Blouin ex rel. Estate of Pouliot v. Spitzer

• Decision Date: 02 February 2004
• Docket Number: No. 02-7997.,02-7997.
• Citation: 356 F.3d 348
• Parties: Alice BLOUIN, As Administratrix of the ESTATE OF Sheila POULIOT, and of the Goods, Chattels and Credits Which Were of the Deceased, Sheila Pouliot, Plaintiff-Appellant, v. Eliot L. SPITZER, Individually, and in his Official Capacity as Attorney General of the State of New York; Winthrop H. Thurlow, Individually, and in his Official Capacity as Assistant Attorney General of the State of New York, Defendants-Appellees.
• Court: U.S. Court of Appeals — Second Circuit

356 F.3d 348

Alice BLOUIN, As Administratrix of the ESTATE OF Sheila POULIOT, and of the Goods, Chattels and Credits Which Were of the Deceased, Sheila Pouliot, Plaintiff-Appellant, v. Eliot L. SPITZER, Individually, and in his Official Capacity as Attorney General of the State of New York; Winthrop H. Thurlow, Individually, and in his Official Capacity as Assistant Attorney General of the State of New York, Defendants-Appellees.

No. 02-7997.

United States Court of Appeals, Second Circuit.

Argued: March 6, 2003.

Decided: February 2, 2004.

Appeal from the United States District Court for the Northern District of New York, Howard G. Munson, Senior District Judge.

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James T. Snyder (James E. Reid, on the brief), Greene & Reid, LLP, Syracuse, NY, for Plaintiff-Appellant.

Robert M. Goldfarb, Assistant Solicitor General (Daniel Smirlock, Deputy Solicitor General, Peter H. Schiff, Senior Counsel, on the brief), for Eliot Spitzer, Attorney General of the State of New York, Albany, NY, for Defendants-Appellees.

Before: POOLER, SACK, and B.D. PARKER, Circuit Judges.

B.D. PARKER, Jr. Circuit Judge.

Now deceased, Sheila Pouliot suffered profound physical and mental disabilities since infancy and was never competent to make her own medical treatment decisions. In December 1999, incapacitated and terminally ill, she was admitted to the State University of New York ("SUNY") Upstate Medical Center at Syracuse. Aware of her condition, her family, her treating physicians, and other hospital personnel all agreed that only palliative care-without invasive, life-prolonging, or resuscitative measures-was appropriate. Several days later, the New York Attorney General's office intervened. It advised hospital officials that this course of care was contrary to New York law, that no third party was competent to direct the withdrawal of life-prolonging measures from a patient who had never been competent and who, consequently, had never consented to such steps, and that the administration of artificial nutrition, hydration, and antibiotics was required.

This treatment was instituted. Shortly thereafter, the Attorney General's office went to state court seeking and obtaining the appointment of a guardian for Pouliot, although it insisted that the guardian could not consent to the withdrawal of life-prolonging measures. After some initial disagreement, the parties and the guardian agreed to the continued administration of hydration and nutrition, and this was done for approximately two months. It became apparent, however, that this course of treatment caused Pouliot intense suffering with no corresponding medical benefits-beyond prolonging her life. She died after this treatment was terminated pursuant to a court order, which was entered over the objections of the Attorney General's office.

Following Pouliot's death, Blouin returned to state court and, on her sister's behalf, sued Eliot Spitzer, the New York Attorney General ("AG"), and Winthrop Thurlow, the assistant AG who had handled the matter (collectively, "the AG's office"), asserting claims under state and federal law. The AG's office removed the case to federal court, where it eventually obtained summary judgment. The district court concluded that, although Spitzer and Thurlow were not entitled to absolute immunity, they were entitled to qualified immunity because their intervention violated no clearly established constitutional right of Pouliot's. Because we agree that they were entitled to qualified immunity, although for reasons somewhat different from the district court's, we affirm.

BACKGROUND

Sheila Pouliot became profoundly physically and mentally handicapped after contracting encephalitis during infancy. As a consequence, throughout her life she suffered mental retardation and fairly severe cerebral palsy, which was manifested by incomplete quadriparesis. She was completely dependent on others for assistance with basic life functions and resided during her life at a state-run residential group home in Syracuse.

By 1999, Pouliot, in her early forties, had become chronically ill as a result of complications from cerebral palsy, including a seizure disorder, osteoporosis, the dislocation of various joints, and widespread flexion contractures involving her elbows, knees, and hips. She also lost the ability to eat, and nutrition was artificially administered through a feeding tube. She began suffering from serious illness relating to failing gut function, characterized by recurrent aspiration pneumonia, episodes of gastrointestinal bleeding, and chronic, severe constipation.

When she reached the hospital in December, Pouliot was acutely ill and, by all accounts, near death. She was experiencing low oxygen levels and a high fever. She was suffering from hypotension, aspiration pneumonia, internal bleeding, severe abdominal pain, and a non-functioning intestine. Pouliot's family, medical staff, SUNY Hospital's Ethics Committee, and clergy met on December 22 and decided that her condition was terminal and that the appropriate treatment was the provision of palliative care, involving mainly the intravenous delivery of morphine. It was also decided that neither artificial nutrition and hydration nor antibiotics would be administered. This decision was reflected in the contemporaneous notes of Dr. Catherine V. Caldicott, one of Pouliot's treating physicians:

After >1 hour discussion with team, family, Social Worker, nursing staff, chaplain and Ethics consultant, we are in full agreement that this may be Ms. Pouliot's terminal illness. We agree that the most humane course is to provide comfort in the way of [morphine sulfate] as needed and to refrain from invasive resuscitative and recovery measures.

This course of treatment commenced while arrangements were made to return Pouliot to the group home for hospice care. After recording some early discomfort, Dr. Caldicott's notes of December 25 indicate that, by late in the day, Pouliot was "resting comfortably" with her family by her side. On December 27, however, after observing that Pouliot appeared dehydrated, Dr. Caldicott wrote:

I have been ordered by the State of N.Y. to provide resuscitative measures. This is against the family's wishes and is causing much strife. However, I will proceed [with] IV fluids and IV antibiotics (even though they are of questionable benefit in cases of aspiration pneumonia). She is comfortable and in no respiratory distress.

Blouin contends that this note documents the AG's office's intervention into Pouliot's care, and she characterizes this intervention as a unilateral direction. The AG's office, on the other hand, maintains that it merely rendered legal advice following inquiries from hospital officials about the appropriate treatment for Pouliot. To the extent there is a factual dispute, on the AG's office's summary judgment motion, Blouin's version must be credited.¹ It is the state's intervention-which Blouin attributes to the AG's office-into the previously agreed-upon course of final care for Pouliot that gave rise to this lawsuit. Blouin's central constitutional claim is that this intervention, without the consent of her sister or a surrogate decisionmaker, caused unwarranted and unnecessary pain and suffering and violated her sister's right to bodily integrity, protected by the Fourteenth Amendment.

The modified treatment measures resulted in more discomfort and deterioration. On December 28, for example, Dr. Caldicott noted that although Pouliot "appears less comfortable," she would continue to administer fluids and antibiotics "as ordered by counsel." The next day she noted that Pouliot "appears very uncomfortable — grimacing mostly [with] occasional grunts" and that she "[w]ill need to re-assess utility or futility of continued antib[iotics], fluids and [oxygen] for this condition." On the 30th, Dr. Caldicott wrote, "Although I believe continued antib[iotics] are futile, I am directed to continue them by other authorities."² Pouliot's family was traumatized by this shift in her medical treatment.

Throughout her life, Pouliot was never legally competent to make medical decisions, so they were made by her mother until she contracted Alzheimer's Disease and no longer had the capacity to do so. Under New York law, for persons 18 years of age or older lacking capacity to consent to medical treatment, "informed consent to such ... treatment shall be obtained from a guardian lawfully empowered to give such consent, an actively involved spouse, an actively involved parent, an actively involved adult child, a surrogate decisionmaking committee or a court of competent jurisdiction." 14 N.Y.C.R.R. § 633.11(b) (2003). After Pouliot's mother became incapacitated, since Pouliot did not have a spouse, other parent, adult child, or other individual authorized to make treatment decisions on her behalf, no one was authorized to make them.

Recognizing this, the AG's office commenced a proceeding on December 30 in Supreme Court, Onondaga County, seeking the appointment of a temporary guardian ad litem pending the appointment of a permanent guardian.³ That same day, the court appointed Gerald J. Neri, Esq., guardian ad litem. Notwithstanding Neri's appointment, however, the AG's office took the position that no one other than a competent patient could decide to withhold nutrition and hydration and that, consequently, both Neri and the court were "without authority to terminate or direct the termination or the continued withholding of nutrition and hydration." Tr. of Dec. 30, 1999 at 31-32. On January 3, 2000, after hearing argument over the appropriate course of care, the court ordered "that all medical treatment for Sheila Pouliot be terminated, except for nutrition as tolerated, [and] palliative hydration care, based on the best interest of the patient." Order of Jan. 3, 2000 at 3.

The next day, Blouin commenced a proceeding in ...