William S. BIGLEY, Appellant,
ALASKA PSYCHIATRIC INSTITUTE, Appellee.
[Copyrighted Material Omitted]
[Copyrighted Material Omitted]
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James B. Gottstein, Law Project for Psychiatric Rights, Inc., Anchorage, for Appellant.
Timothy M. Twomey, Assistant Attorney General, Anchorage, and Talis J. Colberg, Attorney General, Juneau, for Appellee.
Before : FABE, Chief Justice, MATTHEWS, EASTAUGH, CARPENETI, and WINFREE, Justices.
A psychiatric patient committed to the Alaska Psychiatric Institute (API) challenges the superior court's order approving API's petition for involuntary administration of psychotropic drugs under AS 47.30.839. He alleges that the trial court violated due process guarantees and that it erred in its findings that API's proposed treatment was in his best interests and that no less intrusive alternative was available. Because the patient was subsequently released without treatment, the case is technically moot, but we decide it because it falls within the public interest exception to the mootness doctrine. We conclude that, because the patient did not receive adequate notice of the nature of the proceedings and access to his medical chart, he was denied due process. We accordingly issue declaratory relief clarifying these due process requirements.
II. FACTS AND PROCEEDINGS
This case concerns a petition by API to administer psychotropic medication to an unconsenting adult, William Bigley. Bigley's first hospitalization at API was in 1980. He exhibited threatening and bizarre behavior, delusions, and auditory hallucinations; API diagnosed him with schizophreniform disorder and treated him with anti-psychotic medications. During another hospitalization at API in 1981, he was diagnosed with paranoid schizophrenia.
Bigley was hospitalized dozens of times in the next two decades in a " revolving door" pattern of arrest, hospitalization, release, and relapse. In 1996 a court appointed the Office of Public Advocacy (OPA) as Bigley's conservator to manage his finances, and OPA became Bigley's guardian later in 2004. Throughout the years of his mental illness, it appears that Bigley generally denied that he had any psychiatric problems. He has often quit taking the psychotropic medications prescribed to him after his hospitalizations have ended. Bigley resented being placed under guardianship and has sought to terminate the guardianship. Doctors attribute Bigley's resistance to medication to his delusional belief that people are attempting to poison him. However, it is also true that the medications have sometimes produced harmful physical side effects, ranging from relatively minor (weight gain, sedation) to serious and irreversible (a movement disorder known as tardive dyskinesia).
According to a 2004 report by a court-appointed visitor, Bigley's mental condition and living conditions had recently taken an alarming turn for the worse. He had been living in an apartment for four years, but his angry and belligerent behavior escalated and he was evicted. He appeared underweight. The visitor thought he was " spinning out of control" and " quite angry," and concluded that he was unable to manage his own affairs.
By early 2007 Bigley had been in API at least sixty-eight times. He had periods
where his symptoms were moderate enough that he was able to live in assisted living or other forms of housing for short periods. There were other times when he lived on the streets. According to doctors at API, his periods of stability coincided with his acceptance of the medication prescribed to him, while when he stopped taking the medications, his delusions and disturbing behavior became more intense and he became homeless. For a period in 2007, Bigley received assistance with living in the community from a nonprofit mental health services provider called CHOICES, Inc.
In 2008 Bigley's situation was highly unstable. He had lost his most recent housing at a motel and refused another room his guardian found for him. Bigley's guardian reported that Bigley was not eating or drinking, could not express himself coherently, did not seem to recognize him, and refused an offer of money or a bus pass. The guardian said he had never seen Bigley in such a bad state and called the police.
Meanwhile, Bigley was involved in a series of disturbances at the First National Bank in Anchorage. Bigley often came into the bank to withdraw funds. In recent visits he had become disruptive, making hostile and threatening statements to bank employees and customers. Employees became frightened, so the bank banned him from the premises and hired a security guard to deal with his visits. On April 25 a police officer who responded to one of these disturbances took Bigley into custody and requested an emergency mental health evaluation.
At API Bigley was agitated, angry, and delusional. He refused to eat or drink, and had to be housed in locked seclusion because his behavior intimidated other residents, some of whom tried to retaliate physically. API records say he believed his food and drink were poisoned, that he had God-like powers, spoke repeatedly of natural and man-made catastrophes, and talked about blowing things up. While the professionals who dealt with him did not think he was dangerous, they worried his aggressive behavior could sooner or later provoke someone he encountered outside the hospital to assault him.
1. Commitment and related proceedings
On April 26, 2008, a magistrate issued an ex parte order committing Bigley to psychiatric evaluation after finding probable cause that he was mentally ill and that he was gravely disabled or presented a likelihood of causing serious harm to himself or others. The order also appointed the public defender to represent Bigley.
On April 28 API petitioned for a thirty-day commitment, and also petitioned for court approval of non-crisis administration of psychotropic medication. On that same day, an attorney, James Gottstein of the Law Project for Psychiatric Rights, e-mailed API and the public defender to inform them that he was representing Bigley with respect to what he called the " forced drugging" petition. In the e-mail he stated the view that Bigley had likely acted out as a way to get shelter at API during cold weather. He proposed a plan under which Bigley would be housed and fed at API.
The public defender's office represented Bigley at the commitment hearing on April 30, 2008. Attorney Gottstein filed a limited entry of appearance to represent Bigley regarding the petition for court-ordered administration of medication. The public defender objected to Gottstein's appearing on Bigley's behalf. The master agreed that should Bigley be committed, Gottstein could appear for Bigley during the subsequent involuntary medication proceedings. However, until that time, the master said she would not allow Gottstein to appear as counsel, cautioning him that " you're not co-counsel and you're not to be sitting at the table with them or interfering with their conduct of the case."
At the April 30 hearing, the master heard evidence and found that Bigley was gravely disabled under AS 47.30.915(7). On May 5 the superior court adopted the findings of fact and ordered Bigley committed to API
for mental health treatment for a period not to exceed thirty days.
2. Proceedings on administration of psychotropic medication
On May 7 API moved for an expedited hearing on the medication petition, noting that under AS 47.30.839(e), a hearing is required on the patient's capacity to give or withhold informed consent within seventy-two hours of the petition. On May 9 (a Friday) the court notified the parties that it was going to hold an expedited hearing on the medication petition on May 12 (Monday).
At the May 12 hearing on the medication petition, Gottstein objected to the expedited proceedings, saying the hearing was premature because to his knowledge Bigley had not yet been committed. It then emerged that Gottstein had not received notice of the court's May 5 commitment order. Gottstein also stated that he had yet to receive Bigley's medical chart despite earlier requests to API. He further argued that the API petition was defective because it did not provide adequate information about the proposal to medicate Bigley, such as the specific drugs, dosages, side effects, and benefits. He said that he needed this information to adequately prepare for the hearing.
Gottstein also proposed that a pretrial or settlement conference be held for the purpose of crafting a plan that would allow for an alternative to Bigley taking the medication. The court decided to proceed with the hearing and allow API to present its case, but said that it would make additional hearing time available for Gottstein to respond if necessary.
Early in the proceedings on the medication petition, Gottstein moved to dismiss, arguing that Bigley was competent earlier when he refused to take medications and that a less intrusive alternative existed of providing him support in the community to help him to function without medications. Gottstein also objected to the " compressed schedule" for the hearing, which he said would prevent him from adequately preparing his case. The court decided to allow API to proceed with its case, but asked Gottstein how much additional time he needed for his presentation and set aside additional time on May 14 for that purpose.
a. Evidence on Bigley's capacity for informed consent
The court-appointed visitor, Marie Ann Vassar, testified she attempted to meet with Bigley that morning to assess his competence and found him " extremely agitated," delusional, and unable or unwilling to cooperate in an assessment. She said there was no evidence of an advance directive with regard to psychotropic medication. She also said that the guardian supported the use of such medication.
API presented the testimony of Dr. Lawrence Maile, director of API's forensic evaluation unit and its clinical director. He testified that he had treated Bigley on a number of prior occasions. He testified that Bigley's refusal to take medication was based on the delusional belief that API was trying to poison and kill him. Maile said that Bigley was not capable of having a rational conversation about the medications or understanding the proposed treatment. Bigley's counsel argued that on prior occasions, Bigley had while competent expressed opposition to taking medication and had ceased to take it after being discharged from the hospital, and that the court must abide by such statements of his preference.
The court concluded that Bigley was not now competent and that there was no evidence of any prior occasions on which Bigley had, while competent, stated an opposition to being medicated in the future. Bigley's own demeanor in the courtroom apparently influenced the judge's determination that Bigley lacked capacity. In her findings, the judge observed that Bigley " was quite agitated and maintained a running monologue throughout most of the court proceedings."
b. Evidence relating to the best interests determination
With respect to the determination of Bigley's best interests, the main subjects of the evidence were (i) the benefits that API claimed the treatment would provide and (ii)
the harms that Bigley claimed would result from administering psychotropic medication.
i. Evidence on benefits of administering psychotropic drugs
API proposed to treat Bigley with risperidone, an anti-psychotic medication that API records indicate had been part of an effective regimen in the past, and which, at the hearing, API doctors said helped make Bigley calmer and more capable of rational interaction so that he could function in the community. Dr. Kahnaz Khari, a staff psychiatrist at API, testified that the use of this kind of medication was required by the standard of care of psychiatrists in this community. She said she believed it was in Bigley's best interests to receive the medications.
Dr. Khari said it was likely Bigley would be injected since he refused to take the oral form of the drug. She also planned to administer a medication from the benzodiazepine family to calm Bigley down until the risperidone took effect. Dr. Khari conceded that Bigley was not likely to be compliant with medication after release. She said that as a result API favored giving him an injection that only has to be administered every two weeks: " At least that keeps him stable for some short period."
Dr. Khari said that she would expect that with medication Bigley might remain delusional, but with a lower level of intensity and a better ability to think rationally and engage with other people. She said that in the past, she had seen Bigley on medication and he was functioning better and living in an assisted living facility. " [H]e was able to have more rational interaction, and he wasn't labile.... So I have seen him in a higher quality of living standard that he can have with the medication versus when he's not on medication." She testified that without the medication, she was concerned he would " not be able to provide the care for himself, like not eating, not sleeping."
Dr. Maile, the API clinical director, also testified that Bigley would benefit from the drugs. He testified that when Bigley took medications, he was a " very different," " pleasant man" " who is not threatening and not at risk to generate the harm from others by his perpetual threats to them." Without medication, " he tends not to take care ...