Imagine being in an underprepared hospital
essentially marooned from the city around it due to flooding, full of patients,
and failing power; this was Memorial Medical Center in New Orleans after
Katrina. During all of the mayhem, the doctors in charge of the hospital
decided that patients with DNR orders would be the absolute last individuals
evacuated from the hospital. Virtually none of the patients or their families
were consulted or informed of the decision, with the exception of the few
family members there at the time. One “lucky” daughter found out only after she
had led a group of boats to evacuate the hospital. She was completely outraged
when her mother was barred from leaving due to the standing order. This news
caused her to say exactly what have asked, “I didn’t realize a DNR order meant
Do Not Rescue.”
As we've previously discussed in TBL, a DNR stands for Do Not Resuscitate. Individuals who are suffering from chronic illnesses with little chance of recovery, or simply older individuals, commonly have DNR orders. These orders give healthcare providers and family members clear instructions to not revive the holder if their heart or breathing stops. These can be reversed either by the holder or in some cases by the power of attorney.
As we've previously discussed in TBL, a DNR stands for Do Not Resuscitate. Individuals who are suffering from chronic illnesses with little chance of recovery, or simply older individuals, commonly have DNR orders. These orders give healthcare providers and family members clear instructions to not revive the holder if their heart or breathing stops. These can be reversed either by the holder or in some cases by the power of attorney.
Now, back to NOLA. This particular daughter was able to have a
provider rescind the DNR, but only after threatening to halt the evacuation.
What about all of the patients who had no family member to fight for them?
Should the providers have informed them of the awful plan and given them the
chance to rescind theirs’ as well, or kept them in the dark like so many did?
In this disaster situation, autonomy and greater justice seem to have been at
odds. Obviously, every patient deserves the autonomy to make their own decisions
and be aware of their situation. But, in this situation, the providers seemed
to value the greater justice of other patients who had a better chance of survival
during and after the evacuation. Beneficence and non-maleficence were extremely
subjective during the crisis, as “helping and not harming” one patient commonly
sacrificed care to another. I don’t think any provider purposely brought harm
to anyone, but they also don’t seem to have been prepared to make the decisions
they were forced to. Then again, neither was the entire city of NOLA.
Note: This
situation was retrieved from the book Five
Days at Memorial. I strongly recommend everyone read this and Sheri Fink’s
other book War Hospital.
Sources
Fink,
S. (2016). Five days at Memorial: life and death in a storm-ravaged hospital.
New York: Broadway Books.
Martin,
L. J. (2016, June 2). Do-not-resuscitate order. Retrieved November 25, 2017,
from https://medlineplus.gov/ency/patientinstructions/000473.htm
This brings up some incredibly difficult ideas of the ethics of who to save when it cannot be everyone. I don't think that one can ethically justify the implementation of a DNR before the person has died, and in this case, many of the patients could be months, or even years, from death. The idea that they have less right to be evacuated than other patients based on their wishes to be left to rest upon their death does not give healthcare providers the right to value the life they do have left less. These patients remain members of society who have a right to live just like the rest of us.
ReplyDeleteWhile I understand the situation was difficult and no one really knew what was going on, DNR patients should not have been treated any differently than other patients because in doing so, it was implied that they have less rights than another person, when all they really want is to be left to rest when their time comes.
This is something that I cannot fathom ever having to deal with personally, on either end as a physician or family member. I think the decision of signing a DNR is one that already takes a toll on an individual and their family emotionally, and though they are choosing if their body were to fail them to not be revived it doesn't consider situations like Hurricane Katrina and being under-prepared for the disaster that came from it. I agree with your point on how I don't think physicians intentionally went chose to go against the justice of the DNR patients and choosing to evacuate them last. Though, when analyzing this situation from the patients' views, it was unfair for them to be chosen against due to personal choices they had made about their medical care.
ReplyDeleteI also understand where the physicians were coming from with needing to uphold beneficence and non-malfeasance to their patients in such a stressful situation, and choices had to be made since resources weren’t enough for everyone to leave. I think the bigger issue that came with the patients that had a DNR was that they were targeted because of this decision, and that wasn’t something they had volunteered for when making that choice. I think overall there was going to be a tough decision that needed to be made, and someone would ultimately receive the lesser of the two options.
This post makes me want to go out and buy the book you mentioned because I want to know more and the outcome of such a difficult situation. While there were so many people in need of help during this time after Katrina, it makes sense that the physicians had to make some sort of order for evacuation. After working in a hospital, I know that there are evacuation plans already set in stone and practiced in case of an emergent situation. At children's hospital all patients are to be evacuated except those who need to be on a ventilator or other machinery dire for their survival. I never understood what would happen to those patients though, would they just stay and be cared for and hope for the best? or would they eventually be evacuated with a travel team? Luckily, we are not in a place that hurricanes occur and therefore the situation is less likely to happen. I am surprised to hear that in New Orleans their evacuation plan was to put all patients with a DNR at the bottom of the list to be evacuated. Although DNR does mean Do Not Resuscitate, the patients are still alive and therefore I believe they should be treated like any other patient. This is definitely a tricky situation that leaves me on the fence of what I would have done. I am not sure if I would practice beneficence and justice by getting the majority of patients who have a better chance at survival out first. Or if I would practice non-malfeasance and attempt to not harm any individuals despite their DNR status. I think something that could have been done is maybe start by moving from the most dangerous part of the hospital from damage of the hurricane, to the higher floors. But again, this is really tough and I don't think anyone would know or trust their decision on what to do.
ReplyDelete