http://radio.wosu.org/post/mount-carmel-fires-doctor-accused-giving-woman-lethal-dose-fentanyl#strea

[dhb]

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[chocomorsel]

[QUOTE="chocomorsel, post: 20658653, member: 101189"

I specifically asked, how do we know these patients, who are unconscious, hypotensive, barely breathing, are truly suffering in the abscense of any signs and symptoms of pain, agitation and “psychological suffering” as you want to call it?

I don't think anyone is arguing for giving sedation/analgesia to those patients unless the intention is to 'snuff' them, not give 'assistance' during the dying process.

Aside from the news event at hand, the circumstance in question, I thought, is one where someone is terminal and experiencing pain/duress but is so physiologically brittle that assistance in the form of analgesia/sedation could bring about their death.

Some folks were saying if, for example, 100 mcgs an hour over several hours (in an aware, suffering patient) would hasten death, at the end of the day, a 1000 mcg bolus is the functional equivalent in the same circumstance. An obtunded, unaware person wasn't (I didn't think) part of the conversation here.[/QUOTE]


We treat all patients at the end of life, aware and unaware, very similarly. With PRN doses of benzos and narcs. No one gets palliatively extubated in the ICU or palliative care unit without PRN doses of something.
My point is, why do we feel ALL these patients need these drugs? We are completely lying to ourselves when we do this because all we are doing is hastening their dying process whether for the benefit of their families, or for us.
If people are agreeing with that, then they should not judge harshly someone like the OP is what I am saying. Although I don’t know for a fact, we can all hypothesize correctly what his intentions were. He wasn’t doing this to able bodied patients who were full code as far as the news media has let us in on.

 

[fakin' the funk]

The drugs are to ease the pain and suffering of the family sitting at the bedside moreso than the patient dying in the bed.

This is a ridiculous and inflammatory claim.

 

[fakin' the funk]

Ok, I am going to play your game. I specifically asked, how do we know these patients, who are unconscious, hypotensive, barely breathing, are truly suffering in the abscense of any signs and symptoms of pain, agitation and “psychological suffering” as you want to call it? Who can prove to some of us that these patients are “suffering”? Why do we feel the need to assist in their deaths with narcs and benzos? Do we think this patients are going to hold off death in time to make it out the hospital if we don’t assist them?

I hope that’s clear enough for you now because this is the third time I have posed those questions and no one has answered them.

I'm not playing a game. Your questions haven't been answered yet because they're unanswerable. They address a problem that doesn't exist.

The patient you describe "unconscious, hypotensive, barely breathing" sounds (without other clinical context) to be actively and imminently dying, like within minutes to hours. The patient as you describe it has no objectively indicated need for any medications intended to ease discomfort, pain, air hunger, dyspnea, secretion burden, etc etc, so I don't know why anyone would give any medications. [SIDE NOTE - why are you measuring BP in this actively dying pt?] No wonder you can't get your questions answered. This is a straw man.

The conduct of end-of-life care is very individualized. Especially - as we are talking about here - end-of-life care in the ICU, or end-of-life care that is initiated when ICU-level curative care is withdrawn. Some patients are seconds or minutes away from dying when their CVVH or vent or pressor doses are reduced in any way. Others are intubated and ventilated but if "terminally" extubated might live for days or weeks. It depends on their terminal diagnosis, apparent prognosis, etc, etc. Their care needs depend on their symptoms. Dyspnea and air hunger are extremely common at the end of life. So is psychological distress / existential suffering, if the patient can express it.

For the bolded text above, I'm not sure what issue or concern you're raising, but it seems to be very you-specific and not a broader concern in the world of end-of-life care.

 

[fakin' the funk]

We treat all patients at the end of life, aware and unaware, very similarly. With PRN doses of benzos and narcs. No one gets palliatively extubated in the ICU or palliative care unit without PRN doses of something.
My point is, why do we feel ALL these patients need these drugs? We are completely lying to ourselves when we do this because all we are doing is hastening their dying process whether for the benefit of their families, or for us.
If people are agreeing with that, then they should not judge harshly someone like the OP is what I am saying. Although I don’t know for a fact, we can all hypothesize correctly what his intentions were. He wasn’t doing this to able bodied patients who were full code as far as the news media has let us in on.

I really think that your claims like this reflect an incomplete understanding of the issues in end-of-life care (physical or psychological suffering), or, your preferred interpretation of various clinical scenarios you've been in, because you seem to be inferring the intent to hasten death as a primary effect.

It could also be that you misunderstand the principle of double effect, which is really crucial for the type of end-of-life care that is commonplace. The 4 necessary conditions for double effect:

1. The nature-of-the-act condition. The action must be either morally good or indifferent.
2. The means-end condition. The bad effect must not be the means by which one achieves the good effect.
3. The right-intention condition. The intention must be the achieving of only the good effect, with the bad effect being only an unintended side effect.
4. The proportionality condition. The bad effect must not be disproportionate to the good effect.

 

[chocomorsel]

I really think that your claims like this reflect an incomplete understanding of the issues in end-of-life care (physical or psychological suffering), or, your preferred interpretation of various clinical scenarios you've been in, because you seem to be inferring the intent to hasten death as a primary effect.

It could also be that you misunderstand the principle of double effect, which is really crucial for the type of end-of-life care that is commonplace. The 4 necessary conditions for double effect:

1. The nature-of-the-act condition. The action must be either morally good or indifferent.
2. The means-end condition. The bad effect must not be the means by which one achieves the good effect.
3. The right-intention condition. The intention must be the achieving of only the good effect, with the bad effect being only an unintended side effect.
4. The proportionality condition. The bad effect must not be disproportionate to the good effect.

I understand it. But thank you so very much for trying to explain it to me. I am inferring nothing. I simply disagree with your attempts at justification for pushing these drugs and then calling on to your "good effect" "bad effect" arguments but at the same time criticizing someone who did the exact same thing, except in a high speed fashion.

Last I checked, before tubes are pulled, and machines are stopped, and monitors are turned off, nurses are measuring blood pressures. And are you telling me that people are being terminally extubated without any orders for benzos/narcs no matter how quick or imminent their death? And that they aren't getting anything before they die in those few hours? You already know the answer to that.

Let's agree to disagree. I stick to my views. You stick to yours. We are all entitled. Explain and define your moral arguments all day long, it won't change my mind.

 

[Mman]

Meanwhile, the public thinks the truly massive doses of opiates and benzos used for actual court-ordered executions are insufficient to the point of being cruel and inhumane.

Intent matters, but the imagination-conjured notions and perceptions of ignorant laypeople matter more.

lay people? what about the surgeon says the patient is waking up if they so much as twitch during the case?

 

[pgg]

This is a ridiculous and inflammatory claim.

You're telling me you've never seen comfort-care morphine given to an expiring patient with agonal respirations?

We know the patient is already well past perceiving any suffering. But it looks painful to layperson family members. Moreover, the family's perception of suffering can cause lasting harm to them, guilt, helplessness, PTSD. End of life care involves caring for any loved ones that happen to be present too.

There are ethicists who argue that the use of neuromuscular blocking drugs is appropriate for the explicit purpose of halting agonal respirations in a patient for whom care has been otherwise withdrawn. Here's just one article arguing that it's ethically and legally defensible -

The agony of agonal respiration: is the last gasp necessary?

If rocuronium is defensible then perhaps 1000 mcg of fentanyl given with the same intent is too.

You seem to think this is all clearly black and white. It's not.

 

[Mman]

You seem to think this is all clearly black and white. It's not.

I think it's important to distinguish arguments made as to the legality of actions as opposed to arguments made in regards to the ethics of the situation. In an ideal world the legalese would match up with the ethics, but unfortunately that is not really true at present.

It is possible to be ethically correct but legally in the wrong.

 

[chocomorsel]

I think it's important to distinguish arguments made as to the legality of actions as opposed to arguments made in regards to the ethics of the situation. In an ideal world the legalese would match up with the ethics, but unfortunately that is not really true at present.

It is possible to be ethically correct but legally in the wrong.

Totally agree.

 

[drmwvr]

'We propose that there is an ethical basis, in rare circumstances, for the use of neuromuscular blockade to suppress prolonged episodes of agonal respiration in the well-sedated patient in order to allow a peaceful and comfortable death."

Even these authors tacitly admit that they feel a little icky about what they propose when they insert the 'rare' qualifier.

Arguing principles is hardly seeing things in black and white. When emotion and sentimentality are removed from the conversation, the optics might suffer, but if they are left to drive the conversation, there's no end to where unintended consequences might lead.

 

[pgg]

I think it's important to distinguish arguments made as to the legality of actions as opposed to arguments made in regards to the ethics of the situation. In an ideal world the legalese would match up with the ethics, but unfortunately that is not really true at present.

It is possible to be ethically correct but legally in the wrong.

Oh I agree, and I'm not personally interested in ever testing any of the boundaries in our legal system. Fakin The Funk might be on my jury and I'd be sad in prison.

But in the article I linked the authors also stated

As we noted earlier, the principle of double effect does not excuse the physician from all legal responsibility. We think it is highly unlikely, however, that a jury would convict a doctor of murder who followed our recommendations, since the doctor would not be planning to cause death.

I don't think the legal conclusion is black and white certain either.

 

[drmwvr]

It is possible to be ethically correct but legally in the wrong.

Well...just as easily as it is to be ethically wrong and legally wrong. Ethics are far more up for debate than the law.

 

[Mman]

Well...just as easily as it is to be ethically wrong and legally wrong. Ethics are far more up for debate than the law.

It's all up for debate. I think the ethics have far less disagreement amongst physicians than discussions of what the law should be.

 

[fakin' the funk]

You're telling me you've never seen comfort-care morphine given to an expiring patient with agonal respirations?

a) no I wouldn't tell you that, because it's not true, and I didn't claim that
b) what SaltyDog said is not what you've just queried of me here. His claim is inflammatory and ridiculous as he claimed it.

 

[fakin' the funk]

Let's agree to disagree. I stick to my views. You stick to yours. We are all entitled. Explain and define your moral arguments all day long, it won't change my mind.

Well it's good to know you're approaching this discussion in good faith and with an open mind. /s

 

[fakin' the funk]

We know the patient is already well past perceiving any suffering. But it looks painful to layperson family members. Moreover, the family's perception of suffering can cause lasting harm to them, guilt, helplessness, PTSD. End of life care involves caring for any loved ones that happen to be present too.

These are good points. The use of the word "caring" is important because the "second victims" need care too. But I think it's inappropriate to translate their need for care into interventions for the patient.

 

[fakin' the funk]

The agony of agonal respiration: is the last gasp necessary?

This article is fascinating, and also, ridiculous. My favorite part is the very very last sentence:

"Although we do not use neuromuscular blocking agents for this purpose at the current time, we hope this discussion results in dialogue which allows future application."

Gotta love skin in the game.

 

[nimbus]

The problem with the case in Columbus seems to be that the doctor ordered large doses of fentanyl without ever discussing end of life care or comfort care measures with family members. The deaths came as a complete surprise to some of the families. He should have had a conference to discuss the prognosis and the plan before acting. Bizarre.

 

[chocomorsel]

Well it's good to know you're approaching this discussion in good faith and with an open mind. /s

I already knew the arguments and you tried to be condescending at your attempt to break it down for me. Thank you, much appreciated.
You are a person who only likes to pick certain pieces of an argument instead of the whole piece to try to make people look a certain way. If I don't change my mind about how I feel, it's not because I am being closed minded, it's because after reading about the ethics behind it, I still feel like in the end we are trying to justify giving unnecessary drugs to a certain subset of patients who most likely don't need them in order to hasten their death. Which, personally, hastening someone's death on their deathbed is not a problem for me.

Whatever dude. You answered some of my questions and PROVED MY POINT in your response to @pgg when you told him that you’ve seen agonal patients, imminently expiring, get pain meds for comfort. When you clearly tried to make it look like that me bringing up that scenario was specific only to me. Clearly not and most of us have seen it.

Goodbye. And thank you @pgg

 

[chocomorsel]

The problem with the case in Columbus seems to be that the doctor ordered large doses of fentanyl without ever discussing end of life care or comfort care measures with family members. The deaths came as a complete surprise to some of the families. He should have had a conference to discuss the prognosis and the plan before acting. Bizarre.

Well then yes, that's a problem.

 

[Ronin786]

This is a ridiculous and inflammatory claim.

How is it ridiculous? I've literally seen countless occasions where patients are administered benzos/opioids before extubation. All while still having sedative infusions running. If I show up with a hospital with a shattered leg, I can't decide to be comfort measures only and get a bolus of fentanyl every time I groan. Yet the sickest patients in the hospital can and we pretend that it doesn't hasten their death.

 

[narcusprince]

The problem with the case in Columbus seems to be that the doctor ordered large doses of fentanyl without ever discussing end of life care or comfort care measures with family members. The deaths came as a complete surprise to some of the families. He should have had a conference to discuss the prognosis and the plan before acting. Bizarre.

The death coming as a complete surprise sounds like what the lawyers told them to say. Im sure those patients statuses had been changed to comfort care. Btw I have been in that ICU as an observer. The icu is located next to ohio state medical school. The wealthier patients go to ohio state while the rest go to this hospital. Im sure once the lawyers speak to the families I can almost guarantee they changed their story. I hope for Wills sake they had a written consent process for patients becoming comfort care. If not then of course the families would say they didn’t know their loved ones were comfort care. Too loose legal language.

 

[nimbus]

You're telling me you've never seen comfort-care morphine given to an expiring patient with agonal respirations?

We know the patient is already well past perceiving any suffering. But it looks painful to layperson family members. Moreover, the family's perception of suffering can cause lasting harm to them, guilt, helplessness, PTSD. End of life care involves caring for any loved ones that happen to be present too.

There are ethicists who argue that the use of neuromuscular blocking drugs is appropriate for the explicit purpose of halting agonal respirations in a patient for whom care has been otherwise withdrawn. Here's just one article arguing that it's ethically and legally defensible -

The agony of agonal respiration: is the last gasp necessary?

If rocuronium is defensible then perhaps 1000 mcg of fentanyl given with the same intent is too.

You seem to think this is all clearly black and white. It's not.

If it was me I’d prefer a whomping dose of propofol instead of a NMBA...just in case. And maybe some psychedelics before that....because at that point, why not.

 

[fakin' the funk]

Whatever dude. You answered some of my questions and PROVED MY POINT in your response to @pgg when you told him that you’ve seen agonal patients, imminently expiring, get pain meds for comfort. When you clearly tried to make it look like that me bringing up that scenario was specific only to me. Clearly not and most of us have seen it.

Goodbye. And thank you @pgg

We weren't talking about whether or not this phenomenon has ever occurred. You seem to think that it has, or does, validates your opinions on the matter. I can only shrug at this point.

 

[fakin' the funk]

How is it ridiculous? I've literally seen countless occasions where patients are administered benzos/opioids before extubation. All while still having sedative infusions running. If I show up with a hospital with a shattered leg, I can't decide to be comfort measures only and get a bolus of fentanyl every time I groan. Yet the sickest patients in the hospital can and we pretend that it doesn't hasten their death.

A) read his claim as it is (without your suggested scenario, or other qualifiers) and tell me you agree with it
B) who's pretending that giving opioids to the dying doesn't hasten their death?
C) I have given opioids and other rx pre-and-post-terminal-extubation based on assessment of patient factors, expected prognosis, etc. What's the problem there? You gotta be extubated to have comfort measures enacted?

 

[Ronin786]

A) read his claim as it is (without your suggested scenario, or other qualifiers) and tell me you agree with it
B) who's pretending that giving opioids to the dying doesn't hasten their death?
C) I have given opioids and other rx pre-and-post-terminal-extubation based on assessment of patient factors, expected prognosis, etc. What's the problem there? You gotta be extubated to have comfort measures enacted?

I do agree with his claim. Agonal respirations aren't necessarily uncomfortable to somebody with a CO of 0.5L/min and an O2 sat of 30. But they still get a dollop of fentanyl and midazolam to make them appear more comfortable for the family.

With regards to C, when you're in the OR and you have a patient w/COPD on 3L NC that you're teeing up for extubation, you'd never give them 5mg of morphine and pull the tube. Yet the sickest patient in the ICU w/septic shock gets morphine, midazolam and glyco before extubation and we pretend that we had no intention of hastening their demise.

I obviously can't sit here and examine your intentions, but for you to pretend that end-of-life comfort measures don't have some inherent euthanistic properties and motives is being intentionally obtuse. There's a reason ethicists had to get involved and create the double-effect, because it is a morally ambiguous zone.

 

[chocomorsel]

A) read his claim as it is (without your suggested scenario, or other qualifiers) and tell me you agree with it
B) who's pretending that giving opioids to the dying doesn't hasten their death?
C) I have given opioids and other rx pre-and-post-terminal-extubation based on assessment of patient factors, expected prognosis, etc. What's the problem there? You gotta be extubated to have comfort measures enacted?

You are. By arguing about second effect and all that jazz.

 

[chocomorsel]

We weren't talking about whether or not this phenomenon has ever occurred. You seem to think that it has, or does, validates your opinions on the matter. I can only shrug at this point.

It totally validates my opinions. Get it? MY OPINIONS.

 

[chocomorsel]

A) read his claim as it is (without your suggested scenario, or other qualifiers) and tell me you agree with it
B) who's pretending that giving opioids to the dying doesn't hasten their death?
C) I have given opioids and other rx pre-and-post-terminal-extubation based on assessment of patient factors, expected prognosis, etc. What's the problem there? You gotta be extubated to have comfort measures enacted?

Hate to break it to you as you don't seem to see it. You are partaking in euthanasia when you do that. Just giving smaller doses compared to the OP is all. No matter how much we lie to ourselves to put our minds at ease, no matter how many ethical arguments are out there, this is what we are doing.
And my main point is, anyone who does this should not be too harsh on this Mt. Carmel Dr. as well as the one from the West Coast.

These patients can and will die without our morphine and versed and glyco.

 

[IMGASMD]

Hate to break it to you as you don't seem to see it. You are partaking in euthanasia when you do that. Just giving smaller doses compared to the OP is all. No matter how much we lie to ourselves to put our minds at ease, no matter how many ethical arguments are out there, this is what we are doing.
And my main point is, anyone who does this should not be too harsh on this Mt. Carmel Dr. as well as the one from the West Coast.

These patients can and will die without our morphine and versed and glyco.

he didn’t have the intention of that happening......

 

[chocomorsel]

he didn’t have the intention of that happening......

Who? The Mt. Carmel doc?
Or @fakin' the funk? Yeah, I know. It was a second effect.

 

[FiremedicMike]

The problem with the case in Columbus seems to be that the doctor ordered large doses of fentanyl without ever discussing end of life care or comfort care measures with family members. The deaths came as a complete surprise to some of the families. He should have had a conference to discuss the prognosis and the plan before acting. Bizarre.

I'm not sure that's true-- the case that was publicized last week as the catalyst for looking into this issue was apparently a woman who came into the ED with pneumonia, crashed a few times over the next few days, and was ultimately brain dead. She didn't get her massive dose of fentanyl until several hours after the family discussed end of life and DNR items.

The media is being intentionally vague, as usual, and allowing people to assume that the staff is just indiscriminately murdering normal, healthy patients. As more of these cases come out and are scrutinized by people who know what they're looking at, I predict it will become clear that the folks receiving these medications were on their way out the door as it was.

 

[Man o War]

Dr Husel’s wife, a nurse, administered one of the fatal doses. She has been added to the case it looks like. This gets weirder every week.

https://www.google.com/amp/s/www.di...-wife-administered-fatal-dose?template=ampart

 

[deleted171991]

This is why every decent hospital has/should have a (multidisciplinary committee-approved) institutional comfort care order set in the EMR.

If it's not there, don't invent one for your patient! Protect yourselves, no good deed goes unpunished, and everybody has enemies. Comfort care is about the patient's comfort, not the family's. Do not do anything that can be construed as hastening death. Titrate medications the same way you would do if the patient were full code.

 

[nimbus]

This is why every decent hospital has/should have a (multidisciplinary committee-approved) institutional comfort care order set in the EMR.

If it's not there, don't invent one for your patient! Protect yourselves, no good deed goes unpunished, and everybody has enemies. Comfort care is about the patient's comfort, not the family's. Do not do anything that can be construed as hastening death. Titrate medications the same way you would do if the patient were full code.

Agree. This is an area where one should not be a cowboy.

 

[nimbus]

I'm not sure that's true-- the case that was publicized last week as the catalyst for looking into this issue was apparently a woman who came into the ED with pneumonia, crashed a few times over the next few days, and was ultimately brain dead. She didn't get her massive dose of fentanyl until several hours after the family discussed end of life and DNR items.

The media is being intentionally vague, as usual, and allowing people to assume that the staff is just indiscriminately murdering normal, healthy patients. As more of these cases come out and are scrutinized by people who know what they're looking at, I predict it will become clear that the folks receiving these medications were on their way out the door as it was.

I’ve read several different accounts including ones like you describe but I thought I read one where the patient was dead 4 hours after arrival to the hospital.

 

[FiremedicMike]

Attorney: Husel gave patient paralytics before lethal fentanyl dose

And the plot thickens...

 

[anbuitachi]

Attorney: Husel gave patient paralytics before lethal fentanyl dose

And the plot thickens...

sounds like euthanasia ... hes trying to help the patient in his own ways but lawmaker disagrees

 

[ZzzPlz]

Attorney: Husel gave patient paralytics before lethal fentanyl dose

And the plot thickens...

Wow that’s quicker/more humane than most the lethal injection cocktails I’ve read about

 

[dchz]

Ohio Doctor Charged With Killing 25 Patients in Fentanyl Overdoses (Published 2019)

The authorities accused the doctor of deliberately prescribing fatal doses of the powerful opioid to critical-care patients. He pleaded not guilty.

www.nytimes.com

I don't know Husel. I don't know all the facts. But misleading sensationalism is definitely what the attorney is banking on. And the journalists who don't know what is going on is willingly ignorant about it because it's good click bait.

If he is convicted, what will it mean to future defensive medicine and patient care?? For someone that is been sedated with fentanyl for the past week in the ICU, are you only going to order 100mcg of fentanyl because some win-at-all-cost attorney focused on one small detail to try to cash in on this case??

What would it mean for ICU attendings burn out?? (Already not-worth-it-fellowship for many on this sub forum) are we going to constantly practice in fear and focus more on documentation than to take care of patients? (Again contributing to burnout).

Most importantly, will @FFP be more snarky and pessimistic than before??

For the sake of intensive care and the greater good. I hope Husel is acquitted.

 

[narcotics999]

Attorney: Husel gave patient paralytics before lethal fentanyl dose

And the plot thickens...

Was it an IVP or infusion under Vent? Why 2 NMBs?

 

[FiremedicMike]

Was it an IVP or infusion under Vent? Why 2 NMBs?

I have admittedly never worked in an ICU nor been a part of end-of-life care, but I can't really see the appropriateness of any paralytics in these scenarios. I would love to hear from the experts in here as to whether there are any indications for nmb during extubation..

 

[nimbus]

I have admittedly never worked in an ICU nor been a part of end-of-life care, but I can't really see the appropriateness of any paralytics in these scenarios. I would love to hear from the experts in here as to whether there are any indications for nmb during extubation..

Euthanasia.

 

[deleted171991]

Ohio Doctor Charged With Killing 25 Patients in Fentanyl Overdoses (Published 2019)

The authorities accused the doctor of deliberately prescribing fatal doses of the powerful opioid to critical-care patients. He pleaded not guilty.

www.nytimes.com

I don't know Husel. I don't know all the facts. But misleading sensationalism is definitely what the attorney is banking on. And the journalists who don't know what is going on is willingly ignorant about it because it's good click bait.

If he is convicted, what will it mean to future defensive medicine and patient care?? For someone that is been sedated with fentanyl for the past week in the ICU, are you only going to order 100mcg of fentanyl because some win-at-all-cost attorney focused on one small detail to try to cash in on this case??

What would it mean for ICU attendings burn out?? (Already not-worth-it-fellowship for many on this sub forum) are we going to constantly practice in fear and focus more on documentation than to take care of patients? (Again contributing to burnout).

Most importantly, will @FFP be more snarky and pessimistic than before??

For the sake of intensive care and the greater good. I hope Husel is acquitted.

It's very hard to defend boluses of 500 mcg of fentanyl, not to mention 2,000, if true. The NMBs would be the kiss of death for his case, pun intended.

The US is a VERY litigious society, because that's what uneducated and not so bright people do, when they are angry, especially when manipulated by unscrupulous lawyers (which also include prosecutors with political ambitions). They need a scapegoat; the lottery on the side doesn't hurt either, in civil cases. Americans always like to blame other people, never themselves or the patient (it's the doctor who killed the patient, not the 50 pack-years of smoking etc.). Despite many of them calling themselves Christians, all they remember from the Bible is "an eye for an eye". They want "justice", even the imperfect kind that may hurt many other patients (by creating a bad precedent).

So be on the defensive all the time. First do no harm... to your family (that includes NEVER breaking the Law). Only then come the patients' best interests. It's a jungle out there.

You'll see, too, @dchz. I wasn't born a cynic, on the contrary. All immigrants are optimists, by definition.