Husel Trial -- NOT GUILTY

[Birdstrike]

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At least one of those high dose cases the patient lived for says after the dose though. I think that is sufficient to show that the dose is not universally fatal...

Just because the onset of action of fentanyl is < 5 min, does not mean that death must occur within 5 minutes, for the fentanyl to be the cause of death. A gunshot wound takes effect in < 1 second, yet it's not true to say, "If they didn't die instantly, the bullet didn't cause them to die." The effect of instant onset gunshot wounds fatal effects can take seconds, minutes, hours, days or months. But if it takes longer, you don't blame it on something else. It's still death from a GSW and the person who pulled the trigger is still responsible.

Similarly, a drug can cause apnea, hypoxia and associated brain and cardiac injury that is severe and life threatening but may not be fatal, instantly. Hypoxia can lead to cardiac ischemia and infarct. They may not go into v-fib right away. That might happen hours or days later. Similarly, brain ischemia might be severe and render a patient nearly brain dead, but still with unconscious brain stem and breathing function. It can take hours, or days for the ischemia to progress to killing the remaining brain cells that control breathing. Fentanyl doesn't cause people to flatline. It causes either apnea or severely depressed respirations, which leads to hypoxia, then organ ischemia. That can take much longer than 5 minutes to progress to death, even if the onset of action is within 5 minutes.

It makes no sense to say their medical conditions are so severe, they're going to die so quickly, it makes no difference how big of a drug dose they got. But they're going to take so long to die, they need massive doses of pain medicine, near fatal or fatal doses. But it it takes longer for them to die of the medical conditions than you thought, you're still going to blame the medical conditions. Yet, if it takes longer for the fentanyl to kill them than you expected, you're not going to blame the fentanyl.

You guys are looking for every reason under the sun to explain away the potential lethality of ultra-high doses of fentanyl. But the first thing you'd wonder if an intern under you gave a 1,000 mcg of fentanyl to an unintubaned patient and walked way, is, "Did he kill that patient?"

 

[neurodoc]

...
Furthermore, there is no special law against euthanasia with a lighter sentence, or "slap on the wrist" because in someone's opinion, it doesn't "seem as bad" as other killings, to them. The laws the act breaks, are the same laws against all other illegal killings: Murder, manslaughter, homicide.
...

I agree with all your succinctly stated points, but just want to point out that homicide is a legally neutral term that refers to any killing of a human being, including so-called "justifiable homicide," the most common justification being self-defense. Neither euthanasia or whatever else one might call it (e.g. "mercy killing," "putting an end to suffering," etc.) is considered justification for homicide. That I take it is your point and a very good point that needs to be understood by all who are posting on this thread. It is also an idea the prosecution will likely make clear to the jury in its closing argument.

Many posters seem to be either oblivious to or attempt to dismiss your points with strained exaggerated excuses like "some patients have survived similarly high doses of fentanyl" that they believe should exculpate Dr. Husel.

The prosecution may also try to explain the moral principle of "Double Effect," which some here have proposed exempts Dr. H from legal liability for killing patients with excessive doses of narcotic analgesics known to have a dose dependent effect of respiratory depression (usually also associated with pulmonary edema, though I don't know if this was found on any patient's autopsy). Double effect may "excuse" a "bad" result that occurs as an unintended consequence of a "good" act. In this case the "good" act is presumed to be the relief of pain and suffering. The "bad" result is killing the patient or causing unintentional harm (like anoxic encephalopathy) if the patient survives.

How do we know what Dr. H's intent was in these cases? Was it merely a desire to relieve suffering? Was it euthanasia? Even if it was to euthanize his patients, he would probably never admit that in court. If he takes the stand in his defense I'd expect him to say his intent was pain relief. Is there any way for a jury to decide what his "real" intent was? Not to a complete and absolute certainty, but there is evidence that could seriously weaken "Double Effect" as an exculpatory argument or even that his primary intended purpose was merely pain relief. The evidence includes his dosing, which despite the Byzantine arguments to the contrary was far above accepted dosing standards. There seem to be only two ways to explain his excessive dosing: 1) His behavior exhibited "extreme departures from the standards of care" due to recklessness and/or ignorance; or, 2) He really expected to kill the patients with these doses. If the jury believes #1 applies, he is guilty of negligent homicide. If they believe #2 applies, he is guilty of murder. Both are felonies and both carry prison sentences, longer of course for murder.

If he's extremely lucky he could be found not guilty of all charges. We won't know until the jury comes back with its verdict. As noted earlier in this thread this is going to be a seminal legal case.

 

[Robotic Wis-Hipple]

He already was 'roasted slowly over an open fire' during his board investigation and lost his license very quickly.

As far as the jury, I could see their thinking (this is purely speculation, opinion, not intended as fact) going like this: "I don't know for sure if his large fentanyl doses resulted in the death of each and every one of these patients. But I believe it had to in at least one or a few of them, since he was giving multiple times the standard dose. Therefore, I'll take the one (or two) cases where the dose was highest (2.000 mcg, for example) and vote guilty on any that got that dose. Not guilty (or lesser charge) on the others."

That's all it will take. One.

Whether they convict of murder, or some lesser charge like reckless homocide or manslaughter, is almost irrelevant. Either one will result of permanent loss of career, financial ruin and multiple years in a maximum security prison.

Does anyone really think he's going to walk, on each and every count, and not even a single lesser count, will stick?

No. I think he’s getting manslaughter or reckless homicide at the least.

 

[dpmd]

Just because the onset of action of fentanyl is < 5 min, does not mean that death must occur within 5 minutes, for the fentanyl to be the cause of death. A gunshot wound takes effect in < 1 second, yet it's not true to say, "If they didn't die instantly, the bullet didn't cause them to die." The effect of instant onset gunshot wounds fatal effects can take seconds, minutes, hours, days or months. But if it takes longer, you don't blame it on something else. It's still death from a GSW and the person who pulled the trigger is still responsible.

Similarly, a drug can cause apnea, hypoxia and associated brain and cardiac injury that is severe and life threatening but may not be fatal, instantly. Hypoxia can lead to cardiac ischemia and infarct. They may not go into v-fib right away. That might happen hours or days later. Similarly, brain ischemia might be severe and render a patient nearly brain dead, but still with unconscious brain stem and breathing function. It can take hours, or days for the ischemia to progress to killing the remaining brain cells that control breathing. Fentanyl doesn't cause people to flatline. It causes either apnea or severely depressed respirations, which leads to hypoxia, then organ ischemia. That can take much longer than 5 minutes to progress to death, even if the onset of action is within 5 minutes.

It makes no sense to say their medical conditions are so severe, they're going to die so quickly, it makes no difference how big of a drug dose they got. But they're going to take so long to die, they need massive doses of pain medicine, near fatal or fatal doses. But it it takes longer for them to die of the medical conditions than you thought, you're still going to blame the medical conditions. Yet, if it takes longer for the fentanyl to kill them than you expected, you're not going to blame the fentanyl.

You guys are looking for every reason under the sun to explain away the potential lethality of ultra-high doses of fentanyl. But the first thing you'd wonder if an intern under you gave a 1,000 mcg of fentanyl to an unintubaned patient and walked way, is, "Did he kill that patient?"

The problem is you keep on thinking about what the situation would be for someone in whom the goals of care are prolonging life. Yes in that situation you worry more about what sort of doses are being given especially if there is no monitoring. But these cases are not that situation. The immediate lethality matters for the evaluation of whether the doctrine of double effect is being utilized as does the potential to provide comfort. High dose KCL is immediately lethal and provides no comfort. Had he given that I would agree that beyond a reasonable doubt he was seeking to end life as his only priority. Low dose opioids are not immediately lethal but can still certainly cause apnea, hypoxia, aspiration, and other issues that eventually contribute to death, yet no one comes after a surgeon for murder whose patient suffers one of those complications and eventually dies because of it because they provide comfort and therefore no one suspects you wanted to do anything besides provide comfort. High dose opioids in his experience were not immediately lethal some percentage of the time and they provided comfort. The dose makes you suspect that his priority may not have been the comfort but with his experience being that his patients needed higher levels of opioids even before becoming comfort care and having good reasons for that to be true how can you prove his intent was not comfort?

 

[dpmd]

I agree with all your succinctly stated points, but just want to point out that homicide is a legally neutral term that refers to any killing of a human being, including so-called "justifiable homicide," the most common justification being self-defense. Neither euthanasia or whatever else one might call it (e.g. "mercy killing," "putting an end to suffering," etc.) is considered justification for homicide. That I take it is your point and a very good point that needs to be understood by all who are posting on this thread. It is also an idea the prosecution will likely make clear to the jury in its closing argument.

Many posters seem to be either oblivious to or attempt to dismiss your points with strained exaggerated excuses like "some patients have survived similarly high doses of fentanyl" that they believe should exculpate Dr. Husel.

The prosecution may also try to explain the moral principle of "Double Effect," which some here have proposed exempts Dr. H from legal liability for killing patients with excessive doses of narcotic analgesics known to have a dose dependent effect of respiratory depression (usually also associated with pulmonary edema, though I don't know if this was found on any patient's autopsy). Double effect may "excuse" a "bad" result that occurs as an unintended consequence of a "good" act. In this case the "good" act is presumed to be the relief of pain and suffering. The "bad" result is killing the patient or causing unintentional harm (like anoxic encephalopathy) if the patient survives.

How do we know what Dr. H's intent was in these cases? Was it merely a desire to relieve suffering? Was it euthanasia? Even if it was to euthanize his patients, he would probably never admit that in court. If he takes the stand in his defense I'd expect him to say his intent was pain relief. Is there any way for a jury to decide what his "real" intent was? Not to a complete and absolute certainty, but there is evidence that could seriously weaken "Double Effect" as an exculpatory argument or even that his primary intended purpose was merely pain relief. The evidence includes his dosing, which despite the Byzantine arguments to the contrary was far above accepted dosing standards. There seem to be only two ways to explain his excessive dosing: 1) His behavior exhibited "extreme departures from the standards of care" due to recklessness and/or ignorance; or, 2) He really expected to kill the patients with these doses. If the jury believes #1 applies, he is guilty of negligent homicide. If they believe #2 applies, he is guilty of murder. Both are felonies and both carry prison sentences, longer of course for murder.

If he's extremely lucky he could be found not guilty of all charges. We won't know until the jury comes back with its verdict. As noted earlier in this thread this is going to be a seminal legal case.

You missed possibility number 3) he knew or suspected opioid tolerance was higher than normal and selected his dosing to account for that (which was supported by I believe two different patients who got a big dose and were noted to be suffering, one by the nurse and one by the family who asked for something to be done to help the patient unless both of those things were described for a single patient, and required another dose half an hour later).

 

[dadaddadaBATMAN]

He already was 'roasted slowly over an open fire' during his board investigation and lost his license very quickly.

As far as the jury, I could see their thinking (this is purely speculation, opinion, not intended as fact) going like this: "I don't know for sure if his large fentanyl doses resulted in the death of each and every one of these patients. But I believe it had to in at least one or a few of them, since he was giving multiple times the standard dose. Therefore, I'll take the one (or two) cases where the dose was highest (2.000 mcg, for example) and vote guilty on any that got that dose. Not guilty (or lesser charge) on the others."

That's all it will take. One.

Whether they convict of murder, or some lesser charge like reckless homocide or manslaughter, is almost irrelevant. Either one will result of permanent loss of career, financial ruin and multiple years in a maximum security prison.

Does anyone really think he's going to walk, on each and every count, and not even a single lesser count, will stick?

Didn’t know about the board review already completed, thanks.

I think that I don’t know what a jury will say, in the same way that I don’t think it’ll rain tomorrow but it still might.

Probably will get hit with a manslaughter or equivalent charge. Intent is difficult to prove, especially when incompetence is still on the table.

It’s entirely possible there’s available information that would remove reasonable doubt.

If any of the patients were on 50ug fentanyl an hour than got 1000, guilty

If any were opiate naïve, guilty.

If any weren’t properly documented true comfort care, guilty.

My points have mainly been that we don’t know what missing information there is in the case. Pt on 300 ug/hr fentanyl being terminally extubated 1000ug doesn’t seem too crazy, even if I wouldn’t do that, probably not murder.

I am confused why so many cases were excluded. I am confused why only one person is being charged. I am confused why so many progress notes have been able to be excluded by the prosecution. And why no information from the mar on possible divided doses has been included.

These are the things that make me pause.

But my gut? Dude’s guilty.

I also think a lot of other folks are guilty, and not being charged

 

[AlmostAnMD]

I also think a lot of other folks are guilty, and not being charged

This is another frustrating part of all this. 100% the pharmacists, talon aside (guy was new and seems like an idiot, filed the initial voice report because he had never seen a 1000 mcg dose) absolutely knew. In trial they mention "conversations " between them and risk management. We never got to know what those conversations were about but I promise you they were about euthanasia, which is why this continued for years because they absolutely knew what was going on.

As mentioned previously even the voice report reviewers okayed the dosing as "appropriate for palliative care." The system supported all of this until cops got involved, then it was time to decide who to blame and that person was husel alone.

 

[Robotic Wis-Hipple]

Didn’t know about the board review already completed, thanks.

I think that I don’t know what a jury will say, in the same way that I don’t think it’ll rain tomorrow but it still might.

Probably will get hit with a manslaughter or equivalent charge. Intent is difficult to prove, especially when incompetence is still on the table.

It’s entirely possible there’s available information that would remove reasonable doubt.

If any of the patients were on 50ug fentanyl an hour than got 1000, guilty

If any were opiate naïve, guilty.

If any weren’t properly documented true comfort care, guilty.

My points have mainly been that we don’t know what missing information there is in the case. Pt on 300 ug/hr fentanyl being terminally extubated 1000ug doesn’t seem too crazy, even if I wouldn’t do that, probably not murder.

I am confused why so many cases were excluded. I am confused why only one person is being charged. I am confused why so many progress notes have been able to be excluded by the prosecution. And why no information from the mar on possible divided doses has been included.

These are the things that make me pause.

But my gut? Dude’s guilty.

I also think a lot of other folks are guilty, and not being charged

I agree with this post 100%.

Add to it the very idea that it’s better for 100 men to go free than 1 innocent go to jail. If reasonable doubt exists you can’t give him murder. Especially if all cases were appropriately determined to be comfort care and terminally extubated.

If any were assumed or assigned such clinical status under false or rushed pretenses or actually terminally extubated against the next of kin/MPOA’s wishes….. throw the book at him.

I also still think this case will add significant restrictions/hurdles to comfort care going forward and because of that some patients will suffer in their final hours, and that’s truly unfortunate.

 

[Birdstrike]

Interesting, most every patient I have had in the icu who is getting fentanyl drip has been on 100 to 300 mcg per hour. I am no longer the one that writes the orders but I do take a peek at their drips when I round.

Yep. Intubated patients who have been on a drip for weeks. BIG difference from an unintubated patient, you’re not going to intubate after you give them 1,000 mcg then walk away.

 

[Birdstrike]

I also think a lot of other folks are guilty, and not being charged

None of us know, for certain, that no one else is going to be charged. There’s no statute of limitations on the charge of murder, usually. They could be waiting to see if they get convictions on Husel, and if so, how many and how strong they were. Then, maybe they’ll charge others for their roles. Or maybe not. We don’t know.

Several of the nurses involved, lost, or had their licenses, suspended due to their role. It wouldn’t be a hard bridge to cross, to get some criminal charges, if it’s ultimately documented what happened was criminal.

Or maybe they just want to pin it all on him to set an example, and be done. It’s hard to say for sure.

 

[neurodoc]

You missed possibility number 3) he knew or suspected opioid tolerance was higher than normal and selected his dosing to account for that (which was supported by I believe two different patients who got a big dose and were noted to be suffering, one by the nurse and one by the family who asked for something to be done to help the patient unless both of those things were described for a single patient, and required another dose half an hour later).

No. That "possibility" was subsumed under possibility #1, namely recklessness and/or ignorance. A responsible physician whose aim is to safely treat pain rather than kill a patient would not start out with "a big dose" most physicians would consider in the potentially lethal range, but would start with less lethal but generally accepted effective doses and if these are found to be insufficient to carefully titrate up from there. As regards the nurse who noted a patient suffering, was that one of the nurses who was fired by the hospital and perhaps has a reason to justify involvement in the administration of extremely high doses of fentanyl? (Just asking).

Another thing we need to realize about fentanyl is that it has a well-known side effect of inducing muscle (including diaphragmatic and chest wall) rigidity that can make it more difficult for patient ventilation. If ones aim is pain relief (including that of "air hunger") there are other opiate and opioid narcotics that would be more appropriate to achieve that goal.

The degree to which folks are willing to bend over backwards to justify the behavior for which Dr. H is now on trial is truly amazing.

 

[dpmd]

No. That "possibility" was subsumed under possibility #1, namely recklessness and/or ignorance. A responsible physician whose aim is to safely treat pain rather than kill a patient would not start out with "a big dose" most physicians would consider in the potentially lethal range, but would start with less lethal but generally accepted effective doses and if these are found to be insufficient to carefully titrate up from there. As regards the nurse who noted a patient suffering, was that one of the nurses who was fired by the hospital and perhaps has a reason to justify involvement in the administration of extremely high doses of fentanyl? (Just asking).

Another thing we need to realize about fentanyl is that it has a well-known side effect of inducing muscle (including diaphragmatic and chest wall) rigidity that can make it more difficult for patient ventilation. If ones aim is pain relief (including that of "air hunger") there are other opiate and opioid narcotics that would be more appropriate to achieve that goal.

The degree to which folks are willing to bend over backwards to justify the behavior for which Dr. H is now on trial is truly amazing.

The degree to which people dismiss opioid tolerance as a real thing and therefore place low arbitrary max doses in their heads is truly amazing. I feel very sorry for the patients you undertreat.

 

[AlmostAnMD]

None of us know, for certain, that no one else is going to be charged.

There is a lot of read-between-the-lines at the trial, especially when the jury isn't in the room and both sides are arguing before the judge about things they aren't allowed to talk about.

I'll say this much: I'm pretty confident there is a reason why many of the staff are prosecution witnesses. My guess is they took a deal that said they wouldn't be charged as long as they testified against him. Many of the deals that are civil and we could actually hear about explicitly stated that the terms included NOT testifying for the defense, that much I have heard multiple times.

 

[Robotic Wis-Hipple]

No. That "possibility" was subsumed under possibility #1, namely recklessness and/or ignorance. A responsible physician whose aim is to safely treat pain rather than kill a patient would not start out with "a big dose" most physicians would consider in the potentially lethal range, but would start with less lethal but generally accepted effective doses and if these are found to be insufficient to carefully titrate up from there. As regards the nurse who noted a patient suffering, was that one of the nurses who was fired by the hospital and perhaps has a reason to justify involvement in the administration of extremely high doses of fentanyl? (Just asking).

Another thing we need to realize about fentanyl is that it has a well-known side effect of inducing muscle (including diaphragmatic and chest wall) rigidity that can make it more difficult for patient ventilation. If ones aim is pain relief (including that of "air hunger") there are other opiate and opioid narcotics that would be more appropriate to achieve that goal.

The degree to which folks are willing to bend over backwards to justify the behavior for which Dr. H is now on trial is truly amazing.

Rigid chest is definitely a thing, but I’ve seen it only 1 time, and it was associated with Remi. And I’ve pushed 1000mcg of fentanyl a fair amount of times.

The entirety of your statement/argument is well said. I don’t think you’ll find any “reasonable” physician that would IV push 1000mcgs of fentanyl in this setting. There’s so many reasons not to;

It’s very unlikely to be necessary

if extreme tolerance or longterm fentanyl infusion of 250+mcg/hr and thus significant blood level you may expect a large bolus to be required, but again, not 1000mcgs. You very easily could just push the hourly rate q-whatever minute you’re comfortable with until you get therapeutic effect.

Avoidance of the appearance of aggressive/cowboy tactics or ill-intent

He’s definitely flawed as a human and especially as a physician. Just not 100% sure he’s a murderer.

 

[Birdstrike]

I'll say this much: I'm pretty confident there is a reason why many of the staff are prosecution witnesses. My guess is they took a deal that said they wouldn't be charged as long as they testified against him.

Ding, ding, ding…We have a winner. You’ve got it. This method seems more than a little bit unethical, but you’re right. Prosecutors do it all the time.

It seems to me the 5th amendment should have included a right not to be extorted for incriminating testimony. What’s to prevent people from giving exaggerated, embellished, or downright false testimony against someone else, in exchange for freedom or reduced charges?

 

[Birdstrike]

The degree to which people dismiss opioid tolerance as a real thing and therefore place low arbitrary max doses in their heads is truly amazing. I feel very sorry for the patients you undertreat.

Sure, in theory or in pure laboratory conditions, there’s no max dose to opiates. But in real life, there’s nothing arbitrary about having a “max dose” in your head, in regards to opiates.

That “max dose” must meet all 3 of these criteria:

1- Helps patients without harming them at the minimum effective dose,

2- Doesn’t set off alarms with medical boards, and

3 - Doesn’t set off alarms with law enforcement.

We don’t have an inalienable, constitutional right to prescribe controlled substances. We have that privilege on loan from a state and federal drug enforcement agency. Follow the law.

If you don’t have some red line or max dose you won’t go over, that meets those criteria, you’re skydiving with “your truth,” but without a parachute.

 

[Birdstrike]

Pre-meds, med students, residents:

Most of you are probably too young to remember the cases of Dr. Jack Kevorkian and Dr. William Hurwitz. Both are important case studies in what not to do. They both claimed to be well intentioned while easing suffering. Both did lots of jail time.

 

[neurodoc]

The degree to which people dismiss opioid tolerance as a real thing and therefore place low arbitrary max doses in their heads is truly amazing. I feel very sorry for the patients you undertreat.

Just to let you know, I do not undertreat my patients or dismiss opioid tolerance. For the past several decades I've safely and effectively treated pain in patients who presented with and without opioid tolerance. I also understand the temptation to win an argument with ad hominem attacks. I too have been tempted to respond that way to some of the stuff I've read here but found it easy to resist the temptation.

 

[HemeOncHopeful19]

Ding, ding, ding…We have a winner. You’ve got it. This method seems more than a little bit unethical, but you’re right. Prosecutors do it all the time.

It seems to me the 5th amendment should have included a right not to be extorted for incriminating testimony. What’s to prevent people from giving exaggerated, embellished, or downright false testimony against someone else, in exchange for freedom or reduced charges?

What really seems ridiculous to me following this trial/thread is that apparently the jury is not allowed to even know if a witness made such a deal? Nor are they allowed to see the original statements those witnesses made?

 

[Birdstrike]

What really seems ridiculous to me following this trial/thread is that apparently the jury is not allowed to even know if a witness made such a deal? Nor are they allowed to see the original statements those witnesses made?

Incredible, isn't it?

 

[AlmostAnMD]

Yeah.

Judge made a big deal about what civil details could be included. He specifically said knowing the damages award to each plantiff would bias the jury so no dollar amounts are allowed to be mentioned. Prosecution keeps any mention of it minimal but they couldn't completely hide it.

 

[Birdstrike]

Yeah.

Judge made a big deal about what civil details could be included. He specifically said knowing the damages award to each plantiff would bias the jury so no dollar amounts are allowed to be mentioned. Prosecution keeps any mention of it minimal but they couldn't completely hide it.

How many civil cases have concluded and what were the results, do you know?

 

[AlmostAnMD]

All were settled, I don't know the dollar values but I think they are public since lawyers mentioned they weren't sealed.

Only one case is still pending. This was mentioned in trial. Defense was very crippled when it came to mentioning this, judge was not a fan of her question of "do you think a conviction in this case will help your civil suit?" to which she said, "I don't know, I'm not a lawyer."

I don't know exactly how many of the 38 fired peeps had settlements. Seems to be quite a few of them but I doubt it was all. Family-wise all settled but the one pending case I mentioned.

 

[nimbus]

Even if their chance of long term, meaningful survival is zero, it still doesn't make euthanasia or murder legal in Ohio. Whether or not this guy broke the law, and whether or not laws related to death and dying should be changed, are two entirely different issues, are they not?

Ohio (my home state) is where they were trying to save ectopic embryos.

 

[Birdstrike]

Ohio (my home state) is where they were trying to save ectopic embryos.

How?

 

[coffeebythelake]

How?

By not letting the mother abort it

 

[Jabbed]

Everybody agrees that opiates are almost essential to end of life care and the only real controversy here is related to dosing and intent.

Everybody agrees that a bolus of KCl would be euthanasia and not palliative.

What about propofol/versed gtts? It’s not standard of care by any means, but would you consider terminally extubating a patient but continuing ongoing propofol/versed gtts for palliation to be ethical?

 

[nimbus]

How?

New Ohio Bill Falsely Suggests That Reimplantation of Ectopic Pregnancy Is Possible

Ohio House Bill 413 falsely suggests that reimplantation of ectopic pregnancy is possible. In this article, Ob/Gyns Ken Rao, MD, and Salena Zanotti, MD, discuss the evolution of available treatments for ectopic pregnancy and share their concerns that this language may lead to dangerous treatment...

consultqd.clevelandclinic.org

 

[dpmd]

Everybody agrees that opiates are almost essential to end of life care and the only real controversy here is related to dosing and intent.

Everybody agrees that a bolus of KCl would be euthanasia and not palliative.

What about propofol/versed gtts? It’s not standard of care by any means, but would you consider terminally extubating a patient but continuing ongoing propofol/versed gtts for palliation to be ethical?

Palliative sedation is a standard option in end of life care. Why would there be any legal or ethical difference to continuing it for a patient being terminally extubated versus beginning it for a non intubated dying patient?

 

[Robotic Wis-Hipple]

Everybody agrees that opiates are almost essential to end of life care and the only real controversy here is related to dosing and intent.

Everybody agrees that a bolus of KCl would be euthanasia and not palliative.

What about propofol/versed gtts? It’s not standard of care by any means, but would you consider terminally extubating a patient but continuing ongoing propofol/versed gtts for palliation to be ethical?

Disclaimer: I’m not a palliative care doc.

I would think this would lead to even more concerns as well as a much much shorter slippery slope than you see with opioids for a number of reasons;

1.) opioids are flawed but the best analgesics we have. Comfort care is about comfort. Propofol/Versed are not analgesic.

2.) The goal of comfort care is to try to provide comfort and allow hopefully some family time. Propofol and/or versed titrated to “comfort” would not allow for any communication, and if it did, you’re essentially rendering the patient amnestic. Which you could argue ethically but you lose the family time argument.

3.) Propofol and Versed have a much smaller therapeutic window than the opioids and therefore could very quickly lead to the same “were you sedating or were you hastening death” concerns.

Edit: well, it seems as though perhaps I have no idea. So there’s also that.

 

[Robotic Wis-Hipple]

Palliative sedation is a standard option in end of life care. Why would there be any legal or ethical difference to continuing it for a patient being terminally extubated versus beginning it for a non intubated dying patient?

Honest question;

Do you continue propofol sedation during a terminal extubation?

Have you or would you initiate one for the purpose of terminal extubation?

I legit had no idea this was done. I don’t think I’ve ever seen this (in training) but I also admit I’m not actually there when these things are done anymore.

 

[dpmd]

Honest question;

Do you continue propofol sedation during a terminal extubation?

Have you or would you initiate one for the purpose of terminal extubation?

I legit had no idea this was done. I don’t think I’ve ever seen this (in training) but I also admit I’m not actually there when these things are done anymore.

Haven't continued drips during terminal extubation but have bolused the fentanyl and versed for some patients before extubation. I would be willing to continue or initiate sedative drips if I felt there was a need for it. I can think of one patient that in retrospect a sedative drip would have helped because the morphine drip was not titrated appropriately by a nurse who was too afraid of getting trouble and the patient was able to speak to me about the suffering he went through because of it. Nurse still might have underdosed the sedative too but at least the patient would have had less perception of suffering. The one palliative sedation I was involved in (patient with terminal diagnosis not intubated ever and not getting relief with palliative meds despite titration) we used fentanyl and versed if I recall correctly.

 

[NITRAS]

Everybody agrees that opiates are almost essential to end of life care and the only real controversy here is related to dosing and intent.

Everybody agrees that a bolus of KCl would be euthanasia and not palliative.

What about propofol/versed gtts? It’s not standard of care by any means, but would you consider terminally extubating a patient but continuing ongoing propofol/versed gtts for palliation to be ethical?

What is your goal? Propofol give sedation only, which usually is not usually the goal. Also requires higher level of care than most palliative beds are going to give them. Versed and other benzos have a place. I had a backup plan from palliative docs Versed drip for probable status a couple times, but don’t remember actually ordering it. Usually lorazepam is more useful because of longer half-life.

 

[Birdstrike]

Why would there be any legal or ethical difference to continuing it for a patient being terminally extubated versus beginning it for a non intubated dying patient?

You're making this W A Y too complicated. What you do, is you look around and you drive along with traffic. Don't be the guy going 10 mph faster. Don't be the guy going 10 mpw slower. Stay around the average pace, +/- a little bit. And even if you get the urge or it 'feels right,' whatever the hell you do, don't go 20 times faster. That'll land you on the front page, every time.

Tldr: Stay below radar.

 

[Jabbed]

What is your goal? Propofol give sedation only, which usually is not usually the goal. Also requires higher level of care than most palliative beds are going to give them. Versed and other benzos have a place. I had a backup plan from palliative docs Versed drip for probable status a couple times, but don’t remember actually ordering it. Usually lorazepam is more useful because of longer half-life.

This is very specifically in reference to ICU patients that are having care withdrawn in the ICU and are probably on these drips already.

I posed the question specifically because most clinicians would reflexively recoil at the idea of having a non-ventilated patient on a propofol gtt despite there being a basis for it in palliative care for terminal restlessness. My underlying point is that despite all of us being highly trained and encountering end-of-life issues on a somewhat regular basis, we are still biased by notions of dogma through our training institutions and clinical practice.

Would I have bolused 1000 mcg? No. But in the occasional terminal extubation that occurs in the ED, I instruct the nurse to continue the fentanyl gtt and bolus the patient 100-200 mcg every few minutes titrated to respiratory comfort and tell them that I’ll co-sign whatever dose they put in.

 

[dpmd]

This is very specifically in reference to ICU patients that are having care withdrawn in the ICU and are probably on these drips already.

I posed the question specifically because most clinicians would reflexively recoil at the idea of having a non-ventilated patient on a propofol gtt despite there being a basis for it in palliative care for terminal restlessness. My underlying point is that despite all of us being highly trained and encountering end-of-life issues on a somewhat regular basis, we are still biased by notions of dogma through our training institutions and clinical practice.

Would I have bolused 1000 mcg? No. But in the occasional terminal extubation that occurs in the ED, I instruct the nurse to continue the fentanyl gtt and bolus the patient 100-200 mcg every few minutes titrated to respiratory comfort and tell them that I’ll co-sign whatever dose they put in.

Do you ever get told the resultant dose? I usually didn't find out when I gave similar instructions because of the way charting worked back then.

 

[WilcoWorld]

For those on this thread who discount testimony simply because you can't imagine how or why a doctor would do such a thing I'd like to remind you of Dr. David Newman.

 

[WilcoWorld]

The healthcare system i work with currently actually tried really hard to keep patients who are DNR out of the ICU.

I'm not trying to lecture to you - you probably already get this - but "DNR" does NOT mean no intensive care, so your hospital needs to change that approach.

 

[WilcoWorld]

At times these statements and reporting just sound far too crazy to believe. And that’s the problem. Do we really think Husel was coming on service at 7pm and aggressively diuresing the ICU census 1000ug of fentanyl and an FU to family members at a time? On patients he literally just met that night?

If one of your ICU colleagues came in at night and terminally extubated a pt you thought would live literally hours into his shift would you not go directly to your director if not the medical board? I mean holy crap.

And finally even if he did, the patient’s family doesn’t authorize medications. I don’t know why that’s being reported that multiple family members didn’t authorize fentanyl. If they’d agreed to comfort care/terminal extubation, then the drugs/doses given can be debated medically but the docs orders don’t need to be screened or preapproved by family.

I agree with your last point. Families can't and therefor shouldn't make those kinds of decisions.

 

[WilcoWorld]

If the stepdaughter was asking a question he didn't have the answer for yet and the mother was saying to make him comfortable you would say no to the mom to wait for the CT head results to give to the stepdaughter?

Depends on whether I think I am unable to keep the patient from suffering unnecessarily in order to do so, but probably yes.

What I would likely do is explore the stepdaughter's concerns to see whether the head CT was needed to address them. If it would make a big difference to the family, then I'll wait for the additional information (even though I KNOW it won't change the outcome).

The dead know what they're doing when they leave this world behind, all the suffering gets done by the ones we leave behind.
-David Berman

 

[WilcoWorld]

If a study was ordered while we are full steam ahead and the decision maker decides to halt and transition to comfort only, you better believe I wouldn’t bother discuss the results or wait for the results unless the decision maker needed said results to make the decision.

Once the decision is made to transition to comfort, The goal becomes to support the family in any way they need, and mostly stay out of their way so they can have their last moments with their loved one.

It would be weird for a family member to ask about the result and the doctor to ignore it. I would certainly get the result of the CT but if the decision maker had other reasons to decide we’re done; we’re done.

If you are the ICU doc, I agree 100%

For the palliative folks out there: As a palliative care doctor you are also treating the family. If I need to let a case play out for another day in order to achieve family harmony around death (without causing the patient undue suffering), then I'm going to do that.

 

[Robotic Wis-Hipple]

This. I’d like an example if the patient is on 200-250mcg/hr.

No, I've never started at that high of a bolus. The 10% is a rule of thumb, just to get me into the ballpark. If I look at the number & know it's going to result in a call from the pharmacist and a panicked nurse, I adjust down.

This is very specifically in reference to ICU patients that are having care withdrawn in the ICU and are probably on these drips already.

I posed the question specifically because most clinicians would reflexively recoil at the idea of having a non-ventilated patient on a propofol gtt despite there being a basis for it in palliative care for terminal restlessness. My underlying point is that despite all of us being highly trained and encountering end-of-life issues on a somewhat regular basis, we are still biased by notions of dogma through our training institutions and clinical practice.

Would I have bolused 1000 mcg? No. But in the occasional terminal extubation that occurs in the ED, I instruct the nurse to continue the fentanyl gtt and bolus the patient 100-200 mcg every few minutes titrated to respiratory comfort and tell them that I’ll co-sign whatever dose they put in.

Quoted for multi-page train of thought. Yes, this is mostly a pointless academic not rooted in current law discussion.

This is where I think a lot of my hesitation to just consider Husel a monster comes from. There is very clearly a “standard” for opioid dosing that really is rooted more in fear or medico-legal self preservation than science.

Some very smart docs who actually practice palliative and/or intensive care have weighed in (including the not quoted @neurodoc). @WilcoWorld described their practice and provided a formula that they use as a general guideline to get started. The interesting thing, again as a pedantic discussion, is that if this formula spits out 100ug of fentanyl as a bolus it’s perfect, but if it spits out 400ug or 480ug, etc then this quite simply can’t be done. Why? Why is a formula taught or perhaps just anecdotally developed and then used ok for low doses but falls apart at “x” dose? Clearly, it’s for political/legal reasons as both @WilcoWorld and myself have said, we wouldn’t push a high dose for fear of freaking out nurses, ending up on a TPS report, or appearing to hasten death.

But that’s not how an opioids’ context sensitive halftime or tolerance work. It makes no sense medically. Its literally a made up line in the sand, done individually or locally. It’s like the heavy drinkers, chronic pain patients, or IVDU’s that come in for surgery and everyone freaks out when they hit the PACU order set limit of 2mg Dilaudid and are still screaming in pain. Now is not the time to try to save them from their IV drug habit or chronic pain induced opioid tolerance.

Why is a literally dying patient’s position any different?

Of course, all of this is remedied by reasonable dosing, quickly titrated up to effect. But in that scenario, which I hope all that are providing this care are doing, what’s the difference between 1,000ug IVP vs 200ug q5min adding up to 1,000ug in 25min if patient passes 30-60min later as has been testified to in multiple cases here?

The truth is that in this case, like often in the practice of medicine, the danger and risk comes from a lot more than the medicine. It’s your personality, interpersonal skills, bedside manner, cavalier attitude or appearance of such, politics, and the legal terms dictated by non-medical entities that end up getting you in trouble.

And that sucks. This will likely end up another brick in the wall being built to surround us all with yet another treatment limitation or max allowable dose. You know, for safety.

 

[neurodoc]

Why is a literally dying patient’s position any different?

Of course, all of this is remedied by reasonable dosing, quickly titrated up to effect. But in that scenario, which I hope all that are providing this care are doing, what’s the difference between 1,000ug IVP vs 200ug q5min adding up to 1,000ug in 25min if patient passes 30-60min later as has been testified to in multiple cases here?

I agree that reasonable dosing and quick titration to effect is the best way to go in this scenario. Of course you should be at the bedside constantly monitoring the patient's response to the drug. The difference between starting out with 1,000ug is that if the patient goes into immediate respiratory arrest or hypotensive shock you clearly used too much and just killed your patient (and please don't argue that in that case the disease killed him...read what I just said and you will have to admit your drugs acted as a coup de grace). Titrating for beneficial effect is clearly the better way, and it can be done rather quickly.

This raises the question what is the effect you're looking for and how would you recognize it? A look of calmness on the patient's face rather than the appearance of agonal respiration? I'm fairly sure all of us have been with patients at the moment of death and have a sense of the difference between peaceful and agonizing death. A peaceful natural death can be achieved with careful titration rather than administering a fentanyl coup de grace.

 

[Southpaw]

Some very smart docs who actually practice palliative and/or intensive care have weighed in (including the not quoted @neurodoc). @WilcoWorld described their practice and provided a formula that they use as a general guideline to get started. The interesting thing, again as a pedantic discussion, is that if this formula spits out 100ug of fentanyl as a bolus it’s perfect, but if it spits out 400ug or 480ug, etc then this quite simply can’t be done. Why? Why is a formula taught or perhaps just anecdotally developed and then used ok for low doses but falls apart at “x” dose? Clearly, it’s for political/legal reasons as both @WilcoWorld and myself have said, we wouldn’t push a high dose for fear of freaking out nurses, ending up on a TPS report, or appearing to hasten death.

I left the discussion after this, and after @WilcoWorld said we were at the point where people were trying to deliberately misunderstand one another and the thread should be closed. I found a palliative care physician putting forth a formula which I assume is taught in the palliative care world, which would result in some awfully high doses much of the time, and then saying they'd never give such a dose, just super interesting. If that's the case, then just ditch the formula and give everyone 12.5-25mcg q15min as they air starve themselves to death while the prosecution's medical expert reads Psalms.

I have no stake in this game, other than to say I think it's truly atrocious that Husel is charged with murder. And @Birdstrike is saying everyone should practice to the most common denominator even in situations where family has tossed in the towel and per the details shared here, those patients had no meaningful hope of recovery. Does that make 1 gram of fentanyl okay? No. But in my opinion it certainly doesn't mean everyone should be giving homeopathic doses like the prosecution's medical expert is saying.

I'm not here to say the doses used were appropriate. They weren't. Smaller doses should have been used. A middle ground should have been found. However, I am here to say that nurses, pharmacy, Husel's superiors, peer review, root cause teams, hospital admins, etc. were all okay with the care provided for years. The families were fine with the care provided for years. Now the guy is charged with 14 counts of murder and 'the system' has clearly stacked the deck against him. I'm just saying it's not right.

 

[Birdstrike]

This is where I think a lot of my hesitation to just consider Husel a monster comes from.

Nothing about this requires you think of anyone as a 'monster.' Good people sometimes screw up. Good people sometimes even break the law. Just because somebody isn't a 'monster' doesn't mean they never broke the law. Well intentioned people, sometimes make mistakes, even very big mistakes, with consequences.

 

[WilcoWorld]

Yes palliative sedation is an acceptable practice, but no I wouldn't call it common. It's reserved for suffering that has been so refractory to comfort-directed efforts that specifically target the sources of suffering you're left feeling like the only option is to put the patient to sleep (literally, NOT figuratively).

 

[WilcoWorld]

I left the discussion after this, and after @WilcoWorld said we were at the point where people were trying to deliberately misunderstand one another and the thread should be closed. I found a palliative care physician putting forth a formula which I assume is taught in the palliative care world, which would result in some awful high doses much of the time, and then saying they'd never give such a dose, just super interesting.

I'll take the blame for being unclear on that point. I should have clarified that the formula of 50% daily opioid as a basal rate 10% daily opioid as a bolus dose is really best suited for oral regimens. So someone who takes 280mg of oral morphine will get 75mg of XR morphine BID and take 30mg IR morphine for breakthrough pain (because the pills come in 15mg increments). The formula isn't really for calculating your compassionate extubation doses, it's for calculating a discharge regimen. In compassionate extubation there are three things that make the formula less useful:
1- The formula is for calculating pain doses of opioids, in compassionate extubation the symptom we're targeting is more often respiratory distress.
2 - After compassionate extubation I'm treating with IV bolus doses, which I can give very frequently and then rapidly assess effect and redose. The 10% of total daily need is based on the idea that it's taken about every 2-4 hours, and as such is much higher than a dose I'm giving every 10 minutes.
3 - The formula is for use in a stable situation, where the opioid needs have been consistent over a few days. In the time after compassionate extubation many things are rapidly changing about the patient's physiology.

My intent with that post was to respond to the idea that those of us objecting to Husel's doses do not understand or chose to ignore opioid tolerance. However my post was insufficiently clear and has actually confused the discussion rather than clarified anything. mea culpa

 

[Robotic Wis-Hipple]

Nothing about this requires you think of anyone as a 'monster.' Good people sometimes screw up. Good people sometimes even break the law. Just because somebody isn't a 'monster' doesn't mean they never broke the law. Well intentioned people, sometimes make mistakes, even very big mistakes, with consequences.

This is true. But I’m with Southpaw and in that case I have a hard time giving him murder.

I mean on any given day in my PACU I could find at least one patient I could walk up and slam 500mcg of fentanyl into and they’d thank me by saying pain went from a 10/10 to a 7/10. Literally just yesterday a pt had a relatively minor abdominal surgery, with a post op TAP block and yet got 3mg dilaudid and 300mcg of fentanyl in about 45min before I had to use ketamine. (After assessing that the IV was functional, assuming the TAP block failed even more than the typical modest yield of a TAP block, and trying the faster acting medication to try to gain control)

But to your other main point, do I walk up and slam 500mcg in? Of course not. Why? Because socially there’d be 50% of the RNs in the unit ready to write me up or report me to the hospital if not the state board and clinically my judgement or gestalt would probably be off 25% of the time and I’d be bagging if not re-intubating a portion of those I thought could take it.

But if I did give 500mcg every now and then and 10% had to be put on NIPPV or reintubated, and 10% of those then had a complication or increased LOS, and 10% of those died and they quickly traced it back to me, am I charged with murder? Clearly my aggressive if not reckless administration of a risky medication caused this from a root cause analysis standpoint. But it was done in an area with safety equipment, and I could argue 10/10 pain in the typical gomer is not without cardiovascular risk etc. In the subset of patients that have been determined to be dying unavoidably, is giving what everyone sees as an outrageous dose clearly murder? I just think it’s both hard to prove and counter to the goals of care in that situation. Reckless? Yes. Idiotic? Yes. Unnecessary? Yes.

But allowing all the deck stacking in order to nail one doc sits very poorly with me. Even if he should be barred from practice.

 

[Birdstrike]

This is true. But I’m with Southpaw and in that case I have a hard time giving him murder...But allowing all the deck stacking in order to nail one doc sits very poorly with me. Even if he should be barred from practice.

I don't disagree with you, for the most part.

I also think a lot of jurors will have a hard time convicting on "murder," per se. But if I was a betting man, I'd bet they will convict on the least severe homicide charge on at least 1 or 2 of the charges, where he gave the highest dose and most lethal combo. I don't see him doing life in prison. He may get a large sentence initially, to make an example of him and get the word out, but I bet it ultimately gets reduced to 4 or 5 years in jail, like Dr. William Hurwitz. Sort of like someone who makes a really stupid, negligent decision while driving and kills a couple of people. Not quite a Jeffery Dahmer situation. But something that they don't want to go unpunished.

But this is all speculation and opinion. I put the likelihood at 80%. I could be wrong. We shall see.

 

[neurodoc]

This is true. But I’m with Southpaw and in that case I have a hard time giving him murder.

... In the subset of patients that have been determined to be dying unavoidably, is giving what everyone sees as an outrageous dose clearly murder? I just think it’s both hard to prove and counter to the goals of care in that situation. Reckless? Yes. Idiotic? Yes. Unnecessary? Yes.

I agree with you. "Murder" should require some form of "malice aforethought" and I do not believe Dr. H. had any malicious intent. The prosecutors are charging him with murder perhaps because they view him guilty of euthanasia which as their laws are written is "intentional murder" albeit without what many would consider "malice." Were I on the jury I don't think I could vote for a murder verdict.