Laurie Willson, RN
9 LAURIE STEVENSON,
10 CALLED AS A WITNESS, BEING FIRST DULY SWORN,
11 WAS EXAMINED AND TESTIFIED AS FOLLOWS:
12 DIRECT EXAMINATION
13 BY MR. STIRBA:
14 Q. MISS STEVENSON, WOULD YOU PLEASE STATE YOUR FULL NAME
15 AND SPELL YOUR LAST NAME?
16 A. IT'S LAURIE ELLEN STEVENSON. S-T-E-V-E-N-S-O-N.
17 Q. AND CALLING YOUR ATTENTION TO THE TIME PERIOD OF
18 DECEMBER OF 1995 AND JANUARY 1996, DID YOU GO BY ANOTHER
19 NAME?
20 A. YES, I DID.
21 Q. AND WHAT WAS THAT NAME?
22 A. THAT WAS LAURIE ELLEN WILLSON.
23 Q. NOW YOU ARE MRS. STEVENSON, IS THAT RIGHT?
24 A. YES, I AM.
25 Q. ARE YOU PRESENTLY EMPLOYED?
3103
1 A. YES, I AM.
2 Q. AND WHERE ARE YOU EMPLOYED?
3 A. I WORK FOR THE VETERANS' AFFAIRS MEDICAL CENTER IN
4 WILKES-BARRE, PENNSYLVANIA.
5 Q. WE HAVE THE MACHINE ON, SO YOU'RE GONNA HAVE TO TRY TO
6 KEEP YOUR VOICE UP IF YOU COULD PLEASE.
7 AND WHAT DO YOU DO FOR THE VETERANS' ADMINISTRATION IN
8 WILKES-BARRE, PENNSYLVANIA?
9 A. I AM A CERTIFIED REGISTERED NURSE PRACTITIONER.
10 Q. AND WHAT QUALIFICATIONS DO YOU HAVE SUCH THAT YOU ARE A
11 CERTIFICATED NURSE PRACTITIONER?
12 A. I HAVE A MASTER'S DEGREE IN NURSING WITH A SPECIALTY IN
13 GERIATRICS AND ADULT MEDICINE.
14 Q. AND EXPLAIN TO US PLEASE WHAT EDUCATION YOU'VE HAD IN
15 THE FIELD OF GERIATRICS.
16 A. I STUDIED AT THE UNIVERSITY OF UTAH FOR A MASTER'S
17 DEGREE IN GERIATRIC MEDICINE AS A NURSE PRACTITIONER IT'S A
18 TWO-YEAR ADVANCED DEGREE BEYOND THE BACHELOR'S LEVEL, WHICH
19 PREVIOUS I HELD IN NURSING.
20 Q. AND IS THERE A DIFFERENCE BETWEEN A REGISTERED NURSE AND
21 A NURSE PRACTITIONER?
22 A. YES, THERE IS. NURSE PRACTITIONERS IN THE STATE OF UTAH
23 ARE LICENSED TO PRESCRIBE INDEPENDENTLY OF A PHYSICIAN AND
24 HOLD AN INDEPENDENT LICENSE TO PRACTICE AS A NURSE
25 PRACTITIONER PRIMARY CARE PROVIDER IN THE STATE.
3104
1 Q. AND DO YOU HAVE A LICENSE AS A NURSE PRACTITIONER?
2 A. YES, I DO.
3 Q. AND WHICH STATE DO YOU HOLD THAT LICENSE IN?
4 A. IN UTAH.
5 Q. HOW LONG -- LET ME DIRECT YOUR ATTENTION TO THE PERIOD
6 OF DECEMBER OF 1995 AND JANUARY 1996. WERE YOU EMPLOYED AT
7 THAT TIME?
8 A. YES, I WAS.
9 Q. AND WHERE WERE YOU EMPLOYED?
10 A. AT THE HOSPITAL MEDICAL CENTER.
11 Q. AND SPECIFICALLY, WERE YOU WORKING AT A PARTICULAR UNIT
12 AT THAT TIME?
13 A. AT THE GEROPSYCHIATRIC UNIT OF THE HOSPITAL.
14 Q. NOW, PRIOR TO YOUR EMPLOYMENT AT THE DAVIS HOSPITAL, HAD
15 YOU PREVIOUSLY BEEN EMPLOYED IN THE FIELD OF NURSING?
16 A. YES.
17 Q. AND COULD YOU TELL US PLEASE WHAT POSITIONS YOU HELD
18 PRIOR TO THE POSITION AT THE DAVIS HOSPITAL?
19 A. PREVIOUS TO THAT I WAS AT BENCHMARK HOSPITAL AS NURSE
20 MANAGER OF THE GEROPSYCHIATRIC OUTPATIENT UNIT FOR PROBABLY
21 A YEAR. PREVIOUS TO THAT I WAS A NURSE AT THE UNIVERSITY OF
22 UTAH FOR SEVERAL YEARS. PREVIOUS TO THAT I WAS A NURSE IN
23 SEVERAL DIFFERENT FACILITIES IN BOSTON, MASSACHUSETTS, IN
24 PSYCHIATRY AND GERIATRICS ALTERNATIVELY, SEVERAL DIFFERENT
25 YEARS. I'VE BEEN A NURSE NOW FOR -- SINCE 1985.
3105
1 Q. AND IN TERMS OF YOUR EDUCATION IN THE FIELD OF NURSING,
2 COULD YOU TELL US PLEASE WHAT EDUCATION YOU HAVE HAD?
3 A. I STARTED FIRST AS A DIPLOMA NURSE, WHICH I DON'T THINK
4 THEY HAVE ANYMORE. I STUDIED AT THE HOSPITAL SCHOOL OF
5 NURSING IN BOSTON --
6 Q. WHAT KIND OF NURSING IS THAT?
7 A. DIPLOMA NURSE.
8 Q. AND WHAT IS A DIPLOMA NURSE?
9 A. A DIPLOMA NURSE IS A NURSE WHO'S STUDIED THE FIELD OF
10 NURSING WITHIN A HOSPITAL SETTING, NOT AT A UNIVERSITY.
11 THAT'S A THREE-YEAR DIPLOMA, NOT A DEGREE. AND THAT WAS
12 FROM THE NEW ENGLAND DEACONESS HOSPITAL SCHOOL OF NURSING,
13 MASSACHUSETTS. AFTER THAT, I RETURNED TO SCHOOL, GOT MY
14 BACHELOR'S DEGREE FROM NORTHEASTERN UNIVERSITY IN BOSTON,
15 AND TOOK ABOUT A YEAR OFF AND THEN WENT TO THE UNIVERSITY OF
16 UTAH FOR MY MASTER'S DEGREE.
17 Q. DID YOU HAVE THE MASTER'S DEGREE AT THE TIME THAT YOU
18 WERE EMPLOYED AT THE DAVIS HOSPITAL?
19 A. YEAH, I COMPLETED MY MASTER'S THESIS AT THAT TIME.
20 Q. AND GENERALLY, WHAT DOES A MASTER'S DEGREE IN NURSING
21 ENTAIL?
22 A. IT ENTAILS AT LEAST TWO YEARS OF ADVANCED EDUCATION IN
23 THE SPECIALTY OF NURSING AND IN THE SPECIALTY FIELD IN WHICH
24 YOU INTEND TO PRACTICE WHICH IN MY CASE WAS GERIATRIC
25 MEDICINE. IT REQUIRES A THESIS TO BE WRITTEN AND PRESENTED
3106
1 AND PUBLISHED AS PART OF THAT DEGREE. SO IT'S AN EXTENSIVE
2 PROCESS.
3 Q. DID YOU WRITE SUCH A THESIS?
4 A. YES, I DID.
5 Q. AND WHAT WAS YOUR THESIS ON?
6 A. NURSES' IDENTIFICATION OF DRUG INDUCED MOVEMENT DISORDER
7 IN THE ELDERLY.
8 Q. NOW, AT THE TIME THAT YOU WERE EMPLOYED AT THE DAVIS
9 HOSPITAL, YOU WERE WORKING AT -- ON THE GEROPSYCHIATRIC WARD
10 OR UNIT, HOW LONG HAD YOU ACTUALLY WORKED FROM -- AT THE
11 DAVIS HOSPITAL BEFORE YOU WERE EMPLOYED ON THE UNIT? OR
12 WHEN DID YOU FIRST START?
13 A. I'M SORRY, I LOST TRACK OF THAT QUESTION.
14 Q. WHEN DID YOU FIRST START WORK AT THE DAVIS HOSPITAL?
15 A. '95, SOMEWHERE LIKE THAT.
16 Q. AND WERE YOU INITIALLY EMPLOYED ON THE GEROPSYCHIATRIC
17 UNIT?
18 A. YES.
19 Q. AND GENERALLY, WHAT KIND OF PATIENT DID YOU SEE ON THAT
20 UNIT THAT YOU CARED FOR?
21 A. THEY WERE ELDERLY PATIENTS WITH BOTH MEDICAL AND
22 PSYCHIATRIC PROBLEMS CONCOMITANTLY. COMMON DIAGNOSIS OF
23 DEPRESSION, DEMENTIA, DELIRIUM, ANXIETY DISORDERS, AND
24 CHRONIC ILLNESSES ASSOCIATED WITH THEIR AGE AND CONDITION.
25 Q. AND GENERALLY, WHAT KIND OF CARE DID YOU PROVIDE IN
3107
1 TERMS OF YOUR EMPLOYMENT THERE?
2 A. THAT I GUESS WOULD DEPEND ON THE PATIENT. NURSING CARE
3 IS INDIVIDUALIZED TO THE NEEDS OF THE PATIENT, DEPENDING ON
4 THEIR DIAGNOSIS AND THE SYMPTOMS THAT THEY PRESENT. FOR
5 PATIENTS WHO ARE PRIMARILY ILL IN A PSYCHIATRIC WAY, WE
6 PROVIDED GROUP INTERVENTION, ONE-TO-ONE TIME WITH THE
7 PATIENT. MEDICATIONS WHEN APPROPRIATE. FOR THOSE WHO ARE
8 MEDICALLY SICK, WE TOOK CARE OF THEIR MEDICAL NEEDS FROM A
9 NURSING STANDPOINT IN TERMS OF WHATEVER CONDITION THEY WERE
10 PRESENTING TO US.
11 Q. WERE THERE PARTICULAR TIMES THAT YOU WORKED DURING THE
12 DAY, DURING THE PERIOD OF DECEMBER OF 1995 TO THE BEGINNING
13 PART OF JANUARY 1996?
14 A. PARTICULAR TIMES DURING THE --
15 Q. YES. IN OTHER WORDS, WAS THERE A PARTICULAR SHIFT THAT
16 YOU WORKED?
17 A. PRIMARILY, EVENINGS OR NIGHT SHIFT. MOST OF THAT TIME,
18 I THINK ON THE NIGHT SHIFT, 11:00 TO 7:00.
19 Q. 11:00 TO 7:00?
20 A. 11:00 P.M. TO 7:00 A.M., YEAH.
21 Q. AND WERE YOUR RESPONSIBILITIES WORKING 11:00 TO 7:00
22 DIFFERENT THAN THE RESPONSIBILITIES OF SOMEBODY WHO WOULD BE
23 WORKING ON ANOTHER SHIFT?
24 A. I WOULD SAY THE CARE GIVEN IS MORE FOCUSSED TO THOSE
25 PATIENTS WHO ARE MORE ACUTELY ILL. MANY OF THEM WHO WERE
3108
1 NOT AS ACUTELY ILL WOULD HAVE SLEPT THROUGH THE NIGHT. AND
2 MY RESPONSIBILITY THEN WOULD JUST TO BE SURE THAT THEY WERE
3 SAFE. THOSE PATIENTS WHO WERE SICK AND AWAKE WOULD REQUIRE
4 MORE OF MY TIME AND ATTENTION. AND ANYBODY WHO WAS ACUTELY
5 ILL WOULD GET FREQUENT VITAL SIGNS, FREQUENT VISITS FROM
6 MYSELF. VIOLENT BEHAVIOR, AGITATED BEHAVIOR WOULD HAVE TO
7 BE DEALT WITH APPROPRIATELY AS NEEDED.
8 Q. NOW, THIS CASE INVOLVES FIVE PATIENTS WHO RECEIVED CARE
9 AT THE DAVIS HOSPITAL DURING THE PERTINENT TIME PERIOD,
10 DECEMBER OF '95 THROUGH JANUARY OF '96. HAVE YOU HAD A
11 CHANCE TO REVIEW SOME RECORDS RELATING TO THOSE FIVE
12 PATIENTS?
13 A. YES, I HAVE.
14 Q. AND JUST GENERALLY, WHAT RECORDS HAVE YOU REVIEWED?
15 A. THE NAMES OF THE PATIENTS?
16 Q. THE RECORDS, WHAT RECORDS HAVE YOU REVIEWED?
17 A. OH, THE MEDICAL RECORD INCLUDING MY NURSE'S NOTES. AND
18 MEDICATION ADMINISTRATION RECORDS, DOCTORS' ORDERS, THE
19 TRANSCRIBED PROGRESS NOTES THAT I HAD WRITTEN, WEEKLY
20 ADVOCATE NOTES THAT I HAD WRITTEN, THAT SORT OF THING.
21 Q. IS -- YOU KNOW THE NAMES OF THE PATIENTS. IS THERE A
22 PARTICULAR RECOLLECTION YOU HAVE OF ANY ONE OF THEM?
23 A. NO, NOT PARTICULARLY, OTHER THAN A VAGUE RECOLLECTION OF
24 MR. ENNIS ALLDREDGE.
25 Q. AND WHAT IS YOUR RECOLLECTION OF HIM?
3109
1 A. I RECALL HIM BEING PROFOUNDLY ILL AT THE TIME THAT I WAS
2 TAKING CARE OF HIM IN A MEDICAL SENSE. HE HAD A TERMINAL
3 MEDICAL DIAGNOSIS, AS I RECALL. AND I REMEMBER HIM BEING
4 QUITE ILL AT THE TIME.
5 Q. DO YOU HAVE A RECOLLECTION OF LYDIA SMITH?
6 A. LYDIA SMITH IS SOMEONE I RECOLLECT FROM A PREVIOUS PLACE
7 OF EMPLOYMENT. SHE WAS A PATIENT OF MINE IN THE OUTPATIENT
8 PROGRAM THAT I WORKED IN PREVIOUSLY TO DAVIS HOSPITAL. SO
9 MOST OF MY MEMORIES ABOUT WHO LYDIA COME FROM THAT
10 EXPERIENCE. I DO RECALL THAT SHE WAS ADMITTED TO DAVIS AND
11 I TOOK CARE OF HER, BUT I HAVE NO SPECIFIC MEMORIES OF DOING
12 SO.
13 Q. WHERE WERE YOU EMPLOYED AT THE TIME THAT YOU HAD
14 PREVIOUSLY TAKEN CARE OF LYDIA?
15 A. IN A PROGRAM CALLED THE ENCORE PROGRAM, A
16 GEROPSYCHIATRIC OUTPATIENT DAY TREATMENT KIND OF A PROGRAM
17 AT -- IN WOODS CROSS, BENCHMARK HOSPITAL, WAS THE PROGRAM.
18 Q. BASED UPON YOUR EXPERIENCE WITH HER AND YOUR CARE
19 PREVIOUS TO THE TIME THAT SHE WAS ADMITTED TO THE
20 GEROPSYCHIATRIC UNIT, WERE YOU ABLE TO OBSERVE A CHANGE IN
21 HER BEHAVIOR OR HER CONDITION BETWEEN THE TIME YOU CARED FOR
22 HER IN THE FIRST SETTING AND WHEN SHE WAS ON THE DAVIS UNIT?
23 A. HER ILLNESS HAD PROGRESSED MARKEDLY. HER DEMENTIA WAS
24 PROFOUND AT THE TIME THAT SHE WAS READMITTED TO DAVIS
25 HOSPITAL. SHE AT THE TIME THAT I CARED FOR HER IN
3110
1 OUTPATIENT WAS VERY DEMENTED AND NOT FULLY ABLE TO CARE FOR
2 HERSELF. BY THE TIME SHE WAS AT DAVIS HOSPITAL, SHE WAS
3 PRETTY MUCH DEPENDING ON NURSING FOR ALL OF HER NEEDS.
4 Q. 0YOU HAVE SOME BINDERS IN FRONT OF YOU, MISS STEVENSON,
5 AND THOSE ARE EXHIBITS IN THIS CASE. AND WE'RE GONNA GO
6 THROUGH SOME OF YOUR NURSING NOTES. IT MAY BE HELPFUL TO
7 REFER TO THE BINDERS. THE FIRST BINDER I WANT YOU TO HAVE
8 IN FRONT OF YOU IS A BINDER INVOLVING ELLEN ANDERSON. DO
9 YOU HAVE THAT IN FRONT OF YOU?
10 A. YES, I DO.
11 Q. SPECIFICALLY, IF YOU WOULD TURN TO -- AND THERE'S LITTLE
12 NUMBERS DOWN AT THE BOTTOM OF EACH PAGE. IF WOULD YOU TURN
13 TO MED-170 PLEASE.
14 A. OKAY.
15 Q. NOW, DO YOU RECOGNIZE YOUR WRITING ON THAT PARTICULAR
16 DOCUMENT?
17 A. YES, I DO.
18 Q. AND GENERALLY TELL US PLEASE WHAT THAT DOCUMENT IS.
19 A. THOSE ARE THIS PATIENT'S ADMITTING ORDERS TO THE
20 GEROPSYCHIATRIC UNIT.
21 Q. AND WHAT HAVE YOU WRITTEN IN A GENERAL WAY ON THAT
22 PARTICULAR DOCUMENT?
23 A. I'VE -- DESCRIPTION OF HER CONDITION, HER DIAGNOSIS,
24 LABORATORY TESTING THAT NEEDS TO BE DONE, ANY TREATMENTS
25 THAT NEED TO BE DONE, A LIST OF HER ALLERGIES, THE CURRENT
3111
1 MEDICATIONS THAT SHE'LL BE RECEIVING, AND A NOTATION THAT I
2 TRANSCRIBED THOSE ORDERS.
3 Q. NOW, FOR EXAMPLE, I NOTICE AT THE TOP THERE'S A
4 CONDITION, AND THEN IT SAYS, COLON, POOR. DO YOU SEE THAT?
5 A. YES, I DO.
6 Q. AND WAS THAT AN ASSESSMENT YOU MADE AT THE TIME OF HER
7 ADMISSION?
8 A. YES.
9 Q. AND WHAT DO YOU MEAN BY CONDITION POOR?
10 A. THAT THE PATIENT A THE TIME WAS SERIOUSLY ILL.
11 Q. AND THEN I NOTICE -- HAVE TO MOVE THIS DOWN ON THE
12 MACHINE -- AS WE GO DOWN INTO THE MEDS, DO YOU SEE THAT
13 SECTION?
14 A. YES, I DO.
15 Q. AND THOSE ARE MEDICATIONS THEN THAT YOU LIST THAT WERE
16 ORDERED FOR HER?
17 A. YES.
18 Q. DOWN TOWARDS THE BOTTOM, THERE IS YOUR SIGNATURE, IS
19 THERE NOT?
20 A. YES.
21 Q. AND IN FACT, YOUR SIGNATURE APPEARS UNDER PRINTING WHICH
22 SAYS DR. WEITZEL, CORRECT?
23 A. RIGHT, IN TWO PLACES.
24 Q. AND THEN THERE'S A T.O. DO YOU SEE THAT?
25 A. YES.
3112
1 Q. AND WHAT DOES THE T.O. STAND FOR?
2 A. T.O. REFERS TO TELEPHONE ORDER.
3 Q. AND THEN WHERE YOU SIGNED IT THE SECOND TIME -- AND BY
4 THE WAY, I NOTICE IT SAYS R.N., S. -- M.S.W.
5 A. M.S.N., MASTER OF SCIENCE IN NURSING.
6 Q. M.S.N. AND YOU -- THE WORD NOTED APPEARS.
7 A. UH-HUH.
8 Q. TELL US PLEASE WHAT NOTED MEANS IN THAT CONTEXT.
9 A. NOTED MEANS THAT I TOOK THOSE ORDERS FROM THE ORDER
10 SHEET AND THEN TRANSCRIBED THEM INTO THE MEDICATION
11 ADMINISTRATION RECORD, VERIFIED THEM APPROPRIATELY, PUT THEM
12 IN THE CARDEX THAT LISTS THE MEDICATIONS THAT WOULD BE
13 GIVEN, ANY OF THE TREATMENTS THAT WOULD BE GIVEN, AND WHAT
14 HER CONDITION WAS. THERE ARE VARIOUS PLACES THAT THAT
15 INFORMATION BELONGS IN THE RECORD.
16 Q. AND THEN YOU HAVE INDICATED 12/29/95 AND A TIME, 2130.
17 IS THAT THE TIME WHEN YOU WOULD HAVE NOTED OR TRANSCRIBED
18 THE ORDER?
19 A. YES.
20 Q. IS THAT TIME THE SAME TIME WHEN YOU WOULD HAVE ACTUALLY
21 RECEIVED THE ORDER?
22 A. NO, NOT NECESSARILY.
23 Q. CAN YOU TELL BY LOOKING AT THIS DOCUMENT WHEN YOU
24 ACTUALLY RECEIVED THE ORDER?
25 A. NO.
3113
1 Q. CAN YOU EXPLAIN THE RELATIONSHIP BETWEEN THE
2 SIGNIFICANCE OF THE TIME NOTED AND WHEN YOU IN FACT RECEIVED
3 THE ORDER, SO THAT WE UNDERSTAND?
4 A. BEING PROBABLY MAYBE ONE OF ONLY TWO NURSES WORKING THAT
5 SHIFT, AND GIVEN THE CONDITION OF THE PATIENT NOTED AS POOR,
6 AND HEAVEN KNOWS WHO ELSE IN THE HOSPITAL AT THE TIME BEING
7 ILL AND REQUIRING MY ATTENTION, TRANSCRIBING AN ORDER WOULD
8 NOT BE ON THE TOP OF MY PRIORITY LIST. CARE OF THE PATIENT
9 COMES FIRST. PAPERWORK COMES AFTER CARE OF THE PATIENT. SO
10 ANY -- ANYTHING ON THE LIST THAT SAYS, DO IT NOW, WOULD HAVE
11 BEEN DONE FIRST PROBABLY BEFORE ANY OF THIS WAS TRANSCRIBED
12 INTO OTHER PARTS OF THE RECORD.
13 Q. DO YOU KNOW THE TIME OF THE SHIFT THAT YOU WERE WORKING
14 THIS DAY? BASED UPON WHAT YOU HAVE IN FRONT OF YOU?
15 A. SINCE IT WAS NOTED AT 2130, THAT WOULD BE 9:30 P.M, THEN
16 I WOULD HAVE BEEN WORKING THE 3:00 TO 11:00 SHIFT ON THAT
17 DAY.
18 Q. AND CAN YOU TELL US AT ANY TIME DURING THAT SHIFT WHEN
19 YOU WOULD HAVE RECEIVED THIS ORDER?
20 A. I CAN'T TELL BY THE RECORD WHEN THAT WOULD HAVE BEEN.
21 Q. DO YOU KNOW IF DR. WEITZEL SAW ELLEN ANDERSON DURING
22 YOUR SHIFT?
23 A. I HAVE NO MEMORY OF HIM SEEING HER; HOWEVER, HE HAS
24 SIGNED OFF MY NOTE AND DATED IT, MY ORDERS AND DATED IT, SO
25 I ASSUME THAT HE SAW HER ON THAT DAY.
3114
1 Q. PARDON ME?
2 A. I ASSUME THAT HE SAW HER ON THAT DAY.
3 Q. AND YOU'VE REFERRING TO -- WHEN YOU SAY HE SIGNED OFF ON
4 IT, IS THIS WHAT YOU'RE REFERRING TO, THE SIGNATURE ACROSS
5 FROM DR. WEITZEL --
6 A. YES.
7 Q. -- IMPRINTED?
8 A. YES.
9 Q. AND WHAT IS THE SIGNIFICANCE OF THE PHYSICIAN SIGNING
10 OFF ON THE ORDER?
11 A. IT MEANS THAT HE REVIEWED THE ORDERS AND THAT AGREES
12 WITH WHAT HE TOLD ME ON THE PHONE.
13 Q. NOW, IF YOU COULD TURN PLEASE TO 188.
14 A. OKAY.
15 Q. DO YOU RECOGNIZE YOUR SIGNATURE ON THAT DOCUMENT?
16 A. YES, I DO.
17 Q. AND THAT'S ACROSS WHERE IT SAYS R.N. SIGNATURE?
18 A. YES.
19 Q. DO YOU KNOW WHY YOU AFFIXED YOUR SIGNATURE THERE ON THAT
20 DOCUMENT?
21 A. BECAUSE I WAS THE ONE WHO COMPLETED THE ASSESSMENT.
22 Q. AND WHAT IS THE ASSESSMENT YOU'RE REFERRING TO?
23 A. IT IS A COMPREHENSIVE NURSING ASSESSMENT OF THE PATIENT
24 THAT IS DONE ON ADMISSION TO THE HOSPITAL.
25 Q. AND TELL US PLEASE WHAT THE PURPOSE OF THE ASSESSMENT
3115
1 WAS.
2 A. IT WAS TO GIVE A COMPREHENSIVE VIEW FROM A NURSING
3 PERSPECTIVE OF THE NEEDS OF THE PATIENT AND THEIR CONDITION
4 AT THE TIME THAT THEY ARRIVED.
5 Q. AND HOW WAS IT THAT YOU ACQUIRED THE INFORMATION WHICH
6 IS CONTAINED ON THE ASSESSMENT?
7 A. I WOULD HAVE DONE SO BY INTERVIEWING THE PATIENT AND ANY
8 FAMILY MEMBERS OR OTHER SIGNIFICANT PERSONS TO THAT PATIENT
9 WHO WERE PRESENT AT THE TIME.
10 Q. ON THIS PARTICULAR DOCUMENT, 188, IT SAYS TEACH PAIN
11 MANAGEMENT INTERVENTIONS UNDER EDUCATION. DO YOU SEE THAT?
12 A. YES, I DO.
13 Q. IS THAT IN YOUR WRITING?
14 A. YES, IT IS.
15 Q. COULD YOU TELL US PLEASE WHY YOU WOULD HAVE WRITTEN
16 TEACH PAIN MANAGEMENT INTERVENTIONS AT THAT TIME?
17 A. THAT IS A REFERENCE TO EDUCATION NEEDED TO THE PATIENT
18 AND/OR THE FAMILY. AND CERTAINLY, IT IS THE JOB OF THE
19 NURSE TO PROVIDE ANY INFORMATION TO THE FAMILY THAT THEY CAN
20 DO REASONABLY WITHIN THEIR OWN POWER TO HELP THE PATIENT TO
21 BE MORE COMFORTABLE. OBVIOUSLY, IF I HAD WRITTEN THAT, IT
22 WOULD SAY THAT IN MY IMPRESSION, THE PATIENT WAS HAVING PAIN
23 AND THAT THE PATIENT WOULD BENEFIT FROM FAMILY MEMBERS
24 KNOWING HOW TO HELP THEM FEEL BETTER.
25 Q. BASED UPON YOUR REVIEW OF THIS FILE, CAN YOU TELL US WHY
3116
1 YOU HAD SUCH AN IMPRESSION THAT THE PATIENT WAS IN PAIN?
2 A. I'D HAVE TO GO BACK AND LOOK, IS THAT -- I HAVE
3 DOCUMENTATION THAT SHE'S MOANING AND CRYING. THERE'S
4 DOCUMENTATION THAT SHE HAS HAD MULTIPLE FRACTURES, WRIST
5 FRACTURE, HIP FRACTURE, PROBLEMS WITH BONES AND JOINTS,
6 HISTORY OF BACK PAIN AND SPINAL FRACTURE, ALL DOCUMENTED BY
7 ME IN THIS SAME DOCUMENT THAT WE'RE READING RIGHT NOW.
8 Q. NEXT IF YOU COULD TURN TO 190 CONCERNING PATIENT ELLEN
9 ANDERSON. DO YOU HAVE THAT IN FRONT OF YOU?
10 A. YES.
11 Q. AND WHAT IS THAT THAT IS CHARTED THERE?
12 A. THAT IS A NURSING PROGRESS NOTE.
13 Q. AND WHO WROTE THAT NOTE?
14 A. I DID.
15 Q. AND WHAT'S THE DATE OF THE NOTE?
16 A. LOOKS LIKE 12/29/95.
17 Q. IF YOU SKIP DOWN FROM HERE TOWARDS THE BOTTOM, YOU SEE
18 IT SAYS -- OR IN THE MIDDLE RATHER, YOU SEE MED NOTE, DO YOU
19 SEE THAT?
20 A. YES.
21 Q. WHAT IS A MED NOTE?
22 A. ENTRIES IN THE MARGIN OF A NOTE WERE PUT THERE BY
23 NURSING CONSISTENTLY IN THE HOSPITAL TO DOCUMENT PATIENT'S
24 RESPONSE TO MEDICATIONS THAT WERE GIVEN AS A MEASURE OF
25 MONITORING OURSELVES DOING THAT BEHAVIOR AS NURSES.
3117
1 Q. AND COULD YOU EXPLAIN TO US WHAT DOCUMENTATION YOU HAD
2 REFLECTED THERE CONCERNING THE MEDICATION GIVEN?
3 A. OKAY. IT SAYS THAT I GAVE MORPHINE 10 MILLIGRAMS I.M.
4 AND AT 2000, WHICH WOULD BE 10:00 O'CLOCK, FOR SEVERE PAIN.
5 PATIENT BECOMES RIGID AND SCREAMS WHEN TOUCHED. RELATED HER
6 PROFOUND OSTEOPOROSIS. GIVEN PER ORDER DR. WEITZEL.
7 Q. IT SAYS FOR SEVERE PAIN. DID YOU ASSESS AT THAT TIME
8 THAT A PATIENT ELLEN ANDERSON WAS IN SEVERE PAIN?
9 A. YES, I DID.
10 Q. AND COULD YOU TELL US PLEASE THE BASIS FOR YOUR
11 ASSESSMENT?
12 A. IT'S DOCUMENTED AS PATIENT IS RIGID AND SCREAMING WHEN
13 TOUCHED. THAT IS A VERY COMMON RESPONSE TO SEVERE PAIN.
14 MODERATE PAIN PATIENTS DON'T SCREAM. SEVERE PAIN PATIENTS
15 WILL SCREAM.
16 Q. NOW, YOU HAVE AN R. DO YOU SEE THAT UNDER -- DOES THAT
17 STAND FOR RESPONSE?
18 A. RESPONSE.
19 Q. AND IT SAYS PATIENT CALMER TWO HOURS. IS THAT PAST
20 MORPHINE INJECTION?
21 A. TWO HOURS AFTER MORPHINE INFECTION, YES.
22 Q. AND THEN IF YOU GO DOWN TO WHERE IT SAYS P., DOES THAT
23 STAND FOR PLAN?
24 A. YES.
25 Q. AND IT SAYS PLEASE SEE MASTER -- T.X. STANDS FOR
3118
1 TREATMENT?
2 A. TREATMENT PLAN.
3 Q. TELL US PLEASE WHAT -- WHAT IS A TREATMENT PLAN?
4 A. A TREATMENT PLAN IN REFERENCE TO A NURSING -- NURSE
5 HAVING WRITTEN IT IS A NURSING TREATMENT PLAN WHICH
6 DOCUMENTS THE NURSING CARE THAT WILL BE GIVEN OR IS BEING
7 GIVEN TO THE PATIENT AT THE TIME. IT IS A DOCUMENT THAT
8 REMAINS IN THE CHART FOR THE REFERENCE OF ALL THE NURSES
9 CARING FOR THE PATIENT, NOT JUST THE NURSE WHO WROTE THE
10 TREATMENT PLAN. IT INCLUDES INTERVENTIONS CARRIED OUT BY
11 THE NURSE INCLUDING INDEPENDENT AND DEPENDENT MEASURES THAT
12 HAVE BEEN IDENTIFIED. INDEPENDENT NURSING MEASURES ARE
13 THOSE THAT IF I WROTE THE TREATMENT PLAN, I DETERMINED
14 MYSELF THAT WOULD BENEFIT PATIENT. DEPENDENT MEASURES WOULD
15 BE THOSE ORDERED BY THE PHYSICIAN THAT THE NURSE CARRIES
16 OUT.
17 Q. WHAT ARE NURSING INTERVENTIONS IN THE CONTEXT OF A
18 TREATMENT PLAN?
19 A. NURSING INTERVENTIONS ARE THOSE THINGS THAT THE NURSE
20 DOES FOR THE PATIENT IN ORDER TO HELP THEM FEEL BETTER.
21 PROVIDING CARE FOR THE PATIENT. IT'S THE DOCUMENTATION OF
22 THE CARE THAT IS GIVEN BY A NURSE TO THE PATIENT.
23 Q. WAS THERE A NURSING PLAN CONCERNING EACH ONE OF THESE
24 FIVE PATIENTS?
25 A. YES.
3119
1 Q. NOW, I'M GONNA SHOW YOU -- IF YOU WOULD TURN TO 197 IN
2 ELLEN ANDERSON'S BINDER PLEASE.
3 A. OKAY.
4 Q. WHAT IS SHOWN BY DOCUMENT 197?
5 A. THAT IS HER MASTER TREATMENT PLAN.
6 Q. AND THAT'S WHAT YOU WERE JUST TELLING US ABOUT IN YOUR
7 PRIOR TESTIMONY, IS THAT RIGHT?
8 A. THAT'S CORRECT.
9 Q. AND IS YOUR WRITING ON THIS PARTICULAR DOCUMENT?
10 A. YES, IT IS.
11 Q. AND COULD YOU TELL US WHERE IT IS?
12 A. IT'S ALL OVER THE DOCUMENT.
13 Q. ALL RIGHT. WELL, FOR EXAMPLE, AT THE TOP, JUST SO WE
14 ORIENT OURSELVES, IT HAS PROBLEM STATEMENT, PROBLEM RELATED
15 TO OR EVIDENCED BY. AND THEN DID YOU WRITE ANXIETY -- WHAT
16 DOES R.T. STAND FOR?
17 A. ANXIETY RELATED TO.
18 Q. ANXIETY --
19 A. RELATED TO ANXIETY DISORDER AS EVIDENCED BY EXTREME
20 AGITATION, INCONSOLABLE CRYING, AND SCREAMING.
21 Q. OKAY. AND WHERE DID YOU GET THAT INFORMATION SUCH THAT
22 YOU WROTE IT ON THE MASTER TREATMENT PLAN?
23 A. THAT WOULD BE FROM HER ADMITTING DIAGNOSIS AND THE
24 BEHAVIOR THAT SHE DEMONSTRATED. BUT --
25 Q. THEN YOU WROTE UNDER LONG-TERM GOALS, PATIENT WILL BE
3120
1 DISCHARGED TO A LONG-TERM CARE FACILITY THAT IS APPROPRIATE
2 TO HER PHYSICAL NEEDS AND ABLE TO MANAGE HER PSYCHIATRIC
3 MEDICATION, AND THERE APPEARS TO BE A DATE OF 12/29. IS
4 THAT WHEN YOU WOULD HAVE WRITTEN THAT?
5 A. YES.
6 Q. AND GENERALLY, WHAT IS -- WHAT IS CONTAINED UNDER
7 LONG-TERM GOALS? WHY IS THAT WRITTEN THERE IN THE TREATMENT
8 PLAN?
9 A. BECAUSE THE HOSPITALIZATION AT DAVIS HOSPITAL WOULD HAVE
10 BEEN A SHORT-TERM INTERVENTION FOR THE PATIENT, THE GOAL
11 BEING TO STABILIZE HER CONDITION AND THEN HAVE HER CONTINUE
12 ON TO A MORE SUITABLE LONG-TERM ARRANGEMENT, WHETHER THAT BE
13 HOME OR LONG-TERM CARE PLACEMENT. AND AT THE TIME OF
14 ADMISSION, ALL OF THE STAFF WERE INTENT ON DOING OUR BEST TO
15 CHOOSE THE RIGHT OPTION AND HELP FAMILY TO MAKE THE RIGHT
16 CHOICES.
17 Q. THEN YOU HAVE UNDER SHORT-TERM GOALS, PATIENT WILL
18 DEMONSTRATE A DECREASE IN FREQUENCY -- I CAN'T READ THAT.
19 A. IN FREQUENCY AND INTENSITY OF CRYING AND SCREAMING IN
20 THE NEXT SEVEN DAYS.
21 Q. OKAY. AND THEN WE HAVE UNDER INTERVENTIONS, YOU LIST A
22 NUMBER OF THOSE INTERVENTIONS, IS THAT RIGHT?
23 A. THAT'S CORRECT.
24 Q. WHERE DID YOU GET THE INFORMATION SUCH THAT YOU WERE
25 ABLE TO WRITE THOSE VARIOUS INTERVENTIONS?
3121
1 A. THAT IS BASIC TO THE EDUCATION OF A NURSE. IT'S THE
2 NURSING CARE NECESSARY FOR THE NURSING DIAGNOSIS, WHICH IS
3 ESSENTIALLY WHAT IS AT THE TOP OF THE PAGE, THE PROBLEM
4 STATEMENT, IF YOU WILL. THOSE ARE THE INTERVENTIONS MOST
5 COMMONLY CARRIED OUT BY THE NURSE FOR THE PATIENT. THEY ARE
6 SPECIALIZED TO THIS PARTICULAR PATIENT, AS I OFTEN DID.
7 THEY'RE NOT STANDARDIZED TREATMENT PLANS. NOT EVERYBODY IS
8 THE SAME. TRY TO ADJUST THEM BASED ON EACH INDIVIDUAL'S
9 PATIENT -- PATIENT NEEDS.
10 Q. WHEN YOU SAY BASED UPON THE EXPERIENCE OF THE NURSE,
11 WHAT DO YOU MEAN IN TERMS OF THE INTERVENTIONS?
12 A. EXPERIENCE, EDUCATION, KNOWLEDGE, IN TERMS OF WHAT DOES
13 A PATIENT WITH ANXIETY REQUIRE IN TERMS NURSING CARE. THAT
14 WOULD BE SOMETHING FROM MY EDUCATION AND EXPERIENCE IN
15 WORKING WITH THOSE PATIENTS.
16 Q. IF YOU WOULD PLEASE, THAT'S ALL WE'RE GOING TO DO ON
17 ELLEN ANDERSON'S CHART. WOULD YOU PLEASE TURN AND OBTAIN
18 THE BINDER CONCERNING MARY CRANE?
19 DO YOU HAVE THAT IN FRONT OF YOU?
20 A. UH-HUH, YES, I DO.
21 Q. OKAY. IF YOU WOULD TURN TO 298 PLEASE. DIRECTING YOUR
22 ATTENTION TO -- IT SAYS PAIN SCALE, ONE THROUGH FIVE, RATE
23 YOUR PAIN. DO YOU SEE THAT?
24 A. YES.
25 Q. AND THEN THERE APPEARS TO BE A NUMBER.
3122
1 A. YES.
2 Q. WHAT NUMBER IS THAT?
3 A. FIVE.
4 Q. AND WHO WROTE THAT?
5 A. I DID.
6 Q. AND WOULD YOU TELL US PLEASE WHAT THAT MEANS THAT YOU
7 WROTE A FIVE?
8 A. OKAY. THE PAIN SCALE IS A MEASURE USED BY NURSING STAFF
9 IN ASSESSMENT OF THE PATIENT TO TRY AND OBJECTIFY PAIN FOR
10 THE PATIENT SO THAT THEY CAN MEASURE IT IN A WAY IN WHICH
11 THE NURSE THEN CAN MEASURE PAIN RELIEF. SO ON ADMISSION, WE
12 WOULD ASK THE PATIENT, YOU KNOW, WHERE ARE WE STARTING FROM
13 WITH YOUR PAIN, ZERO BEING ABSOLUTELY NO PAIN, AND FIVE
14 BEING THE WORST PAIN THAT YOU COULD POSSIBLY STAND. AND
15 THEN THE VARIATIONS BETWEEN THAT, THREE BEING OF COURSE IN
16 THE MIDDLE TWO LESS THAN THAT, FOUR GREATER THAN THAT.
17 Q. WHERE WOULD YOU HAVE GOTTEN THE INFORMATION SUCH THAT
18 WOULD YOU HAVE RATED MARY CRANE'S SITUATION AS THE WORST
19 PAIN IMAGINABLE, AND THAT IS A FIVE?
20 A. I WOULD HAVE ASKED HER.
21 Q. NOW, IF YOU COULD GO TO 311 PLEASE IN THE NURSES' NOTE
22 SECTION.
23 A. OKAY.
24 Q. AT THE TOP THERE IS A NURSING NOTE IN YOUR HANDWRITING,
25 IS THAT RIGHT?
3123
1 A. THAT'S CORRECT.
2 Q. COULD YOU READ THAT PLEASE IN ITS ENTIRETY?
3 A. NIGHT SHIFT FREE TEXT NOTE. PATIENT HAS BEEN AWAKE MOST
4 OF SHIFT. 0200. TRAZODONE 100 MILLIGRAMS P.R.N. AND
5 TYLENOL TWO TABLETS GIVEN FOR SLEEP AND DISCOMFORT
6 RESPECTIVELY. PATIENT ABLE TO REST QUIETLY UNTIL 0600 AFTER
7 MEDICATION WAS GIVEN.
8 Q. NOW, THE MEDICATION TRAZODONE, CAN YOU TELL FROM THAT
9 NOTE WHY YOU GAVE TRAZODONE TO MARY CRANE AT THIS TIME?
10 A. TO HELP WITH SLEEP.
11 Q. AND THE TYLENOL WAS GIVEN FOR WHAT PURPOSE?
12 A. FOR DISCOMFORT.
13 Q. BASED UPON THAT NOTE CAN YOU ASSESS WHETHER OR NOT THERE
14 WAS A BENEFICIAL EFFECT FROM THOSE MEDICATIONS?
15 A. YES. PATIENT WAS THEN ABLE TO REST QUIETLY UNTIL
16 6:00 O'CLOCK AFTER THE MEDICATION WAS GIVEN.
17 Q. IS THERE A SIGNIFICANCE THAT YOU CHARTED P.R.N. AFTER
18 TRAZODONE 100 MILLIGRAMS?
19 A. YES. THAT INDICATES THAT THE MEDICATION WAS NOT A
20 SCHEDULED MEDICATION, BUT GIVEN AT MY DISCRETION BASED ON
21 THE NEEDS OF THE PATIENT.
22 Q. IF YOU COULD TURN PLEASE TO 325. AND THERE IS A NOTE ON
23 THAT PAGE IN YOUR HANDWRITING?
24 A. YES.
25 Q. NOW, IT'S THE ONE THAT HAS, STARTS WITH THREE ELEVEN, IS
3124
1 THAT RIGHT?
2 A. 3:00 TO 11:00, YES.
3 Q. AND WHAT DOES THAT STAND FOR?
4 A. THAT STANDS FOR THE SHIFT THAT I WAS WORKING ON THAT
5 DAY.
6 Q. NOW, THERE'S A REFERENCE A LITTLE BIT DOWN TOWARDS THE
7 MIDDLE THERE, ABOUT DIFFICULTY, LOOKS LIKE CHAIN SECRETIONS.
8 A. LOOKS TO ME LIKE CONTINUES TO HAVE MUCH DIFFICULTY
9 CLEARING SECRETIONS.
10 Q. OKAY. CAN YOU EXPLAIN TO US WHAT THAT IS REFERRING TO?
11 A. THE NOTE IS A DESCRIPTION OF MY EFFORTS OR ANOTHER STAFF
12 MEMBER'S EFFORTS THAT I OBSERVED FEEDING THE PATIENT. AND
13 AT THE TIME THAT THIS NOTE WAS WRITTEN, APPARENTLY THE
14 PATIENT WAS NOT ABLE TO COUGH OR SWALLOW OR REMOVE
15 SECRETIONS THAT MAY HAVE BEEN LODGED IN THE BACK OF THE
16 THROAT AT THE TIME.
17 Q. AND WAS THERE A NURSING INTERVENTION AS A RESULT OF WHAT
18 YOU ASSESSED?
19 A. I'M TRYING TO READ MY NOTE. OKAY. UNDER RESPONSE IT
20 STATES, PATIENT REQUIRED SUCTIONING TIMES TWO TO ASSIST IN
21 MANAGEMENT OF SECRETIONS.
22 Q. WHAT IS SUCTIONING?
23 A. THAT WOULD MEAN THAT I TOOK A MACHINE THAT GENERATES
24 SUCTION THROUGH A TUBE THAT IS SMALL ENOUGH TO FIT IN THE
25 BACK OF THE PATIENT'S THROAT TO CLEAR SECRETIONS AWAY THAT
3125
1 SHE WOULD NOT HAVE BEEN ABLE TO DO SO HERSELF AND NEEDED
2 NURSING ASSISTANCE TO DO THAT. SO WE'D USE THAT DEVICE TO
3 CLEAR THOSE SECRETIONS OUT OF THE PATIENT'S MOUTH AND
4 THROAT.
5 Q. CAN YOU TELL WHY AT THIS POINT THE PATIENT WAS HAVING
6 DIFFICULTY CLEARING HER THROAT?
7 A. I MAKE REFERENCE TO A CONSULTANT'S NOTE BY SPEECH
8 THERAPY -- OBVIOUSLY, I WOULD HAVE READ THAT AT THE TIME --
9 WHO REQUESTED THAT LIQUIDS BE THICKENED. SO IN THEIR
10 EVALUATION, THE PATIENT WAS NOT ABLE TO HANDLE LIQUIDS THAT
11 WERE OF NORMAL CONSISTENCY, AND WOULD CHOKE ON THEM.
12 Q. WHO WOULD HAVE ASKED THAT A SPEECH THERAPIST OR
13 CONSULTANT SEE THE PATIENT?
14 A. THAT WOULD BE THE PHYSICIAN.
15 Q. IF WOULD YOU GO TO MED-328 PLEASE IN THAT BINDER.
16 A. OKAY.
17 Q. DO YOU HAVE THAT IN FRONT OF YOU?
18 A. YES.
19 Q. THERE'S A NOTE UP AT THE TOP THAT HAS ELEVEN SEVEN.
20 THAT WOULD BE THE TIME YOU WERE WORKING, CORRECT?
21 A. CORRECT.
22 Q. COULD YOU READ THAT TO US PLEASE?
23 A. NIGHT SHIFT, FREE TEXT NOTE, PATIENT RESTED QUIETLY
24 THROUGHOUT THE SHIFT. AWAKE SEVERAL TIMES. SUCTION TIMES
25 ONE FOR SMALL AMOUNT OF THICK, DRY, ORAL SECRETIONS.
3126
1 RESPIRATIONS REMAIN LABORED. 0-2 CONTINUOUSLY BY NASAL
2 CANNULA. COLOR PALE.
3 Q. NOW, IS THERE A SIGNIFICANCE TO THE FACT THAT ON THAT
4 NOTE YOU CHARTED HER RESPIRATIONS REMAIN LABORED?
5 A. THAT IS AN INDICATION OF THE LEVEL OF DISTRESS THAT I
6 OBSERVED AS THE NURSE TAKING CARE OF THE PATIENT.
7 Q. AND WHAT DO YOU MEAN WHEN YOU USE THE WORD LABORED IN
8 THAT CONTEXT?
9 A. THAT MEANS THAT IT IS VERY DIFFICULT AND PERHAPS PAINFUL
10 FOR THAT PATIENT TO TAKE A DEEP BREATH.
11 Q. DOES THAT HAVE ANY SIGNIFICANCE TO YOU IN TERMS OF THE
12 REASONS WHY SHE IS SUFFERING LABORED RESPIRATIONS AT THIS
13 TIME?
14 A. A PATIENT SUFFERING LABORED RESPIRATIONS IS IN DISTRESS
15 AND THEIR MEDICAL CONDITION IS MOST LIKELY DETERIORATING.
16 Q. THEN YOU ALSO REFER TO 0-2 CONTINUOUS BY NASAL CANNULA.
17 WHAT IS THAT REFERRING TO?
18 A. THAT MEANS THAT WE WERE GIVING HER SUPPLEMENTAL OXYGEN
19 BEYOND THAT THAT WE CAN BREATHE IN ROOM AIR IN ORDER HELP
20 HER OXYGENATE HER BLOOD. SINCE SHE WAS HAVING THESE
21 SECRETIONS, THE OXYGEN IN HER BLOOD WAS LESS THAN IT OUGHT
22 TO HAVE BEEN, AND OXYGEN BY NASAL CANNULA IS AN EFFORT TO
23 IMPROVE THAT OXYGEN SUPPLY TO THE PATIENT.
24 Q. IS THAT AN INTERVENTION BY A NURSE THAT IS DEPENDENT OR
25 INDEPENDENT?
3127
1 A. IT CAN BE EITHER. IF THE PATIENT IS IN DISTRESS, THE
2 NURSE CAN ADMINISTER OXYGEN TO ASSIST THE PATIENT, THEN
3 LATER CALL FOR AN ORDER TO RECEIVE IT.
4 Q. AN ORDER WOULD BE FROM --
5 A. FROM THE PHYSICIAN. GENERALLY YOU WOULD GIVE IT TO THE
6 PATIENT FIRST, AND THEN CALL ON THE PHONE.
7 Q. AND THEN YOU ALSO INDICATE, YOU CHART COLOR PALE.
8 A. UH-HUH.
9 Q. IS THERE A SIGNIFICANCE TO THE FACT THAT YOU CHARTED
10 COLOR PALE IN THE CONTEXT OF THIS PATIENT?
11 A. PATIENTS WHO ARE GETTING ENOUGH OXYGEN GENERALLY HAVE A
12 PINK COLOR TO THE SKIN, NORMAL LIKE ANY OF US. PATIENTS
13 WHOSE OXYGEN SUPPLY IS POOR, THEY FIRST BECOME PALE, AND
14 WITHOUT SUPPLEMENTAL OXYGEN, WILL BECOME BLUISH IN COLOR,
15 INDICATING THAT THEY'RE NOT GETTING ENOUGH OXYGEN TO BREATHE
16 WITH, YOU KNOW, SUPPLY TO THE BRAIN OR VITAL ORGANS.
17 Q. IF YOU COULD NEXT TURN TO A BINDER THAT WOULD HAVE
18 JUDITH LARSEN'S NAME IN IT PLEASE.
19 DO YOU HAVE THAT IN FRONT OF YOU?
20 A. I DO.
21 Q. IF YOU WOULD TURN TO 530, WHICH IS A NURSING NOTE.
22 A. OKAY.
23 Q. THAT'S A NOTE THAT YOU WROTE, IS THAT RIGHT?
24 A. THAT'S CORRECT.
25 Q. AND WE ONCE AGAIN HAVE 3:00 TO 11:00, THAT WOULD BE THE
3128
1 3:00 TO 11:00 SHIFT?
2 A. CORRECT.
3 Q. AND WHAT'S THE DATE ON THAT NOTE?
4 A. LOOKS LIKE 12/8/95.
5 Q. THAT WOULD BE UP AT THE TOP, IS THAT RIGHT?
6 A. YEAH.
7 Q. YOU HAVE PROB, P-R-O-B. DOES THAT STAND FOR PROBLEM?
8 A. CORRECT.
9 Q. THEN YOU HAVE A B. IS THAT BEHAVIOR?
10 A. YES.
11 Q. AND THEN AS WE GO DOWN HERE WE HAVE AN I. DOES THAT
12 STAND FOR INTERVENTION?
13 A. CORRECT.
14 Q. AND THEN AN R. IS A RESPONSE.
15 A. YES.
16 Q. WHERE DID YOU GET THAT FORMATTING IN TERMS OF THE
17 WRITING OF YOUR NOTE?
18 A. THAT WAS DICTATED TO US BY THE HOSPITAL. THERE ARE
19 VARIOUS OPTIONS FOR WRITING PROGRESS NOTES. USUALLY ALL OF
20 THEM WILL INCLUDE SOME OBSERVATION OF THE PATIENT'S BEHAVIOR
21 OR WHAT THE PATIENT SAYS. INTERVENTION'S PRETTY MUCH WHAT
22 YOU HAVE DONE FOR THE PATIENT AND THE DOCUMENTATION OF THE
23 RESPONSE TO THE INTERVENTIONS BY THE PATIENT.
24 Q. COULD YOU PERHAPS IN LOOKING AT THAT ONE ENTRY THAT YOU
25 HAVE THERE, COULD YOU WALK US THROUGH FROM PROBLEM THROUGH
3129
1 BEHAVIOR TO WHAT THE INTERVENTION WAS AND THE RESPONSE SO
2 THAT WE JUST GENERALLY HAVE AN UNDERSTANDING OF HOW YOU
3 WOULD HAVE CHARTED THIS PARTICULAR PROBLEM.
4 A. PROBLEM BEING ALTERATION IN THOUGHT PROCESS, THAT WOULD
5 BE GENERATED BY THE TREATMENT PLAN THAT WE MENTIONED
6 PREVIOUSLY. DETERMINATION OF THE PROBLEMS AS SEEN BY
7 NURSING FOR THE PATIENT. BEHAVIOR SHOULD RELATE BACK TO THE
8 PROBLEM IN TERMS OF WHAT ARE YOU PARTICULARLY OBSERVING IN
9 THE PATIENT, RELATED TO THE PROBLEM AS IT IS IDENTIFIED.
10 HERE I'M SAYING THINGS THAT SHE'S NOT INTERACTING WITH HER
11 ENVIRONMENT. DOING SELF-STIMULATING BEHAVIOR, INCLUDING
12 ROCKING AND REPETITIVE RHYTHMIC SPEECH. ECHOLALIA, WHICH IS
13 A REPETITIVENESS OF WORDS SHE MAY HAVE HEARD IN THE
14 ENVIRONMENT BACK AT YOU, REPETITIVELY OVER AND OVER, LIKE
15 HELLO, HELLO, HELLO, HELLO, FOR EXAMPLE.
16 Q. IS THAT A SYMPTOM OF ANY PARTICULAR PROBLEM?
17 A. IT'S A SYMPTOM OF DEMENTIA TYPE ILLNESS. IN NURSING
18 TERMS, NURSES WOULD TERM THAT AN ALTERATION IN HER THOUGHT
19 PROCESS.
20 Q. OKAY. PLEASE CONTINUE THEN.
21 A. OKAY. INTERVENTION, THOSE WOULD BE THE THINGS I HAD
22 DONE FOR THE BEHAVIOR THAT WAS OBSERVED. AND THE FIRST
23 THING THERE IS TO ADMINISTER RISPERDAL AND KLONOPIN AS
24 ORDERED. THOSE ARE PSYCHOTROPIC MEDICATIONS COMMONLY GIVEN
25 FOR SUCH BEHAVIOR. MONITOR AND DOCUMENT HER BEHAVIOR WHICH
3130
1 I HAD SO DONE IN THE NOTE. AND DOCUMENT RESPONSE TO
2 MEDICATIONS AND PROVIDE A SAFE ENVIRONMENT FOR THE PATIENT.
3 Q. WHAT DOES THAT MEAN?
4 A. A PATIENT WITH ALTERATION IN HER THOUGHT PROCESS MAY NOT
5 BE REASONABLE, MAY NOT BE ABLE TO MAKE DECISIONS IN ORDER TO
6 KEEP THEMSELVES SAFE. AND IT WOULD BE THE JOB OF THE NURSE
7 TO PROVIDE A SAFE ENVIRONMENT FOR THE PATIENT TO BE IN TO
8 PREVENT THEM FROM HAVING INJURY TO THEMSELVES OR FROM
9 INJURING SOMEONE ELSE.
10 Q. THEN YOU HAVE UNDER RESPONSE, YOU HAVE SOME FURTHER
11 CHARTING.
12 A. THE RESPONSE WOULD BE THE PATIENT'S RESPONSE TO THE
13 INTERVENTIONS THAT I PROVIDED. PATIENT REMAINED ACUTELY
14 DISTRESSED UNTIL 2000, WHICH WAS 10:00 O'CLOCK. CRYING
15 INCONSOLABLY IN BED. PROVIDED BACK RUB TIMES 20 MINUTES.
16 PATIENT WAS ABLE TO QUIET FOR AN HOUR. AWOKE AGAIN CRYING
17 UNCONTROLLABLY. GIVEN ATIVAN 1 MILLIGRAM. MUCH CALMER IN A
18 HALF HOUR. ONE HOUR LATER PATIENT RESTED QUIETLY.
19 RESPIRATIONS SLOW, DEEP, AND REGULAR. NOT ROUSED BY
20 15-MINUTE NURSING CHECKS.
21 Q. NOW, CAN YOU TELL IF THE ATIVAN THAT WAS GIVEN WAS A
22 P.R.N. ORDER?
23 A. THAT WOULD HAVE BEEN A P.R.N. ORDER --
24 Q. AND CAN YOU --
25 A. -- SINCE IT INDICATES THAT I WAS THE PERSON WHO MADE THE
3131
1 DECISION TO GIVE THE MEDICATION.
2 Q. I SEE. CAN YOU TELL US PLEASE WHY, GIVEN WHAT YOU'VE
3 CHARTED THERE, ATIVAN WAS APPROPRIATE?
4 A. BECAUSE JUST PREVIOUS TO THAT, YOU'LL SEE THAT SHE WAS
5 CRYING UNCONTROLLABLY DESPITE MY EFFORTS AT OTHER CALMING
6 MEASURES SUCH AS RUBBING HER BACK AND SPENDING TIME WITH THE
7 PATIENT, AND MANIPULATING HER ENVIRONMENT TO MAKE HER MORE
8 COMFORTABLE. GIVEN ALL OF THOSE NON MEDICATION TYPES OF
9 NURSING INTERVENTIONS, THEN YOU WOULD MOVE TO A MORE
10 AGGRESSIVE APPROACH TO HELP COMFORT THE PATIENT, WHICH WOULD
11 BE TO GIVE MEDICATION.
12 Q. WHAT KIND OF MEDICATION IS ATIVAN?
13 A. IT'S A TRANQUILIZING MEDICATION.
14 Q. IF YOU COULD NEXT TURN TO 533.1.
15 A. OKAY.
16 Q. DO YOU HAVE THAT IN FRONT OF YOU?
17 A. YES.
18 Q. AND THIS IS A NOTE CONCERNING PATIENT JUDITH LARSEN, AND
19 THE DATE AT THE TOP IS 12/10 OF '95?
20 A. YES.
21 Q. AND YOU HAVE SOME WRITING INDICATING A NOTE YOU WROTE AT
22 THAT TIME?
23 A. YES.
24 Q. ESSENTIALLY IS THAT ENTIRE PAGE YOUR NOTE?
25 A. YES.
3132
1 Q. ONCE AGAIN, YOU HAVE THE PROBLEM LISTED, AND WHAT DOES
2 THAT SAY AT THE TOP THERE?
3 A. ALTERATION IN THOUGHT PROCESS.
4 Q. AND THEN YOU HAVE B. FOR BEHAVIOR, THAT'S DESCRIBING THE
5 BEHAVIOR OF THE PATIENT, IS THAT RIGHT?
6 A. YES.
7 Q. AND COULD YOU JUST READ WHAT THE BEHAVIOR WAS THAT YOU
8 CHARTED?
9 A. PATIENT WAS SOMNOLENT MOST OF SHIFT. RESPIRATIONS SLOW
10 AND REGULAR. RATE OF 16 TO 18. DO YOU WANT ME TO CONTINUE?
11 Q. PARDON ME?
12 A. DO YOU WISH ME TO CONTINUE?
13 Q. NO, LET ME STOP YOU RIGHT THERE. IS THERE A
14 SIGNIFICANCE TO YOU THAT YOU CHARTED THE RESPIRATIONS SLOW
15 AND REGULAR AND THE RATE 16 TO 18?
16 A. THOSE ARE NORMAL FINDINGS INDICATING THE PATIENT'S LEVEL
17 OF COMFORT.
18 Q. AND WAS THERE A PARTICULAR REASON WHY WOULD YOU ACTUALLY
19 CHART THAT INFORMATION AT THAT TIME?
20 A. THAT WOULD BE BASED ON HAVING OBSERVED THE PATIENT OVER
21 TIME, AND BEING A NURSE FAMILIAR WITH THE PATIENT, AND
22 HAVING READ EVEN JUST THE PREVIOUS NOTE THAT SHE'S HAD
23 PERIODS OF RESTLESSNESS SO THAT THIS WOULD BE A CHANGE.
24 ALTHOUGH THE PROBLEM IS STILL ALTERATION IN THOUGHT PROCESS,
25 THE BEHAVIOR INDICATES AN IMPROVEMENT IN HER BEHAVIOR
3133
1 RELATIVE TO THAT PROBLEM. SO THAT SHE IS CALMER, MORE
2 COMFORTABLE, BREATHING REGULARLY, NOT IN ACUTE DISTRESS,
3 BASED ON THAT.
4 Q. WHAT IS A NORMAL RANGE OF RESPIRATIONS?
5 A. 16 TO 20.
6 Q. WOULD THE RANGE BE AS LOW AS 12?
7 A. YEAH.
8 Q. AND DID YOU HAVE A RESPONSIBILITY AS A NURSE TO ACTUALLY
9 CHART THE RESPIRATION RATE?
10 A. YES.
11 Q. AND COULD YOU TELL US PLEASE WHAT THAT RESPONSIBILITY
12 WAS?
13 A. NURSES HAVE BOTH DEPENDENT AND INDEPENDENT MEASURES IN
14 TERMS OF INTERVENTIONS, AS I SAID. PHYSICIANS COMMONLY
15 WOULD WRITE A FREQUENCY AT WHICH THEY WANTED VITAL SIGNS
16 RECORDED. I THINK THE STANDARD FOR NEW ADMISSIONS WAS TWICE
17 A DAY FOR A PERIOD OF TIME, BUT AS A NURSE, IF I FOUND THE
18 PATIENT IN DISTRESS, I COULD INDEPENDENTLY DETERMINE THAT
19 THOSE NEEDED TO BE DONE. DO THEM, REPORT THEM TO THE
20 PHYSICIAN IF THEY WERE ABNORMAL.
21 Q. NOW, YOU GO ON TO SAY IN TERMS -- THE FAMILY VISITED,
22 AND I CAN'T REALLY READ WHAT YOU SAY THERE AFTER FAMILY.
23 COULD YOU READ THAT FOR US PLEASE?
24 A. FAMILY VISITED AND LENGTHY TEACHING SESSION WITH THIS
25 R.N. REGARDING PATIENT'S CURRENT MEDICATION AND EXPECTED
3134
1 COURSE OF TREATMENT AND CARE DURING THIS HOSPITAL STAY.
2 Q. COULD I ASK YOU PLEASE WHAT YOU WERE REFERRING TO IN
3 TERMS OF THAT INDICATION IN YOUR NOTE?
4 A. ONE OF THE RESPONSIBILITIES OF NURSING IS TO DOCUMENT
5 EDUCATION THAT YOU AS A NURSE PROVIDE TO THE FAMILY OR TO
6 THE PATIENT. IT WAS IN FACT SOMETHING THAT OUR CARE WAS
7 CONTINUALLY REVIEWED BY IN TERMS OF ITS APPROPRIATENESS, AND
8 WE WERE EVALUATED ON HOW WELL WE WERE DOING OUR JOB BASED ON
9 WHETHER OR NOT WE DOCUMENTED EDUCATION AND PROVIDED
10 EDUCATION TO THE PATIENT OR THE FAMILY AS NEEDED. WHAT THIS
11 PARTICULAR INTERVENTION SAYS IS THAT I REVIEWED ALL OF THE
12 PATIENT'S MEDICATIONS AND PLAN OF CARE AS DELINEATED IN THE
13 MASTER TREATMENT PLAN THAT WE'VE LOOKED AT BEFORE. AND WHAT
14 THE PLAN CARE WAS GOING TO BE FOR THE PATIENT DURING THE
15 HOSPITAL STAY.
16 Q. CAN YOU RECALL -- CAN YOU RECALL THIS PARTICULAR
17 CONVERSATION?
18 A. NO.
19 Q. CAN YOU TELL US GENERALLY WHAT YOU DID IN TERMS OF
20 DISCUSSIONS WITH FAMILY CONCERNING MEDICATIONS?
21 MS. BARLOW: OBJECTION, YOUR HONOR. IT'S NOT ABOUT
22 THESE PATIENTS. I DON'T THINK IT'S RELEVANT.
23 THE COURT: CAN YOU REPHRASE THE QUESTION?
24 MR. STIRBA: YES.
25 Q. DID YOU HAVE A PARTICULAR WAY THAT YOU WOULD INTERVENE
3135
1 IN TERMS OF DISCUSSIONS WITH FAMILIES AT THIS TIME
2 CONCERNING THEIR MEDICATION?
3 MS. BARLOW: SAME OBJECTION, YOUR HONOR. IF IT'S
4 NOT ABOUT THESE PARTICULAR PATIENTS, IT'S NOT RELEVANT.
5 THE COURT: OKAY. IS THIS GOING TO HABIT?
6 MR. STIRBA: IT IS, YOUR HONOR. SHE CAN'T REMEMBER
7 THE SPECIFIC CONVERSATION, BUT I THINK SHE CAN TESTIFY AS TO
8 WHAT SHE GENERALLY DID.
9 THE COURT: OKAY. UNDER RULE 406, THAT'S
10 ADMISSIBLE. GO AHEAD.
11 Q. (BY MR. STIRBA) CAN YOU TELL US PLEASE WHAT YOU
12 GENERALLY WOULD DO?
13 A. GENERALLY, DURING A FAMILY VISIT WITH THE PATIENT AND
14 FAMILY, I WOULD TAKE THE FAMILY MEMBERS ASIDE, PARTICULARLY
15 IF THEY ASKED ME, TO REVIEW THE CURRENT LIST OF MEDICATION,
16 HOW OFTEN THAT MEDICATION WAS BEING GIVEN, WHAT THE PURPOSE
17 OF THAT MEDICATION WAS, WHAT THE COMMON SIDE EFFECTS OF THE
18 MEDICATION MIGHT BE, WHAT OUR EXPECTED RESPONSE FROM THE
19 PATIENT TO THE MEDICATION WAS GOING TO BE, WHAT THE PLAN OF
20 CARE AS FAR AS NURSING INTERVENTIONS WERE GOING TO BE, AND
21 WHAT AS I UNDERSTOOD IT OR WHAT WAS DOCUMENTED IN THE
22 TREATMENT PLAN AS FAR AS WHAT THE PHYSICIAN'S PLAN OF CARE
23 WOULD BE.
24 Q. NOW, YOU GO ON TO SAY IN THIS NOTE, WHERE IT SAYS THE
25 REQUEST THAT PATIENT BE MADE COMFORTABLE AND REQUEST THAT
3136
1 SHE BE A D.N.R. AND THEN YOU'VE UNDERLINED THAT TWICE. DO
2 YOU SEE THAT?
3 A. YES.
4 Q. WHAT DID YOU MEAN WHEN YOU REFERRED TO COMFORTABLE?
5 A. THAT THE PATIENT BE KEPT FREE OF PAIN OR DISCOMFORT.
6 Q. AND WHEN YOU WROTE D.N.R., WHAT DOES THAT STAND FOR?
7 A. THAT'S STANDS FOR DO NOT RESUSCITATE.
8 Q. AND WHAT DOES THAT MEAN?
9 A. THAT REFERS TO CARDIOPULMONARY RESUSCITATION, MEANING
10 THAT IF THE PATIENT'S HEART OR LUNGS SHOULD STOP
11 FUNCTIONING, THE PATIENT STOPS BREATHING, AND THE HEART IS
12 NO LONGER BEATING, THAT THE FAMILY DOES NOT WISH MECHANICAL
13 MEANS OR OTHER MEANS TO RESTART BREATHING OR HEARTBEAT.
14 Q. NOW, YOU'VE UNDERLINED IT TWICE. CAN YOU TELL US, IS
15 THERE A PARTICULAR REASON WHY YOU UNDERLINE TWICE D.N.R. AND
16 PUT IT IN CAPITAL LETTERS?
17 A. WELL D.N.R. NORMALLY IS PUT IN CAPITAL LETTERS, BUT I
18 WOULD HAVE UNDERLINED IT TWICE TO DRAW THE ATTENTION OF
19 OTHER PEOPLE READING THE CHART THAT THE FAMILY'S WISHES
20 REMAIN THAT THE PATIENT BE NOT RESUSCITATED DESPITE ANY
21 CHANGE IN THE PATIENT'S CONDITION.
22 Q. NOW, UNDER RESPONSE, R., ON THE SAME DAY, YOU SAY FAMILY
23 VOICED UNDERSTANDING AND PURPOSE OF ALL MEDICATIONS.
24 DO YOU SEE THAT?
25 A. YES.
3137
1 Q. BY ALL --
2 THE COURT: MOVE THAT UP A LITTLE BIT.
3 MR. STIRBA: I'M SORRY, YOUR HONOR.
4 Q. IT'S UNDER R. THAT'S RESPONSE, RIGHT?
5 A. YES.
6 Q. AND THEN FAMILY VOICED UNDERSTANDING AND PURPOSE OF ALL
7 MEDICATIONS.
8 DO YOU SEE THAT?
9 A. YES.
10 Q. AND WHEN YOU USED THE WORD ALL MEDICATIONS, ARE YOU
11 REFERRING NO THE MEDICATIONS THAT SHE WAS RECEIVING AS OF
12 THIS DATE?
13 A. YES.
14 Q. AND THEN IT GOES ON TO SAY, UNDERSTANDING OF THE
15 PURPOSE, GOAL OF COMFORT MEASURES WAS ALSO ARTICULATED BY
16 FAMILY.
17 DID I READ THAT CORRECTLY?
18 A. YES.
19 Q. WHAT DID YOU MEAN BY THAT?
20 A. THAT REFERS TO THEIR WISH THAT THE PATIENT REMAIN A
21 D.N.R. AND BE MADE COMFORTABLE DURING THAT PERIOD OF TIME.
22 THEY WERE ANTICIPATING THE PATIENT'S DEATH.
23 Q. PARDON ME?
24 A. I -- FROM MY SENSE OF READING MY NOTE, THE PATIENT'S
25 FAMILY WAS ANTICIPATING THE PATIENT'S DEATH.
3138
1 Q. NOW, IF YOU WOULD TURN TO 477 PLEASE, WHICH I BELIEVE IS
2 IN THE PROGRESS NOTES PORTION OF THE BINDER. YOUR WRITING
3 IS AT THE TOP, IS THAT RIGHT?
4 A. THAT'S CORRECT.
5 Q. AND IT APPEARS THAT IT WAS DATED ON 1/2 OF '96, CORRECT?
6 A. YES.
7 Q. NOW, IT SAYS FIRST OF ALL, WEEKLY R.N. ADVOCATE NOTE.
8 CORRECT?
9 A. CORRECT.
10 Q. TELL US PLEASE WHAT IS THE SIGNIFICANCE OF A R.N. WEEKLY
11 ADVOCATE NOTE?
12 A. ON ADMISSION TO THE UNIT, EACH PATIENT WAS ASSIGNED A
13 NURSING ADVOCATE, A NURSE WHOSE RESPONSIBILITY IT WAS TO
14 OVERSEE THE CARE PLAN AND TREATMENT OF THE PATIENT BASED ON
15 A 24-HOUR PERIOD OF TIME. THE 24-HOUR RESPONSIBILITY FOR
16 THE CARE PLAN OF THE PATIENT, DIRECTING OTHER NURSES WHAT
17 THE CARE PLAN WOULD BE, AND MONITORING THE HOSPITAL COURSE
18 OF THAT PATIENT AND CONTRIBUTING NURSING INPUT TO THE
19 MEDICAL TEAM, INTERDISCIPLINARY TEAM, INCLUDING SOCIAL
20 WORKERS, PHYSICIAN, WHOEVER IT MIGHT BE, REGARDING THE
21 NURSING PERSPECTIVE ON THE CONDITION OF THE PATIENT. THAT'S
22 WHY IT'S IN THE PROGRESS NOTES SECTION WHICH IS SHARED WITH
23 ALL THE OTHER DISCIPLINES IN THE HOSPITAL.
24 Q. AND IF YOU COULD EXPLAIN, YOU SAID SHARED WITH ALL THE
25 OTHER INTERDISCIPLINES IN THE HOSPITAL. WHY IS THIS
3139
1 PARTICULAR ADVOCATE NOTE IN THE PROGRESS NOTES SECTION, WHAT
2 SIGNIFICANCE DOES THAT HAVE?
3 A. IT'S INFORMATION THAT I BELIEVED THE REST OF THE MEDICAL
4 TEAM NEEDED TO KNOW AT THE TIME, AND ALL THE NOTES THAT
5 WE'VE READ SO FAR SHOW THAT I'VE BEEN WORKING 3:00 TO 11:00
6 OR 11:00 TO 7:00. MANY OF THE REMAINING MEMBERS OF THE
7 MEDICAL TEAM WOULD WORK 9:00 TO 5:00 OR 7:00 TO 3:00, SO
8 THIS WOULD BE MY PRIMARY MEANS OF COMMUNICATING MY OPINION
9 ABOUT THE PATIENT TO THE REST OF THE TEAM.
10 Q. DOES THIS NOTE INCLUDE IN IT CERTAIN ASSESSMENT DATA BY
11 YOU?
12 A. YES.
13 Q. AND TELL US PLEASE WHAT MATTERS YOU ASSESSED CONCERNING
14 JUDITH LARSEN REFLECTED BY THIS NOTE.
15 A. THAT SHE HAD RAPIDLY AND PROFOUNDLY DETERIORATED WITHIN
16 A WEEK'S TIME.
17 Q. AND DO YOU RECALL WHY SHE HAD RAPIDLY AND DETER -- AND
18 PROFOUNDLY DETERIORATED?
19 A. I DON'T RECALL WITHOUT READING THE NOTE, BUT THE NOTE
20 STATES THAT THE PATIENT WAS HAVING SEIZURES, MULTIPLE
21 EPISODES OF VOMITING COFFEE GROUND MATERIAL, NOT VERBALLY
22 RESPONSES WHERE SHE -- RESPONSIVE WHERE PREVIOUSLY SHE HAD
23 BEEN ABLE TO TALK TO OTHER PEOPLE. THOSE ARE THE
24 ASSESSMENTS THAT I MADE.
25 Q. NOW, YOU REFERENCE IN THE NOTE THE CARE PLAN, IS THAT
3140
1 RIGHT?
2 A. YES.
3 Q. AND IT SAYS, THE CARE PLAN HAS BEEN ALTERED TO REFLECT
4 THE NEED TO SUPPORT PATIENT FAMILY THROUGH A POSSIBLE DEATH
5 AND DYING PROCESS.
6 DID I READ THAT CORRECTLY?
7 A. YES.
8 Q. TELL US PLEASE WHY YOU WOULD HAVE ALTERED OR AMENDED THE
9 CARE PLAN AT THIS TIME.
10 A. BECAUSE THE PATIENT'S CONDITION AND NURSING NEEDS HAD
11 DRAMATICALLY CHANGED, AND THAT THE CARE THAT I WAS PROVIDING
12 WAS REFLECTIVE OF THAT, OF A PATIENT WHO NEEDED CARE OF THE
13 PATIENT CLOSE TO DEATH.
14 Q. AND IS THE ASSESSMENT OF CLOSE TO DEATH, IS THAT AN
15 ASSESSMENT THAT WAS MADE BY YOU?
16 A. FROM A NURSING POINT OF VIEW, YES.
17 Q. AND WHAT KINDS OF -- LET ME START OVER AGAIN. IN TERMS
18 OF ALTERING OR AMENDING THE CARE PLAN, DO YOU RECALL
19 GENERALLY WHAT NURSING INTERVENTIONS WOULD BE REFLECTED
20 CONCERNING SUPPORTING THE FAMILY THROUGH A DEATH AND DYING
21 PROCESS?
22 A. GENERALLY, THE NURSING CARE OF A FAMILY MEMBER AND A
23 PATIENT WHO IS DYING, THE NURSE IS RESPONSIBLE FOR REALLY
24 SOME SPIRITUAL SUPPORT AND EMOTIONAL SUPPORT AND ANY OTHER
25 KIND OF SUPPORT THAT THE NURSE CAN REASONABLY RENDER TO
3141
1 FAMILIES WHEN THEY'VE VISITING. WE DIDN'T READILY HAVE
2 RELIGIOUS SUPPORT AVAILABLE, SO WHATEVER NEEDS THE FAMILY
3 EXPRESSED, TIME IN PRIVATE WITH THEIR FAMILY MEMBERS, TIME
4 TO VOICE THEIR OWN CONCERNS TO ME IN A PRIVATE WAY, ALL OF
5 THAT WOULD HAVE BEEN PROVIDED FOR THE PATIENT AND THE
6 FAMILY.
7 Q. NOW, YOU GO ON TO SAY IN THE LAST LINE THERE OF YOUR
8 NOTE, PATIENT IS CURRENTLY RECEIVING -- AND THAT WOULD BE
9 MORPHINE I.M. EVERY THREE HOURS FOR COMFORT.
10 DID I READ THAT CORRECTLY?
11 A. CORRECT.
12 Q. WHEN YOU USED WORDS FOR COMFORT IN THAT NOTE, WHAT DO
13 YOU MEAN?
14 A. I'M REFERRING TO ALLEVIATING THE DISCOMFORT THAT COMES
15 WITH THE DEATH AND DYING PROCESS IN A PATIENT.
16 Q. AND CAN YOU DESCRIBE FOR US THE KINDS OF DISCOMFORT
17 THAT THE PATIENT WOULD BE EXPERIENCING IN THE DEATH AND
18 DYING PROCESS?
19 MS. BARLOW: YOUR HONOR, I OBJECT UNLESS IT'S THIS
20 PATIENT SPECIFICALLY.
21 THE COURT: WELL, CAN YOU LAY A FOUNDATION? YOU'RE
22 ASKING THE WITNESS TO SAY WHAT SOMEBODY ELSE IS DOING.
23 MR. STIRBA: WELL, PERHAPS WE'LL JUST REFER TO THE
24 NOTES, YOUR HONOR.
25 Q. YOU'VE REVIEWED SOME NURSE'S NOTES CONCERNING YOUR CARE
3142
1 OF JUDITH LARSEN?
2 A. YES.
3 Q. TURN TO 582 PLEASE. NOW, THIS IS -- I'LL WAIT UNTIL YOU
4 GET IT.
5 A. ALMOST THERE. THREE -- 581.
6 Q. DO YOU HAVE 582 IN YOUR BINDER?
7 A. NO, I DO NOT.
8 MR. STIRBA: MAY I ASSIST THE WITNESS, YOUR HONOR?
9 THE COURT: YES.
10 MR. STIRBA: RIGHT THERE, 528, RIGHT. THEY'RE OUT
11 OF ORDER, YOUR HONOR.
12 Q. AND -- BUT WE NOW ARE AT 582, ARE WE?
13 A. YES.
14 Q. AT THE TOP OF 582, THERE IS A DATE AND THIS IS A NOTE ON
15 12/31 OF 1995?
16 A. CORRECT.
17 Q. AND YOU AFFIXED YOUR SIGNATURE ON THE FIRST PORTION OF
18 THAT NOTE, IS THAT RIGHT?
19 A. CORRECT.
20 Q. AND YOU STATE ELEVEN SEVEN, THAT WOULD BE SHIFT, NIGHT
21 SHIFT, FREE TEXT NOTE. RESPIRATION RATE, 10 TO 16 PER
22 MINUTE. PATIENT IS -- WHAT IS THAT WORD?
23 A. GAZING.
24 Q. -- GAZING AT LIGHT FROM BATHROOM. COULD YOU TELL US
25 PLEASE IF THERE IS A SIGNIFICANCE TO THE FACT THAT YOU
3143
1 CHARTED THOSE FACTS?
2 A. DURING THE DEATH AND DYING PROCESS, AS MY EDUCATION IN
3 NURSING AND MY OBSERVATIONS AS A NURSE HAVE TAUGHT ME, ONE
4 OF THE LAST SENSES TO LEAVE A PATIENT IN THE PROCESS OF
5 DYING IS VISION. AND IT IS COMMON NURSING PRACTICE TO LEAVE
6 A LIGHT OR A TELEVISION OR A BATHROOM LIGHT WITH THE DOOR
7 HALF CLOSED ON DURING THE NIGHTTIME WHEN IT IS ANTICIPATED
8 THAT THE PATIENT MAY DIE SO THAT THEY DO NOT DO SO IN THE
9 DARK.
10 Q. SHE IS AWAKE. SHE IS NOT VERBALLY RESPONSIVE. WHAT DO
11 YOU MEAN BY THAT?
12 A. THAT WOULD MEAN THAT PERHAPS HER EYES ARE OPEN, BUT
13 SHE'S NOT ABLE TO ANSWER ME IF I SPOKE TO HER OR TOUCHED
14 HER.
15 Q. IS THERE A PARTICULAR REASON WHY YOU WOULD HAVE CHARTED
16 THAT FACT?
17 A. IN THE PROCESS OF DEATH AND DYING, PATIENTS PROGRESS
18 THROUGH A SERIES OF LOSSES IN FUNCTION. NOT BEING VERBALLY
19 RESPONSIVE IS ONE OF THOSE.
20 Q. AND DOES THAT RELATE TO THE REASON WHY YOU CHARTED THAT
21 FACT?
22 A. YES.
23 Q. AND THEN IT STAYS MORPHINE 5 MILLIGRAMS I.M. GIVEN AT
24 2:30 AND 6:30 FOR PAIN RELIEF.
25 DID I READ THAT CORRECTLY?
3144
1 A. YES.
2 Q. IS THERE A REASON WHY YOU INDICATED THE TIMES IN THAT
3 NOTE?
4 A. YES.
5 Q. AND WOULD YOU TELL US PLEASE WHY YOU DID THAT?
6 A. TO DOCUMENT WHEN THE PAIN MEDICATION WAS GIVEN, DIRECTLY
7 AFTER THAT STATEMENT, I WROTE THIS A BIT OUT OF SEQUENCE.
8 IT STATES THAT THE PATIENT WAS MOANING PRIOR TO THE 2:30
9 DOSE OF MEDICATION, WHICH WOULD INDICATE TO ME THE PATIENT
10 WAS HAVING PAIN AND IN NEED OF THE MEDICATION AS IT HAD BEEN
11 ORDERED.
12 Q. AND YOU SAID OUT OF SEQUENCE. COULD YOU EXPLAIN WHAT
13 YOU MEAN BY THAT?
14 A. MOST PROBABLY I WOULD HAVE WRITTEN PATIENT WAS MOANING
15 AT 2:30, AND THEN SAID THAT I HAD GIVEN A DOSE OF MORPHINE.
16 THIS IS JUST A MATTER OF MY FLOW OF THOUGHT AS I WAS WRITING
17 THE NOTE AT THE END OF SHIFT.
18 Q. BASED UPON WHAT YOU CHARTED THERE, DID YOU ASSESS THAT
19 JUDITH LARSEN WAS IN PAIN?
20 A. YES.
21 THE COURT: IS THIS AN APPROPRIATE PLACE TO TAKE
22 BREAK?
23 MR. STIRBA: FINE, JUDGE.
24 THE COURT: OKAY, LADIES AND GENTLEMEN.
25 (AFTER ADMONISHING THE JURY, THE COURT
3145
1 TOOK A BRIEF RECESS.)
2 THE COURT: OKAY. PLEASE BE SEATED. THE RECORD
3 SHOULD REFLECT THAT THE JURY AS HAS RETURNED. WOULD YOU
4 LIKE TO CONTINUE.
5 MR. STIRBA: YES, THANK YOU, YOUR HONOR.
6 Q. MISS STEVENSON, DOES A NURSE HAVE ANY DUTIES OR
7 RESPONSIBILITIES WHEN, FOR EXAMPLE, ADMINISTERING A
8 MEDICATION SUCH AS MORPHINE IN TERMS OF PRECAUTIONS WITH THE
9 PATIENT?
10 A. AS WITH ANY MEDICATION, YOU WOULD LOOK AT THE MEDICATION
11 TO MAKE SURE THAT THE DOSE AND THE FREQUENCY OF MEDICATION
12 WAS APPROPRIATE TO THE AGE AND CONDITION OF THE PATIENT.
13 Q. ARE YOU FAMILIAR WITH A MONITORING FUNCTION?
14 A. YOU WOULD MONITOR FOR MORPHINE, SPECIFICALLY A
15 RESPIRATORY RATE, LEVEL OF ALERTNESS.
16 Q. AND WOULD YOU TELL US PLEASE HOW YOU WOULD GO ABOUT
17 MONITORING A RESPIRATORY RATE IF YOU WERE GIVING, FOR
18 EXAMPLE, MORPHINE?
19 A. YOU WOULD STAND AND OBSERVE THE RISE AND FALL OF THE
20 CHEST OF THE PATIENT, AND IF YOU COULDN'T SEE IT WITH YOUR
21 EYES, YOU COULD PUT YOUR HAND ON THEIR CHEST TO FEEL AND
22 COUNT THAT WITH A SECOND HAND OF A WATCH PER MINUTE.
23 Q. WOULD THERE BE ANY OTHER MONITORING FUNCTIONS THAT YOU
24 WOULD DO AFTER THE MEDICATION HAS BEEN ADMINISTERED?
25 A. TO DOCUMENT ANY IMPROVEMENT IN THE PATIENT'S CONDITION
3146
1 OR ANY CHANGE IN THE PATIENT'S CONDITION SUBSEQUENT TO THE
2 ADMINISTRATION OF THE MORPHINE, A CHANGE IN THE RESPIRATORY
3 RATE, SIGNS AND SYMPTOMS THE PATIENT MAY SHOW THAT INDICATE
4 THE MEDICATION WAS HELPFUL OR NOT HELPFUL IN RELIEF OF THEIR
5 DISCOMFORT.
6 Q. DO YOU STILL HAVE PATIENT JUDITH LARSEN'S BINDER IN
7 FRONT OF YOU?
8 A. UH-HUH.
9 Q. TURN TO 583 PLEASE.
10 A. OKAY.
11 Q. AND THAT IS ANOTHER NOTE WRITTEN BY YOU, IS THAT RIGHT?
12 A. CORRECT.
13 Q. WHAT IS THE DATE?
14 A. LOOKS LIKE 1/1/96.
15 Q. AND THAT WAS, ONCE AGAIN, AN ELEVEN SEVEN NIGHT SHIFT
16 FREE TEXT NOTE, IS THAT RIGHT?
17 A. CORRECT.
18 Q. IT SAYS, PATIENT CONTINUES TO EXHIBIT CHEYNE-STOKES
19 RESPIRATIONS.
20 DID I READ THAT CORRECTLY?
21 A. CORRECT.
22 Q. WHAT IS THE SIGNIFICANCE OF YOU CHARTING THAT?
23 A. CHEYNE-STROKES RESPIRATIONS ARE A RHYTHM OF RESPIRATIONS
24 THAT ARE PARTICULAR TO A DYING PATIENT.
25 Q. AND THEN YOU GO, PERIODS OF APNEA, 15 TO 20 SECONDS.
3147
1 WHAT DOES THAT MEAN?
2 A. THOSE ARE PERIODS OF TIME DURING WHICH THE PATIENT DOES
3 NOT TAKE A BREATH.
4 Q. AND WHAT IS THE SIGNIFICANCE OF THE FACT THAT YOU
5 CHARTED THAT?
6 A. THE LONGER THE PERIODS OF APNEA, THE CLOSER THE PERIOD
7 OF DEATH -- THE CLOSER TO DEATH THE PATIENT IS BECOMING.
8 Q. NOW, YOU SAY, HAS REFLEXIVE HAND GRASP. WHAT DO YOU
9 MEAN REFLEXIVE HAND GRASPS?
10 A. IT MEANS THAT IF YOU PLACE AN OBJECT IN THAT PERSON'S
11 HAND, THEY CLOSE THEIR FINGERS AROUND IT MUCH LIKE AN INFANT
12 WOULD DO. A NEWBORN HAS THE SAME GRASP REFLEX. PERSONS WHO
13 ARE DYING, HAVE HAD SEVERE BRAIN INJURY OR THEIR BRAIN HAS
14 REGRESSED IN THE DEATH PROCESS TO VERY BASIC INFANTILE SORTS
15 OF REFLECTIONS. AS A NURSE YOU WOULD DOCUMENT THE PRESENCE
16 OF THOSE, SHOWING WHERE IN THE DEATH AND DYING PROCESS WAS
17 THIS PATIENT.
18 Q. NOW, IF WE PROCEED DOWN THROUGH NO -- F., YOU HAVE
19 INDICATIONS OF SOME VITAL SIGNS. YOU REFER TO, NO FAMILY
20 VISITORS TONIGHT. AND THAT WOULD BE ON THE FIRST. WHY DID
21 YOU WRITE THAT IN THE NOTE?
22 A. IT IS CERTAINLY PART OF MY CARE PLAN OF THIS PATIENT TO
23 DOCUMENT AND TO SHOW AND GIVE SUPPORT TO FAMILY MEMBERS IN
24 THE DYING PROCESS OF THIS PATIENT, AND IT WOULD BE IMPORTANT
25 TO SAY WHETHER OR NOT THE FAMILY WAS THERE, AND WHETHER OR
3148
1 NOT IF THEY WERE THERE, DID I GIVE THEM ANY ASSISTANCE.
2 Q. IF YOU'LL GO TO 586 PLEASE.
3 A. OKAY.
4 Q. THIS IS ALSO ANOTHER NOTE CONCERNING PATIENT JUDITH
5 LARSEN. 1/2 OF '96, AND ONCE AGAIN, YOU'RE WORKING THAT
6 NIGHT SHIFT 11:00 TO 7:00, IS THAT RIGHT?
7 A. CORRECT.
8 Q. NOW, PARTICULARLY, I WANNA DIRECT YOUR ATTENTION TO
9 WHERE YOU SAY SOME -- IS THAT GROWING?
10 A. GROANING NOTED SEVERAL MINUTES PRIOR TO 0330 MORPHINE
11 I.M. MEDICATION.
12 Q. THAT WOULD BE MORPHINE I.M. MEDICATION?
13 A. UH-HUH.
14 Q. WHAT DOES GROANING SIGNIFY TO YOU?
15 A. GROANING IS AN EXPRESSION OF PAIN AND ONE THAT AS A
16 NURSE I WAS TAUGHT TO ASSESS. PARTICULARLY IN A NON VERBAL
17 DYING PATIENT, GROANING MAY BE THE ONLY EXPRESSION THAT THEY
18 CAN PRESENT. AND AS SUCH, IT IS MY RESPONSIBILITY AS THE
19 NURSE TO ALLEVIATE THAT DISCOMFORT, IF I CAN.
20 Q. NOW, IT'S STATED IN CONJUNCTION WITH YOUR INDICATION OF
21 A 3:30 A.M. MEDICATION OF MORPHINE. IS THERE A PARTICULAR
22 REASON WHY THOSE TWO ARE TOGETHER?
23 A. IT RELATES TO THE REASON WHY I WOULD GIVE THE
24 MEDICATION. IT IS MY OPTION TO GIVE A PARTICULAR DOSE OF
25 MEDICATION THAT IS ASSIGNED A PARTICULAR HOUR FOR
3149
1 ADMINISTRATION, SAY 3:00 O'CLOCK TO GIVE THAT, OR
2 4:00 O'CLOCK, TO GIVE IT ANYWHERE HALF HOUR BEFORE OR HALF
3 HOUR AFTER. THE OPTION FOR THE NURSE IS WITHIN THE HOUR OF
4 THE WRITTEN TIME FOR ADMINISTRATION. BASED ON A NURSING
5 ASSESSMENT, YOU COULD GIVE THAT DOSE EARLIER OR LATER
6 DEPENDING UPON THE LEVEL OF DISTRESS OF THE PATIENT. IF
7 THEY'RE VERY COMFORTABLE, YOU MAY WAIT UNTIL THE LATTER HALF
8 OF THE HOUR. IF UNCOMFORTABLE, GIVE IT EARLIER.
9 Q. AND WHAT DOES 3:30 SIGNIFY TO YOU IN THE CONTEXT OF THIS
10 NOTE?
11 A. IT COULD MEAN THAT I GAVE THE MEDICATION HALF HOUR
12 EARLY.
13 Q. NOW, YOU INDICATE TURNED AT TWO HOURS A LITTLE BIT
14 FURTHER DOWN THERE. DO YOU SEE THAT?
15 A. TURNED EVERY TWO HOURS.
16 Q. I'M SORRY, TURNED EVERY TWO HOURS. THANK YOU. TELL US
17 PLEASE WHAT TURNING IS IN THIS CONTEXT?
18 A. THAT IS A NURSING MEASURE TO CHANGE THE POSITION OF THE
19 PATIENT, A PATIENT WHO IS SEVERELY ILL IS NOT ABLE OFTEN TO
20 HAVE THE STRENGTH TO TURN THEMSELVES IN THE BED, EVEN TO
21 CHANGE THEIR POSITION SLIGHTLY. IT THEREFORE BECOMES THE
22 RESPONSIBILITY OF THE NURSE TO PROVIDE THAT ABILITY TO THE
23 PATIENT AND MOVE THEM AROUND. IF YOU DO NOT DO THAT, THE
24 RISK FOR BREAKDOWN OF THE SKIN AND ULCER FORMATION IS
25 EXTREMELY HIGH. SKIN BREAKDOWN CAN OCCUR IN A PATIENT IN
3150
1 TWO HOURS' TIME --
2 MS. BARLOW: YOUR HONOR, NOT ONLY IS THIS
3 REPETITIVE, BUT IT'S GONE BEYOND THE QUESTION.
4 THE COURT: LET ME REPHRASE THE QUESTION.
5 MR. STIRBA: SURE.
6 Q. DOES TURNING HAVE ANY SIGNIFICANCE TO YOUR ASSESSMENT OF
7 PAIN?
8 A. TURNING EVERY TWO HOURS IS A COMFORT MEASURE. YOU CAN
9 OBSERVE DISCOMFORT IN A PATIENT IF YOU MOVE THEM.
10 OFTENTIMES WHEN YOU TURN A PATIENT, THEY WILL GRIMACE. THAT
11 DOES NOT NEGATE THE NEED TO MAKE THEM MORE COMFORTABLE.
12 Q. IF YOU WOULD TURN TO 507 PLEASE, WHICH IS IN THE MED
13 GRAPHS SECTION OF PATIENT JUDITH LARSEN'S BINDER.
14 A. I'M SORRY, 50 --
15 Q. 507 PLEASE.
16 A. OKAY.
17 Q. DO YOU HAVE THAT IN FRONT OF YOU?
18 A. YES.
19 Q. WHAT DO YOU RECOGNIZE THAT TO BE?
20 A. THAT'S A MEDICATION ADMINISTRATION RECORD.
21 Q. AND DO YOU SEE YOUR INITIALS ON THAT DOCUMENT?
22 A. YES, I DO.
23 Q. AND THEY LOOK LIKE A FAIRLY GOOD REPRESENTATION OF L.W.
24 AT 30, 330, AND 630 HOURS, IS THAT RIGHT?
25 A. CORRECT.
3151
1 Q. AND CAN YOU TELL -- ARE YOU GIVING MORPHINE OR
2 ADMINISTERING MORPHINE INJECTIONS AT THOSE TIMES AND ON THAT
3 DATE?
4 A. YES.
5 Q. GIVEN YOUR ASSESSMENT OF THE CIRCUMSTANCES OF THIS
6 PATIENT FROM A NURSING PERSPECTIVE, DID YOU FIND ANYTHING
7 INAPPROPRIATE ABOUT GIVING THOSE DOSES AT THOSE TIMES?
8 MS. BARLOW: OBJECTION, YOUR HONOR. SHE'S NOT BEEN
9 LISTED AS AN EXPERT, AND THAT CALLS FOR AN EXPERT OPINION.
10 THE COURT: SUSTAINED.
11 Q. (BY MR. STIRBA) DO YOU BELIEVE THAT IN GIVING THOSE
12 DOSES OF MEDICATION UNDER THOSE TIMES, THAT YOU WERE CAUSING
13 OR CONTRIBUTING IN ANY WAY TO THE DEATH OF JUDITH LARSEN?
14 A. NO.
15 MS. BARLOW: OBJECTION. THAT ALSO CALLS FOR AN
16 EXPERT OPINION. SHE'S NOT AN EXPERT.
17 THE COURT: OVERRULED.
18 Q. (BY MR. STIRBA) YOU MAY ANSWER.
19 A. NO, I DO NOT.
20 Q. WOULD YOU TELL US PLEASE WHY YOU DO NOT?
21 A. IF I HAD BELIEVED AT THE TIME THAT THE DOSE WAS
22 INAPPROPRIATE, I AS THE NURSE HAD WITHIN MY LICENSE THE
23 ABILITY TO HOLD THAT DOSE BASED ON MY ASSESSMENT OF THE
24 PATIENT. IT WAS MY ASSESSMENT OF THE PATIENT THAT
25 DISCOMFORT WAS PRESENT. I ADMINISTERED THE MEDICATION AS
3152
1 ORDERED.
2 Q. WHAT YOU DO MEAN WITHIN THE SCOPE OF YOUR LICENSE?
3 COULD YOU EXPLAIN THAT PLEASE?
4 A. A NURSE IS ALLOWED TO REFUSE TO ADMINISTER A MEDICATION
5 SHE BELIEVES TO BE INAPPROPRIATE OR HARMFUL TO A PATIENT.
6 Q. FINALLY, IF YOU COULD TURN IN THIS BINDER TO 596 PLEASE.
7 IT MIGHT BE IN THE OTHER TAB.
8 A. OKAY.
9 Q. DO YOU HAVE THAT IN FRONT OF YOU?
10 A. YES.
11 Q. TELL US PLEASE WHAT IS IN FRONT OF YOU.
12 A. SAYS SECTION OF THE NURSING CARE PLAN, TREATMENT PLAN.
13 Q. I'M SORRY?
14 A. A SECTION OF THE NURSING TREATMENT PLAN.
15 Q. I KNOW IT'S DIFFICULT, BUT SOMETIMES BECAUSE OF THIS
16 MACHINE, COULD YOU KEEP YOUR VOICE UP PLEASE?
17 A. SURE.
18 Q. AND IS THAT YOUR WRITING ON THIS DOCUMENT?
19 A. YES, IT IS.
20 Q. AND WHY DID YOU CREATE THIS DOCUMENT?
21 A. I CONTRIBUTED TO THIS DOCUMENT BECAUSE I WAS THE NURSE
22 CARING FOR THE PATIENT.
23 Q. AND THIS IS AN ALTERATION OR AMENDMENT OF THE CARE PLAN?
24 A. YES, IT IS.
25 Q. I WANNA GO OVER JUST THE COLUMNS, AND YOU'VE EXPLAINED
3153
1 TO US WHAT THE PURPOSE IS AND WHAT YOU'RE SAYING. THERE'S A
2 DATE THERE OF 1/2, AND IT HAS PROBLEM, CORRECT?
3 A. CORRECT.
4 Q. WHAT IS SUPPOSED TO BE REFERENCED IN THAT COLUMN
5 CONCERNING PROBLEM?
6 A. I'M SORRY, I DIDN'T UNDERSTAND THE QUESTION.
7 Q. GENERALLY, WHAT WOULD GO IN THE PROBLEM CATEGORY ON A
8 DOCUMENT SUCH AS THIS?
9 A. A NURSING -- IN THIS PARTICULAR -- IF I WERE
10 CONTRIBUTING TO IT AS THE NURSE, IT WOULD BE A NURSING
11 DIAGNOSIS OF CONCERNS FOR THE PATIENT OR THE FAMILY.
12 Q. OKAY. AND WHAT IS A NURSING DIAGNOSIS?
13 A. A NURSING DIAGNOSIS IS THOSE ITEMS THAT A NURSE IS
14 LICENSED TO TREAT BY WAY OF NURSING INTERVENTIONS.
15 Q. IN THIS -- THIS DOCUMENT, WHAT ARE THOSE FIRST TWO
16 LETTERS UNDER PROBLEM? I CAN'T READ THAT.
17 A. A.L.T. STANDING FOR ALTERATION.
18 Q. OH, ALTERATION, COPING, PATIENT AND FAMILY, DEATH AND
19 DYING ISSUES.
20 DID I READ THAT CORRECTLY?
21 A. CORRECT.
22 Q. WHAT DID THAT MEAN?
23 A. IT MEANS THAT THE PATIENT AND THE FAMILY ARE HAVING TO
24 DEAL WITH DEATH AND DYING ISSUES. THAT IS A CHALLENGE TO
25 ANY -- OR A FAMILY'S ABILITY TO COPE WITH A NEW PROBLEM.
3154
1 Q. THE NEXT COLUMN HAS EXPECTED OUTCOMES. I CAN'T READ
2 WHAT YOU CIRCLED. WHAT IS THAT?
3 A. WHAT I STATED?
4 Q. IT LOOKS LIKE AN I. BEFORE --
5 A. 1.
6 Q. THANK YOU. PATIENT WILL EXPERIENCE A PEACEFUL -- I
7 CAN'T READ THAT.
8 A. IT SAYS, PATIENT WILL EXPERIENCE A PEACEFUL DEATH FREE
9 FROM DISCOMFORT.
10 Q. AND WHAT DO YOU MEAN BY THAT?
11 A. THAT IN THE PROCESS OF THIS PATIENT'S DEATH, THERE WILL
12 BE MINIMAL STRESS, DISCOMFORT, PAIN TO THE PATIENT, AND THAT
13 WILL BE A COMFORTABLE EXPERIENCE FOR THEM.
14 Q. AND THEN IN THE LAST COLUMN WE HAVE NURSING
15 INTERVENTIONS. AND YOU HAVE LISTED ONE THROUGH NINE,
16 CORRECT?
17 A. CORRECT.
18 Q. LET'S GO OVER THEM ONE AT A TIME. FIRST IT SAYS MONITOR
19 VERSUS --
20 A. MONITOR VITAL SIGNS.
21 Q. VITAL SIGNS, THANK YOU, FREQUENTLY AS ORDERED. WHAT
22 DOES THAT MEAN?
23 A. THAT WOULD REFER TO A DEPENDENT NURSING MEASURE, THE
24 FREQUENCY OF VITAL SIGNS HAVING BEEN SPECIFIED BY THE
25 PHYSICIAN AND THE NURSE CARRYING OUT THOSE VITAL SIGNS,
3155
1 OBTAINING THOSE VITAL SIGNS, TEMPERATURE, BLOOD PRESSURE,
2 PULSE, RESPIRATION.
3 Q. DO YOU KNOW IF THAT WAS DONE IN THIS CASE?
4 A. I WOULD A -- IF THEY WERE DOCUMENTED IN THE RECORD, THEN
5 THEY WOULD BE DONE.
6 Q. WOULD YOU EXPECT THAT TO HAVE BEEN DONE?
7 A. YES.
8 MS. BARLOW: OBJECTION, YOUR HONOR. IT'S EITHER
9 DONE OR NOT DONE. IT'S EITHER IN THE RECORD OR NOT IN THE
10 RECORD. SPECULATION IS NOT HELPFUL AT THIS POINT.
11 THE COURT: OKAY. WELL --
12 MR. STIRBA: I AGREE, YOUR HONOR.
13 THE COURT: OKAY. THEY'LL DISREGARD THE LAST
14 STATEMENT OF THE WITNESS.
15 Q. (BY MR. STIRBA) TWO, COMFORT MEASURES, TURN EVERY TWO
16 HOURS, MOUTH CARE FREQUENTLY, DOES THAT SAY P.R.N.?
17 A. CORRECT.
18 Q. OKAY. WHAT IS THAT REFERRING TO?
19 MS. BARLOW: OBJECTION, YOUR HONOR. THAT IS
20 CUMULATIVE. WE HAVE ALREADY GONE INTO WHAT THAT MEANS WITH
21 THIS WITNESS -- OR THIS WITNESS AND WITH --
22 THE COURT: ARE YOU ASKING WHAT P.R.N. MEANS OR --
23 MR. STIRBA: NO, NO, WHAT THE -- WHAT THE CATEGORY
24 2 IS IN THE CARE OF THIS DOCUMENT WHICH --
25 THE COURT: IS YOUR OBJECTION P.R.N. OR WHOLE --
3156
1 MS. BARLOW: THE WHOLE THING. I MEAN SHE'S ALREADY
2 TESTIFIED AS TO WHAT SHE THINKS COMFORT MEASURES ARE,
3 TURNING IS, AND MOUTH CARE IS --
4 THE COURT: OVERRULED.
5 MS. BARLOW: -- IT'S REPETITIVE.
6 Q. (BY MR. STIRBA) YOU MAY ANSWER.
7 A. COULD YOU REPEAT THE QUESTION.
8 Q. SURE. NUMBER 2, WHAT DOES THAT MEAN IN THE CONTEXT OF
9 THIS DOCUMENT?
10 A. IT MEANS THAT THOSE MEASURES THAT I SPECIFIED WOULD BE
11 CARRIED OUT, TURNING THE PATIENT, CLEANING THE PATIENT'S
12 MOUTH, REMOVING EXCESS SECRETIONS, THAT WOULD INCLUDE THERE
13 AS OFTEN AS THE NURSE DETERMINED WAS NECESSARY.
14 Q. THREE, TALK?
15 A. WITH PATIENT.
16 Q. WITH PATIENT -- I'M SORRY, I CAN'T READ THE REST OF
17 THAT.
18 A. TALK WITH PATIENT WHEN PROVIDING CARE.
19 Q. WHAT -- WHAT IS THE SIGNIFICANCE OF THAT?
20 A. ALONG WITH VISION, HEARING IS ONE OF TWO OF THE FINAL
21 SENSES TO LEAVE A DYING PATIENT. AND ALTHOUGH THE PATIENT
22 MAY NOT BE ABLE TO RESPOND TO YOU VERBALLY OR LOOK AT YOU,
23 CERTAINLY AS AN AID IN COMFORT, YOU WOULD TALK TO THE
24 PATIENT TO LET THEM KNOW YOU WERE THERE.
25 Q. FOUR, VISIT PATIENT'S ROOM FREQUENTLY. WHY WOULD YOU DO
3157
1 THAT?
2 A. TO PREVENT THE PATIENT FROM DYING ALONE.
3 Q. FIVE, IT SAYS PROVIDING SOFTER LIGHTING, IS THAT RIGHT?
4 A. SOFT -- PROVIDE SOFT LIGHTING.
5 Q. AND WHAT IS THE SIGNIFICANCE IN THE CONTEXT OF THIS CARE
6 PLAN OF PROVIDING SOFT LIGHTING?
7 A. AGAIN, THAT VISION IS ONE OF THE LAST SENSES LOST BY A
8 DYING PATIENT, AND IT'S INAPPROPRIATE TO LEAVE THEM IN THE
9 DARK.
10 Q. THEN PROVIDE, LOOKS LIKE MORPHINE I.M. AS ORDERED FOR
11 PAIN, SLASH, DISCOMFORT, AND MONITOR EFFECTS.
12 DID I READ THAT CORRECTLY?
13 A. CORRECT.
14 Q. AND I BELIEVE YOU HAVE TESTIFIED ABOUT THE MONITORING
15 AND THE MORPHINE IN THIS CONTEXT, IS THAT RIGHT?
16 A. YES.
17 Q. SEVEN, ALLOW FAMILY MEMBERS TO VISIT AS NEEDED. I THINK
18 THAT'S SELF-EXPLANATORY.
19 A. UH-HUH.
20 Q. DO YOU AGREE?
21 A. YES.
22 Q. EIGHT, PROVIDE -- I CAN'T READ THAT?
23 A. PROVIDE EMOTIONAL SUPPORT FOR FAMILY. SUPPORT THE GRIEF
24 PROCESS.
25 Q. WHY IS THAT A NURSING INTERVENTION?
3158
1 A. BECAUSE NURSING IS NOT ONLY THE CARE OF THE PATIENT, BUT
2 ALSO THE FAMILY OF THE PATIENT. AND THE ROLE OF THE NURSE
3 IS TO LISTEN TO THE CONCERNS VOICED BY THE FAMILY REGARDING
4 THEIR LOVED ONE AND TO OFFER SUPPORT IF YOU CAN.
5 Q. THEN FINALLY NINE, NOTIFY FAMILY IF DEATH IS IMMINENT.
6 AND WHY DO YOU FEEL IT WAS NECESSARY TO STATE THAT?
7 A. SO THAT IF THEY CHOOSE, THE FAMILY CAN BE AT THE BEDSIDE
8 WITH THE PATIENT.
9 Q. IF YOU'D TURN NOW TO A BINDER, AND IT SHOULD HAVE ENNIS
10 ALLDREDGE'S NAME ON IT PLEASE.
11 A. OKAY.
12 Q. DO YOU HAVE THAT IN FRONT OF YOU?
13 A. YES.
14 Q. IF WOULD YOU TURN TO THE PHYSICIAN'S ORDER SECTION,
15 PARTICULARLY PAGE 13. DO YOU HAVE THAT?
16 A. YES.
17 Q. THERE'S AN ENTRY AT THE TOP, AND DO YOU SEE YOUR
18 SIGNATURE NOTED ON THAT DOCUMENT?
19 A. YES.
20 Q. AND THAT IS ABOVE 1/12/96, CORRECT?
21 A. CORRECT.
22 Q. IS THERE A TIME INDICATED?
23 A. I DON'T SEE ONE OTHER THAN --
24 Q. LIKE AN EYE TEST. RIGHT THERE, DO YOU SEE 2000?
25 A. OH, OKAY, DOWN THERE. THAT'S TIME AT WHICH I NOTED THE
3159
1 ORDER, YES.
2 Q. AND CAN YOU TELL US WHY YOU NOTED THIS PARTICULAR ORDER
3 IN THE FASHION THAT YOU DID?
4 A. THAT'S THE STANDARD OF HOW YOU WOULD NOTE AN ORDER.
5 BRACKET IT AND CO-SIGN IT AS THE PERSON WHO TRANSCRIBED THE
6 ORDER. AND I'M NOT ONLY THE PERSON WHO TOOK THE TELEPHONE
7 ORDER. I'M ALSO THE PERSON WHO PUT THOSE ORDERS IN THE
8 PLACE WHERE THEY WOULD BE CARRIED OUT BY THE NURSE ON THE
9 MEDICATION ADMINISTRATION RECORD, WHAT HAVE YOU, TREATMENT
10 PLAN.
11 Q. AND THE ORDER THAT YOU TOOK BY TELEPHONE WAS WHAT?
12 A. IT SAYS, TO START AN I.V., OF D. FIVE AND A HALF NORMAL
13 SALINE AT A 100 C.C.'S AN HOUR. TO OBTAIN A CHEM 7 IN THE
14 MORNING. AND MAY RESTRAIN WRISTS TO PREVENT PULLING OUT
15 I.V.
16 Q. DO YOU KNOW THE PURPOSE FOR THE ORDER CONCERNING THE
17 I.V. ON THIS DATE?
18 A. THAT WOULD TO BE PROVIDE HYDRATION TO THE PATIENT.
19 Q. DO YOU KNOW THE PURPOSE OF THE ORDER FOR THE CHEM TEST
20 ON THIS DATE?
21 A. TO MEASURE THE LEVEL OF HYDRATION IN THE PATIENT THE
22 FOLLOWING DAY.
23 Q. AND HOW WOULD THIS TEST GO ABOUT DOING THAT?
24 A. IT INCLUDES A MEASURE OF KIDNEY FUNCTION AND SODIUM.
25 THOSE ARE INDICATORS OF WHETHER OR NOT A PATIENT IS HYDRATED
3160
1 OR NOT.
2 Q. AND THEN FINALLY, THIS MAY RESTRAIN WRISTS TO PREVENT
3 PULLING OUT I.V. IS THERE ANY SIGNIFICANCE TO THE FACT THAT
4 YOU CHARTED THAT?
5 A. THAT WOULD BE AN INDICATION OF THE MEDICAL NECESSITY OF
6 THE FLUIDS. FOR ABSOLUTE MEDICAL NECESSITY, WE WOULD BE
7 ABLE TO RESTRAIN A PATIENT IN ORDER TO -- FOR THE MEDICAL
8 GREATER GOOD OF THE PATIENT. WITHOUT THE FLUIDS, THE
9 PATIENT WOULD CONTINUE TO DETERIORATE CERTAINLY.
10 Q. AND THAT IS ORDERED BY THE PHYSICIAN?
11 A. YES.
12 Q. IF YOU'LL TURN TO THE PAGE 18 IN THE PROGRESS NOTES. DO
13 YOU HAVE THAT IN FRONT OF YOU?
14 A. YES.
15 Q. ONCE AGAIN, THIS IS ANOTHER WEEKLY R.N. ADVOCATE NOTE BY
16 YOU, CORRECT?
17 A. CORRECT.
18 Q. IT STATES -- AND IT'S THE DATE OF 1/14 OF '96, CORRECT?
19 A. APPEARS TO BE, YES.
20 Q. WHAT IS THIS N.S.G. OUT HERE?
21 A. NURSING.
22 Q. PLEASE SEE DR. WEITZEL'S NOTE ABOVE RE: M.R.I. RESULTS.
23 THE PATIENT'S CARE PLAN HAS BEEN AMENDED TO REFLECT DEATH
24 AND DYING ISSUES. WHAT CARE PLAN ARE YOU REFERRING TO?
25 A. THE NURSING CARE PLAN AND THE PATIENT.
3161
1 Q. WOULD THIS BE SIMILAR TO THE AMENDMENT THAT YOU
2 TESTIFIED CONCERNING MISS LARSEN?
3 A. YES.
4 Q. PATIENT'S -- I'M SORRY, YEAH, PATIENT'S GOAL IS TO
5 EXPERIENCE A PEACEFUL DEATH FREE --
6 A. OF DISCOMFORT.
7 Q. -- OF DISCOMFORT. COULD YOU EXPLAIN WHAT THAT MEANS
8 PLEASE?
9 A. THAT THE PATIENT WOULD BE FREE OF THE DISCOMFORTS COMMON
10 TO A DYING PATIENT, WHICH INCLUDES CHEST CONGESTION,
11 DISCOMFORT WITH BREATHING, PAIN OF ANY SORT.
12 Q. THEN IT HAS MORPHINE AND ATIVAN I.M. ARE BEING PROVIDED
13 EVERY THREE HOURS AROUND THE CLOCK TO ASSURE PATIENT'S
14 COMFORT. THEN IT SAYS, PLEASE SEE NEW CARE PLAN FOR OTHER
15 ISSUES AND INTERVENTIONS BEING ADDRESSED. WHAT OTHER ISSUES
16 AND INTERVENTIONS ARE YOU REFERRING TO?
17 A. THEY WOULD BE DELINEATED IN THE CARE PLAN.
18 Q. IN THAT PARTICULAR NOTE AND BASED UPON YOUR ROLE AS THE
19 ADVOCATE, NURSE ADVOCATE FOR MR. ALLDREDGE, DID YOU MAKE ANY
20 NURSING ASSESSMENTS OF HIS CONDITION AT THAT TIME?
21 A. THE ASSESSMENT AS IT'S REFLECTED IN THE NOTES STATES
22 THAT THE PATIENT WAS APPROACHING DEATH OR GAVE THE
23 APPEARANCE OF APPROACHING DEATH, AND WAS IN NEED OF THE CARE
24 PROVIDED PATIENTS IN THAT SITUATION.
25 Q. THIS IS ANOTHER NOTE FROM MR. ALLDREDGE'S FILE. IT'S
3162
1 DATED 1/14/96. THIS IS A NURSING NOTE BY YOU ON THAT DATE,
2 IS THAT RIGHT?
3 A. CAN I --
4 Q. OH, I DIDN'T GIVE YOU A MED NUMBER. I'M SORRY. IT'S
5 77.
6 A. OKAY.
7 Q. IS THAT YOUR NOTE?
8 A. YES.
9 Q. ONCE AGAIN, IT APPEARS THAT YOU'RE WORKING THAT 11:00 TO
10 7:00 NIGHT SHIFT. YOU SAY, PATIENT'S LEVEL OF AWARENESS HAS
11 BEEN PROGRESSIVELY -- AND YOU PUT THAT IN QUOTES -- SINKING
12 OVER THE SHIFT. WHAT DO YOU MEAN BY THAT?
13 A. DECREASING PROGRESSIVELY OVER THE SHIFT.
14 Q. AND THEN YOU GO ON TO TALK ABOUT SOME THINGS AND YOU
15 INDICATE THAT THERE IS A DOSE OF MORPHINE 10 MILLIGRAMS AND
16 ATIVAN .5 MILLIGRAMS WERE GIVEN AT 4:30 DUE TO PATIENT'S
17 GRIMACING AND LABORED BREATHING. DO YOU SEE THAT?
18 A. YES.
19 Q. TELL US WHAT YOU MEAN BY GRIMACING AND WHY THAT WAS
20 SIGNIFICANT IN TERMS OF PROVIDING THE MEDICATION.
21 A. GRIMACING IS A COMMON RESPONSE TO PAIN RECOGNIZED
22 THROUGHOUT NURSING, RECOGNIZED BY ME AS A NURSE, AS A
23 RESPONSE TO PAIN. LABORED BREATHING ALSO INDICATES
24 DIFFICULTY IN DOING SO. THAT CAN BE VERY PAINFUL FOR A
25 DYING PATIENT. WORKING AGAINST THE CONGESTION IN THE LUNGS.
3163
1 Q. CAN YOU -- WHEN YOU USE THE TERM LABORED BREATHING, CAN
2 YOU DESCRIBE THE PATTERN THAT YOU ARE INDICATING IN THAT
3 NOTE?
4 A. LABORED BREATHING MEANS THE PATIENT HAS DIFFICULTY
5 TAKING A DEEP BREATH.
6 Q. DOES IT INDICATE OR INCLUDE THE PATIENT GASPING?
7 A. I BELIEVE IF I HAD SEEN THE PATIENT GASPING, I WOULD
8 HAVE DOCUMENTED THAT USING THAT WORD.
9 Q. AND THEN YOU GO ON TO INDICATE CHEYNE-STOKE RESPIRATION
10 WITH PERIODS OF APNEA LASTING UP TO 30 SECONDS. PATIENT WAS
11 GIVEN -- I CAN'T READ THAT.
12 A. NASO-TRACHEAL SUCTION.
13 Q. AND BY RESPIRATORY THERAPIST TIMES 1 AT 4:00 O'CLOCK.
14 WHAT EXACTLY IS THAT NASAL -- AS YOU JUST DESCRIBED IT?
15 A. NASO-TRACHEAL SUCTIONING MEANS A SUCTIONING CATHETER
16 GOES DOWN THE NOSE INTO THE BACK OF THE THROAT. NURSES ON
17 THE FLOOR GENERALLY SUCTION THROUGH THE MOUTH ONLY. WE
18 WOULD CALL UPON RESPIRATORY IF THE PATIENT NEEDED A DEEPER
19 FORM OF SUCTIONING IF THE SECRETIONS APPEARED TO BE DEEPER
20 AND WE COULDN'T REMOVE THEM BY ORAL SUCTIONING MEANS.
21 Q. AND THAT WAS DONE BY A RESPIRATORY THERAPIST?
22 A. YES.
23 Q. WHO WOULD HAVE ORDERED THAT THAT HAD BEEN DONE?
24 A. RESPIRATORY THERAPY WOULD HAVE BEEN ORDERED BY THE
25 PHYSICIAN.
3164
1 Q. AND WHAT IS THE PURPOSE OF THAT PARTICULAR PROCEDURE
2 THAT YOU'VE JUST DESCRIBED?
3 A. TO REMOVE SECRETIONS FROM THE AIRWAY OF THE PATIENT SO
4 THAT THEY CAN BREATHE BETTER.
5 Q. AND THEN YOU GO ON A LITTLE BIT FURTHER, AND IT SAYS --
6 I THINK IT SAYS, CONTINUES TO HAVE DEEP CHEST -- AND YOU PUT
7 IN QUOTES -- RATTLES AS OF 6:00 O'CLOCK. DOES RATTLE HAVE
8 ANY SIGNIFICANCE IN TERMS OF THE CONTEXT OF THIS NOTE?
9 A. IT MEANS THAT THE DEEPER SUCTIONING PROVIDED BY THE --
10 PROVIDED BY THE RESPIRATORY THERAPIST WAS NOT EFFECTIVE,
11 FIRST OF ALL. AND THAT THE CONGESTION WAS DEEPER INTO THE
12 LUNGS THAN COULD HAVE BEEN REMOVED BY A SUCTION CATHETER.
13 Q. GET THAT UP A LITTLE BIT MORE. FINALLY, YOU GO ON TO
14 SAY THAT DR. WEITZEL GAVE TELEPHONE ORDER FOR MORPHINE 10
15 MILLIGRAMS I.M. GIVEN IN LEFT GLUTEUS. NO RESPONSE FROM
16 PATIENT TO THAT NEEDLE STICK. FAMILY REMAINS WITH PATIENT
17 COMFORTING HIM AND TALKING WITH HIM, ASKING FOR HIM TO,
18 QUOTE, LET GO, UNQUOTE. WHAT DO YOU MEAN BY THAT?
19 A. BEGINNING WHERE?
20 Q. I'M REFERRING TO YOUR USE OF THE WORD, LET GO, IN
21 QUOTES.
22 A. IN MY PRACTICE AND MY EXPERIENCE, PATIENTS WHO ARE DYING
23 OFTEN WILL NOT DO SO UNTIL THE FAMILY MEMBER EXPRESSES TO
24 THEM IT IS OKAY TO DO SO. AND VERY OFTEN, FAMILY MEMBERS I
25 HAVE OBSERVED WILL COME VISIT WITH THE PATIENT, TELL THEM IT
3165
1 IS OKAY, AND SHORTLY THEREAFTER, THE PATIENT WILL DIE.
2 Q. IF YOU WOULD TURN TO 92 PLEASE. DO YOU HAVE THAT IN
3 FRONT OF YOU?
4 A. YES, I DO.
5 Q. WAS IS THIS DOCUMENT?
6 A. IT'S A MASTER TREATMENT PLAN.
7 Q. AND DOES THIS RELATE TO A PREVIOUS NOTE THAT YOU READ IN
8 THIS CHART?
9 A. IT'S THE CARE PLAN REFERRED TO REGARDING DEATH AND DYING
10 ISSUES FOR THIS PATIENT.
11 Q. SAYS UP AT THE TOP UNDER PROBLEM STATEMENT, DEATH AND
12 DYING ISSUES RELATING TO LEFT OCCIPITAL C.V.A. AND THEN YOU
13 HAVE IN PARENTHESES ACUTE 1/13/96. DO YOU KNOW WHERE THAT
14 INFORMATION CAME FROM?
15 A. FROM THE M.R.I. REPORT.
16 Q. AND THEN YOU HAVE -- WHAT IS THAT, A. AND B., WHAT DOES
17 THAT REFER TO?
18 A. AS EVIDENCED BY.
19 Q. AS EVIDENCED BY, AND WHAT IS THAT NEXT S.T. S. -- S. X.
20 A. SIGNS AND SYMPTOMS OF IMPENDING DEATH.
21 Q. AND THEN YOU INDICATE STRENGTHS AFFECTING THE PROBLEM,
22 INDICATING A SUPPORTING FAMILY, MEDICAL POWER OF ATTORNEY IN
23 PLACE. WAS -- AND THEN I THINK OVER THERE, WHAT DOES THAT
24 SAY IN THE MARGIN?
25 A. IT SAYS PATIENT IS A D.N.R.
3166
1 Q. IS THERE A SIGNIFICANCE THAT YOU REFER TO IN THIS
2 NURSING CARE PLAN, MEDICAL POWER OF ATTORNEY IN PLACE?
3 A. A MEDICAL POWER OF ATTORNEY IS A DESIGNATION BY THE
4 PATIENT WHEN THEY ARE OF SOUND MIND TO DESIGNATE A
5 SIGNIFICANT PERSON IN THEIR LIFE, WHETHER THAT BE A RELATIVE
6 OR ANOTHER PERSON, TO MAKE MEDICAL DECISIONS FOR THEM SHOULD
7 THEY BECOME UNABLE TO DO SO THEMSELVES.
8 Q. YOU HAVE SHORT-TERM GOALS LISTED. ONE, PATIENT WILL
9 EXPERIENCE A PEACEFUL DEATH FREE FROM DISCOMFORT.
10 DID I READ THAT CORRECTLY?
11 A. CORRECT.
12 Q. AND THEN YOU HAVE A NUMBER OF SPECIFIC INTERVENTIONS
13 INDICATED AS WELL, IS THAT RIGHT?
14 A. YES.
15 Q. IF YOU WOULD NOW TURN TO A BINDER THAT I THINK IS UP
16 THERE TO YOUR LEFT, IT WOULD BE PATIENT LYDIA SMITH'S BINDER
17 PLEASE. IF YOU WOULD TURN INITIALLY PLEASE TO 719. IT'S IN
18 THE PROGRESS NOTE PORTION OF THE BINDER. DO YOU HAVE THAT?
19 A. YES, I DO.
20 Q. MISS STEVENSON, YOU RECOGNIZE YOUR WRITING ON THIS
21 PARTICULAR PROGRESS NOTE?
22 A. I DO.
23 Q. IS THIS ANOTHER WEEKLY R.N. ADVOCATE NOTE THAT YOU WROTE
24 CONCERNING A PATIENT LYDIA SMITH?
25 A. YES.
3167
1 Q. HAVE YOU MADE CERTAIN NURSING ASSESSMENTS ABOUT HER
2 CONDITION AS REFLECTED IN THIS NOTE?
3 A. YES.
4 Q. WOULD YOU TELL US PLEASE WHAT THOSE ASSESSMENTS WERE?
5 A. IT STATES, SHE'S UNABLE TO SWALLOW FOOD, FLUID, OR
6 MEDICATION. NOT VISUALLY RESPONSIVE TO HER ENVIRONMENT.
7 DEMONSTRATING REGRESSED REFLEXES. THE REFLEX OF GRABBING, A
8 SNOUT REFLEX. MINIMALLY -- PUPILS MINIMALLY REACTIVE TO
9 LIGHT. CHEYNE-STOKES RESPIRATIONS.
10 Q. WHAT IS THE SIGNIFICANCE OF YOU HAVING WRITTEN AND
11 DESCRIBED THOSE SYMPTOMS THAT SHE WAS EXPERIENCING AT THAT
12 TIME?
13 A. THOSE ARE NURSING OBSERVATIONS OF A PATIENT WHO IS
14 APPROACHING DEATH.
15 Q. YOU GO ON TO SAY, SHE IS RECEIVING MORPHINE 5 MILLIGRAMS
16 EVERY 3 HOURS FOR COMFORT. THE CARE PLAN HAS BEEN CHANGED
17 TO REFLECT PATIENT AND FAMILY NEEDS AROUND DEATH AND DYING
18 ISSUES. AND THEN YOUR SIGNATURE, IS THAT RIGHT?
19 A. CORRECT.
20 Q. IS THAT CARE PLAN AMENDMENT SIMILAR TO THE CARE PLAN
21 AMENDMENT THAT YOU TESTIFIED TO CONCERNING PATIENT JUDITH
22 LARSEN, AND THAT YOU WERE JUST SHOWN CONCERNING MR.
23 ALLDREDGE?
24 A. YES, IT WOULD BE.
25 Q. IF YOU WOULD TURN PLEASE TO 800, WHICH IS IN THE NURSING
3168
1 NOTE SECTION.
2 A. OKAY.
3 Q. ONCE AGAIN ELEVEN SEVEN, IT'S A NIGHT SHIFT FREE TEXT.
4 THAT'S WRITTEN BY YOU, IS THAT RIGHT?
5 A. THAT'S CORRECT.
6 Q. I WANNA DIRECT YOUR ATTENTION SPECIFICALLY TO THE AREA
7 AT THE BOTTOM WHERE YOU DESCRIBE AND STATE, POSTURE IS RIGID
8 AT TIMES. IS THERE A SIGNIFICANT -- IS ANYTHING SIGNIFICANT
9 ABOUT THE FACT THAT YOU CHARTED THAT AT THAT TIME?
10 A. RIGIDITY CAN BE AN INDICATION OF THEIR DISCOMFORT. IT
11 CAN BE, ONCE AGAIN, ONE OF THOSE MORE REGRESSED REFLEXES
12 THAT PATIENTS EXPERIENCE WHEN THEY DIE.
13 Q. AND IF COULD YOU TURN TO 802 PLEASE. DO YOU HAVE THAT
14 IN FRONT OF YOU?
15 A. YES.
16 Q. AND IS THAT YOUR NOTE ON JANUARY 8 OF 1996?
17 A. YES.
18 Q. THE 11:00 TO 7:00 NIGHT SHIFT AGAIN AS WELL, TRUE?
19 A. YES.
20 Q. IF YOU COULD READ PLEASE FROM WHERE IT SAYS, NIGHT SHIFT
21 FREE TEXT DOWN TO THE 2400 DOSE OMITTED, FOR US.
22 A. OKAY. PATIENT LYING IN BED WITH EYES OPEN THROUGHOUT
23 SHIFT. DEMONSTRATES MUCH REFLEXIVE GRASPING IN RESPONSE TO
24 PHYSICAL STIMULI. UNABLE TO MAKE ANY VERNAL RESPONSES.
25 MORPHINE EVERY 3 HOURS I.M. AS SCHEDULED FOR COMFORT. 2400
3169
1 DOSE OMITTED DUE TO PATIENT APPEARED IN NO ACUTE DISTRESS AT
2 THE TIME.
3 Q. CAN YOU TELL LOOKING AT THE NOTE IN ADDITION TO WHAT YOU
4 STATE IN THE NOTE, WHY YOU WITHHELD THE 2000 DOSE OF
5 MORPHINE?
6 A. IT STATES ADDITIONALLY THAT I WAS ATTENDING TO ANOTHER
7 PATIENT, BEING THE ONLY NURSE ON THE FLOOR. YOU PRIORITIZE
8 YOUR LIST. IF THE PATIENT WAS NOT UNCOMFORTABLE, THEN
9 MISSING A DOSE WOULD HAVE NOT DONE HER ANY HARM.
10 Q. NOW, IF YOU CONTINUE ON WITH THAT PARTICULAR NOTE, AFTER
11 YOU STATE FAMILY, YOU SAY 0300 DOSE GIVEN AT 2:30.
12 DO YOU SEE THAT?
13 A. YES.
14 Q. WHAT IS THE SIGNIFICANCE OF THAT STATEMENT?
15 A. THAT MEANS THAT A DOSE SCHEDULED FOR 3:00 O'CLOCK WAS
16 GIVEN WITHIN THAT HALF HOUR RANGE BEFORE, THAT STILL WOULD
17 HAVE BEEN WITHIN THE HOUR SO THAT I COULD HAVE GIVEN THE
18 3:00 O'CLOCK DOSE BETWEEN 2:30 --
19 Q. WHY WOULD YOU HAVE GIVEN A 3:00 O'CLOCK MAINTENANCE DOSE
20 AT 2:30?
21 A. IT MAY HAVE BEEN MY IMPRESSION THAT THE PATIENT WAS THEN
22 BECOMING UNCOMFORTABLE.
23 Q. THEN YOU ALSO HAVE RESPIRATIONS RATE 10 TO 12. DO YOU
24 SEE THAT?
25 A. UH-HUH.
3170
1 Q. IS THERE REASON WHY YOU WOULD HAVE CHARTED THAT AT THAT
2 TIME?
3 A. TO INDICATE THE PATIENT'S CONDITION, THAT THE
4 RESPIRATORY RATE WAS ADEQUATE.
5 Q. IF YOU COULD TURN TO THE MEDICATION ADMINISTRATION
6 RECORD, WHICH IS UNDER MEDS AND GRAPHS IN THAT BINDER. AND
7 I'LL SPECIFICALLY DIRECT YOUR ATTENTION -- CAN YOU LOOK FOR
8 THE GRAPHS THAT INDICATED MORPHINE SULFATE ORDERS I.M. ON
9 THE 7TH OF JANUARY OF 1996?
10 A. OKAY.
11 Q. DO YOU HAVE THAT IN FRONT OF YOU?
12 A. I DO.
13 Q. DOES THAT INDICATE THAT YOU GAVE A MORPHINE INJECTION ON
14 THAT DAY TO PATIENT LYDIA SMITH?
15 A. THERE WERE TWO DOSES GIVEN AND ONE DOES WAS HELD.
16 Q. OKAY. AND WHEN WAS THE -- THE TWO DOSES THAT WERE GIVEN
17 ON THAT DAY?
18 A. DURING THE 3:00 O'CLOCK HOUR AND THE 6:00 O'CLOCK HOUR.
19 Q. AND WERE THOSE GIVEN BY YOU?
20 A. I WAS THE PERSON WHO SIGNED OUT THE MEDICATION. I
21 ASSUME THAT I WAS THE PERSON WHO GAVE THE MEDICATION.
22 Q. WHEN YOU GAVE THOSE DOSES OF MORPHINE ON THAT DAY, DID
23 YOU BELIEVE THAT YOU WERE CAUSING OR CONTRIBUTING TO THE
24 DEATH OF LYDIA SMITH?
25 A. NO.
3171
1 Q. AND WHY DO YOU SAY THAT?
2 A. BECAUSE IF I BELIEVED THAT I WAS CAUSING THE PATIENT
3 HARM, I WOULD HAVE HELD THE DOSE.
4 Q. IF YOU'D ALSO PLEASE TURN TO THE SECTION OF THE
5 MEDICATION ADMINISTRATION RECORDS WHICH WOULD BE FOR THE 8TH
6 OF JANUARY OF 1996.
7 A. IS THERE --
8 Q. IN FACT, IT MAY BE -- I WAS THINKING IT WAS THE SAME
9 PAGE AS 742.
10 A. WHAT IS THE DATE?
11 Q. ON THE 8TH.
12 A. THERE'S A HOLE WHERE THE BINDER'S GONE THROUGH, SO IT
13 MAY BE THE SAME DATE. THERE ARE TWO ORDERS FOR MORPHINE ON
14 THAT DATE.
15 Q. AND WERE THOSE ADMINISTERED BY YOU?
16 A. NO. ARE YOU REFERRING TO THE 10 MILLIGRAM DOSE?
17 Q. YES.
18 A. NO.
19 Q. OKAY. IF YOU WOULD TURN TO MR. ALLDREDGE'S BINDER
20 PLEASE, SPECIFICALLY HIS MEDICATION AND GRAPHS RECORD. I'LL
21 DIRECT YOUR ATTENTION SPECIFICALLY TO PAGE 47.
22 A. OKAY.
23 Q. DO YOU HAVE THAT IN FRONT OF YOU?
24 A. YEAH.
25 Q. DOES IT INDICATE ON THE 13TH THAT YOU ADMINISTERED
3172
1 MORPHINE PURSUANT TO AN ORDER TO MR. ALLDREDGE?
2 A. YES.
3 Q. AND WHAT TIMES WOULD YOU HAVE ADMINISTERED MORPHINE TO
4 HIM ON THE 13TH?
5 A. IT'S STATES ON 0200 AND 0430.
6 Q. AT THE TIME THAT YOU ADMINISTERED THOSE DOSES OF
7 MORPHINE ON THE 13TH, DID YOU BELIEVE THAT YOU WERE CAUSING
8 OR CONTRIBUTING TO HIS DEATH?
9 A. IF I HAD BELIEVED THAT, I WOULD HAVE HELD THE DOSE.
10 Q. FINALLY, IF YOU COULD PULL JUDITH LARSEN'S BINDER AGAIN
11 PLEASE. AND IF YOU COULD TURN TO THE MED GRAPHS SECTION
12 ONCE AGAIN, AND I'LL SPECIFICALLY DIRECT YOUR ATTENTION TO
13 MORPHINE THAT WAS GIVEN ON THE 31ST OF DECEMBER. AND I'LL
14 TRY TO GET A PAGE REFERENCE FOR YOU SHORTLY.
15 YES, IT WOULD BE 497 IS THE PAGE.
16 A. YES.
17 Q. AND DOES IT REFLECT THERE THAT YOU GAVE MORPHINE
18 INJECTIONS TO JUDITH LARSEN?
19 A. YES.
20 Q. ON THE 31ST?
21 A. YES.
22 Q. AND THAT'S DESIGNATED BY YOUR INITIALS, IS THAT RIGHT?
23 A. YES.
24 Q. AND WHAT TIMES DID YOU DO THAT?
25 A. AT 0230 AND 0630.
3173
1 Q. AND DID YOU BELIEVE THAT AT THE TIME YOU ADMINISTERED
2 THOSE DOSES, THAT YOU WERE CAUSING OR CONTRIBUTING TO THE
3 DEATH OF JUDITH LARSEN?
4 A. NO.
5 Q. TELL US WHY NOT PLEASE.
6 A. BECAUSE IF I HAD BELIEVED I WAS DOING HER HARM, I WOULD
7 HAVE HELD THE DOSE.
8 Q. SIMILARLY, YOU -- ALSO ON THAT PAGE IS INDICATED THAT
9 YOU GAVE TWO INJECTIONS OF MORPHINE ON JANUARY 1, IS THAT
10 RIGHT?
11 A. YES.
12 Q. DID YOU BELIEVE AT THE TIME THAT YOU WERE GIVING THOSE
13 INJECTIONS THAT YOU CAUSED OR CONTRIBUTING TO HER DEATH?
14 A. NO.
15 Q. IF YOU WOULD TURN TO PAGE 507 PLEASE. IT'S IN THE SAME
16 SECTION.
17 A. OKAY.
18 Q. DOES THAT ALSO INDICATE BY YOUR INITIALS THAT YOU GAVE
19 MORPHINE INJECTIONS TO PATIENT JUDITH LARSEN ON JANUARY 2ND
20 OF 1996?
21 A. YES.
22 Q. AND CAN YOU TELL US PLEASE THE TIMES THAT ARE INDICATED?
23 A. IT'S 0030, 0330, AND 0630.
24 Q. AND DID YOU BELIEVE AT THE TIME THAT YOU ADMINISTERED
25 THOSE INJECTIONS THAT YOU WERE CAUSING OR CONTRIBUTING TO
3174
1 THE DEATH OF JUDITH LARSEN?
2 A. NO.
3 Q. AND TELL US PLEASE AGAIN WHY NOT.
4 A. BECAUSE IF I BELIEVED THAT TO BE TRUE, I WOULD HAVE HELD
5 THE DOSE.
6 MR. STIRBA: THAT'S ALL I HAVE AT THIS TIME, YOUR
7 HONOR. THANK YOU.
8 THE COURT: OKAY. LADIES AND GENTLEMEN, RATHER
9 THAN TAKE A BREAK, WE STARTED AT 3:25, WHAT I PROPOSE DO,
10 WHY DON'T WE JUST STAND FOR A COUPLE MINUTES, THEN WE CAN
11 START WITH THE CROSS-EXAMINATION. AND WE'LL GO UNTIL
12 5:00 O'CLOCK TODAY. SO IF YOU WANNA JUST STRETCH OR RELAX
13 FOR A MINUTE, THEN WE CAN --
14 (THE COURT TOOK A BREAK IN PLACE.)
15 THE COURT: WELL, HAS EVERYONE STOOD UP ENOUGH SO
16 THAT WE CAN STAY AWAKE? OKAY. THEN LET'S BE SEATED PLEASE.
17 MISS BARLOW.
18 MS. BARLOW: THANK YOU, YOUR HONOR.
19 CROSS-EXAMINATION
20 BY MS. BARLOW:
21 Q. GOOD AFTERNOON, MRS. STEVENSON. YOU WORK FOR THE
22 VETERANS' ADMINISTRATION, IS THAT CORRECT?
23 A. YES.
24 Q. ARE THEY MOSTLY GERIATRIC PATIENTS THEN THAT YOU WORK
25 WITH?
3175
1 A. I AM THE GERIATRIC NURSE PRACTITIONER. I WORK -- MY
2 TIME IS SPLIT BETWEEN A GERIATRIC OUTPATIENT CLINIC AND
3 NURSING HOME PATIENTS.
4 Q. DID YOU SAY YOU WERE WORKING ON YOUR MASTER'S AT THE
5 TIME YOU WORKED AT DAVIS NORTH HOSPITAL?
6 A. WORKING ON AND COMPLETED MY MASTER'S.
7 Q. HAD YOU COMPLETED IT -- DID YOU GET YOUR MASTER'S DEGREE
8 DURING THE DECEMBER '95 TO JANUARY '96 TIME FRAME?
9 A. I COMPLETED ALL COURSE WORK AND THESIS. I WAS AWARDED
10 THE DIPLOMA IN AUGUST.
11 Q. THEY WILL ONLY GRADUATE PEOPLE AT CERTAIN TIMES, WON'T
12 THEY. DO YOU RECALL THE CRITERIA FOR ADMISSION TO THE
13 GEROPSYCH UNIT?
14 A. SPECIFICALLY, NO. I KNOW THAT THERE WAS A SPECIFIED
15 CRITERIA FOR ADMISSION, YES.
16 Q. AND IN THAT CRITERIA WAS BASICALLY THAT THE PSYCHIATRIC
17 PROBLEMS HAD TO BE MORE SEVERE THAN THEIR MEDICAL PROBLEMS
18 TO GO INTO THE UNIT?
19 A. THAT WAS THE PLAN AS I RECALL, YES.
20 Q. AND IN FACT, THEY NEEDED TO BE MEDICALLY STABLE BECAUSE
21 IT REALLY WASN'T A MEDICAL UNIT; IT WAS A PSYCHIATRIC UNIT,
22 ISN'T THAT CORRECT?
23 A. THAT WAS THE GOAL OF THE UNIT, YES.
24 Q. WHEN DID YOU START WITH THE UNIT?
25 A. I HAVE POOR RECOLLECTION OF EXACT DATES, BUT IT WAS '95,
3176
1 SOMETHING LIKE THAT. JANUARY MAYBE?
2 Q. SO YOU STARTED FIRST PART OF '95 DURING THE WINTER
3 STILL?
4 A. I HAVE NO EXACT RECOLLECTION OF THAT.
5 Q. BUT IT WASN'T JUST RIGHT IN DECEMBER OF 1995; YOU HAD
6 BEEN ON THE UNIT LONGER THAN THAT.
7 A. I'D BEEN ON THE UNIT FOR A WHILE. IT WAS AT LEAST A
8 YEAR I THINK MY EMPLOYMENT THERE.
9 Q. HAD MORPHINE BEEN USED ON THIS UNIT PRIOR TO THE
10 PATIENTS WE'RE TALKING ABOUT HERE TO YOUR KNOWLEDGE?
11 A. I HAVE NO RECOLLECTION OF THAT.
12 Q. AFTER THE DEATH OF THESE PATIENTS, WERE YOU STILL
13 WORKING ON THE UNIT?
14 A. YES, I WAS.
15 Q. AND DID THERE COME A TIME WHEN YOU WERE BASICALLY -- THE
16 WHOLE UNIT WAS BASICALLY TOLD THAT MORPHINE WOULD NOT BE
17 ADMINISTERED ON THIS UNIT --
18 MR. STIRBA: I'M GONNA OBJECT, YOUR HONOR.
19 RELEVANCY. BEYOND THE SCOPE.
20 THE COURT: SUSTAINED.
21 Q. (BY MS. BARLOW) YOU TESTIFIED AS TO SOME OF YOUR
22 HABITS. DO YOU RECALL WHAT TIME OF DAY DR. WEITZEL WOULD
23 COME IN TO SEE THESE PATIENTS?
24 MR. STIRBA: ARE YOU TALKING ABOUT THESE FIVE
25 PATIENTS?
3177
1 MS. BARLOW: THESE PATIENTS.
2 THE COURT: THAT'S WHAT THE QUESTION WAS.
3 THE WITNESS: CAN I ANSWER THE QUESTION?
4 THE COURT: YES.
5 THE WITNESS: COULD YOU REPEAT IT? I'M SORRY.
6 Q. (BY MS. BARLOW) DO YOU RECALL WHAT TIME OF DAY DR.
7 WEITZEL WOULD COME IN TO SEE THESE PATIENTS?
8 A. THAT COULD VARY ACCORDING TO HIS SCHEDULE. AND WHAT WAS
9 HAPPENING ON THE UNIT.
10 Q. YOU WORKED THE 11:00 TO 7:00 SHIFT. DID YOU SEE HIM
11 COME IN BEFORE 7:00 IN THE MORNING?
12 A. THERE WERE OCCASIONS, YES.
13 Q. DID YOU SEE HIM COME IN AFTER 11:00 O'CLOCK AT NIGHT?
14 A. THERE WERE OCCASIONS, YES.
15 Q. WHEN DID YOU GET THE RECORDS TO REVIEW FOR YOUR
16 TESTIMONY TODAY?
17 A. I'VE SEEN -- I DON'T RECALL EXACTLY WHEN I FIRST SPOKE
18 WITH MR. STIRBA, BUT WE HAD A MEETING IN PENNSYLVANIA DURING
19 WHICH TIME HE BROUGHT SOME RECORDS AND I REVIEWED THEM.
20 Q. WHEN WAS THAT MEETING IN PENNSYLVANIA?
21 A. COUPLE MONTHS AGO?
22 Q. COUPLE MONTHS, YOU SAY?
23 A. HUH?
24 Q. I'M SORRY --
25 A. I'M SORRY, I --
3178
1 THE COURT: YOU NEED THAT ON RIGHT NOW?
2 MR. STIRBA: I'LL TURN IT OFF.
3 MS. BARLOW: I MAY -- I MAY NEED IT -- WELL --
4 THE COURT: WE COULD TURN IT OFF AND TURN IT ON.
5 MS. BARLOW: YEAH, LET'S TURN IT OFF. IT DOES GET
6 PRETTY NOISY.
7 THE WITNESS: I'LL TRY TO BE LITTLE LOUDER FOR YOU.
8 Q. (BY MS. BARLOW) OKAY.
9 A. I'M RUNNING OUT OF VOICE.
10 Q. DID YOU MEET WITH COUNSEL AGAIN AFTER THAT MEETING IN
11 PENNSYLVANIA ABOUT YOUR TESTIMONY TODAY?
12 A. ONLY TO REVIEW RECORDS THE DAY PRIOR.
13 Q. YESTERDAY YOU MET WITH HIM?
14 A. UH-HUH.
15 Q. WERE YOU THERE WHEN ANY OF THESE FIVE PATIENTS DIED?
16 A. I BELIEVE THERE ARE SOME NOTES THAT STATE THAT I WAS
17 PRESENT. I DON'T RECALL WHICH SPECIFICALLY.
18 Q. AND IN FACT, MOST OF YOUR TESTIMONY REALLY ISN'T BASED
19 ON AN INDEPENDENT RECOLLECTION OF WHAT HAPPENED WITH THESE
20 FIVE PATIENTS, ISN'T THAT CORRECT?
21 A. THAT WAS SEVERAL YEARS AGO AND I'VE SEEN MANY PATIENTS
22 BETWEEN NOW AND THEN.
23 Q. OH, I RECOGNIZE THAT. I -- YOU'RE NOT THE FIRST NURSE
24 TO TESTIFY TO THAT EFFECT. BUT WHAT YOU -- WHAT YOU'RE
25 TESTIFYING TO IS WHAT YOU REMEMBER -- WHAT YOU SEE IN THE
3179
1 RECORDS, IS THAT CORRECT?
2 A. THAT'S CORRECT.
3 Q. THERE WAS SOME TALK ABOUT DEATH AND DYING ISSUES AND
4 CHANGES TO THE MASTER TREATMENT PLAN. HAVE YOU REVIEWED
5 THESE FIVE TO SEE WHO MADE THAT DEATH AND DYING CHANGE TO
6 THE MASTER TREATMENT PLAN?
7 A. I KNOW THAT SEVERAL OF THOSE CHANGES WERE IN MY
8 HANDWRITING.
9 Q. THAT PROBABLY DIDN'T HAPPEN WITH ELLEN ANDERSON, DID IT?
10 A. I DON'T RECALL WITHOUT LOOKING AT THE RECORD.
11 Q. IF YOU WOULD PULL OUT ELLEN ANDERSON'S, AND TURN TO 196.
12 THIS IS THE MASTER TREATMENT PLAN, IS THAT CORRECT?
13 OH, EXCUSE ME.
14 A. HANG ON.
15 Q. SORRY.
16 A. I HAVE A FEW TO JUGGLE HERE.
17 Q. JUST BECAUSE I HAVE MINE UP HERE -- I'LL GIVE YOU TIME
18 TO --
19 A. I'M SORRY, WHAT PAGE?
20 Q. 196. IT'S BACK UNDER MASTER TREATMENT PLAN.
21 A. UH-HUH.
22 Q. AND WHAT WAS THE PROBLEM -- MASTER PROBLEM -- OR THE
23 PROBLEM THAT YOU LISTED ON 196?
24 A. ANXIETY.
25 Q. AND YOU NEVER HAD OCCASION TO CHANGE THAT TO DEATH AND
3180
1 DYING ISSUES, IS THAT CORRECT?
2 A. THERE IS NOTHING IN THE CHART THAT -- NOTHING IN THE
3 SECTION THAT SAYS THAT THAT'S THERE THAT I CAN SEE AT THIS
4 TIME.
5 Q. DO YOU RECALL ELLEN ANDERSON AT ALL?
6 A. NO, I'M SORRY.
7 Q. DO YOU RECALL TALKING TO HER DAUGHTER AS YOU PREPARED
8 THE NURSING ASSESSMENT?
9 A. I HAVE NO RECOLLECTIONS OTHER THAN WHAT I READ IN THE
10 RECORD.
11 Q. I WANTED TO CLARIFY SOMETHING. WHEN YOU TESTIFIED ON
12 DIRECT AS TO PAGE NUMBER 170, AND THIS MIGHT HAVE JUST BEEN
13 A SLIP OF THE TONGUE, BUT YOU INDICATED THAT YOU HAD ORDERED
14 THESE DRUGS FOR HER OR THESE MEDICATIONS FOR HER, IS THAT
15 CORRECT?
16 A. EXCUSE ME? I'M SORRY, FIRST OF ALL, I NEED THE PAGE.
17 Q. PAGE 170. IS THE PHYSICIAN'S ORDER SECTION.
18 A. NO, I DO NOT WRITE MEDICATION ORDERS.
19 Q. OKAY.
20 A. I TAKE TELEPHONE ORDERS FROM THE PHYSICIAN.
21 Q. THANK YOU. I THOUGHT THAT MIGHT HAVE BEEN JUST A
22 MISSTATEMENT. BECAUSE AT THIS TIME YOU WEREN'T -- NOW YOU
23 COULD BECAUSE YOU'RE A NURSE PRACTITIONER, IS THAT CORRECT?
24 A. THAT'S CORRECT. IT WOULD STILL HAVE TO BE RECOGNIZED
25 WITHIN THE HOSPITAL THAT I WAS WORKING AT. I WOULD HAVE TO
3181
1 BE PRIVILEGED TO WRITE PRESCRIPTIONS THERE.
2 Q. IN FACT, LET ME GO BACK A MINUTE. YOU SAY THAT YOU ARE
3 LICENSED IN THE STATE OF UTAH AS A NURSE PRACTITIONER, IS
4 THAT CORRECT?
5 A. THAT'S CORRECT.
6 Q. WHAT ABOUT IN THE STATE OF PENNSYLVANIA?
7 A. I HAVE A LICENCE IN PENNSYLVANIA AS WELL. HOWEVER, I
8 FUNCTION UNDER MY UTAH LICENSE ON FEDERAL PROPERTY.
9 Q. OH. BECAUSE THAT'S A SEPARATE -- I UNDERSTAND.
10 A. AND THE LAWS ARE DIFFERENT.
11 Q. WHAT IS YOUR LICENSE IN PENNSYLVANIA, IS IT NURSE
12 PRACTITIONER AS WELL?
13 A. YES.
14 Q. YOU INDICATED THAT YOU'VE DEALT WITH AGITATED AND
15 VIOLENT BEHAVIORS IN PSYCHIATRIC PATIENTS. WAS THAT PRIOR
16 TO WORKING AT THE GEROPSYCH UNIT?
17 A. I HAVE MANY YEARS OF EXPERIENCE IN PSYCHIATRY, YES.
18 Q. AND ARE YOU FAMILIAR WITH PSYCHOTROPIC DRUGS?
19 A. YES.
20 Q. SPECIFICALLY, MANY OF THE DRUGS LISTED HERE, TRAZODONE
21 ATIVAN, HALDOL, RISPERDAL, ARE YOU FAMILIAR WITH THEM?
22 A. YES.
23 Q. ARE YOU FAMILIAR WITH THEIR SIDE EFFECTS?
24 A. YES.
25 Q. AND ARE THEY ALL CENTRAL NERVOUS SYSTEM DEPRESSANTS?
3182
1 A. TO VARYING DEGREES, THERE IS A POSSIBILITY OF CENTRAL
2 NERVOUS SYSTEM EFFECTS IN A PSYCHOTROPIC MEDICATION, YES.
3 Q. AND IN FACT, MANY OF THEM ARE VERY SEDATING, ISN'T THAT
4 CORRECT?
5 A. SOME ARE GIVEN FOR THE PURPOSE OF SEDATION. OTHERS ARE
6 GIVEN FOR RELIEF OF DEPRESSION BECAUSE OF THEIR CENTRAL
7 NERVOUS SYSTEM EFFECTS.
8 Q. NOW, YOU SAID ON DIRECT THAT YOU DON'T HAVE ANY
9 RECOLLECTION OF WHETHER DR. WEITZEL CAME IN AND SAW ELLEN
10 ANDERSON WHILE YOU WERE ON THE UNIT, IS THAT CORRECT?
11 A. THAT'S CORRECT.
12 Q. IF TRACY SCHOLL HAD TESTIFIED -- AND I'LL REPRESENT TO
13 YOU THAT SHE DID TESTIFY EARLIER -- THAT WHEN SHE CAME IN ON
14 THE LATER SHIFT, YOU TOLD HER THAT DR. WEITZEL HAD NOT BEEN
15 IN, WOULD BE IN THE NEXT MORNING. WOULD YOU HAVE ANY
16 RECOLLECTION OF THAT?
17 A. I'M SORRY, I DON'T EVEN REMEMBER TRACY SCHOLL.
18 Q. OKAY. DO YOU HAVE ANY PERSONAL KNOWLEDGE AS TO WHETHER
19 DR. WEITZEL CAME IN AND SAW ELLEN ANDERSON WHILE YOU WERE
20 THERE?
21 A. WHAT I HAVE IS WHAT'S IN THE RECORD, AND HE CO-SIGNED MY
22 TELEPHONE ORDERS, HE SIGNED THE STAMP THAT SAYS THAT HE
23 REVIEWED EVERYTHING. THAT TO ME SAYS THAT HE WAS THERE ON
24 THAT DATE, GIVEN HIS SIGNATURE AND THE DATE HE AFFIXED.
25 Q. BUT HE DOESN'T INDICATE WHAT TIME -- OR EXCUSE ME, HE
3183
1 DOESN'T -- WELL, EXCUSE ME, HE DID DATE IT. ANYONE CAN --
2 ANY ONE CAN SIGN THIS AT ANY TIME, CAN THEY NOT? HE COULD
3 HAVE COME IN AT ANY TIME AND SIGNED THIS EVEN AFTER HER
4 DEATH.
5 A. I DON'T KNOW WHY THAT WOULD HAPPEN.
6 Q. WELL, JUST COULD HE HAVE, YES OR NO?
7 A. I -- COULD YOU ASK ME THAT QUESTION AGAIN?
8 Q. COULD HE HAVE COME IN AT ANY TIME, EVEN ON THE 30TH, THE
9 DAY AFTER SHE DIED -- OR EXCUSE ME, THE DAY SHE DIED. SHE
10 DIED EARLY IN THE MORNING ON THE 30TH, AND SIGNED --
11 CO-SIGNED OR WHATEVER YOU CALL THIS, THE TELEPHONE ORDER
12 THAT YOU WROTE?
13 MR. STIRBA: I'M GONNA OBJECT, YOUR HONOR. IT'S
14 ARGUMENTATIVE. CALLS FOR SPECULATION.
15 THE COURT: SUSTAINED.
16 Q. (BY MS. BARLOW) IN FACT, ANY TIME THAT A PERSON --
17 THAT A DOCTOR TELEPHONES IN AN ORDER, SAY IT'S AT 2:30 IN
18 THE MORNING, HE DOESN'T COME RIGHT THEN AND SIGN IT, DOES
19 HE?
20 MR. STIRBA: I'M GONNA OBJECT, YOUR HONOR, AS TO
21 RELEVANCY. SPECULATIVE.
22 THE COURT: ARE YOU TALKING ABOUT DR. WEITZEL?
23 MS. BARLOW: YES.
24 THE COURT: OKAY. GO AHEAD.
25 Q. (BY MS. BARLOW) SAY IF DR. WEITZEL GAVE YOU A
3184
1 TELEPHONE ORDER AT 2:30 IN THE MORNING, YOU WOULDN'T EXPECT
2 THAT HE CAME IN RIGHT THEN AND SIGNED IT, WOULD YOU?
3 A. DEPENDING ON WHERE HE WAS CALLING FROM, IT WOULD TAKE
4 ANY NUMBER, MINUTES OR LONGER TO COME AND SIGN IT.
5 Q. OR HE COULD WAIT UNTIL HE CAME IN ON ROUNDS THE NEXT DAY
6 AND SIGNED IT?
7 A. I DON'T RECALL WHAT THE POLICY OF THE HOSPITAL WAS IN
8 TERMS OF THE TIME FRAME IN WHICH A PHYSICIAN WAS ALLOWED TO
9 WAIT BETWEEN GIVING A TELEPHONE ORDER AND SIGNING IT. THERE
10 IS GENERALLY A HOSPITAL POLICY FOR THOSE SORTS OF THINGS.
11 Q. NOW, IF YOU'LL TURN TO 172.
12 A. OKAY.
13 Q. THE TOP OF THAT LOOKS LIKE IN DR. WEITZEL'S HANDWRITING
14 HE WRITES 12/29/95. PSYCH EVAL DONE, SLASH, DICTATED. DO
15 YOU SEE THAT?
16 A. UH-HUH.
17 Q. NOW, IF YOU'LL TURN OVER TO 167, DO YOU RECOGNIZE WHAT
18 THAT DOCUMENT IS?
19 A. HANG ON. IT'S STATES THAT IT'S A PSYCHIATRIC
20 EVALUATION.
21 Q. AND WOULD THAT -- AND THAT WOULD BE THE PSYCHIATRIC
22 EVALUATION THAT HE INDICATES HE DICTATED, IS THAT CORRECT?
23 A. CORRECT.
24 Q. AND ON PAGE 169, WHICH IS THE THIRD PAGE OF THAT PSYCH
25 EVALUATION, DO YOU SEE WHERE IT'S BEEN SIGNED ROBERT
3185
1 WEITZEL, THEN IT HAS A D. COLON, 12/30/95 AT 12:20. DO YOU
2 KNOW WHAT THAT IS?
3 A. NO, I DON'T.
4 Q. YOU DON'T UNDER -- YOU DON'T KNOW WHAT THE DICTATION
5 SYSTEM IS FOR DOCTORS AT DAVIS HOSPITAL?
6 A. NO.
7 Q. OKAY. WHO GAVE YOU THE INFORMATION FOR THE NURSING
8 ASSESSMENT THAT YOU DID ON ELLEN ANDERSON?
9 A. I DO NOT RECALL SPECIFICALLY. NURSING ASSESSMENTS DONE
10 BY ME, I OBTAIN THE INFORMATION FROM PRIMARILY THREE
11 SOURCES: THE PATIENT, ANY RECORDS THAT WERE BROUGHT WITH
12 HER, AND ANY FAMILY MEMBERS OR SIGNIFICANT FAMILY OR PERSONS
13 WHO MAY HAVE BEEN WITH THE PATIENT AT THE TIME.
14 Q. SO ON 178, YOU WROTE PERSON INTERVIEWED, YOU LEFT THE
15 PATIENT BLANK AND WROTE -- UNDER OTHER, YOU WROTE DAUGHTER.
16 THAT APPEARS YOU TALKED TO A DAUGHTER.
17 A. I'M SORRY, I HAVEN'T CAUGHT UP TO YOU.
18 Q. 178.
19 A. AND TELL ME AGAIN WHAT YOU ARE REFERRING TO? I'M SORRY.
20 Q. AND THE PERSON INTERVIEWED, PATIENT IS LEFT BLANK, THEN
21 OTHER, YOU'VE WRITTEN DAUGHTER, IS THAT CORRECT?
22 A. YES.
23 Q. AND ON PAGE 179, THE NEXT PAGE, YOU'VE WRITTEN WHAT
24 CAUSED YOU TO HAVE TO COME TO THE HOSPITAL. THREE WEEKS
25 DETERIORATION AT CARE CENTER. THAT WITH ANXIETY, CRYING OUT
3186
1 CONSTANTLY, UNABLE TO BE CONSOLED.
2 A. YES.
3 Q. SO WHEN YOU SEE HER CRYING LATER, IS THAT UNUSUAL
4 BEHAVIOR FOR HER?
5 A. NO.
6 Q. AND INDEED, THIS IS A WOMAN WHO IS VERY ANXIOUS, ISN'T
7 THAT CORRECT?
8 A. THAT'S CORRECT.
9 Q. DOESN'T LIKE TO BE LEFT ALONE.
10 A. IF -- IF THAT'S WHAT MY ASSESSMENT STATES.
11 Q. AND INDEED, THE DAUGHTERS TOLD YOU THAT -- THAT SHE WAS
12 INCONSOLABLE, THAT'S WHY SHE WAS THERE. EVEN WHILE THEY
13 WERE PRESENT, SHE WAS INCONSOLABLE, ISN'T THAT CORRECT?
14 A. I DO NOT HAVE A RECOLLECTION. IF IT'S STAYED IN THE
15 RECORD, THEN IT WAS REPORTED TO ME.
16 Q. MEDICAL PAGE 182.
17 A. OKAY.
18 Q. YOU CIRCLED PROBLEM WITH BONES AND JOINTS, HIP FRACTURE,
19 WRIST FRACTURE, HISTORY OF BACK PAIN, SPINAL FRACTURE. DO
20 YOU RECALL WHETHER ANY OF THOSE WERE ACUTE OR CURRENT?
21 A. I DO NOT RECALL.
22 Q. SO YOU DON'T RECALL WHETHER ANY OF THOSE WERE CAUSING
23 HER PAIN AT THAT TIME?
24 A. AS A NURSE, I WOULDN'T MAKE AN ASSESSMENT OF A
25 DIAGNOSIS. MY DIAGNOSIS AS A NURSE IS THE SYMPTOM, WHICH IS
3187
1 PAIN. SO I WOULD BE REPORTING WHAT THE PATIENT IS
2 DEMONSTRATING TO ME, NOT THE DIAGNOSIS OF A BONE FRACTURE,
3 ET CETERA.
4 Q. IF YOU WILL TURN OVER TO 190.
5 A. OKAY.
6 Q. AND THIS IS A NEW ADMIT. NOW, THIS FIRST PART, THE
7 BEHAVIOR PART, ISN'T THAT BASICALLY JUST REITERATING OR
8 SUMMARIZING WHAT YOU SAW IN YOUR ASSESSMENT?
9 A. I HAVE TO READ IT.
10 IT APPEARS TO BE.
11 Q. AND IN THAT YOU WROTE THAT SHE WAS CRYING AND SCREAMING
12 INCONSOLABLY EVEN WHEN FAMILY IS PRESENT.
13 A. YES.
14 Q. SO THAT'S WHAT YOU HAD BEEN TOLD. WE HAVE HERE A VERY
15 ANXIOUS INDIVIDUAL. LET'S LOOK DOWN UNDER THE MED NOTE.
16 YOU -- YOU INDICATE THAT YOU GAVE MORPHINE 10 MILLIGRAMS
17 I.M. AT 2000 HOURS FOR SEVERE PAIN, THEN YOU WRITE, PATIENT
18 BECOMES RIGID AND SCREAMS WHEN TOUCHED.
19 IS PAIN THE ONLY THING THAT CAN CAUSE THAT KIND OF A
20 SYMPTOM?
21 A. IT IS ONE OF THE THINGS THAT CAN CAUSE THAT SYMPTOM. IT
22 IS NOT THE --
23 Q. IS IT THE ONLY --
24 A. IT IS NOT THE ONLY THING.
25 Q. THANK YOU. AND IN FACT, IN A VERY ANXIOUS WOMAN WHO IS
3188
1 NOW IN A PLACE THAT SHE'S NEVER BEEN BEFORE, HER DAUGHTERS
2 HAVE LEFT, COULD THAT EXPLAIN WHY SHE IS SCREAMING WHEN
3 TOUCHED?
4 A. BEING A NURSE THAT WAS PRESENT AT THE TIME, AND FACED
5 WITH MY OWN DOCUMENTATION, MY ASSESSMENT APPEARS TO BE THAT
6 MY IMPRESSION AT THE TIME WAS THAT SHE WAS HAVING PAIN, NOT
7 ANXIETY.
8 Q. BUT CANNOT ANXIETY CAUSE RIGIDITY AND SCREAMING WHEN
9 TOUCHED?
10 A. IT MAY DEPENDING ON THE CIRCUMSTANCES.
11 Q. AND IN FACT, I BELIEVE THAT THE PHYSICIAN ORDER INCLUDED
12 AMBIEN AND TRAZODONE P.R.N. FOR SLEEP FOR THE AMBIEN AND
13 TRAZODONE 150 MILLIGRAMS AT BEDTIME.
14 DID YOU ADMINISTER THOSE DOSES OF ANTIPSYCHOTIC DRUGS?
15 A. I WOULD HAVE TO LOOK AT THE MEDICATION ADMINISTRATION
16 RECORD.
17 Q. IF YOU'D LOOK AT 176 PLEASE. ON 176, YOU NOTED
18 TRAZODONE AS BEING GIVEN AT BEDTIME, IS THAT CORRECT?
19 A. I --
20 Q. AS TO BE GIVEN. ORDERED TO BE GIVEN AT BEDTIME.
21 A. OKAY. I WAS ABOUT TO SAY, MY INITIALS ARE NOT HERE. I
22 TRANSCRIBED THE ORDER. I DID NOT ADMINISTER ANY MEDICATION.
23 IF I HAD, MY INITIALS WOULD BE THERE.
24 Q. SO THE FACT THAT YOUR INITIALS ARE NOT THERE MEANS YOU
25 DIDN'T GIVE THE TRAZODONE --
3189
1 A. THAT'S RIGHT.
2 Q. -- TO HELP HER SLEEP.
3 A. THAT'S RIGHT.
4 Q. AND THEN LET'S LOOK AT THE NEXT PAGE, 177. AND AGAIN,
5 WE HAVE AN ORDER FOR AMBIEN 5 MILLIGRAMS AT BEDTIME, AS
6 NEEDED FOR SLEEP. AND YOU NOTED THAT ORDER?
7 A. IT'S TRANSCRIBED IN MY HANDWRITING, YES.
8 Q. AND DID YOU ADMINISTER THAT FOR SLEEP?
9 A. I SEE NO INITIALS INDICATING THAT I DID.
10 Q. AND ABOVE THAT YOU HAVE TYLENOL. IS THAT TWO TABLETS
11 EVERY FOUR HOURS AS NEEDED FOR PAIN?
12 A. YES.
13 Q. THAT WAS THE ORDER?
14 A. YES.
15 Q. DID YOU ADMINISTER ANY TYLENOL FOR PAIN?
16 A. NO.
17 Q. AND I'M A LITTLE CURIOUS HERE. YOU HAVE ON -- BACK ON
18 190, WHICH IS YOUR NURSING NOTE, AFTER THE SEVERE PAIN
19 RELATED TO PROFOUND OSTEOPOROSIS, GIVEN TO PATIENT PER ORDER
20 OF DR. WEITZEL. WAS THAT THE ORDER THAT HE --
21 A. I'M SORRY, I LOST TRACK OF THE PAGE.
22 Q. 190. SORRY.
23 A. OKAY. I'M HERE. GO AHEAD.
24 Q. OKAY. UNDER MED NOTE IT SAYS, RELATED TO PROFOUND
25 OSTEOPOROSIS GIVEN TO PATIENT PER ORDER DR. WEITZEL.
3190
1 WAS THAT THE ORIGINAL ORDER, THE FIRST ORDER IN THE
2 PHYSICIAN'S ORDERS?
3 A. I BELIEVE THAT'S WHAT IT REFERS TO.
4 Q. OKAY. THERE WAS NO OTHER TELEPHONE --
5 A. UN-UNH.
6 Q. -- ORDER OR ANYTHING. THANK YOU. I JUST WANT TO MAKE
7 SURE I'M NOT CONFUSED HERE.
8 DO YOU RECALL WHY YOU GAVE THE MORPHINE INSTEAD OF
9 EITHER THE TRAZODONE OR THE AMBIEN FOR SLEEP?
10 A. BECAUSE IF A PATIENT IS IN PAIN, SLEEP MEDICATION IS NOT
11 GOING TO ALLEVIATE THAT.
12 Q. NOW, THE Q.H.S. IS AT BEDTIME, IS THAT CORRECT?
13 A. UH-HUH.
14 Q. AND WHAT WAS BEDTIME FOR THESE -- SAY FOR ELLEN ANDERSON
15 THAT EVENING?
16 A. I'M NOT CERTAIN.
17 Q. LET'S TALK ABOUT MARY CRANE. IF YOU COULD PULL HER
18 BINDER OUT PLEASE. IF YOU'D TURN TO PAGE 294, WHICH IS THE
19 FIRST PART OF THE NURSES' NOTES.
20 A. OKAY.
21 Q. THIS APPEARS TO BE ONE THAT ELLEN -- OR EARLENE, EXCUSE
22 ME, NOT ELLEN, BUT EARLENE COZZENS STARTED AND THEN YOU
23 FINISHED THE ASSESSMENT, IS THAT CORRECT?
24 A. IT APPEARS TO BE.
25 Q. AND IT APPEARS THAT THE INFORMATION WAS OBTAINED FROM
3191
1 KAREN BRINGHURST AND KATHY CHARLESWORTH.
2 A. I'M SORRY, I DIDN'T HEAR YOU.
3 Q. IT APPEARS THE INFORMATION WAS OBTAINED FROM KAREN
4 BRINGHURST AND KATHY CHARLESWORTH?
5 A. THAT'S WHAT IT STATES.
6 Q. WE GET OVER TO 298, AND YOU TESTIFIED THAT YOU -- YOU
7 ASKED MARY CRANE HERSELF TO RATE HER PAIN, AND SHE RATED IT
8 AS A 5. IS THAT CORRECT?
9 A. UH-HUH.
10 Q. AND THEN ON THE NEXT PAGE, ON 299, YOU HAVE A HISTORY OF
11 HEADACHES, AND THAT IS CIRCLED. DO YOU RECALL EITHER KATHY
12 OR KAREN TELLING YOU THAT MARY HAD COMPLAINED OFTEN ABOUT
13 HEADACHES, AND IT SEEMED THAT MAYBE THERE WASN'T REALLY A
14 HEADACHE, IT WAS JUST ONE OF THESE PHANTOM COMPLAINTS OF
15 SOMEONE WHO'S DEMENTED, DO YOU RECALL THAT?
16 A. NO, I DO NOT.
17 Q. DO YOU RECALL THEM SAYING THAT HER -- WHAT SHE THOUGHT
18 WERE HEADACHES HAD BEEN TREATED AT THE NURSING HOME HAD BEEN
19 TREATED WITH CALCIUM CARBONATE, WHICH IS BASICALLY A
20 PLACEBO?
21 A. NO, I HAVE NO RECOLLECTION.
22 Q. AND THEN LET'S TURN TO THREE ELEVEN THAT YOU TALKED
23 ABOUT. AT 0200 YOU INDICATED THAT YOU GAVE TWO TABLETS OF
24 TYLENOL FOR DISCOMFORT.
25 A. UH-HUH.
3192
1 Q. AND THAT APPEARED TO WORK, IS THAT NOT CORRECT?
2 A. YES.
3 Q. SO AT THAT TIME, YOU DIDN'T SEE ANY NEED FOR ANYTHING
4 MORE STRONG OR STRONGER THAN TYLENOL?
5 A. THAT'S CORRECT.
6 Q. LET'S TURN TO 325. MR. STIRBA WALKED YOU THROUGH THE
7 DIFFICULTY THAT MARY WAS HAVING CLEARING SECRETIONS. BUT
8 ISN'T IT TRUE THAT YOU WROTE FIRST PART OF BEHAVIOR, PATIENT
9 IS MORE ALERT TODAY?
10 A. THE DIFFICULTY IN CLEARING SECRETIONS AND THE LEVEL OF
11 ALERTNESS ARE NOT NECESSARILY RELATED IN A PATIENT.
12 Q. BUT SHE WAS MORE ALERT. SHE WAS ABLE TO SIT UP AT
13 DINNER. ATE 90 PERCENT OF HER DIET. ISN'T THAT CORRECT?
14 A. 90 PERCENT OF A PUREE DIET.
15 Q. BUT 90 PERCENT OF HER MEALS. SO SHE WAS GETTING AT
16 LEAST 90 PERCENT OF HER NUTRITIONAL VALUE AT THAT TIME.
17 A. UH-HUH.
18 Q. YES OR NO.
19 A. THAT'S CORRECT.
20 Q. ARE YOU AWARE THAT ANTIPSYCHOTIC MEDICATIONS CAN CAUSE A
21 PERSON TO NOT SWALLOW AS WELL AS THEY DID BEFORE?
22 A. YOU'RE TALKING ABOUT DISCONNECT MOVEMENTS OF THE TONGUE,
23 AND IF I HAD OBSERVED THAT IN THE PATIENT, I WOULD HAVE
24 DOCUMENTED SO.
25 Q. ARE YOU AWARE THAT ANTIPSYCHOTIC MEDICATIONS CAN CAUSE A
3193
1 PERSON NOT TO SWALLOW VERY WELL? IT'S JUST A YES OR NO.
2 A. YES.
3 Q. AND IN FACT, COUNTER TO WHAT WE WOULD INTUITIVELY
4 BELIEVE, IF YOU THICKEN LIQUIDS, PEOPLE SWALLOW THEM BETTER,
5 ISN'T THAT CORRECT?
6 A. THAT'S CORRECT.
7 Q. AND THE NEED FOR THICKENED LIQUIDS IS NOT UNUSUAL WITH
8 ELDERLY PATIENTS?
9 A. NO.
10 Q. DO YOU HAVE ANY INDEPENDENT RECOLLECTION OF MARY CRANE?
11 A. NO.
12 Q. OR WHAT HER DIFFICULTIES WERE?
13 A. NOT IMMEDIATELY, NO.
14 Q. AND CLEARLY, SHE DID BECOME TERMINAL AS TIME WENT ON,
15 ISN'T THAT CORRECT?
16 A. BASED ON THE DOCUMENTATION OF MINE THAT I'VE READ, YEAH.
17 Q. OKAY. THE MASTER TREATMENT PLAN STARTS ON 347, AND IT
18 APPEARS THAT YOU ALSO, FOR MARY CRANE, STARTED THE MASTER
19 PROBLEM LIST, IS THAT CORRECT?
20 A. THOSE ARE MY INITIALS.
21 Q. AND WAS THIS EVER ALTERED INTO DEATH AND DYING ISSUES?
22 A. THE ONLY PLACE TO LOOK FOR THAT WOULD BE UNDER
23 TREATMENT, I THINK? MAYBE IN HERE. I DON'T SEE ANYTHING
24 ELSE. I DON'T SEE ANY.
25 Q. IF YOU WOULD PULL OUT JUDITH LARSEN'S. JUDITH LARSEN
3194
1 WAS ON THERE NEARLY A -- ON THE UNIT NEARLY A MONTH. DO YOU
2 RECALL -- HAVE ANY INDEPENDENT RECOLLECTION OF JUDITH?
3 A. I'M SORRY, I DON'T.
4 Q. I BELIEVE YOU WENT FIRST TO PAGE 530. AND ON THE 8TH OF
5 DECEMBER, IT WAS TWO DAYS AFTER HER ADMISSION, ISN'T THAT
6 CORRECT?
7 A. I WOULD HAVE TO SEE HER ADMISSION DATE.
8 Q. WELL, LET ME JUST REPRESENT THAT IT WAS TWO DAYS AFTER
9 THE ADMISSION.
10 A. OKAY.
11 Q. AND YOU HAVE HER MOANING AND CRYING FREQUENTLY, SHE'S
12 ACUTELY DISTRESSED. CRYING INCONSOLABLY IN BED. ARE YOU
13 AWARE THAT THIS IS A WOMAN WHO UP UNTIL JUST A FEW MONTHS
14 BEFORE HER ADMISSION HAD BEEN LIVING ON HER OWN IN HER OWN
15 HOME?
16 A. I HAVE NO RECOLLECTION OF THIS PATIENT.
17 Q. WOULD YOU NOT EXPECT SOMEONE WHO HAD BEEN LIVING ON HER
18 OWN WHO IS NOW IN A HOSPITAL SETTING, WOULD YOU NOT EXPECT
19 THEM TO MOAN AND CRY, PERHAPS BE INCONSOLABLE?
20 A. THERE ARE OTHER BEHAVIORS THAT ARE CONSISTENT WITH
21 DEMENTIA IN COMBINATION WITH THE CRYING THAT I DOCUMENTED.
22 Q. ISN'T THERE AN EMOTIONAL COMPONENT, NOT JUST A PHYSICAL
23 PAIN COMPONENT, BUT AN EMOTIONAL COMPONENT THAT CAN CAUSE
24 MOANING AND CRYING?
25 A. IF THE PATIENT IS AWARE OF THE CIRCUMSTANCES.
3195
1 Q. DO YOU RECALL AS YOU SIT HERE WHETHER SHE WAS AWARE OF
2 THE CIRCUMSTANCES?
3 A. BASED ON MY DOCUMENTATION WHICH REPORTS THAT SHE HAS
4 ECHOLALIA, SHE'S PROBABLY NOT WELL AWARE OF HER
5 CIRCUMSTANCES.
6 Q. BUT YOU'RE NOT ABLE TO GET INTO HER HEAD AND KNOW FOR
7 SURE WHAT SHE'S AWARE OF.
8 A. ECHOLALIA IS A BEHAVIOR DEMONSTRATED BY PATIENTS WITH
9 PROFOUND DEMENTIA.
10 Q. AND IF THEY HAVE PROFOUND DEMENTIA, THEN THEY ARE NEVER
11 AGAIN AWARE OF THEIR SURROUNDINGS?
12 MR. STIRBA: YOUR HONOR, I'M GONNA OBJECT. I THINK
13 THIS GOES BEYOND THE SCOPE. SHE'S NOT AN EXPERT WITNESS.
14 SHE CAN TESTIFY AS TO FACTS. SHE ISN'T -- SHE'S ASKING HER
15 FOR OPINIONS ABOUT CERTAIN THINGS.
16 THE COURT: YOU'RE ASKING HER UNDERSTANDING OR WHAT
17 ARE YOU ASKING?
18 MS. BARLOW: HER UNDERSTANDING, YOUR HONOR.
19 THE COURT: CAN YOU ANSWER THAT QUESTION?
20 THE WITNESS: COULD YOU ASK ME --
21 MS. BARLOW: I WAS AFRAID YOU WERE GONNA ASK ME TO
22 REPEAT IT. CAN WE ASK THE REPORTER TO READ IT BACK?
23 THE COURT: WELL, IT'S NOT GONNA BE AN
24 UNDERSTANDING -- IT WASN'T AN UNDERSTANDING QUESTION. I
25 MEAN THE QUESTION WASN'T --
3196
1 MS. BARLOW: I'LL JUST WITHDRAW IT, YOUR HONOR. IF
2 I CAN'T REMEMBER WHAT IT IS, THEN IT PROBABLY ISN'T
3 SOMETHING THAT I OUGHT TO GO INTO.
4 THE COURT: OKAY. GO AHEAD.
5 Q. (BY MS. BARLOW) I SEEM TO HAVE NOT WRITTEN DOWN A
6 NUMBER HERE. MAYBE I DID. IF YOU WOULD TURN TO 533.1.
7 A. OKAY.
8 Q. YOU TESTIFIED ON DIRECT THAT YOU WERE ANTICIPATING DEATH
9 OR THAT THE FAMILY WAS ANTICIPATING DEATH. DID YOU WRITE
10 THAT ANYWHERE HERE?
11 A. IN THAT THE FAMILY REPEATED THEIR REQUEST THAT PATIENT
12 BE RE -- BE MADE COMFORTABLE, AND THAT THE D.N.R. BE
13 RESPECTED.
14 Q. AND FROM THAT YOU EXTRAPOLATE THEY'RE ANTICIPATING
15 DEATH.
16 A. I HAVE ONLY EVER HAD THOSE DISCUSSIONS IN PATIENTS WHOSE
17 FAMILIES ARE ANTICIPATING DEATH.
18 Q. BUT JUDITH LARSEN DID NOT DIE WITHIN DAYS OF THE 10TH OF
19 DECEMBER, DID SHE?
20 A. I DO NOT KNOW.
21 Q. SHE DIDN'T DIE UNTIL THE 3RD OF JANUARY. ARE YOU AWARE
22 OF THAT?
23 A. I DON'T HAVE DETAILED RECOLLECTIONS SUCH AS THAT.
24 Q. AND IN FACT, SHE MADE WHAT THE RECORD INDICATES,
25 DR. WEITZEL'S WRITING, A MIRACULOUS RECOVERY AFTER THIS
3197
1 POINT. DO YOU RECALL SEEING THAT IN THE RECORD? IN THE
2 PROGRESS NOTES?
3 A. I -- I MAY HAVE SEEN IT IN GOING THROUGH THE CHART, YES.
4 Q. IF YOU WOULD TURN TO 606, WHICH IS THE MEDICAL TREATMENT
5 PLAN, DO YOU SEE ANY INDICATION OF A CHANGE TO DEATH AND
6 DYING ISSUES IN THAT MEDICAL TREATMENT PLAN?
7 A. THERE IS NOTHING LISTED HERE.
8 Q. BUT YOU DID TESTIFY THAT ON 596, WHICH IS NOT IN THE
9 MEDICAL -- OR MASTER TREATMENT PLAN, YOU WROTE IN THE
10 NURSING CARE PROGRAM ABOUT DEATH AND DYING. WHAT'S THE
11 DIFFERENCE BETWEEN THE MASTER TREATMENT PLAN AND THE NURSING
12 CARE PROGRAM?
13 A. THE MASTER TREATMENT PLAN INCLUDES INTERVENTIONS BY ALL
14 DISCIPLINES. THE NURSING TREATMENT PLAN INDICATES TREATMENT
15 PROVIDED BY THE NURSES.
16 Q. SO YOU WROTE IT IN THE NURSING CARE PROGRAM, BUT NOT IN
17 THE MASTER TREATMENT PLAN, IS THAT CORRECT?
18 A. THAT MAY BE TRUE.
19 Q. YOU TALKED ABOUT MED NUMBER 477. YOU WROTE A WEEKLY
20 R.N. ADVOCATE NOTE. AS YOU LOOK THROUGH THESE NOTES, DID
21 ANY OF THE OTHER R.N.'S EVER WRITE WEEKLY ADVOCATES NOTES
22 THAT YOU SAW?
23 A. ON THIS PARTICULAR PATIENT, I WOULD HAVE TO READ THE
24 CHART. THERE'S --
25 Q. IF I TOLD YOU THAT NOBODY -- NO OTHER R.N.'S EVER WROTE
3198
1 THAT, WOULD YOU BE SURPRISED AT THAT?
2 A. IF THIS WERE MY PATIENT AND I WERE ASSIGNED TO HER TO
3 WRITE THE WEEKLY ADVOCATE NOTE, THEN IT WOULD BE ME WRITING
4 THE NOTES. IF I WERE NOT THERE DUE TO A DAY OFF OR AN
5 ABSENCE WHEN A NOTE WAS DUE, IT WAS SOMEONE ELSE'S
6 RESPONSIBILITY TO DO SO. WHETHER OR NOT THEY DID THAT WAS
7 NOT UNDER MY CONTROL.
8 Q. I UNDERSTAND THAT. YOU SAY THAT THE MEDICAL STATUS
9 RAPIDLY AND PROFOUNDLY DETERIORATED THIS WEEK. EXPERIENCED
10 A SEIZURE AND MULTIPLE EPISODES OF VOMITING COFFEE GROUNDS
11 MATERIAL. WASN'T THERE JUST ONE EPISODE OF VOMITING OVER,
12 SAY, A FIVE-HOUR PERIOD?
13 A. IF SOMEONE IS VOMITING FOR FIVE HOURS, THAT'S MORE THAN
14 ONE EPISODE AND --
15 Q. SO YOU -- YOU -- OKAY.
16 A. AND I WOULDN'T BE ABLE TO TELL THAT WITHOUT READING THE
17 CHART BACK TO SEE IF THERE WERE ANY OTHER THINGS DOCUMENTED.
18 I WOULD HAVE WRITTEN THIS NOTE BASED ON PREVIOUS NOTES IN
19 THE RECORD THAT I HAD READ AT THE TIME.
20 Q. ARE YOU AWARE THAT THE SEIZURE OCCURRED APPROXIMATELY 24
21 HOURS AFTER THE FIRST DOSE OF MORPHINE WAS ADMINISTERED TO
22 JUDITH LARSEN?
23 A. I HAVE NO RECOLLECTION.
24 Q. FURTHER DOWN ON THE 3RD OF JANUARY, DR. WEITZEL WROTE A
25 NOTE FURTHER DOWN ON 477, UNDER 1/3, TALKS ABOUT MORPHINE AT
3199
1 7:30 AND 9:30. PATIENT HAS NOT RESPONDED AT ALL DESPITE
2 5 MILLIGRAMS. EYES OPEN. GROANING. APPEARS IN SOME PAIN.
3 UNFORTUNATELY, NURSING STAFF HAVE BEEN HOLDING MORPHINE
4 SULFATE FOR LOW RESPIRATION RATE.
5 DO YOU RECALL SEEING THAT NOTE?
6 A. ACTUALLY, I DON'T REMEMBER SEEING THIS NOTE. IT'S NEW
7 TO MY ATTENTION AT THIS MOMENT IN TIME.
8 Q. REMAINS UNRESPONSIVE TO ANY QUESTIONS.
9 DO YOU RECALL THERE BEING A MEETING CALLED BY -- WELL,
10 AT WHICH DR. WEITZEL TOLD THE NURSES NOT TO WITHHOLD
11 MORPHINE WITHOUT HIS PERMISSION?
12 A. NO.
13 Q. DO YOU THINK IT'S UNFORTUNATE THAT THE NURSES WITHHELD
14 MORPHINE FOR LOW RESPIRATION RATE?
15 MR. STIRBA: OBJECTION. IRRELEVANT. CALLING FOR
16 AN OPINION. AND SHE'S NOT COMPETENT TO RENDER THAT OPINION
17 ABOUT SOMEBODY ELSE'S CARE.
18 THE COURT: I THINK IT'S FOUNDATION. SUSTAIN AS TO
19 FOUNDATION.
20 THIS MAY BE A GOOD PLACE -- IT'S 5:00 O'CLOCK -- TO
21 STOP. SO, LADIES AND GENTLEMEN, WHAT WE'LL DO IS WE'LL COME
22 BACK TOMORROW AT 8:30 AND PLAN ON GOING AGAIN FROM 8:30
23 UNTIL 5:00.
24 (WHEREUPON, COURT AND COUNSEL HELD A SCHEDULING
25 CONFERENCE, THEN COURT ADJOURNED FOR THE EVENING.)
WE HAVE MS. STEVENSON ON THE STAND. YOU
6 UNDERSTAND YOU ARE STILL UNDER OATH?
7 THE WITNESS: YES, I DO.
8 THE COURT: OKAY. MS. BARLOW, IF YOU WOULD LIKE TO
9 CONTINUE.
10 MS. BARLOW: THANK YOU, YOUR HONOR. GOOD MORNING.
11 THE WITNESS: MORNING.
12 CROSS-EXAMINATION, CONT'D
13 BY MS. BARLOW:
14 Q. I BELIEVE WE WERE TALKING ABOUT JUDITH LARSEN YESTERDAY
15 WHEN 5 O'CLOCK CAME. IF YOU WOULD TURN TO PAGE 582 IN
16 MRS. LARSEN'S MEDICAL RECORDS.
17 A. OKAY.
18 Q. WOULD YOU FAMILIARIZE YOURSELF AGAIN WITH THAT NOTE THAT
19 YOU WROTE ON THE 31ST OF DECEMBER. 1430 YOU WROTE THE
20 PATIENT IS NONRESPONSIVE TO VERBAL AND TACTILE TOUCH.
21 A. I'M SORRY?
22 Q. AT 1430. DO YOU SEE THAT?
23 A. I HAVE AN 11 TO 7 NOTE.
24 Q. I'M SORRY. I'M ON THE WRONG PAGE. STARTING OUT GREAT
25 HERE. OKAY. THE 11 TO 7 NOTE RIGHT IN THE MIDDLE YOU
3202
1 INDICATED THAT MORPHINE WAS GIVEN IS THAT EVERY FOUR HOURS
2 I.M. FOR COMFORT.
3 DO YOU RECALL NOW WHAT DISCOMFORT YOU WERE SEEING IN
4 JUDITH LARSEN ON THE 1ST OF JANUARY?
5 A. THE NOTE STATES THAT MORPHINE I.M. WAS GIVEN AT 2:30 AND
6 6:30 FOR PAIN RELIEF. PATIENT WAS MOANING PRIOR TO 2:30
7 DOSE. AND MOANING IS A REPRESENTATION BY THE PATIENT AS
8 ASSESSED BY MYSELF THE NURSE AS REFLECTING HER PAIN LEVEL,
9 YES.
10 Q. DOES MOANING EVER INDICATE ANYTHING OTHER THAN PAIN?
11 A. MY NOTE IS REFLECTIVE OF MY ASSESSMENT OF THE PATIENT AT
12 THAT TIME.
13 Q. I UNDERSTAND THAT. BUT DOES MOANING EVER REFLECT
14 SOMETHING OTHER THAN PAIN?
15 A. NOT THAT -- NOTHING TO ME THAT COMES IMMEDIATELY TO
16 MIND.
17 Q. ARE YOU FAMILIAR WITH THE DIAGNOSTIC AND STATISTICAL
18 MANUAL OF MENTAL DISORDERS, THE D.S.M.?
19 A. YES, I AM.
20 Q. IT'S PUT OUT BY THE AMERICAN PSYCHIATRIC ASSOCIATION; IS
21 THAT CORRECT?
22 A. THAT'S CORRECT.
23 Q. AND IT IS A -- IT'S A MANUAL THAT DEALS WITH PSYCHIATRIC
24 DISORDERS PREDOMINANTLY, RIGHT?
25 A. THAT'S CORRECT.
3203
1 Q. AND ARE YOU AWARE THAT -- ARE YOU AWARE OF THE CONDITION
2 CALLED DELIRIUM?
3 A. I AM AWARE OF THE CHARACTERISTICS OF DELIRIUM, YES.
4 Q. AND ARE YOU AWARE THAT ONE OF THE CHARACTERISTICS OF
5 DELIRIUM IS A DISTURBED EMOTIONAL STATE?
6 A. THAT'S CORRECT.
7 Q. AND ARE YOU AWARE THAT THE DISTURBED EMOTIONAL STATE MAY
8 ALSO BE EVIDENT IN CALLING OUT, SCREAMING, CURSING,
9 MUTTERING, MOANING OR OTHER SOUNDS?
10 A. THAT'S CORRECT.
11 Q. SO YOU ARE AWARE THAT THOSE ARE SOME OF THE
12 MANIFESTATIONS OF DELIRIUM; IS THAT CORRECT?
13 A. YES.
14 Q. SO THERE ARE THINGS OTHER THAN PAIN THAT CAN CAUSE
15 MOANING?
16 A. YES. BUT AS MY ASSESSMENT IN THE -- AS THE NURSE CARING
17 FOR THIS PATIENT, MOANING WAS A REPRESENTATION OF HER PAIN.
18 BEING THE NURSE CARING FOR THE PATIENT, IT IS MY JOB TO
19 INTERPRET THAT SYMPTOM.
20 Q. I UNDERSTAND. AND ANOTHER NURSE MAY INTERPRET THE
21 MOANING DIFFERENTLY; ISN'T THAT CORRECT?
22 A. I CAN'T SPEAK ABOUT WHAT ANOTHER NURSE WOULD DO. I WAS
23 THE NURSE CARING FOR THAT PATIENT AT THAT TIME, THAT WOULD
24 BE MY RESPONSIBILITY.
25 Q. BUT IT'S A VERY SUBJECTIVE THING; ISN'T THAT CORRECT?
3204
1 A. IT'S A SUBJECTIVE THING THAT NURSES ARE TRAINED TO WORK
2 WITH.
3 Q. RIGHT. AND YOU WERE TRAINED AND THE OTHER NURSES THAT
4 WORKED WITH MRS. LARSEN WERE TRAINED TO MAKE THIS SUBJECTIVE
5 ASSESSMENT ABOUT WHAT'S CAUSING THE MOANING; ISN'T THAT
6 CORRECT?
7 A. THAT'S CORRECT.
8 Q. NOW, JUDITH LARSEN ON THE 31ST OF DECEMBER WAS NOT
9 RESPONSIVE, IS THAT CORRECT, WAS NOT VERBALLY RESPONSIVE?
10 A. THAT'S WHAT I CHARTED, YES.
11 Q. CAN SEDATION CAUSE THAT UNRESPONSIVENESS?
12 A. MANY THINGS CAN CAUSE THAT LEVEL OF UNRESPONSIVENESS.
13 Q. AND CAN SEDATION CAUSE THAT LEVEL OF UNRESPONSIVENESS?
14 A. OCCASIONALLY.
15 Q. IN FACT, IF A PERSON IS SO SEDATED THAT THEY ARE
16 COMATOSE, THEN THEY WON'T RESPOND; IS THAT CORRECT?
17 A. IF I BELIEVE THAT THE PATIENT WOULD BE MADE COMATOSE BY
18 MEDICATION THAT I ADMINISTERED, I WOULD NOT HAVE GIVEN THAT.
19 Q. I APPRECIATE THAT. THAT'S NOT MY QUESTION. BUT
20 OVERSEDATION CAN CAUSE A PERSON TO BE COMATOSE; IS THAT NOT
21 CORRECT?
22 MR. STIRBA: YOUR HONOR, I'LL OBJECT IN TERMS OF
23 THE HYPOTHETICAL. SHE'S HERE AS A FACT WITNESS, NOT AS AN
24 EXPERT AND THIS CALLS FOR SPECULATION.
25 THE COURT: SUSTAINED.
3205
1 Q. (BY MS. BARLOW) DID YOU EVER HOLD ANY MEDICATIONS FOR
2 JUDITH LARSEN?
3 A. I WOULD HAVE TO LOOK AT THE MEDICAL RECORD TO SEE.
4 Q. I BELIEVE ON DIRECT EXAMINATION THAT YOU TESTIFIED THAT
5 YOU GAVE THIS -- THESE SHOTS AT 2:30 AND 6:30 BECAUSE YOU
6 ASSESSED PAIN; IS THAT CORRECT?
7 A. SHE WAS GIVEN MEDICATION AS THEY WERE SCHEDULED. IF I
8 GAVE THE DOSE EARLIER THAN THE SCHEDULED TIME, THEN IT WOULD
9 HAVE BEEN BECAUSE IT WAS ASSESSED AS PAIN. IF THE SCHEDULED
10 TIME IS 2:30, THEN SHE WOULD HAVE GOTTEN IT ON TIME AS
11 SCHEDULED.
12 Q. I APOLOGIZE FOR THE LENGTH OF TIME THIS TAKES BUT WITH
13 HER LONG ADMISSION -- OR LONG STAY THERE, THERE'S A LOT OF
14 RECORDS.
15 WILL YOU TURN TO PAGE 497 WHICH IS IN THE MEDICAL
16 ADMINISTRATION RECORDS. DO YOU SEE DOWN AT THE BOTTOM UNDER
17 12/31 WHERE YOUR INITIALS INDICATE THE ADMINISTRATION OF THE
18 2:30 AND 6:30 SHOTS?
19 A. THAT IS CORRECT.
20 Q. AND THOSE ARE NOT GIVEN PRN; IS THAT CORRECT?
21 A. THOSE ARE SCHEDULED DOSES.
22 Q. LET'S TURN TO MR. ALLDREDGE. IT APPEARS THAT YOU DID
23 NOT FILL OUT THE NURSING ASSESSMENT FOR MR. ALLDREDGE SO YOU
24 WERE NOT THERE WHEN HE CAME IN; IS THAT CORRECT?
25 A. ALL THAT WOULD MEAN IS THAT I DID NOT DO THE NURSING
3206
1 ASSESSMENT WHEN HE -- I WOULD HAVE TO LOOK AT SOMETHING LIKE
2 A SCHEDULE OR OTHER PROGRESS NOTES OR WHAT I HAD WRITTEN TO
3 TELL YOU WHETHER I WAS THERE AT THE TIME OF HIS ADMISSION.
4 Q. BECAUSE YOU WOULD NOT BE THE ONLY NURSE ON THE UNIT WHEN
5 HE CAME IN?
6 A. THAT IS CORRECT.
7 Q. IN FACT, CAN YOU SAY -- WHAT, 3 TO 11 IS THAT ONE SHIFT
8 THAT YOU WORK?
9 A. UH-HUH.
10 Q. AND HOW MANY NURSES WERE ON AT THE 3 TO 11 SHIFT WITH
11 YOU?
12 A. I'M NOT CERTAIN. I KNOW THAT IT WAS NOT ONLY JUST ONE
13 NURSE. THERE WAS PROBABLY A NURSE, AN LPN OR A NURSE AND
14 ANOTHER NURSE MOST LIKELY. THE ONLY SHIFT THAT THERE'S JUST
15 A SINGLE RN ON THE FLOOR WOULD BE 11 TO 7.
16 Q. AND THE 11 TO 7 THERE MAY BE C.N.A.'S, CERTIFIED NURSING
17 ASSISTANTS?
18 A. THAT'S CORRECT.
19 Q. IF YOU WOULD TURN TO PAGE 18 ON MR. ALLDREDGE'S BINDER.
20 YOU INSERTED THERE A WEEKLY R.N. ADVOCATE NOTE AS YOU HAD
21 WITH SOME OF THE OTHER PATIENTS. AND YOU INDICATE, PLEASE
22 SEE DR. WEITZEL'S NOTE ABOVE REGARDING M.R.I. RESULTS AND
23 PATIENT'S CARE PLAN HAS BEEN AMENDED TO REFLECT TO DEATH AND
24 DYING ISSUES. YOUR KNOWLEDGE OF THE M.R.I. RESULTS, DID
25 THAT COME JUST FROM DR. WEITZEL?
3207
1 A. I HAVE NO SPECIFIC MEMORY OF THE INCIDENT. I BELIEVE I
2 MAY HAVE READ SOMETHING IN THE RECORD RECENTLY THAT REFLECTS
3 THAT I RECEIVED A REPORT FROM SOMEONE OVER THE PHONE OR
4 SOMEONE DID....
5 Q. AND INDEED ON PAGE 27 IS THE REPORT OF THE M.R.I.; IS
6 THAT NOT CORRECT?
7 A. THAT'S CORRECT.
8 Q. AND THE IMPRESSION WAS BASICALLY THAT THE PATIENT MOVED
9 A LOT AND IT WASN'T REALLY A GOOD REPORT; IS THAT CORRECT?
10 MR. STIRBA: I'M GOING TO OBJECT, YOUR HONOR, THAT
11 CALLS FOR A CHARACTERIZATION BEYOND THE SCOPE OF HER
12 EXPERTISE ON THAT REPORT.
13 THE COURT: SUSTAINED.
14 Q. (BY MS. BARLOW) THEN LET'S READ THE LAST PARAGRAPH --
15 WELL, MAYBE NOT THE WHOLE PARAGRAPH. WELL, WE'LL READ THE
16 WHOLE PARAGRAPH.
17 QUESTION OF INFARCTION INVOLVING THE LEFT OCCIPITAL AND
18 GRAY MATTER. I CANNOT PRECISELY DATE THIS POSSIBLE
19 INFARCTION, ALTHOUGH THERE COULD BE SOME EARLY COMPRESSION
20 OF THE OCCIPITAL HORN.
21 IS THAT THE WAY IT READS?
22 A. THAT'S CORRECT, SUGGESTING ACUTE TO SUBACUTE EVENT.
23 Q. SUGGESTING ACUTE OR SUBACUTE EVENT. YOU, OF COURSE,
24 WOULDN'T DIAGNOSE FROM THIS?
25 A. NO. I ALSO PROBABLY DID NOT HAVE ACCESS TO THE REPORT
3208
1 DIRECTLY. AS I SAID, I THINK THERE'S A PREVIOUS NOTE THAT
2 STATES I TALKED TO SOMEONE OVER THE PHONE. THE INFORMATION
3 GIVEN TO ME OVER THE PHONE IS NOT IN MY CLEAR MEMORY.
4 HOWEVER, WHATEVER IMPRESSION I WAS LEFT WITH AFTER THAT
5 CONVERSATION PROBABLY MOTIVATED THE NOTE. THE REPORTS OFTEN
6 CAME MANY DAYS LATER AFTER THE ACTUAL TESTING WAS DONE.
7 Q. IT APPEARS THAT THIS WAS TRANSCRIBED ON THE 13TH WHICH
8 IS THE DAY AFTER THE REPORT WAS -- WE'LL GO ON FROM THERE.
9 YOU, OF COURSE, DID NOT DIAGNOSE A STROKE?
10 A. NO.
11 Q. YOU HAD THEN NO AUTHORITY TO DIAGNOSE ANYTHING; IS THAT
12 CORRECT?
13 A. THAT'S CORRECT.
14 Q. SO ANYTHING -- ANY DIAGNOSIS OF A STROKE WOULD NOT COME
15 FROM YOU BUT FROM DR. WEITZEL; IS THAT CORRECT?
16 A. DR. WEITZEL, THE INTERPRETER OF THE M.R.I. RESULTS, ANY
17 NUMBER OF OTHER PHYSICIANS SOURCES.
18 Q. RIGHT. BUT IN THIS CASE THE INTERPRETER DID NOT
19 INTERPRET A STROKE DEFINITELY?
20 MR. STIRBA: YOUR HONOR, I'LL OBJECT ONCE AGAIN
21 BEYOND THE SCOPE OF HER COMPETENCE.
22 THE COURT: THE DOCUMENT SPEAKS FOR ITSELF,
23 SUSTAINED.
24 Q. (BY MS. BARLOW) THE PATIENT'S CARE PLAN HAS BEEN
25 AMENDED, THIS IS BACK ON PAGE 18 OF YOUR NOTE, TO REFLECT
3209
1 DEATH AND DYING ISSUES. DID YOU MAKE THAT DETERMINATION OR
2 DID DR. WEITZEL?
3 A. IF I MAKE AN ADJUSTMENT TO THE CARE PLAN, THAT IS A
4 NURSING ASSESSMENT.
5 Q. HOW ABOUT THE MASTER TREATMENT PLAN?
6 A. THE MASTER TREATMENT PLAN, IF I MAKE THE ENTRY IS A
7 NURSING ASSESSMENT. THAT'S INFORMATION AVAILABLE TO ALL
8 DISCIPLINES.
9 Q. SO YOU WOULD MAKE THE DETERMINATION THAT YOU NOW NEED TO
10 LOOK AT DEATH AND DYING ISSUES IN THE MASTER TREATMENT PLAN?
11 A. BASED ON WHAT THE PATIENT APPEARED TO BE TO ME.
12 Q. SO DR. WEITZEL WOULD HAVE NOTHING, NO INPUT ON THAT?
13 A. DR. WEITZEL IS NOT RESPONSIBLE FOR A NURSING DIAGNOSIS
14 OF A PATIENT, NO.
15 Q. BUT NURSES CAN'T DIAGNOSIS, CAN THEY? THEY CAN ASSESS?
16 A. NURSES ARE ALLOWED TO MAKE A NURSING DIAGNOSIS OF A
17 PATIENT, YES.
18 Q. ISN'T IT TRUE IN STATE LAW YOU CAN MAKE ASSESSMENTS BUT
19 NOT DIAGNOSES?
20 A. THE STATE LAW FOR THE STATE OF UTAH STATES THE
21 PATIENT -- NURSES ARE LICENSED TO MAKE NURSING DIAGNOSES
22 WHICH ARE PARTICULARLY SEPARATE FROM PHYSICIAN MEDICAL
23 DIAGNOSES.
24 Q. THAT ISN'T THE WAY THE LAW ACTUALLY READS, IS IT?
25 THE COURT: WELL, I THINK THAT THIS IS A LEGAL
3210
1 ARGUMENT AND I DON'T THINK -- THE WITNESS IS NOT A LAWYER.
2 MS. BARLOW: I RECOGNIZE THAT, YOUR HONOR, BUT --
3 WELL, WE'LL GO ON.
4 Q. (BY MS. BARLOW) SO DEATH AND DYING ISSUES, YOU
5 DETERMINED THAT AND ON PAGE 90 YOU INSERTED THAT INTO THE
6 MASTER PROBLEM LIST; IS THAT CORRECT?
7 A. THAT'S MY HANDWRITING, YES.
8 Q. NOW, YOU WOULD NOT BE PUTTING THIS IN HERE AND DIRECTING
9 THE DOCTOR TO DO ANYTHING TOWARDS DEATH AND DYING ISSUES;
10 ISN'T THAT CORRECT?
11 A. THE NURSING CARE PLAN IS DIRECTION OF CARE FOR THE
12 NURSING CARE OF THE PATIENT.
13 Q. AND DOES THAT INCLUDE THE MASTER TREATMENT PLAN?
14 A. THAT'S CORRECT.
15 Q. AND YOU INSERTED THAT ON THE 14TH WHICH IS THE DAY HE
16 DIED; IS THAT NOT CORRECT?
17 A. I'M NOT CERTAIN OF THE DAY HE DIED. I AM CERTAIN THAT
18 IT STATES I PUT THE NOTE IN ON THE 14TH.
19 Q. THEN LET'S GO BACK TO PAGE ONE WHICH IS THE ADMISSIONS
20 JUST TO REFRESH YOUR MEMORY OF HIS DATE OF DEATH AND TIME.
21 DOWN AT THE BOTTOM IS A DISCHARGE DATE OF 1-14-96 DISCHARGE
22 TIME OF 9:36 A.M. EXPIRED.
23 A. I'M SORRY, I'M JUST HAVING TROUBLE READING THE PAGE.
24 Q. PAGE ONE.
25 A. IT'S VERY LIGHT AND I'M HAVING A LITTLE TROUBLE --
3211
1 Q. DOWN AT THE BOTTOM HANDWRITTEN IN.
2 A. 1/14/96, 9:36 A.M.
3 Q. AND HE EXPIRED?
4 A. THAT'S WHAT'S CHECKED IN THE BOX, YES.
5 Q. DO YOU HAVE ANY PERSONAL KNOWLEDGE OF WHAT BROUGHT HIM
6 TO THE POINT OF DEATH THE 14TH OF JANUARY?
7 A. NO, I DO NOT.
8 Q. IF YOU WOULD TURN TO PAGE 77. YOU WROTE THAT PATIENT'S
9 LEVEL OF AWARENESS HAS BEEN PROGRESSIVELY SINKING OVER THE
10 SHIFT AND YOU TALK ABOUT ALL FAMILY MEMBERS HAVE BEEN
11 PRESENT INTERMITTENTLY. 0500 A DOSE OF MORPHINE AND ATIVAN
12 WERE GIVEN AT 4:30 DUE TO PATIENT GRIMACING AND LABORED
13 BREATHING INDICATING HIS LEVEL OF DISTRESS. AND, AGAIN,
14 THIS WAS IN THE NURSING ASSESSMENT THAT YOU MADE?
15 A. THAT'S CORRECT.
16 Q. DO YOU HAVE ANY IDEA OR DO YOU HAVE ANY -- I SHOULDN'T
17 SAY IDEA.
18 DO YOU KNOW WHAT WAS CAUSING HIS DISTRESS AT THAT TIME?
19 A. AS THE NURSE, IF IT WERE A MEDICAL DIAGNOSIS, THAT WOULD
20 NOT BE FOR ME TO DETERMINE. IF IT WERE A POSITIONING ISSUE,
21 A LEVEL OF PAIN, THOSE ARE THINGS THAT I COULD INTERVENE
22 WITH.
23 Q. SO YOU MADE A NURSING ASSESSMENT AT THAT TIME THAT THE
24 GRIMACING AND LABORED BREATHING SHOWED HIS LEVEL OF
25 DISTRESS.
3212
1 A. (WITNESS NODS HEAD.)
2 THE COURT: YOU'LL HAVE TO ANSWER OUT LOUD.
3 THE WITNESS: YES, I'M SORRY.
4 Q. (BY MS. BARLOW) WE FORGET THAT WE HAVE A REPORTER HERE
5 THAT HAS TO TAKE IT DOWN.
6 AT THIS POINT IT'S 1/14, THE 14TH OF JANUARY, IT'S
7 5 O'CLOCK IN THE MORNING, YOU JUST READ THAT HE EXPIRED AT
8 9:36 SO THIS IS ABOUT FOUR AND A HALF HOURS PRIOR TO HIS
9 DEATH, COULD THE LABORED BREATHING BE INDICATIONS THAT HE IS
10 HYPOXIC OR LACKING IN OXYGEN?
11 MR. STIRBA: YOUR HONOR, WITHOUT MORE FOUNDATION
12 I'M GOING TO OBJECT BEYOND THE SCOPE OF HER COMPETENCY.
13 THE COURT: OKAY. ARE YOU ASKING HER WHAT HER
14 MEDICAL OPINION IS?
15 MS. BARLOW: WELL, HER NURSING ASSESSMENT. WITH
16 HER NURSING TRAINING CAN SHE SAY --
17 THE COURT: WELL, LAY A FOUNDATION AND IF SHE HAS
18 AN UNDERSTANDING OF THAT.
19 Q. (BY MS. BARLOW) BASED ON YOUR TRAINING AS A NURSE, DO
20 YOU KNOW WHETHER LABORED BREATHING CAN BE CAUSED BY HYPOXIA
21 OR LACK OF OXYGEN?
22 A. THE PATIENT WOULD HAVE TO HAVE OTHER SYMPTOMS ALSO
23 INDICATING HYPOXIA.
24 Q. PLEASE, IF YOU'LL JUST ANSWER MY QUESTION.
25 BASED ON YOUR TRAINING, DO YOU KNOW WHETHER LABORED
3213
1 BREATHING CAN BE CAUSED BY HYPOXIA?
2 A. CERTAIN TYPES OF LABORED BREATHING.
3 Q. THANK YOU. YOU DIDN'T --
4 A. MORE PARTICULARLY SHORTNESS OF BREATH.
5 Q. BUT YOU DIDN'T WRITE SHORTNESS OF BREATH.
6 A. NO, I WROTE LABORED BREATHING.
7 Q. BUT DO YOU HAVE ANY INDEPENDENT RECOLLECTION OF JUST
8 WHAT HIS BREATH WAS LIKE AT THAT TIME?
9 A. I WROTE LABORED BREATHING, THEREFORE IT MEANS THAT HE
10 WAS WORKING VERY HARD TO TAKE A DEEP BREATH.
11 Q. ISN'T IT TRUE THAT DRUGS THAT HAVE SEDATIVE EFFECTS,
12 CENTRAL NERVOUS SYSTEM DEPRESSANT EFFECTS CAUSE A PERSON TO
13 FORGET TO BREATH?
14 MR. STIRBA: I WOULD OBJECT --
15 Q. (BY MS. BARLOW) OR MAY CAUSE?
16 MR. STIRBA: I'LL OBJECT, YOUR HONOR, SHE'S NOT
17 HERE AS AN EXPERT.
18 THE COURT: SUSTAINED.
19 Q. (BY MS. BARLOW) BASED ON YOUR TRAINING AS A NURSE, DO
20 YOU KNOW THE EFFECTS OF CENTRAL NERVOUS SYSTEM DEPRESSANT
21 DRUGS?
22 A. YES, I DO.
23 Q. DO YOU KNOW IF THEY HAVE ANY AFFECT ON BREATHING?
24 A. THEY WILL CAUSE BREATHING TO BECOME SHORTER AND MORE
25 SHALLOW.
3214
1 Q. SO THEY DO HAVE AFFECT ON BREATHING? YOU'LL HAVE TO
2 ANSWER OUT LOUD.
3 A. I'M SORRY. YES.
4 Q. SORRY TO HAVE TO KEEP REMINDING OF YOU.
5 BASED ON YOUR NURSING TRAINING AND EXPERIENCE, DO YOU
6 KNOW, JUST A YES OR NO, DO YOU KNOW WHETHER CENTRAL NERVOUS
7 SYSTEM DEPRESSANT DRUGS CAN CAUSE A PATIENT -- OR MAY CAUSE
8 A PATIENT TO FORGET TO BREATH?
9 MR. STIRBA: I'LL OBJECT, YOUR HONOR, IRRELEVANT
10 AND SHE'S NOT HERE AS AN EXPERT.
11 THE COURT: SUSTAINED.
12 MS. BARLOW: I'M NOT ASKING AS A EXPERT. JUST
13 BASED ON HER TRAINING WHETHER SHE KNOWS.
14 THE COURT: OKAY. THE QUESTION IS SUSTAINED.
15 Q. (BY MS. BARLOW) AS A NURSE, WHEN SOMEONE HAS HAD A
16 SEDATIVE, DO YOU HAVE TO TELL THEM TO BREATHE, A PATIENT TO
17 BREATHE?
18 MR. STIRBA: YOUR HONOR, I'LL OBJECT, IT'S A
19 HYPOTHETICAL QUESTION, IT'S IMPROPER.
20 THE COURT: SUSTAINED.
21 Q. (BY MS. BARLOW) BASED ON THE DRUGS THAT THESE PEOPLE
22 HAD BEEN GIVEN -- WELL, LET'S SAY MR. ALLDREDGE, WAS HE
23 SEDATED?
24 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT, LACK
25 OF FOUNDATION AND CALLS FOR AN OPINION.
3215
1 THE COURT: SUSTAINED.
2 Q. (BY MS. BARLOW) LET'S TURN TO THE MASTER TREATMENT
3 PLAN AGAIN, PAGE 92.
4 A. OKAY.
5 Q. AT THE TOP YOU WROTE DEATH AND DYING ISSUES R.F.?
6 A. RELATED TO, R.T.
7 Q. R.T., SORRY. IT'S HARD ON COPIES SOMETIMES TO READ WHAT
8 THEY SAY. R.T., RELATED TO LEFT OCCIPITAL C.B.A. ACUTE
9 1/13. WHERE DID YOU GET THE INFORMATION THAT THERE WAS AN
10 ACUTE LEFT OCCIPITAL CVA ON THE 13TH?
11 A. I DON'T RECALL AT THIS POINT.
12 Q. DID YOU DIAGNOSE THAT THERE WAS A PENDING DEATH?
13 A. YES.
14 Q. IN ENNIS ALLDREDGE?
15 A. YES.
16 Q. IT WASN'T A NURSING ASSESSMENT, THAT WAS A DIAGNOSIS?
17 A. A NURSING ASSESSMENT LEADS TO A NURSING DIAGNOSIS. A
18 NURSING DIAGNOSIS IS THE TERMINOLOGY FOR THE SHORTER
19 VERSIONS OF STATEMENTS THAT WE MAKE AND THE TITLES THAT ARE
20 UNDERNEATH, THERE IS A CARE PLAN. IT'S AN ORGANIZATIONAL
21 TECHNIQUE.
22 Q. IF YOU WOULD PULL OUT LYDIA SMITH'S BINDER. OH, I'M
23 SORRY, BEFORE WE LEAVE MR. ALLDREDGE...I APOLOGIZE FOR GOING
24 BACK AND FORTH.
25 IF YOU WOULD TURN TO PAGE 47.
3216
1 A. OKAY.
2 Q. I WANT TO CLEAR UP SOMETHING. IN FACT, LET'S TURN
3 THIS -- THERE WE GO. THIS IS THE MEDICAL RECORD, EVIDENTLY
4 ORDERS WERE MADE ON THE 13TH WHICH IS THE DAY BEFORE HE DIED
5 AND YOU START AT 8 O'CLOCK IN THE MORNING AND THEN WE RUN
6 DOWN THROUGH 2300, EVIDENTLY IT WAS EVERY THREE HOURS. THEN
7 WHEN WE GET TO TWO AND FIVE -- 0200 AND 0500, THOSE WEREN'T
8 GIVEN ON THE 13TH, WERE THEY?
9 A. THAT WOULD BE -- IT DEPENDS ON HOW THEY DIVIDED THE
10 SHIFT REPORT OUT -- HOW YOU COUNT THE DAY IT DEPENDS ON THE
11 NURSING SCHEDULE. IS THE NIGHT SHIFT THE NIGHT SHIFT OF THE
12 DAY PREVIOUS OR IS IT THE FIRST SHIFT OF THE FOLLOWING DAY,
13 AND SO THE NUMBERS ARE BASED ON THAT FORMAT.
14 Q. RIGHT.
15 A. MEANING THAT THE NIGHT SHIFT APPLIES TO THE PREVIOUS
16 DAY, NOT THE FOLLOWING MORNING.
17 Q. SO IF THE ORDER WAS -- SO IF THE MORPHINE WAS ORDERED
18 AND THEN I'M LOOKING AT PAGE 13, ON 1/13/96 AND NOTED BY
19 EARLENE COZZENS AT 800, 0800, THAT'S WHEN SHE WOULD HAVE
20 WRITTEN THIS OUT; IS THAT CORRECT?
21 A. THAT'S RIGHT.
22 Q. SO THE FIRST DOWN TO 2300, WOULD HAVE BEEN GIVEN ON THE
23 13TH; IS THAT CORRECT?
24 A. THAT'S CORRECT.
25 Q. AND ACTUALLY THE 0200 AND THE 0500 WERE GIVEN ON THE
3217
1 14TH AS THE REST OF US TELL TIME AFTER MIDNIGHT, AS OPPOSED
2 TO NURSES?
3 A. YEAH.
4 Q. AS YOU'VE JUST EXPLAINED. SO TECHNICALLY, THOSE TWO
5 THAT YOU ADMINISTERED AT 0200 AND IT LOOKS LIKE 0430 YOU
6 WROTE WERE GIVEN THE 14TH, AND THEN WE HAVE SOMEONE ELSE WHO
7 GAVE ANOTHER DOSE AT 8 O'CLOCK THAT MORNING?
8 A. THAT'S RIGHT.
9 Q. OKAY. THANK YOU. AND THOSE WERE GIVEN AS SCHEDULED; IS
10 THAT CORRECT?
11 A. THAT'S CORRECT.
12 Q. THEY WERE NOT P.R.N.?
13 A. NO.
14 Q. BUT YOU OBVIOUSLY DIDN'T SEE ANY NEED TO HOLD THAT
15 MEDICATION BECAUSE YOU DIDN'T HOLD IT?
16 A. THAT'S CORRECT.
17 Q. NOW LET'S LOOK AT LYDIA SMITH. MAYBE WE'LL START WITH
18 PAGE 698 SO WE GET OUR TIME PARAMETERS HERE, WHILE
19 RECOGNIZING THAT YOU DON'T HAVE AN INDEPENDENT RECOLLECTION
20 OF THIS.
21 A. I'M SORRY, WHERE ARE WE?
22 Q. LYDIA SMITH 698 ADMIT.
23 A. OKAY.
24 Q. SO SHE CAME IN ON THE 20TH OF DECEMBER; IS THAT CORRECT?
25 IT'S HARD TO READ THERE AT THE TOP.
3218
1 A. IS IT AT THE TOP?
2 Q. YES. ADMIT DATE THIRD BOX OVER.
3 A. 12/20/95 IT SAYS.
4 Q. 12/20/95. AND AT THE BOTTOM WE HAVE -- SO THAT'S AT THE
5 TOP AT 12/20/95 AND THEN AT THE BOTTOM WE HAVE THE DISCHARGE
6 DATE OF WHAT DATE?
7 A. MY COPY SAYS -- THE MONTH IS NOT LEGIBLE AND THEN 8/96.
8 Q. SO JANUARY 8TH, '96?
9 A. THAT MAY BE, IF THAT'S WHAT YOUR YOURS SAYS.
10 Q. AND AT WHAT TIME?
11 A. 12:45 P.M. THIS SAYS.
12 Q. AND IT'S MARKED DOWN HERE THAT --
13 A. EXPIRED.
14 Q. -- THE PATIENT HAD EXPIRED? SO NOW WE KNOW THE TIME
15 FRAME WE'RE WORKING WITHIN. IF YOU WOULD TURN TO 719, THIS
16 IS A PROGRESS NOTE AND IT WAS WRITTEN WHAT DATE THE ONE AT
17 THE BOTTOM, THE ONE THAT YOU WROTE?
18 A. THE MONTH IS NOT LEGIBLE, 8/96.
19 Q. SO JANUARY 8TH YOU WROTE THAT PHYSICAL CONDITION WAS
20 MARKEDLY DETERIORATED, SHE'S UNABLE TO SWALLOW FOOD, FLUID
21 OR MEDICATION. THIS WAS WRITTEN THE DAY SHE DIED; IS THAT
22 CORRECT?
23 A. I'LL HAVE TO CHECK.
24 Q. WELL, WE JUST READ THAT SHE DIED ON THE 8TH AT 12:45.
25 A. OKAY, THAT'S FINE.
3219
1 Q. I'M SORRY. I'M NOT TRYING TO TRIP YOU UP HERE.
2 SO THIS WAS WRITTEN THE DAY THAT SHE DIED. LET'S LOOK
3 AT NURSING NOTES FOR THE 8TH, SEE IF WE CAN DETERMINE WHAT
4 SHIFT YOU WORKED THAT DAY. IF YOU WOULD LOOK AT 802, YOU
5 WORKED THE 11 TO 7 SHIFT THAT DAY. WELL, I'M SORRY, I'LL
6 WAIT UNTIL YOU GET TO IT.
7 A. IT STATES 11 TO 7 IS MY NOTE.
8 Q. SO YOU WOULD HAVE WRITTEN THIS WEEKLY R.N. ADVOCATE NOTE
9 SOMETIME BETWEEN 11 AND 7?
10 A. MOST LIKELY, UNLESS I WAS THERE EARLY OR LATE FOR SOME
11 REASON.
12 Q. SHE'S UNABLE TO SWALLOW FOOD, FLUID OR MEDICATION SO
13 THAT'S A PERCEPTION, OF COURSE, THAT YOU HAD AT THE TIME?
14 A. THAT'S CORRECT.
15 Q. BASED ON YOUR NURSING TRAINING AND EXPERIENCE, DO
16 SEDATIVE DRUGS INTERFERE WITH THE ABILITY TO SWALLOW?
17 MR. STIRBA: OBJECT, YOUR HONOR.
18 THE COURT: SUSTAINED.
19 Q. (BY MS. BARLOW) LET'S -- LOOK AT LET'S LOOK AT 800
20 WHICH IS A NOTE THAT YOU MADE ON THE 7TH WHICH WAS THE DAY
21 BEFORE. 11 TO 7 SHIFT, YOU WROTE PATIENT RESTED QUIETLY
22 THROUGH THE SHIFT, MINIMALLY RESPONSIVE TO MORNING A.M.
23 CARES. RESPIRATION SLOW, DEEP AND REGULAR.
24 YOU INDICATE THAT THEY ARE SLOW BUT YOU DIDN'T NOTE HOW
25 MANY RESPIRATIONS PER MINUTE; IS THAT CORRECT?
3220
1 A. THERE IS A DOCUMENTATION OF HER VITAL SIGNS. IN THE
2 GEROPSYCHIATRIC ASSESSMENT THERE'S A PHYSICAL ASSESSMENT
3 COMPONENT THAT ACCOMPANIES THE NOTE, HER RESPIRATORY RATE AT
4 THAT TIME IS DOCUMENTED AT 16 PER MINUTE.
5 Q. AND WHO WROTE THAT DOCUMENTATION?
6 A. THAT APPEARS TO BE SOMEONE ELSE'S HANDWRITING. IT COULD
7 BE THE NURSING ASSISTANT.
8 Q. YOU DON'T HAVE ANY INDEPENDENT KNOWLEDGE RIGHT NOW WHAT
9 TIME THOSE VITAL SIGNS WERE WRITTEN?
10 A. I HAVE A RECOLLECTION THAT THE INITIAL ASSESSMENTS FOR
11 THE PATIENTS, WHICH IS WHAT THESE ARE, VITAL SIGNS WERE DONE
12 BY THE NIGHT SHIFT IN THE MORNING.
13 Q. AND THEY ARE 16. WAS THAT SLOW TO YOUR MIND?
14 A. SLOW/NORMAL.
15 Q. BUT SLOW/NORMAL, WOULD YOU HAVE WRITTEN SLOW IN YOUR
16 NOTES?
17 A. THAT WAS THE TYPICAL WAY FOR ME TO DESCRIBE A PATIENT
18 WHO IS BREATHING SLOW AND REGULARLY IN SLEEP.
19 Q. ISN'T 12 TO 16 USUALLY NORMAL RESPIRATIONS PER MINUTE?
20 A. NORMAL, YES.
21 Q. SIXTEEN, IS THAT THE HIGH OR THE LOW END OF NORMAL?
22 A. NORMAL CAN BE AS HIGH AS 24.
23 Q. IF YOU WOULD TURN TO 802 YOU WRITE PRETEXT THAT, PATIENT
24 LYING IN BED WITH EYES OPEN THROUGHOUT SHIFT -- IS THAT
25 SHIFT?
3221
1 A. UH-HUH.
2 Q. THANK YOU. IS THAT DEMONSTRATES MUCH REFLEXIVE GRASPING
3 IN RESPONSE TO PHYSICAL STIMULI?
4 A. UH-HUH.
5 Q. BASED ON YOUR NURSING -- WELL, DO YOU HAVE ANY KNOWLEDGE
6 BASED ON YOUR NURSING EXPERIENCE ABOUT REFLEXIVE GRASPING AS
7 OPPOSED TO VOLITIONAL ACTS?
8 A. REFLEXIVE GRASPING OCCURS WHEN YOU PLACE SOMETHING IN
9 THE PATIENT'S HAND AND THEY CLOSE AROUND IT. VOLITIONAL
10 ACTS ARE MOTIVATED SPONTANEOUSLY BY THE PATIENT.
11 Q. AND DO YOU HAVE -- YOU KNOW, THIS IS YES OR NO QUESTION.
12 DO YOU HAVE ANY KNOWLEDGE BASED ON YOUR NURSING TRAINING AS
13 TO WHAT CAUSES A PERSON TO DO REFLEXIVE ACTS AS OPPOSED TO
14 VOLITIONAL ACTS?
15 A. PATIENTS WHO DO REFLEXIVE ACTS HAVE USUALLY SEVERE
16 DAMAGE TO THEIR BRAIN FROM SOME SOURCE.
17 Q. AND BASED ON YOUR NURSING KNOWLEDGE, DO YOU KNOW WHETHER
18 HYPOXIA COULD CAUSE BRAIN DAMAGE?
19 MR. STIRBA: YOUR HONOR, I'LL OBJECT.
20 THE COURT: SUSTAINED.
21 Q. (BY MS. BARLOW) AS A NURSE, ARE YOU TRAINED TO KNOW
22 WHAT CAUSES BRAIN DAMAGE?
23 MR. STIRBA: I WOULD OBJECT AS TO RELEVANCE, YOUR
24 HONOR.
25 THE COURT: LET'S DO THAT -- LET'S DISCUSS THESE
3222
1 THINGS AT BREAK AND GO ON TO SOMETHING ELSE.
2 Q. (BY MS. BARLOW) ABOUT MIDWAY DOWN ON PAGE 802, YOU
3 HAVE 2400 HOUR DOSE OMITTED DUE TO PATIENT APPEARED IN NO
4 ACUTE DISTRESS AT THE TIME AND NURSING STAFF WAS ATTENDING
5 ANOTHER DYING PATIENT AND HER FAMILY. DO YOU KNOW WHETHER
6 THAT WAS MARY CRANE?
7 A. I DO NOT KNOW.
8 Q. THE 0300 DOSE WAS GIVEN AT 0230, RESPIRATION RATE 10 TO
9 12. ISN'T THAT A SLOW RESPIRATION RATE?
10 A. IT'S STILL WITHIN NORMAL.
11 Q. DID YOU SEE SIGNS OF ACUTE DISTRESS HERE IN THIS PATIENT
12 AT 0230 NECESSITATING MORPHINE?
13 A. SHE WAS RECEIVING A SCHEDULED DOSE OF MORPHINE.
14 Q. BUT AT THIS POINT SHE HAD APNEA FROM 10 TO 20 SECONDS,
15 SO IF YOU HAD 20 SECONDS BETWEEN BREATHS YOU ARE -- IN A
16 60-SECOND MINUTE, YOU ARE MAYBE, WHAT, THREE BREATHS PER
17 MINUTE, FOUR?
18 A. I DON'T RECALL THIS PATIENT.
19 Q. NOW, WITH THESE FIVE PATIENTS AND LET'S START SINCE WE
20 HAVE LYDIA SMITH'S BINDER HERE, THE MASTER TREATMENT PLAN
21 WHICH IS STARTS AT 815 FOR LYDIA SMITH. YOU HAVE INSERTED
22 ON THE FIRST PAGE AT 815 -- FIRST THERE WAS -- SOMEONE ELSE
23 WROTE ALTERED THOUGHT PROCESSES ON 12/20 AS THE MASTER
24 PROBLEM LIST?
25 A. THAT'S RIGHT.
3223
1 Q. AND THEN ON THE 8TH YOU WROTE DEATH AND DYING ISSUES; IS
2 THAT CORRECT?
3 A. THAT'S CORRECT.
4 Q. AND THEN ON 818 YOU WENT INTO SHORT-TERM GOALS AND
5 LONG-TERM GOALS AND THIS WAS IN YOUR HANDWRITING?
6 A. THAT'S CORRECT.
7 Q. SO YOU DETERMINED THAT YOU WERE AT THIS POINT WITH DEATH
8 AND DYING ISSUES ON THE 8TH OF JANUARY?
9 A. APPARENTLY.
10 Q. AND INDEED SHE DIED ON THE 8TH OF JANUARY; IS THAT
11 CORRECT?
12 A. IF THAT'S WHAT THE RECORD STATES, YEAH.
13 Q. DID YOU MAKE ANY ASSESSMENT AS TO WHAT BROUGHT HER TO
14 DEATH AND DYING ISSUES ON THE 8TH OF JANUARY?
15 A. THAT WOULD BE A MEDICAL DIAGNOSIS BEYOND MY SCOPE.
16 Q. LET'S LOOK AT THE MASTER TREATMENT PLAN FOR JUDITH
17 LARSEN. IN THE INTEREST OF TIME, I'LL REPRESENT TO YOU THAT
18 THE MASTER TREATMENT PLAN DOES NOT DEAL WITH DEATH AND DYING
19 ISSUES. SO LET'S LOOK BACK AT MED-596 FOR JUDITH LARSEN
20 WHICH IS IN THE CARDEX. THIS IS THE NURSING CARE PROGRAM
21 THAT YOU WROTE. IT APPEARS -- IN FACT, LET ME ASK YOU:
22 ISN'T THAT YOUR HANDWRITING WHEN YOU GET TO 596?
23 A. WHEN I GET THERE. UH-HUH.
24 Q. YOU WROTE THAT; IS THAT CORRECT?
25 A. UH-HUH.
3224
1 Q. AND AS DEATH AND DYING ISSUES ALTERNATIVE -- WELL,
2 ALTERNATIVE -- WELL, A.L.T., COPING PATIENT AND FAMILY DEATH
3 AND DYING ISSUES. PATIENT WILL EXPERIENCE A PEACEFUL DEATH
4 FREE FROM DISCOMFORT. YOU WROTE THAT, IT APPEARS, ON THE
5 2ND OF JANUARY?
6 A. THAT'S CORRECT.
7 Q. I'LL REPRESENT TO YOU ON THE ADMISSION IT INDICATES THAT
8 SHE DIED ON THE 3RD OF JANUARY, IT DOESN'T GIVE A TIME ON
9 THIS BUT SHE DID EXPIRE ON THE 3RD OF JANUARY, SO YOU WROTE
10 THIS THE DAY BEFORE SHE DIED; IS THAT CORRECT?
11 A. THAT APPEARS TO BE TRUE.
12 Q. DID YOU HAVE ANY RECOLLECTION OF WHAT LED UP TO HER
13 DEATH?
14 A. I DON'T AT THIS TIME, NO.
15 Q. ENNIS ALLDREDGE, LET'S LOOK TO THE MEDICAL TREATMENT
16 PLAN ON PAGE 90.
17 A. OKAY.
18 Q. THE 14TH YOU WROTE DEATH AND DYING ISSUES AND I THINK
19 WE'VE ALREADY ESTABLISHED THAT THE 14TH WAS THE DAY THAT HE
20 DIED. DO YOU HAVE ANY KNOWLEDGE OF WHAT LED UP TO HIS DEATH
21 ON THE 14TH?
22 A. NO, I HAVE NO RECOLLECTION.
23 Q. LET'S LOOK AT ELLEN ANDERSON.
24 A. I'M SORRY?
25 Q. ELLEN ANDERSON.
3225
1 A. OKAY.
2 Q. AND PAGE 196 THE MEDICAL TREATMENT PLAN INDICATES
3 ANXIETY, THAT WAS NOTED ON 12/29 WHICH IS WHEN SHE CAME IN.
4 A. OKAY.
5 Q. AND THEN SHE PASSED AWAY AT 8:55 THE NEXT MORNING. IS
6 THERE ANY INDICATION OF DEATH AND DYING ISSUES WITH ELLEN
7 UNDERSTAND?
8 A. NO.
9 Q. AND YOU DON'T KNOW WHAT LED UP TO HER DEATH?
10 A. I'M SORRY, NO.
11 Q. MARY CRANE, I'LL JUST REPRESENT TO YOU THAT SHE -- THERE
12 ARE A LOT OF MEDICAL RECORDS THAT YOU...
13 A. YOU DON'T WANT TO KNOW.
14 Q. AND I KNOW THEY GET CUMBERSOME.
15 A. NOT GOOD.
16 Q. IF YOU WOULD --
17 A. VERY CAREFULLY.
18 Q. -- OPEN TO 347.
19 A. EASIER SAID THAN DONE AT THIS MOMENT.
20 Q. IT'S UNDER MEDICAL TREATMENT PLAN. DID THEY CALL COME
21 OUT? ARE YOU 347 -- WELL, RATHER THAN --
22 A. YES.
23 Q. OKAY. YOU DO HAVE 347?
24 A. YES.
25 Q. NOW, YOU DID NOT ON THE MASTER TREATMENT PLAN INDICATE
3226
1 ANY ALTERATION TO DEATH AND DYING ISSUES ON THAT PLAN, DID
2 YOU?
3 A. I DID NOT, NO.
4 Q. AND, IN FACT, -- WELL, OKAY. BUT THEN LET'S LOOK AT THE
5 CARDEX. YOU DID WRITE A NURSING CARE PROGRAM ON THE 28TH OF
6 DECEMBER; IS THAT CORRECT?
7 A. WHAT PAGE NUMBER?
8 Q. I'M SORRY, THAT'S 335. DID YOU WRITE ANYTHING ABOUT
9 DEATH AND DYING ISSUES?
10 A. ARE WE IN CARDEX?
11 Q. ON CARDEX.
12 A. I DID NOT, NO.
13 Q. DID ANYONE ELSE THAT YOU CAN SEE?
14 A. NO.
15 Q. WHEN YOU WROTE ON I BELIEVE IT'S THREE OF THESE PATIENTS
16 THAT THE CARE PLAN HAD CHANGED TO DEATH AND DYING ISSUES,
17 YOU KNEW THEY WERE DYING AT THAT POINT; IS THAT CORRECT?
18 A. THAT WOULD HAVE BEEN MY IMPRESSION, YES.
19 Q. AND YOU KNEW THAT THERE WAS PROBABLY LITTLE YOU COULD DO
20 TO STOP THE PROCESS AT THAT POINT; IS THAT CORRECT?
21 A. THAT'S CORRECT.
22 Q. BUT YOU DIDN'T WRITE THOSE DEATH AND DYING ISSUES ON
23 THEIR ADMISSION, DID YOU?
24 A. THAT -- I DON'T HAVE A SPECIFIC RECOLLECTION OF WHEN I
25 WROTE EACH FOR EACH PATIENT AND WE'VE BEEN GOING THROUGH
3227
1 THAT HERE.
2 Q. IN FACT, WHEN THEY CAME ON THE UNIT, YOU DIDN'T SEE THAT
3 THEY WERE DYING AT THAT POINT, IS THAT CORRECT?
4 MR. STIRBA: WELL, I'M GOING TO OBJECT, YOUR HONOR,
5 WITHOUT RELEVANCE TO THE FACT THAT SHE EVEN SAW THE PATIENTS
6 AT THAT TIME.
7 THE COURT: IF YOU WANT TO LAY A FOUNDATION THAT
8 SHE DID SO.
9 MS. BARLOW: WELL, WE DON'T WANT TO GO THROUGH
10 EVERY BINDER AGAIN SO I WILL WITHDRAW THAT QUESTION.
11 Q. (BY MS. BARLOW) MARY CRANE HAD A DURAGESIC PATCH
12 ADMINISTERED TO HER, ARE YOU AWARE OF THAT?
13 A. I WOULD BE IF I LOOKED AT THE RECORD.
14 Q. HOW ABOUT IF I REPRESENT TO YOU THAT THAT'S CORRECT?
15 A. THAT'S FINE.
16 MR. STIRBA: YOUR HONOR, I'LL OBJECT TO THE FORM OF
17 THAT QUESTION. I DON'T THINK THE WITNESS IS HERE TO BRIEF
18 COUNSEL.
19 THE COURT: OKAY. WELL, JUST ASK THE QUESTION.
20 Q. (BY MS. BARLOW) THEN WE WILL GO TO THE PHYSICIAN'S
21 ORDER FOR MARY CRANE, SPECIFICALLY PAGE 239.
22 A. OKAY.
23 Q. AND IT APPEARS THAT ON THE 28TH OF DECEMBER THERE WERE
24 TWO ORDERS FOR DURAGESIC PATCH. ONE AT 1915 FOR
25 25 MICROGRAMS AND THEN ONE SLIGHTLY LATER CHANGE DURAGESIC
3228
1 TO 50 MICROGRAMS TRANSDERMAL PATCH EVERY THREE DAYS AND YOU
2 NOTED BOTH OF THOSE; IS THAT CORRECT?
3 A. THAT'S MY SIGNATURE, YES.
4 Q. YOU NOTED ONE THAT IT LOOKS LIKE 1900 HOURS; IS THAT
5 CORRECT?
6 A. THAT COULD BE. IT COULD BE 19, IT COULD BE 17, I...
7 Q. AND THEN YOU NOTED THE OTHER ONE AT 2100 HOURS; IS THAT
8 CORRECT?
9 A. THAT'S CORRECT.
10 Q. BASED ON YOUR NURSING EXPERIENCE, ARE YOU FAMILIAR WITH
11 DURAGESIC PATCHES?
12 A. YES.
13 Q. AND DO YOU KNOW WHAT THEY DO?
14 A. YES.
15 Q. DO THEY CAUSE SEDATION?
16 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT TO
17 THAT QUESTION.
18 THE COURT: OKAY. WHY DON'T -- LADIES AND
19 GENTLEMEN, I THINK WE'VE BEEN GOING ALMOST AN HOUR THIS
20 MIGHT BE A GOOD TIME THAT WE CAN TAKE A QUICK BREAK AT THE
21 MORNING.
22 AT THIS TIME, REMEMBER IT'S YOUR DUTY NOT TO CONVERSE
23 AMONG YOURSELVES OR TO CONVERSE WITH OR ALLOW YOURSELVES TO
24 BE ADDRESSED BY ANY OTHER PERSON ON THE SUBJECT OF THIS
25 TRIAL. IT'S ALSO YOUR DUTY NOT TO FORM OR EXPRESS ANY
3229
1 OPINION UNTIL THE CASE IS FINALLY SUBMITTED TO YOU. WHY
2 DON'T YOU COME BACK AT 15 MINUTES TO TEN.
3 (WHEREUPON THE JURY WAS EXCUSED.)
4 THE COURT: PLEASE BE SEATED. THE RECORD WILL
5 REFLECT THAT THE JURY HAS LEFT THE COURTROOM. DO YOU WANT
6 TO DISCUSS THESE QUESTIONS AND DISCUSS REGARDING THE LAST I
7 THINK THE LAST QUESTION AND OTHER QUESTIONS?
8 MR. STIRBA: YES, YOUR HONOR. I THINK THAT A
9 NURSE -- CERTAINLY WE'VE HAD THIS SINCE THE NURSES ARE
10 INVOLVED IN GIVING SOME MEDICATIONS, I THINK THEY CAN
11 GENERALLY SAY AND THEY HAVE WHAT A MEDICATION IS IF THEY
12 HAVE SOME GENERAL UNDERSTANDING WHAT IT GENERALLY DOES, I
13 THINK THAT'S FAIR. BUT THEN TO ASK A QUESTION, DO THEY
14 CAUSE SEDATION? FIRST OF ALL, THE REAL ISSUE IS IN THIS
15 CASE, GIVEN ALL THE FACTS AND CIRCUMSTANCES, DID THIS
16 PARTICULAR DRUG HAVE A POSITIVE EFFECT OR A NEGATIVE EFFECT
17 WITH RESPECT TO THE CONDITION OF THIS PATIENT, AND IF IT HAD
18 A NEGATIVE EFFECT, WHAT SIGNIFICANCE, IF ANY, DOES THAT
19 HAVE. THOSE ARE YOU ALL MEDICAL KIND OF JUDGEMENTS.
20 THE FACTS OBVIOUSLY, AND I THINK EVERY PHYSICIAN THAT'S
21 TESTIFIED IN THIS COURTROOM HAS SAID, MEDICATIONS ARE
22 INDIVIDUALIZED, THEY DEPEND ON ALL THE CIRCUMSTANCES THAT
23 ARE PRESENTED. AND OBVIOUSLY THIS WITNESS DOESN'T HAVE THAT
24 KIND OF COMPETENCE, DOESN'T HAVE THAT EXPERTISE, SHE'S NOT A
25 DOCTOR, SHE'S NOT HERE AS AN EXPERT.
3230
1 SO TO ASK HER A QUESTION DO THEY CAUSE SEDATION, FIRST
2 OF ALL, IS AN IRRELEVANT QUESTION. SECOND OF ALL, IT'S
3 BEYOND THE SCOPE OF HER COMPETENCE, AND THIRD OF ALL, I
4 THINK IT'S CALLING FOR HER TO KNOW FACTS FOR WHICH SHE
5 CLEARLY WOULDN'T KNOW ANYWAY. SHE DIDN'T TREAT THIS WHOLE
6 PATIENT, SHE DIDN'T FOLLOW THIS WHOLE PATIENT, SHE'S NOT A
7 MEDICAL DOCTOR, SO THAT'S MY CONCERN. AND I THINK THE OTHER
8 QUESTION AND I CAN'T REMEMBER THE QUESTION, JUDGE, BUT I
9 THINK IS IN A SIMILAR BROAD VEIN AND THAT'S REALLY MY
10 POSITION.
11 THE COURT: OKAY. MS. BARLOW?
12 MS. BARLOW: YOUR HONOR, SHE AS A NURSE I THINK
13 SHE'S TESTIFIED SHE KNOWS WHAT DRUGS DO AND I AGREE WITH MR.
14 STIRBA THAT, YOU KNOW, A NURSE NEEDS TO KNOW WHAT DRUGS DO.
15 SHE ALSO HAS TESTIFIED THAT SHE MAKES AN ASSESSMENT AS TO
16 WHETHER, YOU KNOW, THERE ARE CERTAIN SIDE EFFECTS, WHETHER
17 SHE SHOULD ACTUALLY ADMINISTERED THE DRUG OR NOT. AND I
18 THINK BASED ON THAT IT'S ENTIRELY APPROPRIATE TO ASK HER
19 WHAT SHE KNOWS ABOUT A DURAGESIC AND WHETHER SHE KNOWS IT'S
20 A SEDATIVE DRUG OR NOT. I DON'T THINK THAT THAT NECESSARILY
21 CALLS FOR A DOCTOR'S OPINION OR --
22 THE COURT: WELL, YOUR QUESTION WAS THOUGH, DO THEY
23 CAUSE SEDATION.
24 MS. BARLOW: YES. AND I ASKED HER DOES SHE KNOW AS
25 A NURSE WHETHER THEY CAUSE SEDATION. SHE COULD EASILY SAY,
3231
1 NO, I DON'T KNOW. I THINK IT GOES TO NOT MAKING HER AN
2 EXPERT BUT MAKING -- TO LET THE JURY KNOW WHAT SHE KNOWS.
3 THE COURT: WELL, FIRST OF ALL, EARLIER IN HER
4 TESTIMONY YOU WERE ARGUING WITH HER THAT SHE COULDN'T MAKE A
5 DIAGNOSIS UNDER UTAH LAW AND NOW YOU ARE ASKING HER TO
6 BASICALLY GIVE OPINIONS.
7 MS. BARLOW: WELL, NOT MEDICAL OPINIONS. I'M JUST
8 ASKING HER WHAT SHE KNOWS AS A NURSE --
9 THE COURT: WELL, DO THEY CAUSE SEDATION, IS THAT
10 NOT A MEDICAL OPINION?
11 MS. BARLOW: NO. I ASKED HER DOES SHE KNOW AS A
12 NURSE WHETHER THEY CAUSE SEDATION AND IT, YOU KNOW, GOES TO
13 WHAT KNOWLEDGE A NURSE HAS ABOUT THESE DRUGS AND THEY DO
14 HAVE. I MEAN, THEY ARE NOT PHARMACOLOGISTS, THEY ARE NOT
15 MEDICAL DOCTORS, BUT THEY HAVE TO HAVE A CERTAIN --
16 THE COURT: WELL, I GUESS THE PROBLEM IS WHERE ARE
17 WE TRYING TO DO, WHAT ARE WE TRYING TO DO WITH EACH WITNESS?
18 I UNDERSTOOD THAT THIS WAS A TREATING NURSE. WE HAD FOUR,
19 FIVE, SIX OR SEVEN IN THE PLAINTIFF'S CASE. I UNDERSTOOD
20 THEY WERE GOING TO COME HERE, TESTIFY WHAT THEY DID, WHY
21 THEY DID IT AND THEIR EXPERIENCE IN DOING THIS TYPE OF STUFF
22 THAT THEY DID.
23 AND NOW, YOU KNOW, WE'VE ALREADY HAD EXPERTS THAT HAVE
24 COME IN AND TESTIFIED WHETHER THESE DRUGS CAN CAUSE
25 SEDATION, WHETHER THEY CAN DO THIS, WHETHER THEY CAN DO
3232
1 THAT. WE'VE HAD EXPERTS, WE'LL HAVE OTHER EXPERTS. WHY ARE
2 WE DOING IT WITH THIS WITNESS AND BASICALLY GOING THE WHOLE
3 CASE THROUGH A TREATING NURSE? I MEAN, BECAUSE WE'RE ASKING
4 THEM SEDATION WE'RE ASKING THEM THINGS, I MEAN IT BASICALLY
5 BECOMES A CUMULATIVE THING. WE'VE HAD FIVE OR SIX OF THE
6 EXPERTS FOR THE PLAINTIFFS THAT HAVE ALL TESTIFIED ABOUT
7 THIS.
8 MS. BARLOW: BUT I WANT TO GET AT WHAT SHE KNOWS
9 BECAUSE SHE SAID THAT SHE DIDN'T BELIEVE THAT GIVING THESE
10 DOSES WERE GOING TO CAUSE DEATH AND I WANT TO SHOW THE JURY
11 WHAT SHE KNOWS ABOUT -- NOT JUST ABOUT MORPHINE, BUT ABOUT
12 WHAT THE OTHER DRUGS MIGHT CAUSE.
13 THE COURT: BUT TO ASK HER A QUESTION DO THEY CAUSE
14 SEDATION, YOU KNOW, BASICALLY THAT'S GIVING A MEDICAL
15 OPINION. SEDATION -- YOU KNOW, BUT WHO MAKES A DECISION?
16 WHAT DOES SEDATION MEAN? WHAT IS YOUR DEFINITION OF
17 SEDATION?
18 MS. BARLOW: WELL, I THINK IT'S BEEN DEFINED.
19 THE COURT: WELL, IT HASN'T BEEN DEFINED WITH THIS
20 PERSON. I MEAN, WHAT IS IT? WHAT IS SEDATION?
21 MS. BARLOW: WELL, SEDATION IS DEPRESSING THE
22 CENTRAL NERVOUS SYSTEM AND ALL OF THE THINGS THAT HAVE BEEN
23 TESTIFIED TO.
24 THE COURT: OKAY. WELL, I THINK YOU CAN ASK A
25 QUESTION, IN YOUR EXPERIENCE, YOU KNOW, LIKE IF YOU SAY YOU
3233
1 DIAGNOSED IT -- OR YOU ASSESSED IT OR YOU DIAGNOSED IT OR
2 WHATEVER THE WORDS YOU ARE, AS THIS IN YOUR RECORD, IN YOUR
3 EXPERIENCE, COULD IT HAVE BEEN X, YOU KNOW, COULD IT HAVE
4 BEEN SOMETHING ELSE AND SHE CAN SAY YES OR NO. BUT IF YOU
5 ARE GOING TO ASK HER A QUESTION PHRASED, DID THEY CAUSE
6 SEDATION OR SOMETHING ELSE, YOU KNOW, I'M NOT GOING TO ALLOW
7 THAT.
8 I THINK YOU CAN ASK IN HER EXPERIENCE, COULD THIS BE
9 SOMETHING ELSE, THAT'S FINE. AND ASK HER, YOU KNOW, WHY SHE
10 DID WHAT SHE DID AND WHAT SHE DID, BUT NOT JUST TO GO
11 THROUGH AND ASK EVERY OPINION THAT WE'VE ALREADY ASKED
12 EXPERTS. SO WITH THAT DIRECTION THEN WE CAN COME BACK AT
13 9:45. I ALSO HAVE A MOTION THAT'S BEEN FILED, WHEN DO
14 COUNSEL WANT TO ADDRESS THAT?
15 MR. STIRBA: WHENEVER THE COURT FEELS IT IS A
16 CONVENIENT TIME.
17 THE COURT: OKAY. WELL, LET'S -- WE MIGHT DO IT
18 THEN AT THE LUNCH BREAK OR JUST AT THAT POINT. OKAY. LET'S
19 COME BACK AT 9:45.
20 (A BRIEF RECESS WAS TAKEN.)
21 THE COURT: THE RECORD WILL REFLECT THAT THE JURY
22 HAS RETURNED. MS. BARLOW, IF YOU WOULD LIKE TO CONTINUE.
23 MS. BARLOW: THANK YOU, YOUR HONOR.
24 Q. (BY MS. BARLOW) ISN'T IT TRUE, MRS. STEVENSON, THAT
25 EVERY TIME THESE PATIENTS MOANED OR GRIMACED YOU INTERPRETED
3234
1 THAT AS PAIN?
2 A. I COULDN'T SPEAK TO EVERY TIME THESE PATIENTS MOANED OR
3 GRIMACED. I HAVE NO RECOLLECTION SPECIFICALLY OF THESE
4 PATIENTS.
5 Q. IN FACT, YOU NEVER INTERPRETED MOANING AS ANYTHING ELSE;
6 IS THAT CORRECT?
7 A. I HAVE NO RECOLLECTION, I'M SORRY.
8 Q. EACH ONE OF THESE PATIENTS CAME IN AGITATIVE, COMBATIVE
9 AND ANXIOUS AND THEN DECLINED AND EVENTUALLY PASSED AWAY
10 WHILE THEY WERE ON THE UNIT; IS THAT NOT CORRECT?
11 A. THAT'S A VERY GENERAL STATEMENT. I DON'T KNOW THAT I
12 COULD AGREE SPECIFICALLY WITH THAT OR NOT.
13 Q. WELL, LET'S LOOK AT MR. ALLDREDGE, MED-PAGES 60 AND 61
14 SAY HE CAME IN COMBATIVE AND AGITATED.
15 A. DID YOU SAY 60 AND 61?
16 Q. 60 AND 61, YES. BUT PARTICULARLY 60.
17 A. THAT'S NOT MY NOTE.
18 Q. I KNOW, I RECOGNIZE THAT. BUT AT 1400 HOURS IS THE
19 ADMISSION NOTE, PATIENT IS VERY COMBATIVE AND AGITATED. DO
20 YOU RECALL HIM BEING COMBATIVE AND AGITATED?
21 A. I DON'T HAVE ANY SPECIFIC RECOLLECTION OF THIS PATIENT.
22 Q. BUT THEN YOUR LAST NOTE WITH MR. ALLDREDGE IS THAT HE
23 WAS SINKING, I BELIEVE THAT'S A NURSING ADVOCATE NOTE.
24 EXCUSE ME, IT'S NOT A NURSING -- OR A PROGRESS NOTE. IT IS
25 78 -- OR I'M SORRY. I'VE GOT THE WRONG NUMBER. THAT WON'T
3235
1 BE HELPFUL TO US.
2 ARE YOU SUFFERING FROM ANY MEDICAL PROBLEMS AT THIS
3 TIME THAT AFFECT YOUR RECOLLECTION OR YOUR ABILITY TO
4 REMEMBER?
5 A. NO.
6 Q. ARE YOU TAKING ANY MEDICATIONS AT THIS TIME THAT MIGHT
7 AFFECT YOUR MEMORY?
8 A. NO.
9 Q. WERE YOU TAKING ANY MEDICATIONS BACK IN DECEMBER AND
10 JANUARY OF '95 AND '96 THAT WOULD AFFECT YOUR MEMORY OF WHAT
11 HAPPENED THEN?
12 A. I COULD NOT STATE SPECIFICALLY.
13 Q. THERE WERE FIVE PATIENTS THAT DIED IN ABOUT 16 DAYS, DO
14 YOU RECALL THAT?
15 A. YES.
16 Q. MR. STIRBA MET WITH YOU A COUPLE OF MONTHS AGO; IS THAT
17 CORRECT?
18 A. THAT'S CORRECT.
19 Q. HE FLEW OUT TO PENNSYLVANIA TO MEET WITH YOU?
20 A. I'M SORRY?
21 Q. HE CAME OUT TO PENNSYLVANIA TO MEET WITH YOU?
22 A. YES.
23 Q. DID HE BRING RECORDS FOR YOU TO REVIEW AT THAT TIME?
24 A. YES.
25 Q. DID YOU BRING THOSE RECORDS WITH YOU TODAY?
3236
1 A. I DID NOT CARRY ANY RECORDS, NO.
2 Q. DO YOU KNOW WHETHER THEY ARE THE SAME RECORDS THAT
3 YOU'VE BEEN DEALING WITH TODAY?
4 A. THE INFORMATION APPEARS TO BE THE SAME.
5 MS. BARLOW: I THINK THAT'S ALL I HAVE, YOUR HONOR.
6 THE COURT: ANY REDIRECT?
7 MR. STIRBA: YES, YOUR HONOR.
8 REDIRECT EXAMINATION
9 BY MR. STIRBA:
10 Q. DO YOU HAVE MR. ALLDREDGE'S BINDER IN FRONT OF YOU?
11 A. YES.
12 Q. IF YOU WOULD TURN TO THE PROGRESS NOTE SECTION OF THAT
13 BINDER.
14 A. OKAY.
15 Q. NUMBER 18, DO YOU HAVE THAT?
16 A. YES.
17 Q. NOW, THERE IS A WEEKLY R.N. ADVOCATE NOTE THERE THAT IS
18 IN YOUR WRITING.
19 A. THAT'S CORRECT.
20 Q. AND YOU REFLECT IT STATES, PLEASE SEE DR. WEITZEL'S NOTE
21 ABOVE R.E.: M.R.I. RESULTS, DID YOU WRITE THAT?
22 A. YES.
23 Q. AND THEN IF YOU WOULD TURN -- AND BEFORE DO YOU THAT,
24 THE DATE OF THAT IS -- THAT NOTE IS WHAT DATE IS IT?
25 A. FOURTEENTH.
3237
1 Q. OF JANUARY?
2 A. APPEARS TO BE.
3 Q. OKAY. AND THEN IF YOU WOULD TURN, PLEASE, TO THE
4 NURSING NOTE SECTION, SPECIFICALLY 69.
5 A. OKAY.
6 Q. IS THERE WRITING AT THE BOTTOM OF THAT PAGE THAT IS
7 YOURS?
8 A. YES.
9 Q. AND IT STARTS AT 1800 HOURS AND THE DATE IS 1/12 OF '96?
10 A. 1700 HOURS.
11 Q. I'M SORRY. YES, THAT'S CORRECT. I'M DIRECTING YOUR
12 ATTENTION TO WHERE IT HAS "I," DO YOU SEE THAT?
13 A. YES.
14 Q. DO YOU JUST READ, PLEASE, THROUGH THE LAST STATEMENT
15 CONCERNING THE M.R.I.
16 A. IMPRESSION/INTERVENTION: M.R.I,DR. KLINGER CALLED TO
17 REPORT EVIDENCE OF POSSIBLE NEW INFARCT LEFT OCCIPITAL LOBE.
18 PATIENT REMAINS RESTLESS AND MINIMALLY RESPONSIVE EXCEPT TO
19 DISCOMFORT. DR. WEITZEL HAS BEEN NOTIFIED OF M.R.I.
20 RESULTS. IN VIEW OF PATIENT'S DIABETES AND POSSIBLE
21 DEHYDRATION....AND THEN IT CONTINUES ON.
22 Q. AND THEN IT CONTINUES ON FROM THERE. SEEING THIS NOTE
23 NOW, DOES THIS REFRESH YOUR RECOLLECTION AS TO WHETHER OR
24 NOT YOU WOULD HAVE BEEN CONTACTED BY DR. KLINGER OR SOMEBODY
25 FROM DR. KLINGER'S OFFICE?
3238
1 A. THE NOTE REFLECTS THAT DR. KLINGER HIMSELF CALLED TO
2 REPORT EVIDENCE OF A NEW INFARCT. I WOULD HAVE WRITTEN
3 EXACTLY WHAT HE TOLD ME.
4 Q. NOW, IF YOU COULD GET ELLEN ANDERSON'S -- YEAH, ELLEN
5 ANDERSON'S BINDER OUT, PLEASE.
6 AND SPECIFICALLY IF YOU WOULD DIRECT YOUR ATTENTION TO
7 THE DOCTOR'S ORDER, PHYSICIAN'S ORDER TAB AND IT WOULD BE
8 170.
9 A. OKAY.
10 Q. AND THIS IS A DOCUMENT THAT YOU'VE SEEN BEFORE IN YOUR
11 TESTIMONY, RIGHT?
12 A. YES.
13 Q. YOU'VE BEEN ASKED ABOUT THIS. I WANT TO DIRECT YOUR
14 ATTENTION SPECIFICALLY TO IT SAYS TYLENOL AND THEN COULD YOU
15 READ WHAT THE REST OF THAT SAYS, PLEASE?
16 A. TYLENOL TWO TIMES P.O. Q 4 HOURS P.R.N. PAIN.
17 Q. AND DID YOU CHECK WHERE IT IS CHECKED?
18 A. YES.
19 Q. AND WHY DID YOU CHECK THAT?
20 A. BECAUSE I TRANSCRIBED THE ORDER ONTO THE MEDICATION
21 ADMINISTRATION RECORD.
22 Q. AND THEN ALSO BELOW THERE THERE WAS ANOTHER ORDER AND
23 IT'S FOR MORPHINE 10 MILLIGRAMS I.M. NOW FOR PAIN, DID YOU
24 SIMILARLY CHECK THAT?
25 A. YES.
3239
1 Q. AND WHY DID YOU CHECK THAT?
2 A. BECAUSE I TRANSCRIBED IT ONTO THE MEDICAL ADMINISTRATION
3 RECORD.
4 Q. AND NOW HAVING REVIEWED THE RECORDS CONCERNING MS.
5 ANDERSON'S CARE, DO YOU RECALL THAT YOU MADE AN ASSESSMENT
6 OR OBSERVATION OF HER ON THE 29TH OF DECEMBER AT ABOUT 7:30
7 IN THE EVENING?
8 A. YES.
9 Q. AND DO YOU RECALL THE NOTE THAT I'M REFERRING TO?
10 A. I WOULD HAVE TO LOOK AT IT.
11 Q. WHY DON'T WE GET IT. IT WOULD BE IN THE NURSES' NOTES
12 SECTION AND IT WOULD BE -- IT WOULD BE MED-190.
13 A. OKAY.
14 Q. AND YOU HAVE TESTIFIED PREVIOUSLY TO EVENTS AS YOU
15 RECOLLECT THEM REGARDING THIS MED-NOTE THAT IS IN YOUR
16 WRITING; IS THAT RIGHT?
17 A. THAT'S CORRECT.
18 Q. WOULD YOU TELL US, IS THERE ANY SIGNIFICANCE IN THE FACT
19 THAT THERE WAS A DOCTOR'S ORDER FOR TYLENOL P.R.N. FOR PAIN
20 AND ALSO THERE WAS THEN AN ORDER FOR MORPHINE FOR PAIN?
21 A. THE TYLENOL ORDER IS PART OF THE STANDARD ADMITTING
22 ORDERS FOR ANY ADMISSION TO THE HOSPITAL. TO OUR PARTICULAR
23 UNIT, TYLENOL IS USED FOR MILD TO MODERATE DISCOMFORT PAIN.
24 THERE'S AN ADDITIONAL ORDER FOR MORPHINE. MORPHINE IS USED
25 FOR SEVERE PAIN IN PATIENTS WHO NEED MORE IMMEDIATE RELIEF
3240
1 OF THEIR DISTRESS. HAVING GIVEN -- IF I WERE TO GIVE A
2 TYLENOL, FOR EXAMPLE, IN A PATIENT WITH SEVERE PAIN, THEY
3 WOULD THEN HAVE TO WAIT HALF AN HOUR AT LEAST TO EVALUATE
4 THE EFFECTIVENESS OF A MEDICATION SUCH AS TYLENOL BEFORE I
5 COULD GIVE THEM SOMETHING ELSE IN ADDITION IF THEY WERE
6 HAVING SEVERE PAIN.
7 Q. WHY DO YOU SAY A HALF AN HOUR?
8 A. THAT'S THE REASONABLE AMOUNT OF TIME THAT A NURSE WAITS
9 BECAUSE THAT'S AT LEAST AS LONG AS IT WOULD TAKE FOR PAIN
10 RELIEF TO OCCUR AFTER THE PATIENT TOOK AN ORAL MEDICATION.
11 Q. WOULD YOU TELL US, PLEASE, WHY YOU DID NOT ADMINISTER
12 TYLENOL TO MRS. ANDERSON ON THE EVENING OF THE 29TH OF
13 DECEMBER?
14 A. HAVING OBTAINED A STAT ORDER FOR MORPHINE TELLS ME THAT
15 I MUST HAVE TOLD DR. WEITZEL THAT THE PATIENT WAS IN EXTREME
16 DISTRESS.
17 MS. BARLOW: YOUR HONOR, I OBJECT AS TO SOMETHING
18 SHE MUST HAVE TOLD. ONLY WHAT SHE REMEMBERS.
19 THE COURT: YES, SUSTAINED. TELL US WHAT YOU
20 REMEMBER, NOT WHAT YOU SUPPOSE.
21 THE WITNESS: THE NOTE REFLECTS THE PATIENT IN
22 EXTREME DISTRESS. THE MEDICATION WAS ORDERED FOR A PATIENT
23 IN EXTREME DISTRESS.
24 Q. (BY MR. STIRBA) IS TYLENOL A MEDICATION FOR SOMEBODY
25 WHO IS IN SEVERE PAIN?
3241
1 A. NO.
2 Q. NOW, YOU HAVE TALKED TO ME ON A COUPLE OF OCCASIONS AND
3 I HAVE SHOWN YOU SOME RECORDS FROM THE HOSPITAL; IS THAT
4 RIGHT?
5 A. YES.
6 Q. IN FACT, JUST A COUPLE OF DAYS AGO YOU REVIEWED SOME OF
7 THESE RECORDS WHICH YOU'VE TESTIFIED HERE IN COURT; IS THAT
8 RIGHT?
9 A. THAT'S CORRECT.
10 Q. DO YOU REMEMBER WHAT I ASKED YOU TO DO AT THAT TIME?
11 A. YOU ASKED ME TO REVIEW THE RECORDS TO SEE IF I HAD ANY
12 CLEAR RECOLLECTION OF A PATIENT.
13 Q. AND WHAT ELSE DID I TELL YOU?
14 A. YOU TOLD ME TO TELL THE TRUTH.
15 MR. STIRBA: THAT'S ALL I HAVE, YOUR HONOR.
16 THE COURT: ANYTHING FURTHER?
17 MS. BARLOW: YES, YOUR HONOR.
18 RECROSS-EXAMINATION
19 BY MS. BARLOW:
20 Q. IF YOU WOULD OPEN UP MR. ALLDREDGE'S BINDER AGAIN TO
21 NUMBER 69.
22 A. OKAY.
23 Q. YOU READ THE NOTE ABOUT THE M.R.I. DR. KLINGER CALLED
24 TO REPORT AND YOU JUST TESTIFIED THAT HE REPORTED EVIDENCE
25 OF A NEW INFARCT. THAT'S WHAT YOU JUST SAID ON REDIRECT?
3242
1 A. WHAT THE NOTE SAYS.
2 Q. WELL, DO YOU RECALL WHAT YOU SAID ON REDIRECT?
3 A. NO, I DON'T.
4 Q. OKAY. YOU SAID THAT DR. KLINGER SAID THERE WAS EVIDENCE
5 OF A NEW INFARCT. THAT'S NOT WHAT THE NOTE READS, IS IT?
6 A. I CAN ONLY SPEAK TO WHAT THE NOTES SAY.
7 Q. AND THE NOTE SAYS POSSIBLE NEW INFARCT; IS THAT NOT
8 CORRECT?
9 A. THAT'S CORRECT.
10 Q. DO YOU RECALL AT THIS POINT WHEN YOU REPORTED TO DR.
11 WEITZEL THE M.R.I. RESULTS WHETHER YOU SAID IT WAS A NEW
12 INFARCT OR A POSSIBLE NEW INFARCT?
13 A. I DO NOT RECALL THE CONVERSATION, NO.
14 MS. BARLOW: NO FURTHER QUESTIONS, YOUR HONOR.
15 THE COURT: ANYTHING FURTHER OF THIS WITNESS?
16 MR. STIRBA: I HAVE NONE, YOUR HONOR. THANK YOU.
17 THE COURT: MAY SHE BE EXCUSED?
18 MR. STIRBA: SHE MAY.