Court Opinion

ID: 9912146
Source: CourtListenerOpinion
Date Created: 2023-12-21 18:07:13.766163+00
Date Added: 2024-06-11T12:52:24.466376
License: Public Domain

139 Nev., Advance Opinion   St9
                          IN THE SUPREME COURT OF THE STATE OF NEVADA

                    KIMBERLY D. TAYLOR, AN                        No. 83847
                    INDIVIDUAL,
                    Appellant,
                    VS.
                    KEITH BRILL, M.D., FACOG, FACS,                  FIILED
                    AN INDIVIDUAL; AND WOMEN'S
                    HEALTH ASSOCIATES OF                             DEC 2 1 2023
                    SOUTHERN NEVADA-MARTIN PLLC,                    ELI
                                                                 CLERY OF
                    A NEVADA PROFESSIONAL LIMITED               BY
                                                                      IEF DEPUTY CLERK
                    LIABILITY COMPANY,
                    Respondents.

                    KEITH BRILL, M.D., FACOG, FACS,               No. 84492
                    AN INDIVIDUAL; AND WOMEN'S
                    HEALTH ASSOCIATES OF
                    SOUTHERN NEVADA-MARTIN PLLC,
                    A NEVADA PROFESSIONAL LIMITED
                    LIABILITY COMPANY,
                    Appellants,
                    vs.
                    KIMBERLY D. TAYLOR, AN
                    INDIVIDUAL,
                    Respondent.

                    KEITH BRILL, M.D., FACOG, FACS,              No. 84881
                    AN INDIVIDUAL; AND WOMENS
                    HEALTH ASSOCIATES OF
                    SOUTHERN NEVADA-MARTIN PLLC,
                    A NEVADA PROFESSIONAL LIMITED
                    LIABILITY COMPANY,
                    Appellants,
                    vs.
                    KIMBERLY D. TAYLOR, AN
                    INDIVIDUAL,
                    Respondent.

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                                  Appeals from a judgment following a jury verdict in a medical
                       malpractice action, a post-judgment 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.

                       McBride Hall and Heather S. Hall and Robert C. McBride, Las Vegas.
                       for Kimberly D. Taylor.

                       Breeden & Associates, PLLC, and Adam J. Breeden, 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.

                                                        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 t,.r.assumption of the risk when
                       the plaintiff does not raise a claim based on lack of informed cobsent. We
                       conclude that assumption-of-the-risk evidence may be relevant in certain

                              'While Judge Ca.rli Lynn Kierny signed the final judgment, the
                       district court case was assigned to, and the trial was presided over by, Judge
                       Monica Trujillo.
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                 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 plaintiffs consent is
                 uncontested. Thus, the district court erred in allowing such arguments and
                 evidence at trial here.
                                We also consider whether a plaintiff must use expert testimony
                 to show that the billing amounts of the inedical damages they seek are
                 reasonable and customary. While an appropriate expert can testify 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 prohibiting 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 HISTOR Y
                                Kimberly Taylor, the plaintiff in the lawsuit below, had a
                 hysteroscopy 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 transported 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 óut 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. Brill had breached the standard of
                 care by piercing her uterine wall and small intestine during surgery. Taylor
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                also alleged Dr. Brill continued surgery after observing her uterine
                perforation, failed to eVahiarte and diaknOgelier 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 examination, and failed to apprise her of these
                complications. The matter proceeded to a jury trial. Before trial, Taylor
                sought to exclude any references to known risks or complications, as well as
                hospital documents 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 inforrried
                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
                judgment 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
                admission of evidence regarding her k.nowledge of the risks associated with
                the procedure Dr. Brill perfornied.       We then address Taylor's other
                evidentiary challenges, including to the district court's decisions 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 concerning the rejection of a portion of
                Taylor's proposed closing argument.
                Evidentiary decisions
                           We review a district court's decision to admit or exclude
                evidence for an abuse of discretion • and will not disturb such a decision
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                       "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. Beling, 128 Nev. 301, 311, 278 P.3d 501, 508 (2012).
                             Informed consent and assumption of the risk •
                                   Taylor first challenges the district court's d.ecision . to admit
                       evidence 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 evidence
                       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 6ccur in the
                       absenee of negligence.
                                   Only relevant evidence -is admissible.      NRS 48.025; see also

                       Desert Cab Inc. v. Marino, 108 Nev. 32; 35, 823 P..2d 898, 899 (1.992).
                       Relevant evidence is "evidence havina any tendency to make the existence
                       of any fact that is of consequence to the determination. of the action more or
                       less probable than it would be without the evidence." 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
                       of misleading the jury.". NRS 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 providers of health
                       care." NRS 41.A.015. The plaintiff must establish three things:. `(1). that the
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                     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."
                     Prabhu 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 facility wherein the alleged negligence
                     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 of
                     a plaintiff s informed consent. to support it.2 Id. We conclude that such
                     evidence and argument is irrelevant to demonstrating that a medical
                     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 negligent in... performing [the
                     surgery] in the post-consent timeframe" and is therefore inadmissible to

                           2Dr. Brill argues he did not present such a defense, but his answer to
                     the complaint includes the affirmative defense that Taylor "assumed the
                     risks of the procedures, if any, performed."
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                determine whether a medical professional breached the standard of care.
                Brady v. Urbas, 111 A.3d 1155, 1162 (P.a.       015); see also NRS 48.025(2)

                (deeming irrelevant evidence inadmissible).
                            Even if a plaintiff gave informed consent, that would not

                "vitiate [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         Prady, 111 A.3d at 1162. Other

                jurisdiction§ are in accord. See, e.g., Hayes v. Camel, 92.7 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. Owczarek, 93 A.3d 1222, 1233
                (Del. 2014) (concluding that once the plaintiff dismissed their informed
                consent claim, any signed consent forms "became irrelevant, because

                assumption of the risk is not a valid defense to a clairn 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 v. P.B.
                Patel, MD., 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)
                (recognizing that informed consent evidence is generally irrelevant because
                it does "not grant consent for the procedure to be performed negligently [or]
                waive appellant's right to recourse in the event the procedure was
                performed negligently" and that it has the potential to confuse the jury);
                Wright 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

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                      relevant nor material to the issue of the standard of care . . . [or] upon the
                      issue 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, may help inform a jury as it
                      evaluates whether there has been a breach of the accepted standard of care.
                      See Mitchell v. Shihora, 209 A.3d 307, 318 (Pa. 2019) ("[R]isks and
                      complications evidence may assist the jury in determining 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 communications between a Physician
                      and patient regarding the purPose, 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
                      arnbit of NRS 41A.100(1). And courts must analyze on a Ca se-by-ca§e basis
                      whether the evidence should still be excluded because its •potential to
                      confuse the jury substantially outweighs its probative value.            See NRS

                      48.035(4                                                  •

                                  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
                      NRS 41A.100(1). However, la.y witness testimony and haspital 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.        14.

                      Accordingly, the district court abused its discretion by. allowing evidence of
                      Taylor's knowledge of the procedure's risks and consequences and evidence

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                   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 renumeration for the medical

                   services she underwent following her injury from the. surgery performed 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-
                   Ortega v. Cervantes-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 surgery 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, testimony 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 district court relied, in large part, on its
                   finding that testimony about the reasonable and customary• nature of
                   medical 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 services she received were usual, customary, or reasonable, the
                   district court excluded them. In 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 testified as to the
                   amount that the patient was charged, that he believed such charges were
                   reasonable, and that he had no usual and customary fee. 60 Nev. 422, 428,
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                       111 P.2d 53, 56 (1941). But that case does not stand for the proposition that
                       evidence of the reasonableness 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 admissible. NRS 48.015; NRS
                       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 1299, 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).
                             Insurance 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
                       NRS 42.021(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.

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                             NRS 42.021(1) abrogated the common law Collateral source
                 dcctrine 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.
                 NRS 42.021(1); see also McCrosky v. Carson Tahoe Reg'l Med. Ctr., 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 cannot "Hecover any amount against the
                            . or . . . [We 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. Copperpoint Mut. Ins. Holding Co., 138 Nev.,
                 Adv. Op. 33, 509 P.3d 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 & Tr. Co. 1.). Windhaven & 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
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                       benefit to the plaintiff. Insurance write-downs are therefore inadmissible
                       under NRS 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 Palace, 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 important,
                       that [Dr. Brill] must answer for the injury he caused to his patient, and that
                       he cannot be careless toward his patient, etc." In 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

                       "imploding] 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-Ortega, 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 mislead
                       the jury. Additionally, expert or physician 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 NRS 42.021(1) makes admissible.           The errors made below
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                regarding these issues, along with the improper limiting of Taylor's closing
                argument, warrant reversing the judgment in Docket No. 83847 and
                remanding for further proceedings in line with this opinion, including a new
                trial.3
                                Because we reverse the underlying judgment, we necessarily

                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 & Barbara
                Rosenberg Living Tr. v. MacDonald Highlands Realty, LLC, 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).

                                                                                  J.

                •We concur:

                                                 J.
                Parraguirre

                           have considered Taylor's remaining arguments, including her
                          3We

                assertions that the district court erred in limiting her voir dire, in not
                admitting into evidence a demonstrative medical device, in not allowing
                proposed impeachment of a defense expert, in the settling of jury
                instructions, and in allowing misconduct by defense counsel in closing
                argument, and we find no errors.
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