Bradford Hare, MD
5 MR. WILSON: WE'D CALL DR. HARE TO THE STAND AT THIS
6 TIME, YOUR HONOR.
7 THE COURT: WAIT TILL THE JURY COMES IN.
8 MR. WILSON: OH.
9 THE COURT: IF YOU CAN WAIT RIGHT THERE, DOCTOR, FOR
10 JUST A MOMENT.
11 MS. BARLOW: WE DO NEED THE JURY.
12 MR. WILSON: YEAH, I GUESS SO.
13 (JURY ENTERS THE COURTROOM.)
14 THE COURT: RECORD SHOULD SHOW THAT THE JURY IS BACK
15 IN THE JURY BOX, PARTIES AND COUNSEL PRESENT.
16 DR. HARE, WOULD YOU STEP UP, PLEASE? IF YOU'LL COME
17 RIGHT UP HERE, RAISE YOUR RIGHT HAND, PLEASE, AND FACE THE
18 CLERK?
19 BRADFORD D. HARE,
20 BEING FIRST DULY SWORN, WAS EXAMINED AND
21 TESTIFIED AS FOLLOWS:
22 THE COURT: HAVE A SEAT HERE, PLEASE. GIVE US YOUR
23 FULL NAME AND SPELL YOUR LAST NAME FOR US.
24 THE DEFENDANT: OKAY. MY NAME IS BRADFORD D. HARE,
25 H-A-R-E.
1 DIRECT EXAMINATION
2 BY MR. WILSON:
3 Q. DR. HARE, WOULD -- WHERE ARE YOU CURRENTLY EMPLOYED?
4 A. I'M ON THE FACULTY AT THE UNIVERSITY OF UTAH, DEPARTMENT
5 OF ANESTHESIOLOGY.
6 Q. AND DO YOU HOLD A MEDICAL DEGREE?
7 A. YES, I DO.
8 Q. CAN YOU GIVE US A LITTLE BIT OF BACKGROUND INFORMATION
9 RELATIVE TO YOUR EDUCATIONAL BACKGROUND?
10 A. YES. I'LL -- I GUESS I'LL TRY TO KEEP IT BRIEF. I HAVE
11 A BACHELOR'S DEGREE IN PHARMACY, I HAVE A PH.D. IN
12 PHARMACOLOGY, AN M.D. DEGREE, AND THEN SUBSEQUENT TRAINING IN
13 ANESTHESIOLOGY, AND THEN FELLOWSHIP TRAINING IN PAIN
14 MANAGEMENT.
15 Q. OKAY. DO YOU HOLD ANY BOARD CERTIFICATION IN THOSE
16 SPECIALTIES?
17 A. YES, I DO. I'M -- I'M BOARD CERTIFIED IN ANESTHESIOLOGY,
18 AND THEN SUBSPECIALTY CERTIFIED IN PAIN MANAGEMENT.
19 Q. OKAY. AND WHEN DID THAT OCCUR?
20 A. MY BOARD CERTIFICATION IN ANESTHESIOLOGY WAS IN 1979, AND
21 IN PAIN MANAGEMENT IN 1993, THE FIRST YEAR THAT WAS
22 AVAILABLE.
23 Q. OKAY. SO HOW LONG HAVE YOU BEEN PRACTICING IN THE
24 MEDICAL ARENA?
25 A. I'VE ACTUALLY BEEN IN PRACTICE SINCE 1979, SO 23 YEARS.
1 Q. OKAY. AND YOU SAY YOU -- YOU CURRENTLY HOLD A TEACHING
2 POSITION AT THE UNIVERSITY OF UTAH?
3 A. YES, I DO. IT'S A -- A TENURED FACULTY POSITION.
4 Q. OKAY. AND IN RESPECT TO THE -- WHAT OTHER AREAS DO YOU
5 ACTIVELY INVOLVE YOURSELF IN OTHER THAN AS A FACULTY MEMBER?
6 A. I'M -- CLINICALLY I SPEND THE MAJORITY OF MY TIME AT THE
7 PAIN MANAGEMENT CENTER AT THE UNIVERSITY OF UTAH, AND I'M THE
8 SENIOR MEMBER OF THE STAFF THERE. I ALSO WORK IN THE
9 OPERATING ROOM DOING CLINICAL ANESTHESIA, BOTH IN A CARE
10 DELIVERY AND A TEACHING CAPACITY.
11 Q. RELATIVE TO YOUR PROFESSIONAL EXPERIENCE AS AN
12 ANESTHESIOLOGIST, I ASSUME THAT YOU PARTICIPATE IN SURGERIES;
13 IS THAT CORRECT?
14 A. YES, I DO.
15 Q. AND YOU ALSO -- YOU SAY IN -- IN THE PAIN MANAGEMENT AREA
16 PARTICIPATE IN ASSISTING PEOPLE WITH PAIN PROBLEMS, I ASSUME?
17 A. I DO.
18 Q. OKAY. DO THEY RUN THE FULL PARAMETERS RELATIVE TO TYPES
19 OF CONDITIONS?
20 A. YES. WE, IN THE HOSPITAL, WORK WITH PATIENTS WITH ACUTE
21 PAIN OR SHORT-TERM PAIN -- FOR INSTANCE, AFTER SURGERY OR
22 TRAUMA. THEN AT THE PAIN MANAGEMENT CENTER I'M WORKING WITH
23 PEOPLE WITH LONG-STANDING CHRONIC PAIN PROBLEMS, EITHER FROM
24 CANCER, FOR INSTANCE, OR OTHER LONG-TERM PAINFUL CONDITIONS.
25 Q. OKAY. AND DO YOU HAVE ANY EXPERIENCE WITH GERIATRIC
1 PATIENTS?
2 A. A LARGE PERCENTAGE OF MY PATIENTS IN BOTH SETTINGS ARE
3 GERIATRIC PATIENTS.
4 Q. OKAY. CAN YOU TELL US, DOCTOR, RELATIVE TO YOUR TEACHING
5 EXPERIENCE, HOW LONG HAVE YOU BEEN TEACHING?
6 A. AGAIN, AS LONG AS I'VE BEEN ON THE FACULTY, SO 23 YEARS.
7 Q. OKAY. DO YOU -- ARE YOU -- DO YOU -- HAVE YOU ISSUED --
8 EXCUSE ME. HAVE YOU BEEN PUBLISHED ON ANY ARTICLES?
9 A. YES, I HAVE.
10 Q. OKAY. AND RATHER THAN ENUMERATE THEM, ARE THERE -- ARE
11 THESE ARTICLES DEALING WITH PAIN SPECIALTIES?
12 A. A NUMBER OF THEM ARE, YES.
13 Q. OKAY. DO YOU MAKE ORAL PRESENTATIONS FROM TIME TO TIME?
14 A. I DO.
15 Q. OKAY. HAVE YOU TESTIFIED IN COURT BEFORE?
16 A. I HAVE.
17 Q. AND ON HOW MANY OCCASIONS WOULD YOU SAY THAT YOU'VE
18 TESTIFIED IN COURT?
19 A. A RELATIVELY -- A RELATIVE SMALL NUMBER. I'M THINKING
20 OVER THE YEARS PROBABLY LESS THAN A DOZEN.
21 Q. HAVE YOU TESTIFIED IN OTHER TYPES OF PROCEEDINGS?
22 A. YES, I HAVE.
23 Q. OKAY. NOW, I'M GOING TO CALL YOUR ATTENTION -- AND I
24 WANT TO FOCUS YOU ON, IN PARTICULAR, PAIN MANAGEMENT, IF YOU
25 WOULD, PLEASE. AND YOU SAY YOU HAVE A BACKGROUND IN
1 PHARMACOLOGY. WHAT IS PHARMACOLOGY?
2 A. PHARMACOLOGY IS THE STUDY OF HOW MEDICATIONS WORK,
3 EXACTLY HOW THEY AFFECT THE BODY, HOW -- WHAT SYSTEMS IN THE
4 BODY ARE AFFECTED, SO ON AND SO FORTH.
5 Q. OKAY. DO YOU USE THAT EXPERTISE IN THAT AREA IN YOUR
6 WORK?
7 A. I DO. I MEAN, IT'S QUITE VALUABLE BOTH IN TREATMENT OF
8 PAIN AND IN ANESTHESIOLOGY.
9 Q. OKAY. IF I MIGHT, YOU'RE FAMILIAR WITH WHAT'S DESCRIBED
10 AS CENTRAL NERVOUS SYSTEM DEPRESSANT MEDICATIONS?
11 A. YES, I AM.
12 Q. AND IN PARTICULAR, ALSO OPIOID BASED MEDICATIONS?
13 A. YES -- YES, I AM.
14 Q. OKAY. ARE ALL CENTRAL NERVOUS SYSTEM DEPRESSANTS OPIOID
15 BASED?
16 A. NO, THEY AREN'T. THAT WOULD BE JUST ONE -- ONE SUBCLASS,
17 ONE --
18 Q. OKAY.
19 A. -- PARTICULAR TYPE.
20 Q. IN CONNECTION WITH THESE PROCEEDINGS, DOCTOR, DID YOU
21 PREPARE SOME CHARTS RELATIVE TO CENTRAL NERVOUS SYSTEM
22 DEPRESSANTS?
23 A. YES, I DID.
24 Q. I'M GOING TO HAVE YOU TAKE A LOOK AT WHAT'S BEEN MARKED
25 AS STATE'S EXHIBIT 11 AND ASK IF YOU CAN IDENTIFY THAT
1 PARTICULAR CHART, IF YOU WOULD, PLEASE?
2 A. YES. THAT'S A CHART I HELPED PREPARE.
3 Q. OKAY. CAN YOU IDENTIFY WHAT THIS CHART IS ABOUT FOR US?
4 A. YES. WHAT I HOPED TO DEMONSTRATE ON THIS PARTICULAR
5 CHART WERE THE IMMEDIATE EFFECTS OF -- OF SOME OF THE
6 SO-CALLED CENTRAL NERVOUS DEPRESSANT MEDICATIONS, AND THEN
7 SOME OF THE THINGS THAT CAN RESULT IN TERMS OF LONG-TERM
8 EFFECTS ON THE BODY, YOU KNOW, FROM THE EFFECTS OF THESE
9 MEDICATIONS.
10 Q. OKAY. BEFORE WE -- BEFORE WE START TALKING ABOUT THAT,
11 CAN YOU TELL US, ARE THERE CERTAIN PSYCHOTROPIC MEDICATIONS
12 THAT YOU'RE ACQUAINTED WITH THAT HAVE CENTRAL NERVOUS SYSTEM
13 DEPRESSANT QUALITIES?
14 A. YES, QUITE A FEW OF THEM WOULD. ANY OF THE MEDICINES WE
15 REFER TO AS SEDATIVES, ANTIDEPRESSANT -- WELL, CERTAIN OF THE
16 ANTIDEPRESSANT MEDICINES, CERTAIN OF THE SLEEP MEDICATIONS,
17 MEDICATIONS THAT ARE SOMETIMES USED FOR SEIZURES, AND FOR --
18 SOMETIMES FOR THEIR PSYCHOTROPIC EFFECTS. MANY OF THOSE
19 WOULD BE CLASSIFIED AS DEPRESSANTS OF THE NERVOUS SYSTEM.
20 Q. OKAY. CAN YOU TELL ME IN -- IN RESPECT TO THE MATTER
21 THAT WE HAVE HERE BEFORE THE COURT RELATIVE TO CENTRAL
22 NERVOUS SYSTEM DEPRESSANTS, ARE A NUMBER OF THE MEDICATIONS
23 THAT WERE PROVIDED TO THE FIVE PATIENTS THAT WE'RE HERE
24 ABOUT, WERE THEY OF A CENTRAL NERVOUS SYSTEM DEPRESSANT
25 VARIETY?
1 A. YES, THEY ARE.
2 Q. OKAY. NOW, IF -- IF YOU WOULD, PLEASE, CAN YOU DESCRIBE
3 FOR US IN TERMS OF THESE DEPRESSANTS, YOU'VE GOT ON THE ONE
4 SIDE OF THE BOARD THE IMMEDIATE EFFECTS. CAN YOU -- CAN YOU
5 EXPLAIN WHAT YOU'RE -- WHAT YOU HAVE ON THAT BOARD FOR US
6 UNDER IMMEDIATE EFFECTS?
7 A. YES. THE IMMEDIATE EFFECTS -- PROBABLY THE MOST OBVIOUS
8 EFFECTS OF THE CENTRAL NERVOUS SYSTEM DEPRESSANTS IS THAT
9 THEY'LL MAKE PATIENTS DROWSY, MAKE THEM SLEEPY, AND WITH
10 ENOUGH OF THE MEDICATION, YOU KNOW, CAN ACTUALLY PUT THEM
11 INTO AN UNRESPONSIVE OR COMA-TYPE STATE.
12 Q. WHAT -- WHAT DOES THE NEXT -- THE DECREASED BREATHING AND
13 ASPIRATION? WHAT --
14 A. WITH THESE MEDICATIONS, IF THE NERVOUS SYSTEM'S DEPRESSED
15 ENOUGH, SOMEBODY BECOMES SLEEPY ENOUGH, THEY DON'T BREATHE AS
16 DEEPLY ANYMORE AND THEY LOSE THE ABILITY TO WHAT WE CALL
17 GUARD THEIR AIRWAY. NORMALLY, IF YOU SWALLOW, THERE'S
18 REFLEXES THAT PREVENT THE FOOD OR WATER FROM GOING DOWN THE
19 WRONG PIPE. WITH THESE MEDICINES, IN SUFFICIENT AMOUNTS
20 THOSE KINDS OF REFLEXES ARE SUPPRESSED, AND AS A RESULT,
21 THERE'S A TENDENCY FOR SECRETIONS, FOOD, OTHER THINGS TO GO
22 DOWN INTO THE LUNGS INSTEAD OF DOWN INTO THE STOMACH.
23 Q. OKAY. WHAT ABOUT DECREASED BLOOD PRESSURE? WHAT --
24 WHAT -- IS THAT A -- AN EFFECT OF THESE DEPRESSANTS IN THE
25 SYSTEM?
1 A. IT CERTAINLY CAN BE, AND AGAIN, AT -- AT DOSES THAT ARE
2 HIGH ENOUGH TO MAKE A PATIENT REALLY SLEEPY OR UNRESPONSIVE,
3 THE EXPECTED EFFECT WOULD BE TO LOWER BLOOD PRESSURE.
4 Q. AND THE LAST ONE YOU'VE GOT DOWN THERE IS DECREASED FOOD
5 AND -- AND WATER INTAKE. HOW IS THAT APPLICABLE TO A CENTRAL
6 NERVOUS SYSTEM DEPRESSANT?
7 A. IF A PATIENT IS SLEEPY ENOUGH, THEY JUST DON'T EAT OR
8 DRINK. AND, YOU KNOW, THAT I MEAN AGAIN IS JUST A RESULT OF
9 THAT TYPE OF MEDICINE.
10 Q. OKAY. ARE THESE ALL RISKS RELATED TO CENTRAL NERVOUS
11 SYSTEM DEPRESSANTS?
12 A. WELL, THEY'RE CERTAINLY -- I MEAN, YEAH, I WOULD SAY
13 THEY'RE RISKS. AND ANY TIME WE USE THESE MEDICINES THERE
14 ARE -- THERE ARE THINGS WE HAVE TO WATCH OUT FOR.
15 Q. OKAY.
16 A. BE CAREFUL OF.
17 Q. NOW, ON THE RIGHT SIDE OF THE BOARD YOU'VE GOT THE
18 LONG-TERM EFFECTS AS IT RELATE TO THE CENTRAL NERVOUS SYSTEM
19 DEPRESSANTS; IS THAT CORRECT?
20 A. YES, IT IS.
21 Q. AND CAN YOU EXPLAIN TO US WHAT -- WHAT YOU'RE TALKING
22 ABOUT THERE ON THAT RIGHT SIDE?
23 A. THIS MAY NOT BE ENTIRELY CLEAR, BUT WHAT I HOPED TO
24 DEMONSTRATE WITH THAT THAT IF A PATIENT RECEIVES A LARGE
25 AMOUNT OF A CENTRAL NERVOUS SYSTEM DEPRESSANT, THEY BECOME
1 UNRESPONSIVE OR COMATOSE, THEY HAVE DECREASED BREATHING,
2 DECREASED BLOOD PRESSURE. THEN THE RESULT OF THAT IS THAT
3 THERE'S LESS OXYGEN THAT GOES TO THE VITAL ORGANS LIKE THE
4 BRAIN, THE HEART, KIDNEYS, AND THESE ORGANS EITHER BEGIN TO
5 FUNCTION NOT AS WELL AS THEY NORMALLY DO, OR THEY CAN BECOME
6 DAMAGED.
7 Q. I SEE.
8 A. SO IT'S A --
9 Q. IS THERE A CERTAIN LENGTH OF TIME RELATIVE TO THAT
10 PROCESS IN ORDER TO DAMAGE AN ORGAN?
11 A. WELL, IF A LARGE DOSE OF ONE OF THESE MEDICINES IS GIVEN,
12 THE EFFECT OF IT IS TO DRAMATICALLY EFFECT SOMEBODY'S
13 CONSCIOUSNESS, THEIR BREATHING AND SO ON. ONCE THAT EFFECT
14 IS PRESENT THEN -- THEN ORGAN DAMAGE COULD BEGIN TO OCCUR. I
15 MEAN, OBVIOUSLY THESE MEDICINES IN LESSER DOSES CAN BE USED
16 OVER A LONG PERIOD OF TIME, NOT COMPROMISE BLOOD PRESSURE,
17 NOT COMPROMISE OXYGEN AND SO ON, AND NOT -- NOT CAUSE THIS
18 SORT OF DAMAGE. BUT IN THE MORE EXTREME SITUATIONS THEY --
19 THEY CERTAINLY CAN LEAD TO THIS TYPE OF PERMANENT DAMAGE.
20 Q. AND IF THERE IS DAMAGE, IS THAT REVERSIBLE?
21 A. IT COULD BE. DEPENDS ON THE DEGREE OF DAMAGE. SOME
22 MIGHT BE REVERSIBLE, BUT SOME MIGHT NOT BE.
23 Q. NOW, YOU GOT DEHYDRATION LISTED THERE AS A LONG-TERM
24 EFFECT. CAN YOU EXPLAIN THAT FOR US, IF YOU WOULD, PLEASE?
25 A. DOWN AT THE BOTTOM UNDER THE IMMEDIATE EFFECTS, I JUST
1 MENTION THAT PATIENTS MAY NOT EAT OR DRINK AS MUCH WHEN
2 TAKING THESE MEDICINES, ESPECIALLY IF THEY'RE AT HIGHER
3 DOSES. AND THE RESULT WOULD BE DEHYDRATION, MALNUTRITION.
4 AND AS A RESULT THAT, AGAIN, CAN AFFECT BLOOD PRESSURE, IT
5 CAN AFFECT THEIR SENSITIVITY TO OTHER MEDICINES. A
6 DEHYDRATED PATIENT IS GOING TO BE MORE SENSITIVE TO THESE
7 MEDICINES. SO THEN IT BECOMES KIND OF A VICIOUS CYCLE.
8 Q. OKAY. NOW, I'M GOING TO SHOW YOU WHAT'S BEEN MARKED AS
9 PLAINTIFF'S -- STATE'S EXHIBIT NUMBER 12 AND ASK YOU TO TAKE
10 A LOOK AT THAT ONE, IF WOULD YOU, PLEASE. CAN YOU TELL US
11 WHAT THAT EXHIBIT IS ABOUT?
12 A. THIS IS A SIMILAR CHART SHOWING THE EFFECTS OF MORPHINE.
13 AND ACTUALLY IT'S, YOU KNOW, SOME OVERLAP WITH THE PREVIOUS
14 ONE. BUT THIS SHOWS MORE SPECIFIC THINGS WITH THE EFFECTS OF
15 THE DRUG OF MORPHINE, AGAIN, THE IMMEDIATE EFFECTS AND THE
16 LONG-TERM EFFECTS.
17 Q. RELATIVE TO THE IMMEDIATE EFFECTS, HOW DOES IT DIFFER
18 FROM THE OTHER CHART AS TO THE OTHER CENTRAL NERVOUS SYSTEM
19 DEPRESSANTS?
20 A. WELL, THE MAIN REASON WE WOULD USE MORPHINE IN CLINICAL
21 PRACTICE WOULD BE FOR ITS PAIN-RELIEVING EFFECT. OTHER
22 CENTRAL NERVOUS SYSTEM DEPRESSANTS, OR AT LEAST IN GENERAL,
23 MOST OF THEM DON'T HAVE ANY PAIN RELIEVING EFFECTS. SO
24 THAT'S THE -- THE SPECIFIC BENEFIT OF -- OF A DRUG LIKE
25 MORPHINE.
1 Q. OKAY.
2 A. SO PAIN RELIEF IS -- IS ONE OF THE IMMEDIATE EFFECTS THAT
3 SETS IT ASIDE FROM THE OTHERS.
4 Q. NOW, I NOTICED ON THE LONG-TERM EFFECTS YOU'VE -- YOU'VE
5 LISTED PNEUMONIA. IT'S A LITTLE BIT DIFFERENT THAN WHAT
6 WE'VE SEEN ON THE OTHER -- OTHER CHART. CAN YOU EXPLAIN THAT
7 FOR US, IF YOU WOULD, PLEASE?
8 A. WELL, ONE OF THE SPECIFIC EFFECTS OF THE MORPHINE-TYPE
9 DRUGS IS TO SUPPRESS COUGHING. AND THIS IS A REASON THAT
10 CODEINE AND OTHER MEDICINES SUCH AS THAT ARE INCLUDED IN
11 COUGH SYRUP.
12 AND SO, AGAIN, AT HIGHER DOSES WHEN THE PATIENT'S
13 SIGNIFICANTLY AFFECTED, THEY'RE MADE REALLY SLEEPY BY
14 MORPHINE. OR EVEN AT, YOU KNOW, SOMETIMES AT THERAPEUTIC
15 DOSES, THE COUGH REFLEX IS SUPPRESSED AND THE PATIENT ISN'T
16 GOING TO CLEAR SECRETIONS. THE LUNGS ARE GOING TO HAVE MORE
17 OF A TENDENCY TO GET CONGESTED AND PNEUMONIA CAN OCCUR.
18 Q. IS THERE A RISK OF DEATH ASSOCIATED WITH EITHER THE
19 MORPHINE OR THE CENTRAL NERVOUS SYSTEM DEPRESSANTS?
20 A. AGAIN, MANY OF THESE MEDICINES CAN BE USED VERY SAFELY AT
21 THE -- AT APPROPRIATE DOSES, BUT WHEN THE DOSES GO BEYOND THE
22 NORMAL -- AND THIS ISN'T TAKING INTO ACCOUNT THEN, AS I
23 POINTED OUT ON THESE CHARTS, THERE ARE ALL SORTS OF RISKS
24 THAT COME UP.
25 Q. OKAY. WOULD A PHYSICIAN BE AWARE OF THE DANGERS AND THE
1 EFFECTS THAT YOU'VE TALKED ABOUT HERE RELATIVE TO THE USE OF
2 MORPHINE OR OTHER CENTRAL NERVOUS SYSTEM DEPRESSANTS?
3 A. I WOULD SAY ANY PHYSICIAN WHO IS USING MORPHINE OR ANY OF
4 THESE OTHER DRUGS NEEDS TO BE AWARE OF THE SIDE EFFECTS AND
5 THE -- YOU KNOW, THE BENEFITS AND ALSO THE -- THE SIDE
6 EFFECTS OF -- OF ANY OF THESE MEDICINES.
7 Q. TELL ME, DOCTOR, IN TERMS OF YOUR PAIN MANAGEMENT
8 EXPERIENCE, ARE THERE ANY SPECIAL CONSIDERATIONS IN THE USE
9 OF THESE DRUGS WHEN YOU'RE DEALING WITH A GERIATRIC PATIENT?
10 A. WELL, THE -- THE GERIATRIC PATIENTS JUST BY NATURE OF AGE
11 AND SOME OF THE CHANGES THAT OCCUR WITH AGING, TEND TO BE
12 MORE SENSITIVE TO ANY OF THESE MEDICINES. AND AS A RESULT WE
13 HAVE TO BE MUCH MORE CAUTIOUS WHEN WE'RE USING THEM. YOU
14 KNOW, MUCH SMALLER DOSES MAY ACHIEVE THE SAME EFFECT IN AN
15 ELDERLY PATIENT AS, YOU KNOW, MAY REQUIRE A MUCH -- AS I SAY,
16 A MUCH SMALLER DOSE THAN IT WOULD IN A YOUNGER PATIENT.
17 Q. OKAY. AND RELATIVE TO THE USE OF MORPHINE, YOU INDICATED
18 ITS USE IS FOR PAIN?
19 A. PRIMARILY.
20 Q. OKAY. ARE THERE OTHER USES FOR MORPHINE OTHER THAN JUST
21 FOR PAIN?
22 A. OCCASIONALLY IT CAN BE USED IN INTENSIVE CARE SETTINGS
23 FOR ITS CARDIOVASCULAR EFFECTS. THERE CAN BE OTHER
24 DISTRESSFUL EFFECTS, PATIENTS WHO, YOU KNOW, HAVE COMPROMISED
25 BREATHING, YOU KNOW, AND IT'S VERY DISTRESSFUL TO THEM. YOU
1 KNOW, THAT -- IT ALSO CAN BE USED FOR -- FOR SUPPRESSING THAT
2 SORT OF A RESPONSE.
3 Q. RELATIVE TO THE LONG-TERM EFFECTS THAT WE WERE LOOKING AT
4 ON THE -- ON THE RIGHT-HAND SIDE OF THE CHART, YOU -- YOU
5 TALK ABOUT DEHYDRATION AND MALNUTRITION. AND YOU'VE GOT A --
6 A NOTE THERE, INCREASED SENSITIVITY TO THE DRUG EFFECTS. CAN
7 YOU EXPLAIN THAT NOTE FOR US, IF YOU WOULD, PLEASE? WHAT
8 THAT MEANS, INCREASED SENSITIVITY?
9 A. WELL, IT JUST MEANS THAT THE SAME DOSE OF DRUG GIVEN TO A
10 DEHYDRATED PATIENT IS GOING TO HAVE A MUCH GREATER EFFECT
11 THAN -- THAN TO A PATIENT WHO HAS NORMAL HYDRATION OF THE
12 BODY. AND, LIKEWISE, A MALNOURISHED PATIENT IS GOING TO BE
13 MORE -- MORE SENSITIVE TO A GIVEN DOSE OF A MEDICATION.
14 Q. CAN YOU TELL US WHY IS THAT? WHY DOES -- WHY DOES IT
15 INCREASE THE SENSITIVITY TO THE DRUG?
16 A. PART OF IT IS THAT THE VOLUME OF BLOOD OR FLUID
17 CIRCULATING THROUGH THE BODY WOULD BE REDUCED IN A DEHYDRATED
18 PATIENT JUST BY DEFINITION. AND SO THE BLOOD -- OR THE DRUG
19 IS -- IS SPREAD OUT I GUESS OVER A SMALLER VOLUME.
20 OTHER THINGS THAT I'VE MENTIONED THERE, BLOOD PRESSURE,
21 FOR INSTANCE, IS DEPENDENT ON THE VOLUME OF CIRCULATING
22 BLOOD. AND SO THE RESPONSE TO A DRUG LIKE MORPHINE IN A
23 DEHYDRATED PATIENT, THE RESPONSE ON BLOOD PRESSURE IS GOING
24 TO BE GREATER JUST BECAUSE OF -- OF DEHYDRATION.
25 Q. WOULD THE SAME HOLD TRUE RELATIVE TO THE OTHER CENTRAL
1 NERVOUS SYSTEM DEPRESSANTS THAT WE'VE TALKED ABOUT?
2 A. YES, IT WOULD.
3 Q. IN RESPECT TO THE STANDARDS OF PRACTICE IN -- IN -- FOR
4 PAIN MANAGEMENT, ARE YOU FAMILIAR WITH WHAT THOSE STANDARDS
5 ARE?
6 A. YES, I AM.
7 Q. OKAY. CAN YOU -- CAN YOU TELL US, IS THERE A PROCESS
8 THAT PHYSICIANS GO THROUGH IN TERMS OF DETERMINING WHETHER OR
9 NOT TO -- TO -- TO PRESCRIBE A PAIN MEDICATION?
10 A. THERE IS.
11 Q. OKAY. AND WHAT IS THAT PROCESS?
12 A. YOU KNOW, THE FIRST THING WOULD BE A DIAGNOSIS OF THE
13 PATIENT'S PROBLEM. DOES -- DOES THE PATIENT HAVE PAIN. AND,
14 YOU KNOW, THERE ARE A NUMBER OF WAYS THAT WE -- WE CAN GO
15 ABOUT THAT AND -- AND A NUMBER OF THINGS WE CAN RELY UPON,
16 YOU KNOW, THE PATIENT'S REPORT, THE PATIENT'S APPEARANCE, THE
17 PATIENT'S MEDICAL CONDITION. YOU KNOW, IF THEY JUST HAD A
18 SERIOUS INJURY OR A SERIOUS -- A BIG SURGERY, WE KNOW THEY'RE
19 GOING TO HAVE PAIN. SO THERE ARE A LOT OF THINGS THAT WE CAN
20 USE TO COME TO THE CONCLUSION THAT -- THAT A PATIENT HAS A
21 PAINFUL CONDITION.
22 Q. OKAY. AFTER YOU'VE -- YOU FORMED THAT CONCLUSION,
23 WHAT -- WHAT'S THE NEXT STEP IN THE PROCESS?
24 A. THE NEXT STEP WOULD BE TO SELECT AN APPROPRIATE
25 MEDICATION THAT WOULD SEEM OF REASONABLE STRENGTH TO HELP OUT
1 WITH THAT TYPE OF PAIN PROBLEM.
2 Q. OKAY.
3 A. IN OTHER WORDS, A FAIRLY MINOR PAIN PROBLEM WOULD REQUIRE
4 A LESSER MEDICATION THAN A -- THAN A REALLY SERIOUS PAIN
5 PROBLEM.
6 Q. THE DRUG MORPHINE, CAN YOU TELL US WHAT TYPES OF PAIN
7 THAT IT'S USED TO TREAT?
8 A. IT'S USUALLY RESERVED FOR MORE SEVERE PAIN PROBLEMS.
9 Q. AND CAN YOU DESCRIBE WHAT THAT WOULD -- CAN YOU DESCRIBE
10 WHAT A SEVERE PAIN PROBLEM IS?
11 A. I -- I GUESS THIS WOULD BE ONE. IF WE GAVE THE PATIENT
12 A -- IF A PATIENT WERE ABLE TO REPORT TO US ON A ZERO TO TEN
13 SCALE, ZERO WOULD BE NO PAIN AT ALL, TEN THE WORSE THING
14 EVERY, IT WOULD BE SOMETHING ON THE UPPER END OF THAT SCALE.
15 I THINK -- THAT WOULD BE ON PATIENT REPORT.
16 I THINK JUST ON THE BASIS OF -- OF, YOU KNOW, OTHER
17 THINGS THAT WE WOULD SEE, A PATIENT WHO HAD A SERIOUS
18 ORTHOPEDIC INJURY, A BROKEN LEG, A SIGNIFICANT SURGERY, YOU
19 KNOW THAT -- YOU KNOW, WOULD REQUIRE PAIN MEDICINES. ALL --
20 ANY ONE OF THOSE THINGS WOULD -- WOULD BE -- BE -- YOU KNOW,
21 MORPHINE COULD BE A CONSIDERATION.
22 Q. WOULD YOU RELY JUST ON THE PATIENT REPORT ALONE RELATIVE
23 TO THE -- TO THE DIAGNOSIS?
24 A. WELL, ALONG WITH WHAT I WAS SAYING, I GUESS I IMPLIED
25 PHYSICAL EXAMINATION, YOU KNOW, THE PRESENCE OF A -- OF A
1 PHYSICAL FACTOR THERE THAT -- THAT WOULD GIVE YOU SOME IDEA
2 OF WHY THE PATIENT HAS PAIN COMPLAINTS. CERTAINLY IMPORTANT
3 TO IDENTIFY THAT.
4 Q. ALL RIGHT. NOW, LET'S -- LET'S JUST TALK ABOUT YOU
5 INDICATED SOME OF THE SPECIAL CONSIDERATIONS RELATIVE TO THE
6 TREATMENT OF -- OF PAIN IN THE ELDERLY. IF YOU HAVE A
7 PATIENT WHO IS ALSO SUFFERING FROM DEMENTIA OR SOME OTHER
8 PSYCHOLOGICAL PROBLEM, IS THERE ANY OTHER SPECIAL
9 CONSIDERATIONS THAT YOU WOULD TAKE AS A PHYSICIAN IN RESPECT
10 TO THOSE TYPES OF PATIENTS?
11 A. WELL, CERTAINLY SOME OF THOSE PATIENTS ARE GOING TO HAVE
12 PAIN AND IT'S GOING TO BE HARDER BECAUSE THEY MAY NOT BE ABLE
13 TO REPORT THAT OR REPORT IT ACCURATELY. SO I THINK WE HAVE
14 TO HAVE A LOWER THRESHOLD TO APPRECIATE THOSE PATIENTS AND --
15 AND WHETHER THEY MIGHT HAVE A PAINFUL CONDITION. AGAIN, WE
16 RELY ON PHYSICAL EXAMINATION, THEIR MEDICAL HISTORY, OTHER
17 SORTS OF OBJECTIVE FINDINGS. BUT I THINK IF IT CAME DOWN TO
18 IT THAT, YOU KNOW, IF WE SUSPECTED THEY HAD PAIN, YOU KNOW,
19 WE WOULD PROBABLY TRY -- JUST EMPIRICALLY TRY A SMALL AMOUNT
20 OF PAIN MEDICINE TO SEE IF IT IN FACT HELPED THEIR SYMPTOMS.
21 Q. OKAY. RELATED AGAIN BACK TO THE QUESTION I TALKED TO YOU
22 ABOUT, THE STANDARD OF CARE, AND I ASSUME -- AND I RELATED
23 THAT TO PAIN MANAGEMENT, ARE THERE VARYING STANDARDS OF CARE
24 DEPENDING ON WHAT THE AREA OF PRACTICE IS -- IS IN?
25 A. I WOULD SAY NOT -- NOT STANDARD OF CARE. THERE MAY BE
1 VARYING PRACTICES, THING MAY BE DONE A LITTLE DIFFERENTLY
2 FROM ONE AREA OF MEDICINE TO ANOTHER. BUT I THINK THERE'S
3 SOME VERY BASIC PROCEDURES THAT ARE FOLLOWED THAT FIT THE
4 STANDARD OF CARE IN HOW PAIN IS MANAGED.
5 Q. OKAY.
6 A. AND -- AND, I MEAN, THAT'S THE BASIC -- THE STANDARD, YOU
7 KNOW, THAT WE -- WE FOLLOW -- AS I SAY, THE ACTUAL PROCEDURE
8 MAY VARY A LITTLE FROM ONE AREA TO ANOTHER, BUT THE -- BUT
9 THERE'S A CERTAIN STANDARD THAT NEEDS TO BE MET AND THAT
10 APPLIES ACROSS ALL AREAS OF MEDICINE.
11 Q. SO HOW DO WE ARRIVE AT A STANDARD?
12 A. A STANDARD'S REALLY A CONSENSUS. YOU KNOW, THE -- THE
13 PHYSICIANS, FOR INSTANCE, TREATING A CERTAIN MEDICAL PROBLEM,
14 YOU KNOW, WILL REACH SOME AGREEMENT ON WHAT IS AN ACCEPTABLE
15 LEVEL OF WAY TO APPROACH THAT PARTICULAR PROBLEM. AND THEN
16 THAT BECOMES A STANDARD OF CARE.
17 SO IT'S REALLY THE MINIMUM ACCEPTABLE LEVEL OF HOW TO
18 APPROACH OR TREAT THAT PARTICULAR PROBLEM.
19 Q. YOU SAY THE MINIMUM ACCEPTABLE?
20 A. IT IS, YES.
21 Q. OKAY. YOU'VE HAD AN OPPORTUNITY, SIR, HAVE YOU NOT, TO
22 REVIEW THE RECORDS OF THESE FIVE PATIENTS?
23 A. YES, I HAVE.
24 Q. CAN YOU TELL US WHAT RECORDS YOU'VE HAD OCCASION TO
25 REVIEW?
1 A. I REVIEWED -- WELL, I DON'T KNOW IF YOU WANT THE
2 PATIENT'S NAMES -- WELL, I REVIEWED MEDICAL RECORDS, NURSING
3 HOME RECORDS FOR PATIENTS ENNIS ALLDREDGE, ELLEN ANDERSON,
4 LYDIA SMITH, MARY CRANE, AND JUDITH LARSEN.
5 Q. OKAY. AND IN RESPECT TO YOUR RECORDS REVIEW, DID YOU
6 HAVE OCCASION TO FOCUS YOUR ATTENTION TO THE -- TO THE
7 ADMINISTRATION OF CERTAIN C.N.S. DRUGS AND MORPHINE?
8 A. YES, I DID.
9 Q. OKAY. CAN YOU TELL US FIRST OF ALL, DOCTOR, DID YOU HAVE
10 OCCASION TO FORM AN OPINION AS IT RELATED TO THE STANDARD OF
11 CARE AND WHETHER OR NOT THE DEFENDANT, IN PROVIDING PAIN
12 MANAGEMENT CARE TO THESE PATIENTS, PROVIDED CARE AT A
13 STANDARD ABOVE OR BELOW WHAT -- WHAT THE STANDARD OF CARE
14 SHOULD BE?
15 A. I DID FORM AN OPINION, YES.
16 Q. OKAY. I WANT TO TAKE YOU TO -- FIRST OF ALL, TO THE CASE
17 OF -- OF ELLEN ANDERSON, IF YOU WOULD, PLEASE. NOW I SHOW
18 YOU WHAT'S BEEN MARKED AS STATE'S EXHIBIT 2-H AND ASK YOU TO
19 TAKE A LOOK AT THAT EXHIBIT. I THINK YOU HAVE A COPY OF THE
20 EXHIBIT IN YOUR FILE, DO YOU NOT?
21 A. YES, I DO.
22 Q. AND CAN YOU SEE THE EXHIBIT FROM WHERE YOU ARE?
23 A. YES, I CAN.
24 MR. WILSON: CAN THE JURY SEE THE EXHIBIT?
25 THE COURT: DOES IT HAVE A NUMBER, MR. WILSON?
1 MR. WILSON: YEAH. I SAID IT WAS 2-H, YOUR HONOR.
2 THE COURT: ALL RIGHT. THANK YOU.
3 Q. (BY MR. WILSON) CALLING YOUR ATTENTION TO THE EXHIBIT,
4 YOU -- YOU'RE FAMILIAR WITH THE PARTICULAR DRUGS THAT ARE
5 CONTAINED ON THE LEFT-HAND SIDE?
6 A. YES, I AM.
7 Q. OKAY. AND ALSO AS TO THE -- THE MEDICAL RECORDS RELATIVE
8 TO THE ADMINISTRATION OF DRUGS ON DECEMBER 29TH AND
9 DECEMBER 30TH?
10 A. YES, I AM.
11 Q. CAN YOU TELL US, DOCTOR, IN REVIEWING ELLEN ANDERSON'S
12 RECORDS, DID YOU FORM ANY OPINION AS IT RELATED TO HER
13 MEDICAL STABILITY AT THE TIME THAT SHE WAS ADMITTED TO THE
14 GEROPSYCH UNIT?
15 A. YES. SHE, YOU KNOW, HAD SOME LONG-STANDING MEDICAL
16 PROBLEMS, BUT AT THE SAME TIME SEEMED TO NOT BE UNSTABLE IN
17 ANY WAY, HAD NO NEW APPARENT PROBLEMS AT THAT TIME. AND WAS
18 BEING ADMITTED MAINLY FOR THE PSYCHIATRIC EVALUATION AND
19 CARE.
20 Q. AND WHAT RECORDS WAS IT YOU REVIEWED IN -- IN RESPECT TO
21 FORMING THAT OPINION?
22 A. THESE WERE THE RECORDS FROM THE HOSPITAL ADMISSION.
23 THESE WERE SOME RECORDS, I BELIEVE, FROM THE NURSING HOME.
24 Q. OKAY. AND DO YOU KNOW WHETHER OR NOT ELLEN ANDERSON HAD
25 RECEIVED ANY KIND OF PAIN MEDICATION PRIOR TO ADMISSION TO
1 THE GEROPSYCH UNIT?
2 A. SHE APPARENTLY WOULD RECEIVE TYLENOL, YOU KNOW, WITH SOME
3 FREQUENCY AND --
4 Q. WHEN WE TALK ABOUT TYLENOL, ARE WE TALKING ABOUT A
5 CONTROLLED SUBSTANCE?
6 A. NO. NO, WE'RE NOT. WE'RE TALKING ABOUT JUST A, YOU
7 KNOW, WITHOUT A PRESCRIPTION-TYPE PAIN MEDICATION.
8 Q. OKAY. ANY OTHER PAIN MEDICATIONS THAT YOU RECALL FROM
9 YOUR RECORDS REVIEW?
10 A. RARELY SHE WOULD RECEIVE LORTAB, WHICH IS A HYDROCODONE,
11 WHICH IS A CONTROLLED SUBSTANCE, BUT IT WAS VERY UNUSUAL. IT
12 WAS NOT EVEN ON A -- I DON'T BELIEVE EVEN ON A WEEKLY BASIS.
13 Q. CAN YOU TELL US, DOCTOR, WHETHER OR NOT THERE WAS
14 ANYTHING IN THE MEDICAL RECORDS THAT YOU'VE SEEN WHICH
15 INDICATED THAT THE LORTAB HAD NOT BEEN EFFECTIVE IN TREATING
16 HER PAIN?
17 A. I DIDN'T SEE TOO MUCH IN REGARDS TO THE LORTAB. THE
18 TYLENOL THOUGH, YOU KNOW, SEEMED TO BE VERY EFFECTIVE IN
19 TREATING THE PAIN COMPLAINTS THAT SHE HAD.
20 Q. OKAY.
21 A. THIS WAS, AGAIN, I THINK A -- HER DAUGHTER HAD REPORTED
22 THIS TO THE PERSON DOING THE ADMISSION TO THE HOSPITAL.
23 Q. AND CAN YOU TELL US RELATIVE TO THAT ADMISSION, WERE
24 THERE ANY SPECIFIC COMPLAINTS OF PAIN MADE BY THE PATIENT OR
25 HER -- OR HER RELATIVES ON HER BEHALF?
1 A. NOT THAT I'M AWARE OF. IN FACT, THE BEHAVIORS THAT MIGHT
2 BE ATTRIBUTED TO PAIN I BELIEVE WERE INTERPRETED IN -- THIS
3 WAS PASSED ON TO THE FOLKS AT THE HOSPITAL THAT THESE WERE
4 MORE OF AN ANXIETY, I DON'T WANT TO BE LEFT ALONE, ATTENTION
5 GETTING SORT OF A -- A PROBLEM MORE SO THAN ANYTHING RELATED
6 TO -- TO PAIN.
7 Q. OKAY. DID THERE COME A TIME SUBSEQUENT TO HER ADMISSION
8 WHERE SHE WAS RECEIVING ANY KIND OF PAIN KILLER?
9 A. ONCE SHE WAS ADMITTED?
10 Q. YEAH, AFTER SHE WAS ADMITTED.
11 A. YES. WITHIN A FEW HOURS AFTER SHE WAS ADMITTED SHE WAS
12 LEFT ALONE, BECAME AGITATED, AND THE NURSE REPORTED TO THE
13 DOCTOR OF THIS SITUATION, AND MORPHINE 10 MILLIGRAMS
14 INTRAMUSCULARLY WAS ORDERED FOR HER.
15 Q. NOW, CAN YOU CHARACTERIZE FOR US, IF YOU WOULD, WHETHER
16 OR NOT YOU HAVE ANY CONCERNS AS IT RELATED TO THE DOSAGE
17 AMOUNT OF MORPHINE THAT WAS ADMINISTERED TO ALLEN ANDERSON ON
18 THAT DATE?
19 MR. BUGDEN: OBJECTION TO THE RELEVANCE OF WHETHER
20 OR NOT HE HAS ANY CONCERNS.
21 THE COURT: SUSTAINED.
22 Q. (BY MR. WILSON) CAN YOU CHARACTERIZE FOR US, IF YOU
23 WOULD, IN YOUR MEDICAL EXPERIENCE WHETHER OR NOT YOU FELT
24 THAT DOSAGE WAS APPROPRIATE?
25 A. THAT'S A VERY LARGE DOSE FOR A 91-YEAR-OLD PATIENT.
1 Q. OKAY. CAN YOU TELL US WHETHER OR NOT THE MEDICAL RECORD
2 REFLECTS ANY INFORMATION RELATIVE TO THE DOCTOR HAVING
3 PERSONALLY EVALUATED THIS PATIENT?
4 A. IT GAVE NO INDICATION THAT HE PERSONALLY EVALUATED THIS
5 PATIENT.
6 Q. OKAY. WHEN YOU SAY IT'S A RATHER LARGE DOSE, CAN YOU
7 TELL US, DID YOU HAVE AN OPINION AS TO WHAT WOULD HAVE BEEN
8 THE PROPER DOSAGE ADMINISTRATION TO THIS PARTICULAR PATIENT?
9 A. WELL, AGAIN, WITHOUT BELABORING THE POINT, WHEN WE
10 PRESCRIBE PAIN MEDICINE WE TRY TO MATCH UP THE TYPE OF
11 MEDICINE --
12 MR. BUGDEN: I DON'T THINK THIS IS RESPONSIVE.
13 THE COURT: SUSTAINED.
14 Q. (BY MR. WILSON) OKAY. CAN YOU TELL US, DOCTOR, WHAT
15 WOULD YOU HAVE DONE UNDER THESE PARTICULAR CIRCUMSTANCES?
16 MR. BUGDEN: I DON'T KNOW THAT THAT'S RELEVANT.
17 THE COURT: OVERRULE THE OBJECTION.
18 A. I THINK UNDER THESE CIRCUMSTANCES IT WOULD HAVE BEEN VERY
19 REASONABLE TO TRY AN ORAL PAIN MEDICINE FIRST OF ALL, PERHAPS
20 EVEN A TYLENOL THAT SHE'D RESPONDED TO WELL BEFORE SHE CAME
21 INTO THE HOSPITAL. SO I THINK THIS IS A VERY EXTREME
22 MEASURE, YOU KNOW, USING THIS LARGE DOSE OF INJECTABLE
23 MORPHINE.
24 Q. (BY MR. WILSON) OKAY. LET'S JUST ASSUME, IF YOU WOULD,
25 THAT THERE WAS PAIN THAT THIS PATIENT WAS EXPERIENCING. DO
1 YOU HAVE AN OPINION AS TO WHAT WOULD BE AN APPROPRIATE DOSAGE
2 AMOUNT OF MORPHINE, IF ANY?
3 A. IF THIS WERE A PAIN PROBLEM THAT SEEMED TO BE MOST
4 APPROPRIATELY TREATED WITH MORPHINE, STARTING OFF AT A SMALL
5 DOSE, PERHAPS 1 OR 2 MILLIGRAMS WOULD BE THE BETTER PLACE TO
6 START. YOU CAN ALWAYS GIVE MORE.
7 Q. AND WHEN YOU SAY YOU CAN ALWAYS GIVE MORE, WHAT IS THE
8 PROCESS THAT YOU USE TO EVALUATE PAIN RELATIVE TO THE
9 DOSAGES?
10 A. WELL, YOU WOULD GIVE THE DOSE OF MEDICINE, GIVE IT
11 SUFFICIENT TIME TO WORK AND SEE IF YOU SEE THE RESPONSE THAT
12 YOU, YOU KNOW, WOULD LIKE TO SEE. IN OTHER WORDS, SOME
13 INDICATION THAT THE PATIENT HAS GOTTEN RELIEF FROM -- FROM
14 THE PAIN. AND YOU ALSO WATCH FOR SIDE EFFECTS AND MAKE SURE
15 THAT THE PATIENT ISN'T INCURRING UN -- UNWANTED SIDE EFFECTS
16 BECAUSE OF THAT MEDICINE.
17 Q. CAN YOU TELL US ON THIS PARTICULAR OCCASION, IN YOUR
18 REVIEW OF THE RECORDS, DID YOU SEE ANY SIDE EFFECTS OR WHAT
19 YOU WOULD CATEGORIZE AS SIDE EFFECTS AS THE RESULT OF THE
20 ADMINISTRATION OF MORPHINE?
21 A. YES, I DID. THE -- THE PATIENT BECAME MORE SEDATED AFTER
22 THIS MEDICINE, BUT IN ADDITION, THE -- THE FIRST TIME THAT
23 HER BLOOD PRESSURE AND RESPIRATORY RATE WERE CHECKED APPEARS
24 TO BE SEVERAL HOURS LATER. AND AT THAT TIME HER BLOOD
25 PRESSURE WAS VERY LOW, HER RESPIRATORY RATE WAS DEPRESSED.
1 Q. CAN YOU TELL US WHAT HER BLOOD PRESSURE WAS?
2 A. 70 OVER 50.
3 Q. AND CAN YOU CHARACTERIZE WHAT THAT MEANS?
4 A. IN A PATIENT THIS AGE, I WOULD EXPECT THAT SORT OF BLOOD
5 PRESSURE FOR ANY LENGTH OF TIME WOULD RESULT IN -- IN
6 SIGNIFICANT TISSUE DAMAGE, BRAIN DAMAGE, HEART DAMAGE, OTHER
7 ORGAN DAMAGE.
8 Q. DO YOU KNOW HOW OFTEN THE BLOOD PRESSURE AND THE
9 RESPIRATORY RATES WERE BEING MONITORED ON THAT UNIT?
10 A. I BELIEVE AS A MATTER OF ROUTINE IT WAS JUST ONE EVERY
11 SHIFT OR THREE TIMES A DAY. SO THERE WEREN'T ANY SPECIAL
12 ORDERS THAT WERE PUT IN PLACE ONCE THE MORPHINE WAS GIVEN.
13 Q. WHAT WAS IT NEXT YOU SEEN IN THE MEDICAL RECORD RELATIVE
14 TO THE USE OF MORPHINE?
15 A. ABOUT 3 A.M. SHE BEGAN TO APPEAR AGITATED. I BELIEVE THE
16 RECORDS MENTION THAT SHE WAS MOANING, CRYING, AGITATED. I
17 BELIEVE THERE WAS SOME -- SOME MENTION -- WAIT A MINUTE, I'M
18 SORRY. LET ME JUST SEE IF THAT'S EXACTLY RIGHT. I GUESS SHE
19 WAS AWAKENED, SHE WAS KIND OF THRASHING HER ARMS AND MOANING,
20 SCREAMING, AT ABOUT 3:30 A.M.
21 Q. OKAY. WHAT HAPPENED NEXT?
22 A. SHE RECEIVED ANOTHER DOSE OF MORPHINE.
23 Q. WHAT SIZE WAS THE DOSAGE?
24 A. ANOTHER 10 MILLIGRAMS.
25 Q. OKAY. DID YOU AGAIN SEE ANY EFFECTS OF THE MORPHINE
1 WHICH WERE DOCUMENTED IN THE RECORD SUBSEQUENT TO THAT SHOT?
2 A. THE NEXT TIME THE BLOOD PRESSURE AND THE SO-CALLED VITAL
3 SIGNS WERE CHECKED WAS ABOUT 7:30 THAT MORNING. AND SO THIS
4 IS ABOUT FOUR HOURS LATER. AND AT THAT TIME THEY WERE UNABLE
5 TO GET A BLOOD PRESSURE. HER RESPIRATORY RATE WAS
6 SUPPRESSED. PATIENT WAS NOT RESPONSIVE. AND SHORTLY
7 THEREAFTER THE PATIENT DIED, OR WAS FOUND TO BE DEAD.
8 Q. OKAY. CALLING YOUR ATTENTION BACK TO THE ORIGINAL
9 QUESTION RELATED TO THE STANDARD OF CARE, CAN YOU TELL US
10 WHETHER OR NOT THERE -- THE ADMINISTRATION OF THE PAIN
11 MEDICATIONS AND WHAT YOU OBSERVED ABOUT THE MEDICAL RECORD
12 WAS BELOW THE STANDARD OF CARE FOR A PHYSICIAN UNDER THE SAME
13 CIRCUMSTANCE?
14 A. I THINK THIS IS CLEARLY BELOW THE STANDARD OF CARE.
15 Q. AND CAN YOU BE SPECIFIC AS -- AS TO WHAT ACTS OR CONDUCT
16 YOU THINK FELL BELOW THE STANDARD OF CARE?
17 A. I THINK IT WAS AN INAPPROPRIATE CHOICE OF MEDICATION,
18 INAPPROPRIATE CHOICE OF DOSE OF MEDICATION, AND INAPPROPRIATE
19 MONITORING OF THE PATIENT ONCE THE DOSE OF MEDICATION WAS
20 GIVEN.
21 Q. DOCTOR, DO YOU HAVE AN OPINION BASED TO A REASONABLE
22 DEGREE OF MEDICAL CERTAINTY AS TO -- AS TO THE CAUSE OF DEATH
23 OF ELLEN ANDERSON?
24 A. YES, I DO.
25 Q. AND COULD YOU STATE THAT OPINION, PLEASE?
1 A. I BELIEVE SHE DIED FROM THE TOXIC EFFECTS OF MORPHINE.
2 Q. OKAY. CAN YOU DESCRIBE FOR US, IF YOU WOULD -- WELL,
3 STRIKE THAT.
4 ARE YOU FAMILIAR WITH THE TERM HALF-LIFE?
5 A. YES, I AM.
6 Q. AND WHAT IS A HALF-LIFE?
7 A. THE HALF-LIFE IS A TERM DESCRIBED TO -- OR HELP DESCRIBE
8 THE AMOUNT OF TIME A DRUG SPENDS IN THE BODY ONCE IT'S GIVEN.
9 AND THE HALF-LIFE WOULD REFER TO THE AMOUNT OF TIME IT TAKES
10 FOR THE BODY TO ELIMINATE HALF THE DOSE OF THE DRUG THAT WAS
11 GIVEN.
12 Q. WOULD YOU EXPECT THAT THERE'S A PEAK EFFECT RELATIVE TO
13 THE USE OF MORPHINE?
14 A. YES, THERE WOULD BE.
15 Q. AND WOULD YOU EXPECT THAT AT THAT PEAK EFFECT THE PATIENT
16 WOULD BE EXHIBITING DEPRESSED RESPIRATORY EFFECTS OR WHATEVER
17 ADVERSE EFFECTS IF -- IF THE DOSAGE WAS TOO MUCH?
18 A. YES.
19 Q. IN THIS PARTICULAR CASE YOU -- YOU DOCUMENT AN EFFECT
20 THAT TAKES PLACE ABOUT FIVE HOURS AFTER THE FIRST SHOT, AND
21 THEN YOU SEE DOCUMENTATION ANOTHER FIVE HOURS AFTER THE
22 SECOND SHOT; IS THAT CORRECT?
23 A. IT WAS ABOUT FOUR HOURS I GUESS AFTER THAT.
24 Q. FOUR HOURS, EXCUSE ME.
25 A. AFTER THE SECOND ONE, YES.
1 Q. AND I THINK IT WAS PROBABLY -- OR MAYBE IT WAS FIVE HOURS
2 AS TO THE FIRST.
3 A. YES.
4 Q. WOULD IT NOT BE TRUE THAT THE DRUG ITSELF WOULD HAVE BEEN
5 OUT OF THE SYSTEM OF ELLEN ANDERSON BY THAT TIME?
6 A. WELL, THERE ARE -- THERE ARE TWO THINGS TO CONSIDER WITH
7 A RELATIVELY LARGE DOSE -- I MEAN, WE NORMALLY WOULD THINK OF
8 MORPHINE LASTING ABOUT FOUR HOURS IN -- WHEN IT'S MATCHED UP
9 APPROPRIATELY, YOU KNOW, FOR THE PATIENT AND ITS USE. IF A
10 PATIENT IS GIVEN A VERY LARGE DOSE OF IT, THE EFFECTS OF IT
11 ARE GOING TO LAST LONGER THAN FOUR HOURS.
12 THE OTHER THING THAT I THINK IS IMPORTANT IN THIS
13 PARTICULAR SITUATION, GETTING BACK TO MY PREVIOUS FIGURE, IS
14 THAT THIS PATIENT SUSTAINED ORGAN DAMAGE FROM LOW BLOOD
15 PRESSURE, BLOW BREATHING RATE, AS -- YOU KNOW, AS
16 DEMONSTRATED IN THE CHART. AND THAT PROBABLY OCCURRED WITHIN
17 45 MINUTES OR EVEN LESS AFTER SHE RECEIVED THIS DOSE OF
18 MEDICINE AND CONTINUED UP, YOU KNOW, THROUGH THE TIME WHEN
19 HER VITAL SIGNS WERE CHECKED. SO FOR MANY HOURS HER BLOOD
20 PRESSURE WAS LOW, FOR MANY HOURS HER BREATHING WAS LOW.
21 AND GETTING BACK TO WHAT I TALKED ABOUT, LONG-TERM
22 EFFECTS, IT WOULD BE VERY MUCH EXPECTED THAT ORGAN DAMAGE
23 OCCURRED DURING THAT TIME -- PERMANENT ORGAN DAMAGE.
24 Q. I DON'T KNOW AS -- AS YOU EXPLAINED HOW MORPHINE -- WHAT
25 MORPHINE DOES TO YOU TO CAUSE DEATH, HAVE YOU?
1 A. I DON'T THINK I SPECIFICALLY TALKED ABOUT IT, NO.
2 Q. CAN YOU TELL US WHAT IT IS THAT MORPHINE DOES
3 PHYSIOLOGICALLY TO THE BODY THAT CREATES DEATH?
4 A. YES. MORPHINE HAS A DRAMATIC EFFECT ON THE SYSTEM IN THE
5 BRAIN THAT CONTROLS BREATHING. AND IT DEPRESSES THAT
6 PARTICULAR SYSTEM.
7 THE COURT: WASN'T -- DIDN'T WE TALK ABOUT THIS IN
8 THE LONG-TERM EFFECTS OF MORPHINE A MINUTE AGO?
9 MR. WILSON: I -- I THINK I ASKED HIM ABOUT THE RISK
10 OF DEATH, BUT I DON'T THINK I ASKED HIM PARTICULARLY WHAT
11 IT -- WHAT IT DOES TO CREATE DEATH, YOUR HONOR.
12 THE COURT: WELL, LET'S PICK UP THE PACE A LITTLE
13 BIT. GO AHEAD.
14 Q. (BY MR. WILSON) OKAY. WHAT -- JUST -- JUST BRIEFLY, CAN
15 YOU TELL US, YOU SAID IT DOES SOMETHING TO THE BRAIN CENTER?
16 A. YES, IT DOES.
17 Q. AND ESSENTIALLY, WHAT DOES IT DO?
18 A. IT -- IT INHIBITS THE BODY'S DESIRE TO BREATHE.
19 Q. OKAY.
20 A. AND SO AT SOME POINT BREATHING EITHER IS SO SUPPRESSED OR
21 TOTALLY DEPRESSED. AND SO IT'S A VERY SELECTIVE EFFECT.
22 PATIENTS CAN BE EVEN SOMEWHAT CONSCIOUS AND -- AND NOT HAVE
23 ANY DESIRE TO BREATHE.
24 Q. IF A PERSON HAS A -- SOME COMPROMISED ORGANS IN THEIR
25 BODY IN THE FIRST PLACE, SAY THEIR HEART IS BAD OR THEIR
1 LUNGS ARE BAD OR THEIR KIDNEYS ARE BAD, DOES THE MORPHINE
2 HAVE ANY EFFECT ON THOSE?
3 A. IT'S JUST GOING TO HAVE AN EXAGGERATED EFFECT,
4 PARTICULARLY ON ANY ORGANS THAT PERHAPS ARE ALREADY NOT
5 WORKING VERY WELL OR SOMEWHAT DAMAGED.
6 Q. OKAY. NOW, I NEXT SHOW YOU WHAT'S BEEN MARKED AS STATE'S
7 EXHIBIT 3-H, I THINK. 3-H. AND ASK YOU, SIR, HAVE YOU SEEN
8 THAT PARTICULAR EXHIBIT?
9 A. YES, I HAVE.
10 Q. AND THIS -- THIS IS AN EXHIBIT PREPARED ON THE PATIENT
11 JUDITH LARSEN. AND CAN YOU TELL US -- UPON HER ENTRANCE TO
12 THE GEROPSYCH UNIT, CAN YOU TELL US WHETHER OR NOT YOU FORMED
13 AN OPINION BASED UPON YOUR REVIEW OF THE RECORDS AS TO HER
14 MEDICAL STABILITY?
15 A. SHE HAD LONG-TERM MEDICAL PROBLEMS, BUT NONE OF THOSE
16 SEEMED TO BE UNSTABLE. THERE WERE NO NEW PROBLEMS THAT
17 SEEMED TO BE A THREAT TO HER LIFE.
18 Q. OKAY. NOW, IN LOOKING AT THE BOARD ITSELF, YOU CAN SEE A
19 VARIETY OF DIFFERENT MEDICATIONS THAT WERE GIVEN, INCLUDING
20 THE DRUGS KLONOPIN, SERZONE, TRAZODONE, RISPERDAL, AND
21 ATIVAN. CAN YOU TELL US, ARE THEY ALL CENTRAL NERVOUS SYSTEM
22 DEPRESSANTS?
23 A. YES, THEY ARE.
24 Q. OKAY.
25 A. I'M -- I'M NOT SURE IF THE JURY CAN SEE THAT LITTLE TINY
1 PRINTING. MAYBE WE COULD AT LEAST POINT TO THE COLORS --
2 THE COURT: THEY'VE SEEN IT BEFORE.
3 THE WITNESS: OH, THEY HAVE. OKAY.
4 Q. (BY MR. WILSON) AND CAN YOU TELL US RELATIVE TO THE
5 DOSAGE AMOUNTS AND THE DIFFERENT DRUGS ON TOP OF DIFFERENT
6 DRUGS, WHETHER OR NOT THAT -- WHETHER OR NOT YOU HAVE AN
7 OPINION AS TO THE APPROPRIATENESS OF THOSE DOSAGES?
8 A. EACH OF THOSE DRUGS WAS IN A RELATIVELY LARGE AMOUNT,
9 AGAIN, IN AN ELDERLY PATIENT, AND WHEN WE COMBINE DRUGS WITH
10 CENTRAL NERVOUS SYSTEM DEPRESSANT EFFECTS THE -- THE EFFECTS
11 ADD ON TOP OF ONE ANOTHER SO WE GET EVEN A MORE EXAGGERATED
12 EFFECT. SO THESE WERE SIGNIFICANTLY LARGE DOSES OF THESE
13 DEPRESSANT DRUGS.
14 Q. IN RESPECT TO JUDITH LARSEN'S MEDICAL RECORD, DID YOU SEE
15 ANY SIGNS OR SYMPTOMS OF COMPLAINTS OF PAIN -- OR COMPLAINTS
16 OF PAIN, I SHOULD SAY?
17 A. NO, I DIDN'T.
18 Q. ON HER ADMISSION?
19 A. NO. NO, I DIDN'T.
20 Q. DID YOU EVER SEE ANY DURING THE COURSE OF HER TREATMENT
21 AT THE GEROPSYCH UNIT?
22 A. THROUGHOUT THE VAST MAJORITY OF HER TREATMENT THERE,
23 THERE WAS NO MENTION WHATSOEVER OF ANY PAIN PROBLEMS. FOR
24 INSTANCE FOR THE FIRST SIX DAYS SHE WAS THERE, THERE WAS
25 ABSOLUTELY NO MENTION OF ANYTHING IN REGARDS TO PAIN AND --
1 AND LITTLE MENTION FROM THEN ON.
2 Q. NOW, WE -- WE OBSERVED THAT THERE WAS SOME -- SOME
3 DOSAGES OF MORPHINE THAT WERE GIVEN TO HER ON THE 25TH DAY OF
4 DECEMBER. CAN YOU CHARACTERIZE FOR US, HAVE YOU REVIEWED
5 THAT PARTICULAR DATE?
6 A. YES, I HAVE.
7 Q. AND CAN YOU TELL US, SIR, DID YOU SEE ANYTHING THAT
8 WOULD, IN YOUR MEDICAL JUDGMENT, REQUIRE THE ADMINISTRATION
9 OF MORPHINE ON THAT DAY?
10 A. AT THAT POINT THERE WAS A CLINICAL NOTE SUGGESTING THAT
11 THE PATIENT MIGHT BE IN PAIN, AND A TRIAL OF MORPHINE WAS
12 GOING TO BE ATTEMPTED AT THAT POINT TO SEE IF IT HAD ANY
13 BENEFIT.
14 Q. OKAY. AND WHAT DOSAGES WERE ADMINISTERED?
15 A. THOSE WERE 2 MILLIGRAM DOSES.
16 Q. OKAY. NOW, GOING ON UP TO THE DAY OF DECEMBER 29TH, WAS
17 THERE ANY EVENTS ON DECEMBER 29TH THAT YOU CAN SEE OCCURRED
18 TO THE PATIENT JUDITH LARSEN?
19 A. NOTHING -- WELL, I MEAN THERE WERE SOME EVENTS. AS FAR
20 AS ANYTHING THAT SHOWED ANY SIGNS OF PAIN OR DISTRESS, YOU
21 KNOW, THAT WOULD INDICATE MORPHINE, NO. SHE DID HAVE SOME
22 EMESIS ON THAT DAY. YOU KNOW, SHE HAD -- HAD SOME OTHER
23 ONGOING MEDICAL PROBLEMS, BUT -- BUT, YOU KNOW, NOTHING THAT
24 WOULD INDICATE THE NEED FOR MORPHINE.
25 Q. OKAY. CAN YOU TELL US AS TO THE SUBSEQUENT DAYS GOING
1 FROM DECEMBER 30TH TO JANUARY 3RD WHETHER THERE WAS ANY
2 MEDICAL REASON IN YOUR JUDGMENT FOR THE ADMINISTRATION OF
3 MORPHINE?
4 A. THE -- WELL, THE PATIENT HAD HAD THIS -- WHAT THEY CALL
5 COFFEE GROUND EMESIS, MEANING THAT BLOOD-LIKE MATERIAL HAD
6 BEEN VOMITED, WITH THE ASSUMPTION THAT PERHAPS SHE WAS
7 BLEEDING FROM HER DIGESTIVE TRACT. ON THAT BASIS THE --
8 APPARENTLY THE DECISION WAS MADE THAT THIS WAS A FATAL
9 PROBLEM THE PATIENT HAD AND -- AND -- ACCORDING TO THE NOTES,
10 AND MORPHINE WAS BEGIN -- WAS, YOU KNOW, BEING GIVEN AT THAT
11 POINT -- OR STARTED AT THAT POINT.
12 Q. OKAY. BASED UPON YOUR REVIEW OF THE MEDICAL RECORDS OF
13 JUDITH LARSEN AND YOUR EXPERIENCE AND TRAINING AND EXPERTISE,
14 DID YOU FORM AN OPINION AS TO WHETHER OR NOT THE CONDUCT OF
15 THE DEFENDANT AS TO HER TREATMENT AND CARE DEVIATED FROM THE
16 STANDARDS OF CARE AS WOULD BE EXERCISED BY A PHYSICIAN IN THE
17 SAME CIRCUMSTANCES?
18 A. YES, I BELIEVE -- I FEEL THAT THE CARE FELL BELOW THE
19 STANDARD OF CARE.
20 Q. OKAY. CAN YOU TELL US SPECIFICALLY IN WHAT AREAS IT FELL
21 BELOW THE STANDARD OF CARE?
22 A. I -- WELL, I THINK AT LEAST IN REGARDS TO --
23 Q. AND I -- EXCUSE ME. LET ME -- LET ME JUST REFERENCE
24 THIS. RELATIVE TO PAIN MANAGEMENT, IF YOU COULD.
25 A. WELL, AGAIN, AT THAT POINT THERE WERE NO INDICATORS OF
1 PAINFUL CONDITION. AND, YOU KNOW, AT THAT -- AT THAT POINT,
2 YOU KNOW, THE MORPHINE WAS ADMINISTERED. AS I MENTIONED
3 EARLIER, YOU KNOW, A TRIAL OF MORPHINE IN SMALLER DOSES TO
4 SEE IF IT HELPED THE PATIENT, YOU KNOW, MIGHT NOT BE
5 UNREASONABLE. BUT AT THIS TIME THE PATIENT BASICALLY, TO A
6 LARGE DEGREE, WAS UNRESPONSIVE ANYWAY. SO IT REALLY SEEMED
7 UNNECESSARY TO GIVE THE PATIENT DOSES OF A POTENTIALLY TOXIC
8 MEDICATION.
9 Q. CAN YOU TELL US IN RESPECT TO THE -- GOING TO
10 DECEMBER 30TH THROUGH JANUARY 3RD, WHETHER OR NOT YOU'VE SEEN
11 ANY SIGNS OR SYMPTOMS THAT RELATED TO THE EFFECTS OF
12 MORPHINE?
13 A. THE PATIENT WAS UNRESPONSIVE DURING MUCH IF NOT MOST OF
14 THAT TIME. THE -- DON'T BELIEVE TOO MANY BLOOD PRESSURES --
15 WELL, SOME BLOOD PRESSURES AND THINGS WERE TAKEN. THAT
16 TENDED OF KIND OF VARY THROUGH THAT TIME. BUT TO A LARGE
17 DEGREE THE PATIENT WAS UNCONSCIOUS AND -- AND ABOUT THE ONLY
18 THING THAT THE PATIENT WAS RESPONDING TO WAS WHEN THEY WERE
19 POKED WITH A NEEDLE AND GIVEN A SHOT.
20 Q. BASED UPON YOUR REVIEW OF THE RECORDS AND YOUR EXPERIENCE
21 AND EXPERTISE, DID YOU FORM AN OPINION AS TO THE CAUSE OF
22 DEATH OF JUDITH LARSEN TO A REASONABLE DEGREE OF MEDICAL
23 CERTAINTY?
24 A. YES, I DID.
25 Q. AND CAN YOU TELL US WHAT THAT OPINION IS?
1 A. SHE DIED FROM THE TOXIC EFFECTS OF MORPHINE.
2 Q. WAS THERE ANY OTHER CONTRIBUTING FACTORS TO THAT?
3 A. WELL, AGAIN, SHE'D BEEN ON ALL OF THESE OTHER SEDATING
4 MEDICINES OVER A LONG PERIOD OF TIME. AND SOME OF THE OTHER
5 FACTORS I MENTIONED EARLIER IN TERMS OF DEHYDRATION, JUST
6 KIND OF GENERAL WEAKENING FROM THESE OTHER MEDICINES I
7 BELIEVE CONTRIBUTED TO THAT.
8 Q. OKAY. THANK YOU, DOCTOR.
9 NOW I'M GOING TO SHOW YOU WHAT'S MARKED AS STATE'S
10 EXHIBIT 4-E, HAVE YOU TAKE A LOOK AT THAT, IF YOU WOULD,
11 PLEASE. DO YOU HAVE A COPY OF THAT, ALSO?
12 A. YES, I DO.
13 Q. AND CAN YOU TELL -- THAT PURPORTS TO BE THE SAME TYPE OF
14 A CHART RELATED TO THE PATIENT MARY CRANE. DO THE DOSAGES
15 AND THE AMOUNTS OF DOSAGES REPRESENTED ON THAT PARTICULAR
16 GRAPH APPEAR TO BE ACCURATE TO YOU, ACCORDING TO YOUR REVIEW
17 OF THE RECORDS?
18 A. YES, THEY ARE.
19 Q. OKAY. AND CAN YOU TELL US WHETHER THE VARIOUS DRUGS
20 THERE, ARE THEY ALL CENTRAL NERVOUS SYSTEM DEPRESSANTS THAT
21 ARE REPRESENTED THERE?
22 A. I BELIEVE THEY ALL ARE. I CAN DOUBLE CHECK THAT, BUT --
23 LET ME JUST MAKE CERTAIN I'M ANSWERING CORRECTLY. YES, THEY
24 WOULD BE.
25 Q. OKAY. I WANT TO TALK A LITTLE BIT ABOUT THE DURAGESIC
1 PATCH. THIS PATIENT RECEIVED A DURAGESIC PATCH, DIDN'T SHE?
2 A. SHE DID.
3 Q. WE HAVE HERE WHAT'S MARKED AS STATE'S EXHIBIT 13 WHICH
4 I'M JUST GOING TO PUT UP THERE FOR JUST A SECOND. HAVE
5 YOU --
6 THE COURT: CAN YOU SEE THAT, LADIES AND GENTLEMEN?
7 THEY CAN'T SEE IT. IT'S TOO LOW.
8 MR. WILSON: I'LL MOVE THIS DOWN FOR A MINUTE.
9 THE WITNESS: DO YOU NEED TO LOOK AT IT CLOSER?
10 IT'S PRETTY SMALL PRINTING.
11 Q. (BY MR. WILSON) HAVE YOU SEEN THAT EXHIBIT BEFORE,
12 DOCTOR?
13 A. I HAVE.
14 Q. AND WHAT IS THAT?
15 A. THAT'S ACTUALLY A -- A REPRODUCTION OF A PAGE OUT OF THE
16 PHYSICIANS' DESK REFERENCE.
17 Q. WHAT YEAR?
18 A. 1995.
19 Q. OKAY. THAT WAS THE PHYSICIANS' DESK REFERENCE THAT WAS
20 IN USE AT THE TIME OF THESE EVENTS?
21 A. YES, IT WAS.
22 Q. OKAY. CAN YOU TELL US WHAT -- BRIEFLY WHAT A DURAGESIC
23 PATCH IS?
24 A. A DURAGESIC PATCH IS A -- A TYPE OF PAIN MEDICINE AND --
25 A MEDICINE CALLED FENTANYL WHICH IS A VERY -- ACTUALLY A
1 MEDICINE WE USE IN ANESTHESIA QUITE A BIT. IT'S A NARCOTIC
2 PAIN MEDICINE, IS PLACED IN THE PATCH. THIS PATCH IS PLACED
3 ON THE SKIN. THE DRUG GOES THROUGH THE SKIN INTO THE BLOOD
4 STREAM. AND THAT'S HOW THE EFFECTS ARE GOTTEN.
5 Q. OKAY. THE PHYSICIANS' DESK REFERENCE, WHAT IS THAT? IS
6 THAT AN AUTHORITATIVE REFERENCE FOR PHYSICIANS?
7 A. IT IS. IT'S -- IT'S ONE SOURCE OF INFORMATION ON
8 MEDICATIONS. AND IT'S ESSENTIALLY A REPRODUCTION OF ALL OF
9 THE INFORMATION THAT'S BEEN OKAYED BY THE F.D.A. IN TERMS OF
10 HOW THE DRUG CAN BE USED AND HOW -- ANY WARNINGS, YOU KNOW,
11 ALL -- ALL OF THE SORTS OF DOCUMENTED INFORMATION ON -- ON
12 THE MEDICATION.
13 Q. OKAY. ARE THERE ANY PARTICULAR WARNINGS RELATIVE TO THE
14 USE OF THIS DRUG WITH -- WITH ELDERLY PATIENTS?
15 A. YES. WELL, CERTAINLY THE -- THE WARNINGS WITH ANY
16 NARCOTIC WOULD APPLY, YOU KNOW, WITH THIS. SO ELDERLY
17 PATIENTS WOULD BE EXPECTED TO BE MUCH MORE SENSITIVE TO THIS
18 PARTICULAR DOSE -- THIS PARTICULAR DOSE FORM JUST AS THEY
19 WOULD BE TO ANY OF THE OTHER PAIN MEDICINES.
20 Q. NOW, AS I UNDERSTAND IT, THIS IS SORT OF A SYNTHETIC FORM
21 OF MORPHINE?
22 A. IT IS.
23 Q. AND IT'S -- IT'S MADE UP IN WHAT TIME TYPE OF DOSAGES?
24 A. AGAIN, IT'S A -- IT'S A PATCH THAT IS PLACED ON THE SKIN
25 AND WILL LAST FOR THREE DAYS, SO IT GRADUALLY GIVES OFF
1 MEDICATION INTO THE BLOOD STREAM OVER ABOUT A THREE-DAY
2 PERIOD.
3 Q. AND IT HAS -- IT HAS VARIOUS MICROGRAM EQUIVALENTS,
4 DOESN'T IT?
5 A. YES, IT DOES.
6 Q. OKAY. WHAT IS -- HOW MANY DIFFERENT VARIATIONS ARE THERE
7 OF MICROGRAMS?
8 A. THERE ARE AT LEAST THREE OR FOUR. I GUESS THERE ARE FOUR
9 DIFFERENT -- FOUR DIFFERENT ONES.
10 Q. OKAY. AND THEY COME IN WHAT?
11 A. TWENTY-FIVE, 50, 75, AND 100 MIC. PATCHES.
12 Q. OKAY. I'M GOING TO PUT MARY CRANE BACK UP THERE. WHEN
13 SHE WAS ADMITTED TO THE UNIT, CAN YOU TELL US WHETHER OR NOT
14 YOU FORMED ANY OPINION FROM YOUR REVIEW OF THE RECORDS AS TO
15 HER MEDICAL STABILITY?
16 A. AGAIN, SHE HAD REALLY NO LIFE-THREATENING CONDITIONS AT
17 THAT POINT. SHE WAS MEDICALLY STABLE, HAD NO NEW MEDICAL
18 PROBLEMS THAT -- THAT WERE ANY SORT OF AN IMMEDIATE THREAT TO
19 HER LIFE.
20 Q. AND UPON ENTRY TO THE UNIT, WAS SHE GIVEN ANY PAIN
21 MEDICATION?
22 A. YES, SHE WAS.
23 Q. AND WHAT WAS THAT, SIR?
24 A. SHE WAS STARTED ON A DURAGESIC PATCH.
25 Q. AND DO YOU KNOW WHY THAT WAS?
1 A. WELL, SHE DID HAVE A HISTORY OF LOW BACK PAIN, BUT IT WAS
2 LOW BACK PAIN. IT WAS CONTROLLED WITH RATHER MINIMAL
3 MEDICATION BEFORE SHE CAME IN. SHE WAS TAKING, AT MOST, ONE
4 HYDROCODONE TABLET A DAY. AND I BELIEVE HADN'T EVEN HAD ANY
5 OF THAT FOR QUITE A WHILE BEFORE COMING INTO THE HOSPITAL.
6 SO SHE WAS REQUIRING REALLY PRETTY MINIMAL MEDICATION.
7 SO THE -- THE USE OF A DURAGESIC PATCH UNDER THOSE
8 CIRCUMSTANCES WAS, AGAIN, A HUGE JUMP IN THE AMOUNT OF
9 MEDICATION. DURAGESIC IS USUALLY RESERVED FOR -- FOR
10 PATIENTS WHO HAVE BEEN ON A LOT OF PAIN MEDICINE FOR A LONG
11 TIME AND WE'RE JUST INTERESTED IN SWITCHING THEM OVER TO A
12 LONGER ACTING FORM OF -- OF THE SHORTER ACTING MEDICINES THAT
13 THEY'VE BEEN ON. FOR A PATIENT THAT'S REALLY NOT BEEN ON
14 MUCH MEDICATION, THIS WOULD BE A HUGE STEP IN -- IN TERMS OF
15 THE AMOUNT OF MEDICATION THEY'RE GETTING.
16 Q. OKAY. IS -- IS THERE AN EQUIVALENT TO MORPHINE OR IS
17 THERE A CONVERSION TABLE THAT THEY HAVE IN RESPECT TO -- TO
18 MORPHINE?
19 A. YES, THERE IS.
20 Q. AND THE DURAGESIC PATCH.
21 A. YEAH. YES, THERE IS.
22 Q. NOW, I SHOW YOU WHAT'S MARKED AS STATE'S EXHIBIT 14 AND
23 ASK YOU TO TAKE A LOOK AT THAT, IF YOU WOULD, PLEASE. CAN
24 YOU TELL US WHAT THAT IS?
25 A. YES. THIS IS THAT EQUIVALENT TABLE AND IT SHOWS ON THE
1 ONE SIDE THE DIFFERENT DOSE DURAGESIC PATCHES AND THE
2 APPROXIMATE EQUIVALENCY TO ORAL MORPHINE.
3 Q. OKAY.
4 A. INJECTABLE MORPHINE WOULD BE ABOUT A THIRD OF THE ORAL
5 MORPHINE DOSE. SO IT WOULD BE -- YOU KNOW, JUST TO -- JUST
6 TO GET A -- AN IDEA.
7 Q. SO I NOTE THERE WE HAVE A DURAGESIC DOSE OF 25
8 MICROGRAMS, I GUESS IT IS, ON THE RIGHT-HAND SIDE?
9 A. YES.
10 Q. ON THE TOP LINE THERE. AND THEN WE HAVE 45 TO 134 ORAL
11 MORPHINE?
12 A. YES.
13 Q. THAT SEEMS TO BE A FAIRLY BROAD VARIATION OR A WIDE
14 VARIATION IN TERMS OF THE AMOUNT OF -- OF MORPHINE THAT IT IS
15 EQUIVALENT TO; IS THAT CORRECT?
16 A. IT IS. UH-HUH.
17 Q. BUT YOU'RE SAYING THAT FOR AN I.M. INJECTION, YOU TAKE
18 APPROXIMATELY ONE-THIRD OF -- OF THOSE NUMBERS TO REPRESENT
19 WHAT A 25 MICROGRAM PATCH WOULD BE?
20 A. YES.
21 Q. AND NOW IS THAT -- THAT'S THE EQUIVALENT OF MICROGRAMS --
22 OR EXCUSE ME, OF MILLIGRAMS PER DAY, RIGHT?
23 A. YES, IT WOULD BE.
24 Q. OKAY. SO I WOULD DIVIDE -- IF I DIVIDED THE LOWEST
25 NUMBER, I WOULD DIVIDE THAT BY THREE. SO THE EQUIVALENT TO
1 25 OF A DURAGESIC DOSE WOULD BE ABOUT 15 MILLIGRAMS OF
2 MORPHINE PER DAY?
3 A. WELL, THAT WOULD BE ON THE VERY LOW END.
4 Q. THAT WOULD BE ON THE LOW END.
5 A. YES.
6 Q. OKAY. CAN YOU COMMENT, IF YOU WOULD, RELATIVE TO THE
7 EFFECT OF PUTTING DURAGESIC PATCH ON TOP OF THE PSYCHOTROPIC
8 MEDICATION?
9 A. AGAIN, THE -- THE PSYCHOTROPIC MEDICATIONS AND C.N.S.
10 DEPRESSANTS ARE GOING TO HAVE AN ADDITIVE EFFECT, AN
11 ENHANCING EFFECTS TO THE EFFECTS OF THE NARCOTIC.
12 Q. ALL RIGHT. NOW, WERE THERE EVENTS THAT TRANSPIRED ON OR
13 ABOUT JANUARY 3RD, ACCORDING TO THE MEDICAL RECORD, REGARDING
14 MARY CRANE?
15 A. ABOUT THAT TIME SHE WAS THOUGHT TO HAVE A SEIZURE.
16 Q. OKAY. DO YOU NOTE WHETHER OR NOT THERE WAS EVER A -- A
17 FINDING THAT SHE HAD A VAGINAL FISTULA?
18 A. THAT WAS -- THAT WAS ALSO A FINDING AT A -- AT A LATER
19 TIME, YES.
20 Q. OKAY. AND IN REGARDS TO AROUND THAT TIME PERIOD,
21 JANUARY 3RD, WE HAVE IN ADDITION TO THE 50 MICROGRAM
22 DURAGESIC PATCH, WE HAVE SOME MORPHINE THAT WAS ADMINISTERED
23 TO HER ON THAT DATE; IS THAT CORRECT?
24 A. YES, IT IS.
25 Q. AND WE ALSO HAVE SOME DEPAKENE. IS THAT ALSO CORRECT?
1 A. YES, IT IS.
2 Q. AND IS THAT ALSO A CENTRAL NERVOUS SYSTEM DEPRESSANT?
3 A. IT WOULD BE.
4 Q. IN TERMS OF THE JANUARY 4TH, IT APPEARS THAT THE
5 DURAGESIC PATCH WAS INCREASED TO 75 MICROGRAMS; IS THAT
6 CORRECT?
7 A. YES, IT WAS.
8 Q. DID YOU SEE ANYTHING IN THE MEDICAL RECORD RELATIVE TO
9 THE ADMINISTRATION OF BOTH THE MORPHINE AND DURAGESIC PATCH
10 INCREASE THAT INDICATED THIS PATIENT WAS IN PAIN?
11 A. THERE WERE NOTES IN THE PROGRESS NOTES SAYING THAT SHE
12 WAS CRYING OUT APPARENTLY IN -- IN PAIN, BUT I THINK THERE
13 WERE ALSO NOTES SUGGESTING THAT -- THAT SOME OF THESE REPORTS
14 WERE HARD TO INTERPRET OR A BIT SUSPECT.
15 Q. OKAY. DID YOU SEE ANY OTHER SIDE EFFECTS OF EITHER
16 MORPHINE OR AT LEAST OPIOID TOXICITY TO -- TO THIS PARTICULAR
17 PATIENT GOING FROM JANUARY 3RD UP UNTIL THE DATE OF HER
18 DEATH?
19 A. AT ONE POINT ON JANUARY 5TH IT WAS THOUGHT THAT SHE
20 ASPIRATED, IN OTHER WORDS, BREATHED WATER, I BELIEVE, DOWN
21 INTO HER LUNGS.
22 Q. IS THAT A SIDE EFFECT OF MORPHINE INTOXICATION?
23 A. IT IS. AGAIN, IT SUPPRESSES THAT REFLEX THAT HELPS
24 PREVENT THAT.
25 Q. OKAY.
1 A. SO IT APPEARED THAT WAS PART OF THE PROBLEM.
2 Q. WHAT ABOUT SEDATION? WERE THERE ANY NOTES RELATIVE TO
3 SEDATION?
4 A. NOT -- NOT A LOT. THERE WAS SOME MENTION OF FLAT AFFECT.
5 LET ME JUST SEE AT A LATER TIME HERE. THERE'S MENTION ON THE
6 6TH OF LETHARGY, WHICH ANOTHER WAY OF DESCRIBING SEDATION.
7 AND THEN ON THE 7TH SHE WAS DESCRIBED AS UNRESPONSIVE.
8 Q. IS THERE --
9 A. ALL OF THOSE -- ALL OF THOSE THINGS WOULD --
10 Q. IS THERE A DIFFERENCE BETWEEN UNRESPONSIVE AND LETHARGY?
11 A. LETHARGY WOULD -- WOULD -- WOULD SUGGEST A DECREASED
12 LEVEL OF -- OF RESPONSIVENESS, AND UNRESPONSIVENESS IS NO
13 RESPONSIVENESS.
14 Q. OKAY. RELATIVE TO THE CONDUCT OF THE DEFENDANT AS TO THE
15 TREATMENT AND CARE OF MARY CRANE, DID YOU FORM AN OPINION
16 BASED UPON YOUR REVIEW AS TO WHETHER OR NOT THE STANDARD OF
17 CARE -- WHETHER OR NOT HE DEVIATED -- THE DEFENDANT DEVIATED
18 FROM THE STANDARD OF CARE AS WOULD BE EXERCISED BY A
19 PHYSICIAN IN THE SAME CIRCUMSTANCE?
20 A. YES, I -- I BELIEVE HE DEVIATED FROM THE STANDARD, FELL
21 BELOW THE STANDARD.
22 Q. AND CAN YOU, AGAIN, TELL US SPECIFICALLY IN WHAT WAYS HE
23 DEVIATED FROM THE STANDARD?
24 A. THE USE OF THE LARGE AMOUNTS OF THE C.N.S. DEPRESSANT
25 DRUGS IN COMBINATION WITH THE NARCOTICS GRADUALLY WEAKENED
1 THE PATIENT AND EVENTUALLY LED TO HER DEMISE.
2 Q. OKAY. JUST JUMPED AHEAD OF ME. I WAS GOING TO ASK YOU
3 ABOUT THE CAUSE OF DEATH.
4 HAVE YOU FORMED AN OPINION AS TO THE CAUSE OF DEATH?
5 A. YES, I HAVE.
6 Q. TO A REASONABLE DEGREE OF MEDICAL CERTAINTY?
7 A. YES.
8 Q. AND WOULD THAT BE THE SAME THING THAT YOU JUST
9 REFERENCED?
10 A. YES, IT IS.
11 Q. THAT IT WAS A COMBINATION OF THE DURAGESIC PATCH, THE
12 MORPHINE, AND THE CENTRAL NERVOUS SYSTEM DEPRESSANTS?
13 A. YES, IT WAS.
14 MR. WILSON: I'VE GOT TWO MORE PATIENTS LEFT, JUDGE.
15 DO YOU WANT ME TO GO ON WITH THEM BEFORE WE -- BEFORE WE
16 BREAK OR --
17 THE COURT: I THINK MAYBE IT'S A GOOD TIME FOR A
18 BREAK WHILE WE'RE -- BEFORE WE START ANOTHER ONE. LET'S TAKE
19 OUR BREAK, GO TO 3:15.
20 MR. BUGDEN: MAY I APPROACH THE BENCH?
21 THE COURT: YOU MAY. LADIES AND GENTLEMEN, YOU'LL
22 BE EXCUSED. I REMIND YOU OF MY PRIOR ADMONITION.
23 (OFF-THE-RECORD DISCUSSION)
24 THE COURT: WE'LL BE IN RECESS.
25 (RECESS TAKEN)
1 THE COURT: PARTIES AND COUNSEL ARE PRESENT, THE
2 JURY IS IN THE JURY BOX. DR. HARE IS STILL ON THE STAND.
3 AND, DOCTOR, I REMIND YOU THAT YOU'RE STILL UNDER OATH.
4 YOU MAY PROCEED, MR. WILSON.
5 MR. WILSON: THANK YOU, YOUR HONOR.
6 Q. (BY MR. WILSON) DOCTOR, I NEXT WANT TO TALK ABOUT LYDIA
7 SMITH. DID YOU HAVE A CHANCE TO REVIEW HER RECORDS AT THE
8 DAVIS HOSPITAL?
9 A. YES, I DID.
10 Q. AND CAN YOU TELL US, SIR, DID YOU FORM AN OPINION
11 RELATIVE TO HER MEDICAL STABILITY AT THE TIME SHE ENTERED THE
12 UNIT?
13 A. AGAIN, SHE SEEMED TO -- EVEN THOUGH SHE HAD SOME
14 CO-EXISTING MEDICAL PROBLEM, NONE OF THOSE SEEMED TO BE
15 LIFE-THREATENING OR ACUTE AT THE TIME.
16 Q. OKAY. YOU WERE ALSO -- I'M CALLING YOUR ATTENTION TO
17 WHAT'S MARKED AS STATE'S EXHIBIT 5-E. AND CALLING YOUR
18 ATTENTION TO THAT EXHIBIT, THE VARIOUS MEDICATIONS AND THE
19 DOSAGE AMOUNTS THAT ARE REPRESENTED ON THERE, DO THEY
20 CORRESPOND TO YOUR RECOLLECTION AS TO THE REVIEW THAT YOU
21 MADE OF -- OF HER RECORDS?
22 A. YES, THEY DO.
23 Q. OKAY. BRIEFLY, CAN YOU CHARACTERIZE FOR US, IF YOU
24 WOULD, THE EFFECT OF THE VARIOUS MEDICATIONS ON TOP OF ONE
25 ANOTHER?
1 A. AGAIN, THEY WOULD -- AS ALL -- ALL OF THEM ARE C.N.S.
2 DEPRESSANTS, THEY'RE GOING TO HAVE AN ADDED EFFECT TO ONE
3 ANOTHER, AND HIGHER AND HIGHER DOSES ARE GOING TO HAVE A
4 GREATER AND GREATER EFFECT.
5 Q. OKAY. RELATIVE TO THE -- ANY SIGNS OF COMPLAINTS OF
6 PAIN, WERE THERE ANY OF THOSE EVIDENCED IN THE RECORD?
7 A. THERE REALLY WEREN'T ANY -- ANY NOTES THAT INDICATED
8 ANYTHING IN TERMS OF PAIN BEFORE SHE CAME IN THE HOSPITAL, OR
9 FOR AT LEAST THE FIRST -- EVEN BEYOND THE FIRST TWO WEEKS SHE
10 WAS IN THE HOSPITAL THERE WAS NO NOTE IN THE CHART THAT
11 INDICATES ANY SORT OF A PAIN PROBLEM.
12 Q. OKAY. CAN YOU TELL US WHETHER OR NOT TO YOUR VIEW --
13 REVIEW OF THE RECORD WHETHER YOU NOTED ANY SIGNS OR EFFECTS
14 OF -- OF THE TOXICITY OF THE CENTRAL NERVOUS SYSTEM
15 DEPRESSANTS?
16 A. AGAIN, ABOUT TWO OR TWO AND A HALF WEEKS INTO THIS
17 PROCESS WAS ABOUT THE TIME THAT SHE DID BEGIN TO DEMONSTRATE
18 SOME CLEAR SIGNS OF -- OF TOXICITY WITH THESE MEDICATIONS.
19 Q. CAN YOU TELL US WHAT THOSE SIGNS WERE?
20 A. YES. AROUND JANUARY 3RD IT'S MENTIONED THAT SHE'S VERY
21 DROWSY. DID NOT EAT DINNER DUE TO LETHARGIC STATE. SLEEPING
22 QUITE A BIT. LETHARGIC DURING SHIFT. UNRESPONSIVE. DOZED
23 OFF AND ON.
24 THERE ARE JUST NUMEROUS COMMENTS, YOU KNOW, THROUGHOUT
25 THE NOTES DURING THAT TIME.
1 Q. CAN YOU TELL US, DOCTOR, DID YOU NOTE ANY CHANGE IN THE
2 PATIENT'S WEIGHT DURING THAT TIMEFRAME?
3 A. I DON'T RECALL ANYTHING SPECIFICALLY ABOUT HER WEIGHT.
4 THERE'S CERTAINLY NOTES TO THE EFFECT THAT SHE'S NOT EATING
5 AND -- AND SO ON, BUT I -- I DON'T RECALL ANY SPECIFIC WEIGHT
6 NOTES.
7 Q. OKAY. IS THAT ALSO A SIGN OF THE CENTRAL NERVOUS
8 DEPRESSANTS EFFECT?
9 A. CERTAINLY COULD BE, YES.
10 Q. OKAY. NOW, SHE DID NOT RECEIVE MORPHINE UP UNTIL
11 JANUARY 7TH; IS THAT CORRECT?
12 A. YES.
13 Q. AND DID YOU SEE ANY SIGNS OR EVIDENCE OF ANY KIND OF PAIN
14 ON JANUARY THE 7TH WHICH WOULD IN YOUR MEDICAL JUDGMENT
15 REQUIRE THE ADMINISTRATION OF MORPHINE?
16 A. IT ONLY SAYS IN THE NOTES THAT AT TIMES SHE THRASHES
17 ABOUT, SEEMS TO BE IN PAIN, ANXIETY. BUT ANY -- OTHER THAN
18 A, YOU KNOW, VERY GENERAL DESCRIPTION -- AND AGAIN, THIS
19 IS -- YOU KNOW, PRIOR TO THIS TIME THERE REALLY WEREN'T ANY
20 PAIN COMPLAINTS. I'M NOT SURE WHY SUDDENLY THERE WOULD BE
21 PAIN COMPLAINTS.
22 Q. OKAY. DID YOU SEE ANY OTHER REASON FOR THE USE OF
23 MORPHINE AT THAT TIME?
24 A. NO, I CAN'T.
25 Q. ALL RIGHT. SIR, CAN YOU TELL US BASED UPON YOUR REVIEW
1 OF THE MEDICAL RECORDS OF LYDIA SMITH AND -- AND YOUR
2 EXPERIENCE AND TRAINING AND EXPERTISE, DID YOU HAVE OCCASION
3 TO FORM AN OPINION AS TO WHETHER THE TREATMENT BY THE
4 DEFENDANT AS TO -- AND THE CARE OF LYDIA SMITH DEVIATED FROM
5 THE STANDARDS OF CARE AS WOULD BE EXERCISED BY A PHYSICIAN IN
6 THE SAME CIRCUMSTANCES?
7 A. I -- I FEEL THAT THE CARE FELL BELOW THE STANDARD OF
8 CARE.
9 Q. OKAY. CAN YOU BE SPECIFIC AS TO HOW YOU FELT IT FELL
10 BELOW THE STANDARD OF CARE?
11 A. YES. I FEEL THAT SHE WAS TREATED WITH EXCESSIVE DOSES OF
12 SEDATING MEDICINES TO THE POINT OF WHERE IT EVENTUALLY HAD
13 DEBILITATING EFFECTS AND EVENTUALLY FATAL EFFECTS, THE
14 COMBINATION OF THE C.N.S. DEPRESSANTS AND THEN FINALLY THE
15 MORPHINE LED TO HER DEATH.
16 Q. LED TO HER DEATH? AND DO YOU FEEL THAT YOU COULD MAKE
17 THAT JUDGMENT TO A REASONABLE DEGREE OF MEDICAL CERTAINTY?
18 A. YES, I DO.
19 Q. OKAY. LET'S TURN NOW TO ENNIS ALLDREDGE. FIRST OF ALL,
20 HAVE YOU REVIEWED HIS MEDICAL RECORDS FROM DAVIS HOSPITAL?
21 A. YES, I HAVE.
22 Q. AND CAN YOU TELL US BASED UPON YOUR REVIEW, CAN YOU
23 DESCRIBE FOR US WHAT YOU THINK HIS MEDICAL CONDITION WAS ON
24 THE DATE OF HIS ADMISSION TO THE GEROPSYCH UNIT?
25 A. HE, AGAIN, HAD NO LIFE-THREATENING MEDICAL PROBLEMS AT
1 THAT TIME. HE HAD SOME CHRONIC PROBLEM, CHRONIC MEDICAL
2 PROBLEMS, BUT NONE WERE UNSTABLE OR, YOU KNOW, AS I SAY,
3 LIFE-THREATENING AT THAT TIME.
4 Q. OKAY. CAN YOU TELL US -- I'M CALLING YOUR ATTENTION TO
5 EXHIBIT 6-F. CAN YOU TELL US, DOCTOR, DO THE MEDICATIONS
6 THAT ARE REPRESENTED THERE AND THE DOSAGES ON EACH OF THOSE
7 DATES CORRESPOND TO YOUR RECOLLECTION OF WHAT WAS
8 ADMINISTERED TO ENNIS ALLDREDGE?
9 A. YES, THEY DO.
10 Q. AND CAN YOU TELL US WHETHER OR NOT AT THE TIME OF HIS
11 ADMISSION THERE WERE ANY COMPLAINTS OF PAIN BY THIS
12 PARTICULAR PATIENT OR BY RELATIVES ON HIS BEHALF?
13 A. THERE WERE NO -- NO -- THERE'S NO HISTORY OF PAIN
14 COMPLAINTS AND -- AND REALLY NONE NOTED INTO THE CHART EVEN
15 PARTWAY THROUGH HIS -- HIS STAY IN THE HOSPITAL.
16 Q. OKAY. CAN YOU TELL US, WERE THERE ANY EVENTS THAT
17 OCCURRED IN THE HOSPITAL THAT APPEARED TO BE OF A
18 LIFE-THREATENING NATURE?
19 A. THERE WAS -- I MEAN WHETHER -- WHETHER THEY WERE
20 LIFE-THREATENING IN ANOTHER SITUATION, HE WAS EVALUATED FOR
21 THE POSSIBILITY OF HAVING HAD A STROKE, BUT THE EVALUATION
22 WAS INDETERMINATE. THERE WAS REALLY NO CLEAR INDICATION THAT
23 HE -- THAT HE HAD.
24 Q. ASSUMING, SIR, THAT HE HAD HAD INDEED A STROKE, WOULD
25 THERE BE ANY MEDICAL REASON IN YOUR JUDGMENT FOR THE
1 ADMINISTRATION OF MORPHINE?
2 A. AS FAR AS HELPING WITH A STROKE, ABSOLUTELY NOT. IF, YOU
3 KNOW, HIS CONDITION HAD SERIOUSLY DETERIORATED BECAUSE OF A
4 STROKE AND -- AND THIS SUDDENLY BECAME AN END-OF-LIFE
5 SITUATION, YOU KNOW, THEN AT LEAST SOME JUDICIOUS USE OF
6 MORPHINE MAY HAVE BEEN INDICATED.
7 Q. OKAY. DID YOU OBSERVE ANYTHING IN THE MEDICAL RECORD
8 RELATIVE TO ANY KIND OF CLINICAL CORRELATION IN REGARDS TO A
9 STROKE?
10 A. NO.
11 Q. OKAY. CAN YOU TELL US, SIR, BASED UPON YOUR MEDICAL
12 EXPERIENCE AND YOUR REVIEW OF ENNIS ALLDREDGE'S RECORD
13 WHETHER OR NOT YOU FORMED AN OPINION AS TO THE -- WHETHER THE
14 CONDUCT OF THE DEFENDANT AS TO HIS TREATMENT AND CARE OF
15 ENNIS ALLDREDGE DEVIATED FROM THE STANDARDS OF CARE AS WOULD
16 BE EXERCISED BY A PHYSICIAN UNDER THE SAME CIRCUMSTANCE?
17 A. I -- I FEEL IT FELL BELOW THE STANDARD OF CARE.
18 Q. OKAY. AND CAN YOU BE MORE SPECIFIC AS TO HOW YOU FELT IT
19 FELL BELOW THE STANDARD OF CARE?
20 A. I FEEL THAT THE PATIENT WAS OVERTREATED WITH C.N.S.
21 DEPRESSANTS AND EVENTUALLY DIED FROM A COMBINATION OF THE
22 C.N.S. DEPRESSANTS AND THE -- THE MORPHINE.
23 Q. OKAY. AND IS THAT OPINION TO A REASONABLE DEGREE OF
24 MEDICAL CERTAINTY?
25 A. YES, IT IS.
1 Q. OKAY.
2 MR. WILSON: I HAVE NO FURTHER QUESTIONS, YOUR
3 HONOR.
4 THE COURT: MR. BUGDEN, YOU MAY CROSS-EXAMINE.
5 MR. BUGDEN: THANK YOU, JUDGE.
6 CROSS-EXAMINATION
7 BY MR. BUGDEN:
8 Q. DR. HARE, I'M WALTER BUGDEN. HOW DO YOU DO?
9 A. HELLO, SIR.
10 Q. I REPRESENT DR. WEITZEL.
11 DR. HARE, HAVE YOU TREATED PATIENTS IN YOUR PRACTICE FOR
12 SYMPTOMS OF PAIN OR OTHER DISTRESSING SYMPTOMS WITH MORPHINE?
13 A. YES, I HAVE.
14 Q. AND HAVE SOME OF YOUR PATIENTS THAT YOU'VE TREATED WITH
15 MORPHINE DIED?
16 A. THERE HAVE BEEN SOME TERMINAL CANCER PATIENTS, FOR
17 INSTANCE, THAT WE'VE BEEN TREATING WITH MORPHINE WHO HAVE
18 GONE ON TO DIE, YES.
19 Q. WELL, LET ME ASK THE QUESTION A LITTLE BIT DIFFERENTLY.
20 HAVE YOU HAD PATIENTS THAT YOU'VE TREATED WITH MORPHINE TO
21 TRY TO RELIEVE SYMPTOMS OF PAIN OR DISTRESS WHO UPON THEIR
22 DEATH HAD MORPHINE IN THEIR SYSTEM?
23 A. YES. YES, THERE WOULD BE.
24 Q. AND YOU SAY YOU'VE TREATED CANCER PATIENTS WITH MORPHINE.
25 WERE THOSE COMFORT CARE CASES? WERE THOSE CASES WHERE YOU
1 WERE NO LONGER TRYING TO CURE THE PATIENT, BUT YOU WERE
2 TRYING TO JUST PROVIDE COMFORT TO THE PATIENT?
3 A. YES. THESE WERE CANCER PATIENTS WITH PAINFUL CANCER THAT
4 WE'D TREATED FOR PAIN ALL ALONG, AND IT EVENTUALLY DEVELOPED
5 INTO A TERMINAL SITUATION.
6 Q. AND WHEN YOU'RE TREATING PATIENTS IN A TERMINAL SITUATION
7 AND TRYING TO RELIEVE SYMPTOMS OF PAIN, IS THE GOAL OF THE
8 TREATMENT TO PREVENT THE PAIN FROM RETURNING, DR. HARE?
9 A. YES, IT IS.
10 Q. AND SO YOU PICK A DOSAGE OF MORPHINE OR WHATEVER PAIN --
11 WELL, IN THIS CASE WE'RE TALKING ABOUT MORPHINE -- THAT'S
12 INTENDED TO PREVENT THE PAIN FROM RETURNING; IS THAT RIGHT?
13 A. YES. UH-HUH.
14 Q. DR. HARE, I'D LIKE TO ASK YOU SOME QUESTIONS ABOUT
15 YOUR -- YOUR EXPERIENCE. OF COURSE YOU KNOW THAT ALL OF THE
16 PATIENTS IN THIS CASE THAT WE'RE TALKING ABOUT ALL WERE
17 SUFFERING FROM OR HAD THE DIAGNOSIS OF DEMENTIA; IS THAT
18 RIGHT?
19 A. THAT'S RIGHT.
20 Q. AND CAN YOU TELL ME, DR. HARE, HOW MANY PATIENTS YOU'VE
21 TREATED LIKE LYDIA SMITH OR MARY CRANE OR ENNIS ALLDREDGE,
22 JUDITH LARSEN OR ELLEN ANDERSON IN YOUR NURSING HOME
23 PRACTICE, FOR EXAMPLE, PATIENTS IN A NURSING HOME SETTING
24 WITH DEMENTIA?
25 A. ACTUALLY MY -- AGAIN MY PRACTICE IS A PAIN-RELATED
1 PRACTICE AND I'M NOT IN A PRACTICE, YOU KNOW, WHERE I'M
2 PRIMARILY TREATING PATIENTS FOR DEMENTIA.
3 Q. SO --
4 A. SO THIS IS, YOU KNOW, A DIFFERENT -- DIFFERENT SETTING IN
5 THAT REGARD THAN MY PRACTICE.
6 Q. WELL, THAT'S WHAT I -- I WANT TO ASK YOU SOME QUESTIONS
7 SO THAT I CAN HAVE SOME UNDERSTANDING OF WHETHER OR NOT YOU
8 REALLY HAVE EXTENSIVE EXPERIENCE DEALING WITH DEMENTED
9 PATIENTS. AND SO I ASK YOU AGAIN, HOW MANY PATIENTS DO YOU
10 TREAT WITH DEMENTING ILLNESS IN A NURSING HOME SETTING, FOR
11 EXAMPLE? DO YOU TREAT ANY?
12 A. NO, I DON'T.
13 Q. AND HOW ABOUT --
14 A. WELL, THAT PROBABLY -- THAT ISN'T ENTIRELY FAIR. I --
15 THEY'RE -- YOU KNOW, ON OCCASION I'M -- I'M HELPING OUT WITH,
16 YOU KNOW, WITH PATIENTS, CONSULTING. BUT IT'S A
17 RELATIVELY -- RELATIVELY SMALL NUMBER.
18 Q. HOW ABOUT PROVIDING PALLIATIVE CARE TO PATIENTS
19 PRESENTING WITH THE KIND OF DEMENTIA THAT THESE PATIENTS
20 PRESENTED WITH AT THE END OF THEIR LIFE? DO YOU -- DO YOU
21 TREAT PATIENTS, PROVIDE PALLIATIVE CARE? THAT IS RELIEF OF
22 PAIN TO DEMENTED PATIENTS AT THE END OF THEIR LIFE? IS THAT
23 SOMETHING THAT YOU DO?
24 A. I DON'T -- WELL, AGAIN, I SEE SOME PATIENTS WHO HAVE
25 DEMENTIA THAT PRESENT TO ME PRIMARILY WITH PAIN PROBLEMS, AND
1 I HELP OUT WITH THEIR MANAGEMENT. BUT AS FAR AS TREATING --
2 KIND OF THE OTHER WHERE IT'S PRIMARILY TREATING THE DEMENTIA
3 PATIENTS AND THEIR KIND OF GENERAL OVERALL CARE, I DON'T DO
4 THAT. THAT ISN'T PART -- THAT ISN'T MY AREA OF PRACTICE.
5 Q. SO YOU REALLY DON'T TREAT ANY PATIENTS WITH END-STAGE
6 DEMENTIA OR ALZHEIMERS; IS THAT RIGHT?
7 A. NOT AS A -- NOT FOR THAT PROBLEM, NO.
8 Q. AND AREN'T I ALSO RIGHT, DR. HARE, THAT YOU DON'T
9 ROUTINELY TREAT DYING PATIENTS?
10 A. I WOULDN'T SAY ROUTINELY. I DO ON OCCASION, BUT THAT'S
11 NOT A -- IT'S A SMALL PART OF MY PRACTICE.
12 Q. THE MAIN PART OF YOUR PRACTICE IS JUST TREATING PEOPLE
13 WITH CHRONIC PAIN; ISN'T THAT RIGHT?
14 A. CHRONIC PAIN AND ACUTE PAIN, YES.
15 Q. AND AM I RIGHT, DR. HARE, THAT YOU DON'T ROUTINELY TREAT
16 PATIENTS WHO ARE UNABLE TO COMMUNICATE ABOUT THEIR CARE?
17 A. AGAIN, YOU KNOW, I TREAT SOME, BUT IT'S A -- IT WOULD BE
18 A RELATIVELY SMALL NUMBER.
19 Q. AND AM I CORRECT, DOCTOR, THAT YOU REALLY DON'T HAVE ANY
20 EXPERIENCE WITH PROVIDING WHAT'S CALLED HOSPICE CARE?
21 A. I WOULDN'T SAY NOT ANY EXPERIENCE, AGAIN, A SMALL PART OF
22 MY PRACTICE. I DO SEE SOME CANCER PATIENTS, I HELP OUT WITH
23 THEIR CARE, BUT IT'S -- IT'S NOT A -- IT WOULD BE A VERY
24 SMALL PART OF MY PRACTICE.
25 Q. DON'T ALL OF YOUR PATIENTS ACTUALLY WALK IN THE DOOR TO
1 YOU? OR THE MAJORITY OF YOUR PATIENTS COME TO YOUR PAIN
2 CLINIC FOR TREATMENT AND ARE ABLE TO AMBULATE IN?
3 A. A GOOD NUMBER OF THEM DO, BUT WE ALSO WORK WITH HOME
4 NURSING ON A CERTAIN NUMBER OF PATIENTS AND HELP OUT WITH
5 THEIR CARE THROUGH THAT WAY.
6 Q. AND THIS IS THE LAST QUESTION I'LL ASK ABOUT THIS AREA,
7 BUT -- SO THEN IN YOUR PRACTICE YOU'RE NOT AT THE BEDSIDE OF
8 A DEMENTED PATIENT TREATING THAT PATIENT FOR HIS CONDITION OF
9 DEMENTIA. AM I RIGHT?
10 A. THAT'S CORRECT.
11 Q. THANK YOU. AND WOULD I ALSO BE CORRECT, DOCTOR, THAT YOU
12 DON'T ACTUALLY BELONG TO ANY PROFESSIONAL SOCIETIES THAT ARE
13 DEDICATED TO IMPROVING THE CARE OF ELDERLY PATIENTS?
14 A. I BELONG TO A NUMBER OF PAIN SOCIETIES AND ELDERLY
15 PATIENTS ARE IN THEIR CARE AND SPECIFIC NEEDS ARE -- ARE VERY
16 MUCH ADDRESSED BY THOSE SOCIETIES.
17 Q. DO YOU BELONG --
18 A. BUT I DON'T -- LIKE GERONTOLOGY OR SPECIFIC -- YOU KNOW,
19 THE GENERAL CARE OF ELDERLY PATIENTS, NO, I DON'T.
20 Q. THANK YOU. AND AM I CORRECT, DOCTOR -- ARE YOU FAMILIAR
21 WITH A WITNESS WHO'S GOING TO TESTIFY ON BEHALF OF
22 DR. WEITZEL BY THE NAME OF PERRY FINE?
23 A. YES, I AM.
24 Q. AND HOW DO YOU KNOW DR. FINE?
25 A. DR. FINE AND I ARE IN PRACTICE TOGETHER.
1 Q. WHERE IS IT THAT -- IS IT A PAIN CLINIC ASSOCIATED WITH
2 THE UNIVERSITY OF UTAH?
3 A. YES.
4 Q. AND AM I CORRECT, DOCTOR, THAT AFTER YOU WERE INITIALLY
5 CONTACTED BY THE STATE TO REVIEW THE MEDICAL RECORDS IN THIS
6 CASE, THAT YOU RECOMMENDED TO THESE PROSECUTORS THAT THEY
7 CONTACT DR. PERRY FINE TO GET ANOTHER OPINION?
8 A. YES.
9 Q. AND AM I CORRECT THAT YOU RECOMMENDED THAT THE STATE'S
10 LAWYERS CONTACT YOUR COLLEAGUE, DR. FINE, BECAUSE HE WAS
11 SOMEONE MORE QUALIFIED WITH END-OF-LIFE CARE IN ELDERLY
12 DEMENTED PATIENTS?
13 A. YOU KNOW, I HONESTLY DON'T REMEMBER THE EXACT
14 CIRCUMSTANCES, BUT THAT -- THAT COULD BE.
15 Q. OKAY. THANK YOU. AND NOW LET ME ASK YOU ABOUT THE --
16 THE DEMENTING BEHAVIORS OF THESE PATIENTS WHEN THEY WENT TO
17 THE GEROPSYCHIATRIC UNIT. ALL OF THESE PATIENTS WERE
18 REFERRED TO THE HOSPITAL BECAUSE THEIR DEMENTED BEHAVIORS
19 WERE OUT OF CONTROL; ISN'T THAT RIGHT?
20 A. THAT'S RIGHT.
21 Q. THEY WERE ALL ACTING IN AN AGITATED, WILD WAY. THEY
22 COULDN'T -- THEY WEREN'T CAPABLE OF -- THE NURSING HOMES AND
23 LONG-TERM CARE FACILITIES JUST COULDN'T HANDLE THESE PEOPLE.
24 A. THAT'S RIGHT.
25 Q. AND DO YOU AGREE THAT THEY WERE SENT TO THE HOSPITAL
1 PRIMARILY TO RECEIVE PSYCHOTROPIC MEDICATIONS TO TRY TO
2 CONTROL THESE AGITATING BEHAVIORS?
3 A. YES. THAT -- THAT ALONG WITH, YOU KNOW, POSSIBLY
4 NONMEDICATION TREATMENTS, TOO.
5 Q. ONE OF THE CRITICISMS, AS I UNDERSTAND, THAT YOU'VE MADE
6 IS THAT YOU THINK THAT THE PSYCHOTROPIC MEDICATIONS WERE
7 OVERDONE WITH THE PATIENTS; IS THAT RIGHT?
8 A. YES.
9 Q. ARE YOU FAMILIAR WITH A DRUG CALLED RISPERDAL?
10 A. YES, I AM.
11 Q. AND IN 1995 WOULD YOU AGREE THAT RISPERDAL WAS A NEW
12 MEDICATION AT THAT TIME?
13 A. IT WAS.
14 Q. AND WOULD YOU AGREE THAT IT WAS CONSIDERED AT THAT TIME
15 THE BEST MEDICATION AVAILABLE TO TREAT AGITATION?
16 A. AS FAR AS THE -- THE CLINICAL INDICATIONS FOR RISPERDAL
17 AT THAT TIME I'M NOT CERTAIN, YOU KNOW, WHAT THE SPECIFIC
18 INDICATIONS WERE FOR IT. BUT I -- I WOULD SAY -- I WOULD NOT
19 CONTEST THAT IT'S --
20 Q. A GOOD DRUG?
21 A. -- YOU KNOW, A REASONABLE DRUG FOR -- IN THIS -- IN THIS
22 PATIENT POPULATION.
23 Q. OKAY. NOW, AGAIN, ONCE WE'RE AT THE HOSPITAL AND THE
24 PATIENTS ARE BEING TREATED WITH PSYCHOTROPIC MEDICATIONS, DO
25 YOU AGREE GENERALLY SPEAKING THAT THE AGITATED, COMBATIVE,
1 WILD BEHAVIORS IN SPITE OF THE PSYCHOTROPIC MEDICATIONS
2 ESSENTIALLY DID NOT GO AWAY FOR THESE PATIENTS?
3 A. THERE WERE VARIABLE RESULTS. YOU KNOW, THE -- THESE --
4 THESE BEHAVIORS WERE CHANGED AT TIMES, SOMETIMES THEY
5 PERSISTED, SOMETIMES THEY'D BE AWAY FOR A WHILE AND BACK.
6 AND THEN -- AND THEN OF COURSE THE PATIENTS WOULD, YOU KNOW,
7 AT SOME POINT NOT BE WILD AND CRAZY ANYMORE, BUT WOULD BE
8 UNRESPONSIVE.
9 Q. DR. HARE, WHAT WOULD YOU HAVE DONE THAT WOULD HAVE
10 PREDICTABLY LED TO THE DISCHARGE OF THESE PATIENTS FROM THE
11 HOSPITAL? WHAT WOULD YOU HAVE DONE THAT WOULD HAVE
12 PREDICTABLY CONTROLLED THEIR AGITATIVE BEHAVIORS?
13 A. I WOULD TEND TO SAY THAT THIS IS A DIFFICULT GROUP OF
14 PATIENTS.
15 Q. THANK YOU.
16 A. I DON'T KNOW THAT I COULD HAVE PREDICTABLY MADE A
17 DIFFERENCE. AGAIN, THIS IS NOT MY AREA OF PRACTICE, SO
18 I'M -- I'M ONLY --
19 Q. WELL, BUT THE STATE'S OFFERED YOU UP AS AN EXPERT TO THIS
20 JURY. AND SO THAT -- THAT'S WHY I'M ASKING YOU THE QUESTION.
21 A. IN TERMS OF THE PHARMACOLOGY OF THE DRUGS, AND I THINK
22 OTHER EXPERTS HAVE ADDRESSED, YOU KNOW, SOME OF THE OTHER
23 ASPECTS OF CLINICAL CARE.
24 Q. WELL, BUT RIGHT NOW YOU'RE THE ONE ON THE WITNESS STAND,
25 DOCTOR.
1 A. THAT'S FINE, BUT I -- AGAIN, I'M NOT GOING TO TESTIFY TO
2 SOMETHING THAT'S OUTSIDE MY AREA OF EXPERTISE.
3 Q. WELL, BUT YOU ALREADY HAVE. YOU'VE ALREADY TESTIFIED
4 ABOUT THE PHARMACOLOGY.
5 A. I'VE -- WE'VE NOT -- WE HAVE NOT TALKED ABOUT THE PROPER
6 TREATMENT OF -- OF DEMENTED PATIENT. WE'VE TALKED ABOUT THE
7 SIDE EFFECTS OF DRUGS AND THE SIDE EFFECTS THAT WERE
8 DEMONSTRATED IN THESE PATIENTS.
9 Q. OKAY.
10 A. THAT TO ME IS NOT PROPER TREATMENT.
11 Q. OKAY, DR. HARE. WOULD YOU AGREE THEN THAT WHAT YOU'RE
12 TELLING THE JURY IS BECAUSE OF YOUR LACK OF EXPERIENCE
13 TREATING -- TREATING DEMENTED, ELDERLY PATIENTS, THAT YOU
14 REALLY DON'T KNOW WHAT THE STANDARD OF CARE WAS FOR THE
15 TREATMENT OF ELDERLY PATIENTS LIKE THIS WITH DEMENTIA WITH
16 PSYCHOTIC BEHAVIORS? YOU REALLY ARE NOT FAMILIAR WITH THE
17 STANDARD OF CARE? IS THAT WHAT YOU'RE SAYING?
18 A. I THINK THE STANDARD OF CARE FOR PATIENTS IN GENERAL IS
19 TO --
20 Q. THAT WASN'T MY QUESTION, DR. HARE.
21 A. WOULD YOU LIKE ME TO ANSWER?
22 Q. I WOULD LIKE YOU TO ANSWER MY QUESTION.
23 A. OKAY.
24 THE COURT: JUST -- WAIT A MINUTE. LISTEN TO THE
25 QUESTION --
1 THE WITNESS: OKAY.
2 THE COURT: -- AND ANSWER IT. OKAY?
3 THE WITNESS: OKAY.
4 THE COURT: ASK IT AGAIN, MR. BUGDEN.
5 MR. BUGDEN: THANK YOU VERY MUCH, JUDGE.
6 Q. (BY MR. BUGDEN) DOCTOR, THIS IS MY QUESTION. YOU REALLY
7 ARE NOT FAMILIAR WITH THE STANDARD OF CARE FOR THE TREATMENT
8 OF ELDERLY PATIENTS WITH DEMENTED -- WITH DEMENTIA WITH
9 PSYCHOTIC BEHAVIORS. YOU REALLY DON'T KNOW WHAT THE STANDARD
10 OF CARE WAS BECAUSE YOU'RE NOT AN EXPERT IN THAT FIELD.
11 ISN'T THAT TRUE?
12 A. AS FAR AS THE SPECIFICS TO THESE PATIENTS, I WOULD SAY
13 THAT'S TRUE. AS FAR AS THE GENERAL APPROACH TO THE MEDICAL
14 PATIENT, I THINK THERE ARE -- YOU KNOW, THE CARE IS BELOW THE
15 STANDARD IN THAT CASE.
16 Q. BUT DR. HARE, MR. WILSON DIDN'T CALL YOU TO BE A
17 GENERALIST. HE CALLED YOU IN THIS CASE TO TALK ABOUT THESE
18 DEMENTED PATIENTS. AND THOSE ARE THE QUESTIONS I'M PUTTING
19 TO YOU RIGHT NOW.
20 MR. WILSON: YOUR HONOR, I'LL GOING TO OBJECT TO THE
21 FORM OF THAT QUESTION AS TO -- HE'S SPECULATING WHY I CALLED
22 HIM.
23 THE COURT: WELL, I THINK IT'S OBVIOUS TO THE JURY
24 WHY YOU CALLED HIM. WE'LL LEAVE IT AT THAT.
25 GO AHEAD.
1 Q. (BY MR. BUGDEN) YOU'RE NOT AN EXPERT ON THE TREATMENT OF
2 DEMENTED PATIENTS WITH PSYCHOTIC BEHAVIORS, RIGHT?
3 A. I'LL SAY THAT, YES.
4 Q. THANK YOU. LET ME MAKE SURE I'VE GOT THIS STRAIGHT. ARE
5 YOU SAYING AS A GENERAL RULE, DR. HARE, THAT IN YOUR REVIEW
6 OF THE MEDICAL RECORDS, YOU DON'T BELIEVE THESE PATIENTS WERE
7 IN PAIN? IS THAT WHAT YOU'RE TELLING THE JURY?
8 A. I THINK THAT -- THAT THERE'D HAVE TO BE, YOU KNOW,
9 CERTAIN OBSERVATIONS, CERTAIN CONSISTENT FINDINGS, BE THIS
10 FROM THE FAMILY, BE IT FROM THE PREVIOUS TREATING NURSING
11 HOME, BE IT FROM THE NURSES. I THINK THERE'D HAVE TO BE
12 SPECIFIC INDICATIONS THAT A PATIENT HAS PAIN. THESE MAY NOT
13 BE THE PATIENT COMPLAINING, BUT I THINK IN -- IN SOME --
14 Q. LET'S TALK ABOUT THOSE TOGETHER, DOCTOR.
15 THE COURT: LET'S HIM FINISH, MR. BUGDEN.
16 A. SO I THINK THAT AT LEAST IN ONE CASE, IN MARY CRANE'S
17 CASE THERE WAS A GOOD HISTORY FOR CHRONIC BUT LOW BACK PAIN.
18 SO I HAVE NO PROBLEM WITH THAT. NONE OF THE OTHER PATIENTS
19 THOUGH HAD ANY HISTORY OF CHRONIC PAIN PROBLEMS.
20 Q. (BY MR. BUGDEN) NONE OF THE OTHER PATIENTS HAD ANY
21 HISTORIES OF PAIN. THAT'S YOUR --
22 A. OF CHRONIC -- OF CHRONIC PAIN, YES.
23 Q. OKAY. LET'S TALK ABOUT ELLEN ANDERSON. SHE DIDN'T HAVE
24 ANY HISTORY OF CHRONIC PAIN. SHE HAD BROKEN HER HIP AND HAD
25 HIP SURGERY IN JUNE -- JUNE OF 1995, ABOUT FIVE MONTHS BEFORE
1 HER ADMISSION.
2 A. THAT'S RIGHT.
3 Q. ISN'T PAIN -- DON'T YOU EXPECT THAT YOU'RE GOING TO HAVE
4 PAIN IN PATIENTS WHO'VE HAD A HIP REPLACEMENT, DOCTOR?
5 A. AT THE TIME THEY HAVE THE HIP REPLACED, YES. BUT THEN
6 THAT -- HIP REPLACEMENTS ARE DONE TO TREAT PAIN -- PAINFUL
7 HIPS.
8 Q. PARDON ME?
9 A. HIP REPLACEMENTS ARE DONE TO REPLACE -- OR TO TREAT
10 PAINFUL HIPS, AND WITH THE HOPE THAT PAIN WILL GO AWAY ONCE
11 THE HIP IS REPLACED.
12 SO YES, I WOULD SAY AROUND THE TIME THAT SHE BROKE HER
13 HIP AND SHE HAD IT REPLACED, IT WOULD BE PAINFUL. BUT THEN
14 THE EXPECTATION IS THAT THE PAIN GOES AWAY.
15 Q. OKAY. THANK YOU. SHE ALSO HAD NUMEROUS FRACTURES. DID
16 YOU SEE THAT IN THE RECORDS, DOCTOR?
17 A. SHE HAD A HISTORY OF THAT, YES. NOT AT -- NOT AT THIS
18 TIME, NO.
19 Q. BUT SHE'D HAD NUMEROUS FALLS RESULTING IN BREAKING A
20 WRIST, HER ANKLES, THINGS LIKE THAT; IS THAT CORRECT, DOCTOR?
21 A. I DON'T REMEMBER ALL THE DETAILS, BUT I KNOW SHE HAD
22 OTHER INJURIES, YES.
23 Q. WELL, DOCTOR, SHE HAD OSTEOPOROSIS, DIDN'T SHE?
24 A. YES.
25 Q. DOESN'T THAT MEAN THAT HER BONES WERE BRITTLE?
1 A. YES.
2 Q. LIKE PAPER MACHE?
3 A. THERE'S VARIOUS, YOU KNOW, VARIOUS --
4 Q. WAYS TO DESCRIBE THAT?
5 A. -- DEGREES -- WELL, VARIOUS DEGREES OF OSTEOPOROSIS.
6 Q. DO YOU BELIEVE THAT OSTEOPOROSIS CAN BE A PAINFUL
7 CONDITION, DR. HARE?
8 A. I'M NOT AWARE THAT'S IT'S PAINFUL JUST IN AND OF ITSELF.
9 CERTAINLY FRACTURES RESULTING FROM IT WOULD BE.
10 Q. SO IT'S YOUR TESTIMONY TO THE JURY THAT OSTEOPOROSIS IS
11 NOT A PAINFUL CONDITION?
12 A. NOT THAT I'M AWARE OF BY ITSELF.
13 Q. THANK YOU. ENNIS ALLDREDGE, THIS MAN HAD LONG-STANDING
14 DIABETES; IS THAT CORRECT?
15 A. THAT'S RIGHT.
16 Q. HISTORY OF A HEART ATTACK AND BYPASS SURGERY; IS THAT
17 RIGHT?
18 A. YES.
19 Q. ARTHRITIS; IS THAT RIGHT?
20 A. YES.
21 Q. WERE YOU AWARE THAT HE HAD INCREASING COMPLAINTS OF PAIN
22 AT THE LONG-TERM CARE FACILITY WHICH WAS CALLED SUNSHINE
23 TERRACE, DR. HARE?
24 A. NOT THAT I SAW DOCUMENTED IN THE CHART, NO.
25 Q. OKAY.
1 A. NOT THAT HE HAD RECEIVED TREATMENT FOR THAT I WAS AWARE
2 OF.
3 Q. OKAY.
4 MR. BUGDEN: COULD WE SEE NURSING HOME RECORD 139?
5 THE COURT: WHAT EXHIBIT WOULD THAT BE?
6 MR. BUGDEN: WELL, MS. ISAACSON IS GOING TO HELP ME
7 ON THAT, JUDGE. I'M SORRY. WE'RE TALKING ABOUT
8 MR. ALLDREDGE.
9 THE COURT: THAT WOULD BE 6-B --
10 MS. ISAACSON: 6-A, YOUR HONOR.
11 THE COURT: -- OR A.
12 MR. BUGDEN: DO WE HAVE A -- A SLIDE THAT TALKS
13 ABOUT THE INCREASING PAIN?
14 (OFF-THE-RECORD DISCUSSION)
15 Q. (BY MR. BUGDEN) WELL, I'VE GOT A GLITCH HERE, DOCTOR,
16 AND SO I'M NOT REALLY GOING TO BE ABLE TO SHOW YOU THAT SLIDE
17 RIGHT NOW.
18 MS. ISAACSON: IT'S -- IT'S RIGHT THERE UP IN THE --
19 CAN YOU SEE THE -- SAYS NH-139 STARTING JANUARY 1ST, '96.
20 MR. BUGDEN: THANK YOU FOR YOUR HELP.
21 Q. (BY MR. BUGDEN) ON JANUARY 1ST, DR. HARE, OF 1996, SO
22 THAT'S NINE DAYS BEFORE HIS ADMISSION, COMPLAINTS OF PAIN.
23 YOU HADN'T SEEN THAT?
24 MR. MAJOR: YOUR HONOR, WHAT EXHIBIT IS THIS?
25 MS. BARLOW: WHAT PAGE IS IT?
1 THE COURT: 6-A.
2 DO YOU KNOW WHAT PAGE IT WOULD BE?
3 MR. BUGDEN: WELL, WE'RE TRYING TO FIND OUT.
4 MS. ISAACSON: IT'S NH-139, BUT FOR SOME REASON
5 IT'S --
6 MS. BARLOW: 139. THANK YOU.
7 THE COURT: 139. LET'S GO AHEAD.
8 MR. BUGDEN: LET'S STAY ON ONE LINE WHERE WE WERE.
9 THANK YOU.
10 Q. (BY MR. BUGDEN) THERE ARE A NUMBER OF COMPLAINTS OF
11 PAIN. CAN YOU READ THAT, DOCTOR?
12 THE COURT: YOU CAN MOVE OVER CLOSER IF YOU NEED TO.
13 A. I -- I CAN SEE THAT. YES.
14 Q. (BY MR. BUGDEN) DO YOU SEE THAT?
15 A. I SEE THAT NOTED. YES.
16 Q. AND THEN LET'S JUST SORT OF LOOK AT ON 1/2 THERE'S
17 COMPLAINTS OF PAIN, ON 1/3 THERE'S COMPLAINTS OF PAIN, ON 1/4
18 THERE'S COMPLAINTS OF PAIN, 1/5, 1 -- I THINK THIS IS 6, 1/7,
19 1/8, 1/9. WEREN'T THERE COMPLAINTS OF PAIN AT LEAST FOR THE
20 EIGHT OR NINE DAYS LEADING UP TO HIS ADMISSION, DOCTOR?
21 A. THERE WERE. PAIN TREATED WITH TYLENOL, YES.
22 Q. WELL, BUT I'M JUST ASKING YOU --
23 A. OKAY.
24 Q. -- YOU HAD SAID --
25 A. I --
1 Q. -- YOU WEREN'T AWARE OF INCREASING COMPLAINTS OF PAIN.
2 A. I WAS THINKING OF PAIN THAT WOULD REQUIRE, YOU KNOW, MORE
3 EXTENSIVE TREATMENT THAN JUST TYLENOL.
4 Q. WELL, DIDN'T I JUST SAY PAIN?
5 THE COURT: WAIT A MINUTE.
6 THE WITNESS: OKAY. THAT'S -- THAT'S FINE.
7 THE COURT: ONE AT A TIME. MR. BUGDEN, YOU KNOW
8 BETTER.
9 DOCTOR, LET HIM FINISH YOUR QUESTION -- HIS QUESTION
10 BEFORE YOU ANSWER.
11 THE WITNESS: YES, SIR.
12 THE COURT: MR. BUGDEN, LET HIM FINISH BEFORE YOU
13 RESPOND AND GO TO THE NEXT ONE. NOW, LET'S START OVER. GO
14 AHEAD.
15 Q. (BY MR. BUGDEN) I ASKED YOU, DOCTOR, IF YOU WERE AWARE
16 THAT THERE WERE INCREASING COMPLAINTS OF PAIN. I DIDN'T SAY
17 WHAT QUALITY OF PAIN, WHETHER OR NOT YOU BELIEVED IT WAS
18 DESERVING OF MORPHINE. I ASKED YOU WERE YOU AWARE THAT THERE
19 WERE INCREASING COMPLAINTS OF PAIN. YOUR ANSWER WAS NO.
20 RIGHT?
21 A. THAT'S RIGHT.
22 Q. AND NOW I'VE SHOWN YOU THAT AT THE NURSING HOME ON THE
23 EIGHT OR NINE DAYS LEADING UP TO HIS ADMISSION THERE WERE
24 INCREASING COMPLAINTS OF PAIN. YES?
25 A. WELL, THERE WERE COMPLAINTS OF PAIN. I DON'T KNOW ABOUT
1 INCREASING.
2 Q. THEN --
3 A. UH-HUH. YES.
4 Q. THEN YOU -- YOU SAID TREATED WITH TYLENOL.
5 A. YES.
6 Q. IS THAT RIGHT?
7 A. UH-HUH.
8 Q. JUDITH LARSEN, THIS WOMAN ALSO HAD A HISTORY OF FALLS.
9 ISN'T THAT TRUE, DR. HARE?
10 A. SHE DID, YES.
11 Q. AND SHE HAD ANGINA -- ANGINA -- ANGINA; IS THAT RIGHT?
12 A. SHE HAD OTHER -- YES, SHE HAD OTHER MEDICAL CONDITIONS,
13 RIGHT.
14 Q. THEN MARY CRANE, THIS IS THE ONE WITH THE CHRONIC BACK
15 PAIN; IS THAT RIGHT?
16 A. YES, IT IS.
17 Q. AND SHE HAD BEEN TREATED WITH HY-PHEN OR LORTAB; IS THAT
18 RIGHT?
19 A. YES.
20 Q. DID -- DID YOU TESTIFY THAT YOU THOUGHT THAT SHE HADN'T
21 HAD IT RECENTLY?
22 A. I DON'T REMEMBER HOW -- HOW RECENT IT WAS. SHE WAS
23 TAKING PERHAPS ONE TABLET A DAY AND I DON'T RECALL HOW CLOSE
24 TO THE TIME OF ADMISSION, YOU KNOW, SHE HAD BEEN DOING THAT.
25 Q. WELL, AT LEAST IN TERMS OF US ASSESSING WHETHER OR NOT
1 THIS -- THIS WAS A PATIENT WHO HAD BEEN RECEIVING AN OPIATE
2 BASED -- IS LORTAB OR HY-PHEN, IS THAT AN OPIATE BASED --
3 A. YES, IT IS.
4 Q. OKAY. WELL, LET ME JUST REPRESENT TO YOU, DOCTOR, THAT
5 THE JURY HAS SEEN A TWO-PAGE DOCUMENT THAT SHOWS THAT THIS
6 PATIENT RECEIVED LORTAB EVERY DAY BASICALLY FOR THE TWO
7 MONTHS LEADING UP TO HER ADMISSION. YOU WERE NOT AWARE OF
8 THAT?
9 A. I -- WELL, I WAS AWARE THAT SHE WAS RECEIVING IT. I
10 DIDN'T KNOW EXACTLY HOW THAT CORRESPONDED TO THE TIME OF HER
11 ADMISSION.
12 Q. OKAY. WELL --
13 A. THERE WAS ABOUT A TAB -- ONE TABLET A DAY.
14 Q. PARDON ME?
15 A. I BELIEVE IT WAS JUST LIKE ONE TABLET A DAY.
16 Q. OKAY. WERE YOU AWARE THAT WHEN THIS PATIENT REPORTED TO
17 THE HOSPITAL THAT SHE RATED HER PAIN -- YOU SAID ONE OF THE
18 THINGS THAT YOU DO IS LISTEN TO THE PATIENT'S SELF REPORT OF
19 PAIN. THIS PATIENT REPORTED HER PAIN ON A SCALE OF ZERO TO
20 FIVE AS A FIVE. WERE YOU AWARE OF THAT?
21 A. I DON'T BELIEVE I SAW THE -- THE PAIN RATING, BUT I'M
22 WILLING TO ACCEPT THAT SHE DID THAT.
23 Q. OKAY. ALL OF -- WHAT I'M TRYING TO POINT OUT IS THAT YOU
24 DIDN'T SEE ANY SYMPTOMS OF PAIN OR ANY REASON WHY THESE
25 PEOPLE WOULD BE IN PAIN. MARY CRANE REPORTED SHE WAS IN
1 PAIN, AND YOU WEREN'T AWARE OF THAT?
2 A. YES, I TOLD -- I SAID THAT TO BEGIN WITH THAT MARY CRANE
3 HAD A HISTORY OF LOW BACK PAIN AND -- AND I'M WILLING --
4 Q. BUT YOU WEREN'T -- EXCUSE ME.
5 A. I'M WILLING TO ACCEPT THAT THAT WAS AN ONGOING PROBLEM,
6 YES.
7 Q. THEN LYDIA SMITH, THIS WOMAN HAD A FROZEN SHOULDER. WERE
8 YOU AWARE OF THAT?
9 A. YES.
10 Q. AND ABDOMINAL PAIN. WERE YOU AWARE OF THAT?
11 A. SHE -- I -- I -- THERE WAS A HISTORY OF SOME DIFFERENT
12 PROBLEMS, YES.
13 Q. AND SHE HAD SUFFERED A THALAMIC -- IS THAT HOW YOU SAY
14 IT -- STROKE?
15 A. YES.
16 Q. AND IS A THALAMIC STROKE, CAN THAT RESULT IN PAIN --
17 PAINFUL SYNDROMES?
18 A. SOMETIMES.
19 Q. OKAY. DOCTOR, DO YOU AGREE THAT THE NURSE WHO IS AT THE
20 BEDSIDE OF THE PATIENT IS IN -- IN A BETTER POSITION TO
21 ASSESS WHETHER OR NOT A PATIENT IS SUFFERING FROM PAIN THAN
22 SOMEONE LIKE YOURSELF WHO IS A CHART REVIEWER, JUST REVIEWING
23 THE MEDICAL RECORDS SIX YEARS AFTER THE FACT?
24 A. YES. I WOULD SAY THE FIRST-HAND ACCOUNT WOULD DEFINITELY
25 BE BETTER.
1 Q. OKAY. AND --
2 A. BUT IT -- BUT IT WOULD NEED TO BE DOCUMENTED IN THE
3 CHART.
4 Q. OKAY. WELL, AND YOU DON'T THINK THAT THERE WERE SYMPTOMS
5 OF PAIN THAT WERE DOCUMENTED IN THE CHARTS BY THE NURSES?
6 A. IN SOME CASES, YES.
7 Q. OKAY. ARE YOU FAMILIAR, DOCTOR, WITH STUDIES THAT HAVE
8 BEEN DONE ON PAIN WITH THE DEMENTED POPULATION?
9 A. YES, I AM.
10 Q. AND ARE YOU AWARE, FOR EXAMPLE, THAT A STUDY WAS DONE
11 THAT WAS PUBLISHED IN JAMA -- WHAT IS JAMA?
12 A. IT'S THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
13 Q. IS -- IS THAT CONSIDERED ONE OF THE LEARNED TREATISES IN
14 THE MEDICAL PROFESSION, DR. HARE?
15 A. IT'S -- IT'S CERTAINLY A CREDIBLE JOURNAL, YES.
16 Q. ARE YOU FAMILIAR WITH -- WHAT WAS CALLED THE BROWN STUDY
17 THAT WAS DONE ON THE RECOGNITION OF SYMPTOMS OF PAIN IN
18 NURSING HOME RESIDENTS AROUND THE COUNTRY?
19 A. I BELIEVE I'M -- I'M FAMILIAR WITH THAT PARTICULAR STUDY.
20 I -- YOU KNOW, I CAN -- I'M FAMILIAR WITH THOSE TYPES OF
21 STUDIES AND SOME OF THE OUTCOMES, YES.
22 Q. WERE YOU AWARE THAT IN THAT STUDY, APPEARED IN JAMA, THAT
23 IN 1995 UTAH WAS CONSIDERED 50TH OUT OF ALL 50 STATES -- THE
24 WORST, IN OTHER WORDS -- IN THE RECOGNITION OF PAIN IN THE
25 NURSING HOME POPULATION? WERE YOU AWARE OF THAT?
1 A. AGAIN, I DON'T RECALL THE -- THE SPECIFICS OF THAT --
2 THAT PARTICULAR STUDY -- YOU KNOW, THAT PARTICULAR OUTCOME.
3 Q. DO YOU AGREE THAT THE UNDERTREATMENT AND THE UN -- OR THE
4 LACK OF RECOGNITION OF PAIN IN THE ELDERLY DEMENTED
5 POPULATION WAS PREVALENT, WAS WIDESPREAD IN 1995?
6 A. IT WAS IDENTIFIED AS A PROBLEM IN THOSE STUDIES, YES.
7 Q. NOW, IN TERMS OF SYMPTOMS OF PAIN, DO YOU AGREE THAT --
8 AND DO YOU AGREE THAT THE -- THAT THE THRESHOLD FOR
9 IDENTIFYING SYMPTOMS OF PAIN IN THE DEMENTED POPULATION WHERE
10 THE PATIENT CANNOT SELF REPORT PAIN, THAT THE THRESHOLD FOR
11 IDENTIFYING SOMEONE WITH PAIN SHOULD BE LOWER?
12 A. YES.
13 Q. BECAUSE THE PATIENT CAN'T TELL YOU, I -- I HURT.
14 A. THAT'S RIGHT.
15 Q. DO YOU AGREE THAT SCREAMING CAN BE A SYMPTOM OF PAIN, A
16 SIGN OF PAIN, DOCTOR?
17 A. AMONG OTHER THINGS, YES.
18 Q. MOANING?
19 A. AGAIN, AMONG OTHER THINGS, IT COULD BE.
20 Q. SEVERE AGITATION?
21 A. AGAIN, IT -- PAIN COULD BE ONE REASON FOR THAT.
22 Q. AND RIGIDITY OF THE BODY, FOR EXAMPLE?
23 A. I THINK THAT'S PROBABLY LESS LIKELY.
24 Q. SOMEONE WHO DOESN'T WANT TO BE TOUCHED, TENSES UP, YOU
25 DON'T THINK THAT THAT'S A SYMPTOM OF PAIN IN THE DEMENTED
1 POPULATION?
2 A. I -- IT COULD BE UNDER CERTAIN CIRCUMSTANCES. AGAIN, IT
3 COULD BE A SIGN OF A LOT OF OTHER THINGS THOUGH.
4 Q. AND I THINK YOU TOLD THE JURY THAT YOU AGREED THAT ONE OF
5 THE THINGS THAT CAN BE DONE IS TO DO A TRIAL STUDY WITH THE
6 PAIN MEDICATION. IF YOU'RE NOT SURE IF YOU'VE GOT PAIN, YOU
7 CAN TREAT THE SYMPTOM WITH A PAIN MEDICATION, AND IF THE
8 SYMPTOM IMPROVES, IT'S A FAIR ASSUMPTION THAT YOU DID HAVE
9 PAIN AND THAT YOU PICKED -- THAT YOU MADE THE RIGHT
10 DIAGNOSIS.
11 A. THAT'S RIGHT.
12 Q. THAT'S SOMETHING THAT YOU AGREE DOES MEET WITH THE
13 STANDARD OF CARE; IS THAT RIGHT?
14 A. YES.
15 Q. AND WOULD YOU AGREE THAT IN DIAGNOSING PAIN OR
16 IDENTIFYING PAIN IN THE ALZHEIMER OR THE DEMENTED PATIENTS,
17 THAT THAT REQUIRES DRAWING INFERENCES, MAKING EDUCATED
18 GUESSES ABOUT WHAT YOU SEE IN THE CLINICAL SETTING?
19 A. IT DOES.
20 Q. AND YOU WOULD AGREE THAT NURSES ARE TRAINED TO CHART
21 THOSE BEHAVIORS?
22 A. YES, THEY ARE.
23 Q. AND YOU WOULD AGREE THAT DOCTORS -- BECAUSE THEY'RE NOT
24 WITH THE PATIENT 24/7, DOCTORS RELY ON THE CHARTING THAT'S
25 DONE BY THE NURSES. DO YOU AGREE WITH THAT?
1 A. THAT'S RIGHT.
2 Q. ELLEN ANDERSON, WERE YOU AWARE, DOCTOR, THAT AT AROUND
3 7:30 -- I'M NOT SURE IF YOU NEED YOUR RECORD --
4 A. OH, OKAY.
5 Q. -- BUT IF YOU DO, BY ALL MEANS WE CAN GET THEM. BUT I
6 THINK THIS IS A GENERAL, PRETTY EASY QUESTION.
7 WERE YOU AWARE THAT AT 7:30 THAT NIGHT THE NURSE THAT
8 WAS TREATING THIS PATIENT, LAURIE WILSON, RECOGNIZED THAT THE
9 PATIENT WAS SCREAMING AND APPEARED TO BE IN SEVERE PAIN?
10 WERE YOU AWARE THAT THAT'S WHAT THE NURSE CHARTED?
11 A. THAT WAS HER INTERPRETATION, YES.
12 Q. OKAY. AND THEN ALSO AT 3 -- AT AROUND 3:15 OR 3:30 IN
13 THE MORNING A SECOND NURSE RECOGNIZED -- AND I'LL JUST TELL
14 YOU THAT NURSE HAS TESTIFIED IN COURT THAT SHE SAW WHAT SHE
15 THOUGHT WAS EXTREME PAIN IN THIS PATIENT AT 3:15 IN THE
16 MORNING. WERE YOU AWARE OF SOMETHING LIKE THAT IN THE CHART?
17 A. YES.
18 Q. AND YOU DON'T -- YOU'RE NOT TAKING THE POSITION TODAY
19 WITH THE JURY THAT INTERPRETING THE NURSES' DESCRIPTION OF
20 PAIN AND THEN TREATING THOSE SYMPTOMS OF PAIN WAS A BREACH OF
21 THE STANDARD OF CARE. YOU'RE NOT SAYING THAT, ARE YOU?
22 A. NO. NO.
23 Q. DR. WEITZEL WAS CORRECT IN TREATING THE SYMPTOMS OF PAIN.
24 YOU AGREE WITH THAT.
25 A. I THINK THAT -- I THINK THAT THE BIGGER PICTURE NEEDS TO
1 BE LOOKED AT.
2 Q. WELL, I'M ASKING --
3 A. WELL, I -- I -- I NEED TO -- I CAN'T ANSWER THAT YES OR
4 NO BECAUSE I -- I -- I -- BECAUSE THE FAMILY EARLIER HAD TOLD
5 THE ADMITTING NURSE THAT THESE SAME ACTIONS OF THE PATIENT
6 WHO WERE LATER INTERPRETED AS PAIN, WEREN'T IN FACT PAIN.
7 AND I THINK THAT SORT OF INFORMATION HAS TO BE -- YOU KNOW,
8 AGAIN, THE FAMILY IS A VERY IMPORTANT SOURCE OF INFORMATION.
9 OBVIOUSLY FAMILY MEMBERS ARE VERY CARING AND GOING TO, AGAIN,
10 HAVE A VERY LOW THRESHOLD HOW THEY INTERPRET, YOU KNOW,
11 THEIR -- THEIR FAMILY MEMBER'S ACTIONS AND WHETHER IT'S PAIN
12 OR NOT.
13 Q. THANK YOU, DR. HARE.
14 BUT STILL, WHAT WE HAVE IN THIS CASE IS TWO DIFFERENT
15 NURSES, TWO DIFFERENT OCCASIONS, OBSERVING WHAT THEY SAW AS
16 SEVERE OR EXTREME PAIN. AND YOU DON'T CLAIM THAT IT WAS A
17 BREACH OF THE STANDARD OF CARE FOR DR. WEITZEL TO RELY ON THE
18 NURSES' OBSERVATION, DO YOU?
19 A. AGAIN, I THINK THAT BASED ON THE INFORMATION THE NURSES
20 HAD TO WORK WITH, THEY MAY OR MAY NOT HAVE COME TO THE
21 CONCLUSION IT WAS PAIN.
22 Q. WELL, BUT THEY --
23 A. BUT I THINK ONCE THEY CAME TO THE CONCLUSION OF PAIN AND
24 PASSED THAT INFORMATION ON TO HIM, IT WAS NOT UNREASONABLE TO
25 CONSIDER TREATING IT.
1 Q. THANK YOU. ARE YOU FAMILIAR WITH A BOOK CALLED THE MERCK
2 MANUAL?
3 A. YES.
4 Q. WHAT IS THE MERCK MANUAL?
5 A. IT'S A -- I GUESS KIND OF A -- AGAIN, IT'S NOT -- NOT ONE
6 I'M -- I'M OVERLY FAMILIAR WITH. IT'S -- IT'S JUST A
7 COMPILATION OF A LOT OF MEDICAL CONDITIONS, MORE OF A LAY
8 SOURCE FOR MEDICAL INFORMATION.
9 Q. IN THE MERCK MANUAL, DOCTOR, COULD YOU JUST READ THE
10 FIRST SENTENCE, THE WORD MORPHINE AND THEN JUST READ THE
11 FIRST SENTENCE?
12 THE COURT: IS THERE A PAGE WE'RE REFERRING TO
13 THERE?
14 MR. BUGDEN: IT IS PAGE 1855.
15 A. YEAH.
16 Q. (BY MR. BUGDEN) WOULD YOU JUST READ THE FIRST SENTENCE,
17 DOCTOR?
18 A. YEAH. IT SAYS, MORPHINE, AN OPIUM ALKALOID, IS A
19 PROTOTYPE OF THE NARCOTIC ANALGESICS.
20 DO YOU WANT ME TO GO ON, I ASSUME?
21 Q. YEAH.
22 A. OKAY.
23 Q. SECOND SENTENCE, TOO.
24 A. OKAY.
25 Q. THANK YOU.
1 A. IT PROVIDES ANALGESIA AT A DOSE OF ABOUT 10 MILLIGRAMS
2 I.M. THAT DOES NOT RESULT IN SEVERE ALTERATION IN
3 CONSCIOUSNESS.
4 Q. THANK YOU. SO THE MERCK MANUAL SAYS 10 MILLIGRAMS; IS
5 THAT RIGHT?
6 A. IT DOES.
7 Q. DOCTOR, YOU INDICATED THAT IN TREATING PAIN YOU PICK A --
8 YOU KNOW, YOU PICK A MEDICINE, YOU PICK A DOSAGE, AND THEN
9 YOU WAIT TO SEE WHETHER OR NOT THE MEDICINE HAD THE DESIRED
10 EFFECT; IS THAT RIGHT?
11 A. THAT'S RIGHT.
12 Q. AND WITH ELLEN ANDERSON, IN FACT, AT LEAST WHAT THE
13 NURSES HAVE CHARTED IS, FOR EXAMPLE, AFTER THE 8:30 DOSAGE
14 THAT THE MEDICINE APPEARED TO HAVE AN EFFECT OF SEDATING THE
15 PATIENT SO THAT THE PATIENT CALMED DOWN AND WAS ABLE TO
16 SLEEP. ISN'T THAT TRUE, DOCTOR?
17 A. YEAH, I -- I WOULD EXPECT IT WOULD. YES.
18 Q. OKAY. WELL, I GUESS I WON'T GET THE CHART, BUT LET'S
19 TALK ABOUT PEAK EFFECT. THE PEAK EFFECT FOR MORPHINE IS 30
20 MINUTES TO ONE HOUR; IS THAT RIGHT?
21 A. IT WOULD DEPEND ON WHAT -- BY WHAT ROUTE IT'S GIVEN.
22 Q. I.M.?
23 A. I.M. IT WOULD BE, YES.
24 Q. OKAY. AND SO THE PEAK EFFECT IN LANGUAGE THAT I CAN
25 UNDERSTAND MEANS THE TIME AT WHICH YOU WOULD EXPECT THE
1 MAXIMUM IMPACT FROM THE DRUG; IS THAT CORRECT?
2 A. YES.
3 Q. AND THEN THE DURATION OF EFFECT FOR MORPHINE IS WHAT,
4 FOUR HOURS, DOCTOR?
5 A. UNDER MOST CIRCUMSTANCES IT WOULD BE ABOUT FOUR HOURS,
6 YES.
7 Q. AND SO --
8 A. BY THE -- BY THE INTRAMUSCULAR ROUTE, YES.
9 Q. THANK YOU VERY MUCH.
10 AND SO THIS PATIENT RECEIVED A SHOT I THINK AT LET --
11 LET'S SAY EIGHT O'CLOCK. LET'S USE THE OUTSIDE TIME. AT
12 8 P.M.
13 A. OKAY.
14 Q. AND THEN THE DURATION OF EFFECT WOULD BE FOUR HOURS.
15 THAT'S WHAT YOU'VE JUST TOLD US, RIGHT?
16 A. IN A HEALTHY, YOUNGER PATIENT WHO GETS 10 MILLIGRAMS OF
17 MORPHINE IT WOULD BE ABOUT FOUR HOUR, YES.
18 Q. OKAY.
19 A. BUT THIS ISN'T THAT SITUATION.
20 Q. THANK YOU. AND THEN BY 3:30 THE PAIN HAD RETURNED FOR
21 THIS PATIENT; ISN'T THAT RIGHT?
22 A. FOR WHATEVER --
23 Q. THE SYMPTOM -- I -- I KNOW THAT YOU -- YOU DEBATE WHETHER
24 OR NOT THE NURSES KNEW WHAT THEY WERE LOOKING AT.
25 A. BUT WHATEVER SYMPTOM --
1 Q. THE NURSE --
2 A. -- YES, HAD RETURN.
3 Q. THE NURSES CHARTED --
4 THE COURT: MR. BUGDEN, ONE AT A TIME. DOCTOR --
5 THE WITNESS: I'M SORRY.
6 THE COURT: -- LET HIM FINISH BEFORE YOU RESPOND.
7 GO AGAIN.
8 Q. (BY MR. BUGDEN) THE NURSES CHARTED IT, RIGHT? AT 3:30?
9 A. THEY -- THEY CHARTED SYMPTOMS THEY -- THEY INTERPRETED AS
10 PAIN, YES.
11 Q. THAT IS AFTER THE DURATION OF EFFECT, RIGHT?
12 A. AGAIN --
13 Q. THE FOUR-HOUR DURATION OF EFFECT.
14 A. WELL, AGAIN, THAT WOULD BE THE DURATION IN A YOUNG,
15 HEALTHY PATIENT WHO GETS 10 MILLIGRAMS. IN AN ELDERLY
16 PATIENT, THE DURATION COULD BE MUCH LONGER THAN THAT.
17 Q. OKAY. THANK YOU, DOCTOR.
18 AND THEN THE SECOND SHOT WAS AT 3:30, AND AT LEAST --
19 ALTHOUGH I KNOW YOU'RE SAYING IT'S DIFFERENT WITH OLDER
20 PEOPLE -- BUT AT LEAST WHAT THE LITERATURE TALKS ABOUT IS
21 THAT THE DURATION OF EFFECT FOR MORPHINE I.M. WOULD BE FOUR
22 HOURS. YOU AGREE THAT THAT'S WHAT THE LITERATURE TALKS
23 ABOUT?
24 A. WELL, IN --
25 Q. THE --
1 A. -- AGAIN, IN A DIFFERENT CLINICAL SETTING THAN THIS, YES.
2 Q. THANK YOU. AND THIS PATIENT PASSED AWAY FIVE AND A HALF
3 HOURS AFTER THE 3:30 SHOT; ISN'T THAT TRUE, DOCTOR?
4 A. YES, THAT'S RIGHT.
5 Q. THANK YOU.
6 A. ABOUT THAT.
7 Q. THANK YOU. JUDITH LARSEN. DID YOU SEE ANY SYMPTOMS OF
8 PAIN WITH THAT PATIENT OR DID YOU NOT SEE ANY SYMPTOMS OF
9 PAIN?
10 A. I DIDN'T RECALL ANY ONGOING PAIN COMPLAINTS OF ANY REAL
11 SIGNIFICANCE BEFORE SHE CAME INTO THE -- INTO THE HOSPITAL.
12 Q. NO, I'M SORRY. I MEANT TO SAY ONCE SHE'S IN THE
13 HOSPITAL.
14 A. WELL, FOR THE FIRST -- ABOUT THE FIRST SIX DAYS SHE WAS
15 THERE THERE WAS NO MENTION OF PAIN OR PAIN TREATMENT. AND
16 THEN BRIEFLY THERE WAS THOUGHT THAT MAYBE SHE'S HAVING PAIN
17 AND A -- AND A MORPHINE TRIAL WAS -- WAS ATTEMPTED. AND
18 THEN --
19 Q. LET ME STOP YOU -- MAY I STOP YOU THERE, PLEASE?
20 A. YES.
21 Q. THANK YOU. I'M NOT TRYING TO INTERRUPT --
22 A. OKAY.
23 Q. -- BUT YOU GET GOING, YOU'RE LOOKING DOWN, WE DON'T HAVE
24 EYE CONTACT.
25 A. THAT'S FINE.
1 Q. SO YOU AGREE WITH THE MORPHINE TRIAL. YOU AGREE THAT IT
2 WAS CHARTED THAT THIS PATIENT MAY BE IN PAIN, SO LET'S TRY A
3 LOW DOSE OF MORPHINE AND SEE IF SHE RESPONDS TO THAT. YOU
4 AGREE THAT THAT WAS NOT AN UNREASONABLE THING TO DO.
5 A. WELL, I WOULD AGREE WITH A TRIAL OF SOME PAIN MEDICINE.
6 Q. THANK YOU.
7 A. I DON'T KNOW THAT IT WOULD BE MORPHINE.
8 Q. OKAY.
9 THE COURT: MR. BUGDEN, ARE YOU GOING TO BE USING
10 THE PROJECTOR?
11 MR. BUGDEN: I PROBABLY WILL AGAIN, JUDGE. I'M
12 SORRY. I -- I CAN TURN IT BACK ON IF YOU --
13 THE COURT: HOW LONG ARE YOU GOING TO BE?
14 MR. BUGDEN: I DON'T -- OH, TALKING TO HIM?
15 THE COURT: NO, NO, NO. BEFORE YOU USE THE --
16 MR. BUGDEN: I DON'T KNOW THAT. I'M SORRY. I DON'T
17 KNOW.
18 THE COURT: ARE YOU FOLKS OKAY WITH THE LIGHT DIM?
19 DON'T WANT ANYBODY DOZING OFF.
20 ALL RIGHT. GO AHEAD.
21 MR. BUGDEN: LET'S SEE. COULD WE SEE MEDICAL RECORD
22 PAGE 569?
23 WHICH IS 12/26, COUNSEL.
24 THE COURT: WHAT EXHIBIT?
25 MR. BUGDEN: I'M SORRY, JUDGE. THIS IS JUDITH
1 LARSEN.
2 THE COURT: THEN IT WOULD BE 3-B.
3 MS. ISAACSON: I'M SORRY. WE'RE HAVING SOME SORT
4 OF GLITCH. LET'S SHIFT TO THE OTHER COMPUTER.
5 Q. (BY MR. BUGDEN) OKAY. THIS IS JUST TO FAMILIARIZE YOU
6 AND THEN WE'RE GOING TO HAVE A BLOWUP, DOCTOR. IT WILL BE
7 EASIER FOR ALL OF US TO READ.
8 A. GOOD.
9 Q. 12/26/1995.
10 MR. BUGDEN: AND THEN IS THERE A BLOWUP, PLEASE?
11 Q. (BY MR. BUGDEN) OKAY. SO AT EIGHT O'CLOCK, MOANING,
12 APPEARED TO BE IN SOME DISCOMFORT.
13 DO YOU AGREE THAT MOANING COULD BE A SYMPTOM OF PAIN?
14 A. IT COULD BE.
15 Q. THANK YOU.
16 MR. BUGDEN: MAY I SEE THE NEXT SLIDE?
17 AND, JUDGE, THIS IS MED-582 OF THE SAME EXHIBIT.
18 Q. (BY MR. BUGDEN) I'M NOT SURE IF I'M READING THE DATE
19 RIGHT. 12/31, 12/30?
20 MR. BUGDEN: IS THERE A BLOWUP OF THAT, PLEASE?
21 Q. (BY MR. BUGDEN) AGAIN, IT'S BEEN CHARTED FROM 2:30 TO
22 6:30 FOR PAIN RELIEF, PATIENT WAS -- I THINK IT SAYS --
23 MOANING.
24 DO YOU AGREE THAT MOANING COULD BE A SYMPTOM OF PAIN,
25 DOCTOR?
1 A. IT COULD.
2 Q. THANK YOU. LYDIA SMITH, THIS PATIENT WAS -- BY THE TIME
3 SHE CAME TO THE GEROPSYCHIATRIC UNIT SHE WAS ONE MONTH POST
4 STROKE; IS THAT RIGHT?
5 A. YES, IT WAS.
6 Q. AND STROKES CAN RESULT IN PATIENTS HAVING POST STROKE
7 PAIN SYNDROME; IS THAT RIGHT, DOCTOR?
8 A. SOMETIME.
9 Q. AND SHE HAD HAD A THALAMIC STROKE; IS THAT RIGHT?
10 A. I DON'T RECALL THE DETAILS OF THE STROKE THAT SHE HAD.
11 Q. LET'S JUST ASSUME THAT SHE HAD A THALAMIC STROKE,
12 DR. HARE?
13 A. OKAY.
14 Q. AND LET ME JUST TELL YOU THAT THE RECORDS -- MEDICAL
15 RECORDS --
16 MR. WILSON: AND I THINK I'M GOING TO IMPOSE AN
17 OBJECTION HERE BECAUSE I DON'T THINK IT WAS EVER
18 CHARACTERIZED AS A THALAMIC STROKE.
19 THE COURT: WELL, I DON'T RECALL. LET THE JURY SORT
20 THAT OUT.
21 Q. (BY MR. BUGDEN) I'M JUST GOING TO SORT OF KEEP MOVING
22 ACROSS HERE. A STROKE.
23 A. OKAY.
24 Q. THE NURSING RECORDS AND THE MEDICAL RECORDS ARE -- HAVE A
25 NUMBER OF DESCRIPTIONS OF THE PATIENT PULLING HER HAIR OUT
1 AND RIPPING HER CLOTHES OFF. DO YOU REMEMBER THAT, DOCTOR?
2 A. YES.
3 Q. AND ALSO THIS PATIENT SAYING, I HAVE PAIN AND I HURT.
4 I'M NOT GOING TO DIRECT YOU TO A PAGE, I'M JUST GOING TO TELL
5 YOU THAT THAT'S WHAT THE PATIENT WAS SAYING. MIGHT THOSE BE
6 SYMPTOMS, DOCTOR, OF A PATIENT THAT WAS SUFFERING FROM A POST
7 STROKE PAIN SYNDROME, NOT WANTING TO EVEN HAVE CLOTHES ON
8 BECAUSE THEY HURT?
9 A. IT'S -- IT'S POSSIBLE.
10 Q. THANK YOU. AND ALSO, DOCTOR, LET ME JUST ASK YOU, WHAT
11 DO YOU BELIEVE IS THE DIFFERENTIAL DIAGNOSIS FOR A PATIENT
12 WHO HAS RECEIVED PSYCHOTROPIC MEDICATIONS AND STILL CONTINUES
13 TO BE AGITATED? WOULD PAIN BE PART -- AN UNDERLYING
14 COMPONENT OF PAIN, WOULD THAT BE PART OF THE DIFFERENTIAL
15 DIAGNOSIS, DR. HARE?
16 A. I WOULD AGREE. I THINK IT'S SOMETHING THAT NEEDS TO BE
17 CONSIDERED. YES.
18 Q. THANK YOU. AND THEN WITH MARY CRANE, WE TALKED ABOUT THE
19 BACK PAIN, AND THEN EVENTUALLY THERE CAME A TIME THAT THIS
20 PATIENT SUFFERED FROM A RECTOVAGINAL FISTULA, AND THAT'S A
21 HOLE BETWEEN THE RECTUM AND THE VAGINA; IS THAT RIGHT,
22 DOCTOR?
23 A. THAT'S RIGHT.
24 Q. AND WOULD YOU AGREE THAT THAT CAN CAUSE SEVERE PAIN,
25 DOCTOR?
1 A. I WOULD EXPECT SO. I DON'T KNOW FOR A MEDICAL FACT, BUT
2 I WOULD EXPECT IT COULD, YES.
3 Q. OKAY. THANK YOU. DR. HARE, FOUR NURSES -- I'LL JUST
4 REPRESENT THIS TO YOU -- CHARTED SYMPTOMS OF PAIN FOR ENNIS
5 ALLDREDGE, SYMPTOMS THAT YOU MAY DEBATE, BUT SYMPTOMS LIKE
6 WE'VE BEEN TALKING ABOUT. TWO NURSES CHARTED PAIN FOR ELLEN
7 ANDERSON. SIX NURSES CHARTED SYMPTOMS LIKE WE'VE BEEN
8 TALKING ABOUT FOR JUDITH LARSEN. FIVE NURSES CHARTED PAIN
9 SYMPTOMS FOR MARY CRANE. YOU'RE NOT SUGGESTING THAT ALL OF
10 THOSE NURSES WERE WRONG, ARE YOU, WHEN THEY THOUGHT THEY SAW
11 PAIN?
12 A. AGAIN, I -- I -- YOU KNOW, NOT KNOWING THE EXACT
13 CIRCUMSTANCES, I -- I CAN'T SAY WHETHER THEY WERE RIGHT OR
14 WRONG ABOUT IT. AGAIN, SOME OF THE SYMPTOMS COULD HAVE BEEN
15 INTERPRETED THAT WAY.
16 Q. LET'S -- LET'S ASSUME THAT -- FOR THE SAKE OF THIS NEXT
17 COUPLE OF QUESTIONS, DOCTOR, THAT THESE PATIENTS WERE IN
18 PAIN. YOU DON'T -- YOU DON'T -- YOU'RE NOT CLAIMING THAT
19 TREATING THESE SYMPTOMS OF PAIN -- THAT DR. WEITZEL'S
20 DECISION TO TREAT THESE SYMPTOMS OF PAIN BREACHED THE
21 STANDARD OF CARE. YOU DON'T CLAIM THAT, DO YOU?
22 A. NO.
23 Q. AND ONCE YOU SEE SYMPTOMS OF PAIN, THE DOCTOR HAS TO MAKE
24 A DECISION ABOUT, FOR EXAMPLE, WHAT -- WHAT DRUG TO USE; IS
25 THAT RIGHT?
1 A. YES.
2 Q. AND THAT'S A CLINICAL JUDGMENT. THAT'S -- THAT'S
3 SOMETHING THAT THE DOCTOR IN THE FIELD WHO'S TREATING THE
4 PATIENT, HE JUST HAS TO USE HIS BEST JUDGMENT HOW TO TREAT
5 THAT SYMPTOM OF PAIN; IS THAT RIGHT?
6 A. YES, WITHIN THE BOUNDS OF -- OF GOOD CLINICAL PRACTICE,
7 YES.
8 Q. AND DO YOU AGREE, DOCTOR, THAT -- THAT REASONABLY
9 COMPETENT DOCTORS MAY DISAGREE ABOUT A DIAGNOSIS -- A
10 DIAGNOSIS OF A PAINFUL CONDITION? IN OTHER WORDS, YOU MAY
11 NOT SEE PAIN, ANOTHER MAY -- ANOTHER DOCTOR WHO TREATS
12 GEROPSYCHIATRIC PATIENTS MAY BELIEVE THAT THERE WERE SYMPTOMS
13 OF PAIN, AND BECAUSE YOU DIDN'T SEE PAIN AND SOMEONE ELSE DID
14 SEE PAIN, THAT'S NOT A BREACH OF THE STANDARD OF CARE, IS IT?
15 A. NO.
16 Q. THERE ARE MORE THAN TWO APPROACHES TO TREATING ANY
17 PATIENT, AREN'T THERE, DOCTOR?
18 A. THERE WOULD BE.
19 Q. THAT MEETS THE STANDARD OF CARE?
20 A. WITHIN THE -- WELL, TWO APPROACHES WITHIN THE STANDARD OF
21 CARE, YES.
22 Q. WELL, THE STANDARD OF CARE DEFINES A RANGE OF CONDUCT,
23 ISN'T THAT TRUE, DOCTOR?
24 A. THAT'S RIGHT.
25 Q. AND THAT TO -- SO NOW WE HAVE A SYMPTOM OF PAIN AND THE
1 DOCTOR DECIDES TO TREAT THE SYMPTOM OF PAIN. AND YOU AGREE
2 THAT THE DOCTOR'S ENTITLED TO MAKE A CLINICAL JUDGMENT ABOUT
3 WHAT DRUG TO USE TO -- TO TREAT THAT SYMPTOM OF PAIN; IS THAT
4 RIGHT?
5 A. WELL, AGAIN, THE STANDARD OF CARE THOUGH AT LEAST
6 DICTATES SOME GUIDELINES AS TO WHAT DRUG MIGHT BE
7 APPROPRIATE.
8 Q. OKAY. YOU'RE NOT TESTIFYING THAT DR. WEITZEL'S DECISION
9 TO USE MORPHINE TO TREAT THE SYMPTOMS OF PAIN WITH THESE
10 PATIENTS, THAT THAT IN AND OF ITSELF WAS A BREACH OF THE
11 STANDARD OF CARE, ARE YOU?
12 A. I DON'T KNOW ABOUT A BREACH OF THE STANDARD OF CARE --
13 Q. THAT WAS MY QUESTION.
14 A. -- MAYBE A BREACH OF --
15 Q. THAT WAS MY QUESTION. DO YOU WANT ME TO REPEAT IT?
16 A. I WOULD SAY -- OKAY. I -- I WOULD SAY THAT'S NOT A
17 BREACH OF THE STANDARD OF CARE.
18 Q. OKAY. THANK YOU. NOW, WHEN YOU'RE SELECTING A
19 MEDICATION DOSAGE LIKE WITH ELLEN ANDERSON, WE -- WE -- WE'VE
20 SEEN THAT THE MERCK MANUAL TALKS ABOUT 10 MILLIGRAMS. YOU
21 WOULD HAVE DONE SOMETHING DIFFERENT. YOU WOULD HAVE USED A
22 LOWER DOSE OR MAYBE NOT USED MORPHINE AT ALL. BUT DO YOU
23 AGREE, DOCTOR, THAT REASONABLY COMPETENT DOCTORS,
24 CONSCIENTIOUS DOCTORS CAN DISAGREE ABOUT HOW MUCH PAIN
25 MEDICATION IS APPROPRIATE TO TREAT A SYMPTOM OF PAIN?
1 A. THERE COULD, AGAIN, BE SOME DISAGREEMENT WITHIN LIMITS.
2 Q. OKAY. DO YOU AGREE THAT THE GOAL STANDARD FOR THE
3 TREATMENT OF PAIN IS MORPHINE, THAT ALL DRUGS ARE REALLY
4 MEASURED AGAINST MORPHINE FOR THE TREATMENT OF PAIN?
5 A. THAT'S TRUE, ALTHOUGH IT DOESN'T MEAN IT'S THE BEST DRUG
6 FOR ALL PAIN PROBLEMS.
7 Q. OKAY. THANK YOU. AND IN TERMS OF SELECTING A DOSAGE OF
8 MEDICATION FOR THE TREATMENT OF PAIN, THAT IS NOT AN EXACT
9 SCIENCE; ISN'T THAT TRUE?
10 A. I'D SAY SO, YES.
11 Q. AND ON A PRIOR OCCASION, YOU'VE TESTIFIED THAT PICKING AN
12 INITIAL DOSAGE OF PAIN IN SOME SENSE IS KIND OF A GESTALT
13 TYPE THING FOR THE TREATING DOCTOR? YOU GET A SENSE FOR HOW
14 MUCH PAIN THE PATIENT HAS, THEN YOU PICK A DOSAGE?
15 A. THAT'S RIGHT.
16 Q. SO THAT'S NOT AN EXACT SCIENCE, IS IT, DR. HARE?
17 A. NO, THAT'S RIGHT.
18 Q. MEDICINE IS AN ART. IT'S ALSO A SCIENCE, BUT THERE'S A
19 HUGE COMPONENT OF MEDICAL CARE THAT IS AN ART; IS THAT RIGHT,
20 DOCTOR?
21 A. WELL, I THINK IT'S ART BASED ON SCIENCE.
22 Q. THANK YOU.
23 A. IF THERE IS SUCH A THING.
24 Q. ARE YOU FAMILIAR WITH A GENTLEMAN BY THE NAME OF ART
25 LIPMAN?
1 A. YES, I AM.
2 Q. WHO'S ART LIPMAN?
3 A. HE IS A -- A PROFESSOR OF CLINICAL PHARMACY AT THE
4 UNIVERSITY OF UTAH.
5 Q. AND IS HE PRESENTLY A CONSULTANT PHARMACIST TO YOUR
6 UNIVERSITY OF UTAH PAIN CLINIC WHERE YOU WORK?
7 A. HE IS.
8 Q. AND IS HE PRESIDENT OF THE AMERICAN PAIN SOCIETY?
9 A. I'M NOT AWARE THAT HE IS THAT.
10 Q. DO YOU CONSIDER HIM TO BE AN EXPERT IN THE FIELD OF
11 PHARMACOLOGY, DR. HARE?
12 A. I WOULD THINK SO.
13 MR. BUGDEN: MAY I APPROACH THE WITNESS AGAIN,
14 JUDGE?
15 THE COURT: YOU MAY.
16 Q. (BY MR. BUGDEN) ART LIPMAN HAS WRITTEN ABOUT THE
17 PHARMACOLOGY OF OPIOID DRUGS, BASIC PRINCIPLES. ARE YOU --
18 ARE YOU FAMILIAR WITH THAT AT ALL, DOCTOR?
19 A. I -- I'M AWARE OF A NUMBER OF PUBLICATIONS HE'S DONE IN
20 THAT AREA, YES.
21 Q. BY ART LIPMAN.
22 A. YES.
23 Q. BECAUSE HE'S A --
24 A. I'VE CO-AUTHORED PAPERS WITH ART LIPMAN. YES.
25 Q. BECAUSE HE'S A -- YOU RECOGNIZE HIM AS AN EXPERT.
1 A. YES.
2 Q. DO YOU AGREE -- LET ME READ THIS STATEMENT AND ASK YOU IF
3 YOU AGREE WITH THIS. THERE IS NO MAXIMUM --
4 THE COURT: PAGE?
5 MR. BUGDEN: THIS IS IN PHARMACOLOGY OF OPIOID
6 DRUGS, JUDGE, AND IT IS PAGE 146.
7 THE COURT: THANK YOU.
8 MR. WILSON: COULD WE HAVE A DATE ON THE
9 PUBLICATION, TOO?
10 MR. BUGDEN: CAN'T TELL YOU THAT.
11 Q. (BY MR. BUGDEN) LET ME READ THIS SENTENCE TO YOU,
12 DOCTOR, AND ASK YOU IF YOU AGREE WITH IT. I'M GOING TO READ
13 A COUPLE OF SENTENCES TO YOU.
14 THERE'S NO MAXIMUM SAFE DOSE OF MORPHINE IN OTHER
15 PEER -- WHAT DOES THAT MEAN?
16 A. MU.
17 Q. MU?
18 A. MU AGONIST, YEAH.
19 Q. MU AGONIST OPIOIDS. NO MAXIMUM SAFE DOSE OF MORPHINE.
20 DO YOU AGREE WITH THAT OR DISAGREE WITH THAT STATEMENT
21 BY ART LIPMAN?
22 A. WELL, IT'S A PATIENT-BY-PATIENT DETERMINATION. YOU KNOW,
23 ANY -- ALL THAT STATEMENT IS SAYING IS THAT --
24 Q. WELL, LET ME JUST -- I -- I APOLOGIZE TO INTERRUPT. DO
25 YOU AGREE WITH THE STATEMENT? THAT'S THE QUESTION.
1 A. WELL, I -- I THINK IT'S ONLY -- I AGREE WITH IT IN
2 CONTEXT.
3 Q. THANK YOU.
4 A. BUT -- BUT --
5 Q. THANK YOU. YOU'VE ANSWERED THAT QUESTION.
6 A. OKAY.
7 Q. NOW I'M GOING TO ASK YOU ANOTHER ONE. AN INNER-PATIENT
8 VARIANCE OF UP TO 50 FOLD HAS BEEN REPORTED FOR THE DOSE OF
9 MORPHINE REQUIRED TO PROVIDE PAIN RELIEF.
10 DO YOU AGREE WITH THAT STATEMENT, DOCTOR?
11 A. I DON'T KNOW ABOUT 50 FOLD, BUT MAYBE THERE'S SOME
12 EVIDENCE FOR THAT. TEN -- YOU KNOW, FOUR TO TEN FOLD I'D
13 DEFINITELY AGREE WITH, YES.
14 Q. OKAY. DO YOU AGREE WITH THIS STATEMENT, USING MEDIUM
15 DOSES AS A STARTING POINT, CLINICIANS SHOULD INCREASE THE
16 DOSE AGGRESSIVELY, FOR EXAMPLE, 30 TO 50 PERCENT IN EACH
17 DOSING INTERVAL UNTIL PAIN RELIEF IS OBTAINED.
18 DO YOU AGREE OR DISAGREE WITH ART LIPMAN'S STATEMENT
19 THERE ABOUT --
20 A. WELL, THAT'S -- AGAIN, THAT'S IN THE CONTEXT OF
21 MONITORING SIDE EFFECTS. AND I -- I WOULD AGREE WITH IT, BUT
22 THAT'S IN THE CONTEXT OF ALSO MEASURING SIDE EFFECTS AND IF
23 THE SIDE EFFECTS ALLOW YOU TO MAKE THOSE SORT OF CHANGES.
24 Q. OKAY. THANK YOU. NOW, ONE OF THE THINGS YOU'VE
25 TESTIFIED TO IS THE STANDARD OF CARE AS IT RELATES TO
1 DOSAGING. THAT'S WHAT WE'RE DISCUSSING RIGHT NOW, DOCTOR.
2 A. YES.
3 Q. AND I BELIEVE I UNDERSTOOD YOU TO SAY ON DIRECT
4 EXAMINATION THAT YOU AGREE THAT THE STANDARD OF CARE IS
5 ESSENTIALLY A CONSENSUS; IS THAT RIGHT, DOCTOR HARE?
6 A. YES.
7 Q. SOMETHING THAT PEOPLE IN THE PROFESSION HAVE COME TO
8 AGREE IS AN ACCEPTABLE RANGE OF BEHAVIOR?
9 A. YES.
10 Q. THANK YOU. AND ARE -- ARE YOU FAMILIAR WITH THE
11 CONSENSUS GUIDELINES ON -- ON ANALGESIA AND SEDATION IN DYING
12 INTENSIVE CARE PATIENTS, A STUDY THAT WAS WRITTEN BY
13 DR. SINGER?
14 A. I -- I'M -- I KNOW OF THAT STUDY. I'M NOT --
15 Q. OKAY.
16 A. -- YOU KNOW, OVERLY FAMILIAR WITH IT.
17 Q. LET ME ASK YOU IF YOU AGREE WITH THESE STATEMENTS. IN
18 ORDER TO RELIEVE PAIN AND SUFFERING AT THE END OF LIFE,
19 PHARMACOLOGICAL INTERVENTIONS, INCLUDING ANALGESICS -- THAT'S
20 A PAIN RELIEVER; IS THAT RIGHT?
21 A. YES.
22 Q. SEDATIVES OR OTHER ADJUNCTS THAT WILL DECREASE DISCOMFORT
23 IN GENERAL, NARCOTICS ARE USED FOR PAIN, BENZODIAZEPINES ARE
24 USED FOR AGITATION AND ANXIETY.
25 DO YOU AGREE WITH THAT STATEMENT?
1 A. YES.
2 Q. AND THE BENZODIAZEPINES ARE WHAT KIND OF DRUG, FOR US --
3 THE JURORS AND US?
4 A. WITH C.N.S. DEPRESSANTS THIS WOULD BE MEDICATIONS LIKE
5 ATIVAN. THAT'S ONE THAT WAS USED IN -- IN THESE PARTICULAR
6 PATIENTS.
7 Q. OKAY. THANK YOU. SO ACCORDING TO THE CONSENSUS
8 STATEMENT, THE USE OF MORPHONE AND A DRUG LIKE ATIVAN
9 TOGETHER, THE CONSENSUS STATEMENT WAS THAT THAT'S A GOOD
10 THING TO DO?
11 A. IT COULD BE, YES.
12 Q. THANK YOU.
13 A. UH-HUH.
14 Q. AND IF THE PATIENT IS EXPERIENCING PAIN AND SUFFERING
15 BOTH ANALGESICS AND SEDATIVES ARE NOT USED, THIS COMBINATION
16 OF DRUGS MAY PROVIDE BETTER RELIEF OF PAIN AND SUFFERING AT
17 THE END OF LIFE THAN EITHER CLASS OF DRUG ALONE. DO YOU
18 AGREE WITH THAT?
19 A. I WOULD AGREE WITH THAT, YES.
20 Q. OKAY. AND DO YOU AGREE WITH THIS STATEMENT? NO MAXIMUM
21 DOSE OF NARCOTICS OR SEDATIVES EXISTS.
22 DO YOU AGREE WITH THAT?
23 A. WELL, AGAIN, THAT'S IN THE CONTEXT OF THE SIDE EFFECTS
24 THAT THE PATIENTS MIGHT EXPERIENCE. SOME PATIENTS DO DEVELOP
25 TREMENDOUS TOLERANCE TO THESE MEDICATIONS AND -- AND SO THERE
1 ISN'T A MAXIMUM DOSE. BUT THOSE ARE THE PATIENTS WHO GET --
2 WITH A HIGH DOSE GET THE SAME EFFECT WITH SOMEBODY WITH A
3 MUCH LOWER DOSE.
4 Q. THANK YOU. DOCTOR, IN THE AGE GROUP THAT WE'RE TALKING
5 ABOUT, THESE PATIENTS WERE 93, 91, 90, I THINK 83 AND 72.
6 A. UH-HUH.
7 Q. DOCTOR, WOULD YOU AGREE THAT IN THIS AGE GROUP, PEOPLE
8 SOMETIMES JUST DON'T WAKE UP IN THE MORNING? THEIR HEART
9 STOPS BEATING, THEIR LUNGS STOP WORKING, THEY DIE.
10 A. WELL, PEOPLE HAVE TO DIE OF SOMETHING SOMETIME. YES.
11 Q. OKAY. AND LET ME ASK YOU ABOUT PEOPLE WITH DEMENTIA. I
12 REALIZE THAT THAT'S NOT EXACTLY YOUR AREA OF EXPERTISE, BUT
13 DO YOU AGREE THAT PEOPLE WITH DEMENTIA DIE FROM COMPLICATIONS
14 OF THAT DIAGNOSIS?
15 A. THEY CERTAINLY -- THEY CERTAINLY CAN, YES.
16 Q. AND THAT INCLUDES BODY WASTING; IS THAT RIGHT, DOCTOR?
17 A. YES.
18 Q. THAT INCLUDES DISCOORDINATED SWALLOWING?
19 A. YES.
20 Q. DOES THAT INCLUDE -- THAT'S LIKE THE INHIBITED GAG
21 REFLEX --
22 A. YES.
23 Q. -- IS THAT RIGHT, DR. HARE?
24 AND ASPIRATION PNEUMONIA, THAT KILLS OLDER PEOPLE,
25 DOESN'T IT?
1 A. YES.
2 Q. DEMENTING DISEASE?
3 A. IT CAN. UH-HUH.
4 Q. AND URINARY TRACT INFECTIONS, THAT KILLS PEOPLE, TOO,
5 DOESN'T IT?
6 A. YES.
7 Q. NOW, YOU DIDN'T THINK ELLEN ANDERSON WAS IN ANY KIND OF
8 CRITICAL CARE SITUATION UPON HER ADMISSION, AM I RIGHT ABOUT
9 THAT?
10 A. NO, I DIDN'T. I HAD NOT -- THERE WASN'T ANYTHING OBVIOUS
11 FROM MY RECORDS --
12 Q. YOU'VE ANSWERED THAT QUESTION, DOCTOR. THANK YOU.
13 A. OKAY.
14 Q. WERE YOU AWARE, DR. HARE, THAT ALL OF THESE PATIENT HAD
15 ADVANCE DIRECTIVES IN PLACE?
16 A. YES.
17 Q. AND DO YOU AGREE THAT THE ATTENDING PHYSICIAN IS
18 OBLIGATED TO HONOR THE WISHES OF THE PATIENT OR THE PATIENT'S
19 FAMILY MEMBERS THAT HAVE EXECUTED THESE ADVANCE DIRECTIVES?
20 A. YES.
21 Q. AND IF FAMILY MEMBERS DECIDE THAT ENOUGH IS ENOUGH, THAT
22 THEY NO LONGER WANT ANY MORE MEDICAL INTERVENTIONS, AND THAT
23 THEY JUST WANT COMFORT CARE, YOU WOULD AGREE THAT IT'S A
24 PHYSICIAN'S OBLIGATION TO HONOR THE WISHES OF THE FAMILY IN
25 THAT SITUATION; IS THAT RIGHT, DOCTOR?
1 A. I THINK IF THE -- IF THE PHYSICIAN AGREES WITH THAT --
2 THAT DECISION, YES.
3 Q. AND BY COMFORT CARE, WHAT WE TALK ABOUT IS WE'RE NO
4 LONGER TRYING TO CURE THE PATIENT, WE'RE JUST TRYING TO
5 PROVIDE A PAIN-FREE -- A COMFORTABLE PASSING; ISN'T THAT
6 RIGHT?
7 A. YES.
8 Q. AND THE GOAL OF THE POINT THAT YOU'RE TALKING ABOUT,
9 COMFORT CARE, IS TO PREVENT PAIN FROM RETURNING; ISN'T THAT
10 TRUE, DOCTOR?
11 A. WELL, ASSUMING PAIN IS PART OF THE ISSUE, YES.
12 Q. AND IN PROVIDING PAIN RELIEF, YOU'VE INDICATED TO THE
13 JURY THAT THE PROBLEMS ASSOCIATED WITH MORPHINE, RESPIRATORY
14 DEPRESSION, FOR EXAMPLE, THAT'S A WELL-KNOWN CONSEQUENCE OF
15 THE USE OF OPIOIDS LIKE MORPHINE; IS THAT RIGHT?
16 A. THAT'S RIGHT.
17 Q. AND YOU AGREE THAT WHEN PATIENTS OR FAMILIES HAVE GOTTEN
18 TO THE POINT THAT THEY WANT ONLY COMFORT CARE, DOCTORS
19 UNDERSTAND THAT THE USE OF MORPHINE COULD POSSIBLY HASTEN THE
20 DEATH OF THE PATIENT; ISN'T THAT TRUE?
21 A. THAT'S RIGHT.
22 Q. AND SO, FOR EXAMPLE, WHEN YOU PRESCRIBED MORPHINE TO THE
23 PATIENTS YOU'VE TALKED ABOUT -- AND YOU'VE INDICATED THAT
24 SOME OF THE PATIENTS YOU TREATED WITH MORPHINE, THEY PASSED
25 AWAY, THEY DIED WITH MORPHINE ON BOARD.
1 A. YES.
2 Q. AND WHEN YOU PRESCRIBED THE MORPHINE, YOU WERE NOT TRYING
3 TO HASTEN THE DEATH OF THE PATIENT, WERE YOU?
4 A. THAT'S RIGHT.
5 Q. YOU WERE TRYING TO RELIEVE THE PAIN AND THE SUFFERING OF
6 THE PATIENT; ISN'T THAT TRUE?
7 A. YES.
8 Q. BUT THERE WAS A RECOGNIZED UNDERSTANDING THAT IT COULD
9 HASTEN DEATH. EVEN YOU KNEW THAT --
10 A. YES.
11 Q. -- DIDN'T YOU, DR. HARE?
12 A. YES.
13 Q. AND THAT POSSIBLE CONSEQUENCE, THAT WAS JUST A TRADE-OFF
14 THAT IS MADE TO ENSURE THAT THE PATIENT COULD HAVE A
15 PAIN-FREE DEATH, A COMFORTABLE PASSING; ISN'T AT THAT TRUE?
16 A. YES.
17 Q. AND A PAIN-FREE DEATH, ISN'T THAT WHAT ALL OF US WOULD
18 WANT, DR. HARE?
19 A. I WOULD AGREE.
20 MR. BUGDEN: THANK YOU.
21 THE COURT: CROSS-EXAMINATION? REDIRECT. EXCUSE
22 ME.
23 MR. WILSON: JUST A COUPLE OF QUESTIONS, YOUR HONOR.
24 REDIRECT EXAMINATION
25 BY MR. WILSON:
1 Q. DOCTOR, COUNSEL WAS JUST ASKING YOU A SERIES OF QUESTIONS
2 RELATED TO COMFORT CARE. IN RESPECT TO THE FIVE PATIENTS
3 THAT WE HAVE BEFORE THIS COURT, DID YOU SEE ANY REASON TO
4 PROVIDE MORPHINE AS A COMFORT CARE MEASURE TO ANY OF THOSE
5 FIVE PATIENTS?
6 A. I DON'T THINK -- I MEAN, I GUESS KIND OF LOOKING AT
7 THE -- AT THE BIGGER PICTURE, I DON'T THINK THE EXPECTATION
8 WAS THAT THESE WERE TERMINAL CARE PATIENTS WHEN THEY WERE
9 ADMITTED. THERE WAS NO INDICATION OF THAT.
10 MR. BUGDEN: I DON'T BELIEVE THAT THAT'S RESPONSIVE
11 TO THE QUESTION.
12 THE COURT: I WILL SUSTAIN THE OBJECTION.
13 Q. (BY MR. WILSON) CAN YOU TELL US, DOCTOR, IS COMFORT
14 CARE -- HOW IS IT DEFINED IN THE CONTEXT IN THE ABSENCE OF
15 PAIN? IF A PERSON IS DYING WITHOUT -- AND IS NOT IN ANY
16 PAIN, WHAT -- WHAT DO YOU DO COMFORT-CARE WISE TO TREAT THAT
17 PATIENT?
18 A. YOU MAY NOT NEED TO DO ANYTHING. YOU KNOW, AGAIN, YOU --
19 YOU TRY TO RECOGNIZE WHAT FORMS OF DISCOMFORT MIGHT BE
20 OCCURRING AND TREAT THOSE. IF THERE ARE NO FORMS OF
21 DISCOMFORT RECOGNIZED, IT MAY NOT REQUIRE ANY TREATMENT.
22 Q. OKAY.
23 A. NATURE JUST MAY TAKE ITS COURSE.
24 Q. ARE THERE OTHER THINGS THAT YOU CAN DO FOR A PATIENT
25 OTHER THAN ADMINISTER PAIN MEDICATION?
1 A. IN THE CASE OF AN AGITATED PATIENT, YOU KNOW, ONE OR THE
2 OTHER BENZODIAZEPINE-TYPE PATIENT -- OR MEDICINES MIGHT --
3 MIGHT BE A MORE APPROPRIATE CHOICE WITH LESS DANGER OF
4 CAUSING RESPIRATORY DEPRESSION.
5 Q. OKAY. WOULD IT BE A FAIR STATEMENT TO SAY THAT THE GOAL
6 OF COMFORT CARE WOULD BE TO STRIVE FOR A -- NOT ONLY A
7 PAIN-FREE ENVIRONMENT, BUT AN ENVIRONMENT WHERE THE PATIENT
8 WOULD BE ABLE TO INTERACT WITH --
9 MR. BUGDEN: OBJECTION. LEADING.
10 THE COURT: SUSTAINED.
11 Q. (BY MR. WILSON) OKAY. STRIKE THAT.
12 IS THERE ANY OTHER CONTEXT THAT YOU SEE COMFORT CARE
13 ADMINISTERED TO OTHER THAN IN A PAIN -- TO ADDRESS PAIN
14 ISSUES?
15 A. WELL, AGAIN, I THINK FOR A PATIENT WHO'S ANXIOUS,
16 AGITATED, YOU KNOW, THERE ARE -- THERE ARE OTHER REASONS WHY
17 A PATIENT CAN BE DISTRESSED, AND COMFORT CARE CAN BE
18 ADMINISTERED UNDER THOSE CIRCUMSTANCES.
19 Q. THANK YOU.
20 MR. WILSON: I HAVE NO FURTHER QUESTIONS.
21 THE COURT: RECROSS?
22 MR. BUGDEN: I HAVE NO OTHER QUESTIONS, JUDGE.
23 THE COURT: YOU MAY STEP DOWN, DOCTOR.
24 THE WITNESS: THANK YOU.
25 THE COURT: THANK YOU FOR TESTIFYING.
1 MAY THIS WITNESS BE EXCUSED, MR. WILSON?
2 MR. WILSON: HE MAY.
3 THE COURT: MR. BUGDEN?
4 MR. BUGDEN: YES, SIR.
5 THE COURT: AGAIN, THANK YOU, DOCTOR, AND YOU MAY BE
6 EXCUSED.