Husel Trial -- NOT GUILTY

[AlmostAnMD]

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I'm not sure what his defense will be, but if you're a physician (even an orthopedist I imagine) you know what happened after looking at that list. The guy was trying to be merciful in a health system that isn't. I don't know what we gain by putting the full court press on this poor guy, other than making it a point to say 'providers' shouldn't kill people who are already dead. We need to let them die the American way. Maybe the system could've squeezed a few extra bucks out of those poor people if he hadn't bolused the fentanyl. Also, pharmacy and nursing went along with it and they absolutely knew what the score was.

On cross, the detective yesterday admitted he had no idea that a pharmacist was involved with approving these medicines. He's clearly used to investigating murders of the PEW PEW PEW kind. I don't think he knew what he stepped into fully until that moment.

Murder is going to be a high bar to prove.

 

[anonperson]

Unfortunate situation for the physician. These patients are basically dead if not for the insistence of overly cruel family members.

Cardiac arrest x4 and a sub 7 pH... trying to keep this person alive is shameful.

What's up with the family that they somehow find it reasonable to keep a meat puppet "alive"?

Let this be a lesson:
"No good deed goes unpunished "

 

[Vandalia]

I will quote one of my primary care friend's favorite sayings,

The desire of a family to "do everything" for their "loved" one is inversely proportional to the number of times they visited that "loved one" over the last year.

 

[southerndoc]

I'm not sure what his defense will be, but if you're a physician (even an orthopedist I imagine) you know what happened after looking at that list. The guy was trying to be merciful in a health system that isn't. I don't know what we gain by putting the full court press on this poor guy, other than making it a point to say 'providers' shouldn't kill people who are already dead. We need to let them die the American way. Maybe the system could've squeezed a few extra bucks out of those poor people if he hadn't bolused the fentanyl. Also, pharmacy and nursing went along with it and they absolutely knew what the score was.

What I'm not clear was if this was a 1,000 mcg bolus of fentanyl or 1,000 mcg given over 4-6 hours?

 

[e30ftw]

I don't think this is the case to rally behind.

There is an ethical difference between ending a life with opioids and providing relief from suffering while a disease process ends a life. If we do not observe this distinction people may lose whatever trust they still have in physicians.

I agree this is not a case to rally behind simply because the medical details and implications are complicated for the lay-person to understand and the defendant has essentially been labeled a serial killer in the media. It's bad press.

I have no legal expertise obviously but it seems with a criminal case proving murder comes down to intent. While I agree with your statement on ending a life with opioids versus providing relief of suffering, without knowing details of the case beyond this thread, I would question if the fentanyl, while an excessive dose, really had anything to do with the patient deaths.

Considering that fentanyl is fairly hemodynamically stable and the main risk is respiratory depression, and assuming all patients were intubated (seems reasonable given their location and condition) when the fentanyl was given, it is reasonable to assume that fentanyl had little if anything to do with their deaths, considering the safety profile of the drug in overdose in an intubated patient and the numerous other impending causes of death such as cardiac arrest, MODS, circulatory failure, severe metabolic acidosis, etc.

With all that in consideration it seems pretty reasonable that the Husel's intent was to minimize suffering rather than cause harm. Just a thought like I said don't know the full facts of the case. The prosecution's murder charge would make sense if Husel were pushing 200 mEq KCL or something but not an opiate in an intubated patient.

Just playing expert witness for the defense..

 

[WilcoWorld]

assuming all patients were intubated

agreed
This is the crux of the case. Further details on this would be informative

 

[GassYous]

They've never released the medical records or information about these patients until today

Yeah, all these people needed a good fentanyl bolus imo

Is this trial a joke? All of these patients have already been dead for hours if not days

This trial is another cruelty on top of the continued suffering inflicted on those poor people

 

[BoardingDoc]

Is this trial a joke? All of these patients have already been dead for hours if not days

This trial is another cruelty on top of the continued suffering inflicted on those poor people

Is there somewhere that you can see the actual relevant medical information on these patients? I assume it was presented somewhere in the trial but haven't seen actual data.

 

[GassYous]

Is there somewhere that you can see the actual relevant medical information on these patients? I assume it was presented somewhere in the trial but haven't seen actual data.

Someone on the previous page posted a list of names, cardiac arrests (average is about 3 per patient), ph (average is below 7.0), average bp is like 70/40. None of them have anything even remotely compatible with life.

 

[WilcoWorld]

This is a sad case. It appears that while he acted out of mercy, he also broke the law.

Euthanasia is illegal in Ohio.

 

[GassYous]

This is a sad case. It appears that while he acted out of mercy, he also broke the law.

Euthanasia is illegal in Ohio.

What is dead may never die

 

[BoardingDoc]

Someone on the previous page posted a list of names, cardiac arrests (average is about 3 per patient), ph (average is below 7.0), average bp is like 70/40. None of them have anything even remotely compatible with life.

Missed that. Here's a link to the post with the image for anyone else who missed it. There are a handful of people on that list where more information is needed, but yeah, "Cardiac arrest x4, 5 documented organ system failures, on pressors, pH 6.53, lactate 16, last recorded BP 74/33." WTF, most of the people on that list are clearly dead already.

EDIT:
I ran the image through an OCR and made a table for easier copying/pasting. This is insane.


�

	A	B	C	D	E	F	G
1	Patients Actively Dying
2	Patient	Cause of Death	Organ Failures	Vasopressors	pH	Lactate	Last Record BP
3	Troy Allison	Cardiac arrest x 4	5	Yes	6.53	16	74/33
4	Jeremia Hodge	Cardiac arrest x 4	5	Yes	6.73	24	108/58
5	Danny Mollette	Cardiac arrest x 4	4	Yes	6.96	22	115/60
6	Bonnie Austin	Cardiac arrest x 5	4	Yes			64/12
7	Beverlee Schirtzinger	Cardiac arrest	4	Yes	6.96	18	38/21
8	James Allen	Cardiac arrest	4	Yes	7.02	5	83/52
9	Sandra Castle	Cardiac arrest	3				123/43
10	Ryan Hayes	Cardiac arrest	3				97/63
11	James Timmons	Septic shock	4	Yes	6.95	11	78/48
12	Mellissa Penix	Septic shock	4	Yes	6.97	8	93/48
13	Joanne Bellisari	Septic shock	4	Yes			79/49
14	Brandy McDonald	liver failure		Yes	6.93	27	42/28
15	Rebecca Walls	Heart failure		Yes			85/43
16	Francis Burke	Brain Bleed	2				68/43

 

[turkeyjerky]

Reading between the lines of this article, it seems to me that this is a politically motivated witch hunt, likely driven by a hosptial system on the hook for millions in settlement money (wrongfully paid out imo) trying to recover their public image and shift liability to this poor guy. It reads likes an Onion article (italics mine)

"Husel told Chris Allison, whose husband Troy was currently in the ICU after having suffered 4 sequential cardiac arrests and had a pH incompatable with life despite all possible resuscitative measures, he'd like to give her husband something that made him comfortable.
A short time later, Troy was dead.
"It just wasn't adding up," Chris Allison told CNN, regarding the tragic case of husband, whose years of obesity, smoking and neglecting his health finally culminated in his death following cardiac arrest from multiple organ failure and refractory shock.

 

[turkeyjerky]

My take: hospital administrators saw the word "fentanyl" in southern Ohio amidst the opiod crisis and panicked.

 

[dchristismi]

I note that they just say presence or absence of vasopressors, not how many vasopressors...
Because you can have 4 pressors and a bicarb drip and still have a BP in the 50s and not be quite dead yet.

I'm not proud of it, but I kept someone like that alive in residency with that cocktail. It was awful.

 

[Iso4ane]

Like, if you're a doc, showing me the vials that constitute 1,000 mcg of fentanyl does not change my knowledge of that dose.

If you have the right vial, it’s just one larger vial.

And looking at that list of patients, if that was a transfer from some outside hospital and then appeared on a M&M, the summary would be, so these patients arrived dead and stayed dead.

 

[benem]

Reading between the lines of this article, it seems to me that this is a politically motivated witch hunt, likely driven by a hosptial system on the hook for millions in settlement money (wrongfully paid out imo) trying to recover their public image and shift liability to this poor guy. It reads likes an Onion article (italics mine)

"Husel told Chris Allison, whose husband Troy was currently in the ICU after having suffered 4 sequential cardiac arrests and had a pH incompatable with life despite all possible resuscitative measures, he'd like to give her husband something that made him comfortable.
A short time later, Troy was dead.
"It just wasn't adding up," Chris Allison told CNN, regarding the tragic case of husband, whose years of obesity, smoking and neglecting his health finally culminated in his death following cardiac arrest from multiple organ failure and refractory shock.

It’s interesting to see the wife of the patient respond to his death that “it wasn’t adding up”. It’s obvious that he was going to die based on his stats alone. Unfortunately so many families have this false sense of hope up until the end, and then anger with healthcare providers following the death. I remember having to argue with my mother about my grandfather’s care and explain that no, an 85 year old lifelong smoker in respiratory failure wouldn’t qualify for a lung transplant. I had a case like this I saw recently as well, 90 year old Covid+ cancer patient, obvious metastasis, the family wanted me to admit him so he could get chemo the following day. I admitted him to our hospice unit and he died two days later.

 

[Tenk]

This case is literally just a problem with the United States and the Midwest in particular. Nobody talks about DNR so you have all these full code vegetables and it’s freaking ridiculous. I mean just look at this crap. This is a real DNR form from a nursing home that was sent in with a patient.

 

[AlmostAnMD]

lol

So today sucked

There was a lot of sidebar BS and hushed voices with latest witnesses. Barely got any testimony done. But, reading between the lines of what I could hear, it sounds like pea deals were offered/are being offered to everyone other than husel for cooperating against him. And the defense for some reason is not allowed to bring this up in front of the jury.

Even the witnesses discussing the ethics of it aren't allowed, the defense had to dance around columbus police notes they weren't allowed to show. Probably when they said really self-incriminating stuff, like yeah I know it was 1,000 mcg of fentanyl, dude was dying. I've been a pharmacist for years, I know what that drug does.

THe dude with the long hair even has a settlement agreement, that much I definitely heard, but again Jury is not allowed to know.

If everyone just stood with him this might not have happened, I doubt Ohio would send 38 people to jail.

But we're doctors, highest on the fantasy pole lowest on the blame totem

 

[Interpolfanclub]

It’s interesting to see the wife of the patient respond to his death that “it wasn’t adding up”. It’s obvious that he was going to die based on his stats alone. Unfortunately so many families have this false sense of hope up until the end, and then anger with healthcare providers following the death. I remember having to argue with my mother about my grandfather’s care and explain that no, an 85 year old lifelong smoker in respiratory failure wouldn’t qualify for a lung transplant. I had a case like this I saw recently as well, 90 year old Covid+ cancer patient, obvious metastasis, the family wanted me to admit him so he could get chemo the following day. I admitted him to our hospice unit and he died two days later.

Our whole country has the most unreasonable expectations regarding end of life, and one of the reasons is because hospitals and admin have generally encouraged this behavior in the name of "patient experience." Not to mention we are a customer service culture where the "customer" ie patient or family is always right.

Agree with previous poster that what this doc was doing was likely merciful, unfortunately the system does not reward mercy. No good deed goes unpunished is the absolute truth. I don't stick my neck out, if the family wants us to flail on grandma fine. If family seems reasonable I might have a discussion with them but if not I just give them what they want with as little discussion or emotion as possible. It's not worth it.

 

[turkeyjerky]

Is there any indication whether these were bolus doses for fentanyl or cumulative doses over several hours?

 

[dchristismi]

My last EM gig was at an Ivory Tower cancer mecca.
ONLY the oncologists were "allowed" to talk about prognosis, code status or end of life stuff. Palliative was called "Supportive Care." (Being the only overnight doc in the place, I didn't care and had some amazing 3 am deep existential talks with patients, but I digress.)

Now, full disclosure, I love this place. They have a stellar reputation, and they do amazing work. Like extend leptomeningeal disease to yearslong survival. BUT... it kills me when I get an inpatient sent to my hospice house, because I inevitably get 4 days before they die and the family feels like they've had the rug pulled out from under them. Sometimes the oncologist has had an honest discussion with the family, sometimes not.

That family whose loved one had leptomeningeal spread of her breast cancer 2 years prior had no idea that her docs had bought her two whole years! They just felt abandoned and angry and it took a lot of love and gentle persuasion to convince them that their beloved cancer center hadn't just "given up and tossed her aside."

But death and dying is something our society does NOT do well. Never has. Some of us are trying our hardest, but it's stuff like this that causes that deep moral injury that makes more docs (and nurses) do the "easy" thing... just do the compressions. Put the tube in. Hang another pressor. Even when we all know the only thing we're doing is torturing the patient and leading the family on.

 

[WilcoWorld]

Is there any indication whether these were bolus doses for fentanyl or cumulative doses over several hours?

That's an important distinction. Unfortunately, it looks like these were bolus doses:

Schroyer, tasked with verifying medication orders submitted by Mount Carmel doctors, said that when he first saw the 1,000 microgram-order of fentanyl requested for victim Janet Kavanaugh, a 79-year-old who died in December 2017, the dose seemed “a little unusual.” He said he consulted with fellow pharmacist Greg Dresbach, who said although Schroyer “was not crazy” for thinking the fentanyl dose was unusual, it wasn’t an unusual order from Husel. source

 

[southerndoc]

lol

So today sucked

There was a lot of sidebar BS and hushed voices with latest witnesses. Barely got any testimony done. But, reading between the lines of what I could hear, it sounds like pea deals were offered/are being offered to everyone other than husel for cooperating against him. And the defense for some reason is not allowed to bring this up in front of the jury.

Even the witnesses discussing the ethics of it aren't allowed, the defense had to dance around columbus police notes they weren't allowed to show. Probably when they said really self-incriminating stuff, like yeah I know it was 1,000 mcg of fentanyl, dude was dying. I've been a pharmacist for years, I know what that drug does.

THe dude with the long hair even has a settlement agreement, that much I definitely heard, but again Jury is not allowed to know.

If everyone just stood with him this might not have happened, I doubt Ohio would send 38 people to jail.

But we're doctors, highest on the fantasy pole lowest on the blame totem

Are you at the trial or watching on TV?

 

[dpmd]

That's an important distinction. Unfortunately, it looks like these were bolus doses:

Schroyer, tasked with verifying medication orders submitted by Mount Carmel doctors, said that when he first saw the 1,000 microgram-order of fentanyl requested for victim Janet Kavanaugh, a 79-year-old who died in December 2017, the dose seemed “a little unusual.” He said he consulted with fellow pharmacist Greg Dresbach, who said although Schroyer “was not crazy” for thinking the fentanyl dose was unusual, it wasn’t an unusual order from Husel. source

My understanding is that for each of these patients the family agreed to change code status to comfort care only and these were bolus doses for the terminal extubations. Why they were written as a separate order instead of having the nurse give a bolus from the bag that was already hanging for sedation I don't know. I can neither confirm nor deny that a few ICU nurses did the latter with my blessing for terminal extubations I ordered.

 

[WilcoWorld]

My understanding is that for each of these patients the family agreed to change code status to comfort care only and these were bolus doses for the terminal extubations. Why they were written as a separate order instead of having the nurse give a bolus from the bag that was already hanging for sedation I don't know. I can neither confirm nor deny that a few ICU nurses did the latter with my blessing for terminal extubations I ordered.

You've given 1000mcg boluses for extubations?

 

[WilcoWorld]

To be clear, I'm VERY in favor of comfort care and treating dyspnea aggressively with IV opioids, even when we know that the patients are at risk of death. That said, in several years of practice I've never gotten close to a 1000mcg bolus dose for an extubated patient.

 

[dpmd]

You've given 1000mcg boluses for extubations?

I have never stated an amount for the nurses to give but let's just say with those nurses the patients getting terminally extubated definitely don't suffer during the short time they live post extubation.

 

[dpmd]

That said I got 9 of versed and 250 of fentanyl for an EGD once when I weighed around 125 and was wide awake 30 minutes after the scope was out. And I got something around 5 of dilaudid in PACU after my total thyroid but was still in some pain so I am not sure the doses he used would kill me if I wasn't already mostly dead.

 

[e30ftw]

My understanding is that for each of these patients the family agreed to change code status to comfort care only and these were bolus doses for the terminal extubations.

This actually explains the case better if accurate. Prosecution is trying to prove Husel knew the order would result in premature death (by a few seconds/minutes) and defense that as the patients were being terminally extubated his intent was to provide comfort.

The law is the law and apparently the state of Ohio really cares about the right of a terminally extubated comfort care patient to agonal breathe until every last medullary neuron is dead.

I would argue his actions likely relieved patient suffering and were within his ethical obligations to the patient/family, however if given with intent to hasten apnea were against the law. It's a tough case with a lot of grey areas.

 

[dpmd]

This actually explains the case better if accurate. Prosecution is trying to prove Husel knew the order would result in premature death (by a few seconds/minutes) and defense that as the patients were being terminally extubated his intent was to provide comfort.

The law is the law and apparently the state of Ohio really cares about the right of a terminally extubated comfort care patient to agonal breath until every last medullary neuron is dead.

I would argue his actions likely relieved patient suffering and were within his ethical obligations to the patient/family, however if given with intent to hasten apnea were against the law. It's a tough case with a lot of grey areas.

Yeah, I think the law is wrong for this circumstance but I agree he likely was trying to avoid family suffering along with patient suffering by not drawing things out.

 

[WilcoWorld]

I would argue his actions likely relieved patient suffering and were within his ethical obligations to the patient/family, however if given with intent to hasten apnea were against the law.

I suspect you're right that he wanted to reduce suffering - a noble goal. If the prosecution tries to paint him as a monster, that dog won't hunt.
I'm also worried that, at the doses he was ordering, he was trying to cause apnea. That's illegal in Ohio, so now a bunch of RNs and PharmD's are having to testify against a colleague.

Everything about the situation is lousy.

 

[AlmostAnMD]

This actually explains the case better if accurate. Prosecution is trying to prove Husel knew the order would result in premature death (by a few seconds/minutes) and defense that as the patients were being terminally extubated his intent was to provide comfort.

The law is the law and apparently the state of Ohio really cares about the right of a terminally extubated comfort care patient to agonal breathe until every last medullary neuron is dead.

I would argue his actions likely relieved patient suffering and were within his ethical obligations to the patient/family, however if given with intent to hasten apnea were against the law. It's a tough case with a lot of grey areas.

A friend of mine is a lawyer and said as much. It's probably the right thing to do but technically illegal. He thinks he'll be guilty, which will trigger some kind out outrage, then a law change in Ohio and subsequently freed.

 

[MechEDoc]

In NZ, we do somewhat acutely determine the "ceiling of care" and the relative futility of critical care interventions.

Much of what would otherwise get the so-called "full court press" in the U.S. gets maximal medical management +/- palliative care on the floor.

Different country, different norms. Probably much more sane too... If only the USA wasn't so nuts.

 

[dpmd]

A friend of mine is a lawyer and said as much. It's probably the right thing to do but technically illegal. He thinks he'll be guilty, which will trigger some kind out outrage, then a law change in Ohio and subsequently freed.

If they change it will it apply retroactively?

 

[alpinism]

From everything I've been reading it sounds like a nothing but a witch hunt.

I'll say this as someone who theoretically has worked in war zones and theoretically has euthanized patients.

The LD50 for IV fentanyl is roughly 2mg and 1mg is typically not enough to cause death in most cases.

 

[Southpaw]

If these doses were single bolus, given after terminal extubation, with minutes to live, I'd add that Husel had one chance to relieve suffering. Put another way, if he were bolusing the meds by himself at the bedside, titrating to effect, then maybe this is all different. But that's not how ICU medicine is practiced in the US. He puts an order in, it gets approved by pharmacy, drawn up and given by nursing. He has one chance to relieve suffering.

Put another way, to be lawful he'd have to intentionally underdose, or give what most of his colleagues would consider is a 'normal dose' and who knows whether or not that relieves suffering for a patient who'll die within minutes anyway. I doubt I have the guts to do what he did, but I don't know anyone could consider him a murderer. I'm also not sure how you adequately and correctly explain the situation to the family, many of which have forced a full court press on a human what has only induced more suffering.

 

[ACSurgeon]

To be clear, I'm VERY in favor of comfort care and treating dyspnea aggressively with IV opioids, even when we know that the patients are at risk of death. That said, in several years of practice I've never gotten close to a 1000mcg bolus dose for an extubated patient.

this. It’s one thing to give escalating doses of opioids and sedatives. Bolus or drip form. I don’t think anyone ever gives more than 100mcg of fentanyl at a time unless that patient is very opioid tolerant or demonstrated they need (&can handle) more.

Not sure about the circumstances of this physician or his patients, but many patients undergoing terminal extubation are altered and weak and a little precedex or versed with a little opioid and they appear very comfortable.

I am all for comfort care. I frequently tell patients/families during goals of care discussions that while I can’t guarantee heroic efforts/surgery will prolong their life, I can guarantee they won’t be in pain or have anxiety if they transition to comfort care. And I’m always good on that promise. Still, you use escalating doses of blouses or drips to achieve that goal.

 

[ACSurgeon]

If these doses were single bolus, given after terminal extubation, with minutes to live, I'd add that Husel had one chance to relieve suffering. Put another way, if he were bolusing the meds by himself at the bedside, titrating to effect, then maybe this is all different. But that's not how ICU medicine is practiced in the US. He puts an order in, it gets approved by pharmacy, drawn up and given by nursing. He has one chance to relieve suffering.

Put another way, to be lawful he'd have to intentionally underdose, or give what most of his colleagues would consider is a 'normal dose' and who knows whether or not that relieves suffering for a patient who'll die within minutes anyway. I doubt I have the guts to do what he did, but I don't know anyone could consider him a murderer. I'm also not sure how you adequately and correctly explain the situation to the family, many of which have forced a full court press on a human what has only induced more suffering.

If the patient was on the vent then theoretically there’s been time to determine how much medications they need to achieve a comfortable state. You can err on the side of over shooting a bit. However, giving someone several fold higher dose just in case seems different than what I’ve seen across multiple ICUs. Obviously there are some unusual cases that require unusual approaches, so I am discussing the concept rather than what happened in this case.

 

[ACSurgeon]

Our whole country has the most unreasonable expectations regarding end of life, and one of the reasons is because hospitals and admin have generally encouraged this behavior in the name of "patient experience." Not to mention we are a customer service culture where the "customer" ie patient or family is always right.

Agree with previous poster that what this doc was doing was likely merciful, unfortunately the system does not reward mercy. No good deed goes unpunished is the absolute truth. I don't stick my neck out, if the family wants us to flail on grandma fine. If family seems reasonable I might have a discussion with them but if not I just give them what they want with as little discussion or emotion as possible. It's not worth it.

I’m not sure if I’m getting burned out or just shifting towards the middle, but I’m becoming more like what you describe. I have goals of care discussions with everyone coming to the icu and every sick or older surgery patient as part of the consent. However I’m become less aggressive when it comes to try and guide them. I’m very clear with my words and paint them a clear picture, and maybe even make a recommendation but I emphasize this is a value based decision that is different for every family. If I sense they want to limit medical interventions I guide them down that road. If they seem in denial and want everything, Oh well. This is not a hill I’m going to die on.

 

[ACSurgeon]

Missed that. Here's a link to the post with the image for anyone else who missed it. There are a handful of people on that list where more information is needed, but yeah, "Cardiac arrest x4, 5 documented organ system failures, on pressors, pH 6.53, lactate 16, last recorded BP 74/33." WTF, most of the people on that list are clearly dead already.

EDIT:
I ran the image through an OCR and made a table for easier copying/pasting. This is insane.


�

	A	B	C	D	E	F	G
1	Patients Actively Dying
2	Patient	Cause of Death	Organ Failures	Vasopressors	pH	Lactate	Last Record BP
3	Troy Allison	Cardiac arrest x 4	5	Yes	6.53	16	74/33
4	Jeremia Hodge	Cardiac arrest x 4	5	Yes	6.73	24	108/58
5	Danny Mollette	Cardiac arrest x 4	4	Yes	6.96	22	115/60
6	Bonnie Austin	Cardiac arrest x 5	4	Yes			64/12
7	Beverlee Schirtzinger	Cardiac arrest	4	Yes	6.96	18	38/21
8	James Allen	Cardiac arrest	4	Yes	7.02	5	83/52
9	Sandra Castle	Cardiac arrest	3				123/43
10	Ryan Hayes	Cardiac arrest	3				97/63
11	James Timmons	Septic shock	4	Yes	6.95	11	78/48
12	Mellissa Penix	Septic shock	4	Yes	6.97	8	93/48
13	Joanne Bellisari	Septic shock	4	Yes			79/49
14	Brandy McDonald	liver failure		Yes	6.93	27	42/28
15	Rebecca Walls	Heart failure		Yes			85/43
16	Francis Burke	Brain Bleed	2				68/43

Yes no doubt these patients all had 100% mortality likelihood. I just don’t know how often a patient with a pH of 6.5 and a SBP in the 60’s with 5 organ systems failure needs big doses of anything upon extubation. Usually stopping the pressors brings the pretty close to the end. Not sure a brain that isn’t perfusing has awareness of pain. I don’t think the 1000mcg of fentanyl was the reason they died, but not standard practice by any means.

Also, dying icu patients are different than cancer patients in hospice who are dying much more slowly, are awake, and have severe pain as a result. The latter group of patients can easily escalate up to really high doses of opioids but that’s not what this case is about.

 

[ACSurgeon]

I agree this is not a case to rally behind simply because the medical details and implications are complicated for the lay-person to understand and the defendant has essentially been labeled a serial killer in the media. It's bad press.

I have no legal expertise obviously but it seems with a criminal case proving murder comes down to intent. While I agree with your statement on ending a life with opioids versus providing relief of suffering, without knowing details of the case beyond this thread, I would question if the fentanyl, while an excessive dose, really had anything to do with the patient deaths.

Considering that fentanyl is fairly hemodynamically stable and the main risk is respiratory depression, and assuming all patients were intubated (seems reasonable given their location and condition) when the fentanyl was given, it is reasonable to assume that fentanyl had little if anything to do with their deaths, considering the safety profile of the drug in overdose in an intubated patient and the numerous other impending causes of death such as cardiac arrest, MODS, circulatory failure, severe metabolic acidosis, etc.

With all that in consideration it seems pretty reasonable that the Husel's intent was to minimize suffering rather than cause harm. Just a thought like I said don't know the full facts of the case. The prosecution's murder charge would make sense if Husel were pushing 200 mEq KCL or something but not an opiate in an intubated patient.

Just playing expert witness for the defense..

With what little i know about the legal system, the trial and the questions asked to the jury probably won’t try to answer a reasonable question like did the doctor intend to kill the patients or were they dying quickly anyways. It’ll be some other convoluted question to which the answer will be “yes, he was wrong for doing that. “

 

[Rekt]

This entire thread is pretty silly. Maybe a few of you forgot what it's like in the unit. Every ICU I've been in essentially euthanizes patients. It's of course more subtle than a slug of 1g of Fent. This doc did nothing wrong.

Euthanization should be legal. Futility of care should be standardized in the ICU or even in the ED.

The people on that list have been corpses for days.

 

[GassYous]

this. It’s one thing to give escalating doses of opioids and sedatives. Bolus or drip form. I don’t think anyone ever gives more than 100mcg of fentanyl at a time unless that patient is very opioid tolerant or demonstrated they need (&can handle) more.

Not sure about the circumstances of this physician or his patients, but many patients undergoing terminal extubation are altered and weak and a little precedex or versed with a little opioid and they appear very comfortable.

I am all for comfort care. I frequently tell patients/families during goals of care discussions that while I can’t guarantee heroic efforts/surgery will prolong their life, I can guarantee they won’t be in pain or have anxiety if they transition to comfort care. And I’m always good on that promise. Still, you use escalating doses of blouses or drips to achieve that goal.

I've given people 250 at a time before even without a tube for a mac case. People on chronic opioids can take a lot. Spine or cardiac cases can also get 1000s of fentanyl although people are trending towards lower opioid doses these days. Most people on longterm vents are likely on a fent drip and they can take 1000 at a time nbd although it's definitely a large dose and not routine.

 

[nimbus]

Reading between the lines of this article, it seems to me that this is a politically motivated witch hunt, likely driven by a hosptial system on the hook for millions in settlement money (wrongfully paid out imo) trying to recover their public image and shift liability to this poor guy. It reads likes an Onion article (italics mine)

"Husel told Chris Allison, whose husband Troy was currently in the ICU after having suffered 4 sequential cardiac arrests and had a pH incompatable with life despite all possible resuscitative measures, he'd like to give her husband something that made him comfortable.
A short time later, Troy was dead.
"It just wasn't adding up," Chris Allison told CNN, regarding the tragic case of husband, whose years of obesity, smoking and neglecting his health finally culminated in his death following cardiac arrest from multiple organ failure and refractory shock.

What’s not adding up? He died 4 times, then he died a 5th time. He’s not a cat.

 

[nimbus]

I've given people 250 at a time before even without a tube for a mac case. People on chronic opioids can take a lot. Spine or cardiac cases can also get 1000s of fentanyl although people are trending towards lower opioid doses these days. Most people on longterm vents are likely on a fent drip and they can take 1000 at a time nbd although it's definitely a large dose and not routine.

Same. I’ve given some opioid tolerant patients 500mcg in less than 5min and they still talked to me like I haven’t given them anything.

 

[BoardingDoc]

What’s not adding up? He died 4 times, then he died a 5th time. He’s not a cat.

I talked to one of my RNs about this case yesterday. She apparently used to work at this hospital and peripherally knew Husel, though didn't work directly with him. Re: your comment, she says that the health literacy in that area is profoundly low.

I'm sure some of these families are just looking for a payout. That said, she makes it sound like there's probably a decent chance that they're just dumb as a bag of rocks.

 

[Kryptocoin]

Forget about even proving intent (which is very hard to do in criminal cases) , can they prove that fentanyl was the direct cause of death in these patients? It should be pretty easy to prove as fentanyl is a rapid acting agent. If his patients went apneic and coded soon after he pushed meds then yes , they may have a case for illegal euthanasia.

I think they should arrest and charge the family members with pain and suffering for allowing their loved ones to be coded 5x. The severe pain from crushed ribs alone probably warrants 1000mg of fentanyl.

 

[e30ftw]

Sadly the only people who will really benefit from this will be the attorneys and the true victims will be countless future patients forced by family into a peri-mortem purgatory only to be under-dosed comfort meds by physicians who do not want to be prosecuted for murder.

 

[southerndoc]

I never saw an answer @AlmostAnMD about whether you were attending the trial in person or if it's being televised.