Husel Trial -- NOT GUILTY

[WilcoWorld]

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Hmm, interesting. Had no idea. Then again by the time I'm seeing kids they have IV access. I can't think of a single end of life patient I have had where hydrating them would be desirable, but mine tend to be more the mostly dead terminal extubations rather than the bad diagnosis killing them slowly version.

The main indication for hydration at end of life is if a patient develops opioid-related neurotoxicity, but you usually need IV access to get enough opioids for that, so...

 

[ToliBro]

A common morphine dosage is 2-4 mg IV q1hr at end of life, for air hunger.

For generic floor comfort care pt, sure, a good start.

For someone who's been in the ICU for a month receiving high doses of opiates...

 

[Birdstrike]

Do I think that in his heart of hearts he thought he was doing the right thing and relieving suffering? Yes
Do I think he knew the doses he was ordering were likely to hasten the patients' deaths? Yes

If he's found not guilty on all counts, I'd bet it's because the jury agrees with your reasoning, @WilcoWorld

I could see a jury deciding, "He shouldn't have done what he did, but we conclude it does not rise to the level necessary to justify a full blown murder charge. Perhaps if the prosecution had chosen a lesser charge, we could convict. However, since they didn't, we find him not guilty of the charges as they were filled."

 

[bravotwozero]

If he's found not guilty on all counts, I'd bet it's because the jury agrees with your reasoning, @WilcoWorld

I could see a jury deciding, "He shouldn't have done what he did, but we conclude it does not rise to the level necessary to justify a full blown murder charge. Perhaps if the prosecution had chosen a lesser charge, we could convict. However, since they didn't, we find him not guilty of the charges as they were filled."

I hope that ends up being the case. However, it does not look like he is getting a fair trial, given the fact that certain peoples testimony and documents are being prevented in court.

 

[WheezyBaby]

A common morphine dosage is 2-4 mg IV q1hr at end of life, for air hunger.

When I prescribe for end of life air hunger I dose no less frequently than q15 minutes

 

[dpmd]

Today ended early after more sidebar than testimony.

The mount carmel physician executive on the stand today testified he saw five different reports ran regarding doses of 500 mcg or higher given to patients outside of OR or "procedure areas." His carefully worded answer indicated only husel did these doses.

Then things really got out of hand. Apparently months later an additional report was run. That doc on the stand saw the report, so did the vpma from yesterday and both had testified with knowledge loosely around that report.

The problem is the report is privileged. I do not know why. Defense raised many objections about testimony being allowed from people viewing privileged material. This caused a work stoppage for the day that involved defense attorneys, prosecutors and the hospital attorneys (three sets of lawyers!).

There is a separate issue about external peer review. The cases were sent to external peer review but these were also mentioned and are privileged. I do not know their contents.

I suppose I can speculate because prosecutors want the peer reviews and whatever this other report is buried. Maybe its damaging to the prosecutors case?? An MD/JD can comment here but I dont know why else prosecutors and hospital attorneys would care otherwise.

I guess everyone has to go home and write essays to the judge about what should be privileged or not. They turn them in a 2p tomorrow for judge to review so no trial on Friday. Court will resume Monday with a decision.

Lots of lawyering today but no meaningful progress.


Also, I agree with whoever said husel should not testify. In ohio no murder suspect testifies. He is an anesthesia critical care doctor, not a lawyer. Prosecutors are out for blood and they will tear him up. Even if he answers every question flawlessly he would have so much mud slung at him by prosecutors it would still look bad to the jury. Would be very surprised if he testified, defense would only do this if they really saw a winning benefit.

Everything done in the context of peer review is typically privileged. When there is a worry about legal ramifications the hospital lawyer may sit in on the meeting to ensure it remains privileged. What I don't get is how the defense can't request another report to be run this time not covered by privilege. Same for the outside peer review. My understanding of the reason it is privileged is to protect those of us on the committee from getting in trouble for things we say during a discussion and to protect the person being reviewed. Maybe that is a naive incorrect understanding.

 

[coffeebythelake]

Everything done in the context of peer review is typically privileged. When there is a worry about legal ramifications the hospital lawyer may sit in on the meeting to ensure it remains privileged. What I don't get is how the defense can't request another report to be run this time not covered by privilege. Same for the outside peer review. My understanding of the reason it is privileged is to protect those of us on the committee from getting in trouble for things we say during a discussion and to protect the person being reviewed. Maybe that is a naive incorrect understanding.

Yeah I don't understand what is going on with this trial. So they have people who viewed a privileged document and testify to its contents, but they won't allow anyone access to said documents because it is privileged and confidential? That's bogus.

 

[dpmd]

Yeah I don't understand what is going on with this trial. So they have people who viewed a privileged document and testify to its contents, but they won't allow anyone access to said documents because it is privileged and confidential? That's bogus.

Yeah seems weird they could testify regarding privileged stuff. Seems even more weird that they are maybe misrepresenting some stuff (I get the impression that more doctors than husel ordered high doses but they are testifying a report was only showing him because the report was only run about him but they are trying to make it seem like it was run for all doctors)

 

[AlmostAnMD]

Yeah seems weird they could testify regarding privileged stuff. Seems even more weird that they are maybe misrepresenting some stuff (I get the impression that more doctors than husel ordered high doses but they are testifying a report was only showing him because the report was only run about him but they are trying to make it seem like it was run for all doctors)

That's the impression I'm being left with, but I can't confirm that. I don't know why prosecution is okay with the other five reports being public and on the record but this mystery 6th report is hush hush

The other possibility is that it's still all husel, but not all 500 mcg doses were fatal. The report was for doses for husel that were given around, I forget, like 400 minutes within death or something. It's possible the last report was just all doses regardless of time of death. That would yield results that were high but no one died.

We'll find out Monday!

 

[Southpaw]

That's the impression I'm being left with, but I can't confirm that. I don't know why prosecution is okay with the other five reports being public and on the record but this mystery 6th report is hush hush

The other possibility is that it's still all husel, but not all 500 mcg doses were fatal. The report was for doses for husel that were given around, I forget, like 400 minutes within death or something. It's possible the last report was just all doses regardless of time of death. That would yield results that were high but no one died.

We'll find out Monday!

I’m reading between the lines on this case a bit but I believe at least some of the cases were tossed (there were originally 35 patients) because his high doses didn’t immediately kill patients. They lived for days. This is important, at least to me, because he didn’t continue escalating in an attempt to assure they died on his shift. If I were the defense I’d work hard to reveal this if in fact it exists. If patients lived for days after his high ordered doses it goes to show his intent was comfort and not death.

 

[Southpaw]

Yeah I don't understand what is going on with this trial. So they have people who viewed a privileged document and testify to its contents, but they won't allow anyone access to said documents because it is privileged and confidential? That's bogus.

I’ve served on two separate peer review committees and it’s said often our words are protected from legal action. I’m personally comforted by this for reasons I don’t want to get into.

What’s bogus to me here, and I mean it’s reallllyyyy bogus, is that the hospital appears to have cut all these side deals with former employees to not testify for the defense. The hospital has also already paid out $20 mill to the families. The hospital appears to really have it out for Dr Husel for unclear reasons, and I can’t help but root for him even if I wouldn’t have practiced similarly to him.

 

[AlmostAnMD]

he hospital appears to really have it out for Dr Husel for unclear reasons, and I can’t help but root for him even if I wouldn’t have practiced similarly to him.

It's not unclear at all

It's liability

that much is certain.

If he indeed gave large doses but those are not being allowed in court if they didn't kill patients that would absolutely shatter my faith in the justice system....if true I'm hoping his attorneys can pull it out somehow into the light.

 

[Robotic Wis-Hipple]

That's the impression I'm being left with, but I can't confirm that. I don't know why prosecution is okay with the other five reports being public and on the record but this mystery 6th report is hush hush

The other possibility is that it's still all husel, but not all 500 mcg doses were fatal. The report was for doses for husel that were given around, I forget, like 400 minutes within death or something. It's possible the last report was just all doses regardless of time of death. That would yield results that were high but no one died.

We'll find out Monday!

Fentanyl given that did not result in death in <10min is not a fatal dose. Gtfo of here with large doses within 400 minutes of death.

If Husel was giving 500+ mcgs as boluses q15min, q30min, or q1hr and patients lived for 6hrs that tells me that they had been on crazy doses for maintenance pain/sedation. Maybe that was his original flaw, going far higher on his fentanyl sedation regimen than is standard which then necessitated much higher bolus dosing for therapeutic effect.

But if that’s the case certainly other intensivists were rounding on these same patients on >250mcg/hr of fentanyl as if it was local hospital culture without saying anything. Then, those other docs were terminally extubating patients and subsequently underdosing for the level of tolerance they had created.

Any way you slice it to me, there was a culture of providing higher dose opioid in that hospital than is “standard” in the palliative/comfort care arena. Why then is Husel the only one getting the book thrown at him? Because once it came time to let these people die he provided comfort? While others provided standard comfort care to non-standard drug induced tolerant patients?

 

[Birdstrike]

2.000 mcg Fentanyl

Dead 5 minutes later

(Allegedly)

https://fcdcfcjs.co.franklin.oh.us/CaseInformationOnline/imageLinkProcessor.pdf?coords=KCeogr2sR6nXhhTBnywVG%2BcTnwfwY6lnRzkTaWe2WJk0eKskuq%2FalbCE5cJpsGs2lAAo8%2BTaj5SwoLkRTDyRjDr2NI0cPu17DTaG08NqdjgtUZteOnbRCSIzmelG7NzQqMHb3I4aqilEmQO9002KB3cXgwKv0%2BI2wgYJCV3btJU%3D

 

[Birdstrike]

"On November 20, Penix sat up in her bed and complained of stomach pain, according to attorneys. A few hours later, Leeseberg said Husel told the family Penix was brain dead shortly after 9 p.m. The family was encouraged to remove care, to which they consented.

Leeseberg said Penix was given a 2,000 mcg dose of fentanyl at 10:48 p.m. and was pronounced dead five minutes later."

What brain death protocol was used to determine brain death?

If the patients brain was dead, how were they able to feel pain?

If they weren't able to feel pain why did they need fentanyl? If they were in pain, how can you say they were brain dead?

(Allegedly)

Attorney: Husel gave patient 2,000 mcg dose of fentanyl before being removed from hospital

An attorney representing the family of a woman who died at Mt. Carmel West Hospital in November of 2018 is planning to file a wrongful death lawsuit Thursday.

tinyurl.com

 

[Robotic Wis-Hipple]

2.000 mcg Fentanyl

Dead 5 minutes later

(Allegedly)

View attachment 351356View attachment 351356

https://fcdcfcjs.co.franklin.oh.us/CaseInformationOnline/imageLinkProcessor.pdf?coords=KCeogr2sR6nXhhTBnywVG%2BcTnwfwY6lnRzkTaWe2WJk0eKskuq%2FalbCE5cJpsGs2lAAo8%2BTaj5SwoLkRTDyRjDr2NI0cPu17DTaG08NqdjgtUZteOnbRCSIzmelG7NzQqMHb3I4aqilEmQO9002KB3cXgwKv0%2BI2wgYJCV3btJU%3D

Oof. Yeah, so that’s a fatal dose if 2000mcgs was given and TOD declared 5min later.

The sitting up in pain, brain dead or not brain dead, subjective he said, she said part is immaterial.

If they can show brain death exams or brain dead status was rushed or not performed per standard they actually will get murder.

 

[Birdstrike]

If they can show brain death exams or brain dead status was rushed or not performed per standard they actually will get murder.

You're correct, in that if "brain death" was no determined properly, that creates questions. Was 'brain death' prematurely declared to coax families into choosing DNR status and to withdrawal support?

And if so, why were patients who were legally dead, and physiological brain dead with no brain function, no ability to feel pain or suffer, given any fentanyl, let alone 20 times the standard dose?

 

[dpmd]

"On November 20, Penix sat up in her bed and complained of stomach pain, according to attorneys. A few hours later, Leeseberg said Husel told the family Penix was brain dead shortly after 9 p.m. The family was encouraged to remove care, to which they consented.

Leeseberg said Penix was given a 2,000 mcg dose of fentanyl at 10:48 p.m. and was pronounced dead five minutes later."

What brain death protocol was used to determine brain death?

If the patients brain was dead, how were they able to feel pain?

If they weren't able to feel pain why did they need fentanyl? If they were in pain, how can you say they were brain dead?

(Allegedly)

Attorney: Husel gave patient 2,000 mcg dose of fentanyl before being removed from hospital

An attorney representing the family of a woman who died at Mt. Carmel West Hospital in November of 2018 is planning to file a wrongful death lawsuit Thursday.

tinyurl.com

Where is it documented that the families were ever told the patient was brain dead? The fact death was not pronounced until after the extubation and after cardiopulmonary arrest lets us know the patient was not considered brain dead. Also she was intubated on Nov 19 so how did she sit up and complain about anything?

 

[Birdstrike]

Where is it documented that the families were ever told the patient was brain dead?

Read my post and the provided link. I didn't author that quote. It's a direct quote from the linked legal document.

 

[Birdstrike]

Oof. Yeah, so that’s a fatal dose if 2000mcgs was given and TOD declared 5min later.

The sitting up in pain, brain dead or not brain dead, subjective he said, she said part is immaterial.

If they can show brain death exams or brain dead status was rushed or not performed per standard they actually will get murder.

Ohio Brain Death Protocol

Was apnea testing done in the absence of paralytics or sedatives?

Was an EEG, cerebral angiogram or nuclear scan done?

 

[Birdstrike]

In my experience, the vast majority of times someone uses the term "brain dead," what they really mean is "severely brain damaged." They either don't know (or have forgotten) brain dead patients don't have any brain activity at all. They don't breathe (their brain stem is dead). They aren't merely 'comatose,' partially conscious or in and out of consciousness, which involves decreased brain function. They have no brain function at all.

Brain dead patient's don't have pain. They don't need pain medicine. And your patient needs fentanyl and benzos for "comfort," then don't tell the family they're brain dead. "Brain death" has a specific legal meaning. Brain death = legal death. It doesn't mean 'almost dead' or 'partially dead.' Legally it means: dead.

 

[Dred Pirate]

Brain death = legal death. It doesn't mean 'almost dead' or 'partially dead.' Legally it means: dead.

I am the only one imagining Miracle Max saying this?

 

[Jabbed]

In my experience, the vast majority of times someone uses the term "brain dead," what they really mean is "severely brain damaged." They either don't know (or have forgotten) brain dead patients don't have any brain activity at all. They don't breathe (their brain stem is dead). They aren't merely 'comatose,' partially conscious or in and out of consciousness, which involves decreased brain function. They have no brain function at all.

Brain dead patient's don't have pain. They don't need pain medicine. And your patient needs fentanyl and benzos for "comfort," then don't tell the family they're brain dead. "Brain death" has a specific legal meaning. Brain death = legal death. It doesn't mean 'almost dead' or 'partially dead.' Legally it means: dead.

I doubt that they documented brain death. You don’t withdraw care or terminally extubate brain dead patients. You also can’t murder a brain dead patient because they’re already dead. I very much doubt that any intensivist would get this wrong.

This is a journalistic error. I wouldn’t tie yourself into knots trying to draw inferences from it.

 

[dpmd]

Read my post and the provided link. I didn't author that quote. It's a direct quote from the linked legal document.

That is a quote of what the family member says they were told. Not what they were actually told or what was documented by any of the people caring for the lady.

 

[dpmd]

In my experience, the vast majority of times someone uses the term "brain dead," what they really mean is "severely brain damaged." They either don't know (or have forgotten) brain dead patients don't have any brain activity at all. They don't breathe (their brain stem is dead). They aren't merely 'comatose,' partially conscious or in and out of consciousness, which involves decreased brain function. They have no brain function at all.

Brain dead patient's don't have pain. They don't need pain medicine. And your patient needs fentanyl and benzos for "comfort," then don't tell the family they're brain dead. "Brain death" has a specific legal meaning. Brain death = legal death. It doesn't mean 'almost dead' or 'partially dead.' Legally it means: dead.

I have seen lay people confuse the two. Haven't really seen or heard medical people confuse the two. I think it is vastly more likely the family is misremembering what they were told than Dr Husel either lying or mistakenly referring to the patient as brain dead, particularly because of the next steps taken. Brain dead people don't get comfort care. They get declared dead and then they are extubated without any meds being given. Time of death is recorded as the time they are declared brain dead, not however long later their heart stops (because sometimes you leave them on the vent while out of town family gathers, or sometimes they are donors and the organ recovery takes place days later, but they are considered already dead in the interim).

 

[Birdstrike]

That is a quote of what the family member says they were told. Not what they were actually told or what was documented by any of the people caring for the lady.

Family members can be called to testify to that fact. Since this term is already finding its way into plaintiff's written allegations, they almost certainly will. As testimony, it then it becomes evidence presented to the jury like any other witness testimony.

 

[Birdstrike]

I doubt that they documented brain death. You don’t withdraw care or terminally extubate brain dead patients. You also can’t murder a brain dead patient because they’re already dead. I very much doubt that any intensivist would get this wrong.

This is a journalistic error. I wouldn’t tie yourself into knots trying to draw inferences from it.

I also doubt it was documented. But I wouldn't be surprised to hear that the term was used as a means to persuade a family to withdrawal of support. But I'm just speculating based on that news report. There are weeks of testimony left.

 

[wholeheartedly]

It does seem like it was intentional.

But I am also definitely very uncomfortable with the hospital’s behavior and side deals and stuff.

I served on various event mgmt and root cause analysis groups at various hospitals. I was taught the whole reason those discussions and related documents were exempt from discovery is because it allows and encourages hospitals to investigate bad outcomes, near misses, etc. and determine solutions to address issues and take steps to prevent them from happening again. If it’s available for discovery there would be a huge disincentive for hospitals have open, honest discussions to address issues for fear of liability. I agree that’s very important, but not sure how I feel about it in a criminal proceeding.

 

[WilcoWorld]

Brain dead people don't get comfort care. They get declared dead and then they are extubated without any meds being given.

Not in my hospital. Families of brain dead patients don't get a choice of whether or not to keep the body alive, but we certainly provide comfort care to that body as we allow it to die. Sometimes they live longer than we expected, and I often get pressured to "just make it happen".

 

[WilcoWorld]

It does seem like it was intentional.

But I am also definitely very uncomfortable with the hospital’s behavior and side deals and stuff.

I served on various event mgmt and root cause analysis groups at various hospitals. I was taught the whole reason those discussions and related documents were exempt from discovery is because it allows and encourages hospitals to investigate bad outcomes, near misses, etc. and determine solutions to address issues and take steps to prevent them from happening again. If it’s available for discovery there would be a huge disincentive for hospitals have open, honest discussions to address issues for fear of liability. I agree that’s very important, but not sure how I feel about it in a criminal proceeding.

I suspect this is an important distinction. M&M's, etc are protected from CIVIL discovery...probably not CRIMINAL discovery.

 

[dpmd]

Not in my hospital. Families of brain dead patients don't get a choice of whether or not to keep the body alive, but we certainly provide comfort care to that body as we allow it to die. Sometimes they live longer than we expected, and I often get pressured to "just make it happen".

We wouldn't keep keep alive long or even every time but occasionally if the family in question was arriving that night or something we might. But what sort of comfort care are you talking about and how much longer are they living, because now I am wondering about how good your brain death protocols are?

 

[WheezyBaby]

Not in my hospital. Families of brain dead patients don't get a choice of whether or not to keep the body alive, but we certainly provide comfort care to that body as we allow it to die. Sometimes they live longer than we expected, and I often get pressured to "just make it happen".

We wouldn't keep keep alive long or even every time but occasionally if the family in question was arriving that night or something we might. But what sort of comfort care are you talking about and how much longer are they living, because now I am wondering about how good your brain death protocols are?

Have never given meds after a brain death termination of support. Longest I've had a brain death last after extubation was 15 minutes-ish. Curious what "symptoms" are present or treatable in the setting of brain death. If the family has concerns about symptoms they should get a better explanation of what brain death constitutes

 

[WilcoWorld]

Comfort care involves more than opioids.

Airway positioning so the family doesn't hear them gurgle as the patient dies would be one thing...

 

[dpmd]

Comfort care involves more than opioids.

Airway positioning so the family doesn't hear them gurgle as the patient dies would be one thing...

Dead people don't gurgle

 

[harrismeyer]

For generic floor comfort care pt, sure, a good start.

For someone who's been in the ICU for a month receiving high doses of opiates...

I've read a number of the comments on the Husel trial, and frankly I'm surprised at the inaccuracies and misinformation in many of them. Please read my recent Medscape article on the Husel matter and the patient safety issues at Mount Carmel that it raised. There is clear evidence that Husel was the only physician outside the ED prescribing these large doses on Fentanyl, in one large dose. It's clear that his dosing practices for palliative withdrawal were far outside standard medical practice. Most of his patients who died had no evidence of opioid tolerance (and actually there were 35, not just the 14 cited in the murder charges). It's clear that his patients died within minutes of being administered these doses of Fentanyl combined with other opioids. Under Ohio state law, peer review records are only deemed confidential in civil actions, not in criminal actions, so it's legally questionable why it's not permissible for the medical witnesses to testify about the Mount Carmel investigative findings that Husel was the only doctor on staff outside the ED who ordered these large Fentanyl doses. That's a key piece of information for the jury to consider. There's no evidence that many of these patients were feeling pain. There are questions about whether some of these patients might have survived palliative extubation if they hadn't been administered these large Fentanyl and other opioid doses. If some of the commenters believe involuntary euthanasia should be legalized, they should say so explicitly. But euthanasia is illegal in the United States.

EDIT: link removed due to uncertain financial interests - @southerndoc

 

[harrismeyer]

If he's found not guilty on all counts, I'd bet it's because the jury agrees with your reasoning, @WilcoWorld

I could see a jury deciding, "He shouldn't have done what he did, but we conclude it does not rise to the level necessary to justify a full blown murder charge. Perhaps if the prosecution had chosen a lesser charge, we could convict. However, since they didn't, we find him not guilty of the charges as they were filled."

The judge allowed the prosecution's request for lesser included charges, so the jury could convict on those.

 

[harrismeyer]

Everything done in the context of peer review is typically privileged. When there is a worry about legal ramifications the hospital lawyer may sit in on the meeting to ensure it remains privileged. What I don't get is how the defense can't request another report to be run this time not covered by privilege. Same for the outside peer review. My understanding of the reason it is privileged is to protect those of us on the committee from getting in trouble for things we say during a discussion and to protect the person being reviewed. Maybe that is a naive incorrect understanding.

Ohio state law only requires confidentialityprivilege for peer review reports in civil actions, not in criminal actions. Here's the text of the law, and I've confirmed this with both plaintiff and defense-side med mal lawyers in Ohio.

Laws, Acts, and Legislation

archives.legislature.state.oh.us

 

[Birdstrike]

The judge allowed the prosecution's request for lesser included charges, so the jury could convict on those.

You're right. I hadn't caught that. Reckless homicide may be considered. The defense didn't want to allow that ("murder or nothing"). Interesting.

Judge: Prosecutors can present evidence of lesser offenses in Husel murder trial

Potential jurors were brought in Wednesday for the William Husel murder trial. Wednesday morning, 131 people were brought in, according to Judge Michael Holbrook. They have narrowed this group to a panel of 73 that will be part of voir dire on February 14th. There will be 18 people in the box at...

abc6onyourside.com

 

[WilcoWorld]

Dead people don't gurgle

This is not a helpful addition to the discussion. I don't think Husel is on trial for injecting fentanyl into corpses.

 

[southerndoc]

You're right. I hadn't caught that. Reckless homicide may be considered. The defense didn't want to allow that ("murder or nothing"). Interesting.

Judge: Prosecutors can present evidence of lesser offenses in Husel murder trial

Potential jurors were brought in Wednesday for the William Husel murder trial. Wednesday morning, 131 people were brought in, according to Judge Michael Holbrook. They have narrowed this group to a panel of 73 that will be part of voir dire on February 14th. There will be 18 people in the box at...

abc6onyourside.com

Remember, to the DA, this is a game. A conviction is a win for the DA, and that goes on their record for re-election. The bigger the conviction, the better it looks for them. Seriously, that's why innocent people end up in prison sometimes -- because the prosecutors don't want to consider evidence against their case. They will consider offering a plea or lesser charges when it looks to them like they are going to lose the murder case.

 

[Robotic Wis-Hipple]

I've read a number of the comments on the Husel trial, and frankly I'm surprised at the inaccuracies and misinformation in many of them. Please read my recent Medscape article on the Husel matter and the patient safety issues at Mount Carmel that it raised. There is clear evidence that Husel was the only physician outside the ED prescribing these large doses on Fentanyl, in one large dose. It's clear that his dosing practices for palliative withdrawal were far outside standard medical practice. Most of his patients who died had no evidence of opioid tolerance (and actually there were 35, not just the 14 cited in the murder charges). It's clear that his patients died within minutes of being administered these doses of Fentanyl combined with other opioids. Under Ohio state law, peer review records are only deemed confidential in civil actions, not in criminal actions, so it's legally questionable why it's not permissible for the medical witnesses to testify about the Mount Carmel investigative findings that Husel was the only doctor on staff outside the ED who ordered these large Fentanyl doses. That's a key piece of information for the jury to consider. There's no evidence that many of these patients were feeling pain. There are questions about whether some of these patients might have survived palliative extubation if they hadn't been administered these large Fentanyl and other opioid doses. If some of the commenters believe involuntary euthanasia should be legalized, they should say so explicitly. But euthanasia is illegal in the United States.

EDIT: link removed due to uncertain financial interests - @southerndoc

Speaking for myself, (though I presume many others here);
We tend not to pay too close attention to the typical article for public consumption written by journalists as they more often than not are full of attention grabbing quotes and viewpoints from lawyers, hospital officials, and laymen but light on clinically accurate information or context. In short, we are often surprised by the inaccuracies in the reporting.

Your article is better than most however. But let’s take this passage;

“Mollette, who had diabetes, previously had been hospitalized for treatment of a gangrenous foot. When he arrived in the ICU, he was suffering from acute renal failure and low blood pressure, and had had two heart stoppages, according to a 2020 Ohio Board of Pharmacy report. He was placed under the care of William Husel, DO, the sole physician on duty in the ICU during the overnight shift.

Around 9 PM, Husel discussed Mollette’s “grim prognosis” with family members at the patient’s bedside. He advised them that Mollette had “minutes to live” and asked, “How would you want him to take his last breath: on the ventilator or without these machines?”

In less than an hour, Mollette was dead. Some said that what happened in his case was similar to what happened with 34 other ICU patients at Mount Carmel West and Mount Carmel St. Ann’s in Westerville, Ohio, from 2014 through 2018 — all under Husel’s care.”

So this is a pt who came in presumably in septic shock complicated by two cardiac arrests. Presumably he was on pressor(s) for blood pressure support and likely had profound metabolic disturbances. But we don’t know much else about his pre-existing history other than he was diabetic. These things matter and provide context.

Now, I’m absolutely not saying that just from reading the information you provide that my decision would be to make this patient comfort care and terminally extubate shortly upon arrival to the ICU. Many many patients nationwide arrive to the ICU in septic shock on multiple pressors and though hospital mortality is high in these patients it’s certainly not standard to consider them a lost cause the night of arrival.



But then as you proceed in the story an abbreviated conversation is had with family at 9pm (when did the patient arrive to the ICU?), and then “in less than an hour” the patient was dead. Again context matters. Was the fentanyl given, pt extubated, then died an hour later? Or did it take 50minutes to get the fentanyl and ready the family at which point the pt was given fentanyl, extubated, never took another breath, and arrested 3-5minutes later? Context.


With all of that said, if even most of what you report is accurate, he was not only practicing widely outside of standard of care, he was doing much worse. If they have even one instance where 500+ mcgs of fentanyl was given and the patient time of death was called inside of 10min of that dose, he euthanized a pt. Especially if some of these patients hadn’t received any pain medication during that hospitalization. If he was regularly having rushed goals of care discussions with families literally an hour upon arrival to the ICU and making patients comfort care/terminally extubating patients his first night meeting them, this is a gross deviation from expected compassionate communication. If he was regularly giving verbal orders for high dose fentanyl to avoid or bypass pharmacy oversight, again that’s a deviation that speaks to a recognition that he was doing something he knew would be questioned.



I think many of us come into these things with biases secondary to previously read sensationalized reporting aimed at laymen compounded by the desire to believe a colleague had clinical reasons to do what they are charged with. I still hope this is the case, but again, if it’s as you have reported, without significant clinical context missing, he is guilty of hastening death at the least.



P.S. I still maintain, that my fear in this is hospital enforced limits on comfort care medications, which you report the hospital did reduce to 25-50mcg of fentanyl at a time, and the resulting under dosing of susceptible patients in their final moments. Which is a tragedy.

 

[dpmd]

This is not a helpful addition to the discussion. I don't think Husel is on trial for injecting fentanyl into corpses.

I'm not the one who brought up comfort care for brain dead people.

 

[harrismeyer]

I've read a number of the comments on the Husel trial, and frankly I'm surprised at the inaccuracies and misinformation in many of them. Please read my recent Medscape article on the Husel matter and the patient safety issues at Mount Carmel that it raised. There is clear evidence that Husel was the only physician outside the ED prescribing these large doses on Fentanyl, in one large dose. It's clear that his dosing practices for palliative withdrawal were far outside standard medical practice. Most of his patients who died had no evidence of opioid tolerance (and actually there were 35, not just the 14 cited in the murder charges). It's clear that his patients died within minutes of being administered these doses of Fentanyl combined with other opioids. Under Ohio state law, peer review records are only deemed confidential in civil actions, not in criminal actions, so it's legally questionable why it's not permissible for the medical witnesses to testify about the Mount Carmel investigative findings that Husel was the only doctor on staff outside the ED who ordered these large Fentanyl doses. That's a key piece of information for the jury to consider. There's no evidence that many of these patients were feeling pain. There are questions about whether some of these patients might have survived palliative extubation if they hadn't been administered these large Fentanyl and other opioid doses. If some of the commenters believe involuntary euthanasia should be legalized, they should say so explicitly. But euthanasia is illegal in the United States.


Speaking for myself, (though I presume many others here);
We tend not to pay too close attention to the typical article for public consumption written by journalists as they more often than not are full of attention grabbing quotes and viewpoints from lawyers, hospital officials, and laymen but light on clinically accurate information or context. In short, we are often surprised by the inaccuracies in the reporting.

Your article is better than most however. But let’s take this passage;

“Mollette, who had diabetes, previously had been hospitalized for treatment of a gangrenous foot. When he arrived in the ICU, he was suffering from acute renal failure and low blood pressure, and had had two heart stoppages, according to a 2020 Ohio Board of Pharmacy report. He was placed under the care of William Husel, DO, the sole physician on duty in the ICU during the overnight shift.

Around 9 PM, Husel discussed Mollette’s “grim prognosis” with family members at the patient’s bedside. He advised them that Mollette had “minutes to live” and asked, “How would you want him to take his last breath: on the ventilator or without these machines?”

In less than an hour, Mollette was dead. Some said that what happened in his case was similar to what happened with 34 other ICU patients at Mount Carmel West and Mount Carmel St. Ann’s in Westerville, Ohio, from 2014 through 2018 — all under Husel’s care.”

So this is a pt who came in presumably in septic shock complicated by two cardiac arrests. Presumably he was on pressor(s) for blood pressure support and likely had profound metabolic disturbances. But we don’t know much else about his pre-existing history other than he was diabetic. These things matter and provide context.

Now, I’m absolutely not saying that just from reading the information you provide that my decision would be to make this patient comfort care and terminally extubate shortly upon arrival to the ICU. Many many patients nationwide arrive to the ICU in septic shock on multiple pressors and though hospital mortality is high in these patients it’s certainly not standard to consider them a lost cause the night of arrival.



But then as you proceed in the story an abbreviated conversation is had with family at 9pm (when did the patient arrive to the ICU?), and then “in less than an hour” the patient was dead. Again context matters. Was the fentanyl given, pt extubated, then died an hour later? Or did it take 50minutes to get the fentanyl and ready the family at which point the pt was given fentanyl, extubated, never took another breath, and arrested 3-5minutes later? Context.


With all of that said, if even most of what you report is accurate, he was not only practicing widely outside of standard of care, he was doing much worse. If they have even one instance where 500+ mcgs of fentanyl was given and the patient time of death was called inside of 10min of that dose, he euthanized a pt. Especially if some of these patients hadn’t received any pain medication during that hospitalization. If he was regularly having rushed goals of care discussions with families literally an hour upon arrival to the ICU and making patients comfort care/terminally extubating patients his first night meeting them, this is a gross deviation from expected compassionate communication. If he was regularly giving verbal orders for high dose fentanyl to avoid or bypass pharmacy oversight, again that’s a deviation that speaks to a recognition that he was doing something he knew would be questioned.



I think many of us come into these things with biases secondary to previously read sensationalized reporting aimed at laymen compounded by the desire to believe a colleague had clinical reasons to do what they are charged with. I still hope this is the case, but again, if it’s as you have reported, without significant clinical context missing, he is guilty of hastening death at the least.



P.S. I still maintain, that my fear in this is hospital enforced limits on comfort care medications, which you report the hospital did reduce to 25-50mcg of fentanyl at a time, and the resulting under dosing of susceptible patients in their final moments. Which is a tragedy.

Thanks for that good discussion. Having read the the Board of Pharmacy and Board of Nursing reports on several of these cases, I can say that all those things you discussed are exactly what happened. Mollette died within an hour of Husel's discussion with the family at 9 p.m., according to the record. Many of the patients died within half an hour of being administered 500 to 2,000 micrograms of Fentanyl plus other opioids and being extubated, some within a few minutes. Some or many of them had not received prior pain medication. In many or most of these cases, he gave verbal orders for the Fentanyl and other opioids and the medications were administered via Pyxis override, without prior approval of the pharmacist. These are not disputed facts though Husel's defense attorneys are trying to obscure them or prevent them from being entered into evidence. They have particularly sought to block testimony that Husel was the only staff doctor outside the ED ordering those huge doses of Fentanyl. In fact, the other Mount Carmel ICU doctors generally did not even use Fentanyl for palliative extubations. They generally used much smaller doses of other opioids, as Dr. Moody testified.

 

[harrismeyer]

I've read a number of the comments on the Husel trial, and frankly I'm surprised at the inaccuracies and misinformation in many of them. Please read my recent Medscape article on the Husel matter and the patient safety issues at Mount Carmel that it raised. There is clear evidence that Husel was the only physician outside the ED prescribing these large doses on Fentanyl, in one large dose. It's clear that his dosing practices for palliative withdrawal were far outside standard medical practice. Most of his patients who died had no evidence of opioid tolerance (and actually there were 35, not just the 14 cited in the murder charges). It's clear that his patients died within minutes of being administered these doses of Fentanyl combined with other opioids. Under Ohio state law, peer review records are only deemed confidential in civil actions, not in criminal actions, so it's legally questionable why it's not permissible for the medical witnesses to testify about the Mount Carmel investigative findings that Husel was the only doctor on staff outside the ED who ordered these large Fentanyl doses. That's a key piece of information for the jury to consider. There's no evidence that many of these patients were feeling pain. There are questions about whether some of these patients might have survived palliative extubation if they hadn't been administered these large Fentanyl and other opioid doses. If some of the commenters believe involuntary euthanasia should be legalized, they should say so explicitly. But euthanasia is illegal in the United States.

EDIT: link removed due to uncertain financial interests - @southerndoc

I am a journalist and get paid by publications like Medscape and Kaiser Health News and Health Affairs for my articles. That's a full disclosure of my financial interests.

 

[WilcoWorld]

I have seen lay people confuse the two. Haven't really seen or heard medical people confuse the two. I think it is vastly more likely the family is misremembering what they were told than Dr Husel either lying or mistakenly referring to the patient as brain dead, particularly because of the next steps taken. Brain dead people don't get comfort care. They get declared dead and then they are extubated without any meds being given. Time of death is recorded as the time they are declared brain dead, not however long later their heart stops (because sometimes you leave them on the vent while out of town family gathers, or sometimes they are donors and the organ recovery takes place days later, but they are considered already dead in the interim).

I'm not the one who brought up comfort care for brain dead people.

Actually, I think you did.

 

[harrismeyer]

It does seem like it was intentional.

But I am also definitely very uncomfortable with the hospital’s behavior and side deals and stuff.

I served on various event mgmt and root cause analysis groups at various hospitals. I was taught the whole reason those discussions and related documents were exempt from discovery is because it allows and encourages hospitals to investigate bad outcomes, near misses, etc. and determine solutions to address issues and take steps to prevent them from happening again. If it’s available for discovery there would be a huge disincentive for hospitals have open, honest discussions to address issues for fear of liability. I agree that’s very important, but not sure how I feel about it in a criminal proceeding.

As I noted yesterday, Ohio law grants privilege to peer review materials only for civil actions, not for criminal actions.

Laws, Acts, and Legislation

archives.legislature.state.oh.us

 

[ToliBro]

If some of the commenters believe involuntary euthanasia should be legalized, they should say so explicitly. But euthanasia is illegal in the United States.

I am not certain why you quoted me. I would not at all be comfortable administering very large bolus doses (>100mcg fent or equivalent). Sequential dosing and continuous drip adding up to a very large dose, sure, I can point to my assessments via RDOS or whatnot to demonstrate the need for that dose. Otherwise... no. Routine override of very large bolus dose verbal orders? Absolutely not.

 

[Southpaw]

Thanks for that good discussion. Having read the the Board of Pharmacy and Board of Nursing reports on several of these cases, I can say that all those things you discussed are exactly what happened. Mollette died within an hour of Husel's discussion with the family at 9 p.m., according to the record. Many of the patients died within half an hour of being administered 500 to 2,000 micrograms of Fentanyl plus other opioids and being extubated, some within a few minutes. Some or many of them had not received prior pain medication. In many or most of these cases, he gave verbal orders for the Fentanyl and other opioids and the medications were administered via Pyxis override, without prior approval of the pharmacist. These are not disputed facts though Husel's defense attorneys are trying to obscure them or prevent them from being entered into evidence. They have particularly sought to block testimony that Husel was the only staff doctor outside the ED ordering those huge doses of Fentanyl. In fact, the other Mount Carmel ICU doctors generally did not even use Fentanyl for palliative extubations. They generally used much smaller doses of other opioids, as Dr. Moody testified.

The doses were large. I assure you there were anesthesiologists then, and now, using doses that large in the OR.

I don’t dispute anything you’ve written. However the reality is those 14 patients were, at any point in time, the sickest people in the hospital and kept alive only by tubes and pressors. Remove those things and they were dead - fentanyl or not. And in my opinion they’d be dead fast. And I promise you, if I’m ever as sick as any of those patients, let me die and let it happen ASAP.

 

[southerndoc]

I am a journalist and get paid by publications like Medscape and Kaiser Health News and Health Affairs for my articles. That's a full disclosure of my financial interests.

SDN Terms of Service does not allow self-promotion without prior authorization.

 

[harrismeyer]

I’ve served on two separate peer review committees and it’s said often our words are protected from legal action. I’m personally comforted by this for reasons I don’t want to get into.

What’s bogus to me here, and I mean it’s reallllyyyy bogus, is that the hospital appears to have cut all these side deals with former employees to not testify for the defense. The hospital has also already paid out $20 mill to the families. The hospital appears to really have it out for Dr Husel for unclear reasons, and I can’t help but root for him even if I wouldn’t have practiced similarly to him.

One of the defense's big problems is they can't find any credible medical experts to testify that they believe it's acceptable medical practice to order those huge one-shot doses of Fentanyl and that they themselves have done that in their practices. In contrast, there are countless medical experts, like Dr. Ely, who are available to testify that they've never heard of such doses used for palliative extubations. I quoted two in my Medscape story.