Bryan v. Rectors & Visitors of the University of Virginia ( 1996 )

PUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
CINDY BRYAN, Administratrix and
Personal Representative of the
Estate of Shirley A. Robertson,
deceased,
Plaintiff-Appellant,
v. No. 95-2023
RECTORS AND VISITORS OF THE
UNIVERSITY OF VIRGINIA, t/a
University of Virginia Medical
Center,
Defendant-Appellee.
Appeal from the United States District Court
for the Eastern District of Virginia, at Alexandria.
Leonie M. Brinkema, District Judge.
(CA-95-220-A)
Argued: May 9, 1996
Decided: September 13, 1996
Before MURNAGHAN and WILLIAMS, Circuit Judges, and
PHILLIPS, Senior Circuit Judge.
_________________________________________________________________
Affirmed by published opinion. Senior Judge Phillips wrote the opin-
ion, in which Judge Murnaghan and Judge Williams joined.
_________________________________________________________________
COUNSEL
ARGUED: Michael Vincent Greenan, MICHAEL V. GREENAN,
P.C., Warrenton, Virginia, for Appellant. Gerald Richard Walsh,
GERALD R. WALSH, P.C., Fairfax, Virginia, for Appellee. ON
BRIEF: Michael J. Carita, GERALD R. WALSH, P.C., Fairfax, Vir-
ginia, for Appellee.
_________________________________________________________________
OPINION
PHILLIPS, Senior Circuit Judge:
Cindy Bryan, as administratrix of the estate of Shirley Robertson,
brought this action against the University of Virginia under the Emer-
gency Medical Treatment and Active Labor Act (EMTALA), 42
U.S.C. § 1395dd (1994). She alleged that the university's hospital
failed to provide Mrs. Robertson with the stabilizing treatment that
the Act requires and thereby caused her death. The hospital moved to
dismiss under Rule 12(b)(6) of the Federal Rules of Civil Procedure
for failure to state a claim, and the district court granted the motion.
We affirm, though on somewhat different grounds than those relied
upon by the district court.
I.
The gist of Bryan's complaint is that the hospital violated
EMTALA when, having treated Mrs. Robertson for an emergency
condition for twelve days, it determined pursuant to its internal proce-
dures that no further efforts to prevent her death should be made and
then eight days later, when Mrs. Robertson faced a life-threatening
episode, adhered to its prior determination and allowed her to die. The
complaint reads, in pertinent part, as follows:
4. On February 5, 1993, Shirley Robertson was trans-
ferred from Fauquier Hospital to the University of Virginia
Medical Center for an emergency medical condition, most
emergently, respiratory distress.
5. At all times relevant, The university of Virginia
Health Science Center (U.Va.) received clear instructions
from Mrs. Robertson's husband, Charles and all of her chil-
2
dren that the Defendant Hospital take all necessary measures
to keep her alive and trust in God's wisdom.
6. In violation of 42 USC §1395dd, the Defendant
hospital refused to be instructed by the husband and family
of their patient Shirley Robertson, and on February 17,
1993, entered "do not resuscitate" order against the family's
wishes.
7. As a result of the "do not resuscitate" order, Mrs.
Robertson was not stabilized and died on February 25, 1993.
In dismissing the action, the district court interpreted the complaint
as alleging a violation of subsection (b) of the Act, which requires a
hospital to stabilize or transfer any patient who arrives at the hospital
with an emergency condition. It then held that the Act imposes no
obligations on a hospital once the hospital has admitted the patient.
At that point, according to the district court, the hospital's obligations
are covered by state tort law, and EMTALA is out of the picture.
Since Mrs. Robertson had been admitted to the hospital long before
the occurrence of the hospital's alleged misdeeds, the complaint did
not state a claim under EMTALA. On this basis, the court dismissed
the action on the merits.
This appeal followed.
II.
Bryan's essential contention is that EMTALA imposed upon the
hospital an obligation not only to admit Mrs. Robertson for treatment
of her emergency condition, which concededly was done, but thereaf-
ter continuously to "stabilize" her condition, no matter how long treat-
ment was required to maintain that condition. Such a theory requires
a reading of the critical stabilization requirement in subsection (b)(1)
of EMTALA that we cannot accept.
Subsection (b)(1) provides that:
If any individual . . . comes to a hospital and the hospital
determines that the individual has an emergency medical
condition, the hospital must provide either--
3
(A) . . . for such further medical examination and such
treatment as may be required to stabilize the medical condi-
tion, or
(B) for transfer of the individual to another medical
facility . . . .
Bryan's proffered interpretation of that subsection is boldly that, "If
a hospital . . . accepts a patient with an emergency medical condition
either by admission or transfer and continues stabilizing treatment for
any period of time, whether it be one hour, one week or twelve days
and then refuses such stabilizing treatment, such refusal of stabilizing
treatment without transfer violates EMTALA." Appellant's Brief at 5.
As is admitted in the complaint, and so necessarily conceded by
Bryan in her brief and oral argument, stabilizing treatment was pro-
vided by the hospital from Robertson's arrival on February 5 until
February 17. But, the claim is that the hospital's abandonment of such
treatment as of its entering the anti-resuscitation order on February 17
and its failure to offer stabilizing treatment in response to Robertson's
heart attack eight days later constituted an EMTALA violation.
Under this interpretation, every presentation of an emergency
patient to a hospital covered by EMTALA obligates the hospital to do
much more than merely provide immediate, emergency stabilizing
treatment with appropriate follow-up. Rather, without regard to pro-
fessional standards of care or the standards embodied in the state law
of medical malpractice, the hospital would have to provide treatment
indefinitely--perhaps for years--according to a novel, federal stan-
dard of care derived from the statutory stabilization requirement. We
do not find this reading of the statute plausible.
As Bryan recognizes and as this court has frequently observed,
EMTALA is a limited "anti-dumping" statute, not a federal malprac-
tice statute. Vickers v. Nash Gen. Hosp., Inc. , 78 F.3d 139, 142-43
(4th Cir. 1996) (citing numerous cases). Its core purpose is to get
patients into the system who might otherwise go untreated and be left
without a remedy because traditional medical malpractice law affords
no claim for failure to treat. Brooks v. Maryland Gen. Hosp., Inc., 996
F.2d 708, 710 (4th Cir. 1993) (recognizing that"[u]nder traditional
4
state tort law, hospitals are under no legal duty to provide [emergency
care to all]" and holding that EMTALA's purpose is simply to impose
on hospitals the legal duty to provide such emergency care);
Gatewood v. Washington Healthcare Corp., 933 F.2d 1037, 1041
(D.C. Cir. 1991) (holding that EMTALA's purpose is"to create a new
cause of action, generally unavailable under state tort law, for what
amounts to failure to treat"). Numerous cases and the Act's legislative
history confirm that Congress's sole purpose in enacting EMTALA
was to deal with the problem of patients being turned away from
emergency rooms for non-medical reasons. See, e.g., Correa v. Hos-
pital San Francisco, 69 F.3d 1184, 1189 (1st Cir. 1995) (Congress
enacted EMTALA because it was "`concerned about the increasing
number of reports that hospital emergency rooms are refusing to
accept or treat patients with emergency conditions if the patient does
not have medical insurance.'") (quoting H.R.Rep. No. 241(I), 99th
Cong., 1st Sess. 27 (1986), reprinted in 1986 U.S.C.C.A.N. 42, 605),
cert. denied, 116 S. Ct. 1423 (1996); Eberhardt v. City of Los
Angeles, 62 F.3d 1253, 1255 (9th Cir. 1995) (Congress enacted
EMTALA "in response to `a growing concern about the provision of
adequate emergency room medical services to individuals who seek
care. . . .'") (quoting H.R.Rep. No. 241(III), 99th Cong., 1st Sess. 5
(1986), reprinted in 1986 U.S.C.C.A.N. 42, 726); Cleland v. Bronson
Health Care Group, Inc., 917 F.2d 266, 268 (6th Cir. 1990) ("It is
undisputed that the impetus to [EMTALA] came from highly publi-
cized incidents where hospital emergency rooms allegedly . . . failed
to provide a medical screening that would have been provided a pay-
ing patient, or transferred or discharged a patient without taking steps
that would have been taken for a paying patient."); see also 131 Cong.
Rec. S13,892-01 (1985) (remarks of Sens. Durenberger, Kennedy,
Dole, Baucus, Heinz, and Proxmire, emphasizing that the source of
EMTALA was the widely reported scandal of emergency rooms'
increasingly dumping indigent patients from one hospital to the next
while the patients' emergency conditions worsened). Once EMTALA
has met that purpose of ensuring that a hospital undertakes stabilizing
treatment for a patient who arrives with an emergency condition, the
patient's care becomes the legal responsibility of the hospital and the
treating physicians. And, the legal adequacy of that care is then gov-
erned not by EMTALA but by the state malpractice law that everyone
agrees EMTALA was not intended to preempt. That being the legal
5
reality, there is no justification for Bryan's assertion that, under such
a reading of EMTALA, "a hospital could simply treat for a few days
or hours and then refuse treatment if they could not stabilize quickly
and cheaply." Appellant's Brief at 7. Such refusal of treatment after
the establishment of a physician-patient relationship would be regu-
lated by the tort law of the several states. See , e.g., 61 Am. Jur. 2d,
Physicians, Surgeons and Other Healers, § 234 ("[T]he relation of
physician and patient, once initiated, continues until it is ended by the
consent of the parties . . . or until his services are no longer needed,
and until then the physician is under a duty to continue to provide
necessary medical care to the patient."), § 238 ("Failure of the patient
to pay for the physician's services does not justify the physician in
abandoning the patient while he still is in need of medical attendance
. . . .") (1981). And, EMTALA is quite clear that it is not intended to
preempt state tort law except where absolutely necessary. See 42
U.S.C. § 1395dd(f) (mandating that EMTALA preempt no state law
requirement "except to the extent that the requirement directly con-
flicts with a requirement of [EMTALA]"). Such reprehensible disre-
gard for one's patient as Bryan hypothesizes would not constitute the
"dumping" at which EMTALA aims but the well established tort of
abandonment, which the states may expand or constrict as they deem
just but which Congress evidenced no desire to federalize. Presump-
tively aware of this feature of state tort law, Congress did not address
a hypothetical problem that was not before it but addressed a national
scandal that was: emergency rooms' turning away patients at the door
for inability to pay or other similar reasons.
EMTALA seeks to achieve the limited purpose of its enactment by
requiring that the hospital provide limited stabilizing treatment to or
an appropriate transfer of any patient that arrives with an emergency
condition. 42 U.S.C. § 1395dd(b)(1);*see also Vickers, 78 F.3d at
142. And it defines "to stabilize" as "to provide such medical treat-
ment of the condition as may be necessary to assure, within reason-
able medical probability, that no material deterioration of the
_________________________________________________________________
*The Act also requires that every hospital provide an appropriate
screening to every patient who comes to its emergency department and
determine whether the patient, in fact, has an emergency medical condi-
tion. 42 U.S.C. § 1395dd(a). But there is no claim in this case that the
hospital violated the screening requirement.
6
condition is likely to result from or occur during the transfer of the
individual . . . ." 42 U.S.C. § 1395dd(e)(3)(A). The stabilization
requirement is thus defined entirely in connection with a possible
transfer and without any reference to the patient's long-term care
within the system. It seems manifest to us that the stabilization
requirement was intended to regulate the hospital's care of the patient
only in the immediate aftermath of the act of admitting her for emer-
gency treatment and while it considered whether it would undertake
longer-term full treatment or instead transfer the patient to a hospital
that could and would undertake that treatment. It cannot plausibly be
interpreted to regulate medical and ethical decisions outside that nar-
row context.
To resist this conclusion, Bryan relies entirely on our decision in
In the Matter of Baby "K", 16 F.3d 590 (4th Cir. 1994), cert. denied,
115 S. Ct. 91 (1994), but that decision is fully consistent with our
interpretation of the Act here. The patient in issue in Baby K was an
anencephalic infant suffering, when presented for admission, from
respiratory distress. The hospital sought a declaratory judgment that
under those circumstances its prevailing standard of care for anence-
phalic infants should provide the standard for its compliance with
EMTALA's requirement of stabilization of the patient's respiratory
distress. We rejected that contention, holding that EMTALA's stabili-
zation requirement is focused upon the patient's emergency medical
condition, not her general medical condition. Under the circum-
stances, the requirement was to provide stabilizing treatment of the
condition of respiratory distress, without regard to the fact that the
patient was anencephalic or to the appropriate standards of care for
that general condition.
The holding in Baby K thus turned entirely on the substantive
nature of the stabilizing treatment that EMTALA required for a par-
ticular emergency medical condition. The case did not present the
issue of the temporal duration of that obligation, and certainly did not
hold that it was of indefinite duration.
III.
There remains the question whether under this interpretation of the
critical provision of EMTALA, Bryan's complaint states a claim
7
under that statute. Though dismissal under Fed. R. Civ. P. 12(b)(6) is
proper only if a court can conclude that on the claim as pleaded the
claimant could prove no set of facts that would entitle her or him to
relief, Labram v. Havel, 43 F.3d 918, 920 (4th Cir. 1995), we do so
conclude here.
Bryan's complaint alleges no EMTALA violation on the part of the
hospital at any time before Mrs. Robertson had been in the hospital
for twelve days. The only actions by the hospital that are alleged as
violations of EMTALA began on February 17 with the entry of the
anti-resuscitation order and ended on February 25 with the hospital's
failure to prevent Robertson's death. As Bryan has expressly con-
ceded on appeal, the complaint therefore must be taken to admit that
Mrs. Robertson actually received stabilizing treatment in accord with
EMTALA for twelve days following her admission and to confine the
claim of violation only to the ultimate cessation of that or any further
medical treatment upon entry of the anti-resuscitation order. Appel-
lant's Brief at 6.
So constrained in legal theory, Bryan could, under our interpreta-
tion of the limits of the stabilization treatment obligation, "prove no
set of facts that would entitle her to relief." Whether the conduct
alleged may have violated other law is not before us. We hold only
that it did not violate EMTALA, and that the district court did not,
therefore, err in dismissing the claim as alleged.
AFFIRMED
8