Mulhern v. Catholic Health Initiatives A/K/A Catholic Health Initiatives Iowa Corp.. D/B/A Mercy Franklin Ctr. And/Or Mercy Hosp. And/Or Mercy Psychiatric Serv.

• Decision Date: 24 June 2011
• Docket Number: No. 08–1478.,08–1478.
• Citation: 799 N.W.2d 104
• Parties: Todd A. MULHERN, Individually and as Representative of the Estate of Elizabeth M. Von Linden, Appellant,v.CATHOLIC HEALTH INITIATIVES a/k/a Catholic Health Initiatives Iowa Corp. d/b/a Mercy Franklin Center and/or Mercy Hospital and/or Mercy Psychiatric Services, Appellee.
• Court: Iowa Supreme Court

799 N.W.2d 104

Todd A. MULHERN, Individually and as Representative of the Estate of Elizabeth M. Von Linden, Appellant,

v.CATHOLIC HEALTH INITIATIVES a/k/a Catholic Health Initiatives Iowa Corp. d/b/a Mercy Franklin Center and/or Mercy Hospital and/or Mercy Psychiatric Services, Appellee.

No. 08–1478.

Supreme Court of Iowa.

June 24, 2011.

Andrew J. Stoltze and Bruce H. Stoltze of Stoltze & Updegraff, P.C., Des Moines, and Christopher A. Kragnes, Des Moines, for appellant.Stacie M. Codr and Connie L. Diekema of Finley, Alt, Smith, Scharnberg, Craig, Hilmes & Gaffney, P.C., Des Moines, for appellee.WATERMAN, Justice.

Elizabeth Von Linden, a successful business executive, took her own life three weeks after she was discharged as an inpatient from defendant Mercy Hospital's psychiatric ward and six days after her outpatient office visit with Mercy's psychiatrist. Her husband brought a wrongful death action against Mercy, alleging negligent care. Mercy raised defenses, including Von Linden's comparative negligence. The trial court allowed the jury to decide their negligence. The jury found both Mercy and Von Linden negligent and allocated ninety percent of the total fault to Von Linden and ten percent to Mercy, resulting in a defense verdict. We are asked to decide whether our state's comparative fault act, Iowa Code chapter 668 (2003), permits a jury to compare the fault of a noncustodial suicide victim with the negligence of the mental health professionals treating her. We determine Von Linden owed a duty of self-care as an outpatient, and the district court committed no reversible error in allowing the jury to compare her fault. We therefore affirm the judgment for Mercy.

“Suicide has long been the subject of intense religious, ethical, legal and medical debate.” Brandvain v. Ridgeview Inst., Inc., 188 Ga.App. 106, 372 S.E.2d 265, 271 (1988) (citing Victor E. Schwartz, Civil Liability for Causing Suicide: A Synthesis of Law and Psychiatry, 24 Vand. L.Rev. 217 (1971)). “A medical provider treating a patient with suicidal ideas presents a uniquely complex situation for comparative fault.” Champagne v. United States, 513 N.W.2d 75, 78 (N.D.1994). As discussed below, courts have reached divergent conclusions on how to allocate legal responsibility for suicide between the victims and the mental health professionals treating them. Each case turns on its uniquely tragic facts. Our resolution under Iowa law is based on the record made below and is guided by well-reasoned precedent from other states where the overwhelming majority of courts allow juries to compare the fault of a noncustodial patient who commits suicide.

I. Background Facts and Proceedings.

Elizabeth Von Linden, age forty, was in charge of consumer marketing at a large media company. Her job involved substantial travel and stress. She had a history of recurrent episodes of severe depression with interepisode recovery throughout her adult life. During college, she attempted suicide by slitting her wrists and overdosing on sleeping pills. She dropped out of college and, for roughly twenty years, was a functional alcoholic. After attending Alcoholics Anonymous, she stopped drinking. Her sobriety followed a second suicide attempt by carbon monoxide poisoning. She went many years with no medical treatment for her depression.

In late 1999, Von Linden met Todd Mulhern. Mulhern moved in with Von Linden in 2000. Mulhern and Von Linden were married in May 2002. Mulhern, Von Linden, and his ten-year-old daughter initially lived in Von Linden's home in Des Moines. Von Linden and Mulhern then purchased a larger house on the same block and moved in, but had difficulty selling her old house. The financial stress of owning two houses largely fell on Von Linden as the primary breadwinner. This financial stress coupled with work pressures worsened Von Linden's depression, culminating in a suicide attempt on June 6, 2003.

For the two preceding weeks, Von Linden had experienced suicidal thoughts. That night she decided to take her own life. Von Linden, in the middle of the night, went downstairs into the garage and taped a vacuum hose from the tailpipe of her car to run into the back window. She ingested prescription painkillers and Xanax, turned her car on, and fell asleep. The heat from the tailpipe melted the vacuum hose. Mulhern awoke to the odor of car exhaust. He ran downstairs into the garage to find Von Linden, responsive but lethargic, in her car. He took her to Mercy Medical Center's emergency room.

An emergency room physician assessed Von Linden, conducted lab tests, and called Mercy Franklin Center—Mercy's behavioral health section—for a psychiatric evaluation. In the emergency room, Von Linden continued to express suicidal ideations by stating, “I wish it would end” and “I'm sorry I didn't die.” Von Linden consented, however, to being hospitalized.

Von Linden was admitted into the psychiatric ward in the early afternoon of June 6 and spent the next two days there. The medical staff placed Von Linden on a suicide watch upon her admission. Dr. Charles Scott Jennisch, a psychiatrist, was her primary physician. He had not treated her previously. Dr. Jennisch met with Von Linden on June 6 for several hours. He diagnosed her with recurrent, severe major depressive disorder and placed her on new medications. He educated her about the nature of her illness and treatment options. She told him she had never heard such detailed information before, and it gave her hope. She asked to have a short hospital stay followed by outpatient treatment. That night, Von Linden slept well, and the next morning Dr. Jennisch noted she appeared brighter and more hopeful with reduced anxiety.

Dr. Jennisch met with Von Linden and Mulhern again on June 7 and discussed in depth her illness and treatment recommendations. Von Linden told Dr. Jennisch “none of the stressors related to the house are worth dying for.” She denied any suicidal ideation that day. She expressed regret for her suicide attempt and confidence about the potential to treat her illness. She reiterated she did not want inpatient treatment. Both she and her husband asked that she return home that day. Dr. Jennisch discouraged discharge and recommended she remain hospitalized at least another day. She agreed. He discussed educational support with her and the transition to outpatient services at his clinic. He recommended that, after her release as an inpatient, Von Linden participate in a “partial hospitalization” program from 9 a.m. to 3 p.m. daily. She reported improvements in her symptoms and said she did not feel she needed intense inpatient treatment or the partial hospitalization program. Both she and her husband asked that she return to work as quickly as possible.

On June 8, Dr. Jennisch met with Von Linden again. Her condition had markedly improved, and she had met all inpatient treatment goals. Von Linden and her husband asked that she go home. Dr. Jennisch spoke with Von Linden about outpatient treatment plans and gave her written discharge instructions. Von Linden was instructed to remain on the medications and schedule follow-up visits with Dr. Jennisch and with a psychologist for therapy. Finally, she was to attend the “women and self-esteem” and “stress management” group therapy sessions at Mercy Franklin Center. Dr. Jennisch went over these instructions with Von Linden. She was given several emergency numbers, including Dr. Jennisch's and a Help Center number she was to call day or night if her condition worsened. Dr. Jennisch “made it clear to her” she was to call if she had any concerns. Von Linden told Dr. Jennisch that, “if things changed or deteriorated as opposed to actually attempting to take her life, ... she would be very comfortable in either coming to the Help Center ... or in calling [his] clinic.” The discharge summary states “[f]ollow-up and emergency services were discussed in detail,” Von Linden “has our emergency phone numbers,” she is “aware of how to contact us if there are any problems or concerns as well as the Help Center and emergency resources,” and she “readily agrees to utilize those.” A nurse also went over the instructions with Von Linden and Mulhern. Dr. Jennisch discharged Von Linden from the hospital at 10:15 a.m., and she took those instructions home with her.

The next day, June 9, Von Linden returned to work and scheduled follow-up appointments with Dr. Jennisch for June 23 and the psychologist he recommended for July 2. On June 13, Von Linden called Dr. Jennisch's office and obtained permission to increase her medication.

Von Linden and Mulhern next met with Dr. Jennisch on June 23. Dr. Jennisch noted Von Linden was doing better and had tolerated her new medications without any difficulties. Von Linden reported that she had only seen small changes since her discharge from the hospital but had not had any suicidal thoughts. Mulhern reported that she seemed brighter and better able to laugh and enjoy things. Dr. Jennisch spent significant time discussing Von Linden's illness and making recommendations for her continued care. He discussed with her the option of returning to the hospital for the intensive outpatient treatment program, which she declined. Dr. Jennisch “again reviewed emergency services ... as well as stress management techniques.” He agreed to see her again in two weeks and instructed her to call him in the interim if she had any problems or concerns. Dr. Jennisch and plaintiff's expert at trial testified that, as of June 23, she could not be involuntarily committed under Iowa law. Von Linden scheduled another appointment to see Dr. Jennisch on July 7.

Meanwhile, Von Linden was attending work every day. Her supervisor testified at trial that the last day he saw her, June 27, she was performing well at work and appeared to be “in a great mood.” Her work calendar reflected she was planning future appointments. On June 29, Mulhern left to go...