45

1 physical therapists?

2 A. Yes.

3 Q. Do they also involve speech therapy?

4 A. Yes, they do. We have therapy and other level

5 of activities, but I'm just not aware of the details of

6 their program.

7 Q. Now, you became Terry's attending physician in

8 April of '98, correct?

9 A. That's correct.

10 Q. I want to direct your attention to bate number

11 Page 98 in Exhibit 12. It's further back, next to the

12 last page. The number 98 is within the middle of the

13 page. You got it?

14 A. Yes, I have it.

15 Q. Very good. The last entry is dated 4/20/98.

16 A. Yes.

17 Q. Is that your handwriting?

18 A. Yes, it is.

19 Q. I can almost read all of it, but would you

20 read it aloud?

21 A. Yes. "Chart review patient's condition.

22 Discussed with nursing staff and staff nurses.

23 Concerned about contractures of upper extremities and

24 elbows. Right worse than left, antecubital areas.

25 Yeast infection. No areas of cutaneous breakdown. No






46

1 respiratory symptoms. Patient stable. Lungs remain

2 clear. Cardiac examination regular; no murmur.

3 Neurologically unchanged. Impression: Anoxic

4 encephalopathy with residual persistent vegetative

5 state, contractures. Continue nursing home care.

6 Lotrimin cream to antecubital space to prevent yeast

7 infection. Husband declined physical therapy evaluation

8 for treatment of contractures."

9 Q. Have her contractures worsened since April 28,

10 1998, in your opinion?

11 A. I don't believe so.

12 Q. You don't believe so?

13 A. No.

14 Q. She was as contracted in April of 1998 as she

15 is today?

16 A. I believe so.

17 Q. Now, do you know why Mr. Schiavo was not

18 interested in physical therapy for his wife?

19 A. I didn't say that he declined. He declined

20 evaluation by the therapist. And his reason was that

21 she had had multiple evaluations and it seemed not to be

22 appropriate to call on someone else to make the same

23 evaluation.

24 Q. Well, it would be somebody right there on the

25 staff, wouldn't it?






47

1 A. Yes.

2 Q. So she gets no physical therapy?

3 A. Yes.

4 Q. And she has never had physical therapy while

5 under your care?

6 A. Yes. Treatment of the contractures is

7 something which is done as part of bedside nursing. And

8 we ask, you know, if there was anything more that could

9 be done. We asked the professionals who are on staff to

10 evaluate what work needs to be done, as Michael pointed

11 out to me at a particular point in time.

12 Q. So you deferred to his recount of his wife's

13 medical history?

14 A. Yes, I did.

15 Q. And you didn't search out a previous

16 evaluation?

17 A. I don't recall exactly what I did in April of

18 1998. Perhaps, he pointed out to me an evaluation

19 review and I was satisfied. I do remember discussing

20 with him, among other things that come up in the

21 records, but, then we have a limited amount information.

22 Q. And, well, aren't contractures normally

23 treated with physical therapy?

24 A. To a certain extent physical therapy can help,

25 yes.






48

1 Q. And, in fact, isn't physical therapy ordered

2 in order to prevent contractures or to prevent their

3 worsening?

4 A. Well, a physical therapist can help to a

5 certain point in which they provide a daily program for

6 the caregivers to maintain a level of flexibility.

7 Q. Do you work closely with Mr. Schiavo in taking

8 care of Terry?

9 A. Yes, I do.

10 Q. Are you in telephone contact with him?

11 A. Yes, I am.

12 Q. About how frequently?

13 A. If I notice that there are problems, I will

14 call him. But, certainly, if I notice anything that the

15 nurses raise or one of the nurse practitioners, I would

16 be in contact with Michael.

17 Q. So can you estimate how frequently that would

18 be that you would call?

19 A. I would say several times a year.

20 Q. Do you know when the last time you spoke?

21 A. Yes. I think the last time I spoke with him

22 was at the time of the examination in April. He

23 happened to be at the facility at that time.

24 Q. And Terry, in order to get the tube replaced,

25 you had to speak to him?






49

1 A. That's correct.

2 Q. Did she miss any feedings, do you know?

3 A. She gets fed 12 hours a day, so I don't think

4 that -- I couldn't tell you the exact time I had. There

5 was -- couldn't tell you. There was another physician

6 taking care of her.

7 Q. Who was that other physician? I thought you

8 were the main physician.

9 A. No. I do not -- I limit my practice to the

10 long-term care scope. Even though I have privileges at

11 the hospital, I prefer to have hospital specialists

12 attending in her care.

13 Q. So it's the staff physician or the attending

14 physician?

15 A. Yes. The physician on staff; that is correct.

16 Q. Do you know who it was?

17 A. Yes. Dr. Koletis.

18 Q. Do you know how to spell his last name for the

19 court reporter?

20 A. Yes. It's K-O-L-E-T-I-S. I don't think

21 it's Z.

22 Q. You did a good job.

23 Now, are contractures permanent, by the way?

24 A. They can be, yes.

25 Q. Are her contractures permanent?






50

1 A. Yes. As far as I know, yes.

2 Q. Now, when you accepted Terry as a patient, do

3 you remember who you accepted her from?

4 A. Yes, Dr. Mulroy.

5 Q. Dr. Mulroy?

6 A. Yes.

7 Q. And why did her care get transferred to you,

8 if you know?

9 A. I was told that Dr. Mulroy was concerned about

10 the conflict within the family and felt that -- he felt

11 better if he turned her care over to another physician.

12 Q. Did you speak with Dr. Mulroy before you took

13 over her care?

14 A. I believe I did, but I don't recall that

15 conversation.

16 Q. Did he give you his impression of her

17 condition?

18 A. Yes. He did forward the medical records to

19 me.

20 Q. Where do you maintain patient medical records,

21 by the way?

22 A. In the facility where the resident resides.

23 Q. Okay. So her medical records are all at

24 Hospice, as far as you know?

25 A. Yes, or Palm Gardens.






51

1 Q. But Dr. Mulroy's records of his treatment of

2 Terry came with her to Hospice; is that right?

3 A. I'm not sure if Dr. Mulroy's records have been

4 copied to Hospice. I couldn't tell you. They were at

5 Palm Gardens.

6 Q. Why did she get moved from Palm Gardens to

7 Hospice? You moved her, right?

8 A. Yes. That definitely wasn't my decision. I

9 feel there is a reason to move her from one medical

10 facility to another. It was just a decision that was

11 made by Michael.

12 Q. Mr. Schiavo?

13 A. Yes.

14 Q. And you conceded to that, once again?

15 A. Yes.

16 Q. Did you have reservations about putting her in

17 Hospice?

18 A. No, not in Hospice.

19 Q. Aren't patients admitted to Hospice Woodside

20 expected to die within six months?

21 MR. FELOS: Your Honor, I believe that

22 question calls for a legal conclusion by the

23 witness. I would object.

24 THE COURT: Overruled.

25 BY MS. ANDERSON:






52

1 Q. What's the answer to that question, Doctor?

2 A. I estimate that at Hospice -- Terry is the

3 resident who has been here the longest. They said they

4 have had no other resident that are in Hospice Woodside

5 a for longer period.

6 Q. Are the patients generally expected to die

7 within six months of their admittance? Isn't that a

8 Hospice policy?

9 A. No, it's not a Hospice policy. It's just a

10 guideline that is used to determine the prognosis for

11 Hospice.

12 Q. It's kind of a rule of thumb?

13 A. Yes.

14 Q. Now, do you remember when you first began

15 treating her?

16 A. In 1998?

17 Q. Yes.

18 A. Yes.

19 Q. What did you do at the time she came under

20 your care as far as clinical examination?

21 A. The examination was similar to the examination

22 that I made recently. It was a physical examination.

23 She was a new patient, so it took a longer period of

24 time to go through the records, talk to Michael and the

25 nursing staff.






53

1 Q. Now, what was her blood pressure at?

2 A. I do not take blood pressures myself. I rely

3 on blood pressure from the nursing staff. We

4 anticipated your question and I got that information

5 the. Systolic blood pressure range from 115 to 120.

6 Q. And diastolic?

7 A. Diastolic pressure -- you know, I forgot what

8 it was. It was in the low range. I think it was 70

9 plus or minus five.

10 Q. And what was the normal range?

11 A. I guess that would be considered within the

12 normal range.

13 Q. And these blood pressures are current as of

14 yesterday?

15 A. The blood pressures are current as of prior to

16 the beginning of the week.

17 Q. The beginning of the week?

18 A. Yes.

19 Q. Thank you for checking on that, Doctor.

20 Now, before the dialysis that was done in the

21 spring, the one that showed the colonization --

22 A. Yes.

23 Q. -- when was the timing for that that you

24 ordered the urinalysis?

25 A. In -- I don't have an answer on time, so I






54

1 have to read the records because I don't know exactly

2 when it was.

3 Q. If she is susceptible to urinary tract

4 infections, do you routinely order a urinalysis be done

5 on her?

6 A. No. We would not routinely do a urinalysis.

7 We would look for changes in condition, nursing

8 observations, foul odor to the urine, a fever, an

9 increased moaning. We would look for reasons to

10 investigate further. It might be something else besides

11 a urinary tract infection.

12 Q. Now, you've done two urinalyses this year on

13 Terry, correct?

14 A. Yes.

15 Q. And both of them were abnormal, also correct?

16 A. Yes.

17 Q. The first showed bacterial colonization, and

18 you ordered antibiotic therapy for her?

19 A. Yes.

20 Q. And then -- and that was in April?

21 A. Uh-huh.

22 Q. In September, she had a full-blown infection,

23 correct?

24 A. Well, I'm not sure of the term "full-blown,"

25 there was a urinary tract infection.






55

1 Q. I think you said it was significant.

2 A. Number of white cells, a number of significant

3 as opposed to insignificant, which would lead you in a

4 different direction.

5 Q. Well, I understand you are distinguishing it

6 from a colonization.

7 A. Okay.

8 Q. In the sense that she had progressed to an

9 infection as opposed to the colonization that she had

10 exhibited earlier?

11 A. Right.

12 Q. Okay. So two urinalyses, two abnormal

13 readings. Both times she got MRIs, right?

14 A. Yes.

15 Q. Is there any reason you didn't do a follow-up

16 urinalysis after April to make sure you killed off the

17 bacteria?

18 A. Yes. It's generally not recommended.

19 Q. How would you know that the antibiotic that

20 was given to her in April was ineffective and in fact

21 she has had an infection this whole time?

22 A. Along with the urine culture, you could order

23 an antibiotic study and that study tells you

24 specifically whether the antibiotic that you ordered is

25 bactericide, which kills the bacteria. Generally, these






56

1 antibiotics are in very high concentrations in the

2 urine.

3 Q. So you're confident that you killed off this

4 bacteria in April?

5 A. Yes, based upon that information. And I think

6 that you will find when you talk to experts that in

7 urinary tract infections, they would not recommend a

8 follow-up urine culture.

9 Q. When did you -- when did her most recent

10 urinary tract infection start?

11 A. I don't know if I could answer that question

12 to tell you what date that was. But the nurses did note

13 that there was some increase

moaning, they were

14 concerned to be problems. So when you have changes like

15 this, it would be appropriate to check urine.

16 Q. Now, this urinalysis, this most recent one

17 that detected the infection, was pursuant to court

18 order, right?

19 A. Yes, it was pursuant to court order.

20 Q. All right. As far as her annual physical, do

21 you order a urinalysis usually?

22 A. Yes, we would perform a urinalysis. Not

23 necessarily for infection, but to look for other

24 problems or metabolic problems.

25 Q. Albumin is related to liver function, isn't






57

1 it, or kidney function?

2 A. Yes. Her albumin reading was abnormal.

3 Q. What would that abnormal reading indicate to

4 you?

5 A. The abnormal albumin?

6 Q. Yes.

7 A. Well, first off, it would be malnutrition, and

8 there was no evidence of malnutrition. And my thought

9 was that since it was borderline and had been borderline

10 in the past, that this was indicative of someone with

11 very low muscle mass, that she has. She has not moved,

12 so her muscles are all shriveled. They are essentially

13 scar tissue.

14 Q. Her muscles are scar tissue.

15 A. Well, they have atrophied.

16 Q. They have atrophied, haven't they?

17 A. Yes, they have.

18 Q. Would physical therapy help that?

19 A. If you continue to move the muscles.

20 Q. Would she --

21 A. If there's no innervation to the nervous

22 system through the muscles, it won't help.

23 Q. Did she get range of motion therapy?

24 A. She should have range of motion therapy. And

25 not having read the observation, I'm assuming it's been






58

1 done.

2 Q. What would range of motion therapy consist of?

3 Can you describe it for the court?

4 A. Well, I could describe it briefly. Physical

5 therapy consists of -- first, you very slowly move the

6 hands, wrist, shoulders to the point where it might

7 cause some discomfort and then relax it. And that's the

8 range of motion they're able to perform on Terry.

9 Q. Because of her contractures?

10 A. That's correct.

11 Q. You're not sure they are doing that though?

12 A. Yeah, they are.

13 Q. You do know that for sure?

14 A. Not how often and what extent. I would have

15 to review the records and the nurses' notes.

16 Q. How is it that you are sure she is receiving

17 range of motion therapy?

18 A. Because when I examined her, there would be

19 findings that would suggest, you know -- if you're not

20 moving them, as you might find in someone that is not

21 eating properly, that would be an indications that

22 suggesting that the care was taken in the proper matter,

23 that they were not moving the limbs in certain areas.

24 In Terry, you do not see that.

25 Q. Now, is it safe to say that the lab work Terry






59

1 has had done this year pursuant to court order is an

2 unusual amount of work in terms of your care of her?

3 A. There were tests which I wouldn't normally

4 order unless there was some suspicion. And, yes, I did

5 those tests in addition to routine care.

6 Q. So this year she has received more blood work,

7 urinalysis, and so forth, than in any other year under

8 your care?

9 A. I could tell you there were some additional

10 tests that were performed.

11 Q. Additional?

12 A. Yes. You know, the court order was, you know,

13 consistent with the time that I had. The interesting

14 thing was that I had just seen her and George called me

15 and told me that these are the tests we needed, and I

16 had no real problem ordering these extra tests because

17 it was just part of the examination. There was some

18 additional blood tests, endocrine tests, you know, which

19 I would not have requested.

20 Q. So twice a year you order blood work to be

21 done on her?

22 A. Yes.

23 Q. You do?

24 A. Yes.

25 Q. And twice a year you do a urinalysis?






60

1 A. I have been doing the urinalyses when there

2 are symptoms. So the urinalysis may be done more often

3 than twice a year.

4 Q. Is she anemic right now?

5 A. No, she is not.

6 Q. What's her hemoglobin reading on that test?

7 A. In the Exhibit 2, the blood count is not

8 recorded.

9 Q. Was the hemoglobin count not part of that?

10 A. It's not on the exhibit, so I could not give

11 you the exact number. The test was done but not

12 recorded in the exhibit. This shows that the report

13 says the test was completed. But flipping through, I

14 don't have the report, so I could not tell you exactly

15 her hemoglobin. But, I was told it was normal.

16 Q. So the report simply says that they did the

17 test?

18 A. The test. And I receive reports over the

19 phone, as I haven't been in this facility since. The

20 records are kept in the facility, so I received a report

21 over the phone. And the nurse told me that the white

22 count of the hemoglobin were within the normal range and

23 there was one very slight abnormality, which was of no

24 concern.

25 Q. And that's the albumin?






61

1 A. Yeah. That would be the albumin.

2 Q. Isn't her vitamin B-12 deficiency slightly

3 off, also, in that same report?

4 A. The vitamin B-12 is 1,515. It should be

5 somewhere under 200.

6 Q. Reference range is normal, 4.0, to, looks

7 like, 22 nanograms per milliliter.

8 A. It says in the -- okay. You may not be

9 familiar with this report, but on the top, the third

10 line laboratory it says "vitamin B-12 level." And if

11 you read across it says 1,515-H, H being high. If you

12 go a little further, it references "reference range 211

13 to 911."

14 Now, if you look down to the bottom of the

15 page, they explain it further. The normal range to

16 intermittent range is 106 and a deficient range of less

17 than 159. So she is ten times what someone would be if

18 they were deficient. The folic acid, also, is high. As

19 I mentioned earlier, I concluded the borderline albumin

20 was not consistent with a deficiency stated.

21 Q. I can't quite make out the readings under

22 vitamin B-12.

23 A. FHS is folate. And then, under that, FHS,

24 vitamin B-12, and then folic.

25 Q. And you order these tests twice a year?






62

1 A. I order these tests --

2 MR. FELOS: Objection, Your Honor. That's

3 been asked and answered.

4 MS. ANDERSON: Not as to these specifics

5 tests.

6 THE COURT: She's just following up on the

7 tests.

8 THE WITNESS: I order all of the tests twice a

9 year.

10 BY MS. ANDERSON:

11 Q. Not all of them?

12 A. Not all of them, no.

13 Q. Now, she also had an unusual number of imaging

14 tests done, has she not?

15 A. Yes. I would say that there were certainly a

16 number of tests done in the years that I have been

17 treating her.

18 Q. Have you ever ordered a CT scan be done on

19 Terry other than pursuant to the court order?

20 A. No.

21 Q. Did you review a CT scan when she first came

22 under your care?

23 A. A CT scan of the brain.

24 Q. Of the brain. Okay.

25 A. I did not review the actual films, but I was






63

1 given a report from Dr. Mulroy at the time, her prior

2 treating physician.

3 Q. Have you ever reviewed her film?

4 A. No, I have not.

5 Q. Did you look at the film from the CT scan that

6 was done recently?

7 A. No, I have not.

8 Q. She also had a spec scan done. You are aware

9 of that, right?

10 A. Yes.

11 Q. Did you schedule that?

12 A. No, I did not.

13 Q. You left that to Mr. Felos or Mr. Schiavo?

14 A. Yes. I was not involved with the scheduling

15 of those tests or the ordering of those tests, and the

16 copy of those reports would go to Mr. Felos.

17 Q. You were out of the loop on that?

18 A. That's correct.

19 Q. Do you consider yourself particularly

20 qualified to read a CT scan?

21 A. Absolutely not.

22 Q. When Terry initially came under your care,

23 what was her diagnosis?

24 A. Chronic persistent vegetative state.

25 Q. And did you accept that diagnosis?






64

1 A. Yes, I did.

2 Q. Tell me what you did, if anything, to confirm

3 the diagnosis in your own mind to your own professional

4 standards?

5 A. I read the reports of the other physicians,

6 Dr. Barnhill, who I have a lot of faith in him, and my

7 own examination. And the findings were such that I felt

8 she met those criteria.

9 Q. And what did you consider those criteria to

10 be?

11 A. Her brain studies and brain wave tests showed

12 that she has a brain which is predominantly replaced by

13 spinal fluid.

14 Q. Whose report says that?

15 A. That's the report of the scan that I saw.

16 Q. The written report?

17 A. Yes.

18 Q. So you relied on that and relied on

19 Dr. Barnhill's report?

20 A. Yes.

21 Q. What else did you do?

22 A. I performed an examination.

23 Q. Tell me your findings from that examination.

24 A. I found that Terry had no appreciation of her

25 environment or purposeful movement.






65

1 Q. How did you determine that?

2 A. By examination.

3 Q. What did you do specifically?

4 A. Well, I used my voice to see if I could get a

5 response. I used my hand to put over her eyes to see if

6 there was a response to vision or visual threats. These

7 were some of the things that I did to determine if there

8 was a response. I also discussed with the caregivers

9 who work with her day in, day out -- as you know, my

10 time with her short -- and no one felt they were able to

11 have any response from her as far as an appreciation of

12 her environment.

13 Q. What else did you do?

14 A. Also we want to look for metabolic or other

15 conditions that may influence the neurologic stats,

16 depress the neurologic stats. The blood studies that

17 were done might suggest there were other conditions,

18 like her drugs, for instance, that would depress her

19 neurologic condition.

20 Q. So you read labs reports on her?

21 A. Yes.

22 Q. Did you check her reflexes?

23 A. Yes, I did.

24 Q. And were her reflexes in tact?

25 A. She had some spinal cord reflexes, brain stem






66

1 reflexes.

2 Q. Have you ever observed Terry in presence of

3 her mother?

4 A. No, I have not.

5 Q. How much time did you spend with Terry to

6 initially satisfy yourself that she was in a persistent

7 vegetative state?

8 A. The first time I was there I was probably

9 there for an hour.

10 Q. One hour?

11 A. Yes.

12 Q. And part of that time was spent reviewing

13 reports?

14 A. Right. I have to tell you that sometimes I do

15 make my notes -- I have private rooms, so I can make my

16 notes and sit there and observe her, review some records

17 and observe her again. So I can have more and more

18 contact.

19 Q. Did that occur on that occasion? The very

20 first time you were in the presence of Terry Schiavo

21 when you first examined her, did you sit with her for

22 one hour and observe her?

23 A. That's correct. That's why, as I mentioned to

24 you, to satisfy myself that, you know, her condition was

25 what everyone said it was.






67

1 Q. Well, what Dr. Barnhill said it was.

2 A. Well, I don't think there was anyone else who

3 disputes Dr. Barnhill.

4 Q. And Mr. Schiavo told you that his wife was in

5 a vegetative state?

6 A. I don't think he actually came out and used

7 those words to describe his wife's condition.

8 Q. How was it that it came out that you, as

9 opposed to all of the other physicians in Pinellas

10 County, were chosen to be her attending physician?

11 A. Maybe you can ask Mr. Schiavo. He is the one

12 who selected me.

13 Q. Did he come to you because of Dr. Barnhill's

14 recommendation? You said that Dr. Barnhill consults in

15 some of your cases.

16 A. Yes. I don't think that that was the case.

17 But, again, you know, I don't know what criteria he used

18 to select me.

19 Q. Okay. So in addition to using your voice and

20 putting your hands over her eyes and checking her

21 reflexes and reading reports, what else did you do to

22 satisfy yourself that she was in a persistent vegetative

23 state?

24 A. I felt that I was satisfied from that point.

25 I examined reports, discussed with the staff, reviewed






68

1 the records. I felt that she was in a persistent

2 vegetative state. She has not changed during the four

3 years I have taken care of her.

4 Q. And that's based on your quarterly visit with

5 her and observation?

6 A. That's correct. I just mentioned the last

7 time that I testified, I consented to the same thing.

8 So someone who had spent a lot of time going through all

9 of her extensive box of records in detail. I found in

10 one of the notes somewhere where a recreational

11 therapist pointed out to me the only thing in the record

12 that would suggest that she could appreciate her

13 environment.

14 Q. So in your mind, the appreciation of the

15 environment would be the key factor in determining

16 whether she was in PVS.

17 A. I think that's part of the criteria.

18 Q. What else?

19 A. I'm just talking about what the caretakers

20 know, and that was my point. So I just want to point

21 out that I had asked many people. But someone who

22 actually spent a lot of time on your side with respect

23 to this, that's the only information they were able to

24 bring to me and say, look, we will you read this.

25 Q. And that's, of course, assuming that the






69

1 medical chart is totally complete, right?

2 A. From your side, this is the only thing that

3 was brought to me to say, look, here's somebody who has

4 a different opinion.

5 Q. Now, have you ever tried to evoke a smile from

6 Terry?

7 A. I treat her, you know, as I would any other

8 patient, you know. I speak to her when I'm there as

9 another person. And I -- you know, when you're

10 examining someone you say, "I'm going to turn you to the

11 side, listen to your heart." So I would treat her like

12 any patient; not as someone who would not be able to

13 respond. In all of my visits, I have not appreciated

14 any response.

15 Q. Has it always just been you and Terry and,

16 perhaps, a nurse in the room?

17 A. Yes, sir, that's correct. Michael has been

18 there a couple times.

19 Q. Michael has been there?

20 A. Yes.

21 Q. But you have never observed her in the

22 presence of her parents?

23 A. No, I have not.

24 Q. You have never seen her in the presence of her

25 brother or sister, either, right?






70

1 A. No, I have not.

2 Q. The last time you saw her, did she appear to

3 be in any imminent danger of dying; was she in crisis?

4 A. No.

5 Q. You say that her condition is basically the

6 same?

7 A. Yes.

8 Q. Not deteriorating?

9 A. No.

10 Q. And that's since April of '98?

11 A. Yes; that's correct.

12 Q. Is her saliva suctioned on a regular basis?

13 A. I don't think that's been a problem.

14 Q. When you are with her --

15 A. I haven't seen a suction machine. They

16 haven't brought that to my attention that saliva was a

17 problem.

18 Q. So when you have been with her and observed

19 her, she has been swallowing her saliva?

20 A. You could assume that she was swallowing her

21 saliva. Saliva is made from stimulation or food or

22 objects in the mouth. Nothing goes in her mouth, so her

23 saliva production is probably less than a normal

24 person's. So in reference to the amounts of saliva she

25 would make is different in reference to a person in a






71

1 different situation.

2 Q. But regardless of whatever it is, she is

3 swallowing?

4 A. Yes.

5 Q. What is that name of the swallowing test that

6 is done?

7 A. The video swallowing.

8 Q. Right. Has that ever been done on her?

9 A. I don't have that information for you.

10 Q. You have not ordered it, anyway?

11 A. That's correct.

12 Q. Now, assuming somebody has the time, could she

13 be fed by mouth?

14 A. Well, the nurses are very concerned even with

15 oral care because of aspirations.

16 Q. Now, speaking to oral care. A dentist

17 examined her this year, right?

18 A. Yes.

19 Q. When was that?

20 A. That was maybe in April. It was around the

21 same time as my examination.

22 Q. Was that pursuant to court order?

23 A. I don't know if it was court ordered or a

24 suggestion was made.

25 Q. Was it related to this litigation, these






72

1 proceedings?

2 A. Perhaps. You know, all I know is that

3 George Felos asked me if she had a dental examination

4 recently, and I said I will check it out.

5 Q. Now, was the dental examination in April of

6 2002 the first dental exam she had received since you

7 have been her attending physician?

8 A. Probably not. I don't know what the

9 regulations cite. We're not governed by the same state

10 regulations as a nursing home. But in a nursing home, a

11 dental examination is required. So Terry would have had

12 such examination unless there was a refusal to have an

13 exam done.

14 Q. She would have had an annual dental exam if

15 she would have been in a nursing home, right?

16 A. Yes.

17 Q. And you are saying you are not sure if that

18 same statement applies to Hospice?

19 A. Right.

20 Q. So you are not sure if that applies?

21 A. Right. But I didn't go back into the record

22 to Palm Gardens to see if she had one. I guess,

23 obviously -- I noted what the findings were from the

24 dentist and those findings were not of concern. So what

25 it showed last year or the year before were not of






73

1 concern.

2 Q. Well, you are assuming it wasn't done last

3 year or the year before?

4 A. I'm not assuming anything at all. I'm saying

5 if she was at Palm Gardens, unless there was a refusal

6 to have an examination, it should have been done.

7 Q. Were you present during the dental exam?

8 A. No, I was not.

9 Q. Did the dentist recommend a deep cleaning?

10 A. I don't recall reviewing his report. If you

11 have it.

12 Q. Do you know if her teeth were cleaned this

13 year?

14 A. Her teeth were not cleaned this year as far as

15 I know.

16 Q. They were not cleaned by a dental hygienist as

17 a part of normal routine care?

18 A. Right.

19 Q. I'm talking about a dental hygienist. So you

20 know that her teeth were not cleaned; is that what you

21 are saying?

22 A. They were not cleaned by a dental hygienist.

23 Q. I don't know if I have that copy with me right

24 now.

25 MS. ANDERSON: Judge, I'm perceiving some






74

1 restlessness. Would you like to take a break,

2 court reporter?

3 THE COURT: I was going to go to 11:30, which

4 would be two hours. But we can break now if you

5 would like. How much additional time do you

6 anticipate spending with this witness?

7 MS. ANDERSON: Several more hours. Probably

8 two, three more hours. Two hours.

9 THE COURT: Okay. Let's take ten minutes now

10 and, obviously, we will break for lunch.

11 Now, Dr. Gambone, I'm going to have to

12 instruct that you during this break you are still

13 on the witness stand, figuratively speaking.

14 Please, don't talk to anybody except for, perhaps,

15 a bailiff or other court personnel, if you have

16 questions of where to go and so forth. Okay. We

17 will stand in recess for ten minutes.

18 BY MS. ANDERSON:

19 Q. Dr. Gambone, has Terry moved in a Gerry chair.

20 Does she sit in a Gerry chair instead of her wheelchair?

21 A. She sits in a specialized chair. I don't use

22 the term "Gerry" chair.

23 Q. What is a Gerry chair?

24 A. A Gerry chair is a particular brand of chair

25 which has a table at the waist level.






75

1 Q. Is it mobile?

2 A. Yes, a Gerry chair has wheels on it.

3 Q. Have you ordered that Terry not be taken

4 outside for fresh air?

5 A. If there is an order on the chart from me, I

6 don't recall such an order.

7 Q. There is no medical reason she can't go

8 outside?

9 A. That's correct.

10 Q. Do you know if she's been taken outside for

11 fresh air during the entire time you have been her

12 attending physician?

13 A. I do not know that.

14 Q. Would it surprise you if Terry laughed at a

15 funny story?

16 A. Yes.

17 Q. That would be something new for you?

18 A. Yes.

19 Q. Would that be inconsistent with your

20 diagnosis?

21 A. Yes.

22 Q. Would you be surprised if Terry smiled and

23 vocalized and turned her head toward her mother's voice

24 and face?

25 A. Yes.






76

1 Q. Would that be inconsistent with your

2 diagnosis?

3 A. Yes, if it was a response and not just a

4 random act.

5 Q. Right. Assuming that she heard her mother's

6 voice and smiled and turned her head and began

7 vocalizing.

8 A. Yes.

9 Q. That's something you have never observed?

10 A. No, I have not.

11 Q. Would it surprise you if she, say, raised her

12 leg on command?

13 A. Yes.

14 Q. Have you ever given her a command to raise her

15 leg?

16 A. I have, during my examination, said move to

17 the side, but there is no appreciation of a comment or

18 cooperation.

19 Q. Would it surprise you if she laughed in

20 response to piano music?

21 A. Yes, it would surprise me.

22 Q. And that would that be inconsistent with her

23 diagnosis?

24 A. Yes.

25 Q. Would it surprise you if she visually tracked






77

1 an object, a moving object, in front of her face?

2 A. Yes, it would.

3 Q. That's because you are not able to evoke that

4 response from her?

5 A. That's correct.

6 Q. What did you move in front of her face? What

7 object was it?

8 A. Terry would generally look to the right. Most

9 of her eye movements, looking and twitching to the

10 right. So on the right side I think there is something

11 that you said or did cause her to look to the right. If

12 you do it on the left, you're not going to get that same

13 response.

14 MS. ANDERSON: Move to strike. That answer as

15 not responsive, Your Honor.

16 BY MS. ANDERSON:

17 Q. My question, Doctor, was what object did you

18 use to get her to visually track?

19 A. I was talking about moving your body from one

20 side of the room to the other side of the room or to use

21 your hand.

22 Q. Has Terry ever turned her head toward you,

23 toward your presence during your ten-minute examinations

24 of her?

25 A. Not at me.






78

1 Q. Would it surprise you if she did?

2 A. Yes, it would.

3 Q. Now, does Terry require special nursing care?

4 A. Yes. I would say so.

5 Q. And have you given any instructions in that

6 regard?

7 A. Yes, she has instructions for her care.

8 Q. Have you given it?

9 A. Yes. It's called "orders." Physician's

10 orders of her care.

11 Q. What is the nature of her special nursing

12 requirements?

13 A. She has a feeding tube.

14 Q. And that requires special nursing care?

15 A. I suppose that someone could be trained to

16 give those feedings. A lay person could be trained in

17 the medical requirements of a feeding.

18 Q. A lay person could be trained to give what

19 feedings, the tube feedings?

20 A. Yes.

21 Q. Would a lay person be trained to spoon-feed

22 her?

23 A. That's not something that I would recommend.

24 Q. What presently is the state of Terry's

25 gynecological health?






79

1 A. It appears that she has regular menstrual

2 periods. Her last lab showed that the FSH was in the

3 range of normal for someone her age.

4 Q. What is that, the estrogen level?

5 A. Yes.

6 Q. What does the last pap smear show?

7 A. Last pap sheer was done prior to my evaluation

8 of her. Michael told me that in 1996, that she had her

9 last examination and that examination was normal.

10 Q. So she hasn't had a pap smear since 1996?

11 A. That's correct, in six years.

12 Q. What did her last mammogram show?

13 A. I don't know.

14 Q. Do you know if she ever had a mammogram?

15 A. Allow me to look at my report.

16 Q. Absolutely.

17 A. It may be indicated on there. My report

18 indicates that she's never had a mammogram.

19 Q. Does she have kidney stones?

20 A. Excuse me?

21 Q. Does she have kidney stones?

22 A. My report shows there is no history of kidney

23 stones.

24 Q. Have you checked for them?

25 A. Blood in the urine would be an indicator of






80

1 kidney stones. You would not routinely do the test for

2 kidney stones unless someone came down with symptoms or

3 blood in the urine.

4 Q. And you found no blood in the urine on this

5 last test?

6 A. I do not have the report of the urinalysis

7 with me, but there are occasions that blood is found in

8 the urine in small amounts, microscopic amounts,

9 associated with the catheterization process, that is a

10 tube in the bladder to collect the urine. That could be

11 also related to infection.

12 Q. Has she had her gallbladder removed?

13 A. According to my records, the gallbladder was

14 removed in 1994.

15 Q. Are their after-effects of the gallbladder

16 removal that you can detect?

17 A. Not that I'm aware of. She has had multiple

18 blood studies on liver function.

19 Q. Is that the albumin, this test?

20 A. Yes. The albumin is not necessarily, you

21 know, an indicator of liver problems.

22 Q. It's relating to liver function?

23 A. It could be related to many things in the

24 body.

25 Q. I think earlier you said it was related to






81

1 liver function.

2 A. I said that albumin is made by the liver. But

3 if you were to look for a test of liver function,

4 abnormality of albumin would be down on the list of

5 tests that you would look at to diagnosis a problem.

6 Q. So albumin is related to what other bodily

7 condition?

8 A. Malnutrition.

9 Q. Malnutrition. That's what you said. No other

10 thing?

11 A. No, there are other conditions that albumin

12 can relate to.

13 Q. What other conditions?

14 A. Overhydration. If someone were to drink

15 excessive amounts of water, that could affect the count.

16 It's a delusional effect, so to speak.

17 Q. What else, what other condition might explain

18 lower albumin?

19 A. If the body was making immunologic proteins

20 instead of -- there was a diversion of metabolism to

21 make inflammatory proteins, hemoglobins, that would take

22 away from the synthesis, that is the building of the

23 albumin. So in that case you would find the total

24 protein would be higher because there are total proteins

25 that the albumin would be lower in proportion.






82

1 Q. Do you believe that either of those conditions

2 would account for the lower albumin?

3 A. No, I don't.

4 Q. How acute is Terry's hearing?

5 A. I don't know.

6 Q. Do you know how acute her eyesight is?

7 A. She has no reaction to visual threat that I

8 could detect. What I'm doing is taking your hand and

9 putting it over someone's eyes, their reaction would be

10 to blink in response to that.

11 Q. Which eye did you cover, by the way?

12 A. I checked both eyes.

13 Q. I realize that you don't take the blood

14 pressure. But have you observed the nurse taking her

15 blood pressure?

16 A. No, I have not.

17 Q. Do you know, given the state of her

18 contractures, how they do it?

19 A. Yes. The nurse takes her blood pressure in

20 the leg because of the contractures.

21 Q. They put the cuff on the calf?

22 A. Yes.

23 Q. Is there any indication that Terry cannot have

24 a bowel movement?

25 A. Not that I'm aware of.






83

1 Q. To what extent have you relied on Mr. Schiavo

2 for her medical history?

3 A. I think that he has been a part of the medical

4 history. And the history that I obtained and the

5 information that I have given you here are pieces of

6 information that might assist me, along with the medical

7 records.

8 Q. So to the extent that you have information

9 that's not in the medical records, it comes from

10 Mr. Schiavo, pretty much?

11 A. Yes. I think the information outside the

12 medical record comes from Mr. Schiavo, yes.

13 Q. Have you ever interviewed the parents?

14 A. No, I have not.

15 Q. Have you ever met them at all?

16 A. Just to shake hands at one prior hearing, yes.

17 Q. Okay. Do you think Terry feels pain?

18 A. I think the word "feel" -- there is a reflex

19 action at the brain stem level which shows a response to

20 pain. But I don't think the "word" feel is the right

21 word.

22 Q. So she reacts to pain?

23 A. Yes, a physiologic brain stem reaction.

24 Similar to if you were to touch your finger to a hot

25 stove, you would pull your hand away before you realized






84

1 that you were burnt.

2 Q. So it would be sort of instantaneous. It's a

3 reflex?

4 A. It's a reflex, yes.

5 Q. If she appears to be in pain, then, for longer

6 than a second or two, would it be more accurate to say

7 that she is feeling pain?

8 A. I would not use the word "feel" for someone

9 without recognizable cognition. I don't think that's

10 the proper term.

11 Q. Do you order pain medication for Terry?

12 A. Yes, I do.

13 Q. Why, if she doesn't feel?

14 A. The nurses state that she moans from time to

15 time and this seems to be associated with her menstrual

16 period. They asked me to prescribe medication for her

17 menstrual period pain.

18 Q. To relieve pain?

19 A. Yes.

20 Q. But it's not for their benefit, is it?

21 A. It's to their benefit and for Terry's benefit.

22 Q. How is it for the nurses' benefit to medicate

23 Terry for pain; so they don't have to listen to her

24 moan?

25 A. I think that's a good answer.






85

1 Q. Now, that little summary that you used that

2 the brain will protect her hand from being burned on a

3 hot stove by causing you to jerk it away before it even

4 registers --

5 A. Yes.

6 Q. -- that it's hot.

7 A. Right.

8 Q. So that would indicate a very instantaneous

9 pain reaction pain reflex, right?

10 A. Yes. I think we are talking about many

11 reflexes that occur. In light of the reflexes, I just

12 described one of those reflexes to give you an idea of

13 something in your own world how you can relate to a

14 spinal reflex or some reflex that's lower than your

15 actual willful movement. That's all my remark was.

16 Q. It's not a precise analogy, is what you're

17 saying?

18 A. No, it's not a precise analogy. And I think

19 we have many other experts who we know in this area that

20 maybe could delve into that further.

21 Q. So if it were proven to your satisfaction that

22 she has a cognizant awareness of her environment, you

23 would be more comfortable saying Terry feels pain?

24 A. Yes.

25 Q. Have you ever witnessed her moaning, appearing






86

1 to moan in pain?

2 A. No, I have not.

3 Q. Has she ever made any sounds in your presence?

4 A. I do not recall her making any sounds.

5 Q. Would you say that Terry has lived longer than

6 might otherwise be expected given her condition?

7 A. No.

8 Q. Do you have patients who live longer?

9 A. No.

10 Q. Can you reconcile those two answers for me?

11 A. Yes.

12 Q. Would you do it?

13 A. Yes. I guess she is otherwise a physically

14 healthy woman who receives very good care. And it

15 wouldn't surprise me that she has been medically stable

16 up until this period of time.

17 Q. So barring removal of the feeding tube, she

18 could be expected to be to live on, right?

19 A. Yes.

20 Q. Have you ever had a patient just give up the

21 will to live and die?

22 A. Yes.

23 Q. Do you think if Terry had given up her will to

24 live, she would be dead right now?

25 MR. FELOS: Your Honor, I want to object.






87

1 That's supposing that she does have an expressive

2 will, which is what we are here to determine.

3 MS. ANDERSON: He can express his opinion on

4 it.

5 THE COURT: I will allow him to answer the

6 question.

7 THE WITNESS: Could you repeat the question,

8 please?

9 BY MS. ANDERSON:

10 Q. Sure. If Terry had lost her will to live, do

11 you think she would be dead now?

12 A. I don't know.

13 Q. You're not sure?

14 A. I really didn't know her as the person she

15 once was.

16 Q. Well, the will to live is a documented medical

17 phenomenon, is not it?

18 A. A living will, did you say?

19 Q. The will to live, desire to survive.

20 A. Yes, it is.

21 Q. You have probably encountered it a fair amount

22 in your practice, have you not?

23 A. Yes, I have.

24 Q. When patients give up the will to live, what

25 do they do? How can you tell it's their position?





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