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By Ken Farbstein
Michael Jackson had what most of us think we want: Utterly personal attention from a dedicated doctor, on call all the time for him alone.
That doctor, Conrad Murray, is now on trial for manslaughter (see reports here and here) though no one thinks Michael’s death from an overdose of the anesthetic Propofol was deliberate. By all accounts, the treatment that Michael received was anything but normal or typical, but is there anything that typical patients can learn from what went wrong?
Hindsight is 20/20. Clearly, doctors shouldn't administer Propofol on their own. This case is unique. But as a patient advocate, I try to learn from every medical error, and to extract useful guidance that patients can act on in the moment. The lessons of Michael's death have little to do with Propofol. Much remains unclear about exactly what happened, but I see three key lessons:
•Don't assume information about your medications has been communicated from one doctor to another.
•Keep an updated medication list.
•Get a family member or professional patient advocate to help oversee your care.
The story of Michael Jackson's death is explored in my book, Getting Your Best Health Care: Real-World Stories of Patient Empowerment, among case studies of other celebrities. In particular, I examine more fully the role of his medical team. The conflicting accounts this week by the prosecutor, defense lawyer, and early witnesses make it hard to know the whole truth at this time, but useful lessons are already emerging.
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'For the doctor to proceed then without a professional assistant, a cogent patient, or a computer was like a groggy pilot flying at night with no co-pilot or flight instrument panel: flying blind.'
Poor communication among medical personnel
Michael’s primary care provider reportedly communicated some critical information poorly. When emergency medical technicians arrived to try to revive Michael, his primary care doctor did not inform them that he had given Propofol to Michael, according to the prosecutor. That may have affected the way the EMTs tried to revive him.
Flumazenil was used to reverse the effects of benzodiazepines like the Lorazepam that Michael had been taking. Miscommunication may have led the EMTs to administer the Flumazenil in a misdirected effort to counteract the effects of the Lorazepam.
The patient's role
Michael himself seems to have played a role in at least two miscommunications. First, Michael had become addicted to Demerol, which he regularly received from his Beverly Hills dermatologist, without telling his primary care provider.
The addiction reportedly left Michael unable to sleep, sometimes for days, leading him to beg for Propofol — according to the defense lawyer. Second, Michael had swallowed an extra dose of Propofol while the doctor was in the restroom, unbeknownst to the doctor, according to the defense lawyer.
The risk of hand-offs
Such miscommunications of information during medical “hand-offs” among medical personnel like these are common, so patients need to be on guard. Keeping an updated medication list of each drug, its dose, and the reason you’re taking the drug can prevent errors like this. During crises, a patient advocate – either a trained family member or professional advocate – can also catch and correct the miscommunication before the patient suffers for it.
It seems likely that a chain of errors on the part of both Michael and his primary care provider, and perhaps another physician, were responsible for his death. Given the many drugs Michael was taking and they way he received them, it seems there were several wrong-drug, wrong-dose, and wrong-time errors.
Michael Jackson's death also raises three other issues that patients should consider:
Behavioral health and substance abuse
Michael was relying on many drugs, at least one of which was habit-forming. Ideally, a concerned family member, or even Michael himself, would ask his primary care physician about his dependency, and the doctor would have some training in detecting and dealing with substance abuse. In the absence of that, lacking full knowledge about Michael’s habits, the doctor was flying blind, though neither Michael nor he seemed aware of that. (Michael called the Propofol his “milk;” indeed, the drug’s nickname is “milk of amnesia.”)
Did Michael Jackson choose the wrong doctor?
In hindsight, it’s easy to say, "Yes." Beforehand, it was less clear-cut. If Michael had looked up the doctor’s public quality information in HealthGrades, for example, he would have seen the doctor had received only two or three stars on a five-star scale, as rated by a small number of patients on each of ten different dimensions of care, including trustworthiness, communication skills, listening skills, whether they would recommend him to someone else, etc. At that time, the doctor had neither any malpractice activity, nor any actions by the state’s medical board, nor any formal sanctions.
Taking no for an answer
An excerpt from "Getting Your Best Health Care":
Two root causes were working together. First, Jackson refused to be denied; he wouldn’t take no for an answer from his doctor. In the police report, the doctor said he had finally relented, after trying for days to wean Michael off Propofol.
Second, Jackson had chosen a doctor who flew solo. Normally a doctor would write a prescription; a pharmacist would review the prescription for safety before filling it, and the patient would take the medicine. That process allows for a team of three to consider the medicine’s safety: the doctor, the pharmacist, and the patient. Many retail pharmacists routinely use computers that immediately warn of any potentially dangerous interaction among drugs. For a drug like Propofol, which is usually used in hospitals during major surgery, the team would typically include an anesthesiologist and nurse as well.
In this case, the doctor himself may have been groggy, like Jackson, so that neither of them could consider the right questions about the safe use of the drug. For the doctor to proceed then without a professional assistant, a cogent patient, or a computer was like a groggy pilot flying at night with no co-pilot or flight instrument panel: flying blind.
How could this have been prevented? With 20/20 hindsight, it’s easy to say: The doctor should not have administered the injection as he did. He should not have let Jackson browbeat him.
Jackson should have chosen a more professional and conscientious doctor and should have accepted the doctor’s reluctance to order and provide Propofol. In the moment of a medical crisis, however, it’s not so clear-cut. What should we do when we’re in pain? Trust the doctor’s judgment, and suffer? Or insist on prompt and effective treatment?
Trust your doctor’s judgment, and verify it. If the doctor says no, ask why. Keep an open mind, and explore safe treatment alternatives with your doctor.
Few patients have personal, live-in doctors who are always immediately available and willing to provide treatment, as Jackson did. Such a doctor is the one that most people think they want. But it’s more important to have a doctor who can firmly and caringly say “no” and explain why; a doctor who uses nurses and other professional colleagues as backup, and who uses computer systems to warn of dangerous drug orders.
Ken Farbstein, MPP, president of Patient Advocare, is a professional patient advocate who advises people on staying safe through their healthcare crises. See his previous CommonHealth post, 'My Dog Has Better Medical Records Than My Daughter,' here, including his generous offer to field your personal questions to a professional patient advocate.
Ken drew his information on the trial from coverage by Ian Lovett and Timothy Williams of The New York Times, and Anthony McCartney and Linda Deutsch of The Associated Press.
This program aired on September 30, 2011. The audio for this program is not available.
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