Dallaire v. Hsu

Citations: 130 Conn. App. 599; 23 A.3d 792; 2011 Conn. App. LEXIS 429Docket: AC 32435

Court: Connecticut Appellate Court; August 9, 2011; Connecticut; State Appellate Court

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The plaintiff, Denis Dallaire, as administrator of Sandra Dallaire's estate, alleged medical malpractice against defendant Ven C. Hsu for prescribing excessive opiate medications that led to the decedent's death. The trial court ruled in favor of the defendant, and the plaintiff appealed on three grounds: (1) the court's determination that the decedent had significant tolerance to morphine and methadone, and that the standard of care did not require the defendant to consult with previous healthcare providers or obtain her pharmacy records; (2) the finding that the plaintiff did not prove causation; and (3) the dismissal of the plaintiff's expert's opinion on causation. The appellate court affirmed the trial court's judgment. Key findings included that the decedent had a history of Madelung’s disease, chronic pain, and prior narcotic prescriptions. After a series of treatments, the decedent saw the defendant, who prescribed high doses of methadone and other opiates. The decedent was found unresponsive shortly after, with the cause of death determined as opiate toxicity. The defendant's special defense claimed contributory negligence. The appellate court emphasized that the trial court's factual findings are binding unless clearly erroneous, relying on the principle that such findings must be supported by evidence in the record.

Conflicting expert testimony does not inherently indicate a lack of evidence; the trial judge determines the credibility and weight of such testimony. In medical malpractice cases, plaintiffs must demonstrate a standard of care, a deviation from that standard, and a causal link to the injury. In this case, the plaintiff contended that the defendant deviated from the standard of care by misclassifying the decedent as opiate tolerant, a point the court found to be not clearly erroneous. Physicians must exhibit the skill and diligence expected of their peers, and negligence must be supported by evidence, typically through expert testimony.

The case hinged on the definitions of "opiate naive" and "opiate tolerant." The defendant’s expert defined an opiate naive patient as one who has never taken narcotics, while the plaintiff's experts had broader definitions, including those who had taken low doses. The court favored the defendant’s expert’s definition, concluding that the decedent had significant opiate tolerance due to her history of chronic opiate use. The plaintiff's experts believed the decedent was opiate naive and that the defendant should have started treatment with lower doses. However, the court rejected this premise, affirming that the decedent was not opiate naive and thus the defendant’s actions were consistent with the standard of care.

The court determined that Adam's experience in pain management was secondary to his primary specialty in neurology, resulting in his opinions lacking credibility. Buffington's assertion that the decedent was opiate naive to morphine was deemed implausible based on the decedent's medical history, further undermining his credibility. Consequently, the court found justifiable grounds to disregard both experts' opinions, affirming that the decedent was opiate tolerant. 

The plaintiff argued that the defendant breached the standard of care by not consulting the decedent’s previous healthcare providers or obtaining her pharmacy records. The court disagreed, stating the defendant was entitled to independently evaluate the decedent's condition, emphasizing that patient history and honesty are crucial in treatment. The court referenced similar cases where a physician was not held liable for malpractice when they acted independently based on the patient's history. 

The defendant, while not board certified, has practiced as a pain specialist since 1989 and is held to the standard expected of board certified physicians in pain management. With the court affirming that the defendant did not breach the standard of care, the issue of causation was deemed unnecessary for consideration. Additionally, the court noted that the plaintiff's expert, Buffington, failed to convincingly link the prescribed dosages to the decedent’s death. The prescription details indicate that the decedent was prescribed 200 micrograms of Duragesic every 72 hours.

The plaintiff's expert testified that the severe pain experienced by the decedent did not absolve the defendant of breaching the standard of care. In contrast, the defendant's expert argued that the decedent was experiencing a crisis, and the defendant prescribed what he deemed an appropriate medication dosage for the severe pain. The court sided with the defendant’s expert. It clarified medical terms, defining 'opiate naive' as a patient who has not previously used opiates, and 'opiate tolerant' as one whose dosage has increased due to the body’s adaptation to the drug. Connecticut acknowledges comparative negligence but still uses the term 'contributory negligence' in its statutes. The court noted that plaintiffs are not required to present expert testimony when a physician’s actions constitute gross negligence; however, the plaintiff did not claim the defendant acted grossly negligently. During cross-examination, the defendant’s expert indicated that a 240 mg dose of methadone could be lethal for an opiate naive patient. The plaintiff contended that the decedent followed prescribed medication guidelines, invoking a presumption of reasonable behavior under General Statutes § 52-114, which states that in cases of alleged negligence causing death, a presumption exists that the deceased acted reasonably. If contributory negligence is claimed, it must be explicitly pleaded by the defendant, who bears the burden of proof. The court upheld the finding that the defendant did not breach the standard of care, rendering the decedent's potential negligence and the presumption of due care moot. The defendant's expert characterized the case as complex, involving a long-term patient with chronic, severe pain on high doses of multiple narcotics. Another expert suggested that the defendant had a responsibility to verify the patient's medical history and that pain management requires a combination of experience and intuition.