Case Title: Collins v. Lake Forest Hospital

Citation: 

Docket Number: 97375

State: illinois

Court: Illinois Supreme Court

Date: 2004-12-02T00:00:00Z

Document:
Docket No. 97375-Agenda 28-September 2004.
ANDREA COLLINS, Indiv. and as Special Adm'r of the Estate of
Joseph J. Collins, Jr., Deceased, et al., Appellees, v. LAKE FOREST 							
HOSPITAL et al. (Lake Forest Hospital, Appellant).
Opinion filed December 2, 2004.
	JUSTICE KILBRIDE delivered the opinion of the court:
	The limited issue on appeal before this court is whether the
defendant Lake Forest Hospital (hospital) had a duty to inquire into
the availability of a surrogate decisionmaker and implement the
surrogate's treatment decisions under the Health Care Surrogate Act
(Act) (755 ILCS 40/1 et seq. (West 2000)). The circuit court of Lake
County dismissed the amended complaint against the hospital filed by
the decedent's estate as well as by individual members of his family,
and the appellate court reversed. We, in turn, reverse the appellate
court judgment and reinstate the trial court's order dismissing the
plaintiff's amended complaint against the hospital.

BACKGROUND
	The decedent, Joseph J. Collins, Jr., suffered a traumatic head
injury after falling at home and underwent emergency brain surgery at
the hospital on April 20, 1999. When Joseph's initial attending
physician, Dr. Gary Schaffel, examined him, Joseph had little
neurological function and was unconscious and breathing with a
ventilator. Dr. Schaffel expressed no opinion on whether the patient
had the ability to consent to medical treatment and did not make any
entry in the patient's medical chart concerning his decisionmaking
ability. The next day, Dr. Gerald Osher replaced Dr. Schaffel as
Joseph's attending physician. Dr. Osher wrote in Joseph's chart that
he had discussed the case with the surgeon and decided to remove the
patient from the ventilator. He also noted an entry in the chart dated
April 23 stating there had been "lengthy discussion with family (30
minutes) in which [he] explained the grim prognosis. They are in
agreement with the care plans." He could not recall the family
members who had been involved in that discussion. In addition, Dr.
Osher expressed no opinion on whether the patient had the ability to
consent to treatment.
	Joseph's wife called the hospital at approximately 8:35 a.m. on
April 23, 1999, and requested that her husband not be removed from
the ventilator until she and their children, who had recently arrived
from out of town, could get to the hospital that morning. What
actually transpired was that an extubation order was entered at 10:55
a.m., the patient was extubated at 11 a.m., and he died at 11:03 a.m.
Joseph's wife and children did not arrive at the hospital until 11:10
a.m.
	The decedent's wife, children, and estate filed a complaint against
Lake Forest Hospital, naming Dr. Osher as one of the respondents-in-discovery. See 735 ILCS 5/2-402 (West 2000). The hospital filed
motions to dismiss pursuant to sections 2-615, 2-619, and 2-622 of
the Code of Civil Procedure (Code) (735 ILCS 5/2-615, 2-619,
2-622 (West 2000)). The trial court denied the motions as to count
I of the complaint, alleging medical battery, and counts III and VI,
alleging violations of the Act (755 ILCS 40/1 et seq. (West 2000)).
The court later allowed the plaintiffs to file an amended complaint and
to convert Dr. Osher to a defendant.
	Counts I through III of the amended complaint were brought by
the estate against the hospital. Counts IV through VI were brought by
the estate against Dr. Osher and mirrored counts I through III. The
surviving plaintiffs brought parallel counts VII and IX against the
hospital and counts VIII and X against Dr. Osher. Dr. Osher filed a
motion to dismiss counts V and VI, alleging negligence and violations
of the Act. The hospital followed with a similar motion, but it did not
seek to dismiss count III, alleging that the hospital had violated the
Act, because that count had been upheld in the original complaint.
	The trial court granted both defendants' motions to dismiss with
prejudice, and the hospital then filed a motion to dismiss count III of
the amended complaint with prejudice. That motion was subsequently
granted, leaving only counts I and IV, alleging medical battery against
the hospital and Dr. Osher respectively, still pending in the trial court.
The plaintiffs' motion to reconsider was denied, and they appealed.
The appellate court reversed. 343 Ill. App. 3d 353. Dr. Osher did not
seek to appeal the appellate court's judgment. Accordingly, count VI
of the amended complaint, alleging that Dr. Osher had violated the
Act, was remanded to the trial court for further proceedings.
	The hospital filed a petition for leave to appeal, and this court
allowed its petition. See 177 Ill. 2d R. 315(a). The only issue before
this court is the dismissal of count III. That count alleges that the
hospital failed to fulfill its duties under the Act.

ANALYSIS
	The hospital first argues that it had no duties under the Act in this
case. It maintains that the attending physician has the primary role
under the Act and is required to determine whether, to a reasonable
degree of medical certainty, the patient has decisional capacity, as well
as to confer with the surrogate decisionmaker on treatment matters
and to implement any decision by the surrogate to forgo life-sustaining
treatment. 755 ILCS 40/20(c), (d), (f) (West 2000). The only duty the
Act imposes on a "health care provider" such as the hospital is to
"make a reasonable inquiry as to the availability of possible
surrogates." 755 ILCS 40/25(a) (West 2000). The hospital contends
that even this limited duty did not arise here because the duty exists
only after the attending physician has made the determination that the
patient lacks decisional capacity. Since neither attending physician in
this case ever made that determination, the hospital maintains it bore
no duty under the Act.
	As the appellate court noted, the hospital raised this issue for the
first time on appeal, and the court resolved the matter because it was
likely to arise on remand. 343 Ill. App. 3d at 360. Before this court,
the plaintiffs argue that the hospital has again changed the issue from
the one presented in its petition for leave to appeal, alleging a direct
conflict between the appellate decision and the requirement of a
written finding in Ficke v. Evangelical Health Systems, 285 Ill. App.
3d 886 (1996), to whether the hospital owed any duty under the Act
because the attending physician never determined the patient lacked
decisional capacity. We interpret the plaintiffs' argument to be one of
waiver. This court has long held that waiver is a limitation on the
parties, not on this court. Hux v. Raben, 38 Ill. 2d 223, 224 (1967).
At this time we choose to address the issue of a health care provider's
duty under the Act because it is critical to the development of a sound
body of precedent concerning the proper interpretation, and thus
implementation, of legislation concerning vital care and treatment
decisions for patients lacking decisional capacity, including the
termination of life-sustaining procedures. See Golden Rule Insurance
Co. v. Schwartz, 203 Ill. 2d 456, 463 (2003). Because this appeal
involves the grant of a motion to dismiss, we review it de novo.
Feltmeier v. Feltmeier, 207 Ill. 2d 263, 266 (2003).
	The plaintiffs contend that the hospital has skirted "the true
factual basis" of this appeal, that is, whether the attending physicians
knew Joseph lacked decisional capacity. Under the Act, "decisional
capacity" is "the ability to understand and appreciate the nature and
consequences of a decision regarding medical treatment or forgoing
life-sustaining treatment and the ability to reach and communicate an
informed decision in the matter as determined by the attending
physician." 755 ILCS 40/10 (West 2000). A patient "is presumed to
have decisional capacity in the absence of actual notice to the contrary
without regard to advanced age." 755 ILCS 40/20(c) (West 2000).
The plaintiffs assert that the evidence shows the attending physicians
"were aware" Joseph lacked decisional capacity because he had no
chance of recovery and no neurological function after his admission
to the hospital. The plaintiffs contend that this "awareness" by the
attending physicians was sufficient to trigger the hospital's duty to
inquire into "the availability of possible surrogates." 755 ILCS
40/25(a) (West 2000). That is an incorrect interpretation of the
applicable provisions of the Act. While the patient in this case may
have lacked decisional capacity, that is not the key to triggering the
hospital's statutory duty.
	Under the Act,
		"A determination that an adult patient lacks decisional
capacity shall be made by the attending physician to a
reasonable degree of medical certainty. The determination
shall be in writing in the patient's medical record and shall
set forth the attending physician's opinion regarding the
cause, nature, and duration of the patient's lack of decisional
capacity." (Emphases added.) 755 ILCS 40/20(c) (West
2000).
When a patient lacks decisional capacity, the hospital must first inquire
into "the availability and authority of a health care agent under the
Powers of Attorney for Health Care Law." 755 ILCS 40/25(a) (West
2000). In this case, a health care agent had not been authorized.
Consequently, the next sentence of the statute must be considered.
According to that sentence, if the patient lacked decisional capacity
as determined under the Health Care Surrogate Act at issue in this
case, the hospital would be required to "make a reasonable inquiry as
to the availability of possible surrogates listed." 755 ILCS 40/25(a)
(West 2000). The proper interpretation of that sentence lies at the
heart of this controversy.
	The error in the plaintiffs' interpretation is that they focus on the
hospital's alleged notice of the patient's actual condition rather than
on the existence of a written determination by the attending physician
that the patient lacked decisional capacity. See 755 ILCS 40/20(c)
(West 2000). Section 20(c) of the Act specifically requires the
attending physician's determination to be made in writing. 755 ILCS
40/20(c) (West 2000). This writing requirement promotes the
legislature's stated intent in enacting this statute. The Act is intended,
in relevant part, to provide a process for making private medical and
life-sustaining treatment decisions "without judicial involvement of
any kind." 755 ILCS 40/5(b) (West 2000). To effectuate this goal, the
legislature has chosen to mandate that a single individual, namely, the
patient's attending physician, determine in writing whether the patient
lacks decisional capacity. 755 ILCS 40/20(c) (West 2000). This
mandate averts the potential dilemma of multiple decisionmakers
coming to varying conclusions regarding a patient's decisional
capacity. If the Act permitted multiple decisionmakers, the attending
physician and various members of the hospital staff involved in the
patient's care could arrive at very different conclusions, likely
necessitating judicial intervention in direct contradiction to the Act's
goal of avoiding "judicial involvement of any kind" (755 ILCS 40/5(b)
(West 2000)). In anticipation of this problem, the legislature has
placed the responsibility for determining when a patient lacks
decisional capacity solely on the patient's attending physician.
	Thus, the relevant issue in this case is whether the hospital had
notice that Joseph's attending physician made a written determination
that Joseph lacked the capacity to make his own health care and
treatment decisions. See 755 ILCS 40/20(c) (West 2000). The record
indicates that neither attending physician involved in this case ever
made that written determination. The propriety of their failure to make
that determination has no bearing on the only question before us in
this case, namely, the hospital's duty under the Act. The hospital's
duty to inquire into the availability of the appropriate surrogate
decisionmaker was not triggered here because the attending physician
did not make a written determination that the patient lacked decisional
capacity, as explicitly required by the Act. See 755 ILCS 40/20(c)
(West 2000).
	Moreover, even if the hospital's duty to inquire had been
triggered, it appears that the duty was fulfilled. The statute requires
the health care provider, in this case the hospital, to "make a
reasonable inquiry as to the availability of possible surrogates listed"
in the remainder of the section. 755 ILCS 40/25(a) (West 2000).
When the appropriate surrogate has been identified, the hospital must
record "the name, address, telephone number, and relationship of that
person to the patient *** in the patient's medical record." 755 ILCS
40/25(b) (West 2000). It appears that the hospital did, in fact, record
the relevant information concerning Andrea Collins, the proper
surrogate decisionmaker under the statute. The Act also required the
hospital to try to contact that surrogate by telephone within 24 hours
after the patient was determined to lack decisional capacity. 755 ILCS
40/25(a) (West 2000). Since no such determination was ever made by
the attending physician, however, that duty was never triggered.
	As for the plaintiffs' claim that the hospital violated its duty to
follow the surrogate's instructions, while the statute mandates that the
attending physician "promptly implement [a surrogate's] decision to
forgo life-sustaining treatment on behalf of the patient" under certain
specified conditions, there is no analogous provision for health care
providers such as the hospital. See 755 ILCS 40/20(f) (West 2000)
(stating that "[o]nce the provisions of this Act are complied with, the
attending physician shall thereafter promptly implement the decision
to forgo life-sustaining treatment on behalf of the patient unless he or
she believes that the surrogate decision maker is not acting in
accordance with his or her responsibilities under this Act, or is unable
to do so for reasons of conscience or other personal views or
beliefs"). Since the hospital bore no duties under the Act in the
absence of a written determination by the attending physician that the
patient lacked decisional capacity, the trial court properly dismissed
count III, alleging statutory violations by the hospital.
	Finally, the parties address the applicability of the appellate court
decision in Ficke v. Evangelical Health Systems, 285 Ill. App. 3d 886
(1996), to the issue of the hospital's statutory duty. In Ficke, the
decedent's estate and surviving adult children filed a complaint against
both the hospital and the attending physician, claiming, in relevant
part, various violations of the Act when the patient was given life-sustaining treatment contrary to her wishes and the wishes of her
children. There, as here, the attending physician did not make a
determination that the patient lacked decisional capacity. The
appellate court affirmed the trial court's dismissal of the cause of
action against the hospital, finding that "the attending physician, not
the hospital or its staff" had the duty to determine that the patient
lacked decisional capacity and suffered from one of three qualifying
conditions that would have permitted a surrogate decisionmaker to
refuse life-sustaining interventions. Ficke, 285 Ill. App. 3d at 893-94.
This portion of the opinion coincides with our analysis in this case.

CONCLUSION
	We hold that the Act does not impose a duty on a health care
provider, such as the hospital in this case, to inquire into the
availability of a surrogate decisionmaker until after the attending
physician has made a written determination under the Act that the
patient lacks decisional capacity. Since no such determination was
made in this case, the hospital owed no duty to inquire, and the trial
court properly dismissed count III of the plaintiffs' amended
complaint. Therefore, the portion of the appellate court judgment
reinstating count III of the plaintiffs' amended complaint is reversed,
and the cause is remanded to the circuit court for further proceedings
on the counts that remain pending.
Appellate court judgment affirmed in partand reversed in part;circuit court judgment affirmed in partand reversed in part;cause remanded.