Do-not-resuscitate (DNR) status

Do-not-resuscitate (DNR) status is an instruction not to attempt resuscitation if a patient’s breathing or heartbeat stops. At Memorial Medical Center during the Katrina crisis, that narrow clinical instruction acquired a much broader practical consequence: doctors placed DNR patients last in the evacuation order. The resulting confusion exposed a consequential difference between declining resuscitation and declining rescue, and between a patient’s expressed wishes and assumptions made on that patient’s behalf.

Definition and Limits

A DNR order was signed by a doctor, usually with the informed consent of a patient or health-care proxy. Informed consent, established in the United States beginning in the 1950s, was intended to protect patient autonomy against a history of medical abuses. It required doctors to disclose the nature, risks, benefits, and alternatives of proposed interventions so that patients or their proxies could make decisions with relevant information.

The order itself had a specific scope: if a patient’s breathing or heartbeat stopped, the patient should not be revived. It was distinct from a living will. Under Louisiana law, a living will allowed a patient with a terminal and irreversible condition to request in advance that life-sustaining procedures be withheld or withdrawn. Treating these documents as interchangeable obscured the difference between refusing a particular intervention and asking not to be evacuated or cared for.

Jannie Burgess’s Wishes

Jannie Burgess’s hospitalization shows that DNR status could follow considered, personal choices about treatment. She had previously undergone surgery and chemotherapy for uterine cancer; after a period of recovery, she was admitted to Memorial Medical Center in early August 2005 with severe weakness. Doctors found a bowel blockage, and surgery revealed cancer in her liver that could not be removed. Burgess said she did not want to live on machines, and her doctor wrote a DNR order.

After she developed an infection and her kidneys began to fail, doctors discussed dialysis with Burgess, her sister, and a niece who was close to her. Burgess rejected dialysis under any circumstances. Her care then shifted from treating her medical problems toward ensuring her comfort, with small doses of morphine ordered as needed for pain. She was expected to move from intensive care to a regular medical floor when a bed became available. These preferences addressed particular treatments and the goals of her care; they did not, on the evidence given, amount to a request to be excluded from evacuation.

Her situation also carried a history of unequal access to care. Burgess, a Black nurse who had worked in New Orleans hospitals and nursing homes for thirty-five years, had been able to care for patients at private hospitals where she could not herself receive treatment. More than four decades passed after Memorial Medical Center opened as Southern Baptist Hospital before she could be a patient there. In the crisis, the meaning assigned to her DNR order would again affect the care available to her, this time through the evacuation system.

The Evacuation Rule

As floodwaters threatened the hospital, staff understood that patients needed to be moved quickly, before power failed. The initial proposal was to evacuate those most dependent on life support or mechanical aids first, including intensive-care patients, newborns, high-risk pregnant patients, and dialysis patients. Doctors later established an exception: all patients with DNR orders would be evacuated last. Four intensive-care patients fell into that category, including Burgess and Helen Breckenridge.

Richard Deichmann, Memorial Medical Center’s medical chairman, later explained that he had understood the law to require DNR patients to have a certified terminal or irreversible condition. He believed they should go last because they would have the least to lose if disaster struck. Other doctors agreed. Bill Armington reasoned that patients who did not want their lives prolonged by extraordinary measures would not want to be saved at the expense of others. But neither the DNR orders nor the hospital’s disaster plans said that such patients should be placed last. The rule thus rested on clinicians’ interpretation of patients’ wishes, not on an evacuation instruction in the orders themselves.

Karen Wynn learned of the decision from Ewing Cook and Roy Culotta and passed it to Susan Mulderick. The priority was also conveyed to the staff moving Breckenridge: the most salvageable patients had to go first. Breckenridge had been brought downstairs for evacuation, but was sent back to the intensive-care unit under the rule. Staff restored her ventilator and other support, but she soon died. The account describes her death as perhaps imminent, while also recording that it appeared to be the first in the hospital hastened by Katrina. Her case made the practical stakes of the policy visible: an order about what to do after cardiac or respiratory arrest had influenced whether a patient could leave the hospital.

Rescue and Consent

The distinction between DNR status and a decision not to rescue became explicit when transporters stopped moving another patient after seeing her DNR order. Her daughter had approved the order when her ninety-three-year-old, oxygen-dependent mother was admitted for the storm, believing that resuscitation after cardiac arrest would not make sense. When staff were told to leave the floor without taking her mother, the daughter understood the situation differently. She asked for the DNR order to be canceled and said she had not meant for her mother to be left behind.

A doctor was sought to remove the order. The patient was then moved downstairs toward the helipad and rescue, and survived the immediate ordeal. The episode showed that consent to a DNR order was not necessarily consent to the evacuation policy attached to it. Once the daughter understood that the order was being treated as a reason not to rescue her mother, she withdrew it; the patient’s status changed, and so did her place in the evacuation process.

On LifeCare’s seventh floor, Angela McManus likewise tried to rescind the DNR order for her frail seventy-year-old mother, Wilda, after learning that DNR patients were being deferred. Staff told Angela that no doctors were available to make the change. The contrast with the other patient’s case was stark: a proxy could seek to reverse an order when its consequences became clear, but access to a doctor determined whether that request could take effect in time to alter the patient’s situation.

Consequences and Significance

The evacuation rule transformed a medical instruction into a ranking of whose rescue could wait. Its defenders’ reasoning relied on assumptions about what patients with DNR orders would want in a disaster, although those orders did not establish such preferences. The cases show why the distinction matters: Burgess’s refusal of dialysis and mechanical prolongation informed her goals of care, while another patient’s daughter said she had agreed to a DNR order without understanding it as a decision against rescue.

The crisis also placed nurses between institutional decisions and patients or families confronting their consequences. Wynn communicated the rule to Mulderick; other nurses faced patients left waiting, relatives seeking to change orders, and instructions to leave. Later, Wynn described the emotional cost of discussing the events during preparation for possible grand-jury testimony, while Gina Isbell continued to experience nightmares about her patients and anger at how slowly help had come. Those accounts do not make every later injury a consequence of DNR status alone, but they locate the policy within a wider evacuation emergency that staff continued to revisit after leaving the hospital.

DNR status was meant to record a limit on resuscitation, not to declare a life unworthy of rescue. At Memorial Medical Center, the decision to put DNR patients last blurred that boundary. The resulting cases reveal how a seemingly precise medical classification can change meaning when applied as a disaster rule—and how easily a patient’s limited treatment choice can be expanded into a decision the patient or proxy never made.