People in Interest of D.N.W.

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.

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¶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

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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

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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]

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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

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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

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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

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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

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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.

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