HomeMy WebLinkAbout01-04-07
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Joseph A. Ricci, Esq.
Pa. ID 49803
Lavery, Faherty, Young & Patterson, P.C.
225 Market Street
Suite 304
Harrisburg, PA 17101
(717) 233.6633
Counsel for Carlisle Regional Medical Center
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: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY PENNSYLVANIA
IN RE: John Brennman
: DOCKET NUMBER:
: EMERGENCY GUARDIANSHIP
EMERGENCY PETITION FOR PLENARY GUARDIANSHIP OF THE PERSON
AND ESTATE
AND NOW comes, Carlisle Regional Medical Center, by and through its counsel,
Lavery, Faherty, Young & Patterson, P.C. by Joseph A. Ricci, Esquire, and requests that
this Honorable Court enter an Order granting an emergency plenary guardianship of the
person and estate of Mr. John Brenneman for the following reasons:
1. The alleged incapacitated person is Mr. John Brenneman, an adult male aged
80.
2. M,.. Brenneman is currently a patient in the Intensive Care Unit at the
Carlisle Regional Medical Center.
3. Prior to his hospitalization, Mr. Brenneman was receiving care at the Forrest
Park Health Center, 700 Walnut Bottom Road, Carlisle, Cumberland County,
Pennsylvania.
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4. Mr. Brenneman has no known relatives.
5. Currently Mr. Brenneman is receiving medical services at the Carlisle
Regional Medical Center, 45 Sprint Drive, Carlisle, PA 17013.
6. Prior to his admission to the hospital, Mr. Brenneman was receiving medical
care at the Forrest Park Health Center.
7. Prior to his admission to the Forrest Park Health Center, Mr. Brenneman
was a residing at 17 Shirley Lane, Boiling Springs, Cumberland County, Pennyslvania.
8. The Petitioner requests that this Honorable Court appoint Mr. Richard A.
Hess, 15 Shirley Lane, Boiling Springs, Cumberland County, Pennsylvania as temporary
guardian of the person and estate of Mr. Brenneman.
9. Mr. Richard A. Hess is the long time next door neighbor of Mr. Brenneman
and has been his closest friend for 19 years.
10. Mr. Richard Hess has been providing financial assistance to Mr. Brenneman
since his hospitalizations.
11. Mr. Richard Hess has been authorized by Mr. Brenneman to receive
Privileged Healthcare Information. See Affidavit of Dr. Donald Kovacs attached hereto as
Exhibit "A."
12. Mr. Richard Hess does not have any interest that is adverse to the interests
of Mr. Brenneman, the alleged incapacitated person.
13. Mr. Richard Hess has agreed to accept appointment as Guardian of the
Person and Estate of Mr. John Brenneman, the alleged incapacitated person. See Affidavit
of Richard A. Hess attached hereto as Exhibit "B."
,1 ,l
14. The emergency plenary guardianship of the person and estate of Mr. John
Brenneman is necessary for the following reasons:
a) Mr. Brenneman is an elderly gentleman who is currently a patient in the
Intensive Care Unit of the Carlisle Regional Medical Center who is in an
unconscious state and is unlikely to recover the ability to act on his own
behalf. See Affidavit of Dr. T. Alex Boshnakov attached hereto as Exhibit
"C."
b) Mr. Brenneman has no known family members.
c) The Forrest Park Health Center has relinquished responsibility for the
care of Mr. Brenneman upon his admission to the Carlisle Regional Medical
Center.
d) At this time, there is no other reasonable alternative to effect the proper
care of Mr. Brenneman besides the appointment of a plenary guardian of the
person and estate.
e) Mr. Brenneman suffers from an acute metabolic hypoxic encephalopathy
following a cardiac arrest which occurred at the Forrest Park Health Center.
As a result of the hypoxic encephalopathy, Mr. Brenneman will potentially
suffer from numerous medical complications, which will require an ability to
understand the nature of the complications and how they will be treated.
The treatments necessary will include the need to provide informed consent
to permit the medical treatments. Moreover, the medical condition of Mr.
Brenneman is one in which he may desire to withhold medical care since the
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likelihood of recovery is extremely remote absent a medical miracle. See
Selected medical records attached hereto has Exhibit "D."
f) Mr. Brenneman is unable to speak due to his comatose condition;
therefore, he is unable to participate in medical decision making on his own
behalf. See Affidavit of Dr. T. Alex Boshnakov attached hereto as Exhibit
"C."
g) Mr. Brenneman has previously indicated, on numerous occasions, to his
primary care physician a desire to refuse care suggested for purposes of
diagnosing and treating potentially life threatening illnesses such as prostate
cancer, colon cancer, and chronic illnesses such high cholesterol.
h) Mr. Brenneman has indicated to his friend and neighbor, Richard Hess
that he would not desire to receive medical treatment that would merely
prolong his death and not effect a cure. See Affidavit of Richard A. Hess
attached hereto as Exhibit "R"
i) Without the appointment of a guardian, the medical staff of the Carlisle
Regional Medical Center is unable to properly effectuate the wishes of Mr.
Brenneman and provide reasonable and necessary medical treatments to
properly care for Mr. Brenneman, since the patient is unable to provide the
necessary consents for his continued care.
11. A plenary guardianship will permit the appropriate decision-making to take
place in the short term and allow for the wishes of Mr. Brenneman to be carried out.
WHEREFORE it is respectfully requested that this Honorable Court issue an
Order appointing Richard A. Hess, Boiling Springs, Cumberland County, Pennsylvania as
fa ..1
guardian of the person and estate of John Brenneman for the purpose of providing medical
decision-making authority.
Lavery, Faherty, Young & Patterson, P.C.
Date: ~ ~I 07
..
AFFIDAVIT OF DONALD J. KOVACS. M.D.
AND NOW this ~day of January 2007, I, Donald J. Kovacs, M.D., do hereby
swear and affirm:
1. I am a physician licensed to practice medicine in the Commonwealth of
Pennsylvania.
2. My medical practice IS limited to the specialty of Family Practice and
Geriatrics.
3. I am the primary care physician for Carlisle Regional Medical Center patient
John Brenneman and have served in that capacity since 1989.
4. Mr. Brenneman became a patient of the Carlisle Regional Medical Center on
December 28, 2007.
5. Mr. Brenneman is a patient suffering from severe hypoxic encephalopathy as
a result of cardiopulmonary arrest which occurred at the Forrest Park Health Center.
6. Mr. Brenneman is currently comatose and requires mechanical life support
including ventilatory support.
7. Mr. Brenneman has indicated on numerous occasions that he did not wish to
receive care which would prolong his dying and not effect a cure.
8. Mr. Brenneman has, on numerous occasions, refused diagnostic tests to
identify preventable and treatable illnesses such as prostate cancer, colon cancer, and
chronic illnesses such as high cholesterol.
9. Mr. Brenneman's refusal of care is rationally based upon his realization that
he has no family to support, that such illnesses if treated could result in prolonged survival
with a poor quality of life which would be hampered by potentially serious disability.
,
10. Mr. Brenneman has no family. He is widowed. He has no children. He was
an only child and has no siblings. Both of his parents are deceased.
11. Mr. Brenneman has indicated that he has a close friend by the name of
Richard Hess who has been permitted to receive Private Healthcare Information.
12. Mr. Brenneman has indicated that Mr. Hess is a neighbor who has been
providing assistance with financial matters when he has been unable to handle those
matters himself.
13. I had occasion to meet Mr. Hess while Mr. Brenneman was hospitalized in
early December 2006 and found Mr. Hess to be a responsible individual to who expressed a
desire to provide what ever assistance was required for the benefit of Mr. Brenneman.
14. Mr. Brenneman's current medical condition prevents him from being able to
provide his informed consent to any medical care which he may require.
15. Mr. Brenneman's inability to communicate prevents the medical staff at the
Carlisle Regional Medical Center from effectuating the wishes of Mr. Brenneman.
Respectfully submitted,
Date: Jl Lf 10]
~ J l~ MO
Donald J. Kovacs, M.D.
Sworn to r:.:nd !f~rtbecl
of 2~.
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AFFIDAVIT OF RICHARD A. HESS
AND NOW this ~ day of January 2007, I, Richard A. Hess., do hereby swear and
affirm:
1. I am adult individual who resides at 15 Shirley Lane, Boiling Springs,
Cumberland County, Pennsylvania.
2. I am the next door neighbor of John Brenneman, currently a patient in the
Intensive Care Unit of the Carlisle Regional Medical Center.
3. I have known Mr. Brenneman for 19 years.
4. Mr. Brenneman is a widow who has no children, no siblings and no known
extended family.
5. Mr. Brenneman has authorized me to receive Private Healthcare Information
from his primary care physician, Dr. Donald Kovacs.
6. Since Mr. Brenneman became ill in December of 2006 I have been authorized
to assist Mr. Brenneman with his financial matters and have reviewed his mail, deposited
checks and assisted with the payment of bills.
7. Since Mr. Brenneman became ill and was a resident at the Forrest Park
Health Center I was instructed to contact his attorney, Hamilton Davis, Esq. in the event it
was necessary to obtain a copy of Mr. Brenneman's will.
8. I have been advised that representatives of the Carlisle Regional Medical
Center have been told by Attorney Davis that the entirety of Mr. Brenneman's Estate is to
be left in trust for the University attended by Mr. Brenneman's deceased wife.
9. I have no financial interests in the Estate of Mr. Brenneman.
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.
10. As Mr. Brenneman's closest friend, I am in the best position to be able to
respond to inquiries about Mr. Brenneman's medical care.
11. As Mr. Brenneman's closet friend, I am in the best position to see that Mr.
Brenneman's wishes are carried out.
12. Mr. Brenneman has on numerous occasions had conversations with me in
which he expressed his wishes that he not receive medical treatments which would only
prolong his dying and not effect a cure.
13. I am willing to accept an appointment from the Court of Common Pleas of
Cumberland County as Guardian of the Person and Estate of Mr. Brenneman.
Respectfully Submitted,
Date: ~VOJ~ ~ ,2;JOl
~J~a,~
. chard A. Hess
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AFFIDAVIT OF T. ALEX BOSHNAKOV. M.D.
AND NOW this ~ day of January 2007, I, T. Alex Boshuakov, M.D., do hereby
swear and affirm:
1. I am a physician licensed to practice medicine in the Commonwealth of
Pennsylvania.
2. My medical practice is limited to the specialty of Internal Medicine.
3. I am one of the attending physicians for Carlisle Regional Medical Center
patient John Brenneman.
4. Mr. Brenneman became a patient of the Carlisle Regional Medical Center on
December 28, 2007.
5. Mr. Brenneman is a patient suffering from severe hypoxic encephalopathy as
a result of cardiopulmonary arrest which occurred at the Forrest Park Health Center. This
condition renders Mr. Brenneman severely disabled with significant and irreversible
damage to the brain.
6. Mr; Brenneman is currently comatose and requires mechanical life support
including ventilatory support.
7. Mr. Brenneman is unable to communicate and therefore cannot meaningfully
participate in decisions about his medical care.
8. Mr. Brenneman currently requires breathing support with a ventilator;
accordingly, he is currently in need of the use of an endotracheal tube.
9. The long-term use of an endotracheal tube will cause the patient to suffer
painful pressure ulcerations of the throat and lips.
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.
10. Painful pressure ulcers caused by an endotracheal tube can be avoided if the
patient undergoes a surgical procedure known as a tracheostomy.
11. A tracheostomy involves the surgical entry into the trachea to allow the
placement of a breathing tube.
12. A tracheostomy is a surgical procedure which requires a patient's informed
consent.
13. Mr. Brenneman's medical condition prevents him from being able to provide
his informed consent to any medical care which he may require.
12. Failure to obtain the necessary consents for surgical intervention will subject
Mr. Brenneman to painful and unnecessary pressure ulcers of the throat and lips.
13. Mr. Brenneman is unable to obtain adequate nutrition without the surgical
insertion of a feeding tube.
14. Insertion of a feeding tube IS a surgical procedure which requires the
patient's informed consent.
15. Given Mr. Brenneman's current medical condition, the prognosis is grim and
further interventional care will not result in a cure of the patient's condition but will only
prolong his dying.
16. Information provided to the hospital by Mr. Brenneman's pnmary care
physician, Donald Kovacs. M.D. suggests that Mr. Brenneman would not consent to further
interventional care.
17. Without proper authority the Carlisle Regional Medical Center is required to
continue to provide care that the patient may not desire and for which the patient may not
have provided his consent.
, '
18. Mr. Brenneman has no family. He is widowed. He has no children. He was
an only child and has no siblings. Both of his parents are deceased.
19. Mr. Brenneman's current medical condition prevents him from being able to
provide his informed consent to any medical care which he may require.
20. Mr. Brenneman's inability to communicate prevents the medical staff at the
Carlisle Regional Medical Center from effectuating the wishes of Mr. Brenneman.
Respectfully submitted,
Date:
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. .
71796033r"'.':.'"
"~I
. ... ../
CARLISLE
CE
014pm. 12-1
3/29
BRENNEMAN. JOHN
MS2 0205 W
CHIEF COMPLAINT: Dysphagia.
HISTORY OF PRESENT ILLNESS: This 80-year-old white male presents to the emergency room with
progressively worsening dysphagia, nasal congestion, shortness of breath, progressive worsening
hoarseness, poor appetite, and weight loss. He was recently in the hospital where biopsy of the
nasopharyngeal mass was obtained at that time. Biopsy report was apparently negatiVe but etiology of the
mass was not clear at this time. He was sent home from this admission and has persisting and worsening
symptoms at this time.
PAST MEDICAL HISTORY: Past Medical History is positive for polio at the age of 20. He also carries
the diagnosis of hypertension, benign Prostatic hypertrophy and peripheral vascular disease.
PAST SURGICAl HISTORY: Past Surgical History is positive for left Inguinal hernia and repair and
TURP. He also had biopsy of his throat done.
MEDICATIONS: Aspirin, Augmentin, and Chlorthalidone.
AlLERGIES: No known drug allergle..
951466
SOCIAL HISTORY: He is a nonsmoker, nondrinker, lives alone.
FAMILY HISTORY: FomBy Hisloly Is not slgni-'L His father had mlOCallllallnlaralon at lI1e age of 52.
REVIEW OF SYSTEMS: He thinks that he has a right Inguinal hernia noted. He also has significant
bruising of his lower abdomen after admission from before and he states that he has had foot pain
bilaterally for awhile and this has progressively Worsened. He denies any chest pain or shortness of
broall1. Denies any COUgh Of whoe2lng. Ha denies any paJpilatJons. Ha -. any na__ _ilfng,
constipation. or diarrhea, heartburn, indigestion, black or blOOdy bowel movements. Denies dYSUria,
frequency, or urgency since the surgery to his prostate.
GENERAl- His exam reveals him to be alert and oriented x3 in no apparent distress.
VITAL SIGNS - Blood P......... is 143/71, I8OplraIo,y rata 18. W8/ght 185 POUnds, lamp _ 95.8F, _
84.
PtfYSICAL EXAM-NATION
HEENT - Head was normocephalic. Eyes - PERRlA, EOMI. Ears _ no injection or bulging of the
tympanic mombtanos, canaIa ora patent. - - MlIdIy boggy turblnafos. Throat _ wlIhcut slgnillcant
injection. Mouth was without leSions. Dentition was stable.
NECK - Supple aIIhough Ihor. was some dacreasad range of motion of hb neck bilalarally. No neck vain
distention, no bruits or thyromegaly noted.
CHEST - Clear to auscultation.
BACK - Was Positive for somewhat significant kyphosis. .'
HEART - Regular rate and rhythm with ectopy at times, no murmurs or gallops.
Page 1 of2
THIS DOCUMENT IS NOT A LEGAL COpy UNLESS SIGNED.
CARLISLE REGIONAl MEDICAl CENTER
HISTORY & PHYSICAl EXAMINATION
9356223
BRENNEMAN, JOHN
MS2 0205 W 951466
12/10/2006 09/10/1926
KOVACS, DONALD J
, '"
71
CARLISLE MED~CE
4/29
028pm 12-1
.
BRENNEMAN, JOHN
MS2 0205 W
951466
ABDOMEN - Abdomen was ncntender, no masses no hepatosPlenomegaly. Bowel sounds were heart
Ihrough"", Lower abdomen ~ a lefI inguinal hernia repair scar and right Inguinal hernia. He has a
significant amount of bruising across his lower abdomen.
EXTREMITIES - 10_ extremJlies reveal full range of mollon of his joints. There _ -._ pU'ses
ot the do....ts pedla and PllSIeIior Ubia/ puis.. with significant edema of both lower Oldremllies, right
worse than the left, significant onychomycosis and on the right there were erythematous cold toes, on the
left there were warm erythematous toes noted. Both were mildly tender.
SKIN - Without rashes, lesIons and breakdown.
NEURQ - Cranial ...... II through XII were _. No focal neuroJoglc signs were noted. No weakness
or decreaSed sensation of the upper extremities. There was generalized weakness of both lower
extremities bllaterany.
ASSESSMENT:
1. N_i)'ngeaJ m... with aSSOCiated d)'Sphagia, hoarseness. nasal oon_. WOVlt 1000.
2. H_Ia. etloIogy ie uncerlain. Could this be asSOCIated with the m.... We... goi1g 10 gel
a CT of the chest, CT of the head.
3. Ilysphagla. PossIbly there ts dysPhagia bejond the n~I mass. th.......... we will
consult gastroenterology and also go ahead with barium swallow.
4. He has the hIsIoIy ofhypertensJon, benign Proslatlc ~y, signlflcar,1 P8!fphera,VllSQJ/ar
- WIth ""YChom~.. of the - exlramllies is noted. At this polnt we will go ehead with
his workup as ordered and replace his sodium and watch him closely.
JAP/nw
0: 12/1012006 16:38:35
T: 12/1112006 06:51:19
C:
Joseph A. Pion, D.O.
Joseph A. Pion, 0.0.
Page 2 of 2
THIS DOCUMENT IS NOT A LEGAL Copy UNLESS SIGNED.
CARLISLE REGIONAL. MED'CAL. CENTER
HISTORY & PHYSICAL EXAM'NATlOlif
9356223
BRENNEMAN, JOHN
MS2 0205 W 951466
12/1012006 09/10/1926
KOVACS, DONALD J
717960339~.......~....W.\
. J ... (: ,':i~;~>;
,<,jill
CARLISLE
120 pm 12-14'20~
\iJII
8/29
BRENNEMAN, JOHN
MS2 0205 W
CONSULTATION TO:
ATTENDING PHYSICIAN:
DATE:
TYPE OF CONSULTATION:
Gregory l. lewis, M.D.
KOVACS. DONALD J
12/1012006
GASTROENTEROLOGY
951466
HISTORY OF PREsENT ILLNESS: This pleasant 80-year-old ll8n1leman was admilled to the Carllsla
Regional Medical Canter tonight by Dr. Pion because the pallenl has had a prog-lve .....throellOld
difficulty -1Iowing, -g and h__. Apparently th~ _ "-' many _ ago bol was
inleonillenl and has become m.... conslenl and _ in the IlI8lBeVetel -.. The_1lI1S
lhet he had polio in 1947 and since then he he. had Inleonittent hoersaness encI """"lng.
He had a '-1t admission one _k ego. He was admllled by Dr. Koliacs end seen by Dr. Ferrero.
lnnlelty Dr. Ferrero fell the _t had a mass at lhe bese at h~ longue bola biopsy was -1Ir1d felt
lhel he jusl has a 8InInge/y sI1Sjled uYUIe. He felt h~ fcceJ """" __ llOITIlal but he did feellhere was
muc:h erythema in lhe beck of h~ throat. He _1Iy lIrI10lged fer a video SWSlIowlng .tudy, Ihe resuHs
of which .... not known -- lhe - was p/eced on a _ diet by Ihe ._lhenIpIst. The
patient. '-r. lest night "-' to choke and had trouble breelhing IIr1d came to lhe OInBrgency room
today for his admission.
PAST MEDICAl.. HISTORY: Hi. pesl medical hlsby includes aloft inguineJ hem/a rape" by Dr. FrIk:hIey
In 2001. He had alrensurelhrel_1US8Ction In 2000. The _ been Ieklng ~ 25 mg deIy
for hypertension, baby aspirin daily.
ALLERGIES: He has no known drug allergies.
SOCIAL ffI8TORy: SOCIal h~tory ....... lhet he ~ .._ from lhe Air -.. He ~ a wfd-.- who"'"
in Boiling Springs.
FAMII. Y HISTORY: Family history .-.-~ lhet his father had a _ieI infardlcn at age 52,
REVIEW OF SYSTEMs: On - at _so the _I has _Ie dyspnea. related to """"Ing. He
hes no heattbum. no abdominal pain. nonneJ bowai Iunction. He has had a redUCed _ and weight
loss recenlly. He also has some eppe..., dlscomfort 0',,, his right Ingu/neJ .... _ he has a hem~
and is scheduled to see Dr. Hardesty for right inguinal hernia repair.
PHYSiCAl EXAMINATION: GENERAL - On physical """"'Inetion. the _t ~ In no scula distress. He
I. -... VITAL SIGNS - His 1em_1e ~ 97 ~ FeIvenheIt, ptJiso 87 per m"ute. ...pi'etory...
18 per m_. blood -.. 146/83. HEENT - Pupils. -.1llUnd encI end _ to light There Is no
cervlcel~. Toogue is moist CHEsT - Chest """'" Is cIeer. HEART _ HIlSlt """'" Is
regular _I a muonur. ABDOMEN - Abdomlnef exam .....,. .ome -.ym.... in Ihe right inQtdnej
..... of uncerlaln eti%uy. He - to ba"" a right Inguinal hamIe. Howe.er. ft ~ nonlandor. There ~
no <>rgan~ty. EXTREMITIES - Exlremity exam r_. no ademe or phlebltis. NEUROlOGIC _ He ~
oriented 10 person, place, and time.
DIAGNOSTIc STUDtEs: Delabese inclUde. hypona_ with a sodilJm 123 encl. chloride at 88 at
uncertain etiology. Liver functtons .... 1lClnneI. Albumin Is .Iightly low at 3.1. /iemogJobjn 13.8. whJte cell
count 10,100.
Page 1 of2
THIS DOCUMENT IS NOT A lEGAL COpy UNLESS SIGNED.
CARUSLE REGIONAL MEDICAL CENTER
CONSUL TATIO~
ASSESSMENT AND PlAN, I canad Dr. Fe..", who felt this _'. Problem .... not Predomlnantly_,
nose and throel. He did not h"", a m_. therefore. ... Petienl~ hoarsan_ end cho/dng may be POSI
9356223
BRENNEMAN, JOHN
MS2 0205 W951466
12/10/2006 09/10/1926
KOVACS, DONALD J
717960339~~
' ~... ~;"".;.~.;}i~
CARLISLE MEOrlfE
\'.. _ "" .,~ ',,;0
138 pm
12-14-20~.....{'t.'
~~
9/29
BRENNEMAN. JOHN
MS2 0205 W
POlio syndroma which is a syndrome where the pallent. distanUy 18Brs slier 8l<posure 10 IlOIlo. may
dllVe/op Progressive SW"OWIng diffICUIU... I cannollotal/y rule oula stricture of his esophagus and as
part of his video swallowing stUdy there may be images of his esophagus but' am uncertain.
I s_ reccnsultng lI1a speech lherapistlo get her OPinion. Tha paUont may need 10 have his
esophegeeJ anatomy and function Sludled further. I feel a neurolcgy -ueUon may also be holpM In
confirming postpollo syndrome.
He has hyponatremia. One wonders -lI1is is refatecflo _ diuretics or diet or even syndrome of
Inepproprlata AOH. I ..1 take the liberty of ordering some urine e/ectrotytes and a U""'lyols 10 look for
SPecific gravity. He may need a nephrOlogy consult.
Thank you.
GLUsap
0: 12/1012006 19:57:34
T: 12/11/2006 06:30:25
951466
C: Gregory l. Lewis, M.D.
KOVACS, DONAlD J
Gregory L. Lewis, M.D.
Page 2 of 2
THIS DOCUMENT IS NOT A LEGAL COpy UNLESS SIGNED.
CARLISLE REGIONAl MEDICAl CENTER
OONSUl TATION
9356223
BRENNEMAN, JOHN
MS2 0205 W951466
12/1012006 09/10/1926
KOVACS, DONAlD J
71796033
CARLISLE MEe)L CE
~
,~
1039 pm 12-14-
5/29
i ,~ ",
BRENNEMAN, JOHN
CONSULTATION TO:
ATTENDING PHYSICIAN:
DATE:
TYPE OF CONSULTATION:
MS2 0205 W
REASON FOR CONSULTATION: Dysphagia.
Mohammad K. Ismail, M.D.
Donald J. Kovacs, M.D.
12/11/2006
NEUROLOGIC EVALUATION
951466
HISTORY OF PRESeNT ILLNESS: Mr. B""'neman is an 80-year-old vary _ant genlleman for whom
I was con.ulted by Dr. KOVllCs for avaJuation for his dysphagia. The _ is a good hialorian 8l1d _rts
that he has dllllaAty with ~ ..... the age at 19 when he had polio that aIfoc:Ied his neck 8l1d
ahouIder m_. He recalled that he .... In th. Army and al that..... h. always had 11I1 issue With
SWallowing III1j/hlng blggeo-Ihan 88p1lfn l8b1et. He IIfoo llCknOWleciged W he was eick IhIs -. is
a_. He..ports that for the....1 "'" years his _is 98lOOg low and he cannot _loudly. He
has had mora dllllaAty with _ng and _ for the P8SI few months. The patienl_ seen by Dr.
Fa""", a few months ago llI1d at that .....th.... .... tha _fb/fIty of some masstha, .... 0llJl/0rad In tha
n~...... He has been OIled out for any """"'. He is _ -Ilted 10 the hOlpl/al for
evaluation of WOrsening dYSPhagia.
The - denies W he has double vision. He danles W he has droopy ayes or ex_ 8I1IOunt of
fallgu.. He has no numbo... or -,- or any other"..., of the body. He he. some dlfflc:ulty With
urination lII1d _ut.. this 10 - PmbIams. The _, danles any signiflcantlOO/ght Ioas or nigh'
sweats.
PAST MEDICAL HISTORY: Past Medical History is significant:
1. for polio at the age of 19.
2. history of hypertension,
3. history of benign prostatic hypertrophy, and
4. history of peripheral vascular disease.
PAST SURGICAL HISTORY: Past Surgical History is significant for
1. left Inguinal hemla repair and
2. transurethral resection of prostate.
3. He recently had a biopsy of his throat and was reportedly negative.
ALLERGIES: None.
MEDICATIONS: Aspirin, Augmentin and Chlorthalldone.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives alone. He was in the Army.
HABITS: He does not smoke, drink or use illicit drugs at the moment.
REVIEW OF SYSTEMS:
Roo"-ry: The patient_ som. COUgh and shorin... of br.ath. He deoles any Ches' pain 01
dyspnea.
Neurological: The padeo, raports some diffICUlty "'th his light ann due 10 his chron~ 'houIder-...
due to polio. He has swallowing and speech prOblems as described above.
Constltution.,: Danles fa...., chms. night ........ _ gain or lOSs in f8CentP8S1.
Page 1 of 3
THIS DOCUMENT IS NOT A LEGAL COpy UNLESS SIGNED.
CARLISLE REGIONAL MEDICAL CENTER
CONSUL TATIO~
9356223
BRENNEMAN. JOHN
MS2 0205 W951466
12/10/2006 09/10/1926
KOVACS. DONALD J
" 4'" .
BRENNEMAN, JOHN
ICU 0005 0
951466
CHIEF COMPLAINT: Cardiac arrest.
HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old gentleman followed by Dr. Kovacs. He
just recently moved into a nursing home. He has had progressive dysphagia, weight loss and weakness.
He is felt to have a post pOlio syndrome. In reviewing the nursing home records, over the past week, he
has gone from doing his ADLs independently to needing assist of two. This morning, he apparently was
found unresponsive. When paramedics arrived, he was in PEA with a pUlse of about 10. He was
resuscitated to atrial fibrillation at a controlled rate. He was profoundly hypotensive requiring dopamine. In
the emergency department, the patient is completely unresponsive on a ventilator. To the best of my
knowledge, the patient has not had any recent complaints of chest pain or respiratory problems. He is on
Protonix for some recent diagnosis of esophagitis and had his esophagus dilated as well. He apparently
also had a mass in the back of his throat, which was biopsied and was negative.
PAST MEDICAL HISTORY: As above. He also has benign prostatic hypertrophy, peripheral vascular
disease and hypertension.
PAST SURGICAL HISTORY: Transurethral resection of the prostate and left inguinal hernia repair.
CURRENT MEDICATIONS: Protonix 40 milligrams twice a day, chlorthalidone 25 milligrams daily and
p.r.n.'s
ALLERGIES: None.
SOCIAL HISTORY: He moved into a nursing home a couple weeks ago. He is a nonsmoker, nondrinker.
He is widowed and has no children.
REVIEW OF SYSTEMS: Obviously unavailable since the patient is intubated. On reviewing the nursing
home notes, again, he has gotten weaker and more fatigued, had significant dysphasia and decreased
p.o. intake and weight loss.
PHYSICAL EXAMINATION
GENERAL: The patient is not responsive even to deep pain. He seems to be posturing in at decerebrate
manner.
HEENT: Pupils were equally round; they were sluggish to react. Oropharynx reveals an ET tube in place.
NECK: Neck is supple. He does have external JVD when lying flat.
LUNGS: Lungs reveal loose rhonchi anteriorly bilaterally. There was no wheezing, no crackles noted.
HEART: Heart exam reveals irregularly irregular rhythm. There was no murmur auscultated. He has a
concave sternum. PMI was not laterally displaced.
ABDOMEN: Abdomen is soft. He has no reaction to palpation to suggest tenderness. Normal active bowel
sounds. No masses.
.
\.
EXTREMITIES: Extremities were mottled and cold. He has onychomycosis of all of his ten toenails.
Page 1 of 2
THIS DOCUMENT IS NOT A LEGAL COpy UNLESS SIGNED.
CARLISLE REGIONAL MEDICAL CENTER
HISTORY & PHYSICAL EXAMINATION
9357702
BRENNEMAN, JOHN
ICU 0005 0 951466
12/28/2006 09/10/1926
KOVACS, DONALD J
1 "
BRENNEMAN, JOHN
ICU 0005 0
951466
NEUROLOGICAL EXAM: No response to painful stimuli. Decerebrate posturing at times. Toes are
downgoing bilaterally.
SKIN: Skin is cold and mottled.
LABORATORY STUDIES: BUN 22, creatinine 1.3, sodium 119, glucose 112, bicarbonate 28. Chest x-ray
does not show an acute infiltrate. pH 7.31, C02 57, 02109. White count 15.7, hemoglobin 13.3.
Electrocardiogram shows atrial fibrillation. CPKs are pending.
ASSESSMENT:
1. Pulseless electrical activity cardiac arrest.
2. History of progressive decline with weight loss, weakness and dysphasia.
3. Hyponatremia of unclear etiology.
4. Atrial fibrillation.
PLAN: At this point in time, we will support the patient on a ventilator, continue dopamine drip and
aggressive IV fluid rehydration. Because he was becoming less ambulatory over the past week and had a
PEA arrest I do want to rule out PE, especially in the setting of atrial fibrillation. I will see if radiology will do
a CT angio, but because his BUN is 22, I think he may not qualify. Therefore, I will order lower extremity
Dopplers instead. If his CAT scan of his brain is negative, I will place him empirically on subcutaneous
Lovenox twice a day. The patient is normally followed by Dr. Kovacs and he requested that while the
patient is in the ICU, he remain on our service and then get transferred back to Dr. Kovacs' service when
he is out of the ICU. I attempted to reach the patient's only contact, which is a friend, and did leave a
message on his phone, that is Mr. Richard Hess, phone number 580-7814.
CC/jn
0: 12/28/2006 16:06:32
T: 12/28/2006 19:29:40
C:
Christina Collins, M.D.
Page 2 of 2
THIS DOCUMENT IS NOT A LEGAL COpy UNLESS SIGNED.
CARLISLE REGIONAL MEDICAL CENTER
HISTORY & PHYSICAL EXAMINATION
9357702
BRENNEMAN, JOHN
ICU 0005 0 951466
12/28/2006 09/10/1926
KOVACS, DONALD J
. 4' I. ~
BRENNEMAN, JOHN
ICU 0005 0
951466
CONSULTATION TO:
ATTENDING PHYSICIAN:
DATE:
TYPE OF CONSULTATION:
Mohammad K. Ismail, M.D.
KOVACS, DONALD J
12/29/2006
NEUROLOGY
REASON FOR CONSULTATION: Decreased mental status.
HISTORY OF PRESENT ILLNESS: Mr. Breneman is an 80-year-old gentleman followed by Dr. Kovacs
and was recently admitted to the hospital for the evaluation of dysphagia. The patient has a history of
post-polio syndrome and no significant intervention was recommended. The patient was in a nursing
home and in the morning was found unresponsive. The paramedics were called to the scene and they
found him in PEA with a pulse of about 10. The patient was resuscitated through ALS and intubated. He
was brought to the emergency room where he was noted to have a pulse of 110 and blood pressure was
66/46. He was noted to have atrial fibrillation. His temperature was 96.3. The patient was unresponsive
at that time and he was admitted to the Intensive Care Unit for further management.
Since his admission, the patient has not made significant recovery in his mental status. He is not able to
wake up and communicate. The patient has remained unresponsive although his vital signs have been
stable. In reviewing the nursing home chart, it was noted the patient did not complain of any chest pain,
shortness of breath, on the night prior to this incident. In fact, he was making good recovery since his
discharge from the hospital and he was doing his ADLs fairly independently.
PAST MEDICAL HISTORY: Significant for:
1. Hypertension.
2. History of peripheral vascular disease.
3. History of prostatic hypertrophy.
4. History of post-polio syndrome.
PAST SURGICAL HISTORY: Significant for transurethral resection of the prostate and left inguinal hernia
repair in the past.
MEDICATIONS: Protonix 40 milligrams twice a day, Chlorthalidone 25 milligrams daily.
ALLERGIES: None.
SOCIAL HISTORY: The patient moved to a nursing home a few weeks ago. He is retired. Habits - He
does not smoke, drink or use illicit drugs.
REVIEW OF SYSTEMS: Not obtainable. The patient is unresponsive.
PHYSICAL EXAMINATION:
General:
This is an 80-year-old gentleman laying on a bed, intubated and unresponsive.
Vitals:
EYES:
Blood pressure: 104/70. Pulse: 101 and regular. He was afebrile.
Pupils were 3.5 mm and nonreactive to light. Extraocular movements could not be checked and
Doll's eye test was negative. Corneal reflex was minimally present bilaterally. Examination of the
fundi was difficult but no apparent hemorrhage or bleed was noted.
Page 1 of 2
THIS DOCUMENT IS NOT A LEGAL COPY UNLESS SIGNED.
CARLISLE REGIONAL MEDICAL CENTER
CONSULTATION
9357702
BRENNEMAN, JOHN
ICU 0005 D 951466
12/28/2006 09/10/1926
KOVACS, DONALD J
fo ~. ~
BRENNEMAN, JOHN
ICU 0005 0
951466
Cardiovascular:
Heartbeat is regular in rate and rhythm. Auscultation reveals no murmurs, gallops, or abnormal
sounds. Pedal pulses are palpable, both dorsalis pedis and posterior tibial. Carotid artery exam
reveals no bruits and full and equal pulse.
Extremities have no edema or varicosities.
Respiratory:
The patient was on a ventilator with respiratory rate of 14. Breath sounds were present bilaterally.
Musculoskeletal:
Inspection, palpation: of spine and both upper and lower extremities, unless stated otherwise,
showed no misalignment, deformity, asymmetry, tenderness, mass, or swelling.
ROMs were assessed in spine and upper body and lower extremities and found to be normal.
Muscle tone was slightly increased in all four extremities. The patient was having a few
spontaneous projecting type of movements in the upper and lower extremities. However, he is not
showing any sort of response on stimulation from sternal rub and suborbital pressure.
Neurological:
Mental Status: Patient was unresponsive. Not showing any sign of grimace or movement with
deep sternal rub.
Language: Not examined.
Cranial Nerves: Limited. Pupils are fixed and corneal reflex is minimally present. There was no
apparent facial droop.
Reflexes:
The patient has absent ankle jerks and knee jerks bilaterally. Reflexes in the upper extremities
are also diminished. Babinski was negative.
LABORATORY AND X-RAY: CT of the head was ordered yesterday and showed no intracranial bleed.
He also has CT of the chest and thorax that showed extensive mucous plugging within the airways of both
lower lobes. EKG done showed that he has sinus arrhythmia with a heart rate of 117 when he presented
to the emergency room. White count 15.7, hemoglobin 13.3, platelet count 268, BUN 22, sodium 119,
potassium 3.3, blood sugar 112. CPK level 2,105. MB fraction was 28.1. Troponin-11.15.
IMPRESSION: This is an 80-year-old gentleman who has a history of hypertension, peripheral vascular
disease and now presents to the hospital with the sudden onset of loss of consciousness and was noted
to be in a cardiac arrest. Most likely the cause for the decreased mental status is anoxic encephalopathy.
His neurological examination showed that he has fixed pupils and minimal reaction even 12 hours after
the accident. I believe the overall prognosis is poor. Other differentials that need to be considered is
nonconvulsive status epilepticus or infection to the CNS, overdosage of some sedative medications.
PLAN: At this time, I will order an EEG. I would also like to explore other causes for his decreased
mental status as described above. I will continue to follow this patient with you.
MKllle
0: 12/29/200614:49:18
T: 12/29/200621 :06:45
Mohammad K. Ismail, M.D.
C: Mohammad K. Ismail, M.D.
KOVACS, DONALD J
9357702
BRENNEMAN, JOHN
ICU 00050951466
12/28/2006 09/10/1926
KOVACS, DONALD J
Page 2 of 2
THIS DOCUMENT IS NOT A LEGAL COpy UNLESS SIGNED.
CARLISLE REGIONAL MEDICAL CENTER
CONSULTATION
.~Bi40
1/03/07 15:28:52
CARLISLE REGIONAL MEDICAL CTR
Heart
Coid:
Page:
858
1
Report status: TRANSCRIBED
Pat.Type: 11
16:48 350424
K
Admit...: 12/28/2006 16:00
Discharg:
Location: ICU ,0005,D
Trnsc.: 12/31/2006 11:42
Pat Nbr: 9357702 BRENNEMAN,
Req By: 4510 KOVACS, DONALD
Med. Rec: 0000951466
Type: M~D Dict.: 12/30/2006
Physician: ISMAIL, MOHAMMAD
JOHN
J
-------------------------------------------------------------------------------
BRENNEMAN, JOHN ELECTROENCEPHALOGRAM 12/30/2006
CLINICAL HISTORY: This is an 80-year-old gentleman who had a cardiac arrest
and was brought to the hospital with decreased mental status. The patient has
been unresponsive since then. This EEG was ordered to evaluate further
prognosis and rule out nonconvulsive status epilepticus. The patient is not
on any sedative medication.
TECHNICAL SUMMARY: This is a 17-lead, 10-20, bipolar and referential, digital
EEG recording done on a patient who was unresponsive and on the ventilator.
The record opened with the patient unresponsive and with his eyes closed. No
well-defined background alpha rhythm was noted. There was diffuse depression,
and slowing was noted in the theta to delta range. At the time, the rhythm
was 3 to 4 Hz, 10 to 30 microvolts, but generally symmetrical. Unfortunately
this EEG was contaminated with a lot of artifacts related to the intensive
care unit and electrical activity that made it somewhat difficult to interpret
this record. There was poor reactivity in this EEG record. There was no
frank epileptiform discharge noted. Photic stimulation was done at several
frequencies, and eyes were opened manually. No response was noted in the
occipital leads. Overall there was minimal variability in this EEG record.
Single-lead EKG monitoring throughout the record showed some artifacts and
irregularly irregular rhythm.
IMPRESSION: This is a severely abnormal electroencephalographic record due to:
1. Lack of well-defined background alpha rhythm.
2. Lack of variability and reactivity in this electroencephalographic record.
3. Diffuse depression and slowing throughout this electroencephalographic
record.
COMMENT: This EEG pattern is compatible with the diagnosis of severe
metabolic or hypoxic encephalopathy. No apparent epileptiform discharge was
noted to explain the patient's decreased mental status.
MKI/am D: 12/30/2006 16:48:11 T: 12/31/2006 11:31:21
C: Donald J. Kovacs, M.D. Juliusz C. Nitecki, M.D.
Mohammad K. Ismail, M.D.
Dictated by 1141 - ISMAIL, MOHAMMAD K
.
. "" ..
cr~
361 Alexander Spring Road. Carlisle, PA 17015-9129. (717) 249-1212
COLLABORATIVE CARE WORKSHEET
BRENNEMAN, JOHN Patient #: 9357702
12/28/2006 Time: 16:00:00
KOVACS, DONALD J Med Rec #: 0000951466
0005/D
09/10/1926 Sex: M Age: 080
Patient Name:
Admit Date:
Att Phys:
Room/Bed:
DOB:
DISCHARGE ASSESSMENT/SOCIAL SERVICE
Assessment Date/Time: 12/29/2006 15:40:00
Discharge needs are unclear, will follow
Mental Status: Unresponse
Living Arrange: In nursing home
Activities: Total dependent
Agency Support and DMB already in home:
BQUIPMBNT COMMBNTS
Referral Services:
FACILITY SBRVICB RBFBRRAL ACCBPTED
Discharge Plan:
12/29-per review, pt is from Forest Park. Recently admitted there on 12/15.
pt is widowed with no children. will check with Darlene B. @ Forest Park
rei bed status. Ijk
Last Updated: 12/29/2006 15:42:11 LKEEN
USBR
DISCHARGE ASSESSMENT/SOCIAL SERVICE
Assessment Date/Time: 01/02/2007 09:18:00
Care Conference: 01/01/2007 00:00:00
0830: Discussed current medical status w/Dr Boshnakov,Hospitalist and nurs
ing staff at ICU unit. This writer will tic attorney: Hamilton Davis &
neighbor, exploring whether or not there is a POA or family member avail
able to make end of life decisions regarding pt.
0930: T/C Hamilton Davis,Esquire: spoke with receptionist. Introduced self
& role related to pt. Per receptionist, Rick Hess,neighbor called Hamilt
on Davis last week,Mr Davis was unsure if he was pt's attorney or not,
possibly being other attorney in the office is pt's attorney. This writer
requested that Mr Davis be consulted to determine if he is pt's attorney
or not, notifying this writer. Receptionist said OK. Return phone number
provided.
T/C Darlene @ Forest Park NH: Discussed above information. She reports that
when pt was admitted to their facility,pt did not have a Living Will nor
POA. No additional information obtained.
T/C Rick Hess,Neighbor @ 258-6023 1ft message requesting return tic. T/C
Rick Hess @ 580-7814: discussed at length pt's current status. Mr Hess
reports that he would write pt's checks out,pt would then sign them. To
his knowledge, there is no living relative. pt always told him if somethi
ng happened to him to contact Hamilton Davis,Esquire. Mr Hess did contact
Mr Davis last week,but to date, has not received a return tic by him. Per
pt,the bank was his POA,but Mr Hess is not sure whom to contact at the
bank, this writer requested that he check the bank statements & obtain an ad
dress/phone number for this writer to contact. He will return tic with
r.
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111111.1 mmIII 1IIIIIIIIgMII
8995210
9357702
.... ~
cz~
361 Alexander Spring Road. Carlisle, PA 170H5-9129. (717) 249-1212
COLLABORATIVE CARE WORKSHEBT
Patient Name: BRENNEMAN, JOHN
Patient #: 9357702
DISCHARGE ASSESSMENT/SOCIAL SERVICE
Care Conference:
this information as soon as possible. This writer provided my return tic
number.
0950: Received return tic Sarah @ Hamilton Davis,Esquire's office: she repo
rts that Mr Davis drew up pt's will in 1983,but has not had any contact
w/pt since 1991. Sarah reports the will does not provide any living will
or POA information. This writer requested that the will be checked for any
relative information. Sarah will check and return tic.
1010: T/C Office of Aging: 1ft message requesting information ref: no POA
available & assistance needed.
T/C Coroner's Office: spoke w/Mr Norris. He reports that unless there is a
named family member in the will, the hosital will need to seek guardian
ship of pt.
1200: Recd tic Jennifer Mann @ Office of Aging: she reports that unless pt
received current services via OOA, the hospital will need to seek guardi
anship of pt. If pt was currently receiving OOA services, they may be able
to assist.
1430: Spoke w/Bill Ziesmer,CFO/Admin on Call for hospital. Status update
provided regarding need for guardianship of pt. Joe Ricci: 233-6633 is
hospital attorney. T/C Joe Ricci: status update provided regarding need
for hospital to seek guardianship of pt. Mr Ricci request that this writer
tic pt's attorney & request copy of will, name of funeral home that pt's
mother was buried at. He will meet w/hospitalist tomorrow 1/03/2007. This
writer will tic neighbor: Rick Hess & advise of hospital's plan of care.
1630: T/C Hamilton Davis: 717-532-5713 : 1ft VM for Sarah - requested retur
n t/c,notified that Joe Ricci,CRMC Atty pursuing guardianship & request
ing copy of pt's will along w/name of funeral home for pt's mother.
T/C Rick Hess,pt's neighbor: 1ft VM w residence notifying that hospital
atty: Joe Ricci will be contacting him due to seeking guardianship of pt
along w/need for neighbor to report what pt always told him regarding
end of life issues.
Notified Dr Boshnakov that hospital attorney will be coming to hospital to
discuss guardianship with him 1/03/2007. Said OK.
Last Updated: 01/02/2007 09:31:41 SWASTLER
DISCHARGE ASSESSMENT/SOCIAL SERVICE
Assessment Date/Time: 01/03/2007 09:46:50
Care Conference: 00/00/0000 00:00:00
0930: Recd VM Rick Hess - he reports that he found some information,pt used
M&T Bank in Boiling Springs,PA. Additionally,he does have a safety depos
it box at that bank. Perhaps there is some documentation as to his wish
es in this situation there.
0950: Per Dr Boshnakov,Hospitalist. He has spoken with Dr Kovacs,pt's fami
ly physician. Dr Kovac is to review his chart at the office & obtain any
documentation regarding pt's end of life wishes.
1010: T/C M&T Bank,Boiling Springs,PA: spoke with Branch Manager: Rebecca
Dorwart. Status update provided regarding current situation and need
for POA/Living Will or pt's wishes to be provided. Notified that possibl
y pt had safety deposit box at their branch, and M&T was trust holder.Per
1IIIII1 Ila IMIIIIIM ~.IIIIIIIII1I.11111
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8995210
9357702
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361 Alexander Spring Road. Carlisle, PA 1701 ~129 . (717) 249-1212
COLLABORATIVE CARE WORKSHEET
Patient Name: BRENNEMAN, JOHN
Patient #: 9357702
DISCHARGE ASSESSMENT/SOCIAL SERVICE
Care Conference:
Rebecca Dorwart,she reports that per their file,pt is a individual hold
er,M&T is not POA. She does see where they are listed as a possibly hold
er at another location,she will t/c that location & return t/c with this
writer.
1100:Recd return t/c Rebecca Dorwart,Branch Mgr @ M&T,she reports that pt
did not have a safety deposit box @ M&T,nor at any of the branches in Car
lisle,PA - she checked prior to returning t/c with this writer.
1130: T/C Rick Hess @ 580-7814 w/status update regarding above information.
He reports that the other bank pt dealt w/was F&M in Boiling Spring,per
haps they have something in his safety deposit box there.
1140: T/C F&M Bank,Boiling Springs,PA: requested to speak w/Branch Mgr - sp
oke w/Kevin Stoner.Status update provided regarding need for POA/Living
Will,etc. Mr Stoner will check & return t/c with this writer. Per his req
uest,telephone # provided to Rick Hess,Neighbor.
1200: Reed t/c Kevin Stoner,F&M Bank,reports that following investigation
at their bank,pt did not have any safety deposit box at their bank.
1300: Per Dr Boshnakov,per Dr Kovacs,pt would not accept any preventive
care or treatment,always stating "r am too old and dying",refusing various
types of life sustaining tx.
1500: Dr Boshnakov,this writer,Mr Ricci,Esq met to discuss current status.
Last Updated: 01/03/2007 09:46:50 SWASTLER
~
1 11111 11111 lUll III 11111 11111111 1111 1111
Ilia 1111111 ml 11111 III 11111 II III
8995210
9357702