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Diplomate in Internal Medicine

Diplomate in Pulmonary Medicin

October 12, 2012

Re: Victorino Noval (Deceased)

This 78-year-old male was hospitalized at Kaiser on 4/28/10 with symptoms of shortness of breath. The patient developed progressive respiratory insufficiency and required endotracheal intubation and mechanical ventilation. His respiratory symptoms were subsequently felt to be related to aspiration pneumonia.

The patient was treated with intravenous antibiotics and continued to require mechanical ventilation over the next several days. Eventually, his lung function began improving and his requirements for supplemental oxygen eventually decreased.

During the time of this patient’s stay in the intensive care unit, several decisions were made by the patient’s family that resulted in the final decision to withdraw supportive care. The patient was eventually extubated shortly after noon on 5/7/10. He actually maintained normal vital signs over the next several hours, breathing on his own. However, his clinical status eventually deteriorated later that afternoon and he was pronounced dead at 17:25 on 5/7/10.

Several questions have been raised in this case regarding the issue of this patient’s physiologic status at the time of his extubation. As stated previously, his oxygen requirements improved significantly between the morning of 5/6/10 and the morning of 5/7/10. The patient eventually suffered a fatal respiratory arrest due to the fact that intravenous morphine had been administered.

This patient had undergone an echocardiogram during his acute hospitalization that demonstrated normal left ventricular function. He had previously undergone pulmonary function tests that had demonstrated evidence of moderate airflow obstruction. The patient apparently did carry a diagnosis of Parkinson’s disease, though reportedly was managing his own finances (which apparently were more than considerable) just prior to his illness. Based on the physiologic data in this case, it is more probable than not (reasonably medically probable) that this patient would have survived his acute hospitalization in May of 1020 had supportive care been continued. The basis for these conclusions is provided by the patient’s echocardiogram, pulmonary function tests and functional neurologic status prior to his demise. There is no physiologic evidence in these medical records that this patient would have died in the foreseeable future after surviving his acute hospitalization in May of 2010.

If any further questions should arise regarding this complex case, please feel free to contact this office.

Sincerely,

James F. Lineback, M.D., F.C.C.P.

Diplomate American Board of Internal Medicine

Diplomate Subspecialty Board of Pulmonary Disease

Diplomate American Board of Anti-Aging Medicine

Clinical Associate Professor of Medicine

Department of Internal Medicine

UCLA School of Medicine

Qualified Medical Examiner

JFL:sm