Court Opinion

ID: 9912145
Source: CourtListenerOpinion
Date Created: 2023-12-21 18:07:09.640214+00
Date Added: 2024-06-11T12:52:17.450667
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.                                              FILED
                    KEITH BRILL, M.D., FACOG, FACS,
                    AN INDIVIDUAL; AND WOMEN'S                       DEC 2 1 2023
                    HEALTH ASSOCIATES OF                             ELI       UA.BROWN
                    SOUTHERN NEVADA-MARTIN PLLC,                           F   P1FMEC     T
                                                                BY
                    A NEVADA PROFESSIONAL LIMITED                      IEF DEPUTY CLERK

                    LIABILITY COMPANY,
                    Respondents.

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

SUPREME COURT
      OF
   NEVADA                                                            zs         111.11.1
KO) 1947u catT
           ,E `au
                                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 br assumption of the risk when
                    the plaintiff does not raise a claim•based on lack of informed consent. We
                    conclude that assumption-of-the-risk evidence may be relevant in certain

                           'While Judge Carli Lynn Kierny signed the final judgment, the
                    district court case was assigned to, and the trial was presided over by, Judge
                    Monica Trujillo.
SUPREME COURT
        OF
     NEVADA
                                                          9
(0) I947A    401.
                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 medical 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 HISTORY
                               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 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,
                arnongst others. Taylor alleged that Dr. Brill had breached the standard of
                care by piercing her uterine wall and small intestine during surgery. Taylor
SUPREME COURT
        OF
     NEVADA
                                                        3
(0) 1947A
                    also alleged Dr. Brill continued surgery after observing her uterine
                    perforation, failed to evaluate and diagnose 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 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 a ssociated 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
                    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 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 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
    SUPREME COURT
            OF
         NEVADA

                                                          4
   (C)I I 947A

4szy;,-25-qz,,,
                    "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 decision to admit
                    evidence of her knowledge of the risks and potential complications of her
                    surgery through witness testimony, •Tay' or'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 occur 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 (1992).
                    Relevant evidence is "evidence having 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
                1
                    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 41A.015. The plaintiff must establish three things: "(1) that the
SUPREME COURT
        OF
     NEVADA

(01 I947A
                                                         5
                                                                                  4 .='::P4'.."'C'tza;.-: ,,D, •
                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 plaintiffs 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

                     2 Dr. 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."
SUPREME COURT
        OF
     NEVADA

                                                      6
(0) I947A
                   determine whether a medical professional breached the standard of care.
                   Brady v. Urbas, 111 A.3d 1155, 11.62 (Pa. 2015); 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." Brady, 111 A.3d at 1162. Other
                   jurisdictions are in accord. See, e.g., Hayes v. Camel, 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. 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 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 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

SUPREME COURT
      OF
    NEVADA

                                                         7
(0) I947A .16RA,
                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. Shikora, 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
                ambit of NRS 41A.100(1). And courts must analyze on a case-by-case basis
                whether the evidence should still be excluded because its potential to
                confuse the jury substantially outweighs its probative value.        See NRS
                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
                NRS 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

SUPREME COURT
        OF
     NEVADA

                                                      8
101 1947A
                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 frorn 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,
SUPREME COURT
        OF
     NEVADA
                                                       9
(01 I947A
                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-clowns
                            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.

SUPREME COURT
         OF
      NEVADA
                                                     10
(0 I 194 7A
                            NRS 42.021(1) abrogated the common law collateral source
                doctrine 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 "[r]ecover any amount against the
                plaintiff... . or . . . [b]e subrogated to the rights of the plainfiff 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. v. 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
SUPREME COURT
      OF
   NEVADA

  I947A •4"-
                                                      11
                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
                "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-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
SUPREME COURT
        OF
     NEVADA

                                                     12
(0) I 947A
                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
                tria1.3
                            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).

                We concur:

                      Ale4auf)                ,   C.J.
                Stiglich

                                              " J.
                Parraguirr€,"

                          3We have considered Taylor's remaining arguments, including her
                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.
SUPREME COURT
        OF
     NEVADA

                                                         13
tth I947A