Sheila Heward
5 MR. WILSON: CALL SHEILA HEWARD.
6 THE COURT: OKAY. IF YOU'LL COME FORWARD AND BE
7 SWORN.
8 SHEILA K. HEWARD,
9 BEING FIRST DULY SWORN, WAS EXAMINED AND TESTIFIED
10 AS FOLLOWS:
11 DIRECT EXAMINATION
12 BY MR. WILSON:
13 Q. MS. HEWARD, WOULD YOU STATE YOUR FULL NAME FOR THE
14 RECORD, PLEASE?
15 A. SHEILA K. HEWARD.
16 Q. AND WHERE ARE YOU CURRENTLY EMPLOYED?
17 A. DAVIS HOSPITAL AND MEDICAL CENTER.
18 Q. IN WHAT CAPACITY?
19 A. I'M THE DIRECTOR OF QUALITY AND RISK MANAGEMENT.
20 Q. HOW LONG HAVE YOU BEEN EMPLOYED AT THE DAVIS HOSPITAL IN
21 THAT CAPACITY?
22 A. JUST OVER 2 YEARS.
23 Q. OKAY. COULD YOU GIVE US A BRIEF STATEMENT RELATIVE TO
24 YOUR CREDENTIALS -- WELL, FIRST OF ALL, LET ME ASK IT THIS
25 WAY. HOW LONG HAVE YOU BEEN EMPLOYED IN HOSPITAL TYPE
87
1 SERVICES?
2 A. SINCE 1975.
3 Q. OKAY. DO YOU HAVE -- CAN YOU GIVE US A BRIEF BACKGROUND
4 AS TO ANY EDUCATIONAL CREDENTIALS THAT YOU HAVE IN -- IN
5 RESPECT TO THAT FIELD?
6 A. I HAVE A BACHELOR'S OF SCIENCE DEGREE IN CLINICAL
7 LABORATORY PATHOLOGY; I'VE GOT A MASTER'S DEGREE IN HEALTH
8 CARE ADMINISTRATION; AND I'M A CERTIFIED HEALTH CARE
9 EXECUTIVE, BOARD CERTIFIED IN HOSPITAL MANAGEMENT.
10 Q. OKAY. DO YOU HOLD ANY OTHER CERTIFICATIONS?
11 A. I'M A SPECIALIST IN HOSPITAL QUALITY, CERTIFIED
12 PROFESSIONAL IN HEALTH CARE QUALITY.
13 Q. OKAY. IN TERMS OF YOUR EXPERIENCE IN THE HOSPITAL
14 FIELD, COULD YOU GIVE US A BRIEF OUTLINE OF WHAT YOUR
15 EXPERIENCES ENTAIL?
16 A. I WORKED FOR ABOUT 12 YEARS IN THE LABORATORY IN VARIOUS
17 CAPACITIES. I'VE BEEN THE MANAGER OF A COUPLE OF DIFFERENT
18 DEPARTMENTS IN ENVIRONMENTAL SERVICES AND SUPPORT SERVICES,
19 AND I'VE BEEN IN THIS KIND OF ROLE AS THE DIRECTOR OF
20 QUALITY AND RISK MANAGEMENT SINCE 1992.
21 Q. OKAY. PRIOR TO COMING TO DAVIS HOSPITAL, WHAT HOSPITAL
22 DID YOU OCCUPY THAT POSITION AT?
23 A. I WORKED AT TWO DIFFERENT HOSPITALS FOR INTERMOUNTAIN
24 HEALTH CARE, ONE IN POCATELLO FOR 21 YEARS AND ONE IN SALT
25 LAKE CITY, EXCUSE ME, FOR TWO YEARS.
88
1 Q. OKAY. THANK YOU. PRESENTLY AS THE DIRECTOR OF QUALITY
2 AND RISK MANAGEMENT, WHAT ARE YOUR DUTIES AND
3 RESPONSIBILITIES? WHAT DO THEY ENTAIL?
4 A. THERE ARE SEVERAL DIFFERENT ROLES THAT THIS POSITION
5 FILLS. ONE OF THEM IS HOSPITAL AND MEDICAL STAFF QUALITY
6 MONITORING. I'M THE HOSPITAL RISK MANAGER. I OVERSEE
7 WORKER'S COMPENSATION, UTILIZATION REVIEW, INFECTION
8 CONTROL, SOCIAL SERVICES, AND DISCHARGE PLANNING.
9 Q. OKAY. SO I WOULD TAKE IT FROM THAT POSITION YOU'RE --
10 YOU'RE FAMILIAR WITH ALL ASPECTS AND ALL OPERATIONAL PARTS
11 OF THE HOSPITAL?
12 A. FOR THE MOST PART, YES.
13 Q. OKAY. ARE THERE ANY PARTS OF THE HOSPITAL OPERATION
14 THAT YOU'RE NOT FAMILIAR WITH?
15 A. NOT THAT I CAN THINK OF.
16 Q. OKAY. PERHAPS BEFORE WE GO ANY FURTHER YOU COULD
17 FAMILIARIZE THE JURY WITH THE PHYSICAL FACILITY ITSELF. CAN
18 YOU DESCRIBE FOR US WHAT THE PHYSICAL FACILITY OF DAVIS
19 HOSPITAL IS LIKE, HOW MANY FLOORS IT HAS?
20 A. THERE'S FOUR FLOORS, THREE OF WHICH CONTAIN PATIENT CARE
21 AREAS. THE SECOND FLOOR IS O.B. AND POSTPARTUM; THE THIRD
22 FLOOR HAS MULTIPLE UNITS ON IT: THE C.C.U., TELEMETRY,
23 PEDIATRICS, SKILLED NURSING FACILITY, AND GEROPSYCH. AND
24 THE FOURTH FLOOR IS MED/SURG.
25 Q. OKAY. SO THE ONES YOU DELINEATED AS THE SPECIALTY
89
1 UNITS, THOSE WERE LOCATED ON THE THIRD FLOOR?
2 A. CORRECT.
3 Q. OKAY. AND ARE ANY OF THESE UNITS -- WELL, FIRST OF ALL,
4 LET'S -- LET'S DESCRIBE FOR THE JURY, IF YOU WOULD, IN
5 PARTICULAR ON THE THIRD FLOOR YOU'VE INDICATED A NUMBER OF
6 UNITS THAT OPERATE ON THAT FLOOR.
7 A. CORRECT.
8 Q. COULD YOU DESCRIBE FOR THEM WHAT TYPE OF UNITS AGAIN
9 THAT ARE ON THAT THIRD FLOOR?
10 A. THE C.C.U./I.C.U. IS A CRITICAL CARE AND INTENSIVE CARE
11 UNIT.
12 THE SKILLED NURSING FACILITY IS A UNIT THAT OFTEN TAKES
13 PATIENTS THAT HAVE HAD SURGERY AND THEY GO THERE FOR SOME
14 SHORT-TERM REHAB TO BE ABLE TO RETURN TO THEIR PREVIOUS
15 LEVEL OF FUNCTIONING AFTER THEY'VE LEFT THE HOSPITAL.
16 TELEMETRY IS KIND OF A STEP TO THE CRITICAL CARE UNIT.
17 IT'S A FLOOR THAT HAS SOME MONITORING EQUIPMENT PUT IN IT SO
18 THAT YOU CAN PUT PATIENTS ON A CARDIAC MONITOR AND WATCH
19 THEIR CARDIAC ACTIVITY. OFTENTIMES IF SOMEONE'S IN THE
20 CRITICAL CARE UNIT SAY SUFFERING FROM A HEART ATTACK, THEY
21 WILL GO FROM THE C.C.U. TO THE TELEMETRY UNIT BEFORE THEY'RE
22 DISCHARGED.
23 OF COURSE, THERE'S PEDIATRICS, AND THEN THERE'S THE
24 GEROPSYCHIATRIC UNIT WHICH IS A TEN-BED UNIT FOR GENERALLY
25 OVER-65 PATIENTS THAT ARE SUFFERING FROM PSYCHOSES,
90
1 DEMENTIA, DEPRESSION, THINGS OF THAT NATURE.
2 Q. IN TERMS OF THE GEROPSYCH UNIT, CAN YOU TELL US WHAT
3 TYPES OF -- OF EQUIPMENT AND SERVICES ARE PROVIDED IN THE
4 GEROPSYCH UNIT?
5 A. THE GERO --
6 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT.
7 RELEVANCY.
8 MR. WILSON: I THINK, YOUR HONOR --
9 MR. STIRBA: MAY I VOIR DIRE?
10 MR. WILSON: -- IT'S TOTALLY FOUNDATIONAL.
11 THE COURT: OKAY. GO AHEAD AND VOIR DIRE.
12 MR. STIRBA: YEAH.
13 VOIR DIRE EXAMINATION
14 BY MR. STIRBA:
15 Q. MS. HEWARD, MY UNDERSTANDING YOU BECAME EMPLOYED AT
16 DAVIS HOSPITAL WITHIN THE LAST TWO YEARS; IS THAT RIGHT?
17 A. LITTLE OVER TWO YEARS AGO.
18 Q. AND SO YOU STARTED WHEN?
19 A. IN MAY OF '98.
20 Q. OKAY. PRIOR TO THAT TIME, FOR EXAMPLE THE TIME PERIOD
21 OF '95 THROUGH '96, YOU WEREN'T EMPLOYED AT THE HOSPITAL,
22 TRUE?
23 A. CORRECT.
24 MR. STIRBA: THAT'S ALL, YOUR HONOR.
25 MR. WILSON: AGAIN, YOUR HONOR, WE -- WE'D JUST
91
1 INDICATE IT'S FOUNDATIONAL. I CAN ASK SOME FURTHER
2 QUESTIONS FOR PURPOSES OF PREPARATION -- OR FOR FOUNDATION
3 ON THAT.
4 THE COURT: OKAY. YOU CAN DO THAT.
5 DIRECT EXAMINATION, CONT'D
6 BY MR. WILSON:
7 Q. HAVE YOU HAD AN OPPORTUNITY TO REVIEW THE RECORDS IN
8 CONNECTION WITH THIS MATTER THAT WERE MAINTAINED AT THE
9 GEROPSYCH UNIT?
10 A. YES, I HAVE.
11 Q. AND HAVE YOU DONE AN EXTENSIVE REVIEW OF THOSE RECORDS?
12 A. YES, I HAVE.
13 Q. WHAT RECORDS HAVE YOU REVIEWED IN CONNECTION WITH THE
14 OPERATION OF THE UNIT?
15 A. WITH THE OPERATION OF THE UNIT?
16 Q. WELL, THE OPERATION OF THE UNIT ITSELF AND ALSO WITH --
17 WITH -- HAVE YOU HAD OCCASION TO ALSO VIEW THE UNIT ITSELF?
18 A. ABSOLUTELY. YES.
19 Q. ARE YOU AWARE THAT ANY CHANGES HAVE BEEN MADE IN THE
20 PHYSICAL LAYOUT OF THE UNIT SINCE YOUR -- IN RESPECT TO YOUR
21 INVESTIGATION OF THE UNIT?
22 A. THERE'S BEEN NO CHANGES SINCE IT WAS OPENED.
23 Q. OKAY. IN RESPECT TO THE OPERATION OF THE UNIT, HAVE YOU
24 ALSO HAD AN OPPORTUNITY TO REVIEW RECORDS RELATED TO THE
25 CRITERIA FOR THE OPERATION OF THE UNIT?
92
1 A. I'VE -- I KNOW WHAT THE CRITERIA ARE. I VIEWED THE
2 CRITERIA THAT'S CURRENTLY IN PLACE.
3 Q. OKAY. HAVE YOU EVER VIEWED THE CRITERIA THAT WERE IN
4 PLACE BACK IN 1995?
5 A. NO, I HAVE NOT.
6 Q. OKAY. IN RESPECT TO THE UNIT ITSELF, DESCRIBE THE
7 PHYSICAL LAYOUT THEN.
8 A. THE UNIT IS A TEN-BED UNIT WITH FIVE PATIENT ROOMS WITH
9 TWO PATIENTS PER ROOM. THERE'S A NURSES' STATION AND KIND
10 OF A DAY ROOM WHERE THEY DO A LOT OF THE GROUP COUNSELLING,
11 GROUP MEETINGS OF THAT NATURE. OF COURSE, THERE'S A SUPPLY
12 ROOM AND A NURSES' STATION AS WELL.
13 Q. OKAY. IN RESPECT TO THE UNIT, ARE THERE ANY DOORS THAT
14 ARE LOCKED?
15 A. THERE ARE TWO SETS OF DOORS, ONE AT EACH END -- A PAIR
16 AT EACH END OF THE UNIT THAT ARE LOCKED SO THAT PATIENTS MAY
17 NOT LEAVE THE UNIT WITHOUT THE KNOWLEDGE OF THE STAFF.
18 Q. OKAY. NOW, IN TERMS OF THE PHYSICAL LAYOUT OF THE UNIT,
19 CAN YOU TELL US WHAT UNIT IS LOCATED IN CONJUNCTION OR NEXT
20 TO THAT UNIT?
21 A. IMMEDIATELY NEXT TO IT IS THE SKILLED NURSING FACILITY.
22 Q. OKAY. AND ARE YOU FAMILIAR WITH WHAT GOES ON IN THE
23 SKILLED NURSING CENTER?
24 A. AGAIN, THAT UNIT IS DESIGNED FOR PATIENTS THAT HAVE
25 ALREADY BEEN A PATIENT IN THE HOSPITAL AND DON'T NEED AN
93
1 ACUTE LEVEL OF CARE, BUT NEED SOME SHORT-TERM CARE,
2 PRIMARILY THINGS LIKE PHYSICAL THERAPY. FOR INSTANCE, IF A
3 PATIENT HAS A TOTAL HIP REPLACEMENT, AFTER THEY'RE
4 DISCHARGED FROM THE MEDICAL-SURGICAL UNIT THEY OFTEN GO TO
5 THE SNF TO GET PHYSICAL THERAPY, OCCUPATIONAL THERAPY,
6 THINGS OF THAT NATURE TO HELP THEM GET STRONGER BEFORE
7 THEY'RE DISCHARGED.
8 Q. AND WHERE IS THE CRITICAL CARE UNIT LOCATED IN PROXIMITY
9 TO IT?
10 A. IT'S AT THE OTHER END OF THE UNIT.
11 Q. OKAY. IN RESPECT TO BEING AT THE OTHER END OF THE UNIT,
12 ARE WE TALKING SOME DISTANCE THERE?
13 A. IT'S ABOUT AS FAR FROM THE GEROPSYCH UNIT AS YOU CAN
14 GET.
15 Q. OKAY. AND --
16 A. ON THAT FLOOR.
17 Q. OKAY. CAN YOU TELL US IN FEET WHAT YOU WOULD
18 APPROXIMATE?
19 A. PROBABLY 250.
20 Q. OKAY.
21 A. 300 MAYBE.
22 Q. AND IS THERE HALLWAYS LINKING THESE VARIOUS UNITS?
23 A. UH-HUH. YES, THERE ARE.
24 Q. OKAY. NOW, LET'S TALK A LITTLE BIT ABOUT THE PATIENT
25 RECORDS THAT ARE MAINTAINED AT THE HOSPITAL. ARE YOU
94
1 FAMILIAR WITH HOW THE PATIENT RECORDS ARE MAINTAINED?
2 A. YES, I AM.
3 Q. AND IN RESPECT TO THE PATIENT RECORDS THEMSELVES, DO YOU
4 HAVE ANY AUTHORITY OR CUSTODY OVER THOSE RECORDS?
5 A. I'M NOT THE PRIMARY CUSTODIAN, NO.
6 Q. OKAY. IN -- IN RESPECT TO THE RECORDS, DO YOU HAVE
7 ACCESS TO THEM?
8 A. YES, I DO.
9 Q. HAVE YOU, AS A RESULT OF THIS INVESTIGATION, HAD THE
10 OPPORTUNITY TO REVIEW THOSE RECORDS ON A NUMBER OF
11 OCCASIONS?
12 A. YES, I HAVE.
13 Q. OKAY. FIRST OF ALL, I WANT YOU TO DELINEATE, IF YOU
14 WILL, THE TYPES OF -- WELL, LET'S -- LET'S JUST TALK ABOUT
15 ONE TYPE OF RECORD FIRST. THEY MAINTAIN PATIENT RECORDS.
16 A. CORRECT.
17 Q. IS THAT CORRECT?
18 A. YES.
19 Q. CAN YOU TELL US WHAT TYPES OF INFORMATION ARE MAINTAINED
20 IN THOSE PATIENT RECORDS?
21 A. THE FIRST THING THAT'S IN A PATIENT'S MEDICAL RECORD IS
22 A DOCUMENT THAT CONTAINS DEMOGRAPHIC INFORMATION: THE
23 PATIENT'S NAME, ADDRESS, PHONE NUMBER, SOCIAL SECURITY
24 NUMBER, DATE OF BIRTH, DOCTOR THAT'S ADMITTING THEM FOR THAT
25 PARTICULAR VISIT, INSURANCE INFORMATION.
95
1 Q. OKAY.
2 A. IN ADDITION TO THAT, THERE WILL BE -- AND I'M GOING TO
3 DESCRIBE A CHART THAT IS COMPLETE. THE PATIENT'S LEFT THE
4 HOSPITAL AND THE RECORD IS COMPLETE.
5 Q. OKAY.
6 A. THERE WILL BE A DISCHARGE SUMMARY, THERE'LL BE A HISTORY
7 AND PHYSICAL. IN THE CHARTS WITH RESPECT TO THIS PARTICULAR
8 CASE THERE WOULD BE A PSYCHIATRIC EVALUATION. THERE'S
9 GENERALLY SEVERAL PAGES OF PHYSICIAN PROGRESS NOTES AND
10 PHYSICIAN ORDERS. THERE'S LABORATORY AND X-RAY RESULTS. IF
11 ANY THERAPY, SOCIAL SERVICES, THINGS OF THAT NATURE, THEY
12 WOULD HAVE NOTES IN THE RECORD. THERE'S NURSING RECORDS,
13 THERE'S MEDICAL -- MEDICATION ADMINISTRATION RECORDS.
14 Q. OKAY.
15 A. THAT'S PRETTY MUCH IT.
16 Q. IN RESPECT TO THOSE RECORDS, CAN YOU TELL US HOW ARE
17 THOSE RECORDS MAINTAINED OR HOW ARE THEY FORMED?
18 A. HOW ARE THEY FORMED?
19 Q. YEAH.
20 A. WHEN THE PATIENT --
21 Q. ASSUMING -- ASSUMING A PATIENT IS ADMITTED TO THE
22 GEROPSYCH UNIT, HOW WOULD THAT RECORD BE COMPLETED?
23 A. OKAY. THE -- A COPY OF THAT DEMOGRAPHIC INFORMATION
24 THAT I DESCRIBED TO YOU WOULD BE -- WOULD GO TO THE UNIT
25 WITH THE PATIENT. AND ON THE UNIT THEY WOULD COMPILE A
96
1 CHART THAT HAS A NUMBER OF DIVIDERS AND THEY'D BE PUTTING
2 BLANK PAGES IN THERE, LIKE SEVERAL BLANK PAGES FOR THE
3 PHYSICIAN'S PROGRESS NOTES AND ORDERS, SEVERAL PAGES FOR
4 NURSING NOTES. AND AS THE PATIENT -- AS THE PATIENT'S STAY
5 LENGTHENS, MORE AND MORE OF THOSE GET PUT INTO THE CHART AS
6 NEEDED. AS LABORATORY RESULTS COME UP, THEY'RE ADDED TO THE
7 CHART; X-RAY -- THE INTERPRETATION OF X-RAYS, THAT WILL COME
8 UP; E.K.G.'S, IF THEY'RE DONE, RECORDS OF THAT GO INTO THE
9 RECORD. SO OVER THE COURSE OF THE PATIENT'S STAY IT GETS
10 BIGGER AND BIGGER.
11 Q. AND SO ALL OF THOSE COMPONENTS OF THE PATIENT'S MEDICAL
12 RECORD ARE MAINTAINED RIGHT ON THE UNIT ITSELF?
13 A. THAT'S RIGHT.
14 Q. AND ALL OF THE ENTRIES THEN WOULD BE ENTERED IN -- IN
15 THAT PARTICULAR UNIT ITSELF?
16 A. THAT'S RIGHT.
17 Q. OKAY. IN RESPECT TO THE VARIOUS TYPES OF RECORDS, CAN
18 YOU TALK A LITTLE BIT ABOUT WHAT IS CONTAINED IN THE NURSES'
19 NOTES? WHAT IS THAT SUPPOSED TO BE ABOUT?
20 A. THE NURSES' NOTES IS SEVERAL DIFFERENT THINGS. THEY'RE
21 USUALLY A MULTISURFACE, MULTIPAGE DOCUMENT THAT INCLUDES
22 RESULTS OF THE PATIENT ASSESSMENT AT THE VARIOUS TIMES
23 DURING THE DAY. IT WILL CONTAIN BLOOD PRESSURE, PULSE,
24 RESPIRATIONS, TEMPERATURE, A GRAPHIC CHART FOR THAT KIND OF
25 DATA, AND THEN THERE'S A PLACE FOR THEM TO WRITE NARRATIVE
97
1 ABOUT WHAT'S GOING ON WITH THE PATIENT.
2 Q. OKAY. IF A -- IN THE -- IN THE -- SO IS THAT PART OF
3 THE PROGRESS NOTES?
4 A. NO. THOSE ARE THE NURSING NOTES OR THE PATIENT CARE
5 NOTES.
6 Q. OKAY.
7 A. THEY'RE -- EITHER WAY.
8 Q. WHAT IS THE PROGRESS NOTE?
9 A. THE PROGRESS NOTE IS A FORM THAT IS -- ON WHAT -- IT'S
10 GOT TWO COLUMNS. ON ONE SIDE IS WHERE THE PHYSICIAN
11 DOCUMENTS PROGRESS NOTES AFTER THE PHYSICIAN HAS SEEN THE
12 PATIENT DURING THE COURSE OF A STAY WHILE THEY'RE IN THE
13 HOSPITAL; AND ON THE OTHER SIDE OF THAT IS A PLACE FOR THE
14 PHYSICIAN TO WRITE ORDERS.
15 Q. OKAY. SO IF A PHYSICIAN WRITES AN ORDER FOR A CERTAIN
16 TYPE OF MEDICATION, THAT WOULD BE CONTAINED IN THAT
17 PARTICULAR DOCUMENT?
18 A. YES, IT WOULD.
19 Q. WOULD IT BE CONTAINED IN ANY OTHER DOCUMENTS IN THE
20 PATIENT RECORD?
21 A. THE ORDER?
22 Q. YES.
23 A. NO.
24 Q. WHAT ABOUT VERIFICATION THAT THE ORDER WAS INDEED
25 ADMINISTERED?
98
1 A. WHEN A PHYSICIAN WRITES AN ORDER AN R.N. ON THE UNIT
2 WILL NOTE IT. THEY USUALLY DRAW A LINE ACROSS THE BOTTOM OF
3 IT AND WRITE THEIR SIGNATURE AS NOTED. AND THEN IN THE CASE
4 OF A MEDICATION THEN THEY WOULD NOTIFY PHARMACY AND EITHER
5 THEY OR PHARMACY WOULD ADD IT TO THAT MEDICATION
6 ADMINISTRATION RECORD.
7 Q. OKAY. IN RESPECT TO THE DOCTOR'S NOTES, DOES HE HAVE A
8 SEPARATE SECTION OTHER THAN THE PROGRESS NOTES AND THE
9 ORDERS?
10 A. IN SOME CASES. WITH THESE PATIENTS THERE WAS A DOCUMENT
11 CALLED THE INTERDISCIPLINARY RECORD, I BELIEVE, WHERE
12 MULTIPLE DISCIPLINE IS DOCUMENTED ON IT, MADE HANDWRITTEN
13 NARRATIVE NOTES.
14 Q. OKAY. LET ME ASK YOU, IN CONNECTION WITH THOSE PATIENT
15 RECORDS, IS -- IS THERE ANY BILLING INFORMATION THAT'S
16 CONTAINED IN THOSE RECORDS?
17 A. THE ONLY THING THAT HAS TO DO WITH BILLING IS THAT
18 DEMOGRAPHIC PAGE I MENTIONED. IT'S GOT THE -- THE ADDRESS,
19 TELEPHONE NUMBER, SOCIAL SECURITY NUMBER, THE PATIENT. IT
20 HAS THEIR INSURANCE COMPANY, NEXT OF KIN. THEY MIGHT HAVE
21 AN INSURANCE COMPANY NUMBER ON THEM, BUT BEYOND THAT, NO.
22 Q. OKAY. ARE THERE OTHER RECORDS THAT ARE MAINTAINED ON
23 THE UNIT BESIDES THE PATIENT RECORDS?
24 A. THERE'S A SET OF RECORDS CALLED THE CONTROLLED
25 SUBSTANCES LOG.
99
1 Q. OKAY.
2 A. THAT IS A LOG WHERE CONTROLLED SUBSTANCES SUCH AS
3 NARCOTICS ARE LOGGED AS SOON -- THE PHARMACY STOCKS THE UNIT
4 WITH A CERTAIN COMPLEMENT OF MEDICATION. SOME OF THOSE ARE
5 CONTROLLED SUBSTANCES. BECAUSE OF THE NATURE OF CONTROLLED
6 SUBSTANCES, WE HAVE TO ACCOUNT FOR EVERY BIT OF THE
7 MEDICATION.
8 SO IF YOU HAD A CONTROLLED SUBSTANCE THAT WAS
9 PRESCRIBED FOR A PATIENT AND SAY MOST OF A SMALL VIAL WAS
10 USED FOR A DOSE ON A PATIENT AND WHAT REMAINED IN THAT VIAL
11 WAS NOT ENOUGH TO PROVIDE ANOTHER DOSE, THEN THAT WOULD BE
12 WASTED. AND THE CONTROLLED SUBSTANCE LOG IS IF THEY TAKE
13 SOME OUT FOR A PATIENT, THEY HAVE TO WRITE DOWN THE
14 PATIENT'S NAME, THE MEDICATION, THE AMOUNT THAT WAS ORDERED
15 AND WHETHER IT WAS ADMINISTERED, AND THEN IF THERE'S ANY
16 LEFT, IT HAS TO BE WHAT WE CALL WASTED WHICH MEANS IT HAS TO
17 BE DISPOSED OF DOWN A SINK AND WITNESSED BY TWO R.N.'S.
18 Q. OKAY. NOW, IF YOU WERE -- IF YOU WERE TRYING TO --
19 WELL, LET -- LET ME REPHRASE THAT. IF YOU WERE LOOKING AT A
20 PATIENT RECORD AND YOU'RE LOOKING AT THE CONTROLLED
21 SUBSTANCES LOG, IS THERE ANYTHING IN THE PATIENT RECORD
22 WHICH WOULD CORROBORATE ANY NOTES THAT ARE SUPPOSED TO BE IN
23 THE PATIENT RECORD WHICH WOULD CORROBORATE ALSO THE NOTES
24 THAT ARE CONTAINED IN THE CONTROLLED SUBSTANCES LOG?
25 A. YES. THERE WOULD FIRST -- THERE WOULD FIRST HAVE TO BE
100
1 A PHYSICIAN ORDER FOR THE MEDICATION.
2 Q. OKAY.
3 A. AND THEN IT WOULD HAVE TO BE ADDED TO THE MEDICATION
4 ADMINISTRATION RECORD, AND IT WOULD HAVE TO BE SIGNED OFF ON
5 THE MAR BY THE NURSE SAYING THAT THE MEDICATION WAS GIVEN.
6 AND IF THAT MEDICATION WAS A CONTROLLED SUBSTANCE, THEN YOU
7 SHOULD BE ABLE TO GO TO THE CONTROLLED SUBSTANCE LOG, FIND
8 THAT PATIENT'S NAME AND BE ABLE TO CORRELATE WHEN THE
9 MEDICATION WAS TAKEN OUT OF THE LOCKED CONTAINER THAT THE
10 CONTROLLED SUBSTANCES ARE KEPT IN AND ADMINISTERED TO THE
11 PATIENT.
12 Q. AND WHOSE RESPONSIBILITY IS THAT?
13 A. AN R.N.
14 Q. OKAY. I TAKE IT THAT IN YOUR CAPACITY, AGAIN, YOU'RE
15 ALSO -- WOULD HAVE FAMILIARITY, IF NOT CONTROL, OVER THE
16 POLICIES AND PROCEDURES THAT ARE USED IN THE HOSPITAL; IS
17 THAT CORRECT?
18 A. CORRECT. I'M AWARE OF THEM; SOME OF THEM I'M
19 RESPONSIBLE FOR.
20 Q. WHICH ONES ARE YOU RESPONSIBLE FOR?
21 A. FOR THE MOST PART I'M RESPONSIBLE FOR ALL OF THE RISK
22 MANAGEMENT AND QUALITY IMPROVEMENT POLICIES AND PLANNING.
23 Q. OKAY.
24 A. I SERVE ON A COMMITTEE THOUGH THAT ROUTINELY REVIEWS,
25 AMENDS, REVISES POLICIES, SO I'M QUITE FAMILIAR WITH THE
101
1 POLICIES AND PROCEDURES OF THE HOSPITAL.
2 Q. WHERE ARE THOSE POLICIES AND PROCEDURES MAINTAINED?
3 A. EVERY DEPARTMENT HAS A SET.
4 Q. OKAY. I ASSUME YOU ALSO HAVE A SET?
5 A. YES, I DO.
6 Q. DO YOU HAVE A SET OF THOSE POLICIES AND PROCEDURES THAT
7 WERE MAINTAINED IN -- IN 1994, '95, AND '96?
8 A. I DON'T PERSONALLY HAVE THEM. THEY'RE MAINTAINED IN OUR
9 NURSING EDUCATION OFFICE.
10 Q. OKAY. YOU HAVE ACCESS TO THOSE POLICIES AND PROCEDURES?
11 A. I DO.
12 Q. AND DID YOU HAVE OCCASION TO REVIEW THE POLICIES AND
13 PROCEDURES IN CONNECTION WITH -- WITH THIS MATTER?
14 A. YES.
15 Q. GOING BACK --
16 A. SOME OF THEM, YES.
17 Q. SOME OF THEM?
18 A. UH-HUH.
19 Q. CAN YOU TELL US WHAT ONES THAT YOU REVIEWED IN
20 CONNECTION -- AT MY REQUEST IN THIS MATTER?
21 A. I -- I REVIEWED A POLICY AND PROCEDURE CALLED THE DO NOT
22 RESUSCITATE OR D.N.R. POLICY, AND THE ADVANCE DIRECTIVES
23 POLICY.
24 Q. OKAY. I SHOW YOU WHAT'S BEEN MARKED AS STATE'S EXHIBIT
25 NUMBER 1, ASK YOU TO TAKE A LOOK AT THAT, IF YOU WOULD,
102
1 PLEASE.
2 A. OKAY.
3 Q. ARE YOU FAMILIAR WITH THAT EXHIBIT?
4 A. YES, I AM.
5 Q. NOW, IN THAT EXHIBIT THERE ARE TWO SECTIONS. CAN YOU
6 DESCRIBE THOSE SECTIONS FOR US?
7 A. THE FIRST ONE IS A POLICY AND PROCEDURE ENTITLED
8 WITHHOLDING OF RESUSCITATIVE SERVICES, DO NOT RESUSCITATE
9 GUIDELINES.
10 Q. OKAY.
11 A. THE SECOND ONE IS TITLED ADVANCE DIRECTIVES, DECLARATION
12 OF LIVING WILL/SPECIAL POWER OF ATTORNEY.
13 Q. OKAY. CAN YOU TELL US WHAT THE EFFECTIVE DATE IS ON THE
14 FIRST ONE, ON THE --
15 A. THE EFFECTIVE DATE IS 7/1/93.
16 Q. AND I NOTE THAT THAT IS CONTAINED IN THE RIGHT-HAND
17 CORNER OF THE PARTICULAR DOCUMENT?
18 A. YES, IT IS.
19 Q. OKAY. IN RESPECT TO THE -- THAT PARTICULAR SECTION ON
20 THE DOCUMENT, IT ALSO INDICATES AMENDED 5/31/96?
21 A. UH-HUH.
22 Q. CAN YOU TELL US WHAT THAT MEANS?
23 A. THAT IT WAS REVIEWED AND MAY OR MAY NOT HAVE HAD MINOR
24 CHANGES IN LANGUAGE. THE SUBSTANCE OF THE POLICY HAS NOT
25 BEEN CHANGED.
103
1 Q. OKAY. DID THE DOCUMENT THAT WE'RE LOOKING AT THERE, WAS
2 THAT THE DOCUMENT THAT WAS IN EFFECT IN 1993 TO '96?
3 A. THIS PARTICULAR DOCUMENT WAS AMENDED IN 1996, SO THIS IS
4 PROBABLY SLIGHTLY DIFFERENT THAN THE ONE THAT WAS IN PLACE
5 IN '95 AND '96.
6 Q. OKAY. IN RESPECT TO THE SECOND EXHIBIT, AGAIN, THAT
7 BEARS AN EFFECTIVE DATE OF 12/91; IS THAT CORRECT?
8 A. YES, IT IS.
9 Q. AND ALSO INDICATES AN AMENDMENT BACK IN 6/93 AND 8/96?
10 A. YES.
11 Q. CAN YOU TELL US WHERE THAT DOCUMENT WAS OBTAINED?
12 A. FROM THE HOSPITAL POLICIES AND PROCEDURES.
13 Q. OKAY. THESE ALSO BEAR THE SIGNATURE AS RECOMMENDED BY,
14 I THINK ON THE FIRST ONE -- COULD YOU TELL US WHO IT WAS
15 RECOMMENDED BY?
16 A. GILBERT CAILLOUET.
17 Q. OKAY.
18 A. HE WAS THE -- A PHYSICIAN THAT WAS THE CHAIRMAN OF THE
19 MEDICINE DEPARTMENT.
20 Q. OKAY. THESE DOCUMENTS REFLECT THE POLICY OF THE
21 HOSPITAL IN RESPECT TO THE ADMINISTRATION OR THE DO NOT
22 RESUSCITATE ORDERS, AND ALSO IN RESPECT TO LIVING WILLS?
23 A. CORRECT.
24 Q. OKAY. I ASSUME THE HOSPITAL HAS A VARIETY OF POLICIES
25 AND PROCEDURES THAT THEY OPERATE UNDER?
104
1 A. YES.
2 Q. DO ANY OF THOSE POLICIES AND PROCEDURES DEAL WITH THE
3 CREDENTIALING PROCESS?
4 A. WE DO HAVE POLICIES AND PROCEDURES WITH REGARD TO THE
5 CREDENTIALING PROCESS. IN ADDITION, THERE IS EXTENSIVE
6 DOCUMENTATION IN THE MEDICAL STAFF BYLAWS THAT ADDRESSES
7 CREDENTIALING.
8 Q. OKAY. EXPLAIN TO THE JURY, IF YOU WILL -- WELL, LET
9 ME -- LET ME APPROACH IT FROM THIS STANDPOINT. IN THE
10 HOSPITAL SETTING YOU HAVE DOCTORS AND YOU HAVE NURSES AND
11 YOU HAVE OTHER SOCIAL WORKERS AND EMPLOYEES THAT -- THAT
12 WORK IN THE HOSPITAL; IS THAT CORRECT?
13 A. YES.
14 Q. NOW, AS A PHYSICIAN, CAN I BE EMPLOYED BY THE HOSPITAL?
15 A. IN A CAPACITY AS A MEDICAL DIRECTOR. THAT'S CURRENTLY
16 THE KIND OF RELATION -- EMPLOYMENT RELATIONSHIPS WE HAVE
17 WITH PHYSICIANS.
18 Q. SO IF I'M A PHYSICIAN AND I WORK IN THE HOSPITAL, IS
19 THERE A DIFFERENT PROCESS THAT I GO THROUGH THAN WHAT A
20 REGULAR EMPLOYEE LIKE A NURSE OR SOMEBODY ELSE WOULD GO
21 THROUGH?
22 A. YES. YES. FOR A PHYSICIAN TO WORK IN THE HOSPITAL THEY
23 HAVE TO FIRST APPLY TO BE MEMBERS OF THE MEDICAL STAFF; AND
24 THEN THEY ALSO HAVE TO SUPPLY THE HOSPITAL -- AND REQUEST
25 PRIVILEGES, WHICH IS THE TYPE OF CARE AND TREATMENT THEY ARE
105
1 ANTICIPATING HAVING WITH PATIENTS.
2 Q. OKAY. AND SO I HAVE TO APPLY TO THE HOSPITAL IF I'M A
3 PHYSICIAN FOR PRIVILEGES TO -- TO WORK IN THAT HOSPITAL?
4 A. YES, YOU DO.
5 Q. OKAY. AND IS THAT THE CASE AT DAVIS HOSPITAL?
6 A. YES, IT IS.
7 Q. AND CAN YOU TELL US, HOW DO I GO ABOUT APPLYING FOR
8 PRIVILEGES TO WORK AT THAT HOSPITAL?
9 A. THE FIRST THING A PHYSICIAN NEEDS TO DO IS TO CONTACT
10 THE HOSPITAL AND INDICATE AN INTEREST IN APPLYING AS A -- TO
11 THE MEDICAL STAFF AT THE HOSPITAL. THE FIRST THING THEY --
12 THEY GET, I BELIEVE, IS CALLED A PRE-APPLICATION FORM THAT
13 THEY NEED TO FILL OUT AND SEND IN TO THE HOSPITAL. AND THEN
14 THEY FOLLOW UP, THE OFFICE THEN SENDS THEM A FULL
15 APPLICATION FORM TO THE MEDICAL STAFF. AND ALONG WITH THAT
16 PROCESS THEY'RE REQUIRED TO PROVIDE PROOF OF THEIR EDUCATION
17 AND THEIR LICENSE AS AN M.D. THEY NEED TO HAVE PROOF THAT
18 THEY'RE LICENSED IN THE STATE OF UTAH. THEY HAVE TO HAVE
19 PROOF FROM THE D.E.A. OF A LICENSE TO PRESCRIBE CONTROLLED
20 SUBSTANCES. THEY GENERALLY HAVE TO GIVE A NUMBER OF
21 REFERENCES.
22 WE -- WE -- THE HOSPITAL THEN VERIFIES WITH THEIR
23 MEDICAL SCHOOL, WITH THE SCHOOLS OR HOSPITALS THEY DID
24 INTERNSHIPS AND RESIDENCIES IN, AND IF THEY'RE BOARD
25 CERTIFIED IN THEIR SPECIALTY.
106
1 IN ADDITION TO THAT, THEY HAVE TO FILL OUT WHAT'S
2 CALLED A PRIVILEGE REQUEST FORM WHERE THEY OUTLINE WHAT
3 THEY'RE INTERESTED IN -- THE KIND OF CARE AND TREATMENT THEY
4 INTEND TO PROVIDE. IT'S VERY -- IT DEPENDS VERY MUCH ON
5 THEIR SPECIALTY.
6 AND THEN ALL OF THOSE DOCUMENTS, ONCE THEY'RE COMPILED
7 AND EVERYTHING IS -- WE'VE RECEIVED EVERYTHING FROM THE
8 SCHOOLS AND SO ON, THEN A COMMITTEE OF THE MEDICAL STAFF
9 CALLED THE CREDENTIALS COMMITTEE WILL REVIEW THOSE RECORDS
10 AND MAKE SURE THAT EVERYTHING'S IN ORDER AND THEY FEEL
11 COMFORTABLE THAT THE DOCTOR HAS THE CREDENTIALS THAT'S
12 NECESSARY FOR THEM TO PRACTICE IN THE HOSPITAL.
13 Q. OKAY.
14 A. THAT COMMITTEE, BASED ON THAT -- THAT REVIEW, WILL
15 EITHER RECOMMEND OR NOT RECOMMEND THAT THE PHYSICIAN BE
16 GRANTED PRIVILEGES AND IS ACCEPTED AS A MEMBER OF THE
17 MEDICAL STAFF TO WHAT'S CALL THE MEDICAL EXECUTIVE
18 COMMITTEE, WHICH IS KIND OF THE -- IT'S MADE UP OF THE
19 CHAIRMAN OF THE VARIOUS DEPARTMENTS OF THE MEDICAL STAFF IN
20 THE HOSPITAL, ALONG WITH THE PRESIDENT OF THE MEDICAL STAFF
21 AND SO ON.
22 Q. SO THE FIRST THING IS YOU MAKE APPLICATION.
23 A. UH-HUH.
24 Q. YOU FILL OUT THE APPLICATION, AS I UNDERSTAND IT. IT
25 GOES TO THE CREDENTIALS COMMITTEE AND THEN THEY --
107
1 A. ALONG WITH ALL THE OTHER STUFF THAT --
2 Q. ALONG WITH ALL THE OTHER STUFF --
3 A. UH-HUH.
4 Q. -- THAT NEEDS TO BE CONTAINED IN THE APPLICATION. AND
5 THEN THE CREDENTIALS COMMITTEE RECOMMENDS TO THE --
6 A. MEDICAL EXECUTIVE COMMITTEE.
7 Q. OKAY. AS PART OF THAT APPLICATION PROCESS, ONCE THE
8 APPLICATION IS RECOMMENDED AND IF IT'S ACCEPTED BY THE
9 MEDICAL --
10 A. EXECUTIVE COMMITTEE.
11 Q. -- EXECUTIVE COMMITTEE, DOES THAT INDIVIDUAL THEN HAVE
12 PRIVILEGES TO -- TO WORK IN THE HOSPITAL?
13 A. NO, THEY DON'T.
14 Q. OKAY. IS THERE ANOTHER PROCESS THAT THEN THEY HAVE TO
15 GO THROUGH IN ORDER TO HAVE THOSE PRIVILEGES?
16 A. THOSE RECORDS -- ONCE THEY'RE RECOMMENDED TO THE MEDICAL
17 EXECUTIVE COMMITTEE, THE MEDICAL EXECUTIVE COMMITTEE REVIEWS
18 AND ACTS ON THEM AND MAKES A DECISION AS TO WHETHER OR NOT
19 TO RECOMMEND OR NOT RECOMMEND PRIVILEGES AND MEMBERSHIP TO
20 THE BOARD OF TRUSTEES.
21 Q. OKAY. IN THIS APPLICATION PROCESS, DO THE POLICIES AND
22 REGULATIONS OF THE HOSPITAL PLAY ANY PART IN THAT?
23 A. YES.
24 Q. OKAY. AND WHAT PART DO THEY PLAY? IS A PHYSICIAN
25 REQUIRED TO REVIEW -- WHO'S MAKING APPLICATION REVIEW THOSE
108
1 POLICIES?
2 A. THE PHYSICIANS, WHEN THEY ARE ACCEPTED INTO THE MEDICAL
3 STAFF, ARE REQUIRED TO AGREE TO ABIDE BY THE BYLAWS AND
4 RULES AND REGULATIONS OF THE MEDICAL STAFF, THE BYLAWS OF
5 THE HOSPITAL, AND THE POLICIES AND PROCEDURES OF THE
6 HOSPITAL.
7 Q. OKAY. AND YOU INDICATED THAT THERE WAS A PROCESS -- A
8 FURTHER PROCESS AS TO PRIVILEGES. CAN YOU EXPLAIN TO THE
9 JURY WHAT WE MEAN BY PRIVILEGES?
10 A. PRIVILEGES IS THE KIND OF CARE AND TREATMENT THAT THE
11 DOCTOR IS REQUESTING THE OPPORTUNITY TO EITHER PROVIDE OR
12 PRACTICE IN THE HOSPITAL -- WITH PATIENTS IN THE HOSPITAL.
13 FOR INSTANCE, A SURGEON WILL FILL OUT A PRIVILEGE
14 DELINEATION FORM SAYING I WANT TO BE ABLE TO PERFORM
15 APPENDECTOMIES AND CHOLECYSTECTOMIES -- WHICH IS GALLBLADDER
16 SURGERY -- AND BOWEL SURGERY, WHATEVER. AND WHEN YOU LOOK
17 AT THAT PRIVILEGE FORM, YOU THEN LOOK AT THE EDUCATION AND
18 TRAINING THAT THE SURGEON UNDERWENT WHEN HE WAS GOING TO
19 SCHOOL, WHAT KIND OF RESIDENCY HE TOOK, WHETHER OR NOT HE'S
20 BOARD CERTIFIED AS A SURGEON. AND THE CREDENTIALS AND
21 MEDICAL EXECUTIVE COMMITTEE THEN REVIEWS ALL OF THAT AND
22 SAYS YES OR NO.
23 Q. OKAY.
24 A. BASED ON THAT REQUEST FOR PRIVILEGES.
25 Q. SO -- SO YOU COULD -- YOU COULD REQUEST A VARIETY OF
109
1 PRIVILEGES, I TAKE IT.
2 A. YEAH.
3 Q. IF YOU FELT YOU WERE QUALIFIED TO --
4 A. UH-HUH.
5 Q. -- TO PROVIDE THOSE SERVICES?
6 A. UH-HUH.
7 Q. AND IN -- IN RESPECT TO THE CREDENTIALS AND THE
8 EXECUTIVE COMMITTEE, THEN THEY WOULD EITHER APPROVE OR DENY
9 WHATEVER PRIVILEGES YOU CAN -- YOU CAN USE AT THE HOSPITAL?
10 A. YES.
11 Q. WHAT DOES -- WHAT DOES THAT MEAN THOUGH IN TERMS OF THE
12 PHYSICIAN? DOES THAT MEAN IF HE'S DENIED A CERTAIN
13 PRIVILEGE, HE CAN'T DO THOSE TYPES OF THINGS?
14 A. THAT'S RIGHT.
15 Q. OKAY. AND IS THERE A -- IS THERE A DEFINITION IN THE
16 HOSPITAL AS TO WHAT TYPES OF SERVICES DIFFERENT PRIVILEGES
17 ALLOW?
18 A. YES. EACH SECTION OF THE MEDICAL STAFF, THE VARIOUS
19 SPECIALTIES: INTERNAL MEDICINE, PEDIATRICS, CARDIOLOGY,
20 SURGERY, THINGS OF THAT NATURE, ALL HAVE A PRIVILEGE
21 DELINEATION FORM THAT IS SET UP TO REFLECT THE KIND OF
22 PRIVILEGES THAT DOCTORS WITH THAT TRAINING AND EXPERIENCE
23 AND SO ON WOULD BE LIKELY TO REQUEST. A PHYSICIAN THAT'S
24 AN -- HAS A SPECIALTY IN INTERNAL MEDICINE, FOR INSTANCE,
25 WOULD NOT HAVE A PRIVILEGE FORM THAT OFFERED HIM THE
110
1 OPPORTUNITY TO DO SURGERY BECAUSE HE'S NOT A SURGEON.
2 Q. OKAY.
3 A. ONLY THE SECTIONS OF THE MEDICAL STAFF THAT ARE SURGEONS
4 WOULD HAVE THOSE AS AN OPTION ON THEIR PRIVILEGE FORM.
5 Q. ARE THERE ANY GENERAL CATEGORIES THAT PRACTICE IN THE
6 HOSPITAL?
7 A. THERE ARE SOME CATEGORIES OF GENERAL MEDICAL CARE THAT
8 ARE OPTIONS ON MANY OF THE PRIVILEGE FORMS.
9 Q. OKAY. I TAKE IT PSYCHIATRY WOULD BE A SPECIAL
10 SPECIALTY; IS THAT CORRECT?
11 A. YES.
12 Q. OKAY. IN RESPECT TO THE BILLING FOR SERVICES, IS THERE
13 A DIFFERENTIATION BETWEEN A PHYSICIAN PROVIDING SERVICES AND
14 THE HOSPITAL SERVICES?
15 A. YES.
16 Q. CAN YOU EXPLAIN THAT FOR US, PLEASE?
17 A. THE HOSPITAL ONLY BILLS FOR SERVICES THAT ARE PROVIDED
18 BY HOSPITAL EMPLOYEES ON BEHALF OF THE HOSPITAL.
19 Q. OKAY.
20 A. OUR NURSES WORK FOR THE HOSPITAL, THE LAB TECHS, THE
21 RADIOLOGY TECHS, THE PHARMACISTS, SO ON AND SO FORTH.
22 Q. SO --
23 A. AND THE HOSPITAL BILLS FOR THOSE SERVICES AND THAT'S
24 ALL.
25 Q. SO HOW DOES -- HOW ARE YOU PHYSICIANS BILLINGS HANDLED?
111
1 A. PHYSICIANS BILL SEPARATELY. THEY'RE INDEPENDENT
2 CONTRACTORS. THEY'RE NOT EMPLOYED BY THE HOSPITAL.
3 Q. WELL, ASSUMING THAT YOU HAVE A UNIT IN THE HOSPITAL THAT
4 HOUSES PHYSICIANS, WILL THEY -- WILL THEY BILL SEPARATE AND
5 APART FROM THE HOSPITAL ITSELF, TOO?
6 A. YES.
7 Q. OKAY. IS THE GEROPSYCH UNIT OPERATED INDEPENDENTLY BY
8 ANYBODY NOW?
9 A. NO. IT'S OPERATED BY THE HOSPITAL.
10 Q. OKAY. DO YOU KNOW HOW LONG THAT'S BEEN IN PLACE?
11 A. SINCE MID TO LATE 1996.
12 Q. ALL RIGHT. JUST A COUPLE OF MORE QUESTIONS RELATED TO
13 HOSPITAL POLICIES.
14 IS THERE IN PLACE, TO YOUR KNOWLEDGE, PROCEDURES FOR
15 SITUATIONS WHERE A NURSE MAY HAVE A CONFLICT WITH A DOCTOR?
16 A. YES. IT'S CALLED CONFLICT RESOLUTION.
17 Q. OKAY. AND CAN YOU TELL US A LITTLE BIT ABOUT THAT
18 PROCESS, WHAT HAPPENS THERE?
19 A. IF A NURSE HAS A CONFLICT WITH A PHYSICIAN, THE FIRST
20 THING THAT THEY ARE INSTRUCTED TO DO IS GO TO THEIR
21 IMMEDIATE SUPERVISOR.
22 Q. OKAY. AND IF THEY -- IF THEY ARE NOT SATISFIED WITH THE
23 RESULT OF THAT?
24 A. THEN THEY -- THEY CAN GO TO THE PERSON THAT IS THE --
25 THE SUPER -- WHOEVER THE SUPERVISOR REPORTS TO. IT'S KIND
112
1 OF AN UP-THE-LADDER SORT OF THING. THERE'S A NURSE -- A
2 UNIT SUPERVISOR, THEN THERE WOULD BE A DIRECT -- NURSING
3 DIRECTOR, DEPENDING ON A CERTAIN SECTION OF THE HOSPITAL,
4 AND THEN THERE WOULD BE THE CHIEF NURSING OFFICER.
5 Q. I --
6 A. AND THEN ABOVE THAT, THE ADMINISTRATOR OF THE HOSPITAL.
7 Q. I GUESS IT WOULD DEPEND A LITTLE BIT ON THE NATURE OF
8 THE CONFLICT.
9 A. YES, IT WOULD.
10 Q. OKAY. AND IN RESPECT TO A CONFLICT SURROUNDING THE
11 ADMINISTRATION OF MEDICATION, IS THERE A DIFFERENT PROCEDURE
12 WITH THAT?
13 A. NO.
14 Q. TO YOUR KNOWLEDGE, IS THERE ANY POLICY WHICH REQUIRES A
15 NURSE TO GO TO THE PHYSICIAN THAT SHE HAS THE CONFLICT WITH
16 AND TRY TO RESOLVE IT AT THAT LEVEL?
17 A. THERE'S NOTHING IN WRITING, BUT WE ALWAYS --
18 MR. STIRBA: YOUR HONOR -- YOUR HONOR, I'M GOING TO
19 OBJECT AS TO RELEVANCY AND FOUNDATION. WE DON'T KNOW WHAT
20 TIME PERIOD THIS IS. WE DON'T --
21 THE COURT: SUSTAINED.
22 MR. STIRBA: -- EVEN HAVE A POLICY.
23 THE COURT: SUSTAINED.
24 Q. (BY MR. WILSON) WHO IS THE HOSPITAL OPERATED BY OR
25 OWNED BY AT THE PRESENT TIME?
113
1 A. IASIS HEALTHCARE, INCORPORATED.
2 Q. DO YOU KNOW WHO IT WAS OWNED BY BACK IN 1995 AND '96?
3 A. I BELIEVE IT WAS COLUMBIA.
4 Q. OKAY. HAS IT CHANGED OWNERSHIP TO ANOTHER PARTY SINCE
5 THAT TIME?
6 A. YES. IT WAS OWNED BY PARACELSUS PRIOR TO IASIS.
7 Q. OKAY.
8 MR. WILSON: MAY I HAVE JUST A MINUTE, YOUR HONOR?
9 THE COURT: YES.
10 (WHEREUPON, THERE'S AN OFF-THE-RECORD DISCUSSION BETWEEN
11 MR. WILSON AND MS. BARLOW.)
12 Q. (BY MR. WILSON) IN YOUR -- IN YOUR POSITION IN QUALITY
13 AND RISK MANAGEMENT, WHEN YOU CAME ON BOARD AT THE HOSPITAL,
14 DID YOU HAVE OCCASION TO REVIEW THOSE POLICIES DEALING
15 WITH -- WITH CONFLICT RESOLUTION BETWEEN PHYSICIANS AND
16 NURSES AND OTHER PERSONNEL?
17 A. YES.
18 Q. OKAY. DID YOU -- DID YOU HAVE AN OCCASION THEN TO
19 REVIEW THE POLICIES THAT WERE IN PLACE BACK IN 1993 AND
20 '94 --
21 A. NO, I DID NOT.
22 Q. -- AND '95? PARDON?
23 A. NO. UNLESS THEY HADN'T BEEN CHANGED SINCE THEN.
24 Q. OKAY.
25 A. IT WOULD DEPEND ON THE AMENDMENT DATES.
114
1 Q. I APPRECIATE THAT. THANK YOU.
2 MR. WILSON: I HAVE NO FURTHER QUESTIONS, YOUR
3 HONOR.
4 MR. STIRBA: COULD I HAVE A MINUTE TO CONSULT WITH
5 COUNSEL?
6 THE COURT: YES.
7 (WHEREUPON, THERE'S AN OFF-THE-RECORD DISCUSSION BETWEEN
8 MR. STIRBA AND MR. WILSON.)
9 CROSS-EXAMINATION
10 BY MR. STIRBA:
11 Q. MS. HEWARD, YOU'RE FAMILIAR WITH THE FEDERAL PATIENT
12 SELF-DETERMINATION ACT?
13 A. YES, I AM.
14 Q. AND THAT'S AN ACT THAT WAS PASSED IN 1990 BY THE U.S.
15 CONGRESS, CORRECT?
16 A. I'LL TAKE YOUR WORD FOR IT.
17 Q. TAKE MY WORD FOR IT. AND -- AND THE ACT IS SOMETHING
18 THAT IMPOSES SOME OBLIGATIONS ON HOSPITALS TO PROVIDE SOME
19 INFORMATION CONCERNING MEDICAL DIRECTORS -- DIRECTIVES TO
20 PATIENTS; ISN'T THAT TRUE?
21 A. YES, SIR.
22 Q. AND WHEN WE USE THE TERM "MEDICAL DIRECTIVES," WHAT
23 WE'RE TALKING ABOUT ARE REPRESENTATIONS BY THE PATIENT AS TO
24 CERTAIN KINDS OF CARE THAT MAY OR MAY NOT BE GIVEN UNDER
25 CERTAIN CIRCUMSTANCES, CORRECT?
115
1 A. CORRECT.
2 Q. IN OTHER WORDS, IT'S SIMILAR TO A LIVING WILL, IS IT
3 NOT?
4 A. AN ADVANCE DIRECTIVE IS -- CAN ENCOMPASS A NUMBER OF
5 THINGS, AMONG THEM A LIVING WILL.
6 Q. AND IN YOUR REVIEW OF THE MEDICAL RECORDS IN THIS CASE,
7 YOU SAW, DID YOU NOT, THAT THERE WERE EITHER MEDICAL
8 DIRECTIVES OR LIVING WILLS THAT WERE IN THE MEDICAL FILES
9 FOR THESE PATIENTS?
10 A. I BELIEVE SO, YES. I'D HAVE TO LOOK AT ALL FIVE OF THEM
11 TO MAKE SURE, BUT I BELIEVE SO.
12 Q. AND THOSE PARTICULAR DOCUMENTS WERE DOCUMENTS WHICH
13 WOULD HAVE LIMITED CERTAIN KINDS OF MEDICAL TREATMENT, IS
14 THAT NOT RIGHT?
15 A. YES.
16 MR. STIRBA: MR. MAY, IF YOU COULD BE
17 MR. TECHNOLOGY, PLEASE.
18 (MR. MAY TURNS ON DISPLAY.)
19 MR. STIRBA: MAY I CONSULT WITH COUNSEL AGAIN, YOUR
20 HONOR, PLEASE?
21 THE COURT: YES.
22 (WHEREUPON, THERE'S AN OFF-THE-RECORD DISCUSSION
23 BETWEEN MR. STIRBA AND MR. WILSON.)
24 Q. (BY MR. STIRBA) I'VE PUT UP ON THE SCREEN -- CAN
25 YOU -- CAN YOU SEE THAT VERY WELL FROM WHERE YOU'RE SEATED,
116
1 MS. HEWARD?
2 A. YEAH.
3 Q. OKAY. THAT'S A -- SAYS AT THE TOP MEDICAL TREATMENT
4 PLAN, AND IT SAYS FOR MICHAEL SUMKO, AND THEN IT -- IS THE
5 ATTENDING PHYSICIAN FOR ELLEN ANDERSON. DO YOU SEE THAT?
6 A. YES.
7 Q. AND I'M GOING TO GO AND SORT OF SCOOT THIS UP A LITTLE
8 BIT SO WE CAN SEE DOWN AT THE BOTTOM. APPARENTLY THERE'S A
9 SIGNATURE THERE DOWN AT THE BOTTOM THAT LOOKS LIKE BARBARA
10 POHLMAN. DO YOU SEE THAT?
11 A. UH-HUH.
12 Q. NOW, IS THIS -- IS THIS A DOCUMENT THAT YOU RECALL
13 SEEING, FOR EXAMPLE, IN MS. ANDERSON'S MEDICAL FILE?
14 A. YES.
15 Q. AND IS THIS IN THE NATURE OF A DIRECTIVE THAT WOULD BE
16 IN THE FILE THAT WOULD DIRECT ATTENDING PHYSICIANS IN TERMS
17 OF WITHHOLDING OR WITHDRAWING CERTAIN CARE FOR HER UNDER
18 CERTAIN CIRCUMSTANCES?
19 A. YES.
20 Q. AND, SPECIFICALLY, IT SAYS THERE, DOES IT NOT, THAT THE
21 FOLLOWING CARE AND TREATMENT OR WITHHOLDING OF TREATMENT IS
22 DIRECTED WITH RESPECT TO THE DECLARANT. AND THEN IT SAYS,
23 WITHHOLD TREATMENT OF OXYGEN THERAPY, RESPIRATION --
24 RESPIRATOR TREATMENTS, SUCTIONING, MECHANICAL VENTILATION,
25 VENTILATOR SUPPORT, C.P.R., CHEST COMPRESSIONS, CARDIAC
117
1 MEDICATIONS DURING C.P.R., DEFIBRILLATION, CHEMOTHERAPY,
2 RADIATION, SURGERY, I.V. FLUIDS, N.G., GASTRIC TUBE, AND
3 SPEAK WITH AUTHORIZED AGENT BEFORE USING ANTIBIOTICS.
4 DID I READ THAT CORRECTLY?
5 A. I BELIEVE SO.
6 Q. AND IF A PHYSICIAN HAD THIS IN THE FILE -- AND YOU'VE
7 ALREADY TESTIFIED THAT THIS IS SOMETHING THAT WAS IN HER
8 FILE -- IT'S TRUE, IS IT NOT, THAT A PHYSICIAN SHOULD
9 OTHERWISE COMPLY WITH THOSE DIRECTIVES AS INDICATED IN
10 HOSPITAL POLICY; ISN'T THAT CORRECT?
11 A. PARTIALLY.
12 Q. AND IN WHAT PART IS IT NOT CORRECT, MA'AM?
13 A. THE HOSPITAL POLICY AND PROCEDURE WITH REGARD TO
14 WITHHOLDING, WITHDRAWING, OR DO NOT RESUSCITATE CALL FOR
15 ANOTHER PHYSICIAN TO EXAMINE THE PATIENT AND AGREE WITH THE
16 ATTENDING PHYSICIAN AS TO WHETHER OR NOT THE D.N.R. IS
17 APPROPRIATE, GIVEN THE PERSON'S CONDITION.
18 Q. YES. AND THAT'S WITH RESPECT TO THE D.N.R. BUT IT'S
19 ALSO TRUE IN THAT POLICY, IT STATES SPECIFICALLY THAT THE
20 HOSPITAL IS FULLY COGNIZANT OF UTAH LAW IN REGARD TO
21 DIRECTIVES, AND THAT IS A PHYSICIAN MUST FOLLOW THOSE
22 DIRECTIVES; ISN'T THAT TRUE?
23 A. YES.
24 Q. AND IT ALSO STATES IN THE POLICY THAT IF A PHYSICIAN
25 FOLLOWS THOSE DIRECTIVES IN GOOD FAITH, THAT PHYSICIAN IS
118
1 IMMUNE BOTH CRIMINALLY AND CIVILLY; ISN'T THAT TRUE?
2 A. I CAN'T ANSWER THAT. I HAVE NO PERSONAL KNOWLEDGE.
3 Q. YOU'RE NOT AWARE THAT'S IN THE POLICY?
4 A. (NO RESPONSE.)
5 Q. AND YOUR ANSWER IS YOU'RE NOT AWARE THAT'S IN THE
6 POLICY?
7 A. I DON'T RECALL THOSE WORDS.
8 Q. TURN TO --
9 A. IF YOU COULD --
10 Q. TURN TO PAGE 5.
11 A. OF WHICH POLICY?
12 Q. OF THE ADVANCE DIRECTIVES POLICY. PARAGRAPH 7 READS --
13 MR. WILSON: YOUR HONOR, I'M GOING TO INTERPOSE AN
14 OBJECTION AT THIS TIME. WE HAVEN'T OFFERED THIS PARTICULAR
15 EXHIBIT INTO EVIDENCE. AND I THINK THAT IF MR. STIRBA IS
16 WILLING TO STIPULATE TO ITS SUBMISSION INTO EVIDENCE AT THIS
17 TIME, THEN I'D BE MORE THAN WILLING TO ALLOW HIM TO CONTINUE
18 TO REFER TO THE POLICY AS IT'S CONTAINED IN THE ADVANCE
19 DIRECTIVE.
20 MR. STIRBA: WELL, MY QUESTION REALLY IS, IS SHE
21 AWARE OF THE POLICY IN REGARD TO THE QUESTION. I BELIEVE
22 SHE ANSWERED SHE WAS NOT. AND I WAS DIRECTING HER ATTENTION
23 TO A PARTICULAR PARAGRAPH AND WAS GOING TO READ IT TO HER.
24 MR. WILSON: WELL, I APPRECIATE THAT.
25 THE COURT: WELL, JUST -- ARE YOU GOING -- IS THERE
119
1 GOING TO BE A STIPULATION AS TO THE RECEIPT OF THIS EXHIBIT?
2 MR. STIRBA: NO, I DON'T THINK I CAN STIPULATE TO
3 THAT PARTICULAR PORTION.
4 THE COURT: OKAY. AND YOU'RE JUST GOING TO POINT
5 OUT THAT QUESTION JUST AS CROSS-EXAMINATION?
6 MR. STIRBA: RIGHT, AND ASK HER IF THAT'S THE
7 POLICY.
8 THE COURT: OKAY. I -- THAT'S OVERRULED THEN.
9 I'LL ALLOW IT FOR THAT QUESTION.
10 MR. WILSON: YOUR HONOR, IF I MIGHT JUST ARGUE IT A
11 LITTLE BIT FURTHER.
12 FROM THE STANDPOINT -- I THINK THE OBJECTION THAT
13 MR. STIRBA HAS MADE OR WOULD MAKE EARLIER IS THAT THE
14 DECLARANT HERE TESTIFIED TO THE EFFECT THAT SHE WASN'T SURE
15 WHETHER THIS WAS THE POLICY THAT WAS IN EFFECT BACK AT THE
16 TIME OF THESE PARTICULAR DEATHS, SO WE DID NOT INTEND TO ASK
17 FOR THE ADMISSION OF THIS PARTICULAR EXHIBIT. I THINK WITH
18 THAT INFIRMITY, WE DON'T KNOW WHETHER THAT PARTICULAR
19 PROVISION THAT HE'S GOING TO ADDRESS WITH HER RELATES TO
20 WHAT WAS IN EFFECT AT THE TIME OR NOT.
21 THE COURT: WELL, I THINK THAT'S HIS QUESTION. HE
22 WANTS TO ASK HER THE QUESTION AS TO WHAT WAS THE POLICY THAT
23 WAS IN EFFECT?
24 MR. STIRBA: RIGHT.
25 THE COURT: OKAY. OVERRULED.
120
1 Q. (BY MR. STIRBA) NOW, MS. HEWARD, THE ADVANCE
2 DIRECTIVE -- PAGE 1 -- POLICY, INDICATES IT WAS AMENDED 6/93
3 AND 8/96, TRUE? AT THE TOP?
4 A. YES.
5 Q. AND THE EFFECTIVE DATE IS 12/91, TRUE?
6 A. YES.
7 Q. NOW, IF YOU TURN TO THE PAGE THAT I HAVE DIRECTED YOUR
8 ATTENTION TO, THAT IS PAGE 5 OF 5, PARAGRAPH 7, I'M ASKING
9 YOU IF THIS IS CONTAINED IN THAT POLICY AND WAS THE POLICY
10 OF THE HOSPITAL AT THE TIME: PHYSICIAN AND MEDICAL CARE
11 PROVIDERS AND THEIR AGENTS, ACTING IN GOOD FAITH UNDER THE
12 PERSONAL CHOICE AND LIVING WILL, ARE IMMUNE FROM CRIMINAL OR
13 CIVIL ACTION OR PENALTY AND ARE NOT DEEMED TO HAVE COMMITTED
14 UNPROFESSIONAL CONDUCT.
15 WAS THAT THE POLICY OF THE HOSPITAL AT THE TIME?
16 THE COURT: THE TIME MEANING '95?
17 A. IN '95 AND '96?
18 Q. (BY MR. STIRBA) YES.
19 A. THIS IS THE POLICY OF THE HOSPITAL EFFECTIVE AUGUST OF
20 '96. I DO NOT HAVE A COPY OF THE POLICY -- FOR INSTANCE,
21 THIS POLICY, AFTER IT WAS AMENDED IN '93 AND BEFORE IT WAS
22 AMENDED IN AUGUST OF '96.
23 Q. SO YOUR ANSWER IS YOU DO NOT KNOW?
24 A. THAT'S RIGHT.
25 Q. NOW, SHOW YOU ANOTHER DOCUMENT UP ON THE SCREEN. THAT,
121
1 ONCE AGAIN, IS ANOTHER MEDICAL TREATMENT PLAN FOR
2 MR. ALLDREDGE. TRUE?
3 A. APPEARS SO, YES.
4 Q. AND IS THAT A DOCUMENT THAT YOU ALSO HAVE SEEN THAT IS
5 CONTAINED IN MR. ALLDREDGE'S MEDICAL FILE?
6 A. I BELIEVE SO.
7 Q. AND I NOTICE THERE THERE'S A DIAGNOSIS OF ALZHEIMER'S
8 DISEASE. DO YOU SEE THAT?
9 A. YES.
10 Q. AND THEN IF I PUSH THIS DOWN A LITTLE BIT IT STATES:
11 THE FOLLOWING CARE AND TREATMENT OR WITHHOLDING OF TREATMENT
12 IS DIRECTED WITH RESPECT TO THE DECLARANT: NO C.P.R., NO
13 RESPIRATORS. THERE APPEARS TO BE A SIGNATURE OF VONDA
14 ALLDREDGE, WIFE. DO YOU SEE THAT?
15 A. YES.
16 Q. THE DATE OF THAT DOCUMENT IS 10/11/95, TRUE?
17 A. YES.
18 Q. HERE'S ANOTHER DOCUMENT, MS. HEWARD, WHICH IS, ONCE
19 AGAIN, ANOTHER MEDICAL TREATMENT PLAN. BY THE WAY, IS THIS
20 PARTICULAR FORM -- IS THIS A FORM THAT YOU'VE SEEN BEFORE?
21 A. I'VE SEEN IT IN THESE RECORDS. THESE WERE BROUGHT TO
22 THE HOSPITAL WITH THE PATIENT.
23 Q. I SEE. SO THIS ACTUAL MEDICAL TREATMENT --
24 A. THESE --
25 Q. -- PLAN FORM WAS NOT SOMETHING THAT'S GENERATED BY THE
122
1 DAVIS HOSPITAL?
2 A. THESE WERE -- PREDATED THEIR ADMISSION TO THE HOSPITAL.
3 Q. OKAY. AND THIS ONE APPEARS TO BE FOR JUDITH LARSEN
4 DATED SEPTEMBER 19TH OF 19 -- I BELIEVE THAT IS '85.
5 PROBABLY SHOULD BE '95, BUT IT SAYS '85. TRUE?
6 A. IT SAYS '85.
7 Q. AND THIS WAS ALSO A DOCUMENT THAT YOU SAW IN HER MEDICAL
8 FILE AS WELL?
9 A. I BELIEVE SO.
10 Q. AND THERE'S A SIGNATURE DOWN THERE, MERLIN LARSEN,
11 INDICATING SON, CORRECT?
12 A. YES.
13 Q. AND IT STATES THAT NO C.P.R., NO I.V.'S FOR NUTRITION,
14 HYDRATION, MEDICATION, NO FEEDING TUBES, NO MECHANICAL
15 RESPIRATORY ASSISTANCE, NO ELECTRIC SHOCK OR DEFIBRILLATION,
16 NO TREATMENT FOR CANCER, OXYGEN, AND ORAL MEDICATION MAY BE
17 GIVEN FOR RELIEF OF PAIN -- I'M SORRY. MEDICATION MAY BE
18 GIVEN FOR RELIEF OF PAIN AND FOR COMFORT.
19 DID I READ THAT CORRECTLY?
20 A. YES.
21 Q. THIS WAS ALSO SOMETHING THAT WAS IN THE FILE OF
22 MS. LARSEN, CORRECT?
23 A. CORRECT.
24 Q. ALSO, THERE'S A DOCUMENT, LIVING WILL, WHICH I HAVE PUT
25 ON THE SCREEN. WAS THIS DOCUMENT ALSO SOMETHING THAT YOU
123
1 SAW IN THE MEDICAL FILE?
2 A. I BELIEVE SO.
3 Q. AND THIS IS DATED THE 28TH OF MAY, AND IT LOOKS LIKE A
4 '95.
5 A. YES.
6 Q. DO YOU UNDERSTAND IT TO BE A '95?
7 A. YES.
8 Q. AND THAT LOOKS LIKE A DOCUMENT THAT WAS, IN FACT, SIGNED
9 BY MS. LARSEN DOWN AT THE BOTTOM. DO YOU SEE THAT?
10 A. YES.
11 Q. AND ONCE AGAIN, THAT PARAGRAPH WHICH ADDRESSES
12 PARAGRAPH 4 -- AND I WON'T READ IT IN ITS ENTIRETY EXCEPT --
13 WELL, I WILL READ ITS ENTIRETY: I UNDERSTAND THAT THE TERM
14 LIFE-SUSTAINING PROCEDURE INCLUDES ARTIFICIAL NUTRITION AND
15 HYDRATION, AND ANY OTHER PROCEDURES THAT I SPECIFY BELOW TO
16 BE CONSIDERED LIFE SUSTAINING, BUT DOES NOT INCLUDE THE
17 ADMINISTRATION OF MEDICATION OR THE PERFORMANCE OF ANY
18 MEDICAL PROCEDURE WHICH IS INTENDED TO PROVIDE COMFORT OR TO
19 ALLEVIATE PAIN.
20 THEN IT SAYS: IF MY CONDITION IS CERTIFIED TO BE
21 TERMINAL AS IN PARAGRAPH 2, I REQUEST THAT THE SUSTENANCE,
22 MEANING NUTRITION AND HYDRATION AND RESPIRATION, BE
23 TERMINATED OR WITHHELD. MEDICATION TO RELIEVE PAIN MAY BE
24 GIVEN IF OBVIOUSLY NEEDED.
25 DID I READ THAT CORRECTLY?
124
1 A. YES.
2 Q. YES?
3 A. YES.
4 Q. ANOTHER DOCUMENT -- NOW, THIS APPEARS TO BE A DOCUMENT
5 THAT'S ACTUALLY CREATED BY THE HOSPITAL, CORRECT?
6 A. IT'S A HOSPITAL FORM, YES.
7 Q. AND THAT IS SOMETHING THAT YOU HAVE SEEN IN THE FILE --
8 I BELIEVE THIS RELATES TO LYDIA SMITH. I'LL GET DOWN TO THE
9 BOTTOM SO YOU CAN SEE THE SIGNATURES.
10 A. I CAN'T TELL.
11 Q. IT DOESN'T LOOK TO YOU LIKE THAT'S KENT SMITH OR -- DOWN
12 AT THE BOTTOM?
13 A. THAT MIGHT BE A SMITH, YES.
14 Q. OKAY.
15 A. I DON'T SEE ANYTHING WITH LYDIA'S NAME ON THERE THOUGH.
16 Q. UP AT THE TOP, MA'AM --
17 A. YES.
18 Q. -- DO YOU SEE THE STAMP, LYDIA SMITH?
19 A. NOW I DO, YES.
20 Q. AND IS THIS ALSO A DOCUMENT THAT IS CONTAINED IN HER
21 MEDICAL FILE?
22 A. I BELIEVE SO.
23 Q. AND THIS PARTICULAR DOCUMENT APPEARS TO BE DATED 1/7 OF
24 '96, TRUE?
25 A. YES.
125
1 Q. AND UNDER THE CATEGORIES THERE WHERE IT SAYS: THE
2 FOLLOWING CARE AND TREATMENT IS DIRECTED WITH RESPECT TO THE
3 DECLARANT, THERE'S A NUMBER OF CATEGORIES, MOST OF WHICH ARE
4 CHECKED NO. TRUE?
5 A. TRUE.
6 Q. AND BY "NO" WE MEAN THAT IS A CATEGORY OF TREATMENT THAT
7 THE PATIENT OR THE PATIENT'S REPRESENTATIVE HAS DIRECTED NOT
8 TO BE GIVEN UNDER CERTAIN CIRCUMSTANCES, RIGHT?
9 A. RIGHT.
10 Q. JUST LIKE WHERE IT SAYS "YES" UNDER DO NOT RESUSCITATE,
11 D.N.R., THAT MEANS, IN FACT, DO NOT RESUSCITATE. TRUE?
12 A. YES.
13 Q. NOW, THIS PARTICULAR DOCUMENT WHICH IS ON A DAVIS
14 HOSPITAL FORM, IS THIS A FORM THAT GENERALLY IS REQUIRED TO
15 BE PROVIDED TO PATIENTS PURSUANT TO THE FEDERAL
16 SELF-DETERMINATION ACT OF 1990?
17 A. IT IS NOT REQUIRED. THEY HAVE THE OPPORTUNITY TO
18 COMPLETE ONE, IF THEY CHOOSE.
19 Q. OH, I SEE. I'M NOT SUGGESTING THEY HAVE TO COMPLETE IT,
20 BUT THE HOSPITAL HAS AN OBLIGATION TO MAKE CERTAIN ADVICE --
21 A. TO MAKE IT AVAILABLE.
22 Q. -- TO THE PATIENT AND MAKE IT AVAILABLE; ISN'T THAT
23 CORRECT?
24 A. THAT'S CORRECT.
25 Q. AND THAT'S PURSUANT TO FEDERAL LAW, TRUE?
126
1 A. AS FAR AS I KNOW, YES.
2 Q. AND FINALLY, MS. HEWARD, I HAVE PLACED ON THE BOARD
3 ANOTHER DOCUMENT, AND UP AT THE TOP IT SAYS MARY CRANE. CAN
4 YOU READ THAT? IT'S KIND OF -- I CAN HIT THE FOCUS.
5 A. I CAN READ -- I THINK I CAN READ MARY.
6 MR. STIRBA: YEAH. THANK YOU, JOHN.
7 (WHEREUPON, THERE'S AN OFF-THE-RECORD DISCUSSION
8 BETWEEN MR. STIRBA AND MR. MAY.)
9 Q. (BY MR. STIRBA) THIS IS WHERE I THINK MARY CRANE IS,
10 MA'AM (INDICATING).
11 A. I SEE MARY.
12 Q. HAVE YOU SEEN THIS DOCUMENT BEFORE SUCH THAT YOU CAN
13 RECOGNIZE THIS AS MS. CRANE'S DOCUMENT?
14 A. I BELIEVE -- I BELIEVE IT IS IN HER MEDICAL RECORD.
15 Q. OKAY. AND THAT'S DATED 12/28 OF 1995, CORRECT?
16 A. NINE OR SEVEN. I CAN'T TELL. PROBABLY NINE.
17 Q. WELL, PROBABLY NINE.
18 A. THAT'S CORRECT.
19 Q. YOU HAVE NO REASON TO BELIEVE SHE WAS IN THE HOSPITAL IN
20 '75. WE KNOW SHE WAS ADMITTED TO THE HOSPITAL IN '95,
21 CORRECT?
22 A. YES.
23 Q. AND, ONCE AGAIN, WE HAVE SIMILAR LIMITATIONS UNDER THE
24 FOLLOWING CARE AND TREATMENT IS DIRECTED WITH RESPECT TO THE
25 DECLARANT -- THAT IS MS. CRANE. AND WE HAVE A NUMBER OF
127
1 CATEGORIES CHECKED YES, CORRECT?
2 A. YES.
3 Q. AND WE HAVE A NUMBER OF CATEGORIES THAT ARE CHECKED NO.
4 A. CORRECT.
5 Q. TRUE?
6 A. YES.
7 Q. AND, SPECIFICALLY, UNDER SURGERY WHERE IT SAYS ADVISE
8 FAMILY, WE HAVE NO. CORRECT?
9 A. CORRECT.
10 Q. AND UNDER I.V. FLUIDS, WE HAVE NO. TRUE?
11 A. YES.
12 Q. AND THEN THERE'S A SIGNATURE AT THE BOTTOM OF THE
13 DOCUMENT AND THAT APPEARS TO BE THE SIGNATURE OF KAREN
14 BRINGHURST, CORRECT?
15 A. YES.
16 Q. DO YOU UNDERSTAND MS. BRINGHURST TO BE MS. CRANE'S
17 DAUGHTER?
18 A. YES.
19 Q. NOW, YOU TESTIFIED ABOUT THE MEDICAL RECORDS AND I THINK
20 IT'S IMPORTANT, FOR PURPOSES OF THIS CASE -- IT'S TRUE, IS
21 IT NOT, THAT IN THE MEDICAL RECORDS -- FOR EXAMPLE, AT SOME
22 POINT WE'RE GOING TO HAVE EXHIBITS AND THOSE MEDICAL RECORDS
23 ARE GOING TO BE IN BINDERS. THEY MAY NOT BE READ, BUT
24 THEY'LL BE BINDERS LIKE THIS. AND THEY'LL BE TABBED AND ONE
25 OF THE TABS IS GOING TO SAY, BASICALLY, A CATEGORY THAT SAYS
128
1 MEDICATION ADMINISTRATION RECORD.
2 A. YES.
3 Q. ARE YOU FAMILIAR WITH THAT? YOU REFER TO IT AS MARS,
4 RIGHT?
5 A. M-A-R.
6 Q. M-A-R. IN THE MAR IS A PLACE WHERE THE NURSES CHART THE
7 ACTUAL MEDICATION THAT HAS BEEN GIVEN TO THE PATIENT; ISN'T
8 THAT TRUE?
9 A. YES.
10 Q. AND -- AND -- AND IT'S TRUE, IS IT NOT, THAT SINCE
11 THAT'S THE ACTUAL PLACE WHERE THE NURSES CHART THAT, THAT
12 REALLY IS THE BEST EVIDENCE TO DETERMINE WHAT, IN FACT, THE
13 PATIENT RECEIVED; ISN'T THAT CORRECT?
14 A. BEST EVIDENCE? YEAH, IT'S -- IT'S ONE PIECE OF
15 EVIDENCE.
16 Q. SURE. YOU -- YOU SAID YOU COULD CORRELATE IT TO THE --
17 TO SOME OTHER PHARMACY RECORDS, BUT THE QUESTION REALLY IS,
18 THAT'S WHERE THE NURSES ARE SUPPOSED TO WRITE IT DOWN WHEN
19 THEY GIVE THE MEDICATION; ISN'T THAT CORRECT?
20 A. YES.
21 Q. AND THEN YOU ALSO TALKED ABOUT PROGRESS NOTES AND YOU
22 TALKED ABOUT -- I BELIEVE YOU SAID DOCTOR'S ORDERS.
23 A. YES.
24 Q. IT'S TRUE, IS IT NOT, THAT THERE'S A SECTION IN THE
25 MEDICAL RECORDS THAT IS SPECIFICALLY DOCTOR'S ORDERS; ISN'T
129
1 THAT CORRECT?
2 A. THE FORM THAT IS -- HAS DOCTOR'S ORDERS ON IT IS HALF,
3 LEFT SIDE OF A PIECE OF PAPER THAT IS DOCTOR'S
4 ORDERS/PROGRESS NOTES. THEY RESIDE SIDE-BY-SIDE IN THE
5 RECORD.
6 Q. OKAY. AND IN THESE PARTICULAR RECORDS, IT'S TRUE, IS IT
7 NOT, THAT THE WAY THEY WERE USED IS THAT DOCTORS ACTUALLY
8 HAD ORDERS GENERALLY IN ONE AREA.
9 A. YES.
10 Q. AND THEN, GENERALLY, IN ANOTHER AREA THEY WOULD HAVE
11 PROGRESS NOTES.
12 A. YES.
13 Q. AND, IN FACT, NOT ONLY WOULD THE DOCTORS HAVE PROGRESS
14 NOTES, BUT, FOR EXAMPLE, SOCIAL WORKERS WOULD WRITE IN
15 PROGRESS NOTES, TRUE?
16 A. YES.
17 Q. AND NURSES MAY WRITE IN PROGRESS NOTES, CORRECT?
18 A. YES.
19 Q. SO WHEN THESE FOLKS SEE THOSE EXHIBITS, THERE'S PROBABLY
20 GOING TO BE A DIFFERENCE BETWEEN WHERE THE ACTUAL ORDERS ARE
21 BY THE PHYSICIAN, GENERALLY, AND WHERE THE ACTUAL PROGRESS
22 NOTES IS WHERE THE DOCTORS OR SOMEBODY ELSE IS SORT OF
23 CHARTING THE PROGRESS OF THE PATIENT; ISN'T THAT CORRECT?
24 A. NOT NECESSARILY. ON THE SHEET OF PAPER THAT HAS THE
25 PHYSICIAN'S ORDERS, RIGHT NEXT TO IT IT SAYS "PROGRESS
130
1 NOTES." GENERALLY, WHEN A PHYSICIAN SEES A PATIENT IN THE
2 HOSPITAL THEY WRITE THEIR PROGRESS NOTE FOR THAT DAY AND THE
3 ORDER IS RIGHT NEXT TO IT ON THE OTHER SIDE OF THE PAGE.
4 Q. OKAY. DO YOU UNDERSTAND, BASED UPON WHAT YOU'VE DONE IN
5 THIS CASE, THAT WHEN THOSE ACTUAL MEDICAL RECORDS ARE HERE
6 THAT ARE GOING TO BE INTRODUCED INTO EVIDENCE THAT THERE'S
7 AN ACTUAL TAB AND A SECTION FOR DOCTOR'S ORDERS AND THERE'S
8 GOING TO BE AN ACTUAL TAB AND A SECTION FOR PROGRESS NOTES?
9 DO YOU UNDERSTAND THAT?
10 A. THAT COULD BE, YES.
11 MR. STIRBA: THAT'S ALL I HAVE. THANK YOU.
12 THE COURT: OKAY. ANY REDIRECT?
13 MR. WILSON: YES. AND MAYBE MR. STIRBA CAN SHOW ME
14 HOW TO HANDLE THE MACHINE.
15 THE COURT: I THINK MR. MAY'S GOING TO HAVE TO DO
16 THAT.
17 MR. STIRBA: MR. MAY.
18 MR. WILSON: CAN I TAKE YOUR EXHIBITS, PLEASE?
19 MR. STIRBA: SURE.
20 (WHEREUPON, THERE'S AN OFF-THE-RECORD DISCUSSION.)
21 MR. WILSON: ALL RIGHT. THANK YOU.
22 REDIRECT EXAMINATION
23 BY MR. WILSON:
24 Q. JUST A COUPLE OF QUESTIONS. YOU'VE SEEN A BUNCH OF --
25 SEVERAL MEDICAL TREATMENT PLANS AND LIVING WILLS AND MEDICAL
131
1 DIRECTIVES. WHEN A PERSON IS ADMITTED TO THE HOSPITAL, ARE
2 THEY REQUIRED TO SIGN ANY NEW DOCUMENTS IN RESPECT TO THOSE
3 TYPES OF -- OF ADVANCE DIRECTIVES OR MEDICAL TREATMENT PLAN?
4 A. THEY ARE NOT REQUIRED TO DO THAT.
5 Q. OKAY. DOES THE HOSPITAL REQUEST THAT THEY BRING WITH
6 THEM ANY PRIOR MEDICAL TREATMENT PLANS OR LIVING WILLS AT
7 THE TIME OR ASK THEM IF THEY HAVE THOSE IN PLACE?
8 A. THE HOSPITAL IS REQUIRED TO ASK PATIENTS IF THEY HAVE AN
9 ADVANCE DIRECTIVE OR A LIVING WILL OR A DURABLE POWER OF
10 ATTORNEY. IF THEY HAVE ONE, WE REQUEST THAT THEY BRING IT
11 TO THE HOSPITAL IF THEY DON'T HAVE IT WITH THEM. IT IS THEN
12 MADE A PART OF THE MEDICAL RECORD.
13 IF THEY DO NOT HAVE ONE, WE OFFER THEM THE OPPORTUNITY
14 TO MAKE ONE. AND WE HAVE STAFF IN THE HOSPITAL THAT WILL
15 ASSIST WITH THAT PROCESS, IF THEY SO CHOOSE.
16 Q. OKAY.
17 THE WITNESS: TURN IT SO YOU CAN READ IT, LOOKING
18 AT IT.
19 THE COURT: IT'S THE OTHER WAY.
20 MR. WILSON: I GOT TO TURN IT THIS WAY, DON'T I?
21 ALL RIGHT.
22 Q. (BY MR. WILSON) THIS IS THE FIRST ITEM, I THINK, THAT
23 COUNSEL SHOWED TO YOU. WHAT DATE DOES THAT BEAR?
24 A. LOOKS LIKE THE 17TH OF JUNE, '95.
25 Q. OKAY. AND WHAT DATE DOES THE SIGNATURE BEAR DOWN ON THE
132
1 ATTENDING PHYSICIAN?
2 A. OH, THAT'S WHAT I WAS LOOKING AT. THAT LOOKS LIKE THE
3 17TH OF JUNE. THE ONE AT THE TOP SAYS THE 19TH OF JUNE.
4 Q. JUST -- JUST LOOKING DOWN HERE FURTHER WHERE YOU HAVE
5 THE SIGNATURE LINE -- MAYBE YOU COULD STEP UP TO THE BOARD.
6 A. RIGHT HERE?
7 Q. YES. DOES THAT LOOK LIKE JUNE --
8 A. THAT ONE LOOKS LIKE THE 17TH OF JUNE TO ME.
9 Q. OKAY.
10 A. OR THE 19TH.
11 Q. WOULD YOU LOOK UP IN THE PRINTING AT THE TOP? DOES THAT
12 SAY ANYTHING ABOUT THE 17TH DAY OF JULY?
13 A. YEAH, RIGHT HERE.
14 Q. OKAY. IN RESPECT TO YOUR REVIEW, THIS WAS -- YOU'VE
15 TESTIFIED THAT THIS APPEARED TO BE -- YOU BELIEVED IT TO BE
16 ONE OF THE RECORDS THAT WAS CONTAINED IN BARBARA POHLMAN --
17 OR I SHOULD SAY ELLEN ANDERSON'S MEDICAL RECORD; IS THAT
18 CORRECT?
19 A. YES.
20 Q. SO WOULD THIS BE SOMETHING THAT WAS BROUGHT FROM ANOTHER
21 ENTITY TO -- TO BE PLACED IN HER MEDICAL FILE?
22 A. YES.
23 Q. OKAY. YOU DON'T HAVE ANY PERSONAL KNOWLEDGE, DO YOU, AS
24 TO WHAT WAS HAPPENING TO ELLEN ANDERSON AT THE TIME THAT SHE
25 EXECUTED THAT DIRECTIVE OR HER DAUGHTER EXECUTED IT FOR HER?
133
1 A. NONE.
2 Q. SO YOU DON'T KNOW WHAT THE CIRCUMSTANCES WERE
3 SURROUND -- FOR THE EXECUTION OF THAT MEDICAL TREATMENT
4 PLAN.
5 A. YOU'RE RIGHT, I DON'T.
6 Q. OKAY. IN RESPECT TO THE NEXT EXHIBIT -- WELL, LET ME
7 SHOW YOU THE -- THE ONE THAT WAS SIGNED BY KAREN BRINGHURST,
8 DOWN AT THE BOTTOM?
9 A. YES.
10 Q. LET ME JUST MOVE IT DOWN HERE A WAYS. WHEN A
11 PHYSICIAN -- WHAT DATE DOES THAT BEAR AT THE TOP?
12 A. 12/28/95.
13 Q. AND WHAT DATE DOES IT BEAR BY THE PHYSICIAN'S SIGNATURE?
14 A. 12/30/95.
15 Q. OKAY. DO YOU HAVE ANY INFORMATION AS TO WHEN THAT
16 PARTICULAR DOCUMENT WAS FILLED OUT?
17 A. I WOULD ASSUME IT WAS --
18 MR. STIRBA: WELL, I'M GOING TO OBJECT, YOUR HONOR.
19 IT'S -- HER ASSUMPTION IS IRRELEVANT. SHE EITHER KNOWS OR
20 SHE DOESN'T, AND I DON'T THINK THERE'S ADEQUATE FOUNDATION
21 THAT SHE WOULD.
22 MR. WILSON: OKAY.
23 Q. (BY MR. WILSON) LET ME ASK YOU THIS. WHEN THE -- WHEN
24 THE PHYSICIAN FILLS THIS OUT, IS HE REQUIRED TO FILL IN THE
25 BLANKS?
134
1 A. I WOULD EXPECT SO.
2 Q. IS THERE ANYTHING THERE AS TO -- A CHECK MARK OR
3 ANYTHING AS TO WHO IT WAS SIGNED BY?
4 A. I'M SORRY, I DON'T FOLLOW YOU.
5 Q. WELL, IT HAS SEVERAL BLANKS. FIRST OF ALL, THE
6 PATIENT'S NAME IS BLANK.
7 A. YES.
8 Q. THE PHYSICIAN'S NAME IS -- IS BLANK.
9 A. CORRECT.
10 Q. THERE'S NOTHING INDICATING WHAT KIND OF DISEASE OR
11 ILLNESS THIS PERSON IS -- IS SUFFERING FROM, IS THERE?
12 A. YEAH, YOU'RE RIGHT.
13 Q. AND IT DOESN'T INDICATE WHETHER IT'S DIRECTED BY THE
14 DECLARANT OR WHETHER IT'S DIRECTED BY SOMEBODY RELATED TO
15 THE DECLARANT, DOES IT?
16 A. RIGHT.
17 Q. WHEN THOSE ITEMS ARE FILLED OUT AT THE HOSPITAL, DO YOU
18 KNOW WHETHER OR NOT THEY'RE -- ARE THEY GIVEN ASSISTANCE IN
19 FILLING THOSE ITEMS OUT, THOSE PARTICULAR TYPES OF MEDICAL
20 TREATMENT PLANS? AGAIN, I'LL SHOW YOU THE -- THE DOCUMENT.
21 A. I CAN'T TESTIFY TO WHAT THEY DID THEN.
22 Q. OKAY. IS THERE ANY POLICY OR PROCEDURE AS TO HOW THOSE
23 SHOULD BE PRESENTED TO -- TO THE PATIENT?
24 A. NOT THAT I'M AWARE OF, BUT --
25 Q. OKAY. SHOW YOU THE DOCUMENT THAT YOU PREVIOUSLY
135
1 TESTIFIED TO. YOU THINK IT WAS PART OF THE MEDICAL RECORD?
2 A. YES.
3 Q. AND THAT APPEARS TO HAVE THE SIGNATURE OF MERLIN LARSEN;
4 IS THAT CORRECT?
5 A. YES.
6 Q. DOES THAT PARTICULAR MEDICAL TREATMENT PLAN, IS IT A
7 FORM FROM A DAVIS HOSPITAL?
8 A. THERE'S NO WAY FOR ME TO TELL.
9 Q. OKAY.
10 A. IT'S NOT IDENTIFIED AS DAVIS HOSPITAL.
11 Q. SHOW YOU THE SECOND PART OF -- EXCUSE ME. IS THERE ANY
12 INDICATION ON THAT DOCUMENT THAT IT BEARS A DIFFERENT DATE
13 THAN SEPTEMBER THE 19TH, 1985?
14 A. NO.
15 Q. OKAY. DO YOU KNOW A DR. SUMKO?
16 A. NO, I DO NOT.
17 Q. OKAY.
18 MR. WILSON: I HAVE NO FURTHER QUESTIONS, YOUR
19 HONOR.
20 THE COURT: OKAY. ANYTHING FURTHER OF THIS
21 WITNESS?
22 MR. STIRBA: NO, YOUR HONOR. THANK YOU.