B-130360, MAR. 6, 1957

B-130360: Mar 6, 1957

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WAS COMMITTED FOR THE FIFTH TIME TO THE MORNINGSIDE HOSPITAL ON OCTOBER 13. WHEN SHE WAS UNDERGOING A ROUTINE PHYSICAL EXAMINATION PREPARATORY TO HER DISCHARGE AND RETURN TO ALASKA THE FOLLOWING DAY. IT WAS DISCOVERED THAT SHE WAS THREE TO FOUR MONTHS PREGNANT. HER DISCHARGE WAS CANCELED. AKELKOK'S CASE WAS REVIEWED AT SOME LENGTH. AT THE TIME THIS FORWARD STEP IN THE HANDLING OF MENTAL PATIENTS WAS TAKEN CERTAIN DIFFICULTIES WERE FORESEEN. IT WAS DECIDED TO KEEP THE PATIENT UNDER MEDICAL CARE. THOMPSON SAID: "WITH THIS HISTORY ("* * * THE PATIENT'S PREVIOUS HISTORY OF ACUTE EMOTIONAL EPISODES UNDER SIMILAR CIRCUMSTANCES IN EVEN MORE PERMISSIVE ENVIRONMENTS.''" IT WAS. "THE APPARENT STABILITY OF HER PRESENT REMISSION BEING AS IT IS PUTTO WHAT IS IN HER CASE THE ULTIMATE TEST IS A GRATIFYING ASPECT OF THIS UNFORTUNATE OCCURRENCE.

B-130360, MAR. 6, 1957

TO MR. CHARLES BONNEVILLE, AUTHORIZED CERTIFYING OFFICER, OFFICE OF TERRITORIES:

YOUR LETTER OF JANUARY 15, 1957, REQUESTS OUR DECISION REGARDING THE GOVERNMENT'S FINANCIAL OBLIGATION FOR THE SUPPORT OF MRS. MASSA AKELKOK, A PATIENT AT MORNINGSIDE HOSPITAL, PORTLAND, OREGON.

MRS. AKELKOK, WHO HAD BEEN LEGALLY ADJUDGED INSANE IN ALASKA, WAS COMMITTED FOR THE FIFTH TIME TO THE MORNINGSIDE HOSPITAL ON OCTOBER 13, 1953. ON FEBRUARY 28, 1956, WHEN SHE WAS UNDERGOING A ROUTINE PHYSICAL EXAMINATION PREPARATORY TO HER DISCHARGE AND RETURN TO ALASKA THE FOLLOWING DAY, IT WAS DISCOVERED THAT SHE WAS THREE TO FOUR MONTHS PREGNANT. HER DISCHARGE WAS CANCELED. IN A LETTER DATED MAY 15, 1956, FROM THE MEDICAL DIRECTOR OF THE HOSPITAL, DR. THOMPSON, TO THE GOVERNMENT'S RESIDENT MEDICAL OFFICER, DR. KELLER, MRS. AKELKOK'S CASE WAS REVIEWED AT SOME LENGTH.

ACCORDING TO THIS LETTER, SOMETIME IN JUNE 1955 THE MEDICAL STAFF AT MORNINGSIDE HOSPITAL ADOPTED THE POLICY OF ACCORDING GROUND PRIVILEGES TO WOMEN PATIENTS RATHER THAN CONFINING THEM TO LOCKED QUARTERS. AT THE TIME THIS FORWARD STEP IN THE HANDLING OF MENTAL PATIENTS WAS TAKEN CERTAIN DIFFICULTIES WERE FORESEEN, INCLUDING THE POSSIBILITY OF OCCASIONAL INCIDENTS SUCH AS THAT WHICH BEFELL MRS. AKELKOK. DR. KELLER CONCURRED IN THE ORIGINAL DECISION IMPLEMENTING THIS NEW POLICY AND, DESPITE THE INVOLVED UNFORTUNATE OCCURRENCE, NO ONE HAS SUGGESTED ABANDONMENT OF THE POLICY. AT THE STAFF MEETING OF MARCH 1, 1956, IT WAS DECIDED TO KEEP THE PATIENT UNDER MEDICAL CARE. WHEN SPEAKING OF THIS ASPECT OF THE CASE, DR. THOMPSON SAID:

"WITH THIS HISTORY ("* * * THE PATIENT'S PREVIOUS HISTORY OF ACUTE EMOTIONAL EPISODES UNDER SIMILAR CIRCUMSTANCES IN EVEN MORE PERMISSIVE ENVIRONMENTS.''" IT WAS, OF COURSE, ESSENTIAL THAT MRS. AKELKOK'S DISCHARGE FROM THE HOSPITAL AND RETURN TO ALASKA BE POSTPONED FOR A PERIOD LONG ENOUGH TO DETERMINE HER EMOTIONAL STABILITY UNDER THESE CIRCUMSTANCES.

"THE APPARENT STABILITY OF HER PRESENT REMISSION BEING AS IT IS PUTTO WHAT IS IN HER CASE THE ULTIMATE TEST IS A GRATIFYING ASPECT OF THIS UNFORTUNATE OCCURRENCE. IT WOULD SEEM THAT SOLID GAINS HAVE BEEN MADE BY MRS. AKELKOK IN THE CONTROL OF HER EMOTIONAL STATUS DURING THIS PERIOD OF HOSPITALIZATION.'

BECAUSE THE MEDICAL STAFF CONSIDERED THE POSSIBILITY OF A SITUATION SUCH AS THIS ARISING WHEN THE "GROUND RULES" WERE CHANGED, YET DECIDED TO PROCEED ON A "CALCULATED RISK" BASIS, YOU HAVE REQUESTED A DEDUCTION OF THE AMOUNT PAID FOR MRS. AKELKOK'S CARE FROM MARCH 1 TO NOVEMBER 30, 1956, AND YOU HAVE ORDERED A SUSPENSION OF AMOUNTS CLAIMED FOR FUTURE CARE. MOREOVER, YOU SAY THAT REPORTS RECEIVED FROM THE MEDICAL OFFICER SINCE AUGUST INDICATE THAT THE PATIENT IS STILL ELIGIBLE FOR DISCHARGE, BUT NO ARRANGEMENTS HAVE BEEN MADE.

STATUTORY AUTHORITY FOR CARE OF THE ALASKA INSANE IS CONTAINED IN TITLE 48 U.S.C. SECTION 46, AND FOLLOWING SECTIONS. PURSUANT TO THIS AUTHORITY THE SECRETARY OF THE INTERIOR ENTERED INTO CONTRACT NO. 14 04-001-81 ON JUNE 18, 1953, WITH THE SANITARIUM COMPANY, WHICH OPERATES MORNINGSIDE HOSPITAL. AMONG THE PROVISIONS OF THIS CONTRACT ARE THE FOLLOWING:

"SECTION 3. (A) THE COMPANY AGREES TO MAINTAIN, TO CARE FOR, AND TO ADMINISTER MEDICAL AND PSYCHIATRIC TREATMENT TO SAID PATIENTS, IN A MANNER SATISFACTORY TO THE SECRETARY, UNDER THE CONDITIONS AND AT THE RATE OF COMPENSATION HEREINAFTER PROVIDED.

"SECTION 6. (A) THE SECRETARY SHALL HAVE THE RIGHT TO PLACE A MEDICAL OFFICER (HEREINAFTER REFERRED TO AS "THE MEDICAL OFFICER") AT THE HOSPITAL WHO SHALL SUPERVISE THE EXECUTION OF THE TERMS OF THIS CONTRACT. THE MEDICAL OFFICER SHALL DIRECT AND SUPERVISE THE ACCEPTANCE, THE WELFARE AND TREATMENT, AND THE RELEASE OF ALL PATIENTS.

"SECTION 10. THE COMPANY, WITH THE APPROVAL OF THE MEDICAL OFFICER, SHALL DISCHARGE ANY PATIENT, * * *, UNDER THE FOLLOWING CONDITIONS:

(1) UPON THE WRITTEN CERTIFICATION BY THE MEDICAL OFFICER THAT SUCH PATIENT IS CONSIDERED TO BE RECOVERED.

(2) UPON THE WRITTEN CERTIFICATION BY THE MEDICAL OFFICER THAT SUCH PATIENT, WHILE NOT CONSIDERED RECOVERED, IS CONSIDERED TO BE IN REMISSION AND IS NOT DEEMED DANGEROUS TO HIMSELF OR OTHERS AND IS ABLE TO SUPPORT HIMSELF.'

THE SECTION REGARDING DISCHARGE OF PATIENTS, WHICH SUBSTANTIALLY FOLLOWS THE CONDITIONS SET FORTH AT 48 U.S.C. 47B, CONTAINS OTHER CONDITIONS FOR DISCHARGE, BUT NONE OF THE OTHERS APPEARS APPLICABLE TO MRS. AKELKOK.

AS STATED IN THE CONTRACT, THE HOSPITAL AGREED TO ADMINISTER MEDICAL AND PSYCHIATRIC TREATMENT IN A MANNER SATISFACTORY TO THE SECRETARY OF THE INTERIOR. RESPONSIBLE STAFF OFFICERS OF THE INSTITUTION INITIATED A POLICY OF GROUND PRIVILEGES FOR WOMEN PATIENTS, A POLICY WHICH WAS AGREED TO, OR AT LEAST NOT OBJECTED TO, BY THE MEDICAL OFFICER WHO IS THE SECRETARY'S REPRESENTATIVE. SINCE THIS POLICY WAS ADOPTED FOR THE BENEFIT OF ALL PATIENTS, UNUSUAL RESULTS WITH ONE PATIENT, EVEN THOUGH PREDICTED AND ASSUMED AS A CALCULATED RISK, CANNOT OBVIATE THE GOVERNMENT'S OBLIGATION TO COMPENSATE THE HOSPITAL AT THE CONTRACT RATE. OR, FROM ANOTHER VIEW, THE GOVERNMENT WILL GAIN FINANCIALLY WHEN THE VAST MAJORITY OF PATIENTS WHO COMPLETE THEIR RECOVERY MORE QUICKLY BECAUSE OF THE NEW GROUND RULES ARE RELEASED FROM THE HOSPITAL AT AN EARLIER DATE.

NOTWITHSTANDING THE CHANGE IN POLICY THE GOVERNMENT'S LIABILITY FOR PAYMENT IS FIXED BY STATUTE AND THE INVOLVED CONTRACT; AND FOR PRACTICAL PURPOSES HERE, MRS. AKELKOK MAY BE DISCHARGED ONLY UPON "WRITTEN CERTIFICATION BY THE MEDICAL OFFICER.' SINCE IT DOES NOT APPEAR IN THE RECORD THAT DR. KELLER HAS EVER CERTIFIED HER RELEASE, THE UNITED STATES IS RESPONSIBLE FOR MRS. AKELKOK'S CARE UNTIL SUCH TIME AS A CERTIFICATE OF DISCHARGE ISSUES.

WE ARE NOT UNMINDFUL THAT A MEDICAL OFFICER ENJOYS CONSIDERABLE DISCRETION WHEN DETERMINING THE ELIGIBILITY OF ANY GIVEN PATIENT FOR DISCHARGE. CERTAINLY, SUCH DISCRETIONARY POWER IS NECESSARY IN SITUATIONS WHERE, AS HERE, THE DETERMINATION IS HIGHLY SUBJECTIVE AND BASED UPON THE EVALUATION OF COMPLEX TECHNICAL INFORMATION. WHILE A QUESTION MAY ARISE IN THE MIND OF A LAYMAN AS TO THE NECESSITY OF KEEPING MRS. AKELKOK, ALLEGEDLY ELIGIBLE FOR DISCHARGE, IN MORNINGSIDE HOSPITAL FOR SIX MONTHS AFTER THE CHILD'S BIRTH AND ONE YEAR AFTER HER SCHEDULED RETURN TO ALASKA, AN EXPERIENCED PSYCHIATRIST MIGHT AGREE THAT SUCH RETENTION IS WARRANTED.

OUR DECISION B-54982, MARCH 8, 1946, REGARDING THE QUESTION WHETHER THE GOVERNMENT SHOULD BEAR THE COST OF MAINTAINING A CHILD BORN TO AN INMATE AT MORNINGSIDE HOSPITAL, IS NOT FOR APPLICATION NOR CONTROLLING HERE.

ACCORDINGLY, OUR OFFICE WILL INTERPOSE NO OBJECTION TO PAYMENTS TO THE SANITARIUM COMPANY FOR MRS. AKELKOK'S CARE FOR THE PERIOD PRIOR TO HER DISCHARGE. HOWEVER, IN VIEW OF THE PROTRACTED PERIOD OF HER APPARENT REMISSION OR ELIGIBILITY FOR DISCHARGE, IT MAY BE THAT THE MEDICAL OFFICER AND THE HOSPITAL AUTHORITIES SHOULD REVIEW HER PRESENTMENTAL CONDITION WITH A VIEW, IF SUCH CONDITION WARRANTS, TO HER DISCHARGE AT AN EARLY DATE.