An Unquiet Death, Chapter 4: Drug of Choice

On his first day home from the hospital, Jerome Lackner’s hospice nurse wrote that death was “imminent.” The intake form indicated a marked shift in his condition.

When Jerome was discharged from Mercy General Hospital on the afternoon of June 24, 2010, his vital signs were stable, according to hospital records. He was breathing comfortably without oxygen. He was able to move around and had eaten most of his lunch. He was listed as “alert, oriented and able to make his medical decisions.”

A day later, Becky signed the intake form for Sutter VNA & Hospice, which noted Jerome as too weak to sign for himself. Two doctors, including his primary care physician, provided signatures approving his admission into hospice, saying he had six months or less to live.

The intake form describes him as bed-bound, on continuous oxygen, lethargic and confused. It said he was eating very little. “Death is imminent,” the nurse noted. “No action required.”

The form contained other information about Jerome’s medical history that contradicted earlier medical records. It said he took no narcotics in the previous week, though he had received both morphine and Fentanyl at Mercy; it repeated the assertion that he had lost 30 pounds in the last six weeks.

Hospice nurses and a social worker visited every few days at first. They were guides. Becky and her friend Joseph Poirier provided most of the care, with help from a hired aide, according to the hospice notes. They moved Jerome in and out of his bed, with its protective rails, in and out of his wheelchair.

The nurses answered questions about Jerome’s eating and sleeping needs, and helped with his oxygen tank. They explained how to comfort him in the dying process, and provided the doctor’s orders for treating pain if it arose.

As the first week stretched into a second, the nurses came more often – at least an hour or two every day. They called Becky or Joseph occasionally for spot checks, according to the notes recorded by the rotating staff.

Morphine is often the drug of choice for hospice patients. It’s meant to blunt the pain, steady breathing, calm fears and gently help a person die in relative comfort. These are the goals of hospice. So powerful a drug requires great care.

The nurses, by policy, weren’t supposed to touch Jerome’s morphine. They left it to Becky and Joseph. The nurses told them to monitor Jerome’s pain and assess whether he was short of breath. They were to give him morphine as needed, using an escalating scale based on the severity of his symptoms.

The hospice record runs to 141 pages, but is unclear about exactly when Joseph or Becky gave the morphine, or the amounts that Jerome received. It describes problems with the handling of the morphine that would form the basis for years of investigation into how Jerome died.

Getting him ‘under control’

The morphine came in a small vial. Becky and Joseph were trained to suction the clear, bitter liquid into a needleless syringe, then squirt it under Jerome’s tongue. They could give it up to once an hour, as needed, the doctor instructed: a quarter-syringe for mild pain, half a syringe for moderate pain, and a full syringe for severe pain.

In the early days of hospice, Jerome didn’t seem to need morphine. Each time the nurses assessed his pain, they rated it as low.

The record doesn’t say how much Becky and Joseph gave him day by day, but by July 5, 10 milliliters had been used, the equivalent of 20 “moderate” doses. By July 6 – Day 12 – Jerome was described as anxious and anorexic. When the nurse asked if Jerome had pain, he said, “no I do not have any pain, go away, get out of here,” she wrote.

On the morning of July 7, Joseph reported that Jerome was angry and combative, striking out at Becky. Joseph “managed to get condition under controle (sic) with medications,” the nurse wrote. Joseph told her he had given Jerome three doses of morphine in three hours, according to the hospice notes; the dosage size was unspecified.

The record does not detail the exact timing and amounts of subsequent morphine doses, but they appear to continue with some frequency. In a late entry for the night of July 7, a visiting nurse wrote that “Joseph stated he was medicating (patient) hourly.” She noted they had 20 milliliters of morphine left, and told them it was plenty to last the night. Just a few hours later, at 1 a.m., a second vial of morphine prescribed by the hospice director was picked up from the local Walgreens, according to a later coroner’s report.

The hospice record for July 8 indicates discord over the morphine. A nurse wrote that in a phone call, Becky said she had lost the new vial from Walgreens. Becky called again later to say she found it, half full. Joseph then told the nurse that Becky had watered down Jerome’s morphine, because “…she thinks its (sic) killing him,” the nurse wrote.

Later that night, a nurse told them that Jerome was “actively dying,” according to the hospice record. They were instructed to discard the diluted morphine, and a third vial was ordered. Joseph later would provide the coroner with his accounting of his medication log for the final hours of Jerome’s life; it showed 10 half-syringe doses of morphine over 13 hours.

In recent phone interviews, and in court documents, Becky and Joseph gave their perspective about those difficult days.

“I dumped the morphine and started giving him just Valium and stuff to cool him down,” Becky said. “Because he was dying and I didn’t want him to die.” She said her plan seemed to backfire when his pain spiked. “I called the hospice in the middle of the night when he was screaming. They came and gave him some morphine,” Becky said.

“Hospice said, ‘We leave it up to you, for his comfort,’” Joseph said. “(The nurses) told me to give a syringe every hour. I didn’t do that. I did .5.” He gave morphine to ease Jerome’s distress, “to help another human being …” Joseph said.

“What was hard was watching him gasp for air. It reminded me of my dad,” who experienced something similar, Joseph said.

The hospice record does not reflect those accounts. It shows no prescriptions for Valium, nor a panicky overnight call from Becky; in any case, hospice workers were not allowed to dispense morphine. The record mentions no desperate gasping – “air hunger” that morphine relieves.

Becky’s behavior – losing the morphine, then watering it – disturbed the hospice professionals enough to bar her from the process. Calling her “unstable,” they threatened to contact county authorities to ensure Jerome’s proper treatment, according to the hospice record. Joseph promised “that he will be fully in charge of medications and (Becky) would never be left alone with patient,” the record shows.

Amid such confusion, the record is hazy about how much morphine Jerome ultimately ingested. Notes about the first of the three vials were sketchy. It’s likewise unclear how much Jerome got from the second vial – lost then found, adulterated then discarded. A nurse said 5 milliliters was used from the third vial.

More uncertainty arose from Joseph’s way of ensuring that Jerome took his morphine. A coroner would later say that Joseph added it to Jerome’s beverages. That practice is generally considered improper, because it makes it hard to know how much a patient swallows. And it can undermine consent.

The night of July 8, Joseph said in an interview, he contacted nurses three or four times as he gave Jerome hourly doses. “They said, ‘Keep doing what you’re doing. His body is shutting down.’”

When a nurse arrived in the morning, Jerome seemed calm, according to hospice notes. His slow breaths sounded raspy, because he was no longer able to clear mucous from his throat. The nurse heard quiet gurgling, the “death rattle.” On July 9, two weeks after he began hospice, Jerome died.

The nurse noted in the record that Joseph destroyed the remaining morphine.

Becky “was sobbing uncontrollably,” the nurse wrote.

‘Chaos’ vs ‘chemical restraint’

More than a million Americans die during hospice annually, four of 10 in their own homes, usually cared for by family or friends. What happened in Jerome’s case might have reflected understandable confusion amid the awful stress of watching a loved one die.

“Do not underestimate the chaos of a household with a patient who is dying,” said Jeffrey Beane, a former hospice director for The Permanente Medical Group, who examined some of Jerome’s records for The Bee. Despite mix-ups and errors during those final days, he saw the situation as normal.

“Most families do well. Most families get through this. But a lot of families have problems…” he said. “They need a lot of support. They come unglued. Elderly spouses have a really hard time.”

Perhaps Jerome should have been given less morphine and more medicine to control agitation, Beane said. But “hospice nurses don’t walk around worrying, ‘Is this family trying to murder my patient?’”

Judy Melinek, a forensic pathologist who also reviewed some documents for The Bee, said the pressure and fatigue “of taking care of a difficult, combative individual … can exert great stress on even the most kind and patient of caregivers.” Given Becky and Joseph’s likely loss of sleep and the emotional toll, she said, confusion and changing stories seem unsurprising.

Other experts raised questions about another possibility – forced drugging, with disquieting implications about Jerome’s fate.

In general, in hospice, “you are not going to give a drug to someone if they aren’t experiencing the symptom,” said Thomas Reid, who directs the Hospice and Palliative Medicine Fellowship at UC San Francisco. If morphine is given without clear evidence that the patient is really in pain or suffering from acute breathlessness, that “is typically referred to as chemical restraint,” he said.

“In some cases morphine itself can be the cause of delirium,” Reid said. Delirium can compound agitation and confusion, and obscure a patient’s needs and desires.

Vincent Di Maio, one of the nation’s leading forensic pathologists, said he found the events surrounding the morphine troubling.

“If the person giving the morphine isn’t reliable, and doesn’t always give it at the right time, they give a little too much, that complicates everything …” he said. “This could be total incompetence or moderate incompetence or intent. And you can’t tell.

“And so, that’s the problem with this. Once these people get into a hospice, you always worry that (caretakers) expect the person to die, and they don’t treat them like they may survive.”

A call from Joseph

In the weeks after their father returned to Davis, Zelda and her sisters had no contact with him.

“We were a little bit in shock and letting the dust settle” after the recent upsets, Zelda said. “We were going to regroup and figure out how we were going to have a relationship with him after all that had happened. …We had no reason to believe his health was an issue.”

They said they made sure Jerome had his phone. He promised to call if anything went wrong, Zelda said, but he never did. She was away for two weeks, traveling. In time, Johanna tried him. No answer.

Nineteen days after Jerome left Santa Cruz, and less than an hour after he died, Zelda’s phone trilled. It was Joseph. She remembers him saying her dad “wasn’t in any pain” when he passed.

“I was in shock. I was crying and couldn’t catch my breath,” Zelda said. She hung up and called her sisters and mother.

“We met at Sara’s house, to be together. Once I walked into the house, I realized I didn’t know what to say. I had a very strange conversation with this man. I didn’t even know who he was. I still didn’t know what had happened.”

Zelda said she called Joseph back, and learned that her father had been in hospice. She said she gasped, realizing that they could have intervened, or at least said goodbye – had they known.

Federal rules call for a hospice to prepare close family members for a loved one’s death, to assess conflicts that could affect the grieving process. The hospice record does not mention that Jerome had children until after his death; the nurses seemed unaware that the extended family was deeply conflicted over the dying patriarch.

As the sisters huddled in grief, Johanna remembered having gotten a stream of text messages from Joseph when her dad was in Santa Cruz, after he’d filed for legal separation. Becky had briefly refused to speak with Jerome, on legal advice, according to a letter from her attorney to Jerome’s.

Joseph had acted as her proxy. “I’m a friend of his wife … Why aren’t you letting your father go?” she recalled him writing. “Bring him home now. This is criminal, what you’re doing.”

Johanna said she had turned off her phone, calling the texts “stressful and creepy.”

Following Joseph’s call, Zelda said, she and her sisters were immediately suspicious. “It just didn’t add up. … Especially because (Jerome) was fine when he left.”

After a few hours, Zelda called the coroner on behalf of her family. She faxed Jerome’s new will and legal-separation papers. She recounted her concerns.

She raised the prospect of foul play.

Charles Piller: 916-321-1113, @cpiller