In the Matter of the Civil Commitment of: Leah Christina Graeber. ( 2016 )

This opinion will be unpublished and
may not be cited except as provided by
Minn. Stat. § 480A.08, subd. 3 (2014).
STATE OF MINNESOTA
IN COURT OF APPEALS
A15-1139
In the Matter of the Civil Commitment of:
Leah Christina Graeber
Filed January 19, 2016
Affirmed
Ross, Judge
Dakota County District Court
File No. 19HA-PR-11-157
David A. Jaehne, West St. Paul, Minnesota (for appellant)
Lori Swanson, Attorney General, Stephanie M. Hilstrom, Assistant Attorney General,
Marsha E. Devine, Assistant Attorney General, St. Paul, Minnesota; and
James C. Backstrom, Dakota County Attorney, Donald E. Bruce, Assistant County
Attorney, Hastings, Minnesota (for respondent)
Considered and decided by Ross, Presiding Judge; Halbrooks, Judge; and
Chutich, Judge.
UNPUBLISHED OPINION
ROSS, Judge
Civil commitment patient Leah Graeber is the subject of a district court order
authorizing physicians to administer Clozaril to her. Graeber appeals from that order,
arguing that the court should have allowed her to continue medication-free. We affirm
because, among other things, the district court did not clearly err in finding facts that
support the order.
FACTS
The state has civilly committed Leah Graeber intermittently since 2001. Her current
commitment began in 2011 after she drove her car faster than 100 miles per hour, crossed
a grassy median, and struck an oncoming car, killing an 11-year-old boy and seriously
injuring his three family members. The district court committed Graeber as mentally ill
and dangerous, and she began treatment at the Minnesota security hospital in St. Peter.
Graeber has often refused to take prescribed medications. Her refusals have
prompted the district court several times to issue so-called Jarvis orders, which have
generally authorized hospital staff to administer neuroleptic Clozaril (commonly called
Clozapine). Clozaril’s side effects include sedation, orthostatic hypotension, temperature
elevation, hypersalivation, and, in rare cases, suppression of white-blood-cell production.
In March 2015, Graeber’s treating psychiatrist filed a petition seeking renewed
authorization to treat Graeber with several neuroleptic medications, including Clozaril. The
district court appointed Dr. Thomas Gratzer to examine Graeber. Dr. Gratzer’s report
agreed with the proposed treatment using various neuroleptics, but it failed to include
Clozaril. Dr. Gratzer later testified that omitting Clozaril had been an oversight.
The district court issued a Jarvis order finding Graeber incompetent to make
consent-oriented decisions about the use of neuroleptic medications and authorizing
physicians to use several listed neuroleptics. The order did not authorize Clozaril expressly
but stated that Graeber was willing to try the drug. The Dakota county attorney moved to
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amend the order to include up to the maximum recommended dosage of 900 milligrams of
Clozaril daily. Dr. Gratzer again examined Graeber.
At the amendment hearing in June, security-hospital psychiatrist James Christensen
testified that Graeber had recently been through a “medication wash” so that hospital staff
could observe her behavior without medication and so they could begin new medications
without other drugs interfering. Dr. Christensen testified that the medication wash
worsened Graeber’s symptoms. He explained that Clozaril is generally prescribed to
patients who, like Graeber, have not responded to other neuroleptics. And he explained that
the security hospital closely monitors patients’ side effects. He opined that Graeber’s
prognosis is very poor without neuroleptic medication and that Clozaril is the “only
antipsychotic remaining that is likely to make an impact.” Dr. Gratzer testified that he also
supported using Clozaril because Graeber had failed to improve on other medications.
Graeber opined that Clozaril is unnecessary. She testified that medication causes her
to experience mood swings, crying fits, and anxiety, and that, when she is not taking
medication, she has felt less anxious, slept less, and attended her group meetings. Graeber’s
mother and sister also testified that they believed Graeber improved when she was off
medications.
The district court issued an amended Jarvis order, finding that Clozaril had been
inadvertently omitted from Dr. Gratzer’s prior recommendation. The court rejected as
incredible the testimony that Graeber’s mother and sister had offered, and it found that
Graeber had continued to be “actively psychotic,” consistent with her past behavior. It
therefore authorized up to 900 milligrams of Clozaril daily.
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Graeber appeals.
DECISION
I
We will affirm a district court’s order authorizing use of neuroleptic medication
unless its findings are clearly erroneous. In re Civil Commitment of Raboin, 704 N.W.2d
767, 769 (Minn. App. 2005). Court approval is required to administer neuroleptic
medications when a civilly committed patient refuses the treatment. Minn. Stat.
§ 253B.092, subd. 8(a) (2014). The order must specify which medications the court is
authorizing. Raboin, 704 N.W.2d at 771. For Jarvis orders, courts must consider whether
the patient has capacity to make decisions regarding neuroleptic medication, and if the
patient lacks capacity, what a reasonable person would do under the circumstances. Minn.
Stat. § 253B.092, subds. 5, 7 (2014).
The district court originally found that Graeber lacked capacity in its first Jarvis
order, which Graeber did not appeal within the statutory period. We therefore address only
the district court’s implied determination as to whether a reasonable person under the
circumstances would consent to treatment with Clozaril.
The district court considers several factors when making this determination. Among
other things these include the patient’s values, the medical risks and benefits, treatment
alternatives, and the past efficacy of neuroleptic medications. Id., subd. 7(c). Although
Graeber has often opposed using any neuroleptic medications, the district court found that
she was willing to try Clozaril. This finding in turn supports the conclusion that Clozaril
does not apparently conflict with Graeber’s values. The district court received medical
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testimony that favorably balanced Clozaril’s potential benefits against its potential side
effects and that patients are closely monitored to identify and respond to any side effects.
Dr. Christensen testified that 900 milligrams daily is the maximum dosage, and Dr. Gratzer
testified that he supported using Clozaril up to 900 milligrams daily. This testimony is
sufficient for the district court to find unpersuasive the testimony of Graeber’s mother, who
had contended that 900 milligrams is too much.
II
Graeber includes an untimely challenge that we do not consider. She argues that the
district court was bound to maintain her medication-free for six months to observe whether
her improvement continued. But only the district court’s amended Jarvis order is before
us, not the earlier order in which the district court found that Graeber was not competent
to consent and that she needed neuroleptic medications. A party has only 60 days to appeal
from any order under the civil commitment provisions. Minn. Stat. § 253B.23, subd. 7
(2014). The amended order, which Graeber timely appealed, essentially added Clozaril to
the other medications that the district court had previously authorized. Although we have
addressed that appeal and Graeber’s challenge to the Clozaril authorization specifically,
we will not review the previous order from which she did not timely appeal.
Affirmed.
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