Louisiana State Attorney General Charles Foti has charged 3 former healthcare workers at Memorial Hospital in New Orleans with murdering four patients by injecting them with lethal doses of morphine in the days following Hurricane Katrina.
A single doctor, Anna Pou, MD, was accused, as well as two nurses, Lori Budo and Cheri Landry. All three have good professional records, as far as we know.
In the medical community in New Orleans, support has generally swung to Dr. Pou, who is well-known otolaryngologist, or ENT (Ears, Nose, & Throat specialist). Most New Orleans doctors I know reacted with anger when the story broke, indignant that the attorney general would accuse people who risked their lives to care for patients in the aftermath of the storm of unethical behavior. By and large, they feel that this process is simply an attempt to scapegoat medical personnel for the failures of the government and of hospital administrators to get all the patients out on a timely basis.
Certainly the decision to prosecute the three women raises many questions.
When a diver plunges to the bottom of an ocean full of fish and only comes up with three guppies, it makes one wonder. There were a dozen hospitals operating in New Orleans during Katrina, and 34 people died at Memorial. Dozens more died in other facilities. Out of all those deaths, and all those hospitals, it perplexes that a 10-month investigation could only come up with 1 doctor, 2 nurses, and 4 patients. Were the rumors totally overblown? Or was there a widespread problem, and is what we have just a trio of scapegoats?
It is possible that in all those hospitals with all those doctors and patients only three exhibited suspicious behavior, but it gives pause to anyone with common sense. We are supposed to think that all the rest of those deaths are on the up and up. That there is no moral difference between a patient euthanized and one abandoned. That someone who stayed behind to care for patients for 5 days in 110 degree heat, with no electricity and no drugs besides morphine, is morally indistinguishable from Jeffrey Dahmer. That no one else bears any responsibility for what happened. Just these three villains.
There are many things about this accusation that should concern us. For one, Pou is an ENT. Not to insult ENTs – all the ENTs I know are fine doctors – but an ENT is a specialist surgeon and someone who would not typically be expected to care for chronically ill patients in a disaster setting. The unevacuated patients at Memorial should have been under the care of an internist, or a cardiologist, or perhaps even an emergency room specialist. Someone trained to handle general medical problems and emergencies. If you were in a hospital during a hurricane, would you think it appropriate that your pneumonia or heart failure was left to a doctor who does sinus surgeries for a living?
Perhaps if Dr. Pou had been an internist or ICU specialist she would have handled the situation in a different way. There are ways to manage dying patients that lie within the bounds of both law and ethics and nonetheless would have brought the whole thing to the same endpoint without any room for accusation.
How do I put this? She could have finessed it. This may sound like a lawyer’s game, but it is not. In medical ethics, there is a recognized difference between actively killing a patient and allowing him to die. Dr. Pou could have heavily sedated a patient with morphine for the purpose of relieving suffering, and then allowed the underlying disease to run its course.
There nothing ethically objectionable to administering huge doses of morphine to a patient as long as the intent is to relieve pain. Hospice patients die all the time like that. A patient may have terminal cancer, and a doctor will give enough pain medicine to put the patient to sleep. Then the sleeping patient is allowed to expire. Of course, this can only be done if the patient is in pain. But as long as the pain is well documented, there is no absolute limit to the amount of pain medicine the doctor can give.
A doctor well versed in palliative medicine or internal medicine would have understood that. Although some ENTs handle head and neck cancer and trauma patients, it is rare for an ENT to be experienced in acute hospital care or end-of-life issues. It may be that Dr. Pou was out of her depth.
This, however, is just guesswork. Dr. Pou was a medical school professor and a distinguished academic. But it is hard to see why a person of such knowledge and skill would, in her right mind, choose to actively euthanize 4 patients when alternative approaches were possible. That is, unless she was pushed beyond her competency. Euthanasia is prohibited in Louisiana under any circumstances. She had to have known that.
Of course, proving euthanasia will be a very difficult legal task. Charles Foti claims to have autopsy evidence that all four patients received lethal injections of morphine. If he knows a way to prove such a thing medically, it is news to me.
Opioid (morphine) overdose is a hard thing to prove without corroborating evidence. People build up tolerance to opioids just as drinkers grow to tolerate alcohol. A 20 mg dose of morphine could be fatal to someone who has never had it before, but many cancer patients take 1000 mg daily and continue to function. Since all four victims in this case were hospitalized patients, the odds are that some or all of them had received painkillers before. Estimating a lethal dose in such a patient is not a simple thing. One of the patients was allegedly close to 400 pounds. This also does a lot to complicate the picture.
As is often true in medical cases criminal or civil, most of the evidence used against the three accused will come from the medical records. That is, what the defendants wrote about themselves will be the main evidence against them. It does not appear that anyone besides the defendants was in the room when the patients died. Unless there is a statement in the patients’ charts that clearly implies that the patients were to be euthanized, it will be very difficult for a jury to distinguish between willful killing and accidental overdose in an honest attempt to relieve pain.
If Dr. Pou was naïve about end-of-life matters, or if she was deranged by the pressures of Katrina, she may have consciously documented an intent to kill. But every doctor I know (even the dumb ones) know enough to never, ever, record anything in the chart that would suggest that a massive morphine injection was intentional. My impression is that Dr. Pou is pretty smart; I doubt a smoking gun will ever be found.
Though I side with most doctors in their feelings of anxiety and regret that these three would be charged with murder, I am not willing to say that the investigation is a sham. If it is possible to find out what happened, it is imperative that we do so. Much of the mayhem that occurred in New Orleans after the storm, specifically looting and lawless behavior, happened because some people thought that the normal rules of behavior were no longer applicable. I would never put Dr. Pou on the same level as a looter. But re-establishing law and order was crucial in reversing a horrendous situation that awful week, and that process is continuing even now. If the three accused broke the law or any ethical standard, this should be known.
I straddle the fence on many things, but euthanasia is not one of them. There are too many ethical ways to assist patients to an easeful death for euthanasia to be even a consideration in the vast majority of patients. Euthanasia is like a magnetic force that distorts the thinking of everyone in its vicinity. Once it is placed on the table it tends bends our thoughts and concerns, often obscuring viable alternatives that would be considered if euthanasia were not an option. The problem with people who fancy euthanasia is that when they are pushed to the wall, it is the first thing they think of. Given this, I think it is important that if anyone was euthanized, a public statement needs to be made and at least a slap on the wrist issued.
I do not understand, however, why the matter could not have been turned over to the Louisiana State Medical Board. A group of doctors and nurses would have been in the best position to judge if rules of ethics were broken. I dismiss the concern that doctors look after their own and would let Dr. Pou off easily. This case is in the national spotlight, and the Medical Board would have been under tremendous pressure to justify its verdict.
Critics of the medical system often point out that doctors are loath to discipline their own. This would be a golden opportunity for the medical profession to prove it can do the job, and do it right. I am a member of the Louisiana State Medical Society, and I have not heard anyone advocating for the Board to take the public lead in this case. That concerns me. The Medical Board should not be in the cleanup position here. It should be first up.
The sad part about this case is that, whether Pou, Budo, and Landry are convicted or not, the unmistakable message is that all three would have been smarter if they had run away. No one is being prosecuted for abandonment. Why didn’t they run? Obviously, because they felt a sense of responsibility to the patients, a sense that no one else seems to have had. Charles Foti wasn’t on a helicopter evacuating patients that week. Neither was Mayor Ray Nagin, or Governor Blanco, or FEMA Director Michael Brown, or Secretary of Homeland Security Michael Chertoff, or President Bush. It is the great travesty of this situation that the people who are really responsible for the conditions at Methodist are still AWOL, just as they were a year ago.
I think if I were Dr. Pou’s attorney, I would subpoena George W. Bush. His testimony is relevant (how could anyone in charge of the Katrina rescue not target hospitals first?), and I cannot see how the case could be any more of a circus than it already is. Maybe New Orleans can finally get the answers it deserves out of the president.
If these four patients were euthanized, Dr. Pou, Ms. Budo, and Ms. Landry should be disciplined. They should not go to jail, though. Given the extremity of their situation, the fact that Dr. Pou is an ENT and therefore should not have been put in the position of caring for chronically ill patients, given that rescuers were inexcusably slow and that the doctors who should have been in charge had all run off, there is no reason for anyone to be charged with murder. Licenses should be suspended, even revoked, fines levied, but no jail.
As a former member of the New Orleans medical community I confess that we were not prepared for Katrina. Many doctors abandoned patients. Many facilities (including the Lifecare unit at Methodist) did not arrange in advance for appropriate physician coverage. Many hospitals, especially the one I worked at, Chalmette Medical Center, should have been evacuated. There should have been advance planning to ensure every doctor knew who was evacuating and who was staying and that no patient was abandoned. Arrangements should have been made to get medical personnel back to occupied hospitals as soon as the storm winds died down. This did not happen.
In 2004, a catagory 4 storm named Hurricane Ivan grazed the Louisiana coast on its way to a devastating strike on Pensicola, Florida. The near-miss produced a temporary upheaval that should have been a warning to every hospital and doctor in the New Orleans area. At Chalmette Medical Center, the hospital administration complained that too many doctors evacuated, leaving inpatients without responsible physicians. A few rules in the hospital bylaws were tweaked, but nothing comprehensive was done. After Ivan, all hospitals should have set up an emergency plan that would ensure that every patient stranded in the hospital would have a doctor of the appropriate specialty available at all times. Either that, or there needed to be a plan to evacuate everyone. Most hospitals did neither, and that was not Dr. Pou’s fault.
I still have uncomfortable feelings when I reflect that I left. I was in a 3-person medical practice. My two partners told me the day prior to Katrina's landfall that they both intended to stay. Since I had two children under the age of 5, and thought it was foolish for all three of us to stay, I elected to evacuate. At least I arranged coverage for my patients. A lot of people did not.
That is why I would prefer to see Pou, Budo, and Landry dealt with by their professional societies rather than by the law. The professional societies can distinguish between unethical behavior and actions that rise to the level of true crime. The courts cannot; they must render a strict verdict, murder or no murder. Moreover, if we are going to prosecute the people truly responsible for the conditions at Memorial hospital that led to murder, we will have defendants numbering in the hundreds, if not the thousands.