... identify what opiates (and preferably also any other meds, like benzos) they have been taking. If they've been taking them for a long time vs less than a week, especially if they're trying a new opiate, the idea is to convert their daily dosage to their "Morphine Equivalent Dose", then the new opiate is given at a slightly lower dose than its equivalent Morphine Equivalent Dose and titrated upward.
If you don't ask what pills a patient is taking, you risk things like what happened to my grandfather -- he was hospitalized for his heart and assumed the doctors were giving him all his routine meds. He was psychotic within 3 days, and the psych doc consulted finally asked what all he took. My grandmother came up there with a suitcase full of pill bottles, because she didn't know which ones were current or leftovers from a discontinued med. (He took both Valium and Empirin-4, so yes, withdrawal psychosis from one or the other.)
Did you know they make fentanyl nasal inhalers for severe breakthrough pain? Highest dose they make is 800 micrograms (400 mcg in each nostril), but that's more than the 500 mcg one they were attempting to call murder.
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One other factor here is that anger is part of grief. When my mother passed away, I was angry at her for drinking herself to death and blowing it off when the doctor found bilirubin in her urine and wanted her to go back (her body, her choice.... but it hurt to watch).
But because of the *way* she died -- from a bowel perforation after she was given (over mine and my sister's objections, because she had a previous gastric bypass and already had constant loose stool) the standard dose of lactulose for a person with a normal gut... and COVID protocols meaning we couldn't sit with her and advocate for her.... the doctor NEVER calling to give us an update themselves or to talk about alternatives to lactulose... yes, I was VERY angry at the hospital/that doctor.
She might have had a few more months if the lactulose overdose didn't cause intramural gas and a perforation. But that time would have not been fun for her. She only realized her liver had complexly given out on her less than three weeks before her death, and a lot of that time was in the hospital alone. She didn't have time to make a will, or tell us what she wanted (when she was in her right mind, which she was after two days in the hospital on the first admission). or even really come to terms with the fact she was dying.
I don't know this case intimately, but I've seen people keep on fighting a futile fight because of their family's views too many times -- death and the process of dying is never "pretty", but some are harder to see than others. I've lost both my parents, and while I won't say anything about either was "easy"... it was harder to deal with a phone call from someone asking us (since Mom wasn't considered competent right then) what we thought she wanted regarding resuscitation, life support, etc than the phone call I got from the doctor who was treating my father to tell me HE was hospitalized and out of his right mind so his refusal of medical care had been deemed unreliable. Maybe it was harder because a call like that told us indirectly she was at death's door, but no doctor had ever spoken to either of us to tell us that.
But I only filed a JCAHO complaint, a Medicare complaint, and briefly considered suing for at least her copays from those two hospitalizations. They went ahead and waived them without me asking -- doubt that's standard after a death, so I guess they knew I was pissed.
If someone from the Medicare complaint people had told me that yes, he really should have considered he fact she already had nearly liquid stool as a result of the gastric bypass, and said yes the alternative drug should have been given instead.... I would have felt my anger was then justified by an outside party who didn't know her or me, and then HATE that doctor forever. I can only imagine what these families are going through, regardless of if he was simply negligent or really trying to be the Angel of Death to elderly patients without their consent.
I assume you've been following this case awhile, yes? I apologize for my ignorance on specifics.
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