                     IN THE COURT OF APPEALS OF IOWA

                                   No. 19-0234
                               Filed August 7, 2019


IN THE MATTER OF K.T.,
Alleged to be Seriously Mentally Impaired,

K.T.,
     Respondent-Appellant.
________________________________________________________________


        Appeal from the Iowa District Court for Polk County, Robert B. Hanson,

Judge.



        K.T. appeals a district court order finding her seriously mentally impaired.

AFFIRMED.



        Alexander Smith of Parrish Kruidenier Dunn Boles Gribble Gentry Brown &

Bergmann L.L.P., Des Moines, for appellant.

        Thomas J. Miller, Attorney General, and Gretchen Kraemer, Assistant

Attorney General, for appellee State.



        Considered by Potterfield, P.J., and Bower and Greer, JJ.
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GREER, Judge.

       K.T. challenges the district court’s finding of serious mental impairment and

claims there is insufficient evidence that she is unable to make responsible

decisions with respect to her care, hospitalization, or treatment. On our review,

we affirm.

       I. Background Facts and Proceedings.

       On January 9, 2019, while K.T. was hospitalized, a psychiatric nurse

practitioner and a hospital social worker filed commitment paperwork. The nurse

practitioner noted K.T. has had a long hospitalization and he does not believe she

can care for herself. The nurse practitioner explained,

       Since being hospitalized, [K.T.] has had difficulties with disruptive
       behaviors. She has delusional and paranoid thoughts. She has
       attempted to elope from the unit several times. She has refused to
       take any medications that have been offered to her to help and
       control her behaviors and to help with her psychotic symptoms.

       On January 14, after a hearing, a magistrate found K.T. was “very

aggressive towards others,” could not take care of herself, had no insight into her

illness or need for treatment, and did not take prescribed medications.        The

magistrate ordered that K.T. be committed for inpatient treatment. K.T. timely

appealed this ruling to the district court.

       On February 6, K.T.’s treating physician submitted a report to the court. The

physician opined K.T. is mentally ill and experiencing “Major Neurocognitive

Disorder with significant cognitive deficits in multiple spheres including memory

and executive functioning.” The report noted K.T. has poor insight into her illness

and need for treatment. The report continued,
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               [K.T. i]s not safe in her home setting and has been admitted
       multiple times in the past year for treatment of fractured bones,
       infections, acute mental status changes, and stroke. She is
       intermittently not cooperative with cares for diabetes and
       hypertension. Has left skilled nursing facilities prior to being
       stabilized.

       On February 7, the district court held a trial de novo. The court heard

testimony and received reports from K.T.’s treating physician. At the conclusion

of the trial, the court found that K.T. has a mental illness, lacks sufficient judgment

to make responsible decisions with regard to her hospitalization or treatment, and,

as a result, K.T. was likely to physically injure herself or others if allowed to remain

at liberty without treatment and was incapable of satisfying her needs for medical

care. The district court ordered commitment. K.T. appeals.

       II. Standard of Review.

       “We review challenges to the sufficiency of the evidence in involuntary

commitment proceedings for errors at law.” In re B.B., 826 N.W.2d 425, 428 (Iowa

2013). An applicant must prove the elements of serious mental impairment by

clear and convincing evidence.       Id.   “Clear and convincing evidence is less

burdensome than evidence establishing proof beyond a reasonable doubt, but

more burdensome than a preponderance of the evidence.”                 Id.   Clear and

convincing evidence “means that there must be no serious or substantial doubt

about the correctness of a particular conclusion drawn from the evidence.” Id.

(quoting In re J.P., 574 N.W.2d 340, 342 (Iowa 1998)).

       “[T]he district court’s findings of fact are binding on us if supported by

substantial evidence.” J.P., 574 N.W.2d at 342. “Evidence is substantial if a
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reasonable trier of fact could conclude the findings were established by clear and

convincing evidence.” In re B.T.G., 784 N.W.2d 792, 796 (Iowa Ct. App. 2010).

       III. Analysis.

       To establish that an individual is seriously mentally impaired,

               The respondent must be found to have (1) a mental illness,
       consequently (2) to lack “sufficient judgment to make responsible
       decisions with respect to the person’s hospitalization or treatment”
       and (3) to be likely, if allowed to remain at liberty, to inflict physical
       injury on “the person’s self or others,” to inflict serious emotional
       injury on a designated class of persons, or be unable to satisfy the
       person’s physical needs.

J.P., 574 N.W.2d at 343 (quoting Iowa Code § 229.1(14) (1997)); see also Iowa

Code § 229.1(20) (2019) (defining “Seriously mentally impaired”).

       On appeal, K.T. challenges the district court’s ruling only with regard to the

second element: whether she lacked sufficient judgment to make responsible

decisions with respect to her hospitalization or treatment. “This element ‘requires

the State to prove that the person is unable, because of the alleged mental illness,

to make a rational decision about treatment, whether the decision is to seek

treatment or not.’” In re N.L., No. 16–0094, 2016 WL 3271884, at *1 (Iowa Ct. App.

June 15, 2016) (quoting In re Mohr, 383 N.W.2d 539, 541 (Iowa 1986)). “In

determining whether the person can make a rational decision, ‘the focus must be

on whether the grounds for the decision are rational or reasonable not what

conclusion is reached.’” Id. (quoting J.P., 574 N.W.2d at 343). “A decision,

although medically inadvisable, may be rationally reached, and if so, it is not the

court’s place to second guess the decision.” J.P., 574 N.W.2d at 343.

       K.T. wants to return to her home against the advice of her physicians

because her son is available to care for her in that setting. K.T. argues that it is
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common for patients to want to return home rather than stay in a hospital or other

facility. For that reason, K.T. argues her desire to return home and have her son

care for her is rational and reasonable, even if it was against the advice of her

physicians. Therefore, she argues, she does not lack sufficient judgment to make

responsible decisions regarding her hospitalization or treatment. K.T.’s son did

not testify.

       At trial, K.T.’s treating physician, board certified in adult psychiatry, testified

that prior to the beginning of these commitment proceedings, while K.T. was living

at home with her son, she was admitted to the hospital multiple times due to urinary

tract infections and injuries from frequent falls. The physician also opined that K.T.

lacked insight into her illness and was noncompliant with medications.              That

noncompliance impeded her ability to medically slow the progression of her

cognitive deterioration from the neurocognitive disorder. After already suffering a

stroke and being diagnosed as having vascular dementia, K.T. refused to take

antihypertensives, which put her at further risk for strokes. The physician noted

that following one hospitalization, K.T. received in-home nursing care until the care

team refused to continue providing treatment in the home, believing the in-home

setting was not appropriate for K.T.’s needs.

       The district court based its finding that K.T. lacked sufficient judgment to

make responsible decisions about her hospitalization or treatment on the following:

       a) by her lack of insight into her mental illness and the coordinate
       need for treatment of that mental illness which prevents her from
       adequately assessing the potential benefit of same, b) her refusal to
       take her psychiatric medications, c) her intermittent failure to
       cooperate with treatment regarding her other health conditions,
       namely, diabetes and hypertension, and d) her history of leaving
       skilled nursing facilities prior to reaching stabilization.
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The district court concluded that K.T. was incapable of satisfying her needs for

essential medical care based on:

       i) her intermittent failure to cooperate with care for her diabetes and
       hypertension conditions as well as her refusal to take her psychiatric
       medications, and ii) her history of frequent falls, infections, acute
       mental status changes, strokes, and chronic pain while residing at
       home.

       Although it may be understandable for a patient to want to return home,

based on the evidence presented in this case, K.T.’s desire to return home was

not rational or reasonable.     We conclude substantial evidence supported the

district court’s finding that K.T. was seriously mentally impaired and there is no

error of law with regard to the district court’s conclusion that K.T. lacked sufficient

judgment to make responsible decisions regarding her needs for essential medical

care, hospitalization, or treatment.

       IV. Disposition.

       For the foregoing reasons we affirm the district court’s commitment order.

       AFFIRMED.
