Do-not-resuscitate (DNR) orders

Do-not-resuscitate (DNR) orders at Memorial Medical Center recorded limits on resuscitation, but they did not answer every question raised by the hospital’s evacuation crisis. The book distinguishes a patient’s wishes about resuscitation from decisions about evacuation priority, continuing care, and medication. As power and medical systems failed, those distinctions became consequential—and later, contested.

Meaning and limits

In Anna Pou’s public explanation after the disaster, a DNR order meant that critically ill patients could be allowed to die naturally rather than receive heroic resuscitation. That description concerned what clinicians should do if a patient’s condition reached the point of requiring resuscitation. It did not, by itself, establish that the patient should receive no care while alive, or that death should be hastened.

The book places DNR status alongside, but not identically with, decisions about palliative care. During an interview, Virginia Rider asked Susan Mulderick whether staff had discussed comfort measures that might also speed dying. Mulderick denied that this was the purpose of her discussions, describing them instead as efforts to make patients comfortable. She cited Ativan as an example of a medication that might relax a patient. The distinction matters in the account: an order limiting resuscitation and a decision to administer comfort medication are separate matters, even when both arise near the end of life.

DNR status during evacuation

As Memorial’s second-floor lobby became a makeshift care area, Karen Wynn saw about a dozen patients designated as “3’s” gathered near an ATM, wearing prominent DNR tags. Other patients waited on stretchers and cots along the lobby and corridor for transfer through an opening into the garage. The scene places DNR labels within the hospital’s practical evacuation arrangements: patients were identified and grouped while staff were still trying to move people through a damaged, increasingly hazardous building. The passage does not establish that DNR status alone determined who would be evacuated or when; it shows the designation operating in a setting where triage and transport decisions were pressing.

Tesfalidet Ewale’s course makes the limits of the label especially clear. He was a sixty-six-year-old Eritrean political asylee with chronic illnesses and a presumed heart infection. A transfer to LifeCare Hospitals had been declined because the company did not accept Medicaid patients, so he remained at Memorial. His daughter had initially resisted his DNR designation. On the Tuesday before his death, a nurse reassured her by phone that Ewale, though drowsy, could be roused and grasp hands, and that he might be flown to a hospital in Atlanta.

Ewale had previously been resuscitated and later came off a ventilator, stabilizing with a special oxygen mask. His physicians, including Roy Culotta, nevertheless considered another resuscitation futile given his grave conditions and poor prognosis. After the power failed and the vacuum lines stopped working, staff could not effectively suction his airways. At Culotta’s direction, Ewale received Ativan and morphine for comfort; after choking on secretions for hours, he was pronounced dead shortly before two o’clock Wednesday afternoon. The sequence shows that the DNR designation existed alongside other clinical judgments and treatment decisions. It does not erase the earlier effort to resuscitate him, his subsequent stabilization, or the expectation communicated to his daughter that he might be evacuated.

Individual wishes and consent

The investigation also examined what particular patients had wanted, rather than treating a DNR order as a complete account of a person’s wishes. Before the storm, a seventy-eight-year-old woman with advanced Parkinson’s disease had been admitted because she depended on electrical equipment. Her physician, Horace Baltz, had given her a DNR order at her request: she did not want extraordinary resuscitation if her heart or respiratory system failed. She was not acutely ill when admitted, and her sister, who was her caregiver, was separated from her at Memorial. The patient died there on Thursday. Her death surprised Baltz, who questioned what had happened and whether she might have been euthanized. Her case underscores the difference between a patient’s stated limits on resuscitation and permission for some other action to cause death.

Virginia Rider’s concern likewise centered on consent. She could understand that a person might choose assistance in dying under some circumstances, but she believed the patients at Memorial had not requested what investigators suspected might have been done to them. In speaking with a doctor who had treated Emmett Everett before the storm, she learned that Everett had wanted treatment, including surgery, to help him recover and return home. His case made individual preference a central issue in evaluating the hospital’s decisions, rather than allowing illness or dependence to stand in for a patient’s own wishes.

Comfort medication and later scrutiny

After the crisis, Pou publicly said staff had done everything in their power to provide the best treatment and make patients comfortable, while explaining that some critically ill patients had DNR orders. That account became part of a wider dispute over the deaths at Memorial. In interviews, Mulderick presented the Thursday medication discussions as an effort to provide comfort, not to accelerate dying. Yet prescriptions seized from the pharmacy showed that Pou and other doctors had already been prescribing Ativan and other ordinary comfort medications for patients during the disaster. Investigators therefore questioned the account that Pou needed another physician to introduce those drugs.

The evidence presented in the book does not make DNR status a synonym for euthanasia, nor does it make a DNR order an explanation for every death. Instead, it shows how the designation entered a chain of separate decisions: whether to attempt resuscitation, how to treat distress, how to allocate evacuation effort, and whether actions reflected each patient’s wishes. The controversy turned in part on keeping those decisions distinct. A DNR order could limit one intervention; it could not, on its own, resolve what care remained due to a living patient or supply consent for actions beyond that limit.