, stay calm, stay calm, stay calm.

Melissa Doi

Please God . . .

Dispatcher 8695

You’re doing a good job ma’am, you’re doing a good job.

Melissa Doi

No, it’s so hot, I’m burning up.

Dispatcher 8695

Okay ma’am, the floor is hot, everything is hot, is there, are there, are there desks there? You go up high, you get yourself away from the smoke. Okay, I know you know, hold on a second.

Dispatcher 8695

(into radio) 83rd floor, three people trapped.

unidentified

(into radio) Where?

Dispatcher 8695

(into radio) Way out on the 83rd floor, they’re trapped, very hot . . . that’s what I’m doing, just letting you know.

Melissa Doi

(excited interrupting) Wait! Wait! We hear voices! (screaming to firefighters) HELLO! HELP!

Dispatcher 8695

Hello, ma’am? Ma’am?

Melissa Doi

(screaming to firefighters) HEEEEELP

Dispatcher 8695

Okay, stay calm, ma’am, ma’am.

Melissa Doi

(screaming to firefighters) HEEEEELP

Dispatcher 8695

Stay calm, stay calm, just don’t move.

Melissa Doi

Oh my God . . .

Dispatcher 8695

They coming through to you now?

Melissa Doi

Find out if there’s anybody here on the 83rd floor.

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Table 2. (Cont’d.)

Speaker

Transcript

Dispatcher 8695

Ma’am, don’t you worry, you stay on the phone with me and we’ll . . .

Melissa Doi

Can you find out if there’s anybody on the 83rd floor, because we thought we heard somebody!

Dispatcher 8695

Ma’am, now listen, excuse me, I already notified the lieutenant, okay?

unidentified

garbled radio traffic

Dispatcher 8695

I already notified the lieutenant that there’s five people on the 83rd floor, very hot and smoky, so they won’t overlook you, okay dear?

Melissa Doi

Can you . . . can you . . .

Dispatcher 8695

I already did that dear.

Melissa Doi

Stay on the line with me please, I feel like I’m dying.

Dispatcher 8695

Yes ma’am, I am going to stay with you.

Melissa Doi

They’re here?

Dispatcher 8695

Are they inside with you yet dear?

Melissa Doi

No.

Dispatcher 8695

Okay, stay calm until they get inside.

Melissa Doi

Can you find out where they are?

Dispatcher 8695

Okay, stay calm, stay clam, stay calm until they get inside.

Melissa Doi

Can . . . (voice stops)

unidentified

radio traffic between Dispatcher 8695 and an unknown

*The full call can be heard at these links (NPR, 2006; New York Times, 2006a): http://www.npr.org/templates/story/story.php?storyId=5658516 – or – http://www.nytimes.com/packages/khtml/2006/03/31/nyregion/20060331_TAPES_AUDIOSS.html **The call is only audible two-ways for the first 4 minutes. Beyond that, only the dispatcher side is released, which makes clear that the caller is giving out her parents name for the dispatcher to call them. The caller becomes unconscious about half way into the long call, the dispatcher keeps trying to rouse her.

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unseen visual and audio archives, while other YouTube users have posted relevant broadcasts or remixed archives emphasizing particular focuses. YouTube has been an important archival tool in documenting the “9/11 Jumpers,” for example; footage captured by traditional media outlets was generally banned or sanitized. Lay photojournalism and videography has become an important part of the investigative archive too and was critical in the NIST investigations (NIST, 2005). We can only imagine what type of digital and media archive would have been left behind had 9/11 occurred in the Facebook and YouTube age. Nevertheless, the archive is still incomplete, as rich as it is. As one example, a “September 11” YouTube channel is in development, in which the public is encouraged to upload oral histories (YouTube, 2011). There is also an emerging archive collecting text-based messages, such as e-mails, phone texts, and Blackberry messages (September 11 Digital Archive, 2011). This exploration is based on a content analysis of the visual and audible record and core documents that collected hundreds of oral histories. The 9/11 archive is far from complete, and as with any historical event, time will surely provide additional content and insights. Theaters of Attack The study of 9/11 is a vast undertaking. Borrowing military vernacular used to discuss different “theaters” of military conflict in major world wars (see, for example, the National Archives usage of the European or Pacific theaters of WWII), 9/11 may be divided broadly into the New York City and Washington, DC, theaters. However, a closer analysis of that day reveals disparate civilian experiences. Thus, it is more useful to understand this day as four distinct civilian theaters of attack, which can be categorized as (a) the In-Flight theater, comprising civilian passengers on American Airlines Flight 11 (which crashed into the North Tower); United Airlines Flight 175 (which crashed into the South Tower); American Airlines Flight 77 (which crashed into the Pentagon), and United Airlines Flight 93 (which crashed into an empty field in Shanksville, PA, enroute to the Capitol building in Washington, DC); (b) the WTC theater, comprising civilians inside the North and South Towers; (c) the Pentagon theater, comprising civilians working at the Pentagon who were non-military personnel; and finally (d) the “peri-WTC theater,” comprising civilians who were near or around the WTC, its surrounding infrastructure (such as the Marriott Hotel), or caught in the disaster as pedestrians. This analysis focuses solely on the WTC theater. THE WTC THEATER Post-9/11 analysis has noted that the “twin towers” were twins in every way, from their initial erection to final destruction. However, civilians within the North

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Table 3. Transcript of Call from Kevin Cosgrove, WTC 2, 105th Floor Time: Approximately 9:44 AM* Speaker

Transcript

Dispatcher

What’s the telephone number I can tell FD to push up? What’s the telephone number you’re calling from?

Kevin Cosgrove

I can barely see.

Dispatcher

You can barely see?

Kevin Cosgrove

4-4-1

Dispatcher

4-4-1

Kevin Cosgrove

2-6-2-3

Dispatcher

That’s on the 105th floor of the Northwest corner, right?

Kevin Cosgrove

Right.

Dispatcher

At number Two World Trade Center?

Kevin Cosgrove

Right . . . Lady, there’s two of us in this office. We’re not ready to die, but it’s getting bad.

Dispatcher

I understand, sir. We’re trying to get all the apparatuses there. I am trying to let them know where you are. Stay on the line.

Kevin Cosgrove

Oh, please hurry.

Fire Dept.

Let me talk to the caller please . . . Let me talk to the caller. Where is he?

Dispatcher

He’s on the line.

Fire Dept.

Let me talk to him . . . Where is the fire, sir?

Kevin Cosgrove

Smoke really bad. 105 Two Tower.

Fire Dept.

Alright. Sit tight. We’ll get to you as soon as we can.

Kevin Cosgrove

They keep saying that, but the smoke’s really bad now.

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Table 3. (Cont’d.)

Speaker

Transcript

Fire Dept.

That’s all we can do now.

Kevin Cosgrove

What floor are you guys up to?

Fire Dept.

We’re getting there. We’re getting there.

Kevin Cosgrove

Doesn’t feel like it, man. I got young kids.

Fire Dept.

I understand that, sir. We’re on the way.

Kevin Cosgrove

Doesn’t feel like it, man. I got young kids.

Fire Dept.

I understand that, sir. We’re on the way.

Dispatcher

He’s on the 105th floor in the Northwest corner.

Kevin Cosgrove

He hung up on me . . . Hello, operator?

Dispatcher

Yes?

Kevin Cosgrove

Come on, man.

Dispatcher

We have everything we need, sir.

Kevin Cosgrove

I know you do, but doesn’t seem like it . . .You got lots of people up here.

Dispatcher

I understand.

Kevin Cosgrove

I know you got a lot in the building, but we are on the top. Smoke raises, too. We are on the floor. We’re in the window. I can barely breathe now. I can’t see.

Dispatcher

Okay, just try to hang in there. I’m going to stay with you.

Kevin Cosgrove

You can say that, you’re in an air-conditioned building. What the hell happened?

Dispatcher

Okay. I’m still here . . . still trying . . . The Fire Department is trying to get to you.

Kevin Cosgrove

Doesn’t feel like it.

Dispatcher

Okay, try to calm down so you can conserve your oxygen, okay? Try to . . .

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Table 3. (Cont’d.)

Speaker

Transcript

Kevin Cosgrove

Tell God to blow the wind from the West. It’s really bad. It’s black. It’s arid. Does anyone else wanna chime in here? We’re young men. We’re not ready to die.

Dispatcher

I understand.

Kevin Cosgrove

How the hell are you going to get my ass down? I need oxygen.

Dispatcher

They’re coming. They’re getting you. They have a lot of apparatuses on the scene.

Kevin Cosgrove

It doesn’t feel like it, lady. You get them in from all over. You get ’em in from Jersey. I don’t give a shit. Ohio.

Dispatcher

Okay, sir. What’s your last name?

Kevin Cosgrove

Name’s Cosgrove. I must have told you about a dozen times already. C.O.S.G.R.O.V.E. My wife thinks I’m alright. I called and said I was leaving the building and that I was fine and then—bang . . . Cherry. Doug Cherry. Doug Cherry’s next to me. 105. Whose office? John Ostaru’s office?

Dispatcher

That’s where he said? That’s the office?

Kevin Cosgrove

We’re in John Ostaru’s office. O.S.T.A.R.U.

Dispatcher

A.R.U.

Kevin Cosgrove

Right. That’s the office we’re in. There are three of us in here.

Dispatcher

Ostaru. Hello?

Kevin Cosgrove

Hello! We’re looking in . . . We’re overlooking the Financial Center. Three of us. Two broken windows. (Thunderous sound heard) OH GOD . . . OH . . .

*This transcript lasts about 4:55 minutes. The entire call lasted about 15 minutes, and ends with the tower’s collapse at exactly 9:59 AM. Approximately 10 minutes of this call has been withheld from the public record at the request of the family. The approximate time of the call was likely around 9:44 AM. The released portions of this call can be downloaded from (New York Times, 2006b): http://www.nytimes.com/2006/04/11/us/11cnd-moussaoui.html The call is also presented in Voices from the Towers (History Channel, 2011).

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Tower (WTC 1) and South Tower (WTC 2) had different experiences within different time frames. Between the two towers, 2,092 civilians died (NIST, 2005). Civilians are defined as occupants and visitors of the towers rather than people who arrived at the site from another location (flight passengers or first responders). It’s estimated that 1,500 civilians survived the impact of the planes’ crashes but died because they were unable to exit the buildings. Based on tenant and occupancy records, visitor estimates, absentee records for that time frame, as well as data on pre-evacuation in WTC 2, it’s estimated that no more than 600 people could have been killed immediately upon impact (Dwyer & Flynn, 2005). A local election and the first day of school led to reduced occupancy of both towers at the time of the attacks. Cousins But Not Twins WTC 1 was struck first at 8:46:30 a.m. and was hit between floors 93 and 99; floors immediately below and above impact became engulfed in flames and smoke. On floors 92-110, 1,355 civilians had no access out of the building, as all stairwells were blocked, and roof access was locked (NIST, 2005). In this scenario, there was no pre-evacuation opportunity, but 20 more floors than in WTC 2 were situated below impact, with access and more time to escape. However, a large breakfast that morning held by the firm Risk Waters at the restaurant Windows on the World (floors 105-106), trapped roughly 70 civilians who would normally not have been there (Dwyer & Flynn, 2005). That morning, 170 civilians were dining or working in the restaurant upon impact (Dwyer & Flynn, 2005). All 1,355 civilians at or above impact perished. Within 5-8 minutes of the crash, most of the 7,545 people below impact began to evacuate (NIST, 2005). By 10:28, when the tower collapsed, all but 107 of the civilians below impact floors had managed to exit the building. Those who did not escape were mobility impaired (representing 6% of the occupants that day), trapped by debris, or started their exit too late. Unique to the WTC 1 experience were civilians at or above impact floors who fell or jumped off the building; falling bodies were observed within just minutes of impact. Ultimately, the trajectory of the plane, angle of impact, and the nature of fire and its consumption of combustible materials led to a longer time frame between impact and collapse (102 minutes). WTC 2 was struck at 9:02:59, impacting floors 77 through 85. Preemptive evacuation was distinct to this tower. At the time of impact, 40% of the building occupants had already left the building, while 90% were in the process of evacuating. At 8:46 a.m., WTC 2 had 8,600 occupants; by 9:03, some 3,200 had left the building, and 4,800 were below the impact floors. By 9:59, at the time of collapse, 8,000 had left the building; all but 11 civilians below impact floors had exited the building. At the time of impact, 637 people were at or above the impact floors (77-110); of those, 18 managed to escape by 9:59 by finding stairwell access, while 619 perished (NIST, 2005). Between 8:46 and 9:03, confusion and

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hesitation regarding immediate evacuation from WTC 2 prevented hundreds from exiting before the second plane struck. Different companies imparted different messages about evacuation, which resulted in uneven evacuation procedures. Of note, Fuji Bank (floors 79-83) and Morgan Stanley (floors 44-74) immediately evacuated within minutes of 8:46 a.m. due to their own internal policies. Other large companies allowed employees to make individual decisions about evacuation. Delayed preemptive evacuation was also due to confused instructions; a security message broadcast at 9:00 throughout WTC 2’s loudspeakers that the “building was secure” and they should return to their offices (several did or wound up on the 78th floor at impact). At 9:02, a contradictory message was broadcast, which said that while the “problem” was in WTC 1, if they felt conditions warranted evacuation, they should (Dwyer & Flynn, 2005; 911 Commission, 2004; NIST, 2005). The majority of civilians who preemptively evacuated survived. WTC 2 was also distinctive in that the 78th floor sky lobby and elevator transfer point was an impact floor. Many had been in the process of evacuating or returning to their offices (due to the 9 a.m. message) and found themselves on the 78th floor when the second plane hit. This had resulted in a virtual battlefield of carnage, in which the dead and critically injured lay together immobile in large numbers in one large area. Those still alive prior to the collapse would have seen a first responder reach their floor (Dwyer & Flynn, 2005; History Channel, 2011). Unique to this tower too was an intact stairwell from the roof to the lobby (Stairway A), which was compared to the half-empty lifeboats on the Titanic (Dwyer & Flynn, 2005); few knew about its existence, and emergency dispatchers were not privy to it. In WTC 2, the trajectory of the plane, angle of impact, and the nature of fire and its consumption of combustible materials led to a much shorter time frame between impact and collapse (57 minutes). In both towers, timely evacuation separated the living from the dying. In WTC 1, evacuation was clocked at a slower pace than the slowest pace clocked in a non-emergency (NIST, 2005). The longer burn time of the tower enabled most below impact floors (91 and below) to exit in time. In WTC 2, some 16 minutes of pre-emptive evacuation sped up evacuation and allowed large numbers to exit using the elevators (NIST, 2005). In both towers, the physical challenge of evacuation, transfer hallways, and clearing debris during descent, slowed people down. Delayed evacuation had universal causes in both towers despite the vastly different timelines and different floors of impact. Delayed evacuation was caused by confused instructions; in WTC 1, emergency dispatchers and Port Authority staff initially told people to stay put (even if they were below impact). Some emergency dispatchers began to shift instructions to evacuate, but not all. In both towers, “milling” behaviors (Kuligowski & Mileti, 2009) occurred on floors where risk perception was ambiguous or low. Milling refers to information-seeking (which

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tends to delay exiting); engaging in conversation with others in small or larger groups to make sense of events, canvassing opinions about next steps; and general procrastination regarding grabbing personal items or making calls to check in with loved ones about what to do. In both towers, individual acts of professionalism and heroism led many civilians to delay exiting by assisting others with escape or even looking for trapped people. In WTC 2, several executives played the role of “shepherd” within their companies and began herding their employees to the stairwell exits or elevator banks within the 16-minute window of the first and second attacks, leaving themselves trapped at or above impact. In both towers, the events of the February 26, 1993 bombing played a significant role in civilian decision-making; some delayed evacuation or decided to climb to the roof on 9/11 (Dwyer & Flynn, 2005; Fahy & Proulx, 1996; 911 Commission, 2004; Proulx & Fahy, 2003; Quenemoen et al., 1996). In the 1993 experience, both towers evacuated into very smoky stairwells in complete darkness; those evacuations lasted hours, in which evacuees in the stairwells suffered from more smoke inhalation than those who stayed on upper floors and waited for first responders. In 1993, vehicle fires ensued in the garage, where a large bomb had been exploded, which did little damage to the upper floors but dispersed toxic smoke from burning rubber into the stairwells, in particular. Those who remained in their offices actually fared better than those who evacuated into the stairwells. In 1993, there were also unsafe and questionable rooftop evacuations. As a result, new building policies—not communicated to civilians—resulted in roof access in both towers being permanently closed, which could only be re-opened by software programs operated by security inside the towers (Dwyer & Flynn, 2005; 911 Commission, 2004; NIST, 2005). Thus, decision-making for civilians facing a life-threatening situation had taken different pathways and ran on different timelines in WTC 1 and 2. Risk perception was what defined these critical decisions as “end-of-life” decisions. End-of-Life Decisions in WTC 1 For the purposes of this analysis, a stipulative definition of “end of life” is provided, which is adapted from a consensus definition proposed by the National Institutes of Health (NIH) in 2004: “The presence or imminent threat of symptoms or functional impairments resulting from underlying irreversible injuries, which require formal or informal care and can lead to death” (NIH, 2004). Such a definition encompasses asymptomatic civilians aware of some or all of their deteriorating environmental conditions, such as (on lower floors) the building swaying, seeing large falling objects and bodies from windows, strange noises, falling debris (and on higher floors and impact floors), smoke, fire, barriers to exits; as well as symptomatic civilians (on impact and higher floors) finding it difficult to breathe and/or suffering from other injuries or even preexisting

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conditions (severe obesity or inability to walk well) restricting mobility or ability to evacuate. Half of the survivors interviewed stated that they felt they were in a “life-threatening” situation; two thirds reported feeling violent movement in the building, and a third actually heard the roar of the plane (NIST, 2005). Perception of risk also increased with either greater environmental cues or by obtaining information about what was happening (Kuligowsky & Mileti, 2009). End-of-life decision-making began in WTC 1 immediately after impact. No core document in existence can absolutely determine how many civilians were instantly killed upon impact. On the impact floors and above, we know hundreds of civilians began an information-seeking process by calling dispatchers and/or family members. Those who were instantly killed would include those in the direct collision path of the plane, as well as those killed from the burst of heat from the burning jet fuel. Below impact, fireballs swept through lower floors and killed some people instantly as low as the Concourse level (NIST, 2005). Approximately 3,000 calls to emergency dispatchers were logged in the first 10 minutes of the first plane crash; many of these calls were from eyewitnesses on the ground or frantic family members, but many were from within WTC 1. Chris Hanley (106th floor) was one of the first calls to dispatchers (Table 1). The transcript of his call reveals the typical instructions to callers on aboveimpact floors. By 9:02 a.m., 26 calls were made to emergency dispatchers by representatives of large groups. Between 9:03 and 9:10, there were only 7 calls to emergency dispatchers from above-impact floors and three final calls from floors 104 and 105 between 9:43 and 9:57. More people on or above impact floors jumped than made calls to emergency dispatchers (NIST, 2005). Many civilians prioritized by making calls to family members (Dwyer & Flynn, 2005; History Channel, 2011). The family of Jeffrey Nussbaum has made his last cell phone bill public (Table 4). The phone bill reveals decisions about which connections had priority. Calls to emergency dispatchers from lower floors, where risk perception was lower, were information-seeking calls to find out what occurred and whether they should evacuate, as environmental cues varied (Kuligowski & Mileti, 2009). Initial instructions to those below impact floors were to stay (Dwyer & Flynn, 2005; 911 Commission, 2004; NIST, 2005). From impact floors and above, where risk perception was greater, calls to emergency dispatchers can be more accurately described as “medical emergency” calls, looking for life-saving guidance. In these calls, emergency dispatchers generally stuck to the “high rise fire” script, instructing civilians to stay put and wait for help to arrive; if hallways were smoky, they were instructed to block airways, dampen clothing, get low on the floor, and to wait for help. Callers amidst an inferno were more panicked and asked about breaking windows; emergency dispatchers advised them not to. Civilians on impact floors and higher made quick decisions to ignore emergency dispatcher instructions and broke windows in order to breathe. They gathered in large groups at the open windows; many climbed out to seek the

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Table 4. Below is the last cell phone record of Jeffrey Nussbaum (above impact in the North Tower), showing all calls made since the time of impact, until his last call, about 25 minutes prior to collapse. This record appears in the documentary, Voices from the Towers (The History Channel, 2011). 8:56 AM:

personal call

8:59 AM:

personal call

9:02 AM:

9-1-1

9:06 AM:

9-1-1

9:10 AM:

personal call

9:13AM:

personal call

9:15 AM:

personal

9:24 AM:

201/INC (possibly an internal call within WTC 1)

9:24 AM:

9-1-1

9:34 AM:

9-1-1

9:55 AM:

9-1-1

9:57 AM:

9-1-1

10:04 AM:

9-1-1

Analysis Nussbaum makes two personal calls before calling dispatchers. He then makes a total of seven calls to dispatchers beginning from 9:02 to 10:04. In between calls to emergency dispatchers, he makes four other personal calls. Rotating between information seeking and connecting with loved ones was a common pattern.

attention of first responders, waving articles of clothing or makeshift “flags” for help. These images and live footage became the iconographic visual record of 9/11 (see nist.gov; also Understanding 911, 2011; YouTube, 2012). Broken and open windows led to a phenomenon coined the “9/11 Jumpers,” many of whom were seeking oxygen at windows and were accidentally pushed out or fell out. Many apparently walked toward blown out windows or walls, unable to see properly, groping in the dark, and fell (Leonard, 2011), while some were even blown out by surrounding explosions (one such occurrence is captured on video). Some reflexively jumped, but many decided to jump, which the visual record has clearly captured (International Center for 9/11 Studies); some jumped while

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holding hands, while some constructed makeshift parachutes (Associated Press, 2005; Cauchon & Moore, 2002; Dwyer & Flynn, 2005; Flynn & Dwyer, 2004; Leonard, 2011; Junod, 2009). According to some accounts, the first falling person was seen around 8:48 a.m. (Dwyer & Flynn, 2005) or 8:52 a.m. (NIST, 2005). NIST estimates approximately 111 civilians fell or jumped, but a more recent estimate is approximately 200 (Junod, 2009). A falling body was also responsible for the first firefighter death on 9/11 (Dwyer & Flynn, 2005). Photographs and video footage of falling civilians remain the only visual record of dying civilians in the WTC. Most notable is the photograph the “Falling Man” (Junod, 2009; Kroes, 2011; Nadel, 2011b; Singer & Junod, 2006). Another photograph, “Falling Woman,” served as a means of body identification (Associated Press, 2006; Leonard, 2011). “The Waving Woman of 9/11” captures video footage of Edna Cintron (a confirmed decedent from WTC 1, who popular culture websites claim is the woman waving); she waves for attention as she stands in the gaping hole made by the plane (Webfairy.org, 2012). The photographic record has been used as a forensic tool, as fallen bodies disintegrated when they reached the ground. As for the civilians no one could see, there is the audible record, which contains disturbing calls to dispatchers and voicemails left for family members. In one representative voicemail left by 31-year-old Melissa Harrington Hughes for her husband, Sean Hughes, the voicemail message states (History Channel, 2011), “Sean it’s me . . . I just wanted to let you know that I love you and I’m stuck in this building in New York. There’s lots of smoke and I just wanted you to know that I love you always.” This caller lived in California, was married for under a year, and was only in WTC 1 for a one-day meeting; she was trapped above an impact floor. In a second representative voicemail, 29-year-old Brian Nunez, who worked at Cantor Fitzgerald on an impact floor, left this for his brother, Neal (History Channel, 2011): “Neal, it’s Brian—a plane crashed into the Trade Center. It’s on fire, and I’m in it, and I can’t breathe. Tell everyone I love them, and if I don’t get out of here . . . Goodbye.” The voice messages demonstrate clear decisions to die with “closure.” Amidst the chaos and confusion, it was important for trapped civilians to contact family members and explain their specific whereabouts, predicaments, communicate their love, and sometimes, estate information. Unbeknownst to the trapped civilians, these calls also became forensic tools in the absence of recovered bodies. The oral histories from surviving family members also validate the audible record. Of note are the recounted calls of Michael Trinidad to his ex-wife, Monique Ferrer (NPR, 2011b), and Tom McGinnis to his wife (Dwyer & Flynn, 2005, pp. 237-238). Decisions to call family members also saved lives. In the cases of those on lower floors, with lower risk perception (Kuligowski & Mileti, 2009), calls to loved ones facilitated timely evacuation decisions because loved ones could communicate what they were seeing on the news, prompting their exits.

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End-of-Life Decisions in WTC 2 In WTC 2, end-of-life decisions were qualitatively different than in WTC 1 because the first decision surrounded preemptive self-evacuation, motivated in many cases by bearing witness to WTC 1’s demise. On higher floors, falling bodies were seen, and sometimes eye contact was made as the person fell (Dwyer & Flynn, 2005; History Channel, 2011; Leonard, 2011). Another decision for those perceiving life-threatening risk was to make “reassurance calls” to family members. Such calls relayed they were okay, in the “other building,” and were going to leave. However, reassurance calls also delayed evacuation. After WTC 2 was struck, 637 people were on impact floors or higher, compared to 1,355 in WTC 1. Of those, many were instantly killed or critically injured on the 78th floor. Those who were above the impact zone would become trapped at the 79th floor unless they knew about Stairwell A. When facing impassable stairwells on the 79th floor, civilians chose to go up to the roof, which was locked (as it was in WTC 1), and wound up congregating in offices on higher floors to wait for help and alert dispatchers as to where they were. Such was the case with Aon executive Kevin Cosgrove, who descended from the 99th to 79th floor and found it was blocked. He then ascended to the 105th floor and gathered with co-workers in a boardroom. He called his brother to say his goodbyes and then made his last call to an emergency dispatcher (Table 3), dying on the phone at collapse. It is notable that only three civilians were recorded to have jumped or fallen from WTC 2 (Junod, 2006; Leonard, 2011). There are some reasonable explanations for this variation. First, WTC 2 civilians on impact floors or higher had witnessed falling bodies in great detail from WTC 1, which may have deterred them. Second, preemptive evacuation from higher floors, combined with large numbers of casualties on impact floors simply left fewer individuals trapped above impact to make this decision. (In WTC 1, the decision to jump was likely made by less than 1%; most had probably fallen by oxygen seeking or climbing out with the intent to get help.) Finally, emergency dispatchers told WTC 2 callers that the firefighters were already “in the building,” creating anticipation that rescue was imminent. NIST (2005) estimated that if neither building had collapsed, it would have taken several hours to rescue those on floors 90 and above. The audible record contains two calls from dying civilians: Melissa Doi on the 83rd floor, and Kevin Cosgrove from the 105th floor (Tables 2 and 3). Here, the callers ask where the rescuers are because they are running out of time; the purpose of the calls is different than calls from WTC 1, asking what to do. Most important, the Cosgrove and Doi calls demonstrate how poorly end-of-life discussions were handled by emergency dispatchers, as well as how important truth-telling and not being abandoned was to the callers, reinforced in classic end-of-life literature (Christakis, 1999; Kübler-Ross, 1969). As truthtelling is avoided, the callers become more agitated; Doi grows more anxious, and Cosgrove grows more angry.

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The audible record, supported by oral histories shows, in contrast, a “better death” experience through the phone calls of Shimmy Biegleisen on the 97th floor, who dies comforted by soothing voices of close family, friends, and a doctor whom the family patches into the call (Dwyer & Flynn, 2005, p. 195; History Channel, 2011). Clearly, decisions about who to call led to qualitatively different death experiences. DISCUSSION The death and dying experiences of civilians in the WTC theater can be categorized into the following groups: (A) sudden death, of which there was virtually no suffering or foreknowledge; (B) deaths with prolonged suffering, in which there was a maximum of 102 minutes of suffering; (c) death by falling or jumping (aka “9/11 Jumpers”), in which an autonomous end-of-life decision may have been exercised as a palliative approach. Category A includes civilians killed instantly upon the planes’ impacts or civilians evacuating on lower floors fully expecting to reach the exit with no collapse imaginable or anticipated. In WTC 2, preemptive evacuation decisions made during a 16-minute window between attacks were life and death decisions, while delaying evacuation after impact from lower floors was more problematic in light of the timeline between impact and collapse. Without the use of elevators in preemptive evacuation, thousands more would have been trapped above impact. In WTC 1, those on floors 91 and below who delayed evacuation would be caught in collapse. Perception of risk increased the likelihood of self-evacuation, in spite of confused instructions (Kuligowski & Mileti, 2009). In both towers, some individual acts of heroism, which delayed/interrupted a civilian’s evacuation, led to improbable survival. The most notable example is from WTC 2, in the oft-recorded story of Brian Clark saving Stanley Prainmath, and discovering Stairwell A (Dwyer & Flynn, 2005, pp. 97-99). This situation describes the more unusual reward of saving oneself by saving another. More commonly, acts of heroism in both towers led to utilitarian outcomes, in which the hero (or shepherd) did not survive, but facilitated escape for many others. About 6% of WTC civilians (about 1,000 in the towers that day) were mobility impaired due to preexisting health problems. In WTC 1, about 60 had been left in a group on the 12th floor, rescued by firefighters, who all died in the collapse. Many were assisted by co-workers but slowed down evacuation for others. Category B comprised civilians who were trapped or critically injured, which increased suffering at the end of life. Decision-making revolved around communication: prioritizing and rationing calls to maximize utility and potential benefit. One call would be made to emergency dispatchers by a representative of hundreds of people, in some cases (NIST, 2005). Calls made revolved around full disclosure and truth-telling; callers wanted the same in return. In emergency

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dispatch calls, “truthful prognostication” (Christakis, 1999) about the status of their conditions was requested. In this respect, telling callers that firefighters are “on their way” or “in the building” (which was true) is not as accurate as “I don’t know how long it will take them to get up to you” or “I don’t know if they will get to you in time.” Christakis (1999) points out that false hope can contribute to greater suffering, and failure to prognosticate deaths accurately leads people to “die deaths they deplore in locations they despise” (Christakis, 1999, p. xiv). Kübler-Ross (1969) showed that the dying do not wish to be isolated, abandoned, or misled. Trapped and dying civilians in the WTC who could not escape still could make decisions about who to call and how to die. Such decisions were obfuscated by hopeful rather than truthful prognostication from emergency dispatchers. Category C comprised civilians trapped at or above impact floors, mainly in WTC 1, where the intensity of fires from atomized jet fuel was greatest on floors 93-97 (NIST, 2005). Many who fell were either leaning out of windows that were crowded with people seeking oxygen or had decided that it was better to walk outside the building altogether to prolong life and/or get attention. Several voluntarily jumped, even if it was a more reflexive action; some held hands while doing so. Forensically, civilian deaths in category C were deemed homicides, not suicides. As the photographic archive of falling civilians was made available to families, there were cultural and religious fears that many of these deaths were, in fact, suicides, which many families could not accept. It is argued here that within a clinical ethics framework, decisions to jump were “palliative” decisions exercised at the end of life to ease suffering. The choice being made was not to die, or whether to die, but how to die. Ultimately, it was a quality-of-life decision. The Role of Emergency Dispatchers Based on the audible record, it is clear that for WTC civilians in categories B and C, the emergency dispatchers were critical informants for end-of-life decisions, but were neither supplying accurate information to callers nor prepared for having end-of-life dialogues with the dying. On 9/11, the emergency dispatchers followed a high-rise fire protocol script (Dwyer, 2006; Clawson, Martin, & Hauert, 1994), and responses to the dying civilians were largely scripted responses. The Hanley call demonstrates the classic response to early callers. Here, the caller is just starting to panic and has not yet concluded he is dying; he maintains a courteous decorum. The Doi and Cosgrove calls are clearly calls from the dying as conditions dramatically deteriorate. In Doi’s call, the emergency dispatcher eventually breaks from the script and attempts to rouse the caller long after Doi has lost consciousness or died. The emergency dispatcher is clearly vicariously traumatized by what she is hearing. In Cosgrove’s call, the emergency dispatcher remains scripted. Responses to Cosgrove’s comments about his imminent death are simply, “I

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understand” or verifying his location and name. The emergency dispatcher is trying to reassure and, instead of responding to the highly alarming information he is disclosing to her, keeps re-asking redundant questions, such as the correct spelling of his name, phone number he’s calling from, and verifying his location. This may be a method of distraction and avoidance since what he is actually saying is too disturbing. A deeper probe into the training of emergency dispatchers (personal communication) reveals that trainees typically have a high school education or lower. They receive no specific instruction or education about how to talk to the dying or how to have end-of-life dialogues. Instead, they are trained to use scripted protocols for various situations. The scripts range from high-rise fire situations to cars that are sinking in a water mass after an accident. But there is no training or protocolized script, even as of this writing, for handling end-of-life calls from the dying. Training for emergency dispatchers is extremely fragmented and varies from state to state, with different legislation for each state. Various organizations foster different goals within the emergency management system in the United States. Evidence-based training and protocol standards, including Critical Incident Stress Debriefing, are set by the National Academies of Emergency Dispatch (NAED). Unifying telecommunications and the 3-digit telephone number “9-1-1,” which has been designated as the “Universal Emergency Number,” is led by the National Emergency Number Association (NENA). (9-1-1 was initially proposed for the United States in 1957 by the National Association of Fire Chiefs but has since become the one number for all emergencies.) Meanwhile, a different association, the National Emergency Management Association (NEMA), is the liaison organization between the states and the federal government. NEMA is the professional association for each state’s emergency management directors (including the eight territories and DC). NEMA helps to advance and determine policy as well as training for directors. Within this web of various emergency management organizations, the focus since 9/11 has been on improving technology and communication systems rather than developing specific training or protocols for dispatchers handling end-of-life calls. There has not been any scholarly inquiry before or since 9/11 that analyzes how end-of-life calls are handled by emergency dispatchers. The 9/11 Commission Report (2004) revealed widespread communication breakdown within the network of first responders. The emergency dispatchers responding to the calls were more ignorant of unfolding events than the television viewing public. Their computer networks were not functioning, and they had no television sets in front of them. The volume of calls to emergency dispatchers had overwhelmed the system, creating a communication vacuum, inconsistent instructions, as well as inappropriate instructions for the environmental threats facing the callers. Improving communication systems is thus an imperative. However, understanding how to have an end-of-life dialogue and the importance

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of truth-telling and truthful prognostication is just as imperative for emergency dispatch training as it is for healthcare providers, even in the absence of the events on 9/11. Putting dying callers on hold, interrupting their pleas with requests to repeat information, was the typical response on that day. For emergency dispatchers who abandoned the scripted response, discussions were guided by their own instincts rather than rooted in training; this contributed to moral distress and moral residue. Within the rich literature of end of life, there is recognition that end-of-life discussions are distinct in trauma situations (Jacobs, Jacobs, & Burns, 2005), but such research has been limited to trauma patients actually reaching the ICU. There is no literature on end-of-life discussions for trauma patients dying on-site, as on 9/11. Pastoral care experts suggest (see Acknowledgments) that reflexive phrases used by emergency dispatchers (see Doi and Cosgrove in Tables 2 and 3), such as “calm down” or “everything’s going to be fine” (hopeful, rather than truthful statements), further agitate and deny the dying experience. Responses that communicate that the dying are being heard facilitate more closure, which helps in the death experience. Such responses may vary, but include, “Tell me who I can call for you and what you want me to tell them” or “This must be very scary for you, and I am sorry I can’t change what is happening. But I am listening. I am here.” Dying callers also need to know the true status of their situation, and on that day, the better death experiences were facilitated by the dying themselves and not by any instructions provided to them by dispatchers. Truth-telling and appropriate end-of-life dialogues can also occur when communication systems are down, which occurred that day. For Cosgrove, rather than false assurances that the firefighters are on their way to him, it would have been better to state, “I don’t know if they will get to your floor in time, given what you’re telling me. Would you like me to call someone for you or connect you to a family member?” Cosgrove’s death had a profoundly negative impact on his son (Stout & Lewis, 2006), who was a teenager at the time of his death. A closure call to his family (and son) may have had a more positive impact on his bereaved family, which could have been facilitated by truthful prognostication by an emergency dispatcher. For Doi, who makes reference to her religion in her last call, truthful prognostication may have facilitated dying in prayer or in connection with her family instead of losing consciousness on the phone with an emergency dispatcher, who began to cheerlead in the absence of formal training in end-of-life dialogues. CONCLUSIONS For civilians in WTC 1 and 2, end-of-life decision-making began as soon as a life-threatening risk was perceived. For many, these decisions led to timely evacuation and escape. For some, these decisions facilitated escape and assistance for others while delaying their own timely evacuation. For those trapped at or

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above impact floors, end-of-life decisions revolved around palliation, closure, truth-telling, and truth-seeking. An examination of materials in the public domain reveals two critical archives of end-of-life experiences in the WTC theater: a visual archive without sound and an audible archive without visuals. The visual and audible archives documented different dying experiences within this unique demographic of highly autonomous individuals with full decision-making capacity at the end of their lives. Both archives demonstrated that these civilians made many different kinds of end-of-life decisions, which led to qualitatively different deaths. The visual archive documents only civilians on impact floors who fell or decisively jumped as an act of palliation, ultimately leading to a better death than the only other alternative. The audible archive reveals that dying civilians facilitated closure for themselves and their family members by making full use of their cell phones, calling loved ones, communicating their coordinates, feelings, and, in several cases, necessary facts surrounding their estates. Both the visual and audible archive demonstrated that civilians also experienced intensified suffering directly consequent to unprepared emergency dispatchers, insufficient emergency instructions, barriers to exits, and inaccurate information. Ultimately, truth-telling, truthful prognostication, and appropriate end-of-life dialogues could have reduced suffering or improved the quality of the dying experience, while even facilitating escape for some who delayed evacuation because they were told to stay where they were. While it would not be feasible or practical to develop a network of pastoral care experts to patch in to calls from the dying (personal communication), it is entirely feasible and practical for pastoral and palliative care experts to develop appropriate emergency dispatch training and protocols for end-of-life dialogues with dying callers. Lessons learned from this terrible morning can inform many areas of scholarship. End-of-life scholars recognize that WTC civilians who died on 9/11 used whatever tools and technologies they had available to communicate what they wanted: they did not want to be abandoned; they wanted truthful prognostication, and they didn’t want to suffer. They made decisions about how to die by facilitating closure, staying in connection, truth-seeking, and finding other ways to die without suffering. ACKNOWLEDGMENTS The author wishes to acknowledge Reverend Joe S. Alverson, MDiv, BCC, Director, Pastoral Care Services, University of Kentucky Medical Center, and Reverend Donald G. Fulton, MDiv, MA, BCC., Chaplain, University of Kentucky Medical Center for their review of select portions of this manuscript, and helpful comments. REFERENCES Associated Press. (2005). We saw the jumpers . . . choosing to die. The Guardian, August 12. Retrieved from: http://www.guardian.co.uk/world/2005/aug/13/september11.usa

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Footnotes 1. This site posts the data sets collected by NIST as well as materials requested under the FOIA. The site's purpose is to use this footage to promote a “9/11 Conspiracy” theory (the false belief that 9/11 was perpetrated by the U.S. government, which is a manifestation of the psychological trauma of this event on the general public, and serves the Believer by promoting the idea that the U.S. government is far more organized and superior than what the facts reveal: layers of vulnerability and incompetence.) The footage is authentic and available for analysis from multiple perspectives. 2. Telephone call in response to an e-mailed general query on September 21, 2012, about “end-of-life dialogue” training for emergency dispatchers. 3. An incomplete archive still in its collection phase of digital print materials, including e-mails. 4. Full archives of American network television coverage spanning September 11-13, 2001, presented in long segments of over 30 minutes.

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5. Summary home page presenting pertinent broadcast moments, and linking to subarchives. 6. Full archive of 3,000 hours of international television news from 20 channels over 7 days (September 11-17, 2001), presented in 30-second segments for select analysis by scholars. 7. This is a website hosted by a “9/11 Conspiracy” theorist. The video footage of Edna Cintron is authentic, but frequently misused by conspiracy theorists as “proof” that the fires must not have been as hot as NIST reports if a WTC 1 occupant is actually standing outside the impact hole made by American Airlines Flight 11.

Direct reprint requests to: M. Sara Rosenthal, Ph.D. Professor of Bioethics Departments of Internal Medicine, Pediatrics and Behavioral Science, and Director, Program for Bioethics University of Kentucky Program for Bioethics Department of Internal Medicine, K-522 740 South Limestone Lexington, KY 40536 e-mail: [email protected]