Opinion ID: 2851006
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Heading Rank: 1

Heading: 2d 647 (Pa. Super. 1980),] adopted the theory of

Text: ostensible agency, when it held that the trial court erred in failing to instruct the jury that it could find the hospital vicariously liable for negligence of a physician, despite the fact the physician was an independent contractor. See also Simmons v. St. Clair [Memorial] Hospital, [481 A.2d 870 (Pa. Super. 1984)]. Thompson, 591 A.2d at 707. We also went on to recognize that a hospital could be held liable under the doctrine of corporate negligence, if the hospital fails to uphold the proper standard of care owed to a patient. Id. at 707. The ostensible agency theory adopted in Capan, supra, is based on Section 429 of the Restatement (Second) of Torts, which provides: One who employs an independent contractor to perform services for another which are accepted in the reasonable belief that the services are being rendered by the employer or by his servants, is subject to liability for physical harm caused by the negligence of the contractor in supplying such services, to the same extent as though the employer were supplying them himself or by his servants. Restatement (Second) of Torts § 429. Under the theory of ostensible agency, a hospital could be held liable for the negligence of an independent contractor physician where (1) the patient looked to the institution, rather than the individual physician, for care, or (2) the hospital “held out” the physician as its employee. Capan, 430 A.2d at 650; Simmons, 481 A.2d at 875. [J-6-2015] - 9 In 2002, the Pennsylvania legislature enacted the MCARE Act, codifying the vicarious liability of hospitals under the doctrine of ostensible agency: (a) Vicarious liability.−A hospital may be held vicariously liable for the acts of another health care provider through principles of ostensible agency only if the evidence shows that: (1) a reasonably prudent person in the patient’s position would be justified in the belief that the care in question was being rendered by the hospital or its agents; or (2) the care in question was advertised or otherwise represented to the patient as care being rendered by the hospital or its agents. (b) Staff privileges.−Evidence that a physician holds staff privileges at a hospital shall be insufficient to establish vicarious liability through principles of ostensible agency unless the claimant meets the requirements of subsection (a)(1) or (2). 40 P.S. § 1303.516. As noted above, in the instant case, the trial court granted a compulsory nonsuit based on its finding that Appellant failed to establish that Dr. Malaisrie was the ostensible agent of the Hospital because he did not demonstrate under Section 1303.516(a)(1) that a reasonably prudent person in Decedent’s position would have been justified in the belief that the care in question was rendered by the Hospital or its agents.5 A trial court may enter a compulsory nonsuit on any and all causes of action: if, at the close of the plaintiff’s case against all defendants on liability, the court finds that the plaintiff has failed to establish a right to relief. Absent such finding, the trial court shall deny the application for a nonsuit. On appeal, entry of a 5 The parties do not dispute that subsection (a)(1) of Section 1303.516 is the only subsection at issue in the case. [J-6-2015] - 10 compulsory nonsuit is affirmed only if no liability exists based on the relevant facts and circumstances, with appellant receiving “the benefit of every reasonable inference and resolving all evidentiary conflicts in [appellant’s] favor.” The compulsory nonsuit is otherwise properly removed and the matter remanded for a new trial. Scampone, 57 A.3d at 595-96 (citing, inter alia, Pa.R.C.P. No. 230.1). On appeal, Appellant maintains that the question of what a reasonably prudent person in Decedent’s position would have been justified in believing is best determined by a jury. Further, relying on Capan and Simmons, wherein the Superior Court determined that the evidence presented was sufficient to raise a jury question as to whether the doctors were ostensible agents of the respective hospitals, Appellant offers the following facts as evidence which would support a jury finding that a reasonably prudent person in Decedent’s position would have been justified in believing that Dr. Malaisrie’s care was being rendered by the hospital or its agents: (1) Dr. Malaisrie first became involved in treating Decedent as part of an emergency response team at the hospital; (2) Dr. Malaisrie had no prior doctor/patient relationship with Decedent; and (3) Dr. Malaisrie rendered emergency treatment to Decedent at the request of the hospital, and not at the request of Decedent or Decedent’s family. Appellant’s Brief at 18-19. The Hospital responds that the “facts” now offered by Appellant are “new” in that they were not established at trial, Appellees’ Brief at 17-18, and, to the extent Appellant relies on statements made during Appellant’s counsel’s opening statement, the Hospital avers that statements by counsel are not evidence. According to the Hospital, the totality of evidence established at trial relevant to the issue of whether Dr. Malaisrie was an ostensible agent of the Hospital was: (1) after Nurse Yakish observed increased bleeding from Decedent’s tracheotomy site, “she paged anesthesia”; (2) “ENT was also contacted”; (3) Dr. Glasser, the anesthesiologist, arrived first; (4) Dr. Malaisrie, the ENT physician, arrived approximately ten minutes after Dr. Glasser; and (5) Dr. Glasser [J-6-2015] - 11 testified at trial that he was an independent contractor, not an agent of the hospital. Id. at 19-20. Additionally, the Hospital asserts: “The patient had been ‘awake and cooperative’, and remained awake when Dr. Glasser arrived, and when Dr. Malaisrie arrived. The patient was ‘stable’ and continued to be conscious until ‘sometime in the middle’ of the subsequent procedure.” Id. at 20 (record citations omitted). Based on this summary of the evidence, the Hospital contends that Appellant failed to offer any evidence upon which a jury could conclude that a reasonably prudent person in Decedent’s position would be justified in the belief that Dr. Malaisrie rendered care as the Hospital’s agent. The Hospital further maintains that the cases upon which Appellant relies, including Capan and Simmons, do not support Appellant’s position because they are factually distinguishable and predate the enactment of the MCARE Act. The Hospital contends: Permitting a jury to impose liability on this record would effectively nullify the legislature’s enactment of section 516 (and would violate the public policy concerns underlying it) because any hospital could potentially be subject to “ostensible agent” liability for any provider, based on no evidence other than the barest fact of emergency treatment by a doctor authorized to practice in the hospital - exactly what section 516(b) prohibits. The ostensible agency “exception” would become the rule, and section 516(a)(1) would be rendered meaningless. Appellees’ Brief at 28-29.6 6 The Pennsylvania Medical Society and the Pennsylvania Defense Institute filed a joint amicus brief, and the Hospital & Healthsystem Association of Pennsylvania filed a separate amicus brief, in support of the Hospital. The Pennsylvania Association for Justice filed an amicus brief in support of Appellant. [J-6-2015] - 12 Initially, we cannot agree with the Hospital’s argument that allowing a jury to determine whether Decedent was justified in believing that Dr. Malaisrie was acting as an agent of the Hospital when she treated Decedent will undermine and/or obviate Section 516 of the MCARE Act by subjecting a hospital to ostensible agent liability “based on no evidence other than the barest fact of emergency treatment by a doctor authorized to practice in the hospital.” Appellees’ Brief at 29. As noted above, Section 1303.516(b) provides that evidence that a physician holds staff privileges at a hospital “shall be insufficient to establish vicarious liability through principles of ostensible agency unless the claimant meets the requirements of subsection (a)(1) or (2).” 40 P.S. § 1303.516(b) (emphasis added). In order for a hospital to be held vicariously liable under Section 1303.516(a)(1), a plaintiff must establish that “a reasonably prudent person in the patient’s position would be justified in the belief that the care in question was being rendered by the hospital or its agents.” 40 P.S. § 1303.516(a)(1). We fail to see how allowing a jury to determine whether Appellant has demonstrated that a reasonably prudent person in Decedent’s position would be justified in the belief that the care in question was being rendered by the hospital − a basis for liability specifically contemplated by the MCARE Act itself − undermines or obviates the Act, as the Hospital suggests. Turning to the underlying question of whether a reasonably prudent person in Decedent’s position would be justified in the belief that the care in question was being rendered by the Hospital or its agents pursuant to 40 P.S. § 1303.516(a)(1), as noted above, Appellant cites the Superior Court’s decisions in Capan and Simmons. In Capan, the decedent was admitted to the hospital via the emergency room for treatment of a severe nosebleed. While in the hospital, the decedent developed delirium tremens and became violent. The nursing staff summoned the doctor who was on-call to answer [J-6-2015] - 13 emergencies, and the on-call doctor administered a series of drugs to the decedent in an effort to calm him. After the on-call doctor left the hospital that evening, the decedent suffered cardiac arrest and died. The decedent’s estate filed a wrongful death and survival action against the hospital and several physicians, and the trial court, inter alia, granted a nonsuit as to the survival action in favor of the hospital. On appeal, the Superior Court held that the trial court erred in failing to instruct the jury that it could find the hospital vicariously liable for the negligence of the on-call doctor based on ostensible agency, despite the fact that the on-call doctor was an independent contractor. The Superior Court reasoned: The conception that the hospital does not undertake to treat the patient, does not undertake to act through its doctors and nurses, but undertakes instead simply to procure them to act upon their own responsibility, no longer reflects the fact. Present-day hospitals, as their manner of operation plainly demonstrates, do far more than furnish facilities for treatment. They regularly employ on a salary basis a large staff of physicians, nurses and interns, as well as administrative and manual workers, and they charge patients for medical care and treatment, collecting for such services, if necessary, by legal action. Thus, a patient today frequently enters the hospital seeking a wide range of hospital services rather than personal treatment by a particular physician. It would be absurd to require such a patient to be familiar with the law of respondeat superior and so to inquire of each person who treated him whether he is an employee of the hospital or an independent contractor. Similarly, it would be unfair to allow the “secret limitations” on liability contained in a doctor’s contract with the hospital to bind the unknowing patient. 430 A.2d at 649 (citations omitted). The Superior Court concluded that, as the decedent had entered the hospital through the emergency room and the on-call doctor had treated the decedent in his capacity as house physician, not as the decedent’s [J-6-2015] - 14 personal physician, “the jury could have concluded that [the decedent] relied upon the hospital rather than the [on-call doctor] himself for treatment. Additionally, the jury could have found that [the hospital] held out [the on-call doctor] as its employee by providing his services for dealing with emergencies within the hospital.” Id. at 650. In Simmons, the decedent was admitted to the hospital after he was taken to the emergency room following a suicide attempt. Hospital personnel contacted Dr. Alan Wright, the on-call psychiatrist, and Dr. Wright arranged for the decedent’s admission to the psychiatric unit. The decedent remained in the hospital for approximately 18 days, during which time he was treated by Dr. Wright. The decedent was readmitted to the hospital by Dr. Wright after another suicide attempt approximately five months later and placed in the “general observation” level of the psychiatric unit, where patients are observed every 30 minutes. Several days after he was admitted, the decedent used ties from hospital robes to hang himself from the plumbing fixtures in the bathroom adjoining his assigned room. The decedent’s father filed suit against the hospital, and at trial attempted to introduce evidence to prove that Dr. Wright was an actual or ostensible agent of the hospital. The trial court instructed the jury that Dr. Wright was not an employee, agent, or servant of the hospital and that the hospital was not responsible for his actions. The jury returned a verdict in favor of the hospital. Following argument on post-trial motions, an en banc panel of the trial court granted a new trial, determining, inter alia, that the trial court erred in withdrawing the question of Dr. Wright’s agency from the jury. The hospital appealed. The Superior Court affirmed, concluding “there was evidence of record from which the jury may have determined that Dr. Wright was either an actual or ostensible agent” of the hospital. 481 A.2d at 873. Citing Capan, the Superior Court noted: Decedent herein was first admitted to [the hospital] through the emergency room and decedent first came in contact with [J-6-2015] - 15 Dr. Wright at that time because he was the “on call” emergency physician. Decedent’s parents were told that Dr. Wright was the head of the psychiatry department at the hospital and that he was “qualified”. Dr. Wright was the admitting physician when decedent entered the hospital the second time. Under these circumstances, we find that the jury could have concluded that decedent looked to the hospital for care and that the hospital “held out” the doctor as its employee. Thus, we find that the court en banc properly determined that it was error to withdraw the issue of ostensible agency from the jury. Id. at 874-75. The high courts of several of our sister states have taken a similar approach. For example, in Jackson v. Power, 743 P.2d 1376 (Ak. 1987), the Alaska Supreme Court held that a hospital has a non-delegable duty to provide non-negligent emergency care physicians on a 24-hour basis, and cannot “shield itself from liability by claiming it is not responsible for the results of negligently performed health care when the law imposes a duty on the hospital to provide that health care.” Id. at 1385. The court limited its holding “to those situations where a patient comes to the hospital, as an institution, seeking emergency room services and is treated by a physician provided by the hospital,” and declined to extend its holding “to situations where the patient is treated by his or her own doctor in an emergency room provided for the convenience of the doctor. Such situations are beyond the scope of the duty assumed by an acute care hospital.” Id. In Gatlin v. Methodist Med. Ctr. Inc., 772 So. 2d 1023 (Miss. 2000), the Mississippi Supreme Court reversed the trial court’s directed verdict in favor of the hospital, holding that the question of whether the hospital was vicariously liable for the negligence of an anesthesiologist, who failed to make sure there was sufficient blood available for surgery on a patient who arrived at the hospital’s emergency room with several gunshot wounds, was for the jury. In doing so, the Court emphasized that the [J-6-2015] - 16 appropriate focus in determining whether a hospital may be held vicariously liable for the negligence of an independent contractor physician is the relationship between the patient and the health care provider, not the relationship between the hospital and its physicians: Where a hospital holds itself out to the public as providing a given service, in this instance, emergency services, and where the hospital enters into a contractual arrangement with one or more physicians to direct and provide the service, and where the patient engages the services of the hospital without regard to the identity of a particular physician and where as a matter of fact the patient is relying upon the hospital to deliver the desired health care and treatment, the doctrine of respondeat superior applies and the hospital is vicariously liable for damages proximately resulting from the neglect, if any, of such physicians. By way of contrast and distinction, where a patient engages the services of a particular physician who then admits the patient to a hospital where the physician is on staff, the hospital is not vicariously liable for the neglect or defaults of the physician. 772 So. 2d at 1027 (quoting Hardy v. Brantly, 471 So. 2d 358, 369 (Miss. 1985)). The Gatlin Court observed that, although there may be exceptions, a patient’s non-selection of his physician is often the rule in the case of anesthesiologists, radiologists, and emergency room physicians. 772 So. 2d. at 1028; see also Paintsville Hosp. Co. v. Rose, 683 S.W.2d 255, 256-57 (Ky. 1985) (noting expansion of ostensible agency theory from anesthesiologists to other physicians who are not employed by the hospital but are furnished through the institutional process, such as pathologists, radiologists, and emergency room physicians). In Simmons v. Tuomey Reg’l Med. Ctr., 533 S.E.2d 312 (S.C. 2000), the South Carolina Supreme Court, adopting Section 429 of the Restatement (Second) of Torts, held “a hospital owes a nondelegable duty to render competent service to its emergency [J-6-2015] - 17 room patients.” Id. at 322. Although the Tuomey case involved emergency room physicians, the court did not limit its holding to the emergency room setting, but instead restricted it: to those situations in which a patient seeks services at the hospital as an institution, and is treated by a physician who reasonably appears to be a hospital employee. Our holding does not extend to situations in which the patient is treated in an emergency room by the patient’s own physician after arranging to meet the physician there. Nor does our holding encompass situations in which a patient is admitted to a hospital by a private, independent physician whose only connection to a particular hospital is that he or she has staff privileges to admit patients to the hospital. Such patients could not reasonably believe his or her physician is a hospital employee. Id. at 323. We recognize, as the Hospital points out, that the Superior Court decisions in both Capan and Simmons predate the enactment of the MCARE Act. However, the language of the MCARE Act specifically provides that “[a] hospital may be held vicariously liable for the acts of another health care provider through principles of ostensible agency.” 40 P.S. § 1303.516(a) (emphasis added). In our view, the requirement for establishing ostensible agency under Section 1303.516(a)(1) − where the evidence must show that a reasonably prudent person in the patient’s position would be justified in the belief that the care in question was being rendered by the hospital or its agents − is substantially the same as the requirement for establishing ostensible agency under Section 429 of the Restatement (Second) of Torts − where the recipient of services must demonstrate a reasonable belief that the services were rendered by the employer or by his servants. Accordingly, Capan, Simmons, and the cases from our sister states are instructive on the underlying question of whether, and under what circumstances, a reasonably prudent person in Decedent’s position would [J-6-2015] - 18 be justified in believing the care in question was being rendered by the Hospital or its agents. Guided by these cases, and based on our review of the record, we conclude there was sufficient evidence to create a jury question concerning whether a reasonably prudent person in Decedent’s position would be justified in the belief that Dr. Malaisrie was acting as the Hospital’s agent when she rendered care to Decedent. It is undisputed that Decedent first entered the Hospital through the emergency room, and ultimately was admitted to the ICU. The Hospital does not dispute that, after Nurse Yakish observed blood “squirting” from Decedent’s tracheotomy site, anesthesiology and ENT services were paged. See N.T., 6/5/12, at 60 (Dr. Salgo testifying that “the ENT service and anesthesiology services were asked to help. Anesthesiology showed up and so did ENT after anesthesiology.”); N.T., 6/6/12, at 7 (Dr. Glasser testifying that at approximately 4:30 p.m. on January 10, 2009, “there was a page for anesthesia services to come to the Intensive Care Unit. The page we get on our beeper or an overhead page.”). Dr. Glasser testified that he remained in Decedent’s room “until the ENT physician arrived, and whose patient it primarily was.” Id. at 11. He estimated that Dr. Malaisrie arrived in Decedent’s room ten minutes after he did. Id. at 12. Dr. Glasser further testified that, shortly after Dr. Malaisrie arrived, he received another page and left the room. Id. at 42 (“I was paged to go to the other area. I wouldn’t have gone to the other area, but the Doctor had arrived and she was the primary service for that patient for the tracheotomy so I did leave, yes.”). When Dr. Glasser returned approximately 15 minutes later, he observed that Decedent was “stable,” but coughing and “breathing on his own, possibly intermittently. They were assisting him with the bag, but it wasn’t at all times. And he was stable at that time, but he was still having the coughing and bleeding a little bit.” Id. at 12. [J-6-2015] - 19 In this Court’s view, when a hospital patient experiences an acute medical emergency, such as that experienced by Decedent in the instant case, and an attending nurse or other medical staff issues an emergency request or page for additional help, it is more than reasonable for the patient, who is in the throes of medical distress, to believe that such emergency care is being rendered by the hospital or its agents. Accordingly, we hold that the trial court’s grant of a nonsuit under Section 1303.516(a) was erroneous in the instant case, and that the question of whether a reasonably prudent person in Decedent’s position would be justified in his belief that the care rendered by Dr. Malaisrie was rendered by her as an agent of the Hospital should have proceeded to the jury. We, therefore, reverse the Superior Court’s decision affirming the trial court’s grant of a nonsuit in favor of the Hospital on this issue, and remand the matter for further proceedings.