Informed consent and patient autonomy

Informed consent and patient autonomy concern who has authority over medical decisions and what a patient’s stated choices actually mean. The distinction becomes especially consequential in the account of Memorial Medical Center during Hurricane Katrina: a Do Not Resuscitate order, which applied to resuscitation after breathing or heartbeat stopped, was converted by some doctors into a reason to give patients lower priority for evacuation. The narrative sets that emergency decision against the specific wishes of Jannie Burgess, who had clearly refused dialysis and chosen comfort-focused care.

Consent, Refusal, and the Meaning of a DNR

Informed consent is presented as a legal principle established in the United States beginning in the 1950s, in response to historical abuses. It requires doctors to disclose the nature, risks, benefits, and alternatives of proposed interventions, protecting the patient’s role in medical decision-making. A DNR order is narrower than a general refusal of treatment: it directs that a patient whose breathing or heartbeat has stopped should not be revived. It is also distinct from a living will, which under Louisiana law allows a person with a terminal and irreversible condition to request in advance that life-sustaining procedures be withheld or withdrawn.

The distinction matters because a patient’s refusal of one intervention does not by itself establish a wish to refuse other treatment, assistance, or rescue. The account notes that a DNR order is signed by a doctor and is almost always based on informed consent from the patient or a health-care proxy. Consent therefore attaches to a particular medical decision; it cannot simply be enlarged into a general judgment about whether a person would want to be saved.

Jannie Burgess’s Stated Wishes

Jannie Burgess’s hospitalization makes the principle concrete. In early August 2005, severe weakness led to her admission to Memorial Medical Center, where doctors found a bowel blockage and, during surgery, cancer in her liver that could not be removed. She said she did not want to live on machines and received a DNR order. After she developed an infection and her kidneys began to fail, dialysis was identified as the treatment that would be needed to keep her alive if the kidneys stopped working. She said she did not want dialysis under any circumstances.

Her doctor discussed those preferences with Burgess, her sister, and her niece. The goal of care then shifted from treating her medical problems to ensuring her comfort; small doses of morphine were ordered as needed for pain. She was expected to leave intensive care for a regular medical floor when a bed became available. These decisions give her preferences a specific scope: she refused resuscitation and dialysis, while her care plan addressed comfort. The evidence does not present that plan as a request to be denied evacuation.

Burgess’s history also places the question of autonomy within unequal access to care. She had worked for decades as a nurse in New Orleans hospitals and nursing homes, yet, because of racial segregation, could care for patients at many private hospitals without being able to receive care there herself. Memorial opened in 1926 as Southern Baptist Hospital; more than four decades passed before she could be a patient there. Her case thus connects the formal right to make medical choices with the prior question of whether a person has been admitted to institutions that recognize them as a patient.

From Medical Instruction to Evacuation Rule

As floodwaters threatened Memorial, staff faced the evacuation of nearly two hundred patients and feared losing power. Doctors initially discussed moving the sickest patients and those most dependent on life-support equipment first. They then created an exception: all patients with DNR orders would be evacuated last. Four ICU patients were affected, including Burgess and Helen Breckenridge, who depended on battery-powered pumps and hand-assisted breathing during her transfer downstairs. A doctor ordered that Breckenridge be taken back up because she could not go in the first sweep.

Richard Deichmann, the medical chairman, later explained that he believed the law required DNR patients to have a certified terminal or irreversible condition. He considered them to have the least to lose if disaster struck. Another doctor, Bill Armington, thought patients who did not want life prolonged by extraordinary measures would not want to be saved at the expense of others. But the DNR orders and Memorial’s disaster plans did not state that preference. The evacuation rule therefore rested on doctors’ interpretations of what patients might want, rather than on the limited meaning of the orders themselves.

The decision also reflected an emergency system in which written preparedness did not ensure a workable response. Memorial’s committee had rated its readiness for power outages, generator failure, and floods as good, yet the crisis required staff to act quickly before power failed. In that setting, a medical instruction was made to carry a second meaning: it became a sorting rule for access to rescue. The narrative’s contrast is not between consent and urgency as abstract opposites, but between a patient’s particular choices and an institutional inference applied to a whole category of patients.

Authority and Advocacy in the Crisis

The evacuation scenes show that emergency authority was contested as well as compressed. On the helipad, a nurse who was also an Air Force captain told Deichmann she had been trained to run a flight line; he put her in charge, and she cleared the helipad so pilots could land. Later, neonatal nurses refused to let a pilot take their patients to a hospital that had not agreed to receive them. The nursing director insisted that the pilot obtain approval to fly to Baton Rouge before taking the babies. These episodes do not document consent conversations with patients, but they show staff challenging decisions that could affect vulnerable people and insisting on safer conditions for their transfer.

A separate discussion about medication further clarifies why comfort care, patient choice, and hastened death cannot be treated as interchangeable. In an interview, Susan Mulderick said that her discussion of medication had concerned palliative care and comfort, not speeding the dying process. She gave Ativan as an example of a drug to relax patients. Search records, however, showed that Ativan and other ordinary comfort medications had already been prescribed for patients by Anna Pou and other doctors throughout the disaster. The account distinguishes the stated purpose of medication from the separate question of what patients wanted; a prescription alone does not establish a patient’s wishes.

Aftermath and Ethical Significance

The later experiences of staff show that the crisis continued to shape how they understood their actions. Gina Isbell, who had lost her home and community in St. Bernard Parish, described poor sleep, nightmares of patients, and guilt about both the staff she had scheduled and the patients who died. After the grand jury declined to indict Anna Pou, Isbell celebrated with former colleagues, but remained angry that help had arrived too slowly and felt permanently changed by the storm. Karen Wynn, preparing for possible grand-jury testimony, found that discussing events could leave her struggling for weeks to feel well again; she recognized symptoms of post-traumatic stress in herself and colleagues and no longer wanted the responsibility of nursing management.

John Thiele’s later critical illness offers a further, limited contrast in judgments about treatment. After weeks of sedation, he recalled frightening distortions and later said that, despite the severity of his condition, every problem he faced was potentially reversible. He maintained that this mattered: he would have continued treating a patient in his condition, even while acknowledging that recovery was unlikely. The contrast does not resolve what individual patients at Memorial wanted, but it underlines how judgments about prognosis and treatment can depend on distinctions that a broad label cannot capture.

Across these accounts, autonomy is more than a general right invoked at the bedside. It depends on listening to the patient, identifying the precise treatment being accepted or refused, and not turning that decision into an unsupported judgment about the value of further care or rescue. The DNR-last rule exposes the consequences of collapsing those meanings under pressure: a choice intended to limit resuscitation was treated as evidence of a wider choice that the patients’ orders had not made.