Dr. Fink is an MD/PhD from Stanford who won a Pulitzer Prize for investigative reporting for a shorter account of the story—“The Deadly Choices at Memorial,” published in the New York Times Magazine ( 8/25/09 ) and ProPublica ( http://http://www.propublica.org/site/author/sheri_fink ).
Her medical and investigative reporting skills serve her well in superbly describing in minute detail the gradual disintegration of the hospital's support systems and the descent into chaos. At the end of the five days, 45 bodies lay in the chapel, morgue, hallways, ER, and Life Care floor of Memorial—the largest number of deaths during the storm in any hospital or nursing home in New Orleans.
The circumstances surrounding these deaths form the centerpiece of this captivating book. She interviewed more than 500 participants, including administrators, caregivers, family members, and rescue teams to stitch together this remarkable narrative. To her great credit, the investigative reporting was so skillfully done that, after finishing the text, this reader was unable to determine her personal conclusions about whether crimes had been committed.
The story begins with the hospital ill prepared for the scale of the emergency but with a dedicated, experienced and committed staff, many of whom had been through hurricanes before. As the days pass and the support systems of all types begin to fail, physicians and nurses have to try to provide care while evacuating patients under progressively unbearable conditions. By day four, the hospital was stifling, with temperatures above 100 degrees, water had stopped flowing, toilets were backed up, no lights or electrical monitoring systems were operational, the stench of sewage was everywhere, windows were broken out, and gunshots rang out throughout the neighborhood. Rumors circulated of looting, criminal gangs, and martial law. Unexplainable and inconsistent orders disseminated throughout the hospital.
This was the setting in which doctors and nurses had to make decisions about how to best care for their most severely compromised chronically ill patients.
A much different atmosphere existed for the second part of the book, titled “Reckoning.” Here the legal and investigative teams did their work after the hurricane had passed, lights returned, air-conditioned facilities were available, and New Orleans returned to some semblance of normality. Dr. Fink carefully documents the process by which the Attorney General of Louisiana's staff builds its case.
The evolution of the legal case is complicated by politics, personal passions, and turf issues. As the attorney general's staff sorted through the evidence, they ultimately focused on just three individuals, although others might have been included. Evidence from several doctors, nurses, and health care workers both inside and outside the hospital provide damning testimony suggesting that crimes were committed.
When notified of their pending arrest, all three hospital staff members agree to voluntarily surrender, but the attorney general's staff carries out public nighttime arrests with full news coverage of the three in handcuffs. CNN weighs in with colorful stories of “the angels of death stalking the halls of the hospital.”
The three are charged with second-degree murder for intentionally killing four patients. The Attorney General himself at a news conference incorrectly states, referring to morphine and Versed: “Either one can kill you, but when you use both of them together it becomes a lethal cocktail that guarantees that they are going to die. This is not euthanasia; this is plain and simple homicide.”
The legal case is bolstered by outside forensic pathologists who find morphine and Versed in many of the patients and declare that this was evidence of homicide. A prominent ethicist declared that “nine patients euthanized is not consistent with the ethical standards of palliative care that prevail in the United States.”
Buttressed by this, the attorney general's staff urged that the case move forward. But murder under most circumstances is a local jurisdiction, and the case fell to the District Attorney of Orleans Parish who was far less convinced by the evidence and more compelled by the disastrous circumstances at the hospital. Public opinion was firmly on the side of the medical staff, and 76 percent of Orleans Parish polled supported the staff, and only eight percent favored indictment. National organizations such as the AMA, the National Nurses Association, the American College of Surgeons, and others provided support for the accused.
The Orleans Parish District Attorney brought the case to the Grand Jury on July 24, 2007—nearly two years after the events. Although many readers may know the outcome, I will not spoil the end of the book by disclosing the verdict.
This is a very powerful book, masterfully constructed with wonderfully nuanced presentations of complex situations where systems and people are under great stress. As Dr. Fink asserts, “The scenario was familiar to every student of mass disasters around the world. Systems always failed. The official response was always unconscionably slow. Coordination and communication were particularly bad.”
The story itself is a fascinating labyrinth of complications and unexplainable decisions.
Important Lessons for the Practicing Oncologist
But the book has important lessons for the practicing oncologist as well. Many of us have been called upon to walk the fine line between relieving pain and comforting patients by using drugs that may ultimately hasten death.
The faint line between comforting the dying and euthanasia becomes largely one of intent. While that is understood by oncologists, this book makes it clear that it is often not well accepted by other doctors, nurses, and health professionals, who may have strong feelings against such intervention under any circumstances.
The critical testimony by outside forensic pathologists and ethicists adds to the disquiet. The legal and justice systems may have very different standards generated for typical situations and applied to crisis settings.
All this has made this reader reassess what society understands about the care of the desperately ill. Lest you think that the issue has been resolved, the Institute of Medicine in 2012 in their report on “Crisis Standards of Care” (National Academies Press) wrote, “Neither the law nor ethics support the intentional hastening of death even in a crisis.”
Five Days at Memorial is a wonderful book with insights on many different levels about human behavior during crises and about society's expectations of medical care. Read it—you won't regret it!
CROWN, 2013, ISBN 0307718964; AVAILABLE IN HARDCOVER, PAPERBACK, AUDIO, AND KINDLE EDITIONS
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