Alaska Supreme Court Affirms Commitment and Use of Select Medications, Considering Indication and Necessity
In re Necessity for the Hospitalization of Carter K., 557 P.3d 755 (Alaska 2024), the Alaska Supreme Court deliberated on Carter K’s appeal of orders for involuntary psychiatric commitment and administration of psychotropic medications. The court affirmed the trial court’s ruling on involuntary commitment and involuntary administration of olanzapine. The court vacated the trial court’s order for involuntary administration of lorazepam, citing insufficient evidence supporting its use.
Facts of the Case
Before Mr. K’s scheduled release from jail in October 2022, mental health personnel petitioned for his hospitalization for a psychiatric evaluation. This petition was granted by the court, and Mr. K was transferred to Alaska Psychiatric Institute (API) on October 9, 2022. After two days, his treatment team petitioned for a 30-day commitment and involuntary medication administration. Hearings on each matter were held before a superior court master on October 12. Mr. K waived his presence at the hearings, and he was represented by an attorney. His primary treating clinician at API, a nurse practitioner (NP), and a court visitor (person appointed by court to investigate and make recommendations regarding medication) were state witnesses. The NP was qualified as an expert with no objection by Mr. K’s attorney.
At the commitment hearing, the NP diagnosed Mr. K with schizophrenia and described him as demonstrating “heavily psychotic symptoms” at the time of evaluation, including thought disorganization and delusions of being abducted and having his body parts and fluids replaced with uranium. The NP also testified that, if discharged, Mr. K would be unable to safely meet his basic needs given the severity of his symptoms, rendering him gravely disabled. Testimony indicated that Mr. K demonstrated some semblance of caring for himself at API and in jail because both were structured, sheltered settings that provided him with his basic needs. The NP noted that, outside of these settings, he had no guardian nor financial means to support himself. The master found Mr. K gravely disabled because schizophrenia significantly impaired his judgment and ability to function independently, and recommended a 30-day commitment.
At the subsequent medication hearing, the NP opined that Mr. K’s presenting symptoms interfered with his ability to make an informed decision regarding medications, as his refusal was based on reasons deemed illogical, namely that medications would cause his body to rust. Olanzapine was recommended because it was expected to improve Mr. K’s psychotic symptoms, allow him to engage in a discharge plan, and permit him to continue treatment in a less restrictive setting. Diphenhydramine was recommended to treat potential extrapyramidal side effects from olanzapine, and lorazepam was recommended to treat possible agitation or aggression. Although Mr. K had not been agitated or aggressive at API, prior records indicated a history of such behavior. The court visitor testified to Mr. K’s inability to provide or withhold informed consent regarding medication treatment. The master recommended approving administration of the requested medications.
The master’s findings were not objected to by either party, and the superior court adopted them, ordering a 30-day commitment and involuntary treatment with olanzapine, diphenhydramine, and lorazepam. Mr. K appealed the commitment and medication orders to the Supreme Court of Alaska. He argued the court did not possess sufficient evidence of grave disability, nor did it explore less restrictive alternatives to hospitalization. Additionally, he argued that the court approved involuntarily administration of olanzapine and lorazepam in error, as it relied on facts not in evidence and did not conduct the required inquiries. Additionally, he argued ineffective assistance of counsel because of the lack of objection to the master’s ruling.
Ruling and Reasoning
The Alaska Supreme Court upheld the trial court’s ruling on Mr. K’s 30-day commitment order and affirmed the order for involuntary administration of olanzapine. But the order for involuntary administration of lorazepam was vacated.
The court noted that, because Mr. K did not object to the master’s findings in a timely manner, he was required to demonstrate plain error on his appeal, which was defined as “‘an obvious mistake’ that is ‘obviously prejudicial’” (Carter K., p 761, quoting In re Hospitalization of Gabriel C., 324 P.3d 835 (Alaska 2014), p 838). The court indicated that timely appeals are imperative given the loss of civil liberty at stake with involuntary psychiatric hospitalization to protect “unwarranted deprivations of respondents’ liberty” (Carter K., p 762). Although Mr. K attempted to raise the concern of ineffective assistance of counsel, the court indicated that such matters should be raised at the trial court level.
On review of the superior court’s findings, the court stated that no plain error was evident in determining that Mr. K was gravely disabled as the result of mental illness, nor did the court err in its findings that no feasible, less restrictive alternative treatment options would meet his needs. Therefore, the court did not err in finding that commitment was the least restrictive alternative available. Turning to the justification of involuntary medication administration, the court considered several factors consistent with prior case law in Myers v. Alaska Psychiatric Institute, 138 P.3d 238 (Alaska 2006) to determine whether involuntary medication is in the person’s best interests: the patient’s history, including prior medication trials and side effects from medications; explanation of the diagnosis, symptoms, and prognosis with and without medication; information about the indication and purpose of medications, potential risks and side effects, along with treatment of said side effects; explanation of interactions with other medications or drugs; and information about alternative treatments, including nontreatment, as well as the risks and benefits of each.
Regarding olanzapine, the court found that all Myers factors were considered by the superior court, that the administration of olanzapine was in Mr. K’s best interests, and no less intrusive treatment was available. But the court ruled that the superior court erred in its order of lorazepam because it failed to consider some of the Myers factors that would support that the medication was the least intrusive means and in the patient’s best interests.
Discussion
Determinations made in Carter K. are highly relevant to general and forensic psychiatrists, especially those working in inpatient settings that pursue civil commitment or treatment over objection for their patients. First, there is a delicate balance between preservation of patients’ liberties and ensuring the protection of the individual and society. When pursuing civil commitment, less restrictive alternatives, including community-based treatment, should be considered. Although the legal criteria vary from state to state, many states include grave disability as a justification for civil commitment, and psychiatrists should be aware of the statues relevant to their jurisdiction.
Second, testifying on the matter of grave disability in civil commitment proceedings can be challenging, given the psychiatrist may have to compare the patient’s functioning in a highly structured setting versus less restrictive, community-based settings. Determining a patient’s baseline functioning often requires review of collateral information, but this information may not be known or readily available. The testifying NP opined that Mr. K had previously functioned at a higher level in the community, but careful consideration is necessary when making such inferences, as some individuals experiencing mental health symptoms do not come to the attention of law enforcement or medical professionals. Another consideration when opining on grave disability is whether individuals’ inability to care for themselves is a result of underlying mental illness. Aside from mental illness, there are other psychosocial factors that may contribute to an individual’s unstable housing, financial insecurity, or criminal justice involvement. Alternatively, other individuals are resourceful and can access community resources, including shelter, even though there may be a history of mental illness and indications that the person cycles from “jail to street” (Carter K, p 759). Obtaining information about patients’ engagement in and response to their outpatient treatment allows for stronger testimony comparing their baseline functioning with episodes of psychiatric decompensation.
Third, states also differ in their statutes and procedures regarding psychiatric medication refusals on inpatient units. In this case, the court considered previously established factors to determine the need to treat Mr. K over his objection, factors consistent with a treatment team’s obtaining informed consent from a patient. When testifying in such hearings, psychiatrists should establish that informed consent was attempted and describe the patient’s responses to the information. Testimony in these settings is also an opportunity to educate the court on psychiatric diagnoses, appropriate treatments for these conditions, potential alternatives considered, and the potential risks of no treatment. Although the opinion vacated the order to treat Mr. K with lorazepam, it did not comment upon use of lorazepam where there was an immediate danger to the patient or others, in which case use of the medication may be appropriate.
Finally, it is not uncommon for patients to waive their appearance at such hearings. Procedural safeguards, including the right to counsel, right to attend the hearing, and right to appeal, are in place to ensure protection of an individual’s liberties. But patients may waive their appearances without knowledge of their counsel’s legal strategies or the potential repercussions for future appeals. Furthermore, some patients may refuse to engage with counsel or waive their appearance secondary to their symptoms and, once their symptoms abate, have awareness of the impact of their prior decisions. In Mr. K’s case, the waiver of his court appearance and delayed appeal limited his avenues for relief, and he may have benefited from attending his initial hearings. It is unclear whether the basis for his appeal was primarily rooted in his dissatisfaction with the outcome, his opinion that he was ineffectively represented, or both. Patients often ask treating psychiatrists if they should attend court hearings. Psychiatrists who are familiar with common court processes can encourage patients to speak with their counsel; this can provide valuable education for a patient unfamiliar with the process.
- © 2025 American Academy of Psychiatry and the Law
