Santana-Concepcion v. Centro Medico del Turabo, Inc., 1st Cir. (2014)

7/26/2019 Santana-Concepcion v. Centro Medico del Turabo, Inc., 1st Cir. (2014)

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United States Court of AppealsFor the First Circuit

No. 12- 2013

MARI A SANTANA- CONCEPCI ÓN, ET AL. ,

Pl ai nt i f f s , Appel l ant s ,

CONJ UGAL PARTNERSHI P CRUZ- SANTANA, ET AL. ,

Pl ai nt i f f s,

v.

CENTRO MÉDI CO DEL TURABO, I NC. , d/ b/ a Hospi t al HI MASan Pabl o Bayamón; DR. J ULI O ROSADO- SÁNCHEZ, ET AL. ,

Def endant s, Appel l ees,

HI MA SAN PABLO PROPERTI ES, I NC. ; GRUPO HI MA SAN PABLO, I NC. ,

Def endants.

APPEAL FROM THE UNI TED STATES DI STRI CT COURTFOR THE DI STRI CT OF PUERTO RI CO

[ Hon. Sal vador E. Casel l as, U. S. Di st r i ct J udge]

Bef or e

Lynch, Chi ef J udge, Tor r uel l a and Li pez, Ci r cui t J udges.

Gl enn Car l J ames f or appel l ant s. J osé Ar t uro Gonzál ez- Vi l l ami l , wi t h whom Buf et e Gonzál ez-

Vi l l ami l was on br i ef , f or appel l ees Cent r o Médi co del Tur abo,I nc. , Hi ma San Pabl o Bayamón and i t s i nsur er HI MA San Pabl o Capt i veI nsurance Company Li mi t ed.

J osé A. Mi r anda- Dal ecci o, wi t h whomMi r anda Cár denas & Cór dovawas on br i ef , f or appel l ees Dr . J ul i o Rosado- Sánchez and t heconj ugal par t ner shi p Rosado- Phi l i ppi .



Sept ember 23, 2014



LIPEZ, Circuit Judge. Thi s i s a medi cal mal pr act i ce and

i nf or med consent case f r om Puer t o Ri co i nvol vi ng cl ai ms by t he

pat i ent and her chi l dr en. The di st r i ct cour t hel d t hat t he st at ut e

of l i mi t at i ons bar r ed t he cl ai ms brought by t he pat i ent and her

adul t chi l dr en, gr ant i ng summary j udgment t o t he def endant s on t hat

basi s. Gi ven t hat t he st at ut e of l i mi t at i ons does not appl y t o

mi nor chi l dr en unt i l t hey r each maj or i t y age, t he di st r i ct cour t

addr essed t he mer i t s of t hei r mal pr act i ce and i nf ormed consent

cl ai ms. Concl udi ng t hat t he "er r or of j udgment " def ense f or ecl osed

mal pr act i ce l i abi l i t y and t hat t he f ai l ur e of pr oof on causat i on

f or ecl osed l i abi l i t y f or l ack of i nf or med consent , t he cour t

gr ant ed summary j udgment on t hose cl ai ms as wel l . We af f i r m.

I.

We recount t he f act s i n t he l i ght most f avor abl e to the

appel l ant s, who were t he non- movi ng par t y at summary j udgment .

O' Connor v. St eeves, 994 F. 2d 905, 907 ( 1st Ci r . 1993) .

On August 16, 2006, pl ai nt i f f - appel l ant

Sant ana- Concepci ón, a r egi st er ed nur se, af t er submi t t i ng to a CT

scan of her br ai n at Rochest er Gener al Hospi t al i n Rochest er , New

Yor k, was di agnosed wi t h a l ar ge ar achnoi d cys t . 1 Af t er f ur t her

medi cal t est i ng, Sant ana- Concepci ón' s doct or s t her e advi sed her

t hat her ar achnoi d cyst di d not r equi r e sur ger y.

1 An ar achnoi d cyst i s a membr ane- l i ned f l ui d sac, l ocat edbetween t he l ower br ai n and spi nal cord r egi on of t he cr ani um.St edman’ s Medi cal Di ct i onary 353 ( 5t h ed. 1982) .

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Whi l e i n Puer t o Ri co dur i ng t he f al l of t hat year ,

Santana- Concepci ón exper i enced ext r eme pai n and went t o t he

emergency r oom at HI MA- San Pabl o Hospi t al on November 15. The

emer gency room physi ci an r ef er r ed her t o neur osur geon Dr . J ul i o

Rosado- Sánchez ( "Dr . Rosado") , who di agnosed her wi t h a

"sympt omat i c ar achnoi d cyst " and recommended sur ger y and ant i edema

medi cat i on t o hel p r el ease t he i ncr eased i nt r acrani al pr essur e.

Dr . Rosado expl ai ned t o Sant ana- Concepci ón t hat she needed an

oper at i on as soon as possi bl e and t hat i t coul d be a l i f e- or - deat h

si t uat i on. Sant ana- Concepci ón r epl i ed, " Good, not a pr obl em. Do

as you see f i t , as f ar as you t ake away t hi s pai n. I j ust need

t hi s pai n t o go away. " Dr . Rosado operated on Sant ana- Concepci ón

on November 17, 2006, per f ormi ng expl orat ory br ai n sur gery ar ound

t he cyst and pl aci ng a shunt t o rel i eve pr essur e cr eat ed by t he

cyst .

Sant ana- Concepci ón r etur ned t o Rochest er t hat wi nt er and

vi si t ed her physi ci an t her e on J anuar y 2, 2007. Her physi ci an

r ecor ded t he det ai l s of t hat vi si t as f ol l ows:

Thi s i s a 46- year - ol d f emal e wi t hhi st or y of an ar achnoi d cyst , who comes i nt oday i n f ol l ow- up. She act ual l y appar ent l yhad a VP shunt pl aced i n Puer t o Ri co when shewas seen i n t he ER [ and] t he cyst was

eval uated t here. Thi s was i n mi d- November .She st at es t hat she has no f ur t her depr essi vesympt oms. She has however , had sympt oms of decreased vi si on, di f f i cul t y wi t h gai t andbal ance, and she has not i ced t hat her voi cei s much l ouder t han pr evi ousl y and her sons

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need t o have t o poi nt out t o her t hat she i st al ki ng l oudl y.

She has had no sei zur e act i vi t y. Shewas st ar t ed on Di l ant i n at t hat poi nt . Shedi d not br i ng her r ecor ds t oday f or me t o l ook

at .

. . .

We wi l l l ook at her r ecor ds and t hent r y to get her r ef er r ed back t o Dr . Maxwel lf or neur osur ger y t o f ol l ow t he shunt as wel las Dr . Honch. Wi l l cont i nue t he Di l ant i n andDepakot e f or now and check l evel s of t hose asa CBC and compl et e met abol i c panel and come upwi t h a t r eat ment pl an af t er we see herrecords.

Her son, who spoke f l uent Engl i sh, accompani ed her on t hat vi si t .

On Febr uary 20, 2007, Sant ana- Concepci ón was hospi t al i zed

at Rochest er General Hospi t al wi t h sympt oms of headache, di zzi ness,

and vi sual changes. A CT scan and an MRI r eveal ed t hat she had a

shunt wi t hi n her ar achnoi d cyst . Two days l at er ,

Sant ana- Concepci ón agai n met wi t h her t r eat i ng physi ci an. Herphysi ci an r ecor ded t he det ai l s of t hat vi si t as f ol l ows:

Thi s i s a 46- year - ol d f emal e wi t hhi st or y of ar achnoi d cyst , S/ P VP shuntpl acement i n Puer t o Ri co who comes i n t oday i nf ol l ow- up f r om a hospi t al st ay. She had whatappear s t o be as a f i nal di agnosi s beni gnposi t i onal ver t i go. However , she di d see aneur ol ogi st i n consul t who r ecommended t hatshe mi ght consi der get t i ng t he shunt t aken out

as i t i s not decreasi ng t he si ze of t he cystand has seemed t o r esul t i n some behavi orchanges.

She al so compl ai ns of i nt er mi t t ent pai nat t he shunt si t e behi nd t he l ef t ear .

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On Apr i l 19, 2007, Sant ana- Concepci ón vi si t ed her doct or

i n Rochest er yet anot her t i me compl ai ni ng of pai n. Dur i ng t hi s

vi si t her physi ci an al l egedl y made t he comment t hat whoever di d

t hi s t o her ( meani ng t he shunt sur ger y) was a "but cher . "

Sant ana- Concepci ón, al ong wi t h her husband and f our

chi l dr en, 2 f i l ed t hi s sui t agai nst Dr . Rosado and HI MA- San Pabl o

Hospi t al on Mar ch 3, 2008, a l i t t l e mor e t han a year af t er

Sant ana- Concepci ón' s second hospi t al i zat i on i n New Yor k. They

cl ai med t hat Dr . Rosado f ai l ed t o adequat el y i nf or m Sant ana-

Concepci ón of t he r i sks associ at ed wi t h t he shunt sur ger y bef or e

obt ai ni ng her consent , and t hat he f ai l ed t o abi de by t he

pr evai l i ng medi cal st andar ds appl i cabl e to t he t r eat ment he

pr ovi ded ( i . e. , engaged i n mal pr act i ce) . The al l eged mal pr act i ce

concer ned t he t r eat ment deci si on t o oper at e on t he cyst , r ather

t han t he adequacy of Dr . Rosado' s surgi cal t echni que i n t he

oper at i ng r oom. The pl ai nt i f f s cont ended t hat t he hospi t al was

vi car i ousl y l i abl e f or Dr . Rosado' s conduct .

The di st r i ct cour t gr ant ed summar y j udgment t o t he

def endant s on al l cl ai ms. The cour t hel d t hat t he cl ai ms of

Sant ana- Concepci ón and her adul t chi l dr en wer e al l t i me- bar r ed. I t

f ur t her hel d t hat t he medi cal mal pr act i ce cl ai m of her mi nor

chi l dr en was f or ecl osed by t he "er r or of j udgment " def ense and t he

2 Santana- Concepci ón' s husband has si nce passed away. Sher epr esent s hi s hei r s ' i nt er ests i n t hi s l i t i gat i on.

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i nf or med consent cl ai m f ai l ed on t he el ement of causat i on. 3 Thi s

appeal f ol l owed.

II.

We r evi ew t he di st r i ct cour t ' s summary j udgment deci si ons

de novo. Domí nguez- Cr uz v. Sut t l e Car i be, I nc. , 202 F. 3d 424, 428

( 1st Ci r . 2000) . Summary j udgment i s pr oper l y gr ant ed when " t he

movant shows t hat t here i s no genui ne di sput e as t o any mat er i al

f act and t he movant i s ent i t l ed t o j udgment as a mat t er of l aw. "

Fed. R. Ci v. P. 56( a) . When consi der i ng t he summary j udgment

r ecor d, "[ a] l l r easonabl e i nf er ences ar e to be dr awn i n f avor of

t he part y opposi ng summary j udgment , i n t hi s case appel l ant [ s] ,

j ust as al l di sput ed f act s ar e vi ewed i n t he l i ght most f avor abl e

t o [ t hem] . " O' Connor , 994 F. 2d at 907. I n assessi ng cl ai ms t hat

genui ne mater i al i ssues exi st , we must deci de whether " t he evi dence

i s such t hat a r easonabl e j ur y coul d r et ur n a ver di ct f or

[ Sant ana- Concepci ón or her chi l dr en] . " Ander son v. Li ber t y Lobby,

I nc. , 477 U. S. 242, 248 ( 1986) .

Feder al j ur i sdi cti on i n t hi s case i s based on di ver si t y

of ci t i zenshi p. See 28 U. S. C. § 1332. 4 We appl y t he l aw of Puer t o

Ri co t o t he medi cal mal pr act i ce and i nf or med consent cl ai ms i n t hi s

3 The di st r i ct cour t ' s r easoni ng i s expl ai ned i n mor e det ai li nf r a. We l ar gel y t r ack t he cour t ' s anal ysi s.

4 Pl ai nt i f f s ar e r esi dent s of New Yor k. Def endant s ar er esi dent s of Puer t o Ri co.

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case because t hat i s where the medi cal t r eat ment at i ssue took

pl ace.

A. Santana-Concepción and Adult Childrens' Claims

1. Statute of Limitations

The pl ai nt i f f s f i l ed sui t on Mar ch 8, 2008. For t he

cl ai ms t o sur vi ve t he st at ut e of l i mi t at i ons on summar y j udgment ,

t here must be a genui ne i ssue of mater i al f act as t o whether t hey

wer e f i l ed wi t hi n t he l i mi t at i ons per i od.

a. Application to Malpractice Claims of

Santana-Concepción and Adult Children

Puer t o Ri co l aw af f or ds one year t o f i l e sui t f or medi cal

mal pr act i ce af t er " t he aggr i eved per son ha[ s] knowl edge t her eof . "

P. R. Laws Ann. t i t . 31, § 5298 ( 2008) ; see al so Or t i z v. Muni ci pi o

De Or ocovi s, 13 P. R. Of f i c. Tr ans. 619, 621 ( 1982) . Al t hough t he

r unni ng of t he st at ut e of l i mi t at i ons does not wai t f or t he i nj ur y

t o "r each i t s f i nal degr ee of devel opment , " i t does not begi n t or un unt i l t her e i s "knowl edge" of t he mal pr act i ce. Or t i z, 13 P. R.

Of f i c. Tr ans. at 621. Such knowl edge must i ncl ude bot h t he i nj ur y

and t he causal l i nk bet ween t he i nj ur y and t he al l egedl y negl i gent

medi cal pr ocedur e. Guzman- Camacho v. St at e I ns. Fund Corp. , 418 F.

Supp. 2d 3, 8 ( D. P. R. 2006) ; Ri ver a- Encar naci ón v. Est ado Li br e

Asoci ado de P. R. , 13 P. R. Of f i c. Tr ans. 498, 502 ( 1982) . 5

5 By stat ut e Puer t o Ri co has est abl i shed t hat t he l i mi t at i onsper i od f or medi cal mal pr act i ce begi ns not when t he i nj ur y occur s,but when t he pat i ent f i r st has knowl edge of t he i nj ur y. P. R. LawsAnn. t i t . 31, § 5298 ( "The f ol l owi ng pr escr i be i n one ( 1) year :

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Under t he l aw of t or t s i n Puer t o Ri co, i ncl udi ng medi cal

mal pr act i ce and l ack of i nf or med consent , r el at i ves ar e ent i t l ed t o

"compensat i on f or t he suf f er i ngs, emot i onal di st r ess, or ment al

angui sh exper i enced as a consequence of t he mater i al or other

damages caused di r ect l y t o t hei r r el at i ves. " Sant i ni - Ri ver a v.

Ser v Ai r , I nc. , 137 P. R. Dec. 1, 10- 12 ( 1994) . The per i od

avai l abl e to exer ci se such an act i on i s one year , and begi ns t o r un

when t he pl ai nt i f f s l ear n about t he damages suf f er ed by t he

r el at i ve- vi ct i m. I d.

Wi t h r egar d t o t he medi cal mal pr act i ce cl ai ms of t he

pl ai nt i f f and her adul t chi l dr en, t he st at ut or y cl ock began t i cki ng

soon af t er t he onset of Sant ana- Concepci ón' s f i r st negat i ve

post - operat i on sympt oms. Sant ana- Concepci ón sought t r eat ment f or

t hese symptoms i n ear l y 2007. The symptoms were f i r st document ed

on J anuar y 2, 2007, and t hen on her subsequent vi si t s t o t he

hospi t al i n Febr uary 2007. The neur ol ogi st who exami ned

Sant ana- Concepci ón i n Febr uary r ecommended "get t i ng t he shunt t aken

out as i t [ was] not decr easi ng t he si ze of t he cyst and ha[ d]

seemed t o resul t i n some behavi or changes. "

Sant ana- Concepci ón nonet hel ess cont ends t hat because she

di d not under st and Engl i sh, and t her ef ore coul d not r ead t he not es

. . . ( 2) Act i ons to demand ci vi l l i abi l i t y f or gr ave i nsul t s orcal umny, and f or obl i gat i ons ar i si ng f r om t he f aul t or negl i gencement i oned i n § 5141 of t hi s t i t l e [whi ch i ncl udes medi calmal pr act i ce] , f r om t he t i me t he aggr i eved per son had knowl edgethereof . " ) .

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f r om her hospi t al vi si t s, she di d not l ear n t hat her sympt oms wer e

r el at ed t o t he shunt sur ger y unt i l Apr i l 2007 when a doct or t ol d

her about t he pr obl em. Thi s ver si on of event s i gnor es mul t i pl e

undi sput ed f act s i n t he r ecor d. Fi r st , Sant ana- Concepci ón was

accompani ed by her Engl i sh- speaki ng son when she vi si t ed Rochest er

Gener al Hospi t al on J anuar y 2, 2007. Fur t her mor e, t he not es f r om

t hat vi si t i ncl ude a r emar k f r om t he doct or t hat "[ s] he act ual l y

appar ent l y had a VP shunt pl aced i n Puer t o Ri co when she was seen

i n t he ER [ and] t he cyst was eval uated t here. Thi s was i n mi d-

November . " I ndeed, at t hat vi si t t he doctor apparent l y r ecommended

t hat she consi der havi ng the shunt r emoved because i t was not

decreasi ng t he si ze of t he cyst and may be causi ng some of t he

behavi or al i ssues. However , t he not es al so r eveal t hat she di d not

br i ng her medi cal r ecor ds wi t h her t o t he exam. Thus, t he doctor

coul d have known about t he shunt pr ocedur e onl y i f she i nf ormed hi m

of i t dur i ng t he vi si t . No r easonabl e j ur y, conf r ont ed wi t h t hi s

undi sput ed evi dence, coul d concl ude t hat Sant ana- Concepci ón, or her

adul t chi l dr en, were not aware of any adver se consequences of her

sur ger y by J anuar y 2, 2007. Accor di ngl y, t he di st r i ct cour t

pr oper l y grant ed summary j udgment on t he medi cal mal pr act i ce cl ai ms

of Sant ana- Concepci ón and her adul t chi l dr en.

b. Application to the Informed Consent Claims of

Santana-Concepción and Adult Children

The st at ut e of l i mi t at i ons f or a physi ci an' s f ai l ure t o

obt ai n t he pat i ent ' s i nf or med consent f or sur ger y, a cause of

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act i on separ at e f r om a medi cal mal pr act i ce cl ai m, begi ns t o run

when t he aggr i eved l ear ns t hat she was subj ected t o an unaut hor i zed

medi cal pr ocedur e. Vi l l ar i ni - Gar ci a v. Hosp. Del Maest r o, I nc. , 8

F. 3d 81, 84- 85 ( 1st Ci r . 1993) ( ci t i ng P. R. Laws Ann. t i t . 31,

§ 5298) . A cl ai m, such as t he one here, pr emi sed on t he al l eged

f ai l ur e of t he physi ci an t o adequat el y i nf or m t he pat i ent of

pot ent i al negat i ve consequences, i s aki n t o a f ai l ur e- t o- war n cl ai m

i n t he medi cal cont ext . We have sai d t hat t he st at ut e begi ns t o

r un f or t hose cl ai ms at t he poi nt when "a r easonabl e person [ woul d]

concl ude that a warni ng of such possi bl e consequences shoul d have

been gi ven bef or e t he oper at i on. " I d. at 85.

Wi t h regard to t he i nf ormed consent cl ai ms of Sant ana-

Concepci ón and her adul t chi l dr en, t he cause of act i on accrued when

t hey l ear ned t hat she was exper i enci ng negat i ve si de ef f ect s of t he

shunt operat i on per f ormed by Dr . Rosado. The pr esence of a shunt

i n Sant ana- Concepci ón' s cyst was document ed i n t he t r eat ment not es

f r om her J anuar y 2, 2007 consul t at i on wi t h her doct or , t he CT and

MRI r ecor ds f r om her hospi t al i zat i on on Febr uar y 20, 2007, and t he

t r eat ment not es f r om her f ol l ow- up consul t at i on on Febr uar y 22,

2007. At t hose consul t at i ons, Sant ana- Concepci ón di scussed var i ous

sympt oms t hat she had been exper i enci ng si nce t he shunt was put i n

pl ace, i ncl udi ng "decreased vi si on, di f f i cul t y wi t h gai t and

bal ance, " and pai n at t he shunt si t e. I n addi t i on, t he not es f r om

Sant ana- Concepci ón' s Febr uar y 22 f ol l ow- up vi si t show t hat she

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di scussed t he pot ent i al r emoval of t he shunt t o al l evi at e her

symptoms wi t h t he neurol ogi st who t ended t o her whi l e she was

hospi t al i zed. A r easonabl e j ur y, conf r ont ed wi t h t hi s undi sput ed

evi dence, woul d be compel l ed t o f i nd t hat , at l east by Febr uar y 22,

2007, a r easonabl e person woul d have concl uded t hat she shoul d have

been war ned of t he pr evi ousl y undi scl osed pot ent i al negat i ve

consequences of shunt sur ger y. Accor di ngl y, t he di st r i ct cour t

proper l y gr ant ed summar y j udgment on Santana- Concepci ón' s i nf ormed

consent cl ai m.

At l east one of t he ot her adul t pl ai nt i f f s,

Sant ana- Concepci ón' s sons Hermi ni no and Car l os Manuel , was present

at each of her consul t at i ons wi t h doct or s i n J anuar y and Febr uar y

2007 i n New Yor k t o t r ansl at e thei r mot her ' s i nt er act i ons wi t h her

doct or s. Hence, t he br ot her s r ecei ved cont empor aneous i ndi cat i ons

t hat Sant ana- Concepci ón' s shunt sur gery had negat i ve consequences,

t he r i sks of whi ch shoul d have pr evi ousl y been di scl osed t o her . 6

Accor di ngl y, t he di st r i ct cour t pr oper l y di smi ssed t he i nf or med

consent cl ai ms of t he adul t chi l dr en.

6 Thi s i s not a case where t he i nf ormed consent cl ai ms of apat i ent ' s r el at i ves pot ent i al l y accr ue l at er t han t he pat i ent ' s owncl ai ms because t he rel at i ves di d not cont empor aneousl y l ear n t hedet ai l s of a par t i cul ar medi cal pr ocedur e and i t s ef f ect s.

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B. Minor Plaintiffs' Claims7

"I n Puer t o Ri co, st at ut es of l i mi t at i ons do not r un

agai nst mi nor s unt i l t hey r each t he l egal age of 21. " Ocasi o-

Ber i os v. Br i st ol Myer s Squi bb, 73 F. Supp. 2d 171, 174 ( D. P. R.

1999) ; P. R. Laws Ann. t i t . 32, § 254( 1) ( "I f a per son ent i t l ed t o

br i ng an act i on, ot her t han t he r ecover y of r eal pr oper t y, be at

t he t i me t he cause of act i on accrued . . . [ w] i t hi n t he age of

maj or i t y . . . t he t i me of such di sabi l i t y i s not a par t of t he

t i me l i mi t ed f or t he commencement of t he act i on. " ) . Hence, t he

mi nor pl ai nt i f f s' cl ai ms cannot be def eat ed by t he st at ut e of

l i mi t at i ons at summar y j udgment . Recogni zi ng t hi s l egal

pr oposi t i on, t he di st r i ct cour t addr essed t he cl ai ms of t he mi nor

chi l dr en on t he mer i t s.

1. Medical Malpractice

I n Puer t o Ri co a medi cal mal pr act i ce pl ai nt i f f must

est abl i sh t hr ee el ement s: " ( 1) t he basi c nor ms ( ' nor mas mi ni mas' )

of knowl edge and medi cal car e appl i cabl e t o gener al pr act i t i oner s

7 Puer t o Ri co cour t s have " r ecogni zed t he r i ght of a per son t or ecei ve compensat i on when hi s or her spouse or ot her r el at i vesuf f er s har mi n t he most di ver se si t uat i ons [ i ncl udi ng] i n cases of . . . medi cal mal pr act i ce. " Sant i ni - Ri ver a, 137 P. R. Dec. at 8;see P. R. Laws Ann. t i t . 31, § 5141 ( pr ovi di ng a cause of act i on

agai nst a t or t f easor who "causes damage t o another t hr ough f aul t ornegl i gence" ( emphasi s added) ) . Acknowl edgi ng t hat " t he Puert o Ri coSupr eme Cour t consi st ent l y has r ef er r ed t o r el at i ves' causes of acti on as ' separ at e' or ' i ndependent ' f r om t he pr i nci palpl ai nt i f f ' s cl ai m, " we have anal yzed t he appl i cat i on of t he st at ut eof l i mi t at i ons t o t hem as st andal one cl ai ms. Gonzál ez Fi guer oa v. J . C. Penney P. R. , I nc. , 568 F. 3d 313, 321 ( 1st Ci r . 2009) .

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or speci al i st s; ( 2) pr oof t hat t he medi cal per sonnel f ai l ed t o

f ol l ow t hese basi c nor ms i n t he t r eat ment of a pat i ent ; and ( 3) a

causal r el at i on bet ween t he act or t he omi ssi on of t he physi ci an

and t he i nj ur y by t he pat i ent . " Sant i ago v. Hosp. Cayet ano Col l y

Tost e, 260 F. Supp. 2d 373, 381 ( D. P. R. 2003) ( col l ect i ng cases) .

Puert o Ri co cour t s have l ong r ecogni zed a def ense of

"er r or of j udgment , " whi ch def eat s t he second el ement of t he t or t .

Under t hat doct r i ne, when t he evi dence shows t hat di f f erent cour ses

of t r eat ment exi st ed f or t he i nj ur ed par t y' s condi t i on, and

l egi t i mat e debate exi st ed between medi cal expert s as t o whi ch

t r eat ment woul d be appr opr i at e, a physi ci an' s j udgment cal l cannot

be t he basi s f or a medi cal mal pr act i ce cl ai m. Lozada v. Est ado

Li br e Asoci ado de P. R. , 16 P. R. Of f i c. Tr ans. 250, 267 ( 1985) ;

Ol i ver os v. Abr éu, 1 P. R. Of f i c. Tr ans. 293, 315 ( 1973) ( "[ A

physi ci an] i s not l i abl e of mal pr act i ce when he i s f aced wi t h a

si t uat i on where educat ed and reasonabl e doubt about what shoul d be

t he cour se t o f ol l ow i s pr esent . ") . " I t i s , t her ef or e,

i nsuf f i ci ent f or a pl ai nt i f f i n a mal pr act i ce case mer el y t o show

t hat anot her doct or woul d have chosen t o t r eat t he pat i ent i n a

manner di f f er ent f r om t he manner i n whi ch t he at t endi ng physi ci ans

t r eat ed hi m. " Rol on- Al var ado v. Muni ci pal i t y of San J uan, 1 F. 3d

74, 78 ( 1st Ci r . 1993) . The di st r i ct cour t f ound t hat def ense

appl i cabl e her e.

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The medi cal mal pr act i ce al l eged here i s t he deci si on of

Dr . Rosado to per f orm t he shunt pl acement operat i on on Sant ana-

Concepci ón. Speci f i cal l y at i ssue was whet her her cyst war r ant ed

sur gi cal or phar macol ogi cal t r eat ment . 8 Santana- Concepci ón argued

t hat because her cyst di d not cause hydr ocephal us, 9 a f act t hat i s

undi sput ed, i t was not "sympt omat i c" and sur gery woul d never be

i ndi cat ed.

The summar y j udgment r ecor d i ncl udes t he deposi t i on

t est i mony of pl ai nt i f f s' exper t , Dr . Ravi Ti koo. When asked about

t he shunt pr ocedur e per f ormed on Sant ana- Concepci ón, Dr . Ti koo

test i f i ed as f ol l ows:

Q [ def ense counsel ] . Doctor , woul d you agr eewi t h thi s st at ement : Tr eat ment f or ar achnoi dcyst s i s sympt omat i c?

A. Dependi ng on how you' r e def i ni ngsymptomat i c; yes.

Q. How ar e you def i ni ng i t .A. When someone has si gni f i cant hydr ocephal usor sever e sympt oms and exam f i ndi ngs f r om t hecyst.

Q. But i t doesn' t have t o be hydr ocephal usonl y; i s t hat cor r ect ?

8 Ther e i s no evi dence i n t he r ecor d t hat a sur gi cal t r eat mentopt i on, ot her t han pl aci ng a shunt , exi st ed.

9 Hydr ocephal us i s " a condi t i on i n whi ch t he pr i mar ychar act er i st i c i s excessi ve accumul at i on of f l ui d i n t he br ai n. "Nat i onal I nst i t ut e of Neur ol ogi cal Di sor der s and St r oke," Hy dr o c e p ha l u s F ac t S h e e t , " a v ai l a b l e a tht t p: / / www. ni nds. ni h. gov/ di sor der s/ hydr ocephal us/ det ai l _hydr ocephal us. ht m ( l ast vi si t ed August 22, 2014) .

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A. Cor r ect .

Q. Woul d you agr ee wi t h t hi s: When sympt omswar r ant , t he surgi cal pl acement of a shuntmay be r equi r ed t o decompress t he cyst ?

A. Can you r epeat t hat?

[ quest i on r epeat ed]

A. Yes.

Q. Doct or , woul d you agr ee t hat t he deci si onof when i t i s t hat t he sympt oms war r antshunt i ng i s a cl i ni cal j udgment cal l ?

A. To a cer t ai n ext ent , yes.

Q. And t hat cal l , you have never t aken i t i nyour l i f e?

A. Cor r ect .

Q. Doctor , woul d you agr ee wi t h t hef ol l owi ng: Unt r eat ed ar achnoi d cyst s maycause per manent sever e neurol ogi cal damage duet o t he pr ogr essi ve expansi on of t he cyst orhemor r hage?

A. I n t he appr opr i at e ci r cumst ance, yes.Q. Woul d you agr ee wi t h t he f ol l owi ngst at ement : Wi t h t r eat ment , most i ndi vi dual swi t h sympt omat i c arachnoi d cyst s do wel l ?

A. Many, yes.

Q. Doct or , woul d you agr ee wi t h t he f ol l owi ng:Cont r oversy sur r ounds t he t r eat ment of ar achnoi d cyst s?

A. Yes.Q. Some cl i ni ci ans advocat e t r eat i ng onl ypat i ent s wi t h sympt omat i c cyst s whereas ot hersbel i eve t hat even [ a] sympt omat i c cyst [ s]shoul d be decompr essed t o avoi d f ut ur ecompl i cat i ons?

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A. I woul d - my opi ni on i s t hat doct or s t hatr ecommend asympt omat i c - t r eat ment of asympt omat i c cyst s ar e not i n the maj or i t y,t hey ar e pr obabl y i n t he mi nor i t y.

Q. But t her e ar e some aut hor i t i es t hat s t at e

t hat al so?

A. I n my opi ni on, t hose aut hor i t i es ar e notr easonabl e or cr edi bl e.

Q. But t hose aut hor i t i es or school of t houghtexi st?

A. Yes.

Q. And you don' t agr ee wi t h t hat , but ot her sdon' t agr ee wi t h you; i s t hat cor r ect ?

A. I guess so; yes.

Q. Woul d you agr ee wi t h t he f ol l owi ng: Themost ef f ect i ve sur gi cal t r eat ment appear s t obe exci si on of t he out er cyst membr ane andcyst oper i t oneal [ si c] shunt i ng?

A. I n t he appr opr i at e ci r cumst ance; yes.

I n addi t i on, Sant ana- Concepci ón' s r esponses t o i nt er r ogat or i es

i ndi cat ed t hat she "f el t [ her ] eyes wer e goi ng t o f al l [ si c] of

t hei r socket " when she saw Dr . Rosado f or t he f i r st t i me. I t was

at t he concl usi on of t hat exami nat i on t hat Dr . Rosado recommended

sur ger y t o pl ace a shunt and r el i eve i nt r acrani al pr essur e.

On t hi s r ecor d, a r easonabl e j ur y woul d be compel l ed t o

concl ude that l egi t i mate debate exi st ed among medi cal exper t s as t o

whi ch t r eat ment woul d be appr opr i ate f or Sant ana- Concepci ón' s

ar achnoi d cyst , whi ch, t hough not causi ng hydr ocephal us, di d cause

si gni f i cant pai n. Lozada, 16 P. R. Of f i c. Tr ans. at 267. Gi ven t he

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t est i mony of t he pl ai nt i f f s' own exper t , t hey wer e unabl e t o

gener at e a genui ne i ssue of mat er i al f act as t o t he appl i cat i on of

t he "er r or of j udgment " def ense. Hence, t he di st r i ct cour t was

cor r ect t o gr ant summar y j udgment t o t he mi nor pl ai nt i f f s on t hei r

medi cal mal pr act i ce cl ai ms.

2. Informed Consent

The r emai ni ng cl ai m of t he mi nor pl ai nt i f f s i s based on

t he doct r i ne of i nf or med consent , whi ch " i mposes on physi ci ans t he

dut y to i nf or m t hei r pat i ent s about t he nat ur e and r i sks of t he

pr oposed medi cal t r eat ment i n or der t o pl ace t he pat i ent s i n a

posi t i on t o r each an i nt el l i gent and i nf or med deci si on. " Lozada-

Ti r ado v. Ti r ado- Fl echa, 177 P. R. Dec. 893 ( 2010) . The mi nor

pl ai nt i f f s cl ai m t hat Dr . Rosado per f or med t he shunt pl acement

sur ger y on Sant ana- Concepci ón wi t hout obt ai ni ng her f ul l y i nf or med

consent .

The scope of t he dut y t o i nf or m does not r each ever y

r emot e, hypot het i cal r i sk posed by a medi cal pr ocedur e. I ndeed,

t he scope of t he dut y var i es wi t h t he nat ur e of t he pr oposed

t r eat ment . Sepúl veda de Ar r i eta v. Barr eto, No. RE- 90- 41, 1994 WL

908876 ( P. R. Dec. 23, 1994) . "' I f [ t he medi cal i nt er vent i on] i s t o

save a l i f e, t he sur geon shoul d, above al l , creat e a f avor abl e

at mospher e. I f t he i nt er vent i on i s si mpl y usef ul , he must t hen be

mor e pr eci se i n hi s di scl osur e. ' " I d. ( emphasi s omi t t ed) ( quot i ng

J . At az López, Los médi cos y l a r esponsabi l i dad ci vi l 74 ( 1985) ) .

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I n or der t o pr evai l on a cl ai m f or l ack of i nf or med

consent , a pl ai nt i f f must pr ove t hat t he compl ai ned- of i nj ur y

r esul t ed f r om t he f ai l ur e of t he physi ci an t o f ul l y i nf or m t he

pat i ent ( i . e. , causat i on) . Sepul veda de Ar r i et a, No. RE- 90- 41,

1994 WL 908876. One mi ght expect t hat such causat i on can be proved

by showi ng t hat t he pl ai nt i f f woul d not have consent ed t o t he

medi cal t r eat ment at i ssue i f f ul l y i nf or med of t he r i sks. The

debat e i n most U. S. j ur i sdi ct i ons i s gener al l y over whet her t hat

f act must be shown subj ect i vel y ( i . e. , f r om t he per spect i ve of t he

speci f i c pat i ent ) or obj ect i vel y ( i . e. , f r omt he per spect i ve of t he

r easonabl e pat i ent ) . I d.

"Cont r ar y t o t he Uni t ed St at es model - - t hat f ocuses on

t he deci si on- maki ng pr ocess of t he i nj ur ed par t y, whet her obj ect i ve

or subj ecti ve - - ci vi l l aw t r adi t i on f ocuses on t he al l eged

aggr avat i ng ci r cumst ance. " I d. Hence, i n Puer t o Ri co, t he

quest i on of pr oxi mat e causat i on i s vi ewed f r om t he per spect i ve of

t he physi ci an. I n ot her wor ds, t he anal ysi s does not t ur n on

whet her t he pat i ent woul d have decl i ned t o consent i f pr ovi ded wi t h

t he al l egedl y absent i nf or mat i on. See i d. ( "[ I ] t i s not necessar y

t o det er mi ne i f she, as a pat i ent - - subj ect i vel y or obj ect i vel y - -

woul d or woul d have not consent ed t o t he proposed medi cal

t r eat ment . ") . I nst ead, t he per t i nent quest i on i s "whet her i n t he

nor mal cour se of event s [ t he physi ci an] had t o f or esee t hat t he

l ack of per t i nent i nf or mat i on woul d l ead [ t he] pat i ent . . . t o

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t ake a di f f er ent deci si on t han t he one she woul d have t aken i f she

had been sui t abl y i nf or med. " I d. The di st r i ct cour t hel d t hat i t

woul d not have been f or eseeabl e t hat any f ur t her di scl osur e woul d

have changed Sant ana- Concepci ón' s deci si on t o undergo sur gery. The

cour t grant ed summary j udgment on t hat basi s.

Her e, t he mi nor pl ai nt i f f s cl ai mt hat Sant ana- Concepci ón

was never f ul l y i nf or med of t he r i sks of sur ger y and was never t ol d

t hat f or egoi ng sur ger y was a vi abl e opt i on. The r ecor d i ncl udes an

i nf or med consent f or m si gned by Sant ana- Concepci ón, t he

aut hent i ci t y of whi ch i s not di sput e. The mi nor pl ai nt i f f s

nonethel ess ar gue t hat Sant ana- Concepci ón was not f ul l y i nf ormed

because f our t er ms on t he f or m ( ar achnoi d cyst , dr ai nage,

f enest r at i on, and shunt ) wer e i n Engl i sh r at her t han Spani sh ( whi ch

was t he l anguage of t he r est of t he document ) . They al so argue

t hat Dr . Rosado di d not t el l Sant ana- Concepci ón t hat her condi t i on

was manageabl e wi t hout surgery, i nst ead i mpl yi ng that t he shunt

sur ger y was a l i f e- savi ng necessi t y.

Bot h of t hese ar gument s f ocus on t he wr ong perspect i ve,

however . As expl ai ned above, we must exami ne t he quest i on of

f or eseeabi l i t y f r om Dr . Rosado' s per spect i ve, not Sant ana-

Concepci ón' s. The di st r i ct cour t was cor r ect i n expl ai ni ng t hat

" t o cr eat e a genui ne i ssue of f act under t he appl i cabl e

f or eseeabi l i t y st andar d, pl ai nt i f f s needed t o di r ect t he Cour t t o

f act s Dr . Rosado coul d have r el i ed upon t o f or esee t hat

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Sant ana–Concepci ón was l i kel y t o behave di f f erent t han most peopl e

under t he ci r cumst ances. [ However , ] [ p] l ai nt i f f s have pr ovi ded no

evi dence what soever i n t hi s r egar d. " Dr . Rosado was conf r ont ed

wi t h a pat i ent who had a cyst on her br ai n that was causi ng her

debi l i t at i ng pai n. He under st ood i t t o be a possi bl e l i f e- or - deat h

si t uat i on and communi cated t hat t o her . Sant ana- Concepci ón

i ndi cat ed a wi l l i ngness t o ent er t ai n any t r eat ment opt i on t hat

woul d t ake away her pai n. Doi ng not hi ng was si mpl y not an

accept abl e opt i on, even i f Dr . Rosado had suggest ed i t . Dr . Rosado

ul t i mat el y suggest ed a sur gi cal pr ocedur e t o rel i eve some of t he

pr essure. However , bef or e per f or mi ng t he sur ger y, Dr . Rosado

i nf ormed Sant ana- Concepci ón and her f ami l y of t he maj or r i sks of

sur ger y and obt ai ned wr i t t en consent .

As t he di st r i ct cour t put i t , "[ t ] he concl usi on t hat Dr .

Rosado coul d have f oreseen a deci si on t o f orego sur gery by Sant ana-

Concepci ón i s i nconcei vabl e under t hese ci r cumst ances. " I n ot her

wor ds, t he mi nor pl ai nt i f f s f ai l ed t o gener at e a genui ne i ssue of

mat er i al f act on t he pr oposi t i on t hat Dr . Rosado coul d have

f or eseen t hat pr ovi di ng Spani sh t r ansl at i ons f or t he f our Engl i sh

t er ms, or f ur t her di scussi ng some of t he possi bl e si de ef f ect s of

surgery as r easons f or not undergoi ng i t , woul d have changed

Sanat ana- Concepci ón' s deci si on t o consent t o sur ger y. Accor di ngl y,

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t he di st r i ct cour t was cor r ect t o gr ant summar y j udgment t o t he

def endant s on t he i nf or med consent cl ai ms of t he mi nor pl ai nt i f f s. 10

Affirmed.

10 Because, as expl ai ned supr a, t he hospi t al and r el at edent i t i es wer e sued on t he basi s of vi car i ous l i abi l i t y f or Dr .Rosado' s act i ons, al l cl ai ms agai nst t hose cor por at e def endant sf ai l wi t h t he cl ai ms agai nst hi m.

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