In the Matter of BABY “K” 16 F.3d 590 (4th Cir. 1994)*

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In the Matter of BABY “K” 16 F.3d 590 (4th Cir. 1994)* by Mind Map: In the Matter of BABY “K” 16 F.3d 590 (4th Cir. 1994)*

1. Facts:

1.1. Parties:

1.1.1. Plaintiff (Appelant): Hospital

1.1.2. Defendant (Appellee): Baby K Ms. H

1.2. What Happened:

1.2.1. Baby K was born at the Hospital in October of 1992 with anencephaly, a congenital malformation in which a major portion of the brain, skull, and scalp are missing. The physicians explained to Ms. H that most anencephalic infants die within a few days of birth due to breathing difficulties and other medical complications and recommend supportive measures. The hospital failed in convincing Ms. H to change the code status of Baby K from aggressive treatment to supportive care. At Ms. H's insistence, Baby K was underwent tracheostomy (surgically implanted tube placed in the windpipe to help support her breathing when attached to a ventilator machine). When Baby K had recovered enough to no longer need a ventilator, the hospital transfered Baby K to a nursing home.

1.2.2. Baby K presented to the hospital in respiratory distress. The hospital felt it was morally unethical to continue to provide emergency care to Baby K, given that had a terminal condition and their determination such treatment would have no therapeutic or palliative value.

1.2.3. Baby K's guardian wanted the hospital to continue to provide emergency care when needed (making Baby K a full code).

1.2.4. The hospital failed in convincing Ms. H to change Baby K's code status from aggressive treatment to supportive care.

1.2.5. The hospital brought action for declaratory judgment under the Emergency Medical Treatment and Active Labor Act (EMTALA) that providing respiratory support to anencephalic infant is obliged. Because aggressive treatment would serve no therapeutic or palliative purpose, the hospital maintained that Baby K only be provided with supportive care in the form of nutrition, hydration, and warmth. However, Ms. K and Baby K's court-appointed guardian requested Baby K remain a full code.

1.3. Procedural History:

1.3.1. The United States District Court, Eastern District of Virginia Ruled against the hospital.

1.3.2. The Court of Appeals, 4th Circuit Affirmed District Court's ruling in favor of Baby K.

2. Issue:

2.1. Whether a hospital is responsible for providing emergency medical care for the patient under Emergency Medical Treatment and Labor Act (EMTALA) for treatments it deems medically and ethically inappropriate.

3. Rule of Law:

3.1. EMTALA: In 1986, Emergency Medical Treatment and Labor Act (EMTALA) was enacted by congress to ensure public access to emergency services irrespective of ability to pay or condition.

3.1.1. Under EMTALA, hospitals must conduct appropriate screenings for all patients arriving to emergency departments to determine if an emergency condition exists.

3.1.2. Hospitals are then required to provide stabilizing treatment for patients with an emergency medical conditions (EMC).

3.1.3. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented and the treating hospital is responsible for securing an appropriate alternative facility.

3.1.4. A hospital cannot deny treatment to a person with life-threatening or serious injuries based on a patient's inability to pay; it also cannot "dump" patients by transferring them to another facility before they are properly stabilized.

4. Analysis & Application:

4.1. Plantiff:

4.1.1. The hospital argued that anencephaly is a terminal disease, and as such the life expectancy of Baby K was shortened. In the hospital's view, due to Baby K's condition and the futility of treatment, the morally appropriate action would be to provide palliative treatment. They interpreted and argued EMTALA serves the purpose of providing emergency care for those who have a fighting chance of survival.

4.2. Defendant:

4.2.1. Even though Baby K was previously diagnosed with anencephaly and had no cerebral function, Baby K is still alive and the hospital is obligated to treat Baby K's chief symptoms of respiratory distress. The defendants argued under EMTALA, that the presenting chief complaint of respiratory distress qualifies as an emergency and not providing treatment would lead to certain death.

4.3. Court:

4.3.1. The court determined that EMTALA was enacted to serve anyone who needed emergency care as long as they presented to the emergency department of a hospital in distress and needing emergency services. The court further determined that the Hospital had no right to apply the law or interpret its applicability based on the medical condition or survivability of the patient. Baby K, as a patient presenting symptoms to an emergency department, has the right under EMTALA to receive the same level of care/treatment given to anyone in respiratory distress. The hospital's failure to treat Baby K amounts to failure to uphold the standard of care and patient code status (Full Code) irrespective of patient history.

4.3.2. Although the court sympathizes with the physician in providing the treatment they consider to be morally and ethically inappropriate, the rules of law must be followed and applied, which in this case include adherance to EMTALA and guidelines of care for Code Status. EMTALA: Under EMTALA, the establishment and assurance of an adequate airway and ventilation is part of the patient stabilization process when presenting to the hospital for respiratory distress. Code Status: Full code means that if a person’s heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive.

4.3.3. The Court declined to reinterpret or expand EMTALA and deferred changes to the law to congress who enacted it.

5. Conclusion:

5.1. Decision of the Court:

5.1.1. The court ruled in favor of Baby K, and the hospital was required to provide the same treatment afforded to other patients with emergency respiratory conditions.

5.2. Impact:

5.2.1. Burks v. St. Joseph's Hospital, 227 Wis. 2d 811, 596 N.W.2d 391 (Wis. 1999) This case draws a distinction between EMTALA and malpractice; however it upholds the EMTALA interpretation put forth in the Baby K case that EMTALA pertains to the provision of emergency treatment for all patients regardless of ability to pay.

5.2.2. Preston v. Meriter Hosp., Inc., 271 Wis.2d 721 Court of Appeals of Wisconsin. (Feb. 26, 2004) This is a similar case to Baby K, where the plaintiff was a mother who was suing a hospital for not providing emergency care to her newborn infant. The mother cited Baby K in her reasoning for the suit. However, the court sided with the hospital because the mother did not enter the hospital originally seeking emergency treatment and therefore EMTALA does not apply.

5.3. Importance:

5.3.1. Health care professionals are often faced with making ethical decisions on providing medical care, however there are also potentially financial implications as well. EMTALA was enacted to guard against denial of life-saving emergency care for patients with a financial inability to pay, and to prevent hospitals from "dumping" those patients on other hospitals before stabilization. Health care professionals provide these life-saving treatments. The application of these interventions in an emergency situation is determined by the law (EMTALA) and not the personal feelings/opinions of the treatment team involved. The court makes that clear by noting at the end of the decision how it is not their duty to evaluate based on ethical or moral standards, just the law (EMTALA) An interesting comparison can be made to health systems that lack EMTALA-like legislation. Japan for instance is one such nation, and historically has had issues with patients dying due to bein refused by hospitals, which has raised criticisms on its emergency health services/network (

5.4. Influence:

5.4.1. Medical Futility and Healthcare Costs This case raises a broader issue regarding the costs of healthcare, particularly in end of life situations where Medicare expenditures tend to be disproportionately high and the prognosis is extremely poor. (

5.4.2. Do-Not-Resuscitate Orders and Medical Futility: State vs. Federal It raises a debate on who has the right to declare medical care futile, and who has the right to change code status. There are state laws that provide in certain circumstances physicians may make such decisions.

6. Reference:

6.1. 16 F.3d 590 (1994) In the Matter of BABY "K" (Three Cases). Nos. 93-1899, 93-1923 and 93-1924. United States Court of Appeals, Fourth Circuit.

6.2. Erin A. Nealy, Medical Decision-Making for Children: A Struggle for Autonomy, 49 SMU L. Rev. 133 (1996) Medical Decision-Making for Children: A Struggle for Autonomy

6.3. Cantor MD, Braddock III CH, Derse AR, et al. Do-Not-Resuscitate Orders and Medical Futility. Arch Intern Med. 2003;163(22):2689–2694. doi:10.1001/archinte.163.22.2689

6.4. Burks v. St. Joseph's Hospital, 227 Wis. 2d 811, 596 N.W.2d 391 (Wis. 1999)

6.5. Preston v. Meriter Hosp., Inc., 271 Wis.2d 721 Court of Appeals of Wisconsin. (Feb. 26, 2004)