Television sometimes gives the impression that once a trial is over, the case is done. In real life, cases are not that straightforward. We are revisiting a case covered in this column in 2017 when it was originally decided. This case has since been appealed, remanded back to the trial court, and appealed again. In this article, we will examine the final appeal.
The original facts date back over a decade. The patient, Mr K, was a 28-year-old Black man referred to a government clinic after a pre-employment screening revealed very high blood pressure. At the clinic, the patient was seen by Ms D, a nurse practitioner, who administered clonidine, which immediately reduced Mr K’s blood pressure from 210/170 mm Hg to 200/130 mm Hg. She ordered routine laboratory work, gave him medication to take home, wrote a prescription for a hypertension medication, told him to watch what he ate, and signed the form clearing him for work. The patient was supposed to return for follow-up in a week but he didn’t come back for 2 years when again his blood pressure was flagged during a work screening. He was sent to the clinic where he again saw Ms D.
During the 2 years, Mr K had not suffered any symptoms associated with high blood pressure such as headaches, blurred vision, or shortness of breath. At his appointment, his blood pressure was 240/150 mm Hg. Ms D gave the patient clonidine in the office and sent him home with a prescription for hypertension medication and a signed form allowing him to return to work. Ms D did not order laboratory work at this time but asked Mr K to return in a week. He returned 3 weeks later.
Over the next 2 years, the patient had 10 appointments with Ms D during which his blood pressure was consistently high. At some appointments, she noted that he was noncompliant with his medication such as when he stopped taking a medication because he felt “bad” when he took it or thought it wasn’t working. Ms D did not explain to the patient that the medication could cause adverse effects, that the risks of uncontrolled hypertension include kidney damage, or that he was at an increased risk for kidney damage because he is a young Black man. She didn’t explain to him the importance of staying on his medicine — even if he felt fine — or the consequences of only using medication sporadically.
Ms D ordered laboratory tests (for the first time since his initial visit 3 years previous). The laboratory tests revealed signs of kidney damage, but Ms D did not see the results. At trial, she admitted that if she had seen the results she would have referred the patient to a nephrologist. A year later, she again ordered laboratory work, which revealed stage 4 chronic kidney disease but she failed to communicate this to the patient. Two months later, Mr K collapsed and was diagnosed with stage 5 kidney disease, necessitating a kidney transplant at age 35 years. He eventually sued the government, Ms D’s employer.
The Court Decides
Mr K alleged that Ms D failed to educate him about his hypertension or monitor its progress and as a result his disease progressed to the point where he required dialysis and a transplant. After a 5-day trial, Ms D was found to be negligent and Mr K was awarded almost $30 million in damages. The government appealed, challenging the damages calculation and arguing that Mr K’s comparative negligence in not taking his medication or showing up for his appointments made him responsible for his situation.
The appellate court upheld the damages calculation but sent the case back to the trial court for a determination of Mr K’s comparative negligence under the state’s reasonable person standard. The lower court would have to determine what an objectively reasonable person would understand about hypertension.
To do this, the court heard from 3 experts who established that patients often feel well when they have hypertension, which misleads them into thinking they don’t need treatment if they feel well; high blood pressure is known as a silent killer; patient education is essential to controlling the condition, particularly in younger people; and patients don’t typically understand that medication must be taken daily even if the patient feels fine.
The court concluded that “a reasonable person would not understand that high blood pressure was a serious, chronic condition, and in that context a reasonable person would seek medical treatment when symptoms flared — as one would do for a condition that is acute or episodic rather than chronic and progressive.” This was exactly how Mr K was seeking treatment. It was up to Ms D, as the clinician, to educate her patient so that he understood the nature of his disease, possible consequences, and the absolute necessity of taking medication to control it. Without this education, Mr K could not be expected to understand the consequences of taking the medication sporadically or not at all.
For many diseases, the nature of the disease and its ramifications will be a matter of general knowledge, such that a reasonable person would be expected to perceive the risk and to take action appropriate to address that risk even absent education from a medical practitioner. But in this case, the court found that the expert testimony established that “there is a widespread lack of knowledge as to hypertension, its chronic nature, and the health danger that it poses unrelated to any symptoms, and in such an environment in which the danger is not perceived by the general public, a reasonable person would not be expected to take action to avoid it,” wrote the court in its decision.
This decision highlights the extreme importance of patient education particularly in the case of hypertension. As a clinician, it’s sometimes easy to lose sight of what a regular person knows about a disease. The fact is that many patients don’t understand hypertension or the need to control it, and they don’t know the consequences of leaving it uncontrolled. The job of the health care practitioner is to make sure that when a patient leaves the office, they understand their condition.
Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, New York.