Do Not Resuscitate order

A Do Not Resuscitate order is an instruction about whether to attempt resuscitation if a patient’s heart stops. During the evacuation crisis at Memorial Medical Center, however, the order also became a marker in decisions about who would be rescued first and who would wait. Patients with DNR orders were initially assigned black triage bands and later placed in the final evacuation group alongside patients judged very ill. Families confronted a consequential difference between declining CPR and being treated as a lower priority for evacuation: one patient’s daughter put it plainly, “When I made my mother a DNR, I did not know it meant ‘do not rescue.’ ”

The Order Becomes an Evacuation Category

At an incident-command meeting, staff prepared to move nearly two hundred patients from a hospital threatened by floodwater and power failure. A nurse was sent to retrieve the hospital’s emergency color-coded armbands. Green was for patients able to walk, yellow for those needing assistance, and red for those wholly dependent on others for care. Patients with DNR orders were to receive black bands. The color system thus made the order part of a practical sorting process, not merely a record of a patient’s wishes about resuscitation.

By the following morning, staff had difficulty finding enough official armbands. Doctors and nurses instead categorized the more than one hundred remaining Memorial and LifeCare patients with numbers. Patients in comparatively good health who could sit or walk became “1’s” and were prioritized for evacuation; sicker patients needing more help became “2’s”; and “3’s” were to leave last. The last group included both patients doctors judged very ill and patients with DNR orders, a combination that linked two different considerations: an assessment of medical condition and an advance instruction about resuscitation.

The system was not entirely stable. Patients were sometimes triaged on their wards before being brought downstairs, some were reassessed, and the improvised systems were similar but not identical. A few doctors later recalled using a fourth category to distinguish DNR patients from other seriously ill patients assigned a 3. The accounts show that the order’s practical meaning was shaped by changing local classifications as well as by the formal instruction itself.

Families Discover What DNR Means in Practice

On the fifth floor of Memorial’s Clara Wing, transporters stopped moving a bed-bound patient toward the stairwell after seeing her DNR order. They repeatedly maneuvered other patients around her. Nurses were told not to tell her daughter that the order was the reason. Instead, the daughter was reassured that her mother was not the only patient still on the floor; staff did not tell her that the only other patient there was dead.

That death was James Lafayette’s. The ninety-seven-year-old, who had Alzheimer’s disease, had first come to Memorial’s emergency room before the storm with a cough. After being discharged, he spent two days on the lobby floor before being admitted. When nurse Michelle Pitre-Ryals later found him pulseless, staff gathered with flashlights and attempted a Code Blue, but could not revive him. His death formed the immediate backdrop to the daughter’s discovery that her living mother was being left upstairs.

A man carrying a walkie-talkie then told staff they had to leave the floor. Pitre-Ryals objected because nobody had come for the DNR patient, and the nurses refused to abandon her. She explained to the daughter that the DNR order could be discontinued. The daughter had agreed to it after her ninety-three-year-old, oxygen-dependent mother was admitted for the storm, believing that resuscitation after cardiac arrest would not make sense at her age. In the evacuation emergency, she understood the situation differently: “I didn’t mean for her to be left up here,” she said.

The daughter asked to cancel the order, even telling the nurses, “You people have to get out, and we’re keeping you.” Someone sought a doctor to remove the DNR order. The patient was moved downstairs and into the parking garage, on the way to the helipad and rescue; she survived that immediate ordeal. The episode exposed a practical and ethical distinction that the color bands had obscured: a decision not to restart a heart did not, in the family’s understanding, amount to consent to forgo rescue while the patient was alive.

A Similar Barrier on LifeCare’s Seventh Floor

On LifeCare’s seventh floor, Angela McManus overheard workers discussing the decision to defer evacuation for patients with DNR orders. She expected that her frail seventy-year-old mother, Wilda, would soon be rescued, but learned that her mother’s order put her among those waiting. Angela begged staff to cancel it, saying, “I’ve got to rescind that order.” They told her no doctors were available to do so.

Wilda remained upstairs. Staff in the second-floor staging area told LifeCare workers to stop sending patients down because there was no more room. The sequence left Angela confronting two obstacles at once: she could not find a doctor to change the order, and the downstairs evacuation area had reached its stated capacity. The DNR designation therefore operated amid wider constraints on movement and space, but it had already shaped the expectation that her mother would not be evacuated early.

A different LifeCare patient, Vera LeBlanc, had made her DNR request more than a decade earlier so that her heart would not be restarted if it stopped. It was not a recent decision by a woman understood to be dying: her heart was still beating. After Mark and Sandra LeBlanc had been told Vera would leave by helicopter, they wrote family names and phone numbers on her hospital gown. Instead, she lay near an ATM and a planter in the second-floor lobby, among patients with DNR orders and far from the head of the line. Her demand for water, which Mark fetched for her, was another visible reminder that the people assigned to wait were living patients with immediate needs.

Limits of the Rule and the Meaning of the Contrast

The evacuation experience turned on a slippage between an order about resuscitation and a judgment about rescue. On the fifth floor, the daughter’s request to discontinue her mother’s DNR order changed the path to evacuation; on the seventh floor, Angela could not locate a doctor to make that change, and Wilda remained upstairs. Vera’s order, made years earlier for a specific circumstance, likewise did not mean that her family regarded her as beyond help. These cases make clear why the designation could not be understood by families as a blanket instruction to withhold assistance.

The book also contrasts Memorial’s approach with the response at Charity Hospital. Despite severe conditions, Charity’s leaders did not categorize a group of patients as too ill to rescue; the sickest patients were taken out first rather than last. That contrast does not erase the extraordinary pressures facing Memorial, where staff were improvising triage amid heat, darkness, and a mass evacuation. It does show that putting DNR patients last was not an unavoidable consequence of disaster conditions alone: it was a prioritization choice made within them.

The rule’s significance in the crisis lies in that change of function. A document meant to guide what clinicians should do after cardiac arrest became an evacuation label with consequences before arrest, while patients and families were not consistently told how the label would affect their place in line. In one case, a daughter’s intervention led to an order being canceled and her mother being moved toward rescue. In another, a family’s old instruction remained attached to a mother who was alive but waiting. The difference between “do not resuscitate” and “do not rescue” was not abstract; it determined what families believed they had agreed to, and what they had to fight against.