Opinion ID: 1979517
Heading Depth: 1
Heading Rank: 2

Heading: Alternative Methods of Treatment.

Text: Testimony at trial reflected a difference of medical opinion on whether it was proper under the circumstances to administer lidocaine, and later, after his seizure, electrical shocks, to the decedent. The plaintiff's experts testified that prescribing lidocaine to a patient was only proper if a heart attack or related problem had occurred. In contrast, the defendants' experts testified that the drug had a prophylactic as well as a therapeutic, value, and its administration was proper to prevent an impending heart attack. Similarly, the plaintiff introduced evidence that application of electrical shocks by the health center staff would not have benefited the decedent, and that this administration interrupted CPR, damaged the heart, and paralyzed breathing. On the other hand, the defendants' experts testified that it was appropriate to apply electrical shocks, that those shocks could not damage a heart or paralyze breathing, and that the staff properly administered CPR. The jury was instructed that a physician who is a specialist is required to exercise that degree of skill and care ordinarily used by similar specialists in like circumstances. It was also instructed that a hospital is required to exercise that degree of skill and knowledge normally possessed by hospitals ... under the same or similar circumstances. The plaintiff argues the district court erred in then instructing the jury that the defendants did not breach their duty of care to her husband if it determined there were two or more recognized alternative courses of action which have been recognized by the medical profession or hospitals as proper methods of treatment, and the defendants in the exercise of their best judgment elected one of these proper alternatives. She claims the instruction, alone and together with others, [1] misstated the law, did not apply to the facts, confused and misled the jury, and unduly emphasized the defense of honest mistake in judgment. Iowa Rule of Civil Procedure 196 provides that a district court shall instruct the jury as to the law applicable to all material issues in the case.... Instructions that misstate the law, confuse or mislead, or unduly emphasize issues, theories, or evidence, constitute grounds for reversible error. E.g., Clinton Land Co. v. M/S Associates, Inc., 340 N.W.2d 232, 234 (Iowa 1983); Mills County State Bank v. Fisher, 282 N.W.2d 712, 716 (Iowa 1979); Eickelberg v. Deere & Co., 276 N.W.2d 442, 447 (Iowa 1979); Dickman v. Truck Transport, Inc., 224 N.W.2d 459, 464 (Iowa 1974). Our review is on error. Iowa R.App.P. 4. We begin by noting the general rules regarding jury instructions. A district court has a duty to instruct with reasonable fullness on pleaded issues supported by substantial evidence. Clinton Land Co., 340 N.W.2d at 234. It is then free to phrase instructions in its own words so long as the instructions fully and fairly inform the jury of the issues and applicable law. Id. All instructions must be read together and relate to each other, not piecemeal or in artificial isolation. Dickman, 224 N.W.2d at 464. That an instruction might be worded better does not make it bad. Hardy v. Rynell, 282 N.W.2d 134, 137 (Iowa 1979). Several jurisdictions have concluded a physician is not negligent in selecting among two or more recognized methods in treating a patient. E.g., Young v. United States, 574 F.Supp. 571, 581 (D.Del.1983) (Hawaii law); Arrendale v. United States, 469 F.Supp. 883, 887 (N.D.Tex.1979) (Texas law); Harrigan v. United States, 408 F.Supp. 177, 186 (E.D.Pa.1976) (Pennsylvania law); Rickett v. Hayes, 256 Ark. 893, 511 S.W.2d 187, 194 (1974); Barton v. Owen, 71 Cal.App.3d 484, 139 Cal.Rptr. 494, 503-504 (1977); Baldor v. Rogers, 81 So.2d 658, 660 (Fla.1955); Haase v. Garfinkel, 418 S.W.2d 108, 114 (Mo.1967); Truan v. Smith, 578 S.W.2d 73, 76 (Tenn.1979); Hood v. Phillips, 554 S.W.2d 160, 165 (Tex.1977); accord, Alexander's Instructions on Medical Issues, supra, § 341, at 134; W. Curran & E. Shapiro, Law, Medicine and Forensic Science, 578-79 (1970); Holder, Medical Malpractice Law, supra, at 105; 61 Am.Jur.2d supra, § 216, at 346-47; 70 C.J.S. supra, § 44, at 953. We do not believe that the district court erred in giving the instruction on alternative methods of treatment. As the court stated in Barton: [Such an instruction] embodies the notion that differing doctors may disagree in good faith upon what would encompass the proper treatment or diagnosis of a medical problem in a given situation. Medicine is not a field of absolutes. There is not ordinarily only one correct route to be followed at any given time. There is always the need for professional judgment as to what course of conduct would be most appropriate with regard to the patient's condition. Thus [the instruction] states the rule that where there are several methods of approved diagnosis or treatment, which could be made available to a patient, it is for the doctor to use his best judgment to pick the proper one. 139 Cal.Rptr. at 504 (emphasis added); see Harrigan, 408 F.Supp. at 186; Haase, 418 S.W.2d at 114. Contrary to the plaintiff's assertion, an instruction on a physician's standard of care and one on alternative methods of treatment are not inconsistent: The rule that a specialist is held to a higher standard requires of him more learning and more skill, but it does not change one of the basic tenets ... that where more than one mode of treatment is recognized as proper, the doctor is not negligent in adopting any of such modes. More is required of a specialist, but his best judgment is the most that can be expected. Harrigan, 408 F.Supp. at 185 (citations omitted). We believe that the reasoning of Barton and Harrigan applies to hospital staffs as well as physicians. The plaintiff argues a physician cannot select a particular treatment without a diagnosis. [2] See Campbell v. Oliva, 424 F.2d 1244, 1251 (6th Cir.1970). She concludes that, because the defendant failed to diagnose the decedent's condition, there was no factual basis for the instruction. Medicine has not reached the stage where a physician may always confidently pinpoint the specific disease or injury of a patient. A diagnosis is simply an opinion, which is more than a mere guess, on the existence of a disease or injury, based upon a patient's symptoms. See 26A C.J.S. Diagnosis 933 (1956); Webster's Third International Dictionary (1961). In this case the decedent had undergone two short bouts of pain in one day. There was the possibility that the second one awakened him after he had gone to sleep. The pain had radiated to his arm, and was a squeezing one, which is associated with a heart problem. Moreover, the second EKG appeared abnormal to the defendant. While the defendant had not arrived at any precise conclusion on the decedent's condition, he had impressions and suspicions the decedent was suffering from coronary artery disease and an impending heart attack. Indeed, he entered this diagnosis in the admitting record, and there was testimony at trial to confirm his opinion. We believe this evidence establishes that the defendant made a diagnosis before ordering administration of lidocaine. The plaintiff further argues that under the instruction the jury could not find the defendants negligent in selecting improper treatments, so long as they were recognized ones. The instruction, however, did not preclude a finding of negligence due to the mere selection of recognized treatments: the defendants were required to exercise their best judgment in selecting them. See Barton, 139 Cal.Rptr. at 504. In other words, the jury was instructed that if the defendants had not exercised their best judgment in administering lidocaine and electrical shocks to the decedent under the circumstances, they were negligent. Last, we do not believe the instruction unduly emphasized that a physician is not necessarily negligent for mistakes in diagnosis and treatment, a point covered in a separate instruction. The repetition was no more than was required for a clear presentation of the issues. Eickelberg, 276 N.W.2d at 447. In any event, merely repeating a rule of law is generally not held to be error. See Livingstone v. Dole, 184 Iowa 1340, 1347, 167 N.W. 639, 642 (1918). Read as a whole, the instructions accurately stated the law, did not unduly emphasize any issues, and neither confused nor misled the jury. We hold that, under the circumstances of this case, the district court did not err in refusing to instruct on abandonment. In addition, the district court did not err in instructing the jury that they could not find the defendants negligent if, in the exercise of their best judgment, they employed one of two or more recognized methods in treating the decedent. DECISION OF COURT OF APPEALS AND JUDGMENT OF DISTRICT COURT AFFIRMED.