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C.R. v. Mass. Gen. Hosp. (In re C.R.), 2019 Mass. App. Div. LEXIS 23 (Sept. 4, 2019)

by Anne V. Kim

In an interesting recent decision, the Appellate Division of the Boston Municipal Court provided new interpretation of the statutory framework for emergency involuntary civil commitments for psychiatric treatment. While the opinion is not binding in Superior Court cases, it is significant in that it addresses the widely-reported and troublesome practice of “psychiatric boarding,” in which psychiatric patients are held in the emergency departments of hospitals, sometimes for several days on end, awaiting available beds in the psychiatric unit of the hospital or other appropriate facility for psychiatric care. The lack of available beds in psychiatric units leads to emergency departments crowded with psychiatric patients in need of specialized care, and is an increasing problem nationwide, with apparently no solution in sight.

The In re C.R. opinion signals how other Massachusetts courts might interpret the duties of hospitals to involuntarily committed psychiatric patients in light of the recent Supreme Judicial Court opinion in Pembroke Hosp. v. D.L., 482 Mass. 346 (January 10, 2019), which affirmed the protections of the liberty interests of such patients in the statutory scheme. In Pembroke, the SJC held that when an involuntarily committed patient becomes statutorily required to be “discharged,” the patient must be “set at liberty from involuntary restraint,” and not merely “released from care,” or, as happened to the plaintiff in Pembroke, transferred from one hospital to another.

General Laws c. 123, § 12 allows certain qualified mental health professionals to restrain a person with mental illness and apply for the hospitalization of the person with mental illness for a three-day period at a public or private facility, where it is determined that failure to hospitalize the person would create a likelihood of serious harm. Once a patient is detained under § 12, the facility may file a petition for continued involuntary commitment pursuant to G.L. c. 123, §§ 7 and 8. If the facility does not file a petition under §§ 7 and 8, or the petition for continued commitment fails, and the patient does not choose to stay in the facility voluntarily, the patient must be discharged.

On Friday, August 10, 2018, C.R. arrived at the emergency department of Massachusetts General Hospital, pursuant to G.L. c. 123, § 12. On Wednesday, August 15, 2018, a designated physician determined that C.R. met the criteria for an involuntary three-day admission to the hospital’s psychiatric department. The following day, Thursday, August 16, 2018, MGH filed a petition for involuntary commitment pursuant to G.L. c. 123, §§ 7 and 8. C.R. filed a pro se request for an emergency hearing, and appointed counsel filed a second request for emergency hearing on August 17th. An emergency hearing was held on August 20th, wherein the court denied C.R.’s request for immediate release and scheduled a hearing on MGH’s commitment petition for August 23rd. Before the commencement of the hearing on MGH’s commitment petition, C.R. filed a motion to dismiss the commitment petition on the grounds that it was untimely filed. The court denied the motion to dismiss, and after a hearing, allowed MGH’s commitment petition.

On appeal, the Appellate Division considered three questions:

- Whether G.L. c. 123, § 12(a) permits qualified petitioners to restrain a person for the purpose of applying for a three-day involuntary admission to an inpatient psychiatric facility in an emergency department of a hospital until a bed in the psychiatric unit becomes available;

- If so, whether the three-day limit begins at the time the subject of the petition arrives at the emergency department, or whether it begins at the time of admission to the psychiatric unit; and

- Whether the trial court erred in ruling that MGH had proved beyond a reasonable doubt that failure to hospitalize C.R. would create a likelihood of serious harm and that there was no less restrictive alternative.

First, the court considered the question of the place of detention, i.e. whether it was lawful for MGH to restrain C.R. in its emergency department rather than its psychiatric unit, pursuant to G.L. c. 123, § 12. Because a plain reading of the statute did not resolve the question, the court looked to the legislative intent behind the statutory framework. The court reasoned that the Legislature’s intent was two-fold: to protect psychiatric patients from risk of serious harm and allow their rehabilitation; and to protect their right to liberty. In balancing these, in some ways competing, interests, the court arrived at its first holding: that G.L. c. 123, § 12 allows hospitals to admit psychiatric patients to emergency departments when the hospital expects to have an open bed in a psychiatric facility.

Second, the court addressed the length of the admission permitted by § 12 – whether it was lawful for MGH to restrain C.R. in its emergency department from the time of her arrival on August 10th until August 15th, when MGH filed a petition for C.R.’s continued involuntary commitment, pursuant to G.L. c. 123, §§ 7 and 8. The court again turned to the legislative intent because § 12 is silent as to whether the three-day limit on an emergency involuntary commitment begins to run on the day the patient is first restrained, or on the day the patient is admitted to a psychiatric facility. The court reasoned that the Legislature’s intent to protect the liberty interest of psychiatric patients subject to emergency involuntary civil commitment would not be served by allowing such a patient to be held in an emergency department for an unlimited period, and beginning the three-day limit only upon admission to a psychiatric facility, as under that interpretation, a psychiatric patient could be restrained indefinitely in a hospital’s emergency department while waiting for a bed to open in a psychiatric unit, without any due process. Accordingly, the court held that the three-day statutory limit on a § 12 commitment begins on the day a patient is first restrained, whether in an emergency department or a psychiatric facility.

In applying these holdings to the facts of C.R.’s commitment, the Appellate Division found that the three-day statutory limit on the § 12 commitment began on Friday, August 10, 2018, when C.R. arrived at MGH emergency department. Because the three-day limit is calculated in accordance with Mass. R. Civ. Pro. 6, the weekend of August 11th to 12th was excluded and MGH had until August 15th to file a petition for continued involuntary commitment pursuant to §§ 7-8. Therefore, MGH’s August 16th petition for commitment was untimely and C.R.’s subsequent commitment was not valid. Because the court reached the finding that C.R.’s commitment under §§ 7-8 was not valid due to the untimely petition, the Appellate Division did not reach the third question presented on appeal, whether the petition was correctly decided on the merits. Accordingly, the Appellate Division reversed and remanded the decision of the trial court for an entry of dismissal of the petition for commitment.

The In re C.R. decision will not assuage the “between a rock and a hard place” position that hospitals face when they seek to accommodate psychiatric patients in need, without psychiatric beds readily available. Under this decision, the hospital must file a petition within three days of the patient arriving at the hospital, regardless of whether the patient has been admitted to the psychiatric unit. This puts enormous pressure on the already overburdened emergency department, rather than the appropriate psychiatric unit, to make a determination and file a petition, often before the hospital has had the opportunity to stabilize a patient in the psychiatric unit.