Title: Knight v. BEVERLY HEALTH CARE BAY MANOR

State: alabama

Issuer: Alabama Supreme Court

Document:

820 So. 2d 92 (2001)
Vernon Steve KNIGHT et al.
v.
BEVERLY HEALTH CARE BAY MANOR HEALTH CARE CENTER.
1000510.

Supreme Court of Alabama.
August 31, 2001.
Opinion on Return to Remand November 2, 2001.
*93 Robert S. Edington, Mobile, for appellants.
Manley L. Cummins III and Michelle A. Meurer of Pearson, Cummins & Hart, L.L.C., Spanish Fort, for appellee.
HARWOOD, Justice.
Vernon Steve Knight and William Edward Knight (hereinafter referred to collectively as "the Knights") appeal the trial court's denial of their request to enjoin a nursing-home facility operated by Beverly Health Care[1] from removing a feeding tube from their mother, who is a resident at the facility. We affirm in part and remand.
On June 6, 2000, the Knights sued Beverly Health Care, seeking to enjoin Beverly Health Care from removing a feeding tube that was providing nourishment to their mother, Delores Cameron. On September 11, 2000, James Cameron, as Delores Cameron's attorney-in-fact and as her husband,[2] filed a motion to intervene in the action; he sought an order implementing Mrs. Cameron's "living will," arguing that the provisions of that document necessitated the removal of the feeding tube. Mr. Cameron's motion to intervene was granted on September 15, 2000. The trial court conducted five hearings on the case between September 22, 2000, and November 21, 2000; on December 6, 2000, it denied the injunction and ordered that the feeding tube be removed.
The sad facts shown by the record in this case are as follows. Mrs. Cameron suffered a massive stroke on February 2, 2000. It was her second stroke, and after treatment at a hospital, she was transferred to Beverly Health Care. Mrs. Cameron's physical condition deteriorated and eventually it was necessary to surgically implant a feeding tube to supply her with nutrition. In March 2000, possibly because of another stroke, she became totally unresponsive, and her attending physician diagnosed her as being in a "persistent vegetative state." Two neurologists were consulted; they supported the diagnosis of her attending physician. Her condition has not changed. Mrs. Cameron's husband of more than 40 years, James Cameron, visited her daily, except for a period during which he was recovering from a heart attack. In June 2000, he requested that his wife's doctors abide by the conditions of a "living will" Mrs. Cameron had executed, which specified that any feeding tube that had been inserted be withdrawn in the event she was in a "persistent vegetative state." The Knights objected to removing the feeding tube and brought the action that is the subject of this appeal.
Evidence concerning Mrs. Cameron's medical condition included the testimony of her attending physician, Dr. David MacRae, and a clinical neurologist, Dr. Fritz Lacour. Both Dr. MacRae and Dr. Lacour testified that, to a reasonable degree of medical certainty, they believed that *94 Mrs. Cameron is in a persistent vegetative state. Dr. MacRae testified:
On cross-examination, Dr. MacRae further testified:
The Knights offered as a witness Dr. David McCraney, a neurologist who had performed a 45-minute examination of Mrs. Cameron on the evening before he testified. Dr. McCraney testified:
Following Dr. McCraney's testimony, Dr. Lacour testified as follows:
The Knights and other members of Mrs. Cameron's family testified that during their visits to Mrs. Cameron, she appeared to recognize them; this recognition, they said, was shown by Mrs. Cameron's blinking and visually following their movements about her room.
The trial court received considerable evidence that Mrs. Cameron knowingly executed a living will in 1995. The Knights did not present any evidence indicating that Mrs. Cameron's living will was invalid or that it was otherwise legally ineffective.
On December 6, 2000, the trial court entered an order that stated, in pertinent part:
In this appeal, the Knights argue that the trial court erred in denying their petition to enjoin the removal of their mother's feeding tube because, they say, the court made two erroneous findings: (1) that Mrs. Cameron truly understood when she *97 executed her living will that she would be removed from life-sustaining treatment in her current condition; and (2) that Mrs. Cameron is in a "persistive vegetative state," as defined in her living will, or in a "permanent unconscious state," as that term is defined at § 22-8A-3(10), Ala.Code 1975, a part of Alabama's Natural Death Act, §§ 22-8A-1 to -13.[3]
In regard to their argument challenging the trial court's determination that Mrs. Cameron is in a persistent vegetative state, the Knights argue that the trial court used an incorrect evidentiary standard, i.e., that its finding was based on substantial evidence. They argue that because the finding that Mrs. Cameron was in a persistent vegetative state was a prerequisite to effectuating the terms of her living will and, under the circumstances of this case, to ordering the removal of the feeding tube, the trial court should have applied a higher evidentiary standard. The Knights argue that this Court should require that when a trial court's findings are the basis for an order that would implement the terms of a living will, those findings be supported by clear and convincing evidence. In addition, they argue that the trial court erred by affirmatively ordering that Mrs. Cameron's feeding tube be removed because, they say, the only issue presented to the trial court by the pleadings was whether the removal of the feeding tube should be enjoined.
The trial court heard conflicting testimony and took evidence during five separate hearings on the Knights' petition. Furthermore, the trial judge visited Mrs. Cameron during the course of the hearings. The record contains the following:
The judgment appealed from is therefore based upon ore tenus evidence. Our standard of review of such judgments is settled:
Ex parte Pielach, 681 So. 2d 154, 154-55 (Ala.1996) (citations omitted). Moreover, where the trial court does not make specific factual findings, this court will assume that the trial court made such findings as would support its judgment. Transamerica Commercial Fin. Corp. v. Am-South Bank, 608 So. 2d 375, 378 (Ala.1992).
The Knights argue that their mother did not truly understand that her living will provided that a feeding tube would be removed if she were in the condition she is in currently. In pertinent part, Mrs. Cameron's living will states:
The Knights have presented no evidence tending to show that the trial court's finding that Mrs. Cameron's living will was legally effective was plainly or palpably wrong. We conclude that there is sufficient evidence in the record supporting the trial court's finding that Mrs. Cameron's living will was valid.[4]
The Knights further argue that the trial court applied the wrong evidentiary standard in stating that it "was satisfied by substantial evidence" that Mrs. Cameron was in a persistent vegetative state. We infer that the trial court, by using this language, was merely stating that there was sufficient evidence to support its finding as the trier of fact, rather than stating the evidentiary standard it used.[5] We find nothing in the applicable statutes or in the case law of this State addressing this issue. Accordingly, because this is an issue of first impression, we consider the decisions of other jurisdictions. The Supreme Court of Arizona in Rasmussen v. Fleming, 154 Ariz. 207, 224, 741 P.2d 674, 691 (1987), held:
(Citations omitted.)
The Supreme Court of Maine in In re Gardner, 534 A.2d 947, 953 (Me.1987), stated:
(Footnote omitted.) The Supreme Court of the United States in Cruzan v. Director, Missouri Dep't of Health, 497 U.S. 261, 110 S. Ct. 2841, 111 L. Ed. 2d 224 (1990), held that the states could require clear and convincing evidence as the standard for proving a person's intent not to receive life-sustaining treatments, and several states have required clear and convincing evidence in a variety of situations involving the removal of life-support systems and artificially provided hydration and nutrition. See, In re Christopher, 177 Misc.2d 352, 675 N.Y.S.2d 807 (N.Y.Sup.Ct.1998); Blackman v. New York City Health & Hosps. Corp., 173 Misc.2d 562, 660 N.Y.S.2d 643 (N.Y.Sup.Ct.1997); In re Martin, 450 Mich. 204, 538 N.W.2d 399 (1995); In re Tavel, 661 A.2d 1061 (Del. 1995); In re Application of Barsky, 165 Misc.2d 175, 627 N.Y.S.2d 903 (N.Y.Sup. Ct.1995); Mack v. Mack, 329 Md. 188, 618 A.2d 744 (1993); In re Guardianship of L.W., 167 Wis.2d 53, 94, 482 N.W.2d 60, 76 (1992)(Ceci, J., concurring)("The diagnosis of persistent vegetative state must be by evidence which is clear and convincing. We are, after all, dealing with the death of a human being."); In re Moorhouse, 250 N.J.Super. 307, 593 A.2d 1256 (1991); Curran v. Bosze, 141 Ill. 2d 473, 566 N.E.2d 1319, 153 Ill.Dec. 213 (1990); In re Guardianship of Browning, 568 So. 2d 4 (Fla. 1990); McConnell v. Beverly Enterprises-Connecticut, 209 Conn. 692, 553 A.2d 596 (1989); Elbaum by Elbaum v. Grace Plaza of Great Neck, Inc., 148 A.D.2d 244, 544 N.Y.S.2d 840 (1989); In re Beth Israel Med. Ctr., 136 Misc.2d 931, 519 N.Y.S.2d 511 (N.Y.Sup.Ct.1987); In re Jobes, 108 N.J. 394, 529 A.2d 434 (1987); Workmen's Circle Home & Infirmary for the Aged v. Fink, 135 Misc.2d 270, 514 N.Y.S.2d 893 (N.Y.Sup.Ct.1987); John F. Kennedy Mem'l Hosp., Inc. v. Bludworth, 452 So. 2d 921 (Fla.1984); In re Storar, 52 N.Y.2d 363, 438 N.Y.S.2d 266, 420 N.E.2d 64 (1981); and Leach v. Akron Gen. Med. Ctr., 68 Ohio Misc. 1, 426 N.E.2d 809, 815 (1980).
We note that our Legislature in § 6-11-20(b)(4), Ala.Code 1975, has required that an award of punitive damages must be supported by clear and convincing evidence. That section defines clear and convincing evidence as:
We conclude that the rationale used by the Arizona Supreme Court in Rasmussen is applicable in the instant situation. Determining whether Mrs. Cameron is in a persistent vegetative state in the context of this case is a determination of the type that requires greater certainty than the usual factual determination. After considering the large body of authority from other jurisdictions, we conclude that any finding that Mrs. Cameron is in a persistent *102 vegetative state must be supported by clear and convincing evidence.
After reviewing the evidence presented to the trial court, we conclude that the record contains clear and convincing evidence to support the trial court's finding that Mrs. Cameron is in a persistent vegetative state. However, the law is settled that weighing evidence is not the usual function of an appellate court. Thompson v. Citmoco Servs., Inc., 371 So. 2d 42 (Ala.1978). This is especially true where, as here, the assessment of the credibility of witnesses is involved. The ore tenus rule reflects this deference; it accords a presumption of correctness to the trial court's findings because of that court's unique ability to observe the demeanor of witnesses. Pielach, supra; Hall v. Mazzone, 486 So. 2d 408 (Ala.1986). Thus, although the record is sufficiently complete to obviate the need for any further evidentiary hearing, we conclude that it is appropriate to remand this cause to the trial court for its explicit finding as to whether there is clear and convincing evidence indicating that Mrs. Cameron is in a persistent vegetative state. Further, because we request only that the trial court apply the clear-and-convincing standard to the evidence it has already received and evaluated, we instruct that the trial court return its order on remand to this Court within 14 days.
The Knights lastly contend that the trial court erred by ordering that the feeding tube sustaining Mrs. Cameron be removed. They argue that they sought only to enjoin the implementation of Mrs. Cameron's living will and that the trial court exceeded the scope of their requested relief. However, the record indicates that Mr. Cameron filed a motion to intervene and that the trial court granted that motion. The Knights subsequently moved to have Mr. Cameron added as a defendant and the trial court also granted that motion. During the trial court's first hearing, Mr. Cameron testified as follows:
By these statements, Mr. Cameron essentially requested the trial court to allow the implementation of Mrs. Cameron's living will. Opposing counsel made no objection to his request. Rule 15(b), Ala. R. Civ. P., which addresses amended and supplemental pleadings, states:
In applying Rule 15(b) to a similar procedural situation, this Court stated:
United Cos. Fin. Corp. v. Brown, 584 So. 2d 470, 473 (Ala.1991). Likewise, in this case, once Mr. Cameron requested the trial court to respect Mrs. Cameron's wishes as expressed in her living will, and because the Knights' counsel made no objection, the trial court properly considered Mr. Cameron's request and granted the relief requested.
In summary, we affirm the judgment of the trial court insofar as it determined that Mrs. Cameron had a valid living will; insofar as it implicitly determined that she understood the contents of that living will; and insofar as it determined that it could properly grant the relief Mr. Cameron requested. We remand the case for the trial court to enter an order stating whether its finding that Mrs. Cameron is in a "persistent vegetative state," as defined in her living will, or in a "permanent unconscious state," as defined in § 22-8A-3(10), was supported by clear and convincing evidence. The trial court is further instructed to make its return to this Court within 14 days.
AFFIRMED IN PART AND REMANDED.
MOORE, C.J., and SEE, BROWN, and STUART, JJ., concur.
HARWOOD, Justice.
On August 31, 2001, this Court remanded this case to the trial court for an explicit determination as to whether its finding that Delores Cameron was in a "persistent vegetative state," as defined in her living will, or in a "permanent unconscious state," as defined in Ala.Code 1975, § 22-8A-3(10), was supported by clear and convincing evidence. The trial court has filed its return, stating that its finding was supported by clear and convincing evidence. We likewise find that degree of support in the record. Accordingly, the judgment of the trial court is affirmed.
AFFIRMED.
HOUSTON, SEE, LYONS, BROWN, JOHNSTONE, WOODALL, and STUART, JJ., concur.
[1]  While the style in all the pleadings and materials below refer to this defendant as "Beverly Health Care Bay Manor Health Care Center," the defendant's counsel, in his notice of appearance, stated that the defendant's correct name was "South Alabama Nursing Home, Inc., d/b/a Beverly Healthcare-Mobile." Although it is not clear from the materials before us, it appears that the defendant owns or operates the Bay Manor nursinghome facility, where the Knights' mother resides.
[2]  Mr. Cameron is the Knights' stepfather.
[3]  Mrs. Cameron's living will was drafted in 1995, before the 1997 amendments to the Natural Death Act. Those amendments added and defined the term "permanent unconsciousness" and included the state of permanent unconsciousness as a diagnosed condition that will allow the implementation of a living will. Dr. MacRae testified that, to a reasonable degree of medical certainty, Mrs. Cameron's condition fit both the definition of "persistent vegetative state," as that term is used in her living will, and the definition of "permanent unconsciousness," as that term is used in the Natural Death Act, and that those terms were "one in the same."
[4]  While the trial court did not specifically state an evidentiary standard for its finding that Mrs. Cameron had a valid living will, we note that other jurisdictions have determined that the existence of a valid living will is, in and of itself, clear and convincing evidence of an intent to terminate life-sustaining treatments and artificially provided hydration and nutrition. In John F. Kennedy Mem'l Hosp., Inc. v. Bludworth, 452 So. 2d 921, 926 (Fla. 1984), the Florida Supreme Court held:

"If [a terminally ill incompetent person], while competent, had executed a so-called `living' or `mercy' will, that will would be persuasive evidence of that incompetent person's intention and it should be given great weight by the person or persons who substitute their judgment on behalf of the terminally ill incompetent."
Also, in In re Guardianship of Browning, 568 So. 2d 4, 16 (Fla.1990), the Florida Supreme Court determined:
"Although a surrogate may rely on oral statements made by the incompetent, while competent, to exercise the incompetent's wishes to [forgo] life-sustaining treatment, the presumption of clear and convincing evidence that attaches to a written declaration does not attach to purely oral declarations."
Similarly, the New York Superior Court held in Saunders v. State, 129 Misc.2d 45, 54-55, 492 N.Y.S.2d 510, 517 (N.Y.Sup.Ct.1985):
"The [living will] executed by the petitioner is evidence of the most persuasive quality and is a clear and convincing demonstration that while competent the petitioner clearly and explicitly expressed an informed, rational and knowing decision to decline certain medical treatment by artificial means and devices while in a terminally ill state or condition and it should be given great weight by the hospital authorities and treating physicians attending her."
See also, In re Martin, 450 Mich. 204, 538 N.W.2d 399 (1995).
[5]  In Hines v. Riverside Chevrolet-Olds, Inc., 655 So. 2d 909 (Ala.1994)(overruled on other grounds, State Farm Fire & Cas. Co. v. Owen, 729 So. 2d 834 (Ala.1999)), this Court examined the interplay between § 12-21-12, Ala. Code 1975, which requires substantial evidence to submit an issue of fact to the trier of fact, and § 6-11-20(b)(4), Ala.Code 1975, which requires clear and convincing evidence for an award of punitive damages. This Court held that in order for a judge to submit the issue of punitive damages to the jury as the trier of fact, the judge must be satisfied by substantial evidence. Then, the jury must be satisfied that the plaintiff has presented clear and convincing evidence to support the punitive-damages award. See also, Ex parte Norwood Hodges Motor Co., 680 So. 2d 245 (Ala. 1996).
[6]  This definition is also used in § 25-5-81(c), Ala.Code 1975, a provision of Alabama's Workers' Compensation Act, with regard to the evidentiary standard to be applied in cases that involve injuries arising from gradual deterioration or cumulative physical stress disorders.