Deciphering the Scope of the Qualified Immunity Provision of the Mental Health Procedures Act After Dean v. Bowling Green-Brandywine

The Mental Health Procedures Act: A Brief Overview

The Mental Health Procedures Act (MHPA) provides practitioners with insulation from liability when making medical decisions about mentally ill patients in some settings. See 50 P.S. §§ 7101-7503. The immunity provision is located at Section 114 of the MHPA, and states, in relevant part:

[I]n the absence of willful misconduct or gross negligence, . . . any . . . authorized person who participates in a decision that a person be examined or treated under this act, or that the person be discharged, or placed under partial hospitalization . . . shall not be civilly or criminal liable for such decision or . . . its consequences.

50 P.S. § 7114(a). Pennsylvania courts have defined “gross negligence” as an act or omission evidencing an “extreme departure” from the standard of care. See Feleccia v. Lackawanna College, 215 A.3d 3, 20 (Pa. 2019). Proving that a defendant’s actions rise to the level of gross negligence is quite difficult. The rationale behind the adoption of Section 114 was to encourage treatment of mentally ill patients by quelling provider concerns about increased exposure to liability in such a volatile area of practice.

A cryptic definition of “treatment” can be found elsewhere in the MHPA at Section 104:

Treatment shall include diagnosis, evaluation, therapy, or rehabilitation needed to alleviate pain and distress and to facilitate the recovery of a person from mental illness and shall also include care and other services that supplement treatment and aid or promote such recovery.

50 P.S. § 7104 (emphasis added).

The MHPA’s Lack of Definition of the Term “Mental Illness”

In recent years, much confusion has arisen over the proper application of Section 114 and the particular circumstances under which practitioners and facilities might be entitled to immunity from liability. The reason for the apparent confusion appears to stem, at least in part, from a lack of clarity as to the definition or meaning of the term “mental illness” for purposes of the MHPA. The statute notably does not include a specific definition of “mental illness” or “mentally ill person.” However, Section 102 of the MHPA indicates it applies to “[p]ersons who are mentally retarded, senile, alcoholic, or drug dependent . . . if they are also diagnosed as mentally ill[.]” See 50 P.S. § 7102 (emphasis added).

On February 19, 2020, the Pennsylvania Supreme Court handed down a major decision in Dean v. Bowling Green-Brandywine, 225 A.3d 859 (Pa. 2020), which sheds some light on when this immunity provision applies.

Dean v. Bowling Green-Brandywine

Important to understanding the court’s discussion relating to the scope of the MHPA immunity in Dean are the following salient facts. The plaintiffs’ decedent, Andrew, 23, admitted himself to a treatment facility for opioid dependence. Andrew told the providers he was diagnosed with Bipolar Disorder and ADHD as a child. However, he had not treated recently with a mental health provider and was not medicated for those concerns. During the admission, Andrew experienced adverse reactions (elevated heart rate and blood pressure) to his withdrawal from opioids. The facility attributed the symptoms to anxiety, and Andrew was ordered to undergo a single psychiatric consultation. Andrew was assessed and placed on an anti-anxiety drug. He died the following day after going into cardiac arrest.

Andrew’s parents filed a medical negligence lawsuit against the providers and facilities involved in his treatment. The plaintiffs contended that Andrew died from a cardiac arrhythmia caused, in part, from side effects of the medications he was taking. They further averred that the providers failed to monitor Andrew for symptoms that suggested he was at a high risk of cardiac arrest. The trial court granted a nonsuit as to all the defendants under the MHPA. The facts upon which the trial court based its decision to apply MHPA immunity included: (1) Andrew reported a history of psychiatric illness; (2) he had previously taken drugs for the diagnoses; (3) the diagnoses were “carried” in his chart and verified by his mother; and (4) he had experienced complications during his stay, necessitating a psychiatric evaluation and additional treatment.

The Pennsylvania Supreme Court ruled the trial court committed reversible error in granting a nonsuit in favor of the defendants on the present facts. It cautioned that the MHPA’s immunity “does not automatically apply in every situation involving a patient with a history of mental illness.” The court acknowledged that it previously determined the MHPA’s limited immunity provision applies to a physician or hospital providing care to a mentally ill patient for a physical ailment, where: (1) the provider or hospital had a contract with a mental health facility to provide the treatment for the physical ailment; and (2) the medical treatment was provided to facilitate the patient’s recovery from a mental illness. See, e.g., Allen v. Montgomery Hosp., 696 A.2d 1175, 1178-79 (Pa. 1997). In distinguishing its prior holding in Allen, the court reasoned that the providers had not offered Andrew treatment to facilitate his recovery from a qualifying mental illness. To the contrary, it found Andrew admitted himself to the facility solely for “detoxification from drug dependency” and that his psychiatric evaluation “arose out of his drug withdrawal symptoms only.” The court likewise did not find any “indication the medical care for the physical condition of elevated heart rate and blood pressure ‘was coincident to’ any treatment for mental illness.” It concluded the lower court’s “more expansive application” would prove unworkable in practice, as it would basically “immunize all providers that adopt a routine practice of ordering a ‘psychiatric consult’ for every patient, regardless of presentation[.]”

This opinion serves as an important reminder that the scope of the MHPA immunity is not without limits. In deciding whether the MHPA immunity applies, the key consideration appears to boil down to whether the mental health treatment was a significant reason for why care was being provided in the first place. Thus, a single psychiatric consult provided during a patient’s opioid rehabilitation stay would be insufficient alone, absent more, to trigger immunity under a Section 114 analysis.

However, Dean does not provide concrete guidance as to what additional evidence or facts would have been sufficient to warrant a different outcome. This much is clear after Dean: the issue of whether the MHPA immunity is triggered will necessarily turn on a highly sensitive factual inquiry and, thus, will be decided by courts on a case-by-case basis. The lack of unambiguous documentation reflecting Andrew was seeking mental health treatment in concert with drug detoxification treatment appears to have played a significant role in the court’s determination that MHPA immunity did not apply. The court placed considerable emphasis on the fact that the nursing assessment form noted that Andrew’s sole reason for seeking treatment at the facility was “[t]o get off pills.” Practitioners should be careful to document the specific reasons for ordering any mental health treatment and how that treatment fits within the broader picture of the care being provided. Careful documentation will likely go a long way towards convincing a court there is enough evidence to support a finding that MHPA immunity applies.

This decision is also noteworthy for rejecting a more expansive definition of “mental health treatment” under the MHPA to include care sought by a patient for drug-related dependency problems alone. Under the Pennsylvania Department of Human Services (DHS) regulations, drug dependency does not qualify as a “mental illness.” See 55 Pa. Code § 5100.2. The court cited with approval to this DHS definition in determining that opioid dependence treatment did not amount to care for a qualifying “mental illness.” The DHS regulations should provide practitioners with guidance as to whether specific treatment for certain conditions (e.g., senility, alcoholism and mental retardation are similarly excluded from the definition of “mental illness”) triggers the MHPA immunity.

* Jack is an associate in our Philadelphia, Pennsylvania office. He can be reached at 215.575.2617 or jabennardo@mdwcg.com.

_{Defense Digest, Vol. 26, No. 3, October 2020 is prepared by Marshall Dennehey Warner Coleman & Goggin to provide information on recent legal developments of interest to our readers. This publication is not intended to provide legal advice for a specific situation or to create an attorney-client relationship. ATTORNEY ADVERTISING pursuant to New York RPC 7.1. © 2020 Marshall Dennehey Warner Coleman & Goggin. All Rights Reserved. This article may not be reprinted without the express written permission of our firm. For reprints, contact tamontemuro@mdwcg.com.}