Robert Weitzel, MD
9 ROBERT WEITZEL,
10 CALLED BY THE DEFENDANT, HAVING BEEN DULY
11 SWORN, WAS EXAMINED AND TESTIFIED AS FOLLOWS:
12 DIRECT EXAMINATION
13 BY MR. STIRBA:
14 Q. GOOD MORNING, ROBERT.
15 A. GOOD MORNING.
16 Q. HOW DO YOU FEEL?
17 A. VERY NERVOUS.
18 Q. AND YOU UNDERSTAND YOU'VE BEEN ACCUSED OF SOME VERY
19 SERIOUS ALLEGATIONS?
20 A. YES, I DO.
21 Q. AND ARE YOU READY TO TELL THE JURY ABOUT THE FACTS AND
22 CIRCUMSTANCES AND WHAT HAPPENED?
23 A. YES.
24 Q. DID YOU, ROBERT, INTENTIONALLY OR KNOWINGLY MEDICATE ANY
25 OF THE FIVE PATIENTS INVOLVED IN THIS CASE WITH THE INTENT
3746
1 TO CAUSE THEIR DEATH?
2 A. NO.
3 Q. DID YOU NEGLIGENTLY OR INTENTIONALLY OVERMEDICATE ANY OF
4 THE FIVE PATIENTS INVOLVED IN THIS CASE?
5 A. NO, I DIDN'T.
6 Q. DID YOU INTENTIONALLY OR KNOWINGLY PROVIDE MORPHINE TO
7 ANY OF THE FIVE PATIENTS IN THIS CASE INTENDING TO CAUSE
8 THEIR DEATH?
9 A. NO.
10 Q. WHERE DO YOU PRESENTLY RESIDE?
11 A. IN SALT LAKE CITY.
12 Q. AND HOW OLD ARE YOU?
13 A. FORTY-FOUR.
14 Q. IN DECEMBER OF 1995 AND JANUARY OF 1996 WERE YOU
15 EMPLOYED AT THE DAVIS HOSPITAL?
16 A. YES.
17 Q. WHEN WERE YOU HIRED?
18 A. IN NOVEMBER OF '94.
19 Q. AND WHAT WERE YOU HIRED TO DO?
20 A. INITIALLY -- WELL, I WAS A PSYCHIATRIST THERE AND
21 INITIALLY I WAS TO SPELL DR. JENSEN, BE A STAFF PSYCHIATRIST
22 ON THE GEROPSYCH UNIT.
23 Q. AND DID THERE COME A TIME WHEN THAT POSITION CHANGED IN
24 SOME RESPECTS AFTER NOVEMBER OF '94?
25 A. YES.
3747
1 Q. AND JUST BRIEFLY TELL US HOW YOUR POSITION CHANGED.
2 A. IN MARCH OF '95 I WAS FORMALLY HIRED AS THE ASSOCIATE
3 MEDICAL DIRECTOR OF THE UNIT.
4 Q. AND DID THAT INVOLVE A CHANGE IN YOUR DUTIES?
5 A. NOT SIGNIFICANTLY. I DID TAKE ON A LOT MORE
6 RESPONSIBILITY AND DR. JENSEN SORT OF EASED OUT AT THAT
7 TIME.
8 Q. WHERE DID YOU GO TO MEDICAL SCHOOL?
9 A. SOUTHWESTERN MEDICAL SCHOOL IN DALLAS, TEXAS.
10 Q. AND WHEN DID YOU GRADUATE?
11 A. IN MAY OF 1986.
12 Q. DESCRIBE FOR US, PLEASE, THE PURPOSE OF THE GEROPSYCH
13 UNIT?
14 A. WELL, IT WAS A GENERAL PSYCHIATRIC UNIT FOR GERIATRIC
15 FOLKS, FOR OLDER FOLKS.
16 Q. AND DESCRIBE THE KINDS OF PATIENTS THAT WERE TREATED
17 THERE.
18 A. BASICALLY THREE KINDS. ALL OF THE FOLKS WERE ELDERLY,
19 BUT THE FIRST CATEGORY WOULD BE GENERAL PSYCHIATRIC PATIENTS
20 WHO HAPPENED TO BE ELDERLY. SECOND, WE HAD FOLKS WITH
21 MEDICAL PROBLEMS THAT CAUSED PSYCHIATRIC SYMPTOMS. THAT
22 COULD INCLUDE FOLKS WHO HAD BEEN -- THEIR MEDICATIONS WERE
23 CAUSING PROBLEMS AND FINALLY PEOPLE WITH DIFFERENT FORMS OF
24 DEMENTIA.
25 Q. AND WAS PSYCHIATRIC INTERVENTION NECESSARY?
3748
1 A. IN ALL OF THESE PEOPLE IT WAS CLEARLY NECESSARY.
2 Q. AND TELL US JUST GENERALLY WHAT KIND OF PSYCHIATRIC
3 INTERVENTION WAS REQUIRED.
4 A. WELL, IT VARIED FROM PERSON TO PERSON, BUT ALL OF THESE
5 PEOPLE NEEDED ACUTE CARE AND MEDICATIONS. THEY ADDITIONALLY
6 IN VARYING DEGREES HAD FORMS OF PSYCHOTHERAPY.
7 Q. AND WHO PROVIDED THE THERAPY ON THE UNIT?
8 A. SOCIAL WORKERS, SOMETIMES THE NURSES, RARELY MYSELF. I
9 WAS THE MEDICATION MANAGEMENT PERSON.
10 Q. AND WOULD YOU EXPLAIN WHEN YOU SAY MEDICATION MANAGEMENT
11 PRECISELY WHAT YOUR ROLE WAS?
12 A. A LOT OF PEOPLE THINK OF A PSYCHIATRIST, YOU KNOW, A LOT
13 OF TALK THERAPY, LAYING ON THE COUCH. BUT THE OTHER END OF
14 THE SPECTRUM IS BIOLOGICAL PSYCHIATRY AND THAT'S MORE WHAT I
15 WAS TO DO. WORKING WITH THEIR MEDICAL CONDITION AND THE
16 MEDICATIONS WE HAD AVAILABLE TO TRY AND GET THEIR SYMPTOMS
17 UNDER CONTROL.
18 Q. DID YOU HAVE A ROLE CONCERNING ADMISSIONS TO THE UNIT?
19 A. YES, I DID.
20 Q. AND WOULD YOU TELL US, PLEASE, WHAT YOUR ROLE WAS?
21 A. AFTER AN INITIAL ASSESSMENT BY ONE OF THE SOCIAL WORKERS
22 OR PERHAPS A NURSE, I WAS CALLED, AND AS THE ATTENDING
23 DOCTOR I HAD TO EITHER CALL IN OR WRITE ADMITTING ORDERS. SO
24 BASICALLY I HAD TO OKAY THE ADMISSION.
25 Q. WHAT DID YOU UNDERSTAND THE ADMISSION CRITERIA TO HAVE
3749
1 BEEN DURING THE TIME FRAME OF DECEMBER OF '95 AND JANUARY OF
2 '96?
3 A. BASICALLY THESE FOLKS NEEDED TO BE ACUTELY
4 PSYCHIATRICALLY ILL. THEY COULDN'T JUST HAVE A CHRONIC
5 CONDITION WITHOUT SOME ACUTE CHANGES. THEY COULDN'T HAVE
6 ANY LIFE THREATENING ILLNESSES AT THE TIME OF ADMISSION. I
7 MEAN TO SAY, NOT ANY ACUTE STATE WHICH WAS LIFE THREATENING.
8 THEY MAY HAVE HAD SOME SERIOUS ILLNESSES WHICH AT ANY TIME
9 COULD BECOME ACUTE. THEY HAD TO, OF COURSE, BE ELDERLY.
10 AND THERE WERE SOME EXCLUSION CRITERIA, I THINK.
11 Q. WHAT DO YOU MEAN WHEN YOU SAY ACUTE?
12 A. WELL, USING DEMENTIA AS AN EXAMPLE, THIS IS A CHRONIC
13 PROCESS. IT'S PROBABLY ONGOING OVER YEARS. AND WE WERE NOT
14 TO BE BRINGING IN FOLKS WHO WERE SIMPLY CHRONICALLY
15 DEMENTED. IT WAS MORE THAT THERE HAD BEEN AN ACUTE CHANGE
16 IN THEIR STATUS. ACUTE MEANING OVER HOURS OR WEEKS AT THE
17 MOST.
18 Q. DID A MEDICAL CONDITION OF A PATIENT PLAY A ROLE OR
19 AFFECT THE ADMISSION CRITERIA?
20 A. WELL, THE MEDICAL CONDITION MIGHT CAUSE THE PSYCHIATRIC
21 ILLNESS. IF IT WAS AN ACUTE PROBLEM THAT WAS LIFE
22 THREATENING, THAT AFFECTED THE CRITERIA. WE COULDN'T TAKE
23 THOSE FOLKS. BUT I THINK WE HAD PLENTY OF PEOPLE WHO WERE
24 FAIRLY SICK, GIVEN THE AGE GROUP AND WE WERE -- I WAS
25 WILLING TO TRY AND HELP THEM.
3750
1 Q. DID YOU HAVE A RESPONSIBILITY ON ADMISSION TO CONDUCT AN
2 EXAMINATION OR PREPARE AN EVALUATION?
3 A. BOTH.
4 Q. AND TELL US THE DIFFERENCE BETWEEN AN EXAMINATION AND
5 THE EVALUATION.
6 A. WELL, THE EXAM THAT'S DONE FOR A PSYCHIATRIC ADMISSION
7 IS CALLED A MENTAL STATUS EXAMINATION AND IT CAN REALLY VARY
8 AS TO THE LENGTH. BUT THAT'S GOING AND TALKING TO THE
9 PATIENT AND FINDING OUT HOW THEIR THINKING PROCESS IS, IS IT
10 WORKING AND HOW THEY ARE FEELING. THE OTHER PART IS MORE OF
11 THE PSYCHIATRIC EVALUATION, IS A REPORT THAT IS PREPARED AND
12 IT INCLUDES ALL THE HISTORY I'VE BEEN ABLE TO GATHER AND THE
13 EXAMINATION.
14 Q. TELL US WHAT THE MENTAL STATUS EXAMINATION ENTAILED.
15 A. THAT -- WELL, YOU GO AND TALK WITH THE PATIENT TO THE
16 BEST OF YOUR ABILITY. IT WOULD INCLUDE THINGS LIKE THEIR
17 AFFECT OR THEIR EMOTIONAL STATE, THEIR MOOD, THEIR SENSORIUM
18 WHICH INCLUDES THEIR LEVEL OF CONSCIOUSNESS, THEIR THOUGHT
19 PROCESS, INSIGHT AND JUDGMENT. IT REALLY VARIED AS TO HOW
20 MUCH INFORMATION I COULD GATHER THERE. FOLKS WE'VE BEEN
21 TALKING ABOUT WERE ALL PRETTY DEMENTED. IT MIGHT BE A
22 FAIRLY PERFUNCTORY EXAMINATION ONCE I DISCOVERED THEY DIDN'T
23 HAVE INSIGHT OR JUDGMENT OR ABILITY TO ANSWER A LOT OF MY
24 QUESTIONS.
25 Q. HOW WOULD YOU GO ABOUT PREPARING THE WRITTEN REPORT OR
3751
1 THE EVALUATION?
2 A. WELL, ALONG WITH THE MENTAL STATUS EXAM AND ALL OF THE
3 DIFFERENT HISTORY THAT COULD BE GATHERED, I'D LOOK AT WHAT
4 THE NURSES HAD BEEN ABLE TO GATHER IN THEIR NURSING
5 ASSESSMENT. I'D TALK TO OTHER PROVIDERS. LOOK AT OLD
6 CHARTS. TALK WITH FAMILY. WHATEVER I COULD GATHER. AND
7 THEN I'D NEED TO DICTATE THIS WRITTEN REPORT, THE
8 PSYCHIATRIC EVALUATION.
9 Q. WAS THERE A REQUIREMENT IN TERMS OF WHEN YOU HAD TO
10 DICTATE THE EVALUATION IN RELATIONSHIP TO THE ADMISSION OF
11 THE PATIENT?
12 A. YES. IT WAS SUPPOSED TO BE DONE WITHIN 24 HOURS.
13 HOSPITAL BY-LAWS ASK IT BE DONE WITHIN 24 HOURS.
14 Q. AND YOU RECALL THE DICTATION FOR PATIENT ELLEN ANDERSON
15 WAS DONE ON THE 30TH?
16 A. YES.
17 Q. AND DO YOU KNOW THE DAY THAT YOU ACTUALLY SAW HER?
18 A. I SAW HER ON THE EVENING OF THE 29TH, LATE AFTERNOON.
19 Q. AND WHAT DID YOU DO ON THAT DAY?
20 A. WELL, I CAME IN. I HAD TO SEE HER QUICKLY BECAUSE I HAD
21 A LOT TO DO. I DID THE MENTAL STATUS EXAM. IT WAS PRETTY
22 PERFUNCTORY BECAUSE OF HER -- SHE WAS VERY DEMENTED. SHE
23 WAS SCREAMING. SHE COULDN'T REALLY ASSIST MUCH IN THE EXAM.
24 I DID THAT. AND OTHER THAN THAT I MUST HAVE TALKED WITH THE
25 NURSE AND STAFF TO GET MORE INFORMATION.
3752
1 Q. WHY WAS THE DICTATION DONE ON THE FOLLOWING DAY OF THE
2 ACTUAL REPORT?
3 A. I JUST DIDN'T GET TO IT. MANY TIMES I KNEW I HAD TO DO
4 IT WITHIN 24 HOURS, BUT I DIDN'T HAVE TIME TO GET THAT ONE
5 DONE.
6 Q. NOW, ON THE 29TH YOU REMEMBER IN YOUR PROGRESS NOTE YOU
7 STATED EVAL DONE. DICTATED. DO YOU REMEMBER THAT?
8 A. RIGHT.
9 Q. WHY DID YOU WRITE THAT ON THE 29TH?
10 A. WELL, THAT WAS SORT OF JUST ON MY FIRST NOTE I HAD TO DO
11 A PSYCHIATRIC EVALUATION WHICH IS GENERALLY A TWO- OR
12 THREE-PAGE REPORT AND SO IT'S BASICALLY MY FIRST NOTE. THE
13 WRITTEN NOTE IS PRETTY PERFUNCTORY AND IT WAS MY HABIT TO
14 WRITE PSYCHIATRIC EVAL DONE AND DICTATED ONCE I HAD ACTUALLY
15 SEEN THE PATIENT 'CAUSE I KNEW I WAS GOING TO DICTATE THE
16 THING. LOOKING BACK NOW, I WISH IT HADN'T BEEN MY HABIT
17 'CAUSE IT WASN'T ACTUALLY DICTATED AT THAT VERY MOMENT. BUT
18 I HAD TO GET IT DONE WITHIN 24 HOURS.
19 Q. DO YOU KNOW WHAT THE FORM DISCHARGE SUMMARY IS?
20 A. SURE.
21 Q. AND TELL US, PLEASE, WHAT A DISCHARGE SUMMARY IS.
22 A. THAT IS A DOCUMENT PREPARED AFTER THE PATIENT'S
23 DISCHARGED AND IT PRETTY MUCH GOES THROUGH THE ENTIRE
24 HOSPITALIZATION AND SUMMARIZED WHAT OCCURRED THERE.
25 Q. AND WHAT'S THE PURPOSE FOR A DISCHARGE SUMMARY?
3753
1 A. WELL, IT'S REALLY HELPFUL IF THE PATIENT IS SUBSEQUENTLY
2 HOSPITALIZED. WHEN I GOT PATIENTS ADMITTED TO ME, I WOULD
3 ALWAYS TRY AND GET THE OLD DISCHARGE SUMMARIES 'CAUSE IT HAS
4 THE HOSPITAL COURSE, WHAT MEDICATIONS WERE TRIED AND WHAT
5 THEY WERE DISCHARGED ON, WHAT SORT OF PROCEDURES, IF ANY.
6 IT'S A SHORTHAND WAY OF ENCAPSULATING A WHOLE
7 HOSPITALIZATION.
8 Q. AS WITH THE PSYCHIATRIC EVALUATION, THE WRITTEN REPORT,
9 WAS THERE A REQUIREMENT IN TERMS OF THE TIMING OF WHEN A
10 DISCHARGE SUMMARY WOULD BE DICTATED?
11 A. I BELIEVE THAT WAS 72 HOURS. I'M NOT REALLY SURE OF THE
12 BY-LAWS AT THAT HOSPITAL.
13 Q. AND 72 HOURS FROM WHEN?
14 A. FROM DISCHARGE.
15 Q. NOW, I WANT TO DIRECT YOUR ATTENTION -- YOU HAVE SOME
16 BINDERS UP THERE, ROBERT, AND I WANT YOU TO PULL OUT PATIENT
17 JUDITH LARSEN'S BINDER, PLEASE. AND I WANT TO DIRECT YOUR
18 ATTENTION -- THERE IS A PROGRESS NOTE SECTION THERE AND IT
19 WOULD BE THE NUMBER 470 OR THERE'S A REFERENCE FOR A
20 PROGRESS NOTE ON DECEMBER 15.
21 A. OKAY.
22 Q. DO YOU SEE THAT?
23 A. I'VE GOT IT RIGHT HERE.
24 Q. WHY DON'T YOU READ THAT TO US, PLEASE?
25 A. IT'S MY NOTE THAT SAYS, RESPONDED TO ME THIS MORNING
3754
1 FAIRLY APPROPRIATELY. BLOOD PRESSURE A LITTLE LABILE,
2 DYSPHORIC, OFTEN LETHARGIC. MILDLY FEBRILE YESTERDAY. NOW
3 OKAY. ASSESSMENT. MAJOR DEPRESSIVE DISORDER WITH PSYCHOTIC
4 FEATURES IMPROVED. BETTER INTAKE. PLAN, CONTINUE THERAPY.
5 PROBABLY WON'T NEED HOSPICE, AND SIGNED BY ME.
6 Q. AND YOU PUT HOSPICE IN QUOTES; IS THAT RIGHT?
7 A. UH-HUH.
8 Q. TELL US, PLEASE, WHAT DID YOU MEAN BY YOUR USE OF THE
9 WORD HOSPICE?
10 A. WELL, HOSPICE IS END-OF-LIFE CARE. EARLIER IN THE
11 HOSPITALIZATION MISS LARSEN LOOKED VERY ILL AND I THOUGHT
12 SHE MIGHT BE DYING, BUT SHE IMPROVED QUITE A BIT. AND I'M
13 SAYING, I DON'T THINK SHE'S GOING TO NEED THAT. WE CAN GO
14 BACK TO TRYING OUR ORIGINAL PLAN WHICH WAS TO REVERSE HER
15 PSYCHIATRIC SYMPTOMS AND GET HER BACK PLACED IN HER NURSING
16 HOME AGAIN.
17 Q. AT THE TIME THAT YOU WROTE THAT NOTE, WERE YOU THINKING
18 ABOUT HOSPICE CARE BEING SOMETHING IN HER FUTURE?
19 A. I WAS THINKING -- WELL, I HAD BEEN THINKING IT. BUT NOW
20 I'M THINKING PROBABLY NOT, AT LEAST ANY TIME SOON.
21 Q. HAD YOU HAD PREVIOUS EXPERIENCE IN TERMS OF HOSPICE
22 CARE?
23 A. YES.
24 Q. AND WOULD YOU TELL US GENERALLY WHAT THAT WAS?
25 A. IN RESIDENCY I HAD WORKED AS A VOLUNTEER WITH PEOPLE
3755
1 WITH AIDS; GOING OUT ACTUALLY TO THEIR HOUSES WHERE HOSPICE
2 CARE WAS PROVIDED. I ALSO HAD IN CALIFORNIA WORKED IN THE
3 HOSPITAL THERE WITH THAT SORT OF CARE, END-OF-LIFE CARE.
4 I'VE NEVER WORKED IN A HOSPICE, BUT I'VE BEEN TRAINED IN
5 THAT AND IT'S PART OF MEDICAL TRAINING AND MEDICAL SCHOOL.
6 Q. NOW, YOU RECALL THAT BEFORE PATIENT JUDITH LARSEN DIED,
7 SHE WAS NOT MOVED OFF OF THE UNIT?
8 A. CORRECT.
9 Q. AND SHE WAS NOT RELOCATED. DO YOU REMEMBER THAT?
10 A. RIGHT.
11 Q. WOULD YOU TELL US, PLEASE, THE CIRCUMSTANCES SUCH THAT
12 SHE WAS NOT MOVED?
13 A. WELL, SHE DID IMPROVE AND WE ONCE AGAIN TRIED TO HELP
14 HER WITH HER PSYCHIATRIC PROBLEMS, BUT THEN SHE GOT VERY
15 SICK. SHE HAD A SEIZURE AND THEN SHE HAD A G.I. BLEED. HER
16 SON MERLIN TOLD ME THAT THEY WERE HAVING A REALLY HARD TIME
17 GETTING HER PLACED ANYWHERE. HE HAD STATED THAT A NURSE HAD
18 TOLD HIM THAT SHE WOULD HAVE TO LEAVE THE UNIT. AND HE TOLD
19 ME HOW HARD THAT WAS GOING TO BE AND I SAID, I WON'T MAKE
20 HER LEAVE. SHE CAN STAY ON THE HOSPITAL UNIT. IT LOOKED
21 LIKE SHE WAS DYING. AND I TOLD HIM THAT SHE COULD BASICALLY
22 STAY THERE.
23 Q. AND WHY DID YOU DO THAT?
24 A. WELL, WHEN A PATIENT IS IN THAT STATE, IT'S NOT EASY TO
25 PUT THEM IN AN AMBULANCE AND MOVE THEM SOMEWHERE ELSE, FOR
3756
1 THE PATIENT OR THE FAMILY. HE WAS TELLING ME THAT HE DIDN'T
2 KNOW WHERE HE'D TAKE HER. IT SEEMED LIKE THE RIGHT THING TO
3 DO FOR THE FAMILY.
4 Q. NOW, DID THE EXPERIENCE THAT YOU HAD IN CARING FOR
5 PATIENT JUDITH LARSEN, DID THAT HAVE AN EFFECT ON YOU IN
6 TERMS OF CARE THAT YOU PROVIDED TO THE OTHER PATIENTS IN
7 THIS CASE?
8 A. YES, IT DID.
9 Q. AND WOULD YOU TELL US, PLEASE, HOW SO?
10 A. I'D NEVER BEEN THE ATTENDING PHYSICIAN FOR A PERSON FOR
11 END-OF-LIFE CARE. I, AS A RESIDENT MEDICAL STUDENT, I'VE
12 WORKED WITH FOLKS WHO WERE DYING, BUT THIS WAS MY FIRST
13 EXPERIENCE AS AN ATTENDING AND FRANKLY, I JUST SORT OF FELL
14 INTO IT. BUT IT DID SEEM TO HELP THAT FAMILY AND THAT
15 PATIENT, MISS LARSEN AND HER FAMILY. WHEN THESE OTHER
16 PEOPLE IN THE SAME SITUATION, IT SEEMED LIKE THE LOGICAL AND
17 RIGHT THING TO DO.
18 Q. NOW, THE FOUR PATIENTS THAT ARE INVOLVED IN THIS CASE
19 WHICH YOU DID ACTUALLY ORDER AND THEY RECEIVED PSYCHIATRIC
20 MEDICATIONS, DID YOU ACTUALLY ORDER THAT PSYCHOTROPIC
21 MEDICATIONS WERE APPROPRIATE FOR THEM?
22 A. I DID ORDER THOSE AND THOUGHT THEY WERE APPROPRIATE.
23 Q. AND GENERALLY WOULD YOU TELL US WHY YOU THINK THE
24 MEDICATIONS WERE CALLED FOR?
25 A. WELL, THEY WERE ALL VERY DEMENTED AND BEHAVIORALLY
3757
1 DISTURBED. AND THAT WAS MY JOB. I WAS A PSYCHIATRIST WHO
2 WAS CHARGED WITH FIGURING OUT WHAT THE MEDICAL PROBLEMS
3 WERE, WHAT THE MEDICATIONS WERE DOING AND TRYING TO GET THAT
4 BEHAVIOR CONTROLLED AND HELP THEM FEEL BETTER.
5 Q. AND JUST SO WE'RE CLEAR, THE FOUR PATIENTS WHO ACTUALLY
6 RECEIVED PSYCHOTROPIC MEDICATIONS, DO YOU RECALL WHO THEY
7 WERE?
8 A. SURE.
9 Q. WOULD YOU TELL US, PLEASE?
10 A. WELL, ENNIS ALLDREDGE, JUDITH LARSEN, LYDIA SMITH AND
11 MARY CRANE.
12 Q. AND WOULD YOU TELL US WHAT BENEFITS DID THE DRUGS THAT
13 YOU ORDERED HAVE IN TERMS OF THEIR SYMPTOMS OR THEIR
14 PSYCHIATRIC PROBLEMS?
15 A. WELL, WE USED BASICALLY FOUR CLASSES OF MEDICATIONS
16 THERE. ANTIANXIETY MEDICATION SUCH AS ATIVAN WOULD DECREASE
17 ANXIETY AND CAUSE SOME SEDATION SO PATIENTS WEREN'T CLIMBING
18 OUT OF BED OR THROWING THINGS. ANTIDEPRESSANTS WERE USED.
19 THE PATIENTS APPEARED VERY UNHAPPY AT TIMES AND THAT SEEMED
20 TO BE HELPFUL AND HAS BEEN REALLY HELPFUL FOR A LOT OF
21 DEMENTED PATIENTS. ANTIPSYCHOTICS WERE USED. AND THIS IS
22 MOSTLY FOR CONTROL OF BEHAVIOR THAT'S OUT OF CONTROL. AND
23 THEN MOOD STABILIZERS LIKE DEPAKOTE. AND I GUESS I'D HAVE
24 TO INCLUDE CLONIDINE. ONE PATIENT GOT CLONIDINE IN AN
25 ATTEMPT TO STABILIZE THE MOOD, SEDATE THE PATIENT SOMEWHAT.
3758
1 ALL OF THESE MEDICINES ARE SEDATING TO ONE DEGREE OR ANOTHER
2 AND THAT'S BECAUSE THE PATIENTS ALL CAME IN VERY, VERY,
3 AGITATED AND NEEDED SEDATION.
4 Q. DID YOU HAVE SOME MEDICATION HISTORY ON EACH ONE OF
5 THOSE FOUR PATIENTS PRIOR TO ACTUALLY ORDERING DRUGS OR
6 MEDICATIONS FOR THEM?
7 A. YES. I WOULD HAVE SOME HISTORY IN VARYING DEGREES.
8 Q. AND WHAT SIGNIFICANCE, IF ANY, DID THAT MEDICATION
9 HISTORY HAVE IN TERMS OF WHAT YOU DID?
10 A. WELL, IT TOLD ME IT WOULD HAVE BEEN TRIED BEFORE,
11 WHETHER THAT WAS WORKING OR NOT, THE LEVEL AT WHICH THE
12 MEDICATION HAD BEEN PRESCRIBED AND WHETHER THAT WAS WORKING
13 OR NOT, GIVING ME AN INDICATION OF HOW SICK THE PATIENTS
14 WERE. ALSO SINCE SOME OF THESE PATIENTS WERE CONTINUED ON
15 THE SAME MEDICATIONS THEY WERE NO LONGER ON INITIAL STARTING
16 DOSES. IT REALLY HELPED ME A LOT IN KIND OF GUIDING ME AND
17 HELPING ME MAKE AN EDUCATED GUESS AS TO WHAT WOULD HELP
18 DURING THEIR TIME WITH ME.
19 Q. DID IT HAVE ANY SIGNIFICANCE IN TERMS OF DOSING LEVELS?
20 A. SURE.
21 Q. AND WOULD YOU TELL US HOW SO?
22 A. WELL, SINCE I CAN'T ASK A PATIENT EXACTLY HOW THEY ARE
23 FEELING AND I JUST HAVE TO GO FROM EXTERIOR BEHAVIOR, ANY
24 KIND OF INFORMATION THAT WILL GUIDE ME IS HELPFUL. AND A
25 PREVIOUS HISTORY IS GOING TO HELP. A LOT HAS BEEN MADE OF
3759
1 THESE -- OF THE GERIATRIC DOSAGE HANDBOOK AND DOSAGES
2 PUBLISHED THERE. THOSE ARE GUIDELINES. AND AS A
3 PSYCHIATRIST I HAVE TO GO BY THE CLINICAL BEHAVIOR AND
4 TRYING ADJUSTED MEDICATIONS TO THE PATIENT'S BEHAVIOR AND
5 TRY AND HELP THEM THERE. SO KIND OF FLYING BY THE SEAT OF
6 MY PANTS THERE. WITH PEOPLE WHO ARE DEMENTED ANY KIND OF
7 INFORMATION IS HELPFUL.
8 Q. DID YOU TAKE PRECAUTIONS IN TERMS OF ANY POSSIBLE
9 ADVERSE EFFECTS OF THE PSYCH MEDICATIONS CONCERNING THESE
10 FOUR PATIENTS?
11 A. YES.
12 Q. AND WOULD YOU TELL US THE KIND OF PRECAUTIONS THAT YOU
13 TOOK?
14 A. I GENERALLY CAME TO THE UNIT EVERY DAY OF THE WEEK. I
15 WAS ON CALL 24/7. THE NURSES ARE THERE 24/7 ALL THE TIME
16 AND WOULD BE MY EYES AND EARS WHEN I WASN'T THERE. SO I
17 TALKED WITH THE NURSES. AND I'D SEE THE PATIENTS AND I'D
18 LOOK FOR ADVERSE SIDE EFFECTS. IF THERE WERE ANY, I'D
19 CHANGE THE MEDICATIONS.
20 Q. WERE YOU CONCERNED ABOUT SEDATION OR TOO MUCH SEDATION?
21 A. YES.
22 Q. AND HOW DID YOU MONITOR FOR OVERSEDATION OR TOO MUCH
23 SEDATION?
24 A. CHECKING THE NURSES' NOTES AND CHECKING THE PATIENT.
25 LOOKING AT THE OVERALL PICTURE FOR THE LAST 24 HOURS AND
3760
1 THEN FOR THE LAST WEEK, SAY. THE TREND.
2 Q. NOW, DID YOU RELY ON THE INFORMATION THAT YOU RECEIVED
3 FROM THE NURSES?
4 A. YES, I DID.
5 Q. AND COULD YOU KIND OF EXPLAIN HOW IT WORKED IN TERMS OF
6 YOUR RELATIONSHIP WITH THEM AND THE INFORMATION THEY
7 PROVIDED IN TERMS OF WHAT YOU ACTUALLY ORDERED IN TERMS OF
8 MEDICATION?
9 A. WELL, WHEN I'D COME IN I WOULD TALK WITH WHATEVER NURSE
10 WAS THERE AND GET THEIR IMPRESSION ON EACH PATIENT AS TO HOW
11 THEY WERE DOING. I COULD READ THEIR NOTES. I COULD READ
12 THE NOTES OF THE OTHER PEOPLE ON THE UNIT, WHATEVER HAD BEEN
13 WRITTEN. WE HAD TEAM MEETINGS WHERE WE DISCUSSED PATIENTS
14 AND SORT OF GET EVERYONE'S IDEAS OUT THERE AS TO WHAT THEY
15 WERE SEEING. I SORT OF PUT THIS ALL IN THE HOPPER AND TRY
16 AND MAKE SENSE OF IT.
17 Q. NOW, IN TERMS OF THE FOUR PATIENTS THAT RECEIVED PSYCH
18 MEDICATIONS, DID YOU HAVE OCCASION AT TIMES TO ADJUST OR
19 CHANGE THEIR PSYCH MEDICATIONS?
20 A. YES, PRETTY MUCH EVERY DAY.
21 Q. AND GENERALLY WOULD YOU TELL US WHY YOU WOULD DO THAT?
22 A. WELL, I WOULD COME IN AND SEE WHAT BEHAVIOR THEY WERE
23 HAVING AND ADJUST THE MEDICATION ACCORDINGLY TO TRY AND
24 CONTROL THE SYMPTOMS, HELP THEM FEEL BETTER. IF THEY WERE
25 IN SOME WAY HAVING SIDE EFFECTS, I'D WANT TO PERHAPS BACK
3761
1 OFF ON A MEDICATION OR GIVE THE ANTIDOTE TO THE SIDE EFFECT.
2 Q. NOW, DO YOU HAVE A PATIENT JUDITH LARSEN'S BINDER STILL
3 IN FRONT OF YOU?
4 A. RIGHT HERE.
5 Q. COULD YOU TURN TO -- THERE'S A PROGRESS NOTE. I BELIEVE
6 IT'S FOR THE 13TH OF DECEMBER OF 1995.
7 A. RIGHT HERE.
8 Q. WOULD YOU READ THAT NOTE FOR US, PLEASE, IN ITS
9 ENTIRETY?
10 A. THAT'S MY NOTE ON 470.
11 Q. 12/13. YES. PAGE 470 AT THE TOP.
12 A. ANSWERED ONE QUESTION INTELLIGENTLY TODAY. QUOTE, HOW
13 ARE YOU. QUOTE, I FEEL BAD. THEN --
14 Q. LET ME STOP YOU RIGHT THERE. WAS THERE ANY SIGNIFICANCE
15 TO THE FACT THAT YOU WROTE THAT IN THE PROGRESS NOTE?
16 A. INDICATES THE LEVEL OF DEMENTIA AND IT INDICATES SOME
17 IMPROVEMENT AT THAT POINT.
18 Q. ALL RIGHT. IF YOU WOULD CONTINUE?
19 A. WELL, SHE ANSWERED, I FEEL BAD. THEN REFUSED TO ANSWER.
20 EATING. TAKING FLUIDS NOW. VITAL SIGNS STABLE AFEBRILE.
21 APPEARS TO BE IN SOME PAIN. REMAINS FAIRLY PROFOUNDLY
22 DEMENTED. ASSESSMENT: MAJOR DEPRESSIVE DISORDER WITH
23 PSYCHOTIC FEATURES. PLAN: CONTINUED KLONOPIN TAPER AND
24 SERZONE AND RISPERDAL. MORPHINE FOR PAIN. ROBERT WEITZEL,
25 M.D.
3762
1 Q. NOW, WHERE IT SAYS PLAN, YOU SAID CONTINUE KLONOPIN
2 TAPER. WHAT IS A KLONOPIN TAPER?
3 A. MISS LARSEN HAD BEEN PRESCRIBED XANAX BEFORE ADMISSION.
4 I PREFER NOT TO USE XANAX. IF I'M GOING TO USE A SHORT
5 ACTING VALIUM TYPE DRUG, I USE ATIVAN, AND I WANTED HER OFF
6 THAT. YOU CAN'T JUST STOP ONE OF THESE DRUGS. IT SORT OF
7 LIKE -- WELL, YOU ARE TOLERANT TO IT AND IF YOU STOP
8 ABRUPTLY YOU CAN HAVE SEIZURES AND ALL SORTS OF PROBLEMS.
9 SO I PUT HER ON LONG ACTING BENZODIAZEPINE, KLONOPIN, AND
10 SLOWLY TAPERED IT. THAT'S THE SAFE WAY TO DO IT.
11 Q. WERE THERE TIMES WHEN YOU INCREASED MEDICATION?
12 A. SURE.
13 Q. AND WOULD YOU TELL US THE CIRCUMSTANCES WHEN YOU WOULD
14 HAVE INCREASED MEDICATION CONCERNING THESE FOUR PATIENTS?
15 A. IF I WERE TO COME IN AND FIND THAT THE PATIENTS WERE
16 HAVING THE SAME SORT OF BEHAVIORAL SYMPTOMS THAT HAD BROUGHT
17 THEM THERE ON THE MEDICATIONS THAT WE'D BEEN USING, I WOULD
18 GENERALLY INCREASE THEM OR PERHAPS CHANGE THEM, ADD A
19 MEDICATION, SORT OF INDIVIDUALIZE TO THE PATIENT. BUT IF
20 THERE WERE CONTINUED PROBLEMS, I WOULD PROBABLY INCREASE THE
21 MEDICATION.
22 Q. YOU RECALL A CIRCUMSTANCE INVOLVING PATIENT LYDIA SMITH?
23 A. THERE'S A LOT OF CIRCUMSTANCES WITH HER. WHICH ONE?
24 Q. WELL, WHY DON'T YOU PULL OUT HER BINDER, PLEASE.
25 A. OKAY.
3763
1 Q. AND IF YOU WOULD TURN IN YOUR PROGRESS NOTE SECTION
2 JANUARY 1 OF 1996. IT WOULD BE ON 7/16.
3 A. GOT IT.
4 Q. DO YOU SEE THAT?
5 A. I DO.
6 Q. WOULD YOU PLEASE READ THAT IN ITS ENTIRETY, THAT NOTE?
7 A. OKAY. SLEPT THROUGH THE NIGHT. HAS BEEN REFUSING
8 MEDICATIONS AGAIN AND WAS QUITE RECALCITRANT. GOT
9 AGGRESSIVE THIS EVENING AND RECEIVED ATIVAN INTRAMUSCULARLY
10 WHICH HELPED. VITAL SIGNS STABLE. AFEBRILE. AND THEN
11 ASSESSMENT: REMAINS LABILE AND INTERMITTENTLY AGGRESSIVE.
12 PLAN: INCREASE -- I HAVE DEPAKOTE AND HAVE CROSSED IT OUT
13 FOR DEPAKENE. SIGNED ROBERT WEITZEL, M.D.
14 Q. NOW, THAT INDICATES AN INCREASE IN DEPAKENE.
15 A. RIGHT.
16 Q. WHY DO YOU RECALL THE CIRCUMSTANCES THAT YOU INCREASED
17 DEPAKENE AT THAT TIME?
18 A. IT'S A MOOD STABILIZER AND SHE WAS HAVING A LOT OF
19 AGGRESSION AND ALSO HER MOOD WAS LABILE. HER EMOTIONS WERE
20 UP AND DOWN, ALL OVER THE PLACE, AND I WANTED TO TRY AND GET
21 THAT UNDER CONTROL WITH DEPAKENE.
22 Q. NOW, I THINK PATIENT LYDIA SMITH AND MARY CRANE RECEIVED
23 DEPAKENE SYRUP; IS THAT RIGHT?
24 A. SYRUP AND SPRINKLES. IT'S AN ORAL FORM THAT'S EASY TO
25 TAKE.
3764
1 Q. AND WOULD YOU TELL US WHY THAT IS GIVEN?
2 A. WELL, DEPAKOTE, THE ONE I CROSSED OUT, ONLY COMES IN A
3 PILL AND I THINK IT COMES I.V. BUT WE OFTEN HAD PROBLEMS
4 WITH THESE PATIENTS GETTING THEM TO TAKE THEIR MEDICATIONS,
5 SO FREQUENTLY THE NURSES WOULD MIX THEIR MEDICATION IN WITH
6 ICE CREAM OR FOOD OR A DRINK AND THIS WAS REALLY EASY TO DO
7 WITH DEPAKENE.
8 Q. AND WHAT IS THAT PARTICULAR MEDICATION GIVEN FOR?
9 WHAT'S ITS PURPOSE?
10 A. WELL, IT'S VALPROIC ACID AND IT'S INITIAL -- I THINK ITS
11 F.D.A. APPROVED USE IS FOR CONVULSIONS, FOR SEIZURES. IT'S
12 OFF LABEL USE -- IT'S BEEN -- THERE HAVE BEEN MANY, MANY
13 ARTICLES IN PSYCHIATRY DESCRIBING ITS USE TO CONTROL MANIC
14 BEHAVIOR AND ANY KIND OF AGGRESSIVE AGITATED BEHAVIOR. IT'S
15 A MOOD STABILIZER.
16 Q. AND IN TERMS OF ITS ANTICONVULSANT QUALITY, DID THAT
17 HAVE SOME RELEVANCE TO MARY CRANE'S SITUATION?
18 A. WELL, YES, IT DID. NOT A DIRECT RELEVANCE BUT BECAUSE
19 SHE HAD HAD SEIZURES IN THE PAST, IT'S A GOOD CHOICE BECAUSE
20 IT'S, YOU KNOW, IT'S ANTISEIZURE AND SO YOU CAN KIND OF
21 PROTECT HER THERE. SHE HAD HAD SEIZURES BOTH FROM HER
22 HYPONATREMIA AND PROBABLY FROM THE FACT SHE HAD STROKES AND
23 SUCH PROBLEMS.
24 Q. I THINK WE'VE HAD THIS WORD FURTHER DEFINED BEFORE, BUT
25 JUST FOR YOUR PURPOSE, HYPONATREMIA IS WHAT?
3765
1 A. HYPONATREMIA IS LOW SODIUM IN THE BLOOD. WE'RE NOT SURE
2 WHY, BUT FOR YEARS MISS CRANE HAD HAD SOMETHING CALLED
3 PSYCHOGENIC POLYDIPSIA WHERE PSYCHOGENIC MEANS IT COMES FROM
4 THE MIND AND POLYDIPSIA MEANS DRINKING A LOT. SHE'D DRINK
5 FLUIDS CONSTANTLY. ON HOSPITALIZATION WITH US SHE EXHIBITED
6 SOME OF THAT. AT ONE TIME HER SODIUM HAD BEEN IN I THINK IT
7 WAS 109 AND SHE HAD SEIZURES. THAT'S A REAL SERIOUS
8 CONDITION, THAT SODIUM FLUCTUATION. IT CAN AFFECT LIFE
9 ITSELF, DEFINITELY HER THOUGHT PROCESS.
10 Q. NOW, I WANT YOU TO TURN BACK TO THE BINDER FOR JUDITH
11 LARSEN.
12 A. OKAY.
13 Q. TELL US, ROBERT, DO YOU HAVE A RECOLLECTION OF PATIENT
14 JUDITH LARSEN?
15 A. MOSTLY I REMEMBER HER FAMILY. I DON'T REMEMBER HER THAT
16 WELL. BUT I REMEMBER SOME OF THE CIRCUMSTANCES, ESPECIALLY
17 DEALING WITH HER SON MERLIN.
18 Q. AND WHAT WAS YOUR IMPRESSION OF HER CONDITION AT THE
19 TIME OF HER ADMISSION? AND FEEL FREE TO REFER TO --
20 A. I'M GOING TO LOOK AT MY PSYCH EVAL. THE DIAGNOSIS I
21 FOUND WAS MAJOR DEPRESSION WITH PSYCHOTIC FEATURES AND RULE
22 OUT ORGANIC BRAIN SYNDROME. SHE WAS VERY DEMENTED, VERY
23 AGITATED AND SHE WAS MEDICALLY -- SHE WAS 93 AND SHE WASN'T
24 IN THE BEST OF MEDICAL HEALTH.
25 Q. DID YOU HAVE A ROLE TO PLAY IN TERMS OF HER ADMISSION TO
3766
1 THE HOSPITAL?
2 A. YES.
3 Q. AND WHAT WAS THAT ROLE?
4 A. WELL, ONCE AGAIN, YOU KNOW, THEY WOULD CALL ME AND SAY
5 THERE'S A PATIENT WHOSE -- THAT A FAMILY OR THE DOCTOR IS
6 ASKING FOR ADMISSION AND THEY KIND OF TOLD ME WHAT WAS THE
7 STORY AND I SAID, I THINK WE CAN HELP HER, AND SHE WAS
8 ADMITTED. I WROTE ADMISSION ORDERS. I DID MENTAL STATUS
9 EXAM, PSYCHIATRIC EVAL. GOT THINGS GOING.
10 Q. DID YOU HAVE OR DID YOU FORM A PROGNOSIS UPON HER
11 ADMISSION AS TO HOW SHE WOULD DO?
12 A. IT WAS FAIRLY GUARDED.
13 Q. AND WHY DO YOU SAY IT WAS GUARDED?
14 A. WELL, ALL OF THE PATIENTS WE HAD WERE FAIRLY DIFFICULT
15 PATIENTS ON THE GEROPSYCH UNIT, BUT THE DEMENTED PATIENTS
16 WERE PARTICULARLY HARD 'CAUSE YOU CAN'T TALK WITH THEM AND
17 REALLY THERE IS NO WAY TO REVERSE THE DEMENTIA ITSELF. YOU
18 CAN JUST TRY AND TREAT THE SYMPTOMS. FINALLY, SHE WAS
19 MEDICALLY ILL.
20 Q. DID YOU -- WERE YOU ABLE TO OBSERVE HER DURING HER
21 COURSE OF TREATMENT IN THE HOSPITAL SO THAT YOU COULD
22 CHARACTERIZE HER PROGRESS?
23 A. YES.
24 Q. AND TELL US WHAT PROGRESS THAT SHE MADE WHILE SHE WAS IN
25 THE HOSPITAL.
3767
1 A. WELL, IT WAS UP, THEN DOWN. UP AND THEN DOWN. IT WAS
2 VARIABLE. SHE PROGRESSED AT TIMES AND THEN UNFORTUNATELY
3 SHE GOT ILL AND DIED.
4 Q. NOW, IN THE PSYCH EVALUATION, THE WRITTEN REPORT, DO YOU
5 HAVE THAT IN FRONT OF YOU?
6 A. YES, RIGHT HERE.
7 Q. YOU MAKE -- I THINK YOU STATE YOU INDICATE YOU ARE GOING
8 TO START PATIENT JUDITH LARSEN ON RISPERDAL AND SERZONE.
9 A. RIGHT.
10 Q. DO YOU SEE THAT?
11 A. DISCUSSES RECOMMENDATION. GET FULL MEDICAL WORKUP AND
12 PROBABLY START SERZONE AND RISPERDAL.
13 Q. WHY DID YOU FEEL THAT THOSE MEDICATIONS WERE
14 APPROPRIATE?
15 A. WELL, SHE SEEMED VERY UNHAPPY, CRYING, SCREAMING. I
16 PICKED SERZONE AS AN ANTIDEPRESSANT WHICH IS MILDLY SEDATING
17 AND ANXIETY-RELIEVING. RISPERDAL I PICKED BECAUSE IT'S A
18 NEW ANTIPSYCHOTIC WITHOUT A LOT OF THE SIDE EFFECTS OF THE
19 OLD ONES. AND IT'S A COMMON COMBINATION FOR FOLKS IN THIS
20 STATE, SERZONE AND RISPERDAL.
21 Q. DID SHE ALSO A HAVE A HISTORY OF RECEIVING TRAZODONE?
22 A. YES, SHE DID.
23 Q. AND DID THAT HAVE ANY SIGNIFICANCE TO YOU IN TERMS OF
24 YOUR ORDERING TRAZODONE?
25 A. WELL, SHE HAD BEEN ON 100 MILLIGRAMS AT BEDTIME AND SO I
3768
1 KNOW THAT DESPITE THAT -- WELL, FIRST OF ALL, IT'S NOT
2 HURTING HER. SHE'S CLEARLY STILL NOT SEDATED. AND I KNOW
3 THAT NOW THAT SHE'D BEEN ON TRAZODONE, SO WE CAN CERTAINLY
4 GO UP ON THE DOSE IF WE NEED TO.
5 Q. WHAT'S TRAZODONE PRESCRIBED FOR?
6 A. WELL, IT'S AN ANTIDEPRESSANT AND IT'S A REALLY OLD
7 ANTIDEPRESSANT. IT'S BEEN AROUND FROM WAY BACK. BACK WHEN
8 I FIRST STARTED IN PSYCHIATRY, THE ANTIDEPRESSANTS, ALL OF
9 THEM WERE VERY DANGEROUS. YOU COULD OVERDOSE QUITE EASILY
10 WITH SAY A WEEK OR TEN DAYS' SUPPLY EXCEPT FOR TRAZODONE.
11 SO IT WAS NICE TO HAVE IF YOU WERE WORRIED ABOUT GIVING
12 MEDICATION TO SOMEONE WHO MIGHT TURN AROUND AND TAKE IT ALL.
13 PROBLEM WITH IT, IT'S QUITE SEDATING, AND IN GOOD
14 ANTIDEPRESSANT DOSES OF AROUND 400 TO 600 MILLIGRAMS A DAY,
15 IT'S PROBABLY OVERSEDATING FOR AT LEAST 50 PERCENT OF THE
16 PEOPLE AND MORE LIKE 75 PERCENT IN THE ELDERLY. IT'S STILL
17 USED A LOT, THOUGH, AS A SLEEP AID. IT'S NOT ADDICTIVE.
18 IT'S QUITE SEDATING. IT WORKS. DOES HAVE SOME PROBLEMS YOU
19 HAVE TO WATCH OUT FOR. PEOPLE SOMETIMES WAKE UP IN THE
20 MORNING AND ARE STILL GROGGY AND FALL DOWN ON TRAZODONE, BUT
21 IN MANY WAYS IT'S A REAL GOOD SLEEP AID. AND IT'S RELATED
22 TO SERZONE AND NEFAZODONE, TRAZODONE. SAME CHEMICAL
23 CATEGORY, DIFFERENT DRUGS. BUT I OFTEN COMBINE THE TWO.
24 I'LL GIVE THE SERZONE DURING THE DAY AS AN ANTIDEPRESSANT,
25 TRAZODONE AT NIGHT TO HELP SLEEP. A LOT OF PEOPLE WITH
3769
1 DEPRESSION HAVE PROBLEMS WITH SLEEPING, SO THAT'S HELPFUL.
2 AND THEN THE LOWER DOSE OF TRAZODONE CAN HELP AUGMENT THE
3 SERZONE.
4 Q. WHY DID YOU FEEL TRAZODONE WAS APPROPRIATE FOR JUDITH
5 LARSEN?
6 A. WELL, IT'S PROBABLY THE BEST SLEEP AID THERE IS AND SHE
7 WAS ALSO DEPRESSED. WE NOW HAVE AMBIEN AND I GUESS IT WAS
8 AVAILABLE BACK THEN. IT WAS PRETTY NEW. I WAS HOPEFUL IT
9 WOULD BE HELPFUL IN HER SLEEP AND SEDATE A BIT.
10 Q. NOW, IN THE PSYCH EVALUATION, THE WRITTEN REPORT, YOU
11 REFER TO HER AS UNRESPONSIVE AND NON-RESPONSIVE.
12 A. OKAY. I FOUND UNRESPONSIVE. AND THERE'S
13 NON-RESPONSIVE.
14 Q. USING THOSE WORDS, TELL US WHAT YOU MEAN BY THEM.
15 A. WELL, WHERE IT SAYS UNRESPONSIVE, IT'S UNDER THE
16 HISTORY. IT SAYS SHE'S CRYING, SHOUTING WHEN AWAKE, SLEEPING
17 MOST OF THE TIME, IS FAIRLY UNRESPONSIVE. THAT MEANS WHEN
18 YOU ASK HER A QUESTION, SHE WON'T ANSWER IT IN ANY
19 INTELLIGIBLE WAY.
20 Q. WHAT'S THE SIGNIFICANCE OF THE FACT THAT SHE WOULD NOT
21 ANSWER A QUESTION?
22 A. YOU COULDN'T COMMUNICATE WITH HER AND IT INDICATED SHE
23 WAS PRETTY DEMENTED.
24 Q. AND DID THAT COMPLICATE YOUR ABILITY TO PROVIDE
25 TREATMENT FOR HER?
3770
1 A. YES, IT DID.
2 Q. AND TELL US IN WHAT WAY?
3 A. ONCE AGAIN, YOU CAN'T DIRECTLY ASK A PATIENT WHAT'S
4 GOING ON INSIDE AND YOU JUST SORT OF HAVE TO GO BY THE SIGNS
5 OF WHAT'S GOING ON RATHER THAN SYMPTOMS THAT CAN BE
6 REPORTED.
7 Q. AND BY SIGNS, WHAT DO YOU MEAN?
8 A. WHAT YOU CAN SEE FROM THE OUTSIDE; SCREAMING, MOANING,
9 CRYING OR CONVERSELY MAYBE LAUGHTER OR SMILING. ALSO SIGNS
10 WOULD PROBABLY INCLUDE VITAL SIGNS. ANYTHING YOU CAN
11 MEASURE WITHOUT DIRECTLY ASKING THE PATIENT.
12 Q. NOW, I WANT YOU TO GO BACK IN THE PROGRESS NOTE SECTION,
13 SPECIFICALLY THE NOTES THAT GO FROM DECEMBER 12TH THROUGH
14 THE 19TH. DO YOU HAVE THOSE IN FRONT OF YOU?
15 A. YES. 12TH. YES.
16 Q. HOW WOULD YOU CHARACTERIZE THE CIRCUMSTANCES IN HER
17 CONDITION DURING THAT TIME PERIOD WHILE SHE WAS IN THE
18 HOSPITAL?
19 A. WELL, SHE WAS HAVING -- SHE HAD A BAD SPELL RIGHT BEFORE
20 THAT, BUT THEN SHE IMPROVED. BOTH PHYSICALLY AND MENTALLY
21 SHE WAS DOING BETTER.
22 Q. AND IN FACT, THERE'S AN ENTRY, IS THERE NOT, I BELIEVE
23 IT'S THE 15TH, WHERE YOU REFER TO A MIRACULOUS RECOVERY?
24 A. FOURTEENTH.
25 Q. AND READ THAT NOTE IN ITS ENTIRETY, PLEASE.
3771
1 A. 12/14 HAS MADE A MIRACULOUS RECOVERY. AMBULATED
2 YESTERDAY. TAKING FOOD WELL. VITAL SIGNS STABLE.
3 AFEBRILE. ASSESSMENT: DOING MUCH BETTER. REMAINS
4 DEMENTED. PLAN: CONTINUE CURRENT THERAPY. ROBERT WEITZEL.
5 Q. WHEN YOU WROTE THAT ENTRY IN THE PROGRESS NOTE, DO YOU
6 RECALL IF EARLENE COZZENS HAD ANYTHING TO DO WITH WHAT YOU
7 WROTE AT THAT TIME?
8 A. NO. I HEARD HER TESTIMONY HERE, BUT I DON'T RECALL HER
9 HAVING ANYTHING TO DO WITH THIS NOTE.
10 Q. AND WHY DID YOU REFER TO IT AS A MIRACULOUS RECOVERY?
11 A. IT DID LOOK LIKE A MIRACLE. SHE HAD ON THE 12TH OR ON
12 THE 11TH, I THINK, SHE HAD -- HER OXYGEN SATURATION WAS 77
13 AND SHE WASN'T TAKING FLUIDS AND SHE LOOKED -- THE SITUATION
14 LOOKED PRETTY GRAVE. I TALKED WITH HER SON ABOUT IT. I WAS
15 SO CONCERNED I TALKED WITH HER SON THINKING SHE MIGHT NOT
16 MAKE IT. AND THEN DESPITE ALL THAT, SHE TURNED AROUND AND
17 REALLY REBOUNDED. IT WAS A MIRACLE IN A SENSE. I DON'T
18 THINK I'VE SEEN THAT BEFORE.
19 Q. NOW, DURING THIS TIME PERIOD GENERALLY YOU HAD OCCASION
20 TO WRITE AN ORDER FOR MORPHINE P.R.N.?
21 A. YES, ON THE 13TH.
22 Q. AND WHY DID YOU WRITE SUCH AN ORDER?
23 A. SHE LOOKED LIKE SHE WAS IN PAIN AT TIMES AND I WANTED
24 THE NURSES TO HAVE A P.R.N. IN CASE THEY FELT LIKE SHE
25 NEEDED IT.
3772
1 Q. AND DO YOU RECALL WHEN IT WAS DISCONTINUED?
2 A. THE 19TH.
3 Q. AND TELL US WHY YOU DISCONTINUED THE ORDER ON THE 19TH?
4 A. WELL, THAT DAY I GOT AN AUTOMATIC DRUG STOP ORDER IN THE
5 CHART WHICH CLUED ME IN, CHECK THIS OUT, AND SHE HADN'T BEEN
6 USING IT. IT HADN'T BEEN NEEDING IT AT ALL, SO I JUST
7 DISCONTINUED IT.
8 Q. DO YOU RECALL IF A CONVERSATION WITH BONNIE HARDY
9 INFLUENCED YOUR DECISION TO DISCONTINUE THAT ORDER ON THAT
10 DATE?
11 A. I DON'T RECALL ANY CONVERSATION REGARDING THAT WITH
12 BONNIE.
13 Q. DO YOU RECALL ANY CONVERSATION WITH BONNIE HARDY ON OR
14 ABOUT THAT TIME WHERE SHE EXPRESSED SOME CONCERN ABOUT THAT
15 ORDER BEING IN THE CHART RELEVANT TO OTHER MEDICATIONS WHICH
16 WERE ALSO BEING ORDERED?
17 A. I DON'T RECALL TALKING WITH HER AT THAT TIME ON THIS
18 SUBJECT.
19 Q. NOW, I WANT TO ASK YOU, AFTER THE PERIOD THAT YOU'VE
20 JUST REFERRED TO, DID PATIENT JUDITH LARSEN'S CONDITION
21 IMPROVE OR DETERIORATE?
22 A. AFTER THE 19TH?
23 Q. YES.
24 A. WELL, SHE CONTINUED TO DO PRETTY WELL FOR A WHILE, BUT
25 THEN SHE DID HAVE A PROBLEM. SHE HAD SOME PROBLEMS STARTING
3773
1 AROUND CHRISTMAS.
2 Q. AND WHAT DO YOU RECALL HAPPENED?
3 A. BASICALLY SHE HAD A PRETTY BAD SEIZURE ON THE 26TH AND
4 THEN SHE HAD A BAD G.I. BLEED THEREAFTER.
5 Q. WERE YOU ABLE TO DETERMINE THE CAUSES FOR THE SEIZURE?
6 A. NO, NOT REALLY. SHE HAD HAD STROKES AND THAT'S PROBABLY
7 THE BEST GUESS ON MY PART AS TO WHAT CAUSED IT. SOMEONE
8 SAID, WELL, SHE HAD MORPHINE THE DAY BEFORE --
9 MR. WILSON: OBJECTION, YOUR HONOR, AS TO WHAT
10 SOMEONE SAID.
11 THE COURT: REPHRASE THE QUESTION.
12 Q. (BY MR. STIRBA) WERE YOU ABLE TO DETERMINE THE CAUSE
13 OF HER SEIZURE?
14 A. THERE IS NO WAY TO KNOW EXACTLY WHAT CAUSED IT.
15 Q. AND DID YOU -- YOU SAID YOU REFERRED TO IT AS A PRETTY
16 BAD SEIZURE. COULD YOU EXPLAIN WHY YOU REFER TO IT IN THOSE
17 TERMS?
18 A. WELL, IT WENT ON FOR SOME TIME. I WANT TO FIND MAYBE
19 THE NOTE ON THAT. DR. DIENHART CAME IN AND STARTED DILANTIN
20 FOR IT. IT WAS CONSIDERED TO BE A SIGNIFICANT EVENT.
21 Q. NOW, I WANT YOU TO TURN, PLEASE, TO THE -- THERE ARE TWO
22 NOTES. THERE IS IN YOUR PROGRESS NOTES ONE ON THE 30TH OF
23 DECEMBER AND ONE ON THE 31ST.
24 A. OKAY.
25 Q. DO YOU HAVE THOSE IN FRONT OF YOU?
3774
1 A. RIGHT NOW I DO.
2 Q. AND SPECIFICALLY IF YOU COULD READ FOR US WHAT YOU
3 CHARTED ON THE 30TH OF DECEMBER OF 1995?
4 A. OKAY. MET WITH SON AND DAUGHTER THIS EVENING REGARDING
5 PATIENT'S CONDITION. SHE HAD COFFEE GROUNDS VOMITUS OF
6 GREATER THAN 200 CC THIS MORNING. STOMACH IS DISTENDED.
7 HAS HYPERACTIVE BOWEL SOUNDS. HEART RATE QUITE ERRATIC.
8 ASSESSMENT: GASTROINTESTINAL BLEED. PLAN: MAKE SURE SHE'S
9 COMFORTABLE WITH ROUTINE MORPHINE AND SIGNED. YOU WANT THE
10 31ST TOO?
11 Q. LET ME STOP YOU THERE AND JUST LET'S FOCUS ON THAT
12 ENTRY. DO YOU RECALL THE CONVERSATION THAT YOU HAD WITH THE
13 SON AND DAUGHTER ON THAT DAY?
14 A. SOMEWHAT. I CAN'T REMEMBER EVERYTHING THAT WAS SAID BUT
15 I REMEMBER THAT OCCURRING.
16 Q. AND IN SUBSTANCE WOULD YOU TELL US, PLEASE, WHAT YOU
17 RECALL?
18 MR. WILSON: I'M GOING TO OBJECT, YOUR HONOR. IT'S
19 HEARSAY.
20 THE COURT: OVERRULED.
21 MR. STIRBA: THANK YOU.
22 THE WITNESS: WELL, IN GENERAL TERMS I REMEMBER --
23 I REMEMBER COMING IN AND SHE WAS EXTREMELY ILL. SHE WAS
24 THROWING UP A LOT OF BLOOD. AND SO I MET WITH -- I'M SURE
25 MERLIN WAS THERE. I DON'T KNOW. I CAN'T REMEMBER WHO ELSE.
3775
1 BUT I TOLD THEM, YOU KNOW, SHE LOOKS VERY, VERY ILL AGAIN.
2 I BELIEVE I TOLD THEM THAT WE COULD KEEP HER COMFORTABLE. I
3 THINK I SAID, IF YOU WANT, YOU KNOW, THERE IS I.C.U. DOWN
4 THE HALL, BUT IT'S UP TO YOU. AND APPARENTLY FROM MY NOTE
5 HE SAID NO, KEEP HER COMFORTABLE AND NO EXTRAORDINARY
6 MEASURES.
7 Q. (BY MR. STIRBA) AND BY KEEPING HER COMFORTABLE, WHAT
8 DO YOU MEAN IN THE CONTEXT OF THIS NOTE?
9 A. NURSING CARE, BUT DISCONTINUING MEDICATIONS AND INVASIVE
10 TECHNIQUES. NO I.V.'S AND SUCH. CERTAINLY NO RESPIRATORS
11 OR C.P.R. AND MEDICATIONS TO KEEP HER COMFORTABLE, NAMELY
12 MORPHINE.
13 Q. NOW, YOU REFER TO IN THIS NOTE, SHE HAD COFFEE GROUNDS
14 VOMITUS. DO YOU SEE THAT?
15 A. RIGHT.
16 Q. AND WHAT IS THAT DIAGNOSTIC OF?
17 A. A G.I. BLEED INTO THE STOMACH. IN THE STOMACH YOU'VE
18 GOT ACID. WHEN THE BLOOD HITS THE ACID AND IT TURNS INTO
19 SORT OF A SLURRY THAT LOOKS LIKE COFFEE GROUNDS, IT'S REAL
20 DIAGNOSTIC OF A G.I. BLEED IN THE UPPER G.I.
21 Q. AND YOU HAVE, STOMACH IS DISTENDED. WHAT IS THE
22 SIGNIFICANCE OF YOU STATING THAT?
23 A. G.I. BLEED. SO SIGN AND SYMPTOMS.
24 Q. WHAT DOES DISTENDED MEAN?
25 A. SWOLLEN.
3776
1 Q. NOW, THE NEXT NOTE WHICH IS ON DECEMBER 31ST, WOULD YOU
2 READ THAT IN ITS ENTIRETY, PLEASE?
3 A. OKAY. UNRESPONSIVE. PERIOD. MELENA DURING THE NIGHT.
4 BLOOD PRESSURE FLUCTUATES AND IS LOW GENERALLY. TAKING NO
5 ORAL FOODS OR NOURISHMENT. IS RECEIVING ORAL CARE. I SPOKE
6 WITH HER SON BY TELEPHONE THIS MORNING AND AM MEETING WITH
7 SON AND DAUGHTER SOON. AFEBRILE. ASSESSMENT: G.I. BLEED,
8 LOW BLOOD PRESSURE, UNRESPONSIVE. PLAN: CONTINUE COMFORT
9 CARE, AND IT'S SIGNED.
10 Q. NOW, DID YOU HAVE, BASED ON THE CONVERSATION ON THE 30TH
11 AND THE CONVERSATION ON THE 31ST, DID YOU HAVE AN
12 UNDERSTANDING OF WHAT THE FAMILY WISHES WERE AT THAT TIME?
13 MR. WILSON: OBJECTION.
14 THE WITNESS: YES. YES.
15 THE COURT: WHAT'S THE GROUNDS OF THE OBJECTION?
16 MR. WILSON: THE OBJECTION IS HEARSAY, YOUR HONOR.
17 THE COURT: OVERRULED.
18 Q. (BY MR. STIRBA) AND WHAT DID YOU UNDERSTAND THEIR
19 WISHES TO BE?
20 A. THAT THEIR MOTHER BE KEPT COMFORTABLE AND THAT SHE BE
21 ALLOWED TO DIE A DIGNIFIED DEATH WITHOUT ANY SUFFERING.
22 Q. NOW, AT THAT POINT DID YOU -- WERE YOU ABLE TO MAKE AN
23 ASSESSMENT OF HER CONDITION?
24 A. YES.
25 Q. AND WHAT DID YOU BELIEVE HER CONDITION TO HAVE BEEN?
3777
1 A. WELL, GRAVELY ILL AND DYING ON THE 31ST.
2 Q. NOW, MERLIN LARSEN TESTIFIED ABOUT A CONVERSATION AFTER
3 CHRISTMAS. DO YOU REMEMBER THAT TESTIMONY?
4 A. THERE'S BEEN A LOT OF TESTIMONY. CAN YOU HELP ME A
5 LITTLE.
6 Q. OKAY. DO YOU RECALL A CONVERSATION WITH MERLIN LARSEN
7 AFTER CHRISTMAS?
8 A. WELL, IT'S ALL IN MY NOTES HERE. WE WERE TALKING AT
9 THAT POINT MORE TOWARD THE END OF THE YEAR. ARE YOU TALKING
10 ABOUT THE 30TH AND 31ST OR RIGHT AFTER CHRISTMAS?
11 Q. RIGHT AFTER CHRISTMAS WHEN IT WOULD HAVE BEEN YOU AND
12 MR. LARSEN.
13 A. WELL, I'M SORRY, BUT I DON'T REMEMBER THAT WELL. I
14 DON'T HAVE, YOU KNOW, INDEPENDENT RECOLLECTION OUTSIDE OF
15 THESE NOTES OF TALKING WITH HIM AT THAT POINT.
16 Q. DO YOU HAVE A RECOLLECTION OF TALKING WITH HIM ALONE
17 ABOUT RELOCATING HIS MOTHER?
18 A. THAT WOULD BE, I THINK, MORE TOWARD THIS POINT, 30TH OR
19 SO. YES, I DO.
20 Q. AND DO YOU RECALL WHERE THAT CONVERSATION TOOK PLACE?
21 A. IT WAS ON THE UNIT. I'M NOT SURE IF IT WAS IN HER ROOM
22 OR AROUND THE NURSES' STATION. I DON'T RECALL THAT.
23 Q. AND WAS ANYONE ELSE PRESENT?
24 A. I DON'T REMEMBER.
25 Q. AND WHAT WAS SAID BY HIM AND WHAT WAS SAID BY YOU AT
3778
1 THAT TIME?
2 MR. WILSON: I WOULD OBJECT AGAIN AS TO HEARSAY BY
3 MR. LARSEN, YOUR HONOR.
4 THE COURT: OVERRULED.
5 THE WITNESS: WELL, LIKE I SAID BEFORE, HE WAS REAL
6 CONCERNED THAT SHE WAS -- HE WAS UPSET THAT HE HAD BEEN TOLD
7 BY SOMEBODY THAT WE WOULD HAVE TO MOVE HER. THOSE WERE THE
8 RULES. AND HE DIDN'T KNOW WHERE HE WAS GOING TO GO OR WHERE
9 HE'D TAKE HER. AND I SAID, WE'LL KEEP HER AND LET HER STAY
10 HERE AND KIND OF BEND THE RULES A BIT.
11 Q. (BY MR. STIRBA) AND I WANT YOU TO TELL US, PLEASE,
12 THEN WHY JUDITH LARSEN WAS NOT MOVED FROM THE GEROPSYCH UNIT
13 BEFORE SHE PASSED AWAY.
14 A. WELL, THE FAMILY WAS UPSET. I KNEW THAT WE'RE A
15 HOSPITAL, THAT WE HAVE NURSING STAFF. WE CAN TAKE CARE OF
16 THIS PROBLEM. I'VE SEEN A LOT OF PEOPLE DIE IN THE HOSPITAL
17 WITH CANCER OR WHATEVER AND SAT WITH THEM AND TALKED WITH
18 THEM DURING THAT TIME, PEOPLE WHO WEREN'T DEMENTED. YOU
19 KNOW, IT'S A PERFECTLY APPROPRIATE PLACE. AND IT WAS MY
20 JUDGMENT THAT WE COULD HELP THE FAMILY AND THE PATIENT, AND
21 MOVING THEM IS OFTEN VERY TRAUMATIC, YOU KNOW, WHEN SHE'S AT
22 THAT STATE OF BEDFAST AND VERY SICK. HAVING TO PUT SOMEONE
23 IN AN AMBULANCE AND MOVE THEM SOMEWHERE ELSE ISN'T AN EASY
24 THING. I JUST THOUGHT IT WAS THE RIGHT THING TO DO.
25 Q. NOW, DID THERE COME A TIME WHEN YOU ORDERED THAT PATIENT
3779
1 JUDITH LARSEN RECEIVE MORPHINE AROUND THE CLOCK?
2 A. YES.
3 Q. AND FEEL FREE TO REFER TO THE BINDER, IF YOU NEED TO,
4 BUT --
5 A. I ALREADY HAVE.
6 Q. -- DO YOU REMEMBER WHEN YOU DID THAT?
7 A. THE 30TH.
8 Q. AND WHY WAS IT DONE AROUND THE CLOCK?
9 A. WELL, SHE WAS OBVIOUSLY DYING AND THERE WAS NOTHING WE
10 WERE GOING TO BE ABLE TO DO TO PREVENT THAT AND I WANTED HER
11 TO BE COMFORTABLE. IT'S CLEAR AS CAN BE THAT IF YOU GIVE
12 PEOPLE A P.R.N. DOSAGE --
13 MR. WILSON: OBJECTION, YOUR HONOR. IT'S
14 NON-RESPONSIVE.
15 THE COURT: REPHRASE THE QUESTION.
16 MR. STIRBA: I WILL, JUDGE.
17 Q. IN REFERENCE TO A P.R.N. ORDER, WHY WAS THE DOSING
18 AROUND THE CLOCK DESIRABLE FROM YOUR POINT OF VIEW?
19 A. I WAS CONTRASTING AROUND THE CLOCK TO A P.R.N. IF YOU
20 PUT DOWN P.R.N. AND THE PATIENT HAS TO START SCREAMING OR
21 SHOWING SOME SIGN OF PAIN, YOU KNOW THE PAIN IS OUT OF
22 CONTROL. IF YOU JUST PICK A RATIONAL DOSE AND GIVE IT AT
23 INTERVALS WHERE THERE WILL BE NO BIG PEAKS AND TROUGHS OF
24 THE MEDICATION LEVELS IN THE BLOOD, YOU GET GOOD CONTROL OF
25 THE PAIN AND THE PATIENT DOESN'T HAVE TO SUFFER.
3780
1 Q. WAS THE -- WAS THE MORPHINE ORDERED BY YOU BEFORE OR
2 AFTER THE CONVERSATION WITH THE FAMILY?
3 A. I TALKED WITH THE FAMILY BY THEN. IT WAS AFTER. THE
4 MORPHINE WAS ORDERED AFTER I TALKED WITH THE FAMILY.
5 Q. WERE YOU AWARE AT THIS TIME WHEN YOU ORDERED THE
6 MORPHINE OF CERTAIN WRITTEN DIRECTIVES?
7 A. ON MISS LARSEN? YES.
8 Q. AND TELL US HOW YOU WERE AWARE OF THEM?
9 A. THEY ARE IN THE CHART. AND I CAN'T REMEMBER, YOU KNOW,
10 INDEPENDENTLY DOING THIS, BUT I WOULD HAVE LOOKED IN THE
11 CHART BEFORE TALKING WITH THE FAMILY TO KIND OF FIGURE OUT
12 WHAT WAS GOING ON THERE.
13 Q. DID THE -- DID THE DIRECTIVES, THE WRITTEN DIRECTIVES,
14 DID THEY PLAY A ROLE IN YOUR DECISION-MAKING IN TERMS OF
15 WHAT YOU THOUGHT WAS APPROPRIATE TREATMENT ON DECEMBER 30TH?
16 A. WELL, YES, THEY DID. SHE'D HAD A G.I. BLEED AND SAID NO
17 I.V., SO COULDN'T GIVE HER BLOOD OR FLUIDS. AND IT'S
18 BASICALLY TYING MY HANDS AND MY ABILITY TO TRY AND REVIVE
19 HER. SO I'VE BASICALLY GOT A DYING PATIENT AND IT'S MY DUTY TO
20 TRY AND HELP THERE WITH SUFFERING.
21 Q. FROM THE 30TH UNTIL HER DEATH ON THE 3RD, CAN YOU
22 CHARACTERIZE HER CONDITION DURING THAT TIME PERIOD?
23 A. WELL, SHE WAS VERY VERY ILL. SHE WAS SEDATED. AT TIMES
24 SHE WOULD HAVE SOME BREAK-THROUGH PAIN, BUT GENERALLY SHE
25 WASN'T IN HUGE SUFFERING. SHE BECAME MORE AND MORE
3781
1 DEHYDRATED BECAUSE SHE WASN'T TAKING FLUIDS. IS THAT --
2 Q. AND IN TERMS OF HER CONDITION, DID IT CHANGE MATERIALLY
3 DURING THIS TIME PERIOD FROM THE 30TH TO THE 3RD?
4 A. WELL, SHE JUST GOT SICKER AND SICKER, AND THEN ON THE
5 3RD SHE DIED. THAT'S A PRETTY BIG CHANGE, I THINK.
6 Q. WAS SHE EATING DURING THIS TIME PERIOD?
7 A. NO.
8 Q. WAS SHE TAKING FLUIDS?
9 A. IF ANY, VERY LITTLE.
10 Q. WAS SHE GIVEN AN I.V.?
11 A. NO.
12 Q. AND TELL US WHY SHE WASN'T GIVEN AN I.V.?
13 A. MEDICAL TREATMENT PLAN SAID NO I.V.
14 Q. AS HER ATTENDING PHYSICIAN, AFTER YOU CONCLUDED THAT SHE
15 WAS DYING, DID YOU BELIEVE YOU HAD SOME OBLIGATION TO HER AS
16 YOUR PATIENT?
17 A. ABSOLUTELY.
18 Q. AND WHAT OBLIGATION WAS THAT?
19 A. WELL, TO PROVIDE HER WITH A DIGNIFIED DEATH FREE OF ANY
20 PAIN.
21 Q. NOW, I WANT TO DIRECT YOUR ATTENTION TO -- THERE'S A
22 PROGRESS NOTE, I BELIEVE IT'S JANUARY 3RD, AND THERE'S ALSO
23 AN ORDER ON THAT DATE. WHY DON'T YOU TURN FIRST TO THE
24 PROGRESS NOTE, PLEASE?
25 A. OKAY.
3782
1 Q. AND IF YOU WOULD, PLEASE, READ THE PROGRESS NOTE ON
2 1/3/95 IN ITS ENTIRETY.
3 A. OKAY. DESPITE FIVE MILLIGRAMS OF INTRAMUSCULAR MORPHINE
4 AT 7:30 AND 9:30 IN THE MORNING PATIENT HAS NOT RESPONDED AT
5 ALL. EYES OPEN. GROANING. APPEARS IN SOME PAIN.
6 UNFORTUNATELY, NURSING STAFF HAD BEEN HOLDING MORPHINE FOR
7 LOW RESPIRATORY RATE. REMAINS UNRESPONSIVE TO ANY
8 QUESTIONS. VITAL SIGNS STABLE ACTUALLY AND SHE'S AFEBRILE.
9 ASSESSMENT: STABLE. PLAN: MORPHINE 25 MILLIGRAMS NOW
10 CONTINUED FIVE MILLIGRAMS EACH THREE HOURS P.R.N. AS NEEDED,
11 AND ROBERT WEITZEL.
12 Q. NOW, IF YOU WILL TURN TO THE PHYSICIAN'S ORDER SECTION
13 OF THE BINDER. YOU ENTERED AN ORDER ON THAT DATE. I WOULD
14 LIKE YOU TO READ THAT TO US IN ITS ENTIRETY AS WELL.
15 A. OKAY. THERE'S A BUNCH OF ORDERS BUT THE ONE ON THE TOP,
16 THE FIRST ONE THAT -- WELL, LET'S SEE. THERE IS A BUNCH OF
17 ORDERS THAT DAY.
18 Q. OKAY. LET ME SEE IF I CAN FIND IT IN ANOTHER BINDER AND
19 REFER YOU TO IT. IT WOULD BE THE ORDER ON JANUARY 3RD THAT
20 REFERS TO YOUR REQUEST TO BE CALLED.
21 A. OKAY. I'VE GOT THAT.
22 Q. DO YOU SEE THE ONE I'M REFERRING TO?
23 A. TOP OF THE PAGE ON 466.
24 Q. ONCE AGAIN, I MAY NOT HAVE IT TOTALLY IN FRONT OF ME.
25 WOULD YOU READ THAT, PLEASE?
3783
1 A. 1/3/95. I WRITE, IF AN M.S. OR IF A MORPHINE IS TO BE
2 WITHHELD, PLEASE CALL -- I'M SORRY -- IF ANY MORPHINE IS TO
3 BE WITHHELD, PLEASE CALL ME FIRST. ROBERT WEITZEL.
4 Q. NOW, TELL US, PLEASE, DOES THAT ORDER HAVE A
5 RELATIONSHIP TO THE PROGRESS NOTE THAT YOU JUST READ OF THE
6 SAME DATE?
7 A. YES.
8 Q. AND TELL US WHAT THE RELATIONSHIP IS.
9 A. WELL, LET ME GO BACK TO THE PROGRESS NOTE.
10 UNFORTUNATELY, NURSING STAFF HAS BEEN HOLDING MORPHINE FOR
11 LOW RESPIRATORY RATE. I WANTED THE NURSES TO CALL ME IF
12 THEY WERE GOING TO HOLD THE MEDICATION SO WE COULD TALK
13 ABOUT IT. I WANTED TO BE KEPT INFORMED. ALL NIGHT LONG
14 THEY HAD BEEN HOLDING IT. NOBODY CALLED ME THAT NIGHT AND I
15 WAS PRETTY CONCERNED ABOUT THE STATE THE PATIENT WAS IN WHEN
16 I GOT THERE.
17 Q. AND YOU ARE GOING TO HAVE TO DESCRIBE THE NATURE OF YOUR
18 CONCERN AT THIS POINT IN TERMS OF THIS PATIENT.
19 A. OKAY. WELL, THE NURSE THAT WAS ON THAT NIGHT HAD ONLY
20 BEEN NURSING FOR A YEAR, SO IT'S SOMEWHAT UNDERSTANDABLE,
21 BUT THIS LADY HAD BEEN ON MORPHINE FOR DAYS. SHE WAS DYING.
22 SHE'D BEEN ON A REGULAR AMOUNT AND SHE'D ACTUALLY HAD SOME
23 P.R.N.'S GIVEN BY THE NURSES AND I THINK MAYBE AN HOUR OR
24 TWO BECAUSE OF BREAK-THROUGH PAIN. TO JUST COMPLETELY STOP
25 THE MORPHINE FOR MANY, MANY HOURS I THOUGHT WAS A REAL BAD
3784
1 MISTAKE BECAUSE WHEN I CAME IN, SHE WAS EYES OPEN, GROANING,
2 APPEARS IN PAIN. AND WE'D HAD CONTROL OF THE PAIN. NOW
3 WE'RE IN A SITUATION WHERE IT'S OUT OF CONTROL. I HAD JUST
4 WISHED THAT THEY CALLED ME AND I COULD HAVE SAID, WELL,
5 OKAY, IT'S LOW. WHY DON'T WE USE TWO AT THIS POINT OR LET'S
6 GET MORE FLEXIBLE WITH THE SCHEDULE, BUT LET'S NOT JUST HOLD
7 IT COMPLETELY FOR -- I THINK IT WAS LIKE 12 HOURS OR TEN
8 HOURS AT LEAST.
9 Q. NOW, GIVEN WHAT YOU SAW THAT MORNING, DID YOU CHANGE HER
10 MEDICATIONS THAT DAY?
11 A. WE CONTINUED THE ROUTINE FIVE MILLIGRAMS EVERY THREE
12 HOURS, BUT I HAD TO ADD A LOT OF NOW ORDERS THAT DAY.
13 Q. AND WHY DID YOU HAVE TO ADD A LOT OF NOW ORDERS THAT
14 DAY?
15 A. SHE WAS IN PAIN.
16 Q. AND DID THAT HAVE ANY RELATIONSHIP TO THE FACT THAT SHE
17 HAD NOT RECEIVED ANY MORPHINE FROM APPROXIMATELY 6:30 IN THE
18 EVENING BEFORE?
19 A. YES, IT DID.
20 Q. AND EXPLAIN THAT TO US, PLEASE?
21 A. WELL, IN TWO MAJOR WAYS. SHE HAD BEEN ON A REGULAR DOSE
22 OF MORPHINE FOR DAYS, SO SHE'S GETTING TOLERANT TO IT.
23 SHE'S -- HER BODY SORT OF IS EXPECTING THE MORPHINE. THEN
24 TO HOLD IT LIKE THAT, THE PAIN IS NOW OUT OF CONTROL. WE
25 HAVE NO CONTROL OF THAT PAIN. AND IT'S CLEAR THAT IT TAKES
3785
1 A LOT MORE TO GET IT IN CONTROL. SO BASICALLY THEY SET HER
2 UP FOR A SITUATION WHERE SHE'S GOING TO NEED A LOT OF
3 MORPHINE JUST TO GET IT UNDER CONTROL.
4 Q. NOW, IN REVIEWING THE MEDICATION RECORD FOR THAT DAY,
5 THE 3RD, DO YOU RECALL THE CIRCUMSTANCES IN WHICH YOU WERE
6 PROVIDING OR ORDERING NOW ORDERS THAT DAY?
7 A. WELL, I WAS THERE IN THE MORNING AND WROTE SOME ORDERS.
8 LET'S SEE. ONE AT -- LOOKS LIKE IT WAS PROBABLY TEN. AND I
9 CAN'T REALLY READ THIS CHART. IT'S KIND OF A BAD COPY. BUT
10 THEN ANOTHER ONE AT 11. AND THEN CALLED IN ORDERS AT 2:45,
11 AND 6:20.
12 Q. AND IN TERMS OF THOSE CALL-IN ORDERS, DO YOU RECALL THE
13 COMMUNICATION YOU WERE HAVING WITH THE NURSING STAFF AT THAT
14 TIME?
15 A. I'D CALL AND SAY, HOW'S SHE DOING OR MAYBE THEY PAGED
16 ME. I CAN'T TELL FROM THESE NOTES WHICH HAPPENED. BUT WE
17 TALK ABOUT WHAT WAS HAPPENING AND WHAT SORT OF SIGNS SHE WAS
18 SHOWING AND THAT'S WHEN I'D ORDERED EXTRA MORPHINE.
19 Q. NOW, DO YOU RECALL A STAFF MEETING WHERE THIS SUBJECT
20 CAME UP?
21 A. I DO.
22 Q. AND DO YOU RECALL WHEN THAT WOULD HAVE BEEN IN
23 RELATIONSHIP TO THE 3RD OF JANUARY?
24 A. IT WAS AFTERWARDS. WE HAD REGULAR STAFF MEETINGS AT THE
25 UNIT EITHER ONCE A WEEK OR TWICE A WEEK.
3786
1 Q. AND DO YOU KNOW WHO WAS PRESENT?
2 A. WELL, ABOUT HALF THE STAFF. THE NURSES WERE THERE.
3 SOCIAL WORKERS. THE PROGRAM MANAGER WOULD HAVE BEEN THERE.
4 MYSELF.
5 Q. AND DO YOU RECALL WHAT WAS SAID IN RELATIONSHIP TO THIS
6 CIRCUMSTANCE THAT YOU'VE JUST DESCRIBED?
7 A. YES.
8 Q. AND TELL US WHAT WAS SAID AND BY WHOM.
9 A. WELL, I SAID THAT I WAS CONCERNED ABOUT THIS HAVING
10 HAPPENED AND IN THE FUTURE I'D LIKE TO BE CALLED IF THAT
11 SORT OF THING HAPPENED.
12 Q. WHY WAS THAT IMPORTANT TO YOU?
13 A. WELL, IT'S MY PATIENT. AND WHEN I COME IN THERE AND
14 THEY ARE IN PAIN THERE'S REALLY NO GOOD REASON FOR THAT, I
15 WANTED TO EXPLAIN TO THE STAFF THE WAY PAIN CONTROL WORKS.
16 I DIDN'T WANT IT TO HAPPEN AGAIN.
17 THE COURT: MR. STIRBA, I THINK WE'VE BEEN GOING
18 ABOUT OVER AN HOUR. LET'S TAKE A MORNING BREAK, LADIES AND
19 GENTLEMEN. AT THIS TIME IT'S YOUR DUTY NOT TO CONVERSE
20 AMONG YOURSELVES OR TO CONVERSE WITH OR ALLOW YOURSELVES TO
21 BE ADDRESSED BY ANY OTHER PERSON ON THE SUBJECT OF THIS
22 TRIAL. AND IT IS YOUR DUTY NOT TO FORM OR EXPRESS AN
23 OPINION UNTIL THE CASE IS FINALLY SUBMITTED TO YOU AFTER
24 YOU'VE HEARD ALL OF THE EVIDENCE. SO WE'LL COME BACK AT TEN
25 MINUTES TO TEN.
3787
1 (COURT IN RECESS.)
2 THE COURT: PLEASE BE SEATED. THE RECORD WILL
3 REFLECT THAT THE JURY HAS RETURNED. AND I THINK I WOULD
4 JUST LIKE TO MAKE A STATEMENT TOO THAT PREVIOUSLY BEFORE THE
5 TRIAL STARTED WE HAD A DECORUM ORDER AND THE DECORUM ORDER
6 BASICALLY STATES THAT PEOPLE, TO PREVENT THEM FROM JUST
7 WALKING IN AND OUT, EVEN THOUGH THE DECORUM ORDER SAYS WE'LL
8 LOCK THE DOOR AFTER A SESSION BEGINS, WE HAVEN'T LOCKED THE
9 DOOR IN THE PAST BUT IF PEOPLE KEEP COMING IN AND OUT, THE
10 DECORUM SAYS THAT ONCE YOU LEAVE YOU NEED TO STAY OUT TILL
11 THE BREAK. OBVIOUSLY IF YOU HAVE A MEDICAL EMERGENCY OR
12 SOME OTHER PROBLEM, YOU CAN DO THAT. BUT PLEASE, LET'S TRY
13 TO KEEP -- IF YOU COME INTO THE COURTROOM JUST STAY IN THE
14 COURTROOM. IF YOU GO OUT, MAYBE JUST STAY OUT TILL THE NEXT
15 BREAK. OKAY, MR. STIRBA. YOU LIKE TO CONTINUE.
16 Q. (BY MR. STIRBA) AFTER JUDITH LARSEN PASSED AWAY AND
17 BEFORE THE PROCEEDINGS IN THIS MATTER, DID YOU HAVE ANY
18 COMMUNICATION AGAIN FROM ANYONE IN THE LARSEN FAMILY?
19 A. YES.
20 Q. AND WOULD YOU TELL US WHAT THAT COMMUNICATION WAS?
21 A. I RECEIVED A REALLY NICE CARD AT MY OFFICE FROM
22 MR. LARSEN AND HIS FAMILY THANKING ME AND THE UNIT FOR WHAT
23 WE PROVIDED HERE.
24 Q. I WOULD LIKE TO TURN YOU NOW TO ANOTHER BINDER WITH
25 PATIENT MARY CRANE. IF YOU COULD PULL THAT OUT, PLEASE. DO
3788
1 YOU HAVE THAT IN FRONT OF YOU?
2 A. RIGHT HERE.
3 Q. WHAT DO YOU REMEMBER ABOUT MARY CRANE?
4 A. I REMEMBER HOW SICK SHE WAS WHEN SHE CAME IN. BITS AND
5 DETAILS OF HER INPATIENT OF THE HOSPITALIZATION, WHAT WENT
6 ON. WITHOUT LOOKING AT THIS, YOU KNOW, AFTER MANY YEARS I
7 DON'T REMEMBER A LOT.
8 Q. WHY DON'T YOU, IF YOU NEED TO LOOK AT THAT, TELL US WHAT
9 YOUR ASSESSMENT WAS OF PATIENT MARY CRANE, HER CONDITION ON
10 ADMISSION?
11 A. WELL, I DON'T NEED TO LOOK AT IT FOR THAT. SHE HAD HAD
12 A STROKE IN 1990 AND PROBABLY HAD HAD OTHER STROKES SINCE
13 THEN AND WAS -- SMALLER STROKES -- AND WAS QUITE DEMENTED.
14 SHE WAS VERY ILL MEDICALLY IN THAT SHE HAD THE PSYCHOGENIC
15 POLYDIPSIA AND CHRONIC LOW SODIUM. SHE ALSO HAD PROBABLY
16 MULTI-INFARCT DEMENTIA, MEANING SHE HAD A LOT OF LITTLE
17 STROKES IN ADDITION TO THE BIG ONE IN '90. SHE HAD BACK
18 SURGERY WITH CHRONIC LOW BACK PAIN AND SHE HAD DIABETES AND
19 SHE WAS ALSO BEING TREATED FOR SEIZURE DISORDER.
20 Q. WHAT KIND OF BEHAVIOR WAS SHE EXHIBITING THAT RESULTED
21 IN HER ADMISSION?
22 A. WELL, SHE WAS VERY AGGRESSIVE WITH OTHER PATIENTS AND
23 THE STAFF WHERE SHE HAD BEEN STAYING; HITTING, VERBALLY
24 ABUSIVE, RUNNING INTO OTHERS WITH HER WHEELCHAIR, SCREAMING
25 AND ALSO THE POLYDIPSIA THING WAS SO BAD. WHAT YOU DO WITH
3789
1 THAT, YOUR FIRST STEP IS TO JUST TRY AND RESTRICT FLUIDS.
2 SHE -- APPARENTLY SHE WAS REPORTED TO BE DRINKING OUT OF
3 TOILETS AND SUCH.
4 Q. WAS SHE JUST LOUD UPON ADMISSION?
5 A. NO, MUCH MORE THAN THAT.
6 Q. NOW, I THINK IT INDICATES IN YOUR EVALUATION THAT YOU
7 STARTED HER ON RISPERDAL AND SERZONE.
8 A. I DID.
9 Q. AND WOULD YOU TELL US WHY, PLEASE?
10 A. ONCE AGAIN, RISPERDAL IS A GOOD ANTIPSYCHOTIC, LOW IN
11 SIDE EFFECTS, AND SERZONE IS A GOOD ANTIDEPRESSANT, ALSO LOW
12 ON SIDE EFFECTS. I WANTED HER MOOD TO IMPROVE. I WANTED
13 HER TO CALM DOWN SOME. AND I HOPED THAT HER BEHAVIOR WOULD
14 BECOME LESS PSYCHOTIC. I HAVEN'T DEFINED THAT. TO ME
15 PSYCHOTIC MEANS OUT OF TOUCH WITH REALITY. THAT'S THE
16 PURPOSE OF DRUGS LIKE RISPERDAL AND HALDOL.
17 Q. DO YOU -- DID YOU PRESCRIBE TRAZODONE FOR HER AS WELL?
18 A. YES.
19 Q. WOULD YOU TELL US WHY YOU DID THAT?
20 A. CALM HER DOWN AND HELP HER SLEEP.
21 Q. DID YOU PRESCRIBE TRAZODONE AND SERZONE IN COMBINATION
22 AS WELL?
23 A. YES.
24 Q. AND WOULD YOU TELL US, PLEASE -- FIRST OF ALL, IS THERE
25 A DIFFERENCE IN YOUR MIND BETWEEN THE DRUG TRAZODONE AND THE
3790
1 DRUG SERZONE?
2 A. YES, THERE IS.
3 Q. AND TELL US WHAT THAT DIFFERENCE IS.
4 A. WELL, THEY ARE IN THE SAME CLASS BUT THEY ARE COMPLETELY
5 DIFFERENT CHEMICALS AND THEY HAVE DIFFERENT ACTIONS ON THE
6 BRAIN. AS I SAID, TRAZODONE IS REALLY SEDATING, BUT IT IS
7 AN ANTIDEPRESSANT. SERZONE IS ANTIDEPRESSANT ALSO, MUCH
8 LESS SEDATING.
9 Q. AND WHY WOULD YOU PRESCRIBE THEM IN COMBINATION SUCH AS
10 WITH PATIENT MARY CRANE?
11 A. THEY WERE GIVEN AT DIFFERENT TIMES OF DAY. SERZONE
12 WOULD HAVE BEEN GIVEN B.I.D. TWICE A DAY, MEANING MORNING
13 AND PROBABLY EARLY EVENING. AND TRAZODONE WOULD BE AT
14 BEDTIME. SO YOU WOULD GET SORT OF AN ANTIDEPRESSANT EFFECT
15 OUT OF EACH OF THEM, BUT MOST OF THE SEDATION AT BEDTIME AND
16 THAT WOULD AID WITH SLEEP.
17 Q. DID YOU GIVE MARY CRANE ANY PAIN MEDICATIONS?
18 A. YES.
19 Q. AND WHAT WOULD THAT HAVE BEEN?
20 A. SHE WAS FIRST STARTED ON DURAGESIC.
21 Q. AND DESCRIBE FOR US WHY YOU ORDERED A DURAGESIC FOR HER?
22 A. WELL, SHE HAD BEEN ON OPIATES FOR YEARS. APPARENTLY IN
23 GOING BACK AND LOOKING AT THE RECORDS, SHE HAD THOUSANDS OF
24 DOSES OF LORTAB OR CODEINE OR DARVOCET. AND SHE WAS
25 CONTINUALLY COMPLAINING OF PAIN. AND I TOOK IT SERIOUSLY
3791
1 AND THOUGHT, LET'S GIVE HER SOMETHING FOR THIS, SOMETHING
2 THAT WILL BE AROUND THE CLOCK TYPE DOSAGE FORM, AND I
3 THOUGHT OF DURAGESIC.
4 Q. WHY DID YOU THINK THAT A DURAGESIC PATCH WAS THE MOST
5 APPROPRIATE WAY TO ADDRESS HER PAIN AS YOU DID?
6 A. IT'S PROBABLY THE SIMPLEST FORM TO MAKE SURE THAT THEY
7 GET ADEQUATE PAIN CONTROL ALL THE TIME. NO PILLS. NO
8 SHOTS. NO I.V. NECESSARY. JUST A PATCH APPLIED TO THE SKIN
9 EVERY THREE DAYS. I TALKED WITH A PHARMACIST AT THE
10 HOSPITAL. I HADN'T USED--
11 MR. WILSON: OBJECTION, YOUR HONOR, AS FAR AS
12 ANYTHING THE PHARMACIST MIGHT HAVE BEEN SAID.
13 THE COURT: SUSTAINED.
14 Q. (BY MR. STIRBA) THE RECORDS INDICATE INITIALLY I THINK
15 YOU ORDERED A 25 MICROGRAM DURAGESIC PATCH WHICH YOU CHANGED
16 THE SAME DAY TO 50 MICROGRAMS.
17 A. THAT'S CORRECT.
18 Q. WOULD YOU TELL US, PLEASE, WHY YOU DID THAT?
19 A. WELL, I CALLED THE PHARMACIST AND ASKED. I LOOKED IT UP
20 ALSO TO SEE THE STRENGTH AND HOW IT WOULD RELATE TO, SAY,
21 MORPHINE WHICH IS YOUR GOLD STANDARD WHICH EVERYTHING ELSE
22 IS COMPARED TO. AND IT LOOKED TO ME, GIVEN THE PREVIOUS
23 OPIATES SHE HAD BEEN ON AND THE AMOUNT OF PAIN SHE WAS
24 COMPLAINING OF, THAT 50 MICROGRAMS WOULD BE APPROPRIATE.
25 Q. I WANT YOU TO TURN TO YOUR PSYCH EVALUATION IN THE
3792
1 BINDER, PLEASE.
2 A. OKAY.
3 Q. AND SPECIFICALLY PAGE 233.
4 A. OKAY.
5 Q. AND YOU USE THE WORD "HOPE" IN THAT PARAGRAPH. DO YOU
6 SEE THAT?
7 A. YES.
8 Q. AND PERHAPS MAYBE YOU CAN READ THAT SENTENCE TO US FULLY
9 SO WE UNDERSTAND THE CONTEXT?
10 A. WELL, GOT TO READ THE PARAGRAPH. PATIENT WAS STARTED ON
11 SERZONE AND RISPERDAL TO TREAT HER DEPRESSION AND PSYCHOTIC
12 FEATURES. SHE'S ALSO BEEN ON TRAZODONE FOR SLEEP. I'LL
13 GIVE HER A DURAGESIC PATCH IN A LOWER DOSE FOR HER PAIN.
14 GIVEN HER DEMENTIA AND GENERAL MEDICAL CONDITION I HAVE VERY
15 LITTLE FEAR OF NEGATIVE CONSEQUENCES OF ANY ADDICTION.
16 WE'LL SET FIRM LIMITS ON HER NEGATIVE AND AGGRESSIVE
17 BEHAVIORS AND HOPE THAT IN TWO OR THREE WEEKS SHE'LL
18 IMPROVE.
19 Q. WAS THERE A SIGNIFICANCE TO THE FACT THAT YOU USE THE
20 WORD "HOPE" THERE?
21 A. YES.
22 Q. AND TELL US WHAT SIGNIFICANCE THAT WAS.
23 A. WHEN THE PATIENTS CAME IN, I COULD ONLY HOPE THAT WE
24 COULD GET THEM WELL. AND WE WOULD -- WE WOULDN'T KNOW THEM
25 AT ALL WHEN THEY GOT THERE, AND WE HAD TO TRY AND GATHER
3793
1 DATA AND FIGURE OUT WHAT WAS GOING ON AND WORK WITH THEM AND
2 TRY DIFFERENT MEDICATIONS AND HOPE THAT WE COULD HELP. OUR
3 LENGTH OF STAY TENDED TO BE TWO OR THREE WEEKS, AND I HAD
4 HOPED THAT BY THAT TIME SHE WOULD IMPROVE AND BE ABLE TO GO
5 HOME.
6 Q. HOW WOULD YOU CHARACTERIZE HER PROGRESS IN THE HOSPITAL?
7 A. WELL, SHE WASN'T THERE LONG. AND SHE GOT QUITE SICK AND
8 SHE DIDN'T DO WELL AT THAT POINT.
9 Q. AND WHAT WAS THE SOURCE OF HER GETTING SICK?
10 A. BEST I CAN TELL SHE DID HAVE SEPSIS, DEHYDRATION. AND
11 UNUSUALLY ELEVATED SODIUM. SHE GOT INFECTED.
12 Q. AND DO YOU RECALL THE REASON WHY SHE BECAME INFECTED?
13 A. AT THE TIME I THOUGHT SHE MIGHT HAVE ASPIRATED AND HAD
14 PNEUMONIA, BUT BECAUSE OF THE CHEST X-RAYS WERE ALL NEGATIVE
15 FOR THAT, IT APPEARS THAT THE MOST LIKELY CULPRIT WOULD BE
16 URINARY TRACT INFECTION, WHICH SHE DID HAVE. SHE ALSO HAD
17 THE RECTAL/VAGINAL FISTULA WHICH WOULD -- FECES ARE
18 75 PERCENT BACTERIA. AND SHE HAD A GOOD REASON TO GET
19 INFECTED THERE.
20 Q. DID YOU TREAT THE URINARY TRACT INFECTION?
21 A. WHEN SHE CAME IN, SHE HAD A URINALYSIS THAT SHOWED
22 PYURIA, WHICH ARE WHITE CELLS IN THE URINE. I DID TREAT IT
23 AT THAT TIME WITH CIPRO.
24 Q. DID YOU HAVE ANY INVOLVEMENT IN TREATING THE FISTULA?
25 A. I DID.
3794
1 Q. AND WOULD YOU EXPLAIN FOR US WHAT YOUR INVOLVEMENT WAS?
2 A. THE FISTULA WAS REPORTED BY ONE OF THE NURSES WHO
3 NOTICED THAT THERE WERE FECES COMING OUT OF THE VAGINA. AT
4 THAT POINT WE GOT A GYNECOLOGICAL CONSULT. ACTUALLY
5 DR. DIENHART SAW HER FIRST. WE GOT A GYNECOLOGICAL CONSULT
6 AND DR. MEEKS ORDERED OR ACTUALLY SUGGESTED A LOW RESIDUE
7 DIET AND BROAD SPECTRUM ANTIBIOTIC, IF WE WEREN'T GOING TO
8 DO SURGERY RIGHT AWAY. I WAITED FOR DR. DIENHART TO DO
9 SOMETHING 'CAUSE HE WAS THE INTERNIST WHO WOULD KIND OF --
10 THERE'S NO CLEAR LINE AS TO WHO'S TO DO WHAT IN THAT KIND OF
11 PROBLEM. BUT I SUGGESTED THAT THE NURSE CALL HIM AND LET
12 HIM KNOW ABOUT THE CONSULT AND GIVE HIM MY NUMBER AND ALL.
13 BUT I DIDN'T HEAR FROM HIM SO FINALLY I ORDERED THE DIET AND
14 THE BROAD SPECTRUM ANTIBIOTIC KEFLEX.
15 Q. AND DO YOU RECALL WHEN YOU ORDERED THE BROAD SPECTRUM
16 ANTIBIOTICS?
17 A. ON THE 5TH.
18 Q. I WANT TO DIRECT YOUR ATTENTION TO THE 7TH OF JANUARY OF
19 1996. WERE YOU CONTACTED AT THAT POINT CONCERNING A
20 CONDITION WITH MARY CRANE?
21 A. I'M SURE I WAS.
22 Q. AND DO YOU RECALL SEEING HER ON THAT DAY?
23 A. YES.
24 Q. AND ABOUT WHAT TIME DID YOU SEE HER THAT DAY?
25 A. I THINK I WAS SEEING HER IN THE AFTERNOON INTO THE
3795
1 EVENING.
2 Q. AND DID YOU OBSERVE HER CONDITION ON THAT DAY?
3 A. YES.
4 Q. AND WHAT DID YOU THINK WAS GOING ON?
5 A. WELL, I SAW HER AND DR. DIENHART SAW HER BOTH. I
6 THOUGHT SHE WAS REALLY ILL AND I THOUGHT SHE WAS DYING.
7 Q. AND WHY DID YOU THINK SHE WAS DYING?
8 A. SHE APPEARED INFECTED. SHE HAD A FEVER. SHE HAD AN
9 ELEVATED WHITE COUNT. WE'D DONE A C.B.C. A COUPLE OF DAYS
10 BEFORE. IT WAS UP TO 15. SHE WAS APPARENTLY -- SHE
11 APPEARED VERY DEHYDRATED AND JUST LOOKED VERY SICK. SHE WAS
12 BASICALLY VERY ILL. HER TEMPERATURE WAS UP TO OVER 102.
13 SHE -- WE GOT A SODIUM THAT DAY. IT WAS 159. SHE HAD A
14 SEIZURE. HER OXYGEN SATURATIONS WERE RUNNING 70 TO 80.
15 EVERYTHING WAS LOOKING REALLY BAD.
16 Q. NOW, DID YOU CONSULT WITH DR. DIENHART ABOUT HER
17 CONDITION ON THAT DAY?
18 A. YES, I DID. WE TALKED.
19 Q. AND DO YOU RECALL, DID YOU TALK IN PERSON OR BY PHONE?
20 A. WE TALKED IN PERSON AT THE NURSES' STATION.
21 Q. AND DO YOU RECALL WHAT WAS SAID IN THAT CONVERSATION?
22 A. WELL, HE DID HIS OWN EXAM AND WE TALKED ABOUT THE WHOLE
23 SITUATION AND ALL THE DATA THAT WE HAD. HE TALKED ABOUT
24 THINGS HE COULD DO TO REVERSE IT. I POINTED OUT THAT THE
25 MEDICAL TREATMENT PLAN AND SUCH WOULD NOT ALLOW I.V.'S AND
3796
1 SUCH. AND BASICALLY HE SAID, WELL, I DON'T KNOW. I DON'T
2 THINK WE COULD -- EVEN WITH FULL AGGRESSIVE MEASURES,
3 THERE'S A GOOD CHANCE SHE'S DYING OF SEPSIS. SO, YOU KNOW,
4 I SAID I AGREE AND I'LL TALK TO THE FAMILY.
5 Q. IS SEPSIS A SERIOUS CONDITION?
6 A. VERY.
7 Q. AND WHY DO YOU SAY THAT?
8 A. WELL, EVEN IF IT'S TREATED PROBABLY HALF THE PEOPLE DIE
9 FROM IT. SEPSIS IS BLOOD INFECTION. BLOOD POISONING, IT'S
10 BEEN CALLED. AND IT'S A GOOD TERM BECAUSE BACTERIA PUT OUT
11 ALL KINDS OF TOXIC PRODUCTS. THEY CAN CAUSE RENAL SHUTDOWN,
12 THE KIDNEYS FAIL. CAN CAUSE ABRUPT LOSS OF ALL BLOOD
13 PRESSURE. EVEN WHEN TREATED FULLY WITH I.V. ANTIBIOTICS,
14 IT'S VERY DANGEROUS. AND I COULDN'T GIVE HER I.V.'S
15 Q. NOW DID THERE COME A POINT AFTER THAT CONVERSATION WHEN
16 YOU DID TALK TO HER FAMILY?
17 A. YES, THERE WAS.
18 Q. AND DO YOU RECALL WHO YOU TALKED WITH?
19 A. I TALKED WITH THE DAUGHTERS, AND IT WOULD HAVE BEEN THAT
20 EVENING.
21 Q. AND DO YOU RECALL APPROXIMATELY WHAT TIME YOU WOULD HAVE
22 TALKED WITH THEM?
23 A. EARLY EVENING.
24 Q. AND WHERE DID YOU TALK WITH THEM?
25 A. PRETTY SURE IT WAS IN HER ROOM.
3797
1 Q. AND WAS ANYONE ELSE PRESENT?
2 A. THERE WERE FAMILY MEMBERS THERE, BUT I'M NOT SURE WHO.
3 NURSES WERE IN AND OUT. I THINK THERE WAS ANOTHER PATIENT
4 IN THE ROOM.
5 Q. WHAT WAS THE PURPOSE OF MEETING WITH THE DAUGHTERS IN
6 THE ROOM AT THAT TIME?
7 A. TO EXPLAIN WHAT WAS GOING ON AND SPEND SOME TIME WITH
8 THEM AND MAKE A DECISION AS TO WHERE TO GO FROM THERE.
9 Q. AND TELL US WHAT YOU SAID AND WHAT WAS SAID TO YOU IN
10 THAT CONVERSATION.
11 A. I DON'T REMEMBER THE EXACT WORDS FIVE YEARS LATER, BUT I
12 TOLD THEM THAT SHE WAS REALLY SICK. PROBABLY WOULD HAVE
13 TOLD THEM BASICALLY WHAT I JUST TOLD YOU ABOUT THE DIFFERENT
14 SYMPTOMS AND THE LAB VALUES AND SUCH AND THAT I THOUGHT SHE
15 WAS PROBABLY DYING. THAT I COULD PROVIDE COMFORT CARE
16 DURING THAT.
17 Q. AND DID THEY RESPOND?
18 A. YES.
19 Q. AND WHAT DO YOU RECALL THE RESPONSE WAS?
20 A. SADNESS. THEY WERE UPSET AND THEY AGREED THAT THERE WAS
21 REALLY NOTHING TO BE DONE AND SEEMED THANKFUL THAT WE WOULD
22 PROVIDE COMFORT CARE.
23 Q. DID YOU DISCUSS WITH THEM AT THAT TIME THE USE OF ANY
24 MEDICATION OR PAIN MEDICATION?
25 A. ONE OF THE DAUGHTERS WAS A NURSE. I'M SURE I DID. I
3798
1 CAN'T REMEMBER WHAT EXACTLY WAS TALKED ABOUT, BUT I'M SURE
2 WE TALKED ABOUT WHAT COMFORT CARE MEANT, WHAT MEDICATION
3 WOULD BE USED.
4 Q. DO YOU RECALL IF YOU TOLD THEM THAT YOU WERE GOING TO
5 USE MORPHINE AS A COMFORT MEASURE?
6 A. WELL, NOT SPECIFICALLY, BUT I'M SURE I DID BECAUSE I'D
7 HAD A PREVIOUS EXPERIENCE WITH COMFORT CARE BEING GIVEN.
8 AND THAT'S WHAT I WAS COMFORTABLE WITH, MORPHINE.
9 Q. NOW, YOU MENTIONED SOME LIMITATIONS IN TERMS OF THE
10 MEDICAL TREATMENT PLAN. WHAT ARE YOU REFERRING TO?
11 A. THE PLAN IN THE CHART WHERE FAMILIES OR PATIENTS WOULD
12 FILL OUT A FORM SAYING IF -- WELL, BASICALLY ADVANCE
13 DIRECTIVES AS TO WHAT THEY WANTED DONE IF THEY WERE TO GET
14 ILL.
15 Q. HAD YOU REVIEWED THE MEDICAL TREATMENT PLAN OR THE
16 ADVANCE DIRECTIVES PRIOR TO TALKING TO THE FAMILY THAT
17 EVENING?
18 A. I'M SURE I WOULD HAVE.
19 Q. AND WHY WOULD YOU HAVE DONE THAT?
20 A. WELL, THIS PLAN WAS PROBABLY FILLED OUT WITH THE FAMILY
21 ON THE 28TH WITH EARLENE COZZENS 'CAUSE THAT'S THE WAY IT'S
22 DATED. AND THEN I SIGNED IT LATER. I -- THAT WAS KIND
23 OF -- THEY PUT THIS THING IN FRONT OF ME. I SIGNED IT. I
24 WOULD HAVE LOOKED AT IT BRIEFLY AT THAT POINT. WHEN SHE GOT
25 ILL, I'M SURE I LOOKED AT IT TO KIND OF GET A GUIDE AS TO
3799
1 WHERE THE FAMILY WAS, WHERE THE PATIENT WAS, WHAT THEY WOULD
2 WANT FOR END-OF-LIFE CARE.
3 Q. DID YOU UNDERSTAND FROM YOUR CONVERSATION WITH THE
4 FAMILY THAT WHAT WAS EXPRESSED TO YOU WAS CONSISTENT WITH
5 YOUR UNDERSTANDING OF THE TREATMENT PLAN?
6 A. YOU MEAN WHAT WE TALKED ABOUT THAT NIGHT AND WHAT THE
7 TREATMENT PLAN SAID --
8 Q. YES.
9 A. -- LINED UP.
10 Q. YES.
11 A. YES, I DID. YES, THEY DID.
12 Q. NOW, YOU DID ON THE 7TH, YOU ORDERED MORPHINE TO BE
13 STARTED AT SOME POINT THAT EVENING; IS THAT RIGHT?
14 A. MISS CRANE WAS ON A DURAGESIC AND SHE HAD HAD AN
15 INCREASE BECAUSE OF SOME PAIN SEEN BEFORE -- BREAK-THROUGH
16 PAIN BEFORE THAT. SHE HAD ALSO BEEN ON MORPHINE FROM TIME
17 TO TIME ALSO FOR BREAK-THROUGH PAIN. BUT ON THE 7TH, I
18 ORDERED A ROUTINE ORDER OF MORPHINE TO GO ALONG WITH THE
19 DURAGESIC.
20 Q. AND WHAT PRECISELY WAS YOUR ORDER?
21 A. IT'S RIGHT HERE, FIVE MILLIGRAMS I.M. NOW AND EVERY
22 THREE HOURS AROUND THE CLOCK.
23 Q. WHY DID YOU ORDER FIVE MILLIGRAMS NOW, DO YOU REMEMBER?
24 A. SHE APPEARED TO BE UNCOMFORTABLE.
25 Q. AND WHAT WAS THE SIGNIFICANCE OF DOSING ROUND THE CLOCK
3800
1 EVERY THREE HOURS?
2 A. IT'S THE SAME ONCE AGAIN. RATHER THAN A P.R.N. WHERE
3 YOU'VE GOT TO WAIT FOR SOMEONE TO START CRYING OUT, I WANTED
4 THEM TO HAVE COVERAGE FOR ANY PAIN OR SUFFERING. I KNEW
5 THAT WITH THE INFECTION THAT SHE APPARENTLY HAD AND THE FACT
6 THAT REALLY NOTHING WAS TO BE DONE, THAT SHE WAS GOING TO
7 GET UNCOMFORTABLE WITHOUT PAIN CONTROL. SHE'D BECOME
8 DEHYDRATED AND THAT'S NOT PLEASANT.
9 Q. WAS THERE A SIGNIFICANCE TO THE FACT THAT YOUR INITIAL
10 DOSE WAS FIVE MILLIGRAMS OF MORPHINE?
11 A. WELL, IT SEEMED LIKE A REASONABLE DOSE IF THAT -- IT WAS
12 A KIND OF A MODERATE DOSE.
13 Q. AND DID IT HAVE ANY RELATIONSHIP TO THE FACT THAT SHE
14 HAD A DURAGESIC PATCH AT THAT TIME?
15 A. WELL, GIVEN HER STATUS, I PROBABLY WOULD HAVE STARTED AT
16 TEN IF SHE DIDN'T HAVE THE DURAGESIC PATCH. BUT I KNEW THAT
17 THEY GO TOGETHER. ANOTHER ALTERNATIVE I GUESS WOULD HAVE
18 BEEN TO INCREASE THE DURAGESIC PATCH, BUT I DIDN'T THINK OF
19 THAT.
20 Q. NOW, DO YOU RECALL THAT EVENING, DID YOU HAVE A
21 CONVERSATION WITH EARLENE COZZENS AT SOME POINT ABOUT THE
22 USE OF MORPHINE?
23 A. I VAGUELY RECALL THAT NOW THAT IT'S BEEN MENTIONED IN
24 COURT. I DIDN'T BEFORE.
25 Q. AND WHAT DO YOU RECALL IN TERMS OF WHERE THAT
3801
1 CONVERSATION TOOK PLACE?
2 A. AT THE NURSES' STATION.
3 Q. AND WAS ANYONE ELSE PRESENT?
4 A. NOT THAT I REMEMBER.
5 Q. AND WHAT WAS SAID AT THAT TIME BY MISS COZZENS AND BY
6 YOU?
7 A. WELL, SHE WAS CONCERNED ABOUT THE PATIENT GETTING
8 MORPHINE AND THESE PEOPLE WEREN'T TALKING TO US, WEREN'T
9 COMMUNICATING, AND SHE, I THINK, ASKED HOW DO YOU KNOW SHE
10 NEEDS IT. AND I SAID, WELL, HOW DO YOU KNOW SHE DOESN'T.
11 SHE'S DYING. AND IT'S OUR DUTY TO PREVENT SUFFERING. AND,
12 YOU KNOW, WE SHOULD ERR ON THE SIDE OF PROVIDING COMFORT
13 RATHER THAN WORRYING ABOUT SIDE EFFECTS. WE CAN WATCH HER
14 RESPIRATION. ALL THESE PATIENTS, THEIR RESPIRATIONS WERE
15 RECORDED IN THE CHART THROUGHOUT THEIR HOSPITALIZATIONS,
16 WERE PRETTY NORMAL, AND THAT'S SOMETHING YOU CAN CERTAINLY
17 WATCH FOR. AND WE HAD AN I.C.U. DOWN THE HALL WITH NARCAN,
18 SO IF WE HAD AN OVERDOSE, WE COULD FIX THAT.
19 Q. DID YOU HAVE ANY OTHER CONVERSATIONS WITH EARLENE
20 COZZENS THAT EVENING OTHER THAN THAT ONE?
21 A. NOT THAT I REMEMBER.
22 Q. WHY -- TELL US, PLEASE, WHY AS OF THAT EVENING AT ABOUT
23 2000 HOURS YOU ORDERED A FIVE MILLIGRAM DOSE OF MORPHINE TO
24 BE GIVEN TO A PATIENT MARY CRANE?
25 A. ARE YOU TALKING ABOUT THE INITIAL?
3802
1 Q. YES, AND THE REGIMEN THAT IS SO REFLECTED IN YOUR ORDER.
2 A. WELL, WHEN THE PATIENTS ARE DYING, IT'S MY EXPERIENCE
3 THAT FREQUENTLY THEY BECOME VERY AGITATED SOMETIMES. THEY
4 GASP. THEY GROAN. THEY THRASH AND MOAN. AND IT'S NOT
5 PLEASANT FOR THE PATIENT OR FOR THE FAMILY. AND I DIDN'T
6 WANT HER TO HAVE TO SUFFER THAT.
7 Q. ALL RIGHT. TURN PLEASE NOW TO A BINDER, I BELIEVE YOU
8 HAVE A BINDER THERE WITH PATIENT LYDIA SMITH.
9 A. YES.
10 Q. DO YOU HAVE THAT IN FRONT OF YOU?
11 A. RIGHT.
12 Q. TELL US WHAT MEMORY YOU HAVE OF LYDIA SMITH.
13 A. ONCE AGAIN, SHE WAS VERY DEMENTED. SHE WAS AMBULATORY.
14 VERY AGGRESSIVE AT TIMES AND AGITATED. PSYCHOTIC. I COULD
15 LOOK AT MY PSYCH EVAL AND PROBABLY TELL YOU MORE.
16 Q. LET'S TURN TO YOUR PSYCH EVAL, PLEASE.
17 A. SHE'D HAD A REALLY BAD STROKE IN NOVEMBER. HER DOCTOR
18 AT THAT TIME THOUGHT THAT IT WAS GOING TO KILL HER. SHE DID
19 RECOVER SOME, THOUGH, AND SHE WAS VERY, VERY AGITATED AND
20 COMBATIVE AND ASSAULTIVE AND SPITTING AND SCRATCHING AT
21 PEOPLE. ALSO APPEARED VERY DEPRESSED WHEN SHE ARRIVED. AND
22 THAT WAS THE HISTORY WE HAD. DID YOU ASK ABOUT HER MENTAL
23 CONDITION OR PHYSICAL OR BOTH?
24 Q. I WAS GOING TO ASK YOU ABOUT THE ASSESSMENT YOU MADE OF
25 HER ON ADMISSION. I THINK YOU DESCRIBED THAT. DID YOU
3803
1 PRESCRIBE ANY MEDICATION FOR HER ON ADMISSION?
2 A. YES, I DID.
3 Q. AND TELL US WHAT DID YOU ORDER?
4 A. SHE HAD BEEN ON HALDOL. I CHANGED THAT TO RISPERDAL.
5 SHE HAD BEEN ON SERZONE. I CONTINUED THAT. THEN A FEW DAYS
6 AFTER SHE WAS ADMITTED, SHE WASN'T SLEEPING AND SHE WAS
7 STILL QUITE AGITATED, SO I STARTED HER ON TRAZODONE ON THE
8 24TH.
9 Q. COULD YOU EXPLAIN WHY YOU DISCONTINUED THE HALDOL AND
10 REPLACED IT WITH RISPERDAL?
11 A. RISPERDAL IS A LOT SAFER IN ELDERLY. HALDOL THAT'S BEEN
12 TALKED ABOUT IN COURT HERE HAS SIDE EFFECTS CALLED
13 EXTRAPYRAMIDAL SYMPTOMS. SORT OF LIKE HAVING PARKINSONS
14 DISEASE. AND OF COURSE A LOT OF ELDERLY PEOPLE ARE ON THE
15 VERGE OF HAVING PARKINSONS ANYWAY. PUT THEM ON HALDOL AND
16 IT CAN HAVE SERIOUS SYMPTOMS THERE.
17 Q. DOES HALDOL HAVE A PLACE, FOR EXAMPLE, IN THE TREATMENT
18 AND CARE OF ELDERLY PATIENTS?
19 A. WELL, IT HAS A PLACE IN THE CARE OF ALL PATIENTS STILL
20 BECAUSE IT'S AVAILABLE I.M. OR I.V.
21 Q. WHAT IS THE SIGNIFICANCE OF THAT?
22 A. IF YOU'VE GOT A PATIENT WHO EITHER CAN'T OR REFUSES TO
23 TAKE MEDICATIONS BY MOUTH, YOU STILL HAVE THAT OPTION FOR
24 CONTROL OF PSYCHOTIC BEHAVIOR. YOU CAN GIVE A SHOT. HALDOL
25 IS AVAILABLE, AND OF THE MEDICINES THAT ARE AVAILABLE IN
3804
1 PARENTERAL FORM OR I.M. OR I.V., THAT'S PROBABLY THE BEST.
2 Q. AND WHAT OTHER MEDICATIONS DID YOU PRESCRIBE FOR HER ON
3 ADMISSION AND WHY DID YOU DO SO?
4 A. WELL, I CONTINUED HER ON LASIX AND POTASSIUM, MONOXIN,
5 NORADON AND VASOTEC, TYLENOL. THOSE ARE ALL HER -- JUST THE
6 MEDICATIONS SHE'D PRETTY MUCH BEEN ON BEFORE. I THINK I
7 GAVE HER CIPRO FOR THE URINARY TRACT INFECTION.
8 Q. AND WHAT KIND OF DRUG IS CIPRO?
9 A. IT'S A BROAD SPECTRUM ANTIBIOTIC.
10 Q. YOU MENTIONED A FEW OTHER PSYCHOTROPIC MEDICATIONS
11 INITIALLY IN ADDITION TO DISCONTINUING HALDOL. WOULD YOU
12 PLEASE TELL US WHAT THOSE PSYCH MEDS WERE AND WHY YOU
13 THOUGHT THEY WERE APPROPRIATE ON ADMISSION FOR PATIENT LYDIA
14 SMITH?
15 A. WELL, INITIALLY ANTIPSYCHOTIC. SO I STOPPED THE HALDOL
16 AND STARTED RISPERDAL. WE TALKED ABOUT THAT ONE. AND SHE
17 WAS ON SERZONE AND I CONTINUED IT AT THE SAME DOSE.
18 Q. WHAT KIND OF DRUG IS SERZONE?
19 A. IT'S AN ANTIDEPRESSANT.
20 Q. WHY DO YOU THINK THAT WAS APPROPRIATE?
21 A. SHE WAS DEPRESSED AND AGITATED. SHE WAS ALSO ANXIOUS.
22 AND IT'S GOOD FOR ALL OF THOSE.
23 Q. AND ANY OTHER PSYCHOTROPIC MEDICATIONS THAT YOU ORDERED
24 FOR HER ON ADMISSION?
25 A. NO, I DON'T BELIEVE SO.
3805
1 Q. HOW WOULD YOU CHARACTERIZE HER PROGRESSION IN TERMS OF
2 HER BEHAVIOR DURING HER HOSPITAL STAY?
3 A. IT DIDN'T IMPROVE MUCH.
4 Q. AND IN WHAT WAYS DID IT NOT IMPROVE?
5 A. WELL, I KEPT TRYING TO BALANCE MEDICATIONS FOR HER
6 THROUGHOUT THE TIME SHE WAS THERE AND IT WAS QUITE SOME TIME
7 FROM THE 20TH TO THE 8TH -- 20TH OF DECEMBER TO THE 8TH OF
8 JANUARY. THROUGHOUT THAT TIME JUST ABOUT EVERY DAY SHE HAD
9 BEEN QUITE AGITATED PART OF THE DAY IF NOT ALL OF THE DAY.
10 SHE REMAINED AGGRESSIVE AND SHOWED VERY POOR JUDGMENT.
11 Q. AS A RESULT DID YOU -- DID THIS AFFECT YOUR MEDICATION
12 PRACTICES CONCERNING HER?
13 A. YES.
14 Q. AND TELL US HOW SO.
15 A. WELL, I SLOWLY INCREASED HER DRUGS FOR AGITATION AND
16 PSYCHOSIS.
17 Q. AND WHY DID YOU DO THAT?
18 A. WELL, SHE CAME THERE FOR TREATMENT OF THESE PROBLEMS AND
19 THE HOPE WAS TO GET THEM UNDER CONTROL TO THE EXTENT THAT
20 SHE COULD GO HOME OR BACK TO A NURSING HOME.
21 Q. DO YOU RECALL IF HER AGGRESSION AND HER CONTINUED
22 BEHAVIOR PROBLEMS WERE OF CONCERN TO HER FAMILY?
23 A. YES, THEY WERE.
24 Q. IF YOU WOULD TURN FOR EXAMPLE TO -- IN THE BINDER I
25 THINK A PROGRESS NOTE ON 12/29 AND 12/30, PLEASE.
3806
1 A. OKAY. I HAVE THEM BOTH.
2 Q. LET'S START THIS WAY, ROBERT: IF YOU WOULD READ IN ITS
3 ENTIRETY THE NOTE ON 12/29.
4 A. ONCE AGAIN IS IRRITABLE TODAY. HAS BEEN HITTING OUT
5 AGAIN. VERY DEMENTED. SPOKE WITH HER DAUGHTER REGARDING
6 TREATMENT AND PROGNOSES. VITAL SIGNS STABLE. AFEBRILE.
7 ASSESSMENT: INTERMITTENTLY QUITE AGGRESSIVE. THIS WOULD
8 BLOCK PLACEMENT. PLAN: DEPAKENE INCREASE HALDOL I.M. WHEN
9 AND IF RISPERDAL REFUSED. HALDOL P.R.N. SIGNED BY ME.
10 Q. WHEN YOU SAY SPOKE WITH HER DAUGHTER RE TREATMENT AND
11 PROGNOSIS, WHAT PRECISELY DID YOU SPEAK TO HER DAUGHTER
12 CONCERNING?
13 A. THAT VERY DAY SHE'D ALSO SEEN A SOCIAL WORKER, THE
14 DAUGHTER HAD SEEN A SOCIAL WORKER AND --
15 MR. WILSON: YOUR HONOR, I'M GOING TO INTERPOSE AN
16 OBJECTION WITHOUT FURTHER FOUNDATION SURROUNDING THIS
17 CONVERSATION.
18 THE COURT: WANT TO LAY FOUNDATION.
19 Q. (BY MR. STIRBA) SURE. WHY DON'T YOU READ THE SOCIAL
20 WORK NOTE FOR THAT, WHICH IS RIGHT ABOVE THE 12/29/95 ENTRY
21 IN ITS ENTIRETY, PLEASE?
22 A. OKAY. IT'S FROM THE SOCIAL WORKER, KRISTIN STEGLICH.
23 IT SAYS, SOCIAL WORKER NOTE. SPOKE WITH PATIENT'S SON AND
24 DAUGHTER WHO'S FROM ARIZONA. DISCUSSED PATIENT PROGRESS.
25 FAMILY VERBALIZED CONCERN REGARDING DISCHARGE PLANS. THEY
3807
1 EMPHASIZED IMPORTANCE OF DECREASE IN PATIENT'S AGGRESSIVE
2 BEHAVIOR IF SHE IS TO BE ADMITTED TO ROCKY MOUNTAIN
3 BOUNTIFUL AFTER DISCHARGE. PROVIDED SUPPORT OF COUNSELING.
4 FAMILY CONFERENCE TO BE ARRANGED FOR NEXT WEEK TO DISCUSS
5 DISCHARGE PLANS IN DETAIL. KRISTIN STEGLICH.
6 Q. NOW, WHAT IS THE RELATIONSHIP TO YOUR CONVERSATION ON
7 THE 29TH AND THAT SOCIAL WORK NOTE IN TERMS OF A FAMILY
8 CONCERN?
9 A. WELL, THE FAMILY WAS VERY CONCERNED THAT IF WE DIDN'T
10 GET THE BEHAVIOR UNDER CONTROL THAT THEIR HOPED-FOR
11 PLACEMENT AT ROCKY MOUNTAIN BOUNTIFUL WAS GOING TO FALL
12 THROUGH.
13 Q. AND YOU NOTE ON 12/29 THAT YOU SAY THIS WOULD BLOCK
14 PLACEMENT.
15 A. INTERMITTENTLY QUITE AGGRESSIVE. THIS WOULD BLOCK
16 PLACEMENT.
17 Q. AND WHAT DO YOU MEAN BY THAT?
18 A. IF SHE REMAINS AGGRESSIVE, THEY ARE NOT GOING TO TAKE
19 HER AT THE NURSING HOME, ROCKY MOUNTAIN BOUNTIFUL.
20 Q. AND HOW DID YOU GO ABOUT MEDICALLY ATTEMPTING TO GAIN
21 CONTROL OVER HER BEHAVIOR AT THIS POINT?
22 A. WELL, IN THIS NOTE I SAY I'M GOING TO TRY DEPAKENE. I
23 ADDED IT. AND INCREASED THE HALDOL WHEN RISPERDAL WAS
24 REFUSED. SHE REFUSED A LOT OF RISPERDAL. AND SO I HAD THIS
25 STANDING ORDER THAT -- IT WAS A P.R.N. ORDER THAT IF SHE
3808
1 REFUSED RISPERDAL, GIVE HALDOL INSTEAD.
2 Q. WHEN YOU SAY REFUSED, COULD YOU EXPLAIN WHAT YOU MEAN BY
3 SHE REFUSED?
4 A. SHE WOULD SPIT OUT HER MEDICATION OR SHE WOULD MAYBE BE
5 REFUSING TO EAT ANYTHING. JUST COULDN'T GIVE IT BY MOUTH
6 WITHOUT LIKE PUTTING IN A TUBE OR OTHER --
7 Q. AND ON THE 29TH YOUR NOTE INDICATES INCREASE HALDOL.
8 WHY DID YOU INCREASE HALDOL?
9 A. WELL, BECAUSE SHE IS REALLY AGGRESSIVE AND HALDOL IS
10 HELPFUL THERE. I WOULD PREFER TO USE THE RISPERDAL BECAUSE
11 THE LOWER SIDE EFFECT TO GET CONTROL OF AGGRESSION. BUT
12 HALDOL IS A GOOD ANTI-AGITATION, ANTI-AGGRESSIVE MEDICATION.
13 Q. WHY DID YOU ADD DEPAKENE AS OF THE 29TH?
14 A. AS A MOOD STABILIZER.
15 Q. AND WHAT PURPOSE DID YOU BELIEVE THAT DEPAKENE MAY HAVE
16 SERVED AT THAT POINT IN TERMS OF HER BEHAVIOR?
17 A. WELL, HOPEFULLY IT WOULD CALM HER. HELP HER KIND OF
18 THINK BEFORE SHE ACTS -- ACTED, IF AT ALL POSSIBLE.
19 STABILIZE HER.
20 Q. NOW, THE NOTE ON THE 30TH, IF YOU COULD TURN TO THAT
21 PLEASE.
22 A. GOT IT.
23 Q. COULD YOU READ THAT IN ITS ENTIRETY, PLEASE? AND WHEN
24 YOU ARE READING THESE, I JUST WANT TO CAUTION YOU, GO
25 SLOWLY. IT'S HARD FOR US TO KEEP UP. WE TEND TO READ FAST.
3809
1 READ IT SLOW.
2 A. YOU WANT MY NOTE AND NOT THE SOCIAL WORK NOTE THIS TIME
3 ABOUT IT.
4 Q. WHY DON'T YOU READ YOUR NOTE, PLEASE?
5 A. VERY VARIABLE BEHAVIOR. DAUGHTERS HERE TO VISIT. WE
6 TALKED BRIEFLY. GETTING ABOUT HALF OF HER ANTIPSYCHOTIC VIA
7 I.M. HALDOL UNTIL TODAY WHEN SHE TOOK HER ORAL RISPERDAL,
8 AND BEHAVIOR'S BEEN GOOD TODAY. VITAL SIGNS STABLE.
9 AFEBRILE. ASSESSMENT: STABLE. PLAN: CONTINUED CURRENT
10 CARE. ROBERT WEITZEL.
11 Q. DO YOU RECALL WHAT YOU AND THE DAUGHTER DISCUSSED
12 BRIEFLY ON THE 30TH OF DECEMBER?
13 A. ONCE AGAIN, WE WERE -- WE HAD TO GET THINGS UNDER
14 CONTROL FOR HER TO BE PLACED IN A NURSING HOME, WOULD BE THE
15 TOPIC OF DISCUSSION THERE.
16 Q. AND I NOTICE YOU TALK ABOUT VIA I.M. HALDOL TODAY. WHEN
17 YOU SAY HALF OF HER ANTIPSYCHOTIC, WHAT ARE YOU REFERRING TO
18 WHEN YOU SAY HALF OF HER ANTIPSYCHOTIC VIA I.M. HALDOL?
19 A. WELL, SHE WAS GETTING EITHER HALDOL OR RISPERDAL AS THE
20 ANTIPSYCHOTIC I WAS GIVING. AND SHE'D BEEN, IT SAYS IN THE
21 NOTE RIGHT ABOVE REFUSING TO MAKE TAKE MEDICATION, KICKING,
22 SPITTING. FOR MANY DAYS SHE WOULD DO THAT. AND SO IN ORDER
23 TO GET SOME ANTIPSYCHOTIC ON BOARD, WE'D USE VALIUM AND
24 HALDOL. AND THAT HAD BEEN ABOUT HALF OF THAT UNTIL THAT DAY
25 WHERE SHE TOOK HER ORAL RISPERDAL AND BEHAVIOR'S BEEN GOOD.
3810
1 Q. NOW, DID THERE COME A TIME WHEN HER BEHAVIOR CHANGED?
2 A. YES.
3 Q. AND CAN YOU TELL US GENERALLY WHEN HER BEHAVIOR CHANGED
4 DURING THE COURSE OF HER STAY AT THE HOSPITAL?
5 A. WELL, THE NEXT DAY, YOU KNOW, REFUSING MEDS AGAIN.
6 RECALCITRANT, GOT AGGRESSIVE. AND THEN THE NEXT,
7 DISORIENTED, CONFUSED, DEMENTED. AFTER A DIFFICULT -- OR
8 SLEPT AFTER A DIFFICULT EVENING. THE NEXT ONE, MISSES MANY
9 OF HER DOSES DUE TO NONCOMPLIANCE. MILDLY LABILE AND
10 IRRITABLE. THAT'S THE 3RD. THE 4TH, REMAINS RECALCITRANT,
11 CLIMBING OUT OF BED. VIRTUALLY ENTANGLED IN BED RAILS.
12 VERY POOR JUDGMENT. THE 5TH, VERY OBSTINATE, VERY ANGRY.
13 DEMENTED. AT THAT POINT I INCREASED HER MEDICATION.
14 Q. WHY DID YOU DO THAT?
15 A. I WAS UNDER PRESSURE FROM THE FAMILY AND I WANTED TO TRY
16 AND GET HER BETTER. WANTED TO TRY AND GET HER BEHAVIOR
17 UNDER ENOUGH CONTROL SO SHE COULD GET TO THE NURSING HOME.
18 THAT'S MY JOB.
19 Q. WHAT HAPPENED THEREAFTER?
20 A. WELL, AT THAT POINT SHE WAS ON DEPAKENE, KLONOPIN
21 SERZONE, RISPERDAL, AND TRAZODONE. CONTINUES TO BE VERY
22 NEGATIVE. ON THE 6TH SHE WAS FEELING POORLY, LETHARGIC,
23 AMBULATING A BIT. AND THEN ON THE 7TH SHE APPEARED VERY,
24 VERY WEAK AND SHE LOOKED VERY SICK. MEDICALLY ILL. SHE
25 WASN'T TAKING ANY NOURISHMENT. SHE HAD NO URINE OUTPUT.
3811
1 Q. I WAS GOING TO ASK YOU, DID YOU MAKE A DETERMINATION AS
2 TO HER PHYSICAL CONDITION ON THE 6TH OR THE 7TH?
3 A. WELL, SHE LOST EIGHT POUNDS SINCE ADMISSION. AND THERE
4 WAS NO URINE OUTPUT, NO ORAL INTAKE. AND AS A DOCTOR, YOU
5 JUST KIND OF GET SORT OF AN INTUITION OR SENSE ABOUT HOW
6 PATIENTS ARE DOING. AND MY JUDGMENT WAS THAT SHE LOOKED
7 REALLY SICK, AND I ASKED TO SEE THE FAMILY OR TALK TO THE
8 FAMILY ABOUT IT. WE HAD A DISCUSSION.
9 Q. AND DO YOU RECALL WHEN THAT DISCUSSION TOOK PLACE?
10 A. ON THE 7TH.
11 Q. AND WHERE DID YOU TALK TO THE FAMILY?
12 A. ON THE UNIT. I'M NOT SURE, BUT I THINK PROBABLY IN HER
13 ROOM. IT COULD HAVE BEEN AT THE NURSES' STATION. IT COULD
14 HAVE BEEN BOTH.
15 Q. AND DO YOU RECALL WHO WAS PRESENT?
16 A. KENT SMITH WAS THERE. I DON'T KNOW WHO ELSE WAS THERE.
17 FAMILY MEMBERS.
18 Q. AND WHAT WAS THE PURPOSE OF THE MEETING?
19 A. I WANTED TO TELL THEM WHAT I WAS SEEING. I WAS
20 CONCERNED ABOUT HOW SICK SHE WAS AND I WANTED TO ASK THEM
21 WHAT THEY WANTED DONE.
22 Q. AND COULD YOU TELL US, PLEASE, WHAT YOU SAID AND WHAT
23 OTHERS MAY HAVE SAID IN THAT MEETING ON THE 7TH?
24 A. WELL, I TOLD THEM THAT SHE WAS REALLY SICK. THAT IT WAS
25 BASICALLY UP TO THEM WHERE WE WENT FROM THERE. IT WAS MY
3812
1 PRACTICE TO TELL FOLKS, YOU KNOW, IT'S POSSIBLE THAT WE
2 MIGHT BE ABLE TO REVERSE ALL THIS, BUT IT WOULD REQUIRE
3 INVASIVE TECHNIQUES. PROBABLY THE MEDICAL FLOOR, MAKE A
4 TRANSFER, PERHAPS I.C.U. AND I WOULD JUST HAVE LET THEM
5 MAKE UP THEIR MIND WHERE THEY WANTED TO GO FROM THERE.
6 Q. WHEN YOU SAY REALLY SICK, WHAT DID YOU BELIEVE WAS
7 HAPPENING TO LYDIA SMITH?
8 A. I THOUGHT HER ORAL INTAKE, HER FLUID INTAKE, WAS SO LOW
9 SHE WAS QUITE DEHYDRATED. I KNEW THAT BECAUSE SHE WASN'T
10 PUTTING OUT ANY URINE. I DIDN'T KNOW EXACTLY WHAT WAS
11 HAPPENING, BUT SHE JUST SEEMED VERY, VERY ILL TO THE EXTENT
12 THAT IT LOOKED LIKE WE WERE GOING TO HAVE TO GET AGGRESSIVE
13 MEDICALLY.
14 Q. AND BY THAT YOU MEAN WHAT?
15 A. PROBABLY AT LEAST I.V. PROBABLY SOME SORT OF PARENTERAL
16 NUTRITION.
17 Q. PARENTERAL MEANING?
18 A. EITHER A NASAL GASTRIC TUBE OR I.V. FLUIDS AND FEEDINGS.
19 Q. WHAT DID THE FAMILY TELL YOU IN THAT MEETING?
20 MR. WILSON: OBJECTION; HEARSAY.
21 THE COURT: OVERRULED.
22 THE WITNESS: WELL, THEY SAID THAT THEY DIDN'T WANT
23 HER LIFE PROLONGED AND THEY WERE READY TO LET HER GO.
24 Q. (BY MR. STIRBA) IS THAT REFLECTED IN YOUR PROGRESS
25 NOTE.
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1 A. THAT'S WHAT I WROTE DOWN.
2 Q. WHICH NOTE IS THAT, DOCTOR?
3 A. IT'S JANUARY 7 IN THE PROGRESS NOTES.
4 Q. COULD YOU READ THAT NOTE IN ITS ENTIRETY FOR US, PLEASE?
5 A. VERY WEAK. NOT TAKING ANY NOURISHMENT. NO URINE
6 OUTPUT. FAMILY DISCUSSION WITH TWO SONS AND DAUGHTER
7 REVEALS THAT THEY DON'T WANT HER LIFE PROLONGED, BUT ARE
8 READY TO LET HER GO. AT TIMES SHE THRASHES ABOUT, SEEMS TO
9 BE IN PAIN AND/OR ANXIETY. ASSESSMENT: QUITE ILL. PLAN:
10 HOLD MEDICATIONS. MORPHINE FIVE MILLIGRAMS EACH THREE HOURS
11 INTRAMUSCULARLY. ROBERT WEITZEL M.D.
12 Q. AT THE TIME OF THE DISCUSSION ON THE 7TH, DID YOU KNOW
13 WHETHER THERE WERE SOME WRITTEN DIRECTIVES THAT HAD BEEN
14 FILED IN HER MEDICAL CHART?
15 A. THE BEST I CAN FIGURE THEY WERE FILLED OUT AT THAT
16 POINT. I DON'T THINK THERE WAS A MEDICAL DIRECTIVE BEFORE
17 THEN. I'M NOT SURE, THOUGH. IT COULD BE.
18 Q. DO YOU KNOW HOW IT WAS THAT THEY WERE FILLED OUT ON THE
19 NIGHT OF THE 7TH?
20 A. WELL, I LOOKED AT THE ONE THAT WAS FILLED OUT AND IT
21 APPEARS THAT EARLENE DID THAT WITH THE FAMILY. I SIGNED OFF
22 ON IT.
23 Q. AND WHAT WAS YOUR INVOLVEMENT IN TERMS OF THE
24 PREPARATION OF THAT DOCUMENT?
25 A. WELL, GENERALLY ON THIS SORT OF PAPERWORK WHERE THE
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1 NURSES OR THE SOCIAL WORKER WOULD HAVE WORKED WITH THE
2 FAMILY AND ASKED THEM WHAT THEY WANTED TO PUT IN AND HAD ALL
3 THE SIGNATURES SIGNED, AND THEN BASICALLY I WOULD JUST SIGN
4 OFF ON IT LATER. SO NO INVOLVEMENT IN PREPARATION.
5 Q. DO YOU KNOW WHO INITIATED THE SUGGESTION OR THE
6 RECOMMENDATION THAT A MEDICAL TREATMENT PLAN BE FILLED OUT?
7 A. NO. I DON'T REMEMBER. IT WAS A -- I KNOW ABOUT THIS
8 LAW WHERE YOU HAVE TO OFFER THAT TO PATIENTS. I THINK THAT
9 WOULD HAVE BEEN DONE IN ADMISSION. I DON'T KNOW WHY THIS
10 PARTICULAR FAMILY HADN'T FILLED ANYTHING OUT AND I DON'T
11 KNOW WHO SUGGESTED IT OR, YOU KNOW, I KNOW EARLENE WENT
12 THROUGH WITH IT 'CAUSE SHE SIGNED OFF ON ALL THE RELEVANT OR
13 THE IM