Legal Review and Commentary
Refusal to administer epidural anesthesia leads to $200,000 CA settlement
By Blake Delaney, Buchanan Ingersoll PC, Tampa, FL
News: A pregnant woman in labor was admitted to the hospital. In agony due to the large size of the baby, the patient asked for epidural anesthesia. However, because the woman could not pay for the cost of the epidural in cash in advance, the hospital refused to comply with her request. The woman eventually delivered her baby, who was born with mild Erb's palsy. After filing a lawsuit for negligence based on the nursing staff's refusal to administer an epidural, the parties settled for $200,000.
Background: In December 1998, a 30-year-old woman in labor was admitted to her local hospital. The woman, experiencing tremendous pain, asked for epidural anesthesia, a local anesthetic medication that relaxes pelvic muscles and causes an insensitivity to pain. However, the hospital and the anesthesiology group had a policy of not providing epidural anesthesia to uninsured women or women on Medi-Cal, California's Medicaid program, unless the patient paid $400 cash in advance. Because the patient was on Medi-Cal and did not have the cash, the medical staff refused to comply with the woman's request, even though she offered to write them a check.
The woman continued to ask for an epidural as she suffered in agony prior to delivering her nearly 10-pound baby. During the birth, the obstetrician encountered shoulder dystocia, a rare problem in which the fetal head had been delivered, but the baby's shoulders were "stuck" and could not be delivered. After the obstetrician maneuvered the baby to deliver the shoulders, the girl was born with mild Erb's palsy, a weakness in her arm caused by an injury to the nerves controlling her arm during the birth process.
The mother filed a lawsuit against the hospital, the treating obstetrician, and the on-call obstetrician who delivered the baby. The plaintiff sought damages for emotional distress relating to the hospital's refusal to administer epidural anesthesia. The plaintiff also sought damages for her daughter's lost future earnings, which she alleged to be the direct result of the hospital's negligent conduct. The woman claimed that the delivery was made more difficult because her extreme pain prevented her from being able to cooperate during the delivery.
In her defense, the on-call obstetrician testified in deposition that she would have ordered an epidural if the nurses had informed her of the patient's request for one. The court eventually dismissed both obstetricians from the case.
The hospital, alleged to be vicariously liable through its nursing staff, denied that the woman requested an epidural. It also argued that because the woman's medical chart did not contain a physician's order for an epidural, it would have been improper to administer one. Lastly, the hospital contended that even if the mother had requested an epidural and even if her medical chart had reflected a physician's order to administer one, the anesthesia would not have taken effect before the delivery because the woman delivered so quickly. Consequently, the hospital maintained, its conduct did not cause any injuries to the mother or daughter. Nevertheless, the hospital settled with the plaintiff for $200,000 prior to trial.
What this means to you: This case demonstrates the need for every health care facility's risk management department to develop policies concerning payment for services rendered and communication among staff members. The first aspect of developing a policy governing payment for services rendered is determining who is responsible for billing the patient. "Billing policies should be determined up front and discussed in the contract terms and conditions," says Beth Huntington, BSN, MSN, JD, director of risk management at Baylor Health Care System in Dallas. Although it is not clear from the case study who was in charge of determining payment policies for anesthesia services, most hospitals do not employ anesthesia groups. Instead, an anesthesia group usually will contract with a hospital to provide its services. Consequently, because the anesthesia group provides the service, it (not the hospital) will determine the billing policies, she notes.
A second aspect of a payment policy concerns the manner or methods by which patients must remit payment to the health care provider. "Although it is unclear from the case study whether the patient had prenatal care prior to presenting to the hospital in labor, if she did, the payment expectations should have been discussed and documented in her prenatal record," advises Huntington.
The failure to establish payment protocols with the patient in advance of the patient presenting for treatment is troubling because patients should be made aware of how they will be expected to pay for services rendered as early as possible. Especially considering that the patient in this case was in the middle of labor when the dispute over how she would pay for the epidural anesthesia arose, requiring her to comply with a payment procedure that she may not have been informed of ahead of time is bad practice. Furthermore, Huntington cautions against the hospital's policy of discriminating against Medi-Cal patients. Having different policies for prepayment of out-of-pocket costs with Medi-Cal patients than with private pay or other payer groups may be problematic.
This case also demonstrates the importance of communication among staff members at a health care facility. Huntington attributes much of the liability exposure in this case to poor communication between the nurses and obstetricians. The medical record contained inconsistent information: "The patient must have requested an epidural to someone, or else the issue of her payment would not have come up," says Huntington. If the nurses and doctors had communicated with each other and had documented such conversations in the patient's chart, the hospital's liability would have been reduced.
Finally, the hospital's argument that an epidural would not have taken effect before the delivery even if the patient had requested one is questionable. "Generally, epidural analgesia takes effect immediately," notes Huntington.
Despite the several problem areas emphasized by this case, the hospital's liability was not clear-cut. "I'm not convinced that there was negligence here. But this case had all the potential to be a gross negligence case because it appears that the care offered to a woman in labor was driven by her ability to pay and not her medical condition," says Huntington. Clearly, the suggestion that the hospital conditioned the provision of medical care on the patient's financial profile is troubling. Huntington concludes, "Likely, the hospital agreed to settle in order to save the hospital from a public relations embarrassment — apparent discriminatory treatment due to a patient's ability to pay."
A pregnant woman in labor was admitted to the hospital. In agony due to the large size of the baby, the patient asked for epidural anesthesia.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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