HomeMy WebLinkAbout01-0076
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IN THE MATTER OF
CHERYL I. DYARMAN,
An Alleged Incompetent
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYL VANIA
ORPHANS' COURT DIVISION
NO. 21-01-76
IN RE: MOTION FOR RECONSIDERATION
BEFORE HOFFER. PJ.. BAYLEY and OLER. JJ.
ORDER OF COURT
AND NOW, this 70d day of February, 2001, upon consideration of the motion for
reconsideration filed in the above matter and following oral argument held on February 7,
2001, the motion is denied.
BY THE COURT,
J(JeSley Oler, r.
Robert O'Brien, Esq.
17 West South Street
Carlisle, P A 17013
Robert J. Mulderig, Esq.
28 S. Pitt Street
Carlisle, P A 17013
Jay A. Abom, Esq.
8 South Hanover Street
Suite 204
Carlisle, P A 17013
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IN THE MATTER OF
CHERYL I. DYARMAN,
An Alleged Incompetent
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
NO. 21-01-76
ORDER OF COURT
AND NOW, this 2nd day of February, 2001, upon consideration of the petition for
appointment of an emergency guardian for Cheryl I. Dyarman, an allegedly incompetent
person, and following a hearing held on January 24, 2001 and January 29, 2001, and it
appearing that the allegedly incapacitated person has been suffering for many years from
a debilitating and progressive physical illness known as demyelinating disease, which has
reached the state of guadriplegia, that it is difficult for her to communicate as a result of
the illness, and that she executed a living will in 1995 authorizing hospitalization,
intravenous therapy (including administration of nutrients, fluids and medication by
vein), antibiotics, and pain medications, but prohibiting artificial nutrition by means of
tube in the veins, nose or stomach, cardiopulmonary resuscitation, intubation and
mechanical breathing, kidney dialysis, and chemotherapy to fight cancer), and the court
finding that her ability to fully communicate decisions related to her physical health and
safety has been impaired by her illness and that irreparable harnl may result from a
failure to appoint an emergency guardian of her person with limited powers, Gloria A.
Anderson is appointed emergency guardian of the person of Cheryl I. Dyarman, for a
period of 72 hours, with a right to move for an extension of up to 30 days, for the limited
purpose of authorizing hospitalization for treatnlent of physical illness or condition,
intravenous therapy (including administration of nutrients, fluids and medication by
)
vein), antibiotics and pain medications, but without power to authorize those procedures
proscribed in Ms. Dyarman's living will and without power to authorize ECT treatments,
pending further order of court.
THE GUARDIAN is further requested to take such steps as she deems appropriate
to see that Ms. Dyarman is as comfortable as possible and to facilitate visits from persons
concerned for her welfare, such as members of the clergy, who might be able to alleviate
her suffering.
BY THE COURT,
Robert O'Brien, Esq.
17 West South Street
Carlisle, P A 17013
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JjWesley Ol~)r!, J. ~/\
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Jay A. Abom, Esq.
8 South Hanover Street
Suite 204
Carlisle, P A 17013
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IN RE: PETITION FOR : IN THE COURT OF COMMON PLEAS OF
INVOLUNTARY TREATMENT: CUMBERLAND COUNTY, PA.
OF CHERYL I. DYARMAN
,;-
: CIVIL ACTION-LAW
: NO. 01-0684 CIVIL TERM
IN THE MATTER OF
CHERYL I. DY ARMAN,
An Alleged Incompetent
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PA.
: ORPHANS' COURT DIVISION
: NO. 21-01-76
IN RE: OPINION PURSUANT TO PA. R.A.P. 1925
BEFORE HOFFER, P.J., BAYLEY and OLER, JJ.
OLER, J., February 12,2001.
These cases, filed under the Mental Health Procedures Act and the
guardianship provisions of the Probate, Estates and Fiduciaries Code, involve a
woman named Cheryl I. Dyarman who has become a quadriplegic as the result of
an irreversible and progressive illness known as demyelinating disease. The
object of the petitions presented to the court was to subject Ms. Dyarman
involuntarily to electroconvulsive (i.e., electroshock) treatments for depression.
The petitioner under the Mental Health Procedures Act was Robert L.
O'Brien, Esq., solicitor for the Cumberland/Perry Mental Health and Mental
Retardation Unit.l Attorney O'Brien also represented the petitioner under the
Probate, Estates and Fiduciaries Code, Kathy Myers.2 The court appointed Robert
1 Because of the exigent circumstances of the filing, the court did not inquire into the technicality
of whether the petitioner under the Mental Health Procedures Act was a "responsible party"
qualified to seek the relief requested. See Act of July 9,1976, P.L. 817, ~ 304(c)(l), as amended,
50 P.S. ~ 7304(c)(l) (2000 Supp.).
2 Ms. Myers was an employee of the Cumberland County Nursing Home, where Ms. Dyarman
has lived since 1987. The proposed guardian, Gloria A. Anderson, had been a friend of Ms.
Dyarman's mother and was Ms. Dyarman's attorney-in-fact pursuant to a power of attorney.
J. Mulderig, Esq., to represent Ms. Dyarman in the mental health proceeding, and
John A. Abom, Esq., to represent Ms. Dyarman in the guardianship proceeding.
A hearing on the petition under the Mental Health Procedures Act for
involuntary treatment and on the petition under the Probate, Estates and
Fiduciaries Code for appointment of an emergency guardian to authorize
electroconvulsive therapy was held on Wednesday, January 24, 2001, and
Monday, January 29, 2001, by the undersigned judge. Following the hearing, the
court entered an order in the Mental Health Procedures Act case declining to
commit Ms. Dyarman to a mental institution for involuntary treatment, and
entered the following limited order in the guardianship case:
AND NOW, this 2nd day of February, 2001, upon
consideration of the petition for appointment of an emergency
guardian for Cheryl I. Dyarman, an allegedly incompetent
person, and following a hearing held on January 24, 2001 and
January 29, 2001, and it appearing that the allegedly
incapacitated person has been suffering for many years from a
debilitating and progressive physical illness known as
demyelinating disease, which has reached the state of
[q]uadriplegia, that it is difficult for her to communicate as a
result of the illness, and that she executed a living will in 1995
authorizing hospitalization, intravenous therapy (including
administration of nutrients, fluids and medication by vein),
antibiotics, and pain medications, but prohibiting artificial
nutrition by means of tube in the veins, nose or stomach,
cardiopulmonary resuscitation, intubation and mechanical
breathing, kidney dialysis, and chemotherapy to fight cancer
. . ., and the court finding that her ability to fully communicate
decisions related to her physical health and safety has been
impaired by her illness and that irreparable harm may result
from a failure to appoint an emergency guardian of her person
with limited powers, Gloria A. Anderson is appointed
emergency guardian of the person of Chery 1 I. Dyarman, for a
period of 72 hours, with a right to move for an extension of up
to 30 days, for the limited purpose of authorizing
hospitalization for treatment of physical illness or condition,
intravenous therapy (including administration of nutrients,
fluids and medication by vein), antibiotics and pain
medications, but without power to authorize those procedures
2
proscribed in Ms. Dyarman's living will and without power to
authorize ECT treatments, pending further order of court.
THE GUARDIAN is further requested to take such steps
as she deems appropriate to see that Ms. Dyarman is as
comfortable as possible and to facilitate visits from persons
concerned for her welfare, such as members of the clergy, who
might be able to alleviate her suffering. 3
A motion for reconsideration, objecting to the court's refusal to commit
Ms. Dyarman to a mental institution for involuntary treatment and its refusal to
authorize the guardian to subject her to electroconvulsive therapy, was filed on
February 6, 2001. In response to the motion, a court en banc, comprised of
President Judge George E. Hoffer, Judge Edgar B. Bayley, and the undersigned
judge, was convened. Argument on the motion for reconsideration was heard by
the court en banc on Wednesday, February 7, 2001.
Following the argument, the court en banc declined to modify the prior
orders.4 On February 9, 2001, a Petition for the Application of Extraordinary
Jurisdiction Pursuant to 42 Pa.C.S.A. Section 726 was filed with the Pennsylvania
Supreme Court by Mr. O'Brien. The petition basically requested the relief which
had been sought in this court, and indicated that the guardian was not willing to
exercise the limited protective powers on behalf of Ms. Dyarman that had been
authorized and that she had refused to seek an extension of those powers as
permitted by the order and by law.5
STATEMENT OF FACTS
Cheryl 1. Dyarman is a 52-year-old woman who resides and is cared for at
the Cumberland County Nursing Home. She was admitted to the nursing home in
1987.
3 Order of Court, February 2, 2001 (emphasis added).
4 Order of Court, February 7, 2001.
5 See Act of June 30, 1972, P.L. 508, S 2, as amended, 20 Pa. C.S. S 5513 (2000 Supp.).
3
From an early age Ms. Dyarman has suffered from an irreversible,
progressive illness from which she will not recover known as demyelinating
disease. In anticipation of the progress of the disease, she executed a living will in
1995, containing the terms recited in the order of court quoted above.
The illness has now progressed to the point that Ms. Dyarman is totally
paralyzed with the exception of an ability to move her head somewhat from side to
side and to speak, unclearly and with great difficulty. She can also cry or wail
when acutely distressed.
She is totally unable to assist herself with respect to bodily functions and
needs, including eating or drinking. She is totally dependent upon others for her
physical care.
Ms. Dyarman' s husband left her. She has no children or close relatives. In
the past, some relief from her suffering was provided by her mother, whom she
loved very much, by a gentleman from the Gideon Bible Society who visited her,
and by weekly hair treatments. Her mother died in April, 2000; the gentleman
from the Gideon Bible Society retired due to his own advancing age; and the
weekly hair treatments no longer interest her.
Ms. Dyarman is severely depressed. At one point in the hearing, Mr.
O'Brien requested silence so that those present could hear what Ms. Dyarman was
wailing. She was wailing, with great difficulty, "I want to die."
Mood elevators administered to her in the past have gradually ceased to be
effective. For a number of months she has declined to accept such medication,
and she has become increasingly resistant to efforts to convince her to swallow
food. Her weight has decreased dramatically.
A psychiatrist from Franklin County who consults with the nursing home
and who is familiar with Ms. Dyarman is of the view that electroshock therapy
would be the treatment of choice at this point for her depression, since medication
has lost its efficacy. Such treatment would be inpatient and would consist of a
series of electroconvulsive sessions over a two-week period. The electric current
4
would alter the chemistry of her brain, and might erase some of her memory. The
treatment would in no way alter the relentless course of her physical illness.
The first day of hearing in these cases was held at the nursing home, in Ms.
Dyarman's room, by the undersigned judge. The court observed Ms. Dyarman,
and her indescribably difficult circumstances, and was firmly of the view that she
understood what was transpiring, that she did not want to undergo
electroconvulsive therapy, that her despair was a rational response to an
intolerable situation, and that her unwillingness to accept food presented to her
mouth was borne of a natural reluctance to extend the duration of her physical
deteri orati on.
The court did not believe that Ms. Dyarman was mentally ill in the sense
that her depression was inspired by forces other than her actual condition or that it
was more than the normal reaction of any sentient person to the condition she was
In. The court felt that she had been brave for a long time.6
Following the hearing on the second day, the court entered the orders
related above, denying the request for commitment of Ms. Dyarman to a mental
institution for involuntary treatment and appointing an emergency guardian in the
person of Gloria A. Anderson 7 to facilitate medical treatment, including
intravenous medication and nutrients, in accordance with Ms. Dyarman's living
will, but not authorizing her subjection to electroconvulsive therapy in the absence
of further order of court.
As noted, a court en banc, following argument, declined to modify these
orders. Mr. O'Brien thereafter filed the petition for exercise of extraordinary
jurisdisction by the Pennsylvania Supreme Court mentioned above, indicating the
6 In this regard, it is interesting to note that another recent attempt to have Ms. Dyarman
committed to a mental institution, by way of a petition for emergency involuntary treatment under
Section 302 of the Mental Health Procedures Act, failed when an examining physician at the
Carlisle Hospital refused to approve the commitment.
7 See note 2 supra.
5
guardian's refusal to exercise the powers which had been granted to her under the
court's order and her refusal to request an extension of those powers.
DISCUSSION
A fundamental principle in a case of this type was expressed more than a
century ago by the United States Supreme Court in Union Pacific Railway Co. v.
Botsford, 141 U.S. 250, 251, 11 S. Ct. 1000, 1001, 35 L. Ed. 734, _ (1891).
No right is held more sacred, or is more carefully guarded,
by the common law, than the right of every individual to the
possession and control of his own person ....
This principle, which embodies the right to refuse medical treatment, "has
deep roots in our common law" and is recognized in Pennsylvania. In re Fiori,
543 Pa. 592, 599, 673 A.2d 905, 908 (1996). The right is not, of course, absolute.
Under the Mental Health Procedures Act, a person who is mentally i1l8 to a
degree describable as severely mentally disabled9 and who is in need of treatment
may be subjected to involuntary examination and treatmeneo at certain
institutions. I I However, the burden of proof upon a petitioner in such a case is
8 Mental illness is not specifically defined under the Mental Health Procedures Act. Oler,
Pennsylvania Criminal Law: Defendant's Mental State, S 4.4, at 58 n.32 (Michie Co. 1986); but
see 55 Pa. Code S 5100.2.
9 The Mental Health Procedures Act defines severe mental disability in the following terms:
A person is severely mentally disabled when, as a result of mental illness,
his capacity to exercise self-control, judgment and discretion in the
conduct of his affairs and social relations or to care for his own personal
needs is so lessened that he poses a clear and present danger of harm to
others or to himself.
Act of July 9, 1976, P.L. 817, S 301 (a), as amended. 50 P.S. S 7301(a) (2000 Supp.).
The existence of a clear and present danger of harm to others or oneself is generally
dependent upon the occurrence within the immediately previous 30 days of certain acts by the
sugbject: the infliction or attempted infliction of serious bodily harm upon another, conduct
evidencing self-neglect reasonably likely to have serious consequences within 30 days, attempted
suicide and the reasonable likelihood of repetition, or attempted or actual self-mutilation of a
substantial nature and the reasonable likelihood of repetition. Act of July 9,1976, P.L. 817, S
301(b), as amended, 50 P.S. S 7301(b) (2000 Supp.).
10 Act of July 9, 1976, P.L. 817, S 301(a), as amended. 50 P.S. S 7301(a) (2000 Supp.); id., S
304(a), as amended, S 7304(a) (2000 Supp.).
11 Act of July 9, 1976, P.L. 817, S 105, as amended, 50 P.S. S 7105 (2000 Supp.).
6
"clear and convincing evidence." Act of July 9, 1976, P.L. 817, ~ 304(1), as
amended, 50 P.S. ~ 7304(1) (2000 Supp.). Clear and convincing evidence is the
highest burden in the civil law. 12 In addition, the opinion of an expert, while
entitled to consideration, is not binding upon the court as trier-of- fact, even if
d. dB
uncontra tcte .
Under the Probate, Estates and Fiduciaries Code, a guardian of the person
may be appointed for a person who is incapacitated within the meaning of the
act. 14 For purposes of a guardian of the person, an incapacitated person is "an
adult whose ability to receive and evaluate information effectively and
communicate decisions in any way is impaired to such a significant extent that he
is partially or totally unable .., to meet essential requirements for his physical
health and safety.,,15 An emergency appointment for 72 hours, subject to an
extension, is provided for in the act.16
However, several statutory factors militate in favor of an exercise of this
authority by a court with a degree of restraint. First, one goal of the act is to
permit "incapacitated persons to participate as fully as possible in all decisions
which affect them ...." Act of April 16, 1992, P.L. 108, ~ 7,20 Pa. C.S. ~ 5505
(2000 Supp.). Second, a guardianship of the person is to be "limited" in scope, as
opposed to "plenary" in scope, in the absence of a finding that the person is
"totally incapacitated." Act of April 16, 1992, P.L. 108, ~ 9, 20 Pa. C.S. ~ 5512.2
(2000 Supp.). Third, electroconvulsive therapy is expressly excluded from the
powers of a guardian of the person in the absence of a specific finding and order
of the court to the contrary. Act of April 16, 1992, P.L. 108, ~ 8(d), 20 Pa. C.S. ~
5521(d) (2000 Supp.).
12 Spaw v. Springer, 715 A.2d 1188 (Pa. Super. Ct. 1998).
13 See Moriens v. Albert Einstein Hospital, 363 Pa. Super. 557, 561, 526 A.2d 1203, 1205 (1987).
14 Act of April 16, 1992, P.L. 108, S 9, 20 Pa. C.S. S 5512.1 (2000 Supp.).
15 Act of April 16, 1992, P.L. 108, S 6, 20 Pa. C.S. S 5501 (2000 Supp.).
16 Act of April 16, 1992, P.L. 108, S 10,20 Pa. C.S. S 5513 (2000 Supp.).
7
Fourth, the right of individuals "to control decisions relating to their own
medical care" has been recognized in sections of the Code providing for living
wills. Act of April 16, 1992, P.L. 108, ~ 5, 20 Pa. C.S. ~ 5401-16. Finally, the
burden of proof upon a petitioner in an incapacity case is "clear and convincing
evidence," the highest burden in civil law. Act of April 16, 1992, P.L. 108, ~ 8(a),
20 Pa. C.S. ~ 5511(a).
In the present case, the court did not feel that petitioners had shown by
clear and convincing evidence that Cheryl 1. Dyarman was subject to involuntary
treatment under the Mental Health Procedures Act, nor to the appointment of a
guardian of her person with the extraordinary power to authorize her subjection to
electroconvulsive treatments with a view toward altering her mental attitude as it
related to a hopeless and progressively debilitating physical illness that had
reached the point of almost total paralysis. She had committed no crime which
might be said to have warranted a forfeiture of her basic rights. 17 A guardian of
her person was therefore appointed with powers to carry out the wishes which she
had expressed at a better time in her life.
While the court has no question as to the sincerity of the belief that the
relief requested in the petitions herein would promote the welfare of Ms.
Dyarman, it is also mindful of the observation of Benjamin Franklin more than
two centuries ago:
To bear other peoile's afflictions, every one has
courage and enough to spare. 1
BY THE COURT,
~(
r, Jr., J. .()
17 Cf Commonwealth, Department of Public Welfare v. Kallinger, 134 Pa. Commw. 415, 580
A.2d 887 (1990) (state prisoner may be force-fed).
18 Ben Franklin's Wit and Wisdom, at 22 (Peter Pauper Press).
8
Robert L. O'Brien, Esq.
17 South West Street
Carlisle, P A 17013
Robert J. Mulderig, Esq.
28 South Pitt Street
Carlisle, PA 17013
John A. Abom, Esq.
8 South Hanover Street
Carlisle, P A 17013
9
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IN RE: PETITION FOR
INVOLUNTARY TREATMENT
OF CHERYL I. DYARMAN
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 01-684 CIVIL TERM
IN THE MATTER OF
CHERYL I. DYARMAN
An Alleged Incompetent
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 21-01-76
ORDER OF COURT
AND NOW, this f., rt, day of February, 2001, upon review of the attached
257 61 b 2Jl L 2..:>,\'-> ~ o.Jll; I csd
Motion for Reconsideration, aJHulrin!j is set in th"'at matter for W ('d ~ ~ ' the
'7~ day of Fe 10 r"" -"/ ' 2001, at 1.00 A. ~ in Courtroom #---.-L,
Cumberland County Courthouse, Carlisle, Pennsylvania.
BY THE COURT,
....
. ..
. ~
IN RE: PETITION FOR
INVOLUNTARY TREATMENT
OF CHERYL I. DYARMAN
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 01-684 CIVIL TERM
IN THE MATTER OF
CHERYL I. DYARMAN
An Alleged Incompetent
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 21-01-76
MOTION FOR RECONSIDERATION
1) Movant is Robert L. O'Brien, Esquire, as attorney for Cumberland County
MH Office.
2) Movant had filed a request that Cheryl I. Dyarman be committed to a
psychiatric facility to receive care and treatment. In conjunction with this request,
Movant had also requested that the Court consider appointing a guardian because it
was anticipated that the care required to alleviate Ms. Dyarman's condition was electro-
convulsive therapy (ECT). The guardianship law provides a specific method for the
Court to hear and consider a guardian's approval of ECT treatment.
3) The matter was heard by the Honorable J. Wesley Oler, who, despite
receiving clear and convincing evidence that Ms. Dyarman is suffering from a severe
depression, which has resulted in her refusal to take medicine and nourishment, with
the result that her weight has gone from approximately 105 Ibs in July of 2000 to
approximately 65 Ibs at the present time, declined to commit her for psychiatric care
and would only appoint a guardian for very limited purposes.
.....
,...
.-.
. .
4) Movant believes that the limitations placed on the guardian, and in
particular, the guardian's inability to administer nourishment through a feeding tube, will
only prolong the starvation of Ms. Dyarman.
5) Movant also believes that the failure to order psychiatric care will cause
Ms. Dyarman to continue to suffer delusions and sadness, despite testimony from the
consulting psychiatrist that ECT treatments have a success rate in excess of 900/0 of
those receiving them.
WHEREFORE, Movant respectfully requests that the Court reconsider its
determination in regard to Ms. Dyarman by review by a panel of the Court en bane.
Respectfully submitted,
O'BRIEN, BARIC & SCHERER
By:
r ~06N4--
Robert L. O'Brien, Esquire
Attorney for
1.0. # 28351
17 West South Street
Carlisle, Pennsylvania 17013
robrien@obslaw.com
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IN THE SUPREME COURT OF PENNSYLVANIA
MIDDLE DISTRICT
IN THE MATTER OF CHERYL I.
DYARMAN, AN ALLEGED
INCOMPETENT,
No. 22 MD Misc. Dkt. 2001
Petition for the Application of
Extraordinary Jurisdiction Pursuant to 42
Pa.C.S.A. Section 726
-.;:J L" C I -- 17 G;
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ORDER
PER CURIAM:
AND NOW, this 15th day of February, 2001, the Petition for the Application of
Extraordinary Jurisdiction Pursuant to 42 Pa.C.S.A. Section 726 is hereby DENIED.
TRUE & CORRECT COpy
ATT.:Jt;:~ 1 tl.~O~i.,' ~, .1, ~ "
SH\RLE~
APPEllATE CLERK
-,
IN THE MATTER OF
CHERYL I. DYARMAN,
An Alleged Incompetent
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
NO. 21-01-76
INCAPACITATED PERSON
ORDER OF COURT
AND NOW, this l- Q K day of l' l-1l1 . ,2001, upon review of the
attached Petition, a hearing is scheduled in this matter for Wednesday, the 24th day of _
January, 2001_, at 3:00 p.m., at the Cumberland County Nursing Home, Carlisle,
Pennsylvania.
Personal service of this Order and accompanying Notice and Petition shall be
caused to be made upon the alleged incapacitated person by Petitioner in accordance
with the Probate, Estates and Fiduciaries Code. Notice shall also be given to all other
persons and entities required to be notified under the Code. Proof of service shall be
furnished at the above-scheduled hearing.
.JDln)f ,q, ~ ~o~ ,
D.a' 'ia <6n~eR, Esquire is appointed to assist the alleged incapacitated person.
Cumberland County is directed to pay $150.00 to said attorney for representation of the
incapacitated person at the scheduled hearing and the County is directed to seek
reimbursement from the Commonwealth pursuant to 20 Pa. C. S. A. Section 5511 (c) in
the following fiscal year.
BY THE COURT,
~
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<,', '~IANJ 'i ' ';f
"
IN THE MATTER OF
CHERYL I. DYARMAN,
An Alleged Incompetent
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
NO. .:2/-01 - 7b
INCAPACITATED PERSON
NOTICE
A petition to have you adjudged an incapacitated person has been filed
with this Court by Kathy Myers. A hearing is scheduled in this matter for
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: ~Cf'cLJ': {4; the " 7 ~7'-d ay of :.<< ,/1// <I " ( ,2001, at 3: od a. m ,e) in C 6tJ I Ii uum - . H .
'. -I 1'} I. . tI ",-r
CN'k.--fUi~ ~'LA'_(fu ~y~ :./.
.il.=====::1"tUIII dllJ urlly CuudIIOt::tSe,-Carlisle, Pennsylvania. You are strongly
encouraged to be present at the hearing, and you are warned that important rights may
be lost as a result of the proceeding. You have the right to be represented by counsel
and the right to request the appointment of counsel and to have counsel so appointed
paid by the Court where you are unable to afford to pay an attorney.
YOU SHOULD TAKE THIS NOTICE TO YOUR LAWYER AT ONCE. IF YOU
DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE
THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL
HELP.
Court Administrator
Fourth Floor
Cumberland County Courthouse
Carlisle, Pennsylvania 17013
(717) 240-6200
CHERYL I. DYARMAN,
An Alleged Incompetent
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN THE MATTER OF
NO.
INCAPACITATED PERSON
PETITION FOR APPOINTMENT
OF A TEMPORARY GUARDIAN
OF THE PERSON PURSUANT
TO 20 PA. C.S.A. 5513
1 ) Your Petitioner is Kathy Myers, a representative of Claremont Nursing and
Rehabilitation Center.
2) Respondent is Cheryl I. Dyarman, an incapacitated person, currently
receiving care at Claremont Nursing and Rehabilitation Center, 375 Claremont Drive,
Carlisle, PA 17013. Respondent is an adult individual being presently 52 years of age
with a birth date of August 9, 1948. The Respondent has a POA, Gloria A. Anderson.
Ms. Anderson is the successor to Ms. Dyarman's mother who passed away in May,
2000.
3) Ms. Dyarman suffers from Demyelinating Disease of the spine, a disease
similar in its effect to multiple sclerosis, as well as major depression. She has been in
the nursing home since 1987. Since approximately July, 2000, Ms. Dyarman has
engaged in a pattern of refusing nourishment and medications. Her documented
weight loss is as follows: August 101 Ibs., October 89 Ibs., November 80.4 Ibs.,
December 76.8 Ibs. and January 74 Ibs. The psychiatrist who consults at the nursing
home, Dr. Hegarty of Chambersburg, PA, believes that inpatient psychiatric care and
probably a course of electroconvulsive therapy is necessary to break Ms. Dyarman out
of her depression. Hershey Hospital has reviewed the matter and is willing to admit Ms.
.,
Dyarman to their facility. Ms. Anderson has the authority thru the POA to admit Ms.
Dyarman to the facility. Additionally, a commitment thru the Mental Health Procedures
Act is being considered. Without intervention, Ms. Dyarman's weight loss will continue
and likely result in her death.
4) 20 Pa. C.S.A. Section 5521 (d), authorizes the Court to approve the
Guardian's consenting to certain procedures, one being electroconvulsive therapy.
5) The proposed Guardian has no interest adverse to that of Cheryl I.
Dyarman.
6) Ms. Dyarman has no parent, child, husband or other close relative. Her
income consists of a monthly social security benefit.
WHEREFORE, Petitioner, Kathy Myers, respectfully requests that the Court
order that Respondent Cheryl/. Dyarman be adjudged an incapacitated person and
Gloria A. Anderson be appointed emergency Guardian of the Person and Estate.
Petitioner also requests that the Court give due consideration to authorizing Ms.
Anderson to consent to the use of electroconvulsive therapy as a procedure for Ms.
Dyarman's care.
Respectfully submitted,
O'BRIEN, BARIC & SCHERER
~~ fl~~
BY
Robert L. O'Brien, Esquire
I.D. # 28351
17 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
"t . \'
IN THE MATTER OF
CHERYL I. DYARMAN,
An Alleged Incompetent
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
NO.
INCAPACITATED PERSON
CONSENT TO APPOINTMENT
I, Gloria A. Anderson, of Newville, Cumberland County, Pennsylvania, consent to
be appointed emergency Plenary Guardian of the Estate and Person of Cheryl I.
Dyarman. I represent to the Court that I have no interest adverse to Cheryl I. Dyarman.
~ ~~A~
-
Gloria A. Anderson
VERI FICA TION
I verify that the statements made in the foregoing Petition to Adjudicate
Incapacity and Appoint A Guardian of the Person are true and correct. I understand
that false statements herein are made subject to the penalties of 18 Pa. C.S. Section
4904, relating to unsworn falsification to authorities.
~K~
rob/mhmr/dyarmanemer. pet
. ,
DOCTOR'S PROGRESS NOTES
DATE
RECORD PROGRESS OF CASE, COMPLICATIONS, CHANGES OF
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.....
AUTHORITY TO PAY COURT APPOINTED COUNSEL
MJ\Y 0 J. 20111 fIJ
( !
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-,
1. COURT ~on 2. VOUCHER
o District Justice Pleas 0 Appellate o Other NQ 5778
3. FOR (DJ., C.P., APPELLATE) 4. AT (CITY/STATE) b BUDGET CODE
, ~}.7j/)-/o'-t I - o::{)
6. IN THE qASE OF {~ . /) 7. CHARGE/OFFENSE (PURDON CITATION) 8. 0 PETTY OFFENSE
.;ftJ ((;.; ~~L . )'-14~~ ~ o FELONY 0 MISDEMEANOR
9. PROCEEDINGS (DescriMrielly) I 11. PERSON REPRESENTED 12. CIVIL DOCKET NO.
-WU-(~~O 1r~'-~-!5 1 0 Derendsnt- Adult
2 0 Defendant. Juvenile
3 0 Appellant 13. CRIMINAL DOCKET NO
4 0 Appellee
5 0 Habeas Petitioner o , - 7(P oy ph .
6 0 Matenal Witness
7 0 Parolee Charged With Violation
10. PERSON REPRESENTED (Full Name) 8 0 Probationer Charged With Violation 14. APPEALS DOCKET NO.
(;Yu2Af1L .L1/!&~Ai 9 0 Other:
yo r I - fJ J
-V / -U 16. NAME OF ATTORNEY/PAYEE AND
Appl Dale MAILING AJcRESS
() /Jks&-. P){~ () tA,.) A. 450 --
e s.. l.f~ Uu?1C.-. f7f- c
NAME OF COMMON P~ JUDGE ASSIGNED TO CASE 5v.-lz ;)01 fA (?or'~
cM1(~ ~
17. TELC\qONE Nql l.~SOCIALSECURITYNO OREINNO
:1 -D on 15 "/~~~ €'(q
CLAI M FOR SERVICES OR EXPENSES
19. SERVICE HOURS DATES AMOUNTS CLAIMED
a. Arraignment and/or Plea Multiply rate per hour times total
b. Preliminary Hearing hours to obtain "In Court" com.
pensation. Enter total below.
e. Motions and ReQuests "-
~ d. Bail Hearings ,\ .\A '{ \.,)
a:
::J e. Sentence Hearings r"I\ "\
0 r\ '-
<.> f. Trial \--"'~-~- ~i r-.\
!
g. Revocation Hearings \ 'T.;.' i ,/\) \
h. Juvenile Hearings ,""'\ " " fU'
i. Appeals Court _4' 19A. TOTAL IN COURT COMPo
~ Other (Specify on additional sheets)
TOTAL HOURS ::0 .3'(1/ i{:) . 0'-.;' =$ I~)~~. O()
~HOUR
20. a Interviews and conferences Multiply rate per hour times total
b. Obtaining and reviewing records hours. Enter total "Out of Court"
~.... compensation below.
Oa: c. Legal research and brief writing
~::J
::JO d. Investigative and other work (Specify on additional sheets) 20A. TOTAL OUT OF COURT
Ou COMP.
TOTAL HOURS::: l{ '5 '-rS ~L) ;: $ ~&Y '51.
"". ~"HOUR '~ -' - . D
21. ITEMIZATION OF REIMBURSABLE EXPENSES AMT. PER ITEM
MileaQe $.25 per mile x
a:
w
J: 21A. TOTAL ITEMIZED EXP.
....
0
...$
22. CERTIFICATION OF ATTORNEY/PAYEE 23. GRAND TOTtt CLAIMED
Has compensation and/or reimbursement for work In thIs cue prevIously been applied for? DYES o NO = $ C-)i-/ ;:-j()
If yes. were you paid? DYES o NO If yes.. by whom were you paid? How much? 24. DEDUCT. PRioR PYMTS.
Has the person represented paid any money to you, or to your knowledge anyone else, in connection with the matler for
which you were appointed to provide represen~~~74J.!S.I'IP NO If yes.. give details on additional sheets =$
I swear or affirm the truth or correctness < . 25. NET AMOUNT CLAIMED
of the above statements y Slgnalure/gf1tlomey/~e~ Date =$
26 Al'pnUl/l [T . ~. r( {/!/L-oVfl~L 27. AMT. APPROVED
. FOI~ S.gnature of . Date: t'Vt ;I 1 7. I 200 1
"AYME,NI Judge =$St.ty.~D
cJpy 1 - Mail to ~rt Administrator at completion of service
~
APR 2 7 200~
J /'
---,/
Ahom & Kutulakis
Suite 204
8 South Hanover Street
Carlisle, P A 17013
Ph:(717) 249-0900
Fax:(717) 249-3344
Richard Pierce
Cumberland County Courthouse
One Courthouse Square
Carlisle, P A
17013
April 24, 2001
Attention:
File #:
Inv #:
01-009
31
RE: In re Cheryl Dyarman - incompetency
DATE DESCRIPTION HOURS AMOUNT LAWYER
Jan-23-01 Attendance at Orphan's Court to obtain 0.10 4.50 JAA
Petition
Telephone call to Rob O'Brien re Petitions 0.20 9.00 JAA
Telephone call to David Green re Petition for 0.20 9.00 JAA
Guardianship
Jan-24-01 Attendance at Nursing Home to visit wi client 0.30 13.50 JAA
Attend Meeting with client's social worker 0.70 31.50 JAA
Attendance at incompetency hearing @ --.... 1. 8 0 81.00 JAA
nursing home
Jan-25-01 Attend Meeting with client and spoke wi CNA 1.00 45.00 JAA
who has positive relationship wi client;
discussed competency and mental health issues
wi Kathy Myers
Telephone call to Robert O'Brien 0.10 4.50 JAA
Attend Meeting with Judge Oler re case issues 0.20 9.00 JAA
Jan-29-01 Attendance at court - hearing re Motion to -.. 1.20 54.00 JAA
Appoint Guardian (in chambers)
Invoice #: 31 Page 2 April 24, 2001
,
.
.
Feb-08-0 1 Attendance at re-argument en banc via - 0.60 27.00 JAA
telephone from Hbg. Hospital
Feb-09-01 Telephone call from Supreme Court requesting 0.10 4.50 JAA
response to Motion for Extraordinary Relief
Review and analysis of Petition for 3.00 135.00 JAA
Application for Extraordinary Jurisdiction and
prepare Answer to be faxed to Supreme Court
Telephone call to Gary Gilden 0.10 4.50 JAA
Telephone call to Taylor Andrews 0.10 4.50 JAA
Telephone call from Gary Gilden and Bob 0.50 22.50 JAA
Hoffman of Reed Smith seeking advice
concerning recent case law on the issue of
rights to receive and refuse medical treatment
Telephone call to ACLU 0.10 4.50 JAA
Feb-12-01 Review and analysis of Atty Mulderig's 0.10 4.50 JAA
Answer to Petitioner's Motion
Feb-14-01 Telephone call from Rob O'Brien re case 0.20 9.00 JAA
Feb-15-01 Telephone call from Mrs. Sholly re her visit wi 0.20 9.00 JPK
client
Telephone call from Pa Supreme Court 0.10 4.50 JPK
Feb-23-01 Telephone call from Laura Martz - concerned 0.20 9.00 JAA
citizen seeking info on how to visit Cheryl
Dyarman
Feb-26-01 Attend Meeting with client's aunt and uncle re 1.00 45.00 JAA
case status
Totals 12.10 $544.50
Total Fee & Disbursements $544.50
Balance Now Due $544.50
TAX ID Number 25-1877844
..
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DURABLE (a~NEItAL POWER OF AT'fORNEY
I, CHERYL I. DYARMAN, or Cumberhu\d Cf)IJnty, Pennsylvania. do hereby
nppoiut my mother. JANE R. RUSSELL, or821 Green Spring ROAd, N~wvme, PA 17241,
AS my attorn~y-in-rRd, for me and in my nonle. to mnoage my atTain 85 listed below itS I
might do ir personally present. I hereby revnke Any power of attorney previ()usly eleentetl. ~
If JANE R RtrSSEL..L for any reason fails or ceases t() IlctJJ'-P~~I~GLORIA A.
~ ---.'-'-'--'- ..--. '. -.'.---
^~DERSON. IS my true and laftiful SutttlJor Ilttorne)'..in-rltct with all of the powers
,___ I
hrretofort grnr.ted to JANE It. RUSSELL, Itnd 1 authorize ftnd empower GLORL\ A.
ANDE~~?~1~!er1iry to the death of JANE R. RUSSEL.IJ, or to her inAbility to function
hereunder and 1 hold harmless anYOtle who relies upon such certification AJ\d ( declare that
ftll ads taken 1n reliance thereon shall be as valid as if taken by JANE R. RUSSELL.
This pow~r of attorney shall not be affected by ttlY subsequent diSAbility or
incltpacity. All acts done by my attorney-tn~ract pursuant to this power during any period
of my disability or incapacity shall have the same elTect "nd enure to my benefit ~Ild bind
me slUd my successors in ill!trest 1\S if I were competent and not disabled. I grant to my
attorlley-in-fsd alld suceessor (if applicable) tile fQIlOlving powers:
I. Cash-~CCOUlU.t.. To collett and recei~'e any n10ne)' and Assets to whkh , may
be entitled; to deposit cash ftnd check,. in AUY of my Accounts; to endor~e for dello~it,
trftllsfer or follection, in my lIame Rod for my accouut AllY ehetks pay~ble to my <>rder; ftnd
10 drftw ftnd sign checks or other withdrawal fo..f1t~ fol' rue Rnd in my nnnH~, inchlding Rny
Rccount, opened by my Agent jn my name At ~ny bAnk or banks, s"ving~ sodtty or
elsewhert; and to receive And IIpply the proceeds of SUcll (hecks as my agent defms best;
and to act a~ my rel>r~stntAtive pnyer for nil Sodal Security. MedicAre.. and other ffdernl
"ntl state benefits.
2. SlO.tks.JlOJldlJU1.lLOjher...1(l~tmtI1JS. To (ltke cu~(ody ~r my stocks, bonds
''JlI!'
nnd oilier investments of all kindt. t~ gh/e ordel'~ for the snit, !lurrender or f.chf\l~8f' of Any
~~I . .." ~'!'
GYAkMAN, CHERYL 1 209
~t~OKD #24S9 -
~~~!j DAT( 8~19-19B7
,;, J C B 8 - 9 - 1 94 B
[. CCNH
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~llch in"e5tment~ and to receive the proceed, therefrom; to sign and deliver A!Ilsignfntnts.
stock and buud POWtrs alld oCher docUdlents required for any such sRle. nssignl1tftlf,
surrender or e:uJuulge; to give orders for tile purch8~e of stocks, bond, and other
investments of an,- kind and to settle for same; to live lnstructicns as to the registration
thtreof and the mailing of dividends and interesf.; to dip and deposit coupons attached to
1lllY coupon bonds. whether now owned by me or acquired lit a future date.
3. Bnr.ro.wina.. T() borrow money for my account and upon the seC:tlrity of my estAte
and to pledge as sfcnrity for nrch loan or loans any or all of my property Rod estate, And to
t'~ecllte, .ekllowledge and deli\ier to the lender or lenders .lIth notes. bonds Itnd
."'-
assignmenl! 8S lilY said 9Uorneys mAY deem necessary or BdvisnbJe for such purposes.
4. P~JOn8LPrQP@rty.. To buy or stll at public or private sale for cash or credit
()r by any other means whatsoever, to acquire, dispose of. repair, alter or manale my
tangible personal J)roperty or AllY illtereJts therein.
5. Re.aL~ To l~.se, sell, release. convey, eltinguisb or mortgage Rny
interest in any real estafe 1 own, induding, but DOl Ii m iCed to, any reAl estate, 0'1 Stich terms
RS my agent deems adviSAble, and 10 purchase or otherwise acquire allY intere8t itl Rnd
acquire posseSSio.. of real property and to accept aU deeds for such property; to rn8I1ft~e,
repair, impro'\lt, mAintain. reslore, build, or develop any "eal p,'nperty in whid, I now have
or may later Acquire An interest, and to PAY, conte8f. protest and compromise real estate
tales Ilnd assessments.
6. SAkJlepJluLBJ!ltL To have acces~ to 1"'Y and .All safe deposit bo~es now or ...~
hereafcer standing in my nRlIle. and add to and to remove nil or Itny pArt o~ tht (otltents
thr-reof; ftnd .0 enter into I(\!ses for ~lI(b sftfe deposit bo~es or surre'lder samt'.
7. lu.S.uranc.e.. To procure, chAnge. cnrry or cftuefl insurance of Slid. kind in
~
"tlcl1 Rmounts ftg1tinst any and All risks affecting propt'rty 01. l,erlOn! Rgllinst linb~hty.
2
vYARMAN, CHERYL I 209
RE (O~D ~l1.e59 ·
A~MIT DAfE 8-19-1987
008 0"'9-1948
CCNH
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dltmale or dRim of any sort
8. Ben..cCatj!J1.IlL To "pply for and I'eceive any lov~rnment. il1slIrnnte and
retirement benefits. induding individual retirement ftctOllnts. to "hith I roay be entitled
ftnd to e.ercise any right 10 elect benefits or payment options.
9. IaKs.. To prepare, ex(tute and tile in my name and on my behalf sny tllJ: n
returns such as Jrtt~rnftl Revenue Senice forms numbered 1 through 10,000, iududing
return, report, p..otest~ applic1ltion for rorrectlon of assesstd valuation of real or otl,er
property or claim for refund in any t'o8llection with any faJ imposed by 811Y government
alld to obtain an eltenslon or time for Any of the foregoing or to extfute wai\len of
restrictions on the as!essment of defitiency on any tax.
10. Cl_im!l,. To institute, prosecute, defend, compromise or othernise dispose of
and to appear for me in any proceedings at hnv or in equity.
11. MulOt Vebidtt.. To etecute all the netessary documents for the sfde~ transfer or
encumbering of any motor vehide(s) whi~h I may oWO.
12. Medital Pro~,dur"A. To grant, refuse, withhold or withdraw C00gent on nty
behalf tor any health care service .nd therapeuticftl a..d 8urgical procedures~ including the
administration of dtllgs.
13. Admis.sio.o....lnloJa.dlities... Tn Apply for m}' admission, djuharge and/or
transfer to or from medical, nursing. residential, rehabilitation, convalescent or oUler
similar fatUities on my behalf, and to Jiln Any tootene, Admission, or transfer forms
required by such facilities which are consistent with t.his power, to obtain, receive, Stnd
review copies of my mt"dital records and to consent to the disclosure or .bose r~c()..d! and to
enter into agr'eements fOf my rare by such facilities or elsewhere during my lifetime or for
.,.,
lt~ser periods or time as Illy "gent nllly de~ignate, i..rluding the retention of t'U:{~S rorn.y
{ , '
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,
Jc,Y~kMAN, CHERYL I. 209
f.ctCORD "2459
A~Mlr DATE 8-19-1987
COG 8-9"'19~8
~ CCNH
L0:LT TO, sr N~f
SGd 8Et'
3WOH 3s~nN Ai: awn: Z9ZSEt'2LTl
14. laJment of [\1edital El~nse8... In the absolute discretion of my ssid attorneys,
to "I,ply BUY principal and illtome to the payment of the cOSl of my m"inten~nce and care.
ill allY Mspital_ nursing hom~, public or pri"at~ institution~ or at my residence. and to the
pllymtnt of alaY medical, surgical. dental or nursing care which may be Or is required for
..~
me.
IS. EmploJQ)ent or Pr.re~sinllala.. To hire any prore~siolt8ls that he deems
lte(~ss8ry to render lldvice concerning my attain, ind.-ding but not limited to att()rn~ys,
accountants, and tinantial tonsultant!.
16. Interesb In EstAte. And Trult$. To re~eive a bequest, devise, gin, or otber
transfer of real or personal property and gil'c full re(eipt and Acquittance or a refunding
bond therefor, and to approve at~ount' 01 I"Y estate, tn"t, partnership or other
tntnsactiol1 in whirh the principal may bave an iltterest, and enttr into any ~ornJlromise
alld relelse in regard thereto.
17. Est8t~ and FinAncial PlaQnin~ To perform any acts on my behalf consistent .;;-.
with prudent tltate planning or nnancial management, including, but not limited tOt
creating tru,;ts. making additions or subtractions from ellsting trusts alld transferring title
to real and personal property.
18. Lim.itt.tLGifis.~ To mftke I'limited gills" as such term is defined by 20 Pa.C.S.A.
5603(a)(2). svbject to those provisions.
19. Gentr... Authbrio. To do all otlltr things which my Agent shall detnl
lIecetlsary and propel' in order to tl'ans8ct business f~r me or carry out the foregoinJl
powers, which shall be construed 1\S broadly as possible.
20.
fiJlJuylvAnUL..Lan Goveros~
QuestionJ pert..iniog to the \'alidlty~
construction, alld POWN"! created tinder this instrument shall be determined itl accordance
4
'n!tt
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~~~MAN, CHERYL I 209
~L,OkD h2459 ·
~i ~ ~n r :; Art 8 - 1 9-1 987
vue 8"'9"'948
CCNH
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'?[1,= 86 t'
3WOH 3s~nN AIJ 8wn~ ~qC~C~~lr'
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with the laws of the Conunonwealth of Peno,yl\'smiRo
21. B~U.flnce by Power~. This power may be accepted lod relied upon by anyone to
whom it i5 presented until 9uch person eaher receives written notice or revocadon by me or
A gmtrdian or similsr fiduciary of my estate or has actual knowledge or my death.
All actions or my agent shall bind me and my heirs, distributees, legal
npreselltRlives, S11(Cessors and assigns, and for the purpose of inducing anyone to ad ill
Recordanee with the power' I hllvt grAnted hrrein, I hereby represent, warrant and agree
that if this power 4)f .ttorney i!l terminated or amended for any re.lon~ I and my heirs,
distributees, legal representati~es. sur~essors and assigns will Itold such party or parties
IUlrmle9s from any loss ~llfTered or liability incurred b" such plrty or parties while acting in ~1\..
ft((ordanre with thi~ power prior to that party's receipt of written notice of any such
termination or amendment.
of .ttomey~ consisting of SIX (6) typewritten pftge~, this
IN WrrNESS WHEREOF, 1 hereunto have signed my name to this, dU'T'able powel'
I .3~ dllY or ~7-'
1999.
t--..
IJ
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~it 9
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CHEftYL 1. D~' A MAN
.,.'-
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5
~YAkMAN~ CHERYL 1 209
RiCORD #24)9 ·
ACMIT DATE B~19-19B1
r COB S-9"'19~8
CCNH
SC:Lt te, St NbI
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3~JCH 3Sdi:h /,lJ m~nJ [g[S~t';::L tL
ACKNOWLEDGMENT
COMMONWEALTII OF PF,NNSYLVAN1A
: SS
COUNTY OF CUMBERLAND
On this $ day of ~L.l.Il.A:~ 1999. before me, a NolAry Publit, for the
State of Pennsylvania; penonally appearecflthe above--named CHERYL I. DY ARMAN,
who in due fonn of law acknowledged th~ foregoing power or attorney th'at she executed ,
the SAnte for the purpose. therein contained.
IN \VITNESS WHEREOF, t hereunto set my hAnd and omcialleal.
IfOTAAI,"l SEAL
V~AA J OICF. NOrMY f'IJ8l.IC
N, NEWTON lW' CUM~l"'.~hr1 (}(l. FA
~v to"~ISgjO" f;:~4!~~~ MlI,! ,~, '1M
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',.
. ~"I
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~YAkMAN, CH~RYL I.
KECORO #2459
ACMIT DATE 8-19-1987
LOB 8"9-1948
CCNH
209
,.
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8Cd E6r
3WOH 3SdfN AiJ 8~GJ f9fSZP2LtL
SEN7 ay: GUMB-PERRY MH & MR PROGRAM'
_.- ,
717 240 6415;
JAt~-16-01 1 :40PM;
PAG~ 2
(" .... \' '("11_ \ Cl \
__.,J
MENTAL HEALTH PROCEDURES ACT OF 1976
(sECTIONS 304 AND 305)
(Tl,. btenk, betow maybe completed fcllowin .dmisslonl
/II.
S N
c\-\Et<.iL..
-:i)'tA~MF\N
NAME OF eSV .." "'\
{\)Oit1\"'\ ~S,€.~~
AOMISSION NO,
'3- .
52-
t-
lAME OF COU Y PROGflAM
CUM&E"'" \... F\ ~b
1....1111 OF FA I V
S\ EVE
ADMISSION OATE
INSTRUCTIONS
1. Part 1, the petition for order of the court. is to be completed by the director of the
facUity Of his authorized r<:presentative if the pahent is currently receiving treatment.
If the patient is not (:.urrently receiving treatment. Part I may be completed by any
responsible party.
2. Put II is to be completed by persons authorized by the director of the facility to
explain rights to patients if the p.,Uent is currently ill treatment. If the patient is not
currently in treatment, it sbould be left blank. (See No, 7 below.)
3. Part III i~ to ~ completed an the basis of 8 current examination. If the patient 18
not currently in trc.ament and hD.s not been examined by a physician. !.his section may
be completed on order or the court under Section 304 (c) (5) of Act 143.
4. Part IV is to be completed by the court.
S. If additional sheets &Ie needed at any point, note on this form the number of pages
which are attached.
6. Attacb a copy of the treatment plan (tl any) and copies of the 302. 303 aud 304
forms if previously completed prior to the delivery of this form to the court.
7. It a patient is not currently in treatment. heishe ihould receive a copy of MH 78~-B
and a copy of tbis petition when he/she is notified ('If this hearing,
8. If the p~tieut is subject to crhninal proceedingS/detention, briefly describe below. Note
special use of Form MR 786 for spedal crimtnal provisions.
Il\fPORTANT NOTICE
ANY PERSON 'WHO PROVIDES ANY FALSE INFORMATION ON
PURPOSE WilEN COMPLETING THIS FORM MAY BE SUBJECT
TO CRIMINAL PROSECUTION AND MAY FACE CRIMINAL
PENALTIES INCLUDING CONVICTION OF A MISDEMEANOR.
OJ'~IA
'A(J~ I uP 5
MH 1f1~ . 7/91
SENT BY: DUMB-PERRY MH S MR PROGRAM;
717 240 6415;
JAN-16-01 1:41PM;
PAGE 3/6
PETITION FOR ORDER OF THE COURT
c\o\e::9- 't l.- .1:. D~A~Mf\N
has acted in such 8. manner as to caUse me to
~A""~ OF l'...n~Nr)
believe that be/she isseverely mentally disabled.
D He/She has been exsminated by
fouud to be in need of treatment.
D He/she has not been examined by a physlcian. but I believe he is in need of treatment.
I. therefore. request that: (Check and ~ompletc A. B, C 0: D)
A. D As the patient is ~urrent1y in
( //I~ME o~ FACl\.IT'1
304b) treatment under Section 303, I ask that the court issue 3n order tha.t tbe patient be
involuntarily committed for: D outpatient. 0 partial hospital1zation. 0 inpatlent treatment.
B. D As the patient is currently in receivins involuntary
(305) (NAMe Of fACrunl
treatment under Section 304, I ask that the colJrt issue an order that the pl'tient be
involuntarily committed for another p~riQd of 0 outpatient. D partial hospitalization.
o inpatient treatment.
Ir4ANE OF PffYSI<;IAW
and was
receiving involu.ntary
c. ~ As the patient is not curreutly in D facility r~'eiving treatment. I ask thIS court to lssue
(304 \ an order that the patient be inYohmt~1'11y committed for: D outpatient. 0 partial
CI hospitalization, IE. inpatient treatment. (A patient can only be com.mitted involuntanly
if the patient is severely mentally disabled.)
A per5Qn is :lcvcrcly mentally disabled when. as a result of mental illness. hli/her capacity to
exercise self-control. judgement "DO discretion in the conduct or his/her affairs and social relations
or to care fl;)r ltis/ber own personal needs is so lessened that he/she poses a dear and present danger
of harm to others or to himSelf or her-self. '
Clear and present danger to others shall be shown by establishing that within the pa~t 30
days tbe person has inflicted or attempted to inflict seriQus bodily harro on another and that
there is reaSODable probability that suth conduct will be repeated. A clear and preSent danger
of harm to others may be demonstratc:d by proof that tbe person has made threats of harm
and hAs committed acts in fUT~herance of the threat to commit harm; or
Clear and present danger to h,m~eH shall be shown by establishing that wihtih the past 30
daYJ:
(i) the person has acted in such marwer as to evidence that he/she would be un.able, WIthout
care. supervision and the continued assistance of others, to satisfy his/her need for
nourishtDent, personal or medical care, shelter, or self-protection and safety, and that there
is reasonable probability that deeth1 serious bodily injury or serious physical debilitatioll
would ensure within 30 days unless adequate treatment were afforded under the act; or
(u) the peSon has attempted suicide and that thete i~ the reaso!lable probability of suicide
unless adequate treatment is afforded under tbis act. For the purposes of this subsection. a
clear and present danger may be demonstrated by the procf that the person has made
thrents to commit SUIcide and has committed acts which are in further of the threat to
commit SUicide; or
(Hi) the petSO~ has substantially mutilated himself/her$elf or attempted to mutilate
himself/herself substantially and that there is the reasonable probability of mutilation
unless adequate treatment is afforded under this act, For the purposes of this subsectioll, a
clear and present datlger shall be establtshed by proof that the person has made threats to
CQClII1it mutilation and has committed acts whicb are in furtherance of the threat to
commit mutilatiotl.
Q..~~"'~Jl ~-h.~ ~ ~~o\v-..~~ 4 A
u,ot" vc...~\.~~ ~ \ CLs.. ~ ~s.
~ ,~.Q.., ~'1 c.. "'\.c....~~ \.~~ r-
~ef~es.~~ w 'M-. ~ \J~ ~~~"C..
M~ '85 . 71111
() 1'18'
ICONTINI;CO Qr<l NE)( ~ ~A~E)
"'p.~~ 2 of !
~~NT 8Y: ,CUM8-~~R~: MH & MR PROGRAM;
717 240 6415;
J AN. 1 6 - 01 1: 41 PM;
PAG~ 4/6
D. 0 As the patient is currently in a facility recdvlng voluntary treatment, I, ask tbe court to
4 } issue an order that the patient be iuvoluntsrilyconl1mttcd for 0 out~at1ell~, 0 p~tial
(30 c hospjtalixation, 0 inpatient treatment. A pahi:nt can only be c::.mmlt:ed lnyoluntanly If
the patient is severely meutally disabled. See page 2, above. fOT a dcfiIlition of severe
mental d:sablJity. (Describe tbe behavior of the pationt within the last 30, days wbicb
causes you to believe tha.t he/she IS severely mentally disabled. Use additlOZJlll sheets if
r.eccssar~.) _ ,. ~
~c.)\C.lot:~\ lJ.Q..C4*;.:rv-. Dr ~C\~~~ ~\s ~
\ \ .. ~
Ect 'l-.S ~~:~-cR~.. ~+\ho"Y\..~' r-.e...~ \Je..$ h ~
WIs. D-jc.rIM-A"-' leC-~~..,..A- ~*-~~--\- ~
1-\.-" No k...... ~t'" ~\'\ "::::>y\ ~ ~
IONE,\)
f I ,., 1 ~~\~l
'I .- I.: /
IDATEI
<APQR.~~!l
(cATLl
(l'HONfl
PART II
THE PATIENT'S RIGHTS
I affirm that I have informed the patient of the actions 1 anl taking and have explained to the
patitnt these procedures and his/her rights as described in Form MH 78S-A. I believe that
he/she 0 understands his/her rights, D does bot un~r5tand his/hor rights.
(SIGNA'VRf of I'ERso~l :;:i'~:I'C l\1(;HTSJ
-, (CAi~1
PART III
RESULTS OF EXAMINATION AND DETERl\UNATlON OF NEED
FOR (CONTINUED) TREATMENT
hereby affirm that 1 bave D examined 0 reexamined
(NA,M( OF PA TlfNll
on 10 determine If he!~he 0 lS 0 cotltinue> 10 be severely mentally
disabled aDd in need of trcnlmeJJt.
Results of Examination
(Give complete details of exami11Alioll. If request 1S for 304 or 30St describe oetails glYlIlg
evidence that the patIent is or remains a clear and present danger to hilusclf/herself or otl'iers and
indicate how thi5 is least restrictive treatment setting possible.)
FINDIN05: (Describe your finding! in detail, including your findings of severe mental di~abi1ity.
Use additional sheets it necessary.)
01J'98C
MH 78& . '1,g,
\CONTIHUEO Q~ NEXT PAG!:1
~"'(iE ) OF S
SENT BY: CUMB-PERRY MH & MR PROGRAM'
,
717 240 6415;
JAN-16-01 1:42PM;
PAGE 5/6
TREATMENT ~EEDED: (Descnbe the treatment needed by the patient. Use additional sheets if
necessary.)
In my opinion; (Cbeck A or B.'
A. 0 The patient is 5evcrc1y mentally disabled and in need of (eontlnued) treatment.
B. 0 The p4ltient is not io nee.d of involuDtary treatment.
lSie~A T.Jf\EI
,;)Ai€;:
PART IV
ORDER FOR INVOLU1'\"7ARY TREATMENT
Cbeck one: ( )
D Or der for involuDtary treatment unrler Section 304 (b).
D Order for involuntary treatment under Section 304 (,).
0 Order for involuutar)' treatment under Section 30.5.
In tile court of
of
County
term, 19
In re;
No.
This day of . 19 after hearing and consideration of
(Dctalls of findings. Include details on why treatment is needed. Attach reports. testimony, etc.)
OI78aD
MH '85 - '"l'
ICCI'lTlPlVEO ON i'lIi)llT PAGEl
"AQ~ ~ 01' ,
S~~T BY: CUM8-PERAY MH & MR PROGRAM'
. -. - - .~ - ,
717 240 8415;
JAN-16-01 1 :42PM;
PAGE 8/8
The court fiuUs that the patknt 0 H D is not severely mentally dlsabled alld in. need ~1f
(continued) treatment. Accordmgly. ~hc (Ol\ft orders that: (Check A or B b.;:low)
A. 0
receive:
D outputient.
o partial
~l<<.u,lf' 01' flAilfNI)
hospitu!itatlon. 0 iopatiellt treatment as a severely mtl~tlil1y d\snb\ed perslm flur~u~nt to
the provisions of th~ Menhll Health Procedures Act of 1976 fl.)f a period n"t to exceed
___ days. At present., this treatment setting is the least res1rictive seltiug appropriate for
the patIen.t.
B. D The petSlHl 15 not subject to inva)uctary treatm~l1t.
(Ched. appropriate blode)
D l'he patient was represented 'by
:.NAMf lA iz.no~'lI::V:
(.'.oLlnf:.~ (1f Ai rORI'lIoY)
o The patient declined representatiorl.
(IF HEARING IS COl\;VUCfE-D
BY MENTAL HEALTH Rl7:VI.E\\i-
OFFICER)
for the court
(~,E"I"A, ,[;"".TH HE~IEW (IFFldn,
by t~ court.
(OlH(/
J.
!Pr\IHT HAME 0": )!)J")C.~)
01 '\liE
Mil 7st! . 710\1
PAQE 6 Of 5
CHERYL I. DYARMAN,
An Alleged Incompetent
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN THE MATTER OF
NO.
INCAPACITATED PERSON
NOTICE
A petition to have you adjudged an incapacitated person has been filed
with this Court by Kathy Myers. A hearing is scheduled in this matter for
, the
day of
, 2001, at
a.m.lp.m., in Courtroom
# , Cumberland County Courthouse, Carlisle, Pennsylvania. You are strongly
encouraged to be present at the hearing, and you are warned that important rights may
be lost as a result of the proceeding. You have the right to be represented by counsel
and the right to request the appointment of counsel and to have counsel so appointed
paid by the Court where you are unable to afford to pay an attorney.
YOU SHOULD TAKE THIS NOTICE TO YOUR LAWYER AT ONCE. IF YOU
DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE
THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL
HELP.
Court Administrator
Fourth Floor
Cumberland County Courthouse
Carlisle, Pennsylvania 17013
(717) 240-6200
IN THE MATTER OF
CHERYL I. DYARMAN,
An Alleged Incompetent
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
NO.
INCAPACITATED PERSON
PETITION FOR APPOINTMENT
OF A TEMPORARY GUARDIAN
OF THE PERSON PURSUANT
TO 20 PA. C.S.A. 5513
1 ) Your Petitioner is Kathy Myers, a representative of Claremont Nursing and
Rehabilitation Center.
2) Respondent is Cheryl I. Dyarman, an incapacitated person, currently
receiving care at Claremont Nursing and Rehabilitation Center, 375 Claremont Drive,
Carlisle, PA 17013. Respondent is an adult individual being presently 52 years of age
with a birth date of August 9, 1948. The Respondent has a POA, Gloria A. Anderson.
Ms. Anderson is the successor to Ms. Dyarman's mother who passed away in May,
2000.
3) Ms. Dyarman suffers from Demyelinating Disease of the spine, a disease
similar in its effect to multiple sclerosis, as well as major depression. She has been in
the nursing home since 1987. Since approximately July, 2000, Ms. Dyarman has
engaged in a pattern of refusing nourishment and medications. Her documented
weight loss is as follows: August 101Ibs., October 89 Ibs., November 80A Ibs.,
December 76.8 Ibs. and January 74 Ibs. The psychiatrist who consults at the nursing
home, Dr. Hegarty of Chambersburg, PA, believes that inpatient psychiatric care and
probably a course of electroconvulsive therapy is necessary to break Ms. Dyarman out
of her depression. Hershey Hospital has reviewed the matter and is willing to admit Ms.
Dyarman to their facility. Ms. Anderson has the authority thru the POA to admit Ms.
Dyarman to the facility. Additionally, a commitment thru the Mental Health Procedures
Act is being considered. Without intervention, Ms. Dyarman's weight loss will continue
and likely result in her death.
4) 20 Pa. C.S.A. Section 5521 (d), authorizes the Court to approve the
Guardian's consenting to certain procedures, one being electroconvulsive therapy.
5) The proposed Guardian has no interest adverse to that of Cheryl I.
Dyarman.
6) Ms. Dyarman has no parent, child, husband or other close relative. Her
income consists of a monthly social security benefit.
WHEREFORE, Petitioner. Kathy Myers, respectfully requests that the Court
order that Respondent Cheryl I. Dyarman be adjudged an incapacitated person and
Gloria A. Anderson be appointed emergency Guardian of the Person and Estate.
Petitioner also requests that the Court give due consideration to authorizing Ms.
Anderson to consent to the use of electroconvulsive therapy as a procedure for Ms.
Dyarman's care.
Respectfully submitted,
O'BRIEN, BARIC & SCHERER
BY ~~ Cl~
Robert L. O'Brien, Esquire
I.D. # 28351
17 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
CHERYL I. DYARMAN,
An Alleged Incompetent
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN THE MATTER OF
NO.
INCAPACITATED PERSON
CONSENT TO APPOINTMENT
I, Gloria A. Anderson, of Newville, Cumberland County, Pennsylvania, consent to
be appointed emergency Plenary Guardian of the Estate and Person of Cheryl I.
Dyarman. I represent to the Court that I have no interest adverse to Cheryl I. Dyarman.
Gloria A. Anderson
VERIFICATION
I verify that the statements made in the foregoing Petition to Adjudicate
Incapacity and Appoint A Guardian of the Person are true and correct. I understand
that false statements herein are made subject to the penalties of 18 Pa. C.S. Section
4904, relating to unsworn falsification to authorities.
WirK~
rob/mhmr/dyarmanemer. pet
DOCTOR'S PROGRESS NOTES
RECORD PROGRESS OF CASE, COMPLICATIONS, CHANGES OF
. IMPRESSIONS OR DISGNOSIS, RESULT OF TREATMENT,
TIME COMDITION ON DISCHARGE. EACH ENTRY MUST BE SIGNf=D
AN D DATED.
:s . q1
..~
DOCTOR'S PROGRESS NOTES
~. y " :d'~ A r \ , C Ii ~ R Y L I. 2 0 9
kECOf~D l12459
,;:nIT DATE ~-19-1987
UQj 3-9-1948
~ C r~ H
CCNH/82
DOCTOR'S PROGRESS NOTES
DATE
RECORD PROGRESS OF CASE, COMPLICATIONS, CHANGES OF
IMPRESSIONS OR DISGNOS1S, RESULT OF TREATMENT,
COMDITION ON DISCHARGE. EACH ENTRY MUST BE SIGNED
AND DATED.
IJt.
1M :
~rV1
Jt~
.~
h;t.
6-
DOCTOR'S PROGRESS NOTES
~- ~ A fd-j AN, C H tRY l J
r-. ~ = IJ 1\ D t1 2 4 5 9 ·
~~~I} UATE ~-1?-1?87
Lv-\ ,..-9-,r:j,"
,._ '-' I '.0
I.. I. ~v H
CCNH/82
209
RECORD PROGRESS OF CASE, COMPLICATIONS,CHMIGES OF
IMPRESSIONS OR DISGNOSIS, RESULT: OF TREATMENT,
DATE T'ME COMDITION ON DISCHARGE. EACH ENTRY .MUST BE SIGNED
,l AND DATED.
DOCTOR'S PROGRESS ,NOTES
"
'. .~,,-,,''''''"'-'-"
DOCTOR'S PROGRESS NOTES
, Y i< ~ 1'.;' Ii. ~ II E. R Y L 1. 20 9
:\ ~ (. ;) k 1) ti 2 4 ) 9
A ~ hi 1 t; F, \ E ;:~-1 9 -1 9 B 7
~; ':~; b - 9 - 1 (, !. 8
;: C : ~ r:,
CCN H/82
/
DATE
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, ~ \\~
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l" -z; CD
DOCTOR'S PROGRESS NOTES
RECORD PROGRESS OF CASE,COMPLlCATIONS, CHANGES OF
IMPRESSIONS OR DISGNOSIS, RESULT OF TREATMENT,
TIME COMDITION ON DISCHARGE. EACH ENTRY MUST BE SIGNED
AN P T~D.
~
w~
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~-~~
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. '-~-
DOCTOR'S PROGRESS NOTES
,{ Y tddl; A ~J , ( H S R Y L' I. 2 0 9
t.~i. :C;i(l) .~24S9
A:i'/,IT CA~t S-19-19S7
:.<, ~.~ ~, - 9 - 1 9 ~ fj
CCN H/82
c C r'~ }.i
DOCTOR'SPROGRE$S NOTES
RECORD PROGRES$ OF CASE, COMPUCAT10NS, CHANGES OF
IMPRESSIONS OR DISGNOSIS, RESULT OF TREATMENT,
DATE TIME ~~ Ir~~~.ON DISCHARGE. EACH ENTRY MUST BE SIGNED
S\GNA TURE
'~~.'-'-IJ
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DOCTOR'S PROGRESS NOTES
[ Y;'" Iii:' J.. ;,; "... .
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.. ~ -... 1\ t- ;. i ~ ( y. .,
A :, ,l",~ J r... A , r 1:: ~ ,'. 8
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CCNH/82
f\ECOf\O pf\OGf\ESS OF CASE. COMPLICATIONS. CHANGES OF
IMPf\ESSIONS 01'1 OISGNOSIS. f\ESOLTOF Tf\EATMENT.
O^le. ,'ME COMOITION ON OISCHAf\GE. EACH ENTf\'{ MUST BE SIGNEO ·
""AND DATEO.
O.O~TOB'S PBOG8tsSSNOTe.S..
.' . .. .," . .~......",.r' .."'" .,.' .
. .' . .'. ..,. . . .' . .
S\GNA TUBE
\0 \ \lD
\~
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C\ \~ ~
"-"
JC'-^-!o.J-'-' ~ ,,--,-
/~~.
DOC1'OR'S PROGRESS N01'ES
: y" hi;" !. . ., ,. ~ ,l 'i L 1. 2
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DOCT~R'S PROGRESS NOTES
DATE
TIME
RECORD PROGRESS OF CASE, COMPLICATIONS, CHANGES OF
. IMPRESSIONS OR DISGNOSIS, RESULT. OF TREATMENT,
COMDITION ON DISCHARGE. EACH ENTRY MUST BE SIGNED
AN DATED. .. .
k tU
SIGNATURE
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DOCTOR'S PROGRESS NOTES
GYAkMANI CHERYL 1.
kE~ORD fJ24'J9
A~KIT DATE 8-19-1987
[;08 &-9-19:'b
~ C C~;;H
2:'". .
V
CCN H/82
DOCTOR'S PROGRESS NOTES
RECORD, PROGRESS OF .CASE, COMPLICATIONS, CHANGES OF
IMPRESSIONS OR DISGNOSIS, RESULT OF TREATMENT,
DATE TIME ~~~~~~~~. ~N DISCHARGE. EACH ENTRY MUST BE SIGNED'
SIGNATURE
'.,
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DOCTOR'S PROGRESS NOTES
. ;'~ A t~ , C HER Y L I. 2 0 ?
'''. ~ t! 2 l. S 9
.: i (:ATE [)-19-1987
; b-c;-19~b
_ :. H
-,
RESIDENT MEDICAL DIRECTIVE
To my Family, Doctors, Institutional Health Care Providers and All Those concerned
with My Care:
I, C)li:ZLt/L ~tlJifJ}:Z(i'{) , being of sound mind, willfully
and vOlunE1rily e this declaration to be followed if I lack sufficient capacity
to make or communicate decisions concerning myself. This declaration reflects
my firm and settled commitment to refuse life-sustaining treatment under the
circumstances indicated below.
I direct my physician who has responsibility for my treatment and care to withhold
or withdraw life-sustaining treatment that serves only to prolong the permanent
unconsciousness. By permanently unconscious, I mean a condition that has been
diagnosed in accordance with currently accepted medical standards and with
reasonable medical certainty as total and irreversible loss of consciousness
and capacity for any interaction with others as pertaining my wishes or needs.
Permanently unconscious includes without limitation a persistent vegetative
state or irreversible coma. By terminal condition, I mean an incurable and
irreversible medical condition caused by injury, disease or physical illness
which will, in the opinion of the attending physician, to a reasonable degree
or medical certainty, result in death regardless of the continued application
of life-sustaining treatment.
I direct that treatment be limited to measures to keep me comfortable and relieve
pain, including any pain that might occur by withholding or withdrawing life-
sustaining treatment.
I understand that I will receive the following forms of treatment unless I
indicate the form or forms of treatment which I especially do not want.
Should any specific direction in this declaration be held to be invalid, the
invalidity shall not offset other directions of this declaration which can
be affected without the invalid direction.
I direct that no physician or other health care provider who causes or participates
in the initiating, continuing, withholding or withdrawal of life-sustaining
treatment from me while I lack sufficient capacity to make or communicate decisions
concerning myself shall be subject to liability, and I hereby release any person
or entity who complies herewith.
A~ 7;'
37
li. .
If I am not able to make my wishes known, I want the guidelines below followed:
Qualifying
Yes No Undecided Conditions
1- Card~opulmonary Resusc~tat~on{CPR) /'"
Use of drugs and electric shock to start /
the heart beating and artificial breathing.
2. Intubation and Mechanical Breathing - y/
Insertion of a tube and breathing by machine
I/",
3. Hospitalization V
4. Artifical Nutrition - Given through a tube /
in the veins, nose, or stomach.
5. Intravenous Therapy ( IV's) - Provide ~
nutrients, fluids or medication by vein.
6. Major Surgery - Such as removing the gall /
bladder or part of the intestines.
",-"'C_
7. Kidney Dialysis - Cleaning the blood by (
machine or fluid passed through the belly.
V
8. Chemotherapy - Drugs to fight cancer. '/
9. Invasive Diagnostic Tests - Such as using /
a flexible tube to look into the stomach.
l.----
I 10. Antibiotic - Dru.gs to fight iniection. ~ I
11. Pain Medications - Even if they may dull /""
consciousness and may indirectly V
shorten life.
12. Other I I I
n
'~'~H
Witn~s
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,A
/1 (/l /A.~
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~~-- c' ~/ ~-X-~~l ,;-'"--'r:
Resident' s signat~e ~>-:-<"-- -- .'
/ /-/.IJ
I -
.7' /'~' /
L/'~ J7 ./
Date / / /
c:? ,", .- .----
Date
(.,' .' ....:.
l ..A-<_....S -- ,~/ t. "
Witness ~ <....} , -
.:J - d- .--;. i S-
Date
;'{' --2
09323202122001
ORC621
Case No 2001-00076
Case Name: DYARMAN CHERYL I
Cumberland County - Orphans Court
Page
Age
52
Docket Entries
Filed
1/17/01
1 PETITION FOR APPOINTMENT OF A TEMPORARY GUARDIAN OF THE PERSON
1/23/01
2 PRELIMINARY DECREE -JUDGE OLER
2/02/01
3 ORDER OF COURT-JUDGE OLER
2/07/01
4 ORDER OF COURT - J. WESLEY OLER, JUDGE
2/07/01
5 ORDER OF COURT - J. WESLEY OLER, JUDGE
2/12/01
6 REQUEST FOR ORIGINAL RECORD - SUPREME COURT OF PENNSYLVANIA
22 M.D. MISCELLANEOUS DOCKET,2001
2/12/01
7 IN RE: OPINION PURSUANT TO PA. R.A.P. 1925 BEFORE HOFFER, P.J.,
BAYLEY AND OLER, J.J.
.
. K&6I3feJZ
I _
o F>~\r tIIS
IN RE: PETITION FOR
INVOLUNTARY TREATMENT
OF CHERYL I. DYARMAN
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
No. 01-0684 CIVIL TERM
IN THE MATTER OF
CHERYL I. DYARMAN,
An Alleged Incapacitated
Person
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
No. 21-01-76
IN RE: TRANSCRIPT OF PROCEEDINGS
Proceedings held before the Honorable
J. WESLEY OLER, JR., Judge,
on January 24, 2001, at the Cumberland County Nursing Home,
Carlisle, Pennsylvania,
and on January 29, 2001, in chambers at the
Cumberland County Courthouse, Carlisle, Pennsylvania.
APPEARANCES:
Robert L. O'Brien, Esquire
For the Petitioner
Robert J. Mulderig, Esquire
For Cheryl I. Dyarman
John A. Abom, Esquire
For the Alleged Incapacitated Person
.
.
I N D E X TOW I T N E SSE S
FOR THE PETITIONER DIRECT CROSS
Kathy Myers 3
By Mr. Mulderig 17
By Mr. Abom 18
Gloria Anderson 35
By Mr. Mulderig 37
By Mr. Abom 38
James Hegarty, M.D. 55
By Mr. Mulderig 68
By Mr. Abom 59
REDIRECT
32
FOR THE ALLEGED INCAPACITATED PERSON
None
FOR CHERYL I. DYARMAN
None
I N D E X TOE X H I BIT S
FOR THE PETITIONER
MARKED
None
FOR THE ALLEGED INCAPACITATED PERSON
MARKED
No. 1 - power of attorney
19
No. 2 - resident medical directive
23
FOR CHERYL I. DYARMAN
MARKED
None
RECROSS
34
72
ADMITTED
ADMITTED
48
48
ADMITTED
.
.
1
2
3
4
5
January 24, 2001
Cumberland County
Nursing Home
3:07 p.m.
THE COURT: This is the time and place for a
6 hearing on a petition for involuntary treatment filed in
7 the above-captioned matter. We will let the record
8 indicate that the subject of the petition, Cheryl I.
9 Dyarman, is present at this hearing, which is being
10 conducted at her residence at the Cumberland County Nursing
11 Home. Also present on her behalf is her Court-Appointed
12 Counsel, Robert Mulderig, Esquire. The Petitioner in this
13 case is represented by Robert O'Brien, Esquire. Mr.
14 O'Brien.
15
MR. O'BRIEN: Yes, I would call as a
16 witness, the social worker for Cheryl, Kathy Myers. And,
17 Kathy, do you have available Cheryl's medical records? I
18 take it that they're all present there?
19
20
21 in.
22 Whereupon,
MS. MYERS: Yes.
THE COURT: Wait. We haven't had her sworn
23 KATHY MYERS
24 having been duly sworn, testified as follows:
25 DIRECT EXAMINATION
3
.
.
1 BY MR. O'BRIEN:
2
3 please?
4
5
6
7
8 Center?
9
10
Q
All right. Would you state your name,
A
Q
A
Q
Kathy Myers.
And Kathy, where are you employed?
Claremont Nursing and Rehab Center.
And what do you do at the Claremont Nursing
A
Q
I'm a social worker here.
And could you tell us the background that
11 qualifies you for the position as a social worker?
12
A
I have a degree in psychology, but have
13 worked in the human service, social service field for
14 approximately 15 years and in a variety of capacities
15 beginning with mental health, mental retardion, vocational
16 rehab, and subsequently here.
17 Q And how long have you been this social
18 worker involved with Cheryl Dyarman's case?
19
20
A
Q
Approximately two and a half years.
And how often have you had contact with
21 Cheryl herself in reference to your duties?
22 A Well, since the death of her mother and
23 these issues, it's been more frequent than it would
24 normally be with someone who didn't have the difficulties.
25 And sometimes it's daily. Sometimes it's weekly.
4
.
.
1
2
3
4
5
died.
THE COURT: I'm not sure when her mother
When was that?
THE WITNESS:
THE COURT:
THE WITNESS:
May.
May of 2000?
Yes.
6 MS. ANDERSON: April
7 VICTOR RUSSELL: April 2nd of 2000.
8 THE COURT: We need to just have one person
9 testify. It's confusing for the stenographer otherwise.
10
11
THE WITNESS: April.
THE COURT: Okay.
12 BY MR. O'BRIEN:
13
Q
And prior to her mother's death, how long
14 has Cheryl been in this facility?
15 A Since 1987.
16
Q
And in reviewing some papers that you had
17 shared with me on the admission, as I understood, Cheryl
18 became difficult for her mother as she aged to care for and
19 hence she made arrangements to have Cheryl admitted at this
20 facility?
21
22
A
Q
Correct.
And Cheryl at that time was in her late
2330's?
24
25
A
Yes.
THE COURT: What is Cheryl's date of birth?
5
.
.
1
2
3
4
5
6 BY MR. O'BRIEN:
THE WITNESS: May I grab my paperwork there?
THE COURT: Sure.
THE WITNESS: August 19th.
THE COURT: August 19th of what year?
THE WITNESS: Forty-eight.
7
Q
Are you certain that's correct? I only ask
8 because I had notes here speaking with you that it was
9 August 9th, and another individual had indicated--
10 A I'm sorry. My error. I looked at it wrong.
11 It is August 9th, 1948.
12
13
14
Q
A
Q
So she was admitted here then in 19--
Her admission date was August 19th of '87.
And what do your records show as far as any
15 physical limitations that she had on admission?
16
A
Well, her limitations have regressed, so her
17 limitations at the present are far more significant than at
18 the time she was admitted. She did use a wheelchair to get
19 around but had more use of her limbs at that time. I don't
20 recall if she was able to walk when she was admitted here.
21 But since I've been here the last two and a half years,
22 there has been some decline in physical ability. She was
23 able to get around using an electric wheelchair with her
24 hands, and that ability declined to the point where she was
25 not using it at all.
6
.
.
1
Q
I'm looking at the pre-admission
2 psychosocial history, and I'll quote from that, At the time
3 of admission, Mrs. Dyarman is alert and well-oriented in
4 all spheres and has an excellent memory. Hearing, vision,
5 and speech are adequate for fluent communication. Is
6 Cheryl able to communicate clearly at the present time?
7 A No. It's difficult to understand Cheryl at
8 times. Also some of the content of the communication is
9 not consistent or-- for instance, this is January 23rd or
10 24th, and Cheryl insists it's still October, despite
11 showing her the calendar.
12
Q
Are there other statements that would
13 indicate a misapprehension of events happening around her
14 that you are aware of through other staff members here or
15 through the medical records?
16
A
Well, in reference to meal times, Cheryl,
17 even today when we talked with her, says that she won't eat
18 the foods sent to her by the kitchen because we're sending
19 her someone else's food, that that's not her meal, it's
20
someone else's.
She informed me today that they are now
21 sending her her roommate's or not feeding her roommate,
22
which is not true.
She refuses her medications.
She also
23 tells some staff members that she wants to die, whereas her
24 therapist, Leanne Stewart, from the psychological services
25 has been working very closely with her since the death of
7
.
.
1 her mother.
2 She denies to Leanne that she has ever said
3 that she wanted to die, and she claims that she does not
4
want to die.
It's a real contradictory of things going on
5 here where she's refusing to eat and refusing medications,
6 stating to staff she wants to die, but then also saying
7 that she's moving to a nursing home in Newville where her
8 mother resided.
9 She wants to go because her mother and
10 father were there. I did contact them to see if there was
11 any way, since we thought that might-- Dr. Hegarty, the
12 psychiatrist, also thought it might be a way to improve her
13 state. That's not an option at this time. But she insists
14 that she is going, she's just waiting for her father to get
15 her clothes and move her. And that's not accurate.
16 THE COURT: Is her father living?
17 THE WITNESS: Her stepfather is here.
18 THE COURT: Is that the father she's
19 referring to?
20 THE WITNESS: Yes.
21 THE COURT: All right.
22 BY MR. O'BRIEN:
23 Q Now in regard to her refusal to take
24 nourishment, have you documented a weight loss since the
25 summer of 2000?
8
.
.
1
2
A
Q
Yes.
And could you tell us, chart those weight
3 readings for us, please?
4
5
A
May 2nd-- I'm sorry, in May, she weighed
107.5.
I can give you beginning and end and then in
6 between, if you like. At the present time, as of January
7 16th, she ways 73 pounds, which is 34 and a half pound
8 weight loss. It started out a couple of pounds a week.
9 And we even had an increase one week. And then from
10 November to present, has escalated significantly.
11
Q
Does she eat on occasion or-- I mean, how
12 does she take nourishment? Is she given IV's or anything
13 like that?
14
A
No, she's not given IV's, and she doesn't
15 have a feeding tube. There are certain nurses that she
16 favors over others. And we, in an effort to get food into
17 her, she likes peanut butter and jelly, so we have
18 purchased peanut butter and jelly to have on hand when she
19 eats. She likes root beer. She likes ice cream. We've
20 also taken steps to have those things on hand for her if we
21 can get her to eat them.
22 She also will take her health shake on
23 occasion. Again, it's only for certain nurses that she
24 likes or certain nurses' aids, and even then it's not
25
consistent.
It's been difficult to establish a pattern.
9
.
.
1 One day, it's one way; and another day, it's another.
2 THE COURT: Can you describe her present
3 condition physically for the record?
4 THE WITNESS: The diagnosis, the physical
5 diagnosis?
10
6
THE COURT: No, just state what you can
7 observe, whether she can walk, whether she can talk,
8 whether she can sit up, whether she can feed herself,
9 things that are not in the record now.
THE WITNESS: Okay. Her diagnosis, which lS
11 demyelinating disease of the spine, Cheryl is unable to
12 move her arms or her legs or sit up independently. She
13 requires mechanical or manual assistance to be able to sit
14 up. She requires total assistance for all activities of
15 daily living which is bathing, dressing, eating, hygiene,
16 anything related to that. Totally dependent for care. She
17 is able to talk. Speech is difficult to understand at
18 times.
19
20
21
22
23
24
25
THE COURT: And how is she fed?
THE WITNESS: The nurses feed her.
THE COURT: By hand?
THE WITNESS: Staff members, but by hand,
with spoon, fork.
THE COURT: She's able to chew?
THE WITNESS: Has some difficulty with
10
.
.
1 swallowing at times. I do believe she has a modified diet,
2 without looking into the chart. It's either mechanical
3 soft or pureed. I'm not positive. But she does have some
4 swallowing difficulties, so her diet is altered.
5 THE COURT: Okay.
6 THE WITNESS: To prevent choking.
7
8
THE COURT: Mr. O'Brien.
MR. O'BRIEN: Yes.
9 BY MR. O'BRIEN:
10
Q
The records that you have then, and we will
11 have Dr. Hegarty to support these records, but his notes
12 were attached to the petition, and could you read his
13 entries for the past several months, please?
14
A
Would you like me to start with July of
15 2000, because that's when we began asking him to see her
16 because of our concerns with her not eating and weight loss
17 and depression?
18
Q
Yes. Why donlt you start at that point and
19 give us each-- as you read each entry, the date of the
20 note?
21
22 psychiatrist?
23
24
THE COURT: First, is Dr. Hegarty a
THE WITNESS: Yes.
THE COURT: All right. And his full name
25 is?
11
.
.
1
2
THE WITNESS: You know, I've always known
him as Dr. Hegarty.
I don't know his first name. He did
3 give me a card earlier. If I find it, I might be able to--
4 is there a card under my pen? James Hegarty, M.D.
5
6
7 BY MR. O'BRIEN:
8
THE COURT: Okay.
MR. ABOM: H-e-g-a-r-t-y.
Q
For the record also, does that have his
9 office address on his card?
10
A
Yes. It is Summit Behavioral Health
11 Services, 176 South Coalbrook Avenue, Unit No.2,
12 Chambersburg, Pennsylvania, 17201.
13 Q And it's your understanding that Dr. Hegarty
14 is a Board-certified psychiatrist who consults at the
15 nursing home here on a regular basis?
16
17
A
Q
Yes.
He's-- he has a contract with the county to
18 provide those services?
19
20
A
Q
Yes.
All right. Now getting back to his notes,
21 if you would read those into the record, please?
22
A
His note dated July 12th of 2000, Cheryl has
23 been much more agitated and depressed over the past few
24 weeks. She has been refusing oral medication and meals.
25 On exam, I am unable to make much headway in convincing her
12
.
.
1 to comply with treatment. You know, there's three things
2
here I cannot make out with his handwriting.
It's a
3 positive--
4
5 all right.
6
THE COURT: If you can't read them, that's
THE WITNESS: Oh, positive or passive
7 suicidal ideation. I'm sorry.
8
9
THE COURT: Passive suicidal ideation?
THE WITNESS: Uh-huh. No active suicidal
10 ideation, immediate intent or plan. Cheryl has had a
11 pattern of periodic dietary restriction in the past, and
12
this episode may resolve spontaneously.
In the present, it
13 may be most practical to change her to a liquid
14 antidepressant. An 1M, which is an injected medication,
15 prn would be also appropriate. Would not hospitalize
16 psychiatrically at this point. Though this option could be
17 referred as a last resort. All right. Okay. This could
18 be considered as a last resort. And he refers to ECT.
19
20
THE COURT: He defers to who?
THE WITNESS: Electoconvulsive therapy, ECT,
21 the letters E-C-T.
22
23
24
25
THE COURT: He defers to it?
THE WITNESS: He refers to it.
THE COURT: Oh, refers to it.
THE WITNESS: As a last option. This was in
13
.
.
1 July. To promote weight gain, will recommend liquid
2 Pamelar, which is a medication--
3
THE COURT: Can you spell that for the
4 stenographer?
5
THE WITNESS: Yes, P-a-m-e-l-a-r. Pamlar.
6 September 27th, 2000, his notes start, Difficult situation.
7 Patient previously responded to Remeron but then began
8 refusing oral tablet form--
9 THE COURT: All right. The stenographer
10 didn't catch the word. Initially responded to what?
11 Remeron?
12
THE WITNESS: To Remeron, which is
13 R-e-m-e-r-o-n. That's a medication. But then began
14 refusing oral tablet form of medication. I switched her to
15 liquid Pamelar, but this made her confused. She is now
16 back on Trazadone.
17
18
THE COURT: On what?
THE WITNESS: Trazadone, which is a
19 medication. T-r-a-z-a-d-o-n-e. Given the severity of her
20 neurovegetative symptoms, it is unlikely Trazadone will be
21 sufficiently potent. As she is accepting tablet
22 medication, I would recommend stopping the Trazadone,
23 restarting Remeron (strongest appetite boosting effect)
24 and--
25
MR. MULDERIG: Some drug, up to 45
14
.
.
1
2
milligrams.
THE COURT: Are there many pages of these
3 notes?
4
5
6
THE WITNESS: No.
THE COURT: Okay.
THE WITNESS: He increased her other
7 medication to 45 milligrams over the next four weeks. I
8 can't read what that is.
9
10
THE COURT: Okay.
THE WITNESS: Okay. December 8th or-- I
11 have these out of order. November 8th of 2000,
12 52-year-old, white female, severe major depression. Cheryl
13 continues with depression and pervasive suicidal ideation.
14 She continues to sporadically refuse medication and food.
15 We have not been able to make much progress with it.
16 Cheryl is profoundly depressed and refuses treatment,
17 including ECT. I will recommend Remeron with Zyprexa, but
18 prognosis is poor.
19
THE COURT: What was that second term?
20 THE WITNESS: Zyprexa. It's Z-y-p-r-e-x-a.
21 But prognosis is poor. And the last note was January 10th
22 of 2001, Persistent depression, refusing medications, would
23 benefit from ECT. That's his last note on January 10th.
24 BY MR. O'BRIEN:
25
Q
And Dr. Hegarty has seen Cheryl on this
15
.
.
1 occasion of this hearing?
2
3 arrival.
A
He carne back and saw her today before your
4
5
6
Q
A
But he hasn't made a note on that?
No, he had to leave before he got that done.
THE COURT: I noticed that Ms. Dyarman is
7 wailing and crying. Is that typical or is that just
8 happening at this time?
9
THE WITNESS: It would depend. At this
10 point it's because she doesn't want anything to do with any
11 of this. This is-- she's letting us know that. Right,
12 Cheryl?
13
THE COURT: Are there times when she can
14 speak so that she can be understood?
15 THE WITNESS: Yes. It is generally
16 difficult most of the time, but when she's not upset and
17 wailing or crying, it's much easier to understand her.
18
THE COURT: And when she is able to be
19 understoodf is she speaking lucidly?
20 THE WITNESS: In terms of the content of
21 what she says? No.
22
23
24
25
THE COURT: No?
THE WITNESS: No.
THE COURT: Okay. Mr. O'Brien.
MR. O'BRIEN: I have no further questions.
16
. .
1 THE COURT: Okay. Mr. Mulderig.
2 CROSS EXAMINATION
3 BY MR. MULDERIG:
4
Q
Ma'am, the law says that we're not to
5 determine In this hearing what kind of course of treatment,
6 just whether or not she is in need of treatment and whether
7 or not this is the least restrictive or an inpatient mental
8 health facility is the least restrictive. So the question
9 is, is she safe here?
10
A
Is she safe here? Yes.
I mean, in terms of
11 someone not doing anything to her? Safe in terms of her
12 not eating--
13
14
Q
Have you tried intravenous--
THE COURT: Wait. That's not a complete
15 sentence.
16
THE WITNESS: In terms of her being safe
17 from not eating? Well, no, I guess, if that's what you're
18
19
20
21
asking.
BY MR. MULDERIG:
Q Have you tried intravenous feedings?
A
No, she's refusing, and we are not allowed
22 to do IV feeding if she refuses. The regulations prohibit
23 that.
24
Q
And if she is committed into a mental health
25 hospital, she can refuse the ECT also, can she not?
17
.
.
1 A That's what I understand about the law as
2 it's written[ and I guess that's why we're having this
3 hearing today to determine--
4
Q
This hearing is to determine whether she
5 goes into the hospital or not. But that won't get her the
6 treatment?
7
8
9
A
Right.
MR. MULDERIG: Okay. Thank you.
THE COURT: Now there's a second petition
10 filed involving Ms. Dyarman[ and that is a petition for
11 appointment of a guardian. The Court has appointed John A.
12 Abom[ Esquire[ to represent her with respect to that
13 petition. There was some consideration given prior to this
14 hearing under the Mental Health Procedures Act to
15 incorporating the testimony of this hearing in that second
16 proceeding. Is that agreeable [ Mr. Abom[ to you[ and if
17 SOl do you want to ask the witness some questions?
18
MR. ABOM: Yes to both questions[ Your
19 Honor.
20
21
22 BY MR. ABOM:
THE COURT: All right. Go ahead.
CROSS EXAMINATION
23
Q
To[ shall we say[ flush out the record[ I
24 first want to ask and thank you[ I had the opportunity to
25 speak with[ it's Ms. Myers, earlier today. I think
18
.
.
1 relevant to the question of incapacity is whether there are
2 prior directives signed by Ms. Dyarman at a time when she
3 perhaps was more lucid, and without making an admission or
4 a statement as to lucidity right now, but is it true that
5 she does have a power of attorney in place right now?
6
7
A
Q
Yes, she does.
Is this your only-- do you have a copy with
8 you?
9
10
A
Yes, I do.
MR. ABOM: Just for the Court's information,
11 I spoke with Ms. Myers earlier today about that, and she
12 was unable to secure the current copy. I did see it as I
13
arrived here just before this proceeding.
I'd like to mark
14 it, if I can-- I'll mark the back of it as an exhibit. Oh,
15 we do have an extra copy.
16
17 that.
18 (Whereupon, Alleged Incapacitated Person
19 Exhibit 1 was marked for identification.)
THE COURT: We'll have the stenographer mark
20
THE COURT: We will let the record indicate
21 that the power of attorney has been marked as Alleged
22 Incapacitated Person Exhibit 1.
23 BY MR. ABOM:
24
Q
I will ask you, Miss Myers, does this
25 exhibit-- is it true that this is entitled durable general
19
.
.
1 power of attorney?
2
3
A
Q
Yes.
And does it initially name her mother, Jane
4 Russell, as the-- her attorney-in-fact?
5
6
A
Q
Yes, it does.
And if Miss Russell were to be unable to do
7 it, for example, because she has recently passed away, does
8 it name Gloria Anderson, her successor, as an
9 attorney-in-fact?
10
A
Yes, it does.
11 Q And could you tell us when this document was
12 signed and dated?
13
14
A
Q
13th day of February, 1999.
You were working here back in February of
15 1999, is that correct?
16
17
A
Q
Uh-huh, yes.
Now back when she signed this, at least as
18 comparison to today, was she more able to make decisions
19 regarding her physical health and financial stability and
20 things along those lines?
21
22
A
Q
Yes.
And does, among the things this durable
23 power of attorney provides for, does it make any statement
24 with regard to allowing the attorney-in-fact to consent to
25 various medical procedures?
20
.
.
1
A
Yes, it does.
2 Q Could you, for the Court, I know the judge
3 could read it, but could you read to us what she has
4 granted her attorney-in-fact permission to do with regard
5 to paragraph 10-- I'm sorry, paragraph 12, if you could
6 read that portion of that document?
7 A To grant, refuse, withhold or withdraw
8 consent on my behalf for any health care services and
9 therapeutical and surgical procedures, including the
10 administration of drugs.
11
Q
And with regard to admitting her into
12 certain types of-- certain facilities, is there a paragraph
13 that addresses that with regard to her durable power of
14 attorney?
15
16
A
Q
Yes, there is.
Could you read that paragraph for us into
17 the record?
18
A
To apply for my admission, discharge, and/or
19 transfer to or from medical, nursing, residential,
20 rehabilitation, convalescent or other similar facilities on
21 my behalf, and to sign any consent, admission, or transfer
22 forms required by such facilities which are consistent with
23 this power to obtain, receive, and review copies of my
24 medical records and to consent to the disclosure of those
25 records and to enter into agreements for my care by such
21
.
.
1 facilities or elsewhere during my lifetime or for lesser
2 periods of time as my agent may designate, including the
3 retention of nurses for my care.
4
THE COURT: Is there an attorney whose name
5 is on that who might have prepared it?
6
THE WITNESS: The original is in our
7 business office possibly, unless the power of attorney
8 herself has the original. I don't see an attorney's name
9 on thi s .
10
11 BY MR. ABOM:
12
THE COURT: All right.
Q
Was that witnessed by anyone? Was her
13 signature witnessed by anyone?
14
A
Penny Myers, LPN. Penny Myers is an LPN
15 here at this facility.
16
17
18
19
20
21
22
23
24
25
Q
A
Q
Does she still work here?
She does.
Okay. And was this document also-- the
signature of Miss Dyarman acknowledged by a notary public?
A Yes.
Q On what date?
A 18th of February, 1999.
Q And the notary's name is?
A Vera Rice. Vera J. Rice.
Q Does she also have any other document filled
22
.
.
lout with regard to her wishes should she become either
2 incapacitated or, I want to say unconscious, or terminally
3 ill, something perhaps referred to as a living will?
4
A
Yes, we have a medical directive that, it's
5 a form of our facility, that we present to our residents
6 that she did complete in 1995.
7
Q
Okay.
If I could mark this as an exhibit,
8 and I would have-- would ask that counsel allow that we
9
substitute a copy.
I don't know if this is your only copy,
10 so I would ask that by counsel.
11
12
13
14
15
THE COURT: Mr. O'Brien.
MR. O'BRIEN: I have no problem with that.
THE COURT: Mr. Mulderig.
MR. MULDERIG: No problem whatsoever.
THE COURT: We'll have that marked as
16 Alleged Incapacitated Person Exhibit 2.
17 (Whereupon, Alleged Incapacitated Person
18 Exhibit 2 was marked for identification.)
19 BY MR. ABOM:
20
Q
I asked you about an additional medical
21 directive, and I'm showing you has been marked as Alleged
22 Incapacitated Person No.2. Is that a two-page document
23 entitled resident medical directive?
24
25
A
Q
Yes.
And without-- is it-- this is an exhibit.
23
.
.
1 It certainly speaks for itself. But in general, does this
2 address the situation where-- does this-- was this a
3 document completed by Miss Dyarman back on February 8th of
4 1995?
5
6
7
8
A
Q
A
Q
Yes.
Was this signed by her?
Yes.
Was it witnessed by two other individuals,
9 one being Jane Russell and the other one being?
10
11
12
13
14 indicate--
15
A
Q
A
Audra Legler. Legler, L-e-g-l-e-r.
So you had answered yes to my questions?
Yes.
In the second paragraph, does this document
Q
MR. O'BRIEN: Your Honor, could I interrupt?
16 Did you understand that?
17
18
19
MR. MULDERIG: She said, I want to die.
MR. O'BRIEN: Okay.
THE COURT: It's not clear from the record
20 who we're talking about.
21
MR. O'BRIEN: Yes. Could you indicate what
22 you have heard Cynthia saying?
23 THE WITNESS: Cheryl is saying?
24
25
MR. O'BRIEN: I mean, Cheryl.
THE WITNESS: Cheryl is saying, I want to
24
.
.
1 die.
2
MR. O'BRIEN: Has she been saying that
3 consistently for the past few minutes?
4
5
6 BY MR. ABOM:
7
THE WITNESS: For the past few minutes, yes.
MR. O'BRIEN: Okay. Thank you.
Q
Have there been times you've known her
8 within the past couple months where she said she hasn't
9 wanted to die?
10
11
A
Q
Yes.
Is it-- in the interest-- I'm trying to ask
12 leading questions in the interest of moving things along.
13 Does it appear from the face of this document that this
14 declaration was made to be followed if Miss Dyarman was to
15 lack the sufficient capacity to make or communicate
16 decisions concerning herself?
17
18
A
Q
Yes.
And does it say that it would come into
19 effect if she were to become permanently unconscious or in
20 a state of having a terminal condition?
21
22
23
24
25
correct?
A
Q
Yes.
All right. She is conscious now, is that
A
Correct.
Does this document define what she meant by
Q
25
.
.
1 terminal condition?
2
A
Yes, it says, an incurable and irreversible
3 medical condition caused by injury, disease, or physical
4 illness which will, in the opinion of the attending
5 physician, to a reasonable degree of medical certainty,
6 result in death regardless of continued application of
7 life-sustaining treatment.
8
MR. ABOM: Your Honor, I would like to
9 follow through on this but perhaps with a physician or even
10 the psychiatrist who, I gather, is a physician, too, and
11 ask his opinion about whether or not she has an incurable
12 disease and, I think, things along those lines that
13 actually affect her mental capacity to make decisions.
14
15
THE COURT: All right.
MR. ABOM: So I would ask questions of the
16 physician in that regard.
17 BY MR. ABOM:
18
Q
Miss Myers, to your knowledge, or based on
19 your experience, does Miss Dyarman's physical condition
20 impair her mental ability to make decisions?
21
A
From what I know about the disease, the
22 demyelinating disease of the spine, it is progressive and
23 can effect a person's cognitive ability, in other words,
24 effect the mind, cause deterioration as the disease
25 progresses. To what level or extent, I don't know for
26
.
.
1 sure.
2 Q To what extent is Miss Dyarman able to
3 communicate her decisions? By that, I mean, is she able
4 to, in your opinion, to answer yes and no to questions? Is
5 she able to elaborate on her wishes and desires in any
6 respect?
7
A
Yes, she can answer yes and no questions,
8 and she can express her desires. Are they consistent and
9 reasonable always, in my opinion? No.
10 Q You had given us two prior examples of first
11 being, she believes this is October. I think a second
12 example, and I'm trying to think of it, and perhaps you
13 could refresh my memory.
14
MR. MULDERIG: Where the food carne from was
15 for another person.
16
17 BY MR. ABOM:
THE WITNESS: Right, correct.
18
Q
Can you think of any other examples that
19 might give us similar types of expressions that seem to
20 perhaps not make sense?
21 A Cheryl looked forward to the beauty shop
22 every Monday. I mean, she lived for the beauty shop every
23 Monday. And in August, September, somewhere in there, when
24 she started telling us that it was a different date than
25 what it was, on Mondays the nurses would try to get her up
27
.
.
1 for the beauty shop, and she would claim that it wasn't
2 Monday, it was Saturday, and she was not getting up for the
3 beauty shop. So she hasn't been to the beauty shop since
4 this started because she will not believe us that it's
5 Monday and the beauty shop day. I don't quite understand
6 why.
7
Q
You have said earlier that some of the onset
8 perhaps of a deterioration of Miss Dyarman's mental
9 abilities seem to be triggered perhaps by the passing away
10 of her mother in April of 2000. Was there anything else
11 that was going on in or around that time that may have
12 caused her to either be depressed to the point that she did
13 not want to live? Anything else?
14
A
Yes, around the same time that Cheryl's
15 mother passed on, the religious group, the Gideons, came
16 every Tuesday. And that was probably the second thing that
17 Cheryl looked forward to most, was going to the Gideons.
18 The beauty shop and the Gideons. And the gentleman who
19 conducted the group was old and just unable to continue
20 coming, so they stopped coming right around the same time
21 that her mother passed away.
22 So two very significant things in Cheryl's
23 life disappeared in a short amount of time. And we
24 certainly saw those as significant stressors in her life
25 which triggered these chain of events, so it seemed.
28
.
.
1
Q
You are aware, and I think I will follow-up
2 with some questions with the doctor when we have an
3 opportunity and he has an opportunity to testify, and Mr.
4 Mulderig may have asked a question regarding the
5 electroconvulsive therapy, or you referred to it as ECT,
6 but to what extent, to your knowledge, would that therapy
7 aid or assist in treating the depression to the extent that
8 Miss Dyarman may recover from her depression and lead a
9 better quality of life than perhaps right now?
10
A
Just to clarify. Are you asking what I
11 think the prognosis for this treatment is?
12
13
14
15
Q
A
Yeah. Yes.
I don't know that I can answer that, because
I am not extremely familiar with ECT.
I've read
information about it.
I know it's the last resort for
16 treatment of depression. And it's generally successful.
17 But, again, I don't know the statistics on that. And, you
18 know, I don't even know if-- I can't answer for sure.
19 Nothing else has worked.
20
Q
Is it true that Miss Dyarman, in some
21 respects, is more cooperative with some of the staff here
22 than others?
23
24
A
Q
Yes.
Are some staff members better able to have
25 Miss Dyarman communicate with strangers and other people
29
.
.
1 who might be coming in?
2
3
A
Q
Yes.
How about some family members or friends or
4 other interested people, perhaps Miss Anderson or her
5 stepfather or other individuals, are they better able to
6 speak with and converse with Miss Dyarman?
7
A
Yes. I've talked with Miss Anderson, and I
8 know that she has expressed concern and difficulty with her
9 ability to communicate recently with Cheryl.
10
MR. ABOM: Your Honor, I have no further
11 questions.
12
13
THE COURT: Okay. Mr. O'Brien.
MR. O'BRIEN: I have no questions.
14 THE COURT: Mr. Mulderig.
15 MR. MULDERIG: I have a couple of questions.
16 RECROSS EXAMINATION
17 BY MR. MULDERIG:
18
Q
That power of attorney gives Miss Anderson
19 the authority to approve any medical treatment, is that
20 correct?
21
22
A
Q
I believe so. That's how it read, yes.
Now on this electro-- in paragraph 12, To
23 grant, refuse, withhold or withdraw consent on my behalf
24 for any health care service and therapeutical and surgical
25 procedures, including the administration of drugs. That's
30
.
.
1 what it says, isn't it?
2 A Yes.
3
Q
Okay. On this ECT treatment, is it required
4 that she be inpatient in a hospital to receive this ECT
5 treatment or could she be taken to the hospital, receive
6 the treatment, and be returned here?
7
A
From what I've learned about it since this
8 has begun, some people can receive ECT on an outpatient
9 basis. Some people receive it on an inpatient basis. And
10 I guess that is based upon the recommendation of the
11 psychiatrist and the person's needs. I don't know that all
12 ECT can be given on an outpatient basis.
13 MR. MULDERIG: I have no further questions.
14 THE COURT: Mr. Abom.
15
16
17
18 BY THE COURT:
MR. ABOM: I have no follow-up.
THE COURT: Mr. O'Brien.
MR. O'BRIEN: Nothing, Your Honor.
19
Q
To your knowledge, has anybody discussed the
20 ECT treatments with Ms. Dyarman?
21 A Yes, the psychiatrist has. The nursing
22 staff have. I have. And her therapist from the
23 psychological services has.
24 Q Now when you discuss it with her, do you
25 have the impression she understands what you're talking
31
.
.
1 about?
2
A
I'm not sure. I'm going to say, no.
3 Because this is-- as soon as we begin to address her not
4 eating and our concern for her health, this is the
5 response. So it's difficult.
6 Q The response is that she wails?
7
A
Yes. And I don't know how much she listens
8 to the explanation to understand.
9
Q
How does she make known her desire not to
10 eat?
11
A
Often the same way as she is right now,
12 yelling. She'll state, no, I don't want it, or, it's not
13 mine. Get out of here. And then if you don't leave the
14 room, it will escalate until you do leave the room.
15
Q
So it sounds as if she is able to let you
16 know how she feels about a suggestion?
17
18
19
20
A
Yes.
THE COURT: Okay.
MR. O'BRIEN: One follow-up question.
THE COURT: Sure.
21 REDIRECT EXAMINATION
22 BY MR. O'BRIEN:
23
Q
Is it your understanding, based on your
24 contacts and the reports of others that have spoken with
25 her about ECT treatment, that she is not interested in
32
.
.
1 receiving it?
2
3
4
A
Q
A
That's what she has said, yes.
Is that consistent?
Oh, consistent? Any hospitalization, any
5 treatment is consistent.
6
7
8
9
10
11
12
Q
A
No?
No, she does not want it.
THE COURT: Okay. Mr. Abom.
MR. ABOM: No further follow-up on that.
THE COURT: Mr. Mulderig.
MR. MULDERIG: No follow-up.
THE COURT: Given her history and her
13 illness and the events in her life, is it surprising that
14 she is depressed?
15 THE WITNESS: No. And she has a diagnosis
16 as early as 1980 of depression when her husband left her.
17 THE COURT: Her husband what?
18
THE WITNESS: Her husband left her. And
19 subsequently, she moved in with her parents and was very
20 depressed at that time.
21
THE COURT: Is that before her other illness
22 had been diagnosed?
23
24 child.
25
THE WITNESS: Her illness was diagnosed as a
THE COURT: I see.
33
. .
1 THE WITNESS: If I am accurate.
2 THE COURT: Okay. Mr. Abom.
3 RECROSS EXAMINATION
4 BY MR. ABOM:
5 Q To your knowledge, is there anything in her
6 prior history about any eating disorders or refusals to eat
7 or anything along those lines?
8
A
Yes. Early on, Cheryl was always concerned
9 with her weight. Again, as I understand from her mother's
10 reports and information in her social history, she was
11 always concerned with not eating too much, but generally a
12 physician or her mother could convince her to eat. She's
13 been here since 1987, and we have not had a lot of issues
14 related to her eating until recently.
15 THE COURT: Okay. Mr. Mulderig.
16 MR. MULDERIG: No questions.
17
18
19
20
THE COURT: Mr. O'Brien.
MR. O'BRIEN: No questions, Your Honor.
THE COURT: Okay. Thank you.
MR. O'BRIEN: I then would call in the
21 context of the guardianship proceeding, Gloria Anderson.
22
THE COURT: All right.
It sounds as if
23 counsel are going to be in agreement that the record in
24 each of these cases will be part of the record in the other
25 case?
34
.
.
1
2 Honor.
3
4
5
MR. O'BRIEN: That's acceptable to me, Your
MR. ABOM: I have no objection to that.
MR. MULDERIG: No objection.
THE COURT: Okay.
6 Whereupon,
7 GLORIA A. ANDERSON
8 having been duly sworn, testified as follows:
9 DIRECT EXAMINATION
10 BY MR. O'BRIEN:
11
12
13
14
15 Pennsylvania.
16
17
18
19
Q
A
Would you state your name, please?
Gloria A. Anderson.
And where do you live, Gloria?
810 Green Spring Road, Newville,
Q
A
Q
A
And what is your age?
Thirty-three.
How have you come to know Ms. Dyarman?
Through a friend of her mom's and has become
Q
A
20 a friend of her's.
21
22 Miss Dyarman?
23
24
Q
And how long have you been friendly with
A
Q
For about 15 years.
And during that IS-year period, have you had
25 regular contact with Miss Dyarman?
35
.
.
1
2
A
Q
Yes.
And where would those contacts take place?
3 A Well, my husband and I would actually help
4 her mother and her stepfather bring her home for the
5 holidays. We'd come down to the nursing home and actually
6 bring her home, help them with her and stuff, assist them.
7
Q
Now you have been named as the alternate
8 caretaker, guardian, in the power of attorney form that was
9 entered as an exhibit. Was that done at the request of her
10 mother?
11
12
A
Q
Yes.
And did you discuss with her mother as well
13 as Miss Dyarman your willingness to serve in that capacity?
14
15
A
Q
Yes.
And are you willing to continue to serve in
16 that capacity if the Court were to appoint you formally as
17 a court-appointed guardian of Miss Dyarman?
18
A
Yes.
19 Q Do you have any reason to have any gain or
20 loss in regard to any decision that you may have to make in
21 reference to Miss Dyarman's care, any financial gain or
22 loss, I guess?
23
24
25
A
Is that mine or--
Q
A
Your--
I don't understand everything. This is all
36
.
.
1 new tome.
2
Q
There is nothing that you will gain
3 financially in serving as her guardian, is that your
4 understanding?
5
6
A
Q
Yes.
And my understanding is that Miss Dyarman's
7 income consists of social security benefits which are
8 utilized to payor defray her costs here at the nursing
9 home?
10
11
A
Q
Yes.
One of the issues that has come forth in
12 this hearing is the possibility that Cheryl might need ECT
13 therapies. Would you be willing to consult and consider
14 that in the context of her care?
15
16
A
Yes.
MR. O'BRIEN: I have no further questions.
17 THE COURT: Okay. Mr. Mulderig.
18 CROSS EXAMINATION
19 BY MR. MULDERIG:
20
Q
Do you understand, ma'am, that under the
21 power of attorney, you have authority to have her committed
22 voluntarily to a mental health institution and to order
23 treatment?
24
25
A
Yes.
Do you understand that under the
Q
37
.
.
1 guardianship, you lose that power?
2
3
A
No.
THE COURT: The question was, do you lose
4 the power?
5
MR. O'BRIEN: Could I enter an objection? I
6 believe that's outside the scope of my examination and it
7 asks her to address questions which I believe are legal
8 issues before the Court.
9
THE COURT: Okay. Are you in agreement that
10 you don't know the answer to that question?
11
12
13
14
THE WITNESS: Yes.
THE COURT: Okay.
MR. MULDERIG: I have no further questions.
THE COURT: Mr. Abom.
15 CROSS EXAMINATION
16 BY MR. ABOM:
17
Q
Over the past several months, how often have
18 you come by and seen Miss Dyarman?
19
A
To be honest with you, not regularly,
20 because we have come-- I make calendars for her, come in,
21 because Kathy called and said about her not knowing the
22 days and stuff, so I took and made up calendars, brought
23 them in, and every time I've come in, it just like upsets
24 her, so I didn't want to add more, I don't want to say,
25 fuel to the fire.
38
.
.
1
Q
Have you made any effort yourself to talk to
2 Miss Dyarman about the recommended course of treatment or
3 the proposed course of treatment of the electro-- the ECT?
4 A Not actually that, but I have talked to her
5 in the hospital. I mean, when she was in.
6 Q When was she in the hospital? Do you
7 recall?
8
9
10
11
12
13
A
Q
A
Q
A
Q
December.
December of 2000?
Yes.
And she was-- that was Carlisle Hospital?
Yes, Carlisle Hospital.
And when you talked to her there, what did
14 you talk about?
15 A That she needs to take her medicine and, you
16 know, to calm down, and--
17
THE COURT: What was she in the hospital for
18 in December of 2000?
19
THE WITNESS: They wanted to do an
20 involuntary to the psychiatric admission, and she had to go
21 through the emergency room to have that done. And then she
22 ended up with a bladder infection, so they admitted her for
23 that.
24 THE COURT: I see. Was she actually
25 subjected to involuntary treatment?
39
.
.
1
THE WITNESS: Nobody-- I don't want to say,
2 nobody was interested, but because of her condition and
3 stuff at that time.
4
THE COURT: So as far as you know, she was
5 not subjected to involuntary treatment at that time?
6
7
8
THE WITNESS: No, she was not.
THE COURT: All right.
MR. O'BRIEN: Your Honor, if I could flush
9 out that issue for you. From the information that I have
10 collected is that the nursing home, through the social
11 worker, initiated a 302 commitment process.
12
THE COURT: An emergency commitment?
13 MR. O'BRIEN: An emergency commitment. A
14 warrant was issued by the mental health delegate. Cheryl
15 was brought to the Carlisle Hospital. She was examined by
16 a physician, I believe not a psychiatrist, but an emergency
17 room physician who determined that Cheryl's decision to
18 refuse food and nourishment was one that was knowingly
19 taken, and that based on that, he did not recommend
20 inpatient psychiatric care.
21
22 doctor?
23
24
25 those facts?
MR. ABOM: Do you recall the name of that
MR. O'BRIEN: I don't.
THE COURT: Are counsel able to stipulate to
40
. .
1 (Whereupon, Kathy Myers was shaking her head
2 negatively.)
3 MR. O'BRIEN: That's not correct?
4
THE COURT: Well, I don't want to turn the
5 record into such a confusing state. Apparently there is
6 not a stipulation to those facts, so I'll regard them as
7 not agreed upon. Mr. Abom.
8 BY MR. ABOM:
9
Q
I think I had asked Miss Anderson about your
10 talking with Miss Dyarman at the time she was brought down
11 to Carlisle Hospital. And you had a conversation with her
12 there about perhaps some mental health treatment. What was
13 the nature of the conversation and what did she relate to
14 you?
15
A
She just wanted to die. She refused-- she
16 was even doing the same thing in there for the nurses.
17
Q
When you say, the same thing, go ahead--
18 A The crying, the weeping. Whenever you would
19 talk to her, she would just go--
20
Q
Her wanting, her expressing a desire to die,
21 has that-- has that been an expression, something that has
22 come of late? Has she said things like that over the 15
23 years you've known her?
24
25
A
Q
No, just recent since her mom passed away.
Did it begin as early as April of 2000?
41
.
.
1
A
No, I'd say, it was like May it started out,
2 because I don't think it really dawned on her that her mom
3 did pass away even though she was at the funeral and stuff.
MR. ABOM: If I might have one moment.
THE COURT: Sure.
4
5
6 BY MR. ABOM:
7 Q Is there anyone physician or two or three
8 physicians whose advice you're following with regard to a
9 course of treatment for Miss Dyarman?
10
11 Kathy Myers.
12
13 Ms. Myers that--
14
15
A
No, because I just have been speaking with
Q
Okay. So it's information related through
A
Q
Yes.
And you're acting on her, on the information
16 that's been given to you?
17
18
A
Q
Yes.
Back in December when she expressed she
19 wanted to die, in your opinion, knowing her over 15 years,
20 to what extent do you believe that that reflected her true
21 wishes? I know that's a difficult question to answer.
22
23
24
25
A
Q
A
Q
I'd say, it's almost a depression.
I'm sorry?
She really doesn't want to die.
So in some respects, you don't believe that
42
.
.
1 is her true desire based on your relationship with her over
2 the past 15 years?
3
4
5
6
7
8
9
A
No.
MR. ABOM: No further questions.
THE COURT: Mr. Mulderig.
MR. MULDERIG: No questions.
THE COURT: Mr. O'Brien.
MR. O'BRIEN: No questions.
THE COURT: Okay. Thank you for your
10 testimony.
11
MR. O'BRIEN: Could we go off the record for
12 a minute?
13 (Whereupon, a discussion was held off the
14 record regarding refusal of Carlisle
15 Emergency Room physician to approve
16 involuntary commitment of Ms. Dyarman on
17 December 2000 occasion.)
18
THE COURT: Do counsel for Miss Dyarman want
19 to ask her questions as to what her wishes are?
20
21
22
MR. MULDERIG: I have no questions.
THE COURT: All right.
MR. ABOM: Your Honor, I mean, I feel an
23 obligation to try to ask those questions, if we're able to.
24 Having attempted to speak with her earlier today, I'm
25 concerned that even my attempting to ask her questions will
43
.
.
1 cause her to be so upset that she will not be able to
2 communicate. And, I mean, if-- perhaps I'm proposing
3 somebody else ask questions just with regard to her
4
understanding.
I mean, I can do it.
5 THE COURT: Cheryl, my name is Wesley Oler,
6 and I'm a judge here in Cumberland County. The issues that
7 I'm trying to decide-- just listen for a minute-- are
8 whether you should receive mental health treatment-- just
9 listen-- and whether a guardian should be appointed for
10 you. Now there are two attorneys who have been appointed
11 to represent you.
12
Cheryl, Cheryl, listen. There are two
13 attorneys that have been appointed to represent your
14 interests. We want to know what you want.
15
16
CHERYL DYARMAN: I want to die.
THE COURT: All right. You've indicated--I
17 think you're saying, you want to die.
18
19
CHERYL DYARMAN: I want to die.
THE COURT: Okay. The next question is, do
20 you want to be subjected to involuntary--
21
22
CHERYL DYARMAN: No, no, no.
THE COURT: Let me finish.
--to involuntary
23 mental health treatment?
24
25
CHERYL DYARMAN: No, no, no.
THE COURT: Okay.
I can't understand
44
.
.
1 whether you're saying yes or no.
2
3
4
5
CHERYL DYARMAN: No.
THE COURT: Are you saying, no?
CHERYL DYARMAN: No.
THE COURT: I think you're saying, no. Do
6 you want the Court to appoint a guardian for you?
7
8
9
10
CHERYL DYARMAN: No.
THE COURT: You're saying, no, again--
CHERYL DYARMAN: No.
THE COURT: --I think. Okay. Do counsel
11 want to ask questions?
12
13
14
15
16
17
MR. O'BRIEN: No, Your Honor.
MR. ABOM: No.
MR. MULDERIG: No.
THE COURT: Mr. Mulderig.
MR. MULDERIG: No, Your Honor.
THE COURT: Is there anything else you want
18 to say? I can't understand you.
19
Ms. Myers, do you know what she said?
20 KATHY MYERS: Cheryl, we can't understand
21 you. Can you slow down a little bit? Slow down. He
22 wanted to know, what you do want.
23 CHERYL DYARMAN: I want to die here.
24
25
KATHY MYERS: You want to die here?
CHERYL DYARMAN: I want to die here.
45
.
.
1 KATHY MYERS: I'm sorry. Maybe I didn't
2 hear you. Cheryl, look at me. Stop crying. We're trying
3 to understand you. Can you tell us, what you do want? You
4 want to get out of here?
5
6 he re .
7
8 he re .
9 THE COURT: Okay. Thank you very much.
10 We also have here Ms. Dyarman's stepfather.
11 Is there anything that you wanted to say under oath?
CHERYL DYARMAN: I want you to get out of
KATHY MYERS: You want us to get out of
12
13
attorney.
VICTOR RUSSELL: No. No, she's the power of
I let her make the decisions. She asks me
14 something, I'll try to help her with. That's why I'm with
15 her.
16
17
18
THE COURT: Your name is?
VICTOR RUSSELL: Victor Russell.
THE COURT: Okay. Thank you, Mr. Russell.
19 Anything further at this time from counsel?
20 MR. O'BRIEN: I would just note that Gloria
21 Anderson indicated that her understanding of Cheryl's
22 wishes are that she would like to go to Green Ridge Village
23 and die there, because that is the location her mother
24 passed away.
25
THE COURT: All right. And that's a nursing
46
.
.
1 home in Newville, Pennsylvania. All right. And I think we
2 got your address, Ms. Anderson, but what was it again?
3
MS. ANDERSON: 810 Green Spring Road,
4 Newville, 17201.
5
THE COURT: Okay. It's about 4:15 in the
6 afternoon at this point. And if there's no objection,
7
we'll adjourn for the evening.
I think there was not
8 enough time to hear from the doctor, even if he were here,
9 and I'll ask counsel to contact my secretary to schedule a
10 further proceeding and see whether they can stipulate that
11 it will not be necessary for Ms. Dyarman to be present at
12 that proceeding.
13 MR. MULDERIG: I'll stipulate to that.
14 THE COURT: Well, give it some thought. I
15 don't mind coming here again. And we'll enter this order.
16
17
AND NOW, this--
MR. MULDERIG: Your Honor, one other point.
18 Any testimony that you took from my client relevant to the
19 mental health thing after I stated that I did not want her
20 called, I just point out to you under the Mental Health
21 Procedures Act, she cannot be forced to testify, and as far
22 as you using it for the guardianship, I do not care, but
23 you should not consider it for the mental health matter.
24
THE COURT: All right. There were two
25 exhibits, I think, introduced. Do counsel want to move
47
.
.
1 their admission?
2
MR. ABOM: Your Honor, I do want to move
3 their admission. The first exhibit is the durable power of
4 attorney. The second is the resident medical directive.
5 And again, I ask permission to make a copy of the medical
6 directives so the Claremont Home here can keep a copy.
7
THE COURT: All right. Mr. O'Brien, do you
8 have any objection to that?
9
10
11
12
MR. O'BRIEN: I have no objections.
THE COURT: And Mr. Mulderig.
MR. MULDERIG: No objection whatsoever.
THE COURT: Okay. The Alleged Incapacitated
13 Person's Exhibits 1 and 2 are admitted.
14 (Whereupon, Alleged Incapacitated Person's
15 Exhibits 1 and 2 were admitted into
16 evidence.)
17
THE COURT: And we'll enter this order.
18 (Whereupon, the following Order of Court was
19 entered. )
20 ORDER OF COURT
21 AND NOW, this 24th day of January, 2001,
22 upon consideration of the petition for appointment of an
23 emergency guardian of the person, the record shall remain
24 open, and counsel are requested to contact the Court's
25 secretary to schedule a further hearing and to determine
48
.
.
1 whether they can stipulate that the subject of the
2 proceeding need not be present.
3
4
By the Court,
5
/s/ J. Wesley Oler, Jr.
J.
6
7 ORDER OF COURT
8 AND NOW, this 24th day of January, 2001,
9 upon consideration of the petition for involuntary
10 treatment under the Mental Health Procedures Act, the
11 record shall remain open, and counsel are requested to
12 contact the Court's secretary to schedule a further hearing
13 and to determine whether they can stipulate that the
14 subject of the proceeding need not be present.
15 By the Court,
16 /s/ J. Wesley Oler, Jr.
J.
17
18
THE COURT: All right. Thank you very much.
19 And court is adjourned.
20 (Whereupon, the proceedings adjourned at
21 4:16 p.m.)
22
23
24
25
49
.
.
1
2
3
4
January 29, 2001
In Chambers
12:35 p.m.
THE COURT: We will let the record indicate
5 that the Court has reconvened in the matter of Cheryl I.
6 Dyarman. This is a hearing at which counsel have agreed
7 that the evidence presented in each of the two cases can be
8 considered in the other, with the exception of a caveat by
9 Mr. Mulderig that certain statements of the subject of the
10 proceedings, Cheryl I. Dyarman, would not be admissible in
11 the mental health proceeding.
12 We are convening in chambers of the judge
13 because the psychiatrist in the case, Dr. Hegarty, is
14
15
16
17
18
19
20
21
22
23
24
available to testify only by telephone. My understanding
is that, both counsel representing the subject of the
proceeding, that is Robert Mulderig, Esquire, on behalf of
Cheryl I. Dyarman in the mental health proceeding, and John
A. Abom Esquire, on behalf of Cheryl I. Dyarman in the
incompetency matter, have agreed that her presence will not
be required for this portion of the hearing.
correct?
Is that
MR. MULDERIG: That is correct.
MR. ABOM: Yes, Your Honor
THE COURT: All right. And, Mr. O'Brien, I
25 believe you wanted to call Dr. Hegarty as a witness?
50
.
.
1
MR. MULDERIG: Your Honor, I would be
2 willing to stipulate that Dr. Hegarty is a psychiatrist as
3 an expert witness.
4
MR. ABOM: I'm not going to question his
5 qualifications. Maybe it would be appropriate just to get
6 some of the basic ones for the record.
7
THE COURT: All right. Mr. O'Brien, do you
8 have Dr. Hegarty's number?
9
10
MR. O'BRIEN: Yes, I do.
It's 816-7424.
THE COURT: What is his full name?
11 For the record, is his full name James
12 Hegarty, H-e-g-a-r-t-y?
13
MR. O'BRIEN: I believe it is, Your Honor,
14 by his business card.
15 THE COURT: Okay.
16 (Whereupon, Judge Oler placed a telephone
17 call.)
18 A VOICE: Hi. This is Dr. Jim Hegarty. I
19 will be out of the hospital Thursday evening, January 25th,
20 at 8 p.m., until Monday morning, January 29th, at 8 a.m.
21 In my absence, emergencies will be handled by Dr. James
22 Druckenbrod who can be reached by calling his practice with
23 area code 717-264-2555. Thanks.
24
THE COURT: We will let the record indicate
25 that the message we received in dialing that number
51
.
.
1 indicated that Dr. Hegarty was not present.
2
MR. O'BRIEN: Your Honor, I spoke with him
3 not more than an hour ago, and he said that we could reach
4 him on that. That's his cell phone line. Could we try
5 this number, Your Honor? 267-7480.
6 THE COURT: We can.
7
8
9
(Whereupon, Judge Oler placed a telephone
call.)
A VOICE: Hello. You have reached the
10 Summit Behavioral Health Center. Our office hours are
11 Monday through Thursday, 8 a.m. to 8 p.m., and Friday, 8
12 a.m. to 5:00 p.m. We are either on the other line or away
13 from the desk, so if you would like to leave a message,
14 please do so after the tone, and someone will return your
15
call as soon as possible.
If this is of an urgent nature,
16 you may call our crisis line at 264-2555. Thank you.
17 THE COURT: This is Judge Oler in the
18 Cumberland County Court. We were trying to reach Dr.
19 Hegarty for testimony in a case. Thank you. My number is
20 717-240-6532.
21
MR. O'BRIEN: Let's try the cell phone. If
22 he were on the phone, it might have rolled over to be
23 answered by his answering machine.
24
THE COURT: All right. And that number
25 again was?
52
. .
1 MR. O'BRIEN: 816-7426.
2 (Whereupon, Judge Oler placed a telephone
3
4
call. )
THE COURT: We will indicate that we
5 received a busy signal that time.
6
7
MR. O'BRIEN: 816-7426.
(Whereupon, Judge Oler placed a telephone
8 call.)
9 THE COURT: Well, we have gotten two busy
10 signals and one recording. I'm at your disposal.
11 MR. O'BRIEN: If we can wait a couple more
12 minutes and try him again.
13 MR. MULDERIG: I hope you don't mind, Your
14 Honor, I'm going to step outside, and I'll be right back.
15 (Whereupon, Mr. Mulderig exited the chambers
16 and returned.)
17
18
MR. O'BRIEN: 816-7426.
(Whereupon, Judge Oler placed a telephone
19 call.)
20 THE COURT: We will let the record indicate
21 we got a busy signal again. Let me try it without the 1.
22
23
24
25
816--
MR. O'BRIEN: 7426.
(Whereupon, Judge Oler placed a telephone
call. )
53
.
.
1
2
DR. HAGERTY: Hello. Dr. Hegarty.
THE COURT: Dr. Hegarty, this is Judge Oler
3 in Cumberland County.
4
5
DR. HEGARTY: Yes, Judge Oler.
THE COURT: Thank you very much for making
6 yourself available for testimony.
7
DR. HEGARTY: This is on a cellular phone.
8 Would you like me to call back on a secure line or--
9 THE COURT: No, we can hear you pretty well.
10
DR. HEGARTY: Okay. Great.
11 THE COURT: I'll just ask you to speak
12 loudly, if you will.
13 DR. HEGARTY: Okay.
14 THE COURT: And you are Dr. James Hegarty,
15 H-e-g-a-r-t-y?
16
17
18 hand, please.
19 Whereupon,
DR. HEGARTY: That's right.
THE COURT: And would you raise your right
20 JAMES HEGARTY, M.D.
21 having been duly sworn, testified as follows:
22 THE COURT: And Dr. Hegarty, the first
23 attorney who will be questioning you is Rob O'Brien, and
24 the second and third attorneys will be Jay Abom and Robert
25 Mulderig. And Mr. Abom and Mr. Mulderig are both
54
.
.
1 representing Ms. Dyarman in this mental health proceeding
2 and incompetency proceeding.
3
4
THE WITNESS: Okay.
THE COURT: Mr. O'Brien.
5 DIRECT EXAMINATION
6 BY MR. O'BRIEN:
7 Q Yes. Doctor, for the purpose of a complete
8 record, could you indicate your medical background and your
9 Board licensing as a psychiatrist?
10
A
Yes, I hold a medical degree from Penn State
11 University at Hershey. I completed my residency training
12
in the Massachusetts General Hospital in Boston.
I am
13 Board-certified in psychiatry. And in addition to
14 psychiatry, I serve as medical director for Behavioral
15 Health Services in Chambersburg Hospital, and I'm licensed
16 in the State of Pennsylvania as a physician.
17 Q As I understand, you also have employment in
18 your profession through Cumberland County and consult at
19 the County Nursing Home?
20
21
A
Q
That's correct.
And in connection with that service, did you
22 have occasion to come into contact with Cheryl Dyarman at
23 the nursing home?
24
25
A
Q
I have.
In speaking with you earlier, I understand
55
.
.
1 it's difficult because you don't have the medical records
2 with you, but from your contacts, do you feel comfortable
3 testifying as far as establishing a diagnosis of any mental
4 problem that she might have?
5
6
7
8
A
Q
A
Q
I do.
You are comfortable then?
Yes.
Okay.
In reference to any mental disability
9 that she has, could you indicate the diagnosis and the
10 basis for your diagnosis?
11
A
Well, Cheryl is considered-- I have
12 considered Cheryl to have a diagnosis of recurrent major
13 depression. And that diagnosis is based on multiple
14 clinical encounters with Cheryl over, I believe, a period
15 of about two years. Her symptoms have been characterized
16 by depression, significant loss of appetite, infrequent
17 dose of cheerfulness, loss of energy, social withdrawal,
18 eclectic behavior, sense of hopelessness about her
19 position, and at times expression of both passive suicidal
20 ideation, by which I mean not having the will to live, and
21 at other times, a clear expression of a wish for death.
22 That basically covers the clinical diagnosis of her.
23 Q Now as a result of that recurrent major
24 depression, does Cheryl present a risk of suffering serious
25 bodily injury within the next 30 days if medical
56
.
.
1 treatment-- if medical and psychiatric interventions are
2 not made?
3
A
I believe she does, largely based on her
4 refusal of both adequate nutrition and of necessary
5 medications. I think there is a clear and present risk of
6 death largely due to malnutrition.
7 Q The representatives at the nursing home have
8 made arrangements to transfer her to Hershey Hospital, and
9 they have a psychiatric unit there. Are you familiar with
10 that unit?
11
A
Yes, I'm familiar with the unit and the
12 doctors who are there.
13
Q
And would you agree that that would be an
14 appropriate place for her to receive treatment?
15 A Well, it's a very appropriate place for her
16 to receive treatment in that they certainly can manage her
17 medical issues in terms of her malnutrition and that she's
18 getting to the point of actually becoming dehydrated
19 because of inadequate fluid. They also are equipped to
20 handle her depression.
21 The treatment issue with Cheryl is that she
22 refuses to accept any oral antidepressant medication which
23 could possibly help her if she were to allow us to
24 administer that treatment. But she's consistently refused
25 that egregiously for perhaps months. And now that we have
57
.
.
1 put her at the point of, you know, I think imminent
2 medical danger and conventional psychiatric management
3 where a patient at this point whose life is intentionally
4 in danger secondary to depression would be to administer
5 electroconvulsive therapy, and Hershey does provide that
6 treatment option.
7
Q
Could you explain to us what
8 electroconvulsive therapy is and what the anticipated
9 result of those treatments would be in Cheryl's case?
10
A
Well, electroconvulsive therapy is a
11 treatment in which an electrical stimulant is delivered to
12 the patient's brain triggering a generalized seizure. The
13 treatment, we believe, clinically, what it does is, relieve
14 her chemicals in the brain that are in deficit in severe
15 depression, and the seizure facilitates that. Generally,
16 or actually always, the treatment is delivered in a medical
17
center.
It's done under general anesthesia so the patient
18 doesn't feel any discomfort or pain.
19 An average course of treatment would be to
20 have one of the treatments done every other day chemically
21 for six to nine treatments, so when that's done on an
22 inpatient basis, it typically means hospitalization for
23 about two weeks. The treatments are very safe. There are
24 some side effects associated with it. It's usually some
25 short term memory loss of the events surrounding the
58
.
.
1 treatment, occasionally a headache. It's done any general
2 anesthesia, so there's always a small risk whenever general
3 anesthesia is administered, but it is a highly effective
4 treatment.
5
You know, clinical studies have shown that
6 it has a success rate of 90 percent, which is actually more
7 effective than the medication. And in selected cases such
8 as Cheryl's, it can be life saving.
9
MR. O'BRIEN: Thank you, Doctor.
I have no
10 further questions.
11
THE COURT: Mr. Abom.
12 CROSS EXAMINATION
13 BY MR. ABOM:
14
Q
Thank you, Doctor. Doctor, just by way of
15 familiarizing myself to you, we met very briefly at the
16 home just before you had to run off.
17
18
A
Oh, yes.
What was that? Thursday of last week.
Ilm
Q
19 not sure of the day.
20 A He's feeling fine. My son is feeling fine
21 now.
22
23 BY MR. ABOM:
THE COURT: Good.
24
Q
I want to ask you some questions.
I
25 represent Ms. Dyarman in terms of motions made to have her
59
.
.'
1 declared to be incompetent, and I just want to get a sense
2 both from your personal experiences and your medical
3 training of your impressions and opinions in that regard.
4 And I specifically, just very general question, to what
5 extent is Ms. Dyarman capable of making and communicating
6 decisions regarding her health?
7 A Well, at this time I feel she is not capable
8 of making an informed medical decision for several reasons.
9 The first is that clinically, I feel she is in the midst of
10 a severe major depressive episode, and I believe that she
11 has suicidal intent, and that I think she is able to
12 understand that by refusing nutrition and medication, she
13 is trying to hurt herself. And I believe that behavior in
14 conjunction with statements that she has made at times of
15 her wish to join her deceased mother constitutes suicidal
16 intent.
17 I also believe that her depression, and I'm
18 sure those of you who have seen her have witnessed it
19 likely, causes her a high degree of agitation. Minimal
20 questioning will often result in her screaming obsessively,
21 and it's very difficult many times to engage in a cogent
22 conversation with her about even very simple matters as to
23
whether she may have pain or not.
So for her to be able to
24 appreciate, you know, the risk and benefits of medical
25 treatment, I think it's that capability that is not present
60
.
.
1 at this time.
2
3
Q
A
Sorry.
I cut you off.
So, just to reiterate. The issues are that
4 I feel she's in the midst of a severe major depression that
5
is certainly impairing her cognitive ability.
I think when
6 she has made willful choices or statements, they often have
7 suicidal themes, so I do believe that her suicidal intent
8 is dominating her decision making process, and I do find
9 that suicidal intent to be part of her clinical condition
10 or depression which is treatable and correctable, and I
11 think her judgment is grossly impaired in that she has a
12 fixation, for example, of returning to a nursing home in
13 Cumberland County where her mother passed away.
14 And again, I think in Cheryl's limited
15 capacity, she sees that as a way of being closer to her
16 deceased mother. But all of this clinically really makes
17 it extremely difficult to sit down and have a rational
18 discussion with Cheryl about the needs to take her
19 medication or to eat.
20 I certainly have not been able to in recent,
21 if not perhaps the last couple of months, I have not been
22 able to have that kind of discussion with her. I should
23 say that at times in the past, she's been much more cogent
24 and communicative with me when her depression has been in
25 remission, and it has been at times when she was
61
.
.
1
cooperative with oral antidepressants.
I think during
2 those times, she certainly is capable of making informed
3 treatment decisions, but at this time and perhaps for the
4 last several weeks at least, she has not been capable of
5 that.
6
Q
Okay.
I wanted to follow-up on two points.
7 You started to touch on one of them. To what extent is her
8 condition different today or within the past, you said,
9 several weeks or several months as compared to the overall
10 two years you've been seeing her?
11
A
Well, for much of those two years, you know,
12 when I was initially consulted on Cheryl's case, she had
13 been accepting medication but had started to fail to
14
respond to it.
So at that time, she was accepting
15 medication and she was eating. And initially, my role was
16 really to change her antidepressant therapy to one that was
17 more potent and more effective.
18
So for some time, she was actually more
19 cooperative with treatment and responding to treatment.
20 Over the past several months, and again, I can't get a
21 specific date as I don't have the chart, she reached a
22 point where she simply began to refuse medication, not only
23 her antidepressants but other medications as well.
24 And it's really been in that setting of
25 non-treatment that I think she's deteriorated into a much
62
.
.
1 worse condition, and that's really been characterized by
2 what recently has been essentially refusal of almost all
3 nutrition, significant weight loss, dehydration, and
4 recently resulting in hospitalization at Carlisle, and the
5 current situation which is one of certainly being in
6 imminent great danger and current status quo changing.
7 Hello?
8
Q
I'm still here.
I'm just formulating a
9 question. Sorry. So we haven't cut out yet. The requests
10 in the petition, I don't know if you're aware, is a request
11 to have Miss Dyarman placed at Hershey Medical Center. I'm
12 not sure of the specific name of the facility there. And
13 also a request for permission to-- for ECT. You've
14 described that type of therapy already. will that kind of
15 therapy be necessary immediately? In fact, let me withdraw
16 that part of the question and just ask you this. And my
17 apologies to the court reporter. Will you be undertaking
18 specifically to care for and treat Ms. Dyarman while she's
19 at Hershey Medical Center?
20
A
I will not personally be providing the
21 treatment there. You know, one of the attending
22 psychiatrists there in their inpatient unit will likely
23 have that task. And again, really the final decision of
24 whether or not to proceed with that treatment would have to
25 be reserved for the doctor there who would be administering
63
.
.
1 it. Hello?
2
3
Q
A
Yeah. We're still here.
But I can tell you clinically, you know, in
4 cases where a patient is in medical danger and is either
5 unable or unwillingly to accept necessary treatment orally,
6 you know, specifically medication, ECT is really--
7
THE COURT: We missed a word there, Doctor.
8 You said really something.
9 THE WITNESS: I was saying that ECT is
10 really the only treatment option that can be effective.
11 But again, that decision would need to be, would need to be
12 made at Hershey as well. And, you know, it's standard
13 practice for psychiatrists to have two separate doctors
14 come to that opinion before initiating the treatment. So
15 certainly what would happen at Hershey is that, they would
16 admit her, evaluate her, and would consider that treatment
17 as an option.
18 BY MR. ABOM:
19
Q
Doctor, is it possible to involuntarily
20 administer medications to Miss Dyarman that might have
21 somehow-- I guess that's the first part of the question.
22 And if so, is it possible, are there any medications out
23 there that could be administered that might be helpful to
24 her?
25
A
Well, it really is a question of route of
64
.
.
1 administration. Really, all the medications that we have
2 are available only in an oral preparation, meaning a pill,
3 which generally means administering it by mouth. The only
4 way around that would be to do a surgical procedure to
5 place a feeding tube and administer them that way. But,
6 you know, my way of thinking, placing that feeding tube
7 with Cheryl, which Cheryl would likely try to remove, I
8 think would be more intrusive and intentionally dangerous
9 than treating her.
10 The other thing to stress is that, even if
11 she were to be compliant with medications given by mouth or
12 by feeding tube, the medications take four to six weeks to
13 really work. ECT is typically effective within the first
14 week of treatment. So there's a time factor here that's
15 critical. And certainty given the gravity of her medical
16 situation, four to six weeks is a very long time to wait at
17 this point when giving medication involuntarily. So that
18 is not an option, in my opinion.
19
20
21
22
23
24
Q
Other than possible side effects, other than
possible headaches, will Miss Dyarman-- will this type of
treatment cause any other type of pain or illness to Miss
Dyarman?
A Well, again, as I said, the main side
effect, headache, is not uncommon. There also is
25 invariably some short term memory loss. Generally it is
65
.
.
1
limited to memories around the time of the treatment.
So,
2 for example, you know, if she were to go to Hershey and
3 have the electroconvulsive therapy, she would probably not
4 remember that period of hospitalization very well.
5 Rarely there can be more generalized memory
6 loss, but again it's typically prior events, and there's
7 certainly no clinical evidence that it causes any kind of
8 ongoing memory loss for future events. In fact, studies
9 have been done looking at cognitive ability for patients
10 that have ECT with severe depression, and after, usually
11 their cognitive increases because depression certainly
12 impairs one's ability to think and concentrate.
13 So beyond the headache, the risk for some
14 short term memory loss around the time of the treatment and
15 the risk associated with general anesthesia, ECT is a very,
16 very safe treatment. But, you know, she would have to-- it
17 would have to again be a formal form sent, signed by, you
18 know, whoever the guardian might be for Cheryl before that
19 treatment is administered anyway. But those are the
20 general risks that we talk about before proceeding with
21 ECT.
22
23
Q Doctor,
is suffering right now,
is the depression that Miss Dyarman
is that in any way caused by her
24 physical condition?
25
A
Well, you know, I can't say that
66
.
.
1 physically-- I think I can say with some confidence that
2 it's not exclusively related to that. I think her physical
3 problem certainly don't help matters and likely exacerbates
4 her depression.
5 But I know generally, certainly the
6 depression can appear secondary to medical conditions, but
7 often times other factors come into play. And generally
8 with Cheryl's condition, where we've seen persistent
9 recurrent bouts of depression, I do consider her to have
10 major recurrent depression in addition to her medical
11 problems.
12 So the medical problems are an aggravating
13 factor, but I do not see them as the underlying problem
14 factor.
15
Q
If Miss Dyarman were to positively respond
16 to treatments towards her or for her depression, what's the
17 likelihood that she could resume the normal activities that
18 she enjoyed six months or a year ago?
19
A
It's very likely. Again, you know, the
20 statistics were success at 90 percent. Now Cheryl has some
21 serious medical problems, and it's debilitative, so that
22 will, you know, that will decrease the likelihood of her
23 having a full response. But I think the likelihood of her
24 improving is very high. And we know that when patients are
25 treated, when patients would have become unresponsive for
67
.
.
1 various reasons, and are treated with ECT, they often
2 become responsive to those medicines again.
3 So my hope would be that Cheryl would
4 certainly improve rapidly with ECT, would become receptive
5 to taking her medication and eating properly. And I think
6 if that can be maintained, she'll do quite well. And I
7 expect that she should be able to return to her prior level
8 of functioning, say, six to twelve months ago.
9
MR. ABOM: At this time, I have no further
10 questions.
11
THE COURT: Mr. Mulderig.
12 CROSS EXAMINATION
13 BY MR. MULDERIG:
14
Q
Doctor, you'll have to excuse my ignorance,
15 but what is demyelinating disease of the spine?
16 A Well, demyelinating basically means that the
17 peripheral nerves, you know, are deteriorating. The brain
18 is part of the central nervous system, and they're no
19 longer connecting to every part of the body, the peripheral
20 nerves. But the nerve cells are insulated with a protein
21
called myelin.
It's really like the rubber insulation on a
22 wire.
23 When that insulation begins to breakdown,
24 the nerves, or the wires, that's the analogy basically,
25 cannot carry the signals to the muscles or the other parts
68
.
.
1 of the body in order to perform other functions. So it
2 really causes almost a short circuit, in fact, of the
3 electrical system of the body.
4 Q Okay. And has she lost use of her limbs?
5
A
Well, my understanding is that she has
6 limited use. Again, I don't have the medical records in
7 front of me, so I'm not sure of, in terms of physical
8 therapy, exactly what she can do, but I know that her
9 movement is very limited.
10
11 correct?
12
Q
And her mother died recently, is that
A
Yeah, I believe her mother has died within
13 the past year or so.
14
15 relatives?
16
17
Q
Right. And does she have any other close
A
Q
I don't believe so.
Now you keep referring to the nervous system
18 as the electrical system of the body, is that correct?
19
20
A
Q
That's correct.
And this electroconvulsive therapy is
21 feeding electricity into that system?
22
A
Well, actually it's just feeding it into a
23 very specific part of the brain, not into the entire
24 nervous system.
25
Q
So only the brain is effected? There's no
69
.
.
1
2
feed-out to any other part of the body?
A Well, there's limited, you know.
Certainly
3 it's all interconnected. There's limited exposure
4 elsewhere, but the clinical manifestations are really
5 limited to the central nervous system of the brain.
6
Q
Would this have any effect on the short
7 circuit she has in the rest of her body?
8 A It would have no adverse effect on that.
9 There are very specific conditions that are contraindicated
10 with electroconvulsive therapy, and essentially those
11 conditions are: One would be a large mass within the brain
12 such as the brain tumor or a recent heart attack within
13
four weeks.
Just about any other medical condition
14 including pregnancy are not contraindications to do that
15 when she was not having those problems.
16
Q
Okay. Now another concern I have is, this
17 woman has been living for several years in a nursing home.
18 You say that she has a marked reduction on the use of her
19 limbs, and that she has no close family. Would this not
20 cause the depression to resurface even after the
21 electroconvulsive therapy?
22 A She certainly is at risk for recurring
23 episodes. However, we know that when she was cooperative
24 with oral antidepressant therapy, she had a much higher
25 quality of life, and there was a period of time when her
70
.
.
1 depression was in remission on those medications. And
2 during that period of time, her mother did die, and
3 certainly her neurologic status did not improve.
4 So I did see her depression as being a
5 reversible condition. And certainly, I do treat patients
6 with grieving medical problems and also terminal medical
7
problems.
I do treat them for depression, as I don't
8 believe depression is a normal state of being. And I think
9 where the condition is reversible and treatable, it
10 certainly can improve one's quality of life, even if that
11 quality of life has significant limitations such as Cheryl.
12
MR. MULDERIG: Thank you/ Doctor.
I have no
13 futher questions. Oh, one other question.
14 BY MR. MULDERIG:
15
Q
This order of commitment, does that
16 automatically authorize you to do this therapy or does she
17 have to agree to it?
18
19
A
Q
Is that a question to me?
Yes.
20 A Well, my understanding is that, at the time
21 the treatment would be commenced, there would have to be a
22 formal consent obtained. And I guess maybe I need an
23 education on the legal aspect in this, but I would
24 understand that there would probably need to be a guardian
25 of some sort who would make that informed consent. In
71
.
.
1 other words, the risk of benefits that I described
2 generally would have to be gone over in more detail at an
3 actual set time for treatment.
4 And again, that would need to be done at the
5 treatment center which is indicated. Looks like Hershey
6 has been chosen for that. So I believe there would still
7 be another consent done proximate to the time of treatment.
8
MR. MULDERIG: Thank you, Doctor.
I have no
9 further questions.
10
11
12
THE COURT: Mr. O'Brien.
MR. O'BRIEN: I have no questions.
THE COURT: Mr. Abom.
13 RECROSS EXAMINATION
14 BY MR. ABOM:
15
Q
Doctor, I want to ask you, when Cheryl goes
16 over to Hershey Medical Center, an additional doctor, you
17 said, two people, two doctors have to come up with the
18 recommendation for ECT. So I gather, a second doctor there
19 will be, I guess, evaluating and diagnosing Cheryl's
20 condition, 1S that correct?
21
A
Yes, and I can tell you, I mean, in terms of
22 my own experience, typically there needs to be a
23 psychiatrist who would concur with the need for that
24 treatment. Generally, that's the psychiatrist that would
25
be administering it.
I believe Dr. Chan is in charge of
72
.
.
1 that service at Hershey. But there would also need to be
2 an agreement by the anesthesiologist, who would be
3 providing the general anesthesia, that she's an acceptable
4 risk for that. So you would need at least the approval of
5 those two additional doctors before the treatment could be
6 administered.
7
Q
I understand time is of the essence in this
8 particular case, but yet, is it possible, to your
9 knowledge, I know we need to ask another doctor this, but
10 is it possible to get that report or have that report
11 provided to us when it's written up?
12
13
A
Well, again, it's not generally a report
issued before proceeding with the treatment.
There would
14 be an initial psychiatric evaluation done which can be
15 submitted to Hershey. And typically, those reports include
16 a treatment plan. So there could perhaps be a request,
17 perhaps to service a report authorizing the treatment. But
18 again, you know, I don't want to speak for the doctor at
19 Hershey.
20 I'm assuming that probably what they're
21 going to have to do since, you know, any oral treatment
22 strategy that they might want to do wouldn't work given her
23 refusal, so I'm assuming that is the way, that really it's
24 the only option in terms of treating a nontreatable
25 patient.
73
.
.
1 Q Doctor, what is your expectation of timing
2 in this case? You said there were six to nine treatments
3 that would take place every other day. But before they
4 would begin, do you know what kind of lead time, how long
5 it would take before she would embark on--
6
7
A
Well, generally you need about 24 hours to
complete some screening tests.
For example, she would need
8 to have an x-ray of her brain or a CAT scan or MRI to make
9
sure that there's no tumor there.
So that's done routinely
10 by most facilities, unless she's had one with within the
11
last three months.
I don't know if she's had one or not.
12 She'd need to have a consultation with the
13 anesthesiologist.
14 And she'd have to, you know, she would have
15 another physical exam and some lab work done and the
16 consent signed. So specifically, that does require about
17 24 hours. Most facilities have a set schedule for
18 providing the ECT. It is typically done at those fashions.
19 It's Monday, Wednesday, and Friday morning. If she were to
20 be admitted to a facility on a Wednesday, she might not
21 initiate treatment until Friday.
22 So I guess to answer your question, it's
23 generally a one or two day delay, whenever it takes place
24 and she is ready. But after that, treatment can proceed
25 fairly quickly, and generally they're in the hospital for
74
.
.
1 about two weeks.
2
3
4
5
6
MR. ABOM: Thank you.
THE COURT: Mr. Mulderig.
MR. MULDERIG: No further questions.
THE COURT: Mr. O'Brien.
MR. O'BRIEN: I have no other questions,
7 Your Honor.
8
THE COURT: Dr. Hegarty, thank you very much
9 for taking your lunch hour to testify, and you are excused.
10
11
12
13
14
THE WITNESS: Thank you.
THE COURT: Yes, sir.
(Whereupon, the telephone call was
terminated. )
THE COURT: Is there any further evidence
15 that any counsel wants to present?
16
17
18
19
20
MR. O'BRIEN: I have none.
THE COURT: Mr. Abom.
MR. ABOM: I am not presenting any evidence.
MR. MULDERIG: No evidence, Your Honor.
THE COURT: All right. Do counsel wish to
21 make statements as to their positions?
22
MR. O'BRIEN: Well, I started this process,
23 Your Honor, and I believe it's appropriate that the Court
24 enter an order committing her for inpatient treatment to
25 the Hershey Medical Center, a second order appointing,
75
.
.
1 under the guardianship provisions, appointing Gloria
2 Anderson as emergency guardian. I anticipate that, I
3 believe, that that's a 72 hour or 120 hour appointment, and
4 it can be extended by the Court for an additional 20 days.
5 I would anticipate that that would be
6 utilized to get her into the Hershey Medical Center, and
7 then once we had the analysis done by the staff there, I
8 would file an application to extend it for 20 days, so that
9 then Gloria Anderson could authorize a consent for the ECT.
10
11
THE COURT: All right. Mr. Abom.
MR. ABOM: Well, I would just ask the Court,
12 if the Court does appoint a guardian, to make it limited,
13
as Mr. O'Brien has suggested.
In other words, I see that a
14 guardian generally cannot agree to the electroconvulsive
15
therapy.
I think it would be appropriate to appoint a
16 guardian, even though it seems to me as if the power of
17 attorney might cover this, but to admit her to a facility
18 that we're going to have an independent psychiatric
19 evaluation done, it sounds like.
20 I'd like to know what that evaluation is.
21 And if it also is recommending electro--ECT, then that
22 seems to be the appropriate time for the Court to enter
23 that order, or even if it's modifying or extending the
24 emergency order, and then including that, because as the
25 statute reads, that has to specifically be included in your
76
.
.
1 order, an order for ECT in order to allow that to happen.
2 THE COURT: All right. What is your
3 position on the underlying petition for appointment of a
4 guardian?
5
MR. ABOM: I don't think I can argue at this
6 point that Miss Dyarman actually has the ability to make
7 and communicate decisions. That's based on my own
8 experience and based on speaking with-- that's based on the
9 testimony of the doctors and testimony in speaking with the
10 people I have spoken to down at the nursing home.
11 I can't say with confidence that she does
12 have the capacity to make and communicate decisions.
13 Ultimately, I'm not making a conclusion. I just-- I have
14 not found much at all to lead me to the conclusion that she
15 does have the ability to make and communicate decisions.
16
1 7 judgment?
18
THE COURT: What does she want, in your
MR. ABOM: I think she would like, based
19 on-- I think she would like treatments that would go
20 towards improving her-- let me rephrase that. I don't
21 think she wants life sustaining treatment, based on what
22 she's written in her living will. I do think, however,
23 that she would like a-- some type of treatment if it has
24 the ability, and the doctor was of the opinion very likely,
25 to improve her current situation right now.
77
.
.
1 Nobody has characterized this as any type of
2 life sustaining treatment. And the doctor was of the
3 opinion that he wanted-- he felt it was likely that this
4 would actually improve her mental condition which would
5 improve her physical health. I will say this. It's not
6 really of record, and if you allow me to make it, I did go
7 back the day after our initial hearing to speak with her.
8 I tried to ask her questions, things along
9 the lines of whether or not she understood what was going
10 on. And I pointed out that she repeated on several
11 occasions while we were physically present in her room that
12 she wanted to die. And she specifically said she did not
13
want to die.
I don't know which message to listen to, but
14 in the interest of perhaps safety, as well as not knowing
15 actually what her true intent is, I think it might be
16 appropriate to engage in a treatment that will improve her
17 life.
18
THE COURT: Do you have an impression as to
19 whether she wants to be subjected to involuntary treatment
20 and wants to be subjected to a guardian of her person?
21
MR. ABOM: You asked if I had an impression.
22 My impression, just based on physically being in her room
23 and being yelled at to leave, and even while we were all
24 present in the room, I had the impression she did not want
25 us there. So my overall impression would be that she would
78
.
.
1 not want this. But I don't know if that-- again, I don't
2 know if that decision is based on a mental illness and/or
3 incapacity.
4 THE COURT: All right. Mr. Mulderig.
5 MR. MULDERIG: Your Honor, I think the best
6 way to get this woman into a treatment, were you to find
7 that she is mentally incompetent, is triggering the
8 durability of a power of attorney, leave it up to the power
9 of attorney which has the authority to do both the things
10 that you are asking of it.
11 Whereas if you go this route, the mental
12 health commitment will not do anything other than put her
13 in the hospital but will not approve the electroconvulsive
14 treatment-- therapy, and the guardianship, as I understand
15 the law, will not do that. They would have to have a
16 separate hearing coming back to you to authorize it.
17
THE COURT: Do you have an opinion or a
18 position as to whether she should be subjected to
19 involuntary treatment?
20
MR. MULDERIG: Since there is a power of
21 attorney in existence, and the law is very clear that a 201
22 takes precedence over a 304, since they can do it
23 voluntarily, I would rather have it done that way than have
24 it ended in a docket that she was committed.
25
THE COURT: Okay.
79
.
.
1
MR. MULDERIG: The treatment, I think, I
2 have problems that I'm not sure this is going to accomplish
3 much because I see rational reasons for her not wanting to
4 continue living, because I don't think her quality of life
5 is that good. And I think with our living wills statute
6 and such, we have recognized that people have a right to
7 choose death over suffering. But that is a very
8 philosophical argument.
9 I think the point that the problem with the
10 power of attorney was whether or not it was effective
11 against her will when she was diagnosed, but it seems to me
12 that if she is incompetent, which is what you would have to
13 find for the guardianship, then that can trigger the power
14 of attorney and its durability clause that we do not have
15 to appoint a guardian and all these other steps through the
16 Court as long as the Court finds her to be incompetent and
17 states that the power of attorney, therefore, is in effect.
18 And I think the guardianship law also
19 recognlzes that if there's a power of attorney in place,
20 they do not need a guardian. And it's the same. The power
21 of attorney and the guardian is the same person, as I
22 understand it.
23
THE COURT: Do you have a position as to
24 whether Ms. Dyarman has a mental illness which has caused
25 her to be severely mentally disabled to a degree that she
80
.
.
1 is in need of immediate treatment?
2 MR. MULDERIG: I have only heard the
3 evidence of the psychiatrist. I have nothing to refute it,
4 so she does have a mental illness, and it is true that if
5
she does not get medical treatment, that she will die.
I
6 am not convinced that it's a mental illness treatment that
7 she needs as much as intravenous feeding, but the problem
8 of her living is her weight loss not the mental illness,
9
which may be a cause of her not eating.
So, yes, she does
10 need medical treatment clearly.
11
THE COURT: Well, what I have to decide is
12 whether I should sign an order in the one case subjecting
13 her to involuntary treatment. Confining your attention
14 just to that case and that issue where you're representing
15 her, what is your position?
16
17
MR. MULDERIG: My position, the signing of
that order will not get her the treatment.
This treatment
18 requires her agreement or at least someone who has
19
authority to speak for her.
So again, we are just looking
20 at medical treatment not mental health treatment in this
21
area.
I believe that it would be better if they went
22 under-- I think it's quicker, cleaner, and everything if
23 they went under the power of attorney.
24
THE COURT: Okay.
If there's nothing
25 further, we'll enter this order:
81
eJ
.
(Whereupon, the following Order of Court was
entered. )
ORDER OF COURT
AND NOW, this 29th day of January, 2001,
upon consideration of the petition filed in the
above-captioned matter, and following a hearing, the record
is declared closed, and the matter is taken under
advisement.
By the Court,
/s/ J. Wesley Oler, Jr.
J.
THE COURT: And that order will be entered
in both cases.
(Whereupon, the proceedings concluded at
1:28 p.m.)
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7,9,13,1953,2,5,7,11,18,21,2454,7-
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31 512052,11-12
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[ 1 J 28, 9
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[11J 6:22,242620,2330:961:566:
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[2J 3782,6
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[11 5>21
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[2] 57,22645
Acceptable
[2J 35,: 73,3
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[3] 14 21 62 13-14
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[ 1 J 80, 2
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[2J 8153401
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[lJ 22 19
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[2J 10 14 67 17
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[ 1] 72 3
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[13] 26,13363,539,4,2457,1858
1659,662,1869,2277,678,4,15
Add
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[2] 55,13 67,10
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[4] 23,2072,1673,576'4
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[5] 12,924232,338,747,2
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[1] 210 13
Adequate
[2] 7 5 57 4
Adjourn
[ 1] -17, 7
Adjourned
[2J -19,19-20
Administer
[4] 57,2458,464,2065,5
Administered
[4] 59,3642366,19736
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i31 0],25 oS,] 72,25
Administration
[3J 21,1030,2565,1
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[lJ 5010
Admission
[11] "1/613,1'0/,1,319,32118
2139,20 -18 1,3
Admit
[2] 64,1676,17
Admitted
[8J 5,196,12,18,2039224813,15
74 ,20
Admitting
[ll 21011
Adverse
[ 1] 70, 8
Advice
[ 1] 42, 8
Advisement
[ 1 ] 82, 8
Affect
[lJ 26,13
After
[6J 47,19521466,1070,207424
78 , 7
Afternoon
[ 1] 47, 6
Again
[25] 923291734,945,847,2,15
48552,2553,12,216101462,2063
236401165,2366,6,1767,1968,2
69,672,47312,1879,181019
Against
[lJ 80 11
Age
[1] 35 16
Aged
[ 1 J 5 18
Agent
[ 1] 22,2
Aggravating
ill 67,12
Agitated
11J 12 23
Agitation
[ 1 19
Ago
[3 3671868,8
Agree
[3 13 7L17 76,14
Agreeable
[1: , 16
Agreed
[3 7 so ;',19
Agreement
[4i >;,2338,973,281018
Agreements
[ 1 J 2 c;
Ahead
[2] 2] 41 17
Aid
[ 1
Aids
[1 2-1
Alert
[ 1 '
All
: 4
420,257,4821 l'
2013,5,17 lLJ 182
14 31,11 34 22 3', ~'
46,2547,1,24 .;-
7 52,24 61 63
1077,2,1178,
4 U ,
4 9
1
9 4
18
7 U 3
8 (J
Alleged
[7] IB,21 23,16-17,2: 48 1~ H
Allow
[4J 857,2377,178,6
Allowed
[ 1 J ' 2 :
Allowing
[lJ 20,24
Almost
[3] 2263,269,2
Along
[5 2'J 25:12 26:12 34 7 78 2
Already
[1 h
Also
122 ] 117,8,22 8,6,12 3,20,2~ 12,
813 :5 172522,18,25 46,10 ~~ 17
57 601763,13 65,24 7106 ~. 1
76 80 18
Altered
[ 1 ] : 1 4
Alternate
[ 1;
Always
[5' 127,93408,1158,16592
Am
[6: :~ 25 29,14 34,1 551275,18810
6
Among
[ 1 ""' 22
Amount
, 2 ]
An
162 6,237,48,139,9,:613,1417,
7103,],;-1520822,4,8,1423,7,20,
2526,2,1129,2-331,8-9,1236,938,
5 3J 1940,12-13,16 41021 43,2~ 48,
22 '352,3,1557,135811,19,21
60864,1765,2,1867,1271,2272'2,
16 ""'3,2-3,14 74,8 75,24 76,4,8,18
77: 78 18,2179,1781012
Analogy
[ 1] 68, 2-1
Analysis
[ I! 7 G 7
And
1357] 3 'i,16 4,5-7,10,14,:6-17,19-
20, ,255,13,16,18,2269,14,21,24
7,25,108'],",9,109,2,'>,7,9,14,lE-
18, 10 :,19 1l,10,12,H-18,24 12
13, 2413,11,1814,241513-14,16,
21,25162,7,16,181'/,6,21,2418,2,
10,:6,2419,3,1120,3,6,11-12,19,22
21:8-9,11,21,23-2522:18,2323:8,21,
25240925,1826,2,10,12,2227,4-5,
7-8,12,2328,1-2,5,16,18-19,2329,1,
3,8,16-17,2530,6-8,243106,9,11,22
32'4,7,13,2433,12-13,15,18-19340
10,:33513,16,19,21,2436,2-6,12,
1537,6,13,2238,6,18,21-2339,11,
13,15-16,20-2140,2,18-1941011,13
42'3,154402,6,946,23,2547,1,6,9-
10,,5-16,21485,10,13,15,17,21,24-
25 ";9:8,11,13,19 50:17,24 52:3,11,
14,245310,12,14,1654,14,17,22-25
5S,2,R,11,]5,:8,21 56 9,13,19-20 57
1,45,8,11,13,17,25582,5,8,1559
I 1":',10-13,17,21,2461,8,10,14,
17,24-2562,3,15,17,1920,246301,3-
1,6, ,16,18,2364:4,12,16,2265:5,
8, 66,2,6,10,12,1467,3,7,21,24
68 c,5-6,18 69,4,10,14,20 70 10,19,
25 '11-2,5-6,8-9,22724,192173,
15 ,14-15,19,24-2575,9,2376,3,6,
21,24777-9,12,15,24782,6,10,12,
20,237914,2180:5-6,14-16,:8,20-
218::4,:4,22824,6-7,:2
And/or
12; 21 :8 79 2
Anderson
[14] 5 C 20 8 304,7,1834:21
1241:9 -16:2: 47:2-3 76 2,~
Anesthesia
[5: :7592366:15733
Anesthesiologist
12' ;32 "4::3
Another
[8J c 9 :C 1 27 15 70: lE 72 7 ')] 9
74 :. 5
Answer
[7~ 4,729:13,1838:1042:217,,;\;
22
Answered
[2] ':4 ::.. 52 23
Answering
III 52:23
Anticipate
(2] ! (j 2, 5
Anticipated
11 I 8
Antidepressant
~4i 1':: :4 57 22 62: 16 70 24
Antidepressants
[2] :., 23
Any
[-1C: 61-181116:1020:23218,21
22:25275,1830:19,2433:434636
19-2139'142:7471848:856:3,8
5722581859:164:2265:21667,
23 6? :-1 "0:1,6,13 73:21 75:14-:5,
18 78 1
Anybody
[1] 31:19
Anyone
[2] 22:12-13
Anything
112 9: 12 10 16 16 10 17' 11 28 lC,
13345,/45174611,1979:12
Anyway
[1] 66:19
Apologies
[1] 63:1:
Apparently
[11 -1: 5
Appear
[2] :251367:6
Appetite
L7' :421 5E:l6
Application
[2j 26:6 :6 8
Apply
:1J 21 18
Appoint
[5] 36:16 4S:6 76:12,:"5 80 15
Appointed
15J 18:11 36:17 449-10,13
Appointing
121 75:2576:1
Appointment
141 :81148:2276: 77,3
Appreciate
III 60:24
Appropriate
18113:1551:55714-1575237615,
2278:16
Approval
~ 1 j ""' 3 4
Approve
!31 3C 19 -13-15 79:13
Approximately
[21 414,19
April
is] S 6~7,:0 28 10 4:':25
Are
~64: 45 t; 7,1: 7:5,12,14,20 9 15
1C:9 :5:: :'6 13 17:21 19 1 21 22 27
8 ~9 :,1.J,24 30 S 34:23 36:15 37 7
38 7,? 4{);24 -13:1944/,:0,12453
40 L~ -.16 ,2-149:11 ::0:12 :,2 10,12
54 14,25 ~6 6 57 1,9,12,:9 58 :'4,23
6136-12265,266,1967,12,2-168,1,
17,2C 78 4,9,11,14 75:9 79:10 8:'19
Area
121 51 23 81 21
Argue
[ 1 ] 77: 5
Argument
[ 1 J B 0 8
Arms
11] 10:12
Around
9' 21 7::_~ 2A 11,14,20 6'1:";'
66 1 :...;
Arrangements
12 J 5:]
Arri
11 J 16, 3
Arrived
:1 19 13
As
981 3:15,244115:17-186:149-6
""_1912:213:17-18,25142118:1
194,12,14,21204,8,1722:223:3,7,
15,2126:2-128:2429:532:3,11,15
3316,2334:9,2235:836:7,9,12-13,
1637340,4 4L6,25 43,]9 47:21-22
50:2551:252:1554:2155:9,14,16-
17563,2359:860:2261:1562-921
2364012,1765:2367,13 69,18 ;0:12'
714,7,11 75:2176:2,13,16,2478:1,
14,1879:14,1880:16,21,2381:7
Ask
~23J 6718:17,2419:2423,8,1025:
II 26:11,15 43:19,23,25 44:3 45:11
-17,9 -18 c, 54 11 "9:2463:1672:15
97611788
Asked
1-1123:2(' 29:4 41:9 78:21
Asking
[<1J 11:1,,17:1829:1079:10
Asks
[2] 38-74613
Aspect
71 : 23
Assist
[2] 29:736:6
Assistance
121 10:U-14
Associated
lL:. 58:2466:15
Assuming
12J 73 2CJ,23
At
185J 39-10475:19,226:10,17,19,
257:12,6-78:139:610:1711:1,18
12 1-1 13 16 16 8-9 19:2 20,17 22:1"
33:2CJ 36 9 37:840:3,5 4L10 42:3
462,19 <17:6,11 49:20 50:651:2052
1653:1055:11,18,2256,19,2157:7
581,35'1:1560:7,1461:1,23,2562
3-<1,14 6J 4,11,19 64:12,15 65:16 66
9672068,970-2271,20722,473:
1,-1,18741877:5,10,1478:2381:18,
2CJ 82:14
Attached
11 : 1:~
Attack
IlJ 70:12
Attempted
[1J 4324
Attempting
[ 1 j 43: 2 'i
Attending
[2: 26:463:21
Attention
[lj 8L1J
Attorney
127119:'5,2120:1,4,9,23-2421:4,14
724,7111:1836:837:2146:1348:4
'0-123761779,8-9,2180,10,14,17
19,218123
Attorney's
(11 22: 8
Attorney-in-fact
[-1] 20:4,9,2421:4
Attorneys
[3' -14:10,1354:24
Audra
[ 1 24 : 10
August
6:3--1,9,11,132723
Authority
[-1: 30,193721 79,981-19
Authorize
[3' 71:1676:979:16
Authorizing
11 J 73, 1 ')
Automatically
[1] ".11:16
Available
301750-1454665:2
Avenue
[lJ 12:11
Average
[1- 58,19
Aware
[3: 7:14 29:1 63-10
Away
[8J 20,728-9,2141-2442346:24
521261:13
B
Back
I17J 12'20141016-219:1420:14,
172-10342,1853,1454:878,779,16
Background
[21 41055:8
Based
1141 26:18311032,2340,19431
06:13573 :'1-8,18,2178:22792
Basic
[1] 5L 6
Basically
(3] 56:2268:16,24
Basis
[6J 12:1'031:9,1256,1058,22
Bathing
[1] 10:15
Be
110-1J 4:248:1210:13 12:3 13:13,1'0-
16,1814:2016:14,1820:625:1428:
9,1230:131:4-6,1234:23-2437:13
38:1944:1,9,2047:11,21 -19:2,1450:
7,10,2051:1,5,:9,21-2252:225314
51:23-2457:1358,4,9,1959,860,1
2361:963:15,17,20,2564:10-1123'
65:4,8,1166:5,17-1868:3,6-770:11
71,21,21722,4,7,19,22,2573:1-2,5,
14,1674:2076:4-5,15,22,2578:15,
19-20,25791880:16,2581:9,2182-
12
Beauty
[7] 2721-22281,3,5,18
Became
[ 1 J 5, 18
Because
[23] 6:87:188:911:15-1616:1020:
728,429:13 32,3 38:20-21 40,2 42:
2,10 -16:2350:1356:157:1966:11
76:2480:3-4
Become
[6J 23:125:19351967:2568:2,4
Becoming
11] 5718
Been
1421 3:244:17,235:146:21-227:25
9:2512:23-2415:1519:2123:2125
2,728333,2234-1335,8,2136,7
41:2142:10,164410,135-1:2156:15
61:20-21,23-25624,10,13,2-163:1-2
66,970,1772,6
Beer
11] 9: 19
Before
I13J 162,519:1333:2138:8 '09 16
64:14 66:18,20 73:5,13 74:3,5
Began
[4J 11:1514:7,1362:22
Begin
13] 32:341:2574-4
Beginning
12] 4:159-5
Begins
11 J 68 23
Begun
[ 1 J 31: 8
Behalf
[6J 311 2L8,21 30,2350,16,18
Behavior
121 56:1860:13
Behavioral
[3J 12,1052:1055:14
Being
Ill] 3:917:1624:927:1161:1563:
5 7L4,8 782223
Believe
125] 1L1 28:430:2138:6-740:16
42,20,2550:2551:1356,1457,358
13 60 10,13,17 61:7 69:12,16 7L8
72:6,25752376:381:21
Believes
11J 27 11
Benefit
11J 15 23
Benefits
13J 37 7 60:24 72 1
Best
f 1 J 79 5
Better
[4J 29:9,2-130,5 8L21
Between
: 11 9 6
Beyond
[lJ 66:13
Birth
11 J 5 25
Bit
11J 45 21
Bladder
11J 39:22
Board
[1] 55 9
Board-certified
12: 12:1455:13
Bodily
[lJ 56:25
Body
[6 68:1969:1,3,1870:1,7
Boosting
[ 1 ] 14: 2 3
Boston
[ 1] h, ~ 12
Both
(8 :8-18 5C:lo 04:25 56:19 57:4
7g:9 82 13
Bouts
11 J 67: 9
Brain
191 58,12,1468-1769:23,2570,5,11-
1274:8
Breakdown
11: 68:23
Briefly
:1J 59:15
Bring
12J 36:4,6
Brought
131 38:2240:1541:10
Business
[2! 22:751:14
Busy
[31 53:0,9,21
But
1631 4:126:19,218:6,1310:2211 J,
1114:7,13,1515:17,2116:4,16 :'>
19421-324:126,929,6,1734:11
39:440:2,16472,2256:257:2-1 S9
361:1662:3,13,2364:3,1165:566
6,16,1967:5-6,13,2368:15,2069-8
70:471:2373:1,8-9,177403,24
17781379:1,1380:7,1181:7
Butter
[2] 9 17-18
By
176j 3:13415:126:671882210-
2122,1.912:715,24173,19 :8 22
192,2321:22,2522:11-13 192310
:924:3,6,825:6,25 26:3,;'7 27:3,1~
28'930,1731.183222340435,lC
3'/:1938:16,1840:14-1541:842:6
-194,1550:8,1-151:1-1,21-2252:23
55656:16,2059,13-14,2360,1263'
16-1:1865:3,11-1266:17,2368
71:1.; 72:14 73:2 74:10 76:4,7 82:9
c
Calendar
11] 7: 11
Calendars
12] 38 20,22
Call
1:3J 31534:2050:2551:1752815-
1653,3,8,19,2554,875:12
Called
(3J 382147:206821
Calling
[lJ 51 22
Calm
11J19 16
Came
[3J 16227:1428:15
Can
[5C] 95,21102,6-8140316,13-,4
17:2519:1426:23277-8,182913
31:8,1244:445:2146:347:10 6
49,1,13 50751.2252,65311 CO.; 9
57:1659:864:3,1066:567:1,668:6
69:8 7l:10 72:21 731474:2476:4
77,579:2280,13
Can't
[9J 13415829,1844 25 45:13,20
62,2066,257711
Cannot
[4 J l3 L
: 2 1 6 8 : 20 -/6: 14
Capability
11 J 25
Capable
[4] 5,762:2,4
Capacities
( 1] ,1,: 4
Capacity
[61 251526:13 36:13,16 61 1'5 77:12
Card
[1] l2 3-1,9 51 14
Care
[111 '51810:1621:8,25223 3J'24
36'::>1 17,1-140:2047:226318
Caretaker
11] 36: 8
Carlisle
[61 19 11-12 40-15 41:'1 -13 1~ 61:4
Carry
[lJ 68 25
Case
111J 3134:1834:2550:13 52:1958:
9621273,874,281.12,14
Cases
[5J 34245:1 7 59:7 64:4 8213
CAT
[ 1 J "74 8
Catch
[ 1 : 4
Cause
[5; 26:2-i 44 1 65 2l 70 20 81: 9
Caused
[4J 26:328:1266238024
Causes
[3J 60 :9 66 7 69 2
Caveat
[11 5 C 8
Cell
[2J 52:,,21
Cells
[lJ 68:28
Cellular
, 1 J = 4
Center
l 4 b,8 52-:0 58 17 63:11,
S,lt5 75 25 76 b
Central
12i 68:1., 70 C;
Certain
['J 6 7 9: 15, 23-24 21 12 50 9
Certainly
[18] 24< 28:24 57:16 61 5,20 62:2
635641566:'7,1167"3,56847021
227::3,5,10
Certainty
[2J 26 5 65 15
Chain
[1; 28:25
Chambers
[J] 2,1253:15
Chambersburg
[21 _~ -;: 55 15
Chan
[1] 72-25
Change
!2J 1313 62:16
Changing
[1; c; 3 : 6
Characterized
[3] 561563-178:1
Charge
(1] 72:25
Chart
[3J 92 II 2 62:21
Cheerfulness
[ 1 ]
Chemically
...... ) ::. 3
Chemicals
: 1 J ,,8 14
Cheryl
[62J 38,164:18,215:14,17,19,
6-7,10,1610:1112:2213:101512,
16,2516:1224:23-2527:2128:1730
934:837:12401444:5,12,1",18,21,
24452,4,7,9,20,23,2546:2,550:",
10,17-:855:2256:1112,14,245721
61:1865:766:1867:2068:371:11
72: 15
Cheryl's
[12] 3:1752528:14,2240:174021
58:9 :8611462:1267:8"7219
Chew
1]
1] 33 24
Choking
1] 11 6
Choose
[ 1 ] 80 7
Chosen
[ 1 ]
Circuit
'2] ,,9:270-7
Claim
III 28 1
Claims
[ 1 ] a ]
Claremont
J] .; r;_7 48 6
Clarify
[ 1 1:1
Clause
[1] eo 14
Cleaner
[1] 8: 22
Clear
[4 J 24
Clea
[21 7:681:10
Client
:2157:579:21
[1] 47:1tl
Clinical
[6] 5614,2259:561:966:770:4
Clinically
[4: 58:136:1:961:1664:3
Close
[7' 69:1" 70,19
Closed
[ 1] 82: 7
Closely
[1 J 7: 25
Closer
[ 1] 61 l:J
Clothes
[ : ] 8 .: 5
Coalbrook
[ : 12 1.,
Code
[ 1 i 51 2,
Cogent
[2J 60: 2] 61: 23
Cognitive
4] 262361:566:9,11
Collected
II 40:lC
Come
[13J 25:]835:1836:537:1138:18,
20,2341:2255:2264:1467:772:17
Comfortable
12J 56:2,6
Coming
[5J 28:2030:147157916
Commenced
[lJ 71:21
Commitment
[6J 4011-1343:1671:1579:12
Committed
[3] 17:2437:2179:24
Committing
[lJ 75:24
Communicate
[9] 7:625:1527:329:2530:9 4C2
777,12,15
Communicating
[ 1 J 60: 5
Communication
[2! 7: 5, 8
Communicative
[lJ 61:24
Compared
~l] 62 Y
Comparison
[lJ 20:18
Complete
[4] :71423:655:774:7
Completed
[2] 24:35511
Compliant
[lJ 65:11
Comply
[1 J 13: 1
Concentrate
[1] 66:12
Concern
L3] 30:832'47016
Concerned
,3J J4 8,1143:25
Concerning
i1] 25:16
Concerns
,1: 11: 16
Concluded
[lJ 82:14
Conclusion
[2J 77:13,14
Concur
[ 1] '/2: 2 J
Condition
[16J 10:3252026:1,3,1940:261'9
62:863:166:2467:870:13 71:5,9
72:2078:4
Conditions
! 3 : 6 'J : 6 -, 0 : 9 , 11
Conducted
[2 31028:19
Confidence
(2) 67:177:11
Confining
[1] 81: 13
Confused
[1] 14:15
Confusing
[2J 5:941:5
Conjunction
[1] 6C:14
Connecting
[1] 68:19
Connection
[lJ 55:21
Conscious
[1] 25 22
Consent
[10] 20:2421:8,21,2430:2371:22,
2572:774:1676:9
Consider
[4J 37:1347:236';:1667:9
Consideration
[4] 181348:2249:982:5
Considered
[4] 13:1850:8 "6:11-12
Consistent
[7] "7:99:25212227833:3-5
Consistently
[2J 25:357:24
Consists
[ 1] 37: 7
Constitutes
(1) 60:15
Consult
[2] 37 13 55 18
Consultation
[11 74:12
Consulted
[1] 62:12
Consults
[1] 12:14
Contact
[71 4:208:103":2547:948:2449:
12 55:22
Contacts
[3J 32:2436:256:2
Content
[2J 7:81620
Context
[2J 34:21 3}:14
Continue
[3] 28:1936:1580:4
Continued
[1 J 26: 6
Continues
[2] 15:13-14
Contract
[1] 12:17
Contradictory
[ 1] 8: 4
Contraindicated
[ 1 J 70: 9
Contraindications
[lJ 70::4
Convalescent
[lJ 21:20
Convening
[1 J "0: 12
Conventional
[1 J 58: 2
Conversation
[3J 4111,1360:22
Converse
! 1 J 30 6
Convince
[1] 34 12
Convinced
[ 1 J 81 6
Convincing
[1] 12 25
Cooperative
[4J 29:21621,1910:23
Copies
[lJ 21:23
Copy
[7J 19:7,12,1523:948:5-6
Correct
[15J 5216720:1525:23-2427:16
302041:350:21-2255:2069:11,18-
1972:20
Correctable
[lJ 61: 10
Costs
[ 1 J 3): 8
Could
[31] 4109,2111213:16-1720:11
212-3,5,1623:724:15,2127:1331
534:1238:540843:1152:3-455:8
56:9572358'76402367:1773:5,16
76 9
Counsel
[16J 3:1223'8,1034:2340:2443:18
45:1046:1947'9,2548:;,449:1150
6,15 15,20
County
[9J 3:2,1012:1744: 52:1854:355:
18-1961:13
Couple
[5J 9025:830:15531161:21
Course
[5] 17:519:2-342'95819
Court
[18:] 3:5,20 5:1,4,8,~1,25 6:2,48:
16,18,2110:2,6,19,21,2-111:5,7,21,
2412513:1,8,19,22,24 :4,3,9,17
15:2,5,9,19166,13,18,22,241/1,
14189,11,2019:16,202::222:4,10
23 u,13,15 24:19 26:1430:12,1431
14,16,1832:18,20 33:b,lU,12,17,21,
25342,15,17,19,2235:536:16<7
3717383,8-9,12,143917,2440:4,
1,12,2441:442:5435,7,9,18,2144
5,1,i,lY,22,25 45:3,5-6,810,15,
463,lC,18,25 4"7:5,14,2-148:7,10,12,
17-18,2049:4,7,15,18-1950:4-5,24
51:7,~O,15,?4 5/::6,17-18,24 53:4,9,
20 S4 2,5,9,11,14,17,22 55:4 59:11,
22031764:768:1172:10,1275:3,5,
8,11,14,17,20,2376'4,10-12,22772
16 '78 18 79:4,17,25 80:16,23 81:11,
24821,3,9,12
Court's
[3J 191018,2449:12
Court-appointed
[2: 3:1136:17
Cover
[lJ 76:17
Covers
[1] 56:22
Cream
[1] 9: 19
Crisis
[ 1 J 52: 16
Critical
[lJ 65:15
CROSS
[6J 17:218:2137:18381559:1268
12
Crying
[4J 16:7,1741:1846:2
Cumberland
[7] 3:2,1044652:1854355:1861
13
Current
[-1J 19:1263:5-677:25
Cut
[2] 61263:9
Cynthia
[11 24:22
D
Daily
[2J 4:2510:15
Danger
[4' 58:2,463:664:4
Dangerous
[ 1] (5: 8
Date
[6] '256:1311:1922:2] 27:24 62
21
Dated
[2) 12:2220:12
Dawned
[1] 42: 2
Day
[12J 101 20::328:548:2149:858:
20591974:3,2378:782:4
Days
[4J 38:2256:2576:4,8
Death
[7J 4:225:1372526-656:21576
80 7
Debilitative
[i] 67 21
Deceased
[2) 60: 15 61: 16
December
[6J 1510390-9,1842:1843:17
Decide
[2J 44:781:11
Decision
[7J 36:20401760:861:863:2364:
11 79:2
Decisions
[llJ 20:1825,1626:13,2027:3 -1(,
1360:662:377:7,12,15
Declaration
[lJ 25 14
Declared
[2J GO 1 82:7
Decline
! :LJ Q: 2.2
Declined
[ 1] 6, 24
Decrease
[ l] .<:.,;;.
Defers
[2] 13 1?,22
Deficit
[lJ 58 1~
Define
[lJ 25,25
Defray
[ 1] 37, 8
Degree
[5: 412 5 55-1e 60,19 80,2C
Dehydrated
[1] 57,18
Dehydration
[ l' 63, 3
Delay
11: 4 23
Delegate
[ 1] ~ 0 :-l
Delivered
[2J 58,11,16
Demyelinating
[4J 10 :1 26022 68,15-16
Denies
[ 1 J B 2
Depend
[ 1 J : 6 , 9
Dependent
111 10,16
Depressed
[5J :2,2315,1628,1233,14,20
Depression
[32: 1101" 15 12-13,22 29- 8,1633
1642:2256:13,16,245720584,15
501"7614,10,2466,10-11,226"74,6,
9-1016 '70:2071"1,4,7-8
Depressive
[ 1] 6 C
Describe
[ 1 ] 10, 2
Described
[2] CJ 14 72,1
Designate
11] 22, 2
Desire
[31 32 9 41-20 43 1
Desires
[2] 275,8
Desk
[1] 52 13
Despite
[ 1 J 10
Detail
[ 1 J
Deteriorated
[1] 62,25
Deteriorating
[ 1] 68: 1 ':'
Deterioration
[2) ~6 24 28:8
Determine
[5] 518,3-448,2549,13
Determined
[ 1 J 40 1 '"";'
Diagnosed
[3J 3322-2380:11
Diagnosing
[ :L] '72 : 9
Diagnosis
[10] 104-5,10 33 .~ 56,3,9-:0,12-
13, 2::
Dialing
[1] S1 25
Did
[211 61881012,219,1223,624-
1626012361239,13 40 19 4>13,25
42,347,1955,21712-478,5,12,24
Didn't
[~] 4 )4 14 1 (} 38 24 46 1
Die
122] 7,2383-4,62401725,1,941
15,204219,2444,15,17-184523-25
46 :23 71 78-12-1381:5
Died
[ 3] 5 2
Diet
[2] 11 :,4
Dietary
[11 13,::
Different
[2] 27,2462,8
: C , 12
Difficult
[:1] 5,lS 7"7925101714616 lti
32:5 .;2 21 56:1 60:21 61 17
Diff
ties
[ 2 J 4, 2
Difficulty
[2] 10,25 30,S
DIRECT
13J 3,2535,9555
Directive
[4J 23,4,21,2348,4
Directives
19248,6
Discharge
21 lE
Disclosure
21 , 24
Discomfort
", 58,lE
Discuss
[2J 3102436,12
Discussed
11 19
Discussion
43,1] 61,18,22
Disease
10,11 26,3,12,21-22,2468,15
Disorders
[ 1] 34, 6
Disposal
I., 53,l(
Do
[66J 3,,", 4,76,1411116,1017,22
1817 :9,7,9,1520,6 2L4 3L24 32-
:435,13 36,19 37,20,25 38,3 39,6,
:9402142,2043,1844,4,1945,5,
:0,19,2246,347,22,2548,2,751,7,
952,14 :,6,2,5 6L7-8 65,467,9,13
68,6 69,S 70,14 71,5,7,16 73,21-22
74,475,2077,2278,1879,9,12,15,
17,2280,14,20,23
Docket
79 , 24
Doctor
[22J 2~,2 4U,22 47,8 55,7 59,9,14
63256407,1966,2268,14 7L12 72
8,15-16,1873,9,1874177,2478,2
Doctors
[51 57,]2 64013 72-17 73,5 77,9
Document
[9J 20,11 2L6 22 18,2523,222403,
13 25,13,25
Documented
[ 1 J 8, 24
Does
[42] 8,39,11-12110312,819,5-6,
2420,3,5,7,10,22-23 2L1 22,16-17,
2524,1-2,1325,13,18,2526,1932,9
33756,2457,358,5,1369-1471,15-
1674,1676,1277,11,15-168L4-5,9
Doesn't
[-1] 9,1416-1042,2458,18
Doing
[2J 17,11 4L16
Dominating
[1] 6L 8
Don't
[39J 6,19 1L18 12,222,823926,
2528,52913,17-1831,1132,7,12-
1336,2538,10,2440,1,2341442,2,
2547,1553,1] 56-162,2163,1067,
369,6,16 7L7 73,18 74 1177,5,20
7801379,180,4
Done
[17J 16,536,939,2158,17,20-2159,
16(;,972-4,7731474,9,15,18767,
19 79 23
Dose
[1] 56,17
Down
[7] 36539,16 4L10 45,21 6L17 77
10
Dr
(261 8011 1L11,21 12,2,13 15025 50,
13,25 5L2,8,18,21 52,1,18 54,1-2,4,
7,10,13-14,16,2272,2575,8
Dressing
[1] 10,15
Druckenbrod
[lJ "1,22
Drug
[1] 14,25
Drugs
[2] 2L10 30,25
Due
[1] 57 6
Duly
[31 3,243585421
Durability
[2] 79 8 80 14
Durable
[4J 192520,22 2L13 48 3
During
[4J 22135,2462,171,2
Duties
[ 1] 4, 21
Dyarman
[54] 3,97,316,618,1019,222,19
240325,1427,229,8,20,2530,63L
2035,18,22,2536,13,1738,1839,2
4L10 42,9 43,16,18 44,15,18,21,24
45,2,4,7,9,23,25460547,1150,6,10,
17-1855,1,2259,2560,563,11,18
64,2065,20,2266-2267,1577,680,
24
Dyarman's
[6J 4,1826,1928,836,2137,046,10
E
E-C-T
[lJ 13 21
Each
[4J 1L19 34,2450,7
Earlier
[6] 12318,2519,1128,743,2455
25
Early
[3J 33,1634,841,25
Easier
[lJ 16 17
Eat
[8J 7,17859011,2132,1034,6,12
61 , 19
Eating
[11] 10,15 1L16 17 12,17 32,4 3406,
11,1462,15685819
Eats
[ 1] 9, 19
Eclectic
[1] 56 18
ECT
[29] 13,18,2U 15,17,23 17,25 2~,5,
14 3L3-4,8,12,20 32,25 37,12 39,3
63,13 6406,9 65 13 66,10,15,2168,1,
472,1874,1876,9,2177,1
Education
[1] 7L23
Effect
[8] 14,2325,1926,23-2465,2470,6,
880,17
Effected
[1] 69,25
Effective
[6J 59,3,762,1764,1065,1380,10
Effects
[2] 58,2465,19
Effort
[2] 9,1639,1
Egregiously
[1] 57,25
Eight
[1] 6,5
Either
[5] 1L2 23,1 281252,1264,4
Elaborate
[1] 27,5
Electoconvulsive
(11 1],20
Electric
[ 1] 6, 23
Electrical
[31 58,1169,3,18
Electricity
[11 69,21
Electro
[3] 30,2239,376,21
Electroconvulsive
[10J 29,5 58,5,S,10 66,3 69,20 70
10,21761479,13
Else
[5) 28,10,13291944,345,17
Else's
[2J 7019-20
Elsewhere
[2J 22,170-4
Embark
[1] 74 5
Emergencies
[lJ 5L21
Emergency
[8J 39,2140,12-13,1643,1548,23
762,24
Employed
[ 1 J 4 5
Employment
[1] 55,17
Encounters
[ 1 ] 56 1-1
End
[ 1 ] 9 5
Ended
[2] 39,22 79-24
Energy
[1] 56,17
Engage
[2J 60,2178,16
Enjoyed
[lJ 67,18
Enough
11 J 47, 8
Enter
[7J 2102538,547,15481775,2476,
22 81 25
Entered
[4J 36,948,1982,2,12
Entire
11] 69,23
Entitled
[2] 19,2523,23
Entries
[lJ 1L13
Entry
[lJ 11,19
Episode
[2J 13,1260,10
Episodes
[lJ 70,23
Equipped
[ 1 J , 19
Error
[1] 6,10
Escalate
[1] 32,U
Escalated
[ 1] 9 10
Esquire
[5J 312-]] 18,1250,16,18
Essence
[ 1 J 73, 7
Essentially
[2J 63,270,10
Establish
- L 3 25
Establishing
[ 1: 56, 3
Evaluate
[1] 640 16
Evaluating
[1] 72,19
Evaluation
[3J 73,1476,19-20
Even
(16 7,179,9,2426,929,18 4L16
42,343,2547,860,22651070,20
71,1076,16,2378,23
Evening
[2J 47,7 5L19
Events
[6J 7,1328,2533,13 58 25 66,6,R
Ever
[ 1 J 8, 2
Every
[7] 27,2228,1638-2358,2068,19
74 , 3
Everything
[2J 36,2581,22
Evidence
[7] 48,1650,766,7 75,U,18-19 8L3
Exacerbates
[ 1 J 67, 3
Exactly
[ 1 J 69, 8
Exam
[2J 12,2574,15
Examination
[14J 3,2517,218,21301632,21340
335,937,1838,6,1555,559,1268
1272013
Examined
[lJ 40,15
Example
[5] 20,727,12 6L12 66,2 7407
Examples
[2J 27,10,18
Excellent
[11 7,4
Exception
[ 1 J 5 U , 8
Exclusively
[11 67 0 2
Excuse
[1J 68:14
Excused
[ 1 J 75 9
Exhibit
[:(;] 1914,19,22,25237,1618,23
36 9 48 3
Exhibits
[31 47 2S 48013,15
Existence
[1] 79 L~
Exited
[1] 53 ~_
Expect
[ 1] 68 7
Expectation
[11 -; 4 1
Experience
[JI '0720227708
Experiences
[ 1 ] 60 2
Expert
[ 1 J _ ~ :3
Explain
II J 58 7
Explanation
[ 1] 32 8
Exposure
[ 1 1 '70 3
Express
[ 1] 27 8
Expressed
[2] 30 8 42 18
Expressing
[lJ 4: 20
Expression
[3] 41215619,21
Expressions
[ 1] 19
Extend
[ 1] c 6 6
Extended
[11 "6 4
Extending
[ 1] . 23
Extent
[7] 262527-22906-742020600562
7
Extra
[l~ 19 15
Extremely
[2J 29014 61 17
F
Face
[1] 25 13
Facilitates
IlJ 5So15
Facilities
[6J ?J ;7,20,2222-17410,17
Facility
[8] 5014,2017,822,1523,563,12
7402076,17
Fact
[7J 20,4,9,24 2L4 63,1566,8692
Factor
[31 6501467-1]-14
Factors
[11 "
Facts
[2J 40 25 41 6
Fail
[1] 62-13
Fairly
rl~ 74 -;~
Familiar
[31 290145709,11
Familiarizing
[lJ 59015
Family
[2130370-19
Far
'5] 614,1740-447:2156:3
Fashions
~1: 7... 18
Father
14] 9 :0,14,16,18
Favors
1] ? 16
February
[4J 13-1422-2224 3
Fed
[ : I 19
Feed
[3J 10, 7001
Feed t
[1] 70, 1
Feeding
[9] 7,21901'01'1,2265,5-6,1269,21-
22 R107
Feedings
III 20
Feel
i6) 13-2256,258.1860.7,9 6L4
Feeling
[2J 59,20
Feels
[1] 3216
Felt
[ 1] -; 8 0 3
Female
[1] 15.12
Few
[3] 12,232503-4
Field
[ 1] 4: 13
File
[ ;] 76, 8
Filed
[3] 30618'1082,5
Filled
[1] 22.25
Final
ilJ 63,23
Financial
[2] 20.1936.21
Financially
[ 1 J 37 0 3
Find
[4] 12,3 6L8 79,6 80,13
Finds
[1] RO,16
Fine
[2] 59020
Finish
[1] 44 22
Fire
[lJ 38:25
First
[9J 1L21 12.2 18.2427.1048.3540
2260,9 6L21 65,13
Fixation
[lJ 6L12
Fluent
[ 1] 7, 5
Fluid
[lJ 57.19
Flush
[2J 18,2340,8
Follow
[ 1] 26. 9
Follow-up
[6J 2901 3L15 32,19 3309,11 62,6
Followed
[lJ 25,14
Following
[4J 42,8481882-1,6
Follows
[3) 30243508 5L21
Food
[5] 7.199.1615.1427.1440.18
Foods
[ 1] 7, 18
For
1122; 3.5-6,164011,13 5.9,18 7.5,9
8149,3,20,2310,3,14,16 lL13 12,
814318,1019,10,1920,7,2321,2,
8,16,18,2522.1,323,18240125.3-4
26,2527,15,222801-229,11,15,18
30,24 J2,4 35,23 36,4 38,20 39,17,
2240.9 4L16 42.943.9,11,1844.7,
945647,7,11,22-2348,2249,9 :'0,
2051,6,1152,1954,5-655,7,1456,
10,2157.14-15,2558.21-2260.8,23
6L12 62,3,11,18 63,13,18,25 64,13
66,2,8-9,13,1867016,2570,17,227L
7723,6,18,23734,1874.7,17,25
75,9,2476,4,8-9,2277,1,380,3,13
81 , 19
Forced
[lJ 47.21
Fork
[lJ 10023
Form
[5] 14.8,1423.536.866.17
Formal
[2) 66,17 7L22
Formally
[1] 3616
Forms
[lJ 2L22
Formulating
[11 63, 8
Forth
[lJ 37,11
Forty
[1 J 6,5
Forty-eight
[1 J 6.5
Forward
[2J 27,2128,17
Found
[lJ 77.14
Four
[4J 15.76512,1670,13
Frequent
[1 J 4,23
Friday
[.1] 52,1174.19,21
Friend
[2] 35,19-20
Friendly
[ 1] .1 5 , 21
Friends
[ 1] .1 0 , .1
From
[22J 7.2,249.915,2317.1721.19
24,1925,1326,2127,1429,831,7,
2234,940,946,1947,8,1852,1355
1056.260.2
Front
[ 1 J 69- 7
Fuel
[lJ 38,25
Full
[4J lL24 5Ll0-11 67,23
Functioning
[ 1 J 68, 8
Functions
[1 J 69. 1
Funeral
IlJ 42,3
Further
[17] 16.2530.10 3L13 33.9.17.16
38,13 43 4 46-19 471048,2549,12
59,10680972,975,4,1481,25
Futher
[lJ 7L13
Future
[ 1 J 66, 8
G
Gain
[4J 140136.19,2137.2
Gather
[21 26.1072,18
General
[10J 19.2524.155.1258,1759.1-2
60,4 66,1~,20 73,3
Generalized
[2J 58.1266,5
Generally
[15] 16,15291634,11 58,15 65,3,
2567.5,772.2,2473.1274.6,23,25
76,14
Gentleman
[11 28 18
Get
[191 6,18,238,149,16,2118,527,
2532,1346,4-5,751,560,162,20
73.1076.679.68L5,17
Getting
[3J 12,2028,257,18
Gideons
[3J 28.15,17-18
Give
[51 9;5 lL19 12,3 27-19 47,14
Given
[111 9.12,1414,1918,1327,10 3L
12331242,1665,11,1573,22
Gives
[1] 30.18
Giving
[1; 65:17
Gloria
[8] 20.8342135.7,12-13 46,2076
1, 9
Go
[11] 8.918.2039.2041.17,1943.11
46.2266,277,1978,679,11
Goes
[21 18,572,15
Going
[12] 8.4,1428.11,1732234.2351
453,14732176,1878,980,2
Gone
[1) 72.2
Good
[2] 59,2280,5
Got
[3J 16.547253.21
Gotten
[ 1 J 53, 9
Grab
[1 J 6,1
Grant
[2J 2L7 30.23
Granted
[ 1 J 21, 4
Gravity
[I} 65:15
Great
[2] 54,10636
Green
[3] 35.1-1 46.22 47.3
Grieving
[1] 7106
Grossly
[1] 61,11
Group
[2] 28,15,19
Guardian
[18J 18,1136,8,1737,344,945,6
48,2366,18 7L24 76,2,12,14,16 77,
478.2080.15,20-21
Guardianship
[71 34,21380147,2276,179,1480,
13, 18
Guess
[8] 17,17182 3LI0 36,22 64021 7L
2272.1974.22
H
Had
[28] 3,204,205,166,8-9,15,199,9
1310165182424,11271033,22
341335,2439,2041-9,1159,1662,
12-1370,2474,10-1176,778,21,24
HAGERTY
[ 1 J 54. 1
Half
[3J 40196,21 9,7
Hand
[5J 9,18,2010,21-2254,18
Handle
[ 1] 5'7, 2 J
Handled
[1] 51,21
Hands
[1 J 6.24
Handwriting
[1) 1302
Happen
[2] 64.1577-:
Happening
[2J 7,1316,8
Has
[66J 5.14 6.22 7.4,25 8.2 9,10 10
25 1Ll 12,17,22,24 13,10 15,25 18-
11 ~9,2: 20,7 21,3 22,8 23.21 25.2
26,:129,3,1930,831,8,19,21,2333
2,15351937,1141021-2250,556,9
59.66011,1461.6,11,24-2562.463.
26",2069,4-5,1270,7,17-197,-,11
72,676,13,2577,6,2378,1 79,9 80,
24 8L 18
Hasn't
[3J 16," 25,828,3
Have
[163] 3 4.12,17,20,245.8,196
168:.04 9,1'),17-18,2U 1L3,10-11 12
81511.1516,2517.13,2019,5,7,15-
1622.5,2523.4,8,12,152402225.7
28';,1129,2,4,2430,10,13,153LI3,
15,22,2532,2434,13353,18,21,24
36.",192037.16,2138.13,17,2039.
1,4, 9 42,4,lU 43,20 44,10,13
46.1048 R-9 50,6,19 51852,9,22
53.9 =5 '-'7,22,24 56.1,4,11-12,15 57.
7 , Y , 2 5 5 0] , 2 0 5 9 , 5 , 9 , 2 5 ,: 0 , 1 8 , 2 3 0 ~
61'7,20-)76221 63,11,:3-246413,
20 1 ,i6.3,3-10,16-17 67.9,25 68-
9,1'; 69 6,14 70,6,8,16 ~1,12,17,21
72 L,R,::,17 73,10,21 8,12,14,17
756,16 .1877.10,12-:3,1578.18
1'9 ,17,2380:2,6,12,1";,2381.:2-4,
11
Haven't
[2] J,20 63,9
Having
[9] 32418,225;20358432454,
2156 07.2370.15
He
[19] 12,2,1713,18-19,22-2315.616,
2,4-529340,1945,2147.852-3,22
78 . 3
He's
[2J 12 "59,20
Head
[1] 41 1
Headache
[3J 59165,2466;13
Headaches
[lJ 65:20
Headway
;1J 12 25
Health
[28: ~ 1592212:1017 8,24 18::~
20 ~~83024324 -22 -1;
41:"" ;4 8,234719-20,23 49:_C
11,1~ 1il SS I,IS 60 6 78::1 79
81
Hear
[3 ';6247:854
Heard
[2] 24 22 81
Hearing
[17] :":,97:416:117 5 18:3-4,1~-
15 3~ :248:2549:12506,2078-7
79:16326
Heart
[ 1) c ~.
Hegarty
[28) , :1 11-11,21 12 2,4,6,13
25 3,2551:2,12,18521.1934'-
2,4," :J,13-16,20,22 75:8
Hegarty's
[1: H
Held
l ::. j '1:.) .-~
Hello
[4; 5: 954163:761:1
Help
[5) 6 46 14 57:23 67 3
Helpful
[1) 6; 23
Hence
[1] C::9
Her
125:] 310-11,204225:1,13, 8,22
6:13,- 19,237:11,13,17-19,2 -23,
258 ,9,12,14-17,23917, -22
10 ",_ 12,2011:4,15-16122 13
131; ;-15,1915:616:2,17 :11,
16 L-: ,12203-4,8,1921:4,:' ,13
22 :2 .3 124:625:726:13,2027:3,
5,8, 28:10,12,21,24298304,8
31: :; 32 3-4,9,2533 12-13,16-19,
21,23 ;.; 5,9-10,12,14 35:19364,6,
9,12 3,8,14,2138:7,20-21,2439
4,13,1:;,224(.1;241:1,11,19-20,23-24
-12:2.,:),':9-20431,:'9,24-2544:1,3
46 15,21,2347:1950:195615,18,
225" ';,8,14-17,20,23 58:1,14 5925
606, ,:7-20,22-23615,7-9,11,13,
15,18,22,2462:7,10,16,2364:16,2<1
65:9,1566:2367:2,4,9-10,16,22-23
68:5,' 69:4,8,10,12 70:7,18,25 71:2-
4732274:875:2476:6,17 20,22,
2578:-;-5,7-8,11,15-16,20,2279:12
803-4,1:,16,2581:8-9,13,15,17-
Her's
[ 1 : 20
Here
[36) ;-9,166:8,12,20-217:1; 8:5,
l':2':'S 13 2 17 9-10 19 13 20:14
22:15-:6292131:632:133;:13 37
844:6 -15:23-25 46:4,6,8,10 -17:8,15
48:663:864:265:14
Herself
[5) -12110:822:825:166013
Hershey
(15] 5511 57 8 58-5 63-11,19 6412,
1566:272:5,1673:1,15,1975:2576:
6
Hi
[lJ 5118
High
[2] 60-1967-24
Higher
['1) 0<..'1:
Highly
[ 1 ]
Him
151 11 ~~ 12:2 52:2,4 53:12
His
:19J 1111-12,2412:2,8-9,20,22 :3
2146 :5:2326:1151:4,10-11,14,22
52 4,2~
History
[4: 72331234:6,10
Hold
[ ::..] 55: 1 C
Holidays
r 1] 36
Home
[ 18 ] 3
40
61 12
3,118712
"148655
17 F;: 1 U
153t:4-ti379
19,23577 S9:G
Honest
[1] 38::9
Honor
:23] 18:1924:1526:830:1031:17
341835:240:843:224<;-12,1647
17 -i8 .= so 23 51 1,13 52:2,5 53 14
75:7, ,23795
Hope
[2 J 53: : 3
Hope" sness
[l] 56:18
Hospital
117) 17:2518:531:4-539:5-6,11-12,
17 ,10 15 41:11 51 19 55:12,15 57 8
74:2579:13
Hospitalization
[4] 33:458:2263466:4
Hospitalize
I1J 13 15
Hour
[4J 52-375:976:3
Hours
i3J 5210746,17
How
[14J 417,205:139:1110:1930:3,
2132:7,9,1635:18,2138:1774:4
However
[2] 70-237722
Huh
[2) 13:920:16
Human
[1] -1: 13
Hurt
:lJ 60:13
Husband
[4J 33:16-1836:3
Hygiene
[lJ 10:15
I
I
[296) 3:8,15,174:125:176:1,7-8,
10,198:109:5,1111:112:2-3,2513:
214:1-1,2215,7,10,1716,6,2517:10,
17181-2,23-2519:9,11-12,14,2421:
222:823:2,7-10,12,2024:15,17,24-
2526:8,10,12,15,21,2527:3,11,22
28529:1,10,13-15,17-1830:7,10,13,
15,2131:10-11.13,15,2232:7,1233:
2534:1,9,2035:336:3,22,253716
38:5,7,13,20,22,2439:4-5,2440:1,8-
9,16,2341:4,942:2,4,10,2143:20,
224-1:2,4,15-16,18,2545:5,10,18,23,
2546:1,5,13,2047:1,7,14,19-20,22,
2548:2,5,950:5,10,17-18,2451:1.9,
13,1852:253:1355:10-12,14,17,24-
25565,11,14,2057:3,558:159:9,
24601,4,7,9-11,13,17,2561:2,4-5,
7-8,10,14,20-22 62:1,6,12,20-21,25
63:10,2064:3,9,2165:7,2366:2567:
1-2,5,9,13,2368:5-6,969:6,8,12,16
70,1671:4-5,7-8,12,22-2372:1,6,8,
11,15,18-19,21,2573:7,9,1874:11,
2275:6,16,18,22-2376:2,5,7,11.13,
1577:5,1011,13,18-20,2278:56,8,
10,13,15,21,2479:1,5,14,2380:1,3-
5,9,18,2181:2-3,5,11-12,21-22
I'd
[4J 1913421,2276:20
I'll
[8] 7:219:1441:646,1447:9,13 53:
1454:11
I'm
[35J 4:95:16:107:19:411:313:7
21:5232125:1127:1232:242:23
43:2444:2,6-746:1,1451:453:10,
1455:15571159:1860:1763:8,11
69:77320,2377:1380:2
I've
[6J 6:2112:129:1430:731:738:2.1
Ice
[ 1 J 9: 19
Ideation
[5] 13:7-8,1015:1356:20
Identification
12] 19:1923:18
If
(64) 6208:109:6,2012:3,2113:4
1717,22,2418:1619:14 20:6 21:5
23:7,925:14,1929:1832:13,1534:1,
2236:1640:842:443:2344:247:6,
85213,15,2153:1154:1256:2557:
1,2361:2163:1064-2265:10662
67:1568:671:1074:11,197612,16,
21,2377:2378:6,2179:1-2,1180:12,
1981:4,21-22,24
Ignorance
[1J 68 14
III
11] 23 - 3
Illness
110) 26:433:13,21,2365:2179:280
2481:4,6,8
1M
[lJ 13:14
Immediate
12J 13:1081:1
Immediately
[l] 63 15
Imminent
[2J 58:163
Impair
[1] 26:20
Impaired
[lJ 61:11
Impairing
[ 1] 6 1 : 5
Impairs
[1; 66:12
Impression
16] 31:2578::8,21-22,24-25
Impressions
[ 1] 60 3
Improve
18) 81268471:3,1077:2578:4-5,
16
Improving
[2] 67:2477:20
In
[194J 3:6,12,214:12-14,215:14,16,
226:12,227:3,168:7,239:4-5,16
10:912:251311-12,2516:2017:5-6,
10-11,1618:1519,520:4,9,14,2421
422:623:624:1,1325:11-12,1926:
4,6,16,2327:4-5,9,232810-11,22-
2429:7,2030:1,2231:432:253313,
1934 5,10,20,23-24 36:8,13,15,20
37:3,11,1438:9,20,2339:5-6,17-18
41:1642:18-19,2544:647:1,5502,
5,7-8,10,12-13,17-1851:21,255217,
19543551,12-13,15-17,21,2556:8
57:16-1758:4,9,11,14,1659,7,2560
3,9,13,20 - 21 61: 4,11-12,14,20,23 - 2 4
62:2463:4-5,10,15,2264:3-465:2,
1866:8,23671069:1-2,6-770:7,17
71:1,23,25722,21,2573:7,24742,
2576:13,2577:1,9,16,2278:11,14,
16,22,2479:13,21,2480:17,1981:1,
12,2082:5,13
Inadequate
[lJ 57:19
Incapacitated
[8J 19:18,2223:2,16-17,2248:12,14
Incapacity
[2J 19:179:3
Include
111 73 15
Included
[11 76:25
Including
[6J 15,1721:922,230:2570:1476,
24
Income
[ 1 J 37: 7
Incompetency
[2J 50:1955:2
Incompetent
[4J 60:179:780:12,16
Incorporating
[lJ 18:15
Increase
[ 1 ) 9: 9
Increased
11) 15, 6
Increases
[1] 66:11
Incurable
[2J 26:2,11
Independent
i1: 76:18
Independently
[11 10:12
Indicate
[11J 3:87:1319:2024:14,2150:4
517453:4,2055-856:9
Indicated
[5) 6:944:1646:21 '02:1 12:5
Individual
[l] 6: 9
Individuals
[2] 24:830:5
Infection
[1] 39:22
Information
[6J 19:1029:1534:1040:942:12,15
Informed
[1] 7:2060:862:271:25
Infrequent
11] 56:16
Initial
[2] 73,14787
Initially
[4J 14:1020362:12,15
Initiate
[1] 74:21
Initiated
[lJ 40:11
Initiating
[lJ 64:14
Injected
[lJ 13:14
In'ur
(2] 26:356:25
Inpatient
17] ]"7:73]-4,94070 5A
75 : 24
Insists
[2] 7108:13
Instance
11 J : ~
Institution
[ 1]
Insulated
[ 1] 68:
Insulation
[2J 2:,23
Intent
[6J 13:1060 11,16 61:7,~ 78:15
Intentionally
[2J 58:365:8
Interconnected
[1 J
Interest
63 22
[3] 25:11-1278:14
Interested
[3) 30432:25402
Interests
[lJ 4414
Interrupt
[1] 24:15
Interventions
[1] 57 1
Into
[19] ~:16 11:2 12:2117: 18521:
11,16,7525:1841:548:'5552262
2567769:21-2376:679 (
Intravenous
[3] 17:13,2081:7
Introduced
i1J 47:20
Intrusive
[ 1) 65 8
Invariably
[ 1) 65 2 'i
Involuntarily
[2] 64: 6517
Involuntary
[1l] 3:039:20,2540:5431644:20,
22 49:~ 78:19 79:19 81-13
Involved
[1] 4: 18
Involving
[lJ 18 10
Irreversible
[ 1 J 26: 2
Is
[240J 3:5,9,11,135:256:117:3,5,8-
9,228:14,10-189:7,121010-11,15,
17,1911:4,21,2512:4,10,14 13:14
14:2,12,15,18,20-21158,16,18,21
16 7,11,15,18-1917:6-10,2418:4,
10,:619:1,4,7,2520:1521:12,1522:
4-6,14,2323:9,22,2524:23,2525:11,
2226:102227:2-4,117911,20-21
3019313,1032:3-4,6,11,15,23,25
33:3,5,13-14,2134:535:1636:23,25
372-3,6,12 40:1041:542743:144-
5,1945;1746:11,16,2348:3-44919
50:6,13,15-16,20,22 51:2,10-11,13,
1852:15,17,1954:2,7,235611,13
57:5,2158:3,8,10-11,13,1659:3,6,
2060:5,7,9,11,13,2561:5,8,10-11
622,763:5,1064:4,6,9,15,19,22,25
65-10,13,16,18,24-2566:15,19,22-23
67:2468:15,1869:5,9-10,18,20,25
70:16,2271:8-9,18,2072:5,20,2573:
7-8,10,2374:1,18,24751476:20-21
77:2781579:2,7,20-2180:2,5,7,12,
17,2181:1,4,8,11,15827
Isn't
[1 J 31: 1
Issue
[3] 40 9 57,21 81 14
Issued
(2) 401473:13
Issues
[7] 4:2334:13371138844:657
11 61: 3
It
1133J 3:184:236:8,10-11,258:129:
812:3,1013:12,22-2414:2015:15
16:9,1519:4,12,14,2520:3,5,7-8,10,
2321:1,322:523:2524:1,825,11,
13,18262,2227,12,24-2528:1-2,25
29:5,15,2030:2131:1,3,7,9,2432
17,14-15,23331,7,13 34 22 38:6,23
41 2S 421-244:447:2,11,14,22-23
51:5,1352:2253:2158:13,22,2459:
3,1i,8 60 1861:17,2562:14641,19,
22,25653,2566:7,1669:1,2270:8
71:9,1772:2573:8,1074:5,18,2376:
4,8,12,15-16,19,2177:2378:3,6,15
79:8,10,16,222480:10-11,2281:3-4,
21
It's
[59] 4-23,255:97:7,10,198:49:23-
2510,1110212,13 13,2 15,20 1610,
1718,2,2523,424,1928,4291 1';
32:5,1242::'2,2247:5519 S6 1 57
1558,17,2459,160,21,2562,2464
1266,667,2,19,2168,21692270,3
73,11-12,2374019,2275,23762378
580208106,22
Its
[I] eo 14
Itself
[ l' . ,
IV
~ 1 ] .2 2
IV's
[2] 912,14
J
J
[7] 22 2~ 49 ~,16 82:10
James
[ 5 j 12 .;
51 ,
2154-1420
Jane
[2] 20 24 9
January
[II] 317,99615,21,2348,2149
8 5C 15119-2082,4
Jay
[ < I 54 2-1
Jelly
[2J 9,1"-:8
Jim
[lJ 51 18
John
[2J 18 "~ 50,17
Join
[lJ 60<5
Jr
[3J 49,5,168218
Judge
[12; 21,244065012511652,7,17
53,2, ,18,2454,2,4
Judgment
[2J Ll u 77 17
July
[3J <<,14122214,1
Just
[35] 588,1410,616,717,619,10,
1328,1929,1038,2341,15,19,2442
104';,3,7-846,2047,20510554,11
59,1-1,1660,1,461,363'8,1669,22
701376,1177,1378'2281014,19
K
Kathy
[12]1<6-17,23404-5382141142
114520,24 -16 1,7
Keep
[2] 6f917
Kind
[5] 17,561,2263,14 66,77404
Kitchen
[ 1 J ~ 18
Know
[57' 121-2130116,11210223,926
21,2529,13,15,17-1830,831,1132,
/,::'635::'8381039,164044221
44,14 -15,19,22 58,1 59,5 60,24 62,
116310,216403,6,1265,666,2,16,
18,25675,19,22,2468,1769, 702,
237' 9,18,217404,11,14 76,28 78,
13 1~2
Knowing
13J 2::. 42 19 78,14
Knowingly
[ 1 J .; 18
Knowledge
[5] ,1829,63101934,573,9
Known
[4J 12,125,732,941023
L
Lab
I1J 74'15
Lack
[lJ 25 15
Large
[ 1 J 11
Largely
12] ] t:
Last
[11 2l 13 17-18,25 1521,2329
15 =-8612162:474:11
Late
[2] 5:224122
Law
[5J -~ -I :8179'15,71 8018
Lead
[3: \3 .-,'1..4 77:14
Leadinq
[1] 25,
Lean
[2J 7,24 8,2
Learned
[lJ 310 7
Least
[6] 17,7-820,1762,473,481'18
Leave
[61 16532,13-1452,13 78,23 79,8
Left
[2] 33'16,18
Legal
[2J 38,771023
Legler
[31 24'10
Legs
[lJ 10,12
Lesser
[1] 22 1
Let
[11] 3719,2032,154402246,1350,
45102-15320-2163,1577,20
Let's
[lJ 52 21
Letters
[lJ 13,21
Letting
[lJ 16,11
Level
[~~ 262: 68:7
Licensed
55 , 15
Licensing
;l~ 55:9
Life
[14J 26,,28,23-2429,933,13 58,3
59,870,<571010-1177,2178,2,17
80 4
Life-sustaining
[ 1 J 26, 7
Lifetime
[1] 22, 1
Like
[18J 9,6,131101419,1326,838,23
41,2242,1462252,1354,868,21
72576,19-2077,18-19,23
Likelihood
13J 67,1,',22-23
Likely
[7] 60,1963,2265,767,3,1977,24
78 3
Likes
[4] 9,17,19,24
Limbs
[3 6,1969470,19
Limitations
[4] 6:15-1771:11
Limited
[8J 6101466,169,6,970,2-3,576,12
Line
[4: 52,4,12,1654,8
Lines
[4' 20,2026,12340778:9
Liquid
[3, 13,U 1401,15
Listen
[4] 44,7,9,1278,13
Listens
[ l' 32, 7
Little
[lJ 45,21
Live
i 28'1:i 35,11 56,20
Lived
[lJ 27,22
Living
[8' 8,16101523,370,1777,2280,
-I - 5 810 8
Location
I1J 46,23
Long
[6] 401751335,2165,16740480,16
Longer
[ 1 J 68, 1,l
Look
[ 1 J 46 2
Looked
[3J 610272128,17
Looking
i4J 7,111,266,981,19
Looks
[ 1 J 72, 5
Lose
[2] 38,1,3
Loss
[14J 82'- 9,8 11016 36,20,22 56,16-
1758,2563,365,25
8,148108
Lost
[1] 69 4
Lot
[lJ 340 13
Loudly
[1) 540 12
LPN
[2] 22,14
Lucid
[ 1 J 19, 3
Lucidity
[ 1 ] 19, 4
Lucidly
[11 16,19
Lunch
[1) 75,9
M
M.D.
[2] 12-4 54 20
Ma'am
[2J 17,43720
Machine
[lJ 52,23
Made
[12J 51914,1516,425,1438,2239
157,2,8592560,1461,664,12
Main
[1] 65 23
Maintained
[ 1 J 68, 6
Major
[6] 15,1256,12,2360,1061,467,10
Make
[22] 12:25130215'1520'18,2325'
152613,2027,2032,9 3G,20 38 20
46,13 48,5 71025 74,8 75,21 76,12
77,6,12,1578,6
Makes
[1] 610 16
Making
[7] 19,354560,5,8 6L8 62,2 77 13
Malnutrition
[2J 576,17
Manage
[lJ 57,16
Management
[1] 58,2
Manifestations
[1] 70, 4
Manual
[ 1] 10, 11
Many
[2J 15260,21
Mark
[4J 1913-14,1623,7
Marked
[6J 1919,212315,18,2170,18
Mass
[lJ 7C 11
Massachusetts
[lJ 55 12
Matter
[6] 30747,2350,5,1982:6-7
Matters
[2J 602267,3
May
[16] 53-46,19,413,12-1322,228,
1129,4,836,2042,152,1660,2381,
9
Maybe
[3] 46151'571,22
Me
[20] 5177,201101412,335,137'1
44,2246,2,1353,2154,86102463
1569,77101876,1677,14,20786
80, 11
Meal
[2J 7,16,19
Meals
[1] 12,24
Mean
[11] 9,1117,1024,2427,3,2239,5
43,2244,2,4562072'21
Meaning
[1] 65,2
Means
[3] 58,2265,368,16
Meant
II] 25,25
Mechanical
[2J 10,131102
Medical
[43] 3,17715202521:19,24234,
20,2326,3,530,1948,4-555,8,10,
14561,2557,1,17582,1660,2,8,
2463,11,19640465,15676,10,12,
2169,67013710672,1675,2576,6
8105,1020
Medication
[19] 12,2413,1414,2,13-14,19,22
15,7,1457,2259-760,126101962,
13,15,22 G406 65:17 68,5
Medications
[llJ 7,228,515,2257,562,2364'
20,2265,1,11-127101
Medicine
[lJ 39,15
Medicines
[1 J 68,2
Members
[5J 7,14,2310,2229,2430,3
Memories
[ 1] 66, 1
Memory
[7J 7427'1358,256525665,8,14
Mental
[3D] 41517,7,2418,142613,2028,
8372240,144101244,8,2347,19-
20,23491050,11,1755,156:3,878,
479,2,1180,2481,4,6,8,20
Mentally
[2] 79:7 80:25
Message
[3J 5102552,1] 78,13
Met
[1] 59,15
Midst
[2] 60,961,4
Might
[17' 8,11-1212,322,5271930,1
371242,452,2256,464,20,2366
18732274,2076-177815
Milligrams
[2] 15,1,7
Mind
[3] 26,2,117,1553,13
Mine
[2' 3213 36,23
Minimal
I1J 60,lJ
Minute
[2J 43,1244,7
Minutes
[3] 25,3-453,12
Misapprehension
[ 1 J 7 1 ]
Miss
[35] 19,2420,622,1924,325,1426,
18-1927228829,8,20,2530,4,6-7,
183522,2536,13,17,2137:638,18
39,241 1042,943,18631164020
65,20-2166,2267,1577,6
Missed
[1] 64 7
Modified
[1] ]1 1
Modifying
[1] 76 23
Mom
[2J 41 2-1 42,2
Mom's
[I] 35:19
Moment
[1] 42, 4
Monday
[7) 2722-2328,2,55102052,1174,
19
Mondays
[I) 27 25
Months
[1011101325838,1757,2561021
62,9,2U 6'/,18 68,8 '/411
More
[18J L23 6,17,19 12,23 1932:1 18
29,21382452,353,1159,661023
62,17-1865,866,572,2
Morning
[2] 512074:19
Most
[5J 131316,1628,177410,17
Mother
[21] 4225,1,188,1,8920,32810,
15,21341236,4,10,12 -16,23 60,15
61013,1669,10,1271,2
Mother's
[2J 5,1334,9
Motions
[11 59 25
Mouth
12] 65,3,11
Move
[41 81510,1247,2548,2
Moved
[lJ 33 19
Movement
[ 1] 69, 9
Moving
[2: 8" 25,12
Mr
:169] 113,154,15,126,68221
1-912 t)..7 l<i 25 15:2416:24251
1,3,1918,8,16,18,221910,2322
2311-:4,1924,15,17-18,21,2425
5~G 268,15,1727:14,1729:330:
:2-lS,:7 31:3..3-17 32:19,22 33:8-11
14-2,4,16-18,2035,1,3-4,1037,16-
1',19385,13-14,1640:8,13,21,23
41 3,7-e 42 -1,6 4J:4-8,11,20,22 -is
12-1t=, 18,2C' 47:1],17 48:2, ,9-:1
5-:::' 24511,4,7,9,13522,2153-
1,t,11,13,1",17,23 54 25 55,';,6
9,;.1,13,23641868,9,1;',137L12,
1472 8,10-l2,14 75,2-6,16-19,2276
10-11,;'3775,1878,21 79,4-S,2J 8C,
18>2,16
MRI
[ 1 :
Mrs
[ 1] , 3
Ms
[21] 31956166 18,lJ,25 19,2,11
31:2C 35 18 42-13 43.16 45::9 4n :0
47 2-3,11 :55 1 59:25 GO 5 63 18 80
24
Much
[ :: 7 ] 1:2. 2 J , 2 5 1 5 1 5 16 17 3 2 "7 3.1
11 .;6 '349:1654561:23 62 ~_,25
70 24 75 8 77 14 80: 3 81 7
Mulderig
[55] 3,1214,2517,1,3,1918,823
13-",241727,1429,430,14-15,17
3L13 33 10-1134,15-1635,437,17,
1938,13435-6,2045,14-1647,13,
1748,10-1150,9,16,22 5L1 53,13,
155';,256811,13 7L12,14 72 8 75,
3-4,1979:4-5,2080181:2,16
Multiple
(:] 56:lJ
Muscles
[1] 63 25
My
(40] 611012,4 2L8,18,21,23,25
221-32401127,9,13 30,23 36,3
638,643,2544,547,9,1850,1451,
215:'::1955:1159206215631665-
6,18583,1-169:57::':2072:22777
7822,2581-16
Myelin
[ 1 ] tS 8 : 21
Myers
[18J 316,19,2340418251911,24
22::4261841:142:11,134519-2(',
2446,1,7
Myself
[1] 59 2.5
N
Name
[15] 4 112412,220,3,822,4,8,
2335:: 40 21 445 46:l6 5:1. 10 1:
63
Named
[ 1 ] ] 6 7
Nature
[2: 411352-15
Necessary
[4] ~7 1: 57463:15645
Need
[20J 5,817,6371249,2,1464,11
71022,24724,2373-1,4,974,67,12
80,20811,10
Needs
[5] ]L11 39,15 61 18 72,22 8>7
Negatively
[ .j 1 2
Nerve
[1] 68 20
Nerves
r31 c8:17,20,24
Nervous
:.;] G8 lEl 69 17, 70:5
Neurologic
,1: n 3
Neurovegetative
[1] l4 20
New
( 1] 37 1
Newville
[4J 8 ~ 35 14 47 1,4
Next
[3] lS 7 44 ~9 56:25
Nine
[2] 21742
No
:84] 7 7 9,14 10 6 12 11 13 9 ;'5 4
16 ~,21-23,2S 17-17,2123,12,14,22
274,7,330,;'0,13 3L13,lS 322,12
33,6-7, 153416,1835,3-437
1638, 0,641,24 42,1,10 43,3~
4,6,8,2 -21,2445,1-5,7-9,12-14,
1646,1247,648,9,11540959,966,
768,9,1869,25 70,S,19 71,12 72,8,
1174,975,4,6,19
Nobody
13] 40,1-278,1
Non
(1] 62,25
Non-treatment
[lJ 62-25
None
-:] 75 16
Nontreatable
~lJ 73:24
Normal
[2J 67:1771:8
Normally
[~] 4024
Not
[116] 5,16,257,9,19,21-228,3,13,
15914,2410,9 1L3,16 13,15 15,15
-1617,-1,6-7,11-12,14,17,21,2518,
524,1926,1127,2028,2,4,1329,14
2-3,9,12,2533,734,11,13 38,19,
39,4 40,5-6,16,19 41,3,6~7 44,1
,7,11,19,22-2349,2,1450,10,19
452,1,356,2057,259,1960,7,
,25 6L20~21 62,4,22 63,12,20,24
,18,2466,367,2,1369,7,2370,14-
,19 7L3 73:12 74,11,20 75,18 77,
.0-1-178,5,9,12,14,2479,1,12-13,15
80,2-3,10,14,2081,5-6,8-9,17,20
Notary
:1] 22,19
Notary's
:1] 22,23
Note
16J 1L20 12 22 15,21,23 16,4 46020
Notes
'5] 6,8 1L11 12,20 14,6 15,3
Nothing
[5] 29,19311737,2813,24
Noticed
[ ~] 16, 6
Nourishment
[3] 8,249,1240,18
November
[2] 9,101511
Now
[28] 7,208,2310,912,2014,1518,
919,4-520,1725,2229,930,2231,
2 ,1 3 2 ,11 3 6 - 7 4 4 , 1 0 4 7 ,16 4 8 - 2 1 4 9 ,
8 56,23 57,25 59,21 66,23 67,20 69,
1770,1677-2582,4
Number
[5J 5L8,25 52,5,19,24
Nurses
!6J 9,15,2310,2022,327,25 4L16
Nurses'
[ 1 J 9, 24
Nursing
[18] 33,104,6-78,712,1521-19
3102136,537,840,1046,2555,19,
2357,7 6L12 70,17 77,10
Nutrition
[3] 57,460,1263,3
o
O'Brien
[68J 3,13-154,15,126,68,22 1L7-
912715,2416,24-2523,11-1224-
15,18,21,2425,2,530,12-13 3L16-
1732,19,2234,17-18,2035,1,1037:
1638,540,8,13,23 4L3 43,7-8,11
45,1246,2048,7,950,245L7,9,13
52,2,215301,6,11,17,2354,2355,4
659972,"0-1175,5-6,16,2276,13'
Oath
[1] 46,11
Objection
l6J 353-438,547,648,8,11
Objections
[ 1] 48 9
Obligation
[1] 43,23
Observe
[ 1 J 10, 7
Obsessively
[lJ 60,20
Obtain
[1] 21 23
Obtained
[1] 7L22
Occasion
[5J 9,11,2316-143,1755,22
Occasionally
[ 1 J 59 1
Occasions
[lJ 78,11
October
[2] 7,1027,11
Of
[295J 3,84:14,225,4,7,256,4,13,
197,3,8,13-14,258,4,259,6,810,
11,1411014,16,1912,2213,1114,14,
1915,2,11,2216,1,11,16,2017,5-6,
10-11,1618,11,1519,1,5,14,2120,1,
13-14,23 21,6,10,12-13,23-24 22,2~3,
7,19,2223524325,12-13,2026,4-
6,15,222710,12,18-1028,7-8,10,23,
2529,0,16,2130,15,18,2531:1032-
11,2411,1614,13,21,2435,19-2036
8-9,1737,7,11,14,2138,630,23,0,
1840,2,2141013,22,2542,943,14,
1646,4-5,7,12,2148:3,5,18,20-23
49,1,7-9,1450,5,7-9,12,1516,18,20
51 , 6 ,19 52 "" "" ,{ ,16 ,,6, 3 , 12 , 15 - 19,
21-24 57,4-5,17-19 58,1, 9, 19-20, 25
59,6,14,18-19,256003,5,80,14,18
19,24 61,4,9,12,1~-16,21-22 62,2,4,
7,11,2463,2,5,12,14,16,21,2364021,
2565,6,14-15,202166,1,4,7,1467,
9,22-23 68,8,1~,18-19 69,1-4,7,18,
2370,1,5,7,18,267L2,8,10-11,15,
2572,1,7,21,2573,4,7,247401,4,8
76,16773,9,23-24781-2,6,9,14,2U
79,8-10,2080,4,10,14,17,19,21811,
3,8-9,16,23821,3-5
Off
14J 43,11,13 59,16 61 2
Office
[3J 12,922,752,10
Often
[7J 42032-113817602061667
7 68, 1
Oh
(6J 13,6,2419,1433,459,1771,13
Okay
[45] 5,1110,1011,512,513,1715,
5,9-1016,2417,118,822,1823,7
2401825,530,12 3L3 32,18 33,8 34,
2,15,1935,537,1738,9,1242,1243,
944,19,2545,1046,9,1847,548-12
5L15 54 10,13 55,3 56,8 62,6 69,4
70,1679,2581,24
Old
[lJ 28,19
Oler
[13J 44,549,5,16 5L16 52,7,17 53-
2,7,18,245402,482,10
On
[76] 3,6,115,176,158,49,11,18,
20,22129,15,2514,16-1715:21,25
16,4 2L8,20 22,5,9,21 2403 26,9,18
27,5,2528,11,1529,1730,22-2331,
3,8-9,1232,23330934,840,1942,2,
1543,1,1650,16,1852,4,12,2254,7-
856,13 57,3 58,21 62,6-7,12 68,21
70,6,8,1871,1,2374-5,2077,3,7-8,
19,217810,227902
Once
[11 76 - 7
One
(24] 5,89,910,124,932,1937,11
40-18424,747,1753,1058,2062,7,
1663,5,2170,11 7L13 74010-11,23
81 , 12
One's
[2J 66,12 7L10
Ones
III 5L
Ongoing
[ 1] 66, 8
Only
[12] 6,79,2319:723,950,1462,22
64,1065,2-369,2573,2481,2
Onset
(1] 28,7
Open
i21 48,2449-11
Opinion
[10] 26,4,11274,942,1964,1465
187724780379,17
Opinions
[ 1] 60, 3
Opportunity
[3] 18,2429,3
Option
[8] 81313,16,2558,664,10,1765
1873024
Or
[90J 7,9,14,219,11-12,2410,12-13
1L3 13,6,10 15 10 16,7,17 17 6-7
18,519,3 2L7,19-21 22,1 23,2 25,
15,1926,3,9,11,18,2528,1129,57
303-5,2331,53212 34,6-7 12 3~-
19,21,2337839,242,7451. 52 12
540858,16,1860,23 6L6,10,19 62,8-
963,2464,56511,2167,16,1868-
242560-13 70,12 7L16 73010 74 S,
11 , 23 76, 3 , 23 78, 9 -{ 9 ,17 80, 10 8 1 , 18
Oral
[8] 12,2414,8,1457,2262165,2
70,2473,21
Orally
[1] 64,5
Order
[22] 15,1137,2247,1548,17-18,20
49,769,1 7L15 75,24-25 76 23-24
77,1 8L12,17,25 82,1,3,12
Oriented
[1] 7,3
Original
[2J 22,6,8
Other
[37J 712,141506 2L20 22,25 24,S-
926,2327,1829,2530,4-533,2134,
2447,1750,852,12562158,2062-
23 (;5,10,19,21677682569-1,14
70,1,137101372,1740375,676:13
7912R015
Others
[3] 9,1629:2232,24
Otherwise
11] 5, 9
Our
[9J 1L16 22,6 23,S 32,4 52,10,16
7R,7 80 S
Out
[17] 9813,215,1118,2323,132
1340,942,146,4-5,747205119
63,96402270,17810
Outpatient
[2] 3L8,12
Outside
i2] 38653,14
Over
[14] 9-1612,2315,738,17 4L22 42,
19130152,2256,1462,2072,2,16
79,22 80,7
Overall
[2] 62,978,25
Own
12J 72,2277,7
p
P.m.
(3] 304 50,3 52 12
Page
[1] 23,22
Pages
[ 1] 15, 2
Pain
[3] 58,1860,2365,21
Pamelar
[3] 14,2,5,15
Pamlar
[ 1] 14, 5
Papers
( 1] 5, 16
Paperwork
[ 1] 6, 1
Paragraph
[6] 2L5,12,16 24,13 30 22
Parents
[1] 3319
Part
(8] 34,24 6L9 63,16 64 21 68,18-19
69,2370,1
Particular
III 73,8
Parts
[1] 68,25
Pass
[ 1] 42, 3
Passed
16] 20,728,15,2141,2446,24 6L13
Passing
[ 1] 28, 9
Passive
[3] 13,6,85619
Past
[12] 1L13 12,23 13,1125,3-4,838,
1743,261,2362,8,2069,13
Patient
[5] 14,758,3,1764,473,25
Patient's
[1] 58,12
Patients
[4] 66,967,24-25 7L5
Pattern
[2] 9,2513,11
Pay
[ 1] 37, 8
Peanut
121 9,1718
Pen
[1 I 12 1
Penn
11] 55,10
Pennsylvania
[1] 12,123501547,155,16
Penny
[2] 22 14
People
[ 7 J 2 9 0 2 5 3 0 4 3 1 0 8 - 9 7 2 0 17 7 -/ 0 1 0
8006
Percent
[2] ~, 6 67 20
Perform
[ 1] 69 1
Perhaps
:17] 1Qo3 23 3 2609 2712,20 2eoe-,
29 9 3:1 4 41 12 44 2 57025 6L21 620
3 73 16-:7 78 14
Period
[5' 350245601466047002571
periodic
[1] 1301:
Periods
[1] n 2
Peripheral
[2] 6801',19
Permanently
[1] 25:~9
Permission
:3] 2144856301]
Persistent
[2] 13 22 67 8
Person
[:C) 5819018,2223016-17,2227 1C
48023782080021
Person's
[4J 20 23 31 11 48013-14
Personal
[ 1:
Personally
[ 1 ]
Pervasive
[1] 1501)
Petition
[111 306,811121809-10,1348022
490963<0 03825
Petitioner
[ 1) 3 12
Philosophical
[ 1] 80 8
Phone
[4J 524,2122547
Physical
[11-] u 1.5,22 10420;19263,19 GG
246726907740157805
Physically
[4J 1003670: 7801:,22
Physician
llC] 265,9-10,1634:1240:16-1742:
7431553:16
Physicians
[ 1 J 42 8
Pill
[ 1 J D 5
Place
[9J 305 ]9 5 36 2 57014-]5 65 74
3,238019
Placed
[7) 51165275302,7,18,2463011
Placing
[ 1 ] 65 0 6
Plan
[2J 13 1C 73 ]6
Play
[1 ]
Please
[7J 403903 1L]3 ]2 21 35011 52 :4
54 0 18
PM
[4J 49-2] 51020 520]1 82015
Point
[15] E 24 ]] ]8 13016 160]028 ]2
4700,17,2057185801,3620226517
77:08C:9
Pointed
:j -8 H
Points
[ lJ
Poor
[2J 1518,2:
Portion
[2] 6 50:20
Position
[7J 40115601977037901880023810
15 - 16
Positions
[lJ 75021
Positive
[31 ::031303,6
Positively
[ 11 15
Possibility
[ 1 ] 3' 12
Possible
[7J 52:1564;19,22
Poss
[2J 220 023
Potent
[2J 140216217
Pound
[ 1 J 9 0 7
Pounds
[2 J 907 - 8
Power
[24) 1905,21200],23 2L]3,23 2207
30 ]8 3608 3702] 3801,4 460]2 4803
76167908,2080-]0,13,]7,]9-208L
23
Practical
[lJ 13013
Practice
[2J 5L22 640]3
Pre
[ 1 J 7 0 1
Pre-admission
[ 1 J 7 0 1
Precedence
[lJ 79022
Pregnancy
[lJ 70 14
Preparation
[ 1) 65 0 2
Prepared
: 1] 22 5
Presence
[1] 50 ]9
Present
[2U] 30',11,186-]7706 '06,]0 ]002
130122305470114902,14520156024
5705600257501578011,24
Presented
[1] 5007
Presenting
:lJ 75 ]8
Pretty
[1J 540 9
Prevent
[lJ ]L 6
Previously
[ 1) 14 7
Prior
[7J 513 ]8013 ]902 270]0 3406 6606
68 0 7
Prn
[1) 1] ]5
Probably
[4] 280]66603 7L24 73020
Problem
[7] 23;]2,]456;467;3,]380;9 8L7
Problems
[7J 670]1-]2,2] 700]5 7L6-7 8002
Procedure
[ 1] 65: 4
Procedures
[61 ]80]42025 2L9 30025 4702] 490
Proceed
:2J 6302474-24
Proceeding
[14] 18;]" ]90]3 3402] 47;]0,]2 49-
2,14500]1,]6-]7550]-26602073013
Proceedings
[31 49020500]0820]4
Process
[3] 400]] 6]08 75022
Profession
[lJ 55018
Profoundly
[1; 150]6
Prognosis
[3J 150]82129 ]]
Progress
[1] 15:15
Progresses
[11 26025
Progressive
[11 26;22
Prohibit
[lJ 17;22
Promote
[]J 140]
Properly
[ 1] 68; 5
Proposed
[ ]] 39 0 3
Proposing
[ 1 J 44 0 2
Protein
[1' 68020
Provide
[2J ~2;18 58-5
Provided
[1) 730]]
Provides
I]) 20023
Providing
[3) 63;20730374;18
provisions
[]) 76;]
Proximate
[1) 72; 7
Psychiatric
[7] 3902040020570],9580273;]4
76; ] 8
Psychiatrically
[]J ]3016
Psychiatrist
[13J 8012 1L22 12014 26-10 3Lll,
2] 40 ]6 5001] 5L2 550972023-24
8] 0 3
Psychiatrists
[2J 630226401]
Psychiatry
[2J 5501]-14
Psychological
[2J 7 24 31: 23
Psychology
[1] 40] 2
Psychosocial
[1; 7: 2
Public
[]J 22019
Purchased
[ ]] 9 ] e
Pureed
[]J ]L 3
Purpose
[]] 55' 7
Put
[2) 581790]2
Q
Q
[6] 1201] 24011 300]8 3L]9 4L9 670
] 5
Qualifications
[ 1] 51 5
Qualifies
[ ]] 4; 1]
Quality
[5) 290970025 7L]0-]1 8004
Question
[]7J 1708190] 29;432019383,10
4202] 440]9 5L4 6004 6309,]6 6402],
25 7L1],]8 74;22
Questioning
[2J 540236020
Questions
[36] ]6025 ]8;]7-182401] 250]2 26-
]52704,7292300]1,13,]53];]3340
]6,]8370]63807,]34304,6,8,]9-20,
23,254403450]] 590]0,24 68 ]0 710
137209,1175-4,67808
Quicker
[lJ 8L22
Quickly
[]J 74 25
Quite
[21 28-56806
Quo
[ ] J 63 6
Quote
[1) 702
R
Raise
I]] 540]7
Rapidly
[1] 68 4
Rarely
[1] 66 5
Rate
[ ] J 59 0 6
Rather
[1) 79023
Rational
[2J 61017803
Reach
[2) 52;3,]8
Reached
[3] 5L22 52 9 6202]
Read
[l]J 1] ]2,19 ]2 2] ]3 4 ]5;8 2L3,
6,]6290]430021
Readings
[ ]] 9 0 3
Reads
[1) 76025
Ready
[117424
Real
[ ]] 8 0 4
Really
[]81 4202,24 6L]6 62016,24 630],23
6406,8,10,25650],1] 68021 6902 70
47302378;6
Reason
[]J 36019
Reasonable
[2) 26052709
Reasons
[3J 600868;] 80;3
Recall
[3J 602039074002]
Receive
[8J 2L23 3L4-5,8-9 4408 57014,16
Received
[2J 5L25 5305
Receiving
[ ] J 33; 1
Recent
[3] 4L24 6L20 700]2
Recently
[6] 20;730;934;]463-2.4690]0
Receptive
[ 1] 68; 4
Recognized
[ 1 I 80 0 6
Recognizes
[lJ 80019
Recommend
[4J ]401,22 ]50]740019
Recommendation
[2J 3L1J 72018
Recommended
[]) 39 2
Recommending
[JI 7602]
Reconvened
[ 1 J 50 0 5
Record
[24J 37 ]0-3,9 ]208,21 ]8023 ]9020
2L]7 24 ]934023-24 4L5 430]],]4
48023490115004 5L6,11,24 5302J
5587868206
Recording
I]) 53010
Records
[9J 30:760]47015 ]L]O-]] 2>24-
2506;16906
Recover
[ 1) 29 0 8
RECROSS
[3J 30;]63403720]3
Recurrent
[4J 56012,23679-]0
Recurring
[1) 70022
REDIRECT
[]] 3202]
Reduction
[1 J 700] 8
Reference
[4) 402] 7;]6 36;2] 5608
Referred
[3J ]301723032905
Referring
[2J 8019690]7
Refers
[3J ]30]8,23-24
Reflected
[]J 42020
Refresh
[lJ 27 1]
Refusal
[5J 802343:]45704630273021
Refusals
[lJ 340 6
Refuse
[6J 15014172521:73002340;]862;
22
Refused
[2) 4];]557024
Refuses
[4J 7022 ]50]6 ]702257022
Refusing
[8) 80S ]2-241408,]415022 ]7021
600 12
Refute
[ 1] 8] 3
Regard
[]21 82320;24 2L4,11,\1 23-] 26-
]636020 4L6 42,8 44036003
Regarding
[4J 20'1929,443,14 6C,6
Regardless
[ 1 J 2 6 , 6
Regressed
[ 1 . 1 6
Regular
[2) 121535,25
Regularly
[lJ 38,19
Regulations
[lJ 17 22
Rehab
[21 .; 6 16
Rehabilitation
[lJ 21 20
Reiterate
[ 1 J 6 1 3
Relate
[1 ,1 13
Related
[4] ~U 16 34 14421261'2
Relationship
[ 1; .f 3 :..
Relatives
[lJ 69'15
Relevant
[2! 19147,18
Relieve
[lJ 58,13
Religious
[11 28 15
Remain
[2J 48'2349,11
Remember
[ 1) 6 6 4
Remeron
[6J 147,11-13,2310,1'1
Remission
[2 c. 2571,1
Remove
[ 1 J 6 ~ 7
Repeated
[1) 78'10
Rephrase
[1] 77 20
Report
[4) 73 .v,1~,17
Reporter
ti 3 1 7
Reports
[3J 322.; 34:107315
Represent
[4' lR 1244'11,:"35925
Representatives
: 1; 5 7 ...,
Represented
[ 1 J 3, 1 3
Representing
[3' 50,1" 55'1 81 14
Request
[4] 36,963'10,137316
Requested
[2J 48,2449,11
Requests
[ " 6 3 , 9
Require
,., 74,16
Required
[3] 212231,350,20
Requires
[31 10,13-1481,18
Reserved
[ 1] ci 3 . 2 5
Resided
I 1 i 8
Residence
[ 1) 3 1 0
Residency
11) 55'11
Resident
[2] 232348,4
Residential
[ 1] L -'- 1 9
Residents
~l] 23 5
Resolve
[1) co 12
Resort
[3J "" 17-18 29,15
Respect
[2J 18,1227,6
Respects
121 29,2142,25
Resp
[2J 62, ,15
Responded
[')114:7,10
Responding
11] 62 19
Response
[3J 32,5-6 67 23
Responsive
[11 68, 2
Rest
11) 70,7
Restarting
[ 1 ) 14, 23
Restriction
[1) 13,11
Restrictive
[2) 17,7-8
Result
[4 26,6562358,960,20
Resulting
11) 6304
Resume
I 67 , 1/
Resurface
70 , 2 C
Retardion
11 J 4, 15
Retention
[ 1 J 22, 3
Return
12J 52,1468-7
Returned
[2J 3106 '>3,16
Returning
11] 61012
Reversible
[2J 7105,9
Review
[1] 21023
Reviewing
[ 1] 5, 16
Rice
[2] 22,24
Ridge
111 46,22
Right
[421 4028,2111,2412,2013,5,17
14,916,1118,7,2019,4-522,1025,
2226,1427,1628,2029,932,11340
2240,743,2144,1646,254'7,1,24
48,749,1850,2451,752,2453,14
54016-1766,2369,1475,2076,1077
2,2579,480,6
Risk
[91 562457-559,260,2466,13,15
702272,173,4
Risks
[1] 66,20
Road
[2] 35,14473
Rob
11) 54-23
Robert
141 3,12-13 50,16 54024
Role
62 , 15
Rolled
11J 52,22
Room
[81 32,1439,21401743,1578,11,
22 , 24
Roommate
[1 J 7,21
Roommate's
[ 1 I 7, 21
Root
[ 1 J 9, 19
Route
[2J 64,2579,11
Routinely
[ 1 J 74, 9
Rubber
11J 68 21
Run
[lJ 59 16
Russell
[8J 5,720,4,624,946,12,17-18
s
S
[3) 495,168210
Safe
[6J 17,9-11,1658'2366,16
Safety
[1] 78,14
Said
[15] 8,224,1725,8 33,238,21
4102245,1952,362,8640865,2372,
1774,278,12
Same
17J 2814,20321141,16-1780,20-21
Saturday
[ 1] 28, 2
Saving
[ 1 J 59, 8
Saw
[2J 16,228,24
Say
[18] 18,23230225,1832,238,2440,
1 4 1 1'/ 42, 1 , 22 45, 18 46, 11 6 1 , 23
66,2567,168,870'1877,1178,5
Saying
Ill] 8, 6 24, 2 2 2 3 , 2 5 2 5 ,2 4 4 , 1 -/ 4 5 ,
1,3,5,864,9
Says
[5J 7,1716,2117,426,231,1
Scan
[ 1] 74, 8
Schedule
[4J 47,948,2549,1274,17
Scope
[1] 38 6
Screaming
[lJ 60,20
Screening
[1] 74,7
Second
[101 15,1918,9,1524,1327,1128,
1648,454,2472,1875,25
Secondary
[2J 58,467,6
Secretary
(3] 47,948,2549,12
Secure
[2) 19,1254,8
Security
[ 1 J 37, 7
See
[11) 8-1011,1519,1222,833,2539
2447,1067,13 7104 76,13 80,3
Seeing
[1] 62,10
Seem
[2J 27,1928,9
Seemed
[lJ 28,25
Seems
[3J 76-16,2280,11
Seen
[4J 15-253818601867,8
Sees
[1] 61010
Seizure
[2J 58,12,15
Selected
[1 J 59,7
Sending
[2J 7,18,21
Sense
(3J 27,2056,1860,1
Sent
[2] 7,1866,17
Sentence
[1] 17,15
Separate
(2) 64,1379,16
September
[21 14,627,23
Serious
[2] 06,246721
Serve
[3J 36,13,1555,14
Service
[6J 4,1330,2455,2173,1,17
Services
[6J 7,2412,11,1821083102355,15
Serving
[ 1 J 37, 3
Set
[2J 723 7L17
Setting
[lJ 62 24
Several
[91 11,13381760,862,4,9,2070
1778,10
Severe
[5] 15,1258'1460,1061,466,10
Severely
[lJ 80 25
Severity
[1] 14,19
Shake
[1 J 9,22
Shaking
[lJ 4101
Shall
[31 18,2348,2349,11
Shared
[ 1 J 5 17
She
[217) 5,18-196,12,15,18,20,22,247,
17,20,22-2382-3,6,9,1]-149,4,7,
11-12,14-15,17-19,22-2310,7-8,12,
14,16,191101,312,2414015,2115,
141610,13-14,18-19,2117,6,9-10,
22,24-2518,419,2,5-6,1120,7,17-
1821322,16-17,2523,1,624,1725,
2,8,19,22,2526,11 27,3,5,7-8,11,22,
24281-4,12 30,8 3104-5,25 32,6-7,
9,11,15-16,2533,2,7,14-15,1934010
39,5-6,11,15,17,20-21,2440,4,6,15
41010,13,15,19,2242,3,18,2444,1
45,1946,13,2247,2156,4,957,3,21,
23607,9-12,14,2361,6,11,15,2562,
2,4,12,14-15,18,21-2265,1166,2-3,
166717-1868,769,4-5,8,1470,7,
15,18-19,22-2471,16745.7,14,19-
20,2477,11,14,16,18-19,21,2378,9-
10,12,19,24-2579,7,18,248011-12,
258104-5,7,9
She'd
[21 74,12,14
She'll
[2] 32,1268,6
She's
121J 8,5,7,14,189,14 lU,24 16,11,
1617,2134,1246,1257,17,246104,
2362,2563,1873,374010-1177,22
Shop
[7] 27,212228,1,3,5,18
Short
[6J 28,2358,2565,2566,14 69,2 70,
6
Should
[81 23144,8-947,23612268,779,
18 810 12
Show
[1] 6, 14
Showing
[2J 7,11 23,21
Shown
[1 J 59 5
Side
[3J 58,2465,19,23
Sign
[2J 212181,12
Signal
[2J 53,5,21
Signals
[2) 531068,25
Signature
[2] 22,13,19
Signed
[6J 19,22012,1724,666,177416
Significant
16J 6,1728,22,2456,1663,37111
Significantly
[ 1 J 9, 10
Signing
[lJ 810 16
Similar
[2J 212027,19
Simple
[1] 60,22
Simply
[lJ 62,22
Since
[13] 4,225,156,217,258,11,2428,
331734,13 41024 73,21 79,20,22
Sir
[1 J 75 11
Sit
[4J 108,12-1361017
Situation
[5J 14,624,263,565,1677,25
Six
[6) 58,2165,12,1667,1868,874,2
Slow
[2] 45:21
Small
[ 1] 59, 2
So
1651 6,12,1691711,41614178
18,1723,1024,1126,1528,3,20,22,
2530,2132,5,1538,22,2439,2240
441642,12,2544,118,652,1314
581-',2159,260,236103,762,14,18
63,964,14,2265,14,1766,1,13 67,
12,21683691,7,13,16,25710472,
6,1873,4,16,2374,9,16,2276,878,
258104,9,19
Social
[9] 3:164:9,11,13,1734:1037:740
1056:17
Soft
[ 1 J 11 3
Some
[33! 5166227:8,2310:2511314
2515:13,17287292,20-21,2<1 ]
31:8-941:1242:2547:1451:658:24
59:2462:1865:2566:13 67:1,20 71
25741,157723
Somebody
[ 1 J 44 3
Somehow
[1] 64 21
Someone
[6J .; 24 7:19-20 17:1152:1481:18
Something
[4: 23:341:21461464:8
Sometimes
[2 J .; 25
Somewhere
[1: 2'7 23
Son
[1: 59 20
Soon
[2J 32:352:15
Sorry
[8J 6:109413721: 42:2346:1
61263:9
Sort
[1] "1:25
Sounds
[3J32:15 34 22 76:19
South
[lJ 12:11
Speak
[8J 18:25306432454 ]1 73
18 81:19
Speaking
[6] H :6:19 -t~>10 55:25 778-9
Speaks
[ 1] :::.:; 1
Specific
[4] 216312 69:?3 70:9
Specifically
[6j c= 4 63 1864:674::'6762578
12
Speech
[2] : 17
Spell
[ 1 J : -J : 3
Spheres
[ 1 J
Spine
[3J 1 _. 68:15
Spoke
[2J .~~ 'i 52
Spoken
[2' ,< ""
Spontaneously
[1: " 1 C
Spoon
[ 1 :
Sporadically
[ 1 ~ : S 1';
Spring
[2] 35:14 <17:3
Stability
[ 1] 19
Staff
[
3 D
2229:21,2431:
:.. ~ 6
L... :-i 12:1 62:7,l3 75
:20 32 12 35
13
11 ..;:::, :,::-lJ,
11: 8
Stated
[l~ 47:19
Statement
[2] :... 9 : -t 2: C .
Statements
[ 5: - 1::'
';0 14 61 6 '75 2:
States
[l]
Stating
[1] R: tl
Statistics
(2~ 29 17 67 2J
Status
[2] t=3 6 ~:
Statute
[2] 76: : 5
Sten' pher
[,jJ 5:914:4,919:16
Step
[1] 53:14
Stepfather
[4J 8:1730:536:44610
Steps
[2J 9:2080:15
Stewart
7: 24
Still
[5] 71022:1663:864:272:6
Stimulant
[1] 58:11
Stipulate
[6J 40:2447:10,1349:1,13512
Stipulation
[1] 41:6
Stop
[1) 16: 2
Stopped
[1 i 28: 2 Cl
Stopping
[1 J 14: 2;
Strangers
[1] 29: 2',
Strategy
[1: 73:22
Stress
[lJ 65:10
Stressors
[lJ 28:24
Strongest
[1] 14:23
Studies
[21 '09:5668
Stuff
[<II 36:6382240:342:3
Subject
[5J 3:849:1,1450:9,15
Subjected
[6J 39:2540:5442078:19-2079:18
Subjecting
[lJ 81: 12
Submitted
[ 1 J 73 1,;
Subsequently
[2J 4:1633:19
Substitute
[ 1 J 23: 9
Success
[2J 59667'20
Successful
ll; :,: 9 : 16
Successor
[ 1 J 20: 8
Such
[7J 21:22,2541'559:770:1271:11
80 6
Suffering
[3! 56:2466:2380:7
Sufficient
[l! 25:15
Sufficiently
[lJ 14:2:
Suggested
[1! 76 13
Suggestion
[lJ 32:16
Suicidal
13:"-9151356:1960:11,1561:
7 , 9
Summer
8 : 2 5
Summit
[2] 121052'10
Support
[1] 11 1:
Sure
[13] 516:227:129:1832:2,2042:
5591960'1863:1269:774:980:2
Surgical
[3J 21:930:2465:4
Surprising
[lJ 33:13
Surrounding
[1, 58:25
Sustaining
[lJ 26:777:2178'2
Swallowing
[2] 11:1,4
Switched
[1] 14 14
Sworn
[4] 3:20,2435:854:
Symptoms
[21 14 20 56 15
System
[7] 68:1869:3,17-18,21,2470:5
T
Tablet
[3J 14:8,14.21
Take
[10] 3:188'239:12,2236:239:15
61:1865:12743,5
Taken
[4] 9:2031540:1982:7
Takes
[2] 742379:22
Taking
[2] 68 5 75 9
Talk
[6J 10:7,17391,1441:1966:20
Talked
[4J 7:1730739-4,13
Talking
[3] 24:2031:2541:10
Task
11J 63:23
Telephone
[8J 501451:1652:753:2,7,18,24
75 : 12
Tell
[6] 4:109:220:1146:364:372:21
Telling
[1] 27 24
Tells
[ 1] 7: 23
Term
[4J 15:1958:2565:2566:14
Terminal
[3J 25:2026:171:6
Terminally
[ 1] 23 2
Terminated
[1] 75:13
Terms
[9] 16:2017:10-11,1657:1759:25
69:772:2173:24
Testified
[3J 3:2435:854:21
Testify
[5J 5:929:347:2150'1475:9
Testifying
[ 1) 56: 3
Testimony
[7J 181543:1047:1852:1954:677:
9
Tests
[ 1 J 74: 7
Than
[12] 4:236:1727:2429:9,2252:3
59:765:9,1979'12,23
Thank
[Ie) 1e:8,24 2~ ~ 34:19 43:9 46:9,
1849:1852:16,1954:559:9,1471
1272:875:2,8,10
Thanks
[1] 51:23
That
[367] 3:8,184:105:2,16,226:8,15,
19,247:2,12,14,17,19-20,238:2-3,7,
11,14,189:13,15,2310:9,1611:10,
1812:8,1314:315:8,1916:4-7,11,
1417:4,2318:5,10,12,15-1619:4,11,
17,21,2520:1521:6,13,1622:5,12
23:4-6,8,10,12,15,2224:1625:2,13,
18,2226:12,1627:3,18-19,2428:1,4,
7,11-12,14,16,2129:6..7,13,17,2030:
8,18-1931:4,10-1132:6,24-2533:3,
9,13,20-2134:2335:3,2436:8-9,13,
16,20,23372-3,6,11-12,14,20,2538'
1,9-10394,11,15,21,2340:3,5,9-10,
17-19,2141:21-2242:2,13,20,2543:
2544:1,6,1346:11,20-2347:10,12-
13,18-1948:849:1,13 50:5,7,9,15-
16,19-20,2251:2,2552:1,3-4,2453:
4-555:21564,9,13,22-2357:10,13,
16-17,21,24-25585,14-1559:5,18
60:3,9-14,17,2561:3-4,7,9,11,15,22-
2362:5,14,16,24-256314,16,23-24
64:9-11,14-16,20,23651,4-6,10,17
66:4,7,10,18,20,22-23,2567:1-2,17,
21-22,2468:3,6-7,16,2369:5,8,10,
18,2170:8-9,14,18-19,2371:2,10,15,
18 , 20 , 24 - 2 5 72: 1 , 4 , 6 , 20 , 23 - 24 '/3: 1 ,
3-4,10,20,22-2374:3,9,16,2475:15,
2376:2-3,5,8,13,18,20-21,23-2577:
1,6,11,14,19-20,2378:3,10-11,16,25
79:1-2,7,10,15,21,23-2480:2,5-7,9,
12-14,17,19,2581:4-6,14,17,2182:12
That's
[361 6:77:198:13,1511:1513:414:
1315:2317:14,1718:1-230:21,25
33:235:138:641342:16,2146:14,
2552:454:1655:20582163:164
2165:1468:2469:1972:2474:976:
3 77 7-8
The
[724J 3:5,7-8,10,12,16,204:7,10-11,
13,22,245:1,3-5,811,17,256:1-5,
17-18,21,2471-2,6,8,11,15,18,24-
23811,10-18,20-21,249:610:2-4,6,
9-11,19-22,24-2511:2,5-7,10,12-13,
19,21,23-2412:1,5,8,14,17,21,2313:
4,6,8-9,11..12,19-2514:1,5,9-10,12,
17-19,22152,4-7,9-10,19-2116:6,9,
13,15-16,18,20,22-2417:1,4,7-8,14,
16,22,2518:1,5,9,11,14-15,17,20,23-
24191,10,12,14,16,20-2120:4,22,
2421:2,9,17,24222,4,6-e,10,18,23
2311,13,1524:2,9,1..1,19,23,2525:3-
4,8,11-13,10264,10,14-15,21-22,24
27:14,16,21-22,2528:1-3,5,7,9,12,
14-20292,4,7,11,15,17.2130:12,14,
19,25315-6,10-11,14,16,18-19,21-
22,2532:4,6,8,11,13-14,18,20,2433:
8, 10, 12 - 13, 15, 17- 18,21, ;J 3,25 34: 1- 2,
15,17,19-2435:536:4-5,7-9,16378,
11-12,14,17,20,2538:3-4,6,8-12,14,
17,21,2539:2-3,5-6,17,19-21,2440'
1,4,6-7,9-10,12,14-15,21,24414,10,
13,16-18,2242:3,5,15432,5,7,9,11,
13,18,2144:5-6,16,19,22,25453,5-
6,8,10,15,1746:9,12-13,16,18.23,25
47:5,7-8,14,18,20,22-24 -18:3-7,10,
12,17-18,22-2449:1,4,9-10,12-15,18,
2050:4-5,7-9,11-13,15,17-18,20,24
51:6-7,10-11,15,19,24-2552:6,9,12-
14,17,21-22,2453:4,9,15,20-21542,
5,9,11,14,17,22,2455:3-4,7,12,16,
19,2356:1,9,20,22,2557:7,11,18,21
58:1,8,12,14-17,20,23,2559:7,11,15,
19,2260:9,2461:3-4,18,21,2362:3,
8-9,20-21 63:4,9-10,12,16-2..7,20-21,
23,25647,9-10,14,2165:1,3,10,12-
13,15,23 66:1,3,13-15,18-19,22 67:5,
12-13,16-17,19,22-2368:11,15-21,24-
25691-3,6,13,17-18,23,2570:1,4-7,
11-12,18,2071:9,20-21,2372:1,4,7,
10,12,17,23-2473:2-5,7,13,17-18,23-
247410,12,15,18,25753,5,8,10-12,
14,17,20,23,2576:1,4,6-7,9-12,14,
16,22-2477:2-3,6,8-10,12,14-16,24
78:2,7,9,14,18,2479:4-5,7-9,11,13-
15,17,21,2580:1,9,13,15-18,20-21,
2381:2-3,7-8,11-12,16-17,23-2482:
1,5-7,9,12,14
Their
[5] 48:1,3632266:1175:21
Them
[11] 8:109:2113:436638:2341:6
62:765:567:13 71:7
Themes
[1] 61:7
Then
[17] 6'12869:5,9,2411'1014:7,
1332:1334:2039:2156:676:7,9,21,
2480:13
Therapeutical
[2) 21:930:24
Therapies
[1) 37:13
Therapist
[2] 7:24 31:22
Therapy
[18J 13:20295-658:5,8,1062:16
63:14-1566:369:8,2070'10,21,24
71:1676:1579:14
There
[61J 3:186:1,227:128:109:1512:
415:216:13 18:13 19'12112,1522:
425:727:2328:1034:537239:13
41:5,12,1642:744:10,1245:1746:
11,2347:7,2457:5,9,1258:2363:12,
21-22,2561:7,22-2365:2466:570:9,
2571:21,2472:6,18,2273:1,13,16
74:2,975:1476:778:257920
There's
[12) 13:118:947:659:265:1466:6
69:2570:2-374:980:1981:24
Therefore
[I] 80:17
These
[7J 423111115:2,1128253424
80 15
They
[22] 7:2027:828:20 30:S 39:19,22
47:1049:1,1357:9,16,19 'cl:6 64:15
68:173:2274:379:15,22 eO:20 81:
21, 23
They're
[4) 3:1868'1873:2074:25
Thing
[5] 28:1641:16-1747:1965:10
Things
[12J 8:49:2010:913120:20,2225:
1226:1228:2241:2278:879:9
Think
[45J 18:2526:1227:11-12,1829:1,
1141:942:244:1745:5,1047:1,7,
2557558:160:11,2561:5,11,1462'
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Thinking
[ 1 ] 65; 6
Third
[1] 54:24
Thirty
[lJ 35:17
Thirty-three
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This
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Though
[3] 13:1642:376:16
Thought
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Three
[4j :3::' 35 ..l.' 'i2:7 74:11
Through
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4;2:1: 52 11 55:18 60:15
Thursday
[3 11952:115918
Time
[42J 3:55:226-18-197:2,68139:
616:8,1619:222:228:11,14,20,23
3320382340:3,541:1046:1947:8
53:560:761:162:3,14,1865:14,16
66:1,1468:970:2571:2,2072:3,7
73:7740476:22
Times
[14] 78,1610:1811:116:1325:7
5619,216014,2161:23,2562:2677
Timing
[ 1 -'.J 1
To
[497 215:8,13,18196:18,20,23-
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21 18,13,21-2238:7,10,19,24-25
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Today
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Tone
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Took
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Total
: 1 J
Totally
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Transfer
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22
Treat
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Treating
[3J 29:765:973:24
Treatment
[85] 3:613:115:1617:5-618:626:
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5372339:2-3,2540:541:1242:9
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Treatments
[8] 31:20589,20-21,2367:1674:2
77: 19
Tried
[3] 17:13,2078:8
Trigger
[lJ 80:13
Triggered
[2] 28:9,25
Triggering
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True
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Try
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Trying
[6J 25:1127:1244:746:252:1860:
13
Tube
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Tuesday
[,-J 28:16
Tumor
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Turn
[ 1 J 41: 4
Twelve
[ 1 J 68 - 8
Two
'231 4196:2123:2224:827:1028:
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Two-page
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Type
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Types
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Typical
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Typically
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Uh
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Ultimately
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Unable
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5
Uncommon
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Unconscious
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Under
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Understand
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Understanding
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Understands
:lJ 31:25
Understood
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Undertaking
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Unit
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University
:1] 55:11
Unless
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Unresponsive
[1] 67:25
Until
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Unwillingly
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Up
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Upon
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Upsets
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Urgent
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Us
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Variety
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Various
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Village
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Voluntarily
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13,2479:1
Wanted
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2246:1150-2562:678-3,12
Wanting
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Wants
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Warrant
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Was
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3,979:2480:10-1182:1
Wasn't
[ 1 J 28: 1
Way
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6":4-6662373:2379:6,23
Ways
[1 J 9: 7
We
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976778:11,2380:6,1481:19
We'd
[1 J 36: 5
We'll
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We're
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64:276:18
We've
i2] 9:1967:8
Wednesday
[2J 74: 19-20
Week
[4J 98-9591865:14
Weekly
[ 1 J 4: 2:0
Weeks
[9] 12:2'115:758:2362:'1,965:12,
1670:1375:1
Weeping
ill 41: 18
Weighed
[1] 9: 4
Weight
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81: 8
Well
[34] 4:226:167:3,1617:1736:3,12
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10 "0:7 62:11,23 64:12,25 65-23 66-
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1274:675:2276:1178:1481:11
Well-oriented
[ 1 J 7, 3
Went
[2J 81:21,23
Were
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66:267:15,2074:2,197811,2379:6
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What
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80 12 81 11,15
What's
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Whatsoever
[2J 23:1448:11
Wheelchair
[2J 6:18,23
When
[36J 50126:207:179:1811:1516:
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11
Whenever
[3J 41:1859:274:23
Where
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871:981:14
Whereas
[2J 7:2379:11
Whereupon
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1348:14,1849:2051:1652:753:2,7,
15,18,2454:1975:1282:1,14
Whether
[23] 10:7-817:618:419:126-1144-
8-945147:1049:1,1360:236324
78:9,1979-1880:10,2481:12
Which
[31J 3:97:229:710:10,1513:1414:
2,12,1821:2226:428:2537:738:7
50:656:20572258:1159-661:10
63:565:3,772:573:1478:4,13799
8012,2481:9
While
[3J 63:1878<1,23
White
Who
1:9J 4:2412::413:1922:5 24:2J
Ie 28 18 30-:;' 40:17 44:10 51:22 5-.t
23 12601863:2571:25722373-
281:18
Whoever
[1' 66 18
Whose
[3] :'2 4 42 8 58 ,
Why
[-t' :11818228:646::"4
Will
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60:2063:14,17,20,22
1977:2278:5,1679:1 -13
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( 5 C J 3 7
19 20,24
34 24 37
5119,21,
24 56 20
Willful
[1I 61:6
Willing
[3; 36 ::"5 37 :3 51 2
Willingness
[1] 36 13
Wills
[1 ;
Wire
[ :. : 2:;:
Wires
[1; 68:24
Wish
[3) 50:2160:1575:20
Wishes
(5J 23127542:2143:1946:22
With
[107: 415,18,20,245:176:8,237
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11 66::Q,lS,20 67:1,8 68 1,4,20
1(J,:4 71 6 72 17,23 73 13 74 :0,
778-9,1: 78 7 80 5,9
Withdraw
[ll 21:710:2161:15
Withdrawal
[11 56:17
Withhold
[2J 21:73023
Within
[8, 2= 8562562:8 6S:13 69:12
II-I:: 7-1. 10
Without
[4J 11:219:323:2:' :'3 21
Witness
[53J 3:1653,5,106:1,3,58:17,20
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9, ,23,25145,12,18 15:4,6,:0,2C
16 9,15,2C,23 17:16 18 17 22:6 2~
23,2525 4 2~ 16 33:15,18,23341
38 :1 39 19 40:1.6 50 2551355:3
64 9 75 :C
Witnessed
[4J 2212-13 24:8 60:18
Woman
7e:l? 79 6
Won't
18 : 5
Word
[2] 14 1C 64 '7
Words
[3] 2372J7613
Work
[.; J 22
6513732274:15
Worked
[2] ..;. :3 29
Worker
:5J 3164 9,11,18 40:1~
Working
[2] 7:2520::4
Worse
[ ~ J 63: 1
Would
:98J 3::'54:2,237;1211:1412:21
13:15 :4 22 :5:22 16:923:8,1025
182<58,1527:2528:129:634:2035:
li 362-3371341'18-194620,22
so 1,5521354:8,1757:13
4,~,:9 24-2564:11,15-1665:4,'7-
8663 2568 ]-4 7 6,R,:1,
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18- 4,2579:15,238 128:
Woul
.
t
[ 1] 7 J
Written
[3J 18:273:11 77 22
Wrong
[ 1 J 6: 10
x
X-ray
! 1] 14: 8
y
Yeah
[3] 29:1264:269:12
Year
[3J 6:467:1869:13
Years
[11] 414,196:2135:2341:2342:19
43:256:1562:10-1170:17
Yelled
[lJ 78:23
Yelling
[:J12:12
Yes
,791 31':0,195:5,248:209:111:8,
18,2312:10,16,1914:516:1517:10
18:1819:6,920:2,5,10,16,212L1,
1522:2023:4,2424:5,7,11-12,2125:
4,10,17,2126:227:4,728:1429:12,
2330:2,7,2131:2,2132:7,1733:2
34:836:1,11,14,1837:5,10,15,2438:
1139:10,1242:14,1745:1502351:
954455:7,1056:757:1159:1771:
1972:2175:1181:9
Yet
[2J 63:973:8
You
[221] 3:1742,5,7,10-11,17,20 S:lG
6:7-87:148249:2,5-610:2,611:
10,12,14,18-19121,2113:1,414:3
17:13,2018:8,16-17,2419:7-8,2420:
11,1421:2-3,5,1623:20-2124:11,16,
21-2225:':0 27:10,12,18 28:7 29:1,",
10,1731:2432:13-1534:1935:11,13,
18,21,2436:7,12,15-16,19-2037:2,
13,20-21,2538:1,3,9-10,18-1939:1,
6,13-1540:4,9,2141:11,14,17-1842-
16,20,2543:944:8,10-11,14,17,20
45:36,17-19,21-22,2446:2-3,5,7,9,
11,1847:18,20,22-2348:749:1850:
2551:752:9,13,16,1953:1354:5,8-
9,11-12,14,17,2355:8,17,21,2556:1-
2,6,957:9,1358:1,759:5,9,14-16,
2460:18,2461:262:7-8,1163:16-17,
2164:3,6,8,12 6S:6 66:2,16-17,25
67-19,2268:1769:1770:2,1871:12,
1672:8,15-16,2173:4,18,2174:2,4,
6,1475:2,8-10786,18,2179:6,10-
11,16-1780:12,23
You'll
[lJ 68:14
You're
[101 17:1731:2542:8,1544:1745:1,
5,863:1081:14
You've
15125-7412344:1662:1063:13
Your
[701 4:2,216,1412:1316,218,18
19:721:924:1526:8,18-1927:429-
630:1031:17,1932:2334:5,1835:1,
11,1636:13,2437:3 40:S 41:9 42:19
43:1,9,2244:1345:12,1646:1647:2,
1748:250:2351:1,1352:2,5,1453:
10,13 54:1755:8,1856:2,1060:2-3
73:874:1.2275:7,9,19,2376:2577:
2,1679:581:13,15
Yourself
[2J 39:154:6
z
Zyprexa
[3] 1517,20
.
,
C E R T I FIe A T ION
I hereby certify that the proceedings are
contained fully and accurately in the notes taken by me on
the above cause and that this is a correct transcript of
same.
('.....
---Wendy ~,..
Of f i c i/ti.l
po~i e r
\,
The foregoing record of the proceedings on the
hearing of the within matter is hereby approved and
directed to be filed.
::' : L")
; ..;
\ ~)
i~_., C
Date
83