Kerry Cranmer, MD
17 MR. BUGDEN: DR. CRANMER WOULD YOU STEP FORWARD PLEASE.
18 THE COURT: DOCTOR IF YOU'LL COME RIGHT UP HERE PLEASE
19 RAISE YOUR RIGHT HAND AND FACE THE CLERK SHE'LL PLACE YOU
20 UNDER OATH.
21 WOULD YOU STATE YOUR FULL NAME PLEASE AND SPELL YOUR
22 LAST NAME.
23 THE WITNESS: MY NAME IS KERRY CRANMER C-R-A-N AS IN
24 NANCY, M. AS IN MARY, E-R.
25 THE COURT: THANK YOU.
1 BY MR. BUGDEN:
2 Q. DR. CRANMER, I'VE POURED A GLASS OF WATER IF YOU GET DRY
3 DURING YOUR --
4 A. THANK YOU.
5 Q. TALKING. DOCTOR CAN YOU TELL US WHAT DEGREES OF HIGHER
6 EDUCATION THAT YOU HAVE?
7 A. RECEIVED MY MEDICAL DEGREE AT THE UNIVERSITY OF
8 OKLAHOMA. I AM A CERTIFICATED MEDICAL DIRECTOR THROUGH THE
9 AMERICAN MEDICAL DIRECTORS ASSOCIATION. AND I AM BOARD
10 CERTIFIED IN HOSPICE AND PALLIATIVE CARE.
11 Q. WHERE IS IT YOU PRACTICE MEDICINE DR. CRANMER?
12 A. OKLAHOMA CITY, OKLAHOMA.
13 Q. AND DO YOU SERVE ON ANY PROFESSIONAL ORGANIZATIONS
14 DR. CRANMER?
15 A. I DO.
16 Q. CAN YOU TELL US WHAT SOME OF THOSE ARE AND COULD WE STOP
17 FOR A MOMENT AND COULD I ASK YOU TO PUT UP DR. CRANMER'S
18 RESUME PLEASE?
19 A. PROFESSIONAL ORGANIZATIONS THAT I'M ACTIVELY INVOLVED
20 WITH INCLUDE THE AMERICAN MEDICAL DIRECTORS ASSOCIATION.
21 THAT'S THE ASSOCIATION OF LONG TERM CARE PHYSICIANS
22 NATIONWIDE. ABOUT TEN THOUSAND MEMBERS I WOULD SAY. THE
23 AMERICAN MEDICAL DIRECTORS ASSOCIATION PRETTY MUCH REPRESENTS
24 ALL OF THE PHYSICIANS TAKING CARE OF THE FRAIL ELDERLY IN
25 AMERICA. AND I --
1 Q. I'M GONNA INTERRUPT YOU FROM TIME TO TIME
2 A. PLEASE.
3 Q. AND SOMETIMES WE'LL REFER TO YOUR RESUME BUT WE MAY NOT
4 BLOW IT UP NECESSARILY. BEFORE WE TALK ABOUT SOME OF YOUR
5 THE ORGANIZATIONS THAT YOU BELONG TO, CAN YOU -- I'D LIKE YOU
6 TO TELL US WHAT YOU DO ON A DAILY BASIS, WHAT YOU DO IN YOUR
7 PRACTICE IN MEDICINE, DOCTOR AND THEN WE'LL TALK ABOUT THIS A
8 MOMENT.
9 A. I'M A PRACTICING GERIATRICIAN. OUR GROUP HAS LIMITED
10 OUR PRACTICE TO THE CARE OF THE FRAIL ELDERLY. A
11 GERIATRICIAN IS SOMEONE WHO'S TRAINED IN TAKING CARE OF THE
12 ELDERLY. WHAT WE HAVE DONE, WE'VE TAKEN CARE OF THE FRAIL
13 ELDERLY AND WE DO ASSISTED LIVINGS WE DO NURSING HOME CARE,
14 WE DO MEDICAL CONSULTING AT THE HOSPITALS WE DO MEDICAL
15 CONSULTING AT THE GEROPSYCH UNITS. AND WE TAKE CARE OF THE
16 FRAIL ELDERLY IN OKLAHOMA CITY.
17 Q. IN THIS CASE, THE JURY IS FAMILIAR WITH THE NAME DR.
18 DIENHART AND DR. BITNER WHO ARE INTERNISTS AND IN THIS CASE,
19 THEY'VE TESTIFIED AND EXPLAINED FOR EXAMPLE THAT THEY TOOK
20 HISTORIES AND PHYSICALS OF ALL OF THE -- WELL, NOT ELLEN
21 ANDERSON BUT THE OTHER PATIENTS IN THIS CASE. WHEN YOU SAY
22 YOU HAVE A RELATIONSHIP WITH THE GEROPSYCHIATRIC HOSPITAL IN
23 YOUR HOME, ARE YOU DOING SIMILAR THINGS AS DR. DIENHART AND
24 DR. BITNER?
25 A. YES WE ARE THE MEDICAL CONSULTANT FOR I WOULD SAY
1 PROBABLY 70 PERCENT OF THE POPULATION AT THE GEROPSYCH UNIT.
2 Q. AND DR. CRANMER CAN YOU HELP ME TO UNDERSTAND WHEN YOU
3 TALK ABOUT YOUR DAY-TO-DAY MEDICAL EXPERIENCE INVOLVES CARING
4 FOR THE FRAIL AND ELDERLY, WOULD THAT BE PATIENTS LIKE THE
5 FIVE PATIENTS THAT WE'RE TALKING ABOUT IN THIS CASE?
6 A. YES, THESE ARE PATIENTS THAT ARE VERY FRAIL, THEY'RE
7 ELDERLY IF I REMEMBER RIGHT I THINK THE -- MOST OF THESE
8 PATIENTS WERE OVER 90 YEARS OF AGE. AND THE ONES THAT OF
9 COURSE ARE NOT ARE STILL VERY FRAIL AND THAT'S WHY THEY'RE IN
10 THE NURSING FACILITIES. AND THESE ARE THE PATIENTS THAT WE
11 TAKE CARE OF AS OPPOSED TO LET'S SAY A GERIATRICIAN WHO HAS
12 AN OFFICE PRACTICE AND TAKES CARE OF A 65-YEAR-OLD LADY THAT
13 WALKS IN WITH A, YOU KNOW, AND HAS PRIMARY CARE GIVEN TO
14 HER. THERE'S A DIFFERENCE BETWEEN WHAT WE CALL LONG TERM
15 CARE WHICH IS WHAT WE DO AND TYPICAL GERIATRIC PATIENT -- A
16 DR. THAT TAKES CARE OF GERIATRIC PATIENTS.
17 Q. NOW I'M GONNA AGAIN TURN YOUR ATTENTION AND IT'S NOT
18 REALLY -- WE DON'T REALLY HAVE A BLOWUP HERE BUT YOUR RESUME
19 TALKS ABOUT YOUR PROFESSIONAL EXPERIENCE AND I INTERRUPTED
20 YOU AND I ACTUALLY QUITE FRANKLY CONFESS I PROBABLY DIDN'T
21 LISTEN TO WHAT YOU SAID. I WAS LOOKING AT MY PAGES. I DON'T
22 THINK WE -- WE CERTAINLY DON'T WANNA TALK ABOUT ALL OF THE --
23 ALL OF THESE ITEMS BUT I'M GONNA ASK YOU ABOUT A FEW OF THEM.
24 A. OKAY.
25 Q. THE AMERICAN ACADEMY OF HOSPICE AND PALLIATIVE MEDICINE
1 BOARD OF DIRECTORS. WHAT IS THAT ORGANIZATION?
2 A. THAT AMERICAN ACADEMY OF HOSPICE AND PALLIATIVE MEDICINE
3 ARE THE PHYSICIANS IN AMERICA THAT ARE INVOLVED WITH END OF
4 LIFE CARE. AND THIS IS A NATIONAL ORGANIZATION AND I'VE BEEN
5 ON THEIR NATIONAL BOARD OF DIRECTORS NOW AND I'M ACTUALLY
6 INVOLVED IN DEVELOPING A CERTIFICATION FOR HOSPICE MEDICAL
7 DIRECTORS NATIONWIDE TO RAISE THE LEVEL OF EDUCATION AND THE
8 LEVEL OF STANDARD OF TRAINING, AND SO I'VE BEEN INVOLVED WITH
9 THAT ORGANIZATION, A VERY ACTIVE ORGANIZATION AND PRETTY WELL
10 REPRESENTED ACROSS THE UNITED STATES.
11 Q. ANOTHER QUESTION I MEANT TO ASK YOU BEFORE WE TALK ABOUT
12 YOUR RESUME DOCTOR, DO YOU -- DO YOU TEACH DOCTORS HOW TO
13 CARE FOR THE FRAIL AND ELDERLY POPULATION?
14 A. YES I DO.
15 Q. AND IN YOUR TREATMENT OF THE FRAIL AND ELDERLY
16 POPULATION, DO YOU DEAL WITH DEMENTED PATIENTS VERY OFTEN
17 DOCTOR?
18 A. OH, DEFINITELY.
19 Q. OKAY. I SEE THAT YOU'RE THE TREASURER OF THE AMERICAN
20 MEDICAL DIRECTORS ASSOCIATION FROM MARCH I GUESS PRESENTLY.
21 WHAT IS THE AMERICAN MEDICAL DIRECTORS ASSOCIATION?
22 A. THAT WAS WHAT I WAS DESCRIBING AS THE REPRESENTATIVE
23 ORGANIZATION OF ALL LONG TERM CARE PHYSICIANS NATIONWIDE.
24 IT'S ABOUT TEN THOUSAND MEMBERS. THEY'RE AN ADVISORY GROUP
25 TO HCFA. THEY BASICALLY ARE -- SORRY C.M.S.
1 Q. WHAT'S HCFA?
2 A. THAT IS MEDICARE. HCFA USED TO STAND FOR HEALT CARE --
3 LET'S SEE, I DON'T REMEMBER. HEALTH CARE FINANCE
4 ADMINISTRATION. ANYWAY, THE -- IT'S NOW CALLED C.M.S. CENTER
5 FOR MEDICARE AND MEDICAID SERVICES I BELIEVE. AND THEY
6 ARE -- WE'VE BEEN AN ADVISORY GROUP FOR THEM. WE'VE -- ARE
7 ACTIVE WITH THE AMERICAN MEDICAL ASSOCIATION. ANYTHING
8 INVOLVING LONG TERM CARE WE USUALLY RECOMMEND TO THEM TO THE
9 HOUSE DELEGATES. WE -- AND FORTUNATELY I'VE BEEN INVOLVED IN
10 THEM AND CURRENTLY ON THE BOARD OF DIRECTORS AND EXECUTIVE
11 COMMITTEE.
12 Q. DR. CRANMER YOU ALSO ARE ON -- ARE WITH THE AMERICAN
13 MEDICAL DIRECTORS ASSOCIATION COMMITTEE. THE CLINICAL
14 PRACTICE GUIDELINES FOR CHRONIC PAIN MANAGEMENT, WHAT DOES IT
15 MEAN TO BE ON A COMMITTEE THAT'S INVOLVED IN THE CLINICAL
16 GUIDELINES, CLINICAL PRACTICE GUIDELINES, WHAT DOES THAT
17 MEAN?
18 A. IN 1998, WE DECIDED THAT WE NEEDED TO ESTABLISH SOME
19 STANDARDS OF CARE ON PAIN MANAGEMENT WITH THE FRAIL ELDERLY
20 AND WE CAME UP WITH SOME GUIDELINES. I HAVE A COPY OF THAT
21 WITH ME, BUT BASICALLY WE CAME UP WITH SOME GUIDELINES
22 THROUGH THE AMERICAN MEDICAL DIRECTORS ASSOCIATION, THE
23 CLINICAL PRACTICE GUIDELINES THAT WE'VE PERFORMED THAT WE
24 PROBABLY HAVE ABOUT 14 OF THOSE NOW THAT'S PRETTY HIGHLY
25 ACCEPTED. THIS PARTICULAR ONE, I THINK THEY'VE SOLD ABOUT
1 450,000 OF THESE NATIONWIDE SO --
2 Q. LET MAKE SURE --
3 A. -- IT'S BEEN VERY SUCCESSFUL.
4 Q. -- I'M UNDERSTANDING WHAT IT MEANS TO BE CREATING
5 GUIDELINES. ONE OF THE ISSUES THAT WE'RE GONNA BE TALKING
6 ABOUT A LITTLE BIT LATER IN YOUR TESTIMONY IS THE STANDARD OF
7 CARE AND WHETHER OR NOT DR. WEITZEL HIS CARE OR HIS MEDICAL
8 TREATMENT OF THE PATIENT, THE FIVE PATIENTS IN THIS CASE MET
9 THE STANDARD OF CARE OR FELL BELOW THE STANDARD CARE,
10 DEVIATED FROM THE STANDARD OF CARE. WITH REGARD TO THIS
11 ORGANIZATION THEN WHEN YOU'RE CREATING THE CLINICAL PRACTICE
12 GUIDELINES, DOES THAT MEAN THAT YOU ON A NATIONAL LEVEL ARE
13 ONE OF THE PEOPLE THAT HAVE HELPED TO PROMULGATE OR TO
14 WRITE --
15 MR. WILSON: YOUR HONOR, I'M GONNA OBJECT. IT'S
16 LEADING.
17 THE COURT: IT IS.
18 MR. BUGDEN: CAN YOU TELL ME WHAT IT MEANS -- I'M
19 SORRY --
20 A. LET ME JUST -- LET ME JUST STATE --
21 MR. BUGDEN: THERE'S NO QUESTION BEFORE YOU. YOU NEED
22 TO LET ME ASK YOU THE QUESTION.
23 A. SURE.
24 Q. I JUST NEED TO THINK OF A QUESTION. WELL, WHAT DOES IT
25 MEAN TO BE ON THAT COMMITTEE, WHAT IS IT THAT YOU DO ON THAT
1 COMMITTEE, WHAT HAVE YOU DONE?
2 A. IN 1998, THERE REALLY WERE NO STANDARDS ON PAIN
3 MANAGEMENT IN THE FRAIL ELDERLY. ACTUALLY THERE WERE THREE
4 DIFFERENT DOCUMENTS THAT PRETTY WELL CAME OUT. I WAS
5 FORTUNATE ENOUGH TO WORK WITH THE PHILADELPHIA COLLEGE OF
6 PHARMACY. WE WERE TAKING A LOOK AT -- SHOULD BE ON THAT --
7 Q. IS IT ON THIS RESUME HERE?
8 A. SHOULD BE, YES. AND WE WERE ACTUALLY LOOKING AT -- THAT
9 WAS OUR FIRST ATTEMPT IN LOOKING AT THE FRAIL ELDERLY AND
10 ESPECIALLY IN LONG TERM CARE ENVIRONMENT. AND WE CAME UP
11 WITH SOME GUIDELINES AND SOME ISSUES. THERE WAS ANOTHER
12 ORGANIZATION THAT I'M INVOLVED WITH CALLED THE AMERICAN
13 GERIATRIC SOCIETY, AND THEY PUBLISHED SOME GUIDELINES ON THE
14 FRAIL ELDERLY IN 1998, I BELIEVE, AND THIS WORK THAT WE WERE
15 DOING AT THAT SAME TIME PRIOR TO THEIR PUBLILCATION, AFTER WE
16 FINISHED OUR WORK, THEIR'S WAS PUBLISHED AND THEN OURS WAS
17 PUBLISHED SHORTLY LATER IN 1999 AND WE WERE TRYING TO
18 ESTABLISH THOSE STANDARDS OF PAIN MANAGEMENT IN THE EARLY AND
19 TRYING TO ESTABLISH SOME COMFORT AND DIGNITY FOR THOSE
20 PATIENTS.
21 Q. IF A PRACTITIONER WAS TRYING TO UNDERSTAND WHAT THE
22 STANDARD OF CARE WAS FOR TREATMENT OF THE FRAIL ELDERLY IN
23 END OF LIFE SITUATIONS, WOULD THESE BE THE KIND OF DOCUMENTS
24 THAT A DOCTOR WOULD LOOK TO FOR GUIDANCE ON WHAT THE STANDARD
25 WAS?
1 A. YES, SIR.
2 Q. WE CAN TURN OFF THE PROJECTOR FOR A MOMENT.
3 DR. CRANMER, DO YOU ALSO PARTICIPATE OR WERE YOU A DELEGATE
4 TO A WHITE HOUSE CONFERENCE ON AGING IN 1995?
5 A. ONCE EVERY DECADE, THIS WAS THE FOURTH YEAR, FOURTH TIME
6 THEY'D ACTUALLY HAD THAT. ONCE EVERY DECADE THEY HAVE A
7 MEETING AT THE -- IT'S CALLED THE WHITE HOUSE CONFERENCE ON
8 AGING. GOVERNOR KEATING OF OKLAHOMA HAD SELECTED ME AS HIS
9 DELEGATE AND I REPRESENTED HIM AT THAT -- AT THAT CONFERENCE
10 AND WE'RE PROBABLY LOOKING AT ANOTHER ONE HERE IN ANOTHER
11 THREE YEARS.
12 Q. AND THAT WAS IN 1995, IS THAT RIGHT?
13 A. THAT IS CORRECT.
14 Q. OF COURSE WE'RE GONNA BE TALKING ABOUT STANDARDS OF CARE
15 IN 1995, 1996. DO YOU BELIEVE THAT YOU WERE FAMILIAR WITH
16 THE STANDARDS OF CARE IN 1995, 1996?
17 A. SURE.
18 Q. YOU'VE PUBLISHED NUMEROUS ARTICLES. COULD WE TURN TO
19 PUBLICATIONS? I GUESS I'M GONNA HAVE TO TURN IT BACK ON
20 PLEASE THAT'S ALSO PART OF THE RESUME. HOW MANY ARTICLES DO
21 YOU THINK YOU'VE WRITTEN DEALING IN THE AREA GENERAL SPEAKING
22 OF PAIN MANAGEMENT?
23 A. I'M NOT SURE. PROBABLY TEN. TEN ARTICLES POSSIBLY.
24 Q. AND COULD YOU GO TO THE PAPER FOR PUBLICATIONS PLEASE?
25 ARE WE THERE?
1 MS. ISAACSON: I THINK SO.
2 Q. (BY MR. BUGDEN) THERE WE GO. THAT'S WHAT -- WHERE I'D
3 LIKE TO BE. THANK YOU. I NOTICE, DR. CRANMER, THAT ONE OF
4 THE PUBLICATIONS HAD TO DO WITH, DR. CRANMER, PHYSICIAN
5 ASSISTED SUICIDE PANEL DISCUSSION. WHAT POSITION DID YOU
6 TAKE AT THE PANEL DISCUSSION?
7 A. THAT WAS AT A NATIONAL MEETING OF ABOUT 2,000 PHYSICIANS
8 IN 197. I WAS OPPOSED TO A PHYSICIAN ASSISTED SUICIDE
9 BASICALLY STIPULATING THAT I DID NOT FEEL THAT PHYSICIAN
10 ASSISTED SUICIDE WAS A VALID PHYSICIAN POSITION FOR --
11 MR. WILSON: OBJECT, YOUR HONOR. I'M GOING TO OBJECT AS
12 TO THE RELEVANCE OF THIS LINE OF QUESTIONING.
13 THE COURT: WHAT IS THE RELEVANCY, MR. BUGDEN?
14 MR. BUGDEN: WELL, IT'S ONE OF THE -- ONE OF HIS
15 PUBLICATIONS AND I THINK IT IS IMPORTANT FOR THE JURY TO
16 UNDERSTAND WHAT THIS MAN'S POSITION IS AND THAT HE'S AGAINST
17 IT THIS CONCEPT THAT HAS BEEN MENTIONED TO THE JURY OR
18 THAT -- NOT EXACTLY THAT CONCEPT, BUT MENTIONED BY THE STATE
19 IN IN OPENING STATEMENT.
20 THE COURT: WELL, CERTAINLY, THAT IS ONE OF THE THEORIES
21 THE STATE IS PURSUING. THE COURT WILL OVERRULE THE
22 OBJECTION, BUT I THINK WE'VE HEARD ENOUGH ABOUT THAT --
23 MR. BUGDEN: I'LL MOVE ON DOCTOR --
24 THE COURT: THANK YOU.
25 MR. BUGDEN: -- OR THANK YOU, JUDGE. I'M SORRY.
1 Q. (BY MR. BUGDEN) COULD WE TURN TO THE NEXT PAGE OF
2 PUBLICATIONS? DR. CRANMER, CAN YOU TELL ME ABOUT THIS
3 ARTICLE, INDICATION THAT YOU HAD, END OF LIFE
4 DECISION-MAKING, MYTHS VERSUS OPTIONS. THAT WAS PUBLISHED IN
5 THE JOURNAL OF AMERICAN MEDICAL DIRECTORS ASSOCIATION.
6 A. YEAH, WE WERE DISCUSSING THE ISSUES OF DYING IN AMERICA
7 AND BASICALLY --
8 MR. WILSON: YOUR HONOR, I'M THINK I'M GOING TO
9 INTERPOSE ANOTHER OBJECTION AGAIN ON THE BASIS OF RELEVANCY.
10 I RECOGNIZE THAT -- WE'LL BE MORE THAN WILLING TO STIPULATE
11 AS TO CREDENTIALS OF DR. CRANMER BUT THIS LINE OF QUESTIONING
12 IS GOING ON AND ON INTO AREAS THAT I DON'T KNOW AS EVEN HAVE
13 RELEVANCY TO THESE PARTICULAR FACT CIRCUMSTANCES.
14 THE COURT: WHERE ARE GOING, MR. BUGDEN?
15 MR. BUGDEN: I BELIEVE THAT I'M ENTITLED TO DEMONSTRATE
16 TO THE JURY DR. CRANMER'S EXPERTISE AND ALLOW THE JURY AND
17 ASSIST THE JURY AS TO WHETHER OR NOT THIS DOCTOR
18 HAS MORE EXPERTISE IN THE AREA OF PAIN MANAGEMENT AND END OF
19 LIFE CARE IN A DEMENTED PATIENTS THAN SOME OF THE STATE'S
20 EXPERTS.
21 THE COURT: YOU'RE WELCOME TO DO THAT, BUT LIMIT IT TO
22 THAT --
23 MR. BUGDEN: I HAVE.
24 THE COURT: -- AND MOVE ALONG. GO AHEAD.
25 MR. BUGDEN: JUST TWO PUBLICATIONS I WANTED TO ASK HIM
1 ABOUT AND I WILL MOVE, JUDGE.
2 Q. SO WHAT WERE YOU DISCUSSING IN THAT ARTICLE, JUST
3 GENERALLY SPEAKING PLEASE, A THUMBNAIL?
4 A. SURE. A THUMBNAIL IS THAT WE WERE DISCUSSING HOW WE
5 NEED TO PROVIDE COMFORT AND DIGNITY AND THAT WE WERE TRYING
6 TO REDEFINE WHAT GOOD MEDICAL CARE WAS IN THESE TYPE OF
7 PATIENTS. WE HAVE THE ALL -- I'M SORRY.
8 Q. THAT'S ENOUGH. AND LET ME ASK YOU ABOUT THIS PAPER THAT
9 YOU WROTE, PAIN MANAGEMENT IN GERIATRIC PATIENT. PAIN
10 MANAGEMENT FOR CLINICIANS. WHAT WAS THAT ABOUT, THUMBNAIL?
11 A. THAT IS A CHAPTER OF A TEXTBOOK THAT WE'RE WRITING
12 REGARDING PAIN MANAGEMENT FOR THE ELDERLY PATIENTS.
13 Q. AND THIS IS GONNA BE A TEXTBOOK WRIITTEN BY ART LIPMAN?
14 A. CORRECT.
15 Q. FROM THE UNIVERSITY OF UTAH?
16 A. THAT IS CORRECT.
17 Q. YOU'VE GONNA HAVE A CHAPTER IN HIS BOOK?
18 A. THAT IS CORRECT.
19 Q. DOCTOR -- AND WE'RE DONE WITH THAT. THANK YOU.
20 DR. CRANMER CAN YOU TELL ME, ARE THERE DIFFERENT KINDS OF
21 DEMENTIA?
22 A. MOST DEFINITELY.
23 Q. AND DR. CRANMER CAN YOU EXPLAIN TO US IS THERE A -- WHAT
24 I WILL CALL A BEGINNING, A MIDDLE, AND END TO THE DISEASE OF
25 DEMENTIA?
1 A. TO CLARIFY YOUR FIRST STATEMENT, THERE ARE SEVERAL
2 DIFFERENT CAUSES OF DEMENTIA. ALL OF THE CAUSES OF DEMENTIA
3 HAVE DIFFERENT STAGES THAT THEY GO THROUGH. ACTUALLY, THE
4 ORIGINAL WORK PROBABLY DONE BY BARRY REISBERG STATED THAT
5 THERE'S ACTUALLY SEVEN STAGES OF DEMENTIA, 7TH STAGE BEING
6 TERMINAL OF COURSE. AND AS THE BRAIN CONTINUES TO SHRINK
7 WITH THE DEMENTED PROCESS NO MATTER WHAT'S CAUSING THE
8 DEMENTIA, WHETHER IT'S ALZHEIMER'S TYPE DEMENTIA, WHETHER
9 IT'S LITTLE TINY STROKES, WHAT WE CALL VASCULAR DEMENTIA, NO
10 MATTER WHAT'S CAUSING THE DEMENTIA, THE BRAIN CONTINUES TO
11 SHRINK AND WILL EVENTUALLY LEAD TO DEATH AND WE CALL THAT
12 STAGE SEVEN.
13 Q. IS DEMENTIA AN TERMINAL DISEASE?
14 A. OH, YES .
15 Q. PROGRESSIVE DISEASE?
16 A. PROGRESSIVE AND DEPENDING ON WHICH TYPE OF DEMENTIA THEY
17 HAVE, IT CAN BE VERY INSIDIOUS.
18 Q. DO YOU HAVE AN OPINION TO A DEGREE OF REASONABLE MEDICAL
19 CERTAINTY WHETHER OR NOT THE FIVE PATIENTS THAT WE'LL BE
20 TALKING ABOUT THIS MORNING, WHETHER OR NOT THEY SUFFERED FROM
21 DEMENTIA?
22 A. YES THEY DID.
23 Q. IS THERE A SYSTEM THAT YOU PHYSICIANS, GERIATRICIANS THAT
24 DEAL WITH THE FRAIL AND THE ELDERLY, IS THERE A SYSTEM THAT
25 CLASSIFIES THESE DIFFERENT STAGES OF DEMENTIA THEN?
1 A. I THINK ONE OF THE MOST ACCEPTED CLASSIFICATION SCALES
2 THAT WE'VE USED, ESPECIALLY FOR END OF LIFE PURPOSES HAS BEEN
3 WHAT WE CALL THE FAST SCALE, WHICH WAS DEVELOPED BY BARRY
4 REISBERG. THAT'S THE FUNCTIONAL ASSESSMENTS STAGING TOOL.
5 THE FUNCTIONAL ASSESSMENT STAGING TOOL LOOKS AT HOW A PATIENT
6 IS ABLE TO FUNCTION --
7 Q. HOLD ON JUST A SECOND.
8 A. I'M SORRY.
9 Q. COULD WE SEE THE NEXT SLIDE PLEASE? IS THIS WHAT YOU'RE
10 TALKING ABOUT?
11 A. YEAH, THAT'S THE DESCRIPTION. NOW THERE'S A LINEAR
12 GRAPH I THINK.
13 Q. LET'S LOOK AT THE GRAPH. WE'LL GO TO THE NEXT SLIDE.
14 A. YEAH. THAT'S IT.
15 Q. CAN YOU SEE IT ALL RIGHT FROM WHERE YOU ARE?
16 A. YES, I CAN.
17 Q. ALL RIGHT. CAN YOU EXPLAIN FROM THE CONTEXT OF MY
18 QUESTION, YOU KNOW, HOW YOU CLASSIFY THE DIFFERENT STAGES AND
19 HOW CLINICIANS LIKE YOURSELF WOULD USE THIS SCALE?
20 A. CAN I --
21 Q. YOU CAN STEP DOWN.
22 A. -- STAND? THIS IS A -- THIS IS THE SEVENTH STAGE THAT
23 WE WERE TALKING ABOUT. AND AT STAGE SEVEN C., THAT'S USUALLY
24 THE POINT OF DEATH. STAGE SEVEN A. WE HAVE OUR DESCRIPTORS
25 WE'LL SHOW YOU -- THIS UP A WHILE AGO. USUALLY MY PATIENTS
1 ARE PAST MASTERS. AND WE DON'T REALLY DETERMINE THEIR DEMENTIA
2 STATUS UNTIL USUALLY AROUND STAGE THREE. WHEN I SAY THEY'RE
3 PAST MASTER'S, I ASK 'EM WHO THE PRESIDENT IS, AND THEY'LL
4 SAY, WELL, I DIDN'T VOTE FOR HIM SO IT DOESN'T MATTER, OR
5 THEY'LL SAY, YOU KNOW, WHATEVER TO TRY TO KEEP FROM ANSWERING
6 THE QUESTIONS AND SOMETIMES IT'S HARD TO EVALUATE IN EARLY
7 DEMENTIA. SO STAGE THREE THROUGH FOUR IS WHAT HE'S DEVELOPED
8 THIS GRAPH BY. THIS IS THE FULSTEIN MINI MENTAL STATUS EXAM
9 SO MY NEXT STATEMENT WAS TO TELL YOU THAT THE FULSTEIN MINI
10 MENTAL STATUS TEST HAS KIND OF BEEN A SCORE IN DETERMINING A
11 PATIENT'S MENTAL ACUITY, AND THAT'S ON THAT LINE SHOWING YOU
12 WHERE THEIR FULSTEIN MINI MENTAL STATUS TEST IS. SO WE ASK
13 THOSE QUESTIONS. WE ASK THE QUESTIONS OF DO YOU KNOW WHO THE
14 PRESIDENT IS, DO YOU KNOW WHAT MONTH THIS IS, DO YOU KNOW
15 WHAT DAY THIS IS, DO YOU KNOW WHAT YEAR THIS IS, WHAT SEASON
16 THIS IS. THERE'S 30 DIFFERENT POINTS THAT YOU CAN HAVE AND
17 SO --
18 Q. COULD WE GO TO THE VERBAL DESCRIPTION NOW THE LAST SLIDE
19 AND WITH THIS FAST, THE FUNCTIONAL ASSESSMENT STAGING, AM I
20 CORRECT THAT THIS IS SORT OF AN OBJECTIVE DETERMINER OR AN
21 OBJECTIVE CRITERIA FOR YOU DOCTORS TO TRY TO PINPOINT OR AT
22 LEAST APPROXIMATE THE LEVEL OF DEMENTIA THAT SOMEONE MIGHT
23 SUFFER?
24 A. CORRECT. THIS IS A -- WAS A WHOLE DIFFERENT APPROACH.
25 IT WAS PUBLISHED MANY YEARS AGO AND WE UTILIZE IT BECAUSE IT
1 LOOKS STRICTLY AT THEIR FUNCTIONAL ABILITY. IT LOOKS AT
2 HOW -- WHAT THEY'RE ABLE TO DO. FOR INSTANCE, IF YOU'LL GO
3 DOWN TO SIX, LET'S GO DOWN LEVEL SIX. LEVEL 6-D, IF THEY
4 HAVE URINARY INCONTINENCE IN SIX E. IF THEY HAVE FECAL
5 INCONTINENCE, THAT'S WHAT QUALIFIES THEM BASED ON THEIR
6 FUNCTION AND SO WE CAN DETERMINE JUST ON HOW THEY'RE
7 FUNCTIONING AT WHAT LEVEL OF DEMENTIA THEY'RE USUALLY IN.
8 NOW IF YOU GO BACK TO THE GRAPH, YOU'LL SEE THAT STAGE SIX --
9 Q. SIX D.?
10 A. 6 D. AND E. RIGHT IS RIGHT THERE AND STAGE 7-A IS WHEN
11 THEY IN MEANINGFUL CONVERSATION OF ABOUT FIVE, TEN MINUTES,
12 THAT THEY CAN ONLY SPEAK ONE WORD IN THAT CONVERSATION.
13 STATE SEVEN -- I'M SORRY, SIX WORDS IN THAT CONVERSATION.
14 STAGE SEVEN B. WOULD ONE WORD. STAGE SEVEN C. AT THE POINT
15 OF DEATH THEY NEED HELP TO BE ABLE TO GET UP OR TO BE ABLE TO
16 STAND.
17 Q. DOCTOR DO YOU HAVE AN OPINION TO A DEGREE OF REASONABLE
18 MEDICAL CERTAINTY ABOUT WHAT STAGE OF DEMENTIA THE FIVE
19 PATIENTS HAD REACHED IN THIS CASE?
20 A. RIGHT. I THINK THAT ALL OF THEM WITHOUT A DOUBT ARE ALL
21 IN THE EXTREME PHASES, THE END STAGE OF THEIR DEMENTIA
22 PROCESS. AS FAR AS BEING ABLE TO TELL YOU EACH PATIENT, WE
23 WOULD NEED TO SHOW YOU EXACTLY WHAT THEIR FUNCTIONAL STAGE
24 WAS. MOST OF THEM WERE INCONTINENT OF BOTH BOWEL AND BLADDER
25 AND MOST OF THEM WERE LIMITED IN THEIR COMMUNICATION.
1 Q. OKAY. CAN YOU TELL THE JURY PLEASE HOW A PATIENT WITH
2 DEMENTIA TYPICALLY DIES? TELL US ABOUT THE DEMISE OF THE
3 DEMENTED PATIENT?
4 A. WELL --
5 MR. WILSON: YOUR HONOR, I'M GOING TO OBJECT. I THINK
6 IF HE WANTS TO RELATE IT SPECIFICALLY TO THESE PATIENTS, BUT
7 TO GENERALLY CATEGORIZE HOW A PATIENT WITH DEMENTIA TYPICALLY
8 DIES I DON'T THINK REALLY HAS RELEVANCY UNLESS HE CAN RELATE
9 IT TO THESE PATIENTS.
10 THE COURT: OVERRULE THE OBJECTION. THE JURY HAS A
11 RIGHT TO MAYBE KNOW THAT. GO AHEAD.
12 THE WITNESS: MOST OF THE TIME OUR PATIENTS DIE FROM
13 CO-MORBID CONDITIONS. IN OTHER WORDS --
14 Q. WHAT DOES THAT MEAN?
15 A. CO-EXISTING MEDICAL CONDITIONS. IF THEY HAVE DEMENTIA
16 TO THIS STATE, THEY USUALLY HAVE MULTIPLE OTHER DISEASE
17 PROCESSES AS WELL. MULTIPLE ORGANS THAT ARE FAILING. NOT
18 JUST THE BRAIN, BUT ALSO OTHER ORGANS. AS FAR AS A TYPICAL
19 CAUSE OF DEATH IN THESE PATIENTS, USUALLY IT'S ASSOCIATED
20 WITH ONE OF THESE FAILURES OF ONE OF THESE OTHER ORGANS. IF
21 HOWEVER THE THESE PATIENTS DO NOT HAVE HEART DISEASE LUNG
22 DISEASE KIDNEY DISEASE, STROKE, SOME OTHER FORM OF DISEASE
23 PROCESS THAT CAUSES THEIR DEATH, WHAT HAPPENS IS AS THE BRAIN
24 CONTINUES TO SHRINK, THEY LOSE THE ABILITY TO CONTROL THE
25 MUSCLES IN THEIR SWALLOWING MECHANISM WHICH IS WHAT WE CALL
1 DYSPHASIA, AN INABILITY TO SWALLOW CORRECTLY. AND SO WHAT
2 HAPPENS IS IS EVERY TIME THEY SWALLOW, PARTS OF IT GOES TO
3 THE LUNGS AND PARTS OF IT GOES TO THE STOMACH AND IF IT WAS
4 YOU OR ME WE WOULD BE CHOKING AND COUGHING, BUT THEY DON'T
5 HAVE THAT GAG REFLEX BECAUSE OF THE SHRINKAGE OF THE
6 BRAIN. AS THE BRAIN CONTINUES TO SHRINK, THEY LOSE THE GAG
7 REFLEX, THEY LOSE THE MUSCLES THAT HELP THEM SWALLOW. AND
8 MOST COMMONLY, THEY HAVE RECURRENT ASPIRATION PNEUMONIA. AND
9 THAT RECURRENT ASPIRATION IS USUALLY THE CAUSE OF DEATH.
10 INTERESTINGLY ENOUGH, SIR WILLIAM OSTLER WHO'S BASICALLY THE
11 FATHER OF MODERN MEDICINE, IN 1900 IN HIS FAMOUS TEXTBOOKS, IN
12 THE FIRST THREE EDITIONS STATED THAT PNEUMONIA WAS PROBABLY
13 THE ELDERLY'S WORST ENEMY. AFTER THE THIRD EDITION HE
14 CHANGED IT TO HIS FAMOUS QUOTE: THAT PNEUMONIA IS THE OLD
15 MAN'S BEST FRIEND.
16 Q. WHAT DID HE MEAN BY THAT? OLD MAN'S BEST FRIEND IF IT
17 CAUSES DEATH ?
18 A. THAT'S USUALLY A VERY, A MORE PEACEFUL, LESS PAINFUL
19 METHOD OF ACTUALLY DYING. AND I MIGHT ADD, HE DIED OF LUNG
20 DISEASE TOO .
21 Q. DR. CRANMER, THE JURY HAS HEARD SOME TESTIMONY FROM SOME
22 FAMILY MEMBERS OR I THINK I'M BASICALLY RIGHT, THAT THE
23 FAMILIES OFTEN PERCEIVED THAT THEIR LOVED ONE HAD SOME MENTAL
24 FUNCTIONING PROBLEMS, CONFUSION OR AGITATION, BUT THAT
25 OTHERWISE, THEY WERE HEALTHY. OTHERWISE, THEY WERE FIT AS A
1 FIDDLE. FIT AS A FIDDLE AS A 91 OR A 93 YEAR OLD MIGHT BE.
2 BUT WHEN YOU'RE SUFFERING FROM DEMENTIA AND YOU HAVE THIS
3 SHRINKAGE OF THE BRAIN, DOES THAT ONLY AFFECT YOUR COGNITIVE
4 FUNCTIONING OR DOES THE SHRINKAGE OF THE BRAIN CAUSED BY
5 DEMENTIA AFFECT ORGAN SYSTEMS AND THE GENERAL PHYSICAL HEALTH
6 OF THE PATIENT AS WELL?
7 A. WELL, I THINK IT'S PRETTY SAFE TO SAY THAT ANYBODY THAT
8 HAS DETERIORATION MENTALLY IS GOING TO HAVE A LOT OF OTHER
9 PROBLEMS ASSOCIATED WITH THAT. I THINK THAT ONCE AGAIN YOU
10 KNOW IF YOU'RE LOOKING AT THE DIFFERENT CAUSES OF DEMENTIA,
11 VASCULAR DEMENTIA WHICH IS THE SECOND MOST COMMON CAUSE OF
12 DEMENTIA ARE LITTLE TINY STROKES. I MEAN WE HAVE PATIENTS
13 THAT ARE HAVING STROKES AND LIKE I SAY, SOME OF THESE
14 DEMENTIAS CAN BE MORE SOME INSIDIOUS THAN OTHERS AND SO IF
15 YOU SUDDENLY INSTEAD OF HAVING A SMALL STROKE HAVE A MAJOR
16 STROKE, THEN THAT'S GOING TO HAVE A LOT OF EFFECT ON OUR SYSTEM.
17 BUT, YEAH THERE'S A LOT OF INTERRELATIONSHIP.
18 Q. DR. CRANMER, AS DEMENTIA PROGRESSES, HOW DO YOU OR HOW
19 DOES SOMEONE WHO TREATS THE FRAIL ELDERLY PATIENT, HOW DO YOU
20 TREAT THAT PATIENT? IS THERE A TRANSITION IN THE MEDICAL
21 TREATMENT GOAL?
22 A. WELL, I THINK THIS IS WHAT WE WERE TRYING TO DO BACK IN
23 THE LATE 90S IN 97, 98 99 IS WE WERE TRYING TO REDEFINE WHAT
24 GOOD MEDICAL CARE WAS. YOU KNOW, I THINK ALL OF US WOULD
25 AGREE THAT GOOD MEDICAL CARE WOULD BE RESUSCITATION FOR
1 INSTANCE AND YET ONE OF THE ARTICLES THAT WAS PUBLISHED BACK
2 IN 1990 BASICALLY STIPULATED THAT IN BALTIMORE REGION I
3 BELIEVE IT WAS, 115 PATIENTS THAT WERE IN NURSING HOMES THAT
4 HAD C.P.R. HAD RESUSCITATION WERE BROUGHT TO THE EMERGENCY
5 ROOM. 102 ARRIVED D.O.A. ANOTHER 11, YOU KNOW, SURVIVED
6 AN AVERAGE OF FIVE DAYS. TWO WENT UP TO TWO WEEKS WITH
7 BROKEN RIBS AND THE VENTILATOR. THEY ALL DIED, MOST OF THEM
8 WITH A LOT OF PAIN AND SUFFERING. AND SO IT KIND OF SHOCKED
9 US BECAUSE ALL OF THE SUDDEN WE WERE HAVING TO LOOK AT WHAT
10 IS GOOD MEDICAL CARE AND WHAT IS THE DIFFERENCE BETWEEN THE
11 ALL AMERICAN ACUTE CARE SYSTEM THAT WE HAD ESTABLISHED ALL OF
12 THESE YEARS AND ALL OF THE SUDDEN WHAT WE WOULD CALL
13 PALLIATIVE CARE IN PROVIDING COMFORT AND DIGNITY FOR A
14 PATIENT WHEN WE CAN'T CORRECT THE PROBLEMS. OUR ALL AMERICA
15 ACUTE CARE SYSTEM IS IF IT'S BROKEN, WE'RE GONNA FIX IT. BUT
16 WHAT IF IT’S WORN OUT AND IT CAN'T BE FIXED? AND SO WE HAD
17 TO LOOK AT WHAT WE HAVE TO DO TO MAINTAIN COMFORT AND DIGNITY
18 IN THOSE PATIENTS.
19 Q. IS IT COMMON FOR A DEMENTED PATIENT TO EXPERIENCE PAIN
20 DR. CRANMER?
21 A. OH, YES.
22 Q. HOW DO YOU -- HOW DOES A CLINICIAN IDENTIFY PAIN IN THE
23 DEMENTED PATIENT? THE PATIENT THAT -- LET'S JUST FOR THIS --
24 THIS QUESTION ASSUME THAT IT'S A PATIENT THAT CAN'T SELF
25 REPORT PAIN. HOW DO YOU AS THE CLINICIAN IDENTIFY OR
1 RECOGNIZE PAIN?
2 A. THAT'S A VERY GOOD QUESTION AND THAT'S SOMETHING THAT
3 BEEN RESEARCHED QUITE A BIT. AND IN THE LATE 90S, PROBABLY
4 98, 99, THERE WERE SOME EXCELLENT ARTICLES THAT WERE FINALLY
5 PUBLISHED THAT UTILIZED THESE GUIDELINES THAT WE
6 WERE TALKING ABOUT IN DETERMINING PAIN IN PEOPLE THAT HAD
7 COMMUNICATION AND/OR MENTAL DIFFICULTIES. PROBABLY THE BEST
8 ARTICLE THAT WAS PUBLISHED WAS THIS ONE. GASTON-JOHNSON
9 PUBLISHED THE ARTICLE I BELIEVE IT WAS IN 1996, STATING THAT
10 THE BEST WAY TO DETERMINE PAIN IN THE NONCOMMUNICATIVE OR THE
11 DEMENTED PATIENT WAS BY THESE METHODS. FACIAL EXPRESSION,
12 IMMOBILIZATON OF BODY PARTS, PURPOSEFUL MOVEMENTS --
13 THE COURT: SLOW DOWN PLEASE DOCTOR.
14 THE WITNESS: I'M SORRY. I WAS JUST READING THOSE.
15 THE COURT: GO SLOW --
16 MR. BUGDEN: GO A LITTLE BIT SLOWER.
17 A. PROTECTIVE MOVEMENTS. I HAD A PATIENT -- SINCE YOU
18 ASKED I'LL -- I'LL TELL YOU ABOUT ONE OF MY EXPERIENCES I
19 HAD --
20 MR. WILSON: YOUR HONOR, I THINK THAT'S NONRESPONSIVE.
21 MR. BUGDEN: I'LL ASK A QUESTION --
22 THE COURT: IT IS.
23 MR. BUGDEN: -- HAVE YOU EVER HAD A PATIENT WITH -- THAT
24 DEMONSTRATED A PROTECTIVE MOVEMENT?
25 A. I WAS AT A NURSING FACILITY, I WAS WRITING ON A CHART, I
1 HAD A PATIENT, RALPH, WHO WAS SITTING IN A WHEELCHAIR AND
2 EVERY TIME SOMEBODY WALKED BY, YOU KNOW, RALPH WOULD PULL HIS
3 LEG BACK. AND SO I WENT OVER AND I SAID RALPH IS YOUR LEG
4 HURTING YOU AND HE SAYS NO. AND I SAID WELL EVERY TIME
5 SOMEBODY WALKS PAST YOU YOU KEEP PULLING YOUR LEG BACK. HE
6 SAYS, WELL, I'M AFRAID SOMEONE'S GONNA HIT IT. AND I SAID,
7 WELL, WHEN THEY HIT IT DOES IT HURT. AND HE GOES, OH, YEAH.
8 AND I SAID, WELL, HOW OFTEN DO THEY HIT IT AND HE SAID,
9 WELL, EVERY TIME I GO TO THE DINING ROOM THEY HIT -- HIT IT
10 ON THE DINING ROOM TABLE. AND I SAID, WELL, THAT MUST HURT A
11 LOT. WHY DON'T YOU LET ME GIVE YOU SOMETHING FOR THE PAIN.
12 I'LL TALK TO 'EM ABOUT NOT HITTING YOUR KNEE. TWO WEEKS
13 LATER, I WAS JUST HAPPENED TO NOTICE RALPH OVER THERE AND
14 EVERY TIME SOMEBODY WALKED BY, HE DIDN'T PULL HIS LEG BACK.
15 SO THE PROTECTIVE MOVEMENTS, THE RHYTHMIC MOVEMENTS, THE
16 RESTLESSNESS, TOSSING -- INCREASED CONFUSION. ONE OF THE BIG
17 THINGS THAT WE'VE NOTICED IN THE FRAIL ELDERLY IS IF ALL OF
18 THE SUDDEN WE HAVE PATIENTS THAT ARE SUDDENLY URINATING IN
19 THE TRASH CAN AND THEY'RE INCREASED CONFUSION, YOU KNOW, WE
20 CHECK 'EM FOR URINARY TRACT INFECTION. I MEAN YOU HAVE TO BE
21 DETECTIVES. YOU HAVE TO LOOK FOR THESE ISSUES. SOMETIMES
22 THE INCREASED CONFUSION CAN BE DUE TO CHRONIC PAIN. AND SO
23 CHRONIC PAIN HAS BECOME A MAJOR ISSUE THAT WE'VE BEEN
24 CONCERNED ABOUT IN THESE PATIENTS AND WE HAVE TO LOOK AT ALL
25 THESE THINGS. THE FACIAL EXPRESSIONS, THE MOBILIZATION
1 MOVEMENTS, ALL THESE ISSUES WE HAVE TO BE DETECTIVES AND FIND
2 OUT WHAT'S GOING ON.
3 Q. AS A GENERAL PROPOSITION IN 1995, 1996, WAS PAIN IN THE
4 ELDERLY DEMENTED POPULATION UNDERTREATED DR. CRANMER?
5 A. OH, MOST DEFINITELY.
6 Q. WHEN YOU SEE THE TYPES OF BEHAVIORS THAT YOU'VE
7 INDICATED, THE NONVERBAL EVIDENCE OF THE INDICATORS OF PAIN
8 IN THE DEMENTED NON, YOU KNOW, COGNITIVELY IMPAIRED PERSON,
9 HOW CAN YOU BE CERTAIN THAT YOU'RE SEEING SYMPTOMS OF PAIN
10 RATHER THAN JUST SIMPLY SYMPTOMS OF DEMENTIA?
11 A. WELL, THEY'RE TWO DIFFERENT SYMPTOMS. SYMPTOMS OF
12 DEMENTIA IS USUALLY AGITATION, INCREASED CONFUSION. OF
13 COURSE, THESE ALL CAN CONTRIBUTE TO THAT, EVERYTHING FROM
14 PAIN TO URINARY TRACT INFECTIONS TO WHATEVER ELSE. THERE'S A
15 LOT OF CONTRIBUTING FACTORS BUT BASICALLY THE SYMPTOMS OF
16 DEMENTIA ITSELF YOU KNOW ARE TOTALLY DIFFERENT. THEY'RE NOT
17 GONNA BE CAUSING SOME OF THESE ISSUES THAT WE'RE LOOKING AT.
18 YOU KNOW, IF YOU HAVE A PATIENT AND EVERY TIME YOU'RE, YOU
19 KNOW, TURNING THE PATIENT, THEY'RE MOANING AND SCREAMING WHEN
20 YOU TURN 'EM AND THEY'RE NOT MOANING AND SCREAMING WHEN
21 YOU'RE NOT TURNING 'EM, IT TELLS YOU THAT SOMETHING'S HURTING
22 THEM WHEN YOU'RE TURNING THEM. I MEAN SO THERE -- THERE'S
23 DIFFERENT SYMPTOMS THAT YOU HAVE TO LOOK AT.
24 Q. WHEN A DOCTOR OBSERVES THE BEHAVIORAL SYMPTOMS WE'RE
25 TALKING ABOUT HERE THAT ARE INDICATORS OF PAIN IN THE
1 DEMENTED PERSON, WHAT DOES THE STANDARD OF CARE REQUIRE THAT
2 PHYSICIAN TO DO WHEN HE RECOGNIZES SYMPTOMS OF PAIN?
3 A. YOU NEED TO TREAT THE PAIN.
4 Q. IS THERE A DIFFERENCE IN STANDARD OF CARE FOR THE
5 TREATMENT OF PAIN FOR EXAMPLE OR JUST GENERALLY THE TREATMENT
6 OF THE DEMENTED PATIENT BETWEEN 1995, 1996 AND TODAY?
7 A. OH, YES.
8 Q. HAVE YOU LEARNED MORE IN THE LAST SIX YEARS DOCTOR?
9 A. MOST DEFINITELY.
10 Q. THE MEDICAL COMMUNITY I MEAN, NOT JUST YOU, KERRY
11 CRANMER?
12 A. NO, I HAVE TOO. I THINK THAT IT'S SAFE TO SAY THAT
13 GERIATRICS IN ITSELF IS PROBABLY ONE OF THE LAST AREAS THAT
14 WAS RECOGNIZED AS A SUBSPECIALTY AND I THINK THAT WE'VE
15 LEARNED AN AWFUL LOT ABOUT THE ELDERLY. WE'VE SEEN OUR LIFE
16 EXPECTANCY INCREASE MORE THAN EVER OVER THE LAST 30 YEARS.
17 ONLY TO EXPOSE NEW DISEASES PROCESS THAT WE KNEW NOTHING
18 ABOUT. WE PROBABLY DIDN'T SEE THIS MUCH DEMENTIA 30 YEARS
19 AGO BECAUSE WE -- PEOPLE DIDN'T LIVE LONG ENOUGH TO HAVE
20 DEMENTIA. SO YEAH THERE'S A LOT OF KNOWLEDGE, A LOT OF
21 INFORMATION, A LOT OF RESEARCH, A LOT OF THINGS BEING DONE ON THE
22 GERIATRIC POPULATION. SO WHEN IT COMES TO PAIN MANAGEMENT OR
23 ANY ASPECT OF THE FRAIL ELDERLY THIS IS A -- IT'S A PRETTY
24 NEW SCIENCE. THERE'S LOTS OF STUFF COMING OUT ALL THE TIME.
25 Q. IN 1995,1996, DID YOU USE MORPHINE IN YOUR PRACTICE TO
1 TREAT THE FRAIL ELDERLY WHEN THEY HAD HAD SYMPTOMS OF PAIN,
2 DR. CRANMER.
3 A. YES I DID.
4 Q. DID YOU BELIEVE THAT MORPHINE -- THAT THE USE OF
5 MORPHINE JUST -- NOT TALKING ABOUT DOSING, BUT JUST PICKING
6 THAT DRUG TO TREAT A SYMPTOM OF PAIN IN A FRAIL ELDERLY
7 PATIENT, DID THAT MEET THE STANDARD OF CARE, IS IT CONSISTENT
8 WITH THE STANDARD OF CARE TO USE MORPHINE?
9 A. STILL DOES. I THINK THAT -- I STILL -- I MEAN IN FACT,
10 I STILL USE MORPHINE IN MY HOSPITALIZED PATIENTS. WE HAVE THE
11 OPIOIDS THAT ARE UTILIZED IN THE TREATMENT OF THE GERIATRIC
12 PATIENT – IT’S THE MOST GERIATRIC FRIENDLY MEDICATION THAT WE CAN
13 USE.
14 Q. MET ME STOP YOU RIGHT THERE. THIS JURY HAS HEARD
15 TESTIMONY THROUGHOUT THIS TRIAL THAT THE USE OF MORPHINE IS
16 CONTRAINDICATED, IS SOMETHING THAT SHOULD BE AVOIDED IN THE
17 FRAIL ELDERLY POPULATION. DO YOU AGREE WITH THAT GENERAL
18 PROPOSITION?
19 A. ABSOLUTELY NOT.
20 Q. WHY NOT? WHY DO YOU DISAGREE?
21 A. THAT'S NOT THE CONSENSUS OF THE SCIENCE. THAT'S NOT THE
22 CONSENSUS OF MOST OF THE THOUGHT LEADERS IN AMERICA TODAY.
23 AT CERTAINLY ALL THE NATIONAL CONFERENCES I'VE GONE TO, THEY
24 CERTAINLY HAVE NOT SAID THAT. I DON'T KNOW WHO WOULD BE
25 SAYING THAT. I THINK THAT PEOPLE THAT ARE NOT AWARE OF THIS
1 AGE GROUP, PEOPLE WHO ARE NOT AWARE OF THIS PARTICULAR
2 ENVIRONMENT MAY HAVE SOME. I THINK WE LIVE IN A SOCIETY THAT
3 SAYS, SAY -- SAY NO TO DRUGS, NO PAIN NO GAIN. THERE'S A --
4 THIS SOCIETAL CONCEPT THAT DRUGS ARE BAD, BASICALLY. THE TRUTH
5 IS IN THE FRAIL ELDERLY, IF WE LOOK AT NONSTERIODAL
6 ANTIINFLAMMATORIES FOR INSTANCE, THAT'S VERY VERY DANGEROUS
7 DRUG. IT CAUSES --
8 Q. WHAT'S A NONSTEROIDAL ANTIINFLAMMATORY DRUG, FOR THOSE
9 LIKE MYSELF THAT DON'T KNOW WHAT YOU JUST SAID?
10 MR. WILSON: YOUR HONOR, I'M GOING TO OBJECT. IT'S
11 NOT -- FIRST OF ALL, IT'S NONRESPONSIVE TO THE QUESTION. AND
12 I WOULD APPRECIATE IT IF WE COULD JUST GET QUESTIONS AND
13 ANSWERS. WE'RE GOING ALONG HERE ON A -- ON A LECTURE.
14 THE COURT: OVERRULE --
15 THE WITNESS: SORRY.
16 THE COURT: -- THE OBJECTION. I THINK THEY ARE
17 RESPONSIVE IN MOST PART. PROCEED. MAKE YOUR OBJECTIONS AS
18 THEY COME.
19 Q. SO ANSWER THE QUESTION, AND WHAT I ASKED YOU WAS TO TELL
20 US WHAT NONSTEROIDAL ANTIINFLAMMATORIES ARE AND WHY MORPHINE
21 MIGHT BETTER THAN THE ANTI -- WHATEVER THAT --
22 A. THE NONSTEROIDAL ANTIIMFLAMMATORIES, THOSE LIKE
23 IBUPROFEN, NAPROSEN, THOSE TYPE OF MEDICATIONS ARE
24 CONTRAINDICATED IN THE ELDERLY AND FOR LONG-TERM THERAPY.
25 NOW, WE CAN USE 'EM, BUT WE USE 'EM FOR SHORT-TERM THERAPY.
1 LONG-TERM THERAPY, WE HAVE TOO HIGH A RISK OF G.I. BLEED. WE
2 HAVE MORE PATIENTS DIE FROM G.I. BLEED THAN FROM CAR
3 ACCIDENTS EVERY YEAR IN AMERICA. SO IT'S NOT A GOOD
4 MEDICATION. EVEN THE NEW COX-2'S HAVE RENAL FAILURE. ALL
5 THESE DIFFERENT MEDICINES IN THE GERIATRIC POPULATION KIND OF
6 CHANGE THEIR CONCEPT BECAUSE OF THE PROBLEMS THAT THEY CREATE
7 WITH THAT PATIENT. SO IF YOU LOOK AT ALL MEDICATIONS THAT WE
8 USE, OPIOIDS ARE THE MOST GERIATRIC FRIENDLY MEDICINE WE CAN
9 USE.
10 Q. ARE THERE ADVERSE CONSEQUENCES -- CAN THERE BE ADVERSE
11 CONSEQUENCES TO THE USE OF MORPHINE IN THE GERIATRIC
12 POPULATION -- WITH ANYONE, BUT PARTICULARLY THE GERIATRIC
13 POPULATION?
14 A. WELL, IT CAN BE. I MEAN THERE'S ALWAYS LIMITS THAT YOU
15 HAVE TO APPLY, BUT MOST GENERALLY, MOST OF THE CONCERNS ABOUT
16 OPIOIDS ARE PRETTY MUCH WHAT WE CALL OPIOID MYTHS. BUT I
17 THINK THERE'S -- LIKE ANY OTHER KIND OF MEDICATION, YOU HAVE
18 TO BE REASONABLE.
19 Q. DR. CRANMER HOW DO -- FROM YOUR EXPERIENCE THAT YOU'VE
20 TOLD US ABOUT, TREATING A DEMENTED PATIENT, HOW DO DEMENTED
21 PATIENTS DIE WHEN PAIN MEDICATION IS WITHHELD FROM THE
22 PATIENT?
23 A. THEY HAVE A BAD DEATH. THEY HAVE INCREASED PAIN. THEY
24 ARE -- THEY -- WE'RE TRYING TO ALLEVIATE THE SUFFERING. WE ARE
25 TRYING TO ALLEVIATE -- OUR PURPOSE AND OUR NEW GOAL AS WE ARE
1 SAYING IN PALLIATIVE CARE AS OPPOSED TO THE ALL AMERICAN
2 ACUTE CARE IS TO TRY TO PROVIDE COMFORT AND DIGNITY. THE
3 EXISTENCE OF PAIN, THE EXISTENCE OF DISCOMFORT IS CERTAINLY
4 NOT ACCEPTED IN THAT REALM.
5 Q. NOW, WE TALKED ABOUT USE OF MORPHINE JUST TO TREAT PAIN.
6 NOW I'D LIKE TO ASK YOU IF YOU CAN EXPLAIN TO TO US HOW IN
7 1995, 1996, HOW WOULD A QUALIFIED REASONABLY COMPETENT
8 PHYSICIAN PICK A DOSAGE OF MORPHINE FOR PATIENTS LIKE THE
9 PATIENTS THAT WE SOON ARE GONNA BE TALKING ABOUT IN THIS
10 CASE, FRAIL ELDERLY PEOPLE, OLDER AGE WITH UNDERLYING
11 CO-MORBIDITIES, UNDERLYING MEDICAL PROBLEMS, HOW DO YOU PICK A
12 DOSAGE?
13 A. WELL, IT'S -- YOU HAVE TO BE ABLE TO COME UP WITH A
14 DOSAGE THAT HAS A DESIRED EFFECT ON THAT PATIENT. YOU START
15 SOMEWHERE. YOU START 10 MILLIGRAMS OF MORPHINE I.M. IS A
16 GOOD STARTING POINT. YOU CAN TITRATE UP OR DOWN ACCORDINGLY
17 AND BUT, YOU KNOW, WE HAVE PATIENTS THAT ARE ON 300
18 MILLIGRAMS OF MORPHINE A DAY. WE HAVE PATIENTS --
19 Q. OKAY. LET ME STOP YOU --
20 A. YEAH.
21 Q. 300 MILLIGRAMS OF MORPHINE A DAY SOUNDS LIKE A BIG
22 NUMBER. PUT THAT INTO THE CONTEXT OF WHY THAT'S NOT AN
23 OVERDOSE. I MEAN, JUST THAT NUMBER ALONE JUST SOUNDS LIKE AN
24 AWFULLY LARGE NUMBER.
25 A. EVERY PERSON IS DIFFERENT. SOME PEOPLE CAN TAKE A
1 CERTAIN AMOUNT OF MEDICATIONS AND IT MAY TOTALLY ZONK 'EM.
2 SOME PEOPLE CAN TAKE AN ANTIHISTAMINE DECONGESTANT, LET'S
3 SAY. SOME PEOPLE CAN LICK THE LID AND THAT'S ABOUT ALL THEY
4 NEED. SOME PEOPLE TAKE TWO TABLESPOONS. I MEAN EACH PATIENT
5 IS DIFFERENT. AND YOU HAVE TO TITRATE ANY MEDICATION TO
6 DESIRED EFFECT. FOR INSTANCE, HYPERTENSION, IF YOU HAVE
7 SOMEBODY WITH HIGH BLOOD PRESSURE, WHAT WORKS GOOD FOR ONE
8 PERSON MAY NOT WORK GOOD FOR ANOTHER. SO YOU'RE GOING TO
9 HAVE TO, YOU KNOW, INDIVIDUALIZE THAT THERAPY AND THAT
10 TREATMENT TO THE DESIRED EFFECT.
11 Q. LET ME ASK YOU A GENERAL STATEMENT. ELLEN ANDERSON WAS
12 AT -- SORT OF MORE SPECIFIC THAN WE'VE BEEN TALKING. ELLEN
13 ANDERSON RECEIVED TWO 10-MILLIGRAM DOSAGES OF MORPHINE, ONE
14 AT 7:30 OR EIGHT AT NIGHT AND A SECOND AT 3:30 IN THE
15 MORNING. THE JURY HAS HEARD TESTIMONY FROM A NURSE THAT AT
16 3:15 OR 3:30 SHE OBSERVED WHAT APPEARED TO BE ELLEN ANDERSON
17 TO BE IN SEVERE OR EXTREME PAIN, RIGID MOVEMENTS, SCREAMING,
18 THAT SORT OF BEHAVIOR. WHAT WOULD THAT TELL YOU JUST IN THE
19 CONTEXT OF WHAT WE'VE JUST NOW BEEN TALKING ABOUT, ABOUT
20 LOOKING AT THE RIGHT DOSAGE, WHAT WOULD THAT TELL YOU IN THE
21 CONTEXT OF ELLEN ANDERSON WHERE AT 3:30 THE PAIN SYMPTOMS HAD
22 RETURNED, WHAT WOULD THAT SAY ABOUT THE APPROPRIATENESS OF
23 THE FIRST 10 MILLIGRAM DOSAGE?
24 A. WELL, IF YOU'RE LOOKING AT PARENTERAL USE OF MORPHINE
25 SULFATE, YOU'RE GOING TO HAVE PROBABLY A PEAK LEVEL AT AROUND
1 ONE HOUR, YOU'RE GONNA PROBABLY HAVE AN OVERALL EFFECT FROM
2 ANYWHERE FROM THREE TO FOUR HOURS. YOU JUST DESCRIBED TO ME
3 A TIME DIFFERENCE OF MUCH OVER FOUR HOURS AND IT'D BE VERY
4 SAFE TO SAY THAT THAT MORPHINE WAS OUT OF HER SYSTEM, WAS NOT
5 EFFECTIVE, AND SHE WAS WITHOUT ANY TYPE OF PAIN MANAGEMENT.
6 Q. BY 3:30.
7 A. CORRECT.
8 Q. I'M GONNA WALK YOU THROUGH A SERIES OF QUESTIONS ABOUT
9 THESE PATIENTS BEFORE WE HAVE YOU DESCRIBE EACH OF THE
10 PATIENTS BUT SINCE WE'RE TALKING ABOUT MORPHINE RIGHT NOW,
11 WE'RE GONNA -- WE'RE GOING TO CONTINUE TALKING ABOUT MORPHINE
12 FOR THE NEXT FEW MINUTES. DO YOU HAVE AN OPINION TO A DEGREE
13 OF REASONABLE MEDICAL CERTAINTY WHETHER OR NOT A MORPHINE
14 OVERDOSE CAUSED THE DEATH OF ANY OF THESE PATIENTS?
15 A. OH, NO.
16 Q. WELL, LET'S FIRST, DO YOU HAVE AN OPINION?
17 A. YES I DO.
18 Q. AND WHAT IS YOUR OPINION ABOUT WHETHER MORPHINE OVERDOSE
19 CAUSED THE DEATH OF ANY OF THE FIVE PATIENTS WE'RE GONNA TALK
20 ABOUT?
21 A. NO, I DO NOT BELIEVE THAT.
22 Q. NOW, I'M GONNA SHOW YOU SOME CHARTS IN JUST A MOMENT.
23 IS THERE A -- SOME SCIENCE, SOME MEDICAL SCIENCE THAT WE CAN
24 LOOK AT, SOME PHYSIOLOGICAL FACTS THAT WOULD BE ASSOCIATED
25 WITH A MORPHINE OVERDOSE THAT WE CAN LOOK AT IN THE MEDICAL
1 RECORDS OF THESE PATIENTS THAT WOULD SUPPORT YOUR OPINION
2 THAT THESE PATIENTS DID NOT DIE FROM AN OVERDOSE? IS THERE
3 SOMETHING IN THE RECORD THAT WE COULD LOOK AT THAT WOULD --
4 THAT SUPPORTS YOUR OPINION; YES OR NO?
5 A. YES.
6 Q. AND WHAT ARE THE SORTS OF -- AM I RIGHT -- I THINK THE
7 JURY'S HEARD THIS, THAT THE WAY THAT SOMEONE WOULD DIE FROM A
8 MORPHINE OVERDOSE IS THAT YOU'D HAVE RESPIRATORY DEPRESSION,
9 IS THAT A -- GENERALLY, IS THAT STATEMENT CORRECT ?
10 A. YOU CAN HAVE.
11 Q. OKAY. SO WHAT ARE SOME OF THE INDICATORS IN THE MEDICAL
12 RECORDS THAT YOU LOOKED AT DR. CRANMER TO REACH YOUR
13 CONCLUSION ABOUT WHETHER MORPHINE CAUSED THE DEATH OF ANY OF
14 THESE PATIENTS? WHAT ARE THE INDICATORS YOU LOOKED AT, THE
15 SCIENTIFIC INDICATORS?
16 A. WELL, THE FIRST THING WE LOOKED AT OF COURSE WAS THE
17 EFFECTS OF THE MORPHINE ITSELF, LOOKING AT THE DOSAGE OF THE
18 MORPHINE IN RESPECT TO THE EFFECTS IT MIGHT HAVE HAD ON THEIR
19 VITAL SIGNS. THEN OF COURSE WE WERE LOOKING ALSO AT ANY
20 OTHER CAUSES, ANY OTHER THINGS THAT COULD BE CAUSING THEIR
21 DEATH. WE WERE LOOKING AT THOSE COEXISTING MEDICAL
22 CONDITIONS. WE WERE LOOKING AT THEIR OVERALL PICTURE.
23 Q. I'M GONNA INTERRUPT YOU.
24 A. YES.
25 Q. I'M SORRY. BUT SORT OF LITTLE QUESTION ANSWER HERE. IF
1 YOU HAD A MORPHINE OVERDOSE, WHEN DO YOU -- WHEN DO YOU
2 BELIEVE TO A REASONABLE DEGREE OF MEDICAL CERTAINTY WOULD BE
3 THE MOST DANGEROUS -- WHAT WOULD BE THE MOST DANGEROUS DOSAGE
4 TO BE, THE FIRST DOSAGE, WOULD IT BE THE LAST DOSE, WHAT
5 WOULD BE THE MOST DANGEROUS TIME FOR THE PATIENT?
6 A. WELL, I THINK THAT THAT'S A GOOD STATEMENT. I THINK
7 BEST -- THE BEST THING WE CAN SAY IS THAT THE SCARIEST PART
8 IS THAT INITIAL DOSE. YOU KNOW, YOU'RE NOT REALLY SURE HOW
9 THAT PATIENT'S GONNA RESPOND WITH THE FIRST DOSE. THAT'S
10 PROBABLY THE MOST -- THE MOST CONCERNING. YOU WANNA KNOW HOW
11 THEY'RE GOING TO RESPOND, AND ONCE YOU'VE DETERMINE THAT,
12 THEN YOU CAN GO AHEAD AND ADJUST THE DOSE ACCORDINGLY TO THE
13 PATIENTS EFFECT. SO I THINK THE WORST WOULD BE THE INITIAL
14 DOSE.
15 Q. WHAT IS THE PEAK EFFECT FOR MORPHINE SULFATE I.M.
16 INTRAMUSCULAR .
17 A. PEAK EFFECT'S USUALLY WITHIN THREE TO FOUR HOURS.
18 Q. PEAK EFFECT --
19 A. I'M SORRY, PEAK EFFECT'S WITHIN ONE HOUR. DURATION'S
20 WITHIN THREE TO FOUR HOURS.
21 Q. SO WOULD YOU EXPECT THAT THE MOST DANGEROUS TIME FOR THE
22 PATIENT WOULD BE THE FIRST SHOT AND AT THE PEAK EFFECT, THE
23 MOMENT OF PEAK EFFECT, ONE HOUR INTO THE DOSAGE?
24 A. THAT'S CORRECT.
25 Q. AND SO IF THE PATIENT WAS GOING TO EXPIRE FROM AN
1 OVERDOSE, WOULD YOU EXPECT THEN TO SEE A RESPIRATORY
2 DEPRESSION WITHIN ONE HOUR?
3 A. I WOULD BE MAINLY CONCERNED ABOUT HAVING AN UNEXPECTED
4 RESPONSE WITHIN THAT FIRST HOUR, YES.
5 Q. WOULD YOU STEP DOWN PLEASE? I'D MOVE FOR THE
6 INTRODUCTION OF DEFENDANT'S EXHIBIT 18 AND DEFENDANT'S
7 EXHIBIT 23 AT THIS TIME. CHART JUST SAYS THE TWO DOSAGES.
8 MR. WILSON: NO, NO OBJECTION, YOUR HONOR.
9 MR. BUGDEN: THIS IS THE RESPIRATION --
10 THE COURT: 18 AND 23 ARE RECEIVED OF THE DEFENDANT.
11 MR. WILSON, IF YOU NEED TO MOVE OVER SO YOU CAN SEE, YOU'RE
12 WELCOME TO DO THAT.
13 Q. (BY MR. BUGDEN) OKAY. DR. CRANMER, TELL US WHAT EXHIBIT
14 23 CHARTS. AND I'LL HOLD THIS. I'M GONNA FIRST HAVE YOU
15 TALK ABOUT DEFENDANT'S EXHIBIT 23. WHAT IS THAT CHART?
16 A. THIS LOOKS LIKE THE GRAPHIC SHEET FOR ELLEN ANDERSON AT
17 DAVIS HOSPITAL MEDICAL CENTER.
18 Q. WHAT IS THE GRAPHIC SHEET? TELL US WHAT THAT MEANS.
19 A. THIS IS WHERE THEY'RE PLOTTING THE VITAL SIGNS OF THE
20 PATIENT DURING THEIR HOSPITAL STAY.
21 Q. AND DOES IT INCLUDE THINGS LIKE RESPIRATION RATES?
22 A. IT DOES.
23 Q. AND AM I CORRECT THAT ON THIS CHART THE RESPIRATION HAS
24 BEEN YELLOWED?
25 A. THAT IS CORRECT.
1 Q. AND THAT THEN THE RESPIRATION RATE THAT HAS A GRAPHIC
2 DEPICTION, THERE'S A NUMBER AT THE BOTTOM OF THE CHART THAT
3 THE JURY CAN REFER TO, THAT SEE WHAT THEIR -- WHAT THE
4 RESPIRATION RATE WAS?
5 A. YES . THAT'S -- THIS IS 26 AND 16.
6 THE COURT: JUST A MOMENT. BAILIFF, WILL YOU PULL A
7 CHAIR OVER SO MR. WILSON COULD SIT THERE? JUST PULL ONE OF
8 THOSE FROM THE BACK. THAT'S FINE.
9 Q. (BY MR. BUGDEN) OKAY. DR. CRANMER, NOW --
10 THE COURT: THANK YOU.
11 MR. WILSON: THANK YOU.
12 Q. (BY MR. BUGDEN) -- DEFENDANTS EXHIBITS 18 JUST SHOWS THE
13 TWO SHOTS. AND ONE IS AT 7:30 AND THE OTHER'S AT 3:30, OKAY?
14 NOW, TELL US HOW THAT -- TELL US ABOUT THE RESPIRATION RATES
15 AS IT RELATES TO PEAK EFFECT AND DURATION OF EFFECT WITH THIS
16 PATIENT PLEASE.
17 A. THEY HAVE -- SHOW NO EFFECT. BOTH THESE RESPIRATION
18 RATES ARE NOT -- AS A MATTER OF FACT, 26 IS HIGHER THAN
19 NORMAL. MOSTLY IN THESE PATIENTS ASSOCIATED WITH ANXIETY.
20 BUT BASICALLY, NEITHER ONE OF THESE SHOW ANY KIND OF
21 RESPIRATORY DEPRESSION AT ALL.
22 Q. WELL, 26 IS -- WOULD THAT BE CONSISTENT WITH RESPIRATORY
23 DEPRESSION?
24 A. ABSOLUTELY NOT.
25 Q. OR 16?
1 A. ABSOLUTELY NOT. SO ON THE BASIS OF RESPIRATION RATES
2 WITH ELLEN ANDERSON, HER RESPIRATION RATES, SHE WAS NEVER IN
3 RESPIRATORY DI -- A RESPIRATORY DEPRESSED SITUATION, AM I
4 RIGHT?
5 A. THAT'S CORRECT.
6 Q. THANK YOU. BUT YOU DON'T GET TO SIT DOWN YET.
7 MR. ALLDREDGE -- I'D MOVE FOR THE INTRODUCTION OF DEFENDANT'S
8 EXHIBIT 27, WHICH IS THE GRAPH CHART. AND THEN SUMMARY FOR
9 THE MORPHINE SULFATE, DEFENDANTS EXHIBIT 17 TO MISTER --
10 MR. WILSON: NO OBJECTION.
11 THE COURT: IS IT 17 AND 27?
12 MR. BUGDEN: THEY'RE SEVEN -- YES. YES, SIR, 17 AND 27.
13 27 -- MAY THEY BE RECEIVED, JUDGE?
14 THE COURT: THEY MAY BE, COUNSEL.
15 MR. BUGDEN: DR. CRANMER, 27 AGAIN IS THE GRAPHIC CHART
16 FOR MR. ALLDREDGE. CAN YOU COMPARE OR DESCRIBE -- I'LL HOLD
17 THE MORPHINE SULFATE DOSING, WHICH IS EXHIBIT 17. CAN YOU
18 COMPARE THE RESPIRATION RATES WITH THE MORPHINE SULFATE
19 DOSAGES AND LET ME ASK YOU, ARE ANY -- I'M SORRY. ARE ANY OF
20 THE RESPIRATION RATES TROUBLESOME? ARE ANY OF THEM RESPI --
21 CONSISTENT WITH RESPIRATORY DEPRESSION?
22 A. THEY ARE NOT.
23 Q. AND WITH ME HOLDING THIS, WILL YOU JUST EXPLAIN TO THE
24 JURY WHETHER OR NOT THERE'S ANY INDICATION THAT -- THAT
25 THROUGHOUT THIS PATIENT'S -- AND THIS IS TWO DAYS, BY THE
1 WAY, 1/13 AND 1/14, THE LAST TWO DAYS MR. ALLDREDGE'S LIFE.
2 IS THERE ANY INDICATION THAT WOULD SUGGEST THAT AGAIN THIS
3 MAN HAD A RESPIRATORY DEPRESSION PROBLEM THAT WOULD -- THAT
4 COULD BE CORRELATED TO A MORPHINE OVERDOSE, DR. CRANMER?
5 A. ABSOLUTELY NOT.
6 Q. I'D MOVE FOR THE INTRODUCTION OF DEFENDANT'S EXHIBIT 25
7 WHICH IS THE GRAPHIC CHART FOR MARY CRANE. AND 15 WHICH IS
8 MORPHINE SULFATE, ON 1/3/96, 1/4/96, 1/5/96, 1/7/96. DO YOU
9 HAVE ANY OBJECTION, MR. WILSON?
10 MR. WILSON: NO OBJECTION. YOUR HONOR.
11 THE COURT: 25 AND 15 ARE RECEIVED.
12 Q. (BY MR. BUGDEN) IS THERE ANYTHING TROUBLESOME OR ANY --
13 OR CONSISTENT WITH RESPIRATORY DEPRESSION IN ANY OF THOSE
14 RESPIRATION RATES?
15 A. NO.
16 Q. OKAY. THAT'S ALL I'LL ASK YOU ABOUT THAT. KEEP WALKING
17 OVER THERE. I'D NOW MOVE FOR THE INTRODUCTION OF LYDIA
18 SMITH, JUDGE. EXHIBIT 26 IS THE GRAPHIC CHART. AND EXHIBIT
19 16 IS THE MORPHINE SULFATE FOR THE LAST TWO DAYS, 1/7/96 AND
20 1/8/96 OF MRS. SMITH'S LIFE. DO YOU HAVE ANY OBJECTION
21 MR. WILSON?
22 MR. WILSON: NO OBJECTION.
23 THE COURT: 16 AND 26 ARE RECEIVED.
24 Q. (BY MR. BUGDEN) NOW, AGAIN THIS JURY'S HEARD EVIDENCE
25 FROM A NUMBER OF WITNESSES THAT THESE PATIENTS ALL THAT WE'RE
1 TALKING ABOUT DIED FROM A MORPHINE OVERDOSE. AS WE LOOK AT
2 THE SCIENTIFIC EVIDENCE, AS WE LOOK AT EVIDENCE OF
3 RESPIRATORY DEPRESSION, AS WE LOOK AT RESPIRATION RATES IN
4 THE LAST TWO DAYS OF MRS. SMITH'S LIFE, IS THERE ANY EVIDENCE
5 TO SUGGEST THAT THIS WOMAN HAD RESPIRATORY DEPRESSION ON THE
6 BASIS OF THE RESPIRATION RATES?
7 A. NO.
8 Q. AND FINALLY, YOUR HONOR, I MOVE WITH JUDITH LARSEN FOR
9 THE INTRODUCTION OF DEFENDANT'S EXHIBIT 24 WHICH IS JUDITH
10 LARSEN'S GRAPHIC CHART, AND DEFENDANT'S EXHIBIT 14 WHICH IS
11 MORPHINE SULFATE SUMMARY. DO YOU HAVE ANY OBJECTION?
12 MR. WILSON: NO OBJECTION.
13 THE COURT: 24 AND 14 OF THE DEFENDANT ARE RECEIVED.
14 Q. (BY MR. BUGDEN) NOW, IN JUDITH LARSEN'S SITUATION, ARE
15 THERE ANY RES -- ANY RESPIRATORY RATES THAT ARE -- WHAT'S THE
16 RESPIRATORY RATE THAT WE LIKE TO SEE? WHAT'S THE RANGE OF
17 RESPIRATIONS WE LIKE TO SEE?
18 A. WELL, IF YOU'RE AWAKE AND ALERT, YOU KNOW, WE LIKE TO
19 SEE ANYWHERE FROM, YOU KNOW, 12 TO 18 RESPIRATIONS PER
20 MINUTE. IF THEY'RE SOUND ASLEEP, ANYWHERE FROM 8 TO 16
21 PROBABLY WOULD BE FINE. 8 IS PROBABLY THE LIMIT. 6 IS A
22 LITTLE BIT LOW. I NOTICE THERE'S SOME TIMES HERE, BUT ONCE
23 AGAIN, I'M NOT SURE IF THAT'S DUE TO HER OVERALL CONDITION OR
24 DUE TO THE MORPHINE. WE'D HAVE TO TAKE A LOOK AT THAT
25 INDIVIDUALLY.
1 Q. NOW, AS YOU'VE INDICATED ON THE LAST DAY OF
2 MRS. LARSEN'S LIFE, HER RESPIRATION RATES -- THE LAST
3 RESPIRATION RATES THAT WERE CHECKED WERE LOWER, 6, 6, AND 8,
4 IS THAT CORRECT?
5 A. CORRECT.
6 Q. THAT IS BELOW OPTIMAL, IS THAT RIGHT?
7 A. THE SIX WOULD PROBABLY BE. EIGHT WOULD PROBABLY BE
8 ACCEPTABLE.
9 Q. DO YOU HAVE AN OPINION, DR. CRANMER TO A DECREE OF
10 REASONABLE MEDICAL CERTAINTY WHETHER OR NOT MRS. LARSEN AT
11 THE POINT THAT HER RESPIRATION RATES WERE LOWER, LIKE THOSE
12 THAT WE'RE LOOKING AT, WAS SHE IN THE PROCESS OF DYING AT
13 THAT POINT IN TIME?
14 A. YES SHE WAS.
15 Q. DO YOU BELIEVE THAT SHE WAS IN THE PROCESS OF DYING
16 BECAUSE OF MORPHINE OR BECAUSE OF HER STEADY DECLINE?
17 A. OH, SHE HAD A DEFINITE STEADY DECLINE.
18 Q. WHY DON'T YOU TAKE THE WITNESS STAND AGAIN, DR. CRANMER.
19 NOW I'D LIKE TO ASK YOU SOME GENERAL QUESTIONS ABOUT
20 PSYCHOTROPIC MEDICATIONS. DO YOU TREAT PATIENTS WITH
21 PSYCHOTROPIC MEDICATIONS?
22 A. YES, WE DO.
23 Q. HAS THE STANDARD OF CARE WITH REGARD TO -- OR LET ME ASK
24 A DIFFERENT QUESTION. HAS THE DOSING -- STILL HAVEN'T ASKED
25 IT THE RIGHT WAY. HAVE YOU LEARNED MORE, DR. CRANMER, ABOUT
1 THE DOSING OF A MEDICATION LIKE RISPERDAL SINCE 1995, 1996,
2 HAVE YOU IN THE MEDICAL COMMUNITY LEARNED MORE?
3 A. OF COURSE.
4 Q. WHAT HAVE YOU LEARNED ABOUT RISPERDAL?
5 A. RISPERDAL PROBABLY DIDN'T COME OUT UNTIL 1995, 1994,
6 1995, IN THAT TIME PERIOD. I'M NOT EXACTLY SURE WHEN. WHEN
7 IT FIRST CAME OUT, IT WAS THE FIRST OF THE ATYPICAL
8 ANTIPSYCHOTICS AND --
9 Q. WHAT DOES THAT MEAN, ATYPICAL? WE KNOW ANTIPSYCHOTIC,
10 BUT WHAT DOES ATYPICAL MEAN?
11 A. THE CONVENTIONAL ANTIPSYCHOTIC MEDICATIONS, MEDICATIOINS
12 LIKE HALDOL, MELLARIL, THORAZINE, THOSE TYPES OF MEDICATIONS
13 WERE ANTIPSYCHOTIC MEDICATIONS WE'D BEEN USING FOR YEARS.
14 UNFORTUNATELY IN THE FRAIL ELDERLY, WE HAD A LOT OF SIDE
15 EFFECTS FROM THOSE THAT MADE THEM PROBABLY MORE UNDESIRABLE
16 AS WE FOUND OUT THAT THE NEWER ANTIPSYCHOTICS, THE TYPICAL
17 ANTIPSYCHOTICS DID NOT HAVE THOSE TYPES OF EFFECTS. WHEN THE
18 MEDICATIONS WERE FIRST RELEASED, RISPERDAL WAS THE FIRST OF
19 THEIR KIND TO COME OUT. THE LITERATURE WAS VERY SUPPORTIVE,
20 WE WERE VERY EXCITED ABOUT BEING ABLE TO USE THOSE
21 MEDICATIONS. AND THEY PROVED TO BE VERY, VERY EFFECTIVE WITH
22 A LOT LESS OF THE SIDE EFFECTS. A LOT OF PEOPLE WERE VERY SLOW
23 TO MAYBE START USING THOSE MEDICATIONS, BUT IT TURNS OUT THAT
24 IS THE STANDARD OF CARE NOW.
25 Q. DO YOU USE RISPERDAL?
1 A. YES, WE DO.
2 Q. HAVE YOU LEARNED OVER THE LAST SIX YEARS OR HAS
3 SCIENTIFIC COMMUNITY LEARNED THAT LOWER DOSING OF RIDPERDAL
4 IS BETTER THAN THE DOSING THAT WAS RECOMMENDED OR SUGGESTED
5 IN 1995, 1996?
6 A. YEAH, I THINK THAT WHEN RISPERDAL FIRST CAME OUT, I
7 THINK THEY -- THERE WAS A MUCH BROADER RANGE OF DOSAGE THAT
8 WAS RECOMMENDED. SINCE THAT TIME, AS WITH EVERYTHING ELSE,
9 WE'VE LEARNED THAT PROBABLY WE USE LESS PROBABLY OF THE
10 RISPERDAL THAN WE USED TO WHEN IT WAS FIRST RELEASED BASED ON
11 THE SCIENCE AND BASED ON THE RESEARCH THAT WAS PRODUCED.
12 Q. DR. CRANMER, A COUPLE OF TIMES DURING THIS TRIAL THE
13 JURY'S HEARD REFERENCE TO A BOOK CALLED THE PHYSICIAN'S DESK
14 REFERENCE, THE P.D.R. DO YOU USE THE P.D.R. WHEN YOU'RE
15 MAKING A DOSING DECISION, DR. CRANMER?
16 A. WELL, ONLY IF I'M NOT FAMILIAR WITH THE DRUG OR IF IT'S
17 SOMETHING I HAVEN'T BEEN UTILIZING OR HAVEN'T BEEN EDUCATED
18 ON. I'LL HAVE TO LOOK AT THAT TO SEE BASICALLY SOME OF THE
19 CAVEATS OF THAT PARTICULAR MEDICATION.
20 Q. IS THE P.D.R. A HOLY GRAIL OR A BIBLE OR DOES IT SET
21 FORTH THE ONLY DOSAGE THAT ONE CAN USE?
22 A. OH, NO. I MEAN, P.D.R. IS ADVERTISEMENT BASICALLY ON
23 EVERY MEDICATION THAT'S BEEN APPROVED BY THE F.D.A. AND SO
24 THE F.D.A. HAS BASICALLY STIPULATED THAT ALL OF THESE ISSUES
25 HAVE TO BE INCLUDED FOR A PRODUCT TO BE PUT IN THAT
1 PARTICULAR BOOK. IT'S PROBABLY NOT THE PHYSICIAN'S TOP
2 REFERENCE BUT IT'S EASILY ACCESSIBLE AND SOMETIMES WE DO USE
3 IT.
4 Q. WOULD YOU CONSIDER IT A BREACH OF THE STANDARD OF CARE
5 FOR A CLINICIAN, A DOCTOR IN THE TRENCHES, TO DISREGARD THE
6 P.D.R. AND USE A DIFFERENT DOSE THAN THE P.D.R. SUGGESTS?
7 A. OH, NO. NO.
8 Q. OKAY. HOW IS PSYCHOTIC OR AGITATED, COMBATIVE BEHAVIOR
9 IN THE DEMENTED POPULATION TREATED?
10 A. THE PROBLEM THAT WE HAVE WITH THE DEMENTED PATIENT IS
11 THAT THEY ARE DELUSIONAL. THEY ARE PERCEIVING THINGS THAT
12 AREN'T AS THEY REALLYARE. WE HAVE NO IDEA WHAT THAT
13 DELUSION MAY BE. AND I COULD GIVE YOU -- WELL, I MEAN I
14 DON'T KNOW IF I CAN OR NOT BUT --
15 Q. GIVE US AN EXAMPLE.
16 A. OKAY.
17 Q. YOU'RE ALLOWED TO.
18 A. IF IT'S OKAY, I -- WE HAD A PATIENT THAT WE TOOK CARE OF
19 THAT CRIED CONSTANTLY EVERY TIME WE TALKED TO HER. THIS WAS
20 FOR SIX MONTHS THAT I WAS TAKING CARE OF HER. I THOUGHT SHE
21 HAD EXTRANUCLEAR PALSY WHICH IS A CONDITION THAT CAUSES A
22 LOSS OF THEIR EMOTIONAL CONTROL. AND, BUT ONE DAY SHE
23 MENTIONED HER SONS. AS I WAS EXAMINING HER, ONE OF THE FEW
24 WORDS THAT SHE'D SPOKEN, AND A COUPLE MONTHS LATER, I WAS
25 TALKING TO THE FAMILY. AND I MENTIONED TO THEM ABOUT HER
1 SONS AND SHE SAID, OH, YEAH, SHE SAID HER -- BACK IN 1955 HER
2 OLDEST SON WAS OFF TO COLLEGE, TAKING HIS YOUNGER BROTHER TO
3 HIS FRESHMAN YEAR OFF TO COLLEGE, AND THEY WERE BOTH KILLED
4 IN A CAR ACCIDENT. AND SO WE WERE ABLE TO ASCERTAIN THAT
5 THIS PATIENT'S DELUSION WAS SHE WAS RELIVING THAT DAY EVERY
6 DAY. HER SONS HAD BEEN KILLED, AND SO SHE WAS CRYING
7 CONSTANTLY BECAUSE SHE WAS STILL LIVING AND THAT -- THAT WAS
8 HER NOW. AND WE HAD TO PLACE HER ON ANTIPSYCHOTIC
9 MEDICATIONS TO STOP THE DELUSION, AND SHE QUITE CRYING.
10 Q. IS IT UNUSUAL TO USE POLYPHARMACOLOGY? IS IT UNUSUAL TO
11 USE MULTIPLE MEDICATIONS TO TREAT PSYCHOTIC BEHAVIOR IN THE
12 DEMENTED PATIENT?
13 A. WELL, WE TRY NOT TO, BUT UNFORTUNATELY, THAT'S -- THAT'S
14 SOMETHING THAT ISN'T EASILY OBTAINED. SOMETIMES WE HAVE TO
15 USE A LOT OF DIFFERENT MEDICATIONS FOR DIFFERENT ASPECTS OF
16 THEIR PROBLEM. IF THEY HAVE AGITATION, WE DON'T NECESSARILY
17 USE ANTIPSYCHOTICS FOR THAT PRIMARILY. SOMETIMES WE HAVE TO
18 USE AN ANTIPSYCHOTIC TO THE TREAT THE DELUSION, THEN WE HAVE
19 TO USE ANOTHER MEDICATION FOR THE AGITATION, WHETHER IT'S
20 ATIVAN, DEPAKOTE, ANY OF THE ANXIOLYTICS. IF THEY HAVE A
21 COMPONENT OF DEPRESSION, THEN WE HAVE TO TREAT THE
22 DEPRESSION. IF THEY'RE NOT SLEEPING, WE HAVE TO GIVE THEM
23 SOMETHING FOR SLEEP. AND SO THOSE ARE ISSUES THAT WE HAVE TO
24 ADDRESS. EACH OF THEM ARE A SEPARATE DIAGNOSIS, EACH OF THEM
25 HAVE TO BE TREATED SEPARATELY.
1 Q. WAS THERE ANYTHING UNUSUAL OR DOES IT BREACH THE
2 STANDARD OF CARE FOR PHYSICIANS WITH THE FRAIL ELDERLY TO USE
3 MULTIPLE MEDICATIONS TO TRY TO TREAT THE AGITATION OR THAT
4 COMBATIVENESS OR OTHER DEMENTED BEHAVIORS?
5 A. ONE OF THE BIGGEST PROBLEMS THAT WE'VE HAD IN GERIATRIC
6 MEDICINE IS THAT IN OUR SOCIETY TODAY, AND THE ALL AMERICAN
7 ACUTE CARE SYSTEM, EVERYBODY HAS ABOUT FOUR OR FIVE DOCTORS,
8 AND NOT ANY ONE OF THEM --
9 MR. WILSON: OBJECTIOIN, YOUR HONOR. NONRESPONSIVE.
10 THE COURT: SUSTAINED.
11 Q. DOCTOR, LISTEN TO MY QUESTION.
12 A. SORRY.
13 Q. THAT'S OKAY. I JUST WANT -- MY QUESTION WAS, IS IT
14 UNUSUAL OR DOES IT BREACH THE STANDARD OF CARE FOR A
15 PHYSICIAN TO USE MULTIPLE MEDICATIONS TO TRY TO TREAT
16 DEMENTED BEHAVIORS?
17 A. NO.
18 Q. AN YOU'VE REVIEWED THE MEDICAL RECORDS IN THIS CASE,
19 RIGHT?
20 A. YES .
21 Q. DO YOU HAVE AN OPINION TO A DEGREE OF REASONABLE MEDICAL
22 CERTAINTY WHETHER OR NOT THE MEDICATIONS AND DOSAGES OF
23 PSYCHOTROPIC MEDICATIONS THAT WERE USED IN THIS CASE BREACHED
24 THE STANDARD OF CARE -- DR. WEITZEL BREACHED THE STANDARD OF
25 CARE BY USING MULTIPLE MEDICATIONS?
1 A. NO.
2 Q. DO YOU BELIEVE THAT THE DOSAGES THAT DR. WEITZEL
3 SELECTED OF THE DIFFERENT MEDICATIONS FOR THE DIFFERENT
4 PATIENTS, DO YOU HAVE AN OPINION TO A DEGREE OF REASONABLE
5 MEDICAL CERTAINTY WHETHER THE DOSAGES BREACHED THE STANDARD
6 OF CARE?
7 A. NO. BUT I WOULD LIKE TO SAY THAT, YOU KNOW, IT ALL
8 DEPENDS ON WHAT I'M LOOKING AT. IN 1995 OR 1996, ABSOLUTELY
9 NOT. IF I'M COMPARING IT WITH WHAT I KNOW IN 2002, YOU KNOW,
10 I CAN GO BACK AND SAY, WELL, GOSH, MAYBE I -- MAYBE COULD
11 HAVE USED A LOWER DOSE OR -- BUT AT THAT TIME, I THINK THAT
12 THE MEDICATION OF RISPERDAL IS WHAT YOU'RE TALKING ABOUT
13 EARLIER, FOR INSTANCE, WAS A MUCH BROADER SCOPE, AND NO,
14 THERE WAS NO DEVIATION OF WHAT WAS RECOMMENDED AT THE TIME.
15 Q. DO YOU HAVE AN OPINION TO A DEGREE OF REASONABLE MEDICAL
16 CERTAINTY WHETHER THE PSYCHOTROPIC MEDICATIONS OVERMEDICATED,
17 OVERSEDATED THE PATIENTS IN THIS CASE?
18 A. NO.
19 Q. WITH THE AGITATED DEMENTED PATIENT, IS SEDATION A
20 NEGATIVE? IS SEDATION A BAD THING?
21 A. OVERSEDATION IS A BAD THING. SEDATION IS NOT. I MEAN,
22 THESE PATIENTS ARE HARMFUL TO THEMSELVES AND TO OTHERS
23 BECAUSE OF THEIR DELUSIONAL PROCESS AND BECAUSE OF THEIR
24 AGITATION. AS A RESULT OF THAT AND THEIR BEHAVIORS RESULTING
25 FROM THOSE DELUSIONS, THEY ARE A DANGER TO THEMSELVES AND TO
1 OTHERS. AND SO WE HAVE TO BE ABLE TO SEDATE THOSE ACTIVITIES
2 TO BE ABLE TO APPROACH SOMETIME NORMALCY FOR THESE PEOPLE TO
3 HAVE SOME FORM OF COMFORT AND DIGNITY IN THEIR CONDITION.
4 Q. IF, FOR EXAMPLE SOME OF THE PATIENTS IN THIS CASE AT
5 DIFFERENT TIMES WERE SLEEPING OR SLEEPING, FOR EXAMPLE,
6 DURING THE DAY HOURS, IS THAT SOMEHOW A NEGATIVE? IS THAT AN
7 INDICATION THAT DR. WEITZEL SOMEHOW MISSED THE MARK BECAUSE
8 THE PATIENTS ARE SLEEPING?
9 A. MOST OF MY PATIENTS THAT ARE HAVING THAT TROUBLE ARE
10 HAVING THE SAME PROBLEM AS MY KIDS HAD. THEY WERE STAYING UP
11 AT NIGHTS AND SLEEPING ALL DAY, BUT THERE'S LOT OF CAUSES FOR
12 THAT. I DON'T KNOW THAT I COULD SAY IT WAS MEDICATION
13 EFFECT.
14 Q. DO YOU BELIEVE TO A REASONABLE DEGREE OF MEDICAL
15 CERTAINTY THAT DR. WEITZEL WEAKENED THESE PATIENTS WITH THE
16 PSYCHOTROPIC MEDICATIONS?
17 A. OH, ABSOLUTELY NOT.
18 Q. DO YOU BELIEVE TO A REASONABLE DEGREE OF MEDICAL
19 CERTAINTY THAT DR. WEITZEL SOMEHOW HAS EXACERBATED OR MADE
20 WORSE THEIR UNDERLYING MEDICAL PROBLEMS THAT YOU'VE TOLD US
21 ABOUT?
22 A. NO.
23 Q. YOU DON'T BELIEVE HE DID?
24 A. I DO NOT BELIEVE HE DID.
25 Q. DID YOU HAVE AN OPINION TO A REASONABLE DEGREE OF
1 MEDICAL CERTAINTY WHETHER DR. WEITZEL'S USE OF THE
2 PSYCHOTROPIC MEDICATIONS COMBINED WITH THE MORPHINE SULFATE
3 THAT WAS ADMINISTERED TO ALL THESE PATIENTS, WHETHER OR NOT
4 THE COMBINATION OF THOSE THINGS KILLED THESE PATIENTS, CAUSED
5 THEIR DEATH?
6 A. NO.
7 Q. YOU DON'T BELIEVE IT DID?
8 A. I DO NOT BELIEVE THAT.
9 Q. ARE LIVING WILLS AND ADVANCE DIRECTIVES SOMETHING THAT
10 YOU ROUTINELY WORK WITH, DR. CRANMER?
11 A. MOST DEFINITELY.
12 Q. AND CAN YOU EXPLAIN TO THE JURY HOW AN ADVANCE DIRECTIVE
13 IS UTILIZED IN THE NURSING HOME SETTING THAT YOU HAVE OR THE
14 HOSPITAL SETTING WHEN DIFFERENT SITUATIONS MIGHT ARISE WITH
15 THAT ELDERLY PATIENT?
16 A. OUR JOB AS GERIATRICIANS ARE TO BE PATIENT ADVOCATES.
17 AND WE HAVE TO FIND OUT WHAT THAT PATIENT WANTED OR EXPECTED
18 FOR US TO BE ABLE TO DETERMINE HOW WE'RE TO TREAT THAT
19 PATIENT. WE WERE TALKING EARLIER ABOUT THE ALL AMERICAN
20 ACUTE CARE, FULL COURT PRESS, WE COULD SAY, VERSUS PALLIATIVE
21 CARE, WHAT WE WOULD CALL COMFORT AND DIGNITY. WE HAVE TO
22 FIND OUT WHAT THAT PATIENT WANTED. IT'S NOT A DECISION FOR
23 ME TO MAKE, IT'S NOT A DECISION FOR ANYBODY TO MAKE BUT THE
24 PATIENT THEMSELVES. I TELL MY FAMILIES, I DON'T WANNA GET
25 BEAT UP WHEN I GO TO HEAVEN. I'VE GOT A CROWD WAITING FOR ME
1 NOW AND I WANNA MAKE SURE I'M DOING WHAT THEIR MOTHER OR
2 THEIR FATHER WANTED ME TO DO. SO THOSE ARE VERY IMPORTANT
3 ISSUES, THAT'S PROBABLY THE MOST IMPORTANT PART OF TREATING
4 THE FRAIL ELDERLY IS THE DETERMINING THE PATIENT'S
5 LIMITATIONS, EXPECTATIONS, AND WHAT THEY WANTED.
6 Q. COULD YOU TELL US, DR. CRANMER, HOW YOU TYPICALLY
7 EXPLAIN -- MAYBE YOU'VE JUST DONE THAT WITH YOUR LAST ANSWER,
8 BUT CAN YOU TELL US HOW YOU WOULD TYPICALLY EXPLAIN TO THE
9 FAMILY OR TO A FAMILY THE CHOICE BETWEEN COMFORT CARE AND
10 CRITICAL CARE FOR A PATIENT? I.C.U. INTENSIVE CARE UNIT, HOW
11 WOULD YOU EXPLAIN THAT TO A PATIENT -- OR THE FAMILY. I'M
12 SORRY, NOT THE PATIENT.
13 A. WELL, I THINK THE FIRST THING WE DO IS WE MEET WITH THE
14 FAMILY. WE TELL THEM THAT WE HAVE A CROSSROADS DECISION,
15 THAT WE ARE AT A POSITION WHERE THE PATIENT IS EITHER GOING
16 TO NEED ACUTE CARE, THEY'RE GOING TO NEED AGGRESSIVE CARE, OR
17 WE'RE GOING TO HAVE TO, YOU KNOW, REALIZE THAT THIS IS
18 SOMETHING THAT WE'RE GONNA HAVE TO PROVIDE SOME COMFORT AND
19 DIGNITY AND KEEP THEM COMFORTABLE BECAUSE THEY'RE GOING TO
20 DIE FROM THIS PROCESS. REDEFINING WHAT GOOD MEDICAL CARE IS
21 HAS BEEN A REAL CHALLENGE AND -- AND SOMETIMES THE ALL
22 AMERICAN ACUTE CARE AND THIS AGGRESSIVE CARE SYSTEM DOESN'T
23 IMPROVE THEIR QUALITY OF LIFE. AS A MATTER OF FACT,
24 SOMETIMES IT HASTENS THEIR DEATH. SO IF WE HAVE TO DO
25 SURGERY ON PATIENT, FOR INSTANCE, THE PATIENT CAN'T SURVIVE
1 A SURGERY IF WE HAVE TO DO SOME MAJOR PROCEDURE, SOMETIMES
2 THAT WILL BE HARMFUL TO THE PATIENT, NOT HELPFUL. SOMETIMES
3 MOVING THAT PATIENT OUT OF ONE ENVIRONMENT INTO ANOTHER IS
4 GOING TO CREATE MORE DIFFICULTIES. SO WE HAVE TO GO BACK TO
5 THAT FAMILY AND SAY, THESE ARE THE FACTS, THE FACTS ARE WE
6 CAN -- WE HAVE THIS CONDITION, WE HAVE TO GO EITHER WITH
7 PALLIATIVE CARE OR GO WITH ACUTE CARE. EXPLAIN TO THEM THE
8 OPTIONS AND TRY TO EDUCATE THEM TO WHAT'S GONNA HAPPEN WITH
9 EACH CHOICE AND LEAVE THAT CHOICE UP TO THE FAMILY MEMBER AS
10 THEY PRETTY MUCH KNOW THE PATIENT'S WISHES MORE THAN ANYBODY
11 ELSE.
12 Q. DR. CRANMER I'M NOW GONNA TURN TO EACH OF THE FIVE
13 PATIENTS AND LET ME JUST OUT OF RESPECT FOR THE JURY, LET ME
14 JUST TELL YOU THAT THEY'VE HEARD ALL OF THESE PATIENTS
15 DISCUSSED MANY, MANY TIMES. SO I'M GONNA ASK YOU,
16 DR. CRANMER, TO GIVE US THE THUMBNAIL VIEW OF ELLEN ANDERSON.
17 TRULY A THUMBNAIL VIEW OF THIS PATIENT. AND THEN AFTER
18 YOU'VE DESCRIBED THE THUMBNAIL OR GIVEN OR SHARED WITH US
19 THIS THUMBNAIL, THEN I'M GONNA HAVE SOME FOLLOW-UP QUESTIONS,
20 BUT DO YOUR VERY BEST TO BE BRIEF.
21 A. ALL RIGHT. THIS IS A 91 YEAR OLD FEMALE WHO CAME IN
22 WITH SEVERE AGITATION AND CONTINUED DETERIORATION BECAUSE OF
23 HER COMBATIVENESS. SHE WAS INTERFERING WITH HER.
24 Q. BRIEF DOESN'T MEAN SPEAKING FAST.
25 A. SORRY. AND YOU'VE LEARNED THAT, HUH? OKAY. WELL, LET
1 ME CHANGE MY -- MY RESPONSE AND JUST SAY THAT SHE WAS VERY
2 AGITATED. SHE HAD GONE DOWNHILL BECAUSE OF HER COMBATIVENESS
3 AND REFUSING CARE FOR HERSELF. SHE WAS ADMITTED. SHE HAD
4 PREVIOUSLY HAD A FRACTURED HIP, WHICH I HAVE TO SAY THE
5 LITERATURE SHOWS THAT USUALLY IN THIS AGE POPULATION A
6 FRACTURED HIP CAUSES 50 PERCENT MORTALITY WITHIN SIX MONTHS.
7 I THINK HER FRACTURE HAD BEEN WITHIN THE LAST SIX MONTHS.
8 SHE CAME IN, SHE WAS TOTALLY INCONSOLABLE, NO ONE COULD
9 CONSOLE HER AND I THINK AT THE TIME --
10 Q. NOW, LET'S STOP RIGHT THERE.
11 A. YES.
12 Q. THE JURY'S HEARD FAMILY MEMBERS TO SAY THAT THEY
13 INTERPRETED THE INCONSOLABILITY TO BE ANXIETY AND NOT PAIN.
14 DO YOU HAVE AN OPINION BASED ON YOUR REVIEW OF BOTH HER
15 CO-MORBID CONDITIONS, HER UNDERLYING PROBLEMS, HER
16 OSTEOPOROSIS, HER HIP FRACTURE, AND WHAT WE THEN SEE IN THE
17 MEDICAL RECORD CHARTED BY TWO DIFFERENT NURSES AFTER HER
18 ADMISSION ABOUT WHETHER OR NOT THIS WOMAN WAS SIMPSLY ANXIOUS
19 OR DO YOU HAVE AN OPINION TO A DEGREE OF REASONABLE MEDICAL
20 CERTAINTY WHETHER THIS WOMAN HAD PAIN?
21 A. YEAH, I THINK THAT THOSE ISSUES HAD BEEN TREATED. I
22 MEAN EACH OF THESE ARE DIFFERENT DIAGNOSES. YOU KNOW,
23 ANXIETY IS A DIAGNOSIS. PAIN IS A DIAGNOSIS. EACH OF THOSE
24 WERE ADDRESSED. I MEAN THIS PATIENT CAME IN. SHE WAS GIVEN
25 MEDICATIONS FOR AGITATION, FOR THESE ISSUES, AND THEY DID NOT
1 RESOLVE THE PROBLEM.
2 Q. BEFORE SHE CAME.
3 A. YES, UH-HUH.
4 Q. BECAUSE I JUST WANNA BE SURE WE'RE ON THE SAME PAGE.
5 THIS WOMAN DID NOT RECEIVE ANY ANTIPSYCHOTIC MEDICATIONS --
6 A. WHEN SHE ARRIVED, THAT'S RIGHT.
7 Q. OKAY.
8 A. THIS IS BASED ON WHAT WAS IN HER -- IN HER RECORDS PRIOR
9 TO HER HOSPITALIZATION. AND BECAUSE OF THAT, ONE OF THE
10 PROBLEMS THAT WE CAN SEE A LOT OF TIMES WITH THIS INCREASED
11 AGITATION IS THAT PAIN. AND SO THEY ATTEMPTED TO SEE IF THAT
12 WAS PART OF THE PROBLEM.
13 Q. OKAY. I'M NOT GONNA LET YOU GO BACK TO YOUR OVERVIEW.
14 AND I WILL ASK YOU ABOUT A NUMBER OF QUESTIONS, DR. CRANMER.
15 A. SURE.
16 Q. FIRST, THIS JURY HAS HEARD DIFFERENT OPINIONS FROM THE
17 STATE'S WITNESSES ABOUT WHETHER ELLEN ANDERSON WAS IN A
18 CRITICAL SITUATION, ACUTELY ILL, IN A LIFE-THREATENING
19 SITUATION WHEN SHE WAS ADMITTED TO THE HOSPITAL. DO YOU
20 BELIEVE THAT SHE WAS IN A LIFE-THREATENING OR AN ACUTE
21 SITUATION UPON HER ADMISSION?
22 A. NO. WE JUST LOOKED AT HER VITAL SIGNS AND THEY WERE
23 NORMAL.
24 Q. DO YOU SEE ANY EVIDENCE THAT SHE WAS ON THE VERGE OF A
25 CRISIS BECAUSE OF PNEUMONIA UPON HER ADMISSION?
1 A. I THINK THE RECORDS SHOW THAT SHE HAD BEEN TREATED FOR
2 THAT. AND SHE HAD RESPONDED TO THAT TREATMENT.
3 Q. WOULD YOU EXPECT TO SEE A FEVER IF A PATIENT WAS
4 SUFFERING FROM PNEUMONIA?
5 A. YES.
6 Q. DID ELLEN ANDERSON HAVE A FEVER --
7 A. NO.
8 Q. -- UPON HER ADMISSION OR DURING HER HOSPITAL STAY?
9 A. SHE HAD -- NO. '97 -- 97, NO.
10 Q. NOW, ANOTHER CRITICISM THAT THE JURORS HAVE HEARD FROM
11 THE STATE'S WITNESSES IS THAT THIS PATIENT CAME IN AT THE END
12 OF THE DAY, HAD PAIN, OR HAD SYMPTOMS OF PAIN DESCRIBED TO
13 DR. WEITZEL OVER THE PHONE, AND ONE WITNESS IN PARTICULAR HAS
14 TOLD THE JURY THAT HE THOUGHT IT WAS MOST UNUSUAL THAT THIS
15 PATIENT WAS NOT SEEN BY A PHYSICIAN. IS IT UNUSUAL IN YOUR
16 PRACTICE OF MEDICINE THAT PATIENTS SOMETIMES AREN'T SEEN BY A
17 PHYSICIAN BEFORE ORDERS ARE GIVEN FOR THAT PATIENT?
18 A. HOW LONG WAS THE PATIENT IN THE HOSPITAL?
19 Q. ABOUT 17 HOURS.
20 A. NO. I THINK THAT SOMETIMES A PATIENT CAN ARRIVE AFTER
21 WE'VE LEFT THE HOSPITAL. AND SOMETIMES DEATH CAN OCCUR
22 BEFORE WE'RE ABLE TO SEE THE PATIENT THE NEXT DAY.
23 Q. NOW, WITH ELLEN ANDERSON, SHE GETS SHOTS, AGAIN AT 7:30,
24 AT 3:30. DR. WEITZEL APPARENTLY HAD LEFT FOR THE DAY, DID IT
25 BREACH THE STANDARD OF CARE FOR TREATING FRAIL ELDERLY
1 PATIENTS, FOR DR. WEITZEL TO LISTEN TO WHAT THE NURSE HAD TO
2 SAY AT 7:30 AND AT 3:30 IN THE MORNING AND PRESCRIBE MORPHINE
3 WITHOUT COMING DOWN TO THE HOSPITAL AT THOSE HOURS?
4 A. NO. I THINK THAT THE NURSES WERE ABLE TO ASSESS THE
5 PATIENT'S CONDITION. THE RESPONSE TO THE MEDICATION, THEIR
6 VITAL SIGNS, THEY -- THEY ARE THE EYES AND EARS THAT WE RELY
7 ON.
8 Q. NEXT I'D LIKE TO ASK YOU FOR AGAIN, YOUR THUMBNAIL
9 SKETCH OF JUDITH LARSEN. HER MEDICAL CONDITION UPON
10 ADMISSION AND OVERVIEW.
11 Q. THIS IS A VERY DIFFICULT PATIENT. SHE IS 93 YEARS OF
12 AGE. VERY FRAIL, VERY ELDERLY. SHE SUFFERED AN ACUTE
13 STROKE. SHE HAD MULTIPLE DIFFICULTIES. WHEN SHE FIRST
14 ARRIVED, SHE HAD THRUSH, AN INFECTION OF THE MOUTH FROM YEAST
15 AND THAT CAN BE FAIRLY PAINFUL. AS SHE GOT OVER THAT
16 CONDITION, SHE BASICALLY GOT BETTER. AND THEN SHE STARTED TO
17 GET BAD AGAIN. AND THE PATIENT HAD HAD MULTIPLE PROBLEMS
18 BEFORE SHE CAME IN. SHE HAD DEGENERATIVE DISK DISEASE. SHE
19 HAD CHRONIC PAIN. SHE HAD BEEN ON PAIN MEDICATIONS PRIOR TO
20 HER COMING IN. AND SO SHE HAD MULTIPLE FACTORS AND NOT
21 CO-EXISTING -- YEAH, NOT CO-MORBIDITIES, BUT CO-EXISTING
22 MEDICAL CONDITIONS.
23 Q. NOW, ONE OF THE CRITICISMS THAT THE JURORS HAVE HEARD OF
24 DR. WEITZEL'S CARE OF JUDITH LARSEN IS THAT DR. WEITZEL DID
25 NOT COMPLETE A DELIRIUM WORKUP UPON HER ADMISSION. DO YOU
1 BELIEVE THAT DR. WEITZEL MISSED THE BOAT ON A DELIRIUM WORKUP
2 ON JUDITH LARSEN?
3 A. NOT MEANING TO LECTURE, BUT I HAVE TO UNDERSTAND WHAT
4 DELIRIUM IS BECAUSE DELIRIUM IS A SUPERIMPOSED CONFUSION ON
5 TOP OF THEIR DEMENTIA PROCESS. MY PATIENTS CAN DEVELOP
6 DELIRIUM JUST FROM THE SHADOWS CHANGING IN THE AFTERNOON AND
7 WHAT WE CALL SUNDOWNING. AND THAT'S A SUPERIMPOSED DELIRIUM
8 ON TOP OF HER PRE-EXISTING DEMENTIA. I GUESS IF WE'RE
9 TALKING ABOUT WORKING UP A DELIRIUM, WHAT WE NORMALLY DO IS
10 WE NORMALLY LOOK FOR MAJOR ISSUES THAT COULD CAUSE DELIRIUM,
11 SUCH AS ABNORMAL LAB VALUES, OR CO-EXISTING MEDICAL
12 CONDITIONS THAT WOULD CONTRIBUTE TO THAT AND SO --
13 Q. DID DR. WEITIZEL ORDER LABS ON JUDITH LARSEN?
14 A. YES, HE DID.
15 Q. AND BOTTOM LINE, DO YOU THINK THAT HE SOMEHOW BREACHED
16 THE STANDARD OF CARE BY NOT WORKING UP THE DELIRIUM PROPERLY
17 OR SUFFICIENTLY IN JUDITH LARSEN?
18 A. NO.
19 Q. ANOTHER CRITICISM THAT THE JURORS HAVE HEARD IS THAT
20 DR. WEITZEL FAILED TO ADEQUATELY DOCUMENT WHAT HE WAS
21 THINKING ABOUT WHEN HE ORDERED DIFFERENT MEDICATIONS FOR
22 JUDITH LARSEN. DO YOU THINK THAT THERE WAS SOME DEFICIENCY
23 IN THE WAY DR. WEITZEL DOCUMENTED HIS THOUGHT PROCESS WHEN HE
24 ORDERED DIFFERENT MEDICATIONS FOR THIS PATIENT?
25 A. I'M NOT SURE OF THE QUESTION.
1 Q. THERE'S A CRITICISM BY ONE THE STATE'S EXPERTS THAT
2 DR. WEITZEL DIDN'T PROPERLY DOCUMENT WHAT HE WAS THINKING
3 WHEN HE ORDERED DIFFERENT MEDICINE FOR JUDITH LARSEN. DO YOU
4 THINK HE FAILED TO PROPERLY DOCUMENT HIS THINKING PROCESS
5 WHEN HE ORDERED DIFFERENT MEDICINES?
6 A. I DON'T THINK SO. I'D HAVE TO GO BACK AND LOOK AT EACH
7 ONE OF THOSE INDIVIDUALLY, BUT I DON'T THINK HE HAD ANY
8 INAPPROPRIATE DOCUMENTATION ON HIS THINKING PROCESS. I THINK
9 THAT FROM WHAT YOU'RE ASKING ME --
10 MR. WILSON: YOUR HONOR, HE'S ALREADY RESPONDED TO THE
11 QUESTION.
12 THE COURT: SUSTAINED.
13 Q. (BY MR. BUGDEN) WHAT THE WITNESS HAS SAID, WHAT I WANT
14 YOU TO COMMENT ON, IS, DO YOU THINK HE NEEDED TO HAVE WRITTEN
15 MORE IN HIS CHART TO EXPLAIN WHAT HE WAS THINKING WHEN HE
16 ORDERED DIFFERENT MEDICINES, WHETHER IT BE MORPHINE OR
17 WHATEVER?
18 MR. WILSON: LEADING, YOUR HONOR.
19 A. NO.
20 THE COURT: SUSTAINED. ANSWER'S IN. GO AHEAD.
21 Q. (BY MR. BUGDEN) THERE CAME A TIME WITH JUDITH LARSEN
22 WHEN SHE SUFFERED FROM COFFEE GROUNDS EMESIS AND VOMITING.
23 DO YOU REMEMBER THAT, DOCTOR?
24 A. I DO.
25 Q. AND APPARENTLY THERE WAS A PERIOD OF TIME WHEN
1 DR. WEITZEL DID NOT ANSWER WHAT ONE NURSE HAS SAID WERE PAGES
2 TO DR. WEITZEL. DO YOU EVER NOT RETURN YOUR PAGES,
3 CIRCUMSTANCES WHEN PAGES DON'T GET RETURNED IN THE PRACTICE
4 OF MEDICINE?
5 A. WE -- WE RETURN OUR PAGES, BUT THERE'S A LOT OF REASONS
6 SOMETIMES THAT PAGES AREN'T RECEIVED. I MEAN I DON'T KNOW
7 WHAT THIS WAS -- WHAT THIS WAS ABOUT. I KNOW THAT THERE'S
8 TIMES THAT MY BATTERIES ARE DEAD ON MY BEEPER. THERE'S TIMES
9 THAT THE TOWERS ARE DOWN. THERE'S TIMES THAT A LOT THINGS
10 CAN HAPPEN. I DON'T KNOW --
11 Q. WELL, LET'S JUST ASSUME FOR THIS NEXT QUESTION OR TWO
12 THAT DR. WEITZEL DID NOT RETURN THE PAGE FOR LET'S SAY EIGHT
13 HOURS WHEN THIS WOMAN HAD A BOUT OF VOMITING WITH THIS COFFEE
14 GROUNDS EMESIS. DO YOU BELIEVE THAT DR. WEITZEL'S FAILURE TO
15 RESPOND TO THE PAGE ALTERED THE OUTCOME FOR THIS PATIENT IN
16 ANY WAY?
17 A. ON JUDITH LARSEN?
18 Q. JUDITH LARSEN.
19 A. NO.
20 Q. TALKING ABOUT JUDITH LARSEN.
21 A. NO.
22 Q. AND WAS THERE SOMETHING THAT COULD HAVE BEEN DONE,
23 SOMETHING THAT COULD HAVE BEEN RECOMMENDED, ORDERED, WHEN
24 THIS PATIENT STARTED VOMITING?
25 A. WELL, I THINK THAT, YOU KNOW, ANY TIME YOU HAVE COFFEE
1 GROUND EMESIS, THERE'S SOME THINGS THAT YOU CAN CONSIDER, YOU
2 KNOW, WHETHER IT'S SOMETHING AS SIMPLE AS A PEPCID OR
3 ZANTAC OR WHETHER IT'S SOMETHING TO DETERMINE WHAT'S GOING
4 ON. I THINK AT THIS TIME THE APPROPRIATE THING TO DO IS TO
5 ONCE AGAIN CONTACT THE FAMILY AND FIND OUT HOW AGGRESSIVE WE
6 WANNA BE IN WORKING UP THIS SITUATION. AND IF I REMEMBER
7 RIGHT, I THINK THAT WE HAD ALREADY ESTABLISHED WITH THE
8 FAMILY THE PARAMETERS OF WHICH THEY WANTED TO FOLLOW ON THIS
9 PATIENT. AND SO ONCE AGAIN, WE'RE TALKING ABOUT COMFORT AND
10 DIGNITY AS OPPOSED TO AGGRESSIVE WORKUP, BUT --
11 Q. LET ME STOP YOU, DR. CRANMER. DO YOU -- LET'S SAY THAT
12 YOU MIGHT HAVE ORDERED PEPCID OR SOMETHING LIKE THAT FOR THE
13 VOMITING. DO YOU BELIEVE THAT THAT ALTERED THE OUTCOME FOR
14 THIS PATIENT, THE FACT THAT DR. WEITZEL DID NOT ORDER
15 SOMETHING?
16 A. NO, NO.
17 Q. AND THIS PATIENT, YOU KNOW, HAD WHAT WAS SUSPECTED TO BE
18 A GASTROINTESTINAL BLEEDING SITUATION. DID DR. WEITZEL TALK
19 TO THE FAMILY AFTER THE COFFEE GROUNDS EMESIS MANIFESTED
20 ITSELF? DID HE HAVE ANOTHER CONVERSATION WITH THE FAMILY?
21 A. YES, HE DID.
22 Q. AND DO YOU BELIEVE THAT -- I THINK THE JURY'S ALREADY
23 HEARD THAT MERLIN LARSEN WAS THE SPOKESMAN FOR THIS FAMILY
24 AND THAT MERLIN LARSEN HAD INDICATED --
25 MR. BUGDEN: IT IS LEADING, I AGREE.
1 THE COURT: SUSTAINED.
2 Q. (BY MR. BUGDEN) ALL RIGHT, DR. CRANMER. ARE YOU
3 FAMILIAR WITH INCIDENT -- CHARTING IN THE MEDICAL RECORD OF
4 JUDITH LARSEN WHERE THE FAMILY MANIFESTED ITS INTENTIONS WITH
5 REGARD TO JUDITH LARSEN, THE CARE OF JUDITH LARSEN?
6 A. I THINK THERE WAS LIKE THREE DIFFERENT TIMES THAT THEY
7 REAFFIRMED THEIR STANCE ON JUDITH LARSEN.
8 Q. OKAY. AS YOU REVIEWED THE MEDICAL RECORDS WHERE THE
9 FAMILY HAD MADE ITS INTENTIONS KNOWN WITH REGARD TO THE KIND
10 OF CARE THAT THEY WANTED FOR JUDITH LARSEN, WAS THERE ANY
11 DOUBT IN YOUR MIND AS YOU REVIEWED THOSE MEDICAL RECORDS BY
12 THE TIME OF THE GASTROINTESTINAL BLEEDING SITUATION ABOUT
13 WHAT THIS FAMILY WANTED DONE FOR THEIR MOTHER?
14 A. NO.
15 Q. AND WE'VE TALKED TO THE JURY ABOUT WITH JUDITH LARSEN ON
16 THE LAST DAY OF HER LIFE, THERE WAS IN FACT A RESPIRATORY
17 ISSUE WHERE SHE'S AT SIX OR EIGHT. DO YOU REMEMBER THAT?
18 A. CORRECT.
19 Q. AND IN THE CARE OF JUDITH LARSEN -- LET'S SEE,
20 DR. CRANMER, LET ME JUST INDICATE TO YOU THAT IN A MOMENT I'M
21 GONNA SHOW YOU A CHART THAT'S GONNA INDICATE THAT ON THE LAST
22 DAY OF MRS. LARSEN'S LIFE, SHE RECEIVED 130 MILLIGRAMS OF
23 MORPHINE. EARLIER YOU TALKED ABOUT 300 MILLIGRAMS OF
24 MORPHINE FOR A PATIENT. IN THE CONTEXT OF THE CARE OF JUDITH
25 LARSEN, WAS THERE ANYTHING IMPROPER ABOUT ADMINISITERING 130
1 MILLIGRAMS OF MORPHINE TO JUDITH LARSEN ON THE LAST DAY OF
2 HER LIFE?
3 A. WELL, I THINK THAT'S KIND OF COMPLICATED BY THE FACT
4 THAT THIS PATIENT HAD GONE A PROLONGED PERIOD OF TIME WITHOUT
5 RECEIVING ANY OPIOIDS, AND I THINK THAT THERE WAS SOME
6 EFFORTS MADE TO REESTABLISH A LOADING PROCESS.
7 Q. OKAY. I'M GONNA BREAK THAT DOWN.
8 A. OKAY.
9 Q. AND WOULD YOU STEP DOWN FOR JUST A MOMENT?
10 A. SURE.
11 Q. I'M GONNA AND YOU TO REFER TO STATE'S EXHIBIT 3-H. AS
12 YOU CAN SEE, SHE STARTED RECEIVING THE MORPHINE THE SAME DAY
13 AS THE VOMIT OR MAYBE IT'S AFTER THE VOMITING, BUT AROUND THE
14 TIME OF THE VOMITING, DECEMBER 29TH, SHE EXPIRES ON JANUARY
15 3RD, AND THERE ARE INCREASING DOSES OF MORPHINE. EARLIER
16 BEFORE I ASKED YOU TO STEP DOWN, I HAD ASKED YOU WHETHER OR
17 NOT YOUR REVIEW -- YOUR REVIEW OF THE MEDICAL RECORDS,
18 WHETHER YOU HAD ANY DOUBT ABOUT WHAT THE FAMILY HAD DECIDED
19 THEY WANTED TO HAPPEN WITH THEIR MOTHER. AND WHAT WAS IT
20 THAT THEY WANTED TO HAPPEN WITH THEIR MOTHER FROM YOUR
21 READING OF THE MEDICAL RECORDS?
22 A. THEY CHOSE COMFORT AND DIGNITY. THEY DID NOT WANT
23 AGGRESSIVE CARE.
24 Q. AND IN FULFILLING THE WISHES OF THE FAMILY TO PROVIDE
25 COMFORT AND DIGNITY TO JUDITH LARSEN, WHAT WOULD THAT MEAN IN
1 TERMS OF PAIN MANAGEMENT, DR. CRANMER?
2 A. TO MAINTAIN HER COMFORT. TO KEEP HER WITHOUT PAIN.
3 Q. AND WOULD THAT MEAN ADMINISTERING MORPHINE?
4 A. IF IT WAS NEEDED.
5 Q. AND AGAIN, IN T HE CONTEXT OF DECIDING ON A DOSING
6 DECISION, WE CAN SEE THESE -- EACH SQUARE IS 5 MILLIGRAMS,
7 AND SO YOU CAN SEE 15 MILLIGRAMS THE FIRST DAY. THERE WAS AN
8 EARLIER TRIAL. I'M NOT GONNA TALK ABOUT THAT. I'M ONLY
9 GOING ON DECEMBER 25TH, STARTED ON CHRISTMAS, BUT WE'VE
10 TALKING ABOUT THE DECEMBER 20 -- 30TH REALLY. SAID IT WRONG
11 BEFORE. DECEMBER 30TH UNTIL JANUARY 3RD, AND YOU CAN SEE
12 THAT SHE RECEIVED INCREASING DOSES OF MORPHINE. WOULD THAT
13 BE CONSISTENT WITH THE STANDARD OF CARE FOR PROVIDING
14 PALLIATIVE CARE TO A FAMILY THAT HAD DECIDED THAT THEY --
15 ENOUGH IS ENOUGH, WE'LL LET OUR MOM PASS AWAY PEACEFULLY?
16 DOES THIS MEET THE STANDARD OF CARE?
17 A. YES.
18 Q. AND IS THERE ANYTHING ABOUT THE DOSING IN THE LAST DAYS
19 OF JUDITH LARSEN'S LIFE WHERE SHE RECEIVED INCREASING DOSES
20 OF MORPHINE THAT SUGGESTS TO THAT YOU DR. WEITZEL BREACHED
21 THE STANDARD OF CARE BY INCREASING THE DOSES FOR THIS
22 PATIENT?
23 A. NO.
24 Q. AND THERE CAME A TIME IN THE MEDICAL RECORDS WHEN A
25 NURSE WITHHELD MORPHINE DOSES FOR THIS PATIENT ON I BELIEVE
1 THE DAY BEFORE SHE DIED. THREE DOSES OF MORPHINE WERE
2 WITHHELD BECAUSE THE NURSE HAS TESTIFIED TO THE JURY THAT SHE
3 WAS CONCERNED ABOUT THE RESPIRATIONS.
4 A. UH-HUH.
5 Q. IN COMFORT CARE, WHEN THE FAMILY HAS DECIDED ON A
6 PEACEFUL DEATH, WHAT'S THE SIGNIFICANCE OF CHECKING VITAL
7 SIPES LIKE A RESPIRATION RATE? WHY WOULD YOU DO THAT?
8 A. THAT'S A GOOD QUESTION. BUT IT'S USUALLY A HOSPITAL
9 POLICY OR USUALLY A POLICY THAT WE'RE PROVIDING IN THAT
10 PARTICULAR ENVIRONMENT. IS THERE ANY WAY I COULD LOOK AT A
11 PREVIOUS EXHIBIT SHOWING THOSE RESPIRATIONS WITH THIS?
12 Q. YES. YES, I'LL FIND IT FOR YOU. JUST HOLD ON, DOCTOR.
13 OKAY. NOW WE'RE REFERRING, JUDGE, TO DEFENDANT'S EXHIBIT 24.
14 CAN YOU EXPLAIN ABOUT RESPIRATIONS AND INTERRELATIONSHIP WITH
15 THE MORPHINE?
16 A. IF WE'RE LOOKING AT JANUARY THE 2ND, WHICH IS THIS
17 PARTICULAR DAY, THIS PATIENT WAS TREATED WITH THE SAME AMOUNT
18 OF MORPHINE THAT SHE HAD BEEN TREATED WITH THE PREVIOUS DAY,
19 WHICH WAS JANUARY 1ST. SHE ACTUALLY HAD DECREASED
20 RESPIRATIONS AT THE SAME TIME SHE HAD A HIGH WHITE COUNT AND
21 OTHER THINGS THAT WERE FOUND, AND I THINK THAT THERE WERE
22 OTHER MEDICAL CONDITIONS THAT WERE GOING ON WITH THIS PATIENT
23 AT THE SAME TIME. BUT AT THIS POINT WHEN THE MEDICATIONS
24 WERE HELD, I DON'T HAVE THE TIMES THAT THESE WERE GIVEN, BUT
25 I THINK THEY WERE MORE TOWARDS THE END OF THE DAY THAT THEY
1 WERE BEING HELD, IS THAT CORRECT?
2 Q. I DON'T REMEMBER.
3 A. I'D HAVE TO LOOK AT THE RECORDS TO SEE, BUT I THINK IF I
4 REMEMBER RIGHT, THESE WERE THE LAST DOSES THAT SHE HAD
5 RECEIVED. AND WHEN YOU WITHHOLD DOSES AND IT'S BEEN GIVEN
6 EVERY THREE TO FOUR HOURS, AND YOU GIVE THEM THREE DOSES IN A
7 ROW THAT'S BEEN HELD, NOW YOU'RE TALKING ABOUT ANYWHERE FROM
8 TEN TO 12 HOURS THAT THEY HAVEN'T RECEIVED ANY OPIOIDS. MY
9 CONCERN IS THAT THEY'VE BEEN RECEIVING AT THIS TIME, I DON'T
10 WANNA THROW THIS PATIENT INTO IMMEDIATE WITHDRAWAL OR -- FROM
11 HER PHYSICAL DEPENDENCE. THAT HAS NOTHING TO DO WITH
12 ADDITION, BUT THE PHYSICAL DEPENDENCE COULD HAVE THROWN HER
13 INTO WITHDRAWAL AND COMPLICATED HER MEDICAL STATUS, SO WE HAD
14 TO INCREASE THE MEDICATION TO TRY TO GET HER BACK WHERE SHE
15 WAS AT THAT TIME. BUT AS FAR AS THE DOSAGE OF MEDICATION,
16 ONCE AGAIN, YOU HAVE TO TITRATE TO THE EFFECT. AND YOU HAVE
17 TO BE ABLE TO TITRATE THAT DOSAGE TO BE ABLE TO CONTROL THE
18 PAIN THAT THE PATIENT IS HAVING AT THE TIME.
19 Q. LET ME BREAK DOWN A LITTLE BIT OF WHAT YOU JUST SAID
20 FIRST AS TO NURSE WITHHOLDING THE MEDICATIONS, IN PAIN
21 MANAGEMENT IS THERE A CONCEPT OF MAINTAINING A CONSTANT
22 PLATEAU OR A CONSTANT LEVEL? IS THAT SOMEHOW IMPORTANT?
23 A. THE CURRENT STANDARD OF CARE -- NOW, I'M NOT TALKING
24 ABOUT 1995, 1996, BUT IN 2002, THE CURRENT STANDARD OF CARE
25 IS THAT WE HAVE TO GIVE ROUTINE, NOT P.R.N. MEDICATIONS. IF
1 WE'RE GIVING P.R.N. MEDICATIONS, THERE'S AN ICON IN HOSPICE
2 CARE FROM ENGLAND THAT SAYS THAT THAT ACRONYM ACTUALLY STANDS
3 FOR PAIN RELIEF NEVER. BUT WHAT HAPPENS IS, IS BY GIVING IT
4 ROUTINELY --
5 MR. WILSON: YOUR HONOR, I'M GOING TO OBJECT. IT'S
6 NONRESPONSIVE TO THE QUESTION AS TO 1995, THE FACT SITUATION.
7 THE COURT: OVERRULED THE OBJECTION.
8 BY MR. BUGDEN:
9 Q. OVERRULED. GO HEAD.
10 A. WELL, I'M TRYING TO GET THERE. AND WHAT I'M TRYING TO
11 SAY IS, IS THAT WE FOUND OUT THAT BECAUSE WE'RE GIVING P.R.N.
12 MEDICATIONS, WE'RE GOING TO FROM WHAT WE CALL PAIN CRISIS TO
13 PAIN CRISIS. A PAIN CRISIS IS WHEN THE ENDORPHINS, THE
14 PROSTAGLANDINS, AND ALL THE CHEMICAL ASPECTS OF PAIN HAVE
15 GOTTEN SO FAR OUT OF CONTROL THAT WHAT HAPPENS IS, IS WE HAVE
16 TO GIVE THEM HIGHER DOSES OF MEDICATIONS JUST TO CONTROL THAT
17 PARTICULAR RESPONSE. SO BY GIVING P.R.N. MEDICATIONS, A LOT
18 OF TIMES WHAT WE'RE DOING IS WE'RE GOING FROM PAIN CRISIS TO
19 PAIN CRISIS TO PAIN CRISIS AS OPPOSED TO GIVING THEM
20 SOMETHING ROUTINE THAT'S A SLOW RELEASE AND CONSTANT LEVEL
21 FOR THAT PATIENT.
22 Q. DR. CRANMER, CAREFULLY -- WHEN A NURSE WITHHOLDS
23 MEDICATIONS LIKE THIS WAS DONE, DO YOU BELIEVE THAT THE NURSE
24 HAD ANY PARTICULAR OBLIGATION TO NOTIFY THE PHYSICIAN OF WHAT
25 SHE WAS DOING?
1 A. ON WITHHOLDING THE MEDICATION?
2 Q. YEAH.
3 A. OH, ABSOLUTELY.
4 Q. IN A SIT -- DO YOU BELIEVE THAT IT WAS -- HOW WOULD YOU
5 COMPARE DR. WEITZEL'S DECISION TO GIVE CATCH-UP DOSES OF
6 MORPHINE ON THE DAY AFTER THE NURSE HAD WITHHELD MORPHINE?
7 HOW DOES THAT COMPARE TO THE STANDARD OF CARE?
8 A. WELL, IT'S -- IT IS THE STANDARD OF CARE.
9 Q. THANK YOU. DR. BAIR, ONE OF THE STATE'S EXPERTS, HAS
10 TESTIFIED THAT IF A PATIENT -- IF SOMEONE LOOKS PEACEFUL AND
11 CALM, THEN THEY USUALLY ARE PEACEFUL AND CALM. AND I THINK
12 THE SUGGESTION WAS THAT IF THE PATIENT APPEARED TO BE
13 PEACEFUL AND CALM, THEN THERE WOULDN'T BE ANY REASON TO
14 CONTINUE TO GIVE THE PAIN MEDICATION TO THE PATIENT. DO YOU
15 AGREE WITH THAT? THAT IF A PATIENT WAS PEACEFUL AND CALM
16 THAT YOU SHOULD STOP GIVING THE PAIN MEDICATION?
17 A. I THINK THE REASON WHY THEY WERE PEACEFUL AND CALM IS
18 BECAUSE THEY WERE RECEIVING THE PAIN MEDICATION. I THINK IF
19 YOU'D STOPPED GIVING IT, THEY WOULDN'T BE PEACEFUL AND CALM
20 ANYMORE. I THINK THAT'S THE DESIRED EFFECT YOU'RE AFTER BY
21 GIVING THE PAIN MEDICATION, SO I DON'T UNDERSTAND THAT
22 STATEMENT.
23 Q. ALL RIGHT. NOW I'M GONNA ASK YOU A COUPLE QUESTIONS
24 ABOUT MARY CRANE.
25 THE COURT: LET'S TAKE OUR BREAK AT THIS TIME IF WE
1 COULD, MR. BUGDEN.
2 MR. BUGDEN: THANK YOU.
3 THE COURT: YOU MAY STEP DOWN DOCTOR. AND WE'LL TAKE --
4 BE ON BREAK UNTIL -- WE'LL GO UNTIL 10:30. WE'LL RECONVENE
5 AT THAT TIME. WE'RE IN RECESS.
6 (THE COURT TOOK A BRIEF RECESS.)
7 THE COURT: RECORD SHOULD NOTE THE PARTIES AND COUNSEL
8 ARE PRESENT. DR. CRANMER IS ON THE STAND. DOCTOR, I REMIND
9 YOU THAT YOU'RE STILL UNDER OATH.
10 THE WITNESS: YES.
11 THE COURT: JURY IS IN THE JURY BOX. YOU MAY PROCEED,
12 MR. BUGDEN.
13 MR. BUGDEN: DR. CRANMER, TWO MORE QUESTIONS ON JUDITH
14 LARSEN. AS YOU CONSIDER THE END OF LIFE CARE THAT WAS GIVEN
15 TO THIS PATIENT, COMFORT CARE THAT WAS GIVEN TO THIS PATIENT,
16 IS THERE ANYTHING YOU WOULD HAVE DONE DIFFERENTLY IN THE
17 TREATMENT OF THE PATIENT AND PROVIDING END OF LIFE CARE FOR
18 JUDITH LARSEN?
19 A. NO.
20 Q. AND BEFORE THE BREAK YOU MENTIONED THAT ON THE DAY
21 BEFORE SHE PASSED AWAY, WHEN SOME RESPIRATION RATES WERE
22 DOWN, THAT THAT MAY HAVE BEEN DUE TO SOME, I DON'T KNOW, YOU
23 SAID OTHER PROCESSES. WHAT WAS THE OTHER PROCESS THAT YOU
24 MEANT?
25 A. WELL, THE PATIENT WAS ACTIVELY DYING.
1 Q. DID DR. WEITZEL HAVE ANYTHING TO DO WITH CAUSING PATIENT
2 TO BE ACTIVELY DYING THAT THE POINT?
3 A. NO. HE WAS PROVIDING SOME COMFORT DURING THE DYING
4 PROCESS.
5 Q. OKAY. NOW I'M NOT SUGGESTING THAT YOU'VE DONE
6 OTHERWISE, BUT I'M GONNA -- IN THE NEXT FEW PATIENTS, I'M
7 JUST GONNA SAY AS A GENERAL RULE, BRIEF IS BETTER. OKAY?
8 A. THANK YOU.
9 Q. ON MARY CRANE, CAN YOU GIVE ME YOUR THUMBNAIL OF THIS
10 PATIENT PLEASE, DR. CRANMER?
11 A. MARY CRANE WAS LITTLE BIT OF A DIFFICULT PATIENT. SHE
12 HAD A HISTORY OF DEGENERATIVE DISK DISEASE. SHE HAD A
13 HISTORY OF CHRONIC PAIN. WHEN SHE CAME IN, SHE CAME IN
14 WITH --
15 Q. NOT TRYING TO INTERRUPT YOU, I'M SORRY. APOLOGIZE FOR
16 INTERRUPTING. YOU MAY HAVE SAID BEFORE THE BREAK THAT JUDITH
17 LARSEN HAD A HISTORY OF DEGENERATIVE DISK DISEASE. I MAY
18 HAVE HEARD YOU SAY THAT. IF YOU SAID THAT, WERE YOU
19 MISTAKEN?
20 A. I DIDN'T KNOW I SAID THAT. IF I DID SAY THAT, I WAS
21 PROBABLY TALKING ABOUT MARY CRANE.
22 Q. OKAY. WELL, IT'S --
23 A. IT'S MY PAPERS. I SHOULD HAVE STAPLED THEM TOGETHER
24 MAYBE.
25 Q. OKAY. NOW, BACK TO MARY CRANE. YOU SAY THAT SHE HAD A
1 DEGENERATIVE DISK DISEASE. KEEP GOING WITH THE THUMBNAIL?
2 A. YEAH, SHE HAD A HISTORY OF DEGENERATIVE DISK DISEASE.
3 HISTORY OF CHRONIC PAIN. SHE CAME INTO THE FACILITY WITH NOT
4 ONLY ALZHEIMER'S TYPE DEMENTIA, BUT VASCULAR DEMENTIA, SMALL
5 STROKES. SHE ALSO HAD A PROBLEM WITH PSYCHOGENIC POLYDIPSIA,
6 MEANING THAT SHE WAS DRINKING WATER CONSTANTLY. AND BY
7 DRINKING WATER CONSTANTLY, I THINK SHE'D EVEN DRANK OUT OF
8 THE TOILET BECAUSE SHE WAS JUST WANTING TO DRINK THE WATER,
9 CAUSING PROBLEMS WITH LOW SODIUM. SHE HAD MULTIPLE PROBLEMS
10 GOING ON. SHE -- WITH THESE NUMMEROUS CO-MORBIDITIES, SHE
11 WAS MAINTAINED ON HER PAIN MANAGEMENT, AND SHE DEVELOPED A
12 COMPLICATION OF A VAGINAL/RECTAL FISTULA --
13 Q. OKAY. LET'S STOP -- I'VE GOT A COUPLE OF QUESTIONS WITH
14 WHAT YOU'VE JUST WALKED US THROUGH. FIRST AS TO THE
15 DEMENTIA, DO YOU BELIEVE THAT THIS PATIENT HAD ADVANCED OR
16 END-STAGE DEMENTIA?
17 A. I DO.
18 Q. AND WHAT IS THAT BASED ON IN RELATIONSHIP TO THE FAST
19 SCALE?
20 A. WELL, BASICALLY, WHAT SHE WAS SHOWING IN HER FUNCTIONAL
21 SCALE IS THAT SHE WAS SHOWING INCONTINENCE OF HER BOWEL AND
22 BLADDER. AND THAT PUT HER AT STAGE 6-E OF HER PROCESS. AS
23 FAR AS HER COGNITIVE SKILLS, I BELIEVE THAT HER FULSTEIN MINI
24 MENTAL STATUS WAS AROUND 14 OUT OF 30 QUESTIONS, WHICH IS
25 CONSISTENT. AND SO BETWEEN HER MINI MENTAL STATUS TEST AND
1 HER FAST SCALE, SHE WAS AT STAGE 6-E OF HER PROCESS.
2 Q. OKAY. YOU'VE ANSWERED THAT QUESTION. NOW, BEAR WITH
3 ME, DR. CRANMER. THIS PATIENT DEVELOPED A RECTO/VAGINAL
4 FISTULA. IS THERE ANY WAY FROM A SCIENTIFIC MEDICAL
5 PERSPECTIVE THAT THE TREATMENT OF THIS PATIENT WITH
6 PSYCHOTROPIC MEDICATIONS COULD HAVE HAD ANYTHING TO DO WITH
7 THIS PATIENT DEVELOPING A RECTO-VAGINAL FISTULA?
8 A. OH, ABSOLUTELY NOT.
9 Q. AND IN FACT, IS THERE EVEN SOME REASON TO BELIEVE THAT
10 THE RECTO-VAGINAL FISTULA WAS DEVELOPING BEFORE THE PATIENT
11 HAD ARRIVED AT THE HOSPITAL?
12 A. IT'S POSSIBLE.
13 Q. AND DO YOU BELIEVE -- IS THERE ANY WAY FROM A SCIENTIFIC
14 PERSPECTIVE THAT THE PSYCHOTROPIC MEDICATIONS COULD HAVE
15 SOMEHOW WEAKENED THIS PATIENT AND PREDISPOSED HER TO DEVELOP
16 A RECTO/VAGINAL FISTULA?
17 A. ABSOLUTELY NOT.
18 Q. OKAY. NOW ONE OF THE CRITICISMS THAT THIS JURY'S HEARD
19 ABOUT THE TREATMENT THAT DR. WEITZEL GAVE THIS PATIENT IS
20 THAT ONE DR. HAS TESTIFIED THAT HE DIDN'T THINK THAT AN
21 DURAGESIC PATCH WAS INDICATED FOR THIS PATIENT. DO YOU THINK
22 A DURAGESIC PATCH WAS A GOOD CHOICE FOR THIS PATIENT
23 A. I THINK THAT IT'S GREAT WAY OF GETTING A SUSTAINED LEVEL
24 OF OPIOIDS INTO A PATIENT ON A ROUTINE BASIS, ESPECIALLY A
25 PATIENT WITH A HISTORY OF CHRONIC PAIN, WITH HER DEGENERATIVE
1 DISK DISEASE AND ANY AOTHER PAIN THAT SHE MAY BE HAVING, THEY
2 WERE GETTING A CONSISTENT BLOOD LEVEL WITH THE DURAGESIC
3 TRANSDERMAL PATCH.
4 Q. CAN YOU TELL ME DR. CRANMER, DOES THE MEDICAL PROFESSION
5 TAKE A POSITION ON THE ETHICS OF TREATING A PATIENT WITH A
6 PLACEBO? IS TREATING A WITH A PLACEBO ETHICAL?
7 A. NO.
8 Q. OKAY. DO YOU -- SO WE'VE TALKED ABOUT THE RECTO-VAGINAL
9 FISTULA. THIS PATIENT WAS TREATED WITH CIPRO AND KEFLEX.
10 AND THE JURY'S HEARD CRITICISM OF USE OF THOSE TWO
11 ANTIBIOTICS, CIPRO AND KEFLEX. DO YOU BELIEVE THAT THERE'S
12 SOMETHING WRONG WITH DR. WEITZEL ORDERING CIPRO AND KEFLEX
13 FOR A RECTO-VAGINAL FISTULA?
14 A. FOR A RECTO-VAGINAL FISTULA?
15 Q. RIGHT.
16 A. NO. THOSE ARE BOTH TWO DIFFERENT BROAD SPECTRUM
17 ANTIBIOTICS. THAT WOULD BE A GOOD CHOICE.
18 Q. ONCE THIS PATIENT BEGAN MANIFESTING SYMPTOMS OF PAIN, DO
19 YOU THINK THAT DR. WEITZEL SOMEHOW BREACHED THE STANDARD OF
20 CARE BY NOT ORDERING MORE RADIOLOGICAL TESTS TO -- OF HER
21 ABDOMEN, FOR EXAMPLE?
22 A. I DON'T KNOW -- WE DON'T DO TESTS JUST TO DO TESTS. WE
23 DO TESTS TO DETERMINE WHAT WE WOULD DO DIFFERENT IN A
24 PATIENT'S TREATMENT. WE ALREADY HAVE A RECTO/VAGINAL
25 FISTULA. I'M NOT REAL SURE WHAT THAT WOULD HAVE -- I DON'T
1 THINK THAT WOULD HAVE HELPED US WITH THAT DIAGNOSIS. WE
2 ALREADY HAD THAT.
3 Q. WELL, NOT TO PUT TOO FINE A POINT ON IT, THE STATE'S
4 EXPERT GERIATRICIAN HAS TESTIFIED THAT DR. WEITZEL BREACHED
5 THE STANDARD OF CARE BY NOT ORDERING A C.T. SCAN OF THE
6 ABDOMEN. DO YOU AGREE WITH THAT? WOULD YOU HAVE ORDERED A
7 C.T. SCAN OF THE ABDOMEN IN THIS PATIENT?
8 A. NO.
9 Q. DO YOU BELIEVE THAT FAILURE TO ORDER A C.T. SCAN
10 BREACHED THE STANDARD OF CARE?
11 A. NO.
12 Q. LYDIA SMITH, CAN YOU GIVE ME YOUR THUMBNAIL OF THAT
13 PATIENT PLEASE?
14 A. SHE WAS A 91 YEAR OLD FRAIL FEMALE WHO WAS ADMITTED TO
15 THE GEROPSYCH UNIT THAT WAS HARMFUL TO HERSELF AND OTHERS.
16 SHE WAS VERY AGITATED DURING HER WHOLE STAY. SHE WAS KICKING
17 BITING, HITTING, SCRATCHING. SHE HAD HISTORY OF MULTIPLE
18 MEDICAL PROBLEMS, INCLUDING STROKE PRIOR TO HER ADMISSION.
19 AND CONGESTIVE HEART FAILURE, HIGH BLOOD PRESSURE, MULTIPLE
20 PROBLEMS. SHE'D HAD A HISTORY OF FROZEN SHOULDER. SHE --
21 THERE'S SOME QUESTION I HAD WHETHER SHE MAY HAVE HAD A
22 NEUROPATHIC PAIN PROCESS --
23 Q. WHAT DOES THAT MEAN --
24 A. -- AS I READ THROUGH THE RECORD.
25 Q. WHAT DOES THAT MEAN PLEASE?
1 A. NEUORPATHIC PAIN IS A WHOLE DIFFERENT TYPE OF PAIN.
2 IT'S LIKE POST HERPETIC NEURALGIA. AFTER YOU GET SHINGLES,
3 YOU'LL HAVE PAIN WHERE YOU JUST BARELY TOUCH THE SKIN, AND IT
4 HURTS. IF YOU PRESS HARD, IT DOESN'T HURT. WE SEE THAT WITH
5 DIABETIC NEUROPATHY. WE SEE THAT WITH STATUS POST STROKE
6 NEUOPATHY. IT'S A DAMAGE TO THE NERVE THAT CAUSES PAIN.
7 Q. HOLD ON HERE. THIS PATIENT HAD SUFFERED FROM STROKES,
8 IS THAT RIGHT?
9 A. THAT IS CORRECT.
10 Q. NOW, ONE -- THIS JURY HAS HEARD TESTIMONY FROM -- WELL,
11 FIRST, DID I HEAR YOU CORRECTLY THAT THIS PATIENT MANIFESTED
12 AGITATION THROUGHOUT HER HOSPITAL STAY?
13 A. IT APPEARED TAKE WAY, YES.
14 Q. THIS JURY HAS HEARD TESTIMONY FROM A NURSE WHO PROVIDED
15 CARE TO THIS PATIENT THAT DESCRIBED THIS PATIENT AS FEISTY
16 AND A DARLING WOMAN. WAS THIS WOMAN PRESENTING WITH DARLING
17 BEHAVIORS?
18 MR. WILSON: OBJECTION YOUR HONOR. I -- FIRST OF ALL,
19 IT'S CALLS FOR SPECULATION ON THE PART OF THE WITNESS --
20 THE COURT: OVERRULED. HE CAN TESTIFY.
21 THE WITNESS: YOU KNOW, ALL OF MY PATIENTS ARE DARLING.
22 I MEAN MY BABIES ARE JUST REAL BIG, BUT THE POINT BEING THAT
23 WE -- THIS PATIENT WAS VERY AGITATED, VERY COMBATIVE, VERY
24 DIFFICULT TO TAKE CARE OF.
25 Q. (BY MR. BUGDEN) DR. CAN YOU CONCEIVE OF A SITUATION
1 WHERE IN YOUR TREATMENT OF A PATIENT LIKE LYDIA SMITH, THAT
2 YOU WOULD NOT HAVE TREATED HER WITH PSYCHOTROPIC MEDICATION?
3 A. OH, ABSOLUTELY NOT.
4 Q. AND THERE IS A GENERAL STATEMENT. NOW I'M MOVING -- ALL
5 FIVE PATIENTS PLEASE. I'M SORRY TO GO OUTSIDE OF LYDIA FOR A
6 MOMENT BUT I SHOULD HAVE ASKED YOU THIS BEFORE. ANOTHER
7 CRITICISM OF DR. BAIR, OF GERIATRICIAN WITH -- WHO'S
8 TESTIFIED FOR THE STATE, IS THAT AS IT RELATES TO DELIRIUM,
9 AND HIS CRITICISM THAT DR. WEITZEL DIDN'T DO A DELIRIUM
10 WORKUP OR FAILED TO RECOGNIZE DELIRIUM, A SUGGESTION HAS
11 BEEN MADE THAT DR. WEITZEL BREACHED THE STANDARD OF CARE IN
12 EVERY PATIENT BY FAILING TO TAKE THESE PATIENTS OFF THEIR
13 MEDICATIONS. WOULD YOU HAVE EVER DONE THAT?
14 A. OFF ALL THEIR MEDICATIONS?
15 Q. THAT'S WHAT I BELIEVE THE WITNESS TESTIFIED.
16 A. NO, I DO NOT THINK THAT WOULD BE AN APPROPRIATE
17 DECISION.
18 Q. OKAY. BACK TO LYDIA. LET'S JUMP BACK INTO LYDIA. ONE
19 OF DR. BAIR'S CRITICISMS AND STATEMENTS TO THE JURY IS THAT
20 DR. WEITZEL BREACHED THE STANDARD OF CARE BY NOT COMPLETING A
21 PSYCHIATRIC INTAKE OR PSYCHIATRIC EVALUATION OF THIS PATIENT
22 WITHIN 24 HOURS OF THE PATIENT'S ADMISSION TO THE HOSPITAL,
23 I.E., SPECIFICALLY THAT DR. WEITZEL DIDN'T DO THE PSYCHIATRIC
24 EVALUATION FOR 28 HOURS. DO YOU BELIEVE THAT THAT WAS A
25 BREACH OF THE STANDARD OF CARE FOR DR. WEITZEL TO HAVE NOT
1 DONE THE PSYCH EVAL FOR 28 HOURS?
2 A. A DIFFERENCE IN FOUR HOURS, NO, I --
3 Q. WELL, MORE IMPORTANTLY, DR. CRANMER, IS THERE ANY WAY
4 THAT THE FAILURE TO COMPLETE THE PSYCHIATRIC ADMISSION WHEN
5 THIS PATIENT WAS IN THE HOSPITAL FOR ABOUT TEN DAYS, THAT
6 THAT ALTERED THE OUTCOME FOR THIS PATIENT?
7 A. NO.
8 Q. KEEP YOUR VOICE UP PLEASE.
9 A. NO, IT WOULD NOT.
10 Q. THIS PATIENT MRS. SMITH AGAIN, ANOTHER ONE OF THE
11 CRITICISMS LODGED BY THE STATE'S EXPERT IS THAT HE DISAGREED
12 WITH THE GERIATRIC PHARMACOLOGY THAT DR. WEITZEL ORDERED. I
13 GUESS THAT MEANS THE MULTIPLE MEDICATIONS. AND SPECIFICALY
14 I'LL JUST TELL YOU THAT SHE WAS, ACCORDING TO THE DOCTOR,
15 DR. BAIR, WHO TESTIFIED FOR THE STATE, SHE WAS ON SEVEN
16 MEDICATIONS AND SOMEHOW THERE'S A SUGGESTION THAT THERE WAS
17 SOMETHING UNUSUAL ABOUT THAT. IS SEVEN MEDICATIONS UNUSUAL
18 FOR GERIATRIC DEMENTED PATIENTS?
19 A. MOST OF THE PATIENTS THAT WE GET INTO THE NURSING HOMES
20 ARE USUALLY ON OVER 20 MEDICATIONS. AND SO WE TRY TO SEE IF
21 THERE'S ANY WAY WE CAN HONE THOSE DOWN. I WAS ALLUDING
22 EARLIER THAT MOST OF THESE PATIENTS HAD MULTIPLE DOCTORS,
23 SOME OF WHICH KNOW NOTHING ABOUT THE OVERALL CARE, BUT WE HAVE SO
24 MANY SPECIALISTS THAT SOMETIMES THE MEDICATIONS CAN BE
25 REFINED, BUT NO, SEVEN IS REALLY GOOD.
1 Q. WAS THERE SOMETHING UNIQUELY OR CURIOUSLY OR
2 EXTRAORDINARILY DANGEROUS ABOUT DR. WEITZEL USING A
3 COMBINATION OF SEVEN PSYCHOTROPICS TO TRY TO CONTROL LYDIA
4 SMITH'S AGITATION?
5 A. IT WASN'T -- IT WASN'T WORKING WELL AND HE HAD TO
6 CONTINUE TO ADD NEW REGIMEN. I DON'T THINK THERE'S ANYTHING
7 WRONG WITH THAT.
8 Q. THANK YOU. DO YOU BELIEVE THAT DR.WEITZEL FAILED TO
9 RECOGNIZE DELIRIUM IN THIS PATIENT?
10 A. YOU KNOW, AND I ALLUDED TO THIS EARLIER AND I'M GONNA
11 SAY AGAIN, YOU KNOW, IF WE'RE LOOKING FOR -- I DON'T KNOW,
12 THERE'S A DIFFERENCE BETWEEN IVORY TOWER MEDICINE AND BEING
13 IN THE TRENCHES. IN THE TRENCHES, WE SEE DELIRIUM AT ALL
14 PHASES. IF WE'RE TALKING ABOUT A DELIRIUM WORKUP, WHICH I'M
15 NOT SURE WHAT HE REALLY MEANS BY ALL THAT -- THEN WE'RE DOING
16 BLOOD TESTS, WE'RE LOOKING AT MEDICATIONS FOR POSSIBLE ADDED
17 DELIRIUM. WE'RE LOOKING FOR THOSE CO-MORBIDITIES, THOSE
18 COEXISTING SITUATIONS THAT COULD ADD TO THAT INCREASED
19 CONFUSION --
20 Q. DID DR. WEITZEL DO THOSE --
21 A. HE DID.
22 Q. -- DO HE DO LAB TESTS, DID HE LOOK AT THE MEDICATIONS,
23 HE TITRATE TO EFFECT?
24 A. HE DID.
25 Q. ENNIS ALLDREDGE. MISTER -- GIVE ME YOUR THUMBNAIL ON
1 MR. ALLDREDGE PLEASE.
2 A. OH, ENNIS ALLDREDGE, BLESS HIS HEART, HE WAS -- HE WAS
3 DIABETIC AND REALLY AN ACCIDENT WAITING TO HAPPEN. HE HAD
4 POORLY CONTROLLED DIABETES. HIS HEMOGLOBIN A-1-C WAS TWICE
5 OF WHAT IT SHOULD HAVE BEEN, MEANING THAT HEMOGLOBIN A-1-C IS
6 A TEST WE DO TO SEE HOW THEIR DIABETES HAD BEEN CONTROLLED
7 OVER A LONG PERIOD OF TIME, NOT JUST THAT DAY. A FINGER
8 STICK BLOOD SUGAR, FOR INSTANCE, MIGHT TELL YOU WHAT THE
9 BLOOD SUGAR IS AT THAT TIME, BUT WE ACTUALLY HAVE A TEST THAT
10 WILL KIND OF SHOW WHAT YOU HAS BEEN GOING ON FOR A LONG
11 PERIOD OF TIME, AND WE NEVER WANT THAT BLOOD SUGAR, THAT
12 HEMOGLOBIN A-1-C TO BE OVER -- OVER SEVEN FOR SURE, AND HIS
13 WAS 12 WHEN HE CAME IN. SO FOR A LONG PERIOD OF TIME, HE'D
14 BEEN OUT OF CONTROL. NOW, IF YOU GO TO ANY, YOU KNOW,
15 AMERICAN DIABETIC ASSOCIATION OFFICE, THE FIRST THING THEY'LL
16 DO IS THEY'LL SHOW YOU A PAMPHLET SAYING IF YOU DO NOT
17 CONTROL YOUR DIABETES --
18 MR. WILSON: OBJECTION, YOUR HONOR. IT'S NONRESPONSIVE.
19 THE COURT: SUSTAINED.
20 THE WITNESS: I'M SORRY.
21 Q. (BY MR. BUGDEN) WAS DOC -- OR WAS ENNIS ALLDREDGE'S
22 DIABETIC CONDITION A DANGEROUS CIRCUMSTANCE OR A CONDITION
23 THAT COULD RESULT IN DEATH?
24 A. MOST DEFINITELY.
25 Q. LET'S SAY A CONDITION THAT COULD RESULT IN DEATH.
1 A. MOST DEFINITELY. THE UNCONTROLLED DIABETES, WHAT I
2 SHOULD HAVE SAID, AND I APOLOGIZE FOR BEING SO VERBOSE, IT
3 LEADS TO ARTERIOSCLEROTIC VASCULAR DISEASE WHICH LEADS TO
4 MULTIPLE ORGAN FAILURE.
5 Q. THIS PATIENT HAD AN M.R.I. CONDUCTED OR MAYBE IT WAS A
6 CAT SCAN, BUT IT HAD SOME SORT OF A LOOK AT HIS BRAIN, DURING
7 HIS HOSPITALIZATION, AND THE JURY'S HEARD TESTIMONY FROM A
8 RADIOLOGIST AND OTHERS THAT THE RADIOLOGICAL EXAM WAS
9 COMPROMISED BECAUSE MR. ALLDREDGE WAS MOVING. NOW, DO YOU
10 REMEMBER THAT?
11 A. I DO.
12 Q. AND ONE OF THE CRITICISMS THAT'S BEEN LODGED AGAINST
13 DR. WEITZEL IS THAT HE DID NOT ORDER ANOTHER RADIOLOGICAL
14 EXAM AFTER THE COMPROMISED FIRST ONE. DO YOU BELIEVE IT
15 BREACHED THE STANDARD OF CARE TO NOT ORDER A SECOND CAT SCAN
16 OR M.R.I. OR SOMETHING LIKE THAT?
17 A. WELL, NUMBMER ONE, A CAT SCAN DOESN'T SHOW AS MUCH OF
18 WHITE MATTER OF THE BRAIN AS AN M.R.I. WOULD, SO IT WOULD BE
19 SILLY TO DO A CAT SCAN IF IT DOESN'T SHOW AS MUCH AS THE
20 M.R.I. I READ THE M.R.I. REPORT AND HE WAS ABLE TO READ A
21 LOT OUT OF THE REPORT, BUT HE DID STATE THAT THERE WAS SOME
22 FUZZINESS ON SOME OF THE AREAS, BUT HE STILL SHOWED THAT
23 THOSE AREAS WERE PRESENT. IF --
24 Q. WHAT WAS THE MAJOR FINDING THAT YOU INTERPRETED FROM THE
25 M.R.I.?
1 A. THAT HE HAD HAD STROKES.
2 Q. AND WHETHER IT WAS COMPROMISED OR FUZZY, WAS THERE -- IS
3 THERE ANY DOUBT IN YOUR MIND -- I MEAN WOULD IT PRECLUDE YOU
4 FROM CONCLUDING TO A REASONABLE DEGREE OF MEDICAL CERTAINTY
5 THAT MR. ALLDREDGE HAD SUFFERED A STROKE?
6 A. NO, NO.
7 Q. AND HOW WOULD YOU DO ANOTHER M.R.I. TO GET A BETTER ONE
8 WITH THIS PATIENT WHO ALREADY HAD BEEN SEDATED? WHAT WOULD
9 BE THE ALTERNATIVE?
10 A. YOU WOULD HAVE TO SEDATE HIM TOTALLY, PROBABLY EVEN
11 UNDER ANESTHESIA.
12 Q. WOULD THAT BE DANGEROUS?
13 A. WELL, IT'S NOT PREFERRED ON A FRAIL ELDERLY PATIENT.
14 Q. DO YOU BELIEVE IT WAS APPROPRIATE AFTER DR. WEITZEL HAD
15 ACCESS TO THE M.R.I., YOU'VE TOLD US -- OR THE CAT SCAN THAT
16 YOU'VE TOLD US, WHATEVER IT WAS, THE RADIOLOGICAL EXAM YOU
17 TOLD US ABOUT, FOR DR. WEITZEL TO THEN APPROACH
18 MRS. ALLDREDGE, THE WIFE, AND EXPLAIN TO HER THAT THEY WERE
19 AT A CROSSROADS, THEY NEEDED TO MAKE A DECISION?
20 A. I THINK IT WAS APPARENT THAT HE'D HAD MULTIPLE STROKES.
21 HE HAD HAD TWO LARGE -- LARGER STROKES AND THEN HE'D HAD
22 MULTIPLE SMALLER STROKES THROUGHOUT THE BRAIN.
23 Q. AND DO YOU BELIEVE IT WAS APPROPRIATE FOR DR. WEITZEL TO
24 GO TO THE FAMILY AND ASK THEM, DO YOU WANNA MAKE -- YOU NEED
25 TO MAKE A CARE DECISION?
1 A. YES.
2 Q. WOULD YOU HAVE DONE THE SAME THING?
3 A. DEFINITELY.
4 Q. ANOTHER CRITICISM THAT HAS BEEN MADE -- I MEAN, WOULD
5 YOU HAVE NEEDED ANY MORE MEDICAL CERTAINTY FOR YOU TO GO TO
6 THE FAMILY AND SAY WE'RE AT A CROSSROADS, TIME FOR YOU TO
7 MAKE A DECISION, MRS. ALLDREDGE. WOULD YOU HAVE NEEDED ANY
8 MORE MEDICAL CERTAINTY?
9 A. NO.
10 Q. AND THE FINAL CRITICISM, AS I UNDERSTAND IT, THAT HAS
11 BEEN MADE BY DR. BAIR OF DR. WEITZEL'S TREATMENT OF
12 MR. ALLDREDGE IS THAT HE WAS HIGHLY CRITICAL OF DR. WEITZEL
13 ORDERING ATIVAN AND MORPHINE FOR THIS PATIENT. FIRST, DID --
14 ON THE DAY OF THE PATIENT'S DEATH, DID THE PATIENT RECEIVE,
15 ACTUALLY RECEIVE BOTH ATIVAN AND MORPHINE OR IS DR. BAIR
16 MISTAKEN?
17 A. NO, HE DID NOT RECEIVE THEM.
18 Q. AND DO YOU BELIEVE IT WOULD BREACH THE STANDARD OF CARE
19 IF THEY'RE ORDERED, BUT THAT HE DIDN'T RECEIVE THEM, IS THAT
20 RIGHT?
21 A. THAT'S CORRECT.
22 Q. DO YOU BELIEVE IT WOULD BREACH THE STANDARD OF CARE FOR
23 DR. WEITZEL TO ORDER ATIVAN AND MORPHINE TOGETHER, IS THERE
24 SOMETHING WRONG WITH DOING THAT?
25 A. THOSE ARE FOR TWO SEPARATE DISTINCT ISSUES. ONE IS FOR
1 AGITATION AND INCREASED ANXIETY, AND THE OTHER ONE IS FOR
2 PAIN MANAGEMENT. THOSE ARE TWO SEPARATE -- TWO SEPARATE
3 ISSUES THAT YOU'RE TREATING.
4 Q. DO YOU BELIEVE THAT DR. WEITZEL'S TREATMENT OF ANY OF
5 THESE PATIENTS BREACHED THE STANDARD OF CARE FOR TREATMENT OF
6 FRAIL ELDERLY DEMENTED PATIENTS?
7 A. ABSOLUTELY NOT. I THINK HE WAS KIND OF -- TO BE HONEST
8 WITH YOU, PROBABLY AHEAD OF HIS TIME.
9 MR. BUGDEN: YOUR WITNESS.
10 THE COURT: CROSS-EXAMINE, MR. WILSON.
11 MR. WILSON: THANK YOU, YOUR HONOR. JUST A SECOND HERE.
12 MAY I HAVE JUST ANOTHER SECOND, YOUR HONOR?.
13 BY MR. WILSON:
14 Q. DOCTOR, I'M -- JUST A FOLLOW-UP QUESTION TO THAT LAST
15 SERIES OF QUESTIONS BY COUNSEL, I'M GONNA SHOW YOU WHAT'S
16 IDENTIFIED OUT OF THE MEDICAL RECORDS, THE DAVIS HOSPITAL
17 MEDICAL RECORDS, EXHIBIT 6-B, MED PAGE 0047. CAN YOU TAKE A
18 LOOK AT THAT PARTICULAR DOCUMENT, IF WOULD YOU PLEASE? AND
19 CAN YOU IDENTIFY IT FOR US FOR THE RECORD.
20 A. YES. THIS IS ON ENNIS ALLDREDGE. IT LOOKS LIKE A
21 MEDICATION ADMINISTRATION RECORD, AN M.A.R.
22 Q. OKAY. DID I UNDERSTAND YOUR PREVIOUS TESTIMONY THAT
23 ATIVAN WAS NOT GIVEN WITH THE MORPHINE ON THAT PARTICULAR
24 DAY?
25 A. THIS WAS -- LET ME LOOK AT THE DAYS. I THINK WE WERE
1 TALKING ABOUT THE LAST DAY -- WHAT WAS HIS DATES OF STAY?
2 Q. THE 6TH OR --
3 A. 13TH THROUGH THE 16TH?
4 Q. -- THE 10TH THROUGH THE 14TH.
5 A. RIGHT.
6 Q. DO YOU SHOW MORPHINE BEING ADMINISTERED --
7 A. ON THE THIR --
8 Q. -- ALONG WITH ATIVAN UP UNTIL THE TIME OF HIS DEATH?
9 A. LET ME SEE. ON THE 13TH IT DOES, YES.
10 Q. DOES IT SHOW MORPHINE BEING ADMINISTERED UP UNTIL THE
11 TIME OF HIS DEATH, SIR?
12 A. WHEN WAS THE TIME OF HIS DEATH?
13 MS. BARLOW: 9:36 IN THE MORNING.
14 Q. (BY MR. WILSON) 10:36 --
15 MS. BARLOW: 9:36.
16 Q. (BY MR. WILSON) 9:36 IN THE MORNING ON THE 14TH.
17 A. IT DOES, IT SHOWS AN EIGHT O'CLOCK DOSAGE.
18 Q. OKAY. SO YOU WERE INCORRECT IN YOUR EARLIER TESTIMONY?
19 A. APPARENTLY, YES.
20 Q. EXCUSE ME, I DIDN'T EVEN INTRODUCE MYSELF. I'M MEL
21 WILSON. I'M THE DAVIS COUNTY ATTORNEY. AND WELCOME TO UTAH.
22 A. THANK YOU. IT'S BEAUTIFUL. .
23 Q. THANK YOU. DOCTOR, JUST A FEW GENERAL QUESTIONS TO
24 BEGIN WITH. AS I'M TRYING TO CLARIFY IN MY OWN MIND, AS I
25 UNDERSTAND IT, YOU CURRENTLY OPERATE AS A CONSULTANT FOR A
1 GEROPSYCH UNIT, IS THAT CORRECT?
2 A. THAT IT IS PART OF OUR DUTIES, YES, SIR.
3 Q. OKAY. WHEN YOU SAY OUR DUTIES, WHO ARE WE TALKING
4 ABOUT, OUR?
5 A. WE HAVE A GROUP OF FOUR PRIMARY CARES IN OUR GROUP THAT
6 TAKE CARE OF NURSING FACILITIES, ASSISTED LIVINGS, HOSPITALS,
7 AND GEROPSYCH UNITS.
8 Q. OKAY. AND IN RESPECT TO THOSE DUTIES AND ASSIGNMENTS
9 RELATIVE TO THE GEROPSYCH UNIT, DO I TAKE IT THAT YOU
10 EVALUATE THESE PATIENTS FOR -- FROM A GERIATRIC STANDPOINT AS
11 TO THEIR PHYSICAL MEDICAL PROBLEMS?
12 A. THAT IS CORRECT.
13 Q. SO YOU DON'T HAVE ANYTHING TO DO WITH THE EVALUATION AS
14 IT PERTAINS TO THEIR PSYCHOLOGICAL PROBLEMS, I TAKE IT.
15 A. NOT IN A GEROPSYCH SETTING IN THE HOSPITAL.
16 Q. ALL RIGHT. BUT YOU DO THAT IN -- IN SOME OF THE LONG
17 TERM FACILITIES OR LONG TERM CARE FACILITIES THAT YOU ASSIST,
18 IS THAT CORRECT.
19 A. THAT IS CORRECT. IT'S HARD ENOUGH TO FIND PHYSICIANS
20 THAT WILL GO OUT TO THE NURSING HOMES, LET ALONE
21 PSYCHIATRISTS.
22 Q. OKAY. SO YOU ON A DAILY BASIS, YOU WOULD TEND TO
23 PATIENTS IN THESE LONG TERM CARE FACILITIES?
24 A. THAT IS CORRECT.
25 Q. HOW OFTEN WOULD YOU MAKE EVALUATIONS FOR PURPOSES OF
1 GEROPSYCH ADMISSIONS?
2 A. GEROPSYCH ADMISSIONS TO THE HOSPITAL?
3 Q. WELL, WHEREVER -- LET ME ASK YOU THIS: THE GEROPSYCH
4 UNITS THAT YOU ASSIST, ARE THEY LOCATED IN A HOSPITAL?
5 A. THEY ARE.
6 Q. OKAY. SO THEY ARE IN A HOSPITAL SETTING.
7 A. THAT IS CORRECT.
8 Q. SO I ASSUME THAT THERE'S ADDITIONAL DUTIES AND
9 RESPONSIBILITIES YOU HAVE OTHER THAN JUST AN EVALUATION FOR
10 ADMINISTRATION PURPOSES?
11 A. YEAH, ONCE WE DETERMINE THAT A PATIENT NEEDS TO GO TO A
12 GEROPSYCH UNIT, THAT PATIENT IS ADMITTED UNDER THE
13 GEROPSYCHIATRIST'S CARE.
14 Q. OKAY.
15 A. I MAY OR MAY NOT BE CALLED IN AS A MEDICAL CONSULTANT ON
16 THAT PATIENT'S CARE.
17 Q. ALL RIGHT. BUT YOU MAKE -- YOU ASSIST IN MAKING THAT
18 INITIAL DETERMINATION AS TO WHETHER OR NOT THEY'RE ADMITTED
19 TO THE UNIT?
20 A. YES, WE MAKE A PHONE CALL AND WE TELL THE -- WHAT WE
21 CALL A MAT TEAM, AND WE TELL THE TEAM EXACTLY WHAT WE ARE
22 CONCERNED ABOUT AND WHAT'S GOING ON WITH THE PATIENT AND WHAT
23 WE'VE DONE FOR THE PATIENT.
24 Q. NOW, ARE THERE ADVANTAGES TO A GEROPSYCH UNIT BEING
25 LOCATED IN A HOSPITAL SETTING?
1 A. YES. IT'S SO THAT THE PATIENTS CAN BE SEEN ON A DAILY
2 BASIS BY THE PHYSICIAN AS WELL AS BEING CARED FOR BY THE
3 NURSING FACILITY -- SORRY, THE NURSES AT THE HOSPITAL THAT
4 ARE TRAINED AND SPECIFICALLY IN THAT ARENA.
5 Q. OKAY. SO THEY'RE TRAINED SPECIFICALLY FOR THE PURPOSE
6 OF DOING WHAT?
7 A. TAKING CARE OF AGITATED, DELUSIONAL, COMBATIVE,
8 DIFFICULT TO CARE FOR PATIENTS.
9 Q. OKAY. AND IS PAIN MANAGEMENT A PROCESS THAT THEY'RE
10 INVOLVED IN?
11 A. MUCH MORE NOW TODAY THAN IT HAS BEEN, YES.
12 Q. OKAY. AND IN RESPECT TO THE PAIN MANAGEMENT IN THE
13 SETTING THAT YOU ASSIST, DO YOU HAVE ANYTHING TO DO WITH THAT
14 PAIN MANAGEMENT?
15 A. I DO.
16 Q. SO THE PSYCHIATRIST THEN WOULD REQUEST YOUR ASSISTANCE
17 IN PROVIDING PAIN MANAGEMENT, I ASSUME, TO THESE PATIENTS IN
18 THE GEROPSYCH UNIT.
19 A. IT DEPENDS UPON THE PSYCHIATRIST. SOME OF THEM DO AND
20 SOME OF THEM DON'T.
21 Q. OKAY. AND IN THE COURSE OF EVALUATING THESE PATIENTS, I
22 ASSUME THAT WOULD BE A SIGNIFICANT FACTOR THAT YOU WOULD LOOK
23 AT IN THE COURSE OF MAKING YOUR EVALUATION AS TO THEIR
24 ADMISSION, IS THAT CORRECT?
25 A. SURE.
1 Q. OKAY. NOW, YOU'VE TALKED ABOUT THE -- YOU'VE TALKED
2 ABOUT PSYCHOTROPIC MEDICATIONS AND YOU'VE TALKED ABOUT THE
3 PAIN MEDICATIONS SUCH AS MORPHINE, THE OPIOIDS AND THE
4 NONSTEROIDS AND THOSE TYPES OF MEDICATIONS, IS THAT CORRECT?
5 A. YES, SIR.
6 Q. I WANNA SHOW YOU -- LET'S TALK FIRST ABOUT THE
7 PSYCHOTROPIC MEDICATIONS, IF WOULD YOU PLEASE. I'M GONNA SET
8 THIS UP OVER HERE, HOPEFULLY YOU CAN SEE IT AND THE JURY CAN
9 SEE IT. MAYBE YOU NEED TO STEP DOWN AND TAKE A LOOK AT THIS
10 CHART, IF WOULD YOU PLEASE. CAN YOU SEE IT FROM THERE,
11 DOCTOR?
12 A. I CAN, YES.
13 Q. OKAY.
14 THE COURT: THAT EXHIBIT NUMBER, MR. WILSON?
15 MR. WILSON: EXCUSE ME, YOUR HONOR. THAT'S EXHIBIT
16 NUMBER -- STATE'S EXHIBIT NUMBER 11.
17 Q. THANK YOU.
18 Q. (BY MR. WILSON) I WOULD REPRESENT TO YOU THIS IS A CHART
19 RELATING TO THE CENTRAL NERVOUS SYSTEM DEPRESSANTS. IT'S
20 TRUE, IS IT NOT, THAT IN YOUR REVIEW OF THE RECORDS, THAT A
21 NUMBER OF THE MEDICINES THAT -- MEDICATIONS THAT YOU WERE
22 GIVEN TO THESE PATIENTS WERE CENTRAL NERVOUS SYSTEM
23 DEPRESSANTS, IS THAT CORRECT?
24 A. YES, THESE ARE PSYCHOTROPIC MEDICATIONS.
25 Q. OKAY. AND BY THAT, AS I UNDERSTAND IT, THEY HAVE AN
1 EFFECT ON THE BODY WHERE THEY REDUCE THE BRAIN CENTER'S --
2 THE BRAIN CENTER'S CONTROL OF THE RESPIRATIONS, IS THAT
3 RIGHT? MAYBE YOU CAN EXPLAIN IT TO US.
4 A. WELL, I'M TRYING TO DETERMINE WHAT YOU'RE -- IMMEDIATE
5 EFFECTS DOES NOT -- NORMALLY WHEN WE GIVE SOMEBODY AN
6 ANTIPSYCHOTIC, WE DON'T IMMEDIATELY SEE SLEEPLESSNESS -- OR
7 SLEEP -- SLEEPINESS OR COMA, DECREASED BREATHING OR
8 ASPIRATION, DECREASED BLOOD PRESSURE. I DON'T SEE THOSE WHEN
9 WE GIVE THE MEDICATIONS --
10 Q. DOES A CENTRAL NERVOUS SYSTEM DEPRESSANT HAVE THE
11 ABILITY TO PRODUCE SLEEPINESS AND COMA?
12 A. IF THAT PARTICULAR PATIENT IS TAKING MORE THAN WHAT THEY
13 CAN HANDLE, YES.
14 Q. OKAY, AND WOULD YOU ALSO AGREE THAT IT HAS THE POTENTIAL
15 TO DECREASE THE BREATHING AND INCREASE POSSIBLE ASPIRATION?
16 A. AND I'M SORRY, WHAT ABOUT THE ASPIRATION?
17 Q. AN INCREASED ASPIRATION?
18 A. INCREASE THE RISK FOR ASPIRATION?
19 Q. RISK FOR ASPIRATION.
20 A. I GUESS IF YOU HAD EXCESSIVE DOSAGE, MAYBE.
21 Q. OKAY. AND WHAT ABOUT DECREASED BLOOD PRESSURE? IS THAT
22 ALSO SOMETHING THAT YOU MIGHT SEE IF YOU HAVE EXCESSIVE
23 MEDICATION OF A CENTRAL NERVOUS SYSTEM DEPRESSANT?
24 A. OF ANY MEDICATION, YES.
25 Q. OKAY. OF ANY MEDICATION?
1 A. MOST MEDICATIONS THAT WE UTILIZE CAN HAVE SOME OF THESE
2 EFFECTS, YES.
3 Q. AND IF A PERSON IS OVERLY MEDICATED WITH A CENTRAL
4 NERVOUS SYSTEM DEPRESSANT, THERE'S A RISK ALSO THAT THEY
5 WON'T BE ABLE TO EAT OR DRINK, ISN'T THAT CORRECT?
6 A. MOST OF THESE ARE RELATED TO THE LETHARGY AS YOU HAVE
7 NUMBER ONE, IT SAYS SLEEPINESS OR COMA. USUALLY BECAUSE OF
8 THAT, THEY HAVE THE REST OF THESE EFFECTS THAT ARE GOING
9 ALONG WITH THAT, YES.
10 Q. OKAY. BUT THOSE ARE RISKS ASSOCIATED WITH THE
11 OVERMEDICATION OF CENTRAL NERVOUS SYSTEM DEPRESSANTS, ARE
12 THEY NOT?
13 A. THAT IS CORRECT.
14 Q. OKAY. AS TO THE LONG TERM EFFECTS, DOCTOR, WOULD YOU
15 AGREE THAT AS A RESULT IF THE PERSON IS OVERMEDICATED WITH A
16 CENTRAL NERVOUS SYSTEM DEPRESSANT THAT THERE'S GONNA BE
17 DECREASED OXYGEN TO THE BRAIN, THE HEART, THE KIDNEYS?
18 A. WITH LONG TERM OVERDOSE? IF SOMEBODY HAD SLEEPINESS AND
19 COMA FOR A LONG PERIOD OF TIME, YES.
20 Q. OKAY. AND HOW LONG IN YOUR ESTIMATION WOULD THAT HAVE
21 TO BE?
22 A. IT DEPENDS UPON HOW LONG THEY'VE BEEN ON THE MEDICATION,
23 HOW LONG AND TO WHAT DEGREE THEY'RE SLEEPY OR HAVING A COMA.
24 Q. OKAY. NOW, WHEN WE'RE TALKING ABOUT GERIATRIC PATIENTS,
25 I THINK YOU'VE PREVIOUSLY TESTIFIED AND THE PEOPLE IN THIS
1 PARTICULAR CASE WERE ALL SUFFERING FROM VARIOUS PROBLEMS,
2 CO-MORBIDITY I THINK IS THE TERM THAT YOU USED, IS THAT
3 CORRECT.
4 A. CORRECT.
5 Q. AND A NUMBER OF THOSE PROBLEMS WOULD BE HEART PROBLEMS,
6 LUNG PROBLEMS, KIDNEY PROBLEMS, LIVER PROBLEMS, ALL OF THOSE
7 ORGANS WOULD BE -- WOULD BE IN VARYING STAGES OF DISEASE
8 PROCESS, IS THAT RIGHT?
9 A. THAT'S CORRECT.
10 Q. AND AS A RESULT OF THAT, WOULD NOT A CENTRAL NERVOUS
11 SYSTEM DEPRESSANT HAVE A -- WOULD THERE BE A GREATER RISK, I
12 GUESS IS WHAT I'M SAYING, IN -- IN TERMS OF A RISK OF ORGAN
13 DAMAGE AND FUNCTION IF THEY WERE OVERMEDICATED WITH THOSE?
14 A. WELL, NOW, YOU'RE TALKING ABOUT EXCESSIVE
15 OVERMEDICATION, WE COULD POSSIBLY SEE THAT. THE PROBLEM IS,
16 IS THAT THOSE ORGANS ARE ALSO GOING TO BE AFFECTED BY THEIR
17 INCREASED AGITATION, THEIR INCREASED ANXIETY, ALL OF THESE
18 THINGS CAN BE -- IF WANNA GET TECHNICAL, CAN -- CAH HAVE AN
19 EFFECT ON ALL THESE ORGANS --
20 Q. WELL --
21 A. WELL, YES, OVERMEDICATION --
22 Q. -- I APPRECIATE THAT -- THAT ANSWER, DOCTOR, BUT THE
23 CENTRAL NERVOUS SYSTEM DEPRESSANTS DO CREATE THAT RISK, DO
24 THEY?
25 A. IF THEY'RE OVERUSED, YES.
1 Q. IF THEY'RE OVERUSED. RELATIVE TO THE DEHYDRATION, WOULD
2 YOU AGREE THAT IF A PERSON IS DEHYDRATED AS A RESULT OF THE
3 EFFECTS OF THIS MEDICATION THAT THEY'RE -- THEY'RE ALSO GOING
4 TO HAVE AN INCREASED SENSITIVITY TO THESE DRUGS?
5 A. I DON'T KNOW IF I COULD AGREE WITH THAT STATEMENT. I DO
6 THINK THAT IF YOU HAVE SOMEONE THAT IS DEHYDRATED, YOU MAY
7 HAVE HIGHER BLOOD LEVELS DUE TO THE DEHYDRATION EFFECT JUST
8 DUE TO A CONCENTRATION EFFECT.
9 Q. OKAY. SO YOU'D HAVE TO TAKE THAT INTO CONSIDERATION OF
10 YOUR EVALATION OF PATIENT AS TO -- TO THE MEDICATION THAT YOU
11 WERE USING --
12 A. SURE.
13 Q. -- CORRECT? AND THAT'S SOMETHING I ASSUME THAT IS
14 IMPORTANT TO KNOW AT THAT TIME, CORRECT?
15 A. SURE.
16 Q. NOW, I'M GONNA SHOW YOU A SIMILAR CHART IDENTIFIED AS
17 STATE'S EXHIBIT 12 AND ASK YOU TO TAKE LOOK AT THAT IF YOU
18 WOULD PLEASE. AND THIS IS FOR SPECIFICALLY THE DRUG
19 MORPHINE. CAN YOU TELL US IN LOOKING AT THAT CHART WHETHER
20 YOU AGREE AND -- AND THAT ON THE IMMEDIATE EFFECT STANDPOINT
21 OR MAYBE WE SHOULD CHARACTERIZE THAT, ARE THESE SOME OF THE
22 EFFECTS AND RISKS ASSOCIATED WITH THE OVERMEDICATION OF
23 MORPHINE?
24 A. WELL, JUST LIKE IN YOUR PREVIOUS CHART, I'M A LITTLE BIT
25 CONFUSED BECAUSE IT JUST SAYS MORPHINE, AND I THINK WHAT
1 YOU'RE ASKING ME IS AN OVERDOSAGE OF MORPHINE FOR THAT
2 PARTICULAR PATIENT COULD CAUSE THESE. THE ACTUAL IMMEDIATE
3 EFFECTS OF MORPHINE DOESN'T ALWAYS PRODUCE PAIN RELIEF IF
4 IT'S TOO SMALL OF A DOSE. IT DOESN'T CAUSE SLEEPINESS OR
5 COMA UNLESS IT'S OVERDOSAGE. IT DOESN'T CAUSE DECREASED
6 BREATHING UNLESS IT'S AN OVERDOSAGE. SO I MEAN I --
7 Q. SO ALL OF THESE THINGS UNDERNEATH PAIN RELIEF ARE -- AND
8 YOUR TESTIMONY, IF I MIGHT CHARACTERIZE IT, ARE RISKS OF AN
9 OVERDOSE OF MORPHINE --
10 A. YES.
11 Q. -- CORRECT?
12 A. NOW IF THIS IS -- AND WE CLARIFIED IT ON THE CHART
13 BEFORE, WE WERE LOOKING AT AN OVERDOSE OF THOSE MEDICATIONS.
14 AN OVERDOSE OF ANY OPIOID, YES, CAN CAUSE THESE ISSUES.
15 Q. OKAY. AND CAN AN OVERDOSE OF ANY OPIOIDS RESULT IN
16 THESE TYPES OF LONG-TERM EFFECTS?
17 A. THEY DON'T ALWAYS DEVELOP PNEUMONIA, BUT THEY CAN.
18 Q. AND, DOCTOR, CAN THEY OR ARE THEY -- I'LL STRIKE THAT.
19 IS A PERSON WHO'S SUFFERING AS THESE INDIVIDUALS WERE FROM
20 VARIOUS CO-MORBIDITIES MORE SUSCEPTIBLE TO THE LONG TERM
21 EFFECTS OF AN OVERDOSE OF MORPHINE?
22 A. OKAY. WE'RE TALKING ABOUT AN OVERDOSE OF MORPHINE.
23 ONCE AGAIN, AS THE PREVIOUS CHART WE WERE LOOKING AT, WE'RE
24 TALKING ABOUT THAT MOST OF THESE COMPLICATIONS ARE DUE TO THE
25 INCREASED SLEEPINESS AND COMA THAT CAN BE DERIVED, BECAUSE OF
1 SLEEPINESS AND COMA, THEY CAN HAVE INCREASED RISK OF
2 ASPIRATION PNEUMONIA, THEY CAN HAVE DECREASED OXYGENATION TO
3 THE TISSUES, THEY CAN NOT BE EATING OR DRINKING AS WELL AND
4 HAVE SOME PROBLEMS. BUT ONCE AGAIN, IT'S ALL RELATED TO HOW
5 OVERDOSED THEY ARE ON EITHER THE PSYCHOTROPICS OR THE
6 MORPHINE.
7 Q. OKAY. NOW, WHEN YOU INDICATED IN YOUR -- YOUR
8 EXPERIENCE, INDICATED THAT YOU HAD BEEN CERTIFIED IN
9 PALLIATIVE CARE, BOARD CERTIFIED IF PALLIATIVE CARE?
10 A. HOSPICE AND PALLIATIVE CARE, YES, SIR.
11 Q. AND JUST A SECOND. ARE YOU BOARD CERTIFIED AS
12 GERIATRICIAN ?
13 A. NO.
14 Q. OKAY.
15 A. TOO OLD.
16 Q. YOU'RE TOO OLD?
17 A. YES, SIR.
18 Q. THAT'S ALMOST AN OXYMORON, ISN'T IT, DOCTOR?
19 A. POSSIBLY.
20 Q. OKAY. WE'VE TALKED A LITTLE BIT ABOUT THE RISKS
21 ASSOCIATED WITH THE OVERMEDICATION OR THE OVERDOSE OF
22 MORPHINE AND CENTRAL NERVOUS SYSTEM DEPRESSANTS. IN TERMS OF
23 PAIN MANAGEMENT -- AND I THINK YOU'VE TOUCHED A LITTLE BIT ON
24 THIS, THAT WE TALKED A LITTLE -- YOU TALKED A LITTLE BIT
25 ABOUT HALF-LIFES AND YOU TALKED ABOUT THE PEAK EFFECT OF
1 THESE DRUGS, IS THAT CORRECT?
2 A. YES, SIR.
3 Q. AND AS I UNDERSTAND IT, IN RELATIVE TO THE DRUG
4 MORPHINE, I THINK IT WAS YOUR TESTIMONY THAT YOU WOULD EXPECT
5 TO SEE THE RESULTS OF MORPHINE IN ABOUT AN HOUR.
6 A. YES, SIR.
7 Q. IF THERE WAS ANY SIDE EFFECTS --
8 A. YES, SIR.
9 Q. -- DEMONSTRABLE SIDE EFFECTS FROM THAT MORPHINE. AND
10 RESPIRATIONS IS ONLY ONE OF THOSE POTENTIAL SIDE EFFECTS, IS
11 THAT CORRECT?
12 A. SURE.
13 Q. AND IN RESPECT TO ADMINISTERING DRUGS OF THIS NATURE TO
14 A PATIENT FOR PAIN RELIEF, THE FIRST PROCESS THAT YOU GO
15 THROUGH AS A PHYSICIAN IS THE EVALUATION PROCESS, WOULD IT
16 NOT BE?
17 A. OH, SURE.
18 Q. AND YOU HAVE TO EVALUATE, FIRST OF ALL, THAT PATIENT AND
19 THE PATIENT'S HISTORY. THAT'S PART OF IT, RIGHT?
20 A. WELL, I MEAN AN EVALUATION COULD BE PERFORMED POSSIBLY
21 BY A NURSE THAT'S AT THE FACILITY --
22 Q. OKAY.
23 A. -- IT COULD BE PERFORMED BY AN EVALUATION THAT YOU
24 REQUESTED OF THEM.
25 Q. OKAY.
1 A. YEAH.
2 Q. NOW, YOU LOOKED AT THE MEDICAL RECORDS OF EACH ONE OF
3 THESE FIVE PATIENTS, IS THAT CORRECT?
4 A. I DID.
5 Q. FOR PURPOSES OF THAT -- OF THOSE RECORDS, CAN YOU TELL
6 US PRECISELY WHAT RECORDS YOU REVIEWED IN THE PROCESS OF
7 FORMING YOUR OPINION?
8 A. PRIMARILY THE MEDICAL RECORDS AT THE HOSPITALIZATION.
9 AND THOSE WERE SOME OF THE MEDICAL RECORDS FROM PRIOR TO
10 HOSPITALIZATION, FROM THEIR PREVIOUS PLACEMENT AND -- BUT
11 BASICALLY THOSE WERE ALL THE -- ALL THE DATA.
12 Q. AND SO YOU HAD -- YOU HAD WHAT WAS REPRESENTED TO YOU TO
13 BE, I ASSUME, WHAT WAS CONTAINED IN THE HOSPITAL RECORD AT
14 THE GEROPSYCH UNIT, IS THAT CORRECT?
15 A. I WOULD SAY SO, YES.
16 Q. OKAY. AND THOSE WERE THE ONLY RECORDS YOU REVIEWED?
17 A. I MAY HAVE GLANCED AT A COUPLE OTHER RECORDS ABOUT, BUT
18 NO, THOSE WEER PRIMARILY THE ONES I REVIEWED IF DEPTH, YES.
19 Q. DO YOU RECEIVE ANY SUMMARIES OR ANYTHING RELATIVE THAT
20 MIGHT HAVE BEEN GIVEN TO YOU FROM THE DEFENDANT?
21 A. I REALLY DON'T REMEMBER. AND IF I DID, IT PROBABLY -- I
22 MAY HAVE THUMBED THROUGH IT, BUT NO, I DON'T REMEMBER.
23 Q. OKAY. SO WOULD IT BE A FAIR STATEMENT TO SAY THAT MOST
24 OF YOUR OPINION THEN IS BASED UPON WHAT YOU REVIEWED IN THOSE
25 MEDICAL RECORDS?
1 A. THAT IS CORRECT.
2 Q. OKAY. IN RESPECT TO THE -- LET'S TALK A LITTLE BIT
3 ABOUT THE EVALUATION PROCESS AGAIN. IN THE MEDICAL RECORDS,
4 YOU HAD SOME HISTORY THAT WAS REPORTED ON ADMISSION, IS THAT
5 CORRECT?
6 A. THAT IS CORRECT.
7 Q. AND YOU HAD SOME SELF-REPORTED HISTORY OR PATIENT FAMILY
8 REPORTED HISTORY, IS THAT CORRECT?
9 A. THAT IS CORRECT.
10 Q. YOU ALSO HAD A LOG THAT RELATED TO OR I SHOULD -- FOR
11 LACK OF A BETTER WORD, A LIST OF MEDICATIONS THAT THESE
12 PATIENTS HAD BEEN ON WHILE AT THE NURSING CARE CENTER, IS
13 THAT RIGHT?
14 A. THAT IS CORRECT.
15 Q. NOW, THAT PARTICULAR LIST DID NOT PROVIDE YOU
16 INFORMATION, DID IT, RELATIVE TO HOW OFTEN THEY WERE
17 RECEIVING THESE DOSES OR IN WHAT EXACT FORM THEY WERE
18 RECEIVING THESE DOSES, DID IT?
19 A. WELL, SOME OF 'EM DID. I MEAN SOME OF 'EM SHOWED THAT
20 THESE WERE ROUTINE MEDICATIONS GIVEN ON A CERTAIN BASIS.
21 OTHERS SHOWED THAT THEY WERE -- EXCUSE ME -- GIVEN P.R.N.,
22 MEANING THAT WE DID NOT KNOW HOW OFTEN THEY WERE RECEIVED AND
23 ADMINISTERED.
24 Q. NOW, IN RESPECT TO THE PROCESS THAT YOU WOULD GO THROUGH
25 IN EVALUATING, WOULD IT BE IMPORTANT TO REFERENCE --
1 PARTICULARLY FOR EVALUATING PAIN, WOULD IT BE IMPORTANT TO
2 REFERENCE WHAT -- WHAT INDIVIDUALS WERE REPORTING THIS
3 INDIVIDUAL HAD PAIN?
4 A. I DON'T UNDERSTAND THE QUESTION, SIR.
5 Q. WELL, FOR INSTANCE, MAYBE WE SHOULD GO A SPECIFIC
6 RECORD, IF YOU WOULD. AND DO YOU HAVE YOUR REPORT AND DO YOU
7 HAVE ANY OF THE RECORDS WITH YOU?
8 A. I DO NOT.
9 Q. LET ME JUST GO THROUGH A COUPLE OF QUESTIONS RELATED TO
10 ELLEN ANDERSON, IF YOU WOULD PLEASE.
11 A. SURE.
12 Q. FIRST OF ALL, BASED UPON YOUR REVIEW OF ELLEN ANDERSON'S
13 RECORD, DID YOU FORM AN OPINION RELATIVE TO HER MEDICAL
14 STABILITY AT THE TIME SHE WAS ADMITTED TO THE UNIT?
15 A. YES. SHE WAS SEVERELY AGITATED AND COMBATIVE. 91 YEARS
16 OF AGE. SHE WAS FRAIL. AND THIS INCONSOLABLE CONDITION THAT
17 WE'D DISCUSSED.
18 Q. DID YOU THINK THAT SHE WAS APPROPRIATE FOR ADMISSION TO
19 THE GEROPSYCH UNIT?
20 A. I DO.
21 Q. AND THE REASON SHE WAS BEING ADMITTED WAS REPORTED AS TO
22 BE EXTREME ANXIETY, WOULD THAT BE ACCURATE?
23 A. WELL, THAT WAS WHAT WAS DESCRIBED, AND SHE WAS REPORTED
24 BY THE NURSING STAFF TO BE INCONSOLABLE.
25 Q. AND THAT WAS DESCRIBED BY WHOM?
1 A. THE NURSING STAFF.
2 Q. WELL, IT WAS ALSO DESCRIBED, WAS IT NOT, BY FAMILY
3 MEMBERS THAT THEY REPORTED THAT TO THE NURSES?
4 A. I BELIEVE THAT'S CORRECT.
5 Q. DIDN'T THEY INDICATE THAT THAT WAS THE REASON THAT THEY
6 WERE ASKING THAT THEIR MOTHER BE ADMITTED TO THE UNIT?
7 A. THAT IS CORRECT.
8 Q. AND THE PURPOSE WAS -- AND IT'S REFERENCED IN THE
9 LONG-TERM CARE PLAN -- WAS TO GET THAT ANXIETY UNDER CONTROL,
10 IS THAT CORRECT?
11 A. SURE.
12 Q. NOW, AN INDIVIDUAL FAMILY MEMBER WHO'S BEEN RESIDING
13 WITH THE PATIENT FOR SOME PERIOD OF TIME OR SEEING THE
14 PATIENT ON A DAILY BASIS, WOULD YOU SAY THAT THEY WOULD BE IN
15 A FAIRLY DECENT POSITION TO DETERMINE WHETHER OR NOT THE
16 ANXIETY WAS -- WAS REACTION TO PAIN OR THE ANXIETY WAS -- WAS
17 A CONDITION IN AND OF ITSELF?
18 A. NOT PARTICULARLY, NO.
19 Q. OKAY. SO YOU THINK THERE NEED TO BE FURTHER EVALUATION
20 OF THAT PROCESS.
21 A. CORRECT.
22 Q. OKAY. AND AS FAR AS THAT PROCESS GOES, WHEN WE'RE
23 DEALING WITH A DEMENTED PATIENT, IT'S MY UNDERSTANDING IT
24 BECOMES VERY DIFFICULT?
25 A. AT TIMES IT CAN, YES.
1 Q. AND SO A -- IN MAKING THOSE KINDS OF EVALUATIONS, I
2 ASSUME A PHYSICIAN OR WHOEVER IS DOING THE EVALUATION WOULD
3 HAVE TO BE CAREFUL IN ORDER TO ARRIVE AT A PROPER CONCLUSION.
4 A. THAT'S WHY WE PUT 'EM IN A GEROPSYCH UNIT SO THAT THE
5 NURSING STAFF AND THE PHYSICIANS WHO DEAL WITH THIS EVERY DAY
6 CAN EVALUATE THEM.
7 Q. OKAY. AND IN MAKING THAT CONCLUSION, IS IT ALSO
8 IMPORTANT TO TRY AND ASCERTAIN WHAT IS CAUSING THE PAIN?
9 A. USUALLY WE TRY TO DO THAT, YES BUT UNFORTUNATELY, THAT'S
10 EVEN MORE DIFFICULT THAN DETERMINING IF THEY'RE HAVING PAIN.
11 Q. OKAY. NOW, I WOULD TAKE IT IF A PATIENT IS PRESENTED TO
12 YOU THAT IS SUFFERING FROM THE SAME PROBLEMS THAT ELLEN
13 ANDERSON WAS SUFFERING FROM, AND YOU'RE REPORTED -- IT'S
14 REPORTED TO BE ANXIETY, AND SHE'S BEEN VERY ANXIOUS AND THAT
15 ANXIETY LEVEL HAS INCREASED OVER THE LAST SEVERAL WEEKS,
16 RESULTING IN THIS HOSPITILIZATION, SHE'S BECOME UNCON --
17 INCONSOLABLE, THAT YOU WOULD WANT TO BE VERY CAUTIOUS IN HOW
18 YOU APPROACHED THAT PATIENT'S CARE, WOULD YOU NOT?
19 A. WELL, SURE.
20 Q. AND SO IF RESPECT TO THE MANAGEMENT OF ANY PAIN, IF YOU
21 FORMED A CONCLUSION AS TO THAT PAIN, THAT THERE WAS INDEED
22 PAIN, WOULD IT NOT BE APPROPRIATE TO LOOK AT THE MEDICAL
23 RECORD TO SEE WHAT SHE WAS GIVEN IN THE PAST FOR THE
24 TREATMENT OF PAIN?
25 A. I THINK THAT THAT'S WHAT I HAD LOOKED AT IS THE FACT
1 THAT THIS PATIENT HAD BEEN TREATED FOR ANXIETY WITH
2 ANXIOLYTICS WITHOUT RESPONSE. AND AS I HAD ALLUDED EARLIER,
3 ONE OF THE SIGNS OF PAIN SOMETIMES CAN BE INCREASED CONFUSION
4 OR INCREASED AGITATION. AND THAT WAS ONE PARTICULAR ASPECT
5 THAT HAD NOT BEEN EXPLORED, AND WHEN SHE WAS BROUGHT TO THE
6 GEROPSYCH UNIT, THAT WAS ONE AREA THAT WAS LOOKED AT WAS
7 WHETHER THE PAIN COULD BE CAUSING THE INCONSOLABILITY AND
8 WITH THE INCREASED ANXIETY AND --
9 Q. IN DETERMINING --
10 A. -- AGITATION.
11 Q. -- THAT, THOUGH, YOU WOULD LOOK AT WHAT SHE HAD BEEN
12 TREATED FOR IN THE PAST AND WHAT LEVEL OF PAIN MANAGEMENT HAD
13 BEEN GIVEN TO THIS PATIENT.
14 A. THAT IS CORRECT.
15 Q. RIGHT? NOW, IN THIS PARTICULAR PATIENT, ELLEN ANDERSON,
16 DID YOU SEE ANY MEDICATIONS THAT HAD BEEN PRESCRIBED TO HER
17 FOR PAIN MANAGEMENT?
18 A. I DON'T RECALL. I'D HAVE TO LOOK AGAIN.
19 Q. YOU DON'T REMEMBER?
20 A. NO, I DO NOT.
21 Q. WOULDN'T THAT HAVE BEEN SIGNIFICANT IN TERMS OF YOUR
22 DETERMINATION AS TO WHAT TO ADMINISTER TO HER?
23 A. I THINK SO. ACCORDING TO MY STATEMENT, I STATED THAT
24 SHE WAS STARTED ON THE PAIN MANAGEMENT WHICH WOULD LEAD ME TO
25 BELIEVE THAT SHE HAD NOT BEEN STARTED ON PAIN MANAGEMENT.
1 Q. OKAY. NOW, FURTHERMORE, DOCTOR, I THINK YOU TESTIFIED
2 WHEN WE WERE -- WHEN YOU WERE DISCUSSING THE USE OF MORPHINE,
3 I THINK YOU TESTIFIED ABOUT YOU DOSE TO AND YOU MONITOR FOR
4 EFFECT, RIGHT?
5 A. CORRECT.
6 Q. AND I THINK THE QUESTION WAS ASKED YOU AS TO A DOSAGE IN
7 THIS PARTICULAR INSTANCE AND -- OR IN ANOTHER EXAMPLE BUT I
8 THINK YOU EXPRESSED -- YOU STARTED OUT WITH MAYBE 2
9 MILLIGRAMS OF MORPHINE, IS THAT CORRECT?
10 A. I THINK I SAID 10 MILLIGRAMS.
11 Q. I SEE. YOU SAID 10 MILLIGRAMS OF MORPHINE.
12 A. THAT WOULD BE I. -- I.M. DOSAGE YES.
13 Q. SO YOU WOULD START OUT WITH A 10-MILLIGRAM DOSAGE OF
14 MORPHINE I.M.?
15 A. YES, SIR.
16 Q. AND THEN WHAT PRECAUTIONS WOULD YOU PUT INTO EFFECT TO
17 MAKE SURE THAT THIS PATIENT WAS BEING MONITORED FOR POSSIBLE
18 SIDE EFFECTS?
19 A. WELL, ACCORDING TO YOUR CHART, THE FIRST THING WE'D
20 WANNA BE LOOKING AT IS DID THIS CAUSE INCREASED LETHARGY, DID
21 IT CAUSE PATIENTS TO BE ALMOST COMATOSE, DID IT AFFECT THEIR
22 VITAL SIGNS, DID IT AFFECT ANYTHING ELSE.
23 Q. OKAY. AND DO YOU KNOW HOW THIS PATIENT WAS BEING
24 MONITORED?
25 A. SHE'S BEING -- SHE WAS ON A GEROPSYCH UNIT. SHE WAS
1 BEING MONITORED BY THE NURSING STAFF. AND SHE WAS BEING SEEN
2 BY DR. WEITZEL ON A DAILY BASIS.
3 Q. BUT SHE WASN'T -- SHE WASN'T HOOKED UP TO ANY MACHINES
4 TO MONITOR HER PULSE RATE OR HER BLOOD PRESSURE, HER
5 RESPIRATIONS, WAS SHE?
6 A. NO.
7 Q. AND DID YOU SEE ANYTHING IN THE RECORD WHERE THE NURSE
8 WAS GIVEN ANY ORDERS RELATIVE TO THIS PARTICULAR
9 ADMINISTRATION OF MORPHINE, THAT SHE SHOULD CHECK THOSE
10 RESPIRATIONS MORE OFTEN THAN EIGHT HOURS PER SHIFT OR TWICE A
11 DAY?
12 A. NO.
13 Q. DON'T YOU THINK THAT THAT WOULD HAVE BEEN A SIGNIFICANT
14 OBSERVATION TO MAKE, TO MONITOR THIS PATIENT WITHIN THAT
15 HOUR'S TIME FRAME IN ANY EVENT?
16 A. IF THERE'S A CHANGE IN THE PATIENT'S CONDITION, YES.
17 Q. OKAY. WERE YOU -- DID YOU RECALL IN THE RECORDS, SIR,
18 READING A NOTE IN THE NURSE'S PROGRESS NOTES OR IN THE
19 NURSE'S NOTES RELATIVE TO TAKING HER RESPIRATIONS AT ONE
20 O'CLOCK IN THE MORNING?
21 A. I'D HAVE TO LOOK AGAIN, BUT I KNOW THAT THERE WAS -- THE
22 TIMES THAT WE'D LOOKED AT PREVIOUSLY SHOW THAT HER
23 RESPIRATIONS WERE NORMAL.
24 Q. NOW, IF I WERE TO TELL YOU THE NOTE -- IF I WERE TO TELL
25 YOU THAT THE NOTE INDICATED THAT SHE AT 1:30 HAD ERRATIC
1 RESPIRATIONS OF I THINK IT WAS EIGHT TO 16, WOULD THAT CAUSE
2 YOU ANY CONCERN?
3 A. AT 1:30 IN THE MORNING, NO. SHE COULD HAVE BEEN SOUND
4 ASLEEP AND HAD A LOWER RESPIRATION RATE AND WHEN SHE
5 AWAKENED, SHE COULD HAVE A HIGHER RESPIRATION RATE.
6 Q. WHAT ABOUT A NOTE THAT SAYS THAT SHE WAS -- HAD BLOOD
7 PRESSURE OF 70 OVER 50? WOULD THAT CAUSE YOU CONCERN?
8 A. IT WOULD MAKE ME TRY TO FIGURE OUT IF THERE WAS ANY
9 CAUSE FOR THAT BLOOD PRESSURE READING WHICH WE CAN SEE
10 SOMETIMES WITH SOUND SLEEP.
11 Q. OKAY. AND IF THAT WERE REPORTED TO YOU TO BE THE CASE
12 AT THE TIME THE NURSE CALLED AT 3:30 IN THE MORNING, CAN YOU
13 TELL US, DOCTOR, WOULDN'T THAT BE CAUSE FOR CONCERN FOR
14 GIVING THIS PATIENT ANOTHER DOSE OF MORPHINE?
15 A. NOT NECESSARILY. IF THEY WERE STILL HAVING THAT BLOOD
16 PRESSURE AT THAT PARTICULAR TIME.
17 Q. OKAY. NOW, YOU'VE PREVIOUSLY -- OR YOU PUT IN YOUR,
18 SIR, THAT I THINK YOU SAID YOU THOUGHT SHE PASSED AWAY AS A
19 RESULT OF PNEUMONIA, IS THAT CORRECT? ASSOCIATED WITH THE
20 HEART PROBLEM?
21 A. I THINK WE SAID COMBINATION OF MULTIPLE ISSUES,
22 PNEUMONIA AND/OR HEART.
23 Q. AND SO YOUR TESTIMONY HERE TODAY IS THAT YOU DON'T THINK
24 MORPHINE PLAYED ANY PART IN THIS PATIENT'S DEATH, IS THAT
25 CORRECT?
1 A. I DO NOT.
2 Q. EVEN THOUGH YOU DON'T HAVE IN THE RECORD ANY INDICATION
3 RELATED TO WHAT HER LEVELS OF BLOOD PRESSURE AND HER LEVELS
4 OF RESPIRATIONS DURING THE TIME PERIOD THIS PEAK EFFECT TOOK
5 PLACE, IS THAT CORRECT?
6 A. WELL, WE DO HAVE SOME RECORDS. WE DO HAVE THE VITAL
7 SIGNS THAT WERE TAKEN.
8 Q. YOU DO HAVE THEM AFTER THE FACT, IS THAT CORRECT?
9 A. THAT IS CORRECT.
10 Q. THEY'RE NOT WITHIN THE HOUR, IS THAT CORRECT?
11 A. WELL NO THEY'RE NOT. AS A MATTER OF FACT, THEY -- I'D
12 HAVE TO SEE THEM AGAIN BUT -- AND COMPARE THEM WITH WHAT WAS
13 GOING AT THE TIME OF THE DOSAGE.
14 Q. ALL RIGHT.
15 A. WE'D ALREADY DONE THAT I THINK EARLIER BUT I CAN'T
16 REMEMBER.
17 Q. CAN YOU TELL US DOCTOR --
18 THE COURT: YOU NEED TO PICK UP THE PACE, MR. WILSON, IF
19 YOU COULD.
20 MR. WILSON: THANK YOU, YOUR HONOR.
21 Q. (BY MR. WILSON) JUST TURN -- DO YOU HAVE A COPY OF YOUR
22 REPORT?
23 A. I DO HAVE A REPORT YES WITH ME.
24 Q. YOU INDICATE THAT MORPHINE WAS GIVEN TO THE PATIENT DUE
25 TO HER INCONSOLABLE STATUS.
1 A. LET'S SEE, SHE WAS GIVEN BENZODIAZEPINES, BUT WAS SEEN
2 WITH CONTINUED INCREASED AGITATION, WAS REPORTED
3 INCONSOLABLE --
4 Q. TURN DOWN TO PARAGRAPH 3 OF YOUR -- OF YOUR REPORT.
5 A. THANK YOU. SHE WOULD SCREAM AND BECOME RIGID WHEN
6 APPROACHED BY THE NURSING STAFF. THE METHODS OF CONSOLING
7 PATIENT FAILED. IT WAS FELT THE PATIENT WAS HAVING PAIN AND
8 PAIN CONTROL WAS A SOUND TREATMENT CHOICE. THE NURSES
9 REPORTED TO DR. WEITZEL AND THE PATIENT APPEARED TO BE IN
10 GREAT DEAL OF PAIN. ANOTHER NURSE CALLED EIGHT HOURS LATER
11 AND REPORTED IDENTICAL SITUATION OF A PATIENT SCREAMING AND
12 MOANING AND APPEARED TO BE IN SEVERE PAIN AND DR. WEITZEL
13 ORDERED ANOTHER DOSE OF MORPHINE.
14 Q. DID YOU REVIEW IN THE REPORTS RELATIVE TO A CHEST X-RAY
15 THAT WAS ADMINISTERED ON NOVEMBER THE 18TH ABOUT SIX WEEKS
16 PRIOR TO THIS HOSPITALIZATION?
17 A. I REMEMBER THAT THE PATIENT HAD, IF I -- IF I REMEMBER
18 RIGHT -- LET ME CHECK. I DON'T WANNA MISSPEAK AGAIN.
19 COULD YOU RESTATE THE QUESTION AGAIN, SIR?
20 Q. ON NOVEMBER THE 18TH, DID YOU REVIEW THE CHEST X-RAY
21 REPORT?
22 A. I DID NOT.
23 Q. OKAY. CAN YOU TELL US, SIR, DO YOU RECALL ANYTHING
24 RELATIVE TO A SITUATION AS TO PNEUMONIA OR POSSIBLE PNEUMONIA
25 OCCURRING IN MID NOVEMBER OF 1995?
1 A. I REMEMBER A REPORT OF THAT, THAT SHE HAD PREVIOUSLY HAD
2 THAT, BUT I DID NOT HAVE ANY OF THE RECORDS TO REVIEW.
3 Q. OKAY. IF I WAS TO TELL YOU THAT ON NOVEMBER THE 18TH --
4 WELL, EXCUSE ME, THE CHEST X-RAY WAS TAKEN ON NOVEMBER THE
5 15TH -- I'LL -- I APOLOGIZE TO THE COURT, YOUR HONOR. I'LL
6 TRY TO MOVE IT ON HERE. THE CHEST X-RAY WAS READ BY A
7 DR. DUNN AND HE STATED, INCREASING ATELECTASIS, SMALL AIR
8 SACS IN THE LUNGS ARE COLLAPSED. USUALLY TREATED BY
9 REQUIRING THE PATIENT TO BE BREATHE DEEPLY TO FILL THE AIR
10 SACS. NOW, WOULD THAT BE A PNEUMONIA?
11 A. NO.
12 Q. AND IF THERE WAS NO ANTIBIOTICS THAT WERE ADMINISTERED,
13 WOULD YOU BE SAFE IN ASSUMING THAT THERE WAS NO TREATMENT
14 GIVEN FOR PNEUMONIA?
15 A. I WOULD ASSUME THAT, YES.
16 Q. OKAY. YOU REVIEWED THE X-RAYS THAT WAS TAKEN AT THE
17 HOSPITAL, DID YOU NOT, ON THE 30TH?
18 A. I'M SURE I DID. I'LL HAVE TO CHECK THAT OUT.
19 Q. AND CAN YOU TELL US, SIR --
20 A. YEAH, I DON'T HAVE IT WRITTEN DOWN, BUT I BELIEVE
21 THERE'S A QUESTION OF -- LET'S SEE, QUESTION OF ATELECTASIS
22 OR PNEUMONIA.
23 Q. IN FACT, THERE WAS IN THE REPORTS ON ADMISSION THAT THEY
24 HAD CHECKED HER LUNGS, HER LUNGS WERE CLEAR.
25 A. CORRECT.
1 Q. NOW IF AN INDIVIDUAL WERE SUFFERING FROM A HEART
2 CONDITION AND THEY WERE GIVEN MORPHINE, DO YOU HAVE ANY
3 OPINION AS TO WHETHER OR NOT THAT MIGHT AGGRAVATE THAT
4 CONDITION?
5 A. IF THE PATIENT WAS INCONSOLABLE AND AGITATED AND
6 ANXIOUS, IT MIGHT HELP THE SITUATION.
7 Q. CAN YOU TELL US IN RESPECT TO THE ARTERIOSCLEROSIS IF
8 SHE HAD -- WAS SUFFERING FROM ARTERIOSCLEROSIS, WHICH I
9 UNDERSTAND IS HARDENING OF THE ARTERIES?
10 A. AN AGE 91, I'LL GUARANTEE YOU SHE HAD ARTERIOSCLEROTIC
11 VASCULAR DISEASE PROCESS.
12 Q. AND THAT'S THE -- SO THAT THE HEART HAS TO WORK HARDER I
13 GUESS TO PUMP THE BLOOD?
14 A. SURE.
15 Q. TO GET THE OXYGEN TO THE VITAL ORGANS?
16 A. SURE. THAT HAPPENS ANY TIME AFTER AGE 50.
17 Q. AND MORPHINE WOULD REDUCE THE HEART'S PUMPING ACTION,
18 WOULD IT NOT?
19 A. WELL, NOT NECESSARILY.
20 Q. BUT IT COULD.
21 A. ALL DEPENDS IF THE PATIENT IS SHOWING EVIDENCE OF ANY
22 KIND OF OVERDOSAGE, AND WE WERE TALKING ABOUT COMA AND
23 NONRESPONSIVENESS AND INCREASED LETHERGY.
24 Q. CAN A PNEUMONIA DEVELOP OVERNIGHT?
25 A. THERE ARE SOME CASES WHERE WE HAVE ASPIRATION PROBLEMS,
1 I WAS DESCRIBING EARLIER WHERE A PATIENT CAN VOMIT AND SUCK
2 THE -- THAT DOWN INTO THE LUNGS AND DEVELOP AN ASPIRATION
3 PNEUMONIA YES.
4 Q. OKAY. LET'S MOVE ON THEN TO THE NEXT PATIENT, WHICH IS
5 JUDITH LARSEN. AND AGAIN, RELATIVE TO YOUR REPORT, YOU
6 INDICATE THAT THIS PATIENT ACCORDING TO THE RECORDS WENT UP
7 AND DOWN, IS THAT CORRECT?
8 A. WENT UP AND DOWN, I'M NOT SURE WHAT YOU MEAN SIR.
9 Q. THAT SHE -- SHE GOT SICKER THEN SHE GOT BETTER THEN SHE
10 GOT SICKER --
11 A. YOU KNOW, WE WERE TALK --
12 Q. -- WOULD THAT BE AN ACCURATE CHARACTERIZATION?
13 A. WE HAD SHOWN THAT WHEN SHE WAS TREATED FOR HER THRUSH,
14 SHE ACTUALLY GOT BETTER, AND THEN SHE BEGAN TO DIGRESS
15 AGAIN.
16 Q. YOU NOTE IN THE RECORDS THAT WHEN SHE WAS TAKEN OFF HER
17 MEDICATIONS AT ONE TIME THAT I THINK IT WAS ON THE 12TH, SHE
18 MADE A MIRACULOUS RECOVERY?
19 A. WHAT WAS HER TIME OF ADMISSION? I DON'T HAVE THAT DATE.
20 Q. DATE OF ADMISSION WAS DECEMBER THE 6TH.
21 A. I HAVE IN MY RECORDS THAT ACTUALLY THE PATIENT WAS
22 TREATED FOR HER THRUSH AND HER MORPHINE WAS DISCONTINUED AND
23 AFTER THE PATIENT HAD SHOWN IMPROVEMENT FROM RESOLUTION OF
24 HER THRUSH.
25 Q. I SEE.
1 A. IS THAT WHAT YOU'RE REFERRING TO?
2 Q. TELL ME, DOCTOR, WHEN WAS HER MORPHINE ORDERED? FIRST
3 ORDERED?
4 A. I WOULD HAVE TO LOOK AT THE CHART TO FIND THAT.
5 Q. I SEE. SO YOUR TESTIMONY IS, IS AFTER THEY TREATED THE
6 THRUSH THEY DISCONTINUED THE MORPHINE?
7 A. YEAH, ACCORDING TO MY NOTES, IT SAYS THAT PAIN
8 MEDICATION WAS INITIATED AND THE M.S. WAS DISCONTINUED WHEN
9 THE PATIENT IMPROVED. HOWEVER, HER COURSE WAS THEN
10 COMPROMISED BY SEIZURE ACTIVITY, AND SHE DEVELOPED A NEW
11 PROBLEM.
12 Q. SO YOUR SORT OF COMBINING THE WHOLE MONTH'S TIME FRAME
13 INTO ONE PHOTOGRAPH --
14 A. YES.
15 Q. -- WOULD THAT BE ACCURATE?
16 A. THAT'S CORRECT.
17 Q. YOU INDICATE THAT IN YOUR TESTIMONY, I THINK YOU
18 INDICATED THAT MORPHINE IS AN APPROPRIATE COMFORT CARE
19 MEDICATION AND IT'S USED TO CONTROL PAIN, IS THAT CORRECT?
20 A. THAT IS CORRECT.
21 Q. AND CAN YOU CHARACTERIZE FOR US, SIR, THE DEGREE OF PAIN
22 THAT YOU WOULD UTILIZE THE DRUG MORPHINE FOR?
23 A. USE IT ALL WAY FROM CHRONIC PAIN TO ACUTE PAIN. WE USE
24 IT IN ANY TYPE OF PAIN THAT WE FEEL IS MODERATE TO SEVERE.
25 Q. NOW, AS I UNDERSTAND IT, PAIN IS AN ANTAGONIST TO THE
1 EFFECTS OF MORPHINE, WOULD IT BE AN ACCURATE STATEMENT?
2 A. WELL, YES.
3 Q. OKAY.
4 A. SIMPLISTICALLY, YES.
5 Q. SORT OF WEAR EACH OTHER OUT IS THE WAY IT'S BEEN
6 DESCRIBED TO ME --
7 A. WELL, ACTUALLY, THE -- THE CAUSE OF PAIN IS A SIGNAL OF
8 NEURO -- IT'S NEUROTRANSMITTERS BETWEEN THE SYNAPTIC FIBERS,
9 AND THESE -- THE OPIOID SITES CAN STOP THAT PROCESS WHEN
10 YOU'RE GIVING OPIOIDS WHILE IT'S ACTIVE. AND SO ACTUALLY,
11 THE OPIOIDS CAN STOP THAT PAIN PROCESS OR STOP THAT -- THAT
12 NEUROTRANSMITTER AND HELP STOP THE PROCESS FROM OCCURRING.
13 Q. SO DIAGNOSIS OF THE PAIN, IF YOU FIND THAT THERE'S AN
14 INDIVIDUAL IS IN PAIN, THEN YOU HAVE TO MAKE SOME KIND OF
15 CLINICAL JUDGMENT TO THE DEGREE OF THE PAIN DEPENDING ON HOW
16 MUCH MORPHINE YOU WOULD GET, CORRECT?
17 A. WELL, ACTUALLY, WE DETERMINE BASICALLY HOW SEVERE A
18 PATIENT'S PAIN IS AND THEN WE PRESCRIBE A STARTING DOSE OF
19 MORPHINE TO SEE IF WE CAN HELP CONTROL THAT, AND THEN TITRATE
20 TO THE DESIRED EFFECT.
21 Q. OKAY NOW IN JUDITH LARSEN'S MEDICAL RECORDS DID YOU
22 OBSERVE OR DID YOU SEE ANY RECORD OF ANY KIND OF PAIN THAT
23 WAS BEING REPORTED BY THE PATIENT THE FAMILY, OR EVEN THE
24 NURSES FOR THAT MATTER?
25 A. WELL, SHE HAD BEEN FOUND TO HAVE THE THRUSH. SHE WAS
1 HAVING DIFFICULTY EATING BECAUSE OF THE PAIN THE THRUSH WAS
2 CREATE AND THE PATIENT WAS TREATED FOR THAT.
3 Q. HOW WAS SHE TREATED FOR THAT SIR?
4 A. SHE WAS TREATED NOT ONLY WITH NYSTATIN SWISH AND
5 SWALLOW, WHICH IS THE TREATMENT FOR CANDIDIASIS, BUT SHE WAS
6 ALSO ACCORDING TO THIS, IT LOOKS LIKE SHE WAS TREATED WITH A
7 PAIN MEDICATION AS WELL.
8 Q. WHAT KIND PAIN MEDICATION?
9 A. THIS SAYS M.S.
10 Q. DOES IT SAY WHAT AMOUNT OF MORPHINE WAS ADMINISTERED TO
11 HER?
12 A. I DON'T HAVE THAT RECORD WITH ME BUT IT DOES SAY IN THE
13 CHART, I COULD LOOK AT THAT IF YOU WANT ME TO.
14 Q. AND DO YOU KNOW WHEN THAT THRUSH EXHIBITED ITSELF? WAS
15 THAT ON ADMISSION?
16 A. I BELIEVE IT WAS EARLY ON INTO HER HOSPITAL STAY.
17 Q. OKAY. CAN YOU TELL US SIR RELATIVE TO THE RECORDS,
18 OTHER THAN THE THRUSH CAUSING SOME PAIN AS TO HER BEING ABLE
19 TO EAT, WERE THERE ANY OTHER RECORDS WHICH INDICATED THAT
20 THIS PATIENT WAS IN PAIN?
21 A. IF I REMEMBER RIGHT, I THINK THERE WAS SOME REFERRALS TO
22 SOME DISCOMFORT BY THE NURSING NOTES, BUT I ONCE AGAIN HAVE
23 TO LOOK AT THE CHART TO DETERMINE THAT.
24 Q. SO WHEN WE TALK ABOUT DISCOMFORT AND WE TALK ABOUT PAIN,
25 HOW DO WE EQUATE THAT TO THE USE OF A DRUG LIKE MORPHINE?
1 A. I'M NOT SURE OF YOUR QUESTION.
2 Q. OKAY. I MEAN, DO YOU ADMINISTER MORPHINE FOR
3 DISCOMFORT?
4 A. YES.
5 Q. AND IS THE DEGREE OF DISCOMFORT A CLINICAL JUDGMENT IN
6 YOUR MIND AS TO HOW MUCH MORPHINE YOU ADMINISTERED?
7 A. YEAH, THE CONNEVERSE WOULD BE HOW MUCH WE WOULD WANT THE
8 PATIENT TO CONTINUE TO SUFFER BEFORE WE TREATED IT.
9 Q. OKAY. NOW, LET ME ASK YOU THIS: IT'S TRUE, IS IT NOT,
10 THAT AFTER JUDITH LARSEN WAS TAKEN OFF ALL HER MEDICATIONS
11 AND SHE WAS STARTED ON A REGIMEN OF MORPHINE P.R.N. -- OR NOT
12 P.R.N., BUT ROUTINE MORPHINE --
13 A. CORRECT.
14 Q. -- THAT IN LOOKING AT HER RECORDS, THE ONLY RECORDS
15 INDICATE THAT SHE WAS UNCOMFORTABLE OR SHE APPEARED TO BE IN
16 DISCOMFORT CORRECT?
17 A. YES, SIR.
18 Q. THAT SHE WAS REPORTED TO BE LETHARGIC AND UNRESPONSIVE,
19 CORRECT?
20 A. SHE WAS -- AFTER THE FAMILY'S MEETING, THEY DETERMINED
21 WHAT THEY WANTED TO HAVE PERFORMED FOR MRS. LARSEN. AND THE
22 FAMILY HAD STATED THAT THEY WANTED TO NOT SPARE ANYTHING FOR
23 COMFORT AND DIGNITY, AND THE PATIENT WAS MAINTAINED ON HER
24 ANALGESIC ROUTINELY. AND DURING THAT DYING PROCESS, WE'VE
25 ALREADY SHOWN ON THE RECORDS -- BELIEVE IT WAS THE NIGHT
1 BEFORE AND THE MORNING OF HER DEATH THAT SHE DID HAVE SOME
2 INCREASED LETHARGY AND SOME THINGS ASSOCIATED WITH HER DYING
3 PROCESS.
4 Q. BUT WHAT I'M GETTING AT THEN IS, IN -- IN PROVIDING
5 COMFORT CARE, AS I TAKE IT FROM YOUR PRACTICE, YOU SIT DOWN
6 WITH THE PATIENT'S FAMILY AND BEFORE YOU IMPLEMENT ANY
7 COMFORT CARE PROCEEDS, YOU WILL EXPLAIN TO THEM THE
8 ALTERNATIVES IS THAT CORRECT.
9 A. WE'LL INITIATE SOME COMFORT CARE, BUT WHEN IT COMES TO
10 END OF LIFE, WE HAVE TO DETERMINE WHAT THAT PATIENT'S
11 PRIOR DIRECTIVE WAS, WHAT THAT PATIENT'S DESIRES WERE. AND SO
12 ONCE WE ESTABLISH THAT THROUGH THE SURROGATE, THEN WE
13 DETERMINE HOW FAR WE GO WITH THAT PROVISION.
14 Q. SO YOU WOULD SIT DOWN WITH THE SURROGATE OR THE FAMILY,
15 AND YOU WOULD DISCUSS THAT WITH THEM?
16 A. THAT'S CORRECT.
17 Q. AND YOU WOULD ALSO DISCUSS WITH THEM ALTERNATIVES AS TO
18 WHETHER OR NOT, AS I UNDERSTAND YOUR TESTIMONY, WHETHER OR
19 NOT THEY SHOULD GO INTO ACUTE CARE, WHETHER WE SHOULD GET
20 AGGRESSIVE WITH THE TREATMENT, WHAT THE PROBABILITIES ARE,
21 THOSE KIND OF THINGS?
22 A. TO DISCUSS WHETHER WE SHOULD BE AGGRESSIVE OR IF WE
23 SHOULD PROVIDE COMFORT AND DIGNITY.
24 Q. OKAY. AND SO YOU TRY TO TAKE INTO NOT ONLY THE NEEDS OF
25 THE PATIENT IN PROVIDING END OF LIFE CARE BUT YOU TRY TO TAKE
1 INTO RESPECT THE NEEDS OF THE FAMILY, IS THAT CORRECT?
2 A. WELL, THAT'S TRUE TO A CERTAIN DEGREE, BUT MY POSITION
3 AS A PHYSICIAN FOR THAT PATIENT IS I HAVE TO HONOR THAT
4 PATIENT'S WISHES.
5 Q. OKAY.
6 A. BUT YES, WE DON'T HAVE THE LUXURY OF TAKING CARE OF
7 PATIENTS; WE TAKE CARE OF FAMILIES.
8 Q. SO I WOULD ASSUME IF YOU CAN CONTROL THIS PAIN AT A
9 LEVEL WHERE THE PATIENT IS COMFORTABLE AND -- AND ALSO WOULD
10 BE ABLE TO MAYBE EVEN BE COHERENT ENOUGH TO SPEAK WITH THE
11 FAMILY, THAT WOULD BE THE OPTIMAL SOLUTION, CORRECT?
12 A. OH, THAT'D BE NICE YES.
13 Q. OKAY. SO IN THAT RESPECT, YOU WOULD TITRATE TO EFFECT.
14 A. CORRECT.
15 Q. AND SO IF THE PATIENT WAS LETHARGIC AND WAS SHOWING
16 SIGNS OF OVERSEDATION, WOULD YOU REDUCE THE AMOUNT OF
17 MORPHINE IN THAT EVENT TO TRY AND BRING THE PATIENT UP TO A
18 HIGHER LEVEL?
19 A. I THINK THAT IN THIS PARTICULAR CASE, WE WERE LOOKING AT
20 THE FACT THAT THIS PATIENT HAD HAD CONSIDERABLE AMOUNT OF
21 MORPHINE WITHHELD, AND DURING THAT TIME PERIOD, THE PATIENT
22 WAS GIVEN THE MORPHINE TO MAINTAIN THAT COMFORT CARE. NOW,
23 ONCE THE PATIENT BEGAN HAVING SOME PROBLEMS, ONCE AGAIN, THE
24 MORPHINE WAS BEING GIVEN OVER THAT RATE OF EFFECT FOR THREE
25 TO FOUR HOURS AND TO MAINTAIN THAT CONSTANT LEVEL FOR
1 COMFORT, DIGNITY MAY BE CONTINUED.
2 Q. OKAY. SO WE START -- AS I UNDERSTAND, YOU'RE REFERRING
3 TO WHERE THE NURSE WITHHELD THE MORPHINE.
4 A. CORRECT.
5 Q. AND SHE WITHHELD THREE 10-MILLIGRAMS DOSAGES OF MORPHINE
6 THAT WERE SUPPOSED TO BEEN GIVEN AT 1230, AT 1700, AND AT
7 1830, CORRECT?
8 A. CORRECT.
9 Q. AND YOU'RE SAYING AT THAT POINT PATIENT STARTS
10 EXPERIENCING PAIN BECAUSE SHE'S OBVIOUSLY NOT RECEIVED THE
11 MORPHINE ON A REGULAR BASIS.
12 A. THAT IS CORRECT.
13 Q. NOW, TELL ME DOCTOR, YOU SAY THAT THE INCREASED DOSAGES
14 THEN ARE NEEDED TO BRING THAT PATIENT BACK DOWN TO A LEVEL OF
15 COMFORT.
16 A. ONCE A PATIENT ENTERS INTO A PAIN CRISIS, IT MAY TAKE
17 MORE OPIOIDS TO BRING THAT PATIENT BACK INTO A REASONABLE
18 CONTROLLED STATE.
19 Q. NOW IF THE MEDICAL RECORDS REFLECT THAT AFTER THE
20 INITIAL DOSAGE IS GIVEN AT 1830 WHEN THEY'RE RESTARTED, OF 15
21 MILLIGRAMS, AND THAT THE PATIENT WAS UNRESPONSIVE AND
22 LETHARGIC, WOULD YOU SEE ANY NEED TO GIVE ADDITIONAL DOSAGES
23 OF MORPHINE OF A GREATER DEGREE AFTER THAT?
24 A. I THINK THAT WHAT YOU'D HAVE TO DO IS YOU'D HAVE TO
25 DETERMINE, NUMBER ONE, IF THE PATIENT WAS STILL HAVING PAIN.
1 NUMBER TWO, THE LETHARGY COULD BE DUE TO OTHER ISSUES,
2 INCLUDING HER DILANTIN, INCLUDING HER STROKE, INCLUDING HER
3 SEIZURES, INCLUDING ALL THE ISSUES INVOLVED. I THINK YOU'D
4 HAVE TO TEASE OUT IF THE PATIENT WAS STILL HAVING PAIN, IF
5 THEY WERE, DESPITE FACT THAT THEY WERE LETHARGIC FROM OTHER
6 ISSUESS, I STILL WANNA MAINTAIN THEM WITHOUT PAIN.
7 Q. AND HOW DO YOU GO ABOUT DOING THAT IF YOU DON'T HAVE A
8 PATIENT THAT'S RESPONSIVE?
9 A. YOU CAN ASSESS THE PATIENT, YOU CAN ASSESS THE RECORDS.
10 Q. WELL, IF I WERE TO TELL YOU THAT -- WELL, LET ME GO BACK
11 TO YOUR ANALOGY OF RALPH.
12 A. SURE.
13 Q. YOU SAID RALPH WOULD DRAW HIS LEG BACK EVERY TIME
14 SOMEBODY CAME CLOSE TO HIM. WE HAVE IN THESE MEDICAL RECORDS
15 A NUMBER OF INSTANCES WHERE THE NURSE'S NOTES REFLECT THAT
16 WHEN THE PATIENT IS TURNED TO BE GIVEN THE I.M. INJECTION,
17 THE PATIENT MOANS AND GROANS. NOW WOULDN'T THAT BE SIMILAR
18 IT A RALPH RESPONSE?
19 A. I'M NOT REAL SURE I UNDERSTAND WHAT YOU WERE SAYING.
20 EXCUSE ME --
21 Q. WELL --
22 A. -- WHAT I WAS SAYING THAT SHE MOANED AND GROANED BECAUSE
23 SHE GOT A SHOT?
24 Q. U-HUH.
25 A. OH, I SEE. I DIDN'T SEE THAT.
1 Q. YOU DIDN'T SEE THAT.
2 A. NO.
3 Q. YOU DIDN'T SEE THAT THE NURSE SAID THAT WHEN SHE'S
4 TURNED FOR THE INJECTION, SHE MOANS AND GROANS?
5 A. WELL --
6 Q. WOULDN'T AN INJECTION BE PAINFUL?
7 A. IT CAN BE.
8 Q. OKAY. AND WOULDN'T THAT BE A SIGN THEN IF -- IF I
9 FELT -- IF I WAS A PATIENT AND I FELT SOMEBODY TURNING ME AND
10 KNEW I WAS GOING TO GET AN INJECTION, DON'T YOU THINK I COULD
11 REACT IN THAT FASHION?
12 A. I MEAN MY PATIENTS MOAN AND GROAN WHEN I TURN 'EM
13 BECAUSE THEY DON'T WANNA BE BOTHERED. I MEAN IT'S POSSIBLE,
14 I GUESS. IT'S ALSO POSSIBLE THAT SHE JUST DIDN'T WANNA BE
15 BOTHERED. IT'S ALSO POSSIBLE IT WAS ELICITING PAIN
16 ELSEWHERE.
17 Q. LET'S TURN TO LYDIA SMITH. DID YOU HAVE OCCASION SIR AS
18 TO LYDIA SMITH TO REVIEW HER RECORDS?
19 A. I DID.
20 Q. AND CAN YOU TELL US WHERE THERE -- ON ADMISSION, WERE
21 THERE ANY COMPLAINTS OF PAIN AS TO THIS PATIENT?
22 A. I DID NOT SEE THAT, NO.
23 Q. OKAY. HAVE YOU GOT A COPY OF YOUR REPORT THERE SIR?
24 A. I DO.
25 Q. I WANNA TURN -- TO BRING YOU DOWN TO THE LAST PARAGRAPH
1 IN YOUR REPORT. AND YOU SAY -- IT'S ABOUT, OH, ABOUT SIX,
2 EIGHT LINES DOWN, IT STARTS OUT WITH DR. WEITZEL. CAN YOU
3 READ THAT FOR US?
4 A. YEAH, I MET WITH THE PATIENT'S SON ON JANUARY THE SIXTH
5 AND IT WAS DETERMINED THAT THE PATIENT APPEARED TO BE IN
6 DISCOMFORT AND POSSIBLY SUFFERING FROM CHRONIC PAIN.
7 Q. CAN YOU TELL US WHERE IN THE RECORD YOU GOT THAT
8 INFORMATION DOCTOR?
9 A. ACTUALLY WE GOT THAT FROM THE FACT THAT THIS PATIENT HAD
10 BEEN HAVING CONTINUED SEVERE AGITATIVE BEHAVIOR, SHE HAD HAD
11 SOME HISTORY OF A FROZEN SHOULDER PAST THAT TIME, AND AT THE
12 TIME THAT DR. WEITZEL MET WITH THE SON, IT WAS DETERMINED
13 THAT POSSIBLY THIS AGITATION COULD BE CAUSED BY AGI -- BY
14 PAIN.
15 Q. OKAY. NOW, YOU SAY THAT WAS ON JANUARY THE SIXTH?
16 A. THAT'S WHAT I UNDERSTOOD.
17 Q. NOW, HOW DID YOU UNDERSTAND THAT TO BE THE CASE SIR?
18 A. IN REVIEWING THE RECORDS.
19 Q. OKAY. CAN YOU POINT TO ANYWHERE SPECIFICALLY IN THAT
20 RECORD THAT THERE WAS A MEETING BETWEEN THE PATIENT'S SON AND
21 DR. WEITZEL ON JANUARY THE SIXTH?
22 A. I WOULD HAVE TO SEE THE RECORDS SIR TO SHOW YOU.
23 Q. OKAY. I ASSUME THAT'S THE NURSING HOME RECORDS.
24 A. THAT'S CORRECT -- WELL, NO, NOT THE NURSING HOME.
25 MR. BUGDEN: WELL, NO, I THINK IT'S THE DAVIS --
1 THE COURT: THE HOSPITAL RECORDS.
2 Q. (BY MR. WILSON) HOSPITAL RECORDS, EXCUSE ME. THINK IT'S
3 EXHIBITS FIVE -- FIVE B.
4 A. THANK YOU. WELL, ON THE PROGNOSIS NOTES, I SHOW HERE
5 FOR SURE IN FIRST GLANCE THAT WE HAVE A FAMILY MEETING WITH
6 DR. WEITZEL ON THE EIGHTH.
7 Q. THE EIGHTH?
8 A. I DEFINITELY HAVE FOUND THAT ONE, YES.
9 Q. OKAY. CAN YOU REFERENCE WHAT NOTE THAT WAS?
10 A. I'M SORRY, I'VE TURNED THE PAGE SINCE THEN. LET ME SEE,
11 THIS WOULD HAVE BEEN ON THE PHYSICIAN'S ORDERS AND PROGRESS
12 NOTES FROM DAVIS HOSPITAL MEDICAL CENTER.
13 Q. CAN YOU READ A PAGE NUMBER FOR ME THERE?
14 A. OH, OKAY, THAT WOULD HELP. PAGE NUMBER, THAT WOULD BE
15 00712.
16 Q. 00712?
17 A. YES, SIR.
18 Q. AND IS IT -- WHO WROTE THAT NOTE, CAN YOU TELL US THAT?
19 A. I CAN'T TELL.
20 Q. OKAY. BUT IT DOESN'T REFERENCE ANY MEETING WITH THE SON
21 ON JANUARY 6TH, DOES IT?
22 A. I HAVEN'T FOUND THAT YET, BUT I'M STILL LOOKING.
23 Q. MAYBE I CAN JUST ASK YOU A QUESTION DOCTOR.
24 A. SURE.
25 Q. IF I WERE TELL YOU THAT THERE IS NO SUCH NOTE IN THE
1 MEDICAL RECORD AS TO A MEETING WITH THE SON ON JANUARY THE
2 SIXTH, WOULD YOU SAY THAT YOU WERE MISTAKEN?
3 MR. BUGDEN: YOUR HONOR, I DISAGREE WITH THAT
4 CHARACTERIZATION.
5 THE COURT: WELL, YOU HAVE RIGHT TO ON YOUR REDIRECT.
6 MR. BUGDEN: THANK YOU.
7 THE WITNESS: YOU KNOW, PHYSICIANS DON'T WRITE WELL. I
8 CAN'T TELL YOU THAT I COULDN'T HAVE MISTAKEN A JANUARY 6 FOR
9 JANUARY 8TH, BUT I REALLY DON'T THINK SO. I THINK I SAW IT
10 SOMEWHERE. I'M JUST NOT SURE WHERE I FOUND IT.
11 Q. LET'S READ DOWN FURTHER IN THAT PARAGRAPH?
12 A. SURE.
13 Q. THE NEXT LINE SAYS THE PATIENT WAS PULLING OUT HER HAIR,
14 REMOVING HER CLOTHES POSSIBLY DUE TO NEUROPATHIC PAIN.
15 A. NEUROPATHIC -- NEUROPATHIC PAIN. EXCUSE ME.
16 Q. UH-HUH. I.M. MEDICATION WAS MORE THAN REASONABLE IN
17 THIS PATIENT AND SHE WAS GIVEN 5 MILLIGRAMS OF M.S. Q. EVERY
18 THREE HOURS. AM I CORRECT IN THE WAY I READ THAT?
19 A. THAT IS CORRECT.
20 Q. AND THEN YOU CHARACTERIZE THAT AS A DOSE LESS THAN THE
21 STANDARD OF CARE FOR A PATIENT WITH A POSSIBLE M.I.?
22 A. YES.
23 Q. AND THEN THE NEXT SENTENCE SAYS, THE NEXT DAY THE
24 PATIENT WAS NOT LETHARGIC, BUT WAS SPITTING OUT HER FOOD AND
25 STILL UNDRESSING.
1 A. THAT'S CORRECT.
2 Q. SO I ASSUME FROM READING THAT PARAGRAPH, YOU'RE SAYING
3 THAT SHE WAS GIVEN 5 MILLIGRAMS OF MORPHINE EVERY THREE HOURS
4 THE DAY BEFORE SHE WAS -- APPEARED TO BE NOT LETHARGIC, IS
5 THAT CORRECT?
6 A. YES.
7 Q. CAN YOU SHOW US IN THE MEDICAL RECORDS, DOCTOR, WHEN SHE
8 FIRST RECEIVED HER FIRST 5 MILLIGRAM OF MORPHINE?
9 A. IT LOOKS LIKE THE ORDER WAS WRITTEN ON ONE, SEVEN, 96.
10 Q. OKAY. AND IT WAS WRITTEN AT WHAT TIME?
11 A. IT LOOKS LIKE 2130.
12 Q. OKAY. SO THAT WOULD BE WHAT TIME OF DAY? LET'S SEE --
13 A. THAT WOULD PROBABLY 9:30 --
14 Q. 9:30 IN THE EVENING?
15 A. 9:30 IN THE EVENING, YES. THAT'S WHEN IT WAS NOTED.
16 Q. SO IN RELATIVE TO YOUR REVIEW OF THE RECORDS, SHE DIED
17 THE FOLLOWING DAY ON THE EIGHTH, DID SHE NOT?
18 A. YES SHE DID.
19 Q. OKAY. SO YOU'RE MISTAKEN AGAIN --
20 A. NO, I BELIEVE IT WAS ON THE NINTH.
21 Q. WELL, DO YOU WANNA LOOK AT THE MEDICAL RECORD TO SEE
22 WHEN SHE DIED?
23 A. IT JUST SAYS HERE, IT SAYS, 1/9/96 RETURN PATIENT'S BODY
24 TO THE MORTUARY.
25 Q. IF I WERE TO TELL THAT YOU THE -- HER DEATH OCCURRED ON
1 THE EIGHTH AT APPROXIMATELY 12:45 IN THE AFTERNOON, THAT
2 WOULD NOT COMPORT WITH YOUR RECORD -- OR WITH YOUR
3 RECOLLECTION?
4 A. I'M JUST LOOKING HERE AT THE CHART, SIR. I'M JUST WAS
5 THUMBING THROUGH WHEN YOU SAID THAT AND IT'S RECORDED HERE
6 1/9/96 RELEASE PATIENT'S BODY TO MORTUARY.
7 Q. OKAY. WHEN WAS THE LAST DOSAGE OF MORPHINE GIVEN TO
8 HER? MAYBE YOU OUGHTA LOOK AT THE DRUG RECORD.
9 A. UH-HUH.
10 MR. BUGDEN: YOUR HONOR, WHILE DR. CRANMER'S LOOKING FOR
11 SOMETHING, MAY I APPROACH THE BENCH WITH MR. WILSON?
12 THE COURT: NO.
13 THE WITNESS: CAN I ASK YOU WHERE YOU FOUND THAT M.A.R.,
14 WHERE IT WAS IN THESE CHARTS WHEN YOU SHOWED THAT PREVIOUS
15 ONE TO ME?
16 MS. BARLOW: IT'S BEHIND THE TABS OF MED GRAPH.
17 THE WITNESS: YEAH, I'M LOOKING AT THAT BUT I DON'T SEE
18 AN M.A.R.
19 THE COURT: LET'S TAKE OUR LUNCH BREAK AT THIS TIME AND
20 MAYBE YOU CAN REVIEW SOME OF HIS RECORDS AND SPEED THINGS
21 ALONG.
22 MR. BUGDEN: BEFORE YOU EXCUSE THE JURY, MAY I PLEASE
23 APPROACH THE BENCH?
24 THE COURT: SURE.
25 (A CONFERENCE WAS HELD AT THE BENCH.)
1 THE WITNESS: I DON'T HAVE AN M.A.R. IN THIS -- UNDER
2 THIS TAB. I'M SO SORRY. THIS WASN'T THE COPY I LOOKED AT.
3 THE COURT: LADIES AND GENTLEMEN, THIS WITNESS HAS A
4 PLANE TO CATCH. HE HAS A DAUGHTER WHO'S HAVING A CHILD THIS
5 AFTERNOON --
6 THE WITNESS: MY FIRST GRANDCHILD.
7 THE COURT: FIRST GRANDCHILD. SO WITH YOUR ACQUIESCE,
8 WE'D LIKE GO LITTLE BIT LONGER. IS THAT AGREEABLE WITH YOU?
9 ALL RIGHT. WE'LL GO AHEAD THEN. THANK YOU, MR. BUGDEN.
10 BY MR. WILSON:
11 Q. HAVE YOU BEEN ABLE TO FIND THAT DOCTOR?
12 A. YES, I -- WE FOUND IT UNDER E.K.G. AND IT LOOKS LIKE --
13 THIS IS NOT THE COPY I REVIEWED. I APOLOGIZE. AND IT LOOKS
14 LIKES THAT THE PATIENT RECEIVED MORPHINE ON 1/8 AT 0600
15 HOURS, AT SIX O'CLOCK IN THE MORNING.
16 Q. AND SHE RECEIVED IT AFTER THAT, TOO, DID SHE NOT?
17 A. WELL, I DON'T SEE IT, SIR. I --
18 Q. OKAY. LET'S MOVE ON. THE -- YOU INDICATE -- THEN I
19 WOULD -- I WOULD ASK YOU, SIR, WERE YOU MISTAKEN RELATIVE TO
20 YOUR NOTE AS TO 5 MILLIGRAMS OF MORPHINE BEING GIVEN TO HER
21 EVERY THREE HOURS ON THE DAY BEFORE SHE WAS OBSERVED NOT
22 LETHARGIC BUT SPITTING OUT FOOD AND STILL UNDRESSING?
23 A. YOU KNOW, THESE ARE NOT THE RECORDS I REVIEWED.
24 ACCORDING TO MY NOTE, IT SAYS THE PATIENT'S SON WAS TALKED TO
25 ON THE SIXTH. I CAN'T IDENTIFY IT IN THIS PARTICULAR RECORD.
1 I DO SEE THAT HE DID TALK TO THE FAMILY AGAIN ON THE EIGHTH.
2 I COULD MADE A MISTAKE. I DON'T THINK I DID. BUT IT IS
3 POSSIBLE.
4 Q. THE NEXT LINE DOWN, LET ME ASK YOU THIS, THE DECISION TO
5 WITHDRAW MEDICATIONS WAS MADE DETERMINE IF THEY WERE IN FACT
6 CAUSING HER BEHAVIOR PROBLEMS AS WELL AS COMPLYING WITH THE
7 FAMILY'S WISHES TO DECREASE HER MEDS. ON THE SEVENTH --
8 WELL, THAT -- THAT STATEMENT, THE DECISION TO WITHDRAW THE
9 MEDICATIONS, CAN YOU TELL US WHERE IN THE RECORD THAT THAT
10 APPEARS?
11 A. IT APPEARS THAT ON -- ON THE ORDER SHEET THAT THERE WAS
12 NO ORDER WRITTEN FOR THAT. AS FAR AS THE PROGNOSIS NOTES ON
13 THE --
14 Q. APPARENTLY, DOCTOR, THERE WAS SOMETHING THAT LED YOU TO
15 THE DEC -- DRAW THE CONCLUSION THAT THERE WAS SOME DECISION
16 MADE TO WITHDRAW THE MEDICATIONS ON THE -- ON THE SEVENTH IN
17 COMPLIANCE WITH THE FAMILY'S WISHES. IS THAT RIGHT?
18 A. IT LOOKS LIKE THE PROGRESS NOTE ON 1/7, IT LOOKS LIKE BY
19 DR. WEITZEL, LOOKS LIKE FAMILY DISCUSSION WITH TWO SOMETHING,
20 MAYBE SONS AND DAUGHTER REVEALS THAT THEY DO NOT WANT LIFE
21 PROLONGED, BUT ARE READY TO LET HER GO. AT TIME SHE THRASHES
22 ABOUT AND SEEMS TO BE IN PAIN. AND IT SAYS HOLD MEDS, M.S. Q.
23 THREE HOURS ON FIVE SEVEN.
24 Q. SO YOU DRAW FROM THAT NOTE THE CONCLUSION THAT THE
25 FAMILY'S MADE A DECISION BECAUSE THEY THOUGHT THE MEDS WERE
1 CAUSING HER BEHAVIOR PROBLEMS?
2 A. NO. IT SAYS THAT THEY DO NOT WANNA DO ANY AGGRESSIVE
3 TREATMENT OR ANY AGGRESSIVE WORKUPS, THAT SHE'S 91 YEARS OF
4 AGE AND THAT SHE -- APPARENTLY THEY WANT COMFORT AND DIGNITY
5 AND HE STILL CANNOT GET HER THRASHING ABOUT, PULLING OUT HER
6 HAIR, YELLING AND SCREAMING CONTROLLED, AND THAT THEY WERE
7 TRYING THE PAIN MEDICINES TO SEE IF THIS COULD BE POSSIBLY
8 DUE TO SAME PA -- SOME PAIN PROCESS. AND AS A RESULT, WITH
9 EVERY EFFORT THAT THEY COULD MAKE, THEY DECIDED TO TRY TO GO
10 AHEAD AND TREAT HER WITH PAIN MEDICATIONS AND WITHDRAW SOME
11 OF THE OTHER MEDICATIONS TO SEE IF THAT WOULD HELP.
12 Q. SO YOU THINK THAT WAS A -- A DECISION THAT WAS MADE ON
13 THE SEVENTH WAS TO WITHDRAW HER MEDS TO TRY AND CONTROL HER
14 BEHAVIOR, NOT TO PROVIDE COMFORT CARE?
15 A. NO. I THINK THAT IT WAS -- I DON'T THINK IT REALLY
16 MAKES -- EXCUSE ME -- QUITE CLEAR ON THAT. I THINK THAT
17 PROBABLY IT SOUNDS TO ME LIKE THAT THIS FAMILY HAS MADE IT
18 VERY CLEAR TO THE DOCTOR THEIR WISHES. AND I THINK THAT HER
19 BEHAVIOR WAS SO BIZARRE THAT THEY WERE DOING WHATEVER THEY
20 COULD TO TRY TO CONTROL THAT.
21 Q. WELL, THE NOTE DOES NOT SAY ANYTHING ABOUT THE FAMILY
22 WISHING TO WITHDRAW MEDICATION, DOES IT? OR --
23 A. IT SAYS -- IT SAYS IN THE SAME NOTE THAT PLAN WOULD BE
24 TO HOLD THE MEDICATIONS AND M.S. 5 MILLIGRAMS Q. THREE HOURS.
25 Q. OKAY. BUT IT DOESN'T SAY ANYTHING ABOUT THE FAMILY
1 WISHING TO DECREASE HER MEDS TO CONTROL HER BEHAVIOR
2 PROBLEMS, DOES IT?
3 A. NO, IT DOES NOT SAY THAT.
4 Q. OKAY. LET'S TURN TO ENNIS ALLDREDGE IF YOU -- IF WE
5 NIGHT FOR JUST A MINUTE. ISN'T IT TRUE THAT ON THE DATE OF
6 ADMISSION THAT AFTER BEING GIVEN LARGE DOSES OF HALDOL,
7 ANOTHER MEDICATION, THAT HE -- HE WAS DESCRIBED AS
8 UNRESPONSIVE, EXTREME SEDATION?
9 MR. BUGDEN: COULD YOU SHOW US THE PAGE, COUNSEL, SO WE
10 CAN SEE WHERE YOU'RE TALKING ABOUT? JUST TELL US WHAT PAGE
11 YOU'RE LOOKING AT?
12 Q. (BY MR. WILSON) WELL, DO YOU REMEMBER ANY DESCRIPTION OF
13 THAT SORT?
14 A. NO.
15 Q. PARDON?
16 A. NO. I SHOW HERE THAT HE WAS -- HAD ADVANCED DEMENTIA,
17 HAD BECOME EXCESSIVELY AGITATED WITH BEHAVIOR HARMFUL TO HIMSELF
18 AND OTHERS. HIS PSYCHOSIS LED TO KICKING, BITING CAREGIVERS
19 AND NOT RESPONDING TO BENZODIAZEPINES. AS A RESULT, HE'S
20 ADMITTED TO THE GEROPSYCH UNIT. AND THAT'S WHERE HE WAS
21 FOUND TO HAVE HIS POORLY CONTROLLED DIABETES. SUFFERED FROM
22 ARTERIOSCLEROTIC VASCULAR DISEASE, HYPERTENSION, RENAL
23 FAILURE --
24 THE COURT: SLOW DOWN, DOCTOR.
25 THE WITNESS: I'M SORRY.
1 Q. (BY MR. WILSON) THOSE ARE YOUR NOTES, CORRECT?
2 A. YES.
3 Q. YOU DON'T RECALL ANYTHING DESCRIBING HIM FROM YOUR
4 REVIEW OF THE PHYSICIANS ORDERS AND PROGRESS RECORDS AS BEING
5 LETHARGIC -- LET'S SEE, RESPONSIBLE ONLY TO PAINFUL STIMULI?
6 LET'S ME SHOW YOU WHAT'S BEEN MARKED --
7 A. THANK YOU.
8 Q. -- AND THINK IT'S EXHIBIT 6-B.
9 THE COURT: IT IS 6-B.
10 Q. (BY MR. WILSON) MED PAGE 0011. CAN YOU TAKE A LOOK AT
11 THAT? AND I JUST REFER YOU TO DOWN HERE IN DR. DIENHART'S
12 NOTES. CAN YOU READ THAT FOR US IF YOU WOULD?
13 A. IT SAYS CURRENTLY LETHARGIC. POSSIBLY -- I'M SORRY,
14 RES -- ONLY TO PAINFUL STIMULI. HELD -- OH, HALDOL
15 INJECTION. THAT'S ABOUT ALL I CAN READ.
16 Q. OKAY. WOULD THAT BE A SYMPTOM OF OVERMEDICATION?
17 A. YEAH, WHEN WE GIVE HALDOL I.M., WHICH IS SOMETIMES WHAT
18 WE HAVE TO DO IN PATIENTS THAT ARE SEVERELY AGITATED
19 ESPECIALLY I THINK HE'D PICKED UP A WHEELCHAIR AND THROWN IT
20 AT SOMEBODY. THEY HAD ACTUALLY GIVEN HIM AN IMMEDIATE QUICK
21 RELEASE MEDICATION WHICH WAS AN I.M. HALDOL. THAT'S OPPOSED
22 TO THE ORAL ANTIPSYCHOTICS THAT WE NORMALLY GIVE, AND
23 SOMETIMES WE GIVE THAT SO THAT WE CAN GET THEM CALMED DOWN
24 BECAUSE THEY'RE IN IMMEDIATE JEOPARDY.
25 Q. WAS THERE ANY DOCUMENTATION IN HIS RECORDS RELATED TO
1 PAIN?
2 A. I DO NOT REMEMBER.
3 Q. NOW, YOU PREVIOUSLY TESTIFIED ABOUT A STROKE THAT
4 OCCURRED, AND YOU SAID YOU REVIEWED THAT STROKE. CAN YOU
5 TELL US DOCTOR, WAS THERE ANY NOTES RELATIVE TO ANY CLINICAL
6 CORRELATION FOR THAT STROKE?
7 A. WHAT CLINICAL CORRELATION WOULD YOU BE CONCERNED ABOUT?
8 Q. WELL, ISN'T THERE WAYS THAT YOU AS A PHYSICIAN CAN
9 CLINICALLY CORRELATE WHETHER OR NOT AN INDIVIDUAL HAS
10 SUFFERED A STROKE.
11 A. IT DEPENDS UPON WHERE THE STROKE OCCURRED IN THE BRAIN.
12 Q. OKAY. THE STROKE OCCURRED IN THE BRAIN I THINK ON THE
13 LEFT OCCIPITAL AREA ACCORDING TO THE DIAGNOSTIC REPORT, IS
14 THAT CORRECT?
15 A. THAT IS ONE LOCATION, YES.
16 Q. OKAY. AND WOULD YOU EXPECT THAT THERE WOULD BE THE
17 ABILITY TO OBSERVE THE EFFECTS OF THAT STROKE AS FAR AS THIS
18 INDIVIDUAL'S PHYSICAL CAPACITIES?
19 A. NOT NECESSARILY. OCCIPITAL LOBE IS WHERE THE VISION
20 ACUITY TAKES PLACE AND IT COULD AFFECT PART OF HIS VISION
21 THAT HE MAY NOT HAVE BEEN ABLE TO RELATE TO US.
22 Q. OKAY. DID YOU SEE ANY EFFORT MADE TO TRY AND CLINICALLY
23 CORRELATE THAT STROKE? IN MANNER --
24 A. IT'LL SHOW ON THE M.A. -- M.R.I. THAT HE HAS T-2
25 IMAGING, WHICH IS EVIDENCE OF SMALL STROKES THROUGHOUT BRAIN.
1 AND THIS ONE AREA THAT LOOKED LIKE IT COULD BE AN ACUTE
2 STROKE THAT YOU JUST DESCRIBED, AND THEN ANOTHER LARGER AREA
3 OF AN OLDER STROKE. SO WE SAW EVIDENCE OF MULTIPLE STROKES
4 THROUGHOUT THE BRAIN.
5 Q. AND AS FAR AS ANY -- I THINK THE QUESTION WAS, WAS THERE
6 ANY OTHER EFFORTS OTHER THAN THE M.R.I. TO CLINICALLY
7 CORRELATE THE NATURE OF THAT STROKE?
8 A. NO, SIR.
9 Q. OKAY. DID YOU FORM ANY KIND OF AN OPINION BASED UPON
10 THE M.R.I. AS TO WHETHER OR NOT THAT WAS LIFE-THREATENING IN
11 NATURE?
12 A. THE FACT THAT HE HAD HAD AS MANY STROKES AS HE HAD
13 SHOWED THAT HE HAD AN INSIDIOUS VASCULAR DEMENTIA RELATED OF
14 COURSE PROBABLY TO HIS ARTERIOSCLEROTIC DISEASE, PROBABLY
15 RELATED TO HIS DIABETES MOST OF HIS LIFE, AND AS A RESULT, HE
16 WAS HAVING MULTIPLE STROKES, AND YES, HE WAS LOOKING AT END
17 OF LIFE CARE.
18 Q. I GUESS THE QUESTION WAS, DID YOU SEE THAT IT WAS
19 LIFE-THREATENING AT THAT TIME?
20 A. YES, SIR. HE WAS AT END OF LIFE CARE BECAUSE OF HIS
21 MULTIPLE STROKES.
22 Q. AND IN RESPECT TO YOUR FINDING OF THAT BASED UPON THE
23 M.R.I. ONLY, DID YOU SEE ANY REASON FOR STARTING THIS
24 PARTICULAR PATIENT ON M.S.? ON MORPHINE?
25 A. I WOULD HAVE TO REVIEW THE RECORD AGAIN, BUT IF I
1 REMEMBER RIGHT, THE PATIENT NOT ONLY HAD HIS PREVIOUS
2 PROBLEMS, BUT HE ALSO HAD MYCOSIS FUNGOIDES WHICH HE'D HAD
3 FOR A LONG PERIOD OF TIME. IT'S A TYPE OF LYMPHOMA, AND
4 THERE WAS -- I DON'T SEE ON MY REPORT, BUT -- AND I DON'T
5 REMEMBER FOR SURE, BUT I'D HAVE TO LOOK AT THE CHARTS AGAIN
6 TO SEE IF HE HAD ANY SPECIFIC COMPLAINTS OF PAIN.
7 Q. YOU DON'T REMEMBER ANY, THOUGH, IS THAT CORRECT?
8 A. AS WE MENTIONED PREVIOUSLY, WE THINK THAT A LOT OF TIMES
9 THESE CONTINUED AGITATED BEHAVIORS MAY BE IN FACT DUE TO
10 CHRONIC PAIN.
11 Q. OKAY. BUT YOU WEREN'T ABLE TO DOCUMENT ANY PARTICULAR
12 CAUSE FOR ANY PAIN, IS THAT CORRECT?
13 A. I WOULD HAVE TO LOOK AGAIN AND SEE. I DID NOT REPORT IT
14 ON MY NOTE, NO.
15 MR. WILSON: OKAY. NO FURTHER QUESTIONS YOUR HONOR.
16 THE COURT: REDIRECT MR. BUGDEN.
17 BY MR. BUGDEN:
18 Q. YES, THANK YOU VERY MUCH. YOU WERE JUST ASKED SOME
19 QUESTIONS ABOUT MR. ALLDREDGE. I'M GONNA START THERE AND GO
20 IN THE BACK REVERSE ORDER. YOU WERE SHOWN DR. DIENHART'S
21 NOTE WHERE IT APPEARED THAT THERE WAS SOME LETHARGY AND
22 JOHNNY ON THE SPOT TRYING TO LOOK AT THE RECORDS THAT THE
23 BOOK -- THAT WAS A DIFFERENT BOOK THAN THE ONE THAT YOU HAD.
24 YOUR WEREN'T ABLE TO PUT YOUR FINGER ON SIGNS OF AGITATION.
25 HAVE YOU -- DOES IT SOUND FAMILIAR TO YOU DOCTOR THAT YOU HAD
1 SEEN RECORDS THAT INDICATED AGITATION BY MR. ALLDREDGE EVEN
2 AFTER DR. DIENHART SAW HIM?
3 A. YES. I -- IN VIEWING THAT QUICK GLIMPSE OF THAT
4 CHART, THAT WAS ONE OF THOSE THINGS THAT I HAD THUMBED
5 THROUGH, AND MAYBE THAT'S WHERE I OBTAINED SOME OF THAT DATA.
6 Q. IN TERMS OF DR. DIENHART SAW THIS PATIENT ON --
7 THE COURT: IS THAT AN EXHIBIT, MR. BUGDEN?
8 MS. ISAACSON: IT HAS BEEN MARKED.
9 MR. BUGDEN: IT HAS BEEN MARKED AND WE'LL TELL YOU IN A
10 MOMENT, JUDGE. WHILE SHE'S LOOKING, I'LL JUST ADVISE YOU,
11 DR. CRANMER THAT DR. DIENHART SAW MR. ALLDREDGE ON 1/10 --
12 MS. ISAACSON: DEFENDANT'S 84.
13 MR. BUGDEN: AND THE EXHIBIT THAT'S BEFORE THE JURY IS
14 DEFENDANT'S 84?
15 MS. ISAACSON: THAT'S RIGHT.
16 MR. BUGDEN: MAY THAT BE RECEIVED? MAY THAT BE
17 RECEIVED, MR. WILSON?
18 THE COURT: 84 OF THE DEFENDANT?
19 MR. BUGDEN: THIS IS EXHIBIT 84. DO YOU HAVE ANY
20 OBJECTION TO IT BEING RECEIVED BY THE JURY?
21 MR. WILSON: FOR ILLUSTRATIVE PURPOSES ONLY?
22 MR. BUGDEN: WELL, ACTUALLY, I'D LIKE IT TO BE RECEIVED.
23 THE COURT: IT'S BEEN REFERRED TO BEFORE.
24 MR. WILSON: IT HAS?
25 THE COURT: ON PAGE 111 -- THAT'S MY NOTES, EXCUSE ME.
1 I DON'T KNOW WHAT PAGE IT'S ON. IT'S BEEN REFERRED TO BEFORE
2 DURING THE COURSE OF THE TESTIMONY.
3 MR. WILSON: AND I -- I ASSUME I HAVE NO OBJECTION AGAIN
4 YOUR HONOR AS TO ILLUSTRATIVE PURPOSES.
5 THE COURT: WELL, MAYBE IT'S BEING OFFERED MORE THAN
6 JUST ILLUSTRATIVE. IT'S BEEN REFERRED TO BEFORE WITHOUT
7 OBJECTION.
8 MR. WILSON: OKAY. AND WE'LL LIVE BY WHAT WE SAID.
9 THE COURT: WELL, IT'S NOT BEEN RECEIVED, BUT IT --
10 MR. WILSON: WELL, WE WOULD HAVE AN OBJECTION TO IT
11 BEING RECEIVED, YOUR HONOR.
12 THE COURT: I'LL LET YOU REFER TO IT. GO AHEAD.
13 MR. BUGDEN: THANK YOU, JUDGE.
14 Q. (BY MR. BUGDEN) ON 1/10/96 THE DAY OF ADMISSION, THERE
15 ARE IN FACT OTHER INDICATIONS OF MR. ALLDREDGE APPEARING
16 AGITATED ON THAT DAY, ON 1/10/96 AT 2 P.M. NURSE EARLENE
17 COZZINS NOTES THE PATIENT VERY COMBATIVE AND AGITATED.
18 PATIENT KEEPS TAKING OFF CLOTHES. PATIENT REFUSES TO EAT.
19 SAME DAY AT 4 P.M., A C.N.A., GUESS THAT'S A CERTIFIED NURSE
20 ASSISTANT, WROTE PATIENT REFUSED WATER. WAS RESISTANT WITH
21 RANGE OF MOTION. COMBATIVE AT TIMES. ON 1/10 AT 12 P.M. I'M
22 GOING THE OPPOSITE DIRECTION. SORRY. SHOULD HAVE STARTED
23 THERE. ASSAULTIVE TOWARDS STAFF. HITTING STAFF. AT 2:15 IN
24 THE AFTERNOON, A DIFFERENT NURSE WROTE AGITATED, TRYING TO
25 HIT. SQUEEZE HANDS. SO ALTHOUGH MR. WILSON POINTED OUT THAT
1 DR. DIENHART SAW THE PATIENT LETHARGIC AT SOME POINT THAT
2 DAY, ALSO THROUGHOUT THAT DAY THIS PATIENT WAS AGITATED
3 REPEATEDLY, ISN'T THAT TRUE?
4 A. YES. AND AS I DESCRIBED, I.M. HALDOL, A SHOT OF HALDOL,
5 IS MUCH MORE EFFECTIVE AND IT'S FOR IMMEDIATE JEOPARDY. AND
6 IT WAS GIVEN. AND IF DR. DIENHART -- IS THAT RIGHT?
7 Q. DIENHART, I THINK IS HOW --
8 A. DIENHART WOULD HAVE SEEN HIM AT ANY TIME AFTER THAT SHOT
9 WAS GIVEN, HE MAY HAVE FOUND HIM AT THAT PARTICULAR TIME
10 LETHARGIC FROM THE SHOT.
11 Q. ALSO, PUTTING YOU ON THE SPOT, YOU WEREN'T ABLE TO
12 IDENTIFY SYMPTOMS OF PAIN THAT MR. ALLDREDGE HAD AT THE END
13 OF HIS LIFE --
14 MS. ISAACSON: AND THIS IS EXHIBIT 90.
15 MR. BUGDEN: EXHIBIT 90 I'M OFFERING, YOUR HONOR.
16 MR. WILSON: AND WE WOULD HAVE NO OBJECTION FOR
17 ILLUSTRATIVE PURPOSES ONLY.
18 MR. BUGDEN: WELL, IN FACT, ON 1/14, 1/14, THERE WERE
19 INDICATIONS OF THE PAIN -- OF PAIN SYMPTOMS IN THIS PATIENT.
20 FOR EXAMPLE AT 1/14 AT 7:30 IN THE MORNING THE PATIENT WAS
21 MOANING DURING TURNING PROCEDURE. PATIENT AT 4:30 IN THE
22 MORNING, THE PATIENT WAS GRIMMACING AND LABORED BREATHING
23 INDICATED -- INDICATING HIS LEVEL OF DISTRESS. IN FACT,
24 THERE WERE INDICATIONS THAT MR. ALLDREDGE WAS IN PAIN AT THE
25 END OF HIS LIFE, ISN'T THAT TRUE?
1 MR. WILSON: THE QUESTION IS LEADING, YOUR HONOR. I
2 DON'T KNOW WHETHER --
3 THE COURT: SUSTAINED.
4 Q. (BY MR. BUGDEN) ARE THERE -- I JUST HAVE -- BEAR WITH
5 ME, IT'S MY FAULT. ARE THERE INDICATIONS IN THE RECORD AS
6 WE'RE LOOKING AT, OF PAIN IN THIS PATIENT ON THE LAST DAY?
7 A. I HAD REMEMBERED THAT THERE WAS EVIDENCE. I JUST
8 COULDN'T FIND IT. THIS MAY HAVE BEEN WHERE I GOT IT.
9 Q. THANK YOU. LYDIA SMITH. I THINK YOU WERE ABLE TO
10 ULTIMATELY FIND THE NOTE THAT YOU WEREN'T ABLE TO FIND DURING
11 SOME OF THE QUESTIONS THAT MR. WILSON WAS ASKING YOU, BUT IN
12 FACT, ON PAGE 719 THAT MR. WILSON HAS SHOWN YOU, IN FACT,
13 THERE WAS A CONFERENCE WITH THE FAMILY BETWEEN DR. WEITZEL
14 AND THE FAMILY. CAN WE SHOW THAT? SO ON 1/7/96 -- LOOKING
15 AT THE RIGHT PLACE?
16 A. THAT'S ONE I READ, YES.
17 Q. FAMILY DISCUSSION WITH TWO SONS. THAT'S WHAT YOU WERE
18 REFERRING TO?
19 A. I READ THAT NOTE. WE DID FIND THAT ON 1/7.
20 Q. OKAY. IT'S AT THAT POINT THAT IT APPEARS THAT THE
21 FAMILY HAD A DISCUSSION WITH THE DOCTOR ABOUT WHETHER OR NOT
22 THEY WANTED TO PROLONG LIFE OR COMFORT CARE. AM I ABOUT
23 RIGHT ON THAT?
24 A. THAT IS CORRECT. THE ISSUE WAS, IS THAT I HAD IN MY
25 NOTE THAT THERE WAS A MEETING WITH THE PATIENT'S SON ON
1 JANUARY THE SIXTH AND MAYBE I WAS REFERRING TO THE JANUARY 8
2 NOTE AND COULDN'T READ MY EIGHT.
3 Q. COULD WE SEE PAGE 798, THE SAME MEDICAL RECORD PLEASE?
4 MR. WILSON I THINK ASKED YOU TO READ FROM -- CAN WE HAVE A
5 BLOWUP -- ASKED YOU TO READ FROM YOUR REPORT AND IN YOUR
6 REPORT, YOU HAD TALKED ABOUT THE PATIENT SPITTING OUT -- AND
7 AGAIN, THIS WAS IN THE CONTEXT OF MR. WILSON SUGGESTING THAT
8 THE PATIENT WAS PERHAPS LETHARGIC, BUT IN FACT, THE PATIENT
9 ALSO ACCORDING TO THE NURSING NOTE WAS IN FACT SPITTING OUT
10 OR SPITTING AT US. CAN YOU READ THAT?
11 A. I CAN.
12 Q. HE IS KEPT -- I'M NOT SURE ABOUT THAT WORD. SOMETHING
13 TO STRIP. HE'S BEEN SPITTING IT OUT AT US. SO THERE WAS A
14 NOTE FROM WHICH YOU BASED YOUR TESTIMONY ABOUT THE PATIENT
15 SPITTING AND YOU JUST COULDN'T FIND IT WHEN MR. WILSON WAS
16 ASKING YOU, IS THAT RIGHT?
17 A. THAT IS CORRECT.
18 Q. THEN MR. WILSON AGAIN ASKED YOU IF YOU COULD IDENTIFY ON
19 THE SPOT THE SYMPTOMS OF PAIN IN JUDITH LARSEN AND I BELIEVE
20 HE ASKED YOU WHAT IN THE LAWYER BUSINESS IS CALLED A LEADING
21 QUESTION ABOUT WHETHER OR NOT THERE WAS NO PAIN, AND YOU
22 WEREN'T ABLE TO PUT YOUR FINGER ON SYMPTOMS OF PAIN. WHAT
23 DOCUMENT IS THIS?
24 MS. ISAACSON: THIS IS DEFENDANT'S 50.
25 MR. BUGDEN: DEFENDANT'S 50?
1 MS. ISAACSON: UH-HUH.
2 MR. BUGDEN: MOVE FOR THE INTRODUCTION OF 50, JUDGE.
3 MR. WILSON: WE WOULD HAVE THE -- WE WOULD ACCEPT IT FOR
4 PURPOSES OF ILLUSTRATION ONLY, YOUR HONOR.
5 THE COURT: LET ME JUST LOOK --
6 MR. WILSON: OBJECT TO ADMISSION.
7 THE COURT: I'LL LET IT BE USED FOR ILLUSTRATION
8 PURPOSES. NOT BE ADMITTED. THERE'S NO FOUNDATION.
9 MR. BUGDEN: THANK YOU JUDGE.
10 Q. (BY MR. BUGDEN) THIS IS DOCUMENT IS SYNOPSIS OR A
11 SUMMARY DOCUMENT OF NURSING NOTES, AND ON 1/1 AND 1/2, WERE
12 THERE INDI -- WOULD YOU CONSIDER -- WHY DON'T YOU DISCUSS
13 SOME OF THESE NOTES. WOULD THESE BE INDICATIONS OF PAIN
14 BASED ON YOUR EXPERIENCE IN THE SYMPTOM -- OR IN THE DIAG --
15 I'M SORRY, IN THE RECOGNITION OF PAIN SYMPTOMS IN THE
16 COGNITIVELY IMPAIRED DEMENTED PATIENT?
17 A. DEFINITELY COULD BE, AND EVEN THE ISSUE THAT MR. WILSON
18 AND I DISCUSSED THAT SHE WAS MOANING WHEN WE WERE TURNING THE
19 PATIENT, WHETHER OR NOT SHE WAS COGNITIVE TO ASSOCIATE THAT
20 WITH A SHOT OR WHETHER SHE WAS HAVING PAIN WHEN SHE WAS BEING
21 TURNED, BUT YES, THIS IS WHAT I REMEMBERED AS BEING ON THE
22 1/1 10:45 DOWN HERE IN THE BOTTOM, THE NURSES STATED THAT SHE
23 APPEARED TO BE IN PAIN, WAS GROANING. AND YES, THIS IS --
24 THESE ARE THE THINGS THAT I DETERMINED MY STATEMENTS FROM.
25 Q. WELL --
1 A. WHETHER IT WAS -- I GOT 'EM FROM THIS OR WHETHER I GOT
2 'EM FROM THE CHART, I DON'T REMEMBER, BUT --
3 Q. CAN WE SEE THE NEXT PAIN SLIDE PLEASE? WERE THERE MORE
4 SYMPTOMS THAT CONTINUED TOWARDS THE END OF JUDITH LARSEN'S
5 LIFE? CAN YOU DISCUSS THESE, WHETHER OR NOT THESE WOULD BE
6 DESCRIPTIONS THAT WOULD BE CONSISTENT WITH SYMPTOMS OF PAIN
7 IN THE COGNITIVELY IMPAIRED DEMENTED PERSON?
8 A. PATIENT WITH LOUD MOANING, YES.
9 THE COURT: DOES THAT HAVE A NUMBER, THAT AN EXHIBIT?
10 MR. BUGDEN: SORRY. JUDGE.
11 MS. ISAACSON: 51, YOUR HONOR.
12 MR. BUGDEN: OFFER IT FOR ILLUSTRATIVE PURPOSES.
13 MR. WILSON: NO OBJECTION.
14 THE COURT: RECEIVED FOR THAT PURPOSE.
15 Q. (BY MR. BUGDEN) SO ON 1/3/96 AT 7 P.M. PERSON TWITCHING.
16 WOULD THAT BE AN INDICATION OF PAIN?
17 A. COULD BE. COULD BE FROM OTHER SYMPTOMS, BUT THE PATIENT
18 WAS LOUD, MOANING, WOULD BE INTERPRETED AS POSSIBLY HAVING
19 PAIN. SAYS BELOW THAT, STARING VACANTLY AT TIMES. GROANING.
20 AND TWITCHING. YES, IT APPEARS TO BE THAT SHE IS HAVING SOME
21 DISCOMFORT.
22 Q. DOCTOR, WHEN PATIENTS ARE EXHIBITING SYMPTOMS OF PAIN,
23 IS IT AN APPROPRIATE TREATMENT FOR A DOCTOR SUCH AS YOURSELF
24 TO TRY A PAIN MEDICATION AS A TRIAL --
25 MR. WILSON: OBJECTION, LEADING.
1 THE COURT: SUSTAINED.
2 Q. (BY MR. BUGDEN) IS THERE A REASON TO INITIATE PAIN
3 MEDICATION ON A TRIAL AND ERROR BASIS? WHEN WOULD YOU DO
4 THAT -- I'M SORRY. WHEN WOULD A DOCTOR INITIATE PAIN
5 MEDICATION ON A TRIAL BASIS? WHAT WOULD BE THE REASON TO DO
6 THAT?
7 A. IN THIS PARTICULAR SCENARIO, WE HAVE A PATIENT THAT'S
8 FAMILY HAS STATED THAT HER WISHES WERE COMFORT AND DIGNITY.
9 IT APPEARED THAT SHE HAD END OF LIFE PROCESSES --
10 Q. HOLD ON HERE. COULD WE SEE DECEMBER 25TH?
11 THE COURT: THIS AN EXHIBIT?
12 MS. ISAACSON: THIS IS AN EXHIBIT --
13 MR. BUGDEN: THIS IS A MEDICAL RECORD, JUDGE, EXHIBIT
14 6-B, IS IT?
15 MS. ISAACSON: WHICH PATIENT IS THIS?
16 MR. BUGDEN: ENNIS ALLDREDGE.
17 MS. ISAACSON: THIS IS 6-B.
18 MR. BUGDEN: I'M SORRY, JUDITH LARSEN. I MISSPOKE.
19 JUDITH LARSEN.
20 MS. ISAACSON: IT'S PAGE 474 OF HER MEDICAL RECORDS.
21 THE COURT: THAT WOULD BE 3-B.
22 MS. ISAACSON: THAT'S RIGHT.
23 MR. BUGDEN: DO WE HAVE A BLOWUP OF THIS NOTE?
24 MS. ISAACSON: THAT'S AS BIG AS IT GETS, IS THE --
25 Q. (BY MR. BUGDEN) OKAY. PATIENT -- LET ME READ THIS OUT
1 LOUD. THIS IS -- THIS MEANS THIS IS AN M.D. NOTE, IS THAT
2 RIGHT, DR. CRANMER?
3 A. YES, SIR.
4 Q. REMAINS LESS RESPONSIVE THAN ONE WEEK AGO. WHAT'S THIS
5 WORD MEAN TO YOU?
6 A. WITH THE INITIAL.
7 Q. WITH THE INITIAL IMPROVEMENT. NO AGITATION. THEN
8 THERE'S SOME STUFF ABOUT FEBRILE STABLE. PATIENT SEEMS TO BE
9 IN PAIN. WILL TRY SOME LOW DOSE M.S. -- THAT MEANS MORPHINE
10 SULFATE -- FOR PAIN INTERVAL, IS IT? TO SEE IF THIS IS THE
11 PROBLEM. DO YOU SEE THAT NOTE, DOCTOR?
12 A. I DO.
13 Q. AND DO YOU REMEMBER DOCTOR THAT IN FACT ON CHRISTMAS
14 DAY, DR. WEITZEL SAW THE PATIENT AND INITIATED THE TRIAL
15 DOSAGE AS INDICATED ON EXHIBIT 3-H? CAN YOU SEE THIS?
16 THERE, THAT'S BETTER WITH THIS OFF. DO YOU SEE THAT ON
17 CHRISTMAS DAY, HE STARTED 6 MILLIGRAMS -- OR DOSED 6
18 MILLIGRAMS OF MORPHINE, DO YOU SEE THAT?
19 A. I DO YES.
20 Q. WOULD THAT BE CONSISTENT WITH THE TREATMENT GOAL OF
21 CONSISTING OF PAIN TRIAL?
22 MR. WILSON: OBJECTION YOUR HONOR LEADING.
23 THE COURT: SUSTAINED.
24 Q. (BY MR. BUGDEN) WHY WOULD SOMEONE -- WHY WOULD YOU
25 PRESCRIBE THAT DOSE OF MORPHINE? IS THERE A MEDICAL REASON
1 TO DO THAT ON THE BASIS OF THE NOTE THAT WE JUST SAW?
2 A. HE WROTE A NOTE STATING THE PATIENT HAD APPEARED TO BE
3 IN SOME PAIN AND HE STARTED HER ON A PAIN REGIMEN TO SEE IF
4 IT WOULD HELP HER PAIN.
5 MR. BUGDEN: THAT'S ALL I HAVE. THANK YOU, DOCTOR.
6 MR. WILSON: I DON'T THINK I HAVE ANY FURTHER QUESTIONS
7 YOUR HONOR.
8 THE COURT: YOU MAY STEP DOWN DOCTOR. THANK YOU FOR
9 COMING. MAY THIS WITNESS BE EXCUSED?
10 MR. WILSON: HE MAY, YOUR HONOR.
11 MR. BUGDEN: I HOPE SO.
12 THE COURT: MR. WILSON.
13 MR. WILSON: I HAVE NO OBJECTION.
14 THE COURT: THANKS AGAIN. I HOPE EVERYTHING DEVELOPS
15 OKAY WITH YOUR DAUGHTER.
16 THE WITNESS: THANK YOU SO MUCH.
17 THE COURT: CONGRATULATIONS.