Opinion ID: 625727
Heading Depth: 1
Heading Rank: 3

Heading: deliberate indifference of dr. rohrer

Text: The Estate contends that Dr. Rohrer knew that Rice required inpatient psychiatric care and was deliberately indifferent to Rice's need for such care in failing to obtain it for him. Rohrer knew that Rice's condition was declining: His notes reflect his knowledge of Rice's weight loss, Rice's refusal to take his medications, his unwillingness to communicate, and his otherwise psychotic behavior. On three separate occasions he petitioned for Rice's involuntary commitment to a psychiatric facility, observing on the third occasion in October 2004 that Rice was in peril of dying. Yet, after Dr. Ceniceros at Oaklawn returned Rice to the jail within twenty-four hours in the first two instances, concluding that Rice did not meet the criteria for involuntary commitment and likely was malingering, Rohrer simply acceded to Ceniceros' assessment and took no further action. In the third instance, Rohrer sought Rice's admission to a different facility (Elkhart General), which refused the admission in the mistaken belief that it did not have a contract with the jail to treat inmates. Rice was then taken to Goshen Hospital, where he was declared medically stable and returned to the jail after Ceniceros refused his admission to Oaklawn. When, two months later, Rice was found incompetent to stand trial, he was designated for admission to Logansport State Hospital, which put him on a waiting list. In the view of one of the defense experts, Dr. Daniel Scherb, there was a meritorious argument that Rohrer should have considered securing a court order authorizing Rice to be forcibly medicated and fed by means of a feeding tube. Although Scherb did not believe that Rice's refusal to eat and take medication factored into his death, he acknowledged the possibility that had Rice been medicated, he might not have experienced the psychogenic polydipsia that ultimately resulted in his death. Estate experts opined more affirmatively that had Rice been involuntarily medicated, he would not have died. Thus, in the Estate's view, Rohrer may be found liable for failing to prescribe an effective course of treatmentincluding involuntary admission to a psychiatric facility and/or forced medicationto prevent Rice's death. As with the Estate's claims against the CMS nurses and the jail's staff, the district court rejected this claim for want of proof that Rohrer was deliberately indifferent to Rice's condition. Again, the court emphasized that Rice's medical needs had not been ignored. 2009 WL 1748059, at . Rohrer, like the other medical defendants, was aware of Rice's schizophrenia and took steps to treat it: He visited Rice regularly, monitored his condition between visits, prescribed psychotropic medication subject to Rice's willingness to take it, and petitioned for his commitment to inpatient facilities on three separate occasions. Id., at . Although Rohrer saw Rice only once in late 2004 following Rice's return to the jail from Goshen Hospital, he did instruct the nurses to ask Rice weekly whether he would resume his medications; he knew that Rice was eating some food; and the Estate presented no evidence that any particular psychiatric care, other than forced medication, would have improved his medical condition. Id. Second, the court pointed out that Rice enjoyed both a right under Indiana statutory law to refuse medical treatment as well as a significant liberty interest recognized by the Supreme Court in Washington v. Harper, supra, 494 U.S. 210, 110 S.Ct. 1028, in avoiding unwanted anti-psychotic drugs. Id. Rice could not be forcibly medicated without affording him procedural protections, which among other things entailed a proof of an overriding justification for involuntary medication along with a finding that the drugs were medically appropriate. Id. Where, as in this case, a doctor's obligation to address his patient's serious medical needs conflicts with the patient's right to refuse treatment, the proper resolution of the conflict implicates the physician's medical judgment. Id., at -. Third, because Rice had not experienced compulsive water drinking prior to the night he died, his death as a result of psychogenic polydipsia, hyponatremia, and cardiac arrhythmia was not reasonably foreseeable to Rohrer. Id., at . Finally, assuming, consistent with the criticisms of Rice's care expressed by the Estate's experts, that Rohrer could have done more to treat Rice's schizophrenia, a jury still lacked any basis on which to find that Rohrer was guilty of deliberate indifference to Rice's serious medical needs. Id. We view it as a somewhat closer question than others whether Rohrer was entitled to summary judgment. In resolving the claims against the jail staff, we have stressed that they could justifiably rely on the judgment of the medical professionals, and we have similarly observed that the nurses were entitled to rely on the judgment of the physicians. Rohrer was the medical professional who was responsible for making decisions as to how Rice's schizophrenia should be treated. To the extent that Rice's condition demanded inpatient care, forced medication, or forced nutrition, Rohrer was the physician in a position to pursue such care on Rice's behalf. In fact, Rohrer did seek Rice's involuntary admission to Oaklawn for seventy-two hours for forced medication as well as observation on two occasions, only to have Ceniceros conclude that Rice was malingering and order him returned to the jail within twenty-four hours. Yet, it is undisputed that Rohrer had the ability to have Rice admitted to another facility, which is what he tried to do in October 2004, only to run into Elkhart General's mistaken belief that it had no contract with the jail and Ceniceros' refusal to admit him at Oaklawn when Dr. Mathew explored that possibility with him. The Estate contends that had Rohrer sought Rice's admission to another facility sooner than he did, or alternatively sought authority to medicate Rice involuntarily at the jail (assuming that was possible), then the odds of Rice engaging in compulsive water drinking, and experiencing the fatal complications of that polydipsia, might have been reduced, as Dr. Scherb theorized. Granting it the benefit of those inferences, the Estate has shown a plausible nexus between Rohrer's treatment decisions and Rice's death. But ultimately we agree with the district court that the Estate has made at most a case for negligence on the part of Dr. Rohrer. On this record, no reasonable factfinder could characterize Rohrer's treatment decisions as being deliberately indifferent to Rice's serious medical needs, or, put another way, that his decisions represented `such a substantial departure from accepted professional judgment, practice, or standards as to demonstrate that [he] actually did not base the decision[s] on such a judgment.' Collignon v. Milwaukee County, supra, 163 F.3d at 989 (quoting Youngberg v. Romeo, supra, 457 U.S. at 323, 102 S.Ct. at 2462); see also id. at 988-89 (discussing professional judgment standard as a variant of Eighth Amendment deliberate indifference standard and noting there is little difference between the two). As the district court rightly noted, Rice had a statutory and a constitutional right, provided he did not pose a danger to himself or others, to refuse the very medications that might have mitigated the symptoms of his schizophrenia and lessened the odds of him experiencing psychogenic polydipsia. See Harper, 494 U.S. at 221-22, 110 S.Ct. at 1036-37 (1990); Ind. Stat. XX-XX-X-X, XX-XX-X-X (formerly Ind. Stat. 16-14-1.6-7); In re Mental Commitment of M.P., 510 N.E.2d 645, 647-48 (Ind. 1987); see also Sanville v. McCaughtry, supra, 266 F.3d at 736. Rohrer was aware that Rice's unwillingness to take his prescribed anti-psychotic medications was adversely affecting his mental and physical health, and for that very reason he did try, on three separate occasions, to have Rice involuntarily committed for treatment. But as it turned out, Rohrer's colleague, Ceniceros, concluded that Rice was not psychotic and likely malingering and had him returned to the jail on the first two occasions and refused his admission outright in the third instance after Elkhart General turned Rice away and Goshen's Dr. Mathew spoke to him about the possibility of his admission to Oaklawn. Ceniceros, unlike Rohrer, was board-certified in psychiatry. Even if we assume that it was imprudent for Rohrer to accept Ceniceros' assessment, no evidence supports an inference that Rohrer was consciously disregarding a risk to Rice's well-being. Rohrer believed that involuntary, inpatient treatment was warranted, but his colleague found no need for it. By October 2004, when Rohrer concluded that Rice's life was in danger, it was obviously clear to Rohrer that medical intervention was required notwithstanding what Ceniceros may have thoughtthus Rohrer's decision to seek Rice's admission to a facility other than Oaklawn. Despite the failure of that effort, Rice was declared medically stable by the physicians at Goshen Hospital and returned to the jail with a directive that his diet be supplemented. After that, his weight loss, which was one of the major reasons Rohrer had sought his hospitalization, ceased. And once Rice was declared incompetent to stand trial in December, he was on a waiting list for admission to Logansport. Given the stabilization of Rice's weight, there is nothing in the record suggesting that Rohrer was aware of a serious risk to Rice's life, and certainly there was no warning that Rice might experience the psychogenic polydipsia that led to his death. We assume, as the district court did, that Rohrer and the other medical professionals at the jail could have done more generally to monitor Rice's condition and could have tried sooner and more forcefully to have his schizophrenia treated involuntarily. Perhaps a factfinder could find that Rohrer breached the duty of care he owed to Rice by failing to do more than he did to monitor and treat Rice's mental illness. Some of the gaps in time between Rohrer's visits to Rice, and in particular the fact that Rohrer only saw Rice once following his return to the jail in October 2004, are troubling given Rohrer's own concern that Rice's condition was declining. But the Estate has not shown how any such omissions harmed Rice, and we cannot characterize any omission on his part as deliberate indifference to Rice's medical needs. Earlier in this opinion, we expressed our doubts as to the district court's conclusion that Ceniceros did not qualify as a state actor. The district court never proceeded beyond that threshold question, but assuming that Ceniceros was a state actor, we believe that he would still be entitled to summary judgment on grounds similar to those we have just articulated as to Rohrer. Ceniceros was obviously much more removed from Rice's day-to-day condition than Rohrer was. Indeed, on the occasions that Ceniceros observed Rice firsthand, Rice behaved far differently than he did at the jail, which was what led Ceniceros to conclude that Rice was not in need of inpatient treatment and/or forced medication. But even if Ceniceros is charged with Rohrer's knowledge, the claim against Ceniceros is not strong enough to survive summary judgment. The best argument that can be made against Ceniceros is that, knowing of the concerns that twice led Rohrer to seek Rice's commitment to Oaklawn, he should not so hastily have discharged Rice from Oaklawn on the two occasions Rice was sent there, and he should not have refused Rice's admission in October 2004 when Dr. Mathew at Goshen consulted with him on the need for inpatient psychiatric care. Although we view this question too as closer than others in this case, given the nonpsychotic behavior that Rice had displayed at Oaklawn, we do not believe that a reasonable factfinder could conclude that Ceniceros was deliberately indifferent as opposed to negligent (at worst) in discounting the possibility that Rice was so seriously mentally ill as to need inpatient care and forcible medication. There is evidence that the malingering Ceniceros perceived itself could have been due to Rice's schizophrenia (Dr. Yoder, the Oaklawn psychologist who evaluated Rice's competency in April 2004, so opined), but there is no real dispute that Rice did exhibit signs of manipulative behavior, and whether this behavior was due to Rice's illness or simply to his desire to get out of jail was a matter on which reasonable professionals could (and did) disagree. That point aside, Ceniceros, like Rohrer, had no warning that Rice might experience compulsive water drinking, and therefore did not consciously disregard the circumstances that led to Rice's death.