Opinion
No. 2-16-0445
09-27-2017
In re DENNIS D., Alleged to be a Person Subject to Involuntary Administration of Psychotropic Medication (The People of the State of Illinois, Petitioner-Appellee, v. Dennis D., Respondent-Appellant).
NOTICE: This order was filed under Supreme Court Rule 23 and may not be cited as precedent by any party except in the limited circumstances allowed under Rule 23(e)(1). Appeal from the Circuit Court of Kane County. No. 16-MH-73 Honorable Divya Sarang, Judge, Presiding. PRESIDING JUSTICE HUDSON delivered the judgment of the court.
Justices Schostok and Birkett concurred in the judgment.
ORDER
¶ 1 Held: (1) Although order authorizing the involuntary administration of psychotropic medication to respondent had expired, review of the issues presented in this case was appropriate under the public-interest exception to the mootness doctrine; (2) State was not required to prove that benefits of simultaneous administration of four primary psychotropic medications outweighed the harm where, although the trial court's involuntary-treatment order did not specify in its written order that the drugs were to be administered individually, the treating physician testified that she would not administer the medications to respondent all at one time, the trial court authorized only the treating physician and her staff to administer the medication, and the trial court required the medication to be administered in the manner testified to by the doctor; (3) there was no lack of continuity between evidence presented and the order entered as the trial court's written order did not allow for the simultaneous administration of the requested psychotropic medications; (4) since trial court's written order did not allow for the simultaneous administration of psychotropic medication, trial counsel was not ineffective for failing to challenge order on this basis; but (5) there was a lack of continuity between evidence presented and order entered regarding tests deemed essential for the safe and effective administration of the treatment, thereby requiring reversal of the trial court order.
¶ 2 I. INTRODUCTION
¶ 3 Respondent, Dennis D., appeals from the order of the circuit court of Kane County granting the State's petition to authorize the involuntary administration of psychotropic medication to him for a period not to exceed 90 days pursuant to section 2-107.1 of the Mental Health and Developmental Disabilities Code (Mental Health Code) (405 ILCS 5/2-107.1 (West 2016)). On appeal, respondent raises three issues. First, respondent contends that the involuntary-treatment order entered by the trial court authorized the simultaneous administration of four primary psychotropic medications, but the State failed to prove by clear and convincing evidence that the benefits of such a course of treatment outweighed the harm. Second, respondent argues that the trial court's order must be reversed because there is a lack of continuity between the evidence presented and the order entered in two ways. Third, respondent asserts that he was not afforded the effective assistance of counsel. We agree with respondent's second contention in part and reverse on that point.
¶ 4 II. BACKGROUND
¶ 5 Respondent was admitted to the Elgin Mental Health Center (EMHC) on February 11, 2016, after being found unfit to stand trial on charges of criminal trespass to a residence and criminal damage to property. On April 22, 2016, respondent's treating psychiatrist at EMHC, Dr. Mirella Susnjar, filed a petition seeking an order authorizing the involuntary administration of psychotropic medication to respondent pursuant to section 2-107.1 of the Mental Health Code (405 ILCS 5/2-107.1 (West 2016)). At the time the petition was filed, respondent was 61 years old. ¶ 6 The petition contained two tables, one listing the details of the primary medications sought to be administered by Dr. Susnjar and the other listing the alternative medications sought to be administered. The tables set forth the name of each medication, the range of dosages, and the condition/symptom to be treated. In the first table, Dr. Susnjar listed four primary medications to treat psychosis and mood (Risperidone, Olanzapine, Aripiprazole, and Quetiapine) and one primary medication to act as a mood stabilizer (Divelproex Na). In the second table, Dr. Susnjar also recommended the following alternative medications if the primary medications were not effective or could not be administered effectively: Haloperidol (for psychosis), Chlorpromazine (for psychosis), Lorazepam (for anxiety), Diphenhydramine (for side effects), and Benztropine (for side effects). In addition, Dr. Susnjar sought court authorization to administer the following tests and medical procedures that she deemed essential for the safe and effective administration of the psychotropic medication: "Blood work: CBC and differential, electrolytes, BUN, Creatinine, TSH and thyroid testes [sic], liver function tests, Hb A1 C, lipid panel in blood, EKG and the level of medications if needed." ¶ 7 A hearing on the petition commenced on April 29, 2016. At that hearing, the assistant public defender introduced herself as respondent's attorney. Respondent, however, informed the court that he wanted to represent himself. Following questioning by the court regarding respondent's fitness to represent himself, the court took the matter under advisement and continued the matter for one week. At a hearing on May 6, 2016, after posing additional questions to respondent, the court denied respondent's request to proceed pro se, finding that he had not demonstrated the capacity to waive counsel. The court then continued the matter to May 13, 2016, for a hearing on the petition. ¶ 8 At the May 13 hearing, respondent repeatedly indicated that he wanted to fire the assistant public defender assigned to represent him. The trial court denied respondent's request. The State then called Dr. Susnjar to testify. During Dr. Susnjar's testimony, respondent was removed from the courtroom after he repeatedly disrupted the proceedings. ¶ 9 When Dr. Susnjar initially took the stand, the parties stipulated that she was an expert in the field of psychiatry. Dr. Susnjar testified that she conducted a psychiatric examination of respondent. This involved speaking with respondent, reviewing the records that accompanied his admission, and discussing respondent with other members of the EMHC staff. Dr. Susnjar also noted that respondent had been previously hospitalized for issues related to his mental health 22 times between 1978 and 1998. Upon his release in 1998, respondent had not had any problems until 2014, when he stopped taking his medications. ¶ 10 Dr. Susnjar diagnosed respondent with schizoaffective disorder, bipolar type, which she categorized as a serious mental illness. She explained that respondent displayed psychosis accompanied by mixed symptoms of both mania and depression. Respondent's mania symptoms included rapid speech, insomnia, pacing, demanding behavior, and verbalizing unachievable goals. His depression symptoms included sadness, irritability, despair, and refusing food. Respondent also experienced paranoid and grandiose delusions, including beliefs that he is divine and that a conspiracy exists between his sister and EMHC staff to keep him hospitalized. Further, respondent expressed his belief that he would be found fit or would be released from the facility if he won a chess match, completed a jigsaw puzzle, or fasted. Dr. Susnjar also testified that respondent's speech, thoughts, and writings are disorganized and he frequently talks to himself, which is indicative of a hallucination. ¶ 11 Dr. Susnjar testified that as a result of his mental illness, respondent has exhibited a deterioration of his ability to function, suffering, and threatening behavior. Dr. Susnjar explained that prior to the current onset of symptoms, respondent was able to live independently in the community. However, he does not presently understand the circumstances that led to his arrest or his hospitalization at EMHC. Dr. Susnjar noted that when respondent was initially taken to EMHC, he became angry and violent. At that time, respondent attempted to destroy a computer and knocked down plants in the admissions area of the facility. He also threatened to "destroy everything" and called the medical staff names. Dr. Susnjar also recalled an occasion where respondent banged his fists on the nursing station window and the door to demand his release. Dr. Susnjar testified that as a result of these outbursts, respondent had been administered "restriction of rights" medication on eight occasions. Dr. Susnjar stated that the medication calmed respondent down for about two weeks before his ability to function began to deteriorate again. Dr. Susnjar testified that respondent refuses to voluntarily medicate because he feels that the medication causes a "chemical imbalance" in him. ¶ 12 Dr. Susnjar testified that she is seeking to administer Risperidone orally in a dosage range from 0.5 to 16 milligrams per day to treat psychosis and mood. Dr. Susnjar stated that the potential side effects of Risperidone are neuroleptic malignancy (which she described as being similar to a strong allergic reaction), tardive dyskinesia, sedation, weight gain, diabetes, rigidity, restlessness, and EPS syndrome. Dr. Susnjar also testified regarding the conditions and symptoms to be treated with the remaining primary medications (Olanzapine, Aripiprazole, Quetiapine, Divalproex NA) and alternative medications (Haloperidal, Chlorpromazine, Lorazepam, Diphenhydramine, and Benztropine), as well as their dosages, potential side effects, and methods of administration. Dr. Susnjar was not concerned that there was an increased risk of side effects due to respondent's age. She also noted that respondent had been administered Haloperidol, Lorazepam, and Diphenhydramine as "restriction of rights" medications. Dr. Susnjar did not recall any side effects to respondent from these medications, although respondent did complain of "disbalance." Dr. Susnjar noted, however, that respondent was unable to describe his symptoms and his vital signs were normal. ¶ 13 Dr. Susnjar opined that the benefits of the psychotropic medications she is seeking to administer outweigh the potential risks. Dr. Susnjar explained that without the medication, "the intensity of [respondent's] reactions are so strong that he will have a heart attack at some point or he will injure someone or he will injure himself because he's so—feeling so miserable and tortured by the situation that he cannot understand." Dr. Susnjar stated that while the medications she seeks to administer have potential side effects, she can "control and balance" the side effects by reducing the dosage or substituting another medication. Dr. Susnjar added that although she is requesting to administer several antipsychotic medications, she would not give them to respondent all at one time. She explained that each medication has different side effects and she would like to switch the medication if respondent has a bad reaction to the medication initially administered. She stated that she would first administer Quetiapine because of its sedative effect but then switch to Aripiprazole because it does not cause weight gain. If respondent does improve, she would seek his input regarding the medication to administer. ¶ 14 Dr. Susnjar testified that she is also seeking authorization for tests and other medical procedures to insure the safe and effective administration of the psychotropic medication. Dr. Susnjar stated that this is primarily blood work consisting of a complete blood count with differential, electrolytes, BUN, creatinine, liver function, TSH and thyroid tests, a lipid panel, and medication levels. Dr. Susnjar stated that the blood, which would be taken through a blood draw, will allow her to monitor how respondent's body reacts to the medications being administered. Dr. Susnjar also requested permission to perform an EKG to check the function of respondent's heart. ¶ 15 Dr. Susnjar testified that she has provided claimant with a written document outlining the risks and benefits of the medications she is seeking to administer. She opined, however, that claimant lacks the capacity to make a reasoned decision about the administration of the medications because he denies that he is mentally ill and feels that the medications cause a chemical imbalance in him. Dr. Susnjar noted that less restrictive services had been provided to respondent without any improvement in his symptoms. Dr. Susnjar did not believe that respondent's condition would stabilize absent the administration of psychotropic medication. The court entered into evidence letters written to Dr. Susnjar by respondent and respondent's progress notes at EMHC. ¶ 16 Respondent did not testify at the hearing, but he submitted a document which was later admitted into evidence. In the document, respondent denied having a chemical imbalance or being mentally ill. Respondent claimed that he was misdiagnosed and improperly medicated. He asserted that the allegations in support of the petition seeking the administration of psychotropic medication were a "fraud." ¶ 17 Based on the evidence presented, the court concluded that respondent suffers from a serious mental illness, specifically schizoaffective disorder, bipolar type. The court further concluded that the State had proven by clear and convincing evidence the need for the administration of psychotropic medication. The court authorized the administration of psychotropic medication and testing testified to by Dr. Susnjar, finding that that the benefits of the proposed treatment would outweigh any harm. The court also found that the tests and other medical procedures testified to by Dr. Susnjar are essential to the safe and effective administration of the treatment. In rendering it's decision, the court specified:
"And based upon the testimony, the recipient *** shall receive psychotropic medications administered by the members of the clinical staff at the Elgin Mental Health Center specifically Dr. Susnjar and the clinical staff whose license allows them to administer psychotropic medications pursuant to Illinois law.¶ 18 In conjunction with its oral findings, the trial court entered a two-page written order. The written order contains two tables listing the names of the primary and alternative medications authorized to be administered, their respective dosages, and their methods of administration. Relevant here, the table setting forth the primary medications provides as follows:
The staff is authorized to administer the medication to the recipient *** as testified to by Dr. Susnjar in the manner testified to by the doctor and the dosages testified to by the doctor for a period not to exceed 90 days. The testing procedures testified to by Dr. Susnjar are also hereby ordered to insure the safe and effective administration of the treatment ordered."
| Medication | From | To | Administered |
|---|---|---|---|
| Risperidone | 0.5 mg/day | 16 mg/day | P.O. |
| Olanzapine | 2.5 mg/day | 30 mg/day | P.O., I.M. |
| Aripiprazole | 2 mg/day | 30 mg/day | P.O. |
| Quetiapine | 50 mg/day | 800 mg/day | P.O. |
| Divalproex NA | 250 mg/day | 2,500 mg/day | P.O. |
Tardive dyskinesia is "abnormal grimacing about the mouth occurring some weeks after taking certain psychotropic drugs." Stedman's Medical Dictionary 477 (25th ed. 1990). EPS stands for "extrapyramidal symptoms" which are drug-induced movement disorders such as continuous spasms and muscle contractions. https://en.wikipedia.org/wiki/Extrapyramidal_symptoms (last visited September 18, 2017).
The table refers to two methods for administering the medications, "P.O." and "I.M." "P.O." is Latin for "per os," which means "by or through the mouth." Stedman's Medical Dictionary 1171 (25th ed. 1990). "I.M." means intramuscular. Stedman's Medical Dictionary 764 (25th ed. 1990).
¶ 19 III. ANALYSIS
¶ 20 On appeal, respondent raises three issues. Initially, respondent contends that the order entered by the trial court authorized the simultaneous administration of the four primary psychotropic medications (Risperidone, Olanzapine, Aripiprazole, and Quetiapine). According to respondent, this was improper because the State failed to prove by clear and convincing evidence that the benefits of the simultaneous administration of more than one psychotropic medication outweighed the harm. Respondent also argues that the trial court's order must be reversed because there is a lack of continuity between the evidence presented and the order entered in two ways. First, respondent contends that although Dr. Susnjar stated that she would not administer the four primary psychotropic medications all at one time, the order entered by the trial court allows for the simultaneous administration of these medications. Second, respondent asserts that Dr. Susnjar did not testify regarding the Hb A1 C (hemoglobin or glycated hemoglobin) test, but the trial court order "simply followed the petition and included that test." Finally, respondent maintains that he was not afforded the effective assistance of counsel because, contrary to Dr. Susnjar's testimony, his attorney allowed for the entry of a medication order that authorized the simultaneous administration of the four primary psychotropic medications. Before addressing these arguments, we must discuss the issue of mootness.
¶ 21 A. Mootness
¶ 22 "An appeal is considered moot where it presents no actual controversy or where the issues involved in the trial court no longer exist because intervening events have rendered it impossible for the reviewing court to grant effectual relieve to the complaining party." In re J.T., 221 Ill. 2d 338, 349-50 (2006). In this case, respondent's appeal is moot because the 90-day period covered by the trial court's order has expired. See In re Donald L., 2014 IL App (2d) 130044, ¶ 17. Generally, courts of review do not decide moot questions, render advisory opinions, or consider issues where the result will not be affected regardless of how those issues are decided. In re Barbara H., 183 Ill. 2d 482, 491 (1998). There is no "general exception" to the mootness doctrine for mental health cases. Donald L., 2014 IL App (2d) 130044, ¶ 19. However, there are three established exceptions to the mootness doctrine: (1) the public-interest exception, (2) the capable-of-repetition exception, and (3) the collateral-consequences exception. Donald L., 2014 IL App (2d) 130044, ¶ 19. Most appeals in mental health cases will usually fall within one of these three exceptions. In re Alfred H.H., 233 Ill. 2d 345, 355 (2009). The determination whether a case falls within a particular exception is made on a case-by-case basis. Alfred H.H., 233 Ill. 2d at 355. ¶ 23 In this case, respondent argues that both the public-interest and capable-of-repetition exceptions to the mootness doctrine apply. The State disagrees, in part. According to the State, respondent raises only one issue that potentially falls within an exception to the mootness doctrine. Specifically, the State asserts that respondent's claim that there is a lack of continuity between the evidence presented and the court order regarding the Hb A1 C test could be viewed as falling within the public-interest exception. We find that the public-interest exception applies to all of the issues raised in this case. ¶ 24 The public-interest exception allows a court to consider an otherwise moot case when the following three elements are established: (1) the question presented is of a public nature; (2) there is a need for an authoritative determination for the future guidance of public officers; and (3) there is a likelihood of future recurrence of the question. Alfred H.H., 233 Ill. 2d at 355. "The 'public interest' exception is 'narrowly construed and requires a clear showing of each criterion.' " Alfred H.H., 233 Ill. 2d at 355-56 (quoting In re Marriage of Peters-Farrell, 216 Ill. 2d 287, 292 (2005)). Although questions regarding the sufficiency of the evidence are generally not of a public nature (see Alfred H.H., 233 Ill. 2d at 356-57), questions regarding compliance with the Mental Health Code involve matters of substantial public interest (Donald L., 2014 IL App (2d) 130044, ¶ 20). ¶ 25 In this case, we find that respondent raises issues of statutory compliance that present matters of a public nature. In particular, the issues raised by respondent concern the specificity of the trial court order regarding a request for more than one primary psychotropic medication and the procedures a court must follow to authorize monitoring tests requested as essential to the safe and effective administration of the proposed treatment. This case also raises an issue of how to interpret a court order authorizing the administration of psychotropic medication. The parties have not cited any cases directly on point, thereby showing a need for an authoritative determination of these issues. Further, without an authoritative determination of these matters from a court of review, these issues are likely to recur. Accordingly, we find that the public-interest exception applies. See Donald L., 2014 IL App (2d) 130044, ¶ 21. We now turn to the merits.
¶ 26 B. Involuntary Administration of Medication
¶ 27 The involuntary administration of psychotropic medication to an individual alleged to be mentally ill implicates substantial liberty interests. In re C.E., 161 Ill. 2d 200, 213-17 (1994). However, these liberty interests must be balanced against the State's parens patriae interest in furthering the treatment of mentally ill individuals by forcibly administering psychotropic medication where an individual lacks the capacity to make reasoned decisions concerning his or her need for such medication. C.E., 161 Ill. 2d at 217. To this end, the Mental Health Code provides safeguards to protect mental-health patients from the potential misuse of psychotropic medication by medical staff for purposes other than treating mental illness. In re Larry B., 394 Ill. App. 3d 470, 474 (2009). In particular, section 2-107.1 of the Mental Health Code (405 ILCS 5/2-107.1 (West 2016)) serves as a guide for balancing the liberty interests of the individual and the State's interest in treating mentally-ill citizens. Donald L., 2014 IL App (2d) 130044, ¶ 22. We note that strict compliance with the statutory procedures of the Mental Health Code is required given the important liberty interests involved in involuntary-treatment cases. In re Atul R., 382 Ill. App. 3d 1164, 1168 (2008). ¶ 28 Pursuant to section 2-107.1(a-5)(4) of the Mental Health Code (405 ILCS 5/2-107.1(a-5)(4) (West 2016)), the forced administration of psychotropic medication is authorized only if the trial court finds clear and convincing evidence of each of the following elements:
"(A) That the recipient has a serious mental illness or developmental disability.
(B) That because of said mental illness or developmental disability, the recipient currently exhibits any one of the following: (i) deterioration of his or her ability to function, as compared to the recipient's ability to function prior to the current onset of symptoms of the mental illness or disability for which treatment is presently sought; (ii) suffering, or (iii) threatening behavior.In this case, respondent's arguments pertain to subsections (D) and (G). We address each argument in turn.
(C) That the illness or disability has existed for a period marked by the continuing presence of the symptoms set forth in item (B) of this subdivision (4) or the repeated episodic occurrence of these symptoms.
(D) That the benefits of the treatment outweigh the harm.
(E) That the recipient lacks the capacity to make a reasoned decision about the treatment.
(F) That other less restrictive services have been explored and found inappropriate.
(G) If the petition seeks authorization for testing and other procedures, that such testing and other procedures are essential for the safe and effective administration of the treatment." 405 ILCS 5/2-107.1(a-5)(4) (West 2016).
¶ 29 1. Benefits of Treatment Outweigh Harm
¶ 30 Respondent first argues that the State failed to prove by clear and convincing evidence that the benefits of the involuntary administration of the four primary psychotropic medications (Risperidone, Olanzapine, Aripiprazole, and Quetiapine) outweigh the harm. Respondent does not challenge the evidence as insufficient to authorize the use of these medications to treat psychosis so long as each is used individually. According to respondent, however, the trial court's written order "technically" authorizes Dr. Susnjar to administer the four primary antipsychotic medications simultaneously. From that point of view, respondent asserts that the record was not sufficient to support authorization for the administration of more than one of the medications at a time because there was no evidence regarding the potential complications posed by the interactions of the medications requested. Respondent asserts that administering multiple antipsychotic medications simultaneously poses a risk to the patient. ¶ 31 The State answers that respondent's interpretation of the trial court's involuntary-treatment order is overly broad. The State asserts that there is no language in the order which gives anyone the authority to administer medications in a form or method other than as Dr. Susnjar requested, and Dr. Susnjar testified that she had no intention of administering to respondent more than one psychotropic medication at a time. Further, Dr. Susnjar set forth the medications she wished to administer in a table which listed the medications singly, in a serial fashion, and explained the circumstances under which she would switch to another medication. The State adds that respondent's sufficiency-of-the-evidence argument is limited to a dearth of evidence to support the simultaneous administration of the four primary psychotropic medications. The State asserts, however, that since the court's involuntary-treatment order did not authorize Dr. Susnjar or her designees to administer the medications simultaneously, respondent's argument lacks merit. ¶ 32 Initially, we must determine the appropriate standard of review. As phrased by respondent, this issue could be interpreted as simply a sufficiency-of-the-evidence question. However, underlying respondent's claim that the State failed to prove by clear and convincing evidence that the benefits of the involuntary administration of psychotropic medication outweighed the harm is an issue involving the interpretation of the involuntary-treatment order entered by the trial court. Accordingly, we find that our analysis involves two separate inquires. First, we must determine whether the trial court's involuntary-treatment order gave Dr. Susnjar authorization to simultaneously administer more than one of the four primary psychotropic medications. Issues involving the interpretation of a court order present questions of law, which we review de novo. See In re Estate of Dierkes, 191 Ill. 2d 326, 330 (2000) (noting that statutory interpretation presents a question of law subject to de novo review); CitiMortgage, Inc. v. Parille, 2016 IL App (2d) 150286, ¶ 24 (reviewing trial court's interpretation of a contract de novo); In re Marriage of Stephenson, 2011 IL App (2d) 101214, ¶ 22 (finding issue involving construction of a court rule is reviewed de novo). Only after we resolve the interpretation issue do we address the sufficiency-of-the-evidence claim. When reviewing the sufficiency of the evidence in a case involving the involuntary administration of psychotropic medication, a court of review will not overturn the trial court's ruling unless it is against the manifest weight of the evidence. In re Vanessa K., 2011 IL App (3d) 100545, ¶ 28. A ruling is against the manifest weight of the evidence only when an opposite conclusion is clearly apparent or when the findings appear to be unreasonable, arbitrary, or not based on the evidence. In re Louis S., 361 Ill. App. 3d 774, 779 (2005). ¶ 33 In light of the foregoing, we first examine the trial court order to determine whether it granted Dr. Susnjar authorization to simultaneously administer more than one of the four primary psychotropic medications. "Generally, the intention of the court is determined by the language of the order entered, but where the language of the order is ambiguous, it is subject to construction." Twardowski v. Holiday Hospitality Franchising, Inc., 321 Ill. App. 3d 509, 512 (2001). An ambiguous order "should be interpreted in the context of the record and the situation that existed at the time of [its] rendition." Twardowski, 321 Ill. App. 3d at 512. "The relevant sources include 'pleadings, motions and issues before the court; the transcript of the proceedings before the court; and arguments of counsel.' " In re Marriage of Heasley, 2014 IL App (2d) 130937, ¶ 28 (quoting In re Marriage of Lehr, 317 Ill. App. 3d 853, 858 (2000)). ¶ 34 In this case, the written order entered by the trial court contains a table listing, inter alia, the names of the four primary psychotropic medications. The table lists the medications singly, in a serial fashion, along with their respective dosages and their methods of administration. The order is silent as to whether the medications must be administered individually or whether they may be administered simultaneously. Under these circumstances, we find that the order is ambiguous. After reviewing the record, however, we conclude that the trial court's order does not authorize Dr. Susnjar to simultaneously administer more than one of the four primary psychotropic medications. ¶ 35 Initially, we note that the petition filed by Dr. Susnjar did not indicate whether the four primary psychotropic medications would be administered individually or simultaneously. However, at the hearing on the petition, Dr. Susnjar was expressly asked whether she would administer the four primary psychotropic medications all at one time. She responded in the negative. She then outlined why she requested multiple primary psychotropic medications. She explained that she would administer each of the primary psychotropic medications singly, but switch to a different medication as she became aware of any side effects from the medication being used. Specifically, Dr. Susnjar testified that she would first administer Quetiapine because of its sedative effect. She would then switch to Ariprprazole because it does not cause weight gain. She added that if respondent does improve, she would seek his input regarding the medication to administer. ¶ 36 To the extent that respondent is worried that, without limiting language, the order might be read to allow the four primary psychotropic medications to be administered simultaneously, such a concern is repudiated by the fact that the involuntary-treatment order named only Dr. Susnjar or one of her designees as the sole persons authorized to administer the psychotropic medication to respondent. Further, the court ordered that the medication be administered only in the manner testified to by Dr. Susnjar. As noted above, Dr. Susnjar testified that she did not intend more than one of the four primary antipsychotic medications to be administered at any one time. While the better practice would be to expressly indicate whether the simultaneous administration of more than one psychotropic medication is authorized, respondent does not cite any statutory provision or case law that requires an involuntary-treatment order to include limiting language of this kind. Cf. 405 ILCS 5/2-107.1(a-5)(6) (West 2016) (providing that an involuntary-treatment order "shall specify the medications and the anticipated range of dosages that have been authorized"). ¶ 37 In short, although the trial court did not specify in its written order that the four primary psychotropic medications were to be administered individually, the petition did not request the simultaneous administration of multiple psychotropic medications, the treating physician testified that she would not administer the medications to respondent all at one time, the trial court authorized only the treating physician or her designees to administer the medication, and the trial court required the medication to be administered solely in the manner testified to by the doctor. Under these circumstances, we find that the involuntary-treatment order does not authorize Dr. Susnjar to simultaneously administer to respondent the four primary psychotropic medications. ¶ 38 Turning to the second part of our inquiry, we reject respondent's claim that the State failed to prove by clear and convincing evidence that the benefits of the proposed treatment outweigh the harm. Respondent's argument is premised on his contention that the trial court's involuntary-treatment order authorized the simultaneous administration of the four primary antipsychotic medications. As noted above, however, the record establishes that the simultaneous administration of multiple psychotropic medications was never intended by Dr. Susnjar and the trial court's order does not provide for such a course of treatment. As a result, proof of such a regimen being more beneficial than harmful was not required. Cf. In re Williams, 305 Ill. App. 3d 506, 511-12 (1999) (holding that the State failed to prove by clear and convincing evidence that the benefits of the medication outweighed the harm where doctor's testimony was "general and vague" in that he was not asked whether there were side effects peculiar to certain medications or whether there were potential complications posed by the interactions of said medications and he did not testify regarding the increased dosages of one medication); In re Perona, 294 Ill. App. 3d 755, 766-67 (1998) (finding evidence sufficient to establish that the benefits of the medication outweighed the harm where doctor testified that use of two neuroleptic drugs were occasionally used together because they were more effective together and there was no evidence of any potential negative interactions between the medications). Moreover, respondent does not challenge the evidence as insufficient to authorize the use of these medications to treat psychosis so long as each is used individually. Indeed, we note that Dr. Susnjar's testimony establishes that she carefully reviewed the benefits and side effects of each of the psychotropic medications at the dosages requested, including both the primary and alternative medications. She then determined that the benefits of the psychotropic medications outweigh the harm. Accordingly, we reject respondent's argument that the State failed to prove by clear and convincing evidence that the benefits of the involuntary administration of the psychotropic medication outweighs the harm. Quite simply, the State was not required to present evidence regarding the potential complications posed by the interactions of the medications requested because the court did not authorize the simultaneous use of more than one of the four primary psychotropic medications.
Respondent also argues that, based on the fact that there were a total of 10 medications ordered, that "an argument could be made that the State failed to prove that the proposed treatment is the least restrictive." We decline to address this argument as respondent raises it in a summary fashion with little development. See Enbridge Pipelines (Illinois), L.L.C. v. Troyer, 2015 IL App (4th) 150334, ¶ 21 (finding that the failure to develop an argument violates Illinois Supreme Court Rule 341(h) (eff. Feb. 6, 2013) and results in forfeiture of the claim on appeal). --------
¶ 39 2. Lack of Continuity: Simultaneous Administration
¶ 40 Next, respondent argues that the trial court's order must be reversed because there is a lack of continuity between the evidence presented and the written order in that although Dr. Susnjar stated that she would not administer the four primary psychotropic medications simultaneously, the involuntary-treatment order entered by the trial court allows for the simultaneous administration of these medications. Because of our resolution of the preceding issue, we are compelled to reject respondent's claim that there is a lack of continuity between the evidence and the involuntary-treatment order regarding the simultaneous administration of the four primary psychotropic medications.
¶ 41 3. Ineffective Assistance of Counsel
¶ 42 Respondent also contends that he was deprived of the effective assistance of counsel because his attorney allowed the entry of a medication order that authorized the simultaneous administration of the four primary psychotropic medications. Again, as a result of our resolution of the first issue, we decline to consider respondent's allegations of ineffective assistance of counsel on this basis.
¶ 43 4. Lack of Continuity: Monitoring Tests
¶ 44 Finally, we address respondent's claim that the trial court's order must be reversed because there is a lack of continuity between the evidence presented and the order entered regarding the tests and medical procedures ordered for the safe and effective administration of the psychotropic medication. Specifically, respondent notes that although Dr. Susnjar requested to administer the Hb A1 C (hemoglobin or glycated hemoglobin) test in her petition, she did not testify about this test at the hearing. Nevertheless, the trial court's involuntary-treatment order "simply followed the petition" and authorized the Hb A1 C test in its written order. Respondent contends that this was improper and the trial court's order must be reversed. ¶ 45 The State responds that it presented sufficient evidence of the need to test respondent's blood and the need for an EKG. The State concedes that Dr. Susnjar did not testify regarding the Hb A1 C test even though it was listed in the petition. The State argues, however, that specificity as to the types of tests to be performed on respondent's blood was not necessary under the Mental Health Code. According to the State, "the doctor should not be obligated to state with precision each blood test that would be performed." Rather, the State asserts, it is sufficient to present evidence of the need to test respondent's blood and that the exact testing to be done should remain in the doctor's discretion. Thus, the State reasons, it was sufficient for Dr. Susnjar to testify as to the need for blood tests to monitor the effects of the medication on respondent's organs and why the tests were necessary. ¶ 46 The Mental Health Code allows a party petitioning for an involuntary-treatment order to request testing and medical procedures deemed essential for the safe and effective administration of the treatment. 405 ILCS 5/2-107.1(a-5)(1) (West 2016). Where the petitioner makes such a request, he or she must set forth in the petition the specific testing and procedures sought to be administered. 405 ILCS 5/2-107.1(a-5)(1) (West 2016). Moreover, if the petition does seek authorization for testing and medical procedures, the State must establish by clear and convincing evidence that such testing and other procedures are essential for the safe and effective administration of the treatment. 405 ILCS 5/2-107.1(a-5)(4)(G) (West 2016); In re Clinton S., 2016 IL App (2d) 151138, ¶ 33. We review the issue whether there was sufficient evidence to support the trial court's order under the manifest-weight-of-the-evidence standard. In re Suzette D., 388 Ill. App. 3d 978, 984-85 (2009). As noted above, a ruling is against the manifest weight of the evidence only when an opposite conclusion is clearly apparent or when the findings appear to be unreasonable, arbitrary, or not based on the evidence. Louis S., 361 Ill. App. 3d 774, 779 (2005). ¶ 47 In addressing respondent's argument, we find instructive the cases of In re David S., 386 Ill. App. 3d 878 (2008), Larry B., 394 Ill. App. 3d 470, Donald L., 2014 IL App (2d) 130044, and In re Steven T., 2014 IL App (5th) 130328. In David S., the petition for the involuntary administration of psychotropic medication requested authorization for certain tests and procedures related to the administration of the psychotropic medications. David S., 386 Ill. App. 3d at 879. Specifically, the petition listed "CBC, Chem 18, and EKG." David S., 386 Ill. App. 3d at 879. At the hearing on the petition, the testifying physician stated that he was seeking court approval for the three tests requested in the petition. David S., 386 Ill. App. 3d at 880. However, he did not provide any testimony regarding the reasons for the requested tests and he did not offer testimony regarding the reasonableness and necessity of the tests as related to the safe and proper administration of the medication. David S., 386 Ill. App. 3d at 880. The court authorized all three tests, indicating that they were essential for the safe and effective administration of the psychotropic medications. David S., 386 Ill. App. 3d at 881. On appeal, the respondent argued, among other things, that the order must be reversed because the State failed to prove by clear and convincing evidence that the proposed testing was essential for the safe and effective administration of the requested treatment. David S., 386 Ill. App. 3d at 881. The court agreed, finding that while the trial court's order indicated that the tests ordered were related to the safe and effective administration of the medications ordered, there was no testimony in this regard. David S., 386 Ill. App. 3d at 883-84. ¶ 48 In Larry B., a petition was filed seeking authorization for the administration of medication and testing. Larry B., 394 Ill. App. 3d at 472. The petition stated that the respondent would need periodic blood tests to monitor the level of drugs in his system and prevent side effects from the drugs. Larry B., 394 Ill. App. 3d at 472. At the hearing on the petition, the State asked the psychiatrist if he wanted the court to allow him to "do the testing and procedures necessary to make sure [the administration of psychotropic medication was] safely and effectively done." Larry B., 394 Ill. App. 3d at 478. The psychiatrist responded in the affirmative. Larry B., 394 Ill. App. 3d at 478. However, he did not describe the nature of the tests that he sought permission to administer to the respondent. Larry B., 394 Ill. App. 3d at 473. The court authorized the medications requested as well as testing procedures to monitor the respondent's medicated status. Larry B., 394 Ill. App. 3d at 473. The respondent appealed, arguing, inter alia, that the evidence was insufficient to warrant authorization of the tests the State sought to perform. The reviewing court agreed. Larry B., 394 Ill. App. 3d at 478. Noting that the State was required to prove by clear and convincing evidence that the testing and procedures requested in the petition are " 'essential for the safe and effective administration of the treatment,' " the court concluded that the evidence was insufficient. Larry B., 394 Ill. App. 3d at 478 (quoting 405 ILCS 5/2-107.1(a-5)(4)(G) (West 2008)). The court found that the psychiatrist's testimony "fell far short of the clear and convincing specific expert testimony in support of a request for testing" and that the trial court's authorization of the tests "was made in an informational limbo, not a fully informed state, warranting the reversal of the trial court's order." Larry B., 394 Ill. App. 3d at 478. ¶ 49 Similarly, in Donald L., the respondent's treating psychiatrist sought an order authorizing the involuntary administration of psychotropic medication, testing, and medical procedures. Donald L., 2014 IL App (2d) 130044, ¶ 4. At the hearing on the petition, the doctor named the tests and procedures she wanted to administer, but did not provide any description or explanation of the tests. Donald L., 2014 IL App (2d) 130044, ¶ 9. The court ultimately granted the petition. Donald L., 2014 IL App (2d) 130044, ¶ 15. With respect to the tests, the court quoted the petition in its order, allowing certain specified tests, but also "other tests necessary to evaluate safe administration of medications." Donald L., 2014 IL App (2d) 130044, ¶ 15. On appeal, the respondent argued that the court failed to comply with section 2-107.1(a-5)(4)(G) of the Mental Health Code (405 ILCS 5/2-107.1(a-5)(4)(G) (West 2012)) when it allowed his doctors to administer unspecified tests. Donald L., 2014 IL App (2d) 130044, ¶ 17. We agreed. Donald L., 2014 IL App (2d) 130044, ¶¶ 22-27. We found that the court allowed unknown tests without having any evidence of what those tests might be and absent evidence to determine whether the tests were essential for the safe and effective administration of the proposed treatment, thereby violating section 2-107.1(a-5)(4)(G) of the Mental Health Code. Donald L., 2014 IL App (2d) 130044, ¶ 27. ¶ 50 In Steven T., the respondent's treating psychiatrist filed a petition seeking permission to administer psychotropic medication and supportive medical testing, including a nasogastric tube. Steven T., 2014 IL App (5th) 130328, ¶ 3. A hearing on the petition was then held, at which the treating psychiatrist testified. On direct examination, the doctor did not testify or confirm that he was asking the court for the authority to conduct testing or other medical procedures. Steven T., 2014 IL App (5th) 130328, ¶ 6. On cross-examination, he stated that the respondent would be tested at regular intervals, and "[t]here's a protocol that pharmacy monitors and automatically tests are done." Steven T., 2014 IL App (5th) 130328, ¶ 6. The doctor added that the tests would be done within a month of starting the medication, but he did not testify regarding his request to use a nasogastric tube. Steven T., 2014 IL App (5th) 130328, ¶ 6. Following the hearing, the court entered an order for the involuntary administration of psychotropic medication. Steven T., 2014 IL App (5th) 130328, ¶ 8. The order allowed "specific testing and procedures when necessary to administer the medication" as well as administration of the medication through a nasogastric tube "should the respondent's medical condition be at risk from worsening psychosis." Steven T., 2014 IL App (5th) 130328, ¶ 8. ¶ 51 On appeal, the respondent argued, inter alia, that the State failed to prove by clear and convincing evidence that the tests and other procedures ordered by the court, which included the use of a nasogastric tube, were essential for the safe and effective administration of the medication. Steven T., 2014 IL App (5th) 130328, ¶ 11. The reviewing court agreed. Steven T., 2014 IL App (5th) 130328, ¶¶ 16-17. The court explained that section 2-107.1(a-5)(4)(G) of the Mental Health Code (405 ILCS 5/2-107.1(a-5)(4)(G) (West 2012)) requires the State to present clear and convincing evidence that testing done in conjunction with the administration of psychotropic medication is essential for the safe and effective administration of the treatment and this requires the State to provide "specific testimony about the requested testing and procedures." Steven T., 2014 IL App (5th) 130328, ¶¶ 16. The court found that the State failed to present evidence about the necessity of the requested testing or procedures. Steven T., 2014 IL App (5th) 130328, ¶ 17. The court noted that the treating psychiatrist simply testified that the testing would be conducted at regular intervals and would be done within a month of when the medication was first administered. Steven T., 2014 IL App (5th) 130328, ¶ 17. Moreover, the State did not present any evidence regarding the nasogastric tube procedure at the hearing. Steven T., 2014 IL App (5th) 130328, ¶ 17. In addition, although the petition itself merely stated that the testing and procedures were essential for the safe and effective administration of the medication, the State did not present any evidence to support this claim. Steven T., 2014 IL App (5th) 130328, ¶ 17. The court held that "[w]ithout more than a mere conclusion that the requested testing and nasogastric tube were necessary, the State failed to provide the clear and convincing evidence required by the [Mental Health] Code to administer tests, and potentially the nasogastric tube, without the respondent's consent." Steven T., 2014 IL App (5th) 130328, ¶ 17. ¶ 52 The foregoing cases stand for the proposition that specific evidence is required for a trial court to determine which tests or medical procedures are essential for the safe and effective administration of treatment. David S., 386 Ill. App. 3d at 883-84; Steven T., 2014 IL App (5th) 130328, ¶ 17; Donald L., 2014 IL App (2d) 130044, ¶ 27; Larry B., 394 Ill. App. 3d at 478. Here, the petition for involuntary treatment requested ten tests or medical procedures: (1) CBC and differential; (2) electrolytes; (3) BUN; (4) Creatinine; (5) TSH and thyroid tests; (6) liver function tests; (7) Hb A1 C; (8) lipid panel in blood; (9) EKG; and (10) level of medications. The petition further provided that these tests and procedures were essential for the safe and effective administration of the psychotropic medications. When Dr. Susnjar testified, however, she did not mention the Hb A1 C test and she did not state that it was essential to the safe and effective administration of the treatment. Nevertheless, the involuntary-treatment order authorized the Hb A1 C test. By doing so, the court allowed the test to be administered without clear and convincing evidence that it was "essential for the safe and effective administration of the treatment." This was improper and requires reversal of the involuntary-treatment order. David S., 386 Ill. App. 3d at 883-84; Steven T., 2014 IL App (5th) 130328, ¶ 17; Donald L., 2014 IL App (2d) 130044, ¶ 27; Larry B., 394 Ill. App. 3d 470, 478 (2009). ¶ 53 The State suggests that, unlike administering additional psychotropic medication outside those identified at a hearing, the authorization to take an additional blood test does not constitute a severe interference with a person's liberty. We disagree. The State's position ignores the fact that a patient's mental health and physical health are "inextricably linked." Clinton S., 2016 IL App (2d) 151138, ¶ 32. Section 2-107.1(1-5)(4)(G) of the Mental Health Code (405 ILCS 5/2-107.1(a-5)(4)(G) (West 2016)) is designed to ensure that the tests and procedures requested in the petition are essential to the safe and effective administration of the treatment. Absent clear and convincing evidence that each and every requested test and medical procedure is essential to the safe and effective administration of the proposed treatment, we cannot say that a patient's liberty interests are unaffected. See In re David S., 386 Ill. App. 3d at 884 ("Given the important liberty interests involved, we require firm proof of the elements required for the entry of [an involuntary treatment] order.") In this case, the State presented no evidence at all regarding the Hb Al C test. ¶ 54 The State also argues that even if the court's order was erroneous, the inclusion of one test in the order should not constitute reversible error. The State cites no support for this argument. Moreover, the State's position ignores the plain language of section 2-107.1(a-5)(4)(G) of the Mental Health Code (405 ILCS 5/2-107.1(a-5)(4)(G) (West 2016)) which requires the State to prove by clear and convincing evidence that any testing or medical procedures requested in a petition for involuntary treatment is "essential for the safe and effective administration of treatment." See Clinton S., 2016 IL App (2d) 151138, ¶ 33. The State's position also ignores the cases interpreting this statutory provision (see David S., 386 Ill. App. 3d at 883-84; Steven T., 2014 IL App (5th) 130328, ¶ 17; Donald L., 2014 IL App (2d) 130044, ¶ 27; Larry B., 394 Ill. App. 3d at 478) and the requirement that the Mental Health Code be strictly construed (see Atul R., 382 Ill. App. 3d at 1168. ¶ 55 Finally, the State claims that since respondent did not object to the court's order, and because he does not suggest on appeal that he was prejudiced by the alleged error, he has forfeited this issue. See In re Miller, 301 Ill. App. 3d 1060, 1070-71 (1998) (finding that the respondent forfeited claim or error where, although the trial court's order did not include the specific medications and authorized range of dosages or a designation of the persons authorized to administer the medications, the respondent did not object to the court's order and he did not argue that he was prejudiced by the error). However, in In re Cynthia S., 326 Ill. App. 3d 65, 68-69 (2001), this court applied the plain-error doctrine to a claim under the Mental Health Code. ¶ 56 In Cynthia S., the record did not reflect that the respondent objected to the form of the involuntary-treatment order and she did not argue in her brief that she was prejudiced as a result of the form of the order. Nevertheless, we applied the plain-error doctrine to address the respondent's claim that the order authorizing the administration of medications should be reversed because it failed to name specific individuals to administer the medication as required by section 2-107.1 of the Mental Health Code. Cynthia S., 326 Ill. App. 3d at 67-68. We noted that under the plain-error doctrine, a court may address a forfeited issue if the evidence is closely balanced or the error affects substantial rights. Cynthia S., 326 Ill. App. 3d at 67-68 (citing 134 Ill. 2d R. 615(a) and People v. McVeay, 302 Ill. App. 3d 960, 966 (1999)). We found that because the respondent's appeal involved fundamental liberty interests, the substantial-rights exception to the plain-error doctrine applied and we addressed the respondent's claim. Cynthia S., 326 Ill. App. 3d at 68. The State asserts that Cynthia S. does not apply here because, unlike the present case, that case involved noncompliance with the Mental Health Code. We disagree. As noted above, section 2-107.1(a-5)(4)(G) of the Mental Health Code (405 ILCS 5/2-107.1(a-5)(4)(G) (West 2016)) expressly provides that if a petition for involuntary treatment seeks authorization for testing and other procedures, psychotropic medication may be administered only if the State has established by clear and convincing evidence that, inter alia, "such testing and procedures are essential for the safe and effective administration of the treatment." See Clinton S., 2016 IL App (2d) 151138, ¶ 33. In this case, the State requested, and the court authorized, a test for which no evidence was presented at trial. Thus, contrary to the State's argument, this case does present a case of noncompliance with the Mental Health Code. ¶ 57 In short, strict compliance with the statutory procedures of the Mental Health Code is required given the important liberty interests involved in involuntary treatment cases. Atul R., 382 Ill. App. 3d at 1168. The Mental Health Code allows a party petitioning for an involuntary-treatment order to request testing and medical procedures deemed essential for the safe and effective administration of the treatment. 405 ILCS 5/2-107.1(a-5)(1) (West 2016). Where the party makes such a request, he or she must set forth the specific testing and procedures sought to be administered. 405 ILCS 5/2-107.1(a-5)(1) (West 2016). If the petition does seek authorization for testing and medical procedures, the State must establish by clear and convincing evidence that such testing and other procedures are essential for the safe and effective administration of the treatment. 405 ILCS 5/2-107.1(a-5)(4)(G) (West 2016). However, if the State fails to produce evidence that a particular test or medical procedure is essential for the safe and effective administration of the treatment, but the trial court authorizes the particular test or procedure, the court's involuntary-treatment order is against the manifest weight of the evidence and must be reversed. See David S., 386 Ill. App. 3d at 883-84; Steven T., 2014 IL App (5th) 130328, ¶ 17; Donald L., 2014 IL App (2d) 130044, ¶ 27; Larry B., 394 Ill. App. 3d at 478). In this case, the State's petition provided that the Hb A1 C test was essential for the safe and effective administration of the treatment requested and the trial court's involuntary-treatment order authorized this test. Yet, the State failed to present any evidence about the Hb A1 C test at the hearing on the petition. As a result, the trial court's involuntary-treatment order must be reversed.
¶ 58 III. CONCLUSION
¶ 59 For the reasons set forth above, we reverse the judgment of the circuit court of Kane County. A remand is not necessary since the administration of the medications has been terminated in accordance with the terms of the court's order. See In re Jonathan P., 399 Ill. App. 3d 396, 405 (2010). ¶ 60 Reversed.