PAUL E. DANIELSON, Associate Justice.
Appellant Nancy Millsap, as the Special Administrator of the Estate of Robert Nash, Deceased, appeals the judgment of the Pulaski County Circuit Court entered in favor of Appellee Victor Williams, M.D. On appeal, Millsap argues that (1) the circuit court abused its discretion by providing erroneous and misleading instructions to the jury concerning consent; and (2) that there was sufficient evidence from which the jury could have found that Robert Nash suffered injury as a result of undergoing a nasogastric procedure performed without proper consent. This court assumed jurisdiction of the instant appeal as involving issues needing clarification or development of the law; hence, our jurisdiction is pursuant to Arkansas Supreme Court Rule 1-2(b)(5) (2014). For the reason explained herein, we reverse and remand.
Robert Nash, the father of Millsap, was diagnosed with colon cancer and was referred to Dr. Williams for surgery to remove the cancerous part of his colon. Dr. Williams admitted Mr. Nash to Baptist Medical Center in Little Rock on November 1, 2009. The next day Dr. Williams performed surgery and removed part of Mr. Nash's colon. On November 4, 2009, Dr. Williams ordered placement of a nasogastric ("NG") tube, but Mr. Nash refused the tube several times. On November 6, 2009, after Mr. Nash twice refused the tube, Dr. Williams placed the NG tube and, shortly thereafter, Mr. Nash started showing signs of medical distress and was transferred to a critical care unit for treatment. Mr. Nash remained hospitalized until his discharge on January 7, 2010. According to the allegations in Millsap's complaint, Mr. Nash required constant care and attention following his discharge until the date of his death on September 4, 2010.
Millsap filed a wrongful-death suit against Dr. Williams on April 4, 2011, alleging that he placed an NG tube against Mr. Nash's expressed wishes, and that he placed it improperly, thereby causing Mr. Nash to aspirate and eventually causing him to suffer hypoxic brain injury. In her complaint, Millsap alleged that the negligence of Dr. Williams was a proximate cause of serious and permanent injury to Mr. Nash. She sought damages and demanded a jury trial. An amended complaint was filed on May 23, 2013, adding claims that Dr. Williams placed an NG tube in a patient who was not mentally competent during the procedure and that Dr. Williams failed to obtain consent from Millsap to place the NG tube.
A jury trial was held July 8 though July 11, 2013. Yuris Gaunt, a nurse who helped care for Mr. Nash after his surgery, testified that on November 6, 2009, she talked with Mr. Nash about placing an NG tube because Dr. Williams had ordered one on
On cross-examination, Gaunt stated that it took Dr. Williams several tries to place the NG tube but once he placed it, Mr. Nash quit fighting. She also confirmed that she made two nursing notes at 1:30 p.m. and that while there was no mention in the first note, she stated in the second note that "Patient vomited minimal amount." But, Gaunt could not specifically recall Mr. Nash vomiting and whether it would have occurred before, during, or after the placement of the tube. She also stated that she would not have assisted with the placement of the NG tube if she had heard Mr. Nash state that he did not want the tube.
Kristi Brockette, who at the time of this incident was the charge nurse, testified that Gaunt approached her on the morning of November 6 and told her that she had an order to place an NG tube but that Mr. Nash was refusing it. Gaunt also told her that Mr. Nash appeared agitated and confused. Brockette stated that she went with Gaunt to talk to Mr. Nash to explain the procedure for placing an NG tube and that Mr. Nash was adamant that he did not want it because his brother had died from the placement of an NG tube. She also confirmed Gaunt's recollection that Mr. Nash was having periods of confusion that morning. Brockette instructed Gaunt to notify Dr. Williams that Mr. Nash had refused the NG tube. Brockette also stated that she did not observe any emergency situation that necessitated the placement of the NG tube.
Dr. Stephen Cohen, a colorectal surgeon, testified as an expert witness for Millsap. Dr. Cohen stated that he reviewed Baptist Health's policies regarding consent, as well as the applicable Arkansas statutes, and interpreted them to require a doctor to seek consent before performing
On cross-examination, Dr. Cohen admitted that he had no idea what conversation may have occurred between Dr. Williams and Mr. Nash regarding the placement of the NG tube, and he also admitted that sometimes a patient may refuse to allow a nurse to perform a procedure but will subsequently allow a doctor to do it.
Nancy Millsap, Ms. Nash's daughter, testified that she went to her father's pre-operative appointment with Dr. Williams. She stated that her father expressed concern about needing a colostomy bag and specifically stated that he did not want an NG tube. Millsap explained that her father was fearful of an NG tube because his brother had died with an NG tube in place and that she and her father explained this to Dr. Williams and his nurse. Millsap stated that Dr. Williams told them there were other things that could be done and "that probably he wouldn't need one." Millsap further stated that her father was so fearful of an NG tube that he would not have had the surgery if he had to have a tube, and that he reiterated this to Dr. Williams at the hospital. Millsap stated that she was with her father on the morning of November 6, and that he was hallucinating and thought there were chickens in the hospital room. She also stated that there had been several attempts during the evening of November 5 and the morning of November 6 to place an NG tube, and that each time her father refused it. Millsap stated that when Dr. Williams came in after lunch she told him that the nurses had upset her father with their attempts to place an NG tube. Dr. Williams asked Millsap and the other family members to step out of the room so that he could check Mr. Nash's incision. She stated that at the time she left the room she had no idea Dr. Williams was going to place an NG tube. According to Millsap, when Dr. Williams came out of the room, he said the incision looked good and told the family to wait before going back in because the nurses were changing Mr. Nash's gown. She stated that there was no conversation about Dr. Williams just having placed an NG tube, and that when she finally was allowed back into the hospital room, her father was "gray" and she thought he was dead and screamed for help. She then noticed her father was "tied to the bed, and he had a tube in his nose." Millsap explained that her father was quickly transferred to a critical care unit, and when she was finally allowed to see him, he had been intubated and was on a ventilator.
At the close of Millsap's case, Dr. Williams moved for a directed verdict "on all issues of negligence, proximate causation, and damages." The circuit court denied the motion, and Dr. Williams then testified on his own behalf. Dr. Williams stated that during his presurgical visit with Mr. Nash he discussed with him possible complications associated with the surgery. Dr. Williams did not recall any discussion with Mr. Nash or his daughter about an NG tube and testified that if there had been such a discussion he would have included it in his physician notes. Dr. Williams stated that he first ordered the NG tube on November 4, after receiving a call concerning Mr. Nash and some hiccups and abdominal distention. Then, on November 6, Dr. Williams stated that he examined Mr. Nash and noticed that his abdomen was very distended and that he was uncomfortable and restless. According to Dr. Williams, he told Mr. Nash that he thought he needed to place an NG tube and gave him the reasons for placing it. Dr. Williams stated that Mr. Nash was able to understand him and to communicate with him and that Mr. Nash agreed to the placement of the tube. Dr. Williams did not recall Mr. Nash using his hands to try to push the tube away. He also stated that he did not discuss the placement with the family because Mr. Nash consented to it, and Dr. Williams believed there was some urgency to place the tube. Dr. Williams stated that he subsequently ordered Mr. Nash be moved to the intensive care unit so he could be more closely monitored.
On cross-examination, Dr. Williams stated that he explained the benefits and risks of placing the NG tube and that Mr. Nash did not appear to be confused and appeared capable to give consent. He admitted, however, that he was not aware of Mr. Nash's earlier hallucinations at the time he spoke with him about placing the NG tube. He again stated that Mr. Nash did not resist placement of the tube, and that while his nurse may have held Mr. Nash's hand, no one used force to restrain him during the placement. Dr. Williams admitted that he knew that Mr. Nash had been refusing placement of the NG tube since he ordered it on November 4. He also stated that in response to a previous request for admission proffered by Millsap that he admitted he or his nurse restrained Mr. Nash in order to place the NG tube. When asked if Mr. Nash's condition presented an emergency situation requiring immediate placement of the NG tube, Dr. Williams stated that he believed "it should have been done right then." Dr. Williams stated that he did not note in Mr. Nash's chart that the patient had given consent for placement of the NG tube but that it is not always necessary to document verbal consent. But, when presented with the rules and regulations applicable to medical staff, Dr. Williams admitted that Baptist
Dr. Roderick Boyd, a general surgeon, testified as an expert witness on behalf of Dr. Williams. Dr. Boyd testified that he believed Dr. Williams complied with the standard of care in treating Mr. Nash and that nothing he did caused him injury or resulted in Mr. Nash's death. He also opined that, for purposes of consent, it was sufficient for Dr. Williams to explain the tube placement to Mr. Nash and for Mr. Nash to nod in agreement. Dr. Boyd further opined that the tube needed to be placed "sooner than later." On cross-examination, Dr. Boyd admitted that during a prior deposition he stated that Mr. Nash was not of sound mind at the time Dr. Williams placed the NG tube, but at trial he deferred to Dr. Williams's judgment.
Following this testimony, the defense rested, and Dr. Williams renewed his previous motion for directed verdict and further argued that, based on the testimony of Dr. Williams, Mr. Nash consented to the NG tube, and without any evidence to the contrary, there was no issue to submit to the jury. The circuit court denied the motion, and the parties began discussing the issue of jury instructions.
In the course of considering jury instructions, Millsap objected to the circuit court giving AMI Civ. 1508, on the basis that the case to be submitted the jury was not an informed-consent case, and that instruction was designed for informed consent and incorporated Arkansas statutes on informed consent. Millsap stated that she had no claim based on "adequacy of information to Mr. Nash." According to Millsap, her case was based on a claim that Mr. Nash refused consent and what information he was or was not supplied with was immaterial. Millsap then proffered a modified version of AMI Civ. 1508, which incorporated parts of Arkansas statutes regarding consent to treatment. Dr. Williams argued that the model instruction was appropriate if the court was going to submit the case to the jury on the allegation of lack of consent, because it was his position that Mr. Nash gave consent and the model instruction was therefore applicable, and that modified instructions should be avoided where there is a model instruction that applies. Millsap next objected to the giving of AMI Civ. 1509 for the same reasons — it was an informed-consent instruction and not applicable, as there was no proof of any lack of informed consent. Dr. Williams argued that the instruction was appropriate because the note on use said it should be given where there is an issue of granting or withholding consent. Thereafter, the court rejected Millsap's proffered instruction that was a modified version of AMI Civ. 1508, and gave both AMI Civ. 1508 and 1509. The jury returned a verdict in favor of Dr. Williams, and this appeal followed.
Millsap argues as her first point on appeal that the circuit court abused its discretion in giving the jury erroneous and misleading instructions in a case premised on lack of consent. According to Millsap, the circuit court abused its discretion when it instructed the jury on the issue of informed consent, as such instructions were misleading because the issue of informed
Dr. Williams counters that the circuit court did not abuse its discretion in instructing the jury as the instructions given conformed to the facts and law and were not misleading. In support, Dr. Williams contends that the issue presented to the jury was not whether Mr. Nash had withheld consent in the past but, rather, the issue was whether, due to a serious change of circumstances, Dr. Williams informed the patient of his change in condition such that the patient trusted his doctor and consented to the insertion of the NG tube. Dr. Williams further argues that "informed consent" was most certainly an issue at trial as indicated by Dr. Williams's uncontradicted testimony that Mr. Nash gave consent and that such consent was naturally informed consent.
It is well settled that a party is entitled to a jury instruction when it is a correct statement of the law and when there is some basis in the evidence to support giving the instruction. Barnes v. Everett, 351 Ark. 479, 95 S.W.3d 740 (2003). When instructions are requested that do not conform to the Arkansas Model Jury Instructions (AMI), they should be given only when the circuit court finds that the AMI instructions do not contain an essential instruction or do not accurately state the law applicable to the case. Id. This court will not reverse a circuit court's refusal to give a proffered instruction unless there was an abuse of discretion. Id.
Here, the disputed jury-instruction issue centers on the giving of model instructions on a theory of informed consent and the rejection of a proffered instruction based on Arkansas statutes governing consent to treatment. On the one hand, the circuit court approved Millsap's modified version of AMI Civ. 1507 and instructed the jury as follows:
But, then the circuit court refused Millsap's other proffered instruction, based on statutory language found in Arkansas Code Annotated sections 20-9-601 to -603 (Repl.2014). The proffered instruction stated as follows:
Thus, despite the notice to the jury that Millsap was alleging a claim for failure to obtain consent, there were no further instructions given that explained when a doctor must obtain consent, how consent may be given, or who may give consent. It is obvious from the focus of the evidence presented in this trial, as demonstrated by the testimony recited herein, that Millsap's claim was that Mr. Nash either did not consent to the placement of the NG tube or was unable to give consent because of mental impairment. The only testimony at all about informed consent was the self-serving testimony of Dr. Williams that he explained the need for the NG tube and that Mr. Nash then consented to its placement. This testimony was simply presented to refute Millsap's claim that Mr. Nash never gave consent.
It is true that nonmodel jury instructions should be given only when the circuit court finds that the model instructions do not contain an essential instruction or do not accurately state the law applicable to the case. Nelson v. Stubblefield, 2009 Ark. 256, 308 S.W.3d 586; Barnes, 351 Ark. 479, 95 S.W.3d 740. But, that was precisely the situation that occurred in this case. There was no model jury instruction regarding consent to treatment, and the instructions related to informed consent were not applicable to the case before the jury. While the model instructions are to be used as a rule, a nonmodel instruction may be used when an AMI instruction cannot be modified. Barnes, 351 Ark. 479, 95 S.W.3d 740. Because there was no applicable model instruction, Millsap proffered an instruction based on the consent-to-treatment statutes, but the circuit court rejected it. This court has held that it is error for the circuit court to fail to instruct the jury on a statute applicable to the case. Allstate Ins. Co. v. Dodson, 2011 Ark. 19, 376 S.W.3d 414.
It is axiomatic that when a jury instruction is erroneous or misleading, it is prejudicial and should not be given to the jury. See Bedell v. Williams, 2012 Ark. 75, 386 S.W.3d 493; Allstate, 2011 Ark. 19, 376 S.W.3d 414. Although the circuit court presented the jury with a modified version of AMI Civ. 1507, its subsequent giving of AMI Civ. 1508 and 1509 only served to confuse the jury as to what Millsap's cause of action was and what she was required to present to prove her case. It must be remembered that the purpose of jury instructions is to inform the jury of the legal principles applicable to the facts presented, and to furnish a guide to assist jurors in reaching a verdict. Hearn v. E. Tex. Motor Freight Lines, 219 Ark. 297, 241 S.W.2d 259 (1951). In sum, the circuit court's failure to properly instruct the jury in this case calls into question the validity of the jury's verdict, as it was based on incomplete and confusing instructions. This clearly constituted an abuse of discretion, and we therefore must reverse and remand. Finally, because we are reversing and remanding for a new trial, it is not necessary to address Millsap's second point on appeal regarding the sufficiency of the evidence.
Reversed and remanded.
BAKER, GOODSON, and HOOFMAN, JJ., dissent.
CLIFF HOOFMAN, Justice, dissenting.
Because I believe that the majority errs in reversing and remanding this case and overlooks this court's prior case law, I respectfully dissent. While the majority opinion states that it is unnecessary to address appellant's second point on appeal, the two points are so interrelated that I think they must be addressed together, and I do so in this dissent. Appellant first contends that the trial court abused its discretion by providing erroneous and misleading instructions to the jury concerning "informed consent" rather than her proffered instruction. Specifically, she argues that the trial court provided the jury with AMI Civ. 1508 (2013) and AMI Civ. 1509 (2013) over her objection, which concern whether a patient has been provided with sufficient information in order to provide consent. She alleges that these instructions were misleading because she argues that her case did not involve whether Dr. Williams provided adequate information but whether Dr. Williams received actual consent. In support, she cites to Arkansas Code Annotated §§ 20-9-601 to -603 for a recitation of Arkansas's law regarding consent in general and alleges that "consent" and "informed consent" are two entirely separate issues.
Additionally, she explains that the trial court's instructions did not provide the jury with guidance as to the important elements that are required for consent, "including whether Mr. Nash was even capable of providing consent, and if he was in fact `of unsound mind[,]' whether there
A party is entitled to a jury instruction when it is a correct statement of the law and there is some basis in the evidence to support giving the instruction. Boellner v. Clinical Study Ctrs., LLC, 2011 Ark. 83, 378 S.W.3d 745. However, this court will not reverse a trial court's refusal to give a proffered instruction unless there was an abuse of discretion. Edwards v. Stills, 335 Ark. 470, 984 S.W.2d 366 (1998). Furthermore, it is not error for the trial court to refuse a proffered jury instruction when the stated matter is correctly covered by other instructions. Id. When instructions are requested that do not conform to the Arkansas Model Jury Instructions ("AMI"), they should be given only when the trial court finds that the AMI instructions do not contain an essential instruction or do not accurately state the law applicable to the case, due to our longstanding preference in favor of AMI instructions over non-AMI instructions. Nelson v. Stubblefield, 2009 Ark. 256, 308 S.W.3d 586; Boellner, supra.
Additionally this court has said that AMI instructions are to be used as a rule, and non-AMI instructions should be used only when an AMI instruction does not exist or cannot be modified. Allstate Ins. Co. v. Dodson, 2011 Ark. 19, 376 S.W.3d 414. It is error for the trial court to fail to instruct the jury on a statute applicable to the case; however, it is also error for the trial court to instruct the jury on an inapplicable statute. Id. Portions of a statute not applicable to the facts of the case must be deleted. Id.
Specific objections to instructions are necessary to preserve an issue for appeal. Ark. R. Civ. P. 51. Specifically, Arkansas Rule of Civil Procedure Rule 51 states,
(Emphasis added.) Therefore, this court has interpreted this rule to require specific objections in order to alert the trial court as to why the instruction is wrong. Allstate
At trial, appellant offered the following objections to two of the jury instructions at issue in this appeal and proffered a modified jury instruction.
(Emphasis added.)
In pertinent part, the trial court read the following jury instructions to the jury, encompassing AMI Civ. 1501, 1508, and 1509 (2013):
In place of the trial court reading AMI Civ. 1508, appellant proffered the following modified jury instruction that she alleges incorporates Arkansas Code Annotated §§ 20-9-601 to -603:
At trial, appellant objected to the inclusion of AMI Civ. 1508 and 1509 instead of her proffered jury instruction, explaining that she was not arguing whether the information supplied was adequate but that "[Nash] refused." The jury had already been instructed that the failure to obtain proper consent was a ground for recovery in the modified AMI Civ. 1507 jury instruction proposed by appellant. Therefore, it was not error for the trial court to refuse the proffered jury instruction when the jury had been instructed in other instructions that the failure to obtain consent was a ground for recovery. See Edwards v. Stills, 335 Ark. 470, 984 S.W.2d 366 (1998).
Additionally, the trial court did not abuse its discretion, as the majority opines, for including AMI Civ. 1508 and 1509 in its instructions. The first paragraph in the notes on use of AMI Civ. 1508 provides that "[t]his instruction should be given when a question is submitted as to whether adequate information was supplied by the medical care provider in connection with the granting or withholding of consent to treatment." (Emphasis added.) Similarly, the first sentence in the notes on use of AMI Civ. 1509 provides that "[t]his instruction should be given in addition to AMI 1501 when a question is submitted as to whether adequate information was supplied by the medical care provider in connection with the granting or withholding of consent to treatment." (Emphasis added.) AMI Civ. 1508 explained to the jury that not only was Dr. Williams required to obtain consent but also that he was obligated to supply adequate information for Nash to decide whether to give or withhold consent.
Furthermore, the evidence presented in Dr. Williams's testimony supported such an instruction when Dr. Williams testified that he met with Nash and explained the reasons why he thought that he needed an NG tube. At trial, Dr. Williams testified that on November 6, 2009, he placed an NG tube after Nash consented to the procedure by "nodding his head" after he explained why he thought the procedure was necessary. He explained that Nash was cooperative during the NG placement, that Nash appeared to be of sound mind, and that he did not speak with any family members because Nash had consented to
Appellant also argues on appeal that her proffered jury instruction was necessary to provide the jury with guidance on the important elements that are required for consent, "including whether Mr. Nash was even capable of providing consent, and if he was in fact `of unsound mind[,]' whether there was implied consent requiring both the existence of an emergency AND evidence that no other authorized person was `immediately available' who could provide consent." She further identified on appeal testimonial evidence that supported the inclusion of her proffered instruction. However, contrary to the majority opinion, appellee correctly contends that appellant failed to state this particular argument as a basis for her objection at trial.
At trial, appellant specifically stated the following when objecting to AMI Civ. 1508 and offering the proffered instruction:
(Emphasis added.) While the majority holds that "it is obvious from the focus of the evidence presented in this trial ... that Millsap's claim was that Mr. Nash either did not consent to the placement of the NG tube or was unable to give consent because of mental impairment," the appellant cannot change the specific arguments made before the trial court now on appeal, even if the new argument may be meritorious. In fact, it is well settled that this court will not consider arguments raised for the first time on appeal. Brown v. Lee, 2012 Ark. 417, 424 S.W.3d 817. Moreover, a party cannot change the grounds for an objection or motion on appeal but is bound by the scope and nature of the arguments made at trial. Id. Appellant was required to make a specific objection to alert the trial court as to why she thought the instruction was wrong and was required to be equally specific as to why her proffered modified, instruction should have been given. She may not on appeal change the scope of this argument. Allstate Ins. Co., supra; Bell v. Misenheimer, 2009 Ark. 222, 308 S.W.3d 120. Accordingly, I think we are precluded from addressing the merits of this new argument on appeal, and I would affirm the trial court.
BAKER and GOODSON, JJ., join.