Peo in Interest of Sandoval

25CA0064 Peo in Interest of Sandoval 04-10-2025

COLORADO COURT OF APPEALS

Court of Appeals No. 25CA0064
Pueblo County District Court No. 25MH30004
Honorable Amiel Markenson, Judge

The People of the State of Colorado,

Petitioner-Appellee,

In the Interest of Miguel Augustine Sandoval,

Respondent-Appellant.

ORDER AFFIRMED

Division VI
Opinion by JUDGE SCHUTZ
Welling and Kuhn, JJ., concur

NOT PUBLISHED PURSUANT TO C.A.R. 35(e)
Announced April 10, 2025

Cynthia Mitchell, County Attorney, Kate H. Shafer, Special Assistant County
Attorney, Pueblo, Colorado, for Petitioner-Appellee

Tezak Law, P.C., Mary Tezak, Florence, Colorado, for Respondent-Appellant
¶1 Respondent, Miguel Augustine Sandoval, appeals the district

court’s order authorizing the involuntary administration of two

antipsychotic medications — olanzapine (Zyprexa) and haloperidol

(Haldol) — as well as valproic acid (Depakote), a mood-stabilizing

medication. We affirm the order.

I. Background

¶2 After being found incompetent to proceed to trial on criminal

charges, Sandoval was admitted to the Colorado Mental Health

Hospital in Pueblo (CMHHIP) — roughly his twentieth

hospitalization since adolescence. According to the affidavit of his

treating physician, Dr. Hareesh Pillai, Sandoval has been diagnosed

with schizoaffective disorder. His symptoms include auditory and

visual hallucinations, grandiose delusions, disorganized and

illogical thoughts, agitation, and paranoia.

¶3 Sandoval was prescribed Zyprexa and Depakote on an

involuntary and emergency basis after he invaded his peers’

personal space; told his social worker, “Bitch, I’ll knock the fuck out

of you”; threw a cup at staff; yelled repeatedly; and verbally

threatened to harm staff. He refused to take the medications orally

and received intramuscular injections. He continued to display

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symptoms of his illness, and he once again refused all medications

after the ten-day emergency administration ended. The People

petitioned for a hearing and an order authorizing a six-month

involuntary course of Zyprexa and Depakote, plus Haldol as needed

for episodes of acute agitation.

¶4 Both Dr. Pillai and Sandoval testified at the hearing. Dr. Pillai

testified about each of the four elements required for involuntary

administration of medication under People v. Medina, 705 P.2d 961,

973 (Colo. 1985). He described Sandoval’s symptoms, statements,

and behaviors; the benefits of treatment with antipsychotics and

mood stabilizers; and the potential side effects of treatment with

Zyprexa, Haldol, and Depakote. Sandoval testified that he wanted

to take the antipsychotic medication Geodon instead of Zyprexa

because Geodon had effectively managed his symptoms for many

years without significant adverse side effects. He explained that

Zyprexa had been causing muscle tightness or “locking up” that

once led to him falling to his knees (which he characterized as a

seizure), and his medications had also caused a treatable rash.

Despite his preference for Geodon, Sandoval testified that he would

take Zyprexa, but only orally.

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¶5 At the conclusion of the testimony, the district court found Dr.

Pillai’s testimony to be credible and persuasive and adopted his

opinions. The court found that Sandoval’s testimony was not

credible because his answers were hard to follow and inconsistent.

Ultimately, the court found that each of the Medina elements had

been established by clear and convincing evidence, and it issued an

order authorizing CMHHIP staff to involuntarily administer all of the

requested medications for a period of six months.

¶6 On appeal, Sandoval challenges the sufficiency of the evidence

supporting the court’s order.

II. Legal Authority and Standard of Review

¶7 A district court may authorize the involuntary administration

of medication to a patient only if the People establish each of the

following Medina elements by clear and convincing evidence: (1) the

patient is incompetent to participate effectively in their treatment

decisions; (2) treatment by medication is necessary either to prevent

a significant and likely long-term deterioration in the patient’s

mental condition or to prevent the likelihood of the patient causing

serious harm to themself or others in the facility; (3) a less intrusive

treatment alternative isn’t available; and (4) the patient’s need for

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treatment with medication is sufficiently compelling to override

their bona fide and legitimate interest in refusing medication. Id.;

see People in Interest of Strodtman, 293 P.3d 123, 131 (Colo. App.

2011). A physician’s testimony alone may constitute clear and

convincing evidence. See People v. Pflugbeil, 834 P.2d 843, 846-47

(Colo. App. 1992).

¶8 When, as here, a patient challenges the sufficiency of the

evidence supporting the district court’s findings on any of these

elements, we review the court’s conclusions of law de novo and

defer to its factual findings if they are supported by evidence in the

record. People v. Marquardt, 2016 CO 4, ¶ 8. We view the record as

a whole and in the light most favorable to the People, and we defer

to the fact finder to resolve any conflicts in the testimony and to

determine the credibility of witnesses. See People in Interest of

Ramsey, 2023 COA 95, ¶ 23; see also Strodtman, 293 P.3d at 130.

III. Analysis

¶9 Sandoval challenges the sufficiency of the evidence only for the

third and fourth Medina elements. We address the evidence

supporting each of these elements in turn.

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A. The Third Medina Element

¶ 10 The third Medina element requires a court to determine that

no less intrusive alternative to the proposed medication is available.

Medina, 705 P.2d at 973. This element “encompasses not only the

gravity of any harmful effects from the proposed treatment but also

the existence, feasibility, and efficacy of alternative methods of

treating the patient’s condition or of alleviating the danger created

by that condition.” Id. at 974. A less intrusive alternative is “an

available treatment that has less harmful side effects and is at least

as effective at alleviating a patient’s condition as the proposed

treatment.” Strodtman, 293 P.3d at 133.

¶ 11 Sandoval argues that Geodon is a less intrusive treatment

alternative based on his own testimony that he had been

successfully treated with Geodon in the past. However, the district

court found that Sandoval’s testimony about the efficacy and side

effects of Geodon was not credible, and we defer to the court’s

credibility determinations. Ramsey, ¶ 23.

¶ 12 The district court found that Geodon was not a less intrusive

alternative because Sandoval’s prior dose was inherently risky and

there was no credible testimony that the high dose effectively

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treated Sandoval’s symptoms. Dr. Pillai’s testimony — which the

court found credible — supports this finding. He testified that

Sandoval’s prior stabilizing dose of Geodon was unsafe at nearly

twice the recommended maximum dose and that a moderate dose of

Zyprexa was a safer treatment. Dr. Pillai also testified that in his

opinion, Geodon was not effective in treating Sandoval. Moreover,

he could not confirm Sandoval’s testimony that Geodon caused

minimal side effects.1

¶ 13 Viewing the evidence as a whole and in the light most

favorable to the People, we conclude that the record supports the

court’s finding that no less intrusive treatment alternative is

available to treat Sandoval’s illness. See Strodtman, 293 P.3d at

133; Medina, 705 P.2d at 974.

1 Sandoval argues, for the first time on appeal, that Dr. Pillai

insufficiently explained (1) why he didn’t treat Sandoval with a
lower dose of Geodon or (2) how a moderate dose of Zyprexa would
achieve the same effect as high levels of Geodon. Because the court
did not hear credible testimony that Geodon was “as effective at
alleviating [Sandoval’s] condition as the proposed treatment,” this
specific testimony was unnecessary. People in Interest of
Strodtman, 293 P.3d 123, 133 (Colo. App. 2011).

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B. The Fourth Medina Element

¶ 14 In assessing the fourth Medina element — whether the

patient’s need for treatment is sufficiently compelling to override

any legitimate interest in refusing treatment — a court must

determine (1) “whether the patient’s refusal is bona fide and

legitimate” and, if so; (2) “whether the prognosis without treatment

is so unfavorable that the patient’s personal preference must yield

to the legitimate interests of the state in preserving the life and

health of the patient placed in its charge and in protecting the

safety of those in the institution.” Medina, 705 P.2d at 974.

¶ 15 The district court first found that Sandoval’s expressed

willingness to take and preference for Geodon was not credible, and

therefore he did not have a bona fide and legitimate reason to refuse

the requested medications. Sandoval challenges this finding. We

conclude that Sandoval expressed a bona fide and legitimate reason

to refuse medications.

¶ 16 Sandoval told the district court that he wished to refuse

Zyprexa because it caused muscle stiffness or locking — a side

effect that Dr. Pillai acknowledged was associated with Zyprexa.

Indeed, Dr. Pillai said that he would monitor Sandoval’s muscle

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stiffness and try reducing his Zyprexa dosage once Sandoval

“achieved a relative baseline.” Bona fide and significant adverse

effects can constitute a legitimate reason to refuse medication. See

People in Interest of Uwayezuk, 2023 COA 69, ¶ 62.

¶ 17 However, the court also found that Sandoval’s need for

treatment was compelling, that involuntary treatment was

necessary to prevent harm to others in the facility, and thus, the

state’s legitimate interests in treating him override any bona fide

and legitimate interest in refusing treatment. The record supports

these findings. Dr. Pillai’s affidavit and testimony show that when

unmedicated, Sandoval refused to eat meals because he believed

they were poisoned, was “extremely aggressive and agitated,” and

verbally and physically threatened staff. Thus, in an unmedicated

or inadequately medicated state, the state’s legitimate interests in

treating Sandoval to prevent him from harming himself or others

outweighed his legitimate interest in refusing treatment.

Accordingly, we conclude that sufficient evidence supports the

district court’s ultimate finding as to this Medina element.

IV. Disposition

¶ 18 The order is affirmed.

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JUDGE WELLING and JUDGE KUHN concur.

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