Peo in Interest of Zambrano

25CA0356 Peo in Interest of Zambrano 05-08-2025

COLORADO COURT OF APPEALS

Court of Appeals No. 25CA0356
Pueblo County District Court No. 24MH30123
Honorable Scott B. Epstein, Judge

The People of the State of Colorado,

Petitioner-Appellee,

In the Interest of Joshua D. Zambrano,

Respondent-Appellant.

ORDER AFFIRMED

Division VII
Opinion by JUDGE PAWAR
Lipinsky and Lum, JJ., concur

NOT PUBLISHED PURSUANT TO C.A.R. 35(e)
Announced May 8, 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 Joshua D. Zambrano appeals the district court’s order

authorizing the involuntary administration of antipsychotic and

mood-stabilizing medications. We affirm.

I. Background

¶2 Zambrano was committed to the Colorado Mental Health

Hospital in Pueblo (CMHHIP) after being found incompetent to

proceed in a criminal case. He was diagnosed with schizophrenia

and presented with symptoms including delusional ideations,

paranoia, impulsiveness, and disorganization. Zambrano was

administered emergency medication after he became verbally

aggressive and physically assaultive to CMHHIP staff. Thereafter

the district court granted the People’s petition for the involuntary

administration of Zyprexa and Depakote.

¶3 Over the following two months Zambrano continued to

experience psychotic symptoms that affected his thinking and

behavior. He continued to display assaultive behavior, which

necessitated a request by his treatment team to change his court-

ordered antipsychotic medication. At the request of CMHHIP staff

psychiatrist Dr. Hareesh Pillai, the People petitioned the district

court to authorize the involuntary administration of risperidone

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(Risperdal), olanzapine (Zyprexa), haloperidol (Haldol), and valproic

acid (Depakote).

¶4 The district court held an evidentiary hearing at which Dr.

Pillai and Zambrano testified. Dr. Pillai explained Zambrano’s

disorder and accompanying symptoms. He described the requested

medications, their possible side effects, and their necessity in

treating Zambrano’s symptoms. Also, during the hearing Dr. Pillai

withdrew his request for the involuntary administration of Depakote

and added a request to treat Zambrano with UZEDY, a long-acting

monthly injectable formulation of Risperdal.

¶5 Zambrano denied having a mental illness. He also described

the side effects he had experienced since taking the requested

medications and his general preference not to take any medication.

¶6 Finding that Dr. Pillai testified “credibly and . . . very

persuasively,” the district court granted the petition and entered an

order authorizing the involuntary administration of Risperdal (orally

or by nasogastric “NG” tube daily) or UZEDY (intramuscularly “IM”

monthly), Zyprexa (orally or IM daily), and Haldol (orally or IM

daily).

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II. Legal Principles and Standard of Review

¶7 An involuntarily committed person retains the right to refuse

treatment. See People v. Medina, 705 P.2d 961, 971 (Colo. 1985).

Even so, a court may authorize the involuntary administration of

medication if the People prove the following elements by clear and

convincing evidence:

(1) the patient is incompetent to effectively
participate in the treatment decision;

(2) treatment by antipsychotic medication is
necessary 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 himself or
others in the institution;

(3) no less intrusive treatment alternative is
available; and

(4) the patient’s need for treatment by
antipsychotic medication is sufficiently
compelling to override his bona fide and
legitimate interest in refusing treatment.

Id. at 973. We determine whether the evidence, viewed as a whole

and in the light most favorable to the People, is sufficient to support

the court’s order. People in Interest of R.K.L., 2016 COA 84, ¶ 13. A

physician’s testimony alone may be sufficient to satisfy the Medina

test. Id. at ¶ 30.

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¶8 Applying the Medina test presents a mixed question of fact and

law, meaning we defer to the district court’s factual findings if

supported by the record but review its legal conclusions de novo.

People in Interest of R.C., 2019 COA 99M, ¶ 7. It is for the district

court, as the fact finder, to determine witness credibility; the

sufficiency, probative effect, and weight of the evidence; and the

inferences and conclusions to be drawn from it. Id.

III. Discussion

¶9 Zambrano does not contest the district court’s findings on the

first and second Medina elements. But he contends that the People

did not present sufficient evidence to prove the third and fourth

Medina elements. We disagree.

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

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

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

treatment.” People in Interest of Strodtman, 293 P.3d 123, 133

(Colo. App. 2011).

¶ 11 Dr. Pillai testified that when Zambrano began refusing all

medications, he was given IM backups of Zyprexa and NG backups

of Depakote. However, the NG backup of Depakote was

discontinued after about eight days because the repetitive

placement of the NG tube caused “extreme bleeding” from

Zambrano’s nasal passages and “it was determined that the risk of

daily [NG] tube placement outweighed any benefits.” And while Dr.

Pillai removed his request to administer an NG backup of Depakote,

a portion of the treatment plan includes the possibility of

administering an NG backup of Risperdal should Zambrano refuse

the oral administration.

¶ 12 Based on this testimony, Zambrano contends that there are

less intrusive alternatives to the portion of the treatment plan that

involves administering Risperdal through an NG tube.

¶ 13 First, Zambrano alleges that involuntary administration of

Risperdal could be forgone altogether based on Dr. Pillai’s testimony

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that he had not observed “any acute signs of psychosis or mania”

since the treatment team decided to stop the administration of

Depakote and treat only with Zyprexa.

¶ 14 True, Dr. Pillai testified that he had not observed any acute

signs of psychosis or mania since the treatment team decided to

stop the administration of Depakote. But Dr. Pillai also testified

that “at this point in time, it does not appear that the Zyprexa is

effectively treating [Zambrano’s] underlying symptoms.” Dr. Pillai

explained that while “[Zambrano] has improved from his significant

impulsivity, disorganized thinking, and extremely psychotic

presentation[,] . . . he continues to have underlying symptoms that

affect his behaviors.” For example, Dr. Pillai testified that

Zambrano “continues to have treatment-resistant symptoms,

psychosis, including ongoing delusions and paranoia. And this

makes him a danger to others.”

¶ 15 Further, when asked whether Zambrano could be treated with

Zyprexa alone, Dr. Pillai opined that he could not. Dr. Pillai

explained that while Zambrano had been on therapeutic dosages of

Zyprexa and, for the most part, Depakote since the last court order

for involuntary medication, he “continues to have treatment

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resistant symptoms that influence his behavior.” Moreover, Dr.

Pillai did not expect Zambrano to voluntarily take Zyprexa “given

his refusals over the past few weeks.” Thus, we disagree that the

evidence presented at the hearing supports a finding that Zambrano

could be treated successfully with Zyprexa alone.

¶ 16 Next Zambrano asserts that Haldol could be used in place of

Risperdal with an NG tube based on Dr. Pillai’s testimony that

Haldol is “similar to Risperdal.” But as we understand Dr. Pillai’s

testimony, the treatment plan would be to first administer an oral

dose of Risperdal to see if Zambrano is able to tolerate this

medication. And so long as there were “no acute side effects or

adverse reactions, like allergic reactions,” UZEDY, a long-acting

monthly injectable formulation of Risperdal, would then be

administered. Dr. Pillai also testified that Haldol, which is “similar

to Risperdal,” would be used “as an IM backup for any oral

refusals.” Thus, it appears already part of the treatment plan that

Zambrano would be given Haldol only if he refused the oral

administration of Risperdal.

¶ 17 But even if Dr. Pillai elected to administer the NG form of

Risperdal after an oral refusal, Dr. Pillai explained that Zambrano

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only needed “two to three days of oral medication compliance” to

account for any possible adverse reactions before UZEDY could be

administered. And the “extreme bleeding” from Zambrano’s nasal

passages resulted after “eight or nine days” of repetitive placement

of the NG tube.

¶ 18 Crediting Dr. Pillai’s testimony and explicitly adopting his

opinions, the district court found that there were no “less intrusive

treatment alternatives available” and “[t]he psychiatric medications

are the only form of treatment that can effectively treat

[Zambrano’s] mental illness, at this time.” Because the record

supports the court’s determination, we will not disturb it and, to the

extent Zambrano asks us to second-guess witness credibility or

draw different inferences from the testimony, we decline to do so.

See R.C., ¶ 7.

B. The Fourth Medina Element

¶ 19 The fourth Medina element is whether the patient’s need for

treatment is sufficiently compelling to override any legitimate

interest in refusing treatment. Medina, 705 P.2d at 974. In

assessing whether this element is satisfied, a court must consider

“whether the patient’s refusal is bona fide and legitimate” and, if it

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is, “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.” Id. at 974.

¶ 20 The district court found that there was not a “bona fide or

legitimate reason to refuse the medication.” The court noted that

Zambrano’s stated reason for refusal was generally that he “doesn’t

like medications” and “he claims he’s a conservative Christian, and,

as such, does not believe in taking pharmaceuticals” but “is

voluntarily taking the Zyprexa,” which “seems inconsistent.”

¶ 21 Zambrano alleges that in addition to his religious preferences,

he has a legitimate interest in avoiding severe side effects. In

particular he points to the testimony at the hearing concerning the

use of the NG tube and its associated side effects — namely, his

testimony that he had “been definitely experiencing breathing

problems since the NG tubes were used” and Dr. Pillai’s testimony

that using the NG tube to administer Risperdal “could cause some

difficulties with breathing due to just irritation of the nasal

passages.”

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¶ 22 Avoiding unwanted or harmful side effects from medications is

a bona fide and legitimate reason for refusing treatment. See id.

(“The patient’s refusal may stem from a prior unfavorable

experience with similar treatment . . . .”). Thus, the district court

erred by concluding that Zambrano’s reasons for refusing the

requested medications were not bona fide and legitimate. However,

the court went on to say that, even if Zambrano had a bona fide and

legitimate reason for refusing medications because a sect of his

“conservative Christian religious group . . . [did] not believe in

psychiatric medication, his prognosis is so unfavorable that his

personal preference has to yield to the legitimate interest of the

state in preserving his mental health while he’s placed in their

protective custody at the institution.” The record supports this

determination.

¶ 23 Dr. Pillai opined that the failure to medicate Zambrano would

be more harmful than the risk posed by the requested medications.

In support of this opinion, Dr. Pillai testified that, “[w]ithout the

medications, he will suffer a deterioration that will significantly

impact him and make him more of a danger to others.” Dr. Pillai

noted that before his first round of emergency medications,

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Zambrano “was assaultive and aggressive towards staff members

and had punched out staff members, requiring seclusion and

restraint.” More recently, he punched Dr. Pillai “due to his

unwillingness to take medications.” Despite this, Dr. Pillai agreed

that with the medications, Zambrano’s symptoms improved and “in

general, he has become less aggressive on the unit.”

¶ 24 Dr. Pillai acknowledged that the requested medications had

some potential adverse side effects. But, he explained, Zambrano

would be monitored for any side effects once he started the

requested medication regimen, and additional medications could

neutralize some of the side effects. And Dr. Pillai opined that (1) the

need to treat Zambrano with the requested medications outweighed

the risk of side effects; (2) no alternative treatment would be both as

effective and less intrusive than the requested medications; (3)

without the medications, there would be significant and long-term

deterioration in Zambrano’s mental condition; (4) without the

medications, Zambrano poses a serious risk of harm to others; and

(5) Zambrano had no insight into his mental condition, and his

refusal to take the medications was irrational and unreasonable.

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¶ 25 We therefore conclude that sufficient evidence supports the

court’s finding that, even assuming a bona fide and legitimate

reason for Zambrano’s refusal of treatment, his prognosis without

the requested medications is so unfavorable that his personal

preference must yield to the state’s legitimate interests in preserving

his life and health and protecting the safety of those in the

institution.

IV. Disposition

¶ 26 The order is affirmed.

JUDGE LIPINSKY and JUDGE LUM concur.

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