Legal Review & Commentary
Failure to admit diabetic patient leads to brain damage, $21.4M verdict
By Jonathan D. Rubin, Esq.
Partner
Kaufman Borgeest & Ryan
New York, NY
Christine A. Turiano, Esq.
Associate with Kaufman Borgeest & Ryan
Valhalla, NY
Barbara K. Reding, RN, LHCRM, PLNC
Clinical Risk Manager
Central Florida Health Alliance
Leesburg, FL
News: A 50-year-old diabetic man was transported to the emergency department (ED) twice in 48 hours after being found unresponsive by family. Each time, he was diagnosed with hypoglycemia, stabilized in the ED, and discharged home. He developed severe hypoglycemia 10 hours after his second hospital discharge, and he suffered brain damage as a result. He is completely incapacitated. The patient's sister brought a lawsuit against the hospital on his behalf and alleged negligent care. The jury returned a verdict of $21.4 million. The patient's award was reduced to $19.1 million due to his percentage of fault.
Background: A 50-year-old insulin dependent diabetic man was found unresponsive by family on Oct. 11, 2007. He was transported by ambulance to the ED and suffered a seizure on arrival. His blood glucose level was 14, and 50% dextrose (D50) was administered to treat hypoglycemia. Once his blood glucose level stabilized, he was discharged home with instructions to follow up with his physician in two days. The man returned to the ED on Oct. 13, 2007, after having again been found unresponsive by family. He arrived by ambulance at 9 p.m. and was treated for hypoglycemia. He was administered D50, provided with food, and discharged home at 1 a.m. on Oct. 14, 2007, after his blood glucose level was stabilized. The man went to sleep at 3 a.m. and was found unresponsive by family at 10:30 a.m. He suffered a hypoxic brain injury secondary to hypoglycemia, which resulted in permanent brain damage and the need for 24-hour skilled nursing care.
A lawsuit was filed against the hospital by the man's sister on his behalf. The plaintiff argued that the hospital was negligent in discharging the patient twice without determining the underlying cause of his hypoglycemia. The records did not document a change in diet, insulin, or activity level that could account for the patient's change in condition. Plaintiff also argued that records showed a history of increasingly severe hypoglycemic episodes, causing generalized seizures. Plaintiff contended that repeated episodes of hypoglycemia caused development of "hypoglycemic unawareness," which resulted in the man's higher tolerance for lower glucose levels. As a result, he might not have exhibited typical hypoglycemic symptoms prior to loss of consciousness. Plaintiff additionally argued that the hospital failed to appreciate the patient's history, and the fact that he was taking Lantus (long-acting insulin) at the time of his presentation to the hospital. In light of the patient's history and unexplained hypoglycemia, plaintiff argued that the patient should have been admitted to the hospital for further work up, or at the least, admitted to the Clinical Decision Unit (CDU) for observation. The CDU is available to observe patients who don't necessarily require hospital admission. Plaintiff also highlighted the refusal of each treating physician to take responsibility for the decision to discharge the patient and alleged that family was never instructed to observe the patient following hospital discharge.
In support of the hospital, the defense argued that it is standard ED practice to treat hypoglycemia by stabilizing glucose levels and by discharging the patient to his primary care physician and family. The defense also focused on the patient's 7-year diabetic history, including weekly and biweekly physician visits for uncontrolled diabetes. The patient experienced blood sugar fluctuations despite multiple medication adjustments. The defense argued that the patient's documented noncompliance was the cause of his fluctuating glucose levels (documented 37 times between 2000 and 2007). The defense also referenced his history of schizophrenia, depression, and daily alcohol consumption. The defense argued that the patient's own failure to take medications as prescribed, follow a proper diet, and avoid alcohol contributed to his repeated development of hypoglycemia. The defense also highlighted the patient's 11 prior hospitalizations for hypoglycemia due to the patient's noncompliance.
The jury returned a verdict of $21.4 million dollars for the damages sustained by the patient. However, the verdict was reduced to $19.1 million, which represented the jury's apportionment of 10% of the causal fault to the patient. At the time of the verdict, defense counsel stated that an appeal would be taken. To date, court records don't reflect that an appeal has been filed.
What this means to you: This case presents interesting views related to risk management and responsibility from the plaintiff and defense perspectives. The defense arguments, although designed to prove patient responsibility and demonstrate the patient's noncompliance with his healthcare regimen, serve instead to emphasize the plaintiff's arguments related to breach of duty. With the duty to care comes the additional responsibility to provide such care in an acceptable manner, one that is consistent with the standard practice of other competent professionals providing care in similar circumstances. It is expected that the same degree or standard of knowledge, skill, and care will be performed and executed by healthcare professionals for all patients under the same conditions. Failure to meet the standard of care results in a finding of liability on the part of the defendants.
In terms of assessment and intervention, when making the decision to discharge the patient to home twice within 48 hours, the healthcare providers failed to consider the patient's history of multiple hospitalizations due to severe episodes of hypoglycemia. They failed to incorporate into their plan of care for this patient the concern of frequent physician office visits related to uncontrolled diabetes, unsuccessful diabetic medication management attempts, and most importantly, the patient's psychiatric diagnosis. Two ambulance runs and two episodes of unresponsiveness within 48 hours should have alerted ED staff to the high risk this patient presented. The discharge planners (physicians, nurses, and case managers) should have considered the second event, if not the first, to be an unsafe discharge at the least. A critical glucose level of 14 with associated seizure activity would warrant close monitoring and observation over time, certainly so in light of 11 prior hospitalizations and a documented history of glucose fluctuations. This recently discharged ED patient presenting once again, via ambulance, in acute distress in such a brief timeframe would warrant the prudent consideration of admitting him to an observation or medical unit. Unfortunately, dollars, budgets, and insurance coverage, or lack thereof, often drive or contribute to risky decisions made by healthcare providers. At greatest risk in today's healthcare economic and financial environment is the patient.
The plaintiff's introduction into the case of "hypoglycemic unawareness" brought a compelling argument to the forefront. A potentially developed tolerance for lower glucose levels, coupled with the patient's diagnosis of schizophrenia, might have diminished the patient's ability to fully understand his disease process and decipher the associated warning signs and symptoms of an impending hypoglycemic crisis. Given this patient's fragile mental capacity and brittle diabetic history, providers had a duty to evaluate, investigate, plan, monitor, and advocate for this patient.
The strengths of this case were found in the plaintiff and defense arguments concerning assessment, intervention, and responsibility. With 10% of the damages assessed against the patient and 90% attributed to the hospital and its team members, the jury affirmed the duty and the responsibility to provide prudent and reasonable care, regardless of patient compliance, to rest primarily on the decisions made by the providers. Even so, it was noted that physicians declined to accept culpability or responsibility for the discharge decisions that led to the devastating lifestyle change and long-term care needs of this patient.
By virtue of the hospital's choice and decision to provide healthcare to those in need, the duty to care is established and the breach of that duty in this case was evident. The hospital provided temporary-only intervention and minimal consideration of the need for long-term solutions, which resulted in the subsequent injury of brain hypoxia and a substantial verdict for the plaintiff. The plaintiff's award however, will be needed to provide care for the patient for the remainder of his life.
Reference
Campbell v. Temple University Hospital. Court of Common Pleas of Philadelphia County, PA. Case No. 090200546. 2011 WL 2595418.
News: A 50-year-old diabetic man was transported to the emergency department (ED) twice in 48 hours after being found unresponsive by family. Each time, he was diagnosed with hypoglycemia, stabilized in the ED, and discharged home. He developed severe hypoglycemia 10 hours after his second hospital discharge, and he suffered brain damage as a result.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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