review
Disaster Response or Response as Disaster? by Jay Baruch
O
n September 1, 2005, Memorial Hospital was on “survival mode.” Hurricane Katrina had felled the levees of New Orleans, submerging a modern city with floodwaters of biblical proportions, tasking physicians and nurses to make morally sound decisions under unprecedented conditions, where, as one physician stated, “[T]he laws of man and the normal standards of medicine no longer applied” (p. 9). In Five Days at Memorial, Sheri Fink, a Pulitzer Prize-winning journalist, resists the urge to assign easy blame or take a position. Instead, she weaves together the perspectives of a cast of people tested by this catastrophe and constructs a tapestry of experiences that isn’t neat and comforting but disturbing, compelling, and admirable all at once. The book pivots on the actions of Dr. Ana Pou, a dedicated and compassionate ear, nose, and throat surgeon, and her role in administering morphine and sedatives into the intravenous drips of some very sick patients on the fifth day after Katrina struck, hastening their deaths. Pou later said, “[W]e all did everything in our power to give the best treatment that we could to the patients in the hospital, to make them comfortable” (p. 234). Dr. Pou and the staff at Memorial faced challenges unimaginable by most health care providers in the United States and other developed nations. The hospital’s 273-page set of twenty disaster plans didn’t anticipate flooding or the need to evacuate or how to respond to loss of power and communications. 46 HASTI N G S C E N T E R R E P ORT
With power generators knocked out, ventilators couldn’t pump oxygen to critically ill patients. With temperatures topping one hundred degrees, the stench of overrun toilets and of dirty, dying, and dead bodies thickened the unbreathable air. Worries within the hospital walls were compounded by rumors of lawlessness and looting on the streets and by fears that rage and violence, like the waters of Lake Pontchartrain, would crash the doors and threaten the lives of providers, patients, and families. Evacuation and rescue, not treatment, became the hospital’s focus. Babies, women with high-risk pregnancies, and dialysis patients received the highest evacuation priority. But communication was haphazard; government rescue efforts, disorganized. Tenet Healthcare, Memorial’s parent company, with home offices in Dallas, seemed to lack the expertise, urgency, and moral imperative to arrange timely assistance, leaving health care providers to fear that they were abandoned. Evacuation efforts, when under way, became a slapdash affair. What counted as rescue was open to interpretation. Helicopters unloaded patients at a highway cloverleaf that was understaffed and undersupplied, without any handoff of responsibility, any standardized exchange of medical information. Patients were often left helpless, hungry, and without family. Rescue was not without risks. Weighing burdens and benefits took on a vertiginous logic as conditions deteriorated during the long-awaited rescue efforts, and the hospital itself was
reduced to an organism on life support. A triage protocol was implemented that delegated the sickest patients and those with do-not-resuscitate (DNR) orders to be evacuated last. Patients were dying, the extreme circumstances too much for their feeble bodies to endure. Staff members worked tirelessly, lucky to grab an hour’s sleep. Some patients were scared of being left behind. What happened, on the fifth day at Memorial, to twenty-three patients whose bodies tested for high levels of morphine and sedatives at autopsy? Was the intent of certain staff members to relieve suffering or to achieve death? Even if we allow room for compassionate intentions, one is left pondering whether decision-makers had at least raised and exhausted alternative solutions. Dr. Pou and her colleagues initiated their plan not when the staff desperately awaited rescue but “when the evacuation was at last under way” (p. 251). She and two well-regarded nurses were celebrated as heroes, but their actions drew heated scrutiny, and prosecutors later charged them with criminal counts of manslaughter. Fink’s meticulous research and clear writing marks a work of great achievement that navigates contentious and roiling medical, political, social, and ethical waters while refraining from judgment. But the knotty choices made by Dr. Pou and colleagues remain at the narrative’s spine. I wish Fink didn’t just conceptualize the ethical imperatives in play but explored how the contextual features might have shaped the health care providers’ moral decision-making. For example, to what degree should we account for the extreme conditions as actors influencing the agonizing decisions made in this moral drama? In his book Thinking, Fast and Slow, Daniel Kahneman, psychologist and winner of the Nobel Prize in economic science, draws on a rich psychology literature to Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. By Sheri Fink. Random House, 2013. 576 pages. Hardcover. $27. March-April 2014
illustrate the many ways our decisionmaking is unconsciously shaped by various forms of effort. Switching tasks, time demands, stifling emotional reactions, fatigue, and hunger are all factors that influence the decisions we make. Whether the effort is physical, emotional, or cognitive, it “draw[s] at least partly on a shared pool of mental energy.” To what degree did the accumulated mental and physical fatigue during the first four days at Memorial influence the decisions made on day five? Do readers, and investigators and ethicists who opined later, share an unfair and privileged advantage, analyzing the actions of Dr. Pou and her colleagues from a healthier, well-rested, and well-fed cognitive position? Should we explore the cognitive load shouldered by providers before we question why a signature on a DNR order served as a triage criterion, when the document serves as an expression of patient wishes only and doesn’t work as a predictive instrument for prognosis or survivability? Fink asks why these providers didn’t think more creatively, and fare better, than their counterparts at Charity Hospital, a public facility accustomed to making do with fewer resources. Their staff cared for approximately twice as many people with a lower ratio of staff to patients, and yet, only three patients died at Charity. Was it better morale, regular sleep, more effective leadership, specialized training, and astute disaster preparedness that allowed them to maintain, the best they could, the regular hospital routine? Did these elements
March-April 2014
set the conditions that fostered a better cognitive space that permitted more creative and effective decision-making in the same crisis? Did the institutional challenges endured by Memorial health care providers alter their thinking and judgment? In the epilogue, Fink draws on postKatrina examples—including Hurricane Sandy and the yearly influenza pandemic anxiety—to examine whether, and to what degree, we’re better prepared to make rationing decisions when available resources are overwhelmed. Which patients receive scarce resources like ventilators or a bed in the intensive care unit? For how long, and based on what criteria? Who should be involved in the conversation about the allocation of resources, and who, ultimately, can be entrusted to make those decisions? Fink cites critical work done by the New York State Task Force on Health and the Law, whose plan is based, in part, on the 2006 rationing plan developed by health officials in Ontario, Canada, in the wake of the severe acute respiratory syndrome (SARS) pandemic. Individual states and large medical centers—including the U.S. Veterans Health Administration—have crafted protocols informed by these guidelines. But Fink also points to the uncertainty that comes between guideline development and implementation, between rigid protocols and on-the-scene problem solving, between science-based decisions and those driven by personal values.
Fink eloquently describes how “emergencies are crucibles that contain and reveal the daily, slower burning problems of medicine and beyond—our vulnerabilities; our trouble grappling with uncertainty, how we die, how we prioritize and divide what is most precious and vital and limited; even our biases and blindnesses” (p. 464). Five Days at Memorial should be required reading for physicians, nurses, hospital administrators, lawmakers and government officials, disaster responders, and medical ethicists. It also presents an experience of vicarious trauma for those outside the medical community, raises the hood on the complicated choices facing health care providers in a medical disaster, and hopefully, encourages a dialogue between the medical and nonmedical communities, fostering greater understanding and a more transparent decision-making process. Ethical considerations should foreground disaster planning, which needs to be ruthlessly thorough, and this planning must demonstrate the courage to anticipate worst-case scenarios, catastrophes that challenge available resources, threaten medical standards, and distort our decision-making. Another Katrina or Sandy might be a dot on the distant horizon, but each flu season brings with it the threat of a pandemic, turning emergency departments and hospitals into crucibles where, under terrible pressures, physicians will need to make tough choices. DOI: 10.1002/hast.288
H AS TI N GS C E N TE R RE P O RT
47
Disaster Response or Response as Disaster? by Jay Baruch
O
n September 1, 2005, Memorial Hospital was on “survival mode.” Hurricane Katrina had felled the levees of New Orleans, submerging a modern city with floodwaters of biblical proportions, tasking physicians and nurses to make morally sound decisions under unprecedented conditions, where, as one physician stated, “[T]he laws of man and the normal standards of medicine no longer applied” (p. 9). In Five Days at Memorial, Sheri Fink, a Pulitzer Prize-winning journalist, resists the urge to assign easy blame or take a position. Instead, she weaves together the perspectives of a cast of people tested by this catastrophe and constructs a tapestry of experiences that isn’t neat and comforting but disturbing, compelling, and admirable all at once. The book pivots on the actions of Dr. Ana Pou, a dedicated and compassionate ear, nose, and throat surgeon, and her role in administering morphine and sedatives into the intravenous drips of some very sick patients on the fifth day after Katrina struck, hastening their deaths. Pou later said, “[W]e all did everything in our power to give the best treatment that we could to the patients in the hospital, to make them comfortable” (p. 234). Dr. Pou and the staff at Memorial faced challenges unimaginable by most health care providers in the United States and other developed nations. The hospital’s 273-page set of twenty disaster plans didn’t anticipate flooding or the need to evacuate or how to respond to loss of power and communications. 46 HASTI N G S C E N T E R R E P ORT
With power generators knocked out, ventilators couldn’t pump oxygen to critically ill patients. With temperatures topping one hundred degrees, the stench of overrun toilets and of dirty, dying, and dead bodies thickened the unbreathable air. Worries within the hospital walls were compounded by rumors of lawlessness and looting on the streets and by fears that rage and violence, like the waters of Lake Pontchartrain, would crash the doors and threaten the lives of providers, patients, and families. Evacuation and rescue, not treatment, became the hospital’s focus. Babies, women with high-risk pregnancies, and dialysis patients received the highest evacuation priority. But communication was haphazard; government rescue efforts, disorganized. Tenet Healthcare, Memorial’s parent company, with home offices in Dallas, seemed to lack the expertise, urgency, and moral imperative to arrange timely assistance, leaving health care providers to fear that they were abandoned. Evacuation efforts, when under way, became a slapdash affair. What counted as rescue was open to interpretation. Helicopters unloaded patients at a highway cloverleaf that was understaffed and undersupplied, without any handoff of responsibility, any standardized exchange of medical information. Patients were often left helpless, hungry, and without family. Rescue was not without risks. Weighing burdens and benefits took on a vertiginous logic as conditions deteriorated during the long-awaited rescue efforts, and the hospital itself was
reduced to an organism on life support. A triage protocol was implemented that delegated the sickest patients and those with do-not-resuscitate (DNR) orders to be evacuated last. Patients were dying, the extreme circumstances too much for their feeble bodies to endure. Staff members worked tirelessly, lucky to grab an hour’s sleep. Some patients were scared of being left behind. What happened, on the fifth day at Memorial, to twenty-three patients whose bodies tested for high levels of morphine and sedatives at autopsy? Was the intent of certain staff members to relieve suffering or to achieve death? Even if we allow room for compassionate intentions, one is left pondering whether decision-makers had at least raised and exhausted alternative solutions. Dr. Pou and her colleagues initiated their plan not when the staff desperately awaited rescue but “when the evacuation was at last under way” (p. 251). She and two well-regarded nurses were celebrated as heroes, but their actions drew heated scrutiny, and prosecutors later charged them with criminal counts of manslaughter. Fink’s meticulous research and clear writing marks a work of great achievement that navigates contentious and roiling medical, political, social, and ethical waters while refraining from judgment. But the knotty choices made by Dr. Pou and colleagues remain at the narrative’s spine. I wish Fink didn’t just conceptualize the ethical imperatives in play but explored how the contextual features might have shaped the health care providers’ moral decision-making. For example, to what degree should we account for the extreme conditions as actors influencing the agonizing decisions made in this moral drama? In his book Thinking, Fast and Slow, Daniel Kahneman, psychologist and winner of the Nobel Prize in economic science, draws on a rich psychology literature to Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. By Sheri Fink. Random House, 2013. 576 pages. Hardcover. $27. March-April 2014
illustrate the many ways our decisionmaking is unconsciously shaped by various forms of effort. Switching tasks, time demands, stifling emotional reactions, fatigue, and hunger are all factors that influence the decisions we make. Whether the effort is physical, emotional, or cognitive, it “draw[s] at least partly on a shared pool of mental energy.” To what degree did the accumulated mental and physical fatigue during the first four days at Memorial influence the decisions made on day five? Do readers, and investigators and ethicists who opined later, share an unfair and privileged advantage, analyzing the actions of Dr. Pou and her colleagues from a healthier, well-rested, and well-fed cognitive position? Should we explore the cognitive load shouldered by providers before we question why a signature on a DNR order served as a triage criterion, when the document serves as an expression of patient wishes only and doesn’t work as a predictive instrument for prognosis or survivability? Fink asks why these providers didn’t think more creatively, and fare better, than their counterparts at Charity Hospital, a public facility accustomed to making do with fewer resources. Their staff cared for approximately twice as many people with a lower ratio of staff to patients, and yet, only three patients died at Charity. Was it better morale, regular sleep, more effective leadership, specialized training, and astute disaster preparedness that allowed them to maintain, the best they could, the regular hospital routine? Did these elements
March-April 2014
set the conditions that fostered a better cognitive space that permitted more creative and effective decision-making in the same crisis? Did the institutional challenges endured by Memorial health care providers alter their thinking and judgment? In the epilogue, Fink draws on postKatrina examples—including Hurricane Sandy and the yearly influenza pandemic anxiety—to examine whether, and to what degree, we’re better prepared to make rationing decisions when available resources are overwhelmed. Which patients receive scarce resources like ventilators or a bed in the intensive care unit? For how long, and based on what criteria? Who should be involved in the conversation about the allocation of resources, and who, ultimately, can be entrusted to make those decisions? Fink cites critical work done by the New York State Task Force on Health and the Law, whose plan is based, in part, on the 2006 rationing plan developed by health officials in Ontario, Canada, in the wake of the severe acute respiratory syndrome (SARS) pandemic. Individual states and large medical centers—including the U.S. Veterans Health Administration—have crafted protocols informed by these guidelines. But Fink also points to the uncertainty that comes between guideline development and implementation, between rigid protocols and on-the-scene problem solving, between science-based decisions and those driven by personal values.
Fink eloquently describes how “emergencies are crucibles that contain and reveal the daily, slower burning problems of medicine and beyond—our vulnerabilities; our trouble grappling with uncertainty, how we die, how we prioritize and divide what is most precious and vital and limited; even our biases and blindnesses” (p. 464). Five Days at Memorial should be required reading for physicians, nurses, hospital administrators, lawmakers and government officials, disaster responders, and medical ethicists. It also presents an experience of vicarious trauma for those outside the medical community, raises the hood on the complicated choices facing health care providers in a medical disaster, and hopefully, encourages a dialogue between the medical and nonmedical communities, fostering greater understanding and a more transparent decision-making process. Ethical considerations should foreground disaster planning, which needs to be ruthlessly thorough, and this planning must demonstrate the courage to anticipate worst-case scenarios, catastrophes that challenge available resources, threaten medical standards, and distort our decision-making. Another Katrina or Sandy might be a dot on the distant horizon, but each flu season brings with it the threat of a pandemic, turning emergency departments and hospitals into crucibles where, under terrible pressures, physicians will need to make tough choices. DOI: 10.1002/hast.288
H AS TI N GS C E N TE R RE P O RT
47
