Judy Komlodi v. Anne Picciano, M.D. (071301) , 217 N.J. 387 ( 2014 )


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  •                                                             SYLLABUS
    (This syllabus is not part of the opinion of the Court. It has been prepared by the Office of the Clerk for the convenience of the reader.
    It has been neither reviewed nor approved by the Supreme Court. Please note that, in the interest of brevity, portions of any opinion
    may not have been summarized).
    Judy Komlodi v. Anne Picciano, M.D. (A-13-12) (071301)
    Argued October 7, 2013 -- Decided May 20, 2014
    ALBIN, J., writing for a unanimous Court.
    This appeal concerns the propriety of a jury charge on causation in a medical malpractice action.
    Defendant Dr. Anne Picciano prescribed a Duragesic patch to treat Michelle Komlodi, a patient suffering from chronic back
    pain who was known to abuse drugs and alcohol. The Duragesic patch is intended to be applied to the outer skin and to release the
    powerful pain medication fentanyl over a seventy-two hour period. Michelle orally ingested the Duragesic patch, causing a severe and
    permanent brain injury. Michelle’s mother, as guardian for her incapacitated daughter, filed a medical malpractice action against Dr.
    Picciano and her employer. The primary focus of the trial was whether Dr. Picciano breached the governing duty of care in prescribing
    a Duragesic patch to Michelle, a known abuser of drugs and alcohol, and whether Dr. Picciano, Michelle, or both were substantial
    factors in causing Michelle’s injury. The trial court charged the jury on avoidable consequences and superseding/intervening causation,
    but not on comparative negligence. The court also provided a preexisting condition charge, also known as a Scafidi1 charge, instructing
    the jury to consider whether, based on the patient’s preexisting condition, prescribing the Duragesic patch increased the risk of harm to
    the patient and whether it was a substantial factor in causing the ultimate injury.
    The jury found that plaintiff proved that Dr. Picciano deviated from the applicable standard of care and that the deviation
    increased the risk of harm posed by Michelle’s preexisting condition. Because the jury also found that plaintiff did not prove that the
    increased risk was a substantial factor in producing Michelle’s medical condition, however, based on the Scafidi charge, Dr. Picciano
    did not bear legal fault in causing Michelle’s brain injury. A no-cause verdict was therefore entered in defendants’ favor. In a split
    decision, the Appellate Division overturned the verdict and remanded for a new trial. The majority found that the trial court erred by
    providing the jury a Scafidi charge and a superseding/intervening cause charge, and by including the concept of “but for” causation in
    its proximate cause instruction. Judge Ashrafi, dissenting, disagreed that the Scafidi charge was improper, stating that Michelle’s drug
    addiction was irrefutably a preexisting condition that was a proximate cause of her ingestion of the patch causing her brain injury. He
    also considered the trial court’s reference to “but for” causation harmless error. In his opinion, “[t]he jury’s verdict was based on the
    evidence and on correct instructions as a whole,” and accordingly there was no justification to reverse the no-cause verdict. Defendants
    appealed as of right under Rule 2:2-1(a).
    HELD: The trial court erred in providing a preexisting condition jury charge under the circumstances of this case and, even if the
    Scafidi charge were appropriate, it suffered from multiple defects. The trial court was correct to charge the jury on avoidable
    consequences and superseding/intervening causation, and not comparative negligence, but improperly referenced “but for” causation in
    its instruction on proximate cause. Throughout the causation charge, the trial court failed to tailor the complex concepts of causation to
    the theories and facts advanced by the parties.
    1. To ensure that the jury understands its task of deciding issues of liability and apportionment of damages, the court must provide
    accurate, clear, and understandable instructions on the law tailored to the theories and facts of the case. In a medical-malpractice action,
    the plaintiff has the burden of proving the relevant standard of care governing the defendant-doctor, a deviation from that standard, an
    injury proximately caused by the deviation, and damages suffered from the defendant-doctor’s negligence. In this case, the jury found
    that Dr. Picciano deviated from the applicable standard of care. At issue is the propriety of the trial court’s jury charge on causation.
    (pp. 26-29)
    2. A tortfeasor is generally only liable for the harm she actually caused to the plaintiff. In cases where the plaintiff is responsible for the
    harm she suffers, in whole or in part, the doctrines of comparative negligence, avoidable consequences, and superseding/intervening
    1
    Scafidi v. Seiler, 
    119 N.J. 93
    (1990).
    1
    causation may serve to absolve or limit the defendant’s liability. The comparative-negligence statute permits recovery, and
    apportionment of damages, so long as the plaintiff’s “negligence was not greater than the negligence of the person against whom
    recovery is sought.” N.J.S.A. 2A:15-5.1. Thus, if the plaintiff’s negligence is fifty-one percent and defendant’s is forty-nine percent,
    the plaintiff receives no recovery. Comparative negligence “comes into action when the injured party’s carelessness occurs before
    defendant’s wrong has been committed or concurrently with it.” Ostrowski v. Azzara, 
    111 N.J. 429
    , 438 (1988). In contrast, the
    doctrine of avoidable consequences applies when a plaintiff’s carelessness that occurs after the defendant’s tortious act causes plaintiff
    additional harm. 
    Id. at 438,
    441. Unlike comparative negligence, avoidable consequences is not a defense to liability and serves only to
    mitigate damages. In Ostrowski, the Court held that trial courts “must avoid the indiscriminate application of the doctrine of
    comparative negligence (with its fifty percent qualifier for recovery) when the doctrines of avoidable consequences or preexisting
    condition apply.” 
    Id. at 441.
    In the present case, an avoidable consequences jury charge without a comparative negligence charge was
    appropriate because plaintiff ingested the Duragesic patch after Dr. Picciano allegedly violated the standard of care by prescribing the
    patch. (pp. 29-33)
    3. When a patient is treated for a preexisting condition and a physician’s negligence worsens that condition, it may be difficult to
    identify and prove the precise injury caused by the physician. To address this scenario, in Scafidi the Court held that a jury must decide
    whether any “negligent treatment increased the risk of harm posed by a preexistent condition” and, if so, “whether the increased risk
    was a substantial factor in producing the ultimate 
    result.” 119 N.J. at 108
    . In the typical Scafidi case, the plaintiff seeks treatment for a
    preexisting condition and the physician negligently fails to diagnose or treat the condition, causing the preexisting condition to progress
    and worsen. The amount of damages caused by the aggravation of the preexisting condition due to the physician’s negligence is “the
    value of the lost chance of recovery.” 
    Id. at 112.
    Unlike the doctrines of comparative negligence, avoidable consequences, and
    superseding/intervening causation, Scafidi-type cases generally do not implicate fault on the part of the plaintiff. Here, it is Michelle’s
    failure to properly use the Duragesic patch after Dr. Picciano’s alleged negligence that is at issue. Because the Scafidi charge was used
    to allocate fault, not just damages, it served as a substitute for the comparative-fault charge -- without the fifty-one percent fault bar.
    The Scafidi charge also had the capacity to confuse the jury because it became blurred with the charge on avoidable consequences and
    superseding/intervening cause. In addition, even if the Scafidi charge were appropriate, the trial court improperly failed to tailor the
    legal theories and facts of this case to the law on preexisting conditions or to identify the specific preexisting condition or disease at
    issue. The misapplication of the Scafidi charge requires a remand for a new trial. (pp. 33-38)
    4. Although the panel majority was correct in asserting that “if Michelle’s deliberate act was foreseeable, then it was not a superseding
    cause,” that is not a sufficient reason for not instructing the jury on superseding/intervening cause. Foreseeability is a constituent part of
    proximate cause. If an injury is not a foreseeable consequence of a person’s act, then a negligence suit cannot prevail. A superseding or
    intervening act is one that breaks the “chain of causation” linking a defendant’s wrongful act and an injury suffered by a plaintiff.
    Cowan v. Doering, 
    111 N.J. 451
    , 465 (1988). Intervening causes that are “foreseeable” or the “normal incidents of the risk created,”
    however, will not break the chain of causation and relieve a defendant of liability. Model Jury Charge (Civil) § 6.14 (Aug. 1999). Thus,
    the concepts of foreseeability and superseding/intervening causation are inextricably interrelated and the jury needs to have a full
    understanding of both. Although the trial court here was correct to charge the jury on both concepts, it failed to help the jury sort
    through the complex issues by molding its charge to the facts of the case. The jury had to determine whether, given Michelle Komlodi’s
    medical history of addiction, her oral ingestion of the Duragesic patch was “reasonably foreseeable or was . . . a remote or abnormal
    incident of the risk of self-injury that was not otherwise reasonably foreseeable by defendants.” 
    Cowan, 111 N.J. at 465
    . Intertwined
    with that question was whether Michelle’s act was “volitional and not attributable to [her] disorder or condition.” 
    Ibid. (pp. 38-43) 5.
    The trial court also failed to tailor the avoidable-consequences charge to the legal theories and facts presented. The avoidable-
    consequences charge will only be meaningful to a jury hearing this case if it addresses the special circumstances presented here --
    plaintiff’s capacity to act reasonably to care for herself in light of her drug and alcohol addiction. To that end, the Court provides a
    recommended charge. Finally, the trial court improperly referenced “but for” causation during its instruction on proximate cause. A
    “but for” charge is appropriate when there is only one potential cause of the harm or injury. In contrast, the “substantial factor” test is
    given when there are concurrent causes potentially capable of producing the harm or injury. The substantial-factor test should be used to
    decide proximate cause at the new trial. (pp. 44-48)
    The judgment of the Appellate Division is AFFIRMED and MODIFIED, the no-cause verdict is VACATED, and the matter
    is REMANDED to the trial court for proceedings consistent with this opinion.
    CHIEF JUSTICE RABNER and JUSTICES LaVECCHIA and PATTERSON and JUDGES RODRÍGUEZ and CUFF
    (both temporarily assigned) join in JUSTICE ALBIN’s opinion.
    2
    SUPREME COURT OF NEW JERSEY
    A-13 September Term 2012
    071301
    JUDY KOMLODI, as Guardian for
    MICHELLE KOMLODI, an
    incapacitated person,
    Plaintiff-Respondent,
    v.
    ANNE PICCIANO, M.D. and JFK
    MEDICAL CENTER,
    Defendants-Appellants.
    Argued October 7, 2013 – Decided May 20, 2014
    On appeal from the Superior Court, Appellate
    Division.
    Gary L. Riveles argued the cause for
    appellants (Dughi, Hewit & Domalewski,
    attorneys).
    John B. Collins argued the cause for
    respondent (Bongiovanni, Collins & Warden,
    attorneys).
    E. Drew Britcher argued the cause for amicus
    curiae New Jersey Association for Justice
    (Britcher, Leone, & Roth, attorneys; Mr.
    Britcher and Kristen B. Miller, on the
    brief).
    JUSTICE ALBIN delivered the opinion of the Court.
    In medical malpractice cases, juries are often called on to
    sift through mounds of testimonial evidence, including expert
    testimony, and to absorb complex legal theories on duty of care
    1
    and causation.   Juries cannot fulfill the difficult task of
    rendering a fair and just verdict without accurate, clear, and
    understandable instructions on the law.       That guidance must be
    provided by our trial courts.    Our courts must explain how the
    legal principles apply to the facts and the parties’ competing
    arguments in a charge that is accessible and comprehensible to
    citizens not trained in the law.       This is not an easy
    undertaking, but it is a necessary one.
    In the present case, a family-care physician prescribed a
    powerful medication, a Duragesic patch, to treat a patient who
    suffered from chronic back pain -- a patient who also was known
    to abuse alcohol and drugs.     The seventy-five-microgram
    Duragesic patch is intended to be applied to the outer skin and
    to release the drug fentanyl over a seventy-two hour period.
    The patch has the potency of eighty Percocet tablets.        The
    patient orally ingested the Duragesic patch, causing a severe
    and permanent brain injury.
    The complaint in this medical malpractice action alleges
    that the physician breached the governing duty of care by
    failing to protect a patient with a history of alcohol and drug
    abuse from self-injury.   The central issue in this appeal from
    the jury’s no-cause verdict concerns various portions of the
    trial court’s charge on causation.
    The trial court charged the jury on “preexisting disease or
    2
    condition,” also known as a Scafidi2 charge.    The Scafidi charge
    is typically used in medical malpractice cases in which
    progressive diseases, such as cancer, are not properly treated
    or timely detected and thus the measure of damages is the
    patient’s lost chance of recovery.     The jury here was instructed
    to consider whether, based on the patient’s preexisting
    condition, prescribing the Duragesic patch increased the risk of
    harm to the patient and whether it was a substantial factor in
    causing the ultimate injury.    The trial court, however, never
    identified in its jury charge the preexisting condition or
    related the facts to the law as required by the Model Jury
    Charge.    This case, moreover, did not involve the ineluctable
    progression of a disease on its own.    The ultimate harm caused
    to the patient was from her own conduct -- whether volitional or
    not -- after the physician prescribed the Duragesic.     For that
    reason, the court also charged the jury on
    superseding/intervening causation and avoidable consequences.
    The Appellate Division, in a split decision, overturned the
    verdict and remanded for a new trial, finding that the trial
    court erred in giving the Scafidi charge and, in any event,
    failed to articulate for the jury the nature of the preexisting
    condition or explain the proofs and parties’ arguments in
    relation to the law.    The panel majority also determined that
    2
    Scafidi v. Seiler, 
    119 N.J. 93
    (1990).
    3
    the court should not have given a superseding/intervening cause
    charge because the general charge on foreseeability was
    sufficient.   Additionally, it pointed out that the court had
    mistakenly included the concept of “but for” causation in a case
    involving concurrent causes.
    We agree with the panel majority that the trial court
    misapplied the Scafidi charge.   This was not the traditional
    lost-chance-of-recovery case.    The Scafidi charge, moreover, was
    given for a purpose not intended by our preexisting-condition
    jurisprudence.   Indeed, the defense -- as was made clear in
    summation -- was based on superseding/intervening causation and
    avoidable consequences, not preexisting condition.    We also
    agree with the panel majority that, throughout the charge, the
    trial court failed to explain the complex concepts of causation
    in relation to the proofs and legal theories advanced by the
    parties.
    We part ways with the panel majority’s conclusion that the
    charge on superseding/intervening causation was unnecessary in
    light of the general charge on foreseeability.    To the contrary,
    the superseding/intervening causation charge, if properly given,
    had the capacity to focus the jury’s attention on the
    differences between the parties’ contentions.    Last, the “but
    for” causation reference apparently was an inadvertent mistake
    to which no objection was made by either party.
    4
    We therefore affirm and modify the judgment of the
    Appellate Division and remand for a new trial.
    I.
    A.
    Plaintiff Judy Komlodi, as guardian for her incapacitated
    daughter, Michelle, filed a medical malpractice action against
    defendants Dr. Anne Picciano and JFK Medical Center.    The
    malpractice action arises from the treatment of Michelle by Dr.
    Picciano at the hospital’s outpatient and behavioral health
    clinic.   Dr. Picciano was presented with a thirty-one-year-old
    woman who complained of back pain and suffered from depression,
    anxiety, and drug and alcohol addiction.   Plaintiff alleges that
    Dr. Picciano negligently prescribed a Duragesic patch to treat
    Michelle’s back pain, disregarding the real prospect that her
    drug-addicted daughter would abuse the medication.     Indeed,
    Michelle orally ingested the contents of the patch, which led to
    respiratory arrest and anoxic brain damage, causing severe and
    permanent disabilities.
    The case was tried to a jury.    Here is a summary of the
    testimony heard by the jury.
    B.
    The primary focus of the trial was whether Dr. Picciano
    acted with reasonable care in prescribing a Duragesic patch to
    5
    Michelle and whether Dr. Picciano, Michelle, or both were
    substantial factors in causing the tragic outcome.    Before
    reciting a narrative of events, we begin with a brief
    description of the Duragesic patch, as described by Dr. Picciano
    with reference to the Physician’s Desk Reference (58th ed.
    2004).
    The Duragesic patch contains the powerful pain medication
    fentanyl, an opioid analgesic, in a gel form.   The patch is
    attached to the skin and is designed to release seventy-five-
    micrograms of fentanyl per hour over a seventy-two-hour period.
    The Duragesic patch is not intended for “the management of mild
    or intermittent pain that can otherwise be managed by lesser
    means,” but rather for the treatment of chronic pain that does
    not respond to Percocet, a medication for the relief of moderate
    to moderately severe pain.   The seventy-five-microgram Duragesic
    patch is the equivalent of eighty Percocets.    One side effect of
    the Duragesic patch is suppression of the respiratory system.
    C.
    Dr. Picciano was an employee of JFK Medical Center
    specializing in family medicine and held the position of
    Associate Director of the Family Practice Center.    Michelle had
    been Dr. Picciano’s patient as a teenager, at a time when
    Michelle was being treated by other doctors for drug addiction
    and depression.   On June 7, 2004, Mrs. Komlodi, a former
    6
    nonmedical employee of the Family Practice Center, brought
    Michelle, then age thirty-one, to Dr. Picciano for an
    examination.
    June 7, 2004
    That day, Dr. Picciano learned from Michelle that she had
    been suffering from lower back pain for six months and had
    experienced insomnia, depression, fatigue, anxiety, shortness of
    breath, and weight gain.     Michelle also told of having “passive
    suicidal ideation” and of cutting her wrists two weeks earlier.3
    Michelle related that her back pain began after she stopped
    using heroin and that she did not find relief by taking Aleve,
    Advil, or Tylenol.    Michelle admitted that she was self-
    medicating with alcohol and drugs, such as Percocet and
    Duragesic patches, which were given to her by a friend.
    At trial, Dr. Picciano acknowledged that bodily pains,
    anxiety, depression, and medication craving are all symptoms of
    drug withdrawal.     She also acknowledged that an addict’s craving
    can overcome her will.    Dr. Picciano understood the medical uses
    and the potential abuse of the Duragesic patch.    Too high a
    dose, Dr. Picciano explained, can stop a patient from breathing.
    Moreover, Dr. Picciano understood that the use of the patch with
    other depressants, such as alcohol, could fatally compromise the
    3
    Some of this information was related to a nurse and written on
    Michelle’s medical chart, which was reviewed by Dr. Picciano.
    7
    central nervous system.   She realized that because the Duragesic
    patch might be a medication sought by addicts, it should be
    prescribed with caution to those with a history of alcohol or
    drug abuse.   At the time that she treated Michelle, Dr. Picciano
    also was aware that the Duragesic patch could be cut open and
    the fentanyl directly accessed by an addict.   However, the
    Duragesic manufacturer did not explicitly warn of this potential
    for its abuse until 2005.
    Dr. Picciano ordered an x-ray, seeking to determine the
    source of Michelle’s back pain, and blood work.   Given
    Michelle’s revelations, she also advised Michelle to contact
    Rutgers Behavioral Health.   No medications were prescribed.
    Three days later, Michelle’s blood-test results suggested that
    she might have hepatitis C, a disease that poses a serious
    danger to the liver.
    June 18, 2004
    On June 18, Mrs. Komlodi informed Dr. Picciano that
    Michelle did not have insurance coverage for Rutgers Behavioral
    Health and that Michelle was scheduled for an appointment at JFK
    Behavioral Health Center on July 21 -- more than a month later.
    Mrs. Komlodi expressed concern that, in the intervening month,
    Michelle needed medication to treat her depression.   Dr.
    Picciano knew that a patient who suffers from depression and
    presents a “complicated history with addiction” needs
    8
    “comprehensive care from a mental health facility.”
    Nevertheless, she “reluctantly” agreed to prescribe the anti-
    depressant Zoloft as a bridge until Michelle’s mental health
    appointment.    Dr. Picciano arranged for Mrs. Komlodi to hold the
    pills and give her daughter only one-half a pill every day for
    the first week.
    July 22, 2004
    At Michelle’s appointment on July 22, Michelle told Dr.
    Picciano that she had missed her appointment at JFK Behavioral
    Health Center the day before and had rescheduled it for August
    4.   She also told Dr. Picciano that she was still experiencing
    lower back pain, with the pain registering a “9” on a scale of
    one to ten, and that she was taking “Zoloft that she had gotten
    as samples.”     Michelle had yet to fill the legitimate
    prescription of Zoloft given to her by Dr. Picciano.       Michelle
    stated that, at various times, she was taking Percocet,
    “routinely” using seventy-five-microgram Duragesic patches, or
    consuming “at least” ten alcoholic drinks a day.
    Dr. Picciano explained at trial that, in light of
    Michelle’s hepatitis C diagnosis and the inflammation of her
    liver, the continued use of alcohol presented the greatest
    immediate threat to her life because of its potential to damage
    her liver.     Dr. Picciano could not identify whether the source
    of Michelle’s back pain was a prior automobile accident or
    9
    depression and anxiety.   Her objective was to stop Michelle from
    treating her pain with alcohol.    Percocet was ruled out as an
    appropriate medication because Michelle might take more than the
    prescribed dose or combine it with alcohol.   Dr. Picciano was
    aware that Michelle was procuring illicit drugs, including
    Duragesic patches and Percocet, and abusing alcohol.
    Because Michelle’s mental health appointment was two weeks
    away, Dr. Picciano decided to provide a steady level of
    immediate relief for her back pain by prescribing ten seventy-
    five-microgram Duragesic patches -- a quantity that would last
    for thirty days.   Dr. Picciano warned Michelle that she could
    not drink alcohol while using the Duragesic patch.     Michelle
    assured Dr. Picciano that she would not.    It was Dr. Picciano’s
    assessment that Michelle would not use illicit drugs or alcohol
    if she were on a Duragesic regimen of pain relief.     Indeed, Dr.
    Picciano would never have prescribed the Duragesic patch for
    Michelle if she believed Michelle would continue to use alcohol.
    Dr. Picciano rejected the possibility that Michelle was engaged
    in drug-seeking behavior.
    July 29, 2004
    One week after that appointment, Dr. Picciano received a
    telephone call from Mrs. Komlodi who stated that Michelle had
    been binge drinking and was complaining of severe stomach pains.
    Dr. Picciano told Mrs. Komlodi to take her daughter immediately
    10
    to the emergency room at JFK Medical Center.     There, a blood
    test revealed that Michelle was pathologically intoxicated.       She
    registered a 0.36 percent blood alcohol concentration, an amount
    four-and-one-half times the legally permissible limit for
    driving.4   In addition, her urine tested positive for cocaine.
    Michelle advised the emergency room intake unit that she had
    been prescribed fentanyl for “outpatient detox,” but had yet to
    fill the prescription.
    Dr. Picciano called her partner, Dr. Sherrod Patel, who was
    the attending physician for her practice group at JFK Medical
    Center at that time.    Dr. Picciano described Michelle’s case to
    Dr. Patel and told him to expect her arrival in the emergency
    room.   She also told Dr. Patel that Michelle required
    psychiatric intervention and that he should try to transfer her
    to an inpatient unit.     Michelle was admitted to the hospital
    overnight and released the next day.     Dr. Picciano did not
    cancel the Duragesic prescription.
    Despite the emergency-room chart indicating that Michelle
    had yet to fill the Duragesic prescription, Dr. Picciano not
    only assumed that she had filled it, but also that she had begun
    using the patches.     Dr. Picciano nevertheless made no attempt to
    prevent Michelle from continuing to use the prescribed
    4
    N.J.S.A. 39:4-50(a) (defining “[d]riving while intoxicated” as
    “operat[ing] a motor vehicle with a blood alcohol concentration
    of 0.08% or more”).
    11
    Duragesic, nor did she make any notation in Michelle’s chart to
    alert her practice group that Michelle had been abusing alcohol.
    August 2, 2004
    Just four days after her release from the hospital, on the
    morning of August 2, Michelle consumed “half a pint of
    blackberry red and half a pint of vodka mix.”       During the day,
    Michelle told her mother that her back was bothering her and
    that she had called the pharmacy to fill one half of the
    Duragesic prescription.   (Five patches cost $250 whereas ten
    cost $500.)   Mrs. Komlodi drove her daughter to pick up the
    prescription.    The pharmacist called Dr. Picciano’s office to
    request permission to reduce the number of Duragesic patches
    from ten to five.    A doctor in Dr. Picciano’s practice group
    gave approval, dutifully noting this act in Michelle’s chart.
    Nothing in the chart warned against prescribing fentanyl.
    From the pharmacy, Mrs. Komlodi, her two-year-old
    granddaughter, and Michelle drove to a doctor’s office where
    Mrs. Komlodi had an appointment.       Michelle agreed to babysit the
    toddler in the waiting room.   In the reception area, Mrs.
    Komlodi observed her daughter trying with her teeth to open the
    package that held one of the Duragesic patches.       Michelle asked
    her mother if she had scissors.    Mrs. Komlodi responded that she
    did not and told her daughter to wait until they returned home.
    After Mrs. Komlodi left to meet with her doctor, a receptionist
    12
    noticed that Michelle had passed out.
    Dr. Richard Goldstein found Michelle in the waiting room
    unconscious, blue, not breathing, and without a pulse.   Dr.
    Goldstein and another doctor from the group performed CPR on
    Michelle.    During mouth-to-mouth resuscitation, Dr. Goldstein
    “found a wadded piece of plastic in [Michelle’s] mouth.”     It was
    a Duragesic patch.
    As a result of the fentanyl overdose, Michelle went into
    respiratory and cardiac distress, causing a lack of oxygen to
    the brain.   Michelle was taken to Raritan Bay Medical Center and
    placed on a ventilator for several days.    Later, she was
    released to the JFK Brain Trauma Unit, where she remained for
    over a month.   Michelle suffers from a permanent brain injury
    with physical deficits; severe cognitive, behavioral, and
    psychological impairments; and memory loss.    At the time of
    trial, she was a resident at Universal Institute in Long Branch.
    D.
    Plaintiff’s expert, Dr. John Russo, a specialist in
    internal medicine, testified that Dr. Picciano breached accepted
    standards of medical care by prescribing to a patient, known to
    be abusing both alcohol and drugs, a Duragesic patch for back
    pain without having exhausted typical treatment modalities, such
    as physical therapy and anti-inflammatory medication.    He also
    maintained that Dr. Picciano deviated from those standards by
    13
    prescribing the Duragesic patch to treat Michelle’s “depression,
    anxiety, an eating disorder, alcohol withdrawal or detox from
    alcohol or drugs.”
    Dr. Russo referred to the Physician’s Desk Reference, which
    warns that the “Duragesic should be used with caution in
    individuals who have a history of drug or alcohol abuse
    especially if . . . they are outside a medically controlled
    environment.”   He stated that a physician prescribing a
    Duragesic patch is expected to know that a patient’s misuse of
    the medication can cause respiratory failure and death.    Dr.
    Russo pointedly stated that the standard of care did not allow a
    physician to “give an addict narcotic medications that [she is]
    going to abuse.”     He noted that even in 2004 there were reports
    of addicts orally ingesting the Duragesic patch.     Dr. Russo also
    explained that after Michelle’s episode of binge drinking and
    her hospitalization for pathological intoxication, Dr. Picciano
    should have engaged Mrs. Komlodi to assist in keeping Michelle
    from accessing the prescribed Duragesic.     Dr. Russo concluded
    that Dr. Picciano’s prescribing of the Duragesic patch “was a
    significant contributing factor to the anoxic brain injury”
    suffered by Michelle.
    Defendants’ expert, Dr. Mark Graham, also a specialist in
    internal medicine, testified that Dr. Picciano’s treatment of
    Michelle “was appropriate and within the standards of medical
    14
    care.”    In his opinion, Dr. Picciano understood that Michelle’s
    chronic lower back pain may have been due to “psychiatric
    problems” and therefore properly referred her to mental health
    counseling rather than to an orthopedist.    Dr. Graham believed
    that Dr. Picciano made the best choice from “a list of bad
    options.”    Dr. Picciano knew that Michelle had hepatitis C and
    that Michelle’s continued use of alcohol to treat her back pain,
    anxiety, and depression would ruin her liver.    Dr. Picciano also
    knew that if she did nothing Michelle would continue “using
    drugs off the streets.”    Therefore, to Dr. Graham’s mind, Dr.
    Picciano’s decision to prescribe “a long acting opiate similar
    to the amount that she was getting from the street” was the
    safest choice, provided the medication was used properly.
    Moreover, he stated that not until 2005 did it become general
    medical knowledge that addicts were consuming Duragesic patches
    orally.    Dr. Graham concluded that nothing Dr. Picciano “did
    resulted in the adverse outcome” and that if she “prescribed
    nothing . . . the outcome would likely have been identical to
    what it was.”
    E.
    The trial court denied the motions of both plaintiff and
    defendants for a directed verdict.    At the charge conference,
    plaintiff argued that the court should not instruct the jury on
    apportionment of fault or apportionment of damages between
    15
    plaintiff and defendants.   Plaintiff posited that the standard
    of care governing Dr. Picciano was the duty “to protect the
    patient from [her] drug-seeking behavior and the risk of self-
    inflicted harm whether intentional or unintentional.”      According
    to plaintiff, Dr. Picciano had the duty to foresee the
    consequences of prescribing the medication -- that Michelle’s
    addictive craving would overcome her will and lead her to abuse
    the Duragesic patch.   On that basis, plaintiff submitted that
    the court should not charge on comparative negligence, increased
    risk due to a preexisting condition, or avoidable consequences.
    On the other hand, defendants essentially argued that those
    charges were applicable because the jury could find that
    Michelle was the sole cause of her own tragic condition.     From
    defendants’ perspective, Michelle failed to follow the advice of
    Dr. Picciano to secure mental-health counseling and to use the
    Duragesic patch for its intended purpose.   According to
    defendants, Michelle’s abuse of alcohol for pain relief was
    destroying her liver, and prescribing the Duragesic was a
    medically acceptable treatment for her pain.   Defendants
    contended that Michelle chose to abuse the Duragesic patch in a
    way that could not have been foreseen.
    The court decided to charge on preexisting condition,
    avoidable consequences, and superseding/intervening causation,
    but not on comparative negligence.   In support of its ruling,
    16
    the court cited Ostrowski v. Azzara, 
    111 N.J. 429
    , 441 (1988),
    which held that trial courts “must avoid the indiscriminate
    application of the doctrine of comparative negligence (with its
    fifty percent qualifier for recovery) when the doctrines of
    avoidable consequences or preexisting condition apply.”     Under
    the doctrine of comparative negligence, plaintiff is barred from
    receiving any recovery if she is more than fifty percent at
    fault.   N.J.S.A. 2A:15-5.1.   The court determined that under the
    doctrine of avoidable consequences, the jury could “consider the
    conduct of Michelle as an offset to damages” and apportion
    damages according to each party’s percentage of responsibility.
    The court came to the same conclusion on the theory of increased
    risk resulting from a preexisting condition.    The court
    determined that the jury should be allowed to consider whether
    Dr. Picciano’s prescribing the Duragesic patch increased the
    risk due to Michelle’s preexisting condition and whether
    prescribing the patch was a substantial factor in causing
    Michelle’s brain injury.   This preexisting-condition charge
    allowed the jury to deny plaintiff any recovery.
    The court submitted to the jury a verdict sheet with ten
    interrogatory questions broken down into four categories:
    responsibility, allocation of responsibility, damages, and other
    factors.   The jury’s response to the first three questions in
    the “responsibility” category ended the case.    The jury found
    17
    that plaintiff had proven that Dr. Picciano had deviated from
    accepted standards of family medical practice and that the
    deviation increased the risk of harm posed by Michelle’s
    preexisting condition.   However, the jury found that plaintiff
    did not prove that the increased risk was a substantial factor
    in producing the medical condition of Michelle Komlodi.     This
    last response meant that Dr. Picciano did not bear legal fault
    in causing Michelle’s anoxic brain injury and therefore judgment
    was entered in favor of defendants.
    Plaintiff’s motion for a new trial or judgment
    notwithstanding the verdict was denied.
    II.
    In an unpublished opinion, a split three-judge panel of the
    Appellate Division reversed and remanded for a new trial because
    the trial court incorrectly charged the jury on the law.     The
    panel maintained that the trial court clearly erred by giving a
    Scafidi charge.   According to the panel, a Scafidi charge is
    “‘limited to that class of cases in which a defendant’s
    negligence combines with a preexistent condition to cause
    harm,’” (quoting Verdicchio v. Ricca, 
    179 N.J. 1
    , 23–24 (2004)),
    and the central question in such cases “‘is whether [a]
    plaintiff’s damage claim should be limited to the value of the
    lost chance of recovery,’” (alteration in original) (quoting
    18
    Anderson v. Picciotti, 
    144 N.J. 195
    , 209 (1996)).   The panel
    determined that “defendants did not identify ‘the preexisting
    disease and its normal consequences,’” (quoting Fosgate v.
    Corona, 
    66 N.J. 268
    , 272 (1974)), and therefore “were not
    entitled to a Scafidi charge.”   It also determined that the
    trial court’s vague references to Michelle’s “‘medical
    condition’ and ‘her problems’” were not a sufficient
    articulation of a preexisting condition without tying it “to any
    proofs or theories presented by the parties.”
    The panel also stated that the trial court erred in
    instructing the jury on both “but for” causation and
    “substantial factor” causation in referring to the “preexisting
    condition/increased risk.”   It found that those two forms of
    causation are incompatible and that a “but for” causation charge
    is not appropriate where concurrent causes may be responsible
    for the harmful result.
    In addition, the panel stated that there was “no reason for
    the court to instruct the jury on both foreseeability and
    intervening cause,” for if Michelle’s purposeful misuse of the
    Duragesic patch was “foreseeable,” then the drug abuse would not
    be “a superseding cause that relieves Dr. Picciano from
    negligence.”
    On the other hand, the panel rejected plaintiff’s argument
    that the court should not have instructed the jury on the
    19
    doctrine of avoidable consequences.   The jury, it determined,
    could have concluded that Michelle had a duty to “mitigate[]
    damages by following” Dr. Picciano’s instructions.
    In his dissent, Judge Ashrafi countered that “Michelle
    Komlodi’s drug addiction was irrefutably a preexisting condition
    that was a proximate cause of her ingestion of the injurious
    fentanyl gel . . . [causing] the brain injury she suffered.”      He
    acknowledged that “the trial court erred by including a ‘but
    for’ proximate cause charge in the context of a case involving
    alleged multiple causes of plaintiff’s injuries.”    He
    nevertheless considered this “isolated misstep” not capable of
    producing an unjust result in the context of a lengthy jury
    charge.   On the question of foreseeability and
    superseding/intervening causation, Judge Ashrafi also disagreed
    with the majority, stating that “[b]oth instructions were proper
    statements of the law for the jury to consider in determining
    defendant’s liability.”   In his opinion, “[t]he jury’s verdict
    was based on the evidence and on correct instructions as a
    whole,” and accordingly there was no justification to reverse
    the no-cause verdict.
    Defendants filed an appeal as of right pursuant to Rule
    2:2-1(a).5   The issues before us are limited to those raised in
    5
    Neither party filed a petition for certification challenging a
    ruling of the Appellate Division not raised in the dissent.
    20
    the dissent.   R. 2:2-1(a)(2) (“Appeals may be taken to the
    Supreme Court from final judgments as of right . . . with regard
    to those issues as to which, there is a dissent in the Appellate
    Division . . . .”); Gilborges v. Wallace, 
    78 N.J. 342
    , 349
    (1978) (“[W]here there is a dissent in the Appellate Division,
    the scope of the appeal . . . is limited to those issues
    encompassed by the dissent.”).    We granted the motion of the New
    Jersey Association for Justice (NJAJ) to participate as amicus
    curiae.
    III.
    A.
    Defendants contend that Dr. Picciano did not deviate from
    the appropriate standard of care when she prescribed a Duragesic
    patch for Michelle Komlodi, but even if she did, Michelle caused
    the harm -- an anoxic brain injury -- by ingesting the patch.
    On either theory, defendants insist, they have no legal
    liability.   Defendants argue that the trial court properly gave
    a Scafidi charge because Michelle had a preexisting drug and
    alcohol addiction, and if Dr. Picciano increased the risk of
    harm by prescribing a powerful medication for Michelle’s
    “unremitting back pain,” it was Michelle’s “craving for
    narcotics [that] overcame the valid use of the Duragesic patch.”
    In defendants’ view, Scafidi applies when negligent medical
    21
    treatment exacerbates a preexisting condition, leading to “a
    result which could be foreseeable from that pre-existing
    condition.”   Thus, the Scafidi charge was proper because “[t]he
    pre-existing condition, drug addiction, combined with the
    prescription of a narcotic for back pain, led to a result that
    was foreseeable.”    According to defendants, the role of the jury
    was to determine whether either Dr. Picciano’s treatment or
    Michelle’s preexisting condition was a substantial factor
    causing the anoxic brain injury, and if both were factors to
    apportion damages.   Defendants state that “judicial notice can
    be taken that addicts often overdose, usually unintentionally,
    by accidentally consuming a narcotic or more narcotics than that
    individual intended.”
    Defendants also maintain that the errant “but for” language
    in the jury charge was harmless, for the reasons given by Judge
    Ashrafi.   Last, they submit that the trial court’s charge on
    both superseding/intervening causes and foreseeability was a
    proper statement of law.
    B.
    Plaintiff claims that this was a case of simple negligence
    and therefore the Scafidi charge was improper for two reasons.
    First, Dr. Picciano breached the standard of care by prescribing
    a Duragesic patch to treat the lower back pain of a patient with
    a history of drug and alcohol abuse, and it was foreseeable that
    22
    Michelle would misuse the patch either by orally ingesting it or
    using it while drinking alcohol.     Second, Dr. Picciano was
    negligent because, after prescribing the patch and learning that
    Michelle was abusing alcohol, she did not “take appropriate
    measures to assure that Michelle would not use the patch.”
    Plaintiff maintains that a Scafidi case is one in which a
    doctor negligently treats a preexisting disease, thereby
    increasing the harm caused by the preexisting disease.     In such
    a case “the Scafidi charge is warranted and the plaintiff’s
    damages are limited to the increased risk of harm attributable
    to the defendant’s negligent conduct.”     Here, according to
    plaintiff, Scafidi does not apply because Dr. Picciano was
    treating Michelle for lower back pain and not for the
    preexisting disease of alcohol or drug addiction.     In
    plaintiff’s view, even if Scafidi principles applied, defendants
    failed “to identify the pre-existing condition and reasonably
    apportion the damages” and did not satisfy those principles
    merely by insisting that the anoxic brain injury would have
    occurred anyway “because a drug addict can overdose at any
    time.”   Last on this issue, plaintiff contends that because
    defendants offered no evidence on apportionment of damages, they
    were totally responsible for the injury and damages.
    Plaintiff also claims that the “but for” instruction was
    improper in a case “where there are concurrent or intervening
    23
    causes of harm that do not constitute pre-existing medical
    conditions that the defendant is treating.”   Finally, she urges
    that charging superseding/intervening causation was improper
    because defendants conceded that abuse of the Duragesic patch
    was foreseeable, and therefore such a charge could only have
    served to confuse the jury.
    C.
    Amicus curiae NJAJ also submits that the trial court erred
    in giving a Scafidi charge.   NJAJ states that this case is not
    the “typical Scafidi fact pattern” in which a doctor negligently
    delays medical treatment of a patient afflicted by a preexisting
    disease, leading to an increased risk of harm to the patient.
    In such a case, the preexisting condition itself may lead to a
    harmful result, and the doctor’s negligence accelerates or fails
    to stem the course of the condition.   Here, NJAJ asserts Dr.
    Picciano’s “deviation from the standard of care alone is the
    cause of Michelle’s injuries,” thus rendering inapplicable a
    Scafidi charge.   Further, NJAJ insists that “the trial court
    erred in failing to tailor the charge to the theories and facts
    presented by plaintiffs at trial” and that the “but for” charge
    was so confusing that it fatally undermined the fairness of the
    verdict.
    IV.
    24
    A.
    In this medical malpractice case, the parties presented
    dueling theories on standard of care and causation and hotly
    disputed what inferences should be drawn from the facts.     The
    jury, as the ultimate trier of fact, was presented with the task
    of deciding exceedingly complex issues of liability and
    apportionment of damages.   But a jury cannot fulfill that
    difficult task without accurate, clear, and understandable
    instructions from the court.   Jurman v. Samuel Braen, Inc., 
    47 N.J. 586
    , 591–92 (1966) (“[T]he court’s instructions must . . .
    set forth the issues, correctly state the applicable law in
    understandable language, and plainly spell out how the jury
    should apply the legal principles to the facts as it may find
    them . . . .”).   The faithful performance of the jurors’ duties
    depends on proper guidance from the court.   Talmage v.
    Davenport, 
    31 N.J.L. 561
    , 562 (1864).   Indeed, the trial court
    must tailor the instructions on the law to the theories and
    facts of a complex case for a jury to fully understand the task
    before it.   See Reynolds v. Gonzalez, 
    172 N.J. 266
    , 288-89
    (2002) (reversing medical-malpractice verdict for “trial court’s
    failure to tailor its instruction to the theories and facts
    presented”).
    In a medical-malpractice action, the plaintiff has the
    burden of proving the relevant standard of care governing the
    25
    defendant-doctor, a deviation from that standard, an injury
    proximately caused by the deviation, and damages suffered from
    the defendant-doctor’s negligence.   See 
    Verdicchio, supra
    , 179
    N.J. at 23; Evers v. Dollinger, 
    95 N.J. 399
    , 406 (1983)
    (reversing judgment in favor of defendant because evidence that
    tumor increased in size satisfied plaintiff’s requirement to
    prove damages).   In medical malpractice cases, the standard of
    care generally is not a matter of common knowledge and must be
    established by experts who typically specialize in a field of
    medicine similar to that of the defendant-physician.   Nicholas
    v. Mynster, 
    213 N.J. 463
    , 479 (2013) (noting that in malpractice
    cases generally “‘an expert must have the same type of practice
    and possess the same credentials, as applicable, as the
    defendant health care provider’” (quoting Assem. Health & Human
    Servs. Comm., Statement to Assem. B. 50 at 20 (Mar. 4, 2004))).
    A physician must exercise a duty of care to a patient that,
    generally, any similarly credentialed member of the profession
    would exercise in a like scenario.   Cowan v. Doering, 
    111 N.J. 451
    , 462, 468 (1988).   In certain circumstances -- depending on
    the condition a patient presents -- the duty of care may
    “include the duty to prevent a patient from engaging in self-
    damaging acts.”   
    Id. at 461
    (finding duty of care to prevent
    suicidal patient from self-inflicting harm based on foreseeable
    risk that patient would try to injure herself).   We have held
    26
    that a psychiatrist treating a suicidal patient may have a duty
    to protect the patient from self-harm.     
    Cowan, supra
    , 111 N.J.
    at 462.   A health-care provider may also have a duty to protect
    a particularly vulnerable patient from self-harm.     See Tobia v.
    Cooper Hosp. Univ. Med. Ctr., 
    136 N.J. 335
    , 342 (1994) (stating
    in case involving elderly woman who fell off hospital stretcher
    that it is wrong “to suggest to the jury that although the
    hospital had the duty to care for an incapacitated patient, the
    patient’s lack of care for herself diluted that duty”).     We have
    noted that in cases involving the foreseeability that a patient
    will engage in self-injurious conduct, application of
    comparative negligence may dilute the duty of care.     
    Tobia, supra
    , 136 N.J. at 342; 
    Cowan, supra
    , 111 N.J. at 467.
    In this case, plaintiff and defendants presented
    conflicting expert testimony concerning whether Dr. Picciano
    deviated from the accepted standard of care.    The parties do not
    truly dispute that a “duty of care to prevent self-inflicted
    harm arises” when there is “a foreseeable risk that plaintiff’s
    condition, as it [is] known to defendants, include[s] the danger
    that she [will] injure herself.”     
    Cowan, supra
    , 111 N.J. at 462.
    They dispute whether Dr. Picciano breached this standard.
    Plaintiff argued that prescribing a Duragesic patch to a drug-
    and alcohol-addicted patient, given the ongoing history
    presented by Michelle Komlodi, deviated from the applicable duty
    27
    of care.   Defendants argued that Dr. Picciano prescribed the
    patch as a stop-gap measure to treat Michelle’s pain so that she
    would not self-medicate while she was waiting for her
    appointment at a mental-health clinic.
    In rendering its verdict, the jury pronounced in
    interrogatory number one that Dr. Picciano deviated from the
    standard of care governing a family-practice physician.    That
    finding is not directly at issue in this appeal.   The main focus
    is on the propriety of the charge on causation.
    With this background, we now turn to the various theories
    of causation that are at the heart of this appeal.
    B.
    A basic notion of our law is that, generally, a tortfeasor
    should be liable for only the harm she actually caused to the
    plaintiff.   
    Scafidi, supra
    , 119 N.J. at 112–13.   In cases where
    a plaintiff is responsible, in whole or in part, for the harm or
    injury she suffers, the doctrines of comparative negligence,
    avoidable consequences, or superseding/intervening causation may
    serve to absolve a defendant of liability or limit her damages.
    See 
    Ostrowski, supra
    , 111 N.J. at 436–38 (discussing elements of
    comparative negligence and avoidable consequences); 
    Cowan, supra
    , 111 N.J. at 465 (stating that defendant has no liability
    if there is intervening act that breaks chain of causation).
    Another doctrine -- the one specifically at issue in this case -
    28
    - provides a limitation on liability or damages in a medical
    malpractice action when a defendant-physician fails to timely
    treat or diagnose a preexisting disease or condition, thus
    increasing the risk of harm to the plaintiff.    
    Scafidi, supra
    ,
    119 N.J. at 112 (limiting plaintiff’s damages in preexisting
    disease or condition cases “to the value of the lost chance of
    recovery”).   So, for example, the physician who fails to timely
    detect a progressive disease, such as cancer, is only liable for
    the damages caused by the increased risk of harm resulting from
    her negligence.   See 
    id. at 112–13.
      In a case involving a
    preexisting disease or condition, the defendant-physician, not
    the “innocent” patient, is required to establish the percentage
    of damages attributable to the physician’s negligence.
    
    Verdicchio, supra
    , 179 N.J. at 37 (quoting 
    Fosgate, supra
    , 66
    N.J. at 272).
    Following this Court’s guidance in 
    Ostrowski, supra
    , the
    trial court in this case decided against charging comparative
    negligence.   The comparative-negligence statute permits
    recovery, and apportionment of damages, so long as the
    plaintiff’s “negligence was not greater than the negligence of
    the person against whom recovery is sought.”    N.J.S.A. 2A:15-
    5.1.    Under the statute, if the plaintiff’s negligence is fifty-
    one percent and defendant’s forty-nine percent, the plaintiff
    receives no recovery.   Comparative negligence “comes into action
    29
    when the injured party’s carelessness occurs before defendant’s
    wrong has been committed or concurrently with it.”        
    Ostrowski, supra
    , 111 N.J. at 438 (citing William L. Keeton et al., Prosser
    and Keeton on the Law of Torts § 65 at 458-59 (5th ed. 1984)).
    In contrast to comparative negligence, the doctrine of
    avoidable consequences “normally comes into action when the
    [plaintiff’s] carelessness occurs after the defendant’s legal
    wrong has been committed.”   
    Id. at 438.
       Unlike comparative
    negligence, the doctrine of avoidable consequences is not a
    defense to liability and serves only to mitigate damages.        
    Id. at 441
    (quoting Southport Transit Co. v. Avondale Marine Ways,
    Inc., 
    234 F.2d 947
    , 952 (5th Cir. 1956)).     Avoidable
    consequences will reduce a recovery because a plaintiff cannot
    claim as damages the additional injury she causes to herself
    after a defendant commits a tortious act.     See 
    ibid. A plaintiff whose
    broken wrist is wrongly set by a surgeon cannot
    claim increased damages when, against doctor’s orders, she
    causes additional harm to her wrist while playing tennis.
    Thus, even when comparative negligence is barred,
    “[d]efendants can assert a patient’s self-neglect to limit
    damages.”   
    Tobia, supra
    , 136 N.J. at 343 (stating that if
    plaintiff, after having fallen off stretcher, had worsened her
    condition by disobeying medical instructions, jury could find
    failure to mitigate damages); see also 
    Ostrowski, supra
    , 
    111 30 N.J. at 449
    (noting that diabetic patient’s “continued failure
    to follow dietary and smoking rules” could be considered failure
    to mitigate damages but not comparative negligence); Lynch v.
    Sheininger, 
    162 N.J. 209
    , 230 (2000) (noting in wrongful birth
    claim that trial court might be required to charge avoidable
    consequences if “proofs would sustain a jury finding that the
    [parents] decided to conceive another child notwithstanding
    their knowledge” that pregnancy was likely to be risky).
    In the present case, plaintiff ingested the Duragesic patch
    after Dr. Picciano allegedly violated the standard of care by
    prescribing the patch.     In 
    Ostrowski, supra
    , we said that courts
    “must avoid the indiscriminate application of the doctrine of
    comparative negligence . . . when the doctrines of avoidable
    consequences or preexisting condition 
    apply.” 111 N.J. at 441
    .
    Based on this instruction, the trial court ruled out comparative
    negligence as a defense.    The court’s decision not to charge
    comparative negligence was not appealed.     By its clear terms,
    Ostrowski signaled that a comparative negligence charge should
    not be given when the doctrine of avoidable consequences
    applies.   However, it is also clear here that giving a
    preexisting disease or condition charge was inappropriate.
    C.
    In light of the charges on avoidable consequences and
    superseding/intervening causes, the trial court erred in
    31
    charging the jury on preexisting disease or condition -- the
    Scafidi charge.   We come to that conclusion for several reasons.
    When a patient is treated for a preexisting condition and a
    physician’s negligence worsens that condition, it may be
    difficult to identify and prove the precise injury caused by the
    physician.   See 
    Evers, supra
    , 95 N.J. at 413.    To address this
    scenario, we have held that a jury must decide whether any
    “negligent treatment increased the risk of harm posed by a
    preexistent condition” and, if so, “whether the increased risk
    was a substantial factor in producing the ultimate result.”
    
    Scafidi, supra
    , 119 N.J. at 108.     If the plaintiff satisfies her
    burden of proving these two elements by a preponderance of the
    evidence, then the burden shifts to the defendant to show what
    damages should be attributable solely to the preexisting
    condition as opposed to the physician’s negligence.     See
    
    Fosgate, supra
    , 66 N.J. at 272–73.     The amount of damages caused
    by the aggravation of the preexisting condition due to the
    physician’s negligence is “the value of the lost chance of
    recovery.”   
    Scafidi, supra
    , 119 N.J. at 112.    The jury
    instruction on whether the doctor’s deviation from the standard
    of care increased the risk of harm and whether the increased
    risk was a substantial factor in producing the ultimate harm --
    along with the allocation of damages -- is known as a Scafidi or
    preexisting-condition charge.   See 
    id. at 108-09.
                                    32
    One important distinction between the doctrine of
    preexisting disease and condition and the doctrines of
    comparative negligence, superseding/intervening cause, and
    avoidable consequences is that preexisting disease and condition
    does not involve fault on the part of the plaintiff.     
    Ostrowski, supra
    , 111 N.J. at 438 (“[T]he injured person’s conduct is
    irrelevant to the consideration of the doctrine of aggravation
    of a preexisting condition.”); 
    id. at 437
    (stating that under
    comparative negligence plaintiff is barred from receiving
    recovery when her fault is greater than defendant’s); 
    id. at 443
    (stating that under avoidable consequences plaintiff’s recovery
    is reduced by degree of her fault as expressed by percentage);
    
    Cowan, supra
    , 111 N.J. at 465 (stating that plaintiff’s
    volitional act may constitute superseding/intervening cause
    barring recovery).
    In the typical Scafidi case, the plaintiff seeks treatment
    for a preexisting condition, and the physician, through
    negligence, either fails to diagnose or improperly treats the
    condition, causing it to worsen and sometimes causing the
    plaintiff to lose the opportunity to make a recovery.     See,
    e.g., 
    Reynolds, supra
    , 172 N.J. at 275 (failure to conduct
    appropriate test increased risk of nerve damage and paralysis
    from undiagnosed and untreated condition); 
    Scafidi, supra
    , 119
    N.J. at 98 (failure to properly treat premature labor resulted
    33
    in early birth and death of infant); 
    Evers, supra
    , 95 N.J. at
    404 (delay in treating breast cancer “enhanced the risk that the
    cancer would recur”).    Scafidi-type cases generally do not
    implicate fault on the part of the plaintiff.     The physician
    must take the patient as presented to her and cannot blame the
    patient for the preexisting condition or disease for which the
    patient has sought treatment.
    Thus, in the typical Scafidi case, the inexorable
    progression of a preexisting disease or condition will occur due
    to no fault of the plaintiff, and it is that circumstance that
    will be offset against a treating physician’s negligence.      Here,
    it is Michelle’s failure to properly use the Duragesic patch
    after Dr. Picciano’s alleged negligence -- prescribing the patch
    -- that is at issue.    Because the Scafidi charge here was used
    to allocate fault, not just damages, it served as a substitute
    for the comparative-fault charge -- without the fifty-one
    percent fault bar.   Moreover, the Scafidi charge here became
    blurred with the charge on avoidable consequences and
    superseding/intervening causation.    Defendants’ basic argument
    in summation was that Michelle chose to misuse the Duragesic
    after Dr. Picciano prescribed the patch.    Stated differently,
    Michelle could have avoided the consequence of Dr. Picciano’s
    alleged negligence by properly using the patch.    Notably,
    defendants argue before this Court that Scafidi was appropriate
    34
    because Michelle’s injury was foreseeable given her preexisting
    condition; yet at trial, defendants argued to the jury that Dr.
    Picciano could not have foreseen Michelle’s
    superseding/intervening actions.     These inconsistent arguments
    strongly suggest that the charge had the capacity to confuse or
    mislead the jury.
    In addition, the Scafidi charge suffered from multiple
    defects.   The court merely recited several interrogatory
    questions on the jury verdict form without elaboration or
    further guidance.   The first three interrogatory questions read:
    1) Did plaintiff prove by a preponderance of
    the evidence that Anne Picciano, M.D.,
    deviated from accepted standards of family
    medical practice?
    2) Did plaintiff prove by a preponderance of
    the evidence that the deviation by Dr.
    Picciano increased the risk of harm posed by
    Michelle Komlodi’s pre-existing condition?
    3) Did plaintiff prove by a preponderance of
    the evidence that that increased risk was a
    substantial factor in producing the medical
    condition of Michelle Komlodi?
    These three questions, and a fourth that allowed an allocation
    of damages if the jury answered affirmatively to the first
    three, were the entirety of the court’s Scafidi charge.
    The trial court did not follow Model Jury Charge (Civil) §
    5.50E entitled, “Pre-Existing Condition -- Increased Risk/Loss
    of Chance -- Proximate Cause” (Feb. 2004).     That charge requires
    35
    that the principles of law be charged with reference to the
    specific facts of the case.   The charge instructs the trial
    court to provide “a detailed factual description of the case.”
    Model Jury Charge (Civil) § 5.50E.   That was not done here.    The
    charge also indicates that the preexisting condition or disease
    should be identified.   That was not done here.   For example, the
    Model Jury Charge reads:
    If you determine that the defendant was
    negligent, then you must also decide what is
    the chance that: [(1) the plaintiff would
    not   be  dying   of  cancer;   or  (2)  the
    plaintiff’s husband would not have died of
    the   heart  attack   et   cetera],  if  the
    defendant had not been negligent. . . .
    When the plaintiff came to the defendant,
    he/she had a preexisting condition [here
    describe the condition, e.g., breast cancer;
    heart attack et cetera] which by itself had
    a risk of causing the plaintiff the harm
    he/she ultimately experienced in this case.
    [Ibid.]
    As is evident from the model charge, in instructing the
    jury, the trial court is expected to review facts relevant to
    the charge and to identify the preexisting disease or condition.
    Had the court attempted to do so, the inadvisability of giving
    the charge might have become apparent.   However, even if the
    charge were appropriate, the failure to tailor the legal
    theories and facts to the law on preexisting conditions would
    raise serious questions about the verdict.   
    Reynolds, supra
    , 
    172 36 N.J. at 288-89
    .   “‘[E]rroneous instructions are poor candidates
    for rehabilitation as harmless, and are ordinarily presumed to
    be reversible error.’”   Das v. Thani, 
    171 N.J. 518
    , 527 (2002)
    (quoting State v. Afanador, 
    151 N.J. 41
    , 54 (1997)).
    We agree with the panel majority that the misapplication of
    the Scafidi charge requires a remand for a new trial.
    V.
    We concur with Judge Ashrafi’s dissent that the trial court
    did not err in charging the jury on both foreseeability and
    superseding/intervening causation.     The panel majority was
    correct in asserting that “if Michelle’s deliberate act was
    foreseeable, then it was not a superseding cause.”     That,
    however, is not a sufficient reason for not instructing on
    superseding/intervening causes.    The concepts of foreseeability
    and superseding/intervening causation are inextricably
    interrelated, and the jury needs to be educated to have a full
    understanding of both.   Here, as in other parts of the charge,
    the trial court failed to explain to the jury how the legal
    concepts applied to the facts of the case.
    A.
    Foreseeability is a constituent part of proximate cause,
    and proximate cause is an essential element of a malpractice
    action.   If an injury is not a foreseeable consequence of a
    37
    person’s act, then a negligence suit cannot prevail.     See
    Caputzal v. Lindsay Co., 
    48 N.J. 69
    , 78–79 (1966) (noting that
    there is no liability for “remote consequences” of negligent
    action).   An act is foreseeable when a reasonably prudent,
    similarly situated person would anticipate a risk that her
    conduct would cause injury or harm to another person.     Kelly v.
    Gwinnell, 
    96 N.J. 538
    , 543 (1984) (citing Rappaport v. Nichols,
    
    31 N.J. 188
    , 201 (1959)).    So long as the injury or harm
    suffered was within the realm of reasonable contemplation, the
    injury or harm is foreseeable.    Bendar v. Rosen, 
    247 N.J. Super. 219
    , 229 (App. Div. 1991) (“The tortfeasor need not foresee the
    precise injury; it is enough that the type of injury be within
    an objective ‘realm of foreseeability.’” (citation omitted)).
    In contrast, if an injury or harm was so remote that it could
    not have been reasonably anticipated, the injury or harm is not
    foreseeable.   See 
    Caputzal, supra
    , 48 N.J. at 78–79.
    The superseding/intervening charge complements the general
    charge on proximate cause.    Indeed, the interrelationship
    between foreseeability and superseding/intervening causes is
    recognized by our Model Jury Charges.    Model Jury Charge (Civil)
    § 6.13, “Proximate Cause -- Where There Is Claim That Concurrent
    Causes of Harm Are Present and Claim That Specific Harm Was Not
    Foreseeable” (May 1998), specifically notes that, when
    appropriate, it should be charged with Model Jury Charge (Civil)
    38
    § 6.14, “Where There Is Claim of Intervening or Superseding
    Cause for Jury’s Consideration” (Aug. 1999).
    A superseding or intervening act is one that breaks the
    “chain of causation” linking a defendant’s wrongful act and an
    injury or harm suffered by a plaintiff.   
    Cowan, supra
    , 111 N.J.
    at 465.   A superseding or intervening act is one that is “the
    immediate and sole cause of the” injury or harm.   Model Jury
    Charge (Civil) § 6.14; see also Davis v. Brooks, 
    280 N.J. Super. 406
    , 412 (App. Div. 1993).   Significantly, intervening causes
    that are “foreseeable” or the “normal incidents of the risk
    created” will not break the chain of causation and relieve a
    defendant of liability.   Model Jury Charge (Civil) § 6.14; see
    also 
    Rappaport, supra
    , 31 N.J. at 203.
    As with all disputed issues, the jury is the final arbiter
    of the facts.   Thus, whether a particular risk is foreseeable
    and whether the act of another is one of the “normal incidents
    of the risk created” are issues for the jury.    See 
    Rappaport, supra
    , 31 N.J. at 203.
    
    Cowan, supra
    , provides one illustration of
    superseding/intervening causation in a medical malpractice 
    case. 111 N.J. at 465
    –66.   In that case, at defendant Valley Hospital,
    the defendant doctors and nurses treated the plaintiff, who had
    attempted suicide by overdosing on sleeping pills.   
    Id. at 455.
    At some point, the plaintiff was placed in a room, the door was
    39
    closed, and she was not monitored, contrary to hospital policy.
    
    Id. at 456.
       The plaintiff managed to jump out of the window of
    her room, falling twelve feet and injuring herself.      
    Ibid. We upheld the
    trial court’s instruction on superseding/intervening
    causation.     
    Id. at 465.
      We noted that the plaintiff’s “leap
    from the window” might break the chain of causation “if her act
    were volitional and not attributable to her disorder or
    condition.”    
    Ibid. “The issue fairly
    presented to the jury was
    whether the leap was reasonably foreseeable or was, on the
    contrary, a remote or abnormal incident of the risk of self-
    injury that was not otherwise reasonably foreseeable by
    defendants.”     Ibid. (citing 
    Rappaport, supra
    , 31 N.J. at 203–
    04).    It was left to the jury to determine whether the plaintiff
    was able to exercise reasonable care given her underlying
    condition.     
    Id. at 466.
      We upheld “the jury’s rejection of the
    intervening causation” because the evidence “fully supported”
    the finding that “it was clearly foreseeable that defendants’
    conduct created a risk that plaintiff would engage in self-
    damaging acts.”     
    Ibid. We now apply
    these principles to the case before us.
    B.
    Here, the jury had to determine whether, given Michelle
    Komlodi’s medical history of addiction to alcohol and drugs, her
    oral ingestion of the Duragesic patch was “reasonably
    40
    foreseeable or was . . . a remote or abnormal incident of the
    risk of self-injury that was not otherwise reasonably
    foreseeable by defendants.”   
    Cowan, supra
    , 111 N.J. at 465.
    Intertwined with that question was whether Michelle’s act was
    “volitional and not attributable to [her] disorder or
    condition.”   
    Ibid. Were Michelle’s addictive
    cravings so
    powerful that they were capable of overcoming her will, and
    would a reasonably prudent, similarly credentialed physician
    have understood this dynamic?    In light of Michelle’s apparently
    proper, although illicit, topical use of the Duragesic patch in
    the past, was it reasonably foreseeable that Michelle would
    orally ingest the prescribed Duragesic?    Was there common
    knowledge among family care practitioners about the potential
    abuses of Duragesic patches at the times relevant in this case?
    What would a reasonably well-informed doctor have anticipated
    given the patient’s medical history and prior conduct?     We do
    not suggest that these precise questions had to be framed for
    the jury.   The court here, however, never posed any appropriate
    superseding/intervening causation questions.   Instead, the court
    gave examples completely unrelated to the proofs.
    The trial court was correct to charge the jury on
    superseding/intervening cause.   But it did not mold its
    instructions to the facts of this case.    Juries must know how
    the legal instructions are to be applied to the complex factual
    41
    scenarios before them, and the instructions must be clear and
    understandable.   The jury charge failed to give the jury the
    guidance it needed to sort through the complex issues in this
    case.
    VI.
    Neither plaintiff nor defendant has challenged the
    avoidable-consequences charge given at trial; nevertheless, our
    review of the avoidable-consequences charge leads us to the
    conclusion that it must be adapted to the special circumstances
    of this case.   As with all jury instructions, the trial judge
    should tailor the charge to the facts and the parties’
    arguments.   Model Jury Charge (Civil) § 8.11B, “Duty to Mitigate
    Damages by Medical and Surgical Treatment,” will only be
    meaningful to a jury hearing this case if it addresses the
    special circumstances presented here -- how plaintiff acted in
    light of her drug and alcohol addiction.   The jury must
    determine whether, and to what degree, the plaintiff had the
    capacity to act reasonably to care for herself in light of her
    health or mental condition.   See 
    Cowan, supra
    , 111 N.J. at 460.
    We recommend the following charge:
    Plaintiff    contends   that    because    of
    Michelle’s   impaired   health    or   mental
    condition, defendant had the duty to protect
    Michelle from harming herself.        If you
    42
    decide that plaintiff is entitled to damages
    for Michelle’s injuries, you then must
    decide whether Michelle had the capacity to
    exercise   reasonable   care  to   avoid  or
    mitigate the damages she suffered.
    A plaintiff is responsible for mitigating
    the consequences of a defendant’s negligent
    conduct to the extent reasonable care can be
    exercised by the plaintiff, taking into
    consideration   her    health    or   mental
    condition.
    In this case, defendant claims that Michelle
    could have avoided or mitigated her injuries
    by securing mental health treatment or by
    using the Duragesic patch as instructed. On
    the   other  hand,   plaintiff   claims  that
    Michelle was so impaired by her addiction
    that she was incapable of caring for
    herself, that is, incapable of avoiding or
    mitigating her injuries.     You, members of
    the jury, must decide the facts, and
    ultimately which of the party’s arguments is
    most persuasive, or whether there is some
    merit to both, and if so to what degree.
    In short, you must decide what percentage,
    if any, of Michelle’s damages were caused by
    a   failure   on   her   part   to   exercise
    reasonable care to avoid or mitigate those
    damages -- provided she was capable of doing
    so.   If she was capable of doing so, you
    must reduce her damages accordingly.
    Whether a plaintiff acted reasonably must be
    examined   in  light   of   the  plaintiff’s
    capacity to care for herself.    A plaintiff
    suffering from a health or mental condition
    may be capable, incapable or not fully
    capable of caring for herself as an ordinary
    person would.
    If you find that plaintiff has established
    defendant’s negligence, then defendant must
    prove by a preponderance of the evidence
    that Michelle, in light of her health or
    43
    mental condition, could      reasonably    have
    acted to avoid or mitigate injury.
    A defendant is liable only for that portion
    of   the   injuries   attributable   to  the
    defendant’s negligence.    If you find that,
    in light of her health or mental condition,
    Michelle did not act reasonably to avoid or
    mitigate injury, you must assess the degree
    to which the injuries were the result of
    either defendant’s negligence or Michelle’s
    own   unreasonable  failure   to   avoid  or
    mitigate injury.     You must allocate by
    percentages defendant’s responsibility for
    Michelle’s injuries and Michelle’s failure
    to exercise care to avoid or mitigate those
    injuries.6
    VII.
    The appellate panel majority and the dissent agree that the
    use of a “but for” causation charge in conjunction with a
    substantial-factor charge was error.   Unlike the majority,
    however, the dissent concluded that the error was harmless.   The
    trial court made a seemingly inadvertent reference to “but for”
    causation during its instruction on proximate cause.
    So, first you must find that the
    resulting injury would not have occurred but
    for Dr. Picciano’s negligent conduct.
    Second,  you   must   find   that  the
    negligent conduct was a substantial factor
    in bringing about the resulting injury.  If
    you find that Dr. Picciano’s negligence was
    a cause of the injury and was a substantial
    6
    We refer to the Supreme Court Committee on Model Civil Jury
    Charges, for its review, the charge on avoidable consequences
    for any recommendations it may have for its improvement, bearing
    in mind the various scenarios to which it may apply.
    44
    factor in bringing about the injury, that
    negligence was a proximate cause of the
    injury.
    This was the only reference to “but for” causation in the
    charge.    Importantly, no party objected to the “but for”
    reference.   See R. 1:7-2 (“Except as otherwise provided by R.
    1:7-5 and R. 2:10-2 (plain error), no party may urge as error
    any portion of the charge to the jury or omissions therefrom
    unless objections are made thereto . . . .”).
    These two forms of causation -- “but for” and “substantial
    factor” -- are mutually exclusive.    A “but for” charge is
    appropriate when there is only one potential cause of the injury
    or harm.   See Conklin v. Hannoch Weisman, P.C., 
    145 N.J. 395
    ,
    417 (1996) (“In the routine tort case, ‘the law requires proof
    that the result complained of probably would not have occurred
    “but for” the negligent conduct of the defendant.’” (citation
    omitted)).   In contrast, the “substantial factor” test is given
    when there are concurrent causes potentially capable of
    producing the harm or injury.    
    Id. at 419–20.
       Thus, “a
    tortfeasor will be held answerable if its ‘negligent conduct was
    a substantial factor in bringing about the injuries,’ even where
    there are ‘other intervening causes which were foreseeable or
    were normal incidents of the risk created.’”      Brown v. United
    States Stove Co., 
    98 N.J. 155
    , 171 (1984) (quoting 
    Rappaport, supra
    , 31 N.J. at 203).    A substantial factor is one that is
    45
    “not a remote, trivial or inconsequential cause.”    Model Jury
    Charge (Civil) § 6.13.
    We have determined that there must be a new trial because
    of the erroneous inclusion of the Scafidi charge.    At the new
    trial, the jury charge must explain the parties’ legal theories
    and the proofs in relation to the governing law.    In addition,
    the substantial-factor test will be the test for deciding
    proximate cause.
    VIII.
    For the reasons explained, we affirm and modify the
    judgment of the Appellate Division.   Accordingly, the no-cause
    verdict is vacated, and a new trial is ordered.    This matter is
    remanded to the Law Division for proceedings consistent with
    this opinion.
    CHIEF JUSTICE RABNER and JUSTICES LaVECCHIA and PATTERSON
    and JUDGES RODRÍGUEZ and CUFF (both temporarily assigned) join
    in JUSTICE ALBIN’s opinion.
    46
    SUPREME COURT OF NEW JERSEY
    NO.    A-13                                         SEPTEMBER TERM 2012
    ON APPEAL FROM                 Appellate Division, Superior Court
    JUDY KOMLODI, as Guardian for
    MICHELLE KOMLODI, an
    Incapacitated person,
    Plaintiff-Respondent,
    v.
    ANNE PICCIANO, M.D. and JFK
    MEDICAL CENTER,
    Defendants-Appellants.
    DECIDED                May 20, 2014
    Chief Justice Rabner                         PRESIDING
    OPINION BY          Justice Albin
    CONCURRING/DISSENTING OPINION BY
    DISSENTING OPINION BY
    AFFIRM AS
    CHECKLIST                             MODIFIED/
    VACATE/
    REMAND
    CHIEF JUSTICE RABNER                        X
    JUSTICE LaVECCHIA                           X
    JUSTICE ALBIN                               X
    JUSTICE PATTERSON                           X
    JUDGE RODRÍGUEZ (t/a)                       X
    JUDGE CUFF (t/a)                            X
    6
    1