In re I.G.

• Decision Date: 31 August 2016
• Docket Number: No. 16–163,16–163
• Citation: 153 A.3d 532
• Court: Vermont Supreme Court
• Parties: IN RE I.G.

153 A.3d 532

IN RE I.G.

No. 16–163

Supreme Court of Vermont.

August 31, 2016

William H. Sorrell, Attorney General, Montpelier, and Philip Back, Assistant Attorney General, Waterbury, for Petitioner-Appellee.

Rebecca T. Plummer, Vermont Legal Aid, Inc., Montpelier, for Respondent-Appellant.

PRESENT: Reiber, C.J., Dooley, Robinson and Eaton, JJ., and Hoar, Supr. J., Specially Assigned

ROBINSON, J.

¶ 1. In this case, an involuntarily hospitalized patient diagnosed with schizophrenia appeals the trial court's order allowing for his involuntary medication. Patient argues that the court erred by (1) incorrectly applying the competency standard under 18 V.S.A. § 7625, and (2) failing to address whether a previously prepared document reflecting his desire not to be given psychiatric medication was a "competently expressed written ... preference [ ] regarding medication" under 18 V.S.A. § 7627(b). We conclude that the trial court's findings support its conclusion under § 7625, but agree that the trial court did not squarely address patient's argument under § 7627 in its findings. Accordingly, we reverse on that issue and remand for the trial court to issue findings addressing the applicability of § 7627(b) to patient's prior written expression of his preferences.

¶ 2. Patient is thirty-two years old and is from Morrisville. He was hospitalized at the Vermont Psychiatric Care Hospital (VPCH) in Berlin on April 15, 2016, pursuant to a court order stemming from his arrest and criminal prosecution for allegedly assaulting his girlfriend. Patient had been hospitalized once before—also at VPCH—from May 5, 2015, to July 28, 2015. During that previous hospitalization, patient was diagnosed with schizophrenia and—in July 2015—VPCH unsuccessfully sought a court order to involuntarily medicate him.

¶ 3. In the present case, the court noted that it rejected the State's prior request to involuntarily medicate patient because the State did not prove that he was incompetent and the potential side effects of the medication outweighed its potential benefits.

Shortly after the court in the previous case decided not to involuntarily medicate him, patient was discharged from VPCH and began living at Soteria House, a residence for people with mental illness in Burlington.

¶ 4. While there, patient signed a document purporting to be an advance directive in which he stated that he did not want any psychiatric medication because such medication caused him anger and homicidal ideation and inhibits "the limbic system from powering organs." By a checkbox on the form, he indicated that he was aware that his stated preference might result in longer hospital stays and may result in his being involuntarily committed or treated, and he prioritized the interventions he prefers by listing seclusion, then seclusion and physical restraints combined, then physical restraints first, with medication in pill, liquid, and injection form as his lowest priorities. Patient concedes that this document "did not meet the statutory requirements of an advance directive because it was not signed by two witnesses."

¶ 5. Following his current hospitalization, the State filed an application to involuntarily medicate patient over a ninety-day period on April 21, 2016. A hearing was held on May 4, 2016, at which the State presented one witness—patient's treating psychiatrist—and patient presented two witnesses—himself and a staff person from Soteria House.

¶ 6. First, patient's psychiatrist testified that he had treated patient during both his previous hospitalization and his current hospitalization. The psychiatrist described a pattern of beliefs and behaviors starting in 2012 that led him to diagnose patient with schizophrenia :

[Patient] has shown fixed false beliefs ... he's shown evidence of acting on persecutory delusions in a manner that seems dangerous at certain points. He also shows disorganized thought process. His speech wanders from topic to topic.

He also shows unusual behaviors around clothing and, let's say—taking apart the seams in his clothing to replace the threads with organic material because of a preoccupation with toxins.

...

[H]e thinks medications are also toxic. He's stuck.

Moreover, the psychiatrist testified that patient's behaviors had become more dangerous since the last time he had treated him in the summer of 2015: his "persecutory beliefs became more explicit ... [which] led to his showing more dangerous behavior." This dangerous behavior included the incident for which patient was arrested.

¶ 7. Finally, the psychiatrist testified that Soteria House is for patients "who usually would prefer not to take medications" so their illnesses are managed "mostly with psychosocial interventions." In the psychiatrist's opinion this is not the best form of treatment; medication would be a far more effective solution for patient because it "would help him sort out where the real dangers are ... he'd be safer." But, as the psychiatrist testified, this treatment has been impeded because patient's schizophrenia affects his "understanding" of the medication's benefits and risks.

¶ 8. Next, patient testified extensively about his concerns regarding the side effects of psychiatric medication: Haldol is "a very light anesthetic"; and there are "some addictive qualities to it"; "it can make you drowsy"; and it can produce "tardive diskenesia." He testified that "one of the warnings is that ... it can cause impulsive behavior grouped with homicidal ideation." Patient also testified that he does not trust psychiatric medication because "there's a lot of kickbacks to psychiatrists from pharmaceutical companies." He summarized that he had weighed the benefits and risks of being off the medication and would prefer not taking the medication despite the risk of shortening his life span: "I see [being off the medication] as better than being on the medication because it might take years off my life."

¶ 9. Finally, the staff person from Soteria House testified that patient had expressed his concerns about psychiatric medication several times. The staff member and patient had discussed patient's preferences about medication "on a number of occasions" and patient "was always clear that he preferred not to utilize medication." Discussing whether or not to take medication is "a very typical conversation at Soteria. ... Everyone there is ... dealing with issues around medication, whether to use or whether not to use it." According to the staff member, patient "did a lot of research online" about the medication and did not want to take it because "he was concerned about side effects." The staff member did not know which websites patient had been using for research.

¶ 10. The court issued an order on May 6, 2016, authorizing his involuntary medication for ninety days. Specifically, the court found that patient was not competent to refuse medication and that his aversion to medication was a result of his schizophrenia :

[Patient's] stated reasons for refusing medication are a product of his mental illness. He is unable to make a competent, reasoned decision about whether or not medication is a reasonable form of treatment for his condition.

With respect to the preferences expressed in patient's purported advance directive, the trial court said it was "of limited assistance" to the court. In particular, the court noted that no witnesses or clinicians signed the directive, and concluded, "At most, the court accepts the directive as additional evidence that [patient] does not want to take antipsychotic medications."

¶ 11. Patient filed an appeal that same day, and the court granted a stay of its order pending appeal.

I.

¶ 12. We reject patient's argument that the court erred by incorrectly applying the competency standard under 18 V.S.A. § 7625(c). In particular, he contends that the court (1) "applied an incorrectly high standard of competency," (2) "failed to make certain required findings," and (3) "ignored or misrepresented significant testimony supporting defendant's competency." We conclude that the record supports the trial court's findings, and its findings support its conclusions. In re T.C., 2007 VT 115, ¶ 12, 182 Vt. 467, 940 A.2d 706 (noting this Court will uphold trial court's conclusions if they are not clearly erroneous and are "consistent with the controlling law and ... supported by the findings" (quotation omitted)).

¶ 13. The first step in evaluating a petition for involuntary medication is to evaluate the patient's competency. See 18 V.S.A. § 7627(d) ("As a threshold matter, the Court shall consider the person's competency."). The competency question focuses on the patient's decisionmaking abilities:

In determining whether or not the person is competent to make a decision regarding the proposed treatment, the Court shall consider whether the person is able to make a decision and appreciate the consequences of that decision.

18 V.S.A. § 7625(c) (emphasis added). The competency determination cannot be based on the patient's diagnosis alone or the merits of a psychiatrist's medical advice:

The standard is different, and more difficult for the Commissioner to meet, from the standard for determining whether a person may be involuntarily committed because the statute focuses solely on the patient's decision-making abilities, as they may or may not be affected by mental illness—not the fact of the patient's diagnosis alone, or the merits of the psychiatrist's medical advice. If a mere diagnosis were the end of the analysis, it would preclude the need for a petition procedure altogether.

In re L.A., 2006 VT 118, ¶ 10, 181 Vt. 34, 912 A.2d 977 (emphasis added). Rather, the court must determine whether the patient properly understands the actual—not imagined—consequences of refusing medication. See id.¶¶ 12, 15 ("As long as [the] patient can understand the consequences of refusing medication, the statute permits him [or her] to do so, even if refusing medication will be to his [or her] detrime...