8 year old and fentanyl?

[echobot3000]

Saw this article today and wondered what some of the anesthesia attendings and residents thought about the case?

An 8-year-old was taken off life support, his organs donated. Now, police are investigating

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[pgg]

The so-called whistleblower, their only "full time pediatric death investigator", who's casting doubt and making accusations that the palliative care given by a physician after a group of physicians agreed there could be no meaningful recovery, this character Bertone - is a nurse?

I'd rather have a pony as a mechanic.

 

[BLADEMDA]

UCLA's policy allows the use of opioids "in doses that are clinically appropriate to prevent discomfort," the newspaper reported. Under the policy, "interventions intended to preserve organ function, but which may hasten death, are prohibited."

Cole's ventilator was removed at 10:40 a.m. The chart said his heart stopped at 10:59 a.m. and Brill declared death four minutes later.

The coroner's office assigned Cole's case to Bertone, a registered nurse who was the only full-time pediatric death investigator.

Bertone, who said she reviewed the full medical charts and autopsy records, claims in her lawsuit that the boy "continued to gasp for air" and that Brill then gave him fentanyl "with the purpose of inducing his death."

Bertone's suit and coroner's records state that the administered dose was 500 micrograms. Bertone said she had concerns about that dose being given to a boy who weighed 47 pounds.

Doctor accused of using painkiller to quicken death of 8-year-old boy, police say

 

[BLADEMDA]

Here is the Physician Anesthesiologist, Judith Brill, publicly posted background:

UCLA Med Center

Specialties & Qualifications
Specialty: Anesthesiology



Subspecialties: General Anesthesiology
Education & Medical Training

• UCLA Medical Center
  Residency , Pediatrics
• Boston Children's Hospital
  Residency , Pediatrics
• Massachusetts General Hospital
  Residency , Anesthesiology
• Massachusetts General Hospital
  Residency , Anesthesiology
• Harvard Medical School
  Medical School

Certifications & Licensure

• American Board of Pediatrics
  Certified in Pediatrics
• American Board of Anesthesiology
  Certified in Anesthesiology
• MA State Medical License
  Active through 2017
• CA State Medical License
  Active through 2013

Awards, Honors & Recognitions

• Super Doc

 

[Noyac]

Emotions get in the way of intelligence once again. As a nurse this investigator struggles to understand reality.

 

[BLADEMDA]

A professor emeritus of clinical anesthesiology and perioperative medicine at UCLA, Brill, 65, is a well-regarded expert in the treatment of seriously injured children. She helped write the state guidelines for pediatric critical care and spent much of her free time on medical missions to treat poor children in Africa, Asia and Latin America.

With other members of the medical team, she informed the Hartmans that a brain scan was “markedly abnormal” and suggested extensive damage from lack of oxygen, according to notes she made in Cole’s chart.

The family “unanimously stated that they would prefer to withdraw support” and subsequently decided to donate his organs, Brill wrote.

Because Cole wasn’t brain-dead, the organ retrieval was to occur after the ventilator was removed and his heart stopped beating on its own under a procedure known as donation after cardiac death, or DCD. This type of donation began in the U.S. in the mid-1990s and has become increasingly common in the last decade as the medical community tries to meet the overwhelming need for organ donors. DCD accounted for about 10% of deceased donors last year.

DCD comes with time pressures. Organs can begin deteriorating immediately, and some are not suitable for transplantation after 30 minutes.

Cole was removed from the ventilator at 10:40 a.m. as a transplant team waited outside. He did not stop breathing immediately. What happened next is unclear. The full coroner’s report is sealed from public view pending the outcome of the police investigation, and UCLA declined to comment.

An 8-year-old was taken off life support, his organs donated. Now, police are investigating

 

[BLADEMDA]

Emotions get in the way of intelligence once again. As a nurse this investigator struggles to understand reality.

Maybe, you are correct. But, Brill could be charged with "manslaughter" or even second degree murder by the District Attorney. This case has wide implications for all of us.


Was a Hospitalized Boy's Death Hastened for His Organs? Police Investigate: Report
The probe is one of only a handful of known criminal investigations into a doctor's role in an organ donation.
Was a Hospitalized Boy's Death Hastened for His Organs? Police Investigate: Report

 

[dhb]

You can't kill a dead person.

 

[BLADEMDA]

Police investigating claims a dying boy, eight, who almost drowned in a washing machine was purposely given an overdose to then speed up his death and preserve his organs for donation

• Cole Hartman, eight, went into cardiac arrest after he nearly drowned in a washing machine
• An anesthesiologist is accused of administering drugs that sped up his death
• Physicians told Cole's family that he was not brain-dead but 'would never recover normal neuro function and could never awake'

Read more: Police investigate claims dying boy was given an overdose | Daily Mail Online
Follow us: @MailOnline on Twitter | DailyMail on Facebook

Dr. Judith Brill, 65, has been accused of hastening the death of a boy she'd taken of life support

Read more: Police investigate claims dying boy was given an overdose | Daily Mail Online
Follow us: @MailOnline on Twitter | DailyMail on Facebook

 

[deleted697535]

Why the flip did she give 500 mcg!?!

 

[GravelRider]

Why does LA county have a nurse as the sole "full time pediatric death investigator?" I could understand if this was rural America, but not LA county. You mean to tell me that LA can't find a forensic pathologist who specializes (?) in pediatric deaths?

Can we really get exact measurements of the dosage administered based on blood tests?

I also can't help but think that this is another example of the nursing mentality that they are here to protect patients from the mean and greedy doctors. We see this kind of thinking promoted all the time by marketing campaigns put out by nursing organizations. The doctor in question here seems to have had a career highlighted by dedication to her patients and service to the community.

This seems like a really slippery slope to me. We all know that in the setting of palliative care, opioids like morphine and fentanyl are given to treat respiratory distress. That was likely the stated intention here. One of the "side effects" of giving narcotics is that they hasten death. In these situations, our stated intention is to treat respiratory distress, but often times we actually want to hasten death (unspoken of course) out of compassion for a suffering patient. Who is to say what dose is appropriate in this situation? 50mcg of fentanyl likely would have hastened this patient's death just as quickly as 500mcg of fentanyl. Where do we draw the line? Now do critical care and palliative care physicians have to think twice about administering opioids at all? What about the ethical arguments of the lives that will be lost if we prolong the dying process because now there is a fear of administering opioids to a dying patient? This case sets a dangerous precedent on many levels going forward.



As an aside: There is a growing crusade against opioids in this country due to widespread addiction and abuse of narcotics. I have already altered my practice to use minimal narcotics in the surgical setting. This is likely the right thing to do for patients, but I have to be honest in saying that my main motivation is to CMA.

 

[pgg]

Why the flip did she give 500 mcg!?!

To treat the parents.

Remember, the kid was dead. The fentanyl wasn't for his benefit.


This is a hard concept to explain to laypeople. And nurses like this "full time pediatric death investigator" don't get it either, apparently.

I wonder if she puts FTPDI after the RN on her white coat.

 

[bigdan]

Let's say the numbers are correct (500 mcg to 47 pound 8 y/o)...so fu#king what? Was he on the vent for a while? Getting Fentanyl along the way? I'd be interested to see if these were divided doses, and what his prior Fentanyl requirements were...I remember an 18 y/o, slender woman with sickle cell disease from residency who was a frequent flyer in the ED...her starting analgesic dose during sickle crisis was 12 mg Hydromorphone bolus IV.

I see a lot of very sick (adult) patients, and do a lot of end-of-life/comfort care in my ICU. A clear, common understanding in situations of "comfort measures only" is that I (we) will focus exclusively on ensuring comfort for the patient, and aggressively treat symptoms of suffering, FULLY UNDERSTANDING that some adverse effects/side effects of those medications used in a moribund patient may unintentionally hasten death. I use some variation of this explanation with every family when we talk about the transition from treatment/cure to comfort only. Are we going to face lawsuits for "seeking to induce vomiting" from giving people volatile anesthetics now, too?

I just had a kid, my first one, a few months ago. Man, oh man, how life has changed. Can't even bring myself to complete the thought of what I would feel if I found my kid dead/near dead and then made had to make the choice to withdraw care. To make that choice and then have to watch your kid gasp for air???? Gimme ALL the Fentanyl you have, please.

 

[deleted126335]

There was a case I heard about more than ten years ago second hand. A famous surgeon was involved in a case where they pronounced a patient after coding them. There was still some EKG activity on monitor. Surgeon asked for KCL to quiet the monitor because he and/or someone else found it bothersome. He had some conversations with law enforcement afterwards. Maybe some other consequences.


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[Robotic Wis-Hipple]

You can't kill a dead person.

Well, legally, that kid wasn't dead.

This is obviously a political and emotional cluster that could go poorly for end of life care and those that provide it.

 

[nimbus]

Donation after cardiac death has always been controversial. There are competing interests. This case was inevitable.

 

[OB1🤙]

I know Dr. Brill. You will not find a more competent, caring, humane, ethical, all-around-exemplary physician or human on this planet.

These charges against her are frivolous, baseless, pathetic, disgusting. I don't even know where to start...

I hope that the system does her justice at the end of this fiasco.

 

[urge]

Bogus lawsuit. Won't go anywhere.

 

[deleted126335]

Bogus lawsuit. Won't go anywhere.

Forget the lawsuit. This is a criminal investigation. She may be facing jail time.


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[aneftp]

Forget the lawsuit. This is a criminal investigation. She may be facing jail time.


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It's a waste of legal resources. A very weak case. Especially since she worked at UCLA, a state facility. I assume they are public employees? There is no monetary gain. What's the motive? Unless she's getting kickbacks from the organ donation services.

 

[deleted126335]

Further a prosecutor's political career. Might even be a true believer. Some prosecutors are no better than clip board carriers


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[Ronin786]

This is exactly what happens when the role of expertise is diminished and everything is over sensationalized.

 

[Pharmado]

No one benefits from this situation. The RN who pushed for this investigation has lost her place at her job (rightfully so?). The anesthesiologist is being investigated for criminal charges for what was likely an act of compassion. The family is almost certainly being forced to relive the death of their child all over again. This nurse in her misguided quest has hurt everyone involved in the situation. She's taken a tragic event and made it an ongoing nightmare for everyone who had the misfortune to be involved in the case. Congratulations nurse Denise, you've made your point.

 

[WholeLottaGame7]

That nurse had an ax to grind, and she was going to keep grinding it til there was nothing left. Sounded like she was just waiting for the first pathologist to leave so she could bully the next one into accomodating her personal vendetta.

She should be the one going to prison for smearing what sounds like a well-respected, senior physician, not to mention forcing the family to go through the pain and misery all over again.

 

[drmwvr]

Interesting conversation...awful situation for Dr.Brill. My heart goes out to her and the family...but are some suggesting that, if someone did actually bolus 24 mcg/kg of fentanyl (not saying she did, btw, but that sounds like what is being alleged) for terminal ventilator withdrawal sedation, that would be defensible?

 

[Ronin786]

Interesting conversation...awful situation for Dr.Brill. My heart goes out to her and the family...but are some suggesting that, if someone did actually bolus 24 mcg/kg of fentanyl (not saying she did, btw, but that sounds like what is being alleged) for terminal ventilator withdrawal sedation, that would be defensible?

As mentioned above, who knows what level of sedation they were on before stopping the ventilator.

 

[Pharmado]

I'll bet each of the parents weighed 80 kgs or so, plus a grandparent or two and maybe a sibling. Sounds more like 1 mcg/kg to me. I'd bet she was treating the family as much or more than the patient at this point.

 

[DaTruMD]

I feel that if this goes to trial, the jury will act on emotion. Dr. Brill is going to wish she practiced in a state like Texas.

 

[GravelRider]

Something is fishy to me that they were able to predict the dose of medication given based on postmortem blood concentrations. There are way too many variables for that to make sense to me.

I am sure (hope) her lawyers are all over this, but I did a quick Pubmed search:

Reliability of Postmortem Fentanyl Concentrations in Determining the Cause of Death

"The very wide and overlapping ranges of postmortem fentanyl concentrations effectively nullify the utility of correlating the dose and expected postmortem concentration for any particular death. Based on the variable relationship between dose and blood concentration, the antemortem dose cannot be reliably predicted based on the postmortem concentration. This does not, however, render the medical examiner/coroner unable to determine the cause and manner of death because the toxicology results are only one datum point among several that are considered. Although there was a weakly positive relationship between body mass index and fentanyl concentration, further research is needed to determine whether adipose tissue represents a significant depot for postmortem release of fentanyl."

 

[nimbus]

This case represents a dilemma. It appears pretty clear to me that fentanyl 500mcg was given to the child in order to hasten death in an effort to preserve organ viability. That is against the law and against institutional policy but it makes sense to do so when the decision has been made to pull the plug knowing that the eventual outcome for this child is death. The question is how long do you allow the process of death to take. Minutes or hours? How much hypoxemia, hypotension and hypoperfusion will be tolerated in this situation? Dr Brill made a difficult decision for the good of all interested parties. She did not harm or cause suffering for this dying child. She preserved organ viability for potential recipients. The law needs to catch up to this reality. Hopefully this case will draw the attention of policy makers.

 

[deleted171991]

I wouldn't bet it was for organ viability. It may have been for a very distraught family who had trouble going through the process, in an absolutely brain-dead patient with zero chances of recovery to anything that's worth being called IQ or consciousness. I've seen it happen. I've seen families begging for something to be done, for ending visible and needless suffering ASAP. Society should either not put physicians in these situations, or stop double-guessing their actions and intentions.

I can't say enough how I despise this kind of feel-good unrealistic law and whoever prosecutes based on it. The result of this lawsuit is that more intensivists will do everything to cover their butts, and more patients will die in discomfort. This is like pain doctors as opiate boogeymans, which led to most pain practices not prescribing opiates anymore, to avoid legal headaches, when they were the most qualified to in the first place. Now we have PCPs with minimal pain management training treating chronic pain. Ridiculous.

 

[nimbus]

Something is fishy to me that they were able to predict the dose of medication given based on postmortem blood concentrations. There are way too many variables for that to make sense to me.

I am sure (hope) her lawyers are all over this, but I did a quick Pubmed search:

Reliability of Postmortem Fentanyl Concentrations in Determining the Cause of Death

"The very wide and overlapping ranges of postmortem fentanyl concentrations effectively nullify the utility of correlating the dose and expected postmortem concentration for any particular death. Based on the variable relationship between dose and blood concentration, the antemortem dose cannot be reliably predicted based on the postmortem concentration. This does not, however, render the medical examiner/coroner unable to determine the cause and manner of death because the toxicology results are only one datum point among several that are considered. Although there was a weakly positive relationship between body mass index and fentanyl concentration, further research is needed to determine whether adipose tissue represents a significant depot for postmortem release of fentanyl."

They probably got the dose from the medical record.

 

[GravelRider]

They probably got the dose from the medical record.

Yes, maybe.

Brill's lawyer declined to answer questions about the fentanyl allegation. In a portion of the chart reviewed by The Times, Brill does not mention fentanyl but wrote that "comfort care was provided throughout."

Either way, this still comes down to bad documentation...like many malpractice lawsuits. If she did give 500mcg of fentanyl, she should have realized that is an unusual dose. She may have had a very good reason for it, but the chart does not state it (again, I am assuming here).

 

[nimbus]

Yes, maybe.

Brill's lawyer declined to answer questions about the fentanyl allegation. In a portion of the chart reviewed by The Times, Brill does not mention fentanyl but wrote that "comfort care was provided throughout."

Either way, this still comes down to bad documentation...like many malpractice lawsuits. If she did give 500mcg of fentanyl, she should have realized that is an unusual dose. She may have had a very good reason for it, but the chart does not state it (again, I am assuming here).

I can think of only 1 reason to give 500mcg fentanyl to an ASA5-6 unconscious or semiconscious 21kg 8 year old.

 

[anbuitachi]

Could be tough to defend against. I feel bad for Dr Brill. This is criminal investigation, she could be spending a while in jail. And if this goes to Jury I can easily see this going against her when it comes to juries with no medical background.
I imagine pretty much most anesthesiologists can understand this was not meant to harm the child, and probably was an act of compassion. The kid is not offically brain dead, but pretty much dead. He was having agonal breathing, and likely on fentanyl in the ICU when vented. She gave 500 mcg of fentanyl prob to decrease the agonal breathing and provide comfort as much as possible. I highly doubt 'fentanyl toxicity' was even in her mind when she gave it, and even if she didn't mind speeding up the childs official death, I highly doubt it's for organ purposes, but more to decrease the childs suffering.

Can not believe the nurse did this and was on it for years... wow. Mustve hated Brill

Though why did an anesthesiologist give 500 mcg of fentanyl in the ICU after ventilator withdraw? Are the PICU run by anesthesiologists over there? I dont see a ICU training in her profile

 

[dA pilot]

I can not believe there would be any credible expert prosecution witness that will testify against Dr. Brill.

 

[anbuitachi]

I can not believe there would be any credible expert prosecution witness that will testify against Dr. Brill.

they can easily pay some anesthesiologist to do it... credible is subjective.. they are probably ok with board certification?

 

[Robotic Wis-Hipple]

I can not believe there would be any credible expert prosecution witness that will testify against Dr. Brill.

Oh, are you kidding me? They already have a toxicologist. And I'd be willing to bet they will have no problem finding some clipboard QI warrior with an axe to grind, I mean "doctors" come in all kinds of flavors these days, just look at the lead pediatric death investigator....

 

[Pharmado]

If this does indeed go to court, the case will likely turn on what the family says. If they say he was suffering and Dr. Brill made him comfortable to pass in peace, I can't see a jury convicting her of anything. If the family is against her for any reason, she'd better have a good attorney.

 

[anbuitachi]

If this does indeed go to court, the case will likely turn on what the family says. If they say he was suffering and Dr. Brill made him comfortable to pass in peace, I can't see a jury convicting her of anything. If the family is against her for any reason, she'd better have a good attorney.

But its about whether or not the fentanyl given was used to speed up death. I dont know if they care about comfort

I hope she doesn't spend the rest of her life in prison

 

[WheezyBaby]

Could be tough to defend against. I feel bad for Dr Brill. This is criminal investigation, she could be spending a while in jail. And if this goes to Jury I can easily see this going against her when it comes to juries with no medical background.
I imagine pretty much most anesthesiologists can understand this was not meant to harm the child, and probably was an act of compassion. The kid is not offically brain dead, but pretty much dead. He was having agonal breathing, and likely on fentanyl in the ICU when vented. She gave 500 mcg of fentanyl prob to decrease the agonal breathing and provide comfort as much as possible. I highly doubt 'fentanyl toxicity' was even in her mind when she gave it, and even if she didn't mind speeding up the childs official death, I highly doubt it's for organ purposes, but more to decrease the childs suffering.

Can not believe the nurse did this and was on it for years... wow. Mustve hated Brill

Though why did an anesthesiologist give 500 mcg of fentanyl in the ICU after ventilator withdraw? Are the PICU run by anesthesiologists over there? I dont see a ICU training in her profile

Our peds hospital has an anesthesiology run pain management service. Typically end of life transfers over to palliative, but if she was already consulting in a pain management capacity she may have stayed in through extubation

 

[Mman]

this is an interesting discussion, overwhelmingly likely the patient was given the best care possible, but creates some legal questions based on the exact sequence of events and doses of medicine administered. It said the patient was not brain dead and was extubated and apparently breathing and perhaps writhing a bit but ultimately about to die so received fentanyl for comfort. The question to me is the dosing. They say 500 mcg. Now was that a 500 mcg bolus? Or was it 50-100 mcg boluses over the course of 20 minutes for comfort? Because the latter looks a lot better than the former.

 

[nimbus]

It is also troublesome that the transplant team was in the hospital waiting to harvest the organs. Were they prepared to wait hours or maybe even a day or 2 if the boy's heart didn't stop right away?

 

[deleted162650]

It is also troublesome that the transplant team was in the hospital waiting to harvest the organs. Were they prepared to wait hours or maybe even a day or 2 if the boy's heart didn't stop right away?

That's a high volume transplant center. It doesn't surprise me that much that there would be a transplant team in house.

 

[Ezekiel2517]

The question to me is the dosing. They say 500 mcg. Now was that a 500 mcg bolus? Or was it 50-100 mcg boluses over the course of 20 minutes for comfort? Because the latter looks a lot better than the former.

lmao no ****. I've had to do this quite a few times in the unit, I've never seen a pt given a 500mcg dose straight up like that. I still think it's defensible, it's just not typically how it's done

 

[Mman]

That's a high volume transplant center. It doesn't surprise me that much that there would be a transplant team in house.

even if the transplant team is from outside they still have to be there waiting to go because the main concern is time to cross clamp. The organs go ischemic at time of death. It isn't like a donation after brain death where you can schedule the organ harvest for whenever is convenient. We have a decent number of DCD donors at our hospital and they will typically have the transplant harvest team (even if from other hospital) set up and ready to go in the OR before they extubate. I mean most patients it only takes a few minutes until death, but even if a bit longer it's not like the team or OR can do anything else.

 

[pgg]

It is also troublesome that the transplant team was in the hospital waiting to harvest the organs. Were they prepared to wait hours or maybe even a day or 2 if the boy's heart didn't stop right away?

What's troublesome, if there's anything troublesome in this story other than this nurse, is the entire concept of "donation after cardiac death".

Yeah, let's take a perfectly good set of organs and deliberately extend ischemic time by waiting until cardiac death, for fuzzy reasons. If this was my child, I'd be upset that his final gift of life to others was being compromised in this way.

 

[mppcc]

It is also troublesome that the transplant team was in the hospital waiting to harvest the organs. Were they prepared to wait hours or maybe even a day or 2 if the boy's heart didn't stop right away?

Per protocol they will only have a limited amount of time after withdrawal to harvest.

 

[mppcc]

this is an interesting discussion, overwhelmingly likely the patient was given the best care possible, but creates some legal questions based on the exact sequence of events and doses of medicine administered. It said the patient was not brain dead and was extubated and apparently breathing and perhaps writhing a bit but ultimately about to die so received fentanyl for comfort. The question to me is the dosing. They say 500 mcg. Now was that a 500 mcg bolus? Or was it 50-100 mcg boluses over the course of 20 minutes for comfort? Because the latter looks a lot better than the former.

Agree it is an interesting discussion. While 500mcg for a 49lb child sounds high harm is a judgement made by intent in this case. Palliative cares may hasten death if the primary intent is not to hasten death. It is difficult to determine beyond a reasonable doubt that the intent of the amount of administration was to hasten death.
The fact that any dose brings about later judgement in this case is in my mind the most concerning thing. So if one was to determine that 500mcg was too much after the fact, what about 475, 450, 425...100, 75, 50, or 25mcg? To my knowledge there is no absolute guideline for maximum dosage of opiates in a comfort care setting. There is no protection from prosecution at any dosage. The slippery slope potential in this is titanic. This may bring about serious changes in end of life care that may result in patient suffering regardless of the outcome in this case.

 

[nimbus]

What's troublesome, if there's anything troublesome in this story other than this nurse, is the entire concept of "donation after cardiac death".

Yeah, let's take a perfectly good set of organs and deliberately extend ischemic time by waiting until cardiac death, for fuzzy reasons. If this was my child, I'd be upset that his final gift of life to others was being compromised in this way.

I agree the best practical solution in these hopeless situations is to take organs from not brain dead, not cardiac dead but still living donors. Unfortunately that is unlikely to ever happen.