Opinion ID: 2631631
Heading Depth: 3
Heading Rank: 1

Heading: Alaska's Current Statutory Provisions

Text: To place these arguments in perspective, we must begin by considering Alaska's statutory provisions governing treatment of mental patients. Alaska law recognizes and addresses a distinct class of drugs called psychotropic medications. [5] Psychotropic drugs affect the mind, behavior, intellectual functions, perception, moods, and emotions [6] and are known to cause a number of potentially devastating side effects. [7] [M]ost common . . . are the temporary, muscular side effects (extra-pyramidal symptoms) which disappear when the drug is terminated; dystonic reactions (muscle spasms, especially in the eyes, neck, face, and arms; irregular flexing, writhing or grimacing movements; protrusion of the tongue); [and] akathesia (inability to stay still, restlessness, agitation) ... Additionally, there are numerous other nonmuscular effects, including drowsiness, weakness, weight gain, dizziness, fainting, low blood pressure, dry mouth, blurred vision, loss of sexual desire, frigidity, apathy, depression, constipation, diarrhea, and changes in the blood.[ [8] ] Courts have observed that the likelihood [that psychotropic drugs will cause] at least some temporary side effects appears to be undisputed [9] and many have noted that the drugs maymost infamouslycause Parkinsonian syndrome and tardive dyskinesia. [10] Parkinsonian syndrome consists of muscular rigidity, fine resting tremors, a masklike face, salivation, motor retardation, a shuffling gait, and pill-rolling hand movements. [11] Tardive dyskinesia involves slow, rhythmical, repetitive, involuntary movements of the mouth, lips, and tongue; [12] it is permanent, and its symptoms cannot currently be treated. [13] Side effects aside, the truly intrusive nature of psychotropic drugs may be best understood by appreciating that they are literally intended to alter the mind. [14] Recognizing that purpose, many states have equated the intrusiveness of psychotropic medication with the intrusiveness of electroconvulsive therapy and psychosurgery. [15] A special statutory regime governs involuntary administration of these highly intrusive medications. [16] It allows the state to administer psychotropic medication without obtaining a patient's consent in both crisis and non-crisis situations. [17] This case involves only the latter, and we emphasize at the outset that our opinion does not extend to the use of psychotropic medication in crisis or emergency situations. Under Alaska law, to administer psychotropic drugs in a non-crisis situation without first obtaining the patient's consent, the state must follow a two-step judicial process. The first step requires the state to petition for the person's commitment to a treatment facility. [18] Persons may be involuntary committed in Alaska if the state can show by clear and convincing evidence that they are either mentally ill and, as a result, likely to cause harm to themselves or others, or are gravely disabled. [19] Persons are deemed gravely disabled when they are so unable to care for themselves that it seems very likely that they will come to serious harm without help. [20] To commit a mentally ill person for more than seventy-two hours there must be, in addition, a signed statement by two mental health professionals declaring that treatment staff have considered and dismissed less restrictive alternatives, and that they believe that the proposed course of treatment (including involuntary commitment) will improve the person's condition. [21] An order authorizing a person's involuntary commitment does not authorize the state to treat the committed person with psychotropic drugs. Nor does it amount to a finding that the patient is incapable of giving or withholding informed consent to submit to such treatment. [22] To treat an unwilling and involuntarily committed mental patient with psychotropic medication, the state must initiate the second step of the process by filing a second petition, asking the court to approve the treatment it proposes to give. At this second stage, the state must prove two propositions by clear and convincing evidence: (1) that the committed patient is currently unable to give or withhold informed consent regarding an appropriate course of treatment; [23] (2) that the patient never previously made a statement while competent that reliably expressed a desire to refuse future treatment with psychotropic medication. [24] In order to make informed decisions possible, the law requires treatment facilities to give their patients certain information concerning their situation and need for treatment, including advice about: their diagnosis; proposed medications, including possible side effects and interactions with other drugs; their medical history; alternative treatments; and a statement describing their right to give or withhold consent. [25] For non-emergencies, the standard for determining the patient's capacity to give informed consent is laid out in AS 47.30.837(c). [26] This provision allows a patient to refuse medication unless the state shows, by clear and convincing evidence, that the patient cannot demonstrate the capacity to understand the patient's situation and assimilate relevant facts, is unable to participate in treatment decisions, or is unable to articulate any objections to the proposed medication. [27] Under this provision, a patient's inability to appreciate the presence of a mental disorder is a relevant consideration but is not dispositive. [28] When the state files its petition to authorize psychotropic medication, the law requires a visitor to be appointed to assist the court when it considers the petition. The visitor has a duty to gather and provide information to the court on two issues: first, the visitor must evaluate the patient's present condition by administering a capacity assessment; second, the visitor must conduct a search for any prior expressed wishes of the patient regarding medication. [29] The search for prior expressions regarding medications includes both written and oral statements: The visitor shall gather pertinent information and present it to the court in written or oral form at the hearing. The information must include documentation of the following: (1) the patient's responses to a capacity assessment instrument administered at the request of the visitor; (2) any expressed wishes of the patient regarding medication, including wishes that may have been expressed in a power of attorney, a living will, an advance health care directive under AS 13.52, or oral statements of the patient, including conversations with relatives and friends that are significant persons in the patient's life as those conversations are remembered by the relatives and friends; oral statements of the patient should be accompanied by a description of the circumstances under which the patient made the statements, when possible.[ [30] ] Before authorizing psychotropic treatment, the court must hold a hearing and consider all relevant evidence presented by the petitioner, the respondent, and the visitor. [31] At the end of the hearing, the court may not authorize nonconsensual psychotropic medication if it finds that the patient is presently competent; in such cases, the court must honor the unwilling patient's wishes: If the court determines that the patient is competent to provide informed consent, the court shall order the facility to honor the patient's decision about the use of psychotropic medication.[ [32] ] But if the court finds that the patient is presently incapable of giving or withholding informed consent, and further determines that the patient was also incompetent at the time of any previously expressed wishes not to be medicated, then the statute directs that the court  shall  authorize treatment: If the court determines that the patient is not competent to provide informed consent and, by clear and convincing evidence, was not competent to provide informed consent at the time of previously expressed wishes documented under [the visitor's report], the court shall approve the facility's proposed use of psychotropic medication.[ [33] ] In short, once the court finds that the patient is presently incapable of consenting and has never before expressed medication-related wishes while competent, these provisions leave the court no discretion to consider a patient's best interests: the provisions require it to approve the treatment.