Betancourt v. Trinitas Hospital

Brief Fact Summary. The daughter of Rueben Betancourt (Plaintiff) filed an action for a temporary restraining order against Trinitas Hospital (Defendant) to prevent the removal of necessary treatment while her father was in a persistent vegetative state.  The trial court agreed, and permanently enjoined Defendant, who appealed.

Synopsis of Rule of Law. The grant of an order restraining a hospital from removing treatment is rendered moot when the patient dies.

Facts. Rueben Betancourt (Plaintiff) underwent surgery at Trinitas Hospital (Defendant) to remove a malignant tumor from his thymus gland.  While Plaintiff was recovering in the post-operative intensive care unit, the ventilation tube that was supplying oxygen to him became dislodged which deprived his brain of oxygen.  He developed anoxic encephalopathy, a condition that left him in a persistent vegetative state.  Plaintiff was then discharged and admitted to other facilities that attempted rehabilitative treatments.  He later was readmitted to Trinitas (Defendant) with a diagnosis of renal failure.  Plaintiff remained in the hospital until he died.
  When Plaintiff died, he had not executed an advanced directive under the Advanced Directives for Health Care Act.  He also had not designed a health care representative and had not left any “specific wishes regarding the provision, withholding or withdrawal of any form of health care, including life-sustaining treatment.”  Witnesses for both sides presented different views of Plaintiff’s condition, and the impact of treatment and prognosis.  At the hearing, Plaintiff’s attending physician, Dr. Millman, indicated that Plaintiff was suffering from multi-system organ failure and described his neurological state as “non-cognitive” with no higher mental functioning.  However, he did believe that Plaintiff was responsive to pain because he had personally witnessed Plaintiff’s reactions to it.  Since Plaintiff was admitted, there had not been any change in his neurological condition.  It was Millman’s belief that the chances of Plaintiff every having cognizant function again were “virtually zero.”
  Dr. Schanzer, Chief o Neurology at Trinitas (Defendant), corroborated most of Millman’s views regarding the neurological condition of Plaintiff.  He explained that Plaintiff’s brain had been damaged irreversibly and, because of that, he was in a permanent vegetative state, unable to speak or respond to verbal cues, and even though Plaintiff’s eyes were open and he appeared awake, he was not alert or aware of his environment.  Schanzer disagreed with Millman, however, regarding Plaintiff’s ability to experience pain.  He believed that Plaintiff did not feel pain, and that his responses to stimuli were due to basic reflexes of the brain stem and spinal cord. Schanzer expressed his belief that there was no chance of Plaintiff ever regaining a cognitive state.
  Dr. Khazaei, a nephrologist, concluded that Plaintiff was suffering from end-stage renal disease and would not likely improve.  She expressed that it did not meet accepted standards of medical care to keep subjecting the Plaintiff to dialysis treatments which only prolonged his dying process.  Another doctor retained by Plaintiff’s family, Dr. Goldstein, a nephrologist, stated that Plaintiff’s current dialysis plan “comports in every way with the prevailing standards of care.”  He went to say that the dialysis had been effective and it was not harmful or dangerous to Plaintiff.
  In the end, the Hospital’s (Defendant) prognosis committee concluded that treatment should be discontinued.  While the Hospital (Defendant) administration attempted to get an agreement from Plaintiff’s family to place a “do not resuscitate” (DNR) order and stop dialysis treatment, the family did not budge in their refusal.  Efforts were made to transfer Plaintiff to another facility, but were unsuccessful.  In the end, Trinitas (Defendant) acted unilaterally, placing a DNR order in Plaintiff’s chart as well as surgically removing the dialysis port from his body.  Plaintiff’s daughter requested a temporary restraining order to continue the Plaintiff’s same treatment.
  The trial court ordered Trinitas (Defendant) to re-establish the level of treatment that had been provided to Plaintiff before the dialysis was discontinued and also to remove a DNR order that had been placed in his chart.  In a subsequent hearing, the trial court concluded that decisions regarding Plaintiff’s proper course of treatment could not be made by the hospital; rather, such decisions should be made by a surrogate who could take Plaintiff’s personal value systems into account when deciding what medical treatment was appropriate.  The restraining order was made permanent and Plaintiff’s daughter was appointed guardian.  After Trinitas (Defendant) filed for an appeal, Plaintiff died.  Trinitas (Defendant) next filed a motion to dismiss the appeal as moot.

Issue. Is the grant of an order restraining a hospital from removing treatment rendered moot when the patient dies?

Held. [(Per curiam) Yes.  The grant of an order restraining a hospital from removing treatment is rendered moot when the patient dies.  Mootness is a threshold justiciability determination that comes from the notion that judicial power should only be exercised when a party is immediately threatened with harm.  In other words, an issue is “moot” when the decision hoped for and rendered would have no practical effect on the existing controversy.  Normally, courts will not decide issues when a controversy no longer exists, and the disputed issues have become moot.  However, there have been occasions where the courts decided to hear an otherwise moot appeal, such as when an underlying issue is significantly important and likely to come up again, but capable of evading review.
  In this case, the dispute between the parties was admittedly rendered moot by Plaintiff’s death.  However, the remaining question is whether the court should consider the appeal on its merits because of the substantial public importance of the matter and its capacity to reoccur yet evade review.  Trinitas (Defendant) raises two issues on appeal; (1) the correctness of the court’s order requiring the reinstatement and continuation of Rueben’s medical treatment, and (2) the propriety of the court’s appointing plaintiff to be Plaintiff’s guardian.  As noted in the beginning of our analysis, mootness is a threshold determination of justiciability.  While the justiciability of the first issue is debatable, the second is not.
  Regarding the second issue, whether the judge erred in appointing Plaintiff’s daughter as guardian is not a question of significant public importance and is not likely to reoccur and evade review.  Trinitas (Defendant) makes no argument that its appeal from the guardianship order should not be dismissed as moot, and therefore review is not called for.  The more difficult question is whether the court should address the merits of the hospital’s challenge to the court’s restraining order.  The court recognizes that determining what medical treatment should be provided to incompetent or dying patients is a significantly important matter to the public and that matters such as this are capable of evading judicial review.  The court is, however, also concerned that the record on appeal is not adequate to address the critical issues involved.  A critical factor in the mootness analysis is whether the unusual circumstances of a case make a recurrence of this specific set of facts unlikely.  This is the decisive issue in this case, which is a case of first impression.
  The circumstance that qualifies this issue as unique and causes us to pause is that Plaintiff’s anoxic injury occurred while he was a patient at Trinitas (Defendant).  There is significant dispute regarding the issue of causation of the injury, as well as claims that the Plaintiff’s family allegedly intends to file or has filed a medical malpractice action that rose from that incident.  The unique assailability of the decisions Trinitas’s (Defendant) prognosis committee and the family reached is a complicating factor that is unlikely to occur in other situations.  There was also considerable doubt concerning Plaintiff’s exact neurological condition.  The uncertainty and lack of true consensus regarding his condition may generate a result that will apply to patients in non-cognitive, vegetative states, and also to patients who are impaired and in possession of some level of awareness.  There was also disagreement concerning Plaintiff’s ultimate prognosis.
  This dispute, unresolved below, has significant implications regarding the ultimate decision on the withholding of treatment for a dying patient as opposed to a patient whose quality of life is such that a hospital or doctors may consider the withholding of treatment to be an appropriate resolution.  While the court does dismiss Trinita’s (Defendant) appeal, it does not see that declining to resolve the issue on this record and in this case will be an end to the debate.  The issues presented are profound and universal in application.  They call for thoughtful study and debate not in the context of overheated rhetoric in the battlefield of active litigation, but in thoughtful consideration by the Legislature, executive agencies and commissions tasked with developing the policies that impact on the lives of all.  The motion to dismiss the appeal as moot is granted.]

Discussion. Given that the purpose of the restraining order and the hospital’s appeal concerned the patient’s treatment, the consequence of his death made the court’s decision predictable.  Even so, the court labored over the facts of the case, the dispute between the parties regarding Plaintiff’s condition and course of treatment, and the real fear that hospitals would generally act in their own interests and terminate necessary procedures they consider meaningless.  The court’s statements address the public concern and the need for the legislature to study, debate and resolve the issue.  The court declared the case moot and warned that the problems opened by this case were likely to reoccur.