A doctor assesses Michael Jackson’s cause of death

Source: Artie Wayne on the Web

Since shortly after Michael Jackson’s death, the powerful anesthetic propofol has been suspected as the cause of death. Details of Jackson’s final hours were released today by the Los Angeles coroner’s office. Although the final injection of propofol may have been the immediate cause of death, it’s only one small part of the larger and tragic picture.

There are good accounts of Jackson’s final hours in the Los Angeles Times and at CNN.

The sequence was as follows:
10 mg of Valium at about 1:30 AM
2 mg Ativan (an anti-anxiety drug) at about 2 AM
2 mg Versed (a sedative) at about 3 AM
An additional 2 mg of Ativan at about 5 AM
An additional 2 mg of Versed at about 7:30 AM
Jackson still could not sleep and pleaded for the anesthetic propofol.
25 mg of propofol at about 10:40 AM.

Dr. Kevin Pho provides an analysis from a medical perspective.

So, before the “fatal” propofol dose was given, Jackson was given enough benzodiazepines to put down a large animal, yet alone someone of his slight frame. …

First, it’s obvious that Jackson must have had significant resistance to the sedatives, for these amounts not to put him to sleep. Also consider that the drugs were given intravenously, which only intensifies the effect as well as quickens the onset of action.

Second, there’s no question that Dr. Murray, a cardiologist, was in over his head. Jackson needed medical care far beyond what was offered to him. With a clear pattern of addictive behavior, which Dr. Murray recognized, Jackson would have been better served by a team of clinicians who could have offered better psychosocial support in trying to wean back his benzodiazepine use.

Third, I don’t know how anyone can point solely to propofol as the definitive cause of death. The massive quantities of sedatives that were previously given, either alone or in conjunction with the propofol, could have easily caused Jackson’s presumed respiratory and cardiac arrest. …

And finally, this case highlights the risks of treating celebrity patients. Michael Jackson was calling the shots, and despite Dr. Murray’s reservations, he still received the drugs he requested. Had Dr. Murray refused, he probably would have been fired and replaced.

Doctor to the stars

Kevin O’Reilly quotes a number of doctors who treat celebrities in an American Medical News story:

Physicians can get starstruck too, and may unconsciously try to please these special patients in ways that are medically inappropriate. …

“You really have to assess your own liability,” Dr. Pinsky said. “Are you seduced by the opportunity to bask in the glow of celebrity? Is it particularly appealing to you to have a powerful person say you did a good job? Will you be able to sustain that same person saying, ‘I can’t believe you won’t give me what I want’? You had better be prepared, because that is exactly what you’ll get. You have to do what’s best for the patient and not be seduced by the fame.”

The doctor-patient relationship can become “adulterated” by the elephant in the exam room — the patient’s fame. …

Some celebrities “are really, really nice” but “others are extremely manipulative, and there is a lot of drug-seeking behavior,” Dr. Brazina said. “They have a true sense of entitlement where there’s a sense of, ‘I’m special, I’m different; I don’t have to follow the rules.’ ”

“It is a power issue,” said Dr. Turton, a Sarasota, Fla., internist. “In a normal doctor-patient relationship, there is a well-defined power relationship. The doctor has the power to prescribe, and he follows his professional tenets to do that appropriately, and we depend on him for that. But if the patient has power over the doctor, then it short-circuits those professional guidelines and safeguards. … That is the conflict of interest — who are you really taking care of here, yourself or your patient?”

Many doctors said celebrities rightly believe they easily can get another physician to see them immediately if the doctor does not accede to their demands. This kind of doctor-shopping also changes the power dynamic.

Dr. Pho concludes: “Propofol didn’t kill Michael Jackson. Addiction did.”

Related posts:
Health Culture Daily Dose #14: Pop culture
Michael Jackson