2963
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Trial Transcript Vols. 14 - 17
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 14 OF 21
13 JUNE 28, 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
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1 (WHEREUPON, THE MORNING SESSIONS BEGINS.)
2 THE COURT: OKAY. WE ARE ON THE RECORD WITH
3 COUNSEL PRESENT BEFORE THE JURY COMES IN THIS MORNING.
4 YESTERDAY WE ARGUED -- THE ARGUMENTS WERE HELD ON THE MOTION
5 FOR A DIRECTED VERDICT. I TOOK UNDER ADVISEMENT THE CASE OF
6 ELLEN ANDERSON.
7 BOTH PARTIES HAVE AGREED THAT THE STANDARD TO FOLLOW
8 IS -- ON THIS MOTION IS WHETHER THE EVIDENCE AND ALL
9 INFERENCES THAT CAN BE REASONABLY DRAWN FROM IT ESTABLISH
10 THAT SOME EVIDENCE EXISTS FROM WHICH A REASONABLE JURY COULD
11 FIND THE ELEMENTS OF THE CRIME HAD BEEN PROVEN BEYOND A
12 REASONABLE DOUBT.
13 THIS THING HAS TROUBLED ME, AND I EITHER -- AND WHAT
14 I'M GOING TO DO AT THIS POINT IS BASICALLY DENY THE MOTION.
15 I'M GOING TO MAKE A POINT THAT RULE 17(O) OF THE UTAH RULES
16 OF CRIMINAL PROCEDURE STATES THAT AT THE CONCLUSION OF THE
17 EVIDENCE BY THE PROSECUTION, OR AT THE CONCLUSION OF ALL THE
18 EVIDENCE, THE COURT MAY ISSUE AN ORDER DISMISSING ANY
19 INFORMATION OR ANY INDICTMENT OR ANY COUNT THEREOF, UPON THE
20 GROUND THAT THE EVIDENCE IS NOT LEGALLY SUFFICIENT TO
21 ESTABLISH THE OFFENSE CHARGED THEREIN OR ANY LESSER INCLUDED
22 OFFENSE.
23 AND SO, BASICALLY, THAT GIVES THE OPPORTUNITY TO LOOK
24 AT IT AT TWO POINTS, IF COUNSEL WANTS TO BRING IT UP. BUT
25 AT THIS POINT I'M GOING TO DENY THE MOTION AS TO ELLEN
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1 ANDERSON.
2 SO IS THERE ANYTHING ELSE WE NEED TO DISCUSS BEFORE WE
3 BEGIN TODAY?
4 MR. STIRBA: WE HAVE NOTHING, YOUR HONOR.
5 THE COURT: OKAY.
6 MR. WILSON: THE STATE HAS NOTHING, YOUR HONOR.
7 THE COURT: OKAY. AND DO WE HAVE OUR FIRST WITNESS
8 HERE?
9 MR. STIRBA: YES. I'LL BRING HER IN.
10 THE COURT: WELL, I THINK WE BETTER WAIT.
11 MR. STIRBA: OKAY.
12 THE COURT: WELL, I MEAN, YOU CAN BRING THE WITNESS
13 IN. THAT'S FINE. BUT THEN -- DO YOU WANT TO SEE IF THE
14 JURY -- I MEAN, WE'RE A LITTLE EARLY SO WE MAY HAVE TO TAKE
15 A FEW MINUTES.
16 (WHEREUPON, AT THIS TIME THE JURY ENTERS THE
17 COURTROOM.)
18 THE COURT: THE RECORD WILL REFLECT THAT THE -- THE
19 JURY IS PRESENT. THIS, AGAIN, SHOWS THAT WE'RE EVEN HERE
20 EARLY TODAY. NOW, ALL THE JURORS ALWAYS COME EARLY AND WE
21 STARTED COURT EARLY TODAY, SO I JUST WANT TO -- THAT WILL
22 MAKE UP -- I KNOW THREE MINUTES DOESN'T MAKE UP FOR THE
23 TIMES WE'VE WAITED, BUT WE ARE STARTING JUST A FEW MINUTES
24 EARLY.
25 OKAY. WE HAVE NOW FINISHED THE STATE'S CASE AND IT'S
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1 NOW TIME TO HEAR THE DEFENDANT'S CASE.
2 MR. STIRBA, ARE YOU READY TO CALL YOUR FIRST WITNESS?
3 MR. STIRBA: WE ARE, YOUR HONOR. AND THE DEFENSE
4 WOULD CALL DR. LAUREL HERBST TO THE STAND.
5 THE COURT: OKAY. IF YOU'D COME FORWARD AND BE
6 SWORN.
7 LAUREL HERMANSON HERBST,
8 BEING FIRST DULY SWORN, WAS EXAMINED AND TESTIFIED
9 AS FOLLOWS:
10 DIRECT EXAMINATION
11 BY MR. STIRBA:
12 Q. DOCTOR, PLEASE STATE YOUR FULL NAME AND SPELL YOUR LAST
13 NAME, PLEASE.
14 A. IT'S LAUREL HERMANSON HERBST, H-E-R-B-S-T.
15 Q. AND WHERE DO YOU RESIDE?
16 A. IN SAN DIEGO, CALIFORNIA.
17 Q. AND, PRESENTLY, ARE YOU EMPLOYED?
18 A. YES.
19 Q. AND WOULD YOU TELL US, PLEASE, WHAT YOU DO FOR A LIVING?
20 A. I'M VICE-PRESIDENT OF MEDICAL AFFAIRS AT SAN DIEGO
21 HOSPICE. I'VE BEEN THE MEDICAL DIRECTOR THERE SINCE 1978.
22 Q. AND, GENERALLY, WHAT DO YOU DO IN YOUR CAPACITY AS
23 VICE-PRESIDENT OF SAN DIEGO HOSPICE?
24 A. I'M IN CHARGE OF ALL THE MEDICAL CARE FOR THE TERMINALLY
25 ILL PATIENTS THAT WE CARE FOR. I SUPERVISE THE OTHER
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1 PHYSICIANS, I TRAIN THE MEDICAL STUDENTS AND RESIDENTS FROM
2 THE UNIVERSITY AND THREE OR FOUR OTHER FACILITIES AROUND US.
3 Q. AND YOU HAVE AN M.D. DEGREE?
4 A. I DO.
5 Q. AND WOULD YOU TELL US, PLEASE, WHAT EDUCATION YOU'VE HAD
6 IN THE FIELD OF MEDICAL TRAINING?
7 A. I ATTENDED THE UNIVERSITY OF SOUTHERN CALIFORNIA,
8 RECEIVED MY M.D. IN 1969. I DID A STRAIGHT MEDICINE
9 RESIDENCY AT L.A. COUNTY U.S.C. MEDICAL CENTER, AND THEN
10 FINISHED INTERNAL MEDICINE AT THE SAME INSTITUTION IN 1972.
11 I COMPLETED A HEMATOLOGY/ONCOLOGY FELLOWSHIP IN 1975 AT THE
12 V.A. MEDICAL CENTER IN SAN FRANCISCO.
13 I AM SELF TAUGHT AS A PALLIATIVE CARE PHYSICIAN, AS
14 MOST OF US ARE AT THIS STAGE OF THE GAME; HOWEVER, I AM
15 BOARD CERTIFIED IN PALLIATIVE MEDICINE BY THE NEW BOARD FROM
16 THE AMERICAN BOARD OF HOSPICE AND PALLIATIVE MEDICINE.
17 Q. OKAY. TELL US, PLEASE, WHAT YOU MEAN BY PALLIATIVE
18 MEDICINE.
19 A. IT COMES -- PALLIATIVE COMES FROM THE LATIN WORD PALLIUM
20 WHICH MEANS TO COVER. AND IT MEANS TO AMELIORATE SYMPTOMS
21 OR MAKE PEOPLE FEEL BETTER WITHOUT ATTEMPTING TO CURE THE
22 DISEASE. IT'S A TERM THAT'S APPLIED TO END-OF-LIFE CARE AS
23 THE WHOLE BODY OF KNOWLEDGE THAT'S INTENDED TO MAKE PATIENTS
24 MORE COMFORTABLE.
25 Q. AND WHAT DO YOU MEAN THAT YOU HAVE BOARD CERTIFICATION
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1 IN THE FIELD OR AREA OF PALLIATIVE CARE?
2 A. THE AMERICAN BOARD OF HOSPICE AND PALLIATIVE MEDICINE
3 WAS ORGANIZED TO ASCERTAIN THE CREDENTIALS OF PHYSICIANS WHO
4 HELD THEMSELVES OUT TO BE SPECIALISTS IN PALLIATIVE
5 MEDICINE.
6 TO SIT FOR THE BOARD YOU HAVE TO HAVE A MINIMUM OF TWO
7 YEARS EXPERIENCE AND PROVE EXPERIENCE IN PATIENT CARE. YOU
8 ALSO, UNIQUELY TO THIS BOARD, ARE REQUIRED TO HAVE
9 RECOMMENDATIONS FROM NONPHYSICIANS THAT YOU'RE A NICE PERSON
10 AND CAN WORK IN A TEAM. THEN YOU SIT FOR A TEST AND THE
11 EXAM COVERS ALL OF THE MEDICAL CARE OF THESE PATIENTS.
12 Q. DO YOU HAVE OTHER BOARD CERTIFICATIONS IN THE FIELD OR
13 FIELDS OF MEDICINE?
14 A. I'M BOARD CERTIFIED IN INTERNAL MEDICINE AND IN
15 HEMATOLOGY.
16 Q. AND WHAT DOES -- WHAT IS ENTAILED IN TERMS OF YOUR BOARD
17 CERTIFICATION AS AN INTERNAL MEDICINE DOCTOR?
18 A. TO BE BOARD CERTIFIED IN INTERNAL MEDICINE YOU MUST
19 COMPLETE A CERTIFIED RESIDENCY IN INTERNAL MEDICINE, AND
20 PASS AN EXAM AFTER THEY GET RECOMMENDATIONS FROM YOUR
21 INSTRUCTORS IN THE TRAINING PROGRAMS.
22 Q. AND YOU MENTIONED HEMATOLOGY. WHAT AREA OF THE PRACTICE
23 IS THAT?
24 A. IT'S THE STUDY OF DISEASES RELATED TO THE BLOOD SYSTEM.
25 SO IT WOULD BE ANEMIAS, LEUKEMIAS, THINGS LIKE THAT. AGAIN,
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1 YOU MUST HAVE HAD A CERTIFIED RESIDENCY IN THAT AREA,
2 RECOMMENDATIONS FROM THE PEOPLE WHO TAUGHT YOU, AND THEN
3 PASS AN EXAM.
4 Q. NOW, YOU MENTIONED SAN DIEGO HOSPICE. WHAT GENERALLY --
5 WHAT KIND OF CARE DOES SAN DIEGO HOSPICE PROVIDE?
6 A. SAN DIEGO HOSPICE WAS ORGANIZED IN 1978 TO PROVIDE CARE
7 TO TERMINALLY ILL PATIENTS, NOT NECESSARILY JUST WITH
8 CANCER, BUT WITH ANY KIND OF DISEASE THAT CAN MAKE A PERSON
9 DIE. AND THE INTENTION WAS TO PROVIDE CARE FOR ABOUT THE
10 LAST SIX MONTHS OF LIFE, TO ENHANCE THE PATIENT'S QUALITY OF
11 LIFE THROUGH COMFORT CARE, AND SUPPORT OF PSYCHOSOCIAL AND
12 SPIRITUAL CARE AS WELL.
13 Q. NOW, YOU HAVE BEEN RETAINED AS AN EXPERT WITNESS IN THIS
14 CASE; IS THAT RIGHT?
15 A. I HAVE.
16 Q. AND YOU ARE PREPARED TO RENDER OPINIONS WITH RESPECT TO
17 CERTAIN RECORDS THAT YOU HAVE REVIEWED?
18 A. YES.
19 Q. COULD YOU JUST GENERALLY TELL THE JURY WHAT INFORMATION
20 YOU HAVE REVIEWED FOR PURPOSES OF YOUR TESTIMONY THIS
21 MORNING?
22 A. I WAS SENT THE MEDICAL RECORDS OF THE PATIENTS IN
23 QUESTION: LYDIA SMITH, JUDITH LARSEN, ENNIS ALLDREDGE,
24 ELLEN ANDERSON, AND MARY CRANE. AND THE RECORDS I REVIEWED
25 WERE FROM THE GEROPSYCHIATRIC UNIT OF DAVIS HOSPITAL AND
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1 MEDICAL CENTER. AND THEN YESTERDAY I WAS ABLE TO REVIEW
2 SOME OF THE PRIOR HOSPITAL RECORDS OF THESE PATIENTS AS
3 WELL.
4 Q. NOW, ARE THERE CERTAIN GUIDELINES IN THE FIELD OF
5 END-OF-LIFE CARE RELATING TO A DIAGNOSES OF A TERMINAL
6 CONDITION?
7 A. YES.
8 Q. AND WOULD YOU GENERALLY TELL US WHAT THOSE GUIDELINES
9 ARE?
10 A. THE GUIDELINES WERE BASICALLY CREATED FOR NONCANCER
11 PATIENTS IN 1995. THE GOVERNMENT THAT PAYS FOR HOSPICE CARE
12 FOR MEDICARE PATIENTS WAS CONCERNED SOME PATIENTS WERE
13 LIVING TOO LONG UNDER HOSPICE CARE AND WANTED TO KNOW HOW TO
14 TELL WHEN PATIENTS WERE TERMINALLY ILL. THEY BELIEVED THAT
15 CANCER PATIENTS WERE EASY TO TELL BECAUSE THEY HAD A KNOWN
16 PROGRESSION OF -- AND COURSE OF THE DISEASE.
17 THE GUIDELINES WERE CREATED TO TELL WHAT THE CURRENT
18 LITERATURE SHOWS WOULD PREDICT A TERMINAL ILLNESS IN A
19 NUMBER OF OTHER DISEASES LIKE CARDIAC DISEASE, PULMONARY
20 DISEASE, THE DEMENTIAS, LOU GEHRIG'S DISEASE AND SO ON.
21 Q. WHO CREATED THE GUIDELINES?
22 A. IT WAS A COMMITTEE FROM THE NATIONAL HOSPICE
23 ORGANIZATION WITH INPUT FROM THE HEALTH CARE FINANCING
24 ADMINISTRATION, MEDICARE BRANCH.
25 Q. AND WHEN YOU TALK ABOUT HEALTH CARE FINANCING
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1 ADMINISTRATION, MEDICARE BRANCH, ARE YOU RELATING TO THE
2 FEDERAL GOVERNMENT MEDICARE PROGRAM?
3 A. YES. IT'S THE PEOPLE WHO PAY FOR THE CARE.
4 Q. YOU TALKED ABOUT HOSPICE. PERHAPS MAYBE COULD YOU TELL
5 US PLEASE WHAT HOSPICE CARE MEANS AND WHAT IT ENTAILS?
6 A. HOSPICE CARE IS A SYSTEM OF CARE FOR TERMINALLY ILL
7 PATIENTS THAT WAS EVOLVED IN THE MODERN SENSE IN THE
8 MID-60'S, LATE 60'S IN ENGLAND. DR. CECILY SAUNDERS WAS THE
9 FOUNDER OF THE MODERN HOSPICE MOVEMENT, BUT WAS DRAWING ON
10 EXPERIENCE FROM OTHER PEOPLE WHEN SHE CREATED A SYSTEM THAT
11 WOULD MANAGE PAIN, WOULD MANAGE VOMITING, OTHER SYMPTOMS
12 LIKE THAT, AND PROVIDE AN OPPORTUNITY FOR CLOSURE, SPIRITUAL
13 CARE AND SO ON.
14 THE TERM HOSPICE IS ANOTHER LATIN DERIVED WORD.
15 H-O-S-P-E-S IN LATIN IS THE ROOT WORD FOR HOTEL,
16 HOSPITALITY, HOSPITAL, AND SO ON, A LOT OF WORDS WE NORMALLY
17 USE.
18 THE ORIGINAL HOSPICES IN THE MIDDLE AGES WERE WAY
19 STATIONS FOR PILGRIMS GOING TO THE HOLY LAND. AND SO THE
20 WORD WAS USED TO APPLY TO THE MODERN CARE AS THE PEOPLE WHO
21 WERE TRANSITIONING TO AN AFTERLIFE WERE CONSIDERED HOLY AND
22 SHOULD BE TREATED WITH MORE RESPECT.
23 THE CURRENT AND MODERN SYSTEM OF HOSPICE CARE IN THE
24 UNITED STATES IS ACCEPTED BY ALL MAJOR INSURANCE AGENCIES
25 NOW AS THE OPTIMUM WAY TO CARE FOR DYING PATIENTS.
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1 THE REASON THE SYSTEM WORKS IS THAT WE MEET ALL OF THE
2 HIEARCHY OF HUMAN NEED, NOT JUST THE PHYSICAL CARE, BUT THE
3 INFORMATION THAT PROVIDES SECURITY, THE SOCIAL SUPPORT
4 SYSTEMS THAT CREATE COMFORT FOR THE FAMILY, AND THE
5 SPIRITUAL SUPPORT FOR SELF-ACTUALIZATION OR THE -- THE
6 ANSWER TO THEIR QUESTION -- THAT THE PATIENT CAN ADDRESS THE
7 QUESTION, WHY AM I HERE.
8 Q. DOES MEDICATION PLAY A ROLE IN PROVIDING END-OF-LIFE
9 CARE OR HOSPICE CARE?
10 A. SYMPTOM MANAGEMENT IS ABSOLUTELY CRITICAL TO THE
11 ACHIEVEMENT OF THE OTHER HUMAN GOALS. UNTIL A PATIENT IS
12 NOT IN PAIN AND HAS STOPPED VOMITING AND HAS STOPPED BEING
13 SHORT OF BREATH, HE CANNOT ADDRESS ANY EXISTENTIAL ISSUES OR
14 EVEN SAY GOODBYE TO HIS FAMILY.
15 Q. AND DOES MORPHINE PARTICULARLY PLAY A ROLE IN TERMS OF
16 END-OF-LIFE CARE OR SYMPTOM RELIEF AT THE END OF ONE'S LIFE?
17 A. PAIN MANAGEMENT IS CONSIDERED THE FIRST GOAL FOR ALL
18 PATIENTS IN END-OF-LIFE CARE, AND THE WORLD HEALTH
19 ORGANIZATION RECOGNIZES MORPHINE AS THE GOAL STANDARD FOR
20 PAIN MANAGEMENT ON A WORLDWIDE BASIS FOR PALLIATIVE CARE.
21 Q. AND -- AND WHY IS IT, IN PARTICULAR, THAT MORPHINE IS
22 RECOGNIZED AS THE GOAL STANDARD IN END-OF-LIFE CARE?
23 A. IT IS PROBABLY THE OLDEST PAIN MEDICATION THAT WE HAVE
24 AVAILABLE. WE'VE USED IT BEYOND THE MEMORY OF ANY OF US IN
25 MEDICINE. WE KNOW HOW IT WORKS, WE KNOW ITS SIDE EFFECTS.
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1 IT'S READILY AVAILABLE THROUGHOUT THE WORLD. AND IT'S THE
2 STANDARD BY WHICH ALL OTHER PAIN MEDICATIONS ARE JUDGED WHEN
3 YOU LOOK AT CONVERSION TABLES OF HOW TO TRANSLATE DOSES FROM
4 ONE DRUG TO ANOTHER, IT'S ALWAYS BASED ON A MORPHINE
5 STANDARD.
6 Q. NOW, YOU -- YOU TALKED ABOUT RELIEF FROM SYMPTOMS.
7 COULD YOU JUST GENERALLY TELL US, PLEASE, THE KIND OF
8 SYMPTOMS THAT YOU TREAT AT END OF LIFE?
9 A. FIRST, PAIN, AND PREDOMINANTLY WE DO THAT WITH
10 MEDICATIONS. THEN WE USE OTHER MEDICATIONS TO TREAT THE
11 OTHER KINDS OF SYMPTOMS PATIENTS MAY HAVE AT THE END OF
12 LIFE. FOR MANY PEOPLE NAUSEA AND VOMITING IS AS NOXIOUS A
13 COMPLAINT AS PAIN. SHORTNESS OF BREATH, ANXIETY,
14 SLEEPLESSNESS, WEIGHT LOSS, LACK OF APPETITE, CONSTIPATION,
15 DIARRHEA, IT DEPENDS ON WHAT'S WRONG WITH THE PATIENT WHICH
16 SET OF SYMPTOMS THEY GET, BUT ALL PATIENTS HAVE A NUMBER OF
17 ISSUES.
18 NUMBER OF SITES OF PAIN MAY VARY. THE AVERAGE PATIENT
19 ADMITTED TO A HOSPICE PROGRAM HAS MORE THAN THREE DIFFERENT
20 CAUSES OF PAIN GOING ON AT ONE TIME. AND THEN YOU MULTIPLY
21 EACH OF THE SYMPTOMS BY MULTIPLE CAUSES AND YOU CAN SEE THAT
22 IT'S A VERY COMPLEX PROCESS OFTEN TO MAKE SURE THAT PATIENTS
23 ARE VERY COMFORTABLE.
24 Q. DOES MEDICARE PAY FOR HOSPICE BENEFITS OR END-OF-LIFE
25 CARE?
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1 A. YES.
2 Q. AND IS THERE A PARTICULAR TIME FRAME IN WHICH THOSE
3 BENEFITS ARE AVAILABLE?
4 A. THE PATIENT MUST HAVE A TERMINAL ILLNESS AND THE
5 PHYSICIAN HAS TO CERTIFY THAT THE PATIENT'S PROGNOSIS IS SIX
6 MONTHS OR LESS IF THE DISEASE RUNS ITS NORMAL COURSE.
7 Q. NOW, YOU'VE -- YOU'VE TOLD US ABOUT THE GUIDELINES.
8 A. UH-HUH.
9 Q. CAN YOU GIVE US AN EXAMPLE OR TELL US HOW THE GUIDELINES
10 ARE USED IN PROVIDING END-OF-LIFE CARE OR IN HOSPICE WORK?
11 A. IF WE WERE TO TAKE CARDIAC DISEASE, AS AN EXAMPLE,
12 PATIENTS WHO HAVE END STAGE HEART DISEASE ARE ELIGIBLE FOR
13 HOSPICE CARE IF THEIR PROGNOSIS IS GOING TO BE ABOUT SIX
14 MONTHS OR LESS IN THE NORMAL CIRCUMSTANCE.
15 THE WAY WE WOULD DETERMINE THAT PROGNOSIS IS TO
16 DETERMINE WHETHER THE PATIENT IS HAVING SYMPTOMS AT REST. A
17 PATIENT WHO HAS A DIAGNOSIS OF HEART DISEASE BUT IS ABLE TO
18 GET UP AND AROUND AND LEAD A NORMAL LIFE IS NOT TERMINALLY
19 ILL WITH THE PROGNOSIS OF SIX MONTHS OR LESS. IF A PATIENT
20 HAS DIFFICULTY BREATHING, EVEN WITH MINIMAL ACTIVITY LIKE
21 TALKING OR TRYING TO GET ACROSS THE ROOM TO THE BATHROOM,
22 THAT WOULD BE A SIGN THAT THE PATIENT IS SYMPTOMATIC AT
23 REST.
24 PATIENTS WHO HAVE SUCH SEVERE DISEASE THAT MEDICATION
25 FOR THE HEART DISEASE NO LONGER IMPROVES HIS OR HER
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1 CONDITION ARE CONCERNED TERMINALLY ILL.
2 SO THE CRITERIA FOR HEART DISEASE REQUIRE SYMPTOMS AT
3 REST, MAXIMAL THERAPY HAS FAILED OR HAS BEEN TRIED AND CAN'T
4 BE TOLERATED BY THE PATIENT, OR THERE ARE OTHER ISSUES LIKE
5 THAT THE BLOOD FLOW THROUGH THE HEART TO THE REST OF THE
6 BODY IS SO LOW THAT IT CAN'T SUSTAIN LIFE. THOSE PATIENTS
7 WOULD BE THEN ADMITTED TO HOSPICE CARE.
8 Q. ARE -- ARE THERE GUIDELINES THAT RELATE TO PATIENTS WHO
9 ARE SEVERELY DEMENTED?
10 A. YES, THERE ARE.
11 Q. AND -- AND JUST GENERALLY, HOW DO THOSE GUIDELINES WORK
12 IN TERMS OF A DETERMINATION OF A TERMINAL CONDITION?
13 A. THERE ARE A COUPLE OF FUNCTIONAL SCALES DEALING WITH
14 DEMENTIA THAT ARE APPLIED TO THESE PATIENTS. ONE IS CALLED
15 A FUNCTIONAL ASSESSMENT SCALE. AND WHEN YOU TALK ABOUT
16 FUNCTION IN A HUMAN, IT'S ALL OF THE THINGS THAT YOU DO
17 EVERY DAY. PATIENTS WHO HAVE A DIAGNOSIS OF MILD DEMENTIA,
18 BUT ARE STILL ABLE TO MAKE IT AT WORK, HAVE A FUNCTIONAL
19 ASSESSMENT OR A F.A.S. LEVEL 2. AND THEN AS --
20 Q. NOW, LET ME -- LET ME JUST SLOW YOU DOWN HERE. IN TERMS
21 OF YOUR REFERENCE TO F.A.S. OR FUNCTIONAL ASSESSMENT 2,
22 YOU'RE GOING TO HAVE TO EXPLAIN TO US WHAT THAT MEANS AND
23 WHERE THAT'S COMING FROM.
24 A. RIGHT. THAT'S WHERE I WAS TRYING TO GO. I'M SORRY.
25 Q. OKAY. I'M SORRY.
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1 A. I DIDN'T WANT TO TELL THEM FUNCTIONAL ASSESSMENT 7 UNTIL
2 I EXPLAINED WHAT WAS NORMAL.
3 Q. OH, OKAY. ALL RIGHT.
4 A. OKAY. YOU AND I ARE A 1. WE DON'T HAVE ANY SYMPTOMS.
5 A 2, WE HAVE MINIMAL SYMPTOMS. A 3, THE BOSS PROBABLY HAS
6 FIRED YOU BECAUSE YOU'RE MAKING TOO MANY MISTAKES AT WORK,
7 BUT YOU STILL GET AROUND THE HOUSE AND YOU CAN COOK YOUR
8 LUNCH AND YOU CAN DRESS YOURSELF AND TAKE YOUR OWN SHOWERS
9 AND YOU'RE NOT A PROBLEM TO YOUR FAMILY.
10 WHEN YOU START TO GET TO A FUNCTION LEVEL 4 IN
11 ALZHEIMER'S DISEASE OR OTHER DEMENTIAS, YOU BEGIN TO BE
12 NOTICEABLY FORGETFUL TO EVERYONE AROUND YOU. SOMETIMES YOU
13 GET DIRTY CLOTHES ON AND YOU FORGET YOU WORE THEM YESTERDAY.
14 YOU -- YOU KIND OF LEAVE THE STOVE BURNING IF YOU TRIED TO
15 MAKE A GRILLED CHEESE SANDWICH. YOU KNOW, LITTLE FORGETFUL
16 EPISODES, BUT YOU'RE STILL TALKATIVE AND COMMUNICATING WITH
17 PEOPLE.
18 WHEN THE FUNCTION LEVEL 5 COMES, YOU MAY HAVE TROUBLE
19 DECIDING NORMAL DAILY ROUTINES. YOU NEED TO BE TALKED
20 THROUGH GETTING DRESSED, TOLD TO GO TO THE BATHROOM. YOU
21 WOULD GET LOST IF YOU LEFT THE HOUSE.
22 AND A FUNCTION LEVEL 6, YOU BEGIN TO BE INCONTINENT OF
23 URINE AND BOWELS SO THAT YOU WET YOUR PANTS, YOU CAN'T MAKE
24 IT TO THE BATHROOM TO HAVE A BOWEL MOVEMENT. YOU'RE HAVING
25 DIFFICULTY CARRYING ON CONVERSATIONS. YOU HAVE TO BE
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1 REMINDED TO EAT. PEOPLE SIT FOOD IN FRONT OF YOU AND THEY
2 SAY TAKE YOUR SPOON, YOU KNOW, EAT YOUR MACARONI AND CHEESE,
3 THAT KIND OF THING.
4 WHEN ONE REACHES A FUNCTION LEVEL 7, THEY HAVE
5 SUBDIVIDED IT INTO SEVERAL SUBCATEGORIES, BEGINNING WITH AT
6 A FUNCTION 7(A) THE PATIENT CAN MAYBE SPEAK SIX MEANINGFUL
7 WORDS A DAY. IF I ASK YOU HOW YOU ARE AND YOU SAY FINE,
8 THAT WOULD COUNT AS ONE BECAUSE YOUR NEXT STEP WOULD BE TO
9 BABBLE AT ME ABOUT SOMETHING CRAZY.
10 AT A FUNCTION LEVEL 2 THAT SPEECH LEVEL IS DOWN TO
11 PERHAPS ONE OR TWO MEANINGFUL WORDS IN A DAY, NO MORE.
12 AT A FUNCTION LEVEL 3, YOU'RE NO LONGER SPEAKING AND
13 YOU ACTUALLY HAVE DIFFICULTY PHYSICALLY WITH BEING ABLE TO
14 SIT. YOU CAN'T SIT UP IN A CHAIR WITHOUT BEING SUPPORTED.
15 YOU NEED TO BE TAKEN CARE OF DAY AND NIGHT. IT'S LIKE THE
16 STATE OF A BABY AT THAT POINT.
17 AND THEN THAT PROGRESSES TO LATER WHERE THE PATIENT CAN
18 NO LONGER EVEN SMILE PHYSICALLY, DEVELOPS CONTRACTURES SO
19 THAT THE MUSCLES ARE TIGHT, THE ARMS CAN'T BE EXTENDED, THE
20 LEGS CAN'T BE EXTENDED. AND THOSE PATIENTS THEN TEND TO
21 HAVE A LOT OF COMPLICATIONS LIKE BED SORES AND PNEUMONIA,
22 BLADDER INFECTIONS, THINGS THAT THEIR WHOLE BODY SYSTEM IS
23 JUST FAILING FROM THE LACK OF BEING ABLE TO PARTICIPATE IN
24 THEIR CARE.
25 Q. CAN YOU -- CAN YOU TELL US WHERE THE -- THE FUNCTION
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1 SCALE THAT YOU'VE JUST TESTIFIED TO ORIGINATED FROM OR WAS
2 DEVELOPED OUT OF?
3 A. IT WAS DEVELOPED PRIMARILY IN THE VETERAN'S
4 ADMINISTRATION MEDICAL SYSTEM TO HELP ASSESS THE PROGRESS OF
5 ALZHEIMER'S PATIENTS IN THAT SYSTEM.
6 Q. NOW, YOU'VE SEEN A LITTLE CHART WHICH DEPICTS CERTAIN
7 GUIDELINES REFERRING TO DEMENTIA; IS THAT RIGHT?
8 A. YES.
9 Q. AND WOULD THAT ASSIST IN ILLUSTRATING YOUR TESTIMONY IF
10 WE DISPLAYED THAT TO THE JURY?
11 A. YES.
12 Q. ALL RIGHT.
13 A. THIS CHART WAS TAKEN FROM THE GUIDELINES THAT WERE
14 PUBLISHED BY THE NATIONAL HOSPICE ORGANIZATION WITH THE
15 SUPPORT OF THE GOVERNMENT TO HELP HOSPICE PROGRAMS DECIDE
16 WHEN TO ADMIT DEMENTIA PATIENTS TO HOSPICE CARE.
17 Q. NOW, I'M HOLDING THIS UP, DOCTOR, AND I HOPE YOU CAN SEE
18 IT FROM WHERE YOU ARE.
19 A. RIGHT.
20 Q. BUT IT HAS AT THE TOP, DETERMINING DEMENTIA PROGNOSIS.
21 AND WHAT IS THAT REFERRING TO?
22 A. THAT IS FOR PATIENTS WHO ARE -- TO DETERMINE WHETHER
23 THEY'RE ELIGIBLE FOR HOSPICE CARE, WHETHER THEIR PROGNOSIS
24 IS SIX MONTHS OR LESS.
25 Q. AND WOULD THAT PROGNOSIS RELATE TO A TERMINAL PROGNOSIS?
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1 A. SIX MONTHS OR LESS PROGNOSIS IS CONSIDERED A TERMINAL
2 CONDITION, YES.
3 Q. AND THE FIRST THING IT HAS HERE, IT SAYS, THE PATIENT
4 SHOULD SHOW ALL THE FOLLOWING CHARACTERISTICS. AND ONE:
5 UNABLE TO AMBULATE WITHOUT ASSISTANCE. WHY IS THAT
6 SIGNIFICANT?
7 A. IT SHOWS THE PROGRESS OF THE BRAIN DAMAGE FROM THE
8 DEMENTIA IS BEGINNING TO AFFECT THE MOTOR FUNCTIONS FOR THE
9 PATIENT. SO THAT A PATIENT CAN'T GET UP AND WALK AROUND
10 WITHOUT BEING HELD ON TO AND SUPPORTED IN SOME WAY.
11 Q. IS -- IS -- IS DEMENTIA A TERMINAL ILLNESS OR A
12 TREATABLE ILLNESS?
13 A. DEMENTIA IS NOT A TREATABLE ILLNESS IN THE CURRENT
14 SENSE. WE HAVE SOME MEDICATIONS NOW THAT MAY PROLONG THE
15 COURSE OF THE DISEASE AND SLOW THE PROGRESS OF THE DEMENTIA
16 FOR A WHILE, BUT IT ULTIMATELY IS A TERMINAL ILLNESS.
17 Q. AND THEN WE HAVE: UNABLE TO DRESS WITHOUT ASSISTANCE.
18 WHY IS THAT SIGNIFICANT?
19 A. AGAIN, IT'S THE MOTOR DIFFICULTY, PLUS THE LACK OF
20 DECISION-MAKING CAPACITY THAT THE PATIENTS HAVE.
21 Q. UNABLE TO BATHE PROPERLY. WHY IS THAT SIGNIFICANT?
22 A. BECAUSE THEY -- THEY DON'T KNOW WHAT THEY'RE DOING, THEY
23 CAN'T GET IN AND OUT OF A SHOWER WITHOUT HELP, THEY NEED
24 SOMEONE TO ACTUALLY WASH THEM OR WASH THEIR HAIR.
25 Q. URINARY AND FECAL INCONTINENCE. AND THAT'S AN INABILITY
2980
1 TO CONTROL YOUR BOWEL AND BLADDER; IS THAT RIGHT?
2 A. RIGHT.
3 Q. AND WHY -- WHY IS THAT PHYSIOLOGICAL EVENT SIGNIFICANT
4 IN TERMS OF A TERMINAL PROGNOSIS?
5 A. IT'S ONE OF THE STAGES THAT HAPPENS THAT SHOWS THAT THE
6 DISEASE IS PROGRESSING. WHEN PEOPLE NO LONGER CAN MAKE IT
7 TO THE BATHROOM, WHEN THEY NEED TO HAVE DIAPERS OR CATHETERS
8 AND THEY NEED TO HAVE SOMEONE CLEANING UP AFTER THEM, IT
9 MEANS THAT THEIR DISEASE IS GETTING WORSE. THE BRAIN IS NO
10 LONGER GIVING THEM THE PROPER SIGNALS TO MAINTAIN THAT
11 FUNCTION.
12 Q. AND THEN THERE'S A REFERENCE IN TERMS OF INCONTINENCE.
13 IT SAYS: OCCASIONALLY OR MORE FREQUENTLY OVER THE PAST
14 WEEKS.
15 A. PEOPLE DON'T GO FROM COMPLETELY CONTINENT TO COMPLETELY
16 INCONTINENT OVERNIGHT. PEOPLE, WHEN THEY HAVE DEMENTIA,
17 WILL START HAVING ACCIDENTS. AND WHEN WE GO FROM THE
18 HISTORY WHEN YOU TALK TO A FAMILY AND SAY WELL, THEY HAD AN
19 ACCIDENT LAST WEEK, BUT THAT WAS THE FIRST TIME. THAT'S
20 BEGINNING TO ALERT YOU THAT YOU'RE REACHING THIS STAGE, BUT
21 THAT -- NOT NECESSARILY THAT YOU'RE THERE YET. WHEN THEY
22 SAY WELL, IN THE LAST MONTH WE'VE HAD FIVE EPISODES OF
23 INCONTINENCE AND TWO OF THEM WERE LAST, YOU KNOW, THURSDAY,
24 YOU BEGIN TO GET THE CLUE THAT THINGS ARE GETTING
25 PROGRESSIVELY WORSE.
2981
1 AND SO IT'S NOT JUST COMPLETE INCONTINENCE, BUT IT'S
2 THE PROGRESSION TOWARDS COMPLETE INCONTINENCE THAT SIGNALS
3 US IT'S TIME TO TALK ABOUT HOSPICE CARE FOR THIS TERMINALLY
4 ILL DEMENTED PATIENT.
5 Q. AND THEN I THINK YOU'VE TESTIFIED A LITTLE BIT ABOUT THE
6 NEXT ONE: UNABLE TO SPEAK OR COMMUNICATE MEANINGFULLY. WHY
7 IS THAT SIGNIFICANT IN TERMS OF A TERMINAL PROGNOSIS?
8 A. PATIENTS WITH DEMENTIA LOSE THE CAPACITY TO COMMUNICATE,
9 PROBABLY, WE THINK, BECAUSE THEY LOSE THE CAPACITY TO
10 UNDERSTAND AND INTERPRET THE WORLD AND WHAT'S GOING ON
11 AROUND THEM. SOME MAY LOSE THE CAPACITY TO COMMUNICATE
12 BECAUSE THEY CAN'T THINK OF THE WORDS. AND ALL OF THOSE
13 THINGS END UP WITH A PATIENT WHO DOES NOT COMMUNICATE AND
14 DOES NOT RESPOND TO THE ENVIRONMENT, DOESN'T RESPOND TO
15 VERBAL STIMULI, DOESN'T SEEM TO UNDERSTAND OR -- OR INITIATE
16 ANY KIND OF COMMUNICATION.
17 Q. AND THEN THE NEXT POINT: HAS PRESENCE OF MEDICAL
18 COMPLICATIONS. ARE -- ARE MEDICAL COMPLICATIONS EXPECTED IN
19 TERMS OF THE STAGE WE'RE TALKING ABOUT IN A SEVERELY
20 DEMENTED PERSON?
21 A. YES.
22 Q. AND -- AND WHY -- TELL THE JURY WHY THAT IS.
23 A. AS A PATIENT BECOMES LESS ABLE TO PROVIDE FOR HIS OWN
24 NEEDS AND NEEDS TO BE FED, NEEDS TO BE BATHED, DIAPERED, AND
25 SO ON, THE BODY'S IMMUNE SYSTEM BECOMES LESS EFFECTIVE AND
2982
1 THE PATIENTS TEND TO HAVE A HIGH NUMBER OF WHAT WE CALL
2 INTERCURRENT OR ON TOP OF TYPE OF INFECTIONS. SO THESE
3 PATIENTS OFTEN HAVE PNEUMONIA, THEY OFTEN HAVE BLADDER
4 INFECTIONS, SOMETIMES THEY HAVE FEVERS THAT WE DON'T
5 UNDERSTAND WHY THEY HAVE THE FEVERS. MANY OF THEM GET
6 PNEUMONIA BECAUSE THEY INHALE THE FOOD AS THEY'RE EATING,
7 THEY DON'T SWALLOW PROPERLY. ALL OF THE NERVES GOING TO THE
8 CHEWING/SWALLOWING MECHANISM MAY BE AFFECTED, AND THE
9 PATIENTS THEN, WHEN THEY'RE SWALLOWING, ACTUALLY WHAT WE
10 CALL ASPIRATE OR INHALE -- WHAT YOU DO WHEN YOU CHOKE, ONLY
11 THEY GET IT IN THEIR LUNGS AND GET PNEUMONIA.
12 Q. ARE THOSE MEDICAL COMPLICATIONS AS YOU'VE JUST GENERALLY
13 DESCRIBED, DID YOU DETERMINE THAT SOME OF THOSE EXISTED WITH
14 RESPECT TO THE FIVE PATIENT --
15 A. YES.
16 Q. -- RECORDS THAT YOU REVIEWED?
17 A. YES.
18 Q. AND THEN WE HAVE: THE PRESENCE OF MEDICAL COMORBID
19 CONDITIONS OF SUFFICIENT SEVERITY TO WARRANT MEDICAL
20 TREATMENT. COULD YOU TELL US, PLEASE, WHAT THE TERM
21 "COMORBID" MEANS?
22 A. COEXISTING. COMING ALONG WITH, BUT NOT NECESSARILY
23 RELATED TO. SO A PATIENT MAY HAVE MORE THAN ONE DISEASE. A
24 LOT OF PATIENTS WILL HAVE HEART DISEASE, WHO ARE OLDER, AND
25 SO THEY'LL HAVE A PRIMARY HEART DISEASE AND THEY'LL ALSO
2983
1 HAVE DEMENTIA. OR THEY MAY HAVE EMPHYSEMA AND HAVE
2 DEMENTIA. OR THEY MAY HAVE EMPHYSEMA AND HEART DISEASE AND
3 DEMENTIA. AND THESE THINGS KIND OF THEM COMPLICATE EACH
4 OTHER. YOU CAN IMAGINE THAT IF YOU HAVE SEVERE EMPHYSEMA
5 AND YOU HAVE SUCH BAD DEMENTIA THAT YOU'RE STARTING TO
6 CHOKE, IT MAY, IN FACT, MAKE YOUR EMPHYSEMA MUCH WORSE.
7 AND -- AND VICE VERSA, IF YOU HAVE BAD EMPHYSEMA AND TROUBLE
8 BREATHING, IT MAY MAKE YOUR DEMENTIA WORSE.
9 SO THE THINGS KIND OF INTERACT TO MAKE YOU MUCH MORE
10 ILL THAN YOU WOULD HAVE BEEN WITH ONLY ONE OF THE DISEASES
11 ALONE.
12 Q. WOULD HOSPITALIZATIONS COME WITHIN THE CATEGORY OF
13 SUFFICIENT SEVERITY TO WARRANT MEDICAL TREATMENT?
14 A. YES. ABSOLUTELY.
15 Q. AND THEN YOU HAVE COMORBID; THAT IS, OCCURRING AT THE
16 SAME TIME --
17 A. RIGHT.
18 Q. -- CONDITIONS ASSOCIATED WITH DEMENTIA. THESE ARE
19 MEDICAL CONDITIONS. YOU -- ONE IS ASPIRATION PNEUMONIA. DO
20 YOU SEE THAT'S ON THE CHART?
21 A. RIGHT.
22 Q. WOULD YOU TELL US WHAT ASPIRATION PNEUMONIA IS?
23 A. WELL, THAT'S WHERE THE PATIENT WHO'S -- CANNOT SWALLOW
24 PROPERLY, LOSES THE REFLEX, AND FOOD IS ACTUALLY -- ENTERS
25 THE AIRWAY, ENTERS THE TRACHEA, AND IT GETS SOMEWHERE INTO
2984
1 THE LUNGS AND THEN A PATIENT GETS AN INFECTION ASSOCIATED
2 WITH THAT FOOD GETTING IN THE LUNG. ANY TIME YOU HAVE ORAL
3 CONTENTS IN THE LUNG YOU CAN GET PNEUMONIA BECAUSE THERE ARE
4 A LOT OF BACTERIA IN YOUR MOUTH AND -- AND WHEN IT GETS TO
5 THE LUNG, IT CAN CAUSE A PNEUMONIA.
6 Q. AND THEN THE NEXT ONE SAYS: AN UPPER URINARY TRACT
7 INFECTION. WOULD YOU TELL US, PLEASE, WHAT THAT IS?
8 A. WELL, WE CONSIDER THE WHOLE URINARY TRACT SYSTEM,
9 EVERYTHING FROM THE KIDNEYS THROUGH THE URETERS TO THE
10 BLADDER. AND WHEN YOU HAVE A BLADDER INFECTION IT'S
11 CONSIDERED A LOWER URINARY TRACT INFECTION. IT'S KIND OF
12 GEOGRAPHIC, YOU KNOW, YOU STAND UP AND YOUR KIDNEYS ARE
13 HIGHER THAN YOUR BLADDER.
14 IN PATIENTS WHO HAVE TROUBLE TAKING THEMSELVES TO THE
15 BATHROOM, THEY OFTEN WILL NOT URINATE EVEN WHEN THEIR
16 BLADDERS ARE BEGINNING TO FILL. AND THE URINE CAN BACK UP
17 THE URETER AND INTRODUCE BACTERIA INTO THE KIDNEYS. THE
18 KIDNEYS ARE FULL OF RICH BLOOD VESSELS AND A LOT OF
19 NUTRIENTS FOR BACTERIA, SO WHEN BACTERIA GET IN THE KIDNEYS
20 THEY DEVELOP A SEVERE KIDNEY INFECTION OR WHAT WE CALL
21 PYELONEPHRITIS.
22 Q. IS A -- A URINARY TRACT INFECTION IN A SEVERELY DEMENTED
23 PATIENT MORE DIFFICULT IN TERMS OF ITS CONSEQUENCE OR
24 SIGNIFICANCE THAN IS PERHAPS SOMEBODY WHO IS NOT DEMENTED?
25 A. THE PATIENT PROBABLY WILL NOT BE ABLE TO COMPLAIN OF THE
2985
1 SYMPTOMS OF PAIN OR FEELING THE NEED TO URINATE FREQUENTLY.
2 WE OFTEN HAVE OUR FIRST SIGN THAT THE PATIENT HAS A SEVERE
3 INFECTION WHEN THE PATIENT DEVELOPS A FEVER AND MAY HAVE
4 CHILLS WITH IT. AND THAT'S A SIGN THEN THAT THE BACTERIA IN
5 THE KIDNEY HAVE ACTUALLY GOTTEN INTO THE BLOOD STREAM, WHAT
6 WE CALL SEPTICEMIA. BLOODSTREAM INFECTIONS IN ELDERLY
7 PATIENTS ARE VERY OFTEN LETHAL AND MAY BE THE CAUSE OF DEATH
8 FOR MANY OF THESE PATIENTS.
9 Q. OKAY. THE NEXT ONE IS -- THAT'S -- THAT'S THAT
10 SEPTICEMIA YOU DISCUSSED?
11 A. SEPTICEMIA. YES. THAT MEAN A BLOODSTREAM INFECTION.
12 THAT CAN HAPPEN EITHER FROM ENTRY THROUGH THE LUNGS AND THEN
13 THE BACTERIA GET INTO THE BLOODSTREAM, OR IT CAN HAPPEN
14 THROUGH THE KIDNEYS WHERE THE BACTERIA GET INTO THE
15 BLOODSTREAM. AND THERE ARE MANY BLOOD VESSELS IN BOTH OF
16 THESE AREAS THAT IT'S NOT VERY DIFFICULT FOR THE BACTERIA TO
17 CROSS INTO THE BLOODSTREAM WITHIN THESE TWO ORGANS.
18 Q. YOU NEXT HAVE DECU --
19 A. DECUBITUS ULCERS?
20 Q. YES.
21 A. BED SORES.
22 Q. I COULD SAY ULCERS. I COULDN'T SAY THE FIRST WORD.
23 A. BED SORES. THAT'S A FANCY WORD FOR BED -- BED SORES.
24 Q. OKAY.
25 A. PRESSURE ULCERS. WHEN YOU LIE IN ONE POSITION FOR A
2986
1 LONG TIME YOU WILL, FROM THE PRESSURE, CUT OFF THE
2 CIRCULATION IN THE AREAS WHERE THE BONE MEETS THE MATTRESS.
3 AS YOU LOSE WEIGHT WITH A TERMINAL ILLNESS AND AS YOU BECOME
4 MALNOURISHED WITH NOT BEING ABLE TO EAT WELL, YOU TEND TO
5 HAVE LESS AND LESS PADDING BETWEEN THE BONE AND THE
6 MATTRESS. AND YOU KNOW THAT OUR ELDERLY PEOPLE TEND TO HAVE
7 FRAGILE SKIN ANYWHERE.
8 SO WHERE THE HIP BONES OR THE SACRUM OR TAILBONE MEET
9 THE MATTRESS, THERE TENDS TO BE A CUTOFF OF CIRCULATION JUST
10 FROM THE PRESSURE. AND THE SKIN WILL DIE FROM THAT AND THE
11 PATIENT WILL DEVELOP A BED SORE. THIS IS ANOTHER PLACE
12 WHERE THE GERMS CAN GET INTO THE BLOODSTREAM. BUT IN AND OF
13 THEMSELVES THEY'RE AN INDICATION OF THE WHOLE BODY BEGINNING
14 TO BREAK DOWN.
15 Q. AND THEN YOU HAVE: FEVER RECURRENT AFTER ANTIBIOTICS.
16 WOULD YOU EXPLAIN MEDICALLY WHAT THAT SIGNIFIES AND WHY
17 THAT'S AN -- AN EXPECTATION?
18 A. WHEN THE -- THE VETERAN'S ADMINISTRATION WAS LOOKING AT
19 THEIR POPULATION OF PATIENTS WITH DEMENTIA, THEY FOUND THAT
20 EPISODES OF FEVER TWO TIMES WITHIN A YEAR WERE INDICATIVE
21 THAT THE PATIENT WAS TERMINALLY ILL, REGARDLESS OF THE CAUSE
22 OF THE FEVER. AND MANY TIMES THESE PATIENTS HAVE INTERNAL
23 INFECTIONS THAT WE CAN'T REALLY SEE BY ANY OF OUR X-RAYS OR
24 BY OUR EXAMINATIONS AND -- AND THEY -- THEY GET WALLED OFF,
25 LIKE WE CALL AN ABSCESS, AND THE ORAL ANTIBIOTICS OR
2987
1 BLOODSTREAM ANTIBIOTICS DON'T GET TO THESE INFECTIONS. AND
2 SO EVEN THOUGH THEY'VE HAD ANTIBIOTICS, THEY MAY HAVE
3 RECURRING FEVERS.
4 Q. AND THEN WE HAVE THE NEXT POINT, IT SAYS: DIFFICULTY
5 SWALLOWING FOOD OR REFUSAL TO EAT. WHY IS THAT SIGNIFICANT
6 AND WHY DOES THAT DEVELOP, CONCERNING SEVERELY DEMENTED
7 PATIENTS WHO HAVE A TERMINAL PROGNOSIS?
8 A. THE NATURAL COURSE OF ALZHEIMER'S DISEASE AND OTHER
9 DEMENTIAS IS THAT BOTH MECHANICAL DIFFICULTIES SWALLOWING, A
10 MOTOR PROBLEM WHERE THE PATIENT JUST CAN'T INITIATE THE
11 SWALLOW REFLEX PROPERLY; AND LOSS OF INTEREST IN FOOD, THEY
12 NO LONGER EXPERIENCE THE SENSATION OF HUNGER AND THE DESIRE
13 TO EAT OR THE ABILITY TO GET FOOD INTO THEM -- THEIR OWN
14 MOUTHS, HAPPEN AT ABOUT THE SAME TIME AS THE BRAIN
15 DETERIORATES WITH THE DEMENTIA. IF YOU DON'T EAT FOR A
16 PROLONGED PERIOD OF TIME, IT'S ONE OF THE MECHANISMS OF
17 DEATH FOR THE HUMAN BEING.
18 SO THESE PATIENTS, IN ESSENCE, LOSE WEIGHT, BECOME
19 INCREASINGLY SUSCEPTIBLE TO INFECTIONS AND THESE BED SORES.
20 AND EVEN IF ALL OF THAT DOESN'T OCCUR, PATIENTS WHO DON'T
21 EAT WILL EVENTUALLY DIE.
22 Q. DO YOU KNOW WHY THAT SYMPTOM OF DIFFICULTY IN SWALLOWING
23 OR DISINTEREST IN FOOD DEVELOPS AT SOME POINT CONCERNING A
24 SEVERELY DEMENTED PATIENT?
25 A. I DON'T THINK ANYBODY REALLY UNDERSTANDS THE PRECISE
2988
1 MECHANISM. WE KNOW THAT IT OCCURS AND IT'S PART OF THE
2 ADVANCING DEMENTIA THAT IS ASSOCIATED WITH A TOTAL LACK OF
3 INTEREST IN THE OUTSIDE WORLD, NOT JUST IN FOOD. THEY --
4 THEY DON'T COMMUNICATE AT THAT POINT, THEY DON'T -- THEY
5 DON'T INTERACT. THEY DON'T RESPOND TO NORMAL STIMULI. YOU
6 CAN SHAKE THESE PEOPLE AND THEY DON'T SEEM TO RECOGNIZE THAT
7 THERE'S ANYTHING IN THE ENVIRONMENT.
8 SO WE'RE NOT -- I DON'T THINK WE KNOW EXACTLY WHICH
9 PART OF THE BRAIN GOT AFFECTED BY THE DEMENTIA PROBLEM, BUT
10 WE KNOW THAT IT OCCURS.
11 THE SIGNIFICANCE OF IT BEING ON THIS PARTICULAR LIST AS
12 A -- AN ELEMENT OF PROGNOSIS FOR HOSPICE CARE IS THAT ONE OF
13 THE THINGS THAT HAPPENS IN OUR SOCIETY IS THAT PATIENTS AND
14 THEIR CAREGIVERS THAT ARE ASSIGNED BY THE PATIENTS HAVE THE
15 RIGHT TO MAKE SOME DECISIONS ABOUT THEIR END-OF-LIFE CARE.
16 AND WE CALL THAT THE MEDICAL ETHICAL PRINCIPLE OF AUTONOMY.
17 SO WE --
18 MR. WILSON: YOUR HONOR, I THINK I'M GOING TO
19 INTERPOSE AN OBJECTION HERE. IT'S IN NARRATIVE FORM. I
20 WOULD APPRECIATE A QUESTION.
21 THE COURT: OKAY.
22 MR. STIRBA: SURE.
23 Q. (BY MR. STIRBA) DOCTOR, YOU WERE EXPLAINING THE
24 IMPORTANCE OF THE GUIDELINES IN TERMS OF SOME AUTONOMY OR
25 MEDICAL DIRECTIONS; IS THAT RIGHT?
2989
1 A. YES.
2 Q. COULD YOU EXPLAIN TO US, PLEASE, WHY THE GUIDELINES HAVE
3 SOME RELATIONSHIP TO THE AUTONOMY AND THE DIRECTIONS?
4 A. PATIENTS AND THEIR SURROGATE DECISION MAKERS MAY DECIDE
5 NOT TO HAVE ARTIFICIAL FEEDINGS IMPOSED. TUBE FEEDINGS OR
6 FORCE FEEDINGS OF PATIENTS ARE ONE OF THE THINGS PEOPLE HAVE
7 A RIGHT TO SAY, I DON'T WANT THIS.
8 Q. AND -- AND WHEN YOU SAY THEY HAVE A RIGHT TO SAY THAT,
9 COULD YOU TELL US WHAT YOU MEAN IN THE CONTEXT OF WHY YOU
10 SAY THEY HAVE A RIGHT TO THAT, WHERE THAT COMES FROM?
11 A. WE WRITE ADVANCE DIRECTIVES AND WE HAVE THE -- THE
12 GUIDANCE IN OUR MEDICAL SYSTEM TO HAVE ADVANCE DIRECTIVES.
13 THERE'S A FEDERAL LAW THAT EVERY HEALTH CARE INSTITUTION HAS
14 TO ASK YOU IF YOU HAVE ADVANCE DIRECTIVES. HAVE YOU MADE
15 DECISIONS ABOUT YOUR CARE. IF YOU SAY IN YOUR ADVANCE
16 DIRECTIVE, I DON'T WANT TUBE FEEDINGS, OR THE PERSON YOU
17 ASSIGN TO MAKE DECISIONS FOR YOU WHEN YOU'RE NOT ABLE TO
18 TALK FOR YOURSELF SAYS NO TUBE FEEDINGS AND SOMEBODY DOES
19 THAT TO YOU, IT'S ASSAULT AND BATTERY.
20 SO IT HAS THE FORCE OF LAW IN THE UNITED STATES THAT
21 YOU CAN MAKE THOSE DECISIONS PRIOR TO NEEDING TO MAKE THEM
22 AND PEOPLE HAVE TO ABIDE BY THEM.
23 Q. NOW, WHAT YOU'VE JUST TESTIFIED CONCERNING, THESE
24 GUIDELINES --
25 A. UH-HUH.
2990
1 Q. -- WHICH IS ON THIS ILLUSTRATIVE CHART, DO THESE
2 GUIDELINES AND WHAT YOU'VE TESTIFIED TO, DO THEY RELATE TO
3 THE GUIDELINES YOU WERE TESTIFYING TO PREVIOUSLY CONCERNING
4 MEDICARE PAYMENT FOR HOSPICE CARE?
5 A. YES. THESE ARE RIGHT OUT OF THAT BOOK.
6 Q. DOCTOR, IN YOUR PRACTICE IN TREATING PATIENTS AT END OF
7 LIFE OR PROVIDING END-OF-LIFE CARE, ARE YOU FAMILIAR WITH
8 RECOGNIZED SYMPTOMS OF THE DEATH AND DYING PROCESS?
9 A. YES.
10 Q. AND COULD YOU GENERALLY JUST TELL US, PLEASE, WHY THESE
11 SYMPTOMS ARE IMPORTANT IN TERMS OF PROVIDING END-OF-LIFE
12 CARE?
13 A. THERE ARE TWO LEVELS OF IMPORTANCE FOR RECOGNIZING THAT
14 PEOPLE ARE DYING. ONE IS TO TREAT WHATEVER SYMPTOMS MAY BE
15 BOTHERING THE PATIENT SO THAT IF THERE'S PAIN OR -- OR
16 SHORTNESS OF BREATH, YOU'D TREAT IT.
17 AND THE SECOND IS TO BE ABLE TO INFORM THOSE WHO LOVE
18 THE PATIENT THAT THE PATIENT IS DYING AND MEET THEIR NEED
19 FOR INFORMATION AND PREDICTABILITY.
20 Q. AND WHERE -- WHERE DOES THE INFORMATION ABOUT THESE
21 SIGNS AND SYMPTOMS COME FROM?
22 A. EXPERIENCE. THE EXPERIENCE OF MANY, MANY PHYSICIANS IN
23 THIS COUNTRY AND OTHERS OVER THE COURSE OF THE LAST 30
24 YEARS, A NUMBER OF BOOKS HAVE BEEN PUBLISHED, A NUMBER OF
25 LECTURES HAVE BEEN GIVEN, AND A NUMBER OF EXAMPLES AS WE
2991
1 TEACH EACH OTHER ABOUT, OH, YES, NOW LOOK AND SEE, THIS IS
2 WHAT IS HAPPENING TO THE PATIENT.
3 MOST HOSPICE PROGRAMS PRODUCE INFORMATION TO HAND TO
4 THE FAMILIES TO SAY, HERE'S WHAT YOU WILL SEE WHEN YOUR
5 LOVED ONE APPROACHES DEATH. AND WE ALL HAVE THOSE KINDS OF
6 GUIDELINES TO HAND TO FAMILIES THAT KIND OF DOCUMENT
7 STEP-BY-STEP WHAT WILL HAPPEN TO PEOPLE AS THEY'RE DYING.
8 Q. IS THAT AN IMPORTANT RESPONSIBILITY, IN TERMS OF
9 PROVIDING THAT INFORMATION, IN TERMS OF END-OF-LIFE CARE?
10 A. YES.
11 Q. AND WHY IS THAT?
12 A. WE NEED, AS HUMANS, NOT JUST PHYSICAL CARE, BUT
13 PREDICTABILITY AND INFORMATION. IN ORDER TO PROVIDE THE
14 OPPORTUNITY FOR PEOPLE TO SAY GOODBYE -- IRA BYOCK, WHO'S A
15 SPECIALIST IN PALLIATIVE MEDICINE IN MISSOULA, MONTANA SAID
16 WE NEED FIVE THINGS. WE NEED TO SAY: I LOVE YOU, YOU LOVE
17 ME, I FORGIVE YOU, YOU FORGIVE ME, AND GOODBYE. AND THAT
18 THE OPTIMUM DEATH THAT OCCURS FOR ANY HUMAN IS TO HAVE
19 ACCOMPLISHED THOSE WITH EACH LOVED ONE AND TO BE
20 COMFORTABLE.
21 Q. NOW, ALSO, YOU'VE SEEN ANOTHER LITTLE CHART WHICH
22 ILLUSTRATES THOSE SIGNS AND SYMPTOMS OF THE DEATH AND DYING
23 PROCESS, HAVE YOU?
24 A. YES.
25 Q. AND WOULD THAT ALSO ASSIST YOU WITH RESPECT TO YOUR
2992
1 TESTIMONY CONCERNING THOSE SIGNS AND SYMPTOMS?
2 A. YES.
3 Q. OKAY. I GUESS WE'RE OKAY. NOW, I'M -- I'M HOLDING UP A
4 LITTLE ILLUSTRATION. IT HAS AT THE TOP PHYSICAL SIGNS AND
5 SYMPTOMS, AND THESE ARE THINGS THAT ROUTINELY ARE OBSERVED
6 IN THE DEATH AND DYING PROCESS; IS THAT RIGHT?
7 A. YES.
8 Q. FIRST OF ALL, THE FIRST ONE IS SLEEPING. AND WE KNOW
9 WHAT THAT IS. CAN YOU TELL US HOW THAT SYMPTOM RELATES IN
10 TERMS OF THE DEATH AND DYING PROCESS?
11 A. PEOPLE WHO ARE NEARING DEATH TEND TO SLEEP MORE AND MORE
12 OF THE DAY. THE AVERAGE PERSON WHO IS TERMINALLY ILL AND
13 NOT YET QUITE DYING PROBABLY SLEEPS 10 TO 14 HOURS A DAY.
14 BUT AS PATIENTS APPROACH DEATH, THERE'S LESS AND LESS ENERGY
15 AVAILABLE TO STAY AWAKE AND THESE PATIENTS TEND TO BE NOTED
16 TO HAVE HOUR OR TWO OF WAKEFULNESS, AND THEN HALF HOUR OR SO
17 WAKEFULNESS, SO THAT THE TOTAL AMOUNT OF TIME SPENT SLEEPING
18 IN 24 HOURS INCREASES UNTIL IT'S ALL OF THE 24 HOURS.
19 Q. DO WE KNOW, BASED UPON EXISTING MEDICAL EXPERTISE AND
20 LITERATURE, WHY THAT OCCURS AT THE END OF LIFE?
21 A. NO.
22 Q. AND THEN YOU HAVE FOOD AND FLUID DECREASE. COULD YOU
23 EXPLAIN THAT AND ITS SIGNIFICANCE AT END OF LIFE?
24 A. AS THE HUMAN BODY BEGINS TO SHUT DOWN TOWARDS DEATH,
25 THEY -- THE METABOLIC PRODUCTS THAT NORMALLY ARE CLEARED
2993
1 AWAY VERY QUICKLY TEND TO ACCUMULATE BECAUSE THINGS LIKE THE
2 LIVER IS DYING AND THE KIDNEYS ARE DYING. NOTHING HAPPENS
3 IN AN INSTANT. SO THAT THESE CHEMICALS THAT BUILD UP IN THE
4 SYSTEM TAKE AWAY THE PERSON'S APPETITE AND TAKE AWAY THE
5 PERSON'S THIRST. THAT MAY BE ONE OF THE ELEMENTS
6 RESPONSIBLE FOR THE SLEEPINESS, BUT WE'RE NOT SURE OF THAT.
7 PEOPLE HAVE VERY LITTLE INTEREST IN FOOD. PEOPLE TEND
8 TO LOSE THEIR INTEREST IN THE PEOPLE AROUND THEM MORE AND
9 MORE AND THEN THEY GET LESS AND LESS INTERESTED EVEN IN
10 THEMSELVES, AND THEY'RE MORE INTERESTED IN JUST BEING QUIET.
11 Q. THEN YOU HAVE URINE DECREASE. EXPLAIN THAT SIGNIFICANCE
12 AND WHY THAT OCCURS.
13 A. AS -- AS YOU TAKE IN LESS AND LESS FLUID, YOUR BODY
14 TENDS NOT TO PRODUCE AS MUCH URINE. THE KIDNEYS ARE NOT
15 WORKING AS WELL SO THE PATIENT URINATES LESS AND LESS OFTEN
16 AND SMALLER AND SMALLER AMOUNTS AS THE DEATH APPROACHES.
17 Q. INCONTINENCE?
18 A. THERE IS NO CONTROL OVER THE BLADDER OR BOWEL IN THESE
19 PATIENTS. THEY WILL HAVE TO BE EITHER PADS OR DIAPERS OR
20 OTHER WAYS OF KEEPING THEM CLEAN.
21 Q. THE NEXT ONE SAYS RESTLESSNESS. WOULD YOU PLEASE DEFINE
22 THAT FOR US?
23 A. AS PATIENTS APPROACH DEATH A LOT OF THE CHEMICALS THAT
24 ARE BUILDING IN THE SYSTEM MAY CAUSE THEM TO BE TWITCHY OR
25 IRRITABLE. WE DEFINE A SYNDROME CALLED TERMINAL
2994
1 RESTLESSNESS WHICH IS PRIMARILY THE PATIENT IS MOANING OR
2 MAYBE THRASHING AROUND A BIT IN BED. WE USUALLY TREAT THIS
3 SYMPTOM WITH MEDICATIONS TO CALM THE PATIENT. IT'S PROBABLY
4 A METABOLIC PHENOMENON, ALTHOUGH NO ONE IS ENTIRELY SURE
5 WHAT THE UNDERLYING CAUSE OF THE RESTLESSNESS IS.
6 Q. THE NEXT ONE IS CONGESTION. COULD YOU EXPLAIN TO US
7 WHAT THAT IS CONCERNING?
8 A. THAT'S A NICE WAY OF CALLING DEATH RATTLE, A COMMON
9 NAME. BUT AS PATIENTS APPROACH DEATH THEY BECOME UNABLE TO
10 CLEAR THE SECRETIONS FROM THEIR -- BACK OF THEIR THROATS OR
11 THEIR UPPER AIRWAY AND THE PHLEGM BUILDS UP AND WHEN THEY
12 BREATHE IT MAKES A GURGLING NOISE AND IT SOUNDS LIKE THEY'RE
13 DROWNING. WE HAVE MEDICATIONS THAT WILL CUT DOWN ON THESE
14 SECRETIONS.
15 WE DON'T THINK THAT THIS SYMPTOM BOTHERS PATIENTS VERY
16 MUCH, BUT IT CERTAINLY BOTHERS FAMILIES WHO ARE SITTING WITH
17 A DYING PATIENT. AND SO WE TRY TO CLEAR THIS NOISE UP SO
18 THAT THE FAMILIES ARE A LITTLE MORE COMFORTABLE.
19 Q. IS AGITATION OR THAT RESTLESSNESS, IS THAT ALSO
20 SOMETHING THAT BOTHERS FAMILIES?
21 A. VERY MUCH.
22 Q. AND WOULD YOU HELP US TO UNDERSTAND WHY THAT IS --
23 A. THE PATIENTS --
24 Q. -- FROM YOUR EXPERIENCE?
25 A. -- LOOK LIKE THEY'RE SUFFERING FROM PAIN OR THEY LOOK
2995
1 LIKE THEY'RE SUFFERING FROM ANXIETY OR -- OR BAD DREAMS.
2 IT'S -- THE IMPULSE IS ALWAYS TO BE COMFORTING TO THE PEOPLE
3 WHO ARE THAT RESTLESS BECAUSE THEY LOOK LIKE THEY'RE VERY
4 UNHAPPY WHEN THEY'RE THRASHING AROUND AND -- AND MOANING,
5 SOME EVEN YELL OUT.
6 Q. AND THEN YOU HAVE COOLNESS. WHAT IS THAT REFERRING TO?
7 A. AS THE CIRCULATION SHUTS DOWN AND THE BLOOD PRESSURE
8 FALLS, THE EXTREMITIES GET LESS BLOOD FLOW AND THE
9 TEMPERATURE OF THE EXTREMITIES FALLS.
10 Q. AND WHEN YOU SAY "EXTREMITIES," WHAT ARE YOU REFERRING
11 TO?
12 A. HANDS AND FEET.
13 Q. DO WE KNOW WHY THAT OCCURS?
14 A. THE BLOOD PRESSURE IS LOWER, THERE'S LESS CIRCULATION
15 AND SO THE TEMPERATURE -- CORE TEMPERATURE CAN'T GET TO THE
16 EXTREMITIES. SO ACTUALLY IT IS COOLING FROM LACK OF
17 CIRCULATION.
18 Q. THEN YOU HAVE CHANGE IN BREATHING PATTERN. WHAT CHANGE
19 ARE YOU REFERRING TO?
20 A. AS -- AS THE CORTEX BECOMES LESS FUNCTIONAL --
21 Q. LET ME -- LET ME STOP YOU RIGHT THERE.
22 A. PART OF THE BRAIN.
23 Q. YOU'RE GOING TO HAVE TO EXPLAIN WHAT THE CORTEX IS.
24 A. THE PART OF YOUR BRAIN THAT DOES YOUR THINKING BECOMES
25 LESS AND LESS FUNCTIONAL. WE MOVE DOWN THE BRAIN TO THE
2996
1 LOWER OR MORE PRIMITIVE BRAIN CENTERS THAT CONTROL THE
2 PHYSIOLOGY OF BREATHING. THE MOST PRIMITIVE CENTERS ARE NOT
3 SO GOOD AT KEEPING EVEN RHYTHMS AND SO YOU'LL SEE CHANGES IN
4 BREATHING PATTERNS IN DYING PATIENTS THAT INCLUDE A
5 PHENOMENON WE CALL CHEYNE-STOKES RESPIRATION. YOU'LL HEAR
6 ABOUT THIS WITH SOME OF THE PATIENTS.
7 CHEYNE-STOKES ARE TWO MEN THAT DESCRIBED THIS, SO
8 THERE'S NO SIGNIFICANCE TO THE NAME OTHER THAN IT'S NAMED
9 AFTER DOCTORS AND THEY LIKE TO NAME THINGS AFTER THEMSELVES.
10 BUT IT'S A PATTERN OF BREATHING THAT WAXES AND WANES SO
11 THAT YOU HAVE VERY SHALLOW, VERY SLOW BREATHS, AND THEN IT
12 GETS RAPIDLY BIGGER AND DEEPER AND FASTER UNTIL IT REACHES A
13 PEAK, AND THEN IT SLOWS BACK DOWN AGAIN. SO YOU KIND OF SEE
14 A PATIENT BREATHING -- AND YOU'RE NOT EVEN SURE THEY'RE
15 BREATHING. THEY MAY HAVE SUCH SLOW RESPIRATIONS YOU KIND OF
16 WAIT BETWEEN BREATHS, AND JUST BARELY BREATHING. AND THEN
17 THEY GET FASTER AND FASTER AND DEEPER AND DEEPER AND THEN IT
18 GOES BACK DOWN AND IT WAXES AND WANES IN A FAIRLY EVEN
19 PATTERN. AND THAT'S CHEYNE-STOKES BREATHING, AND THAT'S A
20 VERY BRAIN STEM TYPE OF BREATHING. IT'S VERY PRIMITIVE
21 REFLEX-TYPE BREATHING.
22 SOME PATIENTS WILL JUST GET SLOWER AND NOT GO THROUGH
23 THE CHEYNE-STOKE EPISODE. SOME PATIENTS, BECAUSE THEY HAVE
24 TERMINAL FEVER, WILL ACTUALLY BREATHE FASTER FOR A WHILE
25 BECAUSE THEIR BODY TEMPERATURE, CORE TEMPERATURE IS HIGH AND
2997
1 SO THE REFLEX IS TO BREATHE FASTER.
2 SO THE NUMBER OF REFLEXES THAT CAN TAKE OVER, THE
3 IMPORTANT PART IS THAT IT'S REFLEX BREATHING AND IT'S NOT
4 THE NORMAL BREATHING PATTERNS THAT WE SEE IN -- IN NORMAL
5 PEOPLE.
6 Q. THAT PATTERN THAT YOU'VE JUST DESCRIBED, IS IT
7 DISTINGUISHABLE FROM, FOR EXAMPLE, A PATTERN THAT MAYBE
8 MANIFESTED AS A RESULT OF DEPRESSION CAUSED BY MEDICATION?
9 A. OH, YES. YES BECAUSE PATIENTS --
10 Q. TELL US, PLEASE, WHY THAT IS.
11 A. PATIENTS WHO HAVE RESPIRATORY DEPRESSION FROM MEDICATION
12 DON'T HAVE THE ACCELERATED DEEP BREATHING PHASE. THEY TEND
13 TO BREATHE VERY EVENLY, SLOWLY, AND THEY ACTUALLY MAY
14 BREATHE DEEPLY AND SLOWLY RATHER THAN SHALLOWLY AND SLOWLY.
15 SO THAT CHEYNE-STOKES RESPIRATION DOES NOT LOOK AT ALL LIKE
16 MEDICATION INDUCED DEPRESSION OF RESPIRATION.
17 Q. AND THEN YOU HAVE CONFUSION. WHAT -- WHAT -- WHAT DO
18 YOU MEAN BY CONFUSION?
19 A. AS PATIENTS APPROACH DEATH, THE METABOLIC CHANGES, THE
20 DECLINING BLOOD PRESSURES, THE OTHER THINGS THAT ARE GOING
21 ON WITHIN THE BODY TEND TO CREATE A STATE OF CONFUSION FOR
22 THE PATIENT, EVEN MAYBE BEFORE THEY GET TO THE SLEEPING 24
23 HOURS A DAY. SO THAT IF YOU SEE PATIENTS WHO HAVE SOME
24 COMBINATIONS OF THESE THINGS WITH CONFUSION AND INCONTINENCE
25 AND DECREASING URINE, YOU MAY BEGIN TO THINK THAT THEY'RE
2998
1 ENTERING THE VERY LAST STAGES OF LIFE.
2 Q. DOCTOR, BASED UPON YOUR REVIEW OF THE RECORDS AND THE
3 AVAILABLE GUIDELINES AND OTHER EXPERTISE THAT YOU HAVE, WERE
4 YOU ABLE TO FORM AN OPINION AS TO WHETHER OR NOT ANY OF THE
5 PATIENTS IN THIS CASE WERE SUFFERING FROM A TERMINAL
6 CONDITION UPON ENTERING THE DAVIS HOSPITAL?
7 A. YES, I WAS.
8 Q. AND COULD YOU TELL US, PLEASE, WHAT YOUR OPINION WAS AND
9 IS?
10 A. ALL OF THE PATIENTS SHOWED MOST OF THE SIGNS OF TERMINAL
11 ILLNESS WITH DEMENTIA, SO THAT I BELIEVED THAT ALL THE
12 PATIENTS WOULD HAVE BEEN CANDIDATES FOR HOSPICE CARE, FOR
13 PALLIATIVE CARE, FOR THE INTERVENTIONS AT END OF LIFE THAT
14 WE WOULD NORMALLY ASSOCIATE WITH THE END-OF-LIFE CARE.
15 Q. NOW, YOU HAVE SOME BINDERS TO YOUR LEFT THERE.
16 A. YES, SIR.
17 Q. THE GRAY BINDERS, AND THEY ACTUALLY ARE THE MEDICAL
18 RECORDS FROM THE DAVIS HOSPITAL WHICH YOU HAVE REVIEWED, BUT
19 THOSE ARE THE BINDERS IN EVIDENCE. I WOULD LIKE TO GO
20 THROUGH EACH PATIENT WITH YOU, IF I COULD --
21 A. UH-HUH.
22 Q. -- IN TERMS OF YOUR OPINION AS TO THE NATURE OF THEIR
23 TERMINAL CONDITION.
24 FIRST, I'D LIKE TO ASK YOU ABOUT JUDITH LARSEN, AND
25 MAYBE YOU CAN FIND THAT THERE. DO YOU HAVE THAT BINDER IN
2999
1 FRONT OF YOU?
2 A. I DO.
3 Q. AND YOUR OPINION CONCERNING JUDITH LARSEN IS WHAT,
4 RELEVANT TO WHETHER OR NOT SHE HAD SUFFERED OR WAS SUFFERING
5 A TERMINAL CONDITION UPON ADMISSION?
6 A. I BELIEVE SHE WAS TERMINALLY ILL WITH DEMENTIA.
7 Q. OKAY. COULD YOU TELL US, PLEASE, WHY YOU HAVE SUCH AN
8 OPINION?
9 A. WHEN YOU LOOK AT THE N.H.O. GUIDELINES I REFERRED TO
10 EARLIER, SHE IS OVER 70, WHICH IS ONE OF THE CRITERIA THEY
11 WOULD LIKE TO SEE. HER FUNCTIONAL ASSESSMENT STATUS WAS A
12 7(A); THAT IS, SHE SPOKE ABOUT SIX WORDS OR LESS PER DAY.
13 WAS INCONTINENT AND REQUIRED FULL CARE. AND SHE WAS
14 EXPERIENCING MEDICAL COMPLICATIONS OF HER ILLNESS.
15 Q. AND DID YOU HAVE A CHANCE TO REVIEW SPECIFICALLY THE
16 NURSING NOTES FROM THE 29TH OF DECEMBER THROUGH THE DAY THAT
17 SHE DIED?
18 A. YES.
19 Q. AND IN DOING THAT, WERE YOU ABLE TO DETERMINE CERTAIN
20 SIGNS AND SYMPTOMS THAT INDICATED THAT SHE WAS IN THE DEATH
21 AND DYING PROCESS AT THAT TIME?
22 A. YEAH.
23 Q. (MR. STIRBA TURNS ON ELMO.) WHILE WE ARE WARMING UP,
24 DOCTOR, LET ME DIRECT YOUR ATTENTION TO A NURSING NOTE
25 STARTING ON 12/29/95 AT 2200 HOURS. THERE IS A REFERENCE TO
3000
1 A FIVE-HOUR CYCLE OF SEVERE EMESIS. DO YOU SEE THAT?
2 A. YES.
3 Q. AND IS THAT SOMETHING THAT IS SYMPTOMATIC TO YOU OF THE
4 DEATH AND DYING PROCESS?
5 A. THE SYMPTOM OF EMESIS IN THIS PATIENT WOULD BE A SYMPTOM
6 OF A COMORBID OR INTERCURRENT CONDITION, THE MEDICAL
7 COMPLICATIONS THAT WE WOULD SEE IN A PATIENT WHO HAS
8 DEMENTIA AND THEN BEGINS TO DIE FROM SOME OTHER ILLNESS.
9 Q. WERE YOU ABLE TO DETERMINE THE CAUSE OF THE -- THIS
10 CYCLE OF THROWING UP THAT IS CHARTED BY THE NURSE?
11 A. NO.
12 Q. YOU ALSO SEE DOWN TOWARDS THE BOTTOM THERE IS AN
13 ADDITIONAL REFERENCE TO HER HAVING DIFFICULTY AND VOMITING.
14 WAS THE LENGTH OF THE TIME THAT SHE VOMITED SIGNIFICANT TO
15 YOU?
16 A. IT LOOKS LIKE SHE WAS CONTINUING TO VOMIT, DESPITE THE
17 EFFORTS OF THE NURSES TO MAKE HER MORE COMFORTABLE. AND AT
18 THE BEGINNING OF THIS VOMITING THEY DESCRIBED THAT WHAT SHE
19 WAS BRINGING UP WAS CLEAR WITH BITS OF FOOD. AND THEN LATER
20 SHE BEGAN TO HAVE WHAT LOOKED LIKE PARTIALLY DIGESTED BLOOD
21 IN THE VOMITING. THEY CALLED THE DOCTOR SEVERAL TIMES
22 DURING THIS EPISODE AND HE WAS COMING IN TO SEE HER.
23 Q. THE NEXT NURSES' NOTE FOR THAT TIME PERIOD, THERE'S A
24 REFERENCE DOWN AT THE BOTTOM TO -- UNDER BEHAVIOR AT 7:30:
25 PATIENT UNRESPONSIVE TO -- IT LOOKS LIKE --
3001
1 A. VERBAL.
2 Q. -- VERBAL STIMULI, AND THEN HEART RATE REGULAR.
3 WHY ARE THOSE CHART NOTES SIGNIFICANT TO YOU IN YOUR
4 ASSESSMENT OF SYMPTOMS OF DEATH AND DYING?
5 A. WELL, WHEN WE WENT THROUGH THE LIST OF THINGS ABOUT WHAT
6 PATIENTS SHOWED AS THEY BECAME CLOSER TO DEATH AND THE
7 SLEEPING MORE OR BEING LESS RESPONSIVE TO THE ENVIRONMENT,
8 PATIENTS WHO ARE DYING BECOME LESS ABLE TO RESPOND AND ENTER
9 WHAT WE CALL A COMA. AND I BELIEVE THAT THIS PATIENT WAS
10 WHAT WE CALL SEMICOMATOSE OR ALMOST IN A COMA. SHE WAS ABLE
11 TO OPEN HER EYES OCCASIONALLY, BUT WAS NOT ABLE TO RELATE
12 THAT TO THE ENVIRONMENT. SHE DIDN'T RESPOND TO WHEN THEY
13 MOVED HER, SHE DIDN'T RESPOND TO WHEN THEY SHOOK HER OR
14 TALKED TO HER.
15 Q. THE NEXT ENTRY, WHICH IS ALSO ON 12/30, AT THE TOP IT
16 HAS: LUNG SOUNDS DECREASE IN BASES BILATERALLY. AND THEN
17 WE HAVE THOSE TWO DOCTORS, CHEYNE AND STOKING (SIC), RIGHT?
18 A. THAT'S RIGHT.
19 Q. TELL US, PLEASE, WHY THOSE REFERENCES ARE SIGNIFICANT TO
20 YOU IN YOUR ANALYSIS OF THE DEATH AND DYING PROCESS.
21 A. PATIENTS ONLY EXHIBIT CHEYNE-STOKE RESPIRATIONS WHEN
22 THEY HAVE SEVERE HEAD INJURIES OR WHEN THEY'RE DYING. SO
23 THIS IS A CLEAR INDICATION THAT THIS PATIENT WAS DYING AT
24 THIS TIME. NOW, THEY CAN GO ON FOR SEVERAL DAYS WITH THIS
25 TYPE OF RESPIRATIONS COMING AND GOING, BUT PATIENTS WHO ARE
3002
1 CHEYNE-STOKING WITHOUT ACTUALLY JUST HAVING BEEN, YOU KNOW,
2 HIT IN THE HEAD IN A CAR ACCIDENT OR SOMETHING, ARE
3 EXPERIENCING THAT BRAIN STEM TYPE OF RESPIRATION WHICH
4 INDICATES THAT THE BRAIN IS CLOSING DOWN AND THE PATIENT IS
5 DYING.
6 Q. NOW, THERE'S A REFERENCE HERE AT 2100 HOURS BY NURSE --
7 AND I THINK THAT'S MS. KLEY: CALLED SON, GAVE -- I THINK
8 THAT SAY STATUS -- REPORT ON PATIENT'S CONDITION. SON,
9 MERLIN, STRESSED THAT, QUOTE, ONLY WISHED TO KEEP HER
10 COMFORTABLE.
11 DOES THAT HAVE ANY SIGNIFICANCE TO YOU IN TERMS OF
12 PROVIDING END-OF-LIFE CARE?
13 A. THROUGHOUT THIS PATIENT'S CARE THE SON WAS THE SURROGATE
14 DECISION MAKER, SPOKESPERSON FOR THIS PATIENT, AND HAD
15 REPEATEDLY MADE STATEMENTS AND SIGNED DOCUMENTS THAT HE
16 WANTED NO AGGRESSIVE INTERVENTIONS IF THE PATIENT WERE
17 DYING. HE DIDN'T WANT VENTILATORS OR CARDIAC RESUSCITATION
18 OR TUBE FEEDINGS. HE ONLY WANTED COMFORT CARE FOR HIS
19 MOTHER. AND HE REITERATED THAT AT THIS TIME AND SEVERAL
20 TIMES DURING HER CARE.
21 Q. WHAT DOES COMFORT CARE MEAN IN THE CONTEXT OF
22 END-OF-LIFE CARE?
23 A. MEANS MANAGING THE SYMPTOMS SO THAT THE PATIENT DOESN'T
24 EXPERIENCE DISCOMFORT: PREVENTING AND TREATING PAIN,
25 PREVENTING AND TREATING SHORTNESS OF BREATH, TREATING THE
3003
1 VOMITING, STOPPING THE ANXIETY, PROVIDING A SUPPORTIVE
2 ENVIRONMENT.
3 Q. DOES COMFORT CARE INCLUDE MEDICATIONS?
4 A. USUALLY.
5 Q. NOW, DOWN AT THE BOTTOM OF THIS PAGE, WHICH IS ON THE
6 30TH, THERE'S: MONITORED FREQUENTLY AND CLOSELY.
7 IS THAT SIGNIFICANT TO YOU?
8 A. IT MEANS THAT THE NURSING STAFF WAS AWARE THAT THIS
9 PATIENT WAS NOT IN HER USUAL STATE OF -- OF HEALTH AND WAS
10 NEARING DEATH. IT DOESN'T REQUIRE A PHYSICIAN'S ORDER FOR A
11 NURSE TO INCREASE HER SURVEILLANCE OF A PATIENT. AND TO
12 NOTE THAT IN A NURSING NOTE MEANS I'M REALLY WORRIED THAT
13 THIS PATIENT IS DYING, IN A SENSE.
14 AND SO I -- I THOUGHT IT WAS VERY SIGNIFICANT THAT THE
15 NURSES HAD PICKED UP HOW CRITICALLY ILL THIS PATIENT WAS AT
16 THIS POINT AND WERE -- WERE CAREFULLY WATCHING WHAT WAS
17 GOING ON.
18 Q. THIS IS A CONTINUATION OF A NURSING NOTE, ONCE AGAIN, ON
19 DECEMBER 30, '95. I CALL YOUR ATTENTION TO -- IT LOOKS LIKE
20 UP AT THE TOP: PATIENT CLEANSED -- I THINK THAT SAYS TO
21 RESPONSE. HEART RATE TACHY AND IRREGULAR, RESPIRATIONS
22 EVEN.
23 DID I READ THAT SORT OF CORRECTLY?
24 A. YES.
25 Q. WHAT IS -- WHAT DOES IT MEAN WHEN IT SAYS HEART RATE
3004
1 TACHY AND IRREGULAR?
2 A. HER HEART'S BEATING FASTER THAN NORMAL. TACHY IS AN
3 ABBREVIATION FOR TACHYCARDIA WHICH MEANS RAPID HEART RATE,
4 AND THAT THE RHYTHM WAS NOT REGULAR. THIS PATIENT HAD KNOWN
5 CARDIAC DISEASE AND HAD EPISODES OF ATRIAL FIB, SO THIS WAS
6 AN IRREGULAR. IT WASN'T LUB DUB, LUB DUB, LUB DUB. IT WAS
7 LUB DUB, LUB DUB DUB DUB DUB, YOU KNOW, KIND OF OFF AND ON,
8 AND IT WAS VERY FAST.
9 Q. YOU -- YOU USED A TERM AND I THINK IT WAS HARD TO
10 UNDERSTAND. YOU SAID ATRIAL FIB.
11 A. IT'S --
12 Q. WOULD YOU PLEASE EXPLAIN WHAT THAT MEANS?
13 A. -- THE PACEMAKER OF THIS PATIENT'S HEART, THE NORMAL
14 PACEMAKER, THE PHYSIOLOGIC PACEMAKER WAS NOT WORKING
15 CORRECTLY. AND INSTEAD OF THE ATRIUM CONTRACTING BEFORE
16 EACH HEART BEAT, IT WAS FLUTTERING AND JUST WIGGLING, NOT
17 EFFECTIVELY PUMPING THE BLOOD. SO THE NORMAL, NATURAL
18 PACEMAKER WAS INTERRUPTED.
19 ATRIAL FIBRILLATION IN AND OF ITSELF IS NOT A LETHAL
20 PROBLEM FOR MOST PEOPLE AND MANY OF US WALK AROUND AND TAKE
21 MEDICATION TO CONTROL THE HEART RATE. BUT OTHER THINGS CAN
22 HAPPEN TO THE HEART WHEN THE PATIENT HAS ATRIAL FIBRILLATION
23 THAT MAKE IT A NEAR LETHAL DISASTER FOR SOME PEOPLE. THEY
24 GET BLOOD CLOTS IN THE HEART WHICH THEN GET FIRED OFF AND
25 CAUSE STROKES IN THE BRAIN AND THINGS LIKE THAT.
3005
1 Q. NOW, THERE'S A REFERENCE HERE THAT THE NURSE CHARTED:
2 RESPIRATIONS EVEN, NONLABORED, SHALLOW.
3 WHAT SIGNIFICANCE DOES THAT HAVE THAT IT WAS CHARTED IN
4 THAT FASHION?
5 A. THIS WAS PRIOR TO THE EPISODE OF CHEYNE-STOKE
6 RESPIRATIONS THAT WERE NOTED. AND THIS MEANS THAT THE
7 PATIENT WASN'T YET IN THAT CLOSE TO DEATH STATE, THAT THE
8 PATIENT WAS QUIET AND WAS BREATHING FAIRLY NORMALLY. THAT'S
9 WHAT YOU WOULD DESCRIBE AS A NORMAL BREATHING PATTERN.
10 Q. IN FACT, YOU'RE QUITE RIGHT. IT LOOKS LIKE THIS ENTRY
11 IS AT 9:20 --
12 A. YES. AND THE CHEYNE-STOKES --
13 Q. -- ON THE 30TH AND --
14 A. -- WERE NOTED AT 1650.
15 Q. -- THE CHEYNE-STOKES -- RIGHT.
16 OKAY. NOW, ONCE AGAIN, THERE'S A REFERENCE AT 11:30
17 ABOUT THE FAMILY'S STATEMENTS THEY -- IT SAYS: WANT D.N.R.
18 STATUS MAINTAINED, COMFORT MEASURES GIVEN.
19 WHAT IS D.N.R. STATUS?
20 A. D.N.R. IS AN ABBREVIATION FOR DO NOT RESUSCITATE. AND
21 IT'S ONE OF THE ADVANCE DIRECTIVES CATEGORIES OF SAYING I
22 DON'T WANT YOU TO RESTART MY HEART IF IT STOPS. I DON'T
23 WANT YOU TO DO CARDIAC COMPRESSIONS, AND I DON'T WANT YOU TO
24 PUT ME ON A VENTILATOR.
25 RESUSCITATION IS A COMPLEX PROCESS THAT IS -- INCLUDES
3006
1 A NUMBER OF -- OF ATTEMPTS OF TRYING TO RESTART BREATHING
2 AND HEARTBEAT. AND WHAT THEY'RE SAYING BY DO NOT
3 RESUSCITATE IS IF I DIE, LET ME GO.
4 Q. THIS IS, ONCE AGAIN, ANOTHER NURSES' NOTE FOR JUDITH
5 LARSEN. AND IT APPEARS THIS IS ON 12/31, THE NEXT DAY, AND
6 THERE'S AN ENTRY AT THE TOP WHERE THE NURSE HAS SAID:
7 BEHAVIOR, PATIENT HAS -- HAS BEEN UNRESPONSIVE THIS SHIFT.
8 DOES THAT HAVE ANY SIGNIFICANCE TO YOU IN TERMS OF THE
9 PROCESS YOU'RE DESCRIBING?
10 A. AGAIN, THE PATIENT IS EXHIBITING THAT SHE IS IN COMA OR
11 NEARING COMA.
12 Q. AND THEN YOU HAVE SOME VITAL SIGNS TAKEN HERE. DO THOSE
13 VITAL SIGNS HAVE ANY SIGNIFICANCE TO YOU AS CHARTED BY THE
14 NURSE?
15 A. ONE OF THE THINGS THAT WE NOTED EARLIER ABOUT IMPENDING
16 DEATH IS THAT THE BODY CAN EITHER BECOME COOL OR THEN THE
17 PATIENT CAN HAVE A TERMINAL FEVER. AND A BODY TEMPERATURE
18 OF 96.7 IS LOW, SO THAT THIS PATIENT'S METABOLIC PROCESSES
19 WERE BEGINNING TO CLOSE DOWN. AND THE INDICATION WITH THAT
20 TEMPERATURE IS THAT THE PATIENT IS SHUTTING DOWN.
21 AND LATER YOU CAN SEE THAT SHE DOES THEN DEVELOP A
22 FEVER WHICH CAN ALSO THEN BE AN INFECTION AT THE END OF
23 LIFE. SO THOSE ARE BOTH INDICATORS THAT THIS PATIENT WAS
24 DYING.
25 Q. NOW, AFTER THAT 96.7, IT SAYS: M.S. 5 MILLIGRAMS I.M.
3007
1 GIVEN.
2 WHAT DOES THAT MEAN?
3 A. PATIENT WAS GIVEN A SMALL DOSE OF MORPHINE. AND THE
4 PATIENT HAD HAD SOME MOANING SOUNDS EARLIER AND THAT THE
5 PHYSICIAN HAD ORDERED MORPHINE FOR DISCOMFORT FOR HER.
6 Q. DO YOU HAVE AN OPINION, BASED UPON YOUR EXPERTISE AND
7 REVIEW OF THE RECORDS, AS TO THE APPROPRIATENESS OF THAT
8 PARTICULAR INJECTION THAT YOU'VE JUST DESCRIBED?
9 A. I THINK THIS PATIENT RECEIVED APPROPRIATE TREATMENT WITH
10 MORPHINE. SHE HAD RECURRENT EPISODES OF MOANING AND
11 EVIDENCE OF DISCOMFORT AND PAIN THROUGHOUT THE END OF HER
12 LIFE, AND THAT THE PHYSICIAN ORDERED MORPHINE FOR HER TO
13 PREVENT FURTHER PAIN AND TO STOP THE PAIN SHE WAS IN.
14 Q. NOW, IT SAYS HERE -- A LITTLE BIT LATER IT SAYS:
15 RESPIRATIONS EVEN AT 12 PER MINUTE.
16 WHAT SIGNIFICANCE DOES THAT HAVE, IF ANY?
17 A. THAT'S A NORMAL RESPIRATORY RATE. ONE OF THE VITAL
18 SIGNS THAT WE MONITOR WITH MORPHINE THERAPY IS TO MAKE SURE
19 THAT THE MORPHINE IS NOT STOPPING THE PATIENT'S BREATHING
20 ALL AT ONCE. PATIENTS WHO HAVE SIDE EFFECTS FROM MORPHINE
21 WILL GET SLOWER AND SLOWER AND SLOWER RESPIRATIONS. NOT THE
22 CHEYNE-STOKING THAT WE TALKED ABOUT EARLIER, BUT JUST THEY
23 JUST SLOW DOWN. AND SO THE FACT THAT THIS PATIENT'S
24 RESPIRATORY RATE WAS NORMAL INDICATED THAT THE PATIENT'S
25 MORPHINE DOSE WAS APPROPRIATE.
3008
1 Q. THESE ARE SOME ADDITIONAL NOTES FOR THE 31ST.
2 SPECIFICALLY WE HAVE A REFERENCE HERE TO MORE VITAL SIGNS,
3 UP HERE WHERE IT SAYS VITAL SIGNS 99, AND THEN I -- I THINK
4 THAT'S BLOOD PRESSURE. AND COULD YOU EXPLAIN WHAT
5 SIGNIFICANCE THAT HAS, IF ANY, TO YOU?
6 A. THE PATIENT HAD DEVELOPED WITH A 99 DEGREE TEMP, A VERY,
7 VERY LOW GRADE FEVER. THE BLOOD PRESSURE AT 88/52 IS VERY
8 LOW, SO THAT THE PATIENT IS NOW HAVING POOR CIRCULATION.
9 THE HEART RATE IS 60, WHICH IS ALSO FAIRLY LOW FOR THIS
10 PATIENT. SHE NORMALLY RAN HIGHER THAN THAT, ALTHOUGH A
11 YOUNG ATHLETE WOULD DO FINE WITH A 60 HEART RATE. THE
12 RESPIRATORY RATE IS 16, WHICH IS WITHIN THE NORMAL RANGE AND
13 IS, IN FACT, A LITTLE FASTER THAN IT HAD BEEN EARLIER.
14 Q. IS THE RATE OF 16, AS CHARTED BY THE NURSE THERE,
15 CONSISTENT WITH SOMEONE WHO WOULD BE FEELING ILL EFFECTS OF
16 MORPHINE SEDATION?
17 A. NO. I HAD TO THINK ABOUT ALL THE THINGS YOU SAID TO
18 MAKE SURE I GOT THAT IN THE RIGHT ORDER.
19 Q. SURE.
20 A. THIS PATIENT DID NOT HAVE ANY EVIDENCE OF RESPIRATORY
21 DEPRESSION FROM MORPHINE OR ANY OTHER PROBLEM FROM MORPHINE
22 AT THIS POINT.
23 Q. AND TELL US WHY YOU SAY THAT.
24 A. BECAUSE THOSE VITAL SIGNS ARE CONSISTENT WITH THE
25 TERMINAL ILLNESS THE PATIENT HAD, BUT NOT WITH A MORPHINE
3009
1 OVERDOSE.
2 Q. AND THEN DOWN AT THE BOTTOM WE HAVE: PATIENT -- IT
3 APPEARS TO BE UNRESPONSIVE. I CAN'T QUITE READ THAT.
4 PROVIDE CARE AND COMFORT MEASURES.
5 DOES THAT HAVE ANY SIGNIFICANCE TO YOU IN TERMS OF YOUR
6 ASSESSMENT OF HER CONDITION ON THE 31ST?
7 A. SHE STILL SHOWS EVERY INDICATION OF DYING.
8 THE COURT: MR. STIRBA, HOW MUCH LONGER ON THIS
9 PATIENT ARE YOU GOING TO BE?
10 MR. STIRBA: I PROBABLY HAVE A GOOD 15 MINUTES,
11 YOUR HONOR.
12 THE COURT: OKAY. THEN WHY DON'T WE TAKE A BREAK
13 NOW, LADIES AND GENTLEMEN.
14 IT'S YOUR DUTY NOT TO CONVERSE AMONG YOURSELVES DURING
15 THIS BREAK OR WITH ANYONE ELSE OR ALLOW YOURSELF TO BE
16 ADDRESSED BY ANY OTHER PERSON ON THE SUBJECT OF THIS TRIAL.
17 IT'S ALSO YOUR DUTY NOT TO FORM OR EXPRESS AN OPINION
18 UNTIL THE CASE IS FINALLY SUBMITTED TO YOU AFTER YOU'VE
19 HEARD ALL THE EVIDENCE.
20 SO LET'S COME BACK AT 10 MINUTES TO 10:00.
21 (WHEREUPON, AT THIS TIME THERE'S A RECESS, AFTER WHICH
22 PROCEEDINGS RESUME, AS FOLLOWS:)
23 THE COURT: THE RECORD WILL REFLECT THAT THE JURY
24 IS RETURNED.
25 MR. STIRBA, IF YOU'D LIKE TO GO AHEAD?
3010
1 MR. STIRBA: YES. THANK YOU, YOUR HONOR.
2 Q. (BY MR. STIRBA) DOCTOR, YOU HAVE BEFORE YOU AN ENTRY
3 FOR JUDITH LARSEN, NURSES' NOTE 12/31 OF 1995. AND THE
4 NURSE CHARTS -- THE NIGHT SHIFT NURSE, THE 11:00 TO 7:00
5 SHIFT THAT THE RESPIRATION RATE WAS 10 TO 16 PER MINUTE.
6 IS THAT SIGNIFICANT TO YOU IN TERMS OF THE
7 CIRCUMSTANCES OF MS. LARSEN AT THAT TIME?
8 A. IT -- IT INDICATES THAT THE PATIENT'S RESPIRATORY RATE
9 WAS NORMAL; AND, THEREFORE, NOT DEPRESSED BY THE MORPHINE
10 SHE HAD BEEN GIVEN.
11 Q. AND, IN FACT, HERE THERE IS AN ENTRY -- A NURSE
12 INDICATES MORPHINE 5 MILLIGRAMS I.M. GIVEN AT 2:30 AND 6:30
13 FOR PAIN RELIEF. PATIENT WAS MOANING.
14 IS THERE ANY SIGNIFICANCE TO YOU THAT THAT IS CHARTED
15 THAT SHE WAS MOANING?
16 A. WELL, IT INDICATES THAT THEY WERE TREATING A SYMPTOM OF
17 DISCOMFORT, THAT SHE WAS MOANING FROM PAIN OR FROM OTHER
18 DISCOMFORTS, THAT THAT'S WHAT THEY WERE USING THE MORPHINE
19 FOR.
20 Q. IS MOANING A COMMON SYMPTOM THAT OCCURS IN PEOPLE WHO
21 ARE IN THE DEATH AND DYING PROCESS?
22 A. NOT UNLESS THEY'RE IN PAIN.
23 Q. AND THEN A LITTLE BIT BELOW WE HAVE: PATIENT EYES OPEN
24 AND BLINKING. NOT RESPONDING TO VERBAL OR TACTILE -- I
25 THINK THAT SAYS STIMULI.
3011
1 WHAT IS THAT REFERRING TO?
2 A. THAT MEANS WHEN YOU CALL THE PATIENT'S NAME OR TOUCH HER
3 SHE'S NOT RESPONDING, BUT THAT SHE SEEMS TO BE A LITTLE BIT
4 AWARE. WE WOULD CALL THIS A SEMICOMATOSE STATE.
5 Q. AND DOES THAT HAVE ANY SIGNIFICANCE TO YOU IN TERMS OF
6 YOUR ASSESSMENT AND OPINION OF THE PROCESS OF DEATH AND
7 DYING?
8 A. IT'S A VERY COMMON SITUATION SHORTLY BEFORE DEATH.
9 Q. AND THEN RIGHT DOWN AT THE BOTTOM THE NURSE INDICATES:
10 PATIENT CONDITION POOR.
11 DO YOU AGREE WITH THAT ASSESSMENT?
12 A. YES.
13 Q. THEN THERE'S ANOTHER NOTE ON 1/1, AND AT THE TOP THE
14 NIGHT SHIFT NURSE CHARTS: CHEYNE-STOKES RESPIRATION,
15 PERIODS OF APNEA 15 TO 20 SECONDS.
16 WHAT IS APNEA?
17 A. APNEA IS THE ABSENCE OF A BREATH FOR 15 TO 20 SECONDS.
18 Q. IS IT SIGNIFICANT TO YOU WHAT IS CHARTED THERE OF THE
19 PHENOMENON OF APNEA FOR 15 TO 20 SECONDS?
20 A. IN -- IN THE CONTEXT OF CHEYNE-STOKES RESPIRATION IT
21 REPRESENTS THAT PERIOD OF TIME WHERE I SPOKE OF EARLIER
22 WHERE THE PATIENT'S RESPIRATION IS SO SHALLOW AND SO
23 INFREQUENT YOU AREN'T SURE THEY'RE BREATHING. THOSE ARE THE
24 PERIODS OF TIME OF NOT BEING SURE THE PATIENT'S BREATHING IS
25 THE 15 TO 20 SECOND PERIODS IN THAT DOWN SLOPE, AND THEN THE
3012
1 PATIENT AGAIN THEN BEGINS TO BREATHE VERY QUICKLY AND
2 DEEPLY.
3 Q. IS THAT BREATHING PATTERN THAT IS CHARTED INDICATIVE OF
4 RESPIRATORY DEPRESSION CAUSED BY MEDICATION?
5 A. NO, NOT -- NOT WITH CHEYNE-STOKES RESPIRATIONS. IF
6 THERE WERE ONLY PERIODS OF APNEA WITHOUT CHEYNE-STOKES
7 RESPIRATIONS IT COULD BE CONSIDERED A POSSIBLE SIDE EFFECT
8 OF MORPHINE. BUT IN THIS CONTEXT WHERE BOTH ARE TOGETHER,
9 IT IS A BRAIN STEM TYPE OF BREATHING PATTERN AND A REFLEX
10 BREATHING PATTERN INDICATIVE OF IMPENDING DEATH.
11 Q. AT 730 HOURS THE NURSE REPORTS: PATIENT RIGID AND
12 EXTREMITY MOVEMENTS -- I THINK IT'S -- I GUESS WITH
13 EXTREMITY MOVEMENTS.
14 WHAT IS THAT?
15 A. THAT TENDS TO HAPPEN WHEN THE PATIENT IS NOT
16 COMFORTABLE. PATIENTS WHO ARE IN PAIN OR HAVING OTHER
17 DISCOMFORT WILL TEND TO REACT TO -- WITH STIFFNESS TO BEING
18 TURNED IN BED. THEY'RE TRYING, WITH THIS REPOSITIONING, TO
19 PREVENT BED SORES IN THIS PATIENT WHICH WOULD INCREASE HER
20 DISCOMFORT, BUT THE MOVEMENT OF THE PATIENT IS PRODUCING
21 DISCOMFORT IN HER.
22 Q. AND WHAT -- WHAT EXACTLY IS ENTAILED BY REPOSITIONING?
23 A. WELL, THEY USUALLY ROLL THE PATIENT FROM ONE SIDE TO THE
24 OTHER AND TUCK A PILLOW BEHIND THEM AND STRAIGHTEN UP THE
25 SHEETS, AND SO THEY ACTUALLY HAVE TO MOVE THE PATIENT QUITE
3013
1 A LOT TO DO THAT.
2 Q. NOW, THERE'S ALSO AT 9:35 A NURSE CHARTS: INTERMITTENT
3 BREATHING -- JUST BREATHING. I CAN'T READ THE REST OF IT.
4 A. I THINK IT SAYS UNLABORED BREATHING.
5 Q. I SEE. AND THEN THERE'S AN INDICATION OF 14.
6 A. THAT'S HER RESPIRATORY RATE AT THAT TIME, WHICH IS
7 NORMAL.
8 Q. IS A NORMAL RATE?
9 A. UH-HUH.
10 Q. THIS IS A LATER NURSING NOTE WHICH I HAVE DISPLAYED ON
11 1 -- 1/1 OF '96. I WANT TO DIRECT YOUR ATTENTION TO THE
12 MIDDLE, UNDER (B) WE HAVE: PATIENT UNRESPONSIVE EXCEPT TO
13 PAINFUL STIMULI. AND THEN IT SAYS: GROANS AS INJECTIONS
14 GIVEN. PATIENT OFTEN GROANED WHEN TURNED.
15 WHAT SIGNIFICANCE DOES THAT HAVE TO YOU THAT THAT WAS
16 CHARTED?
17 A. THE STRONGEST ANTAGONIST TO THE EFFECT OF PAIN RELIEF
18 FROM MORPHINE IS PAIN ITSELF. WE OFTEN TALK ABOUT BALANCING
19 PAIN AND PAIN RELIEF TO PRODUCE PAIN RELIEF OPTIMALLY
20 WITHOUT OVERDOSING THE PATIENT.
21 THE FACT THAT THIS PATIENT IS RELATIVELY COMFORTABLE
22 WHEN SHE'S STILL, AND YET GROANS AND MOANS WHEN SHE'S MOVED
23 AROUND OR TREATED, WOULD MEAN THAT SHE'S BARELY GETTING
24 ENOUGH MORPHINE TO KEEP HER COMFORTABLE WHEN SHE'S STILL,
25 BUT CERTAINLY ISN'T AN OVERDOSE BY ANY STRETCH OF THE
3014
1 IMAGINATION BECAUSE SHE'S STILL HAVING PAIN WHEN SHE'S MOVED
2 AROUND.
3 Q. AND THEN A LITTLE BIT BELOW THAT UNDER FREE TEXT MED
4 NOTE, IT APPEARS TO BE 1600 HOURS, WE HAVE THE NOTE:
5 GROANING -- AND THEN I BELIEVE YOU USED THIS WORD BEFORE --
6 TWITCHING; IS THAT RIGHT?
7 A. YES.
8 Q. AND WHAT DOES TWITCHING INDICATE?
9 A. TWITCHING IS ANOTHER SIGN OF THE BODY BEING IRRITATED BY
10 A NOXIOUS STIMULUS. SOMETHING LIKE PAIN WOULD MAKE A PERSON
11 TWITCHY.
12 Q. AND THERE'S AN INDICATION THERE: AND SLIGHTLY LESS
13 TWITCHING OBSERVED 30 MINUTES -- I GUESS THAT'S POST, AND
14 M.S. WOULD BE MORPHINE; IS THAT RIGHT?
15 A. YES.
16 Q. WHAT -- WHAT DOES THAT TELL YOU?
17 A. THE MORPHINE DENTED THE PAIN, PROBABLY DIDN'T COMPLETELY
18 RELIEVE IT.
19 Q. THIS IS ANOTHER ENTRY FOR THE NURSING NOTES, AND IT'S
20 1/1 OF '96.
21 A. UH-HUH.
22 Q. AND IT APPEARS THAT AT 2245 IT SAYS: FREE TEXT, PATIENT
23 APPEARS TO BE IN PAIN.
24 DID I READ THAT CORRECTLY?
25 A. YES.
3015
1 Q. AND THEN IT GOES ON TO SAY: GROANING, AND PATIENT
2 MEDICATED, MORPHINE 5 MILLIGRAMS I.M.
3 AND THEN THERE ARE THOSE VITAL SIGNS CHARTED BY THE
4 NURSE. AND IS THERE A RESPIRATORY RATE INDICATED THERE?
5 A. RESPIRATORY RATE OF 12.
6 Q. AND IN TERMS OF NORMALCY IS --
7 A. THAT IS NORMAL.
8 Q. AND THEN IT SAYS: FREE TEXT, DOCTOR NOTIFIED THAT
9 MORPHINE STILL RESULTS IN NO RELIEF OF PATIENT'S GROANING
10 AND MOANING.
11 DID I READ THAT CORRECTLY?
12 A. YES.
13 Q. WHAT SIGNIFICANCE, IF ANY, DOES THAT ENTRY HAVE?
14 A. WELL, IT -- THE ENTRY ABOVE THE ONE YOU STARTED WITH
15 SAID: MEDICATED MORPHINE 5 MILLIGRAMS, HALF HOUR LATER NO
16 CHANGE NOTED.
17 AND THEN A FEW HOURS LATER: PATIENT APPEARED TO BE IN
18 PAIN AND WAS TREATED.
19 Q. LET ME -- LET ME STOP YOU, DOCTOR. I JUST WANT TO MAKE
20 SURE THAT I'M WITH YOU.
21 A. THAT'S THE FIRST PARAGRAPH THERE.
22 Q. PATIENT MEDICATED WITH MORPHINE 5 MILLIGRAMS I.M., HALF
23 HOUR LATER -- THAT MEANS NO CHANGE NOTED?
24 A. NO. DELTA IS A -- A MATHEMATICAL SYMBOL FOR CHANGE AND
25 WE USE IT AS AN ABBREVIATION WHEN WE'RE WRITING FAST.
3016
1 SO YOU'VE GOT TWO NOW IN A ROW EPISODES OF THE PATIENT
2 CONTINUING TO GROAN AFTER RECEIVING MORPHINE. SO THE
3 PHYSICIAN WAS NOTIFIED THAT THE PATIENT WAS NOT RECEIVING
4 THE RELIEF FROM THE MORPHINE, AND HE THEN GAVE A TELEPHONE
5 ORDER FOR ANOTHER DOSE OF MORPHINE.
6 Q. THIS IS A NURSES' NOTE FOR JANUARY 2ND OF '96. AND I
7 WANT TO DIRECT YOUR ATTENTION, THE NIGHT SHIFT NURSE, 11:00
8 TO 7:00, HAS IN A FREE TEXT NOTE, DOWN TOWARDS THE MIDDLE IT
9 SAYS: HANDS AND FINGERS ARE BLUISH IN COLOR.
10 WHAT DOES THAT SIGNIFY?
11 A. THE PATIENT'S CIRCULATION IS DECREASING. IT'S ONE OF
12 THE SIGNS OF IMPENDING DEATH THAT WE TALKED ABOUT EARLIER ON
13 THAT CHART.
14 Q. AND WHY WOULD THE CIRCULATION IMPAIRMENT MANIFEST ITSELF
15 IN BLUISHNESS COLOR IN THE FINGERS?
16 A. WELL, WHEN THE CIRCULATION IS SLOW THE BODY TAKES MORE
17 OF THE OXYGEN OUT OF THE BLOOD THAT'S SITTING IN THE FINGERS
18 OR IN THE TOES AND -- AND THE BLOOD COLOR TENDS TO TURN
19 BLUER WHEN THE OXYGEN IS USED UP. SO IT'S JUST BECAUSE IT'S
20 GOING THROUGH MORE SLOWLY THAT YOU WOULD TEND TO USE MORE OF
21 IT UP OUT OF THAT PARTICULAR PART OF THE BLOOD AND IT WOULD
22 LOOK BLUE.
23 Q. NOW THERE'S A 9:30 ENTRY AND IT'S A MED ENTRY AND IT --
24 M.S. 5 MILLIGRAMS I.M., AND THEN IT HAS PATIENT MOANING -- I
25 CAN'T QUITE READ THAT.
3017
1 A. AT THIS TIME.
2 Q. AT THIS TIME --
3 A. WITH EYES OPEN.
4 Q. -- AND EYES OPEN AND STARING.
5 IS -- IS THAT CHART NOTE SIGNIFICANT TO YOU?
6 A. WELL, THE PATIENT'S CONTINUING TO EXPERIENCE PAIN. I --
7 FROM THE EXPERIENCE I WOULD HAVE WITH MY PATIENTS -- WOULD
8 SUSPECT IF SHE WERE NOT HAVING PAIN AT THIS TIME, HER EYES
9 WOULD NOT BE OPEN AND STARING. THE MOANING AND STARING GO
10 TOGETHER. IT'S THAT LAST LITTLE THING THAT'S KEEPING HER
11 FROM BEING PEACEFUL IS THE PAIN.
12 Q. THIS IS ANOTHER ENTRY -- I THINK THE FOLLOWING
13 SEQUENCE -- ON 1/2 OF '96. I WANT TO DIRECT YOUR ATTENTION
14 DOWN TO THE BOTTOM. THERE'S AN ENTRY AT 1530 AND IT SAYS:
15 MOANING, 5 MILLIGRAMS M.S. P.R.N. GIVEN I.M.
16 DID I READ THAT CORRECTLY?
17 A. YES.
18 Q. AND P.R.N. MEANS WHAT?
19 A. AS NEEDED.
20 Q. AND WHAT SIGNIFICANCE, IF ANY, IS THAT NOTE TO YOU?
21 A. IT IS A RESPONSE, BASED ON THE NURSE'S JUDGMENT TO THE
22 LEVEL OF MOANING THAT THE PATIENT IS HAVING, THAT THE
23 PATIENT IS HAVING MORE PAIN. THIS PATIENT HAD TWO KINDS OF
24 MEDICATION ORDERS, ONE WERE ORDERS TO BE GIVEN ON A SCHEDULE
25 EVERY FOUR HOURS OR SOMETHING, AND THE NURSE WOULD NOT
3018
1 NECESSARILY HAVE DECISION TO DO IT AT THAT TIME. SHE WOULD
2 JUST, YOU KNOW, GIVE IT ON SCHEDULE. SHE MIGHT DECIDE NOT
3 TO GIVE IT IF THERE WERE AN ADVERSE SYMPTOM GOING ON, BUT
4 IT'S ON A SCHEDULE.
5 WHEN SOMETHING'S ORDERED P.R.N., THE PHYSICIAN IS
6 LEAVING IT TO THE NURSE'S JUDGMENT TO REACT TO A SYMPTOM
7 THAT THE PATIENT IS HAVING, AND IN THIS CASE, TO PAIN.
8 Q. AND IS THERE CHARTED A SYMPTOM SUCH THAT THE NURSE IS
9 REACTING TO IT?
10 A. MOANING. MOANING. JERKING ALL EXTREMITIES. THERE --
11 THOSE ARE INDICATIONS THAT THE PATIENT IS UNCOMFORTABLE.
12 Q. AND I NOTICE THAT DOWN RIGHT HERE THAT LOOKS LIKE
13 B. HARDEY, R.N. WHO WROTE THAT NOTE.
14 A. THAT'S WHAT --
15 Q. DOES THAT LOOK LIKE?
16 A. YES.
17 Q. THIS IS THE NEXT SEQUENTIAL NOTE. IT DOES NOT APPEAR TO
18 HAVE A DATE HERE. I THINK --
19 A. I THINK THE PUNCH WENT THROUGH THE DATE.
20 Q. YEAH. IT'S PUNCHED THROUGH. AT 1830 HOURS, MED ENTRY
21 MORPHINE 5 MILLIGRAMS GIVEN PER DOCTOR'S ORDERS. PATIENT
22 REMAINS UNRESPONSIVE, STARING. COOL CLOTH POSITIONED OVER
23 EYES TO DECREASE -- DOES THAT SAY CRYING?
24 A. PREVENT DRYING.
25 Q. PREVENT DRYING.
3019
1 AND THEN IT HAS HERE IN THE MIDDLE: FINGERS CYANOTIC,
2 HEART RATE IRREGULAR.
3 WHAT DOES CYANOTIC MEAN?
4 A. IT'S A MEDICAL WORD FOR BLUE.
5 Q. AND IS THIS THE SAME --
6 A. IT'S THE SAME AS WAS DESCRIBED EARLIER THAT PATIENT'S
7 CIRCULATION HAS DECREASED. THE BLOOD IS MOVING VERY SLOWLY
8 THROUGH THE FINGERS AND TOES AND SO THE BODY -- THE TISSUES
9 IN THAT AREA ARE USING UP ALL THE OXYGEN AND THE BLOOD IS
10 TURNING BLUER IN COLOR AND IT SHOWS AS BLUE COLOR IN THE
11 FINGERS.
12 Q. THE NURSE ALSO CHARTS THAT THE HEART RATE IS ERRATIC.
13 DO YOU KNOW WHAT THAT MEANS?
14 A. IRREG -- IRREGULAR.
15 Q. I'M SORRY.
16 A. YES.
17 Q. IRREGULAR. YOU'RE RIGHT.
18 A. RIGHT.
19 Q. AND DO YOU KNOW WHAT THAT MEANS?
20 A. WELL, THE PATIENT HAS A CARDIAC CONDITION AND THE
21 PATIENT'S NORMAL PACEMAKER IS NOT WORKING. THE PATIENT HAS
22 AN IRREGULAR HEARTBEAT. SHE'S HAD THAT PERSISTENTLY MOST OF
23 THE TIME.
24 Q. IS THAT SIGNIFICANT IN TERMS OF HER STATUS AT THIS POINT
25 WHEN CHARTED?
3020
1 A. PROBABLY NOT. PROBABLY NOT AS A SIGN THAT SHE'S DYING
2 RIGHT NOW. JUST AS AN INDICATOR THAT THERE'S MORE THAN ONE
3 ILLNESS IN THIS PATIENT.
4 Q. AND THEN SHE ALSO CHARTS OVER HERE, RIGID EXTREMITIES.
5 IS THAT WHAT YOU DESCRIBED PREVIOUSLY?
6 A. YES. THAT THE RIGIDITY TENDS TO BE FROM REACTING TO
7 DISCOMFORT, ESPECIALLY TO PAIN.
8 Q. IS RIGIDITY -- RIGIDITY A SIGN OR A SYMPTOM THAT IS
9 ASSOCIATED WITH THE DEATH AND DYING PROCESS?
10 A. NO. USUALLY THE PATIENT'S MUSCLES RELAX AS THEY GET
11 CLOSER TO DEATH.
12 Q. THIS IS A NOTE ON 1/3. AND WE HAVE, ONCE AGAIN, THE
13 NIGHT NURSE, 11:00 TO 7:00, HAS A FREE TEXT NOTE, AND HERE
14 SHE CHARTS: M.S. HELD TIMES 3 DUE TO RESPIRATIONS 5 TO 8.
15 DOES THAT HAVE ANY SIGNIFICANCE TO YOU IN THE CONTEXT
16 OF THIS NOTE?
17 A. WHAT THAT MEANS IS THAT THE PATIENT WAS MORE COMFORTABLE
18 AND THAT THE PATIENT'S RESPIRATORY RATE BEGAN TO BE AFFECTED
19 BY THE MORPHINE. SO THE NURSE, PER HER NURSING PROTOCOL,
20 WITHHELD ANY FURTHER DOSES OF MORPHINE AS LONG AS THE
21 RESPIRATORY RATE IS 5 TO 8. THIS WOULD BE THE NORMAL
22 RESPONSE TO A RESPIRATORY RATE OF 5 TO 8. I WOULD NOT TREAT
23 FOR THE RESPIRATORY RATE OF 5 TO 8 OR GIVE EXTRA MEDICATION
24 TO RAISE IT IN ANY WAY. I WOULD JUST WAIT FOR THE MORPHINE
25 TO WEAR OFF AND WAIT FOR THE SYMPTOMS TO RETURN BEFORE
3021
1 GIVING MORE MORPHINE. THIS IS AN ENTIRELY APPROPRIATE
2 NURSING ACTION.
3 Q. THEN IT HAS: FINGERS CYANOTIC EARLY IN SHIFT, MUCH
4 IMPROVED THROUGH THE NIGHT. AND I CAN'T READ THAT. NO
5 MOANING; IS THAT RIGHT?
6 A. NO MOTTLING.
7 Q. I'M SORRY. MOTTLING. WHAT IS MOTTLING?
8 A. MOTTLING IS ANOTHER SIGN OF IMPENDING DEATH WHERE THE
9 SKIN COLOR BECOMES SPLOTCHY SO THAT PARTS OF THE SKIN ARE --
10 ARE RED OR BLUE AND PART ARE VERY, VERY PALE. AND IT --
11 IT'S A LITTLE BIT LIKE THE SKIN OF A CANTALOUPE THAT IS
12 IRREGULAR. IT'S NOT ANY REAL PATTERN, BUT IT'S JUST LINES
13 OF COLOR ON A PALE BACKGROUND. AND IT IS A RESULT, AGAIN,
14 OF DROPPING BLOOD PRESSURE AND DECREASING CIRCULATION. IT
15 IS ALMOST UNIVERSAL IN A -- IN AN IMPENDING DEATH LIKE THIS.
16 SO THE FACT THAT SHE DIDN'T HAVE IT MEANT SHE WASN'T REALLY
17 RIGHT -- GOING TO DIE RIGHT THAT SECOND.
18 Q. NOW, IF WE GO DOWN TO THE -- THE NOTE FROM THE 7:00 TO
19 3:00 SHIFT, WE HAVE BEHAVIOR --
20 THE COURT: DO YOU WANT TO LIFT THAT UP A LITTLE
21 BIT?
22 MR. STIRBA: OH, I'M SORRY, YOUR HONOR. THANK YOU.
23 Q. (BY MR. STIRBA) THE 7:00 TO 3:00 SHIFT: BEHAVIOR,
24 PATIENT WAS UNRESPONSIVE FOR THIS SHIFT AND STARING VACANTLY
25 AT TIMES. GROANING AT TIMES, TWITCHING.
3022
1 DOES THAT BEHAVIOR INDICATE ANYTHING TO YOU?
2 A. IT WOULD INDICATE THAT THE PATIENT WAS AGAIN IN PAIN,
3 THAT THE EARLIER MORPHINE HAD PROBABLY WORN OFF BY THEN AND
4 THE PATIENT WAS NOW EXPERIENCING DISCOMFORT.
5 Q. AND THEN DOWN AT THE BOTTOM IT SAYS -- LOOKS LIKE:
6 RESPONSE, PATIENT HAS HAD NO CHANGE IN CONDITION THIS SHIFT.
7 AND THEN WHAT DOES THE S WITH THE MARK OVER IT?
8 A. WITHOUT.
9 Q. WITHOUT RESPONSE DURING CARES AND WHEN FAMILY VISITED.
10 DOES THAT HAVE ANY SIGNIFICANCE TO YOU?
11 A. THE PATIENT -- THE PATIENT IS COMPLETELY UNRESPONSIVE TO
12 HER ENVIRONMENT.
13 Q. AND WHAT DOES THAT MEAN?
14 A. IT MEANS THAT SHE'S DYING.
15 Q. THIS IS A -- A NOTE FOR 1/3 AND IT STARTS AT 1530. IT
16 HAS: FREE TEXT, 5 MILLIGRAMS MORPHINE I.M. GIVEN PER
17 SCHEDULED DOSE BY R.N.
18 A. L.P.N.
19 Q. L.P.N. I'M -- THAT'S RIGHT. THERE'S -- THERE'S THE L.
20 AND DOWN THE BOTTOM -- TOWARDS THE BOTTOM ON 1440, IS THAT
21 THAT MOTTLING AGAIN? EVIDENCES OF LOWER EXTREMITIES IN
22 BACK?
23 A. YES.
24 Q. AND THAT'S WHAT YOU JUST DESCRIBED --
25 A. BEGINNING TO -- TO SHOW THAT SIGN OF IMPENDING DEATH,
3023
1 YES.
2 Q. AND THEN ON 1830, RECEIVED DOCTOR'S ORDER FOR MORPHINE
3 15 MILLIGRAMS I.M. NOW. INCREASE MORPHINE TO 10 MILLIGRAMS
4 3 HOURS DUE TO PATIENT'S AGITATED STATE. AND IT'S BONNIE
5 HARDEY, R.N.
6 A. RIGHT. CORRECT.
7 Q. DOES THAT HAVE ANY SIGNIFICANCE TO YOU?
8 A. WELL, THE 1800 NOTE SAID PATIENT WITH LOUD MOANING,
9 EXTREMITIES TWITCHING, WHICH SOUNDS LIKE HER PAIN WAS
10 INCREASING. IT'S NOT SAID IN HERE, BUT IMPLIED IF THEY
11 RECEIVED DOCTOR'S ORDER THAT SOMEBODY CALLED THE DOCTOR
12 ABOUT THAT IN THAT HALF HOUR PERIOD AND GOT A NEW ORDER TO
13 INCREASE THE DOSE OF MORPHINE IMMEDIATELY, AND THEN OVER A
14 PERIOD OF TIME FOR CONTINUED CARE TO INCREASE HER DOSE FROM
15 5 TO 10 MILLIGRAMS.
16 Q. AND THEN AT 2000 HOURS IT -- IT LOOKS LIKE: PATIENT
17 DECREASED HEART RATE AND DEEP RESPIRATIONS -- I CAN'T READ
18 WHAT -- WHAT THAT SAYS.
19 A. WITHOUT.
20 Q. I'M SORRY. WITHOUT MOMENTS OF DEEP SIGNS AND
21 IRREGULAR --
22 A. I SUSPECT THAT MEANT WITH MOMENTS OF DEEP SIGH. IT'S
23 HARD TO READ.
24 Q. SIGH?
25 A. YEAH.
3024
1 Q. AND DOES THAT HAVE ANY SIGNIFICANCE TO YOU?
2 A. WE WOULD CALL THAT AGONAL BREATHING, THAT THE PATIENT IS
3 ACTUALLY, IN FACT, DYING RIGHT NOW. THAT THE HEART RATE
4 DROPPING AT THE SAME TIME THAT THE RESPIRATORY RATE IS
5 DROPPING MEANS THE PATIENT IS -- IS WITHIN MINUTES OF DEATH.
6 AS A PATIENT'S LAST BREATHS ARE TAKEN, THEY DON'T TEND TO BE
7 REAL SHALLOW. THEY TEND TO BE VERY DEEP AND VERY SLOW, SO
8 THAT YOU'D SEE ONE VERY DEEP, SLOW BREATH, AND THEN WAIT,
9 AND THEN ANOTHER DEEP, SLOW BREATH, AND THEN WAIT, AND THEY
10 KIND OF TAPER OFF THAT WAY SO THAT THE PATIENT IS ACTUALLY
11 DYING RIGHT NOW.
12 Q. YOU USED -- YOU USED THE TERM AGONAL.
13 A. AGONAL MEANS DYING RIGHT NOW.
14 Q. DOCTOR, YOU HAVE ALSO REVIEWED THE RECORD -- RECORDS
15 CONCERNING PATIENT LYDIA SMITH?
16 A. YES.
17 Q. AND DO YOU HAVE AN OPINION AS TO WHETHER OR NOT PATIENT
18 LYDIA SMITH WAS IN A TERMINAL CONDITION AT THE TIME OF HER
19 ADMISSION TO THE DAVIS HOSPITAL?
20 A. LYDIA SMITH MET ALL THE CRITERIA WE DISCUSSED EARLIER
21 FOR A TERMINAL PROGNOSIS FROM ADVANCED DEMENTIA. SHE
22 REQUIRED ACTIVITIES OF DAILY LIVING ASSISTANCE FOR
23 EVERYTHING. HER PERFORMANCE SCORES WERE -- WITH THE
24 FUNCTIONAL ASSESSMENT SCALE -- A 7(B), WHICH MEANT SHE HAD
25 LESS THAN ONE OR TWO INTELLIGIBLE WORDS PER DAY.
3025
1 IN ADDITION, SHE HAD EXPERIENCED AN UNINTENTIONAL
2 WEIGHT LOSS OF MORE THAN 25 PERCENT OF HER BODY WEIGHT IN
3 THE PERIOD IMMEDIATELY PRECEDING HER ADMISSION TO THE
4 HOSPITAL, INDICATING THAT SHE HAD LOST INTEREST IN FOOD AND
5 WAS NOT TAKING A NORMAL DIET.
6 Q. AND GIVEN WHAT YOU'VE JUST TESTIFIED TO, DO YOU HAVE AN
7 OPINION AS TO WHETHER OR NOT SHE WAS IN A TERMINAL CONDITION
8 UPON HER ADMISSION TO THE HOSPITAL?
9 A. WELL, YES. SHE MET ALL THE CRITERIA TO BE CONSIDERED
10 TERMINALLY ILL FROM THE ADVANCED DEMENTIA.
11 Q. YOU ALSO REVIEWED MR. ALLDREDGE'S -- MR. ENNIS
12 ALLDREDGE'S FILE?
13 A. I DID.
14 Q. AND I'LL ASK YOU SIMILARLY, DO YOU HAVE AN OPINION AS TO
15 WHETHER OR NOT MR. ALLDREDGE WAS TERMINALLY ILL ON HIS
16 ADMISSION TO THE DAVIS HOSPITAL?
17 A. MR. ALLDREDGE ALSO WAS TERMINALLY ILL WITH ADVANCED
18 DEMENTIA. HIS FUNCTIONAL ASSESSMENT SCALE WAS ALSO A 7(B),
19 JUST LIKE LYDIA'S. AND HE WAS EXPERIENCING MULTIPLE MEDICAL
20 COMPLICATIONS AND COMORBID CONDITIONS. NOW, THOSE ARE
21 THE -- COMORBID MEANING OTHER SEVERE ILLNESSES EXISTING AT
22 THE SAME TIME.
23 HE HAD INSULIN DEPENDENT DIABETES, CORONARY ARTERY
24 DISEASE HAVING HAD BYPASS SURGERY. HE HAD KIDNEY
25 INSUFFICIENCY. HE WAS BORDERING ON KIDNEY FAILURE. AND
3026
1 HE'D HAD A MALIGNANCY OF HIS LYMPHATIC SYSTEM CALLED MYCOSIS
2 FUNGOIDES WHICH IS A MALIGNANCY OF ONE OF THE T CELLS.
3 T CELLS ARE THE KIND OF LYMPHOCYTE THAT AFFECT YOUR
4 IMMUNE SYSTEM, AND SO HE HAD AN IMMUNE SYSTEM CANCER THAT
5 HAD BEEN TREATED. AND IT'S UNCLEAR FROM THE RECORD HOW
6 ACTIVE THE DISEASE WAS, ALTHOUGH THE INTERNIST NOTE SAID IT
7 WAS END STAGE.
8 Q. AND WHAT DOES END STAGE MEAN TO YOU?
9 A. ADVANCED DISEASE, THAT IT IS NOT CURED.
10 SO FOR ALL OF THESE REASONS, HE WAS TERMINALLY ILL WHEN
11 HE WAS ADMITTED TO THIS FACILITY.
12 Q. MARY CRANE?
13 A. MARY CRANE?
14 Q. DID YOU ALSO REVIEW --
15 A. I DID.
16 Q. -- HER SITUATION AND CIRCUMSTANCE ON ADMISSION?
17 A. MARY CRANE HAD ADVANCED DEMENTIA AND WAS PROBABLY CLOSE
18 TO TERMINALLY ILL, IF NOT QUALIFYING EXACTLY UNDER THE
19 MEDICARE GUIDELINES. HER FUNCTIONAL ASSESSMENT SCORE WAS
20 CLOSER TO A 7(A), WHICH IS RIGHT ON THE BORDER OF BEING
21 ELIGIBLE FOR HOSPICE CARE. BUT SHE HAD SERIOUS --
22 Q. DOCTOR, IF I MAY JUST INTERRUPT YOU. EXPLAIN TO US THE
23 DIFFERENCE BETWEEN YOUR ASSESSMENT OF HER CONDITION AND
24 PERHAPS THE OTHER PATIENTS IN TERMS OF THE SCALE AND THE
25 GUIDELINES.
3027
1 A. SHE WAS MORE COMMUNICATIVE AT THE TIME OF HER ADMISSION.
2 SHE WAS AGITATED AND DEPRESSED, BUT WAS, IN FACT, ABLE TO
3 COMMUNICATE OCCASIONALLY A FEW WORDS THAT WERE MEANINGFUL TO
4 THE STAFF, AND THEN LATER BECAME LESS COMMUNICATIVE BECAUSE
5 OF A MEDICAL COMPLICATION AND AN INTERCURRENT ILLNESS THAT
6 WAS OCCURRING.
7 Q. AND WHAT MEDICAL COMPLICATION ARE YOU REFERRING TO?
8 A. SHE HAD A LONG HISTORY OF RECURRING URINARY TRACT
9 INFECTIONS AND WAS NOTED DURING THIS HOSPITALIZATION TO HAVE
10 DEVELOPED A RECTOVAGINAL FISTULA, WHICH IS AN OPENING
11 BETWEEN HER RECTUM AND HER VAGINA ALLOWING STOOL TO PASS
12 FROM THE NORMAL PASSAGEWAY IN THE BOWEL INTO THE VAGINAL
13 AREA. AND WE THINK THAT THAT CONTAMINATION THEN GOT INTO
14 THE URETHRA, WHICH IS WHERE THE URINE COMES OUT OF THE
15 BLADDER, AND WAS GIVING HER RECURRENT INFECTIONS.
16 THE RESULT OF THIS RECTOVAGINAL FISTULA WAS THAT SHE
17 DEVELOPED A BLOODSTREAM INFECTION CALLED SEPTICEMIA AND DIED
18 FROM THE SEPTICEMIA. SHE DID NOT DIE OF HER DEMENTIA. SHE
19 DIED OF THE COMPLICATION OF SEPTICEMIA.
20 Q. DO YOU HAVE ANYTHING ELSE TO ADD CONCERNING YOUR
21 ASSESSMENT OF HER SITUATION RELEVANT TO THE GUIDELINES YOU
22 TESTIFIED TO?
23 A. JUST THAT THE PAIN MEDICATIONS THAT SHE RECEIVED DURING
24 THIS PERIOD OF TIME WERE IN KEEPING WITH THE LEVEL OF PAIN
25 EXPECTED FROM THE DISEASE THAT SHE HAD.
3028
1 Q. AND -- AND THAT DISEASE WAS WHAT?
2 A. WAS THIS FISTULA AND SEPTICEMIA.
3 Q. I SEE. AND DID YOU SIMILARLY CONDUCT AN EVALUATION AND
4 ASSESSMENT OF PATIENT ELLEN ANDERSON?
5 A. YES, I DID.
6 Q. AND DO YOU HAVE AN OPINION, BASED UPON YOUR REVIEW, OF
7 WHETHER ELLEN ANDERSON, ON HER ADMISSION TO THE DAVIS
8 HOSPITAL, WAS TERMINALLY ILL?
9 A. ELLEN ANDERSON HAD SEVERE DEMENTIA AT THE TIME OF HER
10 ADMISSION. IT'S UNCLEAR THAT SHE WAS ACTUALLY MEETING ALL
11 OF THE GUIDELINES FOR TERMINAL ILLNESS AT THE TIME OF HER
12 ADMISSION, AGAIN, BECAUSE SHE WAS SLIGHTLY MORE
13 COMMUNICATIVE THAN THE OTHERS.
14 HOWEVER, SHE HAD SEVERE ENDOCRINE ILLNESSES, INCLUDING
15 SEVERE CARDIAC DISEASE, AND APPEARED TO HAVE DURING HER STAY
16 THERE ANOTHER CARDIAC EVENT OF SOME SORT WHICH PRECIPITATED
17 HER DEATH. SHE DID NOT DIE OF HER DEMENTIA, BUT SHE DIED OF
18 THIS INTERCURRENT COMPLICATION.
19 SHE ONLY RECEIVED TWO SMALL DOSES OF MORPHINE DURING
20 HER END STAGE AND THIS WOULD HAVE BEEN AN ENTIRELY
21 APPROPRIATE WAY TO MANAGE AN ACUTE CARDIAC EVENT.
22 Q. BASED UPON YOUR REVIEW OF THE RECORDS AND YOUR ANALYSIS
23 OF THEM, DO YOU HAVE AN OPINION AS TO THE KIND OF CARE THAT
24 WAS BEING GIVEN TO LYDIA SMITH, ENNIS ALLDREDGE, MARY CRANE,
25 AND JUDITH LARSEN?
3029
1 A. I DO.
2 Q. AND WHAT KIND OF CARE WAS THAT?
3 A. I BELIEVE THESE PATIENTS WERE RECEIVING GOOD END-OF-LIFE
4 CARE WITH ATTENTION TO THE NEEDS OF THE PATIENT. THERE ARE
5 MANY NOW PRESENT STANDARDS THAT WEREN'T PRESENT AT THE TIME
6 OF THIS CARE FOR THESE PATIENTS THAT WERE ACTUALLY BEING
7 MET.
8 THERE WAS ATTENTION IN EACH PATIENT TO ADVANCE
9 DIRECTIVES, THE FAMILIES WERE COUNSELLED AND -- AND THE
10 CASES WERE DISCUSSED WITH EACH PATIENT. THE PATIENT'S
11 SYMPTOMS WERE MANAGED APPROPRIATELY, AND THE PATIENTS
12 RECEIVED COMPLETE AND ATTENTIVE CARE.
13 Q. WHAT GUIDELINES ARE YOU REFERRING TO THAT NOW ARE
14 EXISTENT THAT WERE NOT EXISTENT THEN?
15 A. WELL, IN THE LAST SEVERAL YEARS IN THE UNITED STATES
16 THERE'S BEEN A HUGE INTEREST IN INCREASING AND IMPROVING
17 END-OF-LIFE CARE. IN 1997 A REPORT WAS PUBLISHED THAT
18 SHOWED THAT MORE THAN HALF OF PATIENTS WHO DIED IN INTENSIVE
19 CARE UNITS DIED IN SEVERE PAIN, UNTREATED AND UNRECOGNIZED
20 BY THEIR PHYSICIANS.
21 IN RESPONSE TO THIS THE AMA, THE AMERICAN MEDICAL
22 ASSOCIATION, HAS JUST COMPLETED AN EXTENSIVE PROGRAM TO
23 DEVELOP A CURRICULUM TO TRAIN ALL PRACTICING PHYSICIANS IN
24 THE APPROPRIATE MANAGEMENT OF PATIENTS AT THE END OF LIFE,
25 WHICH INCLUDE THE ADVANCE DIRECTIVES, THE PAIN AND SYMPTOM
3030
1 CONTROL, THE ATTENTION TO INFORMATION NEEDED BY PATIENTS AND
2 FAMILIES, NORMAL GRIEF AND SO ON. SO THOSE ARE NOW THE
3 CURRENT STANDARDS FOR END-OF-LIFE CARE.
4 Q. THANK YOU.
5 MR. STIRBA: THAT'S ALL THE QUESTIONS I HAVE,
6 DOCTOR.
7 THE WITNESS: OKAY.
8 THE COURT: MR. WILSON?
9 MR. WILSON: THANK YOU, YOUR HONOR.
10 CROSS-EXAMINATION
11 BY MR. WILSON:
12 Q. GOOD MORNING, DOCTOR.
13 A. GOOD MORNING.
14 Q. DOCTOR, IN READING OVER YOUR CURRICULUM VITAE I NOTE
15 THAT YOU'VE SIT ON A NUMBER OF COMMITTEES THAT DEALS WITH
16 ISSUES OF DEATH AND DYING; IS THAT CORRECT?
17 A. YES.
18 Q. AND AS I UNDERSTAND YOUR TESTIMONY EARLIER, YOU'VE BEEN
19 INVOLVED IN THE HOSPICE CARE SINCE I THINK 1978?
20 A. THAT'S CORRECT.
21 Q. AND PREVIOUS TO THAT TIME YOUR EXPERIENCE WAS WHAT,
22 DOCTOR?
23 A. I FINISHED MY FELLOWSHIP IN HEMATOLOGY/ONCOLOGY IN 1975.
24 IN THE TWO YEARS BETWEEN I HAD THREE CHILDREN AND DID NOT
25 PRACTICE.
3031
1 Q. OKAY. IN RESPECT TO THE SAN DIEGO HOSPICE -- I GUESS
2 IT'S THE HOSPICE FACILITY THAT YOU ARE THE DIRECTOR OF?
3 A. I AM THE VICE-PRESIDENT OF MEDICAL AFFAIRS AND MEDICAL
4 DIRECTOR.
5 Q. OKAY. NOW, IN THAT CAPACITY, DO YOU OVERSEE THE
6 ADMISSION OF THE PATIENTS TO THE HOSPICE UNIT?
7 A. I MAY SEE SOME PATIENTS. I HAVE NINE OTHER PHYSICIANS
8 WHO REPORT TO ME WHO ARE PRIMARILY RESPONSIBLE FOR THOSE
9 ADMISSIONS AT THIS TIME.
10 Q. NOW, HOW BIG OF A CENTER IS THIS THAT WE'RE TALKING
11 ABOUT?
12 A. WE HAVE 450 PATIENTS IN HOME CARE; WE HAVE A 24-BED
13 INPATIENT ACUTE FACILITY; AND WE HAVE CONTRACTS WITH OTHER
14 HOSPITALS FOR OVERFLOW.
15 Q. OKAY. WHAT TYPE OF PATIENTS PRIMARILY DO YOU SEE AT
16 THIS PARTICULAR HOSPICE?
17 A. SIXTY PERCENT OF OUR PATIENTS ADMITTED TO THE SAN DIEGO
18 HOSPICE PROGRAM HAVE CANCER, THE OTHER 40 PERCENT HAVE
19 NONCANCER DISEASES, INCLUDING CARDIAC AND PULMONARY DISEASE,
20 ALZHEIMER'S AND OTHER DEMENTIAS, LOU GEHRIG'S DISEASE, AIDS
21 AND SO FORTH.
22 Q. OKAY. IN RESPECT TO THE GERIATRIC PATIENT CASELOAD,
23 WHICH I ASSUME WOULD BE PRIMARILY THE ALZHEIMER'S DISEASE
24 UNIT?
25 A. OF ALL OF THE PATIENTS, THE MAJORITY ARE OVER 65, ABOUT
3032
1 75 PERCENT, REPRESENTING ALL OF THE DISEASES.
2 Q. OKAY. SO IN RESPECT TO -- LET'S JUST FOCUS ON THE
3 DEMENTIA PATIENTS THAT ARE HOUSED AT THE UNIT. I ASSUME
4 THERE'S CRITERIA THAT ARE SET UP BEFORE ADMISSION TO THAT
5 PARTICULAR UNIT?
6 A. THE -- I NEED TO CLARIFY YOUR QUESTION FOR JUST A
7 SECOND.
8 Q. OKAY.
9 A. YOU'RE TALKING ABOUT THE UNIT. THE INPATIENT FACILITY
10 IS LICENSED AS AN ACUTE CARE HOSPITAL AND IS ONLY USED FOR
11 PATIENTS WHOSE SYMPTOMS ARE COMPLETELY OUT OF CONTROL. ALL
12 OF THE OTHER PATIENTS ARE CARED FOR IN THEIR RESIDENTIAL
13 AREA, WHETHER THAT'S IN A NURSING HOME OR IN THEIR OWN
14 HOMES.
15 Q. OKAY. SO IN OTHER WORDS, YOU -- YOU SUPERVISE THE
16 PATIENTS -- OR AT LEAST YOU WOULD ATTEND TO THE PATIENTS IN
17 ANOTHER CARE SETTING; IS THAT CORRECT?
18 A. YES.
19 Q. OKAY. NOW, COUNSEL ASKED YOU SOME QUESTIONS ABOUT
20 MEDICARE PAYMENTS, FROM THAT STANDPOINT.
21 A. YES.
22 Q. MEDICARE WILL ONLY PAY IF A PATIENT IS THEN DIAGNOSED AS
23 TERMINALLY ILL?
24 A. TERMINALLY ILL WITH A PROGNOSIS OF SIX MONTHS OR LESS IF
25 THE DISEASE RUNS ITS NORMAL COURSE.
3033
1 Q. OKAY. NOW, LET'S FOCUS A LITTLE BIT ON THAT
2 PARTICULAR -- WELL, BEFORE WE GET TO THAT, IN TERMS OF THE
3 AREA OF EXPERTISE WHICH YOU -- WHICH YOU HOLD THIS, AS I
4 UNDERSTAND IT, A BOARD CERTIFICATION IN PALLIATIVE CARE?
5 A. YES.
6 Q. AND THAT'S BEEN A FAIRLY RECENT DEVELOPMENT?
7 A. YES. THE FIRST EXAM WAS OFFERED IN 1996.
8 Q. OKAY. AND PREVIOUS TO THAT TIME, THERE WAS NO BOARD
9 CERTIFICATION?
10 A. THAT IS CORRECT.
11 Q. OKAY. WHEN IN 1996 WAS IT OFFERED?
12 A. I BELIEVE IT WAS OCTOBER.
13 Q. OKAY. AND IN RESPECT TO THE GUIDELINES AND CRITERIA
14 THAT YOU'VE TALKED ABOUT AS TO THE DIAGNOSIS OF DEMENTIA, DO
15 YOU KNOW WHEN THOSE GUIDELINES WERE FIRST DEVELOPED?
16 A. THE N.H.O. GUIDELINES FOR PROGNOSIS IN TERMINAL ILLNESS?
17 IS THAT WHAT YOU'RE REFERRING TO?
18 Q. UH-HUH.
19 A. IN 1995 IN THE FALL.
20 Q. OKAY. AND IN RESPECT TO THE GUIDELINES OR TO THE -- IF
21 I MIGHT JUST REFER TO SOME OF THE CHARTS HERE THAT COUNSEL
22 PREVIOUSLY SHOWED YOU. THE PHYSICAL SIGNS AND SYMPTOMS AS
23 IT RELATES TO -- I THINK THESE WERE SIGNS OF DYING?
24 A. IMPENDING DEATH, YES.
25 Q. IMPENDING DEATH. AND BY IMPENDING DEATH, WHAT DO YOU
3034
1 MEAN?
2 A. DEATH WITHIN THE NEXT FEW DAYS.
3 Q. OKAY. ALL OF THESE SYMPTOMS THAT YOU'VE LISTED HERE,
4 ARE THEY -- ARE THEY ESTABLISHED GUIDELINES? HOW WAS THIS
5 DEVELOPED?
6 A. THESE WERE FIRST PUBLISHED BY DAME CECILY SAUNDERS IN --
7 FROM HER HOSPICE PROGRAM IN THE MID-70'S.
8 Q. IN THE MID-70'S.
9 A. YES.
10 Q. OKAY. AND IN RESPECT TO THE OTHER DOCUMENT THAT WAS
11 SHOWN TO YOU DETERMINING THE DEMENTIA PROGNOSIS --
12 A. YES.
13 Q. -- AND THE VARIOUS GUIDELINES THAT ARE SET FORTH THERE,
14 WHEN WAS THAT DEVELOPED?
15 A. THAT WAS PART OF THE N.H.O. GUIDELINES THAT WERE
16 PUBLISHED IN 1995.
17 Q. OKAY. IN THE FALL OF 1995?
18 A. THAT'S CORRECT.
19 Q. OKAY. YOU DON'T HOLD ANY GERIATRIC SPECIALTIES, DO YOU?
20 A. NO, I DO NOT.
21 Q. YOU'RE NOT BOARD CERTIFIED IN -- IN ANY AREA OR
22 SUBCATEGORY OF AREA OF GERIATRICS?
23 A. I'M BOARD CERTIFIED IN INTERNAL MEDICINE WHICH INCLUDES
24 CARE OF ELDERLY PATIENTS, BUT I'M NOT IN THE SUBSPECIALTY OF
25 GERIATRICS.
3035
1 Q. AS A MEMBER OF VARIOUS COMMITTEES, CAN YOU TELL US
2 WHETHER OR NOT YOU'RE ACTIVELY INVOLVED IN THE PROMOTION OF
3 LEGISLATION OR EDUCATIONAL OPPORTUNITIES THAT YOU WOULD
4 PROVIDE TO -- TO THE GENERAL PUBLIC?
5 A. I AM.
6 Q. AND THAT WAS A TWO-PART QUESTION, I'LL REPHRASE IT.
7 WHAT -- HAVE YOU DONE ANYTHING IN THE AREA OF LEGISLATION?
8 A. I HAVE WRITTEN LETTERS TO MY CONGRESS PEOPLE ABOUT
9 LEGISLATION THAT WOULD AFFECT THE CARE OF TERMINALLY ILL
10 PATIENTS.
11 Q. OKAY. SO I ASSUME FROM THAT YOU HOLD SOME STRONG VIEWS
12 IN REGARDS TO THESE TYPES OF ISSUES; IS THAT CORRECT?
13 A. YES. I'VE BEEN VERY ACTIVE WITH THE EDUCATIONAL SIDE OF
14 CARE OF TERMINALLY ILL PATIENTS FOR ALL OF MY CAREER. AND
15 AS SUCH I HAVE HAD SOME -- THE OPPORTUNITY TO DEVELOP SOME
16 VERY STRONG OPINIONS ABOUT THE AVAILABILITY OF CARE FOR
17 THESE PATIENTS.
18 Q. DO YOU BELIEVE IN -- THAT THERE'S A CERTAIN
19 MISUNDERSTANDING AS TO THE ISSUES OF DEATH AND DYING IN THE
20 UNITED STATES?
21 A. CAN YOU REPHRASE THAT MORE SPECIFICALLY?
22 Q. WELL, LET ME ASK YOU THIS. I'LL BE MORE SPECIFIC. DO
23 YOU HAVE STRONG FEELINGS ABOUT, LET'S SAY, THE ISSUES
24 SURROUNDING THE CONCEPT OF PHYSICIAN-ASSISTED SUICIDE?
25 A. I HAVE VERY STRONG FEELINGS SURROUNDING
3036
1 PHYSICIAN-ASSISTED SUICIDE.
2 Q. OKAY. AND WHAT ARE THOSE FEELINGS?
3 A. I AM VERY OPPOSED TO PHYSICIAN-ASSISTED SUICIDE.
4 Q. OKAY. DO YOU HAVE A BELIEF IN THE CONCEPT OF VOLUNTARY
5 ACTIVE EUTHANASIA?
6 A. DO I BELIEVE IT EXISTS OR DO I BELIEVE THAT IT'S RIGHT?
7 I'M TRYING TO UNDERSTAND YOUR QUESTION.
8 Q. LET ME ASK YOU -- I'LL ASK YOU -- DO YOU BELIEVE IT IS
9 RIGHT?
10 A. NO.
11 Q. OKAY. CAN YOU DESCRIBE FOR THE JURY WHAT THAT CONCEPT
12 MEANS?
13 A. TO ME THE CONCEPT OF ACTIVE EUTHANASIA WOULD BE THAT A
14 PHYSICIAN WOULD DO SOMETHING THAT WOULD ACTIVELY END A
15 PATIENT'S LIFE LIKE GIVE A MEDICINE OR AN INJECTION.
16 Q. OKAY. WOULD THE PATIENT NORMALLY PARTICIPATE IN THAT
17 PROCESS?
18 A. THAT'S WHAT THE CONCEPT MEANS.
19 Q. THE VOLUNTARY PART OF THE CONCEPT --
20 A. IS THE PHYSICIAN INVOLVEMENT, YES.
21 Q. -- I ASSUME, IS -- IS THE PART OF THE PATIENT --
22 A. THE ACTIVE --
23 Q. -- MAKING DECISIONS?
24 A. YES. THE ACTIVE IS THE OPERATIVE WORD THAT WOULD
25 IMPLICATE THE PHYSICIAN.
3037
1 Q. OKAY. WHAT ABOUT THE CONCEPT OF TERMINAL SEDATION?
2 A. TERMINAL SEDATION IS A FASCINATING CONCEPT AND I WOULD
3 LIKE TO KNOW WHAT YOU WANT TO KNOW BECAUSE I COULD PROBABLY
4 TALK ABOUT IT FOR TWO HOURS.
5 THE COURT: WELL, WAIT. WAIT UNTIL HE GETS A
6 QUESTION.
7 THE WITNESS: THAT'S WHY I WARNED HIM.
8 Q. (BY MR. WILSON) AS I UNDERSTAND TERMINAL -- AND YOU
9 TELL ME IF I'M RIGHT OR WRONG. AS I UNDERSTAND TERMINAL
10 SEDATION, IT INVOLVES THE ADMINISTRATION OF MEDICATIONS
11 WHICH SEDATE THE PATIENT TO A CERTAIN LEVEL WITHOUT
12 HASTENING OR CAUSING DEATH.
13 A. THAT'S A PRETTY GOOD DEFINITION, YEAH.
14 Q. IS THAT -- IS THAT FAIRLY CORRECT?
15 A. YES.
16 Q. OKAY. AND -- AND THE -- THE PHYSICIAN HAS TO WALK A
17 PRETTY FINE LINE THERE, DOESN'T HE?
18 A. WELL, THERE'S THE CONCEPT ALSO IN MEDICAL ETHICS OF
19 DOUBLE EFFECT WHERE YOU MAY HAVE AN UNINTENDED CONSEQUENCE
20 WHILE YOU'RE TRYING TO GET AN INTENDED CONSEQUENCE. AND IT
21 IS IN THAT REALM THAT THE PHYSICIAN WALKS HIS FINE LINE IN
22 THAT WE WANT TO GIVE ENOUGH MEDICINE TO SEDATE THE PATIENT
23 AND STOP THE SYMPTOMS, AND NOT ENOUGH MEDICINE TO KILL THE
24 PATIENT.
25 IT'S BEEN VERY INTERESTING THAT THE IDEA OF SEDATION AT
3038
1 THE END OF LIFE FOR INTRACTABLE SYMPTOMS HAS BEEN PROBABLY
2 THE -- THE NEW FRONTIER FOR HOW WE GIVE THESE MEDICINES.
3 Q. OKAY.
4 A. A RECENT REPORT FROM JAPAN WHERE THEY ASSESS THE
5 OUTCOMES OF END-STAGE SEDATION SHOWED THAT EITHER MORPHINE
6 OR OTHER DRUGS LIKE THE ATIVAN AND SOME OF THE
7 NEUROPSYCHIATRIC DRUGS GIVEN AT THE END OF LIFE DO NOT
8 SHORTEN THE PATIENT'S LIFE EXPECTANCY. SO ALL OF OUR FEARS
9 ABOUT THIS CONCEPT OF DOUBLE EFFECT HAVE BEEN NOW ALLAYED
10 WHERE WE NOW KNOW THAT EVEN WHEN WE SEDATE THESE PATIENTS,
11 WE'RE NOT KILLING THEM.
12 Q. SO I TAKE IT YOU'RE FAVORABLE TO THAT PARTICULAR
13 CONCEPT?
14 A. WHEN THERE IS NO OTHER WAY TO TREAT THE SYMPTOMS, YES.
15 Q. WHEN THERE IS NO OTHER WAY TO TREAT THE SYMPTOMS.
16 A. RIGHT.
17 Q. AND -- AND THAT'S WHAT YOU SPEAK ABOUT IN TERMS OF THE
18 DOUBLE EFFECT; IS THAT RIGHT?
19 A. THAT'S CORRECT.
20 Q. OKAY. THE PATIENT -- AS I UNDERSTAND THAT CONCEPT,
21 THE -- YOU HAVE TO EVALUATE THE NEEDS OF THE PATIENT?
22 A. EVERY THERAPY SHOULD BE INDIVIDUALLY TAILORED TO THE
23 SPECIFIC NEEDS OF THE PATIENT.
24 Q. LET'S TALK A LITTLE BIT ABOUT THIS TERMINAL ILLNESS
25 PROCESS. THAT BECOMES A VERY SIGNIFICANT AND IMPORTANT PART
3039
1 IN THE PROCESS, AS I UNDERSTAND IT, BEFORE YOU OFFER HOSPICE
2 CARE?
3 A. WITH PATIENTS THE PAYMENT FOR THEIR SERVICES CAN ONLY BE
4 RECEIVED FROM MEDICARE IF THE PATIENTS HAVE A PROGNOSIS OF
5 SIX MONTHS OR LESS.
6 Q. RIGHT.
7 A. WE OFTEN OFFER FREE CARE TO PATIENTS WHO DON'T QUITE
8 MEET THAT CRITERION WHEN THEY NEED A LOT OF HELP. SO IT'S
9 A -- IT'S A REIMBURSEMENT ISSUE. IT'S NOT A WHETHER OR NOT
10 THEY NEED HELP ISSUE.
11 Q. WHO IS THAT MADE BY?
12 A. THE DECISION TO PAY?
13 Q. NO. THE DECISION TO -- THE DECLARATION OF TERMINAL
14 CONDITION.
15 A. DECLARATION IS MADE JOINTLY BY THE PRIMARY PHYSICIAN FOR
16 THE PATIENT AND ONE OF THE HOSPICE PHYSICIANS.
17 Q. SO IT'S EVALUATED BY TWO SEPARATE PHYSICIANS?
18 A. UH-HUH.
19 Q. BEFORE THEY'RE ACCEPTED?
20 A. THE -- THE SECOND PHYSICIAN, THE HOSPICE PHYSICIAN,
21 DOESN'T ALWAYS SEE THE PATIENT, BUT -- BUT RENDERS AN
22 OPINION BASED ON INFORMATION FROM THE PRIMARY PHYSICIAN.
23 Q. OKAY. SO THERE'S -- BUT THERE IS TWO PHYSICIANS --
24 A. RIGHT.
25 Q. -- WHO WILL REVIEW THE MEDICAL RECORD OR -- OR EVEN
3040
1 INTERVIEW THE PATIENT?
2 A. RIGHT.
3 Q. I SEE.
4 A. WELL, THE FIRST PHYSICIAN IS THE PRIMARY PHYSICIAN FOR
5 THE PATIENT.
6 Q. IT HAS TO BE THE PRIMARY PHYSICIAN --
7 A. RIGHT.
8 Q. -- AND THEN --
9 A. AND THEN --
10 Q. -- A PHYSICIAN FROM YOUR -- FROM YOUR HOSPITAL WOULD
11 THEN --
12 A. REVIEW THE MATERIAL.
13 Q. -- REVIEW THE CONTENTS OF THAT?
14 A. RIGHT.
15 Q. OKAY. NOW, IS THAT A SET REQUIREMENT BY MEDICARE?
16 A. YES, IT IS.
17 Q. OKAY. SO ONCE THAT -- AND WHY IS THAT, DOCTOR?
18 A. IT'S THE WAY THE ORIGINAL LAW WAS WRITTEN FOR THE
19 MEDICARE --
20 Q. OKAY.
21 A. -- HOSPICE BENEFIT BACK IN ABOUT 1984.
22 Q. IS THAT A SAFEGUARD?
23 A. I THINK IT WAS A WAY OF HELPING PATIENTS GET TO CARE.
24 Q. OKAY.
25 A. IF YOU -- IF YOU REMEMBER BACK IN THE EARLY 80'S IT
3041
1 WAS -- PEOPLE WERE VERY RELUCTANT TO TELL PATIENTS THAT THEY
2 WERE TERMINALLY ILL AND WEREN'T ABOUT TO SEND THEM TO
3 HOSPICE UNLESS THEY REALLY NEEDED IT.
4 Q. OKAY. BUT THE PROCESS OF HAVING TWO PHYSICIANS REVIEW
5 THE MEDICAL RECORD AND THE ATTENDING PHYSICIAN, ALSO, AND
6 IN -- IN INSTANCES EVEN TALK WITH THE PATIENT --
7 A. UH-HUH.
8 Q. -- OR -- OR EXAMINE THE PATIENT, I GUESS WOULD BE A MORE
9 APPROPRIATE TERM, ISN'T THAT -- DOESN'T THAT PROVIDE A
10 CERTAIN SAFEGUARD?
11 A. IT PROVIDES A SAFEGUARD FOR THE REIMBURSEMENT SYSTEM.
12 Q. OKAY. DOES IT NOT PROVIDE A SAFEGUARD FOR THE PATIENT?
13 A. THERE IS NO CARE DELIVERED TO THE PATIENT IN HOSPICE
14 CARE THAT WOULD HARM THE PATIENT.
15 Q. OKAY. BUT IF I WAS TO BE DIAGNOSED AS TERMINALLY ILL,
16 WOULD IT NOT BE A BENEFIT TO ME TO HAVE TWO PHYSICIANS MAKE
17 THAT DETERMINATION?
18 A. DEPENDS ON WHAT YOU'RE TERMINALLY ILL WITH, I WOULD
19 THINK. THE PATIENT HAS TO ELECT THE MEDICARE HOSPICE
20 BENEFIT AS WELL.
21 Q. OKAY.
22 A. AND AT NO TIME IS THE PATIENT COERCED TO RECEIVING
23 HOSPICE CARE. THERE IS NOTHING ABOUT HOSPICE CARE THAT'S
24 GOING TO SHORTEN A PATIENT'S LIFE EXPECTANCY, OR EVEN
25 DECREASE HIS ABILITY TO GET ANOTHER OPINION ABOUT THERAPY
3042
1 FOR THE PRIMARY DISEASE. ABOUT 60 PERCENT OF CANCER
2 PATIENTS IN THE UNITED STATES RECEIVE SOME HOSPICE CARE.
3 THE RATE FOR OTHER DISEASES THAT KILL PATIENTS IS MUCH, MUCH
4 LOWER. IT IS MORE ON THE RANGE OF 5 TO 7 PERCENT
5 NATIONALLY.
6 Q. SO ONLY 5 TO 7 PERCENT OF THOSE WHO ARE NONCANCER
7 PATIENTS --
8 A. WHO ARE ELIGIBLE FOR HOSPICE CARE EVER RECEIVE IT.
9 Q. EVER RECEIVE IT. AFTER A CERTIFICATION OF THE TERMINAL
10 ILLNESS IS MADE, IS THERE AN EVALUATION PROCESS THAT GOES ON
11 AS TO THE NEEDS OF THAT PARTICULAR PATIENT?
12 A. IT'S AN INTERDISCIPLINARY ASSESSMENT PROCESS.
13 Q. OKAY. SO THERE'S SORT OF A TEAM APPROACH TO --
14 A. UH-HUH.
15 Q. -- TO THIS PATIENT'S CARE?
16 A. THE PATIENTS ALL HAVE A NURSE ASSIGNED AND THEY MAY HAVE
17 OTHER MEMBERS OF THE TEAM LIKE SOCIAL WORKER, CHAPLAIN, A
18 VOLUNTEER.
19 Q. SO YOU LOOK AT THE PATIENT AND YOU SAY, OKAY, WE'RE
20 GOING TO USE A MULTIDISCIPLINARY PROCESS --
21 A. RIGHT.
22 Q. -- TO PROVIDE CARE FOR THIS PATIENT?
23 A. RIGHT. AND -- AND IN MOST HOSPITALS, ACUTE HOSPITALS, A
24 SIMILAR SYSTEM ACTUALLY OCCURS -- EVEN THOUGH IT'S NOT
25 CALLED HOSPICE. WHEN PATIENTS ARE ADMITTED TO A HOSPITAL
3043
1 THEY SEE A PHYSICIAN, THE NURSE DOES AN ASSESSMENT, THE
2 DIETICIAN SEES THE PATIENT.
3 Q. ALL RIGHT.
4 A. THERE'S A SOCIAL WORKER. SO INTERDISCIPLINARY CARE IS
5 PRETTY MUCH THE STANDARD IN MEDICINE ACROSS A LOT OF
6 DIFFERENT SETTINGS.
7 Q. IS THIS -- HAS THIS TYPE OF ASSESSMENT BEEN DONE FOR A
8 LONG PERIOD OF TIME?
9 A. I THINK PROBABLY THE CONCEPT OF INTERDISCIPLINARY CARE
10 HAS BEEN RELATIVELY RECENT IN MEDICINE, POST WORLD WAR II.
11 PRIOR TO THAT THE DOCTOR WAS GOD -- OR THOUGHT HE WAS. BUT
12 NOW THE NURSES HAVE MUCH MORE PRACTICE AUTONOMY AND MORE TO
13 SAY ABOUT HOW THE PATIENTS ARE CARED FOR, THAT WE REQUIRE A
14 DIETARY ASSESSMENT IN -- IN INPATIENT FACILITIES, WE REQUIRE
15 THE NEEDS OF THE PATIENT BE ADDRESSED IN MANY OTHER WAYS.
16 Q. NOW, YOU SPOKE PREVIOUSLY, DOCTOR, THAT YOU HAVE A -- I
17 GUESS IT WAS AN ACUTE CARE UNIT ON THE --
18 A. YES. WE'RE LICENSED BY THE STATE OF CALIFORNIA AS A
19 SPECIAL ACUTE HOSPITAL UNDER A LEGISLATIVE ACT FROM -- FROM
20 CALIFORNIA.
21 Q. SO WHAT TYPE OF PATIENT QUALIFIES FOR ACUTE CARE?
22 A. A PATIENT WHOSE SYMPTOMS ARE OUT OF CONTROL AND WERE
23 HAVING TROUBLE MANAGING THEM AT HOME.
24 Q. OKAY. AND IS IT -- IS IT TO -- NOW, WHEN I -- WHEN I
25 SPEAK OF ACUTE THERE IS SOMETHING THAT -- THAT HAS HAPPENED
3044
1 TO THIS PATIENT, I ASSUME?
2 A. USUALLY. UH-HUH.
3 Q. THAT NEEDS IMMEDIATE RESOLUTION?
4 A. PAIN IS OUT OF CONTROL, THE PATIENT IS VOMITING, THE
5 PATIENT HAS DEVELOPED A BOWEL OBSTRUCTION.
6 Q. OKAY.
7 A. THE PATIENT'S PRIMARY CAREGIVER HAD A HEART ATTACK AND
8 CAN'T BE THE CAREGIVER THIS WEEK AND THE PATIENT NEEDS TO
9 HAVE QUICK AND IMMEDIATE CARE FROM SOMEBODY ELSE.
10 Q. ALL RIGHT.
11 A. PNEUMONIA.
12 Q. SO THEY'RE BROUGHT INTO THE HOSPITAL SETTING.
13 A. YES.
14 Q. BUT THE REST OF THESE PATIENTS ARE TREATED IN THEIR
15 HOMES OR IN THE NURSING CARE CENTERS?
16 A. (NODS HEAD UP AND DOWN.)
17 Q. IN TERMS OF THE COMPONENT OF THESE PARTICULAR PROGRAMS
18 AS FAR AS THERE'S A VARIETY OF COMPONENTS OF COMFORT CARE AS
19 I UNDERSTAND IT; IS THAT RIGHT?
20 A. YES.
21 Q. AND PAIN MANAGEMENT IS ONE OF THOSE COMPONENTS.
22 A. THE FIRST.
23 Q. AND YOU HAVE TO EVALUATE THE PATIENT TO DETERMINE
24 WHETHER OR NOT THERE IS A NEED FOR PAIN MANAGEMENT; IS THAT
25 RIGHT?
3045
1 A. YES.
2 Q. OKAY. AND I ASSUME PART OF THAT EVALUATION WOULD TAKE
3 PLACE WITH THIS MULTIDISCIPLINARY TEAM?
4 A. WELL, YES, AND SOMETIMES IT'S -- IT'S LIMITED TO THE
5 NURSE CALLING THE PHYSICIAN AND REPORTING THAT THE PATIENT
6 IS SHOWING SIGNS AND SYMPTOMS OF PAIN.
7 Q. OKAY. IN RESPECT TO THE RECORDS THAT YOU REVIEWED, ALL
8 OF THESE WERE PATIENTS WHO WERE ADMITTED TO A GEROPSYCH
9 UNIT.
10 A. YES.
11 Q. IS THAT ACCURATE?
12 A. THAT'S TRUE.
13 Q. ARE YOU FAMILIAR WITH THE CRITERIA FOR THE ADMISSION TO
14 THE GEROPSYCH UNIT TO DAVIS HOSPITAL?
15 A. I HAVE NEVER SEEN ANY WRITTEN CRITERIA FROM DAVIS
16 HOSPITAL, NO.
17 Q. OKAY. ARE YOU FAMILIAR WITH THE GENERAL CONTEXT OF
18 CRITERIA THAT A GERIATRIC PATIENT WOULD NEED TO MEET IN
19 ORDER TO BE ADMITTED TO A GEROPSYCH UNIT?
20 A. MY UNDERSTANDING OF GEROPSYCHIATRIC CARE IS THAT IT IS
21 PRIMARILY FOR ACUTE, SEVERE BEHAVIORAL PROBLEMS OR OTHER
22 PSYCHIATRICALLY APPARENT PROBLEMS. I'LL -- YOU KNOW, I'LL
23 CLARIFY THAT IN A SECOND. BUT THAT THERE MAY BE MEDICAL
24 CONDITIONS ALSO PRESENT IN THESE PATIENTS.
25 Q. OKAY.
3046
1 A. SO WHAT I WAS ABLE TO ASCERTAIN FROM READING THESE
2 RECORDS IS THAT ALL THESE PATIENTS HAD BEHAVIORAL CHANGES
3 THAT WERE INTERPRETED AS PSYCHIATRIC, AND THEY ALL HAD
4 MEDICAL EVALUATIONS AT THE TIME OF THEIR ADMISSION BY
5 ANOTHER PHYSICIAN AT THE SAME TIME, EXCEPT ONE PATIENT WHO
6 DIED RATHER QUICKLY AFTER ADMISSION BEFORE THE INTERNIST
7 COULD ARRIVE.
8 Q. AND THAT WAS ELLEN ANDERSON?
9 A. RIGHT.
10 Q. IN RESPECT TO THE CRITERIA AS YOU UNDERSTAND IT, THESE
11 ARE ALL PATIENTS WHO WERE SUFFERING PSYCHOLOGICAL
12 PROBLEMS, IN ADDITION TO SOME MEDICAL PROBLEMS?
13 A. THE TERM PSYCHOLOGICAL CAN BE BROADLY MISCONSTRUED IN
14 MODERN MEDICINE. I'D LIKE TO KNOW WHAT YOU'RE TALKING
15 ABOUT.
16 Q. OKAY. WELL, OBVIOUSLY YOU REVIEWED THE FILES AND -- AND
17 DO YOU AGREE OR DISAGREE THAT THESE PATIENTS WERE
18 APPROPRIATE FOR CARE AT A GEROPSYCH UNIT?
19 A. THEY APPEARED TO BE APPROPRIATE FOR ADMISSION AND
20 EVALUATION IN A GEROPSYCH UNIT, YES.
21 Q. OKAY. IF I WERE TO TELL YOU THAT THE CRITERIA WAS -- IS
22 THAT THE -- THE PSYCHIATRIC OR THE -- THE MENTAL HEALTH
23 PROBLEMS WERE MORE SIGNIFICANT THAN THE MEDICAL PROBLEMS,
24 WOULD THAT COMPORT WITH -- WITH WHAT YOU --
25 A. AT THE TIME EACH ONE OF THESE PATIENTS WERE ADMITTED TO
3047
1 THIS FACILITY, THAT WAS THE MAJOR PRESENTING ISSUE --
2 Q. OKAY.
3 A. -- WAS THE PSYCHIATRIC DISTURBANCE.
4 Q. SO WHEN YOU FORM THE OPINION THAT THESE PATIENTS ARE
5 TERMINAL --
6 A. UH-HUH.
7 Q. -- THAT THEY'RE ALL SUFFERING FROM VARIOUS FORMS OF
8 DEMENTIA OR IN VARIOUS STAGES OF DEMENTIA, AS YOU'VE
9 INDICATED, THAT MEANS THAT THEY COULD HAVE UP TO SIX MONTHS
10 TO LIVE; IS THAT CORRECT?
11 A. YES.
12 Q. OKAY. SO THERE WAS NO IMMEDIATE ACUTE EVENT THAT YOU'D
13 SEEN AT THE TIME OF ADMISSION --
14 A. RIGHT.
15 Q. -- WHICH WOULD --
16 A. RIGHT.
17 THE COURT: WAIT UNTIL HE FINISHES THE QUESTION.
18 GO AHEAD. FINISH YOUR QUESTION.
19 Q. (BY MR. WILSON) WHICH WOULD INDICATE TO YOU THAT THEY
20 WERE IN A DYING PROCESS, AS IT'S BEEN DESCRIBED?
21 A. NONE OF THESE PATIENTS WERE APPARENTLY WITHIN A FEW DAYS
22 OF DEATH WHEN THEY WERE ADMITTED TO THE HOSPITAL.
23 Q. OKAY. AND WOULD THAT BE THE SAME OPINION AS IT RELATES
24 TO ELLEN ANDERSON?
25 A. YES.
3048
1 Q. OKAY. YOU PREVIOUSLY TESTIFIED THAT -- STRIKE THAT.
2 THAT YOU BASED YOUR PROGNOSIS OR YOUR DIAGNOSIS, I GUESS, OF
3 EACH OF THESE PATIENTS ON CERTAIN TYPES OF CRITERIA THAT HAD
4 BEEN DEVELOPED; IS THAT CORRECT?
5 A. YES.
6 Q. ONE OF THOSE CRITERIA, I THINK YOU IDENTIFIED AS -- AS
7 THE F.A.S.?
8 A. FUNCTIONAL ASSESSMENT SCALE, YES.
9 Q. FUNCTIONAL ASSESSMENT SCALE. I'M GOING TO SHOW YOU A
10 CHART -- MAYBE WE CAN TURN THAT -- WELL, I'LL LEAVE IT ON
11 FOR A MINUTE. MAYBE YOU COULD JUST STEP OVER HERE AND TAKE
12 A LOOK AT THAT CHART, IF YOU WOULD, DOCTOR.
13 A. YES.
14 Q. DO YOU RECOGNIZE THAT PARTICULAR CHART?
15 A. YES.
16 Q. AND WHAT IS THAT?
17 A. THIS IS THE LISTINGS OF SOME OF THE FINDINGS IN THE
18 FUNCTIONAL ASSESSMENT SCALE WITH A STUDY THAT WAS DONE
19 SHOWING WHAT SOME OF THE LIFE EXPECTANCIES WERE FOR SOME OF
20 THE PATIENTS IN THIS STUDY.
21 Q. NOW, I THINK YOU'VE TESTIFIED AS TO A NUMBER OF THOSE
22 FINDINGS --
23 A. RIGHT.
24 Q. -- AND AS TO WHERE THEY WOULD BE ON THE STAGE OF THAT
25 CHART.
3049
1 A. RIGHT.
2 Q. AND YOU'VE ALSO INDICATED IN YOUR REPORT, HAVE YOU NOT,
3 CERTAIN STAGES THAT THOSE INDIVIDUAL --
4 A. RIGHT.
5 Q. -- WOULD BE IN ACCORDING TO THAT PARTICULAR CHART?
6 A. THAT'S CORRECT.
7 Q. OKAY.
8 A. BUT THE CRITERIA -- THE N.H.O. CRITERIA FOR ADMISSION OF
9 A PROGNOSIS OF SIX MONTHS OR LESS ONLY AS TO THE FUNCTIONAL
10 ASSESSMENT SCALE IS ONE COMPONENT. THERE ARE A NUMBER OF
11 OTHER PIECES OF THAT.
12 Q. I -- I APPRECIATE THAT, DOCTOR, AND I'LL GET TO THAT IN
13 JUST A MINUTE.
14 A. RIGHT.
15 Q. WOULD YOU TELL ME THOUGH IN TERMS OF YOUR FINDINGS AS TO
16 7(A) AND 7(B), DOES THAT CHART REPRESENT AS PART OF THAT
17 COMPONENT THAT THESE INDIVIDUALS WOULD BE -- YEARS TO DEATH
18 WOULD BE SIX TO FIVE YEARS?
19 A. ACCORDING TO THAT STUDY, IT COULD BE, YES --
20 Q. YES.
21 A. -- THAT LONG, IF THERE WERE NOTHING ELSE WRONG.
22 Q. HAVE A SEAT, IF YOU WOULD, PLEASE.
23 ARE YOU FAMILIAR WITH THE DIAGNOSIS OF DELIRIUM?
24 A. I AM.
25 Q. CAN YOU EXPLAIN TO THE JURY WHAT IS DELIRIUM?
3050
1 A. DELIRIUM IS USUALLY AN ACUTE CHANGE IN MENTAL STATUS
2 OFTEN BROUGHT ON BY ANOTHER DISORDER, ACUTE ILLNESS OF SOME
3 SORT.
4 Q. AND DELIRIUM IS TREATABLE, IS IT NOT?
5 A. SOMETIMES. USUALLY. WHETHER WE WANT TO TREAT IT OR NOT
6 IS ALSO DETERMINED BY THE PATIENT'S ADVANCE DIRECTIVES.
7 Q. SO IT'S AN ORDER OF AN ACUTE NATURE?
8 A. IT CAN BE SUBACUTE IN THAT IT CAN DEVELOP FAIRLY SLOWLY
9 OVER A PERIOD OF SEVERAL DAYS TO WEEKS, BUT IT IS USUALLY A
10 SYMPTOM OF TOXICITY SUCH AS KIDNEY FAILURE OR AN INFECTION,
11 SOMETHING LIKE THAT.
12 Q. COULD IT ALSO BE INDUCED AS A RESULT OF MEDICATIONS?
13 A. OCCASIONALLY.
14 Q. AND DO -- DOES -- CAN YOU HAVE DELIRIUM AND DEMENTIA
15 BOTH?
16 A. YES.
17 Q. BY THE WAY, DOCTOR, IS DEMENTIA -- IS IT VERY DIFFICULT
18 TO DIAGNOSE?
19 A. SOME KINDS OF DEMENTIA IN THE EARLY STAGES ARE EXTREMELY
20 DIFFICULT TO DIAGNOSE. ADVANCED DEMENTIA IS NOT SO HARD.
21 Q. AND ALL OF THESE PATIENTS, AS I UNDERSTAND IT, SUFFERED
22 FROM NOT NECESSARILY ADVANCED DEMENTIA IN EVERY CASE, BUT
23 THEY WERE IN THE LATER STAGES OF DEMENTIA?
24 A. WELL, THEY WERE ALL CONSIDERED ADVANCED. I MEAN,
25 WHETHER OR NOT THEY WERE RIGHT AT THE TERMINAL STAGES OR
3051
1 NOT --
2 Q. OKAY.
3 A. -- TWO OF THEM I WASN'T SO SURE, BUT --
4 Q. OKAY.
5 A. THEY WERE ILL ENOUGH FROM THEIR DEMENTIA TO REQUIRE THAT
6 THEY WERE IN NURSING HOMES. THEY WEREN'T -- THE FAMILIES
7 COULDN'T CARE FOR THEM AT HOME.
8 Q. DID YOU SEE ANYTHING IN THE REVIEW OF YOUR RECORDS WHICH
9 WOULD CAUSE YOU TO BELIEVE THAT ANY OF THESE PATIENTS WERE
10 SUFFERING FROM DELIRIUM?
11 A. NO. WHEN I WAS READING THROUGH THE RECORDS, THE
12 SYMPTOMS OF IMPENDING DEATH VERY OFTEN WERE CONCOMITANT WITH
13 THE CHANGING MENTAL STATUS. NOW, IF YOU WANT TO CALL
14 IMPENDING DEATH A REASON FOR DELIRIUM, PERHAPS, BUT THE
15 REAL, YOU KNOW, ORIGINAL REASONS PEOPLE WERE COMING INTO THE
16 FACILITY WAS LIKE, YOU KNOW, A PATIENT WHO WAS THROWING HIS
17 WHEELCHAIR AROUND OR SOMEBODY ELSE WHO WAS, YOU KNOW,
18 BELLIGERENT AND FALLING. DIDN'T -- THOSE DID NOT SEEM TO BE
19 EPISODES OF DELIRIUM. THEY'D BEEN PRESENT FOR QUITE A LONG
20 TIME AND HAD BEEN FAIRLY STABLE, BUT GETTING WORSE IN THEIR
21 OTHER FACILITIES.
22 Q. THE -- AS I UNDERSTAND YOUR TESTIMONY IN EACH OF THESE
23 PATIENTS YOU'RE SAYING THAT THEY ENTERED -- OR THEY MET THE
24 CRITERIA FOR BEING IN THE GEROPSYCH UNIT AND IT WAS
25 APPROPRIATE THAT THEY BE ADMITTED TO THE GEROPSYCH UNIT.
3052
1 AND THEN YOU'RE SAYING IN EACH INSTANCE, EACH OF THESE
2 PATIENTS, THESE FIVE PATIENTS, SUFFERED AN ACUTE EVENT?
3 A. IT HAPPENS ALL THE TIME IN GERIATRIC CARE. YES, SIR.
4 Q. AND -- AND THEY ALL SUFFERED THIS ACUTE EVENT AND THAT'S
5 WHAT PRECIPITATED THE DYING PROCESS; IS THAT RIGHT?
6 A. YES, SIR. UH-HUH.
7 Q. OKAY. NOW, LET'S -- LET ME, IF -- IF I CAN, I NEEDED
8 TO -- TO TALK A LITTLE BIT ABOUT THESE ADVANCE DIRECTIVES.
9 AND YOU'VE REFERENCED THEM A NUMBER OF TIMES IN -- IN YOUR
10 TESTIMONY, AS FAR AS THAT GOES. YOU'VE INDICATED THAT AS
11 PART OF THE ADMISSION PROCESS THE PATIENT IS ADVISED OF
12 THEIR RIGHT TO DESIGNATE ADVANCE DIRECTIVES; IS THAT
13 CORRECT?
14 A. I BELIEVE THE LANGUAGE IN THE LAW IS THE HOSPITAL OR
15 OTHER HEALTH CARE FACILITY IS REQUIRED TO ASK IF THE PATIENT
16 HAS ADVANCE DIRECTIVES.
17 Q. OKAY. AND IF THEY ANSWER NO, ARE THEY ADVISED OF
18 CERTAIN RIGHTS?
19 A. YES.
20 Q. OKAY. AND IS THERE OPPORTUNITY TO SIT DOWN AND EXPLAIN
21 TO EACH ONE OF THESE PATIENTS WHAT THOSE RIGHTS ARE AND WHAT
22 THEY ENTAIL?
23 A. I DON'T UNDERSTAND THE QUESTION.
24 Q. WELL, AS PART OF THAT PROCESS, I ASSUME -- ARE YOU
25 FAMILIAR WITH INFORMED CONSENT?
3053
1 A. I'M VERY FAMILIAR WITH INFORMED CONSENT.
2 Q. OKAY.
3 A. BUT I STILL DON'T UNDERSTAND YOUR QUESTION.
4 Q. OKAY. DOES THE PATIENT HAVE A RIGHT TO BE INFORMED AS
5 TO THE VARIOUS TYPES OF LIFESAVING MEASURES OR OTHER
6 MEASURES THAT MAY BE TAKEN OR ALTERNATIVES FOR TREATMENT?
7 A. YES.
8 Q. OKAY. DOES THE PATIENT -- IT'S MY UNDERSTANDING THE
9 PATIENT IS ADVISED RELATIVE TO ALL ALTERNATIVES; IS THAT
10 CORRECT?
11 A. I WANT TO COME BACK TO THE ORIGINAL QUESTION BECAUSE THE
12 LAW SAYS YOU HAVE TO ASK PATIENTS IF THEY HAVE ADVANCE
13 DIRECTIVES AND ADVISE THEM OF THEIR RIGHTS. IT DOES NOT SAY
14 YOU HAVE TO TALK TO THEM ABOUT IT.
15 Q. OKAY.
16 A. AND, IN FACT, VERY FEW FACILITIES DO ANYTHING MORE THAN
17 ASK IF THEY HAVE ADVANCE DIRECTIVES AND ADVISE THEM OF THEIR
18 RIGHTS.
19 Q. OKAY.
20 A. SO WHEN WE GET INTO WHAT SHOULD BE PART OF THE
21 DISCUSSION ABOUT ADVANCE DIRECTIVES, IT'S GETTING A LITTLE
22 FAR.
23 Q. WELL, LET ME RECHARACTERIZE MY QUESTION THEN, IF I
24 MIGHT, DOCTOR.
25 DOES THERE COME A TIME IN THIS EVALUATION PROCESS WITH
3054
1 THE PATIENT WHO'S ADMITTED TO HOSPICE CARE WHERE YOU SIT
2 DOWN AND YOU TALK ABOUT THE NEEDS OF THAT PATIENT?
3 A. YES.
4 Q. AND I ASSUME AS PART OF THAT YOU TALK ABOUT VARIOUS
5 FORMS OF TREATMENT?
6 A. WE TALK ABOUT VARIOUS FORMS OF -- OF ALL KINDS OF
7 TREATMENT, YES.
8 Q. AND YOU -- YOU BRING THE MULTIDISCIPLINARY TEAM IN --
9 APPROACH, AND YOU -- YOU ADDRESS ALL KINDS OF NEEDS,
10 INCLUDING EVEN THEOLOGICAL NEEDS OR RELIGION NEEDS; IS THAT
11 CORRECT?
12 A. WE ADDRESS SPIRITUAL CARE. YES, SIR.
13 Q. SPIRITUAL CARE. EXCUSE ME. AND, ALSO, YOU TALK WITH
14 THAT PATIENT ABOUT DEATH AND DYING ISSUES.
15 A. WE ESPECIALLY TRY TO HELP THE FAMILY UNDERSTAND WHAT'S
16 GOING TO HAPPEN. WE TREAT THE PATIENT AND FAMILY AS A UNIT
17 OF CARE. MASLOW'S HIERARCHY OF HUMAN NEEDS SHOWS THE FIRST
18 NEEDS ARE PHYSICAL, THE SECOND ARE FOR INFORMATION AND
19 PREDICTABILITY.
20 Q. OKAY. NOW, YOU PREVIOUSLY TESTIFIED AS TO SOME NEED
21 FOR -- IN THE OVERALL EVALUATION, PARTICULAR IN THE DYING
22 PROCESS, FOR THIS PATIENT TO BE ABLE TO SAY GOODBYE.
23 A. THAT'S RIGHT.
24 Q. AND TO TELL HIS LOVED ONES HE LOVES THEM.
25 A. THAT'S CORRECT.
3055
1 Q. AND FORGIVE ME.
2 A. THAT'S CORRECT.
3 Q. IF I RECALL; IS THAT RIGHT?
4 A. YES. THAT WAS QUOTING IRA BYOCK.
5 Q. OKAY. I WOULD TAKE IT THEN AND I WOULD ASSUME THAT IN
6 ORDER TO ACCOMPLISH THAT OBJECTIVE, THE PATIENT HAS TO HAVE
7 SOME LEVEL OF COGNITIVE FUNCTION TO BE ABLE TO RESPOND IN
8 THAT MANNER.
9 A. MANY TIMES PATIENTS ARE UNABLE TO DO THAT VERBALLY.
10 MANY TIMES IT'S THE FAMILIES WHO HAVE TO DO THE SAYING
11 GOODBYE. PATIENTS WHO ARE DYING ARE VERY RARELY BRIGHT AND
12 ALERT AND AWAKE AT THE END OF LIFE. HOPEFULLY THESE
13 PROCESSES HAVE TAKEN PLACE OVER A PERIOD OF TIME PRIOR TO
14 THE -- TO THE DEATH.
15 IT'S INTERESTING, YOU KNOW, WHEN WE LOOK AT HOW --
16 Q. EXCUSE ME, DOCTOR. I THINK YOU'VE ANSWERED MY QUESTION.
17 A. OKAY.
18 Q. IN RESPECT TO THAT PROCESS, YOU HAVE TO EVALUATE AS THE
19 PHYSICIAN, DO YOU NOT, YOU HAVE TO BALANCE OUT WHAT LEVEL OF
20 CARE YOU GIVE THIS PATIENT AND TREATMENT YOU GIVE THIS
21 PATIENT IN ORDER TO MAINTAIN A CERTAIN LEVEL OF
22 CONSCIOUSNESS, DO YOU NOT?
23 A. WELL, IF WE'RE TALKING IN THEORETICAL TERMS, I'LL SAY
24 YES. IF WE'RE TALKING ABOUT THESE PATIENTS WITH ADVANCED
25 DEMENTIA WHO CANNOT MAKE THEIR OWN DECISIONS AND WHO HAVE
3056
1 SURROGATE DECISION MAKERS, THEN THE WHOLE CONVERSATION HAS
2 TO TAKE PLACE WITH THOSE SURROGATE DECISION MAKERS.
3 Q. OKAY.
4 A. AND IT DID IN EACH ONE OF THESE CASES.
5 Q. YOU -- YOU ASSUME THAT IT DID.
6 A. IT'S RECORDED IN THE MEDICAL RECORD THAT IT DID.
7 THE COURT: MR. WILSON?
8 Q. (BY MR. WILSON) AND IT'S RECORDED BY WHOM, DOCTOR?
9 THE COURT: EXCUSE ME. MR. WILSON, HOW MUCH LONGER
10 DO YOU THINK YOU'RE GOING TO BE?
11 MR. WILSON: I THINK I'LL BE A LITTLE WHILE, YOUR
12 HONOR.
13 THE COURT: OKAY. THEN WE'VE BEEN GOING ABOUT AN
14 HOUR AND 15 MINUTES. THIS MIGHT BE A GOOD PLACE TO TAKE OUR
15 SECOND BREAK.
16 LADIES AND GENTLEMEN, DURING THIS BREAK REMEMBER IT'S
17 YOUR DUTY NOT TO CONVERSE AMONG YOURSELVES OR TO CONVERSE
18 WITH OR ALLOW YOURSELVES TO BE ADDRESSED BY ANY OTHER PERSON
19 ON THE SUBJECT OF THIS TRIAL.
20 IT'S YOUR DUTY NOT TO FORM OR EXPRESS AN OPINION UNTIL
21 THE CASE IS FINALLY SUBMITTED TO YOU.
22 AND LET'S COME BACK AT ABOUT 15 AFTER.
23 (WHEREUPON, AT THIS TIME THERE'S A RECESS, AFTER WHICH
24 PROCEEDINGS RESUME, AS FOLLOWS:)
25 THE COURT: THE RECORD WILL REFLECT THAT THE JURY
3057
1 HAS RETURNED.
2 MR. WILSON, IF YOU'D LIKE TO CONTINUE.
3 MR. WILSON: THANK YOU, YOUR HONOR.
4 Q. (BY MR. WILSON) IF I REMEMBER RIGHT, DOCTOR, I THINK
5 THE LAST QUESTION I ASKED YOU PERTAINED TO A QUESTION AS
6 WHERE DID YOU RECEIVE YOUR INFORMATION AS IT RELATED TO
7 DISCUSSIONS WITH THE FAMILY REGARDING THESE PATIENTS'
8 CONDITIONS?
9 A. FROM MY REVIEW OF THE MEDICAL RECORDS.
10 Q. OKAY. AND IN PARTICULAR, WHAT NOTES DID YOU REFERENCE
11 IN RESPECT TO THOSE DISCUSSIONS?
12 A. I DIDN'T WRITE DOWN THE SPECIFICS, SO IF WE WANT TO GO
13 NOTE BY NOTE IT WILL TAKE A LITTLE TIME. BUT, BASICALLY,
14 THERE WERE NOTES FROM THE PHYSICIANS, THE NURSES, THERE WAS
15 A SOCIAL WORKER'S NOTE ON ONE. THERE WERE A NUMBER OF
16 VARIOUS NOTES, AND REPEATED NOTES ON SEVERAL OF THE PATIENTS
17 ABOUT THE END-OF-LIFE CARE DIRECTIVES THAT WERE BEING STATED
18 BY THE FAMILIES.
19 Q. OKAY. A NUMBER OF THOSE NOTES WERE FROM THE DEFENDANT
20 HIMSELF, RIGHT?
21 A. SOME OF THEM WERE FROM THE NURSES AS WELL.
22 Q. NOW, IN RESPECT TO THE DYING PROCESS, AS TO THE EVENT
23 THAT PRECIPITATES THIS IMMEDIATE DYING PROCESS, CAN YOU TELL
24 US, DOCTOR, HOW DID YOU GO ABOUT ASCERTAINING WHEN THAT
25 OCCURRED?
3058
1 A. ON WHICH PATIENT?
2 Q. WELL, LET'S -- LET'S -- LET'S TALK ABOUT MARY CRANE.
3 A. OKAY. SORRY. OKAY. I HAVE MARY CRANE'S RECORD.
4 Q. CAN YOU TELL THE COURT AND THE JURY JUST WHEN IT WAS YOU
5 DETERMINED, FROM YOUR REVIEW OF THE MEDICAL RECORDS, THAT
6 MARY CRANE WAS -- HAD SUFFERED THIS ACUTE EVENT?
7 A. THERE HAD BEEN A SERIES OF NOTES BOTH FROM PHYSICIANS
8 AND NURSES THAT HAD INDICATED THE PATIENT HAD DEVELOPED A
9 FISTULA. STOOL HAD BEEN NOTED IN THE VAGINA ON JANUARY 1ST.
10 THERE WAS A CONSULTANT -- G.Y.N. CONSULTANT WHO SAW THE
11 PATIENT WHO HAD RECOMMENDED ANTIBIOTICS AND SAID TO CONSIDER
12 SURGERY IF HER PSYCHIATRIC SYMPTOMS COULD BE IMPROVED.
13 AND THEN ON 1/3/96 THERE IS A NURSING NOTE SAYING THAT
14 THE PATIENT IS CRYING OUT, GROANING, AND YELLING, AND THAT
15 THE PATIENT HAD A FEVER.
16 IT WAS AT THIS POINT IN TIME THAT THINGS WERE BEGINNING
17 TO GO REALLY DOWNHILL FOR THIS PATIENT. AND YOU CAN SEE
18 OVER A PERIOD OF THE NURSING NOTES AND PHYSICIAN NOTES FROM
19 THEN ON THERE'S AN INCREASING NUMBER OF PROBLEMS FOR HER
20 WITH THIS RECTOVAGINAL FISTULA.
21 Q. OKAY.
22 A. AND THEN LATER ANOTHER ANTIBIOTIC WAS STARTED, AND ON
23 1/7 THE PATIENT BECAME HYPOTENSIVE -- IN OTHER WORDS, HER
24 BLOOD PRESSURE FELL, AND HER BLOOD OXYGEN SATURATIONS WERE
25 LOW. THEY THOUGHT SHE HAD ASPIRATION PNEUMONIA. AND,
3059
1 AGAIN, YOU KNOW, THE GOALS OF CARE WERE AGAIN DISCUSSED WITH
2 THE FAMILY.
3 Q. AS I UNDER -- I DON'T MEAN TO INTERRUPT YOU, BUT AS I
4 UNDERSTAND IT, YOU'RE SAYING THINGS STARTED TO GO DOWNHILL
5 ON THE 3RD OF JANUARY?
6 A. RIGHT.
7 Q. WHICH IS APPROXIMATELY FIVE DAYS AFTER ADMISSION; IS
8 THAT CORRECT?
9 A. IT WAS SIX OR SEVEN.
10 Q. OKAY. SHE WAS ADMITTED ON THE 28TH OF DECEMBER?
11 A. RIGHT. 28, 29, 30, 31, THERE WAS FOUR DAYS.
12 Q. ANYWAY, SOMEWHERE BETWEEN THAT TIME FRAME. AND ON
13 JANUARY 3RD IS IN YOUR ESTIMATION WHEN SHE FIRST STARTS
14 SHOWING SIGNS OF SUBSTANTIAL DETERIORATION.
15 A. RIGHT.
16 Q. IS THAT YOUR TESTIMONY?
17 A. THAT SHE WAS -- THAT THE TERMINAL INTERCURRENT ILLNESS
18 WAS BEING IDENTIFIED.
19 Q. OKAY. AND THAT TERMINAL INTERCURRENT ILLNESS, AS I
20 UNDERSTAND IT, IN YOUR OPINION, WAS A SEPTICEMIA?
21 A. YES.
22 Q. AND THE PROCESS OF SEPTICEMIA IS ONE OF BACTERIA FROM AN
23 INFECTION THAT IS DISTRIBUTED THROUGHOUT THE BODY IN THE
24 BLOOD?
25 A. RIGHT.
3060
1 Q. OKAY. YOU HOLD SOME BOARD CERTIFICATIONS, I THINK,
2 IN -- WAS IT ONCOLOGY AND ALSO IN HEMATOLOGY?
3 A. I AM BOARD ELIGIBLE IN ONCOLOGY. I NEVER SAT THE EXAM.
4 THAT'S WHEN I WAS HAVING KIDS.
5 Q. OKAY. IN HEMATOLOGY --
6 A. YES.
7 Q. -- AND THAT'S THE STUDY OF THE BLOOD?
8 A. IT INCLUDES ALL THE BLOOD DISEASES, YES.
9 Q. ALL THE BLOOD DISEASES. IS SEPTICEMIA A BLOOD DISEASE?
10 A. NO, IT'S AN INFECTIOUS DISEASE.
11 Q. IT'S AN INFECTIOUS DISEASE. SO DO YOU HAVE ANY
12 EXPERTISE IN INFECTIOUS DISEASES?
13 A. ANYONE WHO TREATS CANCER PATIENTS TREATS INFECTIONS.
14 Q. OKAY. AND IN RESPECT TO YOUR REVIEW OF THESE RECORDS,
15 YOUR OPINION IS IS THIS PATIENT DIED AS A RESULT OF THIS
16 SEPTICEMIA?
17 A. YES.
18 Q. NOW, IN THE PROCESS OF THE SEPTICEMIA, THE INFECTION OF
19 THE BLOOD, HOW DOES THAT DYING PROCESS TAKE PLACE?
20 A. IT'S VERY SIMILAR TO ALL DYING PROCESSES. THE PROCESS
21 OF THE BODY SHUTTING DOWN IS THAT THE BLOOD PRESSURES FALL
22 AND THE PATIENT GETS MORE -- MORE COMATOSE --
23 Q. DOES THE INFECTION INVADE ORGANS OF THE BODY?
24 A. IT MAY.
25 Q. SO IT WOULD VARY AS TO HOW THE PATIENT WOULD DIE AS FAR
3061
1 AS THE -- THE DEGREE OF -- OF INFECTION?
2 A. IT WOULD VARY WITH THE NUMBER OF OTHER PROBLEMS THE
3 PATIENT HAS AS WELL. EACH PATIENT IS UNIQUE IN THAT THEY'RE
4 A UNIQUE CONSTELLATION OF BIOLOGY AND OTHER DIAGNOSES. THIS
5 IS A PATIENT, MARY CRANE, WHO HAD PRIOR C.V.A.'S DUE TO
6 VASCULAR DISEASE IN HER BRAIN.
7 Q. UH-HUH.
8 A. THAT'S GOING TO AFFECT HOW THE DISEASE AFFECTS HER.
9 SHE'S HAD PSYCHOGENIC POLYDIPSIA WITH LOW BLOOD SODIUMS OVER
10 YEARS PRIOR TO THIS. THAT'S GOING TO AFFECT HOW THE
11 SEPTICEMIA AFFECTS HER. SHE'S HAD HYPERTENSION AND SHE'S
12 HAD ULCERS, SO ON.
13 Q. AGAIN, IF I MIGHT INTERRUPT YOU, DOCTOR. I'M SORRY.
14 I -- I JUST WANT TO FOCUS ON THIS SEPTICEMIA.
15 A. WELL, I DON'T THINK YOU CAN FOCUS JUST ON THE SEPTICEMIA
16 IS WHAT I'M TRYING TO SAY.
17 Q. YOU'RE SAYING THAT -- YOU'RE SAYING THE INFECTION COULD
18 HAVE AGGRAVATED THESE OTHER CONDITIONS?
19 A. YES, SIR.
20 Q. OKAY. AND THAT COULD HAVE CREATED THE DEATH OF THIS
21 PATIENT?
22 A. YES.
23 Q. BUT THE PRIMARY CAUSE OF THAT DEATH WOULD THEN BE THE
24 INFECTIOUS DISEASE PROCESS?
25 A. I WOULD SAY SO.
3062
1 Q. OKAY. AND DO YOU HOLD ANY EXPERTISE IN FORENSIC
2 PATHOLOGY?
3 A. NO, I DON'T.
4 Q. OKAY. LET'S TALK ABOUT LYDIA SMITH. EXCUSE ME. BEFORE
5 WE GET ON TO LYDIA SMITH, I'D JUST -- I JUST WANT TO ASK YOU
6 SOME QUESTIONS ABOUT MARY CRANE, FOLLOW-UP QUESTIONS.
7 DID YOU REVIEW THE -- AS YOU REFERRED TO THEM -- THE
8 ADVANCE DIRECTIVES IN THE -- IN THE FILES THAT YOU -- THE
9 HOSPITAL FILES YOU REVIEWED? DID YOU HAVE OCCASION TO LOOK
10 AT ANY OF THOSE ADVANCE DIRECTIVES?
11 A. IF THEY WERE HERE, I LOOKED AT THEM. I'M TRYING TO SEE
12 IF THE COPIES ARE IN THIS PARTICULAR --
13 Q. NOW, WHEN WE TALK ABOUT ADVANCE DIRECTIVES, WE TALK
14 ABOUT A NUMBER OF DIFFERENT TYPES OF DOCUMENTS, DO WE NOT?
15 A. YES, SIR.
16 Q. AND THOSE DOCUMENTS COULD BE ANYWHERE FROM A SPECIAL
17 POWER OF ATTORNEY APPOINTING A FAMILY MEMBER TO ACT ON
18 BEHALF OF A PATIENT -- THAT WOULD BE ONE ADVANCE DIRECTIVE;
19 IS THAT CORRECT?
20 A. DURABLE POWER OF ATTORNEY FOR HEALTH CARE? YES, SIR.
21 Q. PARDON?
22 A. THEY CALL IT A DURABLE POWER OF ATTORNEY FOR HEALTH
23 CARE.
24 Q. OKAY. AS TO ANOTHER TYPE OF ADVANCE DIRECTIVE, IT COULD
25 BE ENTITLED A MEDICAL TREATMENT PLAN? WOULD YOU BE FAMILIAR
3063
1 WITH THAT ONE?
2 A. NOT THAT ONE BY THAT NAME. IS THAT A UTAH FORM?
3 Q. AND THERE ARE OTHER TYPES OF ADVANCE DIRECTIVES SUCH AS
4 THOSE DEALING WITH -- LET ME SEE IF I CAN FIND IT HERE.
5 A. THEY'RE COMMONLY CALLED A LIVING WILL.
6 Q. A LIVING WILL. WHEN A -- I THINK YOU'VE PREVIOUSLY
7 TESTIFIED WHEN A PATIENT IS ADMITTED TO A HOSPITAL FACILITY
8 OR A MEDICAL FACILITY, THEY'RE ASKED THE QUESTION, HAVE YOU
9 EXECUTED AN ADVANCE DIRECTIVE?
10 A. YES.
11 Q. AND USUALLY THEY WILL -- IF THEY ANSWER YES, THEY WILL
12 PROVIDE THAT TO THE HOSPITAL AT THAT TIME?
13 A. OR THEY'LL TELL THEM WHERE THEY CAN FIND A COPY, IF THE
14 PATIENT'S AWARE ENOUGH TO BE ABLE TO DO THAT.
15 Q. OKAY. SOME OF THOSE ADVANCE DIRECTIVES WOULD ALSO
16 ENTAIL THE -- I GUESS WHAT YOU WOULD CALL A DO NOT
17 RESUSCITATE ORDER?
18 A. YES.
19 Q. NOW, TYPICALLY, WHEN ARE ALL OF THESE DOCUMENTS SIGNED?
20 A. AT THE TIME OF ADMISSION.
21 Q. OKAY.
22 A. IF THEY'RE PRESENT.
23 Q. OKAY. SO IF A PERSON IS ADMITTED, AND AT THE TIME OF
24 THEIR ADMISSION THEY ARE IN STABLE MEDICAL CONDITION, AND
25 SUBSEQUENTLY DEVELOP AN ACUTE EVENT, IS THERE ANY PROCESS
3064
1 THAT THE PHYSICIAN IS SUPPOSED TO GO THROUGH OR -- IN TERMS
2 OF MEETING WITH WHOEVER -- A FAMILY MEMBER OR WHOEVER IS THE
3 REPRESENTATIVE FOR THAT INDIVIDUAL?
4 A. YOUR QUESTION'S A LITTLE VAGUE. LET ME SEE IF I CAN GET
5 IT HERE.
6 Q. LET ME -- LET ME FRAME -- LET ME FRAME IT THIS WAY.
7 A. ARE YOU ASKING IF THERE'S SOMETHING IN WRITING?
8 Q. PARDON?
9 A. OR IS THERE A MEDICAL PRACTICE TRADITION OR SOMETHING IN
10 WRITING OR WHAT ARE YOU ASKING ABOUT?
11 Q. WELL, LET'S USE MARY CRANE AS AN EXAMPLE.
12 A. UH-HUH.
13 Q. SHE COMES IN ON THE 28TH. I'LL SHOW YOU, FIRST OF ALL,
14 WHICH IS -- IF YOU'LL PULL OUT HER FILE, AND IT'S LOCATED
15 UNDER MISCELLANEOUS DOCUMENTS. IT'S PAGE 001. I CAN'T --
16 THE COURT: IT'S THE OTHER SIDE.
17 MR. WILSON: OH, I GOT THE WRONG SIDE.
18 Q. (BY MR. WILSON) HAVE YOU BEEN ABLE TO FIND THAT UNDER
19 MISCELLANEOUS DOCUMENTS?
20 A. NO. I HAVE STARTING WITH 00229.
21 MR. WILSON: MAY I APPROACH, YOUR HONOR?
22 (WHEREUPON, AT THIS TIME THERE'S AN OFF-THE-RECORD
23 DISCUSSION BETWEEN MR. WILSON AND MS. BARLOW.)
24 Q. (BY MR. WILSON) OH, EXCUSE ME. I'VE GOT THE WRONG
25 NUMBERS. IT'S MED NUMBER-0338. I APOLOGIZE, DOCTOR -- OR
3065
1 336 IS THE ONE I WAS --
2 A. 336?
3 Q. YEAH. I KEEP DOING IT THE WRONG WAY. UNDER
4 MISCELLANEOUS.
5 A. I DON'T HAVE A MISCELLANEOUS.
6 Q. OR EXCUSE ME. UNDER MED.
7 A. MEDICAL/LEGAL, 336. YES, I HAVE IT.
8 THE COURT: OKAY. GO AHEAD.
9 Q. (BY MR. WILSON) CAN YOU SEE THAT DOCUMENT?
10 A. YES.
11 Q. NOW, DOES THAT APPEAR TO BE A -- AN ADVANCE DIRECTIVE TO
12 YOU?
13 A. IT'S A -- IN A FORM OF AN ADVANCE DIRECTIVE WE CALL
14 INTENSITY OF CARE PREFERENCE. IT'S COMMON --
15 Q. A WHAT?
16 A. INTENSITY OF CARE PREFERENCE.
17 Q. OKAY. NOW, THAT ONE'S DATED 3/21/91; IS THAT CORRECT?
18 A. YES. THAT WOULD HAVE PROBABLY BEEN FILLED OUT WHEN SHE
19 FIRST ENTERED A NURSING HOME OR SOME OTHER SIMILAR
20 RESIDENTIAL CARE FACILITY.
21 Q. AND THEN WE COME TO THE TIME OF HER HOSPITALIZATION AT
22 THE GEROPSYCH UNIT, AND AT THAT TIME I REFER YOU TO MED-0339
23 WHERE SHE EXECUTES A SPECIAL POWER OF ATTORNEY.
24 A. THAT WAS ON DECEMBER 28TH OF '95, YES.
25 Q. SO THAT WAS ON THE SAME DATE, AND THIS HAS BEEN
3066
1 TESTIFIED TO AS EXECUTED BY MARY CRANE ON THAT DATE.
2 A. UH-HUH.
3 Q. NOW, WOULD THAT -- THE FACT THAT SHE WAS ABLE TO READ
4 AND SIGN OFF ON A SPECIAL POWER OF ATTORNEY GIVE YOU ANY
5 INDICATION, AS A PHYSICIAN, AS TO HER MENTAL STATE AND
6 CAPABILITIES AT THAT TIME?
7 A. IT WOULD MAKE YOUR QUESTION WHICH OF THE TWO WAS THE
8 MOST ACCURATE, WHETHER SHE WAS, IN FACT, COMBATIVE AND
9 SEVERELY DEPRESSED, ALTHOUGH SHE COULD HAVE BEEN -- HAD THE
10 CAPACITY TO SIGN A DURABLE POWER OF ATTORNEY WITH SEVERE
11 DEPRESSION.
12 Q. AS I UNDERSTAND IT, IN YOUR PREVIOUS TESTIMONY SHE WAS,
13 IN YOUR OPINION, SUFFERING FROM ADVANCED DEMENTIA, BUT I
14 THINK YOU DID QUALIFY THAT SHE WASN'T AS FAR DOWN THAT
15 DEMENTIA ON THE -- ON THE F.A.S. --
16 A. THAT'S CORRECT.
17 Q. OKAY. LET ME SHOW YOU NOW MED-00341. CAN YOU IDENTIFY
18 THAT PARTICULAR DOCUMENT?
19 A. YES, SIR.
20 Q. HAVE YOU SEEN IT BEFORE?
21 A. YES, SIR.
22 Q. WHAT DOES THAT PURPORT TO BE, DOCTOR?
23 A. THIS IS ANOTHER INTENSITY OF CARE CHOICE LIST SIGNED BY
24 HER DURABLE POWER.
25 Q. OKAY. THIS WAS SIGNED BY THE DAUGHTER AS A RESULT OF
3067
1 THE POWER OF ATTORNEY, RIGHT?
2 A. RIGHT.
3 Q. ON THE 28TH. AND IT ALSO BEARS THE SIGNATURE OF THE
4 ATTENDING PHYSICIAN, DOES IT NOT?
5 A. YES.
6 Q. AND THERE'S A DATE BY THE ATTENDING PHYSICIAN OF
7 12/30/95.
8 A. UH-HUH.
9 Q. WHICH IS TWO DAYS AFTER THIS IS SIGNED BY THE -- BY THE
10 PATIENT OR THE PATIENT'S REPRESENTATIVE, RIGHT?
11 A. YES, SIR.
12 Q. NOW, THE QUESTION IS, THE PATIENT COMES IN, THEY MEET
13 THE CRITERIA OF ADMISSION TO THE GEROPSYCH UNIT. AS MARY
14 CRANE -- AS YOU INDICATED -- DEVELOPS A SEPTICEMIA ON THE
15 3RD, WHICH STARTS HER ON A DOWNHILL PROGRESS, ACCORDING TO
16 YOUR TESTIMONY --
17 A. UH-HUH.
18 Q. -- IS THERE A TIME, DOCTOR, WHEN THE PHYSICIAN SHOULD
19 TALK WITH THE REPRESENTATIVE ABOUT THAT PATIENT'S NEEDS AND
20 CONDITIONS?
21 A. I WOULD THINK THAT THEY WOULD PROBABLY BE IN
22 COMMUNICATION SOMEWHERE WHEN THE INTERVENTIONS NEEDED TO
23 CHANGE.
24 Q. SO WHEN IS IT, IN YOUR EXPERIENCE, THAT THE PHYSICIAN
25 INVOKES THE ADVANCE DIRECTIVE TO DELIVER PALLIATIVE CARE, AS
3068
1 IT'S BEEN CHARACTERIZED?
2 A. IN A GEROPSYCH UNIT?
3 Q. UH-HUH.
4 A. BECAUSE PALLIATIVE CARE IN A HOSPICE SETTING IS VERY
5 DIFFERENT THAN IN A GEROPSYCH UNIT. OBVIOUSLY, WE HAVE A
6 DIFFERENT SET OF -- OF POLICIES AND PROCEDURES AND SO ON.
7 I'M NOT SURE I KNOW WHAT THE STANDARD FOR COMMUNICATION WITH
8 A FAMILY WITH A GEROPSYCH PATIENT IS.
9 BUT IN GENERAL, FROM MY EXPERIENCE YOU WOULD TRY TO BE
10 IN COMMUNICATION WITH --
11 Q. YOU -- YOU WOULD TRY --
12 A. -- WITH A CHANGE IN THE PATIENT'S STATUS.
13 Q. OKAY.
14 A. SO THAT IF THERE WAS A CHANGE IN THE STATUS, WE'D WANT
15 TO KNOW -- YOU KNOW, LET -- LET THE FAMILY KNOW.
16 Q. SO YOU WOULD -- YOU WOULD WANT TO AT LEAST ADVISE, IN
17 YOUR -- YOUR CARE AND TREATMENT --
18 A. UH-HUH.
19 Q. -- THAT PATIENT'S FAMILY OR REPRESENTATIVE OF THE CHANGE
20 IN STATUS?
21 A. RIGHT.
22 Q. WOULD YOU SIT DOWN AND ADVISE THEM AS TO THE
23 ALTERNATIVES THAT ARE AVAILABLE TO THEM AT THAT TIME?
24 A. I DON'T KNOW WHERE YOU'RE GOING WITH THE QUESTION, AND
25 I'M TRYING TO FIGURE OUT WHAT YOU MEAN SO --
3069
1 Q. WELL, LET'S SPECIFICALLY REFER TO MARY CRANE.
2 A. YES, PLEASE.
3 Q. SHE'S -- ON JANUARY 3RD SHE TURNS TO THE WORSE.
4 A. ON JANUARY 3RD STOOL IS NOTED IN HER VAGINA AND A
5 CONSULTANT IS CALLED IN, RIGHT?
6 Q. I THINK IF YOU'LL REFER TO THE RECORD, I THINK THAT
7 OCCURRED ON JANUARY 1ST.
8 A. ALL RIGHT. AND THEN THE 3RD SHE STARTED HAVING SOME
9 PAIN. OKAY.
10 Q. THAT'S RIGHT. ACCORDING TO YOUR REVIEW OF THE
11 RECORDS --
12 A. RIGHT.
13 Q. -- IT WAS ON THE 3RD, AS I RECALL, THAT YOU FELT LIKE
14 SHE WAS STARTING TO PROGRESSIVELY GO DOWNHILL.
15 A. UH-HUH.
16 Q. OKAY. WHAT I WANT TO KNOW IS AT THAT TIME WITH MARY
17 CRANE WERE THERE ALTERNATIVES AVAILABLE FOR THE TREATMENT OF
18 THE SEPTICEMIA THAT YOU'D SEEN DEVELOPING THERE?
19 A. WELL, THE GYNECOLOGIST HAD SUGGESTED THAT SHE BE PUT ON
20 BROAD SPECTRUM ANTIBIOTICS, AND THEN THEY WERE TRYING TO
21 REACH THE INTERNIST ABOUT THAT.
22 Q. OKAY.
23 A. ON THE 5TH THE KEFLEX WAS STARTED, WHICH IS A BROAD
24 SPECTRUM ANTIBIOTIC.
25 Q. SO IT WAS TWO DAYS LATER THE --
3070
1 A. RIGHT.
2 Q. -- ON THE 5TH THAT THE INFECTIOUS DISEASE PROCESS IS
3 FIRST ADDRESSED; IS THAT CORRECT?
4 A. UH-HUH.
5 Q. OKAY.
6 A. THAT'S CORRECT. THERE WAS A --
7 Q. WHEN -- WHEN WAS IT IN RELATIONSHIP TO MARY CRANE'S
8 RECORDS THAT -- OR MAYBE -- MAYBE -- THIS IS THE QUESTION,
9 DOCTOR. DID YOU EVER FORM AN OPINION IN REVIEWING THOSE
10 RECORDS AS TO WHEN THE EVENTS WITH MARY CRANE WERE
11 IRREVERSIBLE?
12 A. I WOULD SAY PROBABLY BY THE 7TH -- ABOUT THE 7TH OF
13 JANUARY. IT'S UNLIKELY THOUGH THAT THIS PATIENT WOULD HAVE
14 HAD ANY DIFFERENT OUTCOME EVEN IF THE ANTIBIOTICS HAD BEEN
15 STARTED EARLIER. WE JUST WOULDN'T HAVE KNOWN THEY WEREN'T
16 REVERSIBLE UNTIL HER BLOOD PRESSURE FELL.
17 Q. THE FACT OF THE MATTER IS THEY WERE NOT STARTED UNTIL
18 THE 5TH; IS THAT CORRECT?
19 A. RIGHT. YOU KNOW, SHE HAD HAD AN EPISODE OF CIPRO, WHICH
20 IS ANOTHER BROAD SPECTRUM ANTIBIOTIC FOR HER URINARY TRACT
21 INFECTION, DURING THIS SAME HOSPITAL STAY. THAT SHOULD HAVE
22 BLUNTED THIS FROM BECOMING A SEPSIS.
23 Q. OKAY.
24 A. THESE ARE THE KINDS OF THINGS THAT WHEN YOU HAVE ELDERLY
25 PATIENTS AND MULTIPLE THINGS WRONG WITH THEN, SOMETIMES YOU
3071
1 DON'T RECOGNIZE YOU'VE GONE OVER THE HILL UNTIL YOU'RE
2 SLIDING DOWN THE HILL ON THE OTHER SIDE.
3 Q. OKAY. NOW, YOU'VE JUST REVIEWED THE -- THE MEDICAL
4 RECORDS. YOU DIDN'T HAVE AN OPPORTUNITY TO LOOK AT THIS
5 PATIENT, DID YOU?
6 A. NO, I DID NOT.
7 Q. SPECIFICALLY REFERRING TO MARY CRANE. I ASSUME THEN
8 THAT HAD YOU HAD THAT OPPORTUNITY, WOULD YOU -- WOULD YOU
9 HAVE BEEN ABLE TO BETTER EVALUATE HER MEDICAL CONDITION
10 SITUATION?
11 A. IT'S ALWAYS EASIER TO EVALUATE A MEDICAL CONDITION WHEN
12 YOU'RE LOOKING AT A PATIENT.
13 Q. OKAY.
14 A. I THINK WE'VE ALL GOT THE SAME HANDICAP WITH THIS
15 RECORD.
16 Q. GOING BACK TO -- TO A QUESTION I HAD FOR YOU ON THESE
17 MEDICAL DIRECTIVES, WE HAVE A VARIETY OF DIFFERENT
18 DIRECTIVES. ARE THERE ANY DIRECTIVES THAT TAKE PRECEDENT
19 OVER OTHER DIRECTIVES?
20 A. I'M NOT FAMILIAR WITH THE UTAH STATE LAWS REGARDING
21 THAT, SIR, I'M SORRY.
22 Q. OKAY.
23 A. IT VARIES FROM STATE TO STATE WHICH ONE TAKES
24 PRECEDENCE.
25 Q. IN YOUR EXPERIENCE IN -- RELATIVE TO HOSPICE CARE, YOU
3072
1 ARE FAMILIAR WITH STATE LAWS FROM STATE TO STATE?
2 A. IN SAN DIEGO.
3 Q. OKAY.
4 A. I MEAN, I UNDERSTAND CALIFORNIA STATE LAW --
5 Q. ALL RIGHT.
6 A. -- WHICH IS THE ONLY STATE I PRACTICE IN.
7 Q. SO YOU WOULDN'T BE ABLE TO RENDER ANY KIND OF OPINION AS
8 TO WHETHER CERTAIN DIRECTIVES TAKE PRECEDENT OR NOT?
9 A. I KNOW THAT THE TRADITIONAL WAY OF LOOKING AT ADVANCE
10 DIRECTIVES IS THAT THE PATIENT'S WORD IS FIRST; AND THEN THE
11 ASSIGNED SURROGATE; THEN THE FAMILY, NEXT OF KIN; AND THEN
12 THE BEST YOU CAN DETERMINE ABOUT WHAT THE PATIENT WOULD HAVE
13 WISHED ARE THE ORDER IN WHICH DECISIONS ARE GENERALLY MADE
14 IN -- IN THE UNITED STATES. BUT I DO NOT KNOW UTAH LAW
15 SPECIFICALLY.
16 Q. SO WHEN -- WHEN WE TALK ABOUT THE PATIENT'S WORD IS
17 FIRST --
18 A. IF THE PATIENT HAS CAPACITY TO MAKE MEDICAL DECISIONS,
19 ONE SHOULD ALWAYS ASK THE PATIENT.
20 Q. OKAY. DO YOU ALWAYS ASK THE PATIENT EVEN IF THERE IS AN
21 ADVANCE DIRECTIVE ALREADY IN EFFECT?
22 A. YES.
23 Q. AND DO YOU ALWAYS ASK THE PATIENT'S REPRESENTATIVE, EVEN
24 IF THERE IS AN ADVANCE DIRECTIVE IN EFFECT?
25 A. BY PATIENT'S REPRESENTATIVE, ARE YOU TALKING ABOUT THE
3073
1 ASSIGNED SURROGATE IN THE DIRECTIVE?
2 Q. THE SURROGATE, YES. WOULD YOU ASK --
3 A. THEY'RE ONLY THE SURROGATE BY VIRTUE OF THE ADVANCE
4 DIRECTIVE.
5 Q. RIGHT.
6 A. SO YES, THAT'S WHO WE WOULD TALK TO.
7 Q. BY THE POWER OF ATTORNEY. OKAY.
8 A. BUT ONLY IF THE PATIENT LACKED CAPACITY TO MAKE THE
9 MEDICAL DECISION IN QUESTION.
10 Q. OKAY. SO THE PHYSICIAN, AS I UNDERSTAND IT, THEN
11 WOULD -- WOULD -- IN THE EVENT OF AN ACUTE EVENT IN THE
12 HOSPITAL SETTING, AS WE HAVE HERE, WOULD THEN GO TO THE
13 SURROGATE OR TO THE PATIENT, ADVISE THEM IF -- IF -- OF THE
14 SITUATION AS FAR AS THE ACUTE EVENT GOES --
15 A. UH-HUH.
16 Q. -- BEFORE THEY INVOKE THE ADVANCE DIRECTIVE?
17 A. THAT IS INVOKING THE ADVANCE DIRECTIVE.
18 Q. THAT IS INVOKING THE ADVANCE DIRECTIVE. AND WHAT DO
19 THEY ADVISE THEM OF? JUST THE CONDITION OF THE PATIENT?
20 A. AND THE RELATIONSHIP TO THE WRITTEN INSTRUCTIONS, IF
21 THERE ARE ANY, OR THE OPPORTUNITIES OR NEEDS FOR CARE.
22 Q. OKAY.
23 A. AND IN THE INTERDISCIPLINARY TEAM, IT CAN BE A LOT OF
24 PEOPLE BESIDES THE PHYSICIAN. YOU KNOW, THIS PATIENT THERE
25 WERE CONVERSATIONS WITH OTHER TEAM MEMBERS PRIOR TO THE 7TH.
3074
1 Q. SO THEN THE PHYSICIAN MEETS WITH THE INTERDISCIPLINARY
2 TEAM TO GO OVER THIS?
3 A. THEY TALK. YEAH.
4 Q. I NEED TO ASK YOU SOME QUESTIONS AS IT RELATES -- DO YOU
5 HAVE ANY EXPERTISE -- YOU'VE INDICATED YOU HAVE SOME
6 EXPERTISE IN PAIN MANAGEMENT. IS THAT -- IS THAT ACCURATE?
7 A. YES, SIR. MEDICAL PAIN MANAGEMENT. I DON'T DO
8 INTERVENTIONAL LIKE ANESTHESIA STUFF.
9 Q. MEDICAL PAIN MANAGEMENT?
10 A. YES, SIR.
11 Q. YOU DON'T HAVE ANY EXPERTISE IN --
12 A. I DON'T DO NERVE BLOCKS OR SURGERY.
13 Q. OH, OKAY.
14 A. WE CALL IT --
15 Q. WHAT TYPE OF PAIN MANAGEMENT DO YOU DO?
16 A. MEDICAL PAIN MANAGEMENT. TREATMENT WITH MEDICINE.
17 Q. ARE YOU FAMILIAR OR DO YOU HAVE ANY FAMILIARITY WITH
18 PSYCHOTROPIC MEDICATIONS?
19 A. SOME, AS IT HELPS WITH THE TERMINALLY ILL PATIENTS.
20 Q. ARE YOU FAMILIAR WITH THE LITERATURE AS IT RELATES TO
21 THE USE OR THE PHARMACOLOGY OF PSYCHOTROPIC AND PAIN
22 MEDICATIONS IN THE ELDERLY?
23 A. SOME OF IT.
24 Q. GENERALLY SPEAKING, IT'S TRUE, DOCTOR, THE ELDERLY
25 ARE -- ARE MORE SENSITIVE TO THE ADMINISTRATION OF THESE
3075
1 TYPES OF CENTRAL NERVOUS SYSTEM DEPRESSANTS, ARE THEY NOT?
2 A. USUALLY WE EXPECT THEM TO BE MORE SENSITIVE AND START
3 WITH SMALL DOSES AND THEN TITRATE AS WE NEED TO THE CHANGES
4 WE'RE TRYING TO PRODUCE IN THE PATIENT.
5 Q. OKAY.
6 A. SO WHILE THE STARTING DOSES ARE USUALLY SMALL, THEY MAY
7 NEED JUST AS MUCH AS ANYBODY ELSE TO GET THE EFFECT WE NEED.
8 Q. BUT YOU START WITH THEM SMALL TO SEE WHAT KIND OF EFFECT
9 YOU'RE GETTING?
10 A. RIGHT.
11 Q. AND THEN YOU WILL EITHER INCREASE IT OR DECREASE IT
12 DEPENDING ON THE EFFECT; IS THAT CORRECT?
13 A. THAT'S CORRECT.
14 Q. NOW, I'M GOING TO SHOW YOU WHAT'S BEEN MARKED AS STATE'S
15 EXHIBIT 31. I'M JUST GOING TO PUT IT UP HERE AND MAYBE I'LL
16 HAVE YOU STEP DOWN FOR JUST A SECOND, IF YOU WOULD, PLEASE,
17 OR LOOK AT THAT. THERE'S A NUMBER OF -- OF DIFFERENT TYPES
18 OF DRUGS WHICH ARE --
19 A. WHAT IS THE SOURCE OF THIS?
20 Q. THIS WAS A EXPERT FOR THE STATE WHO PROVIDE -- OR
21 PREPARED THIS PARTICULAR DOCUMENT.
22 A. WHAT WAS THE SOURCE OF HIS INFORMATION?
23 Q. AS I RECALL, HE TOOK IT FROM THE GERIATRIC DOSAGE
24 HANDBOOK, THAT WAS BACK IN 1995. I JUST WANTED YOU TO
25 FAMILIARIZE YOURSELF WITH THE CHART, IF YOU WOULD.
3076
1 A. UH-HUH.
2 Q. ARE YOU FAMILIAR WITH EACH OF THE DRUGS THAT ARE LISTED
3 ON THAT CHART?
4 A. YES, I AM.
5 Q. OKAY. AND CAN YOU TELL US IN LOOKING AT THE ADULT
6 STARTING DOSE WHICH, FOR THE RECORD, I THINK WAS TAKEN FROM
7 THE P.D.R., AND THE ELDERLY STARTING DOSE WHICH WAS TAKEN
8 FROM THE GERIATRIC HANDBOOK, WOULD THAT COMPORT WITH YOUR
9 OPINION AS TO THE DOSAGES -- THE STARTING DOSAGES THAT WOULD
10 BE ADMINISTERED TO ELDERLY PATIENTS?
11 A. SOME OF THEM I AGREE WITH. I DON'T AGREE WITH THE
12 MORPHINE DOSING. I THINK IT'S TOO LOW, IF A PATIENT HAS
13 SIGNIFICANT PAIN.
14 Q. OKAY.
15 A. BUT I WOULD MONITOR A PATIENT ON ANY OF THESE DRUGS FOR
16 EFFECT AND EFFICACY.
17 Q. LET ME SHOW YOU WHAT'S MARKED AS STATE'S EXHIBIT 30 --
18 AND, AGAIN, I WOULD REPRESENT THIS WAS PREPARED BY A
19 DR. FEHLAUER WHO TESTIFIED EARLIER IN THESE PROCEEDINGS --
20 WHICH REPRESENTS THE PHARMACOLOGY IN THE ELDERLY AND SPECIAL
21 CONSIDERATIONS IN THE ELDERLY. AND I DON'T -- TAKE YOUR
22 TIME AND REVIEW THAT, IF WOULD YOU, PLEASE.
23 A. UH-HUH. OKAY.
24 Q. CAN YOU TELL US WHETHER OR NOT YOU AGREE OR DISAGREE
25 WITH THE REFERENCES ON THE CHART?
3077
1 A. THEY SEEM TO BE REASONABLY CONSISTENT WITH THE
2 EXPERIENCE WE HAVE.
3 Q. SO I TAKE IT YOUR -- YOU WOULD AGREE THAT FOR MOST OF
4 THESE DRUGS THAT WERE LISTED, THERE IS A -- A LONGER
5 DURATION EFFECT IN THE ELDERLY?
6 A. THERE MAY BE A LONGER DURATION EFFECT IN AN ELDERLY
7 PERSON.
8 Q. OKAY. AND IN RESPECT TO THAT "MAY BE," IS IT MY
9 UNDERSTANDING THAT COULD ONLY BE DETERMINED BY MONITORING OF
10 THE PATIENT?
11 A. THAT'S CORRECT.
12 Q. I SHOW YOU WHAT'S MARKED AS STATE'S EXHIBIT 37, WHICH IS
13 A CHART THAT WAS PREPARED BY DR. BRADFORD HARE IN CONNECTION
14 WITH HIS TESTIMONY IN THESE PROCEEDINGS WHICH TALKS ABOUT
15 CENTRAL NERVOUS SYSTEM DEPRESSANTS. NOW, I WOULD ASK YOU TO
16 TAKE A LOOK AT THAT CHART AND TELL ME IF YOU AGREE OR
17 DISAGREE WITH, FIRST OF ALL, THE IMMEDIATE EFFECTS THAT HE'S
18 INDICATED AS TO CENTRAL NERVOUS SYSTEM DEPRESSANTS.
19 A. AN OVERDOSE OF A CENTRAL NERVOUS SYSTEM DEPRESSANT CAN
20 PRODUCE SLEEPINESS OR COMA AND MAY DECREASE THE RESPIRATORY
21 RATE. I DON'T AGREE WITH THE REST OF THE CHART.
22 Q. YOU DON'T AGREE THAT IT WOULD DECREASE BLOOD PRESSURE?
23 A. NO.
24 Q. AND YOU DON'T AGREE THAT AN IMMEDIATE EFFECT COULD BE
25 DECREASED FOOD AND WATER INTAKE?
3078
1 A. NO. NOT DUE TO THE MEDICATION.
2 Q. NOW, WE TALKED -- YOU -- YOU WERE REFERENCING THAT
3 SPECIFICALLY AS TO AN OVERDOSE; IS THAT RIGHT?
4 A. OR TO A HIGH INITIAL DOSE IN AN OPIOID NAIVE PATIENT.
5 Q. OKAY. AS TO THE LONG-TERM EFFECTS THAT ARE LISTED
6 THERE, CAN YOU TELL -- COMMENT ON WHETHER OR NOT YOU AGREE
7 OR DISAGREE WITH THAT?
8 A. IT'S WELL KNOWN AMONG ALL THE PEOPLE WHO DO PAIN
9 MANAGEMENT WITH OPIOIDS THAT THE OPIOID AS A CLASS HAVE NO
10 ORGAN TOXICITY. THEY DO NOT DIRECTLY IMPAIR THE FUNCTION OF
11 ANY ORGAN IN THE BODY, EVER. NOW --
12 Q. SO YOUR TESTIMONY IS -- IS THERE -- THERE WOULD BE NO
13 ORGAN DAMAGE OR REDUCED ORGAN --
14 A. THAT'S CORRECT. THERE IS NO ORGAN DAMAGE FROM OPIOIDS.
15 Q. I SEE. OR REDUCED ORGAN FUNCTION?
16 A. THAT'S CORRECT.
17 Q. OKAY. AND WOULD THERE BE DEHYDRATION, OR COULD THERE BE
18 A LONG-TERM EFFECT WITH THE USE OF CENTRAL NERVOUS SYSTEM --
19 A. I'VE HAD PATIENTS ON OPIOID DRUGS FOR YEARS WHO ARE
20 GOING TO WORK, EATING, FUNCTIONING, LIVING NORMAL LIVES
21 BECAUSE THEY HAVE CHRONIC PAIN SYNDROMES. PATIENTS WHO ARE
22 IN PAIN, WHEN THEY RECEIVE AN OPIOID THE PAIN ANTAGONIZES
23 THE SEDATIVE EFFECTS OF THE OPIOID. WITHOUT SEDATION, NONE
24 OF THE DECREASED INTAKE OR ANYTHING WOULD OCCUR. AND THERE
25 IS NO DIRECT ORGAN TOXICITY FROM ANY OPIOID.
3079
1 Q. LET ME ASK YOU THIS, DOCTOR. ASSUMING THAT THERE IS NO
2 PAIN, IS THERE ANY REASON TO BE ADMINISTERING EITHER
3 MORPHINE OR A CENTRAL NERVOUS SYSTEM DEPRESSANT?
4 A. THERE MAY BE A NUMBER OF REASONS WHY OPIOIDS WOULD BE
5 USED WITHOUT DIRECT EVIDENCE OF PAIN. PATIENTS WHO HAVE A
6 PRESUMPTIVE ILLNESS THAT WOULD CAUSE PAIN MIGHT CAUSE YOU TO
7 TRY DRUGS TO SEE IF THEY -- THEY WOULD BE MORE COMFORTABLE.
8 THE OTHER MAJOR USE OF OPIOIDS IN MY BUSINESS, WHICH IS
9 A LITTLE DIFFERENT THAN THE CASES HERE, IS THAT IT HELPS
10 WITH SHORTNESS OF BREATH OR DYSPNEA AT THE END OF LIFE. IT
11 MAKES PEOPLE FEEL LESS LIKE THEY'RE SUFFOCATING.
12 IT ALSO HAS BEEN TRADITIONALLY USED -- MORPHINE HAS
13 BEEN TRADITIONALLY USED IN END-OF-LIFE CARE SINCE THE
14 BEGINNING OF TIME THAT IT WAS CREATED TO HELP PEOPLE WITH
15 SEDATION AND FEELING CALMER AT THE END OF LIFE.
16 IT'S VERY IMPORTANT THAT WE HAVE TO MAKE A DISTINCTION
17 BETWEEN THE END OF LIFE AND HOSPICE BECAUSE HOSPICE IS KIND
18 OF A REAL SPECIALIZED -- WE'RE FINE TUNING THE PROCESS. BUT
19 GENERALLY END-OF-LIFE CARE, IF YOU LOOK AT VERY OLD MEDICAL
20 LITERATURE, THEY GIVE MORPHINE AT THE END OF LIFE FOR THAT
21 UNEASINESS, SHORTNESS OF BREATH, MOANING, SUSPECTED PAIN, SO
22 ON.
23 Q. SO IN -- IN TERMS OF YOUR PARTICULAR SPECIALTY, AS I
24 UNDERSTAND IT --
25 A. UH-HUH.
3080
1 Q. -- IT'S GIVEN FOR THAT PURPOSE?
2 A. AND IT HAS BEEN GIVEN FOR THAT IN MEDICINE FOREVER.
3 YES.
4 Q. OKAY. IN -- IN TERMS OF THE OTHER MEDICAL SPECIALTIES,
5 WOULD YOU AGREE WITH THE STATEMENT THAT IT'S USED FOR
6 CHRONIC OR SEVERE PAIN?
7 A. OR ACUTE PAIN.
8 Q. OR ACUTE PAIN.
9 A. YES.
10 Q. OKAY. AND THAT'S A PROPER USE IN THAT CONTEXT?
11 A. THAT'S ONE OF THE PROPER USES IN THAT CONTEXT, YES.
12 Q. OKAY. ALL RIGHT. WE DIDN'T TALK SPECIFICALLY ABOUT
13 THIS. I'M JUST GOING TO PUT IT UP FOR A SECOND BECAUSE I
14 THINK ESSENTIALLY YOU'VE ANSWERED THE QUESTIONS AS IT
15 RELATED TO THE OTHER CHART.
16 THIS IS -- IS STATE'S EXHIBIT NUMBER 40. CAN YOU TELL
17 US, AS IT RELATES TO THE IMMEDIATE EFFECTS -- I THINK THE
18 ONLY -- WELL, I'LL ASK YOU THE QUESTION. AS IT RELATES TO
19 THE IMMEDIATE EFFECTS, DO YOU AGREE OR DISAGREE WITH THAT
20 PARTICULAR CHART?
21 A. THE PATIENT SHOULD HAVE PAIN RELIEF WITH AN ADEQUATE
22 DOSE OF MORPHINE, BUT IT MAY BE INADEQUATE TO RELIEVE PAIN
23 IF YOU START WITH TOO LOW A DOSE.
24 SLEEPINESS OR SEDATION CAN OCCUR FROM A DOSE THAT'S
25 HIGHER THAN NEEDED FOR THE PAIN AT HAND. A DECREASED
3081
1 BREATHING RATE MAY OCCUR IN THOSE CASES AS WELL.
2 THERE IS NO LOSS OF THE COUGH REFLEX DUE TO THE
3 MORPHINE ITSELF. THERE MAY BE A LOSS OF COUGH REFLEX IN
4 DEEP COMA, BUT THAT SHOULDN'T BE HAPPENING WHEN WE'RE
5 DEALING WITH PAIN BECAUSE THE PAIN ANTAGONIZES THE OPIOID.
6 I DO NOT AGREE WITH LOW BLOOD PRESSURE, DECREASED FOOD
7 AND WATER INTAKE, AND I DO NOT AGREE WITH THE LONG-TERM SIDE
8 EFFECTS LIST AT ALL.
9 Q. ANY OF THOSE LONG-TERM SIDE EFFECTS?
10 A. NO, I DON'T.
11 Q. OKAY. HAVE YOU REVIEWED ANY STUDIES RELATIVE TO THE USE
12 OF CENTRAL NERVOUS SYSTEM DEPRESSANTS PRIOR TO -- TO COMING
13 TO THESE PROCEEDINGS?
14 A. IN WHAT SENSE, SIR?
15 Q. IN -- IN THE -- IN THE SENSE -- DID YOU REVIEW ANY
16 STUDIES AS IT RELATES TO CENTRAL NERVOUS SYSTEM DEPRESSANTS
17 IN PREPARATION FOR YOUR TESTIMONY HERE IN COURT?
18 A. NO, SIR.
19 Q. AM I CORRECT THEN IN -- IN SUMMARIZING THAT YOUR
20 TESTIMONY AS IT RELATES TO CENTRAL NERVOUS SYSTEM
21 DEPRESSANTS IS BASED PRIMARILY ON YOUR EXPERIENCE?
22 A. THAT'S CORRECT, SIR.
23 Q. OKAY.
24 A. AND -- AND GENERALLY MY READING, BUT NOT ANY READING
25 SPECIFICALLY FOR THIS TRIAL.
3082
1 Q. OKAY. BEFORE WE GET OFF THAT TOPIC, LET'S TALK A LITTLE
2 BIT ABOUT THE TESTIMONY YOU GAVE AS IT RELATES TO
3 CHEYNE-STOKES BREATHING.
4 A. UH-HUH.
5 Q. I THINK YOUR TESTIMONY WAS TO THE EFFECT THAT
6 CHEYNE-STOKES BREATHING WAS NOT INDICATIVE OF ANY
7 INTOXICATION FROM THE EFFECTS OF MORPHINE.
8 A. THAT'S CORRECT, SIR.
9 Q. ARE YOU AWARE OF ANY STUDIES WHICH WOULD CONFIRM THAT
10 PARTICULAR OPINION, DOCTOR?
11 A. NO, I'M NOT, SIR.
12 Q. AGAIN, IS THAT JUST BASED UPON YOUR EXPERIENCE?
13 A. I THINK IT'S BASED ON MINE AND A NUMBER OF OTHER
14 PHYSICIANS' EXPERIENCE. WHEN WE SEE MORPHINE DOING ANYTHING
15 TO THE RESPIRATORY RATE, IT'S TO SLOW IT DOWN.
16 Q. NOW, ARE THERE ANY OTHER THINGS, OTHER THAN THE SAY, AS
17 YOU DESCRIBED IT, THE DYING PROCESS, THAT WOULD CAUSE
18 CHEYNE-STOKES RESPIRATION?
19 A. I THINK I ALSO REFERRED TO ACUTE HEAD INJURIES AS
20 CAUSING CHEYNE-STOKES RESPIRATIONS IN THE -- IN THE COMA
21 PROCESS FOR THOSE PATIENTS.
22 I THINK I'VE ALSO SEEN CHEYNE-STOKES RESPIRATIONS AS A
23 RESULT OF SOME PRIMARY DEGENERATIVE BRAIN DISORDERS WHERE
24 THE PATIENT IS ACTUALLY DYING FROM THE BRAIN DEGENERATION,
25 NEUROGENIC DEGENERATIVE DISEASES.
3083
1 Q. OKAY. AS I UNDERSTAND IT -- AND CORRECT ME IF I'M
2 WRONG -- THE -- THE AREA OF THE BRAIN THAT CONTROLS YOUR
3 BREATHING IS THE LOWER PART OF THE -- OR THE --
4 A. PRIMITIVE REFLEX.
5 Q. -- BACK PART OF THE BRAIN?
6 A. RIGHT.
7 Q. AND IS IT YOUR TESTIMONY THAT THE MORPHINE WOULD NOT
8 IMPACT THAT AREA OR WHAT?
9 A. IT MAY IMPACT IT, BUT IT DOESN'T PRODUCE THAT PATTERN OF
10 BREATHING.
11 Q. I SEE. WELL, IS THERE ANY LITERATURE OR IS THERE
12 ANYTHING IN YOUR EXPERIENCE WHERE RENAL FAILURE WOULD CREATE
13 CHEYNE-STOKES RESPIRATION?
14 A. PATIENTS WHO ARE DYING FROM RENAL FAILURE MAY HAVE
15 CHEYNE-STOKES RESPIRATION, BUT IT'S THE DYING BRAIN.
16 Q. OKAY. IT'S PRIMARILY THE BRAIN THAT'S DOING THAT.
17 A. RIGHT.
18 Q. HOW ABOUT EXTREME HYPOXIA?
19 A. AGAIN, IT'S THE DYING BRAIN.
20 Q. OKAY. NOW, CAN THE EXTREME HYPOXIA -- CAN HYPOXIA BE
21 INDUCED AS A RESULT OF THE TOXICITY LEVELS OF MORPHINE?
22 A. ARE YOU REFERRING TO AN OVERDOSE OF MORPHINE PRODUCING
23 RESPIRATORY DEPRESSION?
24 Q. I AM.
25 A. THEN THAT IS POSSIBLE TO GET HYPOXIA. THE RESPIRATORY
3084
1 RATE WOULD HAVE TO BE AROUND 2 TO 4. AND THEN THE PATIENT
2 WOULD BE BREATHING TOO SLOWLY TO HAVE CHEYNE-STOKES
3 RESPIRATION.
4 Q. I SEE. SO YOUR TESTIMONY THEN IS EXTREME HYPOXIA WOULD
5 NOT DEMONSTRATE OR BE DEMONSTRABLE IN -- IN CHEYNE-STOKES
6 RESPIRATIONS?
7 A. IT CAN CAUSE IT AS A PART OF A DYING PROCESS IF THE
8 REASON FOR THE HYPOXIA IS NOT ALSO SLOWING THE BREATHING
9 DOWN. PEOPLE GET HYPOXIC WHEN THEY HAVE BAD PULMONARY
10 EMBOLI AND THEY CAN CHEYNE-STOKE.
11 Q. OKAY.
12 A. BUT IF YOU'RE BREATHING TOO SLOW, YOU CAN'T
13 CHEYNE-STOKE.
14 Q. OKAY. IS THERE LITERATURE -- IN YOUR EXPERIENCE, CAN
15 EXTREME DEHYDRATION CAUSE CHEYNE-STOKES RESPIRATIONS?
16 A. THAT'S GOING TO BE LIKE THE THIRD OR FOURTH CAUSE DOWN
17 THE DEATH CERTIFICATE IF IT IS BECAUSE YOU'RE GOING TO HAVE
18 DEHYDRATION PRODUCING PERHAPS RENAL FAILURE AND HYPOTENSION
19 AND THEN, YOU KNOW, SOMETHING ELSE IS CAUSING A METABOLIC
20 ABNORMALITY THAT CAUSES THE BRAIN TO DIE WHICH CAUSES THE --
21 YOU KNOW. IT'S -- IT'S STARTING TO SOUND LIKE I SWALLOWED A
22 FLY.
23 MR. WILSON: YOUR HONOR, I STILL HAVE A FEW MORE
24 QUESTIONS TO GO. I DON'T KNOW WHETHER THE COURT WANTS TO --
25 THE COURT: HOW LONG DO YOU THINK YOU'LL BE?
3085
1 MR. WILSON: OH, PROBABLY 10 MORE MINUTES, YOUR
2 HONOR.
3 THE COURT: HOW MUCH TIME WOULD YOU BE, MR. STIRBA?
4 MR. STIRBA: I MIGHT BE 5 OR 10, YOUR HONOR.
5 THE COURT: CAN WE GO ANOTHER 15 OR 20 MINUTES AND
6 FINISH WITH THIS WITNESS? WILL THAT -- WHY DON'T WE JUST
7 TRY AND DO THAT.
8 MR. WILSON: OKAY.
9 THE COURT: LET'S FINISH WITH THIS WITNESS BEFORE
10 WE TAKE A LUNCH BREAK.
11 Q. (BY MR. WILSON) JUST A COUPLE OF QUESTIONS. GOING
12 BACK TO THE DELIRIUM, I DID LOCATE THAT CHART. THIS IS
13 MARKED AS STATE'S EXHIBIT 29. I'D REPRESENT, FOR THE
14 RECORD, THIS IS AN EXHIBIT THAT WAS PREPARED BY DR. FEHLAUER
15 WHO PREVIOUSLY TESTIFIED ON BEHALF OF THE STATE COMPARING
16 DEMENTIA VERSUS DELIRIUM. WOULD YOU TAKE A LOOK AT THAT
17 CHART, DOCTOR?
18 A. WELL, THERE'S SOME INTERESTING COMMENTS ON THERE.
19 Q. WELL, I GUESS MY FIRST QUESTION WOULD BE HAVING REVIEWED
20 THAT, AS TO THE DEMENTIA, THE PARTICULAR FINDINGS I GUESS
21 YOU WOULD -- OR SYMPTOMS OR SIGNS YOU WOULD HAVE RELATED TO
22 THE FINDINGS ON THE OPPOSITE SIDE, WOULD YOUR TESTIMONY --
23 OR WOULD YOU AGREE OR DISAGREE WITH THAT PARTICULAR --
24 A. WELL, THE -- THE THINGS THAT THEY'RE SAYING IN DEMENTIA
25 THAT ARE CORRECT ARE THAT IT'S INSIDIOUS IN ONSET AND IT'S
3086
1 SLOWLY PROGRESSIVE. I DON'T THINK YOU CAN CALL DEMENTIA
2 STABLE SINCE IT GETS WORSE OVER TIME.
3 A NORMAL ATTENTION SPAN IS TRUE FOR EARLIER DEMENTIA,
4 BUT IT GOES AWAY AS THE DEMENTIA INCREASES. PSYCHOMOTOR
5 ACTIVITY, SAYS SOMETIMES RETARDED OR AGITATED. THAT MAY BE
6 TRUE; IT MAY BE NORMAL. HALLUCINATIONS ARE FREQUENTLY
7 PRESENT IN LEWY BODY DEMENTIA. IT'S A FAIRLY NEWLY
8 DESCRIBED ENTITY THAT MAY NOT BE FAMILIAR TO YOUR WITNESS.
9 SPEECH IS VERY OFTEN AFFECTED AS WE HAVE ATTESTED TO
10 THAT THEY LOSE THE ABILITY TO SPEAK AS THEY GET CLOSER TO
11 DEATH. SLEEPING PATTERNS ARE SERIOUSLY AFFECTED IN DEMENTIA
12 AND ARE ONE OF THE MAJOR REASONS WHY FAMILIES CAN NO LONGER
13 CARE FOR PATIENTS AT HOME. THEY HAVE A DAY/NIGHT REVERSAL
14 AND TEND TO BE UP ALL NIGHT LONG.
15 AND MOOD DISTURBANCES ARE OFTEN NOT MANAGEABLE OR
16 STABLE, AND THAT'S ONE OF THE REASONS YOU HAVE GEROPSYCH
17 UNITS.
18 Q. OKAY. AS TO THE SIGNS OR SYMPTOMS LISTED UNDER
19 DELIRIUM, WOULD YOU AGREE OR DISAGREE WITH THAT?
20 A. I AGREE THAT THEY TEND TO BE ACUTE IN ONSET. THEY MAY
21 BE WIDELY FLUCTUATING IN SEVERITY. THERE MAY OR MAY NOT BE
22 IMPAIRED ATTENTION OR LEVEL OF CONSCIOUSNESS. PSYCHOMOTOR
23 ACTIVITY MAY OR MAY NOT BE IMPAIRED. HALLUCINATIONS MAY OR
24 MAY NOT BE PRESENT. SPEECH MAY OR MAY NOT BE DISORGANIZED.
25 IT MAY BE VERY ORGANIZED AND HAVE NOTHING TO DO WITH
3087
1 RAMBLING, BUT ACTUALLY BE PART OF THE DELIRIOUS PROCESS
2 ITSELF.
3 SLEEP PATTERNS MAY BE DISTURBED, YES. THEY MAY BE
4 INCREASING THEIR SLEEPING. AND MOOD DISTURBANCES -- IT'S
5 VERY DIFFICULT TO TALK ABOUT MOOD DISTURBANCES IN DELIRIUM
6 BECAUSE IT'S HARD TO EVEN INTERPRET A MOOD DISTURBANCE IN A
7 DELIRIOUS PATIENT. THE BEHAVIOR -- THE APPARENT BEHAVIOR IS
8 USUALLY ACUTELY CHANGED IN THE COURSE OF HOURS.
9 Q. OKAY. THANK YOU, DOCTOR, ON THAT.
10 JUST A COUPLE OF QUESTIONS THAT RELATES TO THE
11 PATIENTS. WE PREVIOUSLY WENT OVER MARY CRANE. I WOULD LIKE
12 YOU TO GO OVER WITH ME EACH OF THESE PATIENTS, OTHER THAN
13 MARY CRANE, AND I WANT YOU TO DEFINE FOR ME, IF YOU WILL,
14 THE DATE -- WELL, FIRST OF ALL, LET'S -- YEAH, LET'S TALK
15 ABOUT LYDIA SMITH. I WANT YOU TO DEFINE FOR ME, IF YOU
16 WILL, THE DATE THAT YOU FEEL REPRESENTS THE -- THE ONSET OF
17 THE ACUTE PROBLEM WHICH RESULTED IN THE DYING PROCESS.
18 A. THIS PATIENT WAS SERIOUSLY IMPAIRED AT THE TIME OF HER
19 ADMISSION. HER FUNCTIONAL ASSESSMENT SCALE WAS A 7(B). SHE
20 HAD HAD THE UNINTENTIONAL WEIGHT LOSS. HER PERFORMANCE ON
21 ANOTHER SCORE WAS ABOUT 30 PERCENT OF NORMAL IN TERMS OF
22 WHAT SHE COULD DO FOR HERSELF. SHE WAS UNABLE TO SPEAK.
23 SHE REQUIRED ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING.
24 SO SHE WOULD HAVE UNDER THOSE CRITERIA QUALIFIED AS
25 TERMINALLY ILL FOR HOSPICE CARE HAD SHE BEEN REFERRED TO
3088
1 HOSPICE CARE.
2 Q. I APPRECIATE THAT, DOCTOR. I GUESS I WANTED YOU TO
3 FOCUS -- YOU PREVIOUSLY TESTIFIED THAT ALL FIVE OF THESE
4 PATIENTS WERE QUALIFIED, I THINK, FOR HOSPICE CARE. I JUST
5 WANTED TO FOCUS YOUR ATTENTION AS TO THIS PARTICULAR PATIENT
6 AS TO WHEN YOU THINK SHE BECAME -- OR WHEN THERE WAS
7 EVIDENCE TO SUGGEST SHE WAS IN THE DYING PROCESS.
8 A. WELL, I THINK, YOU KNOW, WHEN YOU SEE THAT IN THE EARLY
9 PART OF JANUARY SHE'S DEMONSTRATING INCREASING SOMNOLENCE
10 AND REDUCED RESPONSIVENESS, THEN BY THE 7TH SHE WAS
11 POSTURING AND HAD DECREASED URINE OUTPUT, IT WOULD BE
12 REASONABLE TO ASSUME THAT SHE HAD AN ACUTE PROBLEM GOING ON
13 AT THAT POINT THAT COULD, IN FACT, RESULT IN HER DEATH, AND
14 IN FACT THE GOALS OF CARE WERE DISCUSSED WITH HER FAMILY AT
15 THAT TIME.
16 IF YOU LOOK AT LYDIA SMITH FROM THE BEGINNING, THIS
17 PATIENT HAS HAD --
18 Q. CAN YOU TELL ME WHEN IT WAS DISCUSSED WITH HER FAMILY?
19 WHAT DATE IT WAS DISCUSSED?
20 A. WELL, YEAH. I CAN FIND IT. THIS LADY HAD HAD A NUMBER
21 OF EPISODES WHERE SHE'D ALMOST DIED PRIOR TO HER ADMISSION
22 TO THIS FACILITY.
23 Q. I APPRECIATE THAT, DOCTOR.
24 A. AND HAD HAD A NUMBER OF TIMES WHERE HER FAMILY HAD HAD
25 DISCUSSIONS ABOUT ADVANCE DIRECTIVES AND GOALS OF CARE.
3089
1 SO --
2 Q. THE -- THE QUESTION I THINK IS, IS DID YOU FORM AN
3 OPINION -- MAYBE I CAN PHRASE IT THIS WAY. DID YOU FORM AN
4 OPINION AS TO A DATE THAT IN HER CARE AT THE GEROPSYCH UNIT
5 THAT YOU FELT LIKE SHE HAD BEGUN THE DYING PROCESS?
6 A. I DON'T EVER FORM THAT OPINION EXCEPT IN RETROSPECT.
7 IT'S PRETTY HARD TO PIN DOWN TO SAY WELL, TODAY I KNOW
8 YOU'RE GOING TO DIE.
9 Q. WELL --
10 A. OR I KNOW YOU'RE GOING TO DIE IN THE NEAR FUTURE.
11 Q. MAYBE IT'S NOT A FAIR QUESTION IN THAT REGARD.
12 A. NO.
13 Q. CAN YOU TELL ME WHEN YOU NOTE THAT SHE STARTS TO
14 DETERIORATE?
15 A. WAS WHEN SHE WAS BEGINNING TO BE MORE SOMNOLENT AND LESS
16 RESPONSIVE. THAT WAS ABOUT --
17 Q. WOULD THAT BE ON THE 5TH?
18 A. BETWEEN THE 5TH AND 7TH, YES.
19 Q. OKAY.
20 A. THERE'S A NOTE OF A DISCUSSION WITH THE DAUGHTER -- WITH
21 TWO SONS AND A DAUGHTER ON 1/7/96, A PHYSICIAN NOTE.
22 Q. YOU DEFINED THAT AS A DAUGHTER?
23 A. TWO SONS AND DAUGHTER. FAMILY DISCUSSION. TWO SONS AND
24 A DAUGHTER. THEY DON'T WANT HER LIFE PROLONGED, BUT ARE
25 READY TO LET HER GO.
3090
1 Q. AND YOU INDICATE THAT SHE WAS -- IT WAS THE DAUGHTER
2 THAT WAS DECLINING ANY FORM OF --
3 A. THERE WERE TWO SONS AND A DAUGHTER IN THAT DISCUSSION.
4 Q. OKAY. THAT WAS ON THE 7TH, RIGHT?
5 A. YES.
6 Q. AND SHE DIED ON THE 8TH?
7 A. UH-HUH.
8 Q. OKAY. DID YOU REVIEW THE MEDICATIONS THAT WERE BEING
9 PROVIDED TO LYDIA SMITH, OTHER THAN THE MORPHINE?
10 A. I LOOKED AT THEM.
11 Q. AND CAN YOU -- ARE YOU -- I HAD PREVIOUSLY ASKED YOU IF
12 YOU'D HAD ANY EXPERIENCE IN THE ADMINISTRATION, I THINK, OF
13 PSYCHOTROPIC DRUGS?
14 A. WE ADMINISTER SOME PSYCHOTROPIC DRUGS --
15 Q. I SEE.
16 A. -- IN PALLIATIVE CARE.
17 Q. IS THAT ON A REGULAR BASIS, DOCTOR?
18 A. MAYBE.
19 Q. DO YOU MONITOR PATIENTS WHO'VE BEEN ADMINISTERED
20 PSYCHOTROPIC DRUGS?
21 A. YES.
22 Q. AND ARE YOU AWARE OF THE SIDE EFFECTS OF THOSE
23 PARTICULAR DRUGS?
24 A. SOME OF THEM. SOME OF THE SIDE EFFECTS I AM.
25 Q. OKAY. CAN YOU TELL US WHAT SOME OF THOSE DRUGS ARE THAT
3091
1 YOU'RE FAMILIAR WITH?
2 A. WHY DON'T YOU ASK ME ABOUT A DRUG AND LET ME TELL YOU
3 WHAT I KNOW ABOUT IT.
4 Q. TRAZODONE.
5 A. TRAZODONE IS USED FOR DEPRESSION IN THE PSYCHO --
6 PSYCHIATRIC WORLD. WE RARELY USE IT IN TERMINALLY ILL
7 PATIENTS, SO I DON'T MONITOR ITS SIDE EFFECTS PERSONALLY
8 VERY OFTEN.
9 Q. HOW ABOUT HALDOL?
10 A. HALDOL WE USE FREQUENTLY FOR ACUTE BRAIN SYNDROME, WHICH
11 IS USUALLY DUE TO METASTATIC DISEASE IN THE BRAIN OR ACUTE
12 METABOLIC DISTURBANCES WHEN THERE'S COMBATIVE OR ERRATIC
13 BEHAVIOR.
14 WE USE DOSES ANYWHERE FROM .5 MILLIGRAMS P.O. OR I.M.
15 TO 5 MILLIGRAMS. IT HAS A WIDE RANGE. WE TITRATE UP
16 RAPIDLY TO EFFECT. AND THE ONE THING THAT WE'RE LOOKING FOR
17 IS EXTRA-PYRAMIDAL SIDE EFFECTS --
18 Q. OKAY.
19 A. -- WHERE THE PATIENTS GETS WHAT LOOKS LIKE PARKINSON'S
20 DISEASE FROM THE DRUG.
21 Q. SO IS HALDOL, ATIVAN -- OR, EXCUSE ME, ATIVAN.
22 A. WE USE A LOT OF ATIVAN.
23 Q. OKAY. IS HALDOL, TRAZODONE, AND ATIVAN, ARE THEY ALL
24 CENTRAL NERVOUS SYSTEM DEPRESSANTS? DO THEY HAVE SIDE
25 EFFECTS?
3092
1 A. THEY'RE ALL PSYCHOTROPIC DRUGS WHICH MEANS THAT THEY
2 HAVE THEIR PRIMARY ACTION IN THE CENTRAL NERVOUS SYSTEM.
3 THEY'RE NOT ALWAYS DEPRESSANT.
4 Q. OKAY.
5 A. SOME OF THE PEOPLE GET AGITATED FROM THEM.
6 Q. WOULD ONE OF THOSE SIDE EFFECTS BE LETHARGY AND
7 SOMNOLENCE?
8 A. IF THEY WERE GIVEN IN VERY, VERY HIGH DOSES AND NOT
9 TITRATED AND MONITORED. YOU WOULD THINK IN A GEROPSYCH
10 HOSPITAL THAT THAT WOULD BE THEIR PARTICULAR AREA OF
11 EXPERTISE. ALL THE STAFF WOULD BE ABLE TO MONITOR THOSE
12 SIDE EFFECTS.
13 Q. IN RESPECT TO JUDITH LARSEN, IN YOUR REPORT I NOTE THAT
14 YOU INDICATE THAT SHE MADE A -- IF YOU COULD REFER TO YOUR
15 REPORT --
16 A. I AM.
17 Q. -- I WOULD APPRECIATE IT.
18 A. THAT'S WHERE THE PHYSICIAN HAD NOTED HER MIRACULOUS
19 RECOVERY ON THE 11TH.
20 Q. OKAY. YOU ALSO REFERENCE THAT ON THE DATE OF THE 11TH
21 THAT MORPHINE WAS GIVEN, ADMINISTERED ON THAT PARTICULAR
22 DATE AT 1830 HOURS.
23 A. YES, AND THAT WAS AN ERROR IN THIS REPORT. WHEN I
24 REVIEWED THE CHART THE MORPHINE WAS ORDERED ON THE 11TH AS A
25 SINGLE DOSE, BUT I MISREAD THE MAR SHEETS DATEWISE AND IT
3093
1 WAS NOT GIVEN THAT DAY.
2 Q. OKAY.
3 A. THERE WAS ANOTHER DOSE GIVEN ON ANOTHER TIME AND I WAS
4 MISREADING THAT AND I APOLOGIZE FOR THAT.
5 Q. DO YOU ATTRIBUTE THE MORPHINE AS POSSIBLY BEING --
6 A. WE SEE THIS IN MY POPULATION OF PATIENTS FREQUENTLY AND
7 THAT'S WHY I THOUGHT IT WAS INTERESTING.
8 Q. OKAY.
9 A. WE CALL IT THE LAZARUS SYNDROME WHERE PEOPLE SEEM TO
10 RISE FROM THE DEAD WHEN THEY'RE COMFORTABLE.
11 Q. SO THAT WAS AN ERROR?
12 A. THAT WAS AN ERROR, SIR.
13 Q. SO YOU DON'T HAVE ANY EXPLANATION AS TO WHY SHE SUDDENLY
14 IMPROVED DURING THAT TIME FRAME?
15 A. I DO NOT.
16 Q. OKAY. AGAIN, THE QUESTION IS WHEN, IN YOUR OPINION, DID
17 THIS PARTICULAR PATIENT BEGIN THE -- AND EVIDENCE THE
18 DOWNWARD TURN?
19 A. AND I THINK WE WENT OVER THAT VERY CAREFULLY EARLIER
20 THAT SHE BEGAN VOMITING ON THE 29TH AND THEN BEGAN HAVING
21 GASTROINTESTINAL BLOOD LOSS AT THAT TIME AND BECAME
22 EXTREMELY UNCOMFORTABLE. WE WENT OVER HER NURSING RECORDS
23 IN SOME DETAIL.
24 Q. APPRECIATE THAT, DOCTOR. I JUST WANTED TO RECONFIRM
25 THAT. SO YOUR TESTIMONY IS THAT THAT PROCESS BEGAN ON ABOUT
3094
1 THE 29TH?
2 A. UH-HUH.
3 Q. ENNIS ALLDREDGE, HE WAS IN THE HOSPITAL -- ADMITTED TO
4 THE HOSPITAL ON THE 10TH; IS THAT CORRECT?
5 A. YES.
6 Q. AND CAN YOU TELL US, DOCTOR, WAS HE, IN YOUR OPINION --
7 AS YOU INDICATED EARLIER, MET THE CRITERIA FOR THE GEROPSYCH
8 UNIT AT THAT TIME, THAT HE WAS TERMINAL BUT WAS NOT -- NOT
9 IN THE DYING PROCESS?
10 A. HE WAS THROWING HIS WHEELCHAIR AT HIS NURSING HOME.
11 Q. OKAY. AND YOU ALSO REVIEWED HIS -- HIS MEDICATIONS; IS
12 THAT CORRECT?
13 A. YES.
14 Q. WHEN WAS IT IN THE PROCESS OF HIS STAY IN THE UNIT THAT
15 YOU NOTICED THE DOWNWARD TURN RELATIVE TO HIS BEGINNING THE
16 DYING PROCESS?
17 A. IN MY REPORT I DIDN'T INDICATE A DATE. HE BEGAN
18 RECEIVING MORPHINE FOR DISCOMFORT ON THE 13TH, AND THAT THE
19 DAY BEFORE I THINK IS WHEN HE HAD THE M.R.I. THAT HE WOULD
20 NOT LAY STILL, SO IT WAS REALLY NOT A VERY GOOD STUDY. THEY
21 WEREN'T SURE ABOUT A NEW C.V.A. AT THAT TIME. HE OBVIOUSLY
22 DIED THE 14TH WHICH WAS, YOU KNOW, THE DAY AFTER HE BEGAN
23 RECEIVING SOME MORPHINE FOR HIS DISCOMFORT.
24 Q. SO THE -- THE 12TH OR THE 13TH WOULD BE --
25 A. RIGHT. RIGHT. YEAH.
3095
1 Q. AND THEN ELLEN ANDERSON, OF COURSE SHE DIED IN 17 HOURS.
2 I GUESS THE QUESTION THERE WOULD BE WAS SHE, IN YOUR
3 OPINION -- I THINK YOU HAD SAID SHE MET THE CRITERIA FOR A
4 HOSPICE CARE PATIENT WHICH WOULD MEAN SIX MONTHS OR MORE; IS
5 THAT CORRECT?
6 A. SIX MONTHS OR LESS.
7 Q. OR LESS. EXCUSE ME. SORRY.
8 MR. WILSON: MAY I HAVE JUST A MINUTE, YOUR HONOR?
9 THE COURT: YES.
10 (WHEREUPON, AT THIS TIME THERE'S AN OFF-THE-RECORD
11 DISCUSSION BETWEEN MR. WILSON AND MS. BARLOW.)
12 MR. WILSON: YOUR HONOR, I HAVE NO FURTHER
13 QUESTIONS OF THIS WITNESS.
14 THE COURT: OKAY. ANY REDIRECT?
15 MR. STIRBA: YES, YOUR HONOR.
16 REDIRECT EXAMINATION
17 BY MR. STIRBA:
18 Q. DOCTOR, YOU WERE ASKED ABOUT HYPOXIA. WHAT IS IT?
19 A. LOW BLOOD OXYGEN LEVELS.
20 Q. AND WHAT RELATIONSHIP DOES HYPOXIA HAVE TO A RESPIRATION
21 RATE OF 2 TO 4?
22 A. THE PATIENT WOULD NOT BE PUTTING ENOUGH AIR IN AND OUT
23 OF THE LUNGS TO REPLENISH THE OXYGEN LEVEL IN THE
24 BLOODSTREAM.
25 Q. AND WHY IS HYPOXIA NOT RELATED TO CHEYNE-STOKES
3096
1 RESPIRATION?
2 A. BECAUSE ONE OF THE CHARACTERISTICS OF CHEYNE-STOKES
3 RESPIRATIONS IS THAT YOU BREATHE FASTER AND DEEPER DURING
4 PART OF THE CYCLE, WHICH WOULD THEN INTRODUCE MORE OXYGEN
5 INTO THE BLOODSTREAM AND TREAT THE HYPOXIA.
6 Q. BASED UPON YOUR REVIEW OF THE RECORDS, DO YOU HAVE AN
7 OPINION AS TO WHEN -- AS TO WHETHER ANY OF THE PATIENTS IN
8 THIS CASE SUSTAINED ANY DECREASED BREATHING AS A RESULT OF
9 IMPROPER USE OF MORPHINE?
10 A. THERE ARE A NUMBER OF NOTES IN ALL THE RECORDS
11 SHOWING -- FROM BOTH PHYSICIAN AND NURSE -- THAT THE
12 PATIENTS' RESPIRATORY RATES WERE NOT DIMINISHED.
13 IN JUDITH LARSEN, AT ONE POINT HER RESPIRATORY RATE WAS
14 DIMINISHED -- WE WENT OVER THAT EARLIER -- AND THEY WITHHELD
15 THE MORPHINE UNTIL IT RETURNED TO NORMAL.
16 Q. BASED UPON --
17 A. SO SHE -- REALLY NONE OF THE PATIENTS SHOWED ANY
18 SIGNIFICANT RESPIRATORY DEPRESSION FROM MORPHINE.
19 Q. BASED UPON YOUR REVIEW OF THE RECORDS, DO YOU HAVE AN
20 OPINION AS TO WHETHER ANY OF THE PATIENTS SUFFERED
21 SLEEPINESS OR A COMA AS A RESULT OF IMPROPER USE OF
22 MORPHINE?
23 A. THE RECORDS SHOW THAT ALL OF THESE PATIENTS HAD IMPAIRED
24 MENTAL STATUS PRIOR TO THE INITIATION OF MORPHINE THERAPY
25 SO THAT THEY WERE ALL ALREADY SEDATED OR NEARING COMA.
3097
1 Q. BASED UPON YOUR REVIEW OF THE RECORDS, DO YOU HAVE AN
2 OPINION AS TO WHAT IF ANY OF THESE PATIENTS SUFFERED LOW
3 BLOOD -- BLOOD PRESSURE AS A RESULT OF IMPROPER USE OF
4 MORPHINE?
5 A. THE SIMILAR -- THE VITAL SIGNS THAT WERE RECORDED WERE
6 SIMILAR TO THE RESPIRATORY RATES. THEY DID NOT SHOW A DROP
7 IN BLOOD PRESSURE UNTIL SHORTLY BEFORE DEATH.
8 Q. AND BASED UPON YOUR REVIEW OF THE RECORDS, DO YOU HAVE
9 AN OPINION AS TO WHETHER ANY OF THESE PATIENTS SUFFERED A
10 DECREASED FOOD OR WATER INTAKE AS A RESULT OF THE IMPROPER
11 ADMINISTRATION OR USE OF MORPHINE?
12 A. MOST OF THESE PATIENTS WERE ALREADY SUFFERING FROM
13 IMPAIRED FOOD AND WATER INTAKE. THE BRIEF AMOUNTS OF TIME
14 THAT THEY WERE ALIVE RECEIVING MORPHINE SHOULD NOT HAVE
15 AFFECTED THEIR LIFE EXPECTANCY FROM THAT STANDPOINT ALONE.
16 SO THAT THE FOOD AND WATER INTAKE IS NOT RELEVANT TO THE --
17 TO THE DEATH.
18 Q. BASED UPON YOUR REVIEW OF THE RECORDS AND YOUR EXPERTISE
19 AS AN END-OF-LIFE CARE PHYSICIAN, DO YOU HAVE AN OPINION AS
20 TO WHETHER OR NOT MORPHINE WAS APPROPRIATELY USED IN THE
21 RECORDS THAT YOU REVIEWED?
22 A. YES. I BELIEVE MORPHINE WAS USED APPROPRIATELY FOR
23 SYMPTOM MANAGEMENT IN THESE PATIENTS.
24 MR. STIRBA: THANK YOU.
25 THAT'S ALL I HAVE, YOUR HONOR.
3098
1 THE COURT: ANYTHING FURTHER? IS THERE ANYTHING
2 FURTHER?
3 MR. WILSON: JUST -- JUST ONE THING, YOUR HONOR.
4 MAYBE I COULD HAVE THIS MARKED AS AN EXHIBIT.
5 RECROSS-EXAMINATION
6 BY MR. WILSON:
7 Q. DOCTOR, I SHOW YOU WHAT'S BEEN MARKED AS STATE'S EXHIBIT
8 NUMBER 43 AND JUST ASK YOU TO TAKE A LOOK AT THAT AND SEE IF
9 YOU CAN IDENTIFY THAT, IF WOULD YOU, PLEASE.
10 A. IT'S A -- THE PAGE ON MORPHINE SULFATE ORAL SOLUTION.
11 Q. FROM THE P.D.R.?
12 A. FROM THE P.D.R., 19 -- PAGE 1936. WHAT YEAR, I DON'T
13 KNOW.
14 Q. CAN YOU TELL ME UNDER THE PHARMACODYNAMIC SECTION AS TO
15 THE -- I THINK WE'VE HIGHLIGHTED SOME SECTIONS THERE,
16 DOCTOR, IF YOU COULD READ THAT HIGHLIGHTED SECTION.
17 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT. IT
18 HASN'T BEEN OFFERED, AND IF IT'S OFFERED, IT'S IRRELEVANT.
19 LACK OF FOUNDATION.
20 MR. WILSON: WELL, I THINK WE SET THE FOUNDATION.
21 IT'S FROM THE PHYSICIAN'S DESK REFERENCE.
22 THE COURT: WELL, NO, YOU STATED IT. THE
23 FOUNDATION HAS TO BE LAID WITH THE WITNESS, IF THE WITNESS
24 IS FAMILIAR WITH IT.
25 MR. WILSON: OKAY.
3099
1 Q. (BY MR. WILSON) ARE YOU FAMILIAR WITH THAT PARTICULAR
2 REFERENCE, DOCTOR?
3 A. WHAT YEAR IS THIS P.D.R.?
4 Q. MAYBE I WILL --
5 A. SHOULD BE ON THE BACK OF THE BINDING.
6 Q. MAYBE I'LL TAKE A LOOK AT THIS AND SEE IF -- LOOKS LIKE
7 IT'S THE 1995 EDITION OF THE P.D.R.
8 A. IT'S ONLY FIVE YEARS OUT OF DATE.
9 Q. PARDON?
10 A. IT'S ONLY FIVE YEARS OUT OF DATE.
11 Q. WELL, THIS WAS THE P.D.R. --
12 A. RIGHT.
13 Q. -- THAT WAS IN EFFECT DURING THIS TIME PERIOD; IS THAT
14 CORRECT?
15 A. IT WOULD HAVE BEEN JUST A YEAR OUT OF DATE BECAUSE THE
16 '96 WOULD HAVE COME OUT WHEN THESE PATIENTS WERE ADMITTED.
17 Q. THE '96 WOULD HAVE --
18 A. YES, I AM FAMILIAR WITH THIS.
19 Q. SO -- SO WHAT YOU'RE SAYING IS IS THAT THIS P.D.R. IS
20 OUT OF DATE?
21 A. YES, SIR.
22 Q. AND IT WOULD HAVE BEEN THE -- THE P.D.R. IN EFFECT IN
23 DECEMBER OF 1995, WOULD IT NOT?
24 A. YES, IT WOULD.
25 Q. OKAY. AND IT WOULD HAVE BEEN STILL IN EFFECT THROUGH
3100
1 THE FIRST PART OF '96; IS THAT CORRECT?
2 A. NO. THE '96 WOULD HAVE COME OUT IN JANUARY.
3 Q. I SEE. JANUARY 1ST?
4 A. IT VARIES.
5 Q. NEVER MIND, DOCTOR. I'LL WITHDRAW THE QUESTION.
6 MR. WILSON: I HAVE NO FURTHER QUESTIONS, YOUR
7 HONOR.
8 THE COURT: OKAY. MAY THIS WITNESS BE EXCUSED?
9 MR. STIRBA: YES, YOUR HONOR.
10 THE WITNESS: THIS IS MARKED AS AN EXHIBIT.
11 (TENDERS DOCUMENT TO THE COURT.)
12 THE COURT: OKAY. LADIES AND GENTLEMEN, WE'LL TAKE
13 OUR LUNCH BREAK NOW. DURING THIS TIME REMEMBER IT'S YOUR
14 DUTY NOT TO CONVERSE AMONG YOURSELVES OR WITH ANYONE ELSE OR
15 ALLOW YOURSELVES TO BE ADDRESSED BY ANY OTHER PERSON ON THE
16 SUBJECT OF THE TRIAL.
17 IT'S YOUR DUTY NOT TO FORM OR EXPRESS AN OPINION UNTIL
18 THE CASE IS FINALLY SUBMITTED TO YOU. REMEMBER AS YOU DRIVE
19 IN CARS NOT TO LISTEN TO RADIO OR TELEVISION NEWS REPORTS
20 ABOUT THIS TRIAL OR READ ABOUT IT IN THE NEWSPAPER OR ANY
21 MAGAZINES.
22 WE'LL COME BACK AT 2 O'CLOCK.
23 (WHEREUPON, AT THIS TIME THE JURY LEAVES THE
24 COURTROOM.)
25 THE COURT: OKAY. IS THERE ANYTHING ELSE THAT WE
3101
1 NEED TO DISCUSS BEFORE WE COME BACK AT 2:00?
2 MR. STIRBA: I HAVE NOTHING, JUDGE.
3 THE COURT: OKAY. ALL RIGHT. THEN WE'LL SEE YOU
4 AT 2 O'CLOCK.
5 MR. STIRBA: THANK YOU.
6 (WHEREUPON, THE MORNING SESSION ENDS.)
7
8
9
10
11
12
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3102
1 (WHEREUPON, THE AFTERNOON SESSION BEGINS.)
2 THE COURT: WILL YOU PLEASE BE SEATED? OKAY. THE
3 RECORD WILL REFLECT THAT EVERYONE IS BACK IN THE COURTROOM.
4 WOULD YOU LIKE TO CALL YOUR NEXT WITNESS.
5 MR. STIRBA: YES, YOUR HONOR. WE WOULD CALL LAURIE
6 STEVENSON TO THE STAND.
7 THE COURT: OKAY. IF YOU'D PLEASE COME FORWARD AND
8 BE SWORN.
9 LAURIE STEVENSON,
10 CALLED AS A WITNESS, BEING FIRST DULY SWORN,
11 WAS EXAMINED AND TESTIFIED AS FOLLOWS:
12 DIRECT EXAMINATION
13 BY MR. STIRBA:
14 Q. MISS STEVENSON, WOULD YOU PLEASE STATE YOUR FULL NAME
15 AND SPELL YOUR LAST NAME?
16 A. IT'S LAURIE ELLEN STEVENSON. S-T-E-V-E-N-S-O-N.
17 Q. AND CALLING YOUR ATTENTION TO THE TIME PERIOD OF
18 DECEMBER OF 1995 AND JANUARY 1996, DID YOU GO BY ANOTHER
19 NAME?
20 A. YES, I DID.
21 Q. AND WHAT WAS THAT NAME?
22 A. THAT WAS LAURIE ELLEN WILLSON.
23 Q. NOW YOU ARE MRS. STEVENSON, IS THAT RIGHT?
24 A. YES, I AM.
25 Q. ARE YOU PRESENTLY EMPLOYED?
3103
1 A. YES, I AM.
2 Q. AND WHERE ARE YOU EMPLOYED?
3 A. I WORK FOR THE VETERANS' AFFAIRS MEDICAL CENTER IN
4 WILKES-BARRE, PENNSYLVANIA.
5 Q. WE HAVE THE MACHINE ON, SO YOU'RE GONNA HAVE TO TRY TO
6 KEEP YOUR VOICE UP IF YOU COULD PLEASE.
7 AND WHAT DO YOU DO FOR THE VETERANS' ADMINISTRATION IN
8 WILKES-BARRE, PENNSYLVANIA?
9 A. I AM A CERTIFIED REGISTERED NURSE PRACTITIONER.
10 Q. AND WHAT QUALIFICATIONS DO YOU HAVE SUCH THAT YOU ARE A
11 CERTIFICATED NURSE PRACTITIONER?
12 A. I HAVE A MASTER'S DEGREE IN NURSING WITH A SPECIALTY IN
13 GERIATRICS AND ADULT MEDICINE.
14 Q. AND EXPLAIN TO US PLEASE WHAT EDUCATION YOU'VE HAD IN
15 THE FIELD OF GERIATRICS.
16 A. I STUDIED AT THE UNIVERSITY OF UTAH FOR A MASTER'S
17 DEGREE IN GERIATRIC MEDICINE AS A NURSE PRACTITIONER IT'S A
18 TWO-YEAR ADVANCED DEGREE BEYOND THE BACHELOR'S LEVEL, WHICH
19 PREVIOUS I HELD IN NURSING.
20 Q. AND IS THERE A DIFFERENCE BETWEEN A REGISTERED NURSE AND
21 A NURSE PRACTITIONER?
22 A. YES, THERE IS. NURSE PRACTITIONERS IN THE STATE OF UTAH
23 ARE LICENSED TO PRESCRIBE INDEPENDENTLY OF A PHYSICIAN AND
24 HOLD AN INDEPENDENT LICENSE TO PRACTICE AS A NURSE
25 PRACTITIONER PRIMARY CARE PROVIDER IN THE STATE.
3104
1 Q. AND DO YOU HAVE A LICENSE AS A NURSE PRACTITIONER?
2 A. YES, I DO.
3 Q. AND WHICH STATE DO YOU HOLD THAT LICENSE IN?
4 A. IN UTAH.
5 Q. HOW LONG -- LET ME DIRECT YOUR ATTENTION TO THE PERIOD
6 OF DECEMBER OF 1995 AND JANUARY 1996. WERE YOU EMPLOYED AT
7 THAT TIME?
8 A. YES, I WAS.
9 Q. AND WHERE WERE YOU EMPLOYED?
10 A. AT THE HOSPITAL MEDICAL CENTER.
11 Q. AND SPECIFICALLY, WERE YOU WORKING AT A PARTICULAR UNIT
12 AT THAT TIME?
13 A. AT THE GEROPSYCHIATRIC UNIT OF THE HOSPITAL.
14 Q. NOW, PRIOR TO YOUR EMPLOYMENT AT THE DAVIS HOSPITAL, HAD
15 YOU PREVIOUSLY BEEN EMPLOYED IN THE FIELD OF NURSING?
16 A. YES.
17 Q. AND COULD YOU TELL US PLEASE WHAT POSITIONS YOU HELD
18 PRIOR TO THE POSITION AT THE DAVIS HOSPITAL?
19 A. PREVIOUS TO THAT I WAS AT BENCHMARK HOSPITAL AS NURSE
20 MANAGER OF THE GEROPSYCHIATRIC OUTPATIENT UNIT FOR PROBABLY
21 A YEAR. PREVIOUS TO THAT I WAS A NURSE AT THE UNIVERSITY OF
22 UTAH FOR SEVERAL YEARS. PREVIOUS TO THAT I WAS A NURSE IN
23 SEVERAL DIFFERENT FACILITIES IN BOSTON, MASSACHUSETTS, IN
24 PSYCHIATRY AND GERIATRICS ALTERNATIVELY, SEVERAL DIFFERENT
25 YEARS. I'VE BEEN A NURSE NOW FOR -- SINCE 1985.
3105
1 Q. AND IN TERMS OF YOUR EDUCATION IN THE FIELD OF NURSING,
2 COULD YOU TELL US PLEASE WHAT EDUCATION YOU HAVE HAD?
3 A. I STARTED FIRST AS A DIPLOMA NURSE, WHICH I DON'T THINK
4 THEY HAVE ANYMORE. I STUDIED AT THE HOSPITAL SCHOOL OF
5 NURSING IN BOSTON --
6 Q. WHAT KIND OF NURSING IS THAT?
7 A. DIPLOMA NURSE.
8 Q. AND WHAT IS A DIPLOMA NURSE?
9 A. A DIPLOMA NURSE IS A NURSE WHO'S STUDIED THE FIELD OF
10 NURSING WITHIN A HOSPITAL SETTING, NOT AT A UNIVERSITY.
11 THAT'S A THREE-YEAR DIPLOMA, NOT A DEGREE. AND THAT WAS
12 FROM THE NEW ENGLAND DEACONESS HOSPITAL SCHOOL OF NURSING,
13 MASSACHUSETTS. AFTER THAT, I RETURNED TO SCHOOL, GOT MY
14 BACHELOR'S DEGREE FROM NORTHEASTERN UNIVERSITY IN BOSTON,
15 AND TOOK ABOUT A YEAR OFF AND THEN WENT TO THE UNIVERSITY OF
16 UTAH FOR MY MASTER'S DEGREE.
17 Q. DID YOU HAVE THE MASTER'S DEGREE AT THE TIME THAT YOU
18 WERE EMPLOYED AT THE DAVIS HOSPITAL?
19 A. YEAH, I COMPLETED MY MASTER'S THESIS AT THAT TIME.
20 Q. AND GENERALLY, WHAT DOES A MASTER'S DEGREE IN NURSING
21 ENTAIL?
22 A. IT ENTAILS AT LEAST TWO YEARS OF ADVANCED EDUCATION IN
23 THE SPECIALTY OF NURSING AND IN THE SPECIALTY FIELD IN WHICH
24 YOU INTEND TO PRACTICE WHICH IN MY CASE WAS GERIATRIC
25 MEDICINE. IT REQUIRES A THESIS TO BE WRITTEN AND PRESENTED
3106
1 AND PUBLISHED AS PART OF THAT DEGREE. SO IT'S AN EXTENSIVE
2 PROCESS.
3 Q. DID YOU WRITE SUCH A THESIS?
4 A. YES, I DID.
5 Q. AND WHAT WAS YOUR THESIS ON?
6 A. NURSES' IDENTIFICATION OF DRUG INDUCED MOVEMENT DISORDER
7 IN THE ELDERLY.
8 Q. NOW, AT THE TIME THAT YOU WERE EMPLOYED AT THE DAVIS
9 HOSPITAL, YOU WERE WORKING AT -- ON THE GEROPSYCHIATRIC WARD
10 OR UNIT, HOW LONG HAD YOU ACTUALLY WORKED FROM -- AT THE
11 DAVIS HOSPITAL BEFORE YOU WERE EMPLOYED ON THE UNIT? OR
12 WHEN DID YOU FIRST START?
13 A. I'M SORRY, I LOST TRACK OF THAT QUESTION.
14 Q. WHEN DID YOU FIRST START WORK AT THE DAVIS HOSPITAL?
15 A. '95, SOMEWHERE LIKE THAT.
16 Q. AND WERE YOU INITIALLY EMPLOYED ON THE GEROPSYCHIATRIC
17 UNIT?
18 A. YES.
19 Q. AND GENERALLY, WHAT KIND OF PATIENT DID YOU SEE ON THAT
20 UNIT THAT YOU CARED FOR?
21 A. THEY WERE ELDERLY PATIENTS WITH BOTH MEDICAL AND
22 PSYCHIATRIC PROBLEMS CONCOMITANTLY. COMMON DIAGNOSIS OF
23 DEPRESSION, DEMENTIA, DELIRIUM, ANXIETY DISORDERS, AND
24 CHRONIC ILLNESSES ASSOCIATED WITH THEIR AGE AND CONDITION.
25 Q. AND GENERALLY, WHAT KIND OF CARE DID YOU PROVIDE IN
3107
1 TERMS OF YOUR EMPLOYMENT THERE?
2 A. THAT I GUESS WOULD DEPEND ON THE PATIENT. NURSING CARE
3 IS INDIVIDUALIZED TO THE NEEDS OF THE PATIENT, DEPENDING ON
4 THEIR DIAGNOSIS AND THE SYMPTOMS THAT THEY PRESENT. FOR
5 PATIENTS WHO ARE PRIMARILY ILL IN A PSYCHIATRIC WAY, WE
6 PROVIDED GROUP INTERVENTION, ONE-TO-ONE TIME WITH THE
7 PATIENT. MEDICATIONS WHEN APPROPRIATE. FOR THOSE WHO ARE
8 MEDICALLY SICK, WE TOOK CARE OF THEIR MEDICAL NEEDS FROM A
9 NURSING STANDPOINT IN TERMS OF WHATEVER CONDITION THEY WERE
10 PRESENTING TO US.
11 Q. WERE THERE PARTICULAR TIMES THAT YOU WORKED DURING THE
12 DAY, DURING THE PERIOD OF DECEMBER OF 1995 TO THE BEGINNING
13 PART OF JANUARY 1996?
14 A. PARTICULAR TIMES DURING THE --
15 Q. YES. IN OTHER WORDS, WAS THERE A PARTICULAR SHIFT THAT
16 YOU WORKED?
17 A. PRIMARILY, EVENINGS OR NIGHT SHIFT. MOST OF THAT TIME,
18 I THINK ON THE NIGHT SHIFT, 11:00 TO 7:00.
19 Q. 11:00 TO 7:00?
20 A. 11:00 P.M. TO 7:00 A.M., YEAH.
21 Q. AND WERE YOUR RESPONSIBILITIES WORKING 11:00 TO 7:00
22 DIFFERENT THAN THE RESPONSIBILITIES OF SOMEBODY WHO WOULD BE
23 WORKING ON ANOTHER SHIFT?
24 A. I WOULD SAY THE CARE GIVEN IS MORE FOCUSSED TO THOSE
25 PATIENTS WHO ARE MORE ACUTELY ILL. MANY OF THEM WHO WERE
3108
1 NOT AS ACUTELY ILL WOULD HAVE SLEPT THROUGH THE NIGHT. AND
2 MY RESPONSIBILITY THEN WOULD JUST TO BE SURE THAT THEY WERE
3 SAFE. THOSE PATIENTS WHO WERE SICK AND AWAKE WOULD REQUIRE
4 MORE OF MY TIME AND ATTENTION. AND ANYBODY WHO WAS ACUTELY
5 ILL WOULD GET FREQUENT VITAL SIGNS, FREQUENT VISITS FROM
6 MYSELF. VIOLENT BEHAVIOR, AGITATED BEHAVIOR WOULD HAVE TO
7 BE DEALT WITH APPROPRIATELY AS NEEDED.
8 Q. NOW, THIS CASE INVOLVES FIVE PATIENTS WHO RECEIVED CARE
9 AT THE DAVIS HOSPITAL DURING THE PERTINENT TIME PERIOD,
10 DECEMBER OF '95 THROUGH JANUARY OF '96. HAVE YOU HAD A
11 CHANCE TO REVIEW SOME RECORDS RELATING TO THOSE FIVE
12 PATIENTS?
13 A. YES, I HAVE.
14 Q. AND JUST GENERALLY, WHAT RECORDS HAVE YOU REVIEWED?
15 A. THE NAMES OF THE PATIENTS?
16 Q. THE RECORDS, WHAT RECORDS HAVE YOU REVIEWED?
17 A. OH, THE MEDICAL RECORD INCLUDING MY NURSE'S NOTES. AND
18 MEDICATION ADMINISTRATION RECORDS, DOCTORS' ORDERS, THE
19 TRANSCRIBED PROGRESS NOTES THAT I HAD WRITTEN, WEEKLY
20 ADVOCATE NOTES THAT I HAD WRITTEN, THAT SORT OF THING.
21 Q. IS -- YOU KNOW THE NAMES OF THE PATIENTS. IS THERE A
22 PARTICULAR RECOLLECTION YOU HAVE OF ANY ONE OF THEM?
23 A. NO, NOT PARTICULARLY, OTHER THAN A VAGUE RECOLLECTION OF
24 MR. ENNIS ALLDREDGE.
25 Q. AND WHAT IS YOUR RECOLLECTION OF HIM?
3109
1 A. I RECALL HIM BEING PROFOUNDLY ILL AT THE TIME THAT I WAS
2 TAKING CARE OF HIM IN A MEDICAL SENSE. HE HAD A TERMINAL
3 MEDICAL DIAGNOSIS, AS I RECALL. AND I REMEMBER HIM BEING
4 QUITE ILL AT THE TIME.
5 Q. DO YOU HAVE A RECOLLECTION OF LYDIA SMITH?
6 A. LYDIA SMITH IS SOMEONE I RECOLLECT FROM A PREVIOUS PLACE
7 OF EMPLOYMENT. SHE WAS A PATIENT OF MINE IN THE OUTPATIENT
8 PROGRAM THAT I WORKED IN PREVIOUSLY TO DAVIS HOSPITAL. SO
9 MOST OF MY MEMORIES ABOUT WHO LYDIA COME FROM THAT
10 EXPERIENCE. I DO RECALL THAT SHE WAS ADMITTED TO DAVIS AND
11 I TOOK CARE OF HER, BUT I HAVE NO SPECIFIC MEMORIES OF DOING
12 SO.
13 Q. WHERE WERE YOU EMPLOYED AT THE TIME THAT YOU HAD
14 PREVIOUSLY TAKEN CARE OF LYDIA?
15 A. IN A PROGRAM CALLED THE ENCORE PROGRAM, A
16 GEROPSYCHIATRIC OUTPATIENT DAY TREATMENT KIND OF A PROGRAM
17 AT -- IN WOODS CROSS, BENCHMARK HOSPITAL, WAS THE PROGRAM.
18 Q. BASED UPON YOUR EXPERIENCE WITH HER AND YOUR CARE
19 PREVIOUS TO THE TIME THAT SHE WAS ADMITTED TO THE
20 GEROPSYCHIATRIC UNIT, WERE YOU ABLE TO OBSERVE A CHANGE IN
21 HER BEHAVIOR OR HER CONDITION BETWEEN THE TIME YOU CARED FOR
22 HER IN THE FIRST SETTING AND WHEN SHE WAS ON THE DAVIS UNIT?
23 A. HER ILLNESS HAD PROGRESSED MARKEDLY. HER DEMENTIA WAS
24 PROFOUND AT THE TIME THAT SHE WAS READMITTED TO DAVIS
25 HOSPITAL. SHE AT THE TIME THAT I CARED FOR HER IN
3110
1 OUTPATIENT WAS VERY DEMENTED AND NOT FULLY ABLE TO CARE FOR
2 HERSELF. BY THE TIME SHE WAS AT DAVIS HOSPITAL, SHE WAS
3 PRETTY MUCH DEPENDING ON NURSING FOR ALL OF HER NEEDS.
4 Q. 0YOU HAVE SOME BINDERS IN FRONT OF YOU, MISS STEVENSON,
5 AND THOSE ARE EXHIBITS IN THIS CASE. AND WE'RE GONNA GO
6 THROUGH SOME OF YOUR NURSING NOTES. IT MAY BE HELPFUL TO
7 REFER TO THE BINDERS. THE FIRST BINDER I WANT YOU TO HAVE
8 IN FRONT OF YOU IS A BINDER INVOLVING ELLEN ANDERSON. DO
9 YOU HAVE THAT IN FRONT OF YOU?
10 A. YES, I DO.
11 Q. SPECIFICALLY, IF YOU WOULD TURN TO -- AND THERE'S LITTLE
12 NUMBERS DOWN AT THE BOTTOM OF EACH PAGE. IF WOULD YOU TURN
13 TO MED-170 PLEASE.
14 A. OKAY.
15 Q. NOW, DO YOU RECOGNIZE YOUR WRITING ON THAT PARTICULAR
16 DOCUMENT?
17 A. YES, I DO.
18 Q. AND GENERALLY TELL US PLEASE WHAT THAT DOCUMENT IS.
19 A. THOSE ARE THIS PATIENT'S ADMITTING ORDERS TO THE
20 GEROPSYCHIATRIC UNIT.
21 Q. AND WHAT HAVE YOU WRITTEN IN A GENERAL WAY ON THAT
22 PARTICULAR DOCUMENT?
23 A. I'VE -- DESCRIPTION OF HER CONDITION, HER DIAGNOSIS,
24 LABORATORY TESTING THAT NEEDS TO BE DONE, ANY TREATMENTS
25 THAT NEED TO BE DONE, A LIST OF HER ALLERGIES, THE CURRENT
3111
1 MEDICATIONS THAT SHE'LL BE RECEIVING, AND A NOTATION THAT I
2 TRANSCRIBED THOSE ORDERS.
3 Q. NOW, FOR EXAMPLE, I NOTICE AT THE TOP THERE'S A
4 CONDITION, AND THEN IT SAYS, COLON, POOR. DO YOU SEE THAT?
5 A. YES, I DO.
6 Q. AND WAS THAT AN ASSESSMENT YOU MADE AT THE TIME OF HER
7 ADMISSION?
8 A. YES.
9 Q. AND WHAT DO YOU MEAN BY CONDITION POOR?
10 A. THAT THE PATIENT A THE TIME WAS SERIOUSLY ILL.
11 Q. AND THEN I NOTICE -- HAVE TO MOVE THIS DOWN ON THE
12 MACHINE -- AS WE GO DOWN INTO THE MEDS, DO YOU SEE THAT
13 SECTION?
14 A. YES, I DO.
15 Q. AND THOSE ARE MEDICATIONS THEN THAT YOU LIST THAT WERE
16 ORDERED FOR HER?
17 A. YES.
18 Q. DOWN TOWARDS THE BOTTOM, THERE IS YOUR SIGNATURE, IS
19 THERE NOT?
20 A. YES.
21 Q. AND IN FACT, YOUR SIGNATURE APPEARS UNDER PRINTING WHICH
22 SAYS DR. WEITZEL, CORRECT?
23 A. RIGHT, IN TWO PLACES.
24 Q. AND THEN THERE'S A T.O. DO YOU SEE THAT?
25 A. YES.
3112
1 Q. AND WHAT DOES THE T.O. STAND FOR?
2 A. T.O. REFERS TO TELEPHONE ORDER.
3 Q. AND THEN WHERE YOU SIGNED IT THE SECOND TIME -- AND BY
4 THE WAY, I NOTICE IT SAYS R.N., S. -- M.S.W.
5 A. M.S.N., MASTER OF SCIENCE IN NURSING.
6 Q. M.S.N. AND YOU -- THE WORD NOTED APPEARS.
7 A. UH-HUH.
8 Q. TELL US PLEASE WHAT NOTED MEANS IN THAT CONTEXT.
9 A. NOTED MEANS THAT I TOOK THOSE ORDERS FROM THE ORDER
10 SHEET AND THEN TRANSCRIBED THEM INTO THE MEDICATION
11 ADMINISTRATION RECORD, VERIFIED THEM APPROPRIATELY, PUT THEM
12 IN THE CARDEX THAT LISTS THE MEDICATIONS THAT WOULD BE
13 GIVEN, ANY OF THE TREATMENTS THAT WOULD BE GIVEN, AND WHAT
14 HER CONDITION WAS. THERE ARE VARIOUS PLACES THAT THAT
15 INFORMATION BELONGS IN THE RECORD.
16 Q. AND THEN YOU HAVE INDICATED 12/29/95 AND A TIME, 2130.
17 IS THAT THE TIME WHEN YOU WOULD HAVE NOTED OR TRANSCRIBED
18 THE ORDER?
19 A. YES.
20 Q. IS THAT TIME THE SAME TIME WHEN YOU WOULD HAVE ACTUALLY
21 RECEIVED THE ORDER?
22 A. NO, NOT NECESSARILY.
23 Q. CAN YOU TELL BY LOOKING AT THIS DOCUMENT WHEN YOU
24 ACTUALLY RECEIVED THE ORDER?
25 A. NO.
3113
1 Q. CAN YOU EXPLAIN THE RELATIONSHIP BETWEEN THE
2 SIGNIFICANCE OF THE TIME NOTED AND WHEN YOU IN FACT RECEIVED
3 THE ORDER, SO THAT WE UNDERSTAND?
4 A. BEING PROBABLY MAYBE ONE OF ONLY TWO NURSES WORKING THAT
5 SHIFT, AND GIVEN THE CONDITION OF THE PATIENT NOTED AS POOR,
6 AND HEAVEN KNOWS WHO ELSE IN THE HOSPITAL AT THE TIME BEING
7 ILL AND REQUIRING MY ATTENTION, TRANSCRIBING AN ORDER WOULD
8 NOT BE ON THE TOP OF MY PRIORITY LIST. CARE OF THE PATIENT
9 COMES FIRST. PAPERWORK COMES AFTER CARE OF THE PATIENT. SO
10 ANY -- ANYTHING ON THE LIST THAT SAYS, DO IT NOW, WOULD HAVE
11 BEEN DONE FIRST PROBABLY BEFORE ANY OF THIS WAS TRANSCRIBED
12 INTO OTHER PARTS OF THE RECORD.
13 Q. DO YOU KNOW THE TIME OF THE SHIFT THAT YOU WERE WORKING
14 THIS DAY? BASED UPON WHAT YOU HAVE IN FRONT OF YOU?
15 A. SINCE IT WAS NOTED AT 2130, THAT WOULD BE 9:30 P.M, THEN
16 I WOULD HAVE BEEN WORKING THE 3:00 TO 11:00 SHIFT ON THAT
17 DAY.
18 Q. AND CAN YOU TELL US AT ANY TIME DURING THAT SHIFT WHEN
19 YOU WOULD HAVE RECEIVED THIS ORDER?
20 A. I CAN'T TELL BY THE RECORD WHEN THAT WOULD HAVE BEEN.
21 Q. DO YOU KNOW IF DR. WEITZEL SAW ELLEN ANDERSON DURING
22 YOUR SHIFT?
23 A. I HAVE NO MEMORY OF HIM SEEING HER; HOWEVER, HE HAS
24 SIGNED OFF MY NOTE AND DATED IT, MY ORDERS AND DATED IT, SO
25 I ASSUME THAT HE SAW HER ON THAT DAY.
3114
1 Q. PARDON ME?
2 A. I ASSUME THAT HE SAW HER ON THAT DAY.
3 Q. AND YOU'VE REFERRING TO -- WHEN YOU SAY HE SIGNED OFF ON
4 IT, IS THIS WHAT YOU'RE REFERRING TO, THE SIGNATURE ACROSS
5 FROM DR. WEITZEL --
6 A. YES.
7 Q. -- IMPRINTED?
8 A. YES.
9 Q. AND WHAT IS THE SIGNIFICANCE OF THE PHYSICIAN SIGNING
10 OFF ON THE ORDER?
11 A. IT MEANS THAT HE REVIEWED THE ORDERS AND THAT AGREES
12 WITH WHAT HE TOLD ME ON THE PHONE.
13 Q. NOW, IF YOU COULD TURN PLEASE TO 188.
14 A. OKAY.
15 Q. DO YOU RECOGNIZE YOUR SIGNATURE ON THAT DOCUMENT?
16 A. YES, I DO.
17 Q. AND THAT'S ACROSS WHERE IT SAYS R.N. SIGNATURE?
18 A. YES.
19 Q. DO YOU KNOW WHY YOU AFFIXED YOUR SIGNATURE THERE ON THAT
20 DOCUMENT?
21 A. BECAUSE I WAS THE ONE WHO COMPLETED THE ASSESSMENT.
22 Q. AND WHAT IS THE ASSESSMENT YOU'RE REFERRING TO?
23 A. IT IS A COMPREHENSIVE NURSING ASSESSMENT OF THE PATIENT
24 THAT IS DONE ON ADMISSION TO THE HOSPITAL.
25 Q. AND TELL US PLEASE WHAT THE PURPOSE OF THE ASSESSMENT
3115
1 WAS.
2 A. IT WAS TO GIVE A COMPREHENSIVE VIEW FROM A NURSING
3 PERSPECTIVE OF THE NEEDS OF THE PATIENT AND THEIR CONDITION
4 AT THE TIME THAT THEY ARRIVED.
5 Q. AND HOW WAS IT THAT YOU ACQUIRED THE INFORMATION WHICH
6 IS CONTAINED ON THE ASSESSMENT?
7 A. I WOULD HAVE DONE SO BY INTERVIEWING THE PATIENT AND ANY
8 FAMILY MEMBERS OR OTHER SIGNIFICANT PERSONS TO THAT PATIENT
9 WHO WERE PRESENT AT THE TIME.
10 Q. ON THIS PARTICULAR DOCUMENT, 188, IT SAYS TEACH PAIN
11 MANAGEMENT INTERVENTIONS UNDER EDUCATION. DO YOU SEE THAT?
12 A. YES, I DO.
13 Q. IS THAT IN YOUR WRITING?
14 A. YES, IT IS.
15 Q. COULD YOU TELL US PLEASE WHY YOU WOULD HAVE WRITTEN
16 TEACH PAIN MANAGEMENT INTERVENTIONS AT THAT TIME?
17 A. THAT IS A REFERENCE TO EDUCATION NEEDED TO THE PATIENT
18 AND/OR THE FAMILY. AND CERTAINLY, IT IS THE JOB OF THE
19 NURSE TO PROVIDE ANY INFORMATION TO THE FAMILY THAT THEY CAN
20 DO REASONABLY WITHIN THEIR OWN POWER TO HELP THE PATIENT TO
21 BE MORE COMFORTABLE. OBVIOUSLY, IF I HAD WRITTEN THAT, IT
22 WOULD SAY THAT IN MY IMPRESSION, THE PATIENT WAS HAVING PAIN
23 AND THAT THE PATIENT WOULD BENEFIT FROM FAMILY MEMBERS
24 KNOWING HOW TO HELP THEM FEEL BETTER.
25 Q. BASED UPON YOUR REVIEW OF THIS FILE, CAN YOU TELL US WHY
3116
1 YOU HAD SUCH AN IMPRESSION THAT THE PATIENT WAS IN PAIN?
2 A. I'D HAVE TO GO BACK AND LOOK, IS THAT -- I HAVE
3 DOCUMENTATION THAT SHE'S MOANING AND CRYING. THERE'S
4 DOCUMENTATION THAT SHE HAS HAD MULTIPLE FRACTURES, WRIST
5 FRACTURE, HIP FRACTURE, PROBLEMS WITH BONES AND JOINTS,
6 HISTORY OF BACK PAIN AND SPINAL FRACTURE, ALL DOCUMENTED BY
7 ME IN THIS SAME DOCUMENT THAT WE'RE READING RIGHT NOW.
8 Q. NEXT IF YOU COULD TURN TO 190 CONCERNING PATIENT ELLEN
9 ANDERSON. DO YOU HAVE THAT IN FRONT OF YOU?
10 A. YES.
11 Q. AND WHAT IS THAT THAT IS CHARTED THERE?
12 A. THAT IS A NURSING PROGRESS NOTE.
13 Q. AND WHO WROTE THAT NOTE?
14 A. I DID.
15 Q. AND WHAT'S THE DATE OF THE NOTE?
16 A. LOOKS LIKE 12/29/95.
17 Q. IF YOU SKIP DOWN FROM HERE TOWARDS THE BOTTOM, YOU SEE
18 IT SAYS -- OR IN THE MIDDLE RATHER, YOU SEE MED NOTE, DO YOU
19 SEE THAT?
20 A. YES.
21 Q. WHAT IS A MED NOTE?
22 A. ENTRIES IN THE MARGIN OF A NOTE WERE PUT THERE BY
23 NURSING CONSISTENTLY IN THE HOSPITAL TO DOCUMENT PATIENT'S
24 RESPONSE TO MEDICATIONS THAT WERE GIVEN AS A MEASURE OF
25 MONITORING OURSELVES DOING THAT BEHAVIOR AS NURSES.
3117
1 Q. AND COULD YOU EXPLAIN TO US WHAT DOCUMENTATION YOU HAD
2 REFLECTED THERE CONCERNING THE MEDICATION GIVEN?
3 A. OKAY. IT SAYS THAT I GAVE MORPHINE 10 MILLIGRAMS I.M.
4 AND AT 2000, WHICH WOULD BE 10:00 O'CLOCK, FOR SEVERE PAIN.
5 PATIENT BECOMES RIGID AND SCREAMS WHEN TOUCHED. RELATED HER
6 PROFOUND OSTEOPOROSIS. GIVEN PER ORDER DR. WEITZEL.
7 Q. IT SAYS FOR SEVERE PAIN. DID YOU ASSESS AT THAT TIME
8 THAT A PATIENT ELLEN ANDERSON WAS IN SEVERE PAIN?
9 A. YES, I DID.
10 Q. AND COULD YOU TELL US PLEASE THE BASIS FOR YOUR
11 ASSESSMENT?
12 A. IT'S DOCUMENTED AS PATIENT IS RIGID AND SCREAMING WHEN
13 TOUCHED. THAT IS A VERY COMMON RESPONSE TO SEVERE PAIN.
14 MODERATE PAIN PATIENTS DON'T SCREAM. SEVERE PAIN PATIENTS
15 WILL SCREAM.
16 Q. NOW, YOU HAVE AN R. DO YOU SEE THAT UNDER -- DOES THAT
17 STAND FOR RESPONSE?
18 A. RESPONSE.
19 Q. AND IT SAYS PATIENT CALMER TWO HOURS. IS THAT PAST
20 MORPHINE INJECTION?
21 A. TWO HOURS AFTER MORPHINE INFECTION, YES.
22 Q. AND THEN IF YOU GO DOWN TO WHERE IT SAYS P., DOES THAT
23 STAND FOR PLAN?
24 A. YES.
25 Q. AND IT SAYS PLEASE SEE MASTER -- T.X. STANDS FOR
3118
1 TREATMENT?
2 A. TREATMENT PLAN.
3 Q. TELL US PLEASE WHAT -- WHAT IS A TREATMENT PLAN?
4 A. A TREATMENT PLAN IN REFERENCE TO A NURSING -- NURSE
5 HAVING WRITTEN IT IS A NURSING TREATMENT PLAN WHICH
6 DOCUMENTS THE NURSING CARE THAT WILL BE GIVEN OR IS BEING
7 GIVEN TO THE PATIENT AT THE TIME. IT IS A DOCUMENT THAT
8 REMAINS IN THE CHART FOR THE REFERENCE OF ALL THE NURSES
9 CARING FOR THE PATIENT, NOT JUST THE NURSE WHO WROTE THE
10 TREATMENT PLAN. IT INCLUDES INTERVENTIONS CARRIED OUT BY
11 THE NURSE INCLUDING INDEPENDENT AND DEPENDENT MEASURES THAT
12 HAVE BEEN IDENTIFIED. INDEPENDENT NURSING MEASURES ARE
13 THOSE THAT IF I WROTE THE TREATMENT PLAN, I DETERMINED
14 MYSELF THAT WOULD BENEFIT PATIENT. DEPENDENT MEASURES WOULD
15 BE THOSE ORDERED BY THE PHYSICIAN THAT THE NURSE CARRIES
16 OUT.
17 Q. WHAT ARE NURSING INTERVENTIONS IN THE CONTEXT OF A
18 TREATMENT PLAN?
19 A. NURSING INTERVENTIONS ARE THOSE THINGS THAT THE NURSE
20 DOES FOR THE PATIENT IN ORDER TO HELP THEM FEEL BETTER.
21 PROVIDING CARE FOR THE PATIENT. IT'S THE DOCUMENTATION OF
22 THE CARE THAT IS GIVEN BY A NURSE TO THE PATIENT.
23 Q. WAS THERE A NURSING PLAN CONCERNING EACH ONE OF THESE
24 FIVE PATIENTS?
25 A. YES.
3119
1 Q. NOW, I'M GONNA SHOW YOU -- IF YOU WOULD TURN TO 197 IN
2 ELLEN ANDERSON'S BINDER PLEASE.
3 A. OKAY.
4 Q. WHAT IS SHOWN BY DOCUMENT 197?
5 A. THAT IS HER MASTER TREATMENT PLAN.
6 Q. AND THAT'S WHAT YOU WERE JUST TELLING US ABOUT IN YOUR
7 PRIOR TESTIMONY, IS THAT RIGHT?
8 A. THAT'S CORRECT.
9 Q. AND IS YOUR WRITING ON THIS PARTICULAR DOCUMENT?
10 A. YES, IT IS.
11 Q. AND COULD YOU TELL US WHERE IT IS?
12 A. IT'S ALL OVER THE DOCUMENT.
13 Q. ALL RIGHT. WELL, FOR EXAMPLE, AT THE TOP, JUST SO WE
14 ORIENT OURSELVES, IT HAS PROBLEM STATEMENT, PROBLEM RELATED
15 TO OR EVIDENCED BY. AND THEN DID YOU WRITE ANXIETY -- WHAT
16 DOES R.T. STAND FOR?
17 A. ANXIETY RELATED TO.
18 Q. ANXIETY --
19 A. RELATED TO ANXIETY DISORDER AS EVIDENCED BY EXTREME
20 AGITATION, INCONSOLABLE CRYING, AND SCREAMING.
21 Q. OKAY. AND WHERE DID YOU GET THAT INFORMATION SUCH THAT
22 YOU WROTE IT ON THE MASTER TREATMENT PLAN?
23 A. THAT WOULD BE FROM HER ADMITTING DIAGNOSIS AND THE
24 BEHAVIOR THAT SHE DEMONSTRATED. BUT --
25 Q. THEN YOU WROTE UNDER LONG-TERM GOALS, PATIENT WILL BE
3120
1 DISCHARGED TO A LONG-TERM CARE FACILITY THAT IS APPROPRIATE
2 TO HER PHYSICAL NEEDS AND ABLE TO MANAGE HER PSYCHIATRIC
3 MEDICATION, AND THERE APPEARS TO BE A DATE OF 12/29. IS
4 THAT WHEN YOU WOULD HAVE WRITTEN THAT?
5 A. YES.
6 Q. AND GENERALLY, WHAT IS -- WHAT IS CONTAINED UNDER
7 LONG-TERM GOALS? WHY IS THAT WRITTEN THERE IN THE TREATMENT
8 PLAN?
9 A. BECAUSE THE HOSPITALIZATION AT DAVIS HOSPITAL WOULD HAVE
10 BEEN A SHORT-TERM INTERVENTION FOR THE PATIENT, THE GOAL
11 BEING TO STABILIZE HER CONDITION AND THEN HAVE HER CONTINUE
12 ON TO A MORE SUITABLE LONG-TERM ARRANGEMENT, WHETHER THAT BE
13 HOME OR LONG-TERM CARE PLACEMENT. AND AT THE TIME OF
14 ADMISSION, ALL OF THE STAFF WERE INTENT ON DOING OUR BEST TO
15 CHOOSE THE RIGHT OPTION AND HELP FAMILY TO MAKE THE RIGHT
16 CHOICES.
17 Q. THEN YOU HAVE UNDER SHORT-TERM GOALS, PATIENT WILL
18 DEMONSTRATE A DECREASE IN FREQUENCY -- I CAN'T READ THAT.
19 A. IN FREQUENCY AND INTENSITY OF CRYING AND SCREAMING IN
20 THE NEXT SEVEN DAYS.
21 Q. OKAY. AND THEN WE HAVE UNDER INTERVENTIONS, YOU LIST A
22 NUMBER OF THOSE INTERVENTIONS, IS THAT RIGHT?
23 A. THAT'S CORRECT.
24 Q. WHERE DID YOU GET THE INFORMATION SUCH THAT YOU WERE
25 ABLE TO WRITE THOSE VARIOUS INTERVENTIONS?
3121
1 A. THAT IS BASIC TO THE EDUCATION OF A NURSE. IT'S THE
2 NURSING CARE NECESSARY FOR THE NURSING DIAGNOSIS, WHICH IS
3 ESSENTIALLY WHAT IS AT THE TOP OF THE PAGE, THE PROBLEM
4 STATEMENT, IF YOU WILL. THOSE ARE THE INTERVENTIONS MOST
5 COMMONLY CARRIED OUT BY THE NURSE FOR THE PATIENT. THEY ARE
6 SPECIALIZED TO THIS PARTICULAR PATIENT, AS I OFTEN DID.
7 THEY'RE NOT STANDARDIZED TREATMENT PLANS. NOT EVERYBODY IS
8 THE SAME. TRY TO ADJUST THEM BASED ON EACH INDIVIDUAL'S
9 PATIENT -- PATIENT NEEDS.
10 Q. WHEN YOU SAY BASED UPON THE EXPERIENCE OF THE NURSE,
11 WHAT DO YOU MEAN IN TERMS OF THE INTERVENTIONS?
12 A. EXPERIENCE, EDUCATION, KNOWLEDGE, IN TERMS OF WHAT DOES
13 A PATIENT WITH ANXIETY REQUIRE IN TERMS NURSING CARE. THAT
14 WOULD BE SOMETHING FROM MY EDUCATION AND EXPERIENCE IN
15 WORKING WITH THOSE PATIENTS.
16 Q. IF YOU WOULD PLEASE, THAT'S ALL WE'RE GOING TO DO ON
17 ELLEN ANDERSON'S CHART. WOULD YOU PLEASE TURN AND OBTAIN
18 THE BINDER CONCERNING MARY CRANE?
19 DO YOU HAVE THAT IN FRONT OF YOU?
20 A. UH-HUH, YES, I DO.
21 Q. OKAY. IF YOU WOULD TURN TO 298 PLEASE. DIRECTING YOUR
22 ATTENTION TO -- IT SAYS PAIN SCALE, ONE THROUGH FIVE, RATE
23 YOUR PAIN. DO YOU SEE THAT?
24 A. YES.
25 Q. AND THEN THERE APPEARS TO BE A NUMBER.
3122
1 A. YES.
2 Q. WHAT NUMBER IS THAT?
3 A. FIVE.
4 Q. AND WHO WROTE THAT?
5 A. I DID.
6 Q. AND WOULD YOU TELL US PLEASE WHAT THAT MEANS THAT YOU
7 WROTE A FIVE?
8 A. OKAY. THE PAIN SCALE IS A MEASURE USED BY NURSING STAFF
9 IN ASSESSMENT OF THE PATIENT TO TRY AND OBJECTIFY PAIN FOR
10 THE PATIENT SO THAT THEY CAN MEASURE IT IN A WAY IN WHICH
11 THE NURSE THEN CAN MEASURE PAIN RELIEF. SO ON ADMISSION, WE
12 WOULD ASK THE PATIENT, YOU KNOW, WHERE ARE WE STARTING FROM
13 WITH YOUR PAIN, ZERO BEING ABSOLUTELY NO PAIN, AND FIVE
14 BEING THE WORST PAIN THAT YOU COULD POSSIBLY STAND. AND
15 THEN THE VARIATIONS BETWEEN THAT, THREE BEING OF COURSE IN
16 THE MIDDLE TWO LESS THAN THAT, FOUR GREATER THAN THAT.
17 Q. WHERE WOULD YOU HAVE GOTTEN THE INFORMATION SUCH THAT
18 WOULD YOU HAVE RATED MARY CRANE'S SITUATION AS THE WORST
19 PAIN IMAGINABLE, AND THAT IS A FIVE?
20 A. I WOULD HAVE ASKED HER.
21 Q. NOW, IF YOU COULD GO TO 311 PLEASE IN THE NURSES' NOTE
22 SECTION.
23 A. OKAY.
24 Q. AT THE TOP THERE IS A NURSING NOTE IN YOUR HANDWRITING,
25 IS THAT RIGHT?
3123
1 A. THAT'S CORRECT.
2 Q. COULD YOU READ THAT PLEASE IN ITS ENTIRETY?
3 A. NIGHT SHIFT FREE TEXT NOTE. PATIENT HAS BEEN AWAKE MOST
4 OF SHIFT. 0200. TRAZODONE 100 MILLIGRAMS P.R.N. AND
5 TYLENOL TWO TABLETS GIVEN FOR SLEEP AND DISCOMFORT
6 RESPECTIVELY. PATIENT ABLE TO REST QUIETLY UNTIL 0600 AFTER
7 MEDICATION WAS GIVEN.
8 Q. NOW, THE MEDICATION TRAZODONE, CAN YOU TELL FROM THAT
9 NOTE WHY YOU GAVE TRAZODONE TO MARY CRANE AT THIS TIME?
10 A. TO HELP WITH SLEEP.
11 Q. AND THE TYLENOL WAS GIVEN FOR WHAT PURPOSE?
12 A. FOR DISCOMFORT.
13 Q. BASED UPON THAT NOTE CAN YOU ASSESS WHETHER OR NOT THERE
14 WAS A BENEFICIAL EFFECT FROM THOSE MEDICATIONS?
15 A. YES. PATIENT WAS THEN ABLE TO REST QUIETLY UNTIL
16 6:00 O'CLOCK AFTER THE MEDICATION WAS GIVEN.
17 Q. IS THERE A SIGNIFICANCE THAT YOU CHARTED P.R.N. AFTER
18 TRAZODONE 100 MILLIGRAMS?
19 A. YES. THAT INDICATES THAT THE MEDICATION WAS NOT A
20 SCHEDULED MEDICATION, BUT GIVEN AT MY DISCRETION BASED ON
21 THE NEEDS OF THE PATIENT.
22 Q. IF YOU COULD TURN PLEASE TO 325. AND THERE IS A NOTE ON
23 THAT PAGE IN YOUR HANDWRITING?
24 A. YES.
25 Q. NOW, IT'S THE ONE THAT HAS, STARTS WITH THREE ELEVEN, IS
3124
1 THAT RIGHT?
2 A. 3:00 TO 11:00, YES.
3 Q. AND WHAT DOES THAT STAND FOR?
4 A. THAT STANDS FOR THE SHIFT THAT I WAS WORKING ON THAT
5 DAY.
6 Q. NOW, THERE'S A REFERENCE A LITTLE BIT DOWN TOWARDS THE
7 MIDDLE THERE, ABOUT DIFFICULTY, LOOKS LIKE CHAIN SECRETIONS.
8 A. LOOKS TO ME LIKE CONTINUES TO HAVE MUCH DIFFICULTY
9 CLEARING SECRETIONS.
10 Q. OKAY. CAN YOU EXPLAIN TO US WHAT THAT IS REFERRING TO?
11 A. THE NOTE IS A DESCRIPTION OF MY EFFORTS OR ANOTHER STAFF
12 MEMBER'S EFFORTS THAT I OBSERVED FEEDING THE PATIENT. AND
13 AT THE TIME THAT THIS NOTE WAS WRITTEN, APPARENTLY THE
14 PATIENT WAS NOT ABLE TO COUGH OR SWALLOW OR REMOVE
15 SECRETIONS THAT MAY HAVE BEEN LODGED IN THE BACK OF THE
16 THROAT AT THE TIME.
17 Q. AND WAS THERE A NURSING INTERVENTION AS A RESULT OF WHAT
18 YOU ASSESSED?
19 A. I'M TRYING TO READ MY NOTE. OKAY. UNDER RESPONSE IT
20 STATES, PATIENT REQUIRED SUCTIONING TIMES TWO TO ASSIST IN
21 MANAGEMENT OF SECRETIONS.
22 Q. WHAT IS SUCTIONING?
23 A. THAT WOULD MEAN THAT I TOOK A MACHINE THAT GENERATES
24 SUCTION THROUGH A TUBE THAT IS SMALL ENOUGH TO FIT IN THE
25 BACK OF THE PATIENT'S THROAT TO CLEAR SECRETIONS AWAY THAT
3125
1 SHE WOULD NOT HAVE BEEN ABLE TO DO SO HERSELF AND NEEDED
2 NURSING ASSISTANCE TO DO THAT. SO WE'D USE THAT DEVICE TO
3 CLEAR THOSE SECRETIONS OUT OF THE PATIENT'S MOUTH AND
4 THROAT.
5 Q. CAN YOU TELL WHY AT THIS POINT THE PATIENT WAS HAVING
6 DIFFICULTY CLEARING HER THROAT?
7 A. I MAKE REFERENCE TO A CONSULTANT'S NOTE BY SPEECH
8 THERAPY -- OBVIOUSLY, I WOULD HAVE READ THAT AT THE TIME --
9 WHO REQUESTED THAT LIQUIDS BE THICKENED. SO IN THEIR
10 EVALUATION, THE PATIENT WAS NOT ABLE TO HANDLE LIQUIDS THAT
11 WERE OF NORMAL CONSISTENCY, AND WOULD CHOKE ON THEM.
12 Q. WHO WOULD HAVE ASKED THAT A SPEECH THERAPIST OR
13 CONSULTANT SEE THE PATIENT?
14 A. THAT WOULD BE THE PHYSICIAN.
15 Q. IF WOULD YOU GO TO MED-328 PLEASE IN THAT BINDER.
16 A. OKAY.
17 Q. DO YOU HAVE THAT IN FRONT OF YOU?
18 A. YES.
19 Q. THERE'S A NOTE UP AT THE TOP THAT HAS ELEVEN SEVEN.
20 THAT WOULD BE THE TIME YOU WERE WORKING, CORRECT?
21 A. CORRECT.
22 Q. COULD YOU READ THAT TO US PLEASE?
23 A. NIGHT SHIFT, FREE TEXT NOTE, PATIENT RESTED QUIETLY
24 THROUGHOUT THE SHIFT. AWAKE SEVERAL TIMES. SUCTION TIMES
25 ONE FOR SMALL AMOUNT OF THICK, DRY, ORAL SECRETIONS.
3126
1 RESPIRATIONS REMAIN LABORED. 0-2 CONTINUOUSLY BY NASAL
2 CANNULA. COLOR PALE.
3 Q. NOW, IS THERE A SIGNIFICANCE TO THE FACT THAT ON THAT
4 NOTE YOU CHARTED HER RESPIRATIONS REMAIN LABORED?
5 A. THAT IS AN INDICATION OF THE LEVEL OF DISTRESS THAT I
6 OBSERVED AS THE NURSE TAKING CARE OF THE PATIENT.
7 Q. AND WHAT DO YOU MEAN WHEN YOU USE THE WORD LABORED IN
8 THAT CONTEXT?
9 A. THAT MEANS THAT IT IS VERY DIFFICULT AND PERHAPS PAINFUL
10 FOR THAT PATIENT TO TAKE A DEEP BREATH.
11 Q. DOES THAT HAVE ANY SIGNIFICANCE TO YOU IN TERMS OF THE
12 REASONS WHY SHE IS SUFFERING LABORED RESPIRATIONS AT THIS
13 TIME?
14 A. A PATIENT SUFFERING LABORED RESPIRATIONS IS IN DISTRESS
15 AND THEIR MEDICAL CONDITION IS MOST LIKELY DETERIORATING.
16 Q. THEN YOU ALSO REFER TO 0-2 CONTINUOUS BY NASAL CANNULA.
17 WHAT IS THAT REFERRING TO?
18 A. THAT MEANS THAT WE WERE GIVING HER SUPPLEMENTAL OXYGEN
19 BEYOND THAT THAT WE CAN BREATHE IN ROOM AIR IN ORDER HELP
20 HER OXYGENATE HER BLOOD. SINCE SHE WAS HAVING THESE
21 SECRETIONS, THE OXYGEN IN HER BLOOD WAS LESS THAN IT OUGHT
22 TO HAVE BEEN, AND OXYGEN BY NASAL CANNULA IS AN EFFORT TO
23 IMPROVE THAT OXYGEN SUPPLY TO THE PATIENT.
24 Q. IS THAT AN INTERVENTION BY A NURSE THAT IS DEPENDENT OR
25 INDEPENDENT?
3127
1 A. IT CAN BE EITHER. IF THE PATIENT IS IN DISTRESS, THE
2 NURSE CAN ADMINISTER OXYGEN TO ASSIST THE PATIENT, THEN
3 LATER CALL FOR AN ORDER TO RECEIVE IT.
4 Q. AN ORDER WOULD BE FROM --
5 A. FROM THE PHYSICIAN. GENERALLY YOU WOULD GIVE IT TO THE
6 PATIENT FIRST, AND THEN CALL ON THE PHONE.
7 Q. AND THEN YOU ALSO INDICATE, YOU CHART COLOR PALE.
8 A. UH-HUH.
9 Q. IS THERE A SIGNIFICANCE TO THE FACT THAT YOU CHARTED
10 COLOR PALE IN THE CONTEXT OF THIS PATIENT?
11 A. PATIENTS WHO ARE GETTING ENOUGH OXYGEN GENERALLY HAVE A
12 PINK COLOR TO THE SKIN, NORMAL LIKE ANY OF US. PATIENTS
13 WHOSE OXYGEN SUPPLY IS POOR, THEY FIRST BECOME PALE, AND
14 WITHOUT SUPPLEMENTAL OXYGEN, WILL BECOME BLUISH IN COLOR,
15 INDICATING THAT THEY'RE NOT GETTING ENOUGH OXYGEN TO BREATHE
16 WITH, YOU KNOW, SUPPLY TO THE BRAIN OR VITAL ORGANS.
17 Q. IF YOU COULD NEXT TURN TO A BINDER THAT WOULD HAVE
18 JUDITH LARSEN'S NAME IN IT PLEASE.
19 DO YOU HAVE THAT IN FRONT OF YOU?
20 A. I DO.
21 Q. IF YOU WOULD TURN TO 530, WHICH IS A NURSING NOTE.
22 A. OKAY.
23 Q. THAT'S A NOTE THAT YOU WROTE, IS THAT RIGHT?
24 A. THAT'S CORRECT.
25 Q. AND WE ONCE AGAIN HAVE 3:00 TO 11:00, THAT WOULD BE THE
3128
1 3:00 TO 11:00 SHIFT?
2 A. CORRECT.
3 Q. AND WHAT'S THE DATE ON THAT NOTE?
4 A. LOOKS LIKE 12/8/95.
5 Q. THAT WOULD BE UP AT THE TOP, IS THAT RIGHT?
6 A. YEAH.
7 Q. YOU HAVE PROB, P-R-O-B. DOES THAT STAND FOR PROBLEM?
8 A. CORRECT.
9 Q. THEN YOU HAVE A B. IS THAT BEHAVIOR?
10 A. YES.
11 Q. AND THEN AS WE GO DOWN HERE WE HAVE AN I. DOES THAT
12 STAND FOR INTERVENTION?
13 A. CORRECT.
14 Q. AND THEN AN R. IS A RESPONSE.
15 A. YES.
16 Q. WHERE DID YOU GET THAT FORMATTING IN TERMS OF THE
17 WRITING OF YOUR NOTE?
18 A. THAT WAS DICTATED TO US BY THE HOSPITAL. THERE ARE
19 VARIOUS OPTIONS FOR WRITING PROGRESS NOTES. USUALLY ALL OF
20 THEM WILL INCLUDE SOME OBSERVATION OF THE PATIENT'S BEHAVIOR
21 OR WHAT THE PATIENT SAYS. INTERVENTION'S PRETTY MUCH WHAT
22 YOU HAVE DONE FOR THE PATIENT AND THE DOCUMENTATION OF THE
23 RESPONSE TO THE INTERVENTIONS BY THE PATIENT.
24 Q. COULD YOU PERHAPS IN LOOKING AT THAT ONE ENTRY THAT YOU
25 HAVE THERE, COULD YOU WALK US THROUGH FROM PROBLEM THROUGH
3129
1 BEHAVIOR TO WHAT THE INTERVENTION WAS AND THE RESPONSE SO
2 THAT WE JUST GENERALLY HAVE AN UNDERSTANDING OF HOW YOU
3 WOULD HAVE CHARTED THIS PARTICULAR PROBLEM.
4 A. PROBLEM BEING ALTERATION IN THOUGHT PROCESS, THAT WOULD
5 BE GENERATED BY THE TREATMENT PLAN THAT WE MENTIONED
6 PREVIOUSLY. DETERMINATION OF THE PROBLEMS AS SEEN BY
7 NURSING FOR THE PATIENT. BEHAVIOR SHOULD RELATE BACK TO THE
8 PROBLEM IN TERMS OF WHAT ARE YOU PARTICULARLY OBSERVING IN
9 THE PATIENT, RELATED TO THE PROBLEM AS IT IS IDENTIFIED.
10 HERE I'M SAYING THINGS THAT SHE'S NOT INTERACTING WITH HER
11 ENVIRONMENT. DOING SELF-STIMULATING BEHAVIOR, INCLUDING
12 ROCKING AND REPETITIVE RHYTHMIC SPEECH. ECHOLALIA, WHICH IS
13 A REPETITIVENESS OF WORDS SHE MAY HAVE HEARD IN THE
14 ENVIRONMENT BACK AT YOU, REPETITIVELY OVER AND OVER, LIKE
15 HELLO, HELLO, HELLO, HELLO, FOR EXAMPLE.
16 Q. IS THAT A SYMPTOM OF ANY PARTICULAR PROBLEM?
17 A. IT'S A SYMPTOM OF DEMENTIA TYPE ILLNESS. IN NURSING
18 TERMS, NURSES WOULD TERM THAT AN ALTERATION IN HER THOUGHT
19 PROCESS.
20 Q. OKAY. PLEASE CONTINUE THEN.
21 A. OKAY. INTERVENTION, THOSE WOULD BE THE THINGS I HAD
22 DONE FOR THE BEHAVIOR THAT WAS OBSERVED. AND THE FIRST
23 THING THERE IS TO ADMINISTER RISPERDAL AND KLONOPIN AS
24 ORDERED. THOSE ARE PSYCHOTROPIC MEDICATIONS COMMONLY GIVEN
25 FOR SUCH BEHAVIOR. MONITOR AND DOCUMENT HER BEHAVIOR WHICH
3130
1 I HAD SO DONE IN THE NOTE. AND DOCUMENT RESPONSE TO
2 MEDICATIONS AND PROVIDE A SAFE ENVIRONMENT FOR THE PATIENT.
3 Q. WHAT DOES THAT MEAN?
4 A. A PATIENT WITH ALTERATION IN HER THOUGHT PROCESS MAY NOT
5 BE REASONABLE, MAY NOT BE ABLE TO MAKE DECISIONS IN ORDER TO
6 KEEP THEMSELVES SAFE. AND IT WOULD BE THE JOB OF THE NURSE
7 TO PROVIDE A SAFE ENVIRONMENT FOR THE PATIENT TO BE IN TO
8 PREVENT THEM FROM HAVING INJURY TO THEMSELVES OR FROM
9 INJURING SOMEONE ELSE.
10 Q. THEN YOU HAVE UNDER RESPONSE, YOU HAVE SOME FURTHER
11 CHARTING.
12 A. THE RESPONSE WOULD BE THE PATIENT'S RESPONSE TO THE
13 INTERVENTIONS THAT I PROVIDED. PATIENT REMAINED ACUTELY
14 DISTRESSED UNTIL 2000, WHICH WAS 10:00 O'CLOCK. CRYING
15 INCONSOLABLY IN BED. PROVIDED BACK RUB TIMES 20 MINUTES.
16 PATIENT WAS ABLE TO QUIET FOR AN HOUR. AWOKE AGAIN CRYING
17 UNCONTROLLABLY. GIVEN ATIVAN 1 MILLIGRAM. MUCH CALMER IN A
18 HALF HOUR. ONE HOUR LATER PATIENT RESTED QUIETLY.
19 RESPIRATIONS SLOW, DEEP, AND REGULAR. NOT ROUSED BY
20 15-MINUTE NURSING CHECKS.
21 Q. NOW, CAN YOU TELL IF THE ATIVAN THAT WAS GIVEN WAS A
22 P.R.N. ORDER?
23 A. THAT WOULD HAVE BEEN A P.R.N. ORDER --
24 Q. AND CAN YOU --
25 A. -- SINCE IT INDICATES THAT I WAS THE PERSON WHO MADE THE
3131
1 DECISION TO GIVE THE MEDICATION.
2 Q. I SEE. CAN YOU TELL US PLEASE WHY, GIVEN WHAT YOU'VE
3 CHARTED THERE, ATIVAN WAS APPROPRIATE?
4 A. BECAUSE JUST PREVIOUS TO THAT, YOU'LL SEE THAT SHE WAS
5 CRYING UNCONTROLLABLY DESPITE MY EFFORTS AT OTHER CALMING
6 MEASURES SUCH AS RUBBING HER BACK AND SPENDING TIME WITH THE
7 PATIENT, AND MANIPULATING HER ENVIRONMENT TO MAKE HER MORE
8 COMFORTABLE. GIVEN ALL OF THOSE NON MEDICATION TYPES OF
9 NURSING INTERVENTIONS, THEN YOU WOULD MOVE TO A MORE
10 AGGRESSIVE APPROACH TO HELP COMFORT THE PATIENT, WHICH WOULD
11 BE TO GIVE MEDICATION.
12 Q. WHAT KIND OF MEDICATION IS ATIVAN?
13 A. IT'S A TRANQUILIZING MEDICATION.
14 Q. IF YOU COULD NEXT TURN TO 533.1.
15 A. OKAY.
16 Q. DO YOU HAVE THAT IN FRONT OF YOU?
17 A. YES.
18 Q. AND THIS IS A NOTE CONCERNING PATIENT JUDITH LARSEN, AND
19 THE DATE AT THE TOP IS 12/10 OF '95?
20 A. YES.
21 Q. AND YOU HAVE SOME WRITING INDICATING A NOTE YOU WROTE AT
22 THAT TIME?
23 A. YES.
24 Q. ESSENTIALLY IS THAT ENTIRE PAGE YOUR NOTE?
25 A. YES.
3132
1 Q. ONCE AGAIN, YOU HAVE THE PROBLEM LISTED, AND WHAT DOES
2 THAT SAY AT THE TOP THERE?
3 A. ALTERATION IN THOUGHT PROCESS.
4 Q. AND THEN YOU HAVE B. FOR BEHAVIOR, THAT'S DESCRIBING THE
5 BEHAVIOR OF THE PATIENT, IS THAT RIGHT?
6 A. YES.
7 Q. AND COULD YOU JUST READ WHAT THE BEHAVIOR WAS THAT YOU
8 CHARTED?
9 A. PATIENT WAS SOMNOLENT MOST OF SHIFT. RESPIRATIONS SLOW
10 AND REGULAR. RATE OF 16 TO 18. DO YOU WANT ME TO CONTINUE?
11 Q. PARDON ME?
12 A. DO YOU WISH ME TO CONTINUE?
13 Q. NO, LET ME STOP YOU RIGHT THERE. IS THERE A
14 SIGNIFICANCE TO YOU THAT YOU CHARTED THE RESPIRATIONS SLOW
15 AND REGULAR AND THE RATE 16 TO 18?
16 A. THOSE ARE NORMAL FINDINGS INDICATING THE PATIENT'S LEVEL
17 OF COMFORT.
18 Q. AND WAS THERE A PARTICULAR REASON WHY WOULD YOU ACTUALLY
19 CHART THAT INFORMATION AT THAT TIME?
20 A. THAT WOULD BE BASED ON HAVING OBSERVED THE PATIENT OVER
21 TIME, AND BEING A NURSE FAMILIAR WITH THE PATIENT, AND
22 HAVING READ EVEN JUST THE PREVIOUS NOTE THAT SHE'S HAD
23 PERIODS OF RESTLESSNESS SO THAT THIS WOULD BE A CHANGE.
24 ALTHOUGH THE PROBLEM IS STILL ALTERATION IN THOUGHT PROCESS,
25 THE BEHAVIOR INDICATES AN IMPROVEMENT IN HER BEHAVIOR
3133
1 RELATIVE TO THAT PROBLEM. SO THAT SHE IS CALMER, MORE
2 COMFORTABLE, BREATHING REGULARLY, NOT IN ACUTE DISTRESS,
3 BASED ON THAT.
4 Q. WHAT IS A NORMAL RANGE OF RESPIRATIONS?
5 A. 16 TO 20.
6 Q. WOULD THE RANGE BE AS LOW AS 12?
7 A. YEAH.
8 Q. AND DID YOU HAVE A RESPONSIBILITY AS A NURSE TO ACTUALLY
9 CHART THE RESPIRATION RATE?
10 A. YES.
11 Q. AND COULD YOU TELL US PLEASE WHAT THAT RESPONSIBILITY
12 WAS?
13 A. NURSES HAVE BOTH DEPENDENT AND INDEPENDENT MEASURES IN
14 TERMS OF INTERVENTIONS, AS I SAID. PHYSICIANS COMMONLY
15 WOULD WRITE A FREQUENCY AT WHICH THEY WANTED VITAL SIGNS
16 RECORDED. I THINK THE STANDARD FOR NEW ADMISSIONS WAS TWICE
17 A DAY FOR A PERIOD OF TIME, BUT AS A NURSE, IF I FOUND THE
18 PATIENT IN DISTRESS, I COULD INDEPENDENTLY DETERMINE THAT
19 THOSE NEEDED TO BE DONE. DO THEM, REPORT THEM TO THE
20 PHYSICIAN IF THEY WERE ABNORMAL.
21 Q. NOW, YOU GO ON TO SAY IN TERMS -- THE FAMILY VISITED,
22 AND I CAN'T REALLY READ WHAT YOU SAY THERE AFTER FAMILY.
23 COULD YOU READ THAT FOR US PLEASE?
24 A. FAMILY VISITED AND LENGTHY TEACHING SESSION WITH THIS
25 R.N. REGARDING PATIENT'S CURRENT MEDICATION AND EXPECTED
3134
1 COURSE OF TREATMENT AND CARE DURING THIS HOSPITAL STAY.
2 Q. COULD I ASK YOU PLEASE WHAT YOU WERE REFERRING TO IN
3 TERMS OF THAT INDICATION IN YOUR NOTE?
4 A. ONE OF THE RESPONSIBILITIES OF NURSING IS TO DOCUMENT
5 EDUCATION THAT YOU AS A NURSE PROVIDE TO THE FAMILY OR TO
6 THE PATIENT. IT WAS IN FACT SOMETHING THAT OUR CARE WAS
7 CONTINUALLY REVIEWED BY IN TERMS OF ITS APPROPRIATENESS, AND
8 WE WERE EVALUATED ON HOW WELL WE WERE DOING OUR JOB BASED ON
9 WHETHER OR NOT WE DOCUMENTED EDUCATION AND PROVIDED
10 EDUCATION TO THE PATIENT OR THE FAMILY AS NEEDED. WHAT THIS
11 PARTICULAR INTERVENTION SAYS IS THAT I REVIEWED ALL OF THE
12 PATIENT'S MEDICATIONS AND PLAN OF CARE AS DELINEATED IN THE
13 MASTER TREATMENT PLAN THAT WE'VE LOOKED AT BEFORE. AND WHAT
14 THE PLAN CARE WAS GOING TO BE FOR THE PATIENT DURING THE
15 HOSPITAL STAY.
16 Q. CAN YOU RECALL -- CAN YOU RECALL THIS PARTICULAR
17 CONVERSATION?
18 A. NO.
19 Q. CAN YOU TELL US GENERALLY WHAT YOU DID IN TERMS OF
20 DISCUSSIONS WITH FAMILY CONCERNING MEDICATIONS?
21 MS. BARLOW: OBJECTION, YOUR HONOR. IT'S NOT ABOUT
22 THESE PATIENTS. I DON'T THINK IT'S RELEVANT.
23 THE COURT: CAN YOU REPHRASE THE QUESTION?
24 MR. STIRBA: YES.
25 Q. DID YOU HAVE A PARTICULAR WAY THAT YOU WOULD INTERVENE
3135
1 IN TERMS OF DISCUSSIONS WITH FAMILIES AT THIS TIME
2 CONCERNING THEIR MEDICATION?
3 MS. BARLOW: SAME OBJECTION, YOUR HONOR. IF IT'S
4 NOT ABOUT THESE PARTICULAR PATIENTS, IT'S NOT RELEVANT.
5 THE COURT: OKAY. IS THIS GOING TO HABIT?
6 MR. STIRBA: IT IS, YOUR HONOR. SHE CAN'T REMEMBER
7 THE SPECIFIC CONVERSATION, BUT I THINK SHE CAN TESTIFY AS TO
8 WHAT SHE GENERALLY DID.
9 THE COURT: OKAY. UNDER RULE 406, THAT'S
10 ADMISSIBLE. GO AHEAD.
11 Q. (BY MR. STIRBA) CAN YOU TELL US PLEASE WHAT YOU
12 GENERALLY WOULD DO?
13 A. GENERALLY, DURING A FAMILY VISIT WITH THE PATIENT AND
14 FAMILY, I WOULD TAKE THE FAMILY MEMBERS ASIDE, PARTICULARLY
15 IF THEY ASKED ME, TO REVIEW THE CURRENT LIST OF MEDICATION,
16 HOW OFTEN THAT MEDICATION WAS BEING GIVEN, WHAT THE PURPOSE
17 OF THAT MEDICATION WAS, WHAT THE COMMON SIDE EFFECTS OF THE
18 MEDICATION MIGHT BE, WHAT OUR EXPECTED RESPONSE FROM THE
19 PATIENT TO THE MEDICATION WAS GOING TO BE, WHAT THE PLAN OF
20 CARE AS FAR AS NURSING INTERVENTIONS WERE GOING TO BE, AND
21 WHAT AS I UNDERSTOOD IT OR WHAT WAS DOCUMENTED IN THE
22 TREATMENT PLAN AS FAR AS WHAT THE PHYSICIAN'S PLAN OF CARE
23 WOULD BE.
24 Q. NOW, YOU GO ON TO SAY IN THIS NOTE, WHERE IT SAYS THE
25 REQUEST THAT PATIENT BE MADE COMFORTABLE AND REQUEST THAT
3136
1 SHE BE A D.N.R. AND THEN YOU'VE UNDERLINED THAT TWICE. DO
2 YOU SEE THAT?
3 A. YES.
4 Q. WHAT DID YOU MEAN WHEN YOU REFERRED TO COMFORTABLE?
5 A. THAT THE PATIENT BE KEPT FREE OF PAIN OR DISCOMFORT.
6 Q. AND WHEN YOU WROTE D.N.R., WHAT DOES THAT STAND FOR?
7 A. THAT'S STANDS FOR DO NOT RESUSCITATE.
8 Q. AND WHAT DOES THAT MEAN?
9 A. THAT REFERS TO CARDIOPULMONARY RESUSCITATION, MEANING
10 THAT IF THE PATIENT'S HEART OR LUNGS SHOULD STOP
11 FUNCTIONING, THE PATIENT STOPS BREATHING, AND THE HEART IS
12 NO LONGER BEATING, THAT THE FAMILY DOES NOT WISH MECHANICAL
13 MEANS OR OTHER MEANS TO RESTART BREATHING OR HEARTBEAT.
14 Q. NOW, YOU'VE UNDERLINED IT TWICE. CAN YOU TELL US, IS
15 THERE A PARTICULAR REASON WHY YOU UNDERLINE TWICE D.N.R. AND
16 PUT IT IN CAPITAL LETTERS?
17 A. WELL D.N.R. NORMALLY IS PUT IN CAPITAL LETTERS, BUT I
18 WOULD HAVE UNDERLINED IT TWICE TO DRAW THE ATTENTION OF
19 OTHER PEOPLE READING THE CHART THAT THE FAMILY'S WISHES
20 REMAIN THAT THE PATIENT BE NOT RESUSCITATED DESPITE ANY
21 CHANGE IN THE PATIENT'S CONDITION.
22 Q. NOW, UNDER RESPONSE, R., ON THE SAME DAY, YOU SAY FAMILY
23 VOICED UNDERSTANDING AND PURPOSE OF ALL MEDICATIONS.
24 DO YOU SEE THAT?
25 A. YES.
3137
1 Q. BY ALL --
2 THE COURT: MOVE THAT UP A LITTLE BIT.
3 MR. STIRBA: I'M SORRY, YOUR HONOR.
4 Q. IT'S UNDER R. THAT'S RESPONSE, RIGHT?
5 A. YES.
6 Q. AND THEN FAMILY VOICED UNDERSTANDING AND PURPOSE OF ALL
7 MEDICATIONS.
8 DO YOU SEE THAT?
9 A. YES.
10 Q. AND WHEN YOU USED THE WORD ALL MEDICATIONS, ARE YOU
11 REFERRING NO THE MEDICATIONS THAT SHE WAS RECEIVING AS OF
12 THIS DATE?
13 A. YES.
14 Q. AND THEN IT GOES ON TO SAY, UNDERSTANDING OF THE
15 PURPOSE, GOAL OF COMFORT MEASURES WAS ALSO ARTICULATED BY
16 FAMILY.
17 DID I READ THAT CORRECTLY?
18 A. YES.
19 Q. WHAT DID YOU MEAN BY THAT?
20 A. THAT REFERS TO THEIR WISH THAT THE PATIENT REMAIN A
21 D.N.R. AND BE MADE COMFORTABLE DURING THAT PERIOD OF TIME.
22 THEY WERE ANTICIPATING THE PATIENT'S DEATH.
23 Q. PARDON ME?
24 A. I -- FROM MY SENSE OF READING MY NOTE, THE PATIENT'S
25 FAMILY WAS ANTICIPATING THE PATIENT'S DEATH.
3138
1 Q. NOW, IF YOU WOULD TURN TO 477 PLEASE, WHICH I BELIEVE IS
2 IN THE PROGRESS NOTES PORTION OF THE BINDER. YOUR WRITING
3 IS AT THE TOP, IS THAT RIGHT?
4 A. THAT'S CORRECT.
5 Q. AND IT APPEARS THAT IT WAS DATED ON 1/2 OF '96, CORRECT?
6 A. YES.
7 Q. NOW, IT SAYS FIRST OF ALL, WEEKLY R.N. ADVOCATE NOTE.
8 CORRECT?
9 A. CORRECT.
10 Q. TELL US PLEASE WHAT IS THE SIGNIFICANCE OF A R.N. WEEKLY
11 ADVOCATE NOTE?
12 A. ON ADMISSION TO THE UNIT, EACH PATIENT WAS ASSIGNED A
13 NURSING ADVOCATE, A NURSE WHOSE RESPONSIBILITY IT WAS TO
14 OVERSEE THE CARE PLAN AND TREATMENT OF THE PATIENT BASED ON
15 A 24-HOUR PERIOD OF TIME. THE 24-HOUR RESPONSIBILITY FOR
16 THE CARE PLAN OF THE PATIENT, DIRECTING OTHER NURSES WHAT
17 THE CARE PLAN WOULD BE, AND MONITORING THE HOSPITAL COURSE
18 OF THAT PATIENT AND CONTRIBUTING NURSING INPUT TO THE
19 MEDICAL TEAM, INTERDISCIPLINARY TEAM, INCLUDING SOCIAL
20 WORKERS, PHYSICIAN, WHOEVER IT MIGHT BE, REGARDING THE
21 NURSING PERSPECTIVE ON THE CONDITION OF THE PATIENT. THAT'S
22 WHY IT'S IN THE PROGRESS NOTES SECTION WHICH IS SHARED WITH
23 ALL THE OTHER DISCIPLINES IN THE HOSPITAL.
24 Q. AND IF YOU COULD EXPLAIN, YOU SAID SHARED WITH ALL THE
25 OTHER INTERDISCIPLINES IN THE HOSPITAL. WHY IS THIS
3139
1 PARTICULAR ADVOCATE NOTE IN THE PROGRESS NOTES SECTION, WHAT
2 SIGNIFICANCE DOES THAT HAVE?
3 A. IT'S INFORMATION THAT I BELIEVED THE REST OF THE MEDICAL
4 TEAM NEEDED TO KNOW AT THE TIME, AND ALL THE NOTES THAT
5 WE'VE READ SO FAR SHOW THAT I'VE BEEN WORKING 3:00 TO 11:00
6 OR 11:00 TO 7:00. MANY OF THE REMAINING MEMBERS OF THE
7 MEDICAL TEAM WOULD WORK 9:00 TO 5:00 OR 7:00 TO 3:00, SO
8 THIS WOULD BE MY PRIMARY MEANS OF COMMUNICATING MY OPINION
9 ABOUT THE PATIENT TO THE REST OF THE TEAM.
10 Q. DOES THIS NOTE INCLUDE IN IT CERTAIN ASSESSMENT DATA BY
11 YOU?
12 A. YES.
13 Q. AND TELL US PLEASE WHAT MATTERS YOU ASSESSED CONCERNING
14 JUDITH LARSEN REFLECTED BY THIS NOTE.
15 A. THAT SHE HAD RAPIDLY AND PROFOUNDLY DETERIORATED WITHIN
16 A WEEK'S TIME.
17 Q. AND DO YOU RECALL WHY SHE HAD RAPIDLY AND DETER -- AND
18 PROFOUNDLY DETERIORATED?
19 A. I DON'T RECALL WITHOUT READING THE NOTE, BUT THE NOTE
20 STATES THAT THE PATIENT WAS HAVING SEIZURES, MULTIPLE
21 EPISODES OF VOMITING COFFEE GROUND MATERIAL, NOT VERBALLY
22 RESPONSES WHERE SHE -- RESPONSIVE WHERE PREVIOUSLY SHE HAD
23 BEEN ABLE TO TALK TO OTHER PEOPLE. THOSE ARE THE
24 ASSESSMENTS THAT I MADE.
25 Q. NOW, YOU REFERENCE IN THE NOTE THE CARE PLAN, IS THAT
3140
1 RIGHT?
2 A. YES.
3 Q. AND IT SAYS, THE CARE PLAN HAS BEEN ALTERED TO REFLECT
4 THE NEED TO SUPPORT PATIENT FAMILY THROUGH A POSSIBLE DEATH
5 AND DYING PROCESS.
6 DID I READ THAT CORRECTLY?
7 A. YES.
8 Q. TELL US PLEASE WHY YOU WOULD HAVE ALTERED OR AMENDED THE
9 CARE PLAN AT THIS TIME.
10 A. BECAUSE THE PATIENT'S CONDITION AND NURSING NEEDS HAD
11 DRAMATICALLY CHANGED, AND THAT THE CARE THAT I WAS PROVIDING
12 WAS REFLECTIVE OF THAT, OF A PATIENT WHO NEEDED CARE OF THE
13 PATIENT CLOSE TO DEATH.
14 Q. AND IS THE ASSESSMENT OF CLOSE TO DEATH, IS THAT AN
15 ASSESSMENT THAT WAS MADE BY YOU?
16 A. FROM A NURSING POINT OF VIEW, YES.
17 Q. AND WHAT KINDS OF -- LET ME START OVER AGAIN. IN TERMS
18 OF ALTERING OR AMENDING THE CARE PLAN, DO YOU RECALL
19 GENERALLY WHAT NURSING INTERVENTIONS WOULD BE REFLECTED
20 CONCERNING SUPPORTING THE FAMILY THROUGH A DEATH AND DYING
21 PROCESS?
22 A. GENERALLY, THE NURSING CARE OF A FAMILY MEMBER AND A
23 PATIENT WHO IS DYING, THE NURSE IS RESPONSIBLE FOR REALLY
24 SOME SPIRITUAL SUPPORT AND EMOTIONAL SUPPORT AND ANY OTHER
25 KIND OF SUPPORT THAT THE NURSE CAN REASONABLY RENDER TO
3141
1 FAMILIES WHEN THEY'VE VISITING. WE DIDN'T READILY HAVE
2 RELIGIOUS SUPPORT AVAILABLE, SO WHATEVER NEEDS THE FAMILY
3 EXPRESSED, TIME IN PRIVATE WITH THEIR FAMILY MEMBERS, TIME
4 TO VOICE THEIR OWN CONCERNS TO ME IN A PRIVATE WAY, ALL OF
5 THAT WOULD HAVE BEEN PROVIDED FOR THE PATIENT AND THE
6 FAMILY.
7 Q. NOW, YOU GO ON TO SAY IN THE LAST LINE THERE OF YOUR
8 NOTE, PATIENT IS CURRENTLY RECEIVING -- AND THAT WOULD BE
9 MORPHINE I.M. EVERY THREE HOURS FOR COMFORT.
10 DID I READ THAT CORRECTLY?
11 A. CORRECT.
12 Q. WHEN YOU USED WORDS FOR COMFORT IN THAT NOTE, WHAT DO
13 YOU MEAN?
14 A. I'M REFERRING TO ALLEVIATING THE DISCOMFORT THAT COMES
15 WITH THE DEATH AND DYING PROCESS IN A PATIENT.
16 Q. AND CAN YOU DESCRIBE FOR US THE KINDS OF DISCOMFORT
17 THAT THE PATIENT WOULD BE EXPERIENCING IN THE DEATH AND
18 DYING PROCESS?
19 MS. BARLOW: YOUR HONOR, I OBJECT UNLESS IT'S THIS
20 PATIENT SPECIFICALLY.
21 THE COURT: WELL, CAN YOU LAY A FOUNDATION? YOU'RE
22 ASKING THE WITNESS TO SAY WHAT SOMEBODY ELSE IS DOING.
23 MR. STIRBA: WELL, PERHAPS WE'LL JUST REFER TO THE
24 NOTES, YOUR HONOR.
25 Q. YOU'VE REVIEWED SOME NURSE'S NOTES CONCERNING YOUR CARE
3142
1 OF JUDITH LARSEN?
2 A. YES.
3 Q. TURN TO 582 PLEASE. NOW, THIS IS -- I'LL WAIT UNTIL YOU
4 GET IT.
5 A. ALMOST THERE. THREE -- 581.
6 Q. DO YOU HAVE 582 IN YOUR BINDER?
7 A. NO, I DO NOT.
8 MR. STIRBA: MAY I ASSIST THE WITNESS, YOUR HONOR?
9 THE COURT: YES.
10 MR. STIRBA: RIGHT THERE, 528, RIGHT. THEY'RE OUT
11 OF ORDER, YOUR HONOR.
12 Q. AND -- BUT WE NOW ARE AT 582, ARE WE?
13 A. YES.
14 Q. AT THE TOP OF 582, THERE IS A DATE AND THIS IS A NOTE ON
15 12/31 OF 1995?
16 A. CORRECT.
17 Q. AND YOU AFFIXED YOUR SIGNATURE ON THE FIRST PORTION OF
18 THAT NOTE, IS THAT RIGHT?
19 A. CORRECT.
20 Q. AND YOU STATE ELEVEN SEVEN, THAT WOULD BE SHIFT, NIGHT
21 SHIFT, FREE TEXT NOTE. RESPIRATION RATE, 10 TO 16 PER
22 MINUTE. PATIENT IS -- WHAT IS THAT WORD?
23 A. GAZING.
24 Q. -- GAZING AT LIGHT FROM BATHROOM. COULD YOU TELL US
25 PLEASE IF THERE IS A SIGNIFICANCE TO THE FACT THAT YOU
3143
1 CHARTED THOSE FACTS?
2 A. DURING THE DEATH AND DYING PROCESS, AS MY EDUCATION IN
3 NURSING AND MY OBSERVATIONS AS A NURSE HAVE TAUGHT ME, ONE
4 OF THE LAST SENSES TO LEAVE A PATIENT IN THE PROCESS OF
5 DYING IS VISION. AND IT IS COMMON NURSING PRACTICE TO LEAVE
6 A LIGHT OR A TELEVISION OR A BATHROOM LIGHT WITH THE DOOR
7 HALF CLOSED ON DURING THE NIGHTTIME WHEN IT IS ANTICIPATED
8 THAT THE PATIENT MAY DIE SO THAT THEY DO NOT DO SO IN THE
9 DARK.
10 Q. SHE IS AWAKE. SHE IS NOT VERBALLY RESPONSIVE. WHAT DO
11 YOU MEAN BY THAT?
12 A. THAT WOULD MEAN THAT PERHAPS HER EYES ARE OPEN, BUT
13 SHE'S NOT ABLE TO ANSWER ME IF I SPOKE TO HER OR TOUCHED
14 HER.
15 Q. IS THERE A PARTICULAR REASON WHY YOU WOULD HAVE CHARTED
16 THAT FACT?
17 A. IN THE PROCESS OF DEATH AND DYING, PATIENTS PROGRESS
18 THROUGH A SERIES OF LOSSES IN FUNCTION. NOT BEING VERBALLY
19 RESPONSIVE IS ONE OF THOSE.
20 Q. AND DOES THAT RELATE TO THE REASON WHY YOU CHARTED THAT
21 FACT?
22 A. YES.
23 Q. AND THEN IT STAYS MORPHINE 5 MILLIGRAMS I.M. GIVEN AT
24 2:30 AND 6:30 FOR PAIN RELIEF.
25 DID I READ THAT CORRECTLY?
3144
1 A. YES.
2 Q. IS THERE A REASON WHY YOU INDICATED THE TIMES IN THAT
3 NOTE?
4 A. YES.
5 Q. AND WOULD YOU TELL US PLEASE WHY YOU DID THAT?
6 A. TO DOCUMENT WHEN THE PAIN MEDICATION WAS GIVEN, DIRECTLY
7 AFTER THAT STATEMENT, I WROTE THIS A BIT OUT OF SEQUENCE.
8 IT STATES THAT THE PATIENT WAS MOANING PRIOR TO THE 2:30
9 DOSE OF MEDICATION, WHICH WOULD INDICATE TO ME THE PATIENT
10 WAS HAVING PAIN AND IN NEED OF THE MEDICATION AS IT HAD BEEN
11 ORDERED.
12 Q. AND YOU SAID OUT OF SEQUENCE. COULD YOU EXPLAIN WHAT
13 YOU MEAN BY THAT?
14 A. MOST PROBABLY I WOULD HAVE WRITTEN PATIENT WAS MOANING
15 AT 2:30, AND THEN SAID THAT I HAD GIVEN A DOSE OF MORPHINE.
16 THIS IS JUST A MATTER OF MY FLOW OF THOUGHT AS I WAS WRITING
17 THE NOTE AT THE END OF SHIFT.
18 Q. BASED UPON WHAT YOU CHARTED THERE, DID YOU ASSESS THAT
19 JUDITH LARSEN WAS IN PAIN?
20 A. YES.
21 THE COURT: IS THIS AN APPROPRIATE PLACE TO TAKE
22 BREAK?
23 MR. STIRBA: FINE, JUDGE.
24 THE COURT: OKAY, LADIES AND GENTLEMEN.
25 (AFTER ADMONISHING THE JURY, THE COURT
3145
1 TOOK A BRIEF RECESS.)
2 THE COURT: OKAY. PLEASE BE SEATED. THE RECORD
3 SHOULD REFLECT THAT THE JURY AS HAS RETURNED. WOULD YOU
4 LIKE TO CONTINUE.
5 MR. STIRBA: YES, THANK YOU, YOUR HONOR.
6 Q. MISS STEVENSON, DOES A NURSE HAVE ANY DUTIES OR
7 RESPONSIBILITIES WHEN, FOR EXAMPLE, ADMINISTERING A
8 MEDICATION SUCH AS MORPHINE IN TERMS OF PRECAUTIONS WITH THE
9 PATIENT?
10 A. AS WITH ANY MEDICATION, YOU WOULD LOOK AT THE MEDICATION
11 TO MAKE SURE THAT THE DOSE AND THE FREQUENCY OF MEDICATION
12 WAS APPROPRIATE TO THE AGE AND CONDITION OF THE PATIENT.
13 Q. ARE YOU FAMILIAR WITH A MONITORING FUNCTION?
14 A. YOU WOULD MONITOR FOR MORPHINE, SPECIFICALLY A
15 RESPIRATORY RATE, LEVEL OF ALERTNESS.
16 Q. AND WOULD YOU TELL US PLEASE HOW YOU WOULD GO ABOUT
17 MONITORING A RESPIRATORY RATE IF YOU WERE GIVING, FOR
18 EXAMPLE, MORPHINE?
19 A. YOU WOULD STAND AND OBSERVE THE RISE AND FALL OF THE
20 CHEST OF THE PATIENT, AND IF YOU COULDN'T SEE IT WITH YOUR
21 EYES, YOU COULD PUT YOUR HAND ON THEIR CHEST TO FEEL AND
22 COUNT THAT WITH A SECOND HAND OF A WATCH PER MINUTE.
23 Q. WOULD THERE BE ANY OTHER MONITORING FUNCTIONS THAT YOU
24 WOULD DO AFTER THE MEDICATION HAS BEEN ADMINISTERED?
25 A. TO DOCUMENT ANY IMPROVEMENT IN THE PATIENT'S CONDITION
3146
1 OR ANY CHANGE IN THE PATIENT'S CONDITION SUBSEQUENT TO THE
2 ADMINISTRATION OF THE MORPHINE, A CHANGE IN THE RESPIRATORY
3 RATE, SIGNS AND SYMPTOMS THE PATIENT MAY SHOW THAT INDICATE
4 THE MEDICATION WAS HELPFUL OR NOT HELPFUL IN RELIEF OF THEIR
5 DISCOMFORT.
6 Q. DO YOU STILL HAVE PATIENT JUDITH LARSEN'S BINDER IN
7 FRONT OF YOU?
8 A. UH-HUH.
9 Q. TURN TO 583 PLEASE.
10 A. OKAY.
11 Q. AND THAT IS ANOTHER NOTE WRITTEN BY YOU, IS THAT RIGHT?
12 A. CORRECT.
13 Q. WHAT IS THE DATE?
14 A. LOOKS LIKE 1/1/96.
15 Q. AND THAT WAS, ONCE AGAIN, AN ELEVEN SEVEN NIGHT SHIFT
16 FREE TEXT NOTE, IS THAT RIGHT?
17 A. CORRECT.
18 Q. IT SAYS, PATIENT CONTINUES TO EXHIBIT CHEYNE-STOKES
19 RESPIRATIONS.
20 DID I READ THAT CORRECTLY?
21 A. CORRECT.
22 Q. WHAT IS THE SIGNIFICANCE OF YOU CHARTING THAT?
23 A. CHEYNE-STROKES RESPIRATIONS ARE A RHYTHM OF RESPIRATIONS
24 THAT ARE PARTICULAR TO A DYING PATIENT.
25 Q. AND THEN YOU GO, PERIODS OF APNEA, 15 TO 20 SECONDS.
3147
1 WHAT DOES THAT MEAN?
2 A. THOSE ARE PERIODS OF TIME DURING WHICH THE PATIENT DOES
3 NOT TAKE A BREATH.
4 Q. AND WHAT IS THE SIGNIFICANCE OF THE FACT THAT YOU
5 CHARTED THAT?
6 A. THE LONGER THE PERIODS OF APNEA, THE CLOSER THE PERIOD
7 OF DEATH -- THE CLOSER TO DEATH THE PATIENT IS BECOMING.
8 Q. NOW, YOU SAY, HAS REFLEXIVE HAND GRASP. WHAT DO YOU
9 MEAN REFLEXIVE HAND GRASPS?
10 A. IT MEANS THAT IF YOU PLACE AN OBJECT IN THAT PERSON'S
11 HAND, THEY CLOSE THEIR FINGERS AROUND IT MUCH LIKE AN INFANT
12 WOULD DO. A NEWBORN HAS THE SAME GRASP REFLEX. PERSONS WHO
13 ARE DYING, HAVE HAD SEVERE BRAIN INJURY OR THEIR BRAIN HAS
14 REGRESSED IN THE DEATH PROCESS TO VERY BASIC INFANTILE SORTS
15 OF REFLECTIONS. AS A NURSE YOU WOULD DOCUMENT THE PRESENCE
16 OF THOSE, SHOWING WHERE IN THE DEATH AND DYING PROCESS WAS
17 THIS PATIENT.
18 Q. NOW, IF WE PROCEED DOWN THROUGH NO -- F., YOU HAVE
19 INDICATIONS OF SOME VITAL SIGNS. YOU REFER TO, NO FAMILY
20 VISITORS TONIGHT. AND THAT WOULD BE ON THE FIRST. WHY DID
21 YOU WRITE THAT IN THE NOTE?
22 A. IT IS CERTAINLY PART OF MY CARE PLAN OF THIS PATIENT TO
23 DOCUMENT AND TO SHOW AND GIVE SUPPORT TO FAMILY MEMBERS IN
24 THE DYING PROCESS OF THIS PATIENT, AND IT WOULD BE IMPORTANT
25 TO SAY WHETHER OR NOT THE FAMILY WAS THERE, AND WHETHER OR
3148
1 NOT IF THEY WERE THERE, DID I GIVE THEM ANY ASSISTANCE.
2 Q. IF YOU'LL GO TO 586 PLEASE.
3 A. OKAY.
4 Q. THIS IS ALSO ANOTHER NOTE CONCERNING PATIENT JUDITH
5 LARSEN. 1/2 OF '96, AND ONCE AGAIN, YOU'RE WORKING THAT
6 NIGHT SHIFT 11:00 TO 7:00, IS THAT RIGHT?
7 A. CORRECT.
8 Q. NOW, PARTICULARLY, I WANNA DIRECT YOUR ATTENTION TO
9 WHERE YOU SAY SOME -- IS THAT GROWING?
10 A. GROANING NOTED SEVERAL MINUTES PRIOR TO 0330 MORPHINE
11 I.M. MEDICATION.
12 Q. THAT WOULD BE MORPHINE I.M. MEDICATION?
13 A. UH-HUH.
14 Q. WHAT DOES GROANING SIGNIFY TO YOU?
15 A. GROANING IS AN EXPRESSION OF PAIN AND ONE THAT AS A
16 NURSE I WAS TAUGHT TO ASSESS. PARTICULARLY IN A NON VERBAL
17 DYING PATIENT, GROANING MAY BE THE ONLY EXPRESSION THAT THEY
18 CAN PRESENT. AND AS SUCH, IT IS MY RESPONSIBILITY AS THE
19 NURSE TO ALLEVIATE THAT DISCOMFORT, IF I CAN.
20 Q. NOW, IT'S STATED IN CONJUNCTION WITH YOUR INDICATION OF
21 A 3:30 A.M. MEDICATION OF MORPHINE. IS THERE A PARTICULAR
22 REASON WHY THOSE TWO ARE TOGETHER?
23 A. IT RELATES TO THE REASON WHY I WOULD GIVE THE
24 MEDICATION. IT IS MY OPTION TO GIVE A PARTICULAR DOSE OF
25 MEDICATION THAT IS ASSIGNED A PARTICULAR HOUR FOR
3149
1 ADMINISTRATION, SAY 3:00 O'CLOCK TO GIVE THAT, OR
2 4:00 O'CLOCK, TO GIVE IT ANYWHERE HALF HOUR BEFORE OR HALF
3 HOUR AFTER. THE OPTION FOR THE NURSE IS WITHIN THE HOUR OF
4 THE WRITTEN TIME FOR ADMINISTRATION. BASED ON A NURSING
5 ASSESSMENT, YOU COULD GIVE THAT DOSE EARLIER OR LATER
6 DEPENDING UPON THE LEVEL OF DISTRESS OF THE PATIENT. IF
7 THEY'RE VERY COMFORTABLE, YOU MAY WAIT UNTIL THE LATTER HALF
8 OF THE HOUR. IF UNCOMFORTABLE, GIVE IT EARLIER.
9 Q. AND WHAT DOES 3:30 SIGNIFY TO YOU IN THE CONTEXT OF THIS
10 NOTE?
11 A. IT COULD MEAN THAT I GAVE THE MEDICATION HALF HOUR
12 EARLY.
13 Q. NOW, YOU INDICATE TURNED AT TWO HOURS A LITTLE BIT
14 FURTHER DOWN THERE. DO YOU SEE THAT?
15 A. TURNED EVERY TWO HOURS.
16 Q. I'M SORRY, TURNED EVERY TWO HOURS. THANK YOU. TELL US
17 PLEASE WHAT TURNING IS IN THIS CONTEXT?
18 A. THAT IS A NURSING MEASURE TO CHANGE THE POSITION OF THE
19 PATIENT, A PATIENT WHO IS SEVERELY ILL IS NOT ABLE OFTEN TO
20 HAVE THE STRENGTH TO TURN THEMSELVES IN THE BED, EVEN TO
21 CHANGE THEIR POSITION SLIGHTLY. IT THEREFORE BECOMES THE
22 RESPONSIBILITY OF THE NURSE TO PROVIDE THAT ABILITY TO THE
23 PATIENT AND MOVE THEM AROUND. IF YOU DO NOT DO THAT, THE
24 RISK FOR BREAKDOWN OF THE SKIN AND ULCER FORMATION IS
25 EXTREMELY HIGH. SKIN BREAKDOWN CAN OCCUR IN A PATIENT IN
3150
1 TWO HOURS' TIME --
2 MS. BARLOW: YOUR HONOR, NOT ONLY IS THIS
3 REPETITIVE, BUT IT'S GONE BEYOND THE QUESTION.
4 THE COURT: LET ME REPHRASE THE QUESTION.
5 MR. STIRBA: SURE.
6 Q. DOES TURNING HAVE ANY SIGNIFICANCE TO YOUR ASSESSMENT OF
7 PAIN?
8 A. TURNING EVERY TWO HOURS IS A COMFORT MEASURE. YOU CAN
9 OBSERVE DISCOMFORT IN A PATIENT IF YOU MOVE THEM.
10 OFTENTIMES WHEN YOU TURN A PATIENT, THEY WILL GRIMACE. THAT
11 DOES NOT NEGATE THE NEED TO MAKE THEM MORE COMFORTABLE.
12 Q. IF YOU WOULD TURN TO 507 PLEASE, WHICH IS IN THE MED
13 GRAPHS SECTION OF PATIENT JUDITH LARSEN'S BINDER.
14 A. I'M SORRY, 50 --
15 Q. 507 PLEASE.
16 A. OKAY.
17 Q. DO YOU HAVE THAT IN FRONT OF YOU?
18 A. YES.
19 Q. WHAT DO YOU RECOGNIZE THAT TO BE?
20 A. THAT'S A MEDICATION ADMINISTRATION RECORD.
21 Q. AND DO YOU SEE YOUR INITIALS ON THAT DOCUMENT?
22 A. YES, I DO.
23 Q. AND THEY LOOK LIKE A FAIRLY GOOD REPRESENTATION OF L.W.
24 AT 30, 330, AND 630 HOURS, IS THAT RIGHT?
25 A. CORRECT.
3151
1 Q. AND CAN YOU TELL -- ARE YOU GIVING MORPHINE OR
2 ADMINISTERING MORPHINE INJECTIONS AT THOSE TIMES AND ON THAT
3 DATE?
4 A. YES.
5 Q. GIVEN YOUR ASSESSMENT OF THE CIRCUMSTANCES OF THIS
6 PATIENT FROM A NURSING PERSPECTIVE, DID YOU FIND ANYTHING
7 INAPPROPRIATE ABOUT GIVING THOSE DOSES AT THOSE TIMES?
8 MS. BARLOW: OBJECTION, YOUR HONOR. SHE'S NOT BEEN
9 LISTED AS AN EXPERT, AND THAT CALLS FOR AN EXPERT OPINION.
10 THE COURT: SUSTAINED.
11 Q. (BY MR. STIRBA) DO YOU BELIEVE THAT IN GIVING THOSE
12 DOSES OF MEDICATION UNDER THOSE TIMES, THAT YOU WERE CAUSING
13 OR CONTRIBUTING IN ANY WAY TO THE DEATH OF JUDITH LARSEN?
14 A. NO.
15 MS. BARLOW: OBJECTION. THAT ALSO CALLS FOR AN
16 EXPERT OPINION. SHE'S NOT AN EXPERT.
17 THE COURT: OVERRULED.
18 Q. (BY MR. STIRBA) YOU MAY ANSWER.
19 A. NO, I DO NOT.
20 Q. WOULD YOU TELL US PLEASE WHY YOU DO NOT?
21 A. IF I HAD BELIEVED AT THE TIME THAT THE DOSE WAS
22 INAPPROPRIATE, I AS THE NURSE HAD WITHIN MY LICENSE THE
23 ABILITY TO HOLD THAT DOSE BASED ON MY ASSESSMENT OF THE
24 PATIENT. IT WAS MY ASSESSMENT OF THE PATIENT THAT
25 DISCOMFORT WAS PRESENT. I ADMINISTERED THE MEDICATION AS
3152
1 ORDERED.
2 Q. WHAT YOU DO MEAN WITHIN THE SCOPE OF YOUR LICENSE?
3 COULD YOU EXPLAIN THAT PLEASE?
4 A. A NURSE IS ALLOWED TO REFUSE TO ADMINISTER A MEDICATION
5 SHE BELIEVES TO BE INAPPROPRIATE OR HARMFUL TO A PATIENT.
6 Q. FINALLY, IF YOU COULD TURN IN THIS BINDER TO 596 PLEASE.
7 IT MIGHT BE IN THE OTHER TAB.
8 A. OKAY.
9 Q. DO YOU HAVE THAT IN FRONT OF YOU?
10 A. YES.
11 Q. TELL US PLEASE WHAT IS IN FRONT OF YOU.
12 A. SAYS SECTION OF THE NURSING CARE PLAN, TREATMENT PLAN.
13 Q. I'M SORRY?
14 A. A SECTION OF THE NURSING TREATMENT PLAN.
15 Q. I KNOW IT'S DIFFICULT, BUT SOMETIMES BECAUSE OF THIS
16 MACHINE, COULD YOU KEEP YOUR VOICE UP PLEASE?
17 A. SURE.
18 Q. AND IS THAT YOUR WRITING ON THIS DOCUMENT?
19 A. YES, IT IS.
20 Q. AND WHY DID YOU CREATE THIS DOCUMENT?
21 A. I CONTRIBUTED TO THIS DOCUMENT BECAUSE I WAS THE NURSE
22 CARING FOR THE PATIENT.
23 Q. AND THIS IS AN ALTERATION OR AMENDMENT OF THE CARE PLAN?
24 A. YES, IT IS.
25 Q. I WANNA GO OVER JUST THE COLUMNS, AND YOU'VE EXPLAINED
3153
1 TO US WHAT THE PURPOSE IS AND WHAT YOU'RE SAYING. THERE'S A
2 DATE THERE OF 1/2, AND IT HAS PROBLEM, CORRECT?
3 A. CORRECT.
4 Q. WHAT IS SUPPOSED TO BE REFERENCED IN THAT COLUMN
5 CONCERNING PROBLEM?
6 A. I'M SORRY, I DIDN'T UNDERSTAND THE QUESTION.
7 Q. GENERALLY, WHAT WOULD GO IN THE PROBLEM CATEGORY ON A
8 DOCUMENT SUCH AS THIS?
9 A. A NURSING -- IN THIS PARTICULAR -- IF I WERE
10 CONTRIBUTING TO IT AS THE NURSE, IT WOULD BE A NURSING
11 DIAGNOSIS OF CONCERNS FOR THE PATIENT OR THE FAMILY.
12 Q. OKAY. AND WHAT IS A NURSING DIAGNOSIS?
13 A. A NURSING DIAGNOSIS IS THOSE ITEMS THAT A NURSE IS
14 LICENSED TO TREAT BY WAY OF NURSING INTERVENTIONS.
15 Q. IN THIS -- THIS DOCUMENT, WHAT ARE THOSE FIRST TWO
16 LETTERS UNDER PROBLEM? I CAN'T READ THAT.
17 A. A.L.T. STANDING FOR ALTERATION.
18 Q. OH, ALTERATION, COPING, PATIENT AND FAMILY, DEATH AND
19 DYING ISSUES.
20 DID I READ THAT CORRECTLY?
21 A. CORRECT.
22 Q. WHAT DID THAT MEAN?
23 A. IT MEANS THAT THE PATIENT AND THE FAMILY ARE HAVING TO
24 DEAL WITH DEATH AND DYING ISSUES. THAT IS A CHALLENGE TO
25 ANY -- OR A FAMILY'S ABILITY TO COPE WITH A NEW PROBLEM.
3154
1 Q. THE NEXT COLUMN HAS EXPECTED OUTCOMES. I CAN'T READ
2 WHAT YOU CIRCLED. WHAT IS THAT?
3 A. WHAT I STATED?
4 Q. IT LOOKS LIKE AN I. BEFORE --
5 A. 1.
6 Q. THANK YOU. PATIENT WILL EXPERIENCE A PEACEFUL -- I
7 CAN'T READ THAT.
8 A. IT SAYS, PATIENT WILL EXPERIENCE A PEACEFUL DEATH FREE
9 FROM DISCOMFORT.
10 Q. AND WHAT DO YOU MEAN BY THAT?
11 A. THAT IN THE PROCESS OF THIS PATIENT'S DEATH, THERE WILL
12 BE MINIMAL STRESS, DISCOMFORT, PAIN TO THE PATIENT, AND THAT
13 WILL BE A COMFORTABLE EXPERIENCE FOR THEM.
14 Q. AND THEN IN THE LAST COLUMN WE HAVE NURSING
15 INTERVENTIONS. AND YOU HAVE LISTED ONE THROUGH NINE,
16 CORRECT?
17 A. CORRECT.
18 Q. LET'S GO OVER THEM ONE AT A TIME. FIRST IT SAYS MONITOR
19 VERSUS --
20 A. MONITOR VITAL SIGNS.
21 Q. VITAL SIGNS, THANK YOU, FREQUENTLY AS ORDERED. WHAT
22 DOES THAT MEAN?
23 A. THAT WOULD REFER TO A DEPENDENT NURSING MEASURE, THE
24 FREQUENCY OF VITAL SIGNS HAVING BEEN SPECIFIED BY THE
25 PHYSICIAN AND THE NURSE CARRYING OUT THOSE VITAL SIGNS,
3155
1 OBTAINING THOSE VITAL SIGNS, TEMPERATURE, BLOOD PRESSURE,
2 PULSE, RESPIRATION.
3 Q. DO YOU KNOW IF THAT WAS DONE IN THIS CASE?
4 A. I WOULD A -- IF THEY WERE DOCUMENTED IN THE RECORD, THEN
5 THEY WOULD BE DONE.
6 Q. WOULD YOU EXPECT THAT TO HAVE BEEN DONE?
7 A. YES.
8 MS. BARLOW: OBJECTION, YOUR HONOR. IT'S EITHER
9 DONE OR NOT DONE. IT'S EITHER IN THE RECORD OR NOT IN THE
10 RECORD. SPECULATION IS NOT HELPFUL AT THIS POINT.
11 THE COURT: OKAY. WELL --
12 MR. STIRBA: I AGREE, YOUR HONOR.
13 THE COURT: OKAY. THEY'LL DISREGARD THE LAST
14 STATEMENT OF THE WITNESS.
15 Q. (BY MR. STIRBA) TWO, COMFORT MEASURES, TURN EVERY TWO
16 HOURS, MOUTH CARE FREQUENTLY, DOES THAT SAY P.R.N.?
17 A. CORRECT.
18 Q. OKAY. WHAT IS THAT REFERRING TO?
19 MS. BARLOW: OBJECTION, YOUR HONOR. THAT IS
20 CUMULATIVE. WE HAVE ALREADY GONE INTO WHAT THAT MEANS WITH
21 THIS WITNESS -- OR THIS WITNESS AND WITH --
22 THE COURT: ARE YOU ASKING WHAT P.R.N. MEANS OR --
23 MR. STIRBA: NO, NO, WHAT THE -- WHAT THE CATEGORY
24 2 IS IN THE CARE OF THIS DOCUMENT WHICH --
25 THE COURT: IS YOUR OBJECTION P.R.N. OR WHOLE --
3156
1 MS. BARLOW: THE WHOLE THING. I MEAN SHE'S ALREADY
2 TESTIFIED AS TO WHAT SHE THINKS COMFORT MEASURES ARE,
3 TURNING IS, AND MOUTH CARE IS --
4 THE COURT: OVERRULED.
5 MS. BARLOW: -- IT'S REPETITIVE.
6 Q. (BY MR. STIRBA) YOU MAY ANSWER.
7 A. COULD YOU REPEAT THE QUESTION.
8 Q. SURE. NUMBER 2, WHAT DOES THAT MEAN IN THE CONTEXT OF
9 THIS DOCUMENT?
10 A. IT MEANS THAT THOSE MEASURES THAT I SPECIFIED WOULD BE
11 CARRIED OUT, TURNING THE PATIENT, CLEANING THE PATIENT'S
12 MOUTH, REMOVING EXCESS SECRETIONS, THAT WOULD INCLUDE THERE
13 AS OFTEN AS THE NURSE DETERMINED WAS NECESSARY.
14 Q. THREE, TALK?
15 A. WITH PATIENT.
16 Q. WITH PATIENT -- I'M SORRY, I CAN'T READ THE REST OF
17 THAT.
18 A. TALK WITH PATIENT WHEN PROVIDING CARE.
19 Q. WHAT -- WHAT IS THE SIGNIFICANCE OF THAT?
20 A. ALONG WITH VISION, HEARING IS ONE OF TWO OF THE FINAL
21 SENSES TO LEAVE A DYING PATIENT. AND ALTHOUGH THE PATIENT
22 MAY NOT BE ABLE TO RESPOND TO YOU VERBALLY OR LOOK AT YOU,
23 CERTAINLY AS AN AID IN COMFORT, YOU WOULD TALK TO THE
24 PATIENT TO LET THEM KNOW YOU WERE THERE.
25 Q. FOUR, VISIT PATIENT'S ROOM FREQUENTLY. WHY WOULD YOU DO
3157
1 THAT?
2 A. TO PREVENT THE PATIENT FROM DYING ALONE.
3 Q. FIVE, IT SAYS PROVIDING SOFTER LIGHTING, IS THAT RIGHT?
4 A. SOFT -- PROVIDE SOFT LIGHTING.
5 Q. AND WHAT IS THE SIGNIFICANCE IN THE CONTEXT OF THIS CARE
6 PLAN OF PROVIDING SOFT LIGHTING?
7 A. AGAIN, THAT VISION IS ONE OF THE LAST SENSES LOST BY A
8 DYING PATIENT, AND IT'S INAPPROPRIATE TO LEAVE THEM IN THE
9 DARK.
10 Q. THEN PROVIDE, LOOKS LIKE MORPHINE I.M. AS ORDERED FOR
11 PAIN, SLASH, DISCOMFORT, AND MONITOR EFFECTS.
12 DID I READ THAT CORRECTLY?
13 A. CORRECT.
14 Q. AND I BELIEVE YOU HAVE TESTIFIED ABOUT THE MONITORING
15 AND THE MORPHINE IN THIS CONTEXT, IS THAT RIGHT?
16 A. YES.
17 Q. SEVEN, ALLOW FAMILY MEMBERS TO VISIT AS NEEDED. I THINK
18 THAT'S SELF-EXPLANATORY.
19 A. UH-HUH.
20 Q. DO YOU AGREE?
21 A. YES.
22 Q. EIGHT, PROVIDE -- I CAN'T READ THAT?
23 A. PROVIDE EMOTIONAL SUPPORT FOR FAMILY. SUPPORT THE GRIEF
24 PROCESS.
25 Q. WHY IS THAT A NURSING INTERVENTION?
3158
1 A. BECAUSE NURSING IS NOT ONLY THE CARE OF THE PATIENT, BUT
2 ALSO THE FAMILY OF THE PATIENT. AND THE ROLE OF THE NURSE
3 IS TO LISTEN TO THE CONCERNS VOICED BY THE FAMILY REGARDING
4 THEIR LOVED ONE AND TO OFFER SUPPORT IF YOU CAN.
5 Q. THEN FINALLY NINE, NOTIFY FAMILY IF DEATH IS IMMINENT.
6 AND WHY DO YOU FEEL IT WAS NECESSARY TO STATE THAT?
7 A. SO THAT IF THEY CHOOSE, THE FAMILY CAN BE AT THE BEDSIDE
8 WITH THE PATIENT.
9 Q. IF YOU'D TURN NOW TO A BINDER, AND IT SHOULD HAVE ENNIS
10 ALLDREDGE'S NAME ON IT PLEASE.
11 A. OKAY.
12 Q. DO YOU HAVE THAT IN FRONT OF YOU?
13 A. YES.
14 Q. IF WOULD YOU TURN TO THE PHYSICIAN'S ORDER SECTION,
15 PARTICULARLY PAGE 13. DO YOU HAVE THAT?
16 A. YES.
17 Q. THERE'S AN ENTRY AT THE TOP, AND DO YOU SEE YOUR
18 SIGNATURE NOTED ON THAT DOCUMENT?
19 A. YES.
20 Q. AND THAT IS ABOVE 1/12/96, CORRECT?
21 A. CORRECT.
22 Q. IS THERE A TIME INDICATED?
23 A. I DON'T SEE ONE OTHER THAN --
24 Q. LIKE AN EYE TEST. RIGHT THERE, DO YOU SEE 2000?
25 A. OH, OKAY, DOWN THERE. THAT'S TIME AT WHICH I NOTED THE
3159
1 ORDER, YES.
2 Q. AND CAN YOU TELL US WHY YOU NOTED THIS PARTICULAR ORDER
3 IN THE FASHION THAT YOU DID?
4 A. THAT'S THE STANDARD OF HOW YOU WOULD NOTE AN ORDER.
5 BRACKET IT AND CO-SIGN IT AS THE PERSON WHO TRANSCRIBED THE
6 ORDER. AND I'M NOT ONLY THE PERSON WHO TOOK THE TELEPHONE
7 ORDER. I'M ALSO THE PERSON WHO PUT THOSE ORDERS IN THE
8 PLACE WHERE THEY WOULD BE CARRIED OUT BY THE NURSE ON THE
9 MEDICATION ADMINISTRATION RECORD, WHAT HAVE YOU, TREATMENT
10 PLAN.
11 Q. AND THE ORDER THAT YOU TOOK BY TELEPHONE WAS WHAT?
12 A. IT SAYS, TO START AN I.V., OF D. FIVE AND A HALF NORMAL
13 SALINE AT A 100 C.C.'S AN HOUR. TO OBTAIN A CHEM 7 IN THE
14 MORNING. AND MAY RESTRAIN WRISTS TO PREVENT PULLING OUT
15 I.V.
16 Q. DO YOU KNOW THE PURPOSE FOR THE ORDER CONCERNING THE
17 I.V. ON THIS DATE?
18 A. THAT WOULD TO BE PROVIDE HYDRATION TO THE PATIENT.
19 Q. DO YOU KNOW THE PURPOSE OF THE ORDER FOR THE CHEM TEST
20 ON THIS DATE?
21 A. TO MEASURE THE LEVEL OF HYDRATION IN THE PATIENT THE
22 FOLLOWING DAY.
23 Q. AND HOW WOULD THIS TEST GO ABOUT DOING THAT?
24 A. IT INCLUDES A MEASURE OF KIDNEY FUNCTION AND SODIUM.
25 THOSE ARE INDICATORS OF WHETHER OR NOT A PATIENT IS HYDRATED
3160
1 OR NOT.
2 Q. AND THEN FINALLY, THIS MAY RESTRAIN WRISTS TO PREVENT
3 PULLING OUT I.V. IS THERE ANY SIGNIFICANCE TO THE FACT THAT
4 YOU CHARTED THAT?
5 A. THAT WOULD BE AN INDICATION OF THE MEDICAL NECESSITY OF
6 THE FLUIDS. FOR ABSOLUTE MEDICAL NECESSITY, WE WOULD BE
7 ABLE TO RESTRAIN A PATIENT IN ORDER TO -- FOR THE MEDICAL
8 GREATER GOOD OF THE PATIENT. WITHOUT THE FLUIDS, THE
9 PATIENT WOULD CONTINUE TO DETERIORATE CERTAINLY.
10 Q. AND THAT IS ORDERED BY THE PHYSICIAN?
11 A. YES.
12 Q. IF YOU'LL TURN TO THE PAGE 18 IN THE PROGRESS NOTES. DO
13 YOU HAVE THAT IN FRONT OF YOU?
14 A. YES.
15 Q. ONCE AGAIN, THIS IS ANOTHER WEEKLY R.N. ADVOCATE NOTE BY
16 YOU, CORRECT?
17 A. CORRECT.
18 Q. IT STATES -- AND IT'S THE DATE OF 1/14 OF '96, CORRECT?
19 A. APPEARS TO BE, YES.
20 Q. WHAT IS THIS N.S.G. OUT HERE?
21 A. NURSING.
22 Q. PLEASE SEE DR. WEITZEL'S NOTE ABOVE RE: M.R.I. RESULTS.
23 THE PATIENT'S CARE PLAN HAS BEEN AMENDED TO REFLECT DEATH
24 AND DYING ISSUES. WHAT CARE PLAN ARE YOU REFERRING TO?
25 A. THE NURSING CARE PLAN AND THE PATIENT.
3161
1 Q. WOULD THIS BE SIMILAR TO THE AMENDMENT THAT YOU
2 TESTIFIED CONCERNING MISS LARSEN?
3 A. YES.
4 Q. PATIENT'S -- I'M SORRY, YEAH, PATIENT'S GOAL IS TO
5 EXPERIENCE A PEACEFUL DEATH FREE --
6 A. OF DISCOMFORT.
7 Q. -- OF DISCOMFORT. COULD YOU EXPLAIN WHAT THAT MEANS
8 PLEASE?
9 A. THAT THE PATIENT WOULD BE FREE OF THE DISCOMFORTS COMMON
10 TO A DYING PATIENT, WHICH INCLUDES CHEST CONGESTION,
11 DISCOMFORT WITH BREATHING, PAIN OF ANY SORT.
12 Q. THEN IT HAS MORPHINE AND ATIVAN I.M. ARE BEING PROVIDED
13 EVERY THREE HOURS AROUND THE CLOCK TO ASSURE PATIENT'S
14 COMFORT. THEN IT SAYS, PLEASE SEE NEW CARE PLAN FOR OTHER
15 ISSUES AND INTERVENTIONS BEING ADDRESSED. WHAT OTHER ISSUES
16 AND INTERVENTIONS ARE YOU REFERRING TO?
17 A. THEY WOULD BE DELINEATED IN THE CARE PLAN.
18 Q. IN THAT PARTICULAR NOTE AND BASED UPON YOUR ROLE AS THE
19 ADVOCATE, NURSE ADVOCATE FOR MR. ALLDREDGE, DID YOU MAKE ANY
20 NURSING ASSESSMENTS OF HIS CONDITION AT THAT TIME?
21 A. THE ASSESSMENT AS IT'S REFLECTED IN THE NOTES STATES
22 THAT THE PATIENT WAS APPROACHING DEATH OR GAVE THE
23 APPEARANCE OF APPROACHING DEATH, AND WAS IN NEED OF THE CARE
24 PROVIDED PATIENTS IN THAT SITUATION.
25 Q. THIS IS ANOTHER NOTE FROM MR. ALLDREDGE'S FILE. IT'S
3162
1 DATED 1/14/96. THIS IS A NURSING NOTE BY YOU ON THAT DATE,
2 IS THAT RIGHT?
3 A. CAN I --
4 Q. OH, I DIDN'T GIVE YOU A MED NUMBER. I'M SORRY. IT'S
5 77.
6 A. OKAY.
7 Q. IS THAT YOUR NOTE?
8 A. YES.
9 Q. ONCE AGAIN, IT APPEARS THAT YOU'RE WORKING THAT 11:00 TO
10 7:00 NIGHT SHIFT. YOU SAY, PATIENT'S LEVEL OF AWARENESS HAS
11 BEEN PROGRESSIVELY -- AND YOU PUT THAT IN QUOTES -- SINKING
12 OVER THE SHIFT. WHAT DO YOU MEAN BY THAT?
13 A. DECREASING PROGRESSIVELY OVER THE SHIFT.
14 Q. AND THEN YOU GO ON TO TALK ABOUT SOME THINGS AND YOU
15 INDICATE THAT THERE IS A DOSE OF MORPHINE 10 MILLIGRAMS AND
16 ATIVAN .5 MILLIGRAMS WERE GIVEN AT 4:30 DUE TO PATIENT'S
17 GRIMACING AND LABORED BREATHING. DO YOU SEE THAT?
18 A. YES.
19 Q. TELL US WHAT YOU MEAN BY GRIMACING AND WHY THAT WAS
20 SIGNIFICANT IN TERMS OF PROVIDING THE MEDICATION.
21 A. GRIMACING IS A COMMON RESPONSE TO PAIN RECOGNIZED
22 THROUGHOUT NURSING, RECOGNIZED BY ME AS A NURSE, AS A
23 RESPONSE TO PAIN. LABORED BREATHING ALSO INDICATES
24 DIFFICULTY IN DOING SO. THAT CAN BE VERY PAINFUL FOR A
25 DYING PATIENT. WORKING AGAINST THE CONGESTION IN THE LUNGS.
3163
1 Q. CAN YOU -- WHEN YOU USE THE TERM LABORED BREATHING, CAN
2 YOU DESCRIBE THE PATTERN THAT YOU ARE INDICATING IN THAT
3 NOTE?
4 A. LABORED BREATHING MEANS THE PATIENT HAS DIFFICULTY
5 TAKING A DEEP BREATH.
6 Q. DOES IT INDICATE OR INCLUDE THE PATIENT GASPING?
7 A. I BELIEVE IF I HAD SEEN THE PATIENT GASPING, I WOULD
8 HAVE DOCUMENTED THAT USING THAT WORD.
9 Q. AND THEN YOU GO ON TO INDICATE CHEYNE-STOKE RESPIRATION
10 WITH PERIODS OF APNEA LASTING UP TO 30 SECONDS. PATIENT WAS
11 GIVEN -- I CAN'T READ THAT.
12 A. NASO-TRACHEAL SUCTION.
13 Q. AND BY RESPIRATORY THERAPIST TIMES 1 AT 4:00 O'CLOCK.
14 WHAT EXACTLY IS THAT NASAL -- AS YOU JUST DESCRIBED IT?
15 A. NASO-TRACHEAL SUCTIONING MEANS A SUCTIONING CATHETER
16 GOES DOWN THE NOSE INTO THE BACK OF THE THROAT. NURSES ON
17 THE FLOOR GENERALLY SUCTION THROUGH THE MOUTH ONLY. WE
18 WOULD CALL UPON RESPIRATORY IF THE PATIENT NEEDED A DEEPER
19 FORM OF SUCTIONING IF THE SECRETIONS APPEARED TO BE DEEPER
20 AND WE COULDN'T REMOVE THEM BY ORAL SUCTIONING MEANS.
21 Q. AND THAT WAS DONE BY A RESPIRATORY THERAPIST?
22 A. YES.
23 Q. WHO WOULD HAVE ORDERED THAT THAT HAD BEEN DONE?
24 A. RESPIRATORY THERAPY WOULD HAVE BEEN ORDERED BY THE
25 PHYSICIAN.
3164
1 Q. AND WHAT IS THE PURPOSE OF THAT PARTICULAR PROCEDURE
2 THAT YOU'VE JUST DESCRIBED?
3 A. TO REMOVE SECRETIONS FROM THE AIRWAY OF THE PATIENT SO
4 THAT THEY CAN BREATHE BETTER.
5 Q. AND THEN YOU GO ON A LITTLE BIT FURTHER, AND IT SAYS --
6 I THINK IT SAYS, CONTINUES TO HAVE DEEP CHEST -- AND YOU PUT
7 IN QUOTES -- RATTLES AS OF 6:00 O'CLOCK. DOES RATTLE HAVE
8 ANY SIGNIFICANCE IN TERMS OF THE CONTEXT OF THIS NOTE?
9 A. IT MEANS THAT THE DEEPER SUCTIONING PROVIDED BY THE --
10 PROVIDED BY THE RESPIRATORY THERAPIST WAS NOT EFFECTIVE,
11 FIRST OF ALL. AND THAT THE CONGESTION WAS DEEPER INTO THE
12 LUNGS THAN COULD HAVE BEEN REMOVED BY A SUCTION CATHETER.
13 Q. GET THAT UP A LITTLE BIT MORE. FINALLY, YOU GO ON TO
14 SAY THAT DR. WEITZEL GAVE TELEPHONE ORDER FOR MORPHINE 10
15 MILLIGRAMS I.M. GIVEN IN LEFT GLUTEUS. NO RESPONSE FROM
16 PATIENT TO THAT NEEDLE STICK. FAMILY REMAINS WITH PATIENT
17 COMFORTING HIM AND TALKING WITH HIM, ASKING FOR HIM TO,
18 QUOTE, LET GO, UNQUOTE. WHAT DO YOU MEAN BY THAT?
19 A. BEGINNING WHERE?
20 Q. I'M REFERRING TO YOUR USE OF THE WORD, LET GO, IN
21 QUOTES.
22 A. IN MY PRACTICE AND MY EXPERIENCE, PATIENTS WHO ARE DYING
23 OFTEN WILL NOT DO SO UNTIL THE FAMILY MEMBER EXPRESSES TO
24 THEM IT IS OKAY TO DO SO. AND VERY OFTEN, FAMILY MEMBERS I
25 HAVE OBSERVED WILL COME VISIT WITH THE PATIENT, TELL THEM IT
3165
1 IS OKAY, AND SHORTLY THEREAFTER, THE PATIENT WILL DIE.
2 Q. IF YOU WOULD TURN TO 92 PLEASE. DO YOU HAVE THAT IN
3 FRONT OF YOU?
4 A. YES, I DO.
5 Q. WAS IS THIS DOCUMENT?
6 A. IT'S A MASTER TREATMENT PLAN.
7 Q. AND DOES THIS RELATE TO A PREVIOUS NOTE THAT YOU READ IN
8 THIS CHART?
9 A. IT'S THE CARE PLAN REFERRED TO REGARDING DEATH AND DYING
10 ISSUES FOR THIS PATIENT.
11 Q. SAYS UP AT THE TOP UNDER PROBLEM STATEMENT, DEATH AND
12 DYING ISSUES RELATING TO LEFT OCCIPITAL C.V.A. AND THEN YOU
13 HAVE IN PARENTHESES ACUTE 1/13/96. DO YOU KNOW WHERE THAT
14 INFORMATION CAME FROM?
15 A. FROM THE M.R.I. REPORT.
16 Q. AND THEN YOU HAVE -- WHAT IS THAT, A. AND B., WHAT DOES
17 THAT REFER TO?
18 A. AS EVIDENCED BY.
19 Q. AS EVIDENCED BY, AND WHAT IS THAT NEXT S.T. S. -- S. X.
20 A. SIGNS AND SYMPTOMS OF IMPENDING DEATH.
21 Q. AND THEN YOU INDICATE STRENGTHS AFFECTING THE PROBLEM,
22 INDICATING A SUPPORTING FAMILY, MEDICAL POWER OF ATTORNEY IN
23 PLACE. WAS -- AND THEN I THINK OVER THERE, WHAT DOES THAT
24 SAY IN THE MARGIN?
25 A. IT SAYS PATIENT IS A D.N.R.
3166
1 Q. IS THERE A SIGNIFICANCE THAT YOU REFER TO IN THIS
2 NURSING CARE PLAN, MEDICAL POWER OF ATTORNEY IN PLACE?
3 A. A MEDICAL POWER OF ATTORNEY IS A DESIGNATION BY THE
4 PATIENT WHEN THEY ARE OF SOUND MIND TO DESIGNATE A
5 SIGNIFICANT PERSON IN THEIR LIFE, WHETHER THAT BE A RELATIVE
6 OR ANOTHER PERSON, TO MAKE MEDICAL DECISIONS FOR THEM SHOULD
7 THEY BECOME UNABLE TO DO SO THEMSELVES.
8 Q. YOU HAVE SHORT-TERM GOALS LISTED. ONE, PATIENT WILL
9 EXPERIENCE A PEACEFUL DEATH FREE FROM DISCOMFORT.
10 DID I READ THAT CORRECTLY?
11 A. CORRECT.
12 Q. AND THEN YOU HAVE A NUMBER OF SPECIFIC INTERVENTIONS
13 INDICATED AS WELL, IS THAT RIGHT?
14 A. YES.
15 Q. IF YOU WOULD NOW TURN TO A BINDER THAT I THINK IS UP
16 THERE TO YOUR LEFT, IT WOULD BE PATIENT LYDIA SMITH'S BINDER
17 PLEASE. IF YOU WOULD TURN INITIALLY PLEASE TO 719. IT'S IN
18 THE PROGRESS NOTE PORTION OF THE BINDER. DO YOU HAVE THAT?
19 A. YES, I DO.
20 Q. MISS STEVENSON, YOU RECOGNIZE YOUR WRITING ON THIS
21 PARTICULAR PROGRESS NOTE?
22 A. I DO.
23 Q. IS THIS ANOTHER WEEKLY R.N. ADVOCATE NOTE THAT YOU WROTE
24 CONCERNING A PATIENT LYDIA SMITH?
25 A. YES.
3167
1 Q. HAVE YOU MADE CERTAIN NURSING ASSESSMENTS ABOUT HER
2 CONDITION AS REFLECTED IN THIS NOTE?
3 A. YES.
4 Q. WOULD YOU TELL US PLEASE WHAT THOSE ASSESSMENTS WERE?
5 A. IT STATES, SHE'S UNABLE TO SWALLOW FOOD, FLUID, OR
6 MEDICATION. NOT VISUALLY RESPONSIVE TO HER ENVIRONMENT.
7 DEMONSTRATING REGRESSED REFLEXES. THE REFLEX OF GRABBING, A
8 SNOUT REFLEX. MINIMALLY -- PUPILS MINIMALLY REACTIVE TO
9 LIGHT. CHEYNE-STOKES RESPIRATIONS.
10 Q. WHAT IS THE SIGNIFICANCE OF YOU HAVING WRITTEN AND
11 DESCRIBED THOSE SYMPTOMS THAT SHE WAS EXPERIENCING AT THAT
12 TIME?
13 A. THOSE ARE NURSING OBSERVATIONS OF A PATIENT WHO IS
14 APPROACHING DEATH.
15 Q. YOU GO ON TO SAY, SHE IS RECEIVING MORPHINE 5 MILLIGRAMS
16 EVERY 3 HOURS FOR COMFORT. THE CARE PLAN HAS BEEN CHANGED
17 TO REFLECT PATIENT AND FAMILY NEEDS AROUND DEATH AND DYING
18 ISSUES. AND THEN YOUR SIGNATURE, IS THAT RIGHT?
19 A. CORRECT.
20 Q. IS THAT CARE PLAN AMENDMENT SIMILAR TO THE CARE PLAN
21 AMENDMENT THAT YOU TESTIFIED TO CONCERNING PATIENT JUDITH
22 LARSEN, AND THAT YOU WERE JUST SHOWN CONCERNING MR.
23 ALLDREDGE?
24 A. YES, IT WOULD BE.
25 Q. IF YOU WOULD TURN PLEASE TO 800, WHICH IS IN THE NURSING
3168
1 NOTE SECTION.
2 A. OKAY.
3 Q. ONCE AGAIN ELEVEN SEVEN, IT'S A NIGHT SHIFT FREE TEXT.
4 THAT'S WRITTEN BY YOU, IS THAT RIGHT?
5 A. THAT'S CORRECT.
6 Q. I WANNA DIRECT YOUR ATTENTION SPECIFICALLY TO THE AREA
7 AT THE BOTTOM WHERE YOU DESCRIBE AND STATE, POSTURE IS RIGID
8 AT TIMES. IS THERE A SIGNIFICANT -- IS ANYTHING SIGNIFICANT
9 ABOUT THE FACT THAT YOU CHARTED THAT AT THAT TIME?
10 A. RIGIDITY CAN BE AN INDICATION OF THEIR DISCOMFORT. IT
11 CAN BE, ONCE AGAIN, ONE OF THOSE MORE REGRESSED REFLEXES
12 THAT PATIENTS EXPERIENCE WHEN THEY DIE.
13 Q. AND IF COULD YOU TURN TO 802 PLEASE. DO YOU HAVE THAT
14 IN FRONT OF YOU?
15 A. YES.
16 Q. AND IS THAT YOUR NOTE ON JANUARY 8 OF 1996?
17 A. YES.
18 Q. THE 11:00 TO 7:00 NIGHT SHIFT AGAIN AS WELL, TRUE?
19 A. YES.
20 Q. IF YOU COULD READ PLEASE FROM WHERE IT SAYS, NIGHT SHIFT
21 FREE TEXT DOWN TO THE 2400 DOSE OMITTED, FOR US.
22 A. OKAY. PATIENT LYING IN BED WITH EYES OPEN THROUGHOUT
23 SHIFT. DEMONSTRATES MUCH REFLEXIVE GRASPING IN RESPONSE TO
24 PHYSICAL STIMULI. UNABLE TO MAKE ANY VERNAL RESPONSES.
25 MORPHINE EVERY 3 HOURS I.M. AS SCHEDULED FOR COMFORT. 2400
3169
1 DOSE OMITTED DUE TO PATIENT APPEARED IN NO ACUTE DISTRESS AT
2 THE TIME.
3 Q. CAN YOU TELL LOOKING AT THE NOTE IN ADDITION TO WHAT YOU
4 STATE IN THE NOTE, WHY YOU WITHHELD THE 2000 DOSE OF
5 MORPHINE?
6 A. IT STATES ADDITIONALLY THAT I WAS ATTENDING TO ANOTHER
7 PATIENT, BEING THE ONLY NURSE ON THE FLOOR. YOU PRIORITIZE
8 YOUR LIST. IF THE PATIENT WAS NOT UNCOMFORTABLE, THEN
9 MISSING A DOSE WOULD HAVE NOT DONE HER ANY HARM.
10 Q. NOW, IF YOU CONTINUE ON WITH THAT PARTICULAR NOTE, AFTER
11 YOU STATE FAMILY, YOU SAY 0300 DOSE GIVEN AT 2:30.
12 DO YOU SEE THAT?
13 A. YES.
14 Q. WHAT IS THE SIGNIFICANCE OF THAT STATEMENT?
15 A. THAT MEANS THAT A DOSE SCHEDULED FOR 3:00 O'CLOCK WAS
16 GIVEN WITHIN THAT HALF HOUR RANGE BEFORE, THAT STILL WOULD
17 HAVE BEEN WITHIN THE HOUR SO THAT I COULD HAVE GIVEN THE
18 3:00 O'CLOCK DOSE BETWEEN 2:30 --
19 Q. WHY WOULD YOU HAVE GIVEN A 3:00 O'CLOCK MAINTENANCE DOSE
20 AT 2:30?
21 A. IT MAY HAVE BEEN MY IMPRESSION THAT THE PATIENT WAS THEN
22 BECOMING UNCOMFORTABLE.
23 Q. THEN YOU ALSO HAVE RESPIRATIONS RATE 10 TO 12. DO YOU
24 SEE THAT?
25 A. UH-HUH.
3170
1 Q. IS THERE REASON WHY YOU WOULD HAVE CHARTED THAT AT THAT
2 TIME?
3 A. TO INDICATE THE PATIENT'S CONDITION, THAT THE
4 RESPIRATORY RATE WAS ADEQUATE.
5 Q. IF YOU COULD TURN TO THE MEDICATION ADMINISTRATION
6 RECORD, WHICH IS UNDER MEDS AND GRAPHS IN THAT BINDER. AND
7 I'LL SPECIFICALLY DIRECT YOUR ATTENTION -- CAN YOU LOOK FOR
8 THE GRAPHS THAT INDICATED MORPHINE SULFATE ORDERS I.M. ON
9 THE 7TH OF JANUARY OF 1996?
10 A. OKAY.
11 Q. DO YOU HAVE THAT IN FRONT OF YOU?
12 A. I DO.
13 Q. DOES THAT INDICATE THAT YOU GAVE A MORPHINE INJECTION ON
14 THAT DAY TO PATIENT LYDIA SMITH?
15 A. THERE WERE TWO DOSES GIVEN AND ONE DOES WAS HELD.
16 Q. OKAY. AND WHEN WAS THE -- THE TWO DOSES THAT WERE GIVEN
17 ON THAT DAY?
18 A. DURING THE 3:00 O'CLOCK HOUR AND THE 6:00 O'CLOCK HOUR.
19 Q. AND WERE THOSE GIVEN BY YOU?
20 A. I WAS THE PERSON WHO SIGNED OUT THE MEDICATION. I
21 ASSUME THAT I WAS THE PERSON WHO GAVE THE MEDICATION.
22 Q. WHEN YOU GAVE THOSE DOSES OF MORPHINE ON THAT DAY, DID
23 YOU BELIEVE THAT YOU WERE CAUSING OR CONTRIBUTING TO THE
24 DEATH OF LYDIA SMITH?
25 A. NO.
3171
1 Q. AND WHY DO YOU SAY THAT?
2 A. BECAUSE IF I BELIEVED THAT I WAS CAUSING THE PATIENT
3 HARM, I WOULD HAVE HELD THE DOSE.
4 Q. IF YOU'D ALSO PLEASE TURN TO THE SECTION OF THE
5 MEDICATION ADMINISTRATION RECORDS WHICH WOULD BE FOR THE 8TH
6 OF JANUARY OF 1996.
7 A. IS THERE --
8 Q. IN FACT, IT MAY BE -- I WAS THINKING IT WAS THE SAME
9 PAGE AS 742.
10 A. WHAT IS THE DATE?
11 Q. ON THE 8TH.
12 A. THERE'S A HOLE WHERE THE BINDER'S GONE THROUGH, SO IT
13 MAY BE THE SAME DATE. THERE ARE TWO ORDERS FOR MORPHINE ON
14 THAT DATE.
15 Q. AND WERE THOSE ADMINISTERED BY YOU?
16 A. NO. ARE YOU REFERRING TO THE 10 MILLIGRAM DOSE?
17 Q. YES.
18 A. NO.
19 Q. OKAY. IF YOU WOULD TURN TO MR. ALLDREDGE'S BINDER
20 PLEASE, SPECIFICALLY HIS MEDICATION AND GRAPHS RECORD. I'LL
21 DIRECT YOUR ATTENTION SPECIFICALLY TO PAGE 47.
22 A. OKAY.
23 Q. DO YOU HAVE THAT IN FRONT OF YOU?
24 A. YEAH.
25 Q. DOES IT INDICATE ON THE 13TH THAT YOU ADMINISTERED
3172
1 MORPHINE PURSUANT TO AN ORDER TO MR. ALLDREDGE?
2 A. YES.
3 Q. AND WHAT TIMES WOULD YOU HAVE ADMINISTERED MORPHINE TO
4 HIM ON THE 13TH?
5 A. IT'S STATES ON 0200 AND 0430.
6 Q. AT THE TIME THAT YOU ADMINISTERED THOSE DOSES OF
7 MORPHINE ON THE 13TH, DID YOU BELIEVE THAT YOU WERE CAUSING
8 OR CONTRIBUTING TO HIS DEATH?
9 A. IF I HAD BELIEVED THAT, I WOULD HAVE HELD THE DOSE.
10 Q. FINALLY, IF YOU COULD PULL JUDITH LARSEN'S BINDER AGAIN
11 PLEASE. AND IF YOU COULD TURN TO THE MED GRAPHS SECTION
12 ONCE AGAIN, AND I'LL SPECIFICALLY DIRECT YOUR ATTENTION TO
13 MORPHINE THAT WAS GIVEN ON THE 31ST OF DECEMBER. AND I'LL
14 TRY TO GET A PAGE REFERENCE FOR YOU SHORTLY.
15 YES, IT WOULD BE 497 IS THE PAGE.
16 A. YES.
17 Q. AND DOES IT REFLECT THERE THAT YOU GAVE MORPHINE
18 INJECTIONS TO JUDITH LARSEN?
19 A. YES.
20 Q. ON THE 31ST?
21 A. YES.
22 Q. AND THAT'S DESIGNATED BY YOUR INITIALS, IS THAT RIGHT?
23 A. YES.
24 Q. AND WHAT TIMES DID YOU DO THAT?
25 A. AT 0230 AND 0630.
3173
1 Q. AND DID YOU BELIEVE THAT AT THE TIME YOU ADMINISTERED
2 THOSE DOSES, THAT YOU WERE CAUSING OR CONTRIBUTING TO THE
3 DEATH OF JUDITH LARSEN?
4 A. NO.
5 Q. TELL US WHY NOT PLEASE.
6 A. BECAUSE IF I HAD BELIEVED I WAS DOING HER HARM, I WOULD
7 HAVE HELD THE DOSE.
8 Q. SIMILARLY, YOU -- ALSO ON THAT PAGE IS INDICATED THAT
9 YOU GAVE TWO INJECTIONS OF MORPHINE ON JANUARY 1, IS THAT
10 RIGHT?
11 A. YES.
12 Q. DID YOU BELIEVE AT THE TIME THAT YOU WERE GIVING THOSE
13 INJECTIONS THAT YOU CAUSED OR CONTRIBUTING TO HER DEATH?
14 A. NO.
15 Q. IF YOU WOULD TURN TO PAGE 507 PLEASE. IT'S IN THE SAME
16 SECTION.
17 A. OKAY.
18 Q. DOES THAT ALSO INDICATE BY YOUR INITIALS THAT YOU GAVE
19 MORPHINE INJECTIONS TO PATIENT JUDITH LARSEN ON JANUARY 2ND
20 OF 1996?
21 A. YES.
22 Q. AND CAN YOU TELL US PLEASE THE TIMES THAT ARE INDICATED?
23 A. IT'S 0030, 0330, AND 0630.
24 Q. AND DID YOU BELIEVE AT THE TIME THAT YOU ADMINISTERED
25 THOSE INJECTIONS THAT YOU WERE CAUSING OR CONTRIBUTING TO
3174
1 THE DEATH OF JUDITH LARSEN?
2 A. NO.
3 Q. AND TELL US PLEASE AGAIN WHY NOT.
4 A. BECAUSE IF I BELIEVED THAT TO BE TRUE, I WOULD HAVE HELD
5 THE DOSE.
6 MR. STIRBA: THAT'S ALL I HAVE AT THIS TIME, YOUR
7 HONOR. THANK YOU.
8 THE COURT: OKAY. LADIES AND GENTLEMEN, RATHER
9 THAN TAKE A BREAK, WE STARTED AT 3:25, WHAT I PROPOSE DO,
10 WHY DON'T WE JUST STAND FOR A COUPLE MINUTES, THEN WE CAN
11 START WITH THE CROSS-EXAMINATION. AND WE'LL GO UNTIL
12 5:00 O'CLOCK TODAY. SO IF YOU WANNA JUST STRETCH OR RELAX
13 FOR A MINUTE, THEN WE CAN --
14 (THE COURT TOOK A BREAK IN PLACE.)
15 THE COURT: WELL, HAS EVERYONE STOOD UP ENOUGH SO
16 THAT WE CAN STAY AWAKE? OKAY. THEN LET'S BE SEATED PLEASE.
17 MISS BARLOW.
18 MS. BARLOW: THANK YOU, YOUR HONOR.
19 CROSS-EXAMINATION
20 BY MS. BARLOW:
21 Q. GOOD AFTERNOON, MRS. STEVENSON. YOU WORK FOR THE
22 VETERANS' ADMINISTRATION, IS THAT CORRECT?
23 A. YES.
24 Q. ARE THEY MOSTLY GERIATRIC PATIENTS THEN THAT YOU WORK
25 WITH?
3175
1 A. I AM THE GERIATRIC NURSE PRACTITIONER. I WORK -- MY
2 TIME IS SPLIT BETWEEN A GERIATRIC OUTPATIENT CLINIC AND
3 NURSING HOME PATIENTS.
4 Q. DID YOU SAY YOU WERE WORKING ON YOUR MASTER'S AT THE
5 TIME YOU WORKED AT DAVIS NORTH HOSPITAL?
6 A. WORKING ON AND COMPLETED MY MASTER'S.
7 Q. HAD YOU COMPLETED IT -- DID YOU GET YOUR MASTER'S DEGREE
8 DURING THE DECEMBER '95 TO JANUARY '96 TIME FRAME?
9 A. I COMPLETED ALL COURSE WORK AND THESIS. I WAS AWARDED
10 THE DIPLOMA IN AUGUST.
11 Q. THEY WILL ONLY GRADUATE PEOPLE AT CERTAIN TIMES, WON'T
12 THEY. DO YOU RECALL THE CRITERIA FOR ADMISSION TO THE
13 GEROPSYCH UNIT?
14 A. SPECIFICALLY, NO. I KNOW THAT THERE WAS A SPECIFIED
15 CRITERIA FOR ADMISSION, YES.
16 Q. AND IN THAT CRITERIA WAS BASICALLY THAT THE PSYCHIATRIC
17 PROBLEMS HAD TO BE MORE SEVERE THAN THEIR MEDICAL PROBLEMS
18 TO GO INTO THE UNIT?
19 A. THAT WAS THE PLAN AS I RECALL, YES.
20 Q. AND IN FACT, THEY NEEDED TO BE MEDICALLY STABLE BECAUSE
21 IT REALLY WASN'T A MEDICAL UNIT; IT WAS A PSYCHIATRIC UNIT,
22 ISN'T THAT CORRECT?
23 A. THAT WAS THE GOAL OF THE UNIT, YES.
24 Q. WHEN DID YOU START WITH THE UNIT?
25 A. I HAVE POOR RECOLLECTION OF EXACT DATES, BUT IT WAS '95,
3176
1 SOMETHING LIKE THAT. JANUARY MAYBE?
2 Q. SO YOU STARTED FIRST PART OF '95 DURING THE WINTER
3 STILL?
4 A. I HAVE NO EXACT RECOLLECTION OF THAT.
5 Q. BUT IT WASN'T JUST RIGHT IN DECEMBER OF 1995; YOU HAD
6 BEEN ON THE UNIT LONGER THAN THAT.
7 A. I'D BEEN ON THE UNIT FOR A WHILE. IT WAS AT LEAST A
8 YEAR I THINK MY EMPLOYMENT THERE.
9 Q. HAD MORPHINE BEEN USED ON THIS UNIT PRIOR TO THE
10 PATIENTS WE'RE TALKING ABOUT HERE TO YOUR KNOWLEDGE?
11 A. I HAVE NO RECOLLECTION OF THAT.
12 Q. AFTER THE DEATH OF THESE PATIENTS, WERE YOU STILL
13 WORKING ON THE UNIT?
14 A. YES, I WAS.
15 Q. AND DID THERE COME A TIME WHEN YOU WERE BASICALLY -- THE
16 WHOLE UNIT WAS BASICALLY TOLD THAT MORPHINE WOULD NOT BE
17 ADMINISTERED ON THIS UNIT --
18 MR. STIRBA: I'M GONNA OBJECT, YOUR HONOR.
19 RELEVANCY. BEYOND THE SCOPE.
20 THE COURT: SUSTAINED.
21 Q. (BY MS. BARLOW) YOU TESTIFIED AS TO SOME OF YOUR
22 HABITS. DO YOU RECALL WHAT TIME OF DAY DR. WEITZEL WOULD
23 COME IN TO SEE THESE PATIENTS?
24 MR. STIRBA: ARE YOU TALKING ABOUT THESE FIVE
25 PATIENTS?
3177
1 MS. BARLOW: THESE PATIENTS.
2 THE COURT: THAT'S WHAT THE QUESTION WAS.
3 THE WITNESS: CAN I ANSWER THE QUESTION?
4 THE COURT: YES.
5 THE WITNESS: COULD YOU REPEAT IT? I'M SORRY.
6 Q. (BY MS. BARLOW) DO YOU RECALL WHAT TIME OF DAY DR.
7 WEITZEL WOULD COME IN TO SEE THESE PATIENTS?
8 A. THAT COULD VARY ACCORDING TO HIS SCHEDULE. AND WHAT WAS
9 HAPPENING ON THE UNIT.
10 Q. YOU WORKED THE 11:00 TO 7:00 SHIFT. DID YOU SEE HIM
11 COME IN BEFORE 7:00 IN THE MORNING?
12 A. THERE WERE OCCASIONS, YES.
13 Q. DID YOU SEE HIM COME IN AFTER 11:00 O'CLOCK AT NIGHT?
14 A. THERE WERE OCCASIONS, YES.
15 Q. WHEN DID YOU GET THE RECORDS TO REVIEW FOR YOUR
16 TESTIMONY TODAY?
17 A. I'VE SEEN -- I DON'T RECALL EXACTLY WHEN I FIRST SPOKE
18 WITH MR. STIRBA, BUT WE HAD A MEETING IN PENNSYLVANIA DURING
19 WHICH TIME HE BROUGHT SOME RECORDS AND I REVIEWED THEM.
20 Q. WHEN WAS THAT MEETING IN PENNSYLVANIA?
21 A. COUPLE MONTHS AGO?
22 Q. COUPLE MONTHS, YOU SAY?
23 A. HUH?
24 Q. I'M SORRY --
25 A. I'M SORRY, I --
3178
1 THE COURT: YOU NEED THAT ON RIGHT NOW?
2 MR. STIRBA: I'LL TURN IT OFF.
3 MS. BARLOW: I MAY -- I MAY NEED IT -- WELL --
4 THE COURT: WE COULD TURN IT OFF AND TURN IT ON.
5 MS. BARLOW: YEAH, LET'S TURN IT OFF. IT DOES GET
6 PRETTY NOISY.
7 THE WITNESS: I'LL TRY TO BE LITTLE LOUDER FOR YOU.
8 Q. (BY MS. BARLOW) OKAY.
9 A. I'M RUNNING OUT OF VOICE.
10 Q. DID YOU MEET WITH COUNSEL AGAIN AFTER THAT MEETING IN
11 PENNSYLVANIA ABOUT YOUR TESTIMONY TODAY?
12 A. ONLY TO REVIEW RECORDS THE DAY PRIOR.
13 Q. YESTERDAY YOU MET WITH HIM?
14 A. UH-HUH.
15 Q. WERE YOU THERE WHEN ANY OF THESE FIVE PATIENTS DIED?
16 A. I BELIEVE THERE ARE SOME NOTES THAT STATE THAT I WAS
17 PRESENT. I DON'T RECALL WHICH SPECIFICALLY.
18 Q. AND IN FACT, MOST OF YOUR TESTIMONY REALLY ISN'T BASED
19 ON AN INDEPENDENT RECOLLECTION OF WHAT HAPPENED WITH THESE
20 FIVE PATIENTS, ISN'T THAT CORRECT?
21 A. THAT WAS SEVERAL YEARS AGO AND I'VE SEEN MANY PATIENTS
22 BETWEEN NOW AND THEN.
23 Q. OH, I RECOGNIZE THAT. I -- YOU'RE NOT THE FIRST NURSE
24 TO TESTIFY TO THAT EFFECT. BUT WHAT YOU -- WHAT YOU'RE
25 TESTIFYING TO IS WHAT YOU REMEMBER -- WHAT YOU SEE IN THE
3179
1 RECORDS, IS THAT CORRECT?
2 A. THAT'S CORRECT.
3 Q. THERE WAS SOME TALK ABOUT DEATH AND DYING ISSUES AND
4 CHANGES TO THE MASTER TREATMENT PLAN. HAVE YOU REVIEWED
5 THESE FIVE TO SEE WHO MADE THAT DEATH AND DYING CHANGE TO
6 THE MASTER TREATMENT PLAN?
7 A. I KNOW THAT SEVERAL OF THOSE CHANGES WERE IN MY
8 HANDWRITING.
9 Q. THAT PROBABLY DIDN'T HAPPEN WITH ELLEN ANDERSON, DID IT?
10 A. I DON'T RECALL WITHOUT LOOKING AT THE RECORD.
11 Q. IF YOU WOULD PULL OUT ELLEN ANDERSON'S, AND TURN TO 196.
12 THIS IS THE MASTER TREATMENT PLAN, IS THAT CORRECT?
13 OH, EXCUSE ME.
14 A. HANG ON.
15 Q. SORRY.
16 A. I HAVE A FEW TO JUGGLE HERE.
17 Q. JUST BECAUSE I HAVE MINE UP HERE -- I'LL GIVE YOU TIME
18 TO --
19 A. I'M SORRY, WHAT PAGE?
20 Q. 196. IT'S BACK UNDER MASTER TREATMENT PLAN.
21 A. UH-HUH.
22 Q. AND WHAT WAS THE PROBLEM -- MASTER PROBLEM -- OR THE
23 PROBLEM THAT YOU LISTED ON 196?
24 A. ANXIETY.
25 Q. AND YOU NEVER HAD OCCASION TO CHANGE THAT TO DEATH AND
3180
1 DYING ISSUES, IS THAT CORRECT?
2 A. THERE IS NOTHING IN THE CHART THAT -- NOTHING IN THE
3 SECTION THAT SAYS THAT THAT'S THERE THAT I CAN SEE AT THIS
4 TIME.
5 Q. DO YOU RECALL ELLEN ANDERSON AT ALL?
6 A. NO, I'M SORRY.
7 Q. DO YOU RECALL TALKING TO HER DAUGHTER AS YOU PREPARED
8 THE NURSING ASSESSMENT?
9 A. I HAVE NO RECOLLECTIONS OTHER THAN WHAT I READ IN THE
10 RECORD.
11 Q. I WANTED TO CLARIFY SOMETHING. WHEN YOU TESTIFIED ON
12 DIRECT AS TO PAGE NUMBER 170, AND THIS MIGHT HAVE JUST BEEN
13 A SLIP OF THE TONGUE, BUT YOU INDICATED THAT YOU HAD ORDERED
14 THESE DRUGS FOR HER OR THESE MEDICATIONS FOR HER, IS THAT
15 CORRECT?
16 A. EXCUSE ME? I'M SORRY, FIRST OF ALL, I NEED THE PAGE.
17 Q. PAGE 170. IS THE PHYSICIAN'S ORDER SECTION.
18 A. NO, I DO NOT WRITE MEDICATION ORDERS.
19 Q. OKAY.
20 A. I TAKE TELEPHONE ORDERS FROM THE PHYSICIAN.
21 Q. THANK YOU. I THOUGHT THAT MIGHT HAVE BEEN JUST A
22 MISSTATEMENT. BECAUSE AT THIS TIME YOU WEREN'T -- NOW YOU
23 COULD BECAUSE YOU'RE A NURSE PRACTITIONER, IS THAT CORRECT?
24 A. THAT'S CORRECT. IT WOULD STILL HAVE TO BE RECOGNIZED
25 WITHIN THE HOSPITAL THAT I WAS WORKING AT. I WOULD HAVE TO
3181
1 BE PRIVILEGED TO WRITE PRESCRIPTIONS THERE.
2 Q. IN FACT, LET ME GO BACK A MINUTE. YOU SAY THAT YOU ARE
3 LICENSED IN THE STATE OF UTAH AS A NURSE PRACTITIONER, IS
4 THAT CORRECT?
5 A. THAT'S CORRECT.
6 Q. WHAT ABOUT IN THE STATE OF PENNSYLVANIA?
7 A. I HAVE A LICENCE IN PENNSYLVANIA AS WELL. HOWEVER, I
8 FUNCTION UNDER MY UTAH LICENSE ON FEDERAL PROPERTY.
9 Q. OH. BECAUSE THAT'S A SEPARATE -- I UNDERSTAND.
10 A. AND THE LAWS ARE DIFFERENT.
11 Q. WHAT IS YOUR LICENSE IN PENNSYLVANIA, IS IT NURSE
12 PRACTITIONER AS WELL?
13 A. YES.
14 Q. YOU INDICATED THAT YOU'VE DEALT WITH AGITATED AND
15 VIOLENT BEHAVIORS IN PSYCHIATRIC PATIENTS. WAS THAT PRIOR
16 TO WORKING AT THE GEROPSYCH UNIT?
17 A. I HAVE MANY YEARS OF EXPERIENCE IN PSYCHIATRY, YES.
18 Q. AND ARE YOU FAMILIAR WITH PSYCHOTROPIC DRUGS?
19 A. YES.
20 Q. SPECIFICALLY, MANY OF THE DRUGS LISTED HERE, TRAZODONE
21 ATIVAN, HALDOL, RISPERDAL, ARE YOU FAMILIAR WITH THEM?
22 A. YES.
23 Q. ARE YOU FAMILIAR WITH THEIR SIDE EFFECTS?
24 A. YES.
25 Q. AND ARE THEY ALL CENTRAL NERVOUS SYSTEM DEPRESSANTS?
3182
1 A. TO VARYING DEGREES, THERE IS A POSSIBILITY OF CENTRAL
2 NERVOUS SYSTEM EFFECTS IN A PSYCHOTROPIC MEDICATION, YES.
3 Q. AND IN FACT, MANY OF THEM ARE VERY SEDATING, ISN'T THAT
4 CORRECT?
5 A. SOME ARE GIVEN FOR THE PURPOSE OF SEDATION. OTHERS ARE
6 GIVEN FOR RELIEF OF DEPRESSION BECAUSE OF THEIR CENTRAL
7 NERVOUS SYSTEM EFFECTS.
8 Q. NOW, YOU SAID ON DIRECT THAT YOU DON'T HAVE ANY
9 RECOLLECTION OF WHETHER DR. WEITZEL CAME IN AND SAW ELLEN
10 ANDERSON WHILE YOU WERE ON THE UNIT, IS THAT CORRECT?
11 A. THAT'S CORRECT.
12 Q. IF TRACY SCHOLL HAD TESTIFIED -- AND I'LL REPRESENT TO
13 YOU THAT SHE DID TESTIFY EARLIER -- THAT WHEN SHE CAME IN ON
14 THE LATER SHIFT, YOU TOLD HER THAT DR. WEITZEL HAD NOT BEEN
15 IN, WOULD BE IN THE NEXT MORNING. WOULD YOU HAVE ANY
16 RECOLLECTION OF THAT?
17 A. I'M SORRY, I DON'T EVEN REMEMBER TRACY SCHOLL.
18 Q. OKAY. DO YOU HAVE ANY PERSONAL KNOWLEDGE AS TO WHETHER
19 DR. WEITZEL CAME IN AND SAW ELLEN ANDERSON WHILE YOU WERE
20 THERE?
21 A. WHAT I HAVE IS WHAT'S IN THE RECORD, AND HE CO-SIGNED MY
22 TELEPHONE ORDERS, HE SIGNED THE STAMP THAT SAYS THAT HE
23 REVIEWED EVERYTHING. THAT TO ME SAYS THAT HE WAS THERE ON
24 THAT DATE, GIVEN HIS SIGNATURE AND THE DATE HE AFFIXED.
25 Q. BUT HE DOESN'T INDICATE WHAT TIME -- OR EXCUSE ME, HE
3183
1 DOESN'T -- WELL, EXCUSE ME, HE DID DATE IT. ANYONE CAN --
2 ANY ONE CAN SIGN THIS AT ANY TIME, CAN THEY NOT? HE COULD
3 HAVE COME IN AT ANY TIME AND SIGNED THIS EVEN AFTER HER
4 DEATH.
5 A. I DON'T KNOW WHY THAT WOULD HAPPEN.
6 Q. WELL, JUST COULD HE HAVE, YES OR NO?
7 A. I -- COULD YOU ASK ME THAT QUESTION AGAIN?
8 Q. COULD HE HAVE COME IN AT ANY TIME, EVEN ON THE 30TH, THE
9 DAY AFTER SHE DIED -- OR EXCUSE ME, THE DAY SHE DIED. SHE
10 DIED EARLY IN THE MORNING ON THE 30TH, AND SIGNED --
11 CO-SIGNED OR WHATEVER YOU CALL THIS, THE TELEPHONE ORDER
12 THAT YOU WROTE?
13 MR. STIRBA: I'M GONNA OBJECT, YOUR HONOR. IT'S
14 ARGUMENTATIVE. CALLS FOR SPECULATION.
15 THE COURT: SUSTAINED.
16 Q. (BY MS. BARLOW) IN FACT, ANY TIME THAT A PERSON --
17 THAT A DOCTOR TELEPHONES IN AN ORDER, SAY IT'S AT 2:30 IN
18 THE MORNING, HE DOESN'T COME RIGHT THEN AND SIGN IT, DOES
19 HE?
20 MR. STIRBA: I'M GONNA OBJECT, YOUR HONOR, AS TO
21 RELEVANCY. SPECULATIVE.
22 THE COURT: ARE YOU TALKING ABOUT DR. WEITZEL?
23 MS. BARLOW: YES.
24 THE COURT: OKAY. GO AHEAD.
25 Q. (BY MS. BARLOW) SAY IF DR. WEITZEL GAVE YOU A
3184
1 TELEPHONE ORDER AT 2:30 IN THE MORNING, YOU WOULDN'T EXPECT
2 THAT HE CAME IN RIGHT THEN AND SIGNED IT, WOULD YOU?
3 A. DEPENDING ON WHERE HE WAS CALLING FROM, IT WOULD TAKE
4 ANY NUMBER, MINUTES OR LONGER TO COME AND SIGN IT.
5 Q. OR HE COULD WAIT UNTIL HE CAME IN ON ROUNDS THE NEXT DAY
6 AND SIGNED IT?
7 A. I DON'T RECALL WHAT THE POLICY OF THE HOSPITAL WAS IN
8 TERMS OF THE TIME FRAME IN WHICH A PHYSICIAN WAS ALLOWED TO
9 WAIT BETWEEN GIVING A TELEPHONE ORDER AND SIGNING IT. THERE
10 IS GENERALLY A HOSPITAL POLICY FOR THOSE SORTS OF THINGS.
11 Q. NOW, IF YOU'LL TURN TO 172.
12 A. OKAY.
13 Q. THE TOP OF THAT LOOKS LIKE IN DR. WEITZEL'S HANDWRITING
14 HE WRITES 12/29/95. PSYCH EVAL DONE, SLASH, DICTATED. DO
15 YOU SEE THAT?
16 A. UH-HUH.
17 Q. NOW, IF YOU'LL TURN OVER TO 167, DO YOU RECOGNIZE WHAT
18 THAT DOCUMENT IS?
19 A. HANG ON. IT'S STATES THAT IT'S A PSYCHIATRIC
20 EVALUATION.
21 Q. AND WOULD THAT -- AND THAT WOULD BE THE PSYCHIATRIC
22 EVALUATION THAT HE INDICATES HE DICTATED, IS THAT CORRECT?
23 A. CORRECT.
24 Q. AND ON PAGE 169, WHICH IS THE THIRD PAGE OF THAT PSYCH
25 EVALUATION, DO YOU SEE WHERE IT'S BEEN SIGNED ROBERT
3185
1 WEITZEL, THEN IT HAS A D. COLON, 12/30/95 AT 12:20. DO YOU
2 KNOW WHAT THAT IS?
3 A. NO, I DON'T.
4 Q. YOU DON'T UNDER -- YOU DON'T KNOW WHAT THE DICTATION
5 SYSTEM IS FOR DOCTORS AT DAVIS HOSPITAL?
6 A. NO.
7 Q. OKAY. WHO GAVE YOU THE INFORMATION FOR THE NURSING
8 ASSESSMENT THAT YOU DID ON ELLEN ANDERSON?
9 A. I DO NOT RECALL SPECIFICALLY. NURSING ASSESSMENTS DONE
10 BY ME, I OBTAIN THE INFORMATION FROM PRIMARILY THREE
11 SOURCES: THE PATIENT, ANY RECORDS THAT WERE BROUGHT WITH
12 HER, AND ANY FAMILY MEMBERS OR SIGNIFICANT FAMILY OR PERSONS
13 WHO MAY HAVE BEEN WITH THE PATIENT AT THE TIME.
14 Q. SO ON 178, YOU WROTE PERSON INTERVIEWED, YOU LEFT THE
15 PATIENT BLANK AND WROTE -- UNDER OTHER, YOU WROTE DAUGHTER.
16 THAT APPEARS YOU TALKED TO A DAUGHTER.
17 A. I'M SORRY, I HAVEN'T CAUGHT UP TO YOU.
18 Q. 178.
19 A. AND TELL ME AGAIN WHAT YOU ARE REFERRING TO? I'M SORRY.
20 Q. AND THE PERSON INTERVIEWED, PATIENT IS LEFT BLANK, THEN
21 OTHER, YOU'VE WRITTEN DAUGHTER, IS THAT CORRECT?
22 A. YES.
23 Q. AND ON PAGE 179, THE NEXT PAGE, YOU'VE WRITTEN WHAT
24 CAUSED YOU TO HAVE TO COME TO THE HOSPITAL. THREE WEEKS
25 DETERIORATION AT CARE CENTER. THAT WITH ANXIETY, CRYING OUT
3186
1 CONSTANTLY, UNABLE TO BE CONSOLED.
2 A. YES.
3 Q. SO WHEN YOU SEE HER CRYING LATER, IS THAT UNUSUAL
4 BEHAVIOR FOR HER?
5 A. NO.
6 Q. AND INDEED, THIS IS A WOMAN WHO IS VERY ANXIOUS, ISN'T
7 THAT CORRECT?
8 A. THAT'S CORRECT.
9 Q. DOESN'T LIKE TO BE LEFT ALONE.
10 A. IF -- IF THAT'S WHAT MY ASSESSMENT STATES.
11 Q. AND INDEED, THE DAUGHTERS TOLD YOU THAT -- THAT SHE WAS
12 INCONSOLABLE, THAT'S WHY SHE WAS THERE. EVEN WHILE THEY
13 WERE PRESENT, SHE WAS INCONSOLABLE, ISN'T THAT CORRECT?
14 A. I DO NOT HAVE A RECOLLECTION. IF IT'S STAYED IN THE
15 RECORD, THEN IT WAS REPORTED TO ME.
16 Q. MEDICAL PAGE 182.
17 A. OKAY.
18 Q. YOU CIRCLED PROBLEM WITH BONES AND JOINTS, HIP FRACTURE,
19 WRIST FRACTURE, HISTORY OF BACK PAIN, SPINAL FRACTURE. DO
20 YOU RECALL WHETHER ANY OF THOSE WERE ACUTE OR CURRENT?
21 A. I DO NOT RECALL.
22 Q. SO YOU DON'T RECALL WHETHER ANY OF THOSE WERE CAUSING
23 HER PAIN AT THAT TIME?
24 A. AS A NURSE, I WOULDN'T MAKE AN ASSESSMENT OF A
25 DIAGNOSIS. MY DIAGNOSIS AS A NURSE IS THE SYMPTOM, WHICH IS
3187
1 PAIN. SO I WOULD BE REPORTING WHAT THE PATIENT IS
2 DEMONSTRATING TO ME, NOT THE DIAGNOSIS OF A BONE FRACTURE,
3 ET CETERA.
4 Q. IF YOU WILL TURN OVER TO 190.
5 A. OKAY.
6 Q. AND THIS IS A NEW ADMIT. NOW, THIS FIRST PART, THE
7 BEHAVIOR PART, ISN'T THAT BASICALLY JUST REITERATING OR
8 SUMMARIZING WHAT YOU SAW IN YOUR ASSESSMENT?
9 A. I HAVE TO READ IT.
10 IT APPEARS TO BE.
11 Q. AND IN THAT YOU WROTE THAT SHE WAS CRYING AND SCREAMING
12 INCONSOLABLY EVEN WHEN FAMILY IS PRESENT.
13 A. YES.
14 Q. SO THAT'S WHAT YOU HAD BEEN TOLD. WE HAVE HERE A VERY
15 ANXIOUS INDIVIDUAL. LET'S LOOK DOWN UNDER THE MED NOTE.
16 YOU -- YOU INDICATE THAT YOU GAVE MORPHINE 10 MILLIGRAMS
17 I.M. AT 2000 HOURS FOR SEVERE PAIN, THEN YOU WRITE, PATIENT
18 BECOMES RIGID AND SCREAMS WHEN TOUCHED.
19 IS PAIN THE ONLY THING THAT CAN CAUSE THAT KIND OF A
20 SYMPTOM?
21 A. IT IS ONE OF THE THINGS THAT CAN CAUSE THAT SYMPTOM. IT
22 IS NOT THE --
23 Q. IS IT THE ONLY --
24 A. IT IS NOT THE ONLY THING.
25 Q. THANK YOU. AND IN FACT, IN A VERY ANXIOUS WOMAN WHO IS
3188
1 NOW IN A PLACE THAT SHE'S NEVER BEEN BEFORE, HER DAUGHTERS
2 HAVE LEFT, COULD THAT EXPLAIN WHY SHE IS SCREAMING WHEN
3 TOUCHED?
4 A. BEING A NURSE THAT WAS PRESENT AT THE TIME, AND FACED
5 WITH MY OWN DOCUMENTATION, MY ASSESSMENT APPEARS TO BE THAT
6 MY IMPRESSION AT THE TIME WAS THAT SHE WAS HAVING PAIN, NOT
7 ANXIETY.
8 Q. BUT CANNOT ANXIETY CAUSE RIGIDITY AND SCREAMING WHEN
9 TOUCHED?
10 A. IT MAY DEPENDING ON THE CIRCUMSTANCES.
11 Q. AND IN FACT, I BELIEVE THAT THE PHYSICIAN ORDER INCLUDED
12 AMBIEN AND TRAZODONE P.R.N. FOR SLEEP FOR THE AMBIEN AND
13 TRAZODONE 150 MILLIGRAMS AT BEDTIME.
14 DID YOU ADMINISTER THOSE DOSES OF ANTIPSYCHOTIC DRUGS?
15 A. I WOULD HAVE TO LOOK AT THE MEDICATION ADMINISTRATION
16 RECORD.
17 Q. IF YOU'D LOOK AT 176 PLEASE. ON 176, YOU NOTED
18 TRAZODONE AS BEING GIVEN AT BEDTIME, IS THAT CORRECT?
19 A. I --
20 Q. AS TO BE GIVEN. ORDERED TO BE GIVEN AT BEDTIME.
21 A. OKAY. I WAS ABOUT TO SAY, MY INITIALS ARE NOT HERE. I
22 TRANSCRIBED THE ORDER. I DID NOT ADMINISTER ANY MEDICATION.
23 IF I HAD, MY INITIALS WOULD BE THERE.
24 Q. SO THE FACT THAT YOUR INITIALS ARE NOT THERE MEANS YOU
25 DIDN'T GIVE THE TRAZODONE --
3189
1 A. THAT'S RIGHT.
2 Q. -- TO HELP HER SLEEP.
3 A. THAT'S RIGHT.
4 Q. AND THEN LET'S LOOK AT THE NEXT PAGE, 177. AND AGAIN,
5 WE HAVE AN ORDER FOR AMBIEN 5 MILLIGRAMS AT BEDTIME, AS
6 NEEDED FOR SLEEP. AND YOU NOTED THAT ORDER?
7 A. IT'S TRANSCRIBED IN MY HANDWRITING, YES.
8 Q. AND DID YOU ADMINISTER THAT FOR SLEEP?
9 A. I SEE NO INITIALS INDICATING THAT I DID.
10 Q. AND ABOVE THAT YOU HAVE TYLENOL. IS THAT TWO TABLETS
11 EVERY FOUR HOURS AS NEEDED FOR PAIN?
12 A. YES.
13 Q. THAT WAS THE ORDER?
14 A. YES.
15 Q. DID YOU ADMINISTER ANY TYLENOL FOR PAIN?
16 A. NO.
17 Q. AND I'M A LITTLE CURIOUS HERE. YOU HAVE ON -- BACK ON
18 190, WHICH IS YOUR NURSING NOTE, AFTER THE SEVERE PAIN
19 RELATED TO PROFOUND OSTEOPOROSIS, GIVEN TO PATIENT PER ORDER
20 OF DR. WEITZEL. WAS THAT THE ORDER THAT HE --
21 A. I'M SORRY, I LOST TRACK OF THE PAGE.
22 Q. 190. SORRY.
23 A. OKAY. I'M HERE. GO AHEAD.
24 Q. OKAY. UNDER MED NOTE IT SAYS, RELATED TO PROFOUND
25 OSTEOPOROSIS GIVEN TO PATIENT PER ORDER DR. WEITZEL.
3190
1 WAS THAT THE ORIGINAL ORDER, THE FIRST ORDER IN THE
2 PHYSICIAN'S ORDERS?
3 A. I BELIEVE THAT'S WHAT IT REFERS TO.
4 Q. OKAY. THERE WAS NO OTHER TELEPHONE --
5 A. UN-UNH.
6 Q. -- ORDER OR ANYTHING. THANK YOU. I JUST WANT TO MAKE
7 SURE I'M NOT CONFUSED HERE.
8 DO YOU RECALL WHY YOU GAVE THE MORPHINE INSTEAD OF
9 EITHER THE TRAZODONE OR THE AMBIEN FOR SLEEP?
10 A. BECAUSE IF A PATIENT IS IN PAIN, SLEEP MEDICATION IS NOT
11 GOING TO ALLEVIATE THAT.
12 Q. NOW, THE Q.H.S. IS AT BEDTIME, IS THAT CORRECT?
13 A. UH-HUH.
14 Q. AND WHAT WAS BEDTIME FOR THESE -- SAY FOR ELLEN ANDERSON
15 THAT EVENING?
16 A. I'M NOT CERTAIN.
17 Q. LET'S TALK ABOUT MARY CRANE. IF YOU COULD PULL HER
18 BINDER OUT PLEASE. IF YOU'D TURN TO PAGE 294, WHICH IS THE
19 FIRST PART OF THE NURSES' NOTES.
20 A. OKAY.
21 Q. THIS APPEARS TO BE ONE THAT ELLEN -- OR EARLENE, EXCUSE
22 ME, NOT ELLEN, BUT EARLENE COZZENS STARTED AND THEN YOU
23 FINISHED THE ASSESSMENT, IS THAT CORRECT?
24 A. IT APPEARS TO BE.
25 Q. AND IT APPEARS THAT THE INFORMATION WAS OBTAINED FROM
3191
1 KAREN BRINGHURST AND KATHY CHARLESWORTH.
2 A. I'M SORRY, I DIDN'T HEAR YOU.
3 Q. IT APPEARS THE INFORMATION WAS OBTAINED FROM KAREN
4 BRINGHURST AND KATHY CHARLESWORTH?
5 A. THAT'S WHAT IT STATES.
6 Q. WE GET OVER TO 298, AND YOU TESTIFIED THAT YOU -- YOU
7 ASKED MARY CRANE HERSELF TO RATE HER PAIN, AND SHE RATED IT
8 AS A 5. IS THAT CORRECT?
9 A. UH-HUH.
10 Q. AND THEN ON THE NEXT PAGE, ON 299, YOU HAVE A HISTORY OF
11 HEADACHES, AND THAT IS CIRCLED. DO YOU RECALL EITHER KATHY
12 OR KAREN TELLING YOU THAT MARY HAD COMPLAINED OFTEN ABOUT
13 HEADACHES, AND IT SEEMED THAT MAYBE THERE WASN'T REALLY A
14 HEADACHE, IT WAS JUST ONE OF THESE PHANTOM COMPLAINTS OF
15 SOMEONE WHO'S DEMENTED, DO YOU RECALL THAT?
16 A. NO, I DO NOT.
17 Q. DO YOU RECALL THEM SAYING THAT HER -- WHAT SHE THOUGHT
18 WERE HEADACHES HAD BEEN TREATED AT THE NURSING HOME HAD BEEN
19 TREATED WITH CALCIUM CARBONATE, WHICH IS BASICALLY A
20 PLACEBO?
21 A. NO, I HAVE NO RECOLLECTION.
22 Q. AND THEN LET'S TURN TO THREE ELEVEN THAT YOU TALKED
23 ABOUT. AT 0200 YOU INDICATED THAT YOU GAVE TWO TABLETS OF
24 TYLENOL FOR DISCOMFORT.
25 A. UH-HUH.
3192
1 Q. AND THAT APPEARED TO WORK, IS THAT NOT CORRECT?
2 A. YES.
3 Q. SO AT THAT TIME, YOU DIDN'T SEE ANY NEED FOR ANYTHING
4 MORE STRONG OR STRONGER THAN TYLENOL?
5 A. THAT'S CORRECT.
6 Q. LET'S TURN TO 325. MR. STIRBA WALKED YOU THROUGH THE
7 DIFFICULTY THAT MARY WAS HAVING CLEARING SECRETIONS. BUT
8 ISN'T IT TRUE THAT YOU WROTE FIRST PART OF BEHAVIOR, PATIENT
9 IS MORE ALERT TODAY?
10 A. THE DIFFICULTY IN CLEARING SECRETIONS AND THE LEVEL OF
11 ALERTNESS ARE NOT NECESSARILY RELATED IN A PATIENT.
12 Q. BUT SHE WAS MORE ALERT. SHE WAS ABLE TO SIT UP AT
13 DINNER. ATE 90 PERCENT OF HER DIET. ISN'T THAT CORRECT?
14 A. 90 PERCENT OF A PUREE DIET.
15 Q. BUT 90 PERCENT OF HER MEALS. SO SHE WAS GETTING AT
16 LEAST 90 PERCENT OF HER NUTRITIONAL VALUE AT THAT TIME.
17 A. UH-HUH.
18 Q. YES OR NO.
19 A. THAT'S CORRECT.
20 Q. ARE YOU AWARE THAT ANTIPSYCHOTIC MEDICATIONS CAN CAUSE A
21 PERSON TO NOT SWALLOW AS WELL AS THEY DID BEFORE?
22 A. YOU'RE TALKING ABOUT DISCONNECT MOVEMENTS OF THE TONGUE,
23 AND IF I HAD OBSERVED THAT IN THE PATIENT, I WOULD HAVE
24 DOCUMENTED SO.
25 Q. ARE YOU AWARE THAT ANTIPSYCHOTIC MEDICATIONS CAN CAUSE A
3193
1 PERSON NOT TO SWALLOW VERY WELL? IT'S JUST A YES OR NO.
2 A. YES.
3 Q. AND IN FACT, COUNTER TO WHAT WE WOULD INTUITIVELY
4 BELIEVE, IF YOU THICKEN LIQUIDS, PEOPLE SWALLOW THEM BETTER,
5 ISN'T THAT CORRECT?
6 A. THAT'S CORRECT.
7 Q. AND THE NEED FOR THICKENED LIQUIDS IS NOT UNUSUAL WITH
8 ELDERLY PATIENTS?
9 A. NO.
10 Q. DO YOU HAVE ANY INDEPENDENT RECOLLECTION OF MARY CRANE?
11 A. NO.
12 Q. OR WHAT HER DIFFICULTIES WERE?
13 A. NOT IMMEDIATELY, NO.
14 Q. AND CLEARLY, SHE DID BECOME TERMINAL AS TIME WENT ON,
15 ISN'T THAT CORRECT?
16 A. BASED ON THE DOCUMENTATION OF MINE THAT I'VE READ, YEAH.
17 Q. OKAY. THE MASTER TREATMENT PLAN STARTS ON 347, AND IT
18 APPEARS THAT YOU ALSO, FOR MARY CRANE, STARTED THE MASTER
19 PROBLEM LIST, IS THAT CORRECT?
20 A. THOSE ARE MY INITIALS.
21 Q. AND WAS THIS EVER ALTERED INTO DEATH AND DYING ISSUES?
22 A. THE ONLY PLACE TO LOOK FOR THAT WOULD BE UNDER
23 TREATMENT, I THINK? MAYBE IN HERE. I DON'T SEE ANYTHING
24 ELSE. I DON'T SEE ANY.
25 Q. IF YOU WOULD PULL OUT JUDITH LARSEN'S. JUDITH LARSEN
3194
1 WAS ON THERE NEARLY A -- ON THE UNIT NEARLY A MONTH. DO YOU
2 RECALL -- HAVE ANY INDEPENDENT RECOLLECTION OF JUDITH?
3 A. I'M SORRY, I DON'T.
4 Q. I BELIEVE YOU WENT FIRST TO PAGE 530. AND ON THE 8TH OF
5 DECEMBER, IT WAS TWO DAYS AFTER HER ADMISSION, ISN'T THAT
6 CORRECT?
7 A. I WOULD HAVE TO SEE HER ADMISSION DATE.
8 Q. WELL, LET ME JUST REPRESENT THAT IT WAS TWO DAYS AFTER
9 THE ADMISSION.
10 A. OKAY.
11 Q. AND YOU HAVE HER MOANING AND CRYING FREQUENTLY, SHE'S
12 ACUTELY DISTRESSED. CRYING INCONSOLABLY IN BED. ARE YOU
13 AWARE THAT THIS IS A WOMAN WHO UP UNTIL JUST A FEW MONTHS
14 BEFORE HER ADMISSION HAD BEEN LIVING ON HER OWN IN HER OWN
15 HOME?
16 A. I HAVE NO RECOLLECTION OF THIS PATIENT.
17 Q. WOULD YOU NOT EXPECT SOMEONE WHO HAD BEEN LIVING ON HER
18 OWN WHO IS NOW IN A HOSPITAL SETTING, WOULD YOU NOT EXPECT
19 THEM TO MOAN AND CRY, PERHAPS BE INCONSOLABLE?
20 A. THERE ARE OTHER BEHAVIORS THAT ARE CONSISTENT WITH
21 DEMENTIA IN COMBINATION WITH THE CRYING THAT I DOCUMENTED.
22 Q. ISN'T THERE AN EMOTIONAL COMPONENT, NOT JUST A PHYSICAL
23 PAIN COMPONENT, BUT AN EMOTIONAL COMPONENT THAT CAN CAUSE
24 MOANING AND CRYING?
25 A. IF THE PATIENT IS AWARE OF THE CIRCUMSTANCES.
3195
1 Q. DO YOU RECALL AS YOU SIT HERE WHETHER SHE WAS AWARE OF
2 THE CIRCUMSTANCES?
3 A. BASED ON MY DOCUMENTATION WHICH REPORTS THAT SHE HAS
4 ECHOLALIA, SHE'S PROBABLY NOT WELL AWARE OF HER
5 CIRCUMSTANCES.
6 Q. BUT YOU'RE NOT ABLE TO GET INTO HER HEAD AND KNOW FOR
7 SURE WHAT SHE'S AWARE OF.
8 A. ECHOLALIA IS A BEHAVIOR DEMONSTRATED BY PATIENTS WITH
9 PROFOUND DEMENTIA.
10 Q. AND IF THEY HAVE PROFOUND DEMENTIA, THEN THEY ARE NEVER
11 AGAIN AWARE OF THEIR SURROUNDINGS?
12 MR. STIRBA: YOUR HONOR, I'M GONNA OBJECT. I THINK
13 THIS GOES BEYOND THE SCOPE. SHE'S NOT AN EXPERT WITNESS.
14 SHE CAN TESTIFY AS TO FACTS. SHE ISN'T -- SHE'S ASKING HER
15 FOR OPINIONS ABOUT CERTAIN THINGS.
16 THE COURT: YOU'RE ASKING HER UNDERSTANDING OR WHAT
17 ARE YOU ASKING?
18 MS. BARLOW: HER UNDERSTANDING, YOUR HONOR.
19 THE COURT: CAN YOU ANSWER THAT QUESTION?
20 THE WITNESS: COULD YOU ASK ME --
21 MS. BARLOW: I WAS AFRAID YOU WERE GONNA ASK ME TO
22 REPEAT IT. CAN WE ASK THE REPORTER TO READ IT BACK?
23 THE COURT: WELL, IT'S NOT GONNA BE AN
24 UNDERSTANDING -- IT WASN'T AN UNDERSTANDING QUESTION. I
25 MEAN THE QUESTION WASN'T --
3196
1 MS. BARLOW: I'LL JUST WITHDRAW IT, YOUR HONOR. IF
2 I CAN'T REMEMBER WHAT IT IS, THEN IT PROBABLY ISN'T
3 SOMETHING THAT I OUGHT TO GO INTO.
4 THE COURT: OKAY. GO AHEAD.
5 Q. (BY MS. BARLOW) I SEEM TO HAVE NOT WRITTEN DOWN A
6 NUMBER HERE. MAYBE I DID. IF YOU WOULD TURN TO 533.1.
7 A. OKAY.
8 Q. YOU TESTIFIED ON DIRECT THAT YOU WERE ANTICIPATING DEATH
9 OR THAT THE FAMILY WAS ANTICIPATING DEATH. DID YOU WRITE
10 THAT ANYWHERE HERE?
11 A. IN THAT THE FAMILY REPEATED THEIR REQUEST THAT PATIENT
12 BE RE -- BE MADE COMFORTABLE, AND THAT THE D.N.R. BE
13 RESPECTED.
14 Q. AND FROM THAT YOU EXTRAPOLATE THEY'RE ANTICIPATING
15 DEATH.
16 A. I HAVE ONLY EVER HAD THOSE DISCUSSIONS IN PATIENTS WHOSE
17 FAMILIES ARE ANTICIPATING DEATH.
18 Q. BUT JUDITH LARSEN DID NOT DIE WITHIN DAYS OF THE 10TH OF
19 DECEMBER, DID SHE?
20 A. I DO NOT KNOW.
21 Q. SHE DIDN'T DIE UNTIL THE 3RD OF JANUARY. ARE YOU AWARE
22 OF THAT?
23 A. I DON'T HAVE DETAILED RECOLLECTIONS SUCH AS THAT.
24 Q. AND IN FACT, SHE MADE WHAT THE RECORD INDICATES,
25 DR. WEITZEL'S WRITING, A MIRACULOUS RECOVERY AFTER THIS
3197
1 POINT. DO YOU RECALL SEEING THAT IN THE RECORD? IN THE
2 PROGRESS NOTES?
3 A. I -- I MAY HAVE SEEN IT IN GOING THROUGH THE CHART, YES.
4 Q. IF YOU WOULD TURN TO 606, WHICH IS THE MEDICAL TREATMENT
5 PLAN, DO YOU SEE ANY INDICATION OF A CHANGE TO DEATH AND
6 DYING ISSUES IN THAT MEDICAL TREATMENT PLAN?
7 A. THERE IS NOTHING LISTED HERE.
8 Q. BUT YOU DID TESTIFY THAT ON 596, WHICH IS NOT IN THE
9 MEDICAL -- OR MASTER TREATMENT PLAN, YOU WROTE IN THE
10 NURSING CARE PROGRAM ABOUT DEATH AND DYING. WHAT'S THE
11 DIFFERENCE BETWEEN THE MASTER TREATMENT PLAN AND THE NURSING
12 CARE PROGRAM?
13 A. THE MASTER TREATMENT PLAN INCLUDES INTERVENTIONS BY ALL
14 DISCIPLINES. THE NURSING TREATMENT PLAN INDICATES TREATMENT
15 PROVIDED BY THE NURSES.
16 Q. SO YOU WROTE IT IN THE NURSING CARE PROGRAM, BUT NOT IN
17 THE MASTER TREATMENT PLAN, IS THAT CORRECT?
18 A. THAT MAY BE TRUE.
19 Q. YOU TALKED ABOUT MED NUMBER 477. YOU WROTE A WEEKLY
20 R.N. ADVOCATE NOTE. AS YOU LOOK THROUGH THESE NOTES, DID
21 ANY OF THE OTHER R.N.'S EVER WRITE WEEKLY ADVOCATES NOTES
22 THAT YOU SAW?
23 A. ON THIS PARTICULAR PATIENT, I WOULD HAVE TO READ THE
24 CHART. THERE'S --
25 Q. IF I TOLD YOU THAT NOBODY -- NO OTHER R.N.'S EVER WROTE
3198
1 THAT, WOULD YOU BE SURPRISED AT THAT?
2 A. IF THIS WERE MY PATIENT AND I WERE ASSIGNED TO HER TO
3 WRITE THE WEEKLY ADVOCATE NOTE, THEN IT WOULD BE ME WRITING
4 THE NOTES. IF I WERE NOT THERE DUE TO A DAY OFF OR AN
5 ABSENCE WHEN A NOTE WAS DUE, IT WAS SOMEONE ELSE'S
6 RESPONSIBILITY TO DO SO. WHETHER OR NOT THEY DID THAT WAS
7 NOT UNDER MY CONTROL.
8 Q. I UNDERSTAND THAT. YOU SAY THAT THE MEDICAL STATUS
9 RAPIDLY AND PROFOUNDLY DETERIORATED THIS WEEK. EXPERIENCED
10 A SEIZURE AND MULTIPLE EPISODES OF VOMITING COFFEE GROUNDS
11 MATERIAL. WASN'T THERE JUST ONE EPISODE OF VOMITING OVER,
12 SAY, A FIVE-HOUR PERIOD?
13 A. IF SOMEONE IS VOMITING FOR FIVE HOURS, THAT'S MORE THAN
14 ONE EPISODE AND --
15 Q. SO YOU -- YOU -- OKAY.
16 A. AND I WOULDN'T BE ABLE TO TELL THAT WITHOUT READING THE
17 CHART BACK TO SEE IF THERE WERE ANY OTHER THINGS DOCUMENTED.
18 I WOULD HAVE WRITTEN THIS NOTE BASED ON PREVIOUS NOTES IN
19 THE RECORD THAT I HAD READ AT THE TIME.
20 Q. ARE YOU AWARE THAT THE SEIZURE OCCURRED APPROXIMATELY 24
21 HOURS AFTER THE FIRST DOSE OF MORPHINE WAS ADMINISTERED TO
22 JUDITH LARSEN?
23 A. I HAVE NO RECOLLECTION.
24 Q. FURTHER DOWN ON THE 3RD OF JANUARY, DR. WEITZEL WROTE A
25 NOTE FURTHER DOWN ON 477, UNDER 1/3, TALKS ABOUT MORPHINE AT
3199
1 7:30 AND 9:30. PATIENT HAS NOT RESPONDED AT ALL DESPITE
2 5 MILLIGRAMS. EYES OPEN. GROANING. APPEARS IN SOME PAIN.
3 UNFORTUNATELY, NURSING STAFF HAVE BEEN HOLDING MORPHINE
4 SULFATE FOR LOW RESPIRATION RATE.
5 DO YOU RECALL SEEING THAT NOTE?
6 A. ACTUALLY, I DON'T REMEMBER SEEING THIS NOTE. IT'S NEW
7 TO MY ATTENTION AT THIS MOMENT IN TIME.
8 Q. REMAINS UNRESPONSIVE TO ANY QUESTIONS.
9 DO YOU RECALL THERE BEING A MEETING CALLED BY -- WELL,
10 AT WHICH DR. WEITZEL TOLD THE NURSES NOT TO WITHHOLD
11 MORPHINE WITHOUT HIS PERMISSION?
12 A. NO.
13 Q. DO YOU THINK IT'S UNFORTUNATE THAT THE NURSES WITHHELD
14 MORPHINE FOR LOW RESPIRATION RATE?
15 MR. STIRBA: OBJECTION. IRRELEVANT. CALLING FOR
16 AN OPINION. AND SHE'S NOT COMPETENT TO RENDER THAT OPINION
17 ABOUT SOMEBODY ELSE'S CARE.
18 THE COURT: I THINK IT'S FOUNDATION. SUSTAIN AS TO
19 FOUNDATION.
20 THIS MAY BE A GOOD PLACE -- IT'S 5:00 O'CLOCK -- TO
21 STOP. SO, LADIES AND GENTLEMEN, WHAT WE'LL DO IS WE'LL COME
22 BACK TOMORROW AT 8:30 AND PLAN ON GOING AGAIN FROM 8:30
23 UNTIL 5:00.
24 (WHEREUPON, COURT AND COUNSEL HELD A SCHEDULING
25 CONFERENCE, THEN COURT ADJOURNED FOR THE EVENING.)
3200
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 15 OF 21
13 JUNE 29, 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
3201
1 (WHEREUPON THE MORNING SESSION BEGINS.)
2 THE COURT: OKAY. THE RECORD WILL REFLECT THAT
3 COUNSEL ARE PRESENT, THE DEFENDANT AND THE JURY ARE ALL
4 PRESENT. THANK YOU, LADIES AND GENTLEMEN, AGAIN FOR BEING
5 ON TIME. WE HAVE MS. STEVENSON ON THE STAND. YOU
6 UNDERSTAND YOU ARE STILL UNDER OATH?
7 THE WITNESS: YES, I DO.
8 THE COURT: OKAY. MS. BARLOW, IF YOU WOULD LIKE TO
9 CONTINUE.
10 MS. BARLOW: THANK YOU, YOUR HONOR. GOOD MORNING.
11 THE WITNESS: MORNING.
12 CROSS-EXAMINATION, CONT'D
13 BY MS. BARLOW:
14 Q. I BELIEVE WE WERE TALKING ABOUT JUDITH LARSEN YESTERDAY
15 WHEN 5 O'CLOCK CAME. IF YOU WOULD TURN TO PAGE 582 IN
16 MRS. LARSEN'S MEDICAL RECORDS.
17 A. OKAY.
18 Q. WOULD YOU FAMILIARIZE YOURSELF AGAIN WITH THAT NOTE THAT
19 YOU WROTE ON THE 31ST OF DECEMBER. 1430 YOU WROTE THE
20 PATIENT IS NONRESPONSIVE TO VERBAL AND TACTILE TOUCH.
21 A. I'M SORRY?
22 Q. AT 1430. DO YOU SEE THAT?
23 A. I HAVE AN 11 TO 7 NOTE.
24 Q. I'M SORRY. I'M ON THE WRONG PAGE. STARTING OUT GREAT
25 HERE. OKAY. THE 11 TO 7 NOTE RIGHT IN THE MIDDLE YOU
3202
1 INDICATED THAT MORPHINE WAS GIVEN IS THAT EVERY FOUR HOURS
2 I.M. FOR COMFORT.
3 DO YOU RECALL NOW WHAT DISCOMFORT YOU WERE SEEING IN
4 JUDITH LARSEN ON THE 1ST OF JANUARY?
5 A. THE NOTE STATES THAT MORPHINE I.M. WAS GIVEN AT 2:30 AND
6 6:30 FOR PAIN RELIEF. PATIENT WAS MOANING PRIOR TO 2:30
7 DOSE. AND MOANING IS A REPRESENTATION BY THE PATIENT AS
8 ASSESSED BY MYSELF THE NURSE AS REFLECTING HER PAIN LEVEL,
9 YES.
10 Q. DOES MOANING EVER INDICATE ANYTHING OTHER THAN PAIN?
11 A. MY NOTE IS REFLECTIVE OF MY ASSESSMENT OF THE PATIENT AT
12 THAT TIME.
13 Q. I UNDERSTAND THAT. BUT DOES MOANING EVER REFLECT
14 SOMETHING OTHER THAN PAIN?
15 A. NOT THAT -- NOTHING TO ME THAT COMES IMMEDIATELY TO
16 MIND.
17 Q. ARE YOU FAMILIAR WITH THE DIAGNOSTIC AND STATISTICAL
18 MANUAL OF MENTAL DISORDERS, THE D.S.M.?
19 A. YES, I AM.
20 Q. IT'S PUT OUT BY THE AMERICAN PSYCHIATRIC ASSOCIATION; IS
21 THAT CORRECT?
22 A. THAT'S CORRECT.
23 Q. AND IT IS A -- IT'S A MANUAL THAT DEALS WITH PSYCHIATRIC
24 DISORDERS PREDOMINANTLY, RIGHT?
25 A. THAT'S CORRECT.
3203
1 Q. AND ARE YOU AWARE THAT -- ARE YOU AWARE OF THE CONDITION
2 CALLED DELIRIUM?
3 A. I AM AWARE OF THE CHARACTERISTICS OF DELIRIUM, YES.
4 Q. AND ARE YOU AWARE THAT ONE OF THE CHARACTERISTICS OF
5 DELIRIUM IS A DISTURBED EMOTIONAL STATE?
6 A. THAT'S CORRECT.
7 Q. AND ARE YOU AWARE THAT THE DISTURBED EMOTIONAL STATE MAY
8 ALSO BE EVIDENT IN CALLING OUT, SCREAMING, CURSING,
9 MUTTERING, MOANING OR OTHER SOUNDS?
10 A. THAT'S CORRECT.
11 Q. SO YOU ARE AWARE THAT THOSE ARE SOME OF THE
12 MANIFESTATIONS OF DELIRIUM; IS THAT CORRECT?
13 A. YES.
14 Q. SO THERE ARE THINGS OTHER THAN PAIN THAT CAN CAUSE
15 MOANING?
16 A. YES. BUT AS MY ASSESSMENT IN THE -- AS THE NURSE CARING
17 FOR THIS PATIENT, MOANING WAS A REPRESENTATION OF HER PAIN.
18 BEING THE NURSE CARING FOR THE PATIENT, IT IS MY JOB TO
19 INTERPRET THAT SYMPTOM.
20 Q. I UNDERSTAND. AND ANOTHER NURSE MAY INTERPRET THE
21 MOANING DIFFERENTLY; ISN'T THAT CORRECT?
22 A. I CAN'T SPEAK ABOUT WHAT ANOTHER NURSE WOULD DO. I WAS
23 THE NURSE CARING FOR THAT PATIENT AT THAT TIME, THAT WOULD
24 BE MY RESPONSIBILITY.
25 Q. BUT IT'S A VERY SUBJECTIVE THING; ISN'T THAT CORRECT?
3204
1 A. IT'S A SUBJECTIVE THING THAT NURSES ARE TRAINED TO WORK
2 WITH.
3 Q. RIGHT. AND YOU WERE TRAINED AND THE OTHER NURSES THAT
4 WORKED WITH MRS. LARSEN WERE TRAINED TO MAKE THIS SUBJECTIVE
5 ASSESSMENT ABOUT WHAT'S CAUSING THE MOANING; ISN'T THAT
6 CORRECT?
7 A. THAT'S CORRECT.
8 Q. NOW, JUDITH LARSEN ON THE 31ST OF DECEMBER WAS NOT
9 RESPONSIVE, IS THAT CORRECT, WAS NOT VERBALLY RESPONSIVE?
10 A. THAT'S WHAT I CHARTED, YES.
11 Q. CAN SEDATION CAUSE THAT UNRESPONSIVENESS?
12 A. MANY THINGS CAN CAUSE THAT LEVEL OF UNRESPONSIVENESS.
13 Q. AND CAN SEDATION CAUSE THAT LEVEL OF UNRESPONSIVENESS?
14 A. OCCASIONALLY.
15 Q. IN FACT, IF A PERSON IS SO SEDATED THAT THEY ARE
16 COMATOSE, THEN THEY WON'T RESPOND; IS THAT CORRECT?
17 A. IF I BELIEVE THAT THE PATIENT WOULD BE MADE COMATOSE BY
18 MEDICATION THAT I ADMINISTERED, I WOULD NOT HAVE GIVEN THAT.
19 Q. I APPRECIATE THAT. THAT'S NOT MY QUESTION. BUT
20 OVERSEDATION CAN CAUSE A PERSON TO BE COMATOSE; IS THAT NOT
21 CORRECT?
22 MR. STIRBA: YOUR HONOR, I'LL OBJECT IN TERMS OF
23 THE HYPOTHETICAL. SHE'S HERE AS A FACT WITNESS, NOT AS AN
24 EXPERT AND THIS CALLS FOR SPECULATION.
25 THE COURT: SUSTAINED.
3205
1 Q. (BY MS. BARLOW) DID YOU EVER HOLD ANY MEDICATIONS FOR
2 JUDITH LARSEN?
3 A. I WOULD HAVE TO LOOK AT THE MEDICAL RECORD TO SEE.
4 Q. I BELIEVE ON DIRECT EXAMINATION THAT YOU TESTIFIED THAT
5 YOU GAVE THIS -- THESE SHOTS AT 2:30 AND 6:30 BECAUSE YOU
6 ASSESSED PAIN; IS THAT CORRECT?
7 A. SHE WAS GIVEN MEDICATION AS THEY WERE SCHEDULED. IF I
8 GAVE THE DOSE EARLIER THAN THE SCHEDULED TIME, THEN IT WOULD
9 HAVE BEEN BECAUSE IT WAS ASSESSED AS PAIN. IF THE SCHEDULED
10 TIME IS 2:30, THEN SHE WOULD HAVE GOTTEN IT ON TIME AS
11 SCHEDULED.
12 Q. I APOLOGIZE FOR THE LENGTH OF TIME THIS TAKES BUT WITH
13 HER LONG ADMISSION -- OR LONG STAY THERE, THERE'S A LOT OF
14 RECORDS.
15 WILL YOU TURN TO PAGE 497 WHICH IS IN THE MEDICAL
16 ADMINISTRATION RECORDS. DO YOU SEE DOWN AT THE BOTTOM UNDER
17 12/31 WHERE YOUR INITIALS INDICATE THE ADMINISTRATION OF THE
18 2:30 AND 6:30 SHOTS?
19 A. THAT IS CORRECT.
20 Q. AND THOSE ARE NOT GIVEN PRN; IS THAT CORRECT?
21 A. THOSE ARE SCHEDULED DOSES.
22 Q. LET'S TURN TO MR. ALLDREDGE. IT APPEARS THAT YOU DID
23 NOT FILL OUT THE NURSING ASSESSMENT FOR MR. ALLDREDGE SO YOU
24 WERE NOT THERE WHEN HE CAME IN; IS THAT CORRECT?
25 A. ALL THAT WOULD MEAN IS THAT I DID NOT DO THE NURSING
3206
1 ASSESSMENT WHEN HE -- I WOULD HAVE TO LOOK AT SOMETHING LIKE
2 A SCHEDULE OR OTHER PROGRESS NOTES OR WHAT I HAD WRITTEN TO
3 TELL YOU WHETHER I WAS THERE AT THE TIME OF HIS ADMISSION.
4 Q. BECAUSE YOU WOULD NOT BE THE ONLY NURSE ON THE UNIT WHEN
5 HE CAME IN?
6 A. THAT IS CORRECT.
7 Q. IN FACT, CAN YOU SAY -- WHAT, 3 TO 11 IS THAT ONE SHIFT
8 THAT YOU WORK?
9 A. UH-HUH.
10 Q. AND HOW MANY NURSES WERE ON AT THE 3 TO 11 SHIFT WITH
11 YOU?
12 A. I'M NOT CERTAIN. I KNOW THAT IT WAS NOT ONLY JUST ONE
13 NURSE. THERE WAS PROBABLY A NURSE, AN LPN OR A NURSE AND
14 ANOTHER NURSE MOST LIKELY. THE ONLY SHIFT THAT THERE'S JUST
15 A SINGLE RN ON THE FLOOR WOULD BE 11 TO 7.
16 Q. AND THE 11 TO 7 THERE MAY BE C.N.A.'S, CERTIFIED NURSING
17 ASSISTANTS?
18 A. THAT'S CORRECT.
19 Q. IF YOU WOULD TURN TO PAGE 18 ON MR. ALLDREDGE'S BINDER.
20 YOU INSERTED THERE A WEEKLY R.N. ADVOCATE NOTE AS YOU HAD
21 WITH SOME OF THE OTHER PATIENTS. AND YOU INDICATE, PLEASE
22 SEE DR. WEITZEL'S NOTE ABOVE REGARDING M.R.I. RESULTS AND
23 PATIENT'S CARE PLAN HAS BEEN AMENDED TO REFLECT TO DEATH AND
24 DYING ISSUES. YOUR KNOWLEDGE OF THE M.R.I. RESULTS, DID
25 THAT COME JUST FROM DR. WEITZEL?
3207
1 A. I HAVE NO SPECIFIC MEMORY OF THE INCIDENT. I BELIEVE I
2 MAY HAVE READ SOMETHING IN THE RECORD RECENTLY THAT REFLECTS
3 THAT I RECEIVED A REPORT FROM SOMEONE OVER THE PHONE OR
4 SOMEONE DID....
5 Q. AND INDEED ON PAGE 27 IS THE REPORT OF THE M.R.I.; IS
6 THAT NOT CORRECT?
7 A. THAT'S CORRECT.
8 Q. AND THE IMPRESSION WAS BASICALLY THAT THE PATIENT MOVED
9 A LOT AND IT WASN'T REALLY A GOOD REPORT; IS THAT CORRECT?
10 MR. STIRBA: I'M GOING TO OBJECT, YOUR HONOR, THAT
11 CALLS FOR A CHARACTERIZATION BEYOND THE SCOPE OF HER
12 EXPERTISE ON THAT REPORT.
13 THE COURT: SUSTAINED.
14 Q. (BY MS. BARLOW) THEN LET'S READ THE LAST PARAGRAPH --
15 WELL, MAYBE NOT THE WHOLE PARAGRAPH. WELL, WE'LL READ THE
16 WHOLE PARAGRAPH.
17 QUESTION OF INFARCTION INVOLVING THE LEFT OCCIPITAL AND
18 GRAY MATTER. I CANNOT PRECISELY DATE THIS POSSIBLE
19 INFARCTION, ALTHOUGH THERE COULD BE SOME EARLY COMPRESSION
20 OF THE OCCIPITAL HORN.
21 IS THAT THE WAY IT READS?
22 A. THAT'S CORRECT, SUGGESTING ACUTE TO SUBACUTE EVENT.
23 Q. SUGGESTING ACUTE OR SUBACUTE EVENT. YOU, OF COURSE,
24 WOULDN'T DIAGNOSE FROM THIS?
25 A. NO. I ALSO PROBABLY DID NOT HAVE ACCESS TO THE REPORT
3208
1 DIRECTLY. AS I SAID, I THINK THERE'S A PREVIOUS NOTE THAT
2 STATES I TALKED TO SOMEONE OVER THE PHONE. THE INFORMATION
3 GIVEN TO ME OVER THE PHONE IS NOT IN MY CLEAR MEMORY.
4 HOWEVER, WHATEVER IMPRESSION I WAS LEFT WITH AFTER THAT
5 CONVERSATION PROBABLY MOTIVATED THE NOTE. THE REPORTS OFTEN
6 CAME MANY DAYS LATER AFTER THE ACTUAL TESTING WAS DONE.
7 Q. IT APPEARS THAT THIS WAS TRANSCRIBED ON THE 13TH WHICH
8 IS THE DAY AFTER THE REPORT WAS -- WE'LL GO ON FROM THERE.
9 YOU, OF COURSE, DID NOT DIAGNOSE A STROKE?
10 A. NO.
11 Q. YOU HAD THEN NO AUTHORITY TO DIAGNOSE ANYTHING; IS THAT
12 CORRECT?
13 A. THAT'S CORRECT.
14 Q. SO ANYTHING -- ANY DIAGNOSIS OF A STROKE WOULD NOT COME
15 FROM YOU BUT FROM DR. WEITZEL; IS THAT CORRECT?
16 A. DR. WEITZEL, THE INTERPRETER OF THE M.R.I. RESULTS, ANY
17 NUMBER OF OTHER PHYSICIANS SOURCES.
18 Q. RIGHT. BUT IN THIS CASE THE INTERPRETER DID NOT
19 INTERPRET A STROKE DEFINITELY?
20 MR. STIRBA: YOUR HONOR, I'LL OBJECT ONCE AGAIN
21 BEYOND THE SCOPE OF HER COMPETENCE.
22 THE COURT: THE DOCUMENT SPEAKS FOR ITSELF,
23 SUSTAINED.
24 Q. (BY MS. BARLOW) THE PATIENT'S CARE PLAN HAS BEEN
25 AMENDED, THIS IS BACK ON PAGE 18 OF YOUR NOTE, TO REFLECT
3209
1 DEATH AND DYING ISSUES. DID YOU MAKE THAT DETERMINATION OR
2 DID DR. WEITZEL?
3 A. IF I MAKE AN ADJUSTMENT TO THE CARE PLAN, THAT IS A
4 NURSING ASSESSMENT.
5 Q. HOW ABOUT THE MASTER TREATMENT PLAN?
6 A. THE MASTER TREATMENT PLAN, IF I MAKE THE ENTRY IS A
7 NURSING ASSESSMENT. THAT'S INFORMATION AVAILABLE TO ALL
8 DISCIPLINES.
9 Q. SO YOU WOULD MAKE THE DETERMINATION THAT YOU NOW NEED TO
10 LOOK AT DEATH AND DYING ISSUES IN THE MASTER TREATMENT PLAN?
11 A. BASED ON WHAT THE PATIENT APPEARED TO BE TO ME.
12 Q. SO DR. WEITZEL WOULD HAVE NOTHING, NO INPUT ON THAT?
13 A. DR. WEITZEL IS NOT RESPONSIBLE FOR A NURSING DIAGNOSIS
14 OF A PATIENT, NO.
15 Q. BUT NURSES CAN'T DIAGNOSIS, CAN THEY? THEY CAN ASSESS?
16 A. NURSES ARE ALLOWED TO MAKE A NURSING DIAGNOSIS OF A
17 PATIENT, YES.
18 Q. ISN'T IT TRUE IN STATE LAW YOU CAN MAKE ASSESSMENTS BUT
19 NOT DIAGNOSES?
20 A. THE STATE LAW FOR THE STATE OF UTAH STATES THE
21 PATIENT -- NURSES ARE LICENSED TO MAKE NURSING DIAGNOSES
22 WHICH ARE PARTICULARLY SEPARATE FROM PHYSICIAN MEDICAL
23 DIAGNOSES.
24 Q. THAT ISN'T THE WAY THE LAW ACTUALLY READS, IS IT?
25 THE COURT: WELL, I THINK THAT THIS IS A LEGAL
3210
1 ARGUMENT AND I DON'T THINK -- THE WITNESS IS NOT A LAWYER.
2 MS. BARLOW: I RECOGNIZE THAT, YOUR HONOR, BUT --
3 WELL, WE'LL GO ON.
4 Q. (BY MS. BARLOW) SO DEATH AND DYING ISSUES, YOU
5 DETERMINED THAT AND ON PAGE 90 YOU INSERTED THAT INTO THE
6 MASTER PROBLEM LIST; IS THAT CORRECT?
7 A. THAT'S MY HANDWRITING, YES.
8 Q. NOW, YOU WOULD NOT BE PUTTING THIS IN HERE AND DIRECTING
9 THE DOCTOR TO DO ANYTHING TOWARDS DEATH AND DYING ISSUES;
10 ISN'T THAT CORRECT?
11 A. THE NURSING CARE PLAN IS DIRECTION OF CARE FOR THE
12 NURSING CARE OF THE PATIENT.
13 Q. AND DOES THAT INCLUDE THE MASTER TREATMENT PLAN?
14 A. THAT'S CORRECT.
15 Q. AND YOU INSERTED THAT ON THE 14TH WHICH IS THE DAY HE
16 DIED; IS THAT NOT CORRECT?
17 A. I'M NOT CERTAIN OF THE DAY HE DIED. I AM CERTAIN THAT
18 IT STATES I PUT THE NOTE IN ON THE 14TH.
19 Q. THEN LET'S GO BACK TO PAGE ONE WHICH IS THE ADMISSIONS
20 JUST TO REFRESH YOUR MEMORY OF HIS DATE OF DEATH AND TIME.
21 DOWN AT THE BOTTOM IS A DISCHARGE DATE OF 1-14-96 DISCHARGE
22 TIME OF 9:36 A.M. EXPIRED.
23 A. I'M SORRY, I'M JUST HAVING TROUBLE READING THE PAGE.
24 Q. PAGE ONE.
25 A. IT'S VERY LIGHT AND I'M HAVING A LITTLE TROUBLE --
3211
1 Q. DOWN AT THE BOTTOM HANDWRITTEN IN.
2 A. 1/14/96, 9:36 A.M.
3 Q. AND HE EXPIRED?
4 A. THAT'S WHAT'S CHECKED IN THE BOX, YES.
5 Q. DO YOU HAVE ANY PERSONAL KNOWLEDGE OF WHAT BROUGHT HIM
6 TO THE POINT OF DEATH THE 14TH OF JANUARY?
7 A. NO, I DO NOT.
8 Q. IF YOU WOULD TURN TO PAGE 77. YOU WROTE THAT PATIENT'S
9 LEVEL OF AWARENESS HAS BEEN PROGRESSIVELY SINKING OVER THE
10 SHIFT AND YOU TALK ABOUT ALL FAMILY MEMBERS HAVE BEEN
11 PRESENT INTERMITTENTLY. 0500 A DOSE OF MORPHINE AND ATIVAN
12 WERE GIVEN AT 4:30 DUE TO PATIENT GRIMACING AND LABORED
13 BREATHING INDICATING HIS LEVEL OF DISTRESS. AND, AGAIN,
14 THIS WAS IN THE NURSING ASSESSMENT THAT YOU MADE?
15 A. THAT'S CORRECT.
16 Q. DO YOU HAVE ANY IDEA OR DO YOU HAVE ANY -- I SHOULDN'T
17 SAY IDEA.
18 DO YOU KNOW WHAT WAS CAUSING HIS DISTRESS AT THAT TIME?
19 A. AS THE NURSE, IF IT WERE A MEDICAL DIAGNOSIS, THAT WOULD
20 NOT BE FOR ME TO DETERMINE. IF IT WERE A POSITIONING ISSUE,
21 A LEVEL OF PAIN, THOSE ARE THINGS THAT I COULD INTERVENE
22 WITH.
23 Q. SO YOU MADE A NURSING ASSESSMENT AT THAT TIME THAT THE
24 GRIMACING AND LABORED BREATHING SHOWED HIS LEVEL OF
25 DISTRESS.
3212
1 A. (WITNESS NODS HEAD.)
2 THE COURT: YOU'LL HAVE TO ANSWER OUT LOUD.
3 THE WITNESS: YES, I'M SORRY.
4 Q. (BY MS. BARLOW) WE FORGET THAT WE HAVE A REPORTER HERE
5 THAT HAS TO TAKE IT DOWN.
6 AT THIS POINT IT'S 1/14, THE 14TH OF JANUARY, IT'S
7 5 O'CLOCK IN THE MORNING, YOU JUST READ THAT HE EXPIRED AT
8 9:36 SO THIS IS ABOUT FOUR AND A HALF HOURS PRIOR TO HIS
9 DEATH, COULD THE LABORED BREATHING BE INDICATIONS THAT HE IS
10 HYPOXIC OR LACKING IN OXYGEN?
11 MR. STIRBA: YOUR HONOR, WITHOUT MORE FOUNDATION
12 I'M GOING TO OBJECT BEYOND THE SCOPE OF HER COMPETENCY.
13 THE COURT: OKAY. ARE YOU ASKING HER WHAT HER
14 MEDICAL OPINION IS?
15 MS. BARLOW: WELL, HER NURSING ASSESSMENT. WITH
16 HER NURSING TRAINING CAN SHE SAY --
17 THE COURT: WELL, LAY A FOUNDATION AND IF SHE HAS
18 AN UNDERSTANDING OF THAT.
19 Q. (BY MS. BARLOW) BASED ON YOUR TRAINING AS A NURSE, DO
20 YOU KNOW WHETHER LABORED BREATHING CAN BE CAUSED BY HYPOXIA
21 OR LACK OF OXYGEN?
22 A. THE PATIENT WOULD HAVE TO HAVE OTHER SYMPTOMS ALSO
23 INDICATING HYPOXIA.
24 Q. PLEASE, IF YOU'LL JUST ANSWER MY QUESTION.
25 BASED ON YOUR TRAINING, DO YOU KNOW WHETHER LABORED
3213
1 BREATHING CAN BE CAUSED BY HYPOXIA?
2 A. CERTAIN TYPES OF LABORED BREATHING.
3 Q. THANK YOU. YOU DIDN'T --
4 A. MORE PARTICULARLY SHORTNESS OF BREATH.
5 Q. BUT YOU DIDN'T WRITE SHORTNESS OF BREATH.
6 A. NO, I WROTE LABORED BREATHING.
7 Q. BUT DO YOU HAVE ANY INDEPENDENT RECOLLECTION OF JUST
8 WHAT HIS BREATH WAS LIKE AT THAT TIME?
9 A. I WROTE LABORED BREATHING, THEREFORE IT MEANS THAT HE
10 WAS WORKING VERY HARD TO TAKE A DEEP BREATH.
11 Q. ISN'T IT TRUE THAT DRUGS THAT HAVE SEDATIVE EFFECTS,
12 CENTRAL NERVOUS SYSTEM DEPRESSANT EFFECTS CAUSE A PERSON TO
13 FORGET TO BREATH?
14 MR. STIRBA: I WOULD OBJECT --
15 Q. (BY MS. BARLOW) OR MAY CAUSE?
16 MR. STIRBA: I'LL OBJECT, YOUR HONOR, SHE'S NOT
17 HERE AS AN EXPERT.
18 THE COURT: SUSTAINED.
19 Q. (BY MS. BARLOW) BASED ON YOUR TRAINING AS A NURSE, DO
20 YOU KNOW THE EFFECTS OF CENTRAL NERVOUS SYSTEM DEPRESSANT
21 DRUGS?
22 A. YES, I DO.
23 Q. DO YOU KNOW IF THEY HAVE ANY AFFECT ON BREATHING?
24 A. THEY WILL CAUSE BREATHING TO BECOME SHORTER AND MORE
25 SHALLOW.
3214
1 Q. SO THEY DO HAVE AFFECT ON BREATHING? YOU'LL HAVE TO
2 ANSWER OUT LOUD.
3 A. I'M SORRY. YES.
4 Q. SORRY TO HAVE TO KEEP REMINDING OF YOU.
5 BASED ON YOUR NURSING TRAINING AND EXPERIENCE, DO YOU
6 KNOW, JUST A YES OR NO, DO YOU KNOW WHETHER CENTRAL NERVOUS
7 SYSTEM DEPRESSANT DRUGS CAN CAUSE A PATIENT -- OR MAY CAUSE
8 A PATIENT TO FORGET TO BREATH?
9 MR. STIRBA: I'LL OBJECT, YOUR HONOR, IRRELEVANT
10 AND SHE'S NOT HERE AS AN EXPERT.
11 THE COURT: SUSTAINED.
12 MS. BARLOW: I'M NOT ASKING AS A EXPERT. JUST
13 BASED ON HER TRAINING WHETHER SHE KNOWS.
14 THE COURT: OKAY. THE QUESTION IS SUSTAINED.
15 Q. (BY MS. BARLOW) AS A NURSE, WHEN SOMEONE HAS HAD A
16 SEDATIVE, DO YOU HAVE TO TELL THEM TO BREATHE, A PATIENT TO
17 BREATHE?
18 MR. STIRBA: YOUR HONOR, I'LL OBJECT, IT'S A
19 HYPOTHETICAL QUESTION, IT'S IMPROPER.
20 THE COURT: SUSTAINED.
21 Q. (BY MS. BARLOW) BASED ON THE DRUGS THAT THESE PEOPLE
22 HAD BEEN GIVEN -- WELL, LET'S SAY MR. ALLDREDGE, WAS HE
23 SEDATED?
24 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT, LACK
25 OF FOUNDATION AND CALLS FOR AN OPINION.
3215
1 THE COURT: SUSTAINED.
2 Q. (BY MS. BARLOW) LET'S TURN TO THE MASTER TREATMENT
3 PLAN AGAIN, PAGE 92.
4 A. OKAY.
5 Q. AT THE TOP YOU WROTE DEATH AND DYING ISSUES R.F.?
6 A. RELATED TO, R.T.
7 Q. R.T., SORRY. IT'S HARD ON COPIES SOMETIMES TO READ WHAT
8 THEY SAY. R.T., RELATED TO LEFT OCCIPITAL C.B.A. ACUTE
9 1/13. WHERE DID YOU GET THE INFORMATION THAT THERE WAS AN
10 ACUTE LEFT OCCIPITAL CVA ON THE 13TH?
11 A. I DON'T RECALL AT THIS POINT.
12 Q. DID YOU DIAGNOSE THAT THERE WAS A PENDING DEATH?
13 A. YES.
14 Q. IN ENNIS ALLDREDGE?
15 A. YES.
16 Q. IT WASN'T A NURSING ASSESSMENT, THAT WAS A DIAGNOSIS?
17 A. A NURSING ASSESSMENT LEADS TO A NURSING DIAGNOSIS. A
18 NURSING DIAGNOSIS IS THE TERMINOLOGY FOR THE SHORTER
19 VERSIONS OF STATEMENTS THAT WE MAKE AND THE TITLES THAT ARE
20 UNDERNEATH, THERE IS A CARE PLAN. IT'S AN ORGANIZATIONAL
21 TECHNIQUE.
22 Q. IF YOU WOULD PULL OUT LYDIA SMITH'S BINDER. OH, I'M
23 SORRY, BEFORE WE LEAVE MR. ALLDREDGE...I APOLOGIZE FOR GOING
24 BACK AND FORTH.
25 IF YOU WOULD TURN TO PAGE 47.
3216
1 A. OKAY.
2 Q. I WANT TO CLEAR UP SOMETHING. IN FACT, LET'S TURN
3 THIS -- THERE WE GO. THIS IS THE MEDICAL RECORD, EVIDENTLY
4 ORDERS WERE MADE ON THE 13TH WHICH IS THE DAY BEFORE HE DIED
5 AND YOU START AT 8 O'CLOCK IN THE MORNING AND THEN WE RUN
6 DOWN THROUGH 2300, EVIDENTLY IT WAS EVERY THREE HOURS. THEN
7 WHEN WE GET TO TWO AND FIVE -- 0200 AND 0500, THOSE WEREN'T
8 GIVEN ON THE 13TH, WERE THEY?
9 A. THAT WOULD BE -- IT DEPENDS ON HOW THEY DIVIDED THE
10 SHIFT REPORT OUT -- HOW YOU COUNT THE DAY IT DEPENDS ON THE
11 NURSING SCHEDULE. IS THE NIGHT SHIFT THE NIGHT SHIFT OF THE
12 DAY PREVIOUS OR IS IT THE FIRST SHIFT OF THE FOLLOWING DAY,
13 AND SO THE NUMBERS ARE BASED ON THAT FORMAT.
14 Q. RIGHT.
15 A. MEANING THAT THE NIGHT SHIFT APPLIES TO THE PREVIOUS
16 DAY, NOT THE FOLLOWING MORNING.
17 Q. SO IF THE ORDER WAS -- SO IF THE MORPHINE WAS ORDERED
18 AND THEN I'M LOOKING AT PAGE 13, ON 1/13/96 AND NOTED BY
19 EARLENE COZZENS AT 800, 0800, THAT'S WHEN SHE WOULD HAVE
20 WRITTEN THIS OUT; IS THAT CORRECT?
21 A. THAT'S RIGHT.
22 Q. SO THE FIRST DOWN TO 2300, WOULD HAVE BEEN GIVEN ON THE
23 13TH; IS THAT CORRECT?
24 A. THAT'S CORRECT.
25 Q. AND ACTUALLY THE 0200 AND THE 0500 WERE GIVEN ON THE
3217
1 14TH AS THE REST OF US TELL TIME AFTER MIDNIGHT, AS OPPOSED
2 TO NURSES?
3 A. YEAH.
4 Q. AS YOU'VE JUST EXPLAINED. SO TECHNICALLY, THOSE TWO
5 THAT YOU ADMINISTERED AT 0200 AND IT LOOKS LIKE 0430 YOU
6 WROTE WERE GIVEN THE 14TH, AND THEN WE HAVE SOMEONE ELSE WHO
7 GAVE ANOTHER DOSE AT 8 O'CLOCK THAT MORNING?
8 A. THAT'S RIGHT.
9 Q. OKAY. THANK YOU. AND THOSE WERE GIVEN AS SCHEDULED; IS
10 THAT CORRECT?
11 A. THAT'S CORRECT.
12 Q. THEY WERE NOT P.R.N.?
13 A. NO.
14 Q. BUT YOU OBVIOUSLY DIDN'T SEE ANY NEED TO HOLD THAT
15 MEDICATION BECAUSE YOU DIDN'T HOLD IT?
16 A. THAT'S CORRECT.
17 Q. NOW LET'S LOOK AT LYDIA SMITH. MAYBE WE'LL START WITH
18 PAGE 698 SO WE GET OUR TIME PARAMETERS HERE, WHILE
19 RECOGNIZING THAT YOU DON'T HAVE AN INDEPENDENT RECOLLECTION
20 OF THIS.
21 A. I'M SORRY, WHERE ARE WE?
22 Q. LYDIA SMITH 698 ADMIT.
23 A. OKAY.
24 Q. SO SHE CAME IN ON THE 20TH OF DECEMBER; IS THAT CORRECT?
25 IT'S HARD TO READ THERE AT THE TOP.
3218
1 A. IS IT AT THE TOP?
2 Q. YES. ADMIT DATE THIRD BOX OVER.
3 A. 12/20/95 IT SAYS.
4 Q. 12/20/95. AND AT THE BOTTOM WE HAVE -- SO THAT'S AT THE
5 TOP AT 12/20/95 AND THEN AT THE BOTTOM WE HAVE THE DISCHARGE
6 DATE OF WHAT DATE?
7 A. MY COPY SAYS -- THE MONTH IS NOT LEGIBLE AND THEN 8/96.
8 Q. SO JANUARY 8TH, '96?
9 A. THAT MAY BE, IF THAT'S WHAT YOUR YOURS SAYS.
10 Q. AND AT WHAT TIME?
11 A. 12:45 P.M. THIS SAYS.
12 Q. AND IT'S MARKED DOWN HERE THAT --
13 A. EXPIRED.
14 Q. -- THE PATIENT HAD EXPIRED? SO NOW WE KNOW THE TIME
15 FRAME WE'RE WORKING WITHIN. IF YOU WOULD TURN TO 719, THIS
16 IS A PROGRESS NOTE AND IT WAS WRITTEN WHAT DATE THE ONE AT
17 THE BOTTOM, THE ONE THAT YOU WROTE?
18 A. THE MONTH IS NOT LEGIBLE, 8/96.
19 Q. SO JANUARY 8TH YOU WROTE THAT PHYSICAL CONDITION WAS
20 MARKEDLY DETERIORATED, SHE'S UNABLE TO SWALLOW FOOD, FLUID
21 OR MEDICATION. THIS WAS WRITTEN THE DAY SHE DIED; IS THAT
22 CORRECT?
23 A. I'LL HAVE TO CHECK.
24 Q. WELL, WE JUST READ THAT SHE DIED ON THE 8TH AT 12:45.
25 A. OKAY, THAT'S FINE.
3219
1 Q. I'M SORRY. I'M NOT TRYING TO TRIP YOU UP HERE.
2 SO THIS WAS WRITTEN THE DAY THAT SHE DIED. LET'S LOOK
3 AT NURSING NOTES FOR THE 8TH, SEE IF WE CAN DETERMINE WHAT
4 SHIFT YOU WORKED THAT DAY. IF YOU WOULD LOOK AT 802, YOU
5 WORKED THE 11 TO 7 SHIFT THAT DAY. WELL, I'M SORRY, I'LL
6 WAIT UNTIL YOU GET TO IT.
7 A. IT STATES 11 TO 7 IS MY NOTE.
8 Q. SO YOU WOULD HAVE WRITTEN THIS WEEKLY R.N. ADVOCATE NOTE
9 SOMETIME BETWEEN 11 AND 7?
10 A. MOST LIKELY, UNLESS I WAS THERE EARLY OR LATE FOR SOME
11 REASON.
12 Q. SHE'S UNABLE TO SWALLOW FOOD, FLUID OR MEDICATION SO
13 THAT'S A PERCEPTION, OF COURSE, THAT YOU HAD AT THE TIME?
14 A. THAT'S CORRECT.
15 Q. BASED ON YOUR NURSING TRAINING AND EXPERIENCE, DO
16 SEDATIVE DRUGS INTERFERE WITH THE ABILITY TO SWALLOW?
17 MR. STIRBA: OBJECT, YOUR HONOR.
18 THE COURT: SUSTAINED.
19 Q. (BY MS. BARLOW) LET'S -- LOOK AT LET'S LOOK AT 800
20 WHICH IS A NOTE THAT YOU MADE ON THE 7TH WHICH WAS THE DAY
21 BEFORE. 11 TO 7 SHIFT, YOU WROTE PATIENT RESTED QUIETLY
22 THROUGH THE SHIFT, MINIMALLY RESPONSIVE TO MORNING A.M.
23 CARES. RESPIRATION SLOW, DEEP AND REGULAR.
24 YOU INDICATE THAT THEY ARE SLOW BUT YOU DIDN'T NOTE HOW
25 MANY RESPIRATIONS PER MINUTE; IS THAT CORRECT?
3220
1 A. THERE IS A DOCUMENTATION OF HER VITAL SIGNS. IN THE
2 GEROPSYCHIATRIC ASSESSMENT THERE'S A PHYSICAL ASSESSMENT
3 COMPONENT THAT ACCOMPANIES THE NOTE, HER RESPIRATORY RATE AT
4 THAT TIME IS DOCUMENTED AT 16 PER MINUTE.
5 Q. AND WHO WROTE THAT DOCUMENTATION?
6 A. THAT APPEARS TO BE SOMEONE ELSE'S HANDWRITING. IT COULD
7 BE THE NURSING ASSISTANT.
8 Q. YOU DON'T HAVE ANY INDEPENDENT KNOWLEDGE RIGHT NOW WHAT
9 TIME THOSE VITAL SIGNS WERE WRITTEN?
10 A. I HAVE A RECOLLECTION THAT THE INITIAL ASSESSMENTS FOR
11 THE PATIENTS, WHICH IS WHAT THESE ARE, VITAL SIGNS WERE DONE
12 BY THE NIGHT SHIFT IN THE MORNING.
13 Q. AND THEY ARE 16. WAS THAT SLOW TO YOUR MIND?
14 A. SLOW/NORMAL.
15 Q. BUT SLOW/NORMAL, WOULD YOU HAVE WRITTEN SLOW IN YOUR
16 NOTES?
17 A. THAT WAS THE TYPICAL WAY FOR ME TO DESCRIBE A PATIENT
18 WHO IS BREATHING SLOW AND REGULARLY IN SLEEP.
19 Q. ISN'T 12 TO 16 USUALLY NORMAL RESPIRATIONS PER MINUTE?
20 A. NORMAL, YES.
21 Q. SIXTEEN, IS THAT THE HIGH OR THE LOW END OF NORMAL?
22 A. NORMAL CAN BE AS HIGH AS 24.
23 Q. IF YOU WOULD TURN TO 802 YOU WRITE PRETEXT THAT, PATIENT
24 LYING IN BED WITH EYES OPEN THROUGHOUT SHIFT -- IS THAT
25 SHIFT?
3221
1 A. UH-HUH.
2 Q. THANK YOU. IS THAT DEMONSTRATES MUCH REFLEXIVE GRASPING
3 IN RESPONSE TO PHYSICAL STIMULI?
4 A. UH-HUH.
5 Q. BASED ON YOUR NURSING -- WELL, DO YOU HAVE ANY KNOWLEDGE
6 BASED ON YOUR NURSING EXPERIENCE ABOUT REFLEXIVE GRASPING AS
7 OPPOSED TO VOLITIONAL ACTS?
8 A. REFLEXIVE GRASPING OCCURS WHEN YOU PLACE SOMETHING IN
9 THE PATIENT'S HAND AND THEY CLOSE AROUND IT. VOLITIONAL
10 ACTS ARE MOTIVATED SPONTANEOUSLY BY THE PATIENT.
11 Q. AND DO YOU HAVE -- YOU KNOW, THIS IS YES OR NO QUESTION.
12 DO YOU HAVE ANY KNOWLEDGE BASED ON YOUR NURSING TRAINING AS
13 TO WHAT CAUSES A PERSON TO DO REFLEXIVE ACTS AS OPPOSED TO
14 VOLITIONAL ACTS?
15 A. PATIENTS WHO DO REFLEXIVE ACTS HAVE USUALLY SEVERE
16 DAMAGE TO THEIR BRAIN FROM SOME SOURCE.
17 Q. AND BASED ON YOUR NURSING KNOWLEDGE, DO YOU KNOW WHETHER
18 HYPOXIA COULD CAUSE BRAIN DAMAGE?
19 MR. STIRBA: YOUR HONOR, I'LL OBJECT.
20 THE COURT: SUSTAINED.
21 Q. (BY MS. BARLOW) AS A NURSE, ARE YOU TRAINED TO KNOW
22 WHAT CAUSES BRAIN DAMAGE?
23 MR. STIRBA: I WOULD OBJECT AS TO RELEVANCE, YOUR
24 HONOR.
25 THE COURT: LET'S DO THAT -- LET'S DISCUSS THESE
3222
1 THINGS AT BREAK AND GO ON TO SOMETHING ELSE.
2 Q. (BY MS. BARLOW) ABOUT MIDWAY DOWN ON PAGE 802, YOU
3 HAVE 2400 HOUR DOSE OMITTED DUE TO PATIENT APPEARED IN NO
4 ACUTE DISTRESS AT THE TIME AND NURSING STAFF WAS ATTENDING
5 ANOTHER DYING PATIENT AND HER FAMILY. DO YOU KNOW WHETHER
6 THAT WAS MARY CRANE?
7 A. I DO NOT KNOW.
8 Q. THE 0300 DOSE WAS GIVEN AT 0230, RESPIRATION RATE 10 TO
9 12. ISN'T THAT A SLOW RESPIRATION RATE?
10 A. IT'S STILL WITHIN NORMAL.
11 Q. DID YOU SEE SIGNS OF ACUTE DISTRESS HERE IN THIS PATIENT
12 AT 0230 NECESSITATING MORPHINE?
13 A. SHE WAS RECEIVING A SCHEDULED DOSE OF MORPHINE.
14 Q. BUT AT THIS POINT SHE HAD APNEA FROM 10 TO 20 SECONDS,
15 SO IF YOU HAD 20 SECONDS BETWEEN BREATHS YOU ARE -- IN A
16 60-SECOND MINUTE, YOU ARE MAYBE, WHAT, THREE BREATHS PER
17 MINUTE, FOUR?
18 A. I DON'T RECALL THIS PATIENT.
19 Q. NOW, WITH THESE FIVE PATIENTS AND LET'S START SINCE WE
20 HAVE LYDIA SMITH'S BINDER HERE, THE MASTER TREATMENT PLAN
21 WHICH IS STARTS AT 815 FOR LYDIA SMITH. YOU HAVE INSERTED
22 ON THE FIRST PAGE AT 815 -- FIRST THERE WAS -- SOMEONE ELSE
23 WROTE ALTERED THOUGHT PROCESSES ON 12/20 AS THE MASTER
24 PROBLEM LIST?
25 A. THAT'S RIGHT.
3223
1 Q. AND THEN ON THE 8TH YOU WROTE DEATH AND DYING ISSUES; IS
2 THAT CORRECT?
3 A. THAT'S CORRECT.
4 Q. AND THEN ON 818 YOU WENT INTO SHORT-TERM GOALS AND
5 LONG-TERM GOALS AND THIS WAS IN YOUR HANDWRITING?
6 A. THAT'S CORRECT.
7 Q. SO YOU DETERMINED THAT YOU WERE AT THIS POINT WITH DEATH
8 AND DYING ISSUES ON THE 8TH OF JANUARY?
9 A. APPARENTLY.
10 Q. AND INDEED SHE DIED ON THE 8TH OF JANUARY; IS THAT
11 CORRECT?
12 A. IF THAT'S WHAT THE RECORD STATES, YEAH.
13 Q. DID YOU MAKE ANY ASSESSMENT AS TO WHAT BROUGHT HER TO
14 DEATH AND DYING ISSUES ON THE 8TH OF JANUARY?
15 A. THAT WOULD BE A MEDICAL DIAGNOSIS BEYOND MY SCOPE.
16 Q. LET'S LOOK AT THE MASTER TREATMENT PLAN FOR JUDITH
17 LARSEN. IN THE INTEREST OF TIME, I'LL REPRESENT TO YOU THAT
18 THE MASTER TREATMENT PLAN DOES NOT DEAL WITH DEATH AND DYING
19 ISSUES. SO LET'S LOOK BACK AT MED-596 FOR JUDITH LARSEN
20 WHICH IS IN THE CARDEX. THIS IS THE NURSING CARE PROGRAM
21 THAT YOU WROTE. IT APPEARS -- IN FACT, LET ME ASK YOU:
22 ISN'T THAT YOUR HANDWRITING WHEN YOU GET TO 596?
23 A. WHEN I GET THERE. UH-HUH.
24 Q. YOU WROTE THAT; IS THAT CORRECT?
25 A. UH-HUH.
3224
1 Q. AND AS DEATH AND DYING ISSUES ALTERNATIVE -- WELL,
2 ALTERNATIVE -- WELL, A.L.T., COPING PATIENT AND FAMILY DEATH
3 AND DYING ISSUES. PATIENT WILL EXPERIENCE A PEACEFUL DEATH
4 FREE FROM DISCOMFORT. YOU WROTE THAT, IT APPEARS, ON THE
5 2ND OF JANUARY?
6 A. THAT'S CORRECT.
7 Q. I'LL REPRESENT TO YOU ON THE ADMISSION IT INDICATES THAT
8 SHE DIED ON THE 3RD OF JANUARY, IT DOESN'T GIVE A TIME ON
9 THIS BUT SHE DID EXPIRE ON THE 3RD OF JANUARY, SO YOU WROTE
10 THIS THE DAY BEFORE SHE DIED; IS THAT CORRECT?
11 A. THAT APPEARS TO BE TRUE.
12 Q. DID YOU HAVE ANY RECOLLECTION OF WHAT LED UP TO HER
13 DEATH?
14 A. I DON'T AT THIS TIME, NO.
15 Q. ENNIS ALLDREDGE, LET'S LOOK TO THE MEDICAL TREATMENT
16 PLAN ON PAGE 90.
17 A. OKAY.
18 Q. THE 14TH YOU WROTE DEATH AND DYING ISSUES AND I THINK
19 WE'VE ALREADY ESTABLISHED THAT THE 14TH WAS THE DAY THAT HE
20 DIED. DO YOU HAVE ANY KNOWLEDGE OF WHAT LED UP TO HIS DEATH
21 ON THE 14TH?
22 A. NO, I HAVE NO RECOLLECTION.
23 Q. LET'S LOOK AT ELLEN ANDERSON.
24 A. I'M SORRY?
25 Q. ELLEN ANDERSON.
3225
1 A. OKAY.
2 Q. AND PAGE 196 THE MEDICAL TREATMENT PLAN INDICATES
3 ANXIETY, THAT WAS NOTED ON 12/29 WHICH IS WHEN SHE CAME IN.
4 A. OKAY.
5 Q. AND THEN SHE PASSED AWAY AT 8:55 THE NEXT MORNING. IS
6 THERE ANY INDICATION OF DEATH AND DYING ISSUES WITH ELLEN
7 UNDERSTAND?
8 A. NO.
9 Q. AND YOU DON'T KNOW WHAT LED UP TO HER DEATH?
10 A. I'M SORRY, NO.
11 Q. MARY CRANE, I'LL JUST REPRESENT TO YOU THAT SHE -- THERE
12 ARE A LOT OF MEDICAL RECORDS THAT YOU...
13 A. YOU DON'T WANT TO KNOW.
14 Q. AND I KNOW THEY GET CUMBERSOME.
15 A. NOT GOOD.
16 Q. IF YOU WOULD --
17 A. VERY CAREFULLY.
18 Q. -- OPEN TO 347.
19 A. EASIER SAID THAN DONE AT THIS MOMENT.
20 Q. IT'S UNDER MEDICAL TREATMENT PLAN. DID THEY CALL COME
21 OUT? ARE YOU 347 -- WELL, RATHER THAN --
22 A. YES.
23 Q. OKAY. YOU DO HAVE 347?
24 A. YES.
25 Q. NOW, YOU DID NOT ON THE MASTER TREATMENT PLAN INDICATE
3226
1 ANY ALTERATION TO DEATH AND DYING ISSUES ON THAT PLAN, DID
2 YOU?
3 A. I DID NOT, NO.
4 Q. AND, IN FACT, -- WELL, OKAY. BUT THEN LET'S LOOK AT THE
5 CARDEX. YOU DID WRITE A NURSING CARE PROGRAM ON THE 28TH OF
6 DECEMBER; IS THAT CORRECT?
7 A. WHAT PAGE NUMBER?
8 Q. I'M SORRY, THAT'S 335. DID YOU WRITE ANYTHING ABOUT
9 DEATH AND DYING ISSUES?
10 A. ARE WE IN CARDEX?
11 Q. ON CARDEX.
12 A. I DID NOT, NO.
13 Q. DID ANYONE ELSE THAT YOU CAN SEE?
14 A. NO.
15 Q. WHEN YOU WROTE ON I BELIEVE IT'S THREE OF THESE PATIENTS
16 THAT THE CARE PLAN HAD CHANGED TO DEATH AND DYING ISSUES,
17 YOU KNEW THEY WERE DYING AT THAT POINT; IS THAT CORRECT?
18 A. THAT WOULD HAVE BEEN MY IMPRESSION, YES.
19 Q. AND YOU KNEW THAT THERE WAS PROBABLY LITTLE YOU COULD DO
20 TO STOP THE PROCESS AT THAT POINT; IS THAT CORRECT?
21 A. THAT'S CORRECT.
22 Q. BUT YOU DIDN'T WRITE THOSE DEATH AND DYING ISSUES ON
23 THEIR ADMISSION, DID YOU?
24 A. THAT -- I DON'T HAVE A SPECIFIC RECOLLECTION OF WHEN I
25 WROTE EACH FOR EACH PATIENT AND WE'VE BEEN GOING THROUGH
3227
1 THAT HERE.
2 Q. IN FACT, WHEN THEY CAME ON THE UNIT, YOU DIDN'T SEE THAT
3 THEY WERE DYING AT THAT POINT, IS THAT CORRECT?
4 MR. STIRBA: WELL, I'M GOING TO OBJECT, YOUR HONOR,
5 WITHOUT RELEVANCE TO THE FACT THAT SHE EVEN SAW THE PATIENTS
6 AT THAT TIME.
7 THE COURT: IF YOU WANT TO LAY A FOUNDATION THAT
8 SHE DID SO.
9 MS. BARLOW: WELL, WE DON'T WANT TO GO THROUGH
10 EVERY BINDER AGAIN SO I WILL WITHDRAW THAT QUESTION.
11 Q. (BY MS. BARLOW) MARY CRANE HAD A DURAGESIC PATCH
12 ADMINISTERED TO HER, ARE YOU AWARE OF THAT?
13 A. I WOULD BE IF I LOOKED AT THE RECORD.
14 Q. HOW ABOUT IF I REPRESENT TO YOU THAT THAT'S CORRECT?
15 A. THAT'S FINE.
16 MR. STIRBA: YOUR HONOR, I'LL OBJECT TO THE FORM OF
17 THAT QUESTION. I DON'T THINK THE WITNESS IS HERE TO BRIEF
18 COUNSEL.
19 THE COURT: OKAY. WELL, JUST ASK THE QUESTION.
20 Q. (BY MS. BARLOW) THEN WE WILL GO TO THE PHYSICIAN'S
21 ORDER FOR MARY CRANE, SPECIFICALLY PAGE 239.
22 A. OKAY.
23 Q. AND IT APPEARS THAT ON THE 28TH OF DECEMBER THERE WERE
24 TWO ORDERS FOR DURAGESIC PATCH. ONE AT 1915 FOR
25 25 MICROGRAMS AND THEN ONE SLIGHTLY LATER CHANGE DURAGESIC
3228
1 TO 50 MICROGRAMS TRANSDERMAL PATCH EVERY THREE DAYS AND YOU
2 NOTED BOTH OF THOSE; IS THAT CORRECT?
3 A. THAT'S MY SIGNATURE, YES.
4 Q. YOU NOTED ONE THAT IT LOOKS LIKE 1900 HOURS; IS THAT
5 CORRECT?
6 A. THAT COULD BE. IT COULD BE 19, IT COULD BE 17, I...
7 Q. AND THEN YOU NOTED THE OTHER ONE AT 2100 HOURS; IS THAT
8 CORRECT?
9 A. THAT'S CORRECT.
10 Q. BASED ON YOUR NURSING EXPERIENCE, ARE YOU FAMILIAR WITH
11 DURAGESIC PATCHES?
12 A. YES.
13 Q. AND DO YOU KNOW WHAT THEY DO?
14 A. YES.
15 Q. DO THEY CAUSE SEDATION?
16 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT TO
17 THAT QUESTION.
18 THE COURT: OKAY. WHY DON'T -- LADIES AND
19 GENTLEMEN, I THINK WE'VE BEEN GOING ALMOST AN HOUR THIS
20 MIGHT BE A GOOD TIME THAT WE CAN TAKE A QUICK BREAK AT THE
21 MORNING.
22 AT THIS TIME, REMEMBER IT'S YOUR DUTY NOT TO CONVERSE
23 AMONG YOURSELVES OR TO CONVERSE WITH OR ALLOW YOURSELVES TO
24 BE ADDRESSED BY ANY OTHER PERSON ON THE SUBJECT OF THIS
25 TRIAL. IT'S ALSO YOUR DUTY NOT TO FORM OR EXPRESS ANY
3229
1 OPINION UNTIL THE CASE IS FINALLY SUBMITTED TO YOU. WHY
2 DON'T YOU COME BACK AT 15 MINUTES TO TEN.
3 (WHEREUPON THE JURY WAS EXCUSED.)
4 THE COURT: PLEASE BE SEATED. THE RECORD WILL
5 REFLECT THAT THE JURY HAS LEFT THE COURTROOM. DO YOU WANT
6 TO DISCUSS THESE QUESTIONS AND DISCUSS REGARDING THE LAST I
7 THINK THE LAST QUESTION AND OTHER QUESTIONS?
8 MR. STIRBA: YES, YOUR HONOR. I THINK THAT A
9 NURSE -- CERTAINLY WE'VE HAD THIS SINCE THE NURSES ARE
10 INVOLVED IN GIVING SOME MEDICATIONS, I THINK THEY CAN
11 GENERALLY SAY AND THEY HAVE WHAT A MEDICATION IS IF THEY
12 HAVE SOME GENERAL UNDERSTANDING WHAT IT GENERALLY DOES, I
13 THINK THAT'S FAIR. BUT THEN TO ASK A QUESTION, DO THEY
14 CAUSE SEDATION? FIRST OF ALL, THE REAL ISSUE IS IN THIS
15 CASE, GIVEN ALL THE FACTS AND CIRCUMSTANCES, DID THIS
16 PARTICULAR DRUG HAVE A POSITIVE EFFECT OR A NEGATIVE EFFECT
17 WITH RESPECT TO THE CONDITION OF THIS PATIENT, AND IF IT HAD
18 A NEGATIVE EFFECT, WHAT SIGNIFICANCE, IF ANY, DOES THAT
19 HAVE. THOSE ARE YOU ALL MEDICAL KIND OF JUDGEMENTS.
20 THE FACTS OBVIOUSLY, AND I THINK EVERY PHYSICIAN THAT'S
21 TESTIFIED IN THIS COURTROOM HAS SAID, MEDICATIONS ARE
22 INDIVIDUALIZED, THEY DEPEND ON ALL THE CIRCUMSTANCES THAT
23 ARE PRESENTED. AND OBVIOUSLY THIS WITNESS DOESN'T HAVE THAT
24 KIND OF COMPETENCE, DOESN'T HAVE THAT EXPERTISE, SHE'S NOT A
25 DOCTOR, SHE'S NOT HERE AS AN EXPERT.
3230
1 SO TO ASK HER A QUESTION DO THEY CAUSE SEDATION, FIRST
2 OF ALL, IS AN IRRELEVANT QUESTION. SECOND OF ALL, IT'S
3 BEYOND THE SCOPE OF HER COMPETENCE, AND THIRD OF ALL, I
4 THINK IT'S CALLING FOR HER TO KNOW FACTS FOR WHICH SHE
5 CLEARLY WOULDN'T KNOW ANYWAY. SHE DIDN'T TREAT THIS WHOLE
6 PATIENT, SHE DIDN'T FOLLOW THIS WHOLE PATIENT, SHE'S NOT A
7 MEDICAL DOCTOR, SO THAT'S MY CONCERN. AND I THINK THE OTHER
8 QUESTION AND I CAN'T REMEMBER THE QUESTION, JUDGE, BUT I
9 THINK IS IN A SIMILAR BROAD VEIN AND THAT'S REALLY MY
10 POSITION.
11 THE COURT: OKAY. MS. BARLOW?
12 MS. BARLOW: YOUR HONOR, SHE AS A NURSE I THINK
13 SHE'S TESTIFIED SHE KNOWS WHAT DRUGS DO AND I AGREE WITH MR.
14 STIRBA THAT, YOU KNOW, A NURSE NEEDS TO KNOW WHAT DRUGS DO.
15 SHE ALSO HAS TESTIFIED THAT SHE MAKES AN ASSESSMENT AS TO
16 WHETHER, YOU KNOW, THERE ARE CERTAIN SIDE EFFECTS, WHETHER
17 SHE SHOULD ACTUALLY ADMINISTERED THE DRUG OR NOT. AND I
18 THINK BASED ON THAT IT'S ENTIRELY APPROPRIATE TO ASK HER
19 WHAT SHE KNOWS ABOUT A DURAGESIC AND WHETHER SHE KNOWS IT'S
20 A SEDATIVE DRUG OR NOT. I DON'T THINK THAT THAT NECESSARILY
21 CALLS FOR A DOCTOR'S OPINION OR --
22 THE COURT: WELL, YOUR QUESTION WAS THOUGH, DO THEY
23 CAUSE SEDATION.
24 MS. BARLOW: YES. AND I ASKED HER DOES SHE KNOW AS
25 A NURSE WHETHER THEY CAUSE SEDATION. SHE COULD EASILY SAY,
3231
1 NO, I DON'T KNOW. I THINK IT GOES TO NOT MAKING HER AN
2 EXPERT BUT MAKING -- TO LET THE JURY KNOW WHAT SHE KNOWS.
3 THE COURT: WELL, FIRST OF ALL, EARLIER IN HER
4 TESTIMONY YOU WERE ARGUING WITH HER THAT SHE COULDN'T MAKE A
5 DIAGNOSIS UNDER UTAH LAW AND NOW YOU ARE ASKING HER TO
6 BASICALLY GIVE OPINIONS.
7 MS. BARLOW: WELL, NOT MEDICAL OPINIONS. I'M JUST
8 ASKING HER WHAT SHE KNOWS AS A NURSE --
9 THE COURT: WELL, DO THEY CAUSE SEDATION, IS THAT
10 NOT A MEDICAL OPINION?
11 MS. BARLOW: NO. I ASKED HER DOES SHE KNOW AS A
12 NURSE WHETHER THEY CAUSE SEDATION AND IT, YOU KNOW, GOES TO
13 WHAT KNOWLEDGE A NURSE HAS ABOUT THESE DRUGS AND THEY DO
14 HAVE. I MEAN, THEY ARE NOT PHARMACOLOGISTS, THEY ARE NOT
15 MEDICAL DOCTORS, BUT THEY HAVE TO HAVE A CERTAIN --
16 THE COURT: WELL, I GUESS THE PROBLEM IS WHERE ARE
17 WE TRYING TO DO, WHAT ARE WE TRYING TO DO WITH EACH WITNESS?
18 I UNDERSTOOD THAT THIS WAS A TREATING NURSE. WE HAD FOUR,
19 FIVE, SIX OR SEVEN IN THE PLAINTIFF'S CASE. I UNDERSTOOD
20 THEY WERE GOING TO COME HERE, TESTIFY WHAT THEY DID, WHY
21 THEY DID IT AND THEIR EXPERIENCE IN DOING THIS TYPE OF STUFF
22 THAT THEY DID.
23 AND NOW, YOU KNOW, WE'VE ALREADY HAD EXPERTS THAT HAVE
24 COME IN AND TESTIFIED WHETHER THESE DRUGS CAN CAUSE
25 SEDATION, WHETHER THEY CAN DO THIS, WHETHER THEY CAN DO
3232
1 THAT. WE'VE HAD EXPERTS, WE'LL HAVE OTHER EXPERTS. WHY ARE
2 WE DOING IT WITH THIS WITNESS AND BASICALLY GOING THE WHOLE
3 CASE THROUGH A TREATING NURSE? I MEAN, BECAUSE WE'RE ASKING
4 THEM SEDATION WE'RE ASKING THEM THINGS, I MEAN IT BASICALLY
5 BECOMES A CUMULATIVE THING. WE'VE HAD FIVE OR SIX OF THE
6 EXPERTS FOR THE PLAINTIFFS THAT HAVE ALL TESTIFIED ABOUT
7 THIS.
8 MS. BARLOW: BUT I WANT TO GET AT WHAT SHE KNOWS
9 BECAUSE SHE SAID THAT SHE DIDN'T BELIEVE THAT GIVING THESE
10 DOSES WERE GOING TO CAUSE DEATH AND I WANT TO SHOW THE JURY
11 WHAT SHE KNOWS ABOUT -- NOT JUST ABOUT MORPHINE, BUT ABOUT
12 WHAT THE OTHER DRUGS MIGHT CAUSE.
13 THE COURT: BUT TO ASK HER A QUESTION DO THEY CAUSE
14 SEDATION, YOU KNOW, BASICALLY THAT'S GIVING A MEDICAL
15 OPINION. SEDATION -- YOU KNOW, BUT WHO MAKES A DECISION?
16 WHAT DOES SEDATION MEAN? WHAT IS YOUR DEFINITION OF
17 SEDATION?
18 MS. BARLOW: WELL, I THINK IT'S BEEN DEFINED.
19 THE COURT: WELL, IT HASN'T BEEN DEFINED WITH THIS
20 PERSON. I MEAN, WHAT IS IT? WHAT IS SEDATION?
21 MS. BARLOW: WELL, SEDATION IS DEPRESSING THE
22 CENTRAL NERVOUS SYSTEM AND ALL OF THE THINGS THAT HAVE BEEN
23 TESTIFIED TO.
24 THE COURT: OKAY. WELL, I THINK YOU CAN ASK A
25 QUESTION, IN YOUR EXPERIENCE, YOU KNOW, LIKE IF YOU SAY YOU
3233
1 DIAGNOSED IT -- OR YOU ASSESSED IT OR YOU DIAGNOSED IT OR
2 WHATEVER THE WORDS YOU ARE, AS THIS IN YOUR RECORD, IN YOUR
3 EXPERIENCE, COULD IT HAVE BEEN X, YOU KNOW, COULD IT HAVE
4 BEEN SOMETHING ELSE AND SHE CAN SAY YES OR NO. BUT IF YOU
5 ARE GOING TO ASK HER A QUESTION PHRASED, DID THEY CAUSE
6 SEDATION OR SOMETHING ELSE, YOU KNOW, I'M NOT GOING TO ALLOW
7 THAT.
8 I THINK YOU CAN ASK IN HER EXPERIENCE, COULD THIS BE
9 SOMETHING ELSE, THAT'S FINE. AND ASK HER, YOU KNOW, WHY SHE
10 DID WHAT SHE DID AND WHAT SHE DID, BUT NOT JUST TO GO
11 THROUGH AND ASK EVERY OPINION THAT WE'VE ALREADY ASKED
12 EXPERTS. SO WITH THAT DIRECTION THEN WE CAN COME BACK AT
13 9:45. I ALSO HAVE A MOTION THAT'S BEEN FILED, WHEN DO
14 COUNSEL WANT TO ADDRESS THAT?
15 MR. STIRBA: WHENEVER THE COURT FEELS IT IS A
16 CONVENIENT TIME.
17 THE COURT: OKAY. WELL, LET'S -- WE MIGHT DO IT
18 THEN AT THE LUNCH BREAK OR JUST AT THAT POINT. OKAY. LET'S
19 COME BACK AT 9:45.
20 (A BRIEF RECESS WAS TAKEN.)
21 THE COURT: THE RECORD WILL REFLECT THAT THE JURY
22 HAS RETURNED. MS. BARLOW, IF YOU WOULD LIKE TO CONTINUE.
23 MS. BARLOW: THANK YOU, YOUR HONOR.
24 Q. (BY MS. BARLOW) ISN'T IT TRUE, MRS. STEVENSON, THAT
25 EVERY TIME THESE PATIENTS MOANED OR GRIMACED YOU INTERPRETED
3234
1 THAT AS PAIN?
2 A. I COULDN'T SPEAK TO EVERY TIME THESE PATIENTS MOANED OR
3 GRIMACED. I HAVE NO RECOLLECTION SPECIFICALLY OF THESE
4 PATIENTS.
5 Q. IN FACT, YOU NEVER INTERPRETED MOANING AS ANYTHING ELSE;
6 IS THAT CORRECT?
7 A. I HAVE NO RECOLLECTION, I'M SORRY.
8 Q. EACH ONE OF THESE PATIENTS CAME IN AGITATIVE, COMBATIVE
9 AND ANXIOUS AND THEN DECLINED AND EVENTUALLY PASSED AWAY
10 WHILE THEY WERE ON THE UNIT; IS THAT NOT CORRECT?
11 A. THAT'S A VERY GENERAL STATEMENT. I DON'T KNOW THAT I
12 COULD AGREE SPECIFICALLY WITH THAT OR NOT.
13 Q. WELL, LET'S LOOK AT MR. ALLDREDGE, MED-PAGES 60 AND 61
14 SAY HE CAME IN COMBATIVE AND AGITATED.
15 A. DID YOU SAY 60 AND 61?
16 Q. 60 AND 61, YES. BUT PARTICULARLY 60.
17 A. THAT'S NOT MY NOTE.
18 Q. I KNOW, I RECOGNIZE THAT. BUT AT 1400 HOURS IS THE
19 ADMISSION NOTE, PATIENT IS VERY COMBATIVE AND AGITATED. DO
20 YOU RECALL HIM BEING COMBATIVE AND AGITATED?
21 A. I DON'T HAVE ANY SPECIFIC RECOLLECTION OF THIS PATIENT.
22 Q. BUT THEN YOUR LAST NOTE WITH MR. ALLDREDGE IS THAT HE
23 WAS SINKING, I BELIEVE THAT'S A NURSING ADVOCATE NOTE.
24 EXCUSE ME, IT'S NOT A NURSING -- OR A PROGRESS NOTE. IT IS
25 78 -- OR I'M SORRY. I'VE GOT THE WRONG NUMBER. THAT WON'T
3235
1 BE HELPFUL TO US.
2 ARE YOU SUFFERING FROM ANY MEDICAL PROBLEMS AT THIS
3 TIME THAT AFFECT YOUR RECOLLECTION OR YOUR ABILITY TO
4 REMEMBER?
5 A. NO.
6 Q. ARE YOU TAKING ANY MEDICATIONS AT THIS TIME THAT MIGHT
7 AFFECT YOUR MEMORY?
8 A. NO.
9 Q. WERE YOU TAKING ANY MEDICATIONS BACK IN DECEMBER AND
10 JANUARY OF '95 AND '96 THAT WOULD AFFECT YOUR MEMORY OF WHAT
11 HAPPENED THEN?
12 A. I COULD NOT STATE SPECIFICALLY.
13 Q. THERE WERE FIVE PATIENTS THAT DIED IN ABOUT 16 DAYS, DO
14 YOU RECALL THAT?
15 A. YES.
16 Q. MR. STIRBA MET WITH YOU A COUPLE OF MONTHS AGO; IS THAT
17 CORRECT?
18 A. THAT'S CORRECT.
19 Q. HE FLEW OUT TO PENNSYLVANIA TO MEET WITH YOU?
20 A. I'M SORRY?
21 Q. HE CAME OUT TO PENNSYLVANIA TO MEET WITH YOU?
22 A. YES.
23 Q. DID HE BRING RECORDS FOR YOU TO REVIEW AT THAT TIME?
24 A. YES.
25 Q. DID YOU BRING THOSE RECORDS WITH YOU TODAY?
3236
1 A. I DID NOT CARRY ANY RECORDS, NO.
2 Q. DO YOU KNOW WHETHER THEY ARE THE SAME RECORDS THAT
3 YOU'VE BEEN DEALING WITH TODAY?
4 A. THE INFORMATION APPEARS TO BE THE SAME.
5 MS. BARLOW: I THINK THAT'S ALL I HAVE, YOUR HONOR.
6 THE COURT: ANY REDIRECT?
7 MR. STIRBA: YES, YOUR HONOR.
8 REDIRECT EXAMINATION
9 BY MR. STIRBA:
10 Q. DO YOU HAVE MR. ALLDREDGE'S BINDER IN FRONT OF YOU?
11 A. YES.
12 Q. IF YOU WOULD TURN TO THE PROGRESS NOTE SECTION OF THAT
13 BINDER.
14 A. OKAY.
15 Q. NUMBER 18, DO YOU HAVE THAT?
16 A. YES.
17 Q. NOW, THERE IS A WEEKLY R.N. ADVOCATE NOTE THERE THAT IS
18 IN YOUR WRITING.
19 A. THAT'S CORRECT.
20 Q. AND YOU REFLECT IT STATES, PLEASE SEE DR. WEITZEL'S NOTE
21 ABOVE R.E.: M.R.I. RESULTS, DID YOU WRITE THAT?
22 A. YES.
23 Q. AND THEN IF YOU WOULD TURN -- AND BEFORE DO YOU THAT,
24 THE DATE OF THAT IS -- THAT NOTE IS WHAT DATE IS IT?
25 A. FOURTEENTH.
3237
1 Q. OF JANUARY?
2 A. APPEARS TO BE.
3 Q. OKAY. AND THEN IF YOU WOULD TURN, PLEASE, TO THE
4 NURSING NOTE SECTION, SPECIFICALLY 69.
5 A. OKAY.
6 Q. IS THERE WRITING AT THE BOTTOM OF THAT PAGE THAT IS
7 YOURS?
8 A. YES.
9 Q. AND IT STARTS AT 1800 HOURS AND THE DATE IS 1/12 OF '96?
10 A. 1700 HOURS.
11 Q. I'M SORRY. YES, THAT'S CORRECT. I'M DIRECTING YOUR
12 ATTENTION TO WHERE IT HAS "I," DO YOU SEE THAT?
13 A. YES.
14 Q. DO YOU JUST READ, PLEASE, THROUGH THE LAST STATEMENT
15 CONCERNING THE M.R.I.
16 A. IMPRESSION/INTERVENTION: M.R.I,DR. KLINGER CALLED TO
17 REPORT EVIDENCE OF POSSIBLE NEW INFARCT LEFT OCCIPITAL LOBE.
18 PATIENT REMAINS RESTLESS AND MINIMALLY RESPONSIVE EXCEPT TO
19 DISCOMFORT. DR. WEITZEL HAS BEEN NOTIFIED OF M.R.I.
20 RESULTS. IN VIEW OF PATIENT'S DIABETES AND POSSIBLE
21 DEHYDRATION....AND THEN IT CONTINUES ON.
22 Q. AND THEN IT CONTINUES ON FROM THERE. SEEING THIS NOTE
23 NOW, DOES THIS REFRESH YOUR RECOLLECTION AS TO WHETHER OR
24 NOT YOU WOULD HAVE BEEN CONTACTED BY DR. KLINGER OR SOMEBODY
25 FROM DR. KLINGER'S OFFICE?
3238
1 A. THE NOTE REFLECTS THAT DR. KLINGER HIMSELF CALLED TO
2 REPORT EVIDENCE OF A NEW INFARCT. I WOULD HAVE WRITTEN
3 EXACTLY WHAT HE TOLD ME.
4 Q. NOW, IF YOU COULD GET ELLEN ANDERSON'S -- YEAH, ELLEN
5 ANDERSON'S BINDER OUT, PLEASE.
6 AND SPECIFICALLY IF YOU WOULD DIRECT YOUR ATTENTION TO
7 THE DOCTOR'S ORDER, PHYSICIAN'S ORDER TAB AND IT WOULD BE
8 170.
9 A. OKAY.
10 Q. AND THIS IS A DOCUMENT THAT YOU'VE SEEN BEFORE IN YOUR
11 TESTIMONY, RIGHT?
12 A. YES.
13 Q. YOU'VE BEEN ASKED ABOUT THIS. I WANT TO DIRECT YOUR
14 ATTENTION SPECIFICALLY TO IT SAYS TYLENOL AND THEN COULD YOU
15 READ WHAT THE REST OF THAT SAYS, PLEASE?
16 A. TYLENOL TWO TIMES P.O. Q 4 HOURS P.R.N. PAIN.
17 Q. AND DID YOU CHECK WHERE IT IS CHECKED?
18 A. YES.
19 Q. AND WHY DID YOU CHECK THAT?
20 A. BECAUSE I TRANSCRIBED THE ORDER ONTO THE MEDICATION
21 ADMINISTRATION RECORD.
22 Q. AND THEN ALSO BELOW THERE THERE WAS ANOTHER ORDER AND
23 IT'S FOR MORPHINE 10 MILLIGRAMS I.M. NOW FOR PAIN, DID YOU
24 SIMILARLY CHECK THAT?
25 A. YES.
3239
1 Q. AND WHY DID YOU CHECK THAT?
2 A. BECAUSE I TRANSCRIBED IT ONTO THE MEDICAL ADMINISTRATION
3 RECORD.
4 Q. AND NOW HAVING REVIEWED THE RECORDS CONCERNING MS.
5 ANDERSON'S CARE, DO YOU RECALL THAT YOU MADE AN ASSESSMENT
6 OR OBSERVATION OF HER ON THE 29TH OF DECEMBER AT ABOUT 7:30
7 IN THE EVENING?
8 A. YES.
9 Q. AND DO YOU RECALL THE NOTE THAT I'M REFERRING TO?
10 A. I WOULD HAVE TO LOOK AT IT.
11 Q. WHY DON'T WE GET IT. IT WOULD BE IN THE NURSES' NOTES
12 SECTION AND IT WOULD BE -- IT WOULD BE MED-190.
13 A. OKAY.
14 Q. AND YOU HAVE TESTIFIED PREVIOUSLY TO EVENTS AS YOU
15 RECOLLECT THEM REGARDING THIS MED-NOTE THAT IS IN YOUR
16 WRITING; IS THAT RIGHT?
17 A. THAT'S CORRECT.
18 Q. WOULD YOU TELL US, IS THERE ANY SIGNIFICANCE IN THE FACT
19 THAT THERE WAS A DOCTOR'S ORDER FOR TYLENOL P.R.N. FOR PAIN
20 AND ALSO THERE WAS THEN AN ORDER FOR MORPHINE FOR PAIN?
21 A. THE TYLENOL ORDER IS PART OF THE STANDARD ADMITTING
22 ORDERS FOR ANY ADMISSION TO THE HOSPITAL. TO OUR PARTICULAR
23 UNIT, TYLENOL IS USED FOR MILD TO MODERATE DISCOMFORT PAIN.
24 THERE'S AN ADDITIONAL ORDER FOR MORPHINE. MORPHINE IS USED
25 FOR SEVERE PAIN IN PATIENTS WHO NEED MORE IMMEDIATE RELIEF
3240
1 OF THEIR DISTRESS. HAVING GIVEN -- IF I WERE TO GIVE A
2 TYLENOL, FOR EXAMPLE, IN A PATIENT WITH SEVERE PAIN, THEY
3 WOULD THEN HAVE TO WAIT HALF AN HOUR AT LEAST TO EVALUATE
4 THE EFFECTIVENESS OF A MEDICATION SUCH AS TYLENOL BEFORE I
5 COULD GIVE THEM SOMETHING ELSE IN ADDITION IF THEY WERE
6 HAVING SEVERE PAIN.
7 Q. WHY DO YOU SAY A HALF AN HOUR?
8 A. THAT'S THE REASONABLE AMOUNT OF TIME THAT A NURSE WAITS
9 BECAUSE THAT'S AT LEAST AS LONG AS IT WOULD TAKE FOR PAIN
10 RELIEF TO OCCUR AFTER THE PATIENT TOOK AN ORAL MEDICATION.
11 Q. WOULD YOU TELL US, PLEASE, WHY YOU DID NOT ADMINISTER
12 TYLENOL TO MRS. ANDERSON ON THE EVENING OF THE 29TH OF
13 DECEMBER?
14 A. HAVING OBTAINED A STAT ORDER FOR MORPHINE TELLS ME THAT
15 I MUST HAVE TOLD DR. WEITZEL THAT THE PATIENT WAS IN EXTREME
16 DISTRESS.
17 MS. BARLOW: YOUR HONOR, I OBJECT AS TO SOMETHING
18 SHE MUST HAVE TOLD. ONLY WHAT SHE REMEMBERS.
19 THE COURT: YES, SUSTAINED. TELL US WHAT YOU
20 REMEMBER, NOT WHAT YOU SUPPOSE.
21 THE WITNESS: THE NOTE REFLECTS THE PATIENT IN
22 EXTREME DISTRESS. THE MEDICATION WAS ORDERED FOR A PATIENT
23 IN EXTREME DISTRESS.
24 Q. (BY MR. STIRBA) IS TYLENOL A MEDICATION FOR SOMEBODY
25 WHO IS IN SEVERE PAIN?
3241
1 A. NO.
2 Q. NOW, YOU HAVE TALKED TO ME ON A COUPLE OF OCCASIONS AND
3 I HAVE SHOWN YOU SOME RECORDS FROM THE HOSPITAL; IS THAT
4 RIGHT?
5 A. YES.
6 Q. IN FACT, JUST A COUPLE OF DAYS AGO YOU REVIEWED SOME OF
7 THESE RECORDS WHICH YOU'VE TESTIFIED HERE IN COURT; IS THAT
8 RIGHT?
9 A. THAT'S CORRECT.
10 Q. DO YOU REMEMBER WHAT I ASKED YOU TO DO AT THAT TIME?
11 A. YOU ASKED ME TO REVIEW THE RECORDS TO SEE IF I HAD ANY
12 CLEAR RECOLLECTION OF A PATIENT.
13 Q. AND WHAT ELSE DID I TELL YOU?
14 A. YOU TOLD ME TO TELL THE TRUTH.
15 MR. STIRBA: THAT'S ALL I HAVE, YOUR HONOR.
16 THE COURT: ANYTHING FURTHER?
17 MS. BARLOW: YES, YOUR HONOR.
18 RECROSS-EXAMINATION
19 BY MS. BARLOW:
20 Q. IF YOU WOULD OPEN UP MR. ALLDREDGE'S BINDER AGAIN TO
21 NUMBER 69.
22 A. OKAY.
23 Q. YOU READ THE NOTE ABOUT THE M.R.I. DR. KLINGER CALLED
24 TO REPORT AND YOU JUST TESTIFIED THAT HE REPORTED EVIDENCE
25 OF A NEW INFARCT. THAT'S WHAT YOU JUST SAID ON REDIRECT?
3242
1 A. WHAT THE NOTE SAYS.
2 Q. WELL, DO YOU RECALL WHAT YOU SAID ON REDIRECT?
3 A. NO, I DON'T.
4 Q. OKAY. YOU SAID THAT DR. KLINGER SAID THERE WAS EVIDENCE
5 OF A NEW INFARCT. THAT'S NOT WHAT THE NOTE READS, IS IT?
6 A. I CAN ONLY SPEAK TO WHAT THE NOTES SAY.
7 Q. AND THE NOTE SAYS POSSIBLE NEW INFARCT; IS THAT NOT
8 CORRECT?
9 A. THAT'S CORRECT.
10 Q. DO YOU RECALL AT THIS POINT WHEN YOU REPORTED TO DR.
11 WEITZEL THE M.R.I. RESULTS WHETHER YOU SAID IT WAS A NEW
12 INFARCT OR A POSSIBLE NEW INFARCT?
13 A. I DO NOT RECALL THE CONVERSATION, NO.
14 MS. BARLOW: NO FURTHER QUESTIONS, YOUR HONOR.
15 THE COURT: ANYTHING FURTHER OF THIS WITNESS?
16 MR. STIRBA: I HAVE NONE, YOUR HONOR. THANK YOU.
17 THE COURT: MAY SHE BE EXCUSED?
18 MR. STIRBA: SHE MAY.
19 THE COURT: THANK YOU. WOULD YOU LIKE TO CALL YOUR
20 NEXT WITNESS?
21 MR. STIRBA: YES, WE WOULD CALL DR. ROBERT
22 ROTHFEDER, PLEASE. AND, YOUR HONOR, BEFORE WE GET STARTED
23 WITH DR. ROTHFEDER, I WOULD LIKE TO HAND OUT SOME BINDERS
24 WHICH WILL ASSIST IN THE PRESENTATION OF HIS TESTIMONY THAT
25 HAVE IN IT RELEVANT PORTIONS OF THE EVIDENCE PERTINENT TO
3243
1 HIS TESTIMONY AND I HAVE ONE FOR YOUR HONOR, ONE FOR COUNSEL
2 AND ONE FOR THE JURY MEMBERS.
3 THE COURT: IS THERE ANY OBJECTION TO THAT?
4 MR. MAJOR: WE WOULD LIKE TO REVIEW THAT FIRST,
5 YOUR HONOR.
6 THE COURT: GO AHEAD. IF YOU WOULD LIKE TO COME
7 FORWARD AND BE SWORN.
8 ROBERT KEITH ROTHFEDER,
9 CALLED BY THE DEFENDANT, HAVING BEEN FIRST DULY
10 SWORN, WAS EXAMINED AND TESTIFIED AS FOLLOWS:
11 DIRECT EXAMINATION
12 BY MR. STIRBA:
13 Q. DOCTOR, WOULD YOU STATE YOUR FULL NAME AND SPELL YOUR
14 LAST NAME, PLEASE.
15 A. ROBERT KEITH ROTHFEDER, THAT'S R-O-T-H-F-E-D-E-R.
16 Q. AND WHERE DO YOU RESIDE, SIR?
17 A. I RESIDE IN SANDY, UTAH.
18 Q. AND WHAT DO YOU DO FOR A LIVING?
19 A. I'M A PHYSICIAN. I SPECIALIZE IN EMERGENCY MEDICINE.
20 Q. AND COULD YOU TELL US, PLEASE, YOUR EDUCATIONAL
21 BACKGROUND IN THE FIELD OF MEDICINE.
22 A. YES. FOLLOWING GRADUATION FROM COLLEGE AT RUTGERS
23 UNIVERSITY IN 1969, I ATTENDED MEDICAL SCHOOL AT THE
24 UNIVERSITY OF MINNESOTA MEDICAL SCHOOL IN TWIN CITIES. I
25 GRADUATED FROM MEDICAL SCHOOL IN 1974 AT WHICH TIME I
3244
1 RELOCATED TO SALT LAKE CITY. AND IN SALT LAKE I DID AN
2 INTERNSHIP AND RESIDENCY IN INTERNAL MEDICINE AT THE LDS
3 HOSPITAL AND UNIVERSITY OF UTAH SYSTEM FROM 1974 THROUGH
4 1977. FROM 1977 ON I'VE BEEN IN PRIVATE PRACTICE.
5 Q. AND GENERALLY, WHAT DOES YOUR PRIVATE PRACTICE ENTAIL?
6 A. IT'S CHANGED SOMEWHAT OVER THE YEARS. FROM '77 THROUGH
7 '94 I PRACTICED EMERGENCY MEDICINE FULL-TIME AT THE LAKEVIEW
8 HOSPITAL IN BOUNTIFUL. AND EMERGENCY MEDICINE IN THAT
9 SETTING CONSISTED OF A HOSPITAL BASED PRACTICE WHERE I WOULD
10 SEE PATIENTS IN THE EMERGENCY DEPARTMENT WHO PRESENTED WITH
11 USUAL EMERGENCIES.
12 Q. HAVE YOU PREVIOUSLY TESTIFIED IN COURTS IN THE STATE OF
13 UTAH AS A MEDICAL EXPERT?
14 A. I HAVE IN THE STATE OF UTAH AND ELSEWHERE. MOST OF MY
15 TESTIMONY HAS BEEN WITH REGARD TO ISSUES SUCH AS CAUSE OF
16 DEATH AND AFFECT OF INJURIES UPON LATER LIFE.
17 Q. DO YOU HAVE ANY BOARD CERTIFICATIONS?
18 A. BOARD CERTIFICATION IN EMERGENCY MEDICINE.
19 Q. AND PERHAPS SINCE YOU'VE STATED IT A FEW TIMES, MAYBE
20 YOU COULD TELL US, PLEASE, WHAT EMERGENCY MEDICINE ENTAILS.
21 A. I CAN. ACTUALLY, EMERGENCY MEDICINE IS A RELATIVELY NEW
22 MEDICAL SPECIALTY. WHEN I WAS IN RESIDENCY TRAINING THERE
23 WAS NOT SUCH A SPECIALTY RECOGNIZED AND POSSIBLE EMERGENCY
24 DEPARTMENTS WERE SERVICED BY PHYSICIANS IN A VARIETY OF
25 SPECIALTIES WHO WOULD -- WHO WOULD ROTATE AND TAKE DAYS
3245
1 COVERING THE EMERGENCY ROOM.
2 WELL, IT TURNED OUT THAT THAT WAS LESS THAN IDEAL. YOU
3 MIGHT HAVE A PEDIATRICIAN TAKING CARE OF AN ADULT SURGICAL
4 PATIENT AND THAT TYPE OF THING. SO IN ABOUT THE EARLY AND
5 MID '70S IT BECAME RECOGNIZED THAT A BETTER SITUATION WOULD
6 BE TO HAVE PHYSICIANS WHO SPECIALIZED IN EMERGENCY MEDICAL
7 TREATMENT TO WORK SOLELY IN EMERGENCY DEPARTMENTS AND THAT'S
8 EVOLVED OVER TIME TO THE CURRENT STATUS WHERE IN
9 METROPOLITAN AREAS PHYSICIANS THAT WORK IN HOSPITAL
10 EMERGENCY DEPARTMENTS SPECIALIZED IN THAT.
11 THE TYPICAL -- THE TYPICAL PATIENTS THAT ONE WOULD SEE
12 DURING AN AVERAGE SHIFT IN THE EMERGENCY DEPARTMENT WOULD BE
13 ABOUT 50/50 IN TERMS OF PATIENTS WITH MEDICAL ILLNESSES
14 VERSUS PATIENTS WHO HAVE SUFFERED INJURIES. AND AMONG THOSE
15 PATIENTS WITH MEDICAL ILLNESSES, IT WOULD PRETTY MUCH COVER
16 THE SPECTRUM IN TERMS OF WHAT THEIR PROBLEM WAS. THEY COULD
17 BE HAVING HEART TROUBLE OR A STROKE OR A KIDNEY PROBLEM OR A
18 LIVER PROBLEM OR PSYCHIATRIC PROBLEM. THEY COULD BE MALE,
19 FEMALE, YOUNG, ELDERLY, IN BETWEEN, BASICALLY ANYTHING THAT
20 YOU COULD THINK OF THAT MAKES SOMEBODY ILL BRINGS THEM TO
21 THE EMERGENCY ROOM. SIMILARLY, THE TRAUMA PATIENTS WOULD BE
22 A HOST OF THINGS ANYWHERE FROM PEOPLE CUTTING THEIR FINGERS
23 WASHING DISHES WHO NEEDED TO BE SEWN UP, TO KIDS BREAKING
24 THEIR WRISTS, TO LIFE-THREATENING MULTIPLE TRAUMA IN MOTOR
25 VEHICLE ACCIDENTS.
3246
1 SO IN A NUTSHELL, THAT'S WHAT -- THAT'S WHAT THE
2 PRACTICE OF EMERGENCY MEDICINE IS ABOUT. AND DURING MY
3 CAREER, I WOULD SAY THAT IN THE AVERAGE SHIFT THERE WOULD BE
4 AT LEAST ONE TO TWO PATIENTS COMING IN WHO HAD
5 LIFE-THREATENING PROBLEMS AND WHO WERE AT RISK OF DYING IN
6 THE NEXT FEW MINUTES OR HOURS.
7 Q. HAVE YOU IN YOUR CAREER TREATED PEOPLE WITH ACUTE
8 INJURIES OR ACUTE CIRCUMSTANCES?
9 A. WELL, THOUSANDS, TENS OF THOUSANDS MAYBE.
10 Q. AND COULD YOU TELL US, PLEASE, GENERALLY THE KINDS OF
11 ACUTE CIRCUMSTANCES OR INJURIES THAT YOU HAVE ADDRESSED AS
12 AN EMERGENCY PHYSICIAN?
13 A. CERTAINLY. AMONG THE MEDICAL PATIENTS, THE MOST COMMON
14 ACUTE CIRCUMSTANCES WOULD BE CARDIAC HEART PROBLEMS. PEOPLE
15 COMING IN WITH CHEST PAIN, MANY OF WHOM WOULD TURN OUT TO
16 HAVE HAD HEART ATTACKS, SOME OF THOSE HEART ATTACKS WITH
17 COMPLICATIONS. THE OTHER PATIENTS PRESENTING WITH CHEST
18 PAIN WOULD TURN OUT TO HAVE PNEUMONIAS, WHAT WE CALL
19 PULMONARY EMBOLI, THAT IS BLOOD CLOTS THAT GO TO THE LUNG
20 WHICH ARE LIFE-THREATENING, STROKES WHICH ARE ALSO
21 LIFE-THREATENING ARE VERY COMMON IN THE SENIOR CITIZEN AGE
22 GROUP.
23 OTHER MEDICAL CONDITIONS THAT WERE COMMON WOULD BE
24 PROBLEMS WITH DIABETES AND THE COMPLICATION THEREOF, ASTHMA,
25 INTESTINAL PROBLEMS, ABDOMINAL PAIN AS A PRESENTING
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1 COMPLAINT IS PROBABLY ALMOST AS COMMON AS CHEST PAIN AND
2 THOSE PATIENTS WOULD HAVE THINGS LIKE APPENDICITIS,
3 GALLBLADDER DISEASE, ULCER DISEASE, BLEEDING ULCERS. A
4 NUMBER OF THESE PATIENTS WOULD BE IN POTENTIALLY
5 LIFE-THREATENING SITUATIONS. I MEAN, IT GOES ON AND ON. I
6 COULD SPEND A LOT OF TIME BUT THAT'S THE TYPE OF THING.
7 MEDICALLY WE WOULD SEE ACUTE PSYCHIATRIC EMERGENCIES,
8 SUICIDE ATTEMPTS WHERE PEOPLE TAKE OVERDOSES OF MEDICATION
9 AND OTHER SUBSTANCES. IN TERMS OF TRAUMA, LACERATIONS,
10 FRACTURES, MULTIPLE TRAUMA, BLUNT TRAUMA TO THE CHEST OR
11 ABDOMEN WHICH IS LIFE-THREATENING, PENETRATING TRAUMA TO THE
12 CHEST OR ABDOMEN WHICH WOULD INCLUDE GUNSHOT WOUNDS, KNIFE
13 WOUNDS, PENETRATING INJURIES FROM OTHER PROJECTILES, FROM
14 MOTOR VEHICLE TRAUMA, HEAD INJURIES RESULTING IN
15 UNCONSCIOUSNESS, COMA, ET CETERA, ET CETERA, BLEEDING INSIDE
16 THE HEAD, SUBDURAL HEMATOMAS. AND ON TOP OF THAT YOU HAVE A
17 WHOLE HOST OF EMERGENCIES THAT ARE SEEN ONLY IN PEDIATRIC
18 PATIENTS. YOU SEE A NUMBER OF EMERGENCIES THAT ARE SEEN
19 ONLY IN GYNECOLOGIC PATIENTS, MISCARRIAGES, VAGINAL
20 BLEEDING, ET CETERA, ET CETERA, ET CETERA.
21 Q. IN THE CONTEXT OF YOUR PRACTICE, HAVE YOU CARED FOR AND
22 TREATED A GERIATRIC POPULATION?
23 A. NOWADAYS IN THE EMERGENCY ROOM A LARGE PERCENTAGE OF
24 PATIENTS COMING INTO THE EMERGENCY ROOM ARE GERIATRIC
25 PATIENTS, PATIENTS WITH MULTIPLE EXISTING MEDICAL PROBLEMS;
3248
1 HEART PROBLEMS, DIABETES, OLD STROKES, INFECTIONS AND SO
2 FORTH, WHO COME IN WITH SOME ACUTE CHANGE THAT REQUIRES
3 EVALUATION SUCH AS A NEW COMPLAINT OF PAIN, CHANGE IN MENTAL
4 STATUS, THAT TYPE OF THING. AND ACTUALLY, FREQUENTLY THOSE
5 PATIENTS PRESENTING WITH CHANGE IN MENTAL STATUS, CHANGE IN
6 COMFORT ARE FOUND TO HAVE AN ACUTE MEDICAL PROBLEM WHICH HAS
7 PRECIPITATED THE BEHAVIORAL CHANGE.
8 Q. DEFINE FOR US WHAT YOU MEAN BY AN ACUTE CHANGE OR AN
9 ACUTE MEDICAL STATUS.
10 A. WELL, THE ACUTE BEHAVIORAL CHANGES THAT YOU'LL SEE WILL
11 BE THAT THE PATIENT WILL COME FROM THE HOME OR NURSING HOME
12 AND THEY'LL SAY THEY'RE NOT COMMUNICATING ANYMORE, YESTERDAY
13 THEY WERE COMMUNICATIVE, WE COULD HAVE A CONVERSATION, TODAY
14 THEY WON'T ANSWER ME OR THEY -- THEY ARE DISORIENTED, THEY
15 ARE GOING THROUGH TIMES WHERE THEY DON'T KNOW WHERE THEY
16 ARE, THEY WON'T EAT, THEY WON'T DRINK, THEY'VE SUDDENLY
17 BECOME INCONTINENT OF URINE OR OF STOOL. THEY BECOME --
18 THEY BECOME NOT ALERT, NOT REACTING TO THEIR CIRCUMSTANCE
19 AND THEN A HOST OF -- A HOST OF MEDICAL TYPES OF SIGNS AND
20 SYMPTOMS; THEY ARE BREATHING RAPIDLY, THEY ARE MOANING IN
21 PAIN, THEY ARE RUNNING A FEVER, THEIR PULSE IS RAPID,
22 THEY'RE COUGHING, ET CETERA, ET CETERA.
23 Q. IS THERE -- IS THE GERIATRIC POPULATION PARTICULARLY
24 PRONE IN YOUR EXPERIENCE TO ACUTE MEDICAL CHANGES?
25 A. VERY MUCH SO.
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1 Q. AND WHY IS THAT DOCTOR?
2 A. WELL, THEY ARE FRAGILE. THEY ARE FRAGILE, THEY ARE --
3 MR. MAJOR: WELL, YOUR HONOR, WE'RE GOING TO
4 OBJECT. WE WOULD LIKE AN OPPORTUNITY TO VOIR DIRE THIS
5 WITNESS AND WE MAY WANT TO DO IT OUTSIDE OF THE JURY. WE
6 HAVE SOME CONCERNS ABOUT HIS QUALIFICATIONS AND ABOUT
7 FOUNDATION THAT'S BEEN LAID HERE.
8 THE COURT: WELL, I DON'T KNOW IF ALL THE
9 FOUNDATION HAS BEEN LAID.
10 MR. STIRBA: NO, WE'RE JUST LAYING IT, I THOUGHT.
11 THE COURT: WELL, DO YOU WISH --
12 MR. STIRBA: WELL, I WOULD CERTAINLY -- I MEAN, IF
13 THEY WANT TO VOIR DIRE THE WITNESS, GO RIGHT AHEAD AT THIS
14 POINT.
15 THE COURT: OKAY.
16 VOIR DIRE EXAMINATION
17 BY MR. MAJOR:
18 Q. DOCTOR, YOU JUST -- YOU INDICATED YOU WORK IN THE
19 EMERGENCY ROOM; IS THAT CORRECT?
20 A. PARDON ME?
21 Q. YOU ARE AN EMERGENCY ROOM PHYSICIAN?
22 A. CORRECT.
23 Q. AND THAT'S SOLELY WHAT YOUR EXPERTISE IS IS WORKING IN
24 THE EMERGENCY ROOM?
25 A. I WOULDN'T SAY THAT'S SOLELY MY EXPERTISE.
3250
1 Q. BUT IN WORKING IN THE EMERGENCY ROOM GEN