Opinion ID: 721306
Heading Depth: 2
Heading Rank: 2

Heading: The Treatment Claims

Text: 60 We turn next to Kulak's claims regarding the treatment he received at Kings County and Kingsboro. In his second claim for relief, Kulak asserts that the administration of Haldol at Kings County violated his rights because he did not consent to medication and was not creating an emergency. In his sixth through twelfth claims for relief, Kulak contends that the district court erred in granting summary judgment because Dr. Stastny's expert affidavit establishes that several actions on the part of the Kingsboro physicians fell substantially below minimally acceptable practices. For the reasons discussed below, we find that the district court properly granted summary judgment to the Appellees on all of Kulak's treatment claims. 61 A. The Administration of Haldol at Kings County: It is a firmly established principle of the common law of New York that every individual 'of adult years and sound mind has a right to determine what shall be done with his own body' and to control the course of his medical treatment. Rivers v. Katz, 67 N.Y.2d 485, 492, 495 N.E.2d 337, 341, 504 N.Y.S.2d 74, 78 (1986) (citations omitted). Such a right may be set aside only in narrow circumstances, including those where the patient presents a danger to himself or other members of society or engages in dangerous or potentially destructive conduct within the institution. Rivers, 67 N.Y.2d at 495, 495 N.E.2d at 343, 504 N.Y.S.2d at 80; see Project Release v. Prevost, 722 F.2d 960, 978-80 (2d Cir.1983). In New York, this right to refuse medication derives from a mandatory policy expressed in N.Y. Comp.Codes R. & Regs., tit. 14, § 527.8(c)(1) (1995): 62 (c) Patients who object to any proposed medical treatment or procedure ... may not be treated over their objection except as follows: 63 (1) Emergency treatment. Facilities may give treatment, except electroconvulsive therapy, to any inpatient, regardless of admission status or objection, where the patient is presently dangerous and the proposed treatment is the most appropriate reasonably available means of reducing that dangerousness. Such treatment may continue only as long as necessary to prevent dangerous behavior. 64 A dangerous patient is defined as one who engages in conduct or is imminently likely to engage in conduct posing a risk of physical harm to himself or others. Id. at § 527.8(a)(4). 65 Kulak asserts that the involuntary administration of Haldol did not conform to the mandatory criteria of § 527.8 because he was not creating an emergency justifying involuntary medication. He claims that, at a minimum, issues of fact remain regarding whether Dr. Berkelhammer's decision to medicate was illegal. 66 In applying the § 527.8 criteria, we must accept Kulak's assertion that he acted calmly, though Dr. Berkelhammer claims that Kulak grabbed him in a threatening manner and was extremely irritable. Nevertheless, we find that Dr. Berkelhammer's decision to administer a low-level dose of Haldol was justified under § 527.8 because Kulak could be considered imminently likely to engage in conduct posing a risk of physical harm to himself or others. Kulak admits that he was extremely angry at [his] detention, and, when asked whether he wanted to hurt someone, he answered ambiguously, stating I'm angry. In addition to these statements, Dr. Berkelhammer reviewed the petition sworn to by Kulak's father, which indicated that Kulak had physically threatened members of his family and had threatened to kill himself. Dr. Berkelhammer's diagnosis of Kulak as suffering from bipolar disorder and anxiety was also confirmed by another staff psychiatrist. These factors taken together led Dr. Berkelhammer to conclude that Kulak should be medicated. 67 Dr. Stastny, Kulak's expert, stated that even if Dr. Berkelhammer's decision to administer drugs to control Kulak's behavior were correct, Dr. Berkelhammer could have administered only Ativan, an antianxiety drug, rather than combining Ativan with Haldol, a drug described by the Physicians Desk Reference as appropriate for treating psychosis, Tourette's Syndrome, and agitation in children and geriatric patients. Dr. Stastny's statement, however, does not create a genuine issue of material fact regarding whether Dr. Berkelhammer's behavior amounted to a failure to properly apply the § 527.8 guidelines; it simply suggests an alternate treatment option. 68 Given the factors examined by Dr. Berkelhammer and the admitted agitation of Kulak, we find that Dr. Berkelhammer's decision to medicate Kulak was a proper exercise of his professional judgment and comported with the requirements of § 527.8(c)(1). We therefore affirm the district court's grant of summary judgment to the Appellees on Kulak's second claim for relief. 69 B. The Treatment at Kingsboro: In his sixth through twelfth claims for relief, Kulak asserts that various treatment decisions by Dr. Cairme-Garcia and Dr. Castille while Kulak was confined at Kingsboro denied Kulak due process in violation of § 1983. Kulak claims that he was not provided dosage and side effect information, was not properly monitored, and was given drugs that were not indicated for his illness. Kulak contends that the district court erred in granting summary judgment to the Appellees on these claims because disputed issues of fact exist regarding whether these treatment decisions were constitutionally deficient. We disagree with Kulak and find that the district court properly granted summary judgment to the Appellees. 70 As the Supreme Court has instructed, a doctor will not be liable under § 1983 for the treatment decisions she makes unless such decisions are such a substantial departure from accepted judgment, practice, or standards as to demonstrate that [she] actually did not base the decision on such a judgment. Youngberg v. Romeo, 457 U.S. 307, 323, 102 S.Ct. 2452, 2462, 73 L.Ed.2d 28 (1982); P.C. v. McLaughlin, 913 F.2d 1033, 1042-43 (2d Cir.1990). This standard requires more than simple negligence on the part of the doctor but less than deliberate indifference. See Estate of Porter by Nelson v. Illinois, 36 F.3d 684, 688 (7th Cir.1994); Shaw by Strain v. Strackhouse, 920 F.2d 1135, 1143, 1144-47 (3d Cir.1990). 71 In an effort to defeat summary judgment, Kulak submitted two affidavits from his expert, Dr. Stastny. Dr. Stastny claimed that accepted professional judgment, practice, or standards encompass at the minimum a duty to medicate the patient with drugs appropriate to the patient's illness and susceptibility to side effects, and refrain from combining antipsychotic drugs such as Thorazine and Serentil in the usual course of a patient's treatment. Dr. Stastny asserted that the treatment decisions of Dr. Castille and Dr. Cairme-Garcia substantially departed from these accepted standards because the doctors medicated Kulak with antipsychotic drugs even though nothing in the hospital records indicated that he was psychotic, and administered the antipsychotic drug Thorazine to relieve side effects Kulak suffered from another antipsychotic drug, Serentil. 72 Dr. Stastny's affidavits, however, fail to raise a material issue regarding the treatment decisions of the Kingsboro physicians. Underlying Dr. Stastny's affidavits is his conclusion, based upon a review of the hospital records and a clinical evaluation of Kulak following his discharge from Kingsboro, that Kulak was not manic or psychotic at the time the contested treatment decisions were made. Working from this conclusion, Dr. Stastny determined that the decision to administer antipsychotic medication to Kulak fell below minimally acceptable practice. However, Dr. Stastny's differing diagnosis of Kulak does not create a fact issue because his affidavit does not assert that it was substantially below accepted professional judgment for the treating physicians to believe that Kulak was manic or psychotic. Dr. Stastny, therefore, simply disagreed with the diagnosis made by Dr. Castille and Dr. Cairme-Garcia. 73 Five doctors examined Kulak during the course of his hospitalization and each determined that Kulak was either manic or psychotic. 4 The Appellees' affidavits allege that Kulak made threatening statements to his family, patients, and staff, and exhibited delusions and paranoid ideation. A number of different people observed this behavior over the course of several days. 74 Dr. Stastny assumed that Kulak did not engage in any of the behavior cited by the Appellees because Kulak flatly denied having done so. In this respect, our case presents quite a different situation than one recently faced by this court in Rodriguez v. City of New York, 72 F.3d 1051 (2d Cir.1995), where the plaintiff brought an action under § 1983 claiming that her involuntary commitment to a mental institution violated the mandatory requirements of New York Mental Hygiene Law § 9.39. In Rodriguez, we decided that an expert affidavit asserting that the treating physicians made incorrect and objectively unreasonable decisions created an issue of fact for trial regarding whether the doctors acted within the realm of professional competence in treating the plaintiff. Id. at 1065. 75 The dispute in Rodriguez, however, concerned events in two short commitment interviews, lasting no more than one half hour combined, that took place after Rodriguez had come to the hospital seeking medication. Moreover, Rodriguez conceded that she had made some of the statements the doctors claimed to rely upon in confining her, but claimed that she also made related statements ignored by the doctors that would permit competing inferences to be drawn as to the meanings of the undisputed events. Rodriguez, 72 F.3d at 1064. In contrast, Kulak simply denies every allegation made by the Appellees without regard to the fact that he was observed for several days after being admitted pursuant to a petition by his father specifying Kulak's dangerous behavior. Nothing in Rodriguez purports to hold that bare denials of statements allegedly made by patients under such circumstances is enough to defeat summary judgment. Because the Kingsboro physicians medicated Kulak in a manner suitable to their diagnosis, they did not substantially depart from accepted practices. Kulak's claims regarding the medication decisions thus cannot be sustained. 76 Regarding Kulak's claim that Dr. Cairme-Garcia violated § 1983 by failing to administer a drug to block the side effects of Thorazine and by failing to monitor Kulak for adverse side effects, we note that Dr. Stastny asserted only that hospital personnel must either prescribe a side effect blocker or monitor the patient for side effects. The hospital staff did monitor Kulak, and thus a § 1983 claim on this basis cannot be sustained. 77 Dr. Stastny also stated that the failure to inform Kulak of dosage and side effects when administering Thorazine fell well below accepted practice because [i]t is a basic element of medical practice for a physician to provide all relevant information ... so that the patient may make an informed decision as to whether ... he wishes to accept the treatment regime offered. While Dr. Stastny's affidavit does appear to raise a question of fact on the issue of failure to inform, we nevertheless find that qualified immunity shields Dr. Cairme-Garcia and Dr. Castille from suit on this ground. 78 Qualified immunity will shield from suit a government official sued in his or her individual capacity unless the official's conduct violates clearly established law or such conduct was not objectively reasonable in light of the legal rules that were 'clearly established' at the time it was taken. Anderson v. Creighton, 483 U.S. 635, 639, 107 S.Ct. 3034, 3038, 97 L.Ed.2d 523 (1987) (citing Harlow v. Fitzgerald, 457 U.S. 800, 818, 102 S.Ct. 2727, 2738, 73 L.Ed.2d 396 (1982)); Allen v. Coughlin, 64 F.3d 77, 81 (2d Cir.1995). Here, the district court correctly held that the Kingsboro treating physicians are immune from liability because it would not have been objectively reasonable for them to have known that their conduct violated Kulak's constitutional rights. Though state law exists requiring physicians to inform patients of reasonably foreseeable risks associated with the administration of psychotropic medications such as Thorazine, see N.Y. Comp. Codes R. & Regs., tit. 14, § 527.8(b), nothing in the federal case law put the Kingsboro physicians on notice that their actions might subject them to § 1983 liability. No clear line of federal law establishes that it is a substantial departure from accepted practice for a physician to fail to inform a patient of the risks of psychotropic medications. See Weiss v. Missouri Dept. of Mental Health, 587 F.Supp. 1157, 1161 (E.D.Mo.1984) (finding no clearly established right to be informed of Thorazine's side effects); see also Washington, 494 U.S. at 231, 110 S.Ct. at 1042 (Though it cannot be doubted that the decision to medicate has societal and legal implications, the Constitution does not prohibit the State from permitting medical personnel to make the decision under fair procedural mechanisms.). Though Kulak may succeed on a state law cause of action for failure to inform, we find that the physicians are entitled to qualified immunity from this court on Kulak's § 1983 claim. 79 In sum, none of the decisions to medicate Kulak amounted to a substantial departure from accepted psychiatric practice. Though Dr. Castille and Dr. Cairme-Garcia's failure to inform Kulak of side effects and dosage may, according to Dr. Stastny's affidavit, have amounted to a substantial departure from accepted practice, the physicians are nevertheless shielded from suit by the doctrine of qualified immunity. Therefore, we affirm the grant of summary judgment to the Appellees on Kulak's sixth through twelfth claims for relief.