2017 QCCA 1333, 2017 QCCA 1333

Unofficial English Translation Centre intégré universitaire de santé et de services sociaux de la Capitale- Nationale c. D.M. 2017 QCCA 1333 COURT OF APPEAL CANADA PROVINCE OF QUEBEC REGISTRY OF QUEBEC No.: 200-09-009490-175 (200-17-025682-170) DATE: September 8, 2017 CORAM: THE HONOURABLE NICOLE DUVAL HESLER, C.J.Q. JULIE DUTIL, J.A. SIMON RUEL, J.A. CENTRE INTÉGRÉ UNIVERSITAIRE DE SANTÉ ET DE SERVICES SOCIAUX DE LA CAPITALE-NATIONALE APPELLANT – Plaintiff v.

D… M… RESPONDENT – Defendant -and- S… R… IMPLEADED PARTY – Impleaded party JUDGMENT [ 1 ] The appellant (“CIUSSS”) appeals from a judgment issued April 6, 2017 by the Superior Court, District of Quebec (the H onourable Suzanne Hardy-Lemieux), [1] granting it a two-year authorization to provide medical care to the respondent against his will and despite his refusal of such care, but modifying the proposed treatment plan which was imprecise. [ 2 ] For the reasons of Justice Dutil, with which Chief Justice Duval Hesler and Justice Ruel agree, THE COURT : [ 3 ] ALLOWS the appeal in part, without legal costs, for the sole purpose of replacing paragraphs 82(

a) and (

b) and striking subparagraph (

c) so that the conclusions of the treatment order read as follows: [82] AUTHORIZES the Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, or any other establishment or living environment that would provide care to D… M… , to treat him in accordance with the following treatment plan despite his categorical refusal:

a) antipsychotic medication chosen in light of the defendant’s clinical progession including notably, individually or in combination: Abilify Maintena, Risperidone, Paliperidone, Olanzapine, Lurasidone, Quetiapine, Clozapine or other first-generation antipsychotics;

b) a medication to counter the adverse effects of the psychiatric medication, determined according to the defendant’s clinical progression, including notably: Kemadrin, Cogentin, benzodiazepines such as Ativan, beta blockers such as Inderal, Cogentin, Monicor, Atropine drops, salt capsules, laxatives or emollients as well as the medication necessary to counter psychomotor retardation, upper-limb stiffness, tremors, akathisia or hypersalivation; c) […]

d) any route may be used to administer the medication, including intramuscular injection;

e) periodic blood samples and other analyses and tests;

f) transitional and temporary hospitalization, including meetings with members of the treatment team;

g) lodging in an appropriate living environment, including a transitional environment;

h) transfer to an appropriate environment;

i) out-patient monitoring at a frequency and under the conditions set by the treating physician or the outpatient monitoring team including, notably, the Centre for Treatment and Readaptation teamw ( équipe du Centre de traitement et de réadaptation/CTR ), the assertive community treatment team or the brief intensive home treatment team ( équipe du traitement intensif bref à domicile /TIBD). NICOLE DUVAL HESLER, C.J.Q. JULIE DUTIL, J.A. SIMON RUEL, J.A. Mtre Marie-Nancy Paquet Mtre Camille De Larochellière CONTENTIEUX DU CIUSSS DE LA CAPITALE-NATIONALE For the appellant Mr. D… M… (Not Present) Respondent Ms.

S… R… (Not Present) Impleaded Party Hearing Date: August 8, 2017 REASONS OF DUTIL, J.A. [ 4 ] The primary question in this appeal is the following: what degree of detail is required with respect to the medication to be administered to a person subject to a treatment plan? The duration of the order issued by the first instance judge is also at issue. *** [ 5 ] The facts necessary to understand this case may be summarized as follows. [ 6 ] The respondent is a single, 19-year-old man with no children. He still lives with his mother, the impleaded party, and his younger brother.

He suffers from treatment-resistant schizophrenia and has cognitive difficulties. As soon as he began primary school, he struggled academically and he had to repeat grade two three times. His general education stopped there. He did, however, complete a woodworking program last February. [ 7 ] Doctor Marianne de Bonville has been the respondent’s treating psychiatrist since fall 2015, when he became an adult. She has met with him approximately 20 times since he became her patient. She explained that the respondent’s schizophrenia presents as auditory hallucinations, delusions and confused thinking.

As a result, he has significant motivational difficulty, as well as difficulty in controlling his emotions and in understanding what is said to him. [ 8 ] On the basis of the evidence, the trial judge concluded that the respondent had stopped taking his medication four times since autumn 2014, when he had his first psychotic episode. At that time, he was a minor. He stopped taking his medication after this first episode and had to be hospitalized in 2015. He became an adult in September 2015. He had to be re-hospitalized in the fall of 2015. Auditory hallucinations were telling him to kill his brother.

In addition to having suicidal thoughts, he also heard the voices of friends and gangsters threatening to kill him. Shortly before this hospitalization, the Seroquel XR he had been prescribed had to be reduced because it was causing him drowsiness and fatigue. [ 9 ] As the first instance judge emphasized, when the respondent stops taking his medication, his dangerousness becomes unpredictable. He then relapses and must be hospitalized. [ 10 ] At first instance, the respondent did not contest the duration of the order. The appellant would like a three-year order, but the judge limited the order to two years.

The respondent also told the judge that he was no longer taking medication because he wasn’t feeling well. He said he was “lost, stressed, anxious”. *** [ 11 ] The judge first considered whether the respondent was capable of consenting to the proposed treatment and whether he was categorically refusing care. She referred to the teachings of this Court in F.D. c. Centre Universitaire de Santé McGill (Hôpital Royal- Victoria) . [2] She concluded that he was incapable and had categorically refused the care being offered.

His sudden and partial acceptance of care on the day of the hearing was, in the judge’s view, a stratagem to avoid a judgment. [3] [ 12 ] The judge found that the treatment plan was vague. She highlighted that the person subject to the proceeding should be aware of the facts giving rise to the “[ translation ] remedy sought and the conclusions [the appellant] seeks to oppose against [the respondent].” [4] She acknowledged that the respondent had received the originating application and the attached evidence, but she rejected outright the

approach requiring “[ translation ] a so-called incapable person to find the doctor’s treatment plan in this cumbersome document, to read it and ultimately find the names of the proposed medications at the end.” [5] [ 13 ] The judge was of the view that the obligation to present a detailed treatment plan in the proceeding and to reproduce it in the conclusions “[ translation ] is intensified when the proceeding seeks to force a person, [the respondent], to receive care against his will, knowing that he is incapable of consenting to the care being proposed” and she reviewed the case law to this effect. [6] From the abundant case law, she held that the following factors should form the core of the court’s concerns: • fundamental respect for the inviolability and integrity of the person; • the legal impossibility of forcing an adult to receive care they categorically refuse, unless the Court holds that the person is incapable of consenting to such care; • the hospital must propose medication with sufficient detail to allow a person to understand which medication it wishes to administer; • judicial “blank cheques” are no longer the status quo for judgments authorizing care to be forced upon a person who categorically refuses and is incapable of consenting to care; • the person – as well as, those who may counsel them, if applicable – must be in a position to understand which medication the treating physician would like to be authorized to administer by reading the proceeding; • this medication must correspond to the person’s actual needs, as established at the hearing, and not a medication that may be necessary… eventually. [7] [References omitted] [ 14 ] In the judge’s view, the conclusion formulated by the appellant is so vague that the respondent is only likely to understand that the goal is to give him Clozapine.

She explained her view in this way: [ translation ] [50] With respect for the opposing view, if we consider the description the CIUSSS has provided here as complete – namely the authorization to administer “[ translation ] an antipsychotic chosen in light of the defendant’s clinical progression, including, among others, Clozapine” and “[ translation ] a medication to counter adverse effects of the psychiatric medication” – this is equivalent to being so imprecise that the defendant might possibly understand that the idea is only to give him Clozapine.

But that medication isn’t even the medication currently being administered to Mr. M… [8] [Reference omitted] [ 15 ] The judge indicated that she was better able to understand what medication they sought to administer to the respondent in light of Dr. de Bonville’s explanations.

However, she was still of the opinion that accepting what the CIUSSS was asking for was akin to giving it a “blank cheque” and abandoning the judicial power to review the application for authorization to provide care: [ translation ] [61] The Court concludes that accepting the originating application as-is amounts to giving the CIUSSS a “judicial blank cheque” to administer any antipsychotic medication and any other medication required to counter the side effects of the psychiatric medication.

Doing so would also be a judicial abdication, in favour of the CIUSSS, of the obligation the legislature has given the courts to review applications to provide care. In the Court’s view, this does not comply with either the statutory requirements or the relevant case law. [9] [ 16 ] Consequently, she arrived at the following conclusion: [62] Conscious of the care Mr.

M… requires, the Court authorizes the administration of Abilify Maintena by injection, or of Seroquel or of Clozapine as well as the administration of medication required to counter the secondary effects of taking this medication, as already described. [63] If rapid changes in the medication administered to Mr. M… are required, the CIUSSS need only present an application to amend the judgment which will then be executory. The Court will hear these applications by preference.

As we know, the Court of Appeal has held that “[ translation ] convenience for the medical institution or hospital is not a relevant factor”. [10] [Reference omitted] [ 17 ] As for the duration of the order, she noted that a high degree of caution is appropriate in such contexts. In the present case, this is the first application for an authorization to provide care.

Considering the respondent’s young age, his state of health and the time necessary for the medication to have beneficial effects, she concluded that a two-year period was sufficient. [ 18 ] The judge issued the following order: [82] AUTHORIZES the Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, or any other establishment or living environment that would provide care to D… M…, to treat him in accordance with the following treatment plan despite his categorical refusal:

a) an antipsychotic medication chosen in light of his clinical progression, including notably Abilify Maintena or Seroquel or Clozapine;

b) if Abilify Maintena is administered, a medication to counter the adverse effects of this medication, namely either Ativan or Inderal or Cogentin or Kemadrin;

c) if Clozapine is administered, laxatives, Monocor or another similar beta blocker, and Atropine drops;

d) any route may be used to administer the medication, including intramuscular injection;

e) periodic blood samples and other analyses and tests;

f) transitional and temporary hospitalization, including meetings with members of the treatment team;

g) lodging in an appropriate living environment, including a transitional environment;

h) transfers to an appropriate environment;

i) out-patient monitoring at a frequency and under the conditions set by the treating physician or the outpatient monitoring team including, notably, the Center for Treatment and Rehabilitation team ( équipe du Centre de traitement et de réadaptation/CTR ), the assertive community treatment team or the brief intensive home treatment team ( équipe du traitement intensif bref à domicile /TIBD); [11] *** 1.

Did the first instance judge err in requiring specific names of antipsychotic medications required by the respondent’s state of health and in restricting the authorization to certain antipsychotics and other medication required to counter side effects? [ 19 ] Treatment orders constitute a violation of the fundamental rights to liberty and to the integrity of the person. For this reason, the legislature has entrusted the courts with the duty of ensuring that the law is respected in such matters.

As this Court highlighted in the decision F.D. , the parameters of this review are the following: [ translation ] [26] The Charter of Human Rights and Freedoms , the Civil Code of Québec , the Act Respecting Health Services and Social Services and the Code of Civil Procedure establish the parameters for considering and adjudicating a motion for authorization to administer care. [27] In such matters, it is essential not to lose sight of the following: ➢ Every person is inviolable and is entitled to the integrity of his person; ➢ No one may be made to undergo care except with his consent; ➢ No one (judge, court or physician) may force a person capable of consenting to undergo care that the person refuses, even if it would be in his interest to receive care and even if refusal is likely to lead to his death; ➢ Nowhere does the legislator confer jurisdiction upon a judge or a court (or anyone else) to intervene with respect to the appropriateness of a decision made by a person capable of consenting – choice is respected, no matter what that choice may be; ➢ The jurisdiction granted to a judge or court at

article 16 C.C.Q. is applicable to situations in which the individual is incapable of consent and in no other situation; ➢ Exercise of the jurisdiction that the legislature grants a judge or a court at

article 16 C.C.Q. is dependent upon the essential holding, which must be made by a judge or court (where, as here, the person in question is an adult), that the person in question is incapable of consent and categorically refuses care. [28] In short, through

article 16 C.C.Q. , the legislature has entrusted judges and courts, rather than medical professionals, with the responsibility of making choices in the name of the incapable person and has set out at

article 12 C.C.Q. the parameters within which this jurisdiction may be exercised, namely: ➢ in the sole interest of that person; ➢ as far as possible, in compliance with any wishes the latter may have expressed; ➢ by ensuring that the care is beneficial; ➢ that the care is advisable in the circumstances; ➢ and that the risks incurred are not disproportionate to the anticipated benefits. [12] [References omitted] [ 20 ] This judgment proposed an analytical framework to guide courts faced with an application to obtain authorization for the provision of care. In the present case, because the level of detailed required in the treatment plan is at issue, it is the second stage of this

analysis that is relevant: [ translation ] [54] In short, for any application for authorization for the provision of care in the terms of

article 16 C.C.Q. , a careful and rigorous analysis will always be required following the parameters we summarize in the following framework; the judge may pass to a subsequent question only after having responded to the first as the law requires, and the burden of proof will always rest with the applicant. […] STAGE TWO: EXERCISE OF JURISDICTION (art. 12 C.C.Q .) Only after concluding that jurisdiction to act according to

article 16 C.C.Q. has been established may the judge or tribunal proceed to the second stage. Whether the matter is contested or not, the judge must then meticulously carry out the following analysis (always remembering that in so doing he is making a choice on behalf of another). Given the legislature has entrusted him with this responsibility rather than medical professionals, this responsibility may not be delegated . Obviously this does not mean that the judge or the court is “playing doctor”.

Their role is not to decide what care the person should receive (a decision that rests with members of the medical and not the judicial community); their role is limited to reviewing the legality of the proposed treatment plan in accordance with the factors set out at

article 12 C.C.Q. In so doing, they must therefore question the various personnel to obtain answers that shed light on the situation. This task may be more difficult where the case is uncontested, because reliance cannot be placed on evidence or arguments that could be presented by counsel for the individual concerned.

Question Three : Is the treatment required and, if so, is it described in sufficient detail? ➢ The order sought must concern treatment that is truly necessary (and not that which could be necessary): ▪ in the sole interest of the person; ▪ in compliance with, as far as possible, any wishes the latter may have expressed; ▪ and which is advisable in the circumstances. ➢ “Convenience for the medical institution or hospital” is not a relevant factor, despite all of the constraints this may impose. ➢ The coercive nature of such an order requires that boundaries be set: consequently, the order may not be drafted in a broad or vague manner.

Question Four : Do the benefits of treatment outweigh the adverse effects? ➢ What are the benefits? ➢ What risks are associated with the proposed care? ➢ Are the risks disproportionate to the benefits sought? ➢ Is the treatment advisable in the circumstances?

Question Five : If applicable, what should be the duration of the order? ➢ The judge must analyze the factors submitted in support of the duration of the order, even in the absence of a challenge or counter- expertise, and should only issue the order for the period of time required to ensure that the treatment will have the expected benefits. ➢ The duration of a treatment order should not be indeterminate, even assuming that the evidence establishes that the situation will necessarily endure. Question Six : Are conclusions sought other than the authorization to administer the treatment plan and its duration?

If so, can and should they be granted in the circumstances, as drafted or amended? [13] [References omitted; emphasis in the original] [ 21 ] The present case is an opportunity to elaborate on the meaning attributed to certain components of the second stage of this analysis. During the past few months, the case law has been divided with respect to the appropriate

interpretation of “[ translation ] set[ting] boundaries” and the phrase “[ translation ] the order may not be drafted in a broad or vague manner.” [ 22 ] Two lines of cases have emerged in the Superior Court.

With respect to medication, some judges are of the view that an application for a treatment order drafted like the one before this Court does not meet the criteria set out in the test established in F.D. , [14] while others take the position that this type of application is sufficiently detailed to satisfy that test. [15] [ 23 ] The task of a court called to approve a treatment plan for an incapable adult is delicate and of the utmost importance. Courts must be careful not to give the treatment team “carte blanche”.

This, moreover, was the trial judge’s primary concern. [ 24 ] In F.D. , this Court wrote that “[the role of the court] is not to decide what care the person should receive (a decision that rests

with members of the medical and not the judicial community)”. A court’s role is limited to reviewing the legality of the proposed treatment plan in accordance with the factors set out at

article 12 C.C.Q. : [16] 12. A person who gives his consent to or refuses care for another person is bound to act in the sole interest of that person, complying, as far as possible, with any wishes the latter may have expressed. If he gives his consent, he shall ensure that the care is beneficial notwithstanding the gravity and permanence of certain of its effects, that it is advisable in the circumstances and that the risks incurred are not disproportionate to the anticipated benefit. 12.

Celui qui consent à des soins pour autrui ou qui les refuse est tenu d’agir dans le seul intérêt de cette personne en respectant, dans la mesure du possible, les volontés que cette dernière a pu manifester.

S’il exprime un consentement, il doit s’assurer que les soins seront bénéfiques, malgré la gravité et la permanence de certains de leurs effets, qu’ils sont opportuns dans les circonstances et que les risques présentés ne sont pas hors de proportion avec le bienfait qu’on en espère. [ 25 ] In this judgment, the Court also indicated that the order may not be drafted in a broad or vague manner. [17] But, requiring that the treatment plan not be vague with respect to the medication does not mean it is necessary to dictate, in a limitative way, the medication to be administered.

This may be necessary in some cases, but the present case illustrates the difficulties physicians face in treating schizophrenia and how an order that gives the treatment team no latitude may be inappropriate. [ 26 ] As the Court highlighted in F.D. , “convenience for the medical institution or hospital” is not a relevant factor in determining what care will be provided. The situation in F.D. was very different from the case at bar because the application for authorization to provide care is not a matter of convenience.

Indeed, the McGill University Health Centre was seeking authorization to provide future treatment to a patient in the event that he had a psychotic episode. The administration of an antipsychotic was neither required at the time of the application nor beneficial to the appellant. [18] It was argued that it would be more practical to obtain immediate authorization of a treatment plan in order to avoid coming back to court if the appellant’s state of health ended up requiring such medication. [ 27 ] At all times, the person subject to the treatment plan must be the heart of the matter.

A court may not issue a treatment order without being satisfied that the evidence establishes that care will be beneficial and is advisable in the circumstances, despite any risks. However, this does not mean that determining a single category of medications to be administered will be necessary in every case. [ 28 ] In contrast, a “carte blanche” order would be one which authorizes the applicant to administer “all care and treatment required by the state of health” of the person subject to the proceeding.

An order this vague does not allow for review of the legality of the treatment plan, but this is not the case before the Court here. [ 29 ] In some cases, it may be necessary for a treatment plan to be more detailed. For example, if the evidence establishes that one or more medications cannot be tolerated, a court may certainly limit the order if this is in the best interests of the person concerned. Moreover, the more invasive an order is, the more detailed it will have to be with respect to the treatment authorized. This is what the Court decided in the judgment Québec (Curateur public) c.

Institut Philippe-Pinel de Montréal . In that case, the Court modified an order issued by the first instance judge, limiting the electroshock therapy order to a maximum of 12 sessions. However, the Court did not intervene with respect to the authorization to administer medication, which was drafted as follows: [ translation ] [16] […] [5] AUTHORIZES the treating physicians at the Institut Philippe-Pinel de Montréal , and any other physician who may treat the defendant in the future and throughout the duration of this order, to administer to the defendant: a) [...]

b) a neuroleptic or antipsychotic medication including notably: Clozapine, orally or by short or long-acting intramuscular injection at a dose sufficient to regress the symptoms;

c) a mood stabilizer and antidepressant medication to be adjusted in accordance with the symptomatology;

d) an oral or injectable medication to mitigate or combat the adverse effects of the antipsychotic medication and the mood stabilizer; e) […] [19] [ 30 ] Analyzing an application for authorization to provide care is thus an individualized, case-by-case exercise undertaken on the basis of evidence demonstrating that the person is incapable of consent, has categorically refused care, and that the care is in the person’s best interest. [20] The quest for precision, though justifiable in some circumstances will not be appropriate in others and should under no circumstances be to the detriment of the person subject to the treatment order, as it would be here. [ 31 ] I am, however, of the view that in all cases the application must proceed with the utmost transparency.

Without necessarily providing an exhaustive laundry list of all potential medications, the applicant must provide the court with sufficient information regarding the risks and benefits of the medications to allow the latter to carry out the duty entrusted to it by the legislature, namely review of the legality of the treatment plan (art. 12 C.C.Q. ).

[ 32 ] In my opinion, the evidence here clearly establishes that, in the respondent’s case, the treating physicians required a certain latitude with respect to the medication. Indeed, the evidence reveals that the respondent’s case is particularly complex due to the high number of medications he has already tried and the constant need for adjustment: • The respondent suffers from treatment resistant schizophrenia; [21] • The respondent has rigid and concrete thinking, which limits his openness to explanations.

He harbours the notion that the voices he hears will never go away and that medication is of little or no use; [22] • In psychiatric treatment, the challenges faced by young adults are not the same as those faced by those in their 30s or 40s.

The response to treatment is not the same; [23] • The respondent’s weak response to treatment has already led to numerous pharmaceutical trials: − Abilify per os 22 mg die: no response to treatment; − Risperdal , up to 4 mg: residual symptoms persisted and the respondent complained of numerous side effects including feeling slow and erectile difficulties; ▪ To address the side effects, low doses of Remeron and Abilify were tried without much success. − Zyprexa : partly effective; − Clozapine : triggered a CK increase with some liver function disturbance; − Seroquel XR , up to 800 mg: helped but low-intensity psychotic symptoms persisted (daily auditory hallucinations); [24] • The respondent’s cognitive abilities were affected by active psychosis and it is possible that they will also be affected by sub- optimal or poorly adjusted medication; [25] • The respondent requires a combination of antipsychotics because he is not sufficiently responsive to a single antipsychotic and some of his psychotic symptoms persist regardless; [26] • The respondent’s file is very complex, a true pharmacological puzzle which has required the intervention of multiple hospital pharmacists specialized in youth psychosis and Clozapine; [27] • In complex, difficult-to treat cases such as this, the medical team often needs to combine antipsychotics in order to best treat the psychotic symptoms.

This was, moreover, what the team had to do during the respondent’s last hospitalizations. For the respondent’s well-being, it is therefore necessary that the medical team have access to different molecules; [28] • Over the course of the past several months, the respondent was treated with 400 mg of Abilify Maintena.

The medical team was struck by the clinical improvement which entirely resolved the auditory hallucinations. [29] In the past, however, the respondent presented a total resistance to Abilify, which led Dr. de Bonville to state that it would have taken three months of constant exposure to this molecule to achieve significant progress; [30] • On the other hand, Abilify Maintena seems to create anxiety in the respondent and to exacerbate his ocular tics.

He is currently under ophthalmological observation to determine the origin and treatment of his tics: − The respondent did not respond to treatment with Ativan or Cogentin; − It is possible that these tics are part of meige syndrome, in which case Clozapine would be highly indicated to resolve the problem; [31] • Each antipsychotic medication has its own profile of efficiency and side effects. Each individual reacts very differently to the range of side effects.

Physicians must make choices between different molecules depending on each individual, but they can never predict how an individual will progress; [32] • The respondent does not feel well when medicated. He feels lost, stressed and anxious. [33] [ 33 ] This is, then, a case where even if the diagnosis is known, the precise treatment is not. Adjustments will still need to be made following trials of different antipsychotics. As Dr. de Bonville mentioned during the hearing at first instance, finding the right molecule may take time and require adjustments.

The medical team must be able to make these adjustments without having to come back to court each time. This would be contrary to the respondent’s best interests. [ 34 ] Nevertheless, naming medications in the application for the treatment order, even if the list is neither restrictive nor exhaustive, may be beneficial because this requires the applicant to narrow the treatment plan, allowing the defendant to better understand the treatment the applicant seeks to administer – one of the first instance judge’s concerns – without removing necessary flexibility.

This should be the favoured approach. [ 35 ] I therefore propose to formulate the order so as not to restrict the authorization of antipsychotic medications. It bears mentioning, moreover, that even if the judge clearly announced during the hearing that she would specify which medications were authorized, the text of the conclusion she sets out at paragraph 82(

a) of the judgment seems to be broader than she intended. Indeed, she uses the expression “including notably” before listing three antipsychotic medications. This seems contrary to her intention – that is, to limit the authorization to certain antipsychotic medications.

[ 36 ] At the hearing, at the suggestion of the Court, counsel for the appellant submitted a draft order that would provide the treatment team with the flexibility necessary to provide the required care, while also indicating the medications that Dr. de Bonville described to the first instance judge. In my view, this proposal respects the principles set out at art. 12 C.C.Q. 2. Did the first instance judge err in limiting the duration of the order to a period of two years? [ 37 ] The appellant pleads that the judge erred in limiting the duration of the order to a period of two years.

It submits that the treating physician was unequivocal regarding the need for a three-year order.

This duration was necessary for a significant improvement in the respondent’s health, for the understanding of his illness, for treatment and to help him move forward in life. [ 38 ] Trial judges have broad discretion in determining the duration of treatment orders. [34] In addition, the duration of the order must be as short as reasonably possible without neutralizing the effect of the treatment itself. [35] [ 39 ] Dr. de Bonville’s testimony reveals that a one-year order would be too short to allow for “[ translation ] a significant improvement in his health and in our understanding of his illness.” [36] However, she did not explain why she sought an authorization for three years rather than two.

The respondent challenged the three-year authorization. [ 40 ] The trial judge made and supported her decision. This is a first application for a treatment order for the respondent. His young age (19), his state of health and the requirements Dr. de Bonville described as necessary for the medication to have beneficial effects led her to conclude that a two-year order was sufficient. [ 41 ] I conclude that the judge properly exercised her discretion in this respect. [ 42 ] Therefore, I propose to allow the appeal in part, without legal costs, for the sole purpose of replacing paragraphs 82(

a) and (

b) and eliminating paragraph (

c) so that the conclusions of the order are drafted as follows: [82] AUTHORIZES the Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, or any other establishment or living environment that would provide care to D… M… , to treat him in accordance with the following treatment plan despite his categorical refusal:

a) antipsychotic medication chosen in light of the defendant’s clinical progession including notably, individually or in combination: Abilify Maintena, Risperidone, Paliperidone, Olanzapine, Lurasidone, Quetiapine, Clozapine or other first-generation antipsychotics;

b) a medication to counter the adverse effects of the psychiatric medication, determined according to the defendant’s clinical progression, including notably: Kemadrin, Cogentin, benzodiazepines such as Ativan, beta blockers such as Inderal, Cogentin, Monicor, Atropine drops, salt capsules, laxatives or emollients as well as the medication necessary to counter psychomotor retardation, upper-limb stiffness, tremors, akathisia or hypersalivation; c) […]

d) any route may be used to administer the medication, including intramuscular injection;

e) periodic blood samples and other analyses and tests;

f) transitional and temporary hospitalization, including meetings with members of the treatment team;

g) lodging in an appropriate living environment, including a transitional environment;

h) transfer to an appropriate environment;

i) out-patient monitoring at a frequency and under the conditions set by the treating physician or the outpatient monitoring team including, notably, the Center for Treatment and Rehabilitation team ( équipe du Centre de traitement et de réadaptation/CTR ), the assertive community treatment team or the brief intensive home treatment team ( équipe du traitement intensif bref à domicile /TIBD). JULIE DUTIL, J.A.