Overview of Unit Care
The Geropsychiatric Unit of Davis North Hospital in Layton, Utah was organized to care for elders with psychiatric distress as their primary and presenting complaint. Most of the patients, being elderly, suffered chronic and acute medical illness. In fact, some that presented with psychiatric symptoms turned out to have more classically "medical" illness as etiology, sometimes life-threatening. The unit also cared for patients with purely psychiatric disease and symptoms, and of course a substantial number of demented patients, most of them agitated to the extent that nursing homes and/or caregivers were overwhelmed, and frequently with multiple chronic and acute medical problems.
Although organized to give primarily psychiatric care, with social workers, OT, recreation therapy, and of course psychiatrists, the unit was in a general hospital, with ICU down the hall, physical therapy, pharmacy, and the lab on call. Generalists such as internists and family practitioners were asked to consult on, perform the history and physical, and follow each patient. Thus, the unit was expected to deal also with any coincident medical diseases. Given that many patients were in their 80’s and 90’s, these were expected, as was admission of psychiatric patients who might conceivably die of geriatric illness during hospitalization.
Robert Weitzel, MD was asked in 1994 to serve as relief psychiatrist to Welby Jensen, MD, the Unit Medical Director, who remained in that position throughout this period. He was later named Associate Medical Director, in 1995, and soon was in charge of most direct patient care, as Dr. Jensen was quite busy as full-time medical director of FHP Psychiatry for Northern Utah. Weitzel received a nominal stipend for administrative duties, but the majority of his income came from physician fees for hospital patient care under Medicare.
The unit functioned with the usual psychiatric multidisciplinary team model, with most patient care decisions being discussed and coordinated in twice-weekly team meetings before implementation. Although the physicians had final authority on medical decisions, staff input was invited and of course all care decisions were known of by the entire team, and by extension the entire hospital: medical staff, pharmacy, nursing administration, etc.
The five patients fall into two groups: four who coincidentally became seriously ill during psychiatric hospitalization: the families then directed that interventions be withdrawn, and they were allowed to die; and one (Ellen A.) who was admitted for psychiatric treatment but almost immediately died, age 91, of pre-hospitalization comorbidity.
In the cases of the first group of four patients, all were admitted with severe dementia: extremely disruptive and dysphoric agitation and aggression. Dr. Weitzel tried to control these symptoms with antipsychotics, mood stabilizers, antidepressants, and anxiolytics. Although occasionally the patients were sedated by assertive treatment, in general the records are replete with evidence that doses were individualized so that side-effects were minimized, and that all psychotropics were definitely indicated, in the face of substantial symptoms which did not resolve at usual geriatric doses. (Much was made of this by the state's lawyers, that higher than starting doses were used, despite the patients already having been on psychotropics of many types before arriving at the unit, and the facts of their inpatient hospitalization status.) It should be noted that these patients were at the end of the line, too symptomatic for their care centers, and that aggressive medication dosing is quite appropriate in the hospital setting.
While being treated, each of these four patients incidentally became acutely and seriously medically ill, for reasons having nothing remotely to do with their psychiatric care or medication:
-Judith Larsen, 93, had seizure disorder, then serious GI bleed with hematochezia, melena, and HCT drop of 25%. Her son specifically requested palliative care rather than further interventions.
-Ennis Alldredge, 82, with IDDM, CAD, S/P CABG, multi-infarct dementia, renal insufficiency, and cancer, suffered a stroke as evidenced by MRI and clinical presentation, and was quite dehydrated and pyuric.
-Seventy-two year old Mary Crane, found to have a recto-vaginal fistula and probable aspiration pneumonia, also suffering from chronic hyponatremia secondary to psychogenic polydipsia (in her dementia she would drink from the toilet, unless restrained) developed sepsis and severe hypernatremia.
-Ninety year old Lydia Smith, with recent weight loss of 30 lbs., CHF, CAD, and history of near fatal previous stroke, apparently suffered another CVA, refused fluids, and then developed acute renal failure, with no urine output, and was nonresponsive and moribund.
Each family was contacted at the appearance of acute medical illness, and given a choice of transfer to ICU for aggressive treatment, or withdrawal of interventions, with comfort care, as nature took its course. The families signed advance directives and/or living wills giving instructions that no interventions were allowed; at this point each patient was effectively terminal. (Physicians note: except in exceptional circumstances, giving care proscribed by advance directives can constitute the crime of assault and battery, and at minimum is a civil action as a medical malpractice). All other medications were stopped and the patients were placed on moderate doses of regularly dosed morphine; 5 to 10 milligrams intramuscularly, initially. (See Merck Manual>>) Nursing also had provision for (and used) prn doses, and conversely, nursing was free to hold doses if they deemed them contraindicated, and at times did so. No patient died immediately, overdosed; they lived for some time after being switched to palliative measures only, later to succumb to their underlying pathology.
Although state lawyers have tried to convince others that Dr. Weitzel somehow mischaracterized the patient's health status to get the families to agree to palliative care, this is 1) untrue, and 2) not relevant. The families had an unequivocal right to order interventions withdrawn, at any time. For instance, they could have ordered that Ennis Alldredge's insulin be discontinued months before; he would at that point have been effectively terminal. Dr. Weitzel told the families that their elder appeared seriously ill when they in fact did have a serious downturn after admission; experts have testified that the patients were terminal even on admission: less than six months to live. In fact, some have suggested that the previous treating physicians were remiss in not discussing the terrible prognosis of the patients with the families; that there should have been previous discussion of these impending decisions, and that Dr. Weitzel got "dumped on" by the nursing home physicians. Be that as it may, though, the families had a choice, and they took it. It is extremely disingenuous to now claim that somehow they were tricked into making the wrong choice.
The fifth patient was an entirely different sort of case. Ellen Anderson was admitted, age 91, with a history of severe osteoporosis and arthritis, with multiple fractures of hip, spine, ankle, etc., and with severe dementia, reportedly "screaming whenever touched" for the past six months. She came in late in the afternoon and was seen briefly and admitted. At 7:30 PM Dr. Weitzel was paged and told by the charge nurse that the patient seemed to be in extreme pain, and strong analgesic was requested. Morphine 10 milligrams IM was ordered (See Merck Manual>>), and the patient did well for the next four hours. At 3:30 AM a different nurse called with the patient again "in severe pain" and a request for analgesia, and another 10 milligrams of IM morphine was ordered and given. Then, after early morning EKG showed sinus tachycardia with marked sinus arrhythmia, and CXR an acute pneumonia, the patient became moribund at about 7:30 AM and died at 8:55 AM. The patient received none of the oral medication she had been ordered on admission, as she refused to swallow. Reflection will convince any physician that morphine had nothing to do with the patient’s death – the timing just does not fit, with death more than five hours after a second dose.
There was no outcry over this medical care, which was known of and understood by the entire team and the hospital medical personnel. The consulting generalists were aware of the patients’ care, the pharmacy gave the psychiatrist advice on dosages (and was certainly aware of every dose of opiate being given), and no complaints were filed by anyone. Of course with a cluster of coincident deaths the hospital held a mortality review, with the chief of medicine, unit medical director, associate medical director (Weitzel), hospital CEO, chief of nursing, unit program manager, and risk management specialist. There was no censure of Weitzel: the care was not faulted, but it was decided to take steps to guard against admitting severely medically ill patients, if possible, as they were difficult for the psychiatric nurses, and frequently couldn’t avail themselves of the special psychiatric care (group, etc.) provided there. It was also agreed that those patients in need of palliative care would be transferred to hospice in the future, so that the resources specific for geropsychiatry would not go to waste. Dr. Weitzel continued to work at Davis Hospital for years in good standing, until murder investigations and his arrest intervened.
Please go now to individual patients for a brief presentation of previous
medical history and hospital course, or go directly to the charts. The medical charts have had their type colored to alert readers to
symptoms of agitation, necessitating psychotropic
sedation, signs of impending terminal status,
and evidence of pain.