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This is the East County and the east region's only hospital, said Barry Jantz, CEO of Grossmont Health District. "Sharp- Grossmont Hospital has been here for years, and it was really important that we find ways to improve that." 228

They took me to the hospital. Bullet grazed my head. I feel fine, just a scratch on my head. Traumatized and devastated.— DUBBY (@DubDotDUBBY) August 26, 2018 158

This effort to gut protections for endangered and threatened species has the same two features of most Trump administration actions: it's a gift to industry, and it's illegal. We'll see the Trump administration in court about it, Drew Caputo, Earthjustice vice president of litigation for lands, wildlife, and oceans. said in a statement, according to 352

This isn't the first time Democrats have argued to impeach Trump. Earlier this month, Rep. Pramila Jayapal, D-Washington, said the President has committed "significant constitutional impeachable violations," adding that Democrats needed to act. 244

To understand the legal and ethical issues in Alyssa's case, CNN showed experts key documents, including law enforcement reports; a transcript of portions of CNN's interview with Sherwin, the detective at the Rochester Police Department; and summaries of her care written by doctors at Mayo and Sanford.The experts emphasized that those documents don't tell the whole story; only a thorough reading of her full medical records and interviews with Mayo staff would provide a complete picture."You're only hearing one side," cautioned Dr. Chris Feudtner, a professor of pediatrics, medical ethics and health policy at the University of Pennsylvania Perelman School of Medicine.After reviewing the documents, the experts wondered why Mayo did not allow Alyssa, who was 18 and legally an adult, to leave the hospital when she made clear that she wanted to be transferred, according to the family.They said that typically, adult patients have the right to leave the hospital against medical advice, and they can leave without signing any paperwork."Hospitals aren't prisons. They can't hold you there against your will," said George Annas, an attorney and director of the Center for Health Law, Ethics & Human Rights at the Boston University School of Public Health.But Alyssa's doctors say she wasn't a typical patient."Due to the severity of her brain injury, she does not have the capacity to make medical decisions," her doctors wrote in her records after she'd left the hospital.In that report, the doctors specified that assessments in the last week of her hospital stay showed that she lacked "the capacity to decide to sign releases of information, make pain medication dose changes, and make disposition decisions. This includes signing paperwork agreeing to leave the hospital against medical advice."That hadn't jibed with the captain of investigations for the Rochester police. Sherwin said it didn't make sense that Mayo staffers told police Alyssa had been making her own decisions, yet in the discharge note, they stated she wasn't capable of making her own decisions.It didn't jibe with the experts, either."They can't eat their cake and have it, too," said Feudtner, the medical ethicist at the University of Pennsylvania.Even if Alyssa truly did lack the capacity to make her own medical decisions, the experts had questions about Mayo's efforts to obtain emergency guardianship for Alyssa.Brian Smith, the Rochester police officer who responded to Mayo's 911 call the day Alyssa left Mayo, said a Mayo social worker told him she'd been working for a week or two to get a Minnesota county to take guardianship over Alyssa."The county would have guardianship over her and would make decisions for her," he told CNN.If that happened, Alyssa most likely would have stayed at Mayo, as she was already receiving treatment there, Smith said.Bush-Seim, the Rochester police investigator, spoke with an official at one of the county adult protection agencies. She said it was also her understanding that Mayo wanted the county to take guardianship of Alyssa, or that perhaps Mayo itself wanted to directly take guardianship of her.The legal experts said they were not surprised that Mayo was unable to get court orders for such guardianship arrangements. It's a drastic and highly unusual step for a county or a hospital to take guardianship over a patient, they said, rather than have a family member become the patient's surrogate decision-maker.Robert McLeod, a Minneapolis attorney who helped the state legislature draft its guardianship laws, did not review the documents pertaining to Alyssa, as he did not want to comment on any specific case.He said that before appointing a county or a hospital as a legal guardian, a judge would ask why a family member or close friend hadn't been selected as a surrogate."From my 25 years of experience, a judge is going to say, 'why isn't the family the first and best choice here?' and it had better be a good reason," said McLeod, an adjunct professor at the Mitchell Hamline School of Law in Saint Paul, Minnesota.Other experts agreed.Saver, the professor at the University of North Carolina School of Law, said that in his four years working in the general counsel's office at the University of Chicago Hospitals and Health System, he doesn't once remember the hospital seeking guardianship for a patient who had a responsible relative or friend who could act as surrogates."It's thought of as kind of the atom bomb remedy," Saver said. "I'm a little flummoxed what to make of this. They had family members on the scene to look to."Alyssa said her biological father, Jason Gilderhus, told her that Mayo asked him to become her guardian. He did not become her guardian and did not respond to CNN's attempts to reach him.Even if Mayo had concerns about Alyssa's mother and her biological father didn't work out, there were other friends and relatives to turn to, such as her stepfather, grandmother, great-grandmother, aunt or boyfriend's mother."It's so baffling why they didn't try to designate a surrogate before trying to get a guardian," added Dr. R. Gregory Cochran, a physician and lawyer and associate director of the Health Policy and Law program at the University of California, Hastings College of the Law in San Francisco.Another feature of Alyssa's case also surprised the experts.Caplan, the NYU bioethicist, said that in complicated and contentious cases like this one, doctors typically reach out to their hospital's ethics committee for help.An ethics committee would listen to the doctors, other staff members, the patient and the family to try to resolve the conflict.The family says no one ever mentioned an ethics committee to them, and there's no mention of an ethics committee consult in the discharge summary in Alyssa's medical records.Annas, the lawyer at Boston University, agreed that an ethics committee consultation would have been an obvious and important way to help resolve the dispute before it spun out of control."Disputes between families and hospital staff happen all the time, and they can either escalate or de-escalate," Annas said. "An ethics consult can help sort out the issues so they de-escalate."The experts said they were disappointed that in Alyssa's case, the conflict escalated."I was shocked to see that parents had to pull a fast one to get their daughter out of the hospital," said Cochran, of the University of California."I felt sad," said Feudtner, the ethicist at the University of Pennsylvania. "Viewed in its entirety, this did not go well for anybody who was involved."Gaalswyk, the former Mayo board member, said he hopes the hospital learns something."I hope that someone somewhere will look at what happened in this unfortunate case and improve both our Mayo employee's actions and patient systems so that it not need happen again to any other patient at Mayo," he wrote a Mayo vice president after Alyssa left the hospital. "The situation need not get out of hand like it did." 6998