Respondent is presently a patient at the Central New York Psychiatric Center (CNYPC), following his transfer from Attica Correctional Facility on July 28, 2021. On or about August 7, 2021, Respondent voluntarily accepted intramuscular injections of Haldol, an antipsychotic medication. Even though Respondent has continued to receive such injections multiple times daily, on August 25, 2021, the Executive Director of CNYPC filed a petition to treat Respondent over his objection with oral Risperadone or intramuscular injections of Risperdal Consta. This Court reserved decision after the hearing concluded on September 1, 2021, based upon closing arguments by Respondent’s counsel. Counsel noted that while Respondent had rejected offers to take oral Risperdal, he had never been offered voluntary administration of Risperdal Consta.1 Counsel reasoned that because Respondent is accepting intramuscular injections of Haldol three times daily, he might accept an intramuscular injection of Risperdal Consta. Counsel further argued that any rejection of Risperdal Consta should be interpreted as an expressed preference for Haldol. Respondent declined to attend the hearing despite an opportunity to do so. As such, the Court instructed Respondent’s co-treating psychiatrist and sole witness, Dileep Borra, M.D., to approach Respondent personally to explain the benefits and risks of Risperidone and Risperdal Consta, as well as offer the opportunity to accept either medication. In the event of refusal, Dr. Borra was told to document Respondent’s reasons as to why so that the Court could evaluate whether Respondent was making a knowing — as opposed to a presumed — choice. In a subsequent affidavit sworn to by Dr. Borra, he indicated that he twice approached Respondent in the afternoon following the hearing to discuss the proposed treatment and alternatives. Dr. Borra noted that Respondent refused to engage. The doctor added that he previously attempted such a conversation on August 30, 2021, which Respondent also declined. Dr. Borra concluded, “In summary, [Respondent] was asked to discuss and consider oral or long-acting Risperdal multiple times. Each time, he refused to provide an answer and refused to explain his rationale for his refusal of the proposed treatments.” [Affidavit of Dileep Borra, M.D., sworn to Sept. 1, 2021]. Given the absence of any insight on the part of Respondent as to his thought processes, the Court will turn to the merits of the pending petition. To prevail, the hospital must have shown by clear and convincing evidence that (1) Respondent lacks the capacity to make a reasoned decision with respect to the proposed treatment; and (2) the proposed treatment is narrowly tailored to give substantive effect to Respondent’s liberty interest, taking into consideration all relevant circumstances. The fact that Respondent suffers from a mental illness and is being involuntarily committed does not constitute a sufficient basis to conclude he lacks the mental capacity to comprehend the consequences of his decision to refuse medication. (See generally Rivers v. Katz, 67 NY2d 485 [1986]; Harper v. Louis M., 196 AD3d 1086 [4th Dept 2021]). Dr. Borra testified that Respondent is diagnosed with Schizophrenia. He described Respondent’s symptoms to include hallucinations (e.g., talking to unseen persons), delusions (e.g., claiming that he owns the Brooklyn Bridge and once worked for the President of the United States), and disorganized behavior (e.g., urinating in his room, assaulting staff and lacking insight as to his need for treatment). Dr. Borra’s written report prepared in connection with the treatment-over-objection petition, and which is included in the patient chart admitted as Exhibit 1, sets forth a history of mental health treatment spanning approximately 30 years. Since his incarceration in December 1999, Respondent has been admitted to CNYPC on 11 occasions and been subject to four treatment-over-objection orders. Dr. Borra seeks to administer Risperdal or Risperdal Consta because Respondent has shown good effect when treated with these medications in the past. Dr. Borra stated that the multiple Haldol injections Respondent currently receives are not a medically sustainable course of treatment for several reasons. These doses of Haldol are effective for only a few hours. Dr. Borra explained that frequent administration of short-acting medications can cause tissue complications and increase the risk of infection. Indeed, on cross-examination, Dr. Borra pointed out that Respondent has complained of muscle soreness and thus receives injections alternatively in each arm so as to minimize tissue damage. Notes in the patient chart confirm Respondent’s complaints about soreness and a hindered ability to walk when the injections were first inserted in his gluteal region, followed by a change to administering the injections in his deltoid muscles. In addition to these physiological concerns, Dr. Borra ranks Haldol as his third choice for medication for reasons that relate to Respondent’s psychological health. The doctor prefers Risperdal because this medication is newer and has fewer side effects. Dr. Borra would like to transition Respondent to Risperdal Consta because it is long-acting, provides a “steady state” of medicine levels over time, and has been used to treat Respondent successfully in the past. If Respondent were to have an adverse reaction to Risperdal or Risperdal Consta, then Dr. Borra recommends a form of Invega because of its close relationship to Risperdal and the option for a long-acting injection with Invega Sustenna. Despite Respondent’s voluntary acquiescence to his daily Haldol injections, the Court finds he lacks capacity because nothing in the record suggests Respondent is making a reasoned choice about his mental health treatment. As Dr. Borra makes clear, efforts to engage Respondent in conversation about his treatment options are futile. Dr. Borra told the Court that when he asks Respondent why he would prefer to receive multiple injections each day, as opposed to one injection every two weeks, Respondent has no answer. Respondent rebuffs attempts to discuss various forms of medication, and he shows no understanding that he has taken Risperdal in the past and benefitted from the same. He has given no explanation as to why he will receive Haldol and no other type of medication. Notes in his patient chart simply describe him as rolling onto his stomach or laying prone on his bed when a nurse enters his room to give him a shot. Nor does Respondent appear to understand or acknowledge that he suffers from a mental illness requiring treatment with antipsychotic medication. He refused to meet with Dr. Borra for an evaluation on three separate occasions prior to the filing of the pending petition. He is not otherwise meeting with his treatment team providers in any meaningful way. Even after receiving the Haldol injections for several weeks, Respondent remains housed in the most closely-monitored acute care ward at the hospital. The totality of Respondent’s behaviors, including his refusal to attend the court hearing, leads the Court to conclude that he has no appreciation for his circumstances, no understanding of his mental health condition, and no ability to make a conscious choice about a course of treatment. As for the recommended course of treatment, Respondent’s counsel asked the Court to consider making Haldol the drug of first choice since Respondent has been given a “loading dose” for a long-term injectable form of the medication. The Court however, will not substitute its judgment for that of Dr. Borra or that of the reviewing physician in this case, Vanesa Disla, M.D., who authored an August 19, 2021 report in support of the petition and which is part of Respondent’s patient chart admitted into evidence. Both doctors recommend Risperdal or Risperdal Consta, despite knowledge of Respondent’s compliance with the Haldol injections. The Court credits Dr. Borra’s explanation at the hearing as to why he prefers Rispderal and Invega. Given Respondent’s history with Risperdal, Dr. Borra anticipates this medication will help reduce Respondent’s psychotic symptoms, which in turn will improve his thought process, reduce his risk of harm to self and others, and enable him to return to a less restrictive environment. Dr. Borra testified as to the potential side effects of the medication and confirmed that staff will monitor Respondent for any adverse reactions. Dr. Borra further testified that there is no less intrusive alternative treatment available which could be implemented with any degree of success. Based upon Petitioner’s proof, the Court will grant the relief as requested by Dr. Borra at the hearing and in his report. The Attorney General’s office is directed to upload a proposed order, after obtaining the consent of Respondent’s counsel as to form. In the meantime, it is hereby ORDERED that this Decision shall be sealed in the office of the Oneida County Clerk, and be exhibited only to the parties to the proceedings, or to someone properly interested, upon the Order of the Court. Dated: September 10, 2021
