The State Of Health Care
“We Spend Too Much On These Turkeys...”
A Taste Of What Is To Come
A righteous man regardeth the life of his beast:
but the tender mercies of the wicked are cruel (Prov. 12:10).
...spirited debates among doctors over coffee about what some of his colleagues considered to be excessive resources being poured into hopeless cases. “We spend too much on these turkeys,” he said some would say. “We ought to let them go.”
Aug. 25, 2009
Strained by Katrina, a Hospital Faced Deadly Choices
By SHERI FINK
http://www.nytimes.com/2009/08/30/magazine/30doctors.html?_r=1&scp=4&sq=hurricane%20katrina&st=cse
Despite all the expert determinations of homicide, Minyard was still struggling with what to tell the grand jury. He consulted one more pathologist, Dr. Steven Karch. Karch had staked his career on advancing the argument that the level of drugs found in a cadaver may have no relationship to the levels just before death. Karch flew to New Orleans, examined the evidence and concluded that it was absurd to try to determine causes of death in bodies that had sat at 100 degrees for 10 days. In all of the cases, he advised, the medical cause of death should remain undetermined.
The coroner said he believed that if the case went to trial, the defense would bring in someone like Karch to provide reasonable doubt. “We’d lose the case,” Minyard told me. “It would not be good for the city, for the recovery. It’s just a bigger picture that I had to consider than just that pure basic scientific thing.”
The Smell Of Death
The smell of death was overpowering the moment a relief worker cracked open one of the hospital chapel’s wooden doors. Inside, more than a dozen bodies lay motionless on low cots and on the ground, shrouded in white sheets. Here, a wisp of gray hair peeked out. There, a knee was flung akimbo. A pallid hand reached across a blue gown.
Within days, the grisly tableau became the focus of an investigation into what happened when the floodwaters of Hurricane Katrina marooned Memorial Medical Center in Uptown New Orleans. The hurricane knocked out power and running water and sent the temperatures inside above 100 degrees. Still, investigators were surprised at the number of bodies in the makeshift morgue and were stunned when health care workers charged that a well-regarded doctor and two respected nurses had hastened the deaths of some patients by injecting them with lethal doses of drugs. Mortuary workers eventually carried 45 corpses from Memorial, more than from any comparable-size hospital in the drowned city.
Investigators pored over the evidence, and in July 2006, nearly a year after Katrina, Louisiana Department of Justice agents arrested the doctor and the nurses in connection with the deaths of four patients. The physician, Anna Pou, defended herself on national television, saying her role was to “help” patients “through their pain,” a position she maintains today. After a New Orleans grand jury declined to indict her on second-degree murder charges, the case faded from view.
In the four years since Katrina, Pou has helped write and pass three laws in Louisiana that offer immunity to health care professionals from most civil lawsuits — though not in cases of willful misconduct — for their work in future disasters, from hurricanes to terrorist attacks to pandemic influenza. The laws also encourage prosecutors to await the findings of a medical panel before deciding whether to prosecute medical professionals. Pou has also been advising state and national medical organizations on disaster preparedness and legal reform; she has lectured on medicine and ethics at national conferences and addressed military medical trainees. In her advocacy, she argues for changing the standards of medical care in emergencies. She has said that informed consent is impossible during disasters and that doctors need to be able to evacuate the sickest or most severely injured patients last — along with those who have Do Not Resuscitate orders — an approach that she and her colleagues used as conditions worsened after Katrina.
Pou and others cite what happened at Memorial and Pou’s subsequent arrest — which she has referred to as a “personal tragedy” — to justify changing the standards of care during crises. But the story of what happened in the frantic days when Memorial was cut off from the world has not been fully told. Over the past two and a half years, I have obtained previously unavailable records and interviewed dozens of people who were involved in the events at Memorial and the investigation that followed.
Hospital Of Death
The interviews and documents cast the story of Pou and her colleagues in a new light. It is now evident that more medical professionals were involved in the decision to inject patients — and far more patients were injected — than was previously understood. When the names on toxicology reports and autopsies are matched with recollections and documentation from the days after Katrina, it appears that at least 17 patients were injected with morphine or the sedative midazolam, or both, after a long-awaited rescue effort was at last emptying the hospital. A number of these patients were extremely ill and might not have survived the evacuation. Several were almost certainly not near death when they were injected, according to medical professionals who treated them at Memorial and an internist’s review of their charts and autopsies that was commissioned by investigators but never made public. Because Memorial’s chief of medical staff was away, Richard Deichmann, the hospital’s soft-spoken medical-department chairman, organized the physicians.
At 12:28 p.m., (the day after Katrina hit, Tuesday, Aug. 30) a Memorial administrator typed “HELP!!!!” and e-mailed colleagues at other Tenet hospitals outside New Orleans, warning that Memorial would have to evacuate more than 180 patients. Around the same time, Deichmann met with many of the roughly two dozen doctors at Memorial and several nurse managers in a stifling nurse-training room on the fourth floor, which became the hospital’s command center. The conversation turned to how the hospital should be emptied. The doctors quickly agreed that babies in the neonatal intensive-care unit, pregnant mothers and critically ill adult I.C.U. patients would be at great risk from the heat and should get first priority. Then Deichmann broached an idea that was nowhere in the hospital’s disaster plans. He suggested that all patients with Do Not Resuscitate orders should go last.
There was an important party missing from the conversation. For years, a health care company known as LifeCare Hospitals of New Orleans had been leasing the seventh floor at Memorial. LifeCare operated a “hospital within a hospital” for critically ill or injured patients in need of 24-hour care and intensive therapy over a long period. LifeCare was known for helping to rehabilitate patients on ventilators until they could breathe on their own. LifeCare’s goal was to assist patients until they improved enough to return home or to nursing facilities; it was not a hospice.
The 82-bed unit credentialed its own doctors, most of whom also worked at Memorial. It had its own administrators, nurses, pharmacists and supply chain. It also had its own philosophy: LifeCare deployed the full array of modern technology to keep alive its often elderly and debilitated patients. Horace Baltz, one of the longest-serving doctors at Memorial, told me of spirited debates among doctors over coffee about what some of his colleagues considered to be excessive resources being poured into hopeless cases. “We spend too much on these turkeys,” he said some would say. “We ought to let them go.”
When Bryant 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 the senior doctor’s order to turn off his patient’s heart monitor. When Cook found out, he was furious and thought that the junior doctor did not understand the circumstances. He directed the nurse to reinstate his instructions.
It was dark when the last of the Memorial patients who had been chosen for immediate evacuation were finally gone. Later that night, the Coast Guard offered to evacuate more patients, but those in charge at Memorial declined. The helipad had minimal lighting and no guard rail, and the staff needed rest. Memorial had shaved its patient census from 187 to about 130. On the seventh floor, all 52 LifeCare patients remained, including seven on ventilators. “Been on the phone with Tenet,” a LifeCare representative outside the hospital wrote to Robichaux. “Will eventually be to our patients. Maybe in the morning.”
Fateful Triage Decisions
At about 2 a.m. on Wednesday, Aug. 31 — nearly 48 hours after Katrina made landfall near New Orleans — Memorial’s backup generators sputtered and stopped. Ewing Cook later described the sudden silence as the “sickest sound” of his life. In LifeCare on the seventh floor, critically ill patients began suffering the consequences. Alarm bells clanged as life-support monitors and ventilators switched to brief battery reserves while continuing to force air into the lungs of seven patients. In about a half-hour, the batteries failed and the regular hiss of mechanical breaths ceased. A Memorial nurse appeared and 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 five flights of stairs in the dark.
A LifeCare nurse navigated the staircase alongside an 80-year-old man on a stretcher, manually squeezing air into his lungs with an Ambu bag. As he waited for evacuation on the second floor, she bagged him for nearly an hour. Finally a physician stopped by the stretcher and told her that there was no oxygen for the patient and that he was already too far gone. She hugged the man and stroked his hair as he died.
Visitors who had come to the hospital for safety felt so desperate that they cheered when two airboats driven by volunteers from the Louisiana swamplands roared up to the flooded emergency-room ramp. The flotilla’s organizers, Mark and Sandra LeBlanc, had a special reason to come to Memorial: Vera LeBlanc, Mark’s 82-year-old mother, was at LifeCare, recovering from colon-cancer surgery. Sandra, an E.M.T., knew that her mother-in-law couldn’t swallow, so she was surprised when she saw that Vera and other patients who needed IVs to keep hydrated were no longer getting them. When her husband asked a Memorial administrator why, the administrator told him that the hospital was in survival mode, not treating mode. Furious, Mark LeBlanc asked, “Do you just flip a switch and you’re not a hospital anymore?”
Many of the doctors and nurses had shifted from caring for patients to carrying them and were loading people onto helicopters and watercraft. Vera LeBlanc, the LifeCare patient whose son arranged the airboat flotilla that had arrived hours earlier, was among the patients massed on the second floor. Her chart read “Do Not Resuscitate,” as it had during several hospital admissions for more than a decade, so that her heart would not be restarted if it were to stop. Mark LeBlanc decided he was going to put his mother on one of the airboats he and his wife had directed to the hospital. When the LeBlancs tried to enter the patient area on the second floor, a staff member blocked them, and several doctors told them they couldn’t leave with Vera. “The _________we can’t,” Sandra said. The couple ignored the doctors, and Vera smiled and chatted as Mark and several others picked her up and carried her onto an airboat.
Cook sat on the emergency-room ramp smoking cigars with another doctor. Help was coming too slowly. There were too many people who needed to leave and weren’t going to make it, Cook said, describing for me his thinking at the time. It was a desperate situation and he saw only two choices: quicken their deaths or abandon them. “It was actually to the point where you were considering that you couldn’t just leave them; the humane thing would be to put ’em out.”
Despite how miserable the patients looked, Cook said, he felt there was no way, in this crowded room, to do what he had been thinking about. “We didn’t do it because we had too many witnesses,” he told me.
Cook hadn’t been on the seventh floor since Katrina struck, but he told me that he thought LifeCare patients were “chronically deathbound” at the best of times and would have been horribly affected by the heat. Cook couldn’t imagine how the exhausted Memorial staff would carry nine patients down five flights of stairs before the end of the day. Nobody from outside had arrived to help with that task. If there were other ways to evacuate these patients, he didn’t see them.
Cook said he told Pou how to administer a combination of morphine and a benzodiazepine sedative. The effect, he told me, was that patients would “go to sleep and die.” He explained that it “cuts down your respiration so you gradually stop breathing and go out.” He said he believed that Pou understood that he was telling her how to achieve this. He said that he viewed it as a way to ease the patients out of a terrible situation.
“The Decision Had Been Made To Administer Lethal Doses”
Therese Mendez, a LifeCare nurse executive, had worked overnight on the first floor, she later told investigators. (She declined to speak with me.) After daybreak, she heard the sound of helicopters and watched the evacuation line begin to move. According to Mendez, she returned at around 8 or 9 a.m. to the seventh floor and walked along a corridor. The patients she saw looked bad. Several were unconscious, frothing at the mouth and breathing in an irregular way that often heralds death. Still, while two patients died on the LifeCare’s seventh floor on Wednesday, the others had lived through the night, with only a few given small doses of morphine or the sedative lorazepam for comfort.
Mendez heard that Pou was looking for her. They sat down in an office with an open window. Pou looked distraught and told her that the LifeCare patients probably were not going to survive. Mendez told investigators that she responded, “I think you’re right.”
Mendez said she watched Pou struggle with what she was saying, telling investigators that Pou told her that “the decision had been made to administer lethal doses” of morphine and other drugs. (Pou, through her lawyer, Richard Simmons Jr., denied mentioning “lethal doses.”) Were the LifeCare patients being singled out? Mendez asked. She knew there were other sick patients at Memorial. Mendez recalled that Pou said “no” and that there was “no telling how far” it would go.
According to Mendez, Pou told her that she and other Memorial staff members were assuming responsibility for the patients on the seventh floor; the LifeCare nursing staff wasn’t involved and should leave. (Pou, through her lawyer, disputes Mendez’s account.) Mendez later said she had assumed that the hospital was under martial law, which was not the case, and that Pou was acting under military orders. Mendez left to dismiss her employees, she said, because she feared they would be forced downstairs by authorities.
Robichaux remembered Pou saying that the LifeCare patients were “not aware or not alert or something along those lines.” Robichaux recounted to investigators that she told Pou that that wasn’t true and said that one of LifeCare’s patients — Emmett Everett, a 380-pound man — was “very aware” of his surroundings. He had fed himself breakfast that morning and asked Robichaux, “So are we ready to rock and roll?”
The 61-year-old Honduran-born manual laborer was at LifeCare awaiting colostomy surgery to ease chronic bowel obstruction, according to his medical records. Despite a freakish spinal-cord stroke that left him a paraplegic at age 50, his wife and nurses who worked with him say he maintained a good sense of humor and a rich family life, and he rarely complained. He, along with three of the other LifeCare patients on the floor, had no D.N.R. Order. According to Robichaux, the group concluded that Everett was too heavy to be maneuvered down the stairs, through the machine-room wall and onto a helicopter. Several medical staff members who helped lead boat and helicopter transport that day say they would certainly have found a way to evacuate Everett. They say they were never made aware of his presence.
Kristy Johnson, LifeCare’s director of physical medicine, said she saw what happened next. She told Justice Department investigators that she watched Pou and two nurses draw fluid from vials into syringes. Then Johnson guided them to Emmett Everett in Room 7307. Johnson said she had never seen a physician look as nervous as Pou did. As they walked, she told investigators, she heard Pou say that she was going to give him something “to help him with his dizziness.” Pou disappeared into Everett’s room and shut the door.
As they worked their way down the seventh-floor hallway, Johnson held some of the patients’ hands and said a prayer as Pou or a Memorial nurse gave injections. Wilda McManus, whose daughter Angela had tried in vain to rescind her mother’s D.N.R. order, had a serious blood infection. (Earlier, Angela was ordered to leave her mother and go downstairs to evacuate.) “I am going to give you something to make you feel better,” Pou told Wilda, according to Johnson.
Johnson took one of the Memorial nurses into Room 7305. “This is Ms. Hutzler,” Johnson said, touching the woman’s hand and saying a “little prayer.” Johnson tried not to look down at what the nurse was doing, but she saw the nurse inject Hutzler’s roommate, Rose Savoie, a 90-year-old woman with acute bronchitis and a history of kidney problems. A LifeCare nurse later told investigators that both women were alert and stable as of late that morning. “That burns,” Savoie murmured.
According to Memorial workers on the second floor, about a dozen patients who were designated as “3’s” remained in the lobby by the A.T.M. Other Memorial patients were being evacuated with help from volunteers and medical staff, including Bryant King. Around noon, King told me, he saw Anna Pou holding a handful of syringes and telling a patient near the A.T.M., “I’m going to give you something to make you feel better.” King remembered an earlier conversation with a colleague who, after speaking with Mulderick and Pou, asked him what he thought of hastening patients’ deaths. That was not a doctor’s job, he replied. Patients were hot and uncomfortable, and a few might be terminally ill, but he didn’t think they were in the kind of pain that calls for sedation, let alone mercy killing.
“Can I help you?” he (Thiele) says he asked Pou several times.
“No,” she said, according to Thiele. “You don’t have to be here.”
“I want to be here,” Thiele insisted. “I want to help you.”
Thiele practiced palliative-care medicine and was certified to teach it. He told me that he knew that what they were about to do, though it seemed right to him, was technically “a crime.” He said that “the goal was death; our goal was to let these people die.” Thiele wavered for a moment. He turned to Karen Wynn, the I.C.U. nurse manager at Memorial who led the hospital’s ethics committee. “Can we do this?” he remembers asking the highly respected nurse.
"They prayed for the man to die...."
"We covered his face with a towel” until he stopped breathing..."
Wynn felt that they needed to medicate the patients, she said when she described her experiences publicly for the first time in interviews with me over the past year. She acknowledged having heard rumors that patients were being euthanized, but she said no one had told her that that was what was happening to these patients and that her only aim was to make patients comfortable by sedating them. Wynn said she did not fear staying in the hospital after the 5 p.m. curfew announced by the State Police — she had already decided to ignore the evacuation deadline and stay at the hospital until everyone alive had been taken out. Instead, she said, she was motivated by how bad the patients looked.
Wynn described turning to an elderly woman who was unconscious with labored breathing. She then prepared a syringe with morphine and midazolam, pushed it slowly into the woman’s IV line and watched her breathing ease. The woman died a short time later, which didn’t disturb Wynn because she had appeared to be close to death. She added: “But even if it had been euthanasia, it’s not something we don’t really do every day — it just goes under a different name.”
Thiele gave other patients a shot of morphine and midazolam at doses he said were higher than what he normally used in the I.C.U. He held their hands and reassured them, “It’s all right to go.” Most patients, Thiele told me, died within minutes of being medicated. But the heavyset African-American man didn’t. His mouth was open, his breathing was labored and everyone could hear his awful death rattle. Thiele tried more morphine.... Together they chanted: “Hail Mary, full of grace. They prayed for the man to die.... “We covered his face with a towel” until he stopped breathing, Thiele told me. He says that it took less than a minute for the man to die and that he didn’t suffer. “This was totally against every fiber in my body,” Thiele told me, but he also said he knew what he did was right. “We were abandoned by the government, we were abandoned by Tenet, and clearly nobody was going to take care of these people in their dying moments.” Both Thiele and Wynn recall that they, Pou and the other nurses covered the bodies of the dead and carried them into the chapel, filling it. Thiele said the remaining bodies were wrapped in sheets and placed on the floor in the corridor and in a nearby room. “It was very respectful,” Thiele told me. “It’s not like you would think.”
After months of conducting interviews and collecting documents, investigators came to believe, they said, that doctors and nurses euthanized as many as two dozen patients at Memorial. But medical records were needed to substantiate the findings, and according to investigators, Tenet’s lawyers said that many of those belonging to Memorial patients were unavailable. (The Tenet spokesman said via e-mail that Tenet produced all records in its possession.) Armed with the testimony of LifeCare workers and the medical records of the four patients on the seventh floor, state prosecutors decided their strongest case was against Anna Pou, Cheri Landry and Lori Budo for those deaths.
Records showed that more than half of the 41 bodies from Memorial that were analyzed by Middleberg’s lab tested positive for morphine or midazolam, or both. Middleberg had handled thousands of cases in his career, and the high drug concentrations found in many of the patients stuck out “like a sore thumb,” he told me.
The group considered the 90-year-old pneumonia patient Alice Hutzler, whom the LifeCare nurse Gina Isbell had promised to care for during the hurricane. Morphine and midazolam were found in her liver, brain and muscle tissue, but neither drug had been prescribed, according to her chart, which contained notes until the night before her death on Sept. 1. That chart showed that she was “resting calmly” the previous afternoon, and during the evening her nurses did not document any complaints of pain or distress that indicated she needed the drugs. Hutzler was one of the nine LifeCare patients found on the seventh floor with one or both drugs in their systems. All were seen alive the morning of Sept. 1, and all were listed as dead by Memorial’s pathologist that afternoon.
Despite Wecht and Baden’s strong opinions that the LifeCare deaths were the result of drug injections, Minyard wanted additional information to help him make his decision. He sent the patients’ medical, autopsy and toxicology records to three other experts for an independent review. “Homicide,” Dr. Frank Brescia, an oncologist and specialist in palliative care, concluded in each of the nine cases. “Homicide,” wrote Dr. James Young, the former chief coroner of Ontario, Canada, who was then president of the American Academy of Forensic Sciences. “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.”
A local internal-medicine specialist concluded that while medical records and autopsies for several of the patients revealed medical issues that could reasonably have led to their deaths, most of the patients’ records did not. In his report to Minyard, he wrote that it was “evident” that Emmett Everett was “in stable medical status with no clear evidence that death was imminent or impending.” (Pou’s lawyer says that Everett almost certainly died of an enlarged heart, not an overdose of medication). Despite all the expert determinations of homicide, Minyard was still struggling with what to tell the grand jury. He consulted one more pathologist, Dr. Steven Karch. Karch had staked his career on advancing the argument that the level of drugs found in a cadaver may have no relationship to the levels just before death.
"...if the case went to trial, the defense would bring in someone like Karch
to provide reasonable doubt."
Karch flew to New Orleans, examined the evidence and concluded that it was absurd to try to determine causes of death in bodies that had sat at 100 degrees for 10 days. In all of the cases, he advised, the medical cause of death should remain undetermined. The coroner said he believed that if the case went to trial, the defense would bring in someone like Karch to provide reasonable doubt. “We’d lose the case,” Minyard told me. “It would not be good for the city, for the recovery. It’s just a bigger picture that I had to consider than just that pure basic scientific thing.”
In March 2007, the grand jurors who would consider Anna Pou’s fate were sworn in. That spring, they began meeting about once a week at a secret location. Normally prosecutors are advocates for indictment, calling their strongest witnesses to testify and granting immunity in exchange for critical information. But the assistant district attorney, Michael Morales, whose office received condemnatory letters every day for bringing a case against Pou, told me that he and the Orleans Parish district attorney, Eddie Jordan, “weren’t gung-ho” about prosecuting the case. “We were going to give some deference to the defendant,” he said, because Pou wasn’t the usual career criminal accused of murder. At the same time, because a judge had signed a warrant to arrest Pou and multiple witnesses were willing to testify, “we weren’t going to shirk our duties and tank it.” He said that he personally “didn’t care one way or the other” about the outcome. Rather than presenting the evidence to the jurors and seeking an indictment, as he typically did, he said he invited the jurors, in conjunction with the district attorney’s office, to act as investigators and decide what evidence they wanted to consider. This didn’t sit well with the attorney general and his staff. Foti told me that he repeatedly asked the district attorney’s office to present all the evidence and the experts.
Grand-jury hearings are conducted in secret, making it difficult to know exactly what jurors hear. Minyard told me that in the end, he decided that four of the nine deaths on the seventh floor were homicides, including Emmett Everett and Rose Savoie. Until now, he has never publicly revealed that conclusion. He also said of Pou, “I strongly do not believe she planned to kill anybody, but it looks like she did.” The jury heard from Minyard but not from any of his forensic experts; nor from two family members who were present on the LifeCare floor during most of the ordeal; nor the main Justice Department investigator, who worked the case for a year and helped collect 50,000 pages of evidence. Only two of the main LifeCare witnesses were brought before the jury late in the process. Budo and Landry, who were compelled to testify after the district attorney decided not to prosecute them, had publicly expressed their support for Pou. The grand jurors lived among the general public, which was firmly in Pou’s corner. Pou had one of New Orleans’s premier public-relations agencies representing her. A poll commissioned by her lawyer’s office to assess the potential jury pool found that few New Orleanians favored indictment.
Any grand jurors who might have turned on their radios or TVs, or opened The Times-Picayune, or surfed the Web would have heard samples of the community’s drumbeat of support. Nearly every day, New Orleans’s most popular talk-radio host, Garland Robinette, raised his bass voice on WWL’s “Think Tank” in outrage at “what’s being done to these three . . . for trying to save lives.” On July 17, 2007, a support rally to mark the first anniversary of Pou’s arrest garnered top billing on Robinette’s show and on every local news program. Hundreds gathered in City Park. Speakers aimed their comments directly at the grand jury, warning that medical professionals, whose ranks had already been depleted by Katrina, would flee Louisiana in droves if a doctor was indicted after serving in a disaster.
On July 24, 2007, the jurors filed into Section E of Orleans Parish Criminal District Court, the building where Minyard survived Katrina. Judge Calvin Johnson read aloud the 10 counts of indictment. The grand jury did not indict Pou on any of them. FOUR YEARS AFTER Katrina, it’s summer again in New Orleans, and the myrtle trees are in bloom. Rodney Scott, the patient whom Ewing Cook once took for dead, is still alive. Scott is grateful to be with his family. A former nurse, he says he does not know whether euthanasia occurred at Memorial; but if it had, he wonders what the doctors and nurses could have been thinking. “How can you say euthanasia is better than evacuation” he asked me not long ago. “If they have vital signs,” he said, “get ’em out. Let God make that decision.”
Deliver me, O my God, out of the hand of the wicked,
out of the hand of the unrighteous and cruel man (Psalm 71:4).
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