Mental Health

Mental Health

Mental Health

Recently, in Dean v. Bowling Green-Brandywine, CRC Health Group, Inc., the Pennsylvania Supreme Court considered the scope and application of the qualified immunity provided under Section 114 of the Mental Health Procedures Act (MHPA), 50 P.S. §§7101-7503.

Andrew Johnson, age 23, admitted himself to Bowling Green-Brandywine Addiction Treatment Center (Brandywine) for drug rehabilitation to treat his addiction to opiates (OxyContin) and benzodiazepines (Xanax). These medications were first prescribed to him two years earlier for pain and anxiety related to back injuries arising from an ATV accident. Andrew reported he was diagnosed with Bipolar and ADHD when he was a child. Andrew was not at the time receiving mental health treatment, was not under the care of a psychiatrist, and had never been prescribed any medications to treat any mental health issues. The reason for Andrew’s admission was, “To get off the pills.”

The next day, Defendant Mohammad Ali Khan, M.D., a physician at Brandywine, evaluated Andrew and noted the diagnoses of “Bipolar and ADHD,” were “self-reported.” Dr. Khan placed Andrew on Brandywine’s “Alcohol/Benzodiazepine Detoxification Protocol.”

Andrew was experiencing “anxiety” at the time of his admission. Four days into his detoxification treatment, Andrew was sent to Defendant Jennersville Hospital’s emergency department for evaluation because of an elevated heart rate and his complaint that he was unable to see or move. The emergency medicine physician, Defendant Duncklee, diagnosed Andrew with drug withdrawal and discharged him to Brandywine. Brandywine’s nursing notes reflect Andrew appeared agitated and confused upon his return from Jennersville. Less than twelve hours after his discharge, Andrew was found unresponsive in his room, and was again transferred to Jennersville, where it was noted he was making rambling remarks. Defendant Jennifer Plumb, M.D., diagnosed Andrew with substance abuse and drug withdrawal, and discharged him back to Brandywine.

The next day, Andrew was evaluated by Khan who noted he was suffering from hallucinations and reported seeing shadows. Khan ordered a psychiatric consultation to be conducted by Defendant Asim Khurshid Rana, M.D., a staff psychiatrist at Brandywine. The next day, Andrew was unable to stand on his own, and was not eating or drinking, so Dr. Rana performed her evaluation in Andrew’s room. Dr. Rana noted Andrew’s history of ADHD and that he had been under treatment of a psychiatrist from age four to age 11. and had been tried on Ritalin and Adderall in the past but had not been on any psychiatric medication for many years. She also noted Andrew had a history of bipolar illness, but it is not clear who diagnosed him with that. Dr. Rana’s diagnoses did not include bipolar disorder or ADHD, and he prescribed Neurontin to treat his current symptoms of anxiety. Throughout his 8-day admission to Brandywine, Andrew consistently complained of anxiety.

In the morning of day 7 of his admission, Andrew’s blood pressure and heart rate were elevated. Dr. Khan was notified of the worrisome vital signs, but he declined to examine Andrew, did not issue any new treatment orders, and instructed the nursing staff not to transfer Andrew to the emergency room. The nursing staff again checked Andrew at 10:20 p.m. and noted he was unsteady, had a heart rate of 180 and blood pressure of 145 over 98. Staff administered Clonidine, but no additional treatment. The nursing staff subsequently checked Andrew every two to three hours and noted he was “resting comfortably.”

At approximately 7:50 a.m. the next morning, Andrew was found lying on the floor of his room, face down, without a pulse. He was transferred to Jennersville where he was pronounced dead.

In their Complaint, Andrew’s parents, Melissa Dean and Clifton Edward Johnson, alleged Andrew died of a cardiac arrhythmia because of the combination of medications prescribed during treatment at Brandywine, and that his death was the result of the defendants’ negligence. Defendants Khan, Rana and Plumb each filed new matter, asserting the affirmative defense of qualified immunity under the MHPA, which “establishes rights and procedures for all involuntary treatment of mentally ill persons, whether inpatient or outpatient, and for all voluntary inpatient treatment of mentally ill persons.” 50 P.S. §7103. Section 114 of the MHPA insulates certain individuals from claims of ordinary negligence arising from treatment under the act:

In the absence of willful misconduct or gross negligence, a county administrator, a director of a facility, a physician, a peace officer or any authorized person who participates in a decision that a person be examined or treated under this act, or that a person be discharged, or placed under partial hospitalization, outpatient care or leave of absence, or that the restraint upon such person be otherwise reduced, or a county administrator or other authorized person who denies an application for voluntary treatment or for involuntary emergency examination and treatment, shall not be civilly or criminally liable for such decision or any of its consequences. 50 P.S. §7114(a).

The matter was tried before a jury, and, after the defendants presented their case through medical records and expert testimony, all defendants moved for nonsuit, claiming appellants failed to present evidence of willful misconduct or gross negligence, and defendants were therefore immune from suit under the MHPA. Andrew’s parents opposed the motion for nonsuit based on MHPA immunity by arguing Andrew admitted himself to Brandywine for drug detoxification treatment and was thus not receiving treatment for “mental illness” from Brandywine or any of the physicians. The trial court held the case was governed by the MHPA since Andrew had a psychiatric history and was receiving psychiatric care at Brandywine, therefore the immunity provision applied, and nonsuit was warranted. The trial court further found Jennersville’s emergency room physicians, Duncklee and Plumb, were also immune because they had access to Andrew’s medical records at the time they examined him, and those records included a history of mental illness.

On appeal, a three-judge panel of the Superior Court affirmed the entry of nonsuit as to Brandywine and Khan and Rana, but reversed and remanded for further proceedings related to Duncklee and Plumb. The panel observed the qualified immunity provision of the MHPA applies to individuals and institutions that provide treatment to the mentally ill. The Superior Court noted that, although the MHPA does not contain a definition for “mentally ill person” or “mental illness,” the Department of Human Services (DHS) has issued regulations stating “mental retardation, alcoholism, drug dependence and senility do not [by themselves] constitute mental illness. The presence of these conditions, however, does not preclude mental illness.” quoting 55 Pa. Code. §5100.2. The panel additionally noted the term “treatment” as used in the MHPA is to be interpreted broadly and includes “medical care coincident to mental health care.” Id., quoting Allen v. Montgomery Hospital, 696 A.2d 1175, 1179 (Pa. 1997).

The threshold question for the Supreme Court was whether Andrew received treatment “to facilitate the recovery…from mental illness.” See 50 P.S. §7104. Because the MHPA did not define “mental illness,” the Court referred the PA DHS’s definition, which provides:

Mental illness — [t]hose disorders listed in the applicable APA Diagnostic and Statistical Manual; provided however, that mental retardation, alcoholism, drug dependence and senility do not, in and of themselves, constitute mental illness. The presence of these conditions however, does not preclude mental illness. 55 Pa. Code §5100.2

The Supreme Court determined that notwithstanding Dr. Rana’s psychiatric evaluation, the defendants did not provide Andrew with treatment to facilitate his “recovery from mental illness” such that MHPA immunity applies. Thus, the Court found that applying the immunity under these circumstances would not further the policy goals articulated by the General Assembly. According to the Court, the record was clear Andrew admitted himself to Brandywine for detoxification from drug dependency, and he was placed on the facility’s Alcohol/Benzodiazepine Detoxification Protocol. Although Andrew self-reported a decades-old history of bipolar disorder and ADHD, the record is devoid of evidence he received treatment for those diagnoses at Brandywine. Likewise, his transfer to Jennersville arose out of his drug withdrawal symptoms only; he was not being treated for “mental illness.” We conclude the Superior Court erred in affirming entry of a compulsory nonsuit and hold immunity does not apply under circumstances where: (1) the patient was admitted for and primarily received drug detoxification treatment; and (2) the patient did not receive treatment to facilitate recovery from a mental illness.