Ethical Dilemmas of Decision Making in a Crisis: Tragedy at Memorial Medical Center, New Orleans

Akbar N Jan
Assistant Professor, Department of Human Resource Management & Soft Skill, IBS Hyderabad (Under IFHE - A Deemed to be University u/s 3 of the UGC Act, 1956), Hyderabad, Telangana, India. E-mail: akbarjan75@ibsindia.org,

G V Muralidhara
Director, IBS Bengaluru (Off Campus of IFHE), India. E-mail: muralidharagv@ibsindia.org

Shwetha Kumari
Senior Research Associate, IBS Hyderabad. (Under IFHE - A Deemed to be University u/s 3 of the UGC Act, 1956), Hyderabad, Telangana, India. E-mail: shwetha.kumari@ibsindia.org

The case study describes the moral dilemmas faced by the leaders, doctors, and nurses of Memorial Medical Center (Memorial), New Orleans, during Hurricane Katrina in 2005. The hospital had no electricity, running water, or air conditioning. The temperature shot up to more than 110o Fahrenheit and the putrid smell of dead bodies burnt the back of the throat. Both chaos and heroism defined the scenes at Memorial; Memorial staff worked around the clock with few provisions to sustain them. Further, the case discusses the decision of the hospital leaders that patients with Do-Not-Resuscitate (DNR) orders should get the lowest priority as they had the least to lose. It then describes the triage conducted by Dr. Anna Marie Pou (Dr. Pou), a well-regarded head and neck surgeon. Later, Dr. Pou along with two nurses Cheri Landry, and Lori Budo, euthanized the DNR patients, although there was still hope of evacuation. The case ends with a discussion on the arrest of Dr. Pou, Cheri Landry, and Lori Budo for second-degree murder..

The physicians and staff responsible for the care of patients, many of whom were gravely ill, faced loss of generator power, the absence of routine medical equipment to sustain life, lack of water and sanitation facilities, extreme heat in excess of one hundred degrees, all occurring in an environment of deteriorating security, apparent social unrest and the absence of governmental authority. Dr. Pou and other medical personnel at Memorial Hospital worked tirelessly for five days to save and evacuate patients, none of whom were abandoned. We feel confident that the facts will reveal heroic efforts by the physicians and the staff in a desperate situation.i

- Rick Simmons, Dr. Anna Pou's attorney, December 22, 2005

Memorial showed how difficult questions around resource allocation and end-of-life care-which are with us all the time-can be heightened in a disaster and walking through what happened there is helpful more broadly when it comes to thinking about these areas

- Journalist Dr. Sheri Fink, August 26, 2014

Introduction

In July 2006, Dr. Anna Marie Pou (Dr. Pou), a surgeon with an excellent reputation for patient care, and two nurses Cheri Landry and Lori Budo, who worked through the chaos that followed Hurricane Katrina (Katrina), were accused of giving four patients stranded at their hospital, Memorial Medical Center (Memorial), New Orleans, US, lethal doses of morphine and a sedative. They were charged with second-degree murder in connection with patient deaths.iii Earlier, on September 11, 2005, 13 days after the hurricane hit New Orleans, mortuary workers had recovered 45 decomposing bodies from Memorial. This led to an extensive investigation by the Louisiana attorney general, Charles Foti Jr. (Foti), into the hospital and nursing-home deaths during Hurricane Katrina.

When Hurricane Katrina hit the Gulf Coast of the US especially New Orleans in 2005, many people wondered over the condition of the city after Hurricane Katrina. Hurricane Katrina was among the strongest hurricanes ever to hit the US. It killed almost 2,000 people, displaced over 800,000, and caused property damage worth over eighty billion dollars. After Katrina struck the city, conditions at New Orleans' Memorial were horrendous. Memorial, originally named Southern Baptist Hospital (Baptist), was founded in 1926 in New Orleans. The hospital had all the modern conveniences and had protected patients against all unpredictable problems the Gulf's weather systems had thrown up over the years. The hospital served a diverse clientele, besides serving poor people. In 1990, it merged with Mercy Hospital. In 1996, the combined hospital was purchased by Tenet Healthcare, a Dallas-based commercial chain, and renamed as Memorial. For many New Orleanians, Memorial had always been the place to ride out hurricanes. Although the hospital had a disaster plan, it had not been implemented fully and hence it was not prepared to face any disaster.

As Katrina advanced on August 29, 2005, there were over 183 patients at Memorial and 55 at LifeCare, a hospital that leased the seventh floor of Memorial to operate a long-term acute care unit. About 600 staff members had arrived to provide care, along with hundreds of family members and companions, bringing the census in the medical center to about 2,000. Only a handful of ambulatory patients were evacuated on August 29, with the help of the National Guard. On August 30, 2005, the storm hit Memorial, shattering windows. With the city power supply failing, the hospital interior soon became a fetid space.iv There was no electricity, running water, or air conditioning; the temperature was more than 110o Fahrenheit, and the putrid smell of dead bodies was all-pervasive. On August 30, the most critical patients and the babies in the nursery were evacuated by helicopter.

Dr. Pou was on duty at the time of Katrina and gladly complied with the expectation that she would ride out the storm at the hospital. As the waters gushed toward Memorial, Richard Deichmann, the hospital medical chairman decided that patients with Do-Not-Resuscitate (DNR) orders should get the lowest priority as he thought they had the least to lose. On the morning of August 31, doctors and nurses decided that over 100 remaining Memorial and LifeCare patients should be brought downstairs and divided into three groups to help speed up the evacuation. Those who were in good health and could sit up or walk were categorized as 1s and prioritized as first for evacuation. The patients who were ailing and required more aid were categorized as 2s. Lastly, DNR patients and patients who were very ill according to doctors were categorized as 3s and were slated to be evacuated last. Although no single doctor was officially in charge of categorizing the patients, Dr. Pou was reportedly active and jumped into the center of the action.

By day five, September 1, 2005, the situation appeared more desperate. The rescue was underway, but the condition at the hospital continued to deteriorate. After one of the doctors made the decision to euthanize some of the animals on hand, Susan Mulderick (Mulderick), the nursing director who served as the rotating "emergency-incident commander during Katrina", thought that this was the most merciful way to treat some of the remaining patients who were at LifeCare. Mulderick sought out Dr. Pou, and a plan was formed. Further, Dr. Ewing Cook (Cook), another member of the hospital's staff, advised Dr. Pou how to administer a mix of morphine and benzodiazepine.1 Later, Dr. Pou wrote out prescriptions for substantial amounts of morphine, which, despite the chaos, were filled by the hospital pharmacy. Dr. Pou, nurses Cheri Landry and Lori Budo, along with John Thiele, a pulmonologist, injected several 3s patients with morphine and Midazolam.2 By September 1, 2005, the hospital was completely evacuated, and the hospital workers were lauded for the tremendous work they had done in saving so many lives. But questions remained regarding the final hours at Memorial. By the time evacuations were complete, 45 critically ill patients had died. Dr. Pou was left with painful memories.

Soon after, on September 11, 2005, mortuary workers recovered 45 decomposing bodies from Memorial.

A day later, the Louisiana's attorney general Charles Foti Jr. (Foti), launched an extensive investigation to find out whether hospital staff euthanized the patients during Hurricane Katrina. In 2006, Charles charged Dr. Pou and the two nurses with second-degree murder. Several questions remained to be answered. Was the authority allocated to various people by the leaders of Memorial unclear, leading to many deadly decisions taken by various doctors of the hospital? Was euthanasia medically ethical or was it mass murder?

Memorial Medical Center: A Background Note Memorial Medical Center (Memorial), originally named Southern Baptist Hospital (Baptist), was founded in 1926 in New Orleans, US. The hospital was situated on one of the low points in New Orleans, three miles southwest of the city's French Quarter and three feet below sea level. The hospital infrastructure was so vast that patients could bring their children, parents, and grandparents, and even their dogs, cats, and rabbits. It had 317 beds at the time it was established. The hospital had protected patients against all the unpredictable problems caused by the Gulf's weather systems. The president of the Southern Baptist Hospital Commission board of directors wrote in a letter to the hospital's superintendent in February 1926, "In my humble opinion we have begun at New Orleans what is destined to be the greatest hospital in all the Southland"v (Refer to Exhibit I for Memorial layout).

The hospital had all the modern conveniences and looked like a modern hotel or private home, offering a "general atmosphere of cheerfulness." At the time of its establishment, it had steam-heated blanket warmers on each floor and elegant electric reading lamps hanging over each bedside table in the hospital's private bedrooms. It also had the most advanced X-Ray machines. It had installed a call system incorporating musical gongs and silent luminescent indicators. All operating rooms were equipped with compressed air and vacuum attachments, besides electrical and phone wiring. With the world-class infrastructure, the hospital devoted itself to charity for the poor. It had a three-pronged mission: the alleviation of pain, the prolongation of life, and the relief of suffering. However, it served a diverse clientele, besides serving poor people.

In 1965, when Hurricane Betsy, one of the worst storms in a century, hit the state, the hospital protected over one thousand people who were sheltered inside the hospital and its administrative staff referred proudly to the fact in the hospital newsletter.

In 1969, the religious organization parted itself from the hospital and Southern Baptist Hospital became an independent non-profit entity. In the early 1980s, the hospital spent over $100,000,000 (Project 2000) to add to and renovate the original building. In 1990, the hospital merged with Mercy Hospital (Lindy Boggs Medical Center) and the two hospitals functioned as the Mercy-Baptist Medical Center, with the old Southern Baptist Hospital called the Uptown Campus and Mercy called the Mid-City campus. In 1996, the combined hospital was purchased by Tenet Healthcare, a Dallas-based commercial chain, and renamed as Memorial Medical Center.vi

Hurricane Katrina and Its Impact on New Orleans Hospitals

Hurricane Katrina (Katrina), a category 5 hurricane, made landfall in Florida and Louisiana, particularly the city of New Orleans and surrounding areas in August 2005, causing catastrophic damage. Katrina became a large and extremely powerful hurricane, causing massive destruction and significant loss of life. It was the costliest hurricane to ever hit the US, surpassing the record previously held by the 1992 hurricane, Hurricane Andrew. In addition, Katrina was one of the five deadliest hurricanes to ever strike the US. In all, it was responsible for over 1,833 fatalities and approximately $108 bn in damage (un-adjusted 2005 dollars).vii

Hurricane Katrina formed about 200 miles southeast of the Bahamas on August 23, 2005, as a tropical depression. With winds of about 40 miles per hour (mph), the storm was named Tropical Storm Katrina. On August 25, 2005, Katrina crossed Southern Florida as a moderate Category 1 hurricane, causing several deaths and flooding there, before quickly gathering strength in the Gulf of Mexico. Further, Katrina re-intensified into a hurricane on August 26, 2005, and became a Category V storm on August 28, 2005, with winds blowing at about 175 mph. The storm turned north toward the Louisiana coast.viii On August 28, 2005, Hurricane Katrina reached New Orleans, Louisiana.ix

On August 28, 2005, The National Weather Service (NWS) warned the people of New Orleans that, "most of the area will be uninhabitable for weeks ... perhaps longer." The NWS further stated, "at least one-half of well-constructed homes will have roof and wall failure. All gabled roofs will fail ... leaving those homes severely damaged or destroyed. [...] power outages will last for weeks ... as most power poles will be down and transformers destroyed. Water shortages will make human suffering incredible by modern standards."

Further, local leaders of New Orleans appeared on-screen to inform residents they needed to leave the city. The president of a Parish near New Orleans alerted people who intended to stay to buy hammer, so they could make their way to their rooftops and not die in their roof space. He also cautioned people to remember the old techniques and fill their bathtubs upstairs with water as after the hurricane that would be the only source for drinking, bathing, and flushing toilets. The mayor of New Orleans, Ray Nagin (Nagin), signed a mandatory and immediate evacuation order for the city at 10 am on August 28, 2005. However, the order was delayed by several hours because Mayor Nagin's staff members took time to solve logistical and legal inquiries including if he has the lawful authority to issue it because until then (2005) no mayor of New Orleans had directed an evacuation, though Louisiana law permitted the governor, parish presidents, and, by extension him to order evacuation.

After Katrina moved to the interior of Southern Mississippi on the afternoon of August 29, 2005, it left a trail of misery and devastation. The loss to life and property damage was heightened by breaks in the levees which separated New Orleans from Lake Pontchartrain, Southeastern Louisiana. Approximately 80% of New Orleans was under flood waters on August 31, 2005.

The damage and loss of life inflicted by the hurricane in Louisiana and Mississippi were overwhelming with its effects being felt in Alabama and western Florida. Hurricane Katrina captivated the public and media with extensive coverage.

Though Nagin had issued a command to everyone to leave the city, many did not have the means to move around. Even the state transport had a shortage of drivers and vehicles. Residents who could go on their own were stuck in traffic on the interstate leading out of the city. The Superdome, the giant stadium that hosted the New Orleans Saints football team, was chosen as a shelter of last resort. New Orleanians who had no way of getting out of the city could take a shuttle bus there. Several tourists whose flights had been canceled had no facility to flee on their own either, and hence Nagin's evacuation order exempted essential hotel workers to serve them. Nagin exempted hospitals and their staffs from evacuating, stating that if hospitals were closed and if they turned away marooned people, it could lead to a very dangerous situation. An emergency response leader from the US Centers for Disease Control and Prevention warned several colleagues of the problem in an e-mail hours later "It is assumed that many of the hospital generators will lose power given the expected height of the water."

About 2,500 hospital patients remained in New Orleans as Katrina advanced on the city. Dispatchers for the region's largest ambulance company, Acadian, were flooded with calls to transport patients from threatened hospitals, nursing homes, and houses. Over two dozen ambulances which the company had arranged were frozen on the congested interstate region. To save time, some ambulances began transporting patients to the Superdome instead of taking them out of the city. The main hospital in St. Bernard Parish, Chalmette Medical Center, managed to begin evacuation, but after transporting the first round of critically ill patients, the ambulances did not return. The roadways were so congested with evacuees that vulnerable patients could be trapped for up to a day in an ambulance before arriving at their destination.3

Life and Death at Memorial - Consequences of Ambiguous Leadership Authority

By the time Hurricane Katrina started lashing New Orleans in the wee hours of August 29, 2005, Memorial was overcrowded with patients, healthcare workers and their family members, men, women, pets and children from the nearby locality who came to seek accommodation. "The hospital was being powered by generators. It was hot and incredibly humid, but we had some lighting, elevator services, and workable medical equipment. We had running water on Monday, but the water was not "clean" and could not be used for dialysis or for drinking. Rations of food and water were provided for patients and healthcare workers who were considered essential personnel," stated Dr. Pou in an interview in August 2010.x Since most of the hospitals in Louisiana followed the established protocol of sheltering in place, based on an ideology that patients would be safer in the hospital rather than risking complications during the evacuation, Memorial did the same (Refer to Exhibit II to know about hospitals in New Orleans). As Katrina advanced, there were over 183 patients at Memorial and 55 at LifeCare.4 About 600 staff members had arrived to

provide care.xi Only a few ambulatory patients were evacuated on August 29 with the help of the National Guard.

On August 30, 2005, Governor Blanco ordered a mandatory evacuation of New Orleans. By 11:00 am, numerous sections of the levee system in New Orleans began to breach, submerging 80% of the city. On being asked about Memorial's condition after the storm hit, Dr. Pou stated, "It was obvious to us Tuesday morning that the levees had breached. We could see the city flooding from the hospital windows. The conditions deteriorated after the flood waters rendered the generators inoperable. We lost generator power shortly after midnight on Tuesday, August 30. The toilets overflowed, we lost all electricity, there was no running water and communication was poor. We no longer had the use of modern medical equipment... we cared for patients by flashlight, but there was a shortage of batteries to keep them operating. It was dark, the heat was relentless - many of the windows did not open - and sanitation was poor... conditions became third-world like."5

Subsequently, on August 30, 2005, senior administrators at the Memorial swiftly grasped the threat posed by the advancing waters and counseled L. Rene Goux (Goux), chief executive of Memorial, to close the hospital. As at several US hospitals in flood zones, Memorial's main emergency-power transfer switches were located only a few feet above ground level, leaving the electrical system vulnerable. ''It won't take much water in height to disable the majority of the medical center,'' facilities personnel had cautioned after Hurricane Ivan in 2004.6

Despite Memorial's flood-prone electrical system, its voluminous set of emergency plans did not anticipate the crisis they were facing. Unlike some other hospitals, Memorial had never hired a consultant for hospital emergency plans. Mulderick had evaluated the hospital's emergency preparedness in order to save the hospital's money. She had convened Memorial's emergency preparedness committee to go over a three-page form covering some forty-seven events since 2001 which covered volcanic eruptions to nonfunctioning fire alarms and an undefined 'VIP situation'.7 Mulderick had ranked the hospital's preparedness for hurricanes, floods, and power outages as good. But the hospital's preparedness plan for hurricanes did not anticipate flooding.8

Further, the flooding plan of the hospital did not anticipate the need to evacuate. The evacuation plan did not consider a potential loss of power or communications. Most critically, the hurricane plan relied on the impression that the hospital's generators would keep working for a minimum of seventy-two hours, although they had never been tested to run that long. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a nonprofit organization, which surveyed the Memorial in May 2005, had examined the entire hospital for three days, scrutinizing everything from the signs in the halls to the specifics in patient medical accounts. They had identified almost two dozen areas of required or suggested improvement. But they did not find any deficiencies in the plans9 (Refer to Exhibit III to know more about JCAHO).

Seeing the chaos and helplessness at the hospital at 12:28 pm on August 30, 2005, a Memorial administrator typed "HELP!!!!" and e-mailed colleagues at other Tenet hospitals outside New Orleans, cautionary that Memorial needed to evacuate over 180 patients.10

However, around the same time, Mulderick, chief financial officer Wynn, about two dozen doctors, Curtis Dosch, CEO of Memorial, along with the hospital's medical-department chairman, Richard Deichmann (Deichmann), held a disaster leadership team meeting which focused on how the hospital should be evacuated. During the meeting, the group agreed to enter into a standard triage by allocating aid on the basis of need for medical treatment. The group decided that they should first evacuate infants in the neonatal intensive-care unit, pregnant mothers, and critically ill adult intensive-care unit patients. Unfortunately, Deichmann proposed a strategy that was nowhere in the hospital's disaster plans. He suggested that all patients with DNR orders should go last.xii Other doctors at the meeting agreed with Deichmann's idea. At the time, those attending the meeting did not see it as a crucial decision, since rescuers were likely to evacuate everyone in the hospital within a few hours. Deichmann took stock of those present and reassigned two physicians to cover each of the fifteen patient wards.xiii The doctors were also instructed to categorize every patient and to prepare a count by 4 pm. Doctors were asked to mark down patients for transfer to one of the various types of care settings: an intensive care unit, general hospital ward, a rehabilitation facility, or a nursing home. Further, doctors were instructed that patients ready to be discharged could be given a week's worth of medicines and sent on to an evacuation center. Furthermore, the medical staff was asked to pack up the patients and work on transfer orders.

Dr. Anna Marie Pou (Dr. Pou), a well-regarded head and neck surgeon, was also present. She had built a reputation for herself with her choleric and protective treatment of her patients, although she was occasionally known to be fickle minded. She joined the faculty of Louisiana State University's medical school in 2004 and received an appointment at Memorial.

Dr. Pou was paired up with an internist, Kathleen Fournier (Kathleen). Both of them went to the fourth floor',11 where Dr. Pou and Kathleen had several surgical patients. In the afternoon of August 30, 2005, helicopters from the Coast Guard and private ambulance companies began landing on a long-unused helipad atop an eight-story parking garage adjacent to the hospital. The pilots were impatient as thousands of people required help across the city. The intensive-care unit on the eighth floor called out with shouts for patients: "We need some more! Helicopters are waiting!"xiv Many patients including the most critical ones, babies in the nursery, and family members were evacuated by volunteer airboats which arrived early morning and a few non-ambulatory patients were evacuated by helicopters.12

By August 30, 2005 evening, the hospital was able to evacuate 57 patients, bringing the total of patients left to be evacuated to 123. Of the remaining patients, 52 were patients of LifeCare. Most LifeCare patients were confined to bed and not included in the triage decisions'13 because Memorial was under the impression that LifeCare would be implementing its own evacuation plan. However, Diane Robichaux, LifeCare's assistant administrator, later asked Memorial administrators to add her 52 patients in transport plans being organized with the Coast Guard.

The Memorial doctors had spent days on duty under stress and with little sleep. Ewing Cook (Cook), one of the hospital's senior-most physicians, decided that in order to lessen the burden on the nurses, all but the most critical treatments and care should be discontinued. When Bryant King (King), a 35-year-old internist who was new to Memorial, came to check on one of his patients on the fourth floor, he canceled Cook's order to turn off his patient's heart monitor. When Cook found out, he was furious at King and thought that he did not understand the circumstances. Subsequently, he forced the nurse to reinstate his instructions.

It was dark when the last of the Memorial patients who had been chosen for immediate evacuation was finally gone. By then the hospital had shaved its patient census from 187 to about 130. But, on the seventh floor, all 52 LifeCare patients remained, including 7 on ventilators.14

By August 31, 2005, the auxiliary generators had shut down; the hospital temperature had soared to 110o F, and deceased bodies filled Memorial. With little food or water, patients continued to fight for their lives.15

The Memorial's Command center's16 few working cell phones persistently rang. The Coast Guard members held fast to the idea of continuing rescues overnight, particularly after learning about the 7 LifeCare patients on ventilators, the rising waters, and the possibility of a power cut within hours. A doctor sent a security guard to wake Deichmann up to ask him what to tell a Coast Guard officer about sending more helicopters for the LifeCare patients. Deichmann's response was, "Tell him to send them in the morning." He considered it too dangerous to reopen the helipad and thought the staff members needed rest.17

Meanwhile, Mulderick discussed the matter with Robichaux. With all elevators out of service, Robichaux felt her staff would need extra hands to carry these most critical patients downstairs safely, but Mulderick denied it saying the men she could offer for help had gone to bed. Robichaux agreed to wait for daybreak. In the meantime, on the seventh floor, the critically ill patients at LifeCare had begun suffering the consequences of the power failure. A Memorial nurse announced that the Coast Guard could evacuate some critical patients if they were brought to the helipad immediately. Volunteers began carrying the LifeCare patients who relied on ventilators down to the second-floor lobby. When the Jayhawk helicopter crew arrived from a Coast Guard air training station to rescue patients-even LifeCare patients-the nurse told the pilot that remaining patients were DNR and it was not necessary to rescue them and that the operations had to stop. The nurse said the rescue could resume in the morning at 9 am. The Jayhawk crew were taken aback to hear that decision.

They were shocked when one of the nurses told them that the hospital's priority was to first evacuate its own patients, not to the critically sick patients belonging to another company who was going to die anyway. Later in the morning, Dr. Pou, too took a turn on the second floor, squeezing an inflatable Ambu-bag to ventilate a LifeCare patient. Dr. Pou and her colleagues wondered what they were going to do without the basics, including electricity and running waterxv (Refer to Table 1 to see the condition at the hospital)

On August 31, 2005, Tenet sent around six helicopters, along with boats, to evacuate the remaining patients from Memorial. On the morning of the same day, doctors and nurses decided that over 100 remaining Memorial and LifeCare patients should be brought downstairs and divided into three groups to help speed the evacuation. The patients who were in better health and could sit up or walk were numbered as 1s and prioritized first for evacuation. Those patients who were ailing and needed more aid were categorized as 2s. A final group of patients were categorized as 3s and were slated to be evacuated last. That group included those whom the doctors referred to be very ill and, as doctors had agreed the day before, those with DNR orders.

Although no single doctor was officially in charge of categorizing the patients, Dr. Pou took an active role and was in the thick of all the action, according to two nurses who worked with her. Throughout the morning, makeshift teams of medical staff and family members carried many of the remaining patients to the second-floor lobby where Dr. Pou stood equipped to receive the patients.

Many of the 1s were taken to the emergency-room ramp, where the boats were received. The 2s were placed along the corridor leading to the hole in the machine-room wall that was a shortcut to the helipad. The category 3s patients were moved to a corner of the second-floor lobby of the hospital. Patients who were awaiting evacuation continued to be cared for but category 3s were neglected. Though Dr. Pou and her co-workers were performing triage, they had minimal training in triage systems and were not guided by any triage protocol. A few helicopters arrived after some LifeCare patients were evacuated. By that time, rumors were doing the rounds in the hospital that a decision had been made to defer evacuation of DNR patients. The question about what needed to be done to the hospital's sickest patients were being raised by doctors. By the afternoon, with a few helicopters landing, these patients were suffering. Mulderick who had worked with Cook, pulmonary specialist, for decades, shared her worries with him. According to Cook, it was a desperate situation and he saw only two choices: quicken their deaths or abandon them. Further, Mulderick had a conversation with Deichmann about whether it would be humane to euthanize the hospital's DNR patients.xvi.

As darkness fell, a rumor spread that evacuations would halt for the night because people were shooting at rescuers as the hospital was not letting any more people take shelter at the hospital. In the adjacent parking garage of the hospital, Goux distributed guns to security and maintenance staff to protect the hospital. That night, dozens of LifeCare and Memorial patients lay on soiled and sweaty cots in the second-floor lobby. Several doctors including Dr. Pou, and crews of nurses worked in the blurred light. For the third night in a row, Dr. Pou was working with barely an hour's sleep, changing patients' diapers, giving out water, comforting and praying with nurses.18 By August 31, night Bob Smith, Tenet vice president summarized in an e-mail to Tenet leaders, "They have 115 pts. in-house, 30 bedbound and 40+ wheelchair bound. Expect up to 60 are fragile and may die within the next 24 hours."

At about 8 pm on August 31, a call came into the emergency room manager that everyone would be evacuated on September 1, 2005, at 7 pm.19 On the morning of September 1, 2005, a small group of doctors gathered in a radiology suite on the second floor of the hospital to discuss how difficult it had been for the staff and doctors of the hospital. The doctors at the meeting were unhappy that the hospital leaders had turned down the opportunity to continue the helicopter rescue on the 30th and 31st morning. The prospects for a prompt, government-organized rescue appeared dim.20

By September 1, 2005, the situation appeared more desperate. The rescue was underway, but conditions at the hospital continued to deteriorate. After one of the doctors made the decision to euthanize some of the animals on hand, Mulderick thought that this seemed to be the most merciful way to treat some of the remaining patients as well. Mulderick informed the LifeCare team the idea was not to leave any living patients behind.

Mulderick's idea to medicate the patients found a champion in Dr. Pou. Mulderick sought out Dr. Pou. Meanwhile, Cook left the hospital by boat to rescue his son, who had been trapped in his house since flooding began. However, before leaving, he spoke to Pou about euthanasia.

According to Cook, Dr. Pou was concerned that they would not be able to get the patients out. Cook had not been on the seventh floor since Katrina struck. But he thought LifeCare patients were "chronically death-bound" at the best of times and would have been horribly affected by the heat. Cook could not imagine how the exhausted Memorial staff would carry nine patients before the end of the day to evacuate. Consequently, Dr. Pou was guided by Cook on how to administer a mix of morphine and benzodiazepine sedative on the patients.21 Later, Dr. Pou wrote out large prescriptions for morphine for three of the patients lying in the second-floor lobby. She ordered nine vials each of a concentrated form of IV morphine, totaling 90 milligrams (mg) for each patient. This was the highest dose Dr. Pou had prescribed for pain in the last two days. At the bottom of the prescriptions, Dr. Pou filled in her Drug Enforcement Agency number, as required, which approved her to prescribe legally controlled substances. However, many doctors at the hospitals disagreed with this decision when they heard about it.22

Dr. Pou along with John Thiele, pulmonologist, Lori Budo and Cheri Landry, started giving the morphine as patients who had been injected died, Wynn and her colleagues helped cover them with sheets and moved them into the chapel. They tried to move discreetly to avoid attracting the notice of more cognizant patients still waiting in the evacuation line. Someone unlocked the chapel for them to enter and relocked it when they left. Throughout the day, boats and helicopters drained the hospital of nearly all its patients and visitors. Wynn and a group of other female nurses helped lift the last few patients through the hole in the machine room wall.23

As Sheri Fink (Fink), author of 'Five Days at Memorial' recounted, "He [Sic] Cook later said that he believed that Dr. Pou understood that he was telling her how to help the patients 'go to sleep and die." "What Cook was describing to Dr. Pou was something else entirely. The drug combination 'cuts down your respiration so you gradually stop breathing and go out," added Fink.xvii.

In an interview, Fink on being asked 'how Memorial doctors began hastening their patients' deaths', stated, "At some point on the day that the power failed, a few hours after that, some of the doctors told me that they walked around the hospital, had a look at the situation of the patients and felt that hastening death was the right choice." Fink added "You know, one of them had gone upstairs to the intensive care unit where there was just one patient left. Most of them had been taken out first, but she was very, very sick. She had this do not resuscitate order and had been held back. And he told the nurse, 'Give her enough morphine till she goes.'"

Further, Fink noted, "The other doctor [John Thiele] actually was involved in injecting some of those patients on that Thursday, September 1 of that year. ... And he also told me that the intent was to let these people die. He did describe to me having a moment after he did these acts where he did wonder whether it was the right thing. And he even hesitated just before he started injecting the patients and he asked the woman next to him, a nurse who was on the ethics committee, whether they could really do this. Now, one thing he didn't consider was staying there with the patients until they died."xviii.

Anna Pou: Virtuous or Guilty?

On September 11, 2005, 13 days after Hurricane Katrina hit New Orleans, mortuary workers recovered 45 decomposing bodies from Memorial. This was the largest number of bodies found at any Katrina-struck hospital or nursing home and so it attracted the attention of the state attorney's office. The state's Justice Department's phones soon began ringing with claims of patients' abandonment and euthanasia. One of the people who called was a LifeCare lawyer who relayed a report that nine of the company's patients may have been given lethal doses of medicines by a Memorial doctor and nurses.

The next day, the then Louisiana attorney general, Charles Foti Jr. (Foti), opened investigations into the hospital and nursing-home deaths across the city. Kris Wartelle, an ex-spokeswoman for Foti, stated, "We can confirm that euthanasia is what we are investigating."xix State and federal investigators interviewed LifeCare witnesses and descended on the mold-ridden hospital to search for evidence.

Separately, Foti's staff asked the then Orleans Parish coroner, Dr. Frank Minyard, to perform autopsies and drug tests on approximately 100 bodies that had been recovered from more than a half-dozen hospitals and nursing homes in New Orleans. Experts reported high levels of morphine, midazolam (Versed), and/or Lorazepam in several bodies. In some cases, the experts stated that the levels indicated murder. Experts who agreed that the lethal levels of morphine constituted homicide in numerous of the deaths on the 7th floor of Memorial included renowned forensic pathologists Cyril Wecht (Wecht) and Michael Baden (Baden), along with the director of the toxicology lab where the patients' samples had been tested and three other independent pathologists, including the then-president of the American Academy of Forensics, James Young (Young). Further, Wecht alleged that eight of the nine deaths on the LifeCare floor could be ruled homicides whereas Baden concluded that all nine LifeCare patients' deaths were homicide. Young stated, "All these patients survived the adverse events of the previous days, and for every patient on a floor to have died in one three-and-a-half-hour period with drug toxicity is beyond coincidence."xx

The investigation into the deaths at Memorial gathered pace in October 2005 when King stated in an interview with CNN that he had heard a doctor talk about killing patients. He further added that he had seen Dr. Pou holding a handful of syringesxxi and telling a patient nearby the ATM, "I'm going to give you something to make you feel better."24 On July 17, 2006, Foti stunned the country by arresting and charging Dr. Pou and two nurses Lori Budo and Cheri Landry on four counts of second-degree murder in connection with the deaths of four LifeCare patients.xxii An agent for the Louisiana Justice Department wrote in an affidavit that Dr. 'Pou told a nurse executive three days after the hurricane hit that lethal doses would be administered to patients who could not be evacuated. According to the affidavit, the nurse executive asked, "Lethal doses of what?" and Dr. Pou answered: "Morphine and Ativan."xxiii

Dr. Pou hired Richard T Simmons Jr. (Richard), a criminal and civil defense lawyer who specialized in white-collar offenses, on the advice of her employer, the Louisiana State University Healthcare Network, which had used Simmons's services in another matter. The network agreed to pay Simmons $275 an hour, to defend Dr. Pou.25

Dr. Pou, Landry, and Budo denied the charges, and their attorneys said they had acted heroically, staying to attend to patients rather than flee. Dr. Pou's lawyer, Rick Simmons, alleged she and her patients were "abandoned" by all levels of government. "The certificates of death in these individual patients should read 'abandoned by their government.' That's what happened here," he noted.xxiv

In a television interview aired in September 2006, Dr. 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."26

Foti turned the investigation over to the Orleans Parish District Attorney, Eddie Jordan, who in turn impaneled a grand jury to consider the charges against Dr. Pou. In March 2007, the state grand jury was sworn in to consider the Memorial case. Unlike a typical grand jury, this one dealt with just one case and functioned as an investigation instead of a review of the evidence.27 The grand jury stopped hearing from Minyard's experts, several witnesses who were present at the hospital, or the Department of Justice investigators who had spent a year on the Memorial case and amassed 50,000 pages of evidence.28

After the allegations, many New Orleans residents rallied to Dr. Pou's support, calling her a hero for remaining on duty when other doctors had fled, and many medical organizations issued statements in her defense.29 Dr. Ben deBoisblanc, director of critical care at Charity Hospital, posited "This doctor and these nurses were heroes. They stayed behind of their own volition to care for desperately ill people. They had an opportunity to leave and chose not to." But Kris Wartelle (Kris), a spokeswoman for the attorney general's office, stated the agency had to investigate the claims at Memorial because it had to enforce the law. Kris emphasized, "Where is the sympathy for the victims? Why is there no outcry for the people who would have not died had they gotten out?" These are not terminal people begging to be put out of their misery."xxv

"The terrible events at Memorial emphasized the ethical duty to plan for emergencies. When resources ran short, choosing whose lives were to be prioritized was as much a question of values as of medicine, and deserved wider consideration. At Charity hospital, a New Orleans public institution where the rescue took an additional day, with many more patients than Memorial, flexible thinking helped ensure only a handful died. The sickest were prioritized first. A panel of disaster experts congregated by America's Institute of Medicine discussed about euthanasia during the Hurricane Katrina unequivocally and stated: "Neither the law nor ethics support the intentional hastening of death, even in a crisis."xxvi Aine Donovan, executive director of the Ethics Institute at Dartmouth College in New Hampshire, opined the condition might have been chaotic but it provided no justification for doctors to forget their professional obligations. Nonetheless, Stuart Finder (Finder), a senior medical ethicist at Vanderbilt University's Medical Center in Nashville, empathized with the difficult decisions facing the medical staff dealing with dying patients in extreme pain. "The law isn't designed for crises. It's designed for the norm. People may have made choices to ease the suffering of the dying and as a result, expedite their death," said Finder.xxvii

End Notes

1. Drew Griffin and Kathleen Johnston, "Katrina investigation focuses on more than one person", http://edition.cnn.com/2005/US/12/21/katrina.hospital/index.html, December 22, 2005.
2. Sonja Rasmussen, "5 Days at Memorial: Q&A with Author Sheri Fink", https://blogs.cdc.gov/ publichealthmatters/2014/08/5-days-at-memorial-qa-with-author-sheri-fink/, August 26, 20.
3. Carrie Kahn, "New Orleans Doctor, Nurses Charged with Murder", https://www.npr.org/templates/story/ story.php?storyId=5566057, July 18, 2006.
4. Vincent J Sweeney, "The Story of Hurricane Katrina and Memorial Hospital", https://scholarship.shu. edu/cgi/viewcontent.cgi?referer=https://www.google.com/&httpsredir=1&article=1589&context=student_scholarship, May 1, 2014.
5. Sheri Fink, "Five Days at Memorial", Crown Publishers, 2013.
6. Robert R N Ross and Deanne E B Ros, "Walking to New Orleans: Ethics and the Concept of Participatory Design in Post Disaster Reconstruction", Wipf & Stock Publishers, September 22, 2008.
7. "Extremely Powerful Hurricane Katrina Leaves a Historic Mark on the Northern Gulf Coast", https://www.weather.gov/mob/katrina
8. Kim Ann Zimmermann, "Hurricane Katrina: Facts, Damage & Aftermath", https://www.livescience.com/ 22522-hurricane-katrina-facts.html, August 27, 2015.
9. Charlotte Moore, "Did Hurricane Katrina have an angel of mercy - or an angel of death?", https://www. spectator.co.uk/2014/02/five-days-at-memorial-by-sheri-fink-review/, February 15, 2014.
10. "Hurricane Katrina's Deadly Legacy at Memorial Medical Center", https://www.foxnews.com/health/ hurricane-katrinas-deadly-legacy-at-memorial-medical-center, October 24, 2010.
11. "Hurricane Katrina", https://biotech.law.lsu.edu/katrina/reports/deadly-choices.htm, August 27, 2009.
12. Kellyann Creelman, "Katrina - Memorial Medical Hospital and Dr. Pou", https://docuri.com/download/katrina-memorial-medical-hospital-and-dr-pou_59ae498bf581710a62017ae1_pdf, June 2016.
13. Kellyann Creelman, "Katrina - Memorial Medical Hospital and Dr. Pou", https://docuri.com/download/katrina-memorial-medical-hospital-and-dr-pou_59ae498bf581710a62017ae1_pdf, June 2016.
14. Sheri Fink, "The Deadly Choices at Memorial", https://www.nytimes.com/2009/08/30/magazine/ 30doctors.html, August 25, 2009.
15. "The Best American Magazine Writing 2010", Columbia University Press, 2010.
16. "The Best American Magazine Writing 2010", Columbia University Press, 2010.
17. Christopher White, "A Lethal Legacy: Hurricane Katrina and the Indignity of Euthanasia", https://www.thepublicdiscourse.com/2014/06/13261/, June 11, 2014.
18. "During Katrina, 'Memorial' Doctors Chose Who Lived, Who Died", https://www.npr.org/2013/09/10/ 220687231/during-katrina-memorial-doctors-chose-who-lived-who-died, September 10, 2013.
19. Alan Freeman, "Louisiana probing allegations of euthanasia in Katrina chaos", https://www. theglobeandmail.com/news/world/louisiana-probing-allegations-of-euthanasia-in-katrina-chaos/article 20431387/, April 23, 2018.
20. Dr. Anna Pou, http://dictionary.sensagent.com/dr%20anna%20pou/en-en/
21. Okie Susan, "Dr. Pou and the Hurricane - Implications for Patient Care during Disasters", https://www. nejm.org/doi/full/10.1056/NEJMp0707917, January 3, 2008.
22. "Jury Refuses to Indict Doctor Accused of Killing Patients During Hurricane Katrina", https://www. foxnews.com/story/jury-refuses-to-indict-doctor-accused-of-killing-patients-during-hurricane-katrina, January 13, 2015.
23. "Doctor, 2 Nurses held in Katrina Deaths", http://www.nbcnews.com/id/13916867/ns/us_news-katrina_the_long_road_back/t/doctor-nurses-held-katrina-deaths/#.XCwyRVwzbIU, July 18, 2006.
24. "Doctor Cleared in Katrina Hospital Deaths", http://edition.cnn.com/2007/US/law/07/24/katrina.doctor/ index.html
25. Katrina Medical Arrests Spark Outrage, https://www.denverpost.com/2006/07/22/katrina-medical-arrests-spark-outrage/, July 22, 2006.
26. Sheri Fink, "Hurricane Katrina: After the flood", https://www.theguardian.com/world/2014/feb/07/ hurricane-katrina-after-the-flood, February 2014.
27. Alan Freeman, "Louisiana Probing Allegations of Euthanasia in Katrina Chaos", https://www. theglobeandmail.com/news/world/louisiana-probing-allegations-of-euthanasia-in-katrina-chaos/article 20431387/, April 23, 2018.