Opinion ID: 3170831
Heading Depth: 2
Heading Rank: 2

Heading: The Trial Court Applied the Incorrect Legal Test

Text: Â¶16Â Â Â Â Â Â Â We now turn to the trial courtâs application of Medina to this case. The trial court applied the incorrect legal test to conclude that it could order Marquardt to take the increased dose of Saphris. Specifically, it misapplied the second Medina factor by relying on evidence that Marquardt was not improving on the lower dose, rather than finding that he was deteriorating. Â¶17Â Â Â Â Â Â Â As noted above, a court may order a patient to accept medication when the physician or facility treating the patient shows by clear and convincing evidence: (1) that the patient is incompetent to participate in treatment decisions; (2) âthat treatment by antipsychotic medication is necessary to prevent a significant and likely long-term deterioration in the patientâs mental conditionâ or to prevent a patient from causing serious harm to himself or others; (3) that less intrusive treatment is not available; and (4) that the patientâs need for medication outweighs the patientâs interest in refusing treatment. Medina, 705 P.2d at 973. Only the second element is at issue in this case. Â¶18Â Â Â Â Â Â Â Under the second Medina element, the patient must be in danger of either a significant and likely long-term deterioration in his condition or of causing harm to himself or others. Id. Here, the trial court found that Marquardt was not a threat to the physical safety of himself or others. Rather, the trial courtâs order was based on the deterioration element. To determine whether a patient is in danger of long-term deterioration, the court should consider the patientâs need for the medication, including âthe nature and gravity of the patientâs illness, the extent to which the medication is essential to effective treatment, the prognosis without the medication, and whether the failure to medicate will be more harmful to the patient than any risks posed by the medication.â Id. Â¶19Â Â Â Â Â Â Â The People make two arguments that Marquardt was at risk of significant and likely long-term deterioration: (1) a risk of future deterioration may support a Medina order, and (2) Medinaâs full test for determining when a patient is at risk of significant and likely long-term deterioration allows a trial court to consider a patientâs lack of improvement on a lower medication dose. First, they argue that a possibility of futureÂ deterioration is sufficient to support a medication order under Medina. We disagree. Forcing patients to accept medication based on an abstract, future possibility would render their right to bodily integrity illusory. See Medina, 705 P.2d at 974. Â¶20Â Â Â Â Â Â Â In Medina, the court held that the State cannot order forced medication based solely on the patientâs past violent actions. Id. The Stateâs legitimate interest in institutional security is ânot sufficient to permit it to expose those committed to its care to the risk of antipsychotic medication solely for the purpose of alleviating the risk of some possibility of future injury or damage to the patient or others.â Id. Allowing the State to subdue patients based on pure speculation that a patient who was violent in the past may be violent again âwould be irreconcilable with the personal dignity of the individual and would render the patientâs interest in bodily integrity nothing more than an illusion.â Id. Â¶21Â Â Â Â Â Â Â This conceptâthat past violent actions do not create a presumption of future violenceâmay be applied to the deterioration element as well. A patientâs history of mental illness is insufficient to support an assumption that his condition will deteriorate further when he is, in fact, stable. Speculation that the patient might deteriorate in the future, even though he is presently stable, does not override the patientâs right to bodily integrity. See id. A patient who is stableâneither improving nor deterioratingâis not at risk of additional harm and, therefore, does not require the Stateâs protection from that speculative harm. See id. at 971â82. Therefore, the abstract possibility that a patientâs condition may deteriorate in the future is insufficient to support a Medina order. Â¶22Â Â Â Â Â Â Â Second, the People argue that the trial courtâs medication order was supported by Medinaâs full deterioration test, which includes several additional factors that the trial court should consider when determining if the patient is at risk of significant and likely long-term deterioration. The People argue that the court of appeals relied on a truncated version of the testâfocusing only on the word âdeteriorationââto overturn the order. See also Marquardt, Â¶Â¶ 23, 25 (Casebolt, J., dissenting in part). However the full deterioration test does not alter Medinaâs requirement that a patient be at risk of significant and likely long-term deterioration. Rather, these additional factors provide guidance that must be viewed through the lens of preventing deterioration. Â¶23Â Â Â Â Â Â Â The factors that make up the full test for determining whether a patient is at risk of a significant and likely long-term deterioration include: (1) the nature and gravity of the patientâs illness, (2) the extent to which the medication is essential to effective treatment, (3) the prognosis without treatment, and (4) whether the failure to medicate will be more harmful to the patient than any risks posed by the medication. Id. at Â¶Â¶ 24â25 (citing Medina, 705 P.2d at 973). All of these factors must be viewed in light of the testâs focusâpreventing deterioration. For example, the second factor addresses the extent to which the medication is essential to effective treatment. See Medina, 705 P.2d at 973. However, what may be considered effective treatment depends on whether the goal is stability or improvement. If the goal were improvement, then the likelihood that Marquardt would remain stable, without showing improvement, would suggest that the lower dose is not an effective treatment. However, because Medinaâs goal is preventing deterioration, the treatment is effective when the patient is stable. Â¶24Â Â Â Â Â Â Â With the goal of preventing deterioration in mind, the other factors also suggest that a stable patient does not meet the deterioration element. First, the court must consider the nature and gravity of the patientâs illness. Viewed in light of preventing deterioration, achieving and maintaining stability in a severely mentally ill patient is an achievement. Next, Medina instructs the trial court to consider the patientâs prognosis without treatment. See id. This factor hinges on the underlying assumption that the goal is stability, not improvement. If the focus were on improvement, Marquardtâs prognosis on a lower dose would be bleak. Because the focus is on preventing deterioration, however, Marquardtâs stable condition presents a favorable prognosis. A trial court must also weigh the risks of treatment against the risks of failing to treat the patient. See id. If the patient is stable on the current dose, then adhering to that dose will not cause additional harm. Therefore, if there is no harm in remaining at a lower dose, then this cannot outweigh the risks associated with increasing the dose. Thus, while these additional factors provide useful guidance to trial courts, they do not expand Medinaâs fundamental requirement that the medication must be necessary to prevent significant and likely long-term deterioration, nor do they allow a court to order a higher dose based on a patientâs lack of improvement. Â¶25Â Â Â Â Â Â Â In this case, the trial courtâs factual findings do not support its conclusion that Marquardtâs condition satisfied the second Medina element. The trial court found that there were âno recent incidents which would support the Court making any finding that he is in danger of causing serious harm to himself, or others in the Institution.â Thus, the trial courtâs finding that Marquardt could be forcibly medicated was basedÂ only on the risk of deterioration. However, the trial court found that âit doesnât appear that Mr. Marquardt is deteriorating.â Instead, it found that the higher dose of Saphris âwould increase the quality of his mental condition in a positive fashionâ and potentially lead to Marquardtâs release from the institution. 3 We defer to the trial courtâs factual findings that Marquardt was not deteriorating at the lower dose. We conclude, however, that the trial court erroneously based its order on the positive impact a higher dose of Saphris would have, rather than focusing on whether the higher dose would prevent further deterioration in Marquardtâs condition. Thus, the trial courtâs findings do not support its conclusion that the second Medina element was satisfied. Â¶26Â Â Â Â Â Â Â Therefore, because ordering involuntary medication under Medina must be based on preventing significant and likely long-term deterioration, not on the hope of improvement, we affirm the court of appealsâ holding that the trial court applied the incorrect legal test.