This opinion is nonprecedential except as provided by
                       Minn. R. Civ. App. P. 136.01, subd. 1(c).

                              STATE OF MINNESOTA
                              IN COURT OF APPEALS
                                    A24-0067

           In the Matter of the Civil Commitment of: Leah Christina Graeber.

                                  Filed June 10, 2024
                                       Affirmed
                                    Schmidt, Judge

                             Dakota County District Court
                              File No. 19HA-PR-11-157

Jennifer L. Thon, Jonathon M. Comuzzi, Jones Law Office, Mankato, Minnesota (for
appellant Leah Christina Graeber)

Keith Ellison, Attorney General, St. Paul, Minnesota; and

Kathryn M. Keena, Dakota County Attorney, Jessica A. Bierwerth, Assistant County
Attorney, Hastings, Minnesota (for respondent Dakota County Social Services)

       Considered and decided by Worke, Presiding Judge; Schmidt, Judge; and Florey,

Judge. ∗

                          NONPRECEDENTIAL OPINION

SCHMIDT, Judge

       Appellant Leah Christina Graeber was committed to the Minnesota Commissioner

of Human Services as a person who is dangerous and who poses a risk of harm due to

mental illness. To advance appellant’s treatment—which has stagnated—a licensed

psychiatrist at Minnesota Security Hospital sought authorization to treat appellant with


∗
 Retired judge of the Minnesota Court of Appeals, serving by appointment pursuant to
Minn. Const. art. VI, § 10.
electroconvulsive therapy (ECT), which respondent Dakota County Social Services (the

county) supported, and appellant opposed. After an evidentiary hearing, the district court

granted the petition to authorize ECT. On appeal, appellant argues that the record does not

support the district court’s determination that ECT is reasonable and necessary. Because

the court considered the relevant factors in finding that ECT was reasonable and necessary

for appellant, and the record supports the district court’s findings, we affirm.

                                          FACTS

       Initial commitment and subsequent treatment.

       Appellant was initially committed to the commissioner of human services in 2011.

The commitment stemmed from a 2010 incident in which appellant drove a car over 100

miles per hour, lost control, and struck an oncoming vehicle. The crash killed an 11-year-

old boy and injured his parents and sister. Appellant reported she felt safe driving at that

speed because she was God. In subsequent interviews, appellant claimed the 11-year-old

boy was not dead. Her commitment was finalized, and became indeterminate, in 2012.

       Doctors have diagnosed appellant with schizoaffective disorder, bipolar type, and

controlled-substance disorders. She has been treated with neuroleptic medications and

medications to assist with mood stability. After significant treatment, appellant has earned

most privileges that can be granted to patients.       Appellant also maintains part-time

employment in the hospital. She is neither aggressive nor an imminent danger to herself.

       Yet, despite being on “robust doses of neuroleptic medications,” appellant continues

to have “refractory psychotic and mood symptoms” that “prevent her from moving forward

in treatment to a less restrictive setting.” Appellant has never had any previous ECT.


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      The petition for ECT and first examiner’s recommendation to perform ECT.

      In 2023, a licensed psychiatrist at the hospital petitioned for the authorization to

administer ECT to appellant. The psychiatrist noted that appellant’s “refractory symptoms

are preventing her from moving forward in treatment to a less restrictive setting,” and

“[a]fter exhausting the different psychotropic medication treatment modalities in addition

to therapy, ECT remains the least restrictive treatment for [appellant] at this time.” The

proposed treatment constituted an acute phase of three times per week for a maximum of

30 treatments. If successful, the proposed treatment would move to a maintenance phase,

consisting of two or fewer treatments per week for the duration of appellant’s commitment.

      Prior to a hearing on the petition, the court received a report from a court-appointed

examiner. In his report, the examiner noted that “[m]ultiple records indicate that when

[appellant] is not medication compliant she quickly and ‘profoundly’ decompensates.” The

examiner concluded that ECT was both reasonable and necessary. He also opined that

appellant does not have the capacity to make a competent decision regarding ECT because

she could not “express a clear choice that was not based on delusional thoughts.”

      The second court-appointed examiner also recommended ECT.

      At appellant’s request, the district court appointed a second examiner. The second

examiner opined that appellant “remained psychotic and delusional in September 2023”

and that appellant “demonstrated a poor understanding and was uncooperative,” when a

psychiatrist attempted to discuss ECT with her. The examiner reiterated that appellant was

actively psychotic, persistently delusional, in extreme denial, and that “[p]harmacologic

management has been extensively tried and the reasonable possibilities exhausted.”


                                            3
       The examiner noted that “[i]t was virtually impossible to break through [appellant’s]

delusional grandiosity” and that appellant’s insight is “extremely poor, and her denial is

extreme.” Additionally, the examiner noted that appellant’s judgment “is often just as

impaired, specifically in the area of treatment need and self-care.”

       The examiner discussed the general necessity and reasonableness of ECT before

analyzing the six specific factors articulated by the Minnesota Supreme Court 1 for courts

to consider in determining the necessity and reasonableness of a proposed treatment. The

examiner opined that appellant meets the criteria for the administration of ECT.

       The examiner acknowledged that with ECT, “the most optimistic outcome is, in

general, slightly less than 50% of patients will see slightly less than 50% symptom

improvement.” However, the examiner continued, “[g]iven that this combination of

treatment modalities is reserved for the most seriously mentally ill, even that somewhat

lackluster statistical response is well worth it for those patients who do respond.” The

examiner concluded that appellant has been receiving treatment for over ten years and “is

still severely symptomatic and mentally ill, and . . . [w]ithout this combination of

aggressive treatment, there appears to be no realistic hope that [appellant] can ever be

safely released to the community.”




1
 In Price v. Sheppard, the Minnesota Supreme Court articulated six factors for courts to
consider in determining the necessity and reasonableness of a proposed treatment.

 (Minn. 1976).

                                             4
       Despite her recommendation of ECT, the examiner included a caveat related to the

difficulties presented by the particular facts of this case. The examiner noted that the

majority of cases that use ECT involve a patient who “is at serious risk of physical illness

without ECT, due to immobility and/or inadequate fluid or food intake; or in the alternative,

the patient is so suicidal or aggressive that he is a danger to himself or others.” The

examiner noted that appellant is not aggressive, an imminent danger to herself, or in

physical danger from her symptoms. Nonetheless, the examiner recognized that appellant

has not adequately responded to “less intrusive forms of treatment.”

       While appellant is “adamantly against ECT,” the examiner explained that

appellant’s “reasons for refusing ECT are based on delusion” and she is not able to make

a “rational . . . decision that she would prefer to remain hospitalized in order to avoid ECT.”

From a medical standpoint, the examiner concluded that ECT is “virtually the only option

available that can be hoped to provide at least a moderate degree of improvement and may

offer the potential ability to move forward in treatment.”

       The district court ordered ECT.

       At an October 2023 hearing, the district court received the examiner reports and

heard testimony that ECT is reasonable and necessary. The second examiner testified that

appellant “has gone as far as she can go with neuroleptic medications,” and that healthcare

professionals are “really at a fork in the road and the end of the line with [appellant].” The

second examiner reiterated that appellant “is quite clearly at the point where a combination

of Clozaril and ECT is essentially the only thing left for her.” On cross-examination, the

second examiner acknowledged that appellant is not the typical patient for ECT.


                                              5
       Appellant testified at the hearing about her current setting, including her work,

outings, and treatment. Appellant testified that she is not delusional and that “doctors want

to make [her] look bad and libel and slander everything they can against [her] just to make

[her] suffer [because] they can’t stand what [she] believes in.”

       In its findings of fact, conclusions of law, and order authorizing the administration

of ECT, the district court found that appellant’s “symptoms have persisted despite robust

doses of neuroleptic medication and [the symptoms] are preventing her from moving

forward in treatment.” The district court noted that each examiner determined that ECT

was necessary and reasonable for appellant.

       The district court found appellant was articulate, intelligent, and able to express her

feelings and opinions, including that she was opposed to ECT. But the district court

determined that the second examiner “credibly testified that [appellant] is without the

capacity to determine for herself whether the proposed treatment is necessary or desirable

as she lacks insight into her mental illness and therefore cannot rationally weigh the risks

and benefits involved with such treatment.” Acknowledging that the benefits of ECT are

not “robust,” and appellant is “independent in terms of her activities of daily living,” the

district court gave “great weigh[t]” to the second examiner’s opinion that “even [the]

somewhat lackluster statistical response is well worth it for those patients who do respond.”

The court also credited the examiner’s opinion that health professionals are “largely at the

end of the road in terms of what to offer [appellant]” and “[w]ithout this combination of

aggressive treatment, there appears to be no realistic hope that [appellant] can ever be

safely released to the community.”


                                              6
       The district court made findings for each Price factor and determined that ECT is

necessary and in appellant’s best interests. The court held that appellant’s “clinical

condition has failed to adequately respond to less intrusive treatment modalities. Although

exact efficacy is uncertain, ECT will likely improve [appellant’s] mental status which may

improve her likelihood of getting an order to leave the hospital.”           After “carefully

considering” the Price factors, the district court found clear and convincing evidence that

the treatment of appellant’s mental illness using ECT is necessary and reasonable.

       This appeal follows.

                                        DECISION

       In reviewing an order authorizing medical treatment, we must affirm the district

court’s findings if there is reasonable evidence to support them. See In re Peterson,

 (Minn. App. 1989), rev. denied (Minn. Dec. 1, 1989). We will not

reweigh the evidence and will not conclude that a fact-finder has clearly erred unless we

are left with a definite and firm conviction that a mistake has been made. In re Civ.

Commitment of Kenney, 

, 221 (Minn. 2021).

       Minnesota law authorizes the head of a treatment facility to petition the district court

for an order authorizing the prescribed treatment if a patient is incompetent to give consent

or refuses consent. See Minn. Stat. § 253B.03, subd. 6(b)(3) (2022). The court must then

determine the “necessity and reasonableness of the prescribed treatment.”               Price,

. The district court must balance the patient’s need for treatment against

the intrusiveness of the prescribed treatment. 

 In doing so, the Minnesota Supreme

Court has articulated six factors that district courts should consider:


                                              7
              (1) the extent and duration of changes in behavior patterns and
              mental activity effected by the treatment, (2) the risks of
              adverse side effects, (3) the experimental nature of the
              treatment, (4) its acceptance by the medical community of this
              state, (5) the extent of intrusion into the patient’s body and the
              pain connected with the treatment, and (6) the patient’s ability
              to competently determine for himself whether the treatment is
              desirable.

Id.; see also 

.0600 (2021) (enumerating list of factors for determining

whether ECT is medically indicated). The treatment must also be “presently medically

necessary.” In re Kinzer, 

 (Minn. App. 1985) (emphasis in original)

(speculating about future necessity does not satisfy Price because it improperly delegates

the authority to medical personnel to evaluate the need for treatment and allows for

intrusive therapy to be imposed without notice to the patient or the patient’s attorney).

I.     The district court properly balanced the Price factors.

       Appellant argues that ECT is not “presently medically necessary.” Appellant relies

on the statutory language that provides the procedures to be used “to obtain consent for any

treatment necessary to preserve the life or health of any committed patient.” Minn. Stat.

§ 253B.03, subd. 6(b) (2022). Appellant then cites to a dictionary definition to assert that

“necessary” means “absolutely needed or required.”

       Appellant’s argument largely overlooks the framework established by the supreme

court in Price for determining whether a treatment is necessary and reasonable. Appellant,

instead, pursues a novel analysis that focuses on whether a treatment is “absolutely needed

or required to preserve” the life or health of the patient. But the Price factors subsume the

medical-necessity element that appellant wishes to have this court analyze separately.



                                              8
       In Price, the Minnesota Supreme Court adopted six factors that district courts should

consider in determining the “necessity and reasonableness of the prescribed treatment.”

. These factors have been consistently relied upon to determine the

necessity and reasonableness of treatment, both for ECT and neuroleptic medications. See,

e.g., Jarvis v. Levine, 

 (Minn. 1988) (noting that Price “enunciated

the criteria to be utilized by the probate courts in determining the necessity and

reasonableness of the proposed treatment”). 2 Those factors inherently address the question

that appellant wants separately analyzed: is the treatment medically necessary?

       We decline to extend Price to include appellant’s novel argument that would add an

independent analysis of medical necessity apart from the six factors articulated by the

supreme court. The function of this court is “limited to identifying errors and correcting

them.” Sefkow v. Sefkow, 

 (Minn. 1988); see Binkley v. Allina Health

Sys., 

, 554 n.7 (Minn. 2016) (noting that it is not a court’s place to

contemplate policy considerations entrusted to the legislature). As such, we turn to the

district court’s analysis of the Price factors and review whether the court’s findings are

supported by clear and convincing evidence.




2
  See also In re J.S.G., No. C2-96-1522, 

, at *2 (Minn. App. Dec. 17,
1996); In re Bublitz, No. CX-97-1570, 

, at *4 (Minn. App. Jan. 6, 1998); In
re Witthans, No. CX-94-1280, 

, at *2 (Minn. App. Sept. 27, 1994); In re
Cade, No. C5-97-1024, 

, at *2 (Minn. App. Oct. 28, 1997); In re Civ.
Commitment of Glem, A04-1908, 

, at *4 (Minn. App. Mar. 15, 2005); In
re Civ. Commitment of Tefera, No. A10-1770, 

, at *2 (Minn. App. Mar. 8,
2011). We cite these, and other, nonprecedential cases in this opinion for their persuasive
value. See Minn. R. Civ. App. P. 136.01, subd. 1(c).

                                             9
II.    The district court properly considered and balanced the Price factors.

       Appellant argues the district court’s analysis of the Price factors is not supported by

clear and convincing evidence and challenges the district court’s balancing of those factors.

We address each argument in turn.

       A.     The district court’s consideration of the Price factors is supported by
              clear and convincing evidence.

              1.     Extent and duration of changes effected by the treatment

       The district court found that the treatments proposed “are the least intrusive

treatment option” for “improving [appellant’s] condition.” The administration of ECT

“may decrease [appellant’s] delusional beliefs and psychotic behaviors, while making

[appellant] more comfortable and more able to participate in other forms of treatment.”

Without ECT, the district court found “[appellant’s] condition will likely remain the same

and may even deteriorate.” The court found that the mental-health professionals are “at

the end of the road in terms of what to offer” appellant. The district court determined that,

“[a]lthough exact efficacy is uncertain, ECT will likely improve [appellant’s] mental status

which may improve her likelihood of getting an order to leave the hospital.”

       These findings are supported by clear and convincing evidence because the second

examiner opined that, although slightly less than 50% of patients see improvement, “[t]he

efficacy of ECT is well established” and “can be expected to result in a stabilization of

mood as well as a potential decrease in psychotic symptoms.” While elimination or

significant reduction in delusional beliefs is the preferred goal, “decrease in emotional

instability and distress is acceptable and can result in an increased quality of life even in



                                             10
the absence of significant reduction in the definitive target symptoms.” The examiner

concluded that, despite over ten years of treatment, appellant “is still severely symptomatic

and mentally ill, and . . . [w]ithout this combination of aggressive treatment, there appears

to be no realistic hope that [appellant] can ever be safely released to the community.”

              2.     Risks of adverse side effects

       The district court acknowledged that ECT may result in side effects such as

headaches, muscle aches, drowsiness, confusion, and short-term memory loss. Although

uncommon, the court noted that “potentially serious side effects include, but are not limited

to, the risk associated with receiving general anesthesia, prolonged memory loss, or bone

fractures.” The district court also noted that ECT is performed “under close monitoring by

medical professionals,” and that the other serious side effects are “very uncommon.”

       These findings are supported by clear and convincing evidence in the record. The

second examiner explained how the use of anesthesia has minimized the risks associated

with ECT.     She noted that cognitive impairment is “usually limited and of short

duration, . . . memory impairment tends to disappear several months after cessation of

treatment,” and that “[p]rolonged or severe cognitive impairment, primarily memory loss,

is extremely rare.” Ultimately, the examiner concluded that “ECT is considered one of the

best tolerated biological therapies with low risk for severe complications.”

              3.     Experimental nature of the treatment

       The district court found that the use of ECT “is not an experimental form of

treatment,” and that it “has been utilized for many years to treat mental health disorders.”

This finding is supported by clear and convincing evidence, as demonstrated by the second


                                             11
examiner’s clear statement that ECT “is not experimental” and has been utilized for many

years “for treatment of mood disorders and for other serious psychiatric illnesses.”

              4.     Acceptance by the medical community

       The district court found that ECT is accepted in the general psychiatric community

in Minnesota and most other states. This is supported by clear and convincing evidence in

the record as the second examiner testified that ECT “is accepted in the general psychiatric

community both in Minnesota and in most states. It is in widespread use in many hospitals

in the area and is accepted as a highly effective and safe treatment for serious psychiatric

symptomology.”

              5.     Extent of intrusion into the patient’s body and pain

       The district court found that ECT “involves minimal pain connected with the

treatment,” because patients “are under general anesthesia while the ECT is given.” This

finding is also supported by clear and convincing evidence in the record as the second

examiner testified that the insertion of an intravenous line into the arm and monitoring

procedures are “painless.” Additionally, the examiner noted that the seizure caused by

ECT “is so subtle that it typically must be monitored” on an electroencephalogram.

Overall, the examiner concluded that “there is minimal actual pain” because the patient is

asleep during the procedure, and post-procedure discomfort is generally “mild and brief.”

              6.     Patient’s ability to competently determine whether the treatment is
                     desirable

       The district court found that, at the time of the hearing, appellant “lacked the

capacity to determine whether the proposed treatment was necessary or desirable and



                                            12
lacked the competency to consent to said treatment.” Additionally, the court found that

appellant “lacks insight into her mental illness and therefore cannot rationally weigh risks

and benefits involved with such treatment.”

       These findings are supported by clear and convincing evidence because the second

examiner opined that appellant “is not able to engage in rational discussion regarding the

risks versus benefits of ECT,” and she has “no insight into her mental illness.” The first

examiner shared this opinion, stating that appellant “did not have an awareness of her

situation,” and “was not able to demonstrate an understanding of the treatment with ECT

nor express a clear choice that was not based on delusional thoughts.”

       B.     The district court properly balanced the Price factors.

       Ultimately, the district court considered the Price factors and found, by clear and

convincing evidence, that ECT is necessary, reasonable, and in appellant’s best interests.

The district court’s findings support the conclusion that ECT is presently medically

necessary because, from a medical standpoint, “ECT is virtually the only option that can

be hoped to provide at least a moderate degree of improvement.” 3

       As the district court did, we also recognize that appellant’s circumstances are unique

compared to other cases involving ECT because appellant is “functioning well” in her



3
  In a nonprecedential case, we affirmed a district court’s order finding ECT treatment was
reasonable and necessary, and in doing so we acknowledged that while both doctors agreed
the appellant in that case was “stable and not in immediate danger,” they also agreed that
all pharmacological treatment options had been exhausted, and the appellant would likely
remain depressed and delusional without ECT treatment. Tefera, 

, at *3.
We find that holding persuasive and follow its reasoning given the very comparable
opinion provided in the second examiner’s report in this case. 

                                              13
current setting, there is no medical emergency, appellant’s behavior patterns and mental

activity have “been stable for many years,” and appellant is not aggressive or catatonic.

However, our review is limited to whether the district court’s findings, based on the factors

established in Price, are supported by clear and convincing evidence.           See Sefkow,

 (noting the function of the court of appeals is limited to identifying and

correcting errors). Since the district court’s findings relevant to each of the Price factors

are supported by clear and convincing evidence, and because those findings support the

district court’s decision regarding ECT, we affirm.

       Affirmed.




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