| New York City Health & Hosps. Corp. v Brian H. |
| 2008 NY Slip Op 04135 [51 AD3d 412] |
| May 1, 2008 |
| Appellate Division, First Department |
| New York City Health and Hospitals Corp.,Appellant, v Brian H., a Patient Admitted to Jacobi Medical Center,Respondent. |
—[*1] Marvin Bernstein, New York (Namita Gupta of counsel), for respondent.
Order, Supreme Court, Bronx County (Lucy Billings, J.), entered August 29, 2007, which,after a hearing pursuant to Mental Hygiene Law § 9.31, directed respondent's release fromJacobi Medical Center (JMC), unanimously reversed, on the facts, without costs, and the petitionfor an order retaining respondent for involuntary care and treatment in said hospital granted.
Respondent was admitted to JMC on July 9, 2007, five days after an M-80 firecrackerexploded in his hands, causing severe injuries. Doctors were forced to amputate his left hand andthree fingers on his right hand on July 11, because of potentially fatal infection. The need toamputate was partially due to respondent's delay in seeking medical attention. Two days after thesurgery, respondent left the hospital, against medical advice. He was later returned by the police.
On July 17, 2007, respondent was admitted to the psychiatric unit of JMC on an emergencybasis pursuant to Mental Hygiene Law § 9.39. Two medical certifications supported theadmission. The first, by a physician, described respondent and his immediate medical history asfollows: "Mr. H[ ] is a 48 year old single male with long psychiatric history and history ofmultiple admissions. He was brought to ER by police when found wandering the street with handinjury sustained from firecracker. Patient is delusional and incoherent. He was treated andstabilized surgically before being transferred to Psychiatry for being dangerous to self due topsychosis."
The second certification, by a member of the psychiatric staff, noted that respondent had a"history of bipolar disorder and multiple admissions," and that he appeared "[d]isheveled,unkempt, disorganized in thoughts process and behavior." It described his speech as "pressured,circumstantial with flight of ideas," and his affect as "angry, inappropriate." The certificationfurther described respondent as "guarded, irritably manic," and diagnosed him as having bipolardisorder, as manic, and as an alcohol dependent in remission.[*2]
On July 23, 2007, the hospital applied to have respondentinvoluntarily admitted pursuant to Mental Hygiene Law § 9.27. The application was signedby Dr. Faynblut, respondent's treating psychiatrist, who stated: "48 year old single white malebrought from surgery s/p left hand amputation and three right fingers as he refused treatmentthere and tried to elope. Patient had firecrackers explosion on July 4th and did not seek any help.He remains irritable, labile, easily agitated to labile affect, pressured speech, disorganized,intrusive. Insight/Judgment—poor. Patient needs acute care."
The application was supported by two physicians who had examined respondent. One of thephysicians described respondent as having had "multiple prior psychiatric hospitalizations," andbeing "easily agitated and hostile." He further asserted that respondent's insight and judgmentwere "significantly impaired," that respondent is "acutely manic" and "cannot function safely inthe community and needs longer inpatient treatment." The second physician offered the samediagnosis and further certified that respondent "remains markedly pressured, circumstantial,intrusive, and still with complete impairment of insight and judgment." He further stated thatrespondent was a risk to himself.
On July 29, 2007, respondent gave written notice to JMC that he wanted to be released fromthe hospital within 72 hours. In his notice he acknowledged his bipolar disorder but asserted thathe had reached maximum medical improvement. The next day, the director of psychiatry at JMCapplied for court authorization to retain respondent. He claimed that respondent had "a mentalillness for which care and treatment as a patient in a hospital is essential to such person's welfareand whose judgment is so impaired that he . . . is unable to understand the need forsuch care and treatment," and as a result of this mental illness, "poses a substantial threat of harmto self or others."
On August 15, 2007 a hearing was held on the issue of whether JMC could retain respondent.JMC presented the testimony of Dr. Faynblut, and respondent testified on his own behalf. Therewere no other witnesses. At the outset of the hearing, the parties stipulated that Dr. Faynblutqualified as an expert. They further stipulated to the admission of respondent's hospital records.The court explained that the latter stipulation meant that "the hospital record is admitted as abusiness record, but if there are other objections to specific contents, they'll be raised." At nopoint during the hearing did either party object to any specific entries in the hospital records.
Dr. Faynblut testified that respondent had been admitted for extensive hospitalization fourtimes since November 2006, and that prior thereto he was hospitalized approximately once everythree years. She testified that over time, respondent's level of function had decreased. Sheconfirmed her diagnosis of bipolar disorder, which she explained was based on his history ofmanic and depressive episodes. Dr. Faynblut described her concern for respondent's well-beingshould he be released. She explained that he resides alone in a house without help, and that basedon his history of self-neglect, he would not comply with any follow-up medical plan necessitatedby the amputation surgery.
Dr. Faynblut further testified that the structured setting of the hospital benefited respondentinsofar as it provided necessary encouragement for him to attend to his own hygiene and take thevarious medications prescribed to treat his bipolar disorder. She expressed concern that he woulddecompensate without the hospital's support.[*3]
JMC's counsel attempted to elicit testimony from Dr.Faynblut regarding what she had been told by respondent's family and outpatient treatmentproviders regarding his prospects for complying with a discharge plan. After Dr. Faynblut statedshe was told that respondent has difficulty managing his finances, however, respondent's counselobjected and the court sustained the objection on hearsay grounds. The court made no evidentiaryrulings concerning the medical records.
In respondent's testimony, he acknowledged that he had been hospitalized several times overthe past year, although he claimed to have volunteered for, and complied with, outpatienttreatment. He stated that he sought medical assistance from a doctor two days after the July 4accident, and that the doctor "helped" him and suggested that the following week he have anotherdoctor reexamine the injury. However, he at first refused to disclose the name of the doctor who"helped" him, and asserted he did not remember the doctor's name. He claimed that shortlythereafter, he went to a regularly scheduled appointment with his psychiatrist, and that thepsychiatrist suggested he go to the emergency room. He testified that he went to his sister's housethat evening, and she called an ambulance for him. He claimed that he left the hospital after twodays because a doctor told him he could. He further testified that the medication he was given atthe hospital to address his mental disorder was not appropriate and caused him to decompensate.However, he testified that he was feeling good on his current medication and believed he couldtake care of himself outside of the hospital. He acknowledged that he lives alone and stated he isa retired custodial engineer, receiving $25,000 per year from the New York City Board ofEducation. Also, he denied that his family helps him pay his bills.
At the close of testimony, the IAS court denied the petition and directed respondent's release.The court stated:
"It is true that the Doctor concluded that [respondent] would be unable to manage himself ifnot involuntarily hospitalized, and he would be at high risk and decompensate.
"But, there is absolutely no evidentiary basis for those conclusions. She did testify that herequired supervision or assistance for his hygiene, but was absolutely unspecific. Did she meanwound care, because of the use of only one hand? And no testimony as to the unavailability forfamily visits or visiting nurse to assist him with wound care and medication."
In its ruling, the court made no reference to the extensive hospital records in evidencepursuant to the parties' stipulation. The court did stay respondent's release for one week pendingformulation of a discharge plan, over JMC's counsel's objection that any discharge plan would befutile if respondent was unwilling to cooperate in its execution.
We now reverse and grant JMC's petition. For a hospital to detain a patient for involuntarypsychiatric care, it must demonstrate, by clear and convincing evidence, that the patient ismentally ill and in need of continued, supervised care and treatment, and that the patient poses asubstantial threat of physical harm to himself and/or others (Matter of Ford v Daniel R.,215 AD2d 294, 295 [1995]). Here, respondent does not dispute that he suffers from mentalillness. Moreover, the very circumstances requiring respondent's initial admission to JMC on July9, 2007 are evidence enough that his mental illness substantially threatens his well-being (seeMatter of Consilvio v Diana W., 269 AD2d 310 [2000] [granting order of retention in [*4]part based on evidence that patient failed to seek treatment for abroken ankle]). Respondent failed to seek immediate medical treatment for a severe injury thatno person of sound mental health would have ignored. While his testimony suggests that he wentto JMC voluntarily after his psychiatrist recommended that he seek treatment for his injury, theadmission chart reflects that he refused this advice, that his sister called 911 after he showed upat her house, and that he refused medical care and was deemed lacking capacity by theemergency room doctor. Moreover, he left the hospital against medical advice two days after atraumatic and life-changing surgery.
In any event, Dr. Faynblut's testimony, coupled with respondent's medical chart, the entiretyof which was admitted into evidence without objection, contained more than enough evidence toestablish the need for respondent to be retained. For example, in the two-week period precedingthe hearing, respondent's chart indicated that he was "restless, pacing. . . talking tohimself, making bizarre gestures, very labile switching from overly pleasant to extremelyhostile." He was described during that same period as not having insight into his illness, as beingirritable and easily agitated, and manic and disorganized. While repeated nursing notes stated thatrespondent was "maintaining good control," complying with his medications and permittingtreatment of his wounds, those same notes indicated that he was under close observation.Moreover, respondent's compliance was consistent with Dr. Faynblut's testimony that the hospitalenvironment benefited respondent.
Respondent's medical records contain documentation of hospitalizations prior to the one atissue, which strongly support JMC's position that respondent's immediate well-being isdependent on his being retained in the hospital. For example, in November 2006, respondent wasadmitted to JMC after his sister became concerned about his behavior, which included creating adisturbance at a polling place such that the police were summoned, and calling her repeatedly inthe middle of the night to inquire after her children. His sister reported at the time that he hadceased attending to his activities of daily living, and that his apartment was a "mess." She furtherreported that respondent had attempted to grill hot dogs in their plastic wrapping.
Although the records for that hospitalization indicate respondent was released after showingimprovement, he was admitted to North Central Bronx Hospital two months later for treatment ofsevere depression. At the time of that admission, there was garbage in his refrigerator, threeweeks of unopened mail, and the odor of gas in his apartment. After again being released in amuch-improved condition, he was returned to the hospital less than four weeks later, in a manicand psychotic state, having not slept for two days. Again, he was released in much bettercondition, only to be hospitalized, one month later, in connection with the firecracker accident.Finally, the records state that as few as eight days before the hearing, respondent was minimizinghis psychiatric symptoms and "not address[ing] what happened to his hands prior to admission."
This recent history clearly and convincingly demonstrates that notwithstanding respondent'sposition that he has achieved maximum improvement in the hospital, he is unlikely to berehabilitated from the amputations and be able to adapt to life with only two fingers, without thedirect medical supervision the hospital setting would ensure (see Ford, 215 AD2d at295-296). Respondent's argument to this Court that he has the financial support of his family isbelied by his own testimony that his parents only pay his bills when he is in the hospital. Wenote, too, that the parents live in Florida part of the year, and that his sister has demonstrateddifficulty being with him when he is symptomatic. More importantly, hospital records reveal that[*5]respondent's family objected to his release to his home "asthey feel he is unsafe [there] alone." Significantly, respondent offered no testimony from expertor—at the very least—disinterested witnesses to establish that he is able to attend tohimself at home.
Because we find Dr. Faynblut's admitted testimony, as well as respondent's medical records,provided overwhelming support for JMC's determination that respondent should be retained, wefind it unnecessary to reach the issue of whether Dr. Faynblut's testimony concerningrespondent's ability to manage his finances was properly excluded. Concur—Mazzarelli,J.P., Saxe, Gonzalez and Acosta, JJ.