IN RE: the Civil Commitment of: A.P. (2023)

MEMORANDUM DECISION

Case Summary

[1] A.P. appeals an involuntary commitment order that expired on May 15, 2023, contending it was not supported by sufficient evidence. However, because his appeal is moot and does not fall within an exception to the mootness doctrine, we dismiss the appeal.

Facts and Procedural History

[2] Beginning in January 2022, A.P. had several appointments with Dr. Robert Pascuzzi, a specialist in neuromuscular medicine, because he believed he suffered from amyotrophic lateral sclerosis (“ALS”). Dr. Pascuzzi assessed A.P., which assessment included “taking a history”; listening to a “description of his symptoms”; “conducting a neurological examination”; “looking at muscle strength, muscle bulk, tone, [and] reflexes”; and “performing laboratory tests.” Tr. at 10. Based on the results of his evaluation and testing, Dr. Pascuzzi determined that A.P. “doesn't have that condition.” Id. Dr. Pascuzzi referred A.P. to “the world's foremost authority” on ALS at the Mayo Clinic. Id. at 11. A.P. submitted to a physical examination, “electrical testing,” and “other ancillary testing” at the Mayo Clinic, but the results showed “no evidence for a neuromuscular disease[.]”¹ Id. at 12.

[3] A.P. continued to meet with Dr. Pascuzzi. On “multiple occasions,” A.P. told Dr. Pascuzzi that “he needs to get” a diagnosis of ALS in order to deal “with end-of-life plans, including death, assisted death.” Id. at 15. Based on the test results that showed that A.P. did not have ALS, Dr. Pascuzzi opined that A.P.’s symptoms are “a delusion” that was “posing a significant harm” and referred him to a psychiatrist. Id. at 10. A.P. met with that psychiatrist on one occasion, but “chose not to follow up[.]” Id. at 11.

[4] A.P. stopped working and began living off his savings. He sold his home and moved into a condominium his parents had purchased. At first, A.P. paid monthly rent. However, “at some point, he decided he wasn't going to do that anymore.” Id. at 43. In October, A.P. spent approximately ten thousand dollars on a plane ticket to Switzerland. A.P. indicated to his parents that he was going to Switzerland “for medically aided suicide.” Id. at 56.

[5] On October 31, 2022, A.P. and Community Health Network, Inc. (“Community”) entered into an agreed order of temporary commitment. Pursuant to that agreement, A.P. agreed that he was “suffering from a mental illness,” including “major depression.” Appellant's App. Vol. 2 at 46. A.P. further agreed that, as a result of his mental illness, he “poses a danger to himself” and is “suffering from a substantial impairment or an obvious deterioration of his judgment, reasoning, or behavior that results in his inability to function independently.” Id. A.P. admitted that he “is in need of custody, care, and treatment,” and he agreed to take certain medication. Id. The court accepted the agreed order and committed A.P. to Community until January 31, 2023.

[6] In November, following A.P.’s commitment, A.P. contacted Dr. Pascuzzi and asked to be reevaluated. A.P. reported to Dr. Pascuzzi that he “was getting progressively weaker,” that “his joints were bad,” that he “was living moment to moment,” that his “breathing was bad,” and that his pain was “unbearable.” Tr. at 13. Dr. Pascuzzi reevaluated A.P. and again “concluded he doesn't have ALS.” Id. Dr. Pascuzzi also “could not find evidence for any other neuromuscular condition.” Id. Dr. Pascuzzi continued to believe that A.P.’s “symptoms were psychological in origin.” Id.

[7] A.P. “wasn't happy” with Dr. Pascuzzi's determination and “demand[ed]” that Dr. Pascuzzi diagnose him with ALS. Id. at 14. Dr. Pascuzzi “tried to emphasize” that A.P. had a “psychological or psychiatric condition” that was “driving his behavior.” Id. But A.P. remained “convinced” he has ALS because of a “variety of symptoms” he believed he had. Id. A.P. believed he suffered from “spasticity,” that he “can't breathe well,” that he “can't swallow well,” and that his “speech is bad.” Id. at 15. However, clinical evaluations demonstrated that A.P. “doesn't have objective problems with breathing, swallowing, [or] weakness.” Id.

[8] At some point during the agreed temporary commitment, A.P. “refused” to take the medications that he had agreed to in the order. Id. at 63. The court then found that A.P. had “failed to comply with the requirements” of the agreement and ordered that A.P. be detained and returned to an appropriate mental health center. Appellant's App. Vol. 2 at 50. Also at some point following the October agreed order, A.P.’s father, J.P., saw an “increase in the number of texts” from A.P. that spoke “to his growing discomfort” both physically and mentally. Tr. at 42. A.P.’s texts indicated “his desire to take other action” and included “vague” statements like: “I don't want to be here anymore,” “Can I just die already,” and “I need to consider other ways to do this.” Id.

[9] On February 6, 2023, shortly after the agreed temporary commitment had ended, Community filed an application for emergency detention of A.P. In that application, Community asserted that A.P. had a psychiatric disorder, that he was a “suicide risk,” and that he suffered from “severe delusions.” Appellant's App. Vol. 2 at 20. Community also alleged that A.P. would “continue to decompensate without intervention.” Id. In the attached physician's statement, psychiatrist Dr. Jason Ehret indicated that A.P. “needs immediate inpatient hospitalization to stabilize mental health concerns.” Id. at 21. A.P. was admitted to Community that day.

[10] The next day, Dr. Ehret examined A.P. Following that exam, Dr. Ehret diagnosed A.P. with delusional disorder, somatic type. In his physician's report, Dr. Ehret stated that A.P. “continues to have thoughts [of] terminal illness” and “assisted suicide.” Id. at 25. Dr. Ehret also stated that A.P. “has refused to begin voluntary treatment.” Id. at 26.

[11] Melanie Dacquisto, a nurse, saw A.P. following his commitment. A.P. was “not eating well” and his “hygiene [wa]s hit and miss[.]” Tr. at 26. A.P. reported that he was not eating well because he had “difficulty swallowing.” Id. at 27. Dacquisto reviewed A.P.’s medical records “to make sure that [Community] was meeting his needs” and found a recent “swallow study” that showed “no impairment of his swallow[.]” Id. A.P. further indicated to Dacquisto that he had an upcoming appointment scheduled with a doctor he had found through a group on Twitter who would diagnose him with ALS “on the first visit[.]” Id. at 28. When Dacquisto asked A.P. what would happen if this doctor did not diagnose him with ALS, A.P. indicated that “he would keep going to find ․ somebody that would diagnose him.” Id. A.P. also talked to Dacquisto about “wanting to end his life.” Id. A.P. indicated that if he “can't control the circumstances of [his] life, then at least [he] can control the circumstances of [his] death.” Id.

[12] On February 10, Dr. Ehret examined A.P. again and submitted a supplemental physician's statement. In that supplemental report, Dr. Ehret again opined that A.P. suffers from delusional disorder, somatic type, which “substantially disturbs [A.P.’s] thinking, feelings, or behaviors, and impairs [his] ability to function.” Appellant's App. Vol. 2 at 56. In particular, Dr. Ehret stated that A.P. “suffers from ongoing delusions that he has amyotrophic lateral sclerosis (ALS), which ha[s] been ruled out by multiple experts in ALS[.]” Id. at 56. He further stated that, despite being told by “multiple ALS specialists” that he does not have ALS, A.P. “continues to seek out and obtain additional opinions” in order “to obtain physician assisted suicide overseas.” Id. at 57.

[13] The court held a hearing on Community's application on February 13 and 14. During the hearing, Dr. Pascuzzi testified that he is “concerned that [A.P.] may come to harm the longer his “search for the ALS diagnosis goes on.” Tr. at 15. In particular, he testified that the “most striking and immediate concern” he has is “the potential for [A.P.] taking his life with ․ the delusion that he has a disease he doesn't have.” Id. And he testified that his “number one concern” is making sure A.P. “doesn't take his life.” Id. at 16.

[14] Community also presented the testimony of Dr. Ehret. Dr. Ehret testified that A.P. suffers from delusional disorder, which “impacts his ability to function independently” because he “think[s] his life is over and that there is no reason to do anything else[.]” Id. at 61-62. Dr. Ehret also testified that A.P.’s delusion “impact[s] his ability to hold a job,” that A.P. would not be able to maintain housing “absent family support,” and that A.P. cannot be relied on to take medication. Id. at 62. Dr. Ehret further opined that A.P. “presents a substantial risk that he will harm himself” because he had made it “very clear” that he will “plead assisted suicide” once it is confirmed that he has a terminal illness. Id. at 65. Dr. Ehret also testified that, if A.P.’s mental illness is left untreated, the “risk ․ of suicide is high.” Id. at 68. And he testified that A.P. “stated very clearly that that's his plan.” Id. Dr. Ehret continued that A.P. is dangerous because “he is convinced that he has a terminal illness and that he needs to end his life.” Id. at 73. And Dr. Ehret testified that A.P.’s “whole life revolves around going to appointments to get a diagnosis of ALS.” Id. at 74.

[15] J.P. also testified at the hearing. J.P. testified that A.P. “feels like he doesn't want to go on with life.” Id. at 41. He also testified that, at first, A.P. was only going to end his life through “medically aided death.” Id. But he testified that, as it became “clear that that might not be an option,” A.P. started indicating that he “might be open to doing it other ways, or ending it sooner[.]” Id. He further testified that A.P. spends most of his days “on his bed” because he “just doesn't have the energy or strength to ․ do anything.” Id. at 44. He also testified that, while A.P. used to be “diligent about being healthy,” he now orders out for most of his meals. Id. at 45. And he testified that, for the first two weeks following the agreed commitment, A.P. took his medication but that he notified his parents that “he would no longer be taking them.” Id. at 47.

[16] Following the hearing, the court issued its order of temporary commitment in which it found that A.P. is “suffering from a Delusional Disorder, Somatic Type,” and that he is dangerous to himself and “gravely disabled.” Appellant's App. Vol. 2 at 17. Accordingly, the court ordered that A.P. be committed to Community until May 15, 2023. This appeal ensued.

Discussion and Decision

[17] A.P. appeals the temporary commitment that expired on May 15, 2023, and asserts that it is not supported by sufficient evidence. Community responds and asserts that A.P.’s appeal is moot. “A case is moot when the controversy at issue has been ended, settled, or otherwise disposed of so that the court can give the parties no effective relief.” E.F. v. St. Vincent Hosp. and Health Care Ctr., Inc., 188 N.E.3d 464, 466 (Ind. 2022). However, under Indiana common law, the appellate courts have discretion to decide moot cases that present issues of great public importance that are likely to recur. Id.

[18] In the context of temporary mental health commitments, this Court “routinely consider[s] the merits” of moot cases where the appeal addresses a novel issue, presents a “close case,” or presents an opportunity to develop case law on a complicated topic. Id. at 467. We do so because a “[c]ivil commitment for any purpose has a very significant impact on the individual and constitutes a significant deprivation of liberty that requires due process protection.” Id. (quotations and citation omitted). But “because one of the hallmarks of a moot case is the court's inability to provide effective relief, appellate courts are not required to issue an opinion in every moot case.” Id. (citations omitted). Rather, we apply the mootness exception “on a case-by-case basis.” Id. at 465.

[19] Here, A.P.’s appeal does not present a close call or an opportunity to develop case law on a complicated topic. Cf., e.g., T.W. v. St. Vincent Hosp. and Health Care Ctr., Inc., 121 N.E.3d 1039, 1042 (Ind. 2019) (choosing to address a moot temporary commitment because the appeal involved the important public question of the probate commissioner's authority to enter civil commitment orders). However, A.P. asserts that this appeal should be decided on the merits because it presents “novel issues” as well as issues that “are likely to recur.” Appellant's Br. at 24-25. We cannot agree.

[20] A.P. contends that this appeal presents the “novel issue” of whether “seeking a second opinion” is a “sign of mental illness.” Id. at 25. However, the evidence demonstrates that A.P. did much more than seek a second opinion for what he believes to be a physical ailment. A.P. sought the opinion of Dr. Pascuzzi at least twice as well as the opinions of doctors from Chicago, the Mayo Clinic, the Cleveland Clinic, and JWM.² Indeed, Dr. Ehret testified that A.P. has gone to almost “every ․ program he can go to.” Tr. at 65. And by his own admission, A.P. has submitted to “hundreds” of plasma tests, eight EMGs, two barium swallow tests, and a “spinal tap muscle biopsy.” Id. at 81. But despite all of those tests and appointments, A.P. has never been diagnosed with ALS. Accordingly, Dr. Ehret diagnosed A.P. with delusional disorder, somatic type, with a secondary diagnosis of major depression and opined that A.P. was a danger to himself and gravely disabled. Further, A.P.’s argument on appeal is essentially that there was insufficient evidence to support his civil commitment. But despite A.P.’s arguments to the contrary, neither a diagnosis of delusional disorder nor a claim that the diagnosis is not based on sufficient evidence are novel issues.

[21] A.P. also contends that we should address the merits of his appeal because the issues in this case “are likely to recur.” Appellant's Br. at 25. Specifically, he contends that other “similarly situated people will find their liberty threatened,” including those people who seek a “diagnosis for unknown illnesses and people who have been diagnosed and have yet to find effective treatment.” Id. However, again, A.P. misconstrued the record. Contrary to A.P.’s assertions, this is not simply a case of an otherwise healthy person seeking a second opinion to get a diagnosis for a physical ailment. Rather, this case is based on a person who suffers from a delusional disorder that causes him to firmly, but wrongly, believe that he has a debilitating disease. As discussed above, A.P. has subjected himself to hundreds of tests and numerous appointments despite consistently being informed by specialists that he does not have ALS. Indeed, for many of the symptoms A.P. claims to suffer from, he has no “objective problems” with any of them. Tr. at 15.

[22] Finally, A.P. contends that this Court can provide him with effective relief despite the expiration of his commitment because of the “collateral consequences” of the commitment. Appellant's Br. at 24. Specifically, he asserts that this commitment “will help form the basis of yet another, future commitment.” Id. However, A.P. does not make any argument to explain why relief from this civil commitment will help deter future commitments when he has already been subjected to a prior civil commitment that he agreed to. See Appellant's App. Vol. 2 at 46-48.

[23] We acknowledge that an individual's liberty is restricted during a civil commitment. As a result, contrary to A.P.’s contention on appeal, this Court does not dismiss appeals as moot “as a matter of course.” Appellant's Br. at 26. Rather, our appellate courts “routinely consider the merits” of moot cases where the appeal presents a novel issue, a close call, or an opportunity to develop case law. See E.F., 188 N.E.3d at 467. Here, after a thorough review of the specifics of this case, we hold that A.P. has failed to show that an exception to the mootness doctrine should apply.

Conclusion

[24] A.P.’s appeal is moot, as his temporary commitment has expired. And he has failed to show that an exception to the mootness doctrine should apply. We therefore dismiss A.P.’s appeal.

[25] Dismissed.

FOOTNOTES

1.   The results of one blood test in Indiana showed the presence of an antibody that “can be seen in patients with” myasthenia gravis. Tr. at 12. However, A.P. had “a couple of tests done,” the results of which “didn't show any evidence for” myasthenia gravis. Id. at 17.

2.   It is not clear from the record what JWM is.

Bailey, Judge.

Tavitas, J., and Kenworthy, J., concur.