The full details of what [Dr. Anna] Pou did, and why, may never be known. But the arguments she is making about disaster preparedness ”” that medical workers should be virtually immune from prosecution for good-faith work during devastating events and that lifesaving interventions, including evacuation, shouldn’t necessarily go to the sickest first ”” deserve closer attention. This is particularly important as health officials are now weighing, with little public discussion and insufficient scientific evidence, protocols for making the kind of agonizing decisions that will, no doubt, arise again.
At a recent national conference for hospital disaster planners, Pou asked a question: “How long should health care workers have to be with patients who may not survive?” The story of Memorial Medical Center raises other questions: Which patients should get a share of limited resources, and who decides? What does it mean to do the greatest good for the greatest number, and does that end justify all means? Where is the line between appropriate comfort care and mercy killing? How, if at all, should doctors and nurses be held accountable for their actions in the most desperate of circumstances, especially when their government fails them?
“How long should health care workers have to be with patients who may not survive?” [b]As long as necessary![/b]
As long as those patients are alive.
If you are a doctor or a nurse you have a vocation which gives meaning to not abandoning those in your care. If you are a “health care worker” you get out as soon as the water starts to rise.
Cennydd [#1, 2] and Phil Swain [#3], the abandonment question loses something when considered out of context.
On one level, we would admire the personal courage of a doctor or nurse who chose to remain with an seemingly-dying patient until the end, even though that meant placing their own lives in serious jeopardy.
On the other hand, it could be argued that the doctor and nurse have a moral- and ethical duty to be cautious about putting their own lives in the kind of jeopardy that could deprive others of their future skilled services (not to mention depriving their families of their future presence).
That’d be a tough call if the likely “upside” associated with that jeopardy were no more than the providing of limited comfort to someone who likely had only hours or minutes to live.
It’d be an especially-tough call if the choice had to be made under conditions of sleep deprivation; severe stress; almost-nonexistent resources; uncertainty about the prospect of relief arriving; etc.
(I stress again that I’m talking about abandonment here, NOT euthanasia.)
Greetings.
Triage, with the often difficult and/or tragic decisions that go with it, is one thing. The necessity to withhold or ration care in emergency circumstances can be an arguable judgment call, as can the “abandonment” of patients where means to evacuate them are simply not available. I am not convinced that medical personnel must “go down with the ship”, particularly if they are needed elsewhere.
The simple fact is that in some situations, the only choice one has is between competing tragedies. Not an easy choice to make, I think.
That being said, euthanasia, however well-motivated, is something else entirely. There is a very bright line between allocating insufficient resources in a way that might have been better, and actively causing death, for whatever reason.
regards,
JPB
“If you are a doctor or a nurse you have a vocation which gives meaning to not abandoning those in your care. If you are a “health care worker†you get out as soon as the water starts to rise. ”
It does interest me that the same folks who think that doctors and nurses are just overpaid “health care workers” to be sued if the “customer” is not satisfied, replaced by folks at wal-mart, and who should have their pay slashed and work load increased, are suddenly reminded of the “vocation” of the doctor when the waters are rising, drug seeking criminals are on the ground floor, and the last helicopter is fleeing.
Then of course the “vocation” of the doctor is not simply to treat those who can be treated, and evacuate those who can be evacuated, but apparently to die with those who are dying and cannot be evacuated.
I do not recall that last sentence being in the Hippocratic oath.
The “vocation” of the doctor has already been extended to working without pay for any stranger who comes into their hospital ER. Apparently it now extends to dying in order to make sure that dying strangers have a physician comforter to hold their hands in their last momments.
Sort of reminds me of the helicopters leaving our embassy in Saigon. Failure, cetainly, and I can’t recall that scene without shame. But whose shame? The grunts in Vietnam (the doctors) who gave it their best, and failed? The draft dodgers/(folks who were conveniantly away) who spat on our troops/doctors when they came home? Or the folks in government (US/New Orleans) who sat on their hands doing nothing and then were quick to blame those on the front line for their “failures”.
I do not agree with the euthanasia (if it happened). However the choices appeared to be to stay and die with the patient, to abandon the patient to the mercies of the drug seeking criminals who had infiltrated the ground floor, or to perform mercy killing.
I don’t think I would have performed mercy killing. Whether I would have stayed or fled, I do not know. Neither does any of the comfortable folk sitting in this forum know what they would have done in that situation.
Today one of the patients I saw had won 5 bronze stars and 1 silver star during his three tours in Vietnam. He earned 3 of his bronze stars (and a bunch of shrapnel) carrying wounded comrades to safety under fire. He won his silver star, and dislocated both his shoulders carrying a wounded Vietnamese to safety under fire. I think, the next time I see him, I will ask him what a physician ought to do in that setting. He has a right to judge. He has earned it.
[i]applause @ Clueless (who isn’t!)[/i]
I don’t think some of the posters here actually read the whole article. Notwithstanding the lead in, this actually has nothing to do with abandonment. It has to do with a number of doctors who basically decided who was going to live and who was going to die (although it turned out that a number of those they marked for death actually managed to escape and are alive today) and proceeded to implement said decision by killing those that they decided were at bottom of the list for saving — including one man who was perfectly alert and talking who failed to die after being given two massive doses of morphine, whereupon apparently some participants decided that maybe God wanted him to live but someone put a wet towel on his face and suffocated him anyway. It’s horror story that would be unbelievable coming out of the most desperate third world country. Happening in the U.S. four years ago, it’s simply unimaginable. And the one doctor charged (though there were more involved) was not indicted by a sympathetic grand jury (who did not have all the facts) and now wants to put through a rule that doctors can not be held accountable for anything they do in an emergency. Remind me never to move to New Orleands. Or go to a hospital. Or get sick.
Precisely, Catholic Mom.
Triage during mass casualty situations is one thing; unpleasant, but a reality when physicians and nurses are dealing with overwhelming casualties and limited resources/time to stabilize and treat them. The military does it, and those of us civilians who have gone through ATLS (Advanced Trauma Life Support) and like training are acquainted with it.
And, it’s easy to be a Monday morning quarterback and talk about a stay-or-flee situation like this, as Clueless suggests; what any of us would do when actually in that situation, well, I pray that I’d do the Christian thing and stay with those who needed me, even at the risk of my life. I’d also pray for God to send a Medevac chopper with some firepower backing them up to come pronto.
That said, engaging in “mercy killing” as appears to have gone on here is very far removed from “first do no harm,” in my medical lexicon.
“It has to do with a number of doctors who basically decided who was going to live and who was going to die”
Agreed. (Assuming it happened, which is in dispute). I cannot countenence “mercy killing”. (Mostly because of the damage to the doctors soul, not for any “compassionate reason”).
However, despite the fact that all services have a “leave no wounded comrade behind” policy, it is a fact that sometimes it is not possible to comply with this, without dooming the entire mission. Our soldiers go to heroic lengths to rescue those “left behind”. It is a fact, however, that some are. John McCain could tell us about this. Some of those who are left behind beg their departing comrades for release by death, rather than risk falling into the hands of the enemy.
What is the greater sin? To abandon someone to torture and death by the enemy? Or to kill him so as to spare him the torture part? I think that these were the thoughts that motivated the folks in NO (assuming that mercy killing actually happened).
Me I would not have killed. But to my mind, that is more a sign of my spiritual cowardice, not because of any good quality. Whether I would have had the guts to stay, I really don’t know. I pray that I would have. If somebody was alert, and talking to me, I think I might have. If they were comatose, probably not. But I don’t know what I would have done, and frankly pray that I will never be put in that situation.
Catholic mom is horrified that in a 1st world country, people might kill those “they decided were at bottom of the list for saving—including one man who was perfectly alert and talking who failed to die after being given two massive doses of morphine. . . It’s horror story that would be unbelievable coming out of the most desperate third world country.”
This is the way that national health care in the Netherlands operates already (with government saction).
http://www.euthanasia.com/netherlands.html
The UK appears to already be moving to this model, albeit without official government sanction.
http://www.telegraph.co.uk/health/healthnews/6127514/Sentenced-to-death-on-the-NHS.html
In the Netherlands it is “now considered a form of discrimination against the chronically ill to deny them assisted death because they will be forced to suffer longer than those who are terminally ill and it is considered bias to force endurance of psychological pain when it is not associated with physical illness. ” (see article above)
Can’t wait until the national health care goes through and the government makes sure we all have our “right to avoid psychological pain protected”.
No national health care model can survive financially without some form of triage and rationing.
I read this article on the subway last night on my way to and from the 30-year reunion of my university class. The article oppressed my spirits, and even made it difficult to sleep at night. I found it particularly disturbing that many of those whose actions are now questioned were Christians. Note also that, according to the article, the great bulk of opinion in New Orleans was strongly against opening the case. My Vatican annual says that there are 488,000 Catholics in that diocese, so these and other Christians were by and large, it seems opposed to further investigation.
My question: did Christian faith not constrain these people? Did it ever challenge their perspective? I understand and accept that everybody was under terrible strain. Perhaps I, and other commentators above, underestimate what the article reports as the complete exhaustion of the staff, after three days and nights without much sleep. And yet, and yet … we may wonder whether this was a brutal and inhumane way to treat patients. And implicitly it calls into question many others: FEMA; hospital administrators who it seems did not act when warned that a flood could disable emergency electrics; and local malefactors who used the situation to terrorize the surrounding community, thus bringing fear into the hospital itself. What an indictment. And as I said I am left with the nagging question of whether Christian faith makes a difference in how people behave.
Yes, when they were trying to kill the fat black guy (whose sin seems to have been that he weighed so much that they thought they wouldn’t be able to get him up to the helipad — no wheelchairs??) they were praying the Hail Mary and the Our Father. All of them appear to have been “good” Catholics. My husband actually stopped reading when they got to the part where they killed the two cats (he is a vet). Like the cats had to be killed because they couldn’t survive on their own for awhile?
Well, I have now read past the first 3 pages, and I have to say it really made me want to throw up.
I don’t know how they could have gone, bed to bed, shooting people up, like that, and I would not have participated.
However to answer #14 reread the article. There are no working elevators. Everybody is transported by stretcher up and down stairs. Why don’t you load 10 – 40 pound bags of compost onto a stretcher and see how many flights of stairs you can make. After you have done that, why don’t you try going without sleep for 3 days, and then try it again.
These are not professional movers or weightlifters who are moving patients. They are health care workers, who are a population not known for the amount of time they spend at the gym. They are already physically exausted by evacuating the other patients most of whom are less sick.
ReRead the bit about the nurses and docs trying to keep people alive by bagging them for hours. Why don’t you squeeze a pillow once every five seconds for the next several hours and report back how long you kept it up. Seriously. I think you need to understand what you are suggesting.
I’d like everybody here to perform the above exercise, and to then report back here, after they have worked at fairly heavy manual labor without sleep for 3 days. We have a three day weekend coming up, plan on doing all your chores for the fall and let us know what this does to your compassion, temper, coordination, and ability to think straight. Tell us about the headaches, waves of nausea and the involuntary trembling, and the shaking chills that usually begin after 48 hours of unrelieved activity. I’ve worked 48 hours without sleep fairly often, but I have done over 72 hours only once myself (during residency) and it is an experience I do not wish to repeat.
But I think it would be a good idea if the folks on the blog were to have that experience. CatholicMom and Cennydd in particular.
I mean this very seriously. Please go try it. It is important that you understand what you are saying.
For those who do not care to practice this experiment, a simple google search “how long can humans go without sleep” will make clear that after about 72 hours of sleep deprivation, one starts having not just chills, vomiting and headaches , but fairly fixed hallucinations (which are micro intrusions of REM sleep into wakefulness). At 4 days (the period that the folks at Katrina was approaching), it becomes impossible to tell reality from fantasy and most people pass out, though in experimental/torture type studies people have been tortured awake up to about 10 days. By 11 days there is usually severe brain damage, as the brain literally “shuts down”.
http://www.ensidia.com/community/post/1580/?page=5
The wimp college students above, who tried the experiment I suggested appear to have maxed out between 24-40 hours though one person made it to 72 . None of the rest would have survived their internship, but lets look at the bright side. They don’t have what it takes to be a doctor, let alone be half way useful in a place like Katrina, but they do have what it takes to post snide comments on a blog.
I find it revealing that there were 2000 people sheltering in that hospital in New Orleans. It doesn’t sound as though anybody other than staff and family members offered to lend a hand. The article talks about the pitch darkness of the hospital (especially the stairs, prepared to manuever a 400 lb man down 7 flights) and the gunshots ringing below.
Odd that so few people were available to help out. And so many to condemn afterwards.
This is why “as long as necessary” may not be possible in the absence of robotic care givers.
[Edited by Elf – we understand this is emotive but please restrict comments to the issues rather than directing them personally to other commenters]
[Comment deleted by Elf]
I knew a guy in college who claimed to have once stayed awake for a week. I seriously doubt that — that is, I’m sure that’s what he remembers, but I’m pretty sure he was sleeping at odd moments without realizing it. In any event, he did report vivid hallucinations by the end of that time, and his brain did eventually shut him down. He also claimed that he never felt quite the same since then, so it may well have done something permanent to him.
I have also read that, according to people who are experienced in various forms of torture and brainwashing, extended sleep deprivation is apparently far and away the most effective way of breaking someone.
My personal record is about 52 hours, and I have no desire to repeat that experience.
Throw something like Katrina on top of that, and I’m prepared to be sympathetic to whatever people in that situation do. They are very far from their right minds at that point.
Elf: “please restrict comments to the issues rather than directing them personally to other commenters”
I am continually amazed at the expectations that the general public expects of physicians. A hospital stairway cannot accomodate a stretcher with more than 2 people max at the bottom and two people max at the top. Middle aged nurses used to lifting a maximum of 2 bags of groceries were manouvering over one hundred patients down 7 flights of stairs though a small narrow hole, and up two flights of stairs to the helipad in pitch dark, illuminated by their penlights. By the third day they were dizzy, vomiting, and having nose bleeds, and the hallucinations were just beginning. They can hear the sounds of gunfire near by. None of the hordes of civilians have anything useful to offer except to demand more care.
How long should they have continued? How long do you think you could have continued?
This is important because of course some of our ERs (in Texas, for example) already approach war zone like conditions. In private practice I routinely worked more than 100 hours. If I worked less than 60 I owed the hospital money and didn’t earn a cent. I routinely worked more than 48 hours at a stretch.
The plans currently suggest that physicians and hospitals should simply “do more with less” and work harder and longer. At some point, even Atlas, must shrug. That point arrived in Katrina. It will eventually arrive in more ordinary care, as the patient load increases and the health care resources continue to diminish.
[Clueless [19] – The request not to make comments personal relates to our comment policy at T19, in part to avoid things becoming over-heated. That does not relate to the other content of your posts on this thread which have been well worth reading – Elf]