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John M. Hume, M.D., J.D.
875 Valley Street
Marysville, P A 17053-9792
717-957-2401
May 19,2008
J. Wesley Oler, Jr.
Judge, Cumberland County Court of Common Pleas
One Courthouse Square
Carlisle, P A 17013
RE: Roy Kennedy, An Alleged Incompetent
Dear Judge Oler:
I saw Mr. Kennedy for psychiatric evaluation related to incomptency on 05/09/08. In
conjunction with the evaluation, I also reviewed his medical chart at Forest Park, where he is
currently residing.
I explained to him the nature of the evaluation in that it did not have the usual confidentiality of
the doctor-patient relationship, and that I would be writing a letter to you regarding my findings.
Mr. Kennedy was agreeable to this, as he is quite set in his wishes to be released from his current
placement and return to Mt. Holly Springs, where he, in the past, had lived a significant part of
his adult life. When asked how long he had been in his current placement, he said, "I've been
here since months ago, not quite a year yet (he came to the facility on 06/22/07). I had a hip
replacement and came here to recuperate until I was well enough to get around. I can't
understand why I'm still here." When asked where he would go were he to leave here, he said, "I
would find myself a place. I've worked almost all my life from a room. I had no trouble
whatsoever in getting around." He was able to provide his last address in Mt. Holly Springs,
including the zip code. "I rented a room. I had a kitchen, and I made all of my own stuff."
When asked what explanation he had been given for why he was here, he stated, "They say it's
to protect myself. How they reached that conclusion, I don't know. It's got me really pretty
mad, disturbed, and it's affecting my health. I have to go to a doctor and have my condition
evaluated. I did with half as many medications as they're giving me in here. I don't understand
it. It's like a bomb dropped." When asked how he was getting along with other residents in the
locked area of the facility where he was staying, he stated, "I get along good with those who
have anything left in their mind to get along with." In terms of medication, he stated he was
taking any number of pills, but could not describe their names. It should be noted in reviewing
the chart there was no indication of medication teaching, which would have helped Mr. Kennedy
to have a better understanding of his medications and what they were for.
When asked regarding any family or relatives, he stated that he has only one child, who lives in
Flat Rock, MI. "I'm not a good correspondent, though she offered to visit me. It's a long trip,
and 1 couldn't see too much radically wrong for her to make the trip. Some of these people here
made it their business to correspond with her. I do have nieces and nephews, but I'm the
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RE: Roy Kennedy, An Alleged Incompetent
youngest of seven children in the family, and all the rest of them are gone now. There's just a
friend who visits me. No relatives come."
When asked when he had last seen a doctor, he stated, "I'm not sure exactly, but it was several
weeks ago. Dr. Dell, whose office is in Mt. Holly Springs, comes to see me. I keep asking when
he is going to release me. They don't think I'm able to go out on my own." When asked about
past employment, he stated that he was retired from Pittsburgh Plate Glass in Mt. Holly Springs,
which is where he would go to live. "I know quite a lot of people, and I do my banking there and
go to the stores. I used to take care of every bit of my finances. I had the nephew of a friend do
my banking, but I trusted him too much. {gave orders to get rid of him. I told him at the start
that I would give him so much, about $25.00 a week, and then with the price of gas I increased
that. He had the keys to my post office box. That's given him full control. I don't know what
he's doing with the interest off my CDs. Another thing is this place won't let me out without
Steve Pampeo going with me. I don't think he's putting all the money where it belongs. I'll eat
my words if that isn't true. This whole thing is affecting my health. When I call they ask who
and what, and then they cut me off. I requested to see my income tax papers, but they just said it
had been taken care of. I'm going to have Steve's work audited. His phone number is 608-1757,
and he lives on Geneva Drive. It's in the phone book. I'm going to charge the right person for all
this extra time I've been in here. It's hard to get to see the bills. In fact, I never see them. Steve
pays them and says they're in order. I was concerned about whether my CDs are being rolled
over properly. I'd been doing that for years. I have three or four bonds. I don't see the stuff.
Steve always says he's too busy to share the information with me. I'd have upped what I paid
him ifhe'd done what I told him. This has been a real dilemma."
He then volunteered spontaneously that his medical care was coming from Dr. Dell and Dr.
Daniels, a family practice in his former hometown. "Over two years ago the doctor sent
something in and I had my driver's license lifted because of medications the doctor had ordered
for me. I couldn't understand why. I thought of appealing it, but I felt { was near the end and I
could do that any time."
When asked if he had any sense of what his resources were, he stated, "{ think it's about
$375,000.00. I don't know now because Steve and this place have worked things over and I'm
sure it's less, but {have no idea. I've saved all my life, and {didn't need to worry about income.
My pension includes Social Security of about $882.00 a month and Pittsburgh Plate Glass of
$525.00, somewhere in that range, and interest from at least 3 CDs." He went on to indicate that
he does have a will with his only child as the beneficiary.
When asked what he thought should be done about his being kept in Forest Park, he stated, "It's
vicious and incredible. I can't even get out. I don't know what the state of my affairs is because
they don't show me any of the information." When asked ifhe had gotten in contact at any time
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RE: Roy Kennedy, An Alleged Incompetent
with the Area Agency on Aging, he stated he had the address, but had never called. The medical
records indicate an AAA ombudsman had been informed of his circumstances, but no action
appears to have been undertaken. "I kept waiting for a break to get out of this mess. It's a crime
what they've done. My attorney now is Loren Snyder. He hasn't contacted me since the trial.
Steve Pampeo sat with Steven Hogg at the last hearing." When asked about any information in
relation to the prior hearing, he stated he had no good place to keep it, so he gave it to the people
in the facility, and the documents were, in fact, found in the back of his medical chart.
When asked what he might have for three wishes, he listed them a (1) "I don't know. I take it as
it comes, but be out of here I would put on the top of the list." When asked if he would pay me
$25,000.00 to secure his release, he remarked, "There is always somebody ready to get their
hand in. I shouldn't have to buy my way out of here." I then explained to him that I was only
testing his susceptibility to being taken advantage of, and that the offer I made, if accepted, or
entered into, would be clearly unethical. He continued, "I could think of a hundred things in a
day, but it's very difficult when you're under tension. I've heard of people being detained. I'm
bottled up in here and I have no charges whatsoever."
I had Mr. Kennedy do a Bender Motor Gestalt. He has marked visual difficulties and a
significant intention tremor of the right hand, but despite this he was able to draw all nine figures
with reasonable accuracy compared to the copy he was looking at. It did take him longer than
usual, and he was aware when he had made errors. On three item intermediate recall after five
minutes he was able to get two of three items. When asked the similarity between a pear and a
banana he listed them as fruit. For the similarity between a bike and a truck he noted they have
wheels and require a driver. To the glass house proverb, he said, "Don't criticize anybody else."
He could correctly multiply 7 x 13 in his head for an answer of91. When asked to name the last
five United States Presidents in reverse order, he was able to get Bush, Carter, Bush, Reagan,
and note that the one before that was a Georgian. When given the name, Jimmy, he could
produce Jimmy Carter.
On mental status exam, Mr. Kennedy appeared as a neatly dressed Caucasian male wearing
glasses. There is marked reddening about his right eye, and he notes his vision is significantly
impaired in that eye. He also has a hearing aid in the right ear and heard the conversation
without difficulty. He was met in the day room of the facility and was able to lead me unerringly
directly to his room, where the interview took place. He was correctly oriented for time, place,
and person. Mood and affect were those of annoyance and distress about his long stay at Forest
Park. He complained that his eye problem has not been resolved and that he has developed a
tremor, most noticeable in the right hand. Speech was of normal rate and rhythm. He
emphatically denied delusions or hallucinations, but does have a somewhat angry and suspicious
attitude about the length of time for which he has remained in Forest Park. As review of the
record will reveal, this is probably reality-based. Fund of information is adequate. Recent
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RE: Roy Kennedy, An Alleged Incompetent
memory shows some mild impairment in that he cannot immediately recall everything he would
like, but after a few minutes is able to recall information. This is characteristic of individuals
with advancing age. Mr. Kennedy at this point is 87 years old. It is not reflective of the type of
memory loss seen in dementia of the Alzheimer's type or dementia secondary to cardiovascular
abnormalities. Suicidal or homicidal ideation is emphatically denied. Judgment is adequate.
Insight is fair.
DIAGNOSTIC IMPRESSION:
Axis I
Adjustment Disorder with mixed emotional features, anxiety and depression.
Axis II
No diagnosis.
Axis III
Status post total hip replacement of right hip, osteoarthritis, hypertension
controlled on medication, history of benign prostatic hypertrophy, diverticulosis,
cerebrovascular disease, chronic dizziness, spinal stenosis, degenerative joint
disease of the lumbar spine (observation of the patient walking would belie
significant issues about the latter three diagnoses of history),
Axis IV
Degree of stress moderately severe. Patient is confined in a ward with a
significant number of actively demented patients and has restrictions on his
freedom despite his wishes to the contrary.
Axis V
Current GAF = 65.
Review of the medical record includes a number of significant phenomena. On 09/27/07 there is
a letter from Steven Pampeo to Karen Hasco, the facility social worker, which states in part,
"With his anger issues, I feel Roy needs to stay at Forest Park, where he can be watched closely
and his medicine can be adjusted as needed. An earlier letter from Mr. Pampeo to Ms. Hasco,
dated 09/17/07 states in part, "As of 09/28/07, I will no longer be Mr. Kennedy's financial or
medical directive. Any outstanding bills will be forwarded to your office." There is also a
07/02/07 Power of Attorney document from Mr. Kennedy to Steven Pampeo for financial and
medical matters. On 12/20/07, Mr. Pampeo wrote to Ms. Hasco in part as follows: "I would like
to be informed again when Roy has off grounds appointments so that I can take him myself like I
did in the past. This will keep me informed of all of Roy's needs and keep the cost of the
monthly bill down." The records indicate that Mr. Kennedy had signed his own Living Will on
07/11/07, and a health care Power of Attorney to Mr. Pampeo on 07/11/07. Records indicate
additional diagnoses from admission to include anxiety on 06/24/07, history of cerebrovascular
accident in 1997 noted on 09/18, as well as a history of transient ischemic attacks, status post
prostatectomy, cholecystectomy, lithotripsy, inguinal hernia repair, and left eye cataract surgery
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RE: Roy Kennedy, An Alleged Incompetent
(it is his right eye which is problematic). On 10/28/07 a diagnosis of depression was included
and on 09/28/07 diagnoses were made of psychosis and ambulatory dysfunction, weakness, lung
abnormality not further specified, and dysphagia.
As nearly as could be determined, medications being taken by Mr. Kennedy as of May, 2008
included famotidinel0 mg twice a day (Pepcid AC), Aricept 10 mg at bedtime, Celexa 30 mg
daily (frequent side effects ofthis medication are impaired concentration, amnesia, apathy, and
aggravated depression, even though it is an antidepressant), Trazodone 50 mg at bedtime, Altace
5 mg daily, which had earlier been 5 mg twice a day but there are side effects of hypotension and
renal damage when combined with non-steroidal anti-inflammatory medications, Atenolol25 mg
twice a day (this is a Beta blocker for blood pressure), Seroquel25 mg twice a day (there is a
black box warning in regard to giving Seroquel to patients with dementia that it doubles the
likelihood of heart attack or stroke), Aggrenox25/200, which is a combination of aspirin and
Persantine for antiplatelet activity (side effects of this may include agitation and low blood
pressure), lorazepam 0.5 mg every 6 hours as necessary for anxiety (in the elderly particularly
this may cause confusion and memory loss), bisacodyl suppositories as necessary to help with
bowel movements, APAP extra strength 500 mg two as necessary, not to exceed 4,000 mg in 24
hours (The standard of care is not to exceed 3,000 mg per 24 hours in order to avoid potential
liver problems), APAP 325 mg every four hours for temperatures over 101, and Milk of
Magnesia 5 ml for constipation.
Progress notes indicate on 11/25/07, "Doing okay. Calm behavior. Ambulatory. No pain.
Monitored by psychiatry for dosing of antipsychotic and antidepressant. Blood pressure stable on
current medications. No symptoms of upper respiratory infection. Generally presents with
increased confusion. On 12/14/07 he is noted to be "Doing well. Continues to lobby to leave
facility. Seen by psychiatry and psychology, who concur regarding patient's ability to
comprehend care needs. On 02/22/08 he is described as "Doing well. Fewer episodes of
agitation related to desire to leave and live independently. Requires close supervision for
monitoring of medical problems and prevention of deterioration in activities of daily living.
Blood pressure stable. On 03/25/08, "Ambulatory. No cane or walker needed. Still wishes to
leave. Psychiatry increased Seroquel to 25 mg twice a day. Poor insight into care needs. Eating
and dressing well. Not depressed-appearing. No anxiety noted. Hip replacement functioning
well. Not combative. Requires long term care due to care needs and medications required to
control agitated paranoid behavior." 'Fhere is no description, however, of agitated paranoid
behavior other than his occasionally loud remonstrances regarding his desire to leave the facility.
On 04/20/08, "Roy again lobbies for independent living." Later in that note it states, "I feel his
ability to live safely independently would be short-lived." Then again later on that date
"Reviewed psychiatric notes from their previous visits. Continue current medications and unit
controlled environment." Also of significance was a note of 09/1 0/07 relating to delirium being
resolved, but with increased anxiety and a diagnosis of cardiovascular disease with dementia. In
looking at the chart from 04/25/08 through the date of this evaluation on 05/09/08, only one
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RE: Roy Kennedy, An Alleged Incompetent
blood pressure was taken during that interval and the only other vital sign taken was a
temperature, which clearly suggests there are no pressing medical issues going on with this
patient. Furthermore, with a history of alleged dizziness and problems with his gait, the standard
of care would have required taking sitting, then standing blood pressures, which was not done.
Another note of 03/25/08 notes patient was seen by psychologist and found not able to make
decisions in his own best interest. The author was Karen Hasco, social worker. On 03/12/08,
there was a psychiatric consultation done by Melinda Easley, Certified Registered Nurse
Practitioner, but signed by Dr. Herbert Myers six days later regarding a 30-minute session. The
consult does not describe issues that are actually involved with any degree of understanding. On
02/13/08, there was a psychiatric meeting note by Melinda Easley, signed by the doctor on
02/20/08, which notes dementia with disturbed mood and behavior, though anger is legitimate.
An earlier psychiatric note of 01/16/08, again by the nurse and signed by the doctor eight days
later, describes depression not otherwise specified, dementia, bored and frustrated by
confinement. On 12/19/07, a note signed by Doctor Myers on 12/24/07, states that with patient
and Power of Attorney Steve, "He (patient) continues to be upset at not being able to leave and
go for a walk." Neuropsychiatric consult by Christopher Royer, a psychologist, on 11/08/07,
states, "Lacks capacity to make decisions in his own best interest". However, he did not discuss
the fact the patient was taking 11 medications, many of which cause the various complaints as
side effects of the medications that are noted. This report certainly was not comprehensive. The
initial psychiatric evaluation of Mr. Kennedy on 10/24/07 by Melinda Easley and signed by the
doctor six days later, was very sketchy in its specifics.
Of considerable concern, are the results of a Mini Mental Status Exam done on 07/15/07, when
Mr. Kennedy scored 27/30 and again on 04/07/08, in which he scored 26/30. The cut offline on
this particular evaluation for dementia is 23 or less, so that the studies being done do not agree
with the diagnosis which has been rendered. Furthermore, a decrease of one over the course of
nine months clearly does not describe the usual pattern seen in persons who do, in fact, have
dementia.
In conclusion, it is my opinion, with a reasonable degree of medical certainty, that Mr. Kennedy
has a reasonably adequate understanding of his financial resources and circumstances, and that
his health needs can be met at a substantially less restrictive setting than a locked ward at Forest
Park. Medication education with a daily three part pillbox would, with minimal supervision,
enable Mr. Kennedy to take his medication in accordance with the doctor's recommendations.
Outpatient treatment in a mental health clinic would clearly meet Mr. Kennedy's present mental
health needs. I could find no indication of any efforts to make attempts to help Mr. Kennedy
reintegrate into a less constricted and controlling environment than that in which he finds himself
at present, despite the fact that he has openly expressed his desire not to be at Forest Park. The
diagnosis of dementia is not adequately documented within the chart which I reviewed.
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RE: Roy Kennedy, An Alleged Incompetent
It is my conclusion, in summary, that Mr. Kennedy is capable oftaking care of his own finances
with minimal assistance and that his health needs could readily be met on an outpatient basis,
and that continued confinement at Forest Park is not in his best interest.
Thank you for the opportunity of evaluating Mr. Kennedy. If you have any questions, please do
not hesitate to be in touch with me.
Very TrulyYours,
~
John M. Hume, M.D., J.D.
JMH/DS-kts