Medication order upheld for committed patient

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If a mentally ill patient has a history, albeit inconsistent, of refusing to take anti-psychotic medication a court may conclude that the patient refuses consent under Minn. Stat. sec. 253B.092, subd. 8(a).

In that case, where the patient is under civil commitment the court can order involuntary medication, after finding that a reasonable person would consent to the medication, the Court of Appeals ruled in In the Matter of the Civil Commitment of Lindsay Evan Breault, a March 9 opinion written by Judge Lucinda Jesson.

“[A] patient’s recent, inconsistent compliance with taking prescribed neuroleptic medication as treatment for a mental illness provides a district court with a sufficient basis to conclude that the patient ‘refuses to consent to treatment with neuroleptic medications’ under Minnesota Statutes section 253B.092, subdivision 8(a),” Jesson wrote, joined by Judges Kevin Ross and John Smith, a retired judge serving by appointment.

Attorney Douglas McGuire, coordinator of the Hennepin County Commitment Defense Panel, said the opinion sets out in detail the law of involuntary medication as it has been interpreted and applied. It is a published opinion, whereas some earlier cases have been unpublished, he said

Invasive treatment

Breault was committed in 2012 and 2013 and then again in 2019. When she was admitted to the hospital, she was delusional and acutely psychotic and paranoid. She was prescribed a neuroleptic medication that sedates the nervous system but did not always take it. At a hearing, which Breault did not attend, an examining physician testified that Breault took some medication but the doctor did not know what her compliance was. He recommended that she be medicated and noted that she did not suffer from side effects. The patient was committed as mentally ill but appeals only the court-ordered administration of drugs.

The court said first that even though Breault changed her mind and said she would take the medicine, the case was not moot.

Strict judicial review, including protection against invasive treatment by the involuntary administration of neuroleptic medication, is part of the Minnesota Commitment Act, Jesson noted. “That Breault may be voluntarily accepting the same medication authorized by the court order does not diminish her interest in protecting her right to privacy by avoiding an invasive treatment mandated by the government,” the court said.

‘Refuses’ is not ambiguous  

The court then addressed Breault’s argument that the statute is ambiguous about what level of refusal is necessary to trigger the court’s authority to order the involuntary administration of medicine. She asserted that the court should construe the statute as requiring that an individual is currently refusing medication before it may authorize involuntary administration of medication.

But the court said that the statutory language, “the patient refuses to consent to treatment with neuroleptic medications” is not ambiguous. The present-tense verb form means that the law clearly contemplates recent refusal, the court said.

The court then construed the word “treatment” to mean more than a patient’s acceptance or refusal of medication at a singular point in time. Thus the court read the statute to permit a District Court judge to consider the totality of the recent circumstances surrounding a patient’s compliance with treatment including neuroleptic medicine.

“We read the statute as permitting a district court to consider the totality of the recent circumstances surrounding a patient’s compliance with treatment involving a neuroleptic medication regimen,” Jesson wrote. The Court of Appeals also noted that Breault refused medication on several occasions.

The court also said that the statute does not say “currently” refuses medication and it would not add the words.

It also is not workable to require current refusal because a patient could accept medication to avoid a court order and then resume refusal, creating a “revolving door” to the courthouse.

Reasonable person

The court then determined that the District Court did not clearly err in finding that a reasonable person in Breault’s position would consent to treatment with neuroleptic medicine. The judge considered the factors set out in Minn. Stat. § 253B.092, subd. 7(c)(1)-(4), which include the person’s values, the medical risks and benefits, the efficacy of neuroleptics in the past, and any other relevant factors, and determined that a reasonable person would consent to the medication.

Since Breault contended she would take the medicine voluntarily, she did not have a strong argument that it was against her values.

There was no information in the record of a prior negative response to neuroleptic medicine. The record also included the examiner’s testimony that Breault’s mental illness had not responded to other less-intrusive treatment options and his opinion that Breault would respond favorably to neuroleptic medication with few, if any, negative side effects.

Although the court did not make findings on all the relevant factors, the District Court may consider the totality of the circumstances, the Court of Appeals said. It noted that in cases where a patient participates in the proceedings, the District Court is expected to make “more robust” findings. But where the patient does not participate, the court does not err in relying on the information presented to it, if it is sufficient.

McGuire suggested that the court may have been saying that the findings in Breault were the minimum acceptable and that it may be open to future challenges to the findings.