Husel Trial -- NOT GUILTY

[Birdstrike]

I know you think you've got me, but I disagree. You've instead revealed your own assumption. You "believe that every person doing a palliative extubation [wants] the patient to die more quickly than they otherwise would".

No offense to intensivists or ER docs, but patients live a lot longer than we think they can without life support. PCP's, please back me up on this. Patients who are compassionately extubated survive their ICU stay quite often.

I've personally seen people survive withdrawal of support live for months.

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[Southpaw]

I know you think you've got me, but I disagree. You've instead revealed your own assumption. You "believe that every person doing a palliative extubation [wants] the patient to die more quickly than they otherwise would".

No offense to intensivists or ER docs, but patients live a lot longer than we think they can without life support. PCP's, please back me up on this. Patients who are compassionately extubated survive their ICU stay quite often.

I recall seeing the list of the 14 - many of their pHs were 7 or lower. They were intubated, many on multiple pressors, many had several rounds of CPR before the decision to terminally extubate.

Honest question - is THIS the type of patient you expect to survive their ICU stay?

 

[WilcoWorld]

I recall seeing the list of the 14 - many of their pHs were 7 or lower. They were intubated, many on multiple pressors, many had several rounds of CPR before the decision to terminally extubate.

Honest question - is THIS the type of patient you expect to survive their ICU stay?

I expect that you won't believe me. But yes, at least sometimes. I don't expect such patients to survive their hospitalization - my point is that it isn't the extubation that kills them. It's their disease that kills them.

I think that if you rounded on my palliative unit you'd be surprised. When I'm discussing palliative extubation with families I don't warn them that their loved might die very quickly - I warn them that it will take however long it takes, and I assure them that we'll work as hard as we need to prevent unnecessary suffering.

 

[AlmostAnMD]

Another question just got asked.

They asked to see the defense poster board from opening statements. This included many other patients initially investigated but at lower doses. These charges were subsequently dropped.

However that board was not entered into evidence and as such their request was denied. They could see it while it was on display but cannot see it again.

Interesting. Jury has asked two questions so far, each of their requests denied.

Fyi that board had a bunch of people on there that died with <500 mcg fentanyl doses, something jury was paying attention to evidently.

 

[Birdstrike]

I'll tell you what would have been an incredibly effective defense. For hours, days, weeks, bring in defense witness after defense witness, saying, "Yes, I give 1,000 mcg boluses of fentanyl all the time. Never had a patient die after that."

Then another one, "Oh, yeah. 2,000mcg. No problem! With versed 10mg, too. All the time. Patients live just fine after that."

Just bring in doc, after doc, after doc, for hours, days, weeks, until all the jurors, judge, lawyers are begging you to stop brining in all the docs to say they do exactly what Husel does every days and the patients survive just fine.

That would have be HELLA-effective. It would've changed my mind.

But they didn't. They didn't bring a single one. Because they couldn't FIND one. They couldn't find one, because not a single other person that has that practice pattern exists.

 

[IMGASMD]

Do you expect everyone to believe that every person doing a palliative extubation doesn't intend or want the patient to die more quickly than they otherwise would? That they don't know that the patient is definitely going to die because of that action and are ok with it because of reasons?

No everyone believes in status quo, waiting for the “disease” itself to kill the patient. So we can have a debate about who/what actually “killed” the patient. I can always wash my hands off. They died from lack of oxygen, that I have nothing to do with….. /big capital S

 

[neurodoc]

Do you expect everyone to believe that every person doing a palliative extubation doesn't intend or want the patient to die more quickly than they otherwise would? That they don't know that the patient is definitely going to die because of that action and are ok with it because of reasons?

Palliative extubation is removing a life-sustaining device that would allow a patient to die naturally. This is different from giving a drug that can hasten death by actually causing a patient to stop breathing). I think the difference between the two should be obvious, but perhaps some folk don't think it's that obvious. I believe this topic was address earlier in this thread.

 

[neurodoc]

Are there any physicians on the jury or who were in the jury pool and not empaneled? What about the old concept of being entitled to a jury of ones peers? I know this doesn't mean physicians are entitled to a jury full of physicians in a criminal or civil trial...after all this is not Peer Review. But the questions the jurors have been asking makes me wonder how well they will understand all the testimony they heard, not to mention how to decide the non-testimonial arguments made by the prosecution and defense lawyers in the opening and closing statements.

I can see this whole trial turning into a confusing cluster [blank].

 

[dpmd]

Palliative extubation is removing a life-sustaining device that would allow a patient to die naturally. This is different from giving a drug that can hasten death by actually causing a patient to stop breathing). I think the difference between the two should be obvious, but perhaps some folk don't think it's that obvious. I believe this topic was address earlier in this thread.

I know it is legally different and I agree it feels different (though I can think of scenarios where removing life sustaining stuff would be looked on very unfavorably as opposed to how we view removal of ETT or stopping pressors, for example taking a flotation device away from a non swimmer in the middle of the lake and leaving them out there) but you agree that the physician can absolutely intend to hasten death by taking that action and be perfectly legal in doing so, right?

 

[neurodoc]

I know it is legally different and I agree it feels different (though I can think of scenarios where removing life sustaining stuff would be looked on very unfavorably as opposed to how we view removal of ETT or stopping pressors, for example taking a flotation device away from a non swimmer in the middle of the lake and leaving them out there) but you agree that the physician can absolutely intend to hasten death by taking that action and be perfectly legal in doing so, right?

Taking away a life saver from a non-swimmer to let him drown in the middle of a lake would be murder and not the same as taking a terminally ill about-to-die patient off a vent or pressors that would allow the patient to die naturally is "letting nature take its course" and is ethically and legally acceptable. It's not the same as giving the patient 2000mcg of fentanyl at the time of extubation, which constitutes euthanasia, or "active euthanasia" as some chose to call the kind of stuff that Husel did. Am I making my point clearly enough?

 

[Apollyon]

Are there any physicians on the jury or who were in the jury pool and not empaneled? What about the old concept of being entitled to a jury of ones peers? I know this doesn't mean physicians are entitled to a jury full of physicians in a criminal or civil trial...after all this is not Peer Review. But the questions the jurors have been asking makes me wonder how well they will understand all the testimony they heard, not to mention how to decide the non-testimonial arguments made by the prosecution and defense lawyers in the opening and closing statements.

I can see this whole trial turning into a confusing cluster [blank].

Juries are made up with people that couldn't get out of it. Although theoretically possible, I believe it quite unlikely that there are any physicians on the jury.

I recall reading about malpractice cases, and what would happen in a civil trial. Right now, doctors win 5/6. If that "jury of your peers" was 6 docs, the article surmised that docs would lose a LOT more cases.

 

[bravotwozero]

A jury of your peers is not interpreted as a jury of people in the same profession as you in the eyes of the law. It just means they can’t bring government agents like police/detectives/DA etc that would have a vested interest in ruling in favor of the prosecution i.e. government

 

[dpmd]

Taking away a life saver from a non-swimmer to let him drown in the middle of a lake would be murder and not the same as taking a terminally ill about-to-die patient off a vent or pressors that would allow the patient to die naturally is "letting nature take its course" and is ethically and legally acceptable. It's not the same as giving the patient 2000mcg of fentanyl at the time of extubation, which constitutes euthanasia, or "active euthanasia" as some chose to call the kind of stuff that Husel did. Am I making my point clearly enough?

The former is letting nature take its course too though. Just in a really ****ed up way. Like a bystander walking away with an anaphylaxtic patients epi pen is just letting nature take its course too.

 

[lucid_leprechaun]

Hopefully everyone else is reporting the inflammatory/baiting stuff as well.

I still cant find one good explanation as to how someone is giving a lethal dose of medication to 24+ patients, and no one made a legitimate peep. I'm not talking about a few comments like "Dr Husel is giving larger than usual doses of opioids to end of life patients" or the one ding by pharmacy that went nowhere. I'm talking about a response appropriate for a murderous dose of medication.
How do 3 people die after risk management and upper level administration know about homicides? I understand that due diligence needs to be done.......but 24+ lethal doses?

Assuming closing arguments are monday, my prediction is that lesser charges are included and he's found guilty of some sort of reckless homicide. To me, this seems to apply way more precisely to the situation even though I still don't think they can prove the fentanyl killed these people and not the removal of various forms of life support

Yeah I get a call from pharmacy for 10 mg morphine so…

 

[neurodoc]

A jury of your peers is not interpreted as a jury of people in the same profession as you in the eyes of the law. It just means they can’t bring government agents like police/detectives/DA etc that would have a vested interest in ruling in favor of the prosecution i.e. government

Yes, that seems to be right. And our system of justice also allows for the testimony of "expert witnesses" to explain complex issues (like medical care) so that non-professional jurors can understand them well enough to make just decisions...of course how well that goal is achieved depends on the quality of the expert testimony they hear...

 

[neurodoc]

The former is letting nature take its course too though. Just in a really ****ed up way. Like a bystander walking away with an anaphylaxtic patients epi pen is just letting nature take its course too.

Right, just like pushing someone over the edge of a cliff would be letting nature (in this case gravity) run its course. Not only in a really ****ed up way, but in a way that equals murder. Not so with the removal of futile life support like artificial ventilation in a dying terminally ill patient, which most assuredly is not murder, especially when the patient or his surrogates request DNR. Euthanizing a patient is another matter entirely. I suspect there are some on this forum who believe euthanasia is morally ok and maybe that's why they see nothing wrong in Husel's practice. The fact is that here in the USA euthanasia is legally equivalent to murder and if the jury believes that's what Husel was practicing they could find him guilty of murder. That would be a harsh judgment but still a possible outcome in this case. We'll see how it turns out.

 

[PTPoeny]

Yes, it usually is significantly lower. It would be better if I could give you a citation, but I'm going off my clinical experience hare.

ET tubes hurt like a mofo and often require pretty high doses of opioids (100mcg fentanyl boluses) to be tolerated, once they're out the patient usually settles down and I can get the patients comfortable with more like 12mcg fentanyl boluses. Of course it's not one size fits all. These are general starting points.

I agree that the opioid requirement to treat air hunger is much lower than that needed to treat ETT discomfort, but, the opioid requirement to prevent withdrawal isn't necessarily dramatically lower than whatever they were on before.

I feel like there is very basic information that didn't come out in this thread or other articles that I have read. The dosages and duration of the opioid infusions that these patients were on prior to extubation is hugely important to one side or the other and somehow it just didn't come up? Or at least I haven't seen any quotes about this...

Do adults really survive palliative extubation on a "regular basis"? As peds ICU I had one fellowship attending approaching retirement who had seen a single child survive palliative extubation once and no one else there or where I work now has seen it happen.

 

[AlmostAnMD]

Another question asked by deliberating jury. They asked for the pyxis records. This, too, was denied.

So so far the jury has asked for 3 things, all of those requests have been denied by the court.

 

[WilcoWorld]

I agree that the opioid requirement to treat air hunger is much lower than that needed to treat ETT discomfort, but, the opioid requirement to prevent withdrawal isn't necessarily dramatically lower than whatever they were on before.

I feel like there is very basic information that didn't come out in this thread or other articles that I have read. The dosages and duration of the opioid infusions that these patients were on prior to extubation is hugely important to one side or the other and somehow it just didn't come up? Or at least I haven't seen any quotes about this...

Do adults really survive palliative extubation on a "regular basis"? As peds ICU I had one fellowship attending approaching retirement who had seen a single child survive palliative extubation once and no one else there or where I work now has seen it happen.

Agree that tolerance/dependence matters.

As to your other question - yes. By "survive" I don't mean survival in the sense of getting up and dancing the jig. I mean patients regularly survive after extubation longer than the ICU team expects. In my palliative practice this happens several times a week. I would add that my clinical experience leads me to believe that parents decide to discontinue life support MUCH later for children than most surrogate decision makers make the same decision for adults. It makes sense why, but that's probably a better discussion for another thread.

 

[Robotic Wis-Hipple]

I’m clearly naive as it pertains to law but I cannot understand how this isn’t relevant.

Whether a user removed 10, 2cc 100ug fentanyl vials at once vs 3 vials three times over 20min tells a hugely different story. Though I guess then it adds more questions, was the 300mcg dose given then additional fentanyl dispensed or were the users pulling out smaller doses in batches to avoid pharmacy or Pyxis controls but given as 1000ug at once? I have to assume they have EMR documented administration and are asking the jury to only consider how it was charted and/or how RN witness testimony described.

 

[Tigers540]

Another question asked by deliberating jury. They asked for the pyxis records. This, too, was denied.

So so far the jury has asked for 3 things, all of those requests have been denied by the court.

I think it points to a big issue, whether anyone thinks he’s guilty or innocent……there’s no way 12 random people with probably zero medical background can comprehend 6+ weeks of testimony about this stuff. There’s been a lot of technical jargon.
I’m not sure if these questions or a long deliberation bode well for defense or prosecution.

 

[dchristismi]

For anyone that doesn't know, I do exclusively inpatient hospice. Most all my patients die, but then again, all of our patients die eventually, it's all just in the timing. Mine just tend to die sooner. My goal is that they don't suffer, but I don't influence the timing. (Seriously, that's up to the patient. I've seen way too many times people wait for the daughter from Michigan to show up, and 10 minutes later, they go. Happened again this afternoon, except the daughter seriously had just arrived from Missouri. He made it about an hour.) Anyway...

I cranked up a fentanyl drip yesterday to a 1000mcg/hr with a 500 mcg bolus.
(It was 300/200 that morning... but it wasn't working. Rapid titrating all day.) Aaaand she was awake, alert and still pretty miserable. The feculent vomiting and the new peritoneal signs probably heralding the end showed up mid afternoon. UG.

After a couple hours I threw in the towel and rotated to dilaudid + ketamine. And she was hitting the bolus herself before that. It finally worked. Cervical cancer is a bitch.

But that's another story for another day.
My personal record is a dilaudid infusion at 40 mg/hr with a 20 mg bolus q10 min (and she was using it a lot) plus ketamine at 30mg/hr plus lidocaine 200mg/hr plus some ativan around the clock and other crap. And she was walking around like that. Not walking well, granted, but walking. I think she perfed too, but definitely had sacral plexus involvement, and when you're only 36, well, it's tremendous what the body can tolerate. Another cervical cancer actually.

I routinely have "compassionate" extubations survive beyond the minutes or hours that the inpatient teams think they're going to live. Sometimes days. Occasionally longer. (Why did they get intubated in the first place? Just airway protection? Hypoxia? Hypercarbia? Sometimes these folks just keep chugging along.) Humans are truly amazing. The suffering they can endure is also amazing.

Also FWIW, I don't have a lot of kids, but you all know that chronic parents are in a different category, and yeah, they wait. Also, once patients get to be 95 or older, all bets are off. You make it that long, you're gonna live forever. I have a 99 year old on my service right now who may never die. He's cachectic as all get out, but by golly, we figure he's enjoying all this attention and that's why he's sticking around.

 

[thegenius]

For anyone that doesn't know, I do exclusively inpatient hospice. Most all my patients die, but then again, all of our patients die eventually, it's all just in the timing. Mine just tend to die sooner. My goal is that they don't suffer, but I don't influence the timing. (Seriously, that's up to the patient. I've seen way too many times people wait for the daughter from Michigan to show up, and 10 minutes later, they go. Happened again this afternoon, except the daughter seriously had just arrived from Missouri. He made it about an hour.) Anyway...

I cranked up a fentanyl drip yesterday to a 1000mcg/hr with a 500 mcg bolus.
(It was 300/200 that morning... but it wasn't working. Rapid titrating all day.) Aaaand she was awake, alert and still pretty miserable. The feculent vomiting and the new peritoneal signs probably heralding the end showed up mid afternoon. UG.

After a couple hours I threw in the towel and rotated to dilaudid + ketamine. And she was hitting the bolus herself before that. It finally worked. Cervical cancer is a bitch.

But that's another story for another day.
My personal record is a dilaudid infusion at 40 mg/hr with a 20 mg bolus q10 min (and she was using it a lot) plus ketamine at 30mg/hr plus lidocaine 200mg/hr plus some ativan around the clock and other crap. And she was walking around like that. Not walking well, granted, but walking. I think she perfed too, but definitely had sacral plexus involvement, and when you're only 36, well, it's tremendous what the body can tolerate. Another cervical cancer actually.

I routinely have "compassionate" extubations survive beyond the minutes or hours that the inpatient teams think they're going to live. Sometimes days. Occasionally longer. (Why did they get intubated in the first place? Just airway protection? Hypoxia? Hypercarbia? Sometimes these folks just keep chugging along.) Humans are truly amazing. The suffering they can endure is also amazing.

Also FWIW, I don't have a lot of kids, but you all know that chronic parents are in a different category, and yeah, they wait. Also, once patients get to be 95 or older, all bets are off. You make it that long, you're gonna live forever. I have a 99 year old on my service right now who may never die. He's cachectic as all get out, but by golly, we figure he's enjoying all this attention and that's why he's sticking around.

Don't you think this has everything to do with the pharmacokinetics, or lack thereof...of the medicine? The fentanyl and dilaudid simply are not binding to the receptor sites, or the receptors are too few or not working properly. She doesn't have cancer of the receptors...she has just been on the medicine for so long it doesn't work anymore.

There is nothing wrong with anyone slowly getting to 1000 mcg/hr. We had a HgS who was on dilaudid 60 mg / hr gtt while admitted.

 

[dpmd]

I agree that the opioid requirement to treat air hunger is much lower than that needed to treat ETT discomfort, but, the opioid requirement to prevent withdrawal isn't necessarily dramatically lower than whatever they were on before.

I feel like there is very basic information that didn't come out in this thread or other articles that I have read. The dosages and duration of the opioid infusions that these patients were on prior to extubation is hugely important to one side or the other and somehow it just didn't come up? Or at least I haven't seen any quotes about this...

Do adults really survive palliative extubation on a "regular basis"? As peds ICU I had one fellowship attending approaching retirement who had seen a single child survive palliative extubation once and no one else there or where I work now has seen it happen.

I have never had it happen on one of mine nor have I heard of it happening to anyone I know of. If it is happening often I would think there is a patient selection problem.

 

[Robotic Wis-Hipple]

For anyone that doesn't know, I do exclusively inpatient hospice. Most all my patients die, but then again, all of our patients die eventually, it's all just in the timing. Mine just tend to die sooner. My goal is that they don't suffer, but I don't influence the timing. (Seriously, that's up to the patient. I've seen way too many times people wait for the daughter from Michigan to show up, and 10 minutes later, they go. Happened again this afternoon, except the daughter seriously had just arrived from Missouri. He made it about an hour.) Anyway...

I cranked up a fentanyl drip yesterday to a 1000mcg/hr with a 500 mcg bolus.
(It was 300/200 that morning... but it wasn't working. Rapid titrating all day.) Aaaand she was awake, alert and still pretty miserable. The feculent vomiting and the new peritoneal signs probably heralding the end showed up mid afternoon. UG.

After a couple hours I threw in the towel and rotated to dilaudid + ketamine. And she was hitting the bolus herself before that. It finally worked. Cervical cancer is a bitch.

But that's another story for another day.
My personal record is a dilaudid infusion at 40 mg/hr with a 20 mg bolus q10 min (and she was using it a lot) plus ketamine at 30mg/hr plus lidocaine 200mg/hr plus some ativan around the clock and other crap. And she was walking around like that. Not walking well, granted, but walking. I think she perfed too, but definitely had sacral plexus involvement, and when you're only 36, well, it's tremendous what the body can tolerate. Another cervical cancer actually.

I routinely have "compassionate" extubations survive beyond the minutes or hours that the inpatient teams think they're going to live. Sometimes days. Occasionally longer. (Why did they get intubated in the first place? Just airway protection? Hypoxia? Hypercarbia? Sometimes these folks just keep chugging along.) Humans are truly amazing. The suffering they can endure is also amazing.

Also FWIW, I don't have a lot of kids, but you all know that chronic parents are in a different category, and yeah, they wait. Also, once patients get to be 95 or older, all bets are off. You make it that long, you're gonna live forever. I have a 99 year old on my service right now who may never die. He's cachectic as all get out, but by golly, we figure he's enjoying all this attention and that's why he's sticking around.

Well, it took 1000 posts…. But we found some real world experiences of absolutely ludicrous tolerance, receptor down regulation, and spinal wind up.

 

[WilcoWorld]

Don't you think this has everything to do with the pharmacokinetics, or lack thereof...of the medicine? The fentanyl and dilaudid simply are not binding to the receptor sites, or the receptors are too few or not working properly. She doesn't have cancer of the receptors...she has just been on the medicine for so long it doesn't work anymore.

There is nothing wrong with anyone slowly getting to 1000 mcg/hr. We had a HgS who was on dilaudid 60 mg / hr gtt while admitted.

You certainly want to consider an opioid rotation when you're getting to that high of doses (as well as adjuncts to opioids). I suspect that's why @dchristismi mentioned changing to dilaudid + ketamine after titrating up to 1000mcg/hr.

 

[WilcoWorld]

Well, it took 1000 posts…. But we found some real world experiences of absolutely ludicrous tolerance, receptor down regulation, and spinal wind up.

Yep, and that was in a patient with a malignant bowel obstruction + peritonitis (two extremely painful conditions) who probably had a long history of opioid use. The other condition mentioned (sacral plexus involvement) is also notoriously resistant to treatment.

As an aside, my experience is similar to @dchristismi in that patients with metastatic cervical cancer have some of the highest opioid needs I see.

 

[Robotic Wis-Hipple]

Yep, and that was in a patient with a malignant bowel obstruction + peritonitis (two of the most acutely painful conditions out there) who probably had a long history of opioid use. The other condition mentioned (sacral plexus involvement) is also notoriously resistant to treatment.

As an aside, my experience is similar to @dchristismi in that patients with metastatic cervical cancer have some of the highest opioid needs I see.

This jives with what I see in acute scenarios. Locally invasive/metastatic peritoneal and post radiation abdominal/pelvic disease is incredibly painful and it typically requires opioid doses that fall outside of any pre-made template order sets.

 

[WilcoWorld]

"The duration of survival after extubation exceeded 24 hours in one third of patients"

 

[Robotic Wis-Hipple]

"The duration of survival after extubation exceeded 24 hours in one third of patients"

I know this states depth of coma did not correlate with length of survival….. but I would think neurologic injury patients would be expected to survive longer post palliative extubation than medical/surgical, oncologic, or traumatic critically ill/terminal patients would just by the organ systems involved and impact of metabolic derangements involved. I also think decision to withdraw or go towards palliative is more quickly or more easily decided in catastrophic neurologic injury vs cardio/pulmonary/abdominal/metabolic disease processes which would also lead to increased duration of “survival”.

But this is coming from a non-Intensivist who admits to not really knowing. That’s just my gestalt.

 

[WilcoWorld]

I know this states depth of coma did not correlate with length of survival….. but I would think neurologic injury patients would be expected to survive longer post palliative extubation than medical/surgical, oncologic, or traumatic critically ill/terminal patients would just by the organ systems involved and impact of metabolic derangements involved. I also think decision to withdraw or go towards palliative is more quickly or more easily decided in catastrophic neurologic injury vs cardio/pulmonary/abdominal/metabolic disease processes which would also lead to increased duration of “survival”.

But this is coming from a non-Intensivist who admits to not really knowing. That’s just my gestalt.

I don't disagree with your impression.

I was just trying to provide some support (beyond my own anecdotal experience) for the claim that patients do regularly survive compassionate extubation.

 

[Robotic Wis-Hipple]

I don't disagree with your impression.

I was just trying to provide some support (beyond my own anecdotal experience) for the claim that patients do regularly survive compassionate extubation.

I understood that intent.

My comment was purely meant to voice that as with the vast majority of medicine, generalization from one cohort to another is often fraught with error and despite myself having limited knowledge of critically ill cohorts I could see how neuro patients may be dissimilar to others in this focused instance.

 

[dpmd]

I don't disagree with your impression.

I was just trying to provide some support (beyond my own anecdotal experience) for the claim that patients do regularly survive compassionate extubation.

I think we need to define terms better. Are you calling it survival if they last more than a hour, a day, or longer even if they ultimately die from the disease process that resulted in the terminal extubation? I would only call it survival if they recovered from the disease process that led to terminal extubation so their cause of eventual death was unrelated.

 

[WilcoWorld]

I think we need to define terms better. Are you calling it survival if they last more than a hour, a day, or longer even if they ultimately die from the disease process that resulted in the terminal extubation? I would only call it survival if they recovered from the disease process that led to terminal extubation so their cause of eventual death was unrelated.

No, we're talking about different things.

 

[AlmostAnMD]

No questions from jury today. No deliberations tomorrow so done till Monday.

 

[Radetzky]

There is a lot of confusion in this thread about withdrawal of ventilation.

There are patients who you know will not breathe who you can without error say they will die fairly promptly after extubation.

There are patients where death is certain- whether it takes 2, 24 or 48 hours is irrelevant, they don’t survive the hospital stay and I’ve stopped trying to tell the family how long it might take, I just say honestly I don’t know.

There is a group where death is not certain but the tube and ventilator is no longer making a difference to their outcome- if they’re going to survive they’ll survive with the tube out and if not they won’t.

 

[GassYous]

For anyone that doesn't know, I do exclusively inpatient hospice. Most all my patients die, but then again, all of our patients die eventually, it's all just in the timing. Mine just tend to die sooner. My goal is that they don't suffer, but I don't influence the timing. (Seriously, that's up to the patient. I've seen way too many times people wait for the daughter from Michigan to show up, and 10 minutes later, they go. Happened again this afternoon, except the daughter seriously had just arrived from Missouri. He made it about an hour.) Anyway...

I cranked up a fentanyl drip yesterday to a 1000mcg/hr with a 500 mcg bolus.
(It was 300/200 that morning... but it wasn't working. Rapid titrating all day.) Aaaand she was awake, alert and still pretty miserable. The feculent vomiting and the new peritoneal signs probably heralding the end showed up mid afternoon. UG.

After a couple hours I threw in the towel and rotated to dilaudid + ketamine. And she was hitting the bolus herself before that. It finally worked. Cervical cancer is a bitch.

But that's another story for another day.
My personal record is a dilaudid infusion at 40 mg/hr with a 20 mg bolus q10 min (and she was using it a lot) plus ketamine at 30mg/hr plus lidocaine 200mg/hr plus some ativan around the clock and other crap. And she was walking around like that. Not walking well, granted, but walking. I think she perfed too, but definitely had sacral plexus involvement, and when you're only 36, well, it's tremendous what the body can tolerate. Another cervical cancer actually.

I routinely have "compassionate" extubations survive beyond the minutes or hours that the inpatient teams think they're going to live. Sometimes days. Occasionally longer. (Why did they get intubated in the first place? Just airway protection? Hypoxia? Hypercarbia? Sometimes these folks just keep chugging along.) Humans are truly amazing. The suffering they can endure is also amazing.

Also FWIW, I don't have a lot of kids, but you all know that chronic parents are in a different category, and yeah, they wait. Also, once patients get to be 95 or older, all bets are off. You make it that long, you're gonna live forever. I have a 99 year old on my service right now who may never die. He's cachectic as all get out, but by golly, we figure he's enjoying all this attention and that's why he's sticking around.

So basically what you're saying is that you've committed malpractice, murdered your terminally ill patients and need to be in front of a jury of your peers for using dosages that no one uses or can comprehend. Also we need to check your pyxis records.
-Birdstrike

P.S. What did you in college and do you work with your wife?

 

[neurodoc]

There is a group where death is not certain but the tube and ventilator is no longer making a difference to their outcome- if they’re going to survive they’ll survive with the tube out and if not they won’t.

When you throw a 1000 ot 2000mcg bolus of fentanyl into that scenario it's very hard to say whether or not or how long they would have survived after extubation if respiratory depressant doses of fentanyl had not been given. Again, this simply stated question is the crux of this entire case against Husel.

 

[neurodoc]

Another question asked by deliberating jury. They asked for the pyxis records. This, too, was denied.

So so far the jury has asked for 3 things, all of those requests have been denied by the court.

Makes me wonder if they will be a hung jury.

 

[Birdstrike]

So basically what you're saying is that you've committed malpractice, murdered your terminally ill patients and need to be in front of a jury of your peers for using dosages that no one uses or can comprehend. Also we need to check your pyxis records.
-Birdstrike

P.S. What did you in college and do you work with your wife?

I seriously doubt @dchristismi is a convicted pipe bomber, ran a car stereo theft ring, obstructed justice, and was caught planting evidence to frame someone. But if so, I'm sure such facts would be "so irrelevant" you'd still trust them with your ATM card, 401K password and your life. Either way,

1,000 mcg/hr = 17 mcg/min

Is 17 mcg/min the same as giving a 2,000 mcg bolus, over 1 minute?

17 mcg/min vs 2,000 mcg/min...

Same, right?

 

[Dred Pirate]

Makes me wonder if they will be a hung jury.

If I was a betting man, this would be my guess. If they allowed reckless homicide (or whatever a less charge was) - I think that would be more likely,

 

[turkeyjerky]

If I was a betting man, this would be my guess. If they allowed reckless homicide (or whatever a less charge was) - I think that would be more likely,

Maybe legally, they can’t really split hairs on this, since he was obviously acting intentionally.

 

[dchristismi]

I seriously doubt @dchristismi is a convicted pipe bomber, ran a car stereo theft ring, obstructed justice, and was caught planting evidence to frame someone. But if so, I'm sure such facts would be "so irrelevant" you'd still trust them with your ATM card, 401K password and your life. Either way,

1,000 mcg/hr = 17 mcg/min

Is 17 mcg/min the same as giving a 2,000 mcg bolus, over 1 minute?

17 mcg/min vs 2,000 mcg/min...

Same, right?

You left out the other part, where she was giving herself multiple 500 mcg boluses, on the order of several an hour. One of the problems was that the pump was taking a long time to get those boluses in. She died yesterday, but of her perforated bowel due to the cervical cancer and her malignant obstruction. She was still able to acknowledge her family, albeit minimally.

And no, I'm not a pipe bomber, but I did work with my husband (who does happen to be a nurse) many years ago, before he was my husband. Last I checked, he's not a pipe bomber either.

And if I had your 401K password, I'd probably try to talk you into move things into lower fee index funds. Because active management fees are stupid. But I'm not unilaterally rebalancing your portfolio, just like I'm not unilaterally withdrawing life support without a long talk about what everything means, what to expect, and what the person at the center of the story wants and needs.

 

[PTPoeny]

I think we need to define terms better. Are you calling it survival if they last more than a hour, a day, or longer even if they ultimately die from the disease process that resulted in the terminal extubation? I would only call it survival if they recovered from the disease process that led to terminal extubation so their cause of eventual death was unrelated.

I was thinking that "surviving" meant leaving the hospital or dying from something unrelated if they don't leave. If somebody dies 6 months or a year later even if it was from the original condition I would still call that surviving the extubation.

 

[TJRock]

Looks like the jury is at an impasse. Judge ordered them to continue deliberating.

 

[neurodoc]

Looks like the jury is at an impasse. Judge ordered them to continue deliberating.

Looks like a hung jury, likely due to the absence of manslaughter as a lesser included offense, something that still makes no sense to me and was basically a gift to the defense.

 

[AlmostAnMD]

I do wonder if the state would really try to retry this if they cannot come to a verdict

such an expensive waste of money, this whole ordeal

 

[WilcoWorld]

Looks like a hung jury, likely due to the absence of manslaughter as a lesser included offense, something that still makes no sense to me and was basically a gift to the defense.

With the definition of manslaughter being "the crime of killing a human being without malice aforethought, or otherwise in circumstances not amounting to murder" I wonder if the judge was trying to avoid setting a precedent of doctors getting convicted for their patient's death in the absence of "malice aforethought". Might have been the right call.

 

[Dred Pirate]

I do wonder if the state would really try to retry this if they cannot come to a verdict

such an expensive waste of money, this whole ordeal

if there is a hung jury- can they go back and charge with a lower charge? Or does the judge's ruling carry through for all future trials?

 

[To Infinity and Beyond]

Strangely enough, the jury asked what "reasonable doubt" was. After deliberating today, they called it quits for the day. It's looking more and more like a hung jury.