A judge gave a former nurse who killed at least 29 patients in two states six more life sentences Friday, raising the total to 18, after a hearing in which the defendant had to be gagged with a cloth and duct tape.

Charles Cullen, who committed one of the worst murder sprees ever discovered in the U.S. health care system, spent 30 minutes repeating the sentence, "Your honor, you need to step down," hundreds of times.

Cullen, who was sentenced last week to 11 consecutive life terms in New Jersey, administered lethal overdoses to seven patients at nursing homes and hospitals in Pennsylvania, and tried to kill three others.

Cullen had tried to avoid showing up at his various sentencing hearings.

On Friday, he told Lehigh County President Judge William Platt he was upset over comments the judge made in a newspaper article in which Platt said he was inclined to make Cullen show up at sentencing.

Cullen then began repeating the statement and refused to stop even after being gagged. The hearing went on anyway.

Walter Henne, the son-in-law of victim Irene Krapf, had to raise his voice to be heard over Cullen.

"We think you are a total waste of human flesh," Henne said. "And you know what, Charles Cullen? God agrees with us and we all hope you rot in hell."

Afterward, Henne said he was furious at Cullen's behavior.

"I was so frustrated, I don't know what kept me in the chair," Henne said. "It was absolutely ridiculous. He took this right away from us."

Julie Sanders of Bethlehem, a friend of victim John Gallagher, said Cullen "intentionally meant disrespect to everybody in the courtroom."

Cullen, 46, didn't attend an 11-minute hearing in Northampton County earlier Friday, where he was sentenced to life in prison without parole for the death of Ottomar Schramm.

Cullen escaped the death penalty after agreeing to help prosecutors in seven counties identify patients to whom he had given lethal drug overdoses. He will serve his sentence in New Jersey.

Cullen, who claimed to have killed 40 patients over a 16-year nursing career, has said he killed out of mercy. Many of his victims were old and very sick.

He was arrested in December 2003 after Somerset Medical Center in Somerville, N.J., notified prosecutors about questionable lab results involving patients under his care.

The case prompted lawmakers in both states to pass legislation protecting hospitals and nursing homes from legal action when reporting disciplinary actions taken against employees.