In the Matter of: Cynthia P. Smith.

This opinion will be unpublished and

may not be cited except as provided by

Minn. Stat. § 480 A. 08, subd. 3 (1998).

 

STATE OF MINNESOTA

IN COURT OF APPEALS

C0-99-1789

 

In the Matter of:

Cynthia P. Smith.

 

Filed March 28, 2000

Affirmed

Randall, Judge

 

Hennepin County District Court

File No. PX-99-60355

 

Douglas F. McGuire, Smith & Fisher, Attorneys at law, MSB Center, Suite 400, 1401 West 76th Street, Richfield, MN  55423 (for appellant Cynthia Smith)

 

Amy Klobuchar, Hennepin County Attorney, E. George Widseth, Assistant County Attorney, C-2000 Government Center, Minneapolis, MN  55487 (for respondent petitioners)

 

            Considered and decided by Randall, Presiding Judge, Toussaint, Chief Judge, and Foley, Judge.*

 

U N P U B L I S H E D   O P I N I O N

RANDALL, Judge

            Appellant seeks review of district court orders committing her to a treatment center as mentally ill and authorizing the administration of neuroleptic medication. Appellant argues that clear and convincing evidence was not presented to establish that (a) she meets the statutory definition of a mentally ill person; (b) commitment to Hennepin County Medical Center and the regional treatment center is the least restrictive alternative; (c) she is not competent to give or withhold consent for the use of neuroleptic medication; (d) neuroleptic medication is reasonable and necessary treatment; and (e) the benefits from the use of neuroleptic medication outweigh the risks from such treatment.[1]  We affirm.

FACTS          

                Appellant Cynthia P. Smith's brother and sister petitioned for her commitment as a mentally ill person.  When Smith failed to appear for the scheduled examination and hearing, the district court ordered that she be apprehended and held at Hennepin County Medical Center (HCMC).  A treating psychiatrist petitioned for authorization to administer neuroleptic medication.

            After a hearing, the district court concluded that Smith is mentally ill and in need of treatment.  The district court ordered her commitment to HCMC and Anoka-Metro Regional Treatment Center.[2]  By separate order, the district court concluded that (a) Smith lacked the capacity to give or withhold consent for the use of neuroleptic medication; (b) use of neuroleptic medication to treat Smith's illness is necessary and reasonable; and (c) the benefits to Smith from such treatment outweigh the risks and justify the invasion of her privacy.  The district court then authorized the administration of neuroleptic medication during Smith's commitment.  Smith appeals both orders.

D E C I S I O N

I.          Commitment

                In reviewing a commitment determination, the appellate court considers whether the district court followed the statutory requirements and whether the findings are clearly erroneous.  In re Duvick, 497 N.W.2d 311, 312-13 (Minn. 1993).  The district court's commitment determination will be overturned only if the findings are insufficient to support commitment.  In re McGaughey, 536 N.W.2d 621, 624 (Minn. 1995).  This court views the record in the light most favorable to the district court's decision.  In re Knops, 536 N.W.2d 616, 620 (Minn. 1995).

            A.        Mental-Illness Determination  

            Smith contends that she does not suffer from a substantial psychiatric disorder and asserts that there is not a substantial likelihood that she will cause physical harm to herself or others.

            A mentally ill person includes

any person who has an organic disorder of the brain or a substantial psychiatric disorder of thought, mood, perception, orientation, or memory which grossly impairs judgment, behavior, capacity to recognize reality, or to reason or understand, which is manifested by instances of grossly disturbed behavior or faulty perceptions and poses a substantial likelihood of physical harm to self or others as demonstrated by:

            (1) a failure to obtain necessary food, clothing, shelter, or medical care as a result of the impairment; or

            (2) a recent attempt or threat to physically harm self or others.

 

Minn. Stat. § 253B.02, subd. 13(a) (1998).  The court may commit a person to a treatment program "[i]f the court finds by clear and convincing evidence that the proposed patient is mentally ill" and "finds that there is no suitable alternative to judicial commitment."  Minn. Stat. § 253B.09, subd. 1 (1998). 

            The district court found that Smith suffers from psychotic disorder NOS (Not Otherwise Specified), "which grossly impairs her judgment, behavior, capacity to recognize reality and ability to reason or understand."  The court further found that this mental illness causes Smith to "engage[ ] in grossly disturbed behavior or experience[ ] faulty perceptions" and found that "she poses a substantial likelihood of causing physical harm."  The court determined that Smith is unable to care for her needs and refuses efforts to treat and assist her.

            At the commitment hearing, Smith's brother testified to a number of recent actions by Smith that led him to file a petition for her commitment.  He testified that (a) Smith believed there were harmful voices coming out of a VCR and satellite dish; (b) Smith had started dressing very provocatively; (c) Smith believed he and another sister had killed her kids; (d) he observed an incident in a K-Mart where Smith began accusing the cashier of overcharging her in order for the cashier to buy crack and cocaine; and (e) Smith believes he is her uncle, not her brother, and believes that her father is Luther Vandross.  He further testified that he believed she was not making her house payments, that the house would be foreclosed on in November, and that she refuses to buy food or pay her electric bill.  

            Barbara Bradford, a social worker on Smith's treatment team at HCMC, testified that Smith refused to meet with her.  On one occasion, Smith informed her, "I'm blessed.  I don't need to talk to you."  Bradford also testified that Smith had been completely uncooperative, refusing all testing, medication, and physicals.  According to Bradford, the nursing staff reported that Smith had poor to fair bathing and grooming habits.  Bradford testified that she believed Smith did not "have a grasp on reality."

            Dr. Craig Qualey, Smith's treating psychiatrist, testified that she suffers from a psychotic disorder NOS.  Dr. Qualey testified that because Smith has not cooperated, he has been unable to determine if she is suffering from schizophrenia or from a psychotic disorder related to a general medical condition.  He also testified that Smith does not believe she has a mental illness.  Additionally, he testified, "She's one of the more ill individuals that we've seen in quite some time."

            Finally, the court-appointed examiner, Dr. Owen Nelson, testified that based on the testimony and Smith's records, he concurred with the hospital's diagnosis that Smith has either a delusional disorder NOS or a thought disorder or psychotic disorder NOS.  He also noted that Smith believed that she had been kidnapped and misidentified and believed that the doctor had the wrong Cynthia Smith.  He further stated that it was his understanding that the heat and electricity had been, or would soon be, shut off at Smith's home and cited reports that Smith had been on the sidewalk behaving in an insulting and provocative manner to passersby.

            The testimony presented to the district court is clear and convincing evidence in support of the district court's findings that Smith suffers from mental illness and that she poses a substantial likelihood of harm based on her failure to provide for her physical and medical needs.  See In re Emond, 366 N.W.2d 689, 691-92 (Minn. App. 1985) (holding district court's determination that patient suffered from paranoid schizophrenia supported by testimony and reports of two examiners); In re DeMatthew, 349 N.W.2d 855, 856-57 (Minn. App. 1984) (upholding commitment as mentally ill based on failure to provide necessities where patient was being evicted, improperly clothed, unable to afford food, and refused medical treatment for injury).   Thus, the district court's findings are not clearly erroneous and are sufficient to support Smith's commitment.   

            B.        Least-Restrictive Alternative

            Smith also alleges that the district court erred by finding that commitment to HCMC and Anoka-Metro Regional Treatment Center was the least restrictive alternative. 

            After finding that a person is mentally ill and judicial commitment is necessary, the district court must commit the patient to the least-restrictive treatment program or alternative programs and must consider alternatives including "community-based nonresidential treatment, community residential treatment, partial hospitalization, acute care hospital, and regional treatment center services."  Minn. Stat. § 253B.09, subd. 1.  The district court's findings must identify the less-restrictive alternatives considered and rejected and the reasons for rejecting each alternative.  Id., subd. 2 (1998).

            Here, the district court committed Smith to HCMC and Anoka-Metro Regional Treatment Center.  The court's findings state that after considering other alternatives, it determined that none of the alternatives were suitable because Smith needed an extended period of inpatient hospitalization.

            Based on the witness testimony that Smith does not believe that she is ill and is unwilling to participate in treatment, the district court's finding that inpatient hospitalization is the only appropriate alternative for Smith is supported by clear and convincing evidence and is not a clearly erroneous finding.  See In re Butler, 379 N.W.2d 233, 235 (Minn. App. 1985) (upholding district court's determination that residential treatment at state hospital was least-restrictive alternative where patient denied need for treatment and refused voluntary treatment).

II.        Involuntary Treatment with Neuroleptic Medication

            Smith next asserts that clear and convincing evidence does not support the district court's conclusions that (a) she is not competent to give or withhold consent for the use of neuroleptic medication; (b) neuroleptic medication is reasonable and necessary treatment; and (c) the benefits to her from the use of such medication outweigh the risk.

            If a patient refuses to consent to treatment with neuroleptic medication, such medication may not be administered absent a court order.  Minn. Stat. § 253B.092, subd. 8(a) (1998); Jarvis v. Levine, 418 N.W.2d 139, 150 (Minn. 1988).  The party seeking to administer neuroleptic medication to a patient must prove the necessity of such medication by clear and convincing evidence.  In re Peterson, 446 N.W.2d 669, 672 (Minn. App. 1989), review denied (Minn. Dec. 1, 1989). 

            Before authorizing the involuntary treatment of a patient, the court must first find that the patient lacks the capacity to decide whether to take the medication.  Minn. Stat. § 253B.092, subd. 8(e) (1998).  Capacity is determined by considering

            (1) whether the person demonstrates an awareness of the nature of the person's situation, including the reasons for hospitalization, and the possible consequences of refusing treatment with neuroleptic medications;

            (2) whether the person demonstrates an understanding of treatment with neuroleptic medications and the risks, benefits, and alternatives; and

            (3) whether the person communicates verbally or nonverbally a clear choice regarding treatment with neuroleptic medications that is a reasoned one not based on delusion, even though it may not be in the person's best interests.

 

            Disagreement with the physician's recommendation is not evidence of an unreasonable decision.

 

Id., subd. 5(b) (1998).  If the district court concludes that a person does not have the capacity to make decisions about the administration of neuroleptic medication, and evidence regarding what that person would choose if he or she had capacity is lacking, the court must determine what a reasonable person would do by considering

            (1) the person's family, community, moral, religious, and social values;

            (2) the medical risks, benefits, and alternatives to the proposed treatment;

            (3) past efficacy and any extenuating circumstances of past use of neuroleptic medications; and

            (4) any other relevant factors.

 

Id., subd. 7(c) (1998).

            The district court made numerous findings in support of its conclusions that (a) Smith lacked capacity; (b) use of neuroleptic medication was reasonable and necessary; and (c) the benefits of such medication outweighed the risks.  The district court found that Smith will not take neuroleptic medication voluntarily and found that although her treating physician has attempted to discuss the diagnosis and proposed treatment plan with Smith, she denies that she is mentally ill and, therefore, is "unable to understand the benefits of the medication."  The district court also found that the use of neuroleptic medication to treat the illness from which Smith suffers is widely accepted in Minnesota's medical community and found that Smith's treating physician is currently prescribing neuroleptic medication to relieve her symptoms.  The court recognized that the use of neuroleptic medication may result in side effects, but also recognized that use of such medication "is the best treatment, according to contemporary professional standards, which could render further custody, institutionalization or other services to [Smith] unnecessary."  The district court also found that neuroleptic medication will permit Smith to receive the fullest possible benefit from her psychosocial treatment and individual therapy.

            Smith has continually refused to admit that she suffers from a mental illness and refuses any assistance with her medical or physical needs.  Dr. Qualey testified that he attempted to discuss with Smith the potential risks and benefits of using neuroleptic medication and attempted to determine whether she was competent to make an informed decision, but Smith rejected his attempts by making statements such as, "I'm blessed.  I'm involved with the Bible now, Doctor.  Please go away."  He testified that he was not sure whether she knew that he was her treating psychiatrist and stated:

She is so steeped in religious thought, it could be that she sees us more in terms of being evil or devil worshippers or something like that.  I'm not sure that she even knows that I'm a physician.

 

He testified definitively that he did not believe Smith was capable of making an informed decision regarding her medication.  Further, Dr. Nelson testified that based on the testimony and Smith's records, he believed she lacked the capacity to make an informed decision about her medication.

            Dr. Qualey and Dr. Nelson's testimony is clear and convincing evidence supporting the district court's determination that Smith does not have the capacity to give or withhold consent for medication.  Their testimony demonstrates that Smith does not have an awareness of her mental illness and therefore does not understand the consequences of refusing treatment.  Because of Smith's lack of cooperation, Dr. Qualey has been unable to explain the benefits, risks, and/or alternatives to treatment with neuroleptic medication.  Further, the testimony indicates that Smith's refusal to accept medication is not a reasoned choice but one based on delusions.  

            There is also clear and convincing evidence supporting the district court's conclusion that the use of neuroleptic medication is reasonable and necessary.  When questioned by the court, Dr. Qualey testified that use of this medication is the first line of treatment in this case and that neuroleptic medication is reasonable and necessary for Smith.  He went on to testify:

[S]hort of giving her medication I'm afraid that this woman may be institutionalized for quite a lengthy period of time. * * * She's one of the more ill individuals that we've seen in quite some time.  She definitely needs antipsychotics.

 

Additionally, Dr. Nelson agreed that a person with Smith's symptoms would generally be referred to a psychiatrist for medication.

            Finally, there is clear and convincing evidence supporting the district court's conclusion that the benefits to Smith from the use of neuroleptic medication outweigh the risks.  When questioned by Smith's attorney, Dr. Qualey testified that there are side effects to using neuroleptic medication but stated that Smith is less likely to suffer a lot of the side effects because she is relatively young and does not have many other known medical problems.  Cf. Jarvis, 418 N.W.2d at 145 ("In the case of neuroleptics, the likelihood of at least some temporary side effects appears to be undisputed.").  Again, Dr. Qualey testified that without such medication, Smith will likely be hospitalized for "a lengthy period of time."

            Affirmed.

* Retired judge of the Minnesota Court of Appeals, serving by appointment pursuant to Minn. Const. art. VI, § 10.

[1] As respondent notes, Smith has failed to make arguments or cite authority supporting the issues she raises.  Her analysis consists primarily of a repetition of the issues.  Generally, assignment of error based on assertion alone and unsupported by argument or authority is waived unless prejudicial error is obvious on mere inspection.  Schoepke v. Alexander Smith & Sons Carpet Co., 290 Minn. 518, 519-20, 187 N.W.2d 133, 135 (1971).  We review the issues raised here, however, in the interests of justice.  See Minn. R. Civ. App. P. 103.04 (stating appellate court has discretion to review any issue in interest of justice).

[2] It appears that the district court intended the Anoka-Metro Regional Treatment Center to be an alternative to placement at HCMC