VF-502. Medical Negligence - Informed Consent - Defense of Emergency
We answer the questions submitted to us as follows:
1. Did [name of defendant] perform a [insert medical procedure] on [name of plaintiff]?
______ Yes ______ No
If your answer to question 1 is yes, then answer question 2. If you answered no, stop here, answer no further questions, and have the presiding juror sign and date this form.
2. Did [name of plaintiff] give [his/her] informed consent to the [insert medical procedure]?
______ Yes ______ No
If your answer to question 2 is no, then answer question 3. If you answered yes, stop here, answer no further questions, and have the presiding juror sign and date this form.
3. Would a reasonable person in [name of plaintiff]'s position have refused the [insert medical procedure] if he or she had been fully informed of the possible results and risks of [and alternatives to] the [insert medical procedure]?
______ Yes ______ No
If your answer to question 3 is yes, then answer question 4. If you answered no, stop here, answer no further questions, and have the presiding juror sign and date this form.
4. Was [name of plaintiff] harmed as a consequence of a result or risk that [name of defendant] should have explained before the [insert medical procedure] was performed?
______ Yes ______ No
If your answer to question 4 is yes, then answer question 5. If you answered no, stop here, answer no further uestions, and have the presiding juror sign and date this form.
5. Did [name of defendant] reasonably believe the [insert medical procedure] had to be done immediately in order to preserve the life or health of [name of plaintiff]?
______ Yes ______ No
If your answer to question 5 is no, then answer question 7. If you answered yes to this question, answer question 6.
6. Was [name of plaintiff] unconscious?
______ Yes ______ No
If your answer to question 6 is no, then answer question 7. If you answered yes, stop here, answer no further questions, and have the presiding juror sign and date this form.
7. What are [name of plaintiff]'s damages?
[a. Past economic loss, including [lost earnings/ lost profits/medical expenses:] $______] [b. Future economic loss, including [lost earnings/lost profits/lost earning capacity/ medical expenses:] $______] [c. Past noneconomic loss, including [physical pain/mental suffering:] $______] [d. Future noneconomic loss, including [physical pain/mental suffering:] $______] TOTAL $______
| Signed: | |
| Presiding Juror | |
| Dated: |
[After it has been signed/After all verdict forms have been signed], deliver this verdict form to the [clerk/bailiff/judge].
Directions for Use
The special verdict forms in this section are intended only as models. They may need to be modified depending on the facts of the case.
This verdict form is based on CACI No. 533, Failure to Obtain Informed Consent—Essential Factual Elements, and CACI No. 554, Affirmative Defense—Emergency.
Depending on the facts, alternative language may be substituted for question 6 as in item 2 of CACI No. 554. If specificity is not required, users do not have to itemize all the damages listed in question 7. The breakdown is optional; depending on the circumstances, users may wish to break down the damages even further.
If there are multiple causes of action, users may wish to combine the individual forms into one form.
This form may be modified if the jury is being given the discretion under Civil Code section 3288 to award prejudgment interest on specific losses that occurred prior to judgment.
If the affirmative defense, which is contained in questions 5 and 6, is not an issue in the case, then questions 5 and 6 should be omitted and the remaining questions renumbered accordingly.
(New September 2003)