On Monday, we invited your stories around the Patient Voice Principle that patients deserve “treatment that is appropriate, with disclosure of risk and discussion of less-invasive alternatives.”
Marian Hollingsworth
The story that Marian Hollingsworth sent us about her father broke our hearts. We know that most medical harm is unintentional, careless at worst. However every field has its bad apples; medicine is no exception.
(If you don’t know about “Black Box” antipsychotic drugs, and how dangerous they can be for the elderly, make sure you read to the end.)
Marian’s father, Dr. Keith P. Blair, a dentist in San Diego for almost 60 years.
Marian’s Story: My father, Dr. Keith P. Blair, became an intentional victim of medical harm when he was admitted to the hospital at the age of 86 to find the source of back pain. At the time, he had a little short-term memory problems, but he was able to follow news, sports, and his favorite TV shows, as well as take care of all of his physical needs.
Without my knowledge or consent as power of attorney, my father’s primary care doctor gave him a cocktail of Risperdal, Haldol, Ativan, Morphine and Tylenol with Codeine. He went into a sudden mental decline; I asked the doctor about this and was told the decline was due to “hospital delirium,” a condition where older adults get confused in the different environment in the hospital. He was sent to a nursing home for rehab, where he was given more antipsychotic drugs, along with double doses of Ambien. Again, there was no informed consent; in fact, the nursing home doctor never discussed his conditions with me. In less then three weeks, he suffered severe dehydration, heart and kidney problems, 7 falls in 12 days, contracted a MRSA infection and developed a bedsore. He ended up in a different hospital with severe dehydration and heart problems, where we again were told his decline was not due to any drugs, but rather to “sudden onset Alzheimer’s. He continued to decline and was dead a month after arriving in the ER. He was only in the nursing home 18 days.
After my father’s death, I obtained the nursing home and hospital records and realized what they had done to him, and how many doctors had deliberately lied to me. (I never saw the nursing home doctor until she gave a deposition.) I also discovered a number of falsified consent forms, including a “Do Not Resuscitate” order. I had to file 3 complaints with the California Department of Public Health, and appeal the case to Sacramento before the nursing home finally received 5 deficiencies related to the drugs, and 1 citation for Willful Material Falsification.
Because of my father’s case, the CDPH also passed a new policy mandating that nursing homes have to verify consent before administering antipsychotic drugs. I filed suit against the nursing home doctor, but lost in force arbitration. The Medical Board of California recently told me that my complaint against this doctor resulted in a letter of reprimand with conditions, a discipline that is reserved for cases where the patient suffered no harm.
I have now become a patient safety advocate with the Consumers Union and other groups. I want people to know their rights in a hospital and nursing home, rights that were denied to my father. I also want people to know the dangers of “black box” antipsychotic drugs so they will better be able to protect themselves in a facility.
We applaud the good work Marian did to make patients safer in the state of California, and her commitment to share the benefit of what she learned.
Since 2008 the FDA has required black box warnings on the labels of antipsychotic drugs, that they increase the risk of death in dementia patients. The warnings are “meant to help families balance the risks of these medications against their benefits.” Marian’s father did not have dementia. Nor was the family consulted about the risks versus benefits of using the drug.
The takeaway for families: understand the effects of antipsychotic drugs on elderly and dementia patients, and have a proactive conversation with the care team.
