Court Opinion

ID: 9948849
Source: CourtListenerOpinion
Date Created: 2024-03-08 01:06:37.62884+00
Date Added: 2024-06-11T14:26:05.814770
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FUED
                                                                                      :TH A. BRO..
                                          139 iNev., Advance Opinion 56                    civiF

       IN THE SUPREME COURT OF THE                                                 1EF DEPUTY CLERK-

              STATE OF NEVADA

KIMBERLY D. TAYLOR, AN INDIVIDUAL, APPELLANT, V.
   KEITH BRILL, M.D., FACOG, FACS, AN INDIVIDUAL; AND
   WOMEN'S HEALTH ASSOCIATES OF SOUTHERN
   NEVADA-MARTIN PLLC, A NEVADA PROFESSIONAL LIMITED
   LIABILITY COMPANY, RESPONDENTS.

                                  No. 83847
KEITH BRILL, M.D., FACOG, FACS, AN INDIVIDUAL; AND
   WOMEN'S HEALTH ASSOCIATES OF SOUTHERN
   NEVADA-MARTIN PLLC, A NEVADA PROFESSIONAL LIMITED
   LIABILITY COMPANY, APPELLANTS, V. KIMBERLY D. TAY-
   LOR, AN INDIVIDUAL, RESPONDENT.
                                  No. 84492
KEITH BRILL, M.D., FACOG, FACS, AN INDIVIDUAL; AND
   WOMEN'S HEALTH ASSOCIATES OF SOUTHERN
   NEVADA-MARTIN PLLC, A NEVADA PROFESSIONAL LIMITED
   LIABILITY COMPANY, APPELLANTS, V. KIMBERLY D. TAY-
   LOR, AN INDIVIDUAL, RESPONDENT.
                                 No. 84881
December 21, 2023

   Appeals frorn a judgment following a jury verdict in a medical rnal-
practice action, a post-judgrnent order granting in part and denying
in part a motion to retax and settle costs, and a post-judgment order
denying attorney fees. Eighth Judicial District Court, Clark County;
Monica Trujillo, Judge,' and Joseph T. Bonaventure, Sr. Judge.
   Reversed and remanded.

  Breeden & Associates, PLLC, and Adam J. Breeden, Las Vegas,
for Kimberly D. Taylor.

  McBride Hall and Heather S. Hall and Roberi C. McBride, Las
Vegas, for Keith Brill, M.D., FACOG, FACS, and Women's Health
Associates of Southern Nevada-Martin PLLC.

  Before the Supreme Court, STIGLICH, C.J., and HERNDON and
PARRAGUIRRE, JJ.

   'While Judge Carli Lynn Kierny signed the final judgment, the district court
case was assigned to, and thc trial was presided over by, Judge Monica Trujillo.
                       Taylor v. Brill, M.D.

                           OPINION

  By the Court, HERNDON, J.:
   In these appeals, we consider whether defendants to a medical
malpractice action may defend by arguing, or otherwise present
evidence concerning, the plaintiff's informed consent or assurnp-
tion of the risk when the plaintifï does not raise a claim based on
lack of informed consent. We conclude that assumption-of-the-risk
evidence may be relevant in certain instances where a plaintiff's
consent to the procedure is challenged. But neither the defense itself
nor evidence of informed consent is proper in a medical malpractice
action, like this one, where the plaintiff's consent is uncontested.
Thus, the district court erred in allowing such arguments and evi-
dence at trial here.
   We also consider whether a plaintiff must use expert testimony
to show that the billing amounts of the medical damages they seek
are reasonable and customary. While an appropriate expert can tes-
tify as to the reasonableness of the amount of damages, we hold that
expert testimony is not required when other evidence demonstrates
reasonableness. The district court abused its discretion by prohib-
iting such evidence. Based on these errors, and others discussed
herein, we reverse the district court's judgment and remand this
matter for further proceedings.

              FACTS AND PROCEDURAL HISTORY
   Kimberly Taylor, the plaintiff in the lawsuit below, had a hys-
teroscopy performed by the defendant, Dr. Keith Brill. Dr. Brill
perforated Taylor's uterus and bowel during the procedure. Taylor
reported escalating pain after the surgery and was twice trans-
ported to an emergency room via ambulance. On the second trip,
the attending doctor concluded her symptoms were consistent with
an uncontrolled bowel perforation and performed an emergency
surgery to remove any contamination and to correct what turned
out to be a three-centimeter perforation.
   Taylor then filed a medical malpractice action against Dr. Brill
and the Women's Health Associates of Southern Nevada-Martin
PLLC, amongst others. Taylor alleged that Dr. 13rill had breached
the standard of care by piercing her uterine wall and small intes-
tine during surgery. Taylor also alleged Dr. Brill continued surgery
after observing her uterine perforation, failed to evaluate and diag-
nose her intestine perforation, failed to inform the post-anesthesia
care unit of the uterine perforation and instruct the post-anesthesia
team to observe her for specific concerns requiring further exam-
ination, and failed to apprise her of these complications. The matter
                        Taylor v. Brill, M.D.                       3

proceeded to a jury trial. Before trial, Taylor sought to exclude any
references to known risks or complications, as well as hospital doc-
uments regarding her informed consent and educating her on the
risks of the procedure to be performed. The district court ultimately
ruled that Dr. Brill could introduce evidence of Taylor's knowledge
of the risks and complications associated with the procedure but
not her informed consent form. At the conclusion of trial, the jury
unanimously found in favor of Dr. Brill and denied all of Taylor's
claims. Taylor appeals from the final judv,ment in Docket No. 83847.
Dr. Brill and Women's Heath Associates appeal from certain post-
judgment orders in consolidated Docket Nos. 84492 and 84881.

                           DISCUSSION
   We first address Taylor's challenge to the district court's admis-
sion of evidence regarding her knowledge of the risks associated
with the procedure Dr. Brill performed. We then address Taylor's
other evidentiary challenges, including to the district court's deci-
sions to prohibit her from presenting nonexpert evidence in support
of her damages claim and to allow evidence of insurance write-
downs. Finally, we address Taylor's remaining challenge concerni n
the rejection of a portion of Taylor's proposed closing argument.

Evidentiary decisions
   We review a district court's decision to admit or exclude evi-
dence for an abuse ad iscretion and will not disturb such a decision
"absent a showing of palpable abuse." Las Vegas Metro. Police Dep't
v. Yeghiazarian, 129 Nev. 760, 764-65, 312 P.3d 503, 507 (2013). But
when an evidentiary ruling rests on a question of law, we review it
de novo. Davis v. &ling, 128 Nev. 301, 3 I I, 278 P3d 501, 508 (2012).

     Informed consent and assumption of the risk
   Taylor first challenges the district court's decision to admit evi-
dence of her knowledge of the risks and potential complications of
her surgery through witness testimony, Taylor's hospital discharge
instructions, and associated paperwork. Taylor asserts that such evi-
dence is irrelevant in this case because she did not allege that she
was not informed of the risks associated with her procedure or that
Dr. Brill failed to obtain her consent. Dr. Brill contends that the
evidence is relevant because the complication she experienced was
a known risk of the procedure and the evidence demonstrated that
such a complication could occur in the absence of negligence.
   Only relevant evidence is admissible. N RS 48.025; see also Des-
ert Cal) Inc. v. Marino, 108 Nev. 32, 35, 823 P.2d 898, 899 (1992).
Relevant evidence is "evidence having any tendency to make the
4                        Taylor v. Brill, M.D.

existence of any fact that is of consequence to the determination of
the action more or less probable than it would be without the evi-
dence." NRS 48.015. But relevant evidence is "not admissible if its
probative value is substantially outweighed by the danger of unfair
prejudice, of confusion of the issues or am isleading the jury." N RS
48.035(1).
   To succeed in a professional negligence action, a plaintiff must
prove that, in rendering services, a health care provider failed "to
use the reasonable care, skill or knowledge ordinarily used under
similar circumstances by similarly trained and experienced provid-
ers of health care." N RS 41A .015. The plaintiff must establish three
things: "(I) that the doctor's conduct departed from the accepted
standard of medical care or practice; (2) that the doctor's conduct
was both the actual and proximate cause of the plaintiff's injury;
and (3) that the plaintiff suffered damages." Prahhu v. Levine, 112
Nev. 1538, 1543, 930 P.2d 103, 107 (1996).
   We have not previously considered whether evidence of informed
consent is relevant, or if an assumption-of-the-risk defense is
proper, in a professional negligence action. Generally, the first
two elements of such an action—deviation from the standard of
care and medical causation—are shown by evidence consisting
of"expert medical testimony, material from recognized medical
texts or treatises or the regulations of the licensed medical facil-
ity wherein the alleged nedigence occurred." NRS 41A.100(1). An
assumption-of-the-risk defense, on the other hand, requires proof
of"(1) voluntary exposure to danger, and (2) actual knowledge of
the risk assumed." Sierra Pac. Power Co. v. Anderson, 77 Nev. 68.
71, 358 P.2d 892, 894 (1961) (quoting Papagni v. Purdue, 74 Nev.
32, 35, 321 P.2d 252, 253 (1958)). As the defense "is founded on the
theory of consent," a party may seek to present evidence ola plain-
tiff's informed consent to support it.2 Id. We conclude that such
evidence and argument is irrelevant to demonstrating that a medi-
cal provider conformed to the accepted standard of care or to refute
medical causation when defending against a medical malpractice
claim. See NRS 41A.100(1). Indeed, informed consent evidence
"does not make it more or less probable that the physician was negli-
2ent in . .. performing [the surgery] in the post-consent timeframe"
and is therefore inadmissible to determine whether a inedical pro-
fessional breached the standard of care. l3rady v. Urhas, 111 A.3d
 1155, 1162 (Pa. 2015); see also NRS 48.025(2) (deeming irrelevant
evidence inadmissible).

   'Dr. Brill argues he did not present such a defense, hut his answer to the
complaint includes the affirmative defense that Taylor "assumed the risks of
the procedures. if any, performed."
                       Taylor v. Brill, M.D.                        5

   Even if a plaintiff gave informed consent, that would not "viti-
ate [a medical provider's] duty to provide treatment according to
the ordinary standard of care" because "assent to treatment does
not amount to consent to negligence, regardless of the enumerated
risks and complications of which the patient was made aware."
Brady, 111 A.3d at 1162. Other jurisdictions are in accord. See, e.g.,
Hayes v. Ccmiel, 927 A.2d 880, 889-90 (Conn. 2007) ("[E]vidence
of informed consent, such as consent forms, is both irrelevant and
unduly prejudicial in medical malpractice cases without claims
of lack of informed consent"); Baird v. Owezarek, 93 A.3d 1222,
1233 (Del. 2014) (concluding that once the plaintiff dismissed their
informed consent claim, any signed consent forrns "became irrel-
evant, because assumption of the risk is not a valid defense to a
claim of medical negligence, and because [such evidence] is neither
material [n]or probative of whether [the doctor] met the standard
[of] care" (citation omitted)); Wilson P.B. Patel, M.D., P.C., 517
S.W.3d 520, 525 (Mo. 2017) (concluding that such evidence would
mislead the jury that the plaintiff consented to injury); Waller v.
Aggarwal, 688 N.E.2d 274, 275-76 (Ohio App. Ct. 1996) (recogniz-
ing that informed consent evidence is generally irrelevant because
it does "not grant consent for the procedure to be performed neg-
ligently [or] waive appellant's right to recourse in the event the
procedure was performed negligently" and that it has the poten-
tial to confuse the jury); Wrighi v. Kaye, 593 S.E.2d 307, 317 (Va.
2004) (holding that when a plaintiff does not place consent in issue,
"evidence of information conveyed to [the plaintiff] concerning
the risks of surgery in obtaining her consent is neither relevant nor
material to the issue of the standard of care . [or] upon the issile
of causation").
   Despite the foregoing, certain evidence that may support an
assumption-of-the-risk defense, such as evidence of the known risks
and complications of a particular procedure, rnay help inform a jury
as it evaluates whether there has been a breach of the accepted stan-
dard of care. See Mitchell v. Shikora, 209 A.3d 307, 318 (Pa. 2019)
("[R]isks and complications evidence may assist the jury in deter-
mining whether the harm suffered was more or less likely to be
the result of negligence."). Other courts have distinguished between
inadmissible informed consent evidence—such as consent forms or
COMMUllications between a physician and patient regarding the pur-
pose, nature, and risks of procedures—and admissible evidence of
the risks and complications of surgery. See id. at 316-18. However,
evidence of a procedure's risks must still fall within the ambit of
NRS 41A.100(l). And courts must analyze on a case-by-case basis
whether the evidence should still be excluded because its potential
6                       Taylor v. Brill,

to confuse the jury substantially outweighs its probative value. See
N RS 48.035(1).
   Since expert witness testimony may establish the standard of
care and breach, the testimony regarding risks and complications
of the procedure by Taylor's and Dr. Brill's retained experts was
admissible. See N RS 41A.100(1). However, lay witness testimony
and hospital literature are generally not suitable for this purpose,
making the testimony by Taylor and Dr. Brill, as well as portions
of Taylor's discharge instructions and associated paperwork about
this same subject, inadmissible. Id. Accordingly, the district court
abused its discretion by allowing evidence of Taylor's knowledge
of the procedure's risks and consequences and evidence probative
of Taylor's informed consent. And we are not convinced that the
limiting instruction given to the jury cured the prejudice resulting
from this error.

     Special damages
   Taylor sought special damages as remuneration for the medical
services she underwent following her injury from the surgery per-
formed by Dr. Brill. To be entitled to special damages, Taylor had
to demonstrate that the amounts she was billed were reasonable
and necessary. See Pizzaro-Orlega v. Cervanies-Lopez, 133 Nev.
261, 266, 396 P.3d 783, 788 (2017). The necessity of the medical
services Taylor received after Dr. Brill's allegedly negligent sur-
gery was not contested in the trial court. Taylor's retained expert,
Dr. Berke, clearly testified that the medical services Taylor received
were reasonable and necessary and were caused by the perforations
that arose from Dr. Brill's surgical procedure. The district court
excluded the bulk of the evidence Taylor sought to admit in support
of her special damages claim—including medical bills, testiniony
from health care industry witnesses about those bills, and testimony
from Taylor herself, who had worked in the medical billing industry
with both physicians and hospitals for over two decades. The dis-
trict court relied, in large part, on its finding that testimony about
the reasonable and customary nature ofmedical charges was beyond
the knowledge of a layperson and required an expert. Since Taylor
proffered no expert to testify that the charges for the medical ser-
vices she received were usual, customary, or reasonable, the district
court excluded them. ln doing so, the district court relied on Curti
v. Franceschi, which held that an award for medical services was
supported by substantial evidence where the attending doctor testi-
fied as to the amount that the patient was charged, that he believed
such charges were reasonable, and that he had no usual and custom-
ary fee. 60 Nev. 422, 428, 111 P.2d 53, 56 (1941). But that case does
not stand for the proposition that evidence of the reasonableness
                        Taylor v. Brill, M.D.                          7

of the damages sought can only be proven by an expert witness or
physician. Here, Taylor presented three witnesses—the CFO of the
charging hospital, a health care billing representative, and a health
care customer service billing manager—all of whom would have
testified regarding the charges for the medical treatment provided to
Taylor. Taylor also sought to testify herself on the issue based in part
on her experience working in the medical billing industry for over
two decades. This information was relevant and therefore admis-
sible. NRS 48.015; N RS 48.025. The district court thus abused its
discretion in excluding this evidence, see Yeghiazarian, 129 Nev. at
764-65, 312 P.3d at 507, which affected Taylor's substantial rights,
as it prevented her from proving a prima facia case for damages, see
Brown v. Capanna, 105 Nev. 665, 672, 782 P.2d [299, 1304 (1989)
(holding that an appellant's substantial rights were affected by the
exclusion of testimony that would have helped prove their prima
facie case).

     Inswance write-downs
   Although the district court excluded the vast majority of medical
billing evidence related to Taylor's proposed special damages, it did
admit evidence related to two lower-cost items of medical billing.
Taylor challenges the district court's decision to permit Dr. Brill to
present evidence of insurance write-downs in defending against this
aspect of her damages claim. The district court based its decision
on its interpretation of N RS 42.02 I (1); therefore, the issue presented
is one of law that we review de novo. See Zohar v. Zbiegien, 130
Nev. 733, 737, 334 P.3d 402, 405 (2014) (recognizing that statutory
interpretation questions are issues of law); Davis, 128 Nev. at 311,
278 P.3d at 508.
   NRS 42.021(1) abrogated the common law collateral source doc-
trine by creating an exception for evidence of collateral source
payments in medical malpractice actions:
     In an action for injury or death against a provider of health
     care based upon professional negligence, if the defendant so
     elects, the defendant may introduce evidence of any amount
     payable as a benefit to the plaintiff as a result of the injury or
     death pursuant to ... any contract or agreement of any group,
     organization, partnership or corporation to provide, pay for or
     reimburse the cost of medical, hospital, dental or other health
     care services.
N RS 42.021(1); see also McCrosky v. Carson Tahoe Regl Med.
Cir., 133 Nev. 930, 936, 408 P.3d 149, 154-55 (2017) (discussing
the change from common law). However, if evidence is introduced
pursuant to subsection (1), the source of the collateral benefits
8                      Taylor v. Brill, M.D.

cannot Irlecover any amount against the plaintiff.... or . . . [tde
subrogated to the rights of the plaintiff against a defendant." NRS
42.021(2). This statute was thus intended to prevent a situation where
a jury would reduce a plaintiff's award based on collateral source
evidence, but the collateral source would still seek reimbursement
from the award. Harper v. Copperpoini Mui. Ins. Holding Co., 138
Nev., Adv. Op. 33, 509 R3d 55, 60 (2022) (citing McCrosky, 133
Nev. at 936, 408 P.3d at 155).
    Construing this statute narrowly, we conclude that the district
court erred in finding that the statute permitted the admission of
insurance write-downs. See Branch Banking ct. Tr. Co. v. Wind-
haven & Tollway, LLC, 131 Nev. 155, 158-59, 347 P.3d 1038, 1040
(2015) ("Statutes that operate in derogation of the common law
should be strictly construed . . .."). NRS 42.021(1) contemplates
evidence only of actual benefits paid to the plaintiff by collateral
sources, and insurance write-downs do not create any payable bene-
fit to the plaintiff. Insurance write-downs are therefore inadmissible
under N RS 42.021(1).

Closing arguments
   Lastly, Taylor asserts that the district court improperly limited
her closing arguments. We review de novo whether an attorney's
comments would constitute misconduct. Grosjean v. Imperial Pal-
ace, Inc., 125 Nev. 349, 364, 212 P.3d 1068, 1078 (2009); see also
Lioce v. Cohen, 124 Nev. 1, 20, 174 P.3d 970, 982 (2008).
   Taylor sought to make a closing argument "that the jury with its
verdict should 'send a message' to Defendants that safety is import-
ant, that [Dr. Brill] must answer for the injury he caused to his
patient, and that he cannot be careless toward his patient, etc." ln
denying this request, the district court stated that Taylor "shall not
be permitted to use the phrase 'send a message[ ]' . . . in closing
argument." But Taylor's argument was not inappropriate because it
was based on the evidence in the case, rather than "implor[ing] the
jury to disregard the evidence." Capanna, 134 Nev. at 890-91, 432
P.3d at 731. Asking the jury to send a message is not prohibited "so
long as the attorney is not asking the jury to ignore the evidence."
Id. (quoting Pizarro-Oriega, 133 Nev. at 269, 396 P.3d at 790). The
district court therefore erred in limiting Taylor's closing argument
in this manner.

                          CONCLUSION
   informed consent evidence is inadmissible, and an assumption-
of-the-risk defense is improper, in professional negligence suits
when the plaintiff does not challenge consent, as it serves only to
confuse and rnislead the jury. Additionally, expert or physician
                           Taylor v. Brill, IVI.O.                               9

testimony is not required to demonstrate the reasonableness of
the billing amount of special damages. And evidence of insurance
write-downs does not fall within the type of evidence N RS 42.021(1)
makes admissible. The errors rnade below regarding these issues,
along with the improper limiting of Taylor's closing argument, war-
rant reversing the judgment in Docket No. 83847 and remanding for
further proceedings in line with this opinion, inchiding a new trial.'
   Because we reverse the underlying judgment, we necessar-
ily reverse the order granting in part and denying in part Taylor's
motion to retax and settle costs in Docket No. 84492 and the order
denying Dr. Brill's request for attorney fees in Docket No. 84881.
See Frederic (Ar Barbara Rosenberg Living Tr. v. MacDonald High-
lands Really, LW, 134 Nev. 570, 579-80, 427 P.3d 104, 112 (2018)
(recognizing the necessity of reversing a fees and costs order when
the substantive judgment was being reversed).
  STIGLICH, C.J., and PARRAGUIRRE, J.. concur.

NOTE—AS a service to members of the bench and bar, these printed
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                                              ELIZABETH A. BROWN, Clerk

     \i'Ve have considered Taylor's remaining argunlents, including her assertions
that the district court erred in limiting her voir dire, in not admitting into evi-
dence a demonstrative medical device, in not allowing proposed impeachment
of a defense expert. in the settling of jury instructions, and in allowing miscon-
duct by defense counsel in closing argument, ancl we find no errors.

SPO. CARSON Crrv, NlivADA, 2023