Standards of care in disasters

Standards of care in disasters are the rules and ethical expectations that shape treatment when ordinary medical resources and systems are overwhelmed. The book presents them not as a technical exception to everyday medicine but as a dispute over what can be changed, who has authority to change it, and whether crisis conditions excuse failures that were foreseeable or actions that intentionally hasten death. The debate spans Memorial Medical Center’s known vulnerabilities, its decision to place patients with do-not-resuscitate orders last in evacuation, and later efforts to give disaster clinicians legal protection.

What Disaster Standards Are Meant to Address

Disaster standards arise from a real problem: when the number of patients and the demand for treatment exceed available resources, clinicians may have to prioritize access, adapt treatment, or decide that some patients cannot receive a scarce intervention. But the fact of scarcity does not itself settle which adaptations are justified. It leaves questions about fairness, consent, clinical evidence, accountability, and the continuing duty to care. The book repeatedly distinguishes resource triage from intentionally hastening a patient’s death: the two can be grouped under emergency decision-making, but they are not ethically equivalent.

The account also insists that emergencies do not begin only when a hospital’s ordinary systems collapse. Before Katrina, Memorial’s plant operations director, Eric Yancovich, had studied storm-surge models and calculated the vulnerability of the hospital’s electrical infrastructure. His handwritten assessment showed that less than four feet of flooding along Magnolia Street could send water over the loading dock, while critical parts of the emergency power distribution system were below ground or only inches to a few feet above it. He warned that not much water would be needed to disable most of the medical center and predicted that patients might have to move to the Clara Wing. The hospital made some protective changes, including adding floodgates and raising a diesel-tank vent, but recommended work on transfer switches and pumps was not funded. The disaster therefore exposed not only the limits of emergency care, but the consequences of entering a known hazard with essential systems still vulnerable.

Memorial: Infrastructure, Triage, and the Meaning of a Label

Memorial’s backup generators were expected to support the hospital for three days, although they were not designed for prolonged operation and were ordinarily tested only briefly. Staff on site were not generator mechanics. As the system failed, workers added water to an overheated engine, hauled diesel, and tried to redirect electrical loads. Floodwater reached the basement and threatened transfer switches and distribution panels; the workers waded in knee-deep water to reach the electrical system. After two hours of attempts, the last generator surged and died at about two in the morning on August 31, nearly forty-eight hours after Katrina made landfall. The failure shows how a disaster standard can become a question of system design and preparation: clinicians’ options were narrowed by interdependent equipment failures and risks identified before the storm.

The hospital’s evacuation decisions made the standards debate more immediate. Doctors established an exception to prioritizing the sickest patients and those dependent on machines: patients with do-not-resuscitate orders would go last. Four DNR patients were in the ICU, including Helen Breckenridge and Jannie Burgess, a Black nurse who had spent decades caring for patients in New Orleans hospitals and nursing homes. The history surrounding Burgess made the label especially charged. Baptist Hospital had been among the last Southern hospitals to integrate; although Burgess could care for patients at private hospitals, she could not be treated in them for decades. A rule presented as a neutral sorting device could therefore operate on people whose access to care had already been shaped by racial exclusion.

A DNR order had a narrower meaning than the evacuation rule implied: it instructed clinicians not to revive a patient whose breathing or heartbeat had stopped. It was distinct from a living will, which could request that life-sustaining treatment be withheld or withdrawn in specified circumstances. Richard Deichmann, the medical chairman who said he thought DNR patients should go last, later explained that he believed the law required them to have a certified terminal or irreversible condition and that they had the least to lose in a catastrophe. The book sets this belief against the order’s actual function and against the danger of treating an end-of-life preference as a measure of likely survival. The Institute of Medicine later stated that DNR orders were not useful parameters for disaster triage because they reflect planning preferences more than an accurate estimate of survival.

Legal Protection and the Limits of Emergency Judgment

After the arrests in the Memorial case, Anna Pou’s lawyer, Rick Simmons, brought the controversy to the American Medical Association. At its annual meeting, he argued that disaster conditions could make ordinary requirements for consent and documentation unavailable, and that doctors acting in good faith needed protection. He invoked World Medical Association guidance allowing clinicians to separate patients considered beyond emergency care from others and sedate them. He also proposed federal review of complaints by doctors rather than lawyers and judges, alongside a victim-compensation fund. The AMA delegates voted to develop model legislation shielding disaster doctors from civil and criminal prosecution and encouraging a standard requiring proof that a doctor acted with malice.

Pou subsequently helped Simmons and state advocates write three Louisiana disaster-immunity bills. She told legislators that firsthand experience put her in a position to help formulate rules for extraordinary circumstances and argued that clinicians using alternate standards should not fear being second-guessed and prosecuted. The bills passed unanimously. They immunized health-care professionals from most civil lawsuits for work conducted in accordance with disaster-medicine protocol, except in cases of willful misconduct, and urged prosecutors to wait for a medical panel’s findings before deciding whether to bring criminal charges. The book underscores a consequential gap: the legislation referred to a protocol that did not yet exist. Pou and Simmons included the language in the hope that one would be created. Legislators publicly thanked Pou for her Katrina service without asking what had happened on September 1, 2005, and Pou had not publicly discussed the events.

Competing Views of Care, Fairness, and Accountability

The Institute of Medicine drew a line that the immunity campaign did not resolve. After consulting disaster experts and emergency responders, it concluded that neither law nor ethics supported intentionally hastening death in a crisis. Its recommendations also emphasized public involvement in developing resource-allocation guidelines and required decisions to be transparent, consistent, proportionate to shortages, and accountable. This framework treats disaster medicine as a reason to plan and explain difficult decisions, not as a blank check for abandoning ordinary ethical limits.

Carl Schultz, an emergency-medicine professor and disaster medical services director, warned that lower standards could appeal to governments and companies because they would reduce pressure to improve disaster response. Once care is lowered, he argued, it can be difficult to know where the reduction should stop; policymakers or clinicians might also carry emergency standards into non-emergency situations where resources are tight. Rear Admiral Ann Knebel offered a different emphasis: the goal, she said, should remain the highest standard of care possible under the circumstances, and planning makes it more likely that resources can be reused, reallocated, and maximized. The book brings these positions together in a practical conclusion: saving more lives may depend less on refining how a fixed number of patients is ranked than on preventing shortages and restoring ordinary conditions quickly. At Memorial, the plan to inject patients went forward just as helicopters arrived in greater numbers and expanded the resources available, making situational awareness and reassessment central to the question of what emergency standards should permit.

The Human Consequences of Crisis Standards

The debate is also traced through the people who carried the decisions afterward. Gina Isbell described insomnia, nightmares in which she saw her patients’ faces, hair loss, guilt about the staff she had selected for the storm, and grief for the patients who died. Even after a grand jury declined to indict Pou, Isbell wore a hurricane pendant and remained angry that help had come too slowly. She believed she and her colleagues had done the best they could and would serve again if asked. Karen Wynn, meanwhile, found that preparing for possible grand-jury testimony made her feel as though she were reliving the crisis; after meetings with her attorney, it could take weeks to feel able to move forward. She recognized what she believed were lasting symptoms of post-traumatic stress among herself and colleagues and no longer wanted the responsibilities of nursing management.

John Thiele’s later critical illness sharpened the book’s examination of judgments about likely survival. While sedated, he experienced terrifying visions of monsters and of being underwater, struggling to surface as someone pushed him down. A nurse who spoke with him believed he was remorseful about the patients he had injected; Thiele later rejected that interpretation and said he remained confident in what he had done. He distinguished his condition from that of some Memorial patients because, despite a very poor prognosis, his problems were potentially reversible. That distinction exposes the limits of prognosis as a shortcut for deciding who should receive care. Across infrastructure, triage, law, and memory, the book’s central warning is that disaster standards cannot be judged only by the pressure clinicians faced: they must also be judged by what was foreseeable, what choices remained, how decisions were made, and whether the people affected were treated as patients still owed care.