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Bryan v. University of Virginia --
The Fourth Circuit retrenches on Baby K

The 1994 decision of the Fourth Circuit Court of Appeals in the case of In re Baby K, 16 F.3d 590 (4th Cir 1994) has been regarded by many as an extreme implementation of the "duty to treat" under EMTALA. In that case, the Court held that the duty to treat an anencephalic infant was absolute, despite the fact that treatment of this infant's condition was contrary to medical ethics and to the standard of care.

In September 1996, the Fourth Circuit had occasion to revisit the issue in a somewhat different context, and issued a decision which puts limits on what appeared in 1994 to be an ongoing and interminable duty to continue to provide treatment. The plaintiff in the case of Bryan v Rectors of the University of Virginia, 95 F3d 349 (4th Cir 1996) was the personal representative of the estate of Shirley Robertson. Mrs. Robertson had been admitted in transfer to the University of Virginia Medical Center with a diagnosis of respiratory distress. She was admitted to an ICU bed, and her family gave its instruction (according to the complaint) that the hospital was to take "all necessary measures to keep her alive". The Complaint alleged that the hospital disregarded the family's directions and entered a "do not resuscitate" order against their wishes, twelve days after the patient had been admitted. Thereafter, without physician intervention, the patient died.

It is unknown whether these claims are true from a factual perspective. Since the issue was whether the allegations in the Complaint were sufficient to impose a duty under EMTALA, the court did not have to make a finding of fact as to whether these events occurred as alleged. The Court also noted that it was not asked to address the question of whether such actions would constitute "abandonment" of a patient under state law. The only issue for the court to decide was whether EMTALA was implicated in these facts.

The District Court dismissed the claim, reasoning that EMTALA requires that treatment be afforded to provide stablilization of an emergency medical condition, but that it imposes no duties with regard to ongoing treatment after the point of stabilization. Any such claims, the court found, would be governed solely under state law.

The Circuit Court of Appeals agreed with this analysis, noting,

"As is admitted in the complaint, and so necessarily conceded by Bryan in her brief and oral argument, stabilizing treatment was provided by the hospital from Robertson's arrival on February 5 until February 17. But, the claim is that the hospital's abandonment of such treatment as of its entering the anti-resuscitation order on February 17 and its failure to offer stabilizing treatment in response to Robertson's heart attack eight days later constituted an EMTALA violation.

"Under this interpretation, every presentation of an emergency patient to a hospital covered by EMTALA obligates the hospital to do much more than merely provide immediate, emergency stabilizing treatment with appropriate follow-up. Rather, without regard to professional standards of care or the standards embodied in the state law of medical malpractice, the hospital would have to provide treatment indefinitely--perhaps for years--according to a novel, federal standard of care derived from the statutory stabilization requirement. We do not find this reading of the statute plausible.

"As Bryan recognizes and as this court has frequently observed, EMTALA is a limited 'anti-dumping' statute, not a federal malpractice statute. Its core purpose is to get patients into the system who might otherwise go untreated and be left without a remedy because traditional medical malpractice law affords no claim for failure to treat. And, EMTALA is quit e clear that it is not intended to preempt state tort law except where absolutely necessary. Such reprehensible disregard for one's patient as Bryan hypothesizes would not constitute the 'dumping' at which EMTALA aims but the well established tort of abandonment, which the states may expand or constrict as they deem just but which Congress evidenced no desire to federalize. Presumptively aware of this feature of state tort law, Congress did not address a hypothetical problem that was not before it but addressed a national scandal that was: emergency rooms' turning away patients at the door for inability to pay or other similar reasons. [numerous citations omitted]

"EMTALA seeks to achieve the limited purpose of its enactment by requiring that the hospital provide limited stabilizing treatment to or an appropriate transfer of any patient that arrives with an emergency condition. And it defines 'to stabilize' as 'to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual. . .' The stabilization requirement is thus defined entirely in connection with a possible transfer and without any reference to the patient's long-term care within the system. It seems manifest to us that the stabilization requirement was intended to regulate the hospital's care of the patient only in the immediate aftermath of the act of admitting her for emergency treatment and while it considered whether it would undertake longer-term full treatment or instead transfer the patient to a hospital that could and would undertake that treatment. It cannot plausibly be interpreted to regulate medical and ethical decisions outside that narrow context." [numerous citations omitted]

The Court rejected the argument that its decision in Baby K required that it find an EMTALA violation in this case, stating:

"The holding in Baby K [] turned entirely on the substantive nature of the stabilizing treatment that EMTALA required for a particular emergency medical condition. The case did not present the issue of the temporal duration of that obligation, and certainly did not hold that it was of indefinite duration. "

Summarizing, the Court noted:

"Bryan's complaint alleges no EMTALA violation on the part of the hospital at any time before Mrs. Robertson had been in the hospital for twelve days. The only actions by the hospital that are alleged as violations of EMTALA began on February 17 with the entry of the anti-resuscitation order and ended on February 25 with the hospital's failure to prevent Robertson's death. As Bryan has expressly conceded on appeal, the complaint therefore must be taken to admit that Mrs. Robertson actually received stabilizing treatment in accord with EMTALA for twelve days following her admission and to confine the claim of violation only to the ultimate cessation of that or any further medical treatment upon entry of the anti-resuscitation order."

The Fourth Circuit has thus placed some limits on the obligation of a hospital to provide ongoing treatment to a person for whom medical intervention is no longer justified from the perspective of the standard of medical practice and medical ethics. The Court has also followed others in 1996 (see Vickers and Summers) in carefully limiting the scope of EMTALA to its narrow field of regulation, and in declining invitations to extend it to a widely-applicable federal cause of action for malpractice.