Th e Ho no ra ble Da rl e ne B y rn e g ra nte d th e tw o o rd e rs str iki ngthe e xpe rt op ini on s, wh ile 1 the Ho no ra

ble Marg are t Co op e r r e nd e re d th e fi na l summa ry jud g me nt. 

### TEXA S C OU R T OF A PPEAL S, THIR D DIST R ICT , AT AU STIN

NO. 03-0 7 -00 477 -CV

M ar th a F lor e s, Indi vid ual ly a nd as Ne xtF r ie nd of A lic ia F lor e s, Te r e sa K . K nobl e s, Co nsue lo W alk e r , I ndiv idua llyand a s R e pr e se nt at ive of t he Est at e of C ons ue lo F lor e s, and Manu el F lores , Appellan ts

v. Daryl Eakin , M.D.; Lone Star Oncology Consu ltants, L.L.P.; and Rou nd Rock Hos pital, In c. d/b/a Rou nd Rock Hos pital , Appellees

F ROM THE DISTRICT CO URT OF TRAVIS COUNTY , 98TH JUDICIAL DISTRICT NO. D-1- GN-00- 0026 02 , HO NORAB LE MARGARET A. COO P ER , JUDGE PRESIDI NG

M E M O R

A N D U M O P I N I O N Ap pe lla nts , th e surv ivi ngc hil dr e n o f C onsu elo F lor e s, su e d a pp e lle e s, Dr. Da ryl Eakin, M
. D. ; L one Star Onc ology Consultants, L .L .P.; and Round Rock Hospital, I nc. d/b/a Round Rock Hospital, alleg ing that appellee s’ neg lige nce pr ox imately cause d Flore s’s death. Appellee s succe ssfully moved to strike opinions of appellants’ expert and subsequently obtained a fi na l summa

ry jud g me nt t

hat a pp e lla nts take no thi ngon

the ir c la ims . In tw o is su e s, a pp e lla nts challeng e t wo d i s trict court or ders striking the expert opinions and the subsequent summary jud g me nt. We w ill a ff

ir m th e jud g me nt o f t

he dis tr ic t c ourt
. 1Ap pe lle e s a lso c ha lle ng e d D r. F re dr ic ’s re lia nc e on the “ Ap ache I I ” sc or ingme tho d to 2 d e te r mi n e h o w th e ti mi n g o f

a d mi n is te r in g an ti b io ti c s a f f e c ts s u r v iv a b il it y o f an y o n e c an c e r . We need not a ddress this aspec t of Dr. F redr ic’s testimony beca use the re liability

of Dr. F redr ic’s testimony as to the combined e ffe ct of two primar y canc ers is dispositive. 2 I n Marc h 1998, at ag e 75, Flore s was diag nosed with r ecta l c ance r. Whil e still being evaluated for tr eatment, in Apr il 1998, Flores was al s o d i agn o s ed with lung canc er. The re is no dispute that these two primar y canc ers wer e independe nt and unre lated. F lores under went surg erie s to treat both ca

ncer s along with chemother apy and ra diation therapy . Flore s saw Dr
. E ak i n , an
on c olo g ist , a s p art

of that tr e a tme nt. On J une 26, 1998, Flore s, who had been experiencing nausea , vomiting, and diar rhea for se vera l da

y s, was admitted to Round Rock Hospital. Whil e in the hospital, she beg an running a fe ver, a nd various medica

tions were a dminist ere d. She died in the hospital on J uly 4, 1998. Ap p el l an t s s u edDr
. E ak i n ; Dr
. E ak i n ’s p ra ct i ce g ro u p , L o n e S t ar

On co l o gy Con s u lt an ts , L
. L
. P. ; an d Ro u n d Ro c k H o s p it a l, a ll e g in g n e g li g e n c e in th e c ar e an d tr e a tm e n t of Flore s. Appellants hired D r. Rhett K. Fr edric as their e x pert witness. Appe llees filed a joint motion to strike D r . F r e dr ic ’ s o p in io nte s ti mo n y o nth e g r o u n d s th a t, a mo n g o th e r s , th e te s ti mo n y w as
un su pp or te d s pe c ulatio n an d, the re fo re , unr e lia ble
. Spe c if

ic a lly , a pp e lle e s c ha lle ng e d th e re lia bil ity of Dr . F re dr ic ’s op ini on

that w he re a

patie nt i s a ff

lic te d w ithtw o canc e rs , th e patie nt’ s p ro ba bil ity of surviving the ca

ncer s is determined by

the s u rvivability

of the more serious of the two c ance rs alone. Ad dit ion a lly , D r. Eakin fi le d a se pa rate mot ion

to s tr ike c e rt a in o pin ion s of Dr . F re dr ic 2 reg ardingwhether

Dr. Eakin’s perf

orm an ce had bee n impaired by his alleg ed use of pa in m e dic a tio ns .Eakin ’s mot ion a lso so ug ht s umm ary

jud g me nt o n tr a dit ion a l g ro un ds
. 3 3 The district court gra n t ed Dr. Eakin’s motion and, in part, a ppellees’ joint mot ion, inc lud ingstr iki ngDr . F re dr ic ’s op ini on s a s to “ the surv iva bil ity of tw o c anc e rs ba se d o n unr e lia bil ity and irre levanc e.” Appellee s subsequently filed no-evide nce motions for summary judgme nt, which the district court g rante d. This appea l ensued. 3 I n two issu es , ap p el lants contend that the district c ourt abused its discre tion by striking Dr. Fr edric ’s opinion testimony and, conseque ntly , err ed in g ranting fi n al summary judgme nt. We need only addre ss the district court’s orde r striking Dr. F redr ic’s opinions reg arding the surv iva

bil ity of F lor e s’ s tw o c anc e rs , a s it is d e c isi ve of

bo th i ssu e s. T o p r e v a i l o na

m e d i c a l

- m a l p r a c t i c e c l a i m , a p l a i n t i f f m u s ts h o w ( 1 ) a

l e g a l d u t y, (2) brea ch of that duty , and (3) damag es proximately cause d by

that brea ch. IHS Cedars Treatment Ctr. v. Mason , 1 43 S.W. 3d 79 4, 79 8 (T e x. 20 03 ). “ Te xas co ur ts have lon g re c og nize d th e ne c e ssi ty of expert testimony

in medical-ma lprac tice ca ses.” American Transitional C are Ctrs. of Tex., I

nc. v. Palacios , 46 S.W .3d 873, 876 (Tex. 2001).

To establish proxim ate cause in a medical- malprac tice claim, the plaintiff must show by c omp e te nt m e dic a l te sti mony that the ne g lig e nc e of on e or mor e of the de fe nd ants pr oximate ly
c a u s e d h is in

ju r ies. K r a me r v. Lewisville Mem ’l Hosp. , 858 S.W .2d 397, 399-400 (Te x . 1993); Du ff v . Yeli n , 751 S.W .2d 175, 176 (Tex. 1988). “The neg lige nt act or omission [m ust be] shown to be a substantial fa ctor in bring ing a bo u t t h e h ar m and without which the ha rm would not have
occur red.” Kramer

at 3 9 9 -4 0 0 (c i t i n g Ha v ne r v . E- Z Mart , 825 S.W .2d 456, 459 (Tex. 1992)). To meet this burden, a

ppellants wer e re quired to pr esent leg ally sufficie nt evidence that Flore s moreAs appe llants ex plained in their brie f, 4 Dr. F rede ric’s [si c] c ausation opinions are e ssentially that Ms. Flore s’ ca

ncer s were survivable, he r infec tion would have bee n survivable if a ntibioti c tre atment had be en started pr omptly

when Ms. Fl o re s s p i k ed a f ever , and that Dr . Eakin’s a buse of pr e sc ri pti on

pa in m e dic a tio n w ou ld a ff e c t hi s a bil ity to p ay ne c e ssa ry a tte nti on to Ms. Flore s’ dec lining condition. 4 likely than not would have sur

vived her two canc ers; other

wise, any acts of a ppellees c ould not have been a proxi mate ca

use of F lores’s de ath. 4 Be cause Texas does not rec og nize the “ lost c hance ” doctr ine, there is no liabili ty for neg lige nt medical treatment “that dec rea ses a patient’s chanc e of a voiding de ath or other medical c onditions i n case s where the adve rse r esu l t p ro b ably would have oc curr ed any way .” Id. at 398. I f the plaintiff ha d less than a 5 0 perc ent cha nce of survival abse nt the defe ndant’s neg lige nce, the plaintiff’s cla im is barred. Id. at 400. “He nce, wh er e p re ex isting illnesses or injuries have made a patient’s cha

nce of avoiding the ultimate harm improbable even befor e the a lleg edly

neg lige nt conduct occ u rs
— i
. e., the patient would die or suffe r impairment
any wa y —th e a pp lic a tio n o f t

he se tr a dit ion a l ca

us a tio n pri nc ipl e s will tot a lly ba r r e c ov e ry , e ve n if such neg lige nce ha s deprived the patient of a chanc e of a

voiding the ha

rm.” Id. I na m ed i ca l -m al p ra ct i ce ca s e, re as o n ab l e p ro b ab i l i t y o f s u rv i v al i s d et er m i n edb y t he substance a

nd context of an expert’s opinion. See B urroughs W ellcomeCo. v. Crye , 907 S.W .2d 49 7, 50 0 (T e x. 19 95 ). Th e dis po sit ive iss ue a s to t he a pp e lla nts ’ c la ims is w he the r F lor e s p ro ba bly
wo uld have surv ive d a

bs e nt any ne g lig e nc e by a pp e lle e s. To a vo id su mma ry jud g me nt, a

pp e lla nts had to pre sent leg ally

sufficie nt evidence that there was a 50 perc ent or g reater c hance that Flor es5

wo uld have surv ive d ab sen t app e lle e s’ a lle g e d n e g lig e nc e . T o p ro vid e tha t e vid e nc e , a

pp e lla nts relied solely

on the testimony

of Dr. F redr ic. Dr. F redr ic testified that F lores had a g reater t h an 50 perc ent cha nce of survival of her c ance rs bec ause the re w as a 62 perc en t fi ve-y ear survival rate for the lung c ance r and a 70 perc ent five-y ear survival rate for the rec tal canc er. He opined that the survival rates for a patient wi th t wo pr ima ry c anc e rs mus t be det erm in ed b y loo kin g so le ly

to t he surv iva l r a te s f

or the mos t serious ca ncer . He dismissed the not ion that the presence of t he second primary canc er w ould impact t h e s u r v i v a b i l i t y o f t h e f i r s t
. A c c o r d i n g t o D r . F r e dr i c ’ s A p r i l 4 , 2 0 0 7 , d e p o s i t i o nt e s t i m o n y: Q. I f [sic] have 62 pe rc ent cha nce of survival bec ause of

my lung c ance r and only a 70 per cent chance of survival beca use of my rec tal canc er, the n doesn’t my ch an c e o f

s u r v iv a l h a v e to b e s o me th in g le s s th an6 2 p e r c e n t, if y ou’re jus t a pp lyinga statis tic a l ana ly sis ? A. No, I

don’t think so. And I ’m not sure how to re spond to that fairly . I ’ve never s ee n an y b o d y that I ’m awa

re of addre ss that issue, so there may be some – something you may have some knowledg e of that Idon’t know. Q. Ok ay . May

be a dd re sse d in t

he lit e ra tur e , b ut you

have y ou have n’ t se e n it ? A. Ye s - no sir , I

have n’ t.
L ater , in a supplemental a ffidavit date d May 1, 2007, Dr. F redr ic ave rre d: When a patient has two pr imary canc ers, the patient’s overa ll surviva bility is based upon the individual canc er s an d t h eir surviva bility . Iam awa

re of no medical li te r a tu r e th a t m e a s u r e s s u r

v iv a b il it y o f tw o s e p ar a te p r im ar

y c an c e r s in

an y w ay oth e r tha n by a dd re ssi ng the surv iva

bil ity of ind ivi du a l c anc e rs . Whil e a patie nt w ith two primary canc ers may

experience complications that patients with one ca ncer may not, it does not follow that p ati ents with two primary canc ers will experienc e differ ent over all survival rates from the patients with a si ng le cancer
. I am aware of no mathematica l formula ac cepte d by phy sicians that can be applied in this scena rio.6

I n other words, one ma

y not simpl y

multipl y the proba

bility of survival for

the tw o c anc e rs to arr ive a t a ne w surv iva l pe rc e nta g e . Suc h a c a lc ulatio n w ou ld l e a d to the absurd result of a patient with one ca ncer with a zero per cent f

ive y ear survival a ndon e c an c e r w i t h a o n e h u n dr e d p e r c e n t f i v e y e ar s u r

v i v a l h a v i n g anov e ra ll fifty perc ent cha

nce of survival. Clearly , that is not the case.
A tri a l c ourt ’s de c isi on

to a dm it o r e xclu de e xpe rt te sti mony

is r e vie we d f

or a bu se of discre tion. Helena Chem. Co. v. W ilkins , 47 S.W. 3d 48 6, 49 9 (T e x. 20 01 ). “ Th e te st f or a bu se of discre tion is wh et h er the trial cour t acted w ithout refer ence to any g uiding r ules or princ iples.” E.I. du Pont de Nemours & Co. v . Robinson , 923 S.W .2d 549, 558 (Tex. 1995). I f a pa rty opposes and objec ts to the admission of ex pert testim ony , the propone nt bear s the burden of demonstrating its admissi bility
. Robinson , 923 S.W .2d at 557.

Expe rt te sti mony

is a dmi ssi ble if

(1 ) t he e xpe rt is q ua lif ie d, and (2 ) t he te sti mony

is rele vant and based on a

reliable foundation. W

ilkins , 47 S. W.3 d at 49 9; Robinson , 923 S.W .2d at 556. Scientific testimony is u n re l iable if it is not gr ounded “in the me thods and proce dures of scienc e,” and amounts to no more than a “ subjective be lief or unsupporte d speculation.” Robinson , 9 2 3 S
. W
. 2 d

at 5 5 7 (q u o t i n g Daubert v. M err el l Dow Pharm., Inc

. , 509 U.S. 579, 590 (1993)). Expe rt te sti mony

is al so un re lia

ble if “ the re is s imp ly

too g re a t a

n a na ly tic a l g a p b e tw e e n th e data and the opinion proffe red.” Gammill v. Jac k W illiams C hevrole t , 972 S.W .2d 713, 727 (Tex. 1998) (q u o t i n g Gene ral Elec. Co. v. J oiner , 522 U.S. 136, 146 (1997)). Fa ctors used by

courts to deter

mine whether

expert testimony

is reliable include :
1. the extent to which the theory has bee n or ca

n be tested; 2. the extent to which the technique relies upon the subjective interpre tation of the e xpe rt ;7

3. whether

the theory

has bee n subjected to pe er r eview a nd/or publication; 4. the technique ’s potential rate of e rror ; 5. whether the underly i n g t h eo ry or technique has been g ener ally acc epted a s valid by the re levant scie ntific community ; and 6. the non-judicial uses w hich have been ma de of the theory or tec hnique.
Robinson , 923 S.W .2d at 557. These fac tors are non-exclusive and fle x ible. Id.

He re , D r. F re dr ic of

fe re d n o su

pp or t fo r his op ini on that the pr e se nc e of tw o s e pa rate primary canc ers r esults in a prog nosis identical to the individual pr og nosis of the more serious of the two canc ers. Dr . Fr edric admitted, howev er , that “a patient with two primary canc ers may experience complications that patients with one ca ncer may not.” Alt h o u gh D r . Fr edric rea soned that the surv iva l r a te s o f t he tw o can c e rs c ann ot s imp ly be mul tip lie d, he of

fe re d n o s up po rt

fo r t his
asser tion, just as he of

fe re d n o support for his theory that the survival rates must be considere d separ ately
. Wit hout support from any scientific e vidence or docume ntation, these opinions, without more, re quire too g reat an ana ly tical leap a

nd amount t o m er e u nsupported spec ulation. See Ga mm ill , 972 S.W .2d at 727. As it was appellants’ burden, once challeng ed, to prove the evidenc e reliable , see Robinson , 923 S.W .2d at 557, the district cour t acted w ithin it s discretion in striking Dr . F re dr ic ’s c a

us a tio n te sti mony

ba se d o n D r. F re dr ic ’s “ ina bil ity to te sti fy

on [F lor e s’ s] survivability

of the two c ance rs.” See id. at 556-58. Acc ording ly , we ove rrule a ppellants’ first issue. As for a ppellants’ second issue, appellee s filed a “no-e vidence ” summary judgme nt
c ha lle ng ing , a mon g oth e r e le me nts of a pp e lla nts ’ c la ims , c a

us a tio n. To a vo id s umm ary jud g me nt, appellants had the burden to pr esent expert testimony on eac h challeng ed ele ment. Se e IH S Ce da rs8

Tre atm e nt C

tr. , 1 43 S.W. 3d

a t 79 8; Palacios , 46 S.W .3d at 876. Having held t hat t he dis trict court acte d within it s d i s cre tion in st riking Dr. F redr ic’s ca usation testimony

as to survivability , we, likewise, hold that the district court did not er r in g ranting summary

judgme nt ag ainst appellants on no-evide nce g rounds. Acc ording ly , we ove rrule a ppellants’ sec ond issue. We a ff ir m th e jud g me nt o f t

he dis tr ic t c ourt
.

__________________________________________ Bob Pembe rton, J ustice Be fore Chief J ustice L aw, Justi ces Pury ear and Pember

ton Affir med Filed: August 22, 2008