In this month’s case, a state appeals court was asked to review the decision of an Administrative Law Judge allowing a state hospital to administer psychotropic medications to a patient without the patient’s informed consent.

Just the Facts

The patient, Mr T, had been diagnosed with schizophrenia, and suffered from auditory and visual hallucinations, delusions, and extreme paranoia. Over the years, he had received both inpatient and outpatient treatment for his condition, with varying success. Treatment with psychotropic medication had been of benefit to the patient in the past, but Mr T did not like the way it made him feel. He reported experiencing restlessness as a side effect of the medication and would stop taking the medication due to this feeling.

At some point while living outpatient with a roommate, Mr T went off his medication and began experiencing hallucinations and delusions. As a result of these delusions, Mr T killed his roommate’s dog, and was arrested and charged with animal abuse. He was found not guilty by reason of insanity and was involuntarily committed to the state hospital.

Once admitted to the state hospital, a psychiatric nurse practitioner and physician were assigned to care for Mr T. They made the determination that the patient required several medications. Both the nurse practitioner and the physician made repeated attempts to discuss the need for medication with the patient, and to convey to him the benefits and risks of the treatment. Mr T still refused to take the medication. The hospital gave the patient a notice of involuntary administration of medication, and the patient requested a hearing on the matter.

A hearing was held before an Administrative Law Judge who ultimately issued an order authorizing the hospital to administer psychotropic medications to the patient without his consent. The patient requested reconsideration of the decision, which was denied, and so the patient filed an appeal.

The Appeals Court Decides

A person is presumed competent to consent to or withhold consent from significant procedures, including the administration of psychotropic medication, noted the appeals court. However, state law allows a state institution to medicate a patient without the patient’s informed consent if there is good cause. Several factors must be satisfied in order for good cause to involuntarily medicate a patient: the patient must demonstrate an inability to reasonably comprehend and weigh the risks and benefits of the proposed treatment or no treatment at all; and the inability to consent must be documented in the patient’s record and supported by the patient’s statements or behavior.  

The appeals court noted that the Administrative Law Judge found that the patient had “shown some understanding of the risks of the proposed medications,” but had not shown “an understanding of the benefits of the proposed medications other than the medications that treat anxiety.” Additionally, the Judge found that the patient lacked “insight into the nature and seriousness of his mental illness” and that he did not understand that his hallucinations were a symptom of schizophrenia. The Administrative Law Judge concluded that the patient’s psychiatric nurse practitioner and physician had both determined that the patient was unable to rationally weigh the risks and benefits of the medication because of his delusions, and that substantial evidence in the record supported this finding.