Wednesday, July 19, 2006

What Happened in New Orleans?

Today the Attorney General of the State of Louisiana has initiated charges against a physician and two nurses. It is alleged that in the aftermath of Hurricane Katrina these three administered pain medications to patients in a long term care unit housed at Memorial Medical Center, causing their deaths, and that the medications and/or their dosages were not appropriate. Therefore, the deaths are characterized by the Attorney General this way: “This is not euthanasia. This is a homicide.” There are many news stories about this on the web. Stories here and here seem relatively thorough. This report focuses on the ethical concerns.

The problem at this point, of course, is that we still don’t know what happened. We will have to wait to hear what facts come out at trial. We will have to hear the testimony and the affidavits. I’ll be particularly interested in pathology reports. I also expect there will be “expert testimony.” I think that will be, or perhaps should be, important.

And since we don’t know what happened, there are concerns that still hang out there. We have some sense of the desperate conditions in general in the wake of Katrina: hot and humid days without relief for buildings or for the people in them; loss of the electricity on which so many of our interventions depend; loss of the other professionals to provide the relief on which our physicians and nurses depend; loss of the technical means to move patients to safer, more controlled services; and loss of the social fabric to sustain all those things, leaving the sense that there was no end in sight. We also have some sense that part of providing care, even in the best of circumstances, is the necessity of decision: whether one acts or does not act there are consequences to the decision, consequences of pain and suffering or of their relief; consequences of living and dying.

There are some questions we can keep in the foreground as these facts come out. For example, what is an appropriate dose of pain medication, based not on professional standards or “best practices,” but on the conditions at the bedside when the decision was made. From my own exposure to palliative care and pain management, I’m aware that an individual patient in significant pain may require doses that far exceed normal practice. Moreover, responding to the physical suffering of patients who cannot speak for themselves (and, often, even for those who can) is a matter of art and not of science. Some patients will experience nonlinear results: small, incremental changes can have large, systemic effects. I have written before of my concern about the ethical principle of double effect: that while we need it, we should face it humbly. At the same time I continue to realize that actions intended to relieve suffering can themselves have those nonlinear consequences.

With that in mind, we need to consider what the conditions were for those patients at the time they died. To call the alleged acts homicide is to suggest that these patients could and would have survived the illnesses they suffered in the circumstances they experienced. Several reports since the events have quoted family members of patients who had died at Memorial Hospital. The gist of those stories has been “The last time I saw my loved one he or she seemed fine.” However, in twenty five years in health care I have learned that things can change with frightening suddenness. In the conditions in Memorial Hospital at the time the simply physical stresses on patients could certainly have been incredible. And we need to note that these were patients in long term acute care: that is, patients that required hospital levels of care for exceptionally long hospital stays. The fact that they were “doing well” at the time of Katrina relative to their individual conditions does not suggest that these patients were anywhere near being able to live outside the hospital, even under the best of circumstances.

I think we need to know, too, whether these patients had expressed wishes about their care in health care treatment directives. Sudden changes in a patient could result in the circumstances for which those documents were intended: a patient lacking the capacity to make health care decisions in a circumstance where the physician feels there is little or no hope that the patient will return to a quality of life acceptable to the patient. And, again, these individual cases would need to reflect the situation in the moment, and not in the best or even normal circumstances.

We need to learn about the conditions of the professionals, these and others, who were continuing to provide care to these patients. After days suffering the same environmental circumstances as the patients, doing their best with little rest, no professional relief, and perhaps no end in sight, what was their own capacity to make decisions? In recent years there have been many questions about long hours for medical interns and residents, and the effects of those long hours on patient safety. These were circumstances beyond even those stressful residencies. The defense attorneys have already suggested that this is pertinent. If exhausted professionals, stretched by horrific circumstances, make a decision while trying to do good, and the decision has undesirable consequences, how much weight to we give to the circumstances under which the decisions were made?

Again, we don’t have answers to those questions. We will know more when this actually gets to trial and the stories are told. In the meantime, we need to watch and wait. The headlines will be lively, perhaps sometimes inflammatory. We need to wait for facts, and as best we can use those as the basis for judgment.

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