In this addiction treatment case, an Anesthesiology expert evaluates the treatment received by plaintiff at the hands of the defendant, who was responsible for prescribing medication for the plaintiff. The defendant was 47 years old and had been receiving prescriptions from her physician, for several years to manage her ongoing pain. Instead of trying to locate the source of the pain, the defendant instead prescribed as many as 20 different medications to decedent. The defendant also wrote prescriptions under other patients’ names to give to the decedent. The decedent later died of acute combined drug toxicity of nine drugs. Her family sued the doctor in Pennsylvania Court of Common Pleas for negligence.
Question(s) For Expert Witness
- 1. Was the defendant doctor’s conduct within the standard of care?
- 2. How did the patient die?
- 3. Was the doctor responsible?
Expert Witness Response
Defendant’s prescribing behavior was inappropriate. It is a matter-of-fact that the decedent would have not had access to the types and quantities of drugs that she took leading to her demise without the direct action of the defendant prescribing controlled substances for her in a manner that was not in accordance with treatment principles accepted by any responsible segment of the medical profession. Specifically, the chronic use of Hydrocodone elixir, the combination of multiple short-acting opioid analgesics (Hydrocodone, Oxycodone and Hydromorphone) and the concurrent prescription of multiple central nervous system depressant drugs in the setting where no clear therapeutic benefit was ever established are indicative of the abandonment of such treatment principles.
When asked to sign decedent’s death certificate, defendant responded that he thought the patient may have been suicidal and he was thus uncomfortable signing the death certificate. This response revealed something of his state of mind. If defendant thought decedent was potentially suicidal, he gave no inkling of it in his prescribing behavior. Indeed, the number and type of drugs that were prescribed was well in excess of what would have been necessary for her to have committed suicide. His prescribing behavior showed that he had little concern about the possibility of suicidal ideation prior to her death.
The clinical understanding of how decedent addictively used these medications, as well as the clinical toxicities of the drugs, is necessary in grappling with the overall mechanism of her death. Of the plethora of drugs that were present in her system at the time of her death, only Phentermine was at a “toxic” level. Several aspects of this measurement must be noted, First, all “toxic levels” are determined individually. That is to say that the serum level of any drug is deemed toxic by itself, not in the presence of nine (9) other drugs. Second, the way in which addicts use drugs is in an attempt to “balance” the high, resulting in even greater toxicity, That is to say that a depressant drug (or seven) is attempted to be counteracted by a stimulant drug, like Phenteramine. This results in rising blood levels of the stimulant at the peak level of the depressants; rising blood levels of a drug produces greater toxicity than a stable drug level. Third, there is no means by which anyone could predict the totality of the complex drug-patient and drug-drug interactions that were occurring in her body at the time of her death. The number of combinations and permutations is staggering. What was known, what is known and what should have been accounted for was the level of danger into which the patient was plunged by the prescription pattern that knowingly exposed her to these combinations and permutations of drug-patient and drug-drug interactions. Furthermore, while the blood level of Hydromorphone was “within the therapeutic range,” it was quite high especially in light of the other depressant and stimulant drugs present.
Decedent died as the result of central nervous system depression in the presence of a drug that was likely to produce a cardiac arrhythmia in toxic doses. When a patient is “narcotized,” as decedent was, one of the primary effects is to slow the rate of respiration, resulting in a rise in the arterial carbon dioxide. This rise in carbon dioxide is assured and the effect is to sensitize the heart to arrhythmia. The depression of respiration also leads to a fall in the amount of oxygen in the blood further pushing the patient toward death. When into this milieu one introduces a toxic level of Phentermine, which produces toxicity through cardiac arrhythmia, the die was cast. Arrhythmia ensued and the patient died rapidly, unable to breathe, her lungs rapidly filled with fluid as she occasionally gasped against a closed airway.
The allegation that defendant was also having sex with decedent in exchange for the drugs arose during the course of the investigation. The introduction of sexual favors into the doctor-patient relationship necessarily voids that relationship and places any actions outside of the good faith course of defendant’s professional practice.
In summary, defendant repeatedly engaged in acts which fell below the standard overdose care for a physician in the Commonwealth of Pennsylvania. He failed to act in good faith in the course of his professional practice, acted outside of the scope of the doctor/patient relationship and failed to act in accordance with treatment principles accepted by any responsible segment of the medical profession. His actions were in direct opposition to decedent’s best medical interests, taking advantage of his privileged position as a physician. His actions were the proximate cause of her death.