Petitions for Involuntary Treatment Shall Include Statutorily Required Information
In In Re Pima County Mental Health, No. 20200860221, 533 P.3d 951 (Ariz. 2023), the Supreme Court of Arizona considered whether in a petition for court-ordered treatment, the affidavits filed by two physicians containing generic information without any details specific to the patient met statutory compliance. The Arizona Court of Appeals had vacated the treatment order because the physicians’ affidavits failed to comply with the statute. The Arizona Supreme Court reversed. Although the physicians’ affidavits and attachments did not comply with the statute, the court ruled that there was no prejudicial error in this case.
Facts of the Case
In February 2021, G.B., a 70-year-old female weighing around 83 pounds, was evaluated at St. Mary’s Hospital in Arizona for gastrointestinal complaints. She was diagnosed with delusional disorder, malnutrition, and cachexia. G.B. thought the doctors were trying to harm her, and she insisted on being discharged. An application for an involuntary evaluation of G.B., alleging that she was “Persistently or Acutely Disabled (PAD),” was filed by the hospital. A prepetition screening evaluation and report concluded that PAD standards were met, and the involuntary evaluation process should proceed. Subsequently, a petition for court-ordered evaluation of G.B. was filed and an order for evaluation was issued by the superior court. Pursuant to that order, G.B. was transferred to an inpatient psychiatric unit at University Medical Center South (“Banner”). At Banner, two psychiatrists, Dr. Madan and Dr. Colon, evaluated G.B. and Banner then filed a petition for court-ordered treatment.
The hospital attached to the petition two sets of three stapled-together documents, one set for each doctor. Included in the set were two generic signed and sworn fill-in-the-blank type forms with boilerplate language titled “Physician Affidavit” and “Addendum No. 1 - Persistently or Acutely Disabled” (Pima County, p 954). These forms referenced G.B. as the patient but did not discuss any specific examinations or evaluations conducted by the physicians, nor did they refer to any attached addenda, reports, or evaluations. Also included was a third document titled “Final Report,” that contained the physicians’ notes and findings of their evaluation of G.B.
At the petition hearing, G.B.’s counsel did not object to the admission of the affidavits, addenda, and final reports. Subsequently, the trial court found G.B. to be PAD and ordered treatment. G.B. then appealed, challenging the sufficiency of the physicians’ documentation. Banner contended that the stapled-together documents fulfilled statutory requirements for the petition for treatment as stated in Ariz. Rev. Stat. § 36-533(B) (2022). In a split decision, the appellate court vacated the trial court’s order with the majority finding that strict statutory compliance was required for involuntary treatment proceedings. The court noted that the affidavits of the two physicians failed to comply with the statute based on the lack of a personalized discussion of G.B. to support their conclusion of PAD due to mental illness. The appellate court also assumed but did not conclude that the stapled addenda to the physicians’ affidavits were part of the statutorily required affidavits.
Ruling and Reasoning
The Supreme Court of Arizona noted that G.B.’s case was moot because G.B. was no longer subject to the court’s order. But, the court made an exception to review the case on grounds of public importance because of the likelihood of repetition at the state level and the liberty interests inherent to court-ordered involuntary treatment. The court first delineated the requirements of Ariz. Rev. Stat. § 36-533(B) (2022), which governs the petition for court-ordered treatment. The statute requires that two physicians must assess the patient and provide affidavits. These affidavits must contain details and evidence supporting the physicians’ conclusions based on their observation and study of the patient’s history, a summary of facts supporting their conclusion, and relevant patient exam information. The court then addressed the wording of the statute and guidance on compliance. The court noted that by using the word “shall” in reference to providing the necessary materials outlined in the statutory requirements, §36-533(B) makes compliance mandatory. In addition, the court highlighted that case law had suggested “strict compliance” in cases of involuntary treatment proceedings because of the serious deprivation of liberty involved. But, the court clarified that it did not favor “strict compliance” to be applied in the mental health setting. Instead, the court said that “complete compliance” of each statutory requirement is more appropriate since it allows for technical differences but not errors in compliance.
The court ruled that the physicians' affidavits in G.B.'s case did not comply with the statutory requirements as they lacked personalized information about G.B., including the physicians’ detailed findings from her assessment and medical history, as required by statute. In addition, the court found that the addenda, although satisfying the statute by means of details contained, were nevertheless also insufficient because they were unsworn and not incorporated in the physicians’ affidavits by reference. Being unsworn, the court noted, the additional documents were not affidavits themselves, and could not be included within affidavits without a reference. Although Arizona does not have case law on courts using documents attached to affidavits if they are included by reference in deciding a petition for involuntary treatment, the court noted that Arizona has established this use in other cases, such as with contracts and warrants. Additionally, the court noted that other state courts recognize incorporation by reference when considering a petition for involuntary treatment. Thus, the court said that if extrinsic documents are expressly referenced and are physically attached to the referencing affidavit, they are considered as incorporated into a § 36-533(B) affidavit and, accordingly, meet statutory requirements. The court underscored, however, that it remains best practice to provide all the statutorily required information in the affidavit itself to aid efficiency. With this, the court looked at whether G.B. waived the matter of statutory compliance and found that she did, since G.B.’s attorney did not object to any statutory deficiency either in a pretrial motion or during the hearing. Moreover, the court noted that had G.B. brought up her concerns with the documentation in the trial court, the deficiencies would have been corrected.
Finally, the Supreme Court of Arizona assessed whether a fundamental error had been committed by the trial court in admitting the insufficient affidavits tendered by the hospital, since only the commission of a fundamental error would be grounds for overturning the trial court’s decision. The court explained that a fundamental error goes to the foundation of the case and is prejudicial, deprives one of a right essential to one’s defense and is prejudicial, or precludes the possibility of a fair trial. The court did not find convincing evidence of prejudice against G.B. or her case. G.B. was able to fairly oppose the petition for involuntary treatment by cross-examining Dr. Madan and presenting her own witnesses. In addition, the court noted that the trial court had enough evidence to support its ruling despite the deficiencies in the affidavits. The court found that the acceptance of the physicians' insufficient affidavits was not a prejudicial error and did not prevent G.B. from having a fair trial. Subsequently, the Supreme Court of Arizona vacated the court of appeals’ opinion and affirmed the trial court’s order.
Discussion
There are widespread differences in the way hospitals satisfy statutory requirements for civil commitment petitions. Many hospitals routinely do not provide all statutorily required information in the affidavits themselves and instead provide supplemental materials. The Supreme Court of Arizona took this into consideration in rendering its opinion. Here, the Supreme Court of Arizona emphasized the significant liberty interest at stake when hospitals are petitioning for court-ordered treatment. The court indicated that physicians and hospitals do not have license to overlook statutorily required documentation and the standards for provision of this information. Thus, the court allowed for only a degree of error in submitting the documents, underscoring that any further deviation from the statutory requirements, especially due to carelessness, was unacceptable.
This legal opinion highlights the need for incorporating the teaching of fundamental topics in forensic psychiatry to residents during the formative years of their training. Statutory requirements related to documentation for civil commitment and related matters should be required knowledge, since proper documentation emphasized and taught during residency training would likely reduce such errors in a clinician's practice later in life. Moreover, in cases where a physician might be faced with a malpractice lawsuit because of an adverse outcome, poor documentation could potentially create grounds for additional liability.
- © 2024 American Academy of Psychiatry and the Law
