MEDICAL MATTERS:HOW DID Dr Conrad Murray, now convicted of the involuntary manslaughter of pop star Michael Jackson, end up prescribing and administering a questionable cocktail of drugs for his world famous patient?
The Los Angeles County Coroner said in his ruling that the powerful anaesthetic propofol, as well as the sedative lorazepam, were the primary drugs responsible for Jackson’s sudden death at the age of 50.
Whatever about his questionable behaviour on the day of Jackson’s death, one of the principal reasons Murray got into professional difficulty was a failure to set professional boundaries with his patient.
According to evidence given at the trial, the pop star had great difficulty sleeping. It appears that the occasional use of sleeping tablets were ineffective, leading to Jackson requesting much stronger medication. He was subsequently administered the intravenous anaesthetic agent, propofol.
This drug is designed to be used in a hospital setting because of its potential side effects. So for Murray to agree to a request from his patient to use a drug that is not primarily designed as a hypnotic, outside the usual hospital environment, was a mistake.
According to material used by the Medical Protection Society in the education of doctors, this type of behaviour often arises when a doctor does not set appropriate boundaries in a doctor-patient relationship. Just as it is inappropriate for a doctor to have a sexual relationship with a patient, so also it is vital that he firmly reject any request for inappropriate treatment.
This may involve a request for opiate drugs from someone with an addiction. Or a doctor may be asked to provide a medical certificate for insurance purposes that does not accurately report the dates or type of an illness.
Whatever the trigger, there is research evidence to suggest that if a doctor says yes to the first such inappropriate request, he will find it most difficult to refuse subsequent requests. Setting boundaries and explaining why they are in the patient’s best interest is an essential element of good medical practice.
Propofol is a powerful anaesthetic, in regular use since 1986; one of its attractions is its ability to induce amnesia as well as drowsiness during unpleasant but relatively quick medical procedures. It is not available in tablet form and must be given intravenously by someone trained in its use.
The use of propofol outside an operating theatre, emergency department or intensive care unit is highly unusual. Administering it in a person’s home is downright suspicious. Without using a blood pressure and heart rate monitor, along with devices to check the level of oxygen saturation in the blood as well as a person’s breathing, it is difficult to see how any doctor could justify its use outside the hospital setting.
A white liquid, which explains why some doctors refer to it as the “milk of amnesia”, propofol can be extremely dangerous if not constantly monitored because it can slow breathing and fatally lower blood pressure. And its effects are compounded by other drugs in a person’s system. Propofol may also induce psychological dependency because of associated feelings of euphoria, relief of stress and an ability to induce sexual disinhibition experienced by some people when they wake up.
So how could Murray use propofol in such a highly questionable way? Partly because, despite the involvement of regulatory authorities in approving drugs and deciding on limitations as to their use, an individual doctor retains the right to prescribe any drug “off label”.
And partly because, according to testimony during the trial, Murray had stayed with Jackson at least six nights a week and was regularly asked – and sometimes begged – by the singer to give him drugs powerful enough to put him to sleep. Jackson, the jury heard, was especially eager to be administered propofol. Clearly, he put his personal physician under considerable pressure to behave in an unprofessional manner.
But the main reason why Murray is now in jail, waiting to be sentenced, is that he never set appropriate boundaries with his celebrity patient.