People v. Medina

• Decision Date: 09 September 1985
• Docket Number: Nos. 83SC7,83SC12,s. 83SC7
• Citation: 705 P.2d 961
• Parties: The PEOPLE of the State of Colorado, Petitioner, v. Joseph P. MEDINA, III, Respondent, Colorado Department of Institutions, Intervenor.
• Court: Colorado Supreme Court

Page 961

705 P.2d 961

54 USLW 2180

The PEOPLE of the State of Colorado, Petitioner, v. Joseph P. MEDINA, III, Respondent Colorado Department of Institutions, Intervenor.

Nos. 83SC7, 83SC12.

Supreme Court of Colorado En Banc.

Sept. 9, 1985.

Stephen H. Kaplan, City Atty., Morris P. Evans, Asst. City Atty., Denver, for petitioner.

Frank P. Slaninger, Denver, for respondent.

Duane Woodard, Atty. Gen., Charles B. Howe, Chief Deputy Atty. Gen., Richard H. Forman, Sol. Gen., M. Tracy James, Carolyn Lievers, Asst. Attys. Gen., Denver, for intervenor, Colorado Dept. of Institutions.

QUINN, Chief Justice.

We granted certiorari to review the decision of the court of appeals in People in the Interest of Medina, 662 P.2d 184 (Colo.App.1982), relating to the right of an involuntarily committed and incompetent mental patient to refuse the administration of antipsychotic medicine by attending physicians. The Denver probate court entered an order granting the petition of two psychiatrists to administer antipsychotic medication to the patient in spite of the patient's objection to the medication. The court of appeals reversed the order of the probate court. It held that, in the absence of an emergency requiring immediate action, antipsychotic medicine may not be administered to a nonconsenting mentally ill patient who is incapable of making an informed decision on the proposed treatment unless a court order is obtained authorizing the treatment. In remanding the case for further proceedings, the court of appeals ordered the probate court to consider and make specific findings on the patient's interests, preferences, and a variety of other factors, and to authorize the administration of antipsychotic medication only if there existed state interests of sufficient magnitude to override the absence of consent. 662 P.2d at 188. We conclude that, unless there is an emergency that poses an immediate and substantial threat to the life or safety of the patient or others in the institution, antipsychotic medicine may be administered to a nonconsenting mentally ill patient incapable of making an informed treatment decision only after the trial court conducts a full and fair adversary hearing on the treatment decision and is satisfied by clear and convincing evidence that: (1) the patient is incompetent to effectively participate in the treatment decision; (2) treatment by antipsychotic medication is necessary to prevent a significant and likely long-term deterioration in the patient's mental condition or to prevent the likelihood of the patient's causing serious harm to himself or others in the institution; (3) a less intrusive treatment alternative is not available; and (4) the patient's need for treatment by antipsychotic medication is sufficiently compelling to override any bona fide and legitimate interest of the patient in refusing treatment. Although the standards which we adopt herein are substantially different from those set forth by the court of appeals, we affirm that part of the judgment remanding the case to the probate court for further proceedings.

I.

The respondent, Joseph P. Medina, III, a thirty-four year old with a long history of mental illness and assaultive behavior, was originally certified for short-term mental health care and treatment on February 27, 1980. ¹ On August 27, 1980, pursuant to court order, the respondent was placed by the Department of Institutions in Fort Logan Mental Health Center for long-term care and treatment.

On July 8, 1981, the Denver City Attorney's Office, acting at the request of two psychiatrists on the staff at Fort Logan Mental Health Center, filed a motion in the Denver probate court for an order authorizing treatment of the respondent by the use of antipsychotic medication over the respondent's objection. The motion alleged that the treating psychiatrist had determined that antipsychotic medication would be beneficial to the respondent but that the respondent had been refusing the medication over a number of days. Documents filed in support of the motion indicated that the respondent had a history of violent behavior both inside and outside the mental health facility, remained a danger to himself and others, and was becoming increasingly psychotic and agitated owing to his unmedicated state.

The probate court mailed a copy of the motion to the respondent's attorney, who had represented the respondent at various proceedings since the initial short-term certification, and set the matter for hearing on July 21, 1981. Both the respondent and the respondent's attorney attended the hearing. The evidence elicited at the hearing consisted solely of the testimony of Dr. Kenneth L. Weiner, a psychiatrist who had been treating the respondent at Fort Logan Mental Health Center.

Dr. Weiner testified that the respondent suffered from severe paranoid schizophrenia, which rendered him psychotic most of the time. When in a psychotic state the respondent, according to the doctor, hears voices which cause him inner confusion and anger and generate resulting psychotic fantasies that people are about to hurt him. The respondent sometimes becomes assaultive during these episodes and occasionally attacks others or throws furniture and other objects around the mental health facility. To alleviate these symptoms the psychiatric staff had treated the respondent with antipsychotic medications. Because the respondent initially experienced some muscle rigidity as a side effect of two antipsychotic drugs, haldol and prolixin, his medication was changed to a third antipsychotic compound, thorazine, which was normally administered in three 300 milligram dosages per day. Dr. Weiner stated that the medication enabled the respondent to gain control over some of his paranoia and decreased the incidents of assaultive behavior. In the doctor's opinion, if the respondent were to continue regular doses of the medication, he could eventually be placed in a less-restrictive environment, such as a halfway house.

The respondent, however, had told Dr. Weiner that he did not like the effects of the antipsychotic medication and would only intermittently consent to take it. During the two and one-half week period preceding the hearing the respondent had refused six to ten doses of thorazine. As a result of his refusal to take the medication the respondent had become increasingly agitated and angry. Dr. Weiner testified that he was more disturbed by inner voices than previously, suffered severe headaches, was often assaultive, and escaped from the treatment center on one occasion. It was the doctor's opinion that if the respondent continued to refuse antipsychotic medicine, he would never be well enough to leave the facility and would function poorly even in that setting.

Dr. Weiner acknowledged in his testimony that antipsychotic medication, specifically thorazine, produces various side effects, such as sedation, blurred vision, mouth dryness, low blood pressure, urinary retention, and constipation. These adverse reactions, according to the doctor, are generally short-lived and, in the respondent's case, disappeared shortly after their onset. Dr. Weiner stated that the respondent reacted well to a 900-1200 milligram dosage of thorazine per day, a fairly large amount, and that upon his becoming less psychotic this dosage would be reduced to the range of 500-800 milligrams per day.

The more serious risk from antipsychotic medication, according to Dr. Weiner, is tardive dyskinesia. This condition is characterized by involuntary movements of the tongue, lips, and jaw and may ultimately progress to a stage resulting in involuntary movements of the extremities, neck, and back. Tardive dyskinesia, in its extreme form, may interfere with speech, swallowing, and breathing. There is no known method for preventing the occurrence of tardive dyskinesia, and once this condition develops, the ensuing disability may progressively worsen even if the antipsychotic medication is no longer administered. Dr. Weiner stated that the respondent showed no signs at the present of developing this condition. The doctor acknowledged, however, that due to the high degree of medication and the long history of treatment there was a significant risk that the respondent might develop this condition in the not too distant future.

Although the respondent's ability to absorb information was limited to short time frames of thirty seconds to a minute before psychotic thoughts would take over, Dr. Weiner nonetheless attempted on two occasions to explain to him the risks and benefits of the antipsychotic medication. On the first occasion the respondent immediately left the doctor's office, and the second meeting was similarly unsuccessful. It was Dr. Weiner's opinion that the respondent was so mentally impaired that he was unable to make any informed decision on whether it was in his own best interests to take the antipsychotic medication.

At the conclusion of Dr. Weiner's testimony, the probate court offered the respondent's attorney an opportunity to confer with the respondent. The respondent's counsel advised the court that the respondent did not elect to testify in the matter.

The probate court granted the motion for the administration of antipsychotic medicine and entered a written order to that effect on July 24, 1981. In its order the court found in pertinent part as follows: that the respondent was suffering from a serious illness which rendered him incapable of making an informed decision with respect to treatment by antipsychotic medication; that the administration of the medication was in the interest of the respondent's mental health; that the respondent's refusal to take the medication was unreasonable; that the medication "can be properly monitored and controlled" in order to offset the risk of tardive dyskinesia and other side effects; that the risk of tardive dyskinesia was not so great as to prohibit the use of the medication;...