A Bitter End

Please note: This article is published as an archive copy from Philadelphia City Paper. My City Paper is not affiliated with Philadelphia City Paper. Philadelphia City Paper was an alternative weekly newspaper in Philadelphia, Pennsylvania. The last edition was published on October 8, 2015.

By Emily Guendelsberger |

Everyone agrees that Barbara Mancini's dad wanted to die. But when his troubles were over, hers had just begun.

Photo Credit: Neal Santos Barbara Mancini and Joseph Yourshaw in Florida in 1992. Twenty years later, Mancini would be charged with a felony for handing her father the morphine bottle he used to overdose. Photo Credit: Neal Santos Mancini in her Roxborough home. Mancini in her Roxborough home. A family photograph of Joseph Yourshaw on display in his daughter’s house. Photo Credit: Neal Santos Mancini and Yourshaw at her wedding in 1994. Yourshaw and Mancini in Florida in 1992.

This story is being published in print in two parts; the first will be on newsstands the week of June 26, the second the week of July 3. This is the full piece.

One thing that nobody disagrees about: Joseph Yourshaw wanted to die.

“He talked about it to anyone who would listen to him,” says his daughter, Barbara Mancini, 58. “He said he didn’t want to be a burden on my mom, he didn’t like living like that, he didn’t like being old, he hurt all over.”

Mancini, an emergency room nurse, lives in Roxborough, two hours away from her parents’ home in Pottsville. She helped her father with the official parts of the big decisions he made about his end-of-life care — helping him make a living will and a Do Not Resuscitate order (DNR) in 2010, when he was 91, and serving as his health-care power of attorney.

Her father would often tell her that he wanted to die, she says. “I usually wouldn’t say anything, I’d just listen to him. I’d say, ‘I know, Dad. I know you don’t like living like this.’ What am I going to say? ‘I know it’s hard for you.’”

The constant talk of death was rough on Yourshaw’s wife, Marguerite, who was 83 at the time. “But he needed to say it,” says Mancini. “He said it to me, he said it to anyone who came in the house.”

He certainly said it to employees of the Hospice of Central Pennsylvania — their notes on Yourshaw from periods in 2012 and 2013, when he was enrolled in their home-care program, read like a broken record. Under the heading Most Important to Patient Now, hospice workers wrote, over and over: “Pt [patient] wants to die,” “pt states he is ready to die,” “just wants to die.” His DNR is also noted in every entry.

Records from Yourshaw’s first hospice stay in spring of 2012 note that he was refusing to take any medicines for his high blood pressure or diabetes, and that “he is trying to ‘will himself to die’ by refusing to eat, take meds, etc. ... Pt. appears to be trying very hard to die a.s.a.p.”

But he couldn’t seem to die.

So he tried a little harder. A few weeks after his enrollment, HCP charts note that Yourshaw, a model diabetic who’d eschewed bread and spaghetti for decades, had “drastically increased his intake of sugar (in the form of candy) in last 1-2 weeks.” Most Important to Patient Now, April 4: “To have his wishes respected.”

But Yourshaw still couldn’t seem to die. In fact, his condition was deemed stable enough to leave hospice in June 2012.

So he tried a little harder. When Yourshaw returned to HCP care in mid-January 2013, he was doing a lot worse. Charts note that his diet now consisted of “mostly sugar foods such as candy and soda.” Soon, he was sleeping 18 to 20 hours a day, waking up to lug himself to the bathroom and to eat more candy. Jan. 30: “Again states that he doesn’t know why he can’t die.”

So he tried a little harder. And this is where people start disagreeing.

Photograph of Joseph Yourshaw on display in Mancini's house. Photograph of Joseph Yourshaw on display in Mancini's house.

On the morning of Feb. 7, 2013, after a year and a half of trying to die, Joseph Yourshaw was done waiting. While his wife was out to lunch, he told his daughter he was in pain, and asked her to hand him his hospice-prescribed bottle of morphine. She did. Yourshaw swallowed what remained in the small bottle. He and his daughter then talked for a while. Eventually, he fell asleep as she held his hand. “I just sat there with him,” says Mancini. “I was not about to call and take him to the hospital, because he never wanted to go to the hospital for anything. He made that clear to all of us.”

But, even then, Yourshaw couldn’t seem to die.

He woke up in an emergency room a few hours later. A hospice nurse had stopped by the house, and his daughter had briefed her on what had happened with the morphine. “I didn’t think I had anything to hide!” says Mancini. “It didn’t even occur to me to concoct a story, or not to mention it.”

Mancini had explained to the nurse that her father wanted to die, and that he had a DNR on file. To her shock, the nurse called 911, and the police and paramedics arrived. “I told them, ‘He asked me for his morphine, and I handed it to him,’ and they said, ‘Well, let’s go to the hospital,’” says Mancini. Despite her pleading, Yourshaw was loaded into the ambulance and taken to the hospital. “I said, ‘He’s suffering! He wants to die!’ And that got turned into, ‘She gave him his morphine so he could die.’” That phrasing appears many times in official documentation of what happened.

“So he gets taken off to the hospital; I get taken off to the police station,” says Mancini. As she was being booked on charges of causing or aiding suicide, her father was being given a dose of Narcan, a drug designed to counter heroin overdoses in addicts. The hospice records note: “Pt responded by awakening within 30 seconds of receiving the Narcan. He was able to talk and he kept saying over and over —‘Don’t let them hurt Barbara.’” The ER records note: “After Narcan given, pt. became very active, pulling off gown, trying to climb [out of bed], pulling at heart monitor, mitts applied.”

Says Mancini: “He’d obviously heard what was going on in the house. He was livid. My sister-in-law said she’d never seen him so angry in 30 years.”

Immediately after Yourshaw was revived, a hospice worker, for once, got a different answer from him than his usual wishes for death. Most Important to Patient Now, Feb. 7: “Wants to see Barbara and make sure no one hurts her.”

When Mancini was released by police and arrived at the hospital, though, she was barred from visiting her father in the ER. By the time she was able to see him that night, she says, “His eyes weren’t open; he wasn’t talking or anything. I mean, I said things to him; whether he heard me or not, that’s anybody’s guess.”

In the hospital, Yourshaw developed bedsores, a rash where he’d been catheterized and pneumonia. He hung on for four days — possibly the first time in a year he’d been trying to live rather than die, aware as he was that his daughter could be in serious trouble over his death.

Joseph Yourshaw finally managed to die on Feb. 11, 2013. But his daughter’s problems were just beginning. His death was ruled a homicide, and the state hit Mancini with felony charges that could have resulted in a 10-year prison sentence. And though the case against her was so flimsy that it was thrown out before it went to trial, the Pennsylvania Attorney General’s Office pursued it aggressively.

On Feb. 11, 2014, the anniversary of Yourshaw’s death, Schuylkill County Court of Common Pleas Judge Jacqueline Russell granted Mancini’s petition for habeas corpus. Her written opinion contained harsh words for Kathleen Kane and the Pennsylvania Attorney General’s Office: “As the case presented to the Court would not warrant a submission to a jury due to the lack of competent evidence elicited by the Commonwealth” and “reliance on speculation and guess serving as an inappropriate means to prove its case.”

But an extended prosecution can make even such a slam-bang ruling feel like a Pyrrhic victory.

“The case was dismissed, but I’m going to be dealing with the fallout from this for a long, long time,” says Mancini in an exclusive interview a few months after the ruling, as she was about to return to work after nine months of unpaid leave. “My defense cost $104,000. I’m a nurse, my husband’s a paramedic. We’re not wealthy.” Major death-with-dignity nonprofit Compassion & Choices contributed $20,000 from its legal defense fund, Mancini says, but it’s still a lot. “I’ve got a child in college and a 16-year-old who wants to go to college someday, so …” She gives a pained laugh. “I’m going to be 58 in a couple days, and my husband’s 57, and we think that we probably won’t retire, ever.”

But that’s not what bothers her the most. “I will be forever haunted by the way my father’s life ended,” she says. “He suffered tremendously in the hospital. Not only physically — the anguish that he died with knowing that I was in trouble because of him asking me to hand him his medicine. … I cannot imagine I’ll ever get over that.”

It seemed very much like Mancini and her lawyers had been prepared for an appeals-court battle challenging the constitutionality of the “causing or aiding suicide” statute under which she was charged. But the flimsiness of the commonwealth’s case against her caused the charges to be dismissed before it even went to trial. The vague wording of the law that caused Mancini’s hellish year is still unaddressed, which means everything that happened to Mancini and her father — the felony charges, the year of prosecution, the debt, the overruled DNR, the prolonged death, the horrible memories — could easily happen to another family.

“He could build anything, and he could fix anything,” Mancini says of her father. “He could do anything. My mom likes to say that she never had to call a repairman for anything until the last year of my dad’s life. And he was really smart, very opinionated. Hated Ronald Reagan. He was a champion for the regular guy. Read a lot of periodicals.”

Joseph Yourshaw was, above all, fiercely independent. When he retired from contracting in his late 70s, he hadn’t had a boss in nearly half a century — his last one was in World War II, where he was awarded a Bronze Star for bravery for repairing bombed-out tanks on the front lines during the Battle of the Bulge.

Mancini says that her father got a little forgetful in the last few years of his life. But his mind was clear, and he’d never been diagnosed with dementia or anything that would make him incompetent to make his own decisions about his end-of-life care. In October of 2012, between his first and second stints in hospice, the Pottsville Historical Society interviewed him about his WWII Army experiences. “He described at length where he served, the tanks he worked on, all kinds of stuff, in great detail,” says Mancini. “I never understood that stuff, but if someone was mechanically inclined, they could spend hours talking about how all these engines worked.”

Even after retiring, he renovated and did repairs on a five-acre property the Yourshaws had bought in Florida. “He rebuilt the deck around the pool. He knocked out a brick wall and put these decorative windows in. He’d get up on the roof. He did the entire cement driveway by himself,” says Mancini.

“Here’s something funny that gives you an idea of what kind of guy he was — when he was 83, he was down in Florida and Mom was up in Pottsville, and he called her and told her she needed to come down and bring him some crutches because he’d fallen down a couple times and hurt himself,” Mancini says with a laugh. “So she gets in the car with my brother-in-law and they start to drive down to Florida with these crutches.

“So I call my dad, ask him what’s going on, and he told me he couldn’t walk right and had fallen down a couple times. I say, ‘Dad, you need to call 911 and get to the hospital, you might be having a stroke.’ And he’s, like, ‘No, no, I’m fine, I just need your mother to bring me the crutches.’” I tried and I tried to convince him, but he wouldn’t do it.” Eventually Mancini called his doctor, who was able to talk Yourshaw into calling 911. “He packed a suitcase, locked up the house, went out into the driveway and was sitting there with his suitcase when the ambulance got there. And he’d had a stroke. That was the kind of guy he was. He wanted to do everything himself. He didn’t want anybody’s help.

Barbara Mancini and Joseph Yourshaw in front of the house in Florida in 1992. Barbara Mancini and Joseph Yourshaw in front of the house in Florida in 1992.

“He was convinced that he would be healthy because he was always very physically active and ate a decent diet and worked hard. He thought he was immune to getting anything because of his lifestyle. He didn’t have much regard for people who just sat around all the time,” says Mancini. Toward the end of his life, “when he physically became like that, it was very difficult for him. Some people wouldn’t mind that, but he minded it a lot.

“And he was also in pain — all those years of physical labor take a toll. He had arthritis throughout his body,” as well as complications from diabetes and problems with his kidneys and heart. But he still insisted on cleaning the oil burner until he was 91.

“He was 92 when he decided he wasn’t going to do this anymore,” says Mancini. Yourshaw went to his doctor in October 2011 and told her he was done with taking his diabetes and blood-pressure medications. His family was sad, but respected his decision. “I feel very strongly that a person should have the right to make the decisions that affect the intimate details of their lives,” Mancini says. “I probably feel that way because he felt that way, and my mother feels that way, and that’s what I was raised with.”

Though religion is a big factor in many people’s end-of-life decisions, it wasn’t in Yourshaw’s. For decades, he had been a staunch atheist. “He’d go on and on about it,” Mancini laughs. “He talked about his lack of belief a lot. … He was raised Catholic and had a very difficult upbringing — he was one of 12 children in a very poor family, and I think that was a big influence on how he felt about religion.”

When Yourshaw stopped taking his medicines, Mancini started driving the two hours to Pottsville more often to help out. “I would go up once a week, because I was working, I have two children.” After a flu in December prevented Mancini from driving up a couple weeks in a row, she brought up the idea of hospice care.

“I normally am a person who does a lot of research,” says Mancini, illustrated by the 4-inch-thick, neatly annotated binder of papers and records relating to her case on the table in front of her. “I’ve advocated for family members when they’ve had health issues, and I try to find out as much as I can about things beforehand. I didn’t do it with this.” Mancini often sounds furious or outraged about the past few years. Here, she sounds like she’s in real pain.

When she couldn’t find resources to judge the comparative quality of hospices — at the moment there’s no standard, and hospices use different methods of assessment that aren’t easily comparable — Mancini just went with the recommendation of her father’s primary-care physician. She suggested the nonprofit Hospice of Central Pennsylvania, one of the biggest in the state.

“I thought I was doing the right thing. And I just assumed that when we engaged a hospice, they were gonna do the right thing. That was a really bad judgment flaw on my part.

“I believe that this would not have happened at all if this hospice had done what they were supposed to.”

On the Hospice of Central Pennsylvania’s consent-for-services form, the enrolling patient is asked to acknowledge that he understands the following standard things about what “hospice care” does and does not mean:

Hospice care focuses on comfort, relief from pain and other symptoms, and emotional and spiritual support rather than curative or life-extending treatment or interventions. I understand that certain medical procedures, such as [CPR], are not performed by … staff or volunteers. Hospice services are not intended to take the place of care by my family … but rather to support them in my care. Hospice services are provided primarily in the patient’s place of residence … through intermittent scheduled visits. Consultation and visits for urgent matters and pain and symptom control are available 24 hours a day, seven days a week. I have a choice about the care provided to me. I may discuss and participate in developing the plan of care … [and] may refuse a particular treatment or service.

It took Mancini some work to sell her father on hospice care. It sounded to him like people would be coming into his house and telling him what to do. “He didn’t want them there,” says Mancini. “He only agreed to let them come in there because it would help out my mom.”

Hospice isn’t something you can just decide you’re ready for. Two independent doctors must rule that you have fewer than six months to live before you’re eligible for admission. Two doctors judged Yourshaw as such, and he enrolled in Harrisburg-based HCP for the first time in March 2012.

From the very beginning, Yourshaw’s hospice charts, which Mancini shared with City Paper, make him sound like he wasn’t the easiest patient. “You know the phrase ‘full of piss and vinegar?’” asks Mancini. A note made by his primary-care physician when he announced he would stop taking all medications sums it up pretty well: “Oriented and rational although disagreeing with pretty much everything I discussed with him.”

Entries on Yourshaw’s hospice charts sometimes make him sound like a cranky-old-man cartoon, though they consistently note that he’s alert with “judgment/insight intact”:

Pt. presented with his “usual grumpiness” and direct responses about “I have pain all over” and “nothing matters to me” responses Pt … is exasperated and sighs heavily when queried At end of visit pt refused to rate his pain, when asked pt puts his hands in the air and states “I don’t know” when asked if medicine worked pt again puts hands in air and says “I don’t know”

It wasn’t just difficult to treat Yourshaw because of “piss and vinegar.” He almost constantly refused to assess, talk about or accept any medication for his pain — the primary purpose of hospice care. He particularly seemed to dislike being asked to rate his pain on a 1 to 10 scale. On the second day of hospice records, he’s already having problems with it:

Patient describes constant body ache “all over.” Unable to rate pain using pain scale. Wife states patient’s pain is “3.”

For most of the rest of his records, he just refuses to pick a number or answer in the way the hospice staff wants, saying instead that he does have pain but he’s fine, he’s comfortable. This leads to the regular appearance of the phrase “comfortable despite pain” in Yourshaw’s charts.

The complacency and lack of follow-up that Mancini reads into “comfortable despite pain” still infuriates her as both daughter and a professional. “What they’re supposed to do is relieve the [immediate] pain by giving the person a high enough dose of short-acting agents to provide pain relief, then work on finding a longer-acting agent.

“So here’s my dad: He’s in pain every day, all day. You’re supposed to work at it and find a solution for the pain, find a medication that would work better” rather than “telling my mother, ‘Just keep offering it.’ It clearly doesn’t work!

“I don’t know if they just weren’t prepared to deal with someone like him — although, anybody in health care has to learn to deal with different personalities,” says Mancini. “Sometimes he was ornery with them. … There were times where he said, ‘I’m not takin’ any medicine.’ He definitely didn’t want to take any medicine for his blood sugar. But he was taking stuff for pain.”

Because whatever he told the hospice workers, Yourshaw was in pain. He refused prescription pain medications, but took lots of over-the-counter ones.

When Mancini got her father’s charts, they didn’t reflect that hospice workers had realized why Yourshaw so adamantly refused pain medicine. She says her dad had gotten unpleasant side effects from the first narcotic pain medications he’d tried, but the dosage he’d been prescribed hadn’t been high enough for effective pain relief. Instead of asking for help, he just “stopped taking it. He wasn’t the type of guy to go back to the doctor to get more stuff. Started taking Tylenol and Motrin again.” After a few tries at finding a medication that would work for him, the hospice charts reflect, nurses eventually seem to accept his word that Yourshaw really doesn’t want any medicine and is “comfortable despite pain.”

The second time Yourshaw checked into hospice, he was so adamant about not wanting medicine that hospice nurse Barbara Cattermole, who enrolled him, didn’t leave the standard bag of emergency medications at the Yourshaw home. At Mancini’s preliminary hearing, Cattermole testified: “He refused to take all medications. There was no meds. I didn’t even order an emergency kit because he refused to take any meds.”

An emergency kit, or e-kit, is a “just in case” supply of medications for a wide range of situations. The e-kit Yourshaw was issued at his first enrollment at HCP included lorazepam for anxiety, Haldol for hallucinations, prochlorperazine for vertigo and nausea … and morphine for pain.

“He was provided all these medicines, no questions asked, in a bag,” says Mancini. He didn’t use them, so “when he was discharged, we handed it back.”

In Yourshaw’s last month of life, he was in a lot more pain, and Mancini says she finally was able to talk him into considering morphine as an alternative to Tylenol. Since Cattermole hadn’t left the e-kit, on Feb. 1, 2013, Mancini called HCP and requested a morphine prescription. This call would later be used in court as a sign of premeditation.

“I spoke with Deborah Hornberger, who’s the nurse supervisor,” Mancini says, “and she actually gave me a hard time on the phone — told me it wasn’t appropriate for him to have morphine.” Mancini says Hornberger told her, and it’s in hospice records, that because Yourshaw hadn’t been on opiates before, “it would be more appropriate for him to be on Percoset. Which is an opiate! It didn’t make sense. But she argued with me.”

Given the hospice’s policy that “pain and symptom control are available 24 hours a day, seven days a week,” Mancini was further unsettled when the morphine she’d requested that morning didn’t arrive until 8 p.m. the next evening, 36 hours after she’d called. And when it arrived, Mancini recalls thinking that, based on her 30 years of experience medicating pain in the ER, the dosage seemed really light. “Two-and-a-half milligrams of oral morphine, for someone in severe pain? It’s a joke.” But, she says, she figured hospice wasn’t her specialization, and didn’t bring it up.

“I wasn’t comfortable with how it was going at the time, but I didn’t realize the extent of how poorly they were doing it until after all this happened — after I got the records.”

The Hospice of Central Pennsylvania declined to comment on anything specific for this story. CEO Gil Brown passed along only this statement: “While we cannot discuss a specific case, we’re confident that our physicians, nurses, social workers and chaplains provide appropriate and necessary care for our patients. Our standards of care meet all legal and regulatory requirements and comply with state licensing and scope of practice requirements.”

Mancini got her father’s hospice records in discovery after her preliminary hearing — at which Senior Deputy Attorney General Anthony Forray’s argument for potentially sending her to prison for 10 years included, “This was a lot more than simply handing a bottle of medicine to someone. … There was no morphine in the home. Who was responsible for requesting the morphine to be in the home? The defendant.”

Hornberger was called as a witness to back this up, and testified: “Barbara called me specifically asking me to order morphine for her father. I did tell her that we should try other medication before going to morphine. She said that she was an RN and knew and still insisted on having morphine ordered.”

Forray confirms that his witness had had a chance to review Yourshaw’s hospice records, noting that “The records I have in my possession I believe were obtained from [arresting officer] Captain [Steve] Durkin who, in turn, had obtained them from the coroner.” In other words, pretty much everyone but the defense had seen the records at this point.

Which is why it’s surprising that not one person noticed that Joseph Yourshaw had been prescribed a significantly stronger dosage of morphine by the attending physician at his hospice enrollment, weeks before Mancini called. Admittedly, the records are dense and difficult to read. But it’s right there in the first pages of Yourshaw’s file: “‘Morphine for pain and for shortness of breath, 5-10 mg every 2-4 hours as needed. May titrate 1-2 times the base dose.” The prescription had just never arrived — it was part of the e-kit that Cattermole hadn’t left at the Yourshaw house. “We were never notified that these medicines were ordered, we had no clue!” says Mancini.

The morphine that would have come in the e-kit was stronger than the dosage Mancini had thought seemed a little weak: “He could have had as much as 20 milligrams every two hours. What he ended up getting, ultimately, was 2.5 milligrams every four hours. A fraction” of what the physician initially judged to be appropriate.

Mancini and her lawyer were baffled that nobody had noticed the original prescription — not just in court, but back when she’d first called. “They have electronic health records — it would have been right there for [Hornberger] to see it” when they spoke on the phone, says Mancini.

Other things in the charts further confirmed the uneasiness Mancini had felt. She was surprised to find out that it had taken Hornberger more than six hours to get in touch with Yourshaw’s attending physician — and that that physician doesn’t appear to actually have been in the same room as Yourshaw until after his overdose. Mancini believes very strongly that “no physician ever spoke to him, touched him, examined him” based on the lack of physician contributions to Yourshaw’s charts aside from the occasional signature. You can’t prove a negative that way, but HCP declined to answer any questions.

The Medicare code has a long list of conditions of participation for hospices — standards providers must adhere to to be able to bill Medicare for services. The language, seeing as this is the government, isn’t the clearest. One is patient’s rights, and the first thing on the list is “receive effective pain management and symptom control from the hospice for conditions related to the terminal illness.”

Mancini says HCP was too willing to accept her father’s stoic front at face value, when the repetition of conflicting information — reporting that he simultaneously had pain and was comfortable — should have prompted a closer examination by a physician. “I firmly believe that there was never more than a token effort by the hospice to find an agent and a dosage that would effectively manage my father’s pain,” she says.

The night before Joseph Yourshaw’s overdose, Mancini says, her mother called in tears. Yourshaw had fallen that morning, and now as they were trying to put him to bed “was in so much pain they couldn’t even get his clothes off.” He was wearing one of his old button-down shirts from when he was 50 pounds heavier, but even unbuttoning it and trying to ease the loose-fitting shirt off his shoulder was too painful for him. “My mother and my brother felt like they were breaking his arms.” (Postmortem records would later show that Yourshaw’s arthritis was particularly bad in his shoulders.)

“I drove up that morning from Philly and he was sleeping when I got there,” says Mancini. Her mom stepped out to get lunch and do some shopping, leaving them alone in the house. “After a while, he woke up and asked for a little orange juice. He told me he was in a lot of pain, he asked me to bring his medicine to him, which I did. I had the dosing syringe in my hand, I handed him the medicine, because he always opened the medicine for my mom, it had one of those child-proof caps on it that she could never get open. So I let him open it like he did for her. And he drank it. That’s what happened.”

Afterward, she says, “I sat there and held his hand and we talked for a while about a number of things … how he loved my mother and how he loved us. He talked about the war. Talked about some friends of his,” says Mancini. “Then he got sleepy, so he stopped talking and I just sat there and held his hand.”

Nobody disputes that Joseph Yourshaw wanted to die. He might have been able to do so in peace that day instead of in anguish at the hospital four days later if a hospice nurse hadn’t called about an hour later asking if she could drop in for an unscheduled visit.

The disagreement about the death of Joseph Yourshaw starts when nurse Barbara Cattermole comes by the house about an hour and a half after he drank his morphine. Since, again, HCP declined to comment on the part of all its employees, everything from hospice employees has been taken from her testimony at Mancini’s preliminary hearing.

It all seems to start with the word “give.” A major point in the Commonwealth’s case against Mancini was multiple accounts that she’d said she “gave” her father the morphine. Mancini insists she meant “handed.” Cattermole understood it as “administered.” Everyone who heard Cattermole’s account of what happened before they heard Mancini’s understood it to mean “administered,” too — and that includes the hospital, the coroner, the pathologist and the police. For example, see this cross-examination of responding officer Captain Steven Durkin by defense counsel Fred Fanelli:

A. [S]he told me she gave him his morphine. Q. And by “give,” she handed him the bottle. That's what we're talking about, just for clarity. There's a lot of difference. A. If you want to take it that way. Q. Like if I hand you my cell phone or my pen, that's a lot different than actually administering something to you. A. Yes, that would be different. Q. So she never admitted or made any statements to you that she did anything other than hand the bottle when he asked for the bottle; is that correct? A. She indicated that he wanted to die, so she gave him his morphine.

That last one is the second semantic trouble spot. Mancini says that two things she said to Cattermole and Durkin — that she had given him the bottle of morphine and that he should not be taken to the hospital because he wanted to die — got lumped together to make another key part of the case against her: She gave him his morphine so he would die.

For example, in the Commonewealth’s brief opposing habeas corpus: "The Defendant admitted to giving him the whole bottle of morphine” and “She said several times that she gave him the morphine so he could die.” (Mancini argues that she never said it.)

Another thing was that Cattermole testified that Mancini had asked her to do something: “To get more morphine because her father had not died yet.” In hospice records, Cattermole wrote that Mancini had told her upon her arrival, “I gave my father the bottle of morphine to drink, all of it, and I need more morphine.” Cattermole also told the ER doctors the same thing, and they recorded in their records that Mancini “actually wanted to have more Roxanol provided,” and it’s in the records of the coroner and police.

Mancini says that she never said anything like that. “Complete perjury. It’s a bald-faced lie.”

Why would she say that? Mancini has no idea. “[Cattermole] was the nurse who withheld those medications when my father was enrolled in hospice. I don’t know what was in her brain when she said it.” Again, regardless of what was actually said, which is one person’s word against another, this was used as a key part of the Commonwealth’s case: “Your Honor, the most compelling evidence from Nurse Cattermole when the bottle didn't do the trick, she wanted Nurse Cattermole to get more morphine to do the trick.”

Opiates like heroin and morphine kill people by essentially relaxing the central nervous system so much that the brain forgets to tell the lungs to keep breathing, called “respiratory arrest.” Guides for how to identify and handle opiate overdoses always say to check for slowed breathing, which is cited variously as between 8-12 breaths per minute. (The eventual hospital plan of care for Yourshaw was to give another dose of IV Narcan if his respiration dropped below six, which it never did.)

Roxanol, the brand-name oral form of morphine Yourshaw had been prescribed, reaches its peak effect after an hour and continues to work for 2-4 hours. Cattermole arrived about an hour and a half after Yourshaw ingested the Roxanol at 11:30 a.m. She testified that Mancini was upset when she told her she would need to call 911, and wouldn't let her near her father; Cattermole convinced Mancini to let her do Reiki on Yourshaw (which Mancini says she thought was weird enough to be harmless) and used that to surrpetitiously check his vitals.

She wrote in hospice records that during her chakra spread, Yourshaw’s respiration had been 16 breaths per minute. His respiration had also been recorded at 16 the last time a nurse had seen him two days earlier, which had not been noted as a cause for concern.

When Yourshaw arrived at the hospital at 1:50 p.m., it had been more than two hours since he’d ingested the Roxanol. He was out of it, but his respiration was again recorded at 16, though “shallow.”

With all this put together, it’s not surprising that the hospital, while keeping a close eye on the situation, was not treating this as an all-hands-on-deck urgent situation, and didn’t immediately move to treat him until they were able to contact his wife.

At 2:35, it’s noted that a hospice nurse (Cattermole) is present, and records reflect that she filled in the hospital staff with her version of events:

Hospice worker to me stated … that the daughter had given the Roxanol. Do not wish her to be involved and actually wanted to have more Roxanol provided and then asked the Hospice worker to leave.

Around this time, three hours after he’d swallowed the morphine, Yourshaw’s respiration was recorded at 20.

At 2:45, more than three hours since he’d swallowed the morphine, Yourshaw’s charts note:

WIFE AND DAUGHTER AT BEDSIDE PT SNORING AT THIS TIME

Marguerite Yourshaw had come home from lunch “to find police in her home,” note the hospice records, continuing: “She was upset that she had not said goodbye to him because he was sleeping when she left.” The DAUGHTER was actually a daughter-in-law; Mancini was still at the police station.

At 3:00, three and a half hours after he’d swallowed the morphine, Yourshaw’s respiration was recorded at 22.

Around that time, Mancini got a call on her cell phone. “I was in the police station sitting next to the guy who arrested me, and my mom calls my cell phone and says, ‘They want me to sign a consent for treatment, what should I do?’” says Mancini. Captain Durkin “overhears this and says, ‘Let me talk to the ER doctor.’ He takes the phone and says to the ER doctor, ‘If he dies now, it’s going to go worse for her.’”

“That was my mother’s choice, if you want to call that a choice: Honor my dad’s wishes, or try to help me.” Marguerite signed the permission to treat her husband, and he was given a dose of Narcan at 3:40, more than four hours after he’d drunk the morphine. From hospice records:

After patient received dose of narcan he awoke and was calling out for his daughter Barbara. “Don’t let anyone hurt Barbara” He kept repeating this over and over. He also became agitated and began pulling the pulse ox off and the leads that were monitoring his vital signs.

At 3:50, Yourshaw's respiration was recorded at 20.

Around 4 p.m., more hospice staff shows up — supervisors Deb Hornberger and Barbara Woods, who had spoken to Mancini on the phone. From hospice records:

We proceeded to [Yourshaw’s] room and upon entry, he stated, “Get those foreigners out of here”. His wife stated “they are not foreigners, they are hospice staff”. The patient stated, “I don’t know them so they are foreigners.”

Hospital records:

patient belligerent when spoken to. States “get the hell out of here” and “your hurting me”

Hospice records:

DIL [daughter-in-law] followed us out into the hallway and stated that patient has always been very stubborn. She stated that if he said the sky was green, then the sky was green. The family is very concerned for Barbara.

“The hospice people showed up to fill in the ER on my dad’s history,” says Mancini, and “suddenly it appears that my father has a history of dementia and depression. Which he did not, ever.”

Reviewing her father’s hospital records, Mancini was confused about where this information originated, because he hadn’t been diagnosed with either. “I asked my mother about it, and she said ‘I never said anything like that!’ He’d never been hospitalized there before” and so wouldn’t have an existing record. The ER admission staff, she knew, wouldn’t have just assumed dementia from the circumstances. “You’re supposed to have a physician diagnose dementia,” says Mancini. “You can’t just write it down.”

The attending physician, Dr. Timothy Henninger, writes that the information had come from Cattermole: "According to [her] statement to me, states that the daughter had given him a bottle of Roxanol … He also has a history [sic] dementia” and that when he’d enrolled in hospice had “seemed a little depressed, but was not suicidal.”

Until that point, HCP hadn’t been acting as if Yourshaw had dementia or clinical depression, nor writing it down on his charts. There are notes that he has some memory problems, that he sometimes seems “sad/depressed” and that he’s often grumpy and negative; there’s far more consistent notes that say he’s alert and has his judgment and insight intact. And in the areas where it’s important, he’s treated as competent. He signed his own forms admitting him into hospice, and his physician’s plan of care states “patient may self-administer medications.” Nurse Cattermole allowed him to refuse the e-kit containing all his medicines without consulting with his family, which wouldn’t have been a responsible thing to do with a patient who wasn’t in his right mind.

Mancini says after HCP employees spoke with Dr. Henninger, “suddenly dementia appears on that ER record, and then on the hospital records — because what one doctor writes down, the rest write it down afterwards.”

Mancini suspects the reason the records start stressing dementia and depression only after her father’s overdose is that the hospice was trying to cover its ass. “They realized they’d failed my dad, and I believe that they wanted to divert scrutiny away from their failure and onto me.” HCP, again, declined to answer questions.

At Mancini's wedding in 1994. At Mancini's wedding in 1994.

The hospital didn’t have much opportunity to observe Yourshaw’s mental status, anyway — his hour of post-Narcan fury was the storm before the calm. By 6:20, when he was moved from the ER to a patient room and Mancini was allowed to visit, but he was unresponsive and she wasn’t sure if he could hear her or not.

By the next morning, Yourshaw’s charts note that he’s semi-comatose and has the beginnings of bedsores. The morning after, he’s developed rhonchi (rattling, snore-like sounds) and wheezes in both his lungs, and the beginnings of a rash around where he’d been catheterized.

All of these conditions worsened over the next three days. By Feb. 9, he doesn’t respond to pain stimuli — Mancini hopes that he wasn’t able to feel the rash that had spread down his penis to his scrotum and tailbone, because it would have been extremely painful. In the overview, his attending doctor wrote Yourshaw "was stable and then subsequently spiked a temperature … then developed worsening respiratory distress.” He was put on an antibiotic.

On the morning of Feb. 11, Yourshaw’s condition worsened even more. His blood was found to be very acidic (his kidneys had gone from stage III to stage IV), and a chest X-ray revealed that his lungs, which had been clear when he was admitted, were now full of gunk. He was put on a respirator.

The attending doctor records telling the family that Yourshaw was not going to make it “because of the respiratory failure and probable aspiration pneumonia.” Attempts to fix Yourshaw were stopped at 8 a.m. At 8:39, he “was given morphine for any respiratory distress,” though at a very low dosage. After four days in the hospital, Joseph Yourshaw died at 4:42 that afternoon.

The hospital didn’t list an official cause of death; the field was left blank. Dr. Kimberly A. Hashin’s discharge diagnosis:

Respiratory failure. Aspiration pneumonia. Drug overdose. Acute on chronic kidney disease. Diabetes mellitus type 2 uncontrolled. Failure to thrive.

It seemed very clear to Mancini that her father had died of pneumonia. At the time of his death, she says, he’d been out of the danger zone for morphine toxicity for days. “You develop pneumonia very quickly in the hospital. He had a high fever, he had a rapid heart rate, junky-sounding lungs,” and other symptoms that signaled pneumonia. “The way a narcotic overdose kills you is you stop breathing. He didn’t! He didn’t stop breathing!”

As of 6 p.m., about an hour after Yourshaw’s death, records show that Schuylkill County Coroner Dr. David Moylan had already arrived at the hospital, spoken to the family and viewed the body. He got full autopsy and toxicology reports done, so it was mid-June by the time the final coroner’s report and death certificate were issued.

Cause of death: morphine toxicity complicating hypertensive atherosclerotic cardiovascular disease. Manner of death: homicide.

“When I found out what that death certificate said, I remember saying to my husband, ‘I’m screwed. They’re using me for politics,’” says Mancini.

On the TV series Homicide: Life on the Street, a detective puts it this way: “You go when you’re supposed to go, and everything else is homicide.”

But that’s not technically how it works. There’s five government-recognized manners of death. There’s natural, accidental and undetermined. “One that was initiated by the own person, that would be a suicide,” says coroner Moylan. “A homicide is a death that has been influenced by the hand of another person.” Only homicide results in prosecution.

In many areas, including Schuylkill County, the coroner is an elected official who isn’t required to be certified as a pathologist or medical examiner, nor have any special medical qualifications — the previous Schuylkill County coroners were a retired state police corporal and a funeral director. Smaller counties, where there’s fewer reasons and resources to retain a comparatively rare medical examiner full time, tend to use the coroner system. In most cases, the coroner outsources the actual death examination, but retains the right to make the final decision on the cause and manner of death.

David Moylan David Moylan

Dr. Moylan has more medical qualifications than most coroners; he’s an oncologist with degrees from MIT and Georgetown Medical School, and has used his specialization in radiology and his own equipment and offices at the Simon Kramer Institute to do what he calls a “virtual autopsy” — using multiple CAT scans to put together a 3-D image of a body. Moylan’s not a medical examiner or pathologist, though — in passing, he mentions six manners of death rather than five, although he correctly identifies five shortly after.

Two years after being elected Schuylkill County coroner, he set his eyes on an ambitious prize: the U.S. House of Representatives. Moylan, who describes himself as “a Constitutional Conservative, and proud of it,” last month defeated two opponents in the Republican primary and is now preparing to challenge incumbent Democrat Rep. Matt Cartwright for his seat in Pennsylvania’s 17th Congressional District of Pennsylvania in November. (Incidentally, Harrisburg Republicans gerrymandered the 17th so hard in 2010 that articles about the race include lines like “Moylan dismissed the idea that the district is unwinnable for a Republican.”)

Moylan announced his candidacy on The Sam Lesante Show, a conservative-leaning talk show produced and broadcast in Northeast Pennsylvania, two months after he signed the final report on Yourshaw's death. On The Sam Lesante Show, Moylan said:

“What has motivated me to throw my hat in the ring … is the sanctity of human life. That’s why I get up in the morning and go to work, because I believe in trying to extend people’s lives,” Moylan told Lesante. “When I ran for coroner, I ran as a pro-life coroner.”

“You might say, ‘What the heck is a pro-life coroner?’ It’s important that every decision you make as a coroner to determine the cause and manner of death — how does that affect the sanctity of life? So I’ve done that for the past year and a half.”

Moylan is a practicing Roman Catholic, a religion which was using the terms “sanctity of life” and “pro-life” before they were cool. After Roe v. Wade, evangelical Christians adopted and popularized the terms in reference to abortion, but the official Catholic definition encompasses not just abortion, but contraception, suicide, euthanasia, embryonic stem-cell research, capital punishment, and any other “unauthorized usurpation by human beings of God’s sole lordship over life and death,” as Avery Cardinal Dulles put it.

Moylan’s said that his primary campaign issue is “the sanctity of life.” When asked what that phrase means to him in a telephone conversation, Moylan requests a minute to get some prepared notes: “I’m going to give you my expanded definition of ‘pro-life.’” There’s a long pause filled with sound of rustling papers, then he picks up the phone again.

“The most precious thing on the planet is human life,” he says. “To me, a pro-life agenda would support the protection and improvement of human life in all its forms. … One example of that would be the unborn humans, and their rights to be born and nurtured.”

But that’s only one example of what he thinks of as “pro-life,” he says. It means much more than that. “If you’re going to preserve life, health, liberty and happiness, education’s got to be emphasized … and we have to protect the people from crimes, terrorism, insults, discrimination and also national disasters.”

Asked for examples of decisions he’s made as coroner to protect the sanctity of life, Moylan cites several that are just broad, secular and synonymous with “good” as the latter half of his definition of “pro-life.” Acting as a voice for prisoners who died while incarcerated, for example, or the case of the woman who’d had a heart attack while driving and crashed her car — Moylan identified that she’d had a rare genetic heart condition, and was able warn her children to get tested for it.

He does agree that in today's political conversation, the primary meanings of “sanctity of life” and “pro-life” do not involve prisons or genetic screening, and that viewers of a conservative talk show would have assumed he was talking about abortion. Moylan says he believes faith does have a place in science, but declined to give specific examples of cases where his religious beliefs directly impacted a cause-and-manner-of-death decision. He says that faith had nothing to do with his judgment in the cause and manner of Yourshaw’s death.

“I just read the causes that came from my pathologist, Dr. [Rameen Starling-] Roney. What did the patient die of? Morphine poisoning.” Moylan says he also merely agreed with and certified Starling-Roney’s judgment on the manner of death being homicide rather than suicide. “His analysis, after poring through copious records, was that this man died at the hand of another human being. And that’s what was submitted. It had nothing to do with religion.”

Moylan refers to Starling-Roney as “a high-paid consultant” whom he called in “to look the case over, analyze it, and give me his considered opinion. … to allow an impartial determination.” However, it is not clear how this would have been different from any other case. Moylan says he did not recuse himself in any way from his usual role in the process. He would have had to outsource the autopsy regardless, and often uses Starling-Roney’s company, Forensic Pathology Associates in Allentown. (FPA said nobody there could comment on the case.)

In fact, records show that Moylan and Captain Durkin were present at Yourshaw’s autopsy, though each works about an hour’s drive away. Moylan says he recalls being there, but not what was discussed. The section of the autopsy report dealing with the circumstances of death, which is the information Starling-Roney would used to determine manner of death as homicide or suicide, reflects that much of the information he was working with was hearsay that Mancini never had a chance to deny.

Starling-Roney notes that Yourshaw “reportedly had suicidal ideations” without saying where that had been reported — Yourshaw’s hospice charts don’t say that he was suicidal until the day he attempted suicide. Starling-Roney also writes that Yourshaw “asked his daughter (who is a nurse) to give him morphine so he would die.” Mancini, again, vehemently insists she never said anything like “so he would die," and that it got into the official record in something like a game of Telephone.

This all may seem nitpicky and semantic. But in the legal system, semantics have enormous power. Subtle shades of meaning are what law enforcement uses to determine things like manner of death. And when you write down “homicide” or “suicide,” like writing down “dementia” or “suicidal ideations,” it’s often just accepted without question down the line.

For example: Durkin was asked in court if he’d reviewed Yourshaw’s medical records. He said he had, but “I'm a policeman, not a doctor or a nurse, and a lot of that really means nothing past the first line that cause of death was morphine toxicity,” he says. “I'm not a doctor. I leave doctoring to the doctors.”

Moylan declined to share his beliefs on assisted suicide, but did share an anecdote from when the case was getting a lot of media attention. “A doctor friend called me up and said, ‘Dave, what’s the matter with you people in Schuylkill County? You had an old guy —’” Moylan pretends to cut his upset friend off midsentence. “‘Oh, by the way — what type of cancer did [Yourshaw] have?’ You know what I had to tell him? He didn’t have any cancer. He didn’t have any cancer! His ailment was taking 93 orbits around the sun, that was his problem.”

“And then my friend said, ‘Oh, sorry to bother you.’ He thought the guy had a fatal disease that we weren’t treating properly with adequate doses of morphine. That wasn’t the case.”

To be clear: Yourshaw did not have cancer. But like everyone admitted to hospice, he had to have to doctors agree that he was dying and had fewer than six months to live. His terminal diagnosis on hospice enrollment was “debility, unspecified,” which is perfectly valid.

Moylan says he has no doubt that his office properly attributed Yourshaw’s manner of death. “Homicide doesn’t mean murder — it could be manslaughter, it could be many things. It just means ‘death at the hand of another human being.’ And that’s what occurred here.”

In Schuylkill County a few years prior, David Fitting, who was 26 at the time, had invited some friends over to drink and play beer pong. Around 2 a.m., Fitting’s friend Andrew Mullins, 27, told Fitting and another person that his life had no meaning. Fitting got a loaded handgun from inside the house and left it with Mullins. A few minutes later, Mullins shot himself in the head.

The Commonwealth initially charged Fitting with the same thing Mancini would later be charged with — the second-degree felony of causing or aiding suicide, which carries a potential 10-year prison sentence. Fitting cooperated. He turned himself in, waived his preliminary hearing and took a plea bargain. The felony charges were dismissed; Fitting plead guilty to misdemeanor reckless endangerment and was sentenced to 23 months probation and 20 hours of community service.

Mancini was not interested in cooperating. “To take a plea bargain, you have to plead guilty to something. And I didn’t feel like I was guilty of anything! So to hell with that!” says Mancini. “And look at me — $100,000 bail and fully prosecuted, with the possibility of up to 10 years in prison.”

Mancini says her first attorney, whom she’d found in a rush by asking the advice of the guy who’d done her mother’s will, “was all about getting a plea bargain, plea bargain, plea bargain.” He was used to negotiating pleas for local-level DUI and assault charges, and was surprised by the hard-line stance that the prosecutor, Senior Deputy Attorney General Anthony Forray, took — that Mancini needed to waive her preliminary hearing before a deal could be discussed. (The attorney general’s office declined comment for this story.)

At a preliminary hearing, a judge reviews the witnesses and evidence and decides whether the case is solid enough to go to trial. If you’re planning on fighting charges, it offers a crucial chance to see what evidence the prosecution is bringing to the table so you can plan your defense. If the legal system were poker, waiving your preliminary hearing would be like folding a bad hand before knowing what your opponent has in the hole.

Forray wrote in an email to Mancini’s first lawyer on June 6, 2013:

I am not going to offer a misdemeanor or other resolution without hearing something that changes my current view of the case. We don't give a misdemeanor on a felony case just for the heck of it. I have suggested you should waive the Preliminary Hearing … if you want a Preliminary Hearing you have that right. Put this on the front page of the paper and try to aggressively attack the hospice witnesses, the EMT or the police at a Preliminary Hearing and I guarantee you have a zero chance of a plea resolution. This is a Defendant who is charged with a felony 2. The standard range for conviction is jail time. She has a lot to lose, beyond her nursing license.

Mancini didn’t take very well to what she perceived as being pushed around. She got a new lawyer, Fred Fanelli, whom she picked because he’d demonstrated his willingness to fight the state attorney general’s office and win. Fanelli had recently defended one of a series of sewer-plant operators who were being prosecuted by the Commonwealth. Fanelli’s client was “the only one who fought back and didn’t cop a plea — and he was acquitted within 20 minutes,” says Mancini. The details of the case are probably less relevant than a quote Fanelli gave to the Pottsville Republican Herald at the time: “This case represents the worst of our government, an abuse of power, a bureaucracy unchecked … The bullying stops here. This man is innocent.”

Fanelli was more on board with Mancini’s desire to fight the charges against her. They went ahead with the preliminary hearing, after which they got all her father’s medical records in discovery. “After the preliminary hearing, when [Forray] realized he had some problems with his witnesses, he called my attorney on three separate occasions to talk about a plea bargain,” Mancini says. She wasn’t interested.

“If they were going to pursue this with the vehemence that they did, I was going to fight back tooth and nail,” she says. “I wasn’t going to just lie down and let things happen to me. I’m gonna fight back!”

There’s a couple notable things about the transcript of Mancini’s court proceedings. One is that Fanelli and Forray snark at and object to each other a lot. The other is how often the Constitution and Supreme Court are name-dropped. Here’s an exchange from the preliminary hearing that demonstrates both:

MR. FANELLI: Your Honor, I'm going to ask the charge be dismissed … for a couple of reasons: First, there is United States Supreme Court precedent … that Mr. Yourshaw had the right to — MR. FORRAY: Objection, your Honor. I hate to object to Mr. Fanelli. He's attempting to apparently raise a constitutional argument that would be appropriately raised if it's raised in common pleas court, not at this level. MR. FANELLI: Your Honor, I appreciate counsel's interrupting me, but I am building a record as well and I never want, in the event you don't dismiss this case, I don't want it being said by anybody later on down the chain, you didn't raise it at the first opportunity.

This and other exchanges throughout the legal process made it sound very much like the defense was “building a record” for use in a much higher court.

“We would have been prepared to stand by her all the way to the top,” says Barbara Coombs Lee, president of Compassion & Choices, the nation’s biggest, oldest and most influential right-to-die advocacy group that contributed $20,000 to offset the costs of Mancini’s legal defense. Coombs Lee says her organization acted merely as “a knowledgeable, interested third party,” but this is a little modest; C&C’s legal director, Kathryn Tucker, acted as a consultant to Mancini’s defense, and wrote an amicus curiae brief in support of her petition for habeas corpus. Such “friend of the court” briefs, usually written by advocacy groups with large legal budgets in cases where the decision might have an impact on their cause, are almost always found in appeals rather than lower-court decisions; they’re hardly ever seen as early as a preliminary hearing, like this one.

Forray consistently sounds irritated beyond belief with C&C, saying in the Commonwealth’s brief opposing habeas corpus that he “has never encountered a situation where an outside group has been permitted to make such a filing at the trial level,” and that he believes “we are being put in a situation where we have to respond to arguments that should have never been permitted to be raised by anyone other than the attorney hired by the Defendant to represent her.”

He further wrote that C&C “has chosen to attempt to make this a ‘media circus’, by arranging a media event on the day prior to the Preliminary Hearing.” This is almost certainly the reason Forray was granted a gag order preventing all involved from talking to the press until the case was resolved.

Coombs Lee says that it was entirely Fanelli’s strategy to start throwing around Constitutional implications early and often, but that it was “a good call — this has been litigated at the level of the Supreme Court,” which ruled “that people have a right to as much medication as it takes to relieve their own suffering at the end of life, even if the consequence is abbreviation of that life.” This is also a little misleadingly modest. The case Coombs Lee is referring to, plus a few others that set important precedents, was argued before the Supreme Court by Tucker for a past iteration of C&C.

In short, some very significant players in the national battle over end-of-life issues thought that this case had a lot of potential, right from the beginning.

“I think everybody understood that this was a big case — not only because of Barbara Mancini’s personal jeopardy, but also because of precedents in Pennsylvania,” says Coombs Lee. “These questions — How am I going to die? Will I be able to have the medication that I need? Will my decisions jeopardize my family? — are hot-button items for a generation of Baby Boomers as we deal with our parents and think about ourselves. I think there was a widespread understanding that a high-level appeal would be a teachable moment for the nation.”

Mancini and Yourshaw in Florida in 1992. Mancini and Yourshaw in Florida in 1992.

But, of course, the case didn’t get to the appeals process, because it didn’t even make it to trial. Judge Russell ruled that the prosecution’s case relied on “little independent investigation, significant hearsay, including double hearsay received from third persons, speculation, guess and defendant's alleged incriminating statements” too much for her to conclude that Joseph Yourshaw’s death had even been a crime.

The statute's language:

A person who intentionally aids or solicits another to commit suicide is guilty of a felony of the second degree if his conduct causes such suicide or an attempted suicide, and otherwise of a misdemeanor of the second degree.

So for Mancini to be found guilty of felony charges, the prosecution would have had to prove all of the following:

That Yourshaw’s death would not have occurred but for the morphine overdose.

That Yourshaw had intended to end his life by drinking the whole bottle, as opposed to just relieving his pain.

That Mancini had known her father was planning to end his life when he asked her to give him the bottle.

That Yourshaw would not have been able to overdose without her direct help.

The Commonwealth’s case had been essentially this, as taken from Forray’s closing statements at the preliminary hearing:

This was a lot more than simply handing a bottle of medicine to someone. … There was no morphine in the home. Who was responsible for requesting the morphine to be in the home? The defendant. ... The defendant, on the day in question, indicates that she handed him the bottle because he wanted to die. She's an RN. She knows the effect of morphine. … She very much knows exactly what she wants to do and goes ahead and does it. ... And … the most compelling evidence from Nurse Cattermole when the bottle didn't do the trick, she wanted Nurse Cattermole to get more morphine to do the trick.”

The next time the two sides argue in front of a judge, at the habeas corpus hearing two months later on October 10, 2013, even the dry formality of a court transcript can’t hide how much this sounds like something out of a corny TV legal drama. There’s interruptions! Stammering! The surprise introduction of game-changing evidence! Russell never pounds her gavel nor shouts “I will have order in this courtroom!” but neither would have felt out of place.

The new evidence Mancini's defense wanted to introduce was the hospice doctor’s much stronger, undelivered morphine prescription, which the prosecution had overlooked:

MR. FANELLI: I studied those hospice records, and I'm telling the Court as an officer of the court that … Opioids were prescribed for Mr. Yourshaw … in advance of the phone call by Miss Mancini to the hospice people. If I'm wrong, then counsel should have no objection to that because the records will prove him right; but if I'm right, then the Court should have all of the information before relying on the inference by Mr. Forray that Miss Mancini on her own was seeking out opioids … to assist her father in causing his own death. MR. FORRAY: Your Honor, as I stand here, I'm not aware of that information; and, again, based on the testimony of the hospice nurse, the team leader, she apparently was unaware of that information either. So as an officer of the court I'm telling the Court I don't know that that information does or doesn't exist. MR. FANELLI: [I]t's right in the record. I'm not making it up, and I don't doubt for one second Mr. Forray may not have read this, okay, but it's there.

The transcript then reflects a brief debate, filled with many hyphens signifying stammering and interruptions, about whether the defense should be allowed to introduce new evidence at this point. Eventually Judge Russell asks to see the records.

THE COURT: May I see what you have — you've been raising in your hand — out of curiosity.

Fanelli passes up Yourshaw’s admission plan of care from 2013, with the original morphine prescription highlighted. The next thing recorded is:

THE COURT: Do you want to continue with your argument at this point in time, is that what you'd like to do?

Fanelli says yes, but from that point on, it feels like a football game where one team is up by 50 points at halftime. He rattles off the defense’s counterpoints:

Yourshaw was competent and mobile, and could have gotten the bottle for himself.

Yourshaw had attempted something similar the week before without his daughter present, something hospice workers were aware of — proving he could open the bottle himself and calling into question how much morphine was even left in the bottle on Feb. 7.

It would be difficult to prove that Yourshaw intended to commit suicide rather than relieve his pain really well .

. That the Supreme Court has ruled that terminally ill patients have the right to take as much medicine as they need to relieve their pain, even if it shortens their life.

That almost all the prosecution’s witness testimony would be inadmissible hearsay at trial.

“It seems to me that the total substance of this case against my client is her alleged statements as to what she thought and what her father thought,” Fanelli said. Judge Russell agreed in her opinion, released on the one-year anniversary of Yourshaw's death.

But Fanelli’s final point was about a larger-scope issue that, since the case was thrown out, still remains unaddressed: That the statute Mancini was charged with violating was too vague. “There are so many problems with this statute that need to be addressed and fixed legislatively after it's declared unconstitutional,” said Fanelli.

“The way this statute is worded, they could have charged my mother with assisting suicide because she brought him chocolate candy and soda,” says Mancini. “He had uncontrolled diabetes, and that could have put him into a diabetic coma and killed him. It opens this door — if you supply cigarettes to someone with chronic lung disease, are you going to charge them with assisting suicide? Are you going to charge someone who provides a six-pack to an alcoholic with assisting suicide? Where do you draw the line?”

“Because I handed him his prescribed medicine, not a loaded gun,” says Mancini.

Why did Attorney General Kathleen Kane approve the aggressive pursuit of such a loser of a case for so long? It’s unclear. Even opponents of assisted suicide were puzzled. “It is odd to see one like this prosecuted,” one told New York Times columnist Frank Bruni, then worrying that the publicity this was getting might screw up their efforts with cases “that really call out to be prosecuted.”

Since Kane’s office declined to comment about the case for this story, and at all since Russell’s ruling was handed down, those paying attention across the state and country were left to their own speculations.

The Philadelphia Daily News editorial board just called it “inexplicable.” Left-leaning columnists saw Kane’s decision to pursue the case as an effort to balance the political scales after announcing in July 2013 that she wouldn’t defend the ban on gay marriage. Right-leaning columnists saw it as Kane picking and choosing which cases to prosecute based on personal whim — just like she’d done with gay marriage.

All Kane said, as a defensive-sounding postscript to the press release announcing that her office wouldn’t appeal Russell’s ruling:

If the citizens of the Commonwealth disagree with an existing statute, it is incumbent upon the people to work with the General Assembly to amend the law. Until amendment occurs, it is the legal responsibility of prosecutors to enforce the law as it currently exists.

In other words: Lay off, I’m just doing my job.

Pennsylvania State Sen. Daylin Leach (D-Montgomery Co.) has been trying to amend the law for years; since 2008, he’s introduced the Death With Dignity Act three times. His interest in the subject, he says, started when he had to watch his brother-in-law Taylor die a painful death from lymphoma at 42. From Leach’s Senate memo introducing the act:

If any pet owner in America had forced a dog or cat to endure what Taylor had to endure, he would have been charged with animal cruelty. Yet human beings are, under current law in Pennsylvania, condemned to suffer unspeakable agony with no legal recourse. I believe this has to change.

But change has been slow in coming. “What happened is what happens with almost all legislation in the [state] Senate, which is that it’s introduced, and then it lies in quiet repose in the committee until the end of session, at which point it dies and has to be reintroduced. We don’t pass much of anything, really, and we move even less that’s controversial.” Leach laughs ruefully. “It’s not like there’s some big-money lobby behind it. So we just have to rely on, at some point, someone who’s in a position to move [the bill] having a situation in their own life, or a situation that they’ve heard about, that makes them decide this is important to discuss.”

Leach says that that the loss of his brother-in-law and a couple other family members really invested him in this issue. Often, it takes a loved one’s terminal illness for these issues to seem real. “It makes you think about what you’d want if you were in that position — what would you want your options to be? Who would you want to make the decisions? And I think almost nobody wants the government to make those decisions.

The first state to pass aid-in-dying legislation was Oregon; its 1996 Death With Dignity Act “allows terminally-ill Oregonians to end their lives through the voluntary self-administration of lethal medications, expressly prescribed by a physician for that purpose.” Since then, Washington, Vermont and New Mexico have passed similar legislation. (Aid in dying is also legal in Montana, via a 2009 Supreme Court ruling on a C&C-spearheaded appeal.) The New Jersey state assembly will vote on another measure in the next month or two, though Gov. Chris Christie has said he would veto it if passed.

Leach’s act “was based on the Oregon one, which has survived Supreme Court scrutiny and is clearly Constitutional,” he says. In it, a terminally ill patient could access medicine that would end his life painlessly without needing to lie about their intentions or potentially put his family at legal risk. There would be many hoops to jump through first, obviously: “Two separate doctors — one can be a treating physician, and one would have to be an independent doctor — would have to sign a report saying that the patient has less than six months to live” before that patient would be eligible to ask for the prescription.

“It’s important to know what happens in reality with this,” adds Leach. In Europe and states where aid in dying is legal, “most people who get this medication don’t immediately run out and take it.” Oregon’s act requires the state to “collect information about the patients and physicians who participate in the Act, and publish an annual statistical report,” so the data from there is particularly thorough. Compared to the 122 lethal prescriptions written in Oregon in 2013, only 71 were used.

“When things get really bad, just knowing they have options gives people the strength to hang in there,” says Leach. “Many people who go through the trouble of getting the medication never take it. Others who do take it — in most cases, they get it six months out, four months out, but they don’t take it until the last couple of days” of their lives.

The average person in Oregon who gets one of the prescriptions is white, better-educated than average and dying of cancer, with a median age of 71. A tiny number said they were taking this course because of the potential cost of treatment; nearly all cited the same things Joseph Yourshaw talked about: Loss of autonomy, loss of dignity, being unable to do the things that give life meaning.

“And there would be strict penalties,” Leach adds. “There’s concern that people will be pressuring somebody to end their life early so they can get the money in the will quicker. There’s no evidence that that’s happened, ever. But if it did, it would be a crime with severe penalties.”

Leach says opponents of aid in dying often bring up such what-if hypotheticals that rarely happen in practice, but the root of their opposition is deeper. “There’s what people say in terms of why they oppose it — things like ‘Oh, there’ll be pressure,’ or ‘there’s always miracles’ or whatever. But I have found in detailed discussions with people that those are not the real reasons they’re opposed to it. Most people, the real reason they’re opposed to it, at the end of the day, is religion.”

Believing that ending one’s own life is a sin no matter what the circumstances is fine, says Leach. “But I don’t know why anyone has the right to use the power of the state to force their religious views on other people. If your god doesn’t want you to end your life early when you have a terminal disease, then… don’t! This law wouldn’t require anyone to do anything. But don’t tell someone else who has different religious beliefs that they can’t live their lives according to their own beliefs.”

The Death With Dignity Act would clear up the language in the statute Mancini was charged under, says Leach. Leaving it as vague as it is, says Leach, means a standing risk that what happened to her will happen to someone else. “The charges against her were dropped, but she had to go through an awful lot. And we don’t want family members who are trying to help their loved ones being subjected to the sort of things Mancini was subjected to.”

Leach says he’ll keep introducing the act until it moves. “It’s a basic human right, and eventually we will prevail. It’s just a shame that a lot of families have to go through needless suffering in the meantime,” he says.

Mancini returned to her job in the ER of Lankanau Hospital on April 28, after nine months of unpaid leave. She eased back into it with shorter hours, but is now back to working regular shifts. “It’s gone really well, better than I’d expected,” she says. “I just didn’t know if I’d be able to handle doing it. And when I went back, it was almost as if I’d never left.

She was offered her job back almost immediately after her charges were dismissed. “But I wasn’t ready to return right away. I stayed out another two months because…” she pauses. “Honestly, I went to counseling, ’cause I felt I needed some help before I went back. Working in an ER is a fairly high-stress environment, and I didn’t want to risk messing up.”

“Being away for nine months, I thought I’d have forgotten how to start an IV — turns out I didn’t have any problem with that. I had my insecurities just because of what I’d been through, but it ended up being just fine,” she says. “Everybody’s been very supportive and understanding, and horrified by what happened.”

“There is not a day that goes by that I don’t think about this. And sometimes I spend a lot of time — it intrudes on my life, all the time,” she says.

“I’m trying to move on with my life. But the way my dad died —“ she pauses. “I can’t imagine that I’ll ever get over that. Maybe it’s possible someday, but it seems unimaginable to me right now.”