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 GER