Palliative care and comfort-focused care

Palliative care and comfort-focused care name a goal of treatment: relieving symptoms and attending to comfort when that goal takes priority over others. The book gives the distinction particular force at Memorial Medical Center during the Katrina crisis. There, patients’ stated wishes, medical decisions about treatment, and the practical limits of evacuation did not always point in the same direction. The resulting questions are not interchangeable: choosing not to receive a treatment, receiving care intended to relieve symptoms, and deciding how a patient will be treated when staff must leave are different matters, even when the emergency brings them into close contact.

Meaning and Clinical Practice

John Thiele understood ordinary palliative care as a practice he had studied in a week-long course, which qualified him to teach the relief of symptoms for patients who had chosen to prioritize that aim above other treatment goals. His medical-school motto, emphasizing frequent healing, occasional cure, and constant comfort, also reflected the importance he placed on comfort. In the crisis, however, he believed he had almost no control except the ability to offer it. The gap between a defined clinical practice and what he thought he could do under extreme conditions became central to his reasoning.

For Thiele, comfort was not simply a substitute name for any action taken when cure or rescue seemed unlikely. He accepted the premise that patients could not be moved and staff would have to leave, and feared that a morphine infusion might run out before a patient died, leaving that person in acute suffering. He later described his intended action as abbreviating the usual process of comfort care, but recognized at the time that it was technically a crime. His account therefore presents a contested boundary: symptom relief within care planned around a patient’s goals is not automatically equivalent to deliberately hastening death. His own rationalization blurred that boundary, while his recognition of the legal and ethical difference showed that it had not disappeared.

Patients’ Wishes and the Goals of Treatment

Jannie Burgess’s care illustrates comfort-focused treatment as a response to preferences discussed with the patient and her family. After earlier surgery and chemotherapy had held her uterine cancer in check, she was admitted to Memorial in early August 2005 with severe weakness and a bowel blockage. Surgery revealed cancer in her liver that could not be removed. She did not want to live on machines and rejected dialysis if her kidneys failed. Her doctor discussed those preferences with Burgess, her sister, and her niece, then shifted the goal from treating her medical problems to ensuring comfort. Small doses of morphine were ordered as needed for pain, and she was expected to move from intensive care to a regular medical floor when a bed became available.

That plan depended on distinctions that could be lost when a patient was classified by a single medical order. Burgess’s Do Not Resuscitate order expressed a limit on resuscitation; it did not, by itself, express a wish to be abandoned or left without rescue. During the evacuation, all patients with such orders had been placed last, including Burgess and Helen Breckenridge. When staff were told to leave a floor where no one had come for a DNR patient, nurse Michelle Pitre-Ryals explained to the patient’s daughter that she could ask to discontinue the order. The daughter clarified that she had agreed to DNR status because her ninety-three-year-old mother depended on oxygen and resuscitation after cardiac arrest seemed inappropriate, not because she understood it to mean that her mother should not be rescued. The scene exposes the distance between a treatment preference and the broader decisions made around evacuation.

Burgess’s history also places her care within New Orleans’s segregated medical past. She had become a nurse to support her children after working as a taxi dispatcher and a secretary to a mortician. With light-brown skin, she could care for patients at many private hospitals but could not receive care at them. Born a few months after Memorial opened as Southern Baptist Hospital in 1926, she did not become a patient there until more than four decades later. Her later treatment was therefore not an abstract example of comfort care: it concerned a nurse whose working life had been shaped by unequal access to the institutions in which she provided care.

Disputed Care and Conflicting Accounts

Helen Breckenridge’s history complicates any simple account of comfort-focused treatment. Seventy-seven and seriously ill with lung and heart disease and diabetes, she had been receiving hospice care at another hospital. Her treatment there focused on comfort rather than extending life; she received morphine and powerful sedatives, and when she stopped eating, the hospice did not provide nutrition or fluids. Her brother, a physician, believed she had been pressured into hospice and did not truly wish to be there. He went to court to have her removed and transferred to Memorial’s intensive care unit for aggressive treatment. The episode places competing interpretations of a patient’s wishes alongside one another: the hospice plan treated comfort as the priority, while her brother challenged whether that plan reflected her choice.

The contrast matters because comfort-focused care is not presented as a uniform response to severe illness. Burgess’s preferences against machines and dialysis were discussed with her family and accompanied by a change in the stated goal of her treatment. In Breckenridge’s case, a relative disputed the basis on which hospice care had begun and sought more aggressive intervention. The comparison keeps patient autonomy in view without implying that every case had an uncontested preference or that a DNR order settled every question about care.

Disaster, Abandonment, and Aftermath

The emergency tested whether a plan for comfort could be sustained when the people providing care were also expected to evacuate. Thiele did not believe he could provide what he considered appropriate end-of-life care under those circumstances. He rejected the prospect of leaving a morphine infusion to run out without staff present, but his response was not to stay with the patients until they died naturally; he later said he believed staying would put his life at risk. His account thus holds together the pressures he perceived, the limit he placed on his own responsibility, and his awareness that the action he contemplated crossed a legal line. The book presents this not as routine palliative practice but as an exceptional, morally fraught departure from it.

The wider hospital crisis makes the fragility of that care visible. At Charity Hospital, flooding and the loss of power, plumbing, computers, telephones, and elevators accompanied a prolonged evacuation: patients were not all transferred until Friday afternoon, September 2, compared with Thursday, September 1, at Memorial. Charity had roughly twice as many patients across its two campuses and fewer staff per patient, yet fewer than ten patients died. This comparison does not establish a simple cause for the different outcomes, but it resists treating Memorial’s circumstances as the only possible measure of disaster care.

The aftermath also appears in the experiences of staff. Gina Isbell, who left Memorial by small boat and lost her home and community in St. Bernard Parish, slept poorly, had nightmares in which she saw patients’ faces, and felt guilty about the staff she had selected and terrible about patients who had died. She later wore a hurricane-shaped pendant and remained angry that help had arrived too slowly, describing herself as changed by the storm and its ending. Thiele, after spending weeks in a semi-conscious state, experienced disturbing visions; a nurse who spoke briefly with him about his role believed he was remorseful and wished he could have acted differently. These accounts do not resolve the disputed decisions. They show instead that care under catastrophe continued to be reckoned with afterward, as a question of patients’ chosen goals, the obligations of those who treated them, and what comfort could mean when ordinary care and evacuation failed to align.