Rebuttal - Charles Fehlauer, MD

23                     CHARLES STEVEN FEHLAUER,
      24        CALLED AS A WITNESS, BEING FIRST DULY SWORN, WAS
      25             EXAMINED AND TESTIFIED AS FOLLOWS:


                                                                       4207



       1                      DIRECT EXAMINATION
       2    BY MS. BARLOW:
       3    Q.  WILL YOU PLEASE STATE YOUR NAME AGAIN FOR THE RECORD?
       4    A.  CHARLES STEVEN FEHLAUER.
       5    Q.  DR. FEHLAUER, YOU'VE PREVIOUSLY TESTIFIED IN THIS
       6    MATTER?
       7    A.  YES, I HAVE.
       8    Q.  I'LL REMIND YOU ARE STILL UNDER OATH.  HAVE YOU HAD
       9    OCCASION TO REVIEW A CHEST X-RAY TAKEN ON NOVEMBER 18, 1995
      10    OF ELLEN ANDERSON?
      11    A.  I HAVE.
      12    Q.  AND HAVE YOU REVIEWED THE AUTOPSY OF ELLEN ANDERSON?
      13    A.  I HAVE.
      14    Q.  DID YOU SEE ANY PNEUMONIA IN THE CHEST X-RAY TAKEN IN
      15    NOVEMBER OF 1995?
      16    A.  THERE WAS AN OPACITY IN THE RIGHT CHEST WHICH COULD HAVE
      17    BEEN FLUID OR AN INFILTRATED PROCESS LIKE PNEUMONIA.
      18    Q.  WAS THERE ANYTHING ON THE AUTOPSY ABOUT THE RIGHT CHEST,
      19    THE LUNG IN THE RIGHT CHEST?
      20    A.  THERE WAS NO FINDING OF ACUTE PNEUMONIA IN THE RIGHT
      21    CHEST.
      22    Q.  WERE THERE ANY FINDINGS OF ACUTE PNEUMONIA AT ALL?
      23    A.  YES, IN THE LEFT LUNG.
      24    Q.  WAS THERE ANYTHING DENOTING AN AUTOPSY -- AT AUTOPSY WAS
      25    THERE ANYTHING SHOWING PNEUMONIA ON THE RIGHT SIDE?


                                                                       4208



       1    A.  THERE WAS NO ACUTE PNEUMONIA ON THE RIGHT SIDE.
       2    Q.  ALSO WITH MRS. ANDERSON HAVE YOU HAD OCCASION TO LOOK AT
       3    HER NURSING HOME RECORDS?
       4    A.  I HAVE.
       5    Q.  SHE EVIDENTLY HAD KYPHOSIS.  AM I PRONOUNCING THAT
       6    CORRECTLY?
       7    A.  YES.
       8    Q.  AND WHAT IS THAT?
       9    A.  KYPHOSIS IS A SHAPE TO THE BACK WHERE A SPINE IS
      10    NORMALLY RELATIVELY STRAIGHT, INSTEAD OF BEING RELATIVELY
      11    STRAIGHT IT IS BENT SORT OF LIKE A COMMA.  IT'S SOMETIMES
      12    CALLED A DOWAGER'S HUMP.
      13    Q.  LOOKING AT HER RECORD, WAS SHE CAPABLE OF COMPLAINING OF
      14    PAIN?
      15             MR. STIRBA:  YOUR HONOR, I'M GOING TO OBJECT.  I
      16    BELIEVE THAT'S ALREADY BEEN RULED ON.
      17             MS. BARLOW:  YOUR HONOR, I BELIEVE THAT I WAS
      18    ALLOWED TO GET INTO THAT PART.
      19             THE COURT:  YEAH.  OVERRULED.
      20    Q.  (BY MS. BARLOW)  WAS SHE CAPABLE OF COMPLAINING OF PAIN
      21    WHEN SHE LEFT THE NURSING HOME?
      22    A.  THE DISCHARGE SUMMARY FROM THE NURSING HOME INDICATES
      23    THAT THE PATIENT WAS ABLE TO SPEAK, ABLE TO UNDERSTAND
      24    SPEECH, YES.
      25    Q.  DR. HERBST TESTIFIED FROM A CHART REGARDING SIGNS OF


                                                                       4209



       1    DYING.  HAVE YOU HAD OCCASION TO REVIEW THAT TESTIMONY?
       2    A.  I HAVE.
       3    Q.  I'LL GO THROUGH THESE.  THE FIRST SIGN I BELIEVE WAS
       4    SLEEPING.  IS THIS A SIGN OF DYING?
       5    A.  YES.  SLEEPING CAN BE A SIGN OF DYING, YES.
       6    Q.  WHAT'S THE DIFFERENCE BETWEEN SLEEPING AS A SIGN OF
       7    DYING AND SLEEPING AS JUST SLEEPING?
       8    A.  ANYONE WHO'S SLEEPING CAN BE AWAKENED.  I MEAN, IF YOU
       9    CALL OUT AND SOMEONE'S SLEEPING IT MEANS THEY CAN BE
      10    AWAKENED.  IT DOESN'T MEAN THAT SLEEP IS LEADING TO THEIR
      11    DEATH.  IT JUST MEANS THAT THEY CAN BE AWAKENED.  SLEEPING
      12    MORE THAN USUAL CAN BE A SIGN THAT A PATIENT IS DYING OR
      13    INTOXICATED WITH MEDICATIONS OR ILL, BUT IT CERTAINLY
      14    DOESN'T MEAN THAT IF YOU ARE SLEEPING YOU ARE GOING TO DIE.
      15    Q.  INCONTINENCE IS ALSO LISTED AS A SIGN OF DYING.  IS
      16    THAT -- IS THAT THE ONLY THING IT CAN LEAD TO?
      17    A.  NO.  OBVIOUSLY PEOPLE CAN BE INCONTINENT AND NOT BE IN
      18    THE PROCESS OF DYING.
      19    Q.  RESTLESSNESS WAS LISTED AS A SIGN OF DYING.  IS THAT THE
      20    ONLY THING THAT RESTLESSNESS COMES FROM?
      21    A.  NO.
      22    Q.  THERE'S ALSO TALK OF CONGESTION AND INABILITY TO CLEAR
      23    SECRETIONS FROM THE THROAT.  CAN OTHER THINGS OTHER THAN
      24    DYING CAUSE THAT?
      25    A.  YES.


                                                                       4210



       1    Q.  WHAT?
       2    A.  WELL, YOU CAN HAVE AN INABILITY TO CLEAR SECRETIONS
       3    BECAUSE THE SWALLOWING REFLEX HAS BEEN IMPAIRED.  THE
       4    MATERIAL GETS CAUGHT IN THE THROAT AND YOU NEED TO COUGH AND
       5    CLEAR IT OUT.  YOU CAN BE CONGESTED AND HAVE A RATTLING IN
       6    YOUR THROAT IF YOU HAVE A BAD COLD OR BRONCHITIS.
       7    Q.  COOLNESS IS ALSO INDICATED AS A SIGN OF DYING.  CAN
       8    ANYTHING ELSE CAUSE COOLNESS, A COOLING OF THE SKIN?
       9    A.  WELL, CERTAINLY IF SOMEONE IS CHILLED AND THEIR BODY IS
      10    TRYING TO CONSERVE HEAT, THEIR EXTREMITIES WILL BE COOL.  IF
      11    YOU ARE NERVOUS YOUR EXTREMITIES CAN BE COOL.
      12    Q.  AND TERMINAL FEVER AS A SIGN OF DYING.  WHAT'S TERMINAL
      13    FEVER?
      14    A.  I GUESS, AS DR. HERBST INTENDED TO USE IT, IT'S A FEVER
      15    WHICH OCCURS IN THE PRESENCE OF A TERMINAL EVENT.  BUT
      16    PEOPLE HAVE FEVER.  THAT DOESN'T MEAN THAT THEY ARE
      17    TERMINALLY ILL.
      18    Q.  CONFUSION.  CAN SOMETHING OTHER THAN DEATH CAUSE
      19    CONFUSION?
      20    A.  YES.
      21    Q.  WHAT ELSE?
      22    A.  WELL, EXTERNALLY, THE PRESENCE OF DEMENTIA LIKE THESE
      23    PATIENTS SUFFERED FROM, BUT IT DOESN'T MEAN THAT DEATH IS
      24    OCCURRING THEN.
      25    Q.  THERE WAS SOME TESTIMONY TOO OF --


                                                                       4211



       1             MR. STIRBA:  YOUR HONOR, I'M GOING TO OBJECT TO THE
       2    FORM OF THE QUESTION.
       3             THE COURT:  OKAY.  JUST ASK A QUESTION.
       4             MS. BARLOW:  I'LL REPHRASE IT.  THANK YOU, YOUR
       5    HONOR.
       6    Q.  (BY MS. BARLOW)  WHAT ROLE DO THE KIDNEYS PLAY IN THE
       7    ADMINISTRATION OF MEDICATION?
       8    A.  WELL, THE KIDNEYS PLAY THE ROLE OF REMOVING THE MATERIAL
       9    FROM THE BODY AFTER IT'S BEEN ADMINISTERED.
      10    Q.  SPECIFICALLY THE DRUGS WE'VE BE TALKING ABOUT HERE,
      11    MORPHINE AND THE PSYCHOTROPIC DRUGS, DO THE KIDNEYS PLAY A
      12    ROLE?
      13    A.  YES.
      14    Q.  AND THE ROLE IS?
      15    A.  THE ROLE IS TO EXCRETE THE DRUG ITSELF, OR THE METABOLIC
      16    BY-PRODUCTS OF THE DRUG THAT HAVE BEEN SECRETED BY THE
      17    METABOLISM IN THE BODY.
      18    Q.  WHAT EFFECT WOULD KIDNEY FAILURE OR KIDNEY
      19    MALFUNCTIONING HAVE ON THE EXCRETION OF THESE MEDICATIONS
      20    FROM THE BODY?
      21    A.  WELL, IF THE KIDNEY IS NOT FUNCTIONING TO ITS FULL
      22    CAPACITY THEN THE DRUGS WHICH ARE ELIMINATED FROM THE BODY
      23    BY THE KIDNEYS, OR ITS METABOLITES THAT ARE ELIMINATED,
      24    WOULD BE REDUCED SO THAT THE AMOUNT OF DRUG CLEARED IN ANY
      25    GIVEN PERIOD OF TIME WOULD BE REDUCED.  SO THE HALF LIFE OF


                                                                       4212



       1    DRUGS COULD BE PROLONGED, THE DURATION OF EFFECT COULD BE
       2    PROLONGED.
       3    Q.  HAVE YOU HAD OCCASION TO LOOK AT THE KIDNEY FUNCTION OF
       4    THESE FIVE PATIENTS AS INDICATED IN THE RECORDS?
       5    A.  YES, I HAVE.
       6    Q.  AND HAVE YOU FOUND ANY -- WELL, HAVE YOU FOUND ANYTHING
       7    THAT IS COMMON TO ALL OF THEM?
       8    A.  YEAH.  ALL OF THE PATIENTS, BY CALCULATING THEIR KIDNEY
       9    FUNCTION USING A STANDARD INSTRUMENT CALLED THE COCKCROFT
      10    GAULT EQUATION, WHICH TAKES INTO ACCOUNT A PATIENT'S AGE AND
      11    BODY WEIGHT AND THEIR KIDNEY FUNCTION.  I FOUND THAT ALL OF
      12    THEM SUFFERED A REDUCTION IN THEIR KIDNEY FUNCTION TO AT
      13    LEAST A LEVEL OF LESS THAN 50 PERCENT OR HALF OF NORMAL.
      14    Q.  WHAT WOULD THAT DO FOR THE CLEARANCE OF THE DRUG THAT
      15    THEY WERE GIVEN?
      16    A.  PROBABLY PROLONG THE HALF LIFE AND REDUCE THE CLEARANCE.
      17    Q.  THE RECORD SHOWS SOME TWITCHING OCCURRING IN SOME OF
      18    THESE PATIENTS.  WHAT CAN CAUSE TWITCHING?
      19    A.  WELL, TWITCHING COULD -- WOULD INDICATE A CONTRACTION OF
      20    MUSCLES.  AND A CONTRACTION OF MUSCLES CAN OCCUR IN THE
      21    PRESENCE OF ELECTROLYTE ABNORMALITIES.
      22    Q.  THAT'S A BLOOD PROBLEM?
      23    A.  YES.  IF THE BLOOD POTASSIUM WAS ABNORMAL, FOR EXAMPLE,
      24    YOU CAN HAVE SOME TWITCHING FROM THAT LOW BLOOD CALCIUM.  IN
      25    ADDITION, PEOPLE WITH DEMENTIA, PARTICULARLY PEOPLE WITH END


                                                                       4213



       1    STAGE DEMENTIA, ABOUT 10 PERCENT HAVE SOME FORM OF SEIZURE
       2    DISORDER.  THERE'S MINOR SEIZURES LIKE MYOCLONUS WHERE A
       3    SINGLE MUSCLE WILL CONTRACT AND JERK.  I SEE THAT QUITE
       4    OFTEN.  MUSCLES CAN BE JERKING AND CONTRACTING SEVERAL TIMES
       5    A MINUTE ALL OVER THE BODY.  THE PATIENT NEVER LOSES
       6    CONSCIOUSNESS.  IT'S NOT A FULL-BLOWN SEIZURE LIKE WE THINK
       7    OF.  THEN THERE ARE PARTIAL MOTOR SEIZURES WHERE A LIMB OR A
       8    PART OF THE BODY IS JERKING, BUT IT DOESN'T GENERALIZE INTO
       9    A FULL MOTOR SEIZURE.
      10    Q.  IS THERE ANY INDICATION OF PAIN CONNECTED WITH THAT?
      11    A.  I SUPPOSE THE JERKING COULD BE A SIGN OF PAIN, BUT IT'S
      12    NOT THE ONLY THING THAT IT'S A SIGN OF.
      13    Q.  I BELIEVE MRS. SMITH, ON ADMISSION, THERE WAS AN
      14    INDICATION OF 25 PERCENT WEIGHT LOSS WITHIN THE LAST YEAR, I
      15    BELIEVE IT WAS.  CAN DYING CAUSE WEIGHT LOSS?
      16    A.  WOULD YOU REPHRASE THAT QUESTION.
      17    Q.  WELL, WHAT CAUSES WEIGHT LOSS IN THE ELDERLY?
      18    A.  WELL, THE MOST COMMON REASON THAT A PERSON WOULD LOSE
      19    WEIGHT IS THAT THEY DON'T TAKE ENOUGH FOOD IN.  AND IN FACT,
      20    UNLESS THERE'S A METABOLIC PROCESS THAT CAUSES THE BODY TO
      21    BURN MORE CALORIES, THE ONLY REASON PEOPLE LOSE WEIGHT IS
      22    BECAUSE THEY DON'T TAKE ENOUGH FOOD IN.
      23    Q.  AND IS THAT COMMON IN THE ELDERLY?
      24    A.  UNFORTUNATELY, YES.
      25    Q.  AND WHAT KINDS OF THINGS CAUSE THEM TO NOT TAKE ENOUGH


                                                                       4214



       1    FOOD IN?
       2    A.  WELL, WE COULD START AT THE MOUTH AND SAY THAT IF YOUR
       3    TEETH ARE IN POOR CONDITION THAT'S A GOOD REASON.  PEOPLE
       4    WHO LIVE ON A BUDGET MAY NOT BE ABLE TO AFFORD FOOD.  PEOPLE
       5    IN NURSING FACILITIES GENERALLY HAVE ACCESS TO FOOD AND
       6    PEOPLE WHO ARE ATTEMPTING TO FEED THEM.  THEY MAY HAVE
       7    REDUCED ABILITY TO CHEW AND SWALLOW AT THE NORMAL RATE AND
       8    IT'S HARD TO PUT ENOUGH FOOD DOWN THEM IN A TIMELY FASHION.
       9         THEY MAY HAVE ANXIETY OR AGITATION OR RESISTANCE TO
      10    EATING AND NOT SIT STILL FOR A MEAL OR REFUSE TO EAT.  THEY
      11    MAY HAVE MALABSORPTION PROBLEMS.  THEIR INTESTINES MAY NOT
      12    FUNCTION NORMALLY AND ONCE THE FOOD IS IN IT MAY NOT BE
      13    ADEQUATELY ABSORBED AND THEREFORE THE NUTRIENTS ARE LOST
      14    BEFORE THEY ARE MADE USE OF.  CANCERS ARE ASSOCIATED WITH
      15    WEIGHT LOSS.  IT ALMOST ALWAYS IS AN EFFECT OF LOSS OF
      16    APPETITE.  THERE ARE RARE CASES WHERE THE TUMOR CONSUMES
      17    ENOUGH CALORIES TO CAUSE SOMEONE TO LOSE WEIGHT EVEN WHEN
      18    THEY WERE EATING ADEQUATELY.
      19    Q.  THAT BRINGS US TO THE MYCOSIS FUNGOIDES THAT MR.
      20    ALLDREDGE HAD.  DID YOU REVIEW THE RECORDS ABOUT HIS MYCOSIS
      21    FUNGOIDES?
      22    A.  YES.  TO THE EXTENT THAT I HAD RECORDS, I DID.
      23    Q.  AND WHAT RECORDS DID YOU HAVE?
      24    A.  WELL, THE RECORDS THAT WERE PROVIDED TO ME INCLUDED
      25    OFFICE VISITS FROM HIS PRIMARY PHYSICIAN UP TO APRIL OF


                                                                       4215



       1    1995.
       2    Q.  NOW, THIS HAS BEEN TERMED A LYMPHOMA; IS THAT CORRECT?
       3    A.  YES.  IT'S A CUTANEOUS T CELL LYMPHOMA, WHICH MEANS A
       4    CANCER OF THE SKIN INVOLVING LYMPHOCYTES OR CELLS THAT ARE
       5    INVOLVED IN THE IMMUNE PROCESS.
       6    Q.  IS THAT A TERMINAL CONDITION FOR MR. ALLDREDGE WHEN HE
       7    ENTERED THE HOSPITAL?
       8    A.  WELL, REVIEWING THE RECORDS, IT SAID THAT HE HAD A
       9    HISTORY OF THIS AND THAT HE HAD RECEIVED TOTAL BODY
      10    IRRADIATION.  AND THIS IS A TUMOR THAT WHEN IT'S PRESENT CAN
      11    BE OBSERVED ON THE SKIN.  OR IF IT HAS REACHED A HIGHER
      12    STAGE, A GREATER STAGE, IT RESULTS IN LYMPH NODE
      13    ENLARGEMENT.  AND WHEN I LOOKED AT THE NOTE FROM HIS PRIMARY
      14    PHYSICIAN AND DR. DIENHART, I DIDN'T SEE ANY EVIDENCE THAT
      15    THE SKIN WAS INVOLVED.  NO ONE MADE MENTION OF TUMOR IN HIS
      16    SKIN.  AND WHEN I REVIEWED THE AUTOPSY RESULTS THERE WAS NO
      17    EVIDENCE OF LYMPH NODE INVOLVEMENT.  SO I WOULD HAVE SAID
      18    THAT HE WAS A STAGE ONE TUMOR AND THAT HIS DISEASE WAS
      19    INACTIVE AT THE TIME THAT HE WAS EVALUATED, BASED ON THE
      20    RECORDS I'VE SEEN.
      21    Q.  OKAY.  DID YOU SEE ANY INDICATION IN THE RECORDS OF
      22    THESE INDIVIDUALS OF DEHYDRATION?
      23    A.  YES.
      24    Q.  IS DEHYDRATION A PAINFUL CONDITION?
      25    A.  IF SOMEONE IS THIRSTY AND DEHYDRATED AND UNABLE TO


                                                                       4216



       1    CONVEY THAT THEY ARE THIRSTY, IT'S UNCOMFORTABLE, YEAH.  THE
       2    SENSATION OF THIRST IS ONE OF THE STRONGEST DRIVES A PERSON
       3    CAN HAVE.
       4    Q.  WHAT ABOUT NEAR DEATH?
       5    A.  AS YOU BECOME MORE DEHYDRATED THE URGE TO REQUEST FLUIDS
       6    IS DIMINISHED, HAS BEEN MY OBSERVATION.  AND THE SENSATION
       7    OF NEED FOR THIRST APPEARS DIMINISHED.  AND THIS RELATES TO
       8    THE FACT THAT AS THE KIDNEYS FAIL THE TOXINS WHICH THE
       9    KIDNEYS ELIMINATE BEGIN TO BUILD UP AND THESE PEOPLE HAVE
      10    REDUCED LEVELS OF CONSCIOUSNESS AND REDUCED INTERACTION WITH
      11    THEIR ENVIRONMENT.  I DON'T FIND THAT PEOPLE WHO ARE
      12    SUFFERING FROM TERMINAL DEHYDRATION EXPERIENCE MUCH
      13    DISCOMFORT, IF ANY.         !!!
      14    Q.  AND THAT'S BECAUSE OF THE KIDNEY FAILURE?
      15    A.  YES, THE KIDNEY FAILURE.
      16    Q.  HAVE YOU LOOKED AT THE RECORDS FOR MARY CRANE?
      17    A.  I HAVE.
      18    Q.  WAS SHE AT DEATH'S DOOR WHEN SHE ENTERED THE HOSPITAL?
      19    A.  THE MOST COMPREHENSIVE NOTES ARE FROM DR. DIENHART.  AND
      20    DR. DIENHART'S NOTE INDICATES HE HAD QUITE A CONVERSATION
      21    WITH HER.  HER VITAL SIGNS WERE NORMAL.  SHE DIDN'T HAVE A  !!! She couldn't talk.
      22    FEVER.  HE INDICATED A LIST OF ACTIVE PROBLEMS WHICH HAD
      23    BEEN PRE-EXISTING FOR SOMETIME, BUT HE DIDN'T INDICATE IN
      24    HIS NOTE THAT SHE APPEARED TO BE AT DEATH'S DOOR.  AND THERE
      25    IS NOTHING FROM THE MATERIAL THAT I SAW THAT INDICATES THAT

            See Dr. Dienhart's note>>
                                                                       4217



       1    SHE WAS AT DEATH'S DOOR.
       2    Q.  ARE YOU AWARE OF WHAT A CLINICAL CORRELATION WOULD BE
       3    FOR ASSESSING A STROKE?
       4    A.  YES.
       5    Q.  AND SPECIFICALLY AN OCCIPITAL STROKE?
       6    A.  YES.
       7    Q.  WHAT CLINICAL CORRELATION WOULD YOU DO FOR AN OCCIPITAL
       8    STROKE?
       9    A.  OCCIPITAL STROKE IS A STROKE IN THE BACK PART OF THE
      10    BRAIN.  THE STRUCTURES THAT ARE LOCATED THERE RELATE TO
      11    EYESIGHT, ORGANIZATION OF THE VISUAL WORLD.  AND SOMEWHAT,
      12    IF IT EXTENDS INTO THE LOWER PART OF THE BRAIN, THE ABILITY
      13    TO SENSE WHERE YOU ARE IN THE WORLD AND CONTROL MOVEMENTS.
      14         THE KIND OF TESTING YOU WOULD DO TO SEE IF SOMEONE HAD
      15    AN OCCIPITAL INFARCTION WOULD INVOLVE TRYING TO TEST WHAT
      16    THEY CAN SEE AND WHERE THE DEFICITS ARE LOCATED.  SO YOU
      17    WOULD TRY AND HAVE SOMEONE TELL YOU IF THEY CAN SEE YOUR
      18    FINGER HERE AND SEE YOUR FINGER HERE AND HERE AND HERE.  AND
      19    IF THEY CAN'T COMMUNICATE, YOU CAN EXAMINE THEM BY
      20    CONFRONTATION.  YOU CAN GET IN FRONT OF THEM SO YOU KNOW
      21    WHAT THEY ARE LOOKING AT AND THEN YOU CAN USE A PEN OR OTHER
      22    OBJECT TO TRY AND MAKE THEM FLINCH AS YOU BRING IT IN
      23    TOWARDS THEIR EYES.  IT'S A VERY PRIMITIVE REFLEX THAT IF
      24    YOUR BRAIN SENSES SOMETHING IS COMING TOWARDS YOUR EYE, YOU
      25    TRY AND BLINK OR MOVE AWAY FROM IT.  SO THAT WOULD BE HOW I


                                                                       4218



       1    WOULD TEST FOR OCCIPITAL INFARCTION.
       2    Q.  DID YOU SEE ANY CLINICAL CORRELATION REGARDING THE
       3    POSSIBLE STROKE WITH ENNIS ALLDREDGE?
       4             MR. STIRBA:  YOUR HONOR, I'M GOING TO OBJECT.  I
       5    THINK THIS WAS A SUBJECT OF A PREVIOUS RULING.
       6             THE COURT:  SUSTAINED.
       7    Q.  (BY MS. BARLOW)  ARE YOU FAMILIAR WITH THE NATIONAL
       8    HOSPICE ORGANIZATION?
       9    A.  YES.
      10    Q.  AND THEIR MANUAL?
      11    A.  YES.
      12    Q.  ARE YOU FAMILIAR WITH THE F.A.S. SCALE?
      13    A.  YES.
      14    Q.  AND WHAT IS THE F.A.S. SCALE JUST BRIEFLY?
      15    A.  FUNCTIONAL ASSESSMENT SCALE.  IT'S A SCALE THAT HAS BEEN
      16    DEVELOPED TO ATTEMPT TO PLACE THE AMOUNT OF DISABILITY A
      17    PERSON WITH DEMENTIA IS SUFFERING FROM ON A CONTINUUM OR A
      18    LINE THAT HELPS YOU TO UNDERSTAND WHERE THEY ARE IN THE
      19    COURSE OF THEIR DISEASE.
      20    Q.  AND ARE THERE CERTAIN THINGS YOU LOOK AT TO MAKE A SCORE
      21    FOR PEOPLE?
      22    A.  YES, THERE ARE.
      23    Q.  AND WHEN YOU ARE SCORING PEOPLE, IS THERE ANY GUIDELINE
      24    ABOUT HOW TO SCORE?
      25    A.  YES.  YOU REALLY SHOULD SCORE IT AT THEIR HIGHEST LEVEL


                                                                       4219



       1    OF FUNCTION.
       2    Q.  IS THERE ANY ONE THING THAT YOU LOOK AT AS KIND OF A
       3    BASIS FOR SAYING A PERSON MEETS THE CRITERIA FOR HOSPICE
       4    CARE?
       5    A.  WELL, THE HOSPICE MANUAL THAT LISTS THE CRITERIA TO USE
       6    TO IDENTIFY PEOPLE WHO ARE CANDIDATES FOR HOSPICE MAKE IT
       7    CLEAR THAT THE ONE PREDICTIVE FACTOR OF RELATIVELY LONG LIFE
       8    IN SOMEONE WHO'S PROFOUNDLY DEMENTED IS THE ABILITY TO WALK.
       9    SO IF THE ABILITY TO WALK IS PRESENT THEN IT'S COMMON FOR
      10    THOSE PEOPLE TO LIVE AT LEAST TWO YEARS.
      11    Q.  DID YOU HAVE OCCASION TO LOOK AT THE RECORDS OF THESE
      12    FIVE PATIENTS ABOUT THEIR ABILITY TO WALK?
      13    A.  I DID.
      14    Q.  AND WHAT DID YOU FIND?
      15    A.  I FOUND THAT EXCEPT IN THE CASE OF MRS. LARSEN, AT THE
      16    TIME OF TRANSFER FROM THE NURSING HOME, OR WITHIN A WEEK OR
      17    SO BEFOREHAND, THE PATIENTS ALL WERE CAPABLE OF SOME
      18    AMBULATION; AND SOME OF THEM WERE INDEPENDENT WALKERS.
      19    Q.  DID YOU HAVE OCCASION TO DETERMINE A F.A.S. SCORE FOR
      20    EACH OF THESE INDIVIDUALS PRIOR TO ADMISSION TO THE DAVIS
      21    NORTH HOSPITAL?
      22    A.  I DID.
      23    Q.  AND WHAT DID YOU BASE THAT ON?
      24    A.  I BASED THAT ON THE MATERIALS FROM THE NURSING
      25    FACILITIES, THE DISCHARGE TRANSFER SUMMARIES AND THE PERIOD


                                                                       4220



       1    JUST PRIOR TO, A WEEK OR SO, LEADING UP TO THEIR TRANSFER.
       2    Q.  AND DID YOU PREPARE A CHART ABOUT THE F.A.S.?
       3    A.  I DID.
       4    Q.  IS THIS THE CHART THAT YOU PREPARED?
       5    A.  YES, IT IS.
       6    Q.  STATES EXHIBIT 33.  CAN YOU EXPLAIN WHAT THE TOP OF THAT
       7    CHART IS?
       8    A.  THE TOP OF THAT CHART IS DERIVED FROM THE NATIONAL
       9    HOSPICE ORGANIZATION MANUAL.  AND THE CHART SHOWS THE FAST
      10    STAGE HERE WITH THE SUBSTAGES HERE.  COMPARING THE MENTAL
      11    STATUS EXAMS, THIS BEING A NORMAL SCORE AND THIS BEING AN
      12    ABNORMALLY LOW SCORE.  AND THEN IT GIVES A TIMEFRAME IN
      13    YEARS AS TO ZERO YEARS OF ILLNESS, THIS IS ABOUT WHERE A
      14    PERSON SHOULD BE; AND 19 TO 20 YEARS OF ILLNESS THIS IS
      15    ABOUT WHERE A PERSON SHOULD BE.  TYPICALLY, OBVIOUSLY,
      16    EVERYONE HAS A LITTLE DIFFERENT COURSE THAN CAN BE PUT ON A
      17    SINGLE CHART.
      18    Q.  I BELIEVE THERE'S BEEN TESTIMONY THAT SEVERAL OF THESE
      19    PEOPLE WERE IN THE SEVEN F.A.S. STAGE; IS THAT CORRECT?
      20             MR. STIRBA:  YOUR HONOR, I OBJECT TO THE FORM OF
      21    THE QUESTION AGAIN.
      22             THE COURT:  SUSTAINED.
      23    Q.  (BY MS. BARLOW)  LET ME JUST GO STRAIGHT AT THIS, THEN.
      24    DID YOU HAVE OCCASION TO DETERMINE A F.A.S. SCORE FOR ENNIS
      25    ALLDREDGE?


                                                                       4221



       1    A.  I DID.
       2    Q.  AND WHAT WAS THAT SCORE?
       3    A.  HIS F.A.S. SCORE IN LATE DECEMBER WAS SIX D.
       4    Q.  WHAT WAS THAT BASED ON?
       5    A.  THAT WAS BASED ON HIS BEING AMBULANT AND HAVING URINARY
       6    INCONTINENCE, BUT NOT FECAL INCONTINENCE. Smeared feces!
       7    Q.  IS THERE ANY INDICATION, OR HAVE THERE BEEN ANY STUDIES,
       8    ABOUT THE SURVIVAL RATE OF PEOPLE BASED ON THEIR F.A.S.
       9    SCORE?
      10    A.  THERE HAVE.
      11    Q.  AND IS THAT IN THIS HOSPICE MANUAL?
      12    A.  THEY ARE REFERENCED IN THE HOSPICE MANUAL.  THE STUDIES
      13    ARE NOT GIVEN IN DETAIL IN THE HOSPICE MANUAL.
      14    Q.  HAVE YOU READ THOSE STUDIES?
      15    A.  I REVIEWED SOME STUDIES RELATIVE TO SURVIVAL IN PEOPLE
      16    WITH ALZHEIMER'S DISEASE, YES.
      17    Q.  WITH THE SIX D WHAT IS THE NORMAL SURVIVAL RATE FOR
      18    ENNIS ALLDREDGE?
      19    A.  WELL, THE PATIENT IS STILL AMBULANT, INCONTINENT OF
      20    URINE.  AVERAGE SURVIVAL WOULD BE AROUND SEVEN TO TEN YEARS.
      21    Q.  WHAT ABOUT ELLEN ANDERSON, DID YOU HAVE OCCASION TO
      22    DETERMINE A F.A.S. SCORE FOR HER?
      23    A.  I DID.
      24    Q.  AND WHAT WAS THAT?
      25    A.  BASED ON THE INFORMATION FROM HER DISCHARGE SUMMARY FROM


                                                                       4222



       1    THE NURSING FACILITY IT WAS SIX E.
       2    Q.  AND WHAT WAS THAT BASED ON?
       3    A.  THAT WOULD INDICATE THAT SHE HAD FECAL INCONTINENCE OR
       4    NOT ABLE TO CONTROL HER STOOL.
       5    Q.  AND THE SURVIVAL RATE FOR ELLEN ANDERSON -- WELL,
       6    SOMEONE WITH A SIX E?
       7    A.  IT'S APPROXIMATELY THE SAME, PERHAPS A LITTLE SHORTER.
       8    SEVEN YEARS.
       9    Q.  WHAT ABOUT MARY CRANE?  WOULD YOU LOOK AT HER RECORDS?
      10    A.  I DID.
      11    Q.  AND DID YOU DETERMINE A F.A.S. SCORE FOR HER?
      12    A.  YES.  IT WAS ALSO SIX E, FECAL INCONTINENCE.
      13    Q.  AND ABOUT SEVEN YEARS --
      14    A.  YEAH.
      15    Q.  -- SURVIVAL RATE.  WHAT ABOUT LYDIA SMITH?
      16    A.  SIX D, URINARY INCONTINENCE.
      17    Q.  AND SURVIVAL RATE?
      18    A.  APPROXIMATELY SEVEN YEARS.
      19    Q.  WHAT ABOUT JUDITH LARSEN?
      20    A.  JUDITH LARSEN HAD BEEN IN A WHEELCHAIR FOR SOME TIME.
      21    SHE SCORED A SEVEN C FOR LOSS OF ABILITY TO STAND AND WALK.
      22    Q.  AND THE SURVIVAL RATE FOR A SEVEN C?
      23    A.  SEVEN C COMES IN AT ABOUT FOUR YEARS.
      24    Q.  AND WE RECOGNIZE THAT OF COURSE THINGS ARE --
      25    A.  QUITE A LOT OF VARIABILITY.


                                                                       4223



       1    Q.  VARIABILITY.  BUT THESE HAVE BEEN ACCEPTED AS STANDARD
       2    SURVIVAL RATES FOR PEOPLE IN THESE CONDITIONS; IS THAT
       3    CORRECT?
       4    A.  WELL, CERTAINLY IT GIVES YOU A BALLPARK FIGURE FOR WHAT
       5    TO ADVISE FAMILIES.  THE MOST COMMON REASON A PERSON WITH
       6    DEMENTIA IS PLACED IN A NURSING HOME IS BECAUSE THEY BECOME
       7    INCONTINENT.  IT'S A HARD THING FOR FAMILIES TO MANAGE.  AND
       8    THE AVERAGE LENGTHS OF STAY THAT A PERSON HAS IN A NURSING
       9    HOME AFTER ADMISSION IS ABOUT SEVEN TO TEN YEARS.  SO THAT'S
      10    WHAT I USE TO ADVISE PEOPLE.
      11    Q.  BASED ON YOUR REVIEW OF THE NURSING HOME RECORDS AND THE
      12    DAVIS HOSPITAL RECORDS FOR THESE FIVE INDIVIDUALS, WERE THEY
      13    WITHIN SIX MONTHS OF DYING BASED ON THE F.A.S. SCORE?
      14    A.  BASED ON THE F.A.S. SCORE, FROM MY REVIEW OF THEIR
      15    ILLNESS UP TO THE TIME OF ADMISSION, I WOULD SAY I DON'T
      16    THINK SO.
      17             MS. BARLOW:  IF I MAY HAVE JUST A MOMENT, YOUR
      18    HONOR?
      19             THE COURT:  OKAY.
      20             MS. BARLOW:  THAT'S ALL I HAVE, YOUR HONOR.
      21                       CROSS-EXAMINATION
      22    BY MR. STIRBA:
      23    Q.  DOCTOR, ONE OF THE REASONS WHY YOU SAY YOU DON'T THINK
      24    SO IS BECAUSE YOU HAVE TO EQUIVOCATE ON YOUR OPINION WITH
      25    RESPECT TO WHETHER OR NOT THEY WERE GOING TO LIVE ANOTHER


                                                                       4224



       1    SIX MONTHS IF YOU MERELY FOCUS ON THE F.A.S. SCORE; IS THAT
       2    RIGHT?
       3    A.  THAT'S CORRECT.
       4    Q.  AND IT'S TRUE, IS IT NOT, AS YOU LOOK AT THIS, THIS IS
       5    REALLY A FUNCTIONAL ASSESSMENT OF SOMEBODY WHO ESSENTIALLY
       6    HAS ALZHEIMER'S DISEASE OR DEMENTIA, TRUE?
       7    A.  OR STROKE DEMENTIA, TRUE.
       8    Q.  IT'S NOT ATTEMPTING TO QUANTIFY, FOR EXAMPLE, IF YOU
       9    HAVE ALZHEIMER'S DISEASE OR DEMENTIA AND YOU HAVE CORONARY
      10    ARTERY DISEASE, IS IT?
      11    A.  NO.
      12    Q.  AND IT'S NOT ATTEMPTING TO QUANTIFY IF YOU HAVE
      13    ALZHEIMER'S DISEASE, CORONARY ARTERY DISEASE AND
      14    CEREBROVASCULAR DISEASE, IS IT?
      15    A.  NO.
      16    Q.  AND YOU KNOW CERTAINLY AS A GERIATRICIAN THAT MANY FOLKS
      17    WHO ARE ELDERLY, ESPECIALLY THOSE WHO ARE DEMENTED, AND WHO
      18    SUSTAIN HIM FRACTURES, IT'S A MARKER.  IT'S A SIGN OF
      19    DETERIORATION THAT TYPICALLY FOLLOWS WHEN THAT FRACTURE
      20    OCCURS; ISN'T THAT TRUE?
      21    A.  YES.
      22    Q.  IN FACT, THERE HAVE BEEN STUDIES DONE, HAVE THERE NOT,
      23    THAT APPROXIMATELY 50 TO 80 PERCENT OF PEOPLE WHO IN THE
      24    GERIATRIC POPULATION WHO ARE DEMENTED AND THEN SUSTAIN A HIP
      25    FRACTURE WILL BE TERMINAL WITHIN ONE YEAR; ISN'T THAT TRUE?


                                                                       4225



       1    A.  YES.
       2    Q.  SO THIS REALLY IS A USEFUL GUIDE, BUT IT DOESN'T TAKE
       3    INTO CONSIDERATION OTHER CO-MORBID DISEASE PROCESSES; ISN'T
       4    THAT TRUE?
       5    A.  THAT'S CORRECT.
       6    Q.  AND IN FACT THE HOSPICE GUIDELINES WHICH YOU ARE
       7    FAMILIAR WITH USE THIS PARTICULAR F.A.S. EVALUATION, BUT
       8    THEY ALSO CONSIDER OTHER AREAS OF THE DISEASE PROCESS TO
       9    COME UP ESSENTIALLY WITH THEIR GUIDELINES; ISN'T THAT TRUE?
      10    A.  THAT'S CORRECT.
      11    Q.  FOR EXAMPLE, THEY WOULD CONSIDER WHETHER SOMEBODY HAS
      12    CORONARY ARTERY DISEASE, CORRECT?
      13    A.  YES.
      14    Q.  AND THEY WOULD CONSIDER WHETHER OR NOT SOMEBODY HAS HAD
      15    A FRACTURED HIP, TRUE?
      16    A.  YES.
      17    Q.  AND THEY WOULD CONSIDER WHETHER OR NOT SOMEBODY HAD C.V.
      18    DISEASE AND JUST HAS HAD A STROKE, CORRECT?
      19    A.  YES.
      20    Q.  THOSE ARE ALL SIGNIFICANT FINDINGS THAT YOU HAVE TO TAKE
      21    INTO CONSIDERATION AS A GERIATRICIAN WHEN YOU ARE GOING TO
      22    APPLY THOSE GUIDELINES; ISN'T THAT TRUE?
      23    A.  THAT'S TRUE.
      24    Q.  NOW, IT'S TRUE, IS IT NOT, DOCTOR, THAT I GUESS THE
      25    HOSPITAL RECORDS ARE GOING TO BE THE BEST EVIDENCE FOR


                                                                       4226



       1    WHETHER OR NOT SOMEBODY WAS AMBULATORY ON ADMISSION; IS THAT
       2    CORRECT?
       3    A.  BASED ON MY REVIEW I WOULD SAY THAT I HAVE SOME
       4    RESERVATIONS ABOUT THAT.
       5    Q.  FOR EXAMPLE, YOU TESTIFIED THAT THE ONLY PERSON YOU
       6    THOUGHT WAS NOT AMBULATORY ON ADMISSION WAS JUDITH LARSEN.
       7    DIDN'T YOU JUST SAY THAT?
       8    A.  I DID.
       9    Q.  AND IT'S TRUE, IS IT NOT, THAT IF YOU LOOK AT THE
      10    ADMISSION EVALUATION FOR MARY CRANE DONE ON HER ADMISSION,
      11    THERE'S A LITTLE CHECK MARK UNDER AMBULATORY AND IT SAYS NO.
      12    DO YOU REMEMBER SEEING THAT?
      13    A.  I DO.
      14    Q.  AND IT'S TRUE THAT THAT WAS DONE BY THE INTAKE EVALUATOR
      15    AS HE EVALUATED HER CONDITION; IS THAT CORRECT?
      16    A.  THAT'S CORRECT.
      17    Q.  SIMILARLY IT'S TRUE, IS IT NOT, THAT THE HOSPITAL
      18    RECORDS WOULD REALLY BE THE BEST EVIDENCE AS TO WHETHER OR
      19    NOT ELLEN ANDERSON COULD COMPLAIN OF PAIN; ISN'T THAT TRUE?
      20    A.  NO.  I HAVE SOME DOUBTS ABOUT THAT.
      21    Q.  IT'S TRUE, IS IT NOT, THAT ELLEN ANDERSON ON ADMISSION
      22    COULD NOT AND WAS UNABLE TO COMPLAIN OF PAIN; ISN'T THAT
      23    CORRECT?
      24    A.  NO, THAT'S NOT CORRECT.
      25    Q.  IN FACT, ISN'T IT TRUE THAT -- AND YOU JUST REVIEWED THE


                                                                       4227



       1    RECORDS; ISN'T THAT RIGHT?
       2    A.  YES.
       3    Q.  YOU WEREN'T THERE AT THE TIME DOING A CLINICAL
       4    ASSESSMENT, WERE YOU?
       5    A.  NO.
       6    Q.  YOU HAVEN'T TALKED TO THE FAMILY, HAVE YOU?
       7    A.  NO.
       8    Q.  YOU CERTAINLY DIDN'T TREAT ELLEN ANDERSON BACK IN 1995,
       9    DID YOU?
      10    A.  NO.
      11    Q.  CERTAINLY WEREN'T THERE TALKING TO HER TO FIND OUT
      12    WHETHER OR NOT SHE COULD COMMUNICATE WITH YOU, WERE YOU?
      13    A.  NO.
      14    Q.  AND IN FACT, IT'S TRUE, IS IT NOT, THAT THAT VERY
      15    QUESTION WAS ASKED IN HER NURSING ASSESSMENT FORM, WHERE
      16    THERE IS A PAIN SCALE ONE TO FIVE, AND IT SAYS RATE YOUR
      17    PAIN, AND THE NURSE WROTE UNABLE; ISN'T THAT TRUE?
      18    A.  YES, THAT'S TRUE.
      19    Q.  AND IT'S TRUE, IS IT NOT, THERE ARE OTHER AREAS IN THAT
      20    NURSING ASSESSMENT FORM -- FOR EXAMPLE, THE QUESTION WAS
      21    ASKED WHAT DO YOU LIKE ABOUT YOURSELF.  IT SAYS PATIENT
      22    UNABLE TO RESPOND?
      23    A.  THAT'S TRUE.
      24    Q.  WHAT WOULD YOU LIKE TO CHANGE?  PATIENT UNABLE TO
      25    RESPOND.  AWARENESS OF SELF AND ACCEPTANCE OF PROBLEMS.


                                                                       4228



       1    ANSWER, NO.  EXPLAIN.  EXTREMELY AGITATED, UNABLE TO
       2    RESPOND.  ARE YOU TELLING THIS JURY THAT BASED UPON JUST
       3    REVIEWING THE RECORDS --
       4             MS. BARLOW:  YOUR HONOR, THIS IS ARGUMENTATIVE.
       5             THE COURT:  LET HIM FINISH THE QUESTION.
       6    Q.  (BY MR. STIRBA)  ARE YOU TELLING THIS JURY, JUST BASED
       7    UPON YOUR REVIEW OF THE RECORDS AND WHAT I JUST READ YOU,
       8    THAT ELLEN ANDERSON WAS CAPABLE OF RESPONDING TO THOSE
       9    QUESTIONS AND TELLING SOMEBODY IN THAT HOSPITAL WHETHER OR
      10    NOT SHE WAS IN PAIN?
      11             MS. BARLOW:  OBJECTION.  ARGUMENTATIVE.
      12             THE COURT:  OVERRULED.
      13             THE WITNESS:  BASED ON THE HOSPITAL RECORDS, I
      14    CAN'T SAY THAT SHE COULD.
      15    Q.  (BY MR. STIRBA)  NOW, YOU ALSO REVIEWED ANOTHER RECORD
      16    AND THAT'S THIS X-RAY REPORT CONCERNING THE X-RAY THAT WAS
      17    DONE IN NOVEMBER OF 1995 WHICH APPARENTLY WAS ORDERED BY DR.
      18    KELLER OR DR. WILD.  REMEMBER SEEING THAT?
      19    A.  YES.
      20    Q.  AND IT IS TRUE, IS IT NOT, THAT WHAT THAT REPORT SAYS IS
      21    AS FOLLOWS, REFERENCING THE PULMONARY CIRCUMSTANCE.  IN
      22    ADDITION, THERE IS INCREASING ATELECTASIS AND, SLASH, OR
      23    PNEUMONIA IN BOTH LUNG BASES, RIGHT GREATER THAN LEFT.  ARE
      24    YOU AWARE THAT'S WHAT THE REPORT SAID?
      25    A.  YES.


                                                                       4229



       1    Q.  IT DIDN'T JUST SAY IN THE RIGHT, DID IT?
       2    A.  NO.
       3    Q.  IN FACT, IT WAS A FINDING WITH RESPECT EITHER TO
       4    ATELECTASIS AND/OR PNEUMONIA IN BOTH SIDES OF THE LUNG,
       5    CORRECT?
       6    A.  YES.
       7    Q.  YOU ARE AWARE THAT DR. DIENHART WROTE A CONSULT REPORT
       8    CONCERNING ENNIS ALLDREDGE?
       9    A.  YES.
      10    Q.  AND IN FACT WOULD YOU HAVE -- YOU'VE READ THAT?
      11    A.  YES.
      12    Q.  AND IN FACT, WHAT DR. DIENHART WROTE IN THAT CONSULT
      13    REPORT CONCERNING LYMPHOMA IS, HE PUT END STAGE, DID HE NOT?
      14    A.  IN ONE SECTION, YES.
      15    Q.  AND IT'S TRUE, IS IT NOT, THAT END STAGE MEANS THE
      16    FINALIZATION OF THE DISEASE PROCESS, TRUE?
      17    A.  YES.
      18    Q.  AND IN FACT, THE FINALIZATION OF THAT PARTICULAR DISEASE
      19    PROCESS, IF LEFT UNTREATED OR RESOLVED, WOULD BE DEATH,
      20    WOULDN'T IT?
      21    A.  NOT IF RESOLVED.
      22    Q.  PARDON ME?
      23    A.  YOU SAID UNTREATED OR RESOLVED.  IT WOULDN'T BE DEATH IF
      24    IT RESOLVED.
      25    Q.  THAT'S RIGHT.  UNTREATED OR UNRESOLVED, TRUE?


                                                                       4230



       1    A.  YES.
       2    Q.  YOU ARE CERTAINLY NOT SAYING THAT THE TOTAL IRRADIATION
       3    OF HIS BODY BACK IN, I BELIEVE, TEN TO 15 YEARS BEFORE CURED
       4    THAT LYMPHOMA, ARE YOU?
       5    A.  YEAH.  I WOULD SAY IF HE SURVIVED TEN TO 15 YEARS WITH
       6    TOTAL BODY IRRADIATION, IT WAS CURED.
       7    Q.  FINALLY, DOCTOR, YOU TALKED ABOUT TERMINAL DEHYDRATION.
       8    AND I THINK YOU SAID THAT, WELL, YOU KNOW, IN THE PATIENTS
       9    THAT I KNOW, WHILE THIRST IS A REAL SIGNIFICANT DRIVE, YOU
      10    DIDN'T SENSE THAT THERE WAS A GREAT DEAL OF DISCOMFORT WITH
      11    TERMINAL DEHYDRATION?
      12    A.  THAT'S CORRECT.
      13    Q.  DO YOU AGREE WITH THE STATEMENT, DOCTOR, THAT THE
      14    EASIEST PAIN TO ENDURE IS SOMEBODY ELSE'S?
      15             MS. BARLOW:  OBJECTION, YOUR HONOR.  THAT'S NOT AN
      16    APPROPRIATE QUESTION.
      17             THE COURT:  OVERRULED.
      18             THE WITNESS:  NO.
      19             MR. STIRBA:  THAT'S ALL.
      20             THE COURT:  ANY REDIRECT?
      21             MS. BARLOW:  YES.  THANK YOU.
      22                     REDIRECT EXAMINATION
      23    BY MS. BARLOW:
      24    Q.  YOU'VE TALKED ABOUT THE F.A.S. SCORE.  MR. STIRBA ASKED
      25    YOU ABOUT CO-MORBIDITY.  HAVE YOU HAD OCCASION TO LOOK AT


                                                                       4231



       1    THE CO-MORBIDITY OF THESE FIVE PATIENTS?
       2    A.  YES.
       3    Q.  WERE ANY OF THEM TERMINAL UPON ADMISSION AT DAVIS NORTH
       4    HOSPITAL?
       5             MR. STIRBA:  OBJECTION. IT'S CUMULATIVE.
       6             THE COURT:  OVERRULED.
       7    Q.  (BY MS. BARLOW)  WERE ANY OF THEM TERMINAL UPON
       8    ADMISSION AT DAVIS NORTH HOSPITAL?
       9    A.  THAT'S NOT CLEAR FROM THE RECORDS.
      10    Q.  YOU SAID -- YOU ANSWERED THAT YOU HAD RESERVATIONS, I
      11    GUESS IS THE WAY YOU PUT IT, ABOUT THE HOSPITAL RECORDS
      12    BEING THE BEST DETERMINATION OF WHETHER A PERSON'S
      13    AMBULATORY ON ADMISSION.  WHY DO YOU SAY THAT?
      14    A.  WELL, BECAUSE THE WAY YOU ARE SUPPOSED TO APPLY THE
      15    F.A.S. SCORE IS IN THE STABLE SITUATION.  YOU DON'T APPLY IT
      16    IN AN UNSTABLE SITUATION.  THE NURSING FACILITY HAD BEEN
      17    CARING FOR THESE RESIDENTS FOR AT LEAST MONTHS PRIOR TO
      18    THAT.  THEY HAD BEEN DOING ROUTINE AND FREQUENT ASSESSMENTS
      19    AND WOULD KNOW THE PATIENTS WELL.  THIS IS AN INITIAL
      20    ASSESSMENT PERFORMED BY THE HOSPITAL.  THEY MAY NOT BE FULLY
      21    AWARE OF THE PATIENT'S CAPABILITIES, PARTICULARLY WHEN THE
      22    PATIENT IS DEMENTED AND AGITATED AND REQUIRES SOME SPECIAL
      23    ASSISTANCE TO REACH THEIR HIGHEST FUNCTIONAL GOAL.
      24    Q.  WITH MRS. ANDERSON, YOU SAID YOU HAD RESERVATIONS ABOUT
      25    THE HOSPITAL RECORD BEING THE BEST DETERMINATION ABOUT


                                                                       4232



       1    WHETHER SHE COULD COMPLAIN OF PAIN.  WHY IS THAT?
       2    A.  WELL, IN ONE SECTION IT SAYS THAT SHE'S UNABLE AND
       3    ANOTHER SECTION IT DESCRIBES HER HAVING VOCALIZATION AND
       4    CRYING OUT FOR HER FAMILY.  SO I MEAN, SHE HAD SOME
       5    VERBALIZATIONS.  AND SHE CERTAINLY, AT DISCHARGE FROM THE
       6    NURSING FACILITY ON THEIR ASSESSMENT, WAS LISTED AS BEING
       7    ABLE TO SPEAK.  But only meaningless gibberish.
       8    Q.  NOW, YOU'VE HAD A REPORT READ TO YOU ABOUT THE X-RAY FOR
       9    ELLEN ANDERSON.  DID YOU LOOK AT THAT X-RAY YOURSELF?
      10    A.  I DID.
      11    Q.  AND WHERE DID YOU SEE CLOUDS?
      12    A.  WELL, I SAW HAZINESS IN THE RIGHT CHEST.  TO A FAIR
      13    EXTENT IN THE LOWER PART OF THE LUNG.  AND ON THE LEFT SIDE
      14    THERE WERE FINDINGS OF ATELECTASIS, BUT I DIDN'T CONSIDER IT
      15    IN MY PROFESSIONAL JUDGMENT TO BE INFILTRATES.
      16    Q.  WHAT IS ATELECTASIS?
      17    A.  THE LUNGS ARE COMPOSED OF LITTLE AIR SACKS.  WHEN THE
      18    LITTLE AIR SACKS COLLAPSE AGAINST EACH OTHER THEY FORM SORT
      19    OF A LINEAR, VERY THIN, DENSITY AND THAT'S ATELECTASIS, OR
      20    LOSS OF AIR IN THE ALVEOLI OR SMALL AIR SACKS.
      21    Q.  AND WHAT CAN CAUSE THAT?
      22    A.  IT CAN BE CAUSED BY SHALLOW RESPIRATIONS.
      23    Q.  IF YOU'LL OPEN UP ENNIS ALLDREDGE'S MEDICAL RECORDS,
      24    PAGE NUMBER SEVEN.  AND I BELIEVE UNDER MEDICAL HISTORY,
      25    NUMBER FOUR, WOULD YOU READ THAT, PLEASE.


                                                                       4233



       1    A.  YES.  IT SAYS HISTORY OF MYCOSIS FUNGOIDES END STAGE.
       2    MEDICAL RECORD INDICATES PATIENT HAD TOTAL BODY IRRADIATION
       3    AT ONE POINT.
       4    Q.  AND THIS IS DR. DIENHART'S CONSULT REPORT; IS THAT
       5    CORRECT?
       6    A.  YES.
       7    Q.  NOW, LET'S TURN OVER TO PAGE NINE, WHICH IS THE SAME
       8    CONSULT REPORT, AND THIS IS UNDER THE SECTION CALLED
       9    IMPRESSION.  WOULD YOU READ NUMBER SEVEN.
      10    A.  HISTORY OF MYCOSIS FUNGOIDES UNKNOWN STAGE.  STATUS,
      11    POST-THERAPY WITH TOTAL BODY IRRADIATION.
      12    Q.  IF YOU'LL TURN OVER TO PAGE 11.  DR. DIENHART HAS
      13    WRITTEN IN THE PHYSICIAN ORDER HIS CONSULT.  ON THE
      14    RIGHT-HAND SIDE CAN YOU GO DOWN A WAYS WHERE IT SAYS H.X.
      15    MYCOSIS FUNGOIDES AND READ THAT.  IT'S ABOUT A THIRD OF THE
      16    WAY DOWN, JUST SLIGHTLY BEFORE -- ABOVE THE THIRD.
      17    A.  YES.  IT SAYS HISTORY OF MYCOSIS FUNGOIDES, UNKNOWN
      18    STAGE.  TREATMENT WITH TOTAL BODY IRRADIATION.  QUESTION,
      19    SEZARY.
      20    Q.  SEZARY?
      21    A.  IT'S A SYNDROME THAT OCCURS WITH MYCOSIS FUNGOIDES THAT
      22    INVOLVES THE SKIN.  THERE ARE FINDINGS ON THE SKIN.
      23    Q.  WAS THE MYCOSIS FUNGOIDES AT THAT POINT A TERMINAL
      24    ILLNESS?
      25    A.  BASED ON MY REVIEW OF THE RECORDS, THE EVIDENCE THAT'S


                                                                       4234



       1    THERE FROM THE CONSULTATION NOTE AND AUTOPSY, NO.
       2             MS. BARLOW:  I THINK THAT'S ALL I HAVE, YOUR HONOR.
       3             THE COURT:  ANYTHING FURTHER?
       4             MR. STIRBA:  YES.
       5                      RECROSS-EXAMINATION
       6    BY MR. STIRBA:
       7    Q.  THOSE FINDINGS, DOCTOR, ARE NOT CONSISTENT WITH A
       8    RESOLUTION OF THE DISEASE, ARE THEY?
       9    A.  RESOLUTION OF WHAT DISEASE?
      10    Q.  THE FINDINGS THAT YOU JUST REFERRED TO THAT DR. DIENHART
      11    MADE CONCERNING SKIN ABNORMALITIES?
      12    A.  IN THE QUESTION OF SEZARY?
      13    Q.  YES.
      14    A.  NO.  IT JUST MEANS HE WONDERED IF HE HAD SEZARY.  THAT'S
      15    MY INTERPRETATION.
      16    Q.  THAT'S YOUR INTERPRETATION.  AND IT DOESN'T SAY IN HIS
      17    REPORT, DOES IT, THAT IT'S RESOLVED OR CURED?
      18    A.  NO.
      19             MR. STIRBA:  THAT'S ALL.
      20             MS. BARLOW:  NOTHING FURTHER, YOUR HONOR.
      21             THE COURT:  MAY THIS WITNESS BE EXCUSED?
      22             MS. BARLOW:  YES.

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