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Nursing Home Deposition 2 - Plaintiff's Deposition of Internist - Part 3
BY MR. MACHALINSKI:Q: It appears to reference some fact that a bedsore had healed or pressure sore had healed?
A: Yes. It says D/C healed, 2/10/97. There is no, they don't even tell us which one they are talking to, maybe the one around the scrotum.
MR. LEVIN: It says '97, too?
THE WITNESS: It should be -- yes.
MR. LEVIN: Just for the record you are reading a note that says D slash C healed 2/10/97 which is the date?
THE WITNESS: Right. So I'm going to guess maybe that's a 5.
MR. LEVIN: So it's 2/10/95?
THE WITNESS: Right. But look above it, there is a note that says 2/13/95 which is what I'm talking about in terms of documentation.
2/3/95 by the way this is Bates, that's on 15 and Bates 16 is 2/3/95. This is out of order. We got one, two, three. This is also 2/3. 2/9 is the next note week four. I'm just reading this. Stage II pressure ulcer right hip.Well that's been there since January. This may be larger, three and a quarter by three sonometers Stage II pressure ulcer on the right hip. That was initially set as two and a quarter by two.
So we see that they are getting larger. Then there is one 2/3/95, three Stage II decubiti ulcers in the sacrum.
Then 2/9, three Stage II decubiti ulcers in the sacrum, and they try to draw a picture. One looks a little bit bigger. That looks like it is probably the left cheek, and then there is one on the right cheek and one right over the coccyx with different sizes on it.
You can see that there is a progression of skin breakdown and it mirrors probably when we look at the amount of nutrition and calories.
So basically we have a gentleman who is malnourished, who is kind of eroding his skin and these are painful things, and we see notes of confusion, disorientation, discomfort.
BY MR. MACHALINSKI:Q: He is conscious during this whole period of time?
A: Well, it's hard to say. He is not unconscious. He is disoriented and he is, you know, speaking out in Polish, sometimes in English.
Then we go, and this is all the way through his death. Do you want me to keep going?
MR. LEVIN: Yes, if you want him to go through all the decubs? There are pages and pages of it.
MR. MACHALINSKI: I don't think it's necessary, but I don't want to cut him off.
MR. LEVIN: We don't have to do it now, but at trial it will be our intention to go through each and every decubitus ulcer and describe each one on each day that they occur.
So he can read the record now and do that. I just don't want to be precluded from going into that. As long as we have the understanding that that's our intention and he can do that and to the extent that they are documented in the record, he's going to do that.
MR. MACHALINSKI: Right. For the record I have no objections to that and I --
THE WITNESS: Unless you want me to continue to go on.
MR. MACHALINSKI: No, I don't think it is necessary for purposes of this deposition and the record is what it is and if Dr. Greenberg wants to read the record, that's fine.
MR. LEVIN: He doesn't want to do it for his own.
THE WITNESS: This is not for my own thing, but let me tell you it goes all the way through 2/9 that there are wound cares about his decubiti, and they are progressive.
You know, if you can imagine a chunk of your skin taken out about ye big, ye big being about two or three sonometers round like the size of a baseball, that's going to be painful and discomforting. And it's discomforting, you know, one of the things about decubiti they are very discomforting to the family. It implies to the family that people are not caring for their loved ones and even though they put their expectation is that their loved one be cared for and cared for in a way at least to prevent the kind of injury that kind of, you know, led to this.
BY MR. MACHALINSKI:Q: I understand that we haven't gone through all of the bedsores and the ulcers, but in a general sense getting back to my question a little while ago, in a general sense we talked about the fracture, open reduction, contractures to bedsores, you have also indicated that there was pneumonia all of which ultimately hastened his death, are you aware of any other injuries that were approximately causes as a result of the pedestrian automobile accident?
A: No. Basically none of these things were there before his auto accident so.
Q: How did his, did his mental condition continue to deteriorate between that period of time when he was readmitted to Oak Lawn Pavilion up until the time of his death on 2/20/95?
A: I believe it did. It's hard to tell from the notes because all they ever say is confused and disoriented, but I think there are more notations that he is confused and disoriented. There are more notations that he is speaking in Polish.
Q: Which would seem to suggest that his mental status was continuing to deteriorate?
A: Right.And if you're infected, by the way, people who are, who have dementia when they are infected, they are and because oxygen may decrease and things like that and because of other changes, they get more confused, and as you heal the infection they become less confused.We see that all the time.
Also the fact that, you know, as he gets more confused, this is not a place that doesn't fit his past memories.And as we talked about in dementia, recent memory is really primarily what the major effect is.
That's why, you know, an old patient can tell you what they did 20 years ago and who they spoke to and give you great details about a conversation but can't tell you what they had for breakfast.
MR. LEVIN: Why don't you relate that to the plaintiff here, how are those things --
THE WITNESS: Well, I think what happens is when people are demented and they are infected and things like that, they spend more time in a hallucinatory world. They are not able to orient themselves. They are not able to be oriented. They basically are less communicative.
BY MR. MACHALINSKI:Q: Was he receiving any type of pain medication during this period of time?
A: There were orders through the pain tube for Vicodin. There was some orders for some pain medication.
Q: So he was sedated to a certain extent?
A: Pain medication certainly can sedate and cause confusion. I mean the other medications that he was on, too, which is the antidepressant Zoloft can also suppress appetite, can also cause some disorientation.
Q: Was he on Zoloft prior to the accident?
A: He came back on Zoloft. He was on Haldol prior to the accident. They used Zoloft as a more primary stay post the accident although he did have some Haldol in between but less frequently.
Q: So he would have been on Vicodin between that period of time between the accident and his death?
A: Yes, he had some pain medication.
Q: The Vicodin was designed to relieve the pain?
Q: That pain would be both the leg fracture and the bedsores?
Q: I would like to direct your attention to your opinions which I believe are contained on Page 16 on Exhibit No. 2, opinion No. 1 which I'm reading from the 213 Answers, it is his opinion to a reasonable degree of medical certainty that the care and treatment provided to the deceased by the defendant nursing home fell below the minimum standard of care and constituted negligence.
Is that your opinion, sir?
A: Yes, it is.
Q: The care and treatment addressed in that opinion related to what?
A: Well, they relate to the fact that these bedsores progressed very rapidly, that even though he had a G-tube in, he developed aspiration pneumonia, that he continued to sustain significant weight loss and that he wasn't able to in terms of toileting and things like that.
He clearly is getting worse and the reason why is that because he is not being turned as frequently as he should and there is documentation on occasion patient was turned. There is not consistent documentation of any of those things that people associate with reasonable care of their loved ones in a nursing home.
Q: Is it your opinion that in the absence of that negligent care and treatment, he would not have developed bedsores?
A: I think that he wouldn't have developed them quite as quickly and I think they would have not progressed as rapidly.
This is a man who basically had an automobile accident, had a surgery in November and is dead in February. That's a pretty rapid decline.
Q: Is it your opinion that but for the negligent medical care following his fracture he would not have died in February?
A: I think he might have lived a little bit longer. I can't tell you how much. I can tell you that, you know, certainly his life was significantly shortened.
I think it was shortened because of the accident and then it's shortened again significantly because, you know, he's getting infected, his nutrition is going down, you know, he is making no progress.
Q: You can't tell me how much his life was shortened as a result of the negligent medical care and treatment following the fracture?
A: I think that it is clear that his life expectancy beforehand as we discussed --
MR. LEVIN: Let's be clear, before what?
THE WITNESS: Before the accident was about five years. It's clear that if you look at the literature that his life expectancy may have been about a year. So if you are talking three months, his life expectancy might have been shortened by about nine, nine months that is.
BY MR. MACHALINSKI:Q: That nine months probably would have been spent bedridden?
A: Probably. Because there is no evidence that he was making any progress that he was going to get up and suddenly able to participate in physical therapy or anything like that.
Q: Have we fully expressed your Opinion No. 1?
Q: No. 2, quoting it is his opinion that the nursing home violated its own custom and practices, its own policies and procedures, its own guidelines and the standard of care by permitting a known wanderer to leave the building unnoticed by the nursing home staff, correct?
Q: And that opinion is based on the fact that he was a known wanderer and he, in fact, was able to leave the premises undetected?
Q: And ultimately get hit by a car?
A: And ultimately got hit by a car.
Q: Anything else that you want to expand on that opinion?
A: No. I think the statement is what it is. I mean he should have never been able to get as far as he did.
Q: No. 3, is that pretty much the same as No. 2 except with the addition that with a causation in terms of decrease in quality and length of his life?
A: Yes, I think that's pretty much the same thing. I think you are really -- if he doesn't get hit by a car, his life is longer probably by several years.
MR. LEVIN: I think what he is asking you, he may be asking you what does it mean when you say resulted in a significant decrease in the quality of his life?
THE WITNESS: Well, he is no longer able to walk. I mean the fact that he is not able and mobile to participate in his care to feed himself and things, I mean those are things that we associate with quality of life. Most of us would say that the quality of life of lying in bed is nil.
BY MR. MACHALINSKI:Q: No. 4 basically lists the various injuries that you believe were caused by the subject automobile accident?
MR. LEVIN: Don, by No. 4, we mean the sentence beginning --
MR. MACHALINSKI: Yes, I will read that.
MR. LEVIN: Because 4 won't show up.
BY MR. MACHALINSKI:Q: Right. Is Dr. Greenberg's opinion that as a result of the fractures and medical treatment for the fractures, any combination with his preexisting cognitive and functional impairments, fractures caused or contributed to lack of mobility, weight loss, pain, increasing need for pain and psychotropic medication, malnourishment, dehydration, pressure ulcers and systemic infections accelerating a decline in the quality and length of the deceased's life, correct?
Q: That's your opinion, sir?
A: Yes, it is.
Q: Have we fully discussed that opinion?
A: I believe we have.
Q: The next and the last opinion states as a result of the fractures, the deceased became malnourished and dehydrated, he developed multiple infected pressure sores, he became lethargic, bedridden and developed respiratory distress and other infections, and as a result his death was accelerated.
Is that your opinion, sir?
A: Yes, it is.
Q: Have we fully expressed that opinion?
A: I believe we have.
Q: The systemic infections, what does that refer to?
A: Systemic meaning high fever, probable -- we talked about bacteria in the blood and things like that is probably his ultimate cause of demise whereas a localized decubitus ulcer may be infected and that's localized. We are talking about bacteria that gets in the blood from a urinary tract infection, pneumonia could be considered systemic infection because it has effects beyond just the lung.
Q: We already talked about that I believe?
Q: Do you know who Byron Arbet is?
A: All I know is he was retained by Mr. Levin and that he was an expert in nursing home administration. That's all I know pretty much about him.
Q: Have you ever worked with him on any other cases?
A: I have never met the man personally, and I don't know anything about him other than what you just told me and what Mr. Levin told me briefly when I looked this over.
Q: To the best of your knowledge you haven't worked with him before?
A: That's true.
MR. MACHALINSKI: That's all I have right now.
MR. HELIS: I do have a few questions.
BY MR. HELIS:Q: First of all at various times we have been talking about life expectancy, and you gave a figure for Mr. Pietrzyk of a five-year life expectancy.
The first thing I would like to ask you was when you gave that figure, was that figure taking into account his condition before the accident as well as the situation he found himself in a nursing home?
A: We are talking prior to the accident?
A: What I would tell you is that based on my observation, experience with nursing home patients and patients like this that they can and do live five years or so. It's a progressive decline. It's not as good as when he came in, but they do have an expected life expectancy time of about somewhere around that five years.
He doesn't have major significant medical problems. He comes in not on a lot of medications. His main problem was his dementia. Take away his dementia and wandering or just make him less likely to wander where his wife can take care of him and he is pretty much okay. If he takes his medication and his atrial fibrillation rate is controlled and things like that.
Q: I think my question was much simpler than that. When you gave that five-year figure, are you taking into account his condition from the time he entered the nursing home, the fact that he's in a nursing home, is that five-year figure specifically for Mr. Pietrzyk?
Q: Now, when you are measuring the five-year figure, are you talking about at the moment he enters the nursinghome or some other point?
A: Probably around, you know, within limits somewhere around entering the nursing home.
Q: Now, after the fracture, you indicated that from that point his life expectancy would probably be about a year?
Q: Is that based on any particular study, any particular statistics?
A: Well, it's based on people who have hip fractures and in many ways this is similar to a hip fracture because he has an open reduction, his leg is immobile, he's suffered all the same problems that somebody in his position.
If he would have suffered a hip fracture, his course would have been identical and just because of the immobility factor.
Q: There is some specific studies or documentation of this figure out there somewhere?
A: I think it's out there pretty much if you look at peers and geriatric textbooks and things like that. That figure is pretty well out there.
Q: Do you have any particular textbook or particular study that --
A: No, because it's just one of those well-known facts that patients don't do well.
Q: You are not basing that on anything specific?
Q: The medical care that he received after the fracture, you say that shortened his life by about nine months?
Q: Did you ever see the actual death certificate?
A: I kind of glanced at it, but I did not spend any detailed time with it.
Q: Do you know what the actual cause of death is?
MR. LEVIN: Do you know what the death certificate says, in other words?
MR. HELIS: Not off the top of my head but --
MR. LEVIN: No, no.Are you asking him that question?
MR. HELIS: Right.
THE WITNESS: If I could see a copy of it, I would look at it, but I have not paid enough attention to it because they could have listed multiple causes including -- I mean the most common cause in somebody like this with this type of death is listed as infection.
BY MR. HELIS:Q: Would the person that actually prepared the death certificate be in a better position to determine the cause of death than you are?
MR. LEVIN: I guess I'm going to object because I guess it depends on who prepared it. He would have to know who that person is to answer that question.
THE WITNESS: I don't know who prepared it. I think that the records, you know, you can get two or three people and people who have multisystem disease, multi-problems like this, you will get different people who will decide which is the primary cause.
Some people may say it's aspiration pneumonia, some people would say it's presumed urinary tract sepsis.
In point of fact, I don't think these certificates are exact. If you have the certificate, I will be more than happy to discuss concrete issues with it.
BY MR. HELIS:Q: Who would be in the best position to determine the actual cause of death?
A: Usually attending physician.
Q: Were the causes of death that you gave in your deposition, do you know the same as what was on the death certificate?
A: I do not know.
Q: Were any of the causes of death that you listed things that could have occurred without a leg fracture?
A: Yes, they could have occurred without a leg fracture.
Q: In this particular case, are you tying each of the causes of death that you listed to the leg fracture?
A: Yes, I am.
Q: Other than the fact that they weren't present before and they were present after, do you have any basis for saying that?
A: Yes, I do because they are associated with his decline and his condition. The man became immobile. Because he became immobile, he develops bedsores. Because he is immobile and he is not moving and mobility is very important when we look at the decline in people who are demented.
If people are mobile and moving about, they are being stimulated in many different ways. He is also eating more or less in bed as opposed to sitting and going to a dining room. All those things will attribute to the possibility of aspiration and things like that.
Q: Is the lack of mobility the connecting point that masks for all these problems?
A: I believe it is, yes.
Q: Is there anything you think the hospital could have done to prevent this person's death?
A: No. The hospital did its job. He had a fracture, they operated on it, they did everything that they could do, and at that point it becomes the nursing home's job to rehabilitate him if they can.
Q: Is there anything that the nursing home could have done to prevent his death?
A: Well, again, I wasn't present but I could tell you that, you know, these bedsores, getting him physical therapy, even physical therapy at the bedside, range of motion exercises, working with him at the bedside, trying to work with transfers, trying to get him up.
The only time that this man is up is he goes to physical therapy I believe once or twice where he is actually out of the chair and the other times he is in a geri chair and that constituted his life from a bed which is kind of like a lazy boy, a geri chair.
Q: That's something that is in control of the nursing?
A: I believe that the nursing home certainly has some control; however, again he wouldn't be in that position unless he is hit by the car. But that's their obligation of care.
Q: Do you believe that before this accident Mr. Pietrzyk was a danger to himself if left unattended?
A: Clearly, that's why the family brought him to the nursing home to begin with.
Q: In what respect was he a danger to himself?
A: Obviously he was wandering and his wife couldn't control him well enough to keep him from wandering out of the house and getting hit by a car and walking in traffic, and all those things that we associated with older people who are demented and wander.
Q: Is there a technical definition of wanderer in your profession?
A: Wanderer. I mean, you know, whether you use, it's somebody who is disoriented and gets out. I mean, we use, where we can, I like to use very simple terms and wandering is exactly what he does.
Q: I heard it defined as somebody who is oblivious to their own safety.
Is that a definition of wanderer?
A: I think that's a fair, but it can also be somebody who doesn't know where they are.
There are different stages of dementia and a person who is demented may well enough recognize a car and know that he shouldn't walk in front of a moving car whereas someone who is oblivious and more severely demented may not recognize that the car has the capacity if he walks in front of it to cause him significant damage.
Judging from the record, I can't tell the difference where he was at that phase, but he clearly isn't cognitive enough to realize that getting out of the nursing home is going to cause him a danger just like getting out of his house.
Q: You don't know though whether he specifically recognized the danger of vehicles on the road?
A: No. There is no way of telling.
Q: You mentioned that he was in a somewhat hallucinatory state after the accident?
A: That's when he was confused. The nursing home was documenting that he was confused and disoriented, and he speaks in Polish. Often when people speak in Polish, they can be hallucinatory if that's their primary language and not English even though he spoke English for the last 30 years.
Q: Is there any way that you can from telling from the records that you reviewed to what extent Mr. Pietrzyk actually was conscious from any pain or suffering at that point in time?
A: Only when they say he was medicated for pain.You know, he may also be, when they say he is confused, that may also be secondary to the pain.
If I don't understand what you are, let's say you spoke a different language, whatever language and you came over here and you lived over here and I didn't know that language, I wouldn't be able to interpret what your prize would necessarily be.
Q: To a reasonable degree of medical certainty, can you offer any opinion as to whether he was conscious from any pain or suffering?
A: Well, you know, I think there were times where they documented that he was breathing very heavy and hyperventilating and his pulse goes up. Those are all things associated with increased pain.
Q: Heavy breathing is always associated with increased pain?
A: No, but it can be.All you asked me to was how can you document it and I said if his pulse, his respiration and the rate of his breathing goes up, one can assume that they may be related to it because these episodes, when they were described nobody seemed to know what they were related to but they happen on some regular basis.
It is very possible when they moved him in and out of bed they would slide on the decubiti or something like that or if they repositioned him onto the decubiti.
Q: This is what I'm getting at, Doctor.You talk about things that we might be able to assume.
What I'm asking you now is to a reasonable degree of medical certainty, do you know or do you have an opinion as to what degree he is feeling any actual physical discomfort?
A: From the chart is all I can tell you. I think my certainty is that since nobody else found another cause for it, what I would believe those would be due to pain. Because if you can't find any other cause, then that would be something that's obvious given the size of these decubiti and things like that.
Q: At that time was he having symptoms of pneumonia?
A: Not all those times, no, he was not.
Q: Do you know which times the heavy breathing would incur the pneumonia and which wouldn't?
A: No, I don't. But there are times when he documented. He could also have been in pain and when he was in pain he could have aspirated.
You know, these are things that are really impossible to tell, but what you have to do is you have to make some assumptions based on your experience and taking care of people who have had bedsores and they complain of pain.
When you see that these achieve a certain size, I mean most people would assume that those cause some pain. I certainly would.
Q: Even under medication?
A: Medication cannot -- in order to remove all pain, you have to basically render your patients unconscious.
What I tell my terminal cancer patients is we can control your pain but we can't relieve all your pain and still have you maintain a level of consciousness, and that's the truth.
You know, people get used to relative differences and suffering or pain, and there is no way of telling. I mean, some people are, you know, have a lesser threshold for pain, some have a greater threshold for pain.
Q: You don't happen to know what Mr. Pietrzyk's threshold --
A: No, there is no way of telling.
Q: You don't happen to know what degree the Vicodin and other pain killers he was using were effective or ineffective?
A: There is no way for sure of knowing, not from what the records in the chart says.
MR. HELIS: That's all the questions I have.
MR. LEVIN: Do you have anything more, Don?
MR. MACHALINSKI: I don't think so.
BY MR. LEVIN:Q: Just so I'm clear, it is your opinion based upon a reasonable degree of medical certainty that pressure ulcers or decubitus ulcers are painful for the person who has them, correct?
A: Yes, that is.
Q: It is your opinion based upon a reasonable degree of medical certainty that the lack of mobility that Mr. Pietrzyk experienced after his fracture injury negatively affected his quality of life, correct?
A: That's true.
Q: How did the lack of mobility negatively affect the quality of his life?
A: Well, since he can't walk, he is going to develop those pressure sores, and he can't be simulating.
He's basically confined to his room. He can't participate in any of the activities that nursing homes do try for Alzheimer's patients.
He can't go to the dining room and sit up and eat. He's always in a position pretty much to aspirate.
Q: What is aspiration?
A: Aspiration is when the stomach contents come up through the esophagus and instead of going outward as if you vomit goes down into the lungs, everybody has experienced, for example, something going down the wrong pipe. That's an aspiration.
When our swallowing, when we initiate our swallowing mechanism, sometimes it doesn't work exactly correct in something like liquids or something may fall down and we will cough and things. That is what aspiration is.
Q: Did Mr. Pietrzyk experience aspiration?
A: Yes, he did.
Q: How would that affect him?
A: He would have developed a pneumonia.
Q: Would that be painful?
A: Pneumonia can be painful and they can be discomforting because people are short of breath and they feel it as dyspnea or shortness of breath.
Q: How would he feel, how would Mr. Pietrzyk have felt the aspiration in your opinion?
A: Well, I think, you know, you can experience some chest pain. He may have had some inability to cough because he had some problems with his swallowing mechanism, but that food and things would have caused him to have decreased oxygen in his lungs, would have made it harder for him to ventilate, may have caused him to breath faster, and it creates discomfort in the same sense that we would commonly think of fluid going down the wrong pipe or something, it's uncomfortable for us.
It may make us feel air hunger or, you know, somewhat ill at ease and make us feel frightened when we are short of breath.
Q: I think we covered this but what's the relationship between his lack of mobility caused by the fracture and malnourishment and/or dehydration?
A: Well, the relationship of that is as he becomes with this progressive kind of chronic infection decubiti ulcers, he's not getting as much nutrition and he is not getting as much fluids even though they have this feeding tube in.
They are giving it to him a certain amount of times. He's not, for example, if he is thirsty, he is not able to say or request fluids and things like that. So I think what happens is it's very hard when you are in a catabolic state of your skin is kind of eroding, your body is trying to repair this, in order to build muscle and things like that so you can go on and you can rehabilitate better and hopefully regain your mobility.
I think it's what, it's towards, there is a point where you can't get enough nutrition in in order to meet the excess needs of the body.
Usually with G-tubes or feeding tubes, you can maybe get in 2,000 calories. This man may have required more than 2,000 calories, and the requirement then means that he is going to continue to break down his tissues if he needs more than that amount of requirement.
Q: What exactly is a contracture?
A: A contracture is where if a muscle is kept in a position long enough, it no longer bends, the muscle kind of stiffens into that position. It no longer moves.
Q: It didn't come out clearly in your written opinion, but you believe his contractures were caused by the fracture, correct?
A: The one contracture was the one where they had his cast in a flexion position which means it was, his knee was slightly bent.
So after six weeks, any of us if we had an immobilized joint experienced contracture, and part of physical therapy is to regain that mobility and initially they do that passively by stretching the muscle and they will experience like a muscle cramp trying to stretch that out.
Well in this case it's a more chronic type thing so you got to stretch against the resistance of that rubberband that's kind of shrunken. Like a cut or something that heals, it gets smaller so it holds that position.
Q: Would you agree that you have obviously testified that in your opinion it was the nursing home's obligation to make sure that Mr. Pietrzyk did not leave the nursing home, correct?
A: That's correct.
Q: That is because once he is outside of the nursing home, he may not be capable of caring for his own safety, correct?
A: That's absolutely true.
Q: He doesn't have the decision-making ability to exercise that care that other people would exercise on the streets of Chicago, correct?
A: That's true.
Q: Your only information as to how or when or how he got out of the home was what was that little section of the chart that you read, correct?
A: That's correct.
Q: You don't know, for example, if it was the police who first notified the home that Mr. Pietrzyk had left the home as opposed to the home discovering it before the police told them?
A: There is no information in the chart.
Q: Do you know the name Dr. Largosa?
A: Only as it appears in the chart. I do not know her in any personal or professional sense.
Q: So you don't know whether or not, for example, if Dr. Largosa wrote the death certificate, correct?
A: No, I do not.
Q: But she was or appears to be the treating doctor at times in the nursing home chart?
Q: Have you ever had a chance to read her opinion in these materials that Mr. Pietrzyk's fractured injuries accelerated his death and caused or contributed to his lack of mobility, his poor nutrition and hydration, his infections, his contractures, his respiratory problems, his pressure ulcers, his pain and suffering, his pneumonia and his mental state deterioration and ultimately his death?
If that is her opinion, that certainly consisted with your opinion, is that right?
A: Yes, it is. I think they are nearly identical.
MR. LEVIN: All right, I don't have anything.
MR. MACHALINSKI: Signature?
MR. LEVIN: Reserved.
(FURTHER DEPONENT SAITH NOT.)