In this particular case (a dying person receiving a large dose of morphine) I do not think that we can assume that the usual pharmacokinetics of morphine and naloxone will be maintained. Although it is true that the usual half life of morphine is 1.5-2 hours the assumption that this patient's morphine level was trivial at the time of death based on pharmacokinetics (as laid out in the defence and point 3) is flawed. In fact the patient's post mortem morphine level was 889ng/ml, which is an exceptionally high level. Perhaps her serum naloxone level also remained high resulting in her stable state for many hours, we are not provided any evidence on this.
Why did the patient not metabolize morphine normally? There are 3 likely reasons: 1) Morphine metabolism takes place primarily in the liver and this end of life liver cancer patient likely had baseline impaired liver function, 2) This patient had active critical illness (MRSA Endocarditis/sepsis) that would further impair liver metabolic function, 3) The very high initial dose of morphine may have overwhelmed the metabolic capacity of the patient.
In this scenario the patient is not metabolizing morphine as we would usually predict specifically because she was actively dying. Her very high post mortem morphine level is evidence of the severity of her underlying illness.
While I do not think that there is any harm in this case, and the legal claim was baseless (looks like good physician communication around a gentle death) I think that there is a valid learning point that morphine metabolism is deranged in these types of very fragile patients. This can be helpful to us in practice as morphine effects and side effects can be very prolonged versus in patients with normal pharmacokinetics and we can account for that as we try to manage symptoms in end of life patients.
The more I think about this, the more I think you have an excellent point. This patient's physiology was likely completely different than the healthy patients that normal morphine clearance is based on. Thanks for the insightful comment, this is why I love to publish these to a wider audience!
Jun 14, 2023·edited Jun 14, 2023Liked by Med Mal Reviewer
"In this scenario the patient is not metabolizing morphine as we would usually predict specifically because she was actively dying. Her very high post mortem morphine level is evidence of the severity of her underlying illness."
100% agree and I think the ME report is unfortunately getting misused. I believe this case had to be in NY as I think that's the only state that had therapeutic complication as a manner of death (up until COVID), which was very clearly NOT meant to indicate that there was necessarily malpractice. As MedMalReviewer has reminded us many times, malpractice is a deviation from the standard of care AND evidence of harm, and even if she died "because of the morphine overdose" it does not seem like there was evidence of harm, especially given the communication around not continuing naloxone.
Therapeutic complication is a very specific set of circumstances whereby a medical intervention is the cause of death in the sense that, if the intervention had not happened, the patient would not have died at this moment. It could even be well within the standard of care (e.g. a well known, albeit rare, fatal, complication from a completely elective surgery) but it would still be a TC because without the intervention the person doesn't die *at that moment.*
In the absence of another clear cause of death, the incredibly high morphine level cannot be ignored and that is likely the reason she died that day instead of at a slightly later point in time; however, it is clear there was no harm given her severely reduced life expectancy and goals of care.
I just don’t understand. More and more of these cases are appearing that have [grossly] inappropriate testimony by “expert” plaintiff witnesses that seem to spout falsehoods just to claim a paycheck. I don’t see any sort of reality where this doesn’t get worse until we actual do something as a medical community against what is quite easily bought testimony. Are we really just giving up and letting this go unchecked? The statements given as medical fact on morphine’s effect on distress are just made up lies and the hoops the subsequent statements jump through as the assumed course with liquid pooling because of immobility simply enter the realm of make believe
Up until I started publishing them, they got away with it completely. There are thousands of opinions like this lurking out of sight because it's so hard to access legal records. I don't feel that it's my calling to publicly shame them, but I do often offer the defendants support if they want to try reporting them. There's no unified enforcement or punishment for bad expert witnesses so it's quite challenging. All I can say is that fate will eventually find a way to serve justice.
Might be worth re-considering the no-shaming policies, maybe shame is one of the few things we can do to deter this kind of behavior. Although I doubt that the sell-out docs really care anyway.
In addition to the false testimony re: effects of morphine, the expert apparently didn’t consider the amount of morphine that would have actually infused. Priming the tubing accounts for a waste of 20-30ml (so 20-30mg morphine). When accounting for waste and the morphine administered correctly in the few hours prior, closer to 65-75mg morphine was bolused-- not 100mg.
I have heard that there have been some egregious expert witness physicians who were reported to their national organization and kicked out. This substantially decrease their credibility for future cases since any attorney can ask if they were removed from a professional organization.
This accurate, but is not a great enforcement mechanism. A good attorney will ask about any prior issues related to this, but they don't always know or care. There's no overarching law that says if a professional society censures you, you can't be an expert witness any more. Additionally, not all of these experts are part of professional societies that would censure them.
Agreed, not sure what kind of work is being done on this issue, but there needs to be some regulation of this. Maybe you should have to take some kind of professional exam to become an expert witness, and be given a license to do so, and if you offer a blatantly inaccurate position such as this, the license is revoked.
Separately, I am curious as to why the plaintiff chose to drop the case against the doctors.
I think they all knew the claims against the doctors were BS, and once they extracted money from the hospital, they knew that it wasn't worth pushing the lawsuit forward with the physicians any more.
Pall care where I went to med school gave out morphine like candy to treat "air hunger" (aka dyspnea). Absolutely ludicrous opinion by plantiff's expert.
I can't believe no one has commented on the plaintiff's "Medical Expert" proclaimed themselves to be an expert in the standards of nursing care in multiple specialties as well as physician standards. Were the roles reversed the AMA would be clutching their pearls and fanning themselves.
I saw that but ran out of commentary room at the bottom. Very ridiculous that they appoint themselves an expert in all of these various fields in which they are not actually an expert.
"The opinion offered by the plaintiff’s expert is noteworthy for the false statements and ridiculous claims he makes. He alleges that the overdose caused pulmonary edema, for which there is absolutely no evidence. He claims that a morphine overdose causes “distressing physiologic effects” and a “sensation of breathlessness”. To state it simply, these claims are absolutely false. This physician is either so poorly educated that he doesn’t understand the basics of how opioids function, or he is simply lying to please the plaintiff’s attorney and collect a large paycheck (either option is extremely concerning given his senior role at a large teaching hospital). Respiratory depression caused by opioids would not be expected to cause distress, and there’s no evidence to suggest that the patient was anything but comfortable."
Why are we redacting names of people who appear to be behaving egregiously? Sunlight would appear to be one way of combating how these expert witnesses behave.
This always comes up when I publish a case with a terrible expert opinion. I don't feel like this newsletter is a good forum for publicly shaming doctors (even unethical ones). There are other avenues for reporting these things that are available to the defendants.
At 2mg/hour, this patient would have had carrier fluids. I can guess that the secondary drip (the morphine) might have been at the wrong height, which is what may have contributed to the rapid infusion.
Also, IV roller clamps have been known to fail and they were moving or repositioning the patient when this happened. There are several instances of this reported in ISMP.
In any case, I do not understand the approval of this case to go forward.
I think there may be opportunities to make systems-level changes to avoid med errors like this. Would be ideal if the equipment we used prohibited making errors like this. Also, why not just move the entire pump to the new bed without taking the meds off of it?
Often it’s an order from management. Sometimes nurses trade a pump for a pump with the receiving department when the patient arrives; however, that is occasionally problematic because pumps are programmed for department-specific medication. Therefore, I couldn’t trade an ICU pump for a floor pump.
If a carrier fluid was used it would be a primary infusion and the morphine gtt would be another primary infusion. That would allow both infusions to infuse simultaneously.
If the morphine were piggybacked/secondary on a bag of NS, that would defeat the purpose of a carrier fluid-- only the morphine would infuse until it ran dry, at which point the NS would begin infusing.
Dishonesty is equal in the Plaintiff’s bar and the defense bar. This is not a case I would have taken, and shame on the plaintiff’s attorney here. However, there are indefensible cases being defended by the defense bar every day.
I'm certainly willing to point out negligence when I see it (last week's case was a perfect example). That being said, I've read a good number of egregious expert witness opinions, and they've all been for the plaintiff. If I see an egregious defense expert opinion I'd love to publish it (open call to anyone reading this to send me one via email).
I will see if I can get my hands on a case I had where defense attorneys and defense experts defended giving an ESRD patient methotrexate for an ectopic pregnancy that didn’t actually exist. Then defended sending her home when she showed up the next day and made no attempts to reverse.
Defended the case up until the 11th hour instead of making a reasonable offer before everyone had wasted time and money. To this day, that woman’s death from mtx toxicity and the sequelae remains one of the most horrific I’ve ever seen.
In response to MedMalReviewer Analysis point 3:
In this particular case (a dying person receiving a large dose of morphine) I do not think that we can assume that the usual pharmacokinetics of morphine and naloxone will be maintained. Although it is true that the usual half life of morphine is 1.5-2 hours the assumption that this patient's morphine level was trivial at the time of death based on pharmacokinetics (as laid out in the defence and point 3) is flawed. In fact the patient's post mortem morphine level was 889ng/ml, which is an exceptionally high level. Perhaps her serum naloxone level also remained high resulting in her stable state for many hours, we are not provided any evidence on this.
Why did the patient not metabolize morphine normally? There are 3 likely reasons: 1) Morphine metabolism takes place primarily in the liver and this end of life liver cancer patient likely had baseline impaired liver function, 2) This patient had active critical illness (MRSA Endocarditis/sepsis) that would further impair liver metabolic function, 3) The very high initial dose of morphine may have overwhelmed the metabolic capacity of the patient.
In this scenario the patient is not metabolizing morphine as we would usually predict specifically because she was actively dying. Her very high post mortem morphine level is evidence of the severity of her underlying illness.
While I do not think that there is any harm in this case, and the legal claim was baseless (looks like good physician communication around a gentle death) I think that there is a valid learning point that morphine metabolism is deranged in these types of very fragile patients. This can be helpful to us in practice as morphine effects and side effects can be very prolonged versus in patients with normal pharmacokinetics and we can account for that as we try to manage symptoms in end of life patients.
The more I think about this, the more I think you have an excellent point. This patient's physiology was likely completely different than the healthy patients that normal morphine clearance is based on. Thanks for the insightful comment, this is why I love to publish these to a wider audience!
"In this scenario the patient is not metabolizing morphine as we would usually predict specifically because she was actively dying. Her very high post mortem morphine level is evidence of the severity of her underlying illness."
100% agree and I think the ME report is unfortunately getting misused. I believe this case had to be in NY as I think that's the only state that had therapeutic complication as a manner of death (up until COVID), which was very clearly NOT meant to indicate that there was necessarily malpractice. As MedMalReviewer has reminded us many times, malpractice is a deviation from the standard of care AND evidence of harm, and even if she died "because of the morphine overdose" it does not seem like there was evidence of harm, especially given the communication around not continuing naloxone.
Therapeutic complication is a very specific set of circumstances whereby a medical intervention is the cause of death in the sense that, if the intervention had not happened, the patient would not have died at this moment. It could even be well within the standard of care (e.g. a well known, albeit rare, fatal, complication from a completely elective surgery) but it would still be a TC because without the intervention the person doesn't die *at that moment.*
In the absence of another clear cause of death, the incredibly high morphine level cannot be ignored and that is likely the reason she died that day instead of at a slightly later point in time; however, it is clear there was no harm given her severely reduced life expectancy and goals of care.
I just don’t understand. More and more of these cases are appearing that have [grossly] inappropriate testimony by “expert” plaintiff witnesses that seem to spout falsehoods just to claim a paycheck. I don’t see any sort of reality where this doesn’t get worse until we actual do something as a medical community against what is quite easily bought testimony. Are we really just giving up and letting this go unchecked? The statements given as medical fact on morphine’s effect on distress are just made up lies and the hoops the subsequent statements jump through as the assumed course with liquid pooling because of immobility simply enter the realm of make believe
Up until I started publishing them, they got away with it completely. There are thousands of opinions like this lurking out of sight because it's so hard to access legal records. I don't feel that it's my calling to publicly shame them, but I do often offer the defendants support if they want to try reporting them. There's no unified enforcement or punishment for bad expert witnesses so it's quite challenging. All I can say is that fate will eventually find a way to serve justice.
Might be worth re-considering the no-shaming policies, maybe shame is one of the few things we can do to deter this kind of behavior. Although I doubt that the sell-out docs really care anyway.
In addition to the false testimony re: effects of morphine, the expert apparently didn’t consider the amount of morphine that would have actually infused. Priming the tubing accounts for a waste of 20-30ml (so 20-30mg morphine). When accounting for waste and the morphine administered correctly in the few hours prior, closer to 65-75mg morphine was bolused-- not 100mg.
I have heard that there have been some egregious expert witness physicians who were reported to their national organization and kicked out. This substantially decrease their credibility for future cases since any attorney can ask if they were removed from a professional organization.
This accurate, but is not a great enforcement mechanism. A good attorney will ask about any prior issues related to this, but they don't always know or care. There's no overarching law that says if a professional society censures you, you can't be an expert witness any more. Additionally, not all of these experts are part of professional societies that would censure them.
Agreed, not sure what kind of work is being done on this issue, but there needs to be some regulation of this. Maybe you should have to take some kind of professional exam to become an expert witness, and be given a license to do so, and if you offer a blatantly inaccurate position such as this, the license is revoked.
Separately, I am curious as to why the plaintiff chose to drop the case against the doctors.
I think they all knew the claims against the doctors were BS, and once they extracted money from the hospital, they knew that it wasn't worth pushing the lawsuit forward with the physicians any more.
Another absurd case that should have never been brought!
Pall care where I went to med school gave out morphine like candy to treat "air hunger" (aka dyspnea). Absolutely ludicrous opinion by plantiff's expert.
I can't believe no one has commented on the plaintiff's "Medical Expert" proclaimed themselves to be an expert in the standards of nursing care in multiple specialties as well as physician standards. Were the roles reversed the AMA would be clutching their pearls and fanning themselves.
I saw that but ran out of commentary room at the bottom. Very ridiculous that they appoint themselves an expert in all of these various fields in which they are not actually an expert.
"The opinion offered by the plaintiff’s expert is noteworthy for the false statements and ridiculous claims he makes. He alleges that the overdose caused pulmonary edema, for which there is absolutely no evidence. He claims that a morphine overdose causes “distressing physiologic effects” and a “sensation of breathlessness”. To state it simply, these claims are absolutely false. This physician is either so poorly educated that he doesn’t understand the basics of how opioids function, or he is simply lying to please the plaintiff’s attorney and collect a large paycheck (either option is extremely concerning given his senior role at a large teaching hospital). Respiratory depression caused by opioids would not be expected to cause distress, and there’s no evidence to suggest that the patient was anything but comfortable."
Why are we redacting names of people who appear to be behaving egregiously? Sunlight would appear to be one way of combating how these expert witnesses behave.
This always comes up when I publish a case with a terrible expert opinion. I don't feel like this newsletter is a good forum for publicly shaming doctors (even unethical ones). There are other avenues for reporting these things that are available to the defendants.
At 2mg/hour, this patient would have had carrier fluids. I can guess that the secondary drip (the morphine) might have been at the wrong height, which is what may have contributed to the rapid infusion.
This article explains the problem with secondary infusions and smart pumps. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8096316/
Also, IV roller clamps have been known to fail and they were moving or repositioning the patient when this happened. There are several instances of this reported in ISMP.
In any case, I do not understand the approval of this case to go forward.
I think there may be opportunities to make systems-level changes to avoid med errors like this. Would be ideal if the equipment we used prohibited making errors like this. Also, why not just move the entire pump to the new bed without taking the meds off of it?
Often the department has to keep their own equipment. ED probably wanted their pump back, so the gtt was moved over to the floor’s stocked pump.
Seems like everyone could share, although I know how (not) excited hospital departments are to collaborate with each other.
Often it’s an order from management. Sometimes nurses trade a pump for a pump with the receiving department when the patient arrives; however, that is occasionally problematic because pumps are programmed for department-specific medication. Therefore, I couldn’t trade an ICU pump for a floor pump.
If a carrier fluid was used it would be a primary infusion and the morphine gtt would be another primary infusion. That would allow both infusions to infuse simultaneously.
If the morphine were piggybacked/secondary on a bag of NS, that would defeat the purpose of a carrier fluid-- only the morphine would infuse until it ran dry, at which point the NS would begin infusing.
Dishonesty is equal in the Plaintiff’s bar and the defense bar. This is not a case I would have taken, and shame on the plaintiff’s attorney here. However, there are indefensible cases being defended by the defense bar every day.
I'm certainly willing to point out negligence when I see it (last week's case was a perfect example). That being said, I've read a good number of egregious expert witness opinions, and they've all been for the plaintiff. If I see an egregious defense expert opinion I'd love to publish it (open call to anyone reading this to send me one via email).
I will see if I can get my hands on a case I had where defense attorneys and defense experts defended giving an ESRD patient methotrexate for an ectopic pregnancy that didn’t actually exist. Then defended sending her home when she showed up the next day and made no attempts to reverse.
Defended the case up until the 11th hour instead of making a reasonable offer before everyone had wasted time and money. To this day, that woman’s death from mtx toxicity and the sequelae remains one of the most horrific I’ve ever seen.
Yikes! Send it to me: admin@medmalreviewer.com
"However, there are indefensible cases being defended by the defense bar every day."
Do you understand what a defense attorney's duties to their clients are?
Yes. I have been one.