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  1. #1
    SonNeedsTruth Guest

    Ativan overdose? Medical incompetence?

    What is the name of your state? Virginia

    My family and I are struggling emotionally over what we believe is at least medical incompetence and possible worse. A few months ago, my 81-year old mother complained of stomach pains and nausea for about three days. She finally decided it was time to seek medical help and asked me to take her to the Emergency Room on a Friday evening. Personally, I was relieved that she was seeking professional help.

    Upon admitting, her history of illness and her recent issues were discussed. She was generally in reasonably good health. She drove everyday and cared for my elementary-aged son after school while I worked. She was a cancer survivor and had a colostomy that she cared for without complications for over 20 years. Her diet was limited to a bland diet due to gall stones and she would occasionally have an attack. She was 5'3" tall and weighed 78lbs upon entry to the hospital. Over the past few days, she was unable to eat much due to the nausea and she had dropped a few pounds. It was noted on her medical entry that I had concern over her recent (10-day prior) exposure to pneumonia from me. Approximately nine months prior to this visit to the hospital, she had received care for pneumonia, had chest x-rays and she made a complete recovery. After a brief examination in the ER, she was admitted to a critical care room at the hospital.

    Initially, her care seemed to be fine and I was not concerned. She was started on IV antibiotics and glucose early that morning (roughly 3:00AM). The next morning I visited her in the hospital and we talked. She was very tired and restless from a long night of test and evaluations. She complained to me that she just needed some sleep and was having difficulty resting with the external noises. During the visit, I noticed that she was generally lucid with moments where she would forget things. She seemed very tired, a bit agitated and was restless. She was also very cold and asked for several additional blankets. At this point, she was being treated for mild pneumonia and it was not concerned to be life threatening. Her blood work showed a white blood count of 10,000. There was some concern over her stomach pain and nausea and x-rays were ordered to determine if she had some type of blockage in the intestines. I spoke with her nurse after the visit with her and we discussed a care plan for her upon her release from the hospital.

    Later that afternoon, my brother visited and had similar observations about our mother. She seemed tired, agitated and restless. When we asked her about visitors, she responded that she just really wanted to get some rest.

    Early that evening, I called the hospital to see she was doing. A nurse responded that she was resting comfortably and I decided not to visit that evening. The next morning, I receive a call from the doctor asking if we had any desires concerning a "living will." I was curious why she asked and she explained that my mother was in a "non-responsive" state and that her condition was now life threatening. I was shocked and told the doctor that I could not approve a DNR (Do Not Resist ate) order until I spoke with my brother and sister. I learned later that my response was taken as a limited DNR. I immediately call my brother and sister. We rush to the hospital and immediately notice her depilated state. Her hands were cold, they had her on an oxygen mask and I noticed her blood pressure had dropped considerably. It was now around 75 over 55. When I held her hand and talked to her, I received no response from her. She had a tube inserted into her nose and I noticed the contents of collection from the tube were bile-like in color (greenish and several ounces in volume). Immediately, I asked what had happened since I was there the previous day and I got no immediate response from the doctor or the nurse on staff. I asked the doctor what she believed was wrong with my mother and she indicated concern over a potential blockage in her small intestine. The doctor was concerned that my mother's white blood cell count had jumped to 14,000 and that she was possibly septic from a perforation of the small intestine.

    Later that afternoon, I learned about the DNR that had been placed on her chart and I immediately told the nursing staff to remove this from her chart. The doctor was called in to discuss this with me and my siblings. It was decided at this point that we wanted everything done with the exception of full life support. Over the next 24 hours, her vital signs improved for a short period, but she never regained consciousness and passed away at roughly 6:00PM the next evening. During that entire period, a family member was always by her side.

    After her passing, my sister and I began questioning her care and requested an autopsy to be performed by the hospital. In addition, we requested a full copy of her medical reports. I went through the reports looking for an answer and I believe I found what happened to her. Overall the report was thorough, however, I did notice a period of time where there were few notes about her care. Unfortunately, this is the period of time that I'm most concerned with. It does show that Saturday evening a .5 to 1mg dosage of Ativan was order by one doctor to be administered in her IV. After that a second doctor ordered, at what appears to be midnight, a 2mg injection of Ativan to be administered every 2 hours as needed for agitation. It appears that three doses of Ativan each at 2mg were given over the next six hours. It was this morning that the doctor called me and indicated my mother was non-responsive.

    I apologize over this long-winded diatribe at 5:00AM in the morning, but this brings me to my concern. (It is now been two months and I'm still having problems sleeping many nights). I'm not in the medical profession, but I can read and interpret information from the drug manufacturer. It indicates that the drug must be carefully administered to elderly patients and those with reduced lung capacity. In addition, contra indicators for this drug show the possibility of agitation and the possibility of further restricting airways. Also, the dosage for someone of her age, weight and physical condition seem to be completely inappropriate. All indications from what I read, indicate that someone of that condition should not receive more than 0.5 to 1mg for the first day and it is generally not recommended that more than 2mg be given in a 24 hour period.

    I firmly believe that her comatose state was brought on by the overdose of Ativan and that ultimately her death was directly related to the overdose. The autopsy (performed by the hospital) concluded that the pneumonia was the cause of death and personally I don't believe that is the "root" cause of the problem. What I find especially alarming from the autopsy was the lack of any trace of benzodiazepines (Ativan) in her system. With a dose of over 6mg within that period of time, wouldn't a trace of it be found in her system 72 hours later during the autopsy? This just doesn't make sense to me and sounds like a cover-up to me.

    Am I wrong to believe that this is complete medical incompetence and a possible cover-up by the hospital? I would sincerely appreciate any assistance (legal, medical or otherwise) with this issue.

    Thank you very much in advance,

    Sleepless in Virginia
  2. #2
    rmet4nzkx is offline Senior Member
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    I'm sorry for your loss.
    By all means take your concerns and records to a med/mal attorney for review and consultation.
    The issue of a living will usually is posed upon admission, so it's comming up later is not unusual if your mother was taken to critical care for further evaluation and obversation.
    Your elderly mother was in frail health for some time even though she had survived cancer and other health problems. The state of her GI system, was compromised.
    Your mother was very ill and underweight. She was administred antibiotics but these failed to fight the infection and sounds like an uphill battle that was too late to win by the time she entered the hospital. The cause of death seems to be the same as the autopsy results. Ativan does not affect the infection and was given after the antibiotics, so if any drug were to blame it would be the failure of antibiotics to fight the infection which they cannot always do and Ativan may have spared your mother an agonizing death from the infection. You did not mention blood gasses, pulse ox levels or whether or not ventilation was suggested when speaking about the DNR, so that could have been a fuzzy area.
    The dose of Ativan was WNL for IV even in elderly and titrated up, 2mg IV is considered the safe starting point for elderly and your mother was started at .5mg. You also have to consider other things in how the drug is metabolized and her condition prior to administration and her lack of response to the antibiotics.

    You described her as having not slept much, cold and alert but sounded as if she were agitated. Ativan is metabolized very quickly more so by IV administration so depending on how rapid a metabolizer and the other factors, There may not have been any serum Ativan present, rather it's metabolized forms. There may be some other problems with Ativan, but the problem is not so glaring as an inappropriate dosage.

    Perhaps a careful review of the actual records and consultation by a med/mal attorney can answer your questions, before you do that you may ask her PCP to review the records for their opinion.
  3. #3
    ellencee is offline Senior Member
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    SonNeedsTruth
    You are right to suspect that the dosage of Ativan exceeded the maximum dose. It did so with the first dose (2mg IV) and every dose given thereafter multiplied the level of over-medication.

    The initial dose of Ativan "IV" is the smaller of these two values:
    0.044mg/kg of body weight or a total dose of 2mg. In persons over the age of 50, the smaller dose as calculated above is the maximum dose in 24 hours unless the patient is having surgery in the next 15-20 minutes (respiratory and heart function will be maintained artificially/with assistance.

    The patient weighed 73#, which is 33 kg. 33kg multiplied by 0.044mg equals 1.45mg, which is the dose of Ativan that should have been administered initially and no more should have been administered during the next 24 hour period.

    You don't mention any ABG values or O2 saturation measurements/values.

    From your description of events, my best guess is that your mother became hypoxic due to having pneumonia and being on bedrest, lying on her back, and not receiving oxygen support or respiratory treatments to ensure adequate oxygenation. As a result, she became restless and agitated due to a lack of oxygen to the brain. This was not recognized, evaluated, or treated by the RNs or the MDs.

    Additionally, she was probably dehydrated. Dehydration affects mental acuity and behaviors; it also concentrates blood values, which makes values appear higher than they really are.

    Consult with medmal attorney in your area. Because of your mother's age and general health, and her health history, a medical malpractice suit may be difficult to prove and be financially rewarding. In today's healthcare settings, many hospitals and doctors are willing to reach an out of court settlement, no lawsuit filed/needed. An attorney can send a letter to the hospital's administrator and request a settlement in this matter due to the obvious professional malpractice by two physicians, the RNs on duty for those hours, and the hospital.

    Please keep in mind that I am NOT SAYING that your mother would have survived this episode of pneumonia. I am saying that it appears by failing to recognize, diagnose, and treat hypoxia due to pneumonia they overdosed her and crashed her cardiovascular and respiratory functions by assuming that her agitation was due to psychosis (many patients get ICU psychosis, not just the elderly).

    EC
  4. #4
    rmet4nzkx is offline Senior Member
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    Ellen,
    I agree with most of what you say, and that it is possible that the hospital may settle out of court. I would have liked to have been a fly on the wall at the M&M. I also think it would be difficult to prove in court, however, I think it premature to assign blame on anyone without the actual records. OP is focusing on the Ativan however leaves out many significant data, such as ABG etc. Did Pt approve the DNR when son was not there, which was later partially recinded by son to less than full life support, did he understand what that meant? What Rx was Pt on prior to admission, variances in those dosages could also have contributed to agitation and other Sx, in addition to hypoxia. Pt was already showing some confusion and memory loss prior to Ativan, also first dose was .5mg not 2mg., apparently titrated up and ordered PRN 6-8 hrs later per OP, some of this was out of chronological order, OP says,
    "It does show that Saturday evening a .5 to 1mg dosage of Ativan was order by one doctor to be administered in her IV. After that a second doctor ordered, at what appears to be midnight, a 2mg injection of Ativan to be administered every 2 hours as needed for agitation. It appears that three doses of Ativan each at 2mg were given over the next six hours. It was this morning that the doctor called me and indicated my mother was non-responsive." If it was PRN, was Pt awake and later became non responsive? Was Pt not intubated because of DNR and or modified DNR?
    After this I also would assume that it might be too much Ativan except that it started at .5mg and we have no results of any blood work during treatment re Rx and the autopsy showed NO ATIVAN which could be evidence of a metabolism problem or OP wasn't reading the results showing the metabolites. The other question, was Pt given any other Rx besides Ativan and antibiotic? Like good ol Morphine to make Pt "comfortable"? Op reports the record was thorough, my guess is that there are other clues in there another reason for Pt's PCP to review for their take before consult with med/mal attorney.
  5. #5
    ellencee is offline Senior Member
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    If the OP's account is anywhere near accurate, an overdose of Ativan is present, not once, not twice, not three times--four times an overdose of Ativan was given. Cardiovascular collapse will occur with Ativan overdose and apparently did occur. The OP didn't ask about all of the other medications; it's a moot point anyway. Everything else could have been done correctly and the outcome would probably have been the same due to the Ativan overdose.

    You better believe hospitals, MDs, RNs, etc. are settling out of court. In many ways, it is cost effective to settle without involving attorneys or the courts. The hospital will consider this family's request and will do so on the Ativan overdose alone.

    EC
  6. #6
    rmet4nzkx is offline Senior Member
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    Quote Originally Posted by ellencee
    If the OP's account is anywhere near accurate, an overdose of Ativan is present, not once, not twice, not three times--four times an overdose of Ativan was given. Cardiovascular collapse will occur with Ativan overdose and apparently did occur. The OP didn't ask about all of the other medications; it's a moot point anyway. Everything else could have been done correctly and the outcome would probably have been the same due to the Ativan overdose.

    You better believe hospitals, MDs, RNs, etc. are settling out of court. In many ways, it is cost effective to settle without involving attorneys or the courts. The hospital will consider this family's request and will do so on the Ativan overdose alone.

    EC
    The first dose of Ativan .5mg. was not an overdose, according to pharm site "As with any premedicant, extreme care must be used in administering lorazepam injection to elderly or very ill patients and to those with limited pulmonary reserve, because of the possibility that apnea and/or cardiac arrest may occur.

    Clinical trials have shown that patients over the age of 50 years may have a more profound and prolonged sedation with i.v. lorazepam. Ordinarily an initial dose of 2 mg may be adequate, unless a greater degree of lack of recall is desired.....the lowest effective dose should be considered since drug effect may be prolonged." So Pt get's .5mg in the evening, still awakw, so next doc orders 2mg since .5mg. has not sedated PT, 2mg. 2hr/PRN
    If overdose was COD then should have shown up in Autopsy, if Pt was non responder or rapid metabolizer Ativan may have not shown up and slow metabolizer might have had accumulation but it would have shown up in autopsy. Something is missing.
  7. #7
    ellencee is offline Senior Member
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    OK--so they overdosed her three times instead of four times. It is difficult for me to read posts that are not divided into short paragraphs, so I missed the .5-1mg. It remains that she was profoundly overdosed and it remains that her response to the .5 to 1mg dose clearly indicated that no further Ativan should have been given.

    Ativan is excreted from the body via the kidneys in 20-24 hours. That probably explains why no Ativan, or minimal amounts of Ativan, remained in the body at the time of the autopsy.

    I stand by my free professional advice and encourage the OP to speak with a medmal attorney about negotiating a settlement or contacting the hospital, et al. without an attorney as the administration of Ativan was indisputably excessive and without a plausible defense.

    EC
  8. #8
    SonNeedsTruth Guest

    Smile Thanks for the advice!!

    Ellen and rmet4nzkx:

    Thank you both very much for your responses. I really appreciate your thoughfulness. I have to run tonight, but I promise I'll write back and answer some of your questions.

    I forgot to add a few things, like the restraints and pulse/ox, etc.

    Again, thank you both for you thoughtful responses.

    Jeff
    P.S. Please excuse the numerous misspellings. It was a late night!
  9. #9
    rmet4nzkx is offline Senior Member
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    I'm glad you came back and can supply more data from your mother's chart. In addition to pulse ox levels, which is a measure of the bloods ability to carry oxygen, not the amount of oxygen saturation, several other things must be taken into account for accurate calculations because of her condition, which include temp when ABG's done otherwise they are based on 98.6, the actual type of monitors and/or lab equipment, RBC ect (was she anemic?), there is a formula to calculate in addition to pulse ox if there was no ABG, any other Rx your mother took prior to and during admission, history of any adverse drug reaction, Is she allergic to sulfa? were you there when the restraints put on? You said she was agitated, was she awake when the Ativan was given? Did your mother ask for a DNR when you were not there? Have you contact her PCP for their take on this?
  10. #10
    ellencee is offline Senior Member
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    In addition to pulse ox levels, which is a measure of the bloods ability to carry oxygen, not the amount of oxygen saturation, several other things must be taken into account for accurate calculations because of her condition, which include temp when ABG's done otherwise they are based on 98.6, the actual type of monitors and/or lab equipment, RBC ect (was she anemic?), there is a formula to calculate in addition to pulse ox if there was no ABG
    Not only is this information incorrect, it has nothing to do with whether or not the patient suffered significant damage from an overdose of Ativan. Whether or not the management of the patient's pneumonia was appropriate is only relevant to developing the medmal claim to possibly include additional acts of negligence, thereby increasing the damages (award) based upon a general picture of incompetence. Based on the event diary presented by the OP, the patient did not succumb to pneumonia; the patient succumbed to the Ativan overdose.

    The original poster should consult with a medmal attorney at once. Time is of the essence as the statute of limitations is generally one year when death of the patient is the result of the medical malpractice. The OP has several legal issues to be addressed; one of which is, are all of the adult children going to consent to the medmal claim? With only 9-10 months left in which to file a lawsuit, I feel sure the attorney would like to get the records reviewed and obtain an expert's opinion as soon as possible.

    The best advice I can give to the OP is to schedule a consultation appointment with a medmal attorney at the OP's earliest convenience. I believe that the OP has a >50% chance in negotiating a settlement; the hospital was negligent, the nurses were negligent, the second MD was negligent, and the hospital's pharmacist was negligent. The Risk Management department will be interested in limiting the impact upon the hospital.

    FYI-hemoglobin measurement is the measurement of the blood's oxygen carrying ability.
    Anemia, low hemoglobin, has NO EFFECT on SaO2. SaO2 is the percentage of the oxygen-binding sites on the hemoglobin (there are four sites/hgb) that have oxygen bound to them.
    You are confusing CaO2 (total oxygen content of the blood) with SaO2. CaO2 is dependent on the amount of hemoglobin (oxygen carrying ability) and on the SaO2, plus the affect by the PaO2(free oxygen molecules not bound to the hemoglobin) and the position of the oxygen in the disassociation curve.

    The temperature of the blood during oxygen content or satuaration measurement is going to have little clinical impact on the general patient.

    EC
    Last edited by ellencee; 12-03-2004 at 03:27 PM.
  11. #11
    rmet4nzkx is offline Senior Member
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    Ellen,
    You are the one who suggested that Pt hypoxia was mismanaged, thus the agitation from hypoxia was taken for agitation and Pt treated with Ativan inappropriately, insisting on it being an overdose without all the evidence to make that determinaiton.

    Many people are under the impression that pulse oximitry measures oxygen saturation, although in most caases it does, but since this was a critically ill pt we have to look at the other reasons, because it doesn't measure saturation and there is a formula to calculate it. Once ABG's are done it may be used to monitor, furtheremore, other metabolites bind with Hb in addition to oxygen withn the same bandwith, so both the pulse ox and co-oximiters used for ABG's can make a difference. So, if Pt was anemic or something else bound with Hb then it is possible that all the measures indicated good oxygen saturation, potential recovery, thus pt was not intubated and/or doctor ordered Ativan in good faith with the pt agitated and awake. I'm just looking for reasons to rule out the other causes before assuming Ativan overdose, especially since autopsy gave COD as pneumonia. The Ativan may not have made any difference in the outcome

    Remember, OP was assuming it was Ativan, and focused on that. How many times are elderly patients made comfortable with morphine? You know the drill, pt is agitated pt put on morphine in the middle of the night, kept sedated, then pt family notified, systems start shutting down.... the courts would be cloged with suits. Of course OP should consult with a med/mal attorney but I don't think we can say for sure that Ativan is the cause and not pneumonia.
  12. #12
    ellencee is offline Senior Member
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    I believe the only proximal cause of significant damages is the overdose of Ativan. That does not mean that other negligent events did not occur; it simply means if there is a meritorious claim of professional negligence, I believe the overdose of Ativan will be the basis for such a claim and the other events will only be useful to show a pattern of negligence.

    I'm sure the OP will consult with a medmal attorney and that is the only answer he needs from us--that consulting a medmal attorney is indicated.

    EC
    Last edited by ellencee; 12-04-2004 at 12:00 AM. Reason: why not?

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