People ex rel. Marquardt

Opinion by JUDGE ASHBY T1 Respondent, Larry Wayne Marquardt, appeals from the trial court's order authorizing the involuntary administration to him of antipsychotic medication. We reverse. ' I. Background T2 Mr. Marquardt was committed to the Colorado Mental Health Institute at Pueblo (CMHIP) after having been found not guilty by reason of insanity in-a criminal case. He has been diagnosed with schizoaffective disorder, bipolar type, with prominent paranoia. 13 Since arriving at CMHIP, Mr. Mar-quardt has been voluntarily taking ten railli-grams of Saphris, an antipsychotic medication, once a day. The People petitioned the court to slowly increase the dosage to 20 milligrams per day because he refused to take any dosage above 10 milligrams per day, [655] and his psychiatrist felt that the medication was not effective at that dosage. After a hearing, at which both the psychiatrist and Mr. Marquardt testified, the court ordered that the dosage of this medication could be increased over his objection. 15 Mr. Marquardt appeals. «II. « Discussion 16 Mr. Marquardt contends that the trial court erred in applying the elements established in People v. Medina, 705 P.2d 961 (Colo.1985) to the facts of this case. T7 As a matter of first impression, we must first decide whether Medina is apphca— ble to a nonemergency request to increase antipsychotic medication dosage over a patient's objection. We conclude that it is. We also agree with Mr. Marquardt that the trial court applied an incorrect legal standard in deciding that the evidence presented supported a finding under Medina that an increased dose of his antipsychotic medication is necessary to prevent a significant and likely long-term deterioration in his mental condition. 18 In Medina, the supreme court found that a patient has a right under both common law and Colorado's statutory scheme relating to involuntary commitment to refuse unwanted treatment that could result in serious and permanent disabilities Id. at 971, The court noted that the common law had long protected a person's right to personal autonomy and bodily integrity. This protection was founded upon the principle that the individual is best suited to weigh the risks and benefits of treatment and to decide what the best course of tregtment is for him or her I d. at 968. ~19 However, the Medina court held that an involuntarily committed patient's right to autonomy and bodily integrity is not absolute. There are legitimate state interests in providing care to the patient and security to others, which must also be cons1dered Id. at 971. 110 The procedural protections and standards established in Medina therefore sought to accommodate the following considerations: (1) the patient's right to participate 'in treatment decisions affecting his own body; (2) the state's legitimate interests in providing treatment to a patient placed in its charge; and (8) safeguarding patients, staff, and others in the treatment facility,. Id. at 972. Due to the potentially long-term. and debilitating effects of antipsychotic medication, the development of guidelines to ensure that courts would weigh each of these interests before ordering the administration of such medication over a patient's objection was warranted. {11 The Medina considerations apply équally to a patient's objection to an increase in the dose of antipsychotic medication as to an objection to take medication at all. Therefore, we discern no legal basis on which to distinguish between an objection to taking an increased dose of medication and an objection to taking medication at all. We now address Mr. Marquardt's spemfic contentmns of error. - 1 12 Reviewing a trial court's application of the Medina elements to the facts of a particular case presents a mixed question of law and fact. People in Interest of Strodtman, 293 P.3d 123, 131 (Colo.App.2011). Thus, we defer to the trial court's findings of fact if supported by the record and review its legal conclusions de novo, Id. 118 Under Medina, a physician seeking to administer antipsychotic medication to a patient must prove, by clear and convincing evidence: (1) that the patient is mcompetent to effectively participate in the treatment decision; (2) that 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; (8) that a less intrusive treatment alternative is not available; and (4) that the patient's need for treatment by anti-psychotic medication is sufficiently compelling to override any bona fide and legitimate interest of the patient in refusing treatment. 705 P.2d at 978; see also § 27-65-127(@2)(a)-(b), C.R.S. 2018 (a court may. deprive a per [656] son of a legal right only if it finds that (a) the person has a mental illness and is a danger to himself or herself or others, is» gravely disabled, or is insane; and (b) the requested deprivation is both necessary and desirable). T 14 "Clear and-convincing evidence is evidence persuading the fact finder that the contention is highly probable." People in Interest of A.J.L., 243 P.3d 244, 251 (Colo.2010) ("The clear and convincing evidence standard requires proof by more than a 'preponderance of the evidence, but it is more easily met than the 'beyond a reasonable doubt' standard used in criminal proceedings."). . 115 Although Mr. Marquardt challenges the trial court's application of each of the Medina elements to the evidence presented here, he primarily argues the second element. The parties agree, and the trial court found, that, within that element, there was no basis to find that Mr, Marquardt posed a risk of harm to himself or others at the time of the hearing. Instead, the issue is whether, absent the increased dosage, Mr. Marquardt will suffer a significant and likely long-term deterioration to his mental health. 116 Mr. Marquardt's primary objection to taking an increased dosage is his belief that there is a risk of serious side effects, such as tardive dyskinesia-involuntary muscle movements that can become permdnent. Mr. Marquardt signed releases of information for his psychiatrists to access his prior medical history; yet, as of the hearing date, medical records to substantiate: Mr. Mar-quardt's self-reported negative side effects from medication had not yet been received by his psychiatrists, The record does not show that Mr. Marquardt has suffered the serious side effects of which he is concerned. To the contrary, in clinical use, any serious side effects associated with Saphris have not been reported. Still, Mr. Marquardt distrusts his treating psychiatrists, in part due to his mental iliness; has independently researched various medications and their side effects; and has difficulty effectively discussing treatment options with them. T 17 Mr. Marquardt's treating psychiatrist testified that, at the current dosage, Saphris is only partially therapeutic, as it is not treating all of Mr. Marquardt's symptoms. Even so, Mr. Marquardt is stable at this dosage, is participating in therapy groups and other treatment, has been cooperative with staff, complies with the rules of the unit, and has obtained the highest behavioral level on the ward. 18 The trial court found that, while Mr. Marquardt had previously exhibited violent behavior, since his admission to the facility, the extent of his violent behavior was that he had been argumentative with staff, The psychiatrist noted that there had been a "continuous de-compensation and deterioration over time" in Mr. Marquardt's mental health when looking back at his mental health history over the last thirty years; he did not adequately explain how, on the current medication and dosage, Mr. Marquardt will further deteriorate over time. Rather, his testimony and affidavit both suggest that, although Mr. Marquardt may be unlikely to continue to improve or to be released to a less restrictive facility at the current dosage, at this time he does not see any indication that Mr. Marquardt will either refuse to participate in treatment or experience a significant and long-term deterioration if his dosage is not increased. The trial court's findings and order also recognize that Mr. Marquardt is not deteriorating at his current dosage, but that without the increased dose of medication, his symptoms and overall mental® condition may not improve and he might not be released from the hospital. T 19 We acknowledge that Medina may be too restrictive in limiting judicial power to order medication over a patient's objection to cireumstances that (1) prevent long-term deterioration or (2) present a danger to the patient or others in the facility. A third cireumstance, when appropriately balancing the state's and patient's interests, may include when, without medication or an increase in dosage, the patient is unable over time to effectively progress or benefit from treatment. 120. But the plain language in Medi-ma, which permits court-ordered medication to prevent long-term deterioration, does not include the ability to order medication solely [657] to improve or expedite a patient's participation in treatment or likelihood of release, however laudable those goals may be. See People v. Allen, 111 P.3d 518, 520 (Colo.App.2004) (the court of appeals is bound by decisions of the supreme court). To the contrary, the supreme court found that the probate court's determination that there would be positive effects on the patient's treatment from the medication to be a substantially different holding than a determination that administration of medication was necessary to prevent a significant and likely long-term deterioration of the patient's medical condition. Medina, 705 P.2d at 975 [probate] court made no determination that the antipsychotic medication was necessary to prevent a significant and likely long-term. deterioration of the patient's medical cond1~ tion. Rather, the probate court turned its discussion on the fact. that the respondent 'will most probably experience less anxlety' from the regular administration of the medication and will most likely be removed to a less restrictive environment upon his improvement."). 121 Although the evidence supports the trial court's finding that Mr. Marquardt is unlikely to improve at the current dosage, that is not the correct legal standard under Medina. Thus, the trial court erred by ordering an increased dose of antipsychotic medication to Mr. Marquardt over his objection. Cf. Donaldson v. Dist. Court, 847 P.2d 632, 635 (Colo.1993); Strodiman, 293 P.3d at 133; People v. Pflugbeil, 834 P.2d 843, 847 (Colo.App.1992). In light of this conclusion, we need not address Mr. Marquardt’s remaining contentions of error, 1 22 The order is reversed. JUDGE RICHMAN concurs. JUDGE CASEBOLT concurs in part and dissents in part. -