Michael Jackson dead from propofol, is Dr. Conrad Murray solely to blame?

in Conditions | 38 responses

Recent reports have said that Michael Jackson died from a propofol overdose. Is that really the case?

Here’s what happened, according to the published timeline.

– At about 1:30 a.m., [Dr. Conrad] Murray gave Jackson 10 mg of Valium.
– At about 2 a.m., he injected Jackson with 2 mg of the anti-anxiety drug Ativan.
– At about 3 a.m., Murray then administered 2 mg of the sedative Versed.
– At about 5 a.m., he administered another 2 mg of Ativan.
– At about 7:30 a.m., Murray gave Jackson yet another 2 mg of Versed while monitoring him with a device that measured the oxygen saturation of his blood.
– At about 10:40 a.m., “after repeated demands/requests from Jackson,” Murray administered 25 mg of propofol, the document said.

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.

A few thoughts on this tragic incident.

Michael Jackson dead from propofol, is Dr. Conrad Murray solely to blame? 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.

Fourth, Dr. Murray will likely be arrested. The simple act of giving propofol outside of a monitored setting goes far beyond medical malpractice. It’s criminal.

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.

Celebrity rehab specialist Drew Pinsky says it best: “There is not a separate diagnostic manual for celebrities. These are just people. They are just patients. And if you feel yourself overlooking things or making exceptions, these are huge mistakes. You have to realize that the standard of care is the standard because it’s the best, and if you start offering special care you are probably going to do substandard care.”

And that’s what happened here. Conrad Murray gave in to Michael Jackson’s addictive behavior, and subsequently, Jackson received care far below the standard.

Propofol didn’t kill Michael Jackson. Addiction did.

Comments

http://askanmd.blogspot.com/ Doctor D
Doctor Murry was nuts to give that in a private residence. Jackson had this doc wrapped around his finger, and Murry will pay dearly for his poor judgment.
But, the force behind Jackson’s death was himself. MJ begged, manipulated, and lied to get the meds that eventually killed him. I realize a doc is still responsible for giving in to an addict, but it is irritating how the press is playing this as poor innocent Jackson in the grip of all these bad docs who got him addicted and killed him.
I think of this sort of thing every time someone asks me for a controlled med. I have probably turned down real suffering people due to fear of being blamed for something like this. (No, Doctor D is not writing scripts for propofol.)
In the end it was the addict that killed himself. Murry may have been an accomplice, but Jackson is the prime suspect in my mind.
http://allbleedingstops.blogspot.com shadowfax
Interesting. That’s a pretty low dose. Supposedly, MJ only weighed 112 pounds (50 kg), so the dose was 0.5 mg/kg. The typical induction dose is about 1 mg/kg, and most people do not become apneic with it. Especially if they are habituated to propofol. Course, the benzos potentiate the propofol, so it was probably that combo which caused the arrest. This assumes the doctor is telling the truth about the dosing, and I suspect he may be minimizing it, because the coroner said that he had a “lethal” level of propofol in his system. Presumably a lethal level would require more than the 0.5 mg/kg dose.
Your point is very good that it was the addiction which killed MJ. While poor Dr Murray was left holding the bag, I would suggest that the real culprit was the first doctor to use propofol on MJ. (By report, this was not a new practice for him, and Murray had only been his doctor for a short time.) I would hope that the investigators would look at all the private doctors who had treated Jackson, and any of them who had treated with Propofol should face sanctions.
The Happy Hospitalist
EvinKevin I disagree with your criminal allegation of giving propofol. Clearly the amount of sedative required by MJ to sedate him was enormous. One could argue that MJ adversly responded to this medication cocktail due to his underlying physiology and not the medication itself.
If a physician administered benzodiazepines to an alcoholic at a residential alcohol treatment facility and the patient responded with a resulting respiratory arrest, establishing criminal negligence sets a dangerous precident.
I don’t think it would be difficult to argue that the combined sedative effects of all the meds killed MJ, not the propofol.
And if we are going to criminalize deadly side effects of medications, perhaps all physicians and patients should fear where we are heading
http://www.dermatalk.com Deepak
Thats absolutely true, Propofol is not a single culprit that killed.
Pingback: Michael Jackson’s Death and the Challenges of Chronic Pain
http://www.drjshousecalls.blogspot.com Dr. Mary Johnson
As we endeavor/swim uphill to reform the reformers, more great PR for doctors, huh?
gromit
Left out of this timeline is the likely huge amount of BZDs (alprazolam, apparently) that MJ took on a regular basis – so he wasn’t starting from 0. Sure, a 2 mg dose on its own isn’t unreasonable in the setting of induction, but this guy was just trying to get to sleep. Kevin, I think you were looking for the word “tolerance” and this right here is the definition. 10 of diazepam, 4 of lorazepam, 4 of midazolam – all in a span of 6 hours and on top of whatever else he’d taken in the previous 24 – that’s more BZDs than you’d give for status epilepticus.
HappyHospitalist:
The comparison you suggest (residential treatment facility) wouldn’t be affected by a precedent in this case. Presumably, a resident at the treatment facility would be experiencing symptoms of withdrawal, and IV lorazepam is the standard of care. You could argue that perhaps the patient should be in another setting if withdrawal is that severe, but you’ve at least got a solid indication and rationale for administering IV. In Jackson’s case – what’s the rationale for giving all this stuff IV, much less in the kinds of doses we’re talking about? That’s what makes this case deserving of criminal negligence.
And I wouldn’t call it criminalizing the side effect. First, with this much drug, it’s just an EFFECT – there’s nothing “side” about it. A physician should know better. But what’s criminal here is the poor decisions to continue administering more and different drugs, putting his patient at risk. No doubt Dr. Murray was in over his head, but perhaps he ought to start saying that instead of “I’ve done nothing wrong.”
-g
Anonymous
I understand his death has been ruled a homicide.
Doc99
This has NOT been a great year for California doctors – Octomom and now Jackson. Ugh …
http://thehappyhospitalist.blogspot.com/2009/06/do-internists-have-confidence-in-their.html Happy Hospitalist
gromit, Not practicing the standard of care (which is irrational itself in many situations) leads to civil cases, not criminal cases. If you are going to arrest an ED doctor because they didn’t order a head CT on the surfer who hit his head on his surfboard and then died 3 hours later from an intracranial hemorrhage, and the lawyer argued that the standard of care was to order a head CT even though no symptoms were being exhibited, then you are going to be throwing a lot of doctors in jail from this point on.
Unless you are going to have a list of all medications that can be administered in every possibly conceived situation, and which medications given where are illegal and which arent,you can’t run around claiming that giving propofol in a home mini ICU was criminal.
If Michael had propofol 1000 times before at the same dose and had no ill side effects, most clinicians could safely assume that the dose given is safe in the circumstances given.
I have a patient who comes into the hospital every so often that takes 640 mg (that’s six hundred and forty) of oxycontin twice a day PLUS two immediate release narcs at high doses PLUS a PCA.
I know damn well that those doses are lethal to 99.99999% of the population of humans, elephans, rhino’s and every other animal you could think of. It’s not standard of care for 99.99999% of the population.
But it works for the patient. What if this patient died in the hospital of a complication from those high doses. Should I get convicted of manslaughter? What if the patient died at home of an overdose? Should I get convicted of manslaughter?
In MJ’s case let’s use the benzos as an example and take out the propofol aruement, because really, it’s probably the benzo’s that killed him. Should a doctor be charged with manslaughter because he gave therapeutic doses of benzos to a patient that ultimately proved not to be therapeutic that one time? Perhaps Michael had a few wines or vodka sours and didn’t tell the doc.
Attaching criminal charges to a bad outcome should scare every physician out there because of the ramifications it has on doing anything that isn’t FDA indicated
http://momwithastethoscope.wordpress.com MWAS
Maybe I’m just a naive pediatrician, but how does a private physician get his/her hands on propofol? Do you just call your local medical supply rep and order a bottle? Agree with KevinMD – addiction killed MJ – but multiple parties contributed. Like the Pinsky quote.
http://thehappyhospitalist.blogspot.com/2009/06/do-internists-have-confidence-in-their.html Happy Hospitalist
As for the “lethal levels’ if an autopsy was performed on my oxycontin patient, they would probably shod levels 100X higher than lethal levels.
Does that mean my patient was walking around for 10 years with lethal levels of oxycontin in his system?
Lethal is relative. It’s hard to quantify lethal in a drug addict like MJ. The fact he need enormous doses of benzos indicates a long standing addiction and tolerance to high doses of sedatives, including propofol.
I have alcoholics in the ICU who require huge doses of propofol just to get them to close their eyes. If you checked their levels, would they be lethal? I’m sure they would, except for the fact that my patient isn’t dead.
Nuclear Fire
I’m assuming “lethal level” means LD50. Is that correct?
Chris
No, the LD50 would be very different in a scenario like this. The usual induction drugs, either propofol/vecuronium or etomidate/succinylcholine are always fatal, unless you intubate the patient. The therapeutic dose for a paralytic is also well over the LD50, in the absence of airway support. In MJ’s case, without a paralytic, you could still give him a dose that would make him apneic, which could be fatal unless you provided airway support. The amount that it would take to actually kill someone would probably be MUCH higher.
http://everythinghealth.net Toni Brayer, MD
I am frankly surprised at the attempts to defend Dr. Murray on these comments.
Medications used in lethal combination is what killed Michael Jackson. This type of poly-drug pharmacy is never good and using IV sedatives in a home setting, without Narcan on hand is poor judgment at best, and malpractice for sure. You cannot compare the use of Propofol and high dose sedatives in an ICU or ED with using it at Neverland. Physicians in California hospitals are required to be certified in conscious sedation administration or they cannot touch the stuff.
Reports are that he did CPR in the bed with his hand behind the back for support. I think we can all agree that this is ineffective CPR and would never work for resuscitation.
I do not want to “hang’ Dr. Murray, but we should not be making excuses for his poor judgment, poor clinical skills and risky prescribing when being paid $150K/month. You cannot prove that the money was a factor but $150K can erase a lot of “No”.
http://thehappyhospitalist.blogspot.com/2009/06/do-internists-have-confidence-in-their.html Happy Hospitalist
Toni, are you going to criminalize doctors for not performing correct CPR? I know of many doctors who are not BLS or ACLS certified, who haven’t been in a code situation in 30 years and who wouldn’t have a clue on what to do if a patient collapsed in front of them.
At Happy’s hospital one must also take a test to be certified on conscious sedation. But that’s the standard for Happy’s hospital. That is not a federal or a state standard. Every hospital sets their own standard. You cannot convict someone for not meeting a standard of an institution they are not a part of.
If you are saying propofol can only be given in a hospital, should the pharmacy where the stuff was sold be shut down and the pharmacists, the cashier and the owner be charged with criminal homicide for selling propofol to someone they could not verify was going to use it in a hospital?
If not, why not? The pharmacist should have known that selling propofol to any party, other than a hospital, was criminal.
Are you going to send bad CPR doctors and greedy pharmacists to jail too?
Are you going to send them to jail only if they make $150k a month?
What if Conrad only made $2 a month. Are you going to spare him criminal charges because he was a poor idiot?
Criminalizing off label indications and bad standards sets a terrible precedent for all doctors who’s patients fail them.
MJ probably took propofol 999 times before without incident. Your clinic patient, the little old grandma taking ativan 2 mg four times a day for “nerves” probably took her ativan for 10 years before one day she responded with death.
Are you prepared to go to jail for prescribing lethal doses of medication to your patient? Lethal only because they died, when she did just fine the other 3,649 days.
http://www.tomdegan.blogspot.com Tom Degan
We have to give the man his due: Michael Jackson was – beyond a shadow of a doubt – a great artist whose recorded legacy will endure for decades, maybe even a century or more. But an examination of his life is riddled with questions of all that might have been; all that should have been. It is more than likely that this was a severely mentally ill human being who never sought the treatment he so desperately needed; surrounded by fawning sycophants who enabled his sickness by constantly reassuring him that he could do no wrong. As John Lennon once said in the same context about Elvis Presley, another victim of the excesses of fame: “It’s always the courtiers that kill the king”.
The sad, inescapable truth is that for reasons we will probably never be able to fully understand, his talent and his career were ultimately wasted. Like Charlie Parker, Montgomery Clift, Judy Garland and Lenny Bruce before him, his brilliance as an artist would be overshadowed by severe, psychological torment and an unexplainable desire for self-destruction. Therein lies the real, unspeakable tragedy of Michael Jackson.
Tom Degan
Goshen, NY
http://healthtrain.blogspot.com Gary MD
Michael Jackson’s early demise is a repeat story for many celebrities, whose underlying mental dysfunction is one of the bipolar spectrum disorders. Many personalities are so successful due to this disorder, and often cycle between hypomania and depression. Many are insomniacs, and remain improperly diagnosed and treated with diazepams and other sedatives which do nothing to normalize their cerebral biochemical dysfunction.
One example of a high profile celebrity who was treated successfully (thus far) is Brittany Spears, who was snatched from disaster by her father. The treatment of bipolar disorder now has a good prognosis if treated accurately. Any physician treating ‘celebrities’ should have bipolar disorder right up on top of their differential
http://www.blog.greatzs.com ZMD
Dr. Murray may have had reservations about giving MJ that much medication for insomnia, but I guess the $150,000/month he was supposed to receive helped him get over it. But the joke’s on him because MJ never signed his employment contract.
Roger
This was medical malpractice. He deserves to be sued in civil court and lose. He was practicing outside of his area of expertise and made several mistakes, most notably not having Narcan available to reverse the high doses he was giving.
He, probably, deserves to have his license suspended or revoked, in addition to losing the lawsuit.
To say that practicing medicine, and making an error, is criminal, goes too far.
anon
MWAS “……Maybe I’m just a naive pediatrician, but how does a private physician get his/her hands on propofol?…”
I assume you’re a naive pediatrician who is also a licensed physician. I assume an unrestricted license with a DEA number. The answer: you go to the medical supply catalogues. You can order the equipment to set up your own operating room, with general anesthesia, in your own house if you want to.
The suppliers require a valid state license and DEA. That’s it.
Now billing insurance might be another matter. The state medical board might take an interest in what you’re doing, but they have to know it’s happening in the first place. As in, if you give intravenous anesthetic agents to an internationally famous celebrity and the celebrity dies. That gets their attention.
What bothers me, what I dread, is the actions of these idiots prompts government regulatory agencies to do things that are excessively stupid and restrictive, so they look like they’re doing something.
In reacting to clowns like this guy, the government comes down like a ton of bricks on the oncologist who gives a milligram of midazolam IV with a bone marrow biopsy. That sort of thing.
Reality Rounds
“Propofol didn’t kill Michael Jackson. Addiction did.”
No, Dr. Murray killed MJ. He gave him the drugs, started the IV’s, pushed the medications, etc. I think it is a criminal act, just like you stated. He should have been treated for his addiction and mental health issues, but as I have said in a previous post, the power of the paycheck took precedent over the patient. It makes no difference if MJ had a terminal addiction. On that morning of June 25th, multiple risky and egregious actions occurred voluntarily by a trained physician that killed the patient. Now it is time to face the music, so to speak.
http://thehappyhospitalist.blogspot.com/2009/06/do-internists-have-confidence-in-their.html Happy Hospitalist
Reality, so every ED doctor that prescribes narcotics for “pain” in a drug addict that shows up in the ED and then goes home and overdoses should be charged with homicide? The doc should have known that giving narcotics could be deadly. Or how about benzos? Give 1-2 mg q 4hours prn for anxiety and your patient ends up dead? Perhaps you consider standard therapeutic doses of medications to be criminal if the patients physiology doesn’t respond the way it should.
Perhaps we should criminalize the doctor for writing for Zosyn in a septic patient that doesn’t respond the way they should have and ends up dying. They should have ordered Merrem, or perhaps they should have ordered Daptomycin.
You’re trying to criminalize the administration of medication, clinical dosing for patients who may not respond to routine standard doses. I write for ativan all the time to help hospitalized patients sleep. I write for ativan on discharge all the time to help patients sleep. Are you going to throw me in jail because the patient died taking two doses instead of one because the first dose didn’t help?
Perhaps all the nurses in a hospital that push the doctors standard order of 1-4 mg IV morphine prn pain for a drug addict admitted for “pain control” should spend 20 years in prison for pushing a lethal dose of narcotics that are only known to be lethal until after the fact.
gromit
Happy (is that like nicknaming a fat guy “Slim”?):
I didn’t catch the first time around that you were driving at a distinction between civil vs. criminal. Sorry about that. It’s a fair question to ask, though, but I don’t think you’ll find any clear answer of when exactly you cross that line. Google led me to this article (pdf alert), which doesn’t really give any one answer but at least lists several situations where criminal charges were pursued.
-g
anon
I know what you’re saying HH, but propofol?
Is there any medical use for this drug besides induction of anesthesia and procedural sedation? Maybe I’m missing something; maybe he was getting some sort of procedure done, for all the self-destructive things he did to himself.
I agree with your point about the ER doc. But this is light years beyond the ER doc giving some Percocets for a “pain” patient who’s really scamming drugs. If it’s not criminal, at the very least gross negligence, with a clear and present danger to the public. Summary suspension of medical license pending investigation……..and probably permanent linense revocation, if the facts are as bad as they seem from the press reports.
But hey, I’m not on the Board, nor do I have the facts on hand, I don’t know any more than anyone else reading the papers.
Reality Rounds
Happy,
Your logic is going off the deep end very fast. No I do not think you should go to jail for treating drug addicts with vast amounts of meds that could kill a normal person, in a monitored hospital setting, even if the patient dies from it. I would assume you would have a plan of care spelled out and monitoring guidelines set up for this type of patient. I would assume you and the hospital staff would do everything to revive the apnic patient. You would be practicing as a prudent physician in a legal and controlled environment.
Now if you set up your very own secret Dr. Frankenstein’s lab in a patient’s bedroom to pump large quantities of IV sedation and anesthetics into his body, without any knowledge of how to intubate, do CPR or dial 911, or even give a proper report to the paramedics (like, ahem, forgetting to tell the first responders you gave your victim propofol) then I would be happy, Happy, to send you a cake with a dull file in it for Christmas.
http://thehappyhospitalist.blogspot.com Happy Hospitalist
anon, if you are going to start naming drugs and indications and which ones are criminal and which ones aren’t, then doctors and physicians will fear not knowing when they can prescribe drugs for off label uses and which DA is going to convict them of homicide when a bad outcome occurs.
It’s not light years away. It’s a physician who used their medical judgment. In this case it was bad judgment. But convicting a doctor of homicide for using bad medical judgment will send ED doctors to jail for not ordering a CT scan on a surfer who hits their head and dies of an asymptomatic intracranial hemorrhage three hours later.
Unless you create a law that names every possible medication and every possible bad outcome that is a criminal case vs a civil case.
Good luck with that.
http://everythinghealth.net Toni Brayer, MD
Happy, I gotta agree with Reality Rounds on this one. You are defending an indefensible position. You cannot compare this event with a hospitalized patient. Please, do we have no standards?
http://Drackies.blogspot.com Frank Drackman
Jeez, So How Many Angels can dance on the head of a pin…..
Bruce Small
I thought the physician’s responsibility was to help the patient, which is not quite the same as giving the patient whatever drugs he craves for whatever short-term relief he wants, now.
The local drug dealer can do that, and the local drug dealer might have done a better job of managing the dose. Certainly he couldn’t have done a worse job.
anon
I said from the beginning, I’ll say it again, I would be reluctant (to put it mildly) to bring up criminal charges unless there was evidence of intent. I’ll defer that to real lawyers and all that.
Gross negligence is another matter. And yes it is light years away. I’m a physician too, I use propofol in my field. You don’t use propofol under the conditions like Jackson’s.
No, I wouldn’t criminally prosecute, I’d suspend a license pending investigation. But then again, I’m not on any medical board, so that opinion and a few bucks gets you a latte.
I agree, you don’t criminally prosecute a doctor for bad judgement, or even stupidity. You take away their license to practice.
Elizabeth
Not only did Murray drug up Michael Jackson, he didn’t do CPR the correct way, and he’s an interventional cardiologist! Furthermore, it has been reported that he waited 82 minutes to phone 911 after finding Michael was not breathing. Stop defending the man, he’s a bad doctor, and needs to lose his license. He cared more about money than a human life and in this case failed medical ethics 101. Not withstanding, he murdered Michael Jackson. After learning these sordid details would you want Conrad Murray to be your personal physician? My answer would be no way.
Dawood
P Diddy had very precisely described the genius of Michael Jackson: “He showed that you can actually see the beat. He made the music come to life. He made me believe in magic.”
I’ve tried to collect allnotable tributes paid to Michael Jackson by peers:
http://www.tributespaid.com/category/m/michael-jackson
http://integrativepsychiatry.wordpress.com sonya lazarevic MD
as an aside from the current ongoing argument…
making assessments of MJ’s psychiatric diagnosis based on his profession plus a distant observation without a formal evaluation by a skilled psychiatrist is dangerous and unfair to him or any public or private person.
Karen
Hello all I think you guys are missing something. All of the sedates found in Mr Jackson were given to him by Dr Murray. This was not something he was taken just because it was something that the doctor gave him. And I also want to point out Conrad Murray it seems never bothered to find out what other kind of medications Mr Jackson was taken. And about the CPR he said he performed CPR holding him up with one hand and doing chest compressions with the other one. But he left out the fact that was on the phone for forty seven minutes. So unless he has three arms he was not doing CPR at all.
BNS
I understand the logic of this article. However, there is one large flaw. It is this:
The author assumes that the timeline Murray provided to the LAPD is the truth. We must remember that we are talking about information coming from a doctor who did not call paramedics until 90 minutes after his patient died and then withheld information from those paramedics. This physician also withheld information from the emergency room healthcare professionals and left the hospital after directions from the LAPD to remain there for questioning. The in his interview 2 days later he did not tell the LAPD about the 3 telephone calls, lasting a total of 47 minutes, he made before he called the paramedics to the house.
If the author then chooses to selectively believe that the information above is truthful, then I suppose the resulting article has some merit. But after “considering the source,” I am hesitant to agree that Jackson was wide awake between all of these injections of sedatives, meaning that he had such a resistance to them that an addiction can be assumed.
It seems to me that the sedatives were Dr. Murray’s idea, not Jackson’s. And taking into consideration the fact that Jackson had passed a recent physical and a blood test given by a nurse practioner showed no drugs in his system, I would be more apt to believe that, just as the coroner states on the death certificate, it was the propofol that killed Jackson – the propofol administered by an unlicensed physician outside of a hospital context.
AnesthesiaDoc
It bothers me that the media hasn’t addressed the very disturbing issue of civil vs. criminal in this case. HappyHospitalist’s concerns are very real. I live in a rural area that still has doctors that make housecalls (though I don’t obviously). Are these docs to be prosecuted everytime some patient dies at home from an overdose after taking their xanax and perhaps a glass of wine? This is a very slippery slope and bureaucrats love to follow the letter of the law.
Yes this doc was negligent. Yes he is guilty of VERY poor judgement, poor skill and he was in over his head. Yes he exhibited questionable ethics at best and yes he should lose his license to practice medicine for the rest of his life, but I am personally very afraid of him being prosecuted criminally for practicing medicine in any way, regardless of the setting.
I would expect to see the AMA issuing a position on the topic in general but after their limp stance on “healthcare reform” I have come to see the AMA for what it is…but that’s another topic.
lois
I understand that the Dr, did know what drugs Michael was on,he had the files,so he can’t say he did not know what he was taking. Dr. Murray killed Michael.

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