#HASA2017: Lessons in medical ethics

Sheri Fink, author of Five Days at Memorial. Photo: sherifink.net

Golding’s haunting imagery of how a group of marooned schoolboys rapidly descended into a primitive survival-of-the-fittest mentality wasn’t unlike Fink’s narrative about human frailty and decision making in the face of a medico-ethical crisis in her book, Five days at Memorial.

The blurb on Fink’s website reads: “After Katrina struck and the floodwaters rose, the power failed, and the heat climbed, exhausted caregivers chose to designate certain patients last for rescue. Months later, several health professionals faced criminal allegations that they deliberately injected numerous patients with drugs to hasten their deaths.”

How do we ration care?

“What do you do when nothing works?" Fink asked the Hospital Association of South Africa (Hasa) conference in her keynote address. "Individuals who are well prepared can make a difference. However, she pointed out, after the hurricane, the infrastructure failed. At Memorial, the generators were in the basement, so when the water rose, they no longer worked. In addition, none of the hospital management were around, so there was a lack of leadership and there was not really an emergency plan to speak of to cope with a disaster the magnitude of Katrina.

“So, we come to the R word – rationing. How do we ration care? Emergencies are a laboratory for medical ethics.”

“Creative thinking can help to solve a rationing crisis. It’s important to be flexible,” she says.

The spectre of euthanasia

Memorial had the highest number of deaths out of an estimated 215 bodies found in nursing homes and hospitals in New Orleans post Katrina. Toxicology tests on the 45 bodies recovered from the hospital revealed that 41 of them had morphine and the fast-acting sedative midazolam (Versed) in their blood, which wouldn’t have been uncommon for some of these patients.

Although high-bed trucks and flat-bottomed boats brought in from the Louisiana bayous rescued many of the patients, the last-ditch option for some was landing helicopters on a rusted, dilapidated helipad on the roof of an adjoining building. So, the staff came up a triage system whereby the last group to be evacuated would include those who had a "do not resuscitate" order on their medical charts. Naturally, this included individuals, whose chances of survival without medical intervention were low. But there were also a number who weren’t in a life-threatening situation.

One of the dead was Emmett Everett, a paraplegic who weighed more than 170kg, who was in a unit on the seventh floor of Memorial leased to LifeCare Hospital, which provides long-term acute care for severely ill patients, aiming to improve their health to the point that they no longer need hospital care. Everett was awaiting surgery for a chronic bowel obstruction. On the morning of the evacuation, he was alert and ate breakfast. Yet, he was among those who didn’t make it.

The fallout

After the evacuation the question of whether the medical staff had euthanased some of these patients started emerging. Especially when an internist at Memorial, Bryant King told the media that he believed that "the discussion of euthanasia (among medical staff) was more than talk". And LifeCare told the state attorney general's office that nine of their patients might "have been given lethal doses of medicines by a Memorial doctor and nurses”.

The outcome of the allegations, was that Dr Anna Pou, the doctor in charge of the evacuation, and two nurses were arrested and charged for the murder of four patients. However, the grand jury eventually declined to prosecute them.

Did the doctors and nurses at Memorial have the right to make the decisions about patients' fates that they did? Fink’s book peels back the layers, revealing that medical ethics are not so cut and dried, especially when armchair judging the actions of extremely stressed and fatigued healthcare providers in a dire situation for which they had no prior experience or training. The story is much more complex than can be explained in this short piece, so read Fink's original investigative report on the Memorial evacuation here.