Dr. Steven Miles was asked to review the former Attorney General’s expert report for comment:

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a. Opinion of Dr. Miles

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1. Comments Regarding Allegedly “Stable Patients”

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         Several of former Attorney General experts, all but one of whom were not treating clinicians, referred to some of the patients as “stable.”  The stability of any ill patient reflects a balance between the patient’s condition and the hospital’s capability.  As a sequestered staff burn out or are diverted to evacuations or as material resources are consumed, the hospital’s treatment capacity falls and the patient becomes frailer and has less margin for cure vis a vis the remaining hospital capacity.  Time matters.  The longer a patient in a collapsed hospital goes without customary monitoring with laboratory tests and radiographs, the more likely it becomes that a latent problem with become a crisis.

 

2. Comments Regarding Lack of Record Keeping

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            Medical records including clinician’s notes, consent forms, care plans, records of vital signs, drug administration sheets, orders and discharge summaries are also integral to the modern hospital.  The lack of consent forms and orders played a key role in each of the state’s expert’s opinions.  None of these Attorney General experts seemed familiar with how the dynamics of a collapsed hospital changes record keeping.  (Emphasis Added)

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•    Scarce time and short staff most dramatically reduce record keeping that simply records the past fact of treatment;

•    The collapsed hospital infrastructure also affects records, such as a physician’s orders, that effect care plans;

•    Records, such a care plans, communicate important facts to new shifts.  But if there are no new shifts coming in, then this function might well be triaged as a low priority activity.

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            “Given the highly degraded hospital environment, I do not feel that it is possible, as the Attorney General experts presume, to assess clinical charting on agitation, vital signs, or drug administration without comparing such to a sample of other patients from the same ward at the same time.”

 

3.Comments on the Morphine Forensic Evaluations

 

            Three tacit and unsupported assumptions underlie the former Attorney General experts’ conclusions that the morphine or morphine-midazolam drugs were lethal.

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•  First, the four former Attorney General medical experts opine that research has defined a lethal toxicologic dose of morphine or midazolam.  The experts’ do not offer support for this opinion and there is no evidence that the experts reviewed the literature.

• Second, all of the experts presume that the morphine levels in the post mortem tissue samples reflect levels at the time of death, a notioin that was abandoned many years ago by researchers.  This may be untrue because of the phenomenon pertaining to post-mortem drug levels that is called “post-mortem - redistribution.”  None of the experts took this into account in interpreting the morphine levels.

• Third, the experts tacitly assume that there is a standard dosing by physicians of these drugs because exceeding such doses is reliably lethal.  In fact, prescribed doses among patients who are perceived to be at the end of their lives vary hugely and such variations do not appear to affect time of death.

 

4. Preliminary Conclusions of Dr. Miles

 

a.             Memorial Medical Center from August 29 through the deaths of these patients was a profoundly compromised hospital that lacked customary clinical, data, staffing and environmental services.

(i)           The Attorney General’s medical and bioethics experts do not provide sufficient support for the claim that the presence or absence of orders for  morphine or midazolam is material to the conclusion that the cases that they discussed were homicides.

(ii)         The compromised hospital environment suffered a substantial and prolonged loss of treatment and monitoring capacities for profoundly ill persons.  The medical experts’ conclusions that some or all of these persons were stable or did not die of a fulminant medical condition are not supported by reference to outcomes and clinical courses in this particular hospital environment.

1.            The Attorney General’s medical experts do not provide sufficient support for any conclusion as to the lethality of the morphine levels seen in these cases.

2.            The Attorney General’s medical experts do not provide sufficient support to conclude that the drugs were given in doses that were higher than customary in these cases.

 

1.         Dr. Steven Miles

 

                                b.  Qualifications
       
Dr. Miles is a Minnesota licensed physician, who is board certified in both Internal Medicine and Geriatric Medicine and he practices and teaches hospitalist medicine at the University of Minnesota.  Dr. Miles has:

•    A federal license to use narcotics and regularly use such a drug, including morphine and midazolam, in his clinical work;

•    Extensive experience treating extremely frail persons with chronic conditions similar to those at issue in this report and has treated such persons in nursing homes, hospitals and clinics;

•    Extensive and distinguished background in medical ethics and palliative care and has published and taught on this subject;

•    Worked in disaster situations since 1979 in various locations with the American Refugee Committee (Program Director) and has a working knowledge of situations where an environmental emergency is accompanied by the collapse of a medical infrastructure;

•    Provided medicolegal expertise for investigating lethal events in health care facilities – most often with regard to asphyxial accidents in beds  -with practical experience in the format and content of medical examiner’s products and forensic investigations;

•    Is the author of the paper to introduce the DNR order; Miles SH, Cranford R, Schultz A. The Do-Not-Resuscitate Order in a Teaching Hospital. Annals of Internal Medicine 1982;96(5):660-4.