Libby Zion Law

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 physicians' 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 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 meperidine 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.

Libby Zion's death

Libby Zion (1965–1984) was born to New York City journalist Sidney Zion and publishing executive Elsa H. Zion. Before her hospitalization she had worked for Manhattan Borough President, Andrew J. Stein, as part of a study project. She was to have been employed the following summer on the clerical staff of The New York Times, where her father worked.

Zion was a freshman at Bennington College at her death on March 5, 1984, at age 18. She died within 8 hours of her emergency admission to the New York Hospital Cornell Medical Center. She had an ongoing history of depression, and came to the Manhattan hospital on the evening of March 4, 1984, with a fever, agitation and "strange jerking motions" of her body. She also seemed disoriented at times. The emergency room physicians were unable to diagnose her condition definitively, but admitted her for hydration and observation.

On the hospital ward where Zion was sent, she was evaluated by two residents: Luise Weinstein, an intern eight months out of medical school, and Gregg Stone, who had twenty months of residency training. Neither of them could definitely establish a diagnosis, but Stone tentatively wrote "viral syndrome with hysterical symptoms" suggesting that Zion was overreacting to a relatively mild illness. To alleviate her shaking the two residents prescribed her meperidine, a synthetic opioid painkiller. Zion's primary care physician, Raymond Sherman, approved this medication plan by phone. The events that followed remain controversial. At the subsequent trial different parties presented conflicting accounts of her care.

At 3 in the morning, the two residents left Zion in the care of nurses. Weinstein went off to care for some of the 40 other patients she was covering, and Stone went to sleep in an adjacent building, where he would be available, if necessary, by beeper. After the two doctors left, the nurses contacted Weinstein at least twice to report that Zion had become more agitated. Weinstein ordered physical restraints to hold Zion down and prevent her from hurting herself, and she also prescribed an injection of 1 mg haloperidol—an antipsychotic commonly used in psychiatric emergencies. Because she was busy with her other patients, Weinstein did all this without reevaluating Zion in person. According to the nurses, after these measures Zion finally fell asleep. When a nurse's aide took her temperature at 6:30 a.m., it was dangerously high at 107.6 °F (42.0 °C). The nurses called Weinstein again, and emergency measures were tried to lower Zion's temperature. Shortly thereafter Zion suffered a cardiac arrest and died at 7:30 a.m. To the doctors at the hospital, her death was an inexplicable "bad outcome" in which a healthy young woman had died of a mysterious infection. Weinstein then called Zion's parents, telling them doctors had done everything they could.

Although the medical examiner's report vaguely ascribed her death to "acute pneumonitis", today it is generally accepted that Zion died from complications of serotonin syndrome which was caused by a combination of meperidine and phenelzine.

Publicity and trials

Unsatisfied with the arguments presented by the doctors, Libby's parents became convinced that their daughter's death was due to inadequate staffing at the teaching hospital. 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 premier medical journals.

State investigation

In May 1986 Manhattan District Attorney Robert Morgenthau agreed to let a grand jury consider murder charges. 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 witnesses in toxicology, emergency medicine, and chairmen of internal medicine departments at six prominent medical schools. 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. This distinction forced the doctors' insurance companies to cover the damages rather than them personally.

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.

Law and regulations

Further information: [[:Medical resident work hours]]

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 residency 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 physicians 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.

Cultural references

The Law & Order episode "Prescription for Death" is based on what happened to Libby Zion.