A.S. v. LINCOLNHEALTH
Docket: Lin-20-117
MAINE SUPREME JUDICIAL COURT
January 28, 2021
2021 ME 6
GORMAN, J.
Argued: November 18, 2020. Panel: MEAD, GORMAN, HUMPHREY, HORTON, and CONNORS, JJ. Reporter of Decisions.
[¶1] On February 24, 2020, law enforcement officers brought A.S. to the LincolnHealth Miles Hospital Campus in Damariscotta, and he was held in the emergency department of that hospital for the next thirty days. At no time during that period did LincolnHealth seek or obtain judicial endorsement of its detention of A.S., as required by
I. BACKGROUND
[¶2] On March 13, 2020, A.S. filed a petition for a writ of habeas corpus in the Superior Court (Lincoln County), seeking to be released from the LincolnHealth emergency department. See
[¶3] Before any evidence was presented, A.S. requested judgment on the stipulated record, arguing that LincolnHealth‘s restraint of him was unlawful and that the appropriate remedy was his release. The court (Billings, J.) denied A.S.‘s request, explaining,
[E]ven if I was in complete agreement with [A.S.‘s] legal argument, I think the proper thing for the Court to do is to consider evidence from [LincolnHealth] in regards to whether or not is it appropriate, even if [A.S.] is correct legally—if it is appropriate when considering the equities for the Court to issue the extraordinary writ.
[¶4] A.S. objected to the hearing process, noting that the court was “about to have [an] involuntary commitment hearing without the protections that the statute provide[s].” The court overruled the objection and allowed LincolnHealth to present a series of witnesses. Among LincolnHealth‘s witnesses were its medical director, who explained the process that the hospital had used to find a psychiatric bed for A.S. and the actions that it took while it held A.S. in its emergency department; the vice president of medical affairs for Maine Behavioral Healthcare, who explained Maine Behavioral Healthcare‘s role in trying to find placements for psychiatric patients; and the
[¶5] At the close of LincolnHealth‘s presentation, A.S. moved for judgment as a matter of law based on the uncontradicted evidence that, at no time during the days it held A.S. had LincolnHealth complied with
The hope here and the . . . full intentions of the hospital are to get [A.S.] a placement and to have that occur as soon as possible, at which point due process protections of the involuntary hospitalization statute will kick into full effect, where the hospital that accepts him would have to determine, I think within 72 hours, if he requires continued treatment, at which point a White paper application would be made and . . . he would have a protective custody hearing within, I think, a two-week period.
But . . . unfortunately . . . for [A.S.‘s] protection and the protection of the community, he needs to be held in . . . custody until an appropriate hospital placement can be . . . identified.
(Emphasis added.) LincolnHealth acknowledged there was no “court authority” supporting its interpretation of section 3863 but told the court that this “practice . . . has been occurring for . . . for several years . . . without any licensing violations being issued by [the] Department of Health and Human Services or any other entity objecting to this practice.”
[¶6] Although noting that it was “quite striking that in this case, [A.S.] has been hospitalized . . . until this hearing . . . [with] no court proceeding,” the court nonetheless denied A.S.‘s motion for judgment as a matter of law.
[¶7] At the conclusion of the hearing, after hearing testimony from A.S., the court denied A.S.‘s habeas petition. Without directly addressing section 3863‘s requirement that a hospital obtain judicial authorization for any emergency involuntary hospitalization, the court concluded that the section 3863 process “can be reset every 48 hours, based upon a new Blue Paper being completed based upon a new evaluation by a physician.” In addition, the court concluded that “the proper standard” for adjudicating a habeas petition pursuant to section 3804 “is whether as of now, an application for emergency involuntary admission to a psychiatric hospital could be granted, and basically whether the Blue Paper criteria could be met.” The court then found that “the Blue Paper standard could be met and has been met by the evidence.” The court did not explicitly state what evidentiary standard it applied in making that finding, but the record makes clear that the court rejected A.S.‘s argument that a heightened standard should apply. Instead, the court applied a standard different from the standard of clear and convincing evidence that would apply in an involuntary commitment hearing. See
II. DISCUSSION
A. Mootness
[¶8] The record in this case demonstrates that A.S. was discharged from LincolnHealth on March 25, 2020—after he spent a total of thirty days in LincolnHealth‘s emergency department—and is currently residing with a relative out of state.1 Because A.S. was discharged from LincolnHealth while this appeal was pending, there is no real or effective relief we can provide to him. This absence of controversial vitality renders his appeal moot. See In re Christopher H., 2011 ME 13, ¶ 11, 12 A.3d 64. Generally, we decline to hear an appeal when the issues are moot, but, “we will address the merits where: (1) [s]ufficient collateral consequences will result from the determination of the questions presented so as to justify relief; (2) there exist ‘questions of great
[¶9] The public interest exception and the repeat presentation exception to the mootness doctrine both apply here. When confronted with cases regarding involuntary emergency hospitalization or commitment, we have consistently determined the issues to be of great public concern and applied the public interest exception to the mootness doctrine.2 See, e.g., In re Marcia E., 2012 ME 139, ¶ 4 n.1, 58 A.3d 1115; In re Christopher H., 2011 ME 13, ¶ 12, 12 A.3d 64; In re Walter R., 2004 ME 77, ¶ 9, 850 A.2d 346. We find that the same interests support review in this case. In addition, because the process used by LincolnHealth is apparently used frequently by Maine‘s nonpsychiatric hospitals when those hospitals are forced to “board” psychiatric patients, we specifically determine that the hospitals and the courts dealing with those hospitals are in need of guidance in this area.3
B. Standard of Review
[¶11] As an initial matter, we must determine the standard of review applicable to our review of a trial court‘s adjudication of a “civil” habeas petition, i.e., a habeas petition that seeks release for a “nonprisoner” detainee.
[¶13] In criminal habeas cases, we have typically applied a de novo-like standard to the legal, constitutional, and statutory interpretation issues underlying a habeas decision. See In re Holbrook, 133 Me. 276, 276-77, 177 A. 418, 418-19 (1935); Stern v. Chandler, 153 Me. 62, 74, 134 A.2d 550, 556 (1957).
[¶14] After considering our criminal habeas precedents and the decisions of other jurisdictions on civil habeas petitions, we announce that we will apply the standard of abuse of discretion when reviewing decisions to grant or deny petitions for writs of habeas corpus requesting release of nonprisoner detainees. Here, therefore, we review the trial court‘s denial of A.S.‘s habeas petition by reviewing its legal conclusions de novo, its factual findings for clear error, and its ultimate determination for abuse of discretion.
C. Application of Section 3863
[¶15] At the crux of this appeal is a dispute regarding the interpretation of section 3863, which allows for involuntary emergency admission to a psychiatric hospital when there is a concern that an individual poses a likelihood of serious harm to himself or other persons because of a mental
[¶16] We begin by noting that section 3863 is an imprecise “fit” for what is actually happening in Maine‘s emergency departments as they struggle to deal with patients who need psychiatric beds at a time when the State has failed to create or fund enough of those beds. Nonetheless, we must review the language of the statute, as it is the only statute that provides a hospital with any authority to hold a person who may be dangerous as a result of a mental illness. Section 3863 is also one of a very limited number of statutes that provides the civil authority for a person or entity to hold another person against his wishes.4
[¶17] A.S. argues that LincolnHealth exceeded its authority to detain him pursuant to section 3863 in two ways: (1) by failing to submit any applications for involuntary admission for judicial review, and (2) by detaining him for longer than 120 hours, with or without such authorization. LincolnHealth, on the other hand, argues that its repeated completion of the first two steps in the blue paper process—the filling out of an application, see
[¶18] Section 3863 begins with the following language: “A person may be admitted to a psychiatric hospital on an emergency basis according to the following procedures.” It goes on to state that an emergency involuntary hospitalization requires the completion of three steps: (1) a “health officer, law enforcement officer or other person” must complete an application seeking the emergency admission, (2) a medical practitioner must examine the individual the applicant is seeking to admit and then complete and sign a certificate supporting the application, and (3) a judicial officer must review and endorse
[¶19] The statute also establishes a very limited duration for which a person can be held for admission without the judicial endorsement required by section 3863(3).
A person may not be held against the person‘s will in a hospital under this section, except that a person for whom an examiner has executed the certificate under [section 3863(2)] may be detained in a hospital for a reasonable period of time, not to exceed 24 hours, pending endorsement by a judge or justice, if . . . the person or persons seeking the involuntary admission undertake to secure the endorsement immediately upon execution of the certificate by the examiner.
Eight years ago, in In re Marcia E., 2012 ME 139, ¶ 6 & n.3, 58 A.3d 1115, we interpreted this language and held that “[u]nder no circumstances may a hospital hold a person against his or her will for longer than twenty-four hours unless the hospital has obtained a judge‘s endorsement.” (citing
[¶20] Three years after we issued that decision, in response to concerns that, due to Maine‘s severe shortage of psychiatric beds, section 3863(3)(B)‘s emergency twenty-four-hour hold provided insufficient time for a nonpsychiatric hospital to locate a psychiatric bed for a patient in crisis, paragraphs (D) and (E) of section 3863(3) were enacted. See P.L. 2015, ch. 309,
[¶21] Because the 2015 amendments did not change the language of section 3863(3)(B)(2), hospitals seeking to hold or detain persons for placement into psychiatric hospitals must still obtain judicial authorization for their actions within the first twenty-four hours that the patient is detained. What was changed by the 2015 amendments, however, is the duration of the detention that such a judicial endorsement allows. The unambiguous language of the 2015 amendments permits a hospital that obtained judicial endorsement for a patient‘s detention during the “original” twenty-four-hour period of detention to continue to hold that individual for two additional forty-eight-hour periods if the hospital complies with certain requirements. See
- [t]he hospital has had an evaluation of the person conducted by an appropriately designated individual and that evaluation concludes that the person poses a likelihood of serious harm due to mental illness;
- [t]he hospital, after undertaking its best efforts, has been unable to locate an available inpatient bed at a psychiatric hospital or other appropriate alternative; and
- [t]he hospital has notified the department of the name of the person, the location of the person, the name of the appropriately designated individual who conducted the evaluation pursuant to subparagraph (1) and the time the person first presented to the hospital.
And, if that individual remains in the hospital for the entire forty-eight-hour period permitted by section 3863(3)(D), the individual may be held for an additional forty-eight-hour period if the hospital again satisfies the requirements of section 3863(3)(D), and “[t]he department provides its best efforts to find an inpatient bed at a psychiatric hospital or other appropriate alternative.”
[¶22] As mentioned above, in explaining its decision not to seek any judicial endorsement of its medical determination that A.S. should be held, LincolnHealth asserted that, because it was unable to identify a psychiatric placement for A.S., it was unable to seek judicial approval. Although that
[¶23] As LincolnHealth correctly explained during the hearing before the Superior Court, pursuant to the process created by section 3863, when a hospital is able to find a psychiatric placement for an individual, and a judge
[¶24] As acknowledged by LincolnHealth, this process does “kick into full effect” at the time that an individual is admitted to a psychiatric hospital. LincolnHealth‘s argument that there is simply no due process for those held by but not admitted to hospitals, however, is not supported by the language of the statute or by our case law. In addition, we cannot accept the premise that, when it created two additional forty-eight-hour periods through sections 3863(3)(D) and (E), but did not change the language of section 3863(3)(B)(2), the Legislature intended to allow individuals to be held in emergency departments
[¶25] Our interpretation of the plain language of the statute, however, does not mean that LincolnHealth was required to either discharge A.S. or transfer him to a psychiatric hospital at the end of the first 120-hour period. If the patient cannot be safely released after the entire 120-hour authorized hold period has lapsed and if there is still no psychiatric bed available, the hospital may “restart” the process. See
D. Availability of Habeas Relief
[¶26] LincolnHealth argues that, even if A.S.‘s detention was unauthorized because the hospital did not comply with section 3863, the court acted appropriately in denying A.S.‘s request for release based on its determination, by a preponderance of the evidence, that A.S. posed a likelihood of serious harm that justified his continued detention at the time of the hearing.
[¶27] Pursuant to
[¶28] The rule that we explained in Sleeper is in line with our habeas corpus jurisprudence and its focus on an equitable and flexible approach, tailored to the circumstances surrounding the habeas petition. In Sleeper, we explained that release is not always required even if it is “found that the original commitment was illegal.” Id., 87 A.2d at 121. We also drew a parallel to cases involving a parent‘s habeas petition on behalf of a minor child, noting that “[i]t is the welfare of the child, not the strict legal right of the petitioner[,] upon which ultimate judgment is founded.” Id., 87 A.2d at 121.
[¶29] Here, the court appears to have applied a Sleeper-like standard—focusing on our guidance that the availability of habeas relief in this context does not turn solely on “the strict legality of [the] restraint.” Id., 87 A.2d at 121. The court, however, mistakenly used that guidance—and its concern that releasing A.S. would be contrary to his own health and possibly to the safety of himself and the community—to shape its interpretation of section 3863 and
[¶30] A court facing a similar situation in the future—having to balance an individual‘s liberty interests and his right to due process with concerns about his safety and the safety of the community—should understand that it has the ability to tailor any relief to effectively balance these competing interests. For example, a court could tell the parties that it is granting the habeas petition but that it will stay for twenty-four hours the issuance of the mandate ordering release to allow the hospital to seek, through an application for involuntary admission, judicial endorsement of the patient‘s continued detention.
[¶31] Finally, A.S. argues that the court violated his due process rights7 when the court applied the standard of preponderance of the evidence, rather than clear and convincing evidence, to reach the determination that he posed a likelihood of serious harm to himself or others. “We review de novo whether an individual was afforded procedural due process.” In re Adden B., 2016 ME 113, ¶ 7, 144 A.3d 1158.8
[¶32] Again we reiterate that “civil commitment for any purpose constitutes a significant deprivation of liberty that requires due process protection.” Addington, 441 U.S. at 425. “Due process is a flexible concept that typically requires consideration of a number of factors, including the importance of the individual‘s interest, the potential for governmental error, and the magnitude of the state‘s interest.” Mahaney v. State, 610 A.2d 738, 742 (Me. 1992); see also Mathews v. Eldridge, 424 U.S. 319, 334-35 (1976). “The purpose of the assigned standard of proof is to instruct the factfinder
[¶33] In Addington, the United States Supreme Court held that an “individual‘s interest in the outcome of a civil commitment proceeding is of such weight and gravity that due process requires the state to justify confinement by” clear and convincing evidence. 441 U.S. at 427.
[¶34] As directed by Addington and our own statute,
- [c]lear and convincing evidence that the person is mentally ill and that the person‘s recent actions and behavior demonstrate that the person‘s illness poses a likelihood of serious harm;
- [t]hat adequate community resources for care and treatment of the person‘s mental illness are unavailable;
- [t]hat inpatient hospitalization is the best available means for treatment of the patient; and
- [t]hat it is satisfied with the individual treatment plan offered by the psychiatric hospital to which the applicant seeks the patient‘s involuntary commitment.
[¶35] The immediately identifiable problem with LincolnHealth‘s argument is the length of time it detained A.S.—twenty-five days at the time of the habeas hearing. Although a
[¶36] In determining whether this extended detention—despite its lack of any judicial authorization—should be permitted to continue, the court should have applied the standard of clear and convincing evidence. Therefore, we conclude that A.S.‘s due process rights were violated when the court applied a standard of preponderance of the evidence, rather than clear and convincing evidence, to determine whether he posed a likelihood of serious harm at the time of the habeas hearing. See Addington, 441 U.S. at 425-27.9
III. SUMMARY
[¶37] In summary, when a hospital determines that a person meets the requirements of
[¶38] Because LincolnHealth did not obtain any judicial endorsement of its detention of A.S., that detention was unlawful, and the court erred when it determined that the detention was lawful. The court should have determined that the detention was not lawful pursuant to section 3863(3) and then determined what remedy was appropriate. Finally, because as of the time of the hearing the detention had already lasted twenty-five days, in determining the appropriate remedy and considering whether to release A.S., the court should have decided whether the hospital had established, by clear and convincing evidence, that A.S. needed further hospitalization.
Judgment vacated.
Meegan J. Burbank, Esq. (orally), Berry & Burbank, Boothbay Harbor, for appellant A.S.
James P. Bailinson, Esq. (orally), and Michelle Bush, Esq., MaineHealth, Portland, for appellee LincolnHealth
Steven L. Johnson, Esq. (orally), and Taylor D. Fawns, Esq., Kozak & Gayer, P.A., Augusta, for amicus curiae Maine Hospital Association
Emma E. Bond, Esq. (orally), and Zachary L. Heiden, Esq., American Civil Liberties Union of Maine Foundation, for amicus curiae American Civil Liberties Union of Maine Foundation
Aaron M. Frey, Attorney General, and Molly Moynihan, Asst. Atty. Gen. (orally), Office of the Attorney General, Augusta, for amicus curiae Department of Health and Human Services
Lincoln County Superior Court docket number CV-2020-10
FOR CLERK REFERENCE ONLY
Notes
We note, however, that the statute‘s language—rather than forms created by the Department—direct and control the actions of the hospital.[T]his form was last updated in 2014 and does not properly reflect the statutory requirements. Given this fact, as well as the need for clarity amongst all parties involved in the emergency involuntary commitment process, the Department recognizes that this form should be updated. . . . Amendments to the form may include, for example, an option to indicate whether the hospital has identified an available bed for the detained individual for whom involuntary admission to a psychiatric hospital is being sought. This would resolve the concern of having a judicial officer endorse the “Blue Paper” without being able to then “promptly send” the form to the admitting hospital. . . . Similarly, the form may include a representation by the hospital that it will notify the judicial officer as soon as an inpatient psychiatric hospital is identified. Consistent with the Commissioner‘s discretionary authority, the form may also provide updated instructions in accordance with the current statutory requirements.