Activists Rally to Redlands Doctor’s Cause

Charges that a Redlands physician used a massive dose of morphine to hasten the death of a dying patient have triggered a legal fight by national pain management advocates, who accuse state medical officials of confusing humane treatment with euthanasia.

The state medical board determined that Dr. Harold Luke increased a 76-year-old man’s morphine drip tenfold to “hasten the patient’s death” when he was hospitalized in September 2002. On Aug. 4 of this year, the board approved an administrative law judge’s recommendation to strip Luke of his medical license for “gross negligence.”

But Luke said that as a Seventh-day Adventist, he was opposed to physician-assisted suicide and was only making his patient’s last days as painless and comfortable as possible.

The patient’s children said they were happy with Luke’s care of their father and were dismayed by the state’s action.

Patient advocacy groups have rallied to Luke’s cause, arguing that if the medical board’s judgment stands, it will have a chilling effect on physicians’ ability to care for terminally ill patients afflicted with severe pain.

“If an administrative law judge could, after the fact, second-guess what the intent of a physician at the bedside of a dying patient was, then no physician will feel safe in treating the symptoms of a dying patient,” said Kathryn Tucker, legal director for Compassion & Choices, one of the patient advocacy groups supporting Luke.

The physician has filed a last-ditch appeal, and the Medical Board of California’s Division of Medical Quality agreed last week to postpone its order until Friday so his request can be reviewed.

Luke’s patient, identified as “Morris E.,” was admitted to Redlands Community Hospital from a local nursing home in September 2002 because he was suffering from kidney and heart failure, emphysema, nerve damage and pneumonia. He didn’t have long to live.

Nurses’ records indicate that he initially had coughing fits but experienced no distress or trouble breathing after Luke’s initial morphine dose.

Luke increased the dose from 1 mg. to 5 mg. after a few days, then raised it to 50 mg. without documenting changes in the patient’s behavior or any symptoms of discomfort. Luke later noted such changes in the patient’s discharge summary, medical board records show.

The patient died within an hour of the increase.

Luke acted “without medical necessity,” said state Deputy Atty. Gen. Samuel K. Hammond, who tried the case. “Given the fact that the bulk of his practice involves taking care of terminally ill patients, the judge felt -- rightly so -- the only way to protect the public was to revoke his license.”

A standard in administering morphine is to gradually increase a dose by between 50% and 100% -- rather than by a magnitude of 10 -- while observing the patient’s reaction, said June Dahl, a pharmacology professor at the University of Wisconsin Medical School in Madison who also heads the American Alliance of Cancer Pain Initiatives.

In an August letter to the board, Luke explained that although he did not adequately document the patient’s condition or his own treatment decisions at the time, the patient’s deteriorating state and breathing troubles justified a rapid increase in the morphine dose.

He “was too weak to generate sufficient outward signs of distress for most people to detect, including nurses,” Luke wrote, adding that he did “not intend to hasten his death, but only to provide comfort and avoid agonizing distress shortly prior to his death.”

Luke declined to comment on the case while the board’s decision was pending.

The doctor’s actions are “not a crime,” said Luke’s attorney, Phil Cifarelli, who is also a physician and specializes in medical law.

“You revoke a license from a physician if the physician exhibits egregious conduct: sex with patients, selling narcotics ... we’re nowhere near that,” Cifarelli said, citing Luke’s 32 years of trouble-free practice and his compliance with the patient’s directive not to use lifesaving measures.

The patient’s three children, understanding the gravity of their father’s condition, gathered by his hospital bedside, where he could see them before he died, said his daughter, Lori McCorry, 47, who lives in Atlanta.

According to Luke’s discharge summary, the family “requested terminal compassionate care and not to have any means of prolonging life,” including discontinuing medication except pain relief and breathing aids.

“Dr. Luke was making him comfortable so that his wishes could be carried out,” McCorry said. “My dad was not getting up and he wasn’t going to dance again ... he was a sick man.”

She said she considered the case against Luke “absurd.”

“The state of California should focus on better things.... What they’re doing to [Luke] is wrong,” McCorry said.

Last fiscal year, the state medical board revoked 37 licenses of the 91,000 certified physicians and surgeons in California. Five of the 19 petitions for reconsideration were granted.

This fiscal year, three of 25 appeals were approved.

Luke’s case highlights the thorny issues linked to prescribing painkillers to dying patients. Although morphine effectively assuages pain, in high doses it can inhibit breathing and shorten a patient’s life, medical experts say.

“This same drug that has the ability to relieve pain ... and do sort of the ultimate good is almost the same drug that has the ability to end life,” said Betty Ferrell, a pain management research scientist at City of Hope National Medical Center in Duarte.

“The line between [relieving pain but hastening death] and actually killing a person is an important one and not always clear,” said David Joranson, director of the Pain & Policy Studies Group at the University of Wisconsin.

That ambiguity can dissuade some doctors from freely using morphine on patients in distress, pain experts say.

“Physicians are retrenching in the sense that they’re becoming more and more reluctant in prescribing these drugs -- even though they may think they’re needed -- out of concern for this uncertainty,” Joranson said.

In California, physicians who prescribe opiates to relieve chronic suffering are specifically protected under 1990’s Intractable Pain Treatment Act, and the California Pain Patient’s Bill of Rights, passed in 1997, guarantees seriously ill people access to pain relievers.

Starting in 2006, California doctors must complete 12 hours of pain management education to renew their medical licenses.