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Relationship Between Patient, Nurse, and Doctor

by Attorney Frank E. Reardon

January 1998

            During the last twenty years, the way in which health care has been delivered has changed dramatically.  One particular way in which health care has significantly changed involves the increased litigation of non-physician professionals for the provision of care.  One aspect of this professional shift pertains to registered nurses who are certified in particular specialties, including nurse anesthetics.

            As one might expect, defining the relationship between the certified nurse, the physician, and the patient has not always been easy.  Most states and licensing agencies have required a supervisory relationship.  However, the degree of oversight has sometimes been difficult to specify.  In the recent case of Denton Regional MedicalCenter v. LaCroix, a jury, and then an appeals court, specifically considered and decided the issue.

            A patient was admitted to deliver her first child.  However, prior to the delivery, she experienced difficulty in breathing.  The obstetrician decided to deliver by Caesarian section, and so a certified registered nurse-anesthesiologist was present.  The nurse- anesthesiologist attempted to establish an airway, but was unsuccessful, and so an anesthesiologist was summoned.  Prior to his arrival, however, the patient coded and had to be resuscitated.  During the code, the nurse-anesthesiologist attempted tracheal intubation, but was initially unsuccessful.  The patient suffered an irreversible brain injury.

            Prior to trial, the CRNA and the physician settled their cases.  The plaintiff proceeded  to trial against the hospital, however, on the theory that there were not appropriate policies in place for the supervision and training of nurse-anesthetists.  The jury found against the hospital.

            The hospital appealed, asserting that their policies regarding nurse-anesthetists met the standard of care.  The policy required that CRNA’s have direct supervision by physicians and that an anesthesiologist evaluate and prepare the patient.  However, the plaintiff presented both expert testimony and documents that established that the supervision was not sufficient in this case.  Interestingly, a suggestion was made by the hospital that the obstetrician was supervising the CRNA.  However, the obstetrician disagreed, asserting that he was not qualified to do so.  Finally, a memo from the hospital’s Chief of Anesthesiology which expressed concern about the lack of supervision for CRNA’s was used to buttress the plaintiff’s case.  The plaintiff presented  standards promulgated by the American Society of Anesthesiologists which also required that the anesthesiologist direct the administration of anesthesia and participate in anesthesia induction and emergence. 

           

            The Appeal’s Court sided with the plaintiff.  The court noted that the jury could reasonably find that the guidelines requiring physician supervision had not been complied with.  Therefore, the standard of care would not have been met.

            The use of non-physician professionals requires forethought and planning about their role in the provision of patient care.  Guidelines promulgated by state licensing agencies, the Joint Commission, and professional groups need to be considered and usually adhered to.  These guidelines will usually establish the standard of care by which hospitals will be evaluated.  Naturally, policies that are more rigid in terms of supervision and training will not be a problem.   If policies are adopted which are less stringent, the rational for such a deviation will need to be clearly and concisely set forth in the policy.  An attempt to explain these after the fact will generally be unsuccessful and may be interpreted as a cost saving approach to the detriment of patient care.  Finally, once these policies are adopted, strict adherence to their requirements is mandatory.  These policies  will establish the standard of care by which the hospital will be judged in a court proceeding.