Opinion ID: 706855
Heading Depth: 1
Heading Rank: 4

Heading: the burden of providing the requested service

Text: 26 Both parties agree that Tennessee law requires that the service requested by Samantha be administered by a physician, registered practical nurse, licensed practical nurse, respiratory care specialist, the patient's relatives or the patient herself. TENN.CODE ANN. Secs. 63-6-402, 63-6-410. Thus, the parties also agree that, unlike Tatro, Tennessee law would not allow a school nurse to administer the service in question unless the nurse or medical person possessed the requisite licensing and training. The district court estimated that the cost of hiring a licensed practical nurse was not much more than the cost of hiring a certified nurse's assistant. Thus, the district court found that the burden of providing the requested care was not excessive since Rutherford County had initially agreed to hire such an assistant, including upgrading such assistant to the requisite qualification level. 27 Rutherford County contends that the district court's finding is clearly erroneous. It notes that both the ALJ and the district court found that Samantha required almost constant care. A nurse or medical attendant would have had to devote virtually all of his or her attention to Samantha. Rutherford County contends that it is inherently burdensome to hire one medical professional to care for a single child, since the cost cannot be reasonably or feasibly distributed over the entire student population. Since Rutherford County originally intended for the nursing assistant in question to assist many different children, defendant maintains that the district court mistakenly assumed that the added cost of providing Samantha the requested care was insubstantial. 28 Since we agree that the services requested by Samantha are inherently burdensome, we express no opinion about the financial cost of hiring a licensed practical nurse rather than a nursing assistant. The undue burden in this case derives from the nature of the care involved rather than the salary of the person performing it. We are not persuaded by Department of Education v. Katherine D. ex rel. Kevin & Roberta D., 727 F.2d 809, 815 (9th Cir.1983), a case decided before Tatro. The Ninth Circuit held that the Act required a school district to pay for a handicap child's tracheostomy services, since a trained layperson or school nurse was capable of administering the care. Id. at 815 n. 6. In several decisions since Tatro, however, district courts have held that the Act does not require a school district to provide tracheostomy services, among others, when the handicapped student requires virtually constant care. E.g., Shannon, 787 F.Supp. at 1030; Wright, 666 F.Supp. at 75; Detsel ex rel. Detsel, 637 F.Supp. at 1026-27. In Shannon, the district court explained: 29 Shannon's reliance on Tatro is misplaced. The differences between the level of care required in Tatro and the care required by Shannon are significant. The child in Tatro did not require constant monitoring. The CIC procedure, which the child would soon be able to perform herself, could be performed by a layperson a few times a day. In contrast, Shannon requires constant care to monitor and clear her tube. The parties have stipulated that the care of at least a licensed practical nurse is required. 30 Shannon, 787 F.Supp. at 1030. In Wright, the district court explained that 31 [t]he services required are varied and intensive. They must be provided by a nurse, not a layperson. They are time-consuming and expensive. Above all, the life threatening prospect of a mucous plug demands the constant attention of the nurse. Because of this need for constant vigilance, a school nurse or any other qualified person with responsibility for other children within the school could not safely care for Bevin. 32 It is the private duty aspect of Bevin's nursing services which distinguishes this case from.... Tatro ... and Katherine D. [which] all involved intermittent care which could be provided by the school district at relatively little expense in both time and money. 33 Wright, 666 F.Supp. at 75. Similarly, the district court in Detsel noted that 34 [t]he Supreme Court considered the extent and the nature of the service performed in the Tatro decision. Unlike CIC, the services required by Melissa are extensive. This is not a simple procedure which the child may perform herself. Constant monitoring is required in order to protect Melissa's very life. The record indicates that the medical attention required by Melissa is beyond the competence of a school nurse. 35 Detsel ex rel. Detsel, 637 F.Supp. at 1026-27. 36 We find the reasoning of these decisions persuasive, especially Wright. As therein explained, it is the private duty component of Samantha's care that is inherently burdensome. In Katherine D., the child required suctioning of her tracheostomy two or three times a day and there was no hint that the child faced life threatening consequences in the event the routine care was not administered promptly. Similarly, the child in Tatro required catheterization every three or four hours and the Court did not suggest that the child might die if the school nurse was fifteen minutes late. Unlike this case, neither Tatro nor Katherine D. involved care of a constant nature or of life-threatening consequences to the student. The district court found that Samantha required almost exclusive medical supervision and that such care was necessary in order to protect Samantha's life. Requiring a school to hire a licensed practical nurse to care for one child is inherently burdensome and, undoubtedly, distinguishable from Tatro. 37 Samantha and her parents argue, however, that the district court was clearly erroneous when it concluded that Samantha required constant care and supervision. Samantha's father submitted an affidavit which indicated that, during the previous school year, he and his wife did not actually remain in the classroom with Samantha but waited in an adjacent room with a pager in the event Samantha required medical attention. The district court rejected this contention noting that: 38 [a]lthough Samantha's father avers, in his supplemental affidavit, that it was not the plaintiffs' intention to request exclusive care for Samantha, the evidence presented at the hearing preponderates against any conclusion otherwise. While it is true that a nurse might be able to attend briefly to others in Samantha's room, there is no dispute that Samantha requires constant attention and often one-to-one care. The plaintiffs repeatedly point out in their briefs that Samantha's life-threatening condition requires that Samantha be the attendant's number one priority, and there is no evidence to the contrary. 39 We believe that the evidence adduced at the administrative hearing was more than sufficient to support the district court's finding. Samantha's father testified that Samantha's breathing tube could be easily dislodged if she coughed, changed her clothing, or even played roughly with other children. He stated that, if the tube was not reinserted within fifteen or twenty minutes, Samantha's carbon dioxide level would rise and she would fall asleep. Once asleep, Samantha would cease breathing and die if respiratory functions were not restored within four or five minutes. Neely also explained that when Samantha had a cold she required suctioning approximately every twenty minutes. When asked how someone could tell when Samantha needed suctioning, he responded as follows: 40 I suppose basically you could say you just listen. The sounds that we are listening for is not the same one that you might be. It's just something that you learn or are taught to listen for. Also, I mean, we can tell by her lip color, by her fingernails, just by the way she is acting. 41 As the district court properly noted, if a nurse attended to the needs of other children, there would be no one present to observe Samantha's behavior, lip and skin color or any of the other tell-tale signs that Samantha required immediate suctioning. 42 Since the district court did not give its finding of constant care sufficient weight in its determination that the requested care could be provided without undue burden on the school district, we conclude that it was in error. The care requested by Samantha falls within the medical services exclusion to the IDEA. Accordingly, we REVERSE the decision of the district court and AFFIRM the ALJ's holding for defendant.