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Special Report: Katrina Deaths
Katrina murder allegations put spotlight on dire situations
Risk manager can learn from extreme example, response to charges
(Editor's note: This month's Healthcare Risk Management includes a special report on the allegations that a doctor and two nurses committed second-degree murder while caring for patients in the aftermath of Hurricane Katrina. In one article , the attorney representing the accused doctor says she is innocent.Another article discusses what risk managers can learn from the case. One article has the statement released by Tenet Healthcare Corp. in which the parent company distances itself from the hospital incident and the accused clinicians. And in another article, a medical ethicist discusses what may have happened at the hospital.)
Murder allegations against a physician and two nurses at a New Orleans hospital have stirred up the health care industry, especially the hospitals and other providers that suffered through the dire conditions after Hurricane Katrina hit in August 2005. Louisiana Attorney General Charles C. Foti, JD, accuses the three clinicians of murdering four critically ill patients in the flooded Memorial Medical Center and has had them arrested on charges of being "principals to second-degree murder." Formal murder charges are being considered.
The decision whether to file criminal charges will be made by the New Orleans district attorney, but Foti made it clear that he believes the three intentionally killed the patients. He also made the distinction that the alleged killings were not "mercy killings."
In a press conference, the attorney general accused Anna Pou, MD, and two nurses, Cheri Landry and Lori Budo, of committing second-degree murder and recommended that the New Orleans district attorney file criminal charges.
"This is homicide, not euthanasia," Foti said. He went on to say that the clinicians injected the four patients with a "lethal cocktail that guaranteed they would die." He did not offer a motive for the alleged killings.
Desperate situation after storm
According to the affidavit released by the state attorney general's office, an investigation after Katrina revealed that four of the patients who died at Memorial Medical Center had morphine and the sedative Versed (midazolam hydrochloride), drugs that those patients were not supposed to have, in their systems. The criminal affidavit filed by the state attorney general alleges that Pou and the nurses went from room to room with a set of syringes and vials, injecting at least four patients with a combination of drugs intended to kill those who could not easily be evacuated from the hospital.
Pou's attorney, Richard T. Simmons, JD, with the firm Hailey McNamara in Metairie, LA, says the doctor did not commit murder but he will not comment on the specific allegations made by the attorney general. The allegations are similar to stories told by other health care providers after Katrina, featured on CNN and in other media outlets. They alleged that some clinicians at Memorial Medical Center debated whether to euthanize seriously ill patients — for the patients' own good but also so that the hospital staff could evacuate without leaving patients behind.
Until the waters receded, the only means of escape were by inflatable boat and helicopter. But not all patients could be removed by those methods. Simmons explains the sickest patients could not be moved by boat, and getting patients to the rooftop helicopter pad required carrying them up to the roof and squeezing them through a 3-foot by 3-foot hole knocked in a wall. The affidavit notes that one of the patients allegedly killed by Pou was 61 years old, weighed 380 pounds, and was paralyzed. Another was 89, with dementia and gangrene.
Some patients already had died while being transported under those conditions, Simmons says.
ASHRM president stresses context
Risk managers must be careful not to jump to conclusions about the Memorial Medical Center deaths, says the president of the American Society for Healthcare Risk Management (ASHRM), Peggy B. Martin, ARM, MEd, CPHRM, DFASHRM, senior risk management coordinator at Lifespan Risk Services in Providence, RI.
Whatever happened with the patients who died, their deaths and actions by clinicians must be considered in context, she says.
"Who knows how terrible it was, except the people who were there?" Martin says. "We do know that it was unbelievable situation. This was not a normal day at the hospital, and we can't judge their actions as if it were."
Martin compares the situation to a battlefield. Clinicians may do things in that situation that they would never do in a safe environment, she says.
Martin says risk managers should monitor this case closely because there are potential lessons for risk managers. It would be a mistake to just write off the Memorial Medical Center incident as a wild aberration, a case so extreme that there is nothing to be learned, she says. The incident can be a lesson about the difficult decisions that clinicians face in triage situations, she says.
"We don't usually do well with the idea of rationing health care or how to triage health care when the resources are limited. It's just not something health care providers like to talk about," she says. "This is an example of how those issues can really come to a head, and it's the clinicians who are forced to make decisions in the heat of the moment."
The New Orleans ordeal should make risk managers reassess how their own organizations are prepared to deal with natural disasters or any other incident that could threaten the hospital or force evacuations. Hurricane Katrina may have been an extreme situation, but the same issues could arise from disasters on a smaller scale, she says. A flu pandemic could produce a similar crisis in hospitals, for example.
Evacuation plans should be a key focus, Martin says. The best way to avoid the ethical and legal dilemmas faced by clinicians who are stranded with patients at the hospital is to make sure they don't get stranded in the first place, she points out.
Give clinicians benefit of doubt
Martin stresses that almost no one knows the facts of what happened at Memorial Medical Center, but she says if the clinicians administered drugs that killed the patients, the questions of liability and criminality may come down to intent. The law has made a distinction in recent years between palliative care that inadvertently hastens death and murder, she notes.
"Unless you know there was an intent to murder, you have to go with the clinical decision that physicians make at the time," she says.
Once criminal charges are brought against health care providers, the risk manager will play a key role for the organization, she says. Issues such as insurance coverage and interpreting policy restrictions will fall on the risk manager, she says. Martin cautions that criminal charges can force risk managers beyond their comfort zone, and cases such as Memorial Medical Center are a good chance to study the issues that will arise.
Use case to teach providers
The New Orleans case may make clinicians worry about their own criminal liability in a crisis, says the immediate past president of ASHRM, Pamela L. Popp, JD, MA, DFASHRM, CPHRM, senior director of claims and litigation at Stanford Hospital and Clinics/Lucile Packard Children's Hospital (SHC/LPCH) Insurance Co., part of the Stanford (CA) Medical Center & Clinics. Popp suggests that the case can be an opportunity to educate clinicians about many legal issues involved in medical care.
"It's a good opportunity to teach them about what criminal allegations mean for the facility, for them personally, for their licensure," she says. "Doing a session on 'what my insurance covers' is not going to get many people's attention unless you can point to something happening in the news and use that to explain these issues."
Popp also suggests using the Memorial Medical Center case to illustrate to providers what serving in a disaster can really be like. Health care providers often are eager to volunteer for service in disaster areas, but Popp says they often have a shallow understanding of what situations they may face. These situations may create not only physical and emotional stress, but also potential legal consequences. Providers should be warned about some of the ethical quandaries they may face, Popp says. "It could be a good idea to bring in an ethicist to discuss what they may face," she says.
It's not just an unprecedented disaster such as Hurricane Katrina that may create ethical issues, Popp says. "The same issues could come up with a flu pandemic or a big earthquake that knocks out all the hospitals," she says. "We should make sure our people are prepared for what they might face."
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