Court: Louisiana Court of Appeal; June 29, 2005; Louisiana; State Appellate Court
Sonja Jackson filed a lawsuit against the State of Louisiana and E.A. Conway Medical Center for damages following a surgery intended to remove fibroid tumors, which instead resulted in the removal of her uterus, fallopian tubes, and ovaries. She claimed a lack of informed consent and medical malpractice. The trial court ruled in favor of the defendants, leading Jackson to appeal. The Court of Appeal found no error in the dismissal of the medical malpractice claim but determined that the failure to inform Jackson that the removal of her ovaries would induce menopause constituted a lack of informed consent. Consequently, the court reversed the trial court's ruling on the informed consent claim, awarding Jackson $25,000 in general damages. The case details Jackson’s medical history, including her treatments for dysmenorrhea, menorrhagia, pelvic inflammatory disease, and infertility, along with her evaluation at Louisiana State University Medical Center, which indicated her candidacy for a myomectomy and neosalpingostomy. Despite recommendations for further treatment, transportation issues hindered her access, leading to a referral back to E.A. Conway, where her complaints were documented.
Ms. Jackson, 34 years old, had a history of fibroids and sought fertility treatment. After receiving a Lupron injection, she expressed a desire to remove the fibroid tumors but was unable to travel to Shreveport for further care. A treatment plan was proposed, including additional Lupron injections followed by a referral for myomectomy and neosalpingostomy. However, an alteration in the notes questioned why the procedure could not be performed immediately at the current facility.
She was admitted for surgery on December 27, 1994, with a consent form signed that evening, detailing various procedures including myomectomy, chromopertubation, neosalpingostomy, and potential hysterectomy or salpingo-oophorectomy if necessary. The form did not clarify the meaning of "if indicated" and listed risks such as bleeding, infection, infertility, and ectopic pregnancy. Notably, Dr. Kleinpeter's name appeared as the consulting physician, while Dr. Johnny Swiger signed the consent and performed the surgery.
The surgery, conducted on December 29, 1994, was led by Dr. Swiger and Dr. John Ziegler. The operative report indicated an attempted myomectomy was unsuccessful, leading to a total abdominal hysterectomy and bilateral salpingo-oophorectomy due to bilateral fallopian tube blockage and the location of fibroids. Multiple intra-abdominal adhesions were noted as complications, and the excised fibroid weighed 700 grams.
Ms. Jackson was discharged on January 3, 1995, but was readmitted on January 13, 1995, for heavy bleeding, mistakenly believing she had only had fibroids removed. A review confirmed she underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy, but there is no record of this being communicated to her.
On February 21, 1995, notes from a follow-up visit indicated that Ms. Jackson was unaware she had undergone a hysterectomy, despite having been informed about the procedure during that visit. In her lawsuit against Conway, Ms. Jackson claimed the hysterectomy was performed without her consent, against her wishes for future fertility. She argued that the removal of her uterus, ovaries, and fallopian tubes was unnecessary and not performed in a medical emergency, which deprived her of future hormonal function. Additionally, she alleged that Conway's healthcare providers misled her to believe only fibroids were removed until nearly two months post-surgery.
Conway countered that the hysterectomy was medically necessary and did not affect her fertility, as her condition precluded her ability to conceive prior to the surgery. Conway further argued that even if there was a failure to disclose the possibility of a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO), Ms. Jackson would have consented if the risks had been properly explained.
After a bench trial, the court ruled in favor of Conway on November 15, 2004, dismissing all of Ms. Jackson's claims with prejudice. The court found that Ms. Jackson had been adequately informed about the surgery, supported by an executed consent form and medical records. It noted that the fibroid tumor was significantly larger than her uterus and had perforated the uterine cavity, making the hysterectomy necessary to avoid severe complications. The court also highlighted the presence of severe pelvic adhesions, which necessitated the removal of the tubes and ovaries.
Regarding Ms. Jackson's claim of medical malpractice, the court determined she failed to establish the standard of care concerning the non-usage of Lupron prior to surgery and concluded that she sustained no damages, as her ability to conceive naturally was already compromised due to her medical condition. Ms. Jackson subsequently filed an appeal. The principles of medical malpractice were reiterated, emphasizing the need to prove standard of care, breach, and causation, with expert testimony required in cases involving specialized medical issues.
Conflicting expert opinions regarding a defendant's standard of care compliance lead courts to favor the trier of fact's conclusions. In this case, Ms. Jackson contends that the trial court erred by ruling she sustained no damages and by not evaluating whether her uterus and ovaries' removal breached the standard of care. She claims the court's failure to consider her chance of conception necessitated a de novo review. The court disagrees, noting it evaluated her ability to conceive and concluded she would not have done so naturally or carried a child to term through IVF. The term "probably never" used in the judgment does not indicate a flawed legal standard or warrant de novo review. Appeals focus on judgments, not their reasoning.
The malpractice allegations include failure to administer Lupron injections before surgery and unnecessary removal of reproductive organs against Ms. Jackson's wishes. Expert testimony is essential to assess negligence. Dr. John Ziegler, who assisted in Ms. Jackson's surgery, lacked personal recollection of her treatment. He explained the variable efficacy of Lupron, which was not FDA-approved for treating fibroids at that time, and noted no change in her treatment plan was discussed. Initially, the surgery aimed to remove fibroids and clear the fallopian tubes, but after removing a large fibroid, reconstruction of a viable uterus was impossible. Dr. Ziegler indicated that keeping the uterus would likely cause future problems and that the ovaries and tubes were abnormal due to adhesions and infection, making their removal consistent with the standard of care. Dr. Rodney Wise, director of Conway's ob/gyn department and not directly involved in the treatment, testified that Ms. Jackson had uterine fibroids and blocked tubes before her referral to a fertility clinic.
Testimony indicated that while there was a slight chance of conception for Ms. Jackson, her likelihood of natural conception in 1992 was effectively zero due to infertility caused by a fibroid distorting her uterus, blocked fallopian tubes, and adhesions from pelvic inflammatory disease. The fibroid, initially small in 1992, grew significantly by 1994, causing severe symptoms like pelvic pain and heavy menstruation. Dr. Wise stated that Lupron was not a fertility treatment for Ms. Jackson and that its use was a matter of medical judgment, without a standard requirement for pre-surgery treatment to shrink fibroids. He supported the decision to remove the uterus, citing risks of leaving it intact, including potential vascular issues and complications during a pregnancy. Dr. Wise assessed that Ms. Jackson’s chance of conception would remain virtually zero if a uterine remnant persisted, with a higher risk of rupture in a reconstructed uterus. He also defended the removal of her ovaries, which were severely adhered due to scar tissue, likely causing chronic pain if left in place.
In contrast, Dr. Marcia C. Bowling, an expert for Ms. Jackson, criticized the Conway physicians for not following the Lupron treatment plan, arguing it could have improved Ms. Jackson's chances of preserving her fertility and avoiding a hysterectomy. She contended that the removal of a smaller fibroid would have reduced surgical risks and that a hysterectomy was unwarranted in non-life-threatening situations. Dr. Bowling believed there was a breach of the standard of care, emphasizing the need to prioritize the preservation of the uterus to allow Ms. Jackson the option of pregnancy, especially given the risks associated with uterine rupture.
Dr. Bowling asserted that the removal of Ms. Jackson's ovaries constituted a breach of the standard of care, emphasizing that the ovaries were normal and critical for hormone production at her age. In contrast, Dr. Johnny Swiger, who participated in the surgery, provided an affidavit indicating that the total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO) was necessary and that efforts were made to preserve the uterus and ovaries. He opined that Ms. Jackson would not have been able to conceive regardless of whether her uterus and ovaries were removed. Nurse Donna Carpenter Long testified about advising Ms. Jackson to return to Conway for treatment, though she did not recall the specifics of Ms. Jackson’s case and did not indicate a referral for Lupron therapy.
The trial court found no manifest error in denying Ms. Jackson's medical malpractice claim, noting conflicting expert opinions on whether the standard of care had been breached regarding surgery on a fertility patient. The court upheld that the decision to use Lupron or to remove the uterus and ovaries was a matter of medical judgment. Evidence supported the conclusion that Drs. Ziegler and Swiger acted within their standard of care, as their surgical decisions were based on the anatomical findings encountered. Additionally, it was determined that Ms. Jackson had no realistic chance of conceiving without surgical intervention or in vitro fertilization (IVF), and the record did not indicate that she desired or was informed about IVF as an option. Consequently, the trial court's denial of the malpractice claim was affirmed.
Informed consent for medical treatment, as outlined in La. R.S. 40:1299.40, requires written consent that includes a general description of the procedure, known risks (including severe outcomes like death or disability), acknowledgment of satisfactory answers to questions, and the patient's signature. Such consent is presumed valid unless proven otherwise through misrepresentation of material facts. If consent is obtained differently, the patient must still receive essential information and a chance to ask questions. In cases of alleged lack of informed consent, the plaintiff must demonstrate both that the physician failed to disclose essential information and that this failure caused the claimed damages. This requires establishing a causal link where a reasonable person would not have consented if adequately informed. Expert testimony may be needed to identify significant risks. In reviewing Ms. Jackson's claim, the focus remains on the trial court's findings and the evidence favoring the prevailing party. Ms. Jackson contends she signed a blank consent form for the removal of her uterus and ovaries, claiming it was later filled in by the physicians. Despite initially denying knowledge of the form, she eventually admitted her signature was on it, but asserted it was blank when signed. However, the existing fully executed consent form is presumed valid, and she has not shown misrepresentation that would invalidate it. Her inconsistent statements regarding the signing process led the trial court to potentially discredit her claim.
The presence of outdated consent forms does not demonstrate a practice by Conway of having patients sign blank forms nor undermines the validity of the consent form in this case. Ms. Jackson's claim that she signed a blank form lacks merit. She contends that her consent was not informed, specifically regarding the removal of her uterus and ovaries. Her objections include the unclear phrasing of "if indicated," the absence of menopause discussion, and the abrupt change in treatment from Lupron injections to immediate surgery. Ms. Jackson recalled a meeting with her doctors prior to surgery, where they discussed Lupron and the need for surgery to address a fibroid tumor, but she denied being informed about the possibility of a hysterectomy or ovary removal. Dr. Bowling, her expert, criticized Conway's consent process, asserting that Ms. Jackson did not fully comprehend the procedure and its risks, and noted that hysterectomy should have been explicitly mentioned as a risk associated with myomectomy. In contrast, Dr. Wise defended the consent process, finding it adequate and suggesting that Ms. Jackson may have been uninformed or in denial about the procedure. He confirmed that the potential for a TAH/BSO was documented and explained the term "if indicated" as standard medical terminology indicating the need for medical judgment during surgery. He clarified that it was not unusual for different physicians to collaborate on patient discussions and documentation.
The patient, Ms. Jackson, was involved in a surgical procedure where consent was obtained under specific circumstances. Key points include that the nurse, Eunice Lee, did not recall witnessing the signing of the consent form, nor did she see a blank form presented for signing or anything added post-signature. Dr. Swiger, in his affidavit, affirmed it was standard practice to inform patients of procedures, complications, and alternatives in the presence of a nurse. He claimed to have discussed the surgery with Ms. Jackson, explaining the removal of fibroids and potential removal of her uterus, tubes, and ovaries, along with associated risks such as bleeding and infertility.
The court found no deficiency in informed consent regarding the presence of both Dr. Kleinpeter's and Dr. Swiger's names on the form or the decision to proceed with surgery without Lupron therapy, emphasizing Ms. Jackson's agreement to surgery. The consent form described the procedure as a myomectomy and neosalpingostomy, noting that a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO) would occur "if indicated." It clearly communicated the possible removal of her reproductive organs and associated risks.
However, the form did not specify that the removal of ovaries would lead to surgically induced menopause. The court rejected Conway's claim that mentioning infertility was sufficient to inform Ms. Jackson of this risk. They concluded that a reasonable person in Ms. Jackson's position would have considered the risk of early menopause significant when deciding to consent, especially given her age and desire to become pregnant. Thus, they determined that the failure to disclose this risk constituted a material deficiency in informed consent.
Removal of Ms. Jackson's ovaries was determined not to constitute medical malpractice, as it was deemed a medical judgment by the physicians aimed at preventing complications. The procedure was not performed in response to a life-threatening condition. However, Ms. Jackson was not informed that the removal would lead to menopause, and it cannot be assumed that a reasonable person in her position would have consented to this outcome. The lack of informed consent resulted in damages, as Ms. Jackson experienced menopause at age 34, losing hormone production and facing subsequent health risks, including hot flashes, vaginal atrophy, vaginal dryness, osteoporosis, and heart disease. Although she was placed on hormone therapy post-surgery, it was discontinued due to intolerance. No damages were awarded for infertility, as her fertility issues stemmed from pre-existing conditions rather than the removal of her ovaries. The court awarded $25,000 in general damages for the removal without informed consent about menopause and the shock from discovering the surgery's outcomes. The trial court's dismissal of the medical malpractice claims was affirmed, but the denial of the informed consent claim was reversed. Costs of appeal amounting to $976.50 were assessed against the state.
