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HomeMy WebLinkAbout01-05-07 . 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 : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY PENNSYLVANIA IN RE: John Brennman : DOCKET NUMBER: 2007-15 : GUARDIANSHIP CERTIFICATE OF SERVICE And now this 5th day of January, 2007, I, Joseph A. Ricci, Esq. herby certify that on Thursday January 4th, 2007 I personally served the EMERGENCY PETITION FOR PLENARY GUARDIANSHIP OF THE PERSON AND ESTATE upon the following individuals in the following manner: John Brenneman Room 6, Intensive Care Unit Carlisle Regional Medical Center 45 Sprint Drive Carlisle, PA 17013 By personal service and by having the nursing staff read the order of court to the patient. Vd . UJ (JI,N-it:lj'aV1n8 1l:ln08 S,N'v'Hdl:lO :10 >18318 t C :C Wd S- NVr LOOl Page lof2 I'" ''''''/1 ,-]"'1"'; ",'fYI" -1J I J: ;I-J'--!\J ,\ \ ,'UQ'v',,)Ju ...JV .......I,....J _..J. \/' ., Michael Palermo, Esq. 155 S. Hanover Street Carlisle, P A 17013 Counsel for John Brenneman By service of the Petition and Order of Court by placing the documents in the Courthouse mail folder located in the office of the Prothonotary. Respectfully submitted, titioner, onal Medical Center Page 20f2 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 (") c= ~o i:b::tJ ;"n-o ;[d~P >,..zsg cc; u3 ^ -.j,...) "00 -::5 c .,., , :::0 :0 -, ;l:> -0 :J:: ~ W : IN THE COURT OF COMMON PLEAS N : CUMBERLAND COUNTY PENNSYLVANIA IN RE: John Brennman : DOCKET NUMBER: 2007-15 : GUARDIANSHIP PETITION FOR EXTENSION OF EMERGENCY 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 extend the Order granting emergency plenary guardianship of the person and estate of Mr. John Brenneman for the following reasons: 1. Pursuant to 20 P.S. ~ 5513 a court is permitted to enter an order granting an emergency guardianship for up to seventy-two (72) hours. 2. On Thursday January 4,2007, this Honorable Court entered an order granting temporary emergency guardianship of John Brenneman to Richard Hess. 3. The temporary emergency guardianship expires on Sunday January 7, 2006. 4. The need for the temporary emergency guardianship will continue beyond the expiration of the current court order since John Brenneman is currently in an unresponsive state and his medical condition is unlikely to improve. "-3 l::::) l::::) ....... L. ::J:loo 2: , CJ1 5. This Honorable Court has scheduled a guardianship hearing for Tuesday January 9, 2007 at 11:00. 6. It would be reasonable to extend the temporary emergency guardianship until the time of the hearing scheduled for Tuesday January 9, 2007 since it will be necessary to have an individual who can attend to the healthcare and financial needs of John Brenneman until this Honorable Court can issue an order based upon evidence received at the guardianship hearing scheduled for January 9,2007. WHEREFORE, it is respectfully requested that this Honorable Court issue an order extending the Emergency Temporary Guardianship until completion of the January 9, 2007 guardianship hearing and entry of subsequent order of this Court. Respectfully submitted, Date: ~16 I d7 CERTIFICATE OF SERVICE And now this 5th day of January, 2007, I, Joseph A. Ricci, Esq. herby certify that on Thursday January 4th, 2007 I personally served the EMERGENCY PETITION FOR PLENARY GUARDIANSHIP OF THE PERSON AND ESTATE upon the following individuals in the following manner: John Brenneman Room 6, Intensive Care Unit Carlisle Regional Medical Center 45 Sprint Drive Carlisle, P A 17013 By personal service. Michael Palermo, Esq. 155 S. Hanover Street Carlisle, PA 17013 Counsel for John Brenneman By service of the Petition and Order of Court by placing the documents in the Courthouse mail folder located in the office of the Prothonotary and by postage paid first class United States mail. Respectfully submitted, ~~ ner, edical Center . _j 1 .. 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 r--.:> = (") :5 Go c- ~-:o :l:lP' }g-u (") :z: (J::c. .. ';~~g in , ,.2: (J) 7, :J("")o -u "IO-n :;: ~~)c w : IN THE COURT OF COMMO~EAS. ~_. : CUMBERLAND COUNTY PENNSYLVAMA IN RE: John Brennman : DOCKET NUMBER: 2007-15 : GUARDIANSHIP 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 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. Ms. Brenneman is currently a patient in the Intensive Care Unit at the Carlisle Regional Medical Center, 45 Sprint Drive, Carlisle, Cumberland County, Pennsylvania. 3. Prior to his hospitalization, Mr. Brenneman was receiving care at the Forrest Park Health Center, 700 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania. \f <0 -[-, ~c; (~~ ,..,. ''A 4. Prior to the need for medical care in early December 2006, Mr. Brenneman resided at 17 Shirley Lane, Boiling Springs, Cumberland County, Pennsylvania. Mr. Brenneman had resided at this address in excess of twenty (20) years. 5. Mr. Brenneman was married to Harriet Brenneman. Harriet Brenneman is deceased and Mr. Brenneman has never remarried. 6. Mr. Brenneman and Mrs. Brenneman did not have any children. 7. Mr. Brenneman is an only child and has no siblings. 8. Mr. Brenneman's parents are deceased. 9. Mr. Brenneman has no known relatives. 10. Richard A Hess is an adult male who resides at 15 Shirley Lane, Boiling Springs, Cumberland County, Pennsylvania. See Affidavit of Richard Hess attached hereto as Exhibit "A" 11. Richard A Hess is the next door neighbor of the alleged incompetent, Mr. Brenneman. Id. 12. Richard A Hess and Mr. Brenneman have known each other for 19 years and have become close personal friends. Id. 13. Richard A Hess has been providing assistance to Mr. Brenneman since his hospitalizations in early December of 2006 in the form of caring for Mr. Brenneman's home, retrieving Mr. Brenneman's mail, organizing and making arrangements for the payment of Mr. Brenneman's bills, depositing checks in Mr. Brenneman's accounts and such other duties as have been required from time to time. Id. 14. Richard A Hess has no interests adverse to the interests of Mr. Brenneman. Id. . ... . .. 15. It is believed that the Last Will and Testament of Mr. Brenneman makes no provision for Richard A. Hess and that the entirety of Mr. Brenneman's estate is to be left to an educational institution which had been attended by his wife. Id. 16. Richard A. Hess has agreed to serve as Plenary Guardian of the Person and Estate of John Brenneman, the alleged incompetent. Id. 17. A Plenary Guardianship of the Person and Estate of John Brenneman is necessary for the following reasons: a) Mr. Brenneman first began to experience health complications in late 2006 when he was hospitalized for evaluation of a mass found in his throat. See Medical Record attached hereto as Exhibit "B." b) Although the mass was found to be benign its origin was undetermined. Id. c) Following the evaluation of the mass in his throat, Mr. Brenneman presented to the Carlisle Regional Medical Center Emergency Room on December 10, 2006 with complaints of difficulty swallowing(dysphagia), nasal congestion, shortness of breath, worsening appetite and weight loss. Id. d) At this time Mr. Brenneman was admitted to the hospital for evaluation. Id. e) Mr. Brenneman was diagnosed with low sodium levels, hypertension, benign protatic hypertrophy (enlargement of the prostate), and significant peripheral vascular disease. Id. '4 . II f) Mr. Brenneman was discharged from the hospital, however, he sought admission to the nursing home, Forrest Park Health Center, because of worsening dysphagia, weight loss and increasing weakness. Id. g) During the time Mr. Brenneman was a resident of the Forrest Park Nursing Home his condition continued to deteriorate and he went from being independent in his activities of daily living to requiring the assistance of two aides. Id. h) On the morning of December 28,2007, Mr. Brenneman was found to be unresponsive by the staff at Forrest Park Health Center. Id. i) Emergency Medical Technicians called for assistance found Mr. Brenneman to be unresponsive with only a pulse rate of 10. Id. j) Resucitative efforts resulted in the restoration of a heart rhythm but Mr. Brenneman required intubation and assistance with breathing. Id. k) Mr. Brenneman was transported to the Emergency Room of the Carlisle Regional Medical Center where he was found to be completely unresponsive and in need of mechanical ventilation. Id. 1) At the time of his admission, Mr. Brenneman was found to be unresponsive to deep painful stimuli, he seemed to be posturing in a decerebrate manner which suggested significant brain injury, he had an irregular heart rhythm, but he did have some sluggish reaction of his pupils. Id. m) Since the time of his admission, Mr. Brenneman's condition has worsened and by December 29,2007 neurologic evaluation revealed that Mr. Brenneman's . . f I: pupils had become fixed and non-reactive to light. Mr. Brenneman continued to be dependant upon a ventilator to breath. Id. n) Mr. Brenneman's condition has been diagnosed as anoxic encephalopathy or oxygen deprivation to the brain. Id. 0) Examination of Mr. Brenneman's brain waive pattern revealed patterns consistent with severe metabolic or hypoxic encephalopathy. The brain waive study was further described as severely abnormal. Id. p) The medical prognosis for Mr. Brenneman has been listed as poor. Id. q) Mr. Brenneman's physicians believe that he has little to no chance of recovery from his current unresponsive state. See Affidavit of T. Alex Boshnakov, M.D. attached hereto as Exhibit "C." r) In his current condition, Mr. Brenneman cannot communicate. s) In his current condition, Mr. Brenneman cannot participate in any decision making in regard to his medical care and treatment. t) In his current condition, Mr. Brenneman cannot attend to his personal and financial affairs. u) Because of Mr. Brenneman's current unresponsive state, the medical staff of the Carlisle Regional Medical Center is unable to obtain necessary consents to provide care and treatment that may become necessary. Id. See also Affidavit of Donald J. Kovacs, M.D. attached hereto as Exhibit "D." v) Because of Mr. Brenneman's current unresponsive state, his personal and financial affairs cannot be addressed and his bills will remain unpaid, checks will t" .. not be deposited in his accounts, and financial and personal obligations will be unmet. w) The medical doctors responsible for the care of Mr. Brenneman believe that the current condition will continue without relief or improvement. 18. Attempts have been made to locate legal documents such as an Advanced Directive for Healthcare, a Durable Power of Attorney or other expression of Mr. Brenneman's intent in regard to his care should he become incapacitated. 19. It is the Petitioner's belief that Mr. Brenneman did not execute Advanced Directives or a Durable Power of Attorney for the following reasons: a) Communication with the Forrest Park Health Center has revealed that Mr. Brenneman advised the staff that he did not have an Advanced Directive for Healthcare at the time of his admission. b) No Advanced Directive for Healthcare has been presented to the staff of the Carlisle Regional Medical Center. c) Communication with attorney Hamilton Davis, the attorney responsible for the drafting of Mr. Brenneman's Last Will and Testament revealed that Mr. Brenneman declined attorney Davis's advice to prepare a Durable Power of Attorney. 20. No other alternative with lesser restrictions than the imposition of a Plenary Guardianship is available in this circumstance for the protection of the rights and interests of Mr. Brenneman. t .. "Ii 21. Because of Mr. Brenneman's profound disability and complete inability to care for himself or his affairs, it is necessary to seek a Plenary Guardianship of the Estate and Person so that Mr. Brenneman's wishes can be fully met and discharged. 22. Because of Mr. Brenneman's profound disability and complete inability to care for himself or his affairs, it is necessary to seek a Plenary Guardianship of the Estate and Person so that Mr. Brenneman's rights and obligations can be protected and fulfilled. 23. Because the Petitioner is a health care provider and does not have access to Mr. Brenneman's personal records or accounts it is unable to determine the size or extent of Mr. Brenneman's Estate. 24. Because the Petitioner is a health care provider and does not have access to Mr. Brenneman's personal records or accounts it is unable to determine Mr. Brenneman's net income. 25. It is believed that Mr. Brenneman's neighbor, Richard Hess, with the consent and cooperation of Mr. Brenneman, has been responsible for Mr. Brenneman's finances during the period of time between his hospitalization in December of 2006 and the date of his incapacity. 26. It is believed that Richard Hess is a mature, responsible adult who is fully capable of meeting the obligations of a Plenary Guardian for the following reasons: a) Mr. Hess had been assisting Mr. Brenneman with his financial obligations and responsibilities prior to Mr. Brenneman's incapacity. See Affidavit of Richard Hess attached hereto as Exhibit "A." l... 1" b) Mr. Hess has been authorized by Mr. Brenneman to receive private healthcare information. See Affidavit of Donald Kovacs, M.D. attached hereto as Exhibit "D." c) Mr. Hess has been Mr. Brenneman's closest friend for the past 19 years and is the best position to know and understand Mr. Brenneman's wishes. See Affidavit of Richard Hess attached hereto as Exhibit "A." d) Mr. Hess is a close personal friend who has indicated that he promised Mr. Brenneman prior to the time of his incapacity that he would always be available to assist Mr. Brenneman in what ever way was necessary. WHEREFORE it is respectfully requested that this Honorable Court issue an Order appointing Richard A. Hess, Boiling Springs, Cumberland County, Pennsylvania as Plenary Guardian of the person and estate of John Brenneman. Lavery, Faherty, Young & Patterson, P.C. Date: 1/5'/07 . . cci, Esquire Attorney . No. 49803 arket Street Suite 304 Harrisburg, Pa 17101 (717) 233-6633 Counsel for Carlisle Regional Medical Center r... .." CERTIFICATE OF SERVICE And now this 5th day of January, 2007, I, Joseph A. Ricci, Esq. herby certify that I personally served the PETITION FOR PLENARY GUARDIANSHIP OF THE PERSON AND ESTATE upon the following individuals in the following manner: John Brenneman Room 6, Intensive Care Unit Carlisle Regional Medical Center 45 Sprint Drive Carlisle, PA 17013 By personal service. Michael Palermo, Esq. 155 S. Hanover Street Carlisle, PA 17013 Counsel for John Brenneman By service of the Petition by placing the documents in the Courthouse mail folder located in the office of the Prothonotary and by United States Mail, first class delivery addressed as above. Respectfully submitted, ~. t.. AFFIDAVIT OF RICHARD A. HESS AND NOW this 1\ ~"' . 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. 1. 1.. 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: ~v~'-\ Y. 2lJO\ \ I ~~w Q/~ Richard A. Hess ~ 71796033f' ~ i CARLISLE MEr:" . '. CE '.1014 pm. 12~14~2r ( 3/29 BRENNEMAN, JOHN MS2 0205 W CHIEF COMPLAINT: Dysphagia. HISTORY OF PRESENT IllNESS: Th~ BO-ye''''rnd wMe male Presen~ to the emerQency room wilh progressNely worsening dysphagia, nasal congestion, shortness 01 brealh, progress,," worsening hoarseness, poor appetite, and weighl loss. He was _nfly in !he hospital wIlere biopsy Of lhe nasopharyngeal mass was obtained al lhat time. Biopsy report was apparenlly negollve but etiology of the mass - not clear althis time. He - sent home from lhis admission and has persisting and worsening symptoms at this time. PAST MEDICAl HISTORY: Past Medical Histoty ~ POSfflve for polio at the age Of 20. He also carries lhe diagnosis of h_sion, benign prostatic hypl!f1rophy end peripheral vascular disease. PAST SURGICAl HISTORY: Pas, Surgical H"lStory ~ POsitive for left Inguinal hemla and repair and TURP. He also had biopsy of his throat done. 951466 ALLERGIES: No known drug allergies. MEDICATIONS: Aspirin, Augmentin, and ChlOrthaJidone. SOCiAl HISTORY: He is a nonsmoker, nondrinker, lives alone. FAMll Y HISTORY: FamDy Histoty is not s\:lnlRcant. His falher had ml'CCard1a1 infarction at lhe age of 52. REVIEw OF SYSTEMS: He lhinks !hat he has a right inguina; hernia noted. He also has signtficant bruistng of his '-" abdom... after admission from before and he stales lhat he has had foot pain blJa_,y for awhile end this has progressively WOISened. He denies any chest palo er shonness of breath. Denies any COUgh er wheeztng. He denies any Jla/pilatjons. He denies any nausea, -iting, conslfpation, 0< diarrhea, h_m, in<#gest;"" black or bloody ~ movements. Denies dysuria, frequency, or urgency since the surgery to his prostate. GENERAl_ His exam f6VeaJs him to be alert and 0_ X3 in no _t disb'ess. PtfYSICAL EXAMINATION VITAl SIGNS - Blood Pressure is 143/71, respiratory rale 18, lNOight 165 /lOUnds, temp _ 95.6F, pulse 84. HEENT - Head - nOl'll1Ocepha;~. E)mS - PERRlA, EOMt. E... _ no inJectlon or bulging of the 1)Irnpan~ membnlnes, canals are patent. Nose - Mildly boggy Iurblnalas. Throat_ without signilicant injection. MoUth was Without lesions. Dentition was stable. NECK - SUjJple aJlhoogh /here was some decreased range Of motion of his neck bDaleralJy. No neck vein distention, no bruits or thyromegaly noted. CHEST - Clear to aUSCUltation. BACK - Was positive for somewhat significant kyphosis. .1 HEART - Regular rate and rhythm with ectopy at times, no mtinnurs or gallops. Page 1 of 2 TrilS DOCUMENT IS NOT A LEGAL Copy UNLESS SIGNED. CARLISLE REGIONAL MEDICAL CENTER HISTORY & PHYSICAL ~INAT/ON 9356223 BRENNEMAN, JOHN MS2 0205 W 951466 12/10/2006 09/10/1926 KOVACS, DONALD J I 717960339;;-- ( CARLISLE MED!C - . CE \ 1 a 28 p m 12-14-700- 4/29 BRENNEMAN, JOHN MS2 0205 W ABDOMEN - Abdamen was nantende" na masses na hepatosplenomegaly. Bowel saunds we,. heart tIl/'OUghaut. Lowe, abdomen 'eveals a left ingUina' hernia "pal, scar and "ght inguinal hernia. He hes a significant amount of bruising across his lower abdomen. 951466 EXTREMITIes -Lawe.- """emiltes reveal full ,.nge al mation af h~ Joinls. Thece Was -eased pUlses of th. -is podia and posterior //blat PU~.. wilh significant edema of balh lower """.millas, right WOes. Ihan the I.n, significant onychom)'COSis and on ill. right there were "'Yihemataus cold toes, on ill. feft there were warm erythematous toes noted. Both were mildly tender. SKIN - Without rashes, lesions and breakdown. NEURO - Crenlal nerves lIi11l'OUgh XII w.... intact. Na focat neurologic signs ...... noted. Na weakness or decreased sensation af the uppec exlremm.s. The,. was Qeflere/ized Weakness of boill 10_ extremities bilaterally. ASSESSMENT: 1. Nasopharyngeal mass wilh es_ dysphagia, hoarseness, nesal coogaslIon, we;ghtloss. 2. 'Wona11emia, etiology is un_. Could iII~ be a~ WiIh the mess. We.... going 10 get a CT of the chest, CT of the head. , 3. Dysphagia. POSSibly there Is dj;sphagia beYOnd the nasop/Jaryngeat mass, iII_. we will consull gastroenterology and a/so go ahead with barium swallow. ~ 4. He has iIIe h~tory of h_nslon, benign _ hYPBrlrophy, sign/flcan, ~I vaSCUlar disease WiIh OI1_}<:OS~ of ill. "'- axframities Is noted. Althls point we w;ll go ahead WIIh his workup as ordered and replace his sodium and watch him closely. JAP/nw D: 1211012006 16:38:35 T: 12/11/2006 06:51:19 C: Joseph A. Picn, D.O. -Joseph A. Pion, D.O. Page 2 of 2 THIS DOCUMENT IS NOT A LEGAL Copy UNLESS SIGNED. CARLISLE REGIONAL MEDICAL CENTER HISTORY & PHYSICAL ~MINATlON 9356223 BRENNEMAN, JOHN MS2 0205 W 951466 12/10/2006 09/10/1926 KOVACS, DONALD J i 717960.339/ CARLISLE MEDlr . CE 11 20. pm 12-14-2o.P- I 8/29 BRENNEMAN, JOHN MS2 0205 W CONSUL TATION TO: ATTENDING PHYSICIAN: DATE: TYPE OF CONSULTATION: Gregory l. Lewis, M.D. KOVACS. DONALD J 12/10/2006 GASTROENTEROLOGY 951466 HISTORY OF PRESENT ILLNESS: This pleasant 80-year-old gentleman was admitted to lhe Carlisle Regional Medlcal Center tonight by Dr. Pion because ",e patient has had a progressive sore throat and difficully swallowing, ChoIdng and hoarsen.... Apparently this problem began many j8OI> ago but was intermittent and has become more constant and jl/1lgressive in the las,_ _So The paffent says 'hat he had polio In 1947 and since then he has had In'ermittenl "",....,..s and choking. He had a recent admission one _k ago. He was admitted by Dr. Kovacs and seen by Dr. FOITan:>. Ini,"",y Dr. FOITan:> felt lhe patient had a mass althe base of his longue but a biopsy was _ and felt that he just has a sfrange/y shaped UVU'a. He felt his focat COrds..... llOmJaI but h. did reet there was much el}'lhema ;, the back of his lhroal. He apparently amll1ged for a video swatlOWing study, the resuI~ of wh1ch are not known other than /he paffent was placed on a _ diet by the s_theraplst. The Patlan I. however. las, n/r1Jt bagsn to choke and had trouble breathing and came to the emergency room today for his admission. PAST MEDICAl. HISTORY: Hi. pa., mad;ca/ histo'}' inclUdes a /eft inguinat hernia '"PO. by Dr. Frltchley In 2001. H. had a 'ra'"ll/relh'al prostate resection in 2000. The patient been laking "-Ion 25 mg daily for hypertension, baby aspirin daily. ALLERGIES: He has no known drug allergies. SOCIAl.HISTORY, Social history rewa's tha, he Is retired from the Air Fon:e. He Is a widower wIlo lives in BOiling Springs. FMIL Y HISTORY: Family hlsloly reveals that his falher had a "'l'OCardIaI Infarction at age 52. REVIEW OF SYSlEMS, On review of -~,lhe Pallen' has _ dyspnea, _ 10 choking. He has no heanburn, no abdominai pain, noonal bowel function. He has had a reduced _ and weight loss recently. He also has Som. ap""""" discomfort ""'r his right inguinal area where he has a hernia and is Scheduled to see Dr. Hardesty for right inguinal hernia repair. PHYsICAl. EXAMINATION: GENERAl - On ph~ca/ exami1atton, lhe pallen, Is ;, no acute dlstr.... He is hoarse. lilT AI. SIGNS - His ............... is 97 d"",- F_en. pulse 87 per minute, fllSpirato,y.... 18 par minute. blood pressure 145183. HEENT - Pup;ts, equal, IOUIld and and reactive 10 light. There Is no cervical lymPhadenopathy. Tongue Is moist. CHEST - Chest exam Is dear. HEART _ Heart exam Is regular without a muonu,. ABDOMEN - Abdominal exam """"". .ome ecd1jmoses in the righ' ingu;,.. area of uncena;, etiology. He appears '0 have a rlght Inguinal hernia. However, U is nonlender. There is no organomegaly. EXTREMITIES - Extremlly exam reveal. no edema or Phieb/tls. NEUROlOGIC _ He Is oriented to person, place, and time. DIAGNOSTIC STUD/ES, Dalabes. includ.. hl'POna.emla wilh a sodium 123 and a chloride of B6 of uncenain eIlology. liver functions are noona" Albumin Is .lIghUy low at 3.1. Hemoglobin 13.6, while cell count 10.100. Page 1 of 2 THIS DOCUMENT IS NOT A LEGAL COpy UNLESS SIGNED. CARLISLE REGIONAl MEDICAL CENTER CONSUL TATlON ASSESSMENT AND PlAN, I caued Dr. Ferraro .no felt lhls patient's problem was not -lnanlly ear, nose and lhroal. He did nof have a mass. lherefore. !he paUent~ hoarseness and choking may be poo, 9356223 BRENNEMAN, JOHN MS2 0205 W 951466 12/10/2006 09/10/1926 KOVACS. DONALD J 717960339;;' CARLISLE MEDIr:-.-' CE i BRENNEMAN, JOHN MS2 0205 W - 11 38 p.m 12-14-200--' ( 9/29 951466 polio syndrome which is a syndrome where the patient distantly years after exposure to Polio, may develop progressive swallowing difficulties. , cannot totally rule out a stricture of his esophagus and as part of his video swallowing study there may be images of his esophagus but I am uncertain. I suggest reconsulting the speech therapist 10 get her opinion. The patient may need to have his esophageal anatomy and function studied further. I feel a neurology evaluation may also be helpful in confirming postpolio syndrome. He has hyponatremia. One wonders whether this is related 10 either diuretics or diet or even syndrome of Inappropriate AOH. I wol lake the liberty of ordering some urine electro/yles and a urinalysis to look for specific gravity. He may need a nephrology consult. Thank you. GLUsap D; 12/101200619:57;34 T: 12/1112006 06:30:25 C: Gregory L. Lewis, M,D. KOVACS, DONAlD J Page 2 of 2 THIS DOCUMENT IS NOT A LEGAL Copy UNLESS SIGNED. CARLISLE REGIONAL MEDICAL CENTER CONSULTATIOll Gregory L. Lewis, M.D. 9356223 BRENNEMAN, JOHN MS2 0205 W951466 1211012006 09/10/1926 KOVACS, DONALD J . . 71 79603~f\:> j. ( CARLISLE ME\J''''\L CE .....''3:10:39 p m ( 12-14-~('.'- ( 5/29 BRENNEMAN, JOHN MS2 0205 W CONSULTATION TO: ATTENDING PHYSICIAN: DATE: TYPE OF CONSULTATION: Mohammad K Ismail, M.D. Donald J. Kovacs, M.D. 12/11/2006 NEUROLOGIC EVALUATION 951466 REASON FOR CONSULTATION: Dysphagia. HISTORY OF PRESENT IlLNESS: Mr. Brenneman is an ao;..a, -old ve", pleasant ll9l1lleman for whom ' was consulted by Dr. Kovacs for evaluation for his dysphagia The Pallenl is a _ hislorfan and _ thai he has dilfiaJlty w;o, Swallowing s~ce the age of 19 when he had Polio thaI alfected his neck and Shoo',"" musdes. He _ed thai he was In !he Army _ at thai lime he always had an issue w;o, swallowing anyth~g bigger than llOp/rin tablet. He also ec:knowledge<J W he was sick this problem is BQ9IaVaIed. He r_ thaI for the Past two ~'" his voice Is gelling low and he cannot _loudly. He has had more dlfficul1y WIth swalloWIng and _ for the past few 11lOll1hs. The _, was seen by Dr. Ferraro a few months ago and allhatllme there was !he _Ity of some mass that was 0lCp/0red in the nas~....... He has been ruled out for any hJmor. He,. now admitted to the h_ for evaluation of worsening dYSPhagia. The patient denies W he has dcubte vision. He denies W he has droopy eyes or excessive amount ot tatigoe. He has 110 numbness or _oss or any other part of the body. He has some crlflicUty with urinatton and -uleo /his to prostate _s. The pallent denies any signillcmt 1M>IgIrt loss or nighl 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 hernia repair and 2. transurethral resection of prostate. 3. He recently had a biopsy of his throat and was reportedly negative. ALLERG'ES; None. FAM'L Y HISTORY: Noncontributory. MEDICATIONS: Aspirin, Augmentin and Chlorthalidone. HABITS: He does not smoke, drink Or Use illicit drugs at the moment SOCIAL HISTORY: The patient lives alone. He was in the Army. REVIEW OF SYSTE~: Resplralooy: The palientFllporis some COugh and shortness of breath. He denies any chest pain or dyspnea. Neurological: The patient reporis some difflCUtty _ his right arm due to his eIlron~ shO<Jlde, t>roblems due to polio. He has swalloWing and speech prOblems as described above. Constitutional: Denies fever, eIl"s, night sweats, welghl gain or loss " recent past Page 1 of 3 THIS DOCUMENT is NOT A LEGAL Copy UNLESS SIGNED. CARLISLE REGIONAl MEDICAl CENTER CONSUL TATION 9356223 BRENNEMAN. JOHN MS2 0205 W951466 12/10/2006 09/10/1926 KOVACS, DONAlD J 'lit ,.. 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 AOLs 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. I., Page 1 of 2 THIS DOCUMENT IS NOT A LEGAL COpy UNLESS SIGNED. CARLISLE REGIONAL MEDICAL CENTER HISTORY & PHYSICAL EXAMINATION 9357702 BRENNEMAN, JOHN ICU 00050 951466 12/28/2006 09/10/1926 KOVACS, DONALD J ".' .. BRENNEMAN, JOHN ICU 0005 D 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, 02 109. 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: 12/28/200619:29:40 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 D 951466 12/28/2006 09/10/1926 KOVACS, DONALD J ".' ..., 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. Cornea; reflex was minimally present bilateral/y. 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 00050951466 12/28/2006 09/10/1926 KOVACS, DONALD J ... .... 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, tendemess, 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-I 1.15. 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. MKI/le 0: T: 12/29/200614:49:18 12/29/2006 21 :06:45 C: Mohammad K. Ismail, M.D. KOVACS, DONALD J Mohammad K. Ismail, M.D. Page 2 of 2 THIS DOCUMENT IS NOT A LEGAL COPY UNLESS SIGNED. CARLISLE REGIONAL MEDICAL CENTER CONSULTATION 9357702 BRENNEMAN, JOHN ICU 00050 951466 12/28/2006 09/10/1926 KOVACS, DONALD J .. .PAg1~0 1/03/0715:28:52 CARLISLE REGIONAL MEDICAL CTR Heart Coid: Page: 858 1 Report status: TRANSCRIBED Pat Nbr: 9357702 BRENNEMAN, JOHN Req By: 4510 KOVACS, DONALD J Med. Rec: 0000951466 Type: MED Diet.: 12/30/2006 Physician: ISMAIL, MOHAMMAD Pat.Type: 11 16:48 350424 K Admit...: 12/28/2006 16:00 Discharg: Location: ICU ,0005,D Trnsc.: 12/31/2006 11:42 ------------------------------------------------------------------------------- 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 ~ w>. .. ~CwlstE ----CZ::~ 351 AJexan~er Spring Road. Carlisle, PA 17015-9129 . (717) 249-1212 COLLABORATIVE CARE WORKSHEET 16:00:00 Patient #: 9357702 patient Name: A. drn i t D ate : A tt Phys: R. Dam/Bed: DOB: BRENNEMAN, JOHN 12/28/2006 Time: KOVACS, DONALD J OOOS/D 09/10/1926 Med Rec #: 0000951466 Sex: M Age: 080 DISCHARGE ASSESSMENT/SOCIAL SERVICE ~ssessinent Date/Time: 12/29/200615:40:00 Discharge needs are unclear, will follow Mental Status: Unresponse r:..i.ViIlg Arrange: In nursing home AC tivities: Total dependent Agency Support and DME already in home: EQUIPMENT COMMENTS USER Re ferral Services: FACILITY SERVICE REFERRAL ACCEPTED D.ischarge 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. 1jk Last Updated: 12/29/2006 15:42:11 LKEEN 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,exp1oring 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 faci1ity,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 know1edge,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 1IIIIIIlRII 11111111111111111111111111111111 8995'-1" 1111/111111111111111111111111111 DIll 1/11 IIII Jo .' r'l7G ~~ 361 Alexander Spring Road. Carlisle, PA 17015-9129. (717) 249-1212 COLLABORATIVE CARE WORKSHEET 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 1/111111111111111111111111111111 111111111111/ 8995210 . 1111111 1IIIIIIlIIIIIII 1111111111 1111111111111 9357702 )r .. 'rn ME~ 361 Alexander Spring Road. Carlisle, PA 17015-9129 . (717) 249-1212 COLLABORATIVE CARE WORKSHEET Patient Name: BRENNEMAN, JOHN Patient #: 9357702 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 tic that location & return tic with this writer. 1100:Recd return tic 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 tic 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 tic with this writer. Per his reg uest,telephone # provided to Rick Hess,Neighbor. 1200: Recd tic 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 "I am too old and dying",refusing various types of life sustaining tx. 1500: Dr Boshnakov,this writer,Mr Ricci,Esg met to discuss current status. Last Updated: 01/03/2007 09:46:50 SWASTLER DISCHARGE ASSESSMENT/SOCIAL SERVICE 1111111111111111111111111I111111111111111 I11I 8995210 I 111111 11111 11111 111II gill 1111/11111 11111'" 9357702 Ir. .' .. ~ . AFFIDAVIT OF T. ALEX BOSHNAKOV. M.D. AND NOW this ~ day of January 2007, I; T. Alex Boshnakov, M.D., do hereby swear and affirm: 1. I am a physician licensed to practice medicine ill 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. 'f lOt.. · 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. '( t'.l.... · 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. Date: ~ submitted., ~~THOF~V~ NoIDiiii SIii Susan J. ~'-' NotIry PUIIIc Sou1h IIldcIeeon Twp, Cumberfalld County Comm!lalon Nov. 10 _ ...... PeiiliijiWin/l AllciCiItion 01 NoIiriii Y' -.....) · t AFFIDAVIT OF DONALD J. KOVACS. M.D. AND NOW this l1."-- day of January 2007, I, Donald J. Kovacs, M.D., do hereby swear and affirm: 1. I am a physician licensed to practice medicine ill 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. 'r -,-'" .. l 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, r/ LtltJr ~~I~f1d) Donald J. Kovacs, M.D. Date: