Title: Patricia Liguori v. Elie M. Elmann, M.D., et al.
Citation: N/A
Docket Number: a-52-06
State: new-jersey
Issuer: new-jersey Supreme Court
Date: June 25, 2007

(This syllabus is not part of the opinion of the Court. It has been prepared by the Office of the Clerk for the convenience of the reader. It has been neither reviewed nor approved by the Supreme Court. Please note that, in the interests of brevity, portions of any opinion may not have been summarized). On December 9, 1999, Dr. Elie Elmann, a cardiovascular and thoracic surgeon, performed quadruple coronary artery bypass surgery on Mrs. Geraldine Liguori at Hackensack University Medical Center (HUMC). He was assisted during the surgery by Dr. James Hunter, who at the time was a cardiac surgery assistant/fellow. Following the surgery, Mrs. Liguori was sent to the cardiac intensive care unit (ICU). At approximately 2:30 p.m., a nurse informed Elmann that a chest x-ray revealed that Mrs. Liguori had developed a pneumothorax, a condition commonly referred to as a collapsed lung. Because Elmann was then in the middle of operating on another patient, he directed Hunter to assess Mrs. Liguori s status and, if necessary, to insert a chest tube to alleviate the condition. Elmann testified that he warned Hunter to be careful because Mrs. Liguori had an enlarged heart. After assessing Mrs. Liguori s situation, Hunter determined that it would be necessary to insert a chest tube to relieve the air pressure in the chest cavity. Hunter testified that he knew Mrs. Liguori s heart was enlarged and that he took precautions to avoid injuring it. Hunter made a small incision and used a clamp to create a hole between the ribs so he could insert the tube. He described the whole procedure as pretty uneventful. Hunter was totally satisfied that the tube was functioning [and] that the problem was relieved. There was no evidence of bleeding and the blood pressure was stable. A few minutes after Hunter had returned to the operating room, a nurse contacted Elmann who was still performing surgery on the other patient. That nurse told him that Mrs. Liguori was experiencing substantial bleeding. Elmann sent Dr. Peter Praeger to assess Mrs. Liguori s condition. Upon performing exploratory surgery, Dr. Praeger discovered a hole in the left ventricle of her heart, which he repaired. He noted that the hole was related to the insertion of the chest tube and advised Elmann of Mrs. Liguori s status. Patricia Liguori, Mrs. Liguori s daughter, was in the cardiac waiting room throughout the time of the surgery and the chest tube insertion. Her brother, John J. Liguori, was present for part of the bypass operation. According to Hunter, he would have spoken to Mrs. Liguori s family if he had known they were at the hospital and if there had been time. Elmann and experts who appeared for both plaintiffs and defendants all testified that a collapsed lung that occurs right after surgery constitutes a medical emergency. Elmann spoke to Patricia and John at approximately 6:30 p.m., though the parties recollection of the substance of that conversation is sharply in dispute. Significantly, according to Patricia and John, Elmann did not tell them about the collapsed lung, did not reveal that Hunter had inserted the chest tube and failed to mention that the chest tube had caused the injury to Mrs. Liguori s heart. Elmann, however, testified that he informed Patricia and John completely about the chest tube and its complications. On January 17, 2000, Dr. Leonardo DiVagno, a cardiologist who was assisting Elmann with Mrs. Liguori s care, told Patricia that Mrs. Liguori had sustained a significant amount of bleeding following the laceration to her heart during the insertion of the chest tube. According to Patricia, she was shocked, immediately called her brother, and they transferred their mother to a hospital in North Carolina, where John lived. However, Mrs. Liguori suffered from a series of cascading complications, resulting in her death from septic shock on February 12, 2000. In December 2001, John and Patricia Liguori filed a wrongful death complaint against, among others, Drs. Elmann and Hunter, asserting a variety of theories of recovery including medical malpractice, lack of informed consent, battery and fraudulent misrepresentation. The jury returned a verdict in favor of defendants. Plaintiffs raised thirteen issues on appeal to the Appellate Division. In an unpublished decision, the Appellate Division rejected all thirteen arguments and affirmed the jury verdict. One of the Appellate Division judges filed a dissent, which was limited to a single issue. He asserted that the trial judge erred in the jury charge relating to the appropriate standard of care applicable to Hunter in two respects. First, he reasoned that Hunter should have been held to the standard of care applicable to a specialist rather than the one appropriate for a general practitioner. Second, he suggested that, in circumstances where there is doubt about a physician s level of expertise for purposes of the standard of care, the issue should be decided separately by the jury. Because of the dissent, the question concerning the applicable standard of care is before the Supreme Court as an appeal of right. R. 2:2-1(a)(2). In addition, the Court granted plaintiffs petition for certification of four other questions relating to informed consent, fraudulent misrepresentation, and discovery of experts. HELD: The trial judge s instruction to the jury on the appropriate standard of care applicable to Dr. Hunter, though not entirely in keeping with the Model Jury Charge, nonetheless did not result in error; the Court is satisfied that the jury concluded that Hunter s actions were reasonable in light of all of the facts relating to the emergency he confronted; the Court finds no error in the trial court s dismissal of the fraud claim or in the Appellate Division s analysis of plaintiffs argument on appeal; and, because the change in the expert s opinion, although significant, was one which brought his opinion into alignment with plaintiffs expert, the Court does not perceive, in these circumstances, any prejudice to plaintiffs. 1. Our Model Jury Charge on medical negligence and standard of care, in relevant part, charges the jury that [n]egligence is conduct which deviates from a standard of care and that [t]he determination of whether a defendant was negligent requires a comparison of the defendant s conduct against a standard of care. The trial court had the option of instructing the jury on the standard of care for specialists or the standard of care for general practitioners. Each of these options advises the jury that defendant is to be judged, in essence, against others of like skill, training and knowledge. The trial judge opted for a hybrid charge, using general practitioner language, but also referring to Hunter s job title, assistant cardiac surgeon or assistant cardiac thoracic fellow. The appellate division majority concluded that the general practitioner standard was appropriate because Hunter was not a surgeon and did not hold himself out as a surgeon. More significantly, however, to the majority was the undisputed trial testimony, which made plain that chest tube insertion is not a procedure reserved for specialists. Even if the Supreme Court was to agree with the dissenting judge that Hunter should have been held to a standard of care other than that of a general practitioner, the Court would conclude that there was no reversible error here. The trial judge s effort to span what he perceived to be a gap in the Model Charge by referring to Hunter s job title, while not entirely in keeping with the Model Charge, nonetheless did not result in error. (Pp. 19-26) 2. Plaintiffs contend that the trial court erred in dismissing their informed consent and battery claims, to the extent that those claims were based on Hunter s insertion of the chest tube without first seeking their permission. They suggest that the Court adopt a rule of law that would require physicians to secure consent, even in the context of a medical emergency, unless it is truly impossible and urge the Court to conclude that the record here does not support dismissal of their claim under that theory. In 1989, our Legislature enacted a statutory patient bill of rights providing protections for hospital patients. That statute is consistent with our case law that recognizes the existence of an exception to the informed consent doctrine for medical emergencies. Although some emergencies might well present physicians with sufficient time to seek consent, the Court declines to adopt plaintiffs rigid formulation of the circumstances in which their failure to do so would be permissible. The Court is satisfied that the jury concluded that Hunter s actions were reasonable in light of all of the facts relating to the emergency he confronted. (Pp. 26-29) 3. Plaintiffs also urge the Court to recognize a separate cause of action against Elmann sounding in fraud and arising from what plaintiffs characterize as his post-surgical misrepresentations. A patient generally has three avenues for relief against a physician, namely, (1) deviation from the standard of care . . . ; (2) lack of informed consent; and (3) battery. Howard v. Univ. of Med. &amp; Dentistry of N.J., 172 N.J. 537 (2002). In Howard, the Court declined to create a novel fraud or deceit-based cause of action arising from a doctor s pre-treatment misrepresentation about his professional qualifications. The Court, however, did not address the potential for a post-surgical fraud claim, but cited a New York decision addressing the circumstances in which a fraud claim might arise and rejecting the creation of a new fraud based claim in a medical malpractice case. The Court sees nothing in this record that suggests that it should now deviate from Howard. The claims raised against both Elmann and Hunter are based on asserted lack of informed consent and deviations from the applicable standard of care. The harms suffered by Mrs. Liguori cannot be separated from the insertion of the chest tube, regardless of what Elmann did or did not say about those events. Therefore, the Court finds no error in the trial court s dismissal of the fraud claim or in the Appellate Division s analysis of plaintiffs argument on appeal. (Pp. 29-31) 4. Plaintiffs also contend that the trial court erred in converting their fraud claim into a separate claim based on a lack of informed consent, and that the Appellate Division erred in failing to reverse that decision. As the Appellate Division correctly concluded, plaintiffs claim against Elmann relating to what he did or did not say after the insertion of the chest tube and the surgical repair is in reality an argument that they were not given sufficient information on which they could decide whether or not to permit defendants to proceed to care for Mrs. Liguori. Seen in that light, the claim is indeed one arising out of an asserted lack of informed consent. The trial court properly converted plaintiffs fraud claim into a lack of informed consent claim. (Pp. 31-32) 5. Finally, the Court addresses plaintiffs assertions that they were deprived of a fair trial because they were not alerted in advance of trial to a change in the causation opinion that would be offered by defendants expert, Dr. Richard Kline. Approximately two weeks prior to trial, Dr. Kline advised counsel for defendants that he believed that the injury was caused by the clamp, whereas earlier he had opined that the injury could have been caused directly by the insertion of the clamp or by a sudden shift of the heart in the chest cavity, causing the heart to strike the clamp. In effect, this change in his testimony brought his view about causation directly into alignment with the views of plaintiffs expert. The Court does not retreat from the views it has previously expressed about the significance of a failure to abide by the requirements of the discovery rules. However, because the change in the expert s opinion, although significant, was one which brought his opinion into alignment with plaintiffs expert, the Court does not perceive, in these circumstances, any prejudice to plaintiffs. (Pp. 32-35) The judgment of the Appellate Division is AFFIRMED. CHIEF JUSTICE ZAZZALI and JUSTICES LONG, LaVECCHIA, ALBIN, WALLACE, and RIVERA-SOTO join in JUSTICE HOEN s opinion. SUPREME COURT OF NEW JERSEY A- 52 September Term 2006 PATRICIA LIGUORI, INDIVIDUALLY and as EXECUTRIX OF THE ESTATE OF GERALDINE LIGUORI, and as EXECUTRIX OF THE ESTATE OF JOHN J. LIGUORI, and JOHN C. LIGUORI, Plaintiffs-Appellants, v. ELIE M. ELMANN, M.D., JAMES B. HUNTER, M.D. and CARDIAC SURGERY GROUP, P.A., Defendants-Respondents, and PETER PRAEGER, M.D., DIANE ANDERSON, R.N., LYNNANN ANDERSON, R.N., NILO ANTONIO, R.N., SHARON BREADY, R.N., ELLY CALLIAS, R.N., TOM CAREN, R.N., JESSICA CONNERS, R.N., LUCY COVINO, R.N., TERRY DAVOREN, R.N., BETH DRONEY, R.N., KATHY ENRIGHT, R.N., ERIN GIARRUSSO, R.N., LAURA HYNES, R.N., JENNIFER KRAWAIK, R.N., ISELA LAZICKI, R.N., MELANIE LENDIS, R.N., ANNE LOBASSO, R.N., PATRICIA LOPEZ, R.N., LUZ MALIT, R.N., RACHEL MARCHIONY, R.N., BARBARA MARTIN, R.N., CESAR MARTOS, R.N., KELLIE MCGUIRE, R.N., CILA MERRIAM, R.N., WENDY MITCHELL, R.N., PATRICE O CONNOR, R.N., SUE PATLOCK, R.N., KATHY PAWLOSKI, R.N., JEANNE POLLEY, R.N., PATRICE PULFORIO, R.N., ALICIA QUINN, R.N., ANNIE READIE, R.N., SHEILA RHODES, R.N., DIANE RICHARD, R.N., DEBBIE RODITSKI, R.N., KEVIN ROONEY, R.N., PRATIVA SAHU, R.N., SHEILA SCOLLO, R.N., DONNA SENNA, R.N., GLADYS SILLERO, R.N., JOHN STANTON, R.N., BECKY THUM, R.N., DAWN TRUSIO, R.N., SUE TUDDA, R.N., MARIA VILLALONGO, R.N., TES WELCH, R.N., ALISON WRIGHT, R.N., JANET H. KILROY, R.N., GAIL VANDERHOVEN, R.N., HEATHER CASSIDY, R.N., LUCY XXX, R.N. (Last Name Fictitious), STEPHANIE ZZZ, R.N. (Last Name Fictitious), ELLEN ZOE, R.N., PATRICE MOE, R.N., ROE BOES 1-10, HACKENSACK UNIVERSITY MEDICAL CENTER, JOHN DOES 1-100 and ABC CORPORATIONS 1-20, Defendants. Argued March 5, 2007 Decided June 25, 2007 On appeal from and certification to the Superior Court, Appellate Division. Adam M. Slater argued the cause for appellants (Mazie Slater Katz &amp; Freeman, attorneys; Mr. Slater and Bruce H. Nagel, on the briefs). Scott T. Heller argued the cause for respondents Elie M. Elmann, M.D. and Cardiac Surgery Group, P.A. (Giblin &amp; Combs, attorneys; Mr. Heller and Eric B. Bailey, on the briefs). Judith A. Wahrenberger argued the cause for respondent James B. Hunter, M.D. (Wahrenberger, Pietro &amp; Sherman, attorneys). Dennis J. Alessi submitted a brief on behalf of amicus curiae, Medical Society of New Jersey (Mandelbaum Salburg Gold Lazris &amp; Discenza, attorneys). JUSTICE HOENS delivered the opinion of the Court. This appeal calls upon us to consider several issues that are significant to our medical malpractice jurisprudence. First, we consider the dividing line between specialists and general practitioners for purposes of determining the applicable standard of care. Second, we consider the extent to which medical emergencies fall outside the doctrine of informed consent. Third, we consider whether post-surgical communications from a physician to the members of a patient s family may give rise to a fraud-based cause of action or, in the alternative, to a claim based on lack of informed consent. Finally, we consider whether a discovery violation that inures to plaintiffs benefit nonetheless entitles plaintiffs to a new trial. Other responsibilities include taking in-house call, which means you re in the hospital, you sleep in the hospital, you eat in the hospital; fielding calls regarding the questions that the nurses may have about the patients; also performing any procedures that are required either on an emergent or non-emergent or elective basis, if you will. It involves the preoperative workup of the patients, including histories, physical examinations, consenting patients for surgery; any procedures related to any of the previous-mentioned operations such as chest tube placement, arterial line placement, central line placement, and also to be involved in the postoperative management of the patients. In this case, Dr. Hunter has been described in his profession alternatingly as an assistant cardiac - assistant cardiac thoracic fellow or assistant cardiac surgeon. Therefore, you must decide this case - to decide this case properly, you must know the standard of care imposed by law against which Dr. Hunter s conduct as assistant cardiac surgeon or assistant cardiac thoracic surgeon fellow should be measured. Dr. Hunter, in this case, is a general practitioner. A person who is engaged in the general practice of medicine represents that he will have and employ knowledge and skill normally possessed and used by the average physician practicing his profession as a general practitioner. Given what I have just said, it is important for you to know that the standard of care which a general practitioner as an assistant cardiac surgeon or an assistant cardiac thoracic surgeon fellow is required to observe in his treatment of a patient under the circumstances of this case. Based upon common knowledge alone and without technical training, jurors normally cannot know what conduct constitutes standard of medical practice. Therefore, the standard of practice by which a physician s conduct is to be judged must be furnished by expert testimony. That is to say, by the testimony of persons who by knowledge, training and experience are deemed qualified to testify and to express their opinions on medical subjects. You, as jurors, should not speculate or guess about the standards of care by which the defendant physician, Dr. Hunter, should have conducted himself in the diagnosis and treatment of the deceased plaintiff, Mrs. Liguori. Rather, you must determine the applicable medical standard from the testimony of the expert witnesses that you have heard in this case. You as jurors should not speculate or guess about the standards of care by which the defendant physician(s) should have conducted himself/herself/themselves in the diagnosis and treatment of the plaintiff. Rather, you must determine the applicable medical standard from the testimony of the expert witness(es) you have heard in this case. [Ibid.] SUPREME COURT OF NEW JERSEY NO. A-52 SEPTEMBER TERM 2006 ON APPEAL FROM Appellate Division, Superior Court PATRICIA LIGUORI, INDIVIDUALLY and as EXECUTRIX OF THE ESTATE OF GERALDINE LIGUORI, and as EXECUTRIX OF THE ESTATE OF JOHN J. LIGUORI, and JOHN C. LIGUORI, Plaintiffs-Appellants, v. ELIE M. ELMANN, M.D., JAMES B. HUNTER, M.D. and CARDIAC SURGERY GROUP, P.A., Defendants-Respondents. DECIDED June 25, 2007 Chief Justice Zazzali PRESIDING OPINION BY Justice Hoens CONCURRING OPINION BY DISSENTING OPINION BY