Sunday, February 19, 2017

A Spoonful of Sugar Helps The Meds Go Down

"So what exactly is in this?"
In re I.G., 2016 VT 95

By Amy E. Davis

This is a case in which the SCOV Justices reverse one of their own. Justice Skoglund presided over the case below. The SCOV releases opinions on Friday morning. I picture Justice Skoglund walking into Justice Eaton’s office and saying, “Dammit Scoop!” (Side note: I imagine Justice Eaton’s nickname around chambers is “Scoop.”) I should probably just shaddap and get to the case.

Patient is 32-years old and was hospitalized for psychiatric care in Berlin, Vermont in April 2016 following a court order. Patient had spent another stint in the psychiatric unit about a year prior in 2015, for 2 months. During his last stay, Patient was diagnosed with schizophrenia, and the hospital unsuccessfully sought an order to medicate him. The court had rejected the request because the State did not show Patient was incompetent nor that the potential side effects of medication outweighed its potential benefits.

Right after the 2015 case, Patient went to live at Soteria House, a residence for people with mental illness in Burlington. While there, Patient signed a document that looked and smelled like an advance directive. Patient stated that he did not want medication because it made him angry and murderous, and it inhibits “the limbic system from powering organs.” He also indicated that he was aware he might be involuntarily committed or treated then listed his preferred interventions: (1) seclusion; (2) seclusion plus physical restraints; or (3) physical restraints with medication. The document did not meet the statutory requirements of an advance directive because it needed to be signed by two witnesses, and it was not.

During his most recent hospitalization, the State requested to involuntarily medicate Patient over the course of 3 months. On May 4, 2016, there was a hearing where the State presented the treating psychiatrist (whom we're just going to call "Shrink"), and Patient testified along with a staff person from Soteria House. The shrink testified that he had treated Patient in 2015 and 2016 and Patient presented behaviors that led him to a schizophrenia diagnosis. Shrink also testified that Patient’s behaviors had become more dangerous over the previous years, and that Soteria House is for patients who prefer not to take medications and manage their illnesses with psychosocial interventions. Shrink said medication would be more effective for Patient, but Patient’s schizophrenia prevented him from understanding the medication’s risks and benefits.

Patient testified as to his concerns about the side effects of the medication including drowsiness and homicidal ideation (that escalated quickly). Patient also does not trust the medication because of the "kickbacks" to psychiatrists and pharmaceutical companies. Patient said he had weighed the benefits and the risks and preferred not to take the medication.

The staff person from Soteria House testified that Patient had expressed his concerns about medication on a number of occasions, and Patient was crystal clear that he did not want to take the meds. This discussion was typical at Soteria since everyone there is dealing with issues about taking medication. The staff member also testified that Patient had done a lot of online research about the medication, but did not know which website he used. I hope it wasn’t WebMD—those people can turn a runny nose into an advanced Parkinson’s diagnosis.

On May 6, 2016, the court authorized patient to be involuntarily medicated for 90 days. The court found that patient was not competent to refuse medication and his aversion to the medication was a result of the schizophrenia. The court found the advance directive was of limited assistance because no witnesses or clinicians signed the directive. Patient filed an appeal the same day and the court granted a stay of its order pending the appeal.

The first step in evaluating a petition for involuntary medication is to evaluate the patient’s competence, specifically the patient’s decision-making abilities. That determination cannot be based on the patient’s diagnosis alone or a psychiatrist’s medical advice. It is a difficult standard to meet because a patient’s decision-making abilities may or may not be affected by mental illness. The court has to determine whether the patient understands the actual consequences of refusing medication.

The SCOV finds that the lower court used the correct competency standard and made sufficient findings regarding Patient’s understanding of the consequences of refusing medication. The lower court found that Patient’s stated reason for refusing medication were as a result of his mental illness, and he could not make a competent and reason decision about taking medication.

The shrink’s testimony enhanced the court’s analysis of Patient’s beliefs. The shrink testified that there was no connection between two medications that Patient had linked together. Shrink believed the mental illness played a role in Patient’s inability to understand the consequences of his decisions. Shrink believed that medicating patient would help him understand the risks and benefits.

The SCOV goes on to say that that it is not their position to second-guess the lower court’s findings as the lower court is in the best position to assess the credibility of the witnesses and the weight of the evidence. The SCOV finds the trial court’s findings sufficient to support its conclusion that Patient is not competent.

However, the SCOV agrees with Patient that the trial court did not provide any findings or conclusions as to whether the advanced directive constituted a "competently expressed written preference regarding medication". If Patient did not have a fully-executed advance directive, the court needs to follow the person’s expressed written preferences regarding medications, if any. If the court finds there are no medication preferences, then the court has to consider a variety of factors before issuing an involuntary medication order.

Patient argues that the written instructions in the document were competently expressed, and his own testimony and the testimony of the Soteria House staff member supports his contention that he was competent when he signed the document. The lower court made no findings as to whether Patient was competent at the time he wrote down his preferences. The SCOV is thus unable to infer from the court’s findings whether the court believed Patient was competent at the time he wrote the document. Because the court did not address this issue, the SCOV reverses and remands for further findings.

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