Speaking Out for Dying in Dignity : Nurse Says Outspokenness Led to Charges in 2 Patients’ Deaths

Pedro Contreras was dying.

The 40-year-old Sylmar man had shot himself in the abdomen at a party and raging infection had spread to his vital organs, including his kidneys.

Deep in a coma, his life was maintained at Holy Cross Hospital in Mission Hills by doctors who hooked him up to a dialysis machine, intravenous feedings and a ventilator.

On June 14, 1987, doctors decided that Contreras would never recover. They turned off the dialysis machine, ceased feedings and stopped administering antibiotics. The ventilator, however, was left on.

Two days later, intensive care unit nurse Linda Rangel lowered the oxygen level on the ventilator in a procedure that authorities say and she admits is not medically acceptable.

Los Angeles County prosecutors say she took the action to speed Contreras’ death. She was charged with two counts of attempted murder--for hastening the deaths of Contreras and of Lorraine Sammons, 50, of Lake View Terrace, who shot herself in the head in February, 1987, after she was fired from her job.

No Contest Plea

After bargaining with prosecutors, Rangel pleaded no contest to two counts of attempted voluntary manslaughter in San Fernando Superior Court earlier this month. She was granted probation by Judge John H. Major, ordered to turn in her nursing license and forbidden to return to the health care industry.

Rangel pleaded no contest, she said in a recent interview, because she could not endure the stress of having life imprisonment--the maximum penalty for attempted murder--hanging over her. She said she regrets, however, that she was unable to draw attention during a trial to the inhumane practice of mechanically prolonging the dying process.

Around Holy Cross Hospital, Rangel, an 8-year veteran of the intensive care unit, made no secret of her personal belief that no patient without hope of recovering consciousness should be kept alive with machines.

But she insists that when she tampered with the oxygen level in the Contreras case she only wanted to assess how long he would live, not hasten his death.

Her supervisors, she said, had pressed for an estimate of when the bed he occupied would be free for other critically ill patients. And Contreras’ wife, who had been told her husband’s death was imminent, called repeatedly asking how much longer her husband would hang on.

Rangel said her outspokenness--rather than evidence of wrongdoing--was what led to her arrest on two counts of attempted murder. Prosecutors said she was charged with attempted murder rather than murder because the patients’ deaths did not result directly from her actions.

Sammons had arrived at Holy Cross with a bullet wound in her head. The woman was placed on a respirator in the intensive care unit, where she lingered for a week.

Her heart finally stopped beating on Rangel’s shift. A nurse later told Los Angeles police that she saw Rangel in Sammons’ room before the patient died and that when Sammons’ heart stopped, Rangel did nothing to try to save her.

Rangel says it would have been improper for her to try to resuscitate Sammons after her heart stopped, since doctors deemed her “no code,” meaning no further efforts should be made to save her. And she denies that she tampered with Sammons’ ventilator, as authorities allege.

Her belief in what she calls “dying with dignity” stemmed from her youth in Canada, she said, where her family accepted death as a natural part of life.

Grandfather’s Death

When she was 16, Rangel said, her grandmother elected to take her dying grandfather home from a hospital because she felt the quality of his last days was more important than how much longer he lived.

“She said she would rather take him home and be able to lie in bed beside him,” said Rangel, who helped care for her grandfather until he died.

Rangel moved to Southern California 13 years ago because of a shortage of nursing jobs in her native country. She said she was frequently frustrated in the intensive care unit to see doctors place patients with no chance of recovery on life-support systems.

One comatose patient, she recalls, was kept alive in Holy Cross Hospital on a ventilator--a mechanical device that pumps air in and out of the lungs--for three years even though he was virtually brain dead.

“No one in his right mind would want to live life as a vegetable like that,” she said. “When we have done everything we can . . . a patient should be allowed to die.”

Holy Cross Hospital refused to comment on the use of life-support systems or on any aspect of the Rangel case. In an internal report included in Rangel’s court file, however, officials concluded that her actions ultimately had no impact on the two patients because medical treatment could not have prevented them from dying.

Lacked Authority

Regardless of her ethics or actions, Rangel did not have the legal authority to alter a ventilator setting without a doctor’s orders, authorities said.

Deputy Dist. Atty. Lee Harris of the office’s medical-legal division said Rangel was prosecuted because she “crossed a line into an area reserved solely for a licensed medical practitioner.”

According to a 1983 decision of the California Court of Appeal, doctors can turn off life-sustaining machines such as ventilators if they conclude that “any meaningful recovery of cognitive brain function is exceedingly unlikely” and if, in their opinion, continued treatment would not change that likelihood.

Based on the guidelines set up by the court decision, many doctors cease mechanical support of dying patients. Others, however, such as cardiopulmonary specialist Dr. Reza Nahed, say they will not turn off a ventilator under any circumstances.

Nahed, a consulting physician on the Contreras case, said that even if he ceases all other treatment, he will remove a patient from a ventilator only if the family obtains a court order forcing him to do so.

“Our job is to help patients,” he said.

Discussed Views on Dying

Rangel said she found it rewarding to help people fight and overcome their illnesses. Conversely, witnessing the suffering of patients without hope of recovery caused her emotional stress, she said.

During discussions with other nurses in the quiet hours of the night shift, Rangel said, she often expressed her philosophy and frustrations. And, according to court records, head nurse Sue Wilson said many other intensive care nurses agreed with Rangel.

In June, 1987, the hospital launched an inquiry in response to a complaint from a nurse who said Rangel tried to kill Contreras by lowering the oxygen level of his ventilator. Rangel voluntarily resigned three days later.

At the conclusion of the inquiry, Sheila Bruce, vice president of patient services, wrote in the internal report that the hospital was not “able to demonstrate her actions hurt any patients.”

In January, 1988, the Police Department received an anonymous letter accusing Rangel of multiple homicides and alleging that the hospital had covered up the deaths.

“They had all heard me speak about it, so when the investigators came (other nurses) said, ‘Yeah, I believe Linda could do that,’ ” Rangel said. “I was too vocal for my own good. But talking about something is different than doing it.”

‘Wasn’t Out to Kill’

In the Contreras case, Rangel admits lowering the oxygen level from 90% to 20%--the oxygen content of room air--but contends that she was only trying to gauge the strength of the patient’s heart.

When his heart rate dropped, indicating weakness, she said she quickly returned his ventilator to the higher setting.

“It wasn’t a prudent thing to do, but I wasn’t out to kill this person,” she said.

Contreras’ widow, Paula, said in an interview that she was furious at doctors and hospital administrators because they ignored his request not to be placed on life-support systems.

Attached to his medical charts was her husband’s “living will,” a legal document stating that he did not want his life sustained by artificial, mechanical means.

“He never wanted to be on life support,” Contreras said. “I asked them to go on his wishes . . . but they didn’t care.”

During her husband’s three weeks at Holy Cross, doctors performed medical procedures “above and beyond what was reasonable,” Paula Contreras said. The medical and hospital bills exceeded $500,000, she said.

“The doctors should have just let him be. He was beyond repair,” she said. “They were doing stuff to him that I couldn’t believe.”

Empathy With Wife

Because of her beliefs, Rangel said, she may have empathized too much with Paula Contreras’ suffering.

“Maybe if I hadn’t had that attitude, I wouldn’t have felt the need to assess how long he had left,” she said. “A lot of nurses would have just walked away from it and said, ‘It’s in God’s hands.’ ”

Paula Contreras said she did not wish to see charges pressed against Rangel. Harris said authorities had little choice.

“A message had to be sent to the medical community that responsibilities must be clearly defined and all participants must adhere to that,” the prosecutor said in court proceedings.