DECLARATION OF JOEL ZIVOT, M.D.

, FRCP(C)

I, Joel Zivot, being of sound mind and lawful age, hereby state under penalty of
perjury as follows:

1. I am an associate professor and senior member of the Departments of

Anesthesiology and Surgery, Emory University School of Medicine, in Atlanta,
Georgia. I am the former Medical Director of the Cardiothoracic Intensive Care Unit
at Emory University Hospital and the former fellowship director for training in
Critical Care Medicine. I hold board certification in Anesthesiology from the Royal
College of Physicians and Surgeons of Canada and The American Board of
Anesthesiology. I am board certified in Critical Care Medicine from the American
Board of Anesthesiology. I am also an adjunct professor of law and of the School
of Liberal Arts at Emory University. A copy of my curriculum vitae is attached as
Exhibit 1.

2. I have practiced anesthesiology and critical care medicine for 24 years and in
that capacity, I have personally performed or supervised the care of more than
45,000 patients.

3. I hold a medical license from the state of Georgia, and have held unrestricted
medical licenses in Ohio, the District of Columbia, Michigan, and the Canadian
provinces of Ontario and Manitoba. I hold a license to prescribe narcotics and other
controlled substances from the U.S. Drug Enforcement Administration (DEA).

4. Since 2014, I have been consulting with attorneys for Missouri death row
prisoner Russell Bucklew, regarding Mr. Bucklew’s medical condition and the risks
attendant to executing him by lethal injection. During the past five years, I have
provided expert opinions in a series of declarations and affidavits that were

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submitted in 2014 and 2015, and then later also provided a supplemental expert
report submitted in January 2017.

5. Opinion: In this Declaration, I provide an updated opinion on Mr. Bucklew’s

condition and the risks posed to him by lethal injection. My opinion is based on a
review of Mr. Bucklew’s recent medical records and my physical examination of
him on September 20, 2019. Mr. Bucklew’s condition has continued to deteriorate
as his rare and severe congenital condition--cavernous hemangioma--has
progressed. Mr. Bucklew has unstable, blood-filled tumors in his head, neck and
throat, and these tumors have continued to grow, causing severe pain, distress and
a variety of complications. Mr. Bucklew’s airway is almost completely obstructed,
and he is able to breathe only with the aid of a tracheostomy tube that was inserted
in June 2018. Mr. Bucklew’s blood-filled tumors rupture regularly, causing him to
spit up blood three or four times a day. Because of the severity of Mr. Bucklew’s
condition and the susceptibility of his tumors to rupturing under stress, Mr. Bucklew
remains at great risk of choking to death on his own blood during an execution by
lethal injection.

6. As part of my work on Mr. Bucklew’s case, I have reviewed extensive medical

records, including Bucklew’s records from the Missouri Department of Corrections,
Boone County Hospital, Boone County Jail, Lincoln County Hospital, the
University of Missouri Medical Center, Southeast Missouri hospital, Mercy
Hospital and Barnes Jewish Medical Center.

7. I have also reviewed radiology scans of Mr. Bucklew from August 2005 and
compared them to the written report from imaging performed at the request of the
Department of Corrections in 2010. Further, I have reviewed Mr. Bucklew’s
December 19, 2016, MRI and CT imaging from Barnes Jewish Hospital as well as
the report of medical imaging from Barnes Jewish Hospital dated December 23,

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2016. The findings in the imaging and reports are consistent and show an extensive
soft tissue mass involving the posterior pharyngeal and masticator space including
a significant mass effect.

8. I have also personally examined Mr. Bucklew on three occasions, on May 12,
2014, January 8, 2017, and, most recently, on September 20, 2019.

9. As extensively documented in his medical records and by my own examinations,

Mr. Bucklew suffers from progressive vascular (blood-filled) tumors in his head,
face and throat. These tumors rupture frequently, sometimes three or four times a
day, causing Mr. Bucklew to spit blood into a receptacle. These unstable masses
tend to be even more susceptible to rupture under any stressful condition or increase
in blood pressure. Consistent with the progressive nature of the condition, Mr.
Bucklew’s tumors have continued to grow and cannot be effectively reduced in size
by medical or surgical intervention.

10. A large vascular mass arises through Bucklew’s hard palate, extends into the
upper maxilla on the right, and fully encompasses his uvula and distorts the anatomy
of his airway. In lay terms, this means that Mr. Bucklew has a very large tumor
growing in his face, occupying his nose, throat and airway passages, causing him to
experience constant facial and nasal cavity pain and pressure, as well as constant
difficulty breathing. The tumors have also distorted his facial features, and have
caused bulging and swelling in the right side of his face and the growth of a large
hemangioma on his upper lip. In June of 2018, Mr. Bucklew required the surgical
insertion of a tracheostomy tube to allow him to breath as the large blood-filled
tumor blocked the passage of air through his throat. The tracheostomy is shown in
the photographs below.

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11. Mr. Bucklew’s condition is severe and lifelong and, absent an intervening event
such as execution, will very likely cause his death. Mr. Bucklew is at constant risk
of death from his medical condition, and this could occur at any time.

12. During my examination of Mr. Bucklew on September 20, 2019, I observed

that Mr. Bucklew’s airway is extremely compromised and is fully, or near fully,
obstructed due to the continued growth of the vascular tumors. His airway is also
extremely friable, meaning it is weak and could tear or rupture. If you touch it, it
bleeds. Tumors are easily observable in his throat, as the photographs below show.

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13. Based on the records and the findings of my examination, I conclude that under the
State of Missouri’s lethal injection protocol, Mr. Bucklew continues to be at a very high
risk of choking to death on his own blood during an execution as a result of the rupturing
of the blood-filled tumors in his throat. In such a circumstance, Mr. Bucklew would
experience feelings of suffocation and extreme and excruciating pain.

14. Mr. Bucklew presently has a number 6.0 tracheostomy tube. The number 6 signifies
the diameter of the tube’s opening in millimeters. This very small aperture can be easily
obstructed, and, when I tested Mr. Bucklew’s breathing with temporary tube obstruction,
he was unable to breathe and began to immediately choke. Mr. Bucklew must constantly
manually clear the tracheostomy tube to prevent his own death by suffocation. Blood
seeping from his tumors, or any other secretion (such as mucus), could easily block his
tracheostomy, causing him to strain to breathe, which would lead to further tumor rupture
and visible bleeding from his mouth, nose and tracheostomy.

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15. For all of these reasons, it is my opinion that a very high risk exists that, during an
execution under Missouri’s current lethal injection protocol, Mr. Bucklew will suffer from
extreme or excruciating pain and suffocation as a result of the rupturing of his blood-filled
tumors. Further, the bleeding is likely to be visible to the witnesses and the execution
team.

16. I hold the opinions stated in this Declaration to a reasonable degree of medical
certainty. Should additional information become available at a later date, I reserve the
opportunity to update or add to the opinions stated herein.

I swear or affirm the foregoing statements are true and accurate.

Further affiant sayeth not.

_____________________________
Joel B. Zivot, M.D.

September 24, 2019