Comfort care and palliative medication

Comfort care and palliative medication at Memorial Medical Center during Hurricane Katrina became both an immediate response to patients’ distress and a contested question of intention. Morphine and Midazolam could ease discomfort and air hunger, but they could also suppress breathing. As patients died and investigators later examined drug findings, the crucial issue was not simply whether medication had been given: it was what the medication was meant to do, what effects were foreseeable, and how reliably the available evidence could establish either.

Clinical Meaning and Limits

In the intensive care unit, Karen Wynn was accustomed to giving morphine with Midazolam to patients on ventilators. The combination could sedate them and, when appropriate, reduce their drive to breathe so the ventilator could do that work. It was also used to reduce the possibility of pain, discomfort, or air hunger before a breathing tube was removed and life support withdrawn. In those circumstances, the purpose was comfort during dying, even though suppressing respiration could hasten death.

That practice shaped Wynn’s response when she encountered patients who were still alive but struggling to breathe. She believed they needed comfort; she also believed medication would probably speed their deaths, while understanding the dying process to be underway already. Her judgment rested on what she saw and heard, and on decades of intensive-care experience, rather than on having examined every patient. She reasoned that moving severely breathless people through the hospital and onto improvised evacuation routes could itself worsen their condition, and that sedation might be appropriate even for such a journey. Her reasoning did not erase the ethical difference between treating distress and intending death; it made that difference harder to assess under emergency conditions.

Medication in the Evacuation Crisis

On the seventh floor, Wynn and Anna Pou assessed patients lying near a corridor. When Wynn pointed out an elderly woman breathing with difficulty, morphine and Midazolam were available among the supplies. The drugs were intended for intravenous use, but many patients did not have IV access. Wynn and Pou requested boxes of IV catheters, but not the IV fluids and tubing that would have been required to hydrate patients unable to drink adequately. A nurse held a flashlight while Pou started an IV. Another nurse, who had previously been told not to start IVs for DNR patients during emergency mode, was sent away to pack her belongings.

Wynn gave the elderly woman a diluted dose that she later recalled as a 10-milligram vial of morphine and a small amount of Midazolam in saline. She administered it slowly through the IV and flushed the line. The woman appeared to struggle less to breathe and died within about half an hour. That sequence records both the intended relief and the close timing of medication and death; by itself, it does not establish whether the drugs caused her death or what anyone intended beyond easing her distress.

The same crisis made the meaning of DNR status consequential beyond the bedside. Memorial’s doctors had placed DNR patients last in the evacuation order, although a DNR instruction meant not to revive someone whose breathing or heartbeat had stopped; it did not itself mean that the person was terminal or should not be rescued. On one floor, a patient’s daughter asked to cancel her mother’s DNR order after learning that it was affecting evacuation. Staff found a doctor, the patient was moved toward rescue, and she survived that immediate ordeal. The episode exposed how a decision about resuscitation could be treated as a broader judgment about rescue, even though the two were not equivalent.

Unequal Histories and Competing Duties

Among the four DNR patients in the intensive care unit was Jannie Burgess, a Black nurse who had spent decades caring for patients in New Orleans hospitals and nursing homes. Because of racial segregation, she had once been able to care for patients at private hospitals while being unable to receive care there herself; it was more than four decades after Memorial opened as Southern Baptist Hospital before she could be a patient there. Her presence among those assigned last priority gives the evacuation rule a history beyond the crisis itself. The evidence does not establish that race determined the rule’s application, but it places a formally defined medical category alongside a history in which access to care had not been equal.

The dispute over medication also turned on how clinicians understood the obligations of care when ordinary treatment and evacuation were breaking down. Wynn saw comfort, peace, and some remaining dignity as the care still available. Other workers heard rumors that patients were being euthanized; Wynn, whose intensive-care experience included planned withdrawal of life support, did not regard the presence of dying patients or the use of sedatives as sufficient to settle that question. Her perspective differs from an inference that any treatment capable of shortening life must have been intended to cause death. At the same time, her belief that medication would probably hasten death makes clear that foreseeable consequences were part of the decision, not a remote possibility.

Toxicology and the Problem of Proof

The investigation could not resolve intention merely by detecting medication in patients’ remains. Bodies had decomposed in heat for more than a week, making blood samples unavailable and raising questions about whether postmortem drug concentrations reflected the doses given before death. Investigators initially sent tissue samples from eighteen Memorial patients to National Medical Services, Inc.; a laboratory report found morphine in nine and Midazolam in about five or six. In a later review, twenty-three of forty-one analyzed bodies from Memorial and LifeCare Hospitals tested positive for morphine, Midazolam, or both.

Robert Middleberg cautioned that postmortem tissue results required interpretation alongside each patient’s clinical history. The experts examined whether findings might indicate a single large dose or repeated medication, how kidney or liver disease could affect drug accumulation, whether the combination was dangerous for patients not on respirators, and whether the timing of any respiratory or blood-pressure changes corresponded to known times of death. Steven Karch argued that heat and decomposition made reliable cause-of-death determinations impossible. Michael Baden emphasized that the drugs were present shortly before death and that there was no competing cause of death; Cyril Wecht argued that some measured levels were extremely high, while acknowledging that his small experimental comparison of heated and refrigerated samples was not definitive or independently vetted.

The resulting uncertainty is central to the meaning of comfort medication in the book. Morphine and Midazolam could be used to relieve distress in dying patients, and their effects on breathing could be foreseeable; neither fact alone settles whether a particular administration was appropriate or intended to kill. The controversy turns on the difficult gap between clinical purpose, anticipated consequence, and demonstrable cause of death—a gap made wider by the patients’ conditions, the evacuation emergency, and the limits of evidence gathered after prolonged exposure to heat.