Libby Zion law
Encyclopedia
New York State Department of Health Code, Section 405, also known as the Libby Zion law, is a regulation that limits the amount of resident physician
s' work in New York State hospitals to roughly 80 hours per week. The law was named after Libby Zion who died at the age of 18 under the care of what her father believed to be overworked resident physicians and intern physicians. In July 2003 the Accreditation Council for Graduate Medical Education
(ACGME) adopted similar regulations for all accredited medical training institutions in the United States.
Although regulatory and civil proceedings found conflicting evidence about Zion's death, today her death is widely believed to have been caused by serotonin syndrome
from the drug interaction
between the phenelzine
she was taking prior to her hospital visit, and the Demerol administered by a resident physician. The lawsuits and regulatory investigations following her death, and their implications for working conditions and supervision of interns and residents were highly publicized in both lay media and medical journals.
. Her father, a lawyer, had formerly written for The New York Times. Her mother was a former publishing executive. She had two brothers, Adam and Jed. Her obituary in The New York Times, written the day after her death, stated that she had been ill with a "flu-like ailment" for the past several days. The article stated that after being admitted to New York Hospital
, she died of cardiac arrest
, the cause of which was not known.
Libby Zion had been admitted to the hospital by emergency room physicians on the night of March 4. Raymond Sherman, the Zion family physician, agreed with their plan to hydrate and observe her. Zion was assigned to two residents, Luise Weinstein and Gregg Stone, who both evaluated her. Weinstein, a PGY
-1 resident (sometimes referred to as intern), and Stone, a PGY-2 resident, were unable to determine the cause of Zion's illness, though Stone tentatively suggested that her condition might be a simple overreaction to a normal illness. After consulting with Dr. Sherman, the two prescribed Demerol to control the "strange jerking motions" that Zion had been exhibiting when she was admitted.
Weinstein and Stone were both responsible for covering dozens of other patients. After evaluating Zion, they left. Weinstein went to cover other patients, and Stone went to sleep in an on-call room
in an adjacent building. Zion, however, did not improve, and continued to become more agitated. After being
contacted by nurses by phone, Weinstein ordered physical restraint
s be placed on Zion. She also prescribed haloperidol
by phone to control the agitation.
Zion finally managed to fall asleep, but by 6:30, her temperature was 107 °F (41.7 °C). Weinstein was once again called, and measures were quickly taken to try to reduce her temperature. However, before this could be done, Zion suffered a heart attack and could not be resuscitated. Weinstein informed Zion's parents by telephone.
Several years had gone by before a general agreement was reached regarding the cause of Zion's death. Zion had been taking a prescribed antidepressant, phenelzine
, before she was admitted to the hospital. The combination of that and the meperidine given to her by Stone and Weinstein contributed to the development of "serotonin syndrome
", a condition which led to increased agitation. This led Zion to pull on her intravenous tubes, causing Weinstein to order physical restraints, which Zion also fought against. By the time she finally fell asleep, her fever had already reached too dangerous levels, and she died soon after of a heart attack.
. Sidney Zion questioned the staff's competence for two reasons. The first was the administration of meperidine, known to cause fatal interactions with phenelzine
, the antidepressant that Libby Zion was taking. The second issue was the use of restraints and emergency psychiatric medication. Sidney's aggrieved words were: "They gave her a drug that was destined to kill her, then ignored her except to tie her down like a dog." To the distress of the doctors, Zion began to refer to his daughter's death as a "murder." Sidney also questioned the long hours that residents worked at the time. In a New York Times op-ed piece he wrote: "You don't need kindergarten to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call—forget about life-and-death." The case eventually became a protracted high-profile legal battle, with multiple abrupt reversals; case reports about it appeared in major medical journals.
Robert Morgenthau agreed to let a grand jury
consider murder charges, an unusual decision for a medical malpractice
case. Although the jury declined to indict for murder, in 1987 the intern and resident were charged with 38 counts of gross negligence
and/or gross incompetence. The grand jury considered that a series of mistakes contributed to Zion's death, including the improper prescription of drugs and the failure to perform adequate diagnostic tests. Under New York law, the investigative body for these charges was the Hearing Committee of the State Board for Professional Medical Conduct
. Between April 1987 and January 1989 the Committee conducted 30 hearings at which 33 witnesses testified, including expert witness
es in toxicology
, emergency medicine
, and chairmen of internal medicine departments at six prominent medical schools, several of whom stated under oath that they had never heard of the interaction between meperidine and phenelzine prior to this case. At the end of these proceedings, the Hearing Committee unanimously decided that none of the 38 charges against the two residents was supported by evidence. Its findings were accepted by the full Board, and by the state's Health Commissioner, David Axelrod.
Under New York law however, the final decision in this matter rested with another body, the Board of Regents, which was under no obligation to consider either the Commissioner's or the Hearing Committee's recommendations. The Board of Regents, which at the time had only one physician amongst its 16 members, voted to "censure and reprimand" the resident physicians for acts of gross negligence. This decision did not affect their right to practice. The verdict against the two residents was considered very surprising in medical circles. In no other case had the Board of Regents overruled the Commissioner's recommendation. The hospital also admitted that it had provided inadequate care and paid a $13,000 fine to the state. In 1991, however, the state's appeals court completely cleared the records of the two doctors of findings that they had provided inadequate care to Zion.
The emergency room physician, Maurice Leonard, as well as the hospital (as legal persona) were found not responsible for Zion's death in the civil trial. The jury decided that the hospital was negligent for leaving Weinstein alone in charge of 40 patients that night, but they also concluded that this negligence did not directly contribute to Zion's death. The trial was shown on Court TV
.
by establishing a blue-ribbon panel
of experts headed by Bertrand M. Bell, a primary care physician at the Albert Einstein College of Medicine
in the Bronx. Bell was well-known for his critical stance regarding the lack of supervision of physicians-in-training. Formally known as the Ad Hoc Advisory Committee on Emergency Services, and more commonly known as the Bell Commission, the committee evaluated the training and supervision of doctors in the state, and developed a series of recommendations that addressed several patient care issues, including restraint usage, medication systems, and resident work hours.
In 1989, New York state adopted the Bell Commission's recommendations that residents could not work more than 80 hours a week or more than 24 consecutive hours and that attending physician
s needed to be physically present in the hospital at all times. Hospitals instituted so-called night floats, doctors who worked overnight to spare their colleagues, allowing them to adhere to the new rules. Periodic follow-up audits have prompted the New York State Department of Health
to crack down on violating hospitals. Similar limits have since been adopted in numerous other states. In July 2003 the Accreditation Council for Graduate Medical Education (ACGME) adopted similar regulations for all accredited medical training institutions in the United States.
Residency (medicine)
Residency is a stage of graduate medical training. A resident physician or resident is a person who has received a medical degree , Podiatric degree , Dental Degree and who practices...
s' work in New York State hospitals to roughly 80 hours per week. The law was named after Libby Zion who died at the age of 18 under the care of what her father believed to be overworked resident physicians and intern physicians. In July 2003 the Accreditation Council for Graduate Medical Education
Accreditation Council for Graduate Medical Education
The Accreditation Council for Graduate Medical Education is the body responsible for the accreditation for graduate medical training programs for medical doctors in the United States. It is a non-profit private council that evaluates and accredits medical residency and internship programs...
(ACGME) adopted similar regulations for all accredited medical training institutions in the United States.
Although regulatory and civil proceedings found conflicting evidence about Zion's death, today her death is widely believed to have been caused by serotonin syndrome
Serotonin syndrome
Serotonin syndrome is a potentially life-threatening adverse drug reaction that may occur following therapeutic drug use, inadvertent interactions between drugs, overdose of particular drugs, or the recreational use of certain drugs...
from the drug interaction
Drug interaction
A drug interaction is a situation in which a substance affects the activity of a drug, i.e. the effects are increased or decreased, or they produce a new effect that neither produces on its own. Typically, interaction between drugs come to mind...
between the phenelzine
Phenelzine
Phenelzine is a non-selective and irreversible monoamine oxidase inhibitor of the hydrazine class which is used as an antidepressant and anxiolytic...
she was taking prior to her hospital visit, and the Demerol administered by a resident physician. The lawsuits and regulatory investigations following her death, and their implications for working conditions and supervision of interns and residents were highly publicized in both lay media and medical journals.
Death
Libby Zion (November 1965 – March 5, 1984) was a freshman at Bennington CollegeBennington College
Bennington College is a liberal arts college located in Bennington, Vermont, USA. The college was founded in 1932 as a women's college and became co-educational in 1969.-History:-Early years:...
. Her father, a lawyer, had formerly written for The New York Times. Her mother was a former publishing executive. She had two brothers, Adam and Jed. Her obituary in The New York Times, written the day after her death, stated that she had been ill with a "flu-like ailment" for the past several days. The article stated that after being admitted to New York Hospital
New York Hospital
New York Hospital or “Old New York Hospital” or “City Hospital” was the oldest hospital in New York City and the second oldest hospital in the United States.-Early History:...
, she died of cardiac arrest
Cardiac arrest
Cardiac arrest, is the cessation of normal circulation of the blood due to failure of the heart to contract effectively...
, the cause of which was not known.
Libby Zion had been admitted to the hospital by emergency room physicians on the night of March 4. Raymond Sherman, the Zion family physician, agreed with their plan to hydrate and observe her. Zion was assigned to two residents, Luise Weinstein and Gregg Stone, who both evaluated her. Weinstein, a PGY
PGY
PGY, short for post-graduate year, refers to a North American numerical scheme denoting the progress of post-graduate dental, medicine, or pharmacy residents in their residency program. It is used to stratify responsibility in most training programs and to determine salary...
-1 resident (sometimes referred to as intern), and Stone, a PGY-2 resident, were unable to determine the cause of Zion's illness, though Stone tentatively suggested that her condition might be a simple overreaction to a normal illness. After consulting with Dr. Sherman, the two prescribed Demerol to control the "strange jerking motions" that Zion had been exhibiting when she was admitted.
Weinstein and Stone were both responsible for covering dozens of other patients. After evaluating Zion, they left. Weinstein went to cover other patients, and Stone went to sleep in an on-call room
On-call room
An on-call room is a room in a hospital with either a couch or a bunkbed intended for staff to rest in while they are on call or due to be.In the European Community, the 2003 extension of the working time directive to junior doctors and the ruling that on-call time counts as working hours has...
in an adjacent building. Zion, however, did not improve, and continued to become more agitated. After being
contacted by nurses by phone, Weinstein ordered physical restraint
Physical restraint
Physical restraint refers to the practice of rendering people harmless, helpless or keeping them in captivity by means such as handcuffs, fetters, straitjackets, ropes, straps, or other forms of physical restraint...
s be placed on Zion. She also prescribed haloperidol
Haloperidol
Haloperidol is a typical antipsychotic. It is in the butyrophenone class of antipsychotic medications and has pharmacological effects similar to the phenothiazines....
by phone to control the agitation.
Zion finally managed to fall asleep, but by 6:30, her temperature was 107 °F (41.7 °C). Weinstein was once again called, and measures were quickly taken to try to reduce her temperature. However, before this could be done, Zion suffered a heart attack and could not be resuscitated. Weinstein informed Zion's parents by telephone.
Several years had gone by before a general agreement was reached regarding the cause of Zion's death. Zion had been taking a prescribed antidepressant, phenelzine
Phenelzine
Phenelzine is a non-selective and irreversible monoamine oxidase inhibitor of the hydrazine class which is used as an antidepressant and anxiolytic...
, before she was admitted to the hospital. The combination of that and the meperidine given to her by Stone and Weinstein contributed to the development of "serotonin syndrome
Serotonin syndrome
Serotonin syndrome is a potentially life-threatening adverse drug reaction that may occur following therapeutic drug use, inadvertent interactions between drugs, overdose of particular drugs, or the recreational use of certain drugs...
", a condition which led to increased agitation. This led Zion to pull on her intravenous tubes, causing Weinstein to order physical restraints, which Zion also fought against. By the time she finally fell asleep, her fever had already reached too dangerous levels, and she died soon after of a heart attack.
Publicity and trials
Grieving the loss of their child, Zion's parents became convinced that their daughter's death was due to inadequate staffing at the teaching hospitalTeaching hospital
A teaching hospital is a hospital that provides clinical education and training to future and current doctors, nurses, and other health professionals, in addition to delivering medical care to patients...
. Sidney Zion questioned the staff's competence for two reasons. The first was the administration of meperidine, known to cause fatal interactions with phenelzine
Phenelzine
Phenelzine is a non-selective and irreversible monoamine oxidase inhibitor of the hydrazine class which is used as an antidepressant and anxiolytic...
, the antidepressant that Libby Zion was taking. The second issue was the use of restraints and emergency psychiatric medication. Sidney's aggrieved words were: "They gave her a drug that was destined to kill her, then ignored her except to tie her down like a dog." To the distress of the doctors, Zion began to refer to his daughter's death as a "murder." Sidney also questioned the long hours that residents worked at the time. In a New York Times op-ed piece he wrote: "You don't need kindergarten to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call—forget about life-and-death." The case eventually became a protracted high-profile legal battle, with multiple abrupt reversals; case reports about it appeared in major medical journals.
State investigation
In May 1986 Manhattan District AttorneyDistrict attorney
In many jurisdictions in the United States, a District Attorney is an elected or appointed government official who represents the government in the prosecution of criminal offenses. The district attorney is the highest officeholder in the jurisdiction's legal department and supervises a staff of...
Robert Morgenthau agreed to let a grand jury
Grand jury
A grand jury is a type of jury that determines whether a criminal indictment will issue. Currently, only the United States retains grand juries, although some other common law jurisdictions formerly employed them, and most other jurisdictions employ some other type of preliminary hearing...
consider murder charges, an unusual decision for a medical malpractice
Medical malpractice
Medical malpractice is professional negligence by act or omission by a health care provider in which the treatment provided falls below the accepted standard of practice in the medical community and causes injury or death to the patient, with most cases involving medical error. Standards and...
case. Although the jury declined to indict for murder, in 1987 the intern and resident were charged with 38 counts of gross negligence
Gross negligence
Gross negligence is a legal concept which means serious carelessness. Negligence is the opposite of diligence, or being careful. The standard of ordinary negligence is what conduct one expects from the proverbial "reasonable person"...
and/or gross incompetence. The grand jury considered that a series of mistakes contributed to Zion's death, including the improper prescription of drugs and the failure to perform adequate diagnostic tests. Under New York law, the investigative body for these charges was the Hearing Committee of the State Board for Professional Medical Conduct
Office of Professional Medical Conduct
The Office of Professional Medical Conduct is a branch of the New York State Department of Health. The OPMC is charged with investigating complaints against physicians, unlicensed and licensed residents, and physician assistants in New York...
. Between April 1987 and January 1989 the Committee conducted 30 hearings at which 33 witnesses testified, including expert witness
Expert witness
An expert witness, professional witness or judicial expert is a witness, who by virtue of education, training, skill, or experience, is believed to have expertise and specialised knowledge in a particular subject beyond that of the average person, sufficient that others may officially and legally...
es in toxicology
Toxicology
Toxicology is a branch of biology, chemistry, and medicine concerned with the study of the adverse effects of chemicals on living organisms...
, emergency medicine
Emergency medicine
Emergency medicine is a medical specialty in which physicians care for patients with acute illnesses or injuries which require immediate medical attention. While not usually providing long-term or continuing care, emergency medicine physicians diagnose a variety of illnesses and undertake acute...
, and chairmen of internal medicine departments at six prominent medical schools, several of whom stated under oath that they had never heard of the interaction between meperidine and phenelzine prior to this case. At the end of these proceedings, the Hearing Committee unanimously decided that none of the 38 charges against the two residents was supported by evidence. Its findings were accepted by the full Board, and by the state's Health Commissioner, David Axelrod.
Under New York law however, the final decision in this matter rested with another body, the Board of Regents, which was under no obligation to consider either the Commissioner's or the Hearing Committee's recommendations. The Board of Regents, which at the time had only one physician amongst its 16 members, voted to "censure and reprimand" the resident physicians for acts of gross negligence. This decision did not affect their right to practice. The verdict against the two residents was considered very surprising in medical circles. In no other case had the Board of Regents overruled the Commissioner's recommendation. The hospital also admitted that it had provided inadequate care and paid a $13,000 fine to the state. In 1991, however, the state's appeals court completely cleared the records of the two doctors of findings that they had provided inadequate care to Zion.
Civil trial
In parallel with the state investigation, Sidney Zion also filed a separate civil case against the doctors and the hospital. The civil trial came to a close in 1995 when a Manhattan jury found that the two residents and Libby Zion's primary care doctor contributed to her death by prescribing the wrong drug, and ordered them to pay a total of $375,000 to Zion's family for her pain and suffering. The jury also found that Raymond Sherman, the primary care physician, had lied on the witness stand in denying he knew that Libby Zion was to be given meperidine. Although the jury found the three doctors negligent, none of them were found guilty of "wanton" negligence, i.e. demonstrating utter disregard for the patient, as opposed to a simple mistake. Payouts for wanton negligence would not have been covered by the doctors' malpractice insurance.The emergency room physician, Maurice Leonard, as well as the hospital (as legal persona) were found not responsible for Zion's death in the civil trial. The jury decided that the hospital was negligent for leaving Weinstein alone in charge of 40 patients that night, but they also concluded that this negligence did not directly contribute to Zion's death. The trial was shown on Court TV
Court TV
truTV is an American cable television network owned by Turner Broadcasting, a subsidiary of Time Warner. The network launched as Court TV in 1991, changing to truTV in 2008...
.
Law and regulations
After the grand jury's indictment of the two residents, the New York State Health Commissioner David Axelrod decided to address the systemic problems in residencyResidency (medicine)
Residency is a stage of graduate medical training. A resident physician or resident is a person who has received a medical degree , Podiatric degree , Dental Degree and who practices...
by establishing a blue-ribbon panel
Blue-Ribbon Panel
Blue-ribbon panel is an informal term generally used to describe a group of exceptional persons appointed to investigate or study a given question. The term generally connotes a degree of independence from political influence or other authority, and such panels usually have no direct authority of...
of experts headed by Bertrand M. Bell, a primary care physician at the Albert Einstein College of Medicine
Albert Einstein College of Medicine
Albert Einstein College of Medicine is a graduate school of Yeshiva University. It is a not-for-profit, private, nonsectarian medical school located on the Jack and Pearl Resnick Campus in the Morris Park neighborhood of the borough of the Bronx of New York City...
in the Bronx. Bell was well-known for his critical stance regarding the lack of supervision of physicians-in-training. Formally known as the Ad Hoc Advisory Committee on Emergency Services, and more commonly known as the Bell Commission, the committee evaluated the training and supervision of doctors in the state, and developed a series of recommendations that addressed several patient care issues, including restraint usage, medication systems, and resident work hours.
In 1989, New York state adopted the Bell Commission's recommendations that residents could not work more than 80 hours a week or more than 24 consecutive hours and that attending physician
Attending physician
In the United States, an attending physician is a physician who has completed residency and practices medicine in a clinic or hospital, in the specialty learned during residency. An attending physician can supervise fellows, residents, and medical students...
s needed to be physically present in the hospital at all times. Hospitals instituted so-called night floats, doctors who worked overnight to spare their colleagues, allowing them to adhere to the new rules. Periodic follow-up audits have prompted the New York State Department of Health
New York State Department of Health
The New York State Department of Health, ', is the governmental body responsible for public health in the state of New York. The cabinet-level department is headed by the Health Commissioner, a position held since January 24, 2011 by Nirav R. Shah, M.D., M.P.H.....
to crack down on violating hospitals. Similar limits have since been adopted in numerous other states. In July 2003 the Accreditation Council for Graduate Medical Education (ACGME) adopted similar regulations for all accredited medical training institutions in the United States.