Lesley Blake, MD
5 MR. BUGDEN: DR. LESLEY BLAKE.
6 THE COURT: DOCTOR, IF YOU'LL STEP UP HERE PLEASE. IF
7 YOU'D RAISE YOUR RIGHT HAND AND FACE THE CLERK, SHE'LL PLACE
8 YOU UNDER OATH.
9 IF YOU'LL HAVE A SEAT UP HERE PLEASE. STATE YOUR FULL
10 NAME AND SPELL YOUR LAST NAME PLEASE.
11 THE WITNESS: MY NAME IS LESLEY BLAKE. THAT'S
12 L-E-S-L-E-Y B-L-A-K-E.
13 THE COURT: THANK YOU.
14 BY MS. ISAACSON:
15 Q. DR. BLAKE, WHAT IS YOUR CURRENT EMPLOYMENT? WHERE DO
16 YOU WORK RIGHT NOW?
17 A. I AM CURRENTLY THE DIRECTOR OF GERIATRIC PSYCHIATRY AT
18 NORTHWESTERN UNIVERSITY MEDICAL SCHOOL IN CHICAGO, ILLINOIS.
19 I AM AN ASSOCIATE PROFESSOR OF PSYCHIATRY AND MEDICINE AT
20 NORTHWESTERN UNIVERSITY. AND I AM THE DIRECTOR OF GERIATRIC
21 PSYCHIATRY SERVICES AT NORTHWESTERN MEMORIAL HOSPITAL IN
22 CHICAGO.
23 Q. ARE YOU BOARD CERTIFIED?
24 A. I AM BOARD CERTIFIED IN PSYCHIATRY AND I ALSO HAVE THE
25 ADDED QUALIFICATON IN GERIATRIC PSYCHIATRY.
1 Q. HOW DO YOU SPEND YOUR WORKING DAYS?
2 A. I PROBABLY SPEND ABOUT HALF OF IT WORKING ON INPATIENT
3 GERIATRIC PSYCHIATRY UNIT WHERE I AM THE MEDICAL DIRECTOR.
4 AND THEN THE OTHER HALF IS INVOLVED IN DOING RESEARCH OR ELSE
5 IN TEACHING.
6 Q. ARE YOU INVOLVED IN ANY PROFESSIONAL ORGANIZATIONS?
7 A. I AM A FELLOW OF THE AMERICAN PSYCHIATRIC ASSOCIATION.
8 I AM THE SECRETARY AND THE CHAIR OF THE ETHICS COMMITTEE FOR
9 ILLINOIS PSYCHIATRIC SOCIETY. AND I AM ALSO A MEMBER OF THE
10 AMERICAN ASSOCIATION FOR GERIATRIC PSYCHIATRY WHERE I AM ON
11 THE TRAINING COMMITTEE AND THE COMMUNICATIONS COMMITEE.
12 Q. AND HAVE YOU PUBLISHED ARTICLES ABOUT PSYCHIATRIC
13 TREATMENT OF THE ELDERLY?
14 A. I HAVE PUBLISHED SEVERAL ARTICLES DEALING WITH THE DRUG
15 TREATMENT OF ELDERLY WITH PSYCHIATRIC DISORDERS.
16 Q. HAVE YOU PARTICIPATED IN CLINICAL RESEARCH TRIALS?
17 A. I HAVE PARTICIPATED IN SEVERAL DRUG TRIALS.
18 Q. AND WHAT DOES THAT MEAN FOR THE LAY PERSON?
19 A. WHAT THAT WOULD MEAN IS IT'S EITHER SPONSORED BY THE
20 DRUG COMPANY ITSELF OR ELSE ONE OF THE STUDIES I'M DOING IS
21 SPONSORED BY THE GOVERNMENT, THE NATIONAL INSTITUTE OF MENTAL
22 HEALTH. WHAT THESE STUDIES LOOK AT IS WHETHER DRUGS ARE
23 EFFECTIVE IN THE ELDERLY, HOW WELL THEY ARE TOLERATED, WHAT
24 THE SAFETY PROFILE IS.
25 Q. ARE THERE IN DRUGS THAT ARE INVOLVED IN THIS CASE THAT
1 YOU'VE STUDIED IN CLINICAL RESEARCH TRIALS?
2 A. YES. I WAS ACTUALLY INVOLVED IN THE PIVOTAL STUDY
3 LOOKING AT THE USE OF RISPERDAL IN ELDERLY DEMENTED PATIENTS.
4 Q. AND WHEN DID THAT STUDY TAKE PLACE?
5 A. THAT STUDY BEGAN LATE IN PROBABLY ABOUT NOVEMBER OF '95
6 AND WENT THROUGH TO PROBABLY EARLY '97.
7 Q. WHAT DID YOU FIND OUT ABOUT RISPERDAL IN THAT STUDY?
8 A. WHAT WE FOUND IS THAT IT WAS CERTAINLY SIGNIFICANTLY
9 BETTER THAN PLACEBO IN TREATING PATIENTS WITH AGITATIVE --
10 THAT WAS BETTER THAN A SUGAR PILL. AND WE ALSO FOUND THAT
11 THE DOSE OF 1 MILLIGRAM TO 2 MILLIGRAMS WERE EFFECTIVE.
12 Q. ASK WHEN WERE THOSE RESULTS ACTUALLY PUBLISHED AND
13 KNOWN?
14 A. IT TOOK A WHILE TO GET IT PUBLISHED AND THE PAPER
15 ACTUALLY CAME OUT, THE FIRST AUTHOR WAS IRA KATZ, AND THAT
16 CAME OUT IN 1999.
17 Q. ALL RIGHT. SO YOU ACTUALLY RUN A GERO-PSYCHIATRIC UNIT
18 YOURSELF LIKE THE ONE THAT WE'VE BEEN TALKING ABOUT IN THIS
19 CASE.
20 A. WELL, MY UNIT IS SLIGHTLY DIFFERENT BECAUSE MY
21 UNDERSTANDING IS THE UNIT IN THIS CASE WAS IN A COMMUNITY
22 HOSPITAL. MY UNIT IS IN A VERY LARGE ACADEMIC TEACHING
23 HOSPITAL IN DOWNTOWN CHICAGO WHERE I ALSO HAVE RESIDENTS,
24 PSYCHIATRIC RESTIDENTS, PSYCHIATRIC FELLOWS, INTERNAL
25 MEDICINE FELLOWS, AND ALSO GERIATRIC MEDICINE FELLOWS WORKING
1 ON THE UNIT WITH ME. I ALSO HAVE A GERIATRIC MEDICINE
2 SERVICE AND A PALLIATIVE CARE SERVICE WITH WHOM I CONSULT ON
3 A REGULAR BASIS.
4 Q. DOES THE UNIT THAT YOU SUPERVISE CARE FOR THE SAME TYPE
5 OF PATIENTS THAT ARE INVOLVED IN THIS CASE?
6 A. YES, WE DO. PROBABLY ABOUT 50 PERCENT OF OUR ADMISSIONS
7 ARE PATIENTS WITH BEHAVIOR DISORDERS OF DEMENTIA.
8 Q. WE'RE GONNA BE TALKING A LITTLE BIT TODAY ABOUT THE TERM
9 STANDARD OF CARE. ARE YOU FAMILIAR WITH THE STANDARD OF CARE
10 FOR TREATMENT OF THISE TYPES OF PATIENTS?
11 A. WELL, BASICALLY, WHEN WE THINK ABOUT STANDARD OF CARE,
12 WE THINK ABOUT THE RANGE OF WHAT IS ACCEPTABLE, WHAT IS OKAY
13 MEDICINE. SO ONE HAND, WE HAVE THE REALLY EXCELLENT, SUPER,
14 SUPER CARE THAT WE GET, AND AT THE OTHER HAND, WE HAVE SORT
15 OF THE AVERAGE CARE THAT IS ACCEPTABLE. AND THE STANDARD OF
16 CARE, IF YOU COULD IMAGINE IT SORT OF FALLS WITHIN THAT
17 RANGE. SO THERE'S NO ACTUAL DEFINITION, BUT IT'S BETWEEN
18 SUPER, SUPER CARE AND ADEQUATE CARE.
19 Q. OKAY. AND DOES EACH PHYSICIAN APPROACH EACH PATIENT IN
20 A DIFFERENT WAY?
21 A. ABSOLUTELY. AND I THINK AGAIN WHEN WE'RE THINKING ABOUT
22 STANDARDS OF CARE, WE'VE GOT TO THINK ABOUT, YOU KNOW,
23 WHERE -- WHERE THE HOSPITAL IS BECAUSE CERTAINLY THE STANDARD
24 OF CARE FOR MY HOSPITAL WOULD BE DIFFERENT TO A RURAL
25 HOSPITAL IN ILLINOIS.
1 Q. OKAY. DO YOU WANNA POUR SOME WATER THERE? I KEEP
2 INTERRUPTING YOU. SORRY.
3 A. YES.
4 Q. LET'S TALK A LITTLE ABOUT ABOUT DEMENTIA. YOU HAVE
5 REVIEWED THE MEDICAL RECORDS IN THIS CASE.
6 A. YES, I HAVE.
7 Q. AND BASED UPON YOUR REVIEW OF THE RECORDS, DO YOU
8 BELIEVE THAT ALL FIVE PATIENTS IN THIS CASE HAD DEMENTIA?
9 A. YES, I DO.
10 Q. AND HOW WOULD YOU CHARACTERIZE THE LEVEL OR THE SEVERITY
11 OF THE DEMENTIA OF THE PATIENTS?
12 A. WHEN WE THINK ABOUT DEMENTIA, WE REALLY THINK ABOUT
13 FOUR -- FOUR LEVELS OF SEVERITY. THE FIRST LEVEL IS ACTUALLY
14 THE UNDIAGNOSED PATIENT WITH DEMENTIA. MANY PATIENTS WILL
15 ACTUALLY HAVE IMPAIRMENTS FOR A YEAR OR TWO BEFORE THEY GET
16 DIAGNOSED. THEN THERE ARE THE MILD DEMENTIAS. THESE ARE
17 PATIENTS WHO CAN'T REMEMBER WHERE THEY'VE PARKED THEIR CAR,
18 WHO CAN'T BALANCE THEIR CHECKBOOKS, WHO LOSE THINGS. THEN WE
19 START LOOKING AT THE MODERATE DEMENTIA, AND THESE ARE
20 PATIENTS WHO WOULD LIKE WANDER AWAY FROM THE HOME, NOT BE
21 ABLE TO FIND THEIR HOUSE AGAIN. AND THEN WE HAVE SEVERE
22 DEMENTIA. THESE PATIENTS ARE REALLY UNABLE TO TAKE CARE OF
23 THEMSELVES. THEY CAN'T DRESS THEMSELVES, BATHE THEMSELVES.
24 THEY OFTEN HAVE GAIT DISTURBANCES. THEY'RE VERY PRONE TO
25 FALLING. AND THE MAJORITY OF THESE PATIENTS WILL BE IN
1 NURSING HOMES. AND I THINK THAT ALL OF THE PATIENTS THAT
2 WE'RE TALKING ABOUT TODAY MET THE CRITERIA FOR A SEVERE
3 DEMENTIA.
4 Q. NOW, WE'VE HEARD DIFFERENT TERMS USED ABOUT TYPES OF
5 DEMENTIA, THE TERMS VASCULAR DEMENTIA AND ALZHEIMER'S. HAVE
6 YOU MADE AN ASSESSMENT BASED UPON YOUR REVIEW OF THE RECORDS
7 AS TO WHAT TYPE OF DEMENTIA THESE PATIENTS HAD?
8 A. AGAIN, THEY ALL CERTAINLY DID HAVE DEMENTIA, BUT IT
9 WOULD SEEM WITH THE EXCLUSION OF ELLEN ANDERSON WHO WAS
10 DIFFICULT TO TELL, THAT THEY PROBABLY HAD ALZHEIMER'S DISEASE
11 AND ALSO A VASCULAR DEMENTIA. VASCULAR DEMENTIA IS A
12 CONDITION WHERE PEOPLE HAVE FREQUENT STROKES, SOMETIMES BIG
13 STROKES, SOMETIMES SMALL STROKES.
14 Q. AND SO DO THOSE STROKES ACTUALLY CAUSE THE DEMENTIA?
15 A. YES, THEY DO. IT'S EVERY TIME YOU HAVE A STROKE, YOU --
16 IF KIND OF WIPES OUT A LITTLE BIT MORE OF YOUR BRAIN, SO IF
17 YOU CONTINUALLY HAVE THEM, THERE'S NOT MUCH BRAIN LEFT
18 UNFORTUNATELY.
19 Q. IS THERE A DIFFERENCE IN PROGNOSIS FOR THESE PATIENTS IF
20 IT'S ALZHEIMER'S VERSUS VASCULAR?
21 A. YES, THERE IS. PATIENTS WITH PURE ALZHEIMER'S DISEASE
22 PROBABLY WILL LIVE SORT OF FIVE, FIVE TO SEVEN YEARS AFTER
23 YOU MAKE THE DIAGNOSIS, BUT UNFORTUNATELY, PATIENTS WITH
24 VASCULAR DEMENTIA TEND TO DETERIORATE A LITTLE BIT QUICKER
25 BECAUSE ALZHEIMER'S DISEASE IS JUST A SLOW PROGRESSION, THE
1 CELLS JUST GRADUALLY DIE OFF. BUT IN VASCULAR DEMENTIA,
2 EVERY TIME SOMEBODY HAS A STROKE, OR SOMETHING CALLED A
3 T.I.A., WHICH IS TRANSIENT ISCHEMIC ATTACK, YOU'RE KILLING
4 OFF A WHOLE BUNCH OF CELLS EACH DAY.
5 Q. WITH HAPPENS TO A SEVERLY DEMENTED PATIENT IF YOU DO NOT
6 TREAT THEM WITH PSYCHOTROPIC DRUGS?
7 A. WELL, AGAIN, THIS WOULD BE A SEVERLY AGITATED DEMENTED
8 PATIENT.
9 Q. UH-HUH.
10 A. AND PROBABLY ABOUT 50 PERCENT OF PATIENTS WITH DEMENTIA
11 WILL DEVELOP SOME KIND OF AGITATION. THE PROBLEM IS THAT
12 DURING THE TIME THAT THEY'RE AGITATED, THEY'RE VERY PRONE TO
13 FALL. THEY'RE VERY PRONE -- THEY WON'T BE EATING, THEY WON'T
14 BE TAKING CARE OF THEMSELVES. AND UNFORTUNATELY, WHAT WE'VE
15 SHOWN IS THAT IF YOU DO NOT TREAT THESE PATIENTS SOMEHOW,
16 THEY WILL ACTUALLY -- THEY WILL DIE FROM NOT BEING TREATED.
17 Q. NOW, ARE THERE ALSO SECONDARY EFFECTS OF DEMENTIA, OTHER
18 PHYSICAL THINGS THAT HAPPEN TO THE BODY?
19 A. YES. AS I MENTIONED BEFORE, THEY HAVE THIS GAIT
20 DISTURBANCE, SO PATIENTS ARE MORE LIKELY TO FALL. BUT THEY
21 ALSO GET MUCH MORE PRONE TO INFECTIONS. AND BECAUSE THEY
22 HAVE MORE PROBLEMS SWALLOWING, THAT PART OF THE BRAIN GETS
23 AFFECTED. WHEN THEY EAT, ALL OF THE STUFF THEY'RE EATING
24 COULD GO INTO THEIR LUNGS, WHICH IS REALLY BAD NEWS.
25 Q. IS IT COMMON FOR PHYSICIANS TO TELEPHONE IN ORDERS?
1 A. YES, IT IS. PHYSICIANS ON THE AVERAGE, I KNOW IN MY
2 HOSPITAL, PROBABLY DON'T SPEND MORE THAN AN HOUR TO TWO HOURS
3 TOTAL ON THE UNIT, SO IF THE PATIENT'S CONDITION CHANGES
4 DURING THE REST OF THE TIME BECAUSE THEY'RE NOT IN THE
5 HOSPITAL, THE NURSING STAFF WILL ALERT THEM AND THEY WILL
6 THEN GIVE A TELEPHONE ORDER.
7 Q. LET'S TALK A LITTLE BIT ABOUT PAIN IN THESE TYPE OF
8 PATIENTS. HOW DO YOU IF A NONCOMMUNICATIVE DEMENTED PATIENT
9 IS IN PAIN?
10 A. THAT IS REALLY DIFFICULT. AND I'D LIKE TO SAY WE KNOW
11 HOW TO DO IT, BUT WE DON'T. OBVIOUSLY, SOME -- A PATIENT
12 WHO'S NONCOMMUNICATIVE CANNOT ALWAYS TELL US THEY'RE IN PAIN.
13 AND THE INTERESTING THING IS SOMETIMES WE'LL SAY TO PATIENTS,
14 ARE YOU IN PAIN AND THEY'LL SAY YES. BUT THEN THE NEXT SIX
15 QUESTIONS YOU ASK THEM, YOU KNOW, YOU WOULDN'T ASK THEM ARE
16 THEY SUPERMAN, BUT SAY YOU DID, THEY WOULD SAY YES. SO THE
17 PATIENT'S RESPONSE IS VERY UNRELIABLE. SO WHAT WE HAVE TO
18 LOOK AT IS THE WAY THE PATIENT IS BEHAVING. SO PATIENT, FOR
19 EXAMPLE, IF YOU TRY AND WASH THEM AND THEY START SCREAMING,
20 THAT'S AN INDICATION THEY MAY BE IN PAIN. IF YOU TOUCH THEM
21 AND THEY SCREAM, THEY MAY BE IN PAIN. IF SOMEBODY IS MOANING
22 OR YELLING, AGAIN, WHAT WE THINK IS THAT THIS IS PROBABLY
23 PAIN, BUT THEY CAN'T TELL US.
24 Q. DO PSYCHIATRISTS RELY ON NURSING STAFF IN DECIDING HOW
25 TO TREAT PATIENTS TO A CERTAIN DEGREE?
1 A. ABSOLUTELY. AND I THINK THE HALLMARK OF ANY GOOD
2 INPATIENT PSYCHIATRY UNIT IS REALLY NOT THE QUALITY OF THE
3 DOCTORS -- I HATE TO SAY THAT -- BUT IT'S THE QUALITY OF THE
4 NURSING STAFF BECAUSE AGAIN, THEY ARE THE PEOPLE WHO ARE
5 THERE 24 HOURS A DAY. AND WE RELY VERY STRONGLY ON THEM
6 OBSERVING THE PATIENT AND THEN RELATING WHAT THAT BEHAVIOR IS
7 TO US SO THAT WE CAN THEN MAKE DECISIONS ON MANAGEMENT.
8 Q. WHY DON'T WE TALK ABOUT THE SPECIFIC PATIENTS IN THIS
9 CASE. WHY DON'T WE START WITH ELLEN ANDERSON, AND I'LL PUT
10 UP THE --
11 A. OKAY.
12 Q. -- JUST SO THE JURY CAN FOLLOW ALONG. THEY'VE SEEN
13 THESE CHARTS BEFORE, BUT AT LEAST SEEN THE MEDICATIONS AND
14 HOW THEY RELATE TO SOME OF THE THINGS WE'RE GONNA TALK ABOUT.
15 A. AND PLEASE LET ME KNOW IF YOU CAN'T HEAR ME. I TEND TO
16 MUMBLE A BIT SO DON'T -- FEEL FREE TO -- OKAY. CAN WE JUST
17 START WITH LOOKING AT ELLEN ANDERSON --
18 THE COURT: LET ME INDICATE --
19 MS. BARLOW: I OBJECT. THERE'S NO QUESTIOIN --
20 THE COURT: -- TO YOU, DOCTOR, IT WORKS BETTER IF YOU
21 LET HER ASK QUESTIONS AND YOU RESPOND TO THEM.
22 THE WITNESS: OKAY.
23 THE COURT: OKAY.
24 THE WITNESS: SOUNDS GOOD.
25 THE COURT: LET'S GO.
1 Q. (BY MS. ISAACSON) OKAY. WE'LL TALK ABOUT ELLEN
2 ANDERSON. WHY DON'T WE GO -- WHY DON'T WE GO FIRST TO THE
3 ISSUE OF -- OF PREVIOUS PSYCHOTROPIC MEDICATIONS. HAVE WE
4 PUT TOGETHER A SLIDE THAT SHOWS THAT?
5 A. YES, WE HAVE.
6 MS. ISAACSON: YOUR HONOR, THIS IS GONNA BE DEFENDANT'S
7 32. AND I -- EXCUSE ME. THIS IS DEFENDANT'S 32.
8 Q. (BY MS. ISAACSON) AND WHEN YOU -- WHEN YOU LOOK AT THE
9 TREATMENT OF PATIENTS WITH PSYCHOTROPIC MEDICATIONS, IS IT
10 IMPORTANT FOR YOU TO KNOW WHAT THE PREVIOUS PSYCHOTROPIC
11 MEDICATIONS ARE?
12 A. ABSOLUTELY. BECAUSE WHEN THE A PATIENTS COMES INTO THE
13 HOSPITAL WITH THE AGITATION, WHAT WE HAVE TO DO IS TRY AND
14 WORK OUT WHERE IS THIS AGITATION COMING FROM. AND ONE OF THE
15 CAUSES CAN BE PREVIOUS MEDICATIONS THAT THE PATIENT HAS BEEN
16 ON. SO IT'S VERY IMPORTANT TO LOOK AT THE MEDICATIONS. AND
17 HERE WITH ELLEN ANDERSON, WE CAN SHE THAT SHE WAS ON TWO
18 DIFFERENT ANTIDEPRESSANTS AS WELL AS A SLEEP MEDICATION. AND
19 THAT SHE'D RECENTLY BEEN ON XANAX, WHICH IS IS LIKE A
20 TRANQUILIZER, AND THAT SHE WAS ALSO RECEIVING PAIN MEDICATION
21 PRIOR TO COMING INTO THE HOSPITAL.
22 Q. OKAY. NOW, ULTIMATELY, WE CAN SEE FROM ELLEN ANDERSON'S
23 CHART, SHE WAS NOT ACTUALLY GIVEN ANY PSYCHOTROPICS WHILE SHE
24 WAS ON THE UNIT, BUT I DO WANNA TALK WITH YOU ABOUT YOUR
25 REVIEW OF THE CHARTS AND WHAT SORT OF SYMPTOMS WERE
1 DOCUMENTED BY THE NURSING STAFF AND WHAT YOUR ASSESSMENT OF
2 THAT DOCUMENTATION IS?
3 A. RIGHT.
4 Q. WE'RE GONNA GO NOW TO DEFENDANT'S 29. AND CAN YOU
5 EXPLAIN TO THE JURY WHAT -- WHAT THIS CHART SHOWS?
6 A. RIGHT. THIS -- UNFORTUNATELY, MRS. ANDERSON HAD A VERY
7 SHORT ADMISSION AND THIS REALLY IS MY WAY OF TRYING TO
8 DEMONSTRATE WHAT HER BEHAVIORS WERE LIKE DURING THAT
9 ADMISSION. SHE WAS -- WHEN SHE WAS SEEN, SHE WAS THOUGHT TO
10 BE IN PAIN. SHE GIVEN SOME MORPHINE. THAT WAS EFFECTIVE.
11 SHE WAS THEN MOANING AND SCREAMING AGAIN. SHE WAS GIVEN
12 FURTHER MORPHINE THAT. THAT SEEMED TO REALLY -- SHE HAD A
13 VERY NICE RESPONSE TO THAT. AND THEN SHE -- SHE SEEMED TO
14 SLEEP.
15 Q. AND THEN ULTIMATELY A NUMBER OF HOURS LATER, SHE -- SHE
16 PASSEDS AWAY.
17 A. YES, THAT'S CORRECT.
18 Q. BASED UPON WHAT YOU SAW THE NURSES CHART, WERE THOSE
19 SYMPTOMS THAT YOU IN YOUR EXPERIENCE WOULD HAVE INTERPRETED
20 AS PAIN, THE MOANING, THE SCREAMING, THOSE SORTS OF THINGS?
21 A. ABSOLUTELY. THIS WAS A PATIENT WHO HAD A HISTORY OF
22 WHAT'S CALLED COMPRESSION FRACTURES IN HER SPINE. SHE HAD
23 SEVERE OSTEOPOROSIS. SO THESE WERE ALL THINGS THAT WOULD
24 INDICATE THAT SHE COULD POTENTIALLY BE IN PAIN. AND AGAIN,
25 SHE HAD THESE BEHAVIORS THAT INDICATED THAT SHE WAS IN PAIN.
1 AND SO THE RIGHT THING TO DO WHEN SOMEBODY IS IN PAIN IS TO
2 TREAT THE PAIN.
3 Q. OKAY. WHY DON'T WE MOVE ON TO JUDITH LARSEN NOW AND
4 TALK ABOUT HER PREVIOUS PSYCHTROPIC MEDICATIONS. NOW I'LL
5 PUT UP HER -- AND THIS IS DEFENDANT'S EXHIBIT 53. WHY DON'T
6 YOU TALK A LITTLE BIT ABOUT WHAT SHE WAS ON PREVIOUS TO HER
7 ADMISSION.
8 THE COURT: WHAT NUMBER IS THAT, COUNSEL?
9 MS. ISAACSON: 53, DEFENDANT'S 53.
10 THE COURT: THANK YOU.
11 THE WITNESS: MRS. LARSEN WAS TAKING XANAX, WHICH IS A
12 TRANQUILIZER. SHE WAS TAKING TRAZODONE. THIS IS A DRUG THAT
13 WAS USED FOR DEPRESSION, BUT CAN ALSO BE A VERY EFFECTIVE
14 DRUG TRYING HELP PEOPLE SLEEP, ESPECIALLY IN THE ELDERLY.
15 SHE HAD BEEN TAKING ANTIDEPRESSANT CALLED ZOLOFT, AND SHE'D
16 ALSO BEEN TAKING WHAT WE CALL A NERUOLEPTIC, ONE OF THE MORE
17 OLD FASHIONED NEUROLEPTICS CALLED HALDOL.
18 Q. (BY MS. ISAACSON) OKAY. AND THEN WHY DON'T WE TALK A
19 LITTLE BIT BEFORE WE GO TO HER SYMPTOMS ABOUT WHAT
20 MEDICATIONS SHE WAS PUT ON WHEN SHE CAME ON TO THE UNIT. WHY
21 DON'T YOU WALK RIGHT HERE --
22 A. OKAY.
23 Q. SO SHE WAS ON THOSE MEDICATIONS WHEN SHE CAME IN. WHAT
24 DID DR. WEITZEL PUT HER ON AT ADMISSION?
25 A. DR. WEITZEL PUT HER ON A DRUG CALLED KLONOPIN. AND
1 USUALLY WHAT WE DO IS, IS THAT XANAX IS NOT REALLY A GOOD
2 DRUG IN THE ELDERLY. AND SO WHAT WE TRY TO DO IS WE TRY TO
3 GET THEM OFF IT. SO IT'S VERY DIFFICULT TO WEAN PATIENTS OFF
4 XANAX, SO WHAT WE DO IS WE SWITCH THEM TO A SIMILAR DRUG THAT
5 HAS A SLIGHTLY LONGER ACTION, AND THAT DRUG IS CALLED
6 KLONOPIN. SO THE XANAX WAS SWITCHED TO KLONOPIN. IF YOU
7 STOP XANAX SUDDENLY, THE PATIENT CAN HAVE A SEIZURE AND GET
8 REALLY SICK, SO THAT'S WHY WE SWITCH. AND AS WE CAN SEE OVER
9 THE COURSE OF THE HOSPITALIZATION, WHAT WE TRY AND DO IS
10 GRADUALLY TAPER OFF THE KLONOPIN. HALDOL IS NOT A VERY GOOD
11 DRUG TO USE IN THE ELDERLY. THE ADVANTAGE OF HALDOL IS IT'S
12 THE ONLY NEW DRUG THAT WE GIVE INTRAMUSCULARLY. BUT WHAT WE
13 LIKE TO DO IS JUST SWITCH HALDOL TO RISPERDAL, AND SO THAT'S
14 WHAT RISPERDAL WAS. AND THE SERZONE AGAIN IS AN
15 ANTIDEPRESSANT. THE ADVANTAGE OF SERZONE IS IT ALSO HELPS
16 WITH ANXIETY AS WELL. AND SO THAT'S WHY I BELIEVE THE PATIENT
17 WAS GIVEN SERZONE.
18 Q. WHY DON'T WE TALK -- ARE THERE PARTICULAR DAYS OF
19 BEHAVIOR OF JUDITH LARSEN THAT YOU THINK WOULD BE HELPFUL TO
20 SHOW THE JURY AND COMPARE WITH SOME OF THE MEDICATIONS?
21 A. SURE. WHAT WE COULD LOOK AT IS A FAIRLY TYPICAL DAY,
22 THAT WOULD BE THE 6TH THROUGH THE 7TH OF DECEMBER.
23 Q. LET'S SEE, AND THIS IS DEFENDANT'S 33. SO THIS IS
24 DECEMBER 6TH. SO THIS WAS THE FIRST DAY OF HER ADMISSION
25 ONTO THE SECOND DAY. WHAT DO WE SEE CHARTED BY THE NURSES
1 THE FIRST TWO DAYS?
2 A. WHAT WE SEE IS THAT SHE WAS -- SHE WAS SHOUTING, THAT
3 SHE WAS GIVEN WHAT'S CALLED A P.R.N. MEDICATION ATIVAN. THAT
4 WAS SOMETHING THAT BECAUSE SHE WAS -- SHE WAS SHOUTING AND
5 OUT OF CONTROL, TO HELP HER CALM DOWN. SHE HAD A GOOD
6 RESPONSE TO THAT. HOWEVER, THESE DRUGS DO NOT WORK IN THE
7 LONG TERM, IT WEARS OFF. AND SO AGAIN, SHE WAS CALLING OUT,
8 SHE WAS SOBBING, SHE WAS RAMBLING, AND SHE IS VERY AGITATED
9 AND ANXIOUS AND SCREAMING. SHE HAD ANOTHER DOSE OF ATIVAN.
10 IF WE COULD LOOK AT THE NEXT CHART --
11 Q. SURE.
12 A. -- I THINK THAT WOULD BE HELPFUL.
13 Q. AND THIS IS DEFENDANT'S 34 AND THIS REPRESENTS DECEMBER
14 8TH AND 9TH, IS THAT RIGHT?
15 A. YES, IT DOES. AND AGAIN, WHAT WE SEE IS THAT DESPITE
16 THE FACT THAT SHE WAS RECEIVING THE REGULAR RISPERDAL AND
17 SERZONE, IT REALLY WASN'T TOUCHING HER BEHAVIOR SYMPTOMS. AND
18 SHE CONTINUED TO NEED THE EXTRA DOSES OF ATIVAN TO REALLY TRY
19 AND GET HER TO BE A LITTLE BIT CALMER.
20 Q. AND COULD YOU SHOW THE JURY, JUST SO WE CAN KIND OF
21 SEE --
22 A. SURE.
23 Q. WE START OUT WITH THESE LEVELS OF MEDICATIONS, AND THEN
24 THIS AGITATION IS HAPPENING ON WHICH DAYS?
25 A. SO THIS HERE AS WE SEE IS THE 8TH AND 9TH, WHICH ARE
1 THESE TWO DAYS HERE WHERE WE ARE GIVING -- THIS IS WHEN WE
2 START THE MEDICATION. IT REALLY HASN'T BEEN WORKING YET. SO
3 WHAT WE DO IS, YOU THEN INCREASE THE DOSE OF MEDICATION.
4 MS. ISAACSON: I'M SORRY, YOUR HONOR. I FORGOT TO
5 MENTION THAT WE'RE REFERRING ACTUALLY TO STATE'S EXHIBIT 3-H,
6 WHICH IS THE MEDICATION SUMMARY.
7 THE COURT: I HAVE IT.
8 THE WITNESS: CAN WE LOOK AT DECEMBER 16?
9 Q. (BY MS. ISAACSON) SURE.
10 THE WITNESS: RIGHT. AND AGAIN --
11 THE COURT: WAIT JUST A MINUTE, DOCTOR.
12 Q. (BY MS. ISAACSON) HOLD ON JUST A SECOND. WE'RE ON
13 DEFENDANT'S 35, AND THIS IS A SUMMARY OF DECEMBER 10TH
14 THROUGH 16TH?
15 A. RIGHT.
16 Q. OKAY.
17 A. AND I THINK WHAT AGAIN THIS SHOWS US IS THAT SHE'S
18 CONTINUING TO BE -- TO BE VERY -- TO BE AGITATED. SHE'S
19 MOANING, SHE'S TEARFUL AND CRYING, SHE'S YELLING OUT AND
20 CLAPPING. SHE'S HAVING INCREASED AGITATION AFTER LUNCH. SHE
21 DID HAVE SOME GOOD EFFECT FROM THE P.R.N. ATIVAN, BUT AGAIN,
22 SHE'S CONTINUING TO BE AGITATED. AND SO BASED ON THAT
23 INFORMATION FROM THE NURSING STAFF AND FROM HIS OWN
24 OBSERVATION, IT WOULD MAKE SENSE FOR THE PHYSICIAN AGAIN TO
25 CONTINUE WITH THESE DRUGS AND TO INCREASE THE DOSES.
1 Q. OKAY. NOW, YOU MENTIONED THE CONCEPT OF P.R.N.
2 PSYCHOTROPIC DRUGS. WE HAVE HEARD THAT TERM A LOT. WHAT
3 DOES THAT MEAN?
4 THE COURT: THEY KNOW WHAT IT MEANS. GO ON.
5 Q. (BY MS. ISAACSON) OKAY. HAVE YOU REVIEWED THE P.R.N.
6 MEDICATIONS THAT WERE GIVEN BY THE NURSING STAFF FOR JUDITH
7 LARSEN?
8 A. YES, I HAVE.
9 Q. WHY DON'T WE SHOW THAT SUMMARY. HAVE YOU PREPARED A
10 SUMMARY OF THAT?
11 A. YES, THERE IS A SUMMARY.
12 Q. THIS IS DEFENDANT'S EXHIBIT 99. SO WITH THIS PATIENT,
13 ON HOW MANY DIFFERENT OCCASIONS WAS SHE GIVEN A DOSE BY THE
14 NURSE AT HER DISCRETION?
15 A. SO AGAIN, SHE HAD SEVEN DOSES OF ADDITIONAL MEDICATION,
16 SO THIS WAS DESPITE THE FACT THAT SHE WAS ON THE REGULAR
17 MEDICATIONS. THEY REALLY JUST WEREN'T HOLDING HER. SHE
18 NEEDED ADDITIONAL MEDICATIONS. SO AGAIN, THAT WAS A
19 MEDICATION THAT SHE NEEDED TO AT LEAST BE ON THE REGULAR
20 MEDICATION, AND SHE -- SHE REALLY WASN'T DOING VERY WELL.
21 SHE WAS WAS VERY AGITATED.
22 THE COURT: WHAT EXHIBIT NUMBER WAS THAT, MS. ISAACSON?
23 YOU INDICATED IT, BUT I DIDN'T --
24 MS. ISAACSON: 99.
25 Q. (BY MS. ISAACSON) SHALL WE MOVE ON TO MARY CRANE?
1 A. YES.
2 Q. OKAY.
3 A. OKAY.
4 Q. WHY DON'T WE TALK ABOUT HER PREVIOUS PSYCHOTROPIC
5 MEDICATIONS?
6 A. I THINK WE HAVE A SLIDE ON THAT.
7 Q. I THINK WE DO. IT'S DEFENDANT'S 66. WE'LL SWITCH OFF
8 HERE. AND WHAT WAS SHE ON?
9 A. AGAIN, SHE WAS ON TRANXENE, WHICH IS A -- IT'S A
10 TRANQUILIZER. SHE WAS ON AN ANTIDEPRESSANT, ZOLOFT. SHE WAS
11 ON THORAZINE. NOW THORAZINE IS ONE OF THE OLDER MEDICATIONS
12 THAT WE USE. AGAIN, WE DON'T LIKE USING THORAZINE IN OLDER
13 PATIENTS BECAUSE ONE OF THE SIDE EFFECTS IS THAT IT CAN
14 ACTUALLY CAUSE SOMETHING CALLED A DELIRIUM. AND SO THIS WAS
15 A DRUG THAT ABSOLUTELY HAD TO GO WHEN SHE GOT ADMITTED.
16 AGAIN, SHE WAS TAKING SOME XANAX. AND SHE HAD BEEN TAKING
17 PROZAC, AND SHE WAS ALSO ON PAIN MEDICATION WHEN SHE WAS
18 ADMITTED.
19 Q. AND SO THE FACT THAT DR. WEITZEL SWITCHED HER OFF OF
20 THORAZINE IS SOMETHING THAT YOU ABSOLUTELY AGREE WITH.
21 A. YES. IT MADE GOOD SENSE. ONE, IT WASN'T WORKING
22 CLEARLY BECAUSE SHE WAS STILL AGITATED, BUT SECONDLY, IT'S
23 REALLY NOT A GOOD DRUG TO USE IN THE ELDERLY. AND IN FACT,
24 COULD HAVE BEEN RESPONSIBLE FOR SOME OF THE SYMPTOMS SHE WAS
25 HAVING.
1 Q. OKAY. LET'S TALK ABOUT -- WELL, ACTUALLY, WHY DON'T
2 WE -- WE'LL COME BACK TO THIS IN A MOMENT. WHY DON'T WE TALK
3 ABOUT SOME OF HER SYMPTOMS AND THEN TALK ABOUT THE --
4 A. SURE.
5 Q. -- MEDICAL CHART?
6 A. CAN WE HAVE LOOK AT I THINK 12/29 AND 12/31 PLEASE?
7 Q. SURE. AND THIS IS DEFENDANT'S 54, YOUR HONOR.
8 A. AGAIN, SHE WAS -- SHE WAS CONFUSED. SHE WAS
9 DISORIENTED. SHE WAS SCREAMING CONSTANTLY. AND AGAIN, WHAT
10 WE NOW KNOW -- WE PROBABLY DIDN'T KNOW AS MUCH BACK THEN.
11 AGAIN, THIS IS AN INDICATION THAT SHE PROBABLY IS IN PAIN.
12 PATIENTS WITH STRAIGHT DELIRIUM DON'T USUALLY JUST SCREAM.
13 SHE WAS YELLING FOR HELP. AND THEN WHEN PEOPLE ASKED HER
14 WHAT SHE WANTED, SHE DIDN'T KNOW. AND AGAIN, THIS IS VERY
15 COMMON. PATIENTS WITH DEMENTIA KNOW THERE'S SOMETHING
16 TERRIBLY, TERRIBLY WRONG, BUT THEY -- SHE JUST DIDN'T KNOW
17 WHAT IT WAS. AGGRESSIVE BEHAVIOR TOWARD STAFF. AGAIN, STAFF
18 WERE TYING TO HELP HER, AND SHE BECAME INCREASINGLY AGITATED,
19 TRYING TO HIT THE NURSES. SO THIS IS A VERY AGITATED WOMAN.
20 CAN WE SEE THE NEXT DAY, TOO, PLEASE?
21 Q. SURE. AND THERE IS DEFENDANT'S 55.
22 A. AGAIN, SHE WAS -- SHE CONTINUED TO BE SCREAMING. SHE
23 WAS PHYSICALLY AND VERBALLY ABUSIVE. SHE HAD BEEN HITTING,
24 THROWING FOOR AROUND, CRYING OUT IN GROUP, YELLING AND
25 GRIMMACING. SO AGAIN, THIS WAS A STILL A VERY AGITATED,
1 DISTURBED PATIENT. AND IF WE LOOK HERE --
2 Q. AND WE'RE REFERRING TO STATE'S EXHIBIT 4-E, THE
3 MEDICATION SUMMARY FOR MARY CRANE.
4 A. AGAIN, SHE WAS -- SHE WAS BEING TREATED WITH -- WITH THE
5 ANTIPSYCHOTIC MEDICATIONS. OF INTEREST IS THAT THEY WERE
6 ALSO GIVING HER DURAGESIC, WHICH IS A PAIN MEDICATION TO TRY
7 AND SEE IF THAT WOULD COVER THE PAIN. IT REALLY DOESN'T SEEM
8 LIKE IT WAS AT THAT TIME. AND SO AGAIN, SHE'S HAVING
9 INCREASING AMOUNTS. ON JANUARY THE 3RD, WHEN SHE IS
10 CONTINUING TO BE SO ANXIOUS, ANOTHER MEDICATION CALLED
11 DEPAKENE WAS ADDED. AND THAT AGAIN IS A MEDICATION COMMONLY
12 USED IN PATIENTS WITH AGITATION. AND IT'S ACTUALLY AN
13 ANTIEPILEPTIC DRUG, BUT WE USE IT AS WHAT WE CALL A MOOD
14 STABILIZER. AND THAT AGAIN WAS TO TRY TO STABILIZE HER MOOD.
15 AN SO SHE WAS ON A SIGNIFICANT AMOUNT OF DRUGS, YES, BUT SHE
16 WAS STILL VERY AGITATED AND VERY DISTRESSED.
17 Q. LET'S TALK ABOUT LYDIA SMITH. AGAIN, WE'LL GO TO HER
18 PREVIOUS PSYCHOTROPIC MEDICATIONS. AND THIS IS DEFENDANT'S
19 83. WHAT WAS MS. SMITH TAKING WHEN SHE WAS BROUGHT ON TO THE
20 UNIT?
21 A. SHE WAS TAKING HALDOL. SERZONE, WHICH IS THAT
22 ANTIDEPRESSANT. SHE TAKING ATIVAN AS NEEDED. HALDOL AS
23 NEEDED. AND HAD BEEN TAKING VALIUM. SO AGAIN, SHE'D BEEN ON
24 THESE DRUGS ALREADY AND THEY WERE NOT WORKING, WHICH IS WHY
25 SHE WAS ADMITTED TO THE HOSPITAL.
1 Q. OKAY. WOULD YOU -- WHY DON'T WE GO TO SOME OF HER
2 AGITATIONS, A SUMMARY OF HER AGITATION. AND LET ME PULL
3 HER --
4 A. RIGHT. YES, CAN WE GO TO 12/20 PLEASE?
5 Q. AND DEFENDANT'S EXHIBIT 67, 12/20 TO 12/21.
6 A. AND THIS REALLY INDICATES AGAIN, THIS WOMAN WAS EXTEAMLY
7 AGITATED. SHE WAS SPITTING, KICKING, STRIKING OUT. VERY
8 AGGRESSIVE. UNDRESSING HERSELF. AND NEEDED TO BE GIVEN THE
9 P.R.N. ATIVAN. SO THE MEDICATION SHE WAS PUT ON --
10 Q. LET ME STOP YOU FOR A SECOND. HOW WOULD YOU COMPARE THE
11 LEVEL OF AGITATION THAT YOU SEE WITH LYDIA SMITH AS OPPOSED
12 TO THE PRIOR TWO PATIENTS?
13 A. SHE REALLY SEEMED TO HAVE MORE AGITATION. AND IN FACT,
14 WHEN THE MEDICAL DOCTOR INTERNIST CAME IN TO DO HER PHYSICAL
15 EXAM, HE WAS UNABLE TO EXAMINE HER BECAUSE SHE WAS SO
16 AGITATED. WE LIKE TO GET AN EXAMINATION OF ALL PATIENTS, BUT
17 YOU CAN'T ALWAYS DO IT. SHE WAS KICKING, BITING, SPITTING
18 THE WHOLE TIME. SHE WAS REALLY, REALLY VERY AGITATED. AND
19 IN FACT JUST FROM HER DESCRIPTION, SHE'S PROBABLY MORE
20 AGITATED THAN ANY PATIENT I'VE SEEN ON MY UNIT IN THE LAST
21 TEN YEARS. SHE REALLY WAS COMPLETELY OUT OF CONTROL.
22 Q. WELL, LET'S -- LET'S ME STOP YOU THERE. WHEN YOU'RE
23 TALKING ABOUT THESE FIVE PATIENTS AND THE AGITATION YOU SEE,
24 THE RANGE OF PATIENTS, DEMENTED PATIENTS THAT YOU SEE ON OUR
25 UNIT, ARE THEY -- AT WHAT END OF THE SPECTRUM ARE THEY?
1 MS. BARLOW: YOUR HONOR, I'M GOING TO OBJECT. I DON'T
2 THINK THAT'S RELEVANT, THE PEOPLE THAT ARE ON HER UNIT. I
3 MEAN WE'RE JUST TALKING ABOUT THESE PEOPLE AT THIS TIME. NOT
4 TALKING ABOUT COMPARING THEM WITH OTHER PEOPLE.
5 THE COURT: OVERRULED. I THINK IT GOES TO THE LEVEL OF
6 CARE THAT THEY WERE NEEDING AT THAT TIME. AND I THINK IT HAS
7 RELEVANCY AS FAR AS THAT'S CONCERNED. GO AHEAD.
8 THE WITNESS: THESE PATIENTS REPRESENT PROBABLY THE
9 HIGHER END OF THE AGITATED PATIENTS THAT WE SEE. SOMEBODY
10 LIKE LYDIA, THOUGH, JUST READING THROUGH THE NOTES, SHE IS
11 MORE AGITATED THAN THE PATIENTS THAT I REMEMBER. THE OTHERS
12 FELL INTO -- AGAIN, INTO THE VERY HIGH END OF AGITATION FOR
13 THESE PATIENTS.
14 Q. (BY MS. ISAACSON) AND HOW WOULD YOU DESCRIBE THE
15 DIFFICULTY IN TREATING THIS AGITATION WITH PSYCHOTROPIC
16 MEDICATIONS?
17 A. WELL, DESPITE HAVING -- STARTING AGAIN ON RISPERDAL AND
18 CONTINUING TO SERZONE, SHE CONTINUED TO BE EXTREMELY AGITATED
19 AND NEEDED AGAIN INCREASING DOSES TO TRY AND HELP CONTROL HER
20 BEHAVIOR.
21 Q. AND SO DID IT APPEAR TO YOU, LOOKING AT THE AGITATION
22 THAT WE'VE TALKED ABOUT, THAT -- THAT DR. WEITZEL WAS
23 ATTEMPTING TO ADDRESS THE AGITATION --
24 MS. BARLOW: OBJECTION, YOUR HONOR. THAT'S LEADING.
25 THE COURT: SUSTAINED.
1 Q. (BY MS. ISAACSON) BASED UPON THE AGITATION THAT YOU SAW,
2 WHAT DID YOU SEE DR. WEITZEL DO IN RESPONSE?
3 A. HE CONTINUED TO INCREASE THE MEDICATIONS AND ALSO GAVE
4 P.R.N. MEDICATIONS. AND ONE THING THAT HAPPENS IS IF A
5 PATIENT IS REFUSING OR --
6 MS. BARLOW: OBJECTION, YOUR HONOR. THERE'S NO
7 QUESTION.
8 THE COURT: SUSTAINED.
9 Q. (BY MS. ISAACSON) WHY DON'T WE TALK ABOUT THE P.R.N.
10 MEDICATIONS IN THIS CASE. NOW AGAIN, THESE ARE -- THESE ARE
11 SHOTS OR MEDICATIONS THAT WERE GIVEN BY NURSES AT THEIR OWN
12 DISCRETION, IS THAT RIGHT?
13 A. THAT IS CORRECT.
14 Q. OKAY. LET'S LOOK AT A -- THE SUMMARY OF HER P.R.N. IS
15 THERE ANY OF THE -- DO YOU THINK THAT THERE IS ANY OTHER
16 SIGNIFICANT AGITATION SYMPTOMS -- I MEAN SHE WAS IN THE UNIT
17 FOR A NUMBER OF DAYS. WERE THERE ANY OTHER AREAS OF
18 AGITATION THAT YOU FELT WERE SIGNIFICANT WITH RESPECT TO THE
19 DRUGS THAT WERE ADMINISTERED? ARE THERE ANY OTHER SLIDES
20 THAT YOU'D LIKE TO --
21 A. NO. I THINK THIS GIVES US A GOOD EXAMPLE THAT SHE WAS
22 JUST AN EXTREMELY AGITATED LADY.
23 Q. AND DID THAT STAY CONSISTENT THROUGHOUT HER -- ALMOST
24 HER ENTIRE STAY?
25 A. PRETTY MUCH, YES.
1 Q. OKAY. WHY DON'T WE GO AHEAD AND GO TO THE P.R.N.
2 MEDICATIONS THEN. HERE WE ARE. THIS IS IS DEFENDANT'S
3 ONE -- 101. NOW, AGAIN, THIS REPRESENTS ALL THE TIMES THAT
4 THE NURSES RESPONDED TO SYMPTOMS AND GAVE -- WHAT MEDICATIONS
5 WERE PROVIDED BY THEM?
6 A. BOTH ATIVAN AND HALDOL. AND I THINK AGAIN IF WE COMPARE
7 WITH THE PREVIOUS PATIENTS WHO PROBABLY NEEDED FOUR OR FIVE
8 P.R.N. MEDICATIONS, THIS IS ACTUALLY JUST ONE OF TWO PAGES
9 THAT I HAVE OF WHAT SHE WAS RECEIVING. SO SHE WAS RECEIVING
10 A LOT OF P.R.N. MEDICATION, AGAIN INDICATING THAT THE
11 STANDING DOSES OF MEDICATION THAT SHE WAS BEING PRESCRIBED
12 WAS SIMPLY NOT CONTROLLING HER SYMPTOMS. THESE WERE DRUGS
13 THAT WERE GIVEN WHEN SHE BECAME EVEN MORE AGITATED. THE
14 REASON THAT HALDOL WAS PROBABLY USED --
15 MS. BARLOW: OBJECTION, YOUR HONOR. THERE'S NO
16 QUESTION.
17 THE COURT: SUSTAINED.
18 THE WITNESS: OKAY.
19 Q. (BY MS. ISAACSON) CAN YOU EXPLAIN WHY THESE TWO
20 PARTICULAR DRUGS WOULD HAVE BEEN USED?
21 A. THE REASON THAT HALDOL WOULD HAVE BEEN USED IS, AS I'VE
22 SAID PREVIOUSLY, RISPERDAL IS ONLY AVAILABLE AS AN ORAL
23 MEDICATION. AND SO WHAT YOU WANT TO TRY AND DO IS GET AN
24 ANTIPSYCHOTIC MEDICATION BECAUSE THE GOAL IS NOT TO SEDATE
25 THE PATIENT AT ALL. THE GOAL IS TO TRY AND REALLY CONTROL
1 THE UNDERLYING AGITATION WITHOUT SEDATING THEM. THAT'S WHY
2 HALDOL WOULD HAVE BEEN USED.
3 Q. ALL RIGHT. NOW, YOU INDICATED THAT THERE WAS ANOTHER
4 PAGE OF P.R.N. MEDICATIONS. SHOULD WE -- CAN WE GO TO THAT
5 NOW?
6 A. YES.
7 Q. AND THIS IS DEFENDANT'S EXHIBIT 102. AGAIN --
8 THE COURT: LET ME JUST ASK AT THIS POINT, MS. ISAACSON,
9 HAVE ALL THESE EXHIBITS BEEN PRESENTED TO THE CLERK FOR
10 MARKING?
11 MS. ISAACSON: THEY HAVE. THEY'VE ALL BEEN MARKED.
12 THE COURT: THEY'RE ALL MARKED? OKAY. THANK YOU.
13 MS. ISAACSON: AND COPIES HAVE ALL BEEN PROVIDED TO THE
14 STATE.
15 THE COURT: ALL RIGHT. THANK YOU.
16 MS. BARLOW: ACUTALLY, NO, I DON'T HAVE A COPY OF THEM
17 ALL. I THINK YOU SHOWED THEM TO ME, BUT I DON'T SEE THAT I
18 HAVE IT. BUT THAT'S OKAY BECAUSE I CAN SEE WHAT YOU'RE
19 DOING.
20 MS. ISAACSON: I'M HAPPY TO GRAB AN EXTRA COPY.
21 MS. BARLOW: I'LL GET ONE LATER.
22 THE COURT: OKAY. LET'S GO.
23 Q. (BY MS. ISAACSON) I DON'T THINK I ASKED YOU THIS
24 QUESTION ON THE PREVIOUS PATIENTS, BUT I'LL ASK YOU WITH
25 LYDIA, AND THEN WE'LL GO BACK. DO YOU HAVE AN OPINION BASED
1 UPON YOUR REVIEW OF THE MEDICAL RECORDS AS TO WHETHER
2 DR. WEITZEL'S TREATMENT OF MRS. SMITH WITH PSYCHOTROPIC DRUGS
3 MET THE STANDARD OF CARE FOR 1995 AND 1996?
4 A. I DO.
5 Q. WITH REGARDS TO THE PREVIOUS TWO PATIENTS THAT WE'VE
6 TALKED ABOUT, DO YOU BELIEVE TO A DEGREE OF REASONABLE
7 MEDICAL CERTAINTY THAT IT WAS APPROPRIATE FOR DR. WEITZEL TO
8 TREAT PAIN IN ELLEN ANDERSON?
9 A. I DO.
10 Q. AND WITH REGARD TO JUDITH LARSEN, DO YOU HAVE AN OPINION
11 TO A DEGREE OF REASONABLE MEDICAL CERTAINTY AS TO WHETHER THE
12 PSYCHOTROPIC MEDICATIONS THAT HE USED IF HER CASE MET THE
13 STANDARD OF CARE FOR 1995 AND 1996?
14 A. I DO.
15 Q. LET'S MOVE ON -- OH, MARY CRANE, SAME QUESTION. DO YOU
16 BE -- DO YOU HAVE AN OPINION TO A DEGREE OF REASONABLE
17 MEDICAL CERTAINTY AS TO WHETHER HIS TREATMENT WITH
18 PSYCHOTROPIC MEDICATIONS OF MARY CRANE MET THE STANDARD OF
19 CARE FOR 1995 AND 1996?
20 A. I DO.
21 Q. LET'S GO ON TO THE FINAL PATIENT, ENNIS ALLDREDGE AND
22 HIS PREVIOUS PSYCHOTROPIC MEDICATIONS. THIS IS DEFENDANT'S
23 92. WHAT WAS MR. ALLDREDGE ON WHEN HE WAS ADMITTED?
24 A. HE WAS TAKING BUSPAR WHICH IS A MEDICATION THAT WE USE
25 FOR ANXIETY. IT'S REALLY NOT -- NOT VERY GOOD. HE WAS
1 TAKING RESTORIL, WHICH IS A MEDICATION FOR SLEEP. AND AGAIN,
2 WE TRY NOT TO USE RESTORIL IN THE ELDERLY. HE WAS TAKING
3 ATIVAN AS NEEDED. HE WAS ON RISPERDAL 1 MILLIGRAM TWICE A
4 DAY. HE WAS ON HALDOL AS NEEDED. AND HE WAS ALSO TAKING
5 THIS DRUG MELLARIL THREE TIMES A DAY. AND MELLARIL IS LIKE
6 THORAZINE AND IT HAS LOT OF WHAT ARE CALLED ANTICHOLINERGIC
7 SIDE EFFECTS, SO IT'S NOT A GOOD DRUG TO USE IN THE ELDERLY.
8 AND THESE WOULD HAVE BEEN DRUGS THAT WERE PRESCRIBED BY HIS
9 PREVIOUS PHYSICIAN, CORRECT?
10 A. RIGHT.
11 Q. THESE WERE NOT DRUGS THAT WERE PRESCRIBED BY
12 DR. WEITZEL.
13 A. NO.
14 Q. REFERRING TO -- LET'S ACTUALLY START WITH THE SYMPTOMS
15 THAT WERE SEEN ON THE UNIT WHEN HE WAS ADMITTED.
16 A. YES, IF YOU COULD SHOW THE 1/10, 1/11 SLIDE?
17 Q. AND THIS IS DEFENDANT'S EXHIBIT 84. WHAT DO WE SEE,
18 WHAT SORT OF SYMPTOMS ARE CHARTED BY THE NURSING STAFF ON
19 ADMISSION ON JANUARY 10TH?
20 A. AGAIN, HE WAS VERY COMBATIVE. HE WAS VERY AGITATED. HE
21 WASN'T EATING. AND THAT'S ALWAYS A PROBLEM IF PATIENTS DON'T
22 EAT, YOU TRY TO GET NUTRITION INTO THEM. HE WAS HITTING
23 STAFF. AGAIN, HE WAS COMBATIVE, SQUEEZING STAFF'S HANDS, NOT
24 LETTING GO. AND AGITATED. SQUEEZING THE HANDS OF
25 CAREGIVERS. CONTINUING TO BE RESTLESS, REMOVING BEDDING.
1 AND IF WE COULD SEE THE NEXT SLIDE. AGAIN, HE CONTINUED TO
2 BE AGITATED --
3 THE COURT: EXHIBIT NUMBER?
4 MS. ISAACSON: SORRY. THIS IS EXHIBIT 85.
5 Q. (BY MS. ISAACSON) SO WHAT SYMPTOMS DO WE SEE ON JANUARY
6 11TH?
7 A. AGAIN, THAT HE CONTINUED TO BE AGITATED AND SPITTING.
8 CONTINUED WITH THE AGITATED SPITTING, HITTING, SLAPPING,
9 STRIKING OUT AT CAREGIVERS, AND GRABBING.
10 Q. NOW, YOU TALKED ABOUT SOME OF THE MEDICATIONS THAT
11 MR. ALLDREDGE WAS ON WHEN HE WAS ADMITTED, AND YOU SAID SOME
12 OF THOSE ARE NOT MEDICATIONS THAT YOU WOULD RECOMMEND. WHAT
13 DID DR. WEITZEL DO WITH REGARD TO THOSE MEDICATIONS?
14 A. WELL, HE DISCONTINUED THOSE MEDICATIONS, THE RESTORIL
15 AND THE MELLARIL.
16 Q. AND WE'RE REFERRING TO STATE'S EXHIBITS 6-F.
17 A. AND AGAIN, TREATED HIM WITH RISPERDAL AND ALSO TRAZODONE
18 WHICH AGAIN IS A DRUG USED TO HELP PATIENT SLEEP.
19 Q. AND THEN WITH REGARD TO THE HALDOL THAT WAS PRESCRIBED
20 ON THE FIRST DAY, WHAT WAS THAT IN RESPONSE TO? WHAT WAS
21 THAT PRESCRIPTION IN RESPONSE TO?
22 A. THAT WAS A ONE-TIME ORDER IN RESPONSE TO THE EXTREME
23 AGITATION THAT WAS SEEN WHEN DR. WEITZEL FIRST SAW THE
24 PATIENT ON THE UNIT.
25 Q. AND AGAIN, HOW WOULD YOU CHARACTERIZE ENNIS ALLDREDGE'S
1 AGITATION ON HIS ADMISSION?
2 A. IT SOUNDS LIKE FROM READING THE CHART THAT HE WAS
3 PROBABLY NOT QUITE AS AGITATED AS LYDIA, BUT HE WAS CERTAINLY
4 VERY AGITATED AND AT RISK FROM HURTING HIMSELF OR SOMEBODY
5 ELSE.
6 Q. IS IT ALSO SOMETIMES EVEN MORE DIFFICULT IF A PATIENT IS
7 SEVERELY DEMENTED OR AGITATED AND IS A LARGE PERSON, IS A BIG
8 PERSON?
9 A. YES, IT IS BECAUSE AGAIN, THEY ARE -- A LARGER PERSON IS
10 MORE LIKELY TO HARM STAFF THAN A SMALLER PERSON.
11 Q. WAS EVEN ALLDREDGE ALSO GIVEN P.R.N. MEDICATIONS BY
12 NURSING STAFF?
13 A. YES, HE WAS.
14 Q. WHY DON'T WE GO TO DEFENDANT'S EXHIBIT 103. AND HOW
15 MANY TIMES WAS HE GIVEN P.R.N. MEDICATIONS BY NURSING STAFF?
16 A. HERE AGAIN, HE WAS GIVEN FIVE DOSES OF P.R.N.
17 MEDICATIONS.
18 Q. AND WHICH DAYS WERE THOSE ON?
19 A. THOSE WERE BETWEEN 11TH AND THE 12TH OF JANUARY --
20 Q. SO --
21 A. -- SO THAT WOULD BE --
22 Q. -- SECOND AND THIRD DAY OF HIS ADMISSION.
23 A. -- SECOND AND THIRD DAY OF ADMISSION.
24 Q. OKAY. AND WHAT WOULD THE TRAZODONE HAVE BEEN GIVEN FOR?
25 A. FOR SLEEP. BECAUSE HE WAS AWAKE.
1 Q. WOULD A PATIENT -- YOU CAN GO AHEAD AN HAVE A SEAT,
2 DOCTOR. LET ME GO BACK. DO YOU HAVE AN OPINION TO A
3 REASONABLE DEGREE OF MEDICAL CERTAINTY AS TO WHETHER OR NOT
4 DR. WEITZEL'S TREATMENT OF ENNIS ALLDREDGE WITH PSYCHOTROPIC
5 MEDICATIONS MET THE STANDARD OF CARE FOR 1995 AND 1996?
6 A. I DO.
7 Q. AND WHAT IS THAT OPINION?
8 A. THAT IT DID MEET THE STANDARD OF CARE.
9 Q. WE'VE HEARD FROM DR. BAIR, AND I KNOW YOU'VE REVIEWED
10 HIS REPORT. HE TALKED ABOUT THIS CONCEPT OF DELIRIUM. AND
11 COULD YOU -- I DON'T KNOW HOW -- HOW EXPLICITLY IT WAS
12 EXPLAINED, BUT COULD YOU JUST BRIEFLY EXPLAIN WHAT THE
13 CONCEPT OF DELIRIUM IS AS OPPOSED TO DEMENTIA?
14 A. DELERIUM AND DEMENTIA ARE ACTUALLY TWO VERY DIFFERENT
15 CONDITIONS. DEMENTIA IS A PERMANENT CONDITION WHEREAS
16 DELIRIUM IS SOMETHING THAT IS MORE LIKELY TO HAPPEN IN
17 PATIENTS WITH DEMENTIA BECAUSE OF THE ABNORMAL FUNCTIONING OF
18 PATIENTS WITH DEMENTIOUS BRAINS. DURING DELIRIUM, PEOPLE DO
19 GET -- DO SEEM CONFUSED. THEY CAN APPEAR AGITATED. AND
20 CERTAILY WHEN SOMEBODY IS ADMITTED TO AN ACUTE PSYCHIATRIC
21 UNIT, YOU WOULD WANT TO RULE OUT DELIRIUM.
22 Q. AND SO WHAT ARE THE STEPS THAT YOU THAT WHEN YOU ADMIT
23 SOMEONE WITH DEMENTIA ON TO YOUR UNIT TO EVALUATE THEM?
24 A. THE FIRST THING WE DO IS WE EVALUATE ALL THE DRUGS THAT
25 THAY HAVE BEEN ON PREVIOUSLY TO SEE IF ANY OF THOSE DRUGS
1 COULD POTENTIALLY BE CAUSING THE DELIRIUM. WE THEN DO --
2 Q. AND LET ME STOP YOU THERE. DID YOU SEE A REFLECTION OF
3 THAT BEING DONE IN THE CHARTS?
4 A. YES. BOTH THE THORAZINE AND MELLARIL WHICH COULD
5 POTENTIALLY HAVE BEEN CAUSING DELIRIUM WERE DISCONTINUED.
6 Q. AND SO DR. WEITZEL FULFILLED THAT FIRST STEP THAT YOU'VE
7 DESCRIBED?
8 A. YES.
9 Q. AND THEN WHAT WOULD BE THE NEXT STEP?
10 A. THE NEXT STEP WOULD BE TO ORDER LABORATORY TESTS.
11 Q. AND WHAT WOULD THE PURPOSE OF THE TESTS BE?
12 A. THOSE WOULD BE TO SEE IF THE PATIENT HAD SOMETHING LIKE
13 A URINARY TRACT INFECTION SO YOU'D GET WHAT'S CALLED
14 URINALYSIS TO SEE IF THEIR KIDNEYS WERE FUNCTIONING PROPERLY,
15 TO SEE IF THEIR LIVERS WERE FUNCTIONING PROPERLY. YOU WOULD
16 GET A COMPLETE BLOOD CELL COUNT TO SEE IF THEY HAD SOME OTHER
17 INFECTION.
18 Q. AND WHEN DR. BAIR TALKS ABOUT PERFORMING A DELIRIUM
19 EVALUATION, IS THAT WHAT HE'S TALKING ABOUT?
20 A. THAT IS WHAT I WOULD TALK ABOUT WHEN PERFORMING A
21 DELIRIUM EVALUATION.
22 Q. AND SO IN ALL FIVE OF THESE CASES, DID DR. WEITZEL ORDER
23 SUCH DELIRIUM EVALUATION?
24 A. YES, HE DID.
25 Q. AND DO YOU BELIEVE THAT HE DID WHAT WAS REASONABLE TO
1 TRY TO RECOGNIZE MEDICAL BASES FOR THE DEL -- FOR POTENTIAL
2 DELERIUM IN THESE PATIENTS?
3 A. YES, I DO.
4 Q. NOW, WHAT OTHER THINGS WOULD YOU DO IN THESE STEPS TO
5 TRY TO DEAL WITH THE AGITATION?
6 A. I WOULD ALSO -- ONE OF THE OTHER CAUSES FOR AGITATION
7 CAN BE THE ENVIRONMENT. NOW, OBVIOUSLY, IF SOMEBODY GETS
8 ADMITTED TO THE UNIT, THEN YOU HAVE A CHANGE OF ENVIRONMENT.
9 SO IF THE AGITATION CONTINUES, THEN IT'S NOT AN ENVIRONMENTAL
10 FACTOR. AND A FURTHER THING YOU WOULD LOOK AT IS PAIN. AND
11 AGAIN, YOU'D LOOK AT THAT NOT BECAUSE THE PATIENT'S TELLING
12 YOU THAT THEY'RE IN PAIN, BUT FROM THE BEHAVIOR THAT THE
13 PATIENT IS EXHIBITING.
14 Q. SO NUMBER ONE, YOU'RE LOOKING AT MEDICATIONS AND
15 REVIEWING THAT. THEN NUMBER TWO, LOOKING FOR MEDICAL CAUSES
16 OF DELIRIUM. AND THEN THREE, LOOK AT THE ENVIRONMENT CHANGE
17 AND SEE IF THAT HELPS. AND THEN FINALLY, IF -- IF NONE OF
18 THAT WORKS WITH THE AGITATION, PAIN WOULD BE A CONSIDERATION
19 THAT WOULD BE REASONABLE WITH THESE KIND OF PATIENTS?
20 A. YES.
21 Q. WITH REGARD TO ALL OF THESE CASES, DO YOU HAVE AN
22 OPINION TO A DEGREE OF REASONABLE MEDICAL CERTAINTY AS TO
23 WHETHER THE ADMISSION OF PSYCHOTROPIC DRUGS AND THE TYPES OF
24 DRUGS THAT WERE USED, THE COMBINATION OF DRUGS THAT WERE
25 USED, AND THE LEVELS THAT WERE USED, MET THE STANDARD OF CARE
1 FOR 1995 AND 1996?
2 A. I DO.
3 Q. DO YOU HAVE AN OPINION TO A DEGREE OF REASONABLE MEDICAL
4 CERTAINTY AS TO WHETHER DR. WEITZEL'S ADMINISTRATION OF
5 PSYCHOTROPIC DRUGS CONTRIBUTED TO THEIR DEATHS?
6 A. I DO.
7 Q. AND WHAT IS THAT OPINION?
8 A. I DO NOT FEEL THAT THOSE DRUGS CONTRIBUTED TO THE
9 PATIENTS' DEATHS.
10 Q. AND BASED UPON YOUR REVIEW OF THE RECORDS, DO YOU HAVE
11 AN OPINION TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AS TO
12 WHETHER IT WAS A BREACH OF THE STANDARD OF CARE FOR
13 DR. WEITZEL TO TREAT PAIN IN THESE PATIENTS?
14 A. I DO.
15 Q. AND WHAT IS THAT OPINION?
16 A. I FEEL IT WAS ENTIRELY APPROPRIATE FOR HIM TO TREAT PAIN
17 IN THESE PATIENTS.
18 MS. ISAACSON: THANK YOU. THAT'S ALL I HAVE.
19 THE COURT: MAY CROSS-EXAMINE.
20 MR. WILSON: THANK YOU, YOUR HONOR. PERHAPS WE'LL TURN
21 THE LIGHTS ON.
22 BY MS. BARLOW:
23 Q. GOOD MORNING. DR. BLAKE.
24 A. MORNING.
25 Q. MY NAME IS CHARLENE BARLOW. I'M NOT NEARLY AS TALL AS
1 MS. ISAACSON, SO I HAVE TO PULL THIS DOWN. DR. BLAKE, WE'VE
2 HEARD YOUR QUALIFICATIONS. HAVE YOU EVER TESTIFIED IN A
3 CRIMINAL CASE BEFORE?
4 A. YES, I HAVE.
5 Q. HOW MANY TIMES?
6 A. THREE TIMES.
7 Q. AND THEY'RE CRIMINAL, NOT CIVIL CASES?
8 A. THOSE WERE CRIMINAL CASES.
9 Q. AND DID YOU TESTIFY FOR THE DEFENSE OR FOR THE
10 PROSECUTION IN THOSE CASES?
11 A. ONE WAS FOR THE PROSECUTION, TWO WERE FOR THE DEFENSE.
12 Q. AND I'M ASSUMING THAT YOU GET PAID FOR YOUR EXPERTISE?
13 A. I DO.
14 Q. OKAY. WHAT DO YOU CHARGE HOUR?
15 A. I FEEL VERY EMBARRASSED. I DON'T KNOW. I WORK WITH THE
16 UNIVERSITY. I TELL THEM MY HOURS. I NEVER SEE THE MONEY.
17 Q. AND THEY SEND THE BILL?
18 A. YES. I'M AFRAID I REALLY DON'T KNOW WHAT WE CHARGE.
19 Q. ALL RIGHT. WHEN YOU SAY YOU NEVER SEE THE MONEY, I'M
20 ASSUMING YOU GET PAID FOR WHAT YOU DO.
21 A. WE, ACTUALLY, I'M ON SALARY, SO WHETHER I DO IT OR NOT,
22 IT DOESN'T CHANGE MY SALARY.
23 Q. SO IT HELPS NORTHWESTERN IF YOU GO WORK -- DO SOME WORK
24 LIKE THIS, IS THAT CORRECT?
25 A. IT DOES, YES.
1 Q. OKAY. YOU WERE TALKING ABOUT FOUR LEVELS OF DEMENTIA.
2 YOU SAID DEMENTIA MAY GO UNDIAGNOSED FOR UP TO TWO YEARS, IS
3 THAT CORRECT?
4 A. THAT'S CORRECT.
5 Q. AND THEN IN THE MILD -- AND, YOU KNOW, BACK UP A LITTLE
6 BIT. IN DEMENTIA THERE HAVE BEEN STUDIES AND THERE IS A
7 CERTAIN PROGRESSION OF DEMENTIA, ISN'T THAT CORRECT?
8 A. THAT IS CORRECT.
9 Q. THAT MOST PEOPLE FOLLOW THIS PROGRESSION.
10 A. YES.
11 Q. WHEN YOU SAY ONE TO TWO YEARS, ALMOST EVERYBODY FALLS
12 INTO ONE TO TWO YEARS FOR UNDIAGNOSED.
13 A. SOME PEOPLE MAY GO LONGER, SOME PEOPLE MAY GO SHORTER.
14 THAT'S JUST AN ESTIMATE. IT'S NOTHING SET IN STONE.
15 Q. IT'S A LITTLE HARD BECAUSE OF -- BY THE TIME SOMEONE HAS
16 COME FORWARD AND IS EXHIBITING THE -- THE EFFECTS OF THE
17 DEMENTIA, YOU DON'T KNOW HOW LONG IT'S BEEN GOING ON, SO IT'S
18 HARD TO SAY THAT --
19 A. THAT'S CORRECT --
20 Q. -- ONE TO TWO YEARS.
21 A. -- YES.
22 Q. RIGHT. BUT IN THE MILD, WHEN YOU'VE NOW STARTED
23 FOLLOWING PEOPLE WHO ARE SHOWING DEMENTIA, IS THERE A CERTAIN
24 TIME FRAME THAT WE'RE TALKING ABOUT WHEN A PERSON FALLS INTO
25 THE MILD CATEGORY?
1 A. THAT AGAIN VARIES, AND IT CAN BE TWO YEARS, IT CAN BE AS
2 MANY AS THREE OR FOUR YEARS. AGAIN, IT DEPENDS ON THE KIND
3 OF DEMENTIA.
4 Q. AND MODERATE WHEN THEY START WANDERING, HOW LONG DO THEY
5 FALL INTO THAT CATEGORY?
6 A. AGAIN, IT CAN -- IT CAN VARY TWO TO THREE, MAYBE FOUR
7 YEARS.
8 Q. AND THEN SEVERE, REALLY WHAT TERMINATES A SEVERE
9 DEMENTIA IS THE DEATH, ISN'T THAT CORRECT?
10 A. THAT'S CORRECT.
11 Q. OKAY. AND ABOUT HOW LONG DO PEOPLE FALL INTO THE SEVERE
12 CATEGORY?
13 A. THAT'S USUALLY SHORTER. THAT'S USUALLY A MAXIMUM OF ONE
14 TO TWO YEARS.
15 Q. PEOPLE CAN HAVE -- WELL, LET'S TALK ABOUT ALZHEIMER'S.
16 PEOPLE CAN SUFFER FROM ALZHEIMER'S FOR TEN, 15, 20 YEARS
17 BEFORE THEY DIE, ISN'T THAT CORRECT?
18 A. UNFORTUNATELY, I THINK THAT'S A LITTLE BIT OPTIMISTIC.
19 IT'S USUALLY MORE LIKE TEN YEARS.
20 Q. BUT EVEN THEN, IF YOU'VE GOT A PERSON WHO HAS BEEN
21 EXHIBITING ALZHEIMER'S FOR EVEN FIVE, SIX YEARS, THEY MIGHT
22 HAVE ANOTHER FIVE -- FOUR TO FIVE YEARS OF LIFE EVEN WHEN
23 THEY GET INTO THE SEVERE CATEGORY, ISN'T THAT CORRECT?
24 A. NO. I FEEL ONCE THEY GET INTO THE SEVERE CATEGORY, THEN
25 YOU'RE REALLY LOOKING AT A MUCH SHORTER LIFE SPAN.
1 Q. DEMENTIA YOU TALKED ABOUT HAS SECONDARY EFFECTS. GAIT,
2 GAIT PROBLEMS, BUT YOU TREAT THAT.
3 A. WELL, UNFORTUNATELY, YOU REALLY CAN'T TREAT IT. YOU
4 COULD USE PHYSICAL THERAPY, BUT THERE'S NO -- THERE'S NO WAY
5 OF REVERSING IT.
6 Q. BUT YOU EITHER HAVE THEM AMBULATE WITH A WALKER AS LONG
7 AS THEY CAN.
8 A. YES.
9 Q. I'M ASSUMING YOU TRY TO KEEP THEM AMBULATORY AS LONG AS
10 POSSIBLE, THAT'S --
11 A. YES, YOU DO.
12 Q. -- BETTER FOR ANYBODY, FOR ALL OF US.
13 A. RIGHT.
14 Q. THEY GET INFECTIONS, BUT YOU TREAT THAT.
15 A. WELL, THAT ACTUALLY DEPENDS BECAUSE CERTAINLY, URINARY
16 TRACT INFECTIONS, WE DO TREAT. THERE'S QUITE A LOT OF
17 EVIDENCE OUT NOW THAT WHETHER YOU TREAT PNEUMONIA OR NOT, IT
18 DOESN'T ACTUALLY MAKE MUCH DIFFERENCE TO THE OUTCOME OF THE
19 PATIENT.
20 Q. SO YOU MAY NOT TREAT PNEUMONIA IN A PERSON WHO'S MILDLY
21 DEMENTED?
22 A. NO. WE'RE REALLY TALKING MORE ABOUT SEVERE DEMENTIA.
23 Q. OKAY.
24 A. RIGHT. MILD DEMENTIA, YES.
25 Q. MODERATE DEMENTIA, WOULD YOU TREAT A PERSON FOR
1 PNEUMONIA?
2 A. AGAIN, IT DEPENDS ON HOW SEVERE AND SOMETIMES YOU WOULD,
3 SOMETIMES YOU WOULDN'T.
4 Q. AND YOU WOULD TALK WITH THE FAMILY MEMBERS BEFORE MAKING
5 THAT DECISION WHETHER TO TREAT OR NOT.
6 A. YES.
7 Q. ASPIRATION IS -- IS BASICALLY A PROBLEM OF SOMETIMES AS
8 PEOPLE BECOME DEMENTED, AS THEY DEVELOP ALZHEIMER'S, THEY
9 CAN'T SWALLOW CORRECTLY, IS THAT CORRECT?
10 A. THAT'S CORRECT.
11 Q. AND YOU CAN TREAT THAT.
12 A. ASPIRATION PNEUMONIA, UNFORTUNATELY DOES --
13 Q. I'M SORRY, I'M NOT TALKING ABOUT ASPIRATION PNEUMONIA.
14 I'M TALKING ABOUT THE INABILITY TO SWALLOW. YOU CAN TREAT
15 THAT. YOU -- THERE ARE THINGS YOU CAN DO FOR IT, I SHOULD
16 SAY IT THAT WAY.
17 A. AGAIN, YOU CANNOT REVERSE IT, THOUGH.
18 Q. RIGHT. I UNDERSTAND, BUT YOU CAN THICKEN FLUIDS
19 BECAUSE, FOR WHATEVER REASON, FLUIDS SOMETIMES JUST SLIDE
20 DOWN THE WRONG PIPE.
21 A. YES.
22 Q. AND SO YOU THICKEN THE FLUIDS AND FOR WHATEVER REASON,
23 THAT SEEMS TO ALLOW THEM TO SWALLOW IT BETTER.
24 A. CORRECT.
25 Q. YOU MAY PUREE THE FOOD SO THEY DON'T HAVE -- THEY DON'T,
1 YOU KNOW, GET A BIG CHUNK OF SOMETHING GOING DOWN THE WRONG
2 PIPE.
3 A. YES.
4 Q. BECAUSE IT'S NOT COMFORTABLE TO BE CHOKING.
5 A. I ASSUME NOT. I HAVEN'T TRIED IT.
6 Q. WE ALL TRY NOT TO, YES. NOW, YOU TALKED ABOUT TELEPHONE
7 ORDERS BEING COMMON FOR DOCTORS WHO WORK WITH HOSPITALS. THE
8 DOCTOR MAY BE, YOU SAY NO MORE THAN TWO -- ONE TO TWO HOURS
9 HOURS ON A UNIT. IF A MEDICAL EMERGENCY -- AND I DON'T THINK
10 ANYBODY EXPECTS DOCTORS TO STAY AT THE HOSPITAL 24 HOURS A
11 DAY, BUT IF MEDICAL EMERGENCY ARISES SUCH AS VOMITING OR
12 SEIZURE, YOU WOULD EXPECT A DOCTOR TO RESPOND TO A PAGE IF
13 SOMETHING LIKE THAT IS HAPPENING, WOULDN'T YOU?
14 A. THAT WOULD BE EXPECTED, YES.
15 Q. YES. YOU -- YOU DEAL WITH DEMENTED PEOPLE. SOMETIMES
16 PEOPLE JUST DON'T LIKE TO BE TOUCHED, DO THEY? DEMENTED
17 PEOPLE.
18 A. THAT'S -- THAT'S REALLY HARD TO SAY. I REALLY DON'T
19 KNOW.
20 Q. IN FACT, WITH MRS. ANDERSON, SHE CAME IN TO THE
21 GERO-PSYCH UNIT EXTREMELY FEARFUL OF BEING LEFT ALONE, ISN'T
22 THAT CORRECT?
23 A. THAT IS CORRECT.
24 Q. AND THEN SHE'S LEFT WITH PEOPLE THAT SHE DOESN'T KNOW IN
25 AN ENVIRONMENT SHE DON'T KNOW, ISN'T THAT CORRECT?
1 A. THAT IS CORRECT. ALTHOUGH FROM LOOKING THROUGH THE
2 CHART, EVEN WHEN HER DAUGHTER WAS STILL IN THE ROOM WITH HER,
3 SHE WAS STILL CALLING FOR HER DAUGHTER.
4 Q. AND THAT'S -- THAT WAS HER PROBLEM, THAT WAS THE
5 BEHAVIOR SHE WAS PRESENTING THAT IT HAD GOTTEN TO THE POINT
6 WHERE INSTEAD OF JUST BEING FEARFUL OF BEING ALONE, SHE WAS
7 EVEN FEARFUL WHEN HER DAUGHTER WAS PRESENT, ISN'T THAT
8 CORRECT?
9 A. THAT IS CORRECT.
10 Q. PEOPLE SCREAMING OUT MAY NOT BE SCREAMING OUT IN PAIN,
11 IS THAT CORRECT?
12 A. THERE IS A DIFFERENCE BETWEEN BEING FEARFUL AND THEN
13 ACTUALLY SCREAMING. MOST PEOPLE WHO ARE FEARFUL DO NOT
14 SCREAM.
15 Q. DID YOU LOOK AT THE NURSING HOME RECORDS OF ANY OF THESE
16 PATIENTS?
17 A. NO, I DID NOT.
18 Q. SO YOU DON'T KNOW WHAT THEIR BEHAVIOR WAS AT THE NURSING
19 HOME.
20 A. I JUST KNOW WHAT THE BEHAVIOR WAS LIKE FROM THE
21 ADMISSION --
22 Q. RIGHT.
23 A. -- REFERRAL DESCRIBING THE BEHAVIOR.
24 Q. AND I THINK WE ALL AGREE THAT NURSES ARE THE FRONT LINES
25 OF WHAT'S GOING ON WITH THESE PATIENTS.
1 A. YES.
2 Q. AND ARE YOU FAMILIAR WITH DOCTORS WHO SAY, I'M THE
3 DOCTOR, YOU'RE JUST THE NURSE, JUST DO WHAT I SAY?
4 A. I'VE BEEN VERY FORTUNATE THAT I'VE NOT RUN INTO THAT
5 PROBLEM.
6 Q. HAVE YOU HEARD OF ANY NURSES COMPLAINING OF DOCTORS LIKE
7 THAT?
8 MS. ISAACSON: OBJECTION, RELEVANCE.
9 THE COURT: OVERRULED.
10 Q. (BY MS. BARLOW) HAVE YOU HEARD OF ANY NURSES COMPLAINING
11 OF DOCTORS LIKE THAT?
12 A. I HAVE, YES.
13 Q. WHEN YOU TALK ABOUT THE PRIOR PSYCHOTROPIC DRUGS THAT
14 ALL OF THESE PATIENTS WERE ON, YOU DIDN'T LOOK AT THE NURSING
15 HOME RECORDS TO SEE HOW OFTEN THEY ACTUALLY RECEIVED THOSE
16 DRUGS, DID YOU?
17 A. NO. IT WAS BASED ON THE INFORMATION --
18 Q. THAT --
19 A. -- THAT WAS IN THE CHART, YES.
20 Q. RIGHT. WHICH IS ALSO THE INFORMATION THAT DR. WEITZEL
21 HAD BECAUSE HE DIDN'T HAVE THE NURSING HOME RECORDS EITHER,
22 IS THAT CORRECT?
23 A. I DON'T KNOW WHETHER HE HAD THEM OR NOT.
24 Q. OKAY. THERE WAS A P.R.N. ORDER FOR MRS. ANDERSON OF
25 LORTAB, WHICH IS AN OPIOID-BASED NARCOTIC, IS IT?
1 A. YES.
2 Q. YOU REMEMBER SEEING THAT?
3 A. YES.
4 Q. BUT WITHOUT THE NURSING HOME RECORDS, YOU DON'T KNOW HOW
5 OFTEN SHE RECEIVED THAT IN THE PRIOR MONTH OR TWO MONTHS.
6 A. NO, I DON'T.
7 Q. SO YOU DON'T KNOW THAT SHE DIDN'T RECEIVE IT VERY OFTEN.
8 A. I DON'T KNOW.
9 Q. COULD YOU TELL HOW EFFECTIVE THE PRIOR PSYCHOTROPIC
10 DRUGS HAD BEEN FOR MRS. ANDERSON FROM THE RECORDS YOU SAW?
11 A. I COULD ONLY ASSUME THAT THEY WERE NOT EFFECTIVE BECAUSE
12 THE NURSING HOME WANTED TO HAVE HER HOSPITALIZED.
13 Q. THE BEHAVIOR HAD CONTINUED.
14 A. YES.
15 Q. BUT THESE PSYCHOTROPIC DRUGS, I THINK YOU MENTIONED
16 ATIVAN IS A SHORT-ACTING ONE, IS THAT CORRECT?
17 A. YES.
18 Q. SO THEY -- YOU DON'T KNOW WHETHER THEY WERE EFFECTIVE
19 FOR A CERTAIN TIME PERIOD AND THEN THE BEHAVIORS CAME BACK.
20 A. NO, I DON'T.
21 Q. WHEN YOU WERE TALKING ABOUT MRS. ANDERSON AND GOING
22 THROUGH THE HOURS, THE 17 HOURS THAT SHE WAS BASICALLY ON THE
23 UNIT, YOU DID NOT HAVE THE 0100 NOTE UP THERE, THE ONE
24 O'CLOCK IN THE MORNING NOTE WITH THE BREATHING PROBLEMS WHEN
25 TRACY SCHOLL PAGED DR. WEITZEL, DID YOU?
1 A. NO, I DIDN'T.
2 Q. AND THAT OCCURRED APPROXIMATELY FIVE, FIVE AND A HALF
3 HOURS AFTER THE ADMISSION OF THE FIRST DOSE OF MORPHINE,
4 DIDN'T IT?
5 A. I CANNOT RECOLLECT THE EXACT TIMING.
6 Q. AND IN FACT, AT ONE O'CLOCK IN THE MORNING, TRACY SCHOLL
7 PAGED DR. WEITZEL. HE DIDN'T RESPOND TO THAT PAGE UNTIL 3:30
8 IN THE MORNING, ISN'T THAT CORRECT?
9 A. THAT'S WHAT THE NOTES REFLECT.
10 Q. AND AT 3:30 IN THE MORNING, HE ORDERED MORPHINE. AND IT
11 WAS ADMINISTERED. AND IT WAS ABOUT FIVE AND A HALF HOURS
12 LATER THAT SHE DIED, IS THAT NOT CORRECT?
13 A. WELL, IT SHOWED THAT SHE DIED AND THAT SHE'D HAD
14 MORPHINE. I'M NOT SURE IF THERE WAS A CONNECTION.
15 Q. WELL, I DIDN'T ASK THAT. I'M JUST SAYING --
16 A. RIGHT.
17 Q. -- IT'S ABOUT FIVE --
18 A. YES.
19 Q. -- AND A HALF HOURS LATER. AGAIN WITH MRS. LARSEN, THE
20 PRIOR PSYCHOTROPIC DRUGS, YOU DIDN'T LOOK AT THE NURSING HOME
21 RECORDS TO SEE IF THEY WERE EFFECTIVE EVEN FOR A SHORT PERIOD
22 OF TIME PRIOR TO HER COMING ON THE UNIT.
23 A. NO.
24 Q. YOU DON'T KNOW HOW MANY WERE P.R.N.?
25 A. NO.
1 Q. DR. WEITZEL DISCONTINUED THE XANAX UPON HER ADMISSION TO
2 THE HOSPITAL AND STARTED KLONOPIN. DID HE DOCUMENT -- DID HE
3 GIVE HIS REASONS IN HIS NOTES FOR WHY HE DID THAT?
4 A. NO, HE DIDN'T. I JUST ASSUMED THAT WOULD BE WHY.
5 Q. OH -- YEAH. I UNDERSTAND THAT. IT'S AN ASSUMPTION ON
6 YOUR PART. THEN WE HAVE, YOU KNOW, YOU SHOWED SOME TIME
7 FRAMES, DECEMBER 6TH AND 7TH, DECEMBER 8TH AND 9TH. YOU PUT
8 IN A 10TH THROUGH THE 14TH, AND THEN YOU JUMP TO THE 16TH.
9 DO YOU RECALL A TIME PERIOD WHEN -- DURING THE 11TH AND 12TH
10 THAT MRS. LARSEN'S LETHARGY AND NONRESPONSIVENESS WAS VERY
11 PRONOUNCED?
12 A. AND DURING THOSE TIMES, THE MEDICATION DOSES WERE
13 DECREASED.
14 Q. OKAY. BUT JUST -- DO YOU RECALL DURING THAT TIME
15 PERIOD --
16 A. YES.
17 Q. -- THAT HER LETHARGY AND RESPONSIVENESS INCREASED -- OR
18 UNRESPONSIVENESS INCREASED? YOU SAID YES. I'M SORRY. I
19 WON'T ASK THAT AGAIN. AND THEN YOU RECALL THAT THERE'S A
20 TIME PERIOD ON THE 12TH OF DECEMBER WHEN CERTAIN OF THE
21 NURSES WITHHELD THE PSYCHOTROPIC DRUGS. THEY CIRCLED IT.
22 THEY DIDN'T EVEN GIVE THE PSYCHOTROPIC DRUGS, ISN'T THAT
23 CORRECT?
24 A. THAT IS CORRECT.
25 Q. AND THAT WAS A NURSING DECISION?
1 A. YES.
2 Q. AND YOU -- I'M ASSUMING YOU AGREE WITH THAT NURSING
3 DECISION?
4 A. YES.
5 Q. BECAUSE THESE PEOPLE WERE HAVING PROBLEMS. THEY WERE
6 LETHARGIC, YOU KNOW, THAT MAKES IT DIFFICULT TO SWALLOW.
7 CAUSES RESPIRATION PROBLEMS. SO IT WAS APPROPRIATE FOR A
8 NURSE TO MAKE A DECISION NOT TO GIVE A DRUG THAT WOULD
9 INCREASE THE LETHARGY, WOULD INCREASE THE SWALLOWING
10 PROBLEMS, THE BREATHING PROBLEMS, ISN'T THAT CORRECT?
11 A. IT DEPENDS ON WHAT YOU'RE ACTUALLY TRYING TO TREAT.
12 HERE YOU'RE TRYING TO TREAT AGITATION. IF THE PATIENT IS NOT
13 AGITATED, IF YOU FEEL THAT THEY NEED TO HAVE A DOSE HELD, AND
14 DR. WEITZEL HIMSELF HAD ACTUALLY ORDERED SOME DOSES TO BE
15 HELD.
16 Q. BUT IT WAS HELD.
17 A. YES.
18 Q. AND THAT’S APPROPRIATE. AND THEN WE HAVE MRS. LARSEN --
19 WELL, AND IN FACT, DURING THAT TIME PERIOD, DO YOU RECALL IN
20 THE NURSING NOTES THAT THE FAMILY WAS APPROACHED, I THINK IT
21 WAS BY DR. WEITZEL, BASICALLY TOLD, YOU KNOW, WE CAN KEEP
22 YOUR MOTHER COMFORTABLE. AND THEY SAID, WE DON'T WANNA DO
23 HEROIC MEASURES?
24 A. YES.
25 Q. AND IN FACT, SHE WAS SO LETHARGIC THAT THEY WERE
1 CONCERNED THAT SHE MAY DIE -- WELL, I DON'T KNOW IF CONCERNED
2 IS THE WORD. THERE WAS INDICATION SHE MAY DIE AT THAT TIME.
3 A. I DON'T RECALL THAT BEING SAID, BUT I KNOW THAT THEY
4 WERE TALKING ABOUT COMFORT MEASURES.
5 Q. BUT AFTER THE HOLDING OF THE PSYCHOTROPIC MEDICATION,
6 SHE CAME AROUND, DIDN'T SHE? BY THE 14TH, SHE'S BACK
7 LIGHTER, SHE'S MORE RESPONSIVE, AND IN FACT, SHE BECOMES
8 AGITATED AGAIN, ISN'T THAT CORRECT?
9 A. YES.
10 Q. AND THEN WE HAVE MRS. LARSEN GOING THROUGH A COUPLE OF
11 MEDICAL EMERGENCIES WHILE SHE'S IN THE HOSPITAL. SHE HAS A
12 SEIZURE I BELIEVE ON THE 25TH AND 26TH OF DECEMBER?
13 A. YES.
14 Q. DO YOU RECALL THAT? AND THAT WAS TREATED BY
15 DR. DIENHART, NOT DR. WEITZEL, DO YOU RECALL THAT?
16 A. YES.
17 Q. THEN WE HAVE ON THE 29TH AND 30TH OF DECEMBER, SHE
18 STARTS -- IT'S -- DON'T REMEMBER HOW MANY HOURS OF VOMITING.
19 LOOKS LIKE ABOUT 14-AND-A-HALF-HOUR BOUT OF VOMITING. DO YOU
20 RECALL THAT?
21 A. YES, I DO.
22 Q. DO YOU RECALL THAT THAT THE NURSES BEGAN PAGING
23 DR. WEITZEL AFTER THE VOMITING STARTED, AND HE DIDN'T RESPOND
24 FOR ABOUT EIGHT AND A HALF HOURS AFTER THE VOMITING BEGAN?
25 A. YES. I THINK THEY ALSO PAGED DR. DIENHART AS WELL.
1 Q. YES, THEY DID.
2 A. YES.
3 Q. BUT THE ATTENDING PHYSICIAN IS DR. WEITZEL, ISN'T THAT
4 CORRECT?
5 A. YES.
6 Q. AND VOMITING IS VERY UNCOMFORTABLE, ISN'T IT?
7 A. YES.
8 Q. AND IN FACT, WHEN HE DID RESPOND AT 3:30 IN THE MORNING,
9 WHICH IS THE SAME TIME HE WAS RESPONDING TO ELLEN ANDERSON'S
10 BREATHING PROBLEMS, WHICH THEN BECAME AGITATION BEFORE HE
11 RESPONDED, THE NOTES JUST READ THAT HE WAS MADE AWARE OF
12 THE -- OF THE PATIENTS' CONDITION, ISN'T THAT CORRECT?
13 A. THAT IS CORRECT.
14 Q. AND HE DIDN'T ORDER ANYTHING TO STOP THE VOMITING.
15 ISN'T THAT CORRECT?
16 A. THAT IS CORRECT.
17 Q. AND IN FACT, THE VOMITING CONTINUED FOR ANOTHER SIX
18 HOURS, ISN'T THAT CORRECT?
19 A. YES.
20 Q. NOW, MRS. CRANE YOU THINK WAS PROBABLY IN PAIN WHEN SHE
21 CAME IN, ISN'T THAT CORRECT?
22 A. YES.
23 Q. AND IN FACT, MRS. PAIN DEVELOPED OR EXHIBITED A FISTULA
24 HALFWAY THROUGH HER STAY AT THE HOSPITAL, ISN'T THAT CORRECT?
25 A. THAT IS CORRECT.
1 Q. AND A FISTULA CAN BE CAUSED BY SOME KIND OF DISEASE
2 PROCESS IN THE ABDOMEN, ISN'T THAT TRUE?
3 A. YES.
4 Q. WAS THERE ANY -- AND PROBABLY IS VERY PAINFUL.
5 A. YES.
6 Q. AND I BELIEVE -- LET'S SEE, DR. DIENHART CAME IN,
7 SUGGESTED AN O.B.- G.Y.N. CONSULT. DR. MEEK CAME IN, DID
8 THAT CONSULT, AND RECOMMENDED EITHER SURGERY, IF YOU CAN GET
9 HER CLEARED BY THE INTERNIST. WAS THERE ANY ATTEMPT BY
10 DR. WEITZEL TO GET HER CLEARED BY THE INTERNIST THAT YOU CAN
11 SEE IN THE RECORDS?
12 A. IT'S NOT IN THE RECORDS; HOWEVER, HE ALSO DID SUGGEST
13 MORE CONSERVATIVE --
14 Q. WELL, AND I'LL -- AND I -- SORRY. DIDN'T WANNA --
15 DIDN'T WANNA STOP WITH JUST HALF THE STORY HERE. THE OTHER
16 SUGGESTION IS TO DO A LOW RESIDUE DIET AND A BROAD SPECTRUM
17 ANTIBIOTIC. WHAT WOULD BE THE BROAD SPECTRUM ANTIBIO -- WHAT
18 WOULD THAT BE FOR, THE ANTIBIOTIC?
19 A. AGAIN, I AM NOT AN INTERNIST, I AM A PSYCHIATRIST.
20 Q. OKAY?
21 A. I ASSUME IT WOULD BE FOR INFECTION. THIS IS NOT
22 SOMETHING THAT I FEEL I HAVE ANY EXPERTISE IN.
23 Q. OKAY. THAT WAS ON THE 2ND OF JANUARY WITH MRS. CRANE.
24 AND THERE'S NOTHING IN THE RECORD THAT SHOWS THAT DR. WEITZEL
25 ASKED DR. DIENHART TO COME BACK IN TO START A BROAD SPECTRUM
1 ANTIBIOTIC, ANYTHING OF THAT SORT, IS THERE?
2 A. NO. BUT SIMPLY BECAUSE IT'S NOT IN THE RECORED DOESN'T
3 MEAN THAT THE TWO OF THEM DIDN'T TALK. WHAT IS IN THE RECORD
4 WE KNOW OCCURRED. IT'S VERY DIFFICULT TO KNOW. OFTEN
5 PHYSICIANS WILL TALK --
6 Q. YES, BUT YOU DON'T --
7 A. -- AND YOU DON'T DOCUMENT IT.
8 Q. BUT YOU DON'T KNOW. DR. DIENHART HAS BEEN HERE TO
9 TESTIFY, BUT I'M JUST ASKING ABOUT THE RECORDS. I UNDER --
10 A. YES.
11 Q. YOU KNOW, I UNDERSTAND. IT'S HARD TO GET INTO PEOPLE'S
12 MINDS. AND IN FACT, IT IS THREE DAYS LATER THAT DR. WEITZEL
13 ORDERS KEFLEX FOR MRS. CRANE, IS THAT CORRECT?
14 A. YES.
15 Q. NOW, IS KEFLEX A GRAM-POSITIVE OR GRAM-NEGATIVE, DO YOU
16 KNOW?
17 A. I DON'T KNOW.
18 Q. OKAY. BUT KEFLEX DOES NOT ATTACK -- IT ONLY ATTACKS ONE
19 KIND OF INFECTION, ISN'T THAT CORRECT?
20 A. I REALLY DON'T KNOW.
21 Q. WE'RE OUTSIDE OF YOUR EXPERTISE.
22 A. YES.
23 Q. OKAY. I WON'T -- I WON'T BELABOR THE POINT THEN. NOW,
24 YOU HAVE -- YOU INDICATE AGITATION IN THE CHART -- OR THE
25 SLIDE THAT WAS SHOWN YOU, THROUGH THE 1ST THROUGH THE 3RD OF
1 JANUARY. BUT ON THE 4TH, DROWSINESS BEGAN, ISN'T THAT
2 CORRECT?
3 A. YES.
4 Q. AND IN FACT, WITH ALL OF THESE PATIENTS, YOU SAW
5 AGITATION AND THEN MEDICATION AND DROWSINESS. AGITATION,
6 MEDICATION, AND DROWSINESS. DID YOU SEE THAT PATTERN
7 CONSISTENTLY?
8 A. WE -- THAT -- THAT IS A STANDARD PATTERN THAT YOU SEE
9 WHEN YOU'RE TRYING TO TREAT THESE PATIENTS. IT'S AN ART
10 FORM. IT'S TRIAL AND ERROR --
11 Q. RIGHT.
12 A. -- IT'S VERY DIFFICULT TO GET TO WHERE YOU DON'T HAVE
13 THE PATIENT AGITATED, BUT YOU DON'T HAVE THE PATIENT TOO
14 LETHARGIC. IT REALLY IS SOMETHING THAT CAN TAKE QUITE A
15 WHILE TO REALLY BALANCE THINGS OUT. SO THAT REALLY WOULD NOT
16 BE UNEXPECTED.
17 Q. AND IN FACT, YOUR GOAL, AS YOU SAID, WAS TO -- NOT TO
18 SEDATE, BUT TO CONTROL THE BEHAVIOR.
19 A. EXACTLY. AND SOMETIMES IT TAKES A WHILE UNTIL YOU GET
20 THERE.
21 Q. RIGHT?
22 A. AND SOMETIMES YOU DON'T. I THINK WE HAVE TO ACCEPT
23 THAT.
24 Q. WELL, I UNDERSTAND. ESPECIALLY WITH ELDERLY PATIENTS.
25 A. RIGHT.
1 Q. BUT IN FACT, WITH EACH OF THESE PATIENTS, IT GOT TO THE
2 POINT WHERE THE SEDATION WAS SO SEVERE THAT THEY WERE TOTALLY
3 UNRESPONSIVE. THEY WERE TURNING BLUE, CYANOTIC. THERE WERE
4 THESE KINDS OF PROBLEMS WITH EACH OF THESE PATIENTS TOWARD
5 THE END OF THEIR LIVES, WASN'T -- WEREN'T THERE?
6 A. AND IT'S VERY DIFFICULT TO SAY WHERE THAT CAME FROM
7 BECAUSE --
8 Q. WELL, AND I -- I'M NOT ASKING WHERE IT CAME FROM --
9 A. RIGHT.
10 Q. -- BUT YOU DID SEE THAT --
11 A. YES.
12 Q. -- THAT THE SEDATION GOT TO THE POINT WHERE THEY WERE
13 NOT RESPONSIVE AT ALL.
14 A. I WOULDN'T SAY THAT THE SEDATION GOT TO THAT POINT.
15 THEY GOT TO THE POINT WHERE THEY WERE LETHARGIC OR HAVING
16 PROBLEMS. I'M NOT SURE I WOULD CALL IT SEDATION.
17 Q. BUT SEDATION WOULD BE ONE OF THE REASONS.
18 A. IT COULD BE ONE OF THE REASONS POTENTIALLY.
19 Q. WITH MRS. SMITH, DR. WEITZEL INCREASED HER MEDICATIONS,
20 BUT THAT COULD HAVE A PARADOXIC EFFECT OF INCREASING THE
21 AGITATION, COULD IT NOT?
22 A. I THINK THE -- CORRECT ME IF I'M WRONG, I THINK YOU'RE
23 REFERRING TO A CONDITION CALLED AKATHISIA, IS THAT CORRECT?
24 A. I BELIEVE SO.
25 Q. AND BASICALLY WHAT AKATHISIA IS, IS YOU'RE ABSOLUTELY
1 RIGHT THAT SOME OF THESE MEDICATIONS CAN CAUSE -- IT'S LIKE
2 AN INNER SENSE OF RESTLESSNESS. HOWEVER, THAT IS VERY
3 DIFFERENT -- AND I'VE SEEN BOTH -- TO THE AGITATION. THIS IS
4 WHERE A PATIENT CAN'T SIT STILL. THAT THEY FEEL RESTLESS.
5 IT DOES NOT CAUSE PATIENTS TO BE BITING, KICKING, SCREAMING.
6 Q. SO THE -- LET'S SAY THE ATIVAN, THE RISPERDAL, THE
7 HALDOL, THE KLONOPIN, THE OTHER PSYCHOTROPIC MEDICATIONS THAT
8 WERE HERE, YOU MUST ADMIT THEY WEREN'T JUST ONE AT TIME WITH
9 THESE PATIENTS. VERY OFTEN THERE WAS THREE OR FOUR OR FIVE
10 OR SIX OR SEVEN --
11 A. RIGHT.
12 Q. -- OF THESE. THEY CAN EXACERBATE OR EVEN CAUSE THE --
13 SOME OF THEM CAN CAUSE THE AGITATION THAT THEY ARE INTEND
14 TO --
15 A. AGAIN --
16 Q. -- CURE --
17 A. -- HALDOL AND RISPERDAL HAVE THE POTENTIAL OF CAUSING
18 AKATHISIA, BUT THAT IS VERY DIFFERENCE TO AGITATION. AND I
19 THINK MOST PSYCHIATRISTS CAN DIFFERENTIATE BETWEEN THE TWO.
20 AND I CERTAINLY KNOW THAT MY NURSING STAFF CAN.
21 Q. WITH MR. ALLDREDGE, YOU AGAIN HAD A SLIDE THERE WITH ALL
22 THE AGITATED BEHAVIORS ON THE DAY OF HIS ADMISSION. BUT
23 ACTUALLY, ON THE DAY OF HIS ADMISSION, AT I BELIEVE IT WAS
24 NINE O'CLOCK THAT EVENING WHEN DR. DIENHART CAME IN TO DO HIS
25 HISTORY AND PHYSICAL, HE WAS SO DROWSY, HE WOULD RESPOND TO
1 EVEN PAINFUL STIMULI, ISN'T THAT CORRECT?
2 A. THAT IS CORRECT. AND AGAIN, IT'S ALWAYS DIFFICULT TO
3 MAKE ASSUMPTIONS FROM THE CHART --
4 Q. WELL, AND -- AND SO I'LL ASK YOU NOT TO --
5 A. BUT -- OKAY.
6 Q. WELL, BUT PLEASE DON'T MAKE ANY ASSUMPTIONS FROM THE
7 CHART. WHAT WE HAVE IS YOU SAW -- AND THERE WAS AGITATION.
8 NOBODY'S DISPUTING THAT.
9 A. YES.
10 Q. BUT THERE WAS ALSO DURING THOSE FIRST TWO DAYS PERIODS
11 WHEN HE WAS SO LETHARGIC, HE WOULD NOT RESPOND, ISN'T THAT
12 CORRECT?
13 A. THAT IS CORRECT. AND AGAIN, THIS IS DUE TO THE TRIAL
14 AND ERROR NATURE --
15 Q. WELL, AND I UNDERSTAND THAT --
16 A. -- OF PRESCRIBING.
17 Q. THANK YOU. NOW, YOU TALKED ABOUT -- WELL, AND I THINK
18 IT'S PROBABLY SAFE TO SAY WITH ALL OF THE DRUGS THAT WE'RE
19 TALKING ABOUT HERE, YOU MUST MONITOR PEOPLE CLOSELY AFTER YOU
20 GIVE THEM THESE KINDS OF DRUGS, ISN'T THAT CORRECT?
21 A. YES.
22 Q. AND IN FACT, THAT'S PART OF THE TRIAL AND ERROR.
23 A. YES.
24 Q. AND WHEN YOU TALK ABOUT CHANGING THEIR ENVIRONMENT, YOU
25 SAID THESE PEOPLE HAD A CHANGE IN -- OF ENVIRONMENT. THEY
1 HAD BEEN BROUGHT TO THIS UNIT. SO CLEARLY, ENVIRONMENT
2 WASN'T THEIR PROBLEM. ISN'T THAT WHAT YOU SAID? OR AM I
3 MISSTATING?
4 A. THE ENVIRONMENT WAS PROBABLY NOT THE CAUSE. IF IT WAS
5 SOMETHING IN THE NURSING HOME THAT WAS CAUSING PROBLEMS --
6 Q. UH-HUH.
7 A. -- AND WITH SOME PATIENTS, YOU GET THEM ADMITTED TO THE
8 HOSPITAL AND IT'S FINE, YOU KNOW, SOMETIMES IT'S A NURSE'S
9 AIDE WHO'S BEEN GETTING THEM RILED UP. THEY GET ADMITTED,
10 THEY CALM DOWN.
11 Q. BUT THE MERE FACT THAT YOU'VE TAKEN SOMEONE OUT OF AN
12 ENVIRONMENT THAT THEY ARE FAMILIAR WITH MIGHT CAUSE
13 AGITATION, MIGHT IT NOT? AND PUT THEM IN A TOTALLY DIFFERENT
14 ENVIRONMENT WITH PEOPLE THEY DON'T KNOW.
15 A. YES. UNFORTUNATELY, WE HAVE NO CHOICE, THOUGH, BECAUSE
16 NURSING HOMES --
17 Q. WELL, NO, I UNDERSTAND THAT --
18 A. YES.
19 Q. -- BUT IT CAN -- I MEAN PART OF THE ENVIRONMENT IS
20 SOMEBODY CAN BE RESPONDING TO WHERE AM I NOW. IN FACT, THESE
21 PEOPLE ESPECIALLY, WHERE AM I NOW. THEY'RE NOT SURE WHERE
22 THEY ARE EVEN --
23 A. CORRECT.
24 Q. -- EVEN WHEN THEY'RE WHERE THEY'VE BEEN.
25 A. YES, RIGHT.
1 Q. OKAY. YOU IN YOUR OPINION LETTER INDICATED THAT THESE
2 PEOPLE WOULD PROBABLY NOT BENEFIT FROM GROUPS, IS THAT
3 CORRECT?
4 A. THAT IS CORRECT.
5 Q. AND THAT'S BECAUSE OF THEIR DEMENTIA?
6 A. BECAUSE OF THE DEGREE OF THEIR DEMENTIA. PATIENTS WITH
7 MILD AND MODERATE DEMENTIA CERTAINLY BENEFIT GREATLY FROM
8 GROUPS --
9 Q. RIGHT.
10 A. -- PATIENTS WITH SEVERE DEMENTIA REALLY DON'T.
11 Q. AND THESE PEOPLE HAD SEVERE DEMENTIA.
12 A. YES.
13 Q. IN FACT, PART OF THE REGIMEN FOR THE GEROPSYCH UNIT THAT
14 DR. WEITZEL WAS IN CHARGE OF WAS THAT THESE PEOPLE HAD TO GO
15 TO EIGHT HOURS OF GROUP EVERY DAY. IN FACT, DOCTOR ORDERED
16 THAT THEY GO THERE EVEN IF THEY WERE SLEEPING. ARE YOU AWARE
17 OF THAT?
18 A. I WASN'T AWARE THAT IT WAS -- THAT THEY HAD TO BE THERE
19 FOR EIGHT HOURS A DAY.
20 Q. NOW, YOU IN YOUR LETTER INDICATED THAT THE DOSES WERE
21 HIGHER THAN THOSE THAT ARE USED TODAY, BUT EVEN IF 1995,
22 ESPECIALLY WITH GERIATRIC PATIENTS, THE WHOLE CONCEPT WAS
23 START LOW AND GO SLOW.
24 A. THAT'S CORRECT. AND AT THAT STAGE, WE WERE PROBABLY
25 USING -- USING RISPERDAL AS AN EXAMPLE, WE WERE USING DOSES
1 OF 8 TO 10 MILLIGRAMS IN YOUNG PATIENTS --
2 Q. IN YOUNG PATIENTS.
3 A. -- SO OUR USUAL RULE OF THUMB WOULD BE, AN YOU SAY, TO
4 START AT A LOWER DOSE. SO STARTING 1.5, 2 MILLIGRAMS WOULD
5 BE SIGNIFICANTLY LOWER THAN DOSES WE WERE USING IN YONGER
6 PATIENTS.
7 Q. ARE YOU FAMILIAR WITH THE GERIATRIC DOSING HANDBOOK?
8 A. I AM NOT FAMILIAR WITH IT.
9 Q. OKAY. BUT THERE ARE MORE -- I MEAN THERE ARE DOSING
10 HANDBOOKS --
11 A. YES.
12 Q. -- DEALING WITH GERIATRIC PATIENTS.
13 A. YES, THERE ARE.
14 Q. SO IF YOU'RE NOT -- OKAY. IF YOU'RE NOT FAMILIAR WITH
15 IT, THEN YOU WOULDN'T KNOW WHAT IT SAID, SO I WON'T ASK YOU
16 THAT. AS THE ATTENDING PSYCHIATRIST, WOULD YOU EXPECT TO GO
17 INTO THE UNIT EITHER EARLY IN THE MORNING BEFORE THE PATIENTS
18 ARE AWAKE OR LATE AT NIGHT AFTER THEY'VE GONE TO SLEEP AND DO
19 YOUR EVALUATION OF THE PATIENTS WITHOUT ANY HANDS-ON, WITHOUT
20 ANY ACTUAL OBSERVING OF THEM?
21 A. DOCTORS, BECAUSE OF THEIR SCHEDULE, ROUND AT ALL TIMES.
22 Q. BUT, WOULD YOU DO THAT AS AN ATTENDING PSYCHIATRIST IN
23 YOUR --
24 A. YES, I DO.
25 Q. -- DAILY?
1 A. YES. AND OTHER -- OTHER ATTENDEES IN MY UNIT ALSO DO
2 THAT.
3 Q. SO EVERY DAY YOU WOULD GO IN EITHER BEFORE SIX O'CLOCK
4 OR AFTER, MAYBE ELEVEN O'CLOCK?
5 A. NOT EVERY DAY, BUT ON CERTAIN DAYS, YES, THAT'S WHAT I
6 DO.
7 Q. OKAY. IF THE PSYCHOTROPICS ARE NOT EFFECTIVE, YOU MIGHT
8 BE LOOKING AT A PAIN SITUATION.
9 A. YES.
10 Q. WE'VE ALL AGREED WITH THAT. BUT YOU WOULD WANT TO
11 DIAGNOSE WHAT'S CAUSING THE PAIN, WOULD YOU NOT? IF -- IF AT
12 ALL POSSIBLE.
13 A. IF AT ALL POSSIBLE, BUT WE WOULDN'T WAIT UNTIL WE HAD A
14 DIAGNOSIS OF WHAT WAS TREATING THE PAIN. YOU TREAT THE PAIN,
15 THEN YOU TRY AND SEE WHERE IT'S COMING FROM.
16 Q. A URINARY RETENTION CAN CAUSE PAIN?
17 A. THAT IS POTENTIAL, YES.
18 Q. CONSTIPATION CAN CAUSE PAIN?
19 A. YES.
20 Q. YOU WOULDN'T NECESSARILY TREAT THOSE WITH MORPHINE,
21 WOULD YOU?
22 A. IT DEPENDS ON THE DEGREE OF AGITATION. I'VE NEVER SEEN
23 A PATIENT WHO WAS CONSTIPATED WHO LOOKS THE WAY THAT THESE
24 PATIENTS ARE DESCRIBED. SOMEBODY WHO'S CONSTIPATED MAY BE A
25 LITTLE BIT UNCOMFORTABLE, BUT I NEVER SEEN THEM TO BE
1 SCREAMING AND BITING AND KICKING.
2 Q. WHAT ABOUT A BOWEL IMPACTION, HAVE YOU SEEN ANY OF YOUR
3 PATIENTS WITH THAT KIND OF PROBLEM?
4 A. YES, I HAVE SEEN BOWEL IMPACTIONS.
5 Q. A DISEASE PROCESS -- WELL, WE'VE TALKED ABOUT MARY CRANE
6 AND THE POSSIBLE DISEASE PROCESS THERE. OFTEN THE SYMPTOMS
7 THAT WERE LISTED BY SOME OF THESE NURSES WERE THAT THE -- A
8 PATIENT WAS MOANING, BUT THINGS OTHER THAN PAIN CAN CAUSE
9 MOANING, ISN'T THAT CORRECT?
10 A. MOANING IS THE MOST -- MOST COMMON. I MEAN, PAIN IS THE
11 MOST COMMON REASON FOR PEOPLE TO MOAN. BUT AGAIN, WE DON'T
12 KNOW. IT'S AN ART. WE -- WE TRY AND -- WHAT WE TRY AND DO
13 IS WE LOOK AT METAPHORS THAT WE UNDERSTAND FROM PATIENTS WHO
14 CAN COMMUNICATE WITH US AND USE THOSE TO GUIDE OUR TREATMENT.
15 ARE WE RIGHT OR WRONG? WE DON'T KNOW. WE'RE JUST TRYING TO
16 HELP THEM.
17 Q. AND IF A PERSON GETS TO THE POINT WHERE THEY ARE SO
18 SEDATED THAT AT FIRST THEY'RE ONLY RESPONDING, THEY'RE ONLY
19 MOANING, THEIR ONLY VERBAL KIND OF RESPONSE IS WHEN YOU PUT
20 THE NEEDLE IN, WE'VE GOT A PERSON WHO'S VERY UNRESPONSIVE,
21 WOULDN'T YOU SAY?
22 A. YES.
23 Q. IN YOUR LETTER YOU INDICATED THAT YOU DIDN'T THINK
24 DR. WEITZEL'S ACTIONS ALTERED THE EXPECTED OUTCOME FOR THESE
25 PEOPLE BECAUSE THE EXPECTED OUTCOME IS THAT THEY WERE GOING
1 TO DIE, IS THAT NOT CORRECT?
2 A. IN THESE PATIENTS, YES.
3 Q. IN THESE PATIENTS. IN FACT, THAT'S EXPECTED OUTCOME FOR
4 ALL OF US. WE'RE ALL EVENTUALLY GOING TO DIE, AREN'T WE?
5 A. YES.
6 Q. OKAY. BUT THE PROBLEM IS, IS IF SOMEONE CAUSES THAT
7 OUTCOME UNNATURALLY OR PREMATURELY, THE LAW KIND OF REQUIRES
8 SOME CONSEQUENCESS OF THAT, DOES IT NOT?
9 MS. ISAACSON: OBJECTION.
10 THE COURT: SUSTAINED.
11 Q. (BY MS. BARLOW) COMFORT CARE MEANS NO PAIN WITH A
12 NATURAL DEATH, DOES IT NOT?
13 A. YES.
14 Q. NO HEROIC MEASURES TO STOP A NATURAL DEATH, DOES IT NOT?
15 A. YES.
16 Q. IT DOESN'T MEAN BRINGING A QUICKER DEATH BECAUSE THESE
17 PEOPLE ARE GOING TO DIE ANYWAY, DOES IT?
18 A. NO. BUT -- AND AGAIN, I AM NOT A PALLIATIVE CARE
19 EXPERT. I NEED TO SAY THIS UP FRONT. BUT I CERTAINLY KNOW
20 THAT SOMETIMES IN PALLIATIVE CARE PEOPLE MAY DIE A BIT
21 SOONER, BUT WE -- WE JUST DON'T KNOW. YOU KNOW, YOU CAN'T
22 TELL.
23 Q. NO, YOU -- WELL, YOU CAN'T RUN A -- YOU CAN'T RUN A TEST
24 TO SEE IF THIS PERSON WOULD HAVE DIED FIVE MINUTES LATER IF
25 THEY HADN'T RECEIVED THE MEDICATION.
1 A. CORRECT.
2 Q. OKAY. AND I KNOW YOU HAVEN'T REALLY TALKED ABOUT THE
3 PAIN MANAGEMENT, BUT EVEN WITH ATIVAN, YOU'RE TALKING ABOUT
4 AN INTRAMUSCULAR INJECTION, IS THAT NOT CORRECT?
5 A. YES.
6 Q. AND IN FACT, WITH THE MORPHINE, WITH ALL OF THESE
7 PATIENTS, THEY WERE INTRAMUSCULAR INJECTIONS, ISN'T THAT
8 CORRECT?
9 A. YES.
10 Q. AND WITH MRS. LARSEN, THE LAST 24 HOURS OF HER LIFE,
11 BETWEEN ATIVAN, THE MORPHINE, ANY OTHER MEDICATIONS THAT WERE
12 ADMINISTERED TO HER, SHE RECEIVED 28 INTRAMUSCULAR NEEDLE
13 INJECTIONS IN THE LAST 24 HOURS OF HER LIFE. ARE YOU AWARE
14 OF THAT?
15 A. I DIDN'T KNOW IT WAS 28. SHE HAD -- SHE HAD A LOT.
16 Q. OKAY. THERE ARE LESS PAINFUL WAYS OF ADMINISTERING
17 THESE MEDICATIONS, ISN'T THAT CORRECT?
18 A. ORALLY --
19 Q. BUT THERE ARE LESS PAINFUL WAYS. YOU CAN DO IT ORALLY
20 OR YOU CAN DO IT SUBCUTANEOUS, YOU CAN DO IT WITH
21 SUPPOSITORIES, SOME OF THEM, IS THAT CORRECT?
22 A. SUBCUTANEOUS AND SUPPOSITORY IS PROBABLY NOT LESS
23 DISCOMFORT -- YOU DON'T GET LESS DISCOMFORT THAN I.M. AND I
24 THINK PART OF -- AND AGAIN, I'M NOT TALKING AS AN EXPERT, I'M
25 JUST TALKING AS A REGULAR PHYSICIAN --
1 Q. RIGHT.
2 A. -- WHEN YOU -- WHEN YOU TRY AND TREAT PATIENTS FOR PAIN,
3 WHAT YOU TRY AND DO IS GIVE THE NEXT INJECTION -- THAT IS
4 WHAT EVERYONE ALWAYS TELLS ME -- BEFORE THE PAIN BREAKS
5 THROUGH. AND SO THAT WOULD MINIMIZE THAT AS LONG AS YOU DO
6 IT REGULARLY.
7 Q. IF A PERSON'S -- IF A PERSON HAD A LIVING WILL OR A
8 ADVANCE DIRECTIVE THAT SAID NO I.V.'S, AND YET I.V.'S
9 MIGHT -- AN I.V. FOR ADMINISTRATION OF PAIN MEDICATION WOULD
10 HAVE BEEN LESS PAINFUL, WOULD YOU HAVE APPROACHED THE FAMILY
11 MEMBERS AND SAID, YOU KNOW, I RECOGNIZE EVERYBODY'S TALKING
12 ABOUT NO I.V.'S, BUT IT WOULD BE LESS PAINFUL IF WE
13 ESTABLISHED AN I.V. TO -- TO ADMINISTER THESE PAIN
14 MEDICATIONS, WOULD YOU -- WOULD YOU DO THAT?
15 MS. ISAACSON: OBJECTION, BEYOND THE SCOPE.
16 THE COURT: OVERRULED.
17 Q. (BY MS. BARLOW) AS A PHYSICIAN, WOULD YOU DO THAT?
18 WOULD YOU TALK TO THE FAMILY MEMBERS AND SAY, I KNOW THAT'S
19 WHAT THIS SAYS, NO I.V.'S, BUT REALLY THAT WOULD BE THE LEAST
20 PAINFUL WAY OF TAKING CARE OF THIS END-OF-LIFE SITUATION?
21 A. WELL, I ACTUALLY FEEL DIFFERENTLY. I THINK THESE ARE
22 PATIENTS WHO IT'S VERY DIFFICULT TO GET I.V.'S INTO. AND
23 THAT THE I.V. OFTEN MEANS YOU THEN NEED TO RESTRAIN THEM SO
24 THEY DON'T PULL THE I.V. OUT. AND SO WE REALLY TRY TO -- I
25 THINK I.V.'S ACTUALLY MUCH MORE INTRUSIVE THAN INTRAMUSCULAR
1 INJECTIONS.
2 Q. BUT IF A PERSON IS SO UNRESPONSIVE THAT THE ONLY
3 RESPONSE IS TO A NEEDLE STICK, YOU DON'T HAVE TO WORRY ABOUT
4 TYING THEM DOWN, DO YOU?
5 A. THE I.V.'S GET INFECTED. THEY REALLY ARE NOT A GOOD
6 IDEA IN THIS POPULATION.
7 Q. DO YOU HAVE -- YOU PERSONALLY AS A PHYSICIAN HAVE ANY
8 CONCERNS THAT -- THAT THE CASE WE'RE HERE FOR TODAY MIGHT
9 CAUSE DOCTORS TO GIVE LESS PAIN MEDICINE AT THE END OF LIFE?
10 A. I HAVEN'T -- DON'T THINK SO.
11 MS. BARLOW: OKAY. THANK YOU. I HAVE NO FURTHER
12 QUESTIONS, YOUR HONOR.
13 THE COURT: REDIRECT.
14 MS. ISAACSON: YOUR HONOR, I WILL HAVE A SERIES OF
15 QUESTIONS. WOULD YOU LIKE ME TO DO THEM NOW OR WOULD YOU
16 LIKE TO TAKE A BREAK?
17 THE COURT: HOW LONG WILL IT TAKE, DO YOU THINK?
18 MS. ISAACSON: TEN OR 15 MINUTES.
19 THE COURT: LET'S TAKE OUR BREAK NOW, LADIES AND
20 GENTLEMEN. WE'LL BE IN RECESS UNTIL 10:30. AGAIN REMIND YOU
21 OF MY PRIOR ADMONITON.
22 (THE COURT TOOK A RECESS.)
23 THE COURT: PARTIES AND COUNSEL ARE PRESENT. JURY IS IN
24 THE JURY BOX. DR. BLAKE, WOULD YOU COME BACK TO THE STAND
25 PLEASE? COURT REMINDS YOU THAT YOU'RE STILL UNDER OATH.
1 BY MS. ISAACSON:
2 Q. DR. BLAKE, THERE HAS BEEN SOME SUGGESTION THAT THE
3 AGITATION THAT WAS SEEN IN SOME OF THESE PATIENTS -- IN ALL
4 THESE PATIENTS REALLY, COULD HAVE BEEN CAUSED BY THINGS LIKE
5 CONSTIPATION OR URINARY BLOCKAGE, THOSE SORTS OF THINGS. DO
6 YOU BELIEVE BASED ON YOUR EXPERTISE THAT THE AGITATION THAT
7 WAS SEEN IN THIS CASE ORIGINATED FROM THOSE SORTS OF CAUSES?
8 A. CERTAINLY URINARY RETENTION AND CONSTIPATION CAN CAUSE
9 AGITATION. HOWEVER, THAT'S USUALLY SOMETHING THAT'S PRETTY
10 ACUTE. IT LASTS OVER A FEW DAYS. YOU HAVE TO PASS URINE.
11 SO IF YOU LOOKING AT SOMEBODY WHO HAS AGITATION OVER A COURSE
12 OF THREE, FOUR DAYS, EVEN I THINK SOME OF THESE PATIENTS HAD
13 BEEN AGITATED FOR A COUPLE OF WEEKS BEFORE THEY CAME INTO THE
14 HOSPITAL, SO IT WOULD -- YOU JUST WOULD NOT EXPECT URINARY
15 RETENTION TO DO THAT. THE SAME WITH CONSTIPATION. AND IN
16 FACT, I THINK WE -- REMEMBERING THE CHART ON ENNIS ALLDREDGE,
17 IN FACT, HE WAS SMEARING FECES AT ONE STAGE, SO I THINK WE
18 CAN ASSUME THAT HE WAS HAVING BOWEL MOVEMENTS.
19 Q. WITH REGARD TO THE PSYCHOTROPIC MEDICATIONS, COULD THOSE
20 MEDICATIONS CAUSE THINGS LIKE HEART DISEASE?
21 A. NO.
22 Q. COULD THEY CAUSE THINGS LIKE LUNG DISEASE?
23 MS. BARLOW: OBJECTION, YOUR HONOR. THIS IS BEYOND THE
24 SCOPE OF CROSS.
25 THE COURT: OVERRULED.
1 Q. (BY MS. ISAACSON) COULD PSYCHOTROPIC MEDICATIONS IN
2 THESE CASES CAUSE LUNG DISEASE FOR ANY OF THESE PATIENTS, FOR
3 EXAMPLE?
4 A. NO.
5 Q. IN FACT, A LOT OF THESE PATIENTS, I THINK ALMOST ALL OF
6 THESE PATIENTS, HAD SOME HISTORY OF STROKES, IS THAT YOUR
7 RECOLLECT?
8 A. THAT IS MY RECOLLECTION.
9 Q. IS THERE SOME RISK IF YOU DON'T TREAT AGITATION WITH
10 PSYCHOTROPICS WITH REGARD TO STROKES?
11 A. YES. PATIENTS WITH VASCULAR DEMENTIA, YOU PARTICULARLY
12 WANT TO GET THESE PATIENTS TREATED AND LESS AGITATED BECAUSE
13 THE MORE AGITATED THEY ARE, THE MORE LIABLE THEY ARE TO HAVE
14 FURTHER STROKES. SO THAT'S ANOTHER REASON WHY WE REALLY NEED
15 TO TREAT THESE PATIENTS.
16 Q. SO IF, FOR EXAMPLE, LYDIA SMITH -- ACTUALLY, I THINK IT
17 WAS JUDITH LARSEN WHO HAD A HISTORY OF TWO STROKES IN 1995.
18 IF SHE WERE LEFT TO BE AGITATED AND WASN'T MEDICATED WITH
19 PSYCHOTROPICS, THAT WOULD ACTUALLY INCREASE HER RISK FOR
20 ANOTHER STROKE?
21 A. YES, IT WOULD.
22 Q. THERE ALSO HAS BEEN SOME SUGGESTION BY THE STATE'S
23 EXPERT THAT ONE THING THAT SHOULD HAVE BEEN DONE WAS TO STOP
24 ALL PSYCHOTROPIC MEDICATIONS FOR THESE PATIENTS. WAS THAT A
25 REALISTIC IDEA FOR THESE PATIENTS?
1 A. DO YOU MEAN ON ADMISSION WHEN THEY CAME FROM THE NURSING
2 HOME?
3 Q. YES, TO START WITH CLEAN SLATE, THAT -- I THINK THAT WAS
4 HIS TESTIMONY.
5 A. RIGHT. THAT REALLY WOULD NOT BE THE STANDARD OF CARE
6 SIMPLY BECAUSE THESE PATIENTS ARE COMING IN BECAUSE THEY ARE
7 AGITATED. TO STOP ALL MEDICATIONS WOULD REALLY PUT THEM IN A
8 VERY DIFFICULT SITUATION. WHAT WE DO IS WE STOP THE
9 MEDICATIONS THAT WE THINK COULD POTENTIALLY BE CAUSING A
10 DELIRIUM AND WE KEEP THE OTHER MEDICATIONS ON BOARD.
11 OTHERWISE, THE PATIENTS ARE REALLY GOING TO DO VERY BADLY.
12 Q. COUNSEL ASKED YOU ABOUT A STATEMENT IN YOUR REPORT ABOUT
13 YOUR OPINION THAT WHAT DR. WEITZEL DID IN THIS CASE DID NOT
14 ALTER THE OUTCOME FOR ANY OF THESE PATIENTS. WHAT DID YOU
15 MEAN BY THAT?
16 A. THESE -- THESE WERE ALL SEVERELY DEMENTED, SEVERELY ILL
17 PATIENTS. AND A CERTAIN PROPORTION OF PATIENTS WHO COME INTO
18 THE HOSPITAL ARE GOING TO DIE. THERE'S REALLY NOTHING THAT
19 WE CAN DO. AND THE SICKER THEY ARE, OBVIOUSLY, THE MORE
20 LIKELY THAT IS TO HAPPEN. AND SO I THINK LOOKING BACK ON ALL
21 OF THESE PATIENTS, THEY WERE -- THEY WERE IN THE TERMINAL
22 PHASE OF DEMENTIA, AND NO MATTER WHAT ANYBODY DID, THESE
23 PEOPLE WOULD DIE.
24 MS. ISAACSON: I HAVE NOTHING FURTHER.
25 THE COURT: RECROSS.
1 MS. BARLOW: JUST A COUPLE OF THINGS, YOUR HONOR. THANK
2 YOU.
3 BY MS. BARLOW:
4 Q. YOU JUST INDICATED THAT NO MATTER WHAT ANYONE DID, THESE
5 PEOPLE WERE GOING TO DIE, IS THAT CORRECT?
6 A. YES.
7 Q. AND THAT'S TRUE BEFORE THEY CAME INTO THE HOSPITAL?
8 A. WE DON'T KNOW IN ADVANCE WHO'S GONNA LIVE AND WHO
9 ISN'T --
10 Q. THAT'S -- YES, THAT'S -- THAT'S MY POINT --
11 A. THERE ARE CERTAIN PROPORTION OF PATIENTS, WHEN YOU
12 FOLLOW THEIR COURSE, YOU JUST REALIZE THAT WHAT WE'RE LOOKING
13 AT IS THE TERMINAL PHASE OF DEMENTIA.
14 Q. BUT WHEN YOU'RE TALKING ABOUT THE TERMINAL PHASE, NOW,
15 THIS IS A GEROPSYCH UNIT. THEY ARE SUPPOSED TO BE MEDICALLY
16 STABLE. THEY ARE SUPPOSED TO BE ABLE TO BENEFIT FROM BEING
17 ON THE UNIT. SO YOU WEREN'T EXPECTING THEM TO DIE WITHIN
18 FOUR DAYS? WITHIN 17 HOURS?
19 A. NO. AND CERTAINLY, THE REASON WE ADMIT THE PATIENTS IS
20 TO CONTROL THE BEHAVIOR --
21 Q. WELL, BUT MY -- MY QUESTION IS YOU'RE NOT ABLE --
22 A. -- AND SEND THEM BACK --
23 THE COURT: WAIT A MINUTE. LET HER FINISH --
24 MS. BARLOW: OH, EXCUSE ME.
25 THE COURT: -- MS. BARLOW. GO AHEAD.
1 THE WITNESS: WHEN WE ADMIT THE PATIENTS, CLEARLY OUR
2 EXPECTATION IS THAT WE GOING TO TREAT THEM, GET THEM WHERE
3 THEY'RE MUCH CALMER, AND WHERE THEY CAN BE BACK IN A NURSING
4 HOME. BUT A CERTAIN PROPORTION OF THESE PATIENTS --
5 Q. BUT -- THANK YOU, BUT --
6 A. -- GO BACK --
7 Q. -- THAT GOES BEYOND WHAT I ASKED --
8 A. SORRY.
9 Q. -- SO -- OKAY.
10 A. I APOLOGIZE.
11 Q. NO, NO, THAT'S OKAY. I -- I'M JUST -- JUST WANNA GET ON
12 TO MY NEXT QUESTION. THANK YOU. PSYCHOTROPIC MEDICATIONS
13 YOU SAID DON'T CAUSE HEART -- HEART DISEASE, DON'T CAUSE LUNG
14 DISEASE. HOWEVER, THEY DO HAVE SEDATIVE SIDE EFFECTS, IS
15 THAT CORRECT?
16 A. THAT IS CORRECT.
17 Q. IT CAN DECREASE A PERSON'S ABILITY TO BREATHE. IT'S A
18 CENTRAL -- THEY ARE CENTRAL NERVOUS SYSTEM DEPRESSANTS.
19 A. YES.
20 Q. AND THAT CAN LOWER A PERSON'S BLOOD PRESSURE.
21 A. YES.
22 Q. IT CAN CAUSE THEM TO ASPIRATE BECAUSE THEY AREN'T
23 SWALLOWING BECAUSE THEY'RE MORE SEDATED.
24 A. AND THAT'S WHY WE HOSPITALIZE THEM SO THEY CAN BE
25 MONITORED.
1 Q. RIGHT. AND IN FACT, THIS SEDATION CAN LEAD TO ORGAN
2 DAMAGE, ISN'T THAT CORRECT?
3 A. THERE IS THE POTENTIAL, BUT THEN YOU'VE GOT THE OTHER
4 RISK IF YOU DIDN'T TREAT, IT'S GOING TO LEAD TO ORGAN
5 DAMAGE --
6 Q. I UNDERSTAND THAT, BUT THAT IS ALSO A RISK. YOU SAY IT
7 DOESN'T CAUSE HEART DISEASE AND LUNG DISEASE, BUT THE
8 SEDATING EFFECTS MAY CAUSE THAT PROBLEM.
9 A. WELL, IT'S NOT GONNA CAUSE HEART DISEASE. WHAT IT COULD
10 DO IS IT COULD CAUSE LUNG DISEASE.
11 Q. CAUSE ORGAN DAMAGE?
12 A. I'M NOT QUITE SURE I UNDERSTAND WHAT YOU MEAN BY ORGAN
13 DAMAGE.
14 Q. NOW, YOU INDICATE THAT DR. WEITZEL ACTED APPROPRIATELY
15 BY DISCONTINUING SOME OF THE MEDICATIONS AND KEEPING THE
16 OTHER MEDICATIONS ON BOARD WHEN THESE PEOPLE CAME IN. BUT
17 THAT WASN'T EFFECTIVE TO STOP THEIR AGITATION, WAS IT?
18 A. NO, IT WASN'T, BUT I THINK IT WAS THE RIGHT THING TO
19 DO --
20 Q. WELL, I UNDER --
21 A. -- HAD IT BEEN --
22 Q. YEAH, I UNDERSTAND --
23 A. -- AND OFTEN WORKS OUT THAT WAY --
24 THE COURT: WAIT A MINUTE. ONE AT A TIME --
25 MS. BARLOW: OKAY.
1 THE COURT: -- MS. BARLOW, YOU KNOW HOW IT WORKS --
2 MS. BARLOW: THANK YOU.
3 THE COURT: -- DOCTOR, FOR YOUR BENEFIT, LET HER FINISH
4 BEFORE YOU START SO THE REPORTER CAN GET DOWN WHAT EVERYBODY
5 SAYS. OKAY? THANK YOU.
6 MS. BARLOW: ACTUALLY, I THINK I'VE ASKED ALL THE
7 QUESTIONS I NEED OF THIS WITNESS. THANK YOU, YOUR HONOR.
8 AND THANK YOU, DOCTOR --
9 THE COURT: REDIRECT, MS. ISAACSON.
10 BY MS. ISAACSON:
11 Q. DR. BLAKE, IS THERE A MAGIC PILL TO CURE DEMENTIA OR TO
12 CURE AGITATION --
13 MS. BARLOW: OBJECTION, YOUR HONOR. THIS IS BEYOND THE
14 SCOPE OF CROSS.
15 THE COURT: IT IS, BUT I'LL OVERRULE THE OBJECTION.
16 Q. (BY MS. ISAACSON) IS THERE?
17 A. NO, THERE ISN'T.
18 MS. ISAACSON: THAT'S ALL I HAVE.
19 MS. BARLOW: NOTHING FURTHER, YOUR HONOR.
20 THE COURT: YOU MAY STEP DOWN, DOCTOR.
21 THE WITNESS: THANK YOU.
22 THE COURT: THANK YOU FOR TESTIFYING. MAY THIS WITNESS
23 BE EXCUSED?
24 MS. ISAACSON: YES.
25 MS. BARLOW: YES.
1 THE COURT: MAY BE EXCUSED AND THANKS AGAIN.
2 THE WITNESS: THANK YOU.