Guardianship of R.L.A.

NOTICE: Summary decisions issued by the Appeals Court pursuant to M.A.C. Rule
23.0, as appearing in 97 Mass. App. Ct. 1017 (2020) (formerly known as rule 1:28,
as amended by 73 Mass. App. Ct. 1001 [2009]), are primarily directed to the parties
and, therefore, may not fully address the facts of the case or the panel's
decisional rationale. Moreover, such decisions are not circulated to the entire
court and, therefore, represent only the views of the panel that decided the case.
A summary decision pursuant to rule 23.0 or rule 1:28 issued after February 25,
2008, may be cited for its persuasive value but, because of the limitations noted
above, not as binding precedent. See Chace v. Curran, 71 Mass. App. Ct. 258, 260
n.4 (2008).

COMMONWEALTH OF MASSACHUSETTS

APPEALS COURT

23-P-946

GUARDIANSHIP OF R.L.A.

MEMORANDUM AND ORDER PURSUANT TO RULE 23.0

After a trial, a judge of the Probate and Family Court

found the respondent, R.L.A., to be an incapacitated person, and

entered an amended decree and order pursuant to G. L. c. 190B,

§ 5-306 (b), appointing a guardian to, among other things,

monitor the administration of R.L.A.'s antipsychotic

medications. R.L.A. argues that the judge erred by authorizing

a treatment plan that allowed for the administration of

Thorazine, adopting ("wholesale") the petitioner's proposed

findings, and closing the court room during the proceedings. We

affirm.

Background. On August 27, 2021, R.L.A.'s mother

(petitioner) filed a petition for appointment of a guardian for

an incapacitated person in the Probate and Family Court. The

petitioner was appointed as temporary guardian on September 24,
2021. R.L.A.'s counsel filed an objection to the petition on

September 27, 2021.1

A guardianship trial was held on September 15 and 22, 2022.

At the time of trial, R.L.A. was forty-six years old. She had

been diagnosed with bipolar disorder with psychotic symptoms and

mania. She additionally suffered from psychotic delusions.

R.L.A. was prescribed and taking three antipsychotic

medications, one of which was Thorazine. R.L.A. did not want to

take the full dose of Thorazine because it upset her stomach.

At trial, the petitioner called one witness, Dr. Gyula

Bokor, an attending psychiatrist at the Taunton State Hospital.

Dr. Bokor explained that the low dose of Thorazine that R.L.A.

was taking was insufficient to "stabilize" her multiple

delusions and disorganized thinking.

Following the trial, the judge found that R.L.A. was an

incapacitated person. As a result, the judge entered a decree

of appointment of a guardian. The judge also adopted the

petitioner's proposed treatment plan with certain amendments.

1 On April 12, 2022, a judge of the District Court committed
the respondent to the Taunton State Hospital pursuant to G. L.
c. 123, § 16 (b). The court also authorized treatment with
antipsychotic medication pursuant to G. L. c. 123, § 8 (b).

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Discussion. 1. Substituted judgment treatment order and

"wholesale" adoption of judge's findings.2 To meet the standard

for appointment of a guardian and issuance of a substituted

treatment order, the petitioner was required to prove by a

preponderance of the evidence that R.L.A. was an "incapacitated

person" within the meaning of G. L. c. 190B, § 5-101 (9), and

that, if she were not incapacitated, R.L.A. would choose to be

treated by Thorazine. See Guardianship of A.R., 99 Mass. App.

Ct. 349, 353, 358 (2021); G. L. c. 190B, §§ 1-109 and 5-306A.

We review the judge's rulings for abuse of discretion or other

error of law. See Guardianship of Linda, 401 Mass. 783, 785-786

(1988). "[A] judge's discretionary decision constitutes an

abuse of discretion where we conclude the judge made a clear

error of judgment in weighing the factors relevant to the

decision, such that the decision falls outside the range of

reasonable alternatives" (quotation and citation omitted). L.L.

v. Commonwealth, 470 Mass. 169, 185 n.27 (2014).

2 The decree of guardianship was due to expire on September
15, 2023. The treatment plan challenged by R.L.A. had a review
and termination date of March 21, 2023. As the decree and order
in question expired more than a year ago and no updated decrees
or orders have been presented to us, R.L.A.'s appellate
challenges, even if otherwise properly presented, are moot. See
Guardianship of Erma, 459 Mass. 801, 804 (2011). Even if the
issues were not moot, there is no merit to R.L.A.'s argument
that the evidence was insufficient to establish that she was not
competent or that if competent, she would agree to be treated
with Thorazine.

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The evidence at trial was sufficient to establish R.L.A.'s

inability to make her own medical decisions. A patient may be

deemed "incompetent to make a medical decision" if they do "not

accept that [they] [are] mentally ill" or "cannot fairly weigh

the risks and benefits of treatment" (quotation omitted).

Guardianship of Roe, 411 Mass. 666, 669-670 (1992). At trial,

R.L.A. testified: "I don't consider myself deluded." Dr. Bokor

also testified that R.L.A. "doesn't want to take mood

stabilizers . . . because she said she doesn't need it[.]"

Based on this testimony, the judge properly concluded that

R.L.A. did not accept her diagnosis and therefore could not

determine for herself the risks and benefits of treatment.

R.L.A. argues that the evidence was insufficient to support

the judge's finding that, if not incapacitated, R.L.A. would

consent to the treatment with Thorazine. The relevant factors a

judge must consider in making a substituted judgment

determination include "(1) a person's expressed preferences; (2)

[her] religious convictions; (3) the impact on [her] family; (4)

the probability of adverse side effects from treatment; (5)

[her] prognosis with treatment; and (6) [her] prognosis without

treatment." Guardianship of A.R., 99 Mass. App. Ct. at 358.

See Guardianship of Roe, 383 Mass. 415, 444 (1981).

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In reviewing the judge's determination that R.L.A. would,

if not incapacitated, consent to treatment by antipsychotic

medication, "we must consider whether the facts on the record

support the proposition that [R.L.A.] [her]self would have made

the decision if [s]he were competent" (quotation and citation

omitted). Guardianship of Brandon, 424 Mass. 482, 488 (1997).

We accept the judge's findings of fact unless clearly erroneous,

but we review de novo the legal conclusions drawn from those

facts. See id.

The judge applied the factors set forth above in reaching

her conclusion that R.L.A., if not incapacitated, would consent

to taking the Thorazine. Dr. Bokor testified that the Thorazine

would aid R.L.A.'s disorganized thinking and delusions, but

since R.L.A. had not accepted more than a very low dose, she was

still having unusual thoughts, beliefs, and delusions.

R.L.A. complained to Dr. Bokor that Thorazine causes her to

feel sedated and have an upset stomach. Taking into

consideration R.L.A.'s concerns with Thorazine's side effects,

the judge amended the treatment plan by reducing the doctor's

requested dosage of Thorazine in half.

The judge further concluded that R.L.A.'s prognosis without

medication would be "[d]eterioration over time," whereas with

medication, R.L.A.'s delusions and mania would decrease.

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Accordingly, it was not an abuse of discretion to give greater

weight to evidence of the efficacy of Thorazine in treating

R.L.A's mental health or to determine that R.L.A. -- if

competent -- would choose a medication that lessened her

symptoms of psychosis. See Guardianship of Roe, 383 Mass. at

447-448 (accepting proposition that "the greater the likelihood"

of favorable prognosis, "the more likely an individual would be

to submit to intrusive treatment").

R.L.A. next argues that the judge's adoption of the

petitioner's findings of fact shows that she "did not pay close

attention to the evidence." This assertion is belied by the

record. There was testimony about R.L.A.'s opioid addiction and

inappropriate behaviors, and a statement that R.L.A.'s family

supported her treatment. In addition, there was expert

testimony that the medications were not properly managing

R.L.A.'s symptoms.3 Further, the treatment plan was entered in

evidence. Thus, the findings, albeit proposed by the

petitioner, were supported by the evidence. Consequently, there

was no error.

3 Testimony regarding the clinician's affidavit was not
pertinent to the issue before us, nor was the affidavit
presented to us for review whether there was any error as
suggested by R.L.A.

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2. Closing of the court room. R.L.A. contends that the

judge closed the court room for the guardianship trial, thus

violating her due process right to an open court room. As

stated infra, the issue of closing the court room is moot

because the decree and order before us have expired. There is

no claim by R.L.A. that the matter is an issue likely to repeat

itself.

However, even if her argument was properly before us, the

record provided does not make clear whether the court room was

completely "closed" for both days of trial or for what reason.

The record also does not provide evidence as to which party, if

any, requested that the court room be closed. The respondent

points to one portion of the transcript:

COUNSEL: "Your honor, may I use her name in this setting?"

THE COURT: "Yes, that's why we've closed the -- yes."

COUNSEL: "Thank you, your Honor."

While we could infer, arguendo, that the court room was at

least partially closed, it is unclear to what extent.

Additionally, R.L.A admits that there was no objection to

whatever type of closing occurred. As to the second day of

trial on September 22, 2022, simply because the matter was heard

via Zoom does not establish that the matter was closed to the

public -- others could have "attended" the proceedings by

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signing on to the appropriate Zoom meeting. In her findings of

fact and rulings of law, the judge made no mention of closing

the court room.

"Due process is not a technical conception with a fixed

content, but varies with context, and therefore is a flexible

concept that calls for such procedural protections as the

particular situation demands" (citation omitted). Vazquez Diaz

v. Commonwealth, 487 Mass. 336, 341 (2021). In the context of a

criminal case, "[a]n open court room 'enhances both the basic

fairness of the criminal trial and the appearance of fairness so

essential to public confidence in the system.'" Id. at 351,

quoting Commonwealth v. Cohen (No. 1), 456 Mass. 94, 107 (2010).

However, the right to a public trial is "not absolute" (citation

omitted). Commonwealth v. Jones, 472 Mass. 707, 723 (2015).

In a criminal matter, a judge may prevent some members of

the public from entry without violating the defendant's right to

an open court. See Commonwealth v. Maldonado, 466 Mass. 742,

748, cert. denied, 572 U.S. 1125 (2014). Not "every condition

placed on entry constitutes a constitutional closure of a court

room." Id. In that context, a defendant bears the burden of

proving that the public was in fact excluded from attending the

public proceeding. See Cohen (No. 1), 456 Mass. at 107.

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Assuming, without deciding, that R.L.A. has the same

burden, she has failed to produce sufficient evidence that the

public was excluded from the guardianship trial. Additionally,

R.L.A. did not raise the issue of the alleged closed court room

at trial. We discern no risk, let alone a substantial risk, of

a miscarriage of justice.

Amended decree and order
affirmed.

By the Court (Vuono, Neyman &
D'Angelo, JJ.4),

Clerk

Entered: October 9, 2024.

4 The panelists are listed in order of seniority.

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