OCTOBER 19/26, 1998 VOLUME 6, NUMBER 16/17
Terminally ill patients often experience considerable, intractable pain from their illness. Adequate management of that pain, usually by painkilling medications, is a continuing concern of individual physicians and the entire medical community. In sufficiently large doses, painkilling medication often suppresses the respiratory system and may actually accelerate the patient’s death. This creates a common situation; the physician may be eager to reduce or eliminate pain, but reluctant to prescribe a dose which might lead to the patient’s early death.
Most advocates insist that the physicians’ concern about painkiller overdoses is misguided. They note that there are few cases in which physicians experienced any difficulty from licensing agencies, hospital peer review committees or anyone else for overprescribing pain medications, particularly when treating the terminally ill.
Dr. Stan Naramore’s case may give doctors new cause for alarm. The Kansas physician recently scored a significant victory in his state’s Court of Appeals, but only after a six-year personal nightmare.
Dr. Naramore was charged with murder and attempted murder in two unrelated cases arising out of his medical practice in 1992. In one, he was accused of trying to administer a deadly dose of morphine. In the other, he was accused of withdrawing life-sustaining treatment from a patient who might have been successfully resuscitated.
Mrs. Ruth Leach, a 78-year-old patient of Dr. Naramore’s, had been treated for cancer for several years. In 1992, her condition had deteriorated to the point that her death was anticipated within a short time, and her family gathered at the St. Francis, Kansas, hospital knowing that she would not live much longer.
Mrs. Leach’s son Jim, who happened to be a paramedic, told Dr. Naramore that he believed his mother needed a higher dose of painkilling medication. Dr. Naramore met with the family, warned them that increasing the painkillers could actually hasten Mrs. Leach’s death, and discussed the choices available for her care.
After that meeting, Dr. Naramore and the family returned to Mrs. Leach’s bedside, where he administered two separate painkilling shots. Dr. Naramore asked the family to join hands, he recited Robert Frost’s poem “Into The Woods,” and then he prepared a syringe with a dose of morphine. At this point Mrs. Leach’s son became convinced that Dr. Naramore was attempting to end his mother’s life. The two men met in the hallway outside her room, where Jim Leach told Dr. Naramore “I’d rather my mother lay there and suffer for ten more days than you do anything to speed up her death.” Dr. Naramore decided he did not want to continue with Mrs. Leach’s care, and arranged for her transfer to another hospital. She received additional morphine at the new hospital, and died a few days later.
In the second case, Dr. Naramore treated Chris Willt, an 81-year-old diabetic with a pacemaker and a history of heart disease. Mr. Willt had refused to continue his heart medication, and several days later arrived at the hospital after having been found slumped over at a local convenience store, with an irregular heart beat, and difficulty breathing. Mr. Willt was unable to speak.
After three hours of emergency medical work, Dr. Naramore decided that continued treatment of Mr. Willt was futile. He consulted another local physician, who confirmed his opinion. The mechanical ventilator was turned off, and Mr. Willt died eight minutes later.
Two years after the two deaths, Dr. Naramore was indicted for murder of Chris Willt and attempted murder of Ruth Leach. After a jury trial in rural St. Francis, Kansas, he was convicted on both counts. He appealed to the Kansas Court of Appeals, which overturned his convictions in July of this year.
In its opinion, the Kansas court discussed the fine line between adequate pain management and euthanasia, and the difficulties faced by medical practitioners on a daily basis. Several medical groups had filed briefs with the court, and the judges clearly understood the meaning of “palliative care” as used by the medical professionals. In this case, wrote the Judges, “there is nothing close to a medical consensus that Dr. Naramore’s actions were homicidal. In fact, there was extremely strong testimony to the contrary.”
At trial, Dr. Naramore had produced testimony of six physicians who had reviewed the records of the two deceased patients; one of those had been present during Dr. Naramore’s treatment of patient Chris Willt. The state had relied on the testimony of three other physicians.
With regard to Ruth Leach (the terminal cancer patient for whom Dr. Naramore had prescribed, but not administered, a final dose of morphine), the state’s expert witnesses testified that her respiration had been so slowed that the administration of another morphine injection would have led to her death. Dr. Naramore’s experts disagreed, saying that pain control was an appropriate choice for Ms. Leach, and that the morphine dose was a fraction of what Dr. Naramore would have used if his intention had been to end her life.
In the second case, that of Chris Willt, the experts hired by the state again testified that Dr. Naramore must have had the intention of ending the patient’s life. They testified that he removed a mechanical ventilator from Mr. Willt after having treated him with a paralyzing drug; although they agreed that the drug administration had been appropriate treatment, they questioned Dr. Naramore’s decision to withdraw the life-sustaining machinery before the drug’s effects had worn off.
Again, physicians called by the defendant disagreed. They noted that Mr. Willt had been aggressively treated for three hours, and that Dr. Naramore consulted another physician before deciding that continued treatment would be futile. That doctor, and all Dr. Naramore’s expert witnesses, agreed that Mr. Willt was already dead when the ventilator was disconnected.
The court was faced with two choices. Either the conviction could be reversed outright, and Dr. Naramore found not guilty, or the case could be returned to St. Francis for another trial. By a two-to-one vote, the three appellate court judges chose to dismiss the charges altogether. In their opinion, the judges noted that “there is a reason why there has yet to be in Anglo-American law an affirmed conviction of a physician for homicide arising out of medical treatment based on such highly controverted expert evidence as here.” State v. Naramore, July 24, 1998.
Although Dr. Naramore was ultimately acquitted, his trial, conviction and appeal exacted a heavy price. His license to practice medicine was suspended and he was put through the agony of the trial itself. Although his license has now been restored, the damage to his career and his ability to practice medicine must surely be incalculable. His case should give pause to any practicing medical professional.