Opinion ID: 2334466
Heading Depth: 1
Heading Rank: 5

Heading: Official Immunity Analysis

Text: Dr. Howenstine meets the test for official immunity. She is an official and was acting in her discretionary capacity.
A public office is the right, authority and duty, created and conferred by law, by which ... an individual is invested with some portion of the sovereign functions of the government, to be exercised by him for the benefit of the public. The individual so invested is a public officer. State ex rel. Pickett v. Truman, 333 Mo. 1018, 64 S.W.2d 105, 106 (1933). Whether or not a public employee is a public officer is dependent upon the legal and factual circumstances involved. State ex rel. Eli Lilly & Co. v. Gaertner, 619 S.W.2d 761, 764 (Mo.App.1981). This immunity protects those individuals who, in the face of imperfect information and limited resources, must daily exercise their best judgment in conducting the public's business. Kanagawa v. State, 685 S.W.2d 831, 836 (Mo. banc 1985). Dr. Howenstine's position as medical director existed to discharge the city, county and state obligations to improve the health of the public. The health department was delegated this authority by law. Sec. 205.050; 19 C.S.R. 10-1.010(4). [8] Her particular office was created by agreement between the City of Columbia and the University of Missouri, in part, to maintain collaborative practice arrangements, adopt protocols and standing orders for the nurses to follow and provide consultation to nurses and patients at the clinic. The fact that Dr. Howenstine is an employee of the University of Missouri and that she serves as the medical director of the health department pursuant to an agreement between the City of Columbia and the university is not consequential to the determination. Dr. Howenstine was a public official for purposes of this lawsuit.
Whether a function is discretionary or ministerial is a case by case determination to be made after weighing such factors as the nature of the official's duties, the extent to which the acts involve policymaking or the exercise of professional expertise and judgment. Charron v. Thompson, 939 S.W.2d 885, 886 (Mo. banc 1996). The duties exercised by Dr. Howenstine as medical director of the health department are primarily discretionary. Mr. Muren, however, raises a number of arguments why Dr. Howenstine should not be allowed immunity on this basis. This opinion will address Mr. Muren's arguments in relation to the claims he raised in his petition.
The first group of Mr. Muren's claims involves a determination of whether Dr. Howenstine, as a treating physician, can be vicariously liable for the nurses' actions. Mr. Muren first alleges that Dr. Howenstine failed to properly train and supervise the nurses and nurse practitioners at the Health Department clinic to follow the established policies, procedures and protocols in providing health care to [him], including prescribing and dispensing the medication INH to [him] and monitoring his reaction to the medication[.] He also claims that she failed to conduct adequate history and physical examination on [him]; and failed to provided necessary medical direction, services, consultation and supervision of the nurses who provided services to [him.] Further, Mr. Muren claims that Dr. Howenstine failed to provide adequate patient education to [him] regarding risks, benefits, contraindications, adverse effects of the mediation INH ... and the need for monitoring. Essentially, Mr. Muren argues that Dr. Howenstine's acts were not discretionary because they arose from her acts as a treating physician. In Eli Lilly v. Gaertner, a group of doctors working at a state institution was sued in malpractice for prescribing a drug that harmed the defendant. 619 S.W.2d 761, 762-64 (Mo.App.1981). The court held that the doctors [were] being sued as treating physicians, not as titular heads of any department ... not ... for an erroneous decision requiring the exercise of governmental judgment and discretion but for an allegedly erroneous medical decision.... Id. at 765. Because Dr. Howenstine is not being sued for any neglect on her part in personally providing treatment, this exception does not strictly apply. Mr. Muren, however, continues the argument by asserting that the nurses who actually provided the negligent care and failed to warn could only operate under the umbrella of Dr. Howenstine's medical license. As such, they should be treated as an extension of Dr. Howenstine for which she can be held vicariously liable. The Nursing Practice Act of 1975 expanded the scope of nursing in Missouri. Sec. 335.016(10); Sermchief v. Gonzales, 660 S.W.2d 683, 689 (Mo. banc 1983). In Sermchief , this Court extensively discussed the 1975 changes in the nursing statute. [9] Id. It focused on the elimination of the requirement that a physician directly oversee nursing functions. Id. The nurses in that clinic took histories, made breast and pelvic examinations, dispensed designated medications and diagnosed the existence or nonexistence of contraindications to the use of contraceptives pursuant to written physician protocols and orders. Id. at 684-86. In Sermchief , this Court held: There can be no question that a nurse undertakes only a nursing diagnosis, as opposed to a medical diagnosis, when she or he finds or fails to find symptoms described by physicians in standing orders and protocols for the purpose of administering courses of treatment prescribed by the physician in such orders and protocols. Id. at 689-90. That is exactly how the clinic provides tuberculosis treatment at the clinic in this case. The population-based services here were provided by nurses pursuant to written protocols and collaborative practice arrangements authorized by the state. Sec. 205.050; Sermchief, 660 S.W.2d at 689; 19 C.S.R. 10-1.010(4). The treatment provided by the nurses to Mr. Muren was under independent statutory authority, not under Dr. Howenstine's medical license. Sec. 205.050; Sermchief, 660 S.W.2d at 689; 19 C.S.R. 10-1.010(4). The exception discussed in Eli Lilly does not apply. 619 S.W.2d at 765.
The next group of claims assert that Dr. Howenstine had a duty to ensure the competency of the nurses at the clinic. Mr. Muren claims that Dr. Howenstine failed to ensure that the delegated responsibilities set forth in a collaborative practice arrangement with [the] nurse practitioners ... were consistent with the level of skill, education, training and competence of [the] nurse practitioners and nurses[.] Mr. Muren also asserts that Dr. Howenstine failed to ensure that nurses and nurse practitioners followed guidelines for consulting her or another physician and referring plaintiff Paul Muren to her or another physician for personal medical evaluation[.] He essentially claims that Dr. Howenstine had an additional duty to ensure the competence of the nurses at the clinic. He cites 4 C.S.R. 200-4.200(3)(A), (B), and (I) as the source of this duty. [10] 4 C.S.R. 200-4.200 has five subsections and sets out many of the general rules governing collaborative practice arrangements in Missouri. Section 1 sets out definitions, section 2 provides geographic rules, section 3 gives rules for treatment methods, section 4 gives physician oversight rules and section 5 is entitled Population-Based Public Health Services. Section 5 specifically exempts tuberculosis treatment as a population-based service from all of the rules provided in sections 2, 3, and 4. [11] Dr. Howenstine had no duty to ensure the competency of the nurses in this clinic based on this regulation as those sections, and specifically section 3, do not apply to population-based services. To the extent that Dr. Howenstine had a duty beyond the regulation, it would have been discretionary in nature and subject to immunity.
The final group of claims deals with Dr. Howenstine's oversight of the population-based services provided at the clinic. Mr. Muren alleges that Dr. Howenstine failed to properly and regularly review the work, records and practice of patient assessment, health care, treatment and medications delivered to [him] by nurses and the nurse practitioner pursuant to a collaborative practice agreement[.] He also asserts that Dr. Howenstine failed to be present and to participate in a review of [his] medical condition and the health care provided to him at the Health Department clinic[.] The oversight requirements of population-based services like tuberculosis are detailed in 4 C.S.R. 200-4.200(5). It states: [In] public health clinics that provide population-based health services limited to ... tuberculosis control ... the geographic areas, methods of treatment and review of services shall occur as set forth in the collaborative practice arrangement. Id. at (5)(A). Dr. Howenstine maintains many collaborative practice arrangements at the clinic. Although she maintains collaborative practice arrangements regarding primary care, which may contain duties particular to that practice, the arrangement governing population-based services is very specific to tuberculosis treatment and is silent concerning oversight of those services. [12] Collaborative Practice Arrangement, Policies and Protocols 2001, Columbia/Boone County Health Department Manual 3. The arrangement leaves supervision of the tuberculosis services subject to Dr. Howenstine's discretion. There was no specific duty created in the population-based services collaborative arrangement for Dr. Howenstine to oversee the population-based services provided at the clinic. Dr. Howenstine is immune as an official from all of the claims discussed previously. Her involvement at the clinic was to exercise her discretion in acting on behalf of the government in best discharging its duty to deliver population-based services according to her professional judgment.