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By Damian D. Capozzola, Esq.
The Law Offices of Damian D. Capozzola
Jamie Terrence, RN
President and Founder, Healthcare Risk Services
Former Director of Risk Management Services (2004-2013)
California Hospital Medical Center
Elena N. Sandell, JD
UCLA School of Law, 2018
News: A patient underwent a pre-employment physical examination at an urgent care center. The exam revealed the patient suffered from hypertension and required medication. The patient attended two follow-up visits, then did not follow up again for two years. A nurse failed to fully inform the patient about his condition and the need for further treatment. The patient eventually was found to have suffered extensive kidney damage and stage 4 chronic kidney disease, which ultimately required a kidney transplant.
The patient filed a medical malpractice suit and was awarded $29.7 million in damages. The defendant appealed, alleging the patient was negligent for missing appointments and failing to take his medication. Upon review, the court ruled the patient acted reasonably, and any negligence on his part did not cause the injury.
Background: In 2008, a 28-year-old patient went to a federally funded urgent care center to complete a pre-employment physical examination, which revealed the patient suffered from hypertension and needed medication. No other physical problems were noted. After failing the physical, the patient sought further examination and treatment. He was diagnosed by a nurse practitioner as suffering from hypertension and obesity. The nurse practitioner ordered routine lab work and scheduled the first follow-up visit. During the first visit, the patient was diagnosed with severe hypertension (his blood pressure measuring 210/170), high cholesterol, and obesity. Based on the patient’s factors, including his young age and severe hypertension, he was at severe risk of developing kidney disease.
The patient’s kidney function appeared normal during the first examination. The nurse gave the patient clonidine, which lowered his blood pressure. The patient’s medical notes indicated the nurse provided several samples of blood pressure medication to take at home, and instructed the patient to engage in “healthy eating habits.” However, there was no indication the patient was adequately informed of the details and effects of his hypertension and the potential risk of developing kidney disease. Instead, he was cleared to go to work.
The patient did not follow up for two years, until he failed another work-related physical. According to the patient, during the two-year period, he reported no symptoms of high blood pressure. Records indicated the nurse prescribed a blood pressure medication to take at home and noted in the patient’s chart that he was “noncompliant.” However, no new lab work was ordered, even though tests were two years old and the patient had not taken any blood pressure medication for an extended period.
Between August 2010 and July 2011, the patient returned to the same clinic six times. During this time, the nurse and the clinic did not order any new labs, even though the patient’s blood pressure still was above normal and posed danger. The patient’s medications also were changed frequently. The patient reported he believed the medications were causing him pain. The patient’s chart did not indicate notes that he received any education on his condition and the potential risks associated with not taking his medication.
In July 2011, new lab work was ordered for the patient. Results indicated abnormal kidney function, but these were never seen or reviewed by the nurse. Because of this lapse in review and notification to the patient, he did not return to the clinic for 15 months. When he returned, his blood pressure was within a normal range at 140/60, but he was complaining of dizziness. Results of new lab work revealed extensive kidney damage, and that the patient suffered from stage 4 chronic kidney disease. However, these lab results were not discussed with the patient and he was not referred to a specialist.
Two months later, the patient felt extremely ill. He was transported to a hospital, where he was determined to be in hypertensive crisis. His blood pressure was 275/180. During this visit, the patient was informed for the first time that “hypertension” is synonymous with “high blood pressure,” and he was suffering from stage 5 chronic kidney disease. He was readmitted a few months later to have a fistula surgically inserted so he could begin receiving hemodialysis regularly. Two years after beginning treatment, the patient received a kidney transplant which, although successful, requires him to take immunosuppressive and anti-rejection medication.
The patient filed a medical malpractice suit against the clinic, alleging the clinic’s and nurse’s failure to read and review tests, failure to adequately inform him about his condition and the necessity of taking his medication, and failure to diagnose and treat or refer him to treatment for the kidney disease constituted malpractice. The clinic denied liability, and claimed that the patient’s failure to seek treatment for his hypertension and failure to take medication constituted negligence that caused his injuries.
Following a bench trial, the judge ruled in favor of the plaintiff and awarded him $29.7 million. The defendant appealed, arguing the court failed to apply the correct standard for the patient’s alleged comparative fault. While the appellate court agreed, the trial court eventually found the patient acted reasonably and was not at fault for his injuries, despite his few lapses in attending appointments and refilling medications.
What this means to you: Although unsuccessful in this matter, the defendant care provider raised an important defensive tool in medical malpractice actions: comparative negligence. States employ different applications of this legal principle. In Illinois, where this matter took place, if a party is more than 50% responsible for the injury, then the party is not entitled to any recovery, even if the care provider was 49% responsible. Other states apply a percentage-based reduction, such that if a party is 25% responsible for their own injuries, the party’s damages award is reduced by 25%.
Regardless of the specific application, this principle can allow for physicians and care providers to reduce or eliminate an injured patient’s recovery when the patient bears some responsibility for his or her own injuries. This case provides an example of how such arguments may be raised, and how courts and juries evaluate such arguments.
In this case, the defendant clinic argued the patient’s noncompliance and failure to follow up in a timely manner contributed to at least 50% of his injuries, thus precluding him from any entitlement to damages. The patient claimed that his behavior was justified because the nurse practitioner failed to educate him on his condition and possible consequences, and his delayed follow-ups and refilling of his medication did not contribute to his injuries. Here, the court agreed with the patient and found he acted as a “reasonable person” would have in the same or similar circumstances. The court acknowledged the patient’s delays, but noted he was only 28 years old at the time and otherwise was in good health. It was reasonable for him to only seek medical attention when he felt ill.
Additionally, the patient stated that he first learned that “high blood pressure” and “hypertension” had the same meaning after he was transported to the hospital. This shows the patient clearly was uneducated on his condition and likely was unaware of the health consequences related to the disease. This also is confirmed by the notes, or lack thereof, kept in the patient’s file by the nurse practitioner. In fact, other than indicating “healthy diet,” the nurse did not keep a record of any conversation she had with the patient explaining the severity of his condition and the potential consequences. The nurse instructed the patient several times to return to the clinic “as needed,” rather than on any specific schedule, such as within six months, for regular follow-up visits. These circumstances supported the court’s finding the patient lacked the knowledge to act differently because the care provider failed to adequately inform the patient.
Several expert witnesses testified at trial for both the patient and care provider. All witnesses agreed on one fact: The patient’s blood pressure readings were among the highest they had ever seen. Given the severity of the patient’s results, the experts agreed the case was complicated for a nurse practitioner to handle. They agreed the patient should have been referred to a physician, and monitored closely. Several instances of the patient’s treatment in the clinic provide clear examples of care below the applicable standard: failure to perform lab work for more than two years or obtain lab results from the emergency care center, failure to follow up on the lab work that was ordered but never reviewed, and failure to disclose to patient the progression of his kidney disease and order a specialist visit.
The high award in this case was calculated based on the experts’ testimony on what dialysis entailed in terms of the physical toll, economic loss, and ability to work. Experts agreed the duration of a kidney transplant is 10-12 years. Based on the patient’s life expectancy, he would need additional kidney transplants, which require years of dialysis in preparation and would cost the patient between $10-$14 million. Most experts also agreed the patient’s kidney disease was caused by uncontrolled hypertension.
Most determinative for the court was the testimony of a primary care physician who noted that although the nurse practitioner categorized the patient as “noncompliant,” he believed the patient was simply not educated by the nurse. If he fully understood the risks involved, he would have complied. In fact, the patient’s nephrologist noted the patient was willing and able to follow all medical advice in the years leading up to his kidney transplant. Further, he successfully monitored his blood pressure by himself once he understood the risks and consequences of his disease, and the necessary preventive steps he needed to take. The court found this evidence supported the claim the patient was reasonable and did not contribute to his injuries.
Financial Disclosure: Author Greg Freeman, Editor Jill Drachenberg, Editor Jonathan Springston, Editorial Group Manager Leslie Coplin, Accreditations Director Amy Johnson, MSN, RN, CPN, and Nurse Planner Maureen Archambault report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Consulting Editor Arnold Mackles, MD, MBA, LHRM, discloses that he is an author and advisory board member for The Sullivan Group and that he is owner, stockholder, presenter, author, and consultant for Innovative Healthcare Compliance Group.