Husel Trial -- NOT GUILTY

[Señor S]

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Why are you equating this to an error? He didn't make an error or mistake. He deliberately chose those dosages based on his anecdotal experiences. We can say they are high or "outside the standard of care", but the only thing that matters here is intent. The difference between palliative pain management and euthanasia is 100% intent. I don't know how you can prove his intent here, at least beyond a reasonable doubt. If he wanted to euthanize them or put them out of their misery he'd sneak in their room and give them 100mg of rocuronium after extubation.

And as far as "work to keep the patient alive", he coded / intubated many of these patients prior to withdrawing life support. He worked to keep all of them alive. I'm just not following your narrative.

Did he place those orders to hasten death? I don’t know, you don’t know and none of us ever will IMO. I definitely think there is an argument to be made for “who cares if the dose is too high as long as it guarantees they won’t suffer.”

All great points. Everybody here agrees that Husel was doing weird stuff, but there is (hopefully) a massive chasm between "doing weird stuff" and murder.

I still think he'll get convicted, but it's an injustice.

 

[Tigers540]

I agree. I've watched almost all the testimony because this case is unprecedented, and while I think the whole thing is somewhat of a joke......i would wager money that he gets convicted of something. The fact that experienced medical providers can't come to a consensus on this means that 12 people with zero medical background getting tons of jargon / abbreviations / lingo thrown at them for over a month are going to be totally lost and will probably "settle" on a lesser charge.

But I will say there has been lots of funny business during the trial that will at minimum open it up to an appeal. One of the state's witnesses was handed her mother's morphine pill bottle, and she hid the bottle under the stand and peeled a label off of it WHILE TESTIFYING. The judge has also been odd at times.

 

[Robotic Wis-Hipple]

So far, every single one of you Husel defenders will say, "He's innocent. But, but, ...I ...would never give the doses he did!"

Why not?!

Not a single damn ONE of you gives 2,000mcg fentanyl boluses with Versed 10mg to any of your patients who you're not prepared to breathe for. Ever.

Why?

15 pages of thread and over 700 responses and none of you will say it, so I'm going to say it for you. You don't give any of your patients that combination of medicine because you don't want to kill them. Period. End of story. Oh, sure, you know it might not kill every patient you give it to. Some might be able to withstand it. But you know sure as hell some won't. You know sure as hell some of them would die from it.

All the rationalizations, reasonable-doubt lawyer-talky stuff isn't going to explain away the fact that you know damn well that if it was your normal practice to give your unintubaned patients GRAMS of fentanyl with 10mg versed chasers regularly over months and years, eventually you're going to kill someone, with 100% certainty and ZERO reasonable doubt. There would ZERO doubt of your intent.

Period. End of story. Stop it with all these mental gymnastics. Because you all know damn well if you were doing that, you'd be dangerous. People would be wispering behind your back and people would be very VERY nervous, working anywhere near you.

15 pages and y'all are still playing games.

Let's cut out the crap.

Your argument hinges on all of us knowing that the dose used would kill some percentage of patients. But 100ug would also “kill” some percentage of patients that are vent dependent, on pressors, with a pH <7. So, at what point is it criminal with the understanding that many of these patients had one foot in the grave and one on a banana peel? If any patients die after your dosing of a medication? Or if 25%, or 50%? If death occurs in 15min or 1hr? Where does criminal murder start?

Was he cavalier? Yes. Did he breach standard of care? Yes. Is that murder? I don’t think so unless he intended to euthanize.

Now if he mislead patient families regarding the patients prognosis, or he purposefully mischaracterized patients as brain dead for the purpose of callously terminally extubating them to get them out of his unit….. then it’s worse than murder and I can’t even begin to argue for him. But to get him for murder, they’ve got to prove some of that. Not just for his life, but for all medical professionals in the future that may stray beyond “standard” for either pure or misguided intents.

 

[AlmostAnMD]

Delayed AGAIN. Closing was supposed to be today, Thursday after several delays. Now scheduled for Monday.

 

[WilcoWorld]

The key here is intent. This is a criminal trial with someone's life at stake. If you can't prove his intent beyond a reasonable doubt then it simply isnt murder.

Genuine question - do you believe intent can ever be proven beyond a reasonable doubt in the absence of defendant admitting to intent?

 

[WilcoWorld]

Was he cavalier? Yes. Did he breach standard of care? Yes. Is that murder? I don’t think so unless he intended to euthanize.

Now if he mislead patient families regarding the patients prognosis, or he purposefully mischaracterized patients as brain dead for the purpose of callously terminally extubating them to get them out of his unit….. then it’s worse than murder and I can’t even begin to argue for him.

I agree. Being cavalier warrants a meeting with the department chair, not a criminal conviction. Mischaracterizing a patient as "brain dead" and then intentionally selecting doses that would hasten death warrants a long sentence, even if the patient was going to die no matter what he did.

Thing is, there's testimony to support the latter. Many on here want to reject that testimony, but that's not up to us - that's up to the jury.

 

[yeasports]

I agree. I've watched almost all the testimony because this case is unprecedented, and while I think the whole thing is somewhat of a joke......i would wager money that he gets convicted of something. The fact that experienced medical providers can't come to a consensus on this means that 12 people with zero medical background getting tons of jargon / abbreviations / lingo thrown at them for over a month are going to be totally lost and will probably "settle" on a lesser charge.

But I will say there has been lots of funny business during the trial that will at minimum open it up to an appeal. One of the state's witnesses was handed her mother's morphine pill bottle, and she hid the bottle under the stand and peeled a label off of it WHILE TESTIFYING. The judge has also been odd at times.

do you have a day/time on the trial that this happened by chance? I would love to see that!

 

[Tigers540]

Genuine question - do you believe intent can ever be proven beyond a reasonable doubt in the absence of defendant admitting to intent?

Of course. If he pushed 100mg rocuronium after all these extubations then his intent is clear. There would be no therapeutic benefit and the only outcome is immediate death.

 

[Robotic Wis-Hipple]

I agree. Being cavalier warrants a meeting with the department chair, not a criminal conviction. Mischaracterizing a patient as "brain dead" and then intentionally selecting doses that would hasten death warrants a long sentence, even if the patient was going to die no matter what he did.

Thing is, there's testimony to support the latter. Many on here want to reject that testimony, but that's not up to us - that's up to the jury.

I think intent is incredibly difficult to prove without his own testimony in THIS case. Patient families stating the use of the term brain dead etc can easily be misremembered or misappropriated, speaking nothing of potential financially motivated rationale or prosecutorial guidance. Are the odds high that their testimony is purposely shifted a certain way? No. But judging intent via the biased and layman second hand accounts of families is definitely not 100% without fail and thus there will be reasonable doubt. For intentional murder. It’s a high bar, and I just don’t think we can assign it to him if there’s a 5% chance his intention was not euthanasia.

Now if these weren’t all patients that were clinically judged to be terminal, i.e. they have other intensivists that knew the patient and thought they were recoverable and Husel did what he did then I think intent can be inferred more strongly based on the doses. Much like intent is inferred if I aim a gun at your chest and pull the trigger.

I just don’t think we can infer intent, in these cases of terminal patients. He very well may have had that intention, but you can’t prove it in my mind and because of that you CAN’T give him murder. Any of the other forms of homicide possible? Yes, and if available he’ll get one of them imo.

 

[Birdstrike]

Intent, intent, intent.

It doesn't mean as much as you think. People get convicted of various crimes including homicide and manslaughter all the time without any "intent" being proven or needed. You got drunk crashed into a group of pedestrians. You didn't intend to. Doesn't matter. You still killed them. Still convicted. Still guilty.

Your "but I didn't mean to kill them" defense isn't as strong as you think.

 

[Robotic Wis-Hipple]

Intent, intent, intent.

It doesn't mean as much as you think. People get convicted of various crimes including homicide and manslaughter all the time without any "intent" being proven or needed. You got drunk crashed into a group of pedestrians. You didn't intend to. Doesn't matter. You still killed them. Still convicted. Still guilty.

Your "but I didn't mean to kill them" defense isn't as strong as you think.

I don’t think drunk drivers get murder, typically the type of homicide or manslaughter charges likely on the table for Husel.

You very clearly want to see him get 1st degree murder, and maybe he is. I just don’t think you can prove intent without a shadow of doubt. But, you might be right, I’m not a lawyer.

But if giving doses outside of standard of care that result in a death is intentional murder I think a lot of people/systems place hard limits and patients potentially suffer.

Edit: for more realistic concerns

 

[WilcoWorld]

Of course. If he pushed 100mg rocuronium after all these extubations then his intent is clear. There would be no therapeutic benefit and the only outcome is immediate death.

That makes sense, what about with opioids? Is intent ever discernable in that case?

 

[WilcoWorld]

I think intent is incredibly difficult to prove without his own testimony in THIS case. Patient families stating the use of the term brain dead etc can easily be misremembered or misappropriated, speaking nothing of potential financially motivated rationale or prosecutorial guidance. Are the odds high that their testimony is purposely shifted a certain way? No. But judging intent via the biased and layman second hand accounts of families is definitely not 100% without fail and thus there will be reasonable doubt. For intentional murder. It’s a high bar, and I just don’t think we can assign it to him if there’s a 5% chance his intention was not euthanasia.

Now if these weren’t all patients that were clinically judged to be terminal, i.e. they have other intensivists that knew the patient and thought they were recoverable and Husel did what he did then I think intent can be inferred more strongly based on the doses. Much like intent is inferred if I aim a gun at your chest and pull the trigger.

I just don’t think we can infer intent, in these cases of terminal patients. He very well may have had that intention, but you can’t prove it in my mind and because of that you CAN’T give him murder. Any of the other forms of homicide possible? Yes, and if available he’ll get one of them imo.

Inference of intent is certainly a tricky issue. And I'm not knowledgeable enough about the law to say which charges are most appropriate - it's probably a tough call even for the lawyers/judge...perhaps that's why closing keeps getting delayed?

 

[Birdstrike]

You very clearly want to see him get 1st degree murder

As far as this case, I don't "want" anything to happen other than the jury to make the most just decision possible. I didn't sit for 8 weeks of testimony. The jury, Husel and the families of the dead will have to live with the verdict. It won't affect me much, if at all.

But as far as my opinion, it's this:

I teach residents. My advice to them is to never to give 1,000 or 2,000 mcg boluses of fentanyl with 10mg of versed, to anyone, in any situation, ever. Because to do so is stupid, dangerous, reckless and would draw suspicious of recklessness or worse, onto them. That's my opinion now and it was my opinion before I ever heard of Dr. Husel.

Whether what Husel did meets the legal criteria for murder, reckless homicide or neither, I honestly can't say without having sat in the jury box and heard 100% of the evidence.

He's innocent of any and all crimes in my opinion, until and unless convicted in a court of law.

 

[Tigers540]

That makes sense, what about with opioids? Is intent ever discernable in that case?

Good question, I really don’t think so, not in the setting of palliative care like this after withdrawing life support. The principle of double effect has always protected against that. That’s why this case is so unprecedented. The 1,000mcg dose is somewhat arbitrary, they originally accused him of more murders but threw out the ones where he gave 500mcg.

Like I said this seems more appropriate for internal investigation and action taken on his license maybe, but not jail time.

 

[Tigers540]

Intent, intent, intent.

It doesn't mean as much as you think. People get convicted of various crimes including homicide and manslaughter all the time without any "intent" being proven or needed. You got drunk crashed into a group of pedestrians. You didn't intend to. Doesn't matter. You still killed them. Still convicted. Still guilty.

Your "but I didn't mean to kill them" defense isn't as strong as you think.

And how do you even know it was the fentanyl and not the withdrawal of multiple forms of life support while barely being alive as is? Again, you need to be beyond a reasonable doubt. You can hate that standard, but it’s there for a reason

 

[Robotic Wis-Hipple]

As far as this case, I don't "want" anything to happen other than the jury to make the most just decision possible. I didn't sit for 8 weeks of testimony. The jury, Husel and the families of the dead will have to live with the verdict. It won't affect me much, if at all.

But as far as my opinion, it's this:

I teach residents. My advice to them is to never to give 1,000 or 2,000 mcg boluses of fentanyl with 10mg of versed, to anyone, in any situation, ever. Because to do so is stupid, dangerous, reckless and would draw suspicious of recklessness or worse, onto them. That's my opinion now and it was my opinion before I ever heard of Dr. Husel.

Whether what Husel did meets the legal criteria for murder, reckless homicide or neither, I honestly can't say without having sat in the jury box and heard 100% of the evidence.

He's innocent of any and all crimes in my opinion, until and unless convicted in a court of law.

Doing something that is stupid, dangerous, reckless, or that may draw suspicion isn’t synonymous with murder.

I personally have pushed 1-2000mcg of fentanyl and 10mg of versed in a pt. Not in one I wasn’t about to intubate and anticipate prolonged mechanical ventilation in though which I know is your unstated caveat. But just because you or I wouldn’t do something doesn’t make it overtly reckless and certainly not attempted murder.

I mean hell, I myself would not push 10mg of versed in anyone, ever, that I wasn’t about to intubate. Yet I’m apparently the only one here, I’m the wuss, and that apparently happens on the regular.

 

[neurodoc]

Guaranteed win. His lawyers are private. Trinity malpractice refused to provide him an attorney because they said he committed a crime. But if he's found not guilty he'll turn right around and bend trinity over.

I don't know that the hospital is required to cover legal costs for defense in a CRIMINAL trial...which is what this is. Are you saying they are/were? If they weren't (and I'm pretty sure most if not all malpractice insurance excludes coverage for CRIMINAL defense) then what is your point?

 

[thegenius]

Why are you equating this to an error? He didn't make an error or mistake. He deliberately chose those dosages based on his anecdotal experiences. We can say they are high or "outside the standard of care", but the only thing that matters here is intent. The difference between palliative pain management and euthanasia is 100% intent. I don't know how you can prove his intent here, at least beyond a reasonable doubt. If he wanted to euthanize them or put them out of their misery he'd sneak in their room and give them 100mg of rocuronium after extubation.

And as far as "work to keep the patient alive", he coded / intubated many of these patients prior to withdrawing life support. He worked to keep all of them alive. I'm just not following your narrative.

Good points, you should be his defense attorney

 

[thegenius]

So far, every single one of you Husel defenders will say, "He's innocent. But, but, ...I ...would never give the doses he did!"

Why not?!

Not a single damn ONE of you gives 2,000mcg fentanyl boluses with Versed 10mg to any of your patients who you're not prepared to breathe for. Ever.

Why?

15 pages of thread and over 700 responses and none of you will say it, so I'm going to say it for you. You don't give any of your patients that combination of medicine because you don't want to kill them. Period. End of story. Oh, sure, you know it might not kill every patient you give it to. Some might be able to withstand it. But you know sure as hell some won't. You know sure as hell some of them would die from it.

All the rationalizations, reasonable-doubt lawyer-talky stuff isn't going to explain away the fact that you know damn well that if it was your normal practice to give your unintubaned patients GRAMS of fentanyl with 10mg versed chasers regularly over months and years, eventually you're going to kill someone, with 100% certainty and ZERO reasonable doubt. There would ZERO doubt of your intent.

Period. End of story. Stop it with all these mental gymnastics. Because you all know damn well if you were doing that, you'd be dangerous. People would be wispering behind your back and people would be very VERY nervous, working anywhere near you.

15 pages and y'all are still playing games.

Let's cut out the crap.

Lawyer Birdstrike vs Lawyer Tigers540. Epic battle of words

 

[thegenius]

Doing something that is stupid, dangerous, reckless, or that may draw suspicion isn’t synonymous with murder.

I personally have pushed 1-2000mcg of fentanyl and 10mg of versed in a pt. Not in one I wasn’t about to intubate and anticipate prolonged mechanical ventilation in though which I know is your unstated caveat. But just because you or I wouldn’t do something doesn’t make it overtly reckless and certainly not attempted murder.

I mean hell, I myself would not push 10mg of versed in anyone, ever, that I wasn’t about to intubate. Yet I’m apparently the only one here, I’m the wuss, and that apparently happens on the regular.

I mean...you just answered your own question. Husel wasn't intubating these patients.

 

[neurodoc]

Why are you equating this to an error? He didn't make an error or mistake. He deliberately chose those dosages based on his anecdotal experiences. We can say they are high or "outside the standard of care", but the only thing that matters here is intent. The difference between palliative pain management and euthanasia is 100% intent. I don't know how you can prove his intent here, at least beyond a reasonable doubt...

Yes, it is hard to prove intent...but when one or two patients die much more quickly after "palliative extubation" when they were treated with much larger than they would have if treated with typical doses most other folk would use for mere "pain control" you could call that a mistake. BUT, when you deliberately and repeatedly chose those high doses not just with a couple of your patients but on many, the reasonableness of your doubt diminishes to the point that it becomes UNREASONABLE to insist you aren't performing euthanasia.

 

[thegenius]

All great points. Everybody here agrees that Husel was doing weird stuff, but there is (hopefully) a massive chasm between "doing weird stuff" and murder.

I still think he'll get convicted, but it's an injustice.

Yea man it's the law. I agree.

I actually think Husel is a dangerous doc from the little I know about him. We all are thinking, hoping, that he always has excellent judgement everytime he pushes 1000 fent, 10 versed, and 10 dilaudid.

Basically the same thing can be accomplished if he simply pushed 1/5 those doses, went home, had a beer, watched some TV, and he would be gainfully employed the rest of his life.

 

[Tigers540]

Lawyer Birdstrike vs Lawyer Tigers540. Epic battle of words

Lol I’m no law expert. I admittedly jumped to guilty as soon as I saw the media articles and read “doctor pushing 1,000mcg fent”. But after watching the majority of the trial I’m trying to be as objective as possible.

 

[Robotic Wis-Hipple]

I mean...you just answered your own question. Husel wasn't intubating these patients.

Wasn’t a question. Just a reference to prior conversation and Bird’s comment that he wouldn’t do it to anyone ever.

 

[Tigers540]

Yes, it is hard to prove intent...but when one or two patients die much more quickly after "palliative extubation" when they were treated with much larger than they would have if treated with typical doses most other folk would use for mere "pain control" you could call that a mistake. BUT, when you deliberately and repeatedly chose those high doses not just with a couple of your patients but on many, the reasonableness of your doubt diminishes to the point that it becomes UNREASONABLE to insist you aren't performing euthanasia.

So if he pushed 250mcg would that prove intent as well? Certainly that would hasten many deaths post-extubation. 300? 400? 500? Where does murder begin and comfort care end?

 

[Robotic Wis-Hipple]

Yea man it's the law. I agree.

I actually think Husel is a dangerous doc from the little I know about him. We all are thinking, hoping, that he always has excellent judgement everytime he pushes 1000 fent, 10 versed, and 10 dilaudid.

Basically the same thing can be accomplished if he simply pushed 1/5 those doses, went home, had a beer, watched some TV, and he would be gainfully employed the rest of his life.

I think we all agree here.

 

[Birdstrike]

Why are you equating this to an error? He didn't make an error or mistake. He deliberately chose those dosages based on his anecdotal experiences. We can say they are high or "outside the standard of care", but the only thing that matters here is intent. The difference between palliative pain management and euthanasia is 100% intent. I don't know how you can prove his intent here,

“He deliberately chose those dosages…” is an interesting way to argue for a lack of intent.

 

[Birdstrike]

I personally have pushed 1-2000mcg of fentanyl and 10mg of versed in a pt. Not in one I wasn’t about to intubate and anticipate prolonged mechanical ventilation …

You never pushed 2,000 mcg of fentanyl with 10 mg of Versed in anyone who you weren’t going to mechanically ventilate? Hmm…

That’s so weird. Me neither.

I wonder why?

 

[Señor S]

“He deliberately chose those dosages…” is an interesting way to argue for a lack of intent.

That’s not what he was saying.

 

[Robotic Wis-Hipple]

You never pushed 2 grams of fentanyl with 10 mg of Versed in anyone who you weren’t going to mechanically ventilate? Hmm…

That’s so weird. Me neither.

I wonder why?

We are continuing to go in circles.

I don’t as I expect apnea to be a realistic possibility in any dose 250ug+ and I don’t practice on terminal, opioid tolerant patients that I’m providing comfort care for.

But in his patient population, for his goals of care, I’m not convinced you can prove his intent 100% without a shadow of doubt.

I’d rather one murderer get off on reckless/criminal homicide than wrongly convict one and set precedent.

 

[Tigers540]

“He deliberately chose those dosages…” is an interesting way to argue for a lack of intent.

I’m not even sure what this means.
He intended to give 1000mcg, yes.

 

[neurodoc]

...[snipped]
I’d rather one murderer get off on reckless/criminal homicide than wrongly convict one and set precedent.

Agreed, I don't know with absolute certainty his intent was euthanasia. But at least if he's convicted of some sort of illegal (e.g. reckless) homicide...which I'm inclined to believe... he'll be a convicted felon and unable to practice medicine. That will at least guarantee he would not be able to euthanize future patients.

 

[WilcoWorld]

So if he pushed 250mcg would that prove intent as well? Certainly that would hasten many deaths post-extubation. 300? 400? 500? Where does murder begin and comfort care end?

The Sulmasy test, named after Daniel Sulmasy, is how we can answer this question for ourselves...and the answer isn't in the dose (though I agree with @neurodoc that some doses/practice patterns seriously strain credulity).

The Sulmasy test instructs you to ask yourself "if I take this action and the patient doesn't die, will I be disappointed?" If your answer to this question is "yes", then the Principle of Double Effect doesn't apply and you're practicing euthanasia. Of course, we'll never hear Husel's answer to this question.

 

[Birdstrike]

...the only thing that matters here is intent. ... I don't know how you can prove his intent here...

I’m not even sure what this means.
He intended to give 1000mcg, yes.

Really? You don't see it?

 

[neurodoc]

So if he pushed 250mcg would that prove intent as well? Certainly that would hasten many deaths post-extubation. 300? 400? 500? Where does murder begin and comfort care end?

When your doses far exceed what the vast majority of your professional colleagues accept as effective while at the same time making it almost certain the medication will make an already debilitated unventilated patient stop breathing. That at least is my answer to your very sophistic question. I could think of a few humorous analogies showing the absurdity of your type of reasoning, but I felt a simple honest answer was best.

 

[WilcoWorld]

We are continuing to go in circles.

I don’t as I expect apnea to be a realistic possibility in any dose 250ug+ and I don’t practice on terminal, opioid tolerant patients that I’m providing comfort care for.

But in his patient population, for his goals of care, I’m not convinced you can prove his intent 100% without a shadow of doubt.

2 things:

1 - The law calls for "beyond reasonable doubt" even though "shadow of a doubt" is frequently quoted. I think this is an important distinction as nothing really ever gets beyond the "shadow of a doubt" expect for analytic a priori truths.*
2 - I do practice end of life care, and I take care of a lot of cancer patients who have been on >1000 oral morphine equivalents/day for months, and I have never gotten close to 1000mcg pushes of fentanyl for compassionate extubation. In my professional opinion, if you get that high you're probably doing something wrong.


*sorry, I do deserve to get smacked for bringing up Kant

 

[Tigers540]

Really? You don't see it?

Intent to murder? No. At least not beyond doubt

 

[Tigers540]

When your doses far exceed what the vast majority of your professional colleagues accept as effective while at the same time making it almost certain the medication will make an already debilitated unventilated patient stop breathing. That at least is my answer to your very sophistic question. I could think of a few humorous analogies showing the absurdity of your type of reasoning, but I felt a simple honest answer was best.

I asked for your specific opinion. At what dose does it become murder beyond a reasonable doubt during palliative end of life care?

 

[thegenius]

So if he pushed 250mcg would that prove intent as well? Certainly that would hasten many deaths post-extubation. 300? 400? 500? Where does murder begin and comfort care end?

Murder begins when a jury convicts you of practicing medicine so far out of the standard of care that it can cause death, regardless if you are going to die naturally 1 hr later.

 

[Birdstrike]

The argument that "the medicine couldn't have killed them because it's certain that were going to die immediately anyways" doesn't hold up. We as physicians are terrible at predicting survival and life expectancy.

From a 42 study review of survival in palliative care: "...the evidence suggests that clinicians' predictions are frequently inaccurate. No sub-group of clinicians was consistently shown to be more accurate than any other."

 

[Tigers540]

Murder begins when a jury convicts you of practicing medicine so far out of the standard of care that it can cause death, regardless if you are going to die naturally 1 hr later.

Of course, this all depends on the opinion of the jurors. But I’m on a forum asking for other medical providers’ opinions.

Some would argue 250mcg is outside standard of care. This would open up potential litigation to other providers who never gave 1,000mcg but were in the 100-500mcg range. 250 mcg could hasten death without question. According to the prosecutions expert witness we should be dosing in 25-50mcg increments.

 

[Birdstrike]

Intent to murder? No. At least not beyond doubt

Intent to give doses that everyone (on this thread, at least) agrees have a significant chance of killing non-ventilated patients. Is that what the argument has come down to: "Every doctor in the world knows Fentanyl 2,000mcg + versed 10mg could kill their patients, but one, and he just happens to be my client"?

 

[Tigers540]

Intent to give doses that everyone (on this thread, at least) agrees have a significant chance of killing non-ventilated patients. Is that what the argument has come down to: "Every doctor in the world knows Fentanyl 2,000mcg + versed 10mg could kill their patients, but one, and he just happens to be my client"?

This very doctor gave 2500mcg to a patient who continued to suffer. I wasn’t at bedside and I don’t know the exact tolerances of all these patients. The fentanyl certainly COULD have killed them in my opinion. It’s also possible it had little to no effect on the time of death given their advanced disease states and dependence on ventilators and pressors.

I guess we just disagree.

 

[Birdstrike]

Anyone that's safely giving 1,000-2,000 mcg boluses of fentanyl with 10mg IV versed, please raise your hand right now. Seriously. If you're doing this, or have ever done it even one time in a non-ventilated patient, and they were okay, please speak up now.

 

[Birdstrike]

This very doctor gave 2500mcg to a patient who continued to suffer. I wasn’t at bedside and I don’t know the exact tolerances of all these patients. The fentanyl certainly COULD have killed them in my opinion. It’s also possible it had little to no effect on the time of death given their advanced disease states and dependence on ventilators and pressors.

I guess we just disagree.

You gave 2,500 mcg IV all at one time to a non-ventilated patient?

 

[IMGASMD]

“From a 42 study review of survival in palliative care: "...the evidence suggests that clinicians' predictions are frequently inaccurate. No sub-group of clinicians was consistently shown to be more accurate than any other."

If you accept that conclusion, shouldn’t the reverse be acceptable?

His prediction based on his predictors that these patients WILL tolerate the medications and not die due to that dose?

 

[Robotic Wis-Hipple]

2 things:

1 - The law calls for "beyond reasonable doubt" even though "shadow of a doubt" is frequently quoted. I think this is an important distinction as nothing really ever gets beyond the "shadow of a doubt" expect for analytic a priori truths.*
2 - I do practice end of life care, and I take care of a lot of cancer patients who have been on >1000 oral morphine equivalents/day for months, and I have never gotten close to 1000mcg pushes of fentanyl for compassionate extubation. In my professional opinion, if you get that high you're probably doing something wrong.


*sorry, I do deserve to get smacked for bringing up Kant

Yeah, I’ll admit to naïveté to the particular semantics and the legal ramifications of most of this type of stuff. I still think reasonable doubt exists though I agree he was clearly doing something wrong.

For your #2, despite not practicing palliative or even ICU care myself, I 100% am in agreement with you. Titrating to effect, even if you do get to 1000mcg and documenting as such is the simple answer. But also, at some point alternative strategies beyond opioids should be utilized.

He very clearly did a lot of things wrong, he did many stupid, reckless things. His decision making both medically and self preservation-wise is flawed even when looking superficially. He’s clearly dangerous. You just can’t prove his intent though even I admit it’s more than likely he was trying to make his terminal extubations very short and pain free and therefore likely had an understanding of the fact he was potentially hastening death.

 

[dpmd]

Really? You don't see it?

I'm not sure how much clearer tiger can be. Intending to give 1000 mcg is not in itself a criminal act. The intent that must be shown for a murder charge is the intent to kill. You are correct that intent to kill is not required for other possible charges that are not currently in play (but may become relevant depending on the judge's decision) but tiger is discussing the murder charge specifically.

 

[Tigers540]

You gave 2,500 mcg IV all at one time to a non-ventilated patient?

No. Husel did in 500-1000mcg boluses and the patient still suffered.

What I would/wouldn’t do is irrelevant - but to your answer your question no I would not.