Opinion ID: 2600299
Heading Depth: 1
Heading Rank: 3

Heading: Informed Consent Claims

Text: ¶ 11 Under the doctrine of informed consent, a health care provider has a fiduciary duty to disclose relevant facts about the patient's condition and the proposed course of treatment so that the patient may exercise the right to make an informed health care decision. Miller v. Kennedy, 11 Wash.App. 272, 282, 522 P.2d 852 (1974), aff'd, 85 Wash.2d 151, 530 P.2d 334 (1975). A health care provider may be liable to an injured patient for breaching this duty even if the treatment otherwise meets the standard of care. RCW 7.70.050; Keogan v. Holy Family Hosp., 95 Wash.2d 306, 313, 622 P.2d 1246 (1980). The doctrine of informed consent is based on the individual's right to ultimately control what happens to his body. Id. at 313-14, 622 P.2d 1246. This court first recognized the doctrine in ZeBarth v. Swedish Hospital Medical Center, 81 Wash.2d 12, 499 P.2d 1 (1972). The legislature subsequently codified the prima facie elements of an informed consent claim in RCW 7.70.050. LAWS OF 1975-76, 2d Ex.Sess., ch. 56, § 10; Edwin Rauzi, Informed Consent in Washington: Expanded Scope of Material Facts That the Physician Must Disclose to His Patient, 55 WASH. L.REV. 655 (1980). ¶ 12 There are certain exceptions to the duty of disclosure. It is generally recognized that in emergency situations where immediate action is necessary for the protection of life, consent will be implied when it is impractical to obtain actual consent from a patient or the patient's authorized representative. See generally W.E. Shipley, Annotation, Liability of Physician or Surgeon for Extending Operation or Treatment Beyond That Expressly Authorized, 56 A.L.R.2d 695 (1957) (surveying cases). The emergency exception has deep roots in the common law. See Schloendorff v. Soc'y of N.Y. Hosp., 211 N.Y. 125, 129-30, 105 N.E. 92, 93 (1914) (Every human being of adult years and sound mind has a right to determine what shall be done with his own body . . . except in cases of emergency where the patient is unconscious and where it is necessary to operate before consent can be obtained) (emphasis added) (citation omitted), overruled, in part, on other grounds by Bing v. Thunig, 2 N.Y.2d 656, 163 N.Y.S.2d 3, 143 N.E.2d 3 (1957); RESTATEMENT (SECOND) OF TORTS § 892D (1979) (a person is privileged to act without consent in order to prevent harm to another when an emergency makes it infeasible to obtain consent). It is based on the impracticality of having an adequate, informed consent discussion in the midst of a medical emergency, and the importance of allowing a physician to maintain focus on providing lifesaving treatment to the patient. See Canterbury v. Spence, 150 U.S.App. D.C. 263, 464 F.2d 772, 788-89 (1972). The presumption underlying the emergency exception is that the harm from a failure to treat outweighs any harm threatened by the proposed treatment. Id. at 789. ¶ 13 The emergency exception is codified in RCW 7.70.050(4): If a recognized health care emergency exists and the patient is not legally competent to give an informed consent and/or a person legally authorized to consent on behalf of the patient is not readily available, his consent to required treatment will be implied. ¶ 14 The plaintiffs here contend that dismissal of their informed consent claims on summary judgment was improper because there are material issues of fact as to whether a recognized health care emergency existed after 10 minutes of asystole and whether Liam's father was readily available to consent on Liam's behalf. ¶ 15 The existence of a medical emergency is ordinarily a factual question for the jury. Shine v. Vega, 429 Mass. 456, 709 N.E.2d 58, 65 (1999). Where reasonable minds could not differ on the issue, however, a court may determine that a medical emergency exists as a matter of law. See Keogan, 95 Wash.2d 306, 622 P.2d 1246. In Keogan, this court held that a medical emergency existed, as a matter of law, when a patient arrived by ambulance to the hospital emergency room with severe, crippling chest pain and shortness of breath. Id. at 309, 622 P.2d 1246. Tragically, the physician treated him for an anxiety attack, not recognizing that he was suffering a heart attack, and the patient died. After noting that, It is generally agreed that the doctrine of informed consent does not apply in emergency situations requiring immediate action, this court held in Keogan, id. at 316, 622 P.2d 1246, that the physician had no duty to disclose alternative diagnostic procedures before providing immediate emergency treatment to the patient: Keogan's intense pain, the need for immediate diagnosis of his condition, and the fact that his condition actually was such that it could lead to irremediable disability and quick death-created a medical emergency in which the emergency room physician could not be held to the physician's duty to disclose that is applicable to nonemergency medical care. Id. at 316-17, 622 P.2d 1246. ¶ 16 Accordingly, this court affirmed the trial court's dismissal of an informed consent claim brought on behalf of the decedent's estate. Id. at 317, 622 P.2d 1246. ¶ 17 The plaintiffs argue that Keogan is distinguishable and its holding does not apply under the circumstances presented here. They first suggest that Keogan is inapplicable because it was decided under the common law duty of informed consent, not RCW 7.70.050. In adopting RCW 7.70.050, the legislature codified the common law doctrine of informed consent as set forth in Miller, 11 Wash.App. 272, 522 P.2d 852. See Final B. Rep. on Substitute H.B. 1470, 44th Leg, 1st Ex.Sess., at 23 (Wash.1976) (explaining that the bill incorporates the standard enunciated in Miller and otherwise reflects existing law with respect to the doctrine of informed consent.). We find no indication that the legislature intended to abrogate the traditionally recognized exceptions to the duty to disclose. These exceptions are stated in Holt v. Nelson, 11 Wash.App. 230, 240-41, 523 P.2d 211 (1974), and this court acknowledged their continued viability following the enactment of RCW 7.70.050. Smith v. Shannon, 100 Wash.2d 26, 30, 666 P.2d 351 (1983). In particular, as under the common law, the statutory emergency exception, RCW 7.70.050(4), requires proof of the existence of a medical emergency. Thus, Keogan's holding has continuing application. ¶ 18 The plaintiffs also argue that Keogan is factually distinguishable because the evidence in that case established that the patient `was interested only in surcease of his pain through any means available . . . and that he would have agreed to any care relieving such pain.' Br. of Appellants at 17 (quoting Keogan, 95 Wash.2d at 316, 622 P.2d 1246). In contrast, the evidence here suggests that Liam's parents would not have consented to the continuation of resuscitation efforts if they had been informed of the likelihood that he would be severely disabled, if revived. Application of the emergency exception, however, does not turn on whether the patient would have consented, if fully informed. Under the emergency exception, consent is implied by law in view of the existence of a recognized health care emergency and the impracticality of obtaining informed consent in such circumstances. Proof that a patient would have consented if properly informed is a traditionally recognized defense to an informed consent claim that is distinct from the emergency exception. See Holt, 11 Wash.App. at 241, 523 P.2d 211. Keogan's apparent willingness to consent to any treatment that might alleviate his severe pain is relevant to the emergency exception only insofar as it demonstrates the impracticality of obtaining informed consent when a patient is incapable of making a reasoned decision due to incapacitating pain. In this case, the impracticality of obtaining informed consent is demonstrated by other compelling facts. To an even greater extent than in Keogan, the exigencies of the situation here required immediate treatment because the failure to treat meant certain and immediate death. ¶ 19 The plaintiffs do not dispute that a recognized health care emergency existed immediately following Liam's birth. Nor do they dispute that Liam would have died if Dr. Vaughn had paused or delayed the resuscitation at any point. Rather, relying on Dr. Bodenstein's declaration, they contend that the emergency ceased when resuscitation efforts were unsuccessful after 10 minutes and it was no longer reasonably possible for Liam to survive without severe disabilities. However, to suggest that a medical emergency ceases to exist once it becomes apparent to a physician that a patient will inevitably suffer severe disabilities is untenable. No reasonable person could deny that a recognized health care emergency existed throughout the period of Liam's resuscitation. In terms of gravity and urgency, it is hard to imagine a situation of greater urgency than exists when a nearly full-term newborn with no recognized prenatal disorders requires neonatal resuscitation. Accordingly, we hold that a recognized health care emergency existed in this case, as a matter of law, until the resuscitation ended. ¶ 20 Turning next to whether a legally authorized representative is readily available to consent, this, too is generally a factual question that must be determined by the jury unless reasonable minds could not differ. Undisputedly, a parent may consent on behalf of a minor patient under RCW 7.70.065(2)(a)(iii), and there is no doubt that Liam's father was his legally authorized representative for purposes of giving informed consent. However, we hold that under the circumstances presented here, as a matter of law, Liam's father was not readily available within the meaning of the statute. ¶ 21 Readily available means more than mere physical proximity  there must be sufficient time and opportunity for discussion and deliberation. In Miller v. HCA, Inc., 118 S.W.3d 758 (Tex.2003), the Texas Supreme Court confronted facts similar to those presented here, involving an infant delivered by emergency caesarean section at 23-weeks' gestation that received life-saving resuscitation contrary to the parents' wishes. The infant survived but later suffered a brain hemorrhage, a common complication of premature birth, which resulted in severe and permanent disabilities. In rejecting the parents' informed consent claim, the court in Miller, id. at 769, concluded that even though the parents were present in the delivery room, there was simply no time to obtain their consent to treatment . . . without jeopardizing [the infant's] life because the infant might survive with treatment but would likely die if treatment were postponed. See also Montalvo v. Borkovec, 256 Wis.2d 472, 647 N.W.2d 413, 420 (2002) (holding that the informed consent doctrine does not apply in the context of emergency treatment provided to a neonate following a caesarean procedure because the failure to treat would be tantamount to a death sentence). In this case, as well, there was no time for discussion and deliberation to consider alternatives to treatment, assuming viable alternatives even existed. ¶ 22 The decision to refuse life-saving treatment is the most momentous health care decision that an individual can make. The choice between life and death is a deeply personal decision of obvious and overwhelming finality. Cruzan v. Mo. Dep't of Health, 497 U.S. 261, 281, 110 S.Ct. 2841, 111 L.Ed.2d 224 (1990). The decision is made more complex when it has been entrusted to a surrogate decision-maker. See id. at 287 n. 12, 110 S.Ct. 2841 (The differences between the choice made by a competent person to refuse medical treatment, and the choice made for an incompetent person by someone else to refuse medical treatment, are so obviously different that the State is warranted in establishing rigorous procedures for the latter class of cases which do not apply to the former class.); Norman L. Cantor, The Bane of Surrogate Decision-Making: Defining the Best Interests of Never-Competent Persons, 26 J. LEGAL MED. 155, 162-63 (2005) (identifying several factors that counsel caution in allowing surrogate decision-makers to make end-of-life decisions on behalf of never-competent persons); Rebecca S. Dresser & John A. Robertson, Quality of Life and Non-Treatment Decisions for Incompetent Patients: A Critique of the Orthodox Approach, 17 J.L. MED. & HEALTH CARE 234, 241-42 (1989) (discussing the inherent difficulty of a fully-capacitated surrogate to consider the point of view of a profoundly disabled person). We need not decide, here, whether a parent may decide to refuse life-saving treatment on behalf of a child and, if so, under what circumstances. For purposes of this analysis, we need only recognize that such a decision cannot be truly informed in the context of neonatal resuscitation when the circumstances permit no more than a hasty explanation of probable outcomes by a physician whose attention must primarily focus on life-saving efforts. ¶ 23 We hold that Liam's father was not readily available, as a matter of law, because there was no meaningful opportunity for a deliberate, informed decision to refuse consent where the failure to treat meant certain and immediate death.