Do-not-resuscitate orders

Do-not-resuscitate orders were medical instructions about whether to attempt resuscitation, but at Memorial Medical Center during Hurricane Katrina they took on a second, perilous role: they became a reason to defer evacuation. The order’s narrow purpose—declining resuscitation if a patient’s heart or lungs failed—did not itself mean that the patient should be abandoned or denied rescue. In the heat, darkness, and confusion of the hospital, however, that distinction was not consistently preserved. Patients with DNR orders were assigned the lowest evacuation priority, and families sometimes had no opportunity to correct the consequences until they saw their relatives left behind.

Meaning and Emergency Use

On the morning of August 31, the incident command team planned to gather patients near exits and distribute color-coded armbands. Patients able to walk were to receive green bands, those needing help yellow, those dependent on others for care red, and patients with DNR orders black. The proposed system thus gave DNR status its own visible category, distinct from an assessment of mobility or the assistance a patient needed.

As evacuation preparations continued and official armbands proved difficult to find in sufficient numbers, staff adopted a three-group system for the more than one hundred remaining Memorial and LifeCare patients. Category 1 patients, in fairly good health and able to sit up or walk, would go first. Category 2 patients were sicker and needed more assistance. Category 3 patients, to be evacuated last, included people judged very ill and those with DNR orders. The arrangement made a decision about resuscitation function as a ranking in the rescue queue. It did not establish that every patient with a DNR order was imminently dying, nor did the order itself answer whether that patient could be moved.

The decisions were made by medical professionals, without an established system for explaining the categories to the people most affected by them. In some cases, staff were specifically told not to disclose that DNR status was the reason a patient had not been moved. The result was more than a technical misunderstanding: families who had agreed to limits on resuscitation could find that their decision was being treated as consent to withhold evacuation.

Families Confront the Difference

On the fifth floor of Memorial’s Clara Wing, transporters stopped moving a bed-bound patient after seeing her DNR order. They repeatedly maneuvered other patients around her. Nurses were instructed not to tell her daughter why her mother remained behind. The daughter had previously approved the order after her oxygen-dependent mother was admitted for the storm, reasoning that resuscitation at age ninety-three would not make sense. As the evacuation unfolded, she realized that this was a different decision. She told nurse Michelle Pitre-Ryals that she had not meant for her mother to be left on the floor.

Pitre-Ryals explained that the daughter could request cancellation of the order. The daughter did so, and the patient was moved downstairs, through the parking garage, and toward the helipad. In this instance, correcting the meaning assigned to the DNR order changed the immediate course of events: the patient entered the rescue process rather than remaining behind because of her status.

On LifeCare’s seventh floor, Angela McManus faced a similar barrier. Her frail, seventy-year-old mother, Wilda, also had a DNR order. Angela had expected her mother to be evacuated, but when she heard that patients with DNR orders were being deferred, she asked staff to rescind it. She was told there were no doctors available to do so. Wilda remained upstairs after staff on the second floor said there was no more room and told LifeCare workers to stop bringing patients down.

The order had not been a declaration that Wilda should receive no care. Angela had accepted that her mother should not undergo surgery on backup power and that resuscitation with breathing tubes, electric shocks, or chest compressions would not reverse her chronic underlying problems. But Angela’s decision was not an agreement to preside over her mother’s death or to forgo every chance of survival. Her role, as she understood it, was to see that Wilda remained well cared for. That difference between refusing futile resuscitation and refusing rescue was central to the family’s distress.

Old Instructions, New Circumstances

The crisis also exposed how an order made well before an emergency could be carried into a situation its author had not faced. Vera LeBlanc had requested a DNR order more than a decade earlier so that her heart would not be restarted if it stopped. During the evacuation, she was still alive, lying on a cot near an ATM and a planter in the second-floor lobby, far from the head of the line. Her hospital gown bore the family names and phone numbers Mark and Sandra LeBlanc had written on it after being told she would leave by helicopter. The anticipated flight had not taken her out; her DNR status was among the circumstances keeping her low in the queue.

When Mark and Sandra returned to the patient-care area, a staff member tried to keep them out. Mark threatened to take away the boats they had brought, and the family gained access. Vera was alert enough to demand water. Mark found a five-gallon jug of Kentwood water and gave her a cup, despite the risk that she might choke because she had difficulty swallowing. Her beating heart and insistent voice made the practical stakes visible: the DNR order concerned what to do if her heart stopped, not whether she should be moved while it continued to beat.

Another patient’s case shows that DNR status could coexist with a grave prognosis and complicated judgments about treatment. Tesfalidet Ewale, a sixty-six-year-old Eritrean political asylee, had been designated DNR, a decision his daughter had initially resisted. He had previously been resuscitated, later come off a ventilator, and stabilized with a special oxygen mask, though his medical problems remained severe. After the power failed and vacuum lines stopped working, staff struggled to suction his airways. At Roy Culotta’s direction, Ewale received Ativan and morphine for comfort; after choking on secretions for hours, he was pronounced dead shortly before two on Wednesday afternoon. His death does not make DNR status alone an explanation for what happened. It illustrates how the order, the clinical prognosis, the loss of equipment, and the circumstances of care intersected during the disaster.

Consequences and Significance

The evacuation exposed a category error with immediate human consequences. A DNR order could record a patient’s wish not to undergo resuscitation, or a family’s judgment that resuscitation would not help. At Memorial and LifeCare, the same designation was also used to place patients among those evacuated last. The cases of the Clara Wing patient and Wilda McManus show how little control families could have once this operational rule was applied: one daughter was able to cancel the order and get her mother moved; the other was told no doctor was available, and her mother stayed upstairs.

The distinction mattered to caregivers as well as relatives. Angela McManus accepted that her mother might die and that some interventions would be futile, yet continued to advocate for the care and opportunities for survival still available to her. Karen Wynn, watching the remaining patients in the second-floor lobby, saw DNR patients waiting with prominent tags while other patients lined up for transfer. The designation did not settle what rescue, comfort, or continued care required; under emergency pressure, it could instead become a shortcut that obscured those separate questions.

The book’s account therefore treats DNR orders not as a simple measure of a patient’s worth or a general instruction to stop treatment, but as a limited medical decision whose meaning depended on context and communication. When the hospital translated that decision into evacuation priority without adequately informing families, an instruction about resuscitation risked becoming, in their experience, an instruction not to rescue. The stories of Vera, Wilda, the Clara Wing patient, and Ewale keep the distinction concrete: a standing order, a failing system, a crowded staging area, and a family member’s request could each shape whether a living patient was moved, left waiting, or given another chance to reach safety.