The Perfect Murder

While some deaths are fairly obvious, like a 95-year-old who dies at home in bed and had heart disease, cancer, COPD, diabetes, obesity, and hypertension. Those are most often exactly as they appear to be. As Dan Rather said, “If it’s green and jumps and croaks its probably a frog.” However, in my 20-year experience in nursing homes and some years spent as the county coroner, I wasn’t always so sure whether a death was natural, suicide, or murder. Real life is far removed from the story lines in the television series NCIS.

As a coroner, I once walked into a house at 2:00 am in the morning to see a man who had been dead for a week. On my job as a coroner, I couldn't always tell for sure whether the deaths were murder or not. The absolute mess and remarkable odor surrounding this obese, week-long dead person makes discernment between natural death and murder very difficult. The mortician even refused to take the body into his funeral home but rather put the body in his garage. After a week’s time, the spread of disease is a legitimate concern with a dead body.

I’ve forever wanted to write about committing the perfect murder...that’s one thing we learn as doctors, but I never wanted to be accused of writing a how-to article on murder. But now David Elio Malocco, lawyer and psychologist has written, How to Commit the Perfect Murder: Forensic Science Analyzed. And then there is Jessica Huntley's How to Commit the Perfect Murder in Ten Easy Steps: A Funny, Murderous and Twisted Psychological Thriller. From my perspective, if I really wanted to kill someone, I’d take them hunting because I’ve never heard of a hunting accident being investigated as murder.

When I was the coroner, there were a couple deaths that could have gone either way, suicide or murder. One was a young man who was lying crosswise at the head of the bed on some pillows tilting him away from the top of the bed. He had a neck tie around his neck which was tied to the headboard. So, as he faded into unconsciousness, the tie became tighter. I had some serious concerns about the nature of this death, but the police were determined to label the death as a suicide.

Years ago, I had an elderly diabetic patient in the hospital for COPD. He had five children. Four lived nearby, but one was a nurse in another state. The four children living nearby were willing to allow me to treat their father. But another sibling, a nurse who lived in another state, insisted that her father be put on end-of-life care. For whatever reason, the four children who actually saw their father on a regular basis did not argue against not treating their father even though they had agreed to it before the sister intruded. The end-of-life care prevented giving the patient the insulin he needed for his diabetes and it still took 7 days for him to die.

Hospice is a service to help people leave this world. But there are lots of rules to follow. First of all, there should be the honest belief that the patient has less than six months to live and that they should have none of the usual life-sustaining meds they may be on. In all honesty, sometimes children are anxious to get their inheritance. The meds that can be used in hospice are Ativan and morphine to keep the patient obtunded, which is considered to be merciful. We hear a lot of controversy about patient euthanasia when they are dying of painful deaths such as cancer. To my mind, there is very little difference between euthanasia and hospice. In the end, the average provider can accomplish the same comfort care in a way that I believe is more humanitarian than hospice.

There are many elderly people in nursing homes who have a variety of symptoms when they get sick. The elderly can have bronchitis, pneumonia, urinary tract infection (UTI), kidney infection, myocarditis, or a pulmonary embolus (PE), all of which can cause personality changes which can range from dementia to aggression.

For dementia, in nursing homes the first thing the nurses and administrators do is to have the MD sign an order form stripping the patients of their rights to make their own decisions, especially the right to live. Of course, this is discussed with the family members. Once a patient looses the right to make their own decisions about care, it is easy to withhold care from them.

In my experience, managing nursing home residents with dementia or aggression is slightly more complex. The nursing home environment is heavily regulated by federal and state governments, enough to make a normal person crazy. But what must not happen in a nursing home is one resident interfering with the rights of another resident. So, unwanted gestures or unwanted visits to another person’s room are strongly forbidden.

State requirements open the door to do whatever is necessary to control the environment of events which are required to be reported to the state. The solution usually results in a visit by a psychiatrist rather than a visit by the MD to see if there is a reversible, treatable physical reason for misbehavior.

In our society, psychotropic medications are the go-to for managing the unmanageable. Many of these meds are black-boxed (forbidden) for the management of the elderly because they are associated with death. And here enters the most over-used “correlation does not equal causation” rationalization for using these meds on the elderly. Yes, I’m very tired of hearing that old saw. Sometimes a thing is exactly as it appears to be.

In my opinion, correlation does not equal causation when it comes to the combination of certain psychotropics and death of a debilitated nursing home resident. These are not cause and effect. They are parallel. The patients die not from the psych meds, but from the lack of appropriate treatment for their treatable physical conditions. I can't tell you how many times I have observed nurses filing "code pink" reports for getting pinched by patients who normally do not act this way. It's time nursing staff looked for underlying causes for changes in patient behavior rather than waste time filing out code pink reports.

Years ago, I provided the care for 95-year-old twin males in a nursing home. One developed a UTI and the other did not. As expected, the one with the UTI became “demented.” Therefore, the family decided he should be allowed to die. They couldn’t understand why the other brother was not demented. But once the family decided the man with the UTI should die, they threatened to file a lawsuit if we treated the sick twin with the UTI which was causing the dementia.

To make treating infections in the elderly more difficult, we have antibiotic stewardship. We’re not supposed to even test for UTIs in nursing homes, much less treat UTIs with antibiotics. At the same time, the Centers for Medicare & Medicaid Services (CMS) has decided to punish doctors for non-treatment of kidney infections in elderly people. This leaves MDs damned if they do, and damned if they don’t. Tell me if this makes any sense that we’re not supposed to look for UTIs, but we are punished harshly for allowing kidney infections to develop from untreated UTIs. For MDs, it makes the most sense to test for and treat the UTI before the UTI develops into a kidney infection or the sepsis that goes along with kidney infections.

Then, of course you have the death by more obvious medical misadventure. A few years ago, there was a 62-year old man (not my patient) in the hospital during the Covid pandemic who presented with chest pain. He had an elevated troponin, which is a test used to discover heart muscle damage. The troponin was elevated on several tests and rose with each test. He tested negative for Covid three times. He was treated with Remdesivir, which is toxic to kidneys, and a somewhat useless Covid medication. The treatment lasted for six days. It is said that he reluctantly excepted a discharge for the next day, but by the next day, his chest pain had gotten much worse, and his Troponin was higher than ever. He was sent for treatment to the next largest town but died in the ambulance on the way.

There were several problems with his case. In the first place, this man was fraudulently treated for Covid, which carries a higher rate of reimbursement and is therefore punishable. Secondly, he didn’t have Covid. Thirdly, he had a heart attack, (myocardial infarction) which was not treated. Then you have the failure to treat and the death resulting from failure to treat. Now this case has several problems. This is only one of the 20 cases I’ve presented to the medical board which decided there was absolutely nothing wrong with the care provided. And neither did the Medicaid investigators. It’s hard to imagine how all of the supposed public safety nets such as state medical boards have remained willfully ignorant and inactive in recognizing genuine malpractice.

According to Dr. John Campbell, they were many places in the UK and in Sweden where people in the care homes who tested positive for Covid were placed on an end-of-life plan. Patients and their relatives, in cooperation with their patient physicians, are in the best position to decide on life-saving measures, but Dr. Campbell, assessing the situation, says:

“…but the problem is that doctors, mid levels, and nurses are bound by protocols and national regulations rather than their own clinical judgment. What we need is politicians who are completely honest, completely transparent, and always make decisions which are in the best interest of the people and empower professionals to use their professional discretion for the benefit of all humanity. We need the ethos of true public service."

For six years, one of the complicated patients I saw had had laryngeal carcinoma, and had a tracheostomy and an ill-fitting prosthesis for speaking. A tracheostomy is done to provide an airway when a person is unable to breathe through their nose or mouth. He also had colitis and was on a medication which worked well for him. In his mid 70s, he lived by himself and planted a big garden every summer. Because his prosthesis was ill-fitting I sent him back to his ENT doctor who replaced the ill-fitting prosthesis with another ill-fitting prosthesis and therefore recommended a referral to a tertiary care center like the University of Minnesota or the Mayo Clinic. But by then the patient had had enough of his prosthesis replacements and refused to go to another ENT doctor. So we limped along.

To add insult to injury, his insurance, (Medicaid) told him that he could no longer use the medication he was on to successfully deal with his colitis. So, they gave him what they called an "equivalent," which of course was much cheaper and really didn’t work at all for him. So, in addition to the laryngeal carcinoma, the poorly fitting prosthesis, the COPD, the colitis, and now his new problem of difficulty eating and sustaining his weight on the new medication, he had a COPD exacerbation. This man’s health equilibrium was balanced on the razor’s edge, which was getting sharper. What tipped the balance of this man’s health care situation was his COPD exacerbation and Covid. He was placed in the hospital and was under the care of another doctor. After a few days in the hospital, about 7 o’clock one night, he complained of being short of breath. The nurse on that shift gave him nasal oxygen but she didn’t notice that this was not how this man was breathing. His air exchange was through the breathing hole in his neck, but the nurse failed to recognize that the supplemental oxygen wasn't going into his prothesis. An hour later he was dead. Although this was probably not murder, it was at least an avoidable death This was yet another case I reported to the medical board which once again decided there was nothing wrong with this care.

Covid was certainly a nightmare to live through on many levels, but in my experience with the six nursing homes I was involved with, we didn’t see the same kinds of problems that Dr. Campbell described in Sweden and the UK. Nonetheless, I am certainly aware of the evolution of “do not resuscitate.” The first thing that must happen on the slippery slope of assisted or expedited death is that the patient needs to be declared incompetent and once that happens, the patient is on a very slippery slope not necessarily of their own making. As a physician, I have agreed to sign the papers that the nurses put in front of me. Occasionally, I disagree, only to get the papers back the next time I visit the nursing home, with a request for more “evidence," so I know the papers will keep on coming with every visit. In my experience, our nursing homes come no where near the alleged problems listed in other countries. However, "do not resuscitate" orders do block MDs from providing care for treatable conditions.

The line between euthanasia and withdrawing care at the end of life is very fine. Some family members hasten the death of their relatives by withdrawing care when the patient has a treatable condition, but this is not considered murder. End of life decisions are very difficult and require careful consideration of whether or not the patient has a treatable condition.

Years ago, I met a 93-year-old patient who liked to talk. So, I pulled up a chair and listened. He said, “I want you to treat me like a 73-year-old,” a rather succinct way of telling me that he didn’t want me to discriminate against him based on his age. His pleas did not fall on deaf ears. I want the same thing. At 77 I am now two years passed my U.S. expiration date. I intend to stay put on my ten acres, continue writing, reading, taking care of my chickens, and giving away eggs to my neighbors. I have found a good doctor who would treat my urosepsis or pneumonia if I wanted it to be treated.

In the end, deciding who should live, who should die, and who should be escorted off our mortal soil is a big job. Family members making decisions about their elderly members need to clearly understand what they are doing when they make a decision to prevent treatment of treatable diseases in the elderly. If I had my way, everybody would get the chance to have medical treatment for treatable diseases whatever their age.

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