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Stafford v. Burns

Court of Appeals of Arizona, First Division

January 17, 2017

ANNE M. BURNS, M.D. and JOHN DOE BURNS, husband and wife; EMPOWER EMERGENCY PHYSICIANS, P.C., Defendants/Appellees.

         Appeal from the Superior Court in Maricopa County No. CV2013-000019 The Honorable John Christian Rea, Judge


          Grysen & Associates, Spring Lake, MI By B. Elliott Grysen Co-Counsel for Plaintiffs/Appellants

          Knapp & Roberts, P.C., Scottsdale By David L. Abney Co-Counsel for Plaintiffs/Appellants

          Jones Skelton & Hochuli, P.L.C., Phoenix By Eileen Dennis GilBride, Cristina M. Chait Counsel for Defendants/Appellees

          Presiding Judge Kenton D. Jones delivered the Opinion of the Court, in which Judge Randall M. Howe and Judge Donn Kessler joined.


          JONES, Judge

         ¶1 Dalton and Kristine Stafford (the Staffords) appeal the trial court's orders denying their motions for new trial and for relief from judgment following a jury verdict in favor of Appellees (collectively, Dr. Burns) on the Staffords' claims for medical malpractice and wrongful death after their son, Jesse, died of a methadone overdose.

         ¶2 The Staffords argue the trial court erred in instructing the jury, pursuant to Arizona Revised Statutes (A.R.S.) section 12-572(A), [1] that the Staffords bore the burden of proof by clear and convincing evidence because, they contend, Dr. Burns did not provide medical care "in compliance with" the Emergency Medical Treatment and Active Labor Act (EMTALA). See 42 U.S.C.A. § 1395dd (West). As set forth below, we hold, as relevant here, the heightened standard of proof for claims against a health professional set forth in A.R.S. § 12-572(A) applies whenever the acts or omissions plaintiff contends were deficient were provided in the course of evaluating and treating a patient in a hospital emergency department.

         ¶3 The Staffords also argue the court abused its discretion in denying their motion for new trial based upon various administrative and evidentiary rulings, for which we find no error.

         ¶4 Finally, the Staffords argue the trial court erred in imposing sanctions pursuant to Arizona Rule of Civil Procedure 68(g) because Dr. Burns' pretrial offer of judgment was invalid in that it was not made in good faith. We do not reach the merits of the Staffords' contention because Rule 68(g) contains no such good faith requirement, and we decline to impose one in contravention of the rule's plain language and purpose.

         ¶5 For the reasons stated below, we affirm the trial court's orders.


         ¶6 In the early morning hours of February 5, 2012, Jesse presented at the emergency room of St. Joseph's Hospital after having ingested an unknown quantity of methadone. After several hours of testing, evaluation, and monitoring for a possible methadone overdose, Dr. Burns took over Jesse's care until he was discharged around 1:00 p.m. Jesse was found dead the following day.

         ¶7 In January 2013, the Staffords filed a complaint against Dr. Burns, asserting she negligently caused Jesse's death by wrongfully determining his condition was stable and discharging him prematurely. In response, Dr. Burns asserted she complied with the standard of care and presented evidence suggesting Jesse ingested additional methadone after his discharge that ultimately caused his death.

         ¶8 After a twelve-day trial, the jury returned a defense verdict. The Staffords' motions for new trial and for relief from judgment were denied. The Staffords timely appealed, and we have jurisdiction pursuant to A.R.S. § 12-120.21(A)(1) and -2101(A)(1), (2), and (5)(a).


         I. Application of A.R.S. § 12-572(A)

         ¶9 A plaintiff must generally prove the elements of his medical malpractice claim by a preponderance of the evidence. See Harvest v. Craig, 195 Ariz. 521, 523, ¶ 10 (App. 1999) (citing Thompson v. Sun City Cmty. Hosp., Inc., 141 Ariz. 597, 608 (1984)). In 2009, however, our legislature adopted A.R.S. § 12-572(A), which heightened the burden of proving a malpractice claim against "a health professional . . . who provides or who is consulted to provide services to a patient of a licensed hospital in compliance with [EMTALA]" to clear and convincing evidence. EMTALA is a federal statute enacted to address the growing concern that hospitals were routinely refusing emergency medical treatment to individuals unable to pay for services. See Eberhardt v. City of LA., 62 F.3d 1253, 1255 (9th Cir. 1995) (citing H.R. Rep. No. 241, 99th Cong., 1st Sess. (1986), reprinted in 1986 U.S.C.C.A.N. 726-27); Scottsdale Healthcare, Inc. v. Ariz. Health Care Cost Containment Sys. Admin., 206 Ariz. 1, 6 n.6, ¶ 20 (2003) (citing Bryant v. Adventist Health Sys./W., 289 F.3d 1162, 1165 (9th Cir. 2002)). The Staffords argue the trial court erred in instructing the jury on the clear and convincing burden of proof set forth in A.R.S. § 12-572(A) because, they contend, Dr. Burns was not providing services "in compliance with EMTALA" as another physician had already performed the medical screening and determined Jesse did not have an emergency medical condition. In response, Dr. Burns argues A.R.S. § 12-572(A) applies to "all emergency room services."

         ¶10 Although we review a trial court's denial of a motion for new trial and its decision to give a jury instruction for an abuse of discretion, we review de novo whether jury instructions accurately state the law. Delbridge v. Salt River Project Agric. Improvement & Power Dist., 182 Ariz. 46, 53 (App. 1994) (citing Suciu v. AMF AC Distrib. Corp., 138 Ariz. 514, 520 (App. 1983)); State v. Garcia, 224 Ariz. 1, 18, ¶ 75 (2010) (citing State v. Martinez, 218 Ariz. 421, 432, ¶ 49 (2008)); see also State v. Rios, 217 Ariz. 249, 250, ¶ 5 (App. 2007). The interpretation and application of statutes also present questions of law which we review de novo. City of Phx. v. Glenayre Elecs., Inc., 240 Ariz. 80, 84, ¶ 8 (App. 2016) (citing First Fin. Bank, N.A. v. Claassen, 238 Ariz. 160, 162, ¶ 8 (App. 2015)).

         ¶11 The heightened burden of proof of A.R.S. § 12-572(A) applies where services are provided "in compliance with EMTALA." EMTALA applies to any individual who comes to a hospital's emergency department for treatment.[3] 42 U.S.C.A. § 1395dd(a). Under EMTALA, the hospital is required to provide appropriate medical screening to determine if an emergency medical condition exists.[4] Id. If the patient has an emergency medical condition, the hospital must either provide "such further medical examination and such treatment as may be required to stabilize the medical condition, " or, if safe and appropriate, transfer the patient to another facility for stabilizing care.[5] 42 U.S.C.A. § 1395dd(b)(1). For purposes of EMTALA, a patient is "stabilized" when "no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility." 42 U.S.C.A. § 1395dd(e)(3)(B).

         ¶12The gamut of services that may be necessary to comply with EMTALA cannot readily be distilled into a universally applicable and finite list, and therefore, the phrase cannot be read narrowly. To adopt the Staffords' view, the burden of proof against the health care provider would shift from clear and convincing to a preponderance of the evidence the instant: (1) the screening process is completed and reveals the patient does not have an "emergency medical condition" within the meaning of EMTALA, or (2) a patient is stabilized to the point that his condition would not deteriorate during a transfer. This sort of interpretation is not practical in the context of a person seeking emergency medical care. The evaluation and treatment of a medical condition is necessarily a fluid process, whereby a patient's status as serious or stable may change from moment to moment. This is particularly true where the condition qualifies as an emergency under EMTALA - manifesting through acute symptoms, severe pain, and the risk of serious dysfunction or bodily impairment.

         ¶13We do not read EMTALA to relieve the hospital emergency department from re-screening, re-evaluating, and even possibly re-treating a patient if his condition changes after an initial status determination. Indeed, federal courts have held a hospital's duty under EMTALA can continue up to and even after a patient is admitted for inpatient care. See,e.g., Bryant, 289 F.3d at 1168 (concluding EMTALA duty ends when a patient is admitted in good faith for inpatient care); Thornton v. Sw. Detroit Hosp.,895 F.2d 1131, 1134 (6th Cir. 1990) ("[O]nce a patient is found to suffer from an emergency medical condition in the emergency room, she cannot be ...

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