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This September marks two years since Hurricane Helene swept through Western North Carolina. When it struck in the fall of 2024, hospice and palliative care teams were forced into roles for which they had never trained. Snowstorms and brief power outages were familiar. A hurricane in the mountains was not. “Hurricane-specific [disaster preparedness]? None,” said Shannon Mullis, RN, a Regional Director of Nursing at Four Seasons Hospice. “Because who would have thought?”
Within hours, typical hospice work gave way to something closer to disaster response. With cell service down and roads washed out, the first priority was locating patients and staff alike. Mullis drove to employees’ homes when she could reach them. Alex Kivett-Kimbro, RN, a Clinical Team Leader at Four Seasons Hospice, searched shelters with handwritten lists. “The most difficult part was just finding people,” he said. “Go knock on a neighbor’s door and ask, ‘Do you know where this person is?'”
Once patients were found, care looked nothing like routine hospice practice. Nurses hitched rides with fire departments, rode bulldozers down washed-out roads, hiked across flooded creeks, and carried backpacks of medications, water, and even dog food for patients’ pets. “We just had what we had on hand,” Kivett-Kimbro said. “There were days when supplies were nonexistent except for what we could find through donations or fire departments.”
Scarcity forced decisions clinicians never expected to make. “I never thought we’d be in a position to ration health care,” Kivett-Kimbro said. “Who gets the generator? Which five patients get medications today?” Even now, those decisions linger. “You question yourself. Should I have done something different?”
For patients, the consequences were profound. While symptom-focused care eventually resumed, many could not die where they wished. Homes were damaged or destroyed. Power was unavailable. Hospital transfers became unavoidable. “That’s what hospice is for — to keep people out of the hospital,” Mullis said. “We didn’t meet goals in that way.” Heather Ball, RN, a Case Manager at Four Seasons Hospice, recalled a 97-year-old woman whose home had been washed away. In her final lucid days, the patient begged to return. “She wasn’t talking about a heavenly home,” Ball said. “She meant her house, the one she’d lived in her entire life. And it wasn’t there.”
The flooding that washed away that home was extraordinary. NOAA reported that the rainfall was so extreme it qualified as a once-in-1,000-year event and that a warming climate made it worse. Reviewing the research, NOAA’s Climate.gov noted that several independent studies, including one by the World Weather Attribution group, reached the same conclusion: climate change made Helene’s rainfall roughly 10% heavier and made a deluge like this far more likely to happen in the first place.
The emotional toll of Helene on clinicians was equally heavy. Long workdays ended not with rest, but darkness. There was no power, no way to debrief. “The biggest challenge was the lack of connection,” Kivett-Kimbro said. “You wake up, work 12 to 14 hours, come home, sit in the dark, and do it all again.” Mullis described balancing professional responsibility with personal uncertainty. “I worried about everyone else before myself,” she said. Ball echoed that tension, recalling how she felt “pulled in every direction” between caring for patients, stranded neighbors, and her own family.
Still, moments of humanity endured. Clinicians described neighbors clearing roads with chainsaws, strangers sharing supplies, and emergency responders carrying patients by hand when vehicles could not pass. Often, the visit itself became the intervention: proof that someone was still trying to reach them over washed-out roads. “[Knowing] you’re not alone,” Ball said. “That’s what mattered most.” One hospice patient, evacuated in a funeral home hearse when no ambulance was available, joked upon arrival to a shelter, “This was just my practice ride.”
Two years on, with storms like Helene expected to grow more frequent and intense, those lessons carry new urgency. For hospice and palliative care professionals, Helene underscores urgent action items: plan for prolonged communication and electronic failure with backup paper systems (including paper prescription pads), create protocols for medication and oxygen scarcity, prepare teams for ethical triage, equip clinicians with practical emergency supplies, and remember that staff will require sustained emotional support long after the headlines fade.
Erik Carlson, MD MPH is a Hospice and Palliative Medicine and Healthcare Leadership Fellow at the Icahn School of Medicine at Mount Sinai and a Climate & Health Science Policy Fellow at the University of Colorado Anschutz School of Medicine. He is a co-founder of Hospice and Palliative Professionals for Planetary Health, an organization whose mission is to educate and mobilize hospice and palliative care professionals to address climate change as a public health emergency.