Joseph Cannon, MD
7 JOHN CANNON,
8 CALLED BY THE DEFENDANT, HAVING BEEN DULY
9 SWORN, WAS EXAMINED AND TESTIFIED AS FOLLOWS:
10 DIRECT EXAMINATION
11 BY MR. STIRBA:
12 Q. DOCTOR, WOULD YOU STATE YOUR FULL NAME AND SPELL YOUR
13 LAST NAME, PLEASE?
14 A. JOE N. CANNON, M.D. C-A-N-N-O-N.
15 Q. YOU SAID M.D. WHAT DO YOU DO FOR A LIVING, SIR?
16 A. I'M A MEDICAL DOCTOR.
17 Q. AND HOW LONG HAVE YOU BEEN A MEDICAL DOCTOR?
18 A. 47 YEARS.
19 Q. AND GENERALLY WHERE DO YOU PRACTICE?
20 A. BAY CITY, TEXAS.
21 Q. AND WHAT KIND OF PRACTICE DO YOU HAVE IN BAY CITY?
22 A. FAMILY PRACTICE.
23 Q. AND GENERALLY DESCRIBE THE NATURE OF YOUR FAMILY
24 PRACTICE, PLEASE.
25 A. WELL, FAMILY PRACTICE IS A NEW NAME FOR GENERAL PRACTICE
3471
1 IN THAT WE ADDRESS ALL KINDS OF ILLNESSES AT THE PRIMARY
2 CARE STAGE AND GENERALLY WE SEE ALL AGES OF PATIENTS.
3 Q. AND CAN YOU TELL US, PLEASE, IN TERMS OF YOUR FAMILY
4 PRACTICE, DO YOU SEE GERIATRIC PATIENTS?
5 A. YES, I DO.
6 Q. AND GENERALLY IN WHAT NATURE DO YOU CARE FOR GERIATRIC
7 PATIENTS OR THE GERIATRIC POPULATION?
8 A. WELL, I SEE GERIATRIC PATIENTS IN THE CAPACITY AS A
9 PRIMARY CARE PHYSICIAN, MEANING THAT GENERALLY PATIENTS WILL
10 COME TO ME FIRST WITH THEIR COMPLAINTS OR THEIR MEDICAL
11 NEEDS AND I WILL ADDRESS THAT TO THE EXTENT OF MY TRAINING
12 AND ABILITY AND REFER TO SPECIALISTS THOSE THAT ARE MORE
13 APPROPRIATELY CARED FOR AT THAT LEVEL.
14 Q. IS THERE ANYTHING PARTICULAR ABOUT THE CARE AND
15 TREATMENT OF GERIATRIC PATIENTS THAT YOU FIND IN YOUR
16 PRACTICE?
17 A. OH, YES.
18 Q. AND COULD YOU TELL US, PLEASE, WHAT THAT IS?
19 A. WELL, IN GENERAL OLDER PATIENTS TEND TO HAVE MORE
20 AILMENTS OF ALL KINDS; ACUTE, CHRONIC, DEGENERATIVE. THEY
21 IN GENERAL TEND TO BE MORE FRAIL. THEY ARE MORE SUSCEPTIBLE
22 TO INFECTION, LESS RESILIENT TO INJURY AND THEY ARE -- THEY
23 ARE MORE SENSITIVE TO MEDICATION AS A GENERAL RULE.
24 Q. WHEN YOU SAY THEY ARE MORE SUSCEPTIBLE TO INFECTION,
25 TELL US WHAT YOU MEAN.
3472
1 A. WELL, THE DEFENSE MECHANISM OF THE BODY AGES LIKE THE
2 REST OF OUR BODIES, AND WHEN WE GROW OLDER, WE HAVE LESS
3 RESISTANCE TO INFECTION. WE'RE MORE PRONE TO GET INFECTIONS
4 FROM ORDINARY EVENTS SUCH AS COMMON COLDS AND ACCIDENTS,
5 INJURIES, ET CETERA, AND THE EFFECTS OF THE INFECTIONS CAN
6 BE MORE DEVASTATING IN OLDER PEOPLE.
7 Q. CAN YOU TELL US, PLEASE, WHAT EDUCATION YOU'VE HAD FOR
8 PURPOSES OF YOUR MEDICAL DEGREE?
9 A. I'M A HIGH SCHOOL GRADUATE. I HAVE A BACHELOR'S OF
10 SCIENCE DEGREE FROM BAYLOR UNIVERSITY IN WACO, TEXAS.
11 DOCTOR OF MEDICINE FROM THE BAYLOR COLLEGE OF MEDICINE IN
12 HOUSTON, TEXAS. I SERVED A ONE-YEAR INTERNSHIP, WHICH NOW
13 DAYS WOULD BE CALLED A RESIDENCY, IN THE UNITED STATES NAVAL
14 HOSPITAL, PENSACOLA, FLORIDA. AND I SERVED WHAT WAS THEN
15 CALLED A GENERAL PRACTICE RESIDENCY IN THE CHARITY HOSPITAL
16 OF LAFAYETTE, LOUISIANA.
17 Q. HAVE YOU HAD ANY TRAINING SINCE YOUR MEDICAL SCHOOL
18 EDUCATION IN THE FIELD OF MEDICINE?
19 A. YES. AS A FELLOW OF THE AMERICAN ACADEMY OF FAMILY
20 PRACTICE, I'M REQUIRED TO OBTAIN 50 HOURS OF POST-GRADUATE
21 OR CONTINUING MEDICAL EDUCATION PER YEAR.
22 Q. AND HAVE YOU HAD OCCASION TO REVIEW SOME RECORDS
23 CONCERNING THIS CASE?
24 A. YES.
25 Q. AND YOU HAVE BEEN RETAINED AS AN EXPERT TO RENDER
3473
1 CERTAIN OPINIONS CONCERNING THE FACTS AND CIRCUMSTANCES OF
2 THIS CASE?
3 A. YES.
4 Q. GENERALLY WOULD YOU TELL US, PLEASE, WHAT YOU HAVE
5 REVIEWED?
6 A. I'VE REVIEWED THE CASE RECORDS, HISTORY, PHYSICAL
7 LABORATORY AND X-RAY RESULTS AS WELL AS THE PROGRESS NOTES
8 OF THE NURSES AND PHYSICIANS AND ALL CONSULTATIONS ON FIVE
9 PATIENTS WHO WERE IN THE DAVIS COUNTY HOSPITAL IN LATE 1995
10 AND EARLY 1996.
11 Q. ARE YOU FAMILIAR WITH THE TERM "END-OF-LIFE CARE?"
12 A. YES.
13 Q. AND WOULD YOU TELL US, PLEASE, WHAT THAT CARE IS?
14 A. WHEN A PATIENT IS AT THAT STAGE OF ILLNESS, WHEN THERE'S
15 NO REASONABLE HOPE OF RECOVERY, CERTAIN EVENTS OCCUR WHICH
16 REQUIRE A DIFFERENT PARADIGM OR APPROACH TO TREATMENT. AND
17 THAT TREATMENT GENERALLY ADDRESSES MORE COMFORT AND
18 OBSERVATION THAN IT DOES AGGRESSIVE MEDICAL OR SURGICAL
19 CARE.
20 Q. HAVE YOU IN YOUR PRACTICE PROVIDED SUCH CARE?
21 A. YES, I HAVE.
22 Q. AND CAN YOU GENERALLY TELL US IN WHAT CONTEXT YOU WOULD
23 HAVE PROVIDED SUCH CARE?
24 A. WELL, MANY OF MY PATIENTS ARE ELDERLY AND MANY SUSTAIN
25 STROKES AND OTHER TERMINAL MEDICAL EVENTS, AND AS A RULE I'M
3474
1 THE PRESIDING PROVIDER OF CARE IN THOSE CIRCUMSTANCES.
2 Q. DOES PAIN MEDICATION HAVE A ROLE TO PLAY IN END-OF-LIFE
3 CARE?
4 A. YES, IT DOES.
5 Q. AND WHAT ROLE DOES IT PLAY?
6 A. PROVIDING COMFORT FOR THE PATIENT.
7 Q. AND BY PROVIDING COMFORT, ARE THERE CERTAIN SYMPTOMS
8 THAT ARE TREATED IN END-OF-LIFE CARE WITH PAIN MEDICATION?
9 A. WELL, THERE ARE MANY INDICATORS OF PAIN. FIRST AND MOST
10 OBVIOUS WOULD BE THE MEDICAL CONDITION OF THE PATIENT, FOR
11 EXAMPLE, A FRACTURE OR AN OVERWHELMING INFECTION. SECONDLY
12 WOULD BE COMMUNICATION FROM THE PATIENT IF THEY WERE ABLE TO
13 DO SO. THIRDLY, THERE ARE COMMON GESTURES, MOTIONS OR
14 VOCALIZATIONS WHICH INDICATE PAIN SUCH AS MOANING, GROANING,
15 WRITHING, AND SOMETIMES RIGORS.
16 Q. AND ARE THOSE SYMPTOMS TREATED WITH MEDICATION?
17 A. YES, THEY ARE.
18 Q. AND GENERALLY IN WHAT RESPECT WOULD THEY BE TREATED WITH
19 MEDICATION?
20 A. WELL, GENERALLY A PATIENT IN THAT CONDITION IS UNABLE TO
21 TAKE ORAL MEDICATION, SO AS A RULE ALL MEDICATIONS FOR PAIN
22 AT THAT STAGE ARE RENDERED PARENTALLY OR EITHER
23 INTRAVENOUSLY OR INTRAMUSCULARLY BY INJECTION.
24 Q. ARE YOU FAMILIAR WITH WHAT ARE CALLED MEDICAL
25 DIRECTIVES?
3475
1 A. YES.
2 Q. WOULD YOU TELL US, PLEASE, WHAT MEDICAL DIRECTIVES ARE?
3 A. MEDICAL DIRECTIVES ARE USUALLY WHAT IS CALLED ADVANCE
4 DIRECTIVES WHICH IS A LEGAL DOCUMENT IN WHICH THE PATIENT OR
5 THE PATIENT'S AGENTS, REPRESENTATIVES, COMMUNICATE TO THE
6 PRESIDING MEDICAL AUTHORITIES THEIR DESIRES FOR END-OF-LIFE
7 CARE.
8 Q. AND WHAT ROLE DOES -- DO ADVANCE DIRECTIVES OR MEDICAL
9 DIRECTIVES HAVE IN TERMS OF THE TREATMENT IN END-OF-LIFE
10 CARE?
11 A. WELL, IT'S USUALLY THE RULING GUIDELINE FOR THAT CARE IN
12 THAT MOST OF THE TIME ANY EXTRAORDINARY MEASURES, SURGERY,
13 RESUSCITATION AND SO FORTH, ARE OMITTED AND BY ACCORDING TO
14 THE PATIENT'S WISHES AND THE EXPRESS WISHES, THAT NATURE BE
15 ALLOWED TO TAKE ITS COURSE. IN OTHER WORDS, THAT A PATIENT
16 BE ALLOWED TO DIE NATURALLY WITHOUT UNDUE INTERFERENCE BY
17 LIFE SUPPORT SYSTEMS.
18 Q. IN THE CONTEXT OF END-OF-LIFE CARE, DOES A PHYSICIAN
19 HAVE CERTAIN DUTIES IN TERMS OF HIS OR HER CONDUCT?
20 A. YES, WE DO.
21 Q. AND WOULD YOU TELL US, PLEASE, WHAT THOSE DUTIES ARE?
22 A. WELL, WE'RE LEGALLY AND MORALLY BOUND NOT TO EXCEED THE
23 LIMITS STIPULATED BY THE PATIENT. FOR EXAMPLE, MANY
24 PATIENTS WILL STIPULATE THEY DO NOT WANT TO BE PUT ON A
25 BREATHING MACHINE, MEANING A MECHANICAL VENTILATOR. AND WE
3476
1 ARE, AS I SAY, LEGALLY AND MORALLY BOUND NOT TO VIOLATE THAT
2 UNDER ANY CIRCUMSTANCE UNLESS SOMEHOW THE PATIENT IS ABLE TO
3 COMMUNICATE CHANGE OF MIND. NOW, IN SOME CASES THE FAMILY
4 MAY INDICATE THAT THEY HAVE CHANGED THEIR MINDS ABOUT
5 END-OF-LIFE CARE. SECONDLY, IT'S OUR AIM TO PROVIDE AS MUCH
6 COMFORT TO THE PATIENT AS POSSIBLE BY AVOIDING UNNECESSARY
7 PROCEDURES, BY PROVIDING MEDICATION TO ALLEVIATE PAIN,
8 SUFFERING AND RESTLESSNESS.
9 Q. NOW, YOU MENTIONED ALLEVIATE PAIN, SUFFERING AND
10 RESTLESSNESS. DOES THAT RELATE TO A DUTY THAT A PHYSICIAN
11 HAS AS WELL IN END OF LIFE?
12 A. YES, THAT'S INCLUDED.
13 Q. WHAT DUTY IS THAT THAT YOU ARE REFERRING TO?
14 A. I DON'T UNDERSTAND THE QUESTION.
15 Q. MAYBE THAT'S INARTFULLY PUT. IN TERMS OF THE
16 ALLEVIATION OF PAIN AND SUFFERING, IS A DUTY IMPOSED UPON A
17 PHYSICIAN IN THAT REGARD?
18 A. YES.
19 Q. AND WOULD YOU TELL US, PLEASE, WHAT THAT DUTY IS?
20 A. WELL, THE DUTY IS TO PROVIDE WITHIN OUR ABILITIES AND
21 LIMITATIONS MEDICATIONS AND OTHER MEASURES SUCH AS OXYGEN
22 WHICH MAY RELIEVE THE SUFFERING OF THE PAIN OR THE
23 RESTLESSNESS.
24 Q. NOW, YOU'VE REVIEWED THE MEDICAL RECORDS CONCERNING THIS
25 CASE. HAVE YOU DRAWN AND CONCLUDED WITH RESPECT TO CERTAIN
3477
1 EVENTS IN THESE CASES THAT THOSE DUTIES WERE IMPOSED IN
2 TERMS OF THE CARE PROVIDED IN THIS CASE?
3 A. THOSE DUTIES, MEANING THE DUTIES OF A PHYSICIAN TO
4 PROVIDE APPROPRIATE END-OF-LIFE CARE?
5 Q. YES.
6 A. AS LIMITED BY THE MEDICAL DIRECTIVES?
7 Q. YES.
8 A. YES, I DO.
9 Q. AND WHAT IS YOUR OPINION?
10 A. MY OPINION IS IN EVERY CASE THE PHYSICIANS, NURSES AND
11 OTHER MEDICAL PEOPLE PROVIDED APPROPRIATE END-OF-LIFE CARE
12 HONORING THE ADVANCE DIRECTIVES AS WELL AS THE SPOKEN WISHES
13 OF THE FAMILIES IN ALLEVIATING PAIN AND UNNECESSARY
14 SUFFERING.
15 Q. NOW, IF WE CAN TALK ABOUT THE SPECIFIC CASES AND THERE
16 ARE BINDERS RIGHT THERE THAT YOU CAN REFER TO IF YOU NEED
17 TO, BUT DO YOU RECALL THE CIRCUMSTANCES OF MR. ENNIS
18 ALLDREDGE?
19 A. YES, I DO.
20 Q. AND WOULD YOU TELL US, PLEASE, WHAT CIRCUMSTANCES YOU
21 RECALL WITH RESPECT TO MR. ALLDREDGE?
22 A. WELL, BASICALLY MR. ALLDREDGE WAS AN ELDERLY MAN WITH
23 SEVERE DEMENTIA. IN FACT, HE HAD BECOME TOO VIOLENT AND
24 COMBATIVE TO BE CARED FOR IN EITHER AT HOME OR A NURSING
25 HOME. AND WAS ADMITTED, AS I UNDERSTAND IT, TO THE
3478
1 GEROPSYCHIATRIC UNIT AT DAVIS COUNTY HOSPITAL FOR ADJUSTMENT
2 OF MEDICATIONS TO TRY TO PROVIDE MORE RELIEF FROM THIS
3 EXCESSIVE COMBATIVENESS AND RESTLESSNESS WHICH HE HAD.
4 Q. WAS END-OF-LIFE CARE PROVIDED IN HIS CASE?
5 A. YES, IT WAS.
6 Q. AND WOULD YOU DESCRIBE THE NATURE OF THAT CARE?
7 A. WELL, WHEN IT BECAME APPARENT THAT AN IRREVERSIBLE EVENT
8 AND PROBABLY FATAL EVENT HAD OCCURRED, NAMELY A STROKE IN
9 MR. ALLDREDGE, MEDICATIONS WERE INSTITUTED IN ORDER TO
10 CONTROL RESTLESSNESS AND PAIN. AT THE SAME TIME, ALL
11 UNNECESSARY OR POSSIBLY LIFE-SUSTAINING TREATMENTS WERE
12 DISCONTINUED.
13 Q. DO YOU RECALL THE MEDICATIONS THAT WERE PROVIDED AT THAT
14 TIME?
15 A. WELL, AS I UNDERSTAND IT, HE WAS GIVEN ATIVAN AND
16 RISPERDAL FOR THE RESTLESSNESS AND THE VIOLENT BEHAVIOR AND
17 MORPHINE FOR PAIN.
18 Q. IN TERMS OF THE USE OF MORPHINE, IS THAT A MEDICATION
19 THAT IS USED IN END-OF-LIFE CARE?
20 A. YES, IT IS.
21 Q. AND WOULD YOU TELL US, PLEASE, WHY IT IS USED?
22 A. WELL, IN MY OPINION, IT'S STILL THE BEST PAIN RELIEF
23 AVAILABLE, ALTHOUGH IT MAY BE THE OLDEST PAIN RELIEF IN
24 MEDICAL SCIENCE. BUT IT'S A GREAT DRUG. IT PRODUCES NOT
25 ONLY GOOD ANALGESIA OR RELIEF OF PAIN, BUT ALSO PRODUCES A
3479
1 SENSE OF WELL BEING IN PATIENTS WHO MAY BE SUFFERING FROM
2 ANXIETY AND A GREAT DEAL OF FEAR OR APPREHENSION.
3 Q. DO YOU HAVE AN OPINION AS TO THE PROPRIETY OF USING
4 MORPHINE IN THE CIRCUMSTANCES OF MR. ALLDREDGE?
5 A. I DO.
6 Q. AND WHAT IS YOUR OPINION?
7 A. I THINK IT WAS ENTIRELY APPROPRIATE.
8 Q. DID YOU OBSERVE IN YOUR REVIEW OF THE RECORDS WHETHER OR
9 NOT THE ADVANCE DIRECTIVES OR MEDICAL DIRECTIVES HAD A PLACE
10 WITH RESPECT TO HIS CARE?
11 A. YES.
12 Q. AND WOULD YOU TELL US WHAT THAT PLACE WAS?
13 A. WELL, THERE WAS AN ADVANCE DIRECTIVE IN PLACE AT THE
14 TIME OF HIS ADMISSION AS WELL AS A DO NOT RESUSCITATE ORDER
15 WHICH APPEARED ON THE RECORD. FURTHERMORE, CONSULTATION
16 BETWEEN THE ATTENDING PHYSICIAN, DR. WEITZEL, AND
17 MR. ALLDREDGE'S FAMILY AFTER THE PRESENCE OF HIS STROKE HAD
18 BEEN CONFIRMED AND ALSO OTHER TERMINAL CONDITIONS HAD BEEN
19 DIAGNOSED, THAT THEIR MAIN DESIRE WAS TO SEE THEIR FATHER
20 MADE COMFORTABLE AND IN THEIR WORDS, I BELIEVE, LET HIM DIE
21 NATURALLY.
22 Q. AND WHAT DID THAT SIGNIFY TO YOU, IF ANYTHING?
23 A. WELL, IT SIGNIFIED TO ME THAT DR. WEITZEL WAS UNDER
24 LEGAL AND MORAL OBLIGATION TO FOLLOW THE WISHES --
25 MS. BARLOW: OBJECTION, YOUR HONOR. THAT CALLS FOR
3480
1 A LEGAL CONCLUSION.
2 THE COURT: ANY RESPONSE?
3 MR. STIRBA: I DON'T KNOW. THE QUESTION, DID HE
4 JUST ANSWER IT?
5 THE COURT: WHY DON'T YOU REPHRASE THE QUESTION.
6 Q. (BY MR. STIRBA) MY QUESTION WAS WHAT SIGNIFICANCE, IF
7 ANYTHING, TO YOU DID THIS HAVE IN TERMS OF YOUR OPINION AS
8 TO THE APPROPRIATENESS OF THE CARE IN THIS CASE?
9 A. WELL, IN MY OPINION DR. WEITZEL WAS OBLIGED TO FOLLOW
10 THE FAMILY'S WISHES IN THIS REGARD.
11 Q. DOES A PHYSICIAN HAVE AN OBLIGATION TO PROVIDE CARE
12 DURING THE DYING PROCESS EVEN IF THAT CARE MAY NOT RESOLVE
13 THE PROBLEM THAT IS CAUSING THE DYING PROCESS?
14 MS. BARLOW: OBJECTION, YOUR HONOR. THAT'S
15 LEADING.
16 THE COURT: SUSTAINED. REPHRASE THE QUESTION.
17 MR. STIRBA: SURE.
18 Q. (BY MR. STIRBA) ARE THERE DUTIES RELATING TO PROVIDING
19 CARE TO A DYING PATIENT, DOCTOR?
20 A. YES, THERE ARE.
21 Q. AND WOULD YOU PLEASE DEFINE FOR US THE SCOPE OF THOSE
22 DUTIES ON A PHYSICIAN?
23 A. WELL, A PHYSICIAN IS DUTY BOUND FIRST OF ALL TO DO NO
24 HARM. THAT'S THE HYPOCRITIC OATH. THAT OATH IS MODIFIED BY
25 THE WISHES OF THE PATIENT AND ALSO BY THE CIRCUMSTANCES
3481
1 INVOLVED. NOW, DYING PATIENT IMPLIES THAT PATIENT'S EITHER
2 DYING FROM A CONDITION THAT POSSIBLY CAN BE REVERSED OR BY
3 URGENT ACTION OR TREATMENT OR DUE TO A CONDITION THAT'S
4 IRREVERSIBLE OR YOU MIGHT SAY INEVITABLE. IN THAT CASE,
5 THERE'S A DECISION-MAKING POINT WHICH IS USUALLY SHARED BY
6 THE PHYSICIAN AND THE PATIENT, IF HE'S ABLE, AND IF NOT
7 ABLE, BY HIS FAMILY OR THOSE BEARING POWER OF ATTORNEY.
8 HE'S DUTY BOUND TO FOLLOW THOSE OBLIGATIONS AND THEN
9 EXERCISE THE BEST OF HIS SKILL IN MAINTAINING COMFORT AND
10 WELL-BEING OF THE PATIENT TO THE BEST OF HIS ABILITY.
11 Q. HAVE YOU REVIEWED THE MEDICAL RECORDS RELATING TO
12 PATIENT JUDITH LARSEN?
13 A. YES, I HAVE.
14 Q. AND CAN YOU RECALL THE CIRCUMSTANCES OF JUDITH LARSEN'S
15 STAY IN THE HOSPITAL?
16 A. AS I RECALL, JUDITH LARSEN WAS ANOTHER ELDERLY LADY WHO
17 HAD RECOVERED FROM A FAIRLY RECENT STROKE AND HAD RATHER
18 ACUTELY BECOME UNMANAGEABLE IN TERMS OF HER BEHAVIOR. SHE
19 WAS RESTLESS AND VIOLENT AND COMBATIVE AND WAS ADMITTED TO
20 THE UNIT IN THE HOPES OF CONTROLLING HER RESTLESSNESS AND
21 HER AGGRESSIVE BEHAVIOR.
22 Q. DO YOU HAVE AN OPINION AS TO WHETHER OR NOT SHE RECEIVED
23 END-OF-LIFE CARE?
24 A. YES, SHE DID. DURING THE HOSPITALIZATION SHE HAD
25 ANOTHER STROKE WHICH APPARENTLY WAS A TERMINAL CONDITION AND
3482
1 AT WHICH TIME SHE RECEIVED END-OF-LIFE CARE.
2 Q. AND DO YOU HAVE AN OPINION AS TO THE APPROPRIATENESS OF
3 THE CARE SHE RECEIVED IN THAT RESPECT?
4 A. YES, I DO.
5 Q. AND WHAT IS YOUR OPINION?
6 A. MY OPINION IS THAT CARE WAS APPROPRIATE.
7 Q. AND WHY DO YOU SAY THAT?
8 A. BECAUSE IT WAS OBVIOUS FROM THE ATTENDING PHYSICIAN AND
9 HIS CONSULTANTS THAT MS. ANDERSON HAD INDEED SUSTAINED A
10 STROKE AND SHE WAS UNRESPONSIVE, HOWEVER, WAS STILL VERY
11 RESTLESS AND OBVIOUSLY IN PAIN, AND SHE WAS GIVEN
12 APPROPRIATE MEDICATION TO CONTROL HER PAIN AND RESTLESSNESS.
13 Q. WERE MEDICAL DIRECTIVES OR ADVANCE DIRECTIVES RELATIVE
14 TO HER SITUATION INVOLVED?
15 A. YES, THEY WERE. THEY WERE IN PLACE.
16 Q. AND CAN YOU TELL US WHAT IMPACT, IF ANY, SHE HAD IN
17 TERMS OF THE CARE THAT SHE RECEIVED?
18 A. WELL, AGAIN THE MEDICAL DIRECTIVE OR THE ADVANCE
19 DIRECTIVE DICTATED THAT NO EXTRAORDINARY MEASURES WERE TO BE
20 TAKEN AND THAT NO TREATMENT WAS TO BE RENDERED THAT WAS
21 INTENDED ONLY TO PROLONG HER LIFE OR DELAY THE INEVITABLE
22 DEATH.
23 Q. DID YOU REVIEW THE MEDICAL RECORDS CONCERNING LYDIA
24 SMITH?
25 A. YES, I DID.
3483
1 Q. AND COULD YOU TELL US, PLEASE, WHAT HER CIRCUMSTANCE WAS
2 AS YOU RECALL IT IN THE HOSPITAL?
3 A. AS I RECALL, LYDIA SMITH WAS AN ELDERLY LADY WITH PAST
4 HISTORY OF MULTIPLE STROKES. ATRIAL FIBRILLATION WHICH
5 PREDISPOSES TO STROKES, NONHEMORRHAGIC STROKES. AND SHE HAD
6 DETERIORATED IN HER GENERAL CONDITION, INTELLECTUALLY AS
7 WELL AS PHYSICALLY AND WAS HOSPITALIZED IN HOPES OF
8 CONTROLLING HER RESTLESSNESS AND HER ANXIETY.
9 Q. AND DO YOU RECALL THE SEQUENCE OR THE CIRCUMSTANCES THAT
10 DEVELOPED IN THE HOSPITAL CONCERNING HER PROGRESSION?
11 A. I TEND TO GET HER AND JUDITH LARSEN MIXED UP.
12 Q. THE BINDER IS IN FRONT OF YOU, IF YOU NEED IT. REALLY
13 ISN'T A MEMORY TEST.
14 A. OKAY. I REMEMBER NOW. SHE CAME INTO THE HOSPITAL WITH
15 A URINARY TRACT INFECTION WHICH WAS APPROPRIATELY TREATED BY
16 THE ATTENDING PHYSICIAN AND APPARENTLY WAS REASONABLY STABLE
17 UNTIL ABOUT THE 7TH OF JANUARY AT WHICH TIME SHE BECAME
18 ACUTELY AND SERIOUSLY ILL WITH APPARENT NONHEMORRHAGIC
19 STROKE. I THINK, YES, SHE WAS THE ONE THAT THE C.A.T. SCAN
20 SHOWED LEFT ANTERIOR STROKE. AND SHE WAS NONRESPONSIVE,
21 THRASHING AROUND, CRYING OUT IN PAIN. AND AT THAT TIME,
22 PAIN MEDICATION AS WELL AS OTHER SEDATIVES WERE INSTITUTED.
23 SHE DIED SHORTLY THEREAFTER.
24 Q. WE HAVE A NUMBER OF DIFFERENT CIRCUMSTANCES HERE. ARE
25 YOU SURE THAT YOU WERE TALKING ABOUT LYDIA SMITH? COULD YOU
3484
1 PULL LYDIA SMITH'S BINDER?
2 A. I THINK SO.
3 Q. OKAY.
4 A. I JUST GLANCED AT THE DISCHARGE SUMMARY, YEAH. AFTER
5 FAMILY DISCUSSION WITH TWO SONS AND DAUGHTER, FAMILY DECIDED
6 THEY DID NOT WANT HER LIFE ARTIFICIALLY PROLONGED, BUT
7 RATHER WOULD LIKE COMFORT CARE.
8 Q. AND WHAT IS THE SIGNIFICANCE OF THAT ENTRY TO YOU,
9 DOCTOR?
10 A. WELL, THE SIGNIFICANCE OF THAT IS THAT THIS WAS THE
11 DIRECTIVE TO THE PHYSICIAN REGARDING END-OF-LIFE CARE.
12 SUPERSEDED ANYTHING THAT WENT BEFORE THAT. AND AT THAT
13 TIME, ANY AGGRESSIVE LIFE-SUPPORT TREATMENT OR THERAPEUTIC
14 MEASURES THAT WOULD ARTIFICIALLY PROLONG LIFE WERE TO BE
15 DISCONTINUED AND THAT COMFORT CARE, MAINLY RELIEF FROM PAIN
16 AND RESTLESSNESS, WERE TO BE INSTITUTED.
17 Q. DO YOU RECALL IF THERE WERE WRITTEN DIRECTIVES
18 CONCERNING LYDIA SMITH?
19 A. THERE WERE.
20 Q. AND DID YOU HAVE A CHANCE TO REVIEW THOSE?
21 A. YES, I DID.
22 Q. AND DO YOU REMEMBER IF THEY HAVE ANY SIGNIFICANCE FOR
23 PURPOSES OF YOUR OPINION?
24 A. YES. AS I RECALL, THEY SPECIFICALLY STIPULATED NO CPR,
25 NO INTRAVENOUS FLUIDS, MECHANICAL VENTILATION. I THINK
3485
1 THAT'S THE WAY IT WAS STATED.
2 Q. WE HAVE TO LET THE MACHINE WARM UP. AND I'LL ASK YOU
3 IF YOU'D REFER TO 811 IN THE BINDER FOR LYDIA SMITH.
4 A. 811?
5 Q. YES. DO YOU HAVE THAT IN FRONT OF YOU?
6 A. YEAH, BUT I DON'T UNDERSTAND -- PAGE EIGHT.
7 Q. MED-0811.
8 MR. STIRBA: IF I MAY ASSIST THE WITNESS, YOUR
9 HONOR.
10 THE COURT: YES.
11 THE WITNESS: OKAY. YES, SIR.
12 Q. (BY MR. STIRBA) DO YOU HAVE THAT IN FRONT OF YOU?
13 A. I DO.
14 Q. AND?
15 A. THIS DIRECTIVE IS DATED --
16 THE COURT: IS THERE A QUESTION?
17 Q. (BY MR. STIRBA) LET ME ASK YOU A QUESTION, DOCTOR.
18 WHAT IS IT THAT YOU HAVE IN FRONT OF YOU?
19 A. I HAVE MEDICAL TREATMENT PLAN DATED 1/7/96.
20 Q. AND IS THAT PART OF THE MEDICAL FILE?
21 A. OF LYDIA SMITH.
22 Q. AND IT DOES DICTATE, DOES IT NOT, CERTAIN CARE THAT CAN
23 BE PROVIDED AND CERTAIN CARE THAT CANNOT?
24 A. YES.
25 Q. AND COULD YOU TELL US BASICALLY WHAT THE DIRECTIVE IS
3486
1 INDICATING IN TERMS OF WHAT END-OF-LIFE CARE CAN BE
2 PROVIDED?
3 A. OKAY. WELL, THE INDICATION IS THAT SHE WAS NOT TO BE
4 RESUSCITATED. THAT SHE WAS NOT TO RECEIVE OXYGEN THERAPY,
5 RESPIRATORY THERAPY, SUCTIONING, MECHANICAL VENTILATION,
6 CPR, CHEST COMPRESSION, CARDIAC MEDICATION, DEFIBRILLATION,
7 CHEMOTHERAPY, RADIATION, SURGERY, I.V., FLUIDS, NASOGASTRIC
8 FEEDING TUBE, GASTRIC FEEDING TUBE, ORAL ANTIBIOTICS,
9 INTRAMUSCULAR ANTIBIOTICS OR IV ANTIBIOTICS.
10 Q. GIVEN THOSE DIRECTIVES, DOES THAT HAVE AN IMPACT ON THE
11 CARE THAT COULD HAVE BEEN PROVIDED AS OF THE TIME OF THE 7TH
12 OF JANUARY OF 1996?
13 A. YES, IT DID.
14 Q. AND TELL US IN WHAT RESPECT.
15 A. WELL, IT PRETTY MUCH RESTRICTS THE DOCTOR TO RENDERING
16 COMFORT CARE ONLY.
17 Q. AND BY "COMFORT CARE ONLY," WHAT DO YOU MEAN?
18 A. RELIEF OF PAIN AND RESTLESSNESS AND PROVIDING BODILY
19 COMFORTS; NAMELY, ROUND-THE-CLOCK NURSING.
20 Q. WOULD COMFORT CARE INCLUDE MEDICATION?
21 A. NO. OH, YES. I'M SORRY. I WAS THINKING ANTIBIOTICS.
22 YES, IT WOULD INCLUDE MEDICATION.
23 Q. CERTAINLY. I WANT TO NOW ASK YOU ABOUT THE
24 CIRCUMSTANCES OF PATIENT MARY CRANE AND HER BINDER IS TO
25 YOUR LEFT. DO YOU HAVE THAT BINDER IN FRONT OF YOU?
3487
1 A. YES, I DO.
2 Q. CAN YOU RECALL WHAT WERE THE CIRCUMSTANCES OF PATIENT
3 MARY CRANE IN THE HOSPITAL?
4 A. AGAIN, SHE WAS AN ELDERLY WHITE FEMALE WHO WAS ADMITTED
5 TO THE GEROPSYCHIATRIC UNIT, DAVIS COUNTY HOSPITAL, MAINLY
6 BECAUSE OF FAIRLY ACUTE CHANGE IN BEHAVIOR. SHE ALSO WAS A
7 POST-STROKE VICTIM. SHE HAD MANY MEDICAL PROBLEMS, ONE OF
8 WHICH IS BECAUSE OF THE CHANGE IN HER BEHAVIOR, SHE WAS
9 CONSTANTLY DRINKING WATER AND OTHER LIQUIDS AND HAD SO
10 ALTERED HER BLOOD CHEMISTRY PICTURE THAT SHE WAS IN A
11 PRECARIOUS CHEMICAL BALANCE WHEN SHE ENTERED THE HOSPITAL.
12 SHE ALSO WAS COMBATIVE, VERBALLY ABUSIVE, STRIKING OUT,
13 SPITTING, SCREAMING. SHE WOULD FORCE HERSELF TO VOMIT BY
14 STICKING HER FINGERS DOWN HER THROAT. SHE ALSO -- SHE ALSO
15 HAD A BAD BACK. SHE HAD UNDERGONE SURGERY FOR HERNIATED
16 DISK IN 1984 AND SINCE THAT TIME HAD HAD A MORE OR LESS
17 CONSTANT -- SUFFERED FROM MORE OR LESS CONSTANT LOW BACK
18 PAIN. SHE HAD A HISTORY OF PEPTIC ULCER WITH BLEEDING. SHE
19 HAD HAD SURGERY FOR THAT IN THE 1980S. AND SHE DEVELOPED --
20 MS. BARLOW: YOUR HONOR, HE APPEARS TO BE READING
21 FROM SOMETHING. CAN I KNOW WHAT HE'S READING FROM?
22 Q. (BY MR. STIRBA) WOULD YOU TELL US, PLEASE, WHAT YOU
23 ARE REFERRING TO, DOCTOR?
24 A. THIS IS FROM THE INITIAL PSYCHIATRIC EVALUATION ON
25 ADMISSION OF MS. CRANE TO THE DAVIS COUNTY HOSPITAL.
3488
1 Q. DID HER CONDITION IN THE HOSPITAL DETERIORATE?
2 A. YES, IT DID.
3 Q. AND TELL US, PLEASE, IN WHAT WAY.
4 A. SHE WAS -- SHE WAS SEEN IN CONSULTATION BY AN INTERNIST
5 SHORTLY AFTER ADMISSION. HIS JUDGMENT WAS THAT SHE WAS
6 OVERSEDATED AND HE REDUCED THE PAIN MEDICATION THAT HAD BEEN
7 ORDERED BY DR. WEITZEL. SHORTLY THEREAFTER SHE BECAME
8 INCREASINGLY RESTLESS, CRYING OUT IN PAIN, IN PARTICULARLY
9 LOW BACK PAIN, AND DR. WEITZEL INCREASED THE PAIN MEDICATION
10 AGAIN AND REINSTITUTED PAIN MEDICINE AS NEEDED.
11 Q. WERE YOU ABLE TO DETERMINE IF PATIENT MARY CRANE
12 RECEIVED END-OF-LIFE CARE?
13 A. YES.
14 Q. AND TELL US IN WHAT RESPECT SHE RECEIVED SUCH CARE.
15 A. WELL, ONE OF -- ON THE MORNING OF THE 7TH OF JANUARY THE
16 DOCTOR NOTED THAT SHE HAD BECOME, IN HIS VIEW, TERMINALLY
17 ILL. AND AT THAT TIME, END-OF-LIFE CARE WAS INSTITUTED
18 WHICH CONSISTED MAINLY OF PAIN MEDICATION. I'M TRYING TO
19 FIND AN X-RAY REPORT HERE ON HER. THIS LADY ALSO HAD AN
20 UNDIAGNOSED LESION ON THE RIGHT SHOULDER WHICH APPARENTLY
21 WAS PAINFUL AND WAS NEVER FULLY DIAGNOSED. THEY SUSPECTED A
22 MALIGNANCY IN THE RIGHT SHOULDER.
23 Q. DO YOU RECALL IF THERE WERE DIRECTIVES CONCERNING A
24 PATIENT MARY CRANE?
25 A. YES.
3489
1 Q. WOULD YOU TURN TO 341, MED-341, PLEASE?
2 A. YES, SIR.
3 Q. AND IS THAT A DIRECTIVE OR A MEDICAL TREATMENT PLAN
4 CONCERNING CERTAIN ADVANCE DIRECTIVES?
5 A. YES, IT IS.
6 Q. IS THAT IN THE MEDICAL FILE?
7 A. YES. IT'S AN ADVANCE DIRECTIVE REGARDING MARY CRANE
8 DATED 12/28/95.
9 Q. ONCE AGAIN, THIS DIRECTIVE HAS IN IT CERTAIN LIMITATIONS
10 IN TERMS OF CARE?
11 A. YES, IT DOES.
12 Q. BASED UPON YOUR REVIEW OF HER SITUATION, DO YOU HAVE AN
13 OPINION AS TO THE APPROPRIATENESS OF THE END-OF-LIFE CARE
14 PROVIDED?
15 A. YES, I DO.
16 Q. AND TELL US WHAT YOUR OPINION IS, PLEASE.
17 A. IN MY OPINION THE END-OF-CARE TREATMENT PROVIDED MS.
18 CRANE WAS APPROPRIATE.
19 MR. STIRBA: THAT'S ALL I HAVE YOUR HONOR. THANK
20 YOU.
21 CROSS-EXAMINATION
22 BY MS. BARLOW:
23 Q. GOOD MORNING, DR. CANNON.
24 A. HI.
25 Q. WERE YOU ACQUAINTED WITH DR. WEITZEL PRIOR TO BEING
3490
1 ASKED TO SERVE AS AN EXPERT IN THIS CASE?
2 A. YES.
3 Q. WHAT WAS -- WHAT WAS YOUR ACQUAINTANCESHIP WITH HIM?
4 A. WE WERE ASSOCIATES AT THE MATAGORDA HOSPITAL IN BAY
5 CITY, TEXAS.
6 Q. WOULD YOU SPELL MATAGORDA.
7 A. M-A-T-A-G-O-R-D-A.
8 Q. YOU SAY YOU WERE ASSOCIATES?
9 A. WELL, WE WERE COLLEAGUES, PUT IT THAT WAY.
10 Q. AND WHAT WAS YOUR ASSOCIATION THERE AT MATAGORDA?
11 A. DR. WEITZEL WAS THE MEDICAL DIRECTOR OF THE
12 GEROPSYCHIATRIC UNIT AT THAT HOSPITAL AND I AM AN ACTIVE
13 MEMBER OF THE MEDICAL STAFF.
14 Q. BUT YOU DON'T WORK ON THE GEROPSYCH UNIT AT MATAGORDA?
15 A. I ADMIT PATIENTS TO THAT UNIT AND I'M THEIR ATTENDING
16 PHYSICIAN FOR THEIR MEDICAL NEEDS.
17 Q. OKAY. SO DR. DIENHART SERVED THAT PURPOSE IN MANY OF
18 THESE CASES, IS THAT THE SAME --
19 A. APPARENTLY SO. HE WAS A MEDICAL CONSULTANT TO
20 DR. WEITZEL.
21 Q. AND HOW LONG DID YOU HAVE THAT ASSOCIATION WITH
22 DR. WEITZEL?
23 A. ABOUT A YEAR. I DON'T RECALL EXACTLY.
24 Q. WHO APPROACHED YOU ABOUT TESTIFYING AS AN EXPERT IN THIS
25 CASE?
3491
1 A. MR. STIRBA, PETER STIRBA.
2 Q. HAVE YOU TALKED TO MR. STIRBA ABOUT YOUR TESTIMONY PRIOR
3 TO TODAY?
4 A. YES.
5 Q. HAVE YOU TALKED TO DR. WEITZEL ABOUT YOUR TESTIMONY
6 PRIOR TO THIS TIME?
7 A. YES.
8 Q. AND OF COURSE THEY TOLD YOU TO TELL THE TRUTH; IS THAT
9 CORRECT?
10 A. THAT'S RIGHT.
11 Q. DO YOU HAVE A BOARD CERTIFICATION?
12 A. NO, I DO NOT.
13 Q. DO YOU HAVE OCCASION TO USE PSYCHOTROPIC DRUGS IN YOUR
14 FAMILY PRACTICE?
15 A. YES.
16 Q. WHICH DRUGS DO YOU USE?
17 A. I USE BENZODIAZEPINES. I USE NONBARBITURATE SOPORIFICS
18 OR NIGHTTIME SEDATIVES. I USE SOME PHENOTHIAZINES. I USE
19 THE SEROTONIN REUPTAKE INHIBITORS.
20 Q. WHICH MEANS SOMETHING TO PHYSICIANS.
21 A. YOU ASKED.
22 Q. AND I APPRECIATE YOU TELLING ME. BUT LET'S LOOK AT SOME
23 NAMES THAT MAYBE WE WOULD BE MORE FAMILIAR WITH. YOU USE
24 MORPHINE SULFATE IN YOUR PRACTICE?
25 A. YES.
3492
1 Q. AND TRAZODONE?
2 A. YES.
3 Q. AND BUSPAR?
4 A. YES.
5 Q. ATIVAN?
6 A. YES.
7 Q. HALDOL?
8 A. YES.
9 Q. RISPERDAL?
10 A. YES.
11 Q. SERZONE?
12 A. YES.
13 Q. DURAGESIC?
14 A. YES.
15 Q. DEPAKENE?
16 A. YES.
17 Q. PROJENTIN?
18 A. YES.
19 Q. WOULD YOU LOOK AT THAT CHART WHICH IS STATE'S EXHIBIT
20 NO. 30 AND CAN TELL ME WHETHER YOU AGREE WITH BOTH THE
21 PHARMACOLOGY IN THE ELDERLY THAT'S WRITTEN HERE AND THE
22 SPECIAL CONSIDERATIONS IN THE ELDERLY THAT'S WRITTEN HERE?
23 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT. IT'S
24 BEYOND THE SCOPE OF DIRECT EXAMINATION.
25 THE COURT: SUSTAINED.
3493
1 Q. (BY MS. BARLOW) ARE YOU FAMILIAR WITH DOSING OF THOSE
2 KINDS OF MEDICATIONS IN THE ELDERLY?
3 A. YES.
4 MR. STIRBA: SAME OBJECTION, YOUR HONOR.
5 THE COURT: SUSTAINED.
6 Q. (BY MS. BARLOW) WHEN DID YOU REVIEW THE RECORDS OF
7 THESE FIVE PATIENTS?
8 A. I FIRST REVIEWED THOSE RECORDS ABOUT THREE MONTHS AGO.
9 THEY WERE SENT TO ME BY MR. STIRBA'S OFFICE. AND THEN I
10 REVIEWED THEM AGAIN WHEN I ARRIVED IN SALT LAKE YESTERDAY.
11 Q. DID YOU REVIEW THEM BEFORE YOU PREPARED YOUR EXPERT
12 OPINION LETTER?
13 A. YES, I DID.
14 Q. HAVE YOU LOOKED AT YOUR LETTER SINCE YOU SENT IT?
15 A. NO, I HAVE NOT.
16 Q. ARE YOU AWARE OF ERRORS THAT ARE IN THAT LETTER?
17 A. I'M NOT AWARE OF ANY ERRORS.
18 Q. OKAY. FOR EXAMPLE, YOU HAVE WRITTEN THAT ENNIS
19 ALLDREDGE WAS ADMITTED TO DAVIS HOSPITAL ON THE 11TH OF
20 NOVEMBER 1995, AND THAT IS NOT THE DATE THAT HE ENTERED THE
21 HOSPITAL, WAS IT?
22 A. I THINK THAT'S CORRECT.
23 Q. CORRECT THAT IT WAS OR CORRECT THAT IT WASN'T?
24 A. THAT WAS NOT THE DATE.
25 Q. SAME WITH ELLEN ANDERSON WHEN YOU WROTE SHE WAS ADMITTED
3494
1 TO DAVIS HOSPITAL ON 12 DECEMBER 1995, AND THAT IS NOT
2 CORRECT?
3 A. THAT'S NOT CORRECT.
4 Q. AND YOU ALSO WRITE THAT SHE EXPIRED ON 12 DECEMBER '95,
5 AND THAT'S NOT CORRECT?
6 A. THAT'S NOT CORRECT.
7 Q. WHEN YOU TALKED ABOUT MEDICAL DIRECTIVES HAVE YOU
8 SPECIFICALLY REVIEWED UTAH LAW ABOUT MEDICAL DIRECTIVES?
9 A. I'VE SEEN A COPY OF UTAH ADVANCE DIRECTIVES.
10 Q. WHAT ABOUT THE LAW ITSELF?
11 A. I HAVE NOT SEEN THE LAW ITSELF.
12 Q. ARE YOU AWARE THAT UTAH LAW DOES NOT ALLOW MERCY KILLING
13 OR EUTHANASIA?
14 A. I'M AWARE OF THAT.
15 Q. SO IF A MEDICAL DIRECTIVE SAYS, YOU KNOW, I JUST WANT
16 YOU TO GIVE ME ENOUGH SOMETHING TO KILL ME IF I'M TERMINAL,
17 THAT WOULD NOT BE ALLOWABLE UNDER UTAH LAW, WOULD IT?
18 A. THAT'S CORRECT.
19 Q. SO THERE'S A LIMIT TO WHAT MEDICAL DIRECTIVES CAN TELL A
20 DOCTOR TO DO?
21 A. THAT'S CORRECT.
22 Q. END-OF-LIFE CARE. IN FACT, I THINK YOU SAID THE WHOLE
23 PURPOSE WAS TO LET NATURE TAKE ITS COURSE, NOT HAVE UNDUE
24 INFLUENCES THAT PROLONG LIFE; IS THAT CORRECT?
25 A. THAT'S CORRECT.
3495
1 Q. YOU ALSO TESTIFIED THAT COMFORT CARE WAS TO AVOID
2 UNNECESSARY PROCEDURES. DO YOU HAVE ENNIS ALLDREDGE'S
3 BINDER IN FRONT OF YOU?
4 A. YES.
5 Q. IF YOU WOULD OPEN TO MED-47.
6 A. OKAY.
7 Q. THAT APPEARS TO BE A M.A.R.S. RECORD OR MEDICAL
8 MEDICATION ADMINISTRATION RECORD?
9 A. YES.
10 Q. AND WE HAVE HERE STARTING ON THE 13 OF JANUARY WE HAVE
11 MORPHINE 10 MILLIGRAMS I.M. EVERY THREE HOURS AND IT APPEARS
12 THAT IT WAS ADMINISTERED EVERY THREE HOURS; IS THAT CORRECT?
13 A. THAT'S CORRECT.
14 Q. AND THEN THERE WAS ADMINISTRATION AT 8 O'CLOCK THE NEXT
15 MORNING ON THE 14TH. I THINK IT'S JUST IN THE NEXT COLUMN
16 OVER.
17 A. OKAY. YES.
18 Q. SO THAT IS ONE, TWO, THREE, FOUR, FIVE, SIX, SEVEN,
19 EIGHT, NINE DOSES OF MORPHINE AND THERE'S ALSO AN ORDER FOR
20 ATIVAN I.M. EVERY THREE HOURS; IS THAT CORRECT?
21 A. THAT'S CORRECT.
22 Q. AND IT APPEARS THAT THERE ARE NINE DOSES OF THAT BETWEEN
23 THE 13TH AND THE 14TH; IS THAT CORRECT?
24 A. YES.
25 Q. THEN WE HAVE SOME INSULIN DOWN HERE. HOW WAS THAT
3496
1 ADMINISTERED?
2 A. SUBCUTANEOUSLY.
3 Q. SO THAT WAS BY SHOT?
4 A. YES.
5 Q. IS IT PAINFUL TO RECEIVE AN I.M. INJECTION?
6 A. YES.
7 Q. IS THERE ANY WAY THAT YOU COULD ADMINISTER THESE DRUGS
8 WITHOUT HAVING TO GIVE THEM THAT MANY SHOTS?
9 A. YES.
10 Q. AND HOW WOULD THAT BE?
11 A. INTRAVENOUSLY.
12 Q. ISN'T IT TRUE THAT GIVING WHAT APPEARS TO BE 21 SHOTS
13 DURING THAT TIME PERIOD COULD HAVE BEEN AVOIDED?
14 A. COULD HAVE BEEN AVOIDED, YES.
15 Q. NOW, IF I UNDERSTAND YOUR TESTIMONY CORRECTLY, YOU ARE
16 NOT SAYING THAT ANY OF THESE PEOPLE CAME INTO THE UNIT FOR
17 END-OF-LIFE CARE; IS THAT CORRECT?
18 A. THAT'S CORRECT.
19 Q. AND, IN FACT, EACH WAS -- I KNOW WHILE THEY HAD PHYSICAL
20 AND HEALTH PROBLEMS, EACH WAS MEDICALLY STABLE WHEN THEY
21 CAME INTO THE UNIT; IS THAT CORRECT?
22 A. WITH ONE EXCEPTION.
23 Q. WHICH EXCEPTION IS THAT?
24 A. ELLEN ANDERSON'S CONDITION WAS NOT FULLY KNOWN AT THE
25 TIME OF ADMISSION, IN MY OPINION.
3497
1 Q. AND, IN FACT SHE DIED WITHIN 17 HOURS; IS THAT CORRECT?
2 A. SHE DID, YES.
3 Q. AND THERE WAS NO FINAL MEDICAL CONSULT IN THAT, AT LEAST
4 THERE WAS NO MEDICAL CONSULT?
5 A. THAT'S MY UNDERSTANDING.
6 Q. SHE CAME IN FOR AN ANXIETY PROBLEM; IS THAT CORRECT?
7 A. SHE HAD BEEN DIAGNOSED AS PANIC DISORDER OR ACUTE
8 ANXIETY WITH DEPRESSION.
9 Q. IF YOU WOULD TURN IN ENNIS ALLDREDGE'S BINDER TO PAGE 85
10 WHICH IS A MEDICAL DIRECTIVE.
11 A. WHAT'S THE PAGE?
12 Q. 85.
13 A. OKAY.
14 Q. THAT WAS FILLED OUT AND SIGNED BEFORE HE ENTERED THE
15 UNIT; IS THAT CORRECT?
16 A. THAT'S CORRECT. OR THE SAME DAY. NO, IT WAS BEFORE.
17 Q. AND THE DIRECTIVES ARE NO C.P.R. AND NO RESPIRATORS; IS
18 THAT CORRECT?
19 A. THAT'S CORRECT.
20 Q. IT DOESN'T SAY ANYTHING ABOUT GIVING ANY KIND OF
21 MEDICATION FOR PAIN IN THAT DIRECTIVE?
22 A. THAT'S CORRECT.
23 Q. AND IF YOU WOULD TURN TO PAGE 77 WHICH IS IN THE NURSING
24 NOTES.
25 A. OKAY.
3498
1 Q. ABOUT A THIRD OF THE WAY DOWN IT SAYS 0500, CAN YOU SEE
2 THAT?
3 A. YES.
4 Q. IT SAYS DOSE OF MORPHINE AND ATIVAN WERE GIVEN AT 0430
5 DUE TO PATIENT GRIMACING AND LABORED BREATHING, INDICATING
6 HIS LEVEL OF DISTRESS.
7 A. YES.
8 Q. DO YOU READ THAT AS PAIN?
9 A. YES.
10 Q. DO YOU ALSO READ A NOTATION SUCH AS THAT AS PAIN?
11 A. YES.
12 Q. IS THERE ANYTHING ELSE THAT COULD CAUSE GRIMACING OR
13 LABORED BREATHING OTHER THAN PAIN?
14 A. ANGER OR SEVERE EMOTION OF ONE KIND OR ANOTHER.
15 Q. AND WHAT ABOUT NOT GETTING ENOUGH OXYGEN, WOULD THAT
16 CAUSE THE SAME KIND OF SYMPTOMS OF DISTRESS?
17 A. USUALLY PATIENTS IN OXYGEN DEPRIVATION ARE NOT
18 GRIMACING. THEY ARE USUALLY GASPING AND UNDULY RESTLESS. I
19 DON'T RECALL GRIMACING BEING ONE OF THE SYMPTOMS OF
20 OXYGENIA.
21 Q. WHAT ABOUT IF THEY WERE SEDATED TO THE POINT THAT THEY
22 JUST FORGOT TO BREATHE. WOULD YOU SEE THESE KINDS OF
23 SYMPTOMS?
24 A. FORGOT TO BREATHE?
25 Q. WELL, HAVING TROUBLE BREATHING BECAUSE THEY WERE SO
3499
1 SEDATED.
2 A. I DOUBT IT.
3 Q. YOU INDICATED THAT THERE'S A POINT IN THE DYING PROCESS
4 AND YOU GET TO THE POINT WHERE THE PROCESS IS IRREVERSIBLE;
5 IS THAT CORRECT?
6 A. THAT'S CORRECT.
7 Q. AND AT THAT TIME YOU TALKED TO THE FAMILY?
8 A. YES.
9 Q. AND YOU FOLLOW THE FAMILIES WISHES?
10 A. WHEN POSSIBLE.
11 Q. AND, IN FACT, WITH MR. ALLDREDGE I BELIEVE IN THE
12 PROGRESS NOTES MED-NUMBER 17.
13 A. OKAY.
14 Q. THIS APPEARS TO BE DR. WEITZEL'S HANDWRITING. IN FACT,
15 HE SIGNED IT AT THE BOTTOM.
16 A. YES.
17 Q. IT SAYS ADDENDUM. SPOKE WITH WIFE EXTENSIVELY. SHE
18 FEELS STRONGLY THAT NO EXTRAORDINARY MEASURES SHOULD BE
19 TAKEN TO PROLONG ENNIS'S LIFE GIVEN THE C.V.A. FOUND ON THE
20 M.R.I. DO YOU HAVE ANY INDEPENDENT KNOWLEDGE AS TO WHETHER
21 THAT CONVERSATION TOOK PLACE?
22 A. NO.
23 Q. LET'S LOOK AT THE M.R.I. ITSELF WHICH IS MED-27. HAVE
24 YOU SEEN THAT DOCUMENT BEFORE?
25 A. YES.
3500
1 Q. AND ISN'T IT TRUE THAT THE RADIOLOGIST WHO READ THIS
2 SAID THAT THIS WAS A SUBOPTIMAL IMAGING DUE TO PATIENT
3 MOTION?
4 A. YES.
5 Q. AND HE SAID THERE'S A QUESTION OF AN INFARCT INVOLVING
6 THE LEFT OCCIPITAL. I CANNOT PRECISELY DATE THIS POSSIBLE
7 INFARCTION, ALTHOUGH THERE COULD BE SOME EARLY COMPRESSION
8 OF THE OCCIPITAL HORN. SUGGEST ACUTE/SUBACUTE EVENT. DO
9 YOU READ THAT AS THERE WAS DEFINITELY A STROKE?
10 A. AS A CLINICIAN I WOULD SEE THAT AS EVIDENCE OF A STROKE.
11 Q. HE SAYS CLINICAL CORRELATION AND FOLLOW UP WITH C.T. OR
12 LATER M.R.I. WITH BETTER SEDATION MAY BE USEFUL. BUT YOU
13 ARE SAYING THAT BASED ON JUST THIS YOU WOULD DECIDE THERE
14 HAD BEEN A STROKE AND TREAT IT ACCORDINGLY?
15 A. YES.
16 Q. YOU WOULD NOT HAVE ANOTHER M.R.I. DONE?
17 A. PROBABLY NOT.
18 Q. WOULD -- YOU WOULD NOT HAVE A C.T. SCAN DONE?
19 A. NO.
20 Q. BASED ON THAT, YOU WOULD SAY, OKAY, THIS MAN AT THIS AGE
21 BASED ON THIS HAS HAD A STROKE, LET'S GIVE HIM COMFORT CARE?
22 A. YES.
23 Q. DO YOU HAVE A PSYCHIATRIC BACKGROUND, TRAINING IN
24 PSYCHIATRIC?
25 A. NO.
3501
1 Q. ARE YOU FAMILIAR WITH THE D.S.M.?
2 A. YES.
3 Q. ARE YOU FAMILIAR WITH A CONDITION CALLED DELIRIUM THAT'S
4 IN THE PSYCHIATRIC MANUAL?
5 A. YES.
6 Q. HAVE YOU EVER DIAGNOSED DELIRIUM?
7 A. YES.
8 Q. DO YOU SEE IT IN CONJUNCTION WITH DEMENTIA?
9 A. POSSIBLY.
10 Q. WOULD YOU LOOK AT ANY OF THESE FIVE PATIENTS AT THE
11 RECORDS AND LOOK TO SEE IF THERE WAS DELIRIUM HAPPENING
12 HERE?
13 A. YES.
14 Q. AND YOU DECIDED THERE WAS NOT?
15 A. NO. I DIDN'T SAY THAT.
16 Q. WHAT DID YOU DECIDE?
17 A. WELL, OF COURSE AT TIMES THESE PATIENTS WERE DELIRIOUS
18 AND, YOU KNOW, UNDER THOSE DEFINITIONS.
19 Q. AND IS DELIRIUM TREATABLE?
20 A. IN SOME CASES.
21 MS. BARLOW: JUST A MOMENT, YOUR HONOR.
22 THE COURT: YES.
23 Q. (BY MS. BARLOW) IF YOU WOULD NEXT TURN TO JUDITH
24 LARSEN. I BELIEVE YOU TESTIFIED THAT YOU OPINED THAT SHE
25 HAD HAD ANOTHER STROKE. I MEAN, SHE HAD THE STROKE BEFORE
3502
1 COMING TO THE HOSPITAL?
2 A. YES.
3 Q. LET'S TURN TO 489.
4 A. OKAY.
5 Q. DO YOU RECALL IF THIS WAS AFTER SHE HAD A SEIZURE?
6 A. YES.
7 Q. AND ARE YOU AWARE THAT THE SEIZURE HAPPENED
8 APPROXIMATELY 24 HOURS AFTER SHE WAS GIVEN MORPHINE?
9 A. I'M NOT SURE, BUT I WOULDN'T BE SURPRISED.
10 Q. LET'S LOOK AT THIS IMPRESSION. AND THERE'S A LOT OF
11 OTHER THAT WE'VE HEARD ABOUT BEFORE AND I HOPE WE UNDERSTAND
12 AT THIS POINT, BUT I JUST WANT TO FOCUS ON THE LEFT FRONTAL
13 LOBE REGION MAY SHOW SOME MINIMAL INCREASE IN DENSITY WHICH
14 MAY REFLECT SOME LUXURY PROFUSION WHICH MAY REFLECT A MORE
15 SUBACUTE TYPE PROCESS. AND THAT MEANS SOMETHING THAT REALLY
16 HASN'T QUITE HAPPENED YET, DOESN'T IT, SUBACUTE?
17 A. NO, IT DOESN'T.
18 Q. WHAT DOES IT MEAN?
19 A. WELL, YOU HAVE TO UNDERSTAND ON C.A.T. SCANS AS WELL AS
20 M.R.I. THE CHANGES IN THE BRAIN WHICH OCCUR ACUTELY WITH
21 NONHEMORRHAGIC STROKE MAY NOT SHOW AS MUCH AS 72 HOURS IN
22 SOME CASES.
23 Q. SO SUBACUTE MAY HAPPEN. IT DOESN'T REALLY SHOW UP YET,
24 IS THAT WHAT YOU ARE TELLING ME?
25 A. SOMETHING SHOWS UP BUT HE'S NOT GOING TO MAKE A
3503
1 DIAGNOSIS BASED ON THAT AT THAT TIME.
2 Q. NO DISTINCT EVIDENCE OF A HEMORRHAGE TO HIM SO WE DON'T
3 HAVE A --
4 A. NONHEMORRHAGIC.
5 Q. CLINICAL CORRELATION IS RECOMMENDED, SEE ABOVE
6 DICTATION. BASED ON THIS, YOU WOULD DETERMINE THERE WAS A
7 STROKE?
8 A. IF I WERE A CLINICIAN AND RECEIVED THIS REPORT, I WOULD
9 DIAGNOSE NONHEMORRHAGIC STROKE.
10 Q. INCIDENTALLY I THINK THERE'S A TYPO. THAT LUXURY
11 PROFUSION SHOULD READ LACK OF PROFUSION.
12 Q. WELL, READS WHAT IT READS.
13 A. NEVER HEARD OF LUXURY PROFUSION.
14 Q. SO THAT OCCURRED ON THE 26TH OF DECEMBER. WE'LL GO ON.
15 IF YOU WOULD TURN BACK TO 597 THERE'S A MEDICAL TREATMENT
16 PLAN THAT SAYS 1985, BUT I THINK WE'VE HAD DR. STEVENSON
17 HERE TESTIFYING IT WAS REALLY SIGNED IN SEPTEMBER OF 1995,
18 AND IT HAS CERTAIN THINGS THAT WERE LISTED --
19 A. YES.
20 Q. -- AS CARE AND TREATMENT OR WITHHOLDING OF TREATMENT AS
21 DIRECTED. AND THE LAST ONE -- THE LAST SENTENCE IS AN
22 OXYGEN AND ORAL MEDICATION MAY BE GIVEN FOR RELIEF OF PAIN
23 AND FOR COMFORT; IS THAT CORRECT?
24 A. YES.
25 Q. IN FACT, IT DOESN'T SAY ANYTHING ABOUT GO AHEAD AND GIVE
3504
1 ME A SHOT FOR PAIN OR COMFORT, DOES IT?
2 A. NO.
3 Q. IF YOU PULL OUT MRS. SMITH, YOU WERE READING FROM THE
4 DISCHARGE SUMMARY, I BELIEVE, ON DIRECT EXAMINATION, AND WHO
5 DICTATED THAT DISCHARGE SUMMARY?
6 A. DR. WEITZEL.
7 Q. ON 821 I THINK YOU QUOTED HIM AS SAYING THE PATIENT
8 BECAME QUITE ILL ON THE 7TH.
9 A. YES.
10 Q. NOT TAKING ANY NOURISHMENT OR FLUIDS AND HAD NO URINE
11 OUTPUT. I BELIEVE YOU TESTIFIED ON DIRECT THAT THAT "I.M.
12 NECESSARY" WAS A PATIENT STROKE THAT WAS DIAGNOSED BY A C.T.
13 SCAN, IS THAT WHAT YOU SAID?
14 A. YES.
15 Q. IF YOU WOULD TURN TO THE RADIOLOGY SECTION. DO YOU SEE
16 ANY RECORD OF A C.T. SCAN IN THAT?
17 A. NO.
18 Q. CAN YOU TELL US WHAT RECORD YOU USED TO DETERMINE THAT
19 SHE HAD HAD A STROKE ON THE 7TH?
20 A. I THINK I WAS CONFUSED WITH MRS. LARSEN. HOWEVER,
21 CLINICAL RECORD INDICATES THAT SOMETHING DRAMATIC HAPPENED
22 JUST PRIOR TO THE 7TH.
23 Q. WHICH RECORD ARE YOU LOOKING AT?
24 A. THE NURSES' AND PHYSICIANS' PROGRESS NOTES.
25 Q. IS THAT 719?
3505
1 A. YES.
2 Q. YOU HAVE DR. WEITZEL WRITING ON THE 6TH. I DON'T KNOW IF
3 IT'S JUST MY EYES OR IF THAT'S OUT OF FOCUS.
4 A. IT'S PRETTY BLURRY ON THE COPY.
5 Q. THE COPY I HAVE IS ON THE 6TH. HE WRITES, FEELING
6 POORLY, LETHARGIC, AMBULATING A BIT, MEANING SHE'S WALKING
7 SOME. VITAL SIGNS STABLE, AFEBRILE MEANING SHE HAS NO
8 FEVER. STABLE, CONTINUED CURRENT CARE. THEN ON THE 7TH HE
9 WRITES, VERY WEAK. NOT TAKING ANY NOURISHMENT. NO URINE
10 OUTPUT. FAMILY DISCUSSION WITH TWO SONS AND DAUGHTER.
11 A. REVEALS.
12 Q. REVEALS. IS THAT REVEALS?
13 A. I THINK SO.
14 Q. HARD TO READ WRITING. THAT THEY DON'T WANT HER LIFE
15 PROLONGED, BUT READY TO LET HER GO. AT TIMES SHE REMARKS
16 ABOUT SEEMS TO BE IN PAIN SLASH ANXIETY. QUITE ILL. HOLD
17 MEDS 5 MILLIGRAM EVERY THREE HOURS I.M. SEE ANYTHING
18 INDICATING A STROKE ON THAT?
19 A. NO. WHAT I SAID WAS I THOUGHT THERE WAS A DRAMATIC
20 EVENT IN HER COURSE ON THAT DAY.
21 Q. BASED ON DR. WEITZEL'S WRITING THAT SHE HAD BECOME VERY
22 ILL?
23 A. YES, AND THE NURSES' NOTES.
24 Q. NOW, IF YOU WILL TURN BACK TO UNDER LEGAL PAGE 811.
25 MEDICAL TREATMENT PLAN THAT YOU REFERENCED EARLIER. TOP
3506
1 PART IS NOT TOTALLY FILLED OUT, IS IT? I'M SORRY. I KNOW
2 THERE ARE A LOT OF RECORDS TO GET THERE.
3 A. NO, IT'S NOT.
4 Q. IT DOESN'T SAY WHETHER IT WAS THE DECLARANT THAT
5 DIRECTED IT OR WHETHER IT WAS A PROXY THAT DIRECTED IT UP
6 THERE, DOES IT?
7 A. NO, IT DOESN'T.
8 Q. AND WE GET DOWN HERE. YOU'VE READ THROUGH THE LIST OF
9 THE DO'S AND DON'TS, AS IT WERE, UNDER THE MEDICAL
10 DIRECTIVE. IS THERE ANYTHING THAT SAYS, GIVE ME COMFORT
11 CARE?
12 A. NO.
13 Q. IS THERE ANYTHING THERE THAT SAYS, GIVE ME MEDICATION
14 FOR PAIN?
15 A. NO.
16 Q. MARY CRANE ALSO CAME IN BECAUSE OF CHANGE IN BEHAVIOR;
17 IS THAT CORRECT?
18 A. THAT'S CORRECT.
19 Q. YOU TALK ABOUT HER BLOOD CHEMISTRY BEING ALTERED BECAUSE
20 OF THE EXCESSIVE FLUID INTAKE, BUT THAT'S NOT WHAT SHE WAS
21 ADMITTED TO THE HOSPITAL FOR, WAS IT?
22 A. NO. COULD HAVE BEEN. MAYBE I SHOULD MODIFY THAT A
23 LITTLE BIT. CHANGE IN BEHAVIOR CAN BE ATTRIBUTABLE TO
24 CHEMICAL IMBALANCE IN THE BLOOD.
25 Q. THANK YOU. IF YOU'D TURN TO 233, I BELIEVE YOU WERE
3507
1 TALKING OR -- YES, TALKING ABOUT THE PSYCHIATRIC EVALUATION.
2 AND ON THAT PAGE IN HIS DISCUSSION AND RECOMMENDATION
3 DR. WEITZEL WRITES, I'LL GIVE HER A DURAGESIC PATCH IN LOW
4 DOSE FOR HER PAIN. DO YOU KNOW HOW MUCH IS A LOW DOSE FOR A
5 DURAGESIC PATCH?
6 A. I WOULD SAY 25 TO 50 MICROGRAMS.
7 Q. YOU WERE AWARE THAT HE ORDERED 50 MICROGRAMS; IS THAT
8 CORRECT?
9 A. YES.
10 Q. YOU ALSO TALKED ABOUT A -- I BELIEVE IT WAS A CONSULT ON
11 TWO -- WELL, NO. PHYSICIANS ORDER, ON 242. AND THAT
12 DR. DIENHART DECREASED THE DURAGESIC PATCH TO 25 MICROGRAMS;
13 IS THAT CORRECT?
14 A. THAT'S CORRECT.
15 Q. AND THAT WAS NOTED BY THE NURSE AT 12:10 ON THAT DATE,
16 ON THE 1ST OF JANUARY?
17 A. YES, IT WAS.
18 Q. AND ON THE NEXT PAGE WE HAVE A NEW ORDER FROM
19 DR. WEITZEL INCREASING THE DURAGESIC BACK TO 50 MICROGRAMS
20 EVERY THREE DAYS AND THAT WAS NOTED AT 1700; IS THAT
21 CORRECT?
22 A. YES.
23 Q. SO IN LESS THAN FIVE HOURS THERE WAS A CHANGE IN THE
24 ORDER; IS THAT CORRECT?
25 A. THAT'S CORRECT.
3508
1 Q. I BELIEVE ON DIRECT EXAMINATION YOU SAID THAT WAS BASED
2 ON A COMPLAINT OF PAIN, BACK PAIN SPECIFICALLY?
3 A. YES.
4 Q. WHERE DOES THAT STATEMENT -- WHERE DO YOU TAKE THAT
5 STATEMENT FROM?
6 A. THAT SHOULD BE IN THE PHYSICIAN'S PROGRESS NOTES.
7 Q. ON 252 IT APPEARS TO BE THE PROGRESS NOTES FOR THE 1ST
8 OF JANUARY. IT SAYS, WOKE FREQUENTLY LAST NIGHT. IT SAYS,
9 TWO WITH A DEGREE SIGN. WHAT DOES THAT MEAN?
10 A. I'M SORRY. YOU ARE AT THE TOP?
11 Q. YES, AT THE TOP.
12 A. SECONDARY.
13 Q. SECONDARY TO POSSIBLE PAIN. QUITE AGGRESSIVE THIS
14 MORNING. VERY DIFFICULT WITH NURSES AND STRUCK OUT AT OTHER
15 PATIENTS. AND THEN DOWN FURTHER, NO IMPROVEMENT. DOES SEEM
16 IN PAIN AND THE CURRENT DURAGESIC PATCH IS CERTAINLY NOT
17 SEDATING HER. AND THEN I'M NOT SURE I CAN TELL WHAT THAT
18 MEANS, BUT THEN IT TALKS ABOUT 50 MICROGRAMS. LET'S TURN TO
19 THE NURSES' NOTES.
20 A. I THINK THAT PHRASE THERE MEANS RESTART MEDICATIONS.
21 Q. OKAY. THANK YOU. PROBABLY MAKES SENSE TOO, CONSIDERING
22 THAT'S WHAT HAPPENED. IF YOU WOULD TURN TO 313 AND 314. IF
23 YOU WOULD JUST READ THROUGH THAT. WELL, LET'S START DOWN ON
24 313 AT 1200. THERE IS THE REFERENCE TO DR. DIENHART AND
25 DECREASING THE DURAGESIC PATCH?
3509
1 A. YES.
2 THE COURT: COULD YOU TELL ME HOW MUCH LONGER YOU
3 ARE ANTICIPATING?
4 MS. BARLOW: PROBABLY HALF ANOTHER TEN MINUTES OR
5 SO.
6 THE COURT: LADIES AND GENTLEMEN, WE'VE GONE OVER
7 AN HOUR AND LET'S TAKE OUR NEXT BREAK FOR THE MORNING. AND
8 DURING THIS TIME, REMEMBER IT'S YOUR DUTY NOT TO CONVERSE
9 AMONG YOURSELVES OR TO CONVERSE WITH OR ALLOW YOURSELVES TO
10 BE ADDRESSED BY ANY PERSON ON THE SUBJECT OF TRIAL. IT'S
11 YOUR DUTY NOT TO FORM OR EXPRESS AN OPINION UNTIL THE CASE
12 IS FINALLY SUBMITTED TO YOU. LET'S COME BACK AT TEN AFTER
13 11.
14 (WHEREUPON, THE JURY LEAVES THE COURTROOM.)
15 THE COURT: YOU MAY BE SEATED AND THE RECORD WILL
16 REFLECT THAT THE JURY HAS LEFT THE COURTROOM. CAN YOU TELL
17 ME IN TERMS OF THESE WITNESSES HOW MUCH MORE TIME YOU THINK
18 YOU MAY HAVE ON THIS ONE?
19 MS. BARLOW: I ONLY HAVE FIVE OR TEN MINUTES.
20 THE COURT: ANY REDIRECT?
21 MR. STIRBA: A LITTLE REDIRECT, YOUR HONOR.
22 THE COURT: OKAY. AND THEN WHAT IS THE TIME FRAME
23 ON THE OTHER TWO WITNESSES IN TERMS OF THEIR LENGTH OF TIME?
24 I'M WONDERING ABOUT HAVING MAYBE AN HOUR LUNCH INSTEAD OF AN
25 HOUR AND A HALF SO THAT WE CAN GET THEM IN BEFORE --
3510
1 MR. STIRBA: I THINK WITH AN HOUR AND A HALF FOR
2 LUNCH WE'LL BE FINISHED WITH THE NEXT TWO WITNESSES RIGHT ON
3 SCHEDULE.
4 THE COURT: AT 4:30?
5 MR. STIRBA: YES.
6 THE COURT: YOU ARE SPEAKING FOR THE --
7 MS. BARLOW: I AGREE WITH THAT, YOUR HONOR.
8 THE COURT: YOU THINK -- SO I WANT TO MAKE SURE.
9 I'D LIKE TO GET THEM DONE TO GET THESE EXPERTS DONE TODAY,
10 IF WE CAN GET THESE FOUR WITNESSES. OKAY. WE'LL TAKE AN
11 HOUR AND A HALF. WE'LL SEE YOU AT TEN AFTER 11.
12 (WHEREUPON, COURT WAS IN LUNCH RECESS.)
13 THE COURT: PLEASE BE SEATED. THE RECORD REFLECT
14 THAT THE JURY HAS RETURNED TO THE COURTROOM. MS. BARLOW?
15 MS. BARLOW: YOUR HONOR.
16 Q. (BY MS. BARLOW) DR. CANNON, I THINK WE WERE AT PAGE
17 313 WHEN WE TOOK A BREAK.
18 A. YES.
19 Q. WE'RE ON THE SAME PAGE. GOOD. AND THAT 1200 HOURS
20 DR. DIENHART DECREASED THE DURAGESIC PATCH. WOULD YOU READ
21 THROUGH THE REST OF THAT PAGE AND THE NEXT WHICH IS THE
22 NOTES FOR JANUARY 1ST. IF YOU JUST READ THROUGH THOSE JUST
23 TO YOURSELF, PLEASE.
24 A. OKAY.
25 Q. THERE'S NOTHING IN THERE THAT SAYS ANYTHING ABOUT
3511
1 COMPLAINING OF LOW BACK PAIN, IS THERE?
2 A. NO.
3 Q. AND, IN FACT, AT 1430 SHE WAS KICKING AND HITTING OR
4 BITING STAFF, BITING STAFF'S FINGERS AND THERE'S NO
5 COMPLAINT OF PAIN THERE.
6 A. THAT'S CORRECT.
7 Q. LET'S LOOK BACK AT THE 270 WHICH IS THE RADIOLOGY
8 REPORT. I BELIEVE YOU TALKED ABOUT THE RIGHT SHOULDER
9 HAVING A PROBLEM. AND THE IMPRESSION IS, INCREASED DENSITY
10 OF THE RIGHT SHOULDER, MAY BE DEGENERATIVE OR OLD, TRAUMATIC
11 IN NATURE BUT I CANNOT EXCLUDE COULD REPRESENT METASTATIC
12 DISEASE TO THE REGION -- OR CLINICAL CORRELATION IS
13 RECOMMENDED, FOLLOW-UP FILMS OF THE SHOULDER MAY BE OF
14 BENEFIT AS WELL AS CLINICAL CORRELATION WITH ANY HISTORY OF
15 PRIOR TRAUMA TO THE REGION.
16 THERE'S NOTHING IN THAT THAT INDICATES SHE WAS
17 COMPLAINING OF PAIN FROM THAT SHOULDER, IS THERE?
18 A. NO.
19 Q. AND THERE'S NOTHING IN THE NURSING NOTE INDICATING THAT
20 SHE COMPLAINED OF PAIN IN THAT SHOULDER, IS THERE?
21 A. I DON'T RECALL.
22 Q. IF YOU WOULD TURN TO THE TAB CALLED LABS, SPECIFICALLY
23 258. YOU TESTIFIED ON DIRECT ABOUT THE BLOOD CHEMISTRY
24 PROBLEM; IS THAT CORRECT?
25 A. YES.
3512
1 Q. AND THE SYMBOL N.A. STANDS FOR SODIUM, DOES IT NOT?
2 A. THAT'S CORRECT.
3 Q. AND ON THE DATE OF HER ADMISSION ON THE 28TH OF DECEMBER
4 HER SODIUM WAS 131 WHICH IS LOW; IS THAT CORRECT?
5 A. CORRECT.
6 Q. BUT THE RANGE IS 135 TO 145; IS THAT CORRECT?
7 A. CORRECT.
8 Q. IS 131 SIGNIFICANTLY LOW?
9 A. I THINK SO.
10 Q. THEN IF YOU'LL TURN TO THE NEXT PAGE, 259. THIS WAS A
11 FEW DAYS LATER ON THE 1ST OF JANUARY THAT TEST IS RUN AGAIN
12 AND IT READS 15; IS THAT CORRECT?
13 A. THAT'S CORRECT.
14 Q. SO THAT'S WITHIN NORMAL RANGE?
15 A. YES.
16 Q. AND YOU WOULD EXPECT THAT BECAUSE SHE WAS PUT ON A FLUID
17 RESTRICTION DIET; IS THAT CORRECT?
18 A. YES.
19 Q. THEN WE HAVE 261 WHICH WAS SIX DAYS LATER AND HER SODIUM
20 NOW IS 159; IS THAT CORRECT?
21 A. THAT'S CORRECT.
22 Q. AND IS THAT HIGH?
23 A. YES.
24 Q. IS IT SIGNIFICANTLY HIGH?
25 A. YES.
3513
1 Q. SO OBVIOUSLY THE SODIUM RESTRICTION OR THE WATER
2 RESTRICTION WAS HAVING AN EFFECT ON HER BLOOD CHEMISTRY?
3 A. YES.
4 Q. HAVE YOU SEEN ANY INDICATIONS IN THE RECORD THAT THAT
5 WATER RESTRICTION DIET WAS EVER DISCONTINUED?
6 A. I'LL HAVE TO LOOK THROUGH THE ORDERS. NO.
7 Q. WHEN YOU WERE ASSOCIATED WITH DR. WEITZEL AT MATAGORDO,
8 YOU WERE PAID FOR YOUR MEDICAL CONSULTS; IS THAT CORRECT?
9 FOR THE PHYSICAL HISTORY OF THOSE PATIENTS?
10 A. YES. AS A GENERAL RULE I WAS THE ADMITTING PHYSICIAN
11 AND CHARGED MY USUAL FEES FOR THAT, THEN AFTER THAT IT WAS A
12 VISIT BASIS.
13 Q. USING MEDICARE PAYMENTS?
14 A. YES.
15 Q. WITH ELDERLY?
16 A. YES.
17 Q. HAVE YOU ENTERED INTO ANY FEE AGREEMENT WITH THE DEFENSE
18 FOR YOUR REVIEW AND TESTIMONY --
19 A. YES.
20 Q. -- OF THESE RECORDS? WHAT IS THAT AGREEMENT?
21 A. I AGREED TO PROVIDE THE NECESSARY SERVICES FOR $250 AN
22 HOUR.
23 Q. DO YOU KNOW HOW MANY HOURS YOU'VE SPENT THUS FAR IN THIS
24 MATTER?
25 A. I HAVEN'T FIGURED IT UP YET, BUT I SPENT A NIGHT IN THE
3514
1 DENVER AIRPORT ON ROUTE.
2 Q. WERE YOU REVIEWING WHILE YOU WERE THERE?
3 A. YES. I HOPE. I WAS DOING EVERYTHING TO KILL TIME.
4 Q. SEND THE BILL TO DENVER FOR THAT ONE.
5 A. BILL THEM FOR THAT.
6 Q. WE WON'T ASK WHAT AIRLINES YOU WERE FLYING.
7 HOW MANY HOURS DID YOU SPEND REVIEWING BEFORE YOU SPENT
8 THE NIGHT IN DENVER REVIEWING THESE RECORDS?
9 A. APPROXIMATELY TWO HOURS REVIEWING THE RECORDS, AN HOUR
10 IN CONFERENCE WITH MR. STIRBA, TWO HOURS PREPARING THE
11 REPORT AND THEN ANOTHER HOUR MORE OR LESS ON THE TELEPHONE.
12 MS. BARLOW: MAY I HAVE JUST A MOMENT, YOUR HONOR?
13 THE COURT: YES.
14 MS. BARLOW: I THINK THAT'S ALL I HAVE, DR. CANNON.
15 THANK YOU.
16 THE COURT: ANY REDIRECT?
17 REDIRECT EXAMINATION
18 BY MR. STIRBA:
19 Q. DOCTOR, BASED UPON WHAT YOU HAVE DONE, DID YOU MAKE A --
20 FORM AN OPINION OR MAKE A DIAGNOSIS OF DELIRIUM IN THIS
21 CASE?
22 A. DELIRIUM?
23 Q. YES?
24 A. NO.
25 Q. YOU WERE ASKED ABOUT SOME INJECTIONS THAT WERE GIVEN.
3515
1 WERE YOU ABLE TO DETERMINE THE REASON WHY MORPHINE WAS
2 ADMINISTERED IN THE FASHION IT WAS FROM THE CIRCUMSTANCES
3 HERE?
4 A. YOU MEAN INTRAMUSCULARLY INSTEAD OF OTHER ROUTES?
5 Q. YES.
6 A. YES. WELL, AS I UNDERSTAND IT FROM THE RECORDS, THE
7 PATIENTS THAT WERE ADMINISTERED MORPHINE INTRAMUSCULARLY OR
8 BY SHOTS WERE COMBATIVE AND STARTING AN I.V. WAS A MAJOR
9 ASSAULT, PLUS THE FACT THAT THEY FREQUENTLY PULLED THEM OUT.
10 SO ADMINISTERING THE MORPHINE BY INTRAVENOUS ROUTE WHICH
11 WOULD BE AFTER THE ORIGINAL STICK WOULD BE PAINLESS, WOULD
12 BE A MAJOR UNDERTAKING AND PROBABLY NOT VERY RELIABLE.
13 Q. YOU WERE ASKED QUESTIONS ABOUT THE DIRECTIVES AND
14 WHETHER THEY INCLUDED STATEMENTS CONCERNING PAIN RELIEF
15 THROUGH MEDICATION. DO YOU REMEMBER THAT?
16 A. YES.
17 Q. COULD YOU TELL US, PLEASE, IN TERMS OF DIRECTIVES, DO
18 THEY USUALLY CONTAIN PROVISIONS CONCERNING PAIN RELIEF OR
19 PAIN MEDICATION?
20 A. NO, THEY DON'T. IT'S RATHER BROAD AND I THINK WHAT YOU
21 HAVE TO UNDERSTAND IS WHEN A PATIENT OR THEIR FAMILY,
22 USUALLY THE FAMILY IN THESE CASES, COME TO A PHYSICIAN AND
23 ASK THAT THEIR LOVED ONE BE KEPT COMFORTABLE, KEPT
24 COMFORTABLE IS A BROAD TERM, BUT I WOULD INTERPRET THAT AS
25 INCLUDING PAIN RELIEF. IT DOES NOT STIPULATE HOW THE PAIN
3516
1 RELIEF IS OBTAINED, BUT GENERALLY THAT INVOLVES PAIN
2 RELIEVING DRUGS. AND THE PHYSICIAN IS LEFT UP TO HIS OWN
3 DISCRETION AS FAR AS THE DOSING AND THE SELECTION OF THE
4 DRUG AND THE MANNER ADMINISTERED.
5 Q. CAN YOU GIVE US AN EXAMPLE OF WHAT YOU ARE TALKING ABOUT
6 IN TERMS OF WHERE IT'S LEFT UP TO THE PHYSICIAN?
7 A. YES, I CAN.
8 MS. BARLOW: YOUR HONOR, I OBJECT, UNLESS IT'S ONE
9 OF THESE PATIENTS.
10 THE COURT: WANT TO REPHRASE THE QUESTION?
11 Q. (BY MR. STIRBA) YES. CAN YOU GIVE US AN EXAMPLE OF
12 THE -- WHEN YOU SAY IT'S LEFT UP TO THE PHYSICIAN?
13 A. THERE'S A HYPOTHETICAL CASE --
14 MS. BARLOW: YOUR HONOR, I OBJECT TO THE
15 HYPOTHETICAL.
16 MR. STIRBA: HE'S HERE AS AN EXPERT, YOUR HONOR.
17 THE COURT: OVERRULED.
18 THE WITNESS: IT'S BASED ON EXPERIENCE.
19 THE COURT: OVERRULED.
20 THE WITNESS: A PATIENT IS ADMITTED TO THE HOSPITAL
21 WITH ADVANCED TERMINAL CANCER. PATIENT ALSO HAS ADVANCED OR
22 HAS -- WE CALL IT END-STAGE CHRONIC LUNG DISEASE, MEANING
23 THEY ARE HAVING DIFFICULTY BREATHING EVEN AT REST. THE
24 PATIENT IS ADMITTED TO THE HOSPITAL WITH A STROKE. SHE'S
25 UNCONSCIOUS. SHE'S LYING THERE UNABLE TO COMMUNICATE. SHE
3517
1 HAS AN ADVANCE DIRECTIVE BECAUSE OF HER OTHER CONDITIONS
2 WHICH ARE INCURABLE AND WHICH DEATH IS INEVITABLE. THE
3 PATIENT IS LYING THERE TRYING TO MAINTAIN OXYGEN SATURATION,
4 BREATHING 40 TIMES A MINUTE, USING ACCESSORY MUSCLES OF
5 RESPIRATION WHICH WE NORMALLY DON'T USE IN BREATHING. THE
6 PATIENT OBVIOUSLY IS IN PAIN. SHE IS GROANING. SHE'S
7 WRITHING.
8 THE FAMILY'S VERY DISTRESSED BECAUSE THEIR LOVED ONE IS
9 LYING THERE DYING IN OBVIOUS PAIN. FAMILY APPROACHES THE
10 PHYSICIAN AND ASKS, IS THERE ANYTHING THAT CAN BE DONE TO
11 HELP MOM. AND THE PHYSICIAN, ACCORDING TO HIS DUTY TO THE
12 PATIENT, EXPLAINS TO THE FAMILY THAT HE CAN ADMINISTER PAIN
13 RELIEVING DRUGS WHICH WILL RELIEVE THE PAIN. UNFORTUNATELY
14 THESE DRUGS WILL ALSO TAKE OUT THE USE OF ACCESSORY
15 RESPIRATORY MUSCLES AND IMPAIR THE PATIENT'S BREATHING,
16 LOWER THE OXYGEN SATURATION AND PROBABLY CAUSE DEATH. THE
17 FAMILY IS ASKED TO CONSULT AMONG THEMSELVES AND MAKE A
18 DECISION.
19 THE FAMILY RETURNS AND SAYS, WE HAVE DECIDED THAT WE
20 WANTED MOM TO BE COMFORTABLE IN HER LAST HOURS. THE
21 PHYSICIAN THEN ORDERS A PAIN RELIEVING DRUG SIMILAR TO
22 MORPHINE. THE PATIENT'S RESPIRATORY RATE DROPS. THE
23 WRITHING CEASES OR GROANING CEASES. SHE BECOMES RELAXED AND
24 APPARENTLY COMFORTABLE. AN HOUR AND A HALF LATER SHE DIES.
25 NOW, TO ME THAT IS A CAPSULE OF A PHYSICIAN'S OBLIGATION TO
3518
1 A PATIENT IN THEIR END-OF-LIFE CARE.
2 MR. STIRBA: THANK YOU, DOCTOR.
3 THE COURT: ANY FURTHER QUESTIONS?
4 MS. BARLOW: YES. YES. JUST A LITTLE BIT BASED ON
5 THAT WHAT HE JUST TALKED ABOUT.
6 RECROSS-EXAMINATION
7 BY MS. BARLOW:
8 Q. IF YOU WOULD OPEN ENNIS ALLDREDGE'S BINDER TO MED-13.
9 A. 13?
10 Q. YES. I ASKED YOU EARLIER ABOUT I.M. VERSUS I.V. AND
11 YOU'VE JUST TESTIFIED THAT THESE PEOPLE WERE COMBATIVE SO
12 I.M. WAS BETTER. ISN'T IT TRUE THAT ON THE 12TH OF JANUARY
13 AN I.V. WAS STARTED FOR ENNIS ALLDREDGE?
14 A. YES.
15 Q. AND THAT WAS IN ORDER TO GIVE HIM WHAT?
16 A. INTRAVENOUS FLUIDS.
17 Q. SO HE WAS DEHYDRATED APPARENTLY?
18 A. APPARENTLY.
19 Q. AND THEN THE NEXT DAY AT 8 O'CLOCK IN THE MORNING THE
20 I.V. WAS DISCONTINUED AND MORPHINE AND THIS SAYS HALDOL,
21 ATIVAN HERE WAS STARTED EVERY THREE HOURS AROUND-THE-CLOCK
22 I.M.; IS THAT CORRECT?
23 A. THAT'S CORRECT.
24 Q. AND I.V. WAS DISCONTINUED?
25 A. YES.
3519
1 Q. THE HYPOTHETICAL THAT YOU JUST GAVE TO US, NONE OF THESE
2 PATIENTS CAME INTO THIS UNIT TO TREAT ADVANCED TERMINAL
3 CANCER, DID THEY?
4 A. NO.
5 Q. NONE OF THESE PATIENTS CAME IN WITH END-STAGE CHRONIC
6 LUNG DISEASE FOR TREATMENT OF THAT CONDITION, DID THEY?
7 A. NO.
8 MS. BARLOW: NO FURTHER QUESTIONS, YOUR HONOR.
9 THE COURT: ANYTHING FURTHER?
10 MR. STIRBA: NO, YOUR HONOR. THANK YOU. MAY HE BE
11 EXCUSED?
12 MS. BARLOW: YES, YOUR HONOR.