In Re the Involuntary Commitment of R.R. v. Indiana University Health Bloomington Hospital (mem. dec.) ( 2015 )

MEMORANDUM DECISION
Aug 07 2015, 10:04 am
Pursuant to Ind. Appellate Rule 65(D), this
Memorandum Decision shall not be regarded as
precedent or cited before any court except for the
purpose of establishing the defense of res judicata,
collateral estoppel, or the law of the case.
ATTORNEY FOR APPELLANT ATTORNEYS FOR APPELLEE
Stuart K. Baggerly James L. Whitlatch
Bloomington, Indiana Kathryn DeWeese
Bunger & Robertson
Bloomington, Indiana
IN THE
COURT OF APPEALS OF INDIANA
In Re the Involuntary August 7, 2015
Commitment of Court of Appeals Case No.
53A05-1501-MH-19
R.R. Appeal from the Monroe Circuit
Court
Appellant-Respondent,
The Honorable Stephen R. Galvin,
v. Judge
Cause No. 53C07-1412-MH-419
Indiana University Health
Bloomington Hospital,
Appellee-Petitioner
Bailey, Judge.
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Case Summary
[1] R.R. appeals an order involuntarily committing her to IU Health Bloomington
Hospital (“IU Health”) and authorizing injections of medication. She
challenges the sufficiency of the evidence to support the determination that she
is gravely disabled or to support forced medication. We affirm.
Facts and Procedural History
[2] R.R. is a forty-nine-year-old woman who has been diagnosed as schizophrenic.
On December 13, 2014, R.R. called for an ambulance to take her to a hospital
emergency room. R.R. had experienced prolonged sleep deprivation after
becoming upset with her son, which she described as “very devastating.” (Tr.
at 21.) The ambulance call had been preceded by at least five recent calls from
R.R. to police requesting safety checks. One of the responding officers had
noted that R.R.’s house was “extremely unkept [sic] with a dog and eight cats,
knee deep debris and trash and feces and the county may be taking action to
condemn the house.” (Tr. at 29.)
[3] On December 16, 2014, IU Health filed a petition for involuntary commitment,
attaching the report of Dr. Carey Mayer (“Dr. Mayer”). Dr. Mayer opined that
R.R. was suffering from a psychiatric disorder which substantially disturbs her
thinking, feeling or behavior and impairs her ability to function. More
specifically, he noted: “very psychotic, has paranoid delusions, and likely
hallucinations, has very poor judgment, not taking meds.” (App. at 7.)
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[4] A commitment hearing was conducted on December 19, 2014, at which Dr.
Mayer and R.R. testified. Dr. Mayer testified that R.R. was “unable to ensure
her own safety and shelter,” was hearing voices, and was “afraid of her home.”
(Tr. at 7.) For example, R.R. believed that there were “people peeing down her
chimney.” (Tr. at 7.) According to Dr. Mayer, R.R. had a history of non-
compliance with medication and would best benefit from a newer atypical
antipsychotic injection regimen. R.R. testified that she would take medication
but she objected to injections for fear of side effects.
[5] On the same day, the trial court issued an order finding R.R. to be gravely
disabled and in need of commitment to an appropriate facility for a period
expected to exceed ninety days. R.R. was committed to IU Health, with the
additional grant of authority to IU Health “to treat with the following
medication, unless Respondent does not specifically benefit from these
medications: Invega sustenna.” (App. at 21.) R.R. appeals.
Discussion and Decision
[6] In Indiana, an adult person may be civilly committed either voluntarily or
involuntarily. T.K. v. Dept. of Veterans Affairs, 27 N.E.3d 271, 273 n.1 (Ind.
2015). A “regular commitment” is for an indefinite period of time that may
exceed ninety days. Id. (citing Ind. Code § 12-26-7 et seq.). To obtain an
involuntary regular commitment of an individual, a petitioner must prove by
clear and convincing evidence that: (1) the individual is mentally ill and either
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dangerous or gravely disabled; and (2) detention or commitment of that
individual is appropriate. I.C. § 12-26-2-5(e).
[7] “[T]he purpose of civil commitment proceedings is dual: to protect the public
and to ensure the rights of the person whose liberty is at stake.” In re
Commitment of Roberts, 723 N.E.2d 474, 476 (Ind. Ct. App. 2000). The liberty
interest at stake in such a proceeding goes beyond a loss of physical freedom;
given the stigma and adverse social consequences of confinement, a proceeding
for an involuntary civil commitment is subject to due process requirements.
T.K., 27 N.E.3d at 273. To satisfy the requirements of due process, the facts
justifying an involuntary commitment must be shown by clear and convincing
evidence. Id. “Because everyone exhibits some abnormal conduct at one time
or another, loss of liberty calls for a showing that the individual suffers from
something more serious than is demonstrated by idiosyncratic behavior.” M.M.
v. Clarian Health Partners, 826 N.E.2d 90, 97 (Ind. Ct. App. 2005), trans. denied.
[8] When we review the sufficiency of the evidence supporting a determination
made under the statutory requirement of clear and convincing evidence, we will
consider only the probative evidence and the reasonable inferences supporting
it, without weighing evidence or assessing witness credibility. T.K., 27 NE3d at
273. We will affirm if a reasonable trier of fact could find the necessary
elements proven by clear and convincing evidence. Id.
[9] R.R. does not challenge the finding that she is mentally ill, pursuant to Indiana
Code Section 12-7-2-130, which defines mental illness as a psychiatric disorder
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that substantially disturbs an individual’s thinking, feeling, or behavior and
impairs the individual’s ability to function. She argues that the trial court could
not have found by clear and convincing evidence that she is gravely disabled.
“Gravely disabled” is defined as:
a condition in which an individual, as a result of mental illness, is in
danger of coming to harm because the individual:
(1) is unable to provide for that individual’s food, clothing, shelter, or
other essential human needs; or
(2) has a substantial impairment or an obvious deterioration of that
individual’s judgment, reasoning, or behavior that results in the
individual’s inability to function independently.
I.C. § 12-7-2-96.
[10] R.R. asserts that she is able to provide for her essential needs and to function
independently; she likens her circumstances to those of the appellant in T.K..
There, our Indiana Supreme Court reversed a commitment order, finding that
grave disability had not been shown by clear and convincing evidence, when
the respondent rented his own home, lived by himself, held full-time
employment, owned two vehicles, made no physical outbursts, destroyed no
property, did not put himself or others in actual danger with idiosyncratic
behavior, and was not at risk of suffering a lack of food, shelter, or clothing.
T.K., 27 N.E.3d at 277.
[11] Here, however, IU Health did not merely present evidence of idiosyncratic
behavior. Dr. Mayer testified that R.R. has “paranoid delusions involving
other people attacking her and doing things to her and threatening her and her
loved ones.” (Tr. at 5.) According to Dr. Mayer’s testimony based upon a
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review of R.R.’s mental health treatment, she has both a long history of
hospitalizations and a history of non-compliance with her medication regime.
As of the hearing date, R.R. continued to suffer from “internalized auditory
hallucinations” although they had diminished with medication administered at
the hospital. (Tr. at 13.)
[12] R.R. had a residence where she lived with her son, but she felt afraid there and
repeatedly summoned assistance. Her unsubstantiated concerns – such as fear
that people were urinating down her chimney – caused her to make repeated
emergency calls. One responder, who was both an EMT and a police officer,
noted that R.R.’s house was covered with trash and feces such that
condemnation of the property was expectable. Unlike the appellant in T.K.,
R.R. was at risk of losing her shelter.
[13] The evidence favorable to the commitment order establishes that R.R. suffers
from a substantial impairment of her judgment resulting in an inability to
function independently and that she is in danger of coming to harm because she
is unable to provide for her essential needs. Accordingly, the “trial judge could
have found by clear and convincing evidence” that R.R. was gravely disabled.
T.K., 27 N.E.3d at 274.
[14] R.R. also challenges the medication order. A patient possesses a liberty interest
in freedom from unwarranted intrusions into his or her physical person and
mind while he or she is within an institution. In re Mental Commitment of M.P.,
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510 N.E.2d 645, 646 (Ind. 1987). Accordingly, our supreme court has held that
a petitioner
must demonstrate by clear and convincing evidence that: (1) a current
and individual medical assessment of the patient’s condition has been
made; (2) that it resulted in the honest belief of the psychiatrist that the
medications will be of substantial benefit in treating the condition
suffered, and not just in controlling the behavior of the individual; (3)
and that the probable benefits from the proposed treatment outweigh
the risk of harm to, and personal concerns of, the patient. At the
hearing, the testimony of the psychiatrist responsible for the treatment
of the individual requesting review must be presented and the patient
may present contrary expertise.
Equally basic to court sanctionable forced medications are the
following three limiting elements. First, the court must determine that
there has been an evaluation of each and every other form of treatment
and that each and every alternative form of treatment has been
specifically rejected. It must be plain that there exists no less restrictive
alternative treatment and that the treatment selected is reasonable and
is the one which restricts the patient’s liberty the least degree possible.
Inherent in this standard is the possibility that, due to the patient’s
objection, there may be no reasonable treatment available. This
possibility is acceptable. The duty to provide treatment does not
extend beyond reasonable methods. Second, the court must look to
the cause of the commitment. Some handicapped persons cannot have
their capacities increased by anti-psychotic medication. The drug
therapy must be within the reasonable contemplation of the
committing decree. And thirdly, the indefinite administration of these
medications is not permissible. Many of these drugs have little or no
curative value and their dangerousness increases with the period of
ingestion. The court must curtail the time period within which they
may be administered. If a patient does not substantially benefit from
the medication, it should no longer be administered.
If after the hearing brought about by the objecting patient has taken
place, the court is convinced that the State has met its burden of proof
of showing, by clear and convincing evidence, a professional judgment
having the above recited qualities and characteristics, it should
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sanction the forced medication. If it is not so convinced, it should
reject such treatment.
Id. at 647-48.
[15] Dr. Mayer explained that Invega Sustenna “addresses the underlying neuro
biochemical imbalance that’s in the brain and therefore directly improves the
patient’s functioning and reduces their symptoms.” (Tr. at 7-8). R.R. contends
that she expressed willingness to take that medication orally. She argues that
there was no testimony that each and every form of treatment other than
injectable Invega Sustenna had been considered and rejected or that the
injections represent the least restrictive treatment. Our review of the record
reveals otherwise.
[16] When asked about other forms of treatment, Dr. Mayer initially focused on the
setting for treatment, as opposed to medication. He was concerned that R.R.,
as an out-of-county patient, would not qualify for a transitional care facility that
would otherwise be preferable to inpatient commitment. However, Dr. Mayer
was then specifically asked:
and so, has every other form, it seems like you’ve exhausted many,
many forms of treatment and so have you looked at every form of
treatment that would be possible for [R.R.] and ruled them out and
decided that this recommended treatment then is the, is necessary?
(Tr. at 19.) Dr. Mayer responded, “Yes.” (Tr. at 19.) Ideally, more
elaboration upon Dr. Mayer’s evaluative processes might have been elicited at
that juncture.
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[17] Nonetheless, during the hearing, Dr. Mayer testified that R.R. “becomes very
psychotic” when off her medication, oral medication had been prescribed for
years, and R.R. had a history of non-compliance. (Tr. at 6.) R.R. testified that
she took her medication regularly, specifically, heart medication, cholesterol
medication, and Ambient (something she described as “kind of like my
Risperdone was”). (Tr. at 22.) However, Dr. Mayer testified that R.R.’s liver
enzyme evaluation had revealed some abnormalities, raising “a concern that
she may have been taking the wrong medications and too much of them and
not enough of the right ones.” (Tr. at 29.)
[18] Dr. Mayer considered Invega Sustenna as “a very benign medication in that
class” and specified that the benefits “far outweigh any of the risks.” (Tr. at 8.)
Dr. Mayer opined that the risk of side effects was low and R.R. did not appear
to be experiencing significant side effects from the oral form of medication
given during her hospitalization. According to Dr. Mayer, injections would
require limited occasions of intervention, as it required two injections, four days
apart, and then would become only monthly. The hope was that R.R.’s
estimated 60% improvement in auditory hallucinations with oral medication
could be further improved to the “elimination of psychotic symptoms.” (Tr. at
13.) The trial court did not order a particular medication in the absence of
testimony of other alternatives; we find R.R.’s argument to be a request to
reweigh the evidence presented in this regard.
[19] R.R. also claims that there was no time limitation placed upon the
administration of the medication. Again, we disagree with this contention.
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Indiana Code Section 12-26-15-1(a) requires the annual review of commitment
orders. In compliance therewith, the trial court ordered IU Health to submit a
periodic report not later than December 19, 2015. By statute, the forced
medication order is not indefinite. The time period of medication
administration was curtailed and the order was subject to the limitation of
discontinuance if R.R. did not specifically benefit from the medication.
Sufficient evidence exists for the medication order.
Conclusion
[20] IU Health presented sufficient evidence such that the trial court could find by
clear and convincing evidence that R.R. was gravely disabled. IU Health
established the requisite proof to support the medication order.
[21] Affirmed.
Baker, J., and Mathias, J., concur.
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