Opinion ID: 1094071
Heading Depth: 1
Heading Rank: 2

Heading: patient's refusal of medical screening and/or treatment

Text: I, Cook, Kenneth, have been informed that Walker Regional Medical Center has an obligation to examine and treat emergency medical conditions and women in active labor. I am refusing medical screening and/or treatment necessary to stabilize my condition. I understand that a medical screening is necessary in order for the hospital and physician to determine if I have a medical emergency. I understand that the hospital and/or physician are obligated to treat/stabilize emergency conditions and active labor, but I am refusing such care and thereby release anyone in connection with my care from any injury or harm that may result from my decision. I have been fully informed of the risks associated with my decision. (Emphasis in original.) The affidavit testimony of Cook's cellmate considered important in Lyons I was not presented to the jury. Rather, Lyons expressly elected to forgo calling the cellmate to the stand even though he was available, because the jailer put into the record that he was aware of the fact that Cook wanted to return [to the hospital] and that he claimed that he was sick and they didn't let him. The jailer, Deputy Sheriff Hayron Bridges, who had escorted Cook to and from the hospital, could not recall anything at trial about the cellmate's conversation referenced in Lyons I, but acknowledged that if in his deposition he had said that a trusty, Timothy Smith, had told him after Cook had returned from the hospital that Cook was sick and that he needed to go to the doctor, he was sure that that was correct. He went on to explain, however: That could have been five minutes after I brought him back. You know, the trusties are bad about that. They stick their nose in everything and that was Timothy Smith was a trusty and if he come to the window and told me that, it could have been five minutes after I brought him back. The omission from the evidence at trial of the rest of the cellmate's testimony specifically cited in Lyons I would represent a different state of the record. We conclude that, whatever weight the trial court might have accorded the aforementioned comments in Lyons I, there was in fact new evidence presented at trial relevant to the issues of contributory negligence and assumption of risk that went well beyond that relied on in Lyons I. Lyons argues that none of this is new evidence and it is extremely doubtful based on other witnesses' testimony that Hunter told Kenneth Cook anything other than a blanket statement that you could die. (Lyons's brief, p. 39.) However, as noted, it was the province of the jury to make credibility assessments and otherwise to weigh conflicting testimony, and Lyons does not explain what other witnesses' testimony she has in mind. As noted, when we compare the facts mentioned in Lyons I with the portions of the trial record excerpted above, we respectfully disagree that no new evidence was presented. The proposition asserted by the second sentence of Issue Ithat the trial court erred in instructing the jury on contributory negligence and assumption of the risk can appropriately be considered in combination with the proposition in Issue II that [t]he trial court erred in holding that contributory negligence can legally apply to this medical malpractice case. The trial judge instructed the jury as follows concerning contributory negligence and assumption of the risk: I'm now telling you that the defendants have the burden of proof to convince the jury, to reasonably satisfy you by the evidence of the truthfulness of the claim of affirmative defense; that is contributory negligence and assumption of the risk. I'm going to define those for you and tell you what the elements are. First, let me tell you what negligence itself is. Negligence is the failure to discharge or perform a legal duty owed to another party. Negligence means the failure to exercise reasonable and ordinary care; that is, such care as a reasonably prudent person would have exercised under the same or similar circumstances. Therefore negligence is the failure to do what a reasonably prudent person would do under the same or similar circumstances, or the doing of something which a reasonably prudent person would not do under the same or similar circumstances. So, therefore, contributory negligence is negligence on the part of the plaintiff that proximately contributed to his death. Now, if you're reasonably satisfied from the evidence that the plaintiff was guilty of contributorythat is Mr. Cook, was guilty of contributory negligence, the plaintiff cannot recover for the initial simple negligence of the defendants. In considering whether he was negligent himself, there are three elements essential to assumption of the risk or contributory negligence in cases of this kind. First, is that the party charged with assumption of risk or contributory negligence, number one, had knowledge of the existence of the dangerous condition; and two, with appreciation of that danger; thirdly, failed to exercise care for his own safety by putting himself in the way of the danger. At the close of all of the evidence, Lyons moved for a directed verdict (a judgment as a matter of law) on the issues of contributory negligence and assumption of the risk, on the ground that the opinion in Lyons I had eliminated those defenses from the case. The trial judge denied the motion, noting that the Lyons I opinion was based on the record before [the Supreme Court], and we have a new record here today and that contributory negligence is almost always a matter for the jury to decide. In the course of those discussions, counsel for both sides agreed that the pattern charge number 30.05, Alabama Pattern Jury Instructions: Civil (2d ed.1993), [2] which the definition of contributory negligence in Lyons I parallels, correctly listed the elements of both contributory negligence and assumption of risk. Counsel for Lyons stated that APJI 30.05 was a combined charge. After the judge gave that charge, Lyons objected, again stating that, after Lyons I, the defenses of contributory negligence and assumption of the risk were not appropriate in this case, and also stating that, because contributory negligence has to be in response to an underlying charge of negligence, it could have no field of reference in a medical-malpractice case, because such a case involved only the concept of deviation from the standard of care. She later elaborated on that argument: We further object on the basis that the Court in giving [an instruction on] contributory negligence and assumption of the risk also defined negligence, as it must if it gives that charge, but in a malpractice case there is no negligence. So what the jury was left with was some general charge of negligence, simple negligence, to which there has never been an allegation made against the defendants because we can't make such allegation. All we can make is a deviation from the standard of care in the national medical community. And then in response to that the jury is given the charge that says but the defendants cannot be found responsible for any act of simple negligence. Of course, they never could be responsible for any act of simple negligence because that is not the law of the State of Alabama. The only thing they could be responsible for are acts of medical malpractice under the Alabama Medical Liability Act, so a jury gets to hear acts of simple negligence, which we could never charge them with, and it says we can be contributorily negligent but as to our contributory negligence if we are contributorily negligent, then we could not recover against the defendants for any acts of simple negligence. When the jury subsequently sent out a note requesting that the trial judge [r]estate the contributory negligence factors, he recharged them in essentially the same language he had used initially. Counsel for Lyons objected to the reprised charge, stating as grounds the same ones previously asserted. Pertinent to Lyons's argument that she never alleged negligence in the case because we can't make such an allegation in a medical-malpractice case, we note that she alleged in both her original complaint and her amended complaint, on which she went to trial, that Walker Regional and Hunter's failure to provide Cook with proper care and treatment constituted negligence and wantonness. She went on to assert that Walker Regional and Hunter were negligent and/or wanton in seven specified ways. She also sought punitive damages because of the defendants' wanton conduct. Furthermore, at Lyons's request the trial court gave APJI 33.01, which reads: COMBINED AND CONCURRENT CAUSES If one is guilty of negligence which concurs or combines with negligence of another, and the two combine to produce (injury) or (damage), each negligent person is liable for the resulting (injury) or (damage) and the negligence of each will be deemed the proximate cause of the injury. In arguing this issue on appeal, Lyons states that she agrees that assumption of risk can apply to a medical malpractice, if there are facts to support such a defense [but that] contributory negligence cannot apply to a medical malpractice because it is designed to only apply to negligence causes of action. She cites no cases in support of her position, implied in her argument, that a medical-malpractice claim cannot be predicated on negligence, and, in fact, acknowledges that [t]his Court has previously held that contributory negligence can apply to a medical malpractice. See Cackowski v. Wal-Mart Stores, Inc., 767 So.2d 319, 330 (Ala.2000). Lyons's sole authority in support of Issue II is Dennis v. American Honda Motor Co., 585 So.2d 1336 (Ala.1991). In Dennis, this Court held that, in an action brought under the Alabama Extended Manufacturer's Liability Doctrine (AEMLD) against the manufacturer of a motorcycle helmet the plaintiff was wearing at the time of a motorcycle accident, [t]he defense of contributory negligence in an AEMLD action should be limited to assumption of risk and misuse of the product. The plaintiff's negligence relating to accident causation should not bar recovery. 585 So.2d at 1339. Lyons argues that, by analogy, to allow the defendants in this case to argue contributory negligence as it relates to the causation in this case is contrary to the public policy of protecting patients from medical malpractice. We fail to see the parallel, believing that a closer analogy would be if a defendant in a medical-malpractice action was charged with failure to diagnose a disease and attempted to defend on the basis that the patient had been contributorily negligent in contracting the disease. This Court has frequently discussed medical-malpractice claims as involving negligence. See, e.g., McAfee v. Baptist Med. Ctr., 641 So.2d 265, 267 (Ala.1994), and University of Alabama Health Servs. Found., P.C. v. Bush, 638 So.2d 794, 802 (Ala.1994). We find that the trial court did not err in charging the jury on contributory negligence and assumption of the risk over Lyons's objection. Under the court's combined charge on contributory negligence and assumption of risk, the jury was to determine whether Cook knew of and had an appreciation for the dangerous condition, yet put himself in the way of it. As already noted, Hunter told Cook that he did not have to have the NG tube inserted and implored him: Just stay here and let us treat you.... Maybe there's something else we can do for you. She explained to him that she did not know what was wrong with him and warned that if he left he could bleed to death or suffer a heart attack or a stroke. She emphasized that the medical personnel did not know what was wrong with him and that he could die from his condition if he left the hospital. According to Deb Evans, Hunter was trying to talk him into staying ... trying to, you know, telling him to stay and let us finish evaluating you. According to Evans, Cook refused all treatment. At that point in time he refused any and all treatment. He didn't want anything else done. He rejected all treatment despite being read the against-medical-advice form, which advised him that in refusing treatment he did so with the understanding that a medical screening is necessary in order for the hospital and physician to determine if I have a medical emergency. Cook belligerently and sometimes profanely insisted that he knew what was wrong with him and that it was his appendix; that he knew his rights and the hospital did not have the right to hold him against his will just because he was an inmate; that the hospital could not keep him there; that he did not have to do anything; that the hospital staff didn't know what the `F' [they] were doing and that the hospital was a piece of `S'; that he could go back to jail and, indeed, he stated: I want to go back to jail, you mother `F's,' and Take me back to the jail. I want to go back to the jail. I don't want any treatment. According to Evans, Cook said that he did not want any more treatment. He told the officer to let him loose. Despite Cook's intransigence and verbal abuse, Hunter continued to try to impress upon Cook the need to stay for a full evaluation. She also explained to him that even after he left, he could change his mind and come back, and similarly told the deputy, if he changes his mind or gets worse, bring him back. There was ample opinion testimony before the jury, without objection, that Cook would have known from the duration and significance of his symptoms that he was sick and that his condition could be serious. Even Deb Calhoun, the nursing expert called by Lyons, testified as follows: Q. [I]f you're throwing up for two weeks, you know you're sick, don't you. A. Yes, sir. Q. And he knew he was sick? A. I believe so. Q. Including blood out of his stomach, correct? A. Yes, sir. Q. His right side is hurting, he's in distress? A. Yes, sir. Q. And he knows it? A. I would think so, yes, sir. Q. He just doesn't know why. He knows he's sick but he just doesn't know why. A. Right. Q. He's seen by a doctor and at the time that Mr. Cook leaves against medical advice, the doctor doesn't know why, does he? A. No, sir. .... Q. And [Cook] obviously knew that when he left, his evaluation and treatment was not complete? A. I believe that he did. Q. And he obviously knew he could die because [Hunter] made that very clear, didn't she? A. Yes, sir, I think she tried to. Q. And in spite of all of that knowledge on his part, he left against medical advice, didn't he? A. Yes, sir. Q. Before the doctor could complete the evaluation? A. Yes, sir. Q. For his treatment? A. Yes, sir. Q. He shut it off prematurely, didn't he? A. He did. The following exchange also took place between defense counsel and Calhoun: Q. Now, another result of the patient leaving against medical advice, a patient like Mr. Cook in particular, `Is it that patient themselves, the patient themselves, or himself, places himself at great risk including the risk of death.' A. Yes, sir, that is the risk. Q. You've told us that then and you tell us that now? A. Yes, sir. Q. And Mr. Cook did, in fact, place himself at risk of death when he left against medical advice on May 7, 1994? A. Yes, sir, he did. Q. And as a result he did die, didn't he? A. Yes, sir. Also placed before the jury was the following testimony of Joy Morris, the defendants' nursing expert: Q.... First of all, you understand [Cook] had made the decision to ask to be brought to the emergency department, correct? A. Yes. Q. From that we know he knew he was sick? A. Yes. Q. He's the one who gave the history of throwing up, vomiting, for about two weeks, correct? A. Correct. Q. Based on your experience as a nurse and taking care of people, if somebody presents with the history that they tell you they've been throwing up for two weeks, do they know they're sick? A. Yes. Q. You throw up one time, you know you're sick. A. Yes, sir. Q. Not only throwing up, but throwing up blood; is the correct? A. Yes. Q. Is that strong evidence of knowledge on his part that he was ill? A. Yes. Q. He also knew that the doctor, after seeing himof course, he was seen by a competent emergency room doctor; is that correct? A. From what I've read, yes, sir. Q. Dr. Boone. The doctor, he knew that the doctor was concerned enough to order an NG tube for him? A. Yes, sir. Q. To rule out bleeding in the stomach? A. Yes, sir. .... Q. You know from your review of the case that [Hunter], in connection with her attempts to keep him there, told him a number of times `If you leave, you could die'? A. Yes, sir. Q. As a nurse, is there any more strong warning that a nurse can give a patient trying to keep them from leaving AMA [against medical advice], that if you leave, you may die? A. That's as strong as it gets. Q. Do you know of anything stronger you could have said? A. No, sir. Q. So he knew that that morning at the time he left AMA? A. Yes, sir. When Calhoun was asked if anything stronger could be said to a patient than if he did not allow medical personnel to care for him you may die, she agreed, No, sir, there isn't anything stronger that you could say. She also agreed that she could not have done any more than Hunter did, stating, No, sir. There's no greater risk than death. Dr. Marshall Boone likewise agreed that if Hunter had told Cook that if he left before medical personnel had finished evaluating and treating him, You could die, there was nothing more strong or more clear that could have been said to him at the time. He testified further that I don't know anything more explicit that, you know, `We don't know what's wrong with you. If you leave here, you could die,' that's pretty explicit. He opined that everybody understands the significance of hemorrhaging and that Cook left knowing that Boone was trying to rule out internal bleeding. Boone stated and explained: My understanding of what Mr. Cook did was he refused treatment, which involvedpart of that was the NG tube, but refusing, you know, refusing one aspect of treatment and leaving a facility is two different situations. And if a patient just refuses an aspect of treatment, the patient remains in the facility, the chart remains there and we can go forward with the diagnosis and treatment of the patient. On the other hand, if the patient leaves the facility, then that system breaks down. Dr. Boone was of the opinion that Cook voted with his feet by walking out of the hospital, because we can't keep people that want to leave. Finally, Dr. Boone testified as follows: Q. What is the number one reason, based on your knowledge and your experience, that Mr. Cook died? A. He refused medical treatment for his condition. Q. And left against medical advice? A. Yes. Q. Is that the number one contributing factor to this man's death? A. Yes, sir. I thinkyou know, unfortunately, we could speculate to doomsday that had he known the ketoacidosis instead of just knowing about the bleeding, maybe he would have stayed and had treatment, I think that's speculation. But, you know, medical care, we have to have a relationship with the patient and we're there to help the patient. When I went to that emergency department that Saturday morning, I went to try to take care of the patients that presented to that facility that wanted to be treated. Patients who either didn't come in that day or left without being treated, I couldn't do that. Q. Is that because the patient ends the relationship? A. Absolutely. The jury, in applying the court's charge on contributory negligence and assumption of risk to all of the testimony, could have concluded that Cook, with knowledge of the seriousness of his sickness and with the appreciation that it posed significant danger, including death, failed to exercise care for his own safety, by putting himself in the way of the danger about which he was warned, including death. Under the charge, the jury was not required to focus exclusively on the specific danger posed by the specific condition of diabetic ketoacidosis.