In the Matter of the Commitment of B.E. v. Health and Hospital Corporation d/b/a Sandra Eskenazi Mental Health Center (mem. dec.)

MEMORANDUM DECISION
Pursuant to Ind. Appellate Rule 65(D),
this Memorandum Decision shall not be FILED
regarded as precedent or cited before any Nov 12 2020, 8:53 am
court except for the purpose of establishing
CLERK
the defense of res judicata, collateral Indiana Supreme Court
Court of Appeals
estoppel, or the law of the case. and Tax Court
ATTORNEY FOR APPELLANT
Katelyn Bacon
Marion County Public Defender Agency
Indianapolis, Indiana
IN THE
COURT OF APPEALS OF INDIANA
In the Matter of the November 12, 2020
Commitment of Court of Appeals Case No.
20A-MH-1018
B.E.,
Appeal from the Marion Superior
Appellant-Respondent, Court
v. The Honorable Steven R.
Eichholtz, Judge
Health and Hospital Corporation The Honorable Kelly M. Scanlan,
d/b/a Sandra Eskenazi Mental Commissioner
Health Center, Trial Court Cause No.
49D08-2004-MH-13952
Appellee-Petitioner,
Robb, Judge.
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Case Summary and Issue
[1] B.E. appeals the trial court’s order for her involuntary temporary commitment
to Sandra Eskenazi Mental Health Center, contending there was insufficient
evidence that she was “gravely disabled” due to her mental illness. Concluding
sufficient evidence proved B.E. was gravely disabled, we affirm the
commitment order.
Facts and Procedural History
[2] B.E. is sixty years old and lives with her husband and son in a home they have
owned for twenty years. She is primarily dependent on her husband’s salary for
support. She has hypertension and Type 2 diabetes in addition to being
diagnosed in August 2018 with Bipolar I Disorder and is prescribed a variety of
medications for her conditions. On April 15, 2020, the Health and Hospital
Corporation of Marion County, doing business as Sandra Eskenazi Mental
Health Center (“Hospital”), filed a petition for the involuntary commitment of
B.E., alleging that B.E. suffered from a psychiatric disorder as a result of which
she was gravely disabled. Halimah Oral, M.D., filed a physician’s statement in
support of the petition stating that B.E. has Bipolar I Disorder with psychotic
features that substantially disturbs her thinking, feelings, or behavior and
impairs her ability to function in that “paranoid delusions . . . prevent her from
eating and taking medications for her chronic conditions[.]” Appellant’s
Appendix, Volume II at 16. Dr. Oral further opined that B.E. is gravely
disabled because of a substantial impairment or obvious deterioration in
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judgment, reasoning, or behavior that results in her inability to function
independently, as she “screams when people try to talk to her or runs away,
refuses medications for high blood pressure and diabetes, [and] refuses food[.]”
Id. at 17. Dr. Oral stated that, in her professional opinion, B.E. “is in need of
custody, care, or treatment in an appropriate facility.” Id. In 2018, B.E. had
been hospitalized “with a similar presentation[.]” Transcript, Volume II at 9.
[3] A commitment hearing was held on April 23, 2019. Dr. Oral was the only
witness for the Hospital; B.E. testified on her own behalf. Dr. Oral testified that
the circumstances of B.E.’s admission to the inpatient mental health unit on
April 13 were that she was paranoid, specifically about her husband “trying to
take her property and take control of her body”; had been having
hallucinations; and was becoming increasingly violent toward family members.
Id. at 7. Her speech and thought were erratic and irrational, and she was
unresponsive to questions. Upon admission, she stated she had not been taking
her medications, preferring “an herbal approach.” Id. She was initially very
aggressive toward staff and doctors, requiring “multiple as needed medications”
and intervention by security officers to restrain her on April 18. Id. On that
date, “her aggression rose to the point that . . . she had been defecating on
linens and throwing it [on] staff[.]” Id. After that incident, she became more
cooperative, but continued to refuse all but one medication and refused to speak
to Dr. Oral until the day before the hearing. Before the hearing, B.E. told Dr.
Oral that her husband would not come pick her up after the hearing and that
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she would need a sheriff to transport her home because a taxi might not be
taking appropriate COVID-19 precautions.
[4] Dr. Oral testified that for at least a week, B.E. had been exhibiting five core
features of a Bipolar I Disorder acute manic episode: irritability, grandiosity,
decreased sleep, talkativeness, and distractibility. Dr. Oral noted that Bipolar
Disorder is an episodic disorder and that even if B.E. does not take her
medications, “with time . . . we may have it resolved and go back to baseline.”
Id. at 9. However, without the medications, “[i]t just might be quite a long time
and she might do a lot of harm to her functioning and her family relationships
[and] her own self image in that time. And then she would be [at] an increased
risk . . . of having another episode.” Id. With proper medication management,
Dr. Oral thought B.E. could be discharged to outpatient care within as little as a
week. However, based on her interactions with B.E., Dr. Oral did not believe
that B.E. would voluntarily comply with the treatment plan and take her
medications on her own because she has no insight into her mental or physical
conditions, refusing to believe she “truly has these conditions to the severity
that she does.” Id. at 11. Dr. Oral testified B.E. was gravely disabled as a result
of her mental illness and was in danger of coming to harm because her
substantial impairment in judgment, reasoning, and behavior affects her ability
to function independently.
[5] B.E. disagreed with Dr. Oral’s assessment that she is unable to function on her
own, giving the example that she directs the money from her husband’s
paycheck to pay all the household bills and prepares their tax returns every
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year. She acknowledged that she refused to take the medications prescribed at
the Hospital but explained she would only take medications prescribed by her
primary care physician because “nobody else knows my complete medical
history.” Id. at 19. She testified that if discharged, she would be able to return
to her home, where she, her husband, and her son each have their own room,
but also testified that when she calls the home phone or her husband’s cell
phone, no one answers and the voice messages have been changed.
[6] At the conclusion of the hearing, the trial court made the following findings:
The court does find by clear and convincing evidence that [B.E.]
is suffering from mental illness, specifically Bipolar I Disorder,
manic episode. The court further finds that at this point in time,
[B.E.] is gravely disabled in that she is in danger of coming to
harm because she is demonstrating a substantial deterioration in
her judgment, reasoning and behavior that has resulted in her
inability to function independently at this time. The court bas[e]s
that on the testimony that we had this morning, including Dr.
Oral’s testimony that [B.E.] is at increased risk for additional
future episodes of mania if she is not being treated. That she has
been unable to sleep due to the high energy from her mania. She
is easily distracted not only at night but also during the day,
which Dr. Oral has observed. She is refusing psychiatric
treatment in the hospital and refusing even treatment for her
diabetes, which we presume when she is thinking a little more
rationally she understands the need for her own . . . health for her
diabetes to be treated and for her hypertension to be adequately
treated. . . . Her irritability and aggression make it difficult for
her to function not only in the hospital but also at home. And
she described some paranoid delusions regarding her husband
who is her sole provider. And we had her own testimony that he
is not answering the phone when she calls, although we do not
really know what the reason for that might be at this time. And
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so there is concern for a safe discharge plan as well if she is still in
— experiencing the manic episode untreated. And so for all
these reasons, the court is granting the order of temporary
commitment.
Id. at 21-22. The trial court’s written order determined that B.E. was in need of
custody, care, and treatment for a period not to exceed ninety days. B.E.
appeals the order of temporary commitment.
Discussion and Decision
I. Mootness
[7] When a court is unable to render effective relief to a party, the case is deemed
moot and usually dismissed. R.P. v. Optional Behavior MHS, 26 N.E.3d 1032,
1035 (Ind. Ct. App. 2015). “The long-standing rule in Indiana courts has been
that a case is deemed moot when no effective relief can be rendered to the
parties before the court.” T.W. v. St. Vincent Hosp. & Health Care Ctr., Inc., 121
N.E.3d 1039, 1042 (Ind. 2019) (quotation omitted). And although moot cases
are usually dismissed, our courts have recognized that a case may be decided on
its merits under an exception to the general rule when the case involves
questions of “great public interest[,]” typically involving issues that are likely to
recur. In re Commitment of J.B., 766 N.E.2d 795, 798 (Ind. Ct. App. 2002)
(quotation omitted). “The question of how persons subject to involuntary
commitment are treated by our trial courts is one of great importance to society.
Indiana statutory and case law affirm that the value and dignity of the
individual facing commitment or treatment is of great societal concern.” Id.
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[8] The trial court’s involuntary commitment order was issued on April 27, 2020
and was set to expire no more than ninety days later, or July 26, 2020. Thus,
B.E.’s period of temporary involuntary commitment has expired, as she
acknowledges. See Brief of the Appellant at 10. Nonetheless, B.E. contends we
may render meaningful relief to her because of the “potential harmful collateral
consequences of a civil commitment,” id., and asks that we not dismiss her
appeal as moot because we would be able to grant her meaningful relief.
[9] Although B.E. does not elaborate on what those collateral consequences are or
how a decision by this court now can help her avoid them,1 we will address her
case on the merits, especially considering the Hospital has not filed a brief in
opposition.2
II. Proof B.E. Was Gravely Disabled
[10] We will affirm a temporary commitment order if, “considering only the
probative evidence and the reasonable inferences supporting it, without
weighing evidence or assessing witness credibility, a reasonable trier of fact
could find [the necessary elements] proven by clear and convincing evidence.”
1
We have previously noted that “serious stigma and adverse social consequences” can accompany physical
confinement as a result of a civil commitment, Commitment of B.J. v. Eskenazi Hosp./Midtown CHMC, 67
N.E.3d 1034, 1038 (Ind. Ct. App. 2016), but B.E. does not specifically invoke those effects as reasons to
consider her appeal.
2
When the appellee does not file a brief, this court is not required to advance arguments on the appellee’s
behalf and may reverse if the appellant makes a case of prima facie error. Neal v. Austin, 20 N.E.3d 573, 575
(Ind. Ct. App. 2014). Prima facie error is error “at first sight, on first appearance, or on the face of it.” In re
Paternity of S.C., 966 N.E.2d 143, 148 (Ind. Ct. App. 2012), aff’d on reh’g, trans. denied.
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Civil Commitment of T.K. v. Dep’t of Veterans Affairs, 27 N.E.3d 271, 273 (Ind.
2015) (quotation omitted). The clear and convincing evidence standard is
defined as an intermediate standard of proof greater than a preponderance of
the evidence and less than proof beyond a reasonable doubt. T.D. v. Eskenazi
Health Midtown Cmty. Mental Health Ctr., 40 N.E.3d 507, 510 (Ind. Ct. App.
2015). In order to be clear and convincing, the existence of a fact must be
highly probable. Id.
[11] In Indiana, a person may be involuntarily committed if the petitioner proves by
clear and convincing evidence that “(1) the individual is mentally ill and either
dangerous or gravely disabled; and (2) detention or commitment of that
individual is appropriate.” Ind. Code § 12-26-2-5(e). Here, the trial court found
B.E. to be gravely disabled. Indiana Code section 12-7-2-96 defines “gravely
disabled” as:
a condition in which an individual, as a result of mental illness, is
in danger of coming to harm because the individual:
(1) is unable to provide for that individual’s food, clothing,
shelter, or other essential human needs; or
(2) has a substantial impairment or an obvious deterioration of
that individual’s judgment, reasoning, or behavior that results in
the individual’s inability to function independently.
[12] The trial court found that B.E. is suffering from a mental illness and is gravely
disabled. B.E. does not challenge the finding that she suffers from a mental
illness, but contends the Hospital did not present sufficient evidence that as a
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result of her mental illness, she was in danger of coming to harm because she
had a substantial impairment or obvious deterioration of her judgment,
reasoning, or behavior that resulted in her inability to function independently.
Therefore, she argues, the Hospital did not prove by clear and convincing
evidence that she was gravely disabled.3
[13] In support of her argument, B.E. notes that prior to her hospitalization, she was
“already receiving treatment, including medications, without a commitment
order.” Br. of the Appellant at 14. She took steps to eat healthy and exercise
and was self-quarantining to protect herself from COVID-19 exposure. All of
this may have been true prior to her hospitalization. But the record shows that
at the time of and during her hospitalization, she was not taking her medications,
refusing to eat, was not sleeping, and was relating poorly to her husband, who
was the primary source of her support. Moreover, she was physically and
verbally combative with Hospital staff and doctors during her stay.
[14] As B.E. states, denial of illness and refusal to medicate, standing alone, are
insufficient to establish grave disability because they do not establish, by clear
and convincing evidence, that such behavior “results in the individual’s
3
B.E. also contends the Hospital did not present sufficient evidence that as a result of her mental illness she
was in danger of coming to harm because she is unable to provide for her food, clothing, shelter, and other
essential needs. See Br. of the Appellant at 12-13; Ind. Code § 12-7-2-96(1). The trial court made no findings
regarding B.E.’s ability to provide for herself, but because the definition of gravely disabled is written in the
disjunctive, the trial court’s finding of grave disability may stand if we find sufficient evidence to prove that
B.E.’s judgment, reasoning, or behavior was impaired to the extent she could not function independently.
See Commitment of B.J., 67 N.E.3d at 1039.
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inability to function independently.” Civil Commitment of T.K., 27 N.E.3d at
276 (quoting Ind. Code § 12-7-2-96(2)); see also Br. of Appellant at 13-14. And
also as B.E. states, a commitment order may not be based on future
contingencies. Commitment of B.J., 67 N.E.3d at 1040; see also Br. of Appellant
at 14. But the testimony here goes beyond mere refusal to medicate and denial
of mental illness and is largely grounded in B.E.’s state at the time of the
hearing.
[15] Dr. Oral testified that B.E.’s manic episode was causing her to refuse
medications for her other conditions, including medication for high blood
pressure, which resulted in her blood pressure being “consistently elevated to
one eighties – two hundreds; levels that we would consider hypertensive
urgency or if there was evidence of any organ damage, hypertensive
emergency.” Tr., Vol. II at 11. She believed if she “was in a calm and
controlled environment her blood pressure and her diabetes would normalize.”
Id. She also refused to eat and was unable to sleep. All of this puts B.E. in
danger of coming to harm from a treatable health issue. Dr. Oral also testified
B.E.’s irritability and aggression “make it difficult [for her] to function at home
and on the unit.” Id. Her paranoid delusions about her husband “prevent her
from getting along with him[,] . . . her only support and source of income.” Id.
This puts her in danger of being without shelter or resources. And defecating in
her bed and throwing feces at Hospital staff demonstrates an obvious
deterioration in her judgment and behavior.
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[16] In other words, Dr. Oral’s testimony proves by clear and convincing evidence
that B.E. was not able to function independently and was in danger of coming
to harm as a result of her mental illness. See A.S. v. Ind. Univ. Health Bloomington
Hosp., 148 N.E.3d 1135, 1141 (Ind. Ct. App. 2020) (holding evidence that
patient was agitated, continued to display “very inappropriate[]” behavior
toward and around hospital staff, and made delusional statements was
sufficient to prove by clear and convincing evidence she was gravely disabled
due to her substantially impaired judgment); cf. In re Commitment of D.S., 109
N.E.3d 1056, 1061 (Ind. Ct. App. 2018) (holding where commitment was based
on denial of illness, refusal of medication, and a single isolated incident prior to
hospitalization, evidence was insufficient to support commitment).
Accordingly, the trial court did not err in finding B.E. was gravely disabled and
ordering her temporary commitment to the Hospital.
Conclusion
[17] We conclude the Hospital presented clear and convincing evidence supporting
the trial court’s temporary commitment order. Accordingly, the judgment of
the trial court is affirmed.
[18] Affirmed.
Crone, J., and Brown, J., concur.
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