In its decision filed on April 27, 2017, the Supreme Court of the State of Washington (“Washington Supreme Court”) held that ARNPs (advanced registered nurse practitioners) may be qualified to testify regarding causation in a medical malpractice case if the trial court determines that the ARNP meets the threshold requirements of ER 702 (the ability to independently diagnose and prescribe treatment for a particular malady is strong evidence that the expert might be qualified to discuss the cause of that same malady).
In the case it was deciding, a 70-year-old quadriplegic man was admitted to a local hospital for pneumonia. While there, the nurses allegedly failed to provide proper care by failing to move him, turn him, and provide him with an appropriate bed, resulting in the man developing pressure ulcers. The man subsequently filed a Washington medical malpractice lawsuit against the hospital.
The defendant filed a motion for summary judgment, arguing that the plaintiff had failed to provide expert testimony as required by statute. The plaintiff responded to the defendant’s motion for summary judgment by filing the sworn affidavit of an ARNP with more than 30 years of experience providing direct patient care, serving as clinical nursing faculty for students providing care, and publishing nursing texts on the subject. The ARNP stated that based on her professional objective medical opinion, on a more probable than not basis, the plaintiff’s treating nurses breached the applicable standard of care and that this breach proximately caused the plaintiff’s pressure ulcers.
The trial court held that the plaintiff’s expert was qualified as an expert and could testify as to the applicable standard of care, but that Washington law did not permit the expert to testify on the issue of proximate cause. The plaintiff appealed and the Washington Supreme Court ultimately decided the appeal.
The Washington Supreme Court Decision
The Washington Supreme Court stated that in order to establish causation in a medical malpractice case, the plaintiff must show that the alleged breach of the standard of care was a proximate cause of the injury complained of (RCW 7.70.040(2)), and that expert testimony is always required except in those few situations where understanding causation does not require technical medical expertise.
The Washington Supreme Court noted that Washington’s nursing statutes differ from statutes in other states in that the Washington Legislature has empowered ARNPs to diagnose illnesses and injuries to at least a limited degree (RCW 18.79.050); the plain language makes clear that ARNPs, alongside physicians, are health care providers with specialized training allowing for at least some degree of independent medical diagnosis and treatment.
Noting that ARNPs in Washington are empowered to practice independently and to assume primary responsibility and accountability for the care of patients (WAC 246-840-300(1)), which includes the authority to examine patients and establish diagnoses by patient history, physical examination, and other methods of assessment, and which allows for interpreting diagnostic tests and prescribing therapies and medical equipment (WAC 246-840-300(5)(a), (c), (e)), the Washington Supreme Court held, “If an ARNP is qualified to independently diagnose a particular medical condition, it follows that the ARNP may have the requisite expertise under ER 702 to discuss medical causation of that condition.”
The Washington Supreme Court held, “Because ARNPs in Washington State receive substantially more education, training, and diagnostic authority than registered nurses, a trial court might find in accordance with ER 702 that a particular ARNP is qualified to testify as an expert regarding causation … ER 702 provides the appropriate mechanism for a trial court to determine whether an ARNP’s opinion on causation is sufficient based on the qualifications of the ARNP and the statutory scope of that ARNP’s authority and certification as a health care provider … A sweeping ban on causation testimony from expert ARNPs is unnecessary and inconsistent with the degree of independent care authority granted to those holding an ARNP license in Washington State.”
The Washington Supreme Court concluded: “our state’s statutory rules permit ARNPs to independently diagnose some conditions within the scope of their certification. Whether or not an ARNP has the requisite specialized knowledge to qualify as an expert on causation is a determination left to the trial court under our Rules of Evidence, taking into consideration the ARNP’s particular scope of practice and expertise. Accordingly, we reverse and remand to the trial court to determine whether [the plaintiff’s ARNP] has the requisite qualifications under ER 702 to offer an opinion as to the causation of [the plaintiff’s] injuries.”
At least eight U.S. states permit nurses to testify as to causation: Idaho, Kansas, Nevada, New York, North Carolina, Ohio, Oklahoma, and Pennsylvania.
Seven U.S. states expressly forbid nurses to testify as to causation: Alabama, Georgia, Illinois, Indiana, Mississippi, Tennessee, and Texas. Jurisdictions that categorically disallow nurses from opining on causation in medical malpractice actions rely on explicit limitations and exclusions in their state statutes regulating the practice of nursing.
Source Frausto v. Yakima HMA, LLC, No. 93312-0
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