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.
3813
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
3814
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 IMPORTANT PLACES WHERE SHE WOULD HAVE HAD TO DO SO AS
14 THE PERSON WHO WAS ACTUALLY GETTING IT DONE.
15 Q. NOW, ON THAT EVENING YOU ORDERED THAT MORPHINE BE
16 STARTED; IS THAT RIGHT?
17 A. YES, I DID.
18 Q. AND TELL US WHAT THAT ORDER WAS.
19 A. FIVE MILLIGRAMS EVERY THREE HOURS.
20 Q. DID YOU ENTER THAT ORDER PRIOR OR AFTER YOUR
21 CONVERSATION WITH THE FAMILY?
22 A. AFTER.
23 Q. AND DO YOU RECALL IF YOU SAW THE MEDICAL TREATMENT PLAN
24 BEFORE YOU ENTERED THE ORDER CONCERNING MORPHINE?
25 A. I DON'T ACTUALLY. I DON'T REMEMBER IF I SAW IT BEFORE I
3815
1 TALKED WITH THE FAMILY ABOUT WHAT THEY WANTED AND THIS
2 MEDICAL TREATMENT PLAN IS CONSISTENT WITH WHAT THEY WANTED.
3 I PROBABLY DID SEE IT, BUT I CAN'T REMEMBER, YOU KNOW,
4 WHETHER I READ IT OR NOT BEFORE I STARTED THE MORPHINE OR
5 AFTER.
6 Q. IN THAT MEETING THAT TOOK PLACE WITH THE FAMILY, CAN YOU
7 TELL US, PLEASE, ABOUT HOW LONG YOU MET?
8 A. JUST A GUESS, TEN OR 20 MINUTES.
9 Q. AND DO YOU RECALL IF YOU WOULD HAVE SAID ANYTHING OF A
10 CRITICAL OR PEJORATIVE NATURE ABOUT LYDIA SMITH TO THE
11 FAMILY AT THAT TIME?
12 A. NO. I HAD CALLED THAT MEETING. I'D ASKED THE FAMILY TO
13 COME, AND I'M CERTAINLY NOT GOING TO SAY ANYTHING LIKE WHAT
14 WAS ALLUDED TO EARLIER.
15 Q. YOU'VE HEARD THE TESTIMONY IN THIS COURT. DID YOU SAY
16 ANY SUCH THING ABOUT LYDIA SMITH TO THE FAMILY THAT EVENING?
17 A. NO.
18 Q. WHY DID YOU AT THAT POINT ON THE 7TH ENTER AN ORDER FOR
19 MORPHINE TO BE STARTED CONCERNING PATIENT LYDIA SMITH?
20 A. WELL, IT WAS MY JUDGMENT THAT SHE WAS DYING. AND IT WAS
21 MY TRAINING THAT THERE ARE -- IT'S UNCOMFORTABLE TO -- WHEN
22 YOU ARE DEHYDRATED, NOT BEING GIVEN FLUIDS, I.V. OR SUCH,
23 AND SHE CERTAINLY WASN'T TAKING ANYTHING BY MOUTH, I DIDN'T
24 WANT HER TO BE UNCOMFORTABLE. I DIDN'T WANT HER TO SUFFER.
25 I DIDN'T WANT HER TO HAVE ANY PAIN. I DIDN'T WANT HER
3816
1 THRASHING AROUND AND MOANING. I DIDN'T WANT THE FAMILY TO
2 SEE THAT. I DIDN'T WANT HER TO HAVE A PAINFUL DEATH.
3 Q. IF YOU WOULD NOW, PLEASE, TURN TO THE BINDER CONCERNING
4 ENNIS ALLDREDGE. MR. ALLDREDGE WAS IN THE HOSPITAL FROM
5 WHEN TO WHEN?
6 A. CAME IN ON THE 10TH OF JANUARY AND HE DIED ON THE 14TH.
7 Q. AND DO YOU HAVE A RECOLLECTION OF MR. ALLDREDGE?
8 A. I PROBABLY HAVE THE BEST RECOLLECTION OF MR. ALLDREDGE
9 OF ALL THE PATIENTS.
10 Q. AND WHY IS THAT?
11 A. MR. ALLDREDGE WAS VERY, VERY STRONG AND HE WAS POWERFUL.
12 HE WAS EIGHTY-ONE OR TWO, BUT HE WAS STRONG. AND HE WAS
13 GRABBING OUT AND TRYING TO PINCH AND HIT PEOPLE AND HE
14 GRABBED HOLD OF THE NURSES' ARMS AND SOME OF THEM WEREN'T
15 THAT STRONG. AND HE WAS SCARY TO EVERYBODY, INCLUDING ME.
16 I WAS IN AT ONE POINT WHEN HE FIRST GOT TO THE UNIT, TRYING
17 TO HELP THE NURSES. I WAS IN TO SEE HIM AND THERE WERE ALL
18 THESE NURSES TRYING TO KEEP HIM UNDER CONTROL AND I WAS
19 HELPING TOO AND HE SCARED ME. HE WAS REALLY OUT OF CONTROL
20 AND I REMEMBER THAT. I THINK BEING THIS MANY YEARS LATER
21 IT'S HARD TO REMEMBER ABOUT ANY PARTICULAR PATIENTS AND I'VE
22 HAD A LOT OF PATIENTS SINCE THEN. I REMEMBER MR. ALLDREDGE.
23 I CAN SEE HIM IN MY MIND.
24 Q. WHAT WAS YOUR ASSESSMENT OF HIS CONDITION AT THE TIME OF
25 HIS ADMISSION?
3817
1 A. SEVERE DEMENTIA AND MEDICALLY VERY, VERY ILL. HE HAD A
2 HISTORY OF -- LONG HISTORY OF HEART PROBLEMS WITH BYPASS
3 GRAFTS AND DIABETES, LONG HISTORY OF DIABETES WHICH WASN'T
4 UNDER VERY GOOD CONTROL, WHICH PREDISPOSES YOU TO HEART
5 PROBLEMS AND TO STROKES. HE HAD A FORM OF CANCER. HE HAD
6 HYPOTHYROIDISM. HE PROBABLY HAD STROKES IN THE PAST. AND
7 HE CERTAINLY HAD WHAT ARE CALLED MYOCARDIAL INFARCTIONS OR
8 HEART ATTACKS IN THE PAST. SO HE WAS, ALTHOUGH QUITE
9 STRONG, HE HAD A LOT OF MEDICAL PROBLEMS AGAINST HIM. AND
10 ADDITIONALLY, HE WAS VERY, VERY DEMENTED WITH A LOT OF THE
11 SYMPTOMS YOU SEE IN MEN WITH DEMENTIA.
12 Q. WHAT DO YOU MEAN BY THAT?
13 A. JUST A LOT MORE AGGRESSION. WHEN PEOPLE ARE DEMENTED,
14 YOU HAVE TO TAKE CARE OF THEM. YOU HAVE TO -- THEY KIND OF
15 REGRESS TO BABYHOOD IN MANY WAYS. YOU HAVE TO DO THE
16 A.D.L.'S, ACTIVITIES OF DAILY LIVING. AND WOMEN WILL TEND
17 TO RESPOND TO OTHERS CARING FOR THEM, TAKING CARE OF BASIC
18 NEEDS COOPERATIVELY. BUT MEN GET REALLY ANGRY, MORE SO THAN
19 WOMEN. THEY ARE PROBABLY MORE INDEPENDENT AND THEY DON'T
20 UNDERSTAND AT ALL WHAT'S GOING ON, AND SO WHEN YOU TRY TO
21 DIAPER THEM, THEY JUST BLOW UP.
22 Q. NOW, DID YOU PRESCRIBE SOME MEDICATION FOR MR. ALLDREDGE
23 ON HIS ADMISSION?
24 A. I DID.
25 Q. AND WOULD YOU TELL US IN THE PSYCH MEDICATION AREA WHAT
3818
1 YOU DID?
2 A. WELL, HE'D BEEN ON HALDOL AND ATIVAN AND RISPERDAL,
3 MELLARIL, BUSPAR, AND BENADRYL BEFORE HE GOT THERE. HE'D
4 HAD HUGE DOSES OF ATIVAN, THREE MILLIGRAMS FIVE TIMES. AND
5 HE WAS TOTALLY OUT OF CONTROL ON ARRIVING AT THE UNIT. I'M
6 SURE HE WAS CONFUSED AND SCARED IN THIS NEW ENVIRONMENT, ALL
7 THESE PEOPLE THAT HE'D NEVER SEEN BEFORE. AND I GAVE HIM
8 TEN MILLIGRAMS OF I.M. HALDOL AND A MILLIGRAM OF I.M. ATIVAN
9 AT THAT POINT. AND THEN ORDERED MEDICATIONS FOR ROUTINE
10 DOSES.
11 Q. FOR WHAT PURPOSE WAS THE HALDOL IN COMBINATION WITH THE
12 ATIVAN GIVEN ON ADMISSION?
13 A. FOR HIS SAFETY AND FOR EVERYONE ELSE'S SAFETY.
14 Q. DID YOU TALK PRIOR TO ADMISSION TO HIS TREATING
15 PHYSICIAN?
16 A. DR. CUNNINGHAM, YES.
17 Q. AND WHAT WAS THE PURPOSE OF TALKING TO DR. CUNNINGHAM
18 PRIOR TO ADMISSION?
19 A. GET A HISTORY AND A SENSE FOR WHO THE MAN WAS AND WHAT
20 WE MIGHT BE ABLE TO -- WHAT HAD BEEN DONE AND WHAT WE COULD
21 DO FOR HIM.
22 Q. DESCRIBE, PLEASE, HIS HOSPITALIZATION AND THE COURSE OF
23 IT DURING THE TIME HE WAS AT THE HOSPITAL?
24 A. OKAY. JUST KIND OF STARTING FROM THE BEGINNING. HE GOT
25 THE TEN MILLIGRAMS OF HALDOL WITH ATIVAN AND HE WAS
3819
1 CONTINUED ON BUSPAR. TRAZODONE WAS STARTED AT BEDTIME AND
2 RISPERDAL WAS ORDERED AT I THINK AN EXTRA MILLIGRAM A DAY.
3 YEAH.
4 Q. LET ME ASK YOU ABOUT THAT. YOU DO INDICATE IN YOUR
5 WRITTEN REPORT, THE PSYCHIATRIC EVALUATION, THAT RISPERDAL
6 WAS TO BE INCREASED?
7 A. THAT'S RIGHT.
8 Q. WHY DO YOU BELIEVE THAT INCREASED RISPERDAL WAS
9 APPROPRIATE?
10 A. WELL, HE WAS ONLY ON TWO MILLIGRAMS. HE WAS A BIG MAN.
11 HE HAD BEEN ON THAT FOR SOME TIME AND IT HAD BEEN INCREASED
12 RECENTLY FROM ONE MILLIGRAM AND IT WASN'T GETTING ANYWHERE.
13 SO I THOUGHT LET'S GO TO THREE MILLIGRAMS AND MAYBE THAT
14 WILL HELP GET HIS AGGRESSION AND PSYCHOSIS UNDER CONTROL.
15 Q. CONTINUE ON THEN WITH HIS HOSPITALIZATION.
16 A. WELL, I CONTINUED ALL THE OTHER MEDICATIONS THAT HE WAS
17 ON OF THE GENERAL MEDICAL MEDICATIONS. BUSPAR STAYED THE
18 SAME. THEN THAT DAY WE GAVE HIM THE HALDOL AND ATIVAN AND
19 ORDERED HALDOL AS P.R.N. IF HE REFUSED RISPERDAL.
20 DR. DIENHART SAW HIM.
21 Q. HOW DID HE DO INITIALLY IN TERMS OF HIS BEHAVIOR AND
22 PROGRESSION WITH THE INITIAL MEDICATIONS THAT WERE ORDERED?
23 A. HE STAYED VERY AGITATED FOR THE MOST PART. FIRST DAY
24 AFTER HE GOT THERE HE HAD A PERIOD OF LETHARGY, BUT HE CAME
25 OUT OF IT PRETTY QUICKLY. WE WERE RIGHT BACK INTO
3820
1 AGGRESSION AGAIN. WE HAD TO RESTRAIN HIM QUITE OFTEN. HE
2 WAS DANGEROUS.
3 Q. NOW, DID THAT AGGRESSION CAUSE CERTAIN OTHER
4 INTERVENTIONS IN TERMS OF CONTROLLING HIM?
5 A. THE NURSES WOULD USE A GERIATRIC CHAIR, WHICH IS
6 BASICALLY JUST A BIG OLD CUSHIONED CHAIR ON WHEELS SO YOU
7 CAN MOVE AROUND. HE WOULD HAVE A POSEY RESTRAINT, WHICH IS
8 A VEST SORT OF AFFAIR WITH STRAPS. IT GOES AROUND THE
9 PATIENT AND STRAPS COME AROUND LIKE THIS AND YOU CAN
10 RESTRAIN THE PERSON FROM THRASHING ABOUT. AT TIMES HE HAD
11 WRIST RESTRAINTS AND LEG RESTRAINTS. I FORGOT YOUR
12 QUESTION.
13 Q. WELL, I THINK THAT'S WHAT I WAS ASKING YOU ABOUT, OTHER
14 INTERVENTION THINGS BY THE NURSING STAFF IN TERMS OF
15 CONTROLLING HIS BEHAVIOR.
16 A. WELL, THAT AND THE OTHER THING I WAS WANTING TO SAY IS
17 THAT HE HAD P.R.N. MEDICATION GIVEN BY THE NURSES. THEY HAD
18 TO GIVE HIM SHOTS OF ATIVAN AND HALDOL.
19 Q. DID THERE COME A POINT IN HIS HOSPITAL STAY WHEN HIS
20 CONDITION CHANGED --
21 A. YES.
22 Q. -- AND AN ACUTE CIRCUMSTANCE OCCURRED?
23 A. YES.
24 Q. AND TELL US WHAT YOU RECALL IN THAT REGARD.
25 A. ON THE 12TH I WAS CONCERNED -- HE LOOKED LIKE MAYBE WHAT
3821
1 WAS CAUSING ALL OF THIS WAS A STROKE. HE APPEARED TO HAVE
2 HAD SORT OF A SUDDEN CHANGE BACK -- I THINK IT WAS SUNSHINE
3 TERRACE WHERE HE WAS UNDER DR. CUNNINGHAM. THERE HAD BEEN A
4 FAIRLY SUDDEN CHANGE, AND QUITE FREQUENTLY THAT CAN BE DUE
5 TO A STROKE. WE GOT AN M.R.I. ON THE 12TH. IT WASN'T A
6 VERY GOOD ONE, BUT IT WAS REPORTED TO ME BY THE NURSE AND
7 RADIOLOGIST AND IN THE REPORT IT SAYS, A LEFT OCCIPITAL
8 STROKE. AND SO I THOUGHT, WELL, WE'VE EITHER GOT A FRESH
9 STROKE HERE OR WHAT'S CALLED A SUBACUTE ONE, ONE THAT HAD
10 HAPPENED PROBABLY IN THE LAST WEEK OR TEN DAYS.
11 Q. AND CAN YOU DESCRIBE THE CONDITION OF MR. ALLDREDGE AS
12 YOU OBSERVED IT ON THE 12TH BEFORE THE M.R.I. RESULTS WERE
13 OBTAINED?
14 A. IF I COULD JUST READ MY NOTES?
15 Q. PLEASE.
16 A. REMAINS QUITE DEMENTED. COMBATIVE. MUMBLES
17 INCOHERENTLY. CRIES OUT. WILL NOT TAKE ANY MEDICATIONS.
18 VITALS STABLE AND AFEBRILE. ASSESSMENT: PSYCHOSIS NOT
19 OTHERWISE SPECIFIED. AND AT THAT POINT I INCREASED HIS
20 HALDOL.
21 Q. DID YOU RECEIVE A REPORT ON THE M.R.I.?
22 A. YES.
23 Q. AND DID YOU TAKE ANY ACTION CONCERNING IT?
24 A. WELL, ON THE 12TH HE LOOKED KIND OF DEHYDRATED. HE WAS
25 GETTING DRY. HE WASN'T TAKING ANYTHING BY MOUTH 'CAUSE WHEN
3822
1 ANYONE WOULD TRY AND GIVE HIM SOMETHING TO DRINK, HE WOULD
2 JUST BAT IT AWAY. HE WOULDN'T TAKE ANY MEDICATION HARDLY AT
3 ALL. SO I HAD THEM START I.V. HE HAD TO BE TIED DOWN FOR
4 THAT OR HE WOULD RIP IT OUT. ON THE 13TH I HAD THE
5 INFORMATION REGARDING THE STROKE AND SOME OTHER INFORMATION.
6 SHALL I READ MY NOTE?
7 Q. WHAT OTHER INFORMATION DID YOU HAVE?
8 A. WELL, I GOT THE URINALYSIS BACK AND IT SHOWED A URINARY
9 TRACT INFECTION. I GOT -- I HAD GLUCOSE LEVELS FROM
10 ACCU-CHECKS AND FROM A CHEMISTRY PANEL THAT WERE VARYING
11 FROM 40 TO 226. HE WAS REALLY DRY. HIS SODIUM WAS 148.
12 AND THEN I HAD WHAT WAS IN FRONT OF ME, A PATIENT WHO LOOKED
13 VERY SICK.
14 Q. AND WHAT DID YOU CONCLUDE AS A RESULT OF THE REPORTS YOU
15 JUST INDICATED AND YOUR ASSESSMENT AT THE TIME?
16 A. THAT I NEEDED TO TALK WITH THE FAMILY.
17 Q. AND DID YOU DO THAT?
18 A. I DID.
19 Q. AND DO YOU RECALL THE DAY THAT YOU TALKED WITH THE
20 FAMILY?
21 A. I THINK THERE MAY HAVE BEEN A PHONE CALL ON FRIDAY, BUT
22 I KNOW I MET WITH HIS WIFE SATURDAY MORNING. I THINK THERE
23 MAY HAVE BEEN A BRIEF PHONE CALL TO THEIR HOME ASKING TO
24 TALK WITH HER, BUT I KNOW SHE CAME UP TO THE UNIT 'CAUSE I
25 SAW HER THERE.
3823
1 Q. AND WHAT DATE WAS THAT?
2 A. THE 13TH.
3 Q. AND DO YOU HAVE YOUR NOTE ON THE 13TH IN FRONT OF YOU?
4 A. YES. IT'S KIND OF A LONG ONE.
5 Q. WHY DON'T YOU DO THIS, DOCTOR: WOULD YOU PLEASE READ
6 BEFORE IT SAYS ADDENDUM, THE FIRST PORTION OF YOUR NOTE ON
7 THE 13TH CONCERNING YOUR ASSESSMENT OF MR. ALLDREDGE'S
8 CONDITION?
9 A. OKAY. THIS IS BEFORE I SAW HIS WIFE. I CAME IN AND IT
10 SAYS, PATIENT REMAINS INCOHERENT, UNRESPONSIVE. CRYING.
11 NEEDS RESTRAINT. M.R.I. SHOWS LEFT OCCIPITAL INFARCT.
12 URINALYSIS IS PYURIC. THAT MEANS HE'S GOT A URINARY TRACT
13 INFECTION. GLUCOSE LEVEL IS AT 40 BY ACCU-CHECKS. THAT'S A
14 LITTLE FINGER PRICK.
15 Q. WHAT'S THE SIGNIFICANCE OF THE LEVEL 40?
16 A. THAT'S LOW. SEVENTY TO 110 IS NORMAL. FORTY IS PRETTY
17 LOW. IT GOES MUCH LOWER THAN THAT AND YOU ARE GOING TO GET
18 BRAIN DAMAGE. THAT WAS DONE AT 06:00. SO I GOT THAT AT
19 06:00. AND THEN, HE'S AFEBRILE, VITAL SIGNS STABLE. CHEM
20 SEVEN. THIS IS A CHEMISTRY PANEL AT 0610 REVEALS GLUCOSE OF
21 226. THAT'S A HUGE SWING OF HIS GLUCOSE FROM 40 TO 226. I
22 DOUBT THEY WERE ACTUALLY TEN MINUTES APART, BUT THEY WOULD
23 HAVE BEEN DONE WITHIN AT MOST 30 MINUTES OR SO, AN HOUR.
24 Q. IF YOU WOULD CONTINUE, PLEASE .
25 A. SODIUM AT 148. NORMAL SODIUM IS 135 TO 145. SO HIS
3824
1 SODIUM WAS UP. AND THAT'S SOME INDICATION OF SOME
2 DEHYDRATION. I COULD LOOK UP THE REST OF IT. B.U.N. AND
3 CREATININE WOULD TELL ME MORE. THAT'S WHAT I WROTE.
4 POTASSIUM ADEQUATE. ASSESSMENT: C.V.A., WHICH IS
5 CEREBROVASCULAR ACCIDENT, STANDS FOR STROKE. U.T.I. OR
6 URINARY TRACT INFECTION. DEHYDRATION. APPEARS TO BE QUITE
7 UNCOMFORTABLE. INSULIN DEPENDENT DIABETES MELLITUS.
8 MYCOSIS FUNGOIDES.
9 Q. WHAT'S THAT?
10 A. THAT'S THE LYMPHOMA. IT'S A T-CELL LYMPHOMA, THE
11 CANCER. PLAN: WILL ATTEMPT TO CALL WIFE. WORK OUT A PLAN
12 WITH HER, AND I SIGNED IT. THEN THERE'S AN ADDENDUM.
13 Q. NOW, BEFORE I GET TO THE ADDENDUM, YOU SAID ATTEMPT TO
14 CALL WIFE. DO YOU RECALL TRYING TO DO THAT?
15 A. VAGUELY. YOU KNOW, I THINK I CALLED HER HOUSE AND MAYBE
16 SPOKE WITH HER BRIEFLY AND ASKED HER TO COME UP.
17 Q. AND DO YOU RECALL THE DATE OF THAT CONVERSATION WHEN YOU
18 ATTEMPTED TO CALL HER?
19 A. WELL, THIS IS THE 13TH SO I KNOW I CALLED HER THAT DAY.
20 I DON'T KNOW ABOUT --
21 Q. ALL RIGHT. NOW, IF YOU READ THE ADDENDUM -- AND ONCE
22 AGAIN, PLEASE, BECAUSE I WANT TO ASK YOU TO READ A FEW OTHER
23 ENTRIES HERE, READ IT SLOWLY SO WE CAN FOLLOW ALONG.
24 A. OKAY. STILL THE 13TH. ADDENDUM. SPOKE WITH WIFE
25 EXTENSIVELY. SHE FEELS STRONGLY THAT NO EXTRAORDINARY
3825
1 MEASURES SHOULD BE TAKEN TO PROLONG ENNIS'S LIFE GIVEN
2 C.V.A. FOUND ON M.R.I. SHE REQUESTS WE DISCONTINUE I.V. AND
3 GIVE HIM COMFORT CARE. LET HIM EXPIRE NATURALLY.
4 CONTINUED.
5 Q. AND CONTINUE ON, PLEASE.
6 A. NEXT PAGE, ASSESSMENT: STROKE, ET CETERA. PLAN:
7 DISCONTINUE I.V. DECREASE INSULIN. DISCONTINUE ORAL MEDS.
8 MORPHINE SULFATE TEN MILLIGRAMS EVERY THREE HOURS
9 INTRAMUSCULARLY. ATIVAN. 0.5 MILLIGRAMS EVERY THREE HOURS
10 INTRAMUSCULARLY AS NEEDED. HALDOL AS NEEDED.
11 Q. NOW, DO YOU RECALL THE DATE WHEN YOU WROTE THAT NOTE?
12 A. THE 13TH.
13 Q. AND DO YOU RECALL THE CIRCUMSTANCES OF MEETING WITH THE
14 FAMILY ON THAT DAY?
15 A. I REMEMBER MEETING WITH THEM, YES. WE TALKED ABOUT WHAT
16 WAS GOING ON.
17 Q. OKAY. BEFORE YOU GET THERE, DO YOU RECALL WHERE THE
18 CONVERSATION TOOK PLACE?
19 A. IT WAS ON THE UNIT, BUT I'M NOT SURE NURSING STATION OR
20 IN THE ROOM. I THINK -- I'M SURE WE LOOKED IN ON HIM
21 TOGETHER, BUT THE WHOLE CONVERSATION I THINK WAS LIKE OUT IN
22 THE HALL.
23 Q. AND DO YOU RECALL WHO WAS PRESENT DURING THAT
24 CONVERSATION?
25 A. HIS WIFE FOR SURE, BUT I DON'T REMEMBER ANYONE ELSE.
3826
1 NURSES WERE IN AND OUT. A LOT OF PEOPLE AROUND.
2 Q. AND BY WIFE, JUST SO WE'RE CLEAR, WAS THAT THE WOMAN WHO
3 TESTIFIED IN THIS TRIAL?
4 A. THAT WOULD HAVE BEEN VONDA.
5 Q. VONDA. AND TELL US WHAT YOU SAID AND WHAT VONDA SAID AT
6 THAT TIME.
7 MR. WILSON: OBJECTION, YOUR HONOR, AS TO VONDA.
8 THE COURT: OVERRULED.
9 THE WITNESS: WELL, I WOULD HAVE TESTIFIED -- I
10 MEAN I WOULD HAVE TOLD HER WHAT I HAD SEEN IN HIS CONDITION.
11 I WOULD HAVE, YOU KNOW, BASICALLY EVERYTHING THAT'S HERE, I
12 WOULD HAVE TOLD HER ABOUT. AND I'M SURE I TOLD HER THAT IT
13 DIDN'T LOOK GOOD, THAT HE WAS QUITE ILL. ASKED HER WHAT SHE
14 WANTED TO DO. THERE WAS A LIVING WILL AND THERE WERE A LOT
15 OF DOCUMENTS REGARDING MR. ALLDREDGE AS TO WHAT THE FAMILY
16 WANTED. WE PROBABLY WENT OVER THAT AND SHE TOLD ME WHAT SHE
17 WANTED.
18 Q. (BY MR. STIRBA) NOW, IN TERMS OF WHAT YOU ACTUALLY
19 DID, IN YOUR NOTE IT INDICATES D. SLASH C., WHICH I GUESS
20 STANDS FOR DISCONTINUE I.V.?
21 A. YES. COUPLE OF PLACES.
22 Q. DID YOU TAKE THAT ACTION BEFORE OR AFTER YOU TALKED WITH
23 VONDA?
24 A. AFTER.
25 Q. AND WHY DID YOU DISCONTINUE THE I.V.?
3827
1 A. WELL, I'D STARTED THE I.V. BEFORE I HAD A CHANCE TO TALK
2 TO THEM BECAUSE HE WAS DEHYDRATED. ON THE 12TH I STARTED
3 THE I.V., STARTED GIVING HIM SOME FLUIDS. BUT IN REVIEWING
4 THE MEDICAL TREATMENT PLAN IT SAYS NO I.V., I THINK. I
5 GUESS ON HIM IT DIDN'T. I TALKED WITH HER AND SHE WAS
6 TELLING ME GIVE COMFORT CARE. LET HIM EXPIRE NATURALLY.
7 THIS MAN, IF YOU KEPT AN I.V. IN HIM, HE WAS GOING TO TRY
8 AND RIP IT OUT AND IT IS WHAT'S CALLED AN INVASIVE
9 TECHNIQUE. IT'S EXTRAORDINARY CARE OF SORT.
10 Q. DO YOU CONSIDER AN I.V. AN EXTRAORDINARY MEASURE?
11 A. YES.
12 Q. AND WHY IS THAT?
13 A. WELL, BASICALLY MY UNDERSTANDING OF MEASURES IS THAT
14 GIVING A FOOD OR A MEDICINE IS NOT EXTRAORDINARY, BUT WHEN
15 YOU INVADE THE BODY LIKE STICK A NEEDLE IN A VEIN OR PUT A
16 TUBE IN THROUGH THE STOMACH WALL INTO THE STOMACH, RIGHT
17 THROUGH THE ABDOMEN INTO THE STOMACH, THAT THAT'S
18 EXTRAORDINARY. THAT'S -- THOSE ARE THINGS THAT MEDICINE'S
19 COME UP WITH IN THE LAST 50 YEARS OR SO THAT ARE TECHNIQUES.
20 THEY ARE TECHNICAL THINGS THAT CAN BE DONE, BUT NOT ALWAYS
21 APPROPRIATE.
22 Q. AND THEN YOU HAVE AN ARROW DOWN WHICH INDICATES
23 DECREASED, DOES IT NOT, ON YOUR NOTE?
24 A. WHERE?
25 Q. ON THE 13TH AT THE TOP.
3828
1 A. OH, YES. DECREASE INSULIN.
2 Q. COULD YOU TELL US WHY AT THAT TIME YOU DECREASED THE
3 INSULIN?
4 A. I DON'T THINK I REALLY THOUGHT THAT THROUGH VERY WELL
5 'CAUSE, YOU KNOW, WE WERE HOLDING MEDS. I SHOULD HAVE JUST
6 DISCONTINUED THE INSULIN. BUT HE HAD DIABETES AND I'VE BEEN
7 KIND OF TRAINED TO TREAT THAT WITH INSULIN SO I DECREASED IT
8 THINKING, WELL, WE'LL DISCONTINUE IT.
9 Q. DID YOU TAKE THAT ACTION BEFORE OR AFTER TALKING WITH
10 VONDA?
11 A. AFTER.
12 Q. AND THEN YOU HAVE D. SLASH C. FOR DISCONTINUE ORAL MEDS.
13 DO YOU SEE THAT?
14 A. WE HAD BEEN TRYING TO GIVE HIM ALL SORTS OF ORAL
15 MEDICATION. SO I SAID, LET'S JUST STOP IT.
16 Q. AND WHY DID YOU DO THAT?
17 A. WELL, GIVEN THAT HE WAS DEHYDRATED AND PROBABLY HAD HAD
18 A STROKE AND WAS JUST GENERALLY VERY MEDICALLY ILL AND
19 NOTHING -- THE FAMILY IS TELLING ME THEY DON'T WANT THINGS
20 DONE. THERE IS NO POINT REALLY IN FORCING MEDICATIONS,
21 I.V.'S, ALL OF THIS STUFF. SO I DISCONTINUED THEM.
22 Q. IT GOES ON TO SAY, I GUESS, M.S. MORPHINE TEN MILLIGRAMS
23 EVERY THREE HOURS I.M. DO YOU SEE THAT?
24 A. SURE DO.
25 Q. AND DID YOU ENTER AN ORDER AT THAT TIME THAT MORPHINE BE
3829
1 ADMINISTERED EVERY THREE HOURS?
2 A. YES.
3 Q. AND DID YOU ALSO ORDER ANOTHER MEDICATION IN CONJUNCTION
4 WITH THE MORPHINE AT THAT TIME?
5 A. ATIVAN.
6 Q. TELL US, PLEASE, WHY YOU THOUGHT MORPHINE AND ATIVAN WAS
7 APPROPRIATE TO BE ADMINISTERED AT THIS TIME?
8 A. THEY WORK WELL TOGETHER. MORPHINE IS A PAIN RELIEVER
9 AND IT RELIEVES DYSPNEA. IT RELIEVES THE AGITATION AND
10 GENERAL DISCOMFORT AND FEAR, ANXIETY OF A PERSON WHO'S
11 DYING. ATIVAN IS AN ANXIETY RELIEVER PER SE. AND IT
12 DOESN'T DECREASE RESPIRATIONS SO THEY MIX WELL TOGETHER. HE
13 HAD A LOT OF AGITATION, A LOT OF ANXIETY AND I THOUGHT THESE
14 WERE APPROPRIATE.
15 Q. DID YOU ORDER THE MORPHINE AND THE ATIVAN BEFORE OR
16 AFTER TALKING WITH VONDA?
17 A. AFTER.
18 Q. NOW, I WANT TO DIRECT YOUR ATTENTION TO, THERE'S ANOTHER
19 NOTE ON THE 13TH UNDER YOUR NOTE. DO YOU SEE THAT?
20 A. UNDER PROGRESS NOTES?
21 Q. YES.
22 A. YES.
23 Q. AND CAN YOU IDENTIFY THE SIGNATURE THAT FOLLOWS THAT
24 NOTE?
25 A. IT'S TODD'S, TODD CHAMBERS.
3830
1 Q. AND IT LOOKS LIKE L.C.S.W.?
2 A. RIGHT.
3 Q. THAT STANDS FOR WHAT?
4 A. LICENSED CLINICAL SOCIAL WORKER.
5 Q. COULD YOU READ THAT NOTE IN ITS ENTIRETY WHICH FOLLOWS
6 YOUR NOTE ON THE 13TH, PLEASE?
7 A. I'M DO MY BEST.
8 Q. AND ONCE AGAIN, DO IT SLOWLY.
9 A. OKAY. MET WITH FAMILY FOR ONE AND A HALF HOURS. THEY
10 ASKED ME TO CALL THE MORTUARY IN DELTA, UTAH. I CONTACTED
11 NICHOLS MORTUARY AND THEY WILL COME WITHIN TWO AND A HALF TO
12 THREE HOURS OF BEING NOTIFIED. FAMILY VERY SUPPORTIVE OF
13 MEASURES BEING TAKEN. THEY ARE ESPECIALLY GLAD THAT THE
14 PATIENT IS CLOSE BY IN DAVIS COUNTY SO THAT THEY DON'T HAVE
15 TO TRAVEL TO LOGAN. ATTEMPTED TO NOTIFY DR. DIENHART AND AS
16 OF 1010 HOURS, HE HAS NOT ANSWERED THE PAGE. WILL TRY --
17 Q. AT HOME?
18 A. OKAY. WILL TRY AT HOME IN ORDER TO NOTIFY OF PATIENT'S
19 CONDITION AND M.R.I. RESULTS. PLEASE NOTIFY ME IF ANY
20 FURTHER PROBLEMS ARISE. TODD CHAMBERS, L.C.S.W.
21 Q. BETWEEN THIS TIME AND THE TIME OF MR. ALLDREDGE'S
22 EXPIRATION, DID YOU TALK WITH DR. DIENHART?
23 MR. WILSON: I'M GOING TO OBJECT AS TO ANYTHING
24 DR. DIENHART MAY HAVE SAID, YOUR HONOR.
25 THE COURT: WELL, THE QUESTION WAS, DID HE TALK,
3831
1 NOT WHAT WAS SAID.
2 MR. WILSON: APPRECIATE THAT.
3 THE WITNESS: I DON'T THINK I DID.
4 Q. (BY MR. STIRBA) IS THERE ANYTHING IN YOUR PROGRESS
5 NOTES TO INDICATE THAT YOU TALKED WITH DR. DIENHART?
6 A. WELL, THERE'S NO ORDERS OR ANYTHING FROM DR. DIENHART
7 WHERE HE CAME IN TO SEE THE PATIENT. AND I DON'T SEE
8 ANYTHING WHERE I WROTE ANYTHING ABOUT TALKING TO DR.
9 DIENHART, WHICH I PROBABLY WOULD HAVE AT LEAST NOTED.
10 Q. NOW, I WANT TO DIRECT YOUR ATTENTION TO A PROGRESS NOTE
11 ON 1/14 WHICH IS MED-19. DO YOU SEE THAT?
12 A. YES.
13 Q. WOULD YOU READ THAT IN ITS ENTIRETY, PLEASE?
14 A. MY NOTE?
15 Q. YES. IT'S YOUR NOTE.
16 A. OKAY. CHEYNE-STOKES RESPIRATIONS. DEEP CHEST RALES.
17 HAD BEEN QUIET MOST OF THE NIGHT BUT APPEARED AGITATED THIS
18 MORNING. WAS GIVEN EXTRA MORPHINE. SLIGHTLY FEBRILE.
19 BLOOD PRESSURE IS DOWN. ASSESSMENT: CLOSE TO DEATH. PLAN:
20 CONTINUE COMFORT CARE.
21 Q. NOW, WHEN YOU USE THE TERM COMFORT CARE IN THE CONTEXT
22 OF THAT NOTE, WHAT DID YOU MEAN?
23 A. THE CARE THE WHOLE TEAM WAS GIVING, THE COMFORT CARE
24 FROM THE NURSES, TURNING HIM, MOUTH SWABS, KEEPING CLOSE
25 WATCH ON HOW HE WAS DOING, AND MORPHINE AND ATIVAN THAT I
3832
1 WAS PRESCRIBING.
2 Q. DID YOU -- BETWEEN THE 13TH AND YOUR CONVERSATION WITH
3 VONDA AND THE TIME THAT MR. ALLDREDGE EXPIRED, DID YOU HAVE
4 OCCASION TO SEE THE FAMILY AGAIN?
5 A. I'M SURE I WOULD HAVE BECAUSE APPARENTLY, YOU KNOW,
6 WELL, THEY WERE THERE A LOT. AND ALMOST ALL THE TIME I
7 THINK THE FAMILY WAS AROUND.
8 Q. DID YOU HAVE ANY ADDITIONAL CONVERSATIONS WITH THEM AT
9 THAT TIME OR AFTER THE CONVERSATION WITH VONDA CONCERNING
10 THE CARE THAT MR. ALLDREDGE WAS RECEIVING AT THAT TIME?
11 A. WELL, I'M SURE WE WOULD HAVE SPOKEN, BUT I DON'T
12 REMEMBER ANYTHING THAT WAS SAID IN PARTICULAR.
13 THE COURT: WOULD THIS BE A GOOD TIME TO TAKE A
14 BREAK?
15 MR. STIRBA: THIS WOULD.
16 THE COURT: LADIES AND GENTLEMEN, DURING THIS
17 SECOND MORNING BREAK, REMEMBER IT'S YOUR DUTY NOT TO
18 CONVERSE AMONG YOURSELVES OR TO CONVERSE WITH OR ALLOW
19 YOURSELVES TO BE ADDRESSED BY ANY OTHER PERSON ON THE
20 SUBJECT OF THIS TRIAL. AND THAT IT'S YOUR DUTY NOT TO FORM
21 OR EXPRESS AN OPINION UNTIL YOU'VE -- THE CASE IS FINALLY
22 SUBMITTED TO YOU AFTER YOU'VE HEARD ALL THE EVIDENCE. AND
23 LET'S COME BACK AT 11:15.
24 (WHEREUPON, COURT WAS IN RECESS.)
25 THE COURT: PLEASE BE SEATED. RECORD WILL REFLECT
3833
1 THAT THE JURY IS RETURNED. MR. STIRBA, WOULD YOU LIKE TO
2 CONTINUE?
3 Q. (BY MR. STIRBA) ROBERT, IF YOU WOULD, TURN TO ELLEN
4 ANDERSON'S BINDER, PLEASE. WHAT MEDICATIONS WERE GIVEN TO
5 PATIENT ELLEN ANDERSON?
6 A. JUST ONE MEDICATION. SHE HAD TWO DOSES OF MORPHINE.
7 Q. AND DO YOU RECALL WHEN THOSE DOSES WERE ADMINISTERED TO
8 HER?
9 A. AT 7:30 IN THE EVENING ON THE 29TH AND 3:30 IN THE
10 MORNING ON THE 30TH.
11 Q. AND TELL US, PLEASE, WHY YOU THOUGHT A TEN-MILLIGRAM
12 MORPHINE DOSE WAS APPROPRIATE, WHICH WAS ADMINISTERED TO HER
13 ON THE 29TH.
14 A. SHE WAS IN SEVERE PAIN.
15 Q. AND ON WHAT DID YOU BASE THAT ASSESSMENT ON AT THE TIME?
16 A. I WAS CALLED BY THE NURSE WHO WAS HEAD NURSE AT THAT
17 TIME OR THE CHARGE NURSE ON THE UNIT WHO WAS LAURIE WILLSON,
18 OR I GUESS LAURIE WILLSON STEVENSON NOW. SHE TOLD ME THAT
19 HER ASSESSMENT WAS THAT THE PATIENT WAS IN SEVERE PAIN. AND
20 I HAD A HISTORY OF SEVERE OSTEOPOROSIS WITH SEVERAL
21 DIFFERENT KINDS OF FRACTURES AND PREVIOUS HISTORY OF OPIATE
22 USE FOR PAIN. AND WE DISCUSSED IT. AND LAURIE WILLSON WAS
23 A VERY HIGHLY TRAINED NURSE, ONE I COULD PROBABLY DEPEND ON
24 THE MOST THERE IN TERMS OF --
25 MR. WILSON: OBJECTION, YOUR HONOR. IT'S
3834
1 NONRESPONSIVE.
2 THE COURT: REPHRASE THE QUESTION.
3 Q. (BY MR. STIRBA) DID THE FACT THAT YOUR CONVERSATION
4 WITH LAURIE, NOW STEVENSON, WAS WITH HER, DID THAT HAVE
5 ANYTHING SIGNIFICANT TO YOU IN TERMS OF THE INFORMATION THAT
6 WAS IMPARTED?
7 A. YES.
8 Q. AND TELL US WHY THAT WAS SIGNIFICANT.
9 A. LAURIE GENERALLY KNEW WHAT SHE WAS DOING. AND HER
10 ASSESSMENTS OF PATIENTS WERE RIGHT ON. SHE HAD A LOT OF
11 TRAINING. SHE HAD TRAINING IN GERIATRICS AND IN PSYCHIATRY
12 AND I DEPENDED ON HER. I RESPECTED HER.
13 Q. AND DO YOU RECALL WHAT SHE TOLD YOU IN THAT
14 CONVERSATION?
15 A. THAT THE PATIENT WAS SCREAMING EVERY TIME SHE WAS
16 TOUCHED. MISS ANDERSON WAS, SHE SAID, IN SEVERE PAIN.
17 Q. NOW THE OTHER MORPHINE DOSE WAS GIVEN AT 3:30 THE
18 FOLLOWING MORNING; IS THAT RIGHT?
19 A. THAT'S RIGHT.
20 Q. AND DO YOU RECALL THE CIRCUMSTANCES OF ORDERING THAT
21 TEN-MILLIGRAM DOSE BEING ADMINISTERED AT THAT TIME?
22 A. I WAS PAGED BY NURSE SCHOLLS WHO BASICALLY TOLD ME ONCE
23 AGAIN THE PATIENT'S IN PAIN.
24 MR. WILSON: OBJECTION, YOUR HONOR. IT'S HEARSAY.
25 THE COURT: OVERRULED.
3835
1 Q. (BY MR. STIRBA) YOU HAD A CONVERSATION. TELL THE JURY
2 WHAT NURSE SCHOLLS TOLD YOU IN THAT TELEPHONE CONVERSATION.
3 A. WELL, FOR THIS CONVERSATION, YOU KNOW, I GOT WOKE UP IN
4 THE MIDDLE OF THE NIGHT, AND I WOULD LIKE TO LOOK AT THE
5 NURSE'S NOTES TO SEE WHAT SHE SAID.
6 Q. WELL, WOULD THAT REFRESH YOUR RECOLLECTION?
7 A. IT WOULD.
8 Q. PLEASE DO.
9 A. SHE WRITES, DR. WEITZEL RETURNED PAGE. INFORMED OF
10 PATIENT'S CONDITION. MORPHINE TEN MILLIGRAMS I.M. GIVEN PER
11 DOCTOR ORDER. RIGHT BEFORE THAT SHE WRITES, AT 3:15,
12 PATIENT AWAKENED, THRASHING ARMS AND ATTEMPTING TO THROW
13 BODY. PATIENT MOANING, SCREAMING.
14 SHE WOULD HAVE TOLD ME WHAT WAS GOING ON WITH THE
15 PATIENT, WHICH WAS BASICALLY WHAT HAD BEEN GOING ON AT 7:30,
16 AND THE PREVIOUS ORDER FOR TEN MILLIGRAMS APPEARED TO BE
17 HELPFUL AND I REORDERED IT.
18 Q. NOW, I WANT YOU TO LOOK AT YOUR PROGRESS NOTE --
19 A. OKAY.
20 Q. -- ON THE 30TH. DO YOU SEE THAT?
21 A. RIGHT.
22 Q. AND WOULD YOU READ THAT NOTE IN ITS ENTIRETY, PLEASE?
23 A. 12/30/95 M.D. PATIENT DIED THIS MORNING AT 8:55. SHE
24 HAD ERRATIC BREATHING AND IRREGULAR PULSE. E.K.G. ON
25 ADMISSION SHOWED SINUS TACHYCARDIA WITH ARRHYTHMIA.
3836
1 ASSESSMENT: PROBABLE MYOCARDIAL INFARCTION. RECOMMEND
2 AUTOPSY. PLAN: I WILL RELEASE TO FAMILY. ROBERT WEITZEL,
3 M.D.
4 Q. WHY DID YOU WRITE IN CHART RECOMMEND AUTOPSY?
5 A. THIS WAS UNEXPECTED. IT WAS A SUDDEN DEATH. I HAD NO
6 IDEA WHAT HAD CAUSED IT. I HAD NO SUSPICION IT WAS DUE TO
7 MORPHINE BECAUSE THE LAST MORPHINE HAD BEEN OVER FIVE HOURS
8 BEFORE. BUT I WANTED TO KNOW WHAT HAD HAPPENED. I FIGURED
9 IT WAS PROBABLY A HEART ATTACK. AT HER AGE AND THE
10 CONDITION SHE WAS IN, IT SEEMED LIKE THE BEST GUESS. AND I
11 WAS THINKING AN AUTOPSY WOULD BE HELPFUL TO TELL US EXACTLY
12 WHAT HAPPENED.
13 Q. NOW, YOU REFERENCE IN THAT NOTE AN E.K.G.; IS THAT
14 RIGHT?
15 A. RIGHT.
16 Q. DID YOU KNOW THE RESULTS OF THE E.K.G. BEFORE YOU
17 ORDERED ANY MORPHINE TO BE ADMINISTERED?
18 A. NO.
19 Q. AND WHY IS THAT?
20 A. WELL, IT WASN'T -- YOU KNOW, I WROTE ON ADMISSION.
21 THAT'S PART OF MY ADMISSION ORDERS. IT WAS ACTUALLY DONE AT
22 5:20 IN THE MORNING.
23 Q. AND SIMILARLY, THERE WAS ALSO AN INDICATION THAT A CHEST
24 X-RAY WAS DONE AS WELL?
25 A. RIGHT.
3837
1 Q. AND WERE YOU AWARE OF THE RESULTS OF THE CHEST X-RAY
2 BEFORE YOUR TWO CONTACTS WITH THE NURSES THAT YOU'VE
3 TESTIFIED TO?
4 A. NO.
5 Q. AND WHY IS THAT?
6 A. SIMILARLY, I HAD IT ORDERED IT AS PART OF THE ADMISSION
7 ORDERS, BUT IT WASN'T DONE UNTIL LATER. I'M LOOKING AT THAT
8 CHEST X-RAY AND I DON'T SEE A TIME ON IT. BUT I THINK IN
9 THE NURSES' NOTES IT STATED IT WAS DONE ABOUT THE SAME TIME
10 AS THE E.K.G.
11 Q. NOW, YOU'VE ALREADY TESTIFIED ABOUT DICTATING A REPORT,
12 THE EVALUATION. THAT WOULD HAVE BEEN ON THE 30TH; IS THAT
13 RIGHT?
14 A. YES. THE PSYCH EVAL AND THE DISCHARGE SUMMARY WERE BOTH
15 DONE THAT DAY WHEN I CAME IN.
16 Q. AND SPECIFICALLY WITH RESPECT TO THE PSYCH EVALUATION
17 THAT WAS DONE AFTER ELLEN ANDERSON HAD EXPIRED; IS THAT
18 RIGHT?
19 A. THE DICTATION WAS DONE, YEAH.
20 Q. TELL US WHY YOU WOULD HAVE DICTATED THAT REPORT ON HER
21 CONDITION EVEN THOUGH IT OCCURRED AFTER HER DEATH?
22 A. EVERY PATIENT HAS TO HAVE THAT. THAT'S PART OF MY DUTY
23 IS TO DO A PSYCHIATRIC EVALUATION, DICTATE SOMETHING ON
24 EVERY PATIENT. IT'S PART OF THE REQUIREMENTS FOR MEDICARE
25 AND EVERYTHING ELSE FOR HOSPITALIZATION THAT YOU DO THAT
3838
1 SORT OF REPORT AS A PSYCHIATRIST.
2 Q. NOW, WHAT RECOLLECTION DO YOU HAVE OF SEEING HER WHEN
3 SHE WAS ADMITTED TO THE HOSPITAL?
4 A. VERY LITTLE. IT WAS REALLY BRIEF.
5 Q. AND TELL US WHAT YOU RECALL.
6 A. I HAD TO COME UP THERE FROM MY OFFICE AND SEE HER
7 BRIEFLY TO GET HER CHECKED IN. MOST OF THIS I KNOW FROM MY
8 MENTAL STATUS EXAM THAT, YOU KNOW, SHE WAS SCREAMING. SHE
9 WAS INCOHERENT. IT WAS IMPOSSIBLE TO DO A FULL MENTAL
10 STATUS EXAM. I REMEMBER A LITTLE OLD LADY WHO WAS SCREAMING
11 AND THAT'S ABOUT IT.
12 Q. ROBERT, DO YOU BELIEVE THAT THE CARE THAT YOU PROVIDED
13 TO THESE FIVE PATIENTS WAS IN THEIR BEST INTERESTS?
14 A. YES, I DO.
15 Q. AND WOULD YOU TELL US, PLEASE, WHY YOU BELIEVE THAT?
16 A. WELL, I CERTAINLY HAVE NO REASON TO WANT TO HURT THEM.
17 I'M THERE TO HELP THEM. THAT'S WHAT I TRIED TO DO.
18 Q. AND DID YOU HAVE TO MAKE CLINICAL JUDGMENTS IN TERMS OF
19 WHAT WAS APPROPRIATE FOR THEIR CARE?
20 A. CERTAINLY. THAT'S WHAT IT'S ALL ABOUT.
21 Q. AND COULD YOU TELL US, PLEASE, OR GIVE US SOME EXAMPLES
22 OF THE KIND OF CLINICAL JUDGMENTS THAT YOU HAD TO MAKE?
23 A. DIAGNOSIS WHEN THEY FIRST CAME IN. MEDICATION
24 MANAGEMENT DECISIONS. SOME OF THE DECISIONS ON TRYING TO
25 TREAT MEDICAL PROBLEMS, ORDERING SWALLOWING EVALS AND LABS
3839
1 AND MEDICATIONS.
2 Q. DID THEIR MENTAL CONDITION AFFECT OR COMPLICATE YOUR
3 ABILITY TO MAKE JUDGMENTS IN TERMS OF CARE?
4 A. IT'S A LOT MORE COMPLICATED FOR DEMENTED PATIENTS. YOU
5 CAN'T JUST ASK THEM HOW ARE YOU FEELING OR WHAT ARE YOU
6 THINKING ABOUT. OR YOU CAN'T REALLY WATCH THE THOUGHT
7 PROCESS EXCEPT IN A VERY GROSS WAY. YOU CAN SEE THAT THEY
8 ARE BLOCKING ON EVERYTHING AND IT'S VERY LOOSE. BUT YOU
9 DON'T HAVE THOUGHT PROCESSES TO FOLLOW. SO YES, IT'S VERY
10 COMPLICATED.
11 Q. PARTICULARLY IN TERMS OF THE PAIN MEDICATION THAT WAS
12 PROVIDED AT THE END, DID THE FACT THAT THEY COULD NOT
13 COMMUNICATE EFFECTIVELY COMPLICATE THE DECISIONS YOU MADE?
14 A. COMPLETELY COMPLICATED THINGS.
15 Q. AND TELL US WHY IT DID.
16 A. I SIMPLY CAN'T ASK THEM HOW THEY WERE FEELING. I HAVE
17 TO GO BY SIGNS. PLUS THEY ARE DYING AND SO THERE ARE
18 FURTHER COMPLICATIONS. YOU CERTAINLY DON'T WANT TO GIVE TOO
19 MUCH MEDICATION. YOU DON'T WANT TO KILL SOMEBODY GIVING
20 MEDICATION YOU ARE TRYING TO HELP WITH. YOU WANT TO SUPPORT
21 THEM AND PREVENT SUFFERING, SO IT'S VERY COMPLICATED.
22 Q. WERE YOU AWARE AT THE END IN TERMS OF THE PAIN
23 MEDICATION THAT MORPHINE HAD AS A POTENTIAL SIDE EFFECT A
24 RESPIRATORY DEPRESSANT EFFECT?
25 A. THAT'S -- I'D BEEN TAUGHT THAT IS THE CENTRAL DANGEROUS
3840
1 SIDE EFFECT.
2 Q. AND DID YOU CONSIDER THAT IN TERMS OF THE MEDICATION
3 THAT YOU HAVE PROVIDED AT THE END OF EACH ONE OF THESE
4 PATIENT'S LIVES?
5 A. YES.
6 Q. AND WOULD YOU EXPLAIN HOW YOU CONSIDERED IT?
7 A. YES. I GAVE RATIONAL DOSES AND I USED MY KNOWLEDGE AND
8 WHAT I COULD LOOK UP TO GIVE DOSES THAT I FELT WOULD BE
9 APPROPRIATE WHICH WOULDN'T CAUSE RESPIRATORY DEPRESSION.
10 AND I'M AWARE THAT THE NURSES ARE THERE ALL THE TIME
11 MONITORING THE PATIENTS, AND IF SOMETHING GOES WRONG WE HAVE
12 MEDICATION CALLED NARCAN WE CAN GIVE TO REVERSE THE EFFECTS.
13 AND IT'S SOMETHING THAT'S ON MY MIND. I HAVE TO BALANCE
14 THAT WITH THE NEED TO PREVENT SUFFERING AND PAIN.
15 Q. DID YOU HAVE A PLAN FOR THESE PATIENTS DURING AND AFTER
16 THE TIME YOU DETERMINED THAT THEY WERE DYING?
17 A. YES.
18 Q. AND TELL US WHAT THAT WAS.
19 A. THE PLAN WAS THAT THEY HAVE A PAIN-FREE DIGNIFIED DEATH.
20 Q. AND DID YOU FEEL THAT YOU HAD SOME ETHICAL DUTY TO
21 PROVIDE ADEQUATE RELIEF FROM PAIN AT THE TIME OF THEIR
22 DEATH?
23 A. ABSOLUTELY, YES. I MEAN, I'M ETHICALLY BOUND BY
24 EVERYTHING I'VE EVER LEARNED AND BEEN TAUGHT. IT'S MY DUTY.
25 MR. STIRBA: THANK YOU. THAT'S ALL THE QUESTIONS I
3841
1 HAVE AT THIS TIME, JUDGE.
2 THE COURT: MR. WILSON.
3 MR. WILSON: YOUR HONOR, IF IT PLEASE THE COURT.
4 WOULD THERE BE A POSSIBILITY THAT WE COULD GO TO LUNCH SO I
5 COULD BEGIN MY CROSS-EXAMINATION WITHOUT INTERRUPTION?
6 THE COURT: WHAT DO YOU MEAN WITHOUT INTERRUPTION?
7 DO YOU MEAN WITHOUT INTERRUPTION DOING PART OF IT NOW AND
8 PART OF IT LATER?
9 MR. WILSON: YES.
10 THE COURT: ANY OBJECTION TO THAT?
11 MR. STIRBA: I'M NOT GOING TO OBJECT TO THAT,
12 JUDGE. WE'RE HERE, THOUGH, AND --
13 THE COURT: OKAY. OKAY. LADIES AND GENTLEMEN,
14 HERE'S WHAT WE'LL DO. LET'S COME BACK -- LET'S DO THIS.
15 WE'LL TAKE OUR BREAK NOW AND THEN WE'LL -- LET'S COME BACK
16 AT ONE P.M. INSTEAD OF FROM 12 TO 1:30, WE'LL COME BACK
17 AT -- IS THAT RIGHT, AT ONE O'CLOCK. DURING THIS TIME
18 REMEMBER IT'S YOUR DUTY NOT TO CONVERSE AMONG YOURSELVES OR
19 TO CONVERSE WITH OR ALLOW YOURSELVES TO BE ADDRESSED BY ANY
20 OTHER PERSON ON THE SUBJECT OF THE TRIAL. IT'S YOUR DUTY
21 NOT TO FORM OR EXPRESS AN OPINION UNTIL THE CASE IS FINALLY
22 SUBMITTED TO YOU. ALSO DURING THIS TIME REMEMBER NOT TO
23 LISTEN TO ANY RADIO OR TELEVISION BROADCASTS, ALSO ANY
24 NEWSPAPER OR MAGAZINE REPORTS. SO IF YOU'LL PLEASE COME
25 BACK THEN AT ONE P.M.
3842
1 (WHEREUPON, THE JURY LEAVES THE COURTROOM AT 11:30)
2 THE COURT: YOU CAN BE SEATED AND THE RECORD WILL
3 REFLECT THAT THE JURY HAS LEFT THE COURTROOM. DO YOU
4 ANTICIPATE, MR. WILSON, HOW LONG DO YOU THINK YOU'LL BE ON
5 CROSS-EXAMINATION?
6 MR. WILSON: IT'S SORT OF HARD TO TELL RIGHT NOW,
7 YOUR HONOR. I WOULD IMAGINE A COUPLE OF HOURS.
8 THE COURT: DO WE THINK WE'LL GET DONE TODAY WITH
9 THIS WITNESS?
10 MR. WILSON: I THINK SO.
11 THE COURT: AND THEN ARE THERE GOING TO BE ANY
12 OTHER WITNESSES?
13 MR. STIRBA: ONE SHORT SUMMARY WITNESS, YOUR HONOR,
14 AND THAT'S IT.
15 THE COURT: THAT WILL BE ALL ON THE DEFENSE.
16 MR. STIRBA: YES.
17 THE COURT: AND SO IS IT YOUR FEELING, MR. WILSON,
18 THAT JUST END WITH THEIR WITNESSES TODAY AND START REBUTTAL
19 TOMORROW?
20 MR. WILSON: WE WOULD PREFER THAT, YOUR HONOR.
21 THE COURT: THAT'S WHAT OUR PLAN WILL BE.
22 HOPEFULLY WE'LL GET THIS WITNESS AND THE NEXT ONE DONE.
23 WE'LL SEE YOU BACK AT ONE O'CLOCK.
24 (COURT IN RECESS.)
25
3843
1 (WHEREUPON THE AFTERNOON SESSION BEGAN.)
2 THE COURT: WILL YOU PLEASE BE SEATED? THE RECORD
3 WILL REFLECT THAT THE PARTIES ARE PRESENT, THE DEFENDANT IS
4 ON THE STAND, AND THE JURY HAS RETURNED. MR. WILSON.
5 MR. WILSON: THANK YOU, YOUR HONOR.
6 CROSS-EXAMINATION
7 BY MR. WILSON:
8 Q. GOOD AFTERNOON, DOCTOR.
9 A. GOOD AFTERNOON.
10 Q. I JUST WANTED TO FOLLOW UP WITH A FEW QUESTIONS ABOUT
11 YOUR TESTIMONY AT THE CONCLUSION OF DIRECT. YOU WERE
12 TALKING ABOUT THAT IN RESPECT TO THIS TYPE OF PATIENT,
13 CLINICAL JUDGMENTS ARE DIFFICULT TO MAKE. WOULD THAT BE A
14 FAIR STATEMENT?
15 A. YES, SIR.
16 Q. AND IN THAT PROCESS OF MAKING THOSE JUDGMENTS, YOU
17 INDICATED MANY TIMES IN YOUR TESTIMONY THAT BECAUSE OF THE
18 DIFFICULTY IN EVALUATION, YOU'RE REQUIRED TO RELY ON OTHER
19 HISTORIES, DOCUMENTS, NURSES' NOTES, YOU'RE REQUIRED TO
20 OFTTIMES TO TALK WITH OTHER TREATING PHYSICIANS, IS THAT
21 CORRECT?
22 A. IT'S VERY HELPFUL. NOT REQUIRED, BUT CERTAINLY HELPFUL.
23 Q. OKAY. SO THAT WOULD BE HELPFUL IN THIS PARTICULAR
24 CONTEXT.
25 A. YES, SIR.
3844
1 Q. AND IT'S MAINLY BECAUSE WHAT WE'RE TALKING ABOUT IS A
2 PATIENT WHO DOES NOT HAVE THE ABILITY TO ASSIST YOU VERY
3 MUCH IN TERMS OF BEING ABLE TO MAKE YOUR JUDGMENTS RELATIVE
4 TO PAIN OR RELATIVE TO ANY TYPE OF COMPLAINT THAT THEY MAY
5 HAVE, IS THAT ACCURATE?
6 A. THEY HAVE A REAL HARD TIME, SURE.
7 Q. OKAY. SO WOULD IT BE A FAIR STATEMENT TO SAY THAT IN
8 THAT CONTEXT, A PHYSICIAN WHO HAS A PATIENT OF THAT DEGREE
9 OF DEHABILITATION (SIC) OR ONE WHO IS NOT MENTALLY COMPETENT
10 TO RESPOND TO YOU APPROPRIATELY, WOULD IT BE FAIR TO SAY IN
11 THAT CONTEXT THAT A PHYSICIAN SHOULD ERR ON THE SIDE OF
12 CAUTION?
13 A. YES, SIR, IT WOULD.
14 Q. OKAY. AND SO IN DOING THAT, I ASSUME THAT A PHYSICIAN
15 WOULD NEED THEN TO -- TO EXERCISE THAT CAUTION IN -- IN NOT
16 ONLY THE ADMINISTRATION OF MEDICATIONS, BUT ALSO IN TERMS OF
17 GATHERING TOGETHER INFORMATION THAT MIGHT MAKE HIM OR ASSIST
18 HIM IN MAKING A MORE APPROPRIATE DECISION AS TO THE CARE AND
19 TREATMENT OF THAT PATIENT. IS THAT TRUE?
20 A. I BELIEVE YOU'RE RIGHT.
21 Q. OKAY. FEW OTHER QUESTIONS IN THAT LINE. AS A
22 PHYSICIAN, YOU TAKE AN OATH, IS THAT RIGHT?
23 A. YES, SIR.
24 Q. AND I DON'T KNOW THE WORDS OF THAT OATH, BUT I ASSUME
25 THAT THE WORDS PERTAINING TO ESSENTIALLY YOU HAVE A TRUST
3845
1 THAT DEVELOPS BETWEEN YOU AND A PATIENT, IS THAT CORRECT?
2 A. YES, SIR.
3 Q. AND IN THIS CONTEXT THAT WE'VE BEEN TALKING ABOUT, THAT
4 TRUST EXPANDS EVEN FURTHER, DOES IT NOT, WHERE YOU'VE GOT A
5 PATIENT WHO REALLY CAN'T COMMUNICATE WITH YOU, THERE NEEDS
6 TO BE A TRUST BETWEEN THE PATIENT OR BETWEEN THE FAMILY
7 MEMBERS AND THE PHYSICIAN, IS THAT CORRECT?
8 A. I WOULD HOPE THERE WOULD BE, YES, SIR.
9 Q. AND THE PHYSICIAN IS REALLY IN A SITUATION WHERE THERE
10 IS NO ABILITY FOR EITHER THE PATIENT OR THE FAMILY MEMBER TO
11 REALLY EVALUATE OR SECOND-GUESS THE CARE OF THE TREATING
12 PHYSICIAN. WOULD THAT BE A FAIR STATEMENT?
13 A. I WOULD AGREE WITH THAT WITH RESPECT TO THE PATIENT IN
14 THESE CASES. I CAN'T AGREE WITH THAT WITH RESPECT TO THE
15 FAMILY MEMBER.
16 Q. OKAY. NOW, OBVIOUSLY, A FAMILY MEMBER, UNLESS THEY WERE
17 A PHYSICIAN THEMSELVES, WOULDN'T HAVE THE KNOWLEDGE THAT YOU
18 HAVE, IS THAT CORRECT?
19 A. THEY WOULDN'T HAVE ALL THE MEDICAL KNOWLEDGE I WOULD
20 HAVE, THAT WOULD BE CORRECT.
21 Q. OKAY. THEY WOULDN'T BE ABLE TO EVALUATE THE TESTS OR TO
22 LOOK AT THE CHARTS AND DETERMINE WHAT MAY BE PHYSICALLY
23 WRONG WITH THEIR -- WITH THEIR PARTICULAR LOVED ONE, WOULD
24 THEY?
25 A. THEY WOULD HAVE TO DEPEND ON ME TO MAKE THAT JUDGMENT.
3846
1 Q. OKAY. AND THEY WOULD HAVE TO DEPEND ON YOU IN RESPECT
2 TO SIMILAR SITUATIONS SUCH AS IF YOU WERE TO SIT DOWN AND
3 ADVISE THEM THAT THE PATIENT WAS SUFFERING FROM A CERTAIN
4 TYPE OF DISEASE PROCESS, WHAT THE ALTERNATIVES ARE AVAILABLE
5 FOR TREATMENT OF THAT, WOULDN'T THEY?
6 A. YES, SIR.
7 Q. NOW, THEY COULD ALWAYS SEEK A SECOND OPINION, IS THAT
8 CORRECT?
9 A. CERTAINLY.
10 Q. IF THEY -- IF THEY WANTED TO, TO GET ANOTHER DOCTOR TO
11 CONFIRM WHAT YOU HAD TOLD THEM, IS THAT CORRECT?
12 A. YES, SIR.
13 Q. OKAY. SO IN THAT CONTEXT, DOCTOR, DO YOU BELIEVE THAT
14 IN GENERAL, A FAMILY MEMBER WHO FINDS THEMSELF IN A
15 PARTICULAR CIRCUMSTANCE AS THIS ONE, THAT NORMALLY THEY'RE
16 GOING TO RELY AND THEY'RE GOING TO TRUST IN YOUR MEDICAL
17 JUDGMENT, ARE THEY NOT?
18 A. COULD YOU BE A LITTLE MORE SPECIFIC?
19 Q. WELL, OKAY. I'LL TRY TO BE MORE SPECIFIC. LET'S GO FOR
20 AN EXAMPLE, LET'S SAY YOU SIT DOWN WITH A FAMILY AS YOU HAVE
21 ON A NUMBER OF OCCASIONS IN THIS PARTICULAR PROCEEDING THAT
22 YOU'VE TESTIFIED TO. AND YOU SAY TO THEM, I'M SORRY, BUT
23 YOUR MOTHER'S DYING. NOW, ARE THEY GOING TO MISTRUST YOUR
24 JUDGMENT AT THAT POINT? ARE THEY GONNA TRUST YOUR JUDGMENT
25 AT THAT POINT?
3847
1 A. I THINK THEY'RE GONNA TEND TO TRUST IT.
2 Q. OKAY. AND THAT'S BECAUSE YOU'RE THE DOCTOR, RIGHT?
3 A. RIGHT.
4 Q. YOU'RE THE MAN WHO'S IN CHARGE.
5 A. CORRECT.
6 Q. AND THEY'RE GONNA VALUE THAT DECISION. SO IN THIS
7 CONTEXT, IS IT HARD TO UNDERSTAND WHY A FAMILY MEMBER WOULD
8 SAY TO YOU, I WANT TO GIVE MY MOTHER COMFORT CARE, I WANT
9 HER TO BE MADE COMFORTABLE?
10 A. NO, I DON'T THINK IT IS.
11 Q. IN FACT, THAT'S THE ANSWER YOU WOULD EXPECT, ISN'T IT?
12 A. NOT NECESSARILY.
13 Q. DID YOU GET ANY OTHER ANSWER THAN THAT IN THIS
14 PARTICULAR PROCEEDING WITH THESE FOUR -- AT LEAST FOUR OF
15 THESE PATIENTS?
16 A. I DIDN'T.
17 Q. OKAY. AGAIN, THE FAMILY HAS NO WAY TO EVALUATE FROM A
18 MEDICAL STANDPOINT WHETHER OR NOT YOU'RE TELLING THEM THE
19 TRUTH OR NOT, DO THEY?
20 A. WELL, IN THESE CASES, THEY DID HAVE OTHER SOURCES OF
21 INFORMATION, SO I'D HAVE TO DISAGREE WITH YOU THERE.
22 Q. WHAT OTHER SOURCES OF INFORMATION DID THEY HAVE?
23 A. THE OTHER DOCTORS. EACH OF THESE PATIENTS HAD A
24 CONSULTING MEDICAL DOCTOR, EITHER INTERNIST OR FAMILY
25 PRACTITIONER. THEY COULD TALK WITH THE OTHER NURSES. ALL
3848
1 THE NURSES ON STAFF. THE SOCIAL WORKERS WERE PRIVY TO THE
2 INFORMATION.
3 Q. OKAY.
4 A. BASICALLY, THE WHOLE TEAM KNEW WHAT WAS GOING ON, SO
5 THEY COULD HAVE TALKED WITH ANYBODY. I WAS THE MEDICAL
6 DOCTOR IN CHARGE, THE ATTENDING, AND SO IT WOULD HAVE BEEN
7 NATURAL FOR THEM TO SPEAK WITH ME ALSO.
8 Q. OKAY. BUT WOULD THEY HAVE ANY REASON TO GO TO ANY OF
9 THE OTHER DOCTORS? OR THE CARETAKERS?
10 A. WELL, I GUESS YOU'D HAVE TO ASK THEM THAT, BUT --
11 Q. OKAY. AS I UNDERSTAND IT, YOU GRADUATED FROM -- IN
12 NOVEMBER -- EXCUSE ME, YOU GRADUATED BACK IN 1986 FROM
13 MEDICAL SCHOOL.
14 A. RIGHT.
15 Q. HOW MANY YEARS WERE YOU IN MEDICAL SCHOOL?
16 A. FOUR.
17 Q. AND WHERE DID YOU GO TO MEDICAL SCHOOL AGAIN?
18 A. AT SOUTHWESTERN MEDICAL SCHOOL IN DALLAS, TEXAS.
19 Q. AND AFTER GRADUATING FROM MEDICAL SCHOOL, YOU WENT ON TO
20 INTERNSHIP IN PSYCHIATRY?
21 A. RESIDENCY --
22 Q. RESIDENCY.
23 A. -- WHICH INCLUDES INTERNSHIP AS THE FIRST YEAR.
24 Q. AND HOW LONG WERE YOU IN RESIDENCY FOR?
25 A. TOTAL OF FOUR YEARS.
3849
1 Q. AND WHERE WAS THAT AT?
2 A. TWO YEARS AT DALLAS, TEXAS THROUGH TIMBERLAWN HOSPITAL
3 AND BAYLOR HOSPITAL, AND TWO YEARS AT THE UNIVERSITY OF
4 CALIFORNIA, SAN DIEGO, IN SAN DIEGO.
5 Q. OKAY. ARE YOU BOARD CERTIFIED IN PSYCHIATRY?
6 A. YES.
7 Q. WHEN DID YOU RECEIVE YOUR BOARD CERTIFICATION?
8 A. MAY OF 1994.
9 Q. PRIOR TO -- OR SUBSEQUENT TO GETTING YOUR BOARD
10 CERTIFICATION, WHERE DID YOU WORK, SIR?
11 MR. STIRBA: YOUR HONOR, I'M GONNA OBJECT AS BEYOND
12 THE SCOPE AND ALSO AS TO RELEVANCY.
13 MR. WILSON: I THINK, YOUR HONOR, THAT I OUGHTA BE
14 ABLE TO EXPLORE HIS EXPERIENCE --
15 THE COURT: OVERRULED.
16 MR. WILSON: -- AS IT RELATES TO GERIATRIC PATIENTS
17 AND --
18 THE COURT: I SAID OVERRULED.
19 MR. WILSON: OH, EXCUSE ME. I DIDN'T HEAR YOU,
20 JUDGE.
21 THE WITNESS: MR. WILSON, COULD YOU ASK THAT AGAIN?
22 I KIND OF GOT LOST.
23 Q. (BY MR. WILSON) WHERE DID YOU GO TO WORK AFTER
24 GRADUATING -- OR EXCUSE ME, AFTER BECOMING BOARD CERTIFIED?
25 A. WELL, I WAS WORKING AT THE TIME IN WEST VALLEY CITY AT
3850
1 THE HOSPITAL THERE AND IN MY PRIVATE OFFICE THERE.
2 Q. OKAY. SO YOU MAINTAINED A PRIVATE OFFICE IN WEST
3 VALLEY?
4 A. RIGHT.
5 Q. OKAY. DID YOU HAVE ANY OTHER CONTRACTS WITH ANY OTHER
6 HOSPITALS OR CLINICS AT THAT TIME?
7 A. THAT WOULD HAVE BEEN MAY '94? I BELIEVE I WAS WITH
8 VALLEY MENTAL HEALTH ALSO IN OUTPATIENT CLINICAL PRACTICE.
9 Q. OKAY. AND YOU -- WELL, BEFORE I GET TO THERE, DID A
10 SUBSTANTIAL PART OF YOUR MEDICAL DEGREE STUDIES OR WAS THERE
11 A SIGNIFICANT PART OF YOU MEDICAL DEGREE STUDIES THAT
12 CONCERNED THE PHARMACOLOGY, DRUGS?
13 A. MEDICAL DEGREE?
14 Q. UH-HUH.
15 A. YES.
16 Q. OKAY. SO YOU LEARNED ABOUT THOSE EFFECTS AND THE --
17 BOTH THE EFFECTS OF THE DRUGS AND THE RISKS OF THE DRUGS AT
18 THAT TIME?
19 A. IN MEDICAL SCHOOL, YES --
20 Q. OKAY.
21 A. -- AND IN RESIDENCY ALSO.
22 Q. AND THEN WHEN YOU WENT ON TO YOUR PSYCHIATRIC TRAINING,
23 DID A SUBSTANTIAL PART OF THAT RELATE TO THE ADMINISTRATION
24 OF ESPECIALLY CERTAIN PSYCHOTROPIC MEDICATIONS?
25 A. YES, SIR.
3851
1 Q. AND ALSO AS TO THEIR SIDE EFFECTS THAT COULD BE
2 DEMONSTRATED AS FAR AS THAT GOES.
3 A. YES, SIR.
4 Q. OKAY. AND AS I -- AS YOU'VE TESTIFIED, I THINK YOU
5 INDICATED THAT IN THE SETTING AT THE GEROPSYCH UNIT AT THE
6 DAVIS HOSPITAL, YOU WERE PRIMARILY THERE FOR A BIOLOGICAL
7 PSYCHIATRY?
8 A. MEDICATION MANAGEMENT.
9 Q. OKAY. SO YOU DIDN'T ENGAGE IN THE THERAPEUTIC ASPECTS
10 OF PSYCHIATRY IN THE HOSPITAL SETTING?
11 A. WELL, AS PART OF SEEING PATIENTS, THAT'S
12 PSYCHOTHERAPEUTICALLY BASED, BUT I DID NOT ENGAGE IN
13 PSYCHOTHERAPY PER SE. GROUP THERAPY, FAMILY THERAPY, AND
14 ALMOST ALL INDIVIDUAL THERAPY WAS DONE THROUGH THE FAMILY
15 THERAPIST SOCIAL WORKERS.
16 Q. DID YOU OVERSEE THAT ASPECT OF IT?
17 A. YES, SIR.
18 Q. BUT YOU DID NOT PARTICIPATE IN IT ON A DAY-TO-DAY BASIS.
19 A. NO, SIR.
20 Q. YOUR PRIMARY FUNCTION WAS THEN TO OVERSEE THE
21 MEDICATIONS THAT WERE BEING ADMINISTERED TO THESE PATIENTS?
22 A. AND OVERSEE THE THERAPISTS AND THE NURSING, SORT OF PULL
23 TOGETHER THE ENTIRE MEDICAL HISTORY AND CONDITION OF THE
24 PATIENT AND GO FROM THERE.
25 Q. OKAY. BACK IN I THINK YOU SAID NOVEMBER OF 1994 IS WHEN
3852
1 YOU FIRST BECAME AFFILIATED WITH THE DAVIS HOSPITAL?
2 A. YES, SIR.
3 Q. DID YOU ENTER INTO A CONTRACT AT THAT TIME WITH HORIZONS
4 CORPORATION?
5 A. YES, SIR, I BELIEVE I DID.
6 Q. AND CAN YOU TELL ME, SIR, IN RESPECT TO THAT CONTRACT,
7 IT'S TRUE THAT -- WELL, ACTUALLY, THAT CONTRACT, WAS THAT
8 MADE IN MARCH OF 1995?
9 A. I KNOW THERE WAS ONE MADE IN MARCH OF 1995 WHEN I WAS
10 MADE ASSOCIATE MEDICAL DIRECTOR.
11 Q. OKAY.
12 A. I'M FAIRLY CERTAIN THAT THERE WAS ONE MADE IN NOVEMBER
13 OF '94 WHEN I FIRST BECAME AFFILIATED WITH THE UNIT, SORT OF
14 AS A HELPER FOR DR. JENSEN.
15 Q. SO FIRST OF ALL, YOU CAME ON IN ASSISTANT CAPACITY TO
16 DR. WELBY JENSEN, IS THAT RIGHT?
17 A. PART TIME I GUESS YOU COULD SAY.
18 Q. PART TIME. NOW, YOU WERE STILL MAINTAINING YOUR
19 PRACTICE, YOUR PRIVATE PRACTICE?
20 A. YES, SIR.
21 Q. AND YOU WERE STILL MAINTAINING YOUR PRACTICE WITH VALLEY
22 MENTAL HEALTH?
23 A. I'M NOT REAL CLEAR ON DETAILS OF THAT RIGHT NOW. I
24 THINK IN NOVEMBER I WAS -- YES, I BELIEVE I WAS STILL WITH
25 VALLEY MENTAL HEALTH.
3853
1 Q. OKAY. DID YOU -- AND YOU SUBSEQUENTLY EXPANDED ON THAT
2 PARTICULAR JOB WITH THE DAVIS HOSPITAL, IS THAT RIGHT?
3 A. YES, SIR.
4 Q. AND FACT, IT WAS AT THIS TIME THAT AS DR. WELBY JENSEN
5 TESTIFIED TO, YOU WERE ANXIOUS TO PICK UP MORE CLIENTELE AND
6 HE WAS WILLING TO GIVE UP THE CLIENTELE, ISN'T THAT CORRECT?
7 A. WELL, I WOULD SAY HE WAS ANXIOUS TO GIVE THEM UP AND I
8 WAS WILLING TO TAKE THEM.
9 Q. OKAY. WHAT TYPE OF PAYMENT ARRANGEMENTS WERE MADE AT
10 THAT TIME WITH YOU AND THE HOSPITAL?
11 A. THERE WERE NONE BETWEEN ME AND THE HOSPITAL.
12 Q. OKAY. BETWEEN YOU AND HORIZONS?
13 A. I DON'T REMEMBER THE DETAILS OF THE INITIAL CONTRACT.
14 BUT I WAS HIRED AS ASSISTANT MEDICAL DIRECTOR WITH DUTIES TO
15 CONSIST OF 16 HOURS A MONTH FOR ADMINISTRATIVE TYPE DUTIES
16 FOR HORIZON.
17 Q. SO WHEN YOU WERE HIRED AS ASSISTANT MEDICAL DIRECTOR IN
18 MARCH OF 1995, DID THOSE PAYMENTS ARRANGEMENTS CHANGE AT
19 THAT TIME?
20 A. WELL, SEE, I DON'T REMEMBER THE CONTRACT. IT WAS DONE
21 IN NOVEMBER OF '94, SO I CAN'T REALLY SAY, BUT I DO KNOW
22 THAT WHEN I WAS MADE ASSOCIATE MEDICAL DIRECTOR, THERE WAS A
23 CONTRACT IN WHICH I WAS HIRED AS ASSOCIATE MEDICAL DIRECTOR
24 AND PAID FOR 16 HOURS A MONTH ADMINISTRATIVE TIME.
25 Q. MAY I HAVE THIS MARKED? AT THAT TIME YOU ENTERED INTO A
3854
1 WRITTEN CONTRACT, IS THAT CORRECT?
2 A. WHICH TIME?
3 Q. IN MARCH.
4 A. YES, SIR.
5 Q. AT THAT TIME YOU BECAME AN ASSOCIATE MEDICAL DIRECTOR?
6 A. ASSOCIATE OR ASSISTANT, ONE.
7 Q. OKAY.
8 A. THINK IT WAS ASSOCIATE.
9 Q. AS I UNDERSTAND IT, DOCTOR, YOU WERE PAID A CERTAIN FEE
10 UPON ADMISSION OF A PATIENT AND YOU WERE ALSO ALLOWED TO
11 BILL INDEPENDENTLY FOR SERVICES RENDERED TO THAT PATIENT, IS
12 THAT RIGHT?
13 A. YES, SIR.
14 Q. OKAY. I SHOW YOU WHAT'S BEEN MARKED AS STATE'S EXHIBIT
15 44. ASK YOU TO TAKE A LOOK THAT THE EXHIBIT IF YOU WOULD
16 PLEASE.
17 A. ANY PARTICULAR PLACE?
18 Q. THERE'S A PAGE -- WELL, FIRST OF ALL, WHAT DATE -- WHAT
19 IS THAT DOCUMENT?
20 A. IT'S TITLED ASSOCIATE MEDICAL DIRECTOR SERVICES
21 AGREEMENT.
22 Q. AND WHAT DATE DOES IT BEAR?
23 A. IT'S AN AGREEMENT MADE THIS 22ND DAY OF MARCH 1995,
24 SHALL COMMENCE APRIL 3RD, 1995.
25 Q. WOULD YOU TAKE A LOOK AT THE LAST PAGE WHICH IS
3855
1 DESIGNATED AS PAGE 9?
2 A. PAGE 9.
3 Q. DOES THAT BEAR YOUR SIGNATURE?
4 A. YES, IT DOES.
5 Q. OKAY. DO YOU RECALL SIGNING THAT DOCUMENT?
6 A. NOT INDEPENDENTLY, BUT IT'S MY SIGNATURE.
7 Q. OKAY. NOW, I WANT YOU TO TURN TO PAGE -- IT'S PAGE 3,
8 IF YOU WILL. IT'S MARKED THERE AND THERE IS A PARAGRAPH
9 4 --
10 THE COURT: ARE YOU GOING TO OFFER THIS?
11 MR. WILSON: I AM.
12 THE COURT: OKAY. IS THERE ANY OBJECTION?
13 MR. STIRBA: RELEVANCY, YOUR HONOR.
14 MR. WILSON: I THINK IT GOES TO THE KNOWLEDGE AND
15 INTENT, YOUR HONOR. THERE'S CERTAIN PARAGRAPHS IN THERE
16 THAT REFLECT I THINK ON THE STATE'S CASE.
17 THE COURT: IT'S RECEIVED.
18 MR. WILSON: THANK YOU.
19 Q. THAT PHOTOGRAPH TALKS ABOUT DUTIES AND ADMINISTRATIVE
20 RELATIONSHIPS, DOES IT NOT?
21 A. IT SAYS NUMBER 4, DUTIES AND ADMINISTRATIVE
22 RELATIONSHIPS.
23 Q. OKAY. I WANT YOU TO READ DOWN UNDER GENERAL, WHAT YOUR
24 DUTIES ARE.
25 A. UNDER SUBSECTION A.?
3856
1 Q. YES.
2 A. GENERAL, PHYSICIAN SHALL BE UNDER THE DIRECTION OF THE
3 HORIZONS REGIONAL VICE-PRESIDENT WITH RESPECT TO
4 ADMINISTRATIVE MATTERS AND SHALL BE RESPONSIBLE TO HORIZON
5 FOR ABIDING BY THE ADMINISTRATIVE REGULATIONS OF THE
6 HOSPITAL. IN ADDITION, PHYSICIAN SHALL BE RESPONSIBLE TO
7 HORIZON ASSISTING IN THE DEVELOPMENT OF ADMINISTRATION -- OR
8 I'M SORRY, ADMINISTRATIVE REGULATIONS AS THEY PERTAIN TO HIS
9 RESPONSIBILITIES HEREUNDER, AND FOR COOPERATING WITH THE
10 PROGRAM DIRECTOR OF THE UNIT IN THE EFFECTIVE MANAGEMENT OF
11 THE UNIT. ALSO, PHYSICIAN AGREES TO COMPLY WITH THE
12 POLICIES, RULES, AND REGULATIONS OF BOTH THE HOSPITAL AND
13 THE UNIT.
14 IS THAT ENOUGH?
15 Q. THAT'S IT. YOU APPLIED FOR PRIVILEGES AT THE HOSPITAL
16 AROUND THAT TIME, DID YOU NOT?
17 A. WOULD HAVE HAD TO APPLY BACK IN NOVEMBER WHEN I STARTED
18 WORKING THERE, AND THIS WAS IN MARCH, SIX MONTHS LATER.
19 Q. OKAY. CAN YOU TELL US, DOCTOR, WHAT DOES IT MEAN TO BE
20 GRANTED PRIVILEGES AT THE HOSPITAL?
21 A. THAT MEANS THAT THE HOSPITAL IS ALLOWING YOU TO PRACTICE
22 THERE.
23 Q. AS I UNDERSTAND IT, THE APPLICATION PROCESS IS IN TWO
24 PARTS, IS THAT CORRECT?
25 A. I DON'T KNOW.
3857
1 Q. LET ME SHOW YOU WHAT'S BEEN MARKED AS STATE'S EXHIBIT
2 45, AND ASK YOU TO IDENTIFY THAT.
3 A. HUMANA HOSPITAL DAVIS NORTH DEPARTMENT OF MEDICINE,
4 APPLICATION FOR CLINICAL PRIVILEGES.
5 Q. OKAY. DO YOU RECOGNIZE THAT DOCUMENT?
6 A. WELL, HAVE TO LOOK AT IT. KIND OF A LONG ONE, BUT I
7 RECOGNIZE IT.
8 Q. HAVE YOU SEEN IT BEFORE, SIR?
9 A. YES, I'VE SIGNED IT.
10 Q. OKAY. IN FACT, IT'S IN TWO PARTS, IS IT NOT? THE FIRST
11 IS THE APPLICATION FOR CLINICAL PRIVILEGES, AND HALFWAY
12 THROUGH THERE'S AN APPLICATION FOR MEDICAL STAFF APPOINTMENT
13 AND CLINICAL PRIVILEGES?
14 A. YES.
15 Q. OKAY.
16 A. YOU'VE GOT THEM STAPLED TOGETHER.
17 MR. WILSON: WE'D OFFER THIS IN ALSO, YOUR HONOR,
18 AT THIS TIME.
19 MR. STIRBA: MAY I SEE THE DOCUMENT PLEASE?
20 MR. WILSON: OH, I'M SORRY, COUNSEL.
21 THE COURT: IS THERE ANY OBJECTION?
22 MR. STIRBA: YOUR HONOR, THERE IS. IT'S A
23 RELEVANCY OBJECTION. BEYOND THE SCOPE. AND ALSO BEFORE
24 THIS IS USED EXTENSIVELY, IS THIS SOMETHING I COULD HAVE A
25 CHANCE TO REVIEW FURTHER? I MEAN, I'VE NEVER SEEN IT
3858
1 BEFORE.
2 THE COURT: OKAY. WHY DON'T WE -- CAN YOU GO ON TO
3 SOMETHING ELSE AND THEN WE CAN ADDRESS THAT AT THE BREAK?
4 MR. WILSON: I THINK, YOUR HONOR, IN RESPECT TO
5 THIS LINE OF QUESTIONING, IT'S IMPORTANT -- AND THERE'S
6 ANOTHER DOCUMENT PERHAPS I CAN GIVE TO COUNSEL, PREVIOUSLY
7 PROVIDED, THAT I THINK IS ON POINT AT THIS TIME. BUT I
8 THINK IT PERTAINS TO --
9 THE COURT: WELL, WHAT IS THE OTHER -- WHY DON'T
10 YOU HAVE HIM IDENTIFY IT AND THEN SHOW IT TO OPPOSING
11 COUNSEL.
12 MR. WILSON: COUNSEL'S ALREADY SEEN THIS PARTICULAR
13 EXHIBIT. OUCH. AND I DON'T KNOW WHETHER THE COURT WANTS TO
14 TAKE A SHORT RECESS WHILE WE --
15 THE COURT: WELL, WHY DON'T YOU HAVE THE WITNESS
16 IDENTIFY IT AND THEN --
17 MR. WILSON: WELL, I THINK ON THIS ONE, YOUR HONOR,
18 IT'S -- IT'S NOT PERTAINING TO HIS IDENTIFICATION. THIS IS
19 A HOSPITAL POLICY.
20 THE COURT: OKAY. LADIES AND GENTLEMEN, I THINK
21 WHAT WE'RE GOING TO NEED TO DO IS JUST TAKE A SHORT BREAK TO
22 ADDRESS THIS ISSUE SO THAT WE CAN GO ON.
23 (AFTER ADMONISHING THE JURY, THE COURT
24 EXCUSED THE JURY FROM THE COURTROOM)
25 THE COURT: OKAY. YOU MAY BE SEATED. THE RECORD
3859
1 WILL REFLECT THAT THE JURY HAS LEFT THE COURTROOM. OKAY.
2 FIRST OF ALL AS TO EXHIBIT, PLAINTIFF'S EXHIBIT 45, WHAT
3 EXACTLY IS THAT?
4 MR. WILSON: THAT, YOUR HONOR, IS -- IS
5 DR. WEITZEL'S APPLICATION FOR -- FOR CLINICAL PRIVILEGES AT
6 THE DAVIS HOSPITAL. AND ALSO, HIS SPECIFIC APPLICATION FOR
7 STAFF PRIVILEGES THERE AND WHICH SETS FORTH A NUMBER OF
8 PROVISIONS THAT I WANTED TO GO THROUGH WITH HIM THAT PERTAIN
9 TO WHAT LEVEL HE WAS ENTITLED TO PRIVILEGES FOR, WHAT AREAS
10 HE WAS ENTITLED TO PRACTICE AT THE HOSPITAL, AND ALSO TO
11 INQUIRE INTO THE PROVISION AS TO HIS AGREEMENT TO ABIDE BY
12 HOSPITAL POLICIES AND REGULATIONS.
13 EXHIBIT, STATE'S EXHIBIT NUMBER 46, WHICH IS
14 ORIGINALLY MARKED EXHIBIT 1 IS THE HOSPITAL-WIDE GUIDELINES
15 AND DIRECTIVES AS IT RELATES TO ADVANCE DIRECTORS AND D.N.R.
16 GUIDELINES WHICH ARE A PART OF THE HOSPITAL POLICY. I WOULD
17 SUBMIT TO THE COURT THAT IN THE CONTEXT --
18 THE COURT: YOU SAY PLAINTIFF'S EXHIBIT 1?
19 MR. WILSON: PARDON?
20 THE COURT: DO YOU SAY THAT WAS PLAINTIFF'S EXHIBIT
21 1?
22 MR. WILSON: IT USED TO BE, BUT IT'S NOW MARKED
23 EXHIBIT 46. I'LL JUST HAND IT TO THE COURT AT THIS TIME.
24 THE COURT: OKAY. AND WHAT -- OKAY. WHAT DO YOU
25 CLAIM, FIRST OF ALL, ON PLAINTIFF'S EXHIBIT 45 TO BE THE
3860
1 RELEVANCE? I UNDERSTAND THAT'S THE OBJECTION.
2 MR. WILSON: IN THE CONTEXT OF THE DOCTOR
3 PRACTICING AT THE HOSPITAL, HE HAS AGREED IN SEVERAL
4 DOCUMENTS TO ABIDE BY HOSPITAL GUIDELINES AND POLICIES.
5 THOSE POLICIES REFLECT DIRECTLY ON HIS CARE AND TREATMENT OF
6 THESE PATIENTS. THERE'S SEVERAL PROVISIONS IN THE HOSPITAL
7 POLICIES AND GUIDELINES THAT I WOULD SUBMIT TO THE COURT
8 PERTAIN TO STANDARD OF CARE AS IT RELATES TO HOW HE WAS
9 SUPPOSED TO ADMINISTER THE ADVANCE DIRECTIVES. AND I WOULD
10 SUBMIT ALSO, YOUR HONOR, THAT PART OF THOSE OR AT LEAST SOME
11 OF THOSE ADVANCE DIRECTIVES WERE ADVANCE DIRECTIVES THAT
12 WERE PART OF THE DAVIS HOSPITAL PROCEDURES, AND WERE
13 IMPLEMENTED PURSUANT TO THEIR POLICIES AND IN CONFORMANCE
14 WITH THOSE POLICIES.
15 THE COURT: OKAY. AND SO --
16 MR. WILSON: WE FEEL IT GOES TO HIS KNOWLEDGE, IT
17 GOES TO HIS INTENT IN TERMS OF HIS OMISSIONS FROM NOT
18 FOLLOWING THOSE GUIDELINES IN THIS PARTICULAR INSTANCE. WE
19 THINK THAT'S EVIDENCE WHICH DEMONSTRATES HIS INTENT TO NOT
20 HAVE -- PARTICULARLY NOT TO HAVE A SECOND PHYSICIAN CERTIFY
21 AS TO THE TERMINAL CONDITION OF THESE PARTICULAR PATIENTS.
22 THE COURT: OKAY. AND WHAT'S THE OBJECTION?
23 MR. STIRBA: FIRST WITH RESPECT TO THE PRIVILEGE
24 DOCUMENT, I OBJECT AS TO RELEVANCY BECAUSE WE HAD A
25 DISCUSSION BEFORE WITH THE COURT AS TO EXACTLY WHAT THE
3861
1 SCOPE OF THIS CASE WAS CONCERNING. AND THE RELEVANCY OF
2 HIS -- WHETHER OR NOT HE COMPLIED WITH HOSPITAL PRIVILEGES
3 IS NOT PERTINENT IN THIS CASE. THAT'S A EMPLOYMENT
4 CIRCUMSTANCE BETWEEN DR. WEITZEL AND THE HOSPITAL, IF HE
5 VIOLATED THOSE PRIVILEGES. THE RECORD EVIDENCE SHOWS THAT
6 NO ACTION WAS TAKEN BY DR. WEITZEL DURING THE PERTINENT TIME
7 PERIOD WITH RESPECT TO HIS PRIVILEGES. IN FACT, THERE NEVER
8 HAS BEEN ANY ACTION TAKEN BY THE HOSPITAL WITH RESPECT TO
9 HIM VIOLATING PRIVILEGES, AND THEREFORE, IT'S AN EXTRANEOUS
10 ISSUE TO BRING BEFORE THE COURT IN A FIRST DEGREE MURDER
11 CASE.
12 THAT'S POINT ONE. BUT I HAVE A MORE FUNDAMENTAL
13 PROBLEM. AND, YOU KNOW, THIS HAS BEEN THROUGHOUT THE CASE
14 AND HERE WE GO AGAIN. THIS DOCUMENT P-45, I'VE JUST SEEN
15 FOR THE FIRST TIME WHEN IT WAS PRESENTED TO ME ON
16 CROSS-EXAMINATION. IT'S A MULTI-PAGE DOCUMENT, AND GRANTED,
17 IT APPEARS TO BE SIGNED BY MY CLIENT, BUT I CAN'T POSSIBLY
18 DEAL WITH THIS IN ANY RATIONAL WAY FOR PURPOSES OF ANY KIND
19 OF REDIRECT OR DEALING WITH IT ON CROSS-EXAMINATION. IT
20 SHOULD HAVE BEEN PRODUCED WELL BEFORE THIS AND I SHOULDN'T
21 GET IT JUST IN THE MIDDLE OF CROSS-EXAMINATION OF
22 DR. WEITZEL, SO I'M ALSO CLAIMING UNFAIR SURPRISE.
23 NOW, WITH RESPECT TO THE OTHER DOCUMENT WHICH IS
24 P-46, THAT ALSO IS A RELEVANCY OBJECTION. AND BY THE WAY,
25 THIS IS BEYOND THE SCOPE AS WELL, YOUR HONOR, BOTH BECAUSE I
3862
1 DIDN'T ASK ONE QUESTION ABOUT PRIVILEGES OF DR. WEITZEL WITH
2 RESPECT TO THE DIRECT EXAMINATION. BUT IN TERMS OF
3 RELEVANCY, WE HAVE THE SAME PROBABLE. THIS IS AN ATTEMPT I
4 PRESUME TO SHOW THAT HE DID NOT OTHERWISE COMPLY WITH THESE
5 PARTICULAR POLICIES WHICH WERE IN EFFECT APPARENTLY AT THE
6 HOSPITAL AT THE TIME. SO WE HAVE THE SAME PROBLEM OF
7 RELEVANCY. FIRST, WE HAVE NO SHOWING, FOUNDATION, HE WAS
8 EVEN AWARE OF THESE. SECOND OF ALL, WE HAVE NO FOUNDATION
9 THAT HE EVEN REVIEWED THEM. THIRD OF ALL, WE HAVE NO
10 FOUNDATION THAT THE HOSPITAL ENFORCED THEM. AND FOURTH OF
11 ALL, THE RECORD EVIDENCE WILL BE THAT IN FACT HE WAS NEVER
12 DISCIPLINED BY THE HOSPITAL AS A RESULT OF ANYTHING THAT
13 OCCURRED IN JANUARY OF 1996 AND DECEMBER OF 1995. THESE
14 POLICIES WERE NEVER INVOKED AGAINST HIM AFTER THE HOSPITAL
15 CONDUCTED ITS MORTALITY REVIEW. SO THEY HAVE NO RELEVANCE
16 TO THIS PROCEEDING BECAUSE THEY'VE NEVER BEEN ENFORCED BY
17 THE HOSPITAL, AND IT SEEMS TO ME IT'S CLEARLY AN EMPLOYMENT
18 ISSUE VIS-A-VIS THE HOSPITAL AND DR. WEITZEL INSOFAR AS HE
19 EXCEEDED THE SCOPE OF HIS PRIVILEGES.
20 AND FINALLY, I ALSO HAVE THE SURPRISE OBJECTION.
21 THIS DOCUMENT I HAVE NEVER SEEN BEFORE. IT IS TRUE THAT
22 INITIALLY AT THE BEGINNING OF THIS CASE, THE STATE ATTEMPTED
23 TO INTRODUCE SOME POLICIES WHICH WERE RELEVANT TO THE
24 PERTINENT TIME PERIOD. THERE WAS A CONCERN EXPRESSED AS TO
25 WHETHER OR NOT THEY'RE EVEN APPLICABLE, AND I THINK
3863
1 MS. HEWARD WAS UNABLE TO SAY THAT IN FACT THEY WERE, SO THE
2 COURT EXCLUDED THOSE BECAUSE THERE WASN'T THE REQUISITE
3 FOUNDATION. THESE PARTICULAR POLICIES WHICH APPARENTLY THE
4 STATE HAS HAD, BASED UPON THE PAGE THAT IS THE COVER SHEET,
5 SINCE JUNE 12TH OF 2000, I'VE NEVER SEEN BEFORE. AND THERE
6 CERTAINLY WAS NO ATTEMPT IN THE STATE'S CASE IN CHIEF TO
7 INTRODUCE THESE THROUGH MS. HEWARD OR SOME OTHER
8 FOUNDATIONAL WITNESS THAT WOULD HAVE BEEN APPROPRIATE AT
9 THAT TIME. AND SO ONCE AGAIN, I'M CLAIMING SURPRISE. I
10 OUGHT NOT TO BE GETTING THESE RIGHT IN THE MIDDLE OF
11 CROSS-EXAMINATION AND THEN TRY AND TO ASCERTAIN PRECISELY
12 WHAT'S IN HERE AND FIGURE OUT HOW TO GO FROM THERE. IT JUST
13 SHOULDN'T BE THE WAY IT'S DONE.
14 SO THOSE ARE MY OBJECTIONS WITH RESPECT TO BOTH OF
15 THE DOCUMENTS.
16 MR. WILSON: YOUR HONOR, IN RESPONSE, FIRST OF ALL
17 AS TO TAKING THE LAST FIRST, THIS COURT ADDRESSED IN SOME
18 DETAIL THIS PARTICULAR DOCUMENT OF WHICH MR. STIRBA WAS
19 PROVIDED A COPY OF BACK IN -- EARLY ON IN THESE PROCEEDINGS.
20 AS THE COURT MAY RECALL --
21 THE COURT: PLAINTIFF'S 46?
22 MR. WILSON: YES, PLAINTIFF'S 46. AS IS THE COURT
23 MAY RECALL, IT WAS IDENTIFIED THEN AS PLAINTIFF'S EXHIBIT 1.
24 AND AS THE COURT MAY RECALL AT THAT TIME WHEN WE INITIALLY
25 TRIED TO GET THE POLICIES IN IN RESPECT TO MISS HEWARD'S
3864
1 TESTIMONY, MISS HEWARD INDICATED THAT SHE WASN'T SURE
2 WHETHER THAT WAS THE PARTICULAR POLICY THAT WAS IN EFFECT.
3 WE SUBSEQUENTLY HAD HER PULL THE DOCUMENTS. WE REINSERTED
4 WHAT THE POLICIES WERE IN EFFECT AT THAT TIME. WE SUBMITTED
5 IT TO THE COURT. AND WE ARGUED THE MATTER TO THE COURT AT
6 THAT TIME AS TO ITS RELEVANCY IN THIS MATTER. THE DEFENDANT
7 HAS NOW TAKEN THE STAND AND HE HAS TESTIFIED IN RESPECT TO
8 HIS EMPLOYMENT AT THE DAVIS HOSPITAL. HE HAS TESTIFIED,
9 YOUR HONOR, IN RESPECT TO THE FACT THAT HE WAS OPERATING
10 UNDER THE MANAGEMENT OF HORIZONS IN CONJUNCTION WITH THE
11 HOSPITAL. AND THE POLICIES AND GUIDELINES THAT ARE IN
12 EFFECT IN RESPECT TO THAT PARTICULAR UNIT I THINK ARE VERY
13 RELEVANT.
14 AND FURTHERMORE AS TO THE -- AS TO THE SURPRISE,
15 AS TO THE DOCUMENTS THAT RELATE TO HIS CLINICAL PRIVILEGES,
16 THOSE WERE SUPPLIED TO COUNSEL EARLY ON IN THE COURSE OF
17 DISCOVERY. WE HAVE HAD THOSE DOCUMENTS IN OUR FILE FOR SOME
18 TIME. AND THEY WERE DISCOVERABLE AT THAT TIME. AND THEY
19 WERE SUPPLIED TO COUNSEL AT THAT TIME. SO I DON'T KNOW
20 WHERE HE'S COMING FROM IN TERMS OF SURPRISE AS TO THOSE
21 PARTICULAR DOCUMENTS OR EXHIBITS.
22 I WOULD SUBMIT FURTHERMORE, YOUR HONOR, THAT IN
23 RESPECT TO THE ARGUMENT THAT IT'S BEYOND THE SCOPE, THIS
24 DEFENDANT HAS CHOSEN TO WAIVE HIS RIGHTS TO TAKE THE STAND,
25 AND THE STATE OUGHTA BE ALLOWED SOME LATITUDE HERE IN
3865
1 CROSS-EXAMINING THIS DEFENDANT AS TO WHAT HIS KNOWLEDGE IS
2 AND THE DOCUMENTS SPEAK FOR THEMSELVES. HE SIGNED OFF ON
3 THE DOCUMENTS --
4 THE COURT: WELL, AS TO THAT ISSUE, ARE YOU SAYING
5 THAT IF A CRIMINAL DEFENDANT TAKES THE STAND, THAT HE WAIVES
6 ALL THE RULES ABOUT CROSS-EXAMINATION BEING AS TO THE SCOPE,
7 WITHIN THE SCOPE OF WHAT THE DIRECT EXAMINATION IS? SO THAT
8 THAT'S --
9 MR. WILSON: I'M SAYING THAT THE COURT SHOULD
10 LIBERALLY CONSTRUE THAT IN TERMS OF THE SCOPE. OTHERWISE, I
11 THINK WHAT YOU HAVE IS, YOU HAVE AN ARTIFICIAL LIMITING OF
12 THE ABILITY TO CROSS-EXAMINE THE DEFENDANT WHO HAS NO DUTY
13 OR RESPONSIBILITY TO TESTIFY IN THE FIRST PLACE.
14 THE COURT: NO, BUT -- THAT'S TRUE, HE DOESN'T HAVE
15 TO. AND THEY'VE CHOSE TO TESTIFY. BUT THE QUESTION IS,
16 NOTHING WAS SAID ABOUT PRIVILEGES, THERE -- IT WASN'T GONE
17 INTO ON DIRECT EXAMINATION.
18 MR. WILSON: BUT MUCH HAS BEEN SAID ABOUT HOW HE
19 PERFORMED HIS DUTIES WITHIN THE HOSPITAL CONTEXT, YOUR
20 HONOR. AND I THINK THAT THIS BEARS AS TO HIS
21 RESPONSIBILITIES AND THE PERFORMANCE OF THOSE DUTIES IN THAT
22 CONTEXT.
23 THE COURT: OKAY. WELL, TELL ME THIS: IF THESE
24 ARE ALLOWED IN, AND IT'S -- THEN YOU GO ON TO SAY, HERE'S A
25 POLICY AND YOU DIDN'T DO IT. HERE'S A POLICY AND YOU DIDN'T
3866
1 DO IT. HERE'S A POLICY AND YOU DIDN'T DO IT. HOW IS THAT
2 RELEVANT ON EITHER MURDER, MANSLAUGHTER, OR NEGLIGENT
3 CRIMINAL HOMICIDE?
4 MR. WILSON: WELL, I'LL TELL YOU HOW IT'S RELEVANT,
5 YOUR HONOR. IN TERMS OF THE PARTICULAR POLICY THAT I WANNA
6 GET INTO IS THE POLICY THAT REQUIRES -- IN EVERY INSTANCE IN
7 THAT HOSPITAL SETTING, THE POLICY REQUIRES THAT TWO
8 PHYSICIANS, THE ATTENDING PHYSICIAN AND ANOTHER PHYSICIAN,
9 CERTIFY THAT THIS PERSON IS IN A TERMINAL STATE. YOU HAVE
10 BEFORE YOU EVIDENCE THERE'S ONLY ONE OF THOSE INDIVIDUALS
11 THAT WAS CERTIFIED AS BEING IN A TERMINAL STATE. THE ONLY
12 PERSON HERE IS THE ACCUSED WHO'S TESTIFYING THAT THOSE
13 INDIVIDUALS WERE IN A TERMINAL STATE.
14 THE COURT: HASN'T THIS ISSUE BEEN DECIDED?
15 MR. STIRBA: IT HAS, YOUR HONOR.
16 THE COURT: WE HAD THE ISSUE ABOUT WHETHER STATE
17 LAW OR THE HOSPITAL POLICY OR HORIZON'S POLICY IS GOING TO
18 APPLY. WE HAD ABOUT -- WE BRIEFED IT. WE HAD ABOUT AN HOUR
19 ARGUMENT. I SPENT ABOUT EIGHT OR TEN HOURS REVIEWING ALL OF
20 THESE THINGS. AND THAT ISSUE WAS BASICALLY -- I MADE A
21 DECISION AT THAT POINT THAT IF THERE WAS A CONFLICT BETWEEN
22 THE STATE LAW AT ISSUE HERE AND THE HOSPITAL POLICY, THAT
23 THE STATE ALLOW WAS GOING TO APPLY. NOW, WHY -- IF WE'RE
24 BACK AT THIS ISSUE, ISN'T THIS JUST REARGUING SOMETHING THAT
25 I'VE ALREADY DECIDED?
3867
1 MR. WILSON: IT'S NOT OFFERED TO SHOW HIS
2 COMPLIANCE WITH STATE LAW OR NON COMPLIANCE WITH STATE LAW.
3 THE COURT: OKAY. THEN THEY'RE GOING TO HAVE IT
4 AND IT'S GOING TO SAY, YOU'VE GOT -- THAT THE HOSPITAL
5 POLICY SAYS TWO. STATE LAW TELLS YOU DON'T HAVE TO HAVE
6 TWO. AND WHAT'S THAT GOING TO HELP THE JURY TO DECIDE
7 WHETHER THIS DEFENDANT COMMITTED MURDER, MANSLAUGHTER, OR
8 NEGLIGENT CRIMINAL HOMICIDE?
9 MR. WILSON: I THINK IT'S GOING TO HELP THEM DECIDE
10 WHAT HIS INTENT WAS AND WHY HE DIDN'T HAVE ANOTHER PHYSICIAN
11 CERTIFY --
12 THE COURT: WELL, RUN THAT THROUGH FOR ME. SHOW ME
13 HOW THIS EVIDENCE COMING IN GOES TO INTENT TO COMMIT MURDER,
14 MANSLAUGHTER, OR NEGLIGENT CRIMINAL HOMICIDE. RUN THAT
15 THROUGH. JUST DON'T SAY THE WORDS INTENT.
16 MR. WILSON: OKAY.
17 THE COURT: WALK ME THROUGH IT SO I CAN SEE HOW
18 IT'S RELEVANT.
19 MR. WILSON: OKAY. LET ME SEE, IN TERMS OF THE
20 CASE OF LYDIA SMITH, I THINK THAT'S PROBABLY PRETTY GOOD
21 EXAMPLE. IT'S THE STATE'S CONTENTION THAT THE DEFENDANT,
22 FIRST OF ALL, OVER MEDICATES LYDIA SMITH, CAUSES HER
23 PHYSICAL CONDITION TO DETERIORATE. THE EVIDENCE BEFORE THE
24 COURT AT THIS TIME SHOWS THAT ON JANUARY 7TH, THE EVENING OF
25 JANUARY 7TH, THE DEFENDANT MEETS WITH THE FAMILY MEMBERS,
3868
1 AND PROCEEDS TO ADVISE THEM THAT THEIR MOTHER IS IN -- IS IN
2 THE DYING PROCESS. IN FACT, I THINK HIS TESTIMONY IS, IS HE
3 WASN'T QUITE SURE WHAT SHE WAS DYING FROM AT THAT TIME. AT
4 LEAST THERE'S NO EVIDENCE IN PARTICULAR THAT FOCUSSES ON
5 WHAT LYDIA SMITH WAS DYING FROM. HE ADVISES THEM OF THAT
6 FACT. THEN THEY PROCEED -- OR EARLIER ON, KENT SMITH HAS
7 SIGNED A DIRECTIVE. HE PROCEEDS TO INVOKE THAT DIRECTIVE.
8 TAKES HER OFF ANY OF THE MEDICATIONS AND PROCEEDS TO
9 ADMINISTER MORPHINE FOR COMFORT CARE. THE FACT THAT HE WAS
10 IN THE HOSPITAL SETTING, THE FACT THAT HE KNEW THAT THERE
11 WERE POLICIES AND REGULATIONS WHICH REQUIRED HIM TO GET AN
12 ADDITIONAL CERTIFICATION UNDER THOSE POLICIES AS TO THE FACT
13 THAT LYDIA SMITH WAS IN A TERMINAL STATE, I THINK IS VERY
14 RELEVANT FROM THE STANDPOINT, ANOTHER PHYSICIAN COULD HAVE
15 VERY WELL SAID NO, SHE'S NOT IN A TERMINAL STATE. SHE'S
16 SUFFERING FROM THE EFFECTS OF TOXICITY OF THESE DRUGS, AND
17 IT IS REHABILITATABLE. WE CAN REMEDY THAT SITUATION.
18 I THINK IT ALSO GOES TO HIS INTENT TO COVER UP HIS
19 CRIME. IF YOU CAN USE THE FAMILY MEMBERS AS UNWITTING
20 MEMBERS IN TERMS OF BEING ABLE TO DEMONSTRATE THAT, HEY,
21 SHE'S DYING, AND THEN THEY BUY OFF ON THAT, HEY, THERE'S NO
22 OTHER RECOURSE. THERE'S NO OTHER RECOURSE, YOUR HONOR. AND
23 SO I THINK THIS IS EVIDENCE OF HIS INTENT. I THINK HE WAS
24 VERY WELL AWARE OF THESE POLICIES, AND HE SIGNED OFF ON
25 THESE DOCUMENTS INDICATING THAT. SO I'M NOT OFFERING IT TO
3869
1 SHOW WHETHER OR NOT HE -- WHETHER OR NOT HE COMPLIED WITH
2 THE STATE DIRECTIVES. I'M OFFERING IT TO SHOW THAT IN THIS
3 PARTICULAR INCIDENCE, THAT'S ONE OTHER ITEM OF CONDUCT THAT
4 DEMONSTRATES HIS -- UNDER DEPRAVED CIRCUMSTANCES OR
5 INTENTIONALLY, KNOWINGLY CAUSING THE DEATH OF THESE PEOPLE
6 BECAUSE HE USES IT TO ADMINISTER THE MORPHINE.
7 THE COURT: OKAY. WHAT IS GOING -- WHAT IS GOING
8 TO BE THE FOUNDATION AS TO WHETHER THE DEFENDANT IS AWARE OF
9 THESE THINGS OR NOT?
10 MR. WILSON: WELL, YOUR HONOR, I WAS GONNA POINT
11 HIM TO THE PAGES AND ASK HIM IF THOSE BEAR HIS SIGNATURE.
12 AND THERE'S A PARTICULAR PROVISION --
13 THE COURT: WELL, YOU'RE TALKING ABOUT 45. AREN'T
14 WE TALKING ABOUT 46? AREN'T YOU REFERRING TO 46?
15 MR. WILSON: 46, YOUR HONOR -- WELL, NO, NOT 46. I
16 APOLOGIZE. 46 DOES NOT BEAR HIS SIGNATURE. THE ONLY THING
17 IN 45 INDICATES THAT HE WAS AWARE OF THE HOSPITAL POLICIES,
18 HE AGREES TO CONFORM HIS --
19 THE COURT: OKAY. THE QUESTION IS WHETHER HE'S
20 AWARE OF -- ONE OF THE ISSUES ABOUT FOUNDATION THAT WAS
21 RAISED IS WHETHER OR NOT HE WAS AWARE OF THE POLICY. SO
22 OUTSIDE THE PRESENCE OF JURY, GO AHEAD AND ASK THOSE
23 QUESTIONS FOR THIS WITNESS SO WE CAN SEE WHAT THE FOUNDATION
24 IS.
25 MR. WILSON: DOCTOR -- FIRST OF ALL, YOUR HONOR, I
3870
1 THINK I HAVE TO TALK ABOUT 45.
2 THE COURT: GO AHEAD.
3 MR. WILSON: OKAY.
4 Q. YOU HAVE BEFORE YOU THE CLINICAL -- APPLICATION FOR
5 CLINICAL PRIVILEGES?
6 A. YES, SIR.
7 Q. OKAY. AND IN RESPECT TO THAT APPLICATION, SIR, DID
8 YOU -- I'LL JUST TURN YOU RIGHT NOW TO THE LAST -- SECOND TO
9 THE LAST PAGE OF THE APPLICATION --
10 A. YES, SIR.
11 Q. -- IF YOU WILL. DOES THAT DOCUMENT BEAR YOUR SIGNATURE?
12 A. YES, SIR.
13 Q. OKAY. I'D ASK YOU, THERE'S A PARAGRAPH THAT'S
14 UNDERLINED, IS THERE NOT? IN THE DOCUMENT?
15 A. THE PARAGRAPH RIGHT HERE --
16 Q. YES.
17 A. -- THAT YOU'VE HIGHLIGHTED.
18 Q. OKAY. WHEN WAS THAT DOCUMENT SIGNED, BY THE WAY?
19 A. APRIL 15TH, '95.
20 Q. OKAY. CAN YOU TELL US, SIR, DID YOU REVIEW THAT
21 PARTICULAR DOCUMENT BEFORE YOU SIGNED IT?
22 A. NO, SIR.
23 Q. YOU JUST SIGNED OFF ON IT BLANK?
24 A. I DIDN'T READ THIS FINE PRINT HERE.
25 Q. OKAY. READ THE FINE PRINT, WILL YOU, DOCTOR?
3871
1 A. DO YOU WANT ME TO READ THE PART THAT'S HIGHLIGHTED?
2 Q. YES.
3 A. OKAY. I HAVE RECEIVED AND HAD AN OPPORTUNITY TO READ A
4 COPY OF THE MEDICAL STAFF BYLAWS AND SUCH FACILITY POLICIES
5 AND DIRECTIVES AS ARE APPLICABLE TO APPOINTEES TO THE
6 MEDICAL STAFF, INCLUDING THE BYLAWS AND RULES AND
7 REGULATIONS OF THE MEDICAL STAFF PRESENTLY IN FORCE. I
8 SPECIFICALLY AGREE TO ABIDE BY ALL SUCH BYLAWS, POLICIES,
9 DIRECTIVES, RULES AND REGULATIONS AS ARE IN FORCE AND AS
10 THEY MAY HEREAFTER BE AMENDED DURING THE TIME I AM APPOINTED
11 OR REAPPOINTED TO THE MEDICAL STAFF OR EXERCISE CLINICAL
12 PRIVILEGES AT THE FACILITY.
13 Q. OKAY. AND IT'S YOUR TESTIMONY HERE TODAY, YOU JUST
14 SIGNED THAT FORM IN BLANK.
15 A. SIR --
16 Q. I MEAN YOU DIDN'T EVEN READ IT?
17 A. WELL, I READ PARTS OF THIS. I DON'T THINK I READ THIS
18 WHOLE THING.
19 Q. OKAY. ARE YOU AWARE THAT IN FIRST -- IN FACT, IN
20 RESPECT TO THE FIRST DOCUMENT, YOU'RE REQUIRED, ARE YOU NOT,
21 TO ASSIST IN THE DEVELOPMENT OF ADMINISTRATIVE RULES AND
22 REGULATIONS AS TO THE GEROPSYCH UNIT?
23 A. YOU'RE TALKING ABOUT THIS DOCUMENT HERE?
24 Q. YES. DOCUMENT NUMBER 45 -- OR 44?
25 A. I REMEMBER SOMETHING LIKE THAT IN HERE, UH-HUH. YES,
3872
1 SIR.
2 Q. DID YOU PARTICIPATE IN THOSE?
3 A. YES, SIR.
4 Q. OKAY. AND YOU'RE AWARE THAT THERE'S CERTAIN HOSPITAL
5 POLICIES AND REGULATIONS AS IT PERTAINS TO GUIDELINES FOR A
6 VARIETY OF THINGS, ARE YOU NOT?
7 A. YEAH, I REMEMBER THE BYLAWS WAS A BOOK ABOUT 2 INCHES
8 THICK.
9 Q. OKAY. AS IT PERTAINS TO DIRECTIVES, DOCTOR, WERE YOU
10 AWARE OF THE BYLAWS? ADVANCE DIRECTIVES?
11 A. YOU MEAN DID I KNOW WHAT --
12 THE COURT: IS THAT ONE OF THESE EXHIBITS?
13 MR. WILSON: PARDON? IT'S EXHIBIT NUMBER 46.
14 THE COURT: DO YOU WANNA SHOW IT TO HIM.
15 Q. (BY MR. WILSON) LET ME SHOW YOU THE EXHIBIT.
16 A. OKAY. THIS LOOKS TO BE PART OF THE BYLAWS.
17 Q. OKAY. HAVE YOU -- DID YOU TAKE A LOOK AT THOSE?
18 A. NO, NOT DIRECTLY, NO.
19 Q. AS THE DIRECTOR OF THE GEROPSYCH UNIT, DOCTOR, ARE YOU
20 TELLING US THAT YOU DID NOT HAVE AN OPPORTUNITY TO REVIEW
21 THOSE BYLAWS OR POLICIES?
22 A. AS ASSOCIATE DIRECTOR --
23 Q. UH-HUH.
24 A. -- I HAD AN OPPORTUNITY TO REVIEW THEM.
25 Q. YOU HAD AN OPPORTUNITY TO REVIEW THEM?
3873
1 A. YES, I DID.
2 Q. OKAY. AND YOU IN FACT AGREED TO ABIDE BY THE POLICIES
3 OF THE HOSPITAL, DID YOU NOT?
4 A. YES, I DID.
5 MR. WILSON: OKAY. I WOULD SUBMIT IT, YOUR HONOR.
6 THE COURT: OKAY. TELL ME IF HE WASN'T -- IF HE
7 WAS -- HE HAD THEM AVAILABLE AND HE HAS NOT READ THEM, HOW
8 HE WAS AWARE OF THEM FOR PURPOSES OF INTENT FOR ANY OF THESE
9 THREE CRIMES.
10 MR. WILSON: WELL, I DON'T --
11 THE COURT: WELL, YOU'RE ASKING, YOU SAY THAT THIS
12 GOES TO INTENT. IF HE --
13 MR. WILSON: WELL, HE'S ALREADY TESTIFIED THAT HE
14 WAS AWARE OF THEM AND HE AGREED TO ABIDE BY THEM, YOUR
15 HONOR, FROM THAT STANDPOINT.
16 THE COURT: OKAY. WELL, YOU HAVEN'T LAID ANY
17 FOUNDATION THAT HE'S PERSONALLY AWARE OF THESE THINGS. YOU
18 LAID THE FOUNDATION THAT THEY WERE IN THE BYLAWS AND HE
19 AGREED TO ABIDE BY ALL OF THE PROCEDURES --
20 MR. WILSON: I GUESS I MISUNDERSTOOD.
21 Q. DOCTOR, DIDN'T YOU SAY YOU WERE FAMILIAR WITH BYLAWS AND
22 THE POLICIES?
23 A. WELL, THAT'S KIND OF A --
24 THE COURT: ARE YOU TALKING SPECIFICALLY ABOUT
25 PLAINTIFF'S EXHIBIT 46?
3874
1 Q. (BY MR. WILSON) THOSE -- THOSE ONES THAT ARE IN FRONT
2 OF YOU.
3 A. NO, SIR, I WAS NOT A -- I WAS NOT FAMILIAR WITH THESE.
4 I WAS AWARE THERE WERE BYLAWS OF THE HOSPITAL. YOU KNOW,
5 SIR, I DOUBT THERE'S ONE DOCTOR IN A THOUSAND THAT READS ALL
6 THE BYLAWS --
7 Q. DOCTOR, JUST ANSWER THE QUESTION.
8 A. OKAY.
9 Q. WERE YOU PERSONALLY -- DID YOU PERSONALLY REVIEW THOSE
10 PARTICULAR BYLAWS AND POLICIES?
11 A. DID I REVIEW THESE?
12 Q. UH-HUH.
13 A. NO, SIR.
14 Q. OKAY. AND WHY IS THAT?
15 A. WELL, BECAUSE IT'S A 2-INCH THICK -- I MEAN THIS IS ON
16 TWO THINGS, DO NOT RESUSCITATE GUIDELINES, ADVANCE
17 DIRECTIVES. I SIMPLY DIDN'T HAVE THE TIME.
18 Q. OKAY. IN RESPECT TO THE BYLAWS THEMSELVES OR THE
19 POLICIES THEMSELVES THAT YOU HAVE IN YOUR HAND THERE, AS THE
20 DIRECTOR OR ASSOCIATE DIRECTOR THE GEROPSYCH UNIT, DID YOU
21 NOT FEEL YOU HAD ANY RESPONSIBILITY TO REVIEW THOSE?
22 A. NO, SIR, I DIDN'T.
23 Q. OKAY. AND WHEN THIS -- THESE PATIENTS PRESENTED
24 THEMSELVES TO YOU AND YOU MADE A DETERMINATION TO RENDER
25 HOSPICE CARE, DID YOU NOT FEEL THAT YOU HAD A RESPONSIBILITY
3875
1 TO LOOK AT THE HOSPITAL POLICIES AT THAT TIME TO DETERMINE
2 WHAT ACTION IF ANYTHING YOU HAD TO TAKE?
3 A. NO, SIR.
4 Q. WHY IS THAT, DOCTOR?
5 A. WELL, I PRETTY MUCH BEEN TAUGHT ABOUT END-OF-LIFE CARE
6 AND THROUGHOUT MEDICAL SCHOOL AND RESIDENCY AND I FOLLOWED
7 THE SAME SORT OF CUSTOMARY BEHAVIORS THAT MEDICAL PERSONNEL
8 DO AND ALL OF MY TRAINING AND --
9 Q. SO YOU JUST TOTALLY DISREGARDED --
10 A. -- AND PREVIOUS --
11 Q. -- THE POLICIES, IS THAT RIGHT?
12 A. WELL, I DON'T THINK I'D CHARACTERIZE IT THAT WAY,
13 MR. WILSON.
14 Q. OKAY. WELL, YOU DIDN'T -- YOU DIDN'T REVIEW 'EM. YOU
15 DIDN'T FEEL A NEED TO, IS THAT RIGHT?
16 A. I DIDN'T FEEL I NEEDED TO READ THROUGH THE ENTIRE BYLAWS
17 OF THE HOSPITAL, NO, SIR.
18 Q. EXCUSE ME. YOU DIDN'T FEEL A NEED TO REVIEW THE
19 POLICIES IN RESPECT TO DO NOT RESUSCITATE AND TERMINAL OR
20 ADVANCE DIRECTIVES, IS THAT RIGHT?
21 A. NO, SIR, I DID NOT REVIEW THOSE. I GUESS I FOLLOWED
22 STATE LAW, BUT I DIDN'T FOLLOW THE HOSPITAL POLICY.
23 Q. AND YOU PREVIOUSLY SIGNED OFF ON TWO DOCUMENTS. ONE IS
24 YOUR CONTRACT AND ONE IS THE PRIVILEGES WHERE YOU AGREED TO
25 ABIDE BY THOSE POLICIES.
3876
1 A. YOU'RE RIGHT, SIR.
2 MR. WILSON: I STILL THINK IT'S RELEVANT, YOUR
3 HONOR, AND IT'S PROBATIVE IN RESPECT TO THIS MATTER THAT HE
4 DIDN'T FOLLOW THE BYLAWS OR THE HOSPITAL POLICIES.
5 THE COURT: OKAY. ANYTHING FURTHER ON THE
6 OBJECTION?
7 MR. STIRBA: WELL, YEAH. IT'S BEEN RULED ON ONCE
8 BY THE COURT. THIS IS PRECISELY THE SAME ISSUE THAT WE
9 ARGUED BEFORE. IT CONFLICTS WITH STATE LAW. STATE LAW IS
10 THE ONLY RELEVANT ISSUE HERE. THESE BYLAWS, I'M GONNA SAY
11 AS AN OFFICER OF THE COURT, I DON'T MAKE REPRESENTATIONS
12 LIGHTLY. WE'VE NEVER SEEN 'EM BEFORE. IT'S TRUE THERE WERE
13 SOME THAT WERE EXHIBIT 1, NOT THIS EXHIBIT 46. AND SO THE
14 ISSUE IS VIOLATION OF STATE LAW. THIS IS A CRIMINAL ACTION.
15 THIS IS NOT AN ACTION ABOUT WHETHER OR NOT THE HOSPITAL'S
16 UPSET WITH THIS GUY FOR PRIVILEGES. AND THAT'S REALLY ALL
17 WE'RE LITIGATING AND THAT'S MISLEADING TO THE JURY AND THE
18 COURT'S ALREADY RULED ON IT ONCE. AND THERE'S NO REASON TO
19 GO INTO IT AGAIN. AND FURTHERMORE, THERE'S NO FOUNDATION
20 LAID THAT HE EVEN KNEW ABOUT THESE PARTICULAR DIRECTIVES OR
21 THESE PARTICULAR END-OF-LIFE CARE POLICIES SO THEREFORE,
22 THEY COULDN'T POSSIBLY HAVE BEEN WITHIN HIS PURVIEW WITH
23 RESPECT TO THE CARE HE PROVIDED. SO IT SEEMS TO ME, LAW OF
24 THE CASE, IRRELEVANT, UNFAIR SURPRISE, EXTRANEOUS ISSUE,
25 403, LACK OF FOUNDATION, THOSE ARE ALL OF OUR OBJECTIONS.
3877
1 THE COURT: OKAY. MR. WILSON.
2 MR. WILSON: I'D SUBMIT IT, YOUR HONOR.
3 THE COURT: OKAY. I'M GONNA TAKE A SHORT BREAK AND
4 THEN MAKE A DECISION.
5 (WHEREUPON THE COURT TOOK A RECESS.)
6 THE COURT: OKAY. PREVIOUSLY IN THIS CASE, WE
7 STATED THAT -- OR THAT I HAVE STATED AND WE'VE ADDRESSED
8 THIS ISSUE A NUMBER OF TIMES, THAT THIS IS A MURDER CASE.
9 IT'S NOT A MEDICAL MALPRACTICE CASE. AND ALSO, I'VE
10 PREVIOUSLY RULED THAT THE UTAH STATE PERSONAL CHOICE AND
11 LIVING WILL ACT APPLIES. AND THE HOSPITAL POLICY DOES NOT
12 APPLY. AND THE HOSPITAL POLICY IS IN PLAINTIFF'S EXHIBIT 46
13 REGARDING ADVANCE DIRECTIVES. I RULED UPON THAT EARLIER IN
14 THE CASE WHEN THIS WAS FIRST ADDRESSED. AND I RULED ON THAT
15 PREVIOUSLY BECAUSE THE HOSPITAL POLICY GAVE GREATER
16 RESTRICTIONS THAN STATE LAW DID. AND SO I PREVIOUSLY RULED
17 THAT THE UTAH STATE ACT WOULD APPLY AND NOT THE HOSPITAL
18 POLICY. HOSPITAL POLICY DOESN'T APPLY. IT IS IRRELEVANT.
19 AND I'M NOT GOING TO ALLOW PLAINTIFF'S EXHIBIT 46 BECAUSE IT
20 IS IRRELEVANT.
21 SECONDLY, AS TO EXHIBIT 46, NOT ONLY CONFLICTING
22 WITH STATE LAW AS I PREVIOUSLY RULED, THERE'S NO EVIDENCE
23 THAT THE DEFENDANT WAS FAMILIAR OR HAD READ IT OR WAS AWARE
24 OF IT. AND THIS ISN'T THE CONTRACT CLASS WHERE WE'RE SAYING
25 YOU DIDN'T READ THE CONTRACT, BUT YOU'RE GOING TO HAVE
3878
1 KNOWLEDGE IMPUTED TO YOU. SO PLAINTIFF'S EXHIBIT 46 ISN'T
2 COMING IN FOR THOSE REASONS.
3 AND IN ADDITION, THAT IF IT CAME IN, AS I
4 MENTIONED EARLIER WHEN WE DECIDED THIS ISSUE, IT WOULD BE
5 CONFUSING TO THE JURY AS TO -- WE'VE GOT STATE LAW ON THE
6 ONE HAND AND THEN ANOTHER LAW THAT ISN'T RELEVANT, BUT IT
7 CONFLICTS.
8 AS TO EXHIBIT 45, THE ACTS IN THIS CASE THAT I
9 UNDERSTAND THE STATE IS SEEKING AFTER OUR HEARING ON MONDAY
10 ON THE JURY INSTRUCTIONS, WAS THAT THEY ARE ASKING FOR
11 CHARGES OF MURDER TO GO TO THE JURY, LESSER INCLUDED
12 OFFENSES OF MANSLAUGHTER, AND NEGLIGENT CRIMINAL HOMICIDE.
13 NOW, THE NEGLIGENT CRIMINAL HOMICIDE AND
14 MANSLAUGHTER HAVE LESSER MENTAL ELEMENTS THAN MURDER, THAN
15 THE THREE MURDER MATTERS. AND SO IN THAT CASE, EACH ONE OF
16 THEM SAYS THAT THERE HAS TO BE A GROSS DEVIATION. THE
17 STANDARD IS GROSS DEVIATION FROM THE STANDARD OF CARE.
18 NOW, EXHIBIT 45 IS THE APPLICATION FOR PRIVILEGES
19 AT THE HOSPITAL. IF THE DOCTOR DEFENDANT DID NOT COMPLY
20 WITH THE POLICIES OF THE HOSPITAL, I'M RULING THAT THAT IS
21 NOT A GROSS DEVIATION OF THE STANDARD OF CARE. THAT IS
22 NEGLIGENCE. AND AS I MENTIONED AT THE VERY BEGINNING OF
23 THIS CASE, THIS IS A MURDER CASE. IT IS NOT A MEDICAL
24 MALPRACTICE CASE. AND THINGS THAT ARE NEGLIGENCE --
25 NEGLIGENT ONLY ARE NOT GOING TO COME IN. AND THE FAILURE TO
3879
1 APPLY HOSPITAL STANDARDS OR NOT APPLY HOSPITAL STANDARDS IS
2 NEGLIGENCE. THAT'S BETWEEN HIM AND HIS EMPLOYER. AND WHAT
3 WE'RE GOING TO HAVE IF THAT COMES IN IS BASICALLY A
4 NEGLIGENCE ACTION THAT WILL GO TO THE JURY, AND THAT WILL BE
5 DETERMINED AS TO WHETHER MURDER WAS COMMITTED. I'VE SAID
6 THAT FROM EITHER THE SECOND DAY OF THIS TRIAL, AND I'VE
7 REPEATED IT THROUGHOUT, AND I'M NOT CHANGING THE DIRECTION
8 OF THE TRIAL ON THE LAST THREE DAYS OF THE TRIAL.
9 OKAY. ARE THERE ANY QUESTIONS?
10 MR. WILSON: YOUR HONOR, FOR PURPOSES OF THE RULING
11 OF THE COURT, I WOULD ALSO -- I'D LIKE TO BE ABLE TO OFFER
12 IN THE TESTIMONY THEN AS TO GOING TO CREDIBILITY AS TO THE
13 DEFENDANT'S STATING THAT HE SIGNED OFF ON THE AGREEMENT FOR
14 CLINICAL PRIVILEGES INDICATING THAT HE'D REVIEWED THOSE
15 HOSPITAL POLICIES AND IN GENERAL. I'M NOT TALKING ABOUT THE
16 ADVANCE DIRECTIVES NECESSARILY, BUT I THINK IT DOES GO TO
17 CREDIBILITY BECAUSE HE'S ESSENTIALLY SAYING, YEAH, I SIGNED
18 OFF ON 'EM AND I DIDN'T READ 'EM, AND I THINK THE FACT THAT
19 HE'S ATTESTING IN ONE DOCUMENT THAT HE HAS READ 'EM AND THEN
20 HE'S TESTIFYING HERE IN COURT TO THE FACT THAT HE HAS NOT
21 READ THEM TO ME IS SIGNIFICANT IN TERMS OF AN ISSUE AS TO
22 HIS CREDIBILITY AS TO OTHER STATEMENTS THAT HE MAKES HERE IN
23 COURT. AND I THINK THAT COULD BE AN ARGUMENT TO THE JURY.
24 I'D ALSO FURTHER LIKE TO JUST ARGUE IN RESPECT TO
25 EXHIBIT -- IS IT 45 THAT'S --
3880
1 THE COURT: I HAVE 46.
2 MR. WILSON: -- CLINICAL --
3 THE COURT: 46 IS THE HOSPITAL-WIDE GUIDELINES AND
4 DIRECTIVES. AND I DON'T HAVE 45 IN FRONT OF ME. I THINK 45
5 YOU SAID WAS THE PRIVILEGES OF THE HOSPITAL.
6 MR. WILSON: THAT'S CORRECT, YOUR HONOR. THAT HAS
7 A PROVISION IN IT AND I WANTED TO REFER TO THAT PROVISION IN
8 THE COURSE OF THIS TESTIMONY. SO I WANNA MAKE CLEAR THAT I
9 UNDERSTAND THE RULING OF THE COURT. THAT HE APPLIED FOR --
10 I WOULD JUST PROFFER THAT HE APPLIED FOR LEVEL THREE
11 PRIVILEGES. AT LEVEL THREE PRIVILEGES REQUIRE THAT A
12 PHYSICIAN IN THAT CATEGORY WILL BE EXPECTED TO OBTAIN
13 CONSULTATION FOR ALL CLINICAL PROBLEMS OUTSIDE OF THEIR
14 SPECIALTY. AND IN FACT, I DON'T KNOW AS I NECESSARILY HAVE
15 TO OFFER THE DOCUMENT IN. I COULD PROBABLY JUST ASK HIM THE
16 QUESTION, ISN'T IT TRUE --
17 THE COURT: YOU SHOULD --
18 MR. WILSON: -- THAT YOU'RE REQUIRED TO DO THAT.
19 THE COURT: YEAH.
20 MR. WILSON: AND WE COULD PROCEED IN THAT FASHION.
21 THE COURT: YOU CAN ASK THAT QUESTION WITHOUT AN
22 EXHIBIT. I MEAN YOU CAN ASK --
23 MR. WILSON: AS TO THE OTHER ISSUE THAT I JUST
24 ADDRESSED TO THE COURT, I NEED SOME DIRECTION FROM THE COURT
25 ON THAT.
3881
1 THE COURT: OKAY. AS TO -- AND THIS IS 45 --
2 EXHIBIT 45 AS TO HIS CREDIBILITY?
3 MR. WILSON: EXHIBIT 46 -- WELL, YEAH, EXHIBIT 45
4 GOES TO HIS CREDIBILITY AND ALSO TO THE PROVISION THAT HE'S
5 READ THE HOSPITAL POLICIES WHEN IN FACT HE'S INDICATED
6 SPECIFICALLY HE HASN'T READ THE ONES AS TO THE D.N.R. AND
7 ADVANCE MEDICAL DIRECTIVES.
8 THE COURT: OKAY. AND SO WHAT -- ARE YOU ARGUING
9 THIS UNDER RULE 608 OF THE RULES OF EVIDENCE THAT SAYS
10 EVIDENCE OF A CHARACTER AND CONDUCT OF WITNESS?
11 MR. WILSON: WELL, I THINK IT -- I THINK IT -- NO,
12 I THINK WHAT I'M ARGUING IS, IS THAT IT GOES TO CREDIBILITY
13 OF HIS TESTIMONY HERE IN COURT THAT HE'S SAYING IN ONE -- IN
14 THAT DOCUMENT, THAT HE'S READ THOSE AND IN HIS TESTIMONY
15 HE'S SAYING NO, I DIDN'T READ 'EM. AND AGAIN, MAYBE I CAN
16 JUST ASK THE QUESTION, IF HE'S FAMILIAR WITH THE --
17 THE COURT: GO AHEAD.
18 Q. (BY MR. WILSON) ARE YOU FAMILIAR WITH THE HOSPITAL
19 POLICIES IN REGARDS TO DO NOT RESUSCITATE AND ADVANCE
20 MEDICAL DIRECTIVES?
21 A. DO YOU MEAN AM I THOROUGHLY FAMILIAR WITH THESE
22 POLICIES?
23 Q. YES, THAT'S CONTAINED IN EXHIBIT 46 AT THE PRESENT TIME.
24 A. NO, I'M NOT.
25 Q. OKAY. AND ISN'T IT TRUE, DOCTOR, THAT YOU PREVIOUSLY IN
3882
1 PROVIDING -- YOU PROVIDED AND SIGNED A DOCUMENT ATTESTING TO
2 THE FACT THAT YOU INDEED HAD REVIEWED THOSE POLICIES AND
3 DIRECTIVES, ALL POLICIES AND DIRECTIVES OF THE HOSPITAL, IS
4 THAT CORRECT?
5 MR. STIRBA: OBJECTION. IT MISCHARACTERIZES THE
6 DOCUMENT. IT SPEAKS FOR ITSELF. YOU DON'T NEED TO
7 INTERPRET IT.
8 THE COURT: REPHRASE THE QUESTION.
9 Q. (BY MR. WILSON) OKAY. DOCTOR, DID YOU NOT SIGN A
10 DOCUMENT IDENTIFIED AS -- PRESENTLY IDENTIFIED AS
11 PLAINTIFF'S EXHIBIT 45, WHEREIN YOU INDICATED THAT YOU'VE
12 RECEIVED AND HAD AN OPPORTUNITY TO READ A COPY OF THE
13 MEDICAL STAFF BYLAWS AND SUCH FACILITY POLICIES AND
14 DIRECTIVES AS ARE APPLICABLE TO APPOINTEES TO THE MEDICAL
15 STAFF, INCLUDING BYLAWS AND RULES AND REGULATIONS OF THE
16 MEDICAL STAFF PRESENTLY IN FORCE, AND YOU AGREED
17 SPECIFICALLY TO ABIDE BY ALL SUCH BYLAWS, POLICIES,
18 DIRECTIVES, RULES, AND REGULATIONS AS ARE IN FORCE AND AS
19 THEY MAY HEREAFTER BE AMENDED DURING THE TIME I AM APPOINTED
20 OR REAPPOINTED TO THE MEDICAL STAFF OR EXERCISE CLINICAL
21 PRIVILEGES AT THE FACILITY; DID YOU SIGN A DOCUMENT AGREEING
22 THAT YOU HAD INDEED READ THOSE?
23 A. NO, SIR --
24 MR. STIRBA: OBJECTION --
25 THE WITNESS: NO, SIR, I DID NOT. WHAT IT SAYS, I
3883
1 HAD AN OPPORTUNITY TO READ. IT DOESN'T SAY I READ 'EM.
2 Q. (BY MR. WILSON) SO WHAT YOU'RE SAYING THEN IS THAT
3 EVEN THOUGH YOU HAD THE OPPORTUNITY TO READ THOSE, YOU DID
4 NOT READ THOSE?
5 A. I'M SURE I DIDN'T.
6 Q. AND SO YOU'RE NOT FAMILIAR WITH THOSE.
7 A. NO, SIR, I'M NOT FAMILIAR WITH THEM.
8 Q. OKAY. SO YOU'RE NOT FAMILIAR WITH THE -- WITH THE
9 REQUIREMENTS THAT -- OF THOSE ITEMS IN RESPECT TO THE
10 MEDICAL DIRECTIVES, THE ADVANCE DIRECTIVES?
11 MR. STIRBA: OBJECT, ASKED AND ANSWERED FOUR
12 DIFFERENT TIMES.
13 THE COURT: WELL, WE'LL I GUESS HAVE IT ONE MORE
14 TIME.
15 THE WITNESS: NO, I'M NOT.
16 MR. WILSON: OKAY. I WOULD STILL -- HE DID
17 INDICATE --
18 Q. DID YOU NOT SIGN A DOCUMENT TO THAT EFFECT THAT YOU HAD
19 THE OPPORTUNITY --
20 MR. STIRBA: SPEAKS FOR ITSELF, YOUR HONOR.
21 MR. WILSON: IT'S NOT EVIDENCE, YOUR HONOR.
22 THE COURT: WELL, THIS IS A SITUATION WHERE YOU'RE
23 SAYING HIS CREDIBILITY. I UNDERSTOOD WHEN YOU FIRST ASKED
24 THE QUESTION ABOUT CREDIBILITY THAT, DID HE SIGN A CONTRACT
25 SAYING HE HAD READ IT AND AGREED TO ABIDE BY THEM. AND
3884
1 NOW -- NOW WHAT THE CONTRACT SAYS, HE HAD THE OPPORTUNITY TO
2 READ IT. THAT'S WHAT YOU JUST READ TO HIM.
3 MR. WILSON: OKAY. AS TO THE FIRST PART OF THE
4 QUESTION AS IT RELATES -- DOES THE COURT DESIRE THAT I ASK
5 HIM A QUESTION IN RESPECT ON THAT?
6 THE COURT: WELL, I JUST WANNA KNOW WHAT THE BASIS
7 FOR YOUR CREDIBILITY, ASKING THAT THIS BE INCLUDED FOR
8 PURPOSES OF CREDIBILITY.
9 MR. WILSON: WELL, I WITHDRAW THE QUESTION AT THIS
10 TIME, YOUR HONOR.
11 THE COURT: ALL RIGHT. IS THERE ANYTHING ELSE THAT
12 WE NEED TO DO BEFORE THE JURY --
13 MR. WILSON: I STILL WANT TO KNOW -- CAN I ASK HIM
14 THE QUESTION, DID YOU NOT AGREE THAT YOU WOULD BE -- AS A
15 LEVEL THREE PRIVILEGES, DID YOU NOT AGREE THAT YOU WOULD BE
16 EXPECTED TO OBTAIN CONSULTATION FOR ALL CLINICAL PROBLEMS
17 OUTSIDE OF THIS SPECIALTY?
18 THE COURT: OKAY. IS THERE ANY OBJECTION TO THAT
19 QUESTION?
20 MR. STIRBA: WELL, THERE IS TO THE EXTENT I THINK
21 IT'S IRRELEVANT TO THE FACTS OF THIS CASE. AND I ALSO --
22 ONCE AGAIN, I JUST GOT THIS, SO I'M NOT FAMILIAR WHAT ALL
23 LEVEL THREE REALLY MEANS OR DOESN'T MEAN. I HAVEN'T HAD AN
24 OPPORTUNITY TO LOOK AT IT. AND --
25 THE COURT: WELL, I CAN'T MAKE A DECISION WHEN ONE
3885
1 COUNSEL TELLS ME IT WAS GIVEN AND THE OTHER COUNSEL TELLS ME
2 THEY DIDN'T RECEIVE IT. I CAN'T DECIDE THAT ISSUE. SO --
3 MR. STIRBA: WELL, I APPRECIATE WHAT THE COURT JUST
4 SAID, BUT I SAID WHAT I SAID. BUT I'M TELLING YOU, I THINK
5 IT'S IRRELEVANT WHETHER HE HAD SOME RESPONSIBILITIES AS A
6 DIVISION THREE PSYCHIATRIST. AND I THINK IT'S GONNA BE 403
7 MISLEADING THE JURY BECAUSE YOU'RE BACK IN THE PRIVILEGES
8 SITUATION.
9 THE COURT: OKAY. AND LET'S SAY THAT YOU ASK THAT
10 QUESTION AND THEN HE SAYS HE DID NOT FOLLOW THAT. THEN IS
11 THAT GROSS DEVIATION FROM THE STANDARD OF CARE OR IS THAT
12 NEGLIGENCE?
13 MR. WILSON: WELL, I'M JUST GONNA ASK HIM WHETHER
14 OR NOT HE AGREES THAT HE'S EXPECTED TO OBTAIN CONSULTATION.
15 I THINK HE CAN ANSWER THAT YES OR NO.
16 MR. STIRBA: YEAH, BUT SEE, I DON'T THINK --
17 THE COURT: WELL, THE SUBJECT OF WHETHER OR NOT HE
18 WANTS -- HE SHOULD OR SHOULD NOT, YOU CAN PROBE THAT WITH
19 HIM WHETHER HE SHOULD OR SHOULD NOT ASSOCIATE WITH PEOPLE
20 OUTSIDE HIS SPECIALTY ON THINGS. I DON'T THINK WE HAVE TO
21 HAMMER IT THROUGH, YOU KNOW, THIS SQUARE -- SQUARE HOLE IN A
22 ROUND PEG. YOU CAN ASK THE QUESTION AND GET TO THE ISSUE.
23 IT'S NOT GOING GO IN THROUGH THAT AREA, THOUGH. SO I MEAN
24 THE QUESTION, THE SUBJECT MATTER CAN BE -- HE CAN BE
25 CROSS-EXAMINED ON AND YOU CAN ASK HIM, YOU KNOW, WHETHER OR
3886
1 NOT HE FELT HE SHOULD OR, YOU KNOW, WHY DIDN'T HE.
2 MR. WILSON: OKAY.
3 THE COURT: OKAY. ANYTHING ELSE?
4 MR. WILSON: I HAVE NOTHING FURTHER, YOUR HONOR.
5 THE COURT: OKAY. THEN WHY DON'T YOU HAVE THE JURY
6 COME IN.
7 (JURY RETURNS TO THE COURTROOM.)
8 THE COURT: OKAY. YOU MAY BE SEATED. WELL, I
9 GUESS WE'RE MISSING ONE. YOU'RE ALL SUPPOSED TO COME IN
10 TOGETHER. MR. EDWARDS, WOULD YOU MAYBE TRY TO GO OUT AND
11 SEE -- WHY DOESN'T EVERYBODY JUST SIT DOWN UNTIL WE FIND THE
12 LOST JUROR.
13 OKAY. THE RECORD WILL REFLECT THAT THE JURY IS
14 PRESENT. I'M ALWAYS CONCERNED WHEN WE SAY WE'RE GONNA TAKE
15 A SHORT BREAK AND IT TAKES A LONGER TIME, THAT YOU'LL ALL GO
16 HOME AND NOT COME BACK, SO I'M GLAD YOU ALL STAYED HERE.
17 OKAY. MR. WILSON, IF YOU'D LIKE TO CONTINUE.
18 MR. WILSON: THANK YOU, YOUR HONOR.
19 Q. YOU PREVIOUSLY TESTIFIED, DOCTOR, THAT A SUBSTANTIAL
20 PART OF YOUR TRAINING RELATED TO THE PSYCHOTROPIC
21 MEDICATIONS AND SIDE EFFECTS, IS THAT CORRECT?
22 A. YES, SIR.
23 Q. I ASSUME THAT YOU ALSO RECEIVED TRAINING IN PAIN
24 MEDICATIONS, IS THAT CORRECT?
25 A. YES, SIR.
3887
1 Q. AND IN PARTICULAR, CERTAIN CENTRAL NERVOUS SYSTEM TYPE
2 DEPRESSANTS, IS THAT CORRECT?
3 A. YES, SIR.
4 Q. A NUMBER OF THE PSYCHOTROPIC MEDICATIONS THAT YOU DEAL
5 IN ON A DAILY BASIS ARE CENTRAL NERVOUS SYSTEM DEPRESSANTS
6 IN FACT, ARE THEY NOT?
7 A. YES, SIR.
8 Q. AND DO YOU AGREE WITH THE STATEMENT THAT IF YOU COMBINE
9 CENTRAL NERVOUS SYSTEM DEPRESSANTS WITH ONE ANOTHER THAT
10 THAT WOULD ENHANCE THE EFFECT UPON AN INDIVIDUAL?
11 A. ITS ADDITIVE EFFECT, YES, SIR.
12 Q. IT'S AN ADDITIVE EFFECT. AND WE'VE HEARD LOTS OF
13 TESTIMONY ABOUT HALF LIFES AND DURATION AND ALL OF THOSE
14 KINDS OF FACTORS. IS THAT A REFLECTION OF WHAT YOU'VE
15 HEARD, TOO?
16 A. YES, SIR.
17 Q. AND YOU UNDERSTAND OR DO YOU AGREE THAT IN PARTICULAR
18 WITH GERIATRIC PATIENTS, THAT THEY ARE MORE SENSITIVE TO THE
19 EFFECTS OF THESE TYPES OF MEDICATIONS?
20 A. OVERALL, YES, SIR.
21 Q. OKAY. DO YOU ALSO AGREE THAT IF A PATIENT IS SUFFERING
22 FROM VARIOUS DISEASE PROCESSES BECAUSE OF THE OLD AGE, THAT
23 THAT WOULD FURTHER SENSITIZE THEM IN RESPECT TO THESE TYPES
24 OF MEDICATIONS.
25 A. NO, SIR.
3888
1 Q. YOU DON'T AGREE?
2 A. WELL, THE FACT OF IN GENERAL OLD -- ELDERS ARE MORE
3 SUSCEPTIBLE IS DUE TO THE FACT THAT THEY FREQUENTLY HAVE
4 MEDICAL CONDITIONS.
5 Q. OKAY. DOES THE EFFECT OF MORPHINE -- IS ONE OF THE
6 EFFECTS OF MORPHINE A REDUCTION IN THE PERSON'S RESPIRATION?
7 A. IT CAN BE IN HIGHER DOSES, YES, SIR.
8 Q. OKAY. AND IN RESPECT TO THE USE OF MORPHINE, IF AN
9 INDIVIDUAL WAS SUFFERING FROM SOME OTHER FORMS OF
10 RESPIRATORY PROBLEMS SUCH AS PNEUMONIA, WOULD THAT
11 CONTRIBUTE TO THE ENHANCING EFFECT OF THAT PARTICULAR DRUG
12 OR TO THE DEPRESSION EFFECT OF THAT DRUG?
13 A. IT WOULD DEPEND. IT COULD CONTRIBUTE TO DEPRESSION OR
14 IT COULD ACTUALLY HELP THE BREATHING.
15 Q. I SEE. HAVE YOU DONE MUCH PAIN MANAGEMENT WORK IN YOUR
16 SPECIALTY AS A PSYCHIATRIST?
17 A. I WOULDN'T SAY ANY MORE OR LESS THAN ANY OTHER
18 PSYCHIATRIST.
19 Q. OKAY. MORE OR LESS THAN ANY OTHER PSYCHIATRIST.
20 A. YES, SIR.
21 Q. I TAKE IT YOU DO NOT PARTICIPATE ON A REGULAR BASIS IN
22 ANY KIND OF SURGICAL OR OPERATIONAL TYPE PROCEDURES, IS THAT
23 CORRECT?
24 A. NO, SIR, NOT AS A SURGEON.
25 Q. OKAY.
3889
1 A. AS A CONSULTANT PERHAPS, BUT --
2 Q. AS A CONSULTANT. SO YOU WOULD NOT ADMINISTER VARIOUS
3 TYPES OF ANESTHESIOLOGY OR DRUGS IN THAT CONTEXT, IS THAT
4 CORRECT?
5 A. IN SURGERY, NO, SIR.
6 Q. OKAY. AND IN RESPECT TO A SPECIALIZED AREA IN PAIN
7 MANAGEMENT, YOU HOLD NO BOARD CERTIFICATIONS OR ANY
8 SPECIALIZED EXPERTISE IN THOSE AREAS, DO YOU?
9 A. WELL, I'M A MEMBER OF THE AMERICAN ACADEMY OF PAIN
10 MANAGEMENT, BUT I DO NOT -- I'M NOT BOARD CERTIFIED IN PAIN
11 MANAGEMENT.
12 Q. I SEE. AMERICAN PAIN MANAGEMENT. AND IS THAT AN
13 ORGANIZATION THAT YOU SUBSCRIBE TO?
14 A. YES, SIR. I RECEIVE THEIR JOURNAL EVERY MONTH.
15 Q. I SEE. DID YOU HAVE TO TAKE ANY TESTS OR ANYTHING TO
16 BECOME A MEMBER OF THE AMERICAN ACADEMY OF PAIN MANAGEMENT?
17 A. NO, SIR.
18 Q. SO IT'S PRIMARILY AN INFORMATIONAL SOURCE FOR YOU?
19 A. ANY MEDICAL DOCTOR CAN JOIN THAT ORGRANIZATION. AND
20 IT'S AN INFORMATION SOURCE.
21 Q. DO YOU -- WELL, IT'S TRUE, IS IT NOT, THAT IN TERMS OF
22 AN INTERNAL MEDICINE, YOU DON'T HOLD YOURSELF OUT TO BE A
23 SPECIALIST IN THAT AREA OF THE PRACTICE?
24 A. PSYCHIATRY IS A BRANCH OF INTERNAL MEDICINE. SO I DON'T
25 HOLD MYSELF OUT AS AN INTERNIST. I'M A PSYCHIATRIST.
3890
1 Q. OKAY. IN RESPECT TO CARDIOLOGY, DO YOU HAVE ANY SPECIAL
2 EXPERTISE IN THAT AREA?
3 A. NO, SIR.
4 Q. DO YOU HAVE ANY SPECIAL EXPERTISE IN RADIOLOGY?
5 A. NO, SIR.
6 Q. DO YOU HAVE ANY SPECIAL EXPERTISE IN PHARMACOLOGY?
7 A. I STUDIED PHARMACOLOGY AS A MEDICAL STUDENT, BUT I'M NOT
8 A PHARMACOLOGIST.
9 Q. OKAY. YOU HAVE -- YOU'VE TESTIFIED THAT YOU'VE HAD SOME
10 ACQUAINTANCE AS AN INTERN WITH HOSPICE CARE.
11 A. YES, SIR. AND THROUGHOUT RESIDENCY.
12 Q. PARDON?
13 A. YES, SIR. AND THROUGHOUT RESIDENCY.
14 Q. THROUGHOUT RESIDENCY. DID YOU IN THAT SETTING TEND TO
15 PATIENTS WHO WERE HOSPICE CARE OR DETERMINED TO BE ELIGIBLE
16 FOR HOSPICE CARE?
17 A. YES, SIR.
18 Q. AS I UNDERSTAND IT, ONCE THAT DETERMINATION IS MADE,
19 HOSPICE CARE ESSENTIALLY TAKES PLACE IN A HOME ENVIRONMENT,
20 DOES IT NOT?
21 A. THAT'S ONE PLACE IT CAN OCCUR.
22 Q. FOR THE -- PRIMARILY FOR THE MOST PART, IT DOES TAKE
23 PLACE IN THAT PARTICULAR ENVIRONMENT, DOES IT NOT?
24 A. PROBABLY MORE THAN 50 PERCENT, YES, SIR.
25 Q. OKAY. AND IN RESPECT TO WHAT HOSPICE CARE -- I ASSUME
3891
1 THAT ONE OF THE REASONS IT TAKES PLACE IN THE HOME
2 ENVIRONMENT, BECAUSE THAT'S A SETTING THAT PEOPLE ARE MOST
3 COMFORTABLE IN.
4 A. YES, SIR.
5 Q. WOULD THAT BE A FAIR STATEMENT?
6 A. I THINK SO, YES, SIR.
7 Q. AND THAT'S AN IMPORTANT PART OF COMFORT CARE, IS IT NOT?
8 A. I THINK, YES, SIR. THE HOSPICE, THE WHOLE MOVEMENT HAS
9 TRIED TO TREAT PEOPLE IN THE HOME ENVIRONMENT RATHER THAN IN
10 INSTITUTIONAL SETTINGS.
11 Q. IN RESPECT TO SUCH OTHER AREAS OF EXPERTISE SUCH AS
12 ORTHOPEDICS, DO YOU HOLD YOURSELF OUT TO BE A SPECIALIST IN
13 ANY -- IN THAT?
14 A. NOT IN ORTHOPEDICS, NO.
15 Q. HOW ABOUT ANY KINDS OF FORENSIC PATHOLOGY --
16 A. NO.
17 Q. -- HAVE YOU GOT ANY EXPERTISE THERE?
18 A. NO.
19 THE COURT: WAIT UNTIL THE QUESTION'S DONE.
20 THE WITNESS: OKAY.
21 Q. (BY MR. WILSON) WE WERE TALKING A LITTLE BIT ABOUT THE
22 FISCAL ARRANGEMENTS THAT WERE MADE FOR YOU FOR PAYMENT AT
23 THE GEROPSYCH UNIT. I THINK I ASKED YOU, YOU WERE PAID BY
24 PATIENT ADMISSION, IS THAT CORRECT?
25 A. EARLIER I WAS CONFUSED AS TO YOUR QUESTION. I -- IT
3892
1 SOUNDED AS IF YOU WERE ASKING ME IF I WAS PAID BY HORIZONS
2 PER PATIENT ADMINISTRATION, IS THAT --
3 Q. THAT'S CORRECT.
4 A. NO, SIR, I WAS NOT.
5 Q. OKAY. HOW WERE YOU PAID BY HORIZON?
6 A. I WAS PAID HOURLY FOR MY ADMINISTRATIVE DUTIES ON THE
7 UNIT.
8 Q. AND -- AND THEN YOU WERE PAID BY DIRECT SERVICES FOR --
9 OR PROVIDED SERVICES TO THESE PATIENTS?
10 A. YES, SIR. I SAW THE PATIENTS ON THE UNIT AND BILLED FOR
11 THAT.
12 Q. IS IT TRUE THAT A PATIENT COMING ONTO THE UNIT, THAT YOU
13 WOULD HAVE -- BE ABLE TO SAY ASSESS FOR A PSYCHIATRIC
14 EVALUATION?
15 A. THEIR INITIAL DAY, I WOULD CHARGE BASICALLY FOR THE
16 PSYCHIATRIC EVALUATION AND TREATMENT THAT DAY.
17 Q. ANY OTHER FEES THAT YOU WOULD -- THAT YOU WOULD RECEIVE
18 AS A RESULT OF THAT PATIENT COMING ON TO THE UNIT AT
19 ADMISSION?
20 A. NO, SIR.
21 Q. SO BASICALLY, YOU GET THAT FEE AND THEN IF YOU PROVIDE
22 DAILY CARE, I ASSUME YOU RECEIVE THOSE MONEYS, TOO, IS THAT
23 CORRECT?
24 A. YES, SIR.
25 Q. AND YOU WOULD BILL OUT -- WHO WOULD YOU BILL OUT TO?
3893
1 WOULD YOU BILL OUT TO HORIZONS OR WOULD YOU BILL OUT TO THE
2 PARTICULAR PATIENT?
3 A. NEITHER.
4 Q. BILL OUT TO MEDICARE?
5 A. MEDICARE AND OTHER INSURANCE COMPANIES.
6 Q. OKAY. NOW, AS I UNDERSTAND IT, THIS WAS A FACILITY THAT
7 ALLOWED A MEDICARE PATIENT TO BE HOUSED FOR A LONGER PERIOD
8 OF TIME, IS THAT RIGHT?
9 A. LONGER --
10 Q. WELL, THERE WEREN'T THE RESTRICTIONS PLACED ON A
11 PATIENTS RECEIVING BENEFITS IN A GEROPSYCH UNIT THAT ARE
12 ORDINARILY RESTRICTED IN OTHER TYPES OF FACILITIES, IS THAT
13 CORRECT? IN TERMS OF PAYMENT?
14 A. I DON'T REALLY KNOW EXACTLY WHAT -- WHAT DO YOU MEAN?
15 Q. WELL, YOU WOULD BILL MEDICARE, IS THAT CORRECT?
16 A. YES, SIR.
17 Q. DID -- MEDICARE IMPOSES CERTAIN CRITERIA THAT THESE
18 PATIENTS HAVE TO FIT BEFORE YOU CAN PLACE THEM IN THE UNIT,
19 IS THAT CORRECT?
20 A. I THINK THAT WAS IMPOSED ON THE HOSPITAL. I DON'T THINK
21 IT WAS ON ME.
22 Q. SO YOU'RE NOT AWARE THAT YOU HAD ANY KIND OF
23 RESTRICTIONS ON YOU AS FOR WHAT YOU COULD BILL OUT TO
24 MEDICARE FOR THE CARE OF THESE PATIENTS.
25 A. WELL, I BILLED ONCE A DAY FOR MY SERVICES.
3894
1 Q. OKAY. NOW, YOU PREVIOUSLY TESTIFIED THAT AS TO THE FOUR
2 PATIENTS, WITH THE EXCEPTION OF ELLEN ANDERSON, THAT YOU
3 CONVERTED THEIR CARE TO HOSPICE CARE, IS THAT RIGHT?
4 A. I DON'T KNOW IF I SAID THAT. THEY BECAME ILL AND WE
5 GAVE THEM COMFORT CARE WHILE THEY WERE DYING, AND I SUPPOSE
6 THAT'S A FORM OF HOSPICE CARE.
7 Q. I SEE. IS THAT A TYPE OF TREATMENT THAT MEDICARE PAYS
8 FOR?
9 A. YES, SIR.
10 Q. ON A GEROPSYCH UNIT?
11 A. I DON'T KNOW ABOUT THAT.
12 Q. WERE YOU NOT CONCERNED, DOCTOR, THAT PROVIDING THAT
13 TREATMENT MAY RUN AFOUL OF THE POLICIES AND OPERATIONS OF
14 THE HOSPITAL?
15 A. AT THE TIME I WASN'T.
16 Q. OKAY. DID YOU IN FACT -- WELL, STRIKE THAT. ONE OF THE
17 CRITERIA THAT'S SET FORTH IN EXHIBIT 2 TALKS ABOUT -- AND
18 THIS IS THE INTAKE AND ADMISSION CRITERIA -- TALKS ABOUT THE
19 TOXIC EFFECTS FROM THERAPEUTIC PSYCHOTROPIC MEDICATIONS.
20 THAT WAS ONE OF THE CRITERIA.
21 A. EXHIBIT 2?
22 Q. I DON'T KNOW WHETHER WE HAVE IT AVAILABLE HERE OR NOT.
23 THE COURT: WHICH ONE IS IT? IS IT DEFENDANT'S OR
24 PLAINTIFF'S?
25 MR. WILSON: PLAINTIFF'S I THINK, YOUR HONOR.
3895
1 THE COURT: THIS IS THE PROBLEM WHEN WE HAVE ONE
2 COURT REPORTER -- OR ONE CLERK ON VACATION WHO TOOK ALL
3 THOSE EXHIBITS.
4 MR. WILSON: WELL, I CAN JUST SHOW HIM MY COPY AND
5 MAYBE ASK HIM THE QUESTION OFF THAT. FIRST OF ALL, I'LL
6 SHOW IT TO MR. STIRBA.
7 MR. STIRBA: THANK YOU.
8 Q. (BY MR. WILSON) I REPRESENT TO YOU FOR THE RECORD THAT
9 I THINK THIS IS DESIGNATED AS EXHIBIT 2, AND IT'S ENTITLED
10 DAVIS HOSPITAL MEDICAL CENTER AND SUBJECT ADMISSION CRITERIA
11 AS IT RELATES THE GEROPSYCHIATRIC UNIT. ASK YOU TO TAKE A
12 LOOK AT THAT DOCUMENT, IF YOU WOULD PLEASE.
13 A. YES.
14 Q. DO YOU RECOGNIZE THOSE CRITERIA?
15 A. JUST A SECOND, LET ME LOOK THROUGH HERE.
16 I'M SORRY, DID YOU MENTION SOMETHING ABOUT
17 EXCLUSIONARY CRITERIA?
18 Q. NO. I WAS TALKING ABOUT THE CRITERIA AS IT RELATES TO
19 PSYCHOTROPIC -- TOXICITY OF PSYCHOTROPIC --
20 A. UNDER ADMISSION CRITERIA, YES, SIR, I DO RECOGNIZE THIS.
21 Q. OKAY. SO ONE OF THE CRITERIA THAT'S SET FORTH IS FOR
22 PATIENTS, GERIATRIC PATIENTS WHO MAY BE SUFFERING FROM TOXIC
23 EFFECTS OF THERAPEUTIC PSYCHOTROPIC MEDICATIONS, RIGHT?
24 A. THAT WAS ONE OF THE ADMINISTRATION CRITERIA, YES, SIR.
25 Q. AND IF A PATIENT PRESENTED THEMSELVES TO YOU, YOU WOULD
3896
1 NEED TO EVALUATE FOR THAT PARTICULAR TYPE OF PROBLEM, WOULD
2 YOU NOT?
3 A. YES, SIR.
4 Q. DID YOU DO THAT IN RESPECT TO THESE PARTICULAR CASES?
5 A. YES, SIR.
6 Q. AND DID YOU IN DOING THAT REVIEW RECORDS FROM THE
7 INSTITUTIONS THAT HAD PREVIOUSLY BEEN RENDERING CARE?
8 A. IN ONE DEGREE OR ANOTHER, I SAW RECORDS I THINK ON ALL
9 THESE PEOPLE.
10 Q. IN ONE DEGREE OR ANOTHER.
11 A. YES, SIR. MAYBE NOT GOING BACK FOR YEARS, BUT AT LEAST
12 WHAT THEIR PREVIOUS MEDICATIONS HAD BEEN.
13 Q. BUT LET ME GET ONE THING CLEAR IN MY MIND. AS THE
14 MEDICAL DIRECTOR OF THE UNIT, WERE YOU NOT THE MEDICAL
15 DIRECTOR FINALLY AT ONE TIME?
16 A. I DON'T BELIEVE I WAS.
17 Q. OKAY. AS THE ASSOCIATE MEDICAL DIRECTOR, WERE THERE ANY
18 OTHER ASSOCIATE MEDICAL DIRECTORS OPERATING WITH YOU AT THE
19 TIME OF, SAY, DECEMBER THROUGH JAN -- DECEMBER OF '95
20 THROUGH JANUARY OF '96?
21 A. I WAS IT.
22 Q. YOU WERE IT. IN FACT, YOU'D BEEN IT FOR SOME TIME, HAD
23 YOU NOT?
24 A. SINCE MARCH OF THAT YEAR.
25 Q. SO THAT'S WHEN MR. JENSEN OR DR. JENSEN STEPPED DOWN?
3897
1 A. NO, SIR. HE WAS STILL MEDICAL DIRECTOR AT THAT TIME.
2 DURING DECEMBER OF '95 AND JANUARY '96.
3 Q. HE WAS STILL MEDICAL DIRECTOR?
4 A. YES, SIR.
5 Q. DID HE EVER COME INTO THE HOSPITAL DURING THAT TIME
6 FRAME?
7 A. HE CAME IN FROM TIME TO TIME.
8 Q. NOW, WE'VE HEARD HIS TESTIMONY PREVIOUSLY THAT THE TWO
9 OF YOU DIVIDED UP THE PATIENTS. DID HE TREAT PATIENTS
10 DURING THE TIME PERIOD OF DECEMBER '95 THROUGH JANUARY OF
11 '96?
12 A. I DON'T REMEMBER IF HE DID OR NOT.
13 Q. OKAY. THERE'S NO QUESTION THAT YOU WERE THE PRIMARY
14 PHYSICIAN, IS THAT CORRECT?
15 A. I HAD MOST OF THE PATIENTS AT THAT TIME.
16 Q. AS MEDICAL DIRECTOR OR AS ASSOCIATE MEDICAL DIRECTOR,
17 THOSE PATIENTS THAT YOU HAD CONTROL OVER, YOU WERE THE ONE
18 WHO MADE THE DECISION AS TO WHETHER OR NOT THEY WOULD BE
19 ACCEPTED TO THE UNIT, IS THAT RIGHT?
20 A. YES, SIR. AND I WAS THEIR ATTENDING PHYSICIAN.
21 Q. PARDON?
22 A. I WAS THE ATTENDING PHYSICIAN ON THOSE PARTICULAR
23 PATIENTS.
24 Q. AND AS ATTENDING PHYSICIAN, IT'S TRUE THAT ONCE THAT
25 DECISION WAS MADE TO ADMIT THEM, THERE WAS A PROCESS THEY
3898
1 WOULD GO THROUGH OF BEING PHYSICALLY EVALUATED?
2 A. YES, SIR.
3 Q. AND YOU WOULD DO THE PSYCHIATRIC EVAL?
4 A. YES, SIR.
5 Q. AND I THINK YOU TESTIFIED YOU'D DO A MENTAL STATUS
6 EVALUATION?
7 A. MENTAL STATUS EXAMINATION.
8 Q. EXAMINATION. AND THEN HOW WOULD YOU COMPLETE THAT
9 PSYCHIATRIC EVALUATION?
10 A. WELL, I WOULD GATHER THE HISTORY THAT WAS AVAILABLE FROM
11 PREVIOUS HOSPITALIZATIONS OR DOCTORS OR FAMILY, AND THE
12 NURSING ASSESSMENT, SOCIAL WORKER ASSESSMENT, AND MY
13 ASSESSMENT OF WHAT WAS GOING ON, AND DICTATE THE EVALUATION.
14 Q. AND AS PART OF THAT EVALUATION, YOU WOULD MAKE DECISIONS
15 RELATIVE TO A TREATMENT PLAN, IS THAT RIGHT?
16 A. YES, SIR.
17 Q. NOW, WE TALKED ABOUT THIS TEAM APPROACH THAT YOU WERE
18 INVOLVED IN. YOU WERE THE TEAM LEADER, IS THAT CORRECT?
19 A. I WAS DESIGNATED AS THE LEADER, YES, SIR.
20 Q. AND AS YOU'VE PREVIOUSLY TESTIFIED, YOU DID THE
21 DAY-TO-DAY TREATMENT OF PATIENTS IN THE MEDICAL UNIT.
22 A. YES, SIR.
23 Q. AND IF THERE WAS A PROBLEM AS TO A CASE, YOU WOULD BE
24 THE FINAL DECISION MAKER, IS THAT CORRECT?
25 A. YES, SIR.
3899
1 Q. SO IT'S TRUE AS THE ATTENDING PHYSICIAN, YOU ESSENTIALLY
2 DIRECT ALL OF THE CARE OF THE PATIENT.
3 A. YES, SIR.
4 Q. IT'S TRUE, IS IT NOT, THAT NURSES CANNOT PRESCRIBE
5 MEDICATIONS?
6 A. WELL, NO, SIR.
7 Q. EXCUSE ME, STRIKE THAT. THE NURSES ON THE GEROPSYCH
8 UNIT, WERE ANY OF THEM ELIGIBLE TO PRESCRIBE MEDICATIONS?
9 A. NOT AT THAT TIME, SIR.
10 Q. OKAY. SO ALL OF THE MEDICATION ORDERS FOR YOUR PATIENTS
11 CAME DIRECTLY FROM YOU.
12 A. NO, SIR.
13 Q. IN TERMS OF THE MEDICATIONS THAT WERE OF A PSYCHOTROPIC
14 NATURE, DID THOSE COME FROM YOU AS TO YOUR PATIENTS?
15 A. I THINK ALMOST HUNDRED PERCENT, YES, SIR.
16 Q. THE ONLY TIME, AS I UNDERSTAND IT, THAT THERE WOULD BE
17 OTHER MEDICATIONS WOULD BE IF A CONSULTANT RECOMMENDED
18 CERTAIN MEDICATIONS, OR I SHOULD SAY, PRESCRIBED CERTAIN
19 MEDICATIONS, IS THAT RIGHT?
20 A. WE HAD AN INFORMAL AGREEMENT THAT OTHER CONSULTANTS WERE
21 ALLOWED BY ME TO MAKE RECOMMENDATIONS, AND IF THEY FELT
22 NECESSARY, WRITE PRESCRIPTIONS, YES, SIR.
23 Q. OKAY. IN RESPECT TO THE FIVE PATIENTS THAT WE HAVE
24 BEFORE COURT HERE, CAN YOU THINK OF ONE INSTANCE WHERE A
25 CONSULTANT PRESCRIBED A MEDICATION?
3900
1 A. YES, SIR.
2 Q. AND WHICH INSTANCE WOULD THAT BE, SIR?
3 A. I BETTER GO TO THE PHYSICIAN'S ORDERS. FOR MRS. CRANE,
4 ON THE 1ST OF JANUARY '96, DR. DIENHART DECREASED HER
5 DURAGESIC PATCH TO 25 MICROGRAMS.
6 Q. OKAY. ISN'T IT TRUE, DOCTOR, YOU SUBSEQUENTLY RESCINDED
7 THAT ORDER AND INCREASED IT BACK TO 50 MICROGRAMS?
8 A. IT IS. SHALL I GO ON WITH THAT OR --
9 Q. IS THERE OTHER INSTANCES WHERE PHYSICIANS DIRECTED THE
10 PRESCRIPTION?
11 A. YES, THERE IS.
12 Q. OKAY. DO THAT, WOULD YOU PLEASE?
13 A. OKAY. OKAY. FOR MRS. LARSEN ON 12/8/95 MED RECORD WAS
14 453, DR. DIENHART ONCE AGAIN HAD ORDERED NISTANTIN AND
15 OXYGEN.
16 Q. I WAS REFERRING TO PSYCHOTROPIC MEDICATIONS, I THINK, IN
17 MY QUESTION.
18 A. OKAY. THEN I'LL RESTRICT THIS JUST TO THOSE.
19 OKAY. AND THEN ON THE 26TH, DR. DIENHART ORDERED
20 DILANTIN, WHICH WAS A PSYCHOTROPIC MEDICATION.
21 Q. CAN YOU TELL ME, HOW WAS THAT DILANTIN ORDERED?
22 A. I.V. I.V. LOAD WHICH MEANS BASICALLY, YOU START A LINE
23 AND PUT IT IN QUICKLY THROUGH A PIGGYBACK. HE ALSO ORDERED
24 ATIVAN I.V. ON THAT DATE.
25 Q. CAN YOU TELL US, WAS THE I.V. DISCONTINUED?
3901
1 A. YES, SIR.
2 Q. WHEN WAS IT DISCONTINUED?
3 A. ON THE 26TH, IT LOOKS LIKE ABOUT -- WHEN WAS IT? WELL,
4 ALL I CAN REALLY TELL IS ON THE 26TH, PROBABLY COUPLE HOURS
5 AFTER HE STARTED IT.
6 Q. OKAY. AND WHO DISCONTINUED THAT PARTICULAR ORDER?
7 A. I DID. I DISCONTINUED THE I.V.
8 Q. YOU DISCONTINUED THE I.V.?
9 A. YES, SIR.
10 Q. SO, CAN YOU TELL US WHETHER THE ATIVAN AND THE DILANTIN
11 WERE PRESCRIBED IN ANOTHER FORM? OR ADMINISTERED IN ANOTHER
12 FORM?
13 A. APPARENTLY NOT.
14 Q. OKAY. DOCTOR, YOU WOULD AGREE, WOULD YOU NOT, THAT THE
15 MONITORING OF A PATIENT IS VERY CRUCIAL IN YOUR ABILITY TO
16 ASSESS THE PATIENT'S PROGRESS OR DETERIORATION?
17 A. YES, SIR.
18 Q. AND YOU WOULD FURTHER AGREE THAT THE PATIENT NEEDS TO BE
19 EVALUATED IN SOME INSTANCES ON A DAILY BASIS, AND OTHER
20 INSTANCES, EVEN HOURLY, IS THAT CORRECT?
21 A. I'M SORRY. YOU ASKED ME TO LOOK THROUGH ALL THESE
22 RECORDS FOR INSTANCES OF OTHER DOCTORS PRESCRIBING --
23 Q. UH-HUH.
24 A. -- I HAVEN'T FINISHED. DO YOU WANT ME TO STOP NOW OR --
25 Q. YEAH, I DO.
3902
1 A. OKAY.
2 Q. IF YOU WOULD PLEASE.
3 A. WHAT WAS YOUR QUESTION AGAIN?
4 Q. MY QUESTION IS, WE TALKED ABOUT THE ASSESSMENT AND
5 MONITORING OF THE PATIENTS. AND YOU SAID IT'S VERY
6 CRITICAL, IT'S AN ESSENTIAL PART OF YOUR -- OF THE PROCESS,
7 IS THAT RIGHT?
8 A. TO MONITOR THE PATIENTS, YES, SIR.
9 Q. OKAY. AND IF YOU'RE PRESCRIBING CERTAIN TYPES OF
10 MEDICATIONS, I ASSUME THAT MONITORING NEEDS TO BE DONE IN
11 SOME INSTANCES ON A MORE FREQUENT BASIS THAN IT DOES IN
12 OTHER INSTANCES, IS THAT CORRECT?
13 A. YES, SIR.
14 Q. IN RESPECT TO THE ADMINISTRATION OF CERTAIN CENTRAL
15 NERVOUS SYSTEM DEPRESSANTS, IT IS NOT CRITICAL THEN TO
16 MONITOR THOSE DRUGS ON A FREQUENT BASIS?
17 A. YES, SIR, DEPENDING ON THE DEFINITION OF FREQUENT, I
18 THINK YES.
19 Q. AND YOU TELL ME, IF YOU WERE ADMINISTERING MORPHINE HOW
20 FREQUENTLY DO YOU ADMONISH -- DO YOU MONITOR THE PATIENT'S
21 RESPIRATIONS AND OTHER VITAL FUNCTIONS?
22 MR. STIRBA: YOUR HONOR, I'M GONNA OBJECT TO THAT
23 QUESTION AS IRRELEVANT, YOUR HONOR. WITH RESPECT TO THE
24 CARE OF THESE FIVE PATIENTS, I DON'T HAVE AN OBJECTION TO
25 IT.
3903
1 THE COURT: WERE YOU ASKING ABOUT THESE FIVE
2 PATIENTS?
3 MR. WILSON: WELL, I THINK -- I THINK HIS
4 FAMILIARITY WITH IN GENERAL, YOUR HONOR, IS IMPORTANT IN
5 RESPECT TO --
6 THE COURT: OKAY. WELL, LET'S DEAL WITH THAT SHORT
7 BACKGROUND AND THEN GET TO THE PATIENTS.
8 Q. (BY MR. WILSON) YOU'VE PREVIOUSLY AGREED, DOCTOR, THAT
9 IT NEEDS TO BE -- CERTAIN MEDICATIONS NEED TO BE MONITORED
10 MORE FREQUENTLY.
11 A. YES, SIR.
12 Q. THE QUESTION WAS, IN YOUR EXPERIENCE AS TO MORPHINE, HOW
13 OFTEN DO YOU MONITOR, SAY, THE VITAL STATS OR THE VITAL
14 SIGNS OF A PATIENT?
15 A. I WOULD EXPECT THE NURSES WOULD PROBABLY MONITOR AFTER
16 EACH DOSE.
17 Q. SO IT WOULD DEPEND ON THE ROUTINE OF THE DOSAGE?
18 A. YES, SIR. HOW IT -- YOU MEAN THE FREQUENCY OF THE
19 DOSAGE, YES, SIR --
20 Q. YES.
21 A. -- INTERVAL.
22 Q. AND YOU RELY HEAVILY ON THOSE NURSES' OBSERVATIONS, DO
23 YOU NOT?
24 A. ABSOLUTELY.
25 Q. I ASSUME THAT YOU ALSO RELY ON THE NURSES TO ALERT YOU
3904
1 IF THERE ARE ANY PROBLEMS ASSOCIATED WITH THE PATIENTS, IS
2 THAT CORRECT?
3 A. YES, SIR.
4 Q. AND I ASSUME YOU HAVE A GOOD RELATIONSHIP OR DID HAVE A
5 GOOD RELATIONSHIP WITH THE NURSES ON THE GEROPSYCH UNIT, IS
6 THAT CORRECT?
7 A. WITH SOME BETTER THAN OTHERS.
8 Q. OKAY. BUT YOU GENERALLY HAD CONFIDENCE IN THEIR
9 ABILITIES TO ASSESS AND EVALUATE THE PATIENTS, IS THAT TRUE?
10 A. OVERALL, YES.
11 Q. IF YOU HAVE CONFIDENCE IN THEIR ABILITIES TO MONITOR AND
12 ASSESS THE PATIENTS, CAN YOU TELL ME WHETHER OR NOT YOU
13 WOULD ALLOW THEM TO USE THEIR DISCRETION IN TERMS OF
14 ADMINISTERING THESE MEDICATIONS?
15 MR. STIRBA: I'M GONNA OBJECT AS TO RELEVANCY, YOUR
16 HONOR. IT'S NOT WITH RESPECT TO THESE FIVE PATIENTS. IT'S
17 A BROAD HYPOTHETICAL.
18 MR. WILSON: I'LL LIMIT THAT ONE TO THESE FIVE
19 PATIENTS.
20 Q. DID YOU ALLOW THE NURSES IN THE INSTANCE OF THESE FIVE
21 PATIENTS THE ABILITY TO ASSESS AND DETERMINE WHETHER OR NOT
22 THE MEDICATIONS SHOULD BE ADMINISTERED?
23 A. MANY OF THESE PATIENTS HAD P.R.N. MEDICATIONS, AND THAT
24 IS IN THE PURVIEW OF THE NURSE TO MAKE THAT DECISION --
25 Q. OKAY.
3905
1 A. -- WHETHER OR NOT -- SO THE ANSWER IS YES.
2 Q. IN RESPECT TO THE USE OF MORPHINE, DOCTOR, AS IT RELATES
3 TO THESE FIVE PATIENTS --
4 A. YES, SIR, I'M TALKING ABOUT P.R.N. MORPHINE.
5 Q. OKAY. DO YOU KNOW HOW MANY TIMES YOU ALLOWED A P.R.N.
6 MORPHINE DOSAGE TO BE ADMINISTERED TO THESE FIVE PATIENTS?
7 A. I'D HAVE TO -- NO, SIR, I DON'T HAVE THAT JUST OFF THE
8 TOP OF MY HEAD. I GUESS IN THE SENSE THAT THEY COULD JUST
9 ABOUT GIVE IT AT ANY TIME, SOME AS OFTEN AS EVERY TWO HOURS,
10 I GUESS IT WAS PRETTY FREQUENT.
11 Q. AS I UNDERSTAND IT, DOCTOR, P.R.N. MEANS AS NEEDED.
12 A. YES, SIR.
13 Q. IF IT'S A ROUTINE ORDER EVERY THREE HOURS OR EVERY FOUR
14 HOURS, THAT MEANS THEY ADMINISTERED IT, DOES IT NOT?
15 A. GENERALLY, YES, SIR.
16 Q. GENERALLY. NURSE HAS A DUTY IN AND OF HERSELF TO
17 EVALUATE A PATIENT TO SEE WHETHER OR NOT THEY'RE -- THE DRUG
18 IS HAVING A TOXIC EFFECT, DON'T THEY?
19 A. YES, SIR, A DUTY.
20 Q. AND THEY HAVE A DUTY NOT TO HARM THE PATIENT, DON'T
21 THEY?
22 A. YES, SIR.
23 Q. AND SO THEY COULD WITHHOLD THAT PARTICULAR
24 ADMINISTRATION OF THE DRUG, ISN'T THAT RIGHT?
25 A. YES, SIR.
3906
1 Q. BUT THEN THEY WOULD HAVE TO ACCOUNT TO YOU FOR THAT, IS
2 THAT CORRECT?
3 A. WHAT DOES THAT MEAN?
4 Q. WELL, IF THEY WITHHOLD THE MEDICATION THAT YOU'VE
5 ORDERED TO BE ADMINISTERED, I ASSUME THAT YOU'RE GOING TO
6 WANT TO KNOW WHY.
7 A. YES, SIR.
8 Q. AND IF YOU DISAGREE WITH THAT, YOU'RE GONNA TELL THEM
9 SO, AREN'T YOU?
10 A. MOST LIKELY, YES, SIR.
11 Q. AND YOU DID SO IN THIS PARTICULAR CASE, DIDN'T YOU?
12 A. IN ONE INSTANCE, YES, SIR.
13 Q. AND THAT WAS THE NURSE THAT WITHHELD MEDICATIONS AS IT
14 RELATED TO -- I THINK IT WAS JUDITH LARSEN, WASN'T IT?
15 A. YES, SIR.
16 Q. AND IN FACT, YOU WERE UPSET WITH THAT, WEREN'T YOU?
17 A. I WAS CONCERNED.
18 Q. YOU WERE CONCERNED?
19 A. YES, SIR.
20 Q. YOU WERE SO CONCERNED, YOU WROTE A NOTE THAT YOU DIDN'T
21 WANT ANY MORE MORPHINE WITHHELD UNLESS YOU WERE CALLED, IS
22 THAT RIGHT?
23 A. NO, SIR.
24 Q. YOU DIDN'T SAY THAT?
25 A. ON THE 3RD, I WROTE AN ORDER SAYING IF ANY MORPHINE IS
3907
1 TO BE WITHHELD, PLEASE CALL ME FIRST.
2 Q. OKAY. SO I GUESS WE'RE TALKING A BIT OF SEMANTICS HERE.
3 THE QUESTION WAS, YOU DIDN'T WANT ANY MORPHINE WITHHELD
4 UNLESS YOU WERE CALLED.
5 A. WELL, SEE, IT DOESN'T SAY, DON'T HOLD IT. IT JUST SAYS,
6 IF IT'S GOING TO BE WITHHELD, PLEASE CALL ME.
7 Q. I SEE. I ASSUME THE NURSE DID NOT WITHHOLD ANY MORE
8 MORPHINE, IS THAT CORRECT?
9 A. OFF THE TOP OF MY HEAD, I WOULDN'T KNOW. ARE YOU
10 TALKING ABOUT TRACY SCHOLLS?
11 Q. AS TO JUDITH LARSEN.
12 A. I DON'T THINK SHE WAS WORKING WITH MISS LARSEN ANYMORE.
13 SO I GUESS SHE DIDN'T.
14 Q. DO YOU REMEMBER WHY THE NURSE WITHHELD THE MORPHINE AS
15 IT RE -- IN RESPECT TO MISS LARSEN?
16 A. YES, SIR.
17 Q. WHY WAS THAT?
18 A. SHE CHARTED THAT THE RESPIRATORY RATE WAS LOW.
19 Q. IN FACT, THOSE RESPIRATORY RATES I THINK SHOWED 6, 6,
20 AND 8 OR IN THAT NEIGHBORHOOD FOR THE LAST 24-HOUR PERIOD,
21 IS THAT RIGHT?
22 A. NO, SIR.
23 Q. YOU DON'T RECALL THAT?
24 A. NO, YOU'RE NOT RIGHT.
25 Q. DO YOU RECALL THAT SHE'S -- SHE CHARTED THAT THEY WERE 5
3908
1 TO 8?
2 A. YES, SIR.
3 Q. I GUESS THAT DOESN'T COMPORT WITH 6, 6, AND 8?
4 A. YOU SAID FOR THE LAST 24-HOUR PERIOD. HER REPORTING HAD
5 TO DO WITH A PERIOD OF I THINK AROUND TEN OR 12 HOURS, WHICH
6 OCCURRED, OH, PERHAPS 30 HOURS BEFORE HER DEATH UNTIL ABOUT
7 20 HOURS BEFORE HER DEATH. SHE HAD LATER RESPIRATORY RATES
8 WHICH WERE HIGHER THAN THAT.
9 Q. YOU USE --
10 A. I HAVE THE CHART RIGHT HERE. IF YOU'D LIKE ME, I --
11 Q. DO YOU USE -- DOCTOR, DO YOU USE THE P.D.R. AS A
12 REFERENCE FOR ADMINISTRATION OF MEDICATION?
13 A. YES, SIR, OCCASIONALLY I DO.
14 Q. AND DO YOU EVER USE THE GERIATRIC DOSING HANDBOOK IN
15 YOUR SPECIALTY AS GERIATRIC PSYCHIATRIST?
16 A. I NEVER USED IT BEFORE THIS TRIAL.
17 Q. SO YOU DIDN'T USE IT BACK DURING THIS RELEVANT TIME
18 FRAME?
19 A. NO, SIR. I USED OTHER GUIDEBOOKS AT THAT TIME.
20 Q. I SEE. WHAT BOOKS DID YOU USE, DOCTOR?
21 A. TEXTBOOK OF GERIATRIC PSYCHIATRY. THE AMERICAN MEDICAL
22 ASSOCIATION DRUG EVALUATION. THOSE SORTS.
23 Q. NOW, IN THE P.D.R., IN THE 1995 P.D.R., I'M GONNA READ A
24 STATEMENT AND YOU TELL ME WHETHER YOU DISAGREE -- AGREE OR
25 DISAGREE. RESPIRATORY DEPRESSION -- THIS IS UNDER WARNINGS
3909
1 FOR MORPHINE SULFATE. CLINICAL PHARMACOLOGY .
2 A. '95 P.D.R.
3 Q. '95 P.D.R. RESPIRATORY DEPRESSION IS THE CHIEF HAZARD
4 OF ALL MORPHINE PREPARATIONS. RESPIRATORY DEPRESSION OCCURS
5 MOST FREQUENTLY IN ELDERLY AND DEBILITATED PATIENTS.
6 WOULD YOU AGREE WITH THAT STATEMENT?
7 A. I REALLY DON'T KNOW IF I COULD OR NOT. I DON'T KNOW
8 WHERE THEY GOT THAT EXACTLY. IT'S KIND OF --
9 Q. WELL, I'LL GO ON AND READ A LITTLE BIT FURTHER. AND
10 THOSE SUFFERING FROM CONDITIONS ACCOMPANIED BY HYPOXIA OR
11 HYPO -- HYPERCAPNIA, AND EVEN MODERATE THERAPEUTIC DOSES MAY
12 BE DANGEROUS -- MAY DANGEROUSLY DECREASE PULMONARY
13 VENTILATION.
14 A. IN A GENERAL WAY, I CAN AGREE WITH THAT.
15 Q. IN A GENERAL WAY.
16 A. YES, SIR.
17 Q. ISN'T THAT WHAT WE'RE DEALING HERE WITH THESE FIVE
18 PATIENTS WAS ELDERLY AND DEBILITATED PATIENTS?
19 A. WE'RE NOT DEALING GENERALLY HERE. WE'RE DEALING WITH
20 INDIVIDUAL PATIENTS.
21 Q. ISN'T -- WEREN'T EACH ONE OF THOSE PATIENTS -- THEY WERE
22 OBVIOUSLY OF GERIATRIC AGE --
23 A. YES, SIR.
24 Q. -- ISN'T THAT CORRECT?
25 A. OBVIOUSLY.
3910
1 Q. AND ISN'T YOUR TESTIMONY HERE IN COURT TODAY THAT THEY
2 WERE ALL SUFFERING FROM VARIOUS DISEASES PROCESSES AT THE
3 TIME --
4 A. YES, SIR.
5 Q. -- OF THEIR ADMISSION?
6 A. YES, SIR.
7 Q. BUT YET, YOU ADMITTED THOSE PATIENTS TO THE GERIATRIC
8 UNIT, DIDN'T YOU?
9 A. YES, SIR.
10 Q. YOU CONSIDERED THEM STABLE ENOUGH TO ADMIT TO THE
11 GERIATRIC UNIT, DIDN'T YOU?
12 A. YES, SIR.
13 Q. DO YOU BELIEVE THAT THE DURATION OF EFFECT OF MORPHINE
14 IS LONGER IN THE ELDERLY?
15 A. AS A GENERAL STATEMENT, THAT'S TRUE, BUT IN INDIVIDUAL
16 CASES, IT MAY BE THE SAME AS ANY OTHER ADULT.
17 Q. AND TO DETERMINE IN THOSE INDIVIDUAL CASES, YOU NEED TO
18 ASSESS AND MONITOR THE PATIENT, RIGHT?
19 A. YES, SIR.
20 Q. DO YOU BELIEVE THAT IF MORPHINE IS GIVEN IN SUFFICIENT
21 QUANTITIES THAT IT CAN RESULT IN DEATH?
22 A. YES, SIR.
23 Q. LET ME SHOW YOU WHAT'S BEEN MARKED AS STATE'S EXHIBIT 40
24 AND ASK YOU TO TAKE A LOOK AT THAT IF YOU WOULD PLEASE.
25 A. I'VE SEEN IT BEFORE.
3911
1 Q. OKAY. AS TO THE IMMEDIATE EFFECTS THAT ARE LISTED THERE
2 ON THAT PARTICULAR EXHIBIT, PAIN RELIEF, YOU AGREE WITH
3 THAT?
4 A. IF IT'S GIVEN IN A SUFFICIENT QUANTITY, YES, SIR.
5 Q. SLEEPINESS AND COMA. IS THAT AN IMMEDIATE EFFECT OF
6 MORPHINE?
7 A. IF ENOUGH IS GIVEN.
8 Q. OKAY.
9 A. SOME DOSES ACTUALLY MIGHT GET AN INCREASED ALERTNESS.
10 Q. DECREASED BREATHING. IS THAT AN IMMEDIATE EFFECT OF
11 MORPHINE?
12 A. IN A HIGH ENOUGH DOSE.
13 Q. LOSS OF COUGH REFLEX, ASPIRATION. CAN THAT BE AN EFFECT
14 OF MORPHINE, AN IMMEDIATE EFFECT?
15 A. THE LOSS OF COUGH REFLEX I BELIEVE IS TRUE.
16 ASPIRATION'S NOT NECESSARILY TRUE AT ALL.
17 Q. OKAY. LOW BLOOD PRESSURE. COULD THAT BE AN IMMEDIATE
18 EFFECT OF MORPHINE?
19 A. I'M NOT SURE ABOUT THAT ONE. I'VE BEEN TOLD THAT IT'S
20 NOT.
21 Q. WHAT'S HYPOXIA?
22 A. HYPOXIA MEANS VERY LITTLE OXYGEN.
23 Q. SO IF THERE IS VERY LITTLE OXYGEN, IS HYPOXIA SOMETHING
24 THAT'S A RESULT, AN IMMEDIATE EFFECT OF MORPHINE?
25 A. NO, SIR.
3912
1 Q. YOU DON'T BELIEVE THAT?
2 A. NO, SIR.
3 Q. EVEN THOUGH I JUST READ YOU THE P.D.R. THAT SAYS IT IS?
4 A. WELL, SOME PEOPLE BREATHE BETTER WHEN THEY'VE HAD A
5 LITTLE MORPHINE, SO YOU COULD ACTUALLY HAVE AN IMPROVEMENT
6 IN THEIR OXYGENATION.
7 Q. SO YOU DISAGREE WITH IT.
8 A. YES, SIR.
9 Q. DECREASED FOOD AND WATER INTAKE, WOULD THAT BE AN
10 IMMEDIATE EFFECT THAT COULD RESULT AS A --
11 A. NO, SIR.
12 Q. -- MORPHINE? NO?
13 A. NO, SIR.
14 Q. IF A PERSON --
15 A. OH, I'M SORRY, DID YOU SAY, COULD IT BE?
16 Q. YES.
17 A. OH, YES, SIR, IT COULD BE.
18 Q. AND IT'S A SECONDARY EFFECT, RIGHT?
19 A. YES, SIR.
20 Q. IF A PERSON IS SO SEDATED THAT THEY CAN'T TAKE IN FOOD
21 AND WATER, OBVIOUSLY, THAT'S AN EFFECT OF THE MORPHINE, IS
22 IT NOT?
23 A. IT COULD BE.
24 Q. WELL, I GUESS THE QUESTION WAS TO YOU, IF THE PERSON IS
25 SO SEDATED AND THEY CAN'T TAKE IN FOOD AND THEY CAN'T DRINK
3913
1 WATER, THAT'S AN EFFECT THAT THE MORPHINE -- THAT'S A RESULT
2 OF THE EFFECT OF THE MORPHINE, ISN'T IT?
3 MR. STIRBA: I'M GONNA OBJECT. RELEVANCY.
4 HYPOTHETICAL. IT'S NOT DEALING WITH THESE FIVE PATIENTS.
5 AND IT'S CERTAINLY BEYOND THE SCOPE OF DIRECT EXAMINATION.
6 THE COURT: OKAY. ARE YOU ASKING ABOUT THESE FIVE
7 PATIENTS?
8 MR. WILSON: WELL, AGAIN, YOUR HONOR, I THINK WE'RE
9 TALKING ABOUT THE EFFECTS OF THE USE OF MORPHINE AND WE'RE
10 JUST -- I'M JUST ASKING HIM THE QUESTION OF WHETHER OR NOT
11 THAT CAN BE AN EFFECT.
12 MR. STIRBA: BUT HE'S NOT HERE AS AN EXPERT. HE'S
13 HERE TAKING THE STAND ABOUT WHAT HE DID FACTUALLY WITH
14 RESPECT TO THESE FIVE PATIENTS, AND THAT'S WHAT HE CAN
15 TESTIFY ABOUT.
16 MR. WILSON: I WANT TO KNOW WHETHER HE BELIEVES
17 WHETHER OR NOT DECREASED FOOD AND WATER INTAKE CAN BE A
18 RESULT OF EFFECT OF MORPHINE. THAT'S ALL I'M ASKING.
19 THE COURT: OKAY. CAN YOU ANSWER THAT QUESTION?
20 THE WITNESS: YES, YOUR HONOR, IT COULD BE.
21 Q. (BY MR. WILSON) OKAY. NOW, YOU SEE ON THE OTHER SIDE
22 OF THE BOARD, THE LONG-TERM EFFECTS?
23 A. YES, SIR.
24 Q. PNEUMONIA?
25 A. I SEE IT.
3914
1 Q. IS THAT A LONG-TERM EFFECT OR CAN THAT BE A LONG-TERM
2 EFFECT OF MORPHINE?
3 MR. STIRBA: OBJECT. IRRELEVANT, BEYOND THE SCOPE,
4 AND NOT DEALING WITH THESE PARTICULAR FIVE PATIENTS.
5 THE COURT: ARE YOU JUST GONNA GO THROUGH EACH ONE
6 OF THESE?
7 MR. WILSON: YES, I'M JUST GONNA ASK HIM --
8 THE COURT: OKAY. I'LL LET YOU GO THROUGH THAT,
9 AND THEN LET'S GET TO THE FIVE PATIENTS.
10 Q. (BY MR. WILSON) ALL RIGHT. ORGAN DAMAGE?
11 A. NO, SIR.
12 Q. YOU DON'T BELIEVE MORPHINE CAN CAUSE ORGAN DAMAGE.
13 A. WELL, THE EXPERT THE OTHER DAY TESTIFIED THAT ORGAN
14 DAMAGE IS NOT CAUSED BY MORPHINE. OPIOIDS DO NOT --
15 Q. I'M ASKING YOU WHAT YOU BELIEVE.
16 A. I DO NOT BELIEVE THAT ORGAN DAMAGE IS CAUSED BY
17 MORPHINE.
18 Q. OKAY. DO YOU THINK ORGAN DAMAGE CAN RESULT AS A
19 SECONDARY EFFECT OF MORPHINE?
20 MR. STIRBA: YOUR HONOR, I'M GONNA OBJECT.
21 IRRELEVANT. HE'S ALREADY ASKED ABOUT IT.
22 THE COURT: OVERRULED.
23 THE WITNESS: CAN YOU -- YOU'RE TALKING ABOUT AS
24 A --
25 Q. (BY MR. WILSON) SECONDARY EFFECT OF MORPHINE.
3915
1 A. YES, SIR.
2 Q. HOW ABOUT DEHYDRATION, MALNUTRITION?
3 A. NOT A PRIMARY LONG-TERM EFFECT. IT COULD BE SECONDARY.
4 MR. WILSON: OKAY. MAY I HAVE JUST A MINUTE, YOUR
5 HONOR?
6 THE COURT: YES.
7 Q. (BY MR. WILSON) DOCTOR, DO YOU HAVE THE EXHIBIT ON
8 ELLEN ANDERSON?
9 A. THE GRAY FOLDER HERE? YES, SIR.
10 Q. YOU TESTIFIED TODAY THAT YOU HAVE A RECOLLECTION I GUESS
11 OF ELLEN ANDERSON, IS THAT CORRECT?
12 A. YES, SIR.
13 Q. AND ELLEN ANDERSON WAS ADMITTED TO THE GEROPSYCH UNIT ON
14 THE 29TH OF DECEMBER, IS THAT CORRECT?
15 A. YES, SIR, OF '95.
16 Q. FIRST OF ALL, DOCTOR, DID YOU ENTER SOME TELEPHONE
17 ORDERS AS TO ELLEN ANDERSON'S CARE?
18 A. YES, SIR.
19 Q. DO YOU KNOW WHEN THESE ORDERS WERE ENTERED?
20 A. ON THE 29TH AND 30TH.
21 Q. THE FIRST ORDERS THAT WERE ENTERED, DOCTOR, WHEN WERE
22 THEY ENTERED?
23 A. ON THE 29TH.
24 Q. AT WHAT TIME?
25 A. IT'S IMPOSSIBLE TO TELL EXACTLY, BUT THEY WERE NOTED AT
3916
1 2130. AND SOME OF THE MEDICATION FROM THESE ORDERS WAS
2 GIVEN AT WHAT WOULD BE 1930.
3 Q. IN FACT, THE MORPHINE, THE 10 MILLIGRAMS OF MORPHINE
4 THAT YOU ORDERED WAS GIVEN --
5 A. EXACTLY.
6 Q. -- AT 9:30, WASN'T IT?
7 A. 7:30.
8 Q. 7:30, EXCUSE ME.
9 A. 1930, YES, SIR.
10 Q. IS IT YOUR TESTIMONY HERE TODAY THAT YOU DID THIS MENTAL
11 STATUS EVALUATION OF ELLEN ANDERSON ON THE 29TH?
12 A. YES, SIR.
13 Q. DO YOU REMEMBER WHAT TIME YOU DID THAT, DOCTOR?
14 A. NO, NOT PRECISELY. SOMETIME AROUND 5:00 P.M.
15 Q. AROUND 5:00 P.M.?
16 A. YES, SIR.
17 Q. AND DO YOU REMEMBER WHERE THAT MENTAL STATUS EVALUATION
18 WAS CONDUCTED?
19 A. IT WAS IN THE GEROPSYCH UNIT.
20 Q. DID YOU SEE ANY OTHER PATIENTS AT THAT TIME?
21 A. I DON'T RECALL IF I DID OR NOT. I WOULD HAVE SEEN ALL
22 THE PATIENTS THAT DAY.
23 Q. IN FACT, YOU'D SEEN THEM ALL EARLIER THAT DAY, IS THAT
24 RIGHT?
25 A. BELIEVE SO.
3917
1 Q. DO YOU RECALL WHETHER OR NOT THERE WERE ANY OTHER
2 PATIENTS ADMITTED TO THE GEROPSYCH UNIT ON THAT DAY?
3 A. YES, SIR.
4 Q. DO YOU RECALL WHO THAT WAS?
5 A. NO, SIR.
6 Q. DID YOU SEE THAT PATIENT ON THAT DAY?
7 A. WELL, THERE WERE TWO OTHERS ADMITTED THAT DAY, BUT I
8 DON'T RECALL THEIR NAMES.
9 Q. THERE WERE TWO OTHER PATIENTS ADMITTED THAT DAY?
10 A. YES, SIR.
11 Q. BUT YOU THINK SOMETIME AROUND 5:00 O'CLOCK, YOU VISITED
12 WITH ELLEN ANDERSON?
13 A. YES, SIR.
14 Q. THAT'S ACCORDING TO YOUR RECOLLECTION.
15 A. YES, AND AS -- WHAT DO YOU CALL IT, REFRESHED BY THIS
16 CHART.
17 Q. BUT YOU DIDN'T DICTATE YOUR REPORT AT THAT TIME, IS THAT
18 CORRECT?
19 A. THAT'S CORRECT.
20 Q. DID YOU MAKE NOTES?
21 A. YES, SIR.
22 Q. AND WHERE DID YOU MAKE THOSE NOTES?
23 A. WELL, LET'S SEE, IN THE PROGRESS NOTES, PHYSICIAN
24 PROGRESS NOTES.
25 Q. SO WOULD YOU HAVE MADE THOSE NOTES JUST AFTER YOU DID
3918
1 THE MENTAL ASSESSMENT ON HER?
2 A. MOST LIKELY, YES, SIR.
3 Q. WAS ANYBODY PRESENT IN THE ROOM WHILE YOU DID THAT
4 MENTAL ASSESSMENT ON HER?
5 A. I DON'T REMEMBER.
6 Q. YOU DON'T REMEMBER?
7 A. NO, SIR, I DON'T RECALL AT ALL.
8 Q. OKAY. DO YOU REMEMBER WHETHER IT WAS THE ROOM SHE WAS
9 ASSIGNED TO THAT YOU'D CONDUCTED THIS IN?
10 A. I CAN'T TELL YOU IF IT WAS IN A ROOM. IT COULD HAVE
11 BEEN IN A HALLWAY OR IT COULD HAVE BEEN DOWNSTAIRS AT
12 ADMITTING. COULD HAVE BEEN PRETTY MUCH ANYWHERE IN THE
13 HOSPITAL.
14 Q. AND HOW LONG DID THIS ASSESSMENT TAKE YOU?
15 A. I DON'T RECALL PRECISELY.
16 Q. AND YOU'D PREVIOUSLY CALLED IN THE TELEPHONE ORDER? OR
17 DID YOU WAIT UNTIL AFTER THE ASSESSMENT TO CALL IN THE
18 TELEPHONE ORDERS?
19 A. I CALLED THEM IN AFTER THE ASSESSMENT.
20 Q. WELL, IF YOU WERE AT THE HOSPITAL MAKING THE ASSESSMENT
21 AND YOU HAD TIME TO WRITE IN YOUR NOTES, WHY DIDN'T YOU AT
22 THAT TIME JUST WRITE IN THE ORDERS?
23 A. WELL, I HAVE A CELL PHONE AND I COULD CALL IT IN.
24 Q. SO DID YOU CALL FROM THE HOSPITAL?
25 A. I REALLY DON'T KNOW WHERE I CALLED FROM. MIGHT HAVE
3919
1 BEEN THE HOSPITAL, MY CAR, MY HOUSE, I DON'T KNOW.
2 Q. DO YOU REMEMBER RECEIVING A NUMBER OF PAGES ON THAT
3 PARTICULAR DATE?
4 A. NO, SIR.
5 Q. YOU DO?
6 A. I DON'T REMEMBER ANY SPECIFIC PAGES. I GET PAGED WHEN
7 I'M PRACTICING 20 OR 30 TIMES A DAY. I'M SURE I GOT PAGED
8 THAT DAY.
9 Q. DO YOU REMEMBER ANY PAGES IN CONNECTION WITH JUDITH
10 LARSEN?
11 A. NOT SPECIFICALLY.
12 Q. IF I WERE TO TELL YOU THE RECORDS REFLECT YOU WERE PAGED
13 ABOUT SIX TIMES FROM 7:00 O'CLOCK UNTIL 3:15, WOULD YOU HAVE
14 ANY RECOLLECTION OF THAT, SIR?
15 A. WOULD THAT BE WHAT DATE, THE 29TH?
16 Q. 29TH.
17 A. NO, SIR, I WOULDN'T.
18 Q. BUT YOU WOULDN'T TAKE ISSUE WITH THAT, I TAKE IT?
19 MR. STIRBA: WELL, I'M --
20 THE WITNESS: NOT ON THE FACE OF IT.
21 Q. (BY MR. WILSON) YOU PREVIOUSLY TESTIFIED ABOUT A
22 CONVERSATION YOU HAD WITH -- I THINK IT WAS LAURIE WILLSON,
23 NOW STEVENSON, IS THAT CORRECT?
24 A. YES, SIR.
25 Q. DID YOU ORDER MORPHINE IN YOUR ORIGINAL TELEPHONE ORDER?
3920
1 A. I BELIEVE I DID. YES, SIR.
2 Q. WAS THAT BEFORE OR AFTER YOU TALKED WITH LAURIE
3 STEVENSON?
4 A. WHEN I ORDERED THE MORPHINE?
5 Q. UH-HUH.
6 A. I WOULD THINK I WOULD HAVE ORDERED IT WHEN I TALKED WITH
7 LAURIE STEVENSON. SHE TOOK THE ORDER.
8 Q. NOW, I THINK YOUR TESTIMONY WAS, IT WAS LAURIE STEVENSON
9 WHO TOLD YOU THAT SHE WAS IN SEVERE PAIN.
10 A. YES, SIR.
11 Q. IN YOUR INITIAL MENTAL ASSESSMENT, DID YOU MAKE ANY
12 NOTES THAT SHE WAS SUFFERING FROM SEVERE PAIN?
13 A. YES, SIR. ACTUALLY, IT SAYS FOR DISCOMFORT.
14 Q. FOR DISCOMFORT. SO SEVERE PAIN EQUATES TO DISCOMFORT?
15 A. SEVERE PAIN COULD BE INCLUDED UNDER THE RUBRIC OF
16 DISCOMFORT, YES, SIR. TYPE OF.
17 Q. I ASSUME, SIR, YOU REMEMBER THE PHYSICAL DESCRIPTION OF
18 THIS LADY AT THE TIME YOU OBSERVED HER?
19 A. AT THIS TIME? I DON'T REMEMBER HER.
20 Q. IF I WERE TO TELL YOU SHE WEIGHED 81 POUNDS, WOULD THAT
21 REFRESH YOUR MEMORY?
22 A. WELL, I'VE SEEN THAT IN THE RECORDS, BUT I DON'T HAVE A
23 VISUAL PICTURE OF MISS ANDERSON ANYMORE.
24 Q. OKAY. IN TERMS OF PRESCRIBING MORPHINE FOR THIS
25 PARTICULAR PATIENT, IT'S TRUE, IS IT NOT, THAT BOTH AGE AND
3921
1 WEIGHT ARE CRITICAL FACTORS IN TERMS OF THE DOSAGE AMOUNT?
2 A. I WOULDN'T CALL IT CRITICAL IN THE SENSE OF WEIGHT. AGE
3 IS PROBABLY MORE IMPORTANT. I DON'T KNOW IF I'D EVEN CALL
4 IT CRITICAL THERE.
5 Q. IF CAN YOU TELL ME IN YOUR MENTAL ASSESSMENT, WAS THIS
6 PATIENT ABLE TO SWALLOW TO YOUR -- TO YOUR EVALUATION?
7 A. I CAN'T.
8 Q. CAN YOU TELL ME WHETHER THE PATIENT, IF SHE WAS
9 SCREAMING, WOULD SHE BE ABLE TO EAT?
10 A. IF SHE WAS SCREAMING, WOULD SHE BE ABLE TO EAT?
11 Q. WELL, LET ME ASK IT THIS WAY: YOU'VE GOT SEVERAL TYPES
12 OF CONDUCT GOING ON HERE WHERE SHE'S EXHIBITING CERTAIN
13 TYPES OF BEHAVIOR, IS THAT RIGHT?
14 A. YES, SIR.
15 Q. OKAY. SOME OF THAT CONDUCT IS SCREAMING?
16 A. YES, SIR.
17 Q. SOME OF THAT CONDUCT APPARENTLY WAS KICKING OR
18 THRASHING?
19 A. YES, SIR.
20 Q. OKAY. SOME OF THAT CONDUCT WOULD INDICATE TO YOU THAT
21 SHE'S AWAKE, RIGHT?
22 A. YES, SIR.
23 Q. IS THERE NOT -- WAS THERE NOT CONSIDERATION GIVEN,
24 DOCTOR, TO THE ROUTE OF THE ADMINISTRATION OF THE MORPHINE
25 AS IT PERTAINED TO THIS PARTICULAR PATIENT?
3922
1 A. WAS THERE NOT CONSIDERATION GIVEN?
2 Q. UH-HUH.
3 A. THERE WAS CONSIDERATION GIVEN.
4 Q. AND YOU ELECTED TO USE AN INVASIVE PROCEDURE, IS THAT
5 RIGHT?
6 A. I USED I.M., YES, SIR, THAT'S INVASIVE.
7 Q. INSTEAD OF GIVING HER A PILL.
8 A. YES, SIR.
9 Q. I THINK YOU'VE PREVIOUSLY TESTIFIED ABOUT THAT GIVING
10 SOMEBODY A STICK WITH A NEEDLE IS INVASIVE --
11 A. YES, SIR.
12 Q. -- CORRECT? AND THAT'S WHY YOU DIDN'T TREAT PATIENTS
13 WITH I.V.'S AND CONNECTION -- CONNECTING TYPE OF TUBES, IS
14 THAT RIGHT?
15 A. NO, SIR.
16 Q. WAS IT YOUR PREFERENCE TO GIVE MORPHINE WITH -- IN AN
17 I.M. INJECTION FORM?
18 A. NOT NECESSARILY, BUT FOR THIS PATIENT, IT SEEMED
19 APPROPRIATE.
20 Q. IN FACT, WITH ALL FIVE PATIENTS, THAT WAS THE WAY IT WAS
21 ADMINISTERED, WASN'T IT?
22 A. ALL FIVE OF THESE PATIENTS, YES, SIR.
23 Q. AND ALL FIVE OF THESE PATIENTS, PARTICULARLY JUDITH
24 LARSEN -- WELL, LET ME STRIKE THAT. PARTICULARLY JUDITH
25 LARSEN RECEIVED MORPHINE INJECTIONS MULTIPLE TIMES, IS THAT
3923
1 CORRECT?
2 A. YES, JUDITH LARSEN DID.
3 Q. IS THAT -- WHEN YOU SAY AN INVASIVE PROCEDURE, DOESN'T
4 THAT HURT?
5 A. THE INJECTION?
6 Q. UH-HUH.
7 A. YES, SIR, IT CAN HURT A LITTLE BIT.
8 Q. IT CAN CAUSE PAIN, RIGHT?
9 A. YES, SIR.
10 THE COURT: MR. WILSON, ARE YOU AT A POINT THAT YOU
11 ARE MAY BE GOING TO ANOTHER AREA OR --
12 MR. WILSON: I THINK I'D LIKE TO, IF THE COURT
13 DESIRES TO A BREAK AT THIS TIME.
14 THE COURT: WELL, WE'VE BEEN GOING FOR ABOUT AN
15 HOUR SINCE THE JURY'S BEEN BACK, SO WHY DON'T WE TAKE A
16 BREAK.
17 (AFTER ADMONISHING THE JURY, THE COURT
18 TOOK A BRIEF RECESS.)
19 THE COURT: OKAY. PLEASE BE SEATED. OKAY. THE
20 RECORD WILL REFLECT THAT THE JURY HAS RETURNED. WOULD YOU
21 LIKE TO CONTINUE, MR. WILSON?
22 MR. WILSON: THANK YOU, YOUR HONOR.
23 Q. DOCTOR, WHAT RECORDS DID YOU REMEMBER REVIEWING PRIOR TO
24 MAKING THE ORDERS ON THAT PARTICULAR DATE ON ELLEN ANDERSON,
25 ON THE 29TH OF DECEMBER? THE INITIAL ORDERS?
3924
1 A. WHAT RECORDS DID I REVIEW?
2 Q. YES.
3 A. I DON'T RECALL ANY SPECIFICALLY.
4 Q. YOU DIDN'T REVIEW ANY INTAKE FORMS OR ADMISSION NOTES BY
5 THE NURSES?
6 A. YOU KNOW, I'M A LITTLE CONFUSED AS TO YOUR QUESTION.
7 COULD I GET THAT AGAIN?
8 Q. AS TO ELLEN ANDERSON, THE QUESTION IS, PRIOR OR PREVIOUS
9 TO MAKING THE TELEPHONE ORDER CONCERNING THE ADMINISTRATION
10 OF CERTAIN MEDICATIONS TO ELLEN ANDERSON, WHAT RECORDS IF
11 ANY DID YOU REVIEW?
12 A. ON THE 29TH, MY INITIAL TELEPHONE ORDERS?
13 Q. UH-HUH.
14 A. I CAN'T REMEMBER.
15 Q. YOU CAN'T REMEMBER.
16 A. NO, SIR.
17 Q. DO YOU RECALL REVIEWING ANYTHING ABOUT THIS PATIENT
18 HAVING PREVIOUSLY RECEIVED A PAINKILLER DESIGNATED AS
19 LORTAB?
20 A. WELL, I KNOW WE TALKED ABOUT THAT. I DON'T KNOW IF I
21 SAW THAT FROM THE RECORDS OR THE NURSE MENTIONED IT.
22 Q. WHEN YOU SAY WE TALKED ABOUT IT, WHO ARE WE REFERRING
23 TO?
24 A. THE NURSE.
25 Q. THE NURSE?
3925
1 A. YES, SIR. I CAN'T REMEMBER.
2 Q. I CALL YOUR ATTENTION TO MED-0167.
3 A. ON MISS ANDERSON?
4 Q. YES.
5 A. OKAY. GOT IT.
6 Q. THERE WAS A PRESCRIPTION THAT HAD BEEN ADMINISTERED OR
7 HAD BEEN PRESCRIBED PRIOR TO HER ADMISSION TO THE DAVIS
8 HOSPITAL, IS THAT CORRECT?
9 IS THAT CORRECT, DOCTOR, FROM YOUR REVIEW OF THE
10 RECORDS?
11 A. THERE WAS A PRESCRIPTION --
12 Q. YEAH.
13 A. -- PRESCRIBED?
14 Q. WASN'T SHE RECEIVING LORTAB P.R.N. PRIOR TO ADMISSION TO
15 THE DAVIS HOSPITAL?
16 A. YES, SIR, SHE WAS.
17 Q. AND YOU WERE MADE AWARE OF THAT AT THE TIME?
18 A. ON ADMISSION?
19 Q. UH-HUH.
20 A. YES.
21 Q. SO YOU WERE AWARE THAT IN THE PAST SHE HAD RECEIVED
22 LORTAB FOR PAIN.
23 A. YES, SIR.
24 Q. OKAY. BUT YET YOU CHOSE TO ADMINISTER MORPHINE TO HER
25 ON THIS PARTICULAR DATE, IS THAT CORRECT?
3926
1 A. THAT'S RIGHT.
2 Q. NOW, IN RESPECT TO THE FURTHER NURSES' NOTES, YOU
3 RECEIVED A PAGE AS IT -- IN RESPECT TO THIS PATIENT, DID YOU
4 NOT?
5 A. YES, SIR.
6 Q. AND THAT WAS FROM TRACY SCHOLL, IS THAT CORRECT?
7 A. YES, SIR.
8 Q. AND THAT TOOK PLACE, YOU CALLED BACK ABOUT 3:30 IN THE
9 MORNING, IS THAT CORRECT?
10 A. YES, SIR. DR. WEITZEL RETURNED PAGE AT 3:30.
11 Q. YOU WERE ADVISED AT THAT TIME, WERE YOU NOT, DOCTOR,
12 THAT TRACY SCHOLL HAD RECORDED THE RESPIRATIONS BETWEEN 8 TO
13 16 PER MINUTE ON THAT DATE?
14 A. I CAN'T --
15 Q. AT 1:00 O'CLOCK?
16 A. I CAN'T SAY IF I WAS OR WASN'T.
17 Q. OKAY. WOULD THAT HAVE ANY SIGNIFICANCE TO YOU AS TO
18 THOSE RESPIRATION RATES? IN TERMS OF ADMINISTERING
19 MORPHINE?
20 A. 8 TO 16, THAT'S GOT AN AVERAGE OF 12, SO PROBABLY NOT.
21 Q. IN TERMS OF THE -- HER BLOOD PRESSURE, WHERE IT'S 70
22 OVER 50, ISN'T THAT A RATHER LOW BLOOD PRESSURE RATE?
23 A. YES, SIR.
24 Q. IN FACT, THAT'S SIGNIFICANTLY LOW, ISN'T IT?
25 A. IT'S PRETTY LOW.
3927
1 Q. OKAY. IT'S TRUE, IS IT NOT, DOCTOR, THAT ON BLOOD
2 PRESSURE OF THAT LOW, THAT WOULD CONSTITUTE A RISK TO THIS
3 PATIENT IF YOU WERE TO GIVE HER ANY MORE MORPHINE, IS THAT
4 CORRECT?
5 A. IF I WERE TO GIVE IT AT 1:00 A.M., YES, SIR, COULD BE.
6 Q. DID YOU SEE ANY OTHER VITAL STATS AT THE TIME THAT YOU
7 TALKED WITH TRACY SCHOLL AT 3:30?
8 A. I WOULDN'T HAVE SEEN ANYTHING. I WOULD HAVE DEPENDED ON
9 WHAT SHE WAS TELLING ME OVER THE PHONE.
10 Q. BUT YOU DON'T HAVE ANY RECOLLECTION AS TO ANY -- ANY
11 INFORMATION AS IT PERTAINS TO BLOOD PRESSURE OR
12 RESPIRATIONS, IS THAT RIGHT?
13 A. NO, SIR.
14 Q. AS A PHYSICIAN, ISN'T IT TRUE THAT YOU OUGHT TO INQUIRE
15 AS TO THOSE PARTICULAR VITAL STATS PRIOR TO ADMINISTERING
16 MORPHINE?
17 A. OUGHT I TO INQUIRE? NOT NECESSARILY.
18 Q. IF THE NURSE FELT IT WAS IMPORTANT ENOUGH TO NOTE THOSE
19 IN THE NURSES' NOTES, SHE CALLS YOU ON THE PHONE, PRIOR TO
20 ADMINISTERING MORPHINE, SHOULDN'T YOU REVIEW WITH HER WHAT
21 THIS PATIENT'S CONDITION IS?
22 A. ACTUALLY, I THINK SHE SHOULD REVIEW WITH ME.
23 Q. I SEE. SO IT'S THE RESPONSIBILITY OF THE NURSE TO TELL
24 YOU, NOT FOR YOU TO MAKE ANY KIND OF INQUIRY OF HER. IS
25 THAT WHAT YOU'RE SAYING?
3928
1 A. IF SHE'S SEEING SOMETHING THAT SHE'S WORRIED ABOUT AT
2 THAT TIME, IT WOULD BE HER RESPONSIBILITY TO LET ME KNOW.
3 THIS IS THREE AND A HALF, TWO AND A HALF HOURS LATER.
4 Q. WELL, WE HAVE A PATIENT WHO ACCORDING TO THE INFORMATION
5 YOU HAVE RECEIVED, HAS ONLY RECEIVED LORTAB IN THE PAST, IS
6 THAT CORRECT?
7 A. I DON'T KNOW THAT SHE ONLY RECEIVED IT, BUT I KNOW SHE
8 HAD RECEIVED LORTAB.
9 Q. OKAY. YOU KNEW THAT THERE HAD BEEN A PRESCRIPTION FOR
10 IT IN THE PAST.
11 A. YES, SIR.
12 Q. YOU DID NOT KNOW WHEN SHE RECEIVED HER LAST DOSAGE OF
13 MORPHINE -- OR NOT MORPHINE, EXCUSE ME, OF LORTAB.
14 A. NO, SIR. I WOULDN'T HAVE KNOWN THAT.
15 Q. SO FOR ALL YOU KNOW, THAT COULD HAVE BEEN SOME TIME
16 BEFORE.
17 A. YES, SIR.
18 Q. AND YOU KNEW THAT THAT HAD BEEN PRESCRIBED FOR HER PAIN
19 IN THE PAST, DID YOU NOT?
20 A. YES, SIR.
21 Q. YOU ALSO KNOW THAT FROM THE RECORD THAT SHE HAD
22 SUSTAINED A HIP FRACTURE IN THE PAST, DO YOU NOT?
23 A. I KNOW THAT NOW, YES, SIR.
24 Q. AND I ASSUME YOU WOULD KNOW FROM THE STANDPOINT OF THE
25 PRESCRIPTION OF LORTAB THAT THAT HAD BEEN PRESCRIBED FOR ANY
3929
1 PAIN ASSOCIATED WITH THAT, IS THAT CORRECT?
2 A. I CAN'T TELL YOU AT THIS TIME WHETHER I KNEW AT THAT
3 TIME EXACTLY WHETHER THE LORTAB WAS FOR THE HIP FRACTURE OR
4 GENERALIZED OSTEOPOROSIS, WRIST FRACTURE, ANKLE FRACTURE, OR
5 WHAT. I'M SORRY.
6 Q. THE FACT OF THE MATTER IS, DOCTOR, YOU WENT AHEAD AND
7 ADMINISTERED MORPHINE WITHOUT SOME CRITICAL INFORMATION,
8 DIDN'T YOU?
9 A. I ADMINISTERED MORPHINE WITHOUT ALL THE INFORMATION. I
10 WOULDN'T CALL IT CRITICAL.
11 Q. YOU DON'T THINK BLOOD PRESSURE OF 70 OVER 50 IS NOT
12 CRITICAL?
13 A. THAT WAS TWO AND A HALF HOURS EARLIER.
14 Q. I SEE. BUT YOU DIDN'T KNOW WHAT HER BLOOD PRESSURE
15 WOULD BE AT THIS TIME.
16 A. NO, SIR.
17 Q. AND YOU'RE SAYING TO US THAT YOU DON'T KNOW WHETHER
18 TRACY SCHOLL TOLD YOU ABOUT THE BLOOD PRESSURE ANYWAY.
19 A. THAT'S TRUE.
20 Q. SHE COULD HAVE VERY WELL TOLD YOU ABOUT THE BLOOD
21 PRESSURE, ISN'T THAT TRUE?
22 A. YES, SHE COULD HAVE.
23 Q. AND YOU WENT AHEAD AND ADMINISTERED THE MORPHINE IN THAT
24 PARTICULAR CONTEXT.
25 A. WELL, I DON'T KNOW IF SHE DID OR NOT, SO --
3930
1 Q. YOU ORDERED THE ADMINISTRATION OF THE MORPHINE.
2 A. I DID ORDER THE MORPHINE AT 3:30, YES, SIR.
3 Q. AND PATIENT DIES APPROXIMATELY FIVE HOURS LATER, IS THAT
4 RIGHT?
5 A. YES, SIR.
6 Q. DURING THAT TIME PERIOD, THERE'S A CHEST X-RAY AND
7 THERE'S ALSO A SINUS OR A -- GUESS IT'S A HEART MONITORING
8 THAT'S --
9 A. E.K.G.?
10 Q. E.K.G. THAT'S TAKEN PLACE.
11 A. YES, SIR.
12 Q. AND AS YOU'VE NOTED IN YOUR EARLIER TESTIMONY, YOUR
13 STATEMENT IN THE DISCHARGE SUMMARY IS THAT IS AN OVERSIGHT
14 ON YOUR PART, IT WAS NOT TAKEN ON ADMINISTRATION, IS THAT
15 CORRECT?
16 A. I DON'T BELIEVE SO.
17 Q. DOES THE SINUS TACHYCARDIA, IS THAT FURTHER EVIDENCE OF
18 TOXICITY OF MORPHINE IN THIS PATIENT?
19 A. NOT NECESSARILY.
20 Q. WHEN WAS IT YOU DISCOVERED THE ERROR IN YOUR THINKING IN
21 TERMS OF WHEN THAT E.K.G. WAS ADMINISTERED?
22 A. I DON'T KNOW THAT THERE IS ANY ERROR. I'M NOT SURE WHAT
23 YOU'RE TALKING ABOUT.
24 Q. WELL, DIDN'T YOU -- DIDN'T YOU ADMIT THAT YOUR DISCHARGE
25 SUMMARY WAS WRONG?
3931
1 A. WITH RESPECT TO WHAT?
2 Q. IN RESPECT TO ON ADMISSION HER E.K.G. REVEALED SINUS
3 TACHYCARDIA.
4 A. THAT'S NOT WRONG AT ALL. THAT'S WHAT IT SHOWED.
5 Q. SHE WAS ADMITTED AT 4:00 O'CLOCK ON SUNDAY, WAS SHE NOT?
6 A. SHE WAS ADMITTED A LITTLE AFTER 4:00 ON THE 29TH.
7 Q. ON THE -- EXCUSE ME, 29TH.
8 A. I DON'T KNOW IT WAS SUNDAY OR WHAT, BUT THE 29TH.
9 Q. SHE WAS ADMITTED AT A LITTLE AFTER 4:00 O'CLOCK ON THE
10 29TH.
11 A. I THINK I SEE THE CONFUSION. THIS IS THE ADMISSION
12 E.K.G. IT WAS ORDERED AND IT WAS DONE ON ADMISSION.
13 Q. SO THE E.K.G. ON ADMISSION TAKES PLACE AT 5:00 O'CLOCK
14 THE FOLLOWING MORNING.
15 A. YES, SIR.
16 Q. SO IN REFERENCE TO YOUR REPORT, ARE YOU TELLING US THAT
17 SHE WAS SUFFERING FROM SINUS TACHYCARDIA AND EARLIER ON
18 SUNDAY WHEN SHE WAS ADMITTED TO THE UNIT OR ARE YOU TELLING
19 US IT WAS AT 5:30 IN THE MORNING ON THE 30TH?
20 A. I CAN'T BE SURE ABOUT WHAT HER HEART ARRHYTHMIA MAY HAVE
21 BEEN ON ADMISSION, BUT IT -- CLEARLY AT 5:30 0R 5:40 WHEN IT
22 WAS DONE --
23 Q. THAT'S WHEN IT WAS DONE.
24 A. -- SHE HAD THE SINUS ARRHYTHMIA.
25 Q. OKAY. AND AT THAT TIME, THE SINUS TACHYCARDIA, WHATEVER
3932
1 IT'S CALLED --
2 A. ARRHYTHMIA.
3 Q. -- ISN'T THAT EVIDENCE THAT THIS INDIVIDUAL WAS
4 SUFFERING FROM THE TOXIC EFFECTS OF MORPHINE?
5 A. NO, SIR.
6 Q. YOU DON'T THINK SO.
7 A. NO, SIR.
8 Q. DO YOU THINK THAT HER BLOOD PRESSURE AT 1:00 O'CLOCK AT
9 70 OVER 50 IS EVIDENCE THAT SHE'S SUFFERING FROM THE TOXIC
10 EFFECTS OF MORPHINE?
11 A. NO, SIR. IT WOULD BE FIVE AND A HALF HOURS AFTER SHE
12 DIED, NO.
13 Q. AT 8:55, SHE DIES. YOU COME IN LATER THAT DAY, IS THAT
14 RIGHT?
15 A. YES, SIR. ON THE 30TH.
16 Q. YOU WERE CALLED BY THE NURSE I ASSUME JUST AFTER SHE
17 DIED, IS THAT CORRECT?
18 A. PROBABLY, BUT I'D LIKE TO CHECK THE NURSING NOTE BEFORE
19 I SAY FOR SURE. I THINK I REMEMBER IT SAID THAT DR. WEITZEL
20 PAGED. DR. WEITZEL NOTIFIED 8:55 ON THE 30TH.
21 Q. IS IT OF CONCERN TO YOU, DOCTOR, THAT YOU HAVE A PATIENT
22 WHO IS ADMITTED, IS APPROPRIATE UNDER THE CRITERIA OF THE
23 GEROPSYCH UNIT, WHO IS ADMITTED AT 4:00 O'CLOCK, AND DIES
24 APPROXIMATELY 17 HOURS LATER; IS IT OF CONCERN TO YOU THAT
25 SHE DIED IN SUCH A SHORT PERIOD OF TIME?
3933
1 A. YES, SIR.
2 Q. IN FACT, IT WAS OF CONCERN THAT YOU RECOMMENDED AN
3 AUTOPSY, IS THAT RIGHT?
4 A. WELL, IN MY NOTE, I WROTE RECOMMEND AUTOPSY, YES, SIR.
5 I REALLY WAS CURIOUS AS TO WHAT CAUSED THIS.
6 Q. AND IT'S A FACT, ISN'T IT, DOCTOR, THAT THE ONLY -- THE
7 ONLY DIFFERENCE IN HER MEDICATIONS THAT SHE WAS RECEIVING
8 BEFORE SHE CAME TO THE UNIT AND THE TIME OF HER DEATH WAS
9 THE ADMINISTRATION OF MORPHINE SULFATE, ISN'T IT?
10 A. NO, SIR, THAT'S NOT TRUE.
11 Q. WHAT OTHER -- WHAT OTHER DRUGS DID SHE RECEIVE BESIDES
12 MORPHINE SULFATE THAT HADN'T BEEN PRESCRIBED BEFORE?
13 A. THE DIFFERENCE IS, IS THAT SHE HAD BEEN RECEIVING
14 MEDICATIONS UNTIL SHE GOT THERE. SHE WOULDN'T TAKE ANYTHING
15 THAT EVENING, SO SHE STOPPED GETTING PSYCHOTROPICS, ET
16 CETERA, SO --
17 Q. SO YOU -- YOU ADMINISTERED --
18 A. -- THAT'S THE DIFFERENCE.
19 Q. THE DIFFERENCE IS SHE DIDN'T HAVE SOME OF THOSE
20 MEDICATIONS THEN, IS THAT RIGHT?
21 A. THAT'S ONE DIFFERENCE. ANOTHER DIFFERENCE IS SHE DID
22 GET MORPHINE.
23 Q. THE OTHER DIFFERENCE IS THAT SHE DID GET MORPHINE.
24 A. THAT IS --
25 Q. AND SHE GOT SHOTS THAT HAVE BEEN TESTIFIED TO BY EXPERTS
3934
1 THAT ARE SOME FOUR TIMES THE DOSAGE THAT SHOULD HAVE BEEN
2 ADMINISTERED TO HER, IS THAT CORRECT?
3 MR. STIRBA: I'M GONNA OBJECT. HE DOESN'T HAVE TO
4 REPEAT TESTIMONY OF THE TRIAL.
5 THE COURT: SUSTAINED.
6 MR. STIRBA: OBJECT TO THE FORM OF THE QUESTION.
7 THE COURT: COMMENT ON OTHER WITNESS' TESTIMONY,
8 THAT'S SUSTAINED.
9 Q. (BY MR. WILSON) BUT YOU DIDN'T HAVE ANY PROBLEM WITH
10 THE 10 MILLIGRAMS, DID YOU?
11 A. NO, SIR. I THOUGHT IT WAS APPROPRIATE.
12 Q. AND YOU THOUGHT IT WAS APPROPRIATE AGAIN AT 3:30, IS
13 THAT CORRECT?
14 A. YES, SIR. ESPECIALLY SO WITH REGARD --
15 Q. YOU RECOMMENDED AN AUTOPSY. WHAT DOES THAT MEAN,
16 DOCTOR? DOES IT MEAN THAT THERE WOULD BE AN AUTOPSY
17 ORDERED?
18 A. WELL, I'M A PSYCHIATRIST. AND I DON'T ORDER A LOT OF
19 AUTOPSIES. BUT I GOT THERE THAT MORNING AND WROTE
20 ASSESSMENT, PROBABLE M.I. RECOMMEND AUTOPSY. MY PLAN WAS,
21 WILL RELEASE TO FAMILY.
22 Q. BUT YOU DIDN'T REACH THE FAMILY?
23 A. NO, SIR. MY PLAN WAS WILL RELEASE TO FAMILY, RELEASE
24 HER BODY TO THE FAMILY.
25 Q. OH, YOU WERE GONNA RELEASE HER TO THE FAMILY.
3935
1 A. YES, SIR. I HAVE TO WRITE AN ORDER OF RELEASING THE
2 BODY.
3 Q. SO IN ORDER TO HAVE AN AUTOPSY, I ASSUME YOU WOULD HAVE
4 TO HAVE SOMEBODY FROM THE MEDICAL EXAMINER'S COME OUT TO
5 CONDUCT THAT AUTOPSY OR THE HOSPITAL WOULD HAVE TO CONDUCT
6 IT?
7 A. SOMEONE WOULD HAVE TO.
8 Q. OKAY. WERE YOU FAMILIAR WITH THE HOSPITAL POLICIES ON
9 AUTOPSIES?
10 A. NO, SIR.
11 Q. SO YOU DIDN'T READ THOSE POLICIES.
12 A. NO, SIR.
13 Q. SO YOU NEVER ACTUALLY ATTEMPTED TO GET AN AUTOPSY DONE,
14 DID YOU?
15 A. I CAN'T REMEMBER SPECIFICALLY. I THINK I MAY HAVE SAID
16 TO THE FAMILY IT MIGHT MAKE SENSE TO GET AN AUTOPSY, BUT
17 THERE WAS NONE DONE UNTIL YOUR EXHUMATIONS.
18 Q. ARE YOU FAMILIAR IN THE HOSPITAL POLICIES THAT DEATHS
19 WITH PRIMARILY A PSYCHIATRIC DIAGNOSE -- DIAGNOSIS ARE
20 REQUIRED TO HAVE AUTOPSIES?
21 A. NO, SIR, I WAS NOT FAMILIAR WITH THAT.
22 Q. YOU WEREN'T CONCERNED ENOUGH TO PURSUE IT YOURSELF, WERE
23 YOU?
24 A. I BELIEVE I MAY HAVE SPOKEN WITH THE FAMILY ABOUT IT AND
25 RECOMMENDED IT, BUT THAT'S AS FAR AS IT WOULD HAVE GONE WITH
3936
1 ME.
2 Q. YOU DIDN'T CALL THE MEDICAL EXAMINER, DID YOU?
3 A. NO, SIR.
4 Q. WOULD YOU PULL THE FILE OUT ON JUDITH LARSEN?
5 A. DO YOU HAVE A PAGE?
6 Q. PARDON?
7 A. DO YOU HAVE A PAGE NUMBER?
8 Q. NO, I JUST WANT YOU TO PULL THE FILE OUT RIGHT NOW.
9 A. OKAY.
10 Q. CAN YOU TELL US, DOCTOR, WHAT YOUR IMPRESSIONS -- EXCUSE
11 ME, UPON ADMISSION, JUDITH LARSEN ALSO FIT THE CRITERIA OF
12 THE GERIATRIC PSYCH UNIT, DID SHE NOT?
13 A. YES, SIR.
14 Q. AND AS I UNDERSTAND YOUR TESTIMONY, SHE WENT UP AND DOWN
15 IN HER PROGRESS, IS THAT CORRECT?
16 A. RIGHT.
17 Q. AND ON THE 13TH OF DECEMBER, YOU ORDERED THE
18 ADMINISTRATION OF 15 MILLIGRAMS OF MORPHINE P.R.N., DID YOU
19 NOT?
20 A. NO, SIR. I PUT AN ORDER THAT 15 MILLIGRAMS COULD BE
21 GIVEN, BUT I DID NOT ORDER THE ADMINISTRATION. THAT'S WHAT
22 A P.R.N. IS.
23 Q. SO P.R.N. MEANS THAT IT'S ORDERED IF -- IF THE NURSE
24 DEEMS IT NECESSARY.
25 A. YES, SIR.
3937
1 Q. SUBSEQUENTLY, ON DECEMBER THE 25TH, JUDITH LARSEN IS
2 ADMINISTERED HER FIRST SHOT OF MORPHINE, IS SHE NOT?
3 A. YES, THAT'S RIGHT.
4 Q. SHE'S ADMINISTERED IN FACT THREE 2-MILLIGRAM SHOTS ON
5 THAT PARTICULAR DATE, IS THAT CORRECT?
6 A. YES, SIR.
7 Q. NOW, I UNDERSTAND THESE SHOT VIALS COME IN 10-MILLIGRAM
8 UNITS, IS THAT CORRECT?
9 A. THEY COME A LOT OF DIFFERENT WAYS. I DON'T KNOW WHAT
10 THEY HAVE THERE.
11 Q. THERE WOULDA HAD TO BEEN MORPHINE WASTED ON THAT
12 PARTICULAR OCCASION, IS THAT CORRECT?
13 A. LIKE I SAID, I DON'T KNOW.
14 Q. NOW, YOU'VE PREVIOUSLY TESTIFIED THAT YOU FELT THAT A
15 10-MILLIGRAM SHOT FOR ELLEN ANDERSON WAS APPROPRIATE UNDER
16 THE CIRCUMSTANCES. I'M CURIOUS TO KNOW WHY, DOCTOR -- WELL,
17 LET ME PUT IT THIS WAY: ON THIS PARTICULAR OCCASION, YOU
18 ORDER 2-MILLIGRAM SHOTS IN TWO-HOUR INTERVALS, THREE SHOTS,
19 IS THAT RIGHT?
20 A. BELIEVE SO. LET ME JUST CHECK THE ORDERS. EXACTLY.
21 Q. PREVIOUSLY, YOU'D ORDERED P.R.N. 15-MILLIGRAM SHOT, IS
22 THAT CORRECT?
23 A. YES, SIR.
24 Q. AND THEN AS I UNDERSTAND IT, ON THE 26TH, THAT'S THE
25 DATE SHE HAS THE SEIZURE, IS THAT RIGHT?
3938
1 A. RIGHT.
2 Q. AND SHE'S ADMINISTERED A MORPHINE SHOT ON THAT
3 PARTICULAR DATE OF 2 MILLIGRAMS, IS THAT CORRECT?
4 A. YES, SIR. BEST I CAN TELL, IT WAS AROUND 1:30 -- OH,
5 WAIT, NO, THAT'S INCORRECT. IT WOULD HAVE BEEN IN THE
6 MORNING.
7 Q. I NEGLECTED TO ASK YOU, GOING BACK TO THE 13TH OR THE
8 14TH, YOU NOTE ON THAT PARTICULAR DATE ON PAGE 470 IN YOUR
9 PROGRESS NOTES, I THINK IT IS, THAT SHE HAD A MIRACULOUS
10 RECOVERY.
11 A. RIGHT.
12 Q. IT'S TRUE, IS IT NOT, THAT ON THE 12TH AND THE 11TH, THE
13 NURSES WITHHELD CERTAIN MEDICATIONS FROM JUDITH LARSEN?
14 A. SPECIFICALLY?
15 Q. WELL, THEY WITHHELD SERZONE AND RISPERDAL AND TRAZODONE.
16 DO YOU WANNA TURN TO PAGES 502 AND 503?
17 A. YES, SIR, I'VE GOT 502 HERE. AND LOOKS LIKE RISPERDAL
18 WAS HELD AT BEDTIME ON THE 11TH -- LET'S SEE, MAKE SURE
19 THAT -- ON THE 11TH AND 12TH BECAUSE SHE WAS ASLEEP. AND ON
20 503, THERE ARE ALSO SOME WITHHOLDS. LOOKS LIKE THEY'RE ALL
21 BECAUSE THE PATIENT WAS ASLEEP.
22 Q. SO WAS THIS A DRUG THAT WAS ORDERED ON A ROUTINE BASIS?
23 A. YES, SIR. I BELIEVE ALL OF THESE WERE ORDERED ROUTINE,
24 SURFAK. YEAH, THESE WERE LIKE BOTH HER PSYCHOTROPIC
25 MEDICATIONS AND HER OTHER MEDICATIONS.
3939
1 Q. ISN'T IT TRUE, DOCTOR, THAT THE WITHHOLDING OF THOSE
2 DRUGS HAD A POSITIVE EFFECT ON THIS LADY'S RECOVERY AT THAT
3 TIME? HER MIRACULOUS RECOVERY, AS YOU CHARACTERIZED IT?
4 A. NO, SIR, I DON'T THINK SO. THEY WERE -- THEY WERE NOT
5 HELD ALL THE TIME, JUST AT BEDTIME A COUPLE OF NIGHTS.
6 Q. YOU DON'T THINK THAT HAD ANY IMPACT ON IT AT ALL.
7 A. WELL, I GAVE ALL THOSE MEDICATIONS TO HELP AID IN HER
8 RECOVERY, AND SO HOLDING THEM, I DON'T THINK IS WHAT CAUSED
9 THE RECOVERY.
10 Q. SHE HAS THE SEIZURE ON THE 26TH. DR. DIENHART ORDERS
11 ADMINISTRATION OF THE DILANTIN, IS THAT CORRECT?
12 A. YES, SIR.
13 Q. AND YOU AT THAT TIME ENTER AN ORDER DISCONTINUING THE
14 I.V. OF DILANTIN AND ATIVAN, IS THAT CORRECT?
15 A. A COUPLE OF HOURS LATER I D.C. THOSE IN ONE OF HER
16 MEDICAL TREATMENT PLAN --
17 Q. OKAY.
18 A. -- AND SAID NO I.V.'S.
19 Q. PARDON?
20 A. MEDICAL TREATMENT PLAN SAID NO I.V.'S.
21 Q. NO I.V.'S.
22 A. YES, SIR.
23 Q. THIS WAS ON THE 26TH?
24 A. YES, SIR.
25 Q. YOU REFERENCE IN A NOTE, THINK IT'S ON THE 29TH, IF I
3940
1 CAN FIND THAT PARTICULAR PROGRESS NOTE. CAN YOU TURN TO
2 PAGE 475?
3 A. I'M THERE.
4 Q. WHAT DOES -- CAN YOU READ THAT NOTE TO US, DOCTOR?
5 A. AT THE BOTTOM OF THE PAGE, MY NOTE?
6 Q. YEP, 12/29.
7 A. OKAY. HAS QUIT FEEDING SELF, DASH, STARES OFF INTO
8 SPACE. NO FURTHER SEIZURE ACTIVITY. I WISH TO KEEP HER
9 MEDS TO -- MEDICATIONS TO A MINIMUM. VITAL SIGNS STABLE.
10 AFEBRILE. ASSESSMENT, MAJOR DEPRESSION WITH PSYCHOTIC
11 FEATURES. STATUS, SUPPOSED STROKE, DEMENTIA. PLAN,
12 DISCONTINUE DILANTIN. WILL SEE IF WE CAN GET HER TO BE
13 RESPONSIVE AGAIN. IF SHE SEIZES, WE'LL USE INTRAMUSCULAR
14 ATIVAN. SIGNED ROBERT WEITZEL.
15 Q. THE ATIVAN HAD BEEN DISCONTINUED BACK ON THE 26TH, HAD
16 IT NOT?
17 A. NO, SIR.
18 Q. YOU DISCONTINUED THE -- EXCUSE ME, NOT THE ATIVAN, THE
19 DILANTIN.
20 A. NO, SIR. ACTUALLY, WHAT I WROTE WAS DISCONTINUE I.V.
21 LOOKING AT THIS NOW, I MUST HAVE BEEN UNDER THE IMPRESSION
22 FROM THE 26TH THROUGH THE 29TH, THAT SHE'S STAYING ON
23 DILANTIN BY MOUTH. KIND OF A MIXUP.
24 Q. IN FACT, YOU THOUGHT SHE APPEARED QUITE LETHARGIC,
25 DIDN'T YOU?
3941
1 A. WHEN IS THAT?
2 Q. AS TO THE ATIVAN.
3 A. NO. ARE YOU TALKING ABOUT ON THE 29TH?
4 Q. I'M TALKING ABOUT AFTER THE -- AFTER THE I.V. HAD BEEN
5 DISCONTINUED. DIDN'T YOU MAKE A REFERENCE IN YOUR NOTE AS
6 TO QUITE LETHARGIC AND YOU REFERENCED THAT IT APPEARS TO BE
7 A REACTION TO THE ATIVAN?
8 A. NO, SIR.
9 MR. WILSON: MAY I HAVE JUST A MINUTE, YOUR HONOR?
10 THE COURT: YES.
11 Q. (BY MR. WILSON) EXCUSE ME. I KEEP CONFUSING DILANTIN
12 AND ATIVAN. MAYBE WE CAN RETURN TO THE NOTE ON PAGE 475.
13 A. OKAY.
14 Q. LET'S SEE -- OKAY. THE NOTE YOU READ WAS ON 12/29. THE
15 NOTE JUST ABOVE THAT, WOULD YOU PLEASE READ THAT NOTE FOR
16 US?
17 A. OKAY, SURE. THIS IS THE 28TH, MY NOTE. I MET WITH HER
18 SON AND DAUGHTER-IN-LAW. SHE APPEARS MEDICALLY STABLE AT
19 THIS POINT. THE DILANTIN APPEARS TO BE CAUSING SOME
20 SEDATION. LETHARGY CONTINUES. VITAL SIGNS STABLE.
21 AFEBRILE. ASSESSMENT, STABLE. PLAN, CONTINUE CURRENT CARE.
22 Q. OKAY. NOW, WAS SHE OR WAS SHE NOT, DOCTOR, RECEIVING
23 ANY DILANTIN AFTER THE 26TH?
24 A. FROM EVERYTHING I CAN TELL FROM THE MEDICATION
25 ADMINISTRATION RECORDS, SHE WAS NOT.
3942
1 Q. OKAY.
2 A. THE NURSES INTERPRETED STOP BY I.V. THERAPY AS STOP
3 DILANTIN.
4 Q. BUT YOU DIDN'T INTEND TO STOP THAT.
5 A. NOT NECESSARILY. AS A MATTER OF FACT, I WAS UNDER THE
6 IMPRESSION SHE WAS STILL GETTING IT. I HADN'T WRITTEN STOP
7 DILANTIN.
8 Q. BUT YOU HAD WRITTEN TO STOP THE I.V.
9 A. YES, SIR.
10 Q. SO THE LETHARGY WAS NOT BEING CAUSED BY THE DILANTIN,
11 WAS IT?
12 A. THAT'S RIGHT. IT HAD BEEN STOPPED SOMETIME BEFORE.
13 Q. NOW, THE UPPER G.I. BLEED THAT YOU REFERENCE THAT
14 OCCURRED AFTER THE VOMITING EPISODE ON 29TH AND 30TH, DO YOU
15 RECALL THAT?
16 A. YES, SIR.
17 Q. DID YOU DO ANY FURTHER TESTING TO DETERMINE IF THAT WAS
18 IN FACT AN UPPER G.I. BLEED?
19 MR. STIRBA: I'M GONNA OBJECT, RELEVANCY, YOUR
20 HONOR. BEYOND THE SCOPE.
21 MR. WILSON: STRIKE IT.
22 Q. DID YOU REQUEST ANY CONSULT AS A RESULT OF THE UPPER
23 G.I. BLEED?
24 A. NO, SIR.
25 Q. IT'S TRUE, IS IT NOT, DOCTOR, THAT ONE OF THE NICE
3943
1 THINGS THAT -- ABOUT THE GEROPSYCH UNIT WAS LOCATED IN THE
2 HOSPITAL, IS THAT RIGHT?
3 A. THAT'S RIGHT.
4 Q. SO YOU HAVE AVAILABILITY OF INTERNISTS AND OTHER
5 PHYSICIANS TO ASSIST YOU IN DIAGNOSING MATTERS OF AN
6 INTERNAL NATURE.
7 A. THAT'S TRUE.
8 Q. AND IN RESPECT TO THIS PARTICULAR EVENT, YOU CHOSE NOT
9 TO HAVE ANYBODY COME IN TO ADMINISTER ANY TESTS TO DETERMINE
10 IN FACT IF THE PATIENT WAS SUFFERING FROM AN UPPER G.I.
11 BLEED, IS THAT CORRECT?
12 MR. STIRBA: I'M GONNA OBJECT AS TO RELEVANCE. I
13 BELIEVE THIS WAS THE SUBJECT OF A PREVIOUS RULING, TOO.
14 THE COURT: OVERRULED.
15 Q. (BY MR. WILSON) YOU DID NOT REQUEST ANY PHYSICIANS TO
16 COME IN AND ASSIST YOU IN TERMS OF CONSULTING TO DETERMINE
17 IF THAT IN FACT WAS AN UPPER G.I. BLEED, IS THAT CORRECT?
18 A. SIR, COFFEE GROUNDS VOMITUS, I KNEW IT WAS A G.I. BLEED.
19 THEN THE NEXT DAY MELENA, THAT'S A G.I. BLEED.
20 Q. I SEE.
21 A. SO NO, SIR, I DID NOT.
22 Q. IF YOU SPECIALIZE IN INTERNAL MEDICINE --
23 A. PSYCHIATRY IS A BRANCH --
24 MR. STIRBA: OBJECTION. ARGUMENTATIVE, YOUR HONOR.
25 MR. WILSON: WELL, LET ME ASK --
3944
1 THE COURT: JUST ASK THE NEXT QUESTION.
2 MR. WILSON: OKAY.
3 Q. IN FACT, YOU DIDN'T REQUEST ANY CONSULT IN RESPECT TO
4 JUDITH LARSEN AFTER THE LAST ONE WITH DR. DIENHART WHEN HE
5 OBSERVES THE COFFEE GROUND EMESIS, ISN'T THAT CORRECT?
6 A. I DID NOT.
7 Q. YOU BEGIN A REGIMEN OF THE ADMINISTRATION OF MORPHINE AT
8 THAT TIME ON THE -- I THINK EXTENDING FROM THE 29TH THROUGH
9 THE 30TH, IS THAT RIGHT?
10 A. NO, SIR, I DON'T THINK IT IS. LOOKS LIKE THE 30TH.
11 NIGHT OF THE 30TH, I BELIEVE.
12 Q. SO THAT'S WHEN YOU ENTER THE FIRST ORDERS TO ADMINISTER
13 MORPHINE ON A REGULAR BASIS, IS THAT RIGHT?
14 A. YES, SIR.
15 Q. THAT'S ALSO THE TIME PERIOD I THINK YOU'VE TESTIFIED TO
16 THAT YOU HAD A MEETING OR DISCUSSION WITH MERLIN LARSEN
17 ABOUT HIS MOTHER AND HER SUBSEQUENT CARE, IS THAT RIGHT?
18 A. CORRECT.
19 Q. AND IT WAS AT THAT MEETING THAT YOU MADE THE DECISION,
20 DOCTOR, TO GO FORWARD WITH A COMFORT CARE ROUTINE, IS THAT
21 CORRECT?
22 A. YES, SIR.
23 Q. NOW, WOULD YOU AGREE WITH THE PROPOSITION THAT MORPHINE
24 FOR MEDICAL PURPOSES IS USED FOR THE TREATMENT OF MODERATE
25 TO SEVERE PAIN?
3945
1 A. THAT'S ONE OF THE PURPOSES, YES, SIR.
2 Q. ONE OF THE PURPOSES. IS THAT THE PRIMARY PURPOSE OF
3 MORPHINE? FOR MEDICAL REASONS?
4 A. IT'S THE PURPOSE FOR WHICH IT'S USED MOST, PROBABLY.
5 Q. SO ARE WE TO BELIEVE THAT IN THIS CONTEXT, THE MORPHINE
6 WAS USED FOR ANOTHER PURPOSE OTHER THAN THE PAIN CONTROL?
7 A. NO, SIR.
8 Q. YOU WERE USING IT FOR -- TO CONTROL PAIN IN THIS
9 PARTICULAR PATIENT?
10 A. PAIN AND SUFFERING.
11 Q. PAIN AND SUFFERING. NOW, THAT'S A RATHER VAGUE TERM, IS
12 IT NOT, AS TO SUFFERING?
13 A. YES, SIR. SUFFERING COMES IN MANY FORMS.
14 Q. OKAY. SO AS A PHYSICIAN, YOU DETERMINED THAT IT WAS
15 APPROPRIATE TO USE MORPHINE IN THIS PARTICULAR CONTEXT
16 BECAUSE YOU BELIEVED JUDITH LARSEN TO BE IN PAIN AND
17 SUFFERING.
18 A. THAT'S RIGHT.
19 Q. IS THAT CORRECT?
20 A. YES, SIR.
21 Q. AND AS A PHYSICIAN, YOU HAD DETERMINED IN YOUR OWN MIND
22 THAT JUDITH LARSEN WAS DYING, IS THAT CORRECT?
23 A. YES, SIR.
24 Q. DID YOU SEEK ANY CONSULT AS TO WHETHER OR NOT SHE WAS
25 DYING?
3946
1 A. NO, SIR.
2 Q. YOU WENT TO HER FAMILY AND TOLD THEM SHE WAS DYING, IS
3 THAT CORRECT?
4 A. I THINK YOU COULD SAY IT THAT WAY, YES, SIR.
5 Q. DID YOU TELL MERLIN LARSEN WHAT SHE WAS DYING FROM?
6 A. I'M SURE I WOULD HAVE TOLD HIM ABOUT THE G.I. BLEED.
7 AND THEY WERE AWARE OF THE OTHER MEDICAL PROBLEMS SHE HAD.
8 Q. WAS THERE ANY INDICATION IN HER MEDICAL RECORD AFTER THE
9 DATE OF THE 29TH THAT SHE WAS VOMITING UP ANY COFFEE GROUND
10 EMESIS?
11 A. I'D HAVE TO GO THROUGH THEM PRETTY CLEARLY TO MAKE SURE
12 OF THAT. AFTER THE 29TH?
13 Q. UH-HUH.
14 A. YES, SIR.
15 Q. WHAT EVIDENCE WAS THAT?
16 A. WELL, THERE'S JUST ALL OVER THE PLACE, ON THE 30TH
17 SHE -- MY NOTE WILL TELL YOU SHE HAD COFFEE GROUNDS VOMITUS
18 OF GREATER THAN 200 C.C.'S THIS MORNING, ET CETERA.
19 Q. OKAY. SO WE HAVE THE COUGHING SPELL THAT GOES FROM THE
20 29TH INTO THE 30TH. LET ME ASK YOU THIS THEN: WAS THERE
21 ANY FURTHER EPISODES WHERE SHE VOMITED UP COFFEE GROUNDS
22 EMESIS IN THE MEDICAL RECORDS AFTER THAT DATE?
23 A. NO. THE EVIDENCE CHANGED TO MELENA.
24 Q. PARDON?
25 A. MELENA, M-E-L-E-N-A. MELENA.
3947
1 Q. SO THERE WAS -- THERE WAS NOTHING AS TO COFFEE GROUNDS
2 EMESIS. YOU'RE SAYING THAT THE EVIDENCE CHANGED TO SOME
3 FORM, IS THAT RIGHT?
4 A. YES, SIR, BELIEVE SO.
5 Q. WHAT IS THE NATURE OF THAT FORM, SIR?
6 A. MELENA IS A BLACK TARRY STOOL THAT YOU SEE WITH A G.I.
7 BLEED.
8 Q. SUBSEQUENT TO THE 30TH, DID YOU SEE ANY FURTHER EVIDENCE
9 OF EITHER COFFEE GROUND EMESIS OR A MELANOMA -- OR MELA --
10 MELENA?
11 A. MELENA? I'M GONNA LOOK QUICKLY THROUGH THE NURSES'
12 NOTES AND I DON'T WANNA ANSWER BEFORE I MAKE REAL SURE.
13 READING THROUGH THE -- EACH TO THE END OF 31ST, I
14 DON'T SEE ANYTHING THAT FAR, SO I DOUBT IT.
15 Q. SO THERE'S NOTHING UP UNTIL THE TIME OF HER DEATH THAT
16 EVIDENCE -- WOULD BE EVIDENCE OF ANY UPPER G.I. BLEED, IS
17 THAT CORRECT?
18 A. ANY FURTHER G.I. BLEEDING, NO, SIR.
19 Q. BASED ON THAT, YOU MADE THE DECISION THAT SHE WAS DYING.
20 A. FROM THE G.I. BLEED?
21 Q. UH-HUH.
22 A. ON THAT AND HER GENERAL DEBILITATED CONDITION AND THE
23 FACT THAT I WASN'T ABLE TO GIVE HER BLOOD PRODUCTS OR I.V.'S
24 AND THE FACT THAT SHE WASN'T TAKING P.O. ORAL FLUIDS OR
25 NOURISHMENT.
3948
1 Q. DID YOU EVALUATE AND MONITOR THE EFFECTS OF THE MORPHINE
2 ON HER ON A REGULAR BASIS DURING THIS TIME PERIOD?
3 A. YES, SIR.
4 Q. AND HOW DID YOU DO THAT, SIR?
5 A. WELL, NURSES, EVERY TIME I GIVE MORPHINE, WERE LOOKING
6 AT THE PATIENT. I WAS COMING IN EVERY DAY AND TALKING --
7 Q. IT'S TRUE, IT IS NOT, THAT -- EXCUSE ME. I'M SORRY. I
8 DIDN'T MEAN TO CUT YOU OFF. BUT IT'S TRUE, IS IT NOT, SIR,
9 THAT THE NURSES NOTE AND THERE'S SEVERAL INSTANCES IN THE
10 NOTE THAT WHEN SHE WAS ADMINISTERED THESE INJECTIONS, SHE
11 WOULD CRY OUT AND MOAN?
12 A. I DID SEE MOANING, YES, SIR. I'M NOT SURE IF IT WAS
13 FROM THE ROLLING OR THE INJECTION.
14 Q. BUT IN ANY EVENT, THEY -- THE NOTATIONS REFLECT AT THE
15 TIME OF THE INTERVENTION, THE TIME WHEN THE SHOT IS
16 ADMINISTERED, IS THAT CORRECT?
17 A. YES, SIR. FOR INSTANCE, PATIENT OFTEN GROANS WHEN
18 TURNED FOR PERINEAL OR MOUTH CARE AND DURING SHOTS.
19 Q. LET'S TALK A LITTLE BIT ABOUT THE MEDICAL DIRECTIVE,
20 DOCTOR. CAN YOU TURN TO THE LEGAL SECTION IN THE EXHIBIT
21 THAT YOU HAVE?
22 A. FOR MRS. LARSEN?
23 Q. UH-HUH.
24 A. OKAY. GOT IT.
25 Q. I GUESS I HAVEN'T GOT IT. JUST LOOKING FOR MY --
3949
1 A. 597.
2 Q. EXCUSE ME, MEDICAL-LEGAL. NOW, I THINK YOUR TESTIMONY
3 WAS, IS YOU HAD AN OPPORTUNITY TO REVIEW THOSE DOCUMENTS
4 PRIOR TO ADMINISTERING THIS COMFORT CARE PLAN, IS THAT
5 CORRECT?
6 A. YES, SIR. THESE ARE ALL IN THE CHART.
7 Q. NOW, THE DOCUMENTS THAT ARE IN THE CHART, AS I
8 UNDERSTAND IT, PERTAIN TO, THERE IS A LIVING WILL, IS THAT
9 CORRECT?
10 A. NUMBER 599, YES, SIR.
11 Q. AND WAS THAT IN THE CHART AT THE TIME, DOCTOR, DO YOU
12 REMEMBER THAT?
13 A. WELL, I'M AWARE THAT SOME OF THESE DOCUMENTS, YOU KNOW,
14 SOME OF THESE DOCUMENTS WERE NOT IN THIS CHART OR IN THE
15 MEDICAL CHART AT THE HOSPITAL. SOME OF THEM I HAVE SEEN
16 WHERE THEY'RE IN PREVIOUS CHARTS, AND SO I'M KIND OF MIXED
17 UP AS TO WHAT WAS HERE. THERE'S SOME --
18 Q. WHAT I WANNA KNOW, DOCTOR --
19 A. -- SURE SOME OF IT WAS HERE.
20 Q. -- IS WHAT DOCUMENT DID YOU GO OFF OF IN TERMS OF
21 ADMINISTERING THIS COMFORT CARE?
22 A. MOST LIKELY THE MEDICAL TREATMENT PLAN.
23 Q. OKAY. AND THAT'S THE ONE THAT BEARS THE ERRONEOUS DATE
24 OF SEPTEMBER 19, 1985.
25 A. RIGHT. OR SO IT SAID.
3950
1 Q. NOW, DID YOU KNOW THAT THAT WAS AN ERRONEOUS DATE ON
2 THAT PARTICULAR TIME?
3 A. NO.
4 Q. READ DOWN THROUGH THE FOLLOWING CARE OR TREATMENT,
5 WITHHOLD TREATMENT AS DIRECTED WITH RESPECT TO THE
6 DECLARANT, WILL YOU?
7 A. SURE. NO C.P.R., NO I.V.'S FOR NUTRITION, HYDRATION,
8 MEDICATION. NO FEEDING TUBES. NO MECHANICAL RESPIRATORY
9 ASSISTANCE. NO ELECTRIC SHOCK FOR DEFIBRILLATION, NO
10 TREATMENT FOR CANCER. OXYGEN AND ORAL MEDICATIONS MAY BE
11 GIVEN FOR RELIEF OF PAIN AND FOR COMFORT.
12 Q. NOW, THAT LAST PART, OXYGEN AND ORAL MEDICATION MAY BE
13 GIVEN FOR RELIEF OF PAIN AND FOR COMFORT. THAT WAS THE
14 DIRECTION THAT JUDITH LARSEN THROUGH HER REPRESENTATIVE
15 MERLIN LARSEN GAVE BACK IN SEPTEMBER OF 1995, ISN'T IT?
16 A. IT APPEARS TO BE. YOU KNOW, '95, IT'S DATED '85 BUT --
17 Q. NOW, YOU DIDN'T GIVE HER ORAL MEDICATIONS FOR PAIN AND
18 COMFORT, DID YOU, DOCTOR?
19 A. I GAVE HER INTRAMUSCULAR MEDICATION.
20 Q. OKAY. SO YOU WEREN'T FOLLOWING THE DIRECTIVE IN RESPECT
21 TO WHAT HAD BEEN GIVEN TO YOU, WERE YOU?
22 A. WELL, SIR, IT DOESN'T SAY YOU CAN'T GIVE INTRAMUSCULAR
23 MEDICATION HERE. SO I WAS FOLLOWING THE DIRECTIVE.
24 Q. IT SAYS, OXYGEN AND ORAL MEDICATION MAY BE GIVEN FOR
25 RELIEF OF PAIN AND COMFORT. YOU'RE SAYING THAT THAT SAYS
3951
1 THAT YOU CAN GIVE IT INTRAMUSCULARLY?
2 A. NO, IT DOESN'T SAY THAT, BUT IT DOESN'T PRECLUDE IT
3 EITHER. NOWHERE HERE DOES IT SAY, NO INTRAMUSCULAR
4 MEDICATIONS. AND IF YOU'RE GONNA GIVE -- IF THE PATIENT'S
5 GONNA SAY, I'LL HAVE ORAL MEDICATION FOR RELIEF OF PAIN AND
6 COMFORT, AND I CAN'T GIVE IT BECAUSE THEY'RE NOT TAKING
7 P.O., I'D HAVE TO GIVE IT I.M.
8 Q. I SEE, DOCTOR. AND IN RESPECT TO THE DOCUMENT BEFORE
9 YOU, THAT YOU USED ON THAT PARTICULAR DATE, THIS WAS NOT A
10 MEDICAL TREATMENT PLAN THAT WAS PROVIDED FOR IN THE
11 HOSPITALIZATION AT DAVIS HOSPITAL, WAS IT?
12 A. I DON'T KNOW, BUT IF DR. STEVENS FILLED IT OUT, PROBABLY
13 NOT. I DON'T THINK HE WAS AT THAT HOSPITAL.
14 Q. AND IN RESPECT TO THE OTHER DOCUMENT, WHICH IS THE
15 LIVING WILL, THAT ALSO INDICATES THAT MEDICATION TO RELIEVE
16 PAIN MAY BE GIVEN IF OBVIOUSLY NEEDED, DOESN'T IT?
17 A. YES, IT DOES. UNDER NUMBER 4.
18 Q. BUT IT ALSO IN PARAGRAPH 2, INDICATES THAT IT HAS TO
19 BE -- HER TERMINAL ILLNESS HAS TO BE CERTIFIED BY
20 PHYSICIANS, IS THAT CORRECT?
21 A. DOESN'T SAY THAT HER -- IT HAS TO BE CERTIFIED BY TWO
22 PHYSICIANS, AS FAR AS I CAN SEE.
23 Q. WELL, WOULD YOU READ PARAGRAPH 2?
24 A. I DECLARE THAT IF AT ANY TIME I SHOULD HAVE AN INJURY,
25 DISEASE, OR ILLNESS, WHICH IS CERTIFIED IN WRITING TO BE A
3952
1 TERMINAL CONDITION OR PERSISTENT VEGETATIVE STATE, BY TWO
2 PHYSICIANS WHO HAVE PERSONALLY EXAMINED ME, AND IN THE
3 OPINION OF THOSE PHYSICIANS THE APPLICATION OF
4 LIFE-SUSTAINING PROCEDURES WOULD SERVE ONLY TO UNNATURALLY
5 PROLONG THE MOMENT OF MY DEATH AND TO UNNATURALLY POSTPONE
6 OR PROLONG THE DYING PROCESS, I DIRECT THAT THESE PROCEDURES
7 BE WITHHELD OR WITHDRAWN, AND MY DEATH BE PERMITTED TO OCCUR
8 NATURALLY.
9 Q. NOW, DOESN'T THAT SAY BY TWO PHYSICIANS, DOCTOR?
10 A. IT SAYS BY TWO PHYSICIANS. I WAS ANSWERING YOUR
11 PREVIOUS QUESTION A MINUTE AGO.
12 Q. THE PREVIOUS QUESTION. SO THESE ARE THE DOCUMENTS THEN
13 THAT YOU SAY THAT YOU RELIED ON IN ADMINISTERING COMFORT
14 CARE ON THIS PARTICULAR OCCASION, IS THAT CORRECT?
15 A. NO, SIR.
16 Q. THEY'RE NOT THE DOCUMENTS YOU RELIED ON?
17 A. I CAN'T BE SURE EXACTLY WHICH ONE. I THINK I USED THE
18 MEDICAL TREATMENT PLAN. I KNOW SOME OF THOSE DOCUMENTS
19 WOULD HAVE BEEN IN HER CHART AT THAT TIME. AND LIKE I SAID,
20 I CAN'T TELL IF ALL OF THESE PARTICULAR DOCUMENTS WERE
21 THERE.
22 Q. SO YOU DON'T KNOW, IS THAT RIGHT?
23 A. NO, SIR, I DON'T KNOW FOR SURE WHICH ONE IT WAS.
24 Q. YOU DON'T KNOW FOR SURE WHICH ONE IT WAS.
25 A. NO, SIR.
3953
1 Q. BUT YOU WENT AHEAD AND ADMINISTERED MORPHINE, NOT EVEN
2 KNOWING WHICH ONE IT WAS, IS THAT CORRECT?
3 A. YES, SIR.
4 Q. THE RECORDS REFLECT, DOCTOR, THAT ELLEN ANDERSON
5 RECEIVED APPROXIMATELY 16 INTERMUSCULAR INJECTIONS ON THE
6 LAST DAY OF HER LIFE. WOULD THAT BE ACCURATE WITH YOUR
7 MEMORY?
8 A. NO, SIR.
9 Q. DO YOU WANNA GO THROUGH AND COUNT THOSE INJECTIONS WITH
10 ME?
11 A. I CAN TELL YOU RIGHT NOW THERE WERE TWO.
12 Q. EXCUSE ME, WITH JUDITH LARSEN, I'M SORRY.
13 A. OKAY. JUDITH LARSEN, AND YOU'RE SAYING THERE WERE 16
14 INJECTIONS?
15 Q. THAT'S CORRECT.
16 A. ON THE LAST DAY OF HER LIFE.
17 Q. WELL, THE LAST 24-HOUR PERIOD OF HER LIFE.
18 A. OKAY. MISS LARSEN DIED AT 8:10 IN THE EVENING AND I'M
19 NOT -- I HAVEN'T REALLY FIGURED OUT EXACTLY THE NUMBER. THE
20 WAY THEY'VE BEEN CALCULATED IS DAY BY DAY, SO STARTING AT
21 ZERO HOURS THAT DAY, IS THAT WHAT YOU'RE TALKING ABOUT?
22 Q. WELL, LET ME REPHRASE THAT. MAYBE I MISSPOKE. IT'S
23 TRUE, IS IT NOT, ON JANUARY THE 2ND, 1996, SHE RECEIVED
24 SEVEN SHOTS OF MORPHINE OVER THE TIME PERIOD EXTENDING FROM
25 12:30 A.M. THROUGH 10:30 P.M.?
3954
1 A. I'M NOT SURE. HAVE TO GO THROUGH AND COUNT 'EM.
2 Q. IS IT TRUE? DID YOU COUNT SEVEN SHOTS FOR THAT DAY?
3 A. NO, I DIDN'T. YOU DIDN'T ASK ME TO. DO YOU WANT ME TO?
4 Q. OH, I THOUGHT YOU SAID YOU WERE COUNTING, DOCTOR.
5 A. NO. I SAID I'D HAVE TO. I'D BE HAPPY TO. IT MAY TAKE
6 A WHILE BECAUSE THEY'RE SPREAD ALL OVER THE PLACE. WOULD
7 YOU LIKE THAT?
8 Q. WELL, WHAT I'D -- WHAT I'D LIKE, DOCTOR, ASSUME THAT
9 THERE WAS SEVEN SHOTS ADMINISTERED DURING THAT TIME FRAME.
10 A. ALL RIGHT.
11 Q. AND ASSUME THAT THERE'S SOME NINE SHOTS THAT ARE
12 ADMINISTERED THE NEXT DAY ON THE 3RD BETWEEN THE HOURS OF
13 6:30 A.M. AND 6:30 P.M., WHICH IS ABOUT A 12-HOUR PERIOD.
14 ASSUMING THAT TO BE CORRECT, DOCTOR, DO YOU CALL THAT
15 COMFORT CARE?
16 A. YES, SIR.
17 Q. AND DO YOU -- DO YOU THINK THAT THERE'S ANOTHER ROUTE
18 SUCH AS A I.V. PUMP THAT WOULD HAVE MUCH BEEN MORE
19 COMFORTABLE FOR THIS PARTICULAR PATIENT THAN THE
20 INTERMUSCULAR INJECTION?
21 A. WELL, JUST A LITTLE WHILE AGO WE LOOKED IN HERE AND IT
22 SAYS NO I.V.'S, SO I CAN'T DO THAT.
23 Q. I SEE. YOU CAN'T GIVE ANY I.V.'S EVEN THOUGH IT SAID
24 ORAL MEDICATION, YOU CAN GIVE THE INTERMUSCULAR INJECTION,
25 BUT WE'RE TALKING ABOUT COMFORT OF THE PATIENT.
3955
1 A. WELL, I.V.'S SPECIFICALLY PRECLUDED, SO IT WOULD BE
2 AGAINST THE LAW FOR ME TO GIVE IT.
3 Q. I SEE. WOULD YOU AGREE THAT THAT WOULD HAVE BEEN MORE
4 COMFORTABLE THAN THE INTERMUSCULAR INJECTION?
5 A. NO, SIR.
6 Q. YOU DON'T THINK SO?
7 A. NO, SIR.
8 Q. YOU THINK TURNING THE PATIENT OVER AND OVER AND OVER
9 AGAIN SOME 16 TIMES IN A TWO-DAY PERIOD IS MORE COMFORTABLE
10 THAN HAVING AN I.V. PUMP?
11 A. I'D SAY THERE'S NO CONNECTION. TURNING'S DONE AS PART
12 OF COMFORT CARE BECAUSE IF YOU LEAVE A PATIENT IN THE SAME
13 POSITION FOR SOME TIME, THEY MIGHT GET A DECUBITUS ULCER. I
14 THINK THAT AN I.V. CAN BE QUITE IRRITATING AND
15 UNCOMFORTABLE. I COULDN'T DO IT IN ANY CASE BECAUSE IT
16 WOULD HAVE BEEN ILLEGAL.
17 Q. I SEE.
18 MR. WILSON: MAY I HAVE A MINUTE, YOUR HONOR?
19 THE COURT: YES.
20 Q. (BY MR. WILSON) IS IT TRUE, IS IT NOT, THAT ON THE
21 LAST DAY OF JUDITH LARSEN'S LIFE, HER RESPIRATIONS
22 DECREASED?
23 A. IN THE MORNING THEY WERE LOW. AND THEN LATER THEY WERE
24 UP.
25 Q. WHAT TIME DID SHE DIE, DOCTOR?
3956
1 A. I THINK AT 8:10 AT NIGHT.
2 Q. YOUR TESTIMONY IS, IS THE MORPHINE HAD NOTHING TO DO
3 WITH HER DEATH?
4 A. THE MORPHINE WAS GIVEN FOR COMFORT CARE DURING HER
5 DEATH.
6 Q. THE QUESTION WAS, DOCTOR, DO YOU THINK THAT THE MORPHINE
7 HAD NOTHING TO DO WITH HER DEATH?
8 A. NO, SIR, I DON'T THINK IT CAUSED HER -- OR CONTRIBUTED
9 TO HER DEATH. I THINK IT HAD A LOT TO DO WITH HER DEATH IN
10 THAT IT ALLOWED HER TO HAVE A DIGNIFIED DEATH FREE OF PAIN.
11 Q. THINK YOU USED THE TERM PROVIDED HER WITH DIGNITY. IS
12 THAT CORRECT?
13 A. PROVIDED HER WITH MEDICATION.
14 Q. THINK YOU USED THE TERM PROVIDED HER WITH A DIGNIFIED
15 WAY TO DIE. I THINK THAT WAS YOUR EXACT PHRASEOLOGY,
16 DOCTOR, WASN'T IT?
17 A. I DON'T REMEMBER EXACTLY.
18 Q. SO YOU DON'T BELIEVE THAT THE MORPHINE HASTENED IN ANY
19 WAY HER -- HER DEATH?
20 A. NO, SIR.
21 Q. AND OVER THIS FOUR-DAY TIME PERIOD, YOU CONTINUED TO
22 GIVE INJECTION AFTER INJECTION AFTER INJECTION OF MORPHINE,
23 DID YOU NOT?
24 A. NO. THE NURSES DID.
25 Q. BUT YOU ORDERED IT, DIDN'T YOU, DOCTOR?
3957
1 A. YES, SIR.
2 Q. AND WHAT WERE THE INDICATIONS, DOCTOR, THAT SHE WAS IN
3 ANY KIND OF PAIN?
4 A. SHALL I GO THROUGH AND GET 'EM ALL FOR YOU? THERE'S --
5 Q. I MEAN GENERALLY SPEAKING, WHAT WERE THE NATURE OF THE
6 PAIN COMPLAINTS, DOCTOR?
7 A. WELL, THERE WERE TWO KINDS. OF COURSE, THE NURSES NOTE
8 AND I NOTED PAIN, SUFFERING.
9 Q. UH-HUH.
10 A. WITHOUT THIS MORPHINE, THIS LADY, WITHOUT HER I.V.,
11 SLOWLY BECOMING MORE AND MORE DEHYDRATED, WITH MULTIPLE
12 PROBLEMS, IT'S MY EXPERIENCE AS A PHYSICIAN, THAT SHE WOULD
13 HAVE HAD AN ANGUISHED DEATH.
14 Q. NOW, YOUR EXPERIENCE AS A PHYSICIAN, BUT SHE DID NOT
15 EXHIBIT ANY OF THOSE SIGNS, DID SHE?
16 A. WELL, ACTUALLY, SHE DID SHOW SIGNS OF PAIN.
17 Q. AND WAS THAT MODERATE, WAS THAT MILD, WAS THAT SEVERE
18 PAIN?
19 A. IT WAS BAD ENOUGH THAT DURING THOSE DAYS THE NURSES FELT
20 IT NECESSARY TO GIVE P.R.N.'S OF MORPHINE ON TOP OF WHAT WAS
21 REGULARLY SCHEDULED.
22 Q. THERE WAS ALSO A NURSE WHO WITHHELD THE MORPHINE BECAUSE
23 OF HER RESPIRATIONS, TRUE?
24 A. ABSOLUTELY.
25 Q. AND WAS THAT A VALID RESPONSE ON -- BY THAT NURSE?
3958
1 A. YES, IT WAS WITHIN HER SCOPE OF CARE AND HER DUTIES OR
2 RESPONSIBILITY.
3 Q. BUT YOU DIDN'T THINK THAT WAS APPROPRIATE, DID YOU?
4 A. I THINK IT WOULD HAVE BEEN BETTER IF SHE CALLED ME, AND
5 THAT WE'D MADE THE DOSAGE SCHEDULE MORE FLEXIBLE WITH A --
6 Q. EXCUSE ME.
7 A. -- WITH DIFFERENT LEVELS GIVEN, NOT JUST A STRAIGHT
8 5 MILLIGRAMS.
9 Q. I GUESS WE'LL NEVER KNOW, WILL WE, DOCTOR, WHETHER SHE
10 WOULD HAVE SUFFERED AN ANGUISHED DEATH, AS YOU CALL IT?
11 A. NO, SIR, WE WON'T.
12 Q. THE FACT OF THE MATTER IS, YOU MADE THE DECISION AS TO,
13 NUMBER ONE, THE DECISION THAT SHE WAS DYING, ISN'T THAT
14 TRUE?
15 A. I MADE THE ULTIMATE DECISION THAT IT APPEARED THAT SHE
16 WAS DYING. THE JUDGMENT THAT I SHOULD GO TALK WITH THE
17 FAMILY AND DISCUSS THAT, YES, SIR.
18 Q. AND THEN YOU MADE THE ULTIMATE DECISION TO ADMINISTER
19 MORPHINE, ISN'T THAT TRUE?
20 A. YES, SIR.
21 Q. AND YOU DIDN'T REALLY DISCUSS WITH THE FAMILY THE
22 ALTERNATIVES FOR TREATMENT FOR YOUR MOTHER, DID YOU?
23 A. FOR HER -- FOR THEIR MOTHER, I DISCUSSED --
24 Q. FOR THEIR MOTHER.
25 A. YOU KNOW, I CAN'T REMEMBER THE EXACT WORDS THAT WERE
3959
1 SPOKEN AT THE TIME.
2 Q. DID YOU THINK TO TALK TO MERLIN ABOUT MAYBE SENDING HER
3 HOME AND GETTING HER SOME HOSPICE CARE?
4 A. WELL, NO, SIR. MERLIN WAS TELLING ME HE DIDN'T HAVE A
5 PLACE TO BRING HER.
6 Q. HE WAS TALKING ABOUT A NURSING HOME FACILITY, WASN'T HE?
7 A. RIGHT.
8 Q. OKAY. YOU DIDN'T MAKE THAT SUGGESTION TO HIM THAT HE
9 POSSIBLY COULD TAKE HER HOME, SHE WAS GONNA DIE -- IF SHE
10 WAS GONNA DIE IN A FEW DAYS. WHY NOT?
11 A. I DIDN'T THINK OF IT.
12 Q. WELL, IT'S TRUE, DOCTOR, YOU WOULDN'T HAVE BEEN ABLE TO
13 ADMINISTER THE MORPHINE TO HER IN THAT CONTEXT, WOULD YOU?
14 A. AT HOME?
15 Q. HUH?
16 A. I'M SORRY?
17 Q. YOU WOULDN'T HAVE BEEN ABLE TO ADMINISTER MORPHINE TO
18 HER IF SHE'D GONE HOME, WOULD YOU?
19 A. WELL, SURE, SHE COULD HAVE HAD HOSPICE CARE COME AND
20 GIVE HER MORPHINE.
21 Q. YOU MADE THE DECISION THAT SHE WASN'T GOING TO BE
22 TRANSFERRED OFF THE UNIT, ISN'T THAT CORRECT?
23 A. YES, SIR.
24 Q. EVEN THOUGH SHE DIDN'T FIT THE CRITERIA ANYMORE ONCE SHE
25 WAS SUFFERING FROM A LIFE-THREATENING DISEASE OR ILLNESS,
3960
1 ISN'T THAT CORRECT?
2 A. THAT'S INCORRECT.
3 Q. HOW IS THAT INCORRECT?
4 A. THE ADMINISTRATION CRITERIA TO THE UNIT PRECLUDE
5 LIFE-THREATENING DISEASES OF AN ACUTE SORT. THERE WAS NO
6 RULE THAT SAYS, AS FAR AS I'M AWARE OF, THAT THEY HAVE TO
7 LEAVE THAT UNIT IF THEY BECOME ACUTELY ILL.
8 Q. WELL, THE UNIT IS NOT SET UP FOR ANY KIND OF CRITICAL
9 CARE, IS IT?
10 A. IT'S NOT AN I.C.U.
11 Q. THE I.C.U. IN FACT IS NEXT DOOR TO THE UNIT, ISN'T IT?
12 A. NO, SIR.
13 Q. IS IT JUST DOWN THE HALLWAY?
14 A. IT'S DOWN THE HALLWAY ON THAT LEVEL, ON THAT FLOOR OF
15 THE HOSPITAL, THIRD FLOOR.
16 Q. OKAY. SO IT WOULD HAVE BEEN AN EASY MATTER TO TRANSFER
17 HER OFF THE UNIT TO WHERE SHE COULD BE MONITORED AND
18 ASSESSED MORE APPROPRIATELY, ISN'T THAT TRUE?
19 A. WELL, I WOULDN'T CALL IT AN EASY MATTER BECAUSE ONCE
20 AGAIN, THE PATIENT HAS TO BE MOVED. AND SHE'S RECEIVING THE
21 CARE OF SOME GOOD NURSES WHO ARE PSYCHIATRICALLY TRAINED,
22 AND PART OF THEIR TRAINING IS TO DEAL WITH THIS SORT OF
23 THING IN THE SENSE OF WORKING WITH FAMILIES OVER EMOTIONAL
24 ISSUES THAT CAN COME UP.
25 Q. ISN'T IT TRUE, DOCTOR, THAT PART OF THE COMFORT CARE
3961
1 PHILOSOPHY IS TO TRY AND ASSIST THE FAMILY MEMBERS IN THIS
2 DYING PROCESS?
3 A. YES, SIR. THAT'S WHAT WAS DONE.
4 Q. NOW, YOU HEARD THE TESTIMONY OF MERLIN LARSEN AND HAROLD
5 LARSEN IN HERE, DIDN'T YOU?
6 A. YES, SIR.
7 Q. AND THEY DESCRIBED THEIR MOTHER AS BEING COMATOSE THOSE
8 LAST DAYS OF HER LIFE, DIDN'T THEY?
9 MR. STIRBA: YOUR HONOR, IT'S IMPROPER FORM --
10 THE COURT: SUSTAINED.
11 MR. STIRBA: -- OF THE QUESTION.
12 THE COURT: SUSTAINED.
13 Q. (BY MR. WILSON) ISN'T IT TRUE THAT JUDITH LARSEN WAS
14 IN A COMATOSE STATE THE LAST FEW DAYS OF HER LIFE.
15 A. NO, SIR.
16 Q. SHE WAS NOT LETHARGIC?
17 A. SHE WAS AT TIMES QUITE LETHARGIC.
18 Q. HOW OFTEN DID YOU COME INTO THE UNIT TO SUPERVISE THE
19 MONITORING ASSESSMENT OF JUDITH LARSEN?
20 A. ONCE A DAY.
21 Q. HOW LONG WERE YOU THERE FOR?
22 A. WITH RESPECT TO MRS. LARSEN?
23 Q. UH-HUH.
24 A. I GUESS IT WOULD VARY. I'M NOT SURE.
25 Q. ISN'T IT TRUE, DOCTOR, THAT YOU WOULD FREQUENTLY COME IN
3962
1 IN THE EARLY MORNING HOURS WHEN THESE PATIENTS WERE ASLEEP?
2 A. NO, SIR.
3 Q. THAT'S NOT TRUE?
4 A. NO, SIR, IT'S NOT.
5 Q. OR THAT YOU WOULD COME IN IN THE LATE EVENING HOURS WHEN
6 THEY WERE ALSO ASLEEP?
7 MR. STIRBA: YOUR HONOR, I'M GONNA OBJECT,
8 RELEVANCY, IF WE'RE NOT TALKING ABOUT THE FIVE PATIENTS
9 INVOLVED HERE.
10 THE COURT: ARE YOU TALKING ABOUT THESE PATIENTS?
11 MR. WILSON: I AM.
12 THE COURT: OKAY. GO AHEAD.
13 Q. (BY MR. WILSON) DURING THE TIME PERIOD EXTENDING FROM
14 DECEMBER 6TH UP UNTIL JANUARY 14TH, ISN'T IT TRUE THAT YOU
15 WOULD COME ON TO THE UNIT IN THE EARLY MORNING HOURS, IT WAS
16 YOUR PATTERN TO COME ON TO THE UNIT BEFORE THE PATIENTS WERE
17 AWAKE, ISN'T THAT CORRECT?
18 A. NO, SIR. YOU USED THE WORDS FREQUENT AND PATTERN.
19 OCCASIONALLY I WOULD COME IN EARLY.
20 Q. I SEE. BUT YOU WOULD COME IN ONCE A DAY?
21 A. YES, SIR.
22 Q. AND YOU WERE EMPLOYED AT -- WHERE ELSE WERE YOU EMPLOYED
23 AT THIS TIME, SIR?
24 A. WELL, I WOULD HAVE BEEN IN MY OUTPATIENT OFFICE AT WEST
25 VALLEY CITY. AND DURING THIS TIME, I THINK I NO LONGER
3963
1 WORKED FOR EAST VALLEY MENTAL HEALTH.
2 Q. SO IS THIS THE PRIMARY SOURCE OF YOUR INCOME?
3 A. I'D SAY IT'S PROBABLY SPLIT BETWEEN THIS AND MY
4 OUTPATIENT OFFICE.
5 Q. OKAY. AND IN RESPECT TO THIS PARTICULAR PLACE OF
6 EMPLOYMENT, YOU DIDN'T HAVE ANY SET HOURS, DID YOU?
7 A. WHERE?
8 Q. HUH?
9 A. WHERE? AT THE HOSPITAL?
10 Q. AT THE HOSPITAL.
11 A. WELL, I TOLD THE FOLKS AT THE HOSPITAL THAT I'D
12 DEFINITELY BE THERE DURING THE 8:00 TO 5:00 TIME FOUR OR
13 FIVE DAYS A WEEK SO THAT THE STAFF, THE SOCIAL WORKER STAFF
14 WHO WERE MOSTLY THERE DURING THE DAY, COULD SET UP FAMILY
15 MEETINGS AND SUCH AS THEY NEEDED TO. AND, YOU KNOW, WE HAD
16 TO HAVE SOME REGULAR HOURS BECAUSE WE HAD ALL THESE MEETINGS
17 THAT WE WOULD HAVE AS A TEAM --
18 Q. I SEE. DID YOU --
19 A. -- THE OTHER DAYS I COME IN WHENEVER --
20 Q. DID YOU HAVE A TIME CLOCK?
21 A. NO, SIR.
22 THE COURT: WHY DON'T WE JUST KIND OF SEPARATE,
23 JUST WAIT --
24 THE WITNESS: OH, I'M SORRY.
25 THE COURT: -- FOR ONE ANOTHER --
3964
1 Q. (BY MR. WILSON) SO THERE'S NO -- THERE'S NO RECORD AS
2 TO LOG-IN TIMES OR WHEN YOU LOGGED OUT --
3 A. NO, SIR.
4 Q. -- IS THAT CORRECT.
5 A. NO, SIR.
6 Q. AND YOU WERE FREE TO GO AND LEAVE AS YOU PLEASE.
7 A. YES, SIR.
8 Q. CRITICAL TO THIS TIME PERIOD WE'RE TALKING ABOUT, A GOOD
9 PORTION OF IT IS IN THE HOLIDAY SEASON, IS IT NOT?
10 A. YES, SIR.
11 Q. AND I ASSUME THAT YOU HAVE A FAIRLY ACTIVE LIFESTYLE, IS
12 THAT CORRECT?
13 A. WHAT DO YOU MEAN BY ACTIVE?
14 Q. WELL, I UNDERSTAND YOU LIKE TO SKI.
15 A. I DO SKI.
16 Q. AND WOULD YOU FREQUENTLY GO SKIING DURING THE HOLIDAY
17 TIME PERIOD?
18 A. WELL, HOW DO YOU DEFINE FREQUENTLY?
19 Q. WELL, ONCE OR TWICE A WEEK?
20 A. PROBABLY.
21 Q. DID YOU LIKE TO -- IN FACT, YOU GAVE THE CHRISTMAS PARTY
22 THIS YEAR, DIDN'T YOU?
23 A. YES, SIR.
24 MR. WILSON: I DON'T KNOW, YOUR HONOR, IF YOU'D --
25 I'M GONNA BE -- I HAVE TO GO THROUGH THESE OTHER THREE ONE
3965
1 BY ONE --
2 THE COURT: WELL, LET'S JUST GO UNTIL 5:00 BECAUSE
3 WE TOOK MORE TIME --
4 MR. WILSON: OKAY.
5 THE COURT: -- WHEN WE HAD THE FEW MINUTES OUT OF
6 THE JURY'S PRESENCE, SO LET'S --
7 Q. (BY MR. WILSON) LET'S TALK ABOUT MARY CRANE, DOCTOR.
8 PREVIOUSLY TESTIFIED I THINK ON ADMISSION THAT MARY CRANE
9 WAS VERY SICK, IS THAT CORRECT?
10 A. SHE HAD MULTIPLE MEDICAL PROBLEMS, THAT'S CORRECT.
11 Q. BUT YET YOU FOUND THAT SHE WAS OKAY FOR ADMISSION TO THE
12 GEROPSYCH UNIT, IS THAT CORRECT?
13 A. YES, SIR.
14 Q. SO SHE WAS STABLE, I ASSUME, NOT SUFFERING FROM ANY
15 LIFE-THREATENING DISORDERS, IS THAT CORRECT?
16 A. AS FAR AS I COULD TELL.
17 Q. AS FAR AS YOU COULD TELL.
18 A. ACUTE LIFE-THREATENED.
19 Q. DID YOU -- WHAT RECORDS DID YOU HAVE AVAILABLE TO YOU AT
20 THE TIME THAT YOU FIRST DID YOUR ASSESSMENT OF MARY CRANE?
21 A. AT THIS TIME, FOUR AND A HALF, FIVE YEARS LATER, I DON'T
22 REMEMBER EXACTLY WHAT RECORDS I HAD AVAILABLE.
23 Q. WELL, WOULD THE RECORDS THAT ARE CONTAINED IN THE
24 INITIAL -- WELL, THERE ARE RECORDS THAT ARE IN FROM THE
25 NURSING HOME. ARE THEY CONTAINED IN THE EXHIBIT THAT YOU
3966
1 HAVE IN FRONT OF YOU?
2 A. LOOKS LIKE UNDER OTHER, THERE'S A LOT OF STUFF. I
3 HAVEN'T HAD A CHANCE TO LOOK AT IT YET.
4 Q. YOU DON'T RECALL LOOKING AT THAT STUFF AT THE TIME THAT
5 MARY CRANE CAME TO HOSPITAL, IS THAT CORRECT?
6 A. I PROBABLY DID LOOK THROUGH THIS SOME, I'M SURE I -- I
7 MEAN IT'S LIKE 50 PAGES OR SO, 80 PAGES. I DOUBT I READ IT
8 ALL.
9 Q. YOU PREVIOUSLY TESTIFIED THAT YOU ORDERED A DURAGESIC
10 PATCH FOR 25 MICROGRAMS, IS THAT CORRECT?
11 A. THAT WAS MY INITIAL ORDER ON --
12 Q. AND THEN YOU CHANGED YOUR -- YOU CHANGED YOUR MIND AND
13 ORDERED A 50-MICROGRAM PATCH.
14 A. THAT'S RIGHT.
15 Q. IN FACT, I THINK YOU REFER TO THE MICROGRAM PATCH AS A
16 LOW -- 50 MICROGRAM WAS A LOW DOSAGE ORDER, IS THAT CORRECT?
17 A. YES, SIR.
18 Q. NOW, YOU'VE SEEN THE EXHIBIT THAT'S -- THE P.D.R. LISTED
19 FOR THE DURAGESIC. THAT'S EXHIBIT NUMBER 41. DO YOU WANNA
20 TAKE A LOOK AT THAT, DOCTOR?
21 A. WELL, I ALREADY HAVE.
22 Q. THAT PARTICULAR EXHIBIT RECOMMENDS THAT YOU NOT START
23 OUT AT ANY HIGHER THAN 25 MICROGRAMS, ISN'T THAT TRUE?
24 A. IN NON OPIOID TOLERANT PATIENTS --
25 Q. OKAY.
3967
1 A. -- SHE WAS OPIOID TOLERANT.
2 Q. DID YOU KNOW THAT AT THE TIME?
3 A. YES. SHE HAD BEEN ON LORTAB.
4 Q. DO YOU KNOW HOW MUCH LORTAB SHE WAS RECEIVING?
5 A. APPROXIMATELY ONE A DAY.
6 Q. AND THAT HAD BEEN THE MEDICATION THAT SHE HAD RECEIVED
7 DURING THAT TIME PERIOD, RIGHT? THAT SHE WAS --
8 A. JUST PREVIOUS, YES --
9 Q. -- IN THE NURSING HOME --
10 A. -- WELL, SHE GOT OTHERS, TOO.
11 Q. WELL, BASICALLY, THE -- FOR PAINKILLER WAS THE LORTAB,
12 IS THAT RIGHT?
13 A. SHE ALSO HAD CODEINE AND DARVOCET.
14 Q. AND THEY WERE AT DIFFERENT TIME FRAMES, WEREN'T THEY?
15 A. BELIEVE SO. YES, I THINK SHE WAS ON THE LORTAB RIGHT
16 BEFORE SHE CAME TO US.
17 Q. OKAY. SO SHE RECEIVES THIS OVER A -- ONE LORTAB A DAY,
18 OVER THE -- THIS TIME PERIOD, AND YOU WOULD DESCRIBE THAT AS
19 BEING OPIOID TOLERANT.
20 A. OPIOID TOLERANT, YES, SIR.
21 Q. OPIOID TOLERANT?
22 A. YES, SIR.
23 Q. SO YOU ORDER THE 50-MICROGRAM PATCH.
24 A. YES, SIR.
25 Q. FOR WHAT YOU PERCEIVE AS CHRONIC BACK PAIN.
3968
1 A. YES, SIR.
2 Q. AND THEN IN ADDITION, YOU PUT HER ON A REGIMEN OF
3 VARIOUS TYPES OF SEDATING DRUGS, IS THAT CORRECT?
4 A. VARIOUS TYPES OF PSYCHIATRIC DRUGS --
5 Q. WELL, WITH SEDATING --
6 A. -- AS WELL AS OTHERS --
7 Q. -- QUALITIES, IS THAT CORRECT?
8 A. MANY OF THEM WITH SEDATING QUALITIES TO ONE DEGREE OR
9 ANOTHER.
10 Q. SEE IF WE CAN FIND HER CHART HERE. THAT'S STATE'S
11 EXHIBIT 36. TAKE LOOK AT THAT EXHIBIT. DO THE DOSAGES, THE
12 AMOUNTS OF ADMINISTRATION OF MEDICATIONS GIVEN CONFORM TO
13 YOUR REVIEW OF THE RECORDS?
14 A. ALL THE MEDICATIONS UP HERE ARE MEDICATIONS THAT WERE
15 GIVEN, AND I DON'T REALLY -- I'VE NEVER REALLY LOOKED A THIS
16 CHART AND FIGURED OUT IF YOU HAVE IT PRECISELY ACCURATE AS
17 TO AMOUNTS. AND YOU'VE GOT KIND OF THIS --
18 Q. BUT THOSE ARE MEDICATIONS THAT YOU HAVE ORDERED
19 ADMINISTERED TO HER.
20 A. YES, SIR.
21 Q. IS THAT CORRECT?
22 A. RISPERDAL, SERZONE, TRAZODONE, DEPAKENE, ATIVAN, AND
23 DURAGESIC, YES, SIR.
24 Q. NOW, THE ADDITIVE EFFECTS, AS YOU'VE EARLIER TESTIFIED
25 TO, WOULD BE PRESENT IN THOSE PARTICULAR DRUGS, IS THAT
3969
1 CORRECT?
2 A. PERHAPS.
3 Q. WELL, DIDN'T YOU TESTIFY EARLIER THAT THOSE ARE ALL
4 CENTRAL NERVOUS SYSTEM DEPRESSANT EFFECTS?
5 A. THEY ALL HAVE DEPRESSANT EFFECTS IN DIFFERENT DEGREES
6 AND ACTUALLY IN DIFFERENT WAYS.
7 Q. BUT DIDN'T YOU TESTIFY, DOCTOR, THAT IF YOU GIVE THESE
8 PARTICULAR DRUGS, THEY CAN HAVE ADDITIVE EFFECT?
9 A. YES, SIR.
10 Q. OKAY. AND IN ADDITION TO THE ADDITIVE EFFECTS OF THE
11 PSYCHOTROPICS, YOU ALSO HAVE ADMINISTERED A DURAGESIC PATCH,
12 IS THAT CORRECT?
13 A. IT IS.
14 Q. AND AS I UNDERSTAND IT, THE FIRST DURAGESIC PATCH FELL
15 OFF IN 24 HOURS, SO ANOTHER ONE WAS PLACED ON MARY CRANE, IS
16 THAT CORRECT?
17 A. THINK IT FELL OFF RIGHT AWAY, BUT IT WOULD HAVE BEEN
18 WITHIN THE FIRST 24 HOURS, YES. I --
19 Q. NOW, AS I UNDERSTAND THE TESTIMONY -- OR LET ME ASK YOU
20 THIS QUESTION: THE DURAGESIC PATCH HAS A PERIOD OF TIME
21 THAT IT BUILDS UP INTO THE SYSTEM, IS THAT RIGHT?
22 A. THAT'S THE WAY I UNDERSTAND IT.
23 Q. SO IT BUILDS UP TO A CERTAIN LEVEL.
24 A. CORRECT.
25 Q. NOW, DO YOU AGREE THAT THERE IS A CONVERSION RATIO AS IT
3970
1 PERTAINS TO -- YOU CALLED IT THE GOLD STANDARD OF MORPHINE?
2 FOR THE DURAGESIC PATCH?
3 A. THERE'S A ROUGH GUIDELINE. I'M NOT SURE THAT IT'S BEEN
4 FULLY AUTHENTICATED.
5 Q. AND WHAT'S THE ROUGH GUIDELINE, DOCTOR?
6 A. WELL, FOR EACH DOSE OF DURAGESIC, THERE'S A ROUGH
7 GUIDELINE AS TO APPROXIMATELY HOW MUCH MORPHINE IT EQUALS,
8 ORAL, I.M., I.V., HAVE TO ADJUST FOR THE ROUTE OF
9 ADMINISTRATION.
10 Q. AND WERE YOU AWARE OF THIS GUIDELINE BACK IN 1995?
11 A. I CALLED THE PHARMACIST.
12 Q. I SEE. AND WHAT IS THE GUIDELINE THAT YOU WERE TOLD?
13 WHAT IS A 50-MICROGRAM DURAGESIC PATCH EQUIVALENT TO? IN
14 TERMS OF MORPHINE SULFATE I.M. INJECTION?
15 A. YOU KNOW, I DON'T RECALL THIS ABSOLUTELY, BUT I THINK
16 IT'S EQUIVALENT TO 5 MILLIGRAMS I.M. EVERY FOUR HOURS.
17 Q. SO YOUR TESTIMONY IS A 50-MICROGRAMS PATCH WOULD BE
18 EQUIVALENT TO 20 -- OR EXCUSE ME, 30 MILLIGRAMS IN A DAY, IN
19 A 24-HOUR PERIOD?
20 A. YES, SIR, I'M PRETTY SURE THAT'S THE CASE.
21 Q. THAT'S WHAT YOU RECALL?
22 A. THAT'S WHAT I RECALL. BASICALLY, I ASKED THE PHARMACIST
23 WHAT HE THOUGHT, AND HE SAID 50 SOUNDED FINE.
24 Q. HE TOLD YOU 50 -- SAID 50 WOULD BE JUST FINE.
25 A. THAT'S WHAT I DOCUMENTED HERE.
3971
1 Q. SO HE DIDN'T -- YOU DIDN'T DIAGNOSIS OR PRESCRIBE IT,
2 THE PHARMACIST DID, IS THAT RIGHT?
3 A. NO, SIR. I PRESCRIBED IT. PHARMACIST GAVE ME ADVICE.
4 Q. ON JANUARY -- YOU CONTINUED TO APPLY THAT PATCH OVER THE
5 PERIOD OF TIME, IS THAT CORRECT?
6 A. I'M SORRY?
7 Q. SHE CONTINUES TO HAVE THE PATCH ON ALL DURING THE TIME
8 PERIOD THAT SHE WAS IN THE HOSPITAL.
9 A. YES, SIR.
10 Q. IN FACT, IT'S INCREASED, IS IT NOT, ON JANUARY 4TH TO 75
11 MICROGRAMS?
12 A. YES, IT ITS.
13 Q. ON THE 1ST OF JANUARY, IS THAT THE DATE THAT THE VAGINAL
14 FISTULA IS NOTED?
15 A. IT'S THE FIRST TIME I HAVE IT NOTED. I KNOW THAT THE
16 NURSES NOTED IT THAT NIGHT PREVIOUS, I BELIEVE. THEY
17 BROUGHT IT TO MY ATTENTION ON THE MORNING OF THE 1ST,
18 JANUARY 1ST. THAT'S WHEN I LEFT MY NOTE SAYING, HAS A
19 FISTULA.
20 Q. AND IT'S REPORTED BECAUSE THE NURSE OBSERVES -- AND I
21 THINK IT WAS NURSE LONG OBSERVES A -- SOME FECAL MATTER IN
22 THE VAGINA, IS THAT CORRECT?
23 A. WELL, I DON'T KNOW WHICH NURSE IT WAS. I CAN LOOK THAT
24 UP.
25 Q. WELL, I DON'T THINK THAT'S IMPORTANT. JUST -- JUST
3972
1 SUFFICE IT TO SAY FOR MY QUESTION THAT IT'S NOTED AS FECAL
2 MATTER IN THE VAGINA.
3 A. RIGHT. AND ONE OF THE NURSES TOLD ME ABOUT THAT.
4 Q. AND AT THAT TIME, A CONSULT IS CALLED IN TO DR. MEEKS,
5 IS THAT RIGHT?
6 A. LET'S SEE, DR. DIENHART SAW THAT FIRST I THINK, YEAH.
7 AND THEN DR. MEEKS CAME AND SAW HER ON THE 2ND.
8 Q. DR. MEEKS NOTED THAT THERE WAS NO INFECTION AT THAT
9 TIME, DIDN'T HE?
10 A. NO, HE DIDN'T. HE DIDN'T SAY ANYTHING ABOUT --
11 Q. HE DIDN'T MAKE A NOTE OF ANY INFECTION, DID HE?
12 A. NO. HE JUST SAID, TREAT IT WITH BROAD SPECTRUM
13 ANTIBIOTICS AND LOW RESIDUE DIET.
14 Q. AND THAT WAS DONE ON JANUARY 2ND OF '96.
15 A. YES, SIR.
16 Q. CORRECT?
17 A. YES, SIR.
18 Q. AND HE INDICATED AT THAT TIME THAT IT COULD BE TREATED
19 WITH -- POSSIBLY SUCCESSFULLY TREATED TO 30 TO 35 PERCENT OR
20 25 TO 35 PERCENT BY TREATING WITH BROAD SPECTRUM
21 ANTIBIOTICS, IS THAT CORRECT?
22 A. AND LOW RESIDUE DIET.
23 Q. AND THAT WAS NOT IMPLEMENTED UNTIL THREE DAYS LATER ON
24 THE 5TH, IS THAT CORRECT?
25 A. NO, SIR. THE LOW FIBER DIET WAS ADDED ON THE 3RD, AND
3973
1 THEN ASKED, PLEASE HAVE -- DR. DIENHART MAY ORDER A
2 GYNECOLOGIST'S RECOMMENDATIONS. GIVE HIM MY PHONE NUMBER SO
3 HE CAN CALL ME IF NECESSARY. THE NURSE CALLED DR. DIENHART,
4 BUT HE DIDN'T REALLY DO ANYTHING.
5 Q. DR. DIENHART DIDN'T DO ANYTHING.
6 A. NO. SO FINALLY ON THE 5TH, I WENT AHEAD AND ORDERED IT.
7 Q. I SEE. SO YOU WERE RELYING ON DR. DIENHART?
8 A. YES, SIR.
9 Q. THIS WAS YOUR PATIENT.
10 A. YES, SIR.
11 Q. AND YOUR TESTIMONY IS, IS AS I UNDERSTAND IT, THAT THIS
12 PATIENT DEVELOPS A SEPSIS?
13 A. YES, SIR.
14 Q. IS IT YOUR BELIEF THAT THE SEPSIS WAS CAUSED AS A RESULT
15 OF THIS VAGINAL FISTULA?
16 A. I REALLY DON'T KNOW IF IT WAS THAT OR A URINARY TRACT
17 INFECTION.
18 Q. NOW, IT'S TRUE, IS IT NOT, THAT THE URINARY TRACT
19 INFECTION WAS BEING TREATED WITH CIPRO?
20 A. HAD BEEN TREATED WITH CIPRO.
21 Q. OKAY. AND ISN'T IT TRUE THAT ON THE 4TH OF JANUARY, SHE
22 SHOWS NO BACTERIA?
23 A. YOU MEAN LIKE ON HER URINALYSIS?
24 Q. UH-HUH.
25 A. I DON'T REALLY KNOW WHERE YOU'VE GOT THOSE HERE. CAN
3974
1 YOU HELP ME? OH, LABS.
2 WELL, YOU KNOW, I HAVE ONE HERE, IT DOES HAVE
3 BACTERIA, BUT I CAN'T READ THE DATE ON IT.
4 Q. LET ME SHOW YOU -- OR TURN TO MED PAGE 00269.
5 A. OKAY. AND HERE'S ONE, THE 4TH, IT'S A URINALYSIS THAT
6 SHOWS WHITE BLOOD CELLS ZERO TO ONE. DOESN'T NOTE WHETHER
7 THERE WERE BACTERIA OR NOT FOUND.
8 Q. ISN'T THERE A PROVISION UP, JUST UP FROM THERE THAT
9 SHOWS BACTERIA, AND THEN THERE'S OFF TO THE SIDE NEGATIVE?
10 A. RIGHT. BUT NOBODY'S WRITTEN ANYTHING IN THERE, SO YOU
11 CAN'T TELL WHETHER THERE WERE OR NOT. NEGATIVE WOULD BE THE
12 NORMAL STATE, BUT NOBODY WROTE WHETHER IT WAS NEGATIVE OR
13 POSITIVE. USUALLY IT WOULD BE REPORTED NEGATIVE, FEW, MANY.
14 THE COURT: MR. WILSON --
15 Q. (BY MR. WILSON) SO DID SHE HAVE A -- DID SHE HAVE A
16 URINARY TRACT INFECTION ON THE 4TH, DOCTOR?
17 A. IT'S HARD TO SAY.
18 Q. IT'S HARD TO SAY.
19 THE COURT: MR. WILSON, WOULD THIS BE A GOOD PLACE
20 TO BREAK OR --
21 MR. WILSON: IT WOULD BE.
22 THE COURT: OKAY.
23 (THE COURT ADMONISHED, THEN EXCUSED THE JURY.
24 THE COURT AND COUNSEL HELD A SCHEDULING
25 CONFERENCE, THEN RECESSED FOR THE EVENING.)
3975
1 IN THE DISTRICT COURT OF DAVIS COUNTY
2 STATE OF UTAH
3
*****
4 ______________________________
)
5 STATE OF UTAH, )
)
6 PLAINTIFF, )
)
7 ) REPORTER'S TRANSCRIPT
VS. )
8 ) CASE NO. 991700983
ROBERT ALLEN WEITZEL, )
9 )
DEFENDANT. )
10 ______________________________)
11 *****
12 TRIAL VOLUME 19 OF 21
13 JULY 6, 2000
14 HONORABLE THOMAS L. KAY
15
*****
16
17 APPEARANCES:
18 FOR THE STATE: MR. MELVIN C. WILSON
MR. STEVEN V. MAJOR
19 MS. CHARLENE BARLOW
20
FOR THE DEFENDANT: MR. PETER STIRBA
21 MR. JOHN WARREN MAY
22
23
24
25
3976
1 (WHEREUPON, THE MORNING SESSION BEGINS.)
2 THE COURT: WE DON'T HAVE THE JURY HERE BECAUSE WE
3 HAVE A PROBLEM. ONE OF THE JURORS HE'S THE ONE, TWO, THIRD
4 ONE ON THE FRONT ROW KIND OF REDDISH HAIR AND GLASSES WAS
5 RUSHED TO THE HOSPITAL AND IS IN INTENSIVE CARE WITH CHEST
6 PAINS AND HE WAS SICK YESTERDAY AND I JUST TALKED TO HIS
7 WIFE AND SO WE NEED TO DECIDE -- I MEAN, WE DON'T KNOW
8 WHAT'S GOING TO HAPPEN. THE WIFE IS VERY NERVOUS ABOUT
9 WHAT'S GOING ON AND SO HE'S DOING A BUNCH OF TESTS TODAY.
10 HE WAS TAKEN THERE LAST NIGHT. AND, YOU KNOW, OBVIOUSLY WE
11 HAVE ADDITIONAL JURORS, THAT'S NOT A PROBLEM BUT WE HAVE TO
12 DECIDE WHAT WE'RE GOING TO DO. THERE'S NO -- I WAS TRYING
13 TO SAY WHEN WILL THEY KNOW AND THE WIFE SAYS THEY WILL
14 NOT -- THEY DON'T KNOW. HE WAS RUSHED TO THE HOSPITAL LAST
15 EVENING AND COMPLAINING OF CHEST PAINS AND HE'S IN INTENSIVE
16 CARE.
17 SO I GUESS WHAT I WOULD SUGGEST DOING IS WE'RE NOT
18 GOING TO POSTPONE THE TRIAL TO SEE THE OUTCOME BECAUSE WE
19 DON'T KNOW WHAT'S GOING TO HAPPEN. SO WHAT -- MR. WILSON, I
20 WAS JUST TELLING THE ATTORNEYS THAT THE JUROR, IS IT NUMBER
21 TEN? JUROR NUMBER 10, ONE, TWO, THREE OVER IN -- THE MIDDLE
22 THE JUROR IN THE FRONT ROW REDDISH HAIR AND GLASSES IS
23 INTENSIVE CARE WITH CHEST PAINS AND HE WENT TO THE HOSPITAL
24 LAST NIGHT. AND SO I PROPOSE BASICALLY WE HAVE FOUR
25 ALTERNATE JURORS, YOU KNOW, NOBODY ON THE JURY KNOWS WHO THE
3977
1 ALTERNATE JUROR IS, BUT WE HAVE FOUR ALTERNATE JUROR AND
2 WITH A SIX-WEEK TRIAL, WE'VE BEEN VERY FORTUNATE UP TO THIS
3 POINT TO NOT HAVE ANY PROBLEMS. SO DO YOU HAVE ANY OTHER
4 SUGGESTION OTHER THAN WE JUST GO WITH THE 11 BECAUSE RIGHT
5 NOW -- HE COMPLAINED -- HE WAS SICK YESTERDAY APPARENTLY AND
6 THEN LAST NIGHT THEY RUSHED HIM TO THE HOSPITAL.
7 MR. WILSON: I WOULD HAVE NO OBJECTION, YOUR HONOR.
8 MR. STIRBA: I THINK THAT'S THE WAY WE NEED TO GO.
9 THE COURT: OKAY. IS EVERYBODY READY TO GO THEN?
10 OKAY. THEN DO YOU WANT ME -- WHAT DO YOU WANT ME TO EXPLAIN
11 TO THE JURY WHEN WE COME BACK? JUST SAY THAT WE'LL EXPLAIN
12 THAT TO THEM. I DON'T THINK THEY KNOW.
13 MR. STIRBA: I THINK YOU OUGHT TO JUST INDICATE
14 THAT THERE'S AN ILLNESS AND WE'RE GOING TO PROCEED.
15 THE COURT: IS THAT ALL RIGHT WITH EVERYONE?
16 MR. WILSON: THAT'S FINE WITH THE STATE, YOUR
17 HONOR.
18 THE COURT: OKAY. PLEASE STAND.
19 (WHEREUPON THE JURY ENTERED THE COURTROOM.)
20 THE COURT: PLEASE BE SEATED. THE RECORD WILL
21 REFLECT THAT THE ATTORNEYS AND THE DEFENDANT ARE PRESENT,
22 AND THE 11 MEMBERS OF THE JURY ARE PRESENT.
23 LADIES AND GENTLEMEN OF THE JURY, AS YOU CAN SEE OUR
24 JUROR NUMBER TEN WHO WAS SITS IN THE MIDDLE OF THE FRONT ROW
25 IS NOT HERE. HIS WIFE CALLED THIS MORNING AND LEFT A
3978
1 RECORDING, BUT I WASN'T AWARE OF THAT, I TALKED TO HER JUST
2 ABOUT TEN MINUTES AGO. AND JUROR NUMBER TEN, I DON'T KNOW
3 IF YOU WERE AWARE OF IT, BUT HE WAS NOT FEELING WELL
4 YESTERDAY AND LAST NIGHT THEY RUSHED HIM TO THE HOSPITAL AND
5 HE'S IN INTENSIVE CARE WITH CHEST PAINS. AND HIS WIFE IS
6 VERY SERIOUS, YOU KNOW, ABOUT THIS. WE DON'T KNOW -- SHE
7 DIDN'T SAY IF IT WAS A HEART ATTACK OR WHAT IT WAS BUT THEY
8 DON'T KNOW WHAT'S THE OUTCOME BUT HE'S IN THE LAKEVIEW
9 HOSPITAL I THINK AND HE'S TAKING ALL SORTS OF TESTS TODAY
10 AND WE DON'T KNOW WHAT THE PROBLEM IS.
11 OBVIOUSLY WE ALL ARE VERY CONCERNED AND I EXPRESSED
12 THAT TO HIS WIFE BUT SHE HAS NO IDEA ABOUT WHEN HE'LL BE
13 ABLE TO COME BACK OR WHAT HIS FUTURE IS. SO I'VE TALKED TO
14 THE ATTORNEYS AND THEY, IN LIGHT OF THE CIRCUMSTANCES, WANT
15 TO JUST PURSUE AHEAD WITH THE CASE. AND SO THIS WOULD MEAN
16 EVEN IF HE WERE TO RECOVER TOMORROW, HE WOULD NOT BE HERE
17 BECAUSE HE WOULD NOT HEAR WHAT WAS GOING ON TODAY. SO I
18 JUST WANTED YOU TO BE AWARE OF THAT AND WE'RE ALL VERY SORRY
19 ABOUT THIS BUT -- AND HOPE FOR THE BEST FOR HIM BUT THAT'S
20 WHAT WE'LL HAVE TO DO. SO I APPRECIATE YOU UNDERSTANDING
21 THAT AND YOUR PATIENCE, THAT'S WHY WE WERE LATE THIS
22 MORNING. OKAY. MR. WILSON, IF YOU WOULD LIKE TO CONTINUE.
23 MR. WILSON: THANK YOU, YOUR HONOR.
24 CONTINUED CROSS-EXAMINATION
25 Q. (BY MR. WILSON) DR. WEITZEL, I THINK WHEN WE LEFT OFF
3979
1 YESTERDAY WE WERE TALKING ABOUT MARY CRANE SO IF YOU WANT TO
2 PULL THE EXHIBIT OUT FOR MARY CRANE. I THINK YOU HAVE
3 PREVIOUSLY SEEN STATE'S EXHIBIT 36. HAVE YOU HAD AN
4 OPPORTUNITY -- DO YOU WANT TO STEP UP TO THE BOARD AND TAKE
5 A LOOK AT THAT?
6 A. I'VE SEEN IT.
7 Q. OKAY. I JUST WANTED TO GO THROUGH WITH YOU AND WHETHER
8 OR NOT YOU WANT TO REFER TO THE MEDICAL RECORDS IT'S UP TO
9 YOU, DOCTOR, BUT IT APPEARS THAT THE MEDICATIONS THAT WERE
10 PRESCRIBED TO HER STARTED OUT WITH SOME SERZONE, SOME
11 RISPERDAL, TRAZODONE AND THE DURAGESIC PATCH; IS THAT
12 CORRECT?
13 A. YES, SIR.
14 Q. AND AS WE PROGRESS THROUGH AND I THINK YOUR TESTIMONY
15 WAS THE DURAGESIC PATCH ACCORDING TO YOUR COMPUTATIONS
16 YESTERDAY WAS EQUIVALENT TO POSSIBLY 30 MILLIGRAMS OF
17 MORPHINE A DAY, INJECTABLE MORPHINE; IS THAT CORRECT?
18 A. I BELIEVE SO.
19 Q. OKAY. AS WE GO ALONG WE HAVE -- WELL, FIRST OF ALL,
20 TRAZODONE AND RISPERDAL AND SERZONE, AS I UNDERSTAND IT, ALL
21 HAVE CENTRAL NERVOUS SYSTEM DEPRESSANT QUALITIES; IS THAT
22 CORRECT?
23 A. YES, TO ONE DEGREE OR ANOTHER THEY DO.
24 Q. OKAY. SO WE'VE GOT SERZONE, RISPERDAL TRAZODONE ADDED
25 UPON ONE ANOTHER, RIGHT?
3980
1 A. RIGHT.
2 Q. ALONG WITH THE DURAGESIC PATCH; IS THAT CORRECT?
3 A. RIGHT.
4 Q. AS WE PROGRESS THROUGH, YOU CONTINUE TO PROVIDE THOSE
5 DRUGS AND ON THE 31ST OF DECEMBER WE ALSO ADD ATIVAN; IS
6 THAT CORRECT?
7 A. THAT'S CORRECT.
8 Q. AND ATIVAN, IS THAT A CENTRAL NERVOUS SYSTEM DEPRESSANT
9 QUALITY DRUG TOO?
10 A. YES. THAT WAS A P.R.N. THAT WAS GIVEN THAT DAY AND IT
11 IS, ALTHOUGH IT DOES NOT DEPRESS RESPIRATORY DRIVE, IT IS A
12 CENTRAL NERVOUS SYSTEM DEPRESSANT OF A SORT.
13 Q. OKAY. SO THOSE -- THAT -- THAT PARTICULAR DRUG WAS THEN
14 ADDED. THE NEXT TWO DAYS WE MAINTAIN A DOSAGE OF AGAIN
15 SERZONE, RISPERDAL AND TRAZODONE ALONG WITH THE DURAGESIC
16 PATCH; IS THAT CORRECT?
17 A. YES, SIR.
18 Q. OKAY. ON JANUARY 3RD, IN ADDITION TO THE DURAGESIC
19 PATCH AND THE OTHER DRUGS, WE ADD DEPAKENE AND WE ALSO HAVE
20 TWO SHOTS OF MORPHINE ADMINISTERED ON THAT DAY; IS THAT
21 CORRECT?
22 A. I BELIEVE SO. THAT WAS THE 31ST, DID YOU SAY?
23 Q. JANUARY 3RD.
24 A. OH, 3RD, OKAY.
25 Q. IT LOOKS LIKE ONE DOSE OF SERZONE WAS WITHHELD ON THAT
3981
1 PARTICULAR DATE ACCORDING TO THE CHART.
2 A. OKAY.
3 Q. DEPAKENE, IS THAT A CENTRAL NERVOUS SYSTEM DEPRESSANT
4 DRUG?
5 A. MILDLY, YES, IT IS.
6 Q. OBVIOUSLY THE MORPHINE HAS CENTRAL NERVOUS SYSTEM
7 QUALITIES, DOES IT NOT, DEPRESSIVE QUALITIES?
8 A. IT DOES.
9 Q. THE NEXT DAY ON JANUARY 4TH, THAT'S THE DAY THAT YOU
10 INCREASED THE DURAGESIC PATCH TO 75 MICROGRAMS, CORRECT?
11 A. YES.
12 Q. AND THERE'S DEPAKENE IS INCREASED TO 1,000 MILLIGRAMS
13 AND, AGAIN, WE HAVE THE ADMINISTRATION OF MORPHINE ON THAT
14 PARTICULAR DATE, CORRECT?
15 A. NO, SIR.
16 Q. YOU DON'T SHOW ANY MORPHINE ADMINISTERED ON JANUARY THE
17 4TH?
18 A. NO, SIR. THE DEPAKENE WAS 1,000 MILLIGRAMS ON THE 3RD.
19 IT WAS NOT INCREASED ON THE 4TH.
20 Q. SO THE DEPAKENE WAS ALSO 1,000 ON THE 3RD?
21 A. YES, SIR.
22 Q. AND IT REMAINED THE SAME ON THE 4TH?
23 A. YES, SIR. AND SHE DID GET SOME MORPHINE ON THE 4TH.
24 Q. SHE DID GET SOME MORPHINE ON THE 4TH?
25 A. YES, SIR.
3982
1 Q. NOW, ON THE 5TH IT APPEARS FROM THE CHART, WE'VE STILL
2 GOT THE 75 MICROGRAM DURAGESIC PATCH ON BOARD, CORRECT?
3 A. RIGHT.
4 Q. AGAIN, SHE'S ADMINISTERED DEPAKENE. IT APPEARS SHE'S
5 HAD THE TRAZODONE WITHHELD ON THAT DATE; IS THAT CORRECT?
6 A. THE 5TH, RIGHT? THE NURSE DID NOT PUT EITHER AN INITIAL
7 OR INITIALS AND CIRCLED ON THE TRAZODONE SO I HAVE TO ASSUME
8 THEY DIDN'T GIVE IT THAT DAY.
9 Q. OKAY. IN RESPECT TO THE MORPHINE, IS THAT ACCURATE AS
10 10 MILLIGRAMS OF MORPHINE THAT WAS ADMINISTERED ON THAT DAY?
11 A. ON THE 5TH, CORRECT?
12 Q. ON THE 5TH.
13 A. THIS MUST HAVE BEEN ALL PRN'S BECAUSE I DON'T SEE AN
14 EXTRA LIKE A NOW ORDER FOR THAT. LET ME GO BACK HERE TO MED
15 GRAPH AND LOOK AT IT FOR YOU. RIGHT, IT LOOKS LIKE -- I
16 JUST SHOW 5 MILLIGRAMS GIVEN THAT DAY HERE.
17 Q. ON THE 5TH?
18 A. YES, SIR. THAT'S ALL I'M ABLE TO FIND SO FAR -- OH,
19 WAIT. OKAY. OKAY HERE IS ANOTHER ONE THAT'S 10 MILLIGRAMS.
20 Q. SO THAT'S ACCURATE?
21 A. LOOKS LIKE IT.
22 Q. I FORGOT TO ASK YOU ONE QUESTION. WHEN YOU INCREASE THE
23 DURAGESIC PATCH, AS I UNDERSTAND IT, YOUR FORMULA FOR
24 EQUATING THAT TO MORPHINE SULFATE I.M. WAS ABOUT, OH, I
25 THINK IT WAS EQUATED TO 30 MILLIGRAMS FOR THE 50 MICROGRAM
3983
1 PATCH, SO THAT WOULD BE INCREASED BY 15 MILLIGRAMS, WOULD IT
2 NOT?
3 A. 45 TO THE 75.
4 Q. OKAY. 45 MILLIGRAMS FOR -- OF INJECTABLE MORPHINE FOR
5 THE 75 DURAGESIC PATCH. NOW, DO YOU RECALL READING THE
6 AUTOPSY IN THIS MATTER?
7 A. YES, I'VE READ IT. I DON'T RECALL THE WORDING.
8 Q. DO YOU RECALL THAT IN THE AUTOPSY REPORT THERE WAS A --
9 THERE WAS AN INDICATION THAT THE PATCHES WERE STILL INTACT
10 ON THE BODY OF MARY CRANE?
11 A. I DO.
12 Q. AND THERE WERE TWO PATCHES?
13 A. I DO REMEMBER THAT.
14 Q. SO I ASSUME ONE OF THOSE WAS A 25 MICROGRAM AND ONE WAS
15 A 50 MICROGRAM?
16 A. DO YOU? I REALLY DON'T KNOW.
17 Q. OKAY. BUT YOU, IN FACT, ORDERED 75 MICROGRAMS ON THE
18 DURAGESIC PATCH?
19 A. ON THE 4TH, YES, SIR.
20 Q. THE NEXT DAY IT APPEARS THAT NO MORPHINE WAS
21 ADMINISTERED, BUT, AGAIN, WE HAVE THE SERZONE, THE
22 RISPERDAL, THE 1,000 DEPAKENE AND THE TRAZODONE AND WE STILL
23 HAVE THE 75 MICROGRAM PATCH ON BOARD?
24 A. YES, SIR.
25 Q. IS THAT ACCURATE? AND ON JANUARY 7TH THE DAY THAT SHE
3984
1 DIED WE HAVE -- AGAIN, THIS WAS THE DATE I THINK THAT A NEW
2 75 MICROGRAM PATCH WAS ADMINISTERED TO THE PATIENT; IS THAT
3 CORRECT?
4 A. WELL, SINCE IT'S GIVEN EVERY THREE DAYS, IT SHOULD HAVE
5 BEEN.
6 Q. OKAY. IT LOOKS LIKE THE TRAZODONE WAS NOT ADMINISTERED
7 AND IT LOOKS LIKE THE DEPAKENE SAYS 250 TO 1,000 M.G. CAN
8 YOU TELL US FROM THE RECORDS HOW MUCH DEPAKENE WAS
9 ADMINISTERED ON THAT DAY?
10 A. ON THE 7TH?
11 Q. ON THE 7TH.
12 A. IT LOOKS LIKE ONLY 250.
13 Q. OKAY. DO YOU KNOW THE REASON IN THE NURSES' NOTES WHY
14 THE TRAZODONE AND SOME OF THOSE MEDICATIONS WERE HELD?
15 A. TRAZODONE WAS A H.S. MEDICATION, A BEDTIME MEDICATION,
16 AND ON THE 7TH I ASKED THAT THE MEDICATIONS OTHER THAN
17 MORPHINE BE HELD.
18 Q. NOW, THAT WAS THE DATE, WAS IT NOT, THAT YOU MADE THE
19 DETERMINATION THAT SHE WAS IN THE DYING PROCESS?
20 A. YES, SIR.
21 Q. THE NURSES' NOTES REFLECT A NUMBER OF THINGS THAT WERE
22 GOING ON DURING THAT TIME FRAME AND I JUST WANT TO TALK
23 ABOUT -- JUST WANT TO REFERENCE SOME OF THOSE TO YOU, IF I
24 CAN.
25 A. OKAY.
3985
1 Q. I'M GOING TO FOCUS IN ON SOME OF THE -- TURNING TO
2 MED-310 THIS IS DATED 12/30 OF '95 IN THE NURSES' NOTES.
3 THERE'S A NUMBER OF REFERENCES AND I'M JUST GOING TO READ A
4 COUPLE OF THOSE. FIRST OF ALL, AT THE TOP IT SAYS,
5 RESPIRATIONS AS THOUGH SNORING, HOWEVER EYES WIDE OPEN, DOES
6 NOT ANSWER QUESTIONS, NO VERBAL RESPONSES. THEN TURNING
7 OVER TO PAGE 311 IT'S NOTED DOWN AT THE BOTTOM LEFT-HAND
8 CORNER IN THE MIDDLE OF THE PAGE, THE EMOTIONS ARE LISTED AS
9 DROWSY, THE NEUROLOGICAL AS LETHARGIC. THERE'S A NOTE THAT
10 SAYS PATIENT VERY DROWSY, NOT ABLE TO STAY AWAKE AT 10:30 ON
11 THAT DATE; IS THAT CORRECT?
12 A. YES, SIR, THAT'S BONNIE HARDY'S NOTE.
13 Q. AGAIN, AS WE PROCEED ON THROUGH WHEN WE COME TO
14 JANUARY 1ST, THERE'S A NOTE DOWN IN THE BOTTOM THAT'S
15 CIRCLED NEUROLOGICAL, LETHARGIC. THIS IS ALSO THE DATE THAT
16 DR. DIENHART SEEN HER, ISN'T IT?
17 A. I'M SORRY, I DIDN'T GET -- WHERE IS THAT NOW ON THE 1ST?
18 Q. EXCUSE ME, PAGE 313.
19 A. AND WHERE WERE YOU REFERENCING?
20 Q. FIRST OF ALL, IN THE LEFT-HAND CORNER IT'S CIRCLED
21 LETHARGIC.
22 A. OH, GOTCHA.
23 Q. THAT'S CORRECT?
24 A. YES, SIR.
25 Q. WE ALSO HAVE A NOTE THAT IN THE MIDDLE OF THAT PAGE ON
3986
1 THE RIGHT-HAND SIDE FROM -- IT SAYS DR. DIENHART IN TO SEE
2 PATIENT, RECEIVED ORDERS FOR C.B.C. AND G.Y.N. CONSULT AND
3 THEN IT HAS AN ARROW DURAGESIC PATCH DECREASED TO
4 25 MICROGRAMS. YOU ARE AWARE THAT DR. DIENHART ORDERED A
5 DECREASE IN THE LEVEL OF THE DURAGESIC PATCH, ARE YOU NOT?
6 A. I AM, YES, SIR.
7 Q. YOU ARE ALSO AWARE THAT PURSUANT TO HIS NOTE THAT WAS
8 BECAUSE THE PATIENT APPEARED TO BE OVERLY SEDATED; IS THAT
9 CORRECT?
10 A. WELL, I DON'T KNOW THAT YOU COULD SAY IT WAS OVERLY
11 SEDATED. WHAT HE WROTE WAS, C.B.C. TODAY, DECREASE
12 DURAGESIC PATCH, PARENTHESIS INCREASED SEDATION NOTED.
13 Q. DUE TO INCREASED SEDATION?
14 A. HE WROTE --
15 Q. HE DID REFERENCE IT TO SEDATION, DID HE NOT?
16 A. RIGHT.
17 Q. OKAY. DO YOU UNDERSTAND THAT TO MEAN THAT WAS THE
18 REASON HE DECREASED OR ORDERED THE DECREASE IN THE PATCH?
19 A. I'M SURE THAT WAS HIS CONCERN.
20 Q. BUT YOU DIDN'T SHARE THAT CONCERN, DID YOU, DOCTOR?
21 A. NO, SIR, I DIDN'T.
22 Q. IN FACT, YOU INCREASED IT BACK TO THE 50 MICROGRAM
23 PATCH; IS THAT RIGHT?
24 A. THAT'S RIGHT.
25 Q. TURN NOW IF YOU WOULD TO -- WELL, I GUESS I BETTER
3987
1 FOLLOW THROUGH WITH SOME OF THESE OTHER NOTES. IT'S TRUE,
2 IS IT NOT, THAT AS WE GET CLOSER TO THE 7TH -- WELL, LET'S
3 TALK ABOUT THE 7TH.
4 TURN TO PAGE MED-0328.
5 A. OKAY.
6 Q. THE NOTE DOWN ON THE LEFT-HAND CORNER IS CIRCLED
7 LETHARGIC UNDER NEUROLOGICAL?
8 A. YES, IT IS.
9 Q. THERE'S ALSO A NOTE ON THE RIGHT-HAND SIDE THAT SAYS,
10 PATIENT HAS HAD NO EPISODE OF BEING COMBATIVE BECAUSE SHE
11 HAS BEEN LETHARGIC ALL SHIFT; IS THAT CORRECT?
12 A. IT IS.
13 Q. NOW THAT NOTE IS WRITTEN AT 1400, WHICH WOULD BE
14 2 O'CLOCK; IS THAT RIGHT?
15 A. THAT'S RIGHT.
16 Q. AND IT ALSO INDICATES ON THAT NOTE THAT, DR. DIENHART
17 NOTIFIED OF PATIENT'S STATUS AND HE SEEN THE PATIENT ON THAT
18 DATE, DID HE NOT?
19 A. YES, HE DID.
20 Q. NOW IF WE CAN, LET'S GO BACK, DOCTOR, TO THAT PARTICULAR
21 CONSULT ON THAT DATE IN THE PROGRESS NOTES WHICH WOULD BE
22 MED-00249.
23 A. OKAY.
24 Q. YOU PREVIOUSLY TESTIFIED, DID YOU NOT, THAT YOU WERE
25 MADE AWARE OF DR. DIENHART'S CONCERN AS REFERENCED IN THAT
3988
1 NOTE?
2 A. EXCUSE ME?
3 Q. YOU PREVIOUSLY TESTIFIED, DID YOU NOT, THAT YOU WERE
4 MADE AWARE OF DR. DIENHART'S CONCERN AS REFERENCED IN THAT
5 PARTICULAR NOTE?
6 A. DR. DIENHART AND I SPOKE THAT DAY.
7 Q. OKAY. DO YOU REMEMBER WHAT TIME YOU SPOKE THAT DAY?
8 A. NOT PRECISELY. SOMETIME THAT AFTERNOON.
9 Q. OKAY. ABOUT -- IT WAS IN THE AFTERNOON, IT WAS BEFORE
10 YOU SPOKE TO THE FAMILY MEMBERS; IS THAT CORRECT?
11 A. I BELIEVE SO.
12 Q. AND AS I RECALL IN YOUR DISCUSSIONS YOU TALKED ABOUT HIS
13 DETERMINATION THAT THIS COULD BE AGGRESSIVELY TREATED; IS
14 THAT CORRECT?
15 A. THAT'S WHAT DIENHART WRITES RIGHT HERE.
16 Q. OKAY. AND AS I RECALL YOUR TESTIMONY, YOU TOLD HIM THAT
17 BECAUSE OF THE ADVANCE DIRECTIVES, THERE WAS NO ABILITY TO
18 AGGRESSIVELY TREAT THIS PARTICULAR PATIENT IN THAT FASHION;
19 IS THAT CORRECT?
20 A. I'M NOT SURE I USED THOSE EXACT WORDS. OF COURSE, DR.
21 DIENHART WOULD HAVE BEEN AVAILABLE -- OR HE WOULD HAVE HAD
22 THIS CHART AVAILABLE AND WITH ALL THE SAME DIRECTIVES. I
23 THINK I --
24 Q. WAS THIS A PERSONAL CONVERSATION OR WAS IT OVER THE
25 PHONE?
3989
1 A. IT WAS PERSONAL, WE WERE SITTING AT THE NURSING STATION.
2 Q. AND DO YOU RECALL, DOCTOR, DID YOU NOT, IN FACT, TELL
3 HIM THAT THERE WAS NO ABILITY TO TREAT THIS PARTICULAR
4 PROBLEM?
5 A. GIVEN THE MEDICAL TREATMENT PLAN DIRECTIVES?
6 Q. THAT'S RIGHT.
7 A. YES, I THINK THAT'S WHAT I SAID.
8 Q. OKAY. NOW, THE TREATMENT THAT I UNDERSTAND THAT YOU
9 WERE LOOKING AT RELATED TO THIS POSSIBLE SEPSIS?
10 A. AND DEHYDRATION, HYPERTENSION, VOLUME DEPLETION, FREE
11 WATER DEPLETION.
12 Q. DEHYDRATION, VOLUME --
13 A. YES, SIR.
14 Q. SO SHE WAS -- ESSENTIALLY SHE WAS DEHYDRATED AND THAT
15 WAS --
16 A. LOOKS LIKE --
17 Q. THAT WAS AGGRAVATING I GUESS -- WOULD THAT BE
18 AGGRAVATING THE SEPSIS?
19 A. THEY WORK KIND TOGETHER, THEY WOULD AGGRAVATE EACH
20 OTHER.
21 Q. SO AN AGGRESSIVE TREATMENT WOULD ENTAIL, I ASSUME, SOME
22 HYDRATION THERAPY AS FAR AS GETTING SOME I.V.'S IN TO
23 HYDRATE THE PERSON; IS THAT CORRECT?
24 A. YES, SIR.
25 Q. AND IT WOULD ALSO NECESSITATE AN AGGRESSIVE TREATMENT
3990
1 PROCESS OF ANTIBIOTICS THROUGH AN I.V.; IS THAT CORRECT?
2 A. YOU WOULD ALMOST CERTAINLY NEED TO USE I.V. ANTIBIOTICS.
3 YOU COULD MAYBE USE I.M. LIKE ROCEPHIN. I'M NOT AN
4 INFECTIOUS DISEASE GUY, THOUGH, SO I PROBABLY SHOULDN'T GET
5 OFF ON THAT.
6 Q. BUT ANYWAY, IN YOUR OPINION THERE WAS NO THERE WAS NO
7 ABILITY TO TREAT THIS CONSIDERING THE ADVANCE DIRECTIVES?
8 A. IN MY OPINION SHE WAS REALLY, REALLY ILL AND WITHOUT AN
9 I.V. IT LOOKED LIKE SHE WAS -- THERE WAS NOTHING WE COULD
10 DO.
11 Q. NOW, THIS WAS -- THIS CONVERSATION YOU SAY TOOK PLACE IN
12 THE AFTERNOON. ON THAT VERY SAME PAGE YOU HAVE A NOTE HOLD
13 ALL ABOVE MED'S, MORPHINE S.O. FOUR 5 MILLIGRAMS I.M.,
14 WHICH -- AND DOES THAT MEAN IT'S -- THEN IT HAS Q 3. I
15 ASSUME THAT MEANS AROUND THE CLOCK EVERY THREE HOURS?
16 A. WELL, IT SAYS AROUND THE CLOCK. IT SAYS MORPHINE
17 SULPHATE 5 MILLIGRAMS I.M. NOW AND EVERY THREE HOURS AROUND
18 THE CLOCK.
19 Q. OKAY. NOW THAT NOTE BEARS A TIME OF 2100 HOURS?
20 A. IT WAS NOTED BY THE NURSE AT 2100. THE -- MY ORDER
21 DOESN'T BEAR A TIME. IT JUST HAS THE DATE.
22 Q. YOUR ORDER DOESN'T BEAR A TIME?
23 A. RIGHT.
24 Q. IS THAT SOMETHING THAT YOU FREQUENTLY DO, IS NOT PUT A
25 TIME ON YOUR ORDERS?
3991
1 A. FREQUENTLY?
2 Q. UH-HUH.
3 A. AT THIS --
4 Q. IN LOOKING THROUGH THESE RECORDS, DOCTOR, IS THAT A
5 PATTERN THAT -- OF YOUR NOTE?
6 A. IF YOU'LL LOOK AT THE ORDER RIGHT ABOVE THAT ONE, DR.
7 DIENHART'S ORDER, IN HIS HANDWRITTEN ORDER HE DIDN'T TIME
8 HIS EITHER. NOBODY DID.
9 Q. I NOTICE THAT OVER ON THE -- YES. OVER ON THE
10 RIGHT-HAND SIDE?
11 A. NO, ON THE LEFT.
12 Q. ON THE LEFT HAND OR ON THE RIGHT-HAND SIDE, THOUGH, HE
13 HAS TIMED THAT ORDER, HAS HE NOT?
14 A. THAT'S NOT AN ORDER, THAT'S HIS NOTE.
15 Q. EXCUSE ME. HE'S TIMED HIS PROGRESS NOTES WHEN HE MADE
16 THOSE OBSERVATIONS; IS THAT CORRECT?
17 A. IT LOOKS LIKE 3:10 P.M. I CAN'T REALLY -- HE'S HARD TO
18 READ BUT...
19 Q. SO THAT'S NOT IN YOUR HANDWRITING IN ANY EVENT ON THE
20 7TH AT 2100 HOURS; IS THAT CORRECT?
21 A. NO. THE 2100 HOURS OBVIOUSLY WAS EARLENE COZZENS
22 SIGNING OFF ON THAT.
23 Q. SO THAT JUST MEANS THAT EARLENE COZZENS NOTED IT AND
24 SIGNED OFF ON IT?
25 A. AT THAT TIME.
3992
1 Q. DO YOU KNOW WHEN THE FIRST MORPHINE WAS GIVEN ON THAT
2 PARTICULAR DATE?
3 A. I COULD LOOK IT UP. I DON'T HAVE IT.
4 Q. WOULD YOU DO SO, PLEASE.
5 A. OKAY. IT LOOKS LIKE 2000 HOURS, YEAH, ON THE 7TH.
6 Q. WHICH WOULD BE 8 O'CLOCK IN THE EVENING?
7 A. CORRECT.
8 Q. NOW, AGAIN, DOCTOR, DO YOU REMEMBER MEETING WITH THE
9 FAMILY ON THAT PARTICULAR DATE OR ANY FAMILY MEMBERS?
10 A. THE CRANE FAMILY.
11 Q. THAT'S CORRECT, ERIN BRINGHURST OR KATHY CHARLESWORTH?
12 A. MY NOTE SAYS, I HAVE SPOKEN TO HER TWO DAUGHTERS AND
13 THEY DO NOT WANT EXTRAORDINARY MEASURES TAKEN BUT WOULD
14 RATHER HAVE COMFORT CARE GIVEN.
15 Q. AND WHERE IS THAT NOTE?
16 A. IT'S MED-255, IT'S DATED SEVEN -- OR JANUARY 7TH, '96 IS
17 MY NOTE AT THE TOP OF THE PAGE.
18 Q. MED-255?
19 A. YES, SIR, IN PROGRESS RECORDS.
20 Q. DOES THAT BEAR A TIME?
21 A. NO, SIR.
22 Q. SO YOU DON'T KNOW WHAT TIME THAT WAS WRITTEN?
23 A. AT THIS TIME, I HAVE NO IDEA.
24 Q. IN FACT, LOOKING DOWN YOUR NOTES, DOCTOR, DO ANY OF
25 THOSE NOTES IN THE PROGRESS NOTES BEAR TIMES IN YOUR
3993
1 HANDWRITING?
2 A. VERY INFREQUENTLY. LIKE THE OTHER DAY I WAS TELLING YOU
3 ABOUT ENNIS ALLDREDGE'S TIMES REGARDING HIS GLUCOSE LEVELS.
4 BUT GENERALLY THEY DID NOT HAVE TIME, JUST A DATE.
5 Q. OKAY. IN RESPECT TO THE MEETING, DO YOU HAVE A DISTINCT
6 RECOLLECTION AS TO THE MEETING WITH KAREN BRINGHURST AND
7 KATHY CHARLESWORTH?
8 A. NO.
9 Q. YOU INDICATE IN YOUR NOTE THAT YOU DISCUSSED WITH THE
10 FAMILY AND YOU INDICATE THAT -- YOU'VE GOT PROBABLE
11 ASPIRATIONS PNEUMONIA, POSSIBLE SEPSIS AND VOLUME DEPLETION.
12 DO YOU REMEMBER --
13 A. ACTUALLY, SIR, IT SAYS PROBABLE ASPIRATION PNEUMONIA,
14 QUITE DEMENTED, HYPERTENSION, POSSIBLE SEPSIS, VOLUME
15 DEPLETION.
16 Q. SO YOU LISTED A NUMBER OF FACTORS THERE. BUT YOU HAVE
17 NO RECOLLECTION OF A CONVERSATION WITH KATHY -- OR WITH
18 KAREN BRINGHURST; IS THAT CORRECT?
19 A. AS I SIT HERE NOW, I CANNOT REMEMBER SPECIFICS OF A
20 CONVERSATION AT THAT DATE WITH THOSE PEOPLE.
21 Q. SO AS TO WHAT YOU TOLD THEM, YOU DON'T DISPUTE KAREN
22 BRINGHURST'S TESTIMONY THAT YOU TOLD HER THAT HER MOTHER WAS
23 DYING AND SHE ASKED YOU WHAT CAN BE DONE AND YOU TOLD HER WE
24 CAN GIVE HER MORPHINE TO HASTEN DEATH?
25 MR. STIRBA: I'M GOING TO OBJECT TO THE FORM OF THE
3994
1 QUESTION.
2 THE COURT: DO YOU WANT TO REPHRASE THAT?
3 Q. (BY MR. WILSON) YOU DON'T DISPUTE KAREN BRINGHURST
4 MAKING A STATEMENT TO YOU ON THAT DATE, DO YOU?
5 MR. STIRBA: SAME OBJECTION, YOUR HONOR.
6 THE COURT: YOU CAN ANSWER THAT QUESTION IF YOU
7 CAN.
8 MR. WILSON: PARDON?
9 THE COURT: HE CAN GO AHEAD AND ANSWER THAT
10 QUESTION.
11 THE WITNESS: THE LAST QUESTION WAS SO VAGUE AND
12 GENERAL, I CAN'T ANSWER IT.
13 Q. (BY MR. WILSON) WELL, DO YOU REMEMBER ANY CONVERSATION
14 WITH KAREN BRINGHURST ON THAT DAY?
15 A. AS TO THE SPECIFICS, NO.
16 Q. OKAY. YOU REMEMBER MEETING WITH THE FAMILY ONLY BECAUSE
17 YOU REFLECT THAT FROM YOUR NOTES; IS THAT RIGHT?
18 A. RIGHT.
19 Q. OKAY. I WANT TO YOU TURN TO THE MEDICAL/LEGAL SECTION
20 AND LET'S LOOK AT THE DIRECTIVE, IT'S ON PAGE MED-00341. I
21 THINK YOU'VE PREVIOUSLY TESTIFIED THAT EARLENE COZZENS
22 FILLED THAT OUT?
23 A. THIS IS A DIFFERENT ONE. I DID NOT TESTIFY THAT EARLENE
24 COZZENS FILLED THIS OUT.
25 Q. OH, EXCUSE ME, THAT'S ON THE LYDIA SMITH.
3995
1 DO YOU REMEMBER FILLING THIS ONE OUT?
2 A. WELL, MY SIGNATURE IS THERE SO I MUST HAVE SIGNED IT. I
3 DIDN'T FILL IT OUT, THOUGH.
4 Q. OKAY.
5 A. IT LOOKS LIKE --
6 Q. NOW THIS ONE WAS DATED 12/28, THE DATE OF ADMISSION,
7 RIGHT?
8 A. IT'S DATED 12/28 AT THE TOP, YES, SIR.
9 Q. AND THERE IS A FACILITY REPRESENTATIVE THAT HAS SIGNED
10 OFF DOWN BELOW; IS THAT CORRECT?
11 A. YES, SIR.
12 Q. AND DO YOU KNOW -- DO YOU RECOGNIZE THAT SIGNATURE?
13 A. I DO. THAT'S EARLENE COZZENS', I BELIEVE.
14 Q. OKAY. AND YOUR DATE ON YOUR AS ATTENDING PHYSICIAN IS
15 12/30 OF '95, CORRECT?
16 A. IT IS.
17 Q. SO YOU WOULD HAVE REVIEWED THIS DOCUMENT ON 12/30 OF
18 '95, CORRECT?
19 A. YES, SIR, ALMOST CERTAINLY.
20 Q. NOW, IN LOOKING AT THE DIRECTIVES THERE IS NO
21 PROHIBITION FOR GIVING ORAL ANTIBIOTICS, I.M. ANTIBIOTICS OR
22 I.V. ANTIBIOTICS, IS THERE?
23 A. YES, THERE IS.
24 Q. THERE IS A PROHIBITION AGAINST THAT?
25 A. YES, SIR.
3996
1 Q. WHERE DOES IT SAY THAT?
2 A. ON THE RIGHT-HAND COLUMN FOUR DOWN IT'S CHECKED "NO" TO
3 I.V. FLUIDS AND YOU CAN'T GIVE I.V. ANTIBIOTICS WITHOUT I.V.
4 FLUIDS.
5 Q. OKAY. DOCTOR, THERE'S A -- THERE'S ALSO A COLUMN THAT
6 SAYS I.V. ANTIBIOTICS "YES," ISN'T THERE?
7 A. THERE IS.
8 Q. SO THERE'S A DISCREPANCY BETWEEN THE TWO DIRECTIVES, IS
9 THAT RIGHT?
10 A. IT'S KIND OF AMBIGUOUS.
11 Q. KIND OF AMBIGUOUS. SO DON'T YOU THINK THAT'S SOMETHING
12 THAT YOU OUGHT TO BRING TO THE ATTENTION OF A FAMILY MEMBER
13 BEFORE MAKING A DETERMINATION TO WITHHOLD ALL OF THESE
14 MEDICAL PROCEDURES AND TREAT THE SEPSIS?
15 A. EXCUSE ME, KAREN BRINGHURST IS A NURSE, RIGHT?
16 Q. DOCTOR, JUST ANSWER MY QUESTION. DON'T YOU THINK THAT'S
17 SOMETHING YOU OUGHT TO DISCUSS WITH THE FAMILY?
18 A. WELL, YOU SEE, SIR, KAREN BRINGHURST --
19 Q. DOCTOR, WILL YOU ANSWER MY QUESTION?
20 A. -- SIGNED THIS SO I DON'T THINK I NEEDED TO.
21 Q. YOU DON'T THINK YOU NEEDED TO--
22 A. NO, SHE SIGNED IT HERSELF.
23 Q. SHE SIGNED --
24 MR. STIRBA: EXCUSE --
25 THE COURT: EXCUSE ME, JUST WAIT. DO YOU WANT TO
3997
1 ASK THE QUESTION, PAUSE, ONE ANSWER AND DON'T TALK OVER EACH
2 OTHER. GO AHEAD.
3 Q. (BY MR. WILSON) DID YOU KNOW SHE WAS A NURSE AT THE
4 TIME?
5 A. I PROBABLY DID.
6 Q. PROBABLY DID. YOU DON'T HAVE ANY INDEPENDENT
7 RECOLLECTION OF THAT, DO YOU, DOCTOR?
8 A. WELL, EVERYTHING IS SO CONFUSED BY THE FACT THAT I'VE
9 REVIEWED THESE RECORDS FOR ALMOST A YEAR NOW, I DON'T HAVE
10 ANY --
11 Q. YOU DON'T HAVE ANY INDEPENDENT RECOLLECTION OF EVEN
12 MEETING KAREN BRINGHURST BEFORE THIS TIME, DO YOU?
13 A. NO.
14 Q. IN FACT, DOCTOR, YOU PREVIOUSLY TESTIFIED IT'S IMPORTANT
15 TO OBTAIN HISTORY FROM THE FAMILY PARTICULARLY WITH PATIENTS
16 OF THIS NATURE; IS THAT CORRECT?
17 A. THAT'S CORRECT.
18 Q. DO YOU KNOW HOW MUCH TIME, IF ANY, YOU SPENT WITH KAREN
19 BRINGHURST OR HER FAMILY IN REGARDS TO MARY CRANE?
20 A. AT THIS DATE, I DON'T KNOW.
21 Q. OKAY. DO YOUR RECORDS INDICATE ANY OTHER MEETINGS WITH
22 THE FAMILY IN REGARDS TO THE TREATMENT OF MARY CRANE DURING
23 THIS TIME PERIOD?
24 A. THERE HAVE BEEN -- THERE ARE A LOT OF RECORDS HERE OF
25 DIFFERENT TEAM MEMBERS MEETING WITH THE FAMILY AND, OF
3998
1 COURSE, THEN THE TEAM MEMBERS RELATE WHAT HAPPENED TO ME. I
2 WOULD HAVE TO GO THROUGH EACH OF THESE NOTES TO SEE IF THERE
3 WERE ANY OTHER RECORDINGS OF ME MEETING WITH THE FAMILY.
4 Q. I'M TALKING ABOUT YOUR PERSONAL MEETING WITH THE FAMILY,
5 DOCTOR.
6 A. OKAY. WELL, THEN GIVE ME A MINUTE HERE AND LOOK
7 THROUGH.
8 Q. I TAKE IT YOU WOULD PROBABLY REFERENCE THAT IN YOUR
9 PROGRESS NOTES, WOULD YOU NOT?
10 A. I MAY SEE THE PATIENT'S FAMILY WITHOUT PUTTING IT IN THE
11 PROGRESS NOTES, BUT I'LL LOOK THROUGH HERE AND SEE IF IT'S
12 MENTIONED ANYWHERE IN THE PROGRESS NOTES.
13 Q. I SEE. IN ANY EVENT, YOU HAVE NO RECOLLECTION OF
14 DISCUSSING TREATMENT ALTERNATIVES WITH KAREN BRINGHURST ON
15 THE DAY OF THE 7TH OF JANUARY OF 1996?
16 A. I HAVE NO INDEPENDENT RECOLLECTION AT THIS TIME.
17 Q. ISN'T IT TRUE, DOCTOR, THAT AN INFECTIOUS DISEASE
18 PROCESS LIKE A SEPSIS THAT TIME IS OF THE ESSENCE?
19 A. YES, SIR.
20 Q. SO IF YOU ARE GOING TO BEGIN TREATMENT, IT NEEDS TO BE
21 DONE AS QUICKLY AS POSSIBLE; IS THAT CORRECT?
22 A. THAT WOULD BE HELPFUL.
23 Q. THE NOTE OF DR. DIENHART IS AT 3:10, IS IT YOUR
24 TESTIMONY THAT YOU MET WITH HIM APPROXIMATELY THAT SAME
25 TIME?
3999
1 A. WELL, YOU KNOW, HE WROTE HIS NOTE APPARENTLY AFTER HE
2 TALKED TO ME. THIS IS ON THE 7TH, CORRECT?
3 Q. UH-HUH.
4 A. HE SAYS AS TO SEE BY ME, HE WAS ASKED TO SEE A PATIENT
5 BY ME. AND THEN DOWN BELOW, DISCUSSED WITH DR. WEITZEL,
6 PATIENT TOLD -- FELT TO HAVE DECLINING STATUS IN WHICH NOT
7 HAVE CPR PERFORMED, ET CETERA. SO WE MUST -- WE MUST HAVE
8 TALKED BEFORE HE WROTE THE NOTE OR AS HE WAS WRITING THE
9 NOTE.
10 Q. AND YOUR RECOLLECTION WAS IT TOOK PLACE AT THE NURSES'
11 DESK AT THE GEROPSYCH UNIT?
12 A. I THINK, YEAH. I THINK I REMEMBER -- I DEFINITELY
13 REMEMBER WE HAD THIS DISCUSSION, YOU KNOW.
14 Q. AND THE FIRST ADMINISTRATION OF THE MORPHINE TAKES PLACE
15 AT 8 O'CLOCK THAT EVENING?
16 A. YES, SIR, OF THE NOW ORDERS THAT I THEN ORDERED.
17 Q. THAT'S CORRECT. AND SO SOMETIME BETWEEN FIVE -- OR
18 3 O'CLOCK AND 8 O'CLOCK IN THE EVENING, YOU HAD SOME MEETING
19 WITH THE FAMILY MEMBERS?
20 A. I BELIEVE SO.
21 Q. WOULD YOU TURN TO YOUR DISCHARGE SUMMARY PAGE 354, IF
22 YOU WOULD, PLEASE. AT THE TOP OF THE PAGE YOU INDICATE, I
23 TALKED TO HER GYNECOLOGIST -- SPEAKING OF MARY CRANE AND
24 THAT'S IN THERE, BUT THAT'S WHO WE'RE SPEAKING ABOUT --
25 DR. MEEKS AND HE FELT OKAY WITH NOT DOING SURGERY UNTIL
4000
1 AFTER PSYCHIATRIC CARE HAD BEEN COMPLETED AND FELT THAT A
2 LOW RESIDUE DIET AND BROAD-SPECTRUM ANTIBIOTICS WERE THE
3 BEST COURSE.
4 DO YOU RECALL THAT PARTICULAR CONVERSATION THAT YOU'VE
5 REFERENCED IN THE REPORT?
6 A. NO.
7 Q. YOU DON'T?
8 A. NO.
9 Q. YOU RECALL, I ASSUME, DICTATING THAT PARTICULAR REPORT?
10 A. WELL, NO. I SEE THAT I CERTAINLY DID BUT I DON'T RECALL
11 DOING IT. I DON'T -- I'VE DICTATED A LOT OF DISCHARGE
12 SUMMARIES.
13 Q. IS IT SAFE TO ASSUME, DOCTOR, THAT YOU WERE NOT TOO
14 CONCERNED ABOUT THIS VAGINAL FISTULA AT THE TIME WITH THAT
15 CONVERSATION?
16 A. NO, SIR, IT'S NOT.
17 Q. WELL, IF DR. MEEKS WAS TELLING YOU THAT WE COULD DELAY
18 THE SURGERY UNTIL AFTER THE PSYCHIATRIC CARE HAD BEEN
19 COMPLETED, WHAT DOES THAT MEAN IN TERMS OF -- DOES THAT MEAN
20 AFTER SHE'S DISCHARGED FROM THE INSTITUTION OR FROM THE
21 GEROPSYCH UNIT?
22 A. WELL, I CAN'T SPECULATE AS TO EXACTLY WHAT HE MEANS.
23 Q. OKAY. LET ME ASK YOU THIS: DOWN FURTHER IN THAT
24 PARTICULAR DISCHARGE SUMMARY, YOU ALSO INDICATE, ON THE 5TH,
25 I TALKED WITH DR. MEEKS WHO RECOMMENDED KEFLEX BE USED AS A
4001
1 BROAD-SPECTRUM ANTIBIOTIC, WE STARTED THAT AT 250 MILLIGRAMS
2 QID.
3 A. CORRECT.
4 Q. SO YOU START THE ANTIBIOTIC SOME TIME AFTER THE
5 CONVERSATION WHICH OCCURRED ON THE 3RD, IS THAT CORRECT,
6 WITH DR. MEEKS, THE FIRST CONVERSATION?
7 A. WELL, THE TOP CONVERSATION DOESN'T EXACTLY SAY WHEN WE
8 EVEN TALKED, SO I DON'T KNOW.
9 Q. OKAY. YOU WERE AWARE OF THE VAGINAL FISTULA ON THE 1ST,
10 WERE YOU NOT?
11 A. I THINK THAT'S WHEN IT WAS FIRST REPORTED.
12 Q. OKAY. AND YOU WERE AWARE THAT DR. MEEKS CAME IN AND DID
13 HIS CONSULT ON THE 2ND, WERE YOU NOT?
14 A. CORRECT.
15 Q. AND YOU DID NOT INITIATE ANY KIND OF ACTION TO TREAT THE
16 VAGINAL FISTULA UNTIL THE 5TH; IS THAT CORRECT?
17 A. NO, SIR, IT'S NOT.
18 Q. WHAT ACTION DID YOU INITIATE TO TREAT IT PRIOR TO THAT
19 TIME?
20 A. ON THE 3RD I ORDERED THE LOW FIBER OR LOW RESIDUE DIET
21 THAT HAD BEEN RECOMMENDED AND I WROTE A NOTE SAYING, PLEASE
22 HAVE DR. DIENHART MADE AWARE OF GYNECOLOGIST'S
23 RECOMMENDATIONS, GIVE HIM MY -- BEEPER NUMBER IS CROSSED
24 OUT. I GAVE THEM MY OFFICE NUMBER PHONE NUMBER SAYING HE
25 COULD CALL ME IF NECESSARY. AND I ALSO SPOKE WITH A NURSE
4002
1 AND SAID, HEY, WE'VE GOT TO LET DR. DIENHART KNOW ABOUT THIS
2 RECOMMENDATION FOR ANTIBIOTICS AND, YOU KNOW, SEE WHAT HE
3 WANTS TO DO. HE WAS KIND OF MISSING IN ACTION THERE.
4 Q. I SEE. BUT WHAT YOU ARE SAYING TO ME IS THAT -- THIS IS
5 YOUR PATIENT, RIGHT?
6 A. I'M THE ATTENDING.
7 Q. YOU ARE THE ATTENDING PHYSICIAN AND YOU ADMINISTER PAIN
8 MEDICATIONS LIKE MORPHINE, CORRECT?
9 A. THAT'S TRUE.
10 Q. BUT YOU DIDN'T FEEL THAT YOU HAD THE QUALIFICATIONS TO
11 ADMINISTER A BROAD-SPECTRUM ANTIBIOTIC TO THIS WOMAN AT THAT
12 TIME?
13 A. WELL, GYNECOLOGY IS NOT MY SPECIALTY AT ALL. IT'S NOT A
14 SPECIALTY IN INTERNAL MEDICINE AND SO I FELT LIKE I SHOULD
15 GET THE GYNECOLOGIST AND THE INTERNIST WHO WOULD BE MUCH
16 MORE FAMILIAR WITH THIS SORT OF PROBLEM.
17 Q. WELL, YOU ALREADY HAD THE RECOMMENDATION OF DR. MEEKS,
18 DID YOU NOT?
19 A. FOR A BROAD-SPECTRUM ANTIBIOTIC.
20 Q. RIGHT.
21 A. I DIDN'T KNOW WHICH ONE THEY MIGHT WANT TO USE.
22 Q. SO IT MUST HAVE NOT BEEN SOMETHING THAT WAS SIGNIFICANT
23 IN YOUR MIND AT THE TIME IF YOU DELAYED UNTIL THE 5TH TO
24 ORDER ANY ANTIBIOTICS; ISN'T THAT CORRECT?
25 A. NO, SIR.
4003
1 Q. DOCTOR, DO YOU FEEL THAT THE COMBINATION OF THE
2 PSYCHOTROPIC MEDICATIONS ALONG WITH THE DURAGESIC PATCH AND
3 THE ADMINISTRATION OF THE MORPHINE IN CONNECTION WITH THE
4 TREATMENT THAT WAS GIVEN MARY CRANE CAUSED THE DEATH OF MARY
5 CRANE?
6 A. I DON'T SEE HOW IN ANY WAY THESE MEDICATIONS COULD HAVE
7 CAUSED SEPSIS, NO, SIR, I DO NOT.
8 Q. DO YOU FEEL THAT THESE COMBINATIONS PUT THE PATIENT AT
9 RISK OF DEATH?
10 A. SIR, TAKING AN ASPIRIN PUTS YOU AT RISK OF DEATH.
11 Q. I WANT KNOW, DOCTOR, IN YOUR OPINION, DO YOU FEEL THAT
12 THESE COMBINATIONS PUT MARY CRANE AT A RISK OF DEATH?
13 A. A VERY SLIGHT RISK OF DEATH, YES.
14 Q. DO YOU FEEL THAT THESE COMBINATIONS IN ANY WAY
15 CONTRIBUTED TO HER DEATH?
16 A. NO, SIR.
17 Q. LET'S TALK ABOUT LYDIA SMITH. AGAIN, I CALL YOUR
18 ATTENTION TO STATE'S EXHIBIT 37. WHY DON'T YOU STEP UP AND
19 TAKE A LOOK AT THAT EXHIBIT, PLEASE.
20 A. I'M FAMILIAR WITH IT. I CAN SEE IT FROM HERE.
21 Q. OKAY. I WOULD, AGAIN, LIKE TO JUST SORT OF GO THROUGH
22 WITH YOU THE REGIMEN OF MEDICATIONS THAT WERE ORDERED FOR
23 LYDIA SMITH. WE START OUT ON THE 30TH WITH WHAT'S A HALF
24 DOSE OF ATIVAN OR RECOMMENDED DOSAGE OF ATIVAN AND SERZONE
25 AND A HALF DOSE OF RISPERDAL; IS THAT CORRECT?
4004
1 A. WELL, YOU -- I WOULD HAVE TO DISAGREE WITH THESE AS
2 RECOMMENDED DOSAGES BECAUSE THEY ARE THE LOW END OF THE
3 INITIAL STARTING DOSAGES AND THAT WAS TAKEN FROM A BOOK
4 WHICH IS BASICALLY GUIDELINES FOR MEDICATION, BUT YOU KNOW.
5 Q. OKAY. LET'S IGNORE THE DOSAGE RATES RIGHT NOW.
6 A. OKAY.
7 Q. BUT IN TERMS OF -- FOR PURPOSES OF THIS TESTIMONY I WANT
8 TO KNOW, WERE THESE THE DRUGS THAT WERE ORDERED,
9 ADMINISTERED TO LYDIA SMITH ON THE FIRST DATE OF HER
10 ADMISSION?
11 A. YES, SIR.
12 Q. OKAY. NOW, WE SEE OVER THE NEXT FOUR DAYS THOSE SAME
13 DRUGS AS ORDERED, IS THAT CORRECT, RISPERDAL, SERZONE AND
14 ATIVAN?
15 A. YES, SIR.
16 Q. OKAY.
17 A. YES, SIR.
18 Q. ALL OF THOSE, AGAIN, HAVE CENTRAL NERVOUS SYSTEM
19 DEPRESSANT QUALITIES?
20 A. TO VARYING DEGREES THEY DO.
21 Q. AND AS YOU'VE PREVIOUSLY TESTIFIED, THEY WOULD HAVE
22 ADDITIVE EFFECTS?
23 A. YES, SIR.
24 Q. NOW, IT APPEARS THAT ON THE 24TH DAY OF DECEMBER THAT WE
25 HAVE AN ORDER FOR TRAZODONE BUT IT WAS NOT GIVEN?
4005
1 A. IT LOOKS LIKE IT.
2 Q. AND WE STILL HAVE SERZONE AND RISPERDAL?
3 A. AND ATIVAN.
4 Q. AND ATIVAN. ON THE 25TH DAY OF DECEMBER IT APPEARS THAT
5 THE ATIVAN IS INCREASED AND THE ONLY THING GIVEN ON THE 25TH
6 IS HALDOL AND ATIVAN; IS THAT CORRECT?
7 A. I DON'T KNOW WHAT YOU MEAN BY INCREASED. THERE WAS MORE
8 GIVEN THAT DAY, IT MAY HAVE BEEN A P.R.N. SO I WANT TO SAY
9 THAT IN TERMS OF AN HOUR OR A ROUTINE ORDER, I CAN'T TELL
10 YOU WITHOUT LOOKING AT THE --
11 Q. OKAY. BUT THOSE WERE THE ONLY DRUGS APPARENTLY THAT
12 WERE ADMINISTERED ON THAT DAY, CORRECT?
13 A. CORRECT, YES, SIR.
14 Q. NOW, THE NEXT DAY WE DO ADD TRAZODONE TO THE REGIMEN
15 WHICH IS ALSO A CENTRAL NERVOUS SYSTEM DEPRESSANT, CORRECT?
16 A. SHE FINALLY STARTED GETTING THAT ADMINISTERED.
17 Q. IN ADDITION TO HALDOL ON THE 27TH, WE HAVE TRAZODONE,
18 SERZONE, HALDOL, AND RISPERDAL, RIGHT?
19 A. AND IT LOOKS LIKE YOU DON'T HAVE ATIVAN THAT DAY SO
20 THAT'S KIND OF WHY I WAS THINKING IT WAS PROBABLY P.R.N. SHE
21 WAS GETTING BEFORE.
22 Q. OKAY. THEN WE GO ALONG HERE AND WE CONTINUE TO HAVE
23 SOME MEDICATIONS WITHHELD BUT WE HAVE ESSENTIALLY THE SAME,
24 RISPERDAL, HALDOL AND SERZONE. AND THEN WE GET TO THE 29TH
25 AND WE HAVE A NEW DRUG THAT'S ADDED TO THE 29TH; IS THAT
4006
1 CORRECT?
2 A. ONCE AGAIN, DEPAKENE.
3 Q. OKAY. AND DOES DEPAKENE ALSO HAVE CENTRAL NERVOUS
4 SYSTEM DEPRESSANT QUALITIES?
5 A. IT CAN.
6 Q. OKAY. AND WE GO ALONG, WE'VE GOT DEPAKENE, TRAZODONE,
7 SERZONE, RISPERDAL FOR THE 30TH AND THE 31ST, WE ADD HALDOL
8 BACK IN AND WE CONTINUE THAT PATTERN, BUT IT SEEMS LIKE THE
9 DOSAGES ADMINISTERED ARE GETTING INCREASING, WOULD THAT BE
10 AN ACCURATE REFLECTION OF YOUR RECOLLECTION OF THE RECORDS?
11 A. NO, SIR. ACTUALLY, I THINK THAT'S AN ARTIFACT BASED
12 UPON THE WAY YOU'VE MADE THIS CHART.
13 Q. OKAY. SO YOU DON'T THINK THESE DOSAGES THAT ARE BEING
14 ADMINISTERED ARE INCREASING?
15 A. NO. BECAUSE SHE'S MISSING SO MANY I THINK IT'S PROBABLY
16 STAYING FAIRLY, FAIRLY STABLE FROM STARTING AROUND THE 24TH
17 OR SO.
18 Q. SUFFICE IT TO SAY, DOCTOR, WE CONTINUE WITH THIS REGIMEN
19 OF ATIVAN, DEPAKENE, TRAZODONE, SERZONE HALDOL AND
20 RISPERDAL; IS THAT CORRECT?
21 A. YES, SIR.
22 Q. YOU DISAGREE WITH MAYBE THAT THE DOSAGE AMOUNTS ARE NOT
23 INCREASING, IS THAT RIGHT, BECAUSE OF THE CHART?
24 A. THE ADMINISTRATION AMOUNTS?
25 Q. YES, THE AMOUNTS ADMINISTERED TO HER.
4007
1 A. WHAT SHE WAS ACTUALLY GETTING UNFORTUNATELY --
2 Q. THE QUESTION WAS: DO YOU DISAGREE, THEN, THAT THEY ARE
3 NOT INCREASING?
4 A. DISAGREE THAT THEY ARE NOT? I GUESS I AGREE THAT THE
5 AMOUNTS --
6 Q. DO YOU AGREE OR NOT?
7 MR. STIRBA: YOUR HONOR, I WOULD --
8 THE COURT: EXCUSE ME. I THINK YOU NEED TO LET HIM
9 ANSWER THE QUESTION.
10 MR. WILSON: OKAY. I'M SORRY.
11 THE WITNESS: I WOULD AGREE THAT WHAT'S ORDERED IS
12 SLOWLY INCREASING AND WHAT SHE'S ACTUALLY GETTING ON THE
13 AVERAGE IS PRETTY MUCH STAYING STABLE, ESPECIALLY WHEN YOU
14 LOOK AT WHAT WAS ACTUALLY GIVEN IN TERMS OF, WELL, MY
15 MEDICAL JUDGEMENT AS TO WHAT I SHOULD GIVE TO COMBAT THE
16 SYMPTOMS SHE WAS HAVING AND NOT THIS SORT OF ARTIFICIAL
17 REPRESENTATION OF WHAT SHE WAS GETTING.
18 Q. (BY MR. WILSON) DOCTOR, IF I CHARACTERIZED LYDIA
19 SMITH'S RECORDS AS THAT SHE SEEMED TO BE GOING ALONG AND SHE
20 WAS QUITE AGITATED MOST OF THE TIME, WOULD BITE AND KICK AND
21 CAUSE DISRUPTIVE BEHAVIOR WHILE AT THE GEROPSYCH UNIT FOR A
22 SUBSTANTIAL PERIOD OF THAT TIME, WOULD THAT BE AN ACCURATE
23 STATEMENT?
24 A. YES, IT WOULD.
25 Q. AND SO AS I RECALL YOUR TESTIMONY YESTERDAY, YOU WERE
4008
1 ATTEMPTING TO BRING THAT BEHAVIOR UNDER CONTROL; IS THAT
2 CORRECT?
3 A. THAT'S CORRECT, YES, SIR.
4 Q. BECAUSE YOU WERE CONCERNED AT THE TIME THAT IF YOU
5 DIDN'T BRING IT UNDER CONTROL SHE WOULDN'T BE ABLE TO BE
6 ADMITTED BACK TO THE ROCKY MOUNTAIN CARE CENTER IN
7 BOUNTIFUL, UTAH; IS THAT CORRECT?
8 A. DURING THE FIRST PART OF THE HOSPITALIZATION I WAS JUST
9 TRYING TO TREAT HER AND THEN TOWARD THE END THE FAMILY WAS
10 REPEATEDLY SAYING, YOU KNOW, WE'VE GOT THIS POSSIBLE
11 PLACEMENT BUT IF HER BEHAVIOR IS NOT IMPROVED, THEY SIMPLY
12 WON'T TAKE HER.
13 Q. ISN'T IT TRUE, DOCTOR, THAT YOU, IN FACT, INCREASED THE
14 DOSAGES OF THOSE LISTED MEDICATIONS TOWARDS THE END -- OR I
15 SHOULD SAY TOWARDS THE BEGINNING OF JANUARY IN ORDER TO
16 ACCOMPLISH THAT VERY PURPOSE?
17 A. I DON'T THINK I NEED TO LOOK FOR THAT. YES, YOU ARE
18 RIGHT.
19 Q. NOW, ON JANUARY THE 5TH -- EXCUSE ME, JANUARY THE 3RD,
20 MED-0793. AT THE TOP OF THE PAGE --
21 A. WHAT'S IT UNDER, NURSES' NOTES?
22 Q. NURSING NOTES, EXCUSE ME.
23 A. OKAY. GOT IT.
24 Q. PATIENT VERY DROWSY, DID NOT EAT DINNER, PATIENT
25 LETHARGIC STATE, STAFF HAD TO SUPPORT FOR A TIME AMBULATE --
4009
1 IS IT AMBULATION?
2 A. YES, SIR, FOR -- YES, SIR, AMBULATION TRANSACTION.
3 Q. SO THERE'S ALSO DOWN IN THE CORNER A NOTE THAT SHE
4 APPEARS -- NEUROLOGICALLY, UNDER THAT HEADING, LETHARGIC.
5 AGAIN ON THE 4TH WE HAVE --
6 A. WOULD THAT BE THE NEXT PAGE?
7 Q. YES, EXCUSE ME. MED-0794 IN THE MIDDLE OF THE PAGE,
8 PATIENT HAS BEEN LETHARGIC DURING THE SHIFT, PATIENT HAS
9 BEEN NONRESPONSIVE TO STAFF, HAS BEEN SLEEPING ALL SHIFT.
10 DOWN FURTHER SAYS, PATIENT WOULD NOT AROUSE FOR MEALS,
11 PATIENT ATTENDED GROUP BUT SLEPT THROUGH GROUP, CORRECT?
12 A. THAT'S WHAT IT SAYS THERE. ON THE SAME PAGE IT ALSO
13 SAYS PATIENT RESTLESS, TOSSING AND TURNING, STRIKING OUT,
14 KICKING.
15 Q. IN RESPECT TO THE NEXT NOTE ON THE 7TH?
16 A. THE NEXT NOTE?
17 Q. WELL, EXCUSE ME, MED-00800. IN THE MIDDLE OF THE PAGE,
18 PATIENT NOT ABLE TO TAKE MEDS, PATIENT LETHARGIC AND
19 UNRESPONSIVE, PATIENT NOT SWALLOWING OR RESPONDING TO STAFF;
20 IS THAT CORRECT?
21 A. THAT'S WHAT IT SAYS.
22 Q. AND THEN WE FOLLOW THROUGH TO THE 7TH AT 2200 HOURS ON
23 THE NEXT PAGE 801. PATIENT NOT ABLE TO TAKE ANY MEDS,
24 UNRESPONSIVE MOST OF THE SHIFT, FAMILY AND DOCTOR NOTIFIED
25 OF PATIENT'S CONDITION, FAMILY AND DOCTOR IN TO SEE PATIENT,
4010
1 RESPIRATIONS SHALLOW, COMFORT MEASURES.
2 NOW, THAT WAS NIGHT OF THE MEETING WITH THE SMITH
3 FAMILY, WASN'T IT?
4 A. I'LL HAVE TO LOOK IT UP AND -- IT'S BEEN A LONG TIME.
5 FAMILY DISCUSSION WITH TWO SONS AND DAUGHTER REVEALS THAT
6 THEY DON'T WANT HER LIFE PROLONGED, THEY ARE READY TO LET
7 HER GO. AT TIMES SHE THRASHES ABOUT, SEEMS TO BE IN PAIN.
8 Q. OKAY. IT --
9 A. THAT'S MY NOTE ON THE 7TH.
10 Q. THAT'S YOUR NOTE ON THE 7TH. DO YOU KNOW WHAT TIME THAT
11 NOTE WAS MADE?
12 A. I DON'T HAVE THE TIME.
13 Q. DO YOU HAVE ANY INDEPENDENT RECOLLECTION OF THE MEETING
14 WITH THE SMITH FAMILY?
15 A. NOT AT THIS TIME.
16 Q. SO YOU DON'T KNOW WHAT YOU TOLD THE SMITHS?
17 A. ONLY IN GENERAL TERMS WOULD I KNOW WHAT I TOLD THEM.
18 Q. NOW, YOU REFERENCE A NOTE -- IN YOUR NOTE YOU REFERENCE
19 THAT THIS PATIENT IS -- THRASHES ABOUT, SOME TO BE --
20 A. AT TIMES SHE THRASHES ABOUT, SEEMS TO BE IN PAIN.
21 Q. PAIN/ANXIETY?
22 A. PAIN SLASH ANXIETY.
23 Q. BUT YET YOU JUST -- WE JUST REFERRED TO THE NOTE BACK ON
24 801 OF THE NURSES' NOTE WHICH THEY INDICATE SHE WAS TOTALLY
25 UNRESPONSIVE AT THAT TIME, DID NOT TAKE MEDS --
4011
1 A. IT'S ODD THAT SHE WOULD SAY NOT TAKE MEDS BECAUSE I
2 ORDERED NO MEDICATIONS BY MOUTH. I DON'T KNOW WHERE SHE WAS
3 COMING FROM THERE.
4 Q. YOU WOULD WHAT?
5 A. WELL, ON THAT DAY I HAD ORDERED STOP, YOU KNOW,
6 DISCONTINUE ABOVE MEDICATIONS SO ALL HER OTHER MEDICATIONS
7 THAT YOU ARE TALKING ABOUT HERE --
8 Q. WERE DISCONTINUED ON THE 7TH?
9 A. -- WERE DISCONTINUED SO I DON'T KNOW --
10 Q. WHAT TIME ON THE 7TH, DOCTOR, DOES YOUR NOTE BEAR?
11 A. WELL, MY ORDER WE'LL HAVE TO SEE. IT WAS SIGNED OFF AT
12 2130 SO IT HAD TO HAVE BEEN BEFORE THAT. I CAN'T TELL OTHER
13 THAN THAT.
14 Q. THAT'S 9:30 IN THE EVENING -- OR NO, THAT'S -- YEAH,
15 THAT'S 9:30 IN THE EVENING?
16 A. YES, SIR.
17 Q. IT APPEARS FROM THE CHART THAT SHE DID RECEIVE SOME
18 MEDICATIONS OF DEPAKENE, TRAZODONE, SERZONE AND RISPERDAL?
19 A. THOSE WOULD HAVE BEEN HER MORNING MEDICATIONS.
20 Q. SO THOSE WERE GIVEN TO HER IN THE MORNING BUT AS SHE
21 PROGRESSED THROUGH THE DAY, ACCORDING TO THE NOTES, SHE WAS
22 NOT ABLE TO EAT OR TO TAKE MEDS, CORRECT?
23 A. I HAVEN'T REVIEWED THE FIRST PART OF THE DAY SO LET ME
24 HAVE A LOOK THERE.
25 Q. WHEN WAS IT, DOCTOR, THAT YOU DETERMINED THAT THIS
4012
1 PATIENT WAS IN THE DYING PROCESS?
2 A. I THINK IT WOULD HAVE BEEN ON THE 7TH.
3 Q. DO YOU REMEMBER WHAT TIME ON THE 7TH?
4 A. NOT PRECISELY.
5 Q. I TAKE IT YOUR NOTES DON'T REFLECT ANY TIMES; IS THAT
6 CORRECT?
7 A. WELL, I KNOW THAT THE PROGRESS NOTE DOESN'T AND THE
8 DOCTOR'S ORDER SHOWS THAT IT WAS DONE BEFORE 9:30 BUT THAT'S
9 ALL I CAN REALLY TELL YOU. SOMETIMES THE NURSES IF THEY
10 WERE REALLY BUSY MIGHT TAKE SOME TIME TO TAKE THE ORDER OFF
11 SO IT MAKES IT PRETTY VARIABLE.
12 Q. AS I RECALL YOUR TESTIMONY, YOU ALSO MET WITH THE CRANE
13 FAMILY ON THE 7TH; IS THAT CORRECT?
14 A. YES, SIR, I BELIEVE IT IS.
15 Q. AND THEN YOU MEET WITH THE SMITH FAMILY ON THE 7TH; IS
16 THAT CORRECT?
17 A. I THINK SO. I DON'T HAVE AN INDEPENDENT RECOLLECTION.
18 IT'S SOMEWHAT POSSIBLE IT COULD HAVE BEEN OVER THE PHONE BUT
19 I THINK WE MET IN PERSON.
20 Q. WELL, YOU TESTIFIED YESTERDAY THAT YOU RECALL NEVER
21 HAVING MADE A STATEMENT IN THE PRESENCE OF THE SMITH FAMILY
22 ABOUT LYDIA SMITH BEING AN OLD, CRABBY LADY, DIDN'T YOU?
23 A. WHAT I DID TESTIFY TO IS THAT I WOULD NEVER SAY
24 SOMETHING LIKE THAT, I'M SURE I NEVER SAID IT. I DO NOT
25 RECALL NOT HAVING SAID IT.
4013
1 Q. SO YOUR TESTIMONY YESTERDAY WAS THAT YOU JUST DIDN'T
2 MAKE THAT KIND OF A STATEMENT?
3 A. MY TESTIMONY AS I REMEMBER WAS I CALLED IN THE FAMILY
4 FOR THE MEETING AND I WOULD NEVER SAY ANYTHING LIKE THAT.
5 Q. OKAY.
6 A. SO I GUESS THAT MEANS WE MET.
7 Q. DOCTOR, DID YOU SEEK THE ADVICE OF ANY CONSULTING
8 PHYSICIAN ON THE CONDITION OF LYDIA SMITH?
9 A. I DON'T RECALL HAVING DONE SO.
10 Q. PARDON?
11 A. I DON'T RECALL HAVING DONE SO.
12 Q. DID YOU THINK IT WAS IMPORTANT TO TRY AND ASCERTAIN JUST
13 EXACTLY WHAT THIS INDIVIDUAL WAS DYING FROM?
14 A. IT WAS PRETTY APPARENT THAT SHE HAD NO URINE OUTPUT, SHE
15 LOST MUCH WEIGHT BEFORE THE HOSPITALIZATION, EIGHT POUNDS
16 JUST IN THE TIME SHE WAS THERE, WE HAD MULTIPLE --
17 Q. I GUESS MY QUESTION WAS: DID YOU THINK IT WAS IMPORTANT
18 TO FIND OUT EXACTLY WHAT THIS LADY WAS DYING FROM?
19 A. THERE'S SOME IMPORTANCE THERE, YES, SIR.
20 Q. NOW YOU'VE PREVIOUSLY TESTIFIED YOU ARE NOT SPECIALIZED
21 IN INTERNAL MEDICINE; IS THAT CORRECT?
22 A. THAT IS. I JUST HAVE SOME BASELINE WORK THERE, YOU
23 KNOW, YOU DO YOUR FIRST YEAR IN INTERNAL MEDICINE AND
24 SPECIALIZE IN PSYCHIATRY.
25 Q. YOU HAD PHYSICIANS ON CALL IN THE HOSPITAL SETTING TO
4014
1 CONSULT WITH, DID YOU NOT?
2 A. YES, SIR.
3 Q. BUT YOU CHOSE NOT TO HAVE A CONSULTING PHYSICIAN COME IN
4 AND REVIEW THE CONDITION OF LYDIA SMITH, CORRECT?
5 A. THAT'S TRUE.
6 Q. LET'S TURN TO THE MEDICAL/LEGAL SECTION MED-00811.
7 A. GOT IT.
8 Q. WHICH IS THE MEDICAL TREATMENT PLAN FOR -- SIGNED BY
9 KENT SMITH. DO YOU RECALL THAT DOCUMENT, DOCTOR?
10 A. I HAVE IT HERE IN FRONT OF ME.
11 Q. OKAY. IT BEARS YOUR SIGNATURE, DOESN'T IT?
12 A. YES, SIR.
13 Q. AND THAT SIGNATURE IS DATED 1/7 OF '96?
14 A. RIGHT.
15 Q. ALSO BEARS THE FACILITY REPRESENTATIVE'S SIGNATURE, DOES
16 IT NOT?
17 A. ONCE AGAIN, IT LOOKS LIKE EARLENE COZZENS.
18 Q. OKAY. I NOTE, DOCTOR, THAT THERE'S NO INDICATION IN THE
19 BLANK UNDERNEATH THE TOP AND THE TOP PARAGRAPH AS TO WHAT
20 DISEASE, CURRENT DISEASE OR ILLNESS THIS PATIENT IS
21 SUFFERING FROM; IS THAT CORRECT?
22 A. IT IS. IT'S NOT FILLED IN.
23 Q. I NOTE THAT THERE'S NO CHECK MARKS AS TO WHO THE
24 DECLARANT -- AS TO THE DECLARANT HAVING A PHYSICAL OR MENTAL
25 CONDITION WHICH RENDERS HIM OR HER UNABLE TO GIVE PERSONAL
4015
1 DIRECTION, CORRECT?
2 A. DOESN'T HAVE TO BE. IT SAYS "OR" THERE.
3 Q. BUT THERE'S NO CHECK MARK?
4 A. THAT'S CORRECT.
5 Q. THERE'S NO CHECK MARK AS TO WHETHER IT'S DIRECTED BY THE
6 DECLARANT OR NOT?
7 A. CORRECT.
8 Q. AND I ASSUME YOU HAVE NO RECOLLECTION OF MEETING WITH
9 KENT SMITH AT THE TIME THAT HE EXECUTED THIS DOCUMENT,
10 CORRECT?
11 A. NO, I DON'T REMEMBER. I MAY NOT HAVE BEEN THERE AT ALL
12 FOR THIS.
13 Q. YOU MAY NOT HAVE BEEN THERE AT ALL AT THE TIME THAT HE
14 EXECUTED THE DOCUMENT?
15 A. EARLENE COZZENS LOOKS TO HAVE FILLED IT OUT AND I SIGNED
16 OFF LATER.
17 Q. AGAIN, DOCTOR, YOU HAVE NO RECOLLECTION OF HAVING
18 DISCUSSED ANY OF THE ALTERNATIVES AVAILABLE FOR THE
19 TREATMENT OF LYDIA SMITH WITH THE FAMILY; IS THAT CORRECT?
20 A. I HAVE NO SPECIFIC RECOLLECTION. IT WAS MY PRACTICE TO
21 SAY, YOU KNOW, WE HAVE THE I.C.U., THE MEDICAL FLOOR DOWN
22 THE WAY BUT...
23 Q. YOU HAVE NO SPECIFIC RECOLLECTION, YOU ARE JUST GOING
24 OFF OF WHAT YOUR PRACTICE IS; IS THAT CORRECT?
25 A. RIGHT. AND THAT IS AS REFRESHED BY WHAT I CAN GLEAN
4016
1 FROM THESE RECORDS.
2 Q. ALL RIGHT. LET'S CALL YOUR ATTENTION TO THE FOLLOWING
3 DAY, THAT'S THE DAY THAT LYDIA SMITH DIED.
4 A. THE 8TH.
5 Q. THE 8TH. DO YOU RECALL MEETING BONNIE SMITH-WEIGHT IN
6 HER MOTHER'S ROOM ON THAT PARTICULAR DATE?
7 A. NO.
8 Q. AROUND NOON?
9 A. NO, SIR.
10 Q. DO YOU HAVE ANY RECOLLECTION OF HAVING A CONVERSATION
11 WITH BONNIE SMITH-WEIGHT ABOUT THE ADMINISTRATION OF
12 MORPHINE TO HER MOTHER?
13 A. NO, SIR.
14 Q. SO YOU DON'T RECALL ANY CONVERSATION AT ALL; IS THAT
15 CORRECT?
16 A. NO, SIR. WITH BONNIE SMITH-WEIGHT? NO.
17 Q. DO YOU KNOW WHEN THE LAST MORPHINE SHOT WAS ADMINISTERED
18 TO BONNIE -- EXCUSE ME, TO LYDIA SMITH?
19 A. NOT OFF THE TOP OF MY HEAD BUT I'LL LOOK IT UP. IT
20 LOOKS LIKE BEST I CAN TELL AT 12 NOON ON THE 8TH -- OR WAIT
21 A SECOND.
22 Q. WHAT TIME DID SHE DIE, DOCTOR?
23 A. IT LOOKS LIKE 12:45.
24 Q. 45 MINUTES AFTER THE LAST SHOT WAS ADMINISTERED?
25 A. I'M NOT SURE BECAUSE IT'S IN THE COLUMN FOR THE 7TH SO I
4017
1 DON'T KNOW WHEN -- I CAN'T REALLY TELL FROM THIS WHEN THE
2 LAST SHOT WAS GIVEN. I'LL HAVE TO GO TO THE NURSES' NOTES
3 AND SEE IF IT SAYS.
4 Q. ASSUMING IT WAS GIVEN AT 12 O'CLOCK, SHE DIED AT 12:45,
5 RIGHT?
6 A. SHE DID DIE AT 12:45 FROM WHAT IT SAYS HERE. ASSUMING
7 THAT IT WAS GIVEN AT 12, IT WOULD HAVE BEEN 45 MINUTES
8 LATER.
9 Q. CORRECT. LET ME ASK YOU THIS: IS THAT -- IS NOT THAT
10 CONSISTENT IN YOUR OPINION WITH DEATH AS A RESULT OF
11 MORPHINE BEING ADMINISTERED?
12 A. NO, SIR.
13 Q. SO YOU DON'T FEEL MORPHINE PLAYED ANY PART IN LYDIA
14 SMITH'S DEATH?
15 A. NO, SIR.
16 Q. YOU DON'T FEEL THAT THE COMBINATION OF THE CENTRAL
17 NERVOUS SYSTEM DEPRESSANTS THAT WERE GIVEN PRIOR TO THAT
18 TIME AND ALSO IN COMBINATION WITH THE MORPHINE CREATED ANY
19 GRAVE RISK OF DEATH?
20 A. NO, SIR. I WOULDN'T HAVE DONE THAT.
21 Q. AND I GUESS IT'S YOUR TESTIMONY THAT YOU DON'T BELIEVE
22 THOSE DRUGS IN ANY WAY CONTRIBUTED TO HER DEATH; IS THAT
23 CORRECT?
24 A. THAT'S CORRECT.
25 MR. WILSON: YOUR HONOR, DID YOU WANT TO TAKE A
4018
1 BREAK AT THIS TIME?
2 THE COURT: OKAY. LADIES AND GENTLEMEN, WE'VE BEEN
3 GOING FOR OVER AN HOUR, LET'S TAKE ONE OF OUR MORNING
4 BREAKS. DURING THIS TIME, REMEMBER IT IS YOUR DUTY NOT TO
5 CONVERSE AMONG YOURSELVES OR TO CONVERSE WITH OR ALLOW
6 YOURSELVES TO BE ADDRESSED WITH BY ANY PERSON ON ANY SUBJECT
7 OF THIS TRIAL. IT IS YOUR DUTY NOT TO FORM OR EXPRESS AN
8 OPINION UNTIL THE CASE IS FINALLY SUBMITTED TO YOU. AND SO
9 LET'S COME BACK AT 25 TO TEN.
10 (A BRIEF RECESS WAS TAKEN.)
11 THE COURT: PLEASE BE SEATED. THE RECORD WILL
12 REFLECT THAT THE JURY HAS RETURNED, AND LADIES AND
13 GENTLEMEN, JUST TO CLOSE OUT ON JUROR NUMBER TEN, I SPOKE TO
14 THE HOSPITAL AND THEY INDICATED THAT JUROR NUMBER TEN IS
15 DOING THEY -- YOU KNOW, IT DOESN'T LOOK LIKE IT WAS A HEART
16 ATTACK BUT THEY SAY HE'S IN STABLE CONDITION, HE'S STILL
17 THERE. THEY DON'T KNOW HOW LONG HE'S GOING TO BE THERE.
18 THEY ARE DOING A LOT OF TESTS BUT THEY SAID HE'S NOT IN ANY
19 DANGER, SO I THINK THAT'S GOOD NEWS. AND SO WE'LL JUST
20 CONTINUE. OKAY. MR. WILSON?
21 MR. WILSON: THANK YOU, YOUR HONOR.
22 Q. (BY MR. WILSON) DOCTOR, I THINK WE CAN TURN NOW TO
23 ENNIS ALLDREDGE, IF YOU WOULD GRAB HIS BINDER. A COUPLE OF
24 QUESTIONS BEFORE WE ADDRESS THE EXHIBIT. YOU EVALUATED
25 ENNIS ALLDREDGE, DID YOU NOT?
4019
1 A. YES, SIR.
2 Q. AND THAT TOOK PLACE ON THE 10TH?
3 A. YES, SIR.
4 Q. OF JANUARY OF '96?
5 A. YES, SIR.
6 Q. AT THAT TIME AND I THINK YOU REFERENCED IN YOUR
7 TESTIMONY YESTERDAY THAT MR. ALLDREDGE WAS A VERY STRONG
8 MAN?
9 A. YES, SIR.
10 Q. AND THAT I THINK YOU EVEN INDICATED -- WENT SO FAR TO
11 INDICATE THAT SOME OF THE MEDICATIONS WERE GIVEN TO MR.
12 ALLDREDGE WERE FOR PURPOSES OF PROTECTING BOTH THE STAFF AND
13 MR. ALLDREDGE; IS THAT CORRECT?
14 A. NO. IT WAS FOR -- THE MEDICATIONS WERE FOR MR.
15 ALLDREDGE.
16 Q. WAS THERE A PURPOSE TO PROTECT THE STAFF WITH THOSE
17 MEDICATIONS, TOO?
18 A. EVERYONE. HE HAD RECENTLY BROKEN A LADY'S HIP BY
19 THROWING A WHEELCHAIR AND --
20 Q. SO I ASSUME THE EFFECT YOU ARE LOOKING FOR IN MR.
21 ALLDREDGE WAS TO CALM HIM DOWN AND MAYBE EVEN TO SEDATE HIM;
22 IS THAT CORRECT?
23 A. YES, SIR.
24 Q. DID YOU ARRIVE AT A DIAGNOSIS AND A TREATMENT PLAN FOR
25 MR. ALLDREDGE?
4020
1 A. YES, I DID.
2 Q. WHAT WAS THE DIAGNOSIS, DOCTOR?
3 A. PSYCHOSIS N.O.S.
4 Q. WHAT DOES THAT MEAN?
5 A. IT MEANS -- PSYCHOSIS MEANS OUT OF TOUCH WITH REALITY,
6 N.O.S. IS NOT OTHERWISE SPECIFIED.
7 Q. AND WHAT WAS THE -- YOU INDICATE IN MED-005, WE WILL
8 QUICKLY CONTROL HIS PSYCHOTIC BEHAVIOR WITH SOME I.M. HALDOL
9 AND ATIVAN, CORRECT?
10 A. YES, SIR.
11 Q. NOW, YOU INDICATE, HE HAS CURRENTLY RECEIVED THESE AND
12 IS DOING WELL. NOW, IF YOU'LL REFER TO THE CHART, HOW MUCH
13 ATIVAN WAS ENNIS ALLDREDGE ON AT THE TIME THAT HE WAS
14 ADMITTED TO THE UNIT, DO YOU REMEMBER?
15 A. YOU MEAN WHAT WAS HIS --
16 Q. WHAT WAS HIS DOSAGE AMOUNT?
17 A. WELL, IN THIS CHART IT SHOWS THAT HE WAS GIVEN TWO, 3
18 MILLIGRAM I.M. INJECTIONS AT LEAST RIGHT BEFORE ADMISSION.
19 Q. FROM THE CARE CENTER THAT HE CAME FROM, FROM THE
20 FACILITY?
21 A. YES, SIR. AS I REMEMBER HE -- YOU KNOW, THERE ARE
22 NURSES' NOTES FROM THAT FACILITY AND THE BEST I COULD TELL
23 HE HAD GOTTEN TWO SEPARATE 3 MILLIGRAM INJECTIONS PRETTY
24 MUCH RIGHT BEFORE. I DOUBT IT REALLY AFFECTED HIM THAT
25 MUCH.
4021
1 Q. NOW, YOU HAD THAT INFORMATION I ASSUME AT THE TIME THAT
2 YOU INITIALLY EVALUATED HIM; IS THAT CORRECT?
3 A. YES, SIR.
4 Q. IN LOOKING AT THE CHART AND IF YOU WOULD ALSO REFER TO
5 THE MEDICAL RECORDS, IT APPEARS THAT THERE WAS ATIVAN AND
6 HALDOL AND RISPERDAL GIVEN ON THOSE -- THAT PARTICULAR DATE;
7 IS THAT CORRECT?
8 A. IT IS. ON THE 10TH.
9 Q. THERE WAS ALSO SOME OTHER ITEMS THAT WERE ORDERED BUT
10 APPARENTLY WERE NOT ADMINISTERED; IS THAT ALSO CORRECT?
11 A. HE HAD TRAZODONE ORDERED FOR BEDTIME IT DOESN'T LOOK
12 LIKE HE GOT IT ON THE 10TH.
13 Q. DID YOU SEE WHEN YOU INITIALLY EVALUATED HIM THE TYPE OF
14 COMBATIVE BEHAVIOR THAT HAD BEEN REPORTED TO YOU?
15 A. YES, I DID.
16 Q. NOW, HE WAS IN A WHEELCHAIR AS I UNDERSTAND IT; IS THAT
17 ALSO CORRECT?
18 A. WELL, HE WAS GENERALLY MOVED AROUND BY WHEELCHAIR. HE
19 WAS ALWAYS TRYING TO GET OUT OF THE CHAIR, TRYING TO STAND
20 UP. EVERYONE WAS AFRAID HE WAS GOING TO FALL.
21 Q. IN YOUR EVALUATION YOU NOTE, I WAS NOT INFORMED THAT HE
22 IS NONAMBULATORY BEFORE THE ADMISSION. DID YOU HAVE A
23 CONCERN ABOUT THAT?
24 A. WELL, NOT A HUGE CONCERN BECAUSE WE HAD A LOT OF
25 PATIENTS THAT WERE IN WHEELCHAIRS.
4022
1 Q. I JUST WONDERED WHY YOU WOULD REFERENCE THAT IN YOUR
2 NOTE AS TO HIM BEING NONAMBULATORY BEFORE THE ADMISSION.
3 WAS THAT PART OF THE CRITERIA?
4 A. NO, IT WASN'T. YOU DIDN'T HAVE TO BE AMBULATORY FOR
5 ADMISSION.
6 Q. SO HE WAS ACCEPTED AND AS FAR AS YOU WERE CONCERNED, HE
7 WAS STABLE MEDICALLY, IS THAT CORRECT? PHYSICALLY, EXCUSE
8 ME.
9 A. IN AN ACUTE SENSE HE DIDN'T HAVE ANY LIFE THREATENING
10 ILLNESSES THAT WE COULD SEE WHEN HE ARRIVED.
11 Q. SO AT THAT TIME ANYWAY ON THE DAY OF ADMISSION, HE
12 DIDN'T HAVE ANY LIFE-THREATENING ILLNESSES?
13 A. NO, SIR, THAT'S NOT WHAT I SAID.
14 Q. NOW, THE SECOND DATE OF HIS ADMISSION, THE 11TH, AFTER
15 HIS ADMISSION, EXCUSE ME, HE'S GIVEN BUSPAR, RISPERDAL,
16 TRAZODONE AND ATIVAN; IS THAT CORRECT?
17 A. YES, SIR.
18 Q. IS BUSPAR A -- DOES IT HAVE CENTRAL NERVOUS SYSTEM
19 DEPRESSANT QUALITIES?
20 A. YES, SIR.
21 Q. AS WELL AS TRAZODONE AND SERZONE, CORRECT?
22 A. CORRECT.
23 Q. DID YOU MAKE ANY PARTICULAR NOTE IN YOUR RECORD ON THE
24 11TH AS TO HIS BEHAVIOR?
25 A. YES.
4023
1 Q. DID HIS BEHAVIOR, DOCTOR, IMPROVE FROM WHAT IT HAD BEEN
2 OR AT LEAST AS TO WHAT HAD BEEN REPORTED TO BE?
3 A. NOT REALLY.
4 Q. CALLING YOUR ATTENTION --
5 A. BY THE 11TH? I'M SORRY, IT'S KIND OF A GENERAL
6 QUESTION. I'M NOT SURE WHAT YOU MEAN EXACTLY.
7 Q. CALLING YOUR ATTENTION TO MED-0016 WHICH IS THE --
8 A. I HAVE IT.
9 Q. -- THE PROGRESS NOTES. THERE'S A NOTE IN THE MEDICAL
10 RECORD SIGNED BY AN S. BENNION, L.C.S.W. WHERE SHE NOTES:
11 INDIVIDUAL SESSION, ATTEMPTED TO ENGAGE PATIENT IN
12 CONVERSATION BUT PATIENT WAS SLEEPING AND UNRESPONSIVE. I
13 WILL ATTEMPT TO ENGAGE HIM AT A LATER DATE.
14 A. I SEE THAT.
15 Q. FURTHER ON DOWN ON THE 12TH IT INDICATES UNDER DIETARY
16 NOTE, PATIENT NOT EATING. AND THEN I THINK THE NEXT NOTE IS
17 YOUR NOTE ON THE 12TH, PATIENT QUITE DEMENTED, COMBATIVE,
18 MUMBLES INCOHERENTLY, CRIES OUT, WILL NOT TAKE ANY MEDS,
19 AFEBRILE PSYCHOSIS, N.O.S., CONTINUE CURRENT --
20 A. CARE.
21 Q. -- CARE AND THEN YOU'VE GOT INCREASE HALDOL; IS THAT
22 CORRECT?
23 A. YES, SIR.
24 Q. SO ON THE 12TH YOU GAVE HIM ADDITIONAL DOSAGES OF HALDOL
25 IN ADDITION TO THE ATIVAN; IS THAT CORRECT?
4024
1 A. I THINK WHAT HAPPENED IS THE AMOUNT OF THE P.R.N. WAS
2 INCREASED. RIGHT.
3 Q. WELL, DIDN'T YOU ORDER IT INCREASED, DOCTOR?
4 A. YES, SIR.
5 Q. WHEN WAS IT YOU FIRST BECAME AWARE OF A PROBLEM WITH
6 ENNIS ALLDREDGE OF A MEDICAL NATURE OTHER THAN WHAT YOU HAD
7 PREVIOUSLY OBSERVED?
8 A. THE 13TH I BECAME AWARE OF THE M.R.I.
9 Q. DO YOU KNOW WHEN THAT M.R.I. WAS CONDUCTED?
10 A. NOT SURE OF THE EXACT TIME. IT'S PROBABLY ON THE M.R.I.
11 DO YOU KNOW WHERE THAT IS? THESE ARE KIND OF OUT OF ORDER.
12 Q. DID YOU REVIEW THE M.R.I.?
13 A. AT SOME POINT I DID, YES.
14 Q. AND IN REVIEWING AN M.R.I., WHAT IS IT YOU ARE LOOKING
15 AT ON THAT PARTICULAR DATE? WERE YOU LOOKING AT THE
16 FINDINGS OF THE M.R.I. ITSELF OR WERE YOU LOOKING AT A
17 REPORT OF THE M.R.I.?
18 A. A RADIOLOGICAL REPORT.
19 Q. SO YOU DIDN'T VIEW THE FILM?
20 A. NO, SIR.
21 Q. I GUESS, FOR LACK OF A BETTER WORD?
22 A. THAT'S PERFECT. I DID NOT.
23 Q. OKAY. BASED UPON THAT RADIOLOGY REPORT I UNDERSTAND,
24 DOCTOR, THAT YOU INITIATED A CALL TO THE PATIENT'S WIFE; IS
25 THAT CORRECT?
4025
1 A. VONDA ALLDREDGE.
2 Q. VONDA ALLDREDGE. THAT CALL TOOK PLACE ON THE 13TH?
3 A. YES, SIR.
4 Q. DO YOU REFERENCE THAT CALL IN YOUR NOTES?
5 A. I DO, ON THE 13TH.
6 Q. CAN YOU TELL ME WHICH PAGE YOU REFERENCE THAT ON?
7 A. 0017.
8 Q. NOW, IS THIS UNDER PROGRESS NOTES?
9 A. YES, SIR.
10 Q. OKAY. 00 WHAT?
11 A. IT LOOKS LIKE 17.
12 Q. AGAIN, IS THERE A TIME ON THAT NOTE?
13 A. NO, THERE'S NOT.
14 Q. DO YOU HAVE ANY INDEPENDENT RECOLLECTION OF THAT
15 CONVERSATION OTHER THAN YOUR NOTES?
16 A. I SPOKE WITH MS. ALLDREDGE THAT DAY, YES, I DID.
17 Q. YOU WHAT?
18 A. I SPOKE WITH MS. ALLDREDGE THAT DAY, I TALKED ABOUT THAT
19 YESTERDAY.
20 Q. AS I UNDERSTAND YOUR TESTIMONY, THAT CONVERSATION TOOK
21 PLACE NOT OVER THE PHONE BUT IN THE HOSPITAL?
22 A. YES. THERE WAS A PHONE CALL MADE AND THEN WE SPOKE
23 LATER IN THE HOSPITAL.
24 Q. DO YOU REMEMBER TELLING HER THAT YOU THOUGHT ENNIS HAD
25 SUFFERED A MASSIVE STROKE?
4026
1 A. I DON'T KNOW IF I USED THE WORD MASSIVE STROKE BUT I
2 TOLD HER THAT HE HAD A -- FROM WHAT I COULD TELL THAT HE HAD
3 A STROKE.
4 Q. I WANT YOU TO TURN TO MED-PAGE 0027.
5 A. OKAY.
6 Q. THIS IS THE FROM THE DEPARTMENT OF THE DIAGNOSTIC
7 IMAGING. THIS IS THE M.R.I. OF THE BRAIN OF ENNIS
8 ALLDREDGE, IS IT NOT?
9 A. IT IS. IT'S THE REPORT.
10 Q. THIS WAS THE REPORT YOU REFERRED TO EARLIER IN YOUR
11 TESTIMONY, CORRECT?
12 A. YES, SIR.
13 Q. IT SAYS, PATIENT WAS SEDATED BUT STILL COMBATIVE AND
14 WOULD NOT LAY STILL. AS A RESULT, THE STUDY IS QUITE
15 COMPROMISED DUE TO MOTION, CORRECT?
16 A. THAT'S WHAT IT SAYS.
17 Q. THEN IT GOES DOWN FURTHER AND AT THE BOTTOM, QUESTION OF
18 INFARCTION INVOLVING THE LEFT OCCIPITAL AND GRAY MATTER. I
19 CANNOT PRECISELY DATE THIS POSSIBLE INFARCTION, ALTHOUGH
20 THERE COULD BE SOME EARLY COMPRESSION OF THE OCCIPITAL HORN
21 SUGGESTING ACUTE TO SUBACUTE EVENT. CLINICAL CORRELATION
22 URGED AND FOLLOW UP WITH CT OR LATER MAGNETIC RESONANCE
23 IMAGING WITH BETTER SEDATION MAY BE USEFUL.
24 NOW, DOCTOR, DOESN'T THAT NOTE INDICATE THAT THIS WAS A
25 COMPROMISED RADIOLOGY -- OR I SHOULD SAY X-RAY?
4027
1 A. THAT'S WHAT IT SAYS.
2 Q. OR M.R.I.?
3 A. IT USES THE WORD COMPROMISED.
4 Q. AND DOESN'T THAT MEAN TO YOU THAT IN TERMS OF ERRING ON
5 THE SIDE OF CAUTION A FURTHER STUDY SHOULD HAVE BEEN DONE TO
6 VERIFY WHETHER OR NOT INDEED THERE WAS A OCCIPITAL
7 INFARCTION OF THAT NATURE?
8 A. NO, SIR. IT SAYS CLINICAL CORRELATION IS RECOMMENDED
9 AND I DID THAT. I MADE A JUDGMENT WITH THE FAMILY, I TOLD
10 THEM WHAT THIS WAS AND WHAT IT MEANT.
11 Q. DID YOU CALL IN A CONSULT ON THAT?
12 A. NO, SIR.
13 Q. SO YOU DIDN'T HAVE THE RADIOLOGIST OR ANY OTHER
14 PHYSICIAN REVIEW THAT WITH YOU?
15 A. WELL, THE RADIOLOGIST REVIEWED IT AND GAVE THIS REPORT.
16 Q. HE GAVE HIS REPORT. BUT YOU DIDN'T CALL ANYBODY ELSE IN
17 TO GET ANY INDEPENDENT JUDGMENT FROM SOME OTHER PARTY AS TO
18 THIS BEING A COMPROMISED M.R.I.?
19 A. BASICALLY I ORDERED THE M.R.I. BECAUSE IT LOOKED LIKE HE
20 HAD A STROKE AND IT'S SHOWING A STROKE. IT'S COMPROMISED,
21 IT'S NOT PERFECT. BUT, NO, I DIDN'T THINK THAT I NEEDED TO
22 GET A CONSULT.
23 Q. AGAIN, DOCTOR, YOU PREVIOUSLY TESTIFIED ON MARY CRANE
24 YOU WERE NOT COMFORTABLE WITH ORDERING AN ANTIBIOTIC FOR
25 MARY CRANE BUT YOU DID FEEL COMFORTABLE IN THIS PARTICULAR
4028
1 SETTING IN MAKING A DETERMINATION THAT THIS INDIVIDUAL HAD
2 SUFFERED A STROKE?
3 A. I DIDN'T FEEL PARTICULARLY UNCOMFORTABLE WITH ORDERING
4 AN ANTIBIOTIC FOR MARY CRANE AND I ACTUALLY DID ORDER IT. I
5 SIMPLY THOUGHT IT WOULD BE BETTER TO HAVE DR. DIENHART DO
6 THAT. WITH RESPECT TO THIS M.R.I., AS PART OF PSYCHIATRY,
7 YOU STUDY A LOT OF NEUROLOGY, YOU SEE A LOT OF STROKES AND I
8 SAW A STROKE AND I ORDERED AN M.R.I. AND IT WAS BEING
9 CONFIRMED BY THIS. IT'S NOT A PERFECT CONFIRMATION BUT IT
10 WAS VERY GOOD EVIDENCE OF A STROKE.
11 Q. BUT YOU, IN FACT, DIDN'T FOLLOW THE RECOMMENDATION, DID
12 YOU?
13 A. WHAT RECOMMENDATION IS THAT, TO GET ANOTHER?
14 Q. THE RECOMMENDATION MADE TO HAVE FURTHER -- A FURTHER
15 M.R.I. DONE, DID YOU?
16 A. I FOLLOWED THE RECOMMENDATION TO CLINICALLY CORRELATE.
17 Q. WHO DID YOU CLINICALLY CORRELATE WITH?
18 A. IT DOESN'T RECOMMEND A C.T. OR ANOTHER -- IT DOESN'T
19 RECOMMEND THAT AT ALL. IT SAYS FOLLOW-UP MAY BE USEFUL.
20 Q. BUT THE QUESTION WAS: WHO DID YOU CLINICALLY CORRELATE
21 WITH? AS I RECALL YOUR TESTIMONY, YOU SAID YOU TALKED TO
22 THE FAMILY.
23 A. BY THAT I MEAN I LOOKED AT THE PATIENT AND LOOKED AT
24 WHAT HE WAS EXHIBITING.
25 Q. I SEE. SO THE CLINICAL CORRELATION WAS DONE WITH YOUR
4029
1 LOOKING AT THE PATIENT?
2 A. ABSOLUTELY.
3 Q. AND THEN YOU REPORTED YOUR FINDINGS TO VONDA ALLDREDGE;
4 IS THAT CORRECT?
5 A. I DID, YES, SIR.
6 Q. AND VONDA ALLDREDGE, THE DISCUSSION YOU HAD WITH HER
7 TOOK PLACE AT THE HOSPITAL TO YOUR RECOLLECTION?
8 A. SATURDAY MORNING, THE 13TH.
9 Q. DID YOU -- WELL, LET'S TURN TO MEDICAL/LEGAL IF WE CAN
10 FOR A SECOND. CALLING YOUR ATTENTION TO PAGE 00085.
11 A. OKAY.
12 Q. IT'S ENTITLED MEDICAL TREATMENT PLAN AND THIS APPARENTLY
13 WAS DONE BACK IN OCTOBER OF 1995 WITH DR. CUNNINGHAM WHO WAS
14 THE TREATING PHYSICIAN FOR ENNIS ALLDREDGE; IS THAT CORRECT?
15 A. YES, IT IS.
16 Q. HAD YOU HAD THE OPPORTUNITY TO REVIEW THAT DOCUMENT
17 PREVIOUS TO YOUR DISCUSSION WITH VONDA ALLDREDGE?
18 A. YES.
19 Q. NOW, IT INDICATES THAT -- THIS WAS FILLED OUT SOMETIME
20 BEFORE HIS HOSPITALIZATION. I TAKE IT THERE WERE NO OTHER
21 RECORDS FROM THE HOSPITAL OTHER THAN THIS PARTICULAR ADVANCE
22 DIRECTIVE; IS THAT CORRECT?
23 A. I CAN'T SAY FOR SURE. HE HAD ANOTHER ONE, I DON'T KNOW
24 IF IT WAS IN THE HOSPITAL. IT MAY HAVE BEEN IN THE HOSPITAL
25 AND NOT IN HIS CHART.
4030
1 Q. HE HAD ANOTHER ONE?
2 A. YES, SIR, I'VE SEEN IT.
3 Q. HOW WERE YOU AWARE OF THAT?
4 A. I'VE SEEN THAT SINCE THAT DAY. I DON'T KNOW IF IT WAS
5 THERE THEN.
6 Q. YOU'VE SEEN THAT SINCE THEN?
7 A. UH-HUH.
8 Q. THE ONLY RECOLLECTION YOU HAVE IS THIS PARTICULAR
9 DOCUMENT ON THAT DATE; IS THAT RIGHT, GOING BACK TO THE 13TH
10 OF JANUARY OF 1996?
11 A. I'M NOT SURE I UNDERSTAND THAT QUESTION.
12 Q. WELL, YOU PREVIOUSLY TESTIFIED YOU REVIEWED THIS
13 DOCUMENT BEFORE YOUR DISCUSSION WITH VONDA ALLDREDGE?
14 A. YES, SIR, I WOULD HAVE.
15 Q. THERE'S NO INDICATION OF THAT IN THE RECORD, IS THERE?
16 A. THAT I REVIEWED THE DOCUMENT?
17 Q. UH-HUH.
18 A. NO, SIR.
19 Q. BECAUSE THIS DOCUMENT WAS NOT PREPARED BY THE HOSPITAL,
20 CORRECT?
21 A. IT APPEARS TO HAVE COME FROM SOMEWHERE ELSE. SAME FORM
22 BUT DR. CUNNINGHAM I DON'T THINK WAS AT THAT HOSPITAL.
23 Q. NOW, IT STATES IN THE BODY OF THE DOCUMENT, THE
24 FOLLOWING CARE AND TREATMENT OR WITHHOLDING OF TREATMENT IS
25 DIRECTED WITH RESPECT TO THE DECLARANT, NO CPR, WHICH I
4031
1 ASSUME IS CARDIOPULMONARY RESUSCITATION, CORRECT?
2 A. YES, SIR.
3 Q. AND NO RESPIRATORS?
4 A. CORRECT.
5 Q. DOCTOR, IT'S TRUE, IS IT NOT, THAT DIRECTIVE DOES NOT
6 DIRECT YOU TO WITHHOLD ANY I.V.'S, FLUIDS, DOESN'T PROHIBIT
7 YOU FROM RENDERING TREATMENT OTHER THAN CPR AND RESPIRATORS,
8 CORRECT?
9 A. CORRECT.
10 Q. BUT YET AS I UNDERSTAND YOUR TESTIMONY, YOU ORDERED THE
11 WITHHOLDING OF THE MEDICATIONS, YOU ORDERED THE WITHHOLDING
12 OF THE I.V.'S AND YOU REDUCED THE DILANTIN, CORRECT -- OR
13 NOT DILANTIN -- THE INSULIN?
14 A. INSULIN, YES, SIR.
15 Q. IF A PERSON IS DIABETIC AND YOU REDUCE OR TAKE AWARE
16 THEIR INSULIN, DOES THAT NOT CREATE IN AND OF ITSELF A RISK
17 OF DEATH?
18 A. YES, SIR.
19 Q. NOW, IN ADDITION TO THAT, WE START ON THE 13TH A REGIMEN
20 OF ADMINISTRATION OF MORPHINE, CORRECT?
21 A. CORRECT.
22 Q. AND THAT'S ORDERED AS I RECALL AT 10 MILLIGRAMS EVERY,