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Brandt v. Monte

January 29, 2009

JOHN BRANDT, PLAINTIFF,
v.
LYDA MONTE, ET AL., DEFENDANTS.



The opinion of the court was delivered by: Bumb, United States District Judge

[Docket Nos. 57 & 58]

OPINION

John Brandt (the "Plaintiff"), who was an involuntarily committed patient at Ancora State Psychiatric Hospital ("Ancora") from September 2005 to September 2006,*fn1 brought this lawsuit alleging that state medical authorities violated his civil rights when they forcibly administered antipsychotic medication to him, first, pursuant to an emergency declaration and later, pursuant to a non-emergency procedure. He is now involuntarily committed at Ann Klein Forensic Center, another state hospital.

The treating physician at Ancora, psychiatrist Lyda Monte, and Ancora "treatment team" members Regina O'Connell, a psychologist, Doris Simmerman, a social worker, and John Coffee, a program coordinator, (collectively, the "Ancora Defendants") are all alleged to have had a personal role in the decision to medicate Plaintiff and are therefore sued in their individual capacities.*fn2 La Tayna Wood El, Ancora's chief executive officer, Kevin Martone, assistant commissioner for the New Jersey Division of Mental Health Services, Kevin Ryan, former commissioner of the New Jersey Department of Human Services, James Smith, former acting commissioner of the New Jersey Department of Human Services, and Anthony Haynes, the "Rennie Advocate" at Ancora, (collectively, the "State Defendants") are sued in their official capacities for injunctive relief.

Plaintiff now moves for partial summary judgment, contending that Defendants' undisputed conduct violated his constitutional rights as a matter of law. Defendants cross-move for summary judgment on the grounds, inter alia, that they are immune from suit pursuant to the doctrines of qualified and sovereign immunity. For the reasons stated herein, the Court denies Plaintiff's motion for partial summary judgment, and, in part, grants Defendants' cross-motion for summary judgment.

I. Statement of Facts

A. Background

Plaintiff has had a long history of psychological illness, which, at times, has manifested itself in violent and unlawful behavior. In 2003, Plaintiff was found not guilty by reason of insanity for criminal charges of burglary, criminal mischief, and criminal trespass as a result of breaking in to his exgirlfriend's college dormitory room and, in the midst of a dispute with her, destroying her property. He was thereafter involuntarily committed at Ancora, a psychiatric hospital.

This case arises from an incident at Ancora. In November 2005, Plaintiff was placed in Ancora's Medical Ward to receive treatment for an injury to his leg. His treating doctor, Cecilia Caringal, concluded that he should not be involuntarily committed because he suffered only from an impulse control disorder, an "Axis II" diagnosis, rather than the "Axis I" diagnosis that would normally justify involuntary commitment.*fn3 In February 2006, on Caringal's recommendation, a state commitment court ordered that Plaintiff be transferred from the Medical Ward, that his "treatment team may begin a discharge plan if deemed appropriate," and that he "cooperate with his treatment team and take any medications prescribed by the treating psychiatrist . . . ." (Pl. Stat. Mat. Fcts. 4-5, ¶ 21.) Pursuant to the commitment court's order, the Medical Ward staff prepared paperwork recommending that Plaintiff be discharged and that his privileges be elevated. Before the recommendation could be acted upon, however, Plaintiff was transferred from the Medical Ward to Holly Hall C and placed under the care of the ward psychiatrist, Ancora Defendant Monte. The treatment team in Holly Hall C consisted of Ancora Defendants O'Connell, Simmerman, and Coffee, as well as nurse Deborah Berkebile.

The record is unclear as to whether the treatment team in Holly Hall C was aware of the Medical Ward's upgrade and discharge recommendations.*fn4 The morning that Plaintiff was transferred, on February 9, he met with Monte and the treatment team for a routine intake interview, at which time Monte prescribed antipsychotic medication. Plaintiff, aware of the Medical Ward team's recommendation, believed he did not need antipsychotic medication and refused to consent to administration of the drugs. In the treatment team meeting, Plaintiff grew increasingly agitated. He raised his voice, and at one point left the room. After the meeting's abrupt conclusion, Monte completed a certificate that declared Plaintiff to be an "emergency" and ordered that he be medicated intravenously without his consent. She prescribed Topamax, Vistaril, Zyprexa, and Benadryl. On the "Emergency Certificate," she provided this basis for the emergency declaration:

HOSTILE, AGGRESSIVE, ANGRY, REFUSING TO TAKE MEDS, IMPULSIVE, LONG HX [HISTORY] OF AGGRESSIVE/ASSAULTIVE/CRIMINAL BEHAVIOR, EXTREMELY MANIPULATIVE -- HAS COURT ORDER TO COMPLY WITH PRESCRIBED MEDICATION -- VERY CONFRONTATIONAL WITH HIGH LEVEL OF AGITATION AND HOSTILITY -- HX [HISTORY] OF 2 ESCAPES FROM GPPH [GREYSTONE PARK PSYCHIATRIC HOSPITAL] -- KROL STATUS.

(Pl. Stat. Mat. Fcts. 8, ¶ 37.) In addition to the Emergency Certificate, Monte put Plaintiff on "one-to-one precautions," which requires a hospital staff member to be within an arm's length of the patient at all times and to keep a log noting the patient's behavior every fifteen minutes.

Medication was administered to Plaintiff pursuant to the Emergency Certificate only twice. At Ancora, drugs are routinely administered twice daily, at 8:00 a.m. and 8:00 p.m. Thus, Plaintiff's first emergency administration occurred at 8:00 p.m., almost nine hours after his encounter with the Ancora Defendants; the second emergency administration occurred at 8:00 a.m. the following morning.

That morning, Monte initiated the three-step Non-Emergency Procedure for medicating a patient involuntarily. By noon, this procedure had been completed. Thus, although Plaintiff continued to be medicated against his will, starting with the second day's evening administration, he was medicated pursuant to the Non-Emergency Procedure. The one-to-one precaution log, which documented Plaintiff's behavior for the entire 25-hour period of the Emergency Certificate, did not note any aggressive or otherwise abnormal behavior.

B. Administrative Bulletin 78-3 (Rules for Involuntary Administration of Medication)

Administrative Bulletin 78-3 sets out the procedures that New Jersey state hospitals must follow for forcibly medicating involuntarily committed patients. It deals with the administration of medication in both emergency and non-emergency situations. Indeed, Administrative Bulletin 78-3 was the subject of extensive litigation between 1977 and 1983, when the Third Circuit ultimately upheld its procedure for non-emergency forcible medication. That Third Circuit decision, Rennie v. Klein, discussed more fully below, held that the non-emergency procedure, which requires three levels of approval before patients may be forcibly medicated, struck a constitutionally appropriate balance by protecting the patient's liberty interest in refusing medication, while still allowing medical authorities to administer medication as needed. 720 F.2d 266, 269-270 (3d Cir. 1983).

Section IV(A) of Administrative Bulletin 78-3 provides that medical authorities may administer psychotropic medication only when patients have given voluntary, informed consent. The Bulletin outlines four exceptions to this consent requirement:

(1) emergency administration of medication (the "Emergency Procedure"), (2) non-emergency refusal to give consent (the "Non-Emergency Procedure"), (3) patients incapable of giving informed consent, and (4) incompetent patients.*fn5 (As there is no dispute that Plaintiff was competent and capable of giving informed consent, only the Emergency Procedure and the Non-Emergency Procedure are at issue in this case.)

In relevant part, the Emergency Procedure requires a treating physician to certify "that it is essential to administer psychotropic medication, because without medication there is a substantial likelihood that the patient will harm him/her self or others . . . in the reasonably foreseeable future . . . ." § IV(C)(1)(b). Once this "Emergency Certificate" is completed, medication may be administered for up to 72 hours. Id. The Emergency Procedure provides a mechanism for some type of review, but does not specify who the reviewing authority must be or whether review is even required. § IV(C)(1)(d)-(g).

The Non-Emergency Procedure (referred to in the parties' papers variously as "Refusing Status" and the "Three-Step Form"), outlines a three-step procedure for overriding a patient who refuses medication in the absence of an emergency. First, the treating physician must meet with the patient in an attempt to address his concerns. § IV(C)(2)(b)(1). If the patient persists in refusing medication and the physician believes that medication is a necessary part of the patient's treatment, then the matter is referred to a treatment team. § IV(C)(2)(b)(2). Second, the treatment team must review the physician's recommendation and the patient's objections, and then document its conclusions. § IV(C)(2)(c)(2). If the patient is present, the team must attempt to formulate a treatment plan acceptable to the patient and the team. § IV(C)(2)(c)(1). Third, if the patient still persists in refusing medication, then the Medical Director must conduct a personal examination of the patient. § IV(C)(2)(d)(1). If the Medical Director agrees with the treating physician, then the medication may be administered forcibly. § IV(C)(2)(d)(1)(B). Throughout this process, the patient may consult with an independent hospital staff member known as a "Rennie Advocate." § IV(C)(2)(b)(2)(B).

C. The Parties' Arguments

Plaintiff alleges that the Ancora Defendants administered medication pursuant to the Emergency Procedure in the absence of a genuine emergency. Plaintiff relies upon deposition testimony suggesting that it was the Defendants' routine practice to employ the Emergency Procedure whenever a patient refused medication, and as a means of inducing patient consent during the later-pursued Non-Emergency Procedure.*fn6 Plaintiff also alleges that the Emergency Procedure lacks any meaningful procedural safeguards of the patient's liberty interest, beyond the treating physician's brute declaration of an emergency. Thus, even if Plaintiff had presented a genuine emergency, he argues, the lack of procedural safeguards itself violated his constitutional rights. Finally, Plaintiff alleges that, during the Non-Emergency Procedure, his treating physician ordered the administration of medication in violation of professional standards and treatment team members failed to provide independent and impartial oversight.

Defendants counter that a genuine emergency occurred in this case. They dispute that the Emergency Procedure is routinely used in the absence of emergencies to induce patient consent. Defendants also maintain that the Emergency Procedure provides adequate procedural safeguards and, furthermore, that Plaintiff's rights were preserved in the Non-Emergency authorization of drug administration. In any event, Defendants argue that the doctrines of qualified and sovereign immunity, as well as the Rooker-Feldman Doctrine (discussed below), bar Plaintiff's claims against them.

Plaintiff has moved for partial summary judgment on the grounds that Defendants' undisputed conduct violated his procedural due process rights as a matter of law. Defendants have cross-moved for summary judgment on the grounds that Plaintiff's claims lack a basis in fact and, further, that all Defendants are immune from suit.

II. Legal Standard

Summary judgment shall be granted if there is no genuine issue as to any material fact and the moving party is entitled to a judgment as a matter of law. Fed. R. Civ. P. 56(c); Hersh v. Allen Products Co., 789 F.2d 230, 232 (3d Cir. 1986). A dispute is "genuine" if "the evidence is such that a reasonable jury could return a verdict for the non-moving party." See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). "At the summary judgment stage the judge's function is not . . . to weigh the evidence and determine the truth of the matter but to determine whether there is a genuine issue for trial." Id. at 249. "In making this determination, a court must make all reasonable inferences in favor of the non-movant." Oscar Mayer Corp. v. Mincing Trading Corp., 744 F. Supp. 79, 81 (D.N.J. 1990) (citing Meyer v. Riegel Products Corp., 720 F.2d 303, 307 n.2 (3d Cir. 1983)). However, "the party opposing summary judgment 'may not rest upon the mere allegations or denials of the . . . pleading'; its response, 'by affidavits or as otherwise provided in this rule, must set forth specific facts showing that there is a genuine issue for trial.'" Saldana v. Kmart Corp., 260 F.3d 228, 232 (3d Cir. 2001) (quoting Fed. R. Civ. P. 56(e)).

III. Discussion

A. Legal Background: Rennie v. Klein

In 1982, Youngberg v. Romeo established the general proposition that patients committed to state custody have a constitutionally protected liberty interest in being free from unreasonable bodily restraints. 457 U.S. 307, 315-16 (1982). This constitutional protection is not absolute, however. It may be curtailed when medical authorities, in the exercise of professional judgment, determine that the liberty interest is outweighed by the state's interest in maintaining safety. Id. at 321-22. Thus, "liability may be imposed only when the decision by the professional is such a substantial departure from accepted professional judgment, practice, or standards as to demonstrate that the person responsible actually did not base the decision on such a judgment." Id. at 323.

The following year, the Third Circuit applied these general standards in Rennie v. Klein, holding that involuntarily committed patients have a constitutional right to refuse administration of antipsychotic drugs. 720 F.2d 266, 269 (3d Cir. 1983).*fn7 The state may override this right when the patient is a danger to himself or others, but, Rennie held, in non-emergency situations the state must first provide procedural due process. Id. Because Rennie addressed primarily what process is due in these non-emergency situations, it provides only limited guidance as to the constitutional requirements for forcibly administering medication in emergency situations. However, Rennie at least stands for the following limited propositions.

If a patient constitutes a danger to himself or to others, medical authorities may, in the exercise of professional judgment, administer drugs against the patient's will. Id.*fn8 The exercise of professional judgment does not necessarily require administration of the "least restrictive" treatment, but neither does it free medical authorities to administer whatever treatment they prefer. See id. at 270 n.8 (disclaiming carte blanche deference to medical authorities' judgment). Medical authorities may administer treatment only as "necessary to prevent the patient from endangering himself or others,"*fn9 and the exercise of professional judgment may require them to consider available alternatives in the context of such factors as the harmful side-effects that a patient may experience. Id. at 269-70.*fn10

Although Rennie upheld the Non-Emergency Procedure in Administrative Bulletin 78-3, it did not approve Administrative Bulletin 78-3 in its entirety. Id. at 270 n.9 ("Inasmuch as no specific provision of the regulation has been challenged, that subject, if raised, should be left to the district court for its determination in the first instance." (citation omitted)). The matter at issue in this case -- that is, the constitutional requirements to forcibly medicate involuntarily committed patients in an emergency -- was not squarely resolved in Rennie. 653 F.3d at 848.

Rennie is not the most recent authority to discuss the forcible administration of medication to people in state custody. After Rennie, the Supreme Court heard a line of cases about the involuntary administration of medication in the criminal context. Although these cases did not address civilly committed patients, they have obvious relevance here. See Youngberg, 457 U.S. at 321-22 ("Persons who have been involuntarily committed are entitled to more considerate treatment and conditions of confinement than criminals whose conditions of confinement are designed to punish."); White v. Napoleon, 897 F.2d 103, 112 (3d Cir. 1990) ("Prisoners may well suffer a greater loss of liberty than persons involuntarily committed to mental institutions . . . ."). Taken together, this line of cases -- Washington v. Harper, 494 U.S. 210 (1990), Riggins v. Nevada, 494 U.S. 210 (1992), and Sell v. United States, 539 U.S. 166 (2003) -- establish the following inquiry, in the criminal context, to determine the constitutionality of forcible drug administrations:

Has the Government, in light of the efficacy, the side effects, the possible alternatives, and the medical appropriateness of a particular course of antipsychotic drug treatment, shown a need for that treatment sufficiently important to overcome the individual's protected interest in refusing it?

Sell, 539 U.S. at 183. In particular, Harper held that "the Due Process Clause permits the State to treat a prison inmate who has a serious mental illness with antipsychotic drugs against his will, if the inmate is dangerous to himself or others and the treatment is in the inmate's medical interest." 494 U.S. 210, 227 (1990) (emphasis added). Explaining Harper's holding in a later case, the Court stated that, when deciding to forcibly administer medication, the relevant inquiry is "whether involuntary administration of drugs is necessary significantly to further a particular governmental interest, namely, . . . to [mitigate] the individual's dangerousness . . . ." Sell, 539 U.S. at 181-82. The two subsequent cases, Riggins and Sell, which dealt with involuntary drug administration for purposes of readying a criminal defendant to stand trial, similarly weighed the necessity of the state interest against the significance of the constitutional interest. 539 U.S. at 179; 504 U.S. at 135.

B. Ancora Defendants: Qualified Immunity

At the heart of this lawsuit are Plaintiff's individual capacity claims against the Ancora Defendants, alleging violations of his ...


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