Case Name: John L. YAHN, et al., Plaintiffs-Appellants, v. Dr. Craig P. FOLSE, et al., Defendants-Appellees
Court: Louisiana Court of Appeal
Jurisdiction: Louisiana
Decision Date: 1993-10-27
Citations: 639 So. 2d 261
Docket Number: No. 25176-CA
Parties: John L. YAHN, et al., Plaintiffs-Appellants, v. Dr. Craig P. FOLSE, et al., Defendants-Appellees.
Judges: Before LINDSAY, HIGHTOWER and BROWN, JJ.
Reporter: Southern Reporter, Second Series
Volume: 639
Pages: 261–274

Head Matter:
John L. YAHN, et al., Plaintiffs-Appellants, v. Dr. Craig P. FOLSE, et al., Defendants-Appellees.
No. 25176-CA.
Court of Appeal of Louisiana, Second Circuit.
Oct. 27, 1993.
Opinion on Rehearing April 14, 1994.
Writ Denied Sept. 2, 1994.
Edmund Thomas, Shreveport, Richard Voelker, Baton Rouge, for plaintiffs-appellants.
Hayes, Harkey, Smith, Cascio & Mullins by Haynes L. Harkey, Jr., Monroe, for defendants-appellees.
Before LINDSAY, HIGHTOWER and BROWN, JJ.

Opinion:
jiLINDSAY, Judge.
This is a medical malpractice case. The plaintiffs, the children of John L. Yahn, are Frank Yahn, Beverly Yahn Sanders, Donald F. Yahn and Lewis Yahn. They contend that Dr. Craig P. Folse performed an arteriogram upon their father without consent. Mr. Yahn suffered a stroke during the procedure and died approximately one year later. The trial court rejected the plaintiffs' demands. For the following reasons, we affirm.
FACTS
In February, 1988, John Yahn, who was then 82, was referred'to Dr. Robert Massin-gill after experiencing three episodes of dizziness and fainting in a two year period. Dr. Massingill's examination revealed an aortic aneurysm in the abdomen. Although this was not thought to be the cause of Mr. Yahn's fainting spells, it was a serious, life-threatening condition. Dr. Massingill admitted Mr. Yahn to Richland Parish Hospital for further testing to determine the cause of the fainting and to evaluate whether Mr. Yahn's physical condition was such that he would'be a candidate for surgical repair of the aneurysm.
A CT scan of the brain was done as well as chest x-rays and a bilateral carotid artery ultrasound. Plaque formation was discovered in the right carotid artery and ulceration of plaque was discovered in the left carotid artery. The carotids are arteries leading to the brain. Although the blood flow through these arteries was not significantly restricted by the plaque, there was some concern that bits of plaque from the ulceration could break loose and cause a stroke.
Dr. Massingill referred the patient to Dr. Folse, a radiologist, who determined that an arteriogram was ^necessary to study Mr. Yahn's carotid arteries and the abdominal aneurysm. An arteriogram is an invasive technique which creates some risk of harm to the patient, including stroke. In this procedure, a catheter and guide wire are inserted into an artery in the leg. The catheter and wire are advanced to the necessary point in the arteries and a radiopaque material is injected. The flow of the material through the arteries is. then studied.
On February 23, 1988, prior to performing the arteriogram, Dr. Folse went to Mr. Yahn's room to explain the procedure and to obtain his consent. The parties disagree regarding the events that transpired in Mr. Yahn's room.
Dr. Folse, who had never met Mr. Yahn, claims that he recognized that the patient was hard of hearing. Dr. Folse stated that he explained the procedure and risks to Mr. Yahn and told him that the physicians thought that he needed to have the proce dure. Dr. Folse stated that no signed consent was obtained because Mr. Yahn's daughter, Beverly Sanders, became upset and opposed the procedure. He stated that he talked with Mrs. Sanders outside the room. Dr. Folse testified that he couldn't recall what Mr. Yahn said, but it was his impression when he left the room that he had Mr. Yahn's consent to the procedure.
According to Mrs. Sanders, she told Dr. Folse that her father was illiterate and hard of hearing. Mrs. Sanders became upset when Dr. Folse mentioned that the procedure carried the risk of stroke and she opposed the procedure. When Dr. Folse told Mr. Yahn that he needed to have the procedure done, he responded, "Okay." However, Mrs. Sanders contends that when she told her father that she did not want him to have the procedure, he also responded, "Okay."
| «Shortly after Dr. Folse departed, Mr. Yahn was taken out of his room and the procedure was performed. During the arter-iogram, Mr. Yahn suffered a stroke which paralyzed one side of his body. Thereafter, he was not able to live independently as he had before entering the hospital and required special care to feed, clothe, bathe and care for his basic needs. Mr. Yahn convalesced at his daughter's home from the date of his release from the hospital on April 4, 1988 until June 3, 1988, when he was transferred to a nursing home. Mr. Yahn had died on February 17, 1989. His death certificate lists the cause of death as a cerebrovascular accident, commonly known as a stroke. There was no indication that Mr. Yahn had another stroke following that which he suffered during the arteriogram.
The plaintiffs contend that their father's death resulted from the stroke suffered during the arteriogram. They filed a complaint with a medical review panel, claiming that Dr. Massingill, Dr. Folse, and the Richland Parish Hospital were negligent in performing the arteriogram and in failing to obtain consent for the procedure. On August 30, 1990, the medical review panel found that the evidence did not support a finding that Dr. Massingill, Dr. Folse or Richland Parish Hospital failed to meet the applicable standard of care in performing the arteriogram. However, the panel found that there were important issues of fact regarding the lack of a signed consent. The review panel found that these questions turned on issues of credibility which did not fall within the province of the panel to decide and should be submitted to the court for decision.
On November 28, 1990, the plaintiffs filed suit in district court against Dr. Massingill, Dr. Folse and |4Richland Parish Hospital for damages in connection with the death of Mr. Yahn. On November 19,1992, the trial court entered judgment in favor of the defendants, rejecting the demands of the plaintiffs.
In reasons for judgment, the trial court found no liability on the part of Dr. Massin-gill, stating that he had referred the patient to Dr. Folse who then became primarily responsible for the treatment of the patient after his admission to the hospital. The court also found no liability on the part of Richland Parish Hospital, stating that all necessary forms, rules and regulations were set out and provided for the doctors practicing at the hospital.
The court stated that the issue in the case was whether the medical procedure was adequately explained to Mr. Yahn and whether he heard and understood the explanation. The court expressed concern over the lack of a signed consent form stating, "We will never know now exactly why the consent form was not signed as recorded in the [doctor's] notes." However, the court found that despite Mr. Yahn's hearing deficit, it was possible to communicate with him and that the procedure and the need for the arteriogram were explained to him. The court also found that Mr. Yahn verbally agreed to the procedure. The court stated, "Mr. Yahn did have a basic understanding of what was going on, but even if he did not, faced with a life threatening illness, he would not have refused the test." The court stated that Mr. Yahn's aneurysm was life threatening and no reasonable person under these circumstances would have refused the arteriogram to determine the cause of the fainting and to determine a course of treatment for the aneurysm. Based upon these findings, the trial court rejected the plaintiffs' claims. The plaintiffs appealed the trial court judgment.
^CONSENT
The plaintiffs contend that the trial court erred in finding that Mr. Yahn consented to the arteriogram. They further contend that even if Mr. Yahn gave his consent, it was not informed consent. This argument has merit.
The informed consent doctrine is based on the principle that every human being of adult years and sound mind has a right to determine what shall be done to his or her own body. Hondroulis v. Schuhmacher, 553 So.2d 398 (La.1988). In recognition of the right of self-determination, surgeons and other physicians are required to provide their patients with sufficient information to permit development of an informed and intelligent decision about whether to submit to a proposed course of treatment. Broadway v. St Paul Insurance Company, 582 So.2d 1368 (La.App.2d Cir.1991).
LSA-R.S. 40:1299.40, governing consent to medical treatment, provides in pertinent part:
A. Notwithstanding any other law to the contrary, written consent to medical treatment means a consent in writing to any medical or surgical procedure or course of procedures which (a) sets forth in general terms the nature and purpose of the procedure or procedures, together with the known risks, if any, of death, brain damage, quadriplegia, paraplegia, the loss or loss of function of any organ or limb, of disfiguring scars associated with such procedure or procedures, (b) acknowledges that such disclosure of information has been made and that all questions asked about the procedure or procedures have been answered in a satisfactory manner, and (c) is signed by the patient for whom the procedure is to be performed, or if the patient for any reason lacks legal capacity to consent by a person who has legal authority to consent on behalf of such patient in such circumstances. Such consent shall be presumed to be valid and effective, in the absence of proof that | nexecution of the consent was induced by misrepresentation of material facts.
C. Where consent to medical treatment from a patient, or from a person authorized by law to consent to medical treatment for such patient, is secured other than in accordance with Subsection A above, the explanation to the patient or to the person consenting for such patient shall include the matters set forth in Paragraph (a) of Subsection A above, and an opportunity shall be afforded for asking questions concerning the procedures to be performed which shall be answered in a satisfactory manner. Such consent shall be valid and effective and is subject to proof according to the rules of evidence in ordinary cases.
It is undisputed that written consent to treatment was not obtained from Mr. Yahn. Therefore, under LSA-R.S. 40:1299.-40(A), there is no presumption of valid consent. However, consent to treatment need not be written; it may be verbal if necessary information is conveyed to the patient and the patient is given an opportunity to ask questions which are answered satisfactorily. Whiddon v. Elliott, 594 So.2d 449 (La.App. 1st Cir.1991); Mustacchio v. Parker, 535 So.2d 833 (La.App.2d Cir.1988). When a patient consents to treatment, but does not have sufficient information to make an informed decision concerning his treatment, the physician may be liable for a poor result. Mustacchio v. Parker, supra.
In a trial on the merits of a suit claiming inadequate disclosure of risk information by a physician, the patient has the burden of going forward with evidence tending to establish prima facie the essential elements of the cause of action, and ultimately the burden of persuasion on those elements. Hondroulis v. Schuhmacher, supra.
When circumstances permit, the patient should be advised of the character of his ailment, the general 17nature and risks of the proposed treatment or procedure, the prospects of success, the hazards of failing to undergo any treatment or procedure at all and the risks of alternative methods of treatment. Broadway v. St. Paul Insurance Company, supra; Hondroulis v. Schuhmacher, supra; Doss v. Hartford Fire Insurance Company, 448 So.2d 813 (La.App.2d Cir.1984), writ denied 450 So.2d 359 (La. 1984); Hidding v. Williams, 578 So.2d 1192 (La.App. 5th Cir.1991).
The doctor's duty is to disclose all risks that are "material." A risk is material if a reasonable person in the patient's position would likely attach significance to the risk or cluster of risks in deciding whether or not to forego the proposed treatment. Hondroulis v. Schuhmacher, supra. The determination of materiality of a risk is a two-step process and relies on an objective reasonable man standard in order to shield the physician from aberrational decisions on the part of patients. Broadway v. St. Paul Insurance Company, supra.
igFirst, the existence and nature of the risk must be defined, together with a likelihood of its occurrence. Expert testimony is necessary to establish these factors because only a physician or some other qualified expert is capable of judging what risks exist and the likelihood of its occurrence. Hondroulis v. Schuhmacher, supra; Broadway v. St. Paul Insurance Company, supra; Hidding v. Williams, supra; Distefano v. Bell, 544 So.2d 567 (La.App. 1st Cir.1989), writ denied 550 So.2d 650 (La.1989).
Then the question of materiality becomes one for the trier of fact, who must then determine whether a reasonable person in the plaintiffs position would attach significance to the specific risk. Hidding v. Williams, supra; Broadway v. St. Paul Insurance Company, supra; Hondroulis v. Schuhmacher, supra.
Conclusions by the trier of fact should be affirmed by the appellate court unless the record reflects that the conclusions of fact are not supported by the evidence. Doss v. Hartford Fire Insurance Company, supra; Distefano v. Bell, supra. Reasonable evaluations of credibility and inferences of fact should not be disturbed on review, even though the appellate court may feel its own evaluations and inferences are as reasonable. Distefano v. Bell, supra.
The trial court found that Mr. Yahn's stroke was caused by the arteriogram. That finding has not been questioned on appeal. Also, the trial court judgment finding no liability on the part of Dr. Massingill and Richland Parish Hospital has not been questioned on appeal and is therefore final.
However, the record fails to support the conclusion by the trial court that Mr. Yahn was supplied with adequate information in a manner that he could hear and understand and that he, in fact, gave informed consent to the arteriogram.
It is not disputed that the occurrence of a stroke is a material risk of an arteriogram. It is also not contested that Dr. Folse mentioned in Mr. Yahn's presence the possibility that a stroke could occur during the procedure. It is also not disputed that when Dr. Folse attempted to tell Mr. Yahn that he needed to have the arteriogram, Mr. Yahn responded affirmatively. The dispute in this case is whether the necessary information was provided to Mr. Yahn in such a way that he could hear and understand what was being said and that he gave informed consent.
Mr. Yahn was an elderly man with very little education. He was functionally illiterate and was |flextremely hard of hearing. Witnesses testified that he was deaf in one ear and had only limited hearing in the other ear. Dr. Folse, who had never met Mr. Yahn, went to his room to obtain consent to the arteriogram. He stated that he knew instinctively that the patient was hard of hearing by watching his eyes. Dr. Folse stated that he sat close to Mr. Yahn and spoke to him in a loud voice.
Dr. Folse attempted to tell Mr. Yahn about the pertinent material risks of the procedux*e, such as hemorrhage at the puncture site, clots forming on the catheter, an embolus being knocked off the artery wall, or an allergic reaction to the dye used in the procedure. However, Dr. Folse did not talk about the possibility of a thrombus to the lower extremities, the possibility of a tear in the aneurysm or impairment of kidney function. Dr. Folse testified that he did tell Mr. Yahn about the possibility that the procedure could cause a stroke. This fact is corroborated by the testimony of Beverly Sanders who stated that, when she learned of the possibility that a stroke might be precipitated by the procedure, she became very upset and voiced clear opposition to the arteriogram.
Even though Dr. Folse spoke to Mr. Yahn about the possibility that the arteriogram might result in a stroke, Dr. Folse's own testimony demonstrates that Mr. Yahn may not have heard or understood what was said. Dr. Folse testified that he did not engage Mr. Yahn in conversation or ask him to respond in any way in an attempt to ascertain whether he could hear and understand what was being said to him. At trial, Dr. Folse stated that after the explanation, he could not recall what Mr. Yahn said or what his exact response was, although Dr. Folse had the "impression" when he left the room that he had Mr. Yahn's | mconsent to do the procedure. However, Dr. Folse also acknowledged that Mrs. Sanders was extremely upset over the possibility that the procedure might cause a stroke. Dr. Folse stated that he was so distracted by Mrs. Sanders' reaction that he forgot to get Mr. Yahn to sign a written consent form.
Mrs. Sanders testified that when Dr. Folse entered the room, she told him that her father was hard of hearing. Dr. Folse then turned away from Mr. Yahn and began addressing his comments to Mrs. Sanders. When she objected to the procedure, she claimed that Dr. Folse turned to her father and told him that he needed to have the arteriogram and he said, "Okay." She also stated when she told her father that he should not submit to the procedure he also responded, "Okay." There was testimony to the effect that Mr. Yahn had a habit of saying "okay," regardless of what was said to him.
Further, Mrs. Sanders testified that she spoke with Dr. Folse in the hallway outside the room and told him she did not want her father to have the procedure. She stated that Dr. Folse told her everything would be all right and then walked away. Two orderlies were waiting outside the room to take Mr. Yahn to the radiology department.
Mrs. Gloria Perot, a family friend who was in Mr. Yahn's room while Dr. Folse was explaining the procedure, testified that, even though she has a high school education, she did not understand what Dr. Folse was saying. Mrs. Perot also testified that Mrs. Sanders was very upset at the prospect of Mr. Yahn undergoing this procedure. However, according to Mrs. Perot, Mrs. Sanders said that she would leave the decision up to her father.
The record shows that in attempting to make the required explanation, Dr. Folse was faced with an elderly impatient who was uneducated and extremely hard of hearing. Further, he was confronted with the patient's daughter, Mrs. Sanders, who became very emotional and voiced opposition to the procedure. In light of these factors, not only did Dr. Folse fail to obtain written consent, he was also unable to testify that he had a clear, unequivocal, oral informed consent to the procedure by the patient. All that Dr. Folse could point to at trial was his "impression" that he had Mr. Yahn's consent to the procedure when he left the patient's room. Further, there was no showing of any emergency in this case requiring that the arteriogram be performed immediately. Additional time could have been taken to ensure that Mr. Yahn heard and understood the risks associated with this procedure and gave informed consent. Under these circumstances, we find that the trial court was clearly wrong in finding that Mr. Yahn heard and understood the explanation given by Dr. Folse and that he gave his oral, informed consent to the procedure.
CAUSAL RELATIONSHIP
Even though there was no informed consent, the inquiry does not end. There must be a causal connection between the lack of informed consent and the treatment and damage. The plaintiffs argue that the trial court erred in finding that, under the circumstances of this case, a reasonable person would not have refused to undergo the procedure. This argument is meritless and requires that we affirm the trial court judgment.
If a material risk is not disclosed to the patient and consent is found to be deficient, in order to recover, there must also be a showing that a causal relationship exists between the doctor's failure to disclose the material information and the patient's damage. Broadway v. St. Paul Insurance Company, supra; Hondroulis v. Schuhmacher, supra. The plaintiff has the burden of proving that if the risk had been disclosed, the treatment and the unwanted consequences would have been avoided. If the patient would have undergone the treatment in spite of the risk, then the failure to inform cannot be said to be the cause of the unwanted consequences and the plaintiff cannot recover. Mustacchio v. Parker, supra; Broadway v. St. Paul Insurance Company, supra; Hidding v. Williams, supra; Mike v. Maxwell, 577 So.2d 1090 (La.App. 1st Cir.1991). Factors to consider in determining causation are the condition of the patient at the time of the decision, the necessity for treatment, the seriousness of the undisclosed consequences, the likelihood of the consequences occurring and the measures available for the correction of the consequences, should they occur. Mustacchio v. Parker, supra; LaCaze v. Collier, 434 So.2d 1039 (La.1983); Roussel v. Sharp, 569 So.2d 67 (La.App. 4th Cir.1990).
In this case, Mr. Yahn had two different medical problems that had been identified by preliminary tests. First, the abdominal aneurysm posed a very serious threat to the patient's life. Although Mr. Yahn was not experiencing any pain or discomfort from this condition, Dr. Massingill testified that it did pose a significant threat. Medical testimony in the record indicates that, if left untreated, aneurysms of this type will eventually rupture, resulting in death.
Second, testing showed that Mr. Yahn had some plaque formation in one carotid artery and had ulceration of plaque in the other artery. Although this condition was thought to be a possible cause of Mr. Yahn's fainting spells, there was no showing that this condition was as ligserious or as potentially life threatening as the aneurysm.
The record shows that Mr. Yahn needed to have the aneurysm further evaluated before a surgical repair could be attempted. To evaluate only the aneurysm, a translumbar puncture procedure could have been utilized which would not have involved the carotid arteries and would not have carried the risk of dislodging plaque from those arteries.
The finding of plaque in the carotid arteries, although suspected as a possible cause of the fainting spells, did not seem to pose as great a. threat to Mr. Yahn's life as the aneurysm. However, due to the finding of the plaque build up and ulcerated plaque in the arteries it was decided that the translum-bar procedure would not be utilized, but rather the type of arteriogram actually performed, which involved entry through a vein in the leg. This procedure would allow for study of both the aneurysm and the carotid arteries in a single procedure.
All the medical experts agreed that the risk of stroke was a serious risk associated with arteriograms. Dr. Michael Futrell testified that there was a one percent risk of stroke from this procedure, but in patients over the age of 70, the risk factor was two to four times higher.
Dr. Robert Golson testified that this procedure carried a .5% chance of stroke, but that due to Mr. Yahn's advanced age, his risk factor was five to ten times greater.
Dr. James V. Jones, Jr. testified that ar-teriograms carry a one in one hundred chance of stroke, but that Mr. Yahris risk factor was higher due to his age.
I uThere was no testimony to show what measures could have been undertaken to correct the stroke once it had occurred.
Although Dr. Futrell testified that it would have been reasonable for someone Mr. Yahn's age to refuse to have an arteriogram, he also testified that 90% to 95% of patients agree to undergo an arteriogram after the risks have been explained. Dr. Golson testified that, after being informed of the procedure and the risks involved, patients rarely refuse to undergo the procedure.
Dr. Futrell stated that in patients who are 81 or 82 years old, when the risk of complications or death from a procedure is ten to twenty percent, about twenty-five percent of people choose not to undergo the procedure. According to expert medical testimony in this case, Mr. Yahn's risk of a stroke from this procedure was four to five percent at most.
We also note that Dr. Futrell testified that during the course of his practice, he has performed 5,000 to 6,000 heart catheteriza-tions, a procedure similar to the arteriogram, and has performed 500 to 1,000 carotid arter-iograms. Only three of his patients have suffered mild strokes and none of his patients have died from the procedure.
Dr. Golson testified that he has performed 1,000 to 2,000 arteriograms with only one patient suffering a stroke and that occurred before the procedure began.
Mr. Yahn had an abdominal aortic aneurysm and, according to Dr. Futrell, almost all aortic aneurysms rupture if left untreated, usually resulting in death. Further, Mr. Yahn had ulceration of plaque in one carotid artery which may have been responsible for his fainting spells. This condition, if left untreated, also carried | isthe risk of causing a stroke. The medical experts agreed that, in this case, the arteriogram was an appropriate test and all testified that there was nothing inappropriate in the manner in which the test was performed.
Under these circumstances, where Mr. Yahn was faced with one medical condition that would almost surely cause death if left untreated and another medical condition that carried a serious threat to his health, a reasonable person would have consented to the arteriogram to further evaluate both conditions and allow the treating physicians to formulate an appropriate course of treatment. The trial judge so found, and we are unprepared to say that his finding in this regard is clearly wrong.
Therefore, we find that, even though there was a lack of informed consent to the procedure, a reasonable person, under these circumstances, would not have refused to undergo the arteriogram.
CONCLUSION
For the reasons stated above, although we find that Mr. John Yahn failed to give his informed consent to the arteriogram, we agree with the trial court's finding that, even in the absence of informed consent, a reasonable person under these circumstances would not have refused to undergo the procedure. Accordingly, the plaintiffs claim for damages is denied and the judgment of the trial court is affirmed. Costs in this court and the court below are assessed to the plaintiffs.
AFFIRMED.
BROWN, J., dissents with written reasons.