¶ 1 This appeal by the defendant Tucson Heart Hospital — Carondelet, L.L.C., arises from a wrongful death action filed by Carol Saliea, Louis Salica’s widow. After a twelve-day trial, a jury found Tucson Heart and other parties had negligently caused Salica’s death. The jury determined Tucson Heart was sixty percent responsible and found it liable for damages totaling $600,000.
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On appeal, Tucson Heart argues there was insufficient evidence that its negligence caused
Factual and Procedural Background
¶ 2 “We view the evidence and reasonable inferences therefrom in the light most favorable to upholding the jury’s verdict.”
Acuna v. Kroack,
¶3 While in the hospital that day, Salica was examined by an internist and a pulmo-nologist. The internist believed that, although Salica had some type of “cardiac component” to his illness, he was suffering primarily from pneumonia. The pulmonologist who later examined Salica and reviewed his records disagreed. Having detected a murmur in the mitral valve of Saliea’s heart, the pulmonologist believed Salica was most likely suffering from a mitral-valve disease that was causing cardiac decompensation. Salica was in stable condition when the pul-monologist examined him at 5:00 p.m., but the doctor characterized him as a “really sick guy” and expected him to be cared for by a cardiologist.
¶ 4 Saliea’s own cardiologist and attending physician, Dr. James Myer, did not examine Salica in the hospital until 9:00 p.m. Myer had been informed of Saliea’s status over twelve hours earlier and originally had planned to visit him in the emergency room. When Myer saw him, Salica was receiving supplemental oxygen, and Myer ordered that he be given Lasix to reduce the fluid in his lungs and thereby ease his breathing. Because it is a diuretic, Lasix also increases a patient’s urine output.
¶ 5 During his examination of Salica, Myer detected mitral-valve regurgitation and arranged for his partner, Dr. Charles Katzen-berg, to perform a transesophageal echocar-diogram (TEE) the next morning to identify the defect more specifically. Following Myer’s visit with Salica, the on-call physician covering for Myer, Dr. Edward Byrne-Quinn, would have received any overnight calls made to Myer regarding Salica.
¶ 6 That night, while Salica was in the care of registered nurse Diane LeBlanc, his health deteriorated. His urine production was less than expected, indicating the Lasix was not having its intended effect, and his oxygen saturation consistently was below the minimum level of ninety percent, even though he had been placed on a non-rebreathing device and was receiving the maximum amount of supplemental oxygen possible without intubation. Nurse LeBlanc consulted both her charge nurse and a respiratory therapist about Saliea’s condition during this period. Yet she did not alert a physician about Sali-ea’s status until approximately 6:00 the next morning during a telephone conference initiated by Dr. Katzenberg.
¶ 7 The plaintiffs expert witness, Nurse Halina Orawiee, testified LeBlane’s failure to call a physician between 9:00 p.m. and 6:00 a.m. fell below the standard of care for registered nurses in several respects. Specifically, LeBlanc failed to report that Salica had been placed on a non-rebreathing device at around 12:30 a.m. on September 27 without improvement;
2
she failed to report that his oxygen levels were consistently below the minimum Iqvel, despite the fact that he was receiving the maximum possible amount of
¶ 8 Dr. Mark Perlroth, the plaintiffs expert-witness cardiologist, testified that the standard of care for a cardiologist upon receiving a report about Saliea’s status during LeBlanc’s shift would have called for prompt action. This included admitting Salica to the intensive-care unit (ICU), intubating him, performing a TEE, inserting an intra-aortic balloon, increasing his medications, and consulting with a eardiothoraeie surgeon. 4 Another expert witness, Dr. Andrew Wechsler, testified that the lack of surgical intervention during LeBlane’s shift, resulting in “hours of progression of the underlying heart failure and difficulty in getting oxygen into the body in adequate amounts,” had meaningfully decreased Saliea’s chance of survival.
¶ 9 The following morning, the pulmonologist who examined Salica after Nurse Le-Blanc’s shift had ended found Salica was “significantly worse than when [he] left him the day before.” The internist who previously had examined Salica ordered him to the ICU at approximately 8:20 a.m. Dr. Katzen-berg arrived at the hospital around 10:40 a.m., requested a consultation with a car-diothoracic surgeon about thirty minutes later, and intubated Salica shortly thereafter. By noon, the TEE revealed Salica had suffered a papillary muscle rupture that would require surgery. In preparation for the surgery, Dr. Myer inserted an intra-aortic balloon pump. Doctors successfully repaired Saliea’s mitral valve that day, but he ultimately died from complications and infections resulting from the surgery. Dr. Paul Auwaerter, an infectious-disease specialist, testified Saliea’s susceptibility to those complications was a consequence of his fragile, significantly deteriorated condition at the time of the surgery.
¶ 10 At the close of the plaintiffs evidence, Tucson Heart moved for judgment as a matter of law (JMOL) pursuant to Rule 50(a), Ariz. R. Civ. P., arguing the plaintiff had failed to prove that the negligence of its employee, Nurse LeBlanc, had caused Sali-ea’s death. The tidal court denied the motion. Tucson Heart renewed its motion under Rule 50(b) after the entry of judgment, and the court again denied the motion. This appeal followed.
Discussion
¶ 11 Tucson Heart challenges the denial of its Rule 50 motion, an issue we review de novo.
See Felder v. Physiotherapy Assocs.,
¶ 12 As part of her wrongful death cause of action brought pursuant to A.R.S. § 12-611, 5 the plaintiff had to establish medical malpractice in accordance with AR.S. §§ 12-561(2), 12-562(A), and 12-563. Pursuant to § 12-563, she was required to prove that Salica’s health care providers failed to comply with the accepted standard of care and that “[s]ueh failure was a proximate cause of the injury.” The sole issue raised in this appeal is whether the evidence presented was legally sufficient to establish causation. Specifically, the question is whether that evidence allowed the jury to conclude that the actions of Tucson Heart’s employee, Nurse LeBlanc, proximately caused Saliea’s death.
¶ 13 A “proximate cause” is defined as “that which, in a natural and continuous sequence, unbroken by any efficient intervening cause, produces an injury, and without which the injury would not have occurred.”
6
Robertson v. Sixpence Inns of Am., Inc.,
¶ 14 However, when multiple tortfeasors are alleged
to
have created an indivisible injury and each defendant’s causal role is potentially indeterminable, such causal uncertainty will not prevent a plaintiff from recovering altogether.
E.g., Piner v. Superior Court,
¶ 15 Arizona has adopted the “substantial factor” test from the Restatement (Second) of Torts §§ 431, 433, and 435 (1965), in order to prevent inequities and serve the remedial aims of tort law. See
Piner,
¶ 16 “Causation is generally a question of fact for the jury unless reasonable persons could not conclude that a plaintiff had pi’oved this element.”
Barrett,
¶ 17 Here, LeBlane’s negligence in failing to alert a physician to Salica’s deteriorating status is not disputed on appeal. And, based upon the evidence presented below, the jury reasonably could have concluded that Le-Blanc’s failure to act contributed to Salica’s worsened and weakened condition and was a substantial factor causing his death. As Dr. Perh'oth testified, there were a number of medical interventions that should have been performed promptly had a physician been alerted to Saliea’s worsening condition, including intubation, performing a TEE, inserting an intra-aortie pump, and consulting a eardiothoracic surgeon. By the time these measures were taken, Salica’s oxygen saturation had declined drastically; he was in shock; and his chances of survival, according to Dr. Wechsler, had fallen from over ninety percent to approximately twenty percent. The jury reasonably could have inferred, given the testimony of Dr. Auwaerter, that, had the various parties responsible for Salica’s medical care not acted negligently, Salica would not have been as susceptible to infection and would not have died from his surgery.
¶ 18 Indeed, the present case is factually similar to
Estate of Reinen v. N. Ariz. Orthopedics, Ltd.,
¶ 19 Our supreme court reversed the trial court’s rulings and remanded the case for a new trial.
Id.
¶ 28. As the court noted, the plaintiffs expert witness established that, under the circumstances of the ease, the standard of care for an internist required that Henry personally examine the patient; had this occurred, the necessary treatments then could have been instituted, giving the patient a seventy percent chance of avoiding permanent injury.
Id.
¶ 10. Because this expert testimony “provided evidence of a breach of the standard of care ... and a causal relationship to Reinen’s injuries,” the court concluded dismissing Henry from the case was erroneous.
Id.
The
Reinen
court similarly concluded the trial court had erred in dismissing the orthopedist and the hospital from the case, as the testimony of the plaintiffs expert was sufficient to show both a breach
¶ 20 None of Tucson Heart’s arguments alters our conclusion that the evidence presented below was sufficient to allow the jury to find the element of causation and, consequently, that the trial court properly denied the appellant’s JMOL motion. Tucson Heart suggests the jury received no evidence from which to draw a conclusion about causation in the absence of testimony from the on-call cardiologist, Dr. Byrne-Quinn, that he would have initiated the necessary interventions had he been alerted to Saliea’s deteriorating condition. But, as Reinen illustrates, testimony from this witness was not essential. The jury is not obligated to believe the testimony of a treating physician, and the testimony of qualified expert witnesses is sufficient to establish both a breach of the standard of care and causation. See id. ¶¶ 12-13. Furthermore, as the court noted here in denying the motion for JMOL, the evidence showed that a reasonably prudent cardiologist would have followed up with the necessary interventions promptly upon being informed of Saliea’s status, and “there was ... testimony that a cardiothora-eie surgeon was on call 24 hours a day and could have assembled a surgical team at any time during the nurse’s night shift.”
¶ 21 In the same vein, Tucson Heart contends evidence of causation was deficient because the plaintiff did not offer any specific proof that Nurse LeBlanc’s failure to call a physician was a “necessary condition for the occurrence of the injury.” It alternatively asserts that the plaintiff was required to prove “the injury would not have occurred without [Nurse LeBlane’s] act or omission.” But as
Reinen
demonstrates, these are not the applicable standards in medical malpractice cases where multiple actors contribute to an injury. Under such circumstances, a plaintiff is required to prove only that each defendant’s conduct was a “ ‘substantial factor’ ” in causing the injury.
See Ritchie v. Krasner,
¶ 22 Tucson Heart further suggests the evidence was deficient because the plaintiff was required “to prove that Nui’se LeBlanc’s alleged breach of the standard of care proximately caused Mr. Saliea’s death, not just some alleged pre-death injury.” When viewed as a whole, however’, the expei’t testimony admitted below was sufficient to establish that LeBlanc’s negligence substantially inci-eased the likelihood of Saliea’s death. Accox’ding to those expex’ts, the delay caused by that negligence substantially compromised Saliea’s ability to endux’e and recover from sui'gery.
¶ 23 Although we find the evidence presented below sufficient to support a finding that Nux’se LeBlanc’s negligence was a proximate cause of Saliea’s death, to the extent the evidence of her causal role was unclear due to the acts of Dr., Myer and other physicians or staff treating Salica, the trial court did not err in denying the JMOL motion and submitting the case to the jury. Tucson Heax-t contends the “existence of multiple defendants has no impact on plaintiffs burden to preve causation.” In light of Holtz, however, this is an incoi’rect statement of the law.
¶ 24 In
Holtz,
our supreme coui’t addressed the plaintiffs burden of pxeving causation “where [the] plaintiff is unable to prove which defendant caused which injuries or whether all were caused by one defendant or the other.”
it is more desirable, as a matter of policy, for an injured and innocent plaintiff to recover his entire damages jointly and severally from independent tortfeasors, one of whom could have to pay more than his just share, than to let two or more wrongdoers escape liability altogether, simply because the plaintiff cannot carry the impossible burden of proving the respective shares of causation or because the tortfeasors have not committed a joint tort.
Id.
¶ 25 Although joint and several liability subsequently was abrogated by A.R.S. § 12-2506, the rule from
Holtz
was reaffirmed in
Finer.
¶ 26 Tucson Heart also incorrectly suggests that apportionment of fault is wholly separate from the determination of causation. The rule in
Holtz,
which was developed from the Restatement § 433A, concerned the determination of both causation and damages.
Holtz,
Disposition
¶ 27 Finding no error, we affirm the trial court’s ruling and the judgment entered against Tucson Heart.
Notes
. The jury found Salica's cardiologist, Dr. James Myer, and the corporation with which he was affiliated liable for forty percent of the damages. However, those defendants satisfied the judgments against them and are not parties to the appeal.
. Nurse LeBlanc suggested and Salica's wife testified that Salica was already on the non-re-breathing device when Dr. Myer was with him at 9:00 p.m. However, Myer refuted this testimony, and the record from the respiratory therapist who placed Salica on the device indicated it occurred several hours later. Viewing the evidence in the light most favorable to sustaining the verdicts, we accept the latter version of events for purposes of this appeal.
See Warm Invs., Ltd. v. Higgins,
. LeBlanc admitted at trial that Salica's oxygen saturation was below the minimum level several times between 1:00 and 3:00 a.m.
. At oral argument, Tucson Heart claimed Dr. Perlroth did not testily about the standard of care for a cardiologist upon receiving an overnight call from the nurse; rather, his testimony only pertained to the treatment and interventions Dr. Myer should have undertaken when he examined Salica around 9:00 p.m. Although Perlroth mentioned this window of time in his testimony, he also clarified that a reasonably prudent cardiologist would have implemented these measures upon learning "the most dramatic information about how [Salica] was doing,” namely that his oxygen saturation levels had dropped into the seventy-percent range and that his respiration rate had risen to thirty-six breaths per minute when breathing room air. This "very critical point” came when Salica was being placed on the non-rebreathing device and momentarily had to breathe without supplemental oxygen. And despite the conflicting evidence about when this occurred, we accept for purposes of this appeal that he was placed on the device after midnight, during Nurse LeBlanc's shift, but well after Myer’s visit had ended.
. The statute reads:
When death of a person is caused by wrongful act, neglect or default, and the act, neglect or default is such as would, if death had not ensued, have entitled the party injured to maintain an action to recover damages in respect thereof, then, and in every such case, the person who or the corporation which would have been liable if death had not ensued shall be liable to an action for damages, notwithstanding the death of the person injured, and although tire death was caused under such circumstances as amount in law to murder in the first or second degree or manslaughter.
. An "intervening cause” is defined as "an independent cause that intervenes between defendant's original negligent act or omission and the final result and is necessary in bringing about that result.”
Robertson v. Sixpence Inns of Am., Inc.,
. Apportionment of fault is not called for when a plaintiff suffers separate injuries and liability can be apportioned based only on causation. See A.R.S. § 12-2506(B). (requiring calculation of percentage of fault only for those who "contributed to the alleged injury”).
. This determination is informed by the considerations listed in Restatement § 433.
See Bairett,