The summaries of the Colorado Court of Appeals published opinions constitute no part of the opinion of the division but have been prepared by the division for the convenience of the reader. The summaries may not be cited or relied upon as they are not the official language of the division. Any discrepancy between the language in the summary and in the opinion should be resolved in favor of the language in the opinion.
SUMMARY December 26, 2024
2024COA129
No. 24CA1584, People in Interest of D.N.W. — Health and Welfare — Care and Treatment of Persons with Mental Health Disorders — Involuntary Administration of Medication
A division of this court considers whether a trial court can
mandate the involuntary administration of a “backup” medication.
The division concludes that, as a matter of first impression, a trial
court may indeed have the authority to permit the involuntary
administration of a backup medication, but under very limited
circumstances. COLORADO COURT OF APPEALS 2024COA129
Court of Appeals No. 24CA1584 City and County of Denver Probate Court No. 22MH229 Honorable Beth A. Tomerlin, Magistrate
The People of the State of Colorado,
Petitioner-Appellee,
In the Interest of D.N.W.,
Respondent-Appellant.
ORDER AFFIRMED
Division A Opinion by JUDGE BERGER* Román, C.J., and Hawthorne*, J., concur
Announced December 26, 2024
Kerry Tipper, City Attorney, Daniel B. Horwitz, Assistant City Attorney, Denver, Colorado, for Petitioner-Appellee
Richard Slosman, Boulder, Colorado, for Respondent-Appellant
*Sitting by assignment of the Chief Justice under provisions of Colo. Const. art. VI, § 5(3), and § 24-51-1105, C.R.S. 2024. ¶1 Respondent, D.N.W., appeals the probate court’s order
authorizing the involuntary administration of lithium. We affirm.
I. Background
¶2 D.N.W. was diagnosed with schizoaffective disorder, bipolar
type, and has a long history of psychiatric hospitalizations and
short- and long-term care certifications. Relevant to this appeal,
D.N.W. was certified for long-term care and treatment because she
was gravely disabled. The People filed a notice of extension of
long-term care and treatment and a motion seeking an order
authorizing the involuntary administration of Haldol, lithium,
Ativan, and Cogentin.
¶3 The probate court held a hearing on the motion and heard
testimony from D.N.W.’s psychiatrist, Dr. Charles Koransky. He
was the only witness at the hearing. Through counsel, D.N.W.
waived her presence at the hearing.
¶4 After considering testimony from Dr. Koransky, the court
granted the petition for extension of treatment and also ordered
that the requested medications be administered to D.N.W. against
her will.
1 ¶5 D.N.W. challenges on appeal only the court’s order to
involuntarily administer lithium. She does not challenge the court’s
extension of long-term care or the involuntary administration of
Haldol, Ativan, or Cogentin.
II. Involuntary Administration of Medication
¶6 A court may authorize the involuntary administration of
medications to a patient if the petitioner establishes by clear and
convincing evidence the four elements set forth in People v. Medina,
705 P.2d 961, 973 (Colo. 1985).
¶7 D.N.W. does not challenge the probate court’s findings on the
first, second, or fourth Medina elements related to the
administration of lithium. She does, however, challenge the
sufficiency of the evidence supporting the court’s findings as to the
third Medina element — that a less intrusive alternative is not
available. Reviewing the probate court’s conclusions of law de novo,
and the court’s findings of fact for clear error, People in Interest of
R.K.L., 2016 COA 84, ¶ 13, we reject her challenge.
¶8 The third Medina element requires the petitioner to prove by
clear and convincing evidence that a less intrusive treatment
alternative to the requested medication is unavailable. Medina, 705
2 P.2d at 973. “Under Medina, a ‘less intrusive alternative’
constitutes an available treatment that has less harmful side effects
and is at least as effective at alleviating a patient’s condition as the
proposed treatment.” People in Interest of Strodtman, 293 P.3d 123,
133 (Colo. App. 2011) (quoting Medina, 705 P.2d at 974). This
element “encompasses not only the gravity of any harmful effects
from the proposed treatment but also the existence, feasibility, and
efficacy of alternative methods of treating the patient’s condition or
of alleviating the danger created by that condition.” Medina, 705
P.2d at 974; see R.K.L., ¶ 37.
¶9 D.N.W. contends that there is a less drastic alternative to
lithium — the continued administration of Haldol — given that “she
is responding effectively to Haldol and has not needed to be
prescribed lithium in about nine months.” Further, D.N.W. asserts
that the lithium may have caused her serious side effects of
diarrhea and incontinence. Moreover, she asserts that lithium can
only be administered orally (while Haldol is an injectable), and that
Haldol will treat mania as “successfully” as lithium.
¶ 10 Regarding D.N.W.’s current need for lithium, Dr. Koransky
testified that D.N.W. needed lithium “if she were to become manic
3 and maybe didn’t meet the threshold for hospitalization to hopefully
get her out of the mania and to have more mood stability.” He
explained that, with her diagnosis, there can be and, critically,
there had been “flare-ups” of mania “related to stressors or just
unknown circumstances.” Dr. Koransky conceded that mania
“flare-ups” can be “hard to kind of predict.” But if left untreated,
mania would cause D.N.W. to decompensate and might require
rehospitalization. He further explained that, “[w]hen people are
manic, they can often engage in risky behaviors where they can do
things that can be harmful financially [or to] relationships,” and
sometimes there is a possibility of “increased aggression,” which
could “put [D.N.W.] at risk for harm or violence.”
¶ 11 As to D.N.W.’s concerns about the side effects of lithium,
including diarrhea and incontinence, Dr. Koransky testified that
D.N.W. responded well to lithium in the past. And while she
“attributed the diarrhea and incontinence to the lithium,” she had
since stopped taking lithium, and “there’s been no change” in these
symptoms “with or without the lithium.”
¶ 12 Crediting this testimony, the probate court found that “lithium
[was] currently needed” to “treat mania and [D.N.W.] ha[d]
4 responded well to the lithium in the past when she ha[d] become
manic.” The court also found that, “although [D.N.W.] is not
currently taking [lithium],” her “doctor need[ed] to have [lithium]
available to be able to treat her mania” because “it is hard to predict
when mania could occur and there is a risk of letting her mania go
untreated.” Moreover, the court found that, because D.N.W. “ha[d]
experienced mania in the past” and because of “the risks of having
mania go untreated,” there was “a current need” for lithium.
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The summaries of the Colorado Court of Appeals published opinions constitute no part of the opinion of the division but have been prepared by the division for the convenience of the reader. The summaries may not be cited or relied upon as they are not the official language of the division. Any discrepancy between the language in the summary and in the opinion should be resolved in favor of the language in the opinion.
SUMMARY December 26, 2024
2024COA129
No. 24CA1584, People in Interest of D.N.W. — Health and Welfare — Care and Treatment of Persons with Mental Health Disorders — Involuntary Administration of Medication
A division of this court considers whether a trial court can
mandate the involuntary administration of a “backup” medication.
The division concludes that, as a matter of first impression, a trial
court may indeed have the authority to permit the involuntary
administration of a backup medication, but under very limited
circumstances. COLORADO COURT OF APPEALS 2024COA129
Court of Appeals No. 24CA1584 City and County of Denver Probate Court No. 22MH229 Honorable Beth A. Tomerlin, Magistrate
The People of the State of Colorado,
Petitioner-Appellee,
In the Interest of D.N.W.,
Respondent-Appellant.
ORDER AFFIRMED
Division A Opinion by JUDGE BERGER* Román, C.J., and Hawthorne*, J., concur
Announced December 26, 2024
Kerry Tipper, City Attorney, Daniel B. Horwitz, Assistant City Attorney, Denver, Colorado, for Petitioner-Appellee
Richard Slosman, Boulder, Colorado, for Respondent-Appellant
*Sitting by assignment of the Chief Justice under provisions of Colo. Const. art. VI, § 5(3), and § 24-51-1105, C.R.S. 2024. ¶1 Respondent, D.N.W., appeals the probate court’s order
authorizing the involuntary administration of lithium. We affirm.
I. Background
¶2 D.N.W. was diagnosed with schizoaffective disorder, bipolar
type, and has a long history of psychiatric hospitalizations and
short- and long-term care certifications. Relevant to this appeal,
D.N.W. was certified for long-term care and treatment because she
was gravely disabled. The People filed a notice of extension of
long-term care and treatment and a motion seeking an order
authorizing the involuntary administration of Haldol, lithium,
Ativan, and Cogentin.
¶3 The probate court held a hearing on the motion and heard
testimony from D.N.W.’s psychiatrist, Dr. Charles Koransky. He
was the only witness at the hearing. Through counsel, D.N.W.
waived her presence at the hearing.
¶4 After considering testimony from Dr. Koransky, the court
granted the petition for extension of treatment and also ordered
that the requested medications be administered to D.N.W. against
her will.
1 ¶5 D.N.W. challenges on appeal only the court’s order to
involuntarily administer lithium. She does not challenge the court’s
extension of long-term care or the involuntary administration of
Haldol, Ativan, or Cogentin.
II. Involuntary Administration of Medication
¶6 A court may authorize the involuntary administration of
medications to a patient if the petitioner establishes by clear and
convincing evidence the four elements set forth in People v. Medina,
705 P.2d 961, 973 (Colo. 1985).
¶7 D.N.W. does not challenge the probate court’s findings on the
first, second, or fourth Medina elements related to the
administration of lithium. She does, however, challenge the
sufficiency of the evidence supporting the court’s findings as to the
third Medina element — that a less intrusive alternative is not
available. Reviewing the probate court’s conclusions of law de novo,
and the court’s findings of fact for clear error, People in Interest of
R.K.L., 2016 COA 84, ¶ 13, we reject her challenge.
¶8 The third Medina element requires the petitioner to prove by
clear and convincing evidence that a less intrusive treatment
alternative to the requested medication is unavailable. Medina, 705
2 P.2d at 973. “Under Medina, a ‘less intrusive alternative’
constitutes an available treatment that has less harmful side effects
and is at least as effective at alleviating a patient’s condition as the
proposed treatment.” People in Interest of Strodtman, 293 P.3d 123,
133 (Colo. App. 2011) (quoting Medina, 705 P.2d at 974). This
element “encompasses not only the gravity of any harmful effects
from the proposed treatment but also the existence, feasibility, and
efficacy of alternative methods of treating the patient’s condition or
of alleviating the danger created by that condition.” Medina, 705
P.2d at 974; see R.K.L., ¶ 37.
¶9 D.N.W. contends that there is a less drastic alternative to
lithium — the continued administration of Haldol — given that “she
is responding effectively to Haldol and has not needed to be
prescribed lithium in about nine months.” Further, D.N.W. asserts
that the lithium may have caused her serious side effects of
diarrhea and incontinence. Moreover, she asserts that lithium can
only be administered orally (while Haldol is an injectable), and that
Haldol will treat mania as “successfully” as lithium.
¶ 10 Regarding D.N.W.’s current need for lithium, Dr. Koransky
testified that D.N.W. needed lithium “if she were to become manic
3 and maybe didn’t meet the threshold for hospitalization to hopefully
get her out of the mania and to have more mood stability.” He
explained that, with her diagnosis, there can be and, critically,
there had been “flare-ups” of mania “related to stressors or just
unknown circumstances.” Dr. Koransky conceded that mania
“flare-ups” can be “hard to kind of predict.” But if left untreated,
mania would cause D.N.W. to decompensate and might require
rehospitalization. He further explained that, “[w]hen people are
manic, they can often engage in risky behaviors where they can do
things that can be harmful financially [or to] relationships,” and
sometimes there is a possibility of “increased aggression,” which
could “put [D.N.W.] at risk for harm or violence.”
¶ 11 As to D.N.W.’s concerns about the side effects of lithium,
including diarrhea and incontinence, Dr. Koransky testified that
D.N.W. responded well to lithium in the past. And while she
“attributed the diarrhea and incontinence to the lithium,” she had
since stopped taking lithium, and “there’s been no change” in these
symptoms “with or without the lithium.”
¶ 12 Crediting this testimony, the probate court found that “lithium
[was] currently needed” to “treat mania and [D.N.W.] ha[d]
4 responded well to the lithium in the past when she ha[d] become
manic.” The court also found that, “although [D.N.W.] is not
currently taking [lithium],” her “doctor need[ed] to have [lithium]
available to be able to treat her mania” because “it is hard to predict
when mania could occur and there is a risk of letting her mania go
untreated.” Moreover, the court found that, because D.N.W. “ha[d]
experienced mania in the past” and because of “the risks of having
mania go untreated,” there was “a current need” for lithium.
¶ 13 Viewing Dr. Koransky’s testimony in the light most favorable
to the People, we conclude the record supports the court’s findings.
See R.K.L., ¶ 13; see also People v. Pflugbeil, 834 P.2d 843, 847
(Colo. App. 1992).
¶ 14 A division of this court has addressed circumstances in which
a “backup” medication is inappropriate. But no Colorado published
opinion has addressed the converse — whether and, if so, under
what circumstances a court may order the involuntary
administration of a “backup” medication.
¶ 15 In People in Interest of R.C., 2019 COA 99M, ¶ 16, a division of
this court reversed an order for involuntary administration of a
backup medication. The division concluded that the People did not
5 satisfy the third Medina element as to the backup medications
because administering the primary medication, which would have
produced the desired effect, was a less intrusive treatment
alternative. Importantly, the treating physician testified that R.C.
did not need the backup medications at the time of the hearing and
“did not state unconditionally” that the patient would need to take
them in the future. Id. at ¶ 11 (emphasis added).
¶ 16 The R.C. division found support for its conclusion in R.K.L., in
which a division of this court concluded that “mere speculation”
that a patient “might need [the requested] medications in the
future” was insufficient to satisfy the fourth Medina element.
R.K.L., ¶ 44; R.C., ¶¶ 13-14. And while the division in R.C.
recognized that R.K.L. reached its conclusion in the context of the
fourth Medina element, it nevertheless agreed that the possibility
that a medication may no longer be an effective treatment “at some
unspecified time in the future” was insufficient to justify the entry
of an order authorizing the administration of additional
medications. R.C., ¶ 14.
¶ 17 But, as noted, neither R.K.L. nor R.C. addressed whether there
are any circumstances that justify an order for the involuntary
6 administration of a backup medication. Given the purposes of an
order for involuntary administration, as addressed in Medina, we
think the treating psychiatrist or institution must be given some
flexibility, under prescribed circumstances, to involuntarily
administer a backup medication. Otherwise, the purpose
underlying Medina’s holding would be frustrated. As stated in
Medina, “[t]he state clearly has a legitimate interest in effectively
treating the illnesses of those placed in its charge and, as well, in
protecting patients and others from dangerous and potentially
destructive conduct within the institution.” 705 P.2d at 971.
¶ 18 Considering the legitimate interests of the state, as well as the
patient’s right to “bodily integrity,” we hold that, under the facts of
this case, the court did not err by authorizing the involuntary
administration of a backup medication. Id. at 973. A court has the
authority to authorize the administration of a backup medication
only when the petitioner presents clear and convincing evidence,
and the court finds a specific articulable concern, that the
involuntary administration of the primary medication will be
ineffective, if the patient experiences a recurrence of a condition or
7 symptoms that previously required administration of the backup
medication.
¶ 19 We conclude that the People met this burden in this case. Dr.
Koransky’s testimony provided a specific and articulable concern
sufficient to justify the involuntary administration of lithium. Dr.
Koransky testified unequivocally that D.N.W. has a history of
experiencing mania and, in the not so distant past, required
treatment with lithium to treat these “flare-ups.” Dr. Koransky also
testified that, despite taking Haldol consistently, he expected that
D.N.W. would continue to experience mania “flare-ups” in the
future. Based on his testimony, Dr. Koransky was not seeking the
sort of court-approved backup plan the physician in R.C. sought
should Haldol prove inefficacious. Rather, Dr. Koransky sought
authorization to administer lithium based on a known and
potentially recurring situation particular to D.N.W. based on her
mental health history. The court found Dr. Koransky’s testimony
“uncontroverted and credible.”
¶ 20 Deferring to the court’s determinations of the witness’s
credibility and the weight afforded to his testimony, as we must, we
conclude that the record contains sufficient support for the court’s
8 finding as to the third Medina element. See id. at 974; see also
R.C., ¶ 7.
III. Disposition
¶ 21 The order is affirmed.
CHIEF JUDGE ROMÁN and JUDGE HAWTHORNE concur.