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Mental Health Law

Do General Health Care Proxies Allow Voluntary Commitment? Cohen v. Bolduc, 435 Mass. 608, 760 N.E.2d 714 (Mass 2002)

This case raises the issue of whether a general health care power of attorney authorizing proxy decision making includes the right to voluntarily commit the ward.  It has a good discussion of the policy issues and useful citation to the law in other states.

In 1998, Helen Bolduc, then seventy-four years old, executed a prototypical health care proxy, in which she authorized her daughter, as her agent, to make health care decisions on her behalf in the event she was unable to consent to them. Bolduc's health care proxy provided, in relevant part:

"My Health Care Agent is granted full power and authority to consent to any and all medical treatment which I may need in the event that I am unable to consent to such treatment on my own including without limitation authority to consent for medical care, hospitalization, nursing home admission, or whatever else may in my Health Care Agent's sole judgment be in my best interest . . . . I further state to all the world that there are no limitations imposed upon my Health Care Agent's authority."

Bolduc was later hospitalized and determined to be unable to make her own decisions.  At that time her daughter, acting as proxy, converted Bolduc's status at the hospital to "conditional voluntary" by executing on Bolduc's behalf an application for "conditional voluntary" admission, which was accepted.  On August 7, Bolduc executed a written revocation of her proxy, and indicated her intention to leave the hospital.  Two days later the hospital filed in the Cambridge Division of the District Court Department a petition for involuntary commitment, seeking to retain Bolduc at the hospital involuntarily.  Bolduc moved to dismiss the petition, arguing that it was not timely filed within the 10 day window because her daughter had no authority to commit her.  Without the valid voluntary commitment, the hospital's time for filing would have begun to run when they determined that she was incompetent.

The trial judge rejected the motion to dismiss, found that Bolduc would pose a threat to herself, and entered a six month order of commitment.  She filed an expedited appeal.  Before the appeal was heard, she was discharged from the hospital.  The Appellate Division held that Bolduc's challenge to the order of commitment and the issues raised by her were moot, but addressed the merits of the claims as concerning matters of public importance "capable of repetition, yet evading review."  The court affirmed the decision of the trial judge, and the Mass. Supreme Court accepted the case for review.  The court found that while the Mass. proxy consent statute did not have any specific provisions governing mental health care, the states were divided over whether it is appropriate for a proxy to commit a ward:

"One aspect of mental health treatment -- whether an advance directive should convey the authority to commit a principal to a mental health facility -- has been the subject of some debate among commentators,  is the subject of a uniform law promulgated by the National Conference of Commissioners on Uniform State Laws,*fn14 and has been regulated in different ways in different States. The Massachusetts proxy statute does not address the subject. In contrast, twenty-five other States have enacted statutes that do. Ten States allow advance directives for mental health treatment, but prohibit any commitment -- voluntary or involuntary -- by the agent. Three States allowing such directives prohibit only involuntary commitment.  Eight States allow commitment only if expressly authorized by the principal in her proxy, in some cases for limited periods only. Four other States permit a principal to authorize an agent to admit the principal to a mental health facility provided that the authority is conferred in a document separate from a general durable power of attorney concerning, for example, property or financial assets.  The statutes in the last two categories  are silent as to involuntary commitment and, to our knowledge, no court has sanctioned indefinite involuntary commitment to a mental health facility even where there is express statutory authorization for voluntary commitment." (footnotes omitted)

Key to the court's analysis is that Bolduc did not object to her initial commitment to the hospital.  Had she objected, which would have effectively revoked the proxy, the hospital would have had to petition the court, rather than relying on the proxy's consent.  The court noted that a primary use of proxy consent is for patients who are mentally compromised, thus excluding voluntary commitment would frustrate the purpose of the statute.  This would undermine patient autonomy by forcing the patient into a more restrictive court-ordered commitment, rather than a voluntary commitment that could be dissolved by the proxy or the patient without judicial intervention:

"By executing a health care proxy, a principal determines in advance that a person of her choice (rather than a judge) will make such medical decisions on her behalf. Reading into the proxy statute a restriction on her agent to act in one set of circumstances -- commitment to or retention at a mental health facility where the principal does not object -- would contravene the principles of individual autonomy embodied in this statute and expressed in our case law."

The court noted that Bolduc could have limited her proxy to prevent commitment by the agent, and that once she objected to the commitment, she triggered a judicial review of the proceeding.  The court found that voluntary commitment by the agent did not deprive Bolduc of the due process protections required for mental health commitment, and affirmed both the trial court and the appeals court decision.

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