Allentown, Pa. ? Before receiving six more life sentences, a former nurse who confessed to killing at least 29 patients in two states was gagged with a cloth and duct tape Friday in court after he began loudly repeating the same phrase over and over.

Even after deputies tried to tighten the gag, Charles Cullen’s muffled chant of “Your honor, you need to step down” drowned out statements from some of the victims’ relatives who spoke at the hearing, and continued as the judge read him his sentence.

In one of the worst murder sprees ever discovered in the U.S. health care system, Cullen gave lethal drug overdoses to patients at nursing homes and hospitals in Pennsylvania and New Jersey. The serial killer had been given another life sentence in Pennsylvania earlier Friday and 11 consecutive life terms last week in New Jersey.

Cullen, 46, had tried to avoid showing up at his sentencing hearings. On Friday, Cullen 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.

Platt ordered Cullen gagged after he began repeating “Your honor, you need to step down” and refused to stop until the end of the hearing 30 minutes later. Sheriff’s deputies wrapped a white cloth around his mouth, then stuck two pieces of duct tape over his mouth and tried to tighten the gag as he continued talking.

A muffled Cullen still managed to drown out some of the four relatives and friends who gave victim-impact statements. For victim’s loved ones, his performance was diametrically opposite but no less frustrating than the one gave at the New Jersey sentencing, when he refused to speak or in any way acknowledge the people he hurt.

“We think you are a total waste of human flesh,” said Walter Henne, a son-in-law of one of the victims, raising his voice to be heard over Cullen. “And you know what, Charles Cullen? God agrees with us and we all hope you rot in hell.”