James Pearce, MD
4 JAMES PEARCE,
5 CALLED BY THE PLAINTIFF, HAVING BEEN DULY
6 SWORN, WAS EXAMINED AND TESTIFIED AS FOLLOWS:
7 DIRECT EXAMINATION
8 BY MR. WILSON:
9 Q. DR. PEARCE, WOULD YOU STATE YOUR FULL NAME FOR THE
10 RECORD?
11 A. JAMES RICHARD MCGHIE PEARCE, M-C-G-H-I-E.
12 Q. AND WHAT IS YOUR CURRENT OCCUPATION?
13 A. INTERNAL MEDICINE PRIMARY CARE PRACTICE.
14 Q. AND WHERE DO YOU OFFICE?
15 A. 56 SOUTH AND HIGHLAND DRIVE.
16 Q. CAN YOU TELL US WHEN YOU OBTAINED YOUR MEDICAL DEGREE?
17 A. IN 1970, IN JUNE.
18 Q. AND FROM WHERE?
19 A. CRETIN UNIVERSITY, OMAHA, NEBRASKA. Creighton?
20 Q. ARE YOU BOARD CERTIFIED IN ANY --
21 A. YES, INTERNAL MEDICINE.
22 Q. AND WHEN DID YOU OBTAIN YOUR CERTIFICATION?
23 A. 1974.
24 Q. HOW LONG HAVE YOU PRACTICED IN THE HOLLADAY AREA?
25 A. SINCE 1974.
1007
1 Q. ARE YOU ASSOCIATED WITH OTHER PHYSICIANS THERE?
2 A. YES. I'M IN AN I.H.C. POD, IF YOU WILL, WITH DR. MCCAA,
3 DR. ARENA, DR. PODOLSKY AND DR. STEVENS. I GUESS I GOT THEM
4 ALL.
5 Q. I TAKE IT THAT THERE ARE TIMES THAT YOU COVER FOR EACH
6 OTHER?
7 A. THAT'S CORRECT.
8 Q. THIS CASE INVOLVES AN INDIVIDUAL BY THE NAME OF JUDITH
9 LARSEN. DO YOU RECOGNIZE THAT NAME?
10 A. I DO.
11 Q. HAVE YOU HAD OCCASION TO REVIEW THE FILE MAINTAINED IN
12 YOUR OFFICE IN CONNECTION WITH THAT PATIENT?
13 A. YES, I HAVE.
14 Q. AND I'M JUST GOING TO CUT TO THE CHASE HERE. DID YOU
15 HAVE OCCASION TO SEE JUDITH LARSEN IN REFERENCE TO A
16 HOSPITALIZATION OCCURRING IN JULY OF 1995?
17 A. I DID.
18 Q. AND WHAT HOSPITAL WAS THAT AT?
19 A. COTTONWOOD HOSPITAL.
20 Q. CAN YOU TELL THE COURT WHAT THE NATURE OF THE PROBLEM
21 WAS THAT JUDITH LARSEN WAS HOSPITALIZED ON THAT PARTICULAR
22 OCCASION?
23 A. YES. SHE CAME FROM A NURSING HOME OR REST HOME OF SOME
24 SORT AND SHE WAS ADMITTED FOR DEHYDRATION.
25 Q. HOW LONG WAS THAT HOSPITALIZATION?
1008
1 A. I THINK IT WAS JUST A 24-HOUR ADMISSION, SOMETHING LIKE
2 THAT.
3 Q. WHAT DID YOU PERSONALLY DO IN REFERENCE TO THAT
4 HOSPITALIZATION?
5 A. SHE WAS PRETTY MUCH REHYDRATED IN THE EMERGENCY ROOM, SO
6 WHEN I SAW HER SHE WAS PRETTY MUCH STABILIZED. AND SO I
7 JUST FOLLOWED THROUGH, MADE SURE THAT THE DISPOSITION WAS
8 APPROPRIATE AND THAT HER CARE WOULD BE CONTINUED ON THE
9 OUTPATIENT BASIS.
10 Q. DID YOU MEET WITH THE FAMILY ON THAT OCCASION OR DO YOU
11 REMEMBER?
12 A. YOU KNOW, I DON'T RECALL. I THINK THERE WAS NOBODY
13 AVAILABLE AT THE TIME OF ADMISSION, AS I RECALL, SO
14 SUBSEQUENTLY I GOT SOME HISTORY FROM THE FAMILY. I BELIEVE
15 THAT'S THE WAY IT WENT.
16 Q. DR. PEARCE, DID YOU HAVE OCCASION THEN TO AGAIN EVALUATE
17 THIS PATIENT IN THE HOSPITAL SETTING?
18 A. I DID.
19 Q. AND WHEN DID THAT OCCUR, SIR?
20 A. I THINK IT WAS THE 25TH OF AUGUST.
21 Q. CAN YOU TELL US THE NATURE OF THAT PARTICULAR
22 HOSPITALIZATION?
23 A. WELL, AT THAT TIME THE FAMILY SAID THAT SHE HAD HAD A
24 CHANGE IN HER LEVEL OF AWARENESS, ALERTNESS. THAT SHE HAD
25 HAD DIFFICULTY WITH AMBULATION AND A DIFFICULTY WITH SPEECH.
1009
1 THE SPEECH HAD ALWAYS BEEN SORT OF INAPPROPRIATE, BUT THERE
2 HAD BEEN A CHANGE.
3 Q. AND WERE YOU ABLE TO ASCERTAIN FROM YOUR RECORDS AND
4 FROM EVALUATING HER ON THAT PARTICULAR OCCASION IF THERE
5 INDEED HAD BEEN SOME CHANGES, OR WAS IT WHAT HAD BEEN
6 REPORTED TO YOU BY THE FAMILY?
7 A. YEAH. AT THE TIME OF ADMISSION THEY SAID THAT SHE WAS
8 VERBALIZING QUITE A BIT, BUT THE CONTENT OF HER SPEECH
9 WASN'T VERY APPROPRIATE, REPEATING HERSELF OFTEN. VERY
10 LIMITED MEMORY AND SOME INAPPROPRIATE, AS I MENTIONED, AND
11 SHE WENT FROM THAT TO VERY LITTLE SPEECH AT ALL. MAYBE JUST
12 A WORD OR TWO.
13 Q. WHAT DID THIS INDICATE TO YOU?
14 A. WELL, WE THOUGHT THAT IT WAS PROBABLY ANOTHER STROKE
15 THAT WAS SHOWING UP IN THE SPEECH AREA OF THE BRAIN. IT
16 DIDN'T SHOW UP ON THE C.T. SCAN, BUT THE E.E.G. SUGGESTED
17 THAT THERE WAS AN IRRITATIVE -- SOME IRRITATION, AS THEY
18 SAID, IN THAT AREA WHICH WAS COMPATIBLE WITH AN ACUTE
19 STROKE.
20 Q. THE FACT THIS DIDN'T SHOW UP ON THE C.T. SCAN, IS THAT
21 SIGNIFICANT TO YOU?
22 A. WELL, SOMETIMES WHEN THE E.E.G. IS DONE EARLY IT DOESN'T
23 SHOW UP AND THEN IF YOU ARE INTERESTED IN PURSUING IT, YOU
24 CAN DO A SUBSEQUENT C.T. SCAN AND SOMETIMES IT WILL SHOW ON
25 THE SECOND ONE.
1010
1 Q. DO YOU KNOW WHETHER OR NOT THAT INDEED WAS DONE IN THIS
2 PARTICULAR CASE?
3 A. IT WASN'T. WE DIDN'T THINK -- WE THOUGHT IT WAS
4 EXCESSIVE.
5 Q. WHEN YOU SAY SUBSEQUENT, IF THERE WAS ONE DONE SEPTEMBER
6 THE 14TH, WOULD THAT BE WITHIN THE TIME FRAME THAT YOU MIGHT
7 KNOW WHETHER OR NOT THERE HAD BEEN A NEW STROKE?
8 A. WELL, I THINK THAT THE C.T. WAS COMPARED WITH THE
9 PREVIOUS C.T. THAT HAD BEEN DONE PERHAPS IN JANUARY AND THAT
10 THEY DIDN'T SEE ANY SIGNIFICANT CHANGE.
11 Q. I'M GOING TO PUT A DOCUMENT HERE ON THE SCREEN FOR YOU
12 TO TAKE A LOOK AT. YOU'LL BE ABLE TO SEE IT UP ON THAT
13 BOARD.
14 MR. STIRBA: MAY I KNOW WHAT EXHIBIT YOU ARE
15 REFERRING TO, COUNSEL, OR WHAT RECORD IT IS?
16 MR. WILSON: DO YOU KNOW WHAT RECORD IT IS?
17 MR. STIRBA: JUST TELL WHAT RECORD IT IS.
18 MR. WILSON: THIS IS THE --
19 MR. STIRBA: IS IT ONE OF OUR EXHIBITS, EXHIBIT 16?
20 MR. WILSON: IT'S EXHIBIT 16.1.
21 MR. STIRBA: THAT'S FINE, COUNSEL. THANK YOU.
22 MR. WILSON: AND IT'S A RECORD OF A C.T. SCAN THAT
23 WAS DONE AT COTTONWOOD HOSPITAL. I'VE GOT TO PUT IT THIS
24 WAY.
25 Q. (BY MR. WILSON) CAN YOU READ THAT, DOCTOR?
1011
1 A. WITH DIFFICULTY.
2 THE COURT: IF YOU WANT TO STEP TO THE SCREEN.
3 Q. (BY MR. WILSON) STEP TO THE SIDE THOUGH AND STEP BACK.
4 CAN YOU TELL US WHAT THAT DOCUMENT IS?
5 A. IT'S A REPORT OF A C.T. SCAN OF THE BRAIN.
6 Q. OKAY. AND CAN YOU TELL US WHAT THE FINDINGS ARE IN
7 RESPECT TO THAT PARTICULAR REPORT?
8 A. WELL, THE IMPRESSION, AS YOU CAN SEE THERE, THERE WAS NO
9 EVIDENCE OF ACUTE HEMORRHAGE OR CORTICAL OR CEREBROVASCULAR
10 ACCIDENT DEMONSTRATED. AND THEN THEY SAID LEFT HEMISPHERIC
11 AREA OF MALACIA, WHICH IS SOFTENING OF THE BRAIN WHICH IS
12 CONSISTENT WITH OLD ARTERIES OR ARTERY DISTRIBUTION INFARCTS
13 OR STROKES.
14 Q. SO IF I WERE TO ADVISE YOU THAT SHE HAD SUSTAINED A
15 STROKE BACK IN JANUARY OF 1995, WOULD THAT BE CONSISTENT
16 WITH WHAT YOU FIND ON THAT PARTICULAR DOCUMENT?
17 A. YES, IT WOULD, IF THE STROKE DIDN'T OCCUR EARLIER.
18 Q. OKAY. ON THE AUGUST OCCASION, SIR, DO YOU KNOW HOW LONG
19 SHE WAS HOSPITALIZED FOR?
20 A. LET'S SEE. I THINK IT WAS THE 25TH THROUGH THE 27TH OR
21 28TH, SOMETHING LIKE THAT.
22 Q. OKAY. AND DID YOU SEE HER PERSONALLY ON THOSE -- THAT
23 OCCASION?
24 A. YES, I DID.
25 Q. AND HOW MANY OCCASIONS DO YOU THINK YOU VISITED WITH
1012
1 HER?
2 A. WELL, I SAW HER EVERY DAY, YOU KNOW, THAT SHE WAS IN THE
3 HOSPITAL.
4 Q. SHE WAS SUBSEQUENTLY DISCHARGED. DID YOU HAVE OCCASION
5 TO MEET WITH THE FAMILY ON THAT?
6 A. YES. I MET WITH THE FAMILY. I'M JUST REMEMBERING FROM
7 MY RECORD HERE IN REGARD TO THE DISPOSITION AND WHAT KIND OF
8 CARE SHE SHOULD RECEIVE. IN OTHER WORDS, WHAT THE FAMILY'S
9 WISHES FOR HER AND HOW AGGRESSIVE THEY WANTED US TO BE AND
10 SO FORTH AND TAKING INTO ACCOUNT HER LIVING WILL I BELIEVE
11 THAT SHE HAD SIGNED AND SO FORTH SO THAT WE WOULD KNOW WHAT
12 TO DO. SHE CAME IN REFUSING TO EAT, FOR INSTANCE, AND
13 DURING HER HOSPITAL STAY WE HAD A GREAT DEAL OF DIFFICULTY
14 WITH THAT. HAD SOME STUDIES DONE AND SO FORTH WHICH SHOWED
15 THAT SOME OF WHAT WE CALL ASPIRATION OR SOME OF THE FOOD OR
16 FLUIDS WERE GOING INTO THE LUNGS AND SHE HAD A VERY
17 DIFFICULT TIME INITIATING SWALLOWING AND MECHANICS OF
18 EATING, AND SHE SHOWED NO INTEREST IN EATING OR DRINKING.
19 NORMALLY A PERSON LIKE THAT, IF THEY DON'T HAVE A FEEDING
20 TUBE OF SOME SORT EITHER THROUGH THE STOMACH OR DOWN THE
21 NOSE OR IN A VEIN IN THE ARM AND SO FORTH, IF THEY DON'T
22 HAVE ANY NUTRITION AND THEY DON'T DRINK, USUALLY ONLY LAST
23 ABOUT EIGHT OR TEN DAYS. SO WE WERE LOOKING AT END-OF-LIFE
24 CARE UNLESS SOMETHING HAPPENED DIFFERENTLY.
25 Q. AND IS THAT IN REFERENCE TO THE NOTE THAT YOU MADE IN
1013
1 THE RECORD AS FAR AS RELEASING FOR TERMINAL CARE?
2 A. THAT'S CORRECT.
3 Q. SO YOUR UNDERSTANDING AT THAT TIME WAS -- IS THAT SHE
4 WASN'T EATING. WAS THAT THE PRIMARY FACTOR IN MAKING THAT
5 NOTE?
6 A. WELL, THE PRIMARY FACTOR WAS JUST HER TOTAL PRESENTATION
7 THAT SHE HAD. IN DISCUSSION WITH THE FAMILY, DURING THE
8 PREVIOUS SIX MONTHS HAD A VERY POOR QUALITY OF LIFE.
9 ALTHOUGH SHE HAD SOME SPEECH, IT WAS USUALLY INAPPROPRIATE
10 AND REPETITIVE. AND ALTHOUGH THERE WAS SOME RECOGNITION OF
11 FAMILY MEMBERS, SHE DIDN'T REALLY HAVE ANY JOY IN MEETING
12 WITH THEM AND EXPERIENCING THEM AND THEY DIDN'T HAVE ANY
13 WITH HER. SHE DIDN'T HAVE ANY DECISION-MAKING CAPABILITY OR
14 CHOICE MAKING AND SO THEY THOUGHT THAT SHE -- HER QUALITY OF
15 LIFE WAS SUCH THAT IF ANYTHING SHOULD HAPPEN LIKE INFECTION
16 AND SO FORTH THAT THEY WOULD NOT BE AGGRESSIVE WITH HER.
17 Q. WITH THE TREATMENT. OKAY.
18 MR. WILSON: I HAVE NO FURTHER QUESTIONS, YOUR
19 HONOR.
20 CROSS-EXAMINATION
21 BY MR. STIRBA:
22 Q. GOOD AFTERNOON, DOCTOR.
23 A. GOOD AFTERNOON.
24 Q. I WANT TO SHOW YOU SOME MATERIALS FROM THE TWO TIMES
25 THAT YOU TREATED JUDITH AT THE HOSPITAL AND THIS WOULD BE AT
1014
1 COTTONWOOD; IS THAT RIGHT?
2 A. THAT'S CORRECT.
3 Q. AND THE JULY HOSPITALIZATION APPARENTLY WAS AS A RESULT
4 OF A FALL THAT SHE SUSTAINED AND YOU SAW HER IN THE HOSPITAL
5 AT THAT TIME; IS THAT RIGHT?
6 A. WELL, MY UNDERSTANDING WAS THAT SHE -- THAT SHE ENTERED
7 WITH DEHYDRATION, WAS INCOHERENT AND SO FORTH.
8 Q. YOU KNOW, YOU ARE RIGHT. LET ME JUST SHOW YOU THIS.
9 THIS IS WHAT I WAS REFERRING TO. UNDER HOSPITAL COURSE,
10 "THE PATIENT WAS TREATED WITH HYDRATION AND HAD AN
11 UNEVENTFUL HOSPITAL COURSE OTHER THAN HER FAMILY ATTEMPTED
12 TO WALK HER IN THE MORNING AND SHE LOST HER BALANCE, FELL
13 AND SUFFERED SOME SORENESS."
14 SHE ACTUALLY FELL IN THE HOSPITAL?
15 A. YES.
16 Q. NOW, THERE WERE SOME TESTS DONE AT THAT TIME AND I
17 WANTED TO GO OVER THOSE WITH YOU. AND ONCE AGAIN, FEEL FREE
18 TO STEP DOWN AND LOOK AT THAT. NOW, THAT APPEARS TO BE AN
19 X-RAY REPORT; IS THAT RIGHT?
20 A. THAT'S CORRECT.
21 Q. AND I NOTICE IN THE MIDDLE THERE THE -- FIRST OF ALL,
22 THE ABDOMEN, TWO VIEWS, ERECT AND SUPINE. IT SAYS,
23 EXTENSIVE VASCULAR CALCIFICATION IS SEEN IN THE ABDOMEN
24 WHICH INCLUDES THE SPHENIC ARTERY, THE AORTA AND THE ILIAC
25 ARTERIES.
1015
1 DID I READ THAT CORRECTLY?
2 A. YES.
3 Q. WOULD YOU TELL US WHAT THAT MEANS, PLEASE?
4 A. WELL, THAT MEANS THAT SHE HAD SYSTEMIC BLOOD VESSEL
5 DISEASE, YOU KNOW, SO YOU COULD EXPECT THAT WITH CORONARY
6 ARTERIES. AND I THINK WE SUSPECTED ISCHEMIC HEART DISEASE,
7 AS WE CALL IT, YOU KNOW, OR CHANGE IN THE ARTERIES SO THAT
8 YOU ARE HEADING FOR A HEART ATTACK, FOR INSTANCE. AND YOU
9 COULD EXPECT THAT IN THE ARTERIES INSIDE THE BRAIN AS WELL,
10 PERHAPS IN THE NECK, YOU KNOW. SO IT'S JUST GENERALIZED
11 BLOOD VESSEL DISEASE OR ARTERIAL DISEASE.
12 Q. AND IS MEDICATION PRESCRIBED FOR THAT?
13 A. NO.
14 Q. IS ISOSORBIDE, IS THAT A CARDIAC MEDICATION?
15 A. YES. THAT'S A CORONARY VASAL DILATOR THAT CAN ALSO BE
16 GIVEN FOR ESOPHAGEAL SPASM. WHEN I SAY MEDICINE ISN'T
17 PRESCRIBED FOR IT, I SHOULD SAY THAT WE PUT A PERSON LIKE
18 THAT ON ASPIRIN PERHAPS THINKING THAT MAYBE WE COULD KEEP
19 PLATELETS FROM STICKING TOGETHER, AGGREGATING AND PERHAPS
20 MAKING ANOTHER STROKE. IF THE CHOLESTEROL WAS HIGH WE WOULD
21 PROBABLY GIVE THEM MEDICINES TO TRY TO REDUCE THAT, YOU
22 KNOW, AND TRY TO PREVENT ANY FURTHER PROGRESSION OF THE
23 DISEASE. BUT AS FAR AS GIVING ANY MEDICINE THAT WOULD
24 REVERSE WHAT SHE HAS THERE, UNLESS THE CHOLESTEROL WAS HIGH,
25 THERE ISN'T ANYTHING THAT WE HAVE RIGHT NOW THAT WOULD DO
1016
1 THAT.
2 Q. I NOTICE IN SOME OTHER -- EITHER IN YOUR DISCHARGE
3 SUMMARY OR ONE OF YOUR ADMISSION HISTORY AND PHYSICALS, YOU
4 REFERENCE ISCHEMIC HEART DISEASE?
5 A. YES.
6 Q. IS THIS PARTICULAR X-RAY FINDING CONSISTENT WITH
7 ISCHEMIC HEART DISEASE?
8 A. WELL, ALL YOU CAN SAY IS THERE IS SYSTEMIC ARTERIAL
9 DISEASE AND YOU CAN SUSPECT THAT THERE IS ISCHEMIC HEART
10 DISEASE, BUT YOU COULDN'T SAY IT WAS THERE UNTIL YOU DID
11 SOME STUDY TO DEMONSTRATE IT.
12 Q. PERHAPS YOU COULD EXPLAIN TO THE JURY THE DIFFERENCE
13 BETWEEN THE ISCHEMIC HEART DISEASE AND PERHAPS CORONARY
14 DISEASE.
15 A. WELL, THERE REALLY ISN'T ANY DIFFERENCE. YOU KNOW,
16 THEY ARE ESSENTIALLY THE SAME.
17 Q. WHAT DOES ISCHEMIC MEAN?
18 A. ISCHEMIC MEANS AN AREA OR A TISSUE ISN'T GETTING ENOUGH
19 BLOOD.
20 Q. AND SO, FOR EXAMPLE, IN ISCHEMIC HEART DISEASE, WOULD
21 THE TISSUE BE THE HEART MUSCLE ITSELF?
22 A. YEAH. YES.
23 Q. AND IT'S TRUE, IS IT NOT, THAT IF PORTIONS OF THE HEART
24 MUSCLE TISSUE ARE DEPRIVED OF AN ADEQUATE BLOOD SUPPLY, THAT
25 COULD RESULT IN A HEART ATTACK; IS THAT CORRECT?
1017
1 A. THAT'S CORRECT.
2 Q. AND THEN ALSO ON THIS -- AND PERHAPS YOU CAN SEE IT FROM
3 THERE. IT SAYS, MULTILEVEL DEGENERATIVE CHANGES AND
4 SPURRING SEEN AT THE LUMBAR SPINE. DO YOU KNOW WHAT THAT IS
5 REFERRING TO?
6 A. WELL, THOSE ARE THE KIND OF CHANGES THAT MOST OF US HAVE
7 OVER AGE 30 IN OUR SPINE. THEY JUST COME FROM WEAR AND TEAR
8 AND WHAT'S CALLED OSTEOARTHRITIS AND THE CHANGE OF
9 OSTEOARTHRITIS.
10 Q. IS THERE ANYTHING PARTICULARLY CLINICALLY SIGNIFICANT TO
11 YOU ABOUT THAT FINDING GIVEN THE CIRCUMSTANCES THAT
12 PRESENTED ITSELF AT THAT TIME?
13 A. NO, I DON'T THINK SO.
14 Q. THE NEXT ONE, DOCTOR, IS ANOTHER CHEST X-RAY. AND I
15 WANT TO DRAW PARTICULAR ATTENTION TO THE REFERENCE IN THE
16 MIDDLE. FIRST OF ALL, IT SAYS THE AORTA IS ATHEROSCLEROTIC.
17 DO YOU SEE THAT?
18 A. YES, I DO.
19 Q. WHAT DOES THAT MEAN?
20 A. WELL, ONCE AGAIN, THAT MEANS THAT THE LINING OF THE
21 ARTERY IS SCLEROSED OR IS BECOMING, YOU KNOW, CALCIFIED, FOR
22 INSTANCE, SO IT SHOWS UP ON THE FILM NOT AS ORDINARY, NORMAL
23 SOFT TISSUE, BUT THERE'S DEPOSITS OF CALCIUM AND SO FORTH.
24 AND SO THAT'S WHAT SCLEROTIC MEANS. AND, ONCE AGAIN, IT'S
25 REFERRING TO THE OVERALL PROCESS OF THE ARTERIES AND
1018
1 DEGENERATION OF THOSE ARTERIES AND HARDENING OF THE ARTERIES
2 IS WHAT IT'S CALLED COMMONLY.
3 Q. AND THAT'S CONSISTENT WITH THE DISEASE PROCESS THAT YOU
4 JUST TESTIFIED TO; IS THAT RIGHT?
5 A. YOU MEAN THE OSTEOARTHRITIS?
6 Q. NO. THE HARDENING OF THE ARTERIES IS CONSISTENT WITH
7 EITHER ISCHEMIA OR CORONARY DISEASE; IS THAT RIGHT?
8 A. YES.
9 Q. NOW, THE NEXT ONE AFTER THAT IT SAYS, THE LUNGS SHOW
10 BILATERAL INTERSTITIAL LUNG DISEASE.
11 A. YES.
12 Q. WHAT IS BILATERAL INTERSTITIAL LUNG DISEASE?
13 A. WELL, IT MEANS SOME OF THE NORMAL LUNG TISSUE HAS BEEN
14 REPLACED WITH SCAR TISSUE AND SO IT'S NOT AVAILABLE FOR
15 BREATHING. IT'S NOT AVAILABLE FOR GAS EXCHANGE. AND IT'S A
16 DISEASE THAT WE USUALLY DON'T FIND A DIAGNOSIS OF. AND IT
17 CAN OCCUR FROM MANY DIFFERENT THINGS. VERY LONG LIST OF
18 THINGS CAN HAVE THIS AS AN END POINT.
19 Q. THE FACT THAT THERE WAS A FINDING OF SCAR TISSUE IS
20 INDICATIVE OF WHAT EVENT THAT WOULD HAVE CAUSED THAT?
21 A. WELL, YOU REALLY CAN'T SAY WHAT THE ETIOLOGY WAS. AS I
22 SAY, PROBABLY MORE THAN 50 PERCENT OF THE TIME WE NEVER FIND
23 THE CAUSE. EVEN WHEN THE LUNG TISSUE IS BIOPSIED, WE STILL
24 DON'T KNOW WHAT THE INCITING EVENT WAS.
25 Q. WHAT IS THE TREATMENT FOR THAT CONDITION?
1019
1 A. WELL, YOU KNOW, AT THIS STAGE, YOU KNOW, YOU WOULD WANT
2 TO KNOW IF THE OXYGEN IS OKAY IN THE BLOOD. IF YOU WERE,
3 YOU KNOW, VIGOROUSLY GOING AFTER THIS AND YOU SUPPLEMENT THE
4 OXYGEN, IF IT NEEDED TO BE. YOU COULD RUN THROUGH A
5 DIFFERENTIAL DIAGNOSIS OR A LIST OF THINGS THAT COULD CAUSE
6 SOMETHING LIKE THIS. A BIOPSY WOULD PROBABLY BE SOMETHING
7 YOU COULD DO TO TRY TO FURTHER DETERMINE WHAT THE ETIOLOGY
8 IS. AND IT'S JUST A QUESTION OF HOW AGGRESSIVE TO BE IN ANY
9 ONE INDIVIDUAL.
10 Q. NOW, THAT PARTICULAR DISEASE AS DESCRIBED BY THAT
11 REPORT, WOULD THAT CAUSE AN IMPAIRMENT, FOR EXAMPLE, OF THE
12 ABILITY OF THE BODY TO REGULATE OR DISTRIBUTE OXYGEN?
13 A. IT'S POSSIBLE THAT IT WOULD -- THAT THE OXYGEN, THE
14 ARTERIAL OXYGEN COULD BE DOWN BECAUSE OF THAT. IT'S
15 POSSIBLE. YOU KNOW, DOES IT SAY WHAT DEGREE THIS IS?
16 Q. WELL, IT SAYS -- AFTER THAT IT SAYS, NO DENSE
17 CONSOLIDATION OR MAJOR PLURAL FLUID COMPONENTS ARE DEFINED.
18 AND I DON'T SEE ANYTHING ELSE WITH RESPECT TO THAT ONE. IT
19 SAYS DIFFUSE INTERSTITIAL LUNG DISEASE, IF THAT MEANS
20 ANYTHING.
21 A. YEAH. YOU REALLY CAN'T TELL ANYTHING FROM THAT REPORT,
22 FROM THE X-RAY THEY WERE LOOKING AT, WHETHER THE OXYGEN
23 WOULD BE AFFECTED OR NOT.
24 Q. IS IT TRUE THAT BASED UPON WHAT YOU SEE THERE, WHAT YOU
25 ARE SAYING IS THAT YOU REALLY CAN'T TELL THE CLINICAL
1020
1 SIGNIFICANCE OF THE DISEASE ITSELF JUST FROM LOOKING AT THE
2 REPORT?
3 A. YES, I THINK SO.
4 Q. AND IT'S TRUE, IS IT NOT, THAT YOU PROBABLY WOULD HAVE
5 TO DO SOME OTHER DIAGNOSTIC TESTS TO DETERMINE THE SEVERITY
6 OF THE IMPAIRMENT?
7 A. UH-HUH.
8 Q. AND IT'S ALSO TRUE, IS IT NOT, THAT THAT IMPAIRMENT,
9 THAT IS THE DISEASE ITSELF, COULD BE -- COULD BE
10 SIGNIFICANTLY IMPAIRING TO THE PATIENT; ISN'T THAT TRUE?
11 A. IT'S POSSIBLE.
12 Q. AND BY THE SAME TOKEN, IT COULD BE LESS, SO DEPENDING
13 UPON WHAT TEST YOU'D RUN?
14 A. YES.
15 Q. DO YOU KNOW WHETHER, AFTER THIS FINDING WAS MADE,
16 WHETHER OR NOT MISS LARSEN HAD ANY FURTHER DIAGNOSTIC TESTS
17 WITH RESPECT TO IDENTIFYING THE SEVERITY OF THE LUNG
18 DISEASE?
19 A. I DON'T KNOW. I DON'T THINK ANYTHING AGGRESSIVE. SHE
20 MAY HAVE HAD SOME BLOOD GAS TESTS DONE, PERHAPS. BUT ONCE
21 AGAIN, IT'S NOT -- SHE WAS NOT A PERSON WHO -- IN WHOM YOU
22 WOULD AGGRESSIVELY PURSUE THIS. IN OTHER WORDS, WE WOULD
23 CALL IN A PULMONARY SPECIALIST. THEY WOULD HAVE TO GO DOWN
24 WITH THE BRONCHOSCOPE AND PUT A BIOPSY INSTRUMENT INTO THE
25 LUNG AND GET A PIECE OF THE LUNG AND LOOK AT THAT UNDER THE
1021
1 MICROSCOPE. AND THEY'D PROBABLY HAVE TO GO BACK THROUGH HER
2 MEDICATION HISTORY TO SEE IF SHE HAD EVER RECEIVED A
3 MEDICATION NITROFURANTOIN, FOR INSTANCE, THAT CAN CAUSE
4 SOMETHING LIKE THIS. THE LIST OF THINGS THAT CAN CAUSE THIS
5 IS QUITE LONG.
6 YOU WOULD HAVE TO LOOK AT THAT PERSON AND SAY, IS THIS
7 A PERSON THAT YOU WOULD BE CONCERNED ENOUGH OR YOU WOULD
8 WANT TO DO ALL THAT TO. I THINK THAT JUDGMENT CALL WAS MADE
9 AND DECIDED THAT IT WAS NOT -- THIS WAS NOT A PERSON WHO
10 DESERVED THAT KIND OF WORK UP.
11 Q. AND THE JUDGMENT CALL WAS MADE PRIMARILY BY HER FAMILY
12 IN CONJUNCTION WITH, I ASSUME, CONSULTATION WITH HER
13 PHYSICIAN?
14 A. I THINK PROBABLY OVER THIS PARTICULAR ITEM WE PROBABLY
15 DIDN'T DISCUSS IT. IT WAS PROBABLY JUST ME.
16 Q. BUT THE JUDGMENT THAT YOU MADE, I'M SURE, WAS DRIVEN IN
17 PART BY HER AGE. TRUE?
18 A. YES.
19 Q. AND CERTAINLY BY WHAT YOU UNDERSTOOD THE FAMILY WANTED?
20 A. YES, AND HER MENTAL CONDITION. CERTAINLY. THERE MAY BE
21 A BLOOD GAS REPORT IN THE EMERGENCY ROOM REPORT. SEEMED
22 LIKE THE EMERGENCY ROOM DOES BLOOD GASES ON MANY, MANY
23 PEOPLE, SO THAT IT MIGHT BE THERE.
24 Q. AND WHAT'S THE SIGNIFICANCE OF A BLOOD GAS REPORT?
25 A. WELL, IT WOULD JUST TELL YOU IF THE OXYGEN WAS ADEQUATE
1022
1 IN THE BLOOD OR NOT.
2 Q. IS THAT SIMILAR TO AN OXYGEN SYMMETRY TEST?
3 A. IT'S JUST MEASURING THE OXYGEN IN THE BLOOD.
4 Q. NOW, THIS IS HISTORY AND PHYSICAL EXAMINATION AND I JUST
5 WANTED TO POINT OUT TO YOU IN THE SECOND PARAGRAPH -- ONCE
6 AGAIN, PLEASE FEEL FREE TO APPROACH IF YOU NEED TO -- IT
7 HAS -- YOU STATE ISOSORBIDE MAY HAVE BEEN, HOWEVER, A
8 NITROGLYCERIN PREPARATION FOR HER HEART. DO YOU KNOW
9 WHETHER -- ARE YOU SAYING THERE THAT, IN FACT, THOSE WERE
10 THE MEDICATIONS THAT SHE WAS RECEIVING AT THE TIME?
11 A. THIS IS IN THE NURSING HOME YOU MEAN?
12 Q. NOW, THIS WAS THE JULY ADMISSION IN YOUR HISTORY AND
13 PHYSICAL DICTATION FOR THE JULY HOSPITALIZATION.
14 A. UH-HUH. SO IT'S TALKING ABOUT THE NURSING SHEET IN THE
15 EMERGENCY ROOM SAYING THAT SHE CAME INTO THE HOSPITAL ON
16 THESE MEDICATIONS WHICH THEN INCLUDED SOMETHING FOR THYROID.
17 SHE WAS ON ASPIRIN, SOMETHING FOR THE NERVES, EYE DROPS, AND
18 ISOSORBIDE OR NITROGLYCERIN. AND YOU CAN TELL THAT THE
19 HISTORY WAS NOT EXACT. BUT THAT WOULD BE FOR SYMPTOMATIC
20 RELIEF SO IF SHE HAD CHEST PAIN FROM CORONARY ARTERY DISEASE
21 THEY COULD GIVE HER SOME COMFORT.
22 Q. THAT'S WHAT THE NITROGLYCERIN IS FOR?
23 A. YES.
24 Q. COULD YOU TELL US HOW THAT WORKS?
25 A. IT RELAXES THE MUSCLE OF THE ESOPHAGUS, IF IT'S GIVEN
1023
1 FOR THAT REASON, FOR ESOPHAGEAL SYNERGY, WE CALL IT, SO THAT
2 IF THERE'S INAPPROPRIATE MUSCLE CONTRACTIONS IN THE
3 ESOPHAGUS OR IF A PERSON HAS CORONARY ARTERY SPASM OR IF
4 THEY -- IF THEY NEED TO HAVE A CORONARY ARTERIES RELAXED IN
5 SUCH A WAY OR DILATED SO THAT THEY CAN OBTAIN -- HEART
6 MUSCLE CAN OBTAIN MORE OXYGEN, THEN THIS MEDICINE IS GIVEN.
7 Q. NOW, THE OTHER HOSPITALIZATION WAS IN AUGUST AND YOU
8 SAW HER ON THAT OCCASION AS WELL AT THE COTTONWOOD HOSPITAL;
9 IS THAT RIGHT?
10 A. THAT'S CORRECT.
11 Q. I'M GOING TO PLACE ON THE MACHINE HERE THE DISCHARGE
12 SUMMARY WHICH YOU DICTATED FOR THAT PARTICULAR
13 HOSPITALIZATION. AND I WANT TO DRAW YOUR ATTENTION
14 SPECIFICALLY TO -- AND I HAVE TO MOVE THIS UP A BIT -- PLAN.
15 AND YOU STATE THERE, IN DISCUSSION WITH THE FAMILY IT IS
16 DECIDED THAT THE LAST SIX MONTHS OF HER LIFE HAVE BEEN VERY
17 POOR QUALITY. IN FACT, NO QUALITY AT ALL, WITH POOR
18 RECOGNITION OF PEOPLE, NO CONVERSATION, NO DECISION-MAKING.
19 FIRST OF ALL, WHAT DO YOU MEAN WHEN YOU SAY NO QUALITY
20 AT ALL?
21 A. WELL, YOU KNOW, EVERYONE DETERMINES FOR HIMSELF I GUESS
22 WHAT QUALITY OF LIFE IS. AND FOR ME IT'S ENJOYMENT OF OTHER
23 PEOPLE OR THEIR BEING ABLE TO ENJOY YOU OR BEING ABLE TO
24 MAKE MEANINGFUL DECISIONS OR MAKING SOME KIND OF -- SOME
25 KIND OF PROGRESS, PERSONAL PROGRESS, OR DOING SOMETHING
1024
1 MEANINGFUL. AND IN DISCUSSION WITH THE FAMILY IT SOUNDED
2 LIKE SHE REALLY DIDN'T HAVE ANYTHING LIKE THAT, THAT SHE WAS
3 JUST BEING KEPT ALIVE, ESSENTIALLY.
4 Q. AND THEN YOU GO ON TO STATE THE OPTION AT THE TIME OF
5 DISCHARGE TO PLACE A FEEDING TUBE, PERIPHERAL NUTRITION OR
6 N.G. TUBE. WHAT IS PERIPHERAL NUTRITION OR N.G. TUBE?
7 A. IF A PERSON WON'T EAT, WE WANT TO KEEP THEM ALIVE, THEN
8 WE HAVE TO FIND SOME WAY OF GIVING NUTRITION. SO WE CAN
9 EITHER MAKE A HOLE HERE IN THE ABDOMEN, YOU KNOW, AND PUT A
10 TUBE RIGHT INTO THE STOMACH; OR YOU CAN PUT A NEEDLE IN A
11 VEIN AND CATHETER IN A VEIN AND SO FORTH AND GIVE NUTRITION
12 THAT WAY. OR YOU CAN PUT A TUBE IN THE NOSE AND DOWN INTO
13 THE STOMACH AND FEED THAT WAY.
14 AND SO -- AND SO ALL OF THOSE OPTIONS WERE DISCUSSED
15 WITH THE FAMILY AND THEY THOUGHT IT WAS TOO AGGRESSIVE.
16 Q. IS IT FAIR TO SAY IN A SHORTENED WAY YOU ARE TALKING
17 ABOUT FORCED FEEDING?
18 A. WELL, YEAH. I GUESS YOU COULD SAY THAT IN A WAY BECAUSE
19 SHE WAS REFUSING TO EAT, YOU KNOW, REFUSING TO TAKE THINGS.
20 AND ALSO IF SHE -- YOU KNOW, IF SHE WAS GIVEN SOMETHING SHE
21 HAD VERY POOR ABILITY TO GET IT DOWN. YOU KNOW, MECHANICS
22 OF SWALLOWING AND SO FORTH WERE JUST VERY POOR.
23 Q. WOULD THAT INTERSTITIAL LUNG DISEASE PLAY A PART IN HER
24 INABILITY TO SWALLOW?
25 A. PROBABLY NOT.
1025
1 Q. AND THEN YOU GO ON TO SAY, AND THE FAMILY FEELS THAT
2 THIS WOULD BE AGGRESSIVE AND INAPPROPRIATE. THAT'S BASED
3 UPON YOUR DISCUSSION WITH THE FAMILY?
4 A. YES.
5 Q. AND DO YOU RECALL, WAS THE FAMILY -- WAS THAT PRIMARILY
6 MR. MERLIN LARSEN?
7 A. I DON'T REMEMBER.
8 Q. DID YOU DO ANY -- WELL, DO YOU REMEMBER IF YOU HAD
9 DISCUSSIONS WITH JUST ONE PERSON OR OTHER PEOPLE OR DO YOU
10 HAVE ANY RECOLLECTION?
11 A. I DON'T REALLY REMEMBER. I DON'T REMEMBER. IT SEEMED
12 LIKE THERE WAS A WOMAN THAT I WAS TALKING TO. THAT WAS A
13 LONG TIME AGO AND I DIDN'T WRITE DOWN OR I DIDN'T RECORD WHO
14 THE PEOPLE WERE. SO I DON'T RECALL EXACTLY TO WHOM I WAS
15 SPEAKING.
16 Q. AND THEN YOU GO ON TO SAY, THEY ALSO WANTED NO TREATMENT
17 OF INFECTION SUCH AS URINARY INFECTIONS, PULMONARY,
18 ET CETERA.
19 FIRST OF ALL, WHEN YOU ARE REFERRING TO NO TREATMENT,
20 ARE YOU TALKING ABOUT INTERVENTION OF SOME ANTIBIOTIC
21 THERAPY OR REGIMEN?
22 A. YES.
23 Q. AND URINARY INFECTION. CERTAINLY IF THEY ARE UNTREATED
24 IN SOMEBODY WHO IS 93 YEARS OLD, THAT COULD BE -- CAN BE A
25 FATAL EVENT; IS THAT RIGHT?
1026
1 A. THAT'S CORRECT.
2 Q. AND PULMONARY REFERS TO THE LUNGS, ESSENTIALLY?
3 A. YES.
4 Q. SO WE'RE TALKING ABOUT SOME KIND OF PNEUMONIA OR
5 COMPLICATIONS SIMILAR TO THAT?
6 A. YES.
7 Q. AND IT'S TRUE, IS IT NOT, IF NO ANTIBIOTICS ARE
8 PRESCRIBED OR OTHER WAYS THAT DISEASE PROCESS IS TREATED,
9 THAT CAN BE A FATAL EVENT AS WELL?
10 A. ABSOLUTELY.
11 Q. AND THEN YOU GO ON TO STATE, DISPOSITION, SHE WILL BE
12 TRANSFERRED TO A NURSING HOME FOR TERMINAL CARE. COULD YOU
13 TELL US, PLEASE, WHAT YOU MEAN BY TERMINAL CARE?
14 A. YEAH. YOU KNOW, AS I MENTIONED EARLIER, IF A PERSON
15 DOESN'T EAT OR DRINK WITHIN -- SOMEWHERE BETWEEN ONE AND TWO
16 WEEKS THEY DIE. YOU KNOW, SO THAT'S TERMINAL. AND IF SHE
17 DEVELOPED -- IF THAT SITUATION CHANGED AND SHE DEVELOPED
18 ALMOST ANYTHING, A DECISION WAS MADE THAT WE PROBABLY
19 WOULDN'T TREAT IT. IF SHE GOT PNEUMONIA WE PROBABLY
20 WOULDN'T TREAT IT WITH ANTIBIOTICS. OTHER INFECTIONS, SO
21 FORTH.
22 YOU KNOW, SO THAT -- YOU KNOW, IT'S VERY HARD ON
23 FAMILIES TO KNOW WHEN TO STOP. NEED A LOT OF SUPPORT, A LOT
24 OF PHYSICIAN SUPPORT. IT'S VERY HARD TO MAKE A DECISION ON
25 YOUR MOTHER, FOR INSTANCE, YOU KNOW, WHETHER TO STOP FLUIDS
1027
1 AND LET THE PERSON PASS AWAY OR NOT TO GIVE ANTIBIOTICS FOR
2 PNEUMONIA. IT'S A VERY DIFFICULT DECISION FOR FAMILY AND
3 YOU CAN'T BE OBJECTIVE AND SO FORTH. THEY NEED A LOT OF
4 SUPPORT AND HELP. SO WE TRY TO WALK THEM THROUGH THIS
5 SCENARIO AHEAD OF TIME SO THEY THINK ABOUT, WELL, WHAT IF
6 THIS COMES UP, WHAT WOULD YOU LIKE US TO DO.
7 IT'S LIKE WHEN SOMEBODY GOES IN THE HOSPITAL, WOULD YOU
8 LIKE RESUSCITATION IF THEIR HEART SUDDENLY STOPPED? THAT'S
9 SOMETHING WE ARE REQUIRED TO ASK FAMILY MEMBERS WHEN
10 SOMEBODY LIKE THAT COMES INTO THE HOSPITAL. WOULD THAT BE
11 SOMETHING THEY WOULD WANT FOR HER OR WOULD THAT BE A WAY FOR
12 HER TO LEAVE THIS LIFE COMFORTABLY AND WITH DIGNITY AND SO
13 FORTH.
14 SO THAT'S WHAT THAT'S GETTING AT WAS THAT -- WELL,
15 LOOKING WE REALLY DON'T KNOW WHAT'S GOING TO HAPPEN WITH
16 THIS PERSON NOT EATING. BUT WHEN SHE DID EAT, SOME OF IT
17 WENT INTO THE LUNGS, SO THAT COULD BE A CAUSE OF PNEUMONIA.
18 SO WE HAD TO DISCUSS THAT AND SAY, IF THIS HAPPENS AND SHE
19 STARTS RUNNING A TEMPERATURE AND COUGHING AND SO FORTH, DO
20 YOU WANT HER TO COME BACK TO THE HOSPITAL, EVEN GIVEN THAT
21 WE'RE PROBABLY NOT GOING TO TREAT IT? I THINK THEY DECIDED
22 THEY DIDN'T WANT TO TREAT IT THIS TIME AROUND. BUT SHE'D
23 REACHED A QUALITY OF LIFE LEVEL THAT THEY DIDN'T THINK IT
24 WOULD BE HUMANE TO KEEP HER GOING.
25 Q. FAIR TO SAY THAT IF THERE WAS SOME OTHER DISEASE
1028
1 PROCESS, THE FAMILY ESSENTIALLY JUST WANTED TO LET HER GO?
2 A. YES.
3 Q. OKAY. THANK YOU, DOCTOR.
4 THE COURT: ANYTHING FURTHER?
5 REDIRECT EXAMINATION
6 BY MR. WILSON:
7 Q. JUST A COUPLE OF QUESTIONS, DOCTOR. DO YOU HAVE A
8 DISTINCT RECOLLECTION OF THIS CONVERSATION WITH THE FAMILY?
9 A. NO. NO, JUST WHAT I HAVE RECORDED HERE.
10 Q. DO YOU HAVE ANY IMPRESSION AS TO HOW LONG YOU SPOKE WITH
11 THE FAMILY ON THAT PARTICULAR OCCASION?
12 A. I DON'T.
13 Q. OKAY. THANK YOU, DOCTOR.
14 THE COURT: MAY THIS WITNESS BE EXCUSED?
15 MR. STIRBA: YES.