Apr. 26--The VA Medical Center in Albuquerque gave Dr. Diletta Renier-Berg an "Outstanding Caregiver" award in
2002. By early 2004,
she was on administrative leave and banned from her own hospital office as medical experts, administrators and a criminal investigator delved into whether she hastened death of veterans assigned to her nursing home ward.
Renier-Berg, who received her medical degree in 1984, denied any wrongdoing in a lawsuit she filed against the VA after the agency proposed discharging her in early 2005.
A year earlier, two internal reviews of her treatment of patients -- one by a VA medical team brought in from Arizona and another by a group of doctors and administrators at the Veterans Affairs hospital here -- produced sharply contrasting conclusions.
The Arizona team, while recommending some remedial action, cleared Renier-Berg of the most serious allegations and found her care appeared to be "generally within the standard of acceptable clinical practice."
That conclusion was important in Renier-Berg's lawsuit against the VA, which was settled less than two months after it was filed in February 2005.
Through her attorney, John J. Kelly of Albuquerque, Renier-Berg declined to be interviewed by the Journal.
Kelly also stated, "Given the prohibitions of (federal health privacy law), Dr. Renier-Berg is not going to discuss, much less disclose, protected patient health information ..."
According to her lawsuit, Kelly's position has been that Renier-Berg was exonerated and was the victim of a colleague's vendetta and incompetent administrators.
A settlement agreement reviewed by the Journal shows the VA agreed to pay her damages of $125,000 plus back pay.
She was allowed to return to work for a time, keeping her title as medical director of the medical center's ward 4D and palliative care service.
But her duties were changed. She would no longer be responsible for the actual management, administration or supervision of patient care on 4D, the settlement agreement stated.
The VA also promised to tell prospective employers she was in good standing and that "there is nothing whatsoever adverse in her personnel file."
A year earlier, in March 2004, VA medical center officials were highly critical of Renier-Berg.
The local VA criticized her use of an end-of-life sedation treatment to alleviate suffering and pain and alleged she pushed families into signing end-of-life directives.
She was accused of violating the wishes of patients. The local VA also faulted her for comments she made in the medical record when people were slow to come to grips with what she thought was an inevitable death, and found her personality made it difficult for colleagues and team members on the ward not to bend to her decisions.
The local VA also took issue with the thoroughness of the Arizona team's review.
That doctor-nurse review team led by end-of-life physician Dr. Paul Rousseau spent two days here and reviewed seven patient files, records show.
The Arizona team noted it was prohibited from interviewing Renier-Berg by the VA Office of Inspector General, which had launched a criminal investigation into some of the same issues.
VA officials in Albuquerque would not comment for this story.
But several of Renier-Berg's colleagues signed affidavits on her behalf in 2005 that disputed she violated patients' wishes or coerced families into signing "Do Not Resuscitate" orders.
"During the time I spent with (her) on 4D, I never saw her deny care to a patient, never saw her challenge a patient's choices, never saw her impose a treatment modality that the patient was not accepting," stated nurse practitioner Annette Vignogna Browne.
Browne stated that Renier-Berg was a hard worker and was juggling various duties at the hospital.
"Unfortunately, this meant that she often mentioned that she did not have enough time to adequately document the care she was giving patients."
Former VA medical center chief of medicine Joseph Henry Saiers said in his affidavit that while the patient population increased on 4D during that time, the "number of medical providers decreased."
"The busiest, hardest working doctors should not be penalized for medical records documentation, particularly when serving in a short-staffed work environment like 4D."
Saiers noted Rousseau's report was "... as close as we come in the case to a true peer review ..." He stated that two VA psychiatrists oversaw the inquiry into Renier-Berg's care, one of whom was the chief of staff, the other the chair of the medical center's ethics committee.
He stated that none of them is a true peer of Renier-Berg.
"Neither psychiatrist had much, if any, experience dealing with very ill, complicated patients."
Attorney Kelly said the response by VA medical center management was "written to put the best spin possible on Director (Mary) Dowling's incompetent and inappropriate over-reaction to the allegations of a disgruntled employee."
Added Kelly: "Director Dowling's actions were at all times motivated by her goal and objective of removing Dr. Renier-Berg from her employment."
Dowling, who was director of the VA Medical Center at the time, has retired and declined comment.
Dueling reports
For about a year, Renier-Berg's actions on medical center ward 4D were scrutinized after questions arose over the death of Cluster Gouch, a 70-year-old patient who went untreated for a gastrointestinal bleed, according to an OIG report.
Allegations that she signed a "do not resuscitate" order despite medical records showing the patient had wanted to be treated in an emergency got the attention of the Office of the VA Deputy Under Secretary for Health for Operations and Management in Washington.
That office dispatched the VA team from Arizona to review the events leading to the death of Gouch and others, and to determine, the "clinical quality and ethical validity of her (Renier-Berg's) care."
Rousseau and VA nurse Florence Gores reported back that it didn't appear Renier-Berg "attempted euthanasia" or withheld treatment in the patient cases reviewed.
The team concluded in a February 2004 report that the "overall assessment of care rendered by Dr. Renier-Berg appears to be generally within the standard of acceptable clinical practice ..."
The Arizona team discounted most of the allegations raised by the local VA, finding that she didn't exercise undue pressure to influence or coerce patients or families to accept what is known as palliative care, which focuses on comfort measures and alleviating pain for seriously ill patients.
Rousseau's team did recommend remedial action, finding that the practice of mixing certain drugs to administer to patients on 4D wasn't consistent with practice in other palliative care units; that Renier-Berg should have consulted with the VA ethics committee and psychiatric services in certain cases; and that her documentation practices needed improvement.
Many staff members perceived Renier-Berg as "blunt," "confrontational" and "flamboyant" with a desire to be the center of attention, the Arizona team reported, noting she "frequently practiced as an individual rather than a team member."
But the Rousseau team said only two staff members had concerns regarding "substandard or unethical medical care."
The team also recommended changes in medical center policy and practices in the area of hospice and palliative care such as: more medical center education, establishing criteria for referrals to palliative care, better medical record documentation, and revision of a policy that asked terminally ill patients every two weeks if they wanted to continue their "do not resuscitate" status.
Local VA response
That wasn't the final word on the matter.
One month later, the VA medical center in Albuquerque issued a response to the Arizona team's review, finding that Renier-Berg's use of terminal sedation, which used drugs to render seriously ill patients unconscious, "did indeed hasten death and that certain patients' lives could have been prolonged if palliative treatments other than sedation were appropriately employed."
At the time, the VA had no formal policy on terminal sedation.
Terminal sedation generally is used by physicians as a last resort in cases of critically ill patients suffering pain or other symptoms, according to the VA's National Ethics Committee.
Renier-Berg "did not possess the medical knowledge and skill to utilize all available palliative treatments for symptom relief and instead precipitously and excessively used terminal sedation to relieve suffering that could have been treated through other modalities," the VA response said.
The local VA medical center officials said Renier-Berg didn't give bereaved and distraught families adequate information to allow them to make palliative care decisions.
"... Dr. Renier-Berg's passion for palliative care, whether well intentioned or not, did place undue pressure or duress on vulnerable patients and family members and ... she created an atmosphere of intimidation that made her team unable to object to her actions or policies."
The response went on: "Language such as 'denial and resistance' is not respectful of patient choices nor is designating patients 'unfortunate,' which is common in Renier-Berg's notes.
"Behavioral health would not endorse such confrontational techniques as therapeutic particularly during the dying process," the local VA medical center response stated. "All patients die as they have lived and choose their own manner of passing. It is paternalistic to dictate how they should die and unprofessional to document in notes that patients are not 'accepting death.' "
The local officials also took issue with the Arizona clinicians' findings that Renier-Berg generally followed policy for "do not resuscitate" orders.
For patients who are competent and alert with the ability to understand their diagnosis and prognosis, the VA required the physician to discuss DNR with the patient and document it in a progress report that also assesses a patient's mental status, the response stated.
"No DNR order will be written or considered ... if it is inconsistent with the patient's wishes," the response said.
For patients who are comatose or incompetent or who are unable to make a DNR decision, the physician must consult with a patient's surrogate, the response stated.
Local officials said they found no evidence "that would support that Dr. Renier-Berg properly assessed mental status or documented diagnosis and prognosis adequately ..."
Or that she practiced in accordance with (VA) policy, "particularly when it came to honoring patients' wishes or providing sufficient information to surrogates to make informed decisions," according to the local response.
"... In clinical medicine and under the law, 'if it is not documented, it didn't happen.' "
Renier-Berg declared patients competent who were actually incapable of giving consent, the local response alleged.
Even when surrogates, such as family members, were making decisions, "there is no documentation of (the) presence of advance directives, names of surrogates, their wishes, nor how these wishes relate to the patient's values."
A VA nurse practitioner who gave an affidavit in support of Renier-Berg in 2005 said she was familiar with Renier-Berg's religious background and her "profound Christian faith."
"I have never seen her try to hasten a patient's death, nor do I believe that she would consider doing so," stated Browne.
'Fallacious hope'
As for Gouch, the Arizona team said it was documented that the family and the patient knew his life expectancy was short.
As to allegations that Renier-Berg failed to inform patients or surrogates about treatment options or to obtain their voluntary consent, the Arizona team noted the patients involved were suffering from a terminal condition.
"It is not clear any further aggressive treatment would have been of benefit. Offering options to patients that generate fallacious hope or that is not going to provide a comfortable dying process is not congruent" with VA policy or hospice/palliative philosophy.
But the local VA medical center officials concluded the Arizona team "did not spend a sufficient amount of time on-site or interviewing key personnel to make the determinations articulated here, which have significant bearing on patient safety."
For instance, the Office of Inspector General interviewed the chair of the hospital ethics committee for "over 10 hours. The site visit team (Rosseau's) interviewed the chair for about 20 minutes," the response stated.
The Arizona team didn't take advantage of the "immense amount of information at its disposal directly bearing on (Renier-Berg's) daily practice. The physician leadership of (the VA medical center in Albuquerque) individually reviewed more than 100 cases," the response stated.
The VA in Albuquerque found Renier-Berg often acted on end-of-life cases without obtaining the "necessary" consultations from specialists.
Physicians at the VA medical center reviewed hundreds of cases, the response stated. "Not one ethics consultation was made, nor were any behavioral health consultations (made), specifically to deal with the issue of capacity or end of life, such as evaluating for depression in terminal patients."
Renier-Berg said in a subsequent lawsuit against the VA that then-local medical center director Dowling prepared the response because "failure to rebut the experts' report" would lead to Renier-Berg's reinstatement.
Tuesday: Pain, suffering and "terminal sedation"
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